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or

(2) have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy or bilateral tubal ligation/occlusion, at least 6 weeks prior to screening;  
(3) has a congenital or acquired condition that prevents childbearing. Female and male subjects of reproductive potential must agree to avoid becoming pregnant or impregnating a partner, respectively, while receiving study drug and for 120 days after the last dose of study drug by complying with one of the following: (1) practice abstinence† from heterosexual activity;  
(2) use (or have their partner use) acceptable contraception during heterosexual activity. Acceptable methods of contraception are‡: Single method (one of the following is acceptable):  
o intrauterine device (IUD)
o vasectomy of a female subject's male partner o contraceptive rod implanted into the skin
Combination method (requires use of two of the following):  
o diaphragm with spermicide (cannot be used in conjunction with cervical cap/spermicide) o cervical cap with spermicide (nulliparous women only)
o contraceptive sponge (nulliparous women only) o male condom or female condom (cannot be used together) o hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or progestin-only pill), contraceptive skin patch, vaginal contraceptive ring, or subcutaneous contraceptive injection
†Abstinence (relative to heterosexual activity) can be used as the sole method of contraception if it is consistently employed as the subject's preferred and usual lifestyle and if considered acceptable by local regulatory agencies and ERCs/IRBs. Periodic abstinence (e.g., calendar, ovulation, sympto-thermal, post-ovulation methods, etc.) and withdrawal are not acceptable methods of contraception. ‡If a contraceptive method listed above is restricted by local regulations/guidelines, then it does not qualify as an acceptable method of contraception for subjects participating at sites in this country/region.  
Subjects should be informed that taking the study medication may involve unknown risks to the fetus (unborn baby) if pregnancy were to occur during the study. In order to participate in the study subjects of childbearing potential must adhere to the contraception requirement (described above) from the day of study medication initiation (or 14 days prior to the initiation of study medication for oral contraception) throughout the study period up to 120 days after the last dose of trial therapy. If there is any question that a subject of childbearing potential will not reliably comply with the requirements for contraception, that subject should not be entered into the study.
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5 biospecimen collection 5.1 correlative

The purpose of the correlative studies is to determine if there is a correlation with clinical outcome of PD1 or PDL1 expression and T-Cell infiltrate in pathology from first, and if applicable, second surgical specimens with outcome.  
o To assess tumor tissue for neo-antigens (initial tumor pathology).  
o To collect peripheral monocytes for PD-L1 levels to confirm that low level expression leads to better outcome and if higher levels that are treated with Pembrolizumab might improve outcome. To perform other immune monitoring assessments including, but are not limited to: whole exome sequencing (WES), immune phenotyping of immune cell subsets, functional characterization of immune cell subsets, measurement of immune mediators and the assessment of circulating tumor DNA (ctDNA).
o To correlate MGMT and IDH status with outcome (local pathology report).  
At each timepoint noted in the study calendar, correlative blood will be collected in 8 mononuclear cell preparation tubes (LabConnect Kit B, 8mL CPT™ blue and black top tubes) and processed for the isolation of both PBMCs and plasma. As detailed in the LabConnect lab manual, Correlative blood will be collected at NCI and participating BTTC sites and sent to:
NCI Frederick Lab Leidos Biomedical Research Version Date: *06/30/2021* Attn: Theresa Burks 1050 Boyles Street Bldg. 469/Room 121 Frederick, MD 21702 Phone 301-846-5125, or 301-846-6865 Email: burkst@mail.nih.gov, cc: jon.inglefield@nih.gov
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5.1.1 collection of correlative blood

NOTE: The schedule of correlative blood sample collection should be held/delayed when treatment dosing is held. See section 5 Biospecimen Collection, and at the end of Table 1, and/or the calendar.
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for participants randomized to study

1) Pre-RT treatment (RT+TMZ+Pembro)
2) Post-RT treatment (RT+TMZ+Pembro)/Pre-vaccine (or placebo) induction 3) Post Vaccine (or placebo) induction/Pre-cycle 1 maintenance 4) Every Day 1 on Cycle 2, C4, C6, C8 (if continuing on Pembrolizumab); then, at discretion of Study Chair and BTTC Coordinating Center, every other cycle 5) At time of progression or at end of treatment
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for participants not randomized (ancillary

1) Pre-RT treatment (RT+TMZ+Pembro) 2) Pre-cycle 1 maintenance 3) Every Day 1 on Cycle 2, C4, C6, C8 (if continuing on Pembrolizumab); then, at discretion of Study Chair and BTTC Coordinating Center, every other cycle 4) At time of progression or at end of treatment LabConnect (Fee for Service Provider) will supply kits and track shipments for correlative blood collection. (See LabConnect lab manual.)
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5.1.2 pd-l1 expression on tumor

A collection of sectioned slides from tumor samples for the purpose of immunohistochemical (IHC) analysis will be sent for PD-L1 analysis at the end of the study. Sectioned slides from formalin-fixed, paraffin-embedded (FFPE) samples will be stained for the biomarker(s) of interest, and then evaluated by a pathologist for review of biomarker staining expression levels. This sample will be taken at time of surgery. At the end of the study, the BTTC CC Research Nurse will contact the participating site to request the slides.
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5.1.3 tissue will be interrogated

Generation of the HSPPC-96 vaccine requires > 7 grams of tissue. All **available** tumor aside from what will be used for routine pathologic studies and diagnosis should be sent for HSPPC-96 vaccine preparation. At the end of the study, up to 18 FFPE unstained slides (formalin fixed Version Date: *06/30/2021* paraffin embedded) may be collected. If subsequent tumor biopsies are obtained, including at time of progression, additional tissue specimens may be collected following the same method described above. **These tissue collections for next generation sequencing are at the**
investigator's **discretion.** The **FFPE Tumor Tissue Slide** specimens are maintained at room temperature and shipped ambient by the site upon request by BTTC Coordinating Center to:
Attn: BTTC Coordinating Center Research Nurse Coordinator NCI / Neuro-Oncology Branch / Brain Tumor Trials Collaborative National Institutes of Health Building 82 , Room 215 Bethesda, MD 20892 Phone: 240-858-7083 Email: ukeme.ikiddeh-barnes@nih.gov
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5.1.4 tissue collection at nci

Tumor samples will be collected at time of surgery by the Laboratory of Pathology NCI. Tissue sections will be obtained and will be labeled with the Study Subject ID number. The relationship between the Study Subject ID number and the patient clinical information will be stored in a secure database that is maintained and regularly backed up by the Laboratory of Pathology NCI.  
The Laboratory of Pathology at NCI will process the tissue samples per Appendices 16.2, **16.3**,
16.4, **16.5**.
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5.1.5 sample storage tracking and

All specimens obtained in the protocol are used as defined in the protocol. Any specimens that are remaining at the completion of the protocol will be stored in the conditions described below. The study will remain open so long as sample or data analysis continues. Samples from consenting subjects will be stored until they are no longer of scientific value or if a subject withdraws consent for their continued use, at which time they will be destroyed. If the patient withdraws consent the participant's data will be excluded from future distributions, but data that have already been distributed for approved research use will not be able to be retrieved. The PI will record any loss or unanticipated destruction of samples as a deviation. Reporting will be per the requirements of section 7.2.
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5.2 samples for genetic/genomic analysis

Patients' tissue specimens will be analyzed for exploratory tumor-derived biomarkers. Assays performed may include, but are not limited to: a) immunohistochemistry (IHC) of FFPE samples to determine the frequency of tumor infiltrating lymphocytes (TILs) such as CD8 T cells and CD4 regulatory T cells, as well as the expression of predictive biomarkers such as PD-L1; b) whole exome sequencing (WES) and transcriptome analysis (RNAseq) of flash frozen/OCT samples to evaluate mutational burden and expression of neo-epitopes; and c) functional and phenotypic characterization of vitally frozen immune cell subsets.
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5.2.2 certificate of confidentiality

As part of study efforts to provide confidentiality of subject information, this study has obtained a Certificate of Confidentiality, which helps to protect personally identifiable research information. The Certificate of Confidentiality allows investigators on this trial to refuse to disclose identifying information related to the research participants, should such disclosure have adverse consequences for subjects or damage their financial standing, employability, insurability or reputation. The informed consent includes the appropriate coverage and restrictions of the Certificate of Confidentiality.
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5.2.3 incidental findings

Subjects will be contacted if a clinically actionable gene variant is discovered. Clinically actionable findings for the purpose of this study are defined as disorders appearing in the American College of Medical Genetics and Genomics recommendations for the return of incidental findings that is current at the time of primary analysis. (A list of current guidelines is maintained on the CCR intranet: https://ccrod.cancer.gov/confluence/display/CCRCRO/Incidental+Findings+Lists). Subjects will be contacted at this time with a request to provide a blood sample to be sent to a CLIA certified laboratory. If the research findings are verified in the CLIA certified lab, the subject will be offered the opportunity to come to NIH (at our expense) to have genetic education and counseling to explain this result. If the subject does not want to come to NIH, a referral to a local genetic healthcare provider will be provided (at their expense). Subjects enrolled at participating BTTC sites will be referred to a local genetics health care provider. This is the only time during the course of the study that incidental findings will be returned. No interrogations regarding clinically actionable findings will be made after the primary analysis.
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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 (i.e., at NIH) and ensuring data accuracy, consistency and timeliness. The MDASI-BT Survey responses will be entered by study subjects directly into Scribe/Labmatrix. The principal investigator, associate investigators/research nurses and/or a contracted data manager will assist with the data management efforts. All 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. Such events will be recorded at each examination on the Adverse Event case report forms/worksheets. The investigator will make every attempt to follow all subjects with non-serious adverse events for outcome. For the time period beginning at treatment initiation through 90 days following cessation of treatment, or 30 days following cessation of treatment if the subject initiates new anticancer therapy, whichever is earlier, any serious adverse event, or follow up to a serious adverse event, including death due to any cause, whether or not related to the study treatments, must be reported.
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6.1.1 exceptions to data collection

Adverse events that occur after the consent form is signed but before treatment (RT, Pembrolizumab, TMZ) must be collected by the investigator only if they cause the subject to be excluded from the trial. Sites (NCI or participating BTTC sites) will be responsible for entering data collected at their site. Changes resulting from normal growth and development that do not vary significantly in frequency or severity from expected levels are not to be considered adverse events. Examples of this may include, but are not limited to, onset of menses or menopause occurring at a physiologically appropriate time. An abnormal laboratory value will be considered an AE 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, this will be reported expeditiously per requirements in section **7.2.1**.
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6.1.2 source documentation timeframes

The following information will be entered into NCI-designated eCRF and Scribe/Labmatrix within the indicated timeframes. In addition, the source documents should be provided to the BTTC Coordinating Center's Research Nurse at secure fax: 240-541-4432, encrypted email, or Secure Email and File Transfer within the indicated timeframe. The MDASI-BT responses will be entered by study subjects directly into Scribe/LabMatrix.  
| Data Set / Source Documents                  | Schedule for Submission         |
|----------------------------------------------|---------------------------------|
| Regulatory Documents                         | Prior to Step 1 of registration |
| (as described in the BTTC Operations Manual) |                                 | Version Date: *06/30/2021*  
| Version Date: 06/30/2021 Data Set / Source Documents   | Schedule for Submission                                                                                                                                                                                           |
|--------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Registration Form (eligibility checklist)              | Within 24 hours of signing Informed  Consent (Step 1 registration) Following surgery and confirmation of  diagnosis (Step 2 registration) Prior to end of RT in order to randomize  subject (Step 3 registration) |
| Copy of signed & dated Informed Consent w/             | Within 24 hours of signing Informed                                                                                                                                                                               |
| HIPAA Authorization                                    | Consent (Step 1 registration)                                                                                                                                                                                     |
| Pathology Report (from the most recent preregistration diagnostic biopsy or surgery)                                                        | At time of Step 2 of registration                                                                                                                                                                                 |
| Baseline MDASI - BT Questionnaire                      | Within 14 days (+ 3 working days) after  enrollment                                                                                                                                                               |
| Screening/Baseline Source Documents                    | At time of registration (step 1 or 2, as  applicable)                                                                                                                                                             |
| Other Source Documents                                 | With Participant Status Updates Form                                                                                                                                                                              |
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6.1.3 database entry timeframes

The following data should be entered into the NCI-designated eCFR and Scribe/Labmatrix within the specified timeframes. Source documentation will be kept at the participating site. Sites (NCI or participating BTTC sites) will be responsible for entering data collected at their site.  
Version Date: *06/30/2021*  
| Version Date: 06/30/2021 Data Set                                                                                                                                                                                                                  | Schedule for Data Entry                                                                                                                                                               |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Screening data                                                                                                                                                                                                                                     | Within 14 days of Step 1 Registration                                                                                                                                                 |
| Baseline data                                                                                                                                                                                                                                      | No later than 14 days after Day 1 of radiation  (RT cycle)                                                                                                                            |
| Treatment (Course/Cycle) Data (To include treatment, response, AE, and  clinical evaluation information)                                                                                                                                           | Course initiation case report form (CRF) no  later than 7 days after the cycle begins All other course/cycle CRFs must be entered  no later than 21 days after the cycle is  complete |
| Off Treatment Data                                                                                                                                                                                                                                 | Within 21 days after the: - last date of any modality of protocol  treatment; or, - study discontinuation visit.                                                                      |
| Follow-up (Survival) Data (To include post-protocol treatment and longterm follow up survival data)                                                                                                                                                                                                                                                    | No later than 21 days after follow up visit or  survival call or post-treatment medication  begins.                                                                                   |
| Note: Long-term follow up is required every 8- 16 weeks for two years until patient is off  study. Non-Treatment Data (May include Quality of Life questionnaires (MDASI-BT), Specimen Tracking information,  Pathology Specimen Submission, etc.) | Within 10 days after each scheduled  assessment, event, or activity                                                                                                                   |
| Off Study Data                                                                                                                                                                                                                                     | No later than 21 days after the date the  patient is removed from the study.                                                                                                          |
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6.1.4 confidentiality

All documents, investigative reports, or information relating to the patient are strictly confidential. Any source documents submitted to the BTTC Coordinating Center with protected health information or personally identifiable information (e.g. patient's name) must be sent via Secure Email and File Transfer (SEFT) or secure fax. For NIH only, documents can also be sent via hand-delivery or encrypted email.
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6.1.5 safety data

