Clinical trial NCT02009332
Conditions: Non-muscle Invasive Bladder Cancer (NMIBC)
Sponsor: Aadi Bioscience, Inc.
Start date: 2014-04-09; Completion date: 2019-12-01
Enrollment: 21 participants; Allocation: NON_RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
Purpose of this study is to determine appropriate dosing of ABI-009 and evaluate the safety and anti-tumor activity of ABI-009 in treatment of non-muscle invasive bladder cancer

Detailed description:

Arms: arm 1: Phase 1, Cohort 1: ABI-009 injectable suspension, 100 mg in 80 mL 0.9% saline, administered intravesically and retained for 2 hours, once per week for 6 weeks arm 2: Phase 1, Cohort 2: ABI-009 injectable suspension, 200 mg in 80 mL 0.9% saline, administered intravesically and retained for 2 hours, once per week for 6 weeks arm 3: Phase 1, Cohort 2b: ABI-009 injectable suspension, 100 mg in 80 mL 0.9% saline, administered intravesically and retained for 2 hours, twice per week (total dose 200 mg per week) for 6 weeks arm 4: Phase 1, Cohort 3: ABI-009 injectable suspension, 300 mg in 80 mL 0.9% saline, administered intravesically and retained for 2 hours, once per week for 6 weeks arm 5: Phase 1, Cohort 4: ABI-009 injectable suspension, 400 mg in 80 mL 0.9% saline, administered intravesically and retained for 2 hours, once per week for 6 weeks arm 6: ABI-009 injectable suspension, 200 mg in 80 mL 0.9% saline, administered intravesically and retained for 1 hour, once per week for 6 weeks; Gemcitabine, 2000 mg in 100 mL saline, administered intravesically after voiding of ABI-009 and retained for 1 hour, once per week for 6 weeks
Interventions: intervention 1: ABI-009 intervention 2: Gemcitabine
Intervention descriptions: intervention 1: ABI-009 is a nanoparticle albumin-bound (nab®) formulation of the mammalian Target of Rapamycin ( mTOR) inhibitor, sirolimus. Specifically, ABI-009 is a sterile lyophilized powder of albumin-bound sirolimus nanoparticles with a mean particle size of less than 100 nm. intervention 2: Gemcitabine is administered after ABI-009 in the Phase 2 study.

Protocol documents:
Prot_SAP_000.pdf: 


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SYNOPSIS 
Sponsor:  AADi, LLC 
Name of Finished Product: 
ABI-009, nab-rapamycin, nanoparticle albumin-bound rapamycin 
Name of Active ingredient:  Rapamycin 
Study Title:  
A Combined Phase 1 and Phase 2 Study of Albumin-bound Rapamycin Nanoparticles 
(nab-Rapamycin, ABI-009) in the Treatment of BCG Refractory or Recurrent Nonmuscle-
invasive Transitional Cell Bladder Cancer 
Study Number:  BC001 
Study Phase: 1, 2 
Primary Objective(s):  
In phase 1, to determine the safety, toxicity, and preliminary efficacy profiles of 
intravesically administered nab-rapamycin at the maximum deliverable dose (MDD). In 
phase 2, to evaluate the utility (potential for clinical efficacy) and safety of nab-rapamycin 
in combination with gemcitabine in the treatment of BCG refractory or recurrent 
nonmuscle-invasive transitional cell carcinoma (TCC) of the bladder as measured by 
complete response rate (defined as negative bladder biopsy at 6 weeks post-treatment). 
Secondary Objective(s): 
In phase 1 and 2, to assess molecular correlates for response to intravesical nab-
rapamycin therapy using blood, urine, and tissue bank assembled from patients in this 
study. The molecular markers analyzed will include but not be limited to p53, p63, 
Stathmin, Tau, ribosomal s6 kinase, Ki67, and secreted protein, acidic and rich in cysteine 
(SPARC). In phase 2, to further evaluate the efficacy, including event-free survival (EFS), 
safety, and toxicity profile of intravesically administered nab-rapamycin. 
Study Design: 
This study is a combined phase 1 and phase 2 multi-institution program to determine the 
safety and tolerability profile of intravesical nab-rapamycin in human patients with 
nonmuscle-invasive TCC of the urinary bladder that have previously demonstrated 
resistance to standard intravesical treatment.  
In the phase 1 dose escalation portion of the study, up to 30 patients will be enrolled, 3 
per cohort, using the 3+3 dose escalation rule: 100 mg/week, 200 mg/week, 300 
mg/week, and 400 mg/week for 6 weeks of treatment. There will be an additional cohort 
to evaluate the safety of 2x/weekly dosing if no significant safety issues are found in 
cohort 1: cohort 2b – 100 mg 2x/week (total weekly dose of 200 mg). 
In phase 2, up to 29 patients will receive intravesical nab-rapamycin and gemcitabine 
using the Simon 2-stage design: initially, there will be only 10 patients enrolled with a 
rejection rule that only if there are 2 or more positive responses will the study proceed to 
further enrollment of the next 19 patients. 


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Study Population:  
In phase 1, up to 30 patients will be enrolled, 3 per cohort, using the 3+3 dose escalation 
rule.  In phase 2, up to 29 patients will be enrolled. 
Diagnosis and Main Criteria for Inclusion:  
Patients, ≥18 years of age, with ECOG 0, 1, or 2, must have a diagnosis of nonmuscle-
invasive TCC of the urinary bladder confirmed at the study institution. This will include 
stage Ta, T1, and Tis, and exclude all patients with muscle invasion (≥T2). All grossly 
visible disease must be fully resected within 6 weeks prior to enrollment and pathologic 
stage will be confirmed at the institution where the patient is enrolled. Patients must have 
either recurrent or refractory disease after receiving BCG therapy. Refractory disease is 
defined as failure to achieve tumor-free status by 6 months of initiation of adequate BCG 
therapy. Recurrent disease is defined as reappearance of disease after achieving a 
tumor-free status by 6 months of initiation of adequate BCG therapy. Adequate therapy 
is considered a minimum of 6 weekly doses of BCG followed by a second course of 
therapy in which patient received a minimum of 3 doses. 
Test Product, Dose, and Mode of Administration: 
In the phase 1 dose escalation portion of the study, nab-rapamycin will be given 100 
mg/week, 100 mg 2x/week (total weekly dose 200 mg), 300 mg/week, 200 mg 2x/week 
(total weekly dose 400 mg), and 400 mg/week for 6 weeks of treatment. Patients will 
receive instillations of nab-rapamycin in saline diluent initially at an approximate pH of 5 
to 7.5. Patients will be instructed to avoid excessive fluid intake starting the day before 
treatment. Patients will receive intravesical nab-rapamycin by sterile urethral 
catheterization once or twice weekly for 6 weeks, dependent upon the dosing schedule. 
Prior to instillation, the bladder will be emptied via the sterile urethral catheter. The patient 
will be instructed to keep the drug in the bladder for 2 hours before voiding.  
The phase 2 portion of the study will be initiated with nab-rapamycin at 200 mg/week as 
determined by phase 1 and 2000 mg/week of gemcitabine. Patients will receive 
intravesical instillations of nab-rapamycin followed by gemcitabine in saline diluent at an 
approximate pH of 5.0-7.5. nab-Rapamycin will be instilled first and the patient will be 
instructed to keep the drug in the bladder for one hour before voiding. Upon voiding, 
gemcitabine will then be instilled and the patient will be asked to retain the drug for an 
additional hour before voiding. Mode of administration will be as described above in phase 
1. 
Reference Therapy, Dose, and Mode of Administration: N/A 
Duration of Treatment: 
Patient will continue to receive maintenance instillations until there is a positive 
cystoscopic biopsy or until a maximum of 1 year from the start of therapy. 
Rapamycin Blood Levels: 
Rapamycin concentrations in the blood of patients will be measured at pre-treatment (just 
before instillation) and at 2 hours post-instillation (just before voiding) to determine if there 
is any systemic absorption from the bladder. 


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Efficacy Assessments:  
A complete response is defined as a cancer-negative cystoscopic biopsy at the 6-week 
post-treatment assessment. No response will be defined as cystoscopic biopsy positive 
for cancer.  
Event-free survival (EFS) is defined as time from initiation of therapy to tumor recurrence 
or progression documented by biopsy, or death of any cause. For patients who are lost 
to follow-up or withdraw from the study, or if study termination occurs before recurrence, 
progression or death, the EFS will be censored at last disease assessment (date of last 
cystoscopic biopsy). For patients who start new anticancer treatment (chemotherapy, 
immunotherapy, or radiotherapy) or undergo a cystectomy, the EFS will be censored at 
the last disease assessment (date of last biopsy, cystoscopy) before the start of the new 
anticancer therapy or before the individual undergoes cystectomy. 
Safety Assessments: 
Safety and tolerability will be monitored through reporting of adverse events (AEs) and 
serious adverse events (SAEs), laboratory abnormalities, incidence of patients 
experiencing dose modifications, and/or premature discontinuation of study drug. 
Systemic dose-limiting toxicity (DLT) is defined as any grade systemic toxicity using the 
National Cancer Institute (NCI) Common Toxicity Criteria (CTCAE) version 4.0. Local 
dose limiting toxicity is defined as grade 3 or 4 bladder toxicity using the NCI CTCAE 
version 4.0.  
Statistical Methods: 
The phase 1 segment of the study will have a dose-escalation scheme that will enroll a 
maximum of 30 patients. Dose escalation will follow the 3+3 rule to establish the MDD. 
Once the MDD has been established, the phase 2 segment of the study will be initiated, 
using the Simon 2-stage design. In stage 1, there will be only 10 patients enrolled with a 
rejection rule that only if there are 2 or more positive responses will the study proceed to 
further enrollment of the next 19 patients (stage 2). If 1 or fewer responds in the first stage, 
we will terminate the study for lack of efficacy. If more than 5 patients respond overall, we 
will consider the agent promising.   
The Null Hypothesis is that there will be no difference between the current response rates 
to BCG therapy of 10% [1-3] and the response rate to intravesical nab-rapamycin with 
gemcitabine treatment after 6 weeks of therapy in the Phase 2 trial. The Alternative 
Hypothesis will be that there will be a ≥30% response rate to intravesical nab-rapamycin 
with gemcitabine treatment after 6 weeks of weekly therapy. The overall rejection rule is 
that if there are 5 or greater responses to treatment out of the entire enrollment, we will 
reject our Null Hypothesis and accept our Alternate Hypothesis, that there is a significant 
difference between the response rates of standard BCG therapy and intravesical nab-
rapamycin with gemcitabine treatment. 
The expected sample size for the phase 2 study Simon 2-stage design is 15 patients with 
a maximum of 29 patients. Based on our operating characteristic of 5% type I error and 
20% type II error, the number of patients that is expected to be enrolled will be 15 on 
average with a maximum total of 29 in order to sufficiently power the study. The probability 


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of correctly concluding the therapy is worthy of further study is 80% if the true underlying 
response rate is 30%. The probability of incorrectly concluding the therapy is promising 
is 5% if the true response rate is approximately 10%.  
Correlative studies: 
Six weeks after the last treatment, the patients will undergo a cystoscopy and biopsy. 
Tumor tissue samples will be stored for evaluation of molecular correlative studies to 
predict response to therapy.  
Date of Original Protocol: January 31, 2013 
 
 


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TABLE OF CONTENT 
 
SYNOPSIS ...................................................................................................................... 2 
TABLE OF CONTENT ..................................................................................................... 6 
LIST OF IN-TEXT TABLES ........................................................................................... 10 
LIST OF IN-TEXT FIGURES ......................................................................................... 10 
LIST OF APPENDICES ................................................................................................. 10 
1. 
OBJECTIVES AND ENDPOINTS ................................................................ 13 
1.1. 
Study Objectives .......................................................................................... 13 
1.1.1. 
Phase 1 – Primary Objectives ...................................................................... 13 
1.1.2. 
Phase 1 – Secondary Objectives ................................................................. 13 
1.1.3. 
Phase 2 – Primary Objectives ...................................................................... 13 
1.1.4. 
Phase 2 – Secondary Objectives ................................................................. 13 
1.2. 
Study Endpoints ........................................................................................... 13 
1.2.1. 
Phase 1 – Primary Endpoints ....................................................................... 13 
1.2.2. 
Phase 1 – Secondary Endpoints .................................................................. 13 
1.2.3. 
Phase 2 – Primary Efficacy Endpoints ......................................................... 13 
1.2.4. 
Phase 2 – Secondary Efficacy Endpoints .................................................... 14 
1.2.5. 
Phase 2 – Safety Endpoints ......................................................................... 14 
1.3. 
Pharmacokinetic Analyses and Correlative Studies ..................................... 14 
2. 
BACKGROUND AND RATIONALE .............................................................. 14 
2.1. 
Nonmuscle-invasive Bladder Cancer ........................................................... 14 
2.2. 
mTOR and Rapamycin in Bladder Cancer ................................................... 15 
2.3. 
Rapamycin, Rapalogs .................................................................................. 16 
2.4. 
nab-Rapamycin ............................................................................................ 17 
2.4.1. 
Preclinical Studies with nab-Rapamycin ...................................................... 17 
2.4.2. 
Clinical Studies with nab-Rapamycin ........................................................... 21 
2.4.3. 
Prior Clinical Experience in NMIBC with Intravesical nab-Paclitaxel ............ 22 
2.4.4. 
A Summary of Justification for Use of nab-Rapamycin in NMIBC ................ 23 
3. 
STUDY POPULATION ................................................................................. 25 


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3.1. 
Inclusion Criteria .......................................................................................... 25 
3.2. 
Exclusion Criteria ......................................................................................... 26 
4. 
STUDY DESIGN AND PLAN ....................................................................... 26 
4.1. 
Overall Study Design ................................................................................... 26 
4.2. 
Summary of Evaluation ................................................................................ 29 
4.2.1. 
Prestudy Evaluation ..................................................................................... 32 
4.2.2. 
Week of Instillation and Treatment Day ....................................................... 32 
4.2.3. 
Week 6 instillation ........................................................................................ 33 
4.2.4. 
Six-week Follow-up ...................................................................................... 33 
4.2.5. 
Six-week and Quarterly Response Assessments ......................................... 33 
4.3. 
Study Drug Dosage ...................................................................................... 34 
4.3.1. 
Dose Modifications ....................................................................................... 34 
4.4. 
Correlative Studies ....................................................................................... 34 
4.4.1. 
Tumor Biopsies ............................................................................................ 34 
4.4.2. 
Pharmacokinetic Sampling Method and Rationale ....................................... 34 
4.5. 
Concomitant Medications and Nondrug Therapies ...................................... 35 
4.6. 
Withdrawal/Premature Discontinuation ........................................................ 35 
5. 
STATISTICAL METHODS ........................................................................... 36 
5.1. 
Study Design and Sample Size .................................................................... 36 
5.1.1. 
Adverse Events and Toxicities ..................................................................... 37 
5.2. 
Patient Population ........................................................................................ 37 
5.2.1. 
Analysis Population ...................................................................................... 37 
5.2.2. 
Patient Characteristics ................................................................................. 38 
5.2.3. 
Patient Disposition ....................................................................................... 38 
5.2.4. 
Prior and Concomitant Medications ............................................................. 38 
5.3. 
Safety Analyses ........................................................................................... 38 
5.4. 
Efficacy Analyses ......................................................................................... 38 
5.4.1. 
Biomarker and Pharmacokinetic Analyses ................................................... 38 
6. 
STUDY DRUG MANAGEMENT AND ADMINISTRATION ........................... 39 
6.1. 
nab-Rapamycin ............................................................................................ 39 
6.1.1. 
nab-Rapamycin Packaging, Labeling, and Storage ..................................... 39 
6.1.2. 
nab-Rapamycin Preparation and Administration .......................................... 40 
6.1.3. 
Receipt and Return of nab-Rapamycin ........................................................ 42 


