Patients with T2-T4a N0 urothelial bladder carcinoma (UBC) with residual disease after
transurethral resection of the bladder (TURB, surgical opinion, cystoscopy or radiological
presence) will receive 3 cycles of pembrolizumab (MK-3475) at the dose of 200mg 3 weekly
prior to surgery (radical cystectomy). Cystectomy will be planned to be done within 3 weeks
of the last dose (accounting for a total of 9 weeks).
1. Willing and able to provide written informed consent.
2. Ability to comply with the protocol.
3. Age ≥ 18 years.
4. Histopathologically confirmed transitional cell carcinoma. Patients with mixed
histologies are required to have a dominant (i.e. 50% at least) transitional cell
5. Fit and planned for cystectomy (according to local guidelines).
6. Clinical stage T2-T4a N0 M0 disease by CT (or MRI) + PET/CT (within 4 weeks of
randomization by RECIST v1.1).
7. Residual disease after TURB (surgical opinion, cystoscopy or radiological presence).
8. Representative formalin-fixed paraffin-embedded (FFPE) tumor specimens (blocks
preferred) or at least 15 unstained slides, with an associated pathology report, for
testing at the study sponsor site and determined to be evaluable for tumor PD-L1
expression prior to study enrolment; patients with fewer than 15 unstained slides
available at baseline (but no fewer than 10) may be eligible following discussion with
9. Eastern Cooperative Oncology Group (ECOG) Performance Status of 0 or 1.
10. Adequate hematologic and end-organ function tests.
- Patients taking regular oral steroids, above the allowed limit of 10mg/day
methylprednisolone or analogues, for any reason. Patients must not have had steroids
for 28 days prior to study entry.
- Previously intravenous chemotherapy bladder cancer. Patients who have previously had
radiotherapy or concurrent chemo-radiation would be eligible.
- Malignancies other than UBC within 5 years prior to Cycle 1, Day 1, with the exception
of those with a negligible risk of metastasis or death and treated with expected
curative outcome (such as adequately treated carcinoma in situ of the cervix, basal or
squamous cell skin cancer, or ductal carcinoma in situ treated surgically with
curative intent) or localized prostate cancer treated with curative intent and absence
of prostate-specific antigen (PSA) relapse or incidental prostate cancer (Gleason
score ≤ 3 + 4 and PSA < 10 ng/mL undergoing active surveillance and treatment naive).
- Evidence of measurable nodal or metastatic disease.
- Evidence of significant uncontrolled concomitant disease that could affect compliance
with the protocol or interpretation of results, including significant liver disease
(such as cirrhosis, uncontrolled major seizure disorder, or superior vena cava
- Pregnant female patients. All female patients of childbearing potential with a
positive pregnancy test within 2 weeks prior to the first dose of study treatment will
be excluded from the study.
- Significant cardiovascular disease, such as New York Heart Association cardiac disease
(Class II or greater), myocardial infarction within 3 months prior to enrolment,
unstable arrhythmias, or unstable angina.
- Severe infections within 4 weeks prior to enrolment in the study including but not
limited to hospitalization for complications of infection, bacteraemia, or severe
- Major surgical procedure within 4 weeks prior to enrolment or anticipation of need for
a major surgical procedure during the course of the study other than for diagnosis.
- History of severe allergic, anaphylactic, or other hypersensitivity reactions to
chimeric or humanized antibodies or fusion proteins
- Known hypersensitivity or allergy to biopharmaceuticals produced in Chinese hamster
ovary cells or any component of the pembrolizumab formulation
- History of autoimmune disease including but not limited to myasthenia gravis,
myositis, autoimmune hepatitis, systemic lupus erythematosus, rheumatoid arthritis,
inflammatory bowel disease, vascular thrombosis associated with antiphospholipid
syndrome, Wegener's granulomatosis, Sjögren's syndrome, Guillain-Barré syndrome,
multiple sclerosis, vasculitis, or glomerulonephritis.
- Patients with a history of autoimmune-related hypothyroidism, unless on a stable dose
of thyroid-replacement hormone.
- Patients with uncontrolled Type 1 diabetes mellitus
- Uncontrolled hypercalcemia
- Patients with prior allogeneic stem cell or solid organ transplantation.
- History of idiopathic pulmonary fibrosis
- Positive test for HIV.
- Patients with active hepatitis infection
- Patients with active tuberculosis.
- Prior treatment with anti-programmed death-1 (PD-1), or anti-PD-L1 therapeutic
antibody or pathway-targeting agents.
- Administration of a live, attenuated vaccine within 4 weeks prior to enrolment or
anticipation that such a live, attenuated vaccine will be required during the study
- Treatment with any other investigational agent or participation in another clinical
trial with therapeutic intent within 28 days prior to enrolment
- History of severe immune-related adverse effects from anti-CTLA-4 (CTCAE Grade 3 and
- Treatment with systemic immunostimulatory agents within 4 weeks or five half-lives of
the drug, whichever is shorter, prior to enrolment.