Blood-brain Barrier (BBB) Disruption Using Exablate Focused Ultrasound With Standard of Care Treatment of NSCLC Brain Mets

Inclusion Criteria:

Participant is ≥ 18 years of age
The participant provides written informed consent for the trial
Participant is willing to comply with all study procedures for the duration of the study
Subject has tumor biomarkers that are EGFR (epidermal growth factor receptor) and ALK (anaplastic lymphoma kinase) negative
Participant is a NSCLC subject prescribed pembrolizumab monotherapy per standard of care
Participant is diagnosed with brain metastases that meet the RANO-BM criteria for measurable disease: [MR contrast-enhancing lesion measured in at least one dimension with a minimum size of 10mm, visible on 2 or more axial slices that are 5 mm or less apart with 0 mm skip (preferably < 1.5mm apart with 0 mm skip). The perpendicular diameter should measure at least 5 mm]
Participant has a Karnofsky Performance Status ≥ 70% and/or ECOG 0-2
Participant may have up to 3 device-accessible MR visible Brain Metastases
Female subject is confirmed NOT PREGNANT each procedure day. Male and Female subjects are utilizing highly effective contraception during the study and through 120 days (4 months) after the study
Screening/Baseline laboratory values

Exclusion Criteria

Subject is pregnant or breastfeeding,
Participant has evidence of acute intracranial hemorrhage or significant calcifications in the focused ultrasound sonication beam path
Participant has metastatic melanoma or other tissue histology at risk for spontaneous intracranial hemorrhage in natural history
Participant has signs and symptoms of increased intracranial pressure or symptomatic mass effect, midline shift or evidence of subfalcine, uncal or tonsillar herniation
Participant receiving Bevacizumab (Avastin) therapy, or other drugs with a proclivity for causing bleeding
History of bleeding disorder, coagulopathy or with a history of spontaneous brain tumor hemorrhage, anticoagulation or antiplatelet therapy or medication known to increase the risk of hemorrhage within washout period prior to treatment (i.e., antiplatelet or vitamin K inhibitor anticoagulants within 7 days, non-vitamin K inhibitor anticoagulants within 72 hours, or heparin-derived compounds within 48 hours of treatment)
Participant has a known chronic viral infection such as Hepatitis B, Hepatitis C or HIV or has a known history of/active TB (Bacillus tuberculosis)
Subjects with evidence of cranial or systemic infection
Participant has received a solid organ or hematopoietic stem cell transplant
Participant has received a live vaccine within 28 days prior to the first dose of study agent Examples of live vaccines include, but are not limited to measles, mumps, rubella, varicella/zoster (chicken pox), yellow fever, rabies, Bacillus Calmette-Guérin (BCG), typhoid vaccine, and intranasal influenza vaccines (e.g., FluMist®)
Participant has a severe or uncontrolled medical disorder that would, in the investigator's opinion, impair ability to receive study intervention
Known sensitivity to DEFINITY® ultrasound contrast agent or hypersensitivity to perflutren microsphere or its components, e.g., polyethylene glycol, as found in MiraLAX and bowel prep products
Contraindications to MRI and gadolinium-DTPA including non-MRI-compatible implanted devices, severe claustrophobia, unable to lie supine in MRI
Severely impaired renal function with estimated glomerular filtration rate <30 mL/min/1.73m2, creatinine >1.5 ULN and/or on dialysis
Subjects with significant liver dysfunction, e.g., history of cirrhosis (hemochromatosis or severe alcohol abuse), or active hepatitis (autoimmune or infectious) with elevated AST, ALT INR or bilirubin (ALT: Male 21-72 units/L; Female 9-52 units/L; AST: Male 17-59 units/L, Female 14-36 units/L; INR >1.3; bilirubin >5 times lab normal)
Subject is currently enrolled in another intervention based clinical trial
Has a diagnosis of immunodeficiency or is receiving chronic systemic steroid therapy (in dosing exceeding 10 mg daily of prednisone equivalent) or any other form of immunosuppressive therapy within 7 days prior to the first dose of study drug
Has a known additional malignancy that is progressing or has required active treatment
Presence of leptomeningeal disease
Contraindications to pembrolizumab or has severe hypersensitivity (≥Grade 3) to pembrolizumab and/or any of its excipients
Has a diagnosis of active autoimmune disease (e.g., irritable bowel syndrome, autoimmune Hepatitis, Guillain-Barre Syndrome, etc.) requiring 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. History of (non-infectious) pneumonitis that requires steroids or has current pneumonitis
Has a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the study, interfere with the subject's participation for the full duration of the study, 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