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associated with pembrolizumab general instructions

1. Corticosteroid taper should be initiated upon AE improving to Grade 1 or less and continue to taper over at least 4 weeks.  
2. For situations where pembrolizumab has been withheld, pembrolizumab can be resumed after AE has been reduced to Grade 1 or 0 and corticosteroid has been tapered. Pembrolizumab should be permanently discontinued if AE does not resolve within 12 weeks of last dose or corticosteroids cannot be reduced to ≤10 mg prednisone or equivalent per day within 12 weeks.  
3. For severe and life-threatening irAEs, IV corticosteroid should be initiated first followed by oral steroid. Other immunosuppressive treatment should be initiated if irAEs cannot be controlled by corticosteroids.  
| Immunerelated AEs                                      | Toxicity  grade                                                                                                      | or             |                                                                                                                                                          |                                                              |            |
|--------------------------------------|----------------------------------------------------------------------------------------------------------------------|----------------|----------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------|------------|
| conditions  (CTCAEv5.0)              | Action taken to                                                                                                      | irAE           | management                                                                                                                                               |                                                              |            |
| pembrolizumab                        | with                                                                                                                 | corticosteroid |                                                                                                                                                          |                                                              |            |
| and/or                               | other                                                                                                                |                |                                                                                                                                                          |                                                              |            |
| therapies                            | Monitor and follow-up                                                                                                |                |                                                                                                                                                          |                                                              |            |
| Pneumonitis                          | Grade 2                                                                                                              | Withhold       |                                                                                                                                                         | 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             |                                                                                                                      |                |                                                                                                                                                          |                                                              |            |
| Diarrhea                             | /                                                                                                                    | Grade 2 or 3   | Withhold                                                                                                                                                 |                                                             | Administer |
| Colitis                              | corticosteroids  (initial dose of 1-2  mg/kg prednisone  or equivalent)  followed by taper                           |                |                                                                                                                                                          |                                                              |            |
|                                     | Administer  corticosteroids  (initial dose of 1-2  mg/kg prednisone  or equivalent)  followed by taper               |                |                                                                                                                                                          |                                                              |            |
| Grade 3 or 4,  or recurrent  Grade 2 | Permanently  discontinue                                                                                             |               | Monitor participants for  signs and symptoms of  enterocolitis (i.e., diarrhea,  abdominal pain, blood or  mucus in stool with or  without fever) and of |                                                              |            |  
Version Date: *02/16/21*  
| Version Date: 02/16/21 Immunerelated AEs Toxicity  grade                                                                                                                                                                                                       | or                                                                                                                                         |                                                                                    |                                                                                                           |                                                                                             |       |         |     |       |     |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------|-------|---------|-----|-------|-----|
| conditions  (CTCAEv5.0)                                                                                                                                                                               | Action taken to                                                                                                                            | irAE                                                                               | management                                                                                                |                                                                                             |       |         |     |       |     |
| pembrolizumab                                                                                                                                                                                         | with                                                                                                                                       | corticosteroid                                                                     |                                                                                                           |                                                                                             |       |         |     |       |     |
| and/or                                                                                                                                                                                                | other                                                                                                                                      |                                                                                    |                                                                                                           |                                                                                             |       |         |     |       |     |
| therapies                                                                                                                                                                                             | Monitor and follow-up                                                                                                                      |                                                                                    |                                                                                                           |                                                                                             |       |         |     |       |     |
| Grade 4                                                                                                                                                                                               | Permanently                                                                                                                                | bowel                                                                              | perforation                                                                                               |                                                                                             |       |         |     |       |     |
| discontinue                                                                                                                                                                                           | (i.e., peritoneal signs and  ileus).                                                                                                       |                                                                                    |                                                                                                           |                                                                                             |       |         |     |       |     |
|                                                                                                                                                                                                      | Participants with ≥ Grade  2 diarrhea suspecting  colitis should consider GI  consultation and  performing endoscopy to  rule out colitis. |                                                                                    |                                                                                                           |                                                                                             |       |         |     |       |     |
|                                                                                                                                                                                                      | Participants                                                                                                                               | with                                                                               |                                                                                                           |                                                                                             |       |         |     |       |     |
| diarrhea/colitis should be  advised to drink liberal  quantities of clear fluids.  If sufficient oral fluid  intake is not feasible, fluid  and electrolytes should be  substituted via IV  infusion. |                                                                                                                                            |                                                                                    |                                                                                                           |                                                                                             |       |         |     |       |     |
| Grade 2                                                                                                                                                                                               | Withhold                                                                                                                                   |                                                                                   | Administer  corticosteroids  (initial dose of 0.5-  1 mg/kg prednisone  or equivalent)  followed by taper |                                                                                             |       |         |     |       |     |
| Aspartate  aminotransferase  / Alanine  aminotransferase  increased or  blood bilirubin  increased                                                                                                    | Grade 3 or 4                                                                                                                               | Permanently                                                                        |                                                                                                          | Administer                                                                                  |       |         |     |       |     |
| discontinue                                                                                                                                                                                           | corticosteroids  (initial dose of 1-2  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                                                                                                               |                                                                                                                                            |                                                                                    |                                                                                                           |                                                                                             |       |         |     |       |     |
| 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                                                                                                                                                                             |                                                                                                                                            |                                                                                    |                                                                                                           |                                                                                             |       |         |     |       |     |  
Version Date: *02/16/21*  
| Version Date: 02/16/21 Immunerelated AEs Toxicity  grade                                                                                                                                                                                                                  | or                                                                                                                 |                          |            |                                                                                         |         |                                    |          |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------|--------------------------|------------|-----------------------------------------------------------------------------------------|---------|------------------------------------|----------|
| conditions  (CTCAEv5.0)                                                                                                                                                                                          | Action taken to                                                                                                    | irAE                     | management |                                                                                         |         |                                    |          |
| pembrolizumab                                                                                                                                                                                                    | with                                                                                                               | corticosteroid           |            |                                                                                         |         |                                    |          |
| and/or                                                                                                                                                                                                           | other                                                                                                              |                          |            |                                                                                         |         |                                    |          |
| therapies                                                                                                                                                                                                        | Monitor and follow-up                                                                                              |                          |            |                                                                                         |         |                                    |          |
| Hyperthyroidism                                                                                                                                                                                                  | Grade 2                                                                                                            | Continue                 |           | Treat                                                                                   | with    | non                                    |          |
| selective                                                                                                                                                                                                        | beta                                                                                                                    |                          |            |                                                                                         |         |                                    |          |
| blockers                                                                                                                                                                                                         | (e.g.,                                                                                                             |                          |            |                                                                                         |         |                                    |          |
| 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                                                                                                                                                                                            | (e.g.,                                                                                                             |                          |            |                                                                                         |         |                                    |          |
| levothyroxine                                                                                                                                                                                                    | or                                                                                                                 |                          |            |                                                                                         |         |                                    |          |
| liothyroinine)                                                                                                                                                                                                   | per                                                                                                                |                          |            |                                                                                         |         |                                    |          |
| standard of care                                                                                                                                                                                                 |                                                                                                                   | Monitor                  | for        | signs                                                                                   | and     |                                    |          |
| symptoms                                                                                                                                                                                                         | of                                                                                                                 | thyroid                  |            |                                                                                         |         |                                    |          |
| disorders.                                                                                                                                                                                                       |                                                                                                                    |                          |            |                                                                                         |         |                                    |          |
| Nephritis                                                                                                                                                                                                        | and                                                                                                                | Grade 2                  | Withhold   |                                                                                         |         |                                    |          |
| Renal  dysfunction                                                                                                                                                                                               | Grade 3 or 4                                                                                                       | Permanently  discontinue |           | Administer  corticosteroids  (prednisone 1-2  mg/kg or  equivalent)  followed by taper. |        | Monitor changes of renal  function |          |
| Myocarditis                                                                                                                                                                                                      | Grade 1 or 2                                                                                                       | Withhold                 |           | Based on severity  of AE administer  corticosteroids                                    |        | Ensure                             | adequate |
| evaluation                                                                                                                                                                                                       | to                                                                                                                 | confirm                  |            |                                                                                         |         |                                    |          |
| etiology                                                                                                                                                                                                         | and/or                                                                                                             | exclude                  |            |                                                                                         |         |                                    |          |
| other causes                                                                                                                                                                                                     |                                                                                                                    |                          |            |                                                                                         |         |                                    |          |
| Grade 3 or 4                                                                                                                                                                                                     | Permanently  discontinue                                                                                           |                          |            |                                                                                         |         |                                    |          |
| All                                                                                                                                                                                                              | other                                                                                                              |                          |            |                                                                                         |         |                                    |          |
| immune-related  AEs                                                                                                                                                                                              | Intolerable/  persistent  Grade 2                                                                                  | Withhold                 |           | Based on type and  severity of AE  administer  corticosteroids                          |        | Ensure                             | adequate |
| evaluation                                                                                                                                                                                                       | to                                                                                                                 | confirm                  |            |                                                                                         |         |                                    |          |
| etiology                                                                                                                                                                                                         | and/or                                                                                                             | exclude                  |            |                                                                                         |         |                                    |          |
| other causes                                                                                                                                                                                                     |                                                                                                                    |                          |            |                                                                                         |         |                                    |          |
| Grade 3                                                                                                                                                                                                          | Withhold                                                                                                           | or                       |            |                                                                                         |         |                                    |          |
| discontinue  based on                                                                                                                                                                                            | the                                                                                                                |                          |            |                                                                                         |         |                                    |          |
| type                                                                                                                                                                                                             | of                                                                                                                 | event.                   |            |                                                                                         |         |                                    |          |
| Events                                                                                                                                                                                                           | that                                                                                                               |                          |            |                                                                                         |         |                                    |          |
| require  discontinuation  include and not  limited to:  Gullain-Barre  Syndrome,  encephalitis                                                                                                                   |                                                                                                                    |                          |            |                                                                                         |         |                                    |          |
| Grade                                                                                                                                                                                                            | 4                                                                                                                  | or                       |            |                                                                                         |         |                                    |          |
| recurrent  Grade 3                                                                                                                                                                                               | Permanently  discontinue                                                                                           |                          |            |                                                                                         |         |                                    |          |
| 1.                                                                                                                                                                                                               | Withhold or permanently discontinue pembrolizumab is at the discretion of the investigator or treating  physician. |                          |            |                                                                                         |         |                                    |          |
| NOTE:  For participants with Grade 3 or 4 immune-related endocrinopathy where withhold of pembrolizumab is  required, pembrolizumab may be resumed when AE resolves to ≤ Grade 2 and is controlled with hormonal |                                                                                                                    |                          |            |                                                                                         |         |                                    |          |  
3.3.2.3 Dose modification and toxicity management of infusion-reactions related to pembrolizumab Pembrolizumab may cause severe or life-threatening infusion-reactions including severe hypersensitivity or anaphylaxis. Signs and symptoms usually develop during or shortly after drug infusion and generally resolve completely within 24 hours of completion of infusion. Dose modification and toxicity management guidelines on pembrolizumab associated infusion reaction are provided in Table 6.  
| Table 6: Pembrolizumab Infusion Reaction Dose modification and Treatment Guidelines NCI CTCAE Grade Treatment Premedication at Subsequent  Dosing Grade 1 Increase monitoring of vital signs as medically  indicated until the participant is deemed medically  stable in the opinion of the investigator. None Mild reaction; infusion  interruption not  indicated; intervention  not indicated Grade 2 Stop Infusion. Participant may be  premedicated 1.5h (± 30  minutes) prior to infusion of  pembrolizumab with: Diphenhydramine 50 mg po  (or equivalent dose of  antihistamine). Acetaminophen 500-1000 mg  po (or equivalent dose of  analgesic). Requires therapy or  infusion interruption but  responds promptly to  symptomatic treatment  (e.g., antihistamines,  NSAIDs, narcotics, IV  fluids); prophylactic  medications indicated  for ≤24 hrs Additional appropriate medical therapy may  include but is not limited to: IV fluids Antihistamines NSAIDs Acetaminophen Narcotics Increase monitoring of vital signs as medically  indicated until the participant is deemed medically  stable in the opinion of the investigator. If symptoms resolve within 1 hour of stopping drug  infusion, the infusion may be restarted at 50% of  the original infusion rate (e.g. from 100 mL/hr to 50  mL/hr). Otherwise dosing will be held until  symptoms resolve and the participant should be  premedicated for the next scheduled dose. Participants who develop Grade 2 toxicity  despite adequate premedication should be  permanently discontinued from further study  drug treatment Grades 3 or 4 Stop Infusion. No subsequent dosingGrade 3: Additional appropriate medical therapy may  include but is not limited to: Epinephrine** IV fluids Antihistamines Prolonged (i.e., not  rapidly responsive to  symptomatic medication  and/or brief interruption  of infusion); recurrence  of symptoms following   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
Version Date: *02/16/21*  
| NCI CTCAE Grade                                                                                                                                                                                                                                                                                                                                   | Treatment                                                                                                                                                                                                                                                                                                                                                                                         | Premedication at Subsequent  Dosing   |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------|
| initial                                                                                                                                                                                                                                                                                                                                           | improvement;                                                                                                                                                                                                                                                                                                                                                                                      |                                       |
| hospitalization indicated  for other clinical  sequelae (e.g., renal  impairment, pulmonary  infiltrates) Grade 4: Life-threatening; pressor  or ventilatory support  indicated                                                                                                                                                                   | NSAIDs Acetaminophen Narcotics Oxygen Pressors Corticosteroids Increase monitoring of vital signs as medically  indicated until the participant is deemed medically  stable in the opinion of the investigator. Hospitalization may be indicated. **In cases of anaphylaxis, epinephrine should be  used immediately. Participant is permanently discontinued from  further study drug treatment. |                                       |
| Appropriate resuscitation equipment should be available at the bedside and a physician readily available during the period of  drug administration. For further information, please refer to the Common Terminology Criteria for Adverse Events v5.0 (CTCAE) at  http://ctep.cancer.gov 3.3.2.4 Other allowed dose interruption for pembrolizumab |                                                                                                                                                                                                                                                                                                                                                                                                   |                                       |  
3.3.2.4 Other allowed dose interruption for pembrolizumab Pembrolizumab may be interrupted for situations other than treatment-related AEs such as medical / surgical events or logistical reasons not related to study therapy. Participants should be placed back on study therapy within 3 weeks of the scheduled interruption. The reason for interruption should be documented in the patient's study record.
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3.4 study calendar 1 cycle

