A Window of Opportunity Phase II Study of Pembrolizumab in Patients With Bladder Cancer Undergoing Radical Cystectomy
Phase: PHASE2
Conditions: Stage I Bladder Cancer AJCC v8, Stage II Bladder Cancer AJCC v8, Stage III Bladder Cancer AJCC v8, Stage IIIA Bladder Cancer AJCC v8, Stage IIIB Bladder Cancer AJCC v8
Sponsor: M.D. Anderson Cancer Center

2017-0057 
January 9, 2019 
Page 1 
A Window of Opportunity Phase II Study of Pembrolizumab in Patients with Bladder Cancer 
Undergoing Radical Cystectomy 
Principal Investigator: 
Dr. Neema Navai 
Assistant Professor 
Department of Urology 
UT M. D. Anderson Cancer Center 
1515 Holcombe Blvd. 
Unit 1373 
Houston, TX 77030 
nnavai@mdanderson.org 
Co-PI: 
Dr. Arlene Siefker-Radtke 
Associate Professor 
Department of Genitourinary Medical Oncology 
UT M. D. Anderson Cancer Center 
asiefker@mdanderson.org 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 2 
 
 
 
 
1.0 
 
Abbreviated Title 
A Window of Opportunity Study of Pembrolizumab in 
Patients with Bladder Cancer Undergoing Radical 
Cystectomy 
Trial Phase 
2 
Clinical Indication 
Window of Opportunity therapy in patients who undergo 
radical cystectomy without prior chemotherapy for both 
muscle invasive and non-muscle invasive bladder cancer 
Trial Type 
Safety and preliminary efficacy study 
Name of drug 
Pembrolizumab (Keytruda®) 
Route of administration 
IV 
Treatment dosage 
200 mg x 2 cycles 
Number of participants 
20 
Estimated enrollment 
period 
12 months 
Estimated duration of 
trial 
24 months 
Duration of Participation 
Up to 25 weeks 
 
2.1 TRIAL DESIGN 
 
2.2 
Trial Design 
 
This is an open-label window of opportunity Phase II safety and preliminary efficacy study in 
patients with urothelial carcinoma (either non-muscle invasive or muscle invasive) that are 
scheduled to undergo radical cystectomy without prior neoadjuvant systemic chemotherapy. 
MD Anderson employs a risk based approach to identify those patients who require 
neoadjuvant chemotherapy prior to radical cystectomy, however many patients fail to meet 
these preselected criteria (non-urothelial histology, palpable 3-dimensional mass, 
hydronephrosis, or lymphovascular invasion), are  medically ineligible, or refuse 
chemotherapy. Additionally, those patients who harbor high risk non-muscle invasive bladder 
cancer who fail prior BCG do not require neoadjuvant chemotherapy prior to cystectomy. For 
the purpose of this study, patients who fall into any of these categories will be eligible and 
treated with pembrolizumab during the routine waiting period (6-8 weeks) between 
diagnostic evaluation and radical cystectomy. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 3 
 
 
 
 
This study is divided into 3 phases; the Screening Phase, the Treatment Phase, and the Follow- 
up Phase (post-surgery). All patients who sign an informed consent will enter into the 
Screening Phase, where eligibility criteria will be reviewed and patients will undergo a series 
of screening procedures. Once all eligibility criteria have been met, the patient will move into 
the Treatment Phase, which will consist in two treatments of ‘window of opportunity’ 
pembrolizumab followed by cystectomy. In the Follow-up Phase (post-surgery), patients will 
have follow up visits 30 and 90 days after surgery. 
 
2.1.1 Dosing 
 
In the Treatment Phase, a standard 200 mg dose of pembrolizumab will be tested for safety 
and adverse events. The study cohort will consist of a total of 20 patients in a single arm who 
will receive 200 mg of pembrolizumab every 3 weeks for a total of two cycles at weeks 1 and 
4 by IV infusion. These patients will be followed for safety assessments 3 weeks after receipt 
of their second dose (week 7 ±3 days). The following stopping rules will apply on a rolling 
basis: if ≥ 3 patients experience a drug-related grade 4 adverse event including bowel 
perforation or any drug-related grade 3 skin or gastrointestinal adverse event without clinical 
improvement within 2 weeks of study drug discontinuation and/or initiation of corticosteroid 
therapy to treat the adverse event, no additional patients will be enrolled (see Section 5.3 for 
additional stopping rules that apply). Once patients have received a maximum of two doses, 
they will undergo surgery at or around week 8. An assessment of tumor response will not be 
made prior to radical cystectomy. 
 
2.1.2 Correlative Studies 
 
All participants will be required to participate in the collection of blood and tissue sample for 
banking and future research studies. Up to 60 mL of blood will be collected at each of the 
following time points: baseline or pre-treatment, after the first cycle of treatment, after the 
second cycle of treatment and post cystectomy. 
 
We will also collect archival tissue from a newly obtained core or excisional biopsy of a tumor 
lesion. Newly-obtained is defined as a specimen obtained up to 6 weeks (42 days) prior to 
initiation of treatment on week 1. Subjects for whom newly-obtained samples cannot be 
provided (e.g. inaccessible or subject safety concern) may collect tissue from a previously 
archived specimen. Additionally, archival tissue from the surgical specimen at the time of 
cystectomy will also be collected. 
 
 
 
 
Laboratory assays will be used to explore our hypothesis that there will be markers of immune 
activation/biologic response in the tumors of patients treated with pembrolizumab as 
compared to control untreated tumor samples from similar patients or the same patient (if 
tissue is available). This will include, but not be limited to, studying signals of anti-cancer 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 4 
 
 
 
 
immunological activity by evaluating the frequency of CD4 and CD8 T cells in tumor tissues 
(pre and post-therapy or untreated and treated cohorts). We will also evaluate tissue for 
signals of biomarker activity by evaluating surgical specimens for established and not-so- 
established markers of response to pembrolizumab (e.g. TILS, PD-1 and PD-L1 levels) 
compared to pre-treatment biopsy samples. Immune monitoring as a component of internal 
discovery studies will include but not limited to evaluation of CD4 and CD8 T cells in peripheral 
blood and available tumor samples as previously published[1-4]. 
 
In addition, pre and post-treatment tumors will be assigned to intrinsic basal and luminal 
subtypes by whole genome mRNA expression profiling (with assistance of collaborator David 
McConkey, PhD). Briefly, tumor areas will be macrodissected from 10-micron unstained 
formalin-fixed, paraffin-embedded (FFPE) slides using an H&E template marked by the 
collaborator pathologist. RNA will be isolated using Roche High Pure FFPET kits, RNA quality 
and purity will be analyzed by NanoDrop ND-1000 and an Agilent Bioanalyzer, and gene 
expression profiling will be performed on 40-100 ng of RNA using Illumina’s DASL platform as 
described previously[5]. Slides will be scanned with Bead Station 500X and signal intensities 
will be quantified with GenomeStudio (Illumina, Inc.). Quantile normalization in the Linear 
Models for Microarray Data (LIMMA) package in the R language environment will be used to 
normalize the data, and tumor subtype assignments will be performed using the one nearest 
neighbor (oneNN) classifier described previously[6]. Additionally, we will collaborate with 
Merck Research Laboratories (MRL) in looking at PDL1/PD1 and their panel of gene 
expression signatures of T-cell activity, APC activity, etc. using, for example, the nanostring 
platform. Blood for correlative studies will be banked at MDACC; no specimens are 
anticipated to be sent to Merck. 
 
Lastly we plan exploratory correlative studies to examine the role of the human microbiome 
on Pembrolizumab efficacy and safety. To this end we plan to obtain pre treatment and post 
treatment microbiome samples for further correlative study. These will include collection of 
feces and urine at both timepoints. These studies come on the heels of recent publications 
implicating the microbiome on disease reponse to anti PD1 therapy [10]. These studies 
demonstrated a predictive pattern in the microbiome of melanoma patients treated with anti 
PD1 therapy. The analysis of urinary and fecal microbiomes in the current study will serve as 
background to establish a pattern currently unknown in bladder cancer therapy. 
 
2.1.3 Duration of Study 
 
It is anticipated that 24 months will be required to complete accrual and complete the follow- 
up phase for those enrolled. The primary analysis will be performed when the last enrolled 
patient completes follow-up. The end of the study will occur at the same time as the primary 
analysis. No interim analyses are planned. 
 
2.1.4 Number of Subjects 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 5 
 
 
 
 
Twenty patients will be treated if no dose limiting toxicities (DLT) are encountered. 
 
2.1.5 Study Population 
 
Patients with a diagnosis of urothelial carcinoma of the bladder, both non-muscle invasive 
(NMIBC) and muscle invasive (MIBC) disease who are planned to undergo radical cystectomy, 
without neoadjuvant chemotherapy, will be eligible for enrollment. The study population will 
be enriched with those patients in whom primary BCG therapy has failed for high risk NMIBC. 
Patients who are either not eligible for, refuse, or do not risk stratify (based on standard MD 
Anderson criteria) for neoadjuvant chemotherapy will be eligible. Those patients pretreated 
with conventional neoadjuvant chemotherapy prior to radical cystectomy will not be 
included. 
 
2.1.6 Study Drug Dose and Mode of Administration: 
 
Two Drug Product (DP) dosage forms are available for pembrolizumab: a white to off-white 
lyophilized powder, 50 mg/vial, and a liquid, DP 100 mg/vial, both in Type I glass vials 
intended for single use only. A single dose of drug will be used in the trial at 200 mg, with 
administration at two time points (week 1 and week 4). The drug formulations and 
administration details are listed below: 
 
 Pembrolizumab Powder for Solution for Infusion, 50 mg/vial is reconstituted with 
sterile water for injection prior to use. Pembrolizumab DP is formulated with L- 
histidine as buffering agent, polysorbate80 as surfactant, sucrose as stabilizer/tonicity 
modifier, and hydrochloric acid(HCl) and/or sodium hydroxide (NaOH) for pH 
adjustment (if necessary). 
 
 
 
 
 Pembrolizumab Solution for Infusion 100 mg/vial is a liquid DP and has the identical 
formulation as that of the reconstituted lyophilized vial. Both drug product dosage 
forms are stored under refrigerated conditions (2°C - 8°C). 
 
The product after reconstitution with sterile water for injection and the liquid drug product 
are a clear to opalescent solution which may contain proteinaceous and extraneous 
particulates. The reconstituted lyophilized product and the liquid product are intended for IV 
administration. The reconstituted DP solution or the liquid DP can be further diluted with 
normal saline in IV containers made of polyvinyl chloride (PVC) or non-PVC material. 
Reconstituted vials should be immediately used to prepare the infusion solution in the IV bag 
and the infusion solution should be immediately administered. If not used immediately, vials 
and/or IV bags may be stored at 2-8 °C for up to a cumulative time of 20 hours. If refrigerated, 
the vials and/or IV bags should be allowed to equilibrate to room temperature prior to 
subsequent  use.  Pembrolizumab  solutions  may  be  stored  at  room  temperature  for  a 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 6 
 
 
 
 
cumulative time of up to 6 hours. This includes room temperature storage of reconstituted 
or liquid DP solution in vials, room temperature storage of infusion solution in the IV bag and 
the duration of infusion. Additional information can be found in the Pharmacy Manual. 
 
