Pembrolizumab for the Treatment of Recurrent High Grade Neuroendocrine Carcinoma

Inclusion Criteria:

- Histologically confirmed, metastatic or unresectable neuroendocrine carcinoma of
non-pulmonary origin, high grade as indicated by Ki-67 >20% and/or > 20 mitoses/10
hpf. Patients must have existing Ki-67 results from archival tissue or available
tissue for Ki-67 testing. If no archival tissue is available the subject must agree to
a fresh biopsy for testing to qualify for the study.

- Patients must have progressed during or after first-line treatment for metastatic or
unresectable disease with either a platinum-based regimen (e.g. carboplatin + VP16,
cisplatin + VP-16, FOLFOX) OR temozolomide-based regimen. Patients must have failed at
least one line of therapy but no maximum number of therapies is exclusionary (i.e.
second-line therapy and beyond).

- Have measurable disease based on irRECIST.

- Be greater than or equal to 18 years of age on day of signing informed consent.

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

- Demonstrate adequate organ function as defined in the protocol, all screening labs
should be performed within 14 days of treatment initiation.

- Subjects with a history of known central nervous system (CNS) metastases must have
documentation of stable or improved brain imaging for at least 2 weeks after
completion of definitive treatment. Definitive treatment may include surgical
resection, whole brain irradiation, and/or stereotactic radiation therapy.

- 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.

- Must have recovered from adverse effects of any prior surgery, radiotherapy or other
antineoplastic therapy.

- Last dose of any antineoplastic therapy greater than or equal to 2 weeks (including
chemotherapy, small molecule inhibitors, radiation, and/or other investigational
anticancer agents). Patients receiving hormone manipulation (e.g. SERMs, aromatase
inhibitors, LHRH agonist, etc.) for reasons other than treatment of metastatic breast
cancer may continue this treatment at the discretion of the investigator.

- Able to provide informed consent and willing to sign an approved consent form that
conforms to federal and institutional guidelines.

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 2 weeks of the first dose of treatment.

- Has a diagnosis of immunodeficiency or receiving steroid therapy of any other form of
immunosuppressive therapy within 7 days prior to first dose of trial treatment.
Subjects who receive daily steroid replacement therapy serve as an exception to this
rule. Daily prednisone at doses of 5 to 7.5 mg (or hydrocortisone equivalent doses) is
an example of replacement therapy.

- 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 adverse events
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., less than or equal
to Grade 1 or at baseline) from adverse events due to a previously administered agent.
Note: Subjects with less than or equal to 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. Patients receiving hormone manipulation (e.g.
tamoxifen, aromatase inhibitors, LHRH agonist, etc.) for reasons other than treatment
of metastatic breast cancer may continue this treatment at the discretion of the
investigator.

- 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.
Patients on long-term adjuvant therapy with no evidence of disease are not excluded if
felt appropriate by investigator.

- 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 2 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, 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 has
current pneumonitis.

- 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 pre-screening or screening visit
through 120 days after the last dose of trial treatment.

- Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent.

- Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies).

- Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA
[qualitative] is detected).

- 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 (e.g., Flu-Mist®) are live
attenuated vaccines, and are not allowed.