All patients receiving study agents will be evaluated for safety. The safety parameters include all laboratory tests and hematological abnormalities, CNS observations, physical examination findings, and spontaneous reports of adverse events reported to the investigator by patients. Life-threatening toxicities that are unexpected and assessed to be possibly related to the study agent/s should be reported immediately. Information about all adverse events, whether volunteered by the subject, discovered by investigator questioning, or detected through physical examination, laboratory test or other means, will be collected and recorded on the Adverse Event Case Report Form and followed as appropriate. Medical conditions/diseases present before starting study treatment are only considered adverse events if they worsen after starting study treatment (any procedures specified in the protocol). Adverse events occurring before starting study treatment but after signing the informed consent form are recorded on the Baseline Evaluations Case Report Form.
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6.1.6 data monitoring

All submitted data will be monitored by the BTTC Protocol Manager specifically assigned to this protocol. Requests for correction of data deficiencies will be sent via mail to the Institutional Coordinator. Any major deficiencies will be corrected by telephone communication. All data will be monitored for completeness. Key parameters such as drug dosages including attenuations and escalations, toxicity documentation and tumor measurements will be analyzed. All data deficiencies will be corrected within two weeks.
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6.2 data sharing plans 6.2.1

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 another public repository. - Coded, linked data in BTRIS (automatic for activities in the Clinical Center) - Coded, linked or identified 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.
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6.2.2 genomic data sharing plan

Unlinked genomic data will be deposited in public genomic databases such as dbGaP in compliance with the NIH Genomic Data Sharing Policy.
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6.3 response criteria

6.3.1 **Definitions**
6.3.1.1 Evaluable for toxicity: All patients will be evaluable for toxicity from the time of their first treatment with Pembrolizumab and/or HSPPC-96.  
6.3.1.2 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. These patients will have their response classified according to the definitions stated below. (Note: Patients who exhibit objective disease progression prior to the end of cycle 1 will also be considered evaluable.)
6.3.1.3 Evaluable Non-Target Disease Response: Patients who have lesions present at baseline that are evaluable but do not meet the definitions of measurable disease, have received at least one cycle of therapy, and have had their disease re-evaluated will be considered evaluable for non-target disease. The response assessment is based on the presence, absence, or unequivocal progression of the lesions.
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6.3.2 disease parameters 6.3.2.1 measurable

| RANO Criteria for Response [44]   | CR          | PR          | SD          | PD          |
|-----------------------------------|-------------|-------------|-------------|-------------|
| < 50% ↓ but                       |             |             |             |             |
| T1 gadolinium enhancing disease   | None        | ≥ 50% ↓     | < 25% ↑     | ≥ 25% 1 ↑ 1 |
| T2/FLAIR                          | Stable or ↓ | Stable or ↓ | Stable or ↓ | ↑           |
| New lesion                        | None        | None        | None        | Present1    |
| Corticosteroids                   | None        | Stable or ↓ | Stable or ↓ | n/a†        |
| Clinical status                   | Stable or ↑ | Stable or ↑ | Stable or ↑ | ↓ 1         |
| Requirement for response          | All         | All         | All         | Any1        |  
| RANO Criteria for Response [44]   | CR   | PR   | SD   | PD   |
|-----------------------------------|------|------|------|------|  
¹ Progression occurs when this criterion is present †Increase in corticosteroids alone will not be taken into account in determining progression in the absence of persistent clinical deterioration.  
↓ = decreased, ↑ = increased, CR = complete response, PR = partial response, SD = stable disease, PD = progressive disease. If PD is unclear based on white matter changes, patients may be kept on trial.  
FLAIR, fluid-attenuated inversion recovery; NA, not applicable.
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irano (exploratory)[ 45 ] 6.3.4

| Table11                                                                                                      | RANO Criteria                                                                                                          |                                              |                                            |
|--------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------|----------------------------------------------|--------------------------------------------|
| Malignant Glioma 16                                                                                          | Low-Grade Glioma¹ ⁷                                                                                                    | Brain Metastases 18                          |                                            |
| Complete Response                                                                                            | -Disappearance of all enhancing                                                                                        | -Disappearance of all enhancing and T2/FLAIR | -Disappearance of all enhancing target and |
| disease for > 4 weeks AND                                                                                    | disease for ≥ 4 weeks AND                                                                                              | non-target lesions for ≥ 4 weeks AND         |                                            |
| - No new lesions AND                                                                                         | - No new lesions AND                                                                                                   | - No new lesions AND                         |                                            |
| - Stable/improved T2/FLAIR AND                                                                               | - No more than physiologic steroids AND                                                                                | - No steroids AND                            |                                            |
| - No more than physiologic steroids AND                                                                      | - Stable/improved clinically                                                                                           | - Stable/improved dinically                  |                                            |
| - Stable/improved clinically                                                                                 |                                                                                                                        |                                              |                                            |
| Partial Response                                                                                             | - ≥ 50% ↓ sum of biperpendicular diameters                                                                             | - ≥ 50% ↓ sum of biperpendicular diameters   | - ≥ 30% ↓ sum of longest diameters         |
| of enhancing disease for ≥ 4 weeks AND                                                                       | of T2/FLAIR disease for ≥ 4 weeks AND                                                                                  | of target lesions for ≥ 4 weeks AND          |                                            |
| - No new lesions AND                                                                                         | - No new lesions AND                                                                                                   | - No new lesions AND                         |                                            |
| - Stable/improved T2/FLAIR AND                                                                               | - Stable/improved steroids AND                                                                                         | - Stable/improved steroids AND               |                                            |
| - Stable/improved steroids AND                                                                               | - Stable/improved clinically                                                                                           | - Stable/improved dinically                  |                                            |
| - Stable/improved clinically                                                                                 |                                                                                                                        |                                              |                                            |
| Minor Response                                                                                               | - Non-applicable                                                                                                       | - 25-49% ↓ sum of biperpendicular            | Not applicable                             |
| diameters of T2/FLAIR disease for ≥ 4 weeks AND                                                              |                                                                                                                        |                                              |                                            |
| - No new lesions AND                                                                                         |                                                                                                                        |                                              |                                            |
| - Stable/improved clinically                                                                                 |                                                                                                                        |                                              |                                            |
| Stable Disease                                                                                               | - Does not qualify for CR, PR, PD AND                                                                                  | - Does not qualify for CR, PR, PD AND        | - Does not qualify for CR, PR, PD          |
| - No new lesions AND                                                                                         | - No new lesions AND                                                                                                   |                                              |                                            |
| - Stable/improved T2/FLAIR AND                                                                               | - Stable/improved T2/FLAIR AND                                                                                         |                                              |                                            |
| - Stable/improved steroids AND                                                                               | - Stable/improved steroids AND                                                                                         |                                              |                                            |
| - Stable/improved clinically                                                                                 | - Stable/improved clinically                                                                                           |                                              |                                            |
| - ≥ 25% ↑ sum of biperpendicular                                                                             | - ≥ 25% ↑ sum of biperpendicular                                                                                       | - ≥ 20% ↑ sum of longest                     |                                            |
| Progressive Disease                                                                                          | diameters of enhancing disease OR                                                                                      | diameters of T2/FLAIR disease OR             | diameters of target lesions OR             |
| - New lesions OR                                                                                             | - New lesions OR                                                                                                       | -Unequivocal progression of enhancing        |                                            |
| - Significant worsened T2/FLAIR OR                                                                           | - Significant clinical dedine                                                                                          | nn-target lesions OR                         |                                            |
| - Significant clinical dedin                                                                                 | - New lesions OR                                                                                                       |                                              |                                            |
| - Significant clinical dedine                                                                                |                                                                                                                        |                                              |                                            |
| Confirmation of progression on follow-up imaging 3 months after initial radiographic progression if:         |                                                                                                                        |                                              |                                            |
| No new or significantly worsened neurologic deficits not due to co-morbid event or concurrent medication AND |                                                                                                                        |                                              |                                            |
| 2.                                                                                                           | ::: 6 months from initiation of immunotherapy                                                                          |                                              |                                            |
| iRANO                                                                                                        | I f follow-up imaging confirms progression, the date of actual progression should be back-dated to the date of initial |                                              |                                            |
| radiographic progression                                                                                     |                                                                                                                        |                                              |                                            |
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6.3.6 dose limiting toxicity 6.3.7

6.3.5.1 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. 6.3.5.2 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.  
Any of the following adverse events not due to disease progression or any underlying disease will be documented as a DLT during the first 4 weeks of treatment with Pembrolizumab, TMZ and HSPPC-96/Placebo (attribution should be assigned to drug most suspected) during the first post RT cycle, after completion of induction:
- Grade 4 neutropenia for more than 7 days
- Grade 3 or 4 febrile neutropenia during the first 4 weeks
- Grade 3 or 4 thrombocytopenia for more than 7 days - Grade 4 anemia for more than 7 days
- Grade 3 or 4 non-hematologic adverse events.  
- Exceptions include: - Grade 3 nausea, vomiting or diarrhea will only be considered a DLT if not adequately managed with maximum supportive care within 48 hours.  
- More than 14 days of treatment delay due to the failure to recover from attributable toxicity.  
Subjects experiencing irAEs due to Pembrolizumab and are successfully treated for toxicity, and able to be re-dosed will not be considered to have experienced DLTs. The frequency, grade, and nature of irAE will be recorded.  
Progression free survival will be defined from the time of registration to the time of confirmed progression. In cases where this might be unclear, patients may continue on trial. Defined as the time from registration to the time of death Response review will be done locally and by Study Chair if response is questionable.
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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. An investigator who is a qualified physician will evaluate all adverse events according to (CTCAE), version 5.0. Any adverse event which changes CTCAE grade over the course of a given episode will have each change of grade recorded on the adverse event case report forms/worksheets. All adverse events regardless of CTCAE grade must also be evaluated for seriousness. 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. 7.2 OHSRP OFFICE OF COMPLIANCE AND TRAINING / IRB REPORTING
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7.2.1 expedited reporting

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 per these policies.
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7.2.2 irb requirements for nci

Please refer to the reporting requirements in Policy 801: Reporting Research Events found here.
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7.3 nci clinical director reporting

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 nci guidance for reporting

The site PI (at the participating BTTC site) must immediately report to the coordinating center PI any serious adverse event, whether or not considered drug related, including those listed in the protocol or investigator brochure and must include an assessment of whether there is a reasonable possibility that the drug caused the event within 24 hours of PI awareness of the event. CCR Reportable Event Form (REF) will be used to submit Serious Adverse Events to both the CCR Office of Sponsor and Regulatory Oversight at OSROSafety@mail.nih.gov and the BTTC Coordinating Center. https://ccrod.cancer.gov/confluence/display/CCRCRO/Templates Participating BTTC sites must also report events to the Reviewing IRB as per its policy. For IND studies, the site PI will also directly submit reports to the CCR as IND sponsor per section 8.3. Please also notify the coordinating center PI and study coordinator of your submission a the time you make it. The BTTC Coordinating Center will maintain documentation of all Serious Adverse Events from each institution. The BTTC Coordinating Center will notify all investigators of any serious and unexpected adverse experiences that are possibly related to the study agent/s. The investigators are to file a copy with their protocol file and send a copy to their IRB according to their local IRB's policies and procedures.  
- For the time period beginning when the consent form is signed until treatment initiation, any serious adverse event, or follow up to a serious adverse event, including death due to any cause that occurs to any subject must be reported within 24 hours to the Sponsor
(NCI) if it causes the subject to be excluded from the trial, or is the result of a protocolspecified 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 initiation through 90 days following cessation of treatment, or 30 days following cessation of treatment if the subject initiates new anticancer therapy, whichever is earlier, any serious adverse event, or follow up to a serious adverse event, including death due to any cause, whether or not related to the study treatments, must be reported within 24 hours to the Sponsor (NCI).  
- Additionally, any serious adverse event, considered by an investigator who is a qualified physician to be related to study treatment that is brought to the attention of the investigator at any time following consent through the end of the specified safety followup period specified in the paragraph above, or at any time outside of the time period specified in the previous paragraph also must be reported immediately to the Sponsor.  
All subjects with serious adverse events must be followed up for outcome.
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7.4.1 reporting deviations and unanticipated

Deviation or Unanticipated Problem Reports and any accompanying documentation (to include the local IRB acknowledgement of the event when applicable) are to be submitted by the participating BTTC site to the BTTC Coordinating Center using the CCR Reportable Event
(REF) Form in Appendix **16.10** by email nci_bttc@mail.nih.gov or via fax at: 240-541-4432.  
Deviations or Unanticipated problems must be submitted to the BTTC Coordinating Center within 5 days after becoming aware of the event. When Deviations or Unanticipated Problems are reported to BTTC, but, the local IRB does not require a report, the report that is submitted to the BTTC Coordinating Center must be accompanied by a formal memo explaining the local policy and the rationale for not reporting the event to the local IRB. Neither the FDA nor the ICH GCP guidelines define the term "protocol deviation." The definition is often left to the Lead Institution IRB. Accordingly, since NCI, Center for Cancer Research is the Coordinating Center and the Lead PI must adhere to those policies set by the NIH Intramural IRB, the definitions for unanticipated problem and protocol deviation as described by the NIH Intramural IRB will be applied for reporting purposes for all institutions participating in this study. Definitions are listed in Section 7.1.  
Protocol Deviations or Unanticipated problems occurring at a participating institution will be submitted to that institution's own IRB in accordance with local policies and procedures. However, the participating institution must submit a report to the BTTC Coordinating Center even in instances where the local IRB does not require a report.  
NCI Center for Cancer Research BTTC Coordinating Center: Upon receipt of the deviation/unanticipated reportable event report from the participating institution, the BTTC Coordinating Center will submit the report to the Study Chair for review. Subsequently, the participating institution's IRB deviation/unanticipated reportable event report will be submitted to the NIH Intramural IRB if it meets the criteria under Policy 801: Reporting Research Events found here.
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7.5 nih required data and

The clinical research team will have a teleconference every other week when patients are being actively treated on the trial to discuss each patient. 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 within the appropriate timelines.  
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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7.5.1 data safety monitoring board