2.1.7 Criteria for Evaluation 
 
Safety Measure: Safety will be evaluated for all treated patients using the National Cancer 
Institute (NCI) Common Terminology Criteria for Adverse Events v4.0 (CTCAE). Safety 
assessments will be based on medical review of adverse event reports and the results of vital 
sign measurements, physical examinations, and clinical laboratory tests. The incidence of 
adverse events will be tabulated and reviewed for potential significance and clinical 
importance. 
 
Efficacy Measure: Treatment efficacy of patients treated with pembrolizumab will be through 
histopathologic examination of the final radical cystectomy specimen. Those patients with 
NMIBC who achieve a complete response (pT0) and those with MIBC who are found to harbor 
only residual NMIBC (≤ pT1) will be considered responders. 
 
Biological Activity: Tissue immune response and activation will be evaluated as described 
earlier. This will include a comparison of post-treatment tissue to pre-treatment tissue from 
the same patient when available and to similar patients when not. 
 
3.1 OBJECTIVES AND HYPOTHESES 
 
3.2 
Primary Objective and Hypothesis 
 
3.1.1 Primary Objective 
 
 To characterize the safety profile of pembrolizumab in patients with urothelial 
carcinoma undergoing radical cystectomy. 
 
3.1.2 Hypothesis 
 
Pembrolizumab can be safely administered as a‘window of opportunity’ monotherapy in 
patients undergoing radical cystectomy for bladder cancer. 
 
3.2 
Secondary Objectives and Hypothesis 
 
3.2.1 Secondary Objectives 
 
 To explore anti-cancer immunological activity by evaluating surgical specimens for 
evidence of post-treatment lymphocytic infiltration and residual tumor compared to 
pre-treatment biopsy samples. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 7 
 
 
 
 
 To explore biomarker activity by evaluating surgical specimens and blood samples for 
established and not-so-established markers of response to pembrolizumab. 
 
 To report the tumor yield and sufficiency of tumor for immunological and biomarker 
activity 
 
 To examine the interaction of the human microbiome and pathologic response to 
Pembrolizumab 
 
3.2.2 Hypothesis 
 
Tissue and blood markers will correlate and help predict response to therapy and provide 
biologic markers of activity. Sufficient tumor tissue will be available in most patients to assess 
the planned markers. 
 
4.1 BACKGROUND AND RATIONALE 
 
4.2 
Background 
 
Refer to the Investigator’s Brochure (IB)/approved labeling for detailed background 
information on pembrolizumab. 
 
4.1.1 Pharmaceutical and Therapeutic Background 
 
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades. Accumulating evidence shows a correlation 
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+ regulatory T-cells seems to correlate with improved prognosis and 
long-term survival in many solid tumors. 
 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress 
immune control. 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 to negatively 
regulate antigen receptor signaling upon engagement of its ligands (PD-L1 and/or PD-L2). The 
structure of murine PD-1 has been resolved. 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 inhibition motif (ITIM) and an immunoreceptor tyrosine- 
based  switch  motif  (ITSM).     Following  T-cell  stimulation,  PD-1  recruits  the  tyrosine 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 8 
 
 
 
 
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. 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. PD-1 was shown to be expressed on activated 
lymphocytes including peripheral CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer 
cells. Expression has also been shown during thymic development on CD4-CD8- (double 
negative) T-cells as well as subsets of macrophages and dendritic cells. 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. 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- 
L1 is expressed at low levels on various non-hematopoietic tissues, most notably on vascular 
endothelium, whereas PD-L2 protein is only detectably expressed on antigen-presenting cells 
found in lymphoid tissue or chronic inflammatory environments. PD-L2 is thought to control 
immune T-cell activation in lymphoid organs, whereas PD-L1 serves to dampen unwarranted 
T-cell function in peripheral tissues. Although healthy organs express little (if any) PD-L1, a 
variety of cancers were demonstrated to express abundant levels of this T-cell inhibitor. PD- 
1 has been suggested to regulate tumor-specific T-cell expansion in subjects with melanoma 
(MEL). This suggests that the PD-1/PD-L1 pathway plays a critical role in tumor immune 
evasion and should be considered as an attractive target for therapeutic intervention. 
 
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. Pembrolizumab has recently been approved in the United States 
for the treatment of patients with unresectable or metastatic melanoma and disease 
progression following ipilumumab and, if BRAF V600 mutation positive, a BRAF inhibitor. 
 
4.1.2 Preclinical and Clinical Trial Data 
 
Because of the success of Pembrolizumab against advanced melanoma, there is considerable 
enthusiasm that Pembrolizumab can also be used to treat advanced urothelial carcinoma of 
the bladder. A recent Phase 1b trial demonstrated that Pembrolizumab therapy had anti- 
tumor activity with an acceptable safety profile in patients with locally advanced or 
metastatic urothelial cancer[7]. Furthermore, a recent Phase III trial demonstrated that for 
patients with advanced urothelial cancer that had recurred or progressed on primary 
platinum-based chemotherapy, Pembrolizumab treatment conferred a significantly longer 
overall survival with a lower rate of treatment-related adverse events compared to second 
line chemotherapy[8]. These positive results for Pembrolizumab in the advance disease state 
are encouraging, yet to date, the role of Pembrolizumab in a neoadjuvant setting prior to 
radical cystectomy has yet to be investigated. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 9 
 
 
 
 
For further details, refer to the Investigator’s Brochure for Preclinical and Clinical data. 
 
4.2 
Rationale 
 
4.2.1 Rationale for the Trial and Selected Subject Population 
 
Urothelial carcinoma of the bladder is a common malignancy notable for frequent 
recurrences (non-muscle invasive) and lethality (muscle invasive). Although low grade and 
stage disease can be adequately controlled via local endoscopic resection, the more 
aggressive forms of the disease require surgical removal of the bladder with or without the 
addition of platinum based chemotherapy. 
 
 
Whereas the recommendation for radical cystectomy in patients with muscle invasive 
bladder cancer (MIBC) is routine, for those with non-muscle invasive (NMIBC) disease surgical 
removal of the bladder is generally reserved for those patients with high risk disease or those 
who have failed initial therapy with intravesical therapy. Such patients are frequently treated 
with intravesical chemotherapy (less common) or immunotherapy (more common) with BCG, 
the agent with the strongest known activity for high risk NMIBC. Efficacy for initial 
presentation of NMIBC can approach 70%. Urothelial carcinoma can be therefore effectively 
treated with immunotherapy. 
 
Despite the success, a significant number of tumors progress to invasive urothelial 
carcinomas following intravesical therapy. Patients who develop recurrent NMIBC face 
limited therapeutic alternatives and thus necessitate radical surgery. For these patients, and 
a subset of those with MIBC who are either ineligible for effective chemotherapy or harbor 
localized disease which may be cured by surgery alone the administration of neoadjuvant 
chemotherapy is not necessary. In this study we will test the hypothesis that pembrolizumab 
can be safely administered as a ‘window of opportunity’ monotherapy in patients treated for 
NMIBC or MIBC with radical cystectomy. 
 
4.2.2 Rationale for Dose Selection/Regimen/Modification 
 
An open-label phase I trial (Protocol 001) is being conducted to evaluate the safety and 
clinical activity of single agent pembrolizumab. The dose escalation portion of this trial 
evaluated three dose levels, 1 mg/kg, 3 mg/kg, and 10 mg/kg, administered every 2 weeks 
(Q2W) in subjects with advanced solid tumors. All three dose levels were well tolerated and 
no dose-limiting toxicities were observed. This first in human study of pembrolizumab 
showed evidence of target engagement and objective evidence of tumor size reduction at  
all dose levels (1 mg/kg, 3 mg/kg and 10 mg/kg Q2W). No MTD (maximum tolerated dose) 
has been identified to date. Recent data from other clinical studies within the 
pembrolizumab program has shown that a lower dose of pembrolizumab and a less  
frequent schedule may be sufficient for target engagement and clinical activity. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 10 
 
 
 
 
 
 
PK data analysis of pembrolizumab administered Q2W and Q3W showed slow systemic 
clearance, limited volume of distribution, and a long half-life. Pharmacodynamic data (IL-2 
release assay) suggested that peripheral target engagement is durable (>21 days). This 
early PK and pharmacodynamic data provides scientific rationale for testing Q3W dosing 
schedule. 
 
A population pharmacokinetic analysis has been performed using serum concentration time 
data from 476 patients. Within the resulting population PK model, clearance and volume 
parameters of pembrolizumab were found to be dependent on body weight. The 
relationship between clearance and body weight, with an allometric exponent of 0.59, is 
within the range observed for other antibodies and would support both body weight 
normalized dosing or a fixed dose across all body weights.  Pembrolizumab has been found 
to have a wide therapeutic range based on the melanoma indication. The differences in 
exposure for a 200 mg fixed dose regimen relative to a 2 mg/kg Q3W body weight based 
regimen are anticipated to remain well within the established exposure margins of 0.5 – 5.0 
for pembrolizumab in the melanoma indication. The exposure margins are based on the 
notion of similar efficacy and safety in melanoma at 10 mg/kg Q3W vs. 2 mg/kg Q3W (i.e. 5- 
fold higher dose and exposure). The population PK evaluation revealed that there was no 
significant impact of tumor burden on exposure. In addition, exposure was similar between 
the NSCLC and melanoma indications. Therefore, there are no anticipated changes in 
exposure between different indication settings. 
 
The rationale for further exploration of 2 mg/kg and comparable doses of pembrolizumab in 
solid tumors is based on: 1) similar efficacy and safety of pembrolizumab when dosed at 
either 2 mg/kg or 10 mg/kg Q3W in melanoma patients, 2) the flat exposure-response 
relationships of pembrolizumab for both efficacy and safety in the dose ranges of 2 mg/kg 
Q3W to 10 mg/kg Q3W, 3) the lack of effect of tumor burden or indication on distribution 
behavior of pembrolizumab (as assessed by the population PK model) and 4) the assumption 
that the dynamics of pembrolizumab target engagement will not vary meaningfully with 
tumor type. 
 
