A Phase II Study of the PARP Inhibitor Olaparib in Combination With the DNA Damaging Agent Temozolomide for the Treatment of Advanced Uterine Leiomyosarcoma
Phase: PHASE2
Conditions: Stage III Uterine Corpus Leiomyosarcoma AJCC v8, Stage IV Uterine Corpus Leiomyosarcoma AJCC v8, Uterine Corpus Leiomyosarcoma
Sponsor: National Cancer Institute (NCI)

NCI Protocol #: 10250 
Version Date: February 14, 2023 
 
i 
To:  
CTEP Protocol and Information Office  
From:       Matthew Ingham, M.D. 
Date:  
February 14, 2023 
Re: 
Amendment #8 for Protocol 10250 
————————————————————————————————————— 
SUMMARY OF CHANGES – Protocol 
 
I: 
Protocol Changes by Principal Investigator:  
 
# 
Section 
Comments 
1. 
Title 
Page 
The overall PI has been changed to Dr. Brian Van Tine of Washington 
University. The lead LAO remains the same.  
2. Calendar For patients who remain on the study as of February 2023 (and have been on 
treatment more than 2 years), the study calendar was modified to require in-
person visits every other cycle, and permit telephone or TeleHealth during the 
intervening visits. Laboratory tests must still be performed. This modification 
was made at the request of the site/treating investigators.  
 
 

NCI Protocol #: 10250 
Version Date: February 14, 2023 
 
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NCI Protocol #: 
10250 
 
Local Protocol #: 
Columbia University Medical Center IRB #AAAS4040  
 
ClinicalTrials.gov Identifier:  NCT03880019 
 
TITLE:  A Phase II Study of the PARP Inhibitor Olaparib in Combination with the DNA 
Damaging Agent Temozolomide for the Treatment of Advanced Uterine Leiomyosarcoma 
 
Corresponding Organization: LAO-CT018 / Yale University Cancer Center LAO 
 
Principal Investigator: 
Brian Van Tine, MD 
 
Washington University in St. Louis 
 
Medical Oncology, Barnes and Jewish Hospital 
 
660 South Euclid Avenue 
 
St. Louis, MO 63110 
 
314-747-3096 
 
bvantine@wustl.edu 
 
 
Participating Organizations  
LAO-11030 / University Health Network Princess Margaret Cancer Center LAO 
LAO-CA043 / City of Hope Comprehensive Cancer Center LAO 
LAO-CT018 / Yale University Cancer Center LAO 
LAO-MA036 / Dana-Farber - Harvard Cancer Center LAO 
LAO-MD017 / JHU Sidney Kimmel Comprehensive Cancer Center LAO 
LAO-NC010 / Duke University - Duke Cancer Institute LAO 
LAO-NJ066 / Rutgers University - Cancer Institute of New Jersey LAO 
LAO-OH007 / Ohio State University Comprehensive Cancer Center LAO 
LAO-PA015 / University of Pittsburgh Cancer Institute LAO 
LAO-TX035 / University of Texas MD Anderson Cancer Center LAO 
LAO-NCI / National Cancer Institute LAO 
 
 
 

NCI Protocol #: 10250 
Version Date: February 14, 2023 
 
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Statistician: 
 
 
 
 
Jake Allred, PhD 
 
Mayo Clinic Cancer Center 
 
200 First Street SW 
 
Rochester, MN 55905, USA 
 
(T): 507-538-6252 
 
(F): 507-266- 2477 
 
allred@mayo.edu 
 
 
 
 
 
 
 
 
 
 
NCI-Supplied Agent(s):  Olaparib (NSC 747856) 
 
 
Other Agent(s):  Temozolomide (NSC 362856), Commercial 
 
 
IND #:  124225 
IND Sponsor:  DCTD, NCI 
 
Protocol Type / Version # / Version Date: 
Original / August 1, 2018 
 
 
 
 
Revision 1 / October 17, 2018 
 
 
 
 
Revision 2 / November 21, 2018 
 
 
 
 
Revision 3 / December 31, 2018 
 
 
 
 
Revision 4 / February 22, 2019 
 
 
 
 
Revision 5a / April 5, 2019 
 
 
 
 
Amendment 1 / June 12, 2019 
 
 
 
 
Amendment 2 / July 2, 2019 
 
 
 
 
Amendment 3 / April 16, 2020 
 
 
 
 
Amendment 4 / April 23, 2021 
 
 
 
 
Amendment 5 / September 14, 2021 
 
 
 
 
Amendment 6 / February 18, 2022 
 
 
 
 
Amendment 7 / June 27, 2022 
 
 
 
 
Amendment 8 / February 14, 2023 
 
 

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SCHEMA 
 
 
 
LMS=Leiomyosarcoma, TMZ=temozolomide, BID=twice a day, MGMT=O[6]-methylguanine-
DNA methyltransferase, SLFN11=Schlafen family member number 11, RAD51= DNA repair 
protein RAD51 homolog, ECOG=Eastern Cooperative Oncology Group, PS=performance status. 
 
NOTE: For patients who continue beyond 12 cycles, Radiographic assessment (MRI or CT 
imaging) may be changed to once every 4 cycles (12 weeks) ± 3 days versus once every 2 cycles. 
 
 

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TABLE OF CONTENTS 
SCHEMA .........................................................................................................................................3 
1. 
OBJECTIVES ......................................................................................................................7 
1.1 
Primary Objective ....................................................................................................7 
1.2 
Secondary Objectives ...............................................................................................7 
1.3 
Exploratory Objectives ............................................................................................7 
2. 
BACKGROUND .................................................................................................................7 
2.1 
Study Disease ...........................................................................................................7 
2.2 
CTEP IND Agent .....................................................................................................8 
2.3 
Commercial Agent .................................................................................................13 
2.4 
Rationale for Combination Treatment ...................................................................14 
2.5 
Correlative Studies Background ............................................................................22 
3. 
PATIENT SELECTION ....................................................................................................26 
3.1 
Eligibility Criteria ..................................................................................................26 
3.2 
Exclusion Criteria ..................................................................................................28 
3.3 
Inclusion of Women and Minorities ......................................................................30 
4. 
REGISTRATION PROCEDURES ...................................................................................30 
4.1 
Investigator and Research Associate Registration with CTEP ..............................30 
4.2 
Site Registration .....................................................................................................31 
4.3 
Patient Registration ................................................................................................34 
4.4 
General Guidelines .................................................................................................35 
5. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................35 
5.1 
Summary Table for Specimen Collection ..............................................................35 
5.2 
Specimen Procurement Kits and Scheduling .........................................................35 
5.3 
Specimen Tracking System Instructions ................................................................36 
5.4 
Specimen Collection and Processing .....................................................................40 
5.5 
Shipping Specimens from Clinical Site to the ETCTN Biorepository ..................41 
5.6 
Biomarker Plan ......................................................................................................43 
5.7 
Integrated Correlative Studies ................................................................................45 
5.8 
Exploratory/Ancillary Correlative Studies ............................................................46 
6. 
TREATMENT PLAN ........................................................................................................47 
6.1 
Agent Administration .............................................................................................48 
6.2 
General Concomitant Medication and Supportive Care Guidelines ......................49 
6.3 
Duration of Therapy ...............................................................................................51 
6.4 
Duration of Follow Up ...........................................................................................52 
7. 
DOSE DELAYS AND MODIFICATIONS ......................................................................52 
7.1 
Required Parameters for Initiation of a Treatment Cycle ......................................52 
7.2 
General Principles ..................................................................................................52 
7.3 
Dose Levels for Olaparib and Temozolomide .......................................................53 

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7.4 
Management of Hematologic Toxicity ..................................................................53 
7.5 
Management of Non-Hematologic Toxicities Attributed to Olaparib ...................55 
7.6 
Management of Non-Hematologic Toxicities Related to Temozolomide .............56 
7.7 
Management of New or Worsening Pulmonary Symptoms ..................................56 
7.8 
Management of Nausea and Vomiting ..................................................................56 
7.9 
Interruptions for Intercurrent Non-Toxicity Related Events .................................57 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................57 
8.1 
CTEP IND Agent ...................................................................................................57 
8.2 
Commercial Agent .................................................................................................61 
9. 
STATISTICAL CONSIDERATIONS...............................................................................62 
9.1 
Study Design/Endpoints.........................................................................................62 
9.2 
Sample Size/Accrual Rate ......................................................................................63 
9.3 
Stratification Factors ..............................................................................................64 
9.4 
Analysis of Secondary Endpoints ..........................................................................64 
9.5 
Reporting and Exclusions ......................................................................................65 
10. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................66 
10.1 
Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) .................66 
10.2 
Adverse Event Characteristics ...............................................................................69 
10.3 
Expedited Adverse Event Reporting ......................................................................70 
10.4 
Routine Adverse Event Reporting .........................................................................72 
10.5 
Pregnancy ...............................................................................................................72 
10.6 
Secondary Malignancy ...........................................................................................72 
10.7 
Second Malignancy ................................................................................................73 
10.8 
Overdose ................................................................................................................73 
11. 
STUDY CALENDAR .......................................................................................................73 
11.1 
Laboratory Assessments ........................................................................................75 
11.2 
ECG........................................................................................................................76 
12. 
MEASUREMENT OF EFFECT........................................................................................76 
12.1 
Antitumor Effect – Solid Tumors ..........................................................................76 
13. 
STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS .............................................................................................................81 
13.1 
Study Oversight .....................................................................................................82 
13.2 
Data Reporting .......................................................................................................82 
13.3 
CTEP Multicenter Guidelines ................................................................................84 
13.4 
Collaborative Agreements Language .....................................................................84 
14. 
REFERENCES ..................................................................................................................87 
APPENDIX A 
PERFORMANCE STATUS CRITERIA ..................................................95 
APPENDIX B 
PATIENT DRUG INFORMATION HANDOUT AND 

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WALLET CARD ...............................................................................................................96 
APPENDIX C 
PATIENT INFORMATION SHEET ON DIARRHEA 
MANAGEMENT ...............................................................................................................99 
APPENDIX D  
PATIENT MEDICATION DIARY - OLAPARIB ..................................101 
APPENDIX E  
PATIENT MEDICATION DIARY – TEMOZOLOMIDE .....................103 
APPENDIX F 
ACTIONS REQUIRED IN CASES OF COMBINED 
INCREASE OF AMINOTRANSFERASE AND TOTAL BILIRUBIN – 
HY’S LAW 
105 
APPENDIX G 
ACCEPTABLE BIRTH CONTROL METHODS...................................110 
APPENDIX H 
SCHEMA OF BIOMARKER SAMPLE COLLECTION 
AND PROCESSSING .....................................................................................................111 
 
 
 

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1. OBJECTIVES 
 
1.1 
Primary Objective 
 
1.1.1 To evaluate whether combination treatment with temozolomide (TMZ) + olaparib shows 
preliminary evidence of clinical activity among patients with advanced uterine 
leiomyosarcoma (LMS) as measured by the confirmed objective response rate (ORR). . 
 
1.2 
Secondary Objectives 
 
1.2.1 To evaluate the toxicity profile associated with the combination treatment. 
 
1.2.2 To evaluate the progression free survival (PFS) associated with the combination 
treatment. 
 
1.2.3 To evaluate what proportion of uterine LMS tumors exhibit homologous recombination 
(HR) deficiency as measured by (1) genomic alterations in HR components at baseline 
and (2) DNA repair protein RAD51 homolog (RAD51) foci formation at baseline and 
while on study treatment.  To evaluate the feasibility of these assays in human tissue, and 
to preliminarily evaluate for any association between presence of HR deficiency as 
measured by each assay and increased clinical benefit from the study treatment. 
 
1.3 
Exploratory Objectives 
 
1.3.1 To evaluate what proportion of uterine LMS tumors exhibit HR deficiency as measured 
by Schlafen family member number 11(SLFN11) protein expression at baseline.  To 
evaluate the feasibility of this assay in human tissue, and to preliminarily evaluate for any 
association between presence of HR deficiency as measured by this assay and increased 
clinical benefit from the study treatment. 
 
1.3.2 To evaluate MGMT protein expression in uterine LMS tumors, and to preliminarily 
evaluate for any association between MGMT expression and increased clinical benefit 
from the study treatment. 
 
1.3.3 To perform an optional third tissue biopsy in patients who initially benefit from study 
treatment but later show early evidence of disease progression to evaluate for changes in 
the status of the RAD51 foci, MGMT, and SLFN11 assays at that time.  
 
 
2. 
BACKGROUND 
 
2.1 
Study Disease 
 
Soft tissue sarcoma (STS) is a heterogeneous malignancy of mesenchymal origin comprised of 
more than 50 subtypes with distinct biologic features.  LMS is a clinically aggressive sarcoma 
subtype arising from smooth muscle and most often presents in the uterus or retroperitoneum.  

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LMS, a relatively common sarcoma subtype, accounts for up to 20% of new STS diagnoses 
(George et al., 2018).  Although a subset of cases are surgically resectable at presentation, local 
recurrence or metastatic relapse occurs in approximately 40% of patients (Coindre et al., 2001).  
Advanced LMS is treated with chemotherapy.  The most active regimens, doxorubicin or the 
combination of gemcitabine with docetaxel, are associated with ORR of 15-35% and median 
PFS of 4-6 months (Hensley et al., 2008; Sutton et al., 2005).  Recently, the combination of 
doxorubicin with the novel platelet derived growth factor receptor alpha (PDGFR) monoclonal 
antibody, olaratumab, was shown to prolong survival as compared doxorubicin monotherapy in a 
phase 2 study of unselected soft tissue sarcoma subtypes and received FDA approval (Tap et al., 
2016).  However, response rates for this regimen remain under 20% and, as multiple subtypes 
were included on this study, the specific benefit for LMS remains uncertain.  The cytotoxic agent 
trabectedin and the angiogenic receptor tyrosine kinase inhibitor pazopanib are the other 
therapies approved for LMS and provide a PFS benefit of several months with no improvement 
in overall survival (OS) (van der Graaf et al., 2012; Demetri et al., 2016).  Dacarbazine, and the 
related oral agent temozolomide, are other cytotoxic agents used in the advanced setting. 
Unfortunately, LMS appears resistant to immune checkpoint blockade with anti-PD-1 
monotherapy, with an ORR of 0% in a recent phase 2 study with pembrolizumab (Burgess et al., 
2017).  Thus, LMS represents a relatively common sarcoma subtype in particular need of new 
treatments which reflect the cancer biology of this specific sarcoma.  
 
We propose the combination of olaparib, a potent polyadenosine 5’diphosphoribose (poly [ADP 
ribose]) polymerization (PARP) inhibitor (PARPi), with TMZ, a DNA alkylating agent, as a 
novel treatment for uterine LMS based on compelling preclinical data.  This proposal is further 
strengthened noting that TMZ is a standard of care agent with monotherapy activity in LMS and 
that emerging evidence suggests LMS is a sarcoma subtype with a “BRCAness” phenotype and 
is deficient in DNA damage repair (and, specifically, homologous recombination).   
 
2.2 
CTEP IND Agent 
 
2.2.1 Olaparib (AZD2281) 
 
Olaparib (AZD2281, KU-0059436) is a potent PARPi (PARP-1, -2 and -3) that is being 
developed as an oral therapy, both as a monotherapy (including maintenance) and for 
combination with chemotherapy and other anti-cancer agents. 
 
PARP inhibition is an approach targeting tumors with deficiencies in DNA repair mechanisms.  
PARP enzymes are essential for repairing DNA single strand breaks (SSBs).  Inhibiting PARPs 
leads to the persistence of SSBs, which are then converted to the more serious DNA double 
strand breaks (DSBs) during the process of DNA replication.  During the process of cell division, 
DSBs can be efficiently repaired in normal cells by homologous recombination repair (HR).  
Tumors with HR deficiencies (HRD), such as ovarian cancers in patients with BRCA1/2 
mutations, cannot accurately repair the DNA damage, which may become lethal to cells as it 
accumulates.  In such tumor types, olaparib may offer a potentially efficacious and less toxic 
cancer treatment compared with currently available chemotherapy regimens. 
 

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BRCA1 and BRCA2 defective tumors are intrinsically sensitive to PARP inhibitors, both in 
tumor models in vivo (Rottenberg et al., 2008; Hay et al., 2009) and in the clinic (Fong et al., 
2009).  The mechanism of action for olaparib results from the trapping of inactive PARP onto 
the single-strand breaks (SSBs) preventing their repair (Helleday, 2011; Murai et al., 2012).  
Persistence of SSBs during DNA replication results in their conversion into the more serious 
DNA DSBs that would normally be repaired by HR repair.  Olaparib has been shown to inhibit 
selected tumor cell lines in vitro and in xenograft and primary explant models as well as in 
genetic BRCA knock-out models, either as a stand-alone treatment or in combination with 
established chemotherapies. 
 
2.2.1.1 
Mechanism of Action 
 
The mechanism of action for olaparib activity as a single agent has been proposed to involve the 
trapping of inactivated PARP onto the single-strand breaks preventing their repair and generating 
a potential block for cellular DNA replication (Helleday, 2011; Murai et al., 2012).  An 
important consequence of this is that processing of trapped PARP-DNA complexes and/or the 
stalling of replication forks, or collapsing of replication forks, is predicted to lead to the 
generation of the more serious DNA DSBs.  These DSBs would normally be repaired by a 
process that involves ATM (a major DNA DSB signaling kinase, the ‘MRN’ nuclease protein 
complex; made up of Meiotic Recombination 11 Homolog A [MRE11A], human RAD50 
homolog [RAD50] and Nijmegen breakage syndrome1 [NBS1]) and additional homologous 
recombination DNA repair (HRR) proteins such as DNA repair protein RAD51 homolog 
(RAD51), BRCA1 and BRCA2.  
 