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6.1.4. 
Toxicities of nab-Rapamycin ........................................................................ 42 
6.2. 
Gemcitabine ................................................................................................. 43 
6.2.1. 
Gemcitabine Preparation and Administration ............................................... 43 
6.2.2. 
Toxicities of Gemcitabine ............................................................................. 43 
7. 
ADVERSE EVENT MANAGEMENT GUIDELINES ...................................... 43 
7.1. 
Definition of Adverse Events ........................................................................ 43 
7.2. 
Definition of Serious Adverse Events ........................................................... 44 
7.3. 
Timeframe for Considering an Event to be Reportable AE or SAE .............. 44 
7.4. 
Lack of Efficacy is Not Considered and AE or SAE ...................................... 45 
7.5. 
Patient Reporting of AEs and SAEs ............................................................. 45 
7.6. 
Investigator Reporting of AEs and SAEs ...................................................... 45 
7.7. 
Additional Investigator Responsibilities on Follow-up for SAEs ................... 46 
7.8. 
Criteria for Removal from Study ................................................................... 47 
7.9. 
Institutional Review Board Notification of SAEs ........................................... 47 
7.10. 
Sponsor Notification of Poststudy SAEs ...................................................... 47 
7.11. 
Deaths .......................................................................................................... 47 
8. 
ETHICAL, LEGAL, AND ADMINISTRATIVE ASPECTS .............................. 47 
8.1. 
Ethics ........................................................................................................... 47 
8.1.1. 
Institutional Review Board or Independent Ethics Committee ...................... 47 
8.1.2. 
Ethical Conduct of the Study ........................................................................ 48 
8.1.3. 
Informed Consent ......................................................................................... 48 
8.1.4. 
Data Safety and Monitoring .......................................................................... 48 
8.2. 
Disclosure of the Data .................................................................................. 49 
8.2.1. 
Confidentiality............................................................................................... 49 
8.2.2. 
Publication ................................................................................................... 49 
8.3. 
Investigator Documentation ......................................................................... 49 
8.3.1. 
Form FDA 1572 ............................................................................................ 49 
8.3.2. 
Curriculum Vitae ........................................................................................... 49 
8.3.3. 
Financial Disclosures ................................................................................... 50 
8.3.4. 
Laboratory Certification and Normal Ranges ............................................... 50 
8.4. 
Records Retention ....................................................................................... 50 
8.5. 
Protocol Violations/Deviations ...................................................................... 50 
9. 
TERMINATION OF STUDY ......................................................................... 50 


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10. 
INVESTIGATOR’S PROTOCOL AGREEMENT ........................................... 50 
11. 
REFERENCES ............................................................................................. 51 
12. 
APPENDICES .............................................................................................. 55 


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LIST OF IN-TEXT TABLES 
Table 1: 
Study Evaluation and Treatment Schedule .................................................. 29 
Table 2: 
Dosing Schema of Intravesical nab-Rapamycin ........................................... 36 
Table 3: 
Operating Characteristics of Dose Escalation .............................................. 36 
Table 4: 
Dosing Volume Preparation for Phase 1 Dosing .......................................... 41 
Table 5: 
Dosing Volume Preparation for Phase 2 Dosing .......................................... 41 
 
 
LIST OF IN-TEXT FIGURES 
Figure 1: Antitumor Activity of nab-Rapamycin in Tumor Xenografts .......................... 18 
Figure 2: Antitumor Activity and Body Weight Following Single Agent and 
Combination Treatments .............................................................................. 19 
Figure 3: Animal Survival Following Single Agent and Combination Treatments ........ 20 
Figure 4: Study Evaluations and Treatment Schema for Both Phase 1 and 2............. 31 
 
 
 
LIST OF APPENDICES 
Appendix I. Rapamune® Package Insert – Adverse Reactions………………………. 55 
Appendix II. Adverse Event Fax Cover Sheet…………………………………………… 56 
Appendix III. ECOG Performance Status…………………………………………………. 57 
Appendix IV. Sponsor Signatures………………………………………………………….. 58 
Appendix V. Investigator’s Protocol Agreement…………………………………………. 59 


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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
 
AE  
 
 
Adverse event 
ALT 
 
 
Alanine aminotransferase (SGPT) 
AST  
 
Aspartate aminotransferase (SGOT) 
AUC   
 
Area under the curve 
BCI 
 
 
Bladder cancer index  
BMP  
 
Basic metabolic panel 
β-hCG  
 
β-subunit of human chorionic gonadotropin 
CBC   
 
Complete blood count 
CFR   
 
Code of federal regulations 
CMP  
 
Comprehensive metabolic panel 
CRF   
 
Case report form 
CRO   
 
Contract research organization 
CT  
 
 
Computed tomography 
CTCAE   
Common Terminology Criteria for Adverse Events 
DLT 
 
 
Dose-limiting toxicity 
DHHS  
 
Department of Health and Human Services 
ECOG  
 
Eastern Cooperative Oncology Group 
EKG  
 
Electrocardiogram 
EFS   
 
Event-free survival 
FDA   
 
Food and Drug Administration 
G-CSF  
 
Granulocyte colony-stimulating factor 
GCP   
 
Good Clinical Practice 
GLP  
 
Good Laboratory Practices 
ICH   
 
International Conference on Harmonisation 
IEC   
 
Independent Ethics Committee 
IND   
 
Investigational New Drug 
IRB   
 
Institutional Review Board 
IV   
 
 
Intravenous 
NMIBC 
 
Nonmuscle-invasive bladder cancer 
MDD   
 
Maximum deliverable dose 
NCI   
 
National Cancer Institute 


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SAE   
 
Serious adverse event 
SGOT  
 
Serum glutamic oxaloacetic transaminase (AST) 
SGPT  
 
Serum glutamic pyruvic transaminase (ALT) 
SPARC   
Secreted protein, acidic and rich in cysteine 
TCC  
 
Transitional Cell Carcinoma 
TURBT   
Transurethral resection of bladder tumor  
ULN   
 
Upper limit of normal 
 
 


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1. 
OBJECTIVES AND ENDPOINTS 
1.1. 
Study Objectives 
In a combined phase 1 and phase 2 study to determine the safety, toxicity, and efficacy 
of intravesically administered albumin-bound rapamycin nanoparticles (nab-rapamycin, 
ABI-009, AADi, LLC, Pacific Palisades, CA) in patients with transitional cell carcinoma 
(TCC) of the urinary bladder that has recurred after or is refractory to standard intravesical 
Bacille Calmette-Guérin (BCG) therapy. 
1.1.1. Phase 1 – Primary Objectives 
The primary objectives of the phase 1 study are to determine the MDD and local and 
systemic DLT of intravesically administered nab-rapamycin. 
1.1.2. Phase 1 – Secondary Objectives 
The secondary objectives are to analyze blood, urine, and tissue from patients in this 
study to assess rapamycin blood levels and molecular correlates.  
1.1.3. Phase 2 – Primary Objectives 
The primary objective of this study is to evaluate the utility (potential for clinical efficacy) 
of nab-rapamycin in combination with gemcitabine in the treatment of BCG refractory or 
recurrent nonmuscle-invasive TCC of the bladder. 
1.1.4. Phase 2 – Secondary Objectives 
The secondary objectives are to further evaluate the safety and toxicity profile of 
intravesically administered nab-rapamycin with gemcitabine and to assess rapamycin 
blood levels and molecular correlates. 
1.2. 
Study Endpoints  
1.2.1. Phase 1 – Primary Endpoints  
The primary endpoints of the phase 1 portion of the study are the MDD, DLT, and safety 
/ toxicity profile of intravesically administered nab-rapamycin.  
Systemic DLT will be defined as any grade systemic toxicity using the NCI CTCAE version 
4.0. Local dose limiting toxicity will be defined as grade 3 or 4 bladder toxicity using the 
NCI CTCAE version 4.0.  
1.2.2. Phase 1 – Secondary Endpoints 
The secondary endpoints of the phase 1 portion are to determine rapamycin blood levels 
and analyze molecular correlates in tissue. The molecular markers analyzed will include 
but not be limited to p53, p63, Stathmin, Tau, ribosomal s6 kinase, Ki67, and SPARC. 
1.2.3. Phase 2 – Primary Efficacy Endpoints 
The primary efficacy endpoint of this study is to evaluate the utility of nab-rapamycin in 
combination with gemcitabine as measured by response rate in the treatment of BCG 
refractory or recurrent nonmuscle-invasive TCC. 
Response rate will be measured and documented at the 6-week post-treatment 
assessment, including cystoscopy with biopsy. A complete response is defined as a 


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cancer-negative biopsy at the 6-week post-treatment cystoscopy. No response will be 
defined as positive cystoscopic biopsy.  
1.2.4. Phase 2 – Secondary Efficacy Endpoints  
The secondary efficacy endpoints include event-free survival (EFS), EFS rates at 1 and 
2 years, disease recurrence at 1 and 2 years, disease progression at 1 and 2 years, 
overall survival, and time to cystectomy. Urine cytology will also be assessed as a 
secondary marker for disease recurrence. 
An event is defined as tumor recurrence, tumor progression to muscle invasive bladder 
cancer or death, whichever occurs first. Tumor recurrence must be documented by 
bladder biopsy. 
1.2.5. Phase 2 – Safety Endpoints  
The safety endpoints of the phase 2 portion of the study include treatment-emergent and 
treatment-related AEs. 
Safety and tolerability will be monitored through reporting of AEs and serious adverse 
events (SAEs), laboratory abnormalities, and incidence of patients experiencing dose 
modifications, dose interruptions, and/or premature discontinuation of study drug. 
1.3. Pharmacokinetic Analyses and Correlative Studies 
Blood levels of rapamycin will be analyzed in both phase 1 and 2 of the study. Plasma 
levels of gemcitabine and its metabolite dFdU will be analyzed in phase 2 of the study,  
This clinical study offers an excellent opportunity to assemble a blood, urine, and tissue 
bank for further interrogation regarding the molecular correlative markers that may predict 
sensitivity and resistance to intravesical nab-rapamycin therapy in TCC of the bladder. 
There is not expected to be any formal impact on decision-making within this study based 
on molecular markers and patients will, of course, have the opportunity to refuse to 
participate in tissue banking and still participate in the clinical study. 
The molecular markers analyzed will include but not be limited to p53, p63, Stathmin, 
Tau, ribosomal s6 kinase, Ki67, and SPARC.  
2. 
BACKGROUND and RATIONALE 
2.1. 
Nonmuscle-invasive Bladder Cancer 
In 2011, it was estimated that 69,250 new cases of bladder cancer were diagnosed in the 
United States and 14,990 people died from the disease. Bladder cancer is the fourth 
leading cause of cancer in men and the ninth leading cause of cancer in women in the 
United States [4]. Nonmuscle-invasive bladder cancer (NMIBC) accounts for 70 to 80 
percent of these cases. Bladder cancer has the highest recurrence rate of any 
malignancy. Although NMIBC is a relatively benign disease (Tis, carcinoma in situ [CIS], 
Ta, or T1), it recurs in 50-70% of patients, of which 10-20% will eventually progress to 
high-grade muscle invasive disease [5]. Furthermore, the disease is also characterized 
by having a large pool of patients who have been previously diagnosed and are still 
undergoing treatment for unresolved tumors; more than 1 million patients in the United 
States and Europe are estimated to be affected by the disease [6, 7].  


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The gold standard first-line treatment for NMIBC is intravesical Bacillus Calmette-Guerin 
(BCG) therapy, which elicits a nonspecific local immune response. However, up to 50% 
of patients treated with intravesical therapy for high-risk NMIBC or CIS will recur [8]. 
Several chemotherapeutic agents have been explored in the second-line setting, but 
there is no accepted and/or efficacious standard second-line regimen in the US. 
Additionally, none of the available chemotherapeutic agents, including gemcitabine, 
docetaxel, and valrubicin, that are currently explored in clinical trials are targeted 
therapeutics [clinicaltrials.gov]. 
Because of the lack of targeted therapeutic options, patients who fail to respond to 
standard intravesical therapies are usually left with radical cystectomy as the only 
potential cure. However, this surgery carries significant morbidity and mortality. 
Furthermore, many patients are not appropriate surgical candidates for this procedure 
and some refuse surgery out of fear and concern for their future quality of life without a 
normal, functioning bladder. Because of the high disease recurrence and potential 
morbidity from surgery, the cost per bladder cancer patient is among the highest of all 
cancers, ranging from US$96,000 to US$187,000 [9]. Thus, the development of an 
effective molecularly targeted intravesical therapy is highly desirable. 
This study is a combined phase 1/2 clinical study to assess the safety, toxicity, and 
efficacy of local intravesical administration of nab-rapamycin to treat patients with BCG-
refractory or recurrent NMIBC. This proposal will present a unique opportunity to develop 
the first targeted molecular therapy for intravesical treatment of bladder cancer. It has 
been demonstrated at Columbia University that the mTOR pathway plays an important 
role in bladder cancer development. Additionally, it has been previously established that 
the nanoparticle albumin-bound, nab® platform can successfully deliver hydrophobic 
drugs such as paclitaxel intravesically to bladder cancer patients [10]. Therefore, we 
believe that intravesical nab-rapamycin, a combination of an effective therapeutic agent 
and a proven drug delivery platform, will offer a promising avenue for the treatment of 
bladder cancer.  
2.2. 
mTOR and Rapamycin in Bladder Cancer 
The inhibition of the mTOR signaling pathway is a promising therapy for bladder cancer 
[11]. mTOR is a serine/threonine-specific protein kinase, downstream of the 
phosphatidylinositol 3-kinase (PI3K)/Akt (protein kinase B) pathway, and a key regulator 
of cell survival, proliferation, stress, and metabolism. Additionally, mTOR is involved in 
regulating angiogenesis by controlling endothelial and smooth muscle cell proliferation 
via the hypoxia-inducible factor-1α and vascular endothelial growth factor [12]. mTOR 
pathway dysregulation has been found in many human carcinomas and mTOR inhibition 
produced substantial inhibitory effects on tumor progression [13-15]. Specifically, high 
levels (74%) of phosphorylated mTOR expression were found in human bladder cancer 
tissue array, and phosphorylated mTOR intensity was associated with reduced survival 
[16]. In another study, p-mTOR expression was increased in 65/203 (32.0%) of patient 
urothelial carcinoma specimens cancer vs. non-tumor bladder tissue, and treatment of 
rapamycin showed activity against a panel of human urothelial carcinoma cell lines, 
including UMUC3 [17]. Researchers at Columbia University developed an engineered 
mouse model with targeted deletion of 2 key tumor suppressor genes, p53 and PTEN, in 