The choice of the 200 mg Q3W as an appropriate dose for the switch to fixed dosing is based 
on simulations performed using the population PK model of pembrolizumab showing that the 
fixed dose of 200 mg every 3 weeks will provide exposures that 1) are optimally consistent 
with those obtained with the 2 mg/kg dose every 3 weeks, 2) will maintain individual patient 
exposures in the exposure range established in melanoma as associated with maximal 
efficacy response and 3) will maintain individual patients exposure in the exposure range 
established in melanoma that are well tolerated and safe. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 11 
 
 
 
 
A fixed dose regimen will simplify the dosing regimen to be more convenient for physicians 
and to reduce potential for dosing errors. A fixed dosing scheme will also reduce complexity 
in the logistical chain at treatment facilities and reduce wastage. 
 
4.2.3 Rationale for Endpoints 
 
4.2.3.1 Efficacy Endpoints 
 
Although drug efficacy is not a primary objective of the study, effects on the tumor will be 
evaluated for both descriptive presentation and to aid in informing study size for future phase 
trials with an efficacy endpoint. The main mechanism for doing so will be via histopathologic 
review of the radical cystectomy specimen. Historically patients with MIBC who undergo 
‘window of opportunity’ chemotherapy are defined as responders if they achieve a pT1 stage 
or less. For the purposes of this study a similar efficacy endpoint will be utilized for MIBC 
patients. In the case of NMIBC a pT0 status will be used to identify complete response. 
 
4.2.3.2 Biomarker Research 
 
The identification of specific signatures of tissue response and the association with anti- 
tumor immune activation will serve a secondary objective to the proposed study. Whenever 
possible normal tissue from the same patient will be utilized as a control to comparative 
analysis with tumor specimens after treatment. Analyses will include, but not be limited to, 
studying signals of anti-cancer immunological activity by evaluating the frequency of CD4 and 
CD8 T cells in tumor tissues (pre- and post-therapy or untreated and treated cohorts). We will 
also evaluate tissue for signals of biomarker activity by evaluating surgical specimens for 
established and not-so-established markers of response to pembrolizumab (e.g. TILS, PD-1 
and PD-L1 levels) compared to pre-treatment biopsy samples. In addition, pre- and post- 
treatment tumors will be assigned to intrinsic basal and luminal subtypes by whole genome 
mRNA expression  profiling (with the assistance of collaborator David McConkey, PhD). 
Additionally, we will collaborate with Merck Research Laboratories (MRL) in looking at 
PDL1/PD1 and their panel of gene expression signatures of T-cell activity, APC activity, etc. 
using, for example, the nanostring platform. 
 
5.1 METHODOLOGY 
 
5.2 
Entry Criteria 
 
5.1.1 Diagnosis/Condition for Entry into the Trial 
 
 Scenario 1: Muscle invasive bladder cancer (MIBC): Histologically confirmed, by MD 
Anderson pathologic review, diagnosis of muscle invasive bladder cancer (cT2 or 
greater). No planned systemic chemotherapy prior to radical cystectomy by standard 
practice risk stratification, patient refusal, and/or patient ineligibility. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 12 
 
 
 
 
 Scenario 2: Non-muscle invasive bladder cancer (NMIBC): Histologically confirmed, 
by MD Anderson pathologic review, diagnosis of non-muscle invasive bladder cancer 
(cT1 or less). No planned systemic chemotherapy prior to radical cystectomy by 
standard practice risk stratification, patient refusal, and/or patient ineligibility. Prior 
intravesical therapies, whether BCG, chemotherapy or otherwise, will remain eligible. 
 
5.1.2 Subject Inclusion Criteria 
 
In order to be eligible for participation in this trial, the subject must: 
 
1. Be willing and able to provide written informed consent 
 
2. Be 18 years of age 
 
3. Have absence of metastatic disease as determined by conventional imaging studies 
and be considered a good surgical candidate by the treating physician. 
 
4. Be willing to participate in the collection of blood and tissue for banking and future 
correlative studies as specified in the Study Flow Chart (Section 6.0). 
 
5. Have a performance status of 0 or 1 on the ECOG Performance Scale. 
 
6. Demonstrate adequate organ function as defined in Table 1, all screening labs should 
be performed within 14 days of treatment initiation. 
 
Table 1 Adequate Organ Function Laboratory Values: 
 
System 
Laboratory Value 
Hematological 
Absolute neutrophil count 
(ANC) 
≥1,500 /mcL 
Platelets 
≥100,000 / mcL 
Hemoglobin 
≥9 g/dL or ≥5.6 mmol/L without transfusion or 
EPO dependency within 7 days of assessment 
Renal 
Serum creatinine OR 
≤1.5 X upper limit of normal (ULN) OR 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 13 
 
 
 
 
 
Measured or calculated 
creatinine clearance a 
(GFR can also be used in place 
of creatinine or CrCl) 
≥ 30 mL/min for subject with creatinine levels > 
1.5 X institutional ULN 
Hepatic 
Serum total bilirubin 
≤ 1.5 X ULN OR 
Direct bilirubin ≤ ULN for subjects with total 
bilirubin levels > 1.5 ULN 
AST (SGOT) and ALT (SGPT) 
≤ 2.5 X ULN  OR 
≤ 5 X ULN for subjects with liver metastases 
Albumin 
>2.5 mg/dL 
Coagulation 
International Normalized Ratio 
(INR) or Prothrombin Time (PT) 
Activated Partial 
Thromboplastin Time (aPTT) 
≤1.5 X ULN unless subject is receiving 
anticoagulant therapy 
as long as PT or PTT is within therapeutic range 
of intended use of anticoagulants 
≤1.5 X ULN unless subject is receiving 
anticoagulant therapy 
as long as PT or PTT is within therapeutic range 
of intended use of anticoagulants 
aCreatinine clearance should be calculated per institutional standard. 
 
 
7. Female subject of childbearing potential should have a negative urine or serum 
pregnancy within 72 hours prior to receiving the first dose of study medication. If the 
urine test is positive or cannot be confirmed as negative, a serum pregnancy test will 
be required. 
 
8. Female subjects of childbearing potential (Section 5.7.2) must be willing to use an 
adequate method of contraception as outlined in Section 5.7.2 – Contraception, for 
the course of the study through 120 days after the last dose of study medication. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 14 
 
 
 
 
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception 
for the subject. 
 
9. Male subjects of childbearing potential (Section 5.7.2) must agree to use an adequate 
method of contraception as outlined in Section 5.7.2- Contraception, 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. 
 
5.1.3 Subject Exclusion Criteria 
 
The subject must be excluded from participating in the trial if the subject: 
 
1. Is currently participating and receiving pembrolizumab or has participated in a study 
of an investigational agent and received pembrolizumab or used an investigational 
device within 4 weeks of the first dose of study treatment. 
 
2. 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 study 
treatment. 
 
3. Has a known history of active TB  (Bacillus Tuberculosis). 
 
4. Has a known history of hypersensitivity to pembrolizumab or any of its excipients. 
 
5. Has had prior systemic anti-cancer therapy for the treatment of bladder cancer. Prior 
intravesical therapies, whether BCG [including but not limited to: Persistent high- 
grade disease or recurrence within 6 months of receiving at least two courses of 
intravesical BCG (at least five of six induction doses and at least two of three 
maintenance doses); or T1 high-grade disease at the first evaluation following 
induction BCG alone (at least five of six induction doses)], chemotherapy or otherwise, 
will remain eligible. 
 
6. Has any other malignancy diagnosed within 2 years of screening with the exception 
of basal or squamous cell skin cancer, or non-invasive cancer of the cervix, or any 
other cancer deemed by the treating physician to be of low-risk for progression or 
patient morbidity during the study period. 
 
7. Has known metastatic disease as determined by conventional staging studies 
 
8. 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 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 15 
 
 
 
 
physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, 
etc.) is not considered a form of systemic treatment. 
 
9. Has known history of, or any evidence of active, non-infectious pneumonitis. 
 
10. Has a clinically significant active infection requiring systemic therapy. 
 
11. Has a history or current evidence of any condition, therapy, or laboratory abnormality 
that might confound the results of the trial, interfere with the subject’s participation 
for the full duration of the trial, or is not in the best interest of the subject to 
participate, in the opinion of the treating physician. 
 
12. 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. 
 
13. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent. 
 
14. Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies). 
 
15. Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA 
[qualitative] is detected). 
 
16. Has received a live  vaccine within 30 days of initiation  of study therapy. Note: 
Seasonal influenza vaccines for injection are generally inactivated flu vaccines and are 
allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live attenuated 
vaccines, and are not allowed. 
 
5.2 
Study Treatment 
 
The treatment to be used in this trial is outlined below in Table 2 
Table 2: Trial Treatment: 
Drug 
Dose/ 
Potency 
Dose 
Frequency 
Route of 
Administration 
Regimen/ 
Treatment 
Period 
Use 
Pembrolizumab 
200 mg 
Q3W x 2 
IV infusion 
Day 1 of each 3 
week cycle 
Experimental 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 16 
 
 
 
 
 
 
 
5.2.1 Dose Selection 
The rationale for selection of doses to be used in this trial is provided in Section 4.2.2. 
Details on preparation and administration of pembrolizumab are provided in the Pharmacy 
Manual. 
 
5.2.2 Dose Modification and toxicity management for immune-related AEs associated 
with pembrolizumab 
 
AEs associated with pembrolizumab exposure 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 treatment and may affect more than on 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, 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 
are provided in Table 3. 
 
 
 
 
Table 3: Dose modification and toxicity management guidelines for immune-related AEs 
associated with pembrolizumab 
 
General instructions: 
 
1. Corticosteroid taper should be initiated upon AE improving to Grade 1 or less and continue to taper over at least 4 weeks. 
2. For situations where pembrolizumab has been withheld, pembrolizumab can be resumed after AE has been reduced to Grade 1 or 0 
and corticosteroid has been tapered. Pembrolizumab should be permanently discontinued if AE does not resolve within 12 weeks of 
last dose or corticosteroids cannot be reduced to ≤10 mg prednisone or equivalent per day within 12 weeks. 
3. For severe and life-threatening irAEs, IV corticosteroid should be initiated first followed by oral steroid. Other immunosuppressive 
treatment should be initiated if irAEs cannot be controlled by corticosteroids. 
Immune-related 
AEs 
Toxicity grade or 
conditions 
(CTCAEv4.0) 
Action taken to 
pembrolizumab 
irAE management with 
corticosteroid and/or other 
therapies 
Monitor and follow-up 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 17 
 
 
 
 
 
Pneumonitis 
Grade 2 
Withhold 
 Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
 
Monitor participants for signs 
and symptoms of pneumonitis 
 
Evaluate participants with 
suspected pneumonitis with 
radiographic imaging and 
initiate corticosteroid treatment 
 
Add prophylactic antibiotics for 
opportunistic infections 
Grade 3 or 4, or 
recurrent Grade 2 
Permanently 
discontinue 
Diarrhea / Colitis 
Grade 2 or 3 
Withhold 
 Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
 
Monitor participants for signs 
and symptoms of enterocolitis 
(ie, diarrhea, abdominal pain, 
blood or mucus in stool with or 
without fever) and of bowel 
perforation (ie, peritoneal signs 
and ileus). 
 