As this is a prospective, double-blinded, randomized controlled trial, the NCI/CCR DSMB will be used to monitor the trial. This monitoring will be done for futility, as well as for safety. Since the meetings of the NCI DSMB are annual, futility monitoring may be performed by the DSMB at a special meeting requested by the study team. These ad-hoc DSMB meetings may convene by phone in the event of rapid accrual. The interim data analyses needed for the DSMB futility monitoring will be performed by the BTTC biostatistician. Subjects will be randomized without stratification on a 1:1 basis, using variable block sizes. The first block will be of size n=6 in order to facilitate the evaluation of toxicity and safety in the first 3 patients on each arm. The futility monitoring will be performed as follows: at the first DSMB meeting after which 22 patients have been enrolled into each of the experimental arms, given an experimental arm,
(i) if 16 or more patients survive at 8 months, additional 23 patients will be enrolled into that arm; (ii) if 7 or more patients fail to survive at 8 months, the experimental arm will be terminated early.  
If neither of these two conditions are satisfied, in other words, some patients are followed less than 8 months and their survival at 8 month is unknown, the posterior probability Pr(OS8 < 0.75 | data) will be evaluated using the method of Cai, Liu and Yuan (2014) [48]. If Pr(OS8 < 0.75 | data) > 0.6, the experimental arm will be terminated early; otherwise additional 23 patients will be enrolled into that arm. Note that this posterior stopping rule is consistent with rules (i) and (ii). Interim outcome results will not be revealed to the investigators of the trial; results will be presented to the investigators prior to final accrual to the trial only if the DSMB recommends early termination of the trial. The DSMB will review the rules for early termination for toxicity and provide feedback to the BTTC Biostatistician, the Study Chair, and lead PI who will confirm the condition for early termination. Once confirmed, the Biostatistician will then communicate to CRO (Central Registration Office) to break the blind and provide the listing to the BTTC Biostatistician and Study Chair. The evaluation for safety will be performed independently for each of the two experimental arms as follows:
For each of the experimental arms, stop the enrollment if [\# of patients with DLT]/[\# of patients evaluated] ≥ 2/3, 4/6, 5/10 or *8/20; otherwise continue the enrollment.*
In the case that one arm is discontinued due to futility or safety, enrollment would shift to the remaining arm as the primary objective of this trial is not to compare two arms.
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7.5.2 patient-reported outcomes

Received MDASI-BT forms will be checked versus the timing schedule and considered as valid if they fall within 14 days of the scheduled assessment window. Compliance rates will be calculated as the number of received valid forms over the number of expected forms. Differences between groups in compliance will be tested by use of Fisher's exact test at every time point. We will use descriptive statistics to describe how patients rate symptom severity and interference with function at each time point. Error bar graphs for each of the symptoms will be constructed at each time point. The proportion of patients rating their symptoms to be 5 or greater (on a 0-10 scale) will also be reported. We will construct individual patient profiles for each of the selected symptoms to describe the individual patients' patterns of change over time. We will calculate the mean symptom severity and mean symptom interference at the time of clinical evaluation. Estimates of differences in the mean symptom severity and mean symptom interference between responders and non-responders will be estimated in the intent to treat population. All patients with at least one valid questionnaire will be included in the analyses. Questionnaires completed at study registration will be considered baseline. All questionnaire data received after randomization will be used in the primary analyses. Differences of at least 2 points will be classified as the minimum clinically meaningful change in the symptom severity and symptom interference measures. For example, an increase of 2 points or more would mean a moderate improvement, whereas a decrease of 2 points or more would be interpreted as moderate worsening. For individual symptoms, a rise in a symptom score means deterioration, whereas a reduced score means improvement of the specific symptom.
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7.6 exploratory objectives & endpoints

PDL1 expression and T-Cell infiltrate in tumor will be correlated using Spearman correlation coefficients. Peripheral T-Cell activation and tryptophan metabolites will be summarized by reporting descriptive statistics such as median and inter-quartile range for all time points.
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8 sponsor protocol/safety reporting 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 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 or subject 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.
Note: In addition to the above criteria, adverse events meeting either of the below criteria, although not serious per ICH definition, are reportable to the Merck in the same timeframe as SAEs to meet certain local requirements. Therefore, these events are considered serious by Merck for collection purposes.  
- Is a new cancer (that is not a condition of the study);
- Is associated with an overdose.  
Refer to Section **8.1.1** "Adverse Events" for additional details regarding each of the above criteria. 8.1.2.1 Protocol-Specific Exceptions to Serious Adverse Event Reporting Efficacy endpoints as outlined in this section will not be reported to Merck as described in Immediate Reporting of Adverse Events to the Sponsor (NCI), unless there is evidence suggesting a causal relationship between the drug and the event. Any such event will be submitted to the Merck within 24 hours. Specifically, the suspected/actual events covered in this exception include any event that is disease progression of the cancer under study. Hospitalization related to convenience (e.g. transportation issues, etc.) will not be considered a SAE.
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8.1.3 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)
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8.1.4 severity

The severity of each Adverse Event will be assessed utilizing the CTCAE version 5.
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8.1.5 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.
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8.1.6 events of clinical interest

- an overdose of Merck product, as defined in Section **8.1.7** Definition of an Overdose for This Protocol and Reporting of Overdose to the Sponsor, that is not associated with clinical symptoms or abnormal laboratory results.  
- 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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8.1.7 definition of an overdose

For purposes of this trial, an overdose of pembrolizumab will be defined as any dose of 1,000 mg or greater (≥5 times the indicated dose). No specific information is available on the treatment of overdose of pembrolizumab. Appropriate supportive treatment should be provided if clinically indicated. In the event of overdose, the subject should be observed closely for signs of toxicity. Appropriate supportive treatment should be provided if clinically indicated. If an adverse event(s) is associated with ("results from") the overdose of a Merck product, the adverse event(s) is reported as a serious adverse event, even if no other seriousness criteria are met. If a dose of Merck's product meeting the protocol definition of overdose is taken without any associated clinical symptoms or abnormal laboratory results, the overdose is reported as a 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 24 hours to the Sponsor.
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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. 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 6.1Error! Reference source not found.. All serious adverse events recorded from the time of first investigational product administration must be reported to the sponsor with the exception of any listed in section 8.4.
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8.3 reporting of serious adverse

Any AE that meets 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. Any exceptions to the expedited reporting requirements are found in section 8.4. All SAE reporting must include the elements described in section 8.2.  
SAE reports will be submitted to the NCI Center for Cancer Research (CCR) at: OSROSafety@mail.nih.gov and to the BTTC PI and study coordinator. CCR SAE report form and instructions can be found at: https://ccrod.cancer.gov/confluence/display/CCRCRO/Forms+and+Instructions 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

CCR Safety will only provide the following: SAEs, SUSARs, overdoses and pregnancies. CCR
Safety will not send routine AEs or periodic reports.
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8.4.2 to be sent by

An investigator who is a qualified physician, will evaluate all adverse events:
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8.4.2.2 duration

Record the start and stop dates of the adverse event. If less than 1 day, indicate the appropriate length of time and units. 8.4.2.3 **Action taken** Did the adverse event cause Merck product to be discontinued? 8.4.2.4 Relationship to Merck Product Did Merck product cause the adverse event? The determination of the likelihood that Merck product caused the adverse event will be provided by an investigator who is a qualified physician. The investigator's signed/dated initials on the source document or worksheet that supports the causality noted on the AE form, ensures that a medically qualified assessment of causality was done. This initialed document must be retained for the required regulatory time frame. The criteria below are intended as reference guidelines to assist the investigator in assessing the likelihood of a relationship between the test drug and the adverse event based upon the available information. The following components are to be used to assess the relationship between Merck product and the AE; the greater the correlation with the components and their respective elements (in number and/or intensity), the more likely Merck product caused the adverse event (AE):
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8.4.2.5 exposure

Is there evidence that the subject was actually exposed to Merck product such as: reliable history, acceptable compliance assessment (pill count, diary, etc.), expected pharmacologic effect, or measurement of drug/metabolite in bodily specimen?
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8.4.2.6 time course

Did the AE follow in a reasonable temporal sequence from administration of Merck product? Is the time of onset of the AE compatible with a drug-induced effect (applies to trials with investigational medicinal product)?
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8.4.2.7 likely cause

Is the AE not reasonably explained by another etiology such as underlying disease, other drug(s)/vaccine(s), or other host or environmental factors
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8.4.2.8 dechallenge

Was Merck product discontinued or dose/exposure/frequency reduced? If yes, did the AE resolve or improve? If yes, this is a positive dechallenge. If no, this is a negative dechallenge. (Note: This criterion is not applicable if: (1) the AE resulted in death or permanent disability; (2) the AE resolved/improved despite continuation of the Sponsor's product; or (3) the trial is a single-dose drug trial); or (4) Sponsor's product(s) is/are only used one time.)
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8.4.2.9 rechallenge

Was the subject re-exposed to Merck product in this study? If yes, did the AE recur or worsen? If yes, this is a positive rechallenge. If no, this is a negative rechallenge.  
(**Note**: This criterion is not applicable if: (1) the initial AE resulted in death or permanent disability, or (2) the trial is a single-dose drug trial); or (3) Sponsor's product(s) is/are used only one time).  
NOTE: IF A RECHALLENGE IS PLANNED FOR AN ADVERSE EVENT WHICH WAS
SERIOUS AND WHICH MAY HAVE BEEN CAUSED BY MERCK PRODUCT, OR IF REEXPOSURE TO MERCK PRODUCT POSES ADDITIONAL POTENTIAL SIGNIFICANT RISK TO THE SUBJECT, THEN THE RECHALLENGE MUST BE APPROVED IN ADVANCE BY THE SPONSOR AS PER DOSE MODIFICATION GUIDELINES IN THE PROTOCOL.
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8.4.2.10 consistency with trial treatment

Is the clinical/pathological presentation of the AE consistent with previous knowledge regarding Merck product or drug class pharmacology or toxicology? The assessment of relationship will be reported on the case report forms /worksheets by an investigator who is a qualified physician according to his/her best clinical judgment, including consideration of the above elements. Record one of the following: Use the following scale of criteria as guidance (not all criteria must be present to be indicative of Merck product relationship).  
1. **Yes, there is a reasonable possibility of Merck product relationship**. There is evidence of exposure to Merck product. The temporal sequence of the AE onset relative to the administration of Merck product is reasonable. The AE is more likely explained by Merck product than by another cause.
2. **No, there is not a reasonable possibility of Merck product relationship**. Subject did not receive the Merck product OR temporal sequence of the AE onset relative to administration of Merck product is not reasonable OR the AE is more likely explained by another cause than the Merck product. (Also entered for a subject with overdose without an associated AE.)
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8.4.3 events of clinical interest

These selected non-serious and serious adverse events are also known as Events of Clinical Interest (ECI) and must be reported within 24 hours to Merck. For reporting of ECI refer to section 8.3.  
For the time period beginning when the consent form is signed until treatment initiation, any ECI, or follow up to an ECI, that occurs to any subject must be reported within 24 hours to the Sponsor if it causes the subject to be excluded from the trial, or is the result of a protocolspecified 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 initiation through 90 days following cessation of treatment, or 30 days following cessation of treatment if the subject initiates new anticancer therapy, whichever is earlier, any ECI, or follow up to an ECI, whether or not related to study treatment, must be reported within 24 hours to the Sponsor (NCI). Merck Global Safety facsimile number: +1-215-993-1220 (Sponsor [NCI] will contact Merck)
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8.4.4 reporting serious adverse events

Upon receipt, Sponsor (NCI) will forward SAE reports and any other relevant safety information to the Merck Global Safety facsimile number: +1-215-993-1220 and to Agenus Pharmacovigilance via email: adverse.events@agenusbio.com or fax: 1-781-674-4261. Version Date: *06/30/2021* A copy of all 15 Day Reports and Annual Progress Reports will be submitted to Merck & Co., Inc. (Attn: Worldwide Product Safety; FAX 215 993-1220) and to Agenus Pharmacovigilance (email: adverse.events@agenusbio.com or fax: 1-781-674-4261) at the time of submission to FDA. For the time period beginning at treatment initiation through 90 days following cessation of treatment, or 30 days following cessation of treatment if the subject initiates new anticancer therapy, whichever is earlier, any ECI, or follow up to an ECI, whether or not related to study treatment, must be reported within 24 hours to the Sponsor (NCI). Sites will submit all reportable events to the Sponsor (NCI), and NCI will submit to Agenus and Merck within 2 working days. The DSMB Sponsor will monitor unblinded aggregated efficacy endpoint events and safety data to ensure the safety of the subjects in the trial. Any suspected endpoint which upon review is not progression of the cancer under study will be forwarded to Merck Global Safety and Agenus Pharmacovigilance as a SAE within 2 working days of determination that the event is not progression of the cancer under study. For reporting pregnancy: The designated Sponsor representative will work with the investigator to ensure that all relevant information is provided to Merck and Agenus within 1 to 5 calendar days for SAEs and within 30 days for all other pregnancies. The same timelines apply when outcome information is available.
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8.5 reporting pregnancy

All required pregnancy reports/follow-up to OSRO will be submitted to: OSROSafety@mail.nih.gov and to the CCR PI and study coordinator. Forms and instructions can be found here: https://ccrod.cancer.gov/confluence/display/CCRCRO/Forms+and+Instructions.
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8.5.1 maternal exposure

If a participant 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 becomes known, Pregnancy itself is not regarded as an SAE. However, congenital abnormalities or birth defects and spontaneous miscarriages that meet serious criteria (section 8.3) 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.
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8.5.2 paternal exposure

Male participants should refrain from fathering a child or donating sperm during the study and for 120 days after the last dose of pembrolizumab. Pregnancy of the participant'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 120 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 in expediated manner to the FDA in accordance to 21 CFR 312. 32. 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

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 study endpoints; adherence to the protocol, regulations, 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

