Window of Opportunity Platform Study to Define Immunogenomic Changes With Pembrolizumab Alone and in Rational Combinations in Muscle-Invasive Bladder Cancer
Phase: PHASE2
Conditions: Bladder Cancer
Sponsor: UNC Lineberger Comprehensive Cancer Center

LINEBERGER COMPREHENSIVE CANCER CENTER 
January 9, 2025 
CLINICAL ONCOLOGY RESEARCH PROGRAM 
Amendment 6 
UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL 
SUMMARY OF CHANGES 
Protocol Amendment #6 
LCCC  1827: Window of Opportunity Platform Study to Define Immunogenomic 
Changes with Pembrolizumab Alone and in Rational Combinations in Muscle-
Invasive Bladder Cancer 
AMENDMENT INCORPORATES: 
_X_  Editorial, administrative changes 
__  Scientific changes  
__  Therapy changes  
__   Eligibility Changes  
Rationale for amendment: The purpose of this amendment is to correct the terminology 
used in the secondary objective. The secondary objective should be looking at clinical 
complete response rate, cT0, not pT0.   
Editorial, administrative changes: 
Sections 
2.2.5, 
3.2.5 
and 10.3 
Complete response rate (pT0) corrected to clinical complete response 
rate (cT0). 
Versioning 
Protocol versioning corrected as Amendment 6 of the protocol should be 
version 7. 
THE ATTACHED VERSION DATED January 9, 2025 INCORPORATES THE 
ABOVE REVISIONS  

LINEBERGER COMPREHENSIVE CANCER CENTER 
January 9, 2025 
CLINICAL ONCOLOGY RESEARCH PROGRAM 
 
Amendment 6 
UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL 
 
 
 
 
PROTOCOL AMENDMENT 5 
 
 
LCCC  1827: Window of Opportunity Platform Study to Define Immunogenomic 
Changes with Pembrolizumab Alone and in Rational Combinations in Muscle-
Invasive Bladder Cancer 
 
 
AMENDMENT INCORPORATES: 
         Editorial, administrative changes (IRB approval) 
    X  Scientific changes (IRB approval)         
         Therapy changes (IRB approval) 
    X  Eligibility Changes (IRB approval)  
 
Rationale for amendment:  
The purpose of this amendment is to modify the document to change the eligibility criteria 
so that they do not apply to all participants, and it is indicated that some criteria are only 
applicable to arm 2 of the study. Additionally, Appendix B and the prohibited medications 
section was also modified to indicate that they are only applicable to arm 2.  
 
Summary of Changes 
 
Scientific Changes 
1. Appendix B is changed to indicate that it only applies to entinostat. 
2. Section 5.6 Prohibited Medications/Treatments was updated to indicate that the 
prohibited medications associated with Appendix B are only applicable to arm 2.  
 
Eligiblity Changes 
1. Exclusion criteria 4.2.5, 4.2.16, 4.2.17 and 4.2.22 have been changed to indicate 
that they are only applicable to participants in arm 2.  
 
The attached version dated May 11, 2023 incorporates the above revisions 
 
 
 

LINEBERGER COMPREHENSIVE CANCER CENTER 
January 9, 2025 
CLINICAL ONCOLOGY RESEARCH PROGRAM 
 
Amendment 6 
UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL 
 
 
 
 
PROTOCOL AMENDMENT 4 
 
 
LCCC  1827: Window of Opportunity Platform Study to Define Immunogenomic 
Changes with Pembrolizumab Alone and in Rational Combinations in Muscle-
Invasive Bladder Cancer 
 
 
AMENDMENT INCORPORATES: 
    X  Editorial, administrative changes (IRB approval) 
    X  Scientific changes (IRB approval)         
         Therapy changes (IRB approval) 
         Eligibility Changes (IRB approval)  
 
Rationale for amendment:  
The purpose of this amendment is to provide a defined window of time for correlative 
sample collection and clarify the requirements at the pre-surgery visit for participants 
receiving bladder preserving therapy. Also, this amendment includes instructions for sites 
to obtain Entinostat from Syndax. 
 
Summary of Changes 
 
Administrative Change 
2. Section 6.2.4 was updated to include “Entinostat should be ordered from Syndax 
by completing and emailing provided Drug Request Form.” 
 
Scientific Changes 
3. A new footnote (#15) was added to the T&E table related to the collection of 
correlative samples at the surgery visit. The footnote states that a window of –2 
days will be applied to correlative samples collected at the surgery visit (collection 
should not occur after surgery). 
4. Additional wording was included for footnote 12 of the T&E table to indicate that 
the pre-surgery visit will be abbreviated for subjects receiving bladder preserving 
therapy (TURBT). This footnote was also updated to allow for collection of safety 
labs at the same time as correlative sample collection which occurs up to 2 days 
prior to surgery. 
 
The attached version dated October 3, 2022 incorporates the above revisions 
 
 
 

LINEBERGER COMPREHENSIVE CANCER CENTER 
January 9, 2025 
CLINICAL ONCOLOGY RESEARCH PROGRAM 
 
Amendment 6 
UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL 
 
 
 
PROTOCOL AMENDMENT 3 
 
 
LCCC  1827: Window of Opportunity Platform Study to Define Immunogenomic 
Changes with Pembrolizumab Alone and in Rational Combinations in Muscle-
Invasive Bladder Cancer 
 
 
AMENDMENT INCORPORATES: 
    X  Editorial, administrative changes (IRB approval) 
    X  Scientific changes (IRB approval)         
         Therapy changes (IRB approval) 
    X  Eligibility Changes (IRB approval)  
 
Rationale for amendment:  
The main purpose of this amendment is to allow subjects to enroll who are scheduled to 
undergo trimodality therapy with maximal transurethral resection of the bladder tumor 
(TURBT) followed by concurrent chemoradiation. Updates throughout distinguish and 
clarify this addition relative to study objectives, procedures, tissue collections, and 
analysis. A clarification was made to the conditions and timing of SAEs or events of 
clinical interest related to pembrolizumab. Suggested regimens were added in Appendix E. 
Objectives were added to examine complete response rate in patients undergoing 
trimodality therapy. The section on dose delays and modifications for pembrolizumab have 
been updated. Additionally, Merck reporting guidelines have been updated and an 
additional appendix was added in relation to these updates. Clarified when pembrolizumab 
may be continued in the case of an adverse event related to entinostat. Subject follow-up 
has been modified to follow subjects for every 6 months for 3 years for recurrence and 
survival. Two new objectives and endpoints were added for event-free survival and overall 
survival. Sections for Duration of Follow-up, Duration of Treatment, and Off-Study criteria 
have been added. Additional clarifications to exclusion criteria related to vaccinations, 
pneumonitis, and HBV/HCV testing. Funding source reporting contact information was 
updated. As the trial is moved from a single center to a multicenter study, updated 
information was added to adapt the protocol to a multicenter trial. 
 
Summary of Changes 
 
Editorial/Administrative Changes 
5. Mechanical and minor clarifying edits made where appropriate. 
6. Figure and section references updated as needed. 
7. Added Appendix E: Suggested chemotherapy regimens for patients undergoing 
trimodality therapy 
8. The Title page and Sections 9.2.2, 9.4.1, 11.3, 11.4, 11.5.1, 11.5.3, and 11.6 have 
been updated to include multicenter language. 

LINEBERGER COMPREHENSIVE CANCER CENTER 
January 9, 2025 
CLINICAL ONCOLOGY RESEARCH PROGRAM 
 
Amendment 6 
UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL 
 
9. Section 9.3 related to funding source reporting and Section 9.3.1.1 removed to 
account for updated funding source reporting language. 
10. Section 9.4.2: Updated funding source reporting guidelines.  
a. Time and Events table, Footnote #13; Section 8.2.1 and Section 9.2.1: 
References related to these guidelines were updated. 
11. Section 9.4.3: Updated contact information for SAE communications to Syndax 
have been added. 
12. Appendix F:Additional appendix added in response to Section 9.4.2 updates. 
 
Scientific Changes 
1. Section 1.1: Updates to the study design were added to include subjects scheduled 
to undergo trimodality therapy with maximal TURBT followed by concurrent 
chemoradiation. Tissue collections were also updated to include maximal TURBT 
2.  Section 1.2: Additional background information was added.  
3. Section 1.7: Tissue collections for correlative studies were updated. 
4. Objective 2.2.2: Updated language to indicate use of pre- and post-treatment tumor 
tissue 
5. Objective 2.2.3: Updated to add safety, tolerability and feasibility of 
pembrolizumab with and without entinostat prior to trimodality therapy in MIBC 
patients 
6. Objective 2.2.4: Updated to direct this objective toward cisplatin-ineligible 
subjects undergoing radical cystectomy 
7. Objective 2.2.5: Added objective with corresponding endpoint (3.2.5) to estimate 
complete response rate.   
8. Objective 2.2.6 and 2.2.7/Endpoint 3.2.6 and 3.2.7: Objective/Endpoint 
combinations added for the assessment of event-free survival and overall survival. 
9. Endpoint 3.2.2: Modified to match objective 2.2.2. 
10. Endpoint 3.2.3: Modified endpoint from 90 to 30 days 
11. Section 5.1: Schema: Updated schema to be consistent with study updates  
12. Section 5.2: Updated language from surgical resection to cystectomy (or maximal 
TURBT) 
13. Section 5.4: Updated Dose Delays and Modifications for Pembrolizumab. The table 
for Dose Modification and Toxicity Management Guidelines in this section has 
been replaced with an updated table. 
14. Section 5.4: Entinostat dose modifications edited so that if treatment is held due to 
an adverse event clearly attributable to entinostat that is not listed in the table above 
and not immune-related, then the pembrolizumab may be continued (i.e. 
monotherapy). 
15. Section 5.5: Updated the time frame for concomitant medications to up until the 
time of post-treatment cystectomy or initiation of concurrent chemoradiation  
16. Section 5.8: Added maximal TURBT for potential tissue collection. 
17. Section 5.9-5.11 have been added to address Follow-up, Off-Study Criteria, and 
Duration of Therapy. 
18. Section 7.1.6: Updated to included assessments into the follow-up period. 
19. Section 7.3.1, 7.3.2, 7.3.3: Updated to clarify tissue collection language 
20. Section 8.1: Time and Events Table:  

LINEBERGER COMPREHENSIVE CANCER CENTER 
January 9, 2025 
CLINICAL ONCOLOGY RESEARCH PROGRAM 
 
Amendment 6 
UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL 
 
a. Removed physical exam timing to pre- and post-surgery 
b. Added concomitant medications collection until surgery   
c. Footnotes 1, 9, and 10 updated to clarify tissue collection language 
d. Footnote 13: Updated post-surgery visit timing for trimodality and 
cystectomy subjects 
e. An extra column was added for follow-up of subjects. An additional row 
was added for survival follow-up. 
f. Footnote 14 was added to describe follow-up. 
21. Section 8.2: Updated section to “Post-Treatment Surgery” and added language to 
distinguish between cystectomy and trimodality therapy subjects. 
22. Section 8.2.1: Updated the section for trimodality subjects. 
23. Section 9.2.1: Updated conditions and timing of SAEs caused by a protocol-
mandated intervention, or any grade of events of clinical interest related to 
pembrolizumab 
24. Section 9.4.1: Updated language from cystectomy to post-treatment surgery 
25. Section 10.2: Provided conditions under which would allow for additional inclusion 
of trimodality subjects or restrict further accrual to cystectomy subjects. 
26. Section 10.3: Updated to specify for subjects that undergo cystectomy and added 
analysis for event-free survival and overall survival. 
27. Section 13.5: Appendix E: Added cisplatin every 3 weeks as additional suggested 
regimen. 
 
Eligibility Changes 
1. Criterion 4.12: The criterion has been edited to clarify the tissues collected. 
2. Criterion 4.1.8: The criterion is updated to specify that subjects are planned to 
undergo definitive therapy for MIBC with either surgery (radical cystectomy) or 
trimodality therapy (including repeat TURBT followed by concurrent 
chemoradiation) 
3. Criterion 4.1.10: Updated to clarify that inclusion criteria only applies for subjects 
planning to undergo radical cystectomy 
4. Criterion 4.2.8: Updated to include interstitial lung disease. 
5. Criterion 4.2.20: Updated to note that HBV/HCV testing is not required unless 
mandated by the local health aurhoity. 
6. Criterion 4.2.21: Updated to also exclude live-attenuated vaccine and to provide an 
allowance for killed vaccine. 
 
 
 
The attached version dated August 08, 2021 incorporates the above revisions 
 
 

LINEBERGER COMPREHENSIVE CANCER CENTER 
January 9, 2025 
CLINICAL ONCOLOGY RESEARCH PROGRAM 
 
Amendment 6 
UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL 
 
 
 
 
PROTOCOL AMENDMENT 2 
 
 
LCCC  1827: Window of Opportunity Platform Study to Define Immunogenomic 
Changes with Pembrolizumab Alone and in Rational Combinations in Muscle-
Invasive Bladder Cancer 
 
 
AMENDMENT INCORPORATES: 
    X  Editorial, administrative changes (IRB approval) 
    X  Scientific changes (IRB approval)         
        Therapy changes (IRB approval) 
        Eligibility Changes (IRB approval)  
 
Rationale for amendment:  
The primary purpose of this amendment is to change the treatment from randomization to 
assignment with preference to Arm 2. The event that precipitated this event was due to 
drug supplies. Subjects may be accrued to Arm 2 first to ensure Arm enrollment goals. 
Additionally, the coagulation tests PT/INR were added to the Time and Events Table and 
the Clinical Laboratory Assessments to add clarification and maintain consistency within 
the protocol.   
 
 
Summary of Changes 
 
Editorial/Administrative Changes 
1. Mechanical edits made where appropriate. 
2. Section 5.1, Schema: An editable diagram of the schema was added. 
3. Sections 7.2.4 and 8.1: PT/INR test was added to the Clinical Laboratory 
Assessments and the Time and Events Table and will take place at screening and 
pre-surgery.  
 
Scientific Changes 
1. Sections 1.1, 5.3, 9.1.1, 9.3, 9.4.2.1, 9.4.2.3: Language referring to randomization 
was removed.  
2. Section 5.3: Added language indicating the preference of assignment of subjects. 
 
 
 
 
The attached version dated September 23, 2020 incorporates the above revisions 
 
 

LINEBERGER COMPREHENSIVE CANCER CENTER 
January 9, 2025 
CLINICAL ONCOLOGY RESEARCH PROGRAM 
 
Amendment 6 
UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL 
 
 
 
PROTOCOL AMENDMENT 1 
 
 
LCCC  1827: Window of Opportunity Platform Study to Define Immunogenomic 
Changes with Pembrolizumab Alone and in Rational Combinations in Muscle-
Invasive Bladder Cancer 
 
 
AMENDMENT INCORPORATES: 
        Editorial, administrative changes (IRB approval) 
        Scientific changes (IRB approval)         
X     Therapy changes (IRB approval) 
        Eligibility Changes (IRB approval)  
 
Rationale for amendment:  
The primary purpose of this amendment is to add buccal swabs to be used as a source of 
normal DNA. Additionally, the amendment changes the timing of post-treatment urine 
collection to the pre-surgery visit to ease logistics of urine collection. 
 
 
Summary of Changes 
 
Therapy Changes 
• Section 7.3.1 and the T&E Table were updated to include collection of 
buccal samples 
• The T&E Table was updated to move the timing of post-treatment urine 
collection from the day of surgery to the pre-surgery visit.  
 
 
 
 
 
 
 
 
 
 
The attached version dated July 31, 2019, incorporates the above revisions 
 
 

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
i 
LIST OF ABBREVIATIONS  
5-FU 
5-fluorouracil 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
AST 
Aspartate aminotransferase 
βhCG 
Beta-human chorionic gonadotropin 
BCG 
Bacillus Calmette-Guérin 
CBCD 
Complete blood count with differential 
CD8 
Cluster of differentiation 8 
Cmax 
Maximum plasma drug concentration 
CMP 
Comprehensive metabolic panel 
CpG 
5'—C—phosphate—G—3' 
CPO 
Clinical Protocol Office 
CR 
Complete response 
c-RAF 
RAF proto-oncogene serine/threonine-protein kinase 
CT 
Computer tomography 
cT0 
Clinical complete response rate 
CTLA-4 
Cytotoxic T-lymphocyte associated protein 4 
CYP1A2 
Cytochrome P450 1A2 
CYP2C8 
Cytochrome P450 2C8 
CYP3A4 
Cytochrome P450 3A4 
DEHP 
Diethylhexyl phthalate 
DEHT 
Di-2-ethylhexyl terephthalate 
DLT 
Dose limiting toxicity 
DNA 
Deoxyribonucleic acid 
DNMT 
DNA methyltransferase 
DSMC 
Data safety monitoring committee 
ECOG 
Eastern Cooperative Oncology Group 
eCRF 
Electronic case report form 
EGFR 
Epidermal growth factor receptor 
EVA 
Ethylene vinyl acetate 
FDA 
Food and Drug Administration 
FFPE 
Formalin-fixed, paraffin-embedded tissue 
FoxP3 
Forkhead box P3 protein 
GCP 
Good Clinical Practice 
HAT 
Histone acetyl transferase 
HBs-Ag 
Hepatitis B surface antigen 
HBc 
Hepatitis B core 
HBV 
Hepatitis B virus 
HCV 
Hepatitis C virus 
HDAC 
Histone deacetylase 
HIV 
Human immunodeficiency virus 
IDS 
Investigational drug service 
IFNγ 
Interferon gamma 
Ig 
Immunoglobulin 
IGS 
Immune gene signature 
IHC 
Immunohistochemistry 
IL-2 
Interleukin-2 
INR 
International normalized ratio 
ITIM 
Immunoreceptor tyrosine-based inhibition motif 
ITSM 
Immunoreceptor tyrosine-based switch motif  
IV 
Intravenous 

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
ii 
LCCC 
Lineberger Comprehensive Cancer Center 
mAb 
Monoclonal antibody 
MAPK 
Mitogen-activated protein kinase 
MD 
Doctor of Medicine 
MDSC 
Myeloid-derived suppressor cells 
MIBC 
Muscle-invasive bladder cancer 
MRI 
Magnetic resonance imaging 
NCI-CTCAE 
National Cancer Institute – Common Terminology Criteria for Adverse Events 
NF-κB 
Nuclear factor kappa-light-chain-enhancer of activated B cells 
NK 
Natural killer cell 
NP 
Nurse practitioner 
OHRE 
Office of Human Research Ethics 
ORR 
Objective response rate 
OS 
Overall survival 
PA 
Physician assistant 
PBMC 
Peripheral blood mononuclear cells 
PCR 
Polymerase chain reaction 
PD-1 
Programmed cell death protein 1 
PD-L1 
Programmed death-ligand 1 
PD-L2 
Programmed death-ligand 2 
PES 
Polyethersulfone 
PFT 
Pulmonary function test 
Pgp 
P-glycoprotein 
PI 
Principal investigator 
PK 
Pharmacokinetic(s) 
PR 
Partial response 
PRC 
Protocol review committee 
pT0 
Complete pathologic response 
PVC 
Polyvinyl chloride 
RECIST 
Response evaluation criteria in solid tumors 
RELA 
REL-associated protein 
RN 
Registered nurse 
RNA 
Ribonucleic acid 
SAE 
Serious adverse event 
SAR 
Serious adverse reaction 
SHP 
Src homology region 2 domain-containing phosphatase 
SOP 
Standard operating procedure 
STAT 
Signal transducer and activator of transcription 
t½  
Half-life 
T3 
Triiodothyronine 
T4 
Thyroxine 
TIL 
Tumor infiltrating lymphocyte 
tmax 
Time to maximum drug concentration 
TNFα 
Tumor necrosis factor alpha 
TOTM 
Tri-2-ethylhexyltrimellitate 
Treg 
Regulatory T cell 
TSH 
Thyroid-stimulating hormone 
TURBT 
Transurethral resection of the bladder tumor 
UC 
Urothelial carcinoma 
ULN 
Upper limit of normal 
UNC 
University of North Carolina 
US 
United States 
USP 
United States Pharmacopeia 
 

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
i 
TABLE OF CONTENTS 
LIST OF ABBREVIATIONS ........................................................................................... i 
1.0 
BACKGROUND AND RATIONALE ..................................................................1 
1.1 
Study Synopsis ......................................................................................................1 
1.2 
Disease Background ..............................................................................................2 
1.3 
The PD-L1/PD-1 Pathway in Cancer ....................................................................2 
1.4 
Pembrolizumab......................................................................................................4 
1.5 
Investigational Treatment ......................................................................................6 
1.6 
Entinostat ...............................................................................................................9 
1.7 
Correlative Studies ..............................................................................................12 
2.0 
STUDY OBJECTIVES .........................................................................................14 
2.1 
Primary Objective ...............................................................................................14 
2.2 
Secondary Objectives ..........................................................................................14 
2.3 
Exploratory Objectives ........................................................................................15 
3.0 
STUDY ENDPOINTS ...........................................................................................16 
3.1 
Primary Endpoint ................................................................................................16 
3.2 
Secondary Endpoints ...........................................................................................16 
3.3 
Exploratory Endpoints.........................................................................................17 
4.0 
SUBJECT ELIGIBILITY ....................................................................................18 
4.1 
Inclusion Criteria .................................................................................................18 
4.2 
Exclusion Criteria ................................................................................................20 
5.0 
TREATMENT PLAN ...........................................................................................23 
5.1 
Schema ................................................................................................................23 