In some instances where DNA repair defects may not result in the same level of sensitivity as 
BRCA mutations, and therefore single agent olaparib treatment may not be sufficient to induce 
cell kill through synthetic lethality, it may still be possible to induce tumor cell death through 
combinations with ionizing radiation or chemotherapies that either increase DNA damage 
accumulation or mitotic stress.  The latter is relevant since it is often during mitosis that 
unrepaired DNA damage leads to cell death through a process known as mitotic catastrophe 
(Castedo et al., 2004).  
 
2.2.1.2 
Nonclinical Summary 
 
Olaparib is a potent inhibitor of mammalian PARP-1, PARP-2 and PARP-3 and inhibits selected 
tumor cell lines in vitro and xenograft tumor growth in vivo, either as a stand-alone treatment or 
in combination with established chemotherapies (Investigator’s Brochure, 2018).  Olaparib has a 
half-maximal inhibitory concentration (IC50) against the PARP-1 enzyme of 5 nM, an IC50 
against the PARP-2 enzyme of 1 nM, and an IC50 against the PARP-3 enzyme of 4 nM.  The 
main target of olaparib that is responsible for the induction of synthetic lethality in HRD cancer 
cells is PARP-1.  In cells cultured in vitro, 50% inhibition of PARP-1 activity, as measured by 
the formation of PAR, occurs at concentrations of 6-8 nM, with greater than 90% PAR formation 
being inhibited between 30-100 nM and complete inhibition of PARP-1 activity occurring 
between 100-300 nM.  In vivo, the PARP-1 IC50 was 120 nM (standard error ±33 nM) and the 
IC90 was 576 nM (standard error not calculated).  Olaparib doses leading to tumor regression in a 
BRCA2 mutant PDX model resulted in PARP-1 inhibition of >50% for more than 10 hours and 

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inhibition of >90% for more than 4 hours.  Analysis of a panel of cancer cell lines identified 
those deficient in homologous recombination repair factors, notably BRCA1 and BRCA2, as 
being particularly sensitive to treatment with olaparib. 
 
In vitro, olaparib showed no significant off-target activity at concentrations 6-times the human 
mean free Cmax at the clinical dose of 300 mg twice a day (BID) (3.65 mcM) when screened 
against a diverse panel of molecular targets including enzymes, receptors, transporters and ion 
channels (Investigator’s Brochure, 2018). 
 
In vivo, olaparib was rapidly absorbed and the absolute bioavailability of olaparib following oral 
(PO) dosing was 60% in mice, 20% in rats, and 80% in dogs (Investigator’s Brochure, 2018).  
The major isozymes responsible for the metabolism of olaparib are CYP3A4 and CYP3A5, with 
the majority of the metabolism resulting in oxidation and hydroxylation processes with the main 
site of metabolism being the piperazine and fluorobenzyl ring structures.  In vitro, olaparib was 
found to be both a direct inhibitor (IC50 119 mcM) and a time dependent inhibitor (inactivation 
rate constant [Kinact] 0.0675 min-1; inhibition constant [Ki] 72.2 mcM) of CYP3A.  Excretion of 
the drug was predominately in the feces in both the rat and the dog. 
  
Repeat dose and reproductive toxicology studies were conducted in both rats and dogs with 
exposure levels below those achieved at the clinical therapeutic 300 mg BID (tablet) dose 
(Investigator’s Brochure, 2018).  The repeat-dose toxicology studies of up to 6 months found that 
the primary target organ for toxicity was the bone marrow, with associated changes in peripheral 
hematology parameters, which may be related to the primary pharmacology of olaparib.  All 
changes showed full or partial recovery following withdrawal of olaparib.  Administration of 
olaparib during organogenesis caused reductions in early embryofetal survival and fetal weights 
as well as increases in the incidence of visceral and skeletal abnormalities and major eye and 
vertebral/rib malformations at dose levels that were not maternally toxic. 
 
Combination of olaparib with the mono-methylating agent TMZ or topotecan suggest the 
potentiation of anti-tumor activity in a number of cell lines and in rats with no additional target 
organ toxicities compared to single agent administration (Investigator’s Brochure, 2018). 
 
2.2.1.3 
Summary of Clinical Experience 
 
As of December 15, 2017, approximately 8319 patients have received olaparib in Phase 1, 2, and 
3 trials (Investigator’s Brochure, 2018).  Of the 4575 patients on AstraZeneca-sponsored trials, 
1512 patients received the capsule formulation and 3038 received the tablet formulation and 25 
patients received both the capsule and tablet.  In company sponsored trials, 3133 patients have 
received olaparib as a monotherapy and 1442 patients received olaparib in combination with 
chemotherapy or other anti-cancer agents including patients that received the combination 
therapy sequentially to receiving the monotherapy.  The Phase 3 registration studies and most 
new clinical studies are investigating the tablet formulation which delivers the therapeutic dose 
of olaparib in fewer dose units than the capsule.  The tablet formulation was registered for use in 
the US in August 2017 for ovarian cancer and in January 2018 for breast cancer.  In January 
2018, the tablet formulation was also registered for use in Japan for ovarian cancer.  The 
recommended olaparib monotherapy tablet dose under investigation is 300 mg BID.  

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2.2.1.4 
Clinical Pharmacokinetics and Metabolism 
 
As of December 15, 2017, there is pharmacokinetic (PK) data from 11 clinical studies.  Olaparib 
is orally available and the tablet formulation is rapidly absorbed, reaching peak plasma 
concentration (tmax) in 1.5 hours (Investigator’s Brochure, 2018).  The plasma concentrations 
decline in a biphasic manner with an average terminal elimination half-life (t1/2) of 14.9 hours 
(standard deviation [Sd] 8.2 hours).  The mean apparent oral clearance rate was approximately 
7.4 L/hour (Sd 3.9 L/hour).  The mean volume of distribution (Vd) of olaparib following a single 
administration of 300 mg oral tablet dose was 158 L (Sd 136 L) indicating olaparib is distributed 
into the tissues.   
 
The metabolism of olaparib was assessed in a study of six female patients ranging in age from 
34-72 years (Investigator’s Brochure, 2018).  Upon the administration of a single 100 mg dose of 
olaparib containing 1x50 mg capsule of radiolabeled [14C]-olaparib and 1x50 mg capsule of 
unlabeled olaparib, 70% of the radioactivity in the blood was olaparib.  Three metabolites each 
comprised around 10% of the material: M12 (9.3%, ring-open piperazin-3-ol), M15 (10.3%, 4-
fluorophenol (hydroxy)methyl), and M18 (13.7%, piperazin 3-ol).   
 
Olaparib is eliminated in both the urine (44% of the dose) and feces (42% of the dose) 
(Investigator’s Brochure, 2018).  In the urine, olaparib was the most abundant component, 
accounting for between 10% and 19% of the dosed material.  Up to 37 further drug-related 
components were observed, 18 of which were quantifiable by high performance liquid 
chromatography with mass spectrometric detection (HPLC/MS) with radioactivity detection.  At 
least 20 components were observed in the pooled fecal samples with 6 components accounting 
for >1% of the dose and the remaining metabolites detectable only by HPLC/MS.  The major 
components present were unchanged olaparib (0.6 to 14% of the dose) and M15 (0.9 to 8% of 
the dose).  Four further metabolites (M9, M12, M23 and M25) were also prominent each 
accounting for ≤6% of the dose.  
 
The PK parameters for multiple dosing of olaparib are well predicted from the single dose 
studies.  There is not extensive accumulation with multiple dosing.  At 300 mg oral dose BID, 
the temporal change parameter (AUC at steady state/AUC following a single dose) was 
approximately 1.5 (Sd 0.6) (Investigator’s Brochure, 2018).  
 
At capsule doses ≥40 mg, the inhibition of PARP-1 measured in peripheral blood mononuclear 
cells (PBMC) reached its maximum of 50% to 60% of the baseline, and this level of inhibition 
was achieved by 6 hours after the first dose of olaparib and was maintained with repeated dosing 
(Investigator’s Brochure, 2018).  In tumor biopsies from 60 breast cancer patients who received 
doses of olaparib between 10 mg BID and 400 mg BID, PARP inhibition ranged from 20% to 
80% and did not relate to the dose.  
 
2.2.1.5 
Clinical Safety Summary 
 
Olaparib monotherapy has been associated with adverse reactions generally of mild or moderate 
severity (Common Terminology Criteria for Adverse Events v.5.0 [CTCAE] grade 1 or 2) and 

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generally not requiring treatment discontinuation (Investigator’s Brochure, 2018).  In a pool of 
1248 patients, the most frequently observed adverse reactions across clinical trials in patients 
receiving olaparib monotherapy (≥10%) were nausea, vomiting, diarrhea, dyspepsia, fatigue, 
headache, dysgeusia, decreased appetite, dizziness, and anemia.  Anemia and other hematologic 
toxicities were generally low grade (grade 1 or 2).  However, anemia was the most commonly 
reported grade ≥3 adverse event reported in clinical trials.  The median time to first report of 
anemia was approximately 4 weeks (approximately 7 weeks for grade ≥3).  Anemia can be 
managed with dose interruptions, dose reductions, and blood transfusions where appropriate.  In 
one phase 3 trial in ovarian cancer patients, the incidence of anemia was 43.6% of patients, with 
grade ≥3 in 19.5% of patients, leading to dose interruptions (16.9%), dose reductions (8.2%), 
discontinuation of treatment (3.1%).  In addition, 17.9% of patients treated with olaparib 
required one or more blood transfusions during treatment.   
 
In clinical studies with olaparib the incidence of grade ≥2 shifts (elevations) from baseline in 
blood creatinine was approximately 15% (Investigator’s Brochure, 2018).  Data from a double-
blind placebo-controlled study showed median increase up to 23% from baseline remaining 
consistent over time and returning to baseline after treatment discontinuation, with no apparent 
clinical sequelae; 90% of patients had creatinine values of grade 0 at baseline and 10% were 
grade 1 at baseline.  
 
Nausea was generally reported very early, with first onset within the first month of olaparib 
treatment in the majority of patients (Investigator’s Brochure, 2018).  Vomiting was reported 
early, with first onset within the first 2 months of olaparib treatment in the majority of patients.  
Both nausea and vomiting were reported to be intermittent for the majority of patients and can be 
managed by dose interruption, dose reduction and/or antiemetic therapy.  Antiemetic prophylaxis 
is not required. 
 
Studies of olaparib in combination with various chemotherapy agents indicate an increase in 
bone marrow toxicity (anemia, neutropenia, thrombocytopenia) greater than expected if the 
agents had been administered alone (Investigator’s Brochure, 2018).  The effects are generally 
transient, but treatment delays are common and alternative administration schedules/toxicity 
management processes have been evaluated within some of these studies.  When this type of 
toxicity has occurred, it has been managed by routine clinical practice including dose delays, 
dose reductions, intermittent dosing and/or the use of supportive care measures, including 
granulocyte colony stimulating factor (G-CSF). 
 
The incidence of myelodysplastic syndrome/acute myeloid leukemia (MDS/AML) in patients 
treated in clinical trials with olaparib monotherapy, including long-term survival follow-up, was 
<1.5% and the majority of events had a fatal outcome (Investigator’s Brochure, 2018).  If MDS 
and/or AML are confirmed while on treatment with olaparib, it is recommended that olaparib 
should be discontinued and the patient be treated appropriately. 
 
Pneumonitis has been reported in <1.0% patients treated with olaparib monotherapy in clinical 
studies (Investigator’s Brochure, 2018).  When olaparib was used in clinical studies in 
combination with other therapies there have been events with a fatal outcome.  If patients present 
with new or worsening respiratory symptoms such as dyspnea, cough and fever, or an abnormal 

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chest radiologic finding is observed, olaparib treatment should be interrupted and prompt 
investigation initiated.  If pneumonitis is confirmed, olaparib treatment should be discontinued 
and the patient treated appropriately. 
 
2.2.1.6 
Clinical Efficacy Summary 
 
There have been many clinical trials looking at the efficacy of olaparib both as a monotherapy as 
well as in combination with different chemotherapy treatments (Investigator’s Brochure, 2018).  
As a monotherapy, olaparib has shown statistically significant increases in progression-free 
survival (PFS) in both Phase 2 and Phase 3 trials in advanced ovarian cancer.  In a Phase 3 study 
comparing olaparib to chemotherapy of the physician’s choice in BRCA mutated, HER-2 
negative breast cancer, olaparib increased the PFS and objective response rate.   
 
Olaparib in combination with paclitaxel has increased the overall survival (OS) of patients in 
Phase 2 and a confirmatory Phase 3 trial in 2nd line gastric cancer.  In both trials, there was no 
difference in the PFS (Investigator’s Brochure, 2018).  
 
Olaparib in combination with trabectedin showed partial response or stable disease in 9 out of 22 
patients with STS including LMS and Ewing Sarcoma (ES) in a phase 1b study (Grignani et al. 
2016).   
 
In non-comparative studies, olaparib has shown anti-tumor activity in patients with germline 
BRCA mutated cancers including ovarian, breast, pancreatic, and prostate (Investigator’s 
Brochure, 2018). In a phase 2 study of ES, no significant responses or durable disease control 
was observed (Choy et al. 2014). 
 
The recommended monotherapy dose of olaparib is 300 mg BID (Investigator’s Brochure, 2018).  
 
2.3 
Commercial Agent 
 
2.3.1 Temozolomide 
 
2.3.1.1 
Mechanism of Action 
 
TMZ is not directly active but undergoes rapid nonenzymatic conversion at physiologic pH to 
the reactive compound 5-(3-methyltriazen-1-yl)-imidazole-4-carboxamide (MTIC).  The 
cytotoxicity of MTIC is thought to be primarily due to alkylation of DNA.  Alkylation 
(methylation) occurs mainly at the O6 and N7 positions of guanine (Package Insert, 2017). 
 
2.3.1.2 
Clinical Pharmacokinetics and Metabolism 
 
2.3.1.2.1 
Absorption and Distribution  
 
TMZ is rapidly and completely absorbed after oral administration with a peak plasma 
concentration (Cmax) achieved in a median Tmax of 1 hour (Package Insert, 2017).  Food reduces 
the rate and extent of TMZ absorption.  Mean peak plasma concentration and AUC decreased by 

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32% and 9%, respectively, and median Tmax increased by 2-fold (from 1-2.25 hours) when TMZ 
was administered after a modified high-fat breakfast.  A PK study comparing oral and 
intravenous (IV) TMZ in 19 patients with primary CNS malignancies showed that 150 mg/m2 
TMZ for injection administered over 90 minutes is bioequivalent to 150 mg/m2 TMZ oral 
capsules with respect to both Cmax and AUC of TMZ and MTIC.  Following a single 90-minute 
IV infusion of 150 mg/m2, the geometric mean Cmax values for TMZ and MTIC were 7.3 
mcg/mL and 276 ng/mL, respectively.  Following a single oral dose of 150 mg/m2, the geometric 
mean Cmax values for TMZ and MTIC were 7.5 mcg/mL and 282 ng/mL, respectively.  
Following a single 90-minute IV infusion of 150 mg/m2, the geometric mean AUC values for 
TMZ and MTIC were 24.6 mcg·hr/mL and 891 ng·hr/mL, respectively.  Following a single oral 
dose of 150 mg/m2, the geometric mean AUC values for TMZ and MTIC were 23.4 mcg·hr/mL 
and 864 ng·hr/mL, respectively.  TMZ has a mean apparent Vd of 0.4 L/kg (%CV=13%).  It is 
weakly bound to human plasma proteins; the mean percent bound of drug-related total 
radioactivity is 15%. 
 
2.3.1.2.2 
Metabolism and Elimination  
 
TMZ is spontaneously hydrolyzed at physiologic pH to the active species, MTIC and to TMZ 
acid metabolite (Package Insert, 2017).  MTIC is further hydrolyzed to 5-amino-imidazole-4-
carboxamide (AIC), which is known to be an intermediate in purine and nucleic acid 
biosynthesis, and to methylhydrazine, which is believed to be the active alkylating species.  
Cytochrome P450 enzymes play only a minor role in the metabolism of TMZ and MTIC.  
Relative to the AUC of TMZ, the exposure to MTIC and AIC is 2.4% and 23%, respectively.  
 
2.3.1.2.3 
Excretion  
 
About 38% of the administered TMZ total radioactive dose is recovered over 7 days: 37.7% in 
urine and 0.8% in feces (Package Insert, 2017).  The majority of the recovery of radioactivity in 
urine is unchanged temozolomide (5.6%), AIC (12%), TMZ acid metabolite (2.3%), and 
unidentified polar metabolite(s) (17%).  Overall clearance of TMZ is about 5.5 L/hr/m2.  TMZ is 
rapidly eliminated, with a mean elimination half-life of 1.8 hours, and exhibits linear kinetics 
over the therapeutic dosing range of 75 to 250 mg/m2 /day. 
 
2.4 
Rationale for Combination Treatment 
 
We chose to further evaluate olaparib + TMZ in sarcoma and found this combination particularly 
efficacious in uterine LMS models.  The clinical development of this combination in uterine 
LMS is further supported by the following observations: 
 
(A) TMZ is a standard of care agent with monotherapy efficacy in LMS: Dacarbazine, an IV 
chemotherapy with analogous mechanism of action to TMZ, is FDA-approved for advanced STS, 
and TMZ is listed on the National Comprehensive Cancer Network (NCCN) guidelines as a 
standard of care treatment for STS.  In clinical studies, dacarbazine’s efficacy appeared most 
pronounced in LMS as compared other subtypes (Buesa et al., 1991; Gottlieb et al., 1976).  In 
clinical practice, TMZ, owing to an oral route of administration, is frequently substituted for 
dacarbazine as a later-line treatment for LMS.  In a phase 2 study of TMZ in STS, 45 patients 

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received TMZ at doses of 75–100 mg/m2/day and TMZ had a modest ORR and PFS as 
monotherapy in LMS (Garcia del Muro et al., 2005).  
 