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the bladder epithelium. These deletions result in the development of invasive bladder 
tumors that share histologic and molecular features of the human disease and display 
metastases as are prevalent in human bladder cancer patients [11]. Subsequently they 
have demonstrated that mTOR expression increases as a function of the disease stage 
in progression from superficial disease to invasive bladder cancer, as evident by 
activation of pS6-kinase (image below), which was activated in 54 of 70 cases (77%) of 
T2 muscle-invasive bladder tumors [9].  
Research at Columbia University has also demonstrated that intravesical delivery of 
rapamycin (dissolved in a surfactant/solvent mixture) directly into the bladder lumen was 
highly effective for suppressing the progression of CIS lesions, and that the intravesical 
treatment was more effective than systemically given rapamycin. 
Preclinical studies evaluated the local versus systemic delivery of rapamycin for effects 
on the progression of CIS lesions in a mouse model [9]. mTOR inhibition produced 
substantial inhibitory effects on tumor progression. More important, local delivery of 
rapamycin (via intravesical administration) was significantly more effective than systemic 
administration in blocking the growth of and progression of NMIBC.  Intravesical 
rapamycin administration completely inhibited mTOR activation in the bladder lumen as 
demonstrated by the reduced expression of pS6 level, while it only very modestly inhibited 
mTOR pathway activity in peripheral tissues, such as the pancreas and liver, indicating 
that it had low absorption into systemic tissue. 
Together these suggest the potential for fewer systemic side effects associated with 
intravesical rapamycin. 
In summary, results from this preclinical study demonstrate the importance of mTOR 
activation in bladder cancer tumorigenesis, and support the use of an intravesical mTOR 
inhibitor for high-risk patients with NMIBC cancer to prevent or delay its disease 
progression. 
2.3. 
Rapamycin, Rapalogs 
Rapamycin is a crystalline powder with the empirical formula C51H79NO13 and a 
molecular weight of 914.17. Systemic absorption of chemotherapeutic drugs through the 
bladder wall is negligible for compounds that have a molecular weight greater than 300 
daltons [18]. Current intravesical chemotherapeutic agents, mitomycin C and doxorubicin, 
have molecular weights of 334 and 580 daltons, respectively [19], indicating that a 
rapamycin formulation that is suitable for intravesical delivery should have no or minimal 
systemic absorption.  
Rapamycin is a protein kinase inhibitor that is used for immunosuppression in transplant 
patients and is under investigation as a cancer treatment. Rapamycin inhibits the 
mammalian target of rapamycin (mTOR), regulatory protein kinase in cancer that 
recognizes high stress levels, including depleted nutrient levels and states of hypoxia.  
Rapamycin is an oral drug and is therefore not suitable for intravesical administration.  
Marketed rapamycin analogs (temsirolimus and everolimus) are approved for renal cell 
carcinoma, but neither of them is developed or suitable for intravesical administration. 
Temsirolimus, a prodrug of rapamycin, requires conversion by CYP3A, the expression of 
which is very low in bladder cancer [20] and in the bladder, and is therefore not expected 


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to be effective for intravesical therapy. Everolimus and ridaforolimus (not yet approved, 
in development for sarcoma) are oral preparations. Given systemically, they are primarily 
eliminated via hepatic clearance and therefore result in negligible drug levels in the 
bladder. None of these rapalogs is highly water soluble, and therefore would require 
surfactants and solvents in an intravesical formulation, which could potentially cause 
irritation, local inflammation, and potential reduction of drug efficacy due to micellar 
sequestration. Indeed, previously intravesical therapies with therapeutics that required a 
surfactant have failed, for example in the case of cremophor-based paclitaxel (Taxol), 
and, therefore, improved formulations are needed [21]. 
2.4. 
nab-Rapamycin 
Although rapamycin is an efficacious mTOR inhibitor, it has low oral bioavailability, poor 
solubility, and dose-limiting intestinal toxicity. The novel nanoparticle albumin-bound 
rapamycin (nab-rapamycin) is freely dispersible in saline and is suitable for intravenous 
and intravesical administration.  
The novel nanoparticle albumin-bound or nab® technology (Abraxis BioScience, a 
wholly-owned subsidiary of Celgene Corporation) when applied to hydrophobic 
molecules, such as paclitaxel (nab-paclitaxel; Abraxane®), has led to improved drug 
delivery, safety, and efficacy in various solid tumors compared with the conventional 
paclitaxel formulation. This suggests that the nab formulation of rapamycin may also 
produce similar advantages over the standard rapamycin. 
The nab technology likely enhances tumor penetration and accumulation via the albumin 
receptor-mediated (gp60) endothelial transcytosis. Albumin is highly soluble, has long 
plasma half-life, broad binding affinity, and accumulates in tumors, making it an ideal 
candidate for drug delivery [22, 23]. Albumin circulating in the bloodstream can interact 
with gp60 to initiate caveolae-mediated transcytosis to reach tumor cells [24-26]. Indeed, 
we have seen in our laboratory that nab-paclitaxel transcytosis across the epithelial 
monolayer was dependent on caveolae formation [27]. In accordance with these 
observations, at equal doses, nab-paclitaxel showed greater selectivity to tumors 
compared with solvent-based paclitaxel, which is likely attributed to the biologically active 
ingredient albumin and lack of solvent [28]. Additionally, it is hypothesized that 
extracellular matrix albumin-binding proteins, such as SPARC, may further enhance 
therapeutic accumulation of albumin-bound-therapeutics in tumor cells. SPARC is known 
to be overexpressed in bladder cancer [29]. 
2.4.1. Preclinical Studies with nab-Rapamycin 
Preclinical primary pharmacology studies in vivo demonstrated significant antitumor 
activity of nab-rapamycin as a single agent administered intravenously at 40 mg/kg, 3 
times weekly for 4 weeks, across different tumor xenograft models in nude mice (see 
Figure 1 below), including breast, colorectal, multiple myeloma, and pancreatic cancer.  
This dose level correlates to approximately 120 mg/m2 in human. These findings are 
consistent with published information on rapamycin as an mTOR inhibitor and the role of 
mTOR in tumor growth [30-33]. In addition, recent preclinical study has demonstrated that 
combination of nab-rapamycin with the Akt inhibitor perifosine induced synergistic 
antitumor activity in multiple myeloma [34].   
 


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Figure 1: 
Antitumor Activity of nab-Rapamycin in Tumor Xenografts 
 
 
 
Importantly, a preclinical study was conducted to test the antitumor activity of nab-
rapamycin as a single agent or in combination with other chemotherapeutic agents 
against the UMUC3 human bladder cancer cell line. UMUC3 cells (10 x106 cells in 0.1 ml 
PBS with 20% Matrigel) were injected subcutaneously into the flank of female athymic 
mice, and mice were randomized once the average tumor volumes reach approximately 
100 mm3, and were treated until study end with nab-rapamycin (3 mg/kg, twice weekly, 
IV via tail vein), mitomycin (0.5 mg/kg, twice weekly, IP), cisplatin (3 mg/kg, twice weekly, 
IP), gemcitabine (30 mg/kg, twice weekly, IP), valrubicin (20 mg/kg, twice weekly, IP), and 
docetaxel (3 mg/kg, twice weekly, IP) either as single agent or in combination (nab-
rapamycin plus chemotherapeutic agent). Animals were monitored for tumor volume and 
body weight. 
nab-Rapamycin as a single agent or in combination with other chemotherapeutic agents 
were well tolerated overall, with no significant body weight loss in any group (Figure 2).  
nab-Rapamycin as a single agent or in combination with chemotherapeutic agents 
currently in clinical use to treat NMIBC demonstrated significant antitumor activity and 
significantly prolonged animal survival compared with saline control (Figure 2). Single 
agent gemcitabine showed only modest effects in tumor growth inhibition and animal 
survival, none of which were significantly improved over control. 
None of the nab-rapamycin combination groups showed significant improvement of 
antitumor activity when compared with nab-rapamycin alone due to strong antitumor 
activity of nab-rapamycin as a single agent.  However nab-rapamycin/gemcitabine 
combination showed a numerical trend towards enhanced antitumor activity versus nab-






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rats, ranging from 13.4 - 25.8 hours and resulted in significant blood level at 48 hours 
(~10 ng/ml) and 120 hours (>1 ng/ml). Consistent with literature of rapamycin [9], 
excretion of nab-rapamycin was primarily through the fecal route (68.57 - 69.99%) with 
minimum contribution from the renal route (7.73 - 8.84%). 
The safety and toxicity of nab-rapamycin were evaluated in a series of preclinical studies. 
A CNS safety pharmacology study showed no significant demonstrable behavioral 
changes even at the highest dose level of 90 mg/kg in rat, which is equivalent to 540 
mg/m2 in human [36]. In the HERG study for the assessment of QT prolongation in vitro, 
nab-rapamycin demonstrated a low potency HERG channel blocker potential effect with 
 
In rabbits, single dose intravenous administration of nab-rapamycin (5 to 60 mg/kg) 
resulted in dose-related observable signs of toxicity with all dose levels showing a 
reduction in food and water consumption with edema and bloating (data on file).  All 
rabbits receiving 5, 10, or 20 mg/kg were reported normal by the end of the 14-day 
observation period. Signs of toxicity at high dose of 60 mg/kg continued for the course of 
the study (0-14 days).  
In rats, toxicity as assessed in Good Laboratory Practices (GLP) toxicology studies was 
characterized by involvement of the male reproductive organs, a target organ previously 
associated with rapamycin exposure. nab-Rapamycin was well tolerated at nominal dose 
levels up to 90 mg/kg/dose (73 mg/kg = 440 mg/m2 actual dose administered) with 
mortality occurring at the higher doses of 120 and 180 mg/kg. Toxicities observed at 
nominal doses of 120 mg/kg and 180 mg/kg were consistent with heart failure and 
consequential pulmonary congestion and edema [36].  
Additionally, rapamycin was determined to be not mutagenic in Salmonella strains TA98 
and TA100 both in the presence and absence of S9 metabolic activation, at 
concentrations tested (5, 10, 50, 100 M) and nab-rapamycin did not cause hemolysis at 
a 1:1 dilution in whole blood (data on file). 
Local delivery of nab-rapamycin has been demonstrated to be safe and well tolerated in 
a porcine femoral artery model of balloon angioplasty injury [37]. Periadventitial injection 
of a single dose of 500 μg nab-rapamycin with an endovascular microinfusion catheter 
resulted in a perivascular concentration of nab-rapamycin 1500-times higher than serum 
concentration and rapamycin persisted in the tissue for at least 8 days. Luminal stenosis, 
medial fibrosis and media cell proliferation were significantly reduced by nab-rapamycin 
treatment. There were significantly fewer adventitial leukocytes at 3 days but no 
difference at 28 days. There was no difference in endothelial coverage or regeneration 
by Factor VII and H&E staining at 3, 8 or 28 days. 
For intravescial delivery of nab-rapamycin, minimal or no systemic absorption through the 
bladder wall is expected due to the nature and size of nab-rapamycin nanoparticles and 
the relatively large molecular weight of rapamycin (~900 g/mol). Serum rapamycin levels 
are therefore expected to be significantly lower than those resulted from intravenous 
administration in the preclinical PK and toxicity studies.   
2.4.2. Clinical Studies with nab-Rapamycin 


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A phase 1 study conducted at MD Anderson Cancer Center (FDA IND #74,610, filed Dec 
27, 2007), showed that nab-rapamycin was well tolerated with evidence of responses and 
stable disease in various solid tumors including renal cell carcinoma and bladder cancer, 
both of which typically express mTOR [38]. Twenty-six patients were treated with 45, 
56.25, 100, 125, 150 mg/m2 per week for 3 weeks, followed by a week of rest (28-day 
cycle) nab-rapamycin administered intravenously. The maximum tolerated dose was 
established at 100 mg/m2 after 4 DLTs were observed: 2 cases at 150 mg/m2 (elevated 
transaminase and thrombocytopenia) and 2 at 125 mg/m2 (suicidal ideations and 
hypophosphatemia). Stomatitis and mucositis are common AEs observed with the 
rapalogs; however, with nab-rapamycin, only 2 cases of grade 1 stomatitis occurred at 
100 mg/m2 and 1 case of grade 1 mucositis occurred at 45 mg/m2. Specifically, DLTs 
such as mucositis/stomatitis that have been observed with other mTOR inhibitors were 
not dose-limiting with nab-rapamycin: all mucositis events were grade 1/2.  
Of 19 patients evaluable for efficacy with best overall tumor response assessments, which 
included assessment of target, nontarget, and new lesions across all cycles, 1 patient in 
the 45 mg/m2 (95 mg actual rapamycin dose) cohort diagnosed with adenocarcinoma of 
the kidney and with bone and intrathoracic metastases had a confirmed partial response. 
The target lesion of this patient was reduced by 35.1% and the duration of response lasted 
183 days. Two (11%) patients (at doses 45 and 125 mg/m2, with actual rapamycin doses 
of 88 mg and 193 mg, respectively) had an overall tumor evaluation of stable disease 
(confirmed): 1 patient with mesothelioma had stable disease for 365 days and 1 patient 
with a neuroendocrine tumor in the left axillary node had SD for 238 days. Eight patients 
had stable disease that could not be confirmed either due to absence of follow-up tumor 
evaluation after the first stable disease, or due to progression after the first stable disease. 
It was expected that patients with tumors that have activation of the PI3K/AKT/mTOR 
pathway may benefit most from nab-rapamycin treatment. Indeed, the patient with overall 
tumor evaluation of partial response had kidney adenocarcinoma and the 2 patients with 
the longest clinical benefit had mesothelioma or neuroendocrine tumor; in all 3 cancer 
types mTOR over activity has been described. nab-Rapamycin produced a fairly dose 
proportional increase of Cmax and AUC across the dose range tested, and it significantly 
inhibited mTOR targets S6K and 4EBP1. 
With excellent systemic safety at doses of 100 mg/m2 (167-223 mg actual rapamycin 
dose) given weekly IV, we believe that intravesical therapy with nab-rapamycin should 
result in minimal systemic rapamycin exposure, and is of significant therapeutic avenue 
to investigate in humans with BCG refractory or recurrent NMIBC. 
 
2.4.3. Prior Clinical Experience in NMIBC with Intravesical nab-Paclitaxel 
Research at Columbia University showed in the first clinical phase 1 study in patients with 
BCG-refractory bladder cancer that intravesical nab-paclitaxel exhibited minimal toxicity 
and systemic absorption with promising efficacy [10]. Specifically, in 18 patients with 
BCG-refractory high-grade NMIBC receiving 150 to 500 mg nab-paclitaxel, no grade 2 or 
higher toxicities occurred, with only a few cases of grade 1 adverse events (dysuria, 
hematuria, and frequent urination), and 500 mg was deemed the MDD. Twenty-eight 
percent patients had complete response in this study. In addition, paclitaxel (molecular 
weight 854 daltons) levels in blood after intravesical administration were not detectable 


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except in 1 patient who exhibited a level of 16 ng/ml, which is over 1000 fold lower than 
levels reached in systemic therapy. Given the excellent safety profile and promising 
efficacy of the cytotoxic agent paclitaxel in a nab® product (nab-paclitaxel) delivered 
intravesically to patients with NMIBC, the 100-400 mg intravesical nab-rapamycin (a 
cytostatic agent) proposed for use in this study is likely to be safe in this patient 
population.  
 