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
ii 
5.2 
Treatment Dosage and Administration ...............................................................23 
5.3 
Treatment Arm Assignment ................................................................................24 
5.4 
Toxicities and Dosing Delays/Dose Modifications .............................................24 
5.5 
Concomitant Medications/Treatments/Supportive Care Allowed ......................30 
5.6 
Prohibited Medications/Treatments ....................................................................30 
5.7 
Rescue Medications and Supportive Care ...........................................................31 
5.8 
Study Withdrawal ................................................................................................32 
5.9 
Duration of Follow-up .........................................................................................32 
5.10 
Off-Study Criteria ...............................................................................................32 
5.11 
Duration of Therapy ............................................................................................32 
6.0 
DRUG INFORMATION ......................................................................................34 
6.1 
Pembrolizumab....................................................................................................34 
6.2 
Entinostat .............................................................................................................39 
7.0 
CLINICAL ASSESSMENTS ...............................................................................41 
7.2 
Clinical Laboratory Assessments ........................................................................41 
7.3 
Correlative Studies Procedures ...........................................................................42 
8.0 
EVALUATIONS AND ASSESSMENTS ............................................................44 
8.1 
Time and Events Table ........................................................................................44 
8.2 
Post-Treatment Surgery.......................................................................................47 
8.3 
Handling of Biospecimens Collected for Correlative Research..........................47 
8.4 
Assessment of Safety ..........................................................................................48 
9.0 
ADVERSE EVENTS ............................................................................................49 
9.1 
Definitions ...........................................................................................................49 
9.2 
SAEs or Serious SARs ........................................................................................51 

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
iii 
9.3 
Documentation of Non-Serious AEs or SARs ....................................................52 
9.4 
Adverse Event Reporting ....................................................................................52 
9.5 
FDA Expedited Reporting Requirements for Studies Conducted Under an IND
 
57 
9.6 
Data and Safety Monitoring Plan ........................................................................59 
10.0 STATISTICAL CONSIDERATIONS ................................................................60 
10.1 
Study Design/Study Endpoints ...........................................................................60 
10.2 
Sample Size, Accrual and Duration of Accrual ..................................................60 
10.3 
Data Analysis Plans .............................................................................................60 
11.0 STUDY MANAGEMENT ....................................................................................62 
11.1 
Institutional Review Board (IRB) Approval and Consent ..................................62 
11.2 
Required Documentation.....................................................................................62 
11.3 
Registration Procedures.......................................................................................63 
11.4 
Data Management and Monitoring/Auditing ......................................................63 
11.5 
Adherence to the Protocol ...................................................................................64 
11.6 
Amendments to the Protocol ...............................................................................65 
11.7 
Record Retention .................................................................................................66 
11.8 
Obligations of Investigators ................................................................................66 
12.0 REFERENCES ......................................................................................................67 
13.0 APPENDICES .......................................................................................................71 
13.1 
Appendix A. ECOG Performance Status ............................................................71 
13.2 
Appendix B: Concomitant Medications to Avoid ...............................................72 
13.3 
Appendix C: The CKD-EPI Creatinine Equation ...............................................73 
13.4 
Appendix D: Acceptable Contraceptive Methods ...............................................74 

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
iv 
13.5 
Appendix E: Suggested Chemotherapy Regimens to be Given Concurrently with 
Radiation in the Trimodality Patients .............................................................................75 
13.6 
Appendix F: Merck Reporting: Adverse Events: Definitions and Procedures for 
Recording, Evaluating, Follow-up, and Reporting .........................................................76 

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
1 
1.0 
BACKGROUND AND RATIONALE 
1.1 
Study Synopsis 
LCCC 1827 is an open-label, window of opportunity platform study in patients 
with muscle-invasive bladder cancer (MIBC) that are either (a) deemed ineligible 
to receive (or refuse) cisplatin-based neoadjuvant chemotherapy who are 
scheduled to undergo definitive radical cystectomy or (b) scheduled to undergo 
trimodality therapy with maximal transurethral resection of the bladder tumor 
(TURBT) followed by concurrent chemoradiation. The primary objective of this 
study is to assess changes to immunogenomic markers after treatment with 
pembrolizumab alone and in rational combination with epigenomic or other 
immunomodulatory agents currently in development.  
 
As an initial proof of concept for this window of opportunity platform study 
design, we will investigate immunogenomic changes with pembrolizumab alone 
and in combination with a selective class I histone deacetylase (HDAC) inhibitor 
(entinostat). 
 
The study will enroll 20 subjects with a confirmed diagnosis of MIBC (cT2-
T4aN0M0) who are planned for definitive therapy with either radical cystectomy 
without cisplatin-based neoadjuvant chemotherapy or trimodality therapy. 
Subjects who are planned to undergo radical cystectomy must be deemed 
ineligible for (based on consensus criteria) [1] or refuse neoadjuvant cisplatin-
based chemotherapy. Prior to study entry, subjects must consent to having tissue 
collected for research purposes during the scheduled cystectomy or maximal 
TURBT. After screening and enrollment, baseline blood and archived 
transurethral resection of the bladder tumor (TURBT) tumor tissue will be 
collected from each subject for baseline analyses. Subjects will then start on 
clinical trial treatment followed by either radical cystectomy or maximal TURBT 
followed by chemoradiation. Subjects will be administered pembrolizumab alone 
200 mg IV on day 1 and day 22 (Arm 1) or pembrolizumab on day 1 and day 22 
and entinostat 5 mg given orally on day 1, day 8 and day 15 (Arm 2).  
 
Blood and tumor will then be collected from each subject at the time of post-
treatment surgery (cystectomy or maximal TURBT (within 10 weeks after 
initiation of protocol therapy)) [2, 3]. We do not anticipate delays in surgery due 
to the planned schedule of the preoperative treatment administration for the 
purposes of this study and based on the phase II ENCORE 601 trial 
(pembrolizumab and entinostat in melanoma) which reported an acceptable safety 
profile [4-6]. Phase I data identified grade 1/2 fatigue as the most common 
entinostat-related toxicity, with neutropenia and anemia only occurring at doses 
exceeding those proposed for this study. Safety stopping rules for drug-related 
toxicity will dictate whether the trial should be halted if subjects are experiencing 
drug-related toxicity that delays or interferes with standard of care procedures.  

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
2 
1.2 
Disease Background 
Urothelial carcinoma (UC) is a common and deadly disease [7]. Although most 
cases are non-invasive at initial diagnosis, nearly 25% of these cases will progress 
to MIBC and of those, more than 50% develop recurrent/metastatic urothelial 
carcinoma within two years [8]. With the recent approval of both PD-1 and PD-
L1 inhibitors for metastatic UC, treatment paradigms have dramatically changed; 
however, fewer than 30% of patients respond to treatment, and mechanisms of 
both response and resistance remain largely unknown.  
 
Currently designed clinical trials are insufficient to truly understand the 
immunogenomic changes associated with primary response and resistance 
mechanisms because of the challenges with acquisition of pre- and post-treatment 
research-directed biopsies. Cisplatin-ineligible patients with MIBC and patients 
with MIBC undergoing trimodality therapy (maximal TURBT followed by 
chemoradiation) provide an ideal window of opportunity for mechanistic 
translational studies. Patients with MIBC typically undergo a diagnostic TURBT 
followed by a multidisciplinary assessment to determine definitive treatment, with 
options including radical cystectomy (with or without neoadjuvant cisplatin-based 
chemotherapy) or trimodality therapy with repeat maximal TURBT followed by 
concurrent chemoradiation. In patients that undergo radical cystectomy but are 
ineligible for standard of care cisplatin-based neoadjuvant chemotherapy, there is 
a window of time between the diagnostic TURBT and cystectomy. Cisplatin-
ineligible patients with MIBC therefore present an ideal situation for window of 
opportunity studies, given the ease of pre- and post-treatment tissue collection 
without the need for research-directed biopsies. Similarly, in patients that undergo 
trimodality therapy, there is a window of time between diagnostic TURBT and 
repeat maximal TURBT before chemoradiation, allowing a similar window of 
opportunity. 
 
The window of opportunity study design allows for rapid, biomarker-driven 
translational studies to aid in drug development and to better understand 
mechanisms of both response and resistance. The use of human patients to study 
translational endpoints is vitally important, given the complex interplay of tumor, 
immune microenvironment, and the human immune system, which many current 
in vivo and in vitro tumor models fail to adequately replicate. 
1.3 
The PD-L1/PD-1 Pathway in Cancer 
The importance of intact immune surveillance in controlling outgrowth of 
neoplastic transformation has been known for decades [9]. The PD-1/PD-L1 
pathway is a major co-inhibitory immune checkpoint pathway which may be 
engaged by tumor cells to overcome active T-cell immune surveillance. The 
normal function of PD-1, expressed on the cell surface of activated T-cells under 
healthy conditions, is to down-modulate unwanted or excessive immune 
responses, including autoimmune reactions. PD-1 (encoded by the gene PDCD1) 
is an Ig superfamily member related to CD28 and CTLA-4 which has been shown 
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(PD-L1 and/or PD-L2) [10, 11]. PD-1 and family members are type I 
transmembrane glycoproteins containing an Ig Variable-type (V-type) domain 
responsible for ligand binding and a cytoplasmic tail which is responsible for the 
binding of signaling molecules. The cytoplasmic tail of PD-1 contains 2 tyrosine-
based signaling motifs, an immunoreceptor tyrosine-based switch motif (ITSM). 
PD-1 was shown to be expressed on activated lymphocytes including peripheral 
CD4+ and CD8+ T-cells, B-cells, Tregs and natural killer cells [12]. Expression 
has also been shown during thymic development on CD4-CD8- (double negative) 
T-cells as well as subsets of macrophages and dendritic cells [13]. The ligands for 
PD-1 (PD-L1 and PD-L2) are constitutively expressed or can be induced in a 
variety of cell types, including non-hematopoietic tissues as well as in various 
tumors [14-17]. Both ligands are type I transmembrane receptors containing both 
IgV- and IgC-like domains in the extracellular region and contain short 
cytoplasmic regions with no known signaling motifs. Binding of either PD-1 
ligand to PD-1 inhibits T-cell activation triggered through the T-cell receptor. PD-
L2 is thought to control immune T-cell activation between tumor infiltrating 
lymphocytes (TILs) in cancer tissue and favorable prognosis in various 
malignancies. In particular, the presence of CD8+ T-cells and the ratio of CD8+ 
effector T-cells / FoxP3+ Treg cells correlates with improved prognosis and long-
term survival in several solid tumors. 
Following T-cell stimulation, PD-1 recruits the tyrosine phosphatases SHP-1 and 
SHP-2 to the ITSM motif within its cytoplasmic tail, leading to the 
dephosphorylation of effector molecules such as CD3ζ, PKCθ and ZAP70 which 
are involved in the CD3 T-cell signaling cascade [10, 18-20]. The mechanism by 
which PD-1 down-modulates T-cell responses is similar to, but distinct from that 
of CTLA-4, as both molecules regulate an overlapping set of signaling proteins 
[19, 20]. PD-1 is expressed on activated lymphocytes, including peripheral CD4+ 
and CD8+ T-cells, B-cells, Treg and natural killer cells [12, 21]. Accumulating 
evidence shows a correlation between TILs in cancer tissue and favorable 
prognosis in various malignancies [22-26]. In particular, the presence of CD8+ T-
cells and the ratio of CD8+ effector T-cells / FoxP3+ regulatory T-cells seems to 
correlate with improved prognosis and long-term survival in many solid tumors. 
1.3.1 Bladder Cancer and Immunotherapy 
Bladder cancer was the first malignancy with an FDA-approved immunotherapy 
when Bacillus Calmette-Guérin (BCG), a live but attenuated strain of 
mycobacterium, was approved for localized disease in 1990. Advanced bladder 
cancer is associated with a high mutational complexity and the potential for 
foreign antigen detection by the immune system represents a unique opportunity 
for development of immunotherapeutics [27, 28].  
1.3.2 Immune Checkpoint Inhibitors in Bladder Cancer 
Anti-PD-1 and PD-L1 agents have demonstrated exciting activity in several 
human cancers (most notably lung, renal cell, and melanoma) with an overall 
response rate of 21% in human cancers [29]. Initial data from studies in the 

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metastatic setting of PD-1 and PD-L1 inhibition show activity of these agents in 
bladder cancer as well [30, 31].  
 
Recently, several immune checkpoint inhibitors have been approved for the 
treatment of metastatic urothelial cancer that has progressed after first-line 
platinum-based chemotherapy. Atezolizumab (anti-PD-L1) was first approved in 
May 2016 after a large phase II trial showed an overall response rate (ORR) of 
15% [32]. It has since been approved in the first-line metastatic setting for 
platinum-ineligible patients [33]. Initial data from a phase Ib study of 
pembrolizumab in patients with metastatic bladder cancer (NCT01848834) 
showed an ORR of 24% with a median time to response of only 8 weeks with 
several durable responses noted (median duration of response not yet reached; 
range: 6 to 17+ months) [33]. Subsequently, the KEYNOTE-045 trial randomized 
patients with metastatic UC that had progressed after platinum-based 
chemotherapy to pembrolizumab or investigator’s choice chemotherapy 
(paclitaxel, docetaxel, or vinflunine) [34]. Treatment with pembrolizumab was 
associated with an improvement in overall survival compared with chemotherapy. 
Pembrolizumab is approved for use by the FDA for metastatic bladder cancer 
after platinum-based chemotherapy and in the first-line setting for platinum-
ineligible patients. Nivolumab, durvalumab, and avelumab were also approved in 
early 2017 based on data from several phase II trials demonstrating ORR ranging 
from 19.6% to 31.0% [35, 36]. 
 
Several immune checkpoint inhibitors have also been studied in the neoadjuvant 
setting. A phase II study ABACUS (NCT02662309) demonstrated that 
neoadjuvant atezolizumab given prior to cystectomy in operable muscle invasive 
bladder cancer is safe and associated with a meaningful pathological CR rate 
(29%) [37]. Similarly, the PURE-01 (NCT02736266) study demonstrated that 
pembrolizumab given for 3 cycles prior to radical cystectomy is safe and has 
already exceeded the pT0 responses required at first stage [38]. Therefore, 
immune checkpoint inhibition is a standard of care for second-line treatment of 
metastatic UC, is approved for use in the first-line setting in platinum-ineligible 
patients and has demonstrated promising early activity in the neoadjuvant setting 
for muscle-invasive bladder cancer. 
1.4 
Pembrolizumab 
Pembrolizumab is a potent and highly selective humanized monoclonal antibody 
(mAb) of the IgG4/kappa isotype designed to directly block the interaction 
between PD-1 and its ligands, PD-L1 and PD-L2. This blockade enhances 
functional activity of the target lymphocytes to facilitate an antitumor immune 
response, leading to tumor regression and immune rejection of the tumor. 
Pembrolizumab has recently been approved in the United States for the treatment 
of patients with unresectable or metastatic melanoma, non-small cell lung cancer 
with high PD-L1 expression, head and neck squamous cell carcinoma, and 
classical Hodgkin lymphoma. 
 

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A detailed summary of preclinical and clinical data for pembrolizumab is 
provided in the Investigator’s Brochure. Relevant clinical safety and 
pharmacokinetic data supporting this proposed study are briefly summarized in 
subsequent sections. 
1.4.1 Pre-clinical Studies of Pembrolizumab  
Pembrolizumab strongly enhances T-lymphocyte immune responses in 
cultured blood cells from healthy human donors, cancer patients, and primates. 
In in vitro assays using T-cells isolated from human donor blood cells, 
pembrolizumab induces production of interleukin-2 (IL-2), tumor necrosis factor 
alpha (TNFα), interferon gamma (IFNγ), and activates T cells in subnanomolar 
EC50 concentrations (i.e. concentrations where 50% of the maximum effect is 
achieved; ~0.1 – 0.3 nM).  It is important to emphasize that pembrolizumab 
potentiates existing immune responses only in the presence of antigen and 
specifically activated T-cells [39]. 
Using a murine antibody against PD-1 (mDX400), PD-1 blockade has been 
shown to significantly inhibit tumor growth in a variety of syngeneic murine 
tumor models. In these experiments in mice, mDX400 treatment is synergistic 
with chemotherapeutic agents, such as gemcitabine and 5-fluorouracil (5-FU), 
and combination therapy results in increased complete tumor regression rates in 
vivo [39]. 
1.4.2 Summary from Relevant Clinical Studies of Pembrolizumab in Urothelial 
Carcinoma 
 
Cisplatin Ineligible Patients with Urothelial Carcinoma 
The safety of pembrolizumab was investigated in Study KEYNOTE-052, a 
single-arm trial that enrolled 370 patients with locally advanced or metastatic 
urothelial carcinoma who were not eligible for cisplatin containing chemotherapy. 
Patients with autoimmune disease or medical conditions that required systemic 
corticosteroids or other immunosuppressive medications were ineligible. Patients 
received pembrolizumab 200 mg every 3 weeks until unacceptable toxicity or 
either radiographic or clinical disease progression. The median duration of 
exposure to pembrolizumab was 2.8 months (range: 1 day to 15.8 months), and 
produced a clinically meaningful ORR of 29%. The most common adverse 
reactions (reported in at least 20% of patients) were fatigue, musculoskeletal pain, 
decreased appetite, constipation, rash and diarrhea. Pembrolizumab was 
discontinued due to adverse reactions in 11% of patients. Eighteen patients (5%) 
died from causes other than disease progression. Five patients (1.4%) who were 
treated with pembrolizumab experienced sepsis which led to death, and three 
patients (0.8%) experienced pneumonia which led to death. Adverse reactions 
leading to interruption of pembrolizumab occurred in 22% of patients; the most 
common (≥1%) were liver enzyme increase, diarrhea, urinary tract infection, 
acute kidney injury, fatigue, joint pain, and pneumonia. Serious adverse reactions 
occurred in 42% of patients. The most frequent serious adverse reactions (≥2%) 
were urinary tract infection, hematuria, acute kidney injury, pneumonia, and 

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urosepsis. Immune-related adverse reactions that required systemic 
glucocorticoids occurred in 8% of patients, use of hormonal supplementation due 
to an immune-related adverse reaction occurred in 8% of patients, and 5% of 
patients required at least one steroid dose ≥ 40 mg oral prednisone equivalent. 
 
Previously Treated Urothelial Carcinoma 
The safety of pembrolizumab for the treatment of patients with locally advanced 
or metastatic urothelial carcinoma with disease progression following platinum-
containing chemotherapy was investigated in Study KEYNOTE-045, a 
multicenter, open-label, randomized (1:1), active-controlled trial in which 266 
patients received pembrolizumab 200 mg every 3 weeks or investigator’s choice 
of chemotherapy (n=255), consisting of paclitaxel (n=84), docetaxel (n=84) or 
vinflunine (n=87). Patients with autoimmune disease or a medical condition that 
required systemic corticosteroids or other immunosuppressive medications were 
ineligible. The median duration of exposure was 3.5 months (range: 1 day to 20 
months) in patients who received pembrolizumab and 1.5 months (range: 1 day to 
14 months) in patients who received chemotherapy. 
Pembrolizumab was discontinued due to adverse reactions in 8% of patients. The 
most common adverse reaction resulting in permanent discontinuation of 
pembrolizumab was pneumonitis (1.9%). Adverse reactions leading to 
interruption of pembrolizumab occurred in 20% of patients; the most common 
(≥1%) were urinary tract infection (1.5%), diarrhea (1.5%), and colitis (1.1%). 
The most common adverse reactions (occurring in at least 20% of patients who 
received pembrolizumab) were fatigue, musculoskeletal pain, pruritus, decreased 
appetite, nausea and rash. Serious adverse reactions occurred in 39% of 
pembrolizumab-treated patients. The most frequent serious adverse reactions 
(≥2%) in pembrolizumab-treated patients were urinary tract infection, pneumonia, 
anemia, and pneumonitis [39]. 
 
Pembrolizumab Clinical Safety 
As of March 2018, pembrolizumab monotherapy and combination therapy have 
been administered to 18,793 subjects, with hematologic malignancies and solid 
tumors, in a total of 20 Phase I, II, and III clinical trials sponsored by Merck. 
Safety data are available for a total of 2799 subjects in 4 Merck-sponsored clinical 
trials. The majority of participants, 2727 or 97.4%, experienced 1 or more AEs, 
and 2062 (73.7%) experienced 1 or more AEs reported as drug-related by the 
investigator. The most commonly reported AEs reported in monotherapy trials 
were fatigue (37.3%), nausea (24.5%), decreased appetite (22.5%), diarrhea 
(22.3%), and cough (22.0%) [39]. 
1.5 
Investigational Treatment 
1.5.1 Overview of Epigenetics 
Epigenetic regulation involves heritable modifications to DNA that alter gene 
expression and chromatin structure without changes to the underlying nucleotide 
DNA sequence, and essentially shifts chromatin between two interchangeable 

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states: closed (heterochromatin) and open (euchromatin) by allowing/restricting 
access and/or function of components of the transcriptional machinery (RNA 
polymerase and DNA-binding transcription factors) [40].  
Notably, changes in epigenetic regulation are particularly frequent in UC, 
compared to other malignancies, and targeting epigenetic regulators provides a 
window of opportunity particularly in anticancer therapy of UC [41, 42]. 
Epigenetic changes may include: (1) DNA methylation in CpG dinucleotides 
enriched in regions known as ‘CpG islands’. This process is more permanent, 
because methylated gene promoters along with the recruitment of bulky MB 
methyl-CpG-binding proteins by means of direct steric hindrance block binding of 
transcription factors and RNA polymerase leading up to a closed heterochromatin 
state, and therefore transcriptional repression/silencing. (2) histone modifications 
which are more dynamic, diverse, and are mediated by multiple mechanisms, such 
as post-translational modifications of histone proteins (acetylation, methylation, 
phosphorylation, and ubiquitination), ATP-dependent chromatin remodeling 
complexes, histone variant exchanges, and the action of non-coding RNA (e.g. 
miRNA). Histone methylation is more complex to predict the effect in gene 
transcription, because it is dependent on the extent of methylation [e.g. mono- 
(me1), di- (me2), or tri-methylation (me3)]. It is important to mention that 
promoter methylation can affect histone activity and, vice versa, histone 
acetylation affects promoter methylation levels [43].  
Reversible acetylation of lysine residues on the tails and other more internal 
residues of histone proteins, H3 and H4 (e.g. H3K9, H3K14, H4K5, H4K16), is 
the best studied type of histone modification and is catalyzed by the transfer of 
acetyl group from acetyl-CoA to the ε-amino group at the terminal of the lysine 
side chain by means of histone acetyl transferases (HAT). The addition of the 
acetyl group neutralizes the lysine’s positive charge, thereby weakening the 
interaction with the negatively charged DNA, and leads to a more open chromatin 
structure allowing easier access to transcription factors and increased 
transcription. Histone acetylation also influences transcription by acting as a 
binding target for histone reader groups and regulates (prevents) deposition of 
other histone marks, such as the transcriptionally permissive H3K4me3 or the 
repressive H3K27me3 modification [44]. On the other hand, these acetyl groups 
are removed by histone deacetylases (HDACs). HDACs are divided into 4 classes 
on the basis of structural homology to yeast HDACs, mechanism of enzyme 
activity, and cellular localization. The ‘classic’, or type I, are ubiquitously 
expressed in all cell types and mostly localized to the nucleus (1, 2, 3, and 8). 
Type II are more restricted in distinct cell types (smooth muscle, heart, pancreas, 
and brain) and shuttle between the nucleus and cytosol (4, 5, 6, 7, 9, and 10). 
Type III (NAD-dependent sirtuins 1-7) possess dual enzymatic activity that 
includes mono-ADP-ribosyltransferase, in addition to the HDAC activity. In 
addition, type III HDACs have various subcellular organizations other than the 
nucleus (cytoplasm, mitochondria, and nucleolus). Class IV HDACs have similar 
localization to class II (HDAC11) [45].  