(B) Emerging evidence suggests LMS exhibits defects in HR and harbors BRCAness: The 
relevance of DDR pathways in sarcoma has received little attention until recently.  A whole 
exome and transcriptomic sequencing study of 49 LMS patients, including uterine and non-
uterine cases, was recently published in Nature, reflecting the most comprehensive genomic 
characterization of LMS to date (Chudasama et al., 2018).  Recurrent mutations were found in 
TP53 (49%), RB1 (27%) and ATRX (24%).  Approximately 78% of LMS samples demonstrated 
an alternative lengthening of telomeres phenotype.  In this study, deleterious alterations in HR 
pathway components previously described as synthetic lethal in the setting of PARPi were very 
common: PTEN (57%), BRCA2 (53%), FANCA (27%) ATM (22%), CHEK1 (22%), XRCC3 
(18%), CHEK2 (12%), BRCA1 (10%), RAD51 (10%), FANCD (10%).  Indeed, enrichment of the 
Alexandrov-COSMIC mutation signature AC3 (associated with defective HR repair) was found 
in 98% of LMS samples and the confidence interval of the exposure to AC3 excluded zero in 
57%.  Evidence of HR defects was observed in both uterine and non-uterine cases.  The authors 
also performed clongenic assays with LMS cell lines (SK-UT-1B, SK-UT-1, SK-LMS-1 and 
MES-SA) and found these cell lines contained multiple alterations in HR genes and responded to 
olaparib in a dose dependent fashion.  The authors concluded that most LMS tumors exhibit 
BRCAness and that “genomics-guided clinical trials in LMS patients will be necessary to 
formally establish whether a BRCAness phenotype confers sensitivity to [PARPi] as in breast, 
ovarian and prostate cancers.”  Our proposed study would be the first such evaluation. 
 
Other recently reported genomic sequencing studies reinforce the hypothesis that LMS harbors a 
BRCAness phenotype.  In a study presented at the American Society for Clinical Oncology 
(ASCO) meeting in 2016, LMS harbored the highest frequency of mutations in HR pathway 
components with alterations found in BRCA2, ATM, ATRX and others (Italiano et al., 2017; 
Gounder et al., 2017).  In another targeted sequencing study of 54 LMS patients (mostly uterine), 
mutations in PALB2 and ATRX were seen in 11% and 17%, respectively (Yang et al., 2015).  
 
The ATRX protein is of particular interest in sarcoma.  In the recently published TCGA sarcoma 
analysis, TP53, RB1 and ATRX were the only recurrently mutated genes observed in LMS 
(Cancer Genome Atlas Research Network, 2017).  In LMS, ATRX is mutated in 26-32% of cases 
but reduced expression as detected by immunohistochemistry is present in up to 50% (Mäkinen 
et al., 2016; Soumerai et al., 2015).  As targeted therapies for TP53 and RB1 mutant tumors are 
non-existent, the identification of novel treatments for ATRX mutant sarcomas would be of major 
therapeutic relevance.  ATRX is part of the SWI/SNF2 family of chromatin-remodeling proteins 
and functions in maintenance of genomic stability through modification of heterochromatin.  
ATRX has also been shown to localize to sites of DNA damage and associate with the MRE11-
RAD50-NBS protein complex which is critical for repairing DSBs and restarting stalled 
replication forks (Nandakumar et al., 2017).  Indeed, in one recent study, ATRX appears 
necessary for protection of stalled replication forks and, when ATRX is lost, compensatory PARP 
activation is observed, suggestive of a mechanism whereby ATRX deficient cancer cells are 
reliant on PARP (Huh et al., 2016).  Indeed, very recent literature suggests ATRX deficient 
tumors have markedly enhanced susceptibility to DNA damaging agents including PARPi 
(Nandakumar et al., 2017).  In one study, patient-derived pediatric glioma cell cultures were 

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exposed to more than 400 chemotherapies and targeted small molecular inhibitors, and synthetic 
lethality was observed for ATRX mutants treated with the PARP inhibitors olaparib, rucaparib 
and talazoparib, and these findings were confirmed using CRISPR/Cas9-engineered ATRX 
knockouts (Fazal-Salom et al., 2017).  Given the frequency of ATRX mutations observed in LMS 
and the lack of effective targeted therapies of this disease, further evaluation of PARPi for ATRX 
mutant LMS seems warranted. 
 
2.4.1 Preclinical Data 
 
Olaparib has limited activity in sarcoma cell lines as monotherapy, but the combination of 
olaparib + TMZ has significant anti-proliferative effects in sarcoma cell lines:  Olaparib was 
first tested as monotherapy in a range of sarcoma cell lines.  However, in a 5 day dose-response 
assay in LMS (SK-LMS, SK-UT1, SK-UT1b), malignant peripheral nerve sheath tumor (MPNST, 
ST8814), and liposarcoma (LS141) cell lines, olaparib had limited activity as monotherapy, with 
IC50 for cell viability exceeding 1000 nM in all cell lines tested (Figure 1).  Note, of the LMS cell 
lines, both SK-UT1 and SK-UT1b are derived from uterine LMS, and SK-LMS is derived from 
vulvar LMS. 
 
Figure 1: Olaparib (AZD2281) as a single agent has limited anti-proliferative effect on sarcoma cell lines.  
Cell lines from different sarcoma subtypes were treated with olaparib at doses from 200 – 1000 nmol/L daily for 5 
days and cell viability was assessed.  A colorimetric cell proliferation assay was used to quantify the amount of 
formazan dye generated by the activity of dehydrogenases in the cells which is directly proportional to the number 
of living cells.   
 
Subsequently, combinations of olaparib with chemotherapy were evaluated.  As discussed above, 
the alkylating agent TMZ is considered standard of care monotherapy for several sarcoma subtypes 
and appears particularly active in LMS and therefore the TMZ + olaparib combination was chosen 
for initial evaluation with a focus on LMS.  
 

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Monotherapy treatment with either TMZ (50-300 mcM) or olaparib (1 mcM) had very limited 
antiproliferative activity in LMS cell lines as measured in a 5 day cell viability assay (Figure 2).  
Interestingly, the SK-LMS cell was sensitive to TMZ monotherapy, likely because SK-LMS 
harbors MGMT promoter hypermethylation, a known predictive biomarker for TMZ as reported 
in glioblastoma.  The incidence of MGMT promoter methylation in LMS is not well defined. 
 
Despite limited activity with TMZ or olaparib monotherapy, when sarcoma cell lines were treated 
concurrently with 300 mcM TMZ and 1 mcM olaparib, a profound reduction in cell viability was 
observed, with 90% or greater reduction in viability observed in all cell lines tested (Figure 2).  In 
subsequent experiments, combinations using lower doses of TMZ (50-100 mcM) showed 
comparable efficacy as the higher TMZ dose (300 mcM) (Figure 2).   
 
Our initial experiments were conducted using TMZ concentrations at the IC50 for monotherapy 
activity in cell viability assays for sarcoma cell lines.  However, subsequent to our work being 
presented, the reported clinical recommended phase 2 dose (RP2D) for the TMZ + olaparib 
combination (discussed further below) used 75 mg/m2 TMZ.  Review of the available phase 1 
pharmacokinetic data for TMZ suggests 75 mg/m2 oral dosing corresponds to human plasma 
concentrations of at least 5.6 mcg/mcL (Baruchel et al., 2006; Dhodapkar et al., 1997; Jen et al., 
2000; Hammond et al., 1999).  Using the molar weight for TMZ (194 g/mol), we estimate this 
corresponds to plasma concentrations of at least 28 mcM, which is lower than the TMZ dosing 
used in the preclinical studies (in contrast, the 200 mg twice daily olaparib dose from the RP2D 
achieves considerably higher human plasma concentrations of approximately 11 mcM).  We 
have conducted additional preclinical experiments showing the combination effect persists using 
TMZ concentrations as low as 25 mcM (the lowest concentration of TMZ yet evaluated) (Figure 
2A).  These findings suggest efficacy is conserved even at lower TMZ dose levels and could 
only be enhanced by the higher olaparib concentrations which would be achieved clinically.  
These observations are consistent with other preclinical studies of similar combinations 
(conducted subsequent to ours) suggesting a relatively small amount of DNA damage is 
sufficient to potentiate the activity of PARP inhibitors and may minimize clinical toxicity, and 
these considerations likely account for the dose rationale and schedule in the published lung 
cancer study (Brenner et al., 2012).  

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Figure 2: Growth inhibition of sarcoma cell lines is markedly enhanced with combination of olaparib 
(AZD2281) + TMZ as compared either monotherapy.  Cell lines from different sarcoma subtypes were treated 
with TMZ (50-300 um), olaparib (1 um) or the combination.  Drug treatment was for 5 days.  Methodology for 
viability assays is described in Figure 1. 
 
 
 
Figure 2A: Growth inhibition of LMS sarcoma cell lines is enhanced with combination of olaparib 
(AZD2281) + TMZ as compared either monotherapy.  Cell lines from different sarcoma subtypes were treated 
with TMZ (25 um), olaparib (1 um) or the combination (x-axis) and cell viability (y-axis) was assessed (per methods 
in Figure 1).  Drug treatment was for 5 days.  
 
Combination treatment with olaparib + TMZ induces tumor cell DNA damage and 
apoptosis:  Western blot studies were performed to evaluate the mechanism of combination 
treatment with olaparib + TMZ (Figure 3).  Although TMZ or olaparib monotherapy induced 

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some degree of DNA damage in SK-LMS or SK-UT1b cell lines as measured by phosphorylated 
H2AX (pH2AX), combination treatment led to markedly greater induction of DNA damage.  
This enhanced DNA damage was associated with greater induction of p53 and p21 (data not 
shown) likely reflecting the cellular response to increasing DNA damage.  Treatment with 
olaparib effectively suppressed PAR levels confirming the drug’s mechanism and supporting the 
hypothesis that PARPi in the presence of TMZ led to unrepaired DNA damage and ultimately 
apoptosis.  Critically, in each of the LMS cell lines, the combination treatment effectively 
induced apoptosis as evidenced by cleaved PARP, whereas little or no evidence of apoptosis was 
observed with either monotherapy.  Similar findings were observed when lower doses of TMZ 
(50-100 mcM) were employed. 
 
 
 
Figure 3: Olaparib (AZD2281) + TMZ treatment promotes DNA damage and induces apoptosis in LMS cell 
lines.  LMS cell lines were treated with no drug (-/-), TMZ (300 mcM), olaparib (AZD2281) (1 mcM) or the 
combination for 48 hours.  Cells were lysed and Western blot analyses were performed for PAR, total p53 and 
phospho-γH2AX, cleaved PARP and GAPDH as loading control. 
 
Combination treatment with olaparib + TMZ induces apoptosis and/or G2/M phase cell 
cycle arrest in sarcoma cell lines: To further evaluate the effects of the combination therapy, 
cell cycle analysis was performed after 72 hours of monotherapy or combination treatment.  In 
the SK-UT1 and SK-UT1b cell lines, combination treatment induced apoptosis as measured by 
an increase in the sub-G1 cell population.  A representative cell cycle analysis for the SK-UT1b 
cell line is shown (Figure 4A); similar findings were observed for SK-UT1.  In SK-UT1b and 
SK-UT1, there was little or no appreciable change in the sub-G1 fraction after treatment with 
either monotherapy; however, with combination olaparib + TMZ treatment, the sub-G1 
population increased from 1% to 32% and 23% of treated cells, respectively (Figure 4A-B).  
Importantly, in both cell lines, TMZ doses of 100 or 300 mcM induced comparable amounts of 

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apoptosis in combination with 1 mcM olaparib (Figure 4A-B).  In contrast, in the SK-LMS cell 
line, combination therapy resulted in G2/M phase cell cycle arrest.  
 
 
 
Figure 4A. Olaparib (AZD2281) + TMZ induces apoptosis in SK-UT1b cell line.  Cell cycle analysis was 
performed after 72 hours of treatment with TMZ (100-300 mcM), olaparib (1 mcM) or the combination.  Cells were 
ethanol fixed, stained with propidium iodide and MPM-2 antibody, and analyzed by flow cytometry.  Depicted are 
cell cycle profiles based on DNA content.  Induction of apoptosis is shown as subG1(<2N DNA) population.   
 
 

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Figure 4B. Olaparib (AZD2281) + TMZ induces apoptosis in SK-UT1b cell line. Cell cycle analysis was 
performed after 72 hours of treatment with TMZ (100-300 mcM), olaparib (1 mcM) or the combination.  Cells were 
ethanol fixed, stained with propidium iodide and MPM-2 antibody, and analyzed by flow cytometry.  Cell cycle 
profiles were analyzed based on DNA content.  Induction of apoptosis is shown as subG1(<2N DNA) population. 
Results are shown here in tabular format.  
 
Other chemotherapy combinations failed to show potentiation with olaparib: Gemcitabine 
and doxorubicin are two other cytotoxic chemotherapies often used for the treatment of sarcoma, 
including LMS.  We therefore evaluated the effects of combining these agents with olaparib.  
However, although these chemotherapies had modest activity as monotherapy in LMS sarcoma 
cell lines at concentrations used in other preclinical studies in sarcoma, there was no evidence of 
potentiation when olaparib was added, in contrast to the results observed above with TMZ 
(Figure 5).   
 
 
Figure 5: Combinations of olaparib (AZD2281) with gemcitabine (Gem) or doxorubicin (Dox) showed little 
evidence of potentiation.  LMS cell lines were treated with olaparib, chemotherapy or the combination (at the doses 
shown above).  Drug treatment was for 2 days.  Methodology for viability assays is described in Figure 1. 
 
On the basis of these in vitro findings, we attempted to evaluate olaparib + TMZ treatment in 
mouse xenograft models of SK-UT1b and SK-UT1.  In schedule 1 (SK-UT1b xenograft), 
animals were treated with vehicle control, olaparib 10 mg/kg PO QD, TMZ 50 mg/kg PO QD or 
olaparib 10 mg/kg + TMZ 50 mg/kg PO QD (all treatments for 3 weeks).  In schedule 2 (SK-

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UT1 xenograft) animals were treated with olaparib 10 mg/kg PO BID for 5 of 7 days weekly, 
TMZ 100 mg/kg PO twice per week, or olaparib 10 mg/kg PO BID for 5 of 7 days weekly + 
TMZ 100 mg/kg PO twice per week.  However, both schedules were associated with animal 
weight loss of 20-25% precluding further evaluation in vivo.  The toxicity observed in the 
preclinical in vivo studies may relate to the relatively high doses of TMZ employed as compared 
to those ultimately evaluated in the clinic. 
 
2.4.2 Clinical Data and Rationale for Dose Selection 
 
The combination of olaparib + TMZ is being tested clinically in two settings: small cell lung 
cancer (SCLC) and Ewing sarcoma (ES).  Both studies have shown favorable tolerability for the 
combination in heavily pre-treated patients.  The phase 1 SCLC study used a 3 + 3 design and 
results were recently reported at the 2017 American Association for Cancer Research (AACR) 
Annual Meeting (Farago et al., 2017).  The RP2D was TMZ 75 mg/m2 once daily with olaparib 
200 mg twice daily on days 1-7 of a 21-day cycle.  No dose limiting toxicities or grade 4/5 
adverse events were observed.  The most common grade 3 toxicities were neutropenia (38%), 
anemia (15%) and thrombocytopenia (15%).  The overall response rate was 46% and median 
PFS was 5.6 months which compares favorably with second line chemotherapy in SCLC.  The 
phase 1 study in ES has not been formally reported; however, per our personal communication 
with the study’s principal investigator (Dr. Edwin Choy of Massachusetts General Hospital), the 
same RP2D and schedule were determined, and no problematic toxicities occurred.  These 
findings suggest that olaparib + TMZ is tolerable in human subjects.   
 
2.5 
Correlative Studies Background 
 
2.5.1 Integrated Studies 
 
2.5.1.1 
Genomic Alterations In HR Pathway Genes 
 
PARPi and PARPi combination therapies are currently being explored in several advanced solid 
tumor malignancies.  Although clinical development initially focused on tumors with germline 
BRCA1 and BRCA2 mutations, we now recognize a larger subset of tumors, including LMS, 
harbor a “BRCAness” phenotype and may therefore be sensitive to this therapeutic approach.  
BRCAness has been defined as “a phenocopy of BRCA1 or BRCA2 mutation describing the 
situation in which an HR defect exists in a tumor in the absence of a germline BRCA1 or 
BRCA2 mutation” (Lord and Ashworth, 2016).  
 