Participants with ≥ Grade 2 
diarrhea suspecting colitis 
should consider GI consultation 
and performing endoscopy to 
rule out colitis. 
 
Participants with diarrhea/colitis 
should be advised to drink 
liberal quantities of clear fluids. 
If sufficient oral fluid intake is 
not feasible, fluid and 
electrolytes should be 
substituted via IV infusion. 
Grade 4 
Permanently 
discontinue 
AST / ALT 
elevation or 
Increased 
bilirubin 
Grade 2 
Withhold 
 Administer corticosteroids (initial 
dose of 0.5- 1 mg/kg prednisone 
or equivalent) followed by taper 
 
Monitor with liver function tests 
(consider weekly or more 
frequently until liver enzyme 
value returned to baseline or is 
stable 
Grade 3 or 4 
Permanently 
discontinue 
 Administer corticosteroids (initial 
dose of 1-2 mg/kg prednisone or 
equivalent) followed by taper 
Type 1 diabetes 
mellitus (T1DM) 
or 
Hyperglycemia 
Newly onset 
T1DM or 
Grade 3 or 4 
hyperglycemia 
associated with 
evidence of -cell 
failure 
Withhold 
 Initiate insulin replacement 
therapy for participants with 
T1DM 
 Administer anti-hyperglycemic in 
participants with hyperglycemia 
 
Monitor participants for 
hyperglycemia or other signs 
and symptoms of diabetes. 
Hypophysitis 
Grade 2 
Withhold 
 Administer corticosteroids and 
initiate hormonal replacements as 
clinically indicated. 
 
Monitor for signs and symptoms 
of hypophysitis (including 
hypopituitarism and adrenal 
insufficiency) 
Grade 3 or 4 
Withhold or 
permanently 
discontinue1 
Hyperthyroidism 
Grade 2 
Continue 
 
Monitor for signs and symptoms 
of thyroid disorders. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 18 
 
 
 
 
 
 
Grade 3 or 4 
Withhold or 
permanently 
discontinue1 
 Treat with non-selective beta- 
blockers (eg, propranolol) or 
thionamides as appropriate 
Hypothyroidism 
Grade 2-4 
Continue 
 Initiate thyroid replacement 
hormones (eg, levothyroxine or 
liothyroinine) per standard of care 
 
Monitor for signs and symptoms 
of thyroid disorders. 
Nephritis and 
Renal 
dysfunction 
Grade 2 
Withhold 
 Administer corticosteroids 
(prednisone 1-2 mg/kg or 
equivalent) followed by taper. 
 
Monitor changes of renal 
function 
Grade 3 or 4 
Permanently 
discontinue 
Myocarditis 
Grade 1 or 2 
Withhold 
 Based on severity of AE 
administer corticosteroids 
 
Ensure adequate evaluation to 
confirm etiology and/or exclude 
other causes 
Grade 3 or 4 
Permanently 
discontinue 
All other 
immune-related 
AEs 
Intolerable/ 
persistent Grade 
2 
Withhold 
 Based on type and severity of AE 
administer corticosteroids 
 
Ensure adequate evaluation to 
confirm etiology and/or exclude 
other causes 
Grade 3 
Withhold or 
discontinue based 
on the type of 
event. Events that 
require 
discontinuation 
include and not 
limited to: Gullain- 
Barre Syndrome, 
encephalitis 
Grade 4 or 
recurrent Grade 3 
Permanently 
discontinue 
1. 
Withhold or permanently discontinue pembrolizumab is at the discretion of the investigator or treating physician. 
NOTE: 
For participants with Grade 3 or 4 immune-related endocrinopathy where withhold of pembrolizumab is required, pembrolizumab may 
be resumed when AE resolves to ≤ Grade 2 and is controlled with hormonal replacement therapy or achieved metabolic control (in case 
of T1DM). 
 
 
Dose modification and toxicity management of infusion-reactions related to 
pembrolizumab 
 
Pembrolizumab may cause severe or life threatening infusion-reactions including severe 
hypersensitivity or anaphylaxis. Signs and symptoms usually develop during or shortly after 
drug infusion and generally resolve completely within 24 hours of completion of infusion. 
Dose modification and toxicity management guidelines on pembrolizumab associated 
infusion reaction are provided in Table 4. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 19 
 
 
 
 
 
 
 
 
 
 
Table 4 Pembrolizumab Infusion Reaction Dose modification and Treatment Guidelines 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 20 
 
 
 
 
 
NCI CTCAE Grade 
Treatment 
Premedication at Subsequent 
Dosing 
Grade 1 
Mild reaction; infusion 
interruption not 
indicated; intervention 
not indicated 
Increase monitoring of vital signs as medically indicated until the participant 
is deemed medically stable in the opinion of the investigator. 
None 
Grade 2 
Requires therapy or 
infusion interruption 
but responds promptly 
to symptomatic 
treatment (e.g., 
antihistamines, NSAIDs, 
narcotics, IV fluids); 
prophylactic 
medications indicated 
for ≤24 hrs 
Stop Infusion. 
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 participant 
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. 
Participants who develop Grade 2 toxicity despite adequate premedication 
should be permanently discontinued from further study drug treatment 
Participant may be premedicated 
1.5h (± 30 minutes) prior to 
infusion of 
with: 
Diphenhydramine 50 mg po (or 
equivalent dose of 
antihistamine). 
Acetaminophen 500-1000 mg po 
(or equivalent dose of analgesic). 
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: 
Epinephrine** 
IV fluids 
Antihistamines 
NSAIDs 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Increase monitoring of vital signs as medically indicated until the participant 
is deemed medically stable in the opinion of the investigator.  
Hospitalization may be indicated. 
**In cases of anaphylaxis, epinephrine should be used immediately. 
Participant is permanently discontinued from further study drug 
treatment. 
No subsequent dosing 
Appropriate resuscitation equipment should be available at the bedside and a physician readily available during the period of drug administration. 
For further information, please refer to the Common Terminology Criteria for Adverse Events v4.0 (CTCAE) at http://ctep.cancer.gov 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 21 
 
 
 
 
5.2.3 Timing of Dose Administration 
 
Study treatment should be administered on Day 1 of each 3-week cycle after all 
procedures/assessments have been completed as detailed on the Study Flow Chart (Section 
6.0). Trial treatment may be administered up to 3 days before or after the scheduled Day 1 
of each cycle due to administrative reasons. 
 
Study treatments will be administered on an outpatient basis. 
 
Pembrolizumab 200 mg will be administered as a 30 minute IV infusion every 3 weeks for a 
total of 2 cycles. 
 
5.2.4 Trial Blinding/Masking 
 
This is an open-label trial; therefore, the Sponsor, investigator and subject will know the 
treatment administered. 
 
5.3 
Randomization or Treatment Allocation 
 
Patients will be enrolled sequentially without randomization. According to a standardized, 
dose escalating, phase 2 safety design a total of 20 patients may be enrolled. 
 
Initially 3 patients will be studied at 200 mg given at weeks 1 and 4 by IV infusion. These 
patients will be followed for safety assessments every 3 weeks during the treatment phase 
and at 30 and 90 days post-op visits during the follow-up phase. If < 2 patients in the initial 
cohort of 3 experience a grade >3 drug related adverse event then a subsequent cohort of 17 
patients at 200 mg dose will be enrolled. 
 
The following stopping rules will apply: if at any time ≥ 3 patients experience a drug related 
grade 4 adverse event including bowel perforation or any drug related grade 3 skin or 
gastrointestinal adverse event without clinical improvement within 2 weeks of study drug 
discontinuation and/or initiation of corticosteroid therapy to treat the adverse event; no 
additional patients will be enrolled. If any grade 3 or higher adverse event that is possibly, 
probably or definitely related to study drug, with the exception of any grade 3 or higher 
adverse events that is potentially treatable with steroids and improves to grade 1 or better 
within 2 weeks of steroid therapy initiation and/or study treatment discontinuation, the 
above stopping rule would apply. Also excluded will be grade 3 lipase elevation as this is 
common with this agent but is almost universally asymptomatic. Grade 4 lipase elevation will 
be criteria for stopping. If during monitoring, a patient is found to have disease progression 
within the treatment study period then this will be counted as a grade 4 toxicity event and 
the above stopping rule would apply. If there is a >12 week delay to surgery due disease 
progression, then this will be counted as a grade 4 toxicity event and the above stopping rule 
would apply. If a patient suffers a drug related toxicity which results in an inability to perform 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 22 
 
 
 
 
radical cystectomy further study enrollment will be stopped. If there is a > 12 week delay to 
surgery due to a drug related toxicity in 2 or more patients, further enrollment will be 
stopped. Once patients have received a maximum of two doses of pembrolizumab, they will 
undergo surgery at approximately 6 - 8 weeks. An assessment of tumor response will not be 
made prior to radical cystectomy. 
 
5.4 
Stratification 
 
‘Window of opportunity’ chemotherapy is not advised or administered to patients with 
NMIBC who undergo radical cystectomy. As such, although there will not be an active attempt 
to enrich the study population for such patients, it is likely that the study cohort will contain 
a significant group with NMIBC. However, trial accrual will be sequential and according to the 
earlier described eligibility criteria. As such, no active attempt at stratification will be made. 
 
5.5 
Concomitant Medications/Vaccinations 
 
Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed 
during the ongoing trial. If there is a clinical indication for one of these or other medications 
or vaccinations specifically prohibited during the trial, discontinuation from study therapy or 
vaccination may be required. The treating physician may choose to discuss any questions 
regarding this with the PI of the study; however, the final decision on any supportive therapy 
or vaccination rests with the subject’s treating physician. 
 
5.5.1 Acceptable Concomitant Medications 
 
All treatments that the treating physician considers necessary for a subject’s welfare may be 
administered at the discretion of the treating investigator in keeping with the community 
standards of medical care. All concomitant medications will be recorded in the medical 
record throughout the duration of the study, including prescription, over-the-counter (OTC), 
herbal supplements, and IV medications. Medications and fluids used for anesthesia and 
standard of care pre and post-op care will not be recorded for protocol purposes. Blood 
products, if administered, will be recorded. 
 
Concomitant medications received within 28 days before the first dose of pembrolizumab 
and 30 days after surgery will be recorded. Concomitant medications administered beyond 
30 days after surgery will be recorded only for serious adverse events (SAEs) and events of 
clinical importance (ECIs). 
 