2.4.4. A Summary of Justification for Use of nab-Rapamycin in NMIBC 
Based on the background information provided above, it is likely that nab-rapamycin will 
be safe and potentially effective in the NMIBC patient population. The main points for this 
justification as summarized below: 
 nab-Rapamycin has already been studied in patients with solid tumors by systemic 
IV administration at doses ranging from 45-150 mg/m2 and its safety with systemic 
exposure has been established at 100 mg/m2 (approximately 180 mg systemic 
rapamycin dose) given weekly 3 weeks out of 4 until disease progression (CA401 
study).  
 Systemic absorption of rapamycin (a cytostatic) from the bladder is highly unlikely 
due to the molecular size of rapamycin (~900 daltons), its hydrophobicity and the 
nanoparticle nature of nab-rapamycin, therefore no serious safety concerns are 
expected. Furthermore the safety profile of intravesical nab-paclitaxel (a cytotoxic) 
in this population has already been studied in which only grade 1 local bladder 
related adverse events were observed. 
 Oral rapamycin and other oral and IV rapalogs are not suitable for local instillation 
in the bladder due to nonavailability of suitable formulations for administration into 
the bladder, poor drug levels in the bladder with oral administration, or 
nonavailability of enzymes in the bladder required to convert the prodrug form into 
the active rapamycin form.  
 Preclinical models of bladder cancer that mimic the human disease show very 
promising activity of rapamycin in these models that occurs through suppression 
of mTOR. 
 nab-Rapamycin demonstrated strong antitumor activity against human bladder 
cancer cell line UMUC3 as a single agent, and the activity was further improved in 
combination with gemcitabine.  
 Preclinical systemic toxicology of nab-rapamycin is well studied and a local 
tolerance study of nab-rapamycin in porcine femoral artery injury model showed 
lower inflammation scores compared to the control.  
 A dose higher than 400 mg in this study is not expected to produce additional 
benefit due to potential saturation of the mTOR target. It is to be noted that 
responses in the solid tumor study were seen well below the MTD and at the lowest 
administered dose of 45 mg/m2 (73-96 mg actual rapamycin dose). 


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 Results from the Phase 1 part of this study showed that intravesical nab-rapamycin 
was safe in NMIBC patients with no DLT and no severe drug-related adverse 
events. 
 Intravesical gemcitabine treatment is well tolerated in multiple phase 1, 2, and 3 
clinical studies, with most toxicities being dysuria or frequency. 
 The good individual safety profiles of intravesical nab-rapamycin and gemcitabine 
indicate that the combination of nab-rapamycin and gemcitabine is unlikely to 
cause cumulative toxicities. 
2.5 Justification for Adding Gemcitabine in the Phase 2 
Gemcitabine inhibits DNA synthesis and is widely used to treat systemic bladder cancer 
[39]. More importantly, previous studies have demonstrated the activity of intravesical 
gemcitabine for the treatment of patients with NMIBC that recurred after BCG treatment. 
In a prospective, randomized trial comparing intravesical gemcitabine with mitomycin C 
(MMC) in patients who had progressed or failed BCG therapy [40], the rates of recurrence 
(28% vs 39%) and progression (11% vs 18%) were lower with gemcitabine but did not 
reach statistical significance. The overall incidence of adverse events was significantly 
less with gemcitabine (38.8% vs 72.2%, P = 0.02). A large multi-center study (S0353) 
also demonstrated the feasibility of intravesical delivery of the drug in patients who had 
failed two or more courses of BCG. Gemcitabine was given at dose of 2000 mg/week for 
6 weeks, then monthly for up to 12 months [41]. Of the 47 evaluable patients, 21 (45%) 
were disease free at 3-month evaluation, and 13 of those were continuously disease-free 
at the 12 months (28% of all evaluable patients). Other phase 1 and 2 studies have shown 
that intravesical gemcitabine was tolerable with minimal systemic absorption and 
metabolite difluorodeoxyuridine plasma levels below 7.5 M [42]. Thus, although 
myelosuppresion is a potential side effect of intravenous gemcitabine, intravesical 
gemcitabine has a more favorable toxicity profile, which includes urinary traction infection 
and maculopapillary rash. There is also precedence for the use of gemcitabine in 
combination with another intravesical chemotherapy. In a study with BCG refractory 
NMIBC patients, the sequential administration of intravesical gemcitabine (1000 mg) 
followed by mitomycin C (40 mg) weekly for 6 weeks was well tolerated with only grade 
1 or 2 toxicities observed [43].  
The rationale for selecting gemcitabine specifically for this multidrug regimen derives from 
work done with animal models. In a preclinical study with athymic mice bearing human 
UMUC3 bladder cancer xenografts, nab-rapamycin and chemotherapeutic agents 
currently in clinical use to treat NMIBC (mitomycin, cisplatin, gemcitabine, valrubicin, and 
docetaxel) were administered either alone or as nab-rapamycin based combination 
regimens.  nab-Rapamycin as a single agent or in combination with other 
chemotherapeutic agents were overall well tolerated with no significant body weight loss 
in any group.  nab-Rapamycin as a single agent demonstrated significant antitumor 
activity compared with saline control as well as significantly prolonged animal survival, 
whereas all other single agent groups showed relatively modest antitumor effect.  When 
tested in combination, the nab-rapamycin/gemcitabine combination demonstrated the 
best antitumor efficacy.  Among all nab-rapamycin combination groups, only the nab-
rapamycin/gemcitabine combination demonstrated a significant improvement in tumor 


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growth inhibition and a significantly longer animal survival compared with the 
corresponding chemotherapeutic agents alone.  It was also the only group that showed 
better tumor growth inhibition and substantially longer survival compared with nab-
rapamycin alone. These results suggest that nab-rapamycin bolsters the efficacy of 
gemcitabine, a current chemotherapy approved for the treatment of recurrent/refractory 
NMIBC following BCG treatment. Furthermore, they strongly substantiate the selection of 
a nab-rapamycin/gemcitabine combination for this Phase 2 clinical study of 
recurrent/refractory NMIBC. 
The feasibility and rationale for the combination treatment of intravesical nab-rapamycin 
and gemcitabine are based on individual safety profiles of these two agents and the 
demonstrated combination activity in a preclinical tumor model. Intravesical gemcitabine 
may cause irritation to the bladder and reduce the dwelling time for subsequent 
intravesical drug treatment, therefore, we will administer intravesical nab-rapamycin first 
before gemcitabine. 
 
3. 
STUDY POPULATION 
3.1. 
Inclusion Criteria 
1. Patients must have a diagnosis of transitional cell carcinoma (TCC) of the urinary 
bladder confirmed at the study institution. The patient must have demonstrated 
nonmuscle-invasive bladder cancer refractory or recurrent to standard intravesical 
therapy. Refractory disease is defined as failure to achieve tumor-free status by 6 
months of initiation of adequate BCG therapy. Recurrent disease is defined as 
reappearance of disease after achieving a tumor-free status by 6 months of 
initiation of adequate BCG therapy. Adequate BCG therapy includes at least 6 
weeks induction plus 3 additional doses of either induction or maintenance. 
Patients with a history of other intravesical agents (except nab-rapamycin or 
gemcitabine) in addition to standard BCG will also be allowed to enroll. All grossly 
visible disease must be fully resected and pathologic stage will be confirmed at the 
institution where the patient is enrolled. This will include stage Ta, T1, Tis and 
exclude all patients with muscle invasion (T2).  
a. For phase 1, patients with multifocal low-grade Ta histology will be eligible for 
participation 
b. For phase 2, individuals with Ta disease only must have documentation of high-
grade histology 
c. For phase 2, prior intravesical treatment with nab-rapamycin or gemcitabine is 
not allowed 
2. Age >18 and must be able to read, understand, and sign informed consent 
3. Performance Status: ECOG 0, 1, and 2 (See Appendix III) 
4. Hematologic inclusion within 2 weeks of start of treatment  
a. Absolute neutrophil count >1,500/mm3 
b. Hemoglobin >9.0 g/dl 


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c. Platelet count >100,000/mm3 
5. Hepatic inclusion within 2 weeks of entry 
a. Total bilirubin must be within normal limits. 
b. Adequate renal function with serum creatinine ≤2.5 mg/dL 
 
c. Aspartate transaminase (AST) and alanine transaminase (ALT) ≤2.5 x ULN for 
the institution, alkaline phosphatase  ≤ 2.5 x ULN for the institution, unless 
bone metastasis is present in the absence of liver metastasis 
6. Women of childbearing potential must have a negative pregnancy test. 
7. All patients of childbearing potential must be willing to consent to using effective 
contraception, ie, intrauterine device, birth control pills, depo-provera, and 
condoms while on treatment and for 3 months after their participation in the study 
ends. 
3.2. 
Exclusion Criteria 
1. Any other malignancy diagnosed within 1 year of study entry (except basal or 
squamous cell skin cancers or noninvasive cancer of the cervix) is excluded 
2. Concurrent treatment with any chemotherapeutic agent 
3. Women who are pregnant or lactating 
4. History of vesicoureteral reflux or an indwelling urinary stent 
5. Participation in any other research protocol involving administration of an 
investigational agent within 1 month prior to study entry 
6. History of radiation to the pelvis 
7. History of interstitial lung disease and/or pneumonitis 
8. Evidence of metastatic disease 
 
4. 
STUDY DESIGN AND PLAN 
4.1. 
Overall Study Design 
This study will be designed as a combined phase 1 and phase 2 to determine the safety 
and tolerability profile of intravesical nab-rapamycin in human patients with high-risk 
nonmuscle-invasive TCC of the urinary bladder that have previously demonstrated 
resistance to standard intravesical treatment.  
The nonrandomized phase 1 study will be designed to test if this novel treatment regimen 
has an appropriate safety and toxicity profile to be further investigated to afford patients 
a greater likelihood of complete response than the 20% response noted with currently 
available second line intravesical chemotherapy agents.  
TCC refractory or recurrent patients will be enrolled in the phase 1 portion of the study 
and these patients will receive 1 to 2 weekly instillations of nab-rapamycin in saline diluent 
initially at an approximate pH of 5 to 8. Patients will be instructed to avoid excessive fluid 


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intake starting the day before treatment. Patients will receive intravesical nab-rapamycin 
by sterile urethral catheterization once or twice weekly for 6 weeks. Prior to instillation, 
the bladder will be emptied via the sterile urethral catheter. The patient will be instructed 
to keep the drug in the bladder for 2 hours before voiding. Six weeks after the last 
treatment, the patient will undergo assessment, including cystoscopy and biopsy. 
Following the completion of the phase 1 portion of the study and appropriate analyses of 
the results have been performed establishing the MDD, the phase 2 portion will be 
initiated at 200 mg/week for nab-rapamycin and a fixed dose of 2000 mg/week of 
gemcitabine. The purpose of the phase 2 portion of the study will be to both establish the 
efficacy of the intravesical treatment of nab-rapamycin in combination with gemcitabine 
for patients with BCG refractory or recurrent TCC of the bladder as well as to further 
elucidate the safety and toxicity profiles of the MDD. Patients will receive weekly 
instillations of nab-rapamycin followed by gemcitabine in 100 mL saline diluent initially at 
an approximate pH between 5.0-7.5. Patients will be instructed to avoid excessive fluid 
intake starting the day before treatment. Patients will receive intravesical nab-rapamycin 
and gemcitabine by sterile urethral catheterization once weekly for 6 weeks. Before 
instillation, the bladder will be emptied via sterile urethral catheter. nab-Rapamycin will 
be instilled first and the patient will be instructed to keep the drug in the bladder for one 
hour before voiding. Upon voiding, gemcitabine will then be instilled and the patient will 
be asked to retain the drug for an additional hour before voiding. Finally, 6 weeks after 
the last treatment, the patient will undergo assessment, including cystoscopy and biopsy. 
If a patient in phase 1 or 2 has a complete response after 6 weeks of instillations, the 
patient will receive additional monthly maintenance instillations. If the patient was a 
complete responder of phase 1, that patient will receive maintenance instillations at the 
maximum dose that particular patient received. If the patient was a complete responder 
in phase 2, that patient will receive maintenance instillations of nab-rapamycin and 
gemcitabine. Cystoscopic examinations will be performed every 3 months, and the patient 
will continue to receive monthly maintenance instillations until there is a positive 
cystoscopic biopsy (disease progression), or until a maximum of 1 year from their first 
treatment. Patients will continue to be monitored for local and systemic toxicities 
throughout the duration of maintenance therapy. 
As it has been shown that additional maintenance therapy can increase the duration of 
response to intravesical agents, all patients treated in phase 1 and 2 will be given monthly 
maintenance instillations throughout the duration of their recurrence-free status for up to 
1 year of therapy. This addition will not affect our original hypothesis since the 
maintenance treatment will occur after the primary endpoint for the study is determined. 
This combined phase 1 and phase 2 study would significantly contribute to the body of 
literature that exists examining molecular determinants of response to rapamycin and 
molecular markers of high progression risk in TCC. Multiple genes and chromosomal 
locations have been linked to progression and lack of response in TCC including p53, 
RB, p21, p16 and p27 and loss of chromosome 9,11, and 17 [44, 45]. Aside from 
predicting a more aggressive and deadly natural history, certain genetic aberrations 
provide mechanisms for poor response to therapy.  For instance, p53 is a cell cycle 
regulator that allows a damaged cell to arrest in the G1 phase of the cell cycle and either 
to repair itself of progress along an apoptotic pathway. In addition, the SPARC 


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extracellular glycoprotein, which is a key step in the uptake of nab-rapamycin into the cell, 
has been shown to be over-expressed in certain cancers including bladder cancer,  
thereby increasing nab-rapamycin’s efficacy [46]. The molecular markers analyzed in this 
study will include but not be limited to p53, p63, Stathmin, Tau, ribosomal s6 kinase, Ki67, 
and SPARC. 


