Dose-seeking Study of Pembrolizumab Plus Vemurafenib and Cobimetinib Advanced Melanoma

Pembrolizumab will be given at a dose of 200 mg q3 weeks (this is the standard dosage, ), and
vemurafenib/cobimetinib will be given at 480 mg twice daily/20 mg daily, 720 mg twice
daily/40 mg daily, or 960 mg twice daily/60 mg daily. Treatment with pembrolizumab,
vemurafenib and cobimetinib will commence on the same day.

Inclusion Criteria:

1. Provide written informed consent obtained prior to the initiation of study procedures.

2. Male and female subjects who are at least 18 years of age.

3. Histologically confirmed unresectable stage III or stage IV melanoma (AJCC 7th edition
classification). Cutaneous melanoma and mucosal melanoma will be eligible.

4. Only patients with BRAF V600E or V600K mutated tumors will be enrolled.

5. Baseline skin exam is required for all patients. Note: Cutaneous squamous cell
carcinoma (SCC) lesions identified at baseline must be excised.

6. Measurable disease as defined by the Response Evaluation Criteria in Solid Tumors
(RECIST v1.1). Baseline measurements must be obtained within 4 weeks prior to
registration.

7. Adequate hematologic, renal, and liver function as evidenced by the following (within
4 weeks prior to starting the study drugs):

- WBC ≥ 3,000/mm3

- ANC ≥ 1500

- Hemoglobin ≥ 9g/dL (women) or ≥ 11g/dL (men) Platelets ≥ 100,000/mm3 Serum
Creatinine ≤ 1.5 x upper limit of normal (ULN)

- Serum Bilirubin ≤ 1.5 x ULN

- Serum AST and ALT ≤ 2.5 x ULN

Note: (supportive transfusions will be allowed during screening and during treatment
as deemed necessary by the treating physician)

8. EKG documenting QTc interval < 480 msec and no clinically significant arrhythmia

9. Fully recovered from any effects of major surgery, and be free of significant
infection.

10. ECOG performance status of 0 or 1.

11. Patients must be free of active brain metastases by contrast-enhanced CT/MRI scans
within 4 weeks prior to starting the study drugs. If known to have prior brain
metastases, must not have evidence of active (enlarging and/or symptomatic lesions)
brain disease on MRI evaluations within 4 weeks apart (one of which is at least 4
weeks from SRS or WBRT treatment.

12. Female patients of child bearing potential must have a negative pregnancy test within
7 days from the time of registration .

13. 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.

14. 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 greater than 1 year.

15. 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.

16. Patients with brain metastases may be enrolled if brain metastases have been treated
by surgery and/or radiation and are stable on 2 week repeat scan.

Exclusion Criteria:

1. Serious clinically significant illnesses, such as: cardiovascular disease
(uncontrolled congestive heart failure, uncontrolled hypertension, cardiac ischemia,
myocardial infarction, and severe cardiac arrhythmia), bleeding disorders, symptomatic
autoimmune diseases (such as inflammatory bowel disease, autoimmune hepatitis,
uncontrolled hypo or hyperthyroidism), severe obstructive or restrictive pulmonary
diseases, retinopathy, active systemic infections, and inflammatory bowel disorders.

2. Known HIV or AIDS-related illness, or active HBV and HCV.

3. Has a known history of active TB (Bacillus Tuberculosis)

4. History of grade 4 immune-related adverse events requiring treatment with prednisone,
or grade 3 immune-related adverse events requiring prednisone >10 mg/kg for >12 weeks,
if previously treated with ipilimumab.

5. Prior therapy with anti-PD-1 agent(s) in the metastatic setting. Treatment with
anti-PD1 in the adjuvant setting is permitted.

6. Prior therapy with a BRAF and/or MEK and/or ERK inhibitors in the metastatic setting.
Treatment with BRAF/MEKi in the adjuvant setting is permitted.

7. Refractory nausea, vomiting, small bowel resection or any other gastrointestinal
ailment that would preclude study drug absorption.

8. Cardiac abnormalities

- Mean QTc interval ≥ 480 msec at screening.

- ACS/AMI -within 24 weeks prior to screening.

- PCI/PTCA -within 24 weeks prior to screening.

- Symptomatic heart failure - NYHA Class ≥ II symptoms.

9. Active infection within one-week prior to study, including unexplained fever

10. Systemic steroid or other immunosuppressive therapy within 4 weeks of starting the
study.

11. Lactating females and/or pregnant females.

12. Any significant psychiatric disease, medical or other condition, which in the opinion
of the principal investigator could prevent adequate informed consent or compromise
participation in the clinical trial.