5.5.2 Prohibited Concomitant Medications 
 
Subjects are prohibited from receiving the following therapies during the screening and 
treatment phase of this trial: 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 23 
 
 
 
 
 Antineoplastic systemic chemotherapy or biological therapy 
 
 Immunotherapy not specified in this protocol 
 
 Live vaccines within 30 days prior to the first dose of study treatment and during the 
treatment phase of the study. Examples of live vaccines include, but are not limited 
to, the following: measles, mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, 
typhoid vaccine and intranasal influenza vaccine. 
 
 Systemic glucocorticoids for any purpose other than to modulate symptoms from an 
event of clinical interest of suspected immunologic etiology. The use of physiologic 
doses of corticosteroids may be approved after consultation with the principal 
investigator. 
 
Subjects who, in the assessment by the investigator, require the use of any of the 
aforementioned treatments for clinical management should be removed from the trial. At 
that time, subjects may receive other treatment that the investigator deems to be medically 
necessary. 
 
5.6 
Rescue Medications and Supportive Care 
 
5.6.1 Rescue Medications & Supportive Care 
 
Participants should receive appropriate supportive care measures as deemed necessary by 
the treating investigator. Suggested supportive care measures for the management of AEs 
with potential immunologic etiology are outlined along with the dose modification guidelines 
in Section 5.2.2, [Table 3]. Where appropriate, these guidelines include the use of oral or IV 
treatment with corticosteroids, as well as additional anti-inflammatory agents if symptoms 
do not improve with administration of corticosteroids. Note that several courses of steroid 
tapering may be necessary as symptoms may worsen when the steroid dose is decreased. 
For each disorder, attempts should be made to rule out other causes such as metastatic 
disease or bacterial or viral infection, which might require additional supportive care. The 
treatment guidelines are intended to be applied when the Investigator determines the events 
to be related to pembrolizumab. 
 
Note: If after the evaluation of the event, it is determined not to be related to 
pembrolizumab, the Investigator does not need to follow the treatment guidance. Refer to 
[Table 3] in Section 5.2.2 for guidelines regarding dose modification and supportive care. 
 
It may be necessary to perform conditional procedures such as bronchoscopy, endoscopy, or 
skin photography as part of evaluation of the event. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 24 
 
 
 
 
5.7 
Diet, Activity and Other Considerations 
 
5.7.1 Diet 
 
Subjects should maintain a normal diet unless modifications are required to manage an AE 
such as diarrhea, nausea or vomiting. 
 
5.7.2 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). 
 
Female subjects will be considered of non-reproductive potential if they are either: 
 
(1) postmenopausal (defined as at least 12 months with no menses without an alternative 
medical cause; in women < 45 years of age a high follicle stimulating hormone (FSH) level in 
the postmenopausal range may be used to confirm a post-menopausal state in women not 
using hormonal contraception or hormonal replacement therapy. In the absence of 12 
months of amenorrhea, a single FSH measurement is insufficient.); 
 
OR 
 
(2) have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy or 
bilateral tubal ligation/occlusion, at least 6 weeks prior to screening; 
 
OR 
 
(3) has a congenital or acquired condition that prevents childbearing. 
 
Female and male subjects of reproductive potential must agree to avoid becoming pregnant 
or impregnating a partner, respectively, while receiving study drug and for 120 days after the 
last dose of study drug by complying with one of the following: 
 
(1) practice abstinence† from heterosexual activity; 
OR 
(2) use (or have their partner use) acceptable contraception during heterosexual activity. 
Acceptable methods of contraception are‡: 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 25 
 
 
 
 
Single method (one of the following is acceptable): 
• 
intrauterine device (IUD) 
• 
vasectomy of a female subject’s male partner 
• 
contraceptive rod implanted into the skin 
• 
diaphragm with spermicide (cannot be used in conjunction with cervical 
cap/spermicide) 
• 
contraceptive sponge (nulliparous women only) 
• 
male condom or female condom (cannot be used together) 
• 
hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or progestin- 
only pill), contraceptive skin patch, vaginal contraceptive ring, or subcutaneous 
contraceptive injection 
 
†Abstinence (relative to heterosexual activity) can be used as the sole method of 
contraception if it is consistently employed as the subject’s preferred and usual lifestyle and 
if considered acceptable by local regulatory agencies and ERCs/IRBs. Periodic abstinence 
(e.g., calendar, ovulation, sympto-thermal, post-ovulation methods, etc.) and withdrawal are 
not acceptable methods of contraception. 
 
‡If a contraceptive method listed above is restricted by local regulations/guidelines, then it 
does not qualify as an acceptable method of contraception for subjects participating at sites 
in this country/region. 
 
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 30 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. 
 
5.7.3 Use in Pregnancy 
 
If a subject inadvertently becomes pregnant while on treatment with pembrolizumab, the 
subject will immediately be removed from the study. Additionally, 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. 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 Institutional Review Board (IRB), IND Office, 
and to Merck without delay 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 IND Office will be notified through the eSAE system. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 26 
 
 
 
 
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 Institutional Review Board (IRB), IND Office, 
and to Merck without delay. 
 
5.7.4 Use in Nursing Women 
 
It is unknown whether pembrolizumab is excreted in human milk. Since many drugs are 
excreted in human milk, and because of the potential for serious adverse reactions in the 
nursing infant, subjects who are breast-feeding are not eligible for enrollment. 
 
5.8 
Subject Withdrawal/Discontinuation Criteria 
 
Subjects may withdraw consent at any time for any reason or be dropped from the trial at 
the discretion of the investigator or treating physician should any untoward effect occur. In 
addition, a subject may be withdrawn by the principal investigator if enrollment into the trial 
is inappropriate, the trial plan is violated, or for administrative and/or other safety reasons. 
 
A subject must be discontinued from the trial for any of the following reasons: 
 
 The subject or legal representative (such as a parent or legal guardian) withdraws 
consent 
 
 Unacceptable adverse experiences as described in Table 3 and section 5.6.1 
 
 Unexpected  intercurrent  illness  that  prevents  further  administration  of  study 
treatment 
 
 Investigator’s decision to withdraw the subject 
 
 The subject has a confirmed positive serum pregnancy test 
 
 Noncompliance with study treatment or procedure requirements 
 
 The subject is lost to follow-up: two failed attempts to contact the patient by phone 
or e-mail AND one unanswered certified letter sent to subject’s registered home 
address. 
 Completed study participation or of follow up from initiation of study treatment. 
Subjects who prematurely discontinue from the study treatment, will return to clinic within 
30 days of treatment discontinuation to complete the safety assessments listed under the 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 27 
 
 
 
 
STUDY PHASE 
SCREENING 
PHASE 
TREATMENT PHASE 
FOLLOW-UP 
PHASE 
EARLY 
TREATMENT 
DISCONTIN 
UATION 
 
 
VISIT/CYCLE 
SCREENING 
CYCLE #1 
(Week 1) 
CYCLE #2 
(Week 4) 
PRE-OP/ 
SAFETY 
VISIT 
(Week 7) 
SURGERY 
(Week 6- 8) FOLLOW-UP 
Scheduling window 
(days) 
-28 to -1 
1(±3) 
21(±3) 
35-49(±3) 
42-56(±3) 
30 day (±7) 
and 90 day 
(±7) Post Op 
Informed Consent 
X 
Inclusion/Exclusion 
Criteria 
X 
Demographics/Medic 
al history 
X 
Concomitant 
Medications 
X 
X 
X 
X 
X 
8 
8 
Pembrolizumab 
Administration 
X 
X 
Assessment of 
Disease Extent 1 
X 
Review of Adverse 
Events 
X 
X 
X 
X 
X 
X 
X 
Full Physical Exam 
X 
X 
Directed Physical 
Exam 
X 
X 
X 
X 
Vital Signs and 
Weight 
X 
2 
2 
X 
X 
X 
ECOG Performance 
Status 
X 
X 
X 
X 
X 
X 
Pregnancy Test 
X 
X3 
PT/INR and aPTT 
X9 
X 
X 
X 
X 
X 
CBC with Diff 
X9 
X 
X 
X 
X 
X 
 
 
“Early Treatment Discontinuation” visit listed in Section 6. All other subjects will continue on 
the follow-up phase through 90 days post-op. 
 
 
 
 
6.0  STUDY FLOW CHART 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 28 
 
 
Comprehensive 
Metabolic Panel4 
9 
X 
X 
X 
X 
X 
Urinalysis5 
X9 
X 
X 
X 
X 
X 
T3, FT4 and TSH 
X9 
X 
X 
X 
X 
X 
Pulmonary Function 
Tests 
X 
ACTH, Cortisol 
X 
X 
X 
ESR, CRP 
X 
X 
X 
Testosterone, FSH, 
LH (males) 
X 
X 
X 
Estrogen, FSH, LH 
(females) 
X 
X 
X 
Archival Tissue 
Collection6 
X 
X 
Feces and Urine for 
microbiome studies 
X 
X 
X10 
Blood for Correlative 
Studies 7 
X 
X 
X 
X 
Cystectomy 
X 
 
1 A complete assessment of disease extent will be made at screening per SOC guidelines, and will include but not be limited 
to diagnostic endoscopy with biopsy/resection of the index lesion for pathologic diagnosis. Additionally an examination and 
assessment for palpable disease will be made. Cross sectional imaging of the chest, abdomen and pelvis with the addition of 
whole body nuclear medicine bone imaging where clinically indicated will complete the staging evaluation. Exams performed 
within 6 weeks prior to screening will be  accepted for inclusion in the study if deemed appropriate by the treating physician 
2 Pre and post pembrolizumab dose during treatment administration days 
3 Female subjects of childbearing potential should have a negative urine or serum pregnancy test within 72 hours prior to 
receiving the first dose of study medication. If the urine test is positive or cannot be confirmed as negative, a serum 
pregnancy test will be required. 
4 Includes: Albumin, alkaline phosphatase, ALT, AST, LDH, electrolytes, uric acid, calcium, glucose, phosphorus, magnesium, 
total bilirubin, total protein, BUN and creatinine 
5 Microscopic exam if abnormal results are noted 
6 Archival tissue from a newly obtained core or excisional biopsy of a tumor lesion. Newly-obtained is defined as a specimen 
obtained up to 6 weeks (42 days) prior to initiation of treatment on week 1.  Subjects for whom newly-obtained samples 
cannot be provided (e.g. inaccessible or subject safety concern) may collect tissue from a previously archived specimen. 
Additionally, archival tissue from the surgical specimen at the time of cystectomy will also be collected 
7 Up to 60 mL of blood at baseline or pre-treatment, after the first cycle of treatment, after the second cycle of treatment 
and post-cystectomy will be collected and banked for future research 
8Concomitant medications administered beyond 30 days after surgery will be recorded only for serious adverse events (SAEs) 
and events of clinical importance (ECIs). 
9Within 14 days prior to first dose of pembrolizumab 
10 90 day post op only 
 
 
 
X 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 29 
 
 
 
 
 
 
 
7.1 STUDY PROCEDURES 
 
The Study Flow Chart - Section 6.0 summarizes the trial procedures to be performed at each 
visit. Individual trial procedures are described in detail below. It may be necessary to perform 
these procedures at unscheduled time points if deemed clinically necessary by the 
investigator. 
 