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The clinical significance of HDACs in cancer is that HDAC 1, 2, 3, and 6 are 
upregulated in various cancers. HDACs and HATs have histone-independent 
targets, such as HSP90, TP53, and the NFκB subunit p65 with significant cellular 
effects.  
1.5.2 Histone Acetylation, HDAC Inhibitors and Effects on Host Immune 
Response 
DNA methylation and histone modifications regulate development, 
differentiation, activation, and memory lineage function of host immune response 
[46]. In particular, selective demethylation of several specific CpG dinucleotides 
in the promoter region of IFNγ, IL-3 and IL-13 genes regulate T helper cell 
differentiation into Th1, Th2, Th17 and induction of regulatory T cells. Signaling 
through cytokines activates transcription factors (STAT4, STAT6, GATA-4, T-
bet), which facilitates chromatin remodeling (long-range H4 acetylation, H3K9 
trimethylation) at the enhancer regions of T helper cell-specific genes and 
ultimately influences activation and T cell differentiation [47].  
HDACi have pleiotropic effects on immune cells, and the net effect remains ill-
defined as HDACi can also impair immune surveillance and induce hematologic 
toxicity in cancer patients depending on the dose, type and selectivity of HDACi 
used. For example, entinostat can have differential effects on T cell viability and 
function, depending on the dose used [48]. Nevertheless, several positive effects 
of HDACi were seen, such as the activation and inhibition of apoptosis of CD4+ 
cells [49], CD8+ cells [50], macrophages [51], T regulatory cells [52], and 
myeloid-derived suppressor cells (MDSC) [53]. 
1.5.3 Rationale for Pembrolizumab and Entinostat Combination 
There is a distinct rationale for employing a combinational approach that uses 
pembrolizumab with an epigenomic modifying agent (such as an HDAC 
inhibitor) for the treatment of UC. Global histone acetylation levels are decreased 
in MIBC [54] (i.e., HDACs are overexpressed in MIBC), and class I HDAC over-
expression has been associated with a poor prognosis [55]. Most notably, class I 
HDACs (e.g., HDAC-1-3) are over-expressed in high-grade UC, and particularly 
in MIBC. Epigenomic immunomodulation of the tumor microenvironment by 
class I HDAC inhibitors may prime the immune system to increase PD-1 inhibitor 
efficacy through suppression of myeloid-derived suppressor cells (MDSCs), 
induction of checkpoint ligand expression on tumor cells (e.g., PD-L1) and IFN-
related gene expression, upregulation of both antigen-processing machinery 
(APM) components and surface expression of co-stimulatory molecules, and 
possibly enhancement of NK-mediated tumor cell targeting and killing [56, 57]. 
And, both STAT3 and the RELA subunit of NF-κB have been identified as targets 
of HDAC-1 and HDAC-3. 
 

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Figure 1. Immune gene signature expression increases in entinostat-treated mice. 
Our translational lab (William Y. Kim, MD) has generated preclinical data 
showing that the class I HDAC inhibitor entinostat increases immune gene 
signature expression and induces shifts in immune cell subsets that correspond to 
increased effector memory and decreased suppressive populations (e.g. MDSCs 
and regulatory T cells) (Figure 1). In addition, entinostat alters predicted 
neoantigen expression in our immunocompetent murine models of UC. 
Specifically, comparison of predicted neoantigen expression between baseline and 
vehicle-treated vs baseline and entinostat-treated tumors demonstrated that 
predicted neoantigen expression was unaltered in vehicle-treated tumors. In 
contrast, the numbers of expressed predicted neoantigens were significantly 
decreased in entinostat-treated tumors relative to baseline. These changes are 
consistent with neoantigen pruning by an antigen-driven immune response in 
entinostat-treated tumors. Therefore, a study evaluating entinostat in combination 
with pembrolizumab is warranted to validate these findings in humans. 
1.6 
Entinostat 
1.6.1 Non-Clinical Studies 
Entinostat (pyridine-3-yl)methyl((4-[(2-aminophenyl)carbamoyl]phenyl)methyl) 
carbamate), or SNDX-275, MS-275 is an orally available inhibitor of HDACs 1, 
2, 3, and 11 [IC50 (nM) 124, 139, 187, 427, respectively]. The selectivity of 
entinostat for these HDAC isoforms may account for its better safety and efficacy 
compared to other nonselective pan-HDAC inhibitors [58, 59]. Exposure of 
various cancer cell lines to entinostat resulted in accumulation of hyperacetylated 
histones at concentration between 0.3-1 µM and gene expression changes in 

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various cell processes, such as cell growth, apoptosis, differentiation, cell 
communication, regulation of transcription, cell signaling, and chromosome 
organization. Entinostat demonstrated broad, dose-dependent, tumor-inhibitory 
effects against cancer cell lines with IC50 values ranging between 0.04-4.71 µM. 
Entinostat showed tumor growth inhibition in human tumor xenografts from 
diverse cancer types, such as melanoma, non-small cell lung cancer, and breast 
cancer. The maximum tolerated dose in the animal experiments was 50 mg/kg 
daily. 
As predicted by its epigenetic mechanism of action, entinostat may restore 
sensitivity in resistant cancer cell lines in vitro and in vivo when combined with 
various classes of anticancer agents, such as chemotherapies, anti-estrogens, 
EGFR inhibitors, DNA methyltransferase (DNMT) inhibitors and 
immunotherapies. Examples of entinostat in combination with hormonal therapies 
(aromatase inhibitor, selective estrogen modulators) and DNA methylase 
transferase inhibitors (‘dual epigenetic blockade’) are provided in the 
Investigators’ Brochure and elsewhere [60, 61].  
Proof-of-principle experiments in syngeneic murine models that bear poorly or 
modestly immunogenic tumors suggest that resistance to concurrent CTLA-4 and 
PD-1 blockade can be restored with entinostat. In these models primary targets of 
entinostat were actually circulating granulocytic MDSC, which are known to be 
immunosuppressive, whereas the function of CD8+ cells remained intact [53]. In 
other preclinical models entinostat reduced transcription of FoxP3 in circulating 
Treg, an important transcription factor for survival and function of this other 
immunosuppressive population [52]. In other clinical models entinostat can 
induce favorable changes in effector T cell response against cancer cells [62]. The 
entinostat-induced reduction of circulating MDSC was confirmed in a clinical 
study of entinostat in combination with aromasin compared with aromasin alone 
[63]. Reduction of circulating Tregs and monocytic MDSC was also seen in a 
clinical trial of entinostat administered in combination with high dose bolus IL-2 
in patients with advanced renal cell carcinoma [64]. 
Entinostat administered in rats at doses comparable to those currently used in 
clinical studies had no effects in various physiologic systems (cardiovascular, 
central nervous, respiratory, GI, and urogenital), with the exception of diuresis 
and increased excretion of sodium, potassium, chloride and creatinine.  
Pharmacokinetic studies of entinostat administered across various animal models 
shows considerable differences with respect to oral bioavailability, serum half-life 
(t ½), area-under-curve (AUC) exposure, peak serum concentrations (Cmax), time-
to-peak serum concentrations (tmax). Food decreased absorption of entinostat. The 
highest serum concentrations were seen in liver, kidney, spleen, and glandular 
tissue. Entinostat was moderately stable in preparation of human hepatocytes and 
liver microsomes. Reversible inhibition by entinostat was demonstrated for 
CYP2C8 and CYP3A4 and glycuronidation was the major method of metabolism. 
Entinostat is excreted equally by urine and biliary tract.  

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Toxicologic studies of entinostat across various animals suggested effects on the 
skin, atrophy of lymphatic organs, myelosuppression, gastrointestinal toxicity, 
loss of appetite, weight loss, changes in renal function, hypercholesterolemia, 
reduced fertility, and teratogenicity. 
1.6.2 Safety and Efficacy Studies of Entinostat in Humans  
As of 01 January 2018, pooled safety data are available for entinostat 
monotherapy for 221 patients with solid tumors and for 93 with hematologic 
malignancies; and for 170 patients with breast cancer treated with entinostat and 
AIs, 205 patients with solid tumors treated with entinostat and checkpoint 
inhibitors, 185 patients with solid tumors treated with entinostat and azacytidine, 
232 patients with solid tumors treated with entinostat and other combinations, and 
205 patients treated with combination therapy for hematologic malignancies. The 
other agents administered in combination with entinostat include erlotinib; 
sargramostim (i.e., granulocyte macrophage colony-stimulating factor [GM-
CSF]); 13 cis-retinoic acid; aldesleukin (interleukin-2); imatinib; sorafenib; 
clofarabine; lapatinib and trastuzumab.  
Entinostat has been administered as monotherapy to patients with cancer in 8 
completed clinical studies to date (6 studies in patients with solid tumors and 2 
studies in patients with hematologic malignancies and 2 studies in both solid 
tumors and hematologic malignancies, treating a total of 221 patients, 128 with 
solid tumors and 93 with hematologic malignancies). In addition, 6 healthy male 
subjects received a single dose of [14C]-entinostat in Study SNDX-275-0120, 6 
AEs of mild venipuncture site reactions were reported in a single subject (deemed 
unrelated to study drug and resolved).  
The majority of patients with solid tumors receiving entinostat monotherapy 
experienced at least 1 AE (99%). The AEs reported most frequently were fatigue 
(57%), hypoalbuminemia and fatigue (each 56%), nausea (57%), 
hypophosphatemia (42%), anemia group (41%), and thrombocytopenia group 
(40%), anorexia (35%), vomiting (33%), hyponatremia (30%), headache and 
neutropenia group (29%), leukopenia group (27%), hypocalcemia (24%) and 
diarrhea (23%). The incidences of AEs of grade 3 and 4 severity generally 
followed patterns for all AEs, with hypophosphatemia, anemia, and fatigue being 
reported most frequently. Overall, 54% of patients with solid tumors receiving 
entinostat experienced at least 1 SAE. Several of the SAEs reported commonly 
were gastrointestinal in nature, including decreased appetite (7%), nausea (5%), 
abdominal pain (5%), and diarrhea (5%). Other individual SAEs occurring in 
≥5% of patients included fatigue (9%), dyspnea (7%), neutropenic infection (6%), 
dehydration, anemia group, febrile neutropenia, infection, neutropenia group, 
thrombocytopenia group (each 5%). Three patients (2%) had SAEs with fatal 
outcome related to study drug (pneumonia, sepsis, multiple organ dysfunction 
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1.6.3 Combined Administration of Entinostat and Pembrolizumab 
In SNDX-275-0141, phase 1 study of entinostat in combination with 
pembrolizumab in subjects with solid tumors, three different dose regimens of 
entinostat (1 mg once daily, 5 mg once weekly, and 7 mg once every other week) 
were determined to be well-tolerated in all 26 enrolled patients, as of January 1, 
2018. No overlapping toxicities have been identified between these two drugs 
except for the following: fatigue, arthralgia, AST/ALT elevation, rash, and 
diarrhea. Overall, the treatment regimen has been tolerated well [4-6].  
Ongoing Phase 1b/2 studies SNDX-275-0602 evaluating the combination 
atezolizumab plus entinostat 5 mg once weekly in patients with advanced triple 
negative breast cancer,  and SNDX-275-0603 evaluating the combination of 
entinostat 5 mg once weekly plus avelumab in patients with advanced epithelial 
ovarian cancer, have also demonstrated favorable safety profile [65]. In this study 
we will use the FDA-approved dose of pembrolizumab, 200 mg, administered at 
three-week interval on Day 1 and Day 22 alone (Arm 1) or concurrently with 
entinostat at 5 mg once weekly on Days 1, 8 and 15 (Arm 2). 
1.7 
Correlative Studies 
We hypothesize that the addition of entinostat will enhance the immunogenomic 
changes seen with pembrolizumab, with increased immune gene signature 
expression, decreased predicted neoantigen burden, and increased T cell receptor 
clonality in blood and tumor samples when compared to pembrolizumab alone. 
 
Pre- and post-treatment samples will be analyzed to evaluate changes in 
immunogenomic and epigenomic signatures with pembrolizumab alone and in 
combination with entinostat.  
 
Pre-treatment blood and archived formalin-fixed, paraffin-embedded (FFPE) 
TURBT tumor tissue will be collected. Additionally, we will request banked 
tissue on the subset of subjects who have previously had tissue frozen via UNC’s 
Tissue Procurement Facility’s standing collection protocol, or through our group’s 
routine biospecimen repository protocol (LCCC1212). Subjects will be treated 
with pembrolizumab (± entinostat) as above and then post-treatment blood and 
tumor tissue (from cystectomy or repeat maximal TURBT) will be collected. 
Post-treatment tumor tissue will be flash frozen and FFPE tissue will be collected 
for analysis to ensure comparability of samples between pre- and post-treatment 
tumor samples. 
 
We will perform RNA sequencing to evaluate relevant gene expression 
signatures, including relative expression of pre- and post-treatment STAT3 and 
NF-κB signatures, IFNγ -related genes, MHC class I/II genes, and immune 
checkpoint genes and other immune gene signatures. 
 
We will use whole exome sequencing to predict neoantigens using mRNAseq-
based filtering with our established adapted protocol. 
 

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TCR repertoire amplification and sequencing will be done on tumor and 
peripheral blood samples after DNA extraction. 
 
Additionally, we will assess histone acetylation (H3K9Ac and H3K27Ac) levels 
via immunohistochemistry. For the subset of subjects with frozen pre-treatment 
TURBT and frozen cystectomy or post-treatment maximal TURBT tissue 
available, we will compare ChIP-sequencing for H3K27Ac and other histone 
markers (H3K4Me3 and K3K27Me3, etc.) to assess where changes in histone 
post-translational modifications associate with active transcription. These 
activating post-translational modifications will be correlated with the genes that 
have dynamic changes in neoantigens. 

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2.0 
STUDY OBJECTIVES 
2.1 
Primary Objective 
To characterize the changes in immune gene signature (IGS) expression in blood 
and tumor samples after treatment with pembrolizumab alone compared to the 
combination of pembrolizumab and entinostat.  
 
Hypothesis:  We hypothesize that class I HDAC inhibition with entinostat added 
to pembrolizumab will increase T cell immune gene signature expression 
compared with pembrolizumab alone. 
2.2 
Secondary Objectives  
2.2.1 To characterize the changes in neoantigen expression and T cell receptor (TCR) 
clonality in blood and tumor samples after treatment with pembrolizumab alone 
and the combination of pembrolizumab and entinostat.  
2.2.2 To evaluate the changes in STAT and NF-κB gene signatures and histone 
acetylation (H3K9Ac, H3K27Ac, and others) levels after combination treatment 
with pembrolizumab and entinostat as compared to pembrolizumab alone (subset 
of subjects with frozen pre- and post-treatment tumor tissue available). 
2.2.3 To document safety, tolerability, and feasibility of preoperative administration of 
pembrolizumab with and without entinostat in cisplatin-ineligible MIBC patients 
prior to scheduled surgical resection, and to document safety, tolerability and 
feasibility of pembrolizumab with and without entinostat prior to trimodality 
therapy in MIBC patients (National Cancer Institute – Common Terminology for 
Adverse Events [NCI-CTCAE v5.0]). 
2.2.4 To define the pathologic response rate (<pT2) and pathologic complete response 
rate (pT0) after treatment with pembrolizumab alone and the combination of 
pembrolizumab and entinostat in cisplatin-ineligible subjects undergoing radical 
cystectomy 
2.2.5  To estimate the clinical complete response rate (cT0) after treatment with 
pembrolizumab alone and the combination of pembrolizumab and entinostat in 
patients undergoing maximal TURBT prior to chemoradiation 
2.2.6 To estimate the event free survival (EFS) after treatment with pembrolizumab 
alone and the combination of pembrolizumab and entinostat in patients with 
MIBC 
 

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3.0 
STUDY ENDPOINTS 
3.1 
Primary Endpoint 
Change in immune gene signature expression will be defined based on change in 
the T cell immune gene signature from mRNAseq analysis in the pembrolizumab 
+ entinostat group compared to the pembrolizumab alone group 
3.2 
Secondary Endpoints  
3.2.1 Pre- and post-treatment TCR repertoire and neoantigen changes will be defined 
by changes in TCR clonality and neoantigen load. 
3.2.2 Pre- and post-treatment changes in STAT and NF-κB expression will be evaluated 
using mRNAseq analysis and changes in histone acetylation (H3K9Ac and 
H3K27Ac) levels in a subset of subjects with pre- and post-treatment tumor tissue 
available (diagnostic TURBT and maximal TURBT or cystectomy tissue 
available) 
3.2.3 Toxicity will be evaluated according to guidelines from National Cancer Institute 
– Common Terminology for Adverse Events (NCI-CTCAE) criteria version 5.0 
and include all adverse events continuing or occurring 30 days after completion of 
treatment 
3.2.4 A pathologic response will be defined as <pT2 (pT0-T1N0M0) and pathologic 
complete response will be defined as pT0N0M0 at the time of cystectomy at the 
completion of study treatment. 
3.2.5 The clinical complete response rate (cT0) is defined as cT0 at the time of maximal 
TURBT  
3.2.6 EFS is defined as day 1 of neoadjuvant/protocol treatment to date of first 
documentation of disease progression (or until recurrence after surgery or 
radiation) or death due to any cause. Recurrence includes the development of 
second primary muscle-invasive urothelial malignancies.  
3.2.7 Overall survival is defined as day 1 of neoadjuvant/protocol treatment to date of 
death due to any cause. Patients will be censored at date of last follow-up. 
 
 

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4.0 
SUBJECT ELIGIBILITY 
In order to participate in this study a subject must meet all of the eligibility 
criteria outlined below.   
4.1 
Inclusion Criteria 
4.1.1 Written informed consent obtained to participate in the study and HIPAA 
authorization for release of personal health information.  
4.1.2 Subjects must agree to donate tumor tissue from their diagnostic transurethral 
resection of the bladder tumor (TURBT) and from their post-treatment surgery 
(cystectomy or repeat maximal TURBT). Subjects must also agree to donate 
whole blood prior to initiating therapy, during study therapy and at post-treatment 
surgery. 
4.1.3 Age ≥18 years at the time of consent.  
4.1.4 Eastern Cooperative Oncology Group performance status of ≤ 2. 
4.1.5 Histological confirmation of urothelial carcinoma of the bladder; those with 
mixed histology, including a component of urothelial carcinoma, are eligible. 
Pure small cell carcinoma, pure adenocarcinoma, and pure squamous cell 
carcinoma are excluded. 
4.1.6 Subject has clinical stage T2-T4a N0/X M0 urothelial carcinoma. Clinical T stage 
is based on the pre-study standard of care transurethral resection of the bladder 
tumor (TURBT) sample and imaging studies (abdominal/pelvic CT or MRI scan 
and CT scan of the chest performed within 4 weeks prior to treatment initiation). 
4.1.7 Available formalin-fixed paraffin-embedded (FFPE) archival tumor specimen that 
contains sufficient tissue to generate at least 15 (preferably 20) unstained slides, 
each with tissue sections that are 5 – 10 microns thick. 
4.1.8 Subject is planned to undergo definitive therapy for MIBC with either surgery 
(radical cystectomy) or trimodality therapy (including repeat TURBT followed by 
concurrent chemoradiation). Subjects undergoing trimodality therapy must be 
deemed to not be a candidate for radical cystectomy, or refuse radical cystectomy. 
Suggested chemotherapy regimens are outlined in Appendix E but not mandated 
by protocol. 
4.1.9 Subject demonstrates adequate organ function as defined in the table below; all 
screening laboratory assessments should be performed within 10 days of 
treatment initiation.  
 
 
System 
Laboratory Value 

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4.1.13 Male subjects of childbearing potential must agree to use an adequate method of 
contraception as outlined in Appendix D, starting with the first dose of study 
therapy through 120 days after the last dose of study therapy. 
Note: Abstinence is acceptable if this is the usual lifestyle and preferred 
contraception for the subject. 
 