This is a phase II blinded, randomized trial in newly diagnosed GBM. Evaluable patients must complete 1 cycle of treatment post RT. A Bayesian two-stage design will be used to monitor the efficacy of two experimental arms independently based on the OS at 8 months (OS8) using the following Bayesian rule (Thall and Simon, 1994) [46]:
Stop the experimental arm for futility if Pr (OS8 < 0.75 *| data ) > 0.6.*
That is, if the observed data indicate that there is greater than 60% chance that the OS8 is smaller than 0.75, we stop the experimental arm. We choose 0.75 as the threshold because that is the estimate of OS8 for the standard of care (RT+TMZ). In order to speed up the trial, we use the OS8, rather than the OS at 12 months (i.e., the primary endpoint), for the purpose of interim monitoring. Assuming vague Beta prior Beta (0.25, 0.25) for the OS8, the two-stage Bayesian design can be described as follows:
Enroll 22 patients for each of the experimental arms, if 16 *or more patients* survive at 8 months, we continue to enroll the remaining 23 patients; otherwise stop that experimental arm.  
At the interim analysis, if some patients are followed less than 8 months, we will calculate Pr (OS8 < 0.75 | data) based on the methodology of Cai, Liu and Yuan (2014) by imputing the OS8 for these patients. The following table shows the operating characteristics of the Bayesian phase II design:  
| True OS8             |       |       |       |       |
|----------------------|-------|-------|-------|-------|
| 0.6                  | 0.7   | 0.8   | 0.9   |       |
| Stopping probability | 0.845 | 0.507 | 0.135 | 0.004 |
| Average sample size  | 25.6  | 33.3  | 41.9  | 44.9  |  
Similar Bayesian method will also be used to monitor the rate of DLT. We monitor two experimental arms independently-patients that are randomized. Specifically, for each of the arms, we will stop enrolling patients and inspect the safety data if the Pr(DLT > 25% | data) > 0.9. That is, we will stop enrolling patients if the data indicate that there is more than 90% chance that the true DLT rate is higher than 25%. This decision rule gives the following stopping rule, assuming a Beta(0.1, 0.4) prior distribution for DLT rate, Stop enrolling pts if [\# of pts with DLT] / [\# of pts evaluated] ≥ 2/3, 4/6, 5/10 or *8/20.*
Below are the operating characteristics of the toxicity monitoring rule.  
| True toxicity rate   |       |       |       |       |       |
|----------------------|-------|-------|-------|-------|-------|
| 0.1                  | 0.2   | 0.3   | 0.4   | 0.5   |       |
| Early stop           | 0.028 | 0.136 | 0.372 | 0.692 | 0.906 |
| probability Average  | 27.3  | 25.0  | 20.6  | 14.9  | 9.8   |
| sample size          |       |       |       |       |       |  
In the case that one arm is discontinued due to futility or safety, enrollment would shift to the remaining arm as the primary objective of this trial is not to compare two arms.
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10.1 sample size and accrual

Based on previous experience of newly diagnosed (ND) unmethylated GBM patients treated with Pembrolizumab, the estimated one-year OS for the RT+TMZ+Pembrolizumab arm is 70%, and the estimated one-year OS for the RT+TMZ+Pembrolizumab +HSPPC-96 arm is 90%. Given one-sided significance level of 0.10, the sample size of 45 patients per arm provides 80% power to detect the difference between two experimental arms. Treatment accrual for the randomization arms will be 90 patients (45 patients per arm). Considering vaccine production failures for patients when HSPPC-96 is not produced, accrual in the ancillary cohort is up to 18 patients. Therefore, the randomized treatment accrual ceiling will be 108 patients. Assuming a screen failure rate of 65%, the total accrual ceiling will be 310 patients. Approximately 8 potentially eligible patients are seen per month, and it is anticipated that at least 1-2 per month will be accrued per site. NOTE: DSMB recommended in May 2021 to terminate study early due to slow accrual. Study is closed to enrolment. Patients will be unblinded but will be kept on treatment until completion of TMZ, Pembro, and/or HSPPC-96 and followed for overall survival. Placebo will be discontinued.
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10.2 data analyses plans

Progression-free and overall survival will be determined using a Kaplan-Meier survival curve. Median PFS and OS will be determined from this curve. A one-sided lower 90% confidence limit for median PFS and OS will be determined by the method of Brookmeyer and Crowley [47]. The Chi-square test will be used to compare the one-year OS between two experimental arms. In addition, the weighted log rank test will also be used to compare the OS and PFS between two experimental arms.
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10.3 secondary objectives & endpoints

- PFS-6 (percentage of subjects alive and progression-free at 6 months post-registration):
determined from the value of the Kaplan-Meier curve at 6 months.  
- Response rate: determined as described by RANO **Table 2**. Rates and 95% confidence intervals will be determined using exact binomial probability distributions.  
- Overall survival: Kaplan-Meier curves will be used to analyze overall survival.  
- OS-6, 12 and 24 (overall survival at 6, 12, and 24 months post-registration, respectively):
determined from the level of the Kaplan-Meier curves at these time points.  
- Safety of Pembrolizumab in GBM: Adverse events will be described descriptively by giving frequencies of each event by type, severity, frequency, timing, and attribution.  
- To evaluate the occurrence of symptoms and correlate to disease progression and tolerance to treatment using the MD Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT).
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11 collaborative agreements 11.1 agreement

There is a BTTC consortia agreement in place between all of the participating institutions listed on the Key Study Personnel page of this study. In addition, there are CRADA agreements in place with Merck (03128), and Agenus (03127) who are supporting this study. A listing of all other agreements is found in Appendix 16.16.  
Transfers that are associated with correlative studies conducted under an approved protocol: Investigators in the NIH intramural program may participate in multi-site clinical trials (either as a site or as the coordinating center) under which human materials are transferred from the intramural program to another site for correlative studies that are part of the approved protocol. In such a situation, the protocol clearly documents the tests conducted under the correlative studies, and each institution participating in the clinical study is bound by the terms of their Protocol and their obligations under the statutes and regulations. In addition, intramural protocols are cleared by the IC Clinical Director. In such a situation, use of an HM-MTA is not necessary for these transfers.
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11.2 multi-institutional guidelines 11.2.1 participating

Before an institution may begin participating in a BTTC protocol, they must complete the following steps:
- Submit all required regulatory documents to the BTTC Coordinating Center
- Participate in a site initiation visit, webcast, or conference call
- Receive training regarding study specific CRF's and/or databases After these requirements have been fulfilled, the participating institution will receive by fax, email, or hard copy, a Site Activation Memo. Once the Site Activation Memo has been received, the participating institution may begin to register patients to the protocol.
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11.2.2 irb approvals

The lead PI will provide the NIH Intramural IRB with a copy of the participating institution's initial approval and approved yearly continuing review. Registration will be halted at any participating institution in which a current continuing approval is not on file at the NIH Intramural IRB.
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12 human subjects protections 12.1

This study was designed to include women and minorities, but was not designed to measure differences of intervention effects. Males and females will be recruited with no preference to gender. No exclusion to this study will be based on race. Minorities will actively be recruited to participate. High grade gliomas occur in patients of all races and although there is a slight predominance in men, this is a disease that is also common in women. The molecular targets of pembrolizumab and HSPPC-96 within the tumor are not known to be different among patients based on gender or race; hence this study will be open to all adults.
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12.2 participation of children

Individuals under the age of 18 will not be eligible to participate in this study because they are unlikely to have glioblastoma, and because of unknown toxicities of the study agents in the pediatric patient. Furthermore, the targets of pembrolizumab and HSPPC-96 are not as prevalent in pediatric malignant gliomas and therefore, the efficacy of this regimen will be initially determined in the adult population before consideration of its use in pediatrics.
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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. In circumstances where the subject becomes decisionally impaired due to disease progression, the subject will be taken off-treatment per protocol, but may continue in long term follow-up. In long term follow-up, the risks associated with study related interventions are no more than minimal. However, because in other circumstances, there is a prospect of direct benefit from research participation, 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 to assess ongoing capacity of the subjects and to identify an LAR, as needed. Please see section **12.6.1** for consent procedure.
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12.4 participation of subjects unable

Each institution will follow their own procedure for re-consenting subjects unable to re-consent and will notify the Coordinating Center at time of continuing review of these occurrences.
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12.5 evaluation of benefits and

The primary risk to patients participating in this research study is from the toxicity of pembrolizumab or HSPPC-96 or all drugs as described in section 14 and the consent document.  
Pembrolizumab and HSPPC-96 are investigational agents in the treatment of gliomas. The protocol provides for detailed and careful monitoring of all patients to assess for toxicity. Toxicity data from the current dose level will be collected and reviewed to ensure that there were no severe toxicities that would preclude further patient enrollment. Patients will be treated with therapeutic intent and response to the therapy will be closely monitored.
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12.5.1.2 imaging risks

The MRIs to be done in this study will involve contrast. The risks associated with MRIs and contrast are discussed in the consent form. Although MR imaging with gadolinium has been used as part of the standard care for patients with high grade gliomas, long term toxicities of gadolinium as a consequence of gadolinium accumulation in the body has been reported. All investigators will ascertain the MR imaging history of all prospective study participants to determine the extent of prior exposure to gadolinium contrast. Radiology will be consulted if there is a history of repeated gadolinium exposure.
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12.5.1.3 blood collection

The risk of blood draws in this study is that it may cause pain, bleeding, and/or bruising. The risks associated with blood collection are discussed in the consent form. Participants may faint and/or develop an infection with redness and irritation of the vein at the site where blood is drawn. Frequent blood collection may cause anemia (low red blood cell count), which may create a need for blood transfusions.
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12.5.1.4 questionnaires

The risk of questionnaires in this study is that they may contain questions sensitive in nature. Participants may refuse to answer any question that makes them feel uncomfortable. The primary use of the information collected is to assess the severity of symptoms related to study treatment. Submission of this information is voluntary.
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12.5.1.5 non-physical risks of genetic

Anxiety and stress may arise as a result of the anticipation that unwanted information regarding disease related DNA sequencing or disease tendencies, or misattributed paternity. Patients will be clearly informed that the data related to DNA sequencing and genetic analysis is coded, investigational and will not be shared with patients, family members or health care providers.
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12.5.1.5.2 risk related to possibility

This includes the risk that data related to genotype, DNA sequencing or risk for disease tendency or trait can be released to members of the public, insurers, employers, or law enforcement agencies. Although there are no plans to release results to the patients, family members or health care providers, this risk will be included in the informed consent document.
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12.5.2 benefits

The potential benefit to a patient on this study is a reduction in the bulk of their tumor and improvement in cancer lesions, which may or may not have favorable impact on symptoms and/or survival.
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12.6 consent process and documentation

The informed consent document will be provided as a physical or electronic document to the participant or consent designee as applicable, 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 site approved remote platforms used in compliance with policy, including HRPP Policy 303) 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.  
Note: When required, witness signature will be obtained similarly as described for the investigator and participant as described below. Consent will be documented with required signatures on the physical document (which includes the printout of an electronic document sent to participant. Signatures on electronic documents are described below. Note: FDA only regulates electronic signatures (i.e., an electronic timestamp is generated at the time of signature) in FDA regulated research. Manual (non-electronic) signature on electronic document: When a manual signature on an electronic document is used for the documentation of consent at the NIH Clinical Center, this study will use the Adobe platform (which is not 21 CFR Part 11 compliant) to obtain the required signatures. During the consent process, participants and investigators will view individual copies of the approved consent document on screens at their respective locations. Both the investigator and the subject will sign the document using a finger, stylus or mouse. Electronic signature on electronic document: When permitted by the NIH Clinical Center, an electronic signature may be obtained using the iMedConsent platform to obtain the required signatures. During the consent process, participants and investigators will view individual copies of the approved consent document on screens at their respective locations. The identity of the participant will be determined by a prompt which will require the provision of information from a form of government-issued identification prior to obtaining the signature. If participant does not have such identification available, security questions will be used to confirm identity. Both the investigator and the subject will sign the document electronically per system prompts.
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for bttc participating multicenter sites

Each institution will follow their own local procedure for electronic signature requirements at participating site.
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12.6.1 consent process for adults

For NIH participants addressed in section **12.3**, an LAR will be identified consistent with Policy 403 and informed consent obtained from the LAR, as described in Section **12.6**.
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12.6.2 request for waiver of

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

This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable cause. Written notification, documenting the reason for study suspension or termination, will be provided by the suspending or terminating party to study participants, site investigators, funding agency, the Investigational New Drug (IND) or Investigational Device Exemption (IDE) sponsor and regulatory authorities. If the study is prematurely terminated or suspended, the Principal Investigator (PI) will promptly inform study participants, the Institutional Review Board (IRB), and sponsor and will provide the reason(s) for the termination or suspension. Study participants will be contacted, as applicable, and be informed of changes to study visit schedule. Circumstances that may warrant termination or suspension include, but are not limited to:
- Determination of unexpected, significant, or unacceptable risk to participants
- Demonstration of efficacy that would warrant stopping
- Insufficient compliance to protocol requirements - Data that are not sufficiently complete and/or evaluable
- Determination that the primary endpoint has been met
- Determination of futility Study may resume once concerns about safety, protocol compliance, and data quality are addressed, and satisfy the sponsor, IRB and as applicable, Food and Drug Administration (FDA).
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13.2 quality assurance and quality

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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13.3 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 National Cancer Institute 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. Participating sites will adhere to local conflict of interest policy guidelines.
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13.4 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 transmitted to and stored at the BTTC Coordinating Center. 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 BTTC Coordinating Center research staff will be secured and password protected. At the end of the study, all study databases will be archived at the BTTC Coordinating Center. 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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14.1.2 cas name and number

Anti-(human protein PDCD1 (programmed cell death 1)) immunoglobulin G4 (human-Mus musculus monoclonal heavy chain) disulfide with human-Mus musculus monoclonal light chain, dimer / 1374853-91-4
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14.1.3 molecular formula c6534h10004n1716o2036s46 (peptide)

Sterile, preservative-free, white to off-white lyophilized powder in single-use vials. Each vial is reconstituted and diluted for intravenous infusion. Each 2 mL of reconstituted solution contains 50 mg of pembrolizumab and is formulated in L-histidine (3.1 mg), polysorbate-80 (0.4 mg), sucrose (140 mg). May contain hydrochloric acid/sodium hydroxide to adjust pH to 5.5
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14.1.6 storage and stability

KEYTRUDA is supplied in a carton containing one 50 mg single-use vial (NDC 0006-3029-02). Store vials under refrigeration at 2°C to 8°C (36°F to 46°F).
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14.1.7 supplier

Pharmacy will receive Merck Marketed Drug (MMD) (i.e., commercial supply) of pembrolizumab for use after 30 April 2020. This will replace the previous arrangement in which Merck was providing Pembrolizumab Lot R022867, which expires on 30 Apr 2020.
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14.1.8 mechanism of action