Several approaches to identifying BRCAness have been proposed.  Identification of genomic 
alterations in HR pathway components other than BRCA1 and BRCA2 is perhaps most 
advanced.  Genomic alterations in components of the HR pathway have been evaluated as 
predictive biomarkers for response to PARPi in several preclinical and clinical studies.  Attention 
initially focused on BRCA-deficient tumors.  BRCA deficiency imparts greater than 1,000-fold 
increase in sensitivity to PARPi in a range of tumor models (Farmer et al., 2005; Bryant et al., 
2005).  In a phase 1 clinical study of olaparib in 60 solid tumor patients, Response Evaluation 
Criteria in Solid Tumors (RECIST) objective responses were seen only among the 22 patients 
with BRCA mutations (9 responded) where the clinical benefit rate (radiologic or tumor-marker 

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response or meaningful disease stabilization >4 months) was 63% (Fong et al., 2009).  In a phase 
2 study enrolling endometrial and triple-negative breast cancer patients, the response rate was 
doubled among the cohort with BRCA mutations as compared those without (Gelmon et al., 
2011).  In another phase 2 study, favorable response rates were seen in patients with gBRCA1/2 
mutations with ovarian, breast, pancreatic and prostate cancers treated with olaparib (Kaufman et 
al., 2015).  In a randomized study of olaparib versus placebo as maintenance therapy in 
platinum-sensitive recurrent ovarian cancer, considerably greater PFS benefit was seen in 
patients with germline or somatic BRCA mutations as compared those without such alterations 
(BRCA-mutant: 11 versus 4 months; hazard ratio [HR], 0.18; 95% confidence interval [CI], 
0.10-0.31; non-BRCA mutant: 7 versus 5.5 months; HR, 0.54; 95% CI, 0.34-0.85) (Matulonis et 
al., 2016).  A post-hoc analysis suggested survival benefit from olaparib maintenance was 
limited to those patients with BRCA mutations.  
 
Several preclinical studies across a range of tumor models suggest that mutations in other 
components of HR, particularly ATM, ATR, CHK1, CHK2, RAD51, PALB2, NBS1, FANCD2, 
FANCA, and FANCC, among others, predict sensitivity to PARPi monotherapy (Murai et al., 
2012; McCabe et al., 2006; Michels et al., 2014; O’Kane et al., 2017).  Lord and Ashworth 
(2016) provides a detailed discussion of the biologic function of each gene in the HR pathway 
and potential role as biomarker for PARPi treatment.  In a phase 2 study of olaparib in metastatic 
castration-resistant prostate cancer, pre-treatment tumor tissue was assessed for homozygous 
deletions or deleterious mutations in genes reported to be involved in HR or sensitivity to PARPi 
including: BRCA1/2, ATM, FANCA, CHECK2, PALB2, HDAC2, RAD51, MLH3, ERCC3, 
MRE11, and NBS1 (Mateo et al., 2015).  Overall, 33% of patients harbored an alteration, most 
commonly in BRCA2 and ATM. Patients with an aberration in the HR gene panel had a 
significantly higher response rate to olaparib as compared those who did not (86% versus 6%).  
Durable clinical responses were observed in patients with BRCA1/2, ATM, PALB2, FANCA, and 
HDAC alterations.  
 
More recently, alterations in ATRX have been implicated in PARPi sensitivity, which is 
particularly notable given recurrent mutations in ATRX found in LMS (Cancer Genome Atlas 
Research Network, 2017).  ATRX is part of the SWI/SNF2 family of chromatin-remodeling 
proteins and functions in maintenance of genomic stability through modification of 
heterochromatin.  ATRX has also been shown to localize to sites of DNA damage and associate 
with the MRE11-RAD50-NBS protein complex which is critical for repairing DSBs and 
restarting stalled replication forks (Nandakumar et al., 2017).  Indeed, in one recent study, ATRX 
appears necessary for protection of stalled replication forks and when ATRX is lost compensatory 
PARP activation is observed, suggestive of a mechanism whereby ATRX deficient cancer cells 
are sensitive to PARPi (Huh et al., 2016).  Indeed, very recent literature has suggested that ATRX 
deficient tumors have markedly enhanced susceptibility to DNA damaging agents including 
PARPi (Nandakumar et al., 2017; Watson et al., 2015).  In one study, patient-derived pediatric 
glioma cell cultures were exposed to more than 400 chemotherapies and targeted small 
molecular inhibitors, and synthetic lethality was observed for ATRX mutants treated with the 
PARP inhibitors olaparib, rucaparib and talazoparib, and these findings were confirmed using 
CRISPR/Cas9-engineered ATRX knockouts (Fazal-Salom et al., 2017).  
 

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Several ongoing clinical trials are evaluating “HR deficiency” gene panels.  For example, in an 
ongoing phase 1 study of niraparib plus carboplatin in patients with HR-deficient advanced solid 
tumors (NCT03209401), patients are eligible based on biallelic loss or deleterious mutations, as 
detected by NGS, in the following genes: ARID1A, ATM, ATRX, MRE11A, NBN (NBS1), PTEN, 
RAD50/51/51B, BARD1, BLM, BRCA1, BRCA2, BRIP1, FANCA/C/D2/E/F/G/L, PALB2, WRN, 
CHK2, CHK1, CDKN1A/B/C, CDKN2A, BAP1, FAM175A, SLX4, MLL2, or XRCC.  Weighing 
the current preclinical and clinical evidence as well as available next generation sequencing data 
from LMS, we will include BRCA1, BRCA2, ATM, ATR, ATRX, CHK1, CHK2, RAD51, PALB2, 
FANCA, and NBS1 in our HR panel.  A patient will be considered biomarker-positive if a 
homozygous deletion or deleterious mutation categorized as tier 1-3 is identified in any one of 
these genes.  
 
2.5.1.2 
RAD51 Foci Formation Assay (Functional HR assay) 
 
Several approaches to identifying BRCAness have been proposed.  Functional assays of HR 
repair have emerged as a particularly promising potential biomarker for cancer cell sensitivity to 
DNA damaging therapies including PARPi.  RAD51 plays an essential role in HR by mediating 
pairing of homologous DNA sequences and strand exchange thus allowing for high-fidelity 
repair of DNA damage (Baumann and West, 1998).  The formation of RAD51 foci after 
exposure to DNA damaging agents may serve as a functional and more encompassing measure 
of overall HR activity in the cancer cell (Gachechiladze et al., 2017).  Considerable preclinical 
literature supports RAD51 foci formation as a potential biomarker for PARPi sensitivity.  An 
analysis of seven ovarian cancer cell lines showed those sensitive to PARPi exhibited 
significantly less RAD51 foci formation after irradiation (Shah et al., 2014).  In pancreatic, 
cervical and lung cancer preclinical models, siRNA knockdown of RAD51 markedly increases 
sensitivity to DNA damaging agents (Klein, 2008; Ito et al., 2005).  
 
From a clinical perspective, RAD51 foci formation could be evaluated (1) in vivo using tumor 
biopsy specimens obtained after patients receive DNA damaging treatments or (2) ex vivo 
whereby fresh tumor samples obtained at baseline (pre-treatment) are exposed to DNA damage 
and RAD51 foci formation assessed.  In one study, breast cancer patients were treated with 
neoadjuvant anthracycline-based chemotherapy and biopsies were obtained 24 hours after the 
first cycle of chemotherapy.  RAD51 foci were assessed by immunofluorescence and a RAD51 
score was assigned based on the proportion of proliferative cells with RAD51 foci.  RAD51 foci 
formation correlated with complete pathologic response at surgery, as 33% of those with low 
RAD51 scores (“HR deficient”) achieved pathologic complete response as compared 3% of HR 
proficient group (p=0.01) (Graeser et al., 2010).  Similarly, in esophageal cancer patients treated 
with neoadjuvant DNA-damaging chemotherapy, pathologic complete responses were more 
common in RAD51 “negative” as compared RAD51 “positive” cases (Nakanoko et al., 2014).  
 
Ex-vivo RAD51 assays have also shown promise.  In one study, ascitic fluid cultures from 50 
chemotherapy naïve ovarian cancer patients were assessed with a functional RAD51 
immunofluorescence assay to classify patients as HR-proficient or HR-deficient.  All patients 
subsequently received platinum-based chemotherapy.  HR-deficiency was associated with higher 
ex-vivo PARPi sensitivity and clinical platinum sensitivity (Naipal et al., 2014; Mukhopadhyay 
et al., 2012).  In a study of patient derived xenografts (PDXs) of ovarian cancer, RAD51 foci 

NCI Protocol #: 10250 
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25 
formation after exposure to irradiation predicted sensitivity of PDXs to PARP inhibitors in vitro 
and in vivo (Shah et al., 2014).  Collectively, these data support the further evaluation of RAD51 
foci formation as a possible biomarker for sensitivity to PARPi and PARPi combinations.  For 
the purposes of this study, the assay will be applied to the pre-treatment, on-treatment, and 
optional pre-progression biopsies. This study will evaluate a RAD51 foci assay developed by Dr. 
Geoffrey Shapiro of the Dana Farber Cancer Institute.  
 
2.5.2 Exploratory Studies 
 
2.5.2.1 
MGMT Expression 
 
TMZ is an oral alkylating agent used in the treatment of several cancers, including sarcoma, for 
which this agent is listed on the National Comprehensive Cancer Network guidelines.  TMZ 
treatment results in methylation at several DNA sites, including N7-methylguanine, N3-
methylguanine, and O6-methylguanine.  The first two alterations are associated with low 
cytotoxic potential because these adducts are efficiently repaired by base excision repair.  O6-
methylguanine is responsible for most of the cytotoxicity induced by TMZ.  This abnormal base 
pair stalls the DNA replication fork triggering a DNA damage response.  The O6-methylguanine 
DNA methyltransferase (MGMT) gene encodes the DNA repair enzyme that removes the methyl 
group from O6 guanine thereby efficiently repairing DNA damage imparted by TMZ (Thomas et 
al., 2013).  Expression of the MGMT repair enzyme is epigenetically silenced in several tumor 
types by promoter hypermethylation.  These cancer cells cannot repair TMZ-induced DNA 
damage and undergo programmed cell death upon TMZ treatment.  In contrast, high levels of 
MGMT expression, which allow repair of TMZ-induced DNA damage, have been correlated 
with resistance to alkylating agents in numerous preclinical models (Hegi et al., 2008).  
 
MGMT promoter methylation has been evaluated as a biomarker for response to TMZ in 
glioblastoma, where TMZ is standard of care in the adjuvant and metastatic treatment settings.  
The effects of MGMT promoter methylation on clinical benefit from TMZ were evaluated 
retrospectively using tumor specimens from a phase 2 randomized study of adjuvant 
radiotherapy versus adjuvant radiotherapy + TMZ following definitive resection of glioblastoma 
(Hegi et al., 2005).  Using methylation-specific PCR, 45% of cases were considered to have 
MGMT promoter methylation which was associated with prolonged survival from TMZ 
treatment.  In a separate study, MGMT promoter methylation was associated with higher 
objective response rates to TMZ in advanced, recurrent glioblastoma (Paz et al., 2004).  
Retrospective clinical studies have suggested MGMT promoter methylation predicts for 
increased clinical benefit from TMZ in pancreatic neuroendocrine tumors, melanoma, colorectal 
cancer and other tumor types (Campana et al., 2018; Sartore-Bianchi et al., 2017; Tuominen et 
al., 2015).  In addition, reexpression of the MGMT enzyme by several means, including 
epigenetic modification, has been described as a mechanism of resistance to TMZ monotherapy, 
and therefore reevaluating the status of MGMT protein expression in the on-treatment and pre-
progression biopsies is also of interest (Zhang et al., 2012).  
 
2.5.2.2 
SLFN11 Expression  
 

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26 
Schlafen family member number 11 (SLFN11) is an emerging biomarker for defective HR. 
Expression of SLFN11 is a dominant determinant of sensitivity to DNA damaging agents 
including PARPi in several preclinical cancer models although the mechanism has not been fully 
elucidated (Murai et al., 2016).  Replication protein A (RPA) is a protein complex which binds 
single stranded DNA (ssDNA) and functions to recruit various enzymes involved in maintenance 
and repair of DNA.  SLFN11 may inhibit HR by removing RPA from ssDNA.  SLFN11 may 
also function as a cell cycle checkpoint upstream of ATM and ATR preventing cell cycle 
progression in the setting of DNA damage (Ballestrero et al., 2017).  High SLFN11 levels have 
been proposed to confer a BRCA-like state of HR deficiency and SLFN11 is considered among 
the most promising biomarkers for DNA damaging agents, but SLFN11 has received limited 
evaluation in prospective clinical trials (Mu et al., 2016).  
 
In an analysis using the NCI-60 cell line panel, responsiveness of cancer cells to PARPi and 
PARPi + TMZ combinations strongly correlated with expression of SLFN11 (Murai et al., 
2016).  In SCLC cell lines, loss of SLFN11 confers resistance to PARPi, while SLFN11 
transcript and protein expression correlate directly with PARPi sensitivity (Lok et al., 2017).  In 
SCLC PDX models, SLFN11 expression by immunohistochemistry was strongly associated with 
response to both PARPi monotherapy and PARPi + TMZ combinations (Lok et al., 2017).  
SLFN11 is highly expressed in Ewing sarcoma (ES), desmoplastic small round cell tumor 
(DSRCT), osteosarcoma and rhabdomyosarcoma and correlates with response to PARPi and 
ionizing radiation in those malignancies (Shelat et al., 2017).  In a preclinical study in ES, the 
characteristic EWS-FLI1 fusion protein was shown to regulate SLFN11 expression and SLFN11 
knockdown imparted resistance to combination treatment with PARPi + TMZ (Tang et al., 2015; 
Stewart et al., 2014).   
 
 
3. 
PATIENT SELECTION 
 
3.1 
Eligibility Criteria  
 
3.1.1 Patients must have histologically documented LMS of uterine origin.  Pathology review 
and confirmation of diagnosis will occur at the site enrolling the patient on this study. 
 
3.1.2 Patients must have locally advanced and unresectable or metastatic disease.  
 
3.1.3 Patients must have disease which is measurable at study entry according to RECIST 
version 1.1 criteria.  Additionally, patients must have a site of disease deemed accessible 
for biopsy at no or minimal risk to the patient (including through the use of image-
guidance).  If there are questions regarding the feasibility of biopsy, the case should be 
reviewed with interventional radiology or the appropriate department at the study site 
prior to registration.  
 
3.1.4 Patients must have had prior progression on, or intolerance to, at least one line of 
systemic therapy for advanced LMS.  Adjuvant therapy administered after curative 
resection will not qualify as prior treatment.  There is no upper limit on the number of 

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27 
prior therapies received.  
 
3.1.5 Patients must be ≥18 years of age.  Uterine LMS affects older adults and is rarely 
encountered in children and adolescents. 
 
3.1.6 Patients must demonstrate an Eastern Cooperative Oncology Group (ECOG) 
performance status (PS) of ≤2 (Karnofsky ≥50%, see Appendix A).   
 
3.1.7 Patients must have normal organ and bone marrow function measured within 14 days 
prior to administration of study treatment as defined below: 
 
− 
absolute neutrophil count 
 
≥1,500/mcL 
− 
hemoglobin 
 
 
 
≥9 g/dL* 
− 
platelets  
 
≥100,000/mcL 
− 
total bilirubin 
 
≤1.5 × institutional upper limit of normal (ULN) 
− 
AST(SGOT)/ALT(SGPT) 
 
≤2.5 × institutional ULN 
− 
glomerular filtration rate (GFR) ≥51 mL/min, based on a 24-hour urine test for 
creatinine clearance or estimated using the 
Cockcroft-Gault equation of: 
Estimated GFR = (140-age [years]) × weight (kg)   (× F)a 
serum creatinine (mg/dL) × 72 
 
a where F=0.85 for females and F=1 for males. 
 
* Without transfusion of packed red blood cells within the past 28 days  
 
3.1.8 If patients have evidence of chronic hepatitis B virus (HBV) infection, HBV viral load 
must be undetectable on suppressive therapy if indicated.  Patients with a past or resolved 
HBV infection (defined as the presence of hepatitis B core antibody and absence of 
HBsAg) are eligible. 
 
3.1.9 If patients have a history of hepatitis C virus (HCV) infection, they must be treated with 
undetectable HCV viral load (polymerase chain reaction is negative for HCV RNA). 
 
3.1.10 Patients must be postmenopausal or have evidence of non-childbearing status, OR, for 
women of childbearing potential, must have a negative urine or serum pregnancy test 
within 28 days of study treatment and confirmed again on Day 1 prior to study treatment.   
 
Postmenopausal is defined as: 
 
− 
Amenorrhoeic for ≥ 1 year following cessation of exogenous hormonal treatments 
− 
Luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels in the 
postmenopausal range for women under 50 
− 
radiation-induced oophorectomy with last menses >1 year ago 
− 
chemotherapy-induced menopause with >1 year interval since last menses, or 

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28 
− 
surgical sterilization (bilateral oophorectomy or hysterectomy) 
3.1.11 Patients and their partners, if sexually active and of childbearing potential, must agree to 
the use of two highly effective forms of contraception in combination throughout the 
period of taking study treatment and for 3 months after the last dose of study drug(s) to 
prevent pregnancy in the study patient or partner.   
 
3.1.12 Patients must be able to swallow orally administered medication. 
 
3.1.13 Patients must have a life expectancy ≥16 weeks. 
 
3.1.14 Patients must be able to understand and be willing to sign a written informed consent 
document.  Patients with impaired decision-making capacity (IDMC) will be eligible if 
they have a close caregiver or legally authorized representative (LAR) available to assist 
them. 
 
3.1.15 Patients must be willing and able to comply with the protocol for the duration of the 
study, including undergoing treatment and attending scheduled visits and examinations. 
 
3.1.16 Patients with HIV infection may be enrolled on this study provided:  (a) they are on a 
stable regimen of highly active anti-retroviral therapy (HAART) with no medications 
otherwise prohibited by this protocol (e.g. drug-drug interactions) and (b) require no 
concurrent antibiotics or antifungals for the prevention of opportunistic infections and (c) 
have a CD4 count above 250 cell/mcL and an undetectable viral load on standard PCR-
based tests within 1 month of initiation of study treatment.  Other patients with clinically 
significant immunosuppression, e.g. organ transplant patients, are not eligible.  If 
clarification is needed, this may be discussed with the medical monitor. 
 