4.1.14 Subject is able to tolerate and retain oral medication. 
4.1.15 Life expectancy greater than 3 months. 
4.2 
Exclusion Criteria 
The subject must be excluded from participating in the trial if the subject meets 
any of the following: 
4.2.1 Subject is currently participating in or has participated in a study of an 
investigational agent or using an investigational device within 4 weeks of the first 
dose of pembrolizumab. 
4.2.2 Subject has a diagnosis of immunodeficiency or is receiving systemic steroid 
therapy or any other form of immunosuppressive therapy within 7 days prior to 
the first dose of trial treatment. Inhaled and topical steroids are allowed. 
4.2.3 Subject has a known history of active tuberculosis. 
4.2.4 Subject has known hypersensitivity to pembrolizumab or any of its excipients. 
4.2.5 For subjects in arm 2 only: Subject has allergy to benzamide or inactive 
ingredients of entinostat. 
4.2.6 Subject has a known additional malignancy that is progressing or requires active 
treatment.  Exceptions include basal cell carcinoma of the skin, squamous cell 
carcinoma of the skin, or in situ cervical cancer that has undergone potentially 
curative therapy.   
4.2.7 Subject 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 (e.g., thyroxine, insulin, or 
physiologic corticosteroid replacement therapy for adrenal or pituitary 
insufficiency, etc.) is not considered a form of systemic treatment.  
4.2.8 Subject has a history of (non-infectious) pneumonitis/interstitial lung disease that 
required steroids or a current pneumonitis/interstitial lung disease. 
4.2.9 Subject has an active infection requiring systemic therapy. 

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4.2.10 Subject 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 protocol treatment, or is not in 
the best interest of the subject to participate, in the opinion of the treating 
investigator. Please note that subjects with Grade ≥2 peripheral neuropathy, are 
allowed on this study in addition to subjects with Grade <2 peripheral neuropathy. 
4.2.11 Subject has known psychiatric or substance abuse disorders that would interfere 
with cooperation with the requirements of the trial. 
4.2.12 Subject 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. 
4.2.13 Subject has received prior therapy with an anti-PD-1, anti-PD-L1, anti-PD-L2, 
anti-CD137, or anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) 
antibody (including ipilimumab or any other antibody or drug specifically 
targeting T-cell co-stimulation or checkpoint pathways). 
4.2.14 Subject has had prior systemic cytotoxic chemotherapy for urothelial carcinoma 
(prior intravesicular chemotherapies are permitted). 
4.2.15 Subject is receiving histone deacetylase inhibitors, including valproic acid, DNA 
methyltransferase inhibitors. 
4.2.16 For subjects in arm 2 only: Subject is receiving drugs that are known to inhibit or 
induce P-gp (see Appendix B).  
4.2.17 For subjects in arm 2 only: Subject has gastrointestinal impairment that may 
significantly affect absorption of entinostat, such as ulcerative disease, 
malabsorption syndrome, and a history of small bowel resection. 
4.2.18 Subject has received prior radiation therapy to the bladder for the purpose of 
treating urothelial carcinoma. 
4.2.19 Subject has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 
antibodies). 
4.2.20 Has a known history of Hepatitis B (defined as Hepatitis B surface antigen 
[HBsAg] reactive) or known active Hepatitis C virus (defined as HCV RNA 
[qualitative] is detected) infection. Note: no testing for Hepatitis B and Hepatitis 
C is required unless mandated by local health authority. 

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UNIVERSITY OF NORTH CAROLINA 
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4.2.21 Subject has received a live vaccine or live-attenuated vaccine within 30 days prior 
to the first dose of study drug. Administration of killed vaccines is allowed. 
4.2.22 For subjects in arm 2 only: Subject uses drugs or herbal supplements that are 
known sensitive CYP substrates of CYP1A2, CYP2C8, CYP3A with narrow 
therapeutic range (see Appendix B). 

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UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
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Entinostat2 
Take on an empty stomach 
i.e., at least 2 hours after a 
meal and at least 1 hour 
before the next meal. 
5 mg 
Oral (PO) 
  
Administer on 
Days 1, 8 and 
15 
1. 
See Section 5.7.1 for management guidelines for infusion-related AEs 
2. 
Entinostat should be taken before the pembrolizumab infusion. 
3. 
Allowed window for administration of both pembrolizumab and entinostat is ±1 day 
5.3 
Treatment Arm Assignment 
Patients will be assigned to Arm 1 or 2. The allocation preference is to Arm 2 
first, then Arm 1.   
5.4 
Toxicities and Dosing Delays/Dose Modifications 
Any subject who receives a dose of entinostat and/or pembrolizumab on this 
protocol will be evaluable for toxicity. Each subject will be assessed periodically 
for development of any toxicity according to the Time and Events table. Toxicity 
will be assessed according to the NCI-CTCAE version 5.0. 
 
AEs associated with pembrolizumab exposure, including coadministration with 
additional compounds, may represent an immunologic etiology. These immune-
related AEs (irAEs) may occur shortly after the first dose or several months after 
the last dose of pembrolizumab/combination treatment and may affect more than 
one body system simultaneously. Therefore, early recognition and initiation of 
treatment is critical to reduce complications. Based on existing clinical study data, 
most irAEs were reversible and could be managed with interruptions of 
pembrolizumab/combination treatment, administration of corticosteroids and/or 
other supportive care. For suspected irAEs, ensure adequate evaluation to confirm 
etiology or exclude other causes. Additional procedures or tests such as 
bronchoscopy, endoscopy, skin biopsy may be included as part of the evaluation. 
Based on the severity of irAEs, withhold or permanently discontinue 
pembrolizumab and administer corticosteroids. Dose modification and toxicity 
management guidelines for irAEs associated with pembrolizumab/combination 
treatment are provided in the table below.  
 
Attribution of Toxicity: 
When study interventions are administered in combination, attribution of an 
adverse event to a single component is likely to be difficult.  Therefore, while the 
investigator may attribute a toxicity event to the combination,  to entinostat alone, 
or to pembrolizumab alone, for adverse events listed in the table below, both 
interventions must be held according to the criteria in the table. 
 
Holding Study Interventions: 
When study interventions are administered in combination, if the AE is 
considered immune-related, both interventions should be held according to 
recommended dose modifications. 
 
Restarting Study Interventions: 

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Management of toxicities that are at least possibly related to entinostat, with 
toxicities graded by the Investigator according to the NCI CTCAE version 5.0 
should be managed as follows:  
Toxicity 
Dose Modifications for Entinostat 
Non-hematologic Toxicity 
Grade ≥ 3 
Administer symptomatic remedies/start prophylaxis. 
Hold dose until recovery to Grade 1 or baseline under the following 
directions: 
If not recovered to Grade ≤ 2 within 1 week, permanently 
discontinue study drug. 
Grade ≤ 2 
Administer symptomatic remedies/start prophylaxis. 
Hematologic Toxicity 
Grade ≥ 3 
neutropenia, 
Grade ≥ 3 
uncomplicated 
thrombocytopenia, 
or Grade 2 
complicated 
thrombocytopenia 
Administer symptomatic remedies/start prophylaxis. 
Hold dose until recovery to Grade 1 or study baseline. If not 
recovered by next scheduled dose, skip the dose. If recovered by 
next scheduled dose, resume study drug at prior dose. 
 
Entinostat may also be held for grade 2 treatment-related adverse events if 
deemed necessary by the site investigator. If treatment is held due to an adverse 
event clearly attributable to entinostat that is not listed in the table above and not 
immune-related, then the pembrolizumab may be continued (i.e. monotherapy). If 
the event is clearly attributable to pembrolizumab, then both agents will be held. 
If it is not possible to determine attribution, then both agents will be held. If more 
than one dose hold for the same event occurs, then the attributable drug should be 
permanently discontinued (ie, if entinostat is held twice for the same treatment-
related adverse event, it will be permanently discontinued, but pembrolizumab 
may be continued). Doses of either drug should not be delayed, and any held 
doses will not be made up.  
 
All protocol treatment will be permanently discontinued for any grade 4 non-
hematologic event. Permanent discontinuation of all protocol related treatment 
will also occur for grade 3 non-hematologic adverse events such as myocardial 
infarction, poorly controlled arrhythmias, and adverse events requiring significant 
surgical intervention for management. Additionally, if grade >2 drug-related 
toxicity occurs that does not respond to supportive care within 48 hours and does 
not resolve to grade ≤ 1 within this timeframe, then the subject will be withdrawn 
from all protocol treatment and followed until symptom resolution. 

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Additionally, all protocol treatment will be permanently discontinued if patients 
have clinical disease progression or development of metastatic disease or require 
treatment with high dose steroids beyond 2 weeks. 
 
Dose modifications/dose adjustments of either pembrolizumab or entinostat are 
not allowed.  
 
Safety stopping rules for drug-related toxicity will dictate whether the trial should 
be halted if 2 subjects have their cystectomy (or maximal TURBT) delayed 
beyond the 10 weeks from the time of initiation of study therapy due to drug 
toxicity. 
5.5 
Concomitant Medications/Treatments/Supportive Care Allowed 
All treatments that the investigator considers necessary for a subject’s welfare 
may be administered at his/her discretion, in keeping with the community 
standards of medical care. All concomitant medications will be recorded in the 
electronic case report form (eCRF) including all prescriptions, over-the-counter 
(OTC), non-exclusionary herbal supplements, IV medications and IV fluids. If 
changes occur during the trial period, documentation of drug dosage, frequency, 
route, and date may also be included on the CRF. 
 
All concomitant medications received within 28 days before the first dose of trial 
treatment and 4 weeks after the last dose of trial treatment (up until the time of 
post-treatment cystectomy or initiation of concurrent chemoradiation) should be 
recorded.   
5.6 
Prohibited Medications/Treatments 
Subjects are prohibited from receiving the following therapies during the 
Screening and Treatment Phase of this trial: 
• Any other histone deacetylase inhibitors (HDACi), including valproic 
acid, 
• DNA methyltransferase inhibitors, 
• Any additional anticancer agents, such as chemotherapy, immunotherapy, 
targeted therapy, biological response modifiers will not be allowed, even if 
utilized as treatment of non-cancer indications, 
• Any other investigational agents,.  
• Traditional herbal medicines; these therapies are not fully studied, and 
their use may result in unanticipated drug-drug interactions that may cause 
or confound the assessment of toxicities. 
• For subjects in arm 2 only: Sensitive substrates of CYP1A2, CYP2C8, 
CYP3A with a narrow therapeutic window (see Appendix B). 
• For subjects in arm 2 only: Drugs that are known to inhibit or induce P-
gp (see Appendix B). 
 

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There are no prohibited therapies after clinical trial treatment is completed. 
5.7 
Rescue Medications and Supportive Care 
Subjects should receive appropriate supportive care measures, as deemed 
necessary by the treating investigator. Suggested supportive care guidelines for 
the management of AEs with potential immunologic etiology [66] will be applied 
when the investigator determines the events to be related to pembrolizumab.  
5.7.1 Management of Infusion Reactions for Pembrolizumab  
Signs and symptoms usually develop during or shortly after drug infusion and 
generally resolve completely within 24 hours of completion of infusion. The table 
below outlines guidelines for subjects who experience an infusion-related reaction 
to pembrolizumab administration. 
NCI CTCAE Grade 
Treatment 
Grade 1 
Mild reaction; infusion interruption not 
indicated; intervention not indicated 
Increase monitoring of vital signs as medically 
indicated until the subject is deemed medically 
stable in the opinion of the investigator. 
Grade 2 
Requires infusion interruption but responds 
promptly to symptomatic treatment (e.g., 
antihistamines, NSAIDS, narcotics, IV fluids); 
prophylactic medications indicated for ≤ 24 hrs 
Stop Infusion and monitor symptoms. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids, antihistamines, NSAIDS, 
acetaminophen, narcotics. 
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion of the 
investigator. 
If symptoms resolve within 1 hour of stopping 
drug infusion, the infusion may be restarted at 
50% of the original infusion rate (e.g. from 
100 mL/hr to 50 mL/hr).  Otherwise dosing 
will be held until symptoms resolve and the 
participant should be premedicated for the 
next scheduled dose. 
Grades 3 or 4 
Grade 3: Prolonged (i.e., not rapidly 
responsive to symptomatic medication and/or 
brief interruption of infusion); recurrence of 
symptoms following initial improvement; 
hospitalization indicated for other clinical 
sequelae (e.g., renal impairment, pulmonary 
infiltrates) 
Grade 4: Life-threatening; pressor or 
ventilatory support indicated 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids, antihistamines, NSAIDS, 
acetaminophen, narcotics, oxygen, pressors, 
corticosteroids, epinephrine**. 
Increase monitoring of vital signs as 
medically indicated until the subject is 
deemed medically stable in the opinion of the 
investigator. 
Hospitalization may be indicated. 
**In cases of anaphylaxis, epinephrine should 
be used immediately. 

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5.8 
Study Withdrawal 
Subjects will be removed from protocol therapy and the PI notified when any of 
the criteria listed in section 5.8 apply. The reason for discontinuation of protocol 
therapy will be documented on the eCRF.  
 
If a subject decides to withdraw from the study an effort should be made to 
complete and report study assessments as thoroughly as possible. At the time of 
withdrawal, the investigator should attempt to establish as completely as possible 
the reason for the study withdrawal.  
• 
The subject should be asked if they are willing to allow for the abstraction 
of relevant information from their medical record in order to meet the long 
term follow up (e.g., survival) objectives outlined in the protocol.   
• 
The subject should be asked if they are willing to stay on study after the 
study treatment discontinuation for collection of blood and tissue 
specimens at the time of cystectomy or maximal TURBT. 
• 
A complete final evaluation at the time of the subject’s study withdrawal 
should be obtained with an explanation of why the subject is withdrawing 
from the study.   
• 
If the subject is noncompliant and does not return for an end of study 
follow up assessment, this should be documented in the eCRF.  
• 
If the reason for removal of a subject from the study is an adverse event, 
the principal specific event will be recorded on the eCRF.  
 
Excessive subject withdrawals from protocol therapy or from the study can render 
the study un-interpretable; therefore, unnecessary withdrawal of subjects should 
be avoided. 
5.9 
Duration of Follow-up 
Subjects will be followed every 6 months for 3 years as described in the Time and 
Events Table for recurrence and survival.  
 
5.10 
Off-Study Criteria 
Subjects will be considered off study by any of the following criteria: 
• Subjects have fulfilled all study activities including follow-up activities and 
no further data collection is needed 
• Subject withdraws consent for treatment and any further data collection 
• Death 
• Lost to follow-up 
• Situations in which the treating physician feels it is in the best interest for 
the subject to not continue in the study 
5.11 
Duration of Therapy  
In the absence of treatment delays due to adverse events, treatment may continue 
for 22 days as described in Section 5.2 or until: 

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• Disease progression 
• Inter-current illness that prevents further administration of treatment 
• Unacceptable adverse event(s) 
• Pregnancy 
• Subject decides to withdraw from study treatment,  
• General or specific changes in the subject’s condition render the subject 
unacceptable for further treatment in the judgment of the investigator, 
or 
• Subject is lost to follow up 
 
 

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6.0 
DRUG INFORMATION 
The investigator shall take responsibility for and shall take all steps to maintain 
appropriate records and ensure appropriate supply, storage, handling, distribution 
and usage of investigational product in accordance with the protocol and any 
applicable laws and regulations. 
6.1 
Pembrolizumab 
Pembrolizumab is provided free of charge to clinical trial participants. 
 
6.1.1 Description 
Pembrolizumab solution for infusion is a sterile, non-pyrogenic aqueous solution 
supplied in single-use type I glass vial containing 100 mg/4 mL of 
pembrolizumab (manufactured using the fully formulated drug substance with L-
histidine as a buffering agent, polysorbate 80 as a surfactant, and sucrose as a 
stabilizer/tonicity modifier). The product is preservative-free solution which is 
essentially free of extraneous particulates. 
6.1.2 Drug Supply 
Pembrolizumab will be provided at no cost to the study subject by Merck, the 
manufacturer of the drug. Clinical supplies will be affixed with a clinical label in 
accordance with regulatory requirements. 
 
This trial is open-label; therefore, the subject, the trial site personnel, the Sponsor 
and/or designee are not blinded to treatment. Drug identity (name, strength) is 
included in the label text; random code/disclosure envelopes or lists are not 
provided. 
6.1.3 Storage and Handling Requirements and Dispensing 
Clinical supplies must be stored in a secure, limited-access location under 
refrigerated conditions (2°C to 8°C) and protected from light. (Note: vials should 
be stored in the original box to ensure the drug product is protected from light.). 
In addition, IV bags may be stored under refrigeration at 2°C to 8°C (36°F to 
46°F) for no more than 24 hours. This 24-hour total hold time from reconstitution 
may include up to 4 hours at room temperature (at or below 25°C [77°F]). Any 
additional hold time must be at 2°C to 8°C. If refrigerated, allow the IV bags to 
come to room temperature prior to use. 
 
Receipt and dispensing of trial medication must be recorded by an authorized 
person at the trial site. Clinical supplies may not be used for any purpose other 
than that stated in the protocol. 
 
Parenteral drug products should be inspected visually for particulate matter and 
discoloration prior to administration. Discard the drug product vial if extraneous 
particulate matter other than translucent to white proteinaceous particles is 
observed. 

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Sites should follow their SOPs for drug transport and delivery, with all possible   
effort to minimize agitation of the drug product between the pharmacy and the 
clinic. 
 
Pembrolizumab must not be used if discoloration is observed. Pembrolizumab 
vials should not be shaken or frozen. 
6.1.4 Preparation of Infusion Solution 
Pembrolizumab infusion solutions should be prepared in 0.9% Sodium Chloride 
Injection, USP (normal saline) or regional equivalent or 5% Dextrose Injection, 
USP (5% dextrose) or regional equivalent and the final concentration of 
pembrolizumab in the infusion solutions should be between 1 mg/mL and 10 
mg/mL. 
 
Please note, the preferred diluent is 0.9% sodium chloride, and 5% dextrose is 
only permissible if normal saline is not available. Pembrolizumab should not be 
mixed with other diluents.  
 
Pembrolizumab solutions may be stored at room temperature for a cumulative 
time of up to 4 hours. This includes room temperature storage of admixture 
solutions in the IV bags and the duration of infusion 
 
Aseptic technique must be strictly observed throughout the preparation procedure 
preferably in a biologic safety cabinet or hood since no anti-microbial 
preservative is present in the solutions.  
 
Equilibrate required number of pembrolizumab vials to room temperature. 
The preferred method of dose preparation is the volumetric method, gravimetric 
method is not permitted.  
 
Choose a suitable infusion bag size so that the following conditions are met: 
o Concentration of pembrolizumab is between 1 mg/mL and 10 mg/mL 
o The infusion volume to bag capacity ratio should not be less than 0.3.  In 
other words, the bag must be filled to at least 30% of its capacity.   
 
Choose a suitable infusion bag material. The bag may be empty, or it may contain 
normal saline. The following infusion bag materials are compatible with 
pembrolizumab:  
 PVC plasticized with DEHP 
 Non-PVC (polyolefin) 
 EVA 
 PE lined polyolefin 
 
Calculate the volume of pembrolizumab and normal saline required to prepare the 
infusion (admixture) bag 
 

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36 
Volume of pembrolizumab (mL) = required dose amount (mg) / 25 (mg/mL) 
 
Volume of normal saline = total infusion volume – volume of pembrolizumab 
from above 
 
If a bag pre-filled with normal saline is being used, remove the excess volume of 
normal saline using a sterile syringe (polypropylene, latex-free) attached to a 
suitable needle. Keep in consideration the excess bag fill volume as well as the 
volume of reconstituted pembrolizumab to be added to the bag to prepare the 
infusion solution. 
 
If an empty bag is being used, withdraw the necessary volume of normal saline 
from another appropriate bag and inject into the empty bag. Keep in consideration 
the volume of reconstituted pembrolizumab to be added to the bag to prepare the 
infusion solution. Withdraw the required volume of pembrolizumab from the 
vial(s) (up to 4 mL from each vial) using a sterile syringe attached to a suitable 
needle. The vial(s) may need to be inverted to remove solution. 
 
Volume of pembrolizumab (mL) = required dose amount (mg) / 25 (mg/mL) 
 
Note: If it is necessary to use several vials, it is advisable to withdraw from 
several vials into a suitable size single use syringe using a new needle for each 
vial.  
 
Add the required pembrolizumab into the infusion IV bag containing normal 
saline and gently invert the bag 10-15 times to mix the solution. 
 
In addition, IV bags may be stored under refrigeration at 2°C to 8°C (36°F to 
46°F) for up to 20 hours. If refrigerated, allow the IV bags to come to room 
temperature prior to use.   
 
Do not freeze the pembrolizumab infusion solution. 
 
Discard any unused portion left in the vial as the product contains no preservative. 
6.1.5 Method of Administration 
Pembrolizumab infusions should be administered in 30 minutes, with a window of 
-5 and +10 minutes, using an infusion pump. A central catheter is not required for 
infusion; however, if a subject has a central venous catheter in place, it is 
recommended that it be used for the infusion. The following infusion set materials 
are compatible with pembrolizumab: 
 
o PVC and tri-(2-ethylhexyl) trimellitate (TOTM) infusion set 
o Polyethylene lined PVC infusion set 
o PVC Infusion set that is plasticized using Di-2-ethylhexyl Terephthalate 
(DEHT) 

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o Polyurethane set 
 
A sterile, non-pyrogenic, low-protein binding 0.2 to 5 µm in-line filter made of 
polyethersulfone (PES) must be used during administration to remove any 
adventitious particles. If the infusion set does not contain 0.2 to 5 µm in-line 
filter, it is recommended to use 0.2 to 5 µm add-on filter which may contain an 
extension line (Note: the materials of the extension line and filter should be as 
mentioned above). Attach the infusion line to the pump and prime the line, either 
with normal saline (at least 25 mL) or with infusion solution as per local SOP, 
before starting the infusion. Infuse pembrolizumab over approximately 30 
minutes, with a window of -5 and +10 minutes, through a peripheral line or 
indwelling catheter.  
 