Pembrolizumab (previously known as SCH 900475) is a potent and highly selective humanized monoclonal antibody (mAb) of the IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PD-L1 and PD-L2. This blockade enhances functional activity of the target lymphocytes to facilitate tumor regression and ultimately immune rejection.
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14.1.9 administration for this study

Intravenous  
| Product Name & Potency    | Dosage Form                      |
|---------------------------|----------------------------------|
| Pembrolizumab 50 mg       | Lyophilized Powder for Injection |
| Pembrolizumab 100 mg/ 4mL | Solution for Injection           |  
Drug will be supplied either as powder for injection, 50 mg single-use vial, or a liquid, DP 100 mg/vial (25 mg/mL), both in Type I glass vials intended for single use only. Reconstitution of Pembrolizumab Lyophilized Powder for Injection: Add 2.3 mL of Sterile Water for Injection, USP by injecting the water along the walls of the vial and not directly on the lyophilized powder (resulting concentration 25 mg/mL). Slowly swirl the vial. Allow up to 5 minutes for the bubbles to clear. Do not shake the vial. Pembrolizumab Solution for Infusion 100 mg/vial is a liquid DP (manufactured using the fully formulated DS), and has the identical formulation as that of the reconstituted lyophilized vial.
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14.1.11 preparation for intravenous infusion

The liquid drug product is a clear to opalescent solution which may contain proteinaceous and extraneous particulates. Do not shake or freezer the vial(s). The liquid product is intended for IV administration. The liquid DP can be further diluted with 0.9% Sodium Chloride (normal saline) in IV containers made of polyvinyl chloride (PVC) or non-PVC material. The final concentration of the diluted solution should be between 1 mg/ml to 10 mg/ml. Do not dilute or combine product as an infusion with other medicinal products. Do not co-administer other drugs through the same infusion line. Administer infusion solution intravenously over 30 minutes through an intravenous line containing a sterile, non-pyrogenic, low- protein binding 0.2 micron to 5 micron in-line or add-on filter. The infusion solution should be immediately administered. If not used immediately, vials and/or IV bags may be stored at 2-8 °C for up to a cumulative time of 20 hours. If refrigerated, the vials and/or IV bags should be allowed to equilibrate to room temperature prior to subsequent use. Pembrolizumab solutions may be stored at room temperature for a cumulative time of up to 6 hours. This includes room temperature storage of reconstituted or liquid DP solution in vials, room temperature storage of infusion solution in the IV bag and the duration of infusion.
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14.1.12 incompatibilities

No formal pharmacokinetic drug interaction studies have been conducted with Pembrolizumab. Live vaccines should be prohibited within 30 days prior to the first dose of trial treatment and while participating in the trial.
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14.1.13 side effects 14.1.13.1 non-clinical

In the 1-month and 6-month toxicology study in cynomolgus monkeys, Pembrolizumab administered once a week and once every other week respectively, intravenously up to 200 mg/kg resulted in no adverse treatment related effects. The exposure multiple based on a predicted AUC 0-tau of 4464 μg.day/mL at the maximum anticipated human clinical dose of 10 mg/kg Q2W or Q3W is 15-fold at 200 mg/kg, the NOAEL for the 6-month monkey study. Additionally, in the tissue cross-reactivity study of Pembrolizumab with human and monkey tissues demonstrated the expected on-target staining of the membranes of mononuclear leukocytes in both species. Off-target cross-reactivity staining was also noted in both species but was limited to cytoplasm of various cell types/tissues and the stroma (extracellular connective tissue matrix), and was considered related to the experimental method artifacts, i.e. tissue processing for IHC, that are well recognized limitations of tissue cross-reactivity studies and, thus not considered toxicologically relevant. No reproductive or developmental toxicity studies are planned with Pembrolizumab. Therefore, inclusion of women of childbearing potential in clinical trials should be in accordance with the study protocol and applicable regulatory guidance (e.g., ICH M3(R2): Nonclinical Safety Studies for the Conduct of Human Clinical Trials and Marketing Authorization for Pharmaceuticals).
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14.1.13.2 clinical summary of results

As of 18-Oct-2013, 1,000 patients have been treated with Pembrolizumab at several dose schedules, including 10 mg/kg every 2 weeks. Pembrolizumab has been generally well tolerated, as expected based on preclinical findings and other anti-PD-1 monoclonal antibodies. As of 18- Oct-2013 no serious infusions reactions have been reported in PN001, however, since the potential exists in anti-PD-1 monoclonal antibodies, investigators should be vigilant to this possibility. Less than 1% of patients thus far assayed had confirmed positive ADA samples and among these, no or no clear impact on exposure has been observed. There is no contraindication to further clinical investigation with Pembrolizumab. Pharmacokinetics were as expected, based on Pembrolizumab being an IgG mAb and based on preclinical data, which support dosing once every 2 or 3 weeks. Pembrolizumab monotherapy induces an ORR of 25%/27% in patients with ipilimumab exposed melanoma by central independent RECIST and oncology review/investigator assessed irRC, respectively. Pembrolizumab monotherapy induces an ORR of 39%/43% in patients with ipilimumab-naive melanoma by central independent RECIST and oncology review/investigator assessed irRC, respectively. These responses are remarkably durable. The preliminary 1-year survival rate for patients, many of whom have had multiple therapies, including ipilimumab, who receive Pembrolizumab is 81%. Pembrolizumab monotherapy induces an ORR of 21%/24% in patients with previously-treated NSCLC by central independent RECIST/investigator assessed irRC, respectively, with these responses also remarkably durable. Preliminary data suggest higher levels of PD-L1 expression in tumors of NSCLC are associated with increased activity (ORR 67% by investigator assessed irRC/57% by central independent RECIST); additional data are required to define the optimal PD-L1 cut point. The most commonly reported treatment emergent AEs experienced are fatigue (43.8%), nausea (26.7%), cough (25.3%), pruritus (24.6%), diarrhoea (22.3%) and rash (21.5%). Immune-related adverse events were reported in 21.4% of melanoma patients; most of these events (15.8%) were considered drug-related by the investigator. The most commonly reported, immune-related adverse events across the doseschedules are rash (3.2%), pruritus (2.9%), vitiligo (2.9%), hypothyroidism (2.7%), arthralgia
(2.2%), diarrhoea (2.2%), and pneumonitis (1.9%). Review of the overall benefit: risk ratio of Pembrolizumab favors enrollment of eligible patients into clinical trials of Pembrolizumab. The preliminary data suggest that a dose of Pembrolizumab at 2 mg/kg Q3W is appropriate for patients with melanoma.
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14.1.13.3 important safety considerations

Based on results from the nonclinical studies, there are currently no specific safety considerations. Pembrolizumab is a humanized monoclonal Ab. Thus far, no serious infusion reactions have been reported however, patients should be closely monitored for potential AEs during antibody infusion and potential AEs throughout the study. In the event that a subject experiences an allergic reaction to Pembrolizumab, treatment (i.e., vasopressors, H2-blockers, antihistamines, H1-blockers, steroids) should be administered, as appropriate, and prophylaxis should be considered. Surveillance for the appearance of ADAs is included in all protocols. Pembrolizumab has the same mechanism of action as other anti-PD-1 monoclonal antibodies. Preclinical studies have suggested similar potency, and PK modeling has suggested similar human PK in the class. Accordingly, the AEs observed with other anti-PD-1 antibodies may serve as in indicator for the AEs to expect for Pembrolizumab in cancer patients. Furthermore, AEs from other immunotherapies for cancer were considered in the Events of Clinical Interest (Section ) and Immune-Related Guidance.
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14.1.13.4 immune-related adverse events (i-r

An I-R-AE is defined as a clinically significant AE of any organ that is associated with study drug exposure, is of unknown etiology, and is consistent with an immune-related mechanism. Immune-related adverse events were reported in 21.4% of melanoma patients; most of these events (15.8%) were considered drug- related by the investigator. The most commonly reported, immune-related adverse events across the dose-schedules are rash (3.2%), pruritus (2.9%), vitiligo (2.9%), hypothyroidism (2.7%), arthralgia (2.2%), diarrhoea (2.2%), and pneumonitis (1.9%). The organ most frequently affected by irAEs with Pembrolizumab is the skin. Less frequently affected tissues include thyroid gland, colon, lung, kidney, and liver. Based on the mechanism of action of Pembrolizumab and similar immunomodulatory agents, the sponsor is keenly interested in potential events of colitis, hepatitis, hyper/hypothyroidism, nephritis, pneumonitis. Therefore, the sponsor encourages appropriate academic investigation of signs and symptoms suggestive of any of the above events. Consultation with the appropriate medical specialist should be considered when investigating a possible irAE. These events can occur after the first dose to several months after the last dose of treatment. Mild irAEs are usually treated symptomatically and do not require dosing delays or discontinuation. Higher grade and persistent lower grade irAEs typically necessitate withholding or discontinuing treatment and administration of systemic steroids or other immunosuppressive agents (such as tumor necrosis factor blockers), when systemic steroids are not effective. Early recognition of irAEs and initiation of treatment are critical to reduce the risk of complications, since the majority of irAEs are reversible with the use of steroids and other immune suppressants. 14.1.13.4.1 Other immune-mediated adverse reactions The following additional clinically significant, immune-mediated adverse reactions were reported in less than 1% of patients treated with KEYTRUDA (pembrolizumab) in KEYNOTE-001, KEYNOTE-002, KEYNOTE-006, and KEYNOTE-010:
uveitis, myositis, GuillainBarré syndrome, pancreatitis, encephalitis, sarcoidosis, myasthenic syndrome/myasthenia gravis
(including exacerbation) and), myelitis., and vasculitis. The following were reported in other clinical studies with KEYTRUDA or in postmarketing use: myocarditis and sclerosing cholangitis. Cases of these immune-mediated adverse reactions, some of which were severe, have been reported in clinical trials or in postmarketing use. 14.1.13.5 Nursing Implications Standard treatment protocols per hospital guidelines will be used for this Pembrolizumab. Dose will be administered prior to RT.
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14.2 temozolomide

Temozolomide during Concomitant Radiation Therapy (RT) TMZ will be administered orally on day 1 of radiation therapy (RT) 1-2 hours before each session of radiotherapy or night before RT; and it should be administered the same time throughout the course of RT. TMZ should continue throughout RT at the dose of 75 mg/m2/day. During weekends without radiotherapy (Saturday and Sunday), the drug will be taken at the same time as radiotherapy days.
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14.2.1 chemical name

Temozolomide is 3,4-dihydro-3methyl-4-oxoimidazo[5,1-d]-as-tetrazine-8-carboxamide 14.2.2 **Molecular Formula:** C6H6N6O2 14.2.3 Molecular Weight: **194.15** 14.2.4 **Appearance** white to light tan/light pink powder
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14.2.5 supply commercially available. 14.2.6

Temozolomide will be properly accounted for, handled, and disposed in accordance with existing federal regulations and principles of Good Clinical Practice. All oral study drugs will be recorded in the patient diaries found in Appendix **16.14**. This will be used as a memory aide for subjects. A clinical research team maintains the primary source record. The capsules are packaged in amber glass bottles and should be stored at 25°C. Temperature excursions between 15 and 30°C are permissible. Refer to the commercially labeled bottles for expiration dating. Temozolomide is rapidly and completely absorbed after oral administration; peak plasma concentrations occur in 1 hour. Food reduces the rate and extent of temozolomide absorption. Mean peak plasma concentration and AUC decreased by 32% and 9%, respectively, and Tmax increased 2-fold (from 1.1 to 2.25 hours) when temozolomide was administered after a modified high-fat breakfast. Temozolomide is rapidly eliminated with a mean elimination half-life of 1.8 hours and exhibits linear kinetics over the therapeutic dosing range. Temozolomide has a mean apparent volume of distribution of 0.4 L/kg (%CV=13%). It is weakly bound to human plasma proteins; the mean percent bound of drug- related total radioactivity is 15%. Temozolomide is spontaneously hydrolyzed at physiologic pH to the active species, 3-methyl- (triazen-1-yl)imidazole-4-carboxamide (MTIC) and to temozolomide acid metabolite. MTIC is further hydrolyzed to 5-amino-imidazole-4-carboxamide (AIC), which is known to be an intermediate in purine and nucleic acid biosynthesis and to methylhydrazine, which is believed to be the active alkylating species. Cytochrome P450 enzymes play only a minor role in the metabolism of temozolomide and MTIC. An oral cytotoxic alkylating agent is the lead agent in a new class of compounds known as imidazotetrazines. Cytotoxic agents are designed to prevent the replication of cells that divide rapidly, including those in tumors. Caution should be exercised when temozolomide is administered to patients with severe renal impairment. Temozolomide has not been studied in patients on dialysis. 14.2.10.2 Hepatically Impaired Patients: In a pharmacokinetic study, the pharmacokinetics of temozolomide in patients with mild to moderate hepatic impairment (Child's-Pugh Class I-II) were similar to those observed in patients with normal hepatic function. Caution should be exercised when temozolomide is administered to patients with severe hepatic impairment.
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14.2.10.3 gender

Population pharmacokinetic analysis indicates that women have an approximately 5% lower clearance (adjusted for body surface area) for temozolomide than men. Women have higher incidences of Grade 4 neutropenia and thrombocytopenia in the first cycle of therapy than men. 14.2.10.4 Age: Population pharmacokinetic analysis indicates that age (range 19-78 years) has no influence on the pharmacokinetics of temozolomide.
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14.2.11 drug-drug interactions

In a multiple dose study, administration of temozolomide with ranitidine did not change the Cmax or AUC values for temozolomide or MTIC. Population analysis indicates that administration of valproic acid decreases the clearance of temozolomide by about 5%. The clinical implication of this effect is not known. Population analysis failed to demonstrate any influence of co-administered dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2-receptor antagonists, or phenobarbital on the clearance of orally administered temozolomide.
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14.2.12 adverse events

- Hematologic: Thrombocytopenia, leukopenia, myelodysplastic syndrome
- Gastrointestinal: Nausea, vomiting, anorexia
- Hepatic: Elevated liver enzymes (reversible)
- Skin: Rash
- Neurologic: Convulsions, weakness on one side of the body, abnormal coordination, paralysis
- Other: Constipation, diarrhea, stomatitis, fatigue, decreased performance status, headache
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14.2.13 special handling and precautions