Screening assessments will occur within 28 days prior to start of study therapy unless otherwise indicated. If screening assessments are performed within 3 days prior to dosing, the assessments do not need to be repeated on C1D1 unless otherwise indicated. Assessments after C1D1 may be performed up to 3 days prior to indicated time unless otherwise indicated. LMB-100 dosing cycles after cycle 1 may be delayed for up to two weeks to accommodate schedule conflicts, Federal holidays and inclement weather, etc. Pembrolizumab dosing cycles after may be delayed up to three weeks for the same reasons; however, cycle 3 may be delayed for longer as described in section 3.3.2.1.  
| Cycles 1 & 2                                                         | Subsequent Cycles  (for a maximum of 2  years after initial   |     |                                               |     |     |     |    |    |    |
|----------------------------------------------------------------------|---------------------------------------------------------------|-----|-----------------------------------------------|-----|-----|-----|----|----|----|
| pembrolizumab therapy  and, if applicable,  through second course)15 | Safety FollowUp Visit (~30  days after  completion of  study  therapy)16                                                               | Safety FollowUp Visit (~ 90  days after  completion of  study  therapy)16     | Long-Term  Follow Up  (every 6 - 12  weeks)17 |     |     |     |    |    |    |
| Day  1514                                                            | Day 1                                                         |     |                                               |     |     |     |    |    |    |
| Scree                                                                | Da                                                            | Da  | Da                                            | Da  | Da  |     |    |    |    |
| Procedure                                                            | ning                                                          | y 1 | y 3                                           | y 4 | y 5 | y 8 |    |    |    |
| LMB-100                                                              | X                                                             | X   | X                                             |     |     |     |    |    |    |
| Pembrolizumab                                                        | X                                                             |     |                                               |     |     |     |    |    |    |
| History and PE                                                       | X                                                             | X   | X                                             | X   | X   | X   | X  | X  | X  |
| Weight                                                               | X                                                             | X   | X                                             | X   | X   | X   | X  | X  |    |
| Height                                                               | X                                                             |     |                                               |     |     |     |    |    |    |
| Vital signs1                                                         | X                                                             | X   | X                                             | X   | X   | X   | X  | X  | X  |
| Performance                                                          | 2                                                             | X   | X                                             |     |     |     |    |    |    |
| Score                                                                | X                                                             |     |                                               |     |     |     |    |    |    |
| Labs3                                                                | X 4                                                           | X 5 | X                                             | X   | X   | X   | X  | X  | X  |
| Urinalysis                                                           | X                                                             | X   | X                                             |     |     |     |    |    |    |  
47  
Version Date: *02/16/21*  
| Cycles 1 & 2                                                         | Subsequent Cycles  (for a maximum of 2  years after initial   |                           |                                               |     |     |     |
|----------------------------------------------------------------------|---------------------------------------------------------------|---------------------------|-----------------------------------------------|-----|-----|-----|
| pembrolizumab therapy  and, if applicable,  through second course)15 | Safety FollowUp Visit (~30  days after  completion of  study  therapy)16                                                               | Safety FollowUp Visit (~ 90  days after  completion of  study  therapy)16                           | Long-Term  Follow Up  (every 6 - 12  weeks)17 |     |     |     |
| Day  1514                                                            | Day 1                                                         |                           |                                               |     |     |     |
| Scree                                                                | Da                                                            | Da                        | Da                                            | Da  | Da  |     |
| Procedure                                                            | ning                                                          | y 1                       | y 3                                           | y 4 | y 5 | y 8 |
| Urine  albumin/creatin                                               | Days1-6 (+4 days if patient still in                          |                           |                                               |     |     |     |
| ine ratio                                                            | hospital)                                                     |                           |                                               |     |     |     |
| HLA                                                                  | Typing                                                        |                           |                                               |     |     |     |
| (Class                                                               | I                                                             | and                       | X 6                                           |     |     |     |
| Class II) Urine or serum  hCG in women  of childbearing  potential7  | 8                                                             | X 8                       | X                                             | X   | X   |     |
| X                                                                    |                                                               |                           |                                               |     |     |     |
| Confirmation  of dx9                                                 | X                                                             |                           |                                               |     |     |     |
| NIH Advance                                                          | 10                                                            |                           |                                               |     |     |     |
| Directives                                                           | X                                                             |                           |                                               |     |     |     |
| Form Biopsy                                                          | 6                                                             | C3 and C5 1st course only |                                               |     |     |     |
| (optional)                                                           | X                                                             |                           |                                               |     |     |     |
| Correlative  Research  Studies                                       | Please see section 5.2                                        |                           |                                               |     |     |     |
| CT CAP and/or                                                        | Every2 cycles ± 7 days                                        | X                         |                                               |     |     |     |
| MRI11                                                                | X                                                             | 12                        | X 12                                          | X   |     |     |  
| Cycles 1 & 2                                                         | Subsequent Cycles  (for a maximum of 2  years after initial                                                                                |                         |                                               |      |     |     |    |
|----------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------|-------------------------|-----------------------------------------------|------|-----|-----|----|
| pembrolizumab therapy  and, if applicable,  through second course)15 | Safety FollowUp Visit (~30  days after  completion of  study  therapy)16                                                                                                                                            | Safety FollowUp Visit (~ 90  days after  completion of  study  therapy)16                         | Long-Term  Follow Up  (every 6 - 12  weeks)17 |      |     |     |    |
| Day  1514                                                            | Day 1                                                                                                                                      |                         |                                               |      |     |     |    |
| Scree                                                                | Da                                                                                                                                         | Da                      | Da                                            | Da   | Da  |     |    |
| Procedure                                                            | ning                                                                                                                                       | y 1                     | y 3                                           | y 4  | y 5 | y 8 |    |
| FDG-PET                                                              | X                                                                                                                                          | Every 2 cycles ± 7 days | X 12                                          | X 12 | X   |     |    |
| ECG13                                                                | X                                                                                                                                          | X                       | X                                             | X    | X   | X   | X  |
| Echocardiogra m                                                      | X                                                                                                                                          |                         |                                               |      |     |     |    |
| Adverse Events                                                       | Monitored continuously                                                                                                                     |                         |                                               |      |     |     |    |
| Concomitant                                                          | Monitored continuously                                                                                                                     |                         |                                               |      |     |     |    |
| Medications Telephone/ema il follow-up q 3  months                   | X                                                                                                                                          |                         |                                               |      |     |     |    |
| 1                                                                    | At screening: heart rate, blood pressure, body temperature, pulse oximetry. During the infusions of LMB-100 in Cycle 1, vital signs (heart |                         |                                               |      |     |     |    |  
1 **At screening:** heart rate, blood pressure, body temperature, pulse oximetry. **During the infusions** of LMB-100 in Cycle 1, vital signs (heart rate, blood pressure, body temperature) must be monitored pre-infusion and every 15 minutes (± 5 minutes) during the infusion and then every 30 minutes (± 10 minutes) from the end of the infusion until the infusion line is removed.  
2 Performed within 7 days prior to start of study therapy 3 CBC with differential, Acute Care Panel (Na, K, Cl, CO2, creatinine, glucose, BUN), Hepatic Panel (ALP, AST, ALT, total & direct bilirubin),
Mineral Panel (albumin, Ca, Mg, P), lactate dehydrogenase, creatine kinase, C-reactive protein, PT, PTT, fibrin degradation products, TSH, free T4, total T3.  
4 Performed within 10 days prior to start of study therapy. 5 Only required if more than 10 days have passed since screening assessment. If eligibility criteria are not met at this timepoint, subject may not be treated.  
6 May be performed after study consent is signed but prior to treatment initiation (baseline)
7 Required in women of childbearing potential (see Appendix B for definition).  
8 Performed within 3 days prior to start of study therapy. Must be repeated on C1D1 (pre-treatment) if more than 72 hours have passed since screening assessment and actual treatment initiation.  
9 Please see section 2.2 for tissue requirements 10 As indicated in section 12.3, all subjects will be offered the opportunity to complete an NIH advance directives form. This should be done preferably at baseline but can be done at any time during the study as long as the capacity to do so is retained. The completion of the form is strongly recommended but is not required.  
11 MRIs are only performed for clinical reasons on this study. Under those circumstances, gadolinium is used only if clinically indicated.  
12 Performed only if patient removed from study therapy for reason other than progressive disease on pembrolizumab 13 Single 12-lead ECG will be recorded at screening, then pre- and end of LMB-100 infusion for first cycle and at the withdrawal and follow-up visit. Pre-infusion at all other study drug administrations. Additional unscheduled ECG assessments should be performed if cardiovascular symptoms or abnormalities occur.  
14 Day 15 laboratory assessments may be performed outside of NIH. History may be performed remotely, and physical exam is only required in subjects seen at NIH.  
15 Per section 3.1.2, some subjects may be eligible for up to an additional 17 cycles of therapy, called the second course. Surveillance during the second course will be the same as during the initial course unless otherwise indicated. See Appendix D for further details on second course imaging.  
16 Follow up visit will occur within +/- 1 week of indicated time. The assessments listed refer to those that will be performed if the patient is seen in clinic **(first course and second course)**. If the patient is unable to return to the clinic for the follow up visit, adverse event and ECOG assessments will be performed by telephone or email, we will request that required labs, scans and ECG evaluations be performed locally and provided to us, and if the patient has visited a local oncologist in this timeframe, the progress notes will also be requested.  
17 Scans performed only in patients who have not had progressive disease on pembrolizumab. Scans will continue every 6 weeks until disease progression or start of a new anti-cancer treatment. After disease progression on pembrolizumab or in those subjects who were removed from study therapy for reasons other than disease progression, subjects will be followed every 12 weeks by telephone/email for assessment of survival status, adverse events and initiation of new anti-cancer therapy
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3.5 criteria for removal from

Prior to removal from study, effort must be made to have all subjects complete a safety visit approximately 90 days following the last dose of study therapy. 3.5.1 Criteria for removal from protocol therapy Completion of protocol therapy  
o Note: The number of treatments is calculated starting with the first dose of pembrolizumab. Participants who stop pembrolizumab after receiving 35 doses may be eligible for retreatment if they progress after stopping study treatment provided they meet the requirements detailed in Section 3.1.2. Participants may be retreated in the Second Course Phase (Retreatment) for up to an additional 17 cycles (approximately 1 year).
Progressive disease on pembrolizumab Noncompliance with study treatment or procedure requirements Requirement for use of prohibited medications/vaccines (see 4.2) Recurrent Grade 2 pneumonitis Participant (or LAR if one was designated when participant become incapacitated during study) requests to be withdrawn from active therapy Unacceptable Toxicity as defined in section 3.3 Investigator discretion Positive pregnancy test 3.5.2 Off-Study Criteria Screen failure Investigator decision to end the study Participant requests to be withdrawn from study Study drug no longer available  
Lost to follow up
Death
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3.6 clinical criteria for early

This is a sequential study of LMB-100 followed by Pembrolizumab. The single agent maximum tolerated dose of both agents has been previously established in phase I studies. Although the half-life of LMB-100 is less than 1 hour and we do not expect any LMB-100 present in the blood when pembrolizumab is initiated (at least 16 days from last dose of LMB-100), we have put the following safety parameters in place in case pre-administration of LMB-100 increases toxicity of pembrolizumab. If any of the following occur, enrollment of new patients will be halted until the association with treatment is fully established and mitigation strategies are put in place.  
1. Any grade 5 toxicity related to treatment.  
2. Any new grade 3 or 4 toxicity not previously associated with pembrolizumab.
3. Increased incidence of adverse events known to be associated with pembrolizumab Mitigation strategies will be submitted as amendments to the FDA and IRB. Should the regulatory bodies approve the amendment, the study will resume enrollment.
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4 concomitant medications/measures

All concomitant medications received within 28 days before the first dose of trial treatment and 90 days after the last dose of trial treatment (first course and if applicable, second course) should be recorded. Concomitant medications administered after 90 days after the last dose of trial treatment (first course and if applicable, second course) should be recorded for SAEs and ECIs as defined in Section 7.2.
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4.1 permitted therapy

All treatments that the investigator considers necessary for a participant's welfare may be administered at the discretion of the investigator in keeping with the community standards of medical care. All concomitant medication will be recorded on the case report form (CRF) including all prescription, over-the-counter (OTC), herbal supplements, and IV medications and fluids. If changes occur during the trial period, documentation of drug dosage, frequency, route, and date may also be included on the CRF. Supportive care may be administered according to NIH CC Pharmacy Guidelines unless otherwise specified in section 3.3.
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4.2 prohibited therapy