3.1.17 Patients must be able to have temozolomide provided as a standard of care medication. 
 
 
3.2 
Exclusion Criteria 
 
3.2.1 Patients must not have had any previous treatment with any poly(adenosine 
diphosphate[ADP]-ribose) polymerase (PARP) inhibitors, including olaparib, or prior 
treatment with dacarbazine and/or temozolomide. 
 
3.2.2 Patients must have recovered from adverse events due to prior anti-cancer therapy (i.e., 
may not have residual toxicities > grade 1 or above baseline), excluding alopecia. 
Patients who have endocrinopathies associated with prior immunotherapy treatment but 
which are controlled with replacement therapy are eligible.  
 
3.2.3 Prior to initiating study treatment, at least 28 days must have elapsed from the last dose 
of systemic anti-cancer treatment (cytotoxic, biologic or immunotherapeutic) or radiation 
therapy (except for palliative radiation, in which case a 14-day washout applies). 
 

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29 
3.2.4 Patients must not have had major surgery within 2 weeks of starting study treatment and 
must have recovered from any effects of any major surgery that occurred >2 weeks 
before starting study treatment. 
 
3.2.5 Patients must not be receiving any other investigational agent. 
 
3.2.6 Patients must not have been diagnosed with another malignancy unless curatively treated 
with no evidence of disease for ≥5 years except: adequately treated non-melanoma skin 
cancer, curatively treated in situ cancer of the cervix, ductal carcinoma in situ (DCIS), or 
any other malignant condition considered indolent and unlikely to require active therapy. 
 
3.2.7 Patients must not have myelodysplastic syndrome (MDS)/acute myeloid leukemia 
(AML) or bone marrow biopsy findings consistent with MDS and/or AML.   
 
3.2.8 Patients must not have active central nervous system (CNS) or leptomeningeal disease at 
the time of enrollment.  Patients with a history of such disease previously treated with 
curative intent (such as with surgery or radiation) that have not progressed on subsequent 
imaging, have been clinically asymptomatic, and have not received systemic 
corticosteroids for at least 28 days, are eligible.  
  
3.2.9 Patients must not have a history of allergic reactions attributed to compounds of similar 
chemical or biologic composition to olaparib or TMZ or any of the excipients of any 
study product. 
 
3.2.10 Patients must refrain from concomitant use of known strong CYP3A inhibitors (e.g., 
itraconazole, telithromycin, clarithromycin, protease inhibitors boosted with ritonavir or 
cobicistat, indinavir, saquinavir, nelfinavir, boceprevir, telaprevir) or moderate CYP3A 
inhibitors (e.g., ciprofloxacin, erythromycin, diltiazem, fluconazole, verapamil).  The 
required washout period for strong or moderate CYP3A inhibitors prior to starting 
olaparib is 2 weeks. 
 
Because the lists of these agents are constantly changing, it is important to regularly 
consult a frequently-updated medical reference.  As part of the enrollment/informed 
consent procedures, the patient will be counseled on the risk of interactions with other 
agents, and what to do if new medications need to be prescribed or if the patient is 
considering a new over-the-counter medicine or herbal product.   
 
3.2.11 Patients must refrain from concomitant use of known strong CYP3A inducers (e.g., 
phenobarbital, enzalutamide, phenytoin, rifampicin, rifabutin, rifapentine, 
carbamazepine, nevirapine and St John’s Wort) or moderate CYP3A inducers (e.g., 
bosentan, efavirenz, modafinil).  The required washout period for strong or moderate 
CYP3A inducers prior to starting olaparib is 5 weeks for enzalutamide or phenobarbital 
and 3 weeks for other agents. 
 
3.2.12 Patients must not have an uncontrolled intercurrent illness including, but not limited to, 
ongoing or active infection, uncontrolled ventricular arrhythmia, recent (within 3 months) 

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30 
myocardial infarction, uncontrolled major seizure disorder, unstable spinal cord 
compression, superior vena cava syndrome, extensive interstitial bilateral lung disease on 
high resolution computed tomography (HRCT) scan, or psychiatric illness that would 
limit compliance with study requirements. 
 
3.2.13 Pregnant women are excluded from this study because olaparib is a PARP inhibitor with 
the potential for teratogenic or abortifacient effects.  Because there is an unknown but 
potential risk for adverse events in nursing infants secondary to treatment of the mother 
with olaparib, breastfeeding should be discontinued if the mother is treated with olaparib.  
These potential risks may also apply to other agents used in this study. 
 
3.2.14 Patients must not have gastrointestinal disorders likely to interfere with absorption of the 
study medication. 
 
3.2.15 Patients must not have had involvement in the planning and/or conduct of the study. 
 
3.3 
Inclusion of Women and Minorities 
 
NIH policy requires that women and members of minority groups and their subpopulations be 
included in all NIH-supported biomedical and behavioral research projects involving NIH-
defined clinical research unless a clear and compelling rationale and justification establishes to 
the satisfaction of the funding Institute & Center (IC) Director that inclusion is inappropriate 
with respect to the health of the subjects or the purpose of the research.  Exclusion under other 
circumstances must be designated by the Director, NIH, upon the recommendation of an IC 
Director based on a compelling rationale and justification.  Cost is not an acceptable reason for 
exclusion except when the study would duplicate data from other sources.  Women of 
childbearing potential should not be routinely excluded from participation in clinical research.  
Please see http://grants.nih.gov/grants/funding/phs398/phs398.pdf. 
 
 
4. 
REGISTRATION PROCEDURES 
 
4.1 
Investigator and Research Associate Registration with CTEP 
 
Food and Drug Administration (FDA) regulations require Investigational New Drug (IND) 
sponsors to select qualified investigators.  National Cancer Institute (NCI) policy requires all 
persons participating in any NCI-sponsored clinical trial to register and renew their registration 
annually.  To register, all individuals must obtain a Cancer Therapy Evaluation Program (CTEP) 
Identity and Access Management (IAM) account (https://ctepcore.nci.nih.gov/iam).  In addition, 
persons with a registration type of Investigator (IVR), Non-Physician Investigator (NPIVR), or 
Associate Plus (AP) (i.e., clinical site staff requiring write access to Oncology Patient Enrollment 
Network (OPEN) or Rave or acting as a primary site contact) must complete their annual 
registration using CTEP’s web-based Registration and Credential Repository (RCR) 
(https://ctepcore.nci.nih.gov/rcr).  Documentation requirements per registration type are outlined 
in the table below. 
 

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31 
Documentation Required 
IVR 
NPIVR 
AP 
A 
FDA Form 1572 
 
 
 
 
Financial Disclosure Form 
 
 
 
 
NCI Biosketch (education, training, employment, 
license, and certification) 
 
 
 
 
HSP/GCP training 
 
 
 
 
Agent Shipment Form (if applicable) 
 
 
 
 
CV (optional) 
 
 
 
 
 
An active CTEP-IAM user account and appropriate RCR registration is required to access all 
CTEP and Cancer Trials Support Unit (CTSU) websites and applications.  In addition, IVRs and 
NPIVRs must list all clinical practice sites and IRBs covering their practice sites on the FDA 
Form 1572 in RCR to allow the following: 
• Added to a site roster 
• Assigned the treating, credit, consenting, or drug shipment (IVR only) tasks in OPEN 
• Act as the site-protocol Principal Investigator (PI) on the Institutional Review Board 
(IRB) approval 
 
Additional information can be found on the CTEP website at 
https://ctep.cancer.gov/investigatorResources/default.htm.  For questions, please contact the RCR 
Help Desk by email at RCRHelpDesk@nih.gov. 
 
4.2 
Site Registration 
 
This study is supported by the NCI CTSU. 
 
Each investigator or group of investigators at a clinical site must obtain IRB approval for this 
protocol and submit IRB approval and supporting documentation to the CTSU Regulatory Office 
before they can be approved to enroll patients.  Assignment of site registration status in the 
CTSU Regulatory Support System (RSS) uses extensive data to make a determination of whether 
a site has fulfilled all regulatory criteria including but not limited to the following:  
• An active Federalwide Assurance (FWA) number 
• An active roster affiliation with the Lead Network or a participating organization 
• A valid IRB approval 
• Compliance with all protocol specific requirements. 
 
In addition, the site-protocol PI must meet the following criteria: 
• Active registration status 

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32 
• The IRB number of the site IRB of record listed on their Form FDA 1572 
• An active status on a participating roster at the registering site 
 
Sites participating on the NCI CIRB initiative that are approved by the CIRB for this study are 
not required to submit IRB approval documentation to the CTSU Regulatory Office.  For sites 
using the CIRB, IRB approval information is received from the CIRB and applied to the RSS in 
an automated process.  Signatory Institutions must submit a Study Specific Worksheet for Local 
Context (SSW) to the CIRB via IRBManager to indicate their intent to open the study locally.  
The CIRB’s approval of the SSW is then communicated to the CTSU Regulatory Office.  In 
order for the SSW approval to be processed, the Signatory Institution must inform the CTSU 
which CIRB-approved institutions aligned with the Signatory Institution are participating in the 
study. 
 
4.2.1 Downloading Regulatory Documents 
 
Site registration forms may be downloaded from the 10250 protocol page located on the 
CTSU Web site.  Permission to view and download this protocol is restricted and is based 
on person and site roster data housed in the CTSU RSS.  To participate, Investigators and 
Associates must be associated with the Corresponding or Participating protocol 
organization in the RSS.  
 
• Go to https://www.ctsu.org and log in using your CTEP-IAM username and 
password. 
• Click on the Protocols tab in the upper left of your screen.  
• Either enter the protocol # in the search field at the top of the protocol tree, or 
• Click on the By Lead Organization folder to expand, then select LAO-CT018, and 
protocol #10250. 
• Click on LPO Documents, select the Site Registration documents link, and 
download and complete the forms provided.  (Note: For sites under the CIRB 
initiative, IRB data will load to RSS as described above.) 
 
4.2.2 Requirements For 10250 Site Registration 
 
• IRB approval (For sites not participating via the NCI CIRB; local IRB 
documentation, an IRB-signed CTSU IRB Certification Form, Protocol of Human 
Subjects Assurance Identification/IRB Certification/Declaration of Exemption 
Form, or combination is accepted.) 
• For applicable ETCTN studies with a radiation and/or imaging (RTI) component, 
the enrolling site must be aligned to a RTI provider.  To manage provider 
associations access the Provider Association tab on the CTSU website at 
https://www.ctsu.org/RSS/RTFProviderAssociation, to add or remove associated 
providers.  Sites must be linked to at least one IROC credentialed provider to 
participate on trials with an RT component.  Enrolling sites are responsible for 
ensuring that the appropriate agreements are in place with their RTI provider, and 
that appropriate IRB approvals are in place.   

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33 
• Site Initiation Visit Teleconference 
• ETCTN Specimen Tracking Training with Theradex 
• All data entry users (Clinical Research Associate role) at each participating 
site will need to complete the Theradex-led training. 
• Theradex will provide a certificate of completion, which will need to be 
submitted to the CTSU through the Regulatory Submission Portal. 
• The training is a one-time only requirement per individual.  If an individual 
has previously completed the training for another ETCTN study, the training 
does not need to be completed again nor does the certificate of completion 
need to be resubmitted to the CTSU. However, new versions of the Specimen 
Tracking system may require new training. 
•  This training will need to be completed before the first patient enrollment at 
a given site. 
•  Peter Clark and Diana Vulih  are the main points of contact at Theradex for 
the training (PClark@theradex.com and DVulih@theradex.com, Theradex 
phone: 609-799-7580). 
 
4.2.3 Submitting Regulatory Documents 
 
Submit required forms and documents to the CTSU Regulatory Office, where they will 
be entered and tracked in the CTSU RSS.   
Regulatory Submission Portal: www.ctsu.org (members’ area) → Regulatory Tab 
→Regulatory Submission  
When applicable, original documents should be mailed to: 
CTSU Regulatory Office 
1818 Market Street, Suite 3000 
Philadelphia, PA 19103 
 
Institutions with patients waiting that are unable to use the Portal should alert the CTSU 
Regulatory Office immediately at 1-866-651-2878 in order to receive further instruction 
and support. 
 
4.2.4 Checking Site Registration Status 
 
You can verify your site registration status on the members’ section of the CTSU 
website. 
 
• Go to https://www.ctsu.org and log in to the members’ area using your CTEP-
IAM username and password. 
• Click on the Regulatory tab at the top of your screen. 
• Click on the Site Registration tab. 
• Enter your 5-character CTEP Institution Code and click on Go. 
 
Note:  The status given only reflects compliance with IRB documentation and 
institutional compliance with protocol-specific requirements as outlined by the Lead 

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34 
Network.  It does not reflect compliance with protocol requirements for individuals 
participating on the protocol or the enrolling investigator’s status with the NCI or their 
affiliated networks. 
 
4.3 
Patient Registration 
 
4.3.1 OPEN / IWRS 
 
Patient enrollment will be facilitated using the Oncology Patient Enrollment Network (OPEN).  
OPEN is a web-based registration system available to users on a 24/7 basis.  It is integrated with 
the CTSU Enterprise System for regulatory and roster data interchange and with the Theradex 
Interactive Web Response System (IWRS) for retrieval of patient registration/randomization 
assignment.  Patient enrollment data entered by Registrars in OPEN / IWRS will automatically 
transfer to the NCI’s clinical data management system, Medidata Rave. 
 
The OPEN system will provide the site with a printable confirmation of registration and 
treatment information.  Please print this confirmation for your records.  
 
4.3.2 OPEN/IWRS User Requirements 
 
OPEN/IWRS users must meet the following requirements: 
• Have a valid CTEP-IAM account (i.e., CTEP username and password). 
• To enroll patients or request slot reservations:  Be on an ETCTN Corresponding 
or Participating Organization roster with the role of Registrar.  Registrars must 
hold a minimum of an AP registration type.   
• To approve slot reservations or access cohort management:  Be identified to 
Theradex as the “Client Admin” for the study.  
• Have regulatory approval for the conduct of the study at their site. 
 
Prior to accessing OPEN/IWRS, site staff should verify the following: 
• All eligibility criteria have been met within the protocol stated timeframes.   
• If applicable, all patients have signed an appropriate consent form and Health 
Insurance Portability and Accountability Act (HIPAA) authorization form. 
 
4.3.3 Special Instructions for Patient Enrollment 
 
This Study will use the ETCTN Specimen Tracking System (STS).  
 
• All biospecimens collected for this trial must be submitted using the ETCTN Specimen 
Tracking System (STS) unless otherwise noted.   
• The system is accessed through special Rave user roles:  “CRA Specimen Tracking” for 
data entry at the treating institutions and “Biorepository” for users receiving the 
specimens for processing and storage at reference labs and the Biorepository.   
• Please refer to the Medidata Account Activation and Study Invitation Acceptance link on 
the CTSU website under the Rave/DQP tab. 

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35 
• Important:  Failure to complete required fields in STS may result in a delay in 
sample processing.  Any case reimbursements associated with sample submissions will 
not be credited if samples requiring STS submission are not logged into STS. 
 
Detailed instructions can be found in Section 5.3. 
 
4.3.4 OPEN/IWRS Questions? 
 
Further instructional information on OPEN is provided on the OPEN tab of the CTSU 
website at https://www.ctsu.org or at https://open.ctsu.org.  For any additional questions 
contact the CTSU Help Desk at 1-888-823-5923 or ctsucontact@westat.com.  
 
 
4.4 
General Guidelines 
 
Following registration, patients should begin protocol treatment within 5 business days.  Issues 
that would cause treatment delays should be discussed with the Principal Investigator.  If a 
patient does not receive protocol therapy following registration, the patient’s registration on the 
study may be canceled.  The Study Coordinator should be notified of cancellations as soon as 
possible. 
 
 
5. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
5.1 
Summary Table for Specimen Collection 
 
Time Point 
Specimen 
Send Specimens To: 
PRE-TREATMENT (after informed consent and within 14 days of Cycle 1 Day 1) 
 
• 
4-8 formalin fixed cores1 
• 
10 mL blood in EDTA tube 
 
ETCTN Biorepository 
ON-TREATMENT (C2 D3-5, 2-6 hours post AM olaparib and temozolomide treatment) 
 
• 
4-6 formalin fixed cores1 
ETCTN Biorepository 
PRE-PROGRESSION (if applicable, see Section 5.4.2) 
 
• 
4-8 formalin fixed cores1 
ETCTN Biorepository 
1For new biopsies, a copy of the radiology and operative reports from the tissue removal procedure must 
be sent with the tissue to the ETCTN Biorepository. When completed, upload the corresponding 
pathology reports to Rave.  
 
5.2 
Specimen Procurement Kits and Scheduling  
 
5.2.1 Specimen Shipping Kits  
 
Kits for the collection and shipment of specimens to the ETCTN Biorepository can be 
ordered online via the Kit Management system:  
(https://ricapps.nationwidechildrens.org/KitManagement).  

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36 
 
Users at the clinical sites will need to set up an account in the Kit Management system 
and select a specific clinical trial protocol to request a kit.  Please note that protocol may 
include more than one type of kit.  Each user may order two kit types per protocol per 
day (daily max = 6 kits).  Kits are shipped ground, so please allow 5-7 days for receipt.  
A complete list of kit contents for each kit type is located on the Kit Management system 
website. 
 
Note:  Kits or supplies are only provided for specimens shipped to the Biorepository.  
Institutional supplies must be used for all other specimen collection and processing.  
 