Ensure the entire contents of the bag are dosed and all remaining drug solution in 
the line is administered according to institutional guidelines for saline flushing.  
Document volume administered according to data entry guidelines. 
 
Whenever possible, the lowest infusion rate should be used that will allow 
completion of the infusion within the 30 minutes. Maximum rate of infusion 
should not exceed 6.7 mL/min. through a peripheral line or indwelling catheter. 
However, when it is necessary to infuse a larger volume (i.e. 250 mL), the flow 
rate may go as high as 10 mL/min (maximum) in order to keep the infusion within 
the window as defined above.  
 
Do not administer the product as an intravenous (IV) push or bolus. Do not co-
administer other drugs through the same infusion line. Do not combine, dilute or 
administer it as an infusion with other medicinal products. Unused infusion 
solution for injection should not be used for another infusion of the same subject 
or different subject. 
6.1.6 Return and Retention 
The investigator is responsible for keeping accurate records of the clinical 
supplies received from Merck or designee, the amount dispensed to the subjects 
and the amount remaining at the conclusion of the trial.  
 
Upon completion or termination of the study, all unused investigational product 
will be destroyed at the site per UNC IDS drug destruction policy. It is the 
Investigator’s responsibility to arrange for disposal of all empty containers, 
provided that procedures for proper disposal have been established according to 
applicable federal, state, local and institutional guidelines and procedures, and 
provided that appropriate records of disposal are kept. 
6.1.7 Drug Ordering and Accountability 
Pembrolizumab should be ordered from Merck by completing and emailing 
provided Drug Request Form. 

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6.1.8 Adverse Events Associated with Pembrolizumab 
The most common adverse reactions (reported in ≥20% of subjects in clinical 
trials of pembrolizumab) included fatigue, cough, nausea, pruritus, rash, 
decreased appetite, constipation, arthralgia, and diarrhea.  
6.1.9 Contraindications 
There are no reported contraindications associated with the use of 
pembrolizumab. Pembrolizumab may have adverse effects on a fetus in utero.  
Furthermore, it is not known if pembrolizumab has transient adverse effects on 
the composition of sperm.   
6.1.10 Contraception 
Pembrolizumab may have adverse effects on a fetus in utero. Furthermore, it is 
not known if pembrolizumab has transient adverse effects on the composition of 
sperm. For this trial, male subjects will be considered to be of non-reproductive 
potential if they have azoospermia (whether due to having had a vasectomy or due 
to an underlying medical condition). Acceptable methods of contraception are 
listed in Appendix D. 
Subjects should be informed that taking the study medication may involve 
unknown risks to the fetus (unborn baby) if pregnancy were to occur during the 
study.  In order to participate in the study subjects of childbearing potential must 
adhere to the contraception requirement (described above) from the day of study 
medication initiation (or 14 days prior to the initiation of study medication for 
oral contraception) throughout the study period up to 120 days after the last dose 
of trial therapy.  If there is any question that a subject of childbearing potential 
will not reliably comply with the requirements for contraception, that subject 
should not be entered into the study. 
6.1.11 Use in Pregnancy 
If a subject inadvertently becomes pregnant while on treatment with 
pembrolizumab, the subject will immediately be removed from the study. The site 
will contact the subject at least monthly and document the subject’s status until 
the pregnancy has been completed or terminated. The outcome of the pregnancy 
will be reported to the Sponsor, to Merck without delay and within 24 hours if the 
outcome is a serious adverse experience (e.g., death, abortion, congenital 
anomaly, or other disabling or life-threatening complication to the mother or 
newborn).   
 
The study investigator will make every effort to obtain permission to follow the 
outcome of the pregnancy and report the condition of the fetus or newborn to the 
Sponsor. If a male subject impregnates his female partner the study personnel at 
the site must be informed immediately and the pregnancy reported to the Sponsor 
and, to Merck, and followed as described and in Section 8.4. 
 
 

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Risk Summary 
Based on its mechanism of action, pembrolizumab can cause fetal harm when 
administered to a pregnant woman. In animal models, the PD-1/PD-L1 signaling 
pathway is important in the maintenance of pregnancy through induction of 
maternal immune tolerance to fetal tissue. Human IgG4 (immunoglobulins) are 
known to cross the placenta; therefore, pembrolizumab has the potential to be 
transmitted from the mother to the developing fetus. There are no available 
human data informing the risk of embryo-fetal toxicity. Apprise pregnant women 
of the potential risk to a fetus. 
 
In the US general population, the estimated background risk of major birth defects 
and miscarriage in clinically recognized pregnancies is 2–4% and 15–20%, 
respectively. 
6.1.12 Use in Nursing Women 
It is not known whether pembrolizumab is excreted in human milk. No studies 
have been conducted to assess the impact of pembrolizumab on milk production 
or its presence in breast milk. Because many drugs are excreted in human milk, 
instruct women to discontinue nursing during treatment with pembrolizumab and 
for 4 months after the final dose.  
6.2 
Entinostat 
Entinostat is an investigational product and is provided free of charge to clinical 
trial participants. 
6.2.1 Drug Supply 
Entinostat is an oral drug supplied by Syndax Pharmaceuticals as pink to light red 
(1 mg) or yellow (5 mg) polymorph B coated tablets. Each tablet contains 
mannitol, sodium starch glycolate, hydroxypropyl cellulose, potassium 
bicarbonate, and magnesium stearate as inert fillers. The film coating consists of 
hypromellose, talc, titanium dioxide, and ferric oxide pigments (red and yellow) 
as colorants.  
6.2.2 Storage and Handling 
Entinostat is to be stored at controlled room temperature (15ºC to 25ºC) in a 
secure, locked storage area to which access is limited. Entinostat is to be protected 
from light and not to be exposed to extremes of temperature (greater than 30ºC or 
less than 5ºC). The pharmacist should dispense the investigational material to the 
subject at the clinic visits on Day 1, Day 8 and Day 15 in childproof containers. 
6.2.3 Method of Administration 
Entinostat is to be taken on an empty stomach, at least 2 hours after a meal and at 
least 1 hour before the next meal. If entinostat is vomited, dosing should not be 
re-administered but instead the dose should be skipped. When administered 

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together with pembrolizumab, on Day 1 entinostat should be taken before the 
pembrolizumab infusion.  
6.2.4 Drug Ordering and Accountability 
Entinostat should be ordered from Syndax by completing and emailing provided 
Drug Request Form. The investigator or designee is responsible for keeping 
accurate records of the clinical supplies received from the company sponsor or 
designee, the amount dispensed to the subjects and the amount remaining at the 
conclusion of the trial. An accurate and current accounting of the dispensing of 
investigational study drug for each subject will be maintained on an ongoing basis 
by a member of the study site staff. The amount of study drug dispensed to the 
subject will be recorded in the Investigational Drug Accountability Record.   
6.2.5 Return and Retention of Study Drug 
Upon completion or termination of the study, all unused and/or partially used 
investigational product will be destroyed at the site per institutional policy (e.g., 
UNC IDS drug destruction policy). It is the Investigator’s responsibility to 
arrange for disposal of all empty containers, provided that procedures for proper 
disposal have been established according to applicable federal, state, local and 
institutional guidelines and procedures, and provided that appropriate records of 
disposal are kept. 
6.2.6 Adverse Events Associated with Entinostat 
As of July 1, 2016, entinostat has been evaluated as monotherapy and in 
combination with other agents in > 1055 cancer patients in 31 clinical studies. The 
most commonly reported AEs in entinostat-treated patients treated on a 
continuous dosing schedule included fatigue (63%), gastrointestinal disturbances, 
primarily nausea (55%), vomiting (32%), anorexia (31%), and diarrhea (32%). 
Hematologic abnormalities, including anemia (47%), thrombocytopenia (41%), 
neutropenia (33%), and leukopenia (31%). We do not anticipate that AEs will be 
an issue given that only 3 doses of entinostat will be administered in this trial.  
Overall, the side effects of entinostat when given in combination with other anti-
cancer agents were similar to that seen when entinostat was given alone.  
 
Please refer to the Entinostat Investigator’s Brochure for additional information.

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7.0 
CLINICAL ASSESSMENTS 
Clinical assessments will be performed as outlined in the Time and Events Table 
in Section 7.0. 
7.1.1 Concomitant Medications 
All concomitant medication and concurrent therapies will be documented at 
Screening and throughout the study as summarized in the Time and Events Table 
in  Section 8.1. Dose, route, unit frequency of administration, and indication for 
administration and dates of medication will be captured. 
7.1.2 Demographics  
Demographic information (date of birth, gender, race, ethnicity) will be recorded 
at Screening. 
7.1.3 Medical History  
Relevant medical history, including history of current disease, other pertinent 
respiratory history (e.g., tobacco use), and information regarding underlying 
diseases will be recorded at Screening and a focused medical history on 
symptoms/toxicity will be performed thereafter.  
7.1.4 Physical Examination 
A complete physical examination including height (at screening only), weight, 
ECOG performance status and vital signs (temperature, pulse, blood pressure) 
will be performed by either the investigator or a sub-investigator. New abnormal 
physical exam findings must be documented and will be followed by a physician 
or other qualified staff (MD, NP, RN, and PA) at the next scheduled visit. 
7.1.5 Adverse Events 
Events should be assessed per NCI-CTCAE criteria v5.0. Information regarding 
occurrence of adverse events will be captured throughout the study. Duration 
(start and stop dates), severity/grade, outcome, treatment and relation to study 
drug will be recorded in the electronic case report form (eCRF).  
7.1.6 Disease Assessment 
Baseline disease assessment should be obtained within 4 weeks prior to treatment 
initiation. Assessment of disease will then occur during follow-up, every 6 
months for 3 years. 
7.2 
Clinical Laboratory Assessments 
7.2.1 Hematology 
Blood will be obtained and sent to the clinical site laboratory for a complete blood 
count with white blood cell differential. 

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7.2.2 Blood Chemistry Profile 
Blood will be obtained and sent to the clinical site laboratory for determination of 
comprehensive metabolic panel (sodium, potassium, chloride, CO2, BUN, 
creatinine, glucose, calcium, albumin, total protein, total bilirubin, AST, ALT, 
alkaline phosphatase), magnesium and phosphorus. 
7.2.3 Thyroid panel 
Blood will be obtained and sent to the clinical site laboratory for determination of 
thyroid-stimulating hormone (TSH). Free T4 and free or total T3 will only be 
measured if TSH is abnormal or if there is a clinical suspicion of an AE related to 
the endocrine system. 
7.2.4 PT/INR 
Blood will be obtained and sent to the clinical site laboratory for determination of 
PT/INR at screening and pre-surgery. 
7.2.5 Pregnancy Test 
A serum pregnancy test will be obtained from female subjects who are of 
childbearing potential prior to their participation in the study and prior to each 
subsequent dose of pembrolizumab. 
7.3 
Correlative Studies Procedures 
 
 
 
 
 
7.3.1 Archival Tumor Tissue 
Archived primary tumor in fixed paraffin-embedded blocks or slides from the 
diagnostic TURBT specimen of each subject must be requested at baseline for 
correlative studies. Additionally, we will request banked tissue on the subset of 
patients who have previously had tissue frozen via UNC’s Tissue Procurement 
Facility’s standing collection protocol, or through our group’s biospecimen 
repository protocol (LCCC1212).  
 
mRNA Sequencing and Gene Expression Profiling 
RNA will be extracted from tumor samples, libraries will be prepared using the 
TruSeq RNA Access protocol. mRNA libraries will be sequenced, and relevant 
gene expression signatures will be evaluated, including relative expression of pre- 
and post-treatment STAT3 and NF-κB signatures, IFNγ-related genes, MHC class 
I/II genes, and immune checkpoint genes and other immune gene signatures. 
 
Immunohistochemistry 
Histone acetylation (H3K9Ac and H3K27Ac) levels will be assessed via 
immunohistochemistry.  
 
Whole Exome Sequencing 

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DNA will be extracted and whole-exome sequencing libraries will be generated. 
Exome sequence data will be processed using the established pipeline developed 
at UNC.  Buccal swabs will be used as a source for normal DNA. 
 
ChIP-Sequencing  
For the subset of patients with frozen diagnostic TURBT and post-treatment 
surgical tissue available, we will perform ChIP-sequencing for H3K27Ac and 
other histone markers (H3K4Me3 and K3K27Me3, etc.) to assess where changes 
in histone post-translational modifications associate with active transcription. 
 
T Cell Receptor Repertoire Profiling: immunoSEQ Assay 
TCR repertoire amplification and sequencing will be done on tumor and 
peripheral blood samples after DNA extraction. The TCRb CDR3 regions will be 
amplified and sequenced using immunoSEQ. Pre- and post-treatment TCR 
repertoire clonality will be compared to assess for an antigen-specific immune 
response. 
7.3.2 Blood samples 
Subjects will have their blood collected in ACD tubes (whole blood) at Day 1, 
Day 8, and Day 22 of study treatment, and at the time of post-treatment surgery 
(cystectomy or maximal TURBT) . Sample collection and storage instructions for 
peripheral blood mononuclear cells and plasma samples is provided in the 
Laboratory Manual. 
7.3.3 Tumor and Lymph Node Tissue from Post-Treatment Surgery (Cystectomy 
or maximal TURBT)  
Tumor tissue will be flash frozen and FFPE tissue will be collected for analysis to 
ensure comparability of samples between diagnostic TURBT and post-treatment 
surgery (cystectomy or maximal TURBT). Next generation sequencing and IHC 
studies will be done on post-treatment surgical tumor samples as above in Section 
7.3.1 for diagnostic TURBT samples. Remaining tissue may be stored for future 
research with subject’s permission through our biospecimen repository protocol 
(LCCC1212), or, if requested, any unused slides will be returned to the site of 
origin. Otherwise, all remaining tissue will be destroyed per institutional 
guidelines. Additional details of correlative studies are provided in the 
accompanying Laboratory Manual. 
7.3.4 Urine Microbiome 
Urine for microbiome analysis will be collected by either clean catch and/or 
catheterization. The catheterization collection method will only be used to collect 
urine in cases where the subject will be undergoing bladder catheterization as part 
of routine care. Urine will be frozen and stored until time of sequencing. 16S 
ribosomal sequencing is currently planned to be carried out in conjunction with 
the UNC microbiome core (https://www.med.unc.edu/microbiome/).    
 
 

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8.0 
EVALUATIONS AND ASSESSMENTS 
8.1 
Time and Events Table 
 
Assessments 
Screening2 
Treatment1 
Pre- 
Surgery12 
 
Surgery1 
Post-
Surgery13 
Follow-
up14 
D1 D8 D15 D22 
Informed consent 
× 
 
 
 
 
 
 
History 
× 
× 
 
× 
×12 
× 
 
Physical exam 
× 
× 
 
× 
 
 
 
Performance status 
× 
× 
 
 
 
 
 
Tumor imaging3 
× 
 
 
 
 
 
× 
Pregnancy test4 
× 
 
 
× 
 
 
 
Hematology5 
× 
× 
× 
× 
× 
× 
 
 
Serum chemistries6 
× 
× 
× 
× 
× 
× 
 
 
Thyroid panel7 
× 
 
 
 
× 
 
 
PT/INR 
× 
 
 
 
 
× 
 
 
 
Toxicity assessment 
× 
× 
× 
× 
× 
×12 
 
× 
 
Concomitant medications 
× 
× 
× 
× 
× 
×12 
× 
 
 
Pembrolizumab IV 
 
× 
 
× 
 
 
 
 
Entinostat PO8 
 
× 
× 
× 
 
 
 
 
 
Archival tissue collection9 
× 
 
 
 
 
 
 
 
Blood sample for correlatives10 
 
× 
× 
 
× 
 
×15 
 
 
Fresh tissue collection 
 
 
 
 
 
× 
 
 
Urine collection 
× 
 
 
× 
 
 
 
Buccal swab11 
× 
 
 
 
 
 
 
Survival 
 
 
 
 
 
 
× 

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Footnotes to Time and Events Table 
 
1. A window of ±1 day will be applied to study visits on Day 1, Day 8, Day 15 and Day 22. Post-
treatment surgery refers to radical cystectomy or maximal TURBT and should occur within 10 weeks 
from the time of initiation of study therapy. 
2. Unless otherwise noted, laboratory evaluations may be performed up to 10 days prior to first dose of 
the clinical trial treatment. Laboratory assessments on day 1 do not need to be repeated if screening 
labs were performed less than 72 hours prior to the scheduled visit. 
3. Tumor imaging should include MRI scan or contrasted CT of abdomen and pelvis and CT scan of the 
chest within 4 weeks prior to treatment initiation and during follow-up.. 
4. Serum βhCG must be performed within 72 hours prior to pembrolizumab administration for women of 
childbearing potential. 
5. Hematology must include complete blood count with white blood cell differential.  
6. Serum chemistry must include: sodium, potassium, chloride, CO2, BUN, creatinine, glucose, calcium, 
albumin, total protein, total bilirubin, AST, ALT, alkaline phosphatase, magnesium, phosphorus. 
7. Free T4 and free or total T3 will only be measured if TSH is abnormal or if there is a clinical suspicion 
of an AE related to the endocrine system. 
8. In Arm 2 only. Entinostat should be taken before the pembrolizumab infusion. 
9. Fixed paraffin-embedded blocks or slides from the diagnostic TURBT specimen must be requested for 
subjects at baseline. Sample collection, storage, and shipment instructions for tumor tissue samples are 
provided in the Laboratory Manual.  
10. Blood sample to be obtained in ACD tubes for correlative studies prior to first dose of the study 
treatment on Day 1 and Day 22 prior to administration of pembrolizumab, and at the time of post-
treatment surgery. Sample collection, storage, and shipment instructions for serum samples will be 
provided in the Laboratory Manual. 
11. Buccal swabs will be collected for correlative assays at screening. May be repeated if amount collected 
at baseline is not sufficient for analysis.  
12. Visit will be scheduled as per standard of care. Collection of history, toxicity assessment, and 
concomitant medications at the pre-surgery visit is only required for subjects receiving a cystectomy ( 
i.e. not those receiving bladder preserving maximal TURBT). Samples for safety labs (hematology, 
serum chemistries, thyroid panel, and PT/INR) are required for all subjects and may be collected at the 
same time as blood samples for correlatives, up to 2 days before surgery. 
13. The post-surgery visit should be scheduled 2-4 weeks after maximal TURBT (for trimodality subjects) 
and 4-8 weeks after cystectomy for cystectomy patients. Serious adverse events (SAEs) caused by a 
protocol-mandated intervention, or any grade of events of clinical interest (see section 9.4.2.2) that 
occur within 90 days of the last pembrolizumab administration must be recorded. Collection of 
potential serious adverse events and/or events of clinical interest will occur during regular follow-up 
visits scheduled per community standards of medical care. 
14. Subjects will be followed every 6 months for 3 years after surgery for recurrence and survival. 
Survival status maybe obtained by remote means.  
15. A window of –2 days will be applied to correlative samples collected at the surgery visit. This should 
not occur after surgery. 

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8.2 
Post-Treatment Surgery 
Post-treatment surgery (either cystectomy or maximal TURBT for trimodality 
patients) should occur within 10 weeks of the initiation of study therapy. For 
cystectomy subjects, the surgery with curative intent will occur as per routine 
clinical standard of care and will be performed at the discretion of the surgeon. 
For subjects undergoing trimodality therapy, maximal TURBT should occur 
within 10 weeks of initiation of study therapy, followed by initiation of standard 
of care concurrent chemotherapy and radiation.  
 
Tissue acquisition: A sample of tumor tissue from the post-treatment surgery will 
be preserved for correlative studies. A sample of lymph node tissue from the 
lymph node dissection, if available, and normal tissue from the cystectomy 
specimen will be preserved for correlative studies from all cystectomy subjects. 
These tissues will be preserved in consultation with surgical pathology, and tissue 
released for correlative studies post pathological review. Note: Subjects who do 
not complete clinical trial treatment for whatever reason other than withdrawal 
from the study, but still undergo surgery, will be requested to participate in 
correlative studies. 
 
Blood sample for correlative studies: blood will be collected in ACD tubes (see 
Study Laboratory Manual for details). 
8.2.1 Post-Surgery Visit 
This visit should be scheduled 4-8 weeks after cystectomy, or 2-4 weeks after 
maximal TURBT for trimodality subjects. This visit should occur prior to 
initiation of subsequent standard of care chemotherapy and radiation in 
trimodality subjects. Initiation of chemotherapy and radiation should occur per 
standard of care after maximal TURBT. Serious adverse events (SAEs) related to 
protocol-mandated treatment or any grade of Events of Clinical Interest (see 
section 9.4.2.2) that occur within 90 days of pembrolizumab administration must 
be recorded. 
8.3 
Handling of Biospecimens Collected for Correlative Research 
Biospecimens collected for this study will be stored in the Lineberger 
Comprehensive Cancer Center (LCCC) Tissue Procurement Facility (TPF), or if 
needed, in a secure off-site storage facility. All biospecimen samples will be 
obtained in accordance with procedures outlined in the LCCC 1827 Study 
Laboratory Manual and stored in containers with controlled access. Each sample 
will be assigned a unique code number and no identifiable personal health 
information (PHI) will be on the specimen label. Information about the subject’s 
disease will be linked to the specimens stored in the repository database. TPF-
associated research staff, LCCC Bioinformatics staff who support the TPF 
database and the LCCC Data Warehouse, and researchers with IRB-approval for 
access to PHI for each subject in this study will be able to link specimens to 

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relevant medical information. Some results from laboratory analyses that occurred 
during the subject’s participation in the clinical study may also be included.  
Storage Time: 
• 
The biospecimen will be used first and foremost for research purposes 
outlined within the confines of this protocol. Samples will be 
discarded/destroyed after relevant data are collected for this study; unless 
consent was obtained from the subject to use tissue for other research 
purposes (Specimen Consent checkbox was checked, and consent was 
signed).  
• 
Leftover biospecimen material collected during this study may be stored and 
used for other research purposes including genetic research only if subject’s 
assent was obtained. In this circumstance, there is a 15-year limit on use and 
storage of the biospecimens. If storage is anticipated to be indefinite, there 
will be an opt-out on the informed consent form allowing subjects to choose 
not to allow their specimens to be used for such future research. 
 