Patients should be treated for all concomitant conditions and adverse events according to accepted standards of medical care at the discretion of the investigator. The following treatments are not permitted while patient is receiving study therapy:
Antineoplastic systemic chemotherapy or biological therapy  
Immunotherapy not specified in this protocol Chemotherapy not specified in this protocol Investigational agents other than the study agents Radiotherapy. Note: Radiation therapy to a symptomatic solitary lesion or to the brain may be allowed at the investigator's discretion.  
Live vaccines. Examples of live vaccines include, but are not limited to, the following:
measles, mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and typhoid vaccine. Seasonal influenza vaccines for injection are generally killed virus vaccines and are allowed; however, intranasal influenza vaccines (e.g., FluMist®) are live attenuated vaccines and are not allowed.
Systemic glucocorticoids for any purpose other than to modulate symptoms from an event of clinical interest of suspected immunologic etiology. The use of physiologic doses of corticosteroids may be considered per investigator discretion.  
Participants who, in the assessment by the investigator, require the use of any of the aforementioned treatments for clinical management should be removed from the study. All treatments that the Investigator considers necessary for a participant's welfare may be administered at the discretion of the Investigator in keeping with the community standards of medical care. Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed during the ongoing study. If there is a clinical indication for any medication or vaccination specifically prohibited during the study, discontinuation from study therapy is required. The final decision on any supportive therapy or vaccination rests with the investigator and/or the participant's primary physician. There are no prohibited therapies during the Post-Treatment Follow-up Phase.
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5 biospecimen collection 5.1 correlative

All blood samples for PK assessment will be collected from an IV line different to that receiving the infusion to measure free and total concentrations for LMB-100 for all patients. The date and time of each sample collection will be recorded. If multiple samples are drawn at a given time point, the PK sample should take precedence.  
Free and total plasma concentrations of LMB-100 will be measured using validated ligandbinding assays.  
5.1.1.1 Sample collection:
Blood for PK samples should be drawn from the opposite extremity as the one used for drug delivery. If feasible, a peripheral line used for this purpose should remain in place until the last scheduled collection for a given day. Blood will be collected in 2 mL K2EDTA tubes (purple top)
at the times defined in section 5.2. Samples should be inverted 8 to 10 times after collection. Store on wet ice or at 4°C. Processing within 60 minutes of blood collection is highly preferred.  
5.1.1.2 Sample processing Samples will be processed in the Clinical Pharmacology Program. Please e-mail NCIBloodcore@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964. For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact NCIBloodcore@mail.nih.gov. Upon arrival in the CPP the following procedures should be followed:
1. Store on wet ice until centrifugation. 2. Centrifuge 1500xg for 10 minutes at 4°C within 60 minutes of blood collection. 3. Transfer plasma specimen to 2mL cryovials and store at -70°C.  
The analyses will be performed retrospectively in batched samples or at the end of the trial.  
5.1.1.3 Sample Shipping Samples will be shipped by the CPP on dry ice to the below address for analysis.  
Leidos Biomedical, Inc. Attention: Ms. Yanyu Wang, Dr. Jon Inglefield Building 469, Room 120 Miller Drive Frederick, MD 21702 Phone: 301-846-6905/301-846-6865 5.1.1.4 Sample storage Samples will be stored in the CPP until shipment to the Leidos Biomedical Inc. Lab in Frederick. 5.1.2 Assessment of anti-drug antibodies (ADAs)
5.1.2.1 Sample Collection Samples will be per the schedule in section 5.2 Draw 2mL into K2EDTA tube (purple top). Samples should be inverted 8 to 10 times after collection. Store on wet ice or at 4°C. Processing within 60 minutes of blood collection is highly preferred.  
5.1.2.2 Sample Processing Samples will be processed in the Clinical Pharmacology Program. Please e-mail NCIBloodcore@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964.  
For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact NCIBloodcore@mail.nih.gov. Upon arrival in the CPP, each sample should be processed in the following manner:
1. Store on wet ice until centrifugation. 2. Centrifuge 1500xg for 10 minutes at 4°C within 60 minutes of blood collection. 3. Transfer plasma specimen to 2mL cryovials and store at -70°C.  
Autoantibody levels will be retrospectively assessed.  
5.1.2.3 Sample Shipping Samples will be shipped by the CPP on dry ice to the below address for analysis.  
Leidos Biomedical, Inc. Attention: Ms. Yanyu Wang, Dr. Jon Inglefield Building 469, Room 120 Miller Drive Frederick, MD 21702 Phone: 301-846-6905/301-846-6865 5.1.2.4 Sample Storage Samples will be stored in the CPP until shipment to the Leidos Biomedical Inc. Lab in Frederick. 5.1.3 Retrospective Analysis of Mesothelin and PD-L1 Expression in tumor tissue IHC analysis will be performed by the Laboratory of Pathology at NCI to determine mesothelin and anti PL-L1 expression within the tumor at any time after study enrollment. Leftover tissue from archival specimens or tumor biopsies obtained at screening or from optional collections at baseline, C3D1 and C5D1 may be used for this purpose. Specimens will be used to correlate treatment response with mesothelin expression and with anti PD-L1 in exploratory analyses. Additionally, this tissue will undergo IHC staining to analyze CD4 and CD8 T-Cell subsets.
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5.1.3.1 specimen collection

Collection of optional tumor biopsies should be guided by ultrasound, CT scan, or other method according to the location of the selected lesion using a ≤ 18-gauge needle to provide cores ideally of at least 20 mm in length or equivalent size. At least 2, ideally 4 core biopsies will be obtained at each time point (baseline and after cycle 1). Fine needle aspiration and biopsy of bone lesions are not acceptable. All biopsies collected under this protocol will undergo review in the NCI Laboratory of Pathology. 5.1.4 Mesothelin and Megakaryocyte Potentiating Factor (MPF) Serum Samples The levels of serum mesothelin as well as megakaryocyte potentiating factor, which is released into serum from the processing of mesothelin precursor protein will be assessed in order to determine correlation with therapeutic response.
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5.1.4.1 sample collection

Samples will be obtained prior to the first LMB-100 dose in cycle 1 and at the end of treatment All blood samples will be taken by either direct venipuncture or an indwelling venous access. At each sample collection time, blood (2mL) will be drawn into a 3.5-mL serum separator tube labeled as follows:
- Subject ID Number - Study Number - Time and date of collection 5.1.4.2 Sample Processing Please e-mail NCIBloodcore@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964. For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact NCIBloodcore@mail.nih.gov. Upon arrival in the CPP, each sample should be processed in the following manner: Allow blood to clot for 10 minutes and centrifuge to separate the serum within 30 minutes of collection. If unable to process within 30 minutes, then whole blood tubes may be stored upright in refrigerator (4-8C) for up to 48 hours prior to processing. Processing of samples within 30 minutes is strongly preferred. Stability studies will establish if degradation of soluble mesothelin in whole blood during 0.5 to 48 hours is significant and therefore if the data from these samples should be included in the analysis. Transfer the serum into two pre-labeled cryotubes and immediately freeze by placing on dry ice.  
Transfer frozen serum samples into a - 80C freezer for storage.
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5.1.4.3 sample storage

All serum samples will be stored by Dr. Figg's Clinical Pharmacology Program. 5.1.5 Gene expression-based characterization of the immune landscape before and after treatment with LMB-100 and pembrolizumab As referenced above, optional tumor biopsies will be performed in consenting patients when deemed feasible at the following time points: before initiation of therapy (archival tissue may also be used), at the end of cycle 2 and at the end of cycle 4. We will evaluate tumor biopsies before and after treatment with LMB-100 and after treatment with pembrolizumab using a hybridization-based digital gene expression platform nCounter (NanoString Technologies). This platform allows for unbiased multiplexed quantification of RNA transcripts achieving sensitivity comparable to quantitative reverse-transcription polymerase chain reaction (Q-RT-PCR), without any enzymatic reaction involved in the process. We have expertise in the use of this technology for the characterization of purified cell subsets and for the study of the changes that occur in human tumors, as a consequence of a given treatment, using tumor core biopsy tissues. This analysis can be performed on flash frozen biopsies without any further isolation or enrichment of specific cell types. For the present study, we will screen pre- and post-treatment samples for the expression of markers of immune cell subsets (CD3, CD8, CD4, etc.), local production of cytokines
(interferon-gamma, tumor necrosis factor-alpha, etc.) and chemokines (CXCL13, CCL5, etc.), adhesion molecules and others. The purpose of this study is to characterize the molecular changes that occur within the tumors following treatment with LMB-100 and pembrolizumab. The ultimate goal is to gain a better understanding of the mechanism of action of this treatment, and to identify molecular correlates of clinical outcomes such as objective responses and/or improved survival. In order to achieve these goals, flash frozen samples will be subjected to total RNA isolation followed by hybridization with capture and detection probes specific for 620 transcripts, including genes involved in the regulation of the immune function and markers expressed by tumor cells and tumor stroma. To cover those target transcripts, a combination of a commercially available pre-designed probe set (GX Human Immunology v2, NanoString Technologies) will be used in combination with a custom-designed code set of thirty additional targets (Panel Plus, NanoString Technologies). Hybridization complexes will be quantified using a NanoString nCounter Analysis System, at the Genomics Core Facility of the Center for Cancer Research, NCI. Results obtained by this approach will be correlated with data obtained from immunohistochemistry of tumor biopsies as well as with data from analysis of peripheral blood populations, for a comprehensive study of the mechanism of action of LMB-100 in mesothelioma patients. Samples will be stored in the Laboratory of Dr. Raffit Hassan, Building 10, Room 3B51.
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5.1.6 tumor microenvironment studies using

As referenced above, optional tumor biopsy will be performed in consenting patients when deemed feasible at the following time points: before initiation of therapy (archival tissue may also be used) and after two cycles of therapy. Portions of the tumor tissue collected at both timepoints and stored in the Hassan lab (see section 5.1.5) will be provided to the CAT-I, the laboratory of Dr. Ronald Germain. The tissue will be analyzed for cancer associated immune biomarker alterations including the immune cell and tumor cell co-localization with confocal microscopy and histo-cytometry. The CAT-I lab will return confocal images and quantitative analyses of these images in figure format to the Hassan lab. Samples will be coded in the laboratory of Dr. Raffit Hassan and sent to CAT-I for imaging studies using multiplex staining technologies. The code key will be retained by individuals in the Hassan laboratory and will not be provided to members of the CAT-I lab.
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5.1.7 retrospective analysis of msi

Retrospective DNA analysis for microsatellite instability (MSI) will be performed in subjects that demonstrate either partial or complete response. The analysis will be performed by the Laboratory of Pathology at NCI to determine MSI status within the tumor once the best overall response for a participant has been determined. Leftover tissue from archival specimens or tumor biopsies obtained at screening or from optional collections referenced above may be used for this purpose.
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5.1.8 mechanism of capillary leak

We hypothesize that treatment with LMB-100 damages proximal tubule cells of the kidney which then lose their ability to efficiently recycle albumin. This results in a fall in serum albumin and edema. To test this hypothesis, we will document proximal tubule damage by measuring KIM-1 in urine and document albumin loss by measuring the albumin to creatinine ratio in urine. KIM-1 levels will also be measured in blood.  
5.1.8.1 Sample Collection Urine will be collected at the timepoints indicated in section 5.2 No additional samples will be collected for measurement in blood. Leftover frozen blood samples collected for other research purposes will be used.
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5.1.8.2 sample processing

Please e-mail NCIBloodcore@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964.
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version date 02/16/21

For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact NCIBloodcore@mail.nih.gov. Urine samples must be frozen within 2 - 4 hours of collection.  
5.1.8.3 Sample Analysis Samples will be batched and shipped per instructions provided by the vendor and study team to Pacific Bio, a commercial laboratory, for analysis..  
| 5.2                                                                 | SAMPLE COLLECTION SCHEDULE                                                                                                                                          | Serum              |       |          |
|---------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------|-------|----------|
| mesothelin  and MPF (5.1.4)                                         |                                                                                                                                                                     |                    |       |          |
| PK                                                                  | Tumor Samplea                                                                                                                                                       |                    |       |          |
| (5.1.2) ADA                                                         | CLSb                                                                                                                                                                |                    |       |          |
| (5.1.1)                                                             | (5.1.3,5.1.5,5.1.6,5.1.7)                                                                                                                                           | (5.1.8)            |       |          |
| Cycle                                                               | Day                                                                                                                                                                 | 2 mL               |       |          |
| K2EDTA  tube                                                        | 2 mL                                                                                                                                                                | 2 mL blood in      |       |          |
| K2EDTA                                                              | NA                                                                                                                                                                  | 3.5 mL SST         |       |          |
| tube                                                                | tube                                                                                                                                                                | ≥ 0.5 mL of  urine |       |          |
| Screening                                                           | a                                                                                                                                                                   |                    |       |          |
| Screening                                                           | period ± 3                                                                                                                                                          | X                  |       |          |
| days                                                                | Pre-dose,  EOI, 1, 2,  3, 4, and 6  hours after  start of  infusion                                                                                                 |                    |       |          |
| 1                                                                   | Pre-dose                                                                                                                                                            | X c                | X     | Pre-dose |
| 1                                                                   | 3                                                                                                                                                                   | X                  |       |          |
| 5                                                                   | Pre-dose  and EOI                                                                                                                                                   |                    |       |          |
| 6                                                                   | X                                                                                                                                                                   |                    |       |          |
| 8                                                                   | X                                                                                                                                                                   |                    |       |          |
| Pre-dose,  EOI, 1, 2,  3, 4, and 6  hours after  start of  infusion |                                                                                                                                                                     |                    |       |          |
| 1                                                                   | Pre-dose                                                                                                                                                            |                    |       |          |
| 2                                                                   | 5                                                                                                                                                                   | Pre-dose  and EOI  |       |          |
| 3                                                                   | 1                                                                                                                                                                   | X                  | X c c |          |
| 5                                                                   | 1                                                                                                                                                                   | X                  |       |          |
| End                                                                 | of                                                                                                                                                                  |                    |       |          |
| Treatmentd                                                          | X                                                                                                                                                                   |                    |       |          |
| a.                                                                  | Archival or if not available, a fresh Biopsy or Tumor Effusion (mandatory). Even if archival  sample is available, patient may be asked for optional biopsy sample. |                    |       |          |  
a. Archival or if not available, a fresh Biopsy or Tumor Effusion (mandatory). Even if archival sample is available, patient may be asked for optional biopsy sample.  
b. Except for day 1, samples may be collected ± 1 day from indicated time. Day 1 samples may be collected within 1 day prior to initial dosing c. Optional biopsies - collected at baseline (biopsy if collected at screening can be used as baseline sample) and on day 1 ± 3 days of cycles 3 and 5.  
Version Date: *02/16/21*  
d. Refers to the end of the first course. No additional research samples will be collected during the second course.
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5.3 sample storage tracking and