5.2.2 Scheduling of Specimen Collections 
 
Please adhere to the following guidelines when scheduling procedures to collect tissue:  
 
• 
Tumor tissue specimens collected during biopsy procedures and fixed in formalin 
must be shipped on the same day of collection.  
• 
Tissue can be collected Monday through Wednesday and shipped overnight for 
arrival on Tuesday through Thursday at the ETCTN Biorepository at Nationwide 
Children’s Hospital.   
• 
Fresh blood specimens may be collected and shipped Monday through Friday.   
 
5.3 
Specimen Tracking System Instructions  
 
5.3.1 Specimen Tracking System Overview and Enrollment Instructions 
 
For the ETCTN STS, the following information will be requested: 
• Protocol Number 
• Investigator Identification  
o Institution and affiliate name 
o Investigator’s name 
• Eligibility Verification:  Patients must meet all the eligibility requirements listed in 
Section 3. 
• Additional Requirements: 
o Patients must provide a signed and dated, written informed consent form. 
 
Upon enrolling a patient, IWRS will communicate with OPEN, assigning two separate and 
unique identification numbers to the patient, a Universal patient ID (UPID) and a Treatment 
patient ID.  The UPID is associated with the patient and used each and every time the patient 
engages with the portion of this protocol that uses the ETCTN Specimen Tracking System.  The 
UPID contains no information or link to the treatment protocol.  IWRS will maintain an 
association between the UPID for ETCTN biobanking and molecular characterization and any 
treatment protocols the patient participates in, thereby allowing analysis of the molecular 
characterization results with the clinical data.   
 

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Immediately following enrollment, the institutional anatomical pathology report for the diagnosis 
under which the patient is being enrolled must be uploaded into Rave.  The report must include 
the surgical pathology ID (SPID), collection date, block number, and the IWRS-assigned UPID 
and patient study ID for this trial.  For newly acquired biopsies, the radiology and operative 
report(s) must also be uploaded into Rave.  Important:  Remove any personally identifying 
information, including, but not limited to, the patient’s name, initials, medical record 
number, and patient contact information from the institutional pathology report prior to 
submission. 
 
Additionally, please note that the STS software creates pop-up windows when reports are 
generated, so you will need to enable pop-ups within your web browser while using the software.   
 
For questions regarding the Specimen Tracking System, please contact the Theradex Help Desk 
at CTMSSupport@theradex.com. 
 
A shipping manifest must be included with all sample submissions. 
 
5.3.2 Specimen Labeling 
 
5.3.2.1 Tissue Specimen Labels 
 
Include the following on all tissue specimens or containers (e.g., formalin jar):  
 
• Patient Study ID 
• Universal Patient ID (UPID) 
• Specimen ID (automatically generated by Rave) 
• Time point 
• Specimen type (FFPE Block, Formalin Fixed Tissue, Fresh Tissue in Media, etc.) 
• Tissue type (P for primary, M for metastatic or N for normal) 
• Surgical pathology ID (SPID) number   
• Block number from the corresponding pathology report (archival only) 
• Collection date (to be added by hand) 
 
5.3.2.2 Blood Specimen Labels 
 
Include the following on blood specimens (including whole blood and frozen, processed blood 
products – like serum and plasma): 
 
• Patient Study ID 
• Universal Patient ID (UPID) 
• Specimen ID (automatically generated by Rave) 
• Time point 
• Specimen type (e.g., blood, serum) 
• Collection date (to be added by hand) 
 

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5.3.2.3 Example of Specimen Label 
 
The following image is an example of a tissue specimen label printed on a standard Avery label 
that is 1” high and 2.625” wide. 
 
  
 
The QR code in the above example is for the Specimen ID shown on the second line.   
NOTE:  The QR code label is currently under development at Theradex as of 31-Aug-2018; 
therefore, labels generated by the STS for this study may not include a QR code. 
 
The second line item from the end includes four data points joined together: 
1. Tissue only: Primary (P), Metastatic (M), Normal (N) tissue indicated at the 
beginning of the specimen ID; this field is blank if not relevant (e.g., for blood) 
2. Block ID or blank if not relevant 
3. SPID (Surgical Pathology ID) or blank if none 
4. The last alpha-numeric code is protocol specific and is only included if the protocol 
requires an additional special code classification 
 
The last line on the example label is for the handwritten date and optional time. 
 
5.3.3 Overview of Process at Treating Site 
 
5.3.3.1 OPEN Registration 
 
All registrations will be performed using the Oncology Patient Enrollment Network (OPEN) 
system. OPEN communicates automatically with the Interactive Web Response System (IWRS) 
which handles identifier assignments, any study randomization and any prescribed slot 
assignments. If specimen analysis is required to determine eligibility, the protocol will be setup 
with multi-step registration. 
 
Registration without eligibility specimen analysis:  
1. Site enters registration data into OPEN during one or more steps. 
2. IWRS receives data from OPEN, generates the Patient Study ID and the Universal 
Patient ID, both of which are sent back to OPEN. 
3. IWRS sends all applicable registration data directly to Rave at the end of the final 
registration step. 
 

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Any data entry errors made during enrollment should be corrected in Rave. 
 
5.3.3.2 Rave Specimen Tracking Process Steps 
 
Step 1:  Complete the Histology and Disease form (but do not upload reports until a 
specimen label can be applied to them) and the Baseline forms regarding Prior 
Therapies. Enter the initial clinical specimen data:  
• Specimen Tracking Enrollment CRF:  Enter Time Point, Specimen Category, 
Specimen Type, Block number, Tissue type, Surgical Path ID, and number of 
labels needed (include extra labels to apply to reports to be uploaded). CRF 
generates unique Specimen ID.  
 
Step 2:  Print labels using report in EDC and collect specimen. 
• Label specimen containers and write collection date on each label. 
• After collection, store labeled specimens as described in Section 5.3 
• Apply an extra specimen label to each report before scanning. Return to the 
Histology and Disease form to upload any initial Pathology, Radiology, 
Molecular Reports (up to 4), Surgical (or Operative) reports and Pathology 
Verification form (when applicable). Return to Specimen Tracking Enrollment 
CRF to upload any molecular report (one per specimen) and/or specimen specific 
pathology or related report (one per specimen).  Uploaded reports should have 
protected health information (PHI) data like name, mailing address, medical 
record number or social security number (SSN) redacted. Do not redact surgical 
pathology ID (SPID), block number or relevant dates, and include UPID and 
patient study ID on each document.  
 
Step 3:  Complete specimen data entry. 
• Specimen Transmittal Form: Enter Collection date and time and other required 
specimen details. 
 
Step 4:  When ready to ship, enter shipment information. 
• Shipping Status CRF:  Enter tracking number, your contact information, 
recipient, number of containers and ship date once for the 1st specimen in a 
shipment. 
• Copy Shipping CRF:  Select additional specimens to add to an existing shipment 
referenced by the tracking number. 
 
Step 5:  Print shipping list report and prepare to ship.  
• Print two copies of the shipping list, one to provide in the box, the other for your 
own records. 
• Print pathology or other required reports to include in the box. Be sure the printed 
copy includes the specimen label. 
 
Step 6:  Send email notification.  
• For only one of the specimens in the shipment, click “Send Email Alert” 

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checkbox on the Shipping Status CRF to email recipient. 
 
Step 7:  Ship the specimen(s). 
 
5.4 
Specimen Collection and Processing 
 
5.4.1 Biopsy Collection Procedure 
 
Mandatory core biopsy specimens will be obtained at two time points.  The first (“pre-
treatment”) biopsy will be obtained before beginning study treatment (after informed consent is 
obtained and up to 14 day prior to cycle 1 day 1). The second (“on-treatment”) biopsy will be 
performed during cycle 2, days 3-5.   
 
A third, optional (“pre-progression”) biopsy will be collected from patients who meet certain 
criteria and provide informed consent for this biopsy (see Section 5.4.2 below).  
 
5.4.2 Optional “Pre-Progression” Tumor Biopsy 
 
The investigators will seek to evaluate the RAD51, MGMT, and SLFN11 assays in patients who 
have evidence of clinical benefit from the study drug but later show evidence of radiographic 
progression not meeting RECIST criteria for progressive disease.   
 
To undergo this biopsy, all of the following criteria must be met: 
 
1. The patient has provided informed consent for the optional tumor biopsy, which is part of 
the informed consent document for this study.  
 
2. The patient has evidence of clinical benefit from study treatment manifest by either: 
a. RECIST complete or partial response within the first 6 months of study treatment 
b. Stable disease, by RECIST criteria, of at least 4 cycles (12 weeks) duration 
 
3. At a subsequent timepoint, the patient has study-specified imaging showing evidence of 
radiographic disease progression, but which does not meet RECIST criteria for 
progressive disease (RECIST + 5-19% from the baseline study) and the patient lacks 
clinical progression, and the investigator intends to continue the study treatment.  
 
When all of these criteria apply, a third (“pre-progression”) tumor biopsy will be performed.  
The same procedures as described in Section 5.4.1 will apply to this biopsy.  The biopsy will 
occur during days 3-5 of the next treatment cycle initiated following the timepoint at which these 
criteria are met, 2-6 hours post AM olaparib and temozolomide treatment.  The same site of 
disease should be biopsied if at all possible.  
 
If questions arise regarding whether a given patient is considered appropriate for the optional 
biopsy, the treating investigator should discuss with the principal investigator prior to the 
procedure.  
 

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5.4.3 Formalin-Fixed Tumor Biopsies  
 
1. Label formalin-filled containers according to instructions in section 5.3.1.1.  
2. Obtain the designated number of core biopsies (see Section 5.1) using a 16-gauge or 
18-gauge core needle, and place one core in each cassette.  
3. Snap the cassette lids closed and place cassettes into a formalin-filled pre-labeled 
container as soon as possible after collection to prevent air drying.  Up to two 
cassettes may be placed in one formalin jar. 
4. Secure the container lids and place the containers into the shipping kit according to 
instructions in section 5.5.  Keep tissue in formalin jars at room temperature until 
shipment to the ETCTN Biorepository.  
 
5.4.4 Blood Collection for Germline Testing 
 
During the screening period, a blood sample will be collected to serve as a germline sample for 
evaluation during the whole exome sequencing/RNAseq analysis.  
 
5.4.4.1 Collection of Blood in EDTA Tubes 
 
1. Label EDTA tubes according to the instructions in section 5.3.1.2. 
2. Collect 10 mL blood in EDTA tube(s) and gently invert tube to mix. 
3. Ship on day of collection (whenever possible) according to instructions below. 
4. If blood cannot be shipped on the day of collection (e.g., a late scheduled collection), 
then refrigerate until shipment.  
 
 
5.5 
Shipping Specimens from Clinical Site to the ETCTN Biorepository  
 
Core biopsies that are fixed in formalin and fresh blood should be shipped as one shipment at 
ambient temperature, whenever possible.  The same box sent with kit contents should be used to 
ship specimens to the ETCTN Biorepository.  In winter months, please include extra insulation, 
such as bubble wrap, inside the shipping container. 
 
For formalin-fixed biopsies, if the corresponding anatomical pathology report is not available at 
the time of shipment, then the surgical and/or radiology report must be uploaded to the ETCTN 
specimen tracking system and included in the package, or the specimen will not be processed.  
 
5.5.1 Specimen Shipping Instructions 
 
Tissue in formalin must be shipped on the day of collection.  Collect and ship on Monday 
through Wednesday. 
 
Fresh blood may be shipped on Monday through Friday.  Please select “Saturday Delivery” 
when shipping fresh blood on a Friday.  
 

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5.5.1.1 Shipping Ambient Tissue and Blood in a Single-Chamber Kit 
 
1. 
Before packaging specimens, verify that each specimen is labeled according to the 
instructions above and that the lids of all primary receptacles containing liquid are 
tightly sealed.  Formalin jars should be wrapped in parafilm.  
2. 
Place the specimens in zip-lock bags.  Use a separate bag for each specimen type. 
3. 
Place specimens into a biohazard envelope with absorbent material.  Expel as 
much air as possible and seal the envelope securely.  
4. 
Place the biohazard envelope into a Tyvek envelope. Expel as much air as 
possible and seal securely. 
5. 
Place the specimen(s) and a copy of the shipping manifest and corresponding 
reports such as surgical or radiology reports into the insulated shipping container. 
In winter months, please include extra insulation, such as bubble wrap, inside the 
shipping container, to prevent specimens from freezing.  
6. 
Place the lid on top of the container. Close the outer flaps and tape shut. 
7. 
Attach a shipping label to the top of the shipping container.  
8. 
Attach an Exempt Human Specimen sticker to the side of the container. 
9. 
Ship specimens via overnight courier to the address below. FedEx Priority 
Overnight is strongly recommended to prevent delays in package receipt.  
 
5.5.2 Shipping Address 
 
Ship to the address below.  Ship formalin-fixed and fresh blood specimens the same day of 
specimen collection.  Do not ship specimens the day before a holiday. 
 
ETCTN Biorepository 
The Research Institute at Nationwide Children's Hospital 
700 Children's Drive, WA1340 
Columbus, Ohio 43205 
PH: (614) 722-2865 
FAX: (614) 722-2897 
Email: BPCBank@nationwidechildrens.org 
 
FedEx Priority Overnight service is very strongly preferred.   
 
NOTE:  The ETCTN Biorepository FedEx Account will not be provided to submitting 
institutions. 
 
5.5.3 Contact Information for Assistance 
 
For all queries, please use the contact information below: 
 
ETCTN Biorepository  
Toll-free Phone:  (800) 347-2486 
E-mail:  BPCBank@nationwidechildrens.org 
 

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43 
5.6 
Biomarker Plan  
 
List of Biomarker Assays in Order of Priority 
Priority 
Biomarker 
Name 
Biomarker 
Assay 
Biomarker Type and 
Purpose 
M/O 
Timing 
Specimen 
and 
Quantity 
Needed 
Laboratory 
1 
Genomic 
alterations in HR 
pathway genes 
Whole exome 
sequencing and 
RNAseq 
Integrated 
To assess for genomic alterations in 
genes relevant to homologous 
recombination repair and assess 
effect of such alterations on clinical 
response to treatment. 
M 
 
 
 
 
 
M 
Pre-treatment 
 
 
 
 
 
Pre-treatment 
DNA and 
RNA from 
Tumor biopsy 
2 cores 
 
 
DNA from 
Whole Blood 
(for germline) 
10 mL 
Molecular Characterization 
and Clinical Assay 
Development Laboratory 
(MoCha) 
 
Frederick National 
Laboratory for Cancer 
Research (NCI) 
 
Biswajit Das, PhD 
 
2 
Functional HR 
assay (RAD51)  
RAD51 foci, 
H2AX and 
geminin by IHC 
Integrated 
To evaluate whether RAD51 foci 
formation as assessed at baseline or 
while on-treatment is correlated with 
response to treatment. 
To evaluate whether patients who 
show initial clinical benefit but 
develop radiographic progressive 
disease have a change in assay result 
using an optional biopsy. 
M 
 
M 
 
 
O 
Pre-treatment  
 
On-treatment 
(C2D3-5) 
 
Pre-progression 
10 unstained 
slides from 
tumor biopsy  
per timepoint 
Brigham and Women’s 
Hospital Pathology Core  
Dr. Geoffrey Shapiro, Dana 
Farber Cancer Institute 
3 
SLFN11 
expression 
SLFN11 
expression by 
IHC and possible 
mRNA 
Exploratory 
To evaluate whether SLFN11 
expression is predictive of clinical 
response to treatment. 
O 
O 
Pre-treatment 
Pre-progression  
 
 
10 unstained 
slides from 
tumor biopsy 
per timepoint 
Developmental 
Therapeutics NCI 
Yves Pommier, MD, PhD 
 
4 
MGMT 
expression 
MGMT 
expression by 
IHC and possible 
mRNA  
Exploratory 
To evaluate whether MGMT 
expression is predictive of clinical 
response to treatment. 
O 
O 
Pre-treatment  
Pre-progression 
10 unstained 
slides from 
tumor biopsy 
per timepoint 
Developmental 
Therapeutics NCI 
Yves Pommier, MD, PhD 
 
 

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IHC=Immunohistochemistry, NGS=Next generation sequencing, MGMT=O[6]-methylguanine-DNA methyltransferase, SLFN11=Schlafen family 
member number 11, RAD51= DNA repair protein RAD51 homolog; mRNA = messenger RNA. 

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45 
 
5.7 
Integrated Correlative Studies 
 
Specimens from this study will be received, accessioned, paraffin embedded and stored per 
ETCTN Biorepository guidelines.  Once the study is completed and all material has been 
received, nucleic acids/DNA will be isolated per established procedures and sent to the NCLN 
Genomics laboratory for further analysis.  Slides will be made and distributed in batch to the 
laboratory performing the RAD51 correlative study.  The prioritization of tissue for the study is 
shown in Section 5.6.  
 
5.7.1 Genomic Alterations in HR Pathway Genes 
 
5.7.1.1 Specimen Receipt and Processing at the ETCTN Biorepository 
 
Formalin-fixed tissue from the pre-treatment time point will be used for this assay.  Tissue in 
formalin will be processed and embedded upon receipt at the ETCTN Biorepository, and slides 
will be cut from the biopsies.  For all tumor specimens, the first section will be stained with 
hematoxylin and eosin (H&E) for pathology quality control review to assess tumor content; 
unstained slides will be macrodissected, if needed, and scraped for DNA and RNA co-extraction. 
DNA will be banked in a stock vial and RNA will be divided into 5 aliquots; all nucleic acids 
will be stored in a -80°C freezer until distribution for testing. 
 
DNA will be extracted from blood collected in an EDTA tube at the pre-treatment time point.  
DNA will be stored in a -80°C freezer until distribution for testing. 
 