Compliance Statement 
Biospecimen collection for this study will be conducted in full accordance to all 
applicable University of North Carolina (UNC) Research Policies and Procedures 
and all applicable Federal and state laws and regulations including 45 CFR 46, 
and the Health Insurance Portability and Accountability Act (HIPAA) Privacy 
Rule. Any episode of noncompliance will be documented. 
 
The investigators will perform the study in accordance with this protocol, will 
obtain consent and assent (unless a waiver is granted), and will report unexpected 
problems in accordance with The UNC IRB Policies and Procedures and all 
federal requirements. Collection, recording, and reporting of data will be accurate 
and will ensure the privacy, health, and welfare of research subjects during and 
after the study.  
8.4 
Assessment of Safety  
Any subject who receives at least one dose of study therapy on this protocol will 
be evaluable for toxicity. Each subject will be assessed periodically for the 
development of any toxicity according to the Time and Events table. Toxicity will 
be assessed according to the NCI CTCAE version 5.0.  

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9.0 
ADVERSE EVENTS 
9.1 
Definitions  
9.1.1 Adverse Event (AE) 
An adverse event (AE) is any untoward medical occurrence (e.g., an abnormal 
laboratory finding, symptom, or disease temporally associated with the use of a 
drug) in a subject or clinical investigation subject administered a pharmaceutical 
product and which does not necessarily have a causal relationship with this 
treatment. An AE can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of a medicinal product, whether or not related to the 
medicinal product.  
 
Hospitalization for elective surgery or routine clinical procedures that are not the 
result of an AE (e.g., surgical insertion of central line) need not be considered 
AEs and should not be recorded as an AE. Disease progression should not be 
recorded as an AE, unless it is attributable by the investigator to the study therapy. 
Adverse events may occur during the course of the use of Merck product in 
clinical trials, or as prescribed in clinical practice, from overdose (whether 
accidental or intentional), from abuse and from withdrawal. 
 
All AEs, SAEs and other reportable safety events that occur after the consent 
form is signed but before treatment assignment must be reported by the 
investigator if the event causes the subject to be excluded from the study or is the 
result of a protocol-specified intervention, including but not limited to washout or 
discontinuation of usual therapy, diet, or a procedure.  
 
• All AEs from the time of treatment through 30 days following cessation of 
study therapy must be reported by the investigator.  
• All AEs meeting serious criteria, from the time of treatment through 90 
days following cessation of study treatment, or 30 days following 
cessation of study treatment if the participant initiates new anticancer 
therapy, whichever is earlier must be reported by the investigator.  
• All pregnancies and exposure during breastfeeding, from the time of 
treatment through 120 days following cessation of study treatment, or 30 
days following cessation of study treatment if the participant initiates new 
anticancer therapy must be reported by the investigator.  
• Additionally, any SAE brought to the attention of an investigator at any 
time outside of the time period specified above must be reported 
immediately by the investigator if the event is considered to be drug-
related. 
 

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Investigators are not obligated to actively seek AE or SAE or other reportable 
safety events in former study participants. However, if the investigator learns of 
any SAE, including a death, at any time after a participant has been discharged 
from the study, and he/she considers the event to be reasonably related to the 
study treatment or study participation, the investigator must promptly notify 
Merck. 
9.1.2 Suspected Adverse Reaction (SAR) 
A suspected adverse reaction (SAR) is any AE for which there is a reasonable 
possibility that the drug is the cause. Reasonable possibility means that there is 
evidence to suggest a causal relationship between the drug and the AE. A 
suspected adverse reaction implies a lesser degree of certainty about causality 
than adverse reaction, which means any adverse event caused by a drug.  
 
Causality assessment to a study drug is a medical judgment made in consideration 
of the following factors: temporal relationship of the AE to study drug exposure, 
known mechanism of action or side effect profile of study treatment, other recent 
or concomitant drug exposures, normal clinical course of the disease under 
investigation, and any other underlying or concurrent medical conditions. Other 
factors to consider in considering drug as the cause of the AE: 
• Single occurrence of an uncommon event known to be strongly associated 
with drug exposure (e.g., angioedema, hepatic injury, Stevens-Johnson 
Syndrome) 
• One or more occurrences of an event not commonly associated with drug 
exposure, but otherwise uncommon in the population (e.g., tendon 
rupture); often more than once occurrence from one or multiple studies 
would be needed before the sponsor could determine that there is 
reasonable possibility that the drug caused the event.  
• An aggregate analysis of specific events observed in a clinical trial that 
indicates the events occur more frequently in the drug treatment group 
than in a concurrent or historical control group 
9.1.3 Unexpected AE or SAR 
An AE or SAR is considered unexpected if the specificity or severity of it is not 
consistent with the applicable product information (e.g., Investigator’s Brochure 
(IB) for an unapproved investigational product or package insert/summary of 
product characteristics for an approved product). Unexpected also refers to AEs or 
SARs that are mentioned in the IB as occurring with a class of drugs or as 
anticipated from the pharmacological properties of the drug but are not 
specifically mentioned as occurring with the particular drug under investigation.  
9.1.4 Serious AE or SAR 
An AE or SAR is considered serious if, in the view of either the investigator or 
sponsor, it results in any of the following outcomes: 
• Death; 

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• Is life-threatening (places the subject at immediate risk of death from 
the event as it occurred); 
• Requires inpatient hospitalization (>24 hours) or prolongation of 
existing hospitalization;* 
• Results in congenital anomaly/birth defect; 
• Results in a persistent or significant incapacity or substantial 
disruption of the ability to conduct normal life functions; 
• Important medical events that may not result in death, be life-
threatening, or require hospitalization may be considered a serious 
adverse drug experience when, based upon appropriate medical 
judgment, they may jeopardize the subject and may require medical or 
surgical intervention to prevent one of the outcomes listed in the 
definition. For reporting purposes, also consider the occurrences of 
pregnancy as an event which must be reported as an important medical 
event. 
• Note: In addition to the above criteria, adverse events meeting either of 
the below criteria, although not serious per ICH definition, are 
reportable to the Merck in the same timeframe as SAEs to meet certain 
local requirements. Therefore, these events are considered serious by 
Merck for collection purposes. 
• Is a new cancer (that is not a condition of the study); 
• Is associated with an overdose. 
 
*Hospitalization for anticipated or protocol specified procedures such as administration 
of chemotherapy, central line insertion, metastasis interventional therapy, resection of 
primary tumor, or elective surgery, will not be considered serious adverse events. 
 
Pregnancy that occurs during the study must also be reported as an SAE. 
9.2 
SAEs or Serious SARs  
9.2.1 Timing 
After informed consent but prior to initiation of study medications, only SAEs 
caused by a protocol-mandated intervention will be collected (e.g. SAEs related to 
invasive procedures such as biopsies, medication washout).  
 
For any other experience or condition that meets the definition of an SAE or a 
serious SAR, recording of the event must begin from day 1 of study treatment and 
continue through the 30-day follow-up period after treatment is discontinued. 
Serious adverse events (SAEs) caused by a protocol-mandated intervention, or 
any grade of events of clinical interest (see section 9.4.2.2) that occur within 90 
days of the last pembrolizumab administration must be recorded. 
9.2.2 Documentation and Notification 
SAEs or Serious SARs must be recorded in the SAE console within OnCore® for 
that subject within 24 hours of learning of its occurrence. Additionally, the 

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Multicenter Project Manager must also be notified via email of all SAEs within 
24 hours of learning of its occurrence. 
9.3 
Documentation of Non-Serious AEs or SARs 
For non-serious AEs or SARs, documentation must begin from day 1 of study 
treatment and continue through the 30-day follow-up period after treatment is 
discontinued.  
 
Collected information should be recorded in electronic case report forms (eCRF) 
for that subject. Please include a description of the event, its severity or toxicity 
grade, onset and resolved dates (if applicable), and the relationship to the study 
drug. Documentation should occur at least monthly.  
 
9.4 
Adverse Event Reporting  
9.4.1 IRB Reporting Requirements: 
The UNC-IRB will be notified of all SAEs that qualify as an Unanticipated 
Problem as per the UNC IRB Policies using the IRB’s web-based reporting 
system within 7 days of the Investigator becoming aware of the problem. Please 
note, these events must be reported to the sponsor within 24 hours of learning of 
the occurrence. 
 
Multicenter sites:   
• For multicenter sites using a local IRB of record, please submit adverse 
events per local IRB policy. 
• For multicenter sites relying on the UNC-IRB, an aggregated list of any 
SAEs that qualify as an Unanticipated Problem will be entered into 
OnCore® by the multicenter site and reported to the UNC IRB by the 
Multicenter Regulatory Associate using the IRB’s web-based reporting 
system within 7 days of the Investigator becoming aware of the problem.   
 
Pregnancy 
Pregnancies and suspected pregnancies (including a positive pregnancy test 
regardless of age or disease state) of a female subject occurring while the subject 
is on study, or within 30 days of the subject’s initial dose of study drug and prior 
to post-treatment surgery should be recorded as SAEs. The subject is to be 
discontinued immediately from the study.  
 
The female subject should be referred to an obstetrician-gynecologist, preferably 
one experienced in reproductive toxicity for further evaluation and counseling. 
 
For multicenter sites, the pregnancy, suspected pregnancy, or positive pregnancy 
test must be reported to the Multicenter Project Manager immediately (within 
24 hours) via email. The Multicenter Project Manager will then report the event to 

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the Funding Source (see requirements below).  The female subject should be 
referred to an obstetrician-gynecologist, preferably one experienced in 
reproductive toxicity for further evaluation and counseling. 
 
The Investigator will follow the female subject until completion of the pregnancy 
and must document the outcome of the pregnancy (either normal or abnormal 
outcome). If the outcome of the pregnancy was abnormal (e.g., spontaneous or 
therapeutic abortion), the Investigator should report the abnormal outcome as an 
AE. If the abnormal outcome meets any of the serious criteria, it must be reported 
as an SAE.  
9.4.2 Merck Reporting Requirements: 
Also refer to Appendix 5, as needed. 
9.4.2.1 Adverse Events (AEs), Serious Adverse Events (SAEs), and Other 
Reportable Safety Events 
The definitions of an AE or SAE, as well as the method of recording, 
evaluating, and assessing causality of AE and SAE and the procedures for 
completing and transmitting AE, SAE, and other reportable safety event reports 
can be found in Appendix F.   
 
Adverse events, SAEs, and other reportable safety events will be reported by the 
participant (or, when appropriate, by a caregiver, surrogate, or the participant's 
legally authorized representative). 
 
The investigator and any designees are responsible for detecting, documenting, 
and reporting events that meet the definition of an AE or SAE as well as other 
reportable safety events. Investigators remain responsible for following up AEs, 
SAEs, and other reportable safety events for outcome. 
 
The investigator, who is a qualified physician, will assess events that meet the 
definition of an AE or SAE as well as other reportable safety events with 
respect to seriousness, intensity/toxicity and causality. 
9.4.2.2 Time Period and Frequency for Collecting AE, SAE, and Other Reportable 
Safety Event Information 
All AEs, SAEs, and other reportable safety events that occur after the consent 
form is signed but before intervention allocation/randomization must be 
reported by the investigator if the participant is receiving placebo run-in or other 
run-in treatment, if the event cause the participant to be excluded from the 
study, or is the result of a protocol-specified intervention, including but not 
limited to washout or discontinuation of usual therapy, diet, or a procedure. 
 

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• All AEs from the time of intervention allocation/randomization through 30 
days following cessation of study intervention must be reported by the 
investigator. 
• All AEs meeting serious criteria, from the time of intervention 
allocation/randomization through 90 days following cessation of study 
intervention or 30 days following cessation of study intervention if the 
participant initiates new anticancer therapy, whichever is earlier, must be 
reported by the investigator. 
• All pregnancies and exposure during breastfeeding, from the time of 
intervention allocation/randomization through 120 days following 
cessation of study intervention, or 30 days following cessation of study 
intervention if the participant initiates new anticancer therapy must be 
reported by the investigator. 
• Additionally, any SAE brought to the attention of an investigator at any 
time outside of the time period specified above must be reported 
immediately to Merck if the event is considered drug-related. 
 
Investigators are not obligated to actively seek AEs or SAEs or other reportable 
safety events in former study participants. However, if the investigator learns of 
any SAE, including a death, at any time after a participant has been discharged 
from the study, and he/she considers the event to be reasonably related to the 
study intervention or study participation, the investigator must promptly notify 
Merck. 
 
All initial and follow-up AEs, SAEs, and other reportable safety events will be 
recorded and reported to Merck within the time frames as indicated in the table 
below. 
 
Reporting Time Periods and Time Frames for Adverse Events and Other 
Reportable Safety Events 
Type of Event 
Reporting Time 
Period: 
Consent to 
Randomization/ 
Allocation 
Reporting Time 
Period: 
Randomization/ 
Allocation 
through Protocol-
specified Follow-
up Period 
Reporting Time Period: 
After the Protocol-
specified Follow-up 
Period 
Time Frame 
to Report 
Event and 
Follow-up 
Information 
to Merck: 
 
 
 
 
 
Serious Adverse Event 
(SAE) including Cancer 
and Overdose 
Report if: 
- due to protocol-
specified 
intervention 
- causes exclusion 
- participant is 
receiving placebo 
run-in or other run-
in treatment 
Report all 
Report if: 
- drug/vaccine related. 
(Follow ongoing to 
outcome) 
Within 2 
business days 
but no longer 
than 3 
calendar days 
of learning of 
event 
Pregnancy/Lactation 
Exposure 
Report if: 
- due to 
Report all 
Previously reported – 
Follow to 
Within 2 
business days 

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Type of Event 
Reporting Time 
Period: 
Consent to 
Randomization/ 
Allocation 
Reporting Time 
Period: 
Randomization/ 
Allocation 
through Protocol-
specified Follow-
up Period 
Reporting Time Period: 
After the Protocol-
specified Follow-up 
Period 
Time Frame 
to Report 
Event and 
Follow-up 
Information 
to Merck: 
intervention 
- causes exclusion 
completion/termination; 
report outcome 
but no longer 
than 3 
calendar days 
of learning of 
event 
Event of Clinical 
Interest (require 
regulatory reporting) 
Report if: 
- due to 
intervention 
- causes exclusion 
Report 
- potential drug-
induced liver 
injury (DILI) 
- require 
regulatory 
reporting 
Not required 
Within 2 
business days 
but no longer 
than 3 
calendar days 
of learning of 
event 
 
 
 
 
 
 
9.4.2.3 Method of Detecting AEs, SAEs, and Other Reportable Safety Events 
Care will be taken not to introduce bias when detecting AEs and/or SAEs and 
other reportable safety events. Open-ended and nonleading verbal questioning 
of the participant is the preferred method to inquire about AE occurrence. 
9.4.2.4 Follow-up of AE, SAE, and Other Reportable Safety Event Information 
After the initial AE/SAE report, the investigator is required to proactively 
follow each participant at subsequent visits/contacts. All AEs, SAEs, and other 
reportable safety events including pregnancy and exposure during breastfeeding, 
events of clinical interest (ECIs), cancer, and overdose will be followed until 
resolution, stabilization, until the event is otherwise explained, or the participant 
is lost to follow-up. In addition, the investigator will make every attempt to 
follow all nonserious AEs that occur in allocated or randomized participants for 
outcome. Further information on follow-up procedures is given in Appendix F. 
9.4.2.5 Sponsor Responsibility for Reporting Adverse Events  
All Adverse Events will be reported to regulatory authorities, IRB/IECs and 
investigators in accordance with all applicable country specific regulatory 
requirements, global laws and regulations.  
9.4.2.6 Pregnancy and Exposure During Breastfeeding 
Although pregnancy and infant exposure during breastfeeding are not 
considered AEs, any pregnancy or infant exposure during breastfeeding in a 
participant (spontaneously reported to the investigator or their designee) that 
occurs during the study are reportable to Merck. 
 

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All reported pregnancies must be followed to the completion/termination of the 
pregnancy. Pregnancy outcomes of spontaneous abortion, missed abortion, 
benign hydatidiform mole, blighted ovum, fetal death, intrauterine death, 
miscarriage, and stillbirth must be reported as serious events (Important Medical 
Events). If the pregnancy continues to term, the outcome (health of infant) must 
also be reported. 
9.4.2.7 Events of Clinical Interest (ECIs) 
Selected nonserious and SAEs are also known as ECIs and must be reported to 
Merck.  
Events of clinical interest for this study include:  
1. An overdose of pembrolizumab that is not associated with clinical 
symptoms or abnormal laboratory results. For purposes of this study, an 
overdose of pembrolizumab will be defined as any dose of 1,000 mg or 
greater (≥5 times the indicated dose).  No specific information is 
available on the treatment of overdose of pembrolizumab. In the event of 
overdose, the participant should be observed closely for signs of 
toxicity.  Appropriate supportive treatment should be provided if 
clinically indicated.  If an adverse event(s) is associated with (“results 
from”) the overdose of a Merck product, the adverse event(s) is reported 
as a serious adverse event, even if no other seriousness criteria are met. 
2. An elevated AST or ALT lab value that is greater than or equal to 3X the 
upper limit of normal and an elevated total bilirubin lab value that is 
greater than or equal to 2X the upper limit of normal and, at the same 
time, an alkaline phosphatase lab value that is less than 2X the upper 
limit of normal, as determined by way of protocol-specified laboratory 
testing or unscheduled laboratory testing.*  
 
*Note: These criteria are based upon available regulatory guidance documents. 
The purpose of the criteria is to specify a threshold of abnormal hepatic tests that 
may require an additional evaluation for an underlying etiology. 
9.4.3 Syndax Reporting Requirements 
The investigator must inform Syndax in writing using a SAE form or MedWatch 
3500A form of any SAE within 24 hours of being aware of the event. The date of 
awareness should be noted on the report. The written report must be completed 
and supplied to Syndax within 24 hours at the latest on the following working 
day. The initial report must be as complete as possible, including details of the 
current illness and (serious) adverse event, and an assessment of the causal 
relationship between the event and the investigational product(s). Information not 
available at the time of the initial report (e.g., an end date for the adverse event or 
laboratory values received after the report) must be documented on a follow-up 
report. A final report to document resolution of the SAE is required.  
Completed SAE Report Forms should be emailed to: 
SyndaxSAEReporting@syndax.com 

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or 
Back-up method only: fax to 1-888-529-3580 
 
9.5 
FDA Expedited Reporting Requirements for Studies Conducted Under an 
IND  
A sponsor must report any suspected adverse reaction that is both serious and 
unexpected to the FDA. The sponsor must report an adverse event as a suspected 
adverse reaction only if there is evidence to suggest a causal relationship between 
the drug and the adverse event, such as: 
• A single occurrence of an event that is uncommon and known to be 
strongly associated with drug exposure (e.g., angioedema, hepatic injury, 
Stevens-Johnson Syndrome); 
• One or more occurrences of an event that is not commonly associated 
with drug exposure, but is otherwise uncommon in the population 
exposed to the drug (e.g. tendon rupture); 
• An aggregate analysis of specific events observed in a clinical trial (such 
as known consequences of underlying disease or condition under 
investigation or other events that commonly occur in the study population 
independent of drug therapy) that indicates those events occur more 
frequently in the drug treatment group than in a concurrent or historical 
control group. 
The sponsor must submit each IND safety report on FDA Form 3500A. Each 
notification to FDA must bear prominent identification of its contents, i.e., “IND 
Safety Report,” and must be transmitted to the review division that has the 
responsibility for review of the IND. In each IND safety report, the sponsor must 
identify all IND safety reports previously submitted to FDA concerning a similar 
suspected adverse reaction and must analyze the significance of the suspected 
adverse reaction in light of previous, similar reports or any other relevant 
information.  
 
Timing 
FDA must be notified of potential serious risks within 15 calendar days after the 
sponsor determines the event requires reporting. FDA must be notified of 
unexpected fatal or life-threatening suspected adverse reactions as soon as 
possible but in no case later than 7 calendar days after the sponsor’s initial receipt 
of the information. The sponsor must be notified of the SAE by the investigator 
within 24 hours of the event. If the results of a sponsor’s investigation show that 
an adverse event not initially determined to be reportable is reportable, the 
sponsor must report such suspected adverse reaction in an IND safety report as 
soon as possible, but in no case later than 15 calendar days after the determination 
is made. 
 
Follow-up 

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The sponsor must promptly investigate all safety information it receives. Relevant 
follow-up information to an IND safety report must be submitted as soon as the 
information is available and must be identified as such, i.e., “Follow-up IND 
Safety Report.” Additionally, upon request from FDA, the sponsor must submit to 
FDA any additional data or information that the agency deems necessary, as soon 
as possible, but in no case later than 15 calendar days after receiving the request.  
 