Capsules should not be opened or damaged. Rigorous precautions should be taken to avoid capsule contents having contact with skin or mucous membranes. Capsule contents may be irritating to skin and eyes. Mutagenic and prolonged exposure may cause serious health effects (outside of prescribed dosage in this trial). Temozolomide is potentially mutagenic and should be handled with appropriate precautions by both staff and patients. Capsules should not be opened. If capsules are accidentally opened or damaged, rigorous precautions should be taken with the capsule contents to avoid inhalation or contact with the skin or mucous membranes. Procedures for proper handling and disposal of anticancer drugs should be considered.
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14.2.14 contraindications

Temozolomide is contraindicated in patients who have a history of a hypersensitivity reaction to any of its components or to DTIC.
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14.2.15 pregnancy category d

Temozolomide may cause fetal harm when administered to a pregnant woman. There are no adequate and well-controlled studies in pregnant women. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. **Women of childbearing potential should be advised to avoid**
becoming pregnant during therapy with temozolomide.
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14.2.16 fertility

Treatment of a man with temozolomide may increase the risk of birth defects if he causes a woman to become pregnant while he is taking temozolomide. Men treated with temozolomide may have difficulty causing a woman to become pregnant after their treatment is completed. Men receiving temozolomide should be directed to use effective contraception while they are being treated. There is insufficient data to know what the risk of subsequent problems with fertility will be. Similarly, women who are treated with temozolomide may have difficulty becoming pregnant in the future and may at be at increased risk of having children with birth defects. There is insufficient evidence to determine what the risk of these complications will be.
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14.3 heat shock protein-peptide complex-96

HSPPC-96 is an autologous tumor-derived vaccine under clinical investigation for the treatment of a variety of cancer types. It is composed of the 96-kDa heat shock protein gp96 in complex with autologous tumor-derived peptides. The gp96 in HSPPC-96 is a highly conserved, abundant, nonpolymorphic stress protein found in every cell type of the body. The gp96 isolated from normal or tumor tissues is found in complex with a diverse repertoire of peptides, which are specific to the tissue of origin. Published studies in mouse tumor models have shown that HSPPC-96 confers protective immunity only to the tumor from which it is derived and not to antigenically distinct tumors. The specific immunogenicity of the HSP preparations can be attributed to the unique repertoire of antigenic peptides that exists in different cancers.  
When injected into the host, HSPPC-96 interacts with antigen presenting cells (APCs) such as macrophages, dendritic cells or Langerhans cells, which take up HSPPCs via HSP receptors, including CD91. Once internalized by APCs, the peptides chaperoned by the HSPs are transferred to major histocompatibility complex (MHC) class I and II molecules in intracellular compartments and subsequently expressed at the cell surface. The cells then migrate to lymph nodes, where the complexes are processed so that the peptides chaperoned by the HSPs are represented to naive T cells. The T cells recognize the peptides and, as a result, are stimulated by them. Vaccination with HSPPCs thus elicits both a CD8+ and CD4+ T-cell response targeting potentially all relevant tumor antigens. The interaction of HSPs with receptors on APCs also leads to activation of various components of innate immunity, including cytokine and chemokine release by macrophage and dendritic cells, maturation of dendritic cells and activation of natural killer cells, as shown in both murine and human systems. Tumor immunity is largely mediated by T cells and the ability of HSPPC-96 to stimulate both T-cell arms to recognize a large variety of tumor antigens, coupled with the ability to activate innate immune responses, uniquely positions the product among other cancer vaccine strategies.
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14.3.1 molecular formula

The molecular formula of HSPPC-96 is unknown since the antigenic peptide repertoire isolated from tumor cells is patient specific.
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14.3.2 peptide component

The peptide component of HSPPC-96 is not characterized on a patient specific basis due to the limited quantity of product available and the technical challenges in performing this type of peptide analysis.
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14.3.3 appearance

HSPPC-96 is supplied in a single-use vial as a clear, colorless solution. Each vial contains 25 μg of HSPPC-96 in a solution of 9% sucrose-potassium phosphate for intradermal (ID) injection. The total volume of each vial of HSPPC-96 is 0.47 mL. The total volume that should be administered is approximately 0.4 mL.
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14.3.4 availability

Blinded vaccine (HSPPC-96 or placebo) will be prepared by Agenus Inc. and shipped directly to sites within approximately 4-6 weeks of Agenus' receipt of tumor tissue for randomized patients. The number of vaccine treatments will be based on the amount of vaccine generated. Although HSPPC-96 vaccine will be prepared for patients on the placebo arm, it will not be shipped to sites. Vaccine produced for patients randomized to placebo will be used for quality evaluation and will not be available for clinical use.
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14.3.5 hsppc-96 vaccine label

Each vial of vaccine vial is labeled with the subject/patient study number, subject/patient initials, and subject/patient date of birth (DOB).
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14.3.6 storage and stability

Following successful production of HSPPC-96 vaccine at Agenus Inc. and randomization, vials of blinded vaccine are shipped overnight on dry ice and must be stored at -80 °C ± 20 °C until administration to the patient. NOTE: Once HSPPC-96 is drawn up into the syringe, the vaccine is stable for up to 2 hours at ambient temperature if immediate administration is not possible. Please refer to the Investigator's Brochure for further details. Any unused or expired vaccine remaining after a patient has completed vaccine treatment should be returned to Agenus or destroyed at the site upon approval from Agenus. Destruction records are to be forwarded to Agenus. The shipping kit used to send vaccine from Agenus to the site may be stored until the patient has completed vaccine therapy and utilized for return of any unused or expired vaccine. See Appendix **16.6** for further detail.
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14.3.7 preparation

Withdraw the vial from the freezer and roll gently between two fingers until it is completely thawed (5-10 minutes). Withdraw approximately 0.4 mL, using a low hold up TB or insulin syringe.
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14.3.8 administration

The route of administration is intradermal injection. Inject into 1 site or into 2 adjacent sites (0.2 mL each) a few centimeters apart. Appropriate sites for vaccination include the anterior deltoid regions or subclavicular region bilaterally. Do not administer HSPPC-96/placebo to any side where lymph nodes have been removed or damaged. Rotate the injection sites so that injections are not repeated at the same site at 2 consecutive administrations, and utilize all potential sites for the patient before repeating injections at a previously used injection site. Syringes with slip-tip detachable needles or luer hubs with greater than 0.1 mL dead space should not be utilized.
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14.3.9 toxicities

Local injection-site reactions can occur and are usually of minimal extent and mild severity. If a local injection-site reaction requires medical attention, the investigator can provide local therapy as needed. Occasional systemic toxicities have been reported that have been mild in severity. The most frequently reported events include injection- site reactions of erythema and induration, fatigue, nausea, pyrexia, headache, back pain, arthralgia, constipation, and asthenia.
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14.4 placebo 14.4.1 supply

Placebo will be prepared by Agenus Inc. and shipped directly to sites within approximately 4-6 weeks of Agenus' receipt of tumor tissue for randomized patients. The number of placebo treatments will be based on the amount of vaccine generated.
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14.4.2 product description

Each dose of placebo is supplied in a single-use vial as a clear, colorless solution. Each vial contains a solution of 9% sucrose-potassium phosphate for intradermal (ID) injection. The total volume in each vial of placebo is 0.47 mL. The total volume that should be administered is approximately 0.4 mL.
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14.4.3 placebo label

Each vial of vaccine vial is labeled with the subject/patient study number, subject/patient initials, and subject/patient date of birth (DOB).
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14.4.4 storage

Vials of blinded vaccine are shipped overnight on dry ice and must be stored at–-80 °C ± 20 °C until administration to the patient. Version Date: *06/30/2021* NOTE: Once the placebo is drawn up into the syringe, it is stable for up to 2 hours at ambient temperature if immediate administration is not possible.
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14.4.5 administration

Withdraw the vial from the freezer and roll gently between two fingers until it is completely thawed (5-10 minutes). Withdraw approximately 0.4 mL, using a low hold up TB or insulin syringe.
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14.4.6 dose

The route of administration is intradermal injection. Inject into 1 site or into 2 adjacent sites (0.2 mL each) a few centimeters apart. Appropriate sites for vaccination include the anterior deltoid regions or subclavicular region bilaterally. Do not administer placebo to areas distal to lymph node basins that have been resected or in areas just distal to a surgical scar. Rotate the injection sites so that injections are not repeated at the same site at 2 consecutive administrations, and utilize all potential sites for the patient before repeating injections at a previously used injection site. Syringes with slip-tip detachable needles or luer hubs with greater than 0.1 mL dead space should not be utilized.
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14.5 ordering study agent 14.5.1

Following vaccine manufacture and completion of quality testing, Agenus will send the site the Vaccine Production Notification form indicating whether manufacture of vaccine was successful. Upon randomization, Agenus will then send the appropriate blinded vaccine to the site. Agenus Contact Information for Tissue Procurement and Kit Ordering: supply&logistics@agenusbio.com or fax: 781-674-4220.  
See Appendix **16.3** and Appendix **16.4** for more details.
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14.5.2 pembrolizumab

Pembrolizumab may be requested by the Principal Investigator (or their authorized designees) at each participating institution. All regulatory document requirements, as described in the BTTC Operations Manual, must be current and up to date in the BTTC Coordinating Center. A Study Drug Order Form and Pharmacy Initiation Worksheet Form will need to be completed; these forms can be obtained from the BTTC Coordinating Center. The participating institution must have received a Site Activation Memo from the BTTC Coordinating Center prior to requesting study agents. Signed and Dated drug requests should be emailed to:
Merck Attn: Eleonora Veglia, PhD
Email: nciisdrugorder@merck.com Cc: eleonora.veglia@msd.com Phone: +44 (0) 7824524450 When a number of investigators are participating on a clinical study at the same institution, one investigator should be considered or designated the principal or lead investigator under whom all investigational agents for that protocol should be ordered.
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14.5.4 agent storage and accountability

The investigator is responsible for the proper and secure physical storage and record keeping of investigational agents received for BTTC protocols. Specifically, the investigator must:  
o Maintain a careful record of the receipt, use and final disposition of all investigational agents received, using the NCI Investigational Agent Accountability Record Form
(DARF), **http://ctep.cancer.gov/forms/index.html**
o Store the agent in a secure location, accessible to only authorized personnel, preferably in the pharmacy.  
o Maintain appropriate storage of the investigational agent to ensure the stability and integrity of the agent.  
o Return or destroy any unused investigational agents at the completion of the study or upon notification that an agent is being withdrawn.
The intent of the agent accountability procedures described in this section is to assist the investigator in making certain that agents received from BTTC are used only for patients entered onto an approved protocol. The record keeping described in this section is required under FDA regulation. Investigators are responsible for the use of investigational agents shipped in their name. Even if a pharmacist or chemotherapy nurse has the actual task of handling these agents upon receipt, the investigator is the responsible individual and has agreed to accept this responsibility by signing the FDA 1572: https://www.fda.gov/science-research/clinical-trialsand-human-subject-protection/clinical-trial-forms
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14.5.5 bttc procedures for agent

o Each investigational agent should be stored separately by protocol. If an agent is used for more than one protocol, there should be separate physical storage for each protocol. Remember that agents are provided and accounted for on a protocol-by-protocol basis.  
o Each agent should be accounted for separately by protocol. If an agent is used for more than one protocol, there should be a separate Investigational Agent Accountability Record Form (DARF) for each protocol, http://ctep.cancer.gov/forms/index.html. There should be a separate DARF for each agent in a multi-agent protocol.  
o Separate accountability forms should be maintained for each different strength or dosage form of a particular agent (e.g., an agent with a 1-mg vial and a 5-mg vial would require a different DARF for the 1-mg vial than for the 5-mg vial).  
o The DARF has been designed for use at each location where agents are stored, e.g., main pharmacy, satellite pharmacy, physician's office, or other dispensing areas.
o The DARF is also designed to accommodate both dispensing records and other agent transaction documentation (e.g., receipt of agent, returns, broken vials, etc.). A copy of the DARF may be found at http://ctep.cancer.gov/forms/index.html.  
o Unauthorized inter-institutional transfer of BTTC investigational agents from one participating institution to another is not permitted. For some protocols the lead institution may enter into contractual agreements to forward agents to participating institutions (Refer to the BTTC Operations Manual).  
o BTTC Supplied agents must not be repackaged and forwarded to patients on a routine basis. Refer to the BTTC Operations Manual for BTTC polices on forwarding BTTC supplied agents under certain limited circumstances.
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14.5.6 verification of compliance

Investigators are reminded that compliance with procedures to ensure proper agent usage will be reviewed during site visits conducted under the monitoring program. Specifically, site visitors will check that the agent accountability system is being maintained, and will spot-check the agent accountability records by comparing them with the patients' medical records to verify that the agents were administered to a patient entered in the recorded protocol.
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14.6 returning or destroying unused

All unused and returned pembrolizumab may be destroyed on site. The site must follow their local drug destruction policy and procedure. A copy of the drug destruction record must be submitted to Merck using the Merck form provided (attached as a separate form).  
Contact: Eleonora Veglia, PhD
Scientific Leadership & Research Manager (EU SLRM)
Merck Investigator Initiated Studies Program/ Scientific Engagements MSD, MRL Innovation Hub Two Pancras Square, Kings Cross London N1C 4AG
Tel: +44 (0) 7824524450 Email: eleonora.veglia@msd.com The investigator is responsible for keeping accurate records of the clinical supplies received from Merck or designee, the amount dispensed to and returned by the subjects and the amount remaining at the conclusion of the trial. Upon completion or termination of the study, all used and/or partially used investigational product will be destroyed at the site per institutional policy. It is the Investigator's responsibility to arrange for disposal of all empty containers, provided that procedures for proper disposal have been established according to applicable federal, state, local and institutional guidelines and procedures, and provided that appropriate records of disposal are kept.
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14.6.2 hsppc-96 or placebo return

If a subject is randomized to receive placebo or if there is any remaining vaccine after the subject has finished treatment, it will be coded and linked and used by Agenus or other approved investigators for development and research purposes. Refer to section **16.6** for HSPPC-96 or Placebo return instructions.
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15 references