Samples will be ordered in CRIS and tracked through a Clinical Trial Data Management system. Should a CRIS screen not be available, the CRIS downtime procedures will be followed. Samples will not be sent outside NIH without appropriate approvals and/or agreements, if required. 5.3.1 Clinical Pharmacology Program All samples sent to the Clinical Pharmacology Program (CPP) will be barcoded, with data entered and stored in Labmatrix utilized by the CPP. This is a secure program, with access to Labmatrix limited to defined Figg lab personnel, who are issued individual user accounts. Installation of Labmatrix is limited to computers specified by Dr. Figg. These computers all have a password restricted login screen. Labmatrix creates a unique barcode ID for every sample and sample box, which cannot be traced back to patients without Labmatrix access. The data recorded for each sample includes the patient ID, name, trial name/protocol number, time drawn, cycle time point, dose, material type, as well as box and freezer location. Patient demographics associated with the clinical center patient number are provided in the system. For each sample, there are notes associated with the processing method (delay in sample processing, storage conditions on the ward, etc.).  
Barcoded samples are stored in barcoded boxes in a locked freezer at either -20 or -80C
according to stability requirements. These freezers are located onsite in the BPC and offsite at NCI Frederick Central Repository Services in Frederick, MD. Visitors to the laboratory are required to be accompanied by laboratory staff at all times. Access to stored clinical samples is restricted. Samples will be stored until requested by a researcher named on the protocol. All requests are monitored and tracked in Labmatrix. All researchers are required to sign a form stating that the samples are only to be used for research purposes associated with this trial (as per the IRB approved protocol) and that any unused samples must be returned to the BPC. It is the responsibility of the NCI Principal Investigator to ensure that the samples requested are being used in a manner consistent with IRB approval.  
Following completion of this study, samples will remain in storage as detailed above. Access to these samples will only be granted following OHSRP/IRB approval of an additional protocol, granting the rights to use the material or if the use is not considered to be human subjects research.
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5.3.2 leidos biomedical inc. lab

Blood and tissue collected during the course of this study will follow storage, handling and labeling procedures to ensure that security, confidentiality and sample integrity are maintained. All samples (blood or tissue) are tracked by distinct identification labels that include a unique patient identifier and date of specimen collection. Thus, samples will be coded, with access to the code key linking to personal data restricted to the study investigators. All cryopreserved samples are tracked for freezer location and storage criteria. All Samples are stored in a locked freezer at -70C according to stability requirements. These freezers are located offsite at NCI-Frederick, at the Leidos Biomedical, Inc. Lab in Frederick, MD. Samples will be stored until requested by a researcher named on the protocol. All use and requests for use will be recorded by the Leidos Biomedical, Inc. Lab. Any unused samples must be returned. Some samples as indicated below may be stored in monitored freezers/refrigerators in the investigator's laboratory at specified temperatures with alarm systems in place. At the completion of this protocol, samples will remain in storage as detailed above. If additional studies are to be performed on any samples retaining patient identifiers, obtained during the conduct of this trial, access to these samples will only be granted following IRB approval of an additional protocol, granting the rights to use the material. If specimens are to be discarded at any point, they will be disposed of in accordance with the environmental protection laws, regulations and guidelines of the Federal Government and the State of Maryland. If, at any time, a patient withdraws from the study and does not wish for their existing samples to be utilized, the individual must provide a written request. Following receipt of this request, the samples will be destroyed (or returned to the patient, if so requested).
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5.3.3 nci laboratory of pathology

Tissues designated for clinical diagnostics are transported to the Laboratory of Pathology (LP) where they are examined grossly and relevant portions are fixed, embedded in paraffin and sectioned and stained for diagnostic interpretation. Unutilized excess tissue that is not placed in paraffin blocks is stored in formalin for up to three months, in accordance with College of American Pathologists/Joint Commission on Accreditation of Healthcare Organizations (CAP/JCAHO) guidelines, and then discarded. Following completion of the diagnostic workup, the slides and tissue blocks are stored indefinitely in the LP's clinical archives. All specimens are catalogued and retrieved utilizing the clinical laboratory information systems, in accordance with CAP/JCAHO regulations. The use of any stored specimens for research purposes is only allowed when the appropriate IRB approval has been obtained. In some cases, this approval has been obtained via the original protocol on which the patient was enrolled.
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5.3.4 laboratory of dr. raffit

This study will follow storage, handling and labeling procedures to ensure that security, confidentiality and sample integrity are maintained. All samples (blood or tissue) are tracked by distinct identification labels generated by Labmatrix that include a unique patient identifier and date of specimen collection. Thus, samples will be coded, with access to the code key linking to personal data restricted to the study investigators. Depending on specimen type, samples are stored in liquid nitrogen, in monitored freezers/refrigerators at either -20 or -80C according to stability requirements or in a slide cabinet in the research Laboratory of Dr. Raffit Hassan (Building 10, Room 3B51)
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5.3.5 cat-i laboratory

The CAT-I laboratory (CAT-I) will obtain coded samples from the Hassan laboratory. Upon acquisition, members of the CAT-I laboratory will enter these samples into CEREBRO, an advanced sample labeling system that tracks each sample through every step of the workflow. To meet requirements for availability of primary data and for quality assurance checks, CAT-I will maintain a detailed inventory of the type (slide, paraffin block, tissue, frozen OCT block) and location of each sample in the laboratory. More specifically, paraffin blocks and accompanying slides will be maintained at room temperature in the CAT- I laboratory. Tissues provided by the Hassan laboratory will be fixed, frozen, and stored in the CAT-I's -80°C freezer. The CAT-I laboratory will be locked when CAT-I lab members are not present. Unprocessed samples will be held by the CAT-I or returned to the Hassan laboratory upon their request. Finally, CAT-I will comply with requirements for annual Biospecimen Reporting at the NIH.
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5.3.6 protocol completion/sample destruction

All specimens obtained in the protocol are used as defined in the protocol. Any specimens remaining at the completion of the protocol will be stored in the conditions described above. The study will remain open as long as sample or data analysis continues. Samples from consenting subjects will be stored until they are no longer of scientific value or until a subject withdraws consent for their continued use, at which time they will be destroyed. Once primary research objectives for the protocol are achieved, intramural researchers can request access to remaining samples, provided they have an IRB-approved protocol and patient consent or an exemption from IRB review. The PI will record any loss or unanticipated destruction of samples as a deviation. Reports will be made per the requirements of section 7.2.
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6 data collection and evaluation

The PI will be responsible for overseeing entry of data into an in-house password protected electronic system (C3D) and ensuring data accuracy, consistency and timeliness. The principal investigator, associate investigators/research nurses and/or a contracted data manager will assist with the data management efforts. All data obtained during the conduct of the protocol will be kept in secure network drives or in approved alternative sites that comply with NIH security standards. Primary and final analyzed data will have identifiers so that research data can be attributed to an individual human subject participant. All adverse events, including clinically significant abnormal findings on laboratory evaluations, regardless of severity, will be followed until return to baseline or stabilization of event. Document AEs from the first study intervention, study day 1, through 90 days after removal from study treatment (first course and if applicable, second course) or until off-study, whichever comes first. Adverse events occurring more than 90 days after the last dose of study therapy (first course and if applicable, second course) are required to be recorded only if they are considered to be serious and related to the investigational agent/intervention. An abnormal laboratory value will be recorded in the database as an AE **only** if the laboratory abnormality is characterized by any of the following:
Results in discontinuation from the study  
Is associated with clinical signs or symptoms Requires treatment or any other therapeutic intervention Is associated with death or another serious adverse event, including hospitalization. Is judged by the Investigator to be of significant clinical impact If any abnormal laboratory result is considered clinically significant, the investigator will provide details about the action taken with respect to the test drug and about the patient's outcome.
End of study procedures: Data will be stored according to HHS, FDA regulations, and NIH Intramural Records Retention Schedule as applicable. Loss or destruction of data: Should we become aware that a major breach in our plan to protect subject confidentiality and trial data has occurred, will be reported expeditiously per section 7.2.1.
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6.2 data sharing plans

6.2.1 Human Data Sharing Plan What data will be shared? I will share human data generated in this research for future research as follows:
Coded, linked data in an NIH-funded or approved public repository.  
Coded, linked data in BTRIS (automatic for activities in the Clinical Center)
Identified or coded, linked data with approved outside collaborators under appropriate agreements.
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how and where will the

Data will be shared through: An NIH-funded or approved public repository (clinicaltrials.gov).  
BTRIS (automatic for activities in the Clinical Center)  
Approved outside collaborators under appropriate individual agreements. Publication and/or public presentations.
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when will the data be

Before publication.  
At the time of publication or shortly thereafter.  
6.2.2 Genomic Data Sharing Plan No large scale genomic data will be generated on this study; therefore, the NIH GDS policy does not apply.
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6.3 response criteria