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4.2. 
Summary of Evaluation 
Table 1 details the study evaluations and treatment schedule for both phase 1 and 2. 
Table 1: 
Study Evaluation and Treatment Schedule 
 
 
Parameter 
Pre-
study 
Treatment 
Daya 
Every 
Other
Weekb 
EOS 
6-week 
Follow-
Up 
Monthly Maintenance Treatment Day 
(mo) 
Follow up 
 
 
 
 
 
 
4 
5 
6 
7 
8 
9 
10 
11 
12 
Every 3 mo 
History 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physical examination 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Weight 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital signs 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Intravesical nab-rapamycin (and 
gemcitabine for Phase 2) 
administration c 
 
X 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Urine Cytology d 
X 
 
 
 
X 
 
 
X 
 
 
X 
 
 
X 
X 
Cystoscopy e 
X 
 
 
 
X 
 
 
X 
 
 
X 
 
 
X 
X 
TURBT/Biopsy e 
X 
 
 
 
X 
 
 
X 
 
 
X 
 
 
X 
X 
Pathology 
X 
 
 
 
X 
 
 
X 
 
 
X 
 
 
X 
X 
Performance status (ECOG) 
X 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
CBC, differential, platelet count f 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Clinical chemistry panel f 
X 
X 
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Electrolytes (Na, K, Cl, CO2) 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Coagulation Profile 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Urine pH g 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Serum HCG h 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest x-ray i 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Abdominal CT 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum cholesterol and 
triglycerides 
X 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
EKG g 
X 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
Serum rapamycin levels j 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Plasma gemcitabine and dFdU 
levels (for phase 2) k 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
BCI QoL Questionnaire 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Record Serious AE 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 


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a Weekly or 2x weekly. 
b Even numbered visits. 
c The phase 2 portion of the study will be conducted with nab-rapamycin at 200 mg/week as determined by phase 1 and 2000 mg/week of 
gemcitabine. nab-Rapamycin will be instilled first and the patient will be instructed to keep the drug in the bladder for one hour before voiding. 
Upon voiding, gemcitabine will then be instilled and the patient will be asked to retain the drug for an additional hour before voiding.  
d Aside from specific time points in the Schedule of Assessments, cytology can be at any time if symptoms are present and is in the best interest of 
the patients in the opinion of the investigator. All urine cytology is read by Local Pathology Laboratory. 
e 6‐week, 3‐month, and 6‐month follow‐ups will include cystoscopy and biopsy for all patients not undergoing cystectomy. Biopsy at 6-week follow 
up is mandatory. Cystoscopy during maintenance therapy is repeated every 3 months (ie, at 6, 9, and 12 months). Biopsy at other time points will 
only be performed if indicated based on either positive cytology or cystoscopy. 
f Blood samples for CBC, platelets, chemistry panel, etc should be taken just prior to instillation and include creatinine, serum bilirubin, glucose, 
alkaline phosphatase, ALT, AST. 
g Urine pH includes testing of urine pH, urine analysis, and urine culture during visits. 
h Pre‐treatment EKG and HCG will be only drawn prior to initiation of phase 1 if patients enrolled in phase 2 within 3 months of cessation of trial 1. 
i For participants who are eligible for maintenance therapy, a chest x‐ray will be done during maintenance only at the 6 month follow‐up visit. 
j For phase 1, blood samples for rapamycin levels will be measured at pre-treatment (just before instillation) and at 2 hours post-treatment (just 
before voiding). For phase 2, blood samples for rapamycin levels will be measured at pre-treatment (just before instillation) and just before voiding 
of gemcitabine. Pretreatment blood samples for rapamycin levels are taken together with samples for CBC, chemistry panels, etc.  
k For phase 2, blood samples for gemcitabine and dFdU levels will be measured at pre-treatment (just before instillation) and just before voiding of 
gemcitabine. 
Abbreviations: AE, adverse event; ALT, aminotransferase; AST, aspartate aminotransferase; BCI, bladder cancer index; CBC, complete blood 
count; CT, computed tomography; ECOG, Eastern Cooperative Oncology Group; EKG, electrocardiogram; EOS, end of study; HCG, human 
chorionic gonadotropin; QoL quality of Life 
 
 


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Figure 4 shows the details of the study evaluations and treatment schedule. 
Figure 4: 
Study Evaluations and Treatment Schema for Both Phase 1 and 2 
 
Up to 30
Patients
Dose Escalation (3 + 3 Rule)
• 5 cohorts (Up to 6 pts/cohort)
• 2 schedules (wkly,2x/wk)
• Doses: 100 mg/wk, 200 mg/wk, 300  mg/wk, 
400 mg/wk, 100 mg 2x/wk
• MDD
• Maintenance for 
CR pts
Phase 1
Phase 2
Patient
N = 29
Stage 1 (N = 10)
• Six treatment cycles: 
nab-rapamycin 200 
mg/wk; gemcitabine 2000 
mg/wk
• Maintenance for CR pts
> 2 pts with CR
Stage 2 (N = 19)
• Six treatment 
cycles of nab-
rapamycin and 
gemcitabine
• Maintenance for 
CR pts
< 1 pts with CR
Study Termination
6 Treatment Cycles
6 weeks
6 weeks
6-week 
Follow-Up
Cystoscopy
CR Pts
Up to 9 Monthly Treatments
Cystoscopy: Month 6, 9 & 12
Treatment
Efficacy Evaluation
Maintenance
Quarterly 
Follow-Up 
to 2 yrs
Non-CR 
Pts
End of Study
(Month 1 and 2)
(End of Month 3)
(Month 4- Month 12)
Extended 
Follow-up
(Month 13- Month 24)
Mo: 4   5    6   7    8   9  10  11 12


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4.2.1. Prestudy Evaluation 
Patients will be seen and evaluated by the principle investigator. Potential candidates will 
have a history and physical examination performed by the principle investigator in order 
to make sure they meet the proper inclusion and exclusion criteria. Weight, vital signs, 
and ECOG performance status will be checked by a member of the medical staff. Patients 
will provide a urine sample, which will be sent for urine analysis to check the pH value. 
Patients are required to undergo an initial cystoscopic examination performed by one of 
the study investigators. If not already performed, all grossly visible tumor will be resected 
prior to enrollment. Patient will give a blood sample, which will be sent for a complete 
blood count (CBC), basic metabolic panel (BMP), hepatic function panel, and coagulation 
profile (prothrombin time, partial thromboplastin time, and international normalized ratio). 
In female patients of reproductive age, a serum β-hCG value will be checked to rule out 
evidence of pregnancy. Patients are also required to have a chest X-ray and abdominal 
CT scan within 3 months, and an electrocardiogram (EKG) within 30 days of treatment. If 
these tests have not been performed within the specified timelines, they will be performed 
prior to study enrollment. 
4.2.2. Week of Instillation and Treatment Day 
Before treatment, a member of the treatment staff will evaluate the patient’s CBC and 
clinical chemistry panel. The patient must have a hemoglobin level >9.0 g/dL, an absolute 
neutrophil count >1,500/mm3, a platelet count >100,000/mm3, AST and ALT <2.5 x ULN, 
alkaline phosphatase <2.5 x ULN and creatinine <2.5 mg/dL in order to undergo 
treatment. 
During the treatment day, each patient will have an updated history taken by the principle 
investigator.  At each visit, every patient will be asked specific questions to monitor for 
local bladder toxicity as defined by the NCI CTCAE version 4.0. For example, when 
monitoring for grade 3 or 4 hematuria, the member of the treatment staff will ask about 
persistent gross hematuria and/or blood clots. In order to monitor for grade 3 or 4 toxicity 
bladder spasm, patients will be asked if their symptoms are severe enough to require a 
narcotic. In order to monitor for grade 3 or 4 toxicity urinary frequency and urgency, 
patients will be asked if they are urinating hourly or more with frequency or experiencing 
urgency than prior to beginning treatment.  If questioning reveals any grade 3 or 4 toxicity 
as defined by the NCI CTCAE version 4.0, the patient will be considered to have local 
toxicity and will be removed from the study and treated appropriately. Questioning to 
monitor for grade 2 local toxicity will also be performed and the patient will be treated at 
the discretion of the principle investigator or drug instillation will be postponed 1 week at 
the discretion of the investigator, provided that resolution of symptoms to a maximum of 
grade 1 occurs. 
At every visit, all study patients will have vitals performed, including weight, blood 
pressure, and pulse, and an update of their medical history will be obtained.  Patients will 
provide a urine sample, which will be checked by dipstick for pH and then sent to the 
laboratory for urine analysis. If urine pH is not between 5.0-7.5 and thus outside the range 
of nab-rapamycin (and gemcitabine in phase 2) solubility, the dose will be held. If urine 
pH is found to be below this range, the oral alkalinizing agent potassium citrate will be 
prescribed and the treatment will be administered 1week later pending a normalized urine 


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pH. If the urine pH is greater than 8, oral intake of citrus juices and increased fluid intake 
will be encouraged and the dose will be administered 1 week later pending a normalized 
urine pH. 
Patients will be administered nab-rapamycin (and gemcitabine in phase 2) treatment via 
sterile urethral catheter.  Patients will retain the study drug within their bladder for 2 hours 
and then void in a standard fashion. No special precautions are required regarding 
disposal of the study drug after voiding in a normal toilet. 
 A blood sample will be drawn for CBC, chemistry panel, and rapamycin levels at every 
visit, just before treatment. Two hours after the treatment is initiated (immediately before 
voiding), the patient’s blood will be drawn for serum rapamycin levels, after which they 
will conclude the treatment visit. On even-numbered instillations, patients will have basic 
metabolic panel, hepatic functional panel, lipid panel, and coagulation profile checked.  If 
there is any evidence of grade 3 or 4 systemic toxicity, according to these lab values, the 
patient will be immediately removed from the study and be deemed to have systemic 
toxicity. 
Additionally, at the initial intake visit will receive the Bladder Cancer Index (BCI), a 
disease-specific quality of life questionnaire specifically designed and validated for 
patients with NMIBC [47]. The BCI addresses health outcomes for these patients 
including urinary, bowel, and sexual bother and function. Patients will additionally be 
administered the BCI at their follow-up cystoscopy (approximately 3 months after their 
initial treatment cycle ends). 
4.2.3. Week 6 instillation 
At the end of the 6-week treatment periods, study patients will have an updated history 
taken by the medical staff. Blood will be drawn and a CBC, comprehensive metabolic 
panel, and coagulation profile will be ordered before the visit. The medical staff will 
perform a physical examination and check the patient’s weight, vital signs, and ECOG 
performance status. Similar to previous treatment days, the patient will receive the 
appropriate dose of intravesical nab-rapamycin (with gemcitabine in phase 2), have a 
urine sample checked by dipstick for pH value and have blood drawn for rapamycin. The 
patient will also have an EKG at this visit. 
4.2.4. Six-week Follow-up 
All study patients will undergo an updated history and perform a physical examination.  
Weight, vital signs, and ECOG performance status will be obtained by the medical staff.  
Patients will have blood drawn and a CBC, BMP, hepatic function panel, cholesterol, 
triglycerides, and coagulation profile will be obtained. Patients will provide a urine sample 
for pH value and will have an EKG, and chest X-ray. The BCI quality of life questionnaire 
will also be administered at this point. 
4.2.5. Six-week and Quarterly Response Assessments 
All study patients will undergo response evaluation after a minimum of 6 weeks following 
the last treatment. This will consist of urinary cytology, examination under anesthesia and 
cystoscopy with bladder biopsy or tumor resection. This will serve as the primary endpoint 
for response for the clinical studies.  A complete response will be defined as a negative 


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biopsy. No response will be defined as positive cystoscopic biopsy. Another end-point will 
be event-free survival defined as time from the last treatment until biopsy stage is beyond 
that of the original stage pre-treatment. Cystoscopy with biopsy at 6-week follow up is 
mandatory. At other time points, biopsy will be performed only if indicated based on either 
positive cytology or cystoscopy. 
Only patients who achieve a complete response at the 6-week assessment will move to 
monthly maintenance therapy. All patients in phase 1 and 2 who are treated with 
additional maintenance therapy after a complete response will undergo additional 
evaluations at 6, 9, and 12 months during the maintenance therapy and every 3 months 
during the 2-year follow up or until a positive biopsy occurs. A durable complete response 
will be defined as consistently negative cytology, cystoscopy or biopsies. 
Follow-up CT scans will be performed at the discretion of the study investigators as an 
adjunct to quarterly cystoscopic assessments. 
4.3. 
Study Drug Dosage 
4.3.1. Dose Modifications 
In the event of a systemic or local DLT, no dose modification will be permitted and the 
patient will be removed from study. 
In the event of grade 2 bladder toxicity, nab-rapamycin (and gemcitabine in phase 2) 
instillation will be postponed 1 week, provided that resolution of symptoms to a maximum 
of grade 1 occurs. 
Any patient that misses more than 1 dose or has more than 1 dose postponed, will be 
considered to have experienced a DLT and be removed from the study.  
In the 2x/week schedule, if continuous accumulation of rapamycin blood level is seen for 
3 continuous weeks (ie, rapamycin level not back to baseline prior to next dose), the next 
dose will be delayed by 1 week and the patient will be moved to the corresponding 
1x/week schedule for the remaining 3 weekly treatments. 
4.4. 
Correlative Studies 
4.4.1. Tumor Biopsies 
Six weeks after the last treatment, the patients will undergo a cystoscopy and biopsy. 
Response rates will be determined by cystoscopic biopsy at 6 weeks following treatment. 
Tumor tissue samples will be stored for evaluation of molecular correlative studies to 
predict response to therapy. Tissue samples will be stored in the Tumor Bank at Columbia 
University until used for future analysis of molecular markers.  Testing for markers may 
be performed off-site, but any remaining tissue will be returned to the Tumor Bank for 
potential future testing. Other researchers will not have access to tissue samples unless 
given permission by Dr. McKiernan, the Primary Investigator.   
4.4.2. Pharmacokinetic Sampling Method and Rationale 
During the phase 1 clinical study, blood samples will be taken just prior to treatment and 
at 2 hours after nab-rapamycin treatment is initiated (i.e., just before voiding), collected in 
EDTA-treated tubes, and stored at -80ºC until analysis. During the phase 2 study, blood 
samples will be taken just prior to treatment and just before voiding of gemcitabine. The 


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tissue samples, if collected, will be collected into 15 mL cryovials, flash frozen on dry ice, 
and stored at -80ºC until analysis. 
Rapamycin levels in serum and in bladder tissue samples will be measured by liquid 
chromatography/mass spectrometry (LC/MS) at BASI in West Lafayette, IN. Rapamycin 
concentrations in the target bladder tissue will be correlated with clinical efficacy data, 
and pharmacodynamic biomarkers to help establish effective biological dose. 
Due to the nature and size of the nanoparticles and the relatively large molecular weight 
of rapamycin (~900 g/mol), very low level or no rapamycin is expected to be detected in 
serum, indicating minimal or no systemic absorption through the bladder wall. No 
correlation between nab-rapamycin dosage and serum rapamycin levels is expected to 
be observed. 
Because of effective tissue penetration, intravesical nab-rapamycin treatment is expected 
to result in high drug concentrations in the target bladder tissue, which could decrease 
significantly over time as determined by the tissue samples collected up to 3 or 7 days 
later. It is possible that after a certain nab-rapamycin dose, the rapamycin concentration 
in bladder tissue would be dose-dependent, but above that dose, the rapamycin 
concentration would reach a plateau, indicating saturation of drug absorption.   
For the phase 2 study, plasma levels of gemcitabine and its metabolite dFdU will be 
analyzed. 
4.5. 
Concomitant Medications and Nondrug Therapies 
For the phase 1 portion, nab-rapamycin will be the only chemotherapy drug given. In 
phase 2, nab-rapamycin will be administered before gemcitabine. No other therapeutics 
to treat NMIBC are allowed. Supportive care per the institution’s normal standard of care 
including concomitant medications can be provided at the Investigator’s discretion. 
4.6. 
Withdrawal/Premature Discontinuation 
A patient may voluntarily discontinue study participation at any time. At the Investigator’s 
discretion, patients may be discontinued from the study at any time after discussion with 
the study PI and sponsor. In the event of premature discontinuation, the patient should 
return to the study site as soon as feasible to have the end of study assessments 
performed and the appropriate follow-up evaluations should occur. Patients must be 
withdrawn from this study if any of the following occurs: 
 Progressive disease. 
 Systemic or local DLT 
 Patient declines to continue therapy. 
 Initiation of other anticancer therapy. 
 In the Investigator’s judgment, it is in the patient’s best interest to discontinue the 
study. 
Patients who are withdrawn from this study secondary to a laboratory toxicity or AE should 
be followed by the Investigator as outlined in Section 7. 
 