Notification of Investigators 
The sponsor must notify all participating investigators (i.e., all investigators to 
whom the sponsor is providing drug under its INDs or under any investigator’s 
IND) in an IND safety report of potential serious risks, from clinical trials or any 
other source, as soon as possible, but in no case later than 15 calendar days after 
the sponsor determines that the information qualifies for reporting.  
 
Process 
If the sponsor deems that an event is both a serious adverse reaction (SAR) AND 
unexpected, it must also (in addition to OnCore®) be recorded on the MedWatch 
Form 3500A as per 21 CFR 312.32. Unexpected adverse events or adverse reaction 
refers to an event or reaction that is not listed in the investigator’s brochure or is not 
listed at the specificity or severity that has been observed; or if an investigator’s 
brochure is not required or available, is not consistent with the risk information 
described in the general investigation plan or elsewhere in the current IND 
application.  
 
The MedWatch form should be submitted on MedWatch by the study coordinator.  
 
The MedWatch 3500A form can be accessed at: 
http://www.fda.gov/Safety/MedWatch/HowToReport/DownloadForms/default.htm.  
 
(Please be sure and access form 3500A, and not form 3500 or 3500B).  
 
The MedWatch form should also be sent to the UNC Regulatory Associate and the 
IND Specialist within 48 hours of the sponsor being aware of the event. The 
Regulatory Associate with the aid of the IND Specialist will submit the IND Safety 
Report via IND serial submission to the FDA review division. 
 
All IND safety reports must be submitted on Form 3500A and be accompanied by 
Form 1571. The FDA must be notified or any unexpected or life-threatening 
suspected adverse reactions as soon as possible, but no later than 7 calendar days of 
learning of the event. 
 
Additional Reporting Requirements 
The following additional items must be reported via IND safety report: 
• Findings from other studies. The sponsor must report any findings from 
epidemiological studies, pooled analysis of multiple studies, or clinical 
studies, whether or not conducted under an IND, and whether or not 

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conducted by the sponsor, that suggest a significant risk to humans 
exposed to the drug.  
• Findings from animal or in vitro testing. The sponsor must report any 
findings from animal or in vitro testing, whether or not conducted by the 
sponsor, that suggest a significant risk in humans exposed to the drug, 
such as reports of mutagenicity, teratogenicity, or carcinogenicity, or 
reports of significant organ toxicity t or near the expected human 
exposure. 
• Increased rate of occurrence of serious suspected adverse reactions. 
 
Additional Guidance 
Please refer to 21CFR312.32 and “Guidance for Industry and Investigators: Safety 
Reporting Requirements for INDs and BA/BE Studies” for additional information 
and reporting requirements. All IND Safety Reports will be submitted in 
accordance with these regulations/guidances.  
9.6 
Data and Safety Monitoring Plan 
The Principal Investigator will provide continuous monitoring of subject safety in 
this trial with periodic reporting to the Data and Safety Monitoring Committee 
(DSMC).  
 
Meetings/teleconferences will be held at a frequency dependent on study accrual. 
These meetings will include the investigators as well as protocol nurses, clinical 
research associates, regulatory associates, data managers, biostatisticians, and any 
other relevant personnel the principal investigators may deem appropriate. At 
these meetings, the research team will discuss all issues relevant to study 
progress, including enrollment, safety, regulatory, data collection, etc. 
 
The team will produce summaries or minutes of these meetings. These summaries 
will be available for inspection when requested by any of the regulatory bodies 
charged with the safety of human subjects and the integrity of data including, but 
not limited to, the oversight (Office of Human Research Ethics (OHRE) 
Biomedical IRB, the Oncology Protocol Review Committee (PRC) or the North 
Carolina TraCS Institute Data and Safety Monitoring Board (DSMB).  
 
The UNC LCCC Data and Safety Monitoring Committee (DSMC) will review the 
study on a regular (quarterly to annually) basis, with the frequency of review 
based on risk and complexity as determined by the UNC Protocol Review 
Committee. The UNC PI will be responsible for submitting the following 
information for review: 1) safety and accrual data including the number of 
subjects treated; 2) significant developments reported in the literature that may 
affect the safety of participants or the ethics of the study; 3) preliminary response 
data; and 4) summaries of team meetings that have occurred since the last report. 
Findings of the DSMC review will be disseminated by memo to the UNC PI, 
PRC, and the UNC IRB and DSMB.  

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10.0 STATISTICAL CONSIDERATIONS 
10.1 
Study Design/Study Endpoints 
Our statistical design is based on a primary endpoint of the change in T cell 
immune gene signature with treatment. Based on studies in our lab that analyzed 
changes in immune gene signature expression with chemotherapy in pre-treatment 
TURBT and post-treatment surgery specimens, we hypothesize a change in Z-
score of the T cell immune gene signature of approximately 0.5 with 
pembrolizumab alone with a standard deviation of 0.49, and a similar change with 
the addition of entinostat compared to pembrolizumab alone. 
10.2 
Sample Size, Accrual and Duration of Accrual 
We will accrue 10 subjects in each of the two study arms to detect a difference in 
change in expression using a two group t-test with 80% power and a one-sided 
alpha of 10% (will accrue N=20 total, 10 subjects in each arm).  The hypothesized 
mean change is 0.5 in the pembrolizumab alone arm and 1.0 in the entinostat 
+pembrolizumab arm, and we assume a 0.49 common standard deviation.   
 
After 5 subjects that undergo subsequent trimodality therapy are accrued to the 
study, the number of post-treatment surgery samples that were collected will be 
reviewed by the study team to ensure that adequate tumor sampling has occurred 
in this subset of subjectss. It will then be decided to continue the study allowing 
the inclusion of trimodality subjects (if post-treatment surgical sample collection 
was adequate) or restrict further accrual to cystectomy subjects only. 
 
Accrual will take place over two years.  
10.3 
Data Analysis Plans 
The change in T cell gene signature expression will be calculated for each group 
(pembrolizumab + entinostat compared to pembrolizumab alone) and compared 
between groups using a two group t-test.  Similar analyses will be done for all 
gene signatures.  
  
Appropriate descriptive statistics, including median, interquartile range, means, 
and 95% confidence intervals, will be calculated and reported for all lab values. 
 
The analysis of the toxicity and safety will be based on the frequency of adverse 
events and their severity. Worst toxicity grades per subject will be tabulated for 
adverse events and laboratory measurements by using the National Cancer 
Institute- Common Terminology Criteria for Adverse Events (NCI-CTCAE 
version 5.0) and will be reported in the form of frequency tables. If 2 subjects 
have their surgical resection delayed beyond the 10 weeks from the time of 
initiation of study therapy due to protocol treatment-related adverse events, 
further enrollment to the study will be halted. Based on the nature and severity of 

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the toxicities observed, consideration will be made to amend the study (if risk of 
toxicity is felt to be mitigated by protocol amendment) vs terminating the study. If 
4 or more patients are delayed due to protocol treatment-related adverse events, 
then the study will be terminated. 
 
For subjects that undergo cystectomy, the proportion of patients who have a 
pathologic response to <pT2 will be reported along with a 95% confidence 
interval. Similarly, the proportion of patients who have a clinical complete 
response (cT0) will be reported separately for those undergoing cystectomy and 
trimodality therapy. Patients who progress prior to surgery (unlikely) or do not 
have surgery will still be included in this estimate and will be considered to have 
not been downstaged. The Kaplan Meier method will be used to estimate median 
times, along with 95% confidence intervals, for the secondary objectives of EFS 
and OS, as defined in Section 3.2.6 and 3.2.7.  
 
Results gathered on these subjects will be highly valuable in providing 
information that can be used to inform power and sample size considerations for 
future investigations. 

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11.0 STUDY MANAGEMENT 
11.1 
Institutional Review Board (IRB) Approval and Consent 
It is expected that the IRB will have the proper representation and function in 
accordance with federally mandated regulations.  The IRB should approve the 
consent form and protocol. 
 
In obtaining and documenting informed consent, the investigator should comply 
with the applicable regulatory requirements and should adhere to Good Clinical 
Practice (GCP) and to ethical principles that have their origin in the Declaration 
of Helsinki. 
 
 
 
Before recruitment and enrollment onto this study, the subject will be given a full 
explanation of the study and will be given the opportunity to review the consent 
form. Each consent form must include all the relevant elements currently required 
by the FDA Regulations and local or state regulations. Once this essential 
information has been provided to the subject and the investigator is assured that 
the subject understands the implications of participating in the study, the subject 
will be asked to give consent to participate in the study by signing an 
IRB-approved consent form. 
 
Prior to a subject’s participation in the trial, the written informed consent form 
should be signed and personally dated by the subject and by the person who 
conducted the informed consent discussion. 
11.2 
Required Documentation 
Before the study can be initiated at any site, the following documentation must be 
provided to the Clinical Protocol Office (CPO) at the University of North 
Carolina. 
• A copy of the official IRB approval letter for the protocol and 
informed consent 
• IRB membership list or Federalwide Assurance (FWA) number 
• CVs and medical licensure for the principal investigator and any sub-
investigators who will be involved in the study. 
• Form FDA 1572 appropriately filled out and signed with appropriate 
documentation 
• Financial Disclosures 
• CAP and CLIA Laboratory certification numbers and institution lab 
normal values 
• Executed clinical research contract 
 

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PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
63 
11.3 
Registration Procedures 
All study subjects must be registered with the LCCC CPO Multicenter Office at the 
University of North Carolina. Affiliate site staff must email copy of informed 
consent documentation and completed New Subject Patient Registration Form to 
the assigned UNC Multicenter Project Manager (contact e-mail provided at SIM) 
and to CPOMulticenter@med.unc.edu (M-F 8:30AM – 5:00PM EST) or call 919-
966-7359 to alert the UNC LCCC Multicenter Office of a  potential patient. Upon 
verification of the Informed Consent documentation by the assigned Project 
Manager, a unique subject sequence number will be provided to the site study 
staff.  Affiliate site staff must submit complete eligibility packets (institutionally-
signed eligibility checklist and full source documentation confirming eligibility) 
via email 
to 
the 
assigned 
UNC 
Multicenter 
Project 
Manager 
and 
CPOMulticenter@med.unc.edu to begin review. All subjects must have final 
eligibility verified by the UNC Multicenter Project Manager on behalf of the UNC 
PI prior to starting treatment. Please allow a minimum of 24 hours for source to be 
reviewed and notification of subject eligibility released. A patient registration email 
will be sent to the site’s study staff to officially confirm registration of the patient 
‘On-Study’. All subjects must maintain eligibility from the time of this notification 
through the beginning of treatment. 
11.4 
Data Management and Monitoring/Auditing 
The CPO Multicenter Office of the UNC LCCC will serve as the coordinating 
center for this trial. Data will be collected through a web based electronic data 
capture system Advarra EDC. Other study institutions will be given a password to 
directly enter their own data onto the web site via electronic case report forms 
(eCRFs).  Multicenter personnel will coordinate and manage data for quality 
control assurance and integrity. 
 
All data will be collected and entered into Advara EDC by the multicenter study 
teams at participating institutions.  The investigators at each site will allow monitors 
to review all source documents supporting data entered into Advarra EDC. The 
Multicenter Clinical Data Management Associate can be reached at 
LCCC OnCore@med.unc.edu. 
 
All data will be monitored and source data will be verified on selected 
subjects. Queries will be issued on an ongoing basis on all subjects. Participating 
sites should respond to data queries within 14 days of receipt. The LCCC 
compliance committee or their designee will audit trial sites every twelve months 
while still enrolling or subjects are still on treatment. Participating sites must send 
source and regulatory documents to LCCC upon request, for remote monitoring 
and/or audit review. 
 

LCCC 1827 
 
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PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
64 
11.5 
Adherence to the Protocol 
Except for an emergency situation in which proper care for the protection, safety, 
and well-being of the study subject requires alternative treatment, the study shall 
be conducted exactly as described in the approved protocol.   
11.5.1 Emergency Modifications 
UNC and multicenter investigators may implement a deviation from, or a change 
of, the protocol to eliminate an immediate hazard(s) to trial subjects without prior 
UNC or their respective institution’s IRB/IEC approval/favorable opinion. 
 
For any such emergency modification implemented, a UNC IRB modification 
form must be completed by UNC Research Personnel within five (5) business 
days of making the change. 
 
For Institutions Relying on UNC’s IRB: 
For any such emergency modification implemented, a UNC IRB modification form 
must be completed by UNC Research Personnel within five (5) business days of 
making the change.   
 
For Institutions Relying on Their Own IRB: 
For multicenter investigators relying on their own institution’s IRB, as soon as 
possible after the modification has been made, the implemented deviation or 
change and the reasons for it should be submitted to: 
11.5.2 Single Subject Exceptions 
Eligibility single subject exceptions are not permitted for Lineberger 
Comprehensive Cancer Center Investigator Initiated Trials under any 
circumstances. Other types of single subject exceptions may be allowed if proper 
regulatory review has been completed in accordance with Lineberger 
Comprehensive Cancer Center’s Single Subject Exceptions Policy. 
11.5.3 Other Protocol Deviations/Violations 
According to UNC’s IRB, a protocol deviation is any unplanned variance from an 
IRB approved protocol that:  
• Is generally noted or recognized after it occurs 
• Has no substantive effect on the risks to research subjects 
• Has no substantive effect on the scientific integrity of the research plan 
or the value of the data collected  
• Did not result from willful or knowing misconduct on the part of the 
investigator(s).  
 
An unplanned protocol variance is considered a violation if the variance meets 
any of the following criteria:  
• Has harmed or increased the risk of harm to one or more research 
participants. 

LCCC 1827 
 
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PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
65 
• Has damaged the scientific integrity of the data collected for the study. 
• Results from willful or knowing misconduct on the part of the 
investigator(s). 
• Demonstrates serious or continuing noncompliance with federal 
regulations, State laws, or University policies. 
 
If a deviation or violation occurs, please follow the guidelines below: 
 
Protocol Deviations: UNC or multicenter site personnel will record the deviation 
in OnCore®, and report to any sponsor or data and safety monitoring committee in 
accordance with their policies.  Deviations should be summarized and reported to 
the IRB at the time of continuing review. 
 
Protocol Violations: Any protocol violation that occurs must be reported to your 
IRB per institutional policies and reported to the UNC Multicenter Project Manager 
within 5 days. UNC-CH will determine if the violation affects the safety of the 
subject and integrity of the data.  Once your institution’s IRB response is received, 
please forward to the Multicenter Regulatory Associate. 
 
Unanticipated Problems: 
Any events that meet the criteria for “Unanticipated Problems” as defined by 
UNC’s IRB must be reported by the study personnel using the IRB’s web-based 
reporting system.   
 
Multicenter Sites: 
Any events that meet the criteria for “Unanticipated Problems (UPs)” as defined by 
UNC’s IRB must also be reported to the UNC Multicenter Project Manager. The 
Multicenter Regulatory Associate will report the event to the UNC IRB using the 
IRB’s web-based reporting system.  Examples of such UPs include a lost or stolen 
laptop computer that contains sensitive study information. 
11.6 
Amendments to the Protocol 
Should amendments to the protocol be required, the amendments will be 
originated and documented by the Principal Investigator at UNC. It should also be 
noted that when an amendment to the protocol substantially alters the study 
design or the potential risk to the subject, a revised consent form might be 
required.   
 
For Institutions Relying on UNC’s IRB: 
The written amendment, and if required the amended consent form, must be sent to 
UNC’s IRB for approval prior to implementation.   
 
For Institutions Relying on Their Own IRB: 
Investigators must submit the amendment to their institution’s IRB for approval.  
For multi-center studies, any multicenter site must submit their informed consent 

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
66 
revisions to the Multicenter Regulatory Associate for review and approval prior to 
submission to their IRB.   
 
11.7 
Record Retention 
Study documentation includes all eCRFs, data correction forms or queries, source 
documents, Sponsor correspondence to Investigators, monitoring logs/letters, and 
regulatory documents (e.g., protocol and amendments, IRB correspondence and 
approval, signed subject consent forms). 
 
Source documents include all recordings of observations or notations of clinical 
activities and all reports and records necessary for the evaluation and 
reconstruction of the clinical research study. 
 
Government agency regulations and directives require that all study 
documentation pertaining to the conduct of a clinical trial must be retained by the 
study investigator. Study documents should be kept on file until three years after 
the completion and final study report of this investigational study. 
11.8 
Obligations of Investigators 
The Principal Investigator is responsible for the conduct of the clinical trial at the 
site in accordance with Title 21 of the Code of Federal Regulations and/or the 
Declaration of Helsinki.  The Principal Investigator is responsible for personally 
overseeing the treatment of all study subjects.  The Principal Investigator must 
assure that all study site personnel, including sub-investigators and other study 
staff members, adhere to the study protocol and all FDA/GCP/NCI regulations 
and guidelines regarding clinical trials both during and after study completion. 
 
The Principal Investigator will be responsible for assuring that all the required 
data will be collected and entered into the eCRFs. Periodically, auditing and 
monitoring of trials will be conducted, and the Principal Investigator will provide 
access to his/her original records to permit verification of proper entry of data. At 
the completion of the study, all eCRFs will be reviewed by the Principal 
Investigator and will require his/her final signature to verify the accuracy of the 
data. 
 

LCCC 1827 
 
CONFIDENTIAL 
PI: Tracy L. Rose, MD, MPH  
 
UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
67 
12.0 REFERENCES 
        
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Agarwala, S.S., et al., Efficacy and safety of entinostat (ENT) and pembrolizumab 
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18. 
Deschoolmeester, V., et al., Tumor infiltrating lymphocytes: an intriguing player 
in the survival of colorectal cancer patients. BMC Immunol, 2010. 11: p. 19. 
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Kloor, M., Lymphocyte infiltration and prognosis in colorectal cancer. Lancet 
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Enhances T Cell Activation and Cytokine Production. The Journal of 
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autoimmunity. Immunol Rev, 2010. 236: p. 219-42. 
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Thompson, R.H., et al., PD-1 is expressed by tumor-infiltrating immune cells and 
is associated with poor outcome for patients with renal cell carcinoma. Clin 
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Maude, S.L., et al., Chimeric antigen receptor T cells for sustained remissions in 
leukemia. N Engl J Med, 2014. 371(16): p. 1507-17. 
28. 
Kandoth, C., et al., Mutational landscape and significance across 12 major 
cancer types. Nature, 2013. 502: p. 333. 
29. 
Herbst, R.S., et al., A study of MPDL3280A, an engineered PD-L1 antibody in 
patients with locally advanced or metastatic tumors. Journal of Clinical 
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Powles, T., et al., MPDL3280A (anti-PD-L1) treatment leads to clinical activity in 
metastatic bladder cancer. Nature, 2014. 515(7528): p. 558-62. 
31. 
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advanced or metastatic urothelial cancer (KEYNOTE-012): a non-randomised, 
open-label, phase 1b study. Lancet Oncol, 2017. 18(2): p. 212-220. 
32. 
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metastatic urothelial carcinoma who have progressed following treatment with 
platinum-based chemotherapy: a single-arm, multicentre, phase 2 trial. Lancet, 
2016. 387(10031): p. 1909-20. 
33. 
Tahara, M., et al., Pembrolizumab in Asia-Pacific patients with advanced head 
and neck squamous cell carcinoma: Analyses from KEYNOTE-012. Cancer Sci, 
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34. 
Bellmunt, J., et al., Pembrolizumab as Second-Line Therapy for Advanced 
Urothelial Carcinoma. N Engl J Med, 2017. 376(11): p. 1015-1026. 
35. 
Sharma, P., et al., Nivolumab in metastatic urothelial carcinoma after platinum 
therapy (CheckMate 275): a multicentre, single-arm, phase 2 trial. Lancet Oncol, 
2017. 18(3): p. 312-322. 

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UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
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36. 
Massard, C., et al., Safety and Efficacy of Durvalumab (MEDI4736), an Anti-
Programmed Cell Death Ligand-1 Immune Checkpoint Inhibitor, in Patients With 
Advanced Urothelial Bladder Cancer. J Clin Oncol, 2016. 34(26): p. 3119-25. 
37. 
Powles, T., et al., A phase II study investigating the safety and efficacy of 
neoadjuvant atezolizumab in muscle invasive bladder cancer (ABACUS). Journal 
of Clinical Oncology, 2018. 36(15_suppl): p. 4506-4506. 
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Necchi, A., et al., Pembrolizumab as Neoadjuvant Therapy Before Radical 
Cystectomy in Patients With Muscle-Invasive Urothelial Bladder Carcinoma 
(PURE-01): An Open-Label, Single-Arm, Phase II Study. Journal of Clinical 
Oncology, 2018. 36(34): p. 3353-3360. 
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associated with promoter hypermethylation and loss of acetylation on histone 3. 
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define breast cancer subtypes. Oncotarget, 2016. 7(5): p. 5094-109. 
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42(1-3): p. 160-5. 
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Mazzone, R., et al., Epi-drugs in combination with immunotherapy: a new avenue 
to improve anticancer efficacy. Clin Epigenetics, 2017. 9: p. 59. 
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immunomodulators in cancer therapeutics. Epigenomics, 2016. 8(3): p. 415-28. 
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Lisiero, D.N., et al., The histone deacetylase inhibitor, LBH589, promotes the 
systemic cytokine and effector responses of adoptively transferred CD8+ T cells. 
J Immunother Cancer, 2014. 2: p. 8. 
51. 
Roger, T., et al., Histone deacetylase inhibitors impair innate immune responses 
to Toll-like receptor agonists and to infection. Blood, 2011. 117(4): p. 1205-17. 
52. 
Shen, L., et al., Class I histone deacetylase inhibitor entinostat suppresses 
regulatory T cells and enhances immunotherapies in renal and prostate cancer 
models. PLoS One, 2012. 7(1): p. e30815. 
53. 
Kim, K., et al., Eradication of metastatic mouse cancers resistant to immune 
checkpoint blockade by suppression of myeloid-derived cells. Proc Natl Acad Sci 
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54. 
Ellinger, J., et al., Evaluation of Global Histone Acetylation Levels in Bladder 
Cancer Patients. Anticancer Res, 2016. 36(8): p. 3961-4. 