For the purposes of this study, patients should be re-evaluated for response every 2 cycles (every 6 weeks if scanning continues beyond end of treatment). In addition to a baseline scan, confirmatory scans should also be obtained no less than 4 weeks following initial documentation of objective response. Refer to Appendix C for confirmatory scan and continued treatment instructions. Response and progression will be assessed by the investigator on the basis of physical examinations, computed tomography (CT) or Magnetic Resonance (MR) scans, and potentially other modalities according to standard of care. For peritoneal mesothelioma, the international criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1)[36] will be used. Changes in the largest diameter (unidimensional measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph nodes are used in the RECIST criteria.  
For pleural mesothelioma, modified RECIST for MPM (malignant pleural mesothelioma)[37]
should be used as described in section 6.3.2. iRECIST described in section 6.3.3, based on RECIST 1.1, but adapted to account for the unique tumor response seen with immunotherapeutic drugs, will also be utilized for pleural and peritoneal mesothelioma as follows.  
When the Investigator identifies radiographic progression while on pembrolizumab per RECIST 1.1 or mRECIST, efforts should be made to verify radiologic PD. Treatment should continue until PD has been verified. Regardless of whether PD is verified, if the Investigator considers the participant has progressed, but elects to implement iRECIST, the Investigator will assess for confirmation of progression by iRECIST at subsequent time points. When clinically stable, participants should not be discontinued until progression is confirmed by the Investigator, working with local radiology, according to the rules below. This allowance to continue treatment despite initial radiologic PD takes into account the observation that some participants can have a transient tumor flare in the first few months after the start of immunotherapy, and then experience subsequent disease response. 6.3.1 Peritoneal Mesothelioma 6.3.1.1 Disease Parameters Measurable disease: Measurable lesions are defined as those that can be accurately measured in at least one dimension (longest diameter to be recorded) as:
By chest x-ray: >20 mm;  
By CT scan:
o Scan slice thickness 5 mm or under: >10 mm  
o Scan slice thickness >5 mm: double the slice thickness
With calipers on clinical exam: >10 mm.  
All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters). Malignant lymph nodes. To be considered pathologically enlarged and measurable, a lymph node must be >15 mm in short axis when assessed by CT scan (CT scan slice thickness recommended to be no greater than 5 mm). At baseline and in follow-up, only the short axis will be measured and followed. Non-measurable disease. All other lesions (or sites of disease), including small lesions (longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), are considered non-measurable disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, and abdominal masses (not followed by CT or MRI), are considered as non-measurable. Note: Cystic lesions that meet the criteria for radiographically defined simple cysts should not be considered as malignant lesions (neither measurable nor non-measurable) since they are, by definition, simple cysts. 'Cystic lesions' thought to represent cystic metastases can be considered as measurable lesions, if they meet the definition of measurability described above. However, if non-cystic lesions are present in the same patient, these are preferred for selection as target lesions. Target lesions. All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total, representative of all involved organs, should be identified as **target lesions** and recorded and measured at baseline. Target lesions should be selected on the basis of their size (lesions with the longest diameter), be representative of all involved organs, but in addition should be those that lend themselves to reproducible repeated measurements. It may be the case that, on occasion, the largest lesion does not lend itself to reproducible measurement in which circumstance the next largest lesion which can be measured reproducibly should be selected. A sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target lesions will be calculated and reported as the baseline sum diameters. If lymph nodes are to be included in the sum, then only the short axis is added into the sum. The baseline sum diameters will be used as reference to further characterize any objective tumor regression in the measurable dimension of the disease. Non-target lesions. All other lesions (or sites of disease) including any measurable lesions over and above the 5 target lesions should be identified as **non-target lesions** and should also be recorded at baseline. Measurements of these lesions are not required, but the presence, absence, or in rare cases unequivocal progression of each should be noted throughout follow-up.  
6.3.1.2 Methods for Evaluation of Measurable Disease All measurements should be taken and recorded in metric notation using a ruler or calipers. All baseline evaluations should be performed as closely as possible to the beginning of treatment and never more than 4 weeks before the beginning of the treatment.  
The same method of assessment and the same technique should be used to characterize each identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be imaged but are assessable by clinical exam. Clinical lesions: Clinical lesions will only be considered measurable when they are superficial
(e.g., skin nodules and palpable lymph nodes) and 10 mm diameter as assessed using calipers
(e.g., skin nodules). In the case of skin lesions, documentation by color photography, including a ruler to estimate the size of the lesion, is recommended. Chest x-ray: Lesions on chest x-ray are acceptable as measurable lesions when they are clearly defined and surrounded by aerated lung. However, CT is preferable. Conventional CT and MRI: This guideline has defined measurability of lesions on CT scan based on the assumption that CT slice thickness is 5 mm or less. If CT scans have slice thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. MRI is also acceptable in certain situations (e.g. for body scans). Use of MRI remains a complex issue. MRI has excellent contrast, spatial, and temporal resolution; however, there are many image acquisition variables involved in MRI, which greatly impact image quality, lesion conspicuity, and measurement. Furthermore, the availability of MRI is variable globally. As with CT, if an MRI is performed, the technical specifications of the scanning sequences used should be optimized for the evaluation of the type and site of disease. Furthermore, as with CT, the modality used at follow-up should be the same as was used at baseline and the lesions should be measured/assessed on the same pulse sequence. It is beyond the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body parts, and diseases. Ideally, the same type of scanner should be used and the image acquisition protocol should be followed as closely as possible to prior scans. Body scans should be performed with breath-hold scanning techniques, if possible. PET-CT: At present, the low dose or attenuation correction CT portion of a combined PET-CT is not always of optimal diagnostic CT quality for use with RECIST measurements. However, if the site can document that the CT performed as part of a PET-CT is of identical diagnostic quality to a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be used for RECIST measurements and can be used interchangeably with conventional CT in accurately measuring cancer lesions over time. Note, however, that the PET portion of the CT introduces additional data, which may bias an investigator if it is not routinely or serially performed. Ultrasound: Ultrasound is not useful in assessment of lesion size and should not be used as a method of measurement. Ultrasound examinations cannot be reproduced in their entirety for independent review at a later date and, because they are operator dependent, it cannot be guaranteed that the same technique and measurements will be taken from one assessment to the next. If new lesions are identified by ultrasound in the course of the study, confirmation by CT or MRI is advised. If there is concern about radiation exposure at CT, MRI may be used instead of CT in selected instances. Endoscopy, Laparoscopy: The utilization of these techniques for objective tumor evaluation is not advised. However, such techniques may be useful to confirm complete pathological response when biopsies are obtained or to determine relapse in trials where recurrence following complete response (CR) or surgical resection is an endpoint. Tumor markers: Tumor markers alone cannot be used to assess response. If markers are initially above the upper normal limit, they must normalize for a patient to be considered in complete clinical response. Specific guidelines for both CA-125 response (in recurrent ovarian cancer) and PSA response (in recurrent prostate cancer) have been published.[38-40] In addition, the Gynecologic Cancer Intergroup has developed CA-125 progression criteria which are to be integrated with objective tumor assessment for use in first-line trials in ovarian cancer.[41]
Cytology, Histology: These techniques can be used to differentiate between partial responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as germ cell tumors, where known residual benign tumors can remain). The cytological confirmation of the neoplastic origin of any effusion that appears or worsens during treatment when the measurable tumor has met criteria for response or stable disease is mandatory to differentiate between response or stable disease (an effusion may be a side effect of the treatment) and progressive disease. FDG-PET: While FDG-PET response assessments need additional study, it is sometimes reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in assessment of progression (particularly possible 'new' disease). New lesions on the basis of FDGPET imaging can be identified according to the following algorithm:
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD based on a new lesion.  
b. No FDG-PET at baseline and a positive FDG-PET at follow-up: If the positive FDGPET at follow-up corresponds to a new site of disease confirmed by CT, this is PD. If the positive FDG-PET at follow-up is not confirmed as a new site of disease on CT,
additional follow-up CT scans are needed to determine if there is truly progression occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-PET scan). If the positive FDG-PET at follow-up corresponds to a pre-existing site of disease on CT that is not progressing on the basis of the anatomic images, this is not PD.  
c. FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy in cases where a residual radiographic abnormality is thought to represent fibrosis or scarring. The use of FDG-PET in this circumstance should be prospectively described in the protocol and supported by disease-specific medical literature for the indication. However, it must be acknowledged that both approaches may lead to false positive CR due to limitations of FDG-PET and biopsy resolution/sensitivity.
Note: A 'positive' FDG-PET scan lesion means one which is FDG avid with an uptake greater than twice that of the surrounding tissue on the attenuation corrected image.  
6.3.1.3 RECIST version 1.1 Response Criteria 6.3.1.3.1 Evaluation of Target Lesions Complete Response (CR): Disappearance of all target lesions. Any pathological lymph nodes (whether target or non-target) must have reduction in short axis to <10 mm. Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, taking as reference the baseline sum of diameters. Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study). In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. (Note: the appearance of one or more new lesions is also considered progressions). Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum of diameters while on study. 6.3.1.3.2 Evaluation of Non-Target Lesions Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor marker level. All lymph nodes must be non-pathological in size (<10 mm short axis). Note: If tumor markers are initially above the upper normal limit, they must normalize for a patient to be considered in complete clinical response. Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor marker level above the normal limits. Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions. *Unequivocal progression* should not normally trump target lesion status. It must be representative of overall disease status change, not a single lesion increase. Although a clear progression of "non-target" lesions only is exceptional, the opinion of the treating physician should prevail in such circumstances, and the progression status should be confirmed at a later time by the review panel (or Principal Investigator).
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6.3.1.3.3 evaluation of best overall

The best overall response is the best response recorded from the start of the treatment until disease progression/recurrence (taking as reference for progressive disease the smallest measurements recorded since the treatment started). The patient's best response assignment will depend on the achievement of both measurement and confirmation criteria.  
| Target    | Non-Target                                                                         | New     | Overall   | Best Overall Response when                        |
|-----------|------------------------------------------------------------------------------------|---------|-----------|---------------------------------------------------|
| Lesions   | Lesions                                                                            | Lesions | Response  | Confirmation is Required*                         |
| CR        | CR                                                                                 | No      | CR        | >4 wks. Confirmation**                            |
| CR        | NonCR/Non-PD                                                                                    | No      | PR        |                                                   |
| CR        | Not                                                                                | No      | PR        |                                                   |
| evaluated | >4 wks. Confirmation**                                                             |         |           |                                                   |
| No        | PR                                                                                 |         |           |                                                   |
| PR        | NonCR/NonPD/not  evaluated                                                                                    |         |           |                                                   |
| SD        | NonCR/NonPD/not  evaluated                                                                                    | No      | SD        | Documented at least once >4  wks. from baseline** |
| PD        | Any                                                                                | Yes     | or        | PD                                                |
| No        |                                                                                    |         |           |                                                   |
| Any       | PD***                                                                              | Yes     | or        | PD                                                |
| No        | no prior SD, PR or CR                                                              |         |           |                                                   |
| Any       | Any                                                                                | Yes     | PD        |                                                   |
| *         | See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. |         |           |                                                   |  
| **    | Only for non-randomized trials with response as primary endpoint.                                                                                                                                                                                                                                                            |
|-------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| ***   | In exceptional circumstances, unequivocal progression in non-target lesions may be accepted as  disease progression.                                                                                                                                                                                                         |
| Note: | Patients with a global deterioration of health status requiring discontinuation of treatment without  objective evidence of disease progression at that time should be reported as "symptomatic  deterioration." Every effort should be made to document the objective progression even after  discontinuation of treatment. |
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6.3.2 pleural mesothelioma

Malignant pleural mesothelioma (MPM) lesions are difficult to measure reliably.[37] Therefore, modified criteria were defined in 2004 adjusting target lesion measurements to the specific needs of this disease.  
| Non-Target Lesions                                                                                                                                                                                                                             | New Lesions   | Overall Response   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------|--------------------|
| CR                                                                                                                                                                                                                                             | No            | CR                 |
| Non-CR/non-PD                                                                                                                                                                                                                                  | No            | Non-CR/non-PD*     |
| Not all evaluated                                                                                                                                                                                                                              | No            | not evaluated      |
| Unequivocal PD                                                                                                                                                                                                                                 | Yes or No     | PD                 |
| Any                                                                                                                                                                                                                                            | Yes           | PD                 |
| * 'Non-CR/non-PD' is preferred over 'stable disease' for non-target disease since SD is increasingly used  as an endpoint for assessment of efficacy in some trials so to assign this category when no lesions can be  measured is not advised |               |                    |
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6.3.2.1 modified recist criteria for

Measurable at baseline and defined as tumor thickness measurements perpendicular to the chest wall or mediastinum in two positions at three separate levels on transverse cuts of CT scan. The sum of those 6 measurements define a pleural unidimensional measure. For reproducibility of lesion identification in follow up scans, cuts were taken at least 1 cm apart and close to anatomical landmarks in the thorax. Reassessments should be done at same position at the same level and by the same reader. Nodal, subcutaneous, and other measurable lesion were measured as per RECIST criteria. All unidimensional measurements were added to obtain total tumor measurement. Evaluation of target lesions Complete Response (CR): Disappearance of all target lesions with no evidence of tumor elsewhere.  
Partial Response (PR): At least a 30% decrease in the total tumor measurement Confirmed response (PR and CR): require a repeat scan at least 4 weeks apart Progressive Disease (PD): At least a 20% increase in the total tumor measurement, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study). (Note: the appearance of one or more new lesions is also considered progression).  
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum diameters while on study.  
6.3.2.2 Evaluation of Best Overall Response The best overall response is the best response recorded from the start of the treatment until disease progression/recurrence (taking as reference for progressive disease the smallest measurements recorded since the treatment started). The patient's best response assignment will depend on the achievement of both measurement and confirmation criteria.  
| Target   | Non-Target                                                                                                           | New       | Overall   | Best                                            | Response   | for   | this   |
|----------|----------------------------------------------------------------------------------------------------------------------|-----------|-----------|-------------------------------------------------|------------|-------|--------|
| Lesions  | Lesions                                                                                                              | Lesions   | Response  | Category Also Requires:                         |            |       |        |
| CR       | CR                                                                                                                   | No        | CR        | >4 wks. confirmation                            |            |       |        |
| CR       | Non-CR/NonPD                                                                                                                      | No        | PR        | >4 wks. confirmation                            |            |       |        |
| PR       | Non-PD                                                                                                               | No        | PR        |                                                 |            |       |        |
| SD       | Non-PD                                                                                                               | No        | SD        | documented at least once >4  wks. from baseline |            |       |        |
| PD       | Any                                                                                                                  | Yes or No | PD        |                                                 |            |       |        |
| Any      | PD*                                                                                                                  | Yes or No | PD        | no prior SD, PR or CR                           |            |       |        |
| Any      | Any                                                                                                                  | Yes       | PD        |                                                 |            |       |        |
| *        | In exceptional circumstances, unequivocal progression in non-target lesions may be  accepted as disease progression. |           |           |                                                 |            |       |        |  
Note: Patients with a global deterioration of health status requiring discontinuation of treatment without objective evidence of disease progression at that time should be reported as "*symptomatic deterioration"*. Every effort should be made to document the objective progression even after discontinuation of treatment.
In some circumstances it may be difficult to distinguish residual disease from normal tissue. When the evaluation of complete response depends on this determination, it is recommended that the residual lesion be investigated (fine needle aspirate/biopsy) to confirm the complete response status.  
6.3.3 iRECIST
6.3.3.1 Assessment at Screening and Prior to RECIST 1.1 Progression Until radiographic progression based on RECIST 1.1, there is no distinct iRECIST assessment.  
6.3.3.2 Assessment and Decision at RECIST 1.1 Progression In participants who show evidence of radiological PD by RECIST 1.1 the Investigator will decide whether to continue a participant on study treatment until repeat imaging is obtained (using iRECIST for participant management (see Appendix C). This decision by the Investigator should be based on the participant's overall clinical condition. Clinical stability is defined as the following:
Absence of symptoms and signs indicating clinically significant progression of disease  
No decline in ECOG performance status No requirements for intensified management, including increased analgesia, radiation, or other palliative care
Any participant deemed clinically unstable should be discontinued from study treatment at siteassessed first radiologic evidence of PD, and is not required to have repeat tumor imaging for confirmation of PD by iRECIST. If the Investigator decides to continue treatment, the participant may continue to receive study treatment and the tumor assessment should be repeated 4 to 8 weeks later to confirm PD by iRECIST, per Investigator assessment. Tumor flare may manifest as any factor causing radiographic progression per RECIST 1.1, including:  
Increase in the sum of diameters of target lesion(s) identified at baseline to ≥ 20% and
≥ 5 mm from nadir o Please note: the iRECIST publication uses the terminology "sum of measurements",
but "sum of diameters" will be used in this protocol, consistent with the original RECIST 1.1 terminology.  
Unequivocal progression of non-target lesion(s) identified at baseline Development of new lesion(s)
iRECIST defines new response categories, including iUPD (unconfirmed progressive disease) and iCPD (confirmed progressive disease). For purposes of iRECIST assessment, the first visit showing progression according to RECIST 1.1 will be assigned a visit (overall) response of iUPD, regardless of which factors caused the progression. At this visit, target and non-target lesions identified at baseline by RECIST 1.1 will be assessed as usual. New lesions will be classified as measurable or non-measurable, using the same size thresholds and rules as for baseline lesion assessment in RECIST 1.1. From measurable new lesions, up to 5 lesions total (up to 2 per organ), may be selected as New Lesions - Target. The sum of diameters of these lesions will be calculated, and kept distinct from the sum of diameters for target lesions at baseline. All other new lesions will be followed qualitatively as New Lesions - Non-target.  
6.3.3.3 Assessment at the Confirmatory Imaging On the confirmatory imaging, the participant will be classified as progression confirmed (with an overall response of iCPD), or as showing persistent unconfirmed progression (with an overall response of iUPD), or as showing disease stability or response (iSD/iPR/iCR).
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6.3.3.4 confirmation of progression