Furthermore, additional evaluations/testing may be deemed necessary by the investigator 
for reasons related to subject safety. In some cases, such evaluation/testing may be 
potentially sensitive in nature (e.g., HIV, Hepatitis C, etc.), and thus local regulations may 
require that additional informed consent be obtained from the subject. In these cases, such 
evaluations/testing will be performed in accordance with those regulations. 
 
7.2 
Informed Consent 
 
The Investigator or qualified designee must obtain documented consent from each potential 
subject prior to participating in this clinical trial. The informed consent process will adhere to 
MDACC’s Institutional guidelines and applicable laws and regulations. 
 
7.3 
Inclusion/Exclusion Criteria 
 
All inclusion and exclusion criteria will be reviewed by the investigator or qualified designee 
to ensure that the subject qualifies for the trial. 
 
7.4 
Medical History 
 
A medical history will be obtained by the investigator or qualified designee. Medical history 
will include all active conditions, and any condition diagnosed within the prior 10 years that 
are considered to be clinically significant. Details regarding bladder cancer status and a 
review of all prior cancer treatments including systemic therapies, radiation and/or surgeries 
will be included. Additionally, emphasis on autoimmune disorders and treatments for these 
conditions will be made. 
 
7.5 
Concomitant Medications Review 
 
The investigator or qualified designee will review and record all medications taken by the 
subject within 28 days before the first dose of pembrolizumab and 30 days after surgery. 
Medications and fluids used for anesthesia and standard of care pre and post-op care will not 
be recorded. Blood products, if administered, will be recorded. Concomitant medications 
administered beyond 30 days after surgery will be recorded only for serious adverse events 
(SAEs) and events of clinical importance (ECIs). 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 30 
 
 
 
 
7.6 
Adverse Event (AE) Monitoring 
 
The investigator or qualified designee will assess each subject to evaluate for potential new 
or worsening adverse events throughout the duration of the study. Adverse events will be 
graded according to NCI CTCAE Version 4.0. Toxicities will be characterized in terms regarding 
seriousness, causality, toxicity grading, and action taken with regard to study treatment. 
Refer to Section 8 for further details regarding assessing and recording adverse events. 
 
Any related adverse events Grade >1 which are present at the time of 
discontinuation/withdrawal should be followed until the resolution of the AE to Grade 0-1. 
 
7.7 
Full Physical Exam 
 
The investigator or qualified designee will perform a complete physical exam during the 
screening phase and early treatment discontinuation visit. Clinically significant abnormal 
findings during screening should be recorded as medical history. 
 
7.8 
Directed Physical Exam 
 
The investigator or qualified designee will perform a directed physical exam as clinically 
indicated during the treatment and follow-up phases. Clinically significant abnormal changes 
from screening will be recorded as adverse events. 
 
7.9 
Vital Signs 
 
Vital signs will be measured by triage clinic personnel as per standard of care during the study. 
Additionally, vital signs will be measured pre and post-treatment on weeks 1 and 4. Vital 
signs should include temperature, pulse, respiratory rate, weight and blood pressure. Height 
will be measured at screening only. 
 
7.10 Eastern Cooperative Oncology Group (ECOG) Performance Scale 
 
The investigator or qualified designee will assess ECOG performance status at every protocol 
visit as specified in the Study Flow Chart. 
 
7.11 Tumor Imaging and Assessment of Disease 
 
A complete assessment of disease extent will be made at screening following standard of care 
guidelines, and will include diagnostic endoscopy with biopsy/resection of the index lesion 
for pathologic diagnosis. Additionally an examination and assessment for palpable disease 
will be made. Cross sectional imaging of the chest, abdomen and pelvis with the addition of 
whole body nuclear medicine bone imaging where clinically indicated will complete the 
staging evaluation. Standard of care procedures/images performed within 6 weeks prior to 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 31 
 
 
 
 
screening will be accepted for inclusion in the study if deemed appropriate by the treating 
physician. 
 
7.12 Tumor Tissue Collection and Correlative Studies Blood Sampling 
 
All participants will be required to participate in the collection of blood and tissue specimens 
for banking and future research studies. 
 
7.13 Laboratory Assessments 
 
Details regarding specific laboratory assessments are specified in Table 6. Laboratory tests 
for screening should be performed within 14 days prior to the first dose of pembrolizumab. 
Laboratory assessments for each subsequent visit can be conducted up to 72 hours prior to 
dosing/clinic visit. Results must be reviewed by the investigator or qualified designee and 
found to be acceptable prior to each dose of pembrolizumab. 
 
7.14 Withdrawal/Discontinuation 
 
Subjects who prematurely discontinue from the study treatment, will return to clinic within 
30 days of treatment discontinuation to complete the safety assessments listed under the 
“Early Treatment Discontinuation” visit listed in Section 6. All other subjects will continue on 
to the follow-up phase (30 and 90 day visits after surgery). 
 
8.1 
ASSESSING AND RECORDING ADVERSE EVENTS 
 
An adverse event is defined as any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product and which does not necessarily 
have to have a causal relationship with this treatment. An adverse event can therefore be 
any unfavorable and unintended sign (including an abnormal laboratory finding, for example), 
symptom, or disease temporally associated with the use of a medicinal product or protocol- 
specified procedure, whether or not considered related to the medicinal product or protocol- 
specified procedure. Any worsening (i.e., any clinically significant adverse change in 
frequency and/or intensity) of a preexisting condition that is temporally associated with the 
use of the Merck’s product, is also an adverse event. 
 
Changes resulting from normal growth and development that do not vary significantly in 
frequency or severity from expected levels are not to be considered adverse events. 
Examples of this may include, but are not limited to, teething, typical crying in infants and 
children and onset of menses or menopause occurring at a physiologically appropriate time. 
 
Merck product includes any pharmaceutical product, biological product, device, diagnostic 
agent or protocol-specified procedure, whether investigational (including placebo or active 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 32 
 
 
 
 
comparator medication) or marketed, manufactured by, licensed by, provided by or 
distributed by Merck for human use. 
 
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 adverse events that occur after the consent form is signed but before treatment 
allocation/randomization must be reported by the investigator if they cause the subject to be 
excluded from the trial, or are the result of a protocol-specified intervention, including but 
not limited to washout or discontinuation of usual therapy, diet, placebo treatment or a 
procedure. 
 
The investigator is responsible for ensuring that all AEs and SAEs that are observed or 
informed by the patient during the study are collected and reported, and to assign 
appropriate attribution to the study treatment. 
 
From the time of initiation of pembrolizumab through 30 days after surgery, all adverse 
events must be reported by the investigator. Additionally, all adverse events meeting serious 
criteria, from time of treatment initiation through 90 days following cessation of study 
treatment, or 30 days following cessation of study treatment if the participant initiates new anti 
cancer therapy should be reported by the investigator. All adverse events will be logged into a 
protocol-specific REDCap database. The reporting timeframe for adverse events meeting 
any serious criteria is described in section 8.3.1. The investigator will make every attempt 
to follow all subjects with related non-serious adverse events for outcome or until 
resolution to grade 0-1. 
 
8.2 
Definition of an Overdose for This Protocol and Reporting of Overdose to the 
Sponsor and to Merck 
 
For purposes of this trial, 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. Appropriate supportive treatment should be 
provided if clinically indicated. In the event of overdose, the subject 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. 
 
If a dose of Merck’s product meeting the protocol definition of overdose is taken without any 
associated clinical symptoms or abnormal laboratory results, the overdose is reported as a 
non-serious Event of Clinical Interest (ECI), using the terminology “accidental or intentional 
overdose without adverse effect.” 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 33 
 
 
 
 
All reports of overdose with and without an adverse event must be reported within 5 working 
days to MDACC’s IND Office and within 2 working days to Merck Global Safety. (Attn: 
Worldwide Product Safety; FAX 215661-6229) 
 
8.3 
Reporting of Pregnancy and Lactation to the Sponsor and to Merck 
 
Although pregnancy and lactation are not considered adverse events, it is the responsibility 
of investigators or their designees to report any pregnancy or lactation in a subject 
(spontaneously reported to them) that occurs during the trial. 
 
Pregnancies and lactations that occur after the consent form is signed but before initiation of 
pembrolizumab must be reported by the investigator if they cause the subject to be excluded 
from the trial, or are the result of a protocol-specified intervention, including but not limited 
to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure. 
 
Pregnancies and lactations that occur from the time of initiation of study treatment 
through 120 days following cessation ofstudy treatment, or 30 days following cessation 
of study treatment if the subject initiates new anticancer therapy, whichever is earlier, 
must be reported by the investigator. 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. 
 
Such events must be reported within 5 working days to MDACC’s IND Office and within 2 
working days to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215661-6229) 
 
8.4 
Immediate Reporting of Adverse Events to the Sponsor and to Merck 
 
8.3.1 Serious Adverse Events 
 
An adverse event or suspected adverse reaction is considered “serious” if, in the view of 
either the investigator or the sponsor, it results in any of the following outcomes: 
 
• 
Death 
 
• 
A life-threatening adverse drug experience – any adverse experience that places the 
patient, in the view of the initial reporter, at immediate risk of death from the adverse 
experience as it occurred. It does not include an adverse experience that, had it occurred in 
a more severe form, might have caused death. 
 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 34 
 
 
 
 
• 
A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions. 
 
• 
A congenital anomaly/birth defect. 
 
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 patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
Examples of such medical events include allergic bronchospasm requiring intensive 
treatment in an emergency room or at home, blood dyscrasias or convulsions that do not 
result in inpatient hospitalization, or the development of drug dependency or drug abuse (21 
CFR 312.32). 
 
• 
Important medical events as defined above, may also be considered serious adverse 
events. Any important medical event can and should be reported as an SAE if deemed 
appropriate by the Principal Investigator or the IND Sponsor, IND Office. 
 
• 
All events occurring during the conduct of a protocol and meeting the definition of a 
SAE must be reported to the IRB in accordance with the timeframes and procedures outlined 
in “The University of Texas M. D. Anderson Cancer Center Institutional Review Board Policy 
for Investigators on Reporting Serious Unanticipated Adverse Events for Drugs and Devices”. 
Unless stated otherwise in the protocol, all SAEs, expected or unexpected, must be reported 
to the IND Office, regardless of attribution (within 5 working days of knowledge of the event). 
 
• 
All life-threatening or fatal events, that are unexpected, and related to the study drug, 
must have a written report submitted within 24 hours (next working day) of knowledge of 
the event to the Safety Project Manager in the IND Office. 
 