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Jekyll or Hyde. Cancer Metastasis Rev, 2007. 26(3-4): p. 373-400.  
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27. Deschoolmeester, V., et al., Tumor infiltrating lymphocytes: an intriguing player in the survival of colorectal cancer patients. BMC Immunol, 2010. 11: p. 19.  
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Cutan Pathol, 2010. **37 Suppl 1**: p. 48-53.  
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891-8.  
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35. Liotta, F., et al., *Frequency of regulatory T cells in peripheral blood and in tumourinfiltrating lymphocytes correlates with poor prognosis in renal cell carcinoma.* BJU Int, 2011. 107(9): p. 1500-6.  
36. Srivastava, P.K., M.K. Callahan, and M.M. Mauri, *Treating human cancers with heat* shock protein-peptide complexes: the road ahead. Expert Opin Biol Ther, 2009. 9(2): p.  
179-86.  
37. Binder, R.J., R. Vatner, and P. Srivastava, *The heat-shock protein receptors: some* answers and more questions. Tissue Antigens, 2004. 64(4): p. 442-51.  
38. Bloch, O.R., JJ; , Lim, M; , Sughrue, M; Komotar, R; Abrahams, J; O'Rourke, D;
D'Ambrosio, A; Bruce, JN; Parsa, A., *Newly diagnosed glioblastoma patients treated* with an autologous heat shock protein peptide vaccine: PD-L1 expression and response to therapy. J Clin Oncol, 2015. 33.  
39. Crane, C.A., et al., *Individual patient-specific immunity against high-grade glioma after* vaccination with autologous tumor derived peptides bound to the 96 KD chaperone protein. Clin Cancer Res, 2013. 19(1): p. 205-14.  
40. Kleponis, J., R. Skelton, and L. Zheng, Fueling the engine and releasing the break:
combinational therapy of cancer vaccines and immune checkpoint inhibitors. Cancer Biol Med, 2015. 12(3): p. 201-8.  
41. Dixit, K., et al., ATIM-10. PHASE I/II TRIAL OF RADIATION THERAPY,
TEMOZOLOMIDE AND PEMBROLIZUMAB FOLLOWED BY TEMOZOLOMIDE AND PEMBROLIZUMAB IN PATIENTS WITH NEWLY DIAGNOSED GLIOBLASTOMA.  
Neuro-Oncology, 2016. 18(suppl_6): p. vi19-vi19.  
42. Siu, L.L., et al., Phase I trial of sorafenib and gemcitabine in advanced solid tumors with an expanded cohort in advanced pancreatic cancer. Clin Cancer Res, 2006. 12(1): p.  
144-51.  
43. Armstrong, T.S., et al., *Validation of the M.D. Anderson Symptom Inventory Brain Tumor* Module (MDASI-BT). J Neurooncol, 2006. 80(1): p. 27-35.  
44. Wen, P.Y., et al., *Updated response assessment criteria for high-grade gliomas: response* assessment in neuro-oncology working group. J Clin Oncol, 2010. 28(11): p. 1963-72.  
45. Okada, H., et al., *Immunotherapy response assessment in neuro-oncology: a report of the* RANO working group. Lancet Oncol, 2015. 16(15): p. e534-42.  
46. Thall, P.F. and R. Simon, *Practical Bayesian guidelines for phase IIB clinical trials.*
Biometrics, 1994. 50(2): p. 337-49.  
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Biometrics, 1982. 38(1): p. 29-41.  
48. Cai, C., S. Liu, and Y. Yuan, A Bayesian design for phase II clinical trials with delayed responses based on multiple imputation. Statistics in medicine, 2014. 33(23): p. 40174028.
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16 appendices

| 16.1                                                                                                                                                                                       | PERFORMANCE STATUS CRITERIA ECOG Performance Status Scale          | Karnofsky Performance Scale                                  |             |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------|--------------------------------------------------------------|-------------|
| Grade                                                                                                                                                                                      | Descriptions                                                       | Percent                                                      | Description |
| 100                                                                                                                                                                                        | Normal, no complaints, no  evidence of disease.                    |                                                              |             |
| Normal activity. Fully active,                                                                                                                                                             |                                                                    |                                                              |             |
| 0                                                                                                                                                                                          | able to carry on all pre-disease  performance without restriction. | Able to carry on normal activity;                            |             |
| 90                                                                                                                                                                                         | minor signs or symptoms of  disease. Normal activity with effort;  |                                                              |             |
| 80                                                                                                                                                                                         | some signs or symptoms of  disease.                                |                                                              |             |
| Symptoms, but ambulatory.  Restricted in physically strenuous  activity, but ambulatory and able  to carry out work of a light or  sedentary nature (e.g., light  housework, office work). |                                                                    |                                                              |             |
| 1                                                                                                                                                                                          | Cares for self, unable to carry on                                 |                                                              |             |
| 70                                                                                                                                                                                         | normal activity or to do active  work.                             |                                                              |             |
| In bed <50% of the time.  Ambulatory and capable of all  self-care, but unable to carry out  any work activities. Up and  about more than 50% of waking  hours.                            | Requires occasional assistance,                                    |                                                              |             |
| 60                                                                                                                                                                                         | but is able to care for most of  his/her needs.                    |                                                              |             |
| 2                                                                                                                                                                                          | 50                                                                 | Requires considerable assistance  and frequent medical care. |             |
| 40                                                                                                                                                                                         | Disabled, requires special care  and assistance.                   |                                                              |             |
| In bed >50% of the time.  Capable of only limited self-care, confined to bed or chair more  than 50% of waking hours.                                                                      |                                                                    |                                                              |             |
| 3                                                                                                                                                                                          | Severely disabled,                                                 |                                                              |             |
| 30                                                                                                                                                                                         | hospitalization indicated. Death  not imminent.                    |                                                              |             |
| 20                                                                                                                                                                                         | Very sick, hospitalization  indicated. Death not imminent.         |                                                              |             |
| 100% bedridden. Completely  disabled. Cannot carry on any  self-care. Totally confined to bed  or chair.                                                                                   |                                                                    |                                                              |             |
| 4                                                                                                                                                                                          | 10                                                                 | Moribund, fatal processes  progressing rapidly.              |             |
| 5                                                                                                                                                                                          | Dead.                                                              | 0                                                            | Dead.       |  
16.2 TUMOR TISSUE SUBMISSION FOR VACCINE M**ANUFACTURE**
See Appendix **16.3** for detailed instructions for handling, preparation, and submission of tumor tissue for HSPPC-96 vaccine manufacture. The Tumor Procurement Form (TPF) must be included with the tissue sent to Agenus Inc. Kits for shipping tissue will be supplied by Agenus and should be ordered at time of IRB approval **because they will be needed at time of surgery:** Supply and Logistics Agenus Inc.  
Primary Contact: Tel: +1 (781) 674-4400 x4486 (office) Email: supply&logistics@agenusbio.com The dimensions of the kits are 17" x 17" x 15". Please order one or two kits at a time, based on your anticipated use, and please allow 3-4 days for shipping. Upon receipt of a kit with patient tumor at Agenus, a new kit will automatically be replenished for the site. Version Date: *06/30/2021* 16.3 VACCINE TISSUE PROCUREMENT AND SHIPPING INSTRUCTIONS Tissue procurement kits provided by Agenus Inc. include:  
  
o 50-mL nonpyrogenic tubes and patient information labels o Dry Ice Contents Sticker o Absorbent paper o Plastic bags o Orange-capped pressure vessels (with foam insert) o Cardboard pieces (to support base of pressure vessel and top of dry ice) o Tumor Procurement Form (TPF)
o Shipping box and all shipping/address labels Sites must provide the dry ice
(8kg).  
o The site should contact Agenus at supply&logistics@agenusbio.com **to request courier**
documents (pre-paid shipping label for tumor shipment from site to Agenus) 1 day in advance of the desired shipment and the shipping label will be emailed to the site. The shipment of tissue to Agenus for vaccine creation should be delayed until confirmation of histologic diagnosis, MGMT status and IDH mutational status that would make the tumor eligible for vaccine production. Tumor specimens for vaccine production must be frozen and stored at -80°C ± 20°C. The tumor specimen must not arrive on the weekend or a holiday unless this has been agreed to in advance by Agenus. If the tumor specimen will not be shipped immediately, it should be placed into an -80° (+/- 20°) C freezer until ready to pack and ship. Do this within a maximum of 30 minutes of removal. For tumor specimen stored at sites prior to shipping to Agenus (i.e. overnight or for weekends/holidays), the freezer does not need to be sterile, but it is recommended that it be monitored for temperature (24/7) with alarms or other mechanism for identifying when temperature goes out of specification. The freezer or its location should have controlled access Version Date: *06/30/2021*
(locked with specified group members having access). The freezer should also be on a preventative maintenance program and ideally be hooked up to a back-up power system. In the OR, wrap or place the tumor specimen in a sterile specimen cup, cloth or towel, and place in a basin, on ice (not dry ice). Transport the specimen immediately to the pathology/frozen section suite.
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share the following steps with

kit:
a. Use basic sterile technique. Care should be taken to avoid any possible crosscontamination with tissues or fluids from other patients.  
b. As small a section of tumor as possible should be kept for routine pathologic studies and diagnosis. Tumor for routine pathologic diagnosis should be processed according to institutional standards.  
c. The pathologist should assess viability of the tumor. d. When there is necrosis and/or cystic degeneration in the tumor specimen, the necrotic tissue and/or cystic component should be removed and should not be sent to Agenus.  
e. **All available** tumor aside from what will be used for routine pathologic studies and diagnosis should be sent for HSPPC-96 vaccine preparation. A minimum of ≥ 7 grams of fresh, non-necrotic tumor should be sent (if <7 grams, may not produce sufficient vaccine).
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tumor procurement and shipping procedure

a. The pathologist should section the tissue into 1-2 cm2sections. The sections should then be placed carefully, maintaining sterility, into the 50-mL nonpyrogenic tubes. Each tube should be filled no more than ½-⅔ full to allow for expansion of tumor during freezing.
b. Each tube must be properly labeled (patient/subject identifiers are a match on all tubes).  
c. Each tube should be placed in a plastic pouch, and the pouch sealed closed. d. Wrap the tubes in bubble wrap or place in the foam insert in the upright position. e. Absorbent paper should be placed in the bottom of the orange capped pressure vessel. The sealed tubes in the foam insert are then placed into the pressure vessel and the vessels lid is screwed shut. Dry ice should NOT be placed inside the pressure vessel.  
f. Place some dry ice in the bottom of the insulated shipper box. g. The pressure vessel should be placed above the dry ice, with the base seated in the cardboard support, and more dry ice packed surrounding the container.  
h. Dry ice should be added to about 10 cm from the top of the box, a second cardboard  
  
insert placed above the ice, and the foam plug placed into the box. If an insufficient amount of dry ice is placed in the box, and the tissue is not frozen on arrival, it cannot be processed and the patient must be withdrawn from the study.
The form should be scanned and e-mailed to: supply&logistics@agenusbio.com so that the shipment is expected and can be traced by airbill number if it does not arrive. A copy of the form should also be kept for the records of the study center.  
j. The original **Tumor Procurement Form** should be placed in the clear documentation holder on the inside carboard flap of the box. Close the cardboard flaps and securely taped shut.  
k. A copy of the TPF should be kept for site records. l. The following labels should be over the appropriate areas:
1. Dry Ice (\#9) With Weight 2. "Shipping To" label 3. "Shipped From" label m. Record the amount (in kilograms) of dry ice placed in the package on the Dry Ice label.  
  
Attach the courier air bill to the box. The shipment should be sent to:
Supply and Logistics Agenus Inc. 3 Forbes Road Lexington, MA 02421 United States Tel: +1 (781) 674-4486
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below is a list of

Please take great care in filing out this form correctly, as any such issues may lead to delays in vaccine production and potential rejection of the material if the correct identity cannot be confirmed.  
o Study subject ID number does not match - tube labels vs. procurement form o Patient/subject date of birth does not match - tube labels vs. procurement form o Patient/subject initials do not match - tube labels vs. procurement form (i.e., A-C ≠ C-A) Version Date: *06/30/2021* o Study subject ID number, date of birth or patient initials are illegible on procurement form or tube labels  
o Tube labels used are not the same as those issued by Agenus o Tubes are not labeled at all, or information is recorded directly onto body of tube and is then smeared upon receipt o Pen or marker used to record information on tube label is not indelible ink, and information is then smeared upon receipt o Tubes for more than 1 patient/subject are placed into one pressure vessel o Initials and date of correction are not recorded when cross-outs are made on tube labels or Tumor Procurement Form
Abbreviated Title: GBM Pembro HSPPC
Version Date:   06/30/2021 16.4   T UMOR P ROCUREMENT F RM
Page REFERENCE COPY  
  
TUMOR PROCUREMENT FORM (TPF) FOR PROTOCOL 17C0034 Agenus Document IS-31748, Ver. 01 This document is the proprietary and confidential property of Agenus Inc. Version Date: *06/30/2021* 16.5 LABCONNECT MANUAL FOR WHOLE BLOOD PBMC PROCESSING AND S**HIPPING**
This manual is a separate document.
untitled h1
16.6 hsppc-96 vaccine or placebo

1. Any unused or expired vaccine remaining after a subject has completed vaccine treatment, should be returned to Agenus Inc. according to the following instructions.  
2. Please contact the Agenus Team at BTTC17C0034@agenusbio.com in advance (i.e.,
minimum of 1 day) to inform Agenus when you plan to return unused or expired vaccine. Also copy nci_bttc@mail.nih.gov on this return request communication.  
3. Agenus will provide a pre-paid courier air-way bill via email for this shipment to your site. 4. Use the qualified HSPPC-96 shipping kit that was received with the original shipment of vaccine from Agenus. The shipping kit should have the following materials, which came as part of the vaccine shipment from Agenus:
- Outer cardboard shipping box. - Insulated liner and foam plug.  
- Pressure vessel container (with foam inserts).  
- Cardboard pieces (2: 1 for upright positioning of base of pressure vessel and 1 for placement on top of pressure vessel surrounded with dry ice).  
- Absorbent paper (on bottom of pressure vessel)
5. Place vials to be returned inside of the pressure vessel, inserted upright in the holes of the foam inserts. Screw the lid shut on the pressure vessel. Multiple subjects' /patients' vaccines may be returned in 1 one pressure vessel.  
6. Place a layer of dry ice on the bottom of the insulated liner that is within the outer cardboard shipping box. The pressure vessel container should then be placed above this layer of dry ice, with the base of the pressure vessel inserted into the cardboard support. Additional dry ice is then packed around the closed pressure vessel. The shipping container must be filled with at least 8 kg of dry ice (i.e., level with the top of the pressure vessel). A second cardboard insert should be placed above the dry ice, and the foam plug placed into the box. The box is then sealed with packing tape.  
7. The following labels should be placed on the exterior of the outer cardboard shipping box:
- Dry ice (\#9) with weight (8 kg).  
- Shipping address/content label (where the package is being sent). - Shipped from label (Where the package is shipping from)
8. Contact the courier to arrange for a pick-up, if a standard pick- up time is not established for your site or if this was not done in advance.  
9. Attach the courier air bill to the top of the box. The shipment should be sent overnight to:
Supply and Logistics Agenus Inc.  
3 Forbes Road Lexington, MA 02421 United States Tel: +1 (781) 674-4486 supply&logistics@agenusbio.com Version Date: *06/30/2021* 16.7 HSPPC-96 Intradermal Injection Instructions
hsppc-96 intradermal injection instructions
16.6 hsppc-96 vaccine or placebo