Progression is considered confirmed, and the overall response will be iCPD, if ANY of the following occurs:
Any of the factors that were the basis for the initial iUPD show worsening  
o For target lesions, worsening is a further increase in the sum of diameters of ≥ 5 mm, compared to any prior iUPD time point o For non-target lesions, worsening is any significant growth in lesions overall, compared to a prior iUPD time point; this does not have to meet the "unequivocal" standard of RECIST 1.1 o For new lesions, worsening is any of these:
An increase in the new lesion sum of diameters by ≥ 5 mm from a prior iUPD
time point Visible growth of new non-target lesions The appearance of additional new lesions
Any new factor appears that would have triggered PD by RECIST 1.1 6.3.3.5 Persistent iUPD
Progression is considered not confirmed, and the overall response remains iUPD, if:
None of the progression-confirming factors identified above occurs AND  
The target lesion sum of diameters (initial target lesions) remains above the initial PD
threshold (by RECIST 1.1)
Additional imaging for confirmation should be scheduled 4 to 8 weeks from the scan on which iUPD is seen. This may correspond to the next visit in the original visit schedule. The assessment of the subsequent confirmation scan proceeds in an identical manner, with possible outcomes of iCPD, iUPD, and iSD/iPR/iCR.
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6.3.3.6 resolution of iupd

Progression is considered not confirmed, and the overall response becomes iSD/iPR/iCR, if:
None of the progression-confirming factors identified above occurs, AND  
The target lesion sum of diameters (initial target lesions) is not above the initial PD
threshold.
The response is classified as iSD or iPR (depending on the sum of diameters of the target lesions), or iCR if all lesions resolve. In this case, the initial iUPD is considered to be pseudo-progression, and the level of suspicion for progression is "reset". This means that the next visit that shows radiographic progression, whenever it occurs, is again classified as iUPD by iRECIST, and the confirmation process is repeated before a response of iCPD can be assigned.
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6.3.3.6.1 management following the confirmatory

If repeat imaging does not confirm PD per iRECIST, as assessed by the Investigator, and the participant continues to be clinically stable, study treatment may continue and follow the regular imaging schedule. If PD is confirmed, participants will be discontinued from study treatment. NOTE: If a participant has confirmed radiographic progression (iCPD) as defined above, but the participant is achieving a clinically meaningful benefit, an exception to continue study treatment may be considered. In this case, if study treatment is continued, tumor imaging should continue to be performed following the intervals as outlined in Section 6. 6.3.3.6.2 Detection of Progression at Visits After Pseudo-progression Resolves After resolution of pseudo-progression (i.e., achievement of iSD/iPR/iCR), iUPD is indicated by any of the following events:
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target lesions

o Sum of diameters reaches the PD threshold (≥ 20% and ≥ 5 mm increase from nadir)
either for the first time, or after resolution of previous pseudo-progression. The nadir is always the smallest sum of diameters seen during the entire trial, either before or after an instance of pseudo-progression.  
Non-target lesions
o If non-target lesions have never shown unequivocal progression, their doing so for the first time results in iUPD.  
o If non-target lesions had shown previous unequivocal progression, and this progression has not resolved, iUPD results from any significant further growth of non-target lesions, taken as a whole.  
New lesions
o New lesions appear for the first time  
o Additional new lesions appear o Previously identified new target lesions show an increase of ≥ 5 mm in the new lesion sum of diameters, from the nadir value of that sum o Previously identified non-target lesions show any significant growth
If any of the events above occur, the overall response for that visit is iUPD, and the iUPD evaluation process (see Assessment at the Confirmatory Imaging above) is repeated. Progression must be confirmed before iCPD can occur. The decision process is identical to the iUPD confirmation process for the initial PD, except in one respect. If new lesions occurred at a prior instance of iUPD, and at the confirmatory scan the burden of new lesions has increased from its smallest value (for new target lesions, their sum of diameters is ≥5 mm increased from its nadir), then iUPD cannot resolve to iSD or iPR. It will remain iUPD until either a decrease in the new lesion burden allows resolution to iSD or iPR, or until a confirmatory factor causes iCPD.  
Additional details about iRECIST are provided in the iRECIST publication.[42]
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6.3.4 duration of response

Duration of overall response: The duration of overall response is measured from the time measurement criteria are met for CR or PR (whichever is first recorded) until the first date that recurrent or progressive disease is objectively documented (taking as reference for progressive disease the smallest measurements recorded since the treatment started). The duration of overall CR is measured from the time measurement criteria are first met for CR until the first date that progressive disease is objectively documented. Duration of stable disease: Stable disease is measured from the start of the treatment until the criteria for progression are met, taking as reference the smallest measurements recorded since the treatment started, including the baseline measurements. 6.3.5 Progression-Free Survival Progression free survival (PFS) is defined as the duration of time from start of treatment to time of progression (on or after pembrolizumab) or death, whichever occurs first. 6.3.6 Objective Response Rate Objective response rate (ORR) is defined as the proportion of patients with partial response or complete response.
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6.4 toxicity criteria

The following adverse event management guidelines are intended to ensure the safety of each patient while on the study. The descriptions and grading scales found in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 5.0. A copy of the CTCAE version 5.0 can be downloaded from the CTEP web site (http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm).
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7 nih reporting requirements/data and

Please refer to definitions provided in Policy 801: Reporting Research Events found here.
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7.2 ohsrp office of compliance

Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 802 Non-Compliance Human Subjects Research found here. Note: Only IND Safety Reports that meet the definition of an unanticipated problem will need to be reported t per these policies.
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7.2.2 irb requirements for pi

Please refer to the reporting requirements in Policy 801: Reporting Research Events found here. Problems expeditiously reported to the OHSRP in iRIS will also be reported to the NCI Clinical Director. A separate submission is not necessary as reports in iRIS will be available to the Clinical Director. In addition to those reports, all deaths that occur within 30 days after receiving a research intervention should be reported via email to the Clinical Director unless they are due to progressive disease. To report these deaths, please send an email describing the circumstances of the death to Dr. Dahut at NCICCRQA@mail.nih.gov within one business day of learning of the death.
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7.4.1 principal investigator/research team

The clinical research team will meet on a regular basis when patients are being actively treated on the trial to discuss each patient. Decisions about dose level enrollment and dose escalation if applicable will be made based on the toxicity data from prior patients. All data will be collected in a timely manner and reviewed by the principal investigator or a lead associate investigator. Events meeting requirements for expedited reporting as described in section 7.2.1 will be submitted in the appropriate timeframes. The principal investigator will review adverse event and response data on each patient to ensure safety and data accuracy. The principal investigator will personally conduct or supervise the investigation and provide appropriate delegation of responsibilities to other members of the research staff.
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7.4.2 safety monitoring committee (smc)

This protocol will require oversight from the Safety Monitoring Committee (SMC). Initial review will occur as soon as possible after the annual NIH Intramural IRB continuing review date. Subsequently, each protocol will be reviewed as close to annually as the quarterly meeting schedule permits or more frequently as may be required by the SMC. For initial and subsequent reviews, protocols will not be reviewed if there is no accrual within the review period. Written outcome letters will be generated in response to the monitoring activities and submitted to the Principal investigator and Clinical Director or Deputy Clinical Director, CCR, NCI.
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8 sponsor reporting criteria 8.1

Any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have a causal relationship with this treatment. An adverse event (AE) can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product (ICH E6 (R2))
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8.1.2 serious adverse event (sae)

An adverse event or suspected adverse reaction is considered serious if in the view of the investigator or the sponsor, it results in any of the following:
Death, A life-threatening adverse event (see section 8.1.3) Inpatient hospitalization or prolongation of existing hospitalization  
o A hospitalization/admission that is pre-planned (i.e., elective or scheduled surgery arranged prior to the start of the study), a planned hospitalization for pre-existing condition, or a procedure required by the protocol, without a serious deterioration in health, is not considered a serious adverse event.  
o A hospitalization/admission that is solely driven by non-medical reasons (e.g.,
hospitalization for patient convenience) is not considered a serious adverse event.  
o Emergency room visits or stays in observation units that do not result in admission to the hospital would not be considered a serious adverse event. The reason for seeking medical care should be evaluated for meeting one of the other serious criteria.  
Persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions A congenital anomaly/birth defect.
Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.  
8.1.3 Events to Be Treated as Adverse Events for Manufacturer Reporting In addition to the above SAE 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.
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8.1.4 life-threatening

An adverse event or suspected adverse reaction is considered "life-threatening" if, in the view of either the investigator or sponsor, its occurrence places the patient or subject at immediate risk of death. It does not include an adverse event or suspected adverse reaction that, had it occurred in a more severe form, might have caused death. (21CFR312.32) 8.1.5 Severity The severity of each Adverse Event will be assessed utilizing the CTCAE version 5. 8.1.6 Relationship to Study Product All AEs will have their relationship to study product assessed using the terms: related or not related.  
Related - There is a reasonable possibility that the study product caused the adverse event. Reasonable possibility means that there is evidence to suggest a causal relationship between the study product and the adverse event.  
Not Related - There is not a reasonable possibility that the administration of the study product caused the event.  
8.1.7 Overdose For purposes of this study, an overdose of pembrolizumab will be defined as any dose of 1,000 mg or greater (≥5 times the indicated dose). 8.1.8 Events of clinical interest an overdose of Merck product, as defined in Section 8.1.7  
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.
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8.2 assessment of safety events

AE information collected will include event description, date of onset, assessment of severity and relationship to study product and alternate etiology (if not related to study product), date of resolution of the event, seriousness and outcome. The assessment of severity and relationship to the study product will be done only by those with the training and authority to make a diagnosis and listed on the Form FDA 1572 as the site principal investigator or sub-investigator. AEs occurring during the collection and reporting period will be documented appropriately regardless of relationship. AEs will be followed through resolution.
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saes will be

Assessed for severity and relationship to study product and alternate etiology (if not related to study product) by a licensed study physician listed on the Form FDA 1572 as the site principal investigator or sub-investigator.  
Recorded on the appropriate SAE report form, the medical record and captured in the clinical database.  
Followed through resolution by a licensed study physician listed on the Form FDA 1572 as the site principal investigator or sub-investigator.
For timeframe of recording adverse events, please refer to section 6.1. All serious adverse events recorded from the time of first investigational product administration must be reported to the sponsor.
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8.3 reporting of serious adverse

Any AE that meets a protocol-defined serious criteria or meets the definition of Adverse Event of Special Interest that require expedited reporting must be submitted immediately (within 24 hours of awareness) to OSRO Safety using the CCR SAE report form. All SAE reporting must include the elements described in 8.2. SAE reports will be submitted to the Center for Cancer Research (CCR) at: OSROSafety@mail.nih.gov and to the CCR PI and study coordinator. CCR SAE report form and instructions can be found at: https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=157942842. Following the assessment of the SAE by OSRO, other supporting documentation of the event may be requested by the OSRO Safety and should be provided as soon as possible.
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8.4 safety reporting criteria to

8.4.1 Reported by Sponsor to Manufacturer All events listed below must be reported within 24 hours of investigator knowledge of event to OSROSafety@mail.nih.gov. ORSO will send all reports to the manufacturer as described below.  
All AEs meeting serious criteria, from the time of treatment allocation through 90 days following cessation of study treatment regardless of initiation of subsequent anticancer therapy.  
All pregnancies and exposure during breastfeeding, from the time of treatment allocation through 180 days following cessation of study treatment, or 30 days following cessation of study treatment if the participant initiates new anticancer therapy must be reported by the investigator.  
Additionally, any SAE brought to the attention of an investigator at any time outside of the time period specified above must be reported immediately by the investigator if the event is considered to be drug-related.
Investigators are not obligated to actively seek AE or SAE or other reportable safety events in former study participants. However, if the investigator learns of any SAE, including a death, at any time after a participant has been discharged from the study, and he/she considers the event to be reasonably related to the study treatment or study participation, the investigator must promptly notify Merck.
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8.4.1.1 reporting of overdose to

If an adverse event(s) is associated with ("results from") the overdose (see section 8.1.7) 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 nonserious 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 2 working days hours to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215-661-6229)
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8.4.1.2 reporting of pregnancy and

Although pregnancy and infant exposure during breast feeding are not considered adverse events, it is the responsibility of investigators or their designees to report any pregnancy or lactation in a participant (spontaneously reported to them) that occurs during the study. If a participant inadvertently becomes pregnant while on treatment with pembrolizumab, the participant will be immediately discontinued from study treatment. The site will contact the participant at least monthly and document the participant's status until the pregnancy has been completed or terminated. The outcome of the pregnancy will be reported to Merck within 2 working days if the outcome is a serious adverse experience (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 Merck. If a male participant impregnates his female partner, the study personnel at the site must be informed immediately and the pregnancy must be reported to Merck and followed as described below.  
Pregnancies and infant exposures during breastfeeding that occur after the consent form is signed but before treatment allocation must be reported by the investigator if they cause the participant to be excluded from the trial, or are the result of a protocol-specified intervention, including but not limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure. Pregnancies and infant exposures during breastfeeding that occur from the time of treatment allocation through 180 days following cessation of the Merck product, or 30 days following cessation of treatment if the participant initiates new anticancer therapy, whichever is earlier, must be reported by the investigator. All reported pregnancies must be followed to the completion/termination of the pregnancy. Pregnancy outcomes of spontaneous abortion, missed abortion, benign hydatidiform mole, blighted ovum, fetal death, intrauterine death, miscarriage and stillbirth must be reported as serious events (Important Medical Events). If the pregnancy continues to term, the outcome (health of infant) must also be reported. Such events must be reported within 2 working days to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215-661-6229)
8.4.1.3 Immediate Reporting of Adverse Events to Merck 8.4.1.3.1 Serious Adverse Events and Events to Be Treated as Serious Adverse Events Refer to sections 8.1.2 and 8.1.3 for definitions of SAE and events to be treated as SAEs respectively. For the time period beginning when the consent form is signed until treatment allocation, any serious adverse event, or follow up to a serious adverse event, including death due to any cause that occurs to any participant must be reported within 2 working days to Merck Global Safety if it causes the participant to be excluded from the trial, or is the result of a protocol-specified intervention, including but not limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure. For the time period beginning at treatment allocation through 90 days following cessation of treatment, regardless of initiation of subsequent anticancer therapy, any serious adverse event, or follow up to a serious adverse event, including death due to any cause whether or not related to the Merck product, must be reported within 2 working days to Merck Global Safety. Additionally, any serious adverse event, considered by an investigator who is a qualified physician to be related to Merck product that is brought to the attention of the investigator at any time 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 Merck Global Safety. All participants with serious adverse events must be followed up for outcome.
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sae reports and any other