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5. 
STATISTICAL METHODS 
5.1. 
Study Design and Sample Size 
The phase 1 segment of the study will have a dose-escalation scheme that will enroll up 
to 30 patients. Dose escalation will follow the 3+3 rule to establish the MDD. 
Based on ongoing experiences with nab-rapamycin and prior experience with dose 
escalations for intravesical Abraxane, in this phase 1 segment of the study, patients will 
be enrolled to 4 weekly dosing cohorts, 3 per cohort: cohort 1 – 100 mg/week, cohort 2 – 
200, mg/week, cohort 3 – 300 mg/week, and cohort 4 – 400 mg/week for 6 weeks of 
treatment ( 
Table 2). If no significant safety issues are found in cohort 1, there will be a 2x/weekly 
dosing cohort (cohort 2b – 100 mg 2x/week, total weekly dose of 200 mg) enrolled in 
parallel and evaluated independently from the weekly dosing cohorts for safety and 
preliminary efficacy.  
Table 2: Dosing Schema of Intravesical nab-Rapamycin 
Regimen 
Concentration (Dose Level) 
Intravesical 
Instillation 
Cycles 
Interval a 
Total Weekly 
Dose 
1 
1.25 mg/mL   (100 mg) 
80 mL 
6 
1x / week 
100 mg 
2 
2.5 mg/mL    (200 mg) 
80 mL 
6 
1x/week 
200 mg 
2b b 
1.25 mg/mL   (100 mg) 
80 mL 
6 
2x / week 
200 mg 
3 
3.75 mg/mL   (300 mg) 
80 mL 
6 
1x / week 
300 mg 
4 
5.00 mg/mL   (400 mg) 
80 mL 
6 
1x / week 
400 mg 
a  Patients receiving 1x/week treatment, the treatment window is +/- 1 days of scheduled day. Patients 
receiving 2x/week treatment will receive their 2nd treatment on day 4 (+/- 1 day) of that week 
b Cohort 2b (100 mg 2x / week) will accrue patients at any time after cohort 1 safety is established (i.e. no 
patient develops DLT for the first 3 weekly instillations) and can occur in parallel with cohorts 2, 3, or 4.  
Dosages can be escalated if 3 to 6 patients have undergone the first 3 instillations of the 
medication without experiencing a DLT, as follows. Initially 3 patients will be treated. If 
none develops DLT following the third weekly instillation, the dose can be escalated. If 
only 1 of the first 3 patients develops DLT, then an additional 3 patients will be treated at 
that dose. If the fourth, fifth, and sixth patients do not develop DLT, the dose can be 
escalated; however, the escalation can occur only after all patients in the cohort complete 
their 6 weekly doses. Otherwise the prior dose will be defined as the MDD. At any dose 
level, if 2 or more cases develop DLT, the prior dose will be defined as the MDD once 6 
patients have been treated at this level with less than 2 patients experiencing a DLT. The 
following  
Table 3 gives the operating characteristics of this scheme.  
Table 3: 
Operating Characteristics of Dose Escalation 
True rate of DLT (%) 
Probability of Escalation (%) 
10 
91 
20 
71 
30 
49 
40 
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50 
17 
60 
8 
The primary objective of the phase 2 segment of this study is to evaluate the utility 
(potential for clinical efficacy) of nab-rapamycin in combination with gemcitabine in the 
treatment of BCG refractory or recurrent NMIBC as measured by rate of complete 
responders. Once the MDD has been properly established, only then the nonrandomized 
phase 2 segment of the study will be initiated, using the Simon 2-stage design. In stage 
1, there will be only 10 patients enrolled with a rejection rule that only if there are 2 or 
more positive responses will the study proceed to further enrollment of the next 19 
patients (stage 2). If 1 or fewer respond in the first stage, we will terminate the study for 
lack of efficacy. If more than 5 patients respond overall, we will consider the agent 
promising.   
The Null Hypothesis is that there will be no difference between the current response rates 
to BCG therapy of 10% [1-3] and the response rate to intravesical nab-rapamycin in 
combination with gemcitabine treatment after 6 weeks of therapy. The Alternative 
Hypothesis will be that there will be a ≥30% response rate to intravesical nab-rapamycin 
in combination with gemcitabine treatment after 6 weeks of weekly therapy. The overall 
rejection rule is that if there are 5 or greater responses to treatment out of the entire 
enrollment, we will reject our Null Hypothesis and accept our Alternate Hypothesis, that 
there is a significant difference between the response rates of standard BCG therapy and 
intravesical nab-rapamycin in combination with gemcitabine treatment. 
The expected sample size for the phase 2 study Simon 2-stage design is 15 patients with 
a maximum of 29 patients. Based on our operating characteristic of 5% type I error and 
20% type II error, the number of patients that is expected to be enrolled will be 15 on 
average with a maximum total of 29 in order to sufficiently power the study. The probability 
of correctly concluding the therapy is worthy of further study is 80% if the true underlying 
response rate is 30%. The probability of incorrectly concluding the therapy is promising 
is 5% if the true response rate is approximately 10%.  
5.1.1. Adverse Events and Toxicities 
Dose-limiting systemic toxicity will be defined any grade 3 or 4 systemic toxicity using 
the NCI CTCAE version 4.0. If a patient exhibits any evidence of systemic toxicity, the 
patient will be removed from the study and treated appropriately.  
Dose-limiting local toxicity will be defined as any grade 3 or 4 hematuria, dysuria, 
urinary retention, urinary frequency/urgency, or bladder spasms using the NCI CTCAE 
version 4.0. If a patient exhibits local toxicity, the patient will be removed from the study 
and treated appropriately. 
Patients who experience a systemic or local DLT will be included in determination of the 
MDD. 
5.2. 
Patient Population 
5.2.1. Analysis Population 


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The treated population, which includes all enrolled patients who receive at least 1 dose 
of study drug, will be the primary population used for all safety/tolerability and efficacy 
analyses. 
5.2.2. Patient Characteristics 
Patient characteristics including demographics, disease duration and severity at baseline, 
and relevant medical history will be summarized for the purpose of characterizing the 
patient population. Descriptive statistics including mean, standard deviation, frequency 
distributions, etc., as appropriate, will be presented. 
5.2.3. Patient Disposition 
Patient disposition, including the number of patients enrolled, treated, and reasons for 
discontinuation from the study will be summarized. 
5.2.4. Prior and Concomitant Medications 
All concomitant medications and prior medications taken within 30 days of first study drug 
administration will be coded to therapeutic drug classes and generic drug names using 
the World Health Organization Drug Classification. The incidence of prior and 
concomitant medication usage will be summarized by therapeutic drug class and generic 
drug names. 
5.3. 
Safety Analyses 
Safety and tolerability will be monitored through reporting of AEs and SAEs, laboratory 
abnormalities, incidence of patients experiencing dose modifications, and/or premature 
discontinuation of study drug. 
Systemic DLT is defined as any grade systemic toxicity using the NCI CTCAE version 
4.0. Local dose limiting toxicity is defined as grade 3 or 4 bladder toxicity using the NCI 
CTCAE 4.0.  
5.4. 
Efficacy Analyses 
Six weeks after the last dose, patients will undergo a cystoscopy and biopsy. If a patient 
has a complete response, the patient will receive additional monthly maintenance 
instillations at the dose that particular patient received. Cystoscopic examinations will be 
every 3 months, and the patient will receive therapy until disease progression for a 
maximum of 1 year from the start of therapy. 
A complete response is defined as a cancer-negative biopsy on cystoscopy. No 
response is defined as positive cystoscopic biopsy.  
Another end-point is event-free survival defined as tumor recurrence, tumor progression 
to muscle invasive bladder cancer or death, whichever occurs first. Urine cytology will 
also be assessed as a secondary endpoint. 
5.4.1. Biomarker and Pharmacokinetic Analyses 
This clinical study offers an excellent opportunity to assemble blood, urine, and tissue 
samples for further interrogation regarding the molecular correlative markers that may 
predict sensitivity and resistance to intravesical nab-rapamycin therapy in TCC. There is 
not expected to be any formal impact on decision making within this study based on 


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molecular markers and patients will, of course, have the opportunity to refuse tissue 
samples and still participate in the clinical study. 
The molecular markers analyzed will include but not be limited to p53, p63, Stathmin, 
Tau, ribosomal s6 kinase, Ki67, and SPARC. 
Rapamycin blood levels will be monitored for systemic absorption. Elimination rate 
constant, half-life, volume of distribution, Cmax, tmax, AUCinf, and clearance will be 
summarized. 
 
6. 
STUDY DRUG MANAGEMENT AND ADMINISTRATION 
6.1. 
nab-Rapamycin 
nab-Rapamycin is a cytostatic therapeutic agent, but should be handled as a cytotoxic 
anticancer drug. As with other potentially toxic compounds, caution should be exercised 
in handling nab-rapamycin. The use of gloves is recommended. If nab-rapamycin 
(lyophilized cake or reconstituted suspension) contacts the skin, wash the skin 
immediately and thoroughly with soap and water. If nab-rapamycin contacts mucous 
membranes, the membranes should be flushed thoroughly with water. 
6.1.1. nab-Rapamycin Packaging, Labeling, and Storage 
nab-Rapamycin will be supplied by the Sponsor in single-use vials as lyophilized product. 
Each single-use vial will contain 100 mg rapamycin and human albumin as a stabilizer. 
Each vial will be labeled according to country-specific regulatory requirements for labeling 
of investigational products. For each treatment, the required dose of nab-rapamycin will 
be will be administered in a fixed volume of 80 ml in 0.9% sodium chloride.   
Unopened vials of nab-rapamycin should be stored in a refrigerator (2°-8°C; 36°-46°F) in 
original cartons to protect from light. Reconstituted nab-rapamycin may be stored for up 
to 4 hours at 2-8°C (36°- 46°F), followed by 4 hours at room temperature (<25°C) in the 
IV bag. Both unopened vials of nab-rapamycin and reconstituted nab-rapamycin should 
be stored in an area free of environmental extremes and must be accessible only to study 
personnel. 
Temperature records for nab-rapamycin must be made available to Sponsor nominated 
Contract Research Organization (CRO) monitoring teams for verification of proper study 
drug storage. 
Only completely unused study drug vials should be retained by the site until a 
representative from Sponsor-nominated CRO has completed an inventory. Partially used 
and completely used vials should be destroyed according to the site’s guidelines, and 
their disposition should be recorded on the Investigational Drug Accountability Record 
Form.  
The Investigator, or designee, shall record the dispensing of study drug to patients and 
any remaining study drug after dosing in a study drug accountability record. The study 
drug record will be made available to AADi or authorized AADi-designated monitoring 
personnel for the purpose of accounting for the study drug supply. Inspections of the study 
drug supply for inventory purposes and assurance of proper storage will be conducted as 


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necessary. Any significant discrepancy will be recorded and reported to AADi or their 
designee and a plan for resolution will be documented. 
6.1.2. nab-Rapamycin Preparation and Administration 
nab-Rapamycin is supplied as a sterile, lyophilized powder and should be reconstituted 
by appropriate study personnel before use. Each vial of nab-rapamycin is reconstituted 
with 20 mL of sterile 0.9% Sodium Chloride for Injection, USP to form a white-to-yellow 
translucent suspension containing 5 mg/mL of rapamycin as albumin-bound 
nanoparticles.  
Calculate  
Instillations cannot be done immediately following transurethral resection of bladder tumor 
(TURBT). Investigators must wait a minimum of 10 days before dosing subjects after a 
TURBT, and/or until any bladder wall integrity issues have resolved. 
1. Determine the total dose (in mg) to be administered to the patient: 
Total Dose (mg)  
2. Calculate the total number of vials required by: 
Total Number of Vials = Total dose (mg) / 100 (mg/vial) 
Round up the number of vials to be reconstituted to the next higher whole number if a 
fractional number of vials is obtained by the above formula (eg, if the total number of vials 
= 1.05 or 1.5, then 2 vials would be reconstituted). 
3. Using sterile technique, prepare the vials for reconstitution. 
4. Swab the rubber stoppers with alcohol. 
5. Reconstitute each nab-rapamycin vial by using a 50-cc or 60-cc sterile syringe to inject 
20 mL of 0.9% Sodium Chloride Injection, USP into each vial over a period of not less 
than 1 minute (Note: Change the syringes after reconstituting every 3 vials). 
 Aseptically, reconstitute each vial by injecting 20 mL of 0.9% Sodium Chloride 
Injection, USP. 
 Slowly inject the 20 mL of 0.9% Sodium Chloride Injection, USP over a minimum 
of 1 minute, using the sterile syringe to direct the solution flow onto the INSIDE 
WALL OF THE VIAL. 
 DO NOT INJECT the 0.9% Sodium Chloride Injection, USP directly onto the 
lyophilized cake as this will result in foaming. 
 Once the injection is complete, allow the vial to sit for a minimum of 5 minutes to 
ensure proper wetting of the lyophilized cake/powder. 
 Gently swirl and/or invert the vial slowly for at least 2 minutes until complete 
dissolution of any cake/powder occurs. Avoid generation of foam. 
 If foaming or clumping occurs, stand solution for at least 15 minutes until foam 
subsides. 
 Each mL of reconstituted product will contain 5 mg of rapamycin. 


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6. Calculate the exact total dosing volume (to the nearest mL) of 5 mg/mL suspension 
required for the patient: 
Dosing volume (mL) = Total dose (mg)/5 (mg/mL) 
7. The reconstituted sample should be a white-to-yellow translucent suspension without 
visible particulates. If unsuspended powder is visible, the vial should be gently inverted 
again to ensure complete resuspension, prior to use. 
 
8. Using a new, sterile 50-cc or 60-cc syringe, withdraw the reconstituted 5mg/ml nab-
rapamycin solution from the vial(s). Do not remove the rubber stopper from the nab-
rapamycin vials as this can compromise the sterility of the drug preparation. 
 
9. Inject the contents of the reconstituted nab-rapamycin vials into an empty sterile, 
standard PVC IV bag using an injection port. Inject perpendicularly into the center of the 
injection port to avoid dislodging plastic material into the IV bag. Repeat steps 9 and 10 
until the patient’s entire required dose (total mg) is injected into the IV bag.  
 
10. Add additional 0.9% sterile saline into the bag to make up the final dosing volume to 
80 ml by using the table below for phase 1 (Table 4) and phase 2 (Table 5): 
Table 4: 
Dosing Volume Preparation for Phase 1 Dosing  
Total Weekly Dose  
(Schedule / Week) 
Number of Vials 
Reconstituted 
with 20 mL Saline 
at 
each 
Treatment  
Amount 
of 
5 
mg/mL 
nab-
Rapamycin 
Introduced 
into 
Empty IV Bag 
Additional Saline 
Added to IV Bag 
to Make up Total 
Volume to 80mL 
Final 
Volume 
for 
Intravesical 
Instillation 
Administered 
Concentration 
of 
Rapamycin 
(Total Dose) 
100 mg 
(100 mg 1X weekly) 
1 
20 mL 
60 mL 
80 mL 
1.25 
mg/mL 
(100 mg) 
200 mg 
(200 mg 1X weekly) 
2 
40 mL 
40 mL 
80 mL 
2.50 
mg/mL 
(200 mg) 
200 mg 
(100 mg 2X weekly) 
1 
20 mL 
60 mL 
80 mL 
1.25 
mg/mL 
(100 mg) 
300 mg 
(300 mg/1X weekly) 
3 
60 mL 
20 mL 
80 mL 
3.75 
mg/mL 
(300 mg) 
400 mg 
(400 mg 1X weekly) 
4 
80 mL 
- 
80 mL 
5.00 
mg/mL 
(400 mg) 
 
Table 5: 
Dosing Volume Preparation for Phase 2 Dosing 
Total Weekly Dose  
(Schedule / Week) 
Number of Vials 
Reconstituted 
with 20 mL Saline 
at 
each 
Treatment  
Amount 
of 
5 
mg/mL 
nab-
Rapamycin 
Introduced 
into 
Empty IV Bag 
Additional Saline 
Added to IV Bag 
to Make up Total 
Volume to 80mL 
Final 
Volume 
for 
Intravesical 
Instillation 
Administered 
Concentration 
of 
Rapamycin 
(Total Dose) 
200 mg 
(200 mg 1X weekly) 
2 
40 mL 
40 mL 
80 mL 
2.50 
mg/mL 
(200 mg) 
 
 


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11. Discard any excess solution left over in the vials in accordance with standard 
operating procedures for cytotoxic drugs. 
 