• 
Unless otherwise noted, the electronic SAE application (eSAE) will be utilized for 
safety reporting to the IND Office and MDACC IRB. 
 
• 
Serious adverse events will be captured from the time of the first protocol-specific 
intervention, until 90 days after cessation of study treatment, or 30 days following 
cessation of study treatment if the subject initiates new anticancer therapy, unless 
the participant withdraws consent. Serious adverse events must be followed until clinical 
recovery is complete and laboratory tests have returned to baseline, progression of the 
event has stabilized, or there has been acceptable resolution of the event. 
 
• 
Additionally, any serious adverse events that occur after the time period noted 
above that are related to the study treatment must be reported to the IND Office. This may 
include the development of a secondary malignancy. 
 
Reporting to FDA: 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 35 
 
 
 
 
• 
Serious adverse events will be forwarded to FDA by the IND Sponsor (Safety Project 
Manager IND Office) according to 21 CFR 312.32. 
 
It is the responsibility of the PI and the research team to ensure serious adverse events are 
reported according to the Code of Federal Regulations, Good Clinical Practices, the protocol 
guidelines, the sponsor’s guidelines, and Institutional Review Board policy. 
 
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.  
 
8.3.2 Events of Clinical Interest 
 
Selected non-serious and serious adverse events are also known as Events of Clinical Interest 
(ECI) and must be reported within 5 working days to the Sponsor and within 2 working days 
to Merck Global Safety. (Attn: Worldwide Product Safety; FAX 215-661-6229). 
 
For the time period beginning when the consent form is signed until initiation of 
pembrolizumab, any ECI, or follow up to an ECI, that occurs to any subject must be reported 
within 5 working days to the Sponsor and within 2 working days to Merck Global Safety if it 
causes the subject to be excluded from the trial, or is the result of a protocol-specified 
intervention, including but not limited to washout or discontinuation of usual therapy, diet, 
placebo treatment or a procedure. 
 
For the time period beginning at initiation of pembrolizumab through 9 0 days following 
cessation of study treatment, or 30 days following cessation of treatment if the subject 
initiates new anticancer therapy, whichever is earlier, any ECI, or follow up to an ECI, 
whether or not related to Merck product, must be reported within 5 working days to the 
Sponsor and within 24 hours to Merck Global Safety. 
 
Events of clinical interest for this trial include: 
 
1. an overdose of Merck product, as defined in Section 8.1 - Definition of an Overdose for 
This Protocol and Reporting of Overdose to the Sponsor, that is not associated with clinical 
symptoms or abnormal laboratory results. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 36 
 
 
 
 
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. 
 
8.3.3 Evaluating Adverse Events 
 
An investigator who is a qualified physician will evaluate all adverse events according to the 
NCI Common Terminology for Adverse Events (CTCAE), version 4.0. Any adverse event which 
changes CTCAE grade over the course of a given episode will have each change of grade 
recorded on the adverse event case report forms/worksheets. 
 
All adverse events regardless of CTCAE grade must also be evaluated for seriousness. 
 
Table 5 Evaluating Adverse Events 
 
An investigator who is a qualified physician, will evaluate all adverse events as to: 
 
V4.0 
CTCAE 
Grading 
Grade 1 
Mild; asymptomatic or mid symptoms; clinical or diagnostic 
observations only; intervention not indicated. 
Grade 2 
Moderate; minimal, local or noninvasive intervention 
indicated; limiting age-appropriate instrumental ADL. 
Grade 3 
Severe  or  medically  significant  but  not  immediately  life- 
threatening; hospitalization or prolongation or hospitalization 
indicated; disabling; limiting self-care ADL. 
Grade 4 
Life threatening consequences; urgent intervention indicated. 
Grade 5 
Death related to AE 
Seriousness 
A serious adverse event is any adverse event occurring at any dose or 
during any use of Merck product that: 
†Results in death; or 
†Is life threatening; or places the subject, in the view of the investigator, 
at immediate risk of death from the event as it occurred (Note: This does 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 37 
 
 
 
 
 
not include an adverse event that, had it occurred in a more severe form, 
might have caused death.); or 
†Results in a persistent or significant disability/incapacity (substantial 
disruption of one’s ability to conduct normal life functions); or 
†Results    in    or    prolongs    an    existing    inpatient    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 [including hospitalization 
for an elective procedure] for a preexisting condition which has not 
worsened does not constitute a serious adverse event.); or 
†Is a congenital anomaly/birth defect (in offspring of subject taking the 
product regardless of time to diagnosis);or 
Is a new cancer; (that is not a condition of the study) or 
Is an overdose (whether accidental or intentional).   Any adverse event 
associated with an overdose is considered a serious adverse event. An 
overdose that is not associated with an adverse event is considered a non- 
serious event of clinical interest and must be reported within 24 hours. 
Other important medical events that may not result in death, not be life 
threatening, or not require hospitalization may be considered a serious 
adverse event when, based upon appropriate medical judgment, the 
event may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed previously (designated 
above by a †). 
Duration 
Record the start and stop dates of the adverse event. If less than 1 day, 
indicate the appropriate length of time and units 
Action taken 
Did the adverse event cause the Merck product to be discontinued? 
Relationship 
to test drug 
Did the Merck product cause the adverse event? The determination of the 
likelihood that the Merck product caused the adverse event 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 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 38 
 
 
 
 
 
likelihood of a relationship between the test drug and the adverse event 
based              upon              the               available               information. 
The following components are to be used to assess the relationship 
between the Merck product and the AE; the greater the correlation with 
the components and their respective elements (in number and/or 
intensity), the more likely the Merck product caused the adverse event 
(AE): 
Exposure 
Is there evidence that the subject was actually exposed to the 
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          the           Merck           product? 
Is the time of onset of the AE compatible with a drug-induced 
effect (applies to trials 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 
 
 
 
 
 
 
 
 
 
 
 
Relationship 
to 
Merck 
product 
(continued) 
The  following  components  are  to  be  used  to  assess  the  relationship 
between the test drug and the AE: (continued) 
Dechallenge 
Was 
the 
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. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 39 
 
 
 
 
 
(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; or (3) the trial is a single-dose drug trial); or (4) 
Merck product(s) is/are only used one time.) 
Rechallenge 
Was the subject re-exposed to the 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 trial 
is a single-dose drug trial); or (3) Merck product(s) is/are 
used only one time). 
NOTE: IF A RECHALLENGE IS PLANNED FOR AN ADVERSE 
EVENT WHICH WAS SERIOUS AND WHICH MAY HAVE 
BEEN CAUSED BY THE MERCK PRODUCT, OR IF 
REEXPOSURE 
TO 
THE 
MERCK 
PRODUCT 
POSES 
ADDITIONAL POTENTIAL SIGNIFICANT RISK TO THE 
SUBJECT, THEN THE RECHALLENGE MUST BE APPROVED 
IN ADVANCE BY THE U.S. CLINICAL MONITOR AS PER 
DOSE MODIFICATION GUIDELINES IN THE PROTOCOL. 
Consistency 
with 
Trial 
Treatment 
Profile 
Is   the   clinical/pathological   presentation   of   the   AE 
consistent with previous knowledge regarding the Merck 
product or drug class pharmacology or toxicology? 
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. 
Record one of the following 
Use the following scale of criteria as guidance (not all 
criteria  must  be present  to  be  indicative  of  a  Merck 
product relationship). 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 40 
 
 
 
 
 
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 the Merck product is reasonable. The 
AE is more likely explained by the Merck product than by 
another cause. 
No, there is not a reasonable 
possibility 
Merck 
product 
relationship 
Subject did not receive the Merck product OR temporal 
sequence of the AE onset relative to administration of the 
Merck product is not reasonable OR there is another 
obvious cause of the AE. (Also entered for a subject with 
overdose without an associated AE.) 
 
 
8.3.4 Sponsor Responsibility for Reporting Adverse Events 
 
All Adverse Events will be reported to regulatory authorities, IRB/IECs and investigators in 
accordance with all applicable global laws and regulations. We will record events according 
to phase I trials from the table below. 
 
 
 
 
Recommended Adverse Event Recording Guidelines 
 
 
 
 
Attribution 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 
Unrelated 
Phase I 
Phase I 
Phase I 
Phase II 
Phase I 
Phase II 
Phase III 
Phase I 
Phase II 
Phase III 
Unlikely 
Phase I 
Phase I 
Phase I 
Phase II 
Phase I 
Phase II 
Phase III 
Phase I 
Phase II 
Phase III 
Possible 
Phase I 
Phase II 
Phase I 
Phase II 
Phase I 
Phase II 
Phase I 
Phase II 
Phase I 
Phase II 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 41 
 
 
 
 
 
Phase III 
Phase III 
Phase III 
Phase III 
Probable 
Phase I 
Phase II 
Phase I 
Phase II 
Phase III 
Phase I 
Phase II 
Phase III 
Phase I 
Phase II 
Phase III 
Phase I 
Phase II 
Phase III 
Definitive 
Phase I 
Phase II 
Phase I 
Phase II 
Phase III 
Phase I 
Phase II 
Phase III 
Phase I 
Phase II 
Phase III 
Phase I 
Phase II 
Phase III 
 
 
 
 
 
9.1 STATISTICAL CONSIDERATIONS 
 
The purpose of this study is to assess the safety of treatment with pembrolizumab (two 
cycles) in the ‘window of opportunity’ setting for bladder cancer patients who are scheduled 
to undergo radical cystectomy. Secondary endpoints for efficacy and biomarker activity will 
be described and used to design future studies. 
 
9.2 
Endpoints 
 
9.1.1 Toxicity for Safety Monitoring (TOX) 
 
TOX will be monitored for an approximate 3-month treatment time interval (2 cycles/6 weeks 
+ surgery/2 week scheduling cushion + 30 day surgical complication evaluation). A patient 
will be considered to have a toxicity of concern (TOX) if any of the following apply: 
 
 Any 30-day grade 3 or higher surgical complication at least possibly related to the 
treatment 
 Any toxicity at least possibly related to the treatment that prevents surgery 
o Note, missing surgery due to progression or withdrawal will not count as a TOX 
event. Rapid progression is not seen with pembrolizumab. 
 Death between the start of study and the 30-day post-surgical assessment will count as 
long as it is toxic death at least possibly related to the pembrolizumab or surgery. Deaths 
clearly unrelated to treatment will not count as an event. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 42 
 
 
 
 
9.1.2 Adverse Events 
 
Adverse events will be recorded as described in section 8, using CTC v4 and surgical 
complications 
 
9.1.3 Lymphocytic infiltration pre and post treatment 
 
Pre and post treatment tumor specimens will be formalin-fixed and paraffin-embedded on 
slides and stained with H&E and evaluated by the collaborator pathologist for the 
presence/absence of lymphocytes within the tumor tissue. 
 