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.
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8.4.1.4 events of clinical interest

Selected non-serious and serious adverse events are also known as Events of Clinical Interest (ECI) and are defined in section 8.1.8. These events must be reported 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, any ECI, or follow up to an ECI, that occurs to any participant must be reported within 2 working days to Merck Global Safety if it causes the participant to be excluded from the trial, or is the result of a protocol-specified intervention, including but not limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure. For the time period beginning at treatment allocation through 90 days following cessation of treatment regardless of initiation of subsequent anticancer therapy, any ECI, or follow up to an ECI, whether or not related to Merck product, must be reported within 2 working days to Merck Global Safety.  
8.4.2 Reported by Study Team to Manufacturer All AEs from the time of treatment allocation through 90 days following cessation of study treatment must be reported by the investigator. AEs will be reported per manufacturer's instructions.
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8.5 reporting pregnancy 8.5.1 maternal

If a patient becomes pregnant during the course of the study, the study treatment should be discontinued immediately, and the pregnancy reported to the Sponsor no later than 24 hours of when the Investigator becomes aware of it. The Investigator should notify the Sponsor no later than 24 hours of when the outcome of the Pregnancy become known, Pregnancy itself is not regarded as an SAE. However, congenital abnormalities or birth defects and spontaneous miscarriages that meet serious criteria (8.1.2) should be reported as SAEs. The outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or congenital abnormality) should be followed up and documented. 8.5.2 Paternal exposure Male patients should refrain from fathering a child or donating sperm during the study and for 180 days after the last dose of LMB-100 or pembrolizumab. Pregnancy of the patient's partner is not considered to be an AE. However, the outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or congenital abnormality) occurring from the date of the first dose until 180 days after the last dose should, if possible, be followed up and documented.
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8.6 regulatory reporting for studies

Following notification from the investigator, CCR, the IND sponsor, will report any suspected adverse reaction that is both serious and unexpected. CCR will report an AE as a suspected adverse reaction only if there is evidence to suggest a causal relationship between the study product and the adverse event. CCR will notify FDA and all participating investigators (i.e., all investigators to whom the sponsor is providing drug under its INDs or under any investigator's IND) in an IND safety report of potential serious risks from clinical trials or any other source, as soon as possible, in accordance to 21 CFR Part 312.32. All serious events will be reported to the FDA at least annually in a summary format.
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9 clinical monitoring plan

As a sponsor for clinical trials, FDA regulations require the CCR to maintain a monitoring program. The CCR's program allows for confirmation of: study data, specifically data that could affect the interpretation of primary and secondary study endpoints; adherence to the protocol, regulations, ICH E6, and SOPs; and human subjects protection. This is done through independent verification of study data with source documentation focusing on:  
Informed consent process Eligibility confirmation Drug administration and accountability Adverse events monitoring Response assessment.
The monitoring program also extends to multi-site research when the CCR is the coordinating center. This trial will be monitored by personnel employed by a CCR contractor. Monitors are qualified by training and experience to monitor the progress of clinical trials. Personnel monitoring this study will not be affiliated in any way with the trial conduct.
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10 statistical considerations 10.1 statistical

The primary objective of this trial is to determine if LMB-100 followed by pembrolizumab is associated with an adequately high response rate in each of two separate cohorts of mesothelioma patients. This will require exceeding the response rate of pembrolizumab alone in patients who have pleural mesothelioma that have failed standard therapies, and will require identifying a modest response rate in patients with peritoneal mesothelioma. The secondary objectives are to evaluate safety, duration of response, overall survival (OS), and progression-free survival (PFS) in all patients included in this phase II evaluation. Exploratory objectives include evaluation of a set of laboratory parameters, to be performed only if the treatment combination has a beneficial effect.
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10.2 sample size determination

Since published data indicate that a response rate for pembrolizumab alone in patients with pleural mesothelioma who have failed standard treatments is approximately 20%, this trial will try to demonstrate if a response rate substantially more than 20% may be realized by the addition of LMB-100 in those patients. Patients with pleural mesothelioma will be enrolled in a cohort and evaluated for response using a Simon optimal two-stage phase II trial design (Simon R, Controlled Clinical Trials 10:1-10, 1989) to rule out an unacceptably low PR+CR rate of 20% (p0=0.20) in favor of an improved response rate of 40% (p1=0.40). With alpha=0.10 (probability of accepting a poor treatment=0.10) and beta = 0.20 (probability of rejecting a good treatment=0.20), the first stage will determine the response rate in the 12 evaluable patients who are treated at the safe combination, and if 0 to 2 of the 12 have a clinical response, then no further patients will be accrued. If 3 or more of these 12 patients have a response, then accrual would continue until a total of 25 evaluable patients have been treated. As it may take up to several months to determine if a patient has experienced a response, a temporary pause in the accrual may be necessary to ensure that enrollment to the second stage is warranted. If there are 3 to 7 patients with a response out of 25 patients, this would be an uninterestingly low response rate. If there were 8 or more of 25 (32%) who experienced a response, this would be sufficiently interesting to warrant further study in later trials. Under the null hypothesis (20% response rate), the probability of early termination is 55.8%. Patients with peritoneal mesothelioma have limited data on clinical responses, and will be enrolled in their own cohort and evaluated for response using a separate, small Simon minimax two-stage phase II trial design[43] to rule out an unacceptably low PR+CR rate of 5% (p0=0.05)
in favor of an improved response rate of 30% (p1=0.30). With alpha=0.10 (probability of accepting a poor treatment=0.10) and beta = 0.20 (probability of rejecting a good treatment=0.20), the first stage will determine the response rate in 6 evaluable patients, and if 0 of the 6 have a clinical response, then no further peritoneal mesothelioma patients will be accrued. If 1 or more of these 6 patients have a response, then accrual would continue until a total of 10 evaluable patients with peritoneal disease have been treated. As it may take up to several months to determine if a patient has experienced a response, a temporary pause in the accrual may be necessary to ensure that enrollment to the second stage is warranted. If there is exactly 1 patient with a response out of 10 patients, this would be an uninterestingly low response rate. If there were 2 or more of 10 (20%) who experienced a response, this would be sufficiently interesting to warrant further study in later trials. Under the null hypothesis (5% response rate), the probability of early termination is 73.5%. It is expected that approximately 15-20 patients per year may enroll onto this trial. Thus, it is expected that 18 months may be required to enroll up to 35 evaluable patients (up to 25 with pleural disease and 10 with peritoneal disease). To allow for a small number of inevaluable patients, the accrual ceiling will be set at 38 patients.
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10.3 populations for analyses

Modified Intention-to-Treat: participants who took at least one dose of study intervention will be included in analyses as described below
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10.3.1 evaluable for toxicity

All patients will be evaluable for toxicity from the time of their first treatment with LMB-100. Events occurring after initiation of a second course of therapy will not be included in this analysis. 10.3.2 Evaluable for objective response: Only those patients who have measurable disease present at baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will be considered evaluable for response. Patients on the second course will not be included in this analysis.
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10.4 statistical analyses 10.4.1 general

Patients enrolled in the two cohorts will have the fraction of patients responding reported along with 80% and 95% confidence intervals. 10.4.2 Analysis of the Primary Endpoints Clinical responses will be analyzed by reporting the fraction of evaluable patients in each of the two cohorts who experience a response, along with 80% and 95% two-sided confidence intervals, separately by cohort. 10.4.3 Analysis of the Secondary Endpoints Duration of response will be calculated from the date of clinical response determination until disease progression on or after pembrolizumab or last follow-up without progression on or after pembrolizumab. OS will be determined from on-study date until date of death or date last known alive. PFS will be determined from the on-study date until the date of progression on or after pembrolizumab or date of death without progression (as events) or until the date of last followup if not progressed (as a censored observation). All three of these measures will be calculated as probabilities as a function of time using the Kaplan-Meier method, and will be evaluated on all evaluable patients, separately by cohort, as well as for both cohorts combined if the results are sufficiently similar to permit pooling (p>0.30 for difference between the cohorts), with appropriate caveats if necessary.
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10.4.4 safety analyses

Safety of LMB-100 followed by pembrolizumab will be assessed by reporting the grade of adverse events noted in each patient, and reporting the proportion with grade 3 and grade 4 adverse events. Safety data will be presented in individual listings. Summaries will also be prepared. The safety data will consist of the reporting of all adverse events, vital signs, physical examination data, and appropriate laboratory safety data. 10.4.5 Baseline Descriptive Statistics Basic descriptive statistics on study participants will be summarized in the final publication. 10.4.6 Planned Interim Analyses The number of patients with a clinical response after the first stage of the two-stage phase II cohort will be determined to permit the trial to accrue to the second stage. 10.4.7 Sub-Group Analyses No formal sub-group analyses are planned. 10.4.8 Tabulation of individual Participant Data No individual participant data tabulation will be required. Tables showing results of participants may be presented if warranted.
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10.4.9 exploratory analyses

Patients who undergo biopsies at baseline as well as after two cycles of LMB-100 and/or two cycles of pembrolizumab will have the differences in the parameters obtained by the biopsies compared from baseline to each of the two subsequent time points, as well as between the postLMB-100 biopsy and the post-pembrolizumab biopsy. These analyses will be done using appropriate paired tests (paired t-test or Wilcoxon signed rank test depending on the normality of the differences). All tests will be done with exploratory intent, separately by cohort, without adjustment for multiple comparisons but presented in the context of the number of tests performed.
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11 collaborative agreements 11.1 clinical

The study agent pembrolizumab is supplied under a CTA (\# 1101) with the manufacturer, Merck.
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12 human subjects protections 12.1

LMB-100 is a mesothelin-targeted cFP and has shown preclinical dose-dependent activity in monotherapy and/or combination in xenografts representing MSLN-positive indications (NSCLC, mesothelioma, triple negative breast cancer, gastric cancer, pancreas, ovarian, potentially other tumor indications). LMB-100 has shown synergy in laboratory models with inhibitors of the PD1 axis. Pembrolizumab is an anit-PD1/PD-L1 inhibitor. The rationale to evaluate LMB-100 with pembrolizumab in advanced/metastatic mesothelioma is to determine the effect of the addition of pembrolizumab to LMB-100 therapy. All patients meeting the criteria listed in section 2.1 are eligible for enrollment.
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12.2 participation of children

There are no dosing or adverse event data are currently available on the use of LMB-100 with pembrolizumab in patients <18 years of age; therefore, children are excluded from this study.
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12.3 participation of subjects unable

Adults unable to give consent are excluded from enrolling in the protocol. However, re-consent may be necessary and there is a possibility, though unlikely, that subjects could become decisionally impaired. For this reason and because there is a prospect of direct benefit from research participation (section 12.5), all subjects ≥ age 18 will be offered the opportunity to fill in their wishes for research and care, and assign a substitute decision maker on the "NIH Advance Directive for Health Care and Medical Research Participation" form so that another person can make decisions about their medical care in the event that they become incapacitated or cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH Ability to Consent Assessment Team (ACAT) for evaluation as needed for the following: an independent assessment of whether an individual has the capacity to provide consent; assistance in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the capacity to appoint a surrogate. For those subjects that become incapacitated and do not have pre-determined substitute decision maker, the procedures described in NIH HRPP SOP 14E for appointing a surrogate decision maker for adult subjects who are (a) decisionally impaired, and
(b) who do not have a legal guardian or durable power of attorney, will be followed.
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12.4 evaluation of benefits and

Patient safety will be managed by careful proactive patient selection prior to study to exclude patients at risk from study treatment due to their pre-existing conditions. During the study, safety of patients will be proactively managed by protocol-mandated physical examinations, vital signs assessments, ECGs, clinical laboratory assessments, and collection of adverse events and their assessment. The risks of the study include those associated with study agent as discussed in section 13. 12.4.2 Blood Collection Side effects of blood draws include pain and bruising, lightheadedness, and rarely, fainting.
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12.4.3 ct scans

In addition to the radiation risks discussed below, CT scans may include the risks of an allergic reaction to the contrast. Participants might experience hives, itching, headache, difficulty breathing, increased heartrate and swelling.
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12.4.4 image guided biopsy collection

The risks of the research biopsies collected at baseline, on C2D1 and C4D1 include pain, bleeding and infection at the biopsy site. In addition, as the biopsies may be collected under CT guidance, subjects in this study may be exposed to radiation as discussed below. 12.4.5 Radiation The study will involve radiation from the following sources:
Up to 3 CT scans as referenced above for the collection of biopsies Up to 9 CT scans per year for disease assessment  
Up to 9 FDG-PET scans per year for disease assessment
Subjects in this study may be exposed to approximately 17.7 rem. This amount is more than would be expected from everyday background radiation. Being exposed to excess radiation can increase the risk of cancer. The risk of getting cancer from the radiation exposure in this study is 1.8 out of 100 (1.8%) and of getting a fatal cancer is 0.9 out of 100 (0.9%).
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12.5 risks/benefits analysis