12. Administer the reconstituted nab-rapamycin suspension from the IV bag intravesically 
via transurethral catheter.  
 
13. Reconstituted nab-rapamycin suspension should be used immediately, but may be 
stored for up to 4 hours at 2-8°C (36°- 46°F), followed by 4 hours at room temperature 
(<25°C). 
Stability 
Unopened vials of nab-rapamycin are stable until the date indicated on the package when 
stored between 2-8°C (36°- 46°F), in the original package.  Reconstituted nab-rapamycin 
should be used immediately, but may be refrigerated at 2◦C to 8◦C (36◦C to 46◦F) for a 
maximum of 8 hours if necessary. If not used immediately, each vial of reconstituted 
suspension should be replaced in the original carton to protect it from bright light. Discard 
any unused portion. Neither freezing nor refrigeration adversely affects the stability of the 
product. Some settling of the reconstituted suspension may occur. Ensure complete 
resuspension by mild agitation before use. Discard the reconstituted suspension if 
precipitates are observed. The suspension for infusion prepared as recommended in an 
infusion bag is stable at up to 4 hours at 2-8°C (36°- 46°F), followed by 4 hours at room 
temperature (<25°C) at ambient lighting conditions.  
Storage 
Store the vials in original cartons refrigerated at 2◦C to 8◦C (36◦C to 46◦F). Retain in the 
original package to protect from bright light. 
Handling and Disposal 
Procedures for proper handling and disposal of anticancer drugs should be considered. 
Several guidelines on this subject have been published [48, 49]. There is no general 
agreement that all of the procedures recommended in the guidelines are necessary or 
appropriate. 
6.1.3. Receipt and Return of nab-Rapamycin 
Upon receipt of the study drug supplies, the Investigator or designee will conduct an 
inventory and sign both copies of the study drug receipt and forward 1 copy to the address 
indicated on the form. One copy of the receipt and the packing slip must be retained in 
the Investigator’s regulatory file records. 
A representative from Sponsor or designee will inspect the study drug inventory, Drug 
Accountability Record form(s), and will arrange for the disposition of any remaining 
unused study drug. No study drug may be returned to AADi without the representative 
from AADi or other designated personnel first inspecting the study drug inventory and 
accountability documentation. 
6.1.4. Toxicities of nab-Rapamycin 
This study is the initial study of nab-rapamycin, a formulation of rapamycin, administered 
intravesically. No unexpected toxicities not already known for rapamycin were identified 


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in the nonclinical or clinical toxicity studies. Please see the Rapamune® Package Insert 
(0) for more details on the known precautions, warnings, and adverse reactions of 
rapamycin.  
In a clinical study with IV nab-rapamycin infusion in 26 patients with various advanced 
solid tumors, FDA IND #74,610, filed Dec 27, 2007), nab-rapamycin was well tolerated. 
Four DLTs were observed in the study: 2 cases at 150 mg/m2 (elevated transaminase 
and thrombocytopenia) and 2 at 125 mg/m2 (suicidal ideations and hypophosphatemia). 
While stomatitis and mucositis are common DLTs with rapamycin and rapalogs, all 
stomatitis/mucositis events were grade 1 and 2 (none dose-limiting). At the maximum 
tolerated dose of 100 mg/m2 nab-rapamycin only 2 cases of grade 1 stomatitis occurred 
and 1 case of grade 1 mucositis occurred at 45 mg/m2. Additionally, the most frequent 
grade 3 treatment-related adverse events in ≥5% of all treated patients were 
thrombocytopenia (3 patients), anemia (2), hypophosphatemia (2), and constipation (2). 
There was 1 case of grade 4 thrombocytopenia. 
6.2. 
Gemcitabine 
6.2.1. Gemcitabine Preparation and Administration 
Gemcitabine is a commonly used pharmaceutical formulation and its preparation will be 
according to routine institutional pharmacy protocols.  After voiding of nab-rapamycin, 
Gemcitabine (2000 mg in 100 mL saline diluent) will be intravesically administered into 
bladder, and patients will be asked to retain the drug for one hour before voiding. 
6.2.2. Toxicities of Gemcitabine 
Although myelosuppression is a serious side effect when gemcitabine is used 
intravenously, it has a very favorable toxicity profile when administered intravesically.   
Most frequent toxicities for intravesical gemcitabine include dysuria, frequency, and 
neutropenia [41], other toxicities include hematuria, irritative bladder, bladder ulcer, 
nausea, anemia, thrombocytopenia, fever, dizziness, and pain [42].  Both systemic and 
local toxicities generally were not higher than grade 2. 
 
7. 
ADVERSE EVENT MANAGEMENT GUIDELINES 
All serious, related, unlabeled, (unexpected) AEs will be reported to the FDA as required 
by 21 CFR 312.32, to the clinical trials site’s Institutional Review Board, as well as to the 
Data Safety and Monitoring Committee at the clinical trial site. 
7.1. 
Definition of Adverse Events 
An AE is defined as the development of an untoward medical occurrence, undesirable 
medical condition, recurrence or deterioration of a pre-existing medical condition 
subsequent to exposure of a pharmaceutical product or treatment. An AE is additionally 
defined as occurring at any dose, independent of perceived causal relationship to the 
product. Adverse events may or may not be formal medical diagnoses, and can also 
include signs, symptoms or abnormal laboratory findings. Common examples include 
nausea, chest pain, tachycardia, enlarged liver, or EKG abnormalities.  


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The definition of an AE is independent to a perceived causal relationship to the drug. 
Causality is a separate assessment that is performed for AEs. Causality assessment to 
a study drug or regimen will be a medical judgment based made in consideration of the 
following factors: temporal relationship of the AE to study drug exposure, known 
mechanism of action or side effect profile of study treatment, other recent or concomitant 
drug exposures, normal clinical course of the disease under investigation, and any other 
underlying or concurrent medical conditions. 
Any CTCAE grade 3 or 4, or any clinically significant grade 1 or 2 hematology or 
biochemistry laboratory values not solely considered a result of disease progression will 
be considered an AE.  
7.2. 
Definition of Serious Adverse Events 
A SAE is defined as any AE that results in death, is immediately life-threatening, requires 
inpatient hospitalization (at least a 24-hour), prolongs existing hospitalization, results in 
persistent or significant disability/ incapacity, or is a congenital anomaly/birth defect. 
Additionally, an SAE also includes any "important medical event" that may not have the 
immediate outcome of being life-threatening or result in death or hospitalization, but may 
jeopardize the patient or may require intervention to prevent such outcomes. 
Medical and scientific judgment will be exercised in deciding whether an AE is an 
"important medical event," and would therefore meet SAE criteria. Examples of such 
events are intensive treatment in an emergency room or at home for allergic 
bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization; and 
development of drug dependency or drug abuse. 
There will be an acknowledged distinction between serious and severe AE. Assessment 
of seriousness will be made solely by the serious criteria listed above. Severity of AEs will 
be graded according to the NCI CTCAE v4.0. Therefore, serious events will not be 
automatically considered severe. For example, a stroke that results in only a limited 
degree of disability may be considered a mild (not severe) stroke, but it would still meet 
serious criteria and thus, be captured as an SAE. Similarly, severe events may not always 
be serious. An example would be an episode of severe, transient nausea, which persists 
for several hours. This would be classified as a "severe" episode of nausea, but if it did 
not require treatment, intervention, or somehow meet other serious criteria, it would not 
be considered an SAE. 
In the clinical study setting, AEs are most often subcategorized as either SERIOUS or 
NONSERIOUS. This distinction is critical, as SERIOUS AEs require additional 
documentation that is both time-sensitive and detailed. 
7.3. 
Timeframe for Considering an Event to be Reportable AE or SAE 
All AEs (serious and nonserious) will be documented.  Any experience or condition that 
is identified from the signing of the informed consent through the 30-day follow-up period 
must be captured as an AE. Information collected will include a description of the event, 
date of onset and resolution, assessment of SAE criteria, any action taken (eg, changes 
to study treatment), final outcome, and the investigator’s assessment of causality (ie, the 
relationship to the study treatment). 


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7.4. 
Lack of Efficacy is Not Considered and AE or SAE 
"Lack of efficacy" or treatment nonresponse for an unproven therapy will not generally be 
considered an AE. If there is deterioration in the underlying condition for which the study 
regimen is designed to treat, there may be uncertainty as to whether this is an AE. In such 
a case, the investigating physician must judge the treatment as a possible contributor to 
the deterioration. Unless local governing regulations require otherwise, such deterioration 
will be considered to be an issue of treatment efficacy and not an AE. This situation 
constitutes an exception to the general rule that AEs are initially identified regardless of 
perceived causality attribution. Adverse events that are unequivocally due to progression 
of disease should be recorded as “progressive disease” rather than as AEs. However, the 
development of an additional disease will be regarded as an AE. For example, if a patient 
taking an experimental drug to treat underlying breast cancer develops a second primary 
cancer of nonmetastatic origin, this would be considered a unique AE. 
7.5. 
Patient Reporting of AEs and SAEs 
Patients are to be encouraged to call the site to report any unexpected symptoms or 
problems they encounter between office visits. These events should be considered in the 
same fashion as if they had been reported at a scheduled office visit. At each scheduled 
office visit, after the patient has had an opportunity to spontaneously mention any 
problems, the Investigator should inquire about AEs by asking the following standard 
questions: 
• Have you had any (other) medical problems since your last clinic visit? 
• Have you taken any new prescribed or over-the-counter medicines or herbal/vitamin 
preparations, other than those given to you in this study, since your last visit/assessment? 
• Have any new procedures been performed since your last study visit? 
7.6. 
Investigator Reporting of AEs and SAEs 
The Investigator or designee must completely and promptly record each AE in the source 
documentation and in the appropriate CRF, regardless of relationship to study drug as 
determined by the Investigator. The Investigator must assess AE/SAE causality for any 
patients treated at his/her site and for any patients treated under the direct care of his/her 
sub-Investigators. The Investigator should attempt, if possible, to establish a diagnosis 
based on the patient’s signs and symptoms. When a diagnosis for the reported signs or 
symptoms is known, the Investigator should report the diagnosis, not the symptoms, as 
the AE. 
Clinically significant laboratory abnormalities present at the baseline visit will be recorded 
as pretreatment signs and symptoms. 
Adverse events and SAEs should be reported on the appropriate case report forms. In 
addition, all SAEs must be reported promptly to AADi after the Investigator 
recognizes/classifies the event as a SAE. The specific reporting time frame depends on 
the type of SAE. For life-threatening or fatal events, the Investigator must report initial 
information on the SAE within 1 business day of becoming aware of the event, preferably 
by fax or phone or email; at a minimum, a description of the event and the investigator’s 
judgment of causality must be provided at the time of the initial report. If an SAE is 


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reported by phone or by e-mail, the Investigator must fax a completed SAE report form to 
AADi within 1 business day. For an event that is not life-threatening or fatal, the 
Investigator must fax a completed SAE report form within 2 business days after he/she 
recognizes/classifies the event as an SAE. 
All serious, related, and unexpected AEs will be reported and documented on Form FDA 
3500 A (Med Watch Form) and forwarded to the FDA in accordance with 21 CFR 312.32 
and with 21 CFR 314.80. A copy of the MedWatch that has been submitted to FDA will 
also be forwarded directly to SAE Reporting, AADi, LLC. 
These reports may be sent by FAX or E-MAIL to:  
SAE Reporting 
AADi, LLC 
 
Tel: 310-309-9036  
Fax: 424-252-9026 
E-mail: sae@aadimed.com 
 
FAX transmission will include the following on the provided study SAE REPORT, 
fax cover form (Appendix II): 
 
Study#: BC001 
Study Title: A Combined Phase 1 and Phase 2 Study of Albumin-bound 
Rapamycin Nanoparticles (nab-rapamycin, ABI-009) in the Treatment of 
BCG Refractory or Recurrent Nonmuscle-invasive Transitional Cell Bladder 
Cancer 
Name of Principle Investigator: 
Dr. James M. McKiernan, MD 
7.7. 
Additional Investigator Responsibilities on Follow-up for SAEs 
The Investigator and supporting personnel responsible for patient care should institute 
any supplemental investigations of SAEs based on their clinical judgment of likely 
causative factors. This may include extra clinical laboratory tests, physical examinations, 
or consulting an appropriate specialist. AADi may also request the Investigator to conduct 
supplemental assessments. The results of any additional assessments conducted must 
be reported to AADi. If a patient dies during participation in the study, a death certificate 
is required. If an autopsy is performed, a copy of the report must be submitted to AADi. If 
during the follow-up period for a SAE a patient dies due to another event unrelated to the 
SAE being followed, the event causing the death will be reported as a separate SAE. 
All AEs (serious and nonserious) that are unresolved or unimproved since initial 
presentation will be followed until resolution or improvement of the AE. With respect to 
AEs that are abnormal laboratory or investigational results, an unresolved or persistent 
CTCAE grade 3 or 4 laboratory abnormality at study completion or withdrawal will be 
followed until the laboratory abnormality has either returned to a comparable baseline 
value, or is judged to have a severity of grade 2 or better. 
If, in the investigator's medical judgment, any AE noted in the study is not likely to resolve 
or improve, the investigator will document that opinion in the patient's medical record. 


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Should the patient become lost to follow-up or further information is otherwise 
unattainable, the investigator will note this in the patient's medical record. 
For 30 days subsequent to study completion or withdrawal, new onset AEs will be 
captured. Follow up of these events will follow the same procedure as described above 
for AEs observed during the study period. 
7.8. 
Criteria for Removal from Study 
 Progressive disease 
 Systemic or local DLT 
 Patient declines to continue therapy 
 Initiation of another anticancer therapy 
 In the Investigator’s judgment, it is in the patient’s best interest to discontinue the 
study 
7.9. 
Institutional Review Board Notification of SAEs 
The Investigator is responsible for promptly notifying the IRB of all SAEs, including any 
follow-up information, occurring at his/her site and any SAE regulatory reports and 
Investigational New Drug Safety Reports that he/she receives from AADi. 
7.10. Sponsor Notification of Poststudy SAEs 
For 30 days subsequent to study completion or withdrawal, new onset AEs will be 
captured.  Follow up of these events will follow the same procedure as described above 
for AEs observed during the study period. 
7.11. Deaths 
ANY deaths occurring within the study period or within 30 days after discontinuing 
protocol treatment will be captured without exception, regardless of perceived causal 
relationship to study drug. A single AE term will be selected, the event will be considered 
an SAE, and "death" will serve as the positive criteria applied to the seriousness 
assessment. If the cause of death is unknown, then "death" will be captured as the sole 
AE term. Whenever possible the underlying cause, not the specific mechanism, of death 
will be selected as the SAE term, unless the investigator feels the specific mechanism of 
death is clinically relevant or offers significance that might otherwise be lost if not 
captured.     
 