5.7.1.2 Site Performing Correlative Study 
 
Whole exome sequencing (WES) and RNAseq will be conducted in pre-treatment biopsies at the 
Molecular Characterization and Clinical Development Laboratory (MoCha) of the NCI.  The 
assay will specifically evaluate for genomic mutations, copy number changes and loss of 
heterozygosity in pre-specified HR pathway genes (BRCA1, BRCA2, ATM, ATR, ATRX, 
CHK1, CHK2, RAD51, PALB2, FANCA, and NBS1) using the MoCha pipeline.  Alterations in 
other genes will analyzed by the MoCha WES/RNAseq pipeline will also be characterized and 
reported. 
 
5.7.1.3 
Submission of Sequencing Results Previously Obtained as Standard of Care  
 
WES results are available for 16 of the 22 patients who participated on 10250 using tumor 
biopsies obtained for the study. No results are available for the remaining patients because tissue 
was not available for various reasons, including technical issues accessing the tumor during the 
biopsy or poor tumor content. To better understand whether patients with genomic alterations in 
the HR pathway are more likely to derive clinical benefit from the study treatment and to 
perform the most complete analysis feasible, we would like to request that sites submit next 
generation sequencing (NGS) results from NGS assays previously performed as standard of care 
(i.e. Foundation Medicine, Caris, institutional platform). These reports would be redacted per 
institutional practice and submitted to the study PI.  

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46 
 
5.7.2 RAD51 Foci Formation Assay (Functional HR assay) 
 
5.7.2.1 Specimen Receipt and Processing at the ETCTN Biorepository 
 
For this correlative, 10 unstained , uncharged 4 micron slides from each biopsy (pre-treatment, 
on-treatment and pre-progression, if applicable) will be created, labeled appropriately, and sent 
to the laboratory of Dr. Geoffrey Shapiro of Dana Farber Cancer Institute.    The slides will be 
packed at ambient conditions and sent by overnight courier to: 
 
Bose Kochupurakkal, Ph.D.; Re: NCI 10250 
Harvard Institutes of Medicine HIM324/331 
Center for DNA Damage and Repair 
4 Blackfan Circle, Boston, MA 02115 
 
Prior to shipment, an e-mail will be sent to Bose Kochupurakkal 
(bose_kochupurakkal@dfci.harvard.edu) to inform the laboratory of the shipment. 
 
5.7.2.2 Site Performing Correlative Study 
 
The RAD51 foci formation assay will be performed in pre-treatment, on-treatment and optional 
‘pre-progression’ biopsies at the Brigham and Women’s Hospital Pathology Core under the 
direction of Dr. Geoffrey Shapiro of Dana Farber Cancer Institute.  The RAD51 stain will be 
performed on the VENTANA platform and Geminin stains are performed on the BOND 
platform using standardized protocols.  Antibodies to RAD51, geminin and H2AX are obtained 
from commercial sources that meet GMP standards.  Paraffin sections of a mini-tissue 
microarray containing irradiated and unirradiated breast cancer cell lines MDA-MB436 (BRCA1 
mutant), MDA-MB-468 (BRCA1/2-WT) and the ovarian cancer cell line KURAMOCHI 
(BRCA2 mutant) will be used as controls. 
 
5.8 
Exploratory/Ancillary Correlative Studies 
 
Specimens from this study will be received, accessioned, paraffin embedded and stored per 
ETCTN Biorepository guidelines.  Once the study is completed and all material has been 
received, slides will be made and distributed in batch to the laboratories performing the MGMT 
and SLFN11 correlative studies.  The prioritization of tissue for the study is shown in Section 
5.6.  
 
5.8.1 MGMT Expression  
 
5.8.1.1 Specimen Receipt and Processing at the ETCTN Biorepository 
 
For this correlative, 10 unstained, uncharged slides from the pre-treatment and pre-progression 
biopsy (if applicable) will be created, labeled appropriately, and sent to the laboratory of Dr. 
Yves Pommier of the National Cancer Institute for MGMT expression analysis.  The slides will 
be packed at ambient conditions and sent by overnight courier to: 

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47 
 
Translational Pharmacodynamics Research Group 
Developmental Therapeutics Branch, CCR, NCI, NIH 
10 Center Drive 
Building 10, Room 12C208 
Bethesda, MD 20892 
Phone: 240-760-6330 
 
Prior to shipment, an e-mail will be sent to: Jane Trepel (trepelj@mail.nih.gov) and Sunmin Lee 
(leesun@mail.nih.gov) to inform the laboratory of the shipment.  
 
5.8.1.2 Site Performing Correlative Study 
 
MGMT protein (and possibly RNA expression) will be evaluated using established methodology 
in pre-treatment and optional ‘pre-progression’ biopsies in the laboratory of Dr. Yves Pommier, 
Developmental Therapeutics Branch, NCI.  
 
5.8.2 SLFN11 Expression  
 
5.8.2.1 Specimen Receipt and Processing at the ETCTN Biorepository 
 
For this correlative, 10 unstained, uncharged slides from the pre-treatment and pre-progression 
biopsy (if applicable) will be created, labeled appropriately, and sent to the laboratory of Dr. 
Yves Pommier of the National Cancer Institute for SLFN11 expression analysis.   The slides will 
be packed at ambient conditions and sent by overnight courier to: 
 
Translational Pharmacodynamics Research Group 
Developmental Therapeutics Branch, CCR, NCI, NIH 
10 Center Drive 
Building 10, Room 12C208 
Bethesda, MD 20892 
Phone: 240-760-6330 
 
Prior to shipment, an e-mail will be sent to: Jane Trepel (trepelj@mail.nih.gov) and Sunmin Lee 
(leesun@mail.nih.gov) to inform the laboratory of the shipment.  
 
5.8.2.2 Site Performing Correlative Study 
 
SLFN11 protein (and RNA expression) will be evaluated using established methodology in pre-
treatment and optional ‘pre-progression’ biopsies by immunohistochemistry and mRNA in the 
laboratory of Dr. Yves Pommier, Developmental Therapeutics Branch, NCI.  
 
 
6. 
TREATMENT PLAN 
 

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48 
6.1 
Agent Administration 
 
Treatment will be administered on an outpatient basis.  Reported adverse events and potential 
risks are described in Section 10.  Appropriate dose modifications are described in Section 7.  No 
investigational or commercial agents or therapies other than those described below may be 
administered with the intent to treat the patient's malignancy. 
 
Regimen Description 
Agent 
Premedications; 
Precautions 
Dose 
Route 
Schedule 
Cycle 
Length 
Olaparib 
Do not consume 
grapefruit juice  
200 mg  
Tablets PO BID Days 1-7 
21 days  
(3 weeks) 
 
 
 
Temozolomide 
(TMZ) 
Ondansetron 8 
mg PO once 
with TMZ. 
 
Take on an 
empty stomach 
75 mg/m2  Capsules PO 
once daily 
Days 1-7 
TMZ=temozolomide; PO=oral administration, BID=twice per day. 
 
The patient will be requested to maintain a medication diary of each dose of medication.  The 
medication diary will be returned to clinic staff at the end of each course. 
 
6.1.1 Olaparib 
 
Patients will be administered olaparib twice daily (BID).  Olaparib tablets should be taken at the 
same time each day, approximately 12 hours apart with one glass of water.  The first olaparib 
dose of the day should be taken concomitantly with TMZ.  The olaparib tablets should be 
swallowed whole and not chewed, crushed, dissolved or divided.  Olaparib tablets can be taken 
with or without food; however, since the morning dose is taken with TMZ, both agents will be 
taken together on an empty stomach for the morning dose.  It is prohibited to consume grapefruit, 
grapefruit juice, or Seville oranges while on olaparib therapy. 
 
If vomiting occurs shortly after the olaparib tablets are swallowed, the dose should only be 
replaced if all of the intact tablets can be seen and counted.  Should any patient enrolled on the 
study miss a scheduled dose of olaparib for whatever reason (e.g., as a result of forgetting to take 
the tablets or vomiting), the patient will be allowed to take the scheduled dose of olaparib up to a 
maximum of 2 hours after that scheduled dose time.  If greater than 2 hours after the scheduled 
dose time, the missed dose of olaparib is not to be taken and the patient should take their allotted 
dose at the next scheduled time. 
 
6.1.2 Temozolomide 
 
Patients will be administered TMZ once daily (QD).  The TMZ capsules should be swallowed 
whole with a glass of water and not opened or chewed.  To reduce nausea, TMZ should be taken 

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49 
on an empty stomach and patients will take ondansetron 8 mg PO once concurrently with the 
TMZ dose during cycle 1.  If patients have a medical contraindication to ondansetron, another 
anti-emetic may be substituted.  The use of ondansetron beyond cycle 1 is at the discretion of the 
principle investigator.  
 
TMZ is rapidly and completely absorbed after oral administration with a peak plasma 
concentration achieved in a median of 1 hour.  Food reduces the extent of TMZ absorption. 
 
If vomiting occurs shortly after the temozolomide tablets are swallowed, the dose should only be 
replaced if all of the intact tablets can be seen and counted.  Should any patient enrolled on the 
study miss a scheduled dose of temozolomide for whatever reason (e.g., as a result of forgetting 
to take the tablets or vomiting), the patient will be allowed to take the scheduled dose of 
temozolomide up to a maximum of 12 hours after that scheduled dose time.  If greater than 12 
hours after the scheduled dose time, the missed dose of temozolomide is not to be taken and the 
patient should take their allotted dose at the next scheduled time. 
 
6.2 
General Concomitant Medication and Supportive Care Guidelines 
 
Because there is a potential for interaction of olaparib with other concomitantly administered 
drugs, the case report form must capture the concurrent use of all other drugs, over-the-counter 
medications, vitamins, nutritional supplements, or alternative therapies at the time of enrollment 
and throughout the study.  The case report form should capture the dates of administration 
(including start/end dates if known), dosage (including dosing frequency/schedule), and reason 
for use.  The Principal Investigator should be alerted if the patient is taking any agent known to 
affect or with the potential for drug interactions.  The study team should check a frequently-
updated medical reference for a list of drugs to avoid or minimize use of.  Appendix B (Patient 
Drug Information Handout and Wallet Card) should be provided to patients if available. 
 
6.2.1 Dietary Restrictions and Over-the-Counter/Self-Medication 
 
It is prohibited to consume grapefruit, grapefruit juice, Seville oranges, or Seville orange juice 
while on olaparib therapy.  The use of any natural/herbal products or other traditional remedies 
should be discouraged. 
 
6.2.2 Medications that May NOT be Administered 
 
No other anti-cancer therapy (chemotherapy, immunotherapy, hormonal therapy [hormone 
replacement therapy is acceptable], radiotherapy, biological therapy, or other novel agent) is to 
be permitted while the patient is receiving study medication. 
 
Live virus and live bacterial vaccines should not be administered while the patient is receiving 
study medication and during the 30-day follow-up period. An increased risk of infection by the 
administration of live virus and bacterial vaccines has been observed with conventional 
chemotherapy drugs and the effects with olaparib are unknown. 
 

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50 
6.2.3 Restricted Concomitant Medications 
 
6.2.3.1 
Strong or Moderate CYP3A Inhibitors  
 
Known strong CYP3A inhibitors (e.g., itraconazole, telithromycin, clarithromycin, boosted 
protease inhibitors, indinavir, saquinavir, nelfinavir, boceprevir, telaprevir) or moderate CYP3A 
inhibitors (ciprofloxacin, erythromycin, diltiazem, fluconazole, verapamil) should not be taken 
with olaparib. 
 
6.2.3.2 
Strong or Moderate CYP3A Inducers 
 
Strong (e.g., phenobarbital, phenytoin, rifampicin, rifabutin, rifapentine, carbamazepine, 
nevirapine, enzalutamide and St John’s Wort) and moderate CYP3A inducers (e.g., bosentan, 
efavirenz, modafinil) of CYP3A should not be taken with olaparib. 
 
6.2.3.3 
P-gp inhibitors 
 
It is possible that co-administration of P-gp inhibitors (e.g., amiodarone, azithromycin) may 
increase exposure to olaparib.  Caution should therefore be exercised. 
 
6.2.3.4 
Effect of olaparib on other drugs 
 
The efficacy of hormonal contraceptives may be reduced if co-administered with olaparib. 
 
Based on limited in vitro data, olaparib may increase the exposure to substrates of CYP3A4, 
OATP1B1, OCT1, OCT2, OAT3, MATE1, and MATE2K.  
 
Based on limited in vitro data, olaparib may reduce the exposure to substrates of CYP2B6.  
 
Caution should therefore be exercised if substrates of these isoenzymes or transporter proteins 
are co-administered. 
 
Examples of substrates include (use a frequently-updated resource for comprehensive list): 
• CYP3A4 – hormonal contraceptive, simvastatin, cisapride, cyclosporine, ergot alkaloids, 
fentanyl, pimozide, sirolimus, tacrolimus, and quetiapine 
• CYP2B6 – bupropion, efavirenz 
• OATP1B1 – bosentan, glibenclamide, repaglinide, statins, and valsartan 
• OCT1, MATE1, MATE2K – metformin 
• OCT2 – serum creatinine 
• OAT3 – furosemide, methotrexate 
 
6.2.4 Anticoagulant Therapy 
 

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Patients who are taking warfarin may participate in this trial; however, it is recommended that 
the international normalized ratio (INR) be monitored carefully at least once per week for the 
first month, then monthly if the INR is stable.  Subcutaneous heparin and low molecular weight 
heparin are permitted. 
 
6.2.5 Anti-emetics/Anti-diarrheals 
 
If a patient develops nausea, vomiting, and/or diarrhea, then these symptoms should be reported 
as AEs and appropriate treatment of the event given.  An information sheet for patients regarding 
management and reporting of diarrhea can be found in Appendix C.  
 
6.2.6 Administration of other Anti-Cancer Agents 
 
Patients must not receive any other concurrent anti-cancer therapy, including investigational 
agents, while on study treatment.  Patients may continue the use of bisphosphonates or 
denosumab for bone disease and corticosteroids for the symptomatic control of brain metastases 
provided the dose is stable before and during the study and the agents were started at least 4 
weeks prior to beginning study treatment.  
 
6.3 
Duration of Therapy 
 
Treatment will continue until one of the following criteria applies: 
 
• 
Disease progression per RECIST version 1.1 criteria 
 
• 
Intercurrent illness that prevents further administration of treatment 
 
• 
Unacceptable adverse event(s) 
 
• 
Bone marrow findings consistent with MDS or AML 
 
• 
Patient decides to withdraw from the study 
 
• 
General or specific changes in the patient's condition render the patient unacceptable 
for further treatment in the judgment of the investigator 
 
• 
Clinical progression 
 
• 
Patient non-compliance 
 
• 
Pregnancy 
 
o All women of child bearing potential should be instructed to contact the 
investigator immediately if they suspect they might be pregnant (e.g., missed 
or late menstrual period) at any time during study participation. 
 

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o The investigator must immediately notify CTEP in the event of a confirmed 
pregnancy in a patient participating in the study. 
 
• 
Termination of the study by sponsor 
 
• 
The drug manufacturer can no longer provide the study agent 
 
The reason(s) for protocol therapy discontinuation, the reason(s) for study removal, and the 
corresponding dates must be documented in the case report form (CRF). 
 
6.4 
Duration of Follow Up 
 
Patients removed from study for adverse events will be followed until resolution or stabilization 
of the adverse event. Patients will be followed in clinic or by telephone on an approximately 
every 3 month schedule for 2 years after study participation ends to collect information related to 
disease status, subsequent anti-cancer therapy and any new diagnosis of AML or MDS. Patients 
will continue to be followed every 6 months thereafter until death or withdrawal of consent to 
ascertain any new diagnosis of AML or MDS, and the status of those conditions if diagnosed.  
 
7. 
DOSE DELAYS AND MODIFICATIONS 
 
7.1 
Required Parameters for Initiation of a Treatment Cycle 
 
A new cycle of therapy may begin only if the following criteria are met: 
 
• ANC  1,000/μL 
• Hemoglobin  9 g/dL (for cycle 1, day 1;  8 g/dL for all other cycles) 
• Platelets  100,000/μL  
• Grade ≥ 2 non-hematologic adverse events (except for alopecia) have resolved to grade ≤ 
1, acceptable grade 2 (in the opinion of the treating investigator), or baseline. 
 
 
7.2 
General Principles 
 
The following guidelines apply for dose reductions and delays: 
 
• Dosing for a given cycle will be based on adverse events observed during the prior cycle.  
When multiple adverse events occur, the modification that would require the patient to 
receive the lowest dose combination of the study drugs is used.  
• When toxicity requires a new treatment cycle to be delayed, both agents should be held 
until the toxicity resolves and then resumed simultaneously.  Deviations from this 
approach should be discussed with the principal investigator. 
• If toxicity requires a study agent to be held during the dosing phase (days 1-7) of a cycle, 
the other study agent may be continued at the investigator’s discretion.  If toxicity 
resolves, treatment with the agent that was held should generally resume at the time of 
the next scheduled cycle (i.e. the missed doses should not be made up).  When an adverse 

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event results in a study agent being interrupted during a cycle, all planned assessments 
for that cycle will otherwise occur as scheduled.   
• A subject may incur up to 2 dose reductions of each study agent prior to discontinuation 
of that agent.  Furthermore, TMZ may not be dose reduced below 25 mg/m2 daily, and 
olaparib may not be dose reduced below 100 mg BID; in the event reduction below such 
dose level is indicated, that study agent should be discontinued.  However, after 
discontinuation of one study agent, the other study agent may be continued at the 
discretion of the treating investigator after an assessment of the overall risk-/benefit ratio 
for the patient. 
• For non-hematologic adverse events that have not resolved at the scheduled start of a 
cycle per Section 7.1, treatment may be delayed for up to 3 weeks.  If, after a 3 week 
delay, adverse events have still not resolved, in general the patient should be removed 
from the study.  For the management of non-resolving hematologic toxicity, please see 
Section 7.4.3.   
 