Patients with advanced and/or metastatic pleural or peritoneal mesothelioma are in continuous need of improved therapy options. This is especially true for patients where no standard therapy exists such as the patient population that will be eligible for this trial. Preclinical data has demonstrated promising anti-tumor efficacy of LMB-100 in xenograft models in monotherapy and combination therapy. Laboratory studies have further demonstrated synergy with PD1/PDL1 inhibitors. Therefore, LMB-100 + pembrolizumab may improve clinical outcome of patients with mesothelioma. A number of clinically appropriate strategies to minimize risk to patients have been built into the protocol through the means of inclusion/exclusion criteria, monitoring strategies, and management guidelines. Overall, the potential benefits of mesothelin targeted cFP for mesothelioma patients retaining the ability to consent and those who lose capacity to consent during the course of the trial outweigh the risks associated with the proposed entry-into-human trial with LMB-100 + pembrolizumab
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12.6 consent process and documentation

The informed consent document will be provided to the participant or consent designee(s) (e.g., legally authorized representative [LAR] if participant is an adult unable to consent) for review prior to consenting. A designated study investigator will carefully explain the procedures and tests involved in this study, and the associated risks, discomforts and benefits. In order to minimize potential coercion, as much time as is needed to review the document will be given, including an opportunity to discuss it with friends, family members and/or other advisors, and to ask questions of any designated study investigator. A signed informed consent document will be obtained prior to entry onto the study. The initial consent process as well as re-consent, when required, may take place in person or remotely (e.g., via telephone or other NIH approved remote platforms) per discretion of the designated study investigator and with the agreement of the participant/consent designee(s).  
Whether in person or remote, the privacy of the subject will be maintained. Consenting investigators (and participant/consent designee, when in person) will be located in a private area (e.g., clinic consult room). When consent is conducted remotely, the participant/consent designee will be informed of the private nature of the discussion and will be encouraged to relocate to a more private setting if needed. Consent for the optional biopsies performed on this study will be obtained at the time of the procedure. If the patient refuses the optional biopsy at that time, the refusal will be documented in the medical record and in the research record.  
12.6.1 Request for Waiver of Consent for Screening Activities Prior to the subject signing the consent for this study pre-screening activities listed in section 2.2.1 may be performed. We request a waiver of consent for these activities as they involve only minimal risk to the subjects. A waiver will not adversely affect the rights and welfare of the subjects given that the activities are only intended to determine suitability for screening for participation in research protocols. These activities could not practicably be carried out without the wavier as central recruiting services, utilized in the NIH Clinical Center, perform pre-screening activities for multiple studies and obtaining consent for each one is beyond their resources. The subjects will be provided with additional pertinent information after participation as they will be informed whether or not they are eligible to sign a consent for additional screening.
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13 regulatory and operational considerations

Each clinical site will perform internal quality management of study conduct, data and biological specimen collection, documentation and completion. An individualized quality management plan will be developed to describe a site's quality management. Quality control (QC) procedures will be implemented beginning with the data entry system and data QC checks that will be run on the database will be generated. Any missing data or data anomalies will be communicated to the site(s) for clarification/resolution. Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical trial is conducted and data are generated and biological specimens are collected, documented (recorded), and reported in compliance with the protocol, International Conference on Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory requirements (e.g., Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)). The investigational site will provide direct access to all trial related sites, source data/documents, and reports for the purpose of monitoring and auditing by the sponsor, and inspection by local and regulatory authorities.
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13.2 conflict of interest policy

The independence of this study from any actual or perceived influence, such as by the pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, persons who have a perceived conflict of interest will be required to have such conflicts managed in a way that is appropriate to their participation in the design and conduct of this trial. The study leadership in conjunction with the NCI CCR has established policies and procedures for all study group members to disclose all conflicts of interest and will establish a mechanism for the management of all reported dualities of interest.
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13.3 confidentiality and privacy

Participant confidentiality and privacy is strictly held in trust by the participating investigators, their staff, and the sponsor(s). This confidentiality is extended to cover testing of biological samples and genetic tests in addition to the clinical information relating to participants. Therefore, the study protocol, documentation, data, and all other information generated will be held in strict confidence. No information concerning the study or the data will be released to any unauthorized third party without prior written approval of the sponsor. All research activities will be conducted in as private a setting as possible. The study monitor, other authorized representatives of the sponsor, representatives of the Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and records required to be maintained by the investigator, including but not limited to, medical records (office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical study site will permit access to such records. The study participant's contact information will be securely stored at each clinical site for internal use during the study. At the end of the study, all records will continue to be kept in a secure location for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor requirements. Study participant research data, which is for purposes of statistical analysis and scientific reporting, will be stored at NCI CCR This will not include the participant's contact or identifying information. Rather, individual participants and their research data will be identified by a unique study identification number. The study data entry and study management systems used by clinical sites and by NCI CCR research staff will be secured and password protected. At the end of the study, all study databases will be archived at the NCI CCR. To further protect the privacy of study participants, a Certificate of Confidentiality has been issued by the National Institutes of Health (NIH). This certificate protects identifiable research information from forced disclosure. It allows the investigator and others who have access to research records to refuse to disclose identifying information on research participation in any civil, criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local level. By protecting researchers and institutions from being compelled to disclose information that would identify research participants, Certificates of Confidentiality help achieve the research objectives and promote participation in studies by helping assure confidentiality and privacy to participants.
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14 pharmaceutical information 14.1 lmb-100

Initially LMB-100 on this trial was transferred to the NIH CC Pharmacy by Roche, the first manufacturer of the drug. As of Amendment H, the drug supply manufactured by Selecta Biosciences and transferred to the NIH CC Pharmacy will be utilized. Please note, the Roche supply may continue to be used until expiration, per PI/sponsor/pharmacy discretion.
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14.1.2 toxicity

Information in this section is based on preclinical studies with LMB-100, and clinical studies of the cytolytic fusion protein SS1-P. Patients should receive a full dose of LMB-100 unless a DLT and/or a treatment limiting toxicity is observed. In case of DLT and/or treatment limiting toxicities, treatment with LMB-100 will be stopped until resolution of toxicity to NCI CTCAE
Grade  2 hematological toxicities or Grade  1 non-hematological toxicities. A delay of LMB100 administration for up to two weeks of the planned schedule will be acceptable to allow for resolution of toxicity to NCI CTCAE Grade  2 hematological toxicities or Grade  1 nonhematological toxicities. If toxicity does not resolve to NCI CTCAE Grade  2 hematological toxicities or Grade  1 non-hematological toxicities and the patient is unable to resume treatment with LMB-100 after this time, no additional doses will be administered and the patient will be withdrawn from study treatment.
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14.1.2.1 infusion-related reactions and hypersensitivity

LMB-100 administration may cause infusion-associated symptoms such as fever, chills, hypotension, shortness of breath, skin rash, headache, nausea, and/or vomiting. Such reactions typically occur during or shortly after an infusion, predominantly the first infusion. Patients may also develop IgE-mediated hypersensitivity reactions to LMB-100. IRRs may be indistinguishable from an anaphylactic reaction. Patients should receive full supportive care to treat IRRs or anaphylaxis according to institutional practice. If infusion-associated signs or symptoms occur, patients should be monitored until complete resolution. In vitro data suggest that the risk for the release of pro-inflammatory cytokines upon first administration of LMB-100 to humans is low (human whole blood assay, see section 1.2.4.3.3). Past experience with monoclonal antibodies that demonstrated a risk in the whole blood assay has shown that this risk could be effectively managed in the clinic with appropriate risk-minimization measures. The release of pro-inflammatory cytokines is believed to be partially responsible for the occurrence of IRRs.
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14.1.2.2 risk of immunogenicity and

LMB-100 may cause the formation of ADAs. These may trigger hypersensitivity reactions or immune complex-mediated responses. The development of ADAs to LMB-100, an improved cytolytic fusion protein with a humanized targeting moiety directed against mesothelin and a dehumanized, truncated Pseudomonas exotoxin A is expected to be less likely than SS1P. Clinical trials with SS1P have led to the development of neutralizing ADAs in 75% and 88% of patients after 1 cycle of therapy, in the IV bolus and continuous infusion trials respectively.[44]
Patients will be monitored at regular intervals for the development of ADAs and cytokines. In particular, any clinical signs and symptoms suggestive of a hypersensitivity reaction and/or an immune complex-mediated reaction possibly due to ADA formation will be carefully investigated.  
14.1.2.3 Risk of Inflammatory Reactions to Serosal Membranes LMB-100 administration may cause inflammatory reactions to serosal membranes including pleuritis, characterized by pleuritic chest pain, dyspnea, and hypoxia and pericarditis, characterized by precordial chest pain, congestive heart failure, hypotension, and uremia. Clinical trials with SS1P monotherapy have led to reversible pleuritis and pericarditis. Patients who develop symptoms of serosal inflammation should be closely monitored and receive standard treatments which may include corticosteroids.
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14.1.2.4 risk of capillary leak

LMB-100 administration may cause CLS characterized by hypotension, hypoalbuminemia, edema, weight gain, and hemoconcentration. Clinical trials with SS1P monotherapy have led to the development of reversible CLS. Patients will be monitored with frequent assessments of weight, edema, blood pressure, and serum albumin levels prior to and during treatment. Patients who develop symptoms of CLS should be closely monitored and receive standard symptomatic treatments.
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14.1.2.5 risk of cardiac toxicity

There may be a risk for cardiac immune-related adverse events, specifically **myocarditis**, as a rare but serious complication after treatment with LMB-100. During clinical trial 19C0128, a patient with history of intrahepatic cholangiocarcinoma arising out of primary sclerosing cholangitis, initiated C1 tofacitinib + apixaban treatment on Day 1 and LMB-100 on Day 4. The patient began experiencing fatigue and pleuritic pain symptoms on Day 5. A cardiac MRI was performed that suggested a component of inflammatory myocarditis in addition to capillary leak syndrome.
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14.1.2.6 risk of rhabdomyolysis

There may be a risk of rhabdomyolysis as a rare, but serious complication of treatment with LMB-100. A single patient on this study experienced grade 4 CPK increased, assessed as being due to a grade 2 event of rhabdomyolysis within one week of initial dose of LMB-100. This was determined by the sponsor to be related to the LMB-100.
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14.1.2.7 risk of renal toxicity

LMB-100 administration may cause renal toxicity characterized by increased creatinine, BUN, and proteinuria. In preclinical cynomolgus monkey studies, LMB-100 has shown increases in creatinine and histological changes including regenerative and degenerative changes to the tubular epithelium. Hemolytic uremic syndrome has been reported for other cytolytic fusion antibodies in development. Patients should be monitored with renal laboratory assessments including creatinine, BUN, and urinalysis.  
14.1.2.8 Injection Site Reactions LMB-100 administration may cause adverse reactions at the infusion site characterized by pain, swelling, induration, and nodules. In preclinical NHP studies for both SS1P and LMB-100 reddening and swelling of the infusion site were noted. Patients who develop symptoms of infusion site reactions can be administered pain relieving medication (analgesic) as required, and rotation of infusion sites is recommended.
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14.1.3 handling

LMB-100 is to be handled following all hazardous precautions. There is no evidence currently available to determine the hazardous status of the product. The Clinical Center will exercise caution and categorize LMB-100 as a hazardous agent. 14.1.4 Formulation and preparation LMB-100 drug product (20 mg/20 mL) is provided for syringe infusion as a sterile, colorless to brownish, preservative-free liquid in single-use, 20 mL vials. The nominal fill volume is 20 mL and the approximate concentration of LMB-100 recombinant fusion protein in the vials is 1 mg/mL.  
14.1.5 Stability and Storage 14.1.5.1 Stability Stability tests are ongoing for intact LMB-100 vials. LMB-100 does not contain antimicrobial preservatives and should be used immediately after preparing into dosing syringes. If prepared dosing syringes are not used immediately, total in-use storage times of prepared syringes for infusion should not exceed 24 hours when stored under refrigeration (2°– 8°C).  
14.1.5.2 Storage Store intact vials in the refrigerator (2 - 8°C), protected from light. Do not shake and do not freeze drug vials. LMB-100 should be protected from exposure to direct sunlight during preparation and administration. 14.1.6 Administration procedures Please refer to section 3.2.1. 14.1.7 Incompatibilities Pharmacodynamic drug interaction studies have not been conducted. LMB-100 is contraindicated in subjects with a history of severe allergic anaphylactic reactions to humanized, chimeric or mouse peptides/antibodies or to any components of the product. Other drugs that require parenteral co-administration (if applicable) should be delivered via separate infusion lines and at separate infusion sites and should not be mixed with the study drug. LMB-100 is compatible with non-DEHP, latex-free, lipid resistant, non-PVC extension sets.
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14.1.7.1 mechanism of action

LMB-100 is a novel recombinant anti-mesothelin targeted cytolytic fusion protein (cFP) developed for the treatment of patients with solid tumors that express the mesothelin protein. Mesothelin is a suitable candidate for targeted therapy due to its very limited expression in normal/non-malignant tissue and its high expression in several tumor entities including mesothelioma, ovarian cancer, pancreatic cancer, gastric cancer, breast cancer, and lung cancer. To target mesothelin, a humanized Fab fragment of the anti-mesothelin antibody SS1 is linked to a truncated and de-immunized recombinant 24 kD fragment of Pseudomonas exotoxin (PE24).  
After binding to mesothelin, the complex is internalized by endocytosis and kills cells by inhibition of eukaryotic elongation factor 2 (eEF2), leading to arrest of protein synthesis and secondarily triggering cell death by apoptosis or necrosis.  
14.1.7.2 Molecular Weight: approximately 73 kDa  
 14.1.7.3 Chemical Structure