The route of administration is intradermal injection. Using a 25 g needle or equivalent, inject into 1 site or into 2 adjacent sites (0.2 mL each) a few centimeters apart. Appropriate sites for vaccination include the anterior deltoid regions, subclavicular region bilaterally, and medial inguinal regions of the upper thighs (please see the figure below). Intradermal injections are administered into the outer layers of the skin. The needle should be inserted at a 10-15 degree angle so that it just punctures the skin's surface. Insert the needle about 0.3 cm below the epidermis and stop when the needle's tiup is under the skin. You should feel some resistance as you make the injection and a wheal should form as you complete the injection. If the needle tip moves freely, you have inserted the needle too deeply. At this point, withdraw needle slightly and check again for resistance. The appearance of a wheal indicates that the vaccine has entered the area between the intradermal tissues. If a wheal does not appear, withdraw the needle and repeat the procedure in another site a few centimeters apart. Do not administer HSPPC-96 to areas distal to lymph node basins that have been resected or in areas just distal to a surgical scar. Rotate the injection sites so injections are not repeated at the same site forat 2 consecutive administrations and utilize all potential sites for the patient before repeating injections at a previously used injection site. Syringes with slip-tip detachable needles or luer hubs with greater than 0.1 mL dead space should not be utilized.
agenus
16.6 hsppc-96 vaccine or placebo

Version Date: *06/30/2021*  
| 16.8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             | INFUSION REACTION TREATMENT GUIDELINES  NCI CTCAE Grade Treatment                                                                              | Premedication at  subsequent dosing                                                         |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------|
| Grade 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          | Increase monitoring of vital  signs as medically indicated  until the subject is deemed  medically stable in the opinion  of the investigator. | None                                                                                        |
| Mild reaction; infusion  interruption not indicated;  intervention not indicated Grade 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         | Stop Infusion and monitor  symptoms.                                                                                                           | Subject may be premedicated  1.5h (± 30 minutes) prior to  infusion of pembrolizumab  with: |
| Requires 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                                                          | Diphenhydramine 50 mg po  (or equivalent dose of  antihistamine).                           |
| Antihistamines NSAIDS Acetaminophen                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | Acetaminophen 500-1000  mg po (or equivalent dose of  antipyretic).                                                                            |                                                                                             |
| Narcotics                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |                                                                                                                                                |                                                                                             |
| Increase monitoring of vital  signs as medically indicated  until the subject is deemed  medically stable in the opinion  of the investigator. If symptoms resolve within one  hour of stopping drug infusion,  the infusion may be restarted at  50% of the original infusion  rate (e.g., from 100 mL/hr to 50  mL/hr). Otherwise dosing will  be held until symptoms resolve  and the subject should be  premedicated for the next  scheduled dose. Subjects who develop Grade 2  toxicity despite adequate  premedication should be  permanently discontinued  from further trial treatment  administration. |                                                                                                                                                |                                                                                             | Version Date: *06/30/2021*  
| Version Date: 06/30/2021 NCI CTCAE Grade                                                                                                                                                                                                                                        | Treatment                                                                   | Premedication at  subsequent dosing   |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------|---------------------------------------|
| Grades 3 or 4                                                                                                                                                                                                                                                                   | Stop Infusion.                                                              | No subsequent dosing                  |
| Grade 3:                                                                                                                                                                                                                                                                        | Additional appropriate medical  therapy may include but is not  limited to: |                                       |
| Prolonged (i.e., not rapidly  responsive to symptomatic  medication and/or brief  interruption of infusion);  recurrence of symptoms  following initial  improvement;  hospitalization indicated for  other clinical sequelae (e.g.,  renal impairment,  pulmonary infiltrates) | IV fluids Antihistamines NSAIDS Acetaminophen Narcotics Oxygen Pressors     |                                       |
| Grade 4:                                                                                                                                                                                                                                                                        | Corticosteroids                                                             |                                       |
| Life-threatening; pressor or  ventilatory support indicated                                                                                                                                                                                                                     | Epinephrine                                                                 |                                       |
| Increase monitoring of vital  signs as medically indicated  until the subject is deemed  medically stable in the opinion  of the investigator. Hospitalization may be  indicated. Subject is permanently  discontinued from further  trial treatment  administration.           |                                                                             |                                       |
| Appropriate resuscitation equipment should be available in the room and a physician readily  available during the period of drug administration.                                                                                                                                |                                                                             |                                       |  
Version Date: *06/30/2021*
agenus
16.9 md anderson symptom inventory

This questionnaire is a separate document. Version Date: *06/30/2021* 16.10 CCR REPORTABLE EVENT FORM **(REF)**
NCI Protocol \#:
Protocol Title:  
| Report version: (select one) ☐ Initial Report  ☐ Follow-up  Site Principal Investigator:  Date site PI was notified of the                | Date of problem:   |
|-------------------------------------------------------------------------------------------------------------------------------------------|--------------------|
| problem:  If delay in reporting to the coordinating center, please explain: Location of problem: (e.g., patient's home, doctor's office ) |                    |  
| Description of Subject Does this problem apply to a subject? ☐ yes ☐ not applicable (more than one subject is involved)   |
|---------------------------------------------------------------------------------------------------------------------------|  
If yes, enter details below:
Subject ID: (*do not use medical record number)*
Sex: ☐Male ☐ Female Age: Version Date: *06/30/2021* Diagnosis:
Name the problem: *(select all that apply)*
☐ Specimen collection issue
☐ Informed consent issue
☐ Ineligible for enrollment ☐ Breach of PII
☐ Other, briefly state the nature of the problem:
Detailed Description of the problem: (Include any relevant treatment, outcomes or pertinent history):
What are you reporting?  
☐ **unanticipated problem**
☐ **non-compliance (other than a protocol deviation)**
☐ **protocol deviation** ☐ new information that might affect the willingness of subjects to enroll or continue participation in this study If interventional or expanded access study, please answer the following questions about your site:
☐ **death** Version Date: *06/30/2021* How many participants are still receiving the study intervention? How many participants completed study interventions but remain in follow up? How many participants are enrolled but not yet receiving study interventions? Have similar problems occurred on this protocol at your site?  
☐ Yes ☐ No Describe what steps you have already taken or will be taking **as a result of** this problem: INVESTIGATOR'S SIGNATURE: DATE: Version Date: *06/30/2021* 16.11 UNBLINDING REQUEST MEMO
MEMORANDUM
DATE: TO: Lead PI  
| FROM:                                                                                   | __________________________MD   |
|-----------------------------------------------------------------------------------------|--------------------------------|
| Phone Number:_____________________________ Email address:______________________________ |                                |  
Site:______________________________________ RE: Patient Unblinding Request for A randomized, double blind phase II trial of Surgery, Radiation Therapy plus Temozolomide and Pembrolizumab with and without HSPPC-96 in newly diagnosed Glioblastoma (GBM) I am requesting the following patient to be unblinded: Subject ID \# ________ I am requesting this patient to be unblinded because: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________ Thank you, Signature of requesting physician Date I have reviewed this request and agree that the circumstances warrant patient unblinding Signature of approving MD Date I have reviewed this request but do not agree that the circumstances warrant patient unblinding. The reason I am denying this request is: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________ Signature of disapproving MD Date Version Date: *06/30/2021* 16.12 UNBLINDING NOTIFICATION MEMO MEMORANDUM DATE: _______________  
  
   
FROM: Lead PI, MD RE: Patient Unblinding Notification for protocol titled - A randomized, double blind phase II trial of Surgery, Radiation Therapy plus Temozolomide and Pembrolizumab with and without HSPPC-96 in newly diagnosed Glioblastoma (GBM) With concurrence from the Data Safety Monitoring Board, the Lead PI MD has requested unblinding for the following patient: Subject ID \#________ Date of unblinding: _________  
$\;\;\;$ HSPPC-96 .
$$\mathbf{Placebo}$$
The patient's treatment assignment is: ________HSPPC-96 ________Placebo  
_______________________ _______________________
Be sure to place this memo in the patient's clinic or hospital chart following your institution's guidelines. Thank you, Abbreviated Title: GBM Pembro HSPPC
Version Date:   06/30/2021  
16.13 STUDY PHASES AND CORRELATIVE BLOOD DRAWS
agenus
16.14 p ill d iary

Pill Diary Instructions: Use this pill diary as an aid to record when you took your daily chemotherapy.  
Place a check mark or your initials after each daily dose. If you miss a dose, add a reason in the space  
| provided. Bring this diary and all study drug bottle(s) back to your next clinic.   |                              |      |                         |
|-------------------------------------------------------------------------------------|------------------------------|------|-------------------------|
| Patient Name:                                                                       | Study ID #:                  |      |                         |
| Study Phase/Cycle:                                                                  | Today's date:                |      |                         |
| Week                                                                                | Day                          | Date | Temozolomide (TMZ) Dose |
| Instructions: Take TMZ ____                                                         | _g by mouth before bed daily |      |                         |
| Pre                                                                                 | x                            |      |                         |
| 1                                                                                   |                              |      |                         |
| L                                                                                   | 1                            | x    |                         |
| 2                                                                                   | x                            |      |                         |
| 3                                                                                   | x                            |      |                         |
| 4                                                                                   | x                            |      |                         |
| 5                                                                                   | x                            |      |                         |
| 6                                                                                   | x                            |      |                         |
| 7                                                                                   | x                            |      |                         |
| 2                                                                                   | 8                            | x    |                         |
| 9                                                                                   | x                            |      |                         |
| 10                                                                                  | x                            |      |                         |
| 1                                                                                   | x                            |      |                         |
| 12                                                                                  | x                            |      |                         |
| 13                                                                                  | x                            |      |                         |
| 14                                                                                  | x                            |      |                         |
| 3                                                                                   | 15                           | x    |                         |
| 16                                                                                  | x                            |      |                         |
| 17                                                                                  | x                            |      |                         |
| 18                                                                                  | x                            |      |                         |
| 19                                                                                  | x                            |      |                         |
| 20                                                                                  | x                            |      |                         |
| 21                                                                                  | x                            |      |                         |
| 4                                                                                   | 2                            | x    |                         |
| 23                                                                                  | x                            |      |                         |
| 24                                                                                  | x                            |      |                         |
| 25                                                                                  | x                            |      |                         |
| 26                                                                                  | x                            |      |                         |
| 27                                                                                  | x                            |      |                         |
| 28                                                                                  | x                            |      |                         |
| S                                                                                   | 29                           | x    |                         |
| 30                                                                                  | x                            |      |                         |
| 31                                                                                  | x                            |      |                         |
| 32                                                                                  | x                            |      |                         |  
| 6   |
|-----|  
| 3   | x   |
|-----|-----|
| 34  | x   |
| 35  | x   |
| 37  | x   |
| x   |     |
| 38  | x   |
| 39  | x   |
| 40  | x   |
| 41  | x   |
| 42  | x   |  
Version Date: *06/30/2021*  
| 16.15 AGREEMENTS Agreement Party   | Number                        | Date Executed   |          |
|------------------------------------|-------------------------------|-----------------|----------|
| CRADA                              | Agenus                        | 3127            | 01/13/17 |
| CRADA                              | Agenus                        | 3127.1          | 05/01/18 |
| CRADA                              | Agenus                        | 3127.2          | 07/16/19 |
| CRADA                              | Agenus                        | 3127.3          | 07/28/20 |
| CRADA                              | Merck                         | 3128            | 01/13/17 |
| CRADA                              | Merck                         | 3128.1          | 07/23/18 |
| CDA                                | Advocate Health Care          | 13506-17        | 07/09/17 |
| CDA                                | Agenus and Merck              | 12761-16        | 06/15/16 |
| CDA                                | Head for the Cure             | 13991-18        | 01/09/18 |
| CTA                                | Orlando Health                | 01118-18        | 09/10/18 |
| CTA                                | University of Utah            | 01123-19        | 04/03/19 |
| CTA                                | MUSC Hollings                 | 01125-19        | 11/26/18 |
| CTA                                | Baylor S&W Research Institute | 01127-19        | 02/04/19 |
| CTA                                | NorthShore University         | 01129-19        | 12/04/18 |
| CTA                                | University of North Carolina  | 01134-19        | 02/13/19 |
| CTA                                | Advocate Research             | 01135-19        | 09/19/19 |
| CTA                                | Cedars Sinai Med Ctr          | 01159-19        | 09/05/19 |
| CTA                                | UT Southwestern               | 01163-19        | 09/10/19 |
| CTA                                | Henry Ford Health System      | 01122-19        | 01/14/19 |
| CTA                                | University of Washington      | 01160-19        | 07/25/19 |
| CTA                                | Piedmont Hospital             | 01176-20        | 01/07/20 |
| CTA                                | Baylor College of Medicine    | 01170-20        | 01/10/20 |  
Version Date: *06/30/2021*
agenus
16.16 investigator agreement

I have received and reviewed the Investigator Brochure for Pembrolizumab and HSPPC-96.  
I have read this protocol and agree that the study is ethical. I agree to conduct the study as outlined and in accordance with all applicable regulations and guidelines. I agree to maintain the confidentiality of all information received or developed in connection with this protocol. Protocol Title: A randomized, double blind phase II trial of Surgery, Radiation Therapy plus Temozolomide and Pembrolizumab with and without HSPPC-96 in newly diagnosed Glioblastoma (GBM) Protocol Version Date: 06/30/2021 Signature of Principal Investigator Date Name of Principal Investigator (printed or typed)