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55. 
Poyet, C., et al., Expression of histone deacetylases 1, 2 and 3 in urothelial 
bladder cancer. BMC Clin Pathol, 2014. 14(1): p. 10. 
56. 
Dunn, J. and S. Rao, Epigenetics and immunotherapy: The current state of play. 
Molecular Immunology, 2017. 87: p. 227-239. 
57. 
Zheng, H., et al., HDAC Inhibitors Enhance T-Cell Chemokine Expression and 
Augment Response to PD-1 Immunotherapy in Lung Adenocarcinoma. Clin 
Cancer Res, 2016. 22(16): p. 4119-32. 
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correlate with cellular histone acetylation but not transcription and cell viability. 
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Glaser, K.B., et al., Gene expression profiling of multiple histone deacetylase 
(HDAC) inhibitors: defining a common gene set produced by HDAC inhibition in 
T24 and MDA carcinoma cell lines. Mol Cancer Ther, 2003. 2(2): p. 151-63. 
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Belinsky, S.A., et al., Combination therapy with vidaza and entinostat suppresses 
tumor growth and reprograms the epigenome in an orthotopic lung cancer model. 
Cancer Res, 2011. 71(2): p. 454-62. 
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Sabnis, G.J., et al., HDAC inhibitor entinostat restores responsiveness of 
letrozole-resistant MCF-7Ca xenografts to aromatase inhibitors through 
modulation of Her-2. Mol Cancer Ther, 2013. 12(12): p. 2804-16. 
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Bridle, B.W., et al., HDAC inhibition suppresses primary immune responses, 
enhances secondary immune responses, and abrogates autoimmunity during 
tumor immunotherapy. Mol Ther, 2013. 21(4): p. 887-94. 
63. 
Tomita, Y., et al., The interplay of epigenetic therapy and immunity in locally 
recurrent or metastatic estrogen receptor-positive breast cancer: Correlative 
analysis of ENCORE 301, a randomized, placebo-controlled phase II trial of 
exemestane with or without entinostat. Oncoimmunology, 2016. 5(11): p. 
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Pili, R., et al., Immunomodulation by Entinostat in Renal Cell Carcinoma Patients 
Receiving High-Dose Interleukin 2: A Multicenter, Single-Arm, Phase I/II Trial 
(NCI-CTEP#7870). Clin Cancer Res, 2017. 23(23): p. 7199-7208. 
65. 
Syndax Pharmaceuticals, I., Entinostat Investigator's Brochure. Version 18 ed. 
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Brahmer, J.R., C. Lacchetti, and J.A. Thompson, Management of Immune-Related 
Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: 
American Society of Clinical Oncology Clinical Practice Guideline Summary. J 
Oncol Pract, 2018. 14(4): p. 247-249. 

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UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
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71 
13.0 APPENDICES 
13.1 
Appendix A. ECOG Performance Status 
 
Grade 
Description 
0 
Normal activity. Fully active, able to carry on all pre-disease 
performance without restriction. 
1 
Symptoms, but ambulatory. Restricted in physically strenuous 
activity, but ambulatory and able to carry out work of a light or 
sedentary nature (e.g., light housework, office work). 
2 
In bed <50% of the time. Capable of only limited self-care, 
confined to bed or chair more than 50% of waking hours. 
3 
In bed >50% of the time. Capable of only limited self-care, 
confined to bed or chair more than 50% of waking hours. 
4 
100% bedridden. Completely disabled. Cannot carry on any self-
care. Totally confined to bed or chair. 
5 
Dead. 
* As published in Am. J. Clin. Oncol.: Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., 
Davis, T.E., McFadden, E.T., Carbone, P.P. Toxicity and Response Criteria of the Eastern 
Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982. The Eastern Cooperative 
Oncology Group, Robert Comis M.D., Group Chair. 
 

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UNIVERSITY OF NORTH CAROLINA 
Amendment 6 
 
 
January 9, 2025 
 
72 
13.2 
Appendix B: Concomitant Medications to Avoid (For Subjects in Arm 2 
Only) 
 
Examples of sensitive in vivo CYP substrates and CYP substrates with narrow 
therapeutic range are summarized below.  
  
Examples of substrates that may be affected by entinostat 
CYP 
Enzymes  
 
Substrates with narrow therapeutic range1 
CYP1A2  
Theophylline, tizanidine  
CYP2C8 
Paclitaxel 
CYP3A2  
Alfentanil, astemizole3, cisapride3, cyclosporine, 
dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, 
sirolimus, tacrolimus, terfenadine3  
 
1   CYP substrates with narrow therapeutic range refers to drugs whose exposure-response 
relationship indicates that small increases in their exposure levels by the concomitant use of CYP 
inhibitors may lead to serious safety concerns (e.g., Torsades de Pointes). 
2   Because a number of CYP3A substrates (e.g., darunavir, maraviroc) are also substrates of P-gp, 
the observed increase in exposure could be due to inhibition of both CYP3A and P-gp. 
3    Withdrawn from the United States market because of safety reasons. 
 
P-gp Inhibitors and Inducers 
 
Inhibitors 
Inducers 
Amiodarone, azithromycin, captopril, 
carvedilol, clarithromycin, conivaptan, 
diltiazem, dronedarone, felodipine, 
lopinavir,quercetin, ranolazine,ticagrelor,  
ritonavir, cyclosporine, verapamil, 
erythromycin, ketoconazole, itraconazole, 
quinidine  
Avasimibe, carbamazepine, 
phenytoin, rifampin, St John’s 
Wort, tipranavir/ritonavir  
 
 
 
 

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13.3 
Appendix C: The CKD-EPI Creatinine Equation 
The CKD-EPI creatinine equation is based on the same four variables as the 
MDRD Study equation but uses a 2-slope spline to model the relationship 
between estimated GFR and serum creatinine, and a different relationship for age, 
sex and race. The equation was reported to perform better and with less bias than 
the MDRD Study equation, especially in patients with higher GFR. This results in 
reduced misclassification of CKD. As of November 2009, very few clinical 
laboratories report the estimated GFR using the CKD-EPI creatinine equation. In 
the future, other GFR estimating equations may outperform CKD-EPI.  
The CKD-EPI creatinine equation is:  
GFR = 141 x min(Scr/κ, 1)α x max(Scr/κ, 1)-1.209 0.993Age x 1.018 [if female] x 1.159 [if black] 
κ = 0.7 if female 
κ = 0.9 if male 
α = -0.329 if female 
α = -0.411 if male 
min = the minimum of Scr/κ or 1 
min = the maximum of Scr/κ or 1 
Scr = serum creatinine (mg/dL) 
 
 
 
 
 
 
 
 
Ref: Levey AS, Stevens LA, et al. A New Equation to Estimate Glomerular Filtration Rate. Ann Intern Med. 2009; 150:604-612.  

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13.4 
Appendix D: Acceptable Contraceptive Methods 
● Male or female condom with or without spermicide 
● Cervical cap, diaphragm or sponge with spermicide 
Highly Effective Contraceptive Methods That Are User Dependent a  
Failure rate of <1% per year when used consistently and correctly. 
● Combined (estrogen- and progesterone-containing) hormonal contraception b 
○ Oral  
○ Intravaginal  
○ Transdermal  
○ Injectable 
● Progestogen-only hormonal contraception b 
○ Oral  
○ Injectable  
Highly Effective Methods That Have Low User Dependency  
Failure rate of <1% per year when used consistently and correctly. 
● Progesterone-only contraceptive implant b, c  
● Intrauterine hormone-releasing system (IUS) b  
● Intrauterine device (IUD) 
● Bilateral tubal occlusion 
● Vasectomized partner  
A vasectomized partner is a highly effective contraception method provided that the partner is 
the sole male sexual partner of the WOCBP and the absence of sperm has been confirmed. If 
not, an additional highly effective method of contraception should be used.  
● Sexual abstinence  
Sexual abstinence is considered a highly effective method only if defined as refraining from 
heterosexual intercourse during the entire period of risk associated with the study treatment. 
The reliability of sexual abstinence needs to be evaluated in relation to the duration of the 
study and the preferred and usual lifestyle of the participant.)  
Notes:  
Use should be consistent with local regulations regarding the use of contraceptive methods for 
participants of clinical studies. 
a) Typical use failure rates are lower than perfect-use failure rates (i.e., when used consistently 
and correctly).  
b) If hormonal contraception efficacy is potentially decreased due to interaction with study 
treatment, condoms must be used in addition to the hormonal contraception during the 
treatment period and for at least 120 days, (corresponding to time needed to eliminate study 
treatment plus 30 days for study treatments with genotoxic potential) after the last dose of 
entinostat. 
c) If locally required, in accordance with Clinical Trial Facilitation Group (CTFG) guidelines, 
acceptable hormonal contraceptives are limited to those which inhibit ovulation.  
 

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13.5 
Appendix E: Suggested Chemotherapy Regimens to be Given Concurrently 
with Radiation in the Trimodality Patients 
 
Chemotherapy Regimens 
Cisplatin 70mg/m2 IV every 3 weeks 
Cisplatin 30-35mg/m2 IV weekly 
Fluorouracil 500mg/m2 IV during doses 1-5 and 16-20 of radiation therapy 
Mitomycin 12mg/m2 IV on day 1 
Gemcitabine 27 mg/m2 IV twice weekly 
 
 
 

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13.6 
Appendix F: Merck Reporting: Adverse Events: Definitions and Procedures 
for Recording, Evaluating, Follow-up, and Reporting 
13.6.1 Definition of AE 
 
AE definition 
• An AE is any untoward medical occurrence in a clinical study participant, 
temporally associated with the use of study intervention, whether or not 
considered related to the study intervention. 
• NOTE: An AE can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease (new or 
exacerbated) temporally associated with the use of a study intervention. 
• NOTE: For purposes of AE definition, study intervention (also referred to as 
Merck product) includes any pharmaceutical product, biological product, 
vaccine, diagnostic agent, or protocol specified procedure whether 
investigational or marketed (including placebo, active comparator product, or 
run-in intervention), manufactured by, licensed by, provided by, or distributed 
by Merck for human use in this study. 
 
Events meeting the AE definition 
• Any abnormal laboratory test results (hematology, clinical chemistry, or 
urinalysis) or other safety assessments (eg, ECG, radiological scans, vital 
signs measurements), including those that worsen from baseline, considered 
clinically significant in the medical and scientific judgment of the 
investigator. 
• Exacerbation of a chronic or intermittent pre-existing condition including 
either an increase in frequency and/or intensity of the condition. 
• New conditions detected or diagnosed after study intervention administration 
even though it may have been present before the start of the study. 
• Signs, symptoms, or the clinical sequelae of a suspected drug-drug interaction. 
• Signs, symptoms, or the clinical sequelae of a suspected overdose of either 
study intervention or a concomitant medication. 
• For all reports of overdose (whether accidental or intentional) with an 
associated AE, the AE term should reflect the clinical symptoms or abnormal 
test result. An overdose without any associated clinical symptoms or abnormal 
laboratory results is reported using the terminology “accidental or intentional 
overdose without adverse effect.” 
      
Events NOT meeting the AE definition 
• Medical or surgical procedure (eg, endoscopy, appendectomy): the condition 
that leads to the procedure is the AE. 
• Situations in which an untoward medical occurrence did not occur (social 
and/or convenience admission to a hospital). 
• Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) 
present or detected at the start of the study that do not worsen. 

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• Surgery planned prior to informed consent to treat a pre-existing condition 
that has not worsened. 
13.6.2 Definition of SAE 
If an event is not an AE per definition above, then it cannot be an SAE even if 
serious conditions are met. 
 
An SAE is defined as any untoward medical occurrence that, at any dose: 
 
a. Results in death 
 
b. Is life-threatening 
• The term “life-threatening” in the definition of “serious” refers to an event 
in which the participant was at risk of death at the time of the event. It 
does not refer to an event, which hypothetically might have caused death, 
if it were more severe. 
 
c. Requires inpatient hospitalization or prolongation of existing 
hospitalization 
• Hospitalization is defined as an inpatient admission, regardless of length 
of stay, even if the hospitalization is a precautionary measure for 
continued observation. (Note: Hospitalization for an elective procedure to 
treat a pre-existing condition that has not worsened is not an SAE. A pre-
existing condition is a clinical condition that is diagnosed prior to the use 
of a Merck product and is documented in the participant’s medical history. 
 
d. Results in persistent or significant disability/incapacity 
• The term disability means a substantial disruption of a person’s ability to 
conduct normal life functions. 
• This definition is not intended to include experiences of relatively minor 
medical significance such as uncomplicated headache, nausea, vomiting, 
diarrhea, influenza, and accidental trauma (eg, sprained ankle) that may 
interfere with or prevent everyday life functions but do not constitute a 
substantial disruption. 
 
e. Is a congenital anomaly/birth defect 
• In offspring of participant taking the product regardless of time to 
diagnosis. 
 
f. Other important medical events 
• Medical or scientific judgment should be exercised in deciding whether 
SAE reporting is appropriate in other situations such as important medical 
events that may not be immediately life-threatening or result in death or 
hospitalization but may jeopardize the participant or may require medical 

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or surgical intervention to prevent 1 of the other outcomes listed in the 
above definition. These events should usually be considered serious. 
• Examples of such events include invasive or malignant cancers, intensive 
treatment in an emergency room or at home for allergic bronchospasm, 
blood dyscrasias or convulsions that do not result in hospitalization, or 
development of drug dependency or drug abuse. 
13.6.3 Additional Events Reported in the Same Manner as SAE 
Additional events that require reporting in the same manner as SAE 
 
In addition to the above criteria, AEs meeting either of the below criteria, 
although not serious per ICH definition, are reportable to Merck in the same time 
frame as SAEs to meet certain local requirements. Therefore, these events are 
considered serious by Merck for collection purposes. 
 
• Is a new cancer (that is not a condition of the study) 
• Is associated with an overdose of pembrolizumab 
13.6.4 Recording AE and SAE 
 
AE and SAE recording 
• When an AE/SAE occurs, it is the responsibility of the investigator to review 
all documentation (eg, hospital progress notes, laboratory, and diagnostics 
reports) related to the event. 
• The investigator will record all relevant AE/SAE information on the AE 
CRFs/worksheets at each examination. 
• There may be instances when copies of medical records for certain cases are 
requested by the Merck. In this case, all participant identifiers, with the 
exception of the participant number, will be blinded on the copies of the 
medical records before submission to the Merck. 
• The investigator will attempt to establish a diagnosis of the event based on 
signs, symptoms, and/or other clinical information. In such cases, the 
diagnosis (not the individual signs/symptoms) will be documented as the 
AE/SAE. 
 
Assessment of intensity/toxicity 
• An event is defined as “serious” when it meets at least 1 of the predefined 
outcomes as described in the definition of an SAE, not when it is rated as 
severe. 
1. The investigator will make an assessment of intensity for each AE and 
SAE (and other reportable safety event) according to the NCI Common 
Terminology for Adverse Events (CTCAE), version 5. Any AE that 
changes CTCAE grade over the course of a given episode will have each 
change of grade recorded on the AE CRFs/worksheets. 

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• Grade 1: Mild; asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated. 
• Grade 2: Moderate; minimal, local or noninvasive intervention 
indicated; limiting age-appropriate instrumental activities of daily 
living (ADL). 
• Grade 3: Severe or medically significant but not immediately life-
threatening; hospitalization or prolongation of hospitalization 
indicated; disabling; limiting self-care ADL. 
• Grade 4: Life threatening consequences; urgent intervention indicated. 
• Grade 5: Death related to AE. 
 
Assessment of causality 
1. Did Merck product cause the AE? 
2. The determination of the likelihood that Merck product caused the AE will be 
provided by an investigator who is a qualified physician. The investigator’s 
signed/dated initials on the source document or worksheet that supports the 
causality noted on the AE form, ensures that a medically qualified assessment of 
causality was done. This initialed document must be retained for the required 
regulatory time frame. The criteria below are intended as reference guidelines to 
assist the investigator in assessing the likelihood of a relationship between the test 
product and the AE based upon the available information. 
3. The following components are to be used to assess the relationship between 
Merck’s product and the AE; the greater the correlation with the components and 
their respective elements (in number and/or intensity), the more likely Merck 
product caused the AE: 
• Exposure: Is there evidence that the participant was actually exposed to 
Merck product such as: reliable history, acceptable compliance assessment 
(pill count, diary, etc.), expected pharmacologic effect, or measurement of 
drug/metabolite in bodily specimen? 
• Time Course: Did the AE follow in a reasonable temporal sequence from 
administration of Merck product? Is the time of onset of the AE compatible 
with a drug-induced effect (applies to studies with investigational medicinal 
product)? 
• Likely Cause: Is the AE not reasonably explained by another etiology such as 
underlying disease, other drug(s)/vaccine(s), or other host or environmental 
factors. 
• Dechallenge: Was Merck product discontinued or dose/exposure/frequency 
reduced? 
• If yes, did the AE resolve or improve? 
• If yes, this is a positive dechallenge. 
• If no, this is a negative dechallenge. 
• (Note: This criterion is not applicable if: (1) the AE resulted in death or 
permanent disability; (2) the AE resolved/improved despite continuation of 
the Merck product; (3) the study is a single-dose drug study; or (4) Merck 
product(s) is/are only used 1 time.) 

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• Rechallenge: Was the participant re-exposed to Merck product in this study? 
• If yes, did the AE recur or worsen? 
• If yes, this is a positive rechallenge. 
• If no, this is a negative rechallenge. 
(Note: This criterion is not applicable if: (1) the initial AE resulted in death or 
permanent disability, or (2) the study is a single-dose drug study; or (3) Merck 
product(s) is/are used only 1 time.) 
 
NOTE: IF A RECHALLENGE IS PLANNED FOR AN AE THAT WAS SERIOUS 
AND MAY HAVE BEEN CAUSED BY MERCK PRODUCT, OR IF RE-
EXPOSURE TO MERCK’S PRODUCT POSES ADDITIONAL POTENTIAL 
SIGNIFICANT RISK TO THE PARTICIPANT THEN THE RECHALLENGE 
MUST BE APPROVED IN ADVANCE BY THE SPONSOR AS PER DOSE 
MODIFICATION GUIDELINES IN THE PROTOCOL, AND IF REQUIRED, THE 
INIRB/IEC. 
 
4. Consistency with study intervention profile: Is the clinical/pathological 
presentation of the AE consistent with previous knowledge regarding Merck 
product or drug class pharmacology or toxicology? 
5. The assessment of relationship will be reported on the case report 
forms/worksheets by an investigator who is a qualified physician according to 
his/her best clinical judgment, including consideration of the above elements. 
6. Use the following scale of criteria as guidance (not all criteria must be present to 
be indicative of Merck product relationship). 
• Yes, there is a reasonable possibility of Merck product relationship: 
• There is evidence of exposure to the Merck product. The temporal sequence 
of the AE onset relative to the administration of Merck product is reasonable. 
The AE is more likely explained by Merck product than by another cause. 
• No, there is not a reasonable possibility of Merck product relationship: 
• Participant did not receive the Merck product OR temporal sequence of the 
AE onset relative to administration of the Merck product is not reasonable OR 
the AE is more likely explained by another cause than the Merck product. 
(Also entered for a participant with overdose without an associated AE.) 
7. For each AE/SAE, the investigator must document in the medical notes that 
he/she has reviewed the AE/SAE and has provided an assessment of causality. 
8. There may be situations in which an SAE has occurred and the investigator has 
minimal information to include in the initial report to the Merck. However, it is 
very important that the investigator always make an assessment of causality for 
every event before the initial transmission of the SAE data to Merck. 
9. The investigator may change his/her opinion of causality in light of follow-up 
information and send an SAE follow-up report with the updated causality 
assessment. 
10. The causality assessment is 1 of the criteria used when determining regulatory 
reporting requirements. 

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11. For studies in which multiple agents are administered as part of a combination 
regimen, the investigator may attribute each AE causality to the combination 
regimen or to a single agent of the combination. In general, causality attribution 
should be assigned to the combination regimen (ie, to all agents in the regimen). 
However, causality attribution may be assigned to a single agent if in the 
investigator’s opinion, there is sufficient data to support full attribution of the AE 
to the single agent. 
 
Follow-up of AE and SAE 
• The investigator is obligated to perform or arrange for the conduct of 
supplemental measurements and/or evaluations as medically indicated to elucidate 
the nature and/or causality of the AE or SAE as fully as possible. This may 
include additional laboratory tests or investigations, histopathological 
examinations, or consultation with other health care professionals.  
• New or updated information will be recorded in the CRF.  
• The investigator will submit any updated SAE data to Merck within 2 business 
days but no longer than 3 calendar days of receipt of the information. 
13.6.5 Reporting of AEs, SAEs, and Other Reportable Safety Events to the Merck 
 
SAE reports and any other relevant safety information are to be forwarded to the 
Merck Global Safety facsimile number:  +1-215-661-6229 
 
A copy of all 15 Day Reports and Annual Progress Reports is submitted as required by 
FDA, European Union (EU), Pharmaceutical and Medical Devices agency (PMDA) or 
other local regulators. Investigators will cross reference this submission according to 
local regulations to the Merck Investigational Compound Number (IND, CSA, etc.) at the 
time of submission.  Additionally, investigators will submit a copy of these reports to 
Merck & Co., Inc. (Attn: Worldwide Product Safety; FAX 215-661-6229) at the time of 
submission to FDA.