- Written informed consent and HIPAA authorization for release of personal health
information prior to registration. NOTE: HIPAA authorization may be included in the
informed consent or obtained separately.
- Age ≥ 18 years at the time of consent.
- ECOG Performance Status (PS) of 0-1within 28 days prior to registration. NOTE: Within
0-3 days prior to the anticipated C1D1, ECOG PS must be 0-1.
- Archived tumor tissue must be available and identified during screening and shipped
after subject registration. If archived tissue is not available and the subject is not
undergoing a standard of care biopsy, the subject is not eligible for trial
- PD-L1 results are required, if available. If PD-L1 testing has not been done, it
should be ordered as standard of care prior to C1D1. PD-L1 testing must be performed
by a CLIA certified lab using the Dako 22C3 antibody.
- Histologically or cytologically proven adenocarcinoma of the stomach or GEJ.
- Metastatic, recurrent, or locally advanced unresectable disease.
- Intolerant of or progressed on at least one prior line of therapy for metastatic
disease. NOTE: Neoadjuvant or adjuvant therapy administered < 12 months prior to
diagnosis of recurrent disease counts as one line of therapy.
- Measurable disease per RECIST v1.1
- Candidate for pembrolizumab, ramucirumab, and paclitaxel
- Demonstrate adequate organ function as defined in the table below. All screening labs
to be obtained within 28 days prior to registration. NOTE: Labs must also be obtained
within 10 days prior to C1D1 treatment.
- Absolute Neutrophil Count (ANC) ≥ 1,100/mm3
- Hemoglobin (Hgb) ≥ 8.5 g/dL without transfusion or EPO dependency
- Platelets ≥ 100,000 / mcL
- Creatinine OR Calculated creatinine clearance1 ≤ 1.5 x upper limit of normal
(ULN) OR ≥ 60 mL/min for subject with creatinine levels > 1.5 x institutional ULN
- Total bilirubin ≤ 1.5 X ULN OR Direct bilirubin ≤ ULN for subjects with total
bilirubin levels > 1.5 ULN OR total bilirubin ≤ 2 x ULN if liver metastases are
- Aspartate aminotransferase (AST) and Alanine aminotransferase (ALT) ≤ 2.5 X ULN
OR ≤ 5 x ULN for subjects with liver metastases
- Albumin > 2.5 g/dL
- Females of childbearing potential must have a negative serum pregnancy test within 72
hours days prior to registration. If the urine test is positive or cannot be confirmed
as negative, a serum pregnancy test will be required. NOTE: Females are considered of
child bearing potential unless they are surgically sterile (have undergone a
hysterectomy, bilateral tubal ligation, or bilateral oophorectomy) or they are
naturally postmenopausal for at least 12 consecutive months
- Females of childbearing potential and males must be willing to abstain from
heterosexual activity or to use 2 forms of effective methods of contraception from the
time of informed consent until 120 days after treatment discontinuation. The two
contraception methods can be comprised of two barrier methods, or a barrier method
plus a hormonal method.
- Willingness to return to the enrolling institution for follow up
- Willingness to provide tissue and blood samples for correlative research purposes.
- Co-morbid systemic illnesses or other severe concurrent disease which, in the judgment
of the investigator, would make the patient inappropriate for entry into this study or
interfere significantly with the proper assessment of safety and toxicity of the
- 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 (eg., thyroxine, insulin, or physiologic corticosteroid
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a
form of systemic treatment. NOTE: Inhaled steroids or steroid injections for joint
disease are allowed.
- Patients known to be HIV positive.
- 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 received prior therapy with:
- an anti-PD-1, anti-PD-L1, or anti- PD-L2 agent
- has received prior anti-angiogenesis therapy.
- Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA
[qualitative] is detected).
- Prior severe allergic reactions to a monoclonal antibody or 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.
- Other active malignancy which requires current treatment and which in the opinion of
the site investigator is likely to interfere with evaluation of disease assessment.
NOTE: Continuation of hormonal therapies is allowed.
- Patients with known active central nervous system (CNS) 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
- Uncontrolled intercurrent illness which in the opinion of the investigator poses
unacceptably high risk when combined with study treatment, including but not limited
to the following:
- Symptomatic congestive heart failure
- Unstable angina pectoris
- Severely impaired lung function
- Known history of active TB (Bacillus Tuberculosis)
- Uncontrolled diabetes as defined by fasting serum glucose >1.5 x ULN (NOTE:
Optimal glycemic control should be achieved before starting trial therapy.)
- Significant underlying liver disease such as severe cirrhosis or hepatic
- Has known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial.
- Has an active infection requiring systemic therapy prior to therapy initiation.
- 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.
- 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 known history of or any evidence of active, non-infectious pneumonitis.
- Currently uncontrolled hyper/hypothyroidism or hyper/hypocortism if in the opinion of
the investigator they pose unacceptably high risk when combined with study treatment.
- Received live vaccine ≤ 30 days prior to registration. 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
- Prior pancreatitis that was symptomatic or required medical intervention ≤ 6 months
prior to registration (known toxicity of pembrolizumab).
- Prior enteritis that was symptomatic or required medical intervention ≤ 6 months prior
to registration (known toxicity of pembrolizumab).
- Pre-existing motor or sensory neurotoxicity grade 3 or higher.
- For patients who received palliative RT, there must be no evidence of disease
progression on clinical or imaging exams for at least two weeks prior to first dose of
- Parenteral or oral corticosteroids in the last two weeks prior to starting study
- Prior solid organ or allogeneic transplant