9.1.4 Residual tumor 
 
This will be reported as whether there is any residual tumor in the surgical specimen (present 
/absent) as well as area of the surgical specimen comprised of residual tumor. 
 
9.1.5 Biomarker activity 
 
Immunological markers include CD4 and CD8 T cells and biomarker activity includes TILS, PD- 
1 and PD-L1 levels. These will be measured from the biopsy samples and surgical specimens. 
 
9.1.6 Tumor Yield. 
 
The amount of residual tumor available for analysis and the numbers of patients with 
assessable samples will be recorded. 
 
9.1.7 Human Microbiome 
 
The humane microbiome profile by 16S ribosomal sequencing will be obtained from urine 
and feces. These data will then be used in an ad hoc correlation with our pathologic endpoint. 
 
9.2 
Sample Size Considerations 
 
A pilot group of 20 patients will be assessed to confirm the safety of pre-surgical 
pembrolizumab and also allow for preliminary studies of drug efficacy and markers of tissue 
activity. With this sample size and the interim monitoring described below, we will stop the 
trial early 68% of the time of the underlying population TOX rate is 30%, but only 16% at the 
target of 15%, and 0.7% if it is 5%. If the trial TOX rate is 15% (3/20), the 95% posterior 
credible interval would be (5.4%, 36.3%) using a prior of beta(1, 1). 
 
9.3 
Safety Interim Analyses 
 
The safety analyses will monitor TOX as defined above using the methods of Thall et al[9]. If 
there is high probability that the underlying TOX rate is greater than 15%, the trial will be held 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 43 
 
 
 
 
until all treated patients have completed 30 days post-surgery or gone off study prior to that 
time. The trial will then be stopped early if the risk of severe toxicity has been confirmed. 
Formally, denoting TOX probability by pTOX and assuming this follows a beta (1, 1) prior 
distribution, the trial will be held if Prob(pTOX > 0.15 | data) > 0.95. Monitoring will start 
once the 5th patient has been on trial for 4 weeks (at the end of the first week of cycle 2). 
After that, monitoring will continue monthly until the 20th patient has been followed for the 
full treatment period. A 6th patient will only be enrolled once there is sufficient evidence that 
fewer than 2 patients have TOX, i.e. ≥4 of the first 5 patients complete 30 days after surgery 
with no TOX. For the purposes of ongoing monthly trial monitoring, patients will be evaluable 
if they have been treated and then either have a TOX or have gone 4 weeks without TOX. 
Patients who are without TOX at 4 weeks, but who develop TOX later within the treatment 
interval will count as having a TOX at the next monthly evaluation. Stopping rules and 
operating characteristics were calculated in MultcLean 2.1. 
 
Note, that since we expect enrollment of 1-2 patients per month, it is possible that monthly 
monitoring may allow a small overrun of patients, but this is expected to be only 1-2 
additional patients at any given look. 
 
If there are this many (or more) patients with TOX: 
2 
3 
4 
5 
6 
Stop the trial if there are this many (or fewer) patients who are 
evaluable for TOX: 
5 
9 
13 
17 
20* 
*Always  stop  with  20  patients,  but  if  6  or  more  patients  have  a  TOX  event,  then 
pembrolizumab is unsafe for ‘window of opportunity’ use at this dose and schedule. 
 
The operating characteristics of this design based on simulations are summarized in the 
following table. Note, since accrual will continue during monitoring, it’s possible that these 
results underestimate the numbers of patients by 1-2 patients at the higher TOX rates. 
 
True Prob(TOX) Pr(stop) 
Median # Pts (25%, 75%) 
0.05 
0.03 
20 (20, 20) 
0.10 
0.11 
20 (20, 20) 
0.15 
0.25 
20 (16, 20) 
0.20 
0.43 
20 (5, 20) 
0.25 
0.60 
12 (5, 20) 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 44 
 
 
 
 
 
0.30 
0.75 
7 (5, 19) 
0.35 
0.86 
5 (5, 12) 
0.40 
0.93 
5 (5, 8) 
 
 
The Investigator is responsible for completing a safety summary report and submitting it to 
the IND office Medical Monitor for review. This should be submitted after the first 5 
evaluable patients complete 4 weeks of study treatment prior to cystectomy, and monthly 
thereafter. On every  new report submission, the information from previous reported 
patients will need to be updated, and the information from new patients added 
 
9.4 
Analysis Plan 
 
TOX events will be reported with a 95% credible interval assuming a non-informative prior of 
beta (1,1). Specific events will also be summarized. Then all adverse events and surgical 
complications will be reported overall by grade, attribution, and treatment period (cycle 1, 
cycle 2, between the end of cycle 2 and actual surgery, 30 days following surgery). 
Demographic and baseline laboratory results will be summarized using descriptive and 
graphical statistics. Changes in markers between biopsy and surgical resection will be 
compared with a paired t-test or non-parametric alternative as indicated for continuous 
measures, and with McNemar’s test for binary or ordinal measures. The numbers of patients 
with sufficient samples for laboratory analysis will be used to plan the numbers of patients 
needed for enough evaluable samples future trials. Similarly this experience will guide 
planning for the numbers and types of markers that can be reasonably assessed from surgical 
specimens in this patient population after ‘window of opportunity’ pembrolizumab 
treatment. 
 
10.0 INVESTIGATIONAL PRODUCT 
 
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. 
 
Clinical supplies  must  be stored  in  a secure, limited-access location under the storage 
conditions specified on the label. 
 
Receipt and dispensing of trial medication must be recorded by an authorized person at the 
trial site. 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 45 
 
 
 
 
Clinical supplies may not be used for any purpose other than that stated in the protocol. 
 
Clinical supplies will be affixed with a clinical label in accordance with regulatory 
requirements. 
 
The investigator is responsible for keeping accurate records of the clinical supplies received 
from Merck or designee, the amount dispensed to and returned by the subjects and the 
amount remaining at the conclusion of the trial. 
 
Upon completion or termination of the study, all unused and/or partially used 
investigational product will be destroyed at the site per institutional policy. It is the 
Investigator’s responsibility to a r r a n g e f o r 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. 
 
 
 
 
11.1 ADMINISTRATIVE AND REGULATORY DETAILS 
 
11.2 Confidentiality 
 
All pathology specimens, evaluation forms, reports and other records will be identified 
in a manner designed to maintain patient confidentiality. All records will be kept in a 
secure storage area with limited access. No patient identifiers will be used when 
analyzing the data or reporting the results. 
 
11.3 Compliance with Financial Disclosure Requirements 
 
Before the start of the study, the investigator and each sub-investigator will disclose 
any proprietary or financial interests. The investigator agrees to update this 
information during the study or within one year of its completion. 
 
11.4 Compliance with Law, Audit and Debarment 
 
The institution represents and warrants that neither it, the Principal Investigator, nor 
any of the Institution’s employees performing the Study is (a) under investigation by the 
Food and Drug Administration (“FDA”) or equivalent authority in connection with an 
action to debar, disqualify, or prohibit such person or entity from participating in human 
research or (b) presently debarred, disqualified or prohibited pursuant to 21 U.S.C.  § 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 46 
 
 
 
 
335(a) and 335(b) or any other applicable law or by any regulatory authority or 
government entity. 
 
11.5 Compliance with Trial Registration and Results Posting Requirements 
 
Under the terms of the Food and Drug Administration Modernization Act (FDAMA) and 
the Food and Drug Administration Amendments Act (FDAAA), the Sponsor of the trial is 
solely responsible for determining whether the trial and its results are subject to the 
requirements 
for 
submission 
to 
the 
Clinical 
Trials 
Data 
Bank, 
http://www.clinicaltrials.gov. Information posted will allow subjects to identify 
potentially appropriate trials for their disease conditions and pursue participation by 
calling a central contact number for further information on appropriate trial locations 
and trial site contact information. 
 
 
 
 
12.1 APPENDICES 
 
12.2 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. Ambulatory and capable of all self-care, but 
unable to carry out any work activities. Up and about 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 
Proprietary Information of MD Anderson

2017-0057 
January 9, 2019 
Page 47 
 
 
 
 
The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982. The Eastern 
Cooperative Oncology Group, Robert Comis M.D., Group Chair. 
 
 
 
 
12.3 Common Terminology Criteria for Adverse Events V4.0 (CTCAE) 
 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria 
for Adverse Events (CTCAE) version 4.0 will be utilized for adverse event reporting. 
(http://ctep.cancer.gov/reporting/ctc.html) 
 
REFERENCES: 
 
1. 
Liakou, C.I., et al., CTLA-4 blockade increases IFNgamma-producing CD4+ICOShi cells 
to shift the ratio of effector to regulatory T cells in cancer patients. Proc Natl Acad Sci 
U S A, 2008. 105(39): p. 14987-92. 
2. 
Chen, H., et al., CD4 T cells require ICOS-mediated PI3K signaling to increase T-Bet 
expression in the setting of anti-CTLA-4 therapy. Cancer Immunol Res, 2014. 2(2): p. 
167-76. 
3. 
Ng Tang, D., et al., Increased frequency of ICOS+ CD4 T cells as a pharmacodynamic 
biomarker for anti-CTLA-4 therapy. Cancer Immunol Res, 2013. 1(4): p. 229-34. 
4. 
Carthon, B.C., et al., Preoperative CTLA-4 blockade: tolerability and immune 
monitoring in the setting of a presurgical clinical trial. Clin Cancer Res, 2010. 16(10): 
p. 2861-71. 
5. 
Choi, W., et al., Intrinsic basal and luminal subtypes of muscle-invasive bladder cancer. 
Nat Rev Urol, 2014. 11(7): p. 400-10. 
6. 
Choi, W., et al., p63 expression defines a lethal subset of muscle-invasive bladder 
cancers. PLoS One, 2012. 7(1): p. e30206. 
7. 
Plimack, E.R., et al., Safety and activity of pembrolizumab in patients with locally 
advanced or metastatic urothelial cancer (KEYNOTE-012): a non-randomised, open- 
label, phase 1b study. Lancet Oncol, 2017. 18(2): p. 212-220. 
8. 
Bellmunt, J., et al., Pembrolizumab as Second-Line Therapy for Advanced Urothelial 
Carcinoma. N Engl J Med, 2017. 376(11): p. 1015-1026. 
9. 
Thall, P.F., R.M. Simon, and E.H. Estey, Bayesian sequential monitoring designs for 
single-arm clinical trials with multiple outcomes. Stat Med, 1995. 14(4): p. 357-79. 
10. 
Gopalakrishnan V et al Science. 2018 Jan 5;359(6371):97-103. doi: 
10.1126/science.aan4236. Epub 2017 Nov 2. 
Proprietary Information of MD Anderson