Patient description: The patient is a 33-year-old woman complained of fatigue, weight gain and abnormal spotting between menses. No hirsutism or nipple discharge was detected. Her BMI was 34. Her lab results were remarkable for high TSH level (13 mU/L) and low free T4 level (0.2 ng/dl). Her anti-TPO levels were extremely high (120 IU/ml). She was diagnosed with Hashimoto's thyroiditis. Her aunt, brother and mother have the same disease. After starting 250 mcg Levothyroxine per day, her symptoms improved significantly and her periods are normal. She is still overweight with BMI of 31. Her most recent thyroid profile revealed all results except for anti-TPO within the normal range: TSH: 2.35 mU/L Free T4: 2.7 ng/dl Anti-TPO: 75 IU/ml

Clinical trial eligibility criteria: eligible ages (years): 18.0-999.0,  Infiltrating Bladder Urothelial Carcinoma Sarcomatoid Variant Infiltrating Bladder Urothelial Carcinoma With Glandular Differentiation Infiltrating Bladder Urothelial Carcinoma With Squamous Differentiation Infiltrating Bladder Urothelial Carcinoma, Micropapillary Variant Infiltrating Bladder Urothelial Carcinoma, Plasmacytoid Variant Metastatic Urothelial Carcinoma MTAP Negative Patients must have histologic confirmation of MTAP-deficient metastatic urothelial carcinoma. MTAP-deficiency must be verified by institutional Clinical Laboratory Improvement Act (CLIA)-certified immunohistochemistry (IHC). Histological variants such as glandular, squamous, sarcomatoid, micropapillary, plasmacytoid, and small cell changes will be allowed for this trial if these tumors are MTAP-deficient Patients can be considered for second line of therapy (after chemotherapy or immune checkpoint inhibitor with PD-[L]1 agent) or for third line of therapy (can have previously received chemotherapy and immune checkpoint inhibitor with PD-[L]1 blockade). Any prior intravesical therapy is allowed and does not count as a prior line of therapy Patients who received methotrexate-containing chemotherapy (e.g. methotrexate/vinblastine/adriamycin/cisplatin [MVAC]) as neoadjuvant therapy or first-line systemic therapy at least 12 months prior will be allowed for this trial All patients must have measurable disease by Response Evaluation in Solid Tumors (RECIST) version (v)1.1 and tumors of sufficient sizes for biopsy. In general, liver and lung lesions should be at least 1.0 cm, and patients with lymph node-only disease should have lesions of >= 1.5 cm in shortest dimension. Patients with disease confined to bone may be eligible if a measurable lytic defect is present. The study principal investigator (PI) is the final arbiter in questions related to measurability. Patients with a three-dimensional mass or pelvic sidewall fixation on bladder examination under anesthesia are considered to have measurable disease Patients must have an Eastern Cooperative Oncology Group (ECOG) performance status =< 2 Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) =< 2.5 x upper limit of normal (ULN), or =< 5 ULN if documented liver metastases are present Total bilirubin =< 1.5 x ULN, except subjects with Gilbert's syndrome or liver metastases, who must have a baseline total bilirubin =< 3.0 mg/dL Absolute neutrophil count (ANC) >= 1.5 x 10^9/L Hemoglobin >= 9 g/dL (may have been transfused) Platelets >= 100 x 10^9/L  Primary central nervous system (CNS) malignancies or CNS metastases, including leptomeningeal metastases, are not allowed. Subjects with previously treated brain metastases will be allowed if the brain metastases have been stable for at least 4 weeks following prior treatment and no ongoing steroid requirement Any other malignancy from which the patient has been disease-free for less than 2 years, except for non-melanomatous skin cancer, controlled localized prostate cancer, in situ carcinoma of any site Women who are pregnant or breastfeeding or intend to become pregnant during their participation in the study Presence of third space fluid which cannot be controlled by drainage. For patients who develop or have baseline clinically significant pleural or peritoneal effusions (on the basis of symptoms or clinical examination) before or during initiation of pemetrexed therapy, consideration should be given to draining the effusion prior to dosing. However, if, in the investigator's opinion, the effusion represents progression of disease, the patient should be discontinued from study therapy Known or suspected autoimmune disease. Patients with a history of inflammatory bowel disease (including Crohn's disease and ulcerative colitis) and autoimmune disorders such as rheumatoid arthritis, systemic progressive sclerosis (scleroderma), systemic lupus erythematosus or autoimmune vasculitis (e.g., Wegener's granulomatosis) are excluded from this study Any condition requiring systemic treatment with corticosteroids (> 10 mg daily prednisone equivalents) or other immunosuppressive medications within 14 days prior to first dose of study drug. Inhaled steroids and adrenal replacement steroids doses > 10 mg daily prednisone equivalents are permitted in the absence of active autoimmune disease History of primary immunodeficiency Patients who have prior organ transplantation, including allogeneic stem-cell transplant Vaccinations within 4 weeks of the first dose of avelumab and while on trials is prohibited except for administration of inactivated vaccines True positive test results for hepatitis A, B, or C during screening