 
 
7.3 
Dose Levels for Olaparib and Temozolomide 
 
The following dose levels for both agents will be used during this study and apply to the 
recommended management given throughout this section.  If a patient requires more than 2 dose 
reductions of a study agent, that study agent should be discontinued. 
 
Olaparib dose reductions on study treatment 
Initial Olaparib Dose 
Dose reduction 1 
Dose reduction 2 
200 mg BID 
150 mg BID 
100 mg BID 
 
 
TMZ dose reductions on study treatment 
Initial TMZ Dose 
Dose reduction 1 
Dose reduction 2 
75 mg/m2 QD 
50 mg/m2 QD 
25 mg/m2 QD 
 
7.4 
Management of Hematologic Toxicity  
 
7.4.1 General Approach 
 
 
Observed Hematologic Toxicity 
Recommended Management 
ANC < 500/μL and/or  
Platelets < 50,000/μL 
 
Grade 3 or 4 neutropenic fever requiring 
oral or intravenous antibiotics 
Delay cycle.  Monitor complete blood 
count at least weekly.  When criteria for 
new cycle are met, resume at one dose 
level lower for the agent to which 
toxicity is assessed.  

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Grade 3 thrombocytopenia with bleeding 
 
Hemoglobin < 7 g/dL 
 
Other hematologic adverse events ≥ grade 3 
deemed clinically significant by the treating 
investigator. 
 
 
ANC 500-999/μL and/or  
Platelets 50,000/mcL - 99,999/mcL and/or 
Hemoglobin < 8 g/dL 
 
Delay cycle.  Monitor complete blood 
count at least weekly.  When criteria for 
new cycle are met, resume treatment at 
same dose level.   
 
7.4.2 Use of transfusions and colony stimulating factors 
 
The use of blood product transfusions (packed red blood cells and platelets) is permitted per 
institutional guidelines.  Erythropoietin stimulating agents may be used per institutional and 
National Comprehensive Cancer Network (NCCN) guidelines at the treating investigator’s 
discretion. In the event of cytopenias requiring dose modifications and/or delays, the use of G-
CSF as primary prophylaxis in subsequent cycles is permitted per institutional guidelines and 
investigator judgement, particularly in situations where patients appear to be deriving benefit 
from the study treatment. The use of thrombopoietin agonists for the management of 
thrombocytopenia is not recommended.  
 
7.4.3 Management of prolonged hematologic toxicity 
 
Should any subject develop evidence of prolonged hematologic toxicity, including but not 
limited to ≥2 week interruption/delay in study drug administration due to any of the following, 
additional monitoring is indicated:   
 
• grade 3 anemia (Hgb <8 g/dL) 
• grade 3 neutropenia (ANC <1000/mcL) 
• grade 3 thrombocytopenia (platelets <50/mcL) and/or  
• development of transfusion dependence for red blood cells or platelets 
 
In any of these cases, weekly blood counts including reticulocytes and peripheral smear should 
be monitored.  If toxicity has not resolved to ≤ grade 1 within 3 weeks of study drug treatment 
being held, the patient should be referred to a hematologist for further evaluation and the patient 
should be removed from the study.  Bone marrow biopsy should be considered for evaluation 
including cytogenetics.  Patients who develop MDS or AML while on study treatment should 
discontinue study participation and be managed appropriately by a hematologist oncologist.  
 
7.4.4 Dose re-escalation of olaparib 
 
Patients who have undergone dose modification of olaparib may be considered for dose re-
escalation of that drug if they complete 2 cycles of treatment without dose delays and/or 

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modifications (of any study agent). In that situation, the dose of olaparib may only be re-
escalated by one dose level on one occasion 
 
7.5 
Management of Non-Hematologic Toxicities Attributed to Olaparib 
 
Olaparib may be modified for non-hematologic toxicities per below: 
 
Diarrhea Attributed to Olaparib 
Management Guidelines 
≤ Grade 1 
No change in dose.  
Grade 2 
No change in dose. Evaluate for infectious etiology if 
clinically indicated. Institute anti-diarrheal therapy. If 
diarrhea persists at grade 2 or higher for more than 5 
days despite supportive care, interrupt olaparib or delay 
cycle (as appropriate) and manage supportively. 
Reinstitute at same dose when symptoms improve to ≤ 
grade 1.  
Recurrent grade 2 diarrhea: Interrupt olaparib or delay 
cycle (as appropriate). Evaluate for infectious etiology. 
Manage supportively. Upon resolution to ≤ grade 1, 
resume at one dose level lower for olaparib.  
Grade 3 
Interrupt olaparib or delay cycle (as appropriate) until ≤ 
grade 1. Evaluate for infectious etiology if clinically 
indicated. Institute anti-diarrheal therapy. Resume at 
one dose level lower for olaparib when symptoms 
improve to ≤ grade 1. 
Grade 4 
Discontinue olaparib permanently.  
 
Other Non-Hematologic Toxicity 
Attributed to Olaparib 
Dose Reduction 
Grade 1 or 2 
No change in dose. Continue therapy at the 
investigator’s discretion. 
Grade 3 non-hematologic toxicity deemed 
clinically significant by the treating 
investigator and not attributable to TMZ or 
underlying disease 
Interrupt olaparib or delay cycle (as appropriate) 
until event resolved to grade ≤ 1, acceptable 
grade 2 (in the opinion of the treating 
investigator), or baseline. Resume at one dose 
level lower for olaparib.  
Grade 4 non-hematologic toxicity not 
attributable to TMZ or underlying disease 
Discontinue olaparib permanently. 
 
7.5.1 Renal Impairment 
 
Olaparib has not been studied in patients with severe renal impairment (CrCl ≤ 30 mL/min) or 
end-stage renal disease; if patients develop severe renal impairment (CrCl < 30 mL/min) or end 
stage renal disease, the case should be discussed with the CTEP Medical Monitor. Investigators 

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should be aware that olaparib may cause artificial increases in the blood creatinine level. These 
effects are often mild and occur early in treatment.  
 
7.6 
Management of Non-Hematologic Toxicities Related to Temozolomide 
 
Non-Hematologic Toxicity  
Attributed to TMZ 
Dose Reduction 
Intolerable grade 2 toxicity 
Interrupt TMZ or delay cycle (as appropriate) 
until resolved to grade 1, or deemed tolerable 
with supportive care.  
Grade 3/4 fatigue, nausea, constipation 
and/or diarrhea which persist ≥ 3 days 
despite optimal supportive care 
 
Other grade 3 adverse event deemed 
clinically significant by the treating 
investigator. 
Interrupt TMZ or delay cycle (as appropriate) 
until event resolved to grade 1, acceptable grade 2 
(in the opinion of the treating investigator), or 
baseline. Resume at one lower dose level for 
TMZ.   
Grade 4 (except for grade 4 alopecia, 
fatigue, nausea and vomiting not 
maximally managed with supportive care) 
Discontinue TMZ permanently.  
 
7.7 
Management of New or Worsening Pulmonary Symptoms  
 
If new or worsening pulmonary symptoms (e.g., dyspnea) or radiological abnormalities occur in 
the absence of a clear diagnosis, an interruption in study treatment dosing is recommended and 
further diagnostic workup (including a high-resolution CT scan) should be performed to exclude 
pneumonitis. 
 
Following investigation, if no evidence of abnormality is observed on CT imaging and symptoms 
resolve, then study treatment can be restarted, if deemed appropriate by the investigator. If 
significant pulmonary abnormalities are identified, these need to be discussed with the CTEP 
Medical Monitor. 
 
7.8 
Management of Nausea and Vomiting 
 
Events of nausea and vomiting are known to be associated with olaparib and TMZ treatment.  
Patients should take ondansetron 8 mg PO once with the AM dose of TMZ for at least 1 cycle.  
Another anti-emetic can be substituted if clinically indicated. 
 
These events are generally mild to moderate (CTCAE grade 1 or 2) severity, intermittent, and 
manageable on continued treatment.  The first onset generally occurs in the first month of 
treatment for nausea and within the first 6 months of treatment for vomiting.  For nausea, the 
incidence generally plateaus at around 9 months, and for vomiting at around 6 to 7 months. 
 
Patients should receive additional appropriate anti-emetic treatment at the first onset of nausea or 
vomiting and as required thereafter, in accordance with local treatment practice guidelines.   

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As per international guidance on anti-emetic use in cancer patients (ESMO, NCCN), generally a 
single agent antiemetic should be considered, such as a dopamine receptor antagonist, 
antihistamine, or dexamethasone. 
 
7.9 
Interruptions for Intercurrent Non-Toxicity Related Events 
 
Study treatment dose interruption for conditions other than toxicity resolution should be kept as 
short as possible.  If a patient cannot restart study treatment within 4 weeks for resolution of 
intercurrent conditions not related to disease progression or toxicity, the case should be discussed 
with the CTEP Medical Monitor.  Patients who are discontinued from the study for reasons other 
than progression of disease or treatment-related toxicity may be replaced. 
 
All dose reductions and interruptions (including any missed doses), and the reasons for the 
reductions/interruptions are to be recorded in the eCRF.  
 
Surgery indicated for the management of non cancer-related conditions (e.g. cholecystectomy, 
appendectomy) is permitted.  Study treatment should be stopped at least 7 days prior to planned 
surgery.  After surgery, study treatment can be restarted when the wound has healed.  Surgery 
directed at sites involved by malignancy will usually require cessation of study participation for 
reasons of disease progression.  Surgery that is related to side effects or toxicity from the drug 
should also result in cessation of study participation.  Individual cases may be discussed with the 
CTEP Medical Monitor.  No interruption of study treatment is required for any needle biopsy 
procedure however a blood count should be checked to ensure counts are adequate. 
 
Because the AEs related to olaparib and TMZ may include asthenia, fatigue, and dizziness, 
patients should be advised to use caution while driving or using machinery if these symptoms 
occur.  
 
 
8. 
PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational or commercial 
agents administered in this study can be found in Section 10.1. 
 
8.1 
CTEP IND Agent 
 
8.1.1 Olaparib (AZD2281) (NSC 747856) 
 
Chemical Name:  4-[(3-{[4-(cyclopropylcarbonyl)piperazin-1-yl]carbonyl}-4-
fluorophenyl)methyl]phthalazin-1(2H)-one 
 
Other Names: AZD2281; KU-0059436; CO-CE 42 
 
Classification: PARP inhibitor 
 

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CAS Registry Number: 763113-22-0 
 
Molecular Formula:  C24H23FN4O3 
 
M.W.: 434.46 
 
Approximate Solubility: 0.1 mg/mL pH independent solubility across physiologic range 
 
Mode of Action: Olaparib is an inhibitor of subclasses 1, 2, and 3 of polyadenosine 5′ 
diphosphoribose polymerase (PARP-1, PARP-2, and PARP-3). In tumors that are deficient 
in the homologous recombination DNA repair pathway (example, BRCA mutants), 
inhibition of PARP by olaparib causes accumulation of DNA double-strand breaks and 
genomic instability. Olaparib may also enhance the effects of DNA damage caused by 
ionizing radiation and chemotherapy.  
 
Description: crystalline solid 
 
How Supplied: AstraZeneca supplies and the Pharmaceutical Management Branch (PMB), CTEP, 
Division of Cancer Treatment and Diagnosis (DCTD) distributes olaparib as green, film-
coated tablets in 100 mg and 150 mg strengths.  
 
• 100 mg tablets are 14.5 mm x 7.25 mm oval-shaped 
• 150 mg are 14.5 mm x 7.25 mm oval-shaped 
 
Tablets are packaged in induction-sealed high-density polyethylene (HDPE) bottles with 
child-resistant closures. Each bottle contains 32 tablets with desiccant.  
 
Tablet core components include active drug substance, copovidone, colloidal silicon 
dioxide, mannitol and sodium stearyl fumarate. Film coating contains hydroxypropyl 
methylcellulose (hypromellose), macrogol 400 (polyethylene glycol 400), titanium dioxide, 
iron oxide yellow and iron oxide black. 
 
Storage: Store in a secure location below 30° C (86° F).  
 
If a storage temperature excursion is identified, promptly return olaparib (AZD2281) to 
room temperature and quarantine the supplies.  Provide a detailed report of the excursion 
(including documentation of temperature monitoring and duration of the excursion) to 
PMBAfterHours@mail.nih.gov for determination of suitability.   
 
Stability:  Shelf-life studies are ongoing. Sites are not permitted to re-package tablets. Once the 
bottle is opened, olaparib tablets must be used within 3 months of the opening date; 
unused tablets should be discarded. Instruct patients not to open a bottle until they are 
ready to use it. 
 
Route and Method of Administration:  Oral. Take tablets without regard to meals.  
 
Potential Drug Interactions:  In vivo data indicate that CYP3A4/5 is important for olaparib 
metabolism and clearance in humans. For this reason, avoid concomitant administration of 

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strong and moderate CYP 3A4/5 inducers and inhibitors.  Consult the protocol document 
or study investigator prior to making any dose adjustments related to potential drug-drug 
interactions. 
 
In vitro data shows olaparib is a substrate for P-glycoprotein (P-gp), but not for organic 
anion-transporting polypeptides (OATP1B1 and OATP1B3), organic cation transporter 1 
(OCT1), multi-drug resistance protein 2 (MRP-2) efflux transporter or breast cancer 
resistance protein (BCRP). Administration of strong P-gp inhibitors and inducers should be 
avoided with concurrent olaparib.   
 
Based on in vitro data, olaparib inhibits CYP 3A4 and UGT1A1 enzyme systems and 
induces CYP 1A2, 2B6, and 3A4. Therefore, avoid concomitant administration of sensitive 
substrates, particularly those with narrow therapeutic ranges.   
 
Olaparib is also an inhibitor of P-gp, OATP1B1, OCT1, OCT2, OAT3, multi-drug and toxin 
extrusion proteins (MATE1 and MATE2K) and a weak inhibitor of BRCP, but not an 
inhibitor of OATP1B3 or MRP-2. In vitro studies suggest that olaparib may increase 
exposure of substrates of these transport systems, although the clinical relevance is not clear. 
The manufacturer recommends that statins, in particular, should be administered with 
caution when given concomitantly with olaparib. 
 
Patient Care Implications: Pre-clinical data indicate that olaparib adversely affects embryofetal 
survival and development. Therefore, women of child-bearing potential and their partners 
should agree to use two (2) highly effective forms of contraception starting at signing of the 
informed consent, throughout study participation and for at least one (1) month after the last 
dose of olaparib.  It is not known whether olaparib is found in seminal fluid, so as a 
precaution, male study participants must use a condom during treatment and for three (3) 
months after the last dose and should avoid fathering a child or donating sperm during this 
same time period. The study investigator should discuss the most appropriate forms of 
highly effective contraceptive methods for each patient.  
 
Lactation is a protocol exclusion criterion and not advised since there is potential for serious 
adverse reactions in breastfed infants. Advise lactating women to not breastfeed during 
study treatment and for one (1) month after receiving the last dose of olaparib.  
 
Because the adverse events related to olaparib may include asthenia, fatigue and 
dizziness, patients should be advised to use caution while driving or using machinery. 
 
There are no data on the effect of olaparib on wound healing, therefore as a precaution, 
olaparib treatment should be stopped at least 3 days prior to planned surgery. After 
surgery olaparib can be restarted when the wound has healed. No stoppage of olaparib is 
required for any needle biopsy procedure. 
 
Study treatment should be discontinued for a minimum of 3 days before a patient 
undergoes therapeutic or palliative radiation treatment. Study treatment should be 
restarted within 4 weeks as long as any bone marrow toxicity has recovered. 

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Availability 
 
Olaparib (AZD2281) is an investigational agent supplied to investigators by the DCTD, NCI. 
 
Olaparib (AZD2281) is provided to NCI under a Collaborative Agreement between the 
Pharmaceutical Collaborator and DCTD, NCI (see Section 13.4). 
 
8.1.2 Agent Ordering and Agent Accountability 
 
NCI-supplied agents may be requested by eligible participating Investigators (or their authorized 
designee) at each participating institution.  The CTEP-assigned protocol number must be used 
for ordering all CTEP-supplied investigational agents.  The eligible participating investigators at 
each participating institution must be registered with CTEP, DCTD through an annual 
submission of FDA Form 1572 (Statement of Investigator), NCI Biosketch, Agent Shipment 
Form, and Financial Disclosure Form (FDF).  If there are several participating investigators at 
one institution, CTEP-supplied investigational agents for the study should be ordered under the 
name of one lead participating investigator at that institution. 
 
Submit agent requests through the PMB Online Agent Order Processing (OAOP) application.  
Access to OAOP requires the establishment of a CTEP Identity and Access Management (IAM) 
account and the maintenance of an “active” account status, a “current” password, and active 
person registration status.  For questions about drug orders, transfers, returns, or accountability, 
call or email PMB any time.  Refer to the PMB’s website for specific policies and guidelines 
related to agent management.   
 
Starter supplies will not be provided.  Patients must be registered prior to agent ordering.  Sites 
may request expedited orders Monday-Thursday when they provide courier information. 
 
8.1.2.1 
Agent Inventory Records  
 
The investigator, or a responsible party designated by the investigator, must maintain a careful 
record of the receipt, dispensing and final disposition of all agents received from the PMB using 
the appropriate NCI Investigational Agent (Drug) Accountability Record (DARF) available on 
the CTEP forms page.  Store and maintain separate NCI Investigational Agent Accountability 
