Study of PD1 Blockade by Pembrolizumab With Stereotactic Body Radiotherapy in Advanced Solid Tumors

Inclusion Criteria:

- Willing and able to provide written informed consent/assent for the trial.

- Aged 18 years or older

- Have a histologically confirmed advanced solid tumor for which curative treatment is
not available.

- Have undergone all appropriate standard of care treatment options (in the opinion of
the treating investigator). Patients with NSCLC must have undergone EGFR and ALK
testing and have received appropriate initial therapy.

- Have measurable disease based on RECIST 1.1 including at least two tumor lesions that
meet criteria for multi-organ site ablative radiation therapy (MOSART) SBRT radiation.

- 0.25 cc to 65 cc of viable tumor (i.e. primary disease or metastases)
approximately 5cm in maximal dimension. Tumors larger than 65 cc can be partially
treated. Patients accruing to the expansion cohort for partially irradiated large
tumors must have at least one site of disease >65cc.

- Metastases located in lung, liver, mediastinal/cervical node, Spinal/Paraspinal,
Osseous, abdominal-pelvic (lymph node/adrenal gland)

- For biopsy patients: Be willing to undergo repeat biopsy of a tumor lesion before
treatment and after radiation. Subjects for whom newly-obtained samples cannot be
provided (e.g. inaccessible or subject safety concern) may be exempted from this
requirement after consultation with the Principal Investigator.

- Have a performance status of 0 or 1 on the ECOG Performance Scale.

- Demonstrate adequate organ function

- Absolute neutrophil count (ANC) ≥ 1,500 /mcL

- Platelets ≥ 100,000 / mcL

- Hemoglobin ≥ 8 g/dL

- Serum creatinine OR Measured or calculateda creatinine clearance ≤ 1.5 X upper
limit of normal (ULN) OR ≥ 50 mL/min for subject with creatinine levels > 1.5 X
institutional ULN

- Serum total bilirubin ≤ 1.5 X ULN OR Direct bilirubin ≤ ULN for subjects with
total bilirubin levels > 1.5 ULN

- AST (SGOT) and ALT (SGPT) ≤ 2.5 X ULN OR ≤ 5 X ULN for subjects with liver
metastases

- Albumin ≥ 3.0 mg/dL

- Female subject of childbearing potential should have a negative urine or serum
pregnancy within 72 hours prior to receiving the first dose of study medication. If
the urine test is positive or cannot be confirmed as negative, a serum pregnancy test
will be required.

- Female subjects of childbearing potential should be willing to use 2 methods of birth
control or be surgically sterile, or abstain from heterosexual activity for the course
of the study through 120 days after the last dose of study medication. Subjects of
childbearing potential are those who have not been surgically sterilized or have not
been free from menses for > 1 year.

- Male subjects should agree to use an adequate method of contraception starting with
the first dose of study therapy through 120 days after the last dose of study therapy.

- Have an investigator determined life expectancy of at least 6 months.

Exclusion Criteria:

- Is currently participating and receiving study therapy or has participated in a study
of an investigational agent and received study therapy or used an investigational
device within 4 weeks of the first dose of treatment.

- Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy at a dose
of >10 mg Prednisone daily or equivalent at time of first dose of trial treatment.

- Has a known history of active TB (Bacillus Tuberculosis)

- Hypersensitivity to pembrolizumab or any of its excipients.

- Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study
Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from side effects due
to agents administered more than 4 weeks earlier.

- Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy
within 2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at
baseline) from adverse events due to a previously administered agent.

- Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and
may qualify for the study.

- Note: If subject received major surgery, they must have recovered adequately from
the toxicity and/or complications from the intervention prior to starting
therapy.

- Has a known additional malignancy that is progressing or requires active treatment.
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the
skin that has undergone potentially curative therapy or in situ cervical cancer.

- Has known active central nervous system (CNS) metastases and/or carcinomatous
meningitis. Subjects with previously treated brain metastases may participate provided
they are stable (without evidence of progression by imaging for at least four weeks
prior to the first dose of trial treatment and any neurologic symptoms have returned
to baseline), have no evidence of new or enlarging brain metastases, and are not using
steroids for at least 7 days prior to trial treatment. This exception does not include
carcinomatous meningitis which is excluded regardless of clinical stability.

- Has active autoimmune disease that has required systemic treatment in the past 2 years
(i.e. with use of disease modifying agents, corticosteroids or immunosuppressive
drugs). Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a
form of systemic treatment.

- Has known history of non-infectious pneumonitis that required steroids or active
pneumonitis.

- Has evidence of interstitial lung disease.

- Has an active infection requiring systemic therapy.

- Has a history or current evidence of any condition, therapy, or laboratory abnormality
that might confound the results of the trial, interfere with the subject's
participation for the full duration of the trial, or is not in the best interest of
the subject to participate, in the opinion of the treating investigator.

- Has known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial.

- Is pregnant or breastfeeding, or expecting to conceive or father children within the
projected duration of the trial, starting with the screening visit through 120 days
after the last dose of trial treatment.

- If known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA
qualitative is detected) then patient is not eligible for cohorts including SBRT to
liver lesions.

- Has received a live vaccine within 30 days of planned start of study therapy.

- Note: Seasonal influenza vaccines for injection are generally inactivated flu
vaccines and are allowed, however intranasal influenza vaccines are live
attenuated vaccines and are not allowed.

- Has had prior radiation therapy (defined as >10% of prior prescription dose) to the
area planning to be treated with SBRT

Additional Criteria for Expansion Cohorts:

- Partially Irradiated Large Volume Tumors Cohort

- In addition to the criteria above, patients must have at least one lesion >65cc
(~5cm diameter sphere) that is amenable to partial tumor irradiation.

- Oligometastatic disease

- In addition to the criteria above, patients must have disease limited to 4 total
lesions or less, all of which are amenable to SBRT. Patients with oligometastatic
disease at presentation or oligorecurrent disease are eligible. Patients who had
more than 4 sites of disease previously, but had a complete response at other
sites and limited progressive disease to 4 sites are eligible for participation.
Partial tumor irradiation for lesions >65cc is permitted in this expansion
cohort.