8. 
ETHICAL, LEGAL, and ADMINISTRATIVE ASPECTS 
8.1. 
Ethics 
8.1.1. Institutional Review Board or Independent Ethics Committee 
Before study initiation, this protocol and informed consent form will be submitted for 
review and approval to the IRBs charged with oversight for the clinical sites. In addition, 
any form of proposed advertising and advertising text for patient recruitment must be 
reviewed and approved by AADi prior to submission to the IRB. The Investigator will 


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forward to AADi or other sponsor-nominated designee a copy of the IRB’s approval of this 
protocol, any amendments, informed consent form, and any modifications to the informed 
consent, based on the FDA regulations set forth in 21 CFR 56, as well as those of the 
applicable regulatory bodies in all other participating countries outside of the U.S. 
In addition, the Investigator will be responsible for forwarding to AADi or sponsor-
nominated designee a description of the IRB board members (including profession and 
affiliation) or a United States Department of Health and Human Services (DHHS) General 
Assurance number and expiration date. If neither of these is available, the chairperson 
must submit a statement indicating that the members of the board responsible for the 
review meet FDA and other appropriate regulatory requirements. In addition, the labeling 
for all approved study drugs should be submitted to the IRB for informational purposes.  
Clinical supplies will not be shipped to the clinical site until IRB approval is obtained for 
the protocol. Any existing amendments, informed consent, and photocopies of the 
approved documents must be received by AADi or other sponsor-nominated designee 
prior to drug shipment.  
8.1.2. Ethical Conduct of the Study 
This study will be conducted in compliance with the protocol, Good Clinical Practice, 
Guidelines of the International Conference on Harmonization of Technical Requirements 
for Registration of Pharmaceuticals for Human Use, and in full compliance with the World 
Medical Association Declaration of Helsinki and its most recent amendments. 
8.1.3. Informed Consent 
Written informed consent of the patient to participate in the study must be obtained and 
documented by the Investigator in accordance with the FDA regulations set forth in 21 
CFR 50 as well as the applicable regulatory bodies in all other participating countries 
outside the United States. 
The Investigator must provide the patient with a copy of the informed consent form in a 
language understandable to the patient. Written consent should be obtained before any 
protocol-required procedures are performed, including any procedure not part of normal 
patient care (eg, withdrawal of current medications).  
Changes made by a participating site to the recommended informed consent must be 
forwarded to AADi (or to the sponsor-nominated Project Manager) for approval prior to 
submission to the corresponding IRB. A copy of the signed informed consent will be given 
to the patient or their legal representative and the original must be retained in the 
Investigator’s study records. 
8.1.4. Data Safety and Monitoring 
This treatment regimen uses a chemotherapeutic agent with known toxicity and antitumor 
activity profiles. Because cancer is a life-threatening disease, treatments that result in 
grade 3 and 4 toxicities are considered to have an acceptable risk profile. SAEs will be 
reported to the Sponsor immediately and reviewed as they are received. Any 
unacceptable toxicities or severe toxicities that occur more frequently than expected will 
be discussed by the Chief Medical Officer or designee and the Investigator who will decide 
jointly whether the study should be modified, interrupted, or stopped. 


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8.2. 
Disclosure of the Data 
8.2.1. Confidentiality 
The Investigator and any other study personnel involved in this study shall not disclose, 
or use for any purposes (other than for the performance of this study), any data, records, 
or other information (hereinafter collectively “information”) disclosed to the Investigator or 
other study personnel. Such information shall remain the confidential and proprietary 
property of AADi, and shall be disclosed only to the Investigator or other designated study 
personnel. The obligation of non-disclosure shall not apply to the following: 
• 
relevant disclosure to potential study participants for the purpose of obtaining informed 
consent; 
• 
information after such time that it is or becomes publicly available through no fault of 
the Investigator or other study personnel; and, 
• 
information after such time that it is disclosed to the Investigator by a third party 
entitled to disclose such information. 
If the study site is a ‘covered site’ under the definitions of the Health Insurance Portability 
and Accountability Act (HIPAA), the Investigator will ensure that the patient consents to 
the use of data by AADi and its designees for the purposes of regulatory submissions, 
study publications, and drug approval. 
8.2.2. Publication 
Data from any individual center must not be published or presented until the complete 
multicenter study has been published or presented in full. Any subsequent publications 
should refer to the published multicenter findings.  
The Investigator(s) shall have the right, consistent with academic standards and with due 
regard to the protection of AADi’s confidential information and intellectual property, to 
publish or present the results of work performed in accordance with the study; provided 
that any proposed publication or presentation is first reviewed and approved in writing by 
AADi. AADi shall complete its review within 60 days after receipt of the proposed 
publication or presentation. Upon AADi’s request, proposed publication or presentation 
will be delayed up to 60 additional days to enable AADi to secure adequate intellectual 
property protection of property of AADi that would be affected by such proposed 
publication or presentation. If AADi believes in good faith that any proposed publication 
or presentation contains any confidential information and/or intellectual property, AADi 
shall have the right to remove references to any such confidential information and/or 
intellectual property. 
8.3. 
Investigator Documentation 
8.3.1. Form FDA 1572 
The Investigator must provide AADi with a fully executed Form FDA 1572. Any updates 
must be provided via a new fully executed Form FDA 1572. 
8.3.2. Curriculum Vitae 


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The Investigator must provide AADi with his/her current signed and dated curriculum vitae 
and a current signed and dated curriculum vitae for each sub-Investigator listed on Form 
FDA 1572. Current signed and dated curriculum vitae is defined as updated within 2 years 
of study start up. 
8.3.3. Financial Disclosures 
The Investigator and sub-Investigator(s) must complete a Clinical Investigator Financial 
Certification/Disclosure Statement to report financial interests and arrangements that may 
be of concern to FDA per 21 CFR 54. 
8.3.4. Laboratory Certification and Normal Ranges 
The Investigator will indicate on the Form FDA 1572 the name and location of any local 
and central laboratories that will be used for laboratory assessments. The Investigator will 
provide a copy of all clinical laboratory certifications, certification numbers, dates of 
certifications, lab accreditations, and a list of the normal ranges for all laboratory tests for 
all facilities listed. Updated versions of these documents must be provided to AADi or 
sponsor-nominated designee as appropriate. In the event the clinical laboratory is 
changed during the study, AADi will be promptly notified, and the Form FDA 1572 will be 
updated. Appropriate documentation will be submitted to AADi to verify the certification 
of the new laboratory. 
8.4. 
Records Retention 
In accordance with applicable regulatory requirements, following closure of the study, the 
Investigator will maintain a copy of all site study records in a safe and secure location. 
AADi will inform the Investigator of the time period for retaining these records in order to 
comply with applicable regulatory requirements. AADi reserves the right to terminate the 
study for refusal of the Investigator and/or investigational site to comply with any 
requirements stated in this study protocol. 
8.5. 
Protocol Violations/Deviations 
Apart from the regulatory requirements, it is vital to the success of the study that the 
Investigator adheres to the details of the protocol and thus holds to a minimum the number 
of cases that may be later classified as “incomplete,” “unusable,” or “not evaluable.” 
 
9. 
TERMINATION of STUDY 
AADi reserves the right to discontinue this study at any time. 
 
10. 
INVESTIGATOR’S PROTOCOL AGREEMENT 
The Investigator must sign the Investigator’s Protocol Agreement. The original must be 
kept on file at AADi or with a sponsor-nominated designee and the Investigator must 
retain a copy. The completed Investigator’s Protocol Agreement signifies agreement to 
comply with all procedures outlined by this protocol by the Investigator. An Investigator’s 
Protocol Agreement must be signed if and when a protocol amendment is issued by AADi. 
 


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11. 
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carcinoma. Am J Pathol  176, 3062-3072. 
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and nanoparticles. J Control Release. 
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Zillmann U, and Sinn H (2002). Efficacy and tolerability of an aminopterin-
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24. 
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25. 
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and trafficking in endothelial cells and regulation of endothelial barrier function. 
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26. 
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27. 
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et al. (2006). Increased antitumor activity, intratumor paclitaxel concentrations, 
and endothelial cell transport of cremophor-free, albumin-bound paclitaxel, ABI-
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28. 
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29. 
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S (2001). Analysis of the gene expression of SPARC and its prognostic value for 
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30. 
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33. 
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(2007) Nanoparticle albumin-bound (nab) rapamycin as an anticancer agent 
[abstr 4719], Los Angeles, CA. 
36. 
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37. 
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38. 
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Akcakanat A, Chen H, Naing A, Fu S, Wheler J, et al. (2013). Weekly nab-
Rapamycin in Patients with Advanced Nonhematologic Malignancies: Final 
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40. 
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Miragliuolo A, Guarrasi R, Lanna M, Cennamo G, et al. (2010). Randomized 
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Benson M, Lerner SP, Tangen CM, et al. (2013). SWOG S0353: Phase II trial of 
intravesical gemcitabine in patients with nonmuscle invasive bladder cancer and 
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42. 
Shelley MD, Jones G, Cleves A, Wilt TJ, Mason MD, and Kynaston HG (2012). 
Intravesical gemcitabine therapy for non-muscle invasive bladder cancer 
(NMIBC): a systematic review. BJU Int  109, 496-505. 
43. 
Lightfoot AJ, Breyer BN, Rosevear HM, Erickson BA, Konety BR, and O'Donnell 
MA (2014). Multi-institutional analysis of sequential intravesical gemcitabine and 
mitomycin C chemotherapy for non-muscle invasive bladder cancer. Urol Oncol  
32, 35 e15-39. 
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Reuter VE (1992). Altered expression of the retinoblastoma gene product: 
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mutations in bladder cancers and urine samples. Science  252, 706-709. 
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(2010). Development and validation of the Bladder Cancer Index: a 
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48. 
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49. 
D'Arcy PF (1983). Reactions and interactions in handling anticancer drugs. Drug 
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50. 
Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, and 
Carbone PP (1982). Toxicity and response criteria of the Eastern Cooperative 
Oncology Group. Am J Clin Oncol  5, 649-655. 
 
 
 


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12. 
APPENDICES 
Appendix I. Rapamune® Package Insert – Adverse Reactions 
 
 
 
 
 


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Appendix II. Adverse Events Fax Cover Sheet 
 
Fax 
To: 
SAE Reporting 
AADi, LLC 
From: 
   
Email: 
sae@aadimed.com 
Phone: 
310-309-9036 
Date: 
Fax: 
424-252-9026 
Pages: 
Re: 
 Adverse Event Notification 
CC: 
 Urgent       For Review       Please Comment       Please Reply       Please Recycle 
Comments:   
Study#:  
BC001 
Study Title: 
A Combined Phase 1 and Phase 2 Study of Albumin-bound Rapamycin 
Nanoparticles (nab-rapamycin, ABI-009) in the Treatment of BCG Refractory or 
Recurrent Nonmuscle-invasive Transitional Cell Bladder Cancer 
Name of Principle Investigator: 
Dr. James M. McKiernan, MD 
Confirmed:  This report has been submitted to FDA.   


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Appendix III. ECOG Performance Status 
 
ECOG PERFORMANCE STATUS [50]* 
Grad
e 
ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, eg, light house work, office work 
2 
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 
Capable of only limited self care, confined to bed or chair more than 50% of 
waking hours 
4 
Completely disabled. Cannot carry on any self care. Totally confined to bed or 
chair 
5 
Dead 
* As published in Oken et al., Am J Clin Oncol, 1982: 
 


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Appendix IV. 
Sponsor Signatures 
 
Study Title: 
A Combined Phase 1 and Phase 2 Study of Albumin-bound 
Rapamycin Nanoparticles (nab-Rapamycin, ABI-009) in the 
Treatment of BCG Refractory or Recurrent Nonmuscle-invasive 
Transitional Cell Bladder Cancer 
Study Number:  
 
BC001 
Amendment Date:   
April 20, 2016 
This clinical study protocol was subject to critical review and has been approved by the 
Sponsor. The following personnel contributed to writing and/or approving this protocol:  
 
 
 
Signed: ________________________________ Date: _______________ 
 
 
 
 
 


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Appendix V. Investigator’s Protocol Agreement 
 
Study Title: 
A Combined Phase 1 and Phase 2 Study of Albumin-bound 
Rapamycin Nanoparticles (nab-Rapamycin, ABI-009) in the 
Treatment of BCG Refractory or Recurrent Nonmuscle-invasive 
Transitional Cell Bladder Cancer 
Study Number: 
 
BC001 
Amendment Date:   
April 20, 2016 
 
I confirm that my staff and I have carefully read and understand this protocol. I/we agree 
to comply with the procedures and terms of the study specified herein. In particular, I/we 
have agreed to: 
• abide by all obligations stated on Form FDA 1572 and on other document(s) required 
by local regulatory authority. 
• retain records and documents related to this study for at least 7 years after the last 
approval of a marketing application in an International Conference on Harmonisation 
(ICH) region and until there are no pending or contemplated marketing applications in an 
ICH region or at least 7 years have elapsed since the formal discontinuation of clinical 
development of the investigational product. 
• comply with Good Clinical Practice (GCP) and all applicable regulatory requirements. 
• maintain confidentiality and assure security of AADi, LLC confidential documents. 
• obtain Institutional Review Board (IRB) approval of the protocol, any amendments to the 
protocol, and periodic re-approval as required, and to keep the IRB informed of adverse 
events and periodically report the status of the study to them. 
• not implement any deviations from or changes to the protocol without agreement from 
the sponsor and prior review and written approval from the IRB, except where necessary 
to eliminate an immediate hazard to the patients or for administrative aspects of the study 
(where permitted by all applicable regulatory requirements). 
• assure that each patient enrolled into the study has read, understands, and has signed 
the Informed Consent. 
• ensure that I and all persons assisting me with the study are adequately informed and 
trained about the investigational drug and of their study-related duties and functions as 
described in the protocol. 
• make prompt reports of serious adverse events (SAEs) and deaths (within 1 business 
day of learning of the death and 2 business days of learning of the SAE) to AADi. 
• assure access by AADi monitors, and/or FDA to original source documents. 
• prepare and maintain adequate and accurate case histories designed to record all 
observations and other data pertinent to the investigation on each individual treated in the 
investigation. 


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• arrange for the transfer of appropriate data from case histories to case report forms for 
the collection and transmission of data to the Sponsor. 
• cooperate fully with any study-related GCP audit as performed by AADi quality 
assurance group specified by the sponsor. 
• abide by the stipulations in the Disclosure of Data section and the manuscript 
preparation/authorship guidelines established at the outset of the study. 
 
 
____________________________  
__________________________ 
INVESTIGATOR’S SIGNATURE  
 
DATE 
James M. McKiernan, MD 
  
 
 
 
 
 
 
 
 
____________________________  
__________________________ 
INVESTIGATOR’S SIGNATURE  
 
DATE