A Trial of Pembrolizumab for Refractory Atypical and Anaplastic Meningioma

Inclusion Criteria:

1. Be willing and able to provide written informed consent/assent for the trial.

2. Be 18 years of age on day of signing informed consent.

3. Have measurable disease based on RECIST 1.1.

4. Histologically, previously proven, grade II or III meningioma, HPC or classicradiographic features of a recurrent surgically inaccessible atypical or anaplasticmeningioma.

5. All patients would have to have recurrence despite radiotherapy, unless radiotherapyis contraindicated.

6. No limit on the number of prior surgeries, radiation or radiosurgery treatments.

7. No limit on prior systemic therapies - chemotherapy or biological agents.

8. Patients who received stereotactic radiosurgery (SRS) are eligible withouthistologic documentation of recurrence if at least 6 months have passed fromprevious SRS treatment, and preferably, but not necessarily a 2-fluoro-2-deoxy-D-glucose PET imaging demonstrated hypermetabolism.

9. KPS≥50%

10. At least 4 weeks since any prior therapy.

11. Life expectancy of at least 4 months.

12. Dexamethasone use will be allowed up to a dose of 2mg per day. Steroids dose shouldbe reduced or stopped 7 days prior to treatment with study drug.

13. Demonstrate adequate organ function as defined in Table 1, all screening labs shouldbe performed within 10 days of treatment initiation. Table 1 Adequate Organ Function Laboratory Values Hematological Absolute neutrophil count (ANC)≥1,500 /mcL Platelets≥100,000 / mcLHemoglobin≥9 g/dL or ≥5.6 mmol/L without transfusion or EPO dependency (within 7days of assessment) Renal Serum creatinine OR Measured or calculated creatinineclearance (GFR can also be used in place of creatinine or CrCl)≤1.5 X upper limit ofnormal (ULN) OR

≥60 mL/min for subject with creatinine levels > 1.5 X institutional ULN HepaticSerum total bilirubin ≤ 1.5 X ULN OR Direct bilirubin ≤ ULN for subjects with totalbilirubin levels > 1.5 ULN AST (SGOT) and ALT (SGPT) ≤ 2.5 X ULN OR

≤ 5 X ULN for subjects with liver metastases Albumin >2.5 mg/dL CoagulationInternational Normalized Ratio (INR) or Prothrombin Time (PT) Activated Partial Thromboplastin Time (aPTT)≤1.5 X ULN unless subject is receivinganticoagulant therapy as long as PT or PTT is within therapeutic range of intendeduse of anticoagulants

≤1.5 X ULN unless subject is receiving anticoagulant therapy as long as PT or PTT iswithin therapeutic range of intended use of anticoagulants a Creatinine clearanceshould be calculated per institutional standard.

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

15. Female subjects of childbearing potential (Section 5.7.2) must be willing to use anadequate method of contraception as outlined in Section 5.7.2 - Contraception, forthe course of the study through 120 days after the last dose of study medication. Note: Abstinence is acceptable if this is the usual lifestyle and preferredcontraception for the subject.

16. Male subjects of childbearing potential (Section 5.7.1) must agree to use anadequate method of contraception as outlined in Section 5.7.1- Contraception,starting with the first dose of study therapy through 120 days after the last doseof study therapy.

Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the subject.

Exclusion Criteria:

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

2. Has a diagnosis of immunodeficiency or is receiving other form of immunosuppressivetherapy within 7 days prior to the first dose of trial treatment.

3. Patients who are steroid dependent and cannot reduce the dexamethasone dose to amaximal dose of 2mg per day.

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

5. Hypersensitivity to pembrolizumab or any of its excipients.

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

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

• Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion andmay qualify for the study.

• Note: If subject received major surgery, they must have recovered adequatelyfrom the toxicity and/or complications from the intervention prior to startingtherapy.

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

9. Has known active central nervous system (CNS) metastases and/or carcinomatousmeningitis.

10. Has active autoimmune disease that has required systemic treatment in the past 2years (i.e. with use of disease modifying agents, corticosteroids orimmunosuppressive drugs). Replacement therapy (eg., thyroxine, insulin, orphysiologic corticosteroid replacement therapy for adrenal or pituitaryinsufficiency, etc.) is not considered a form of systemic treatment.

11. Has known history of, or any evidence of active, non-infectious pneumonitis.

12. Has an active infection requiring systemic therapy.

13. Has a history or current evidence of any condition, therapy, or laboratoryabnormality that might confound the results of the trial, interfere with thesubject's participation for the full duration of the trial, or is not in the bestinterest of the subject to participate, in the opinion of the treating investigator.

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

15. Is pregnant or breastfeeding, or expecting to conceive or father children within theprojected duration of the trial, starting with the pre-screening or screening visitthrough 120 days after the last dose of trial treatment.

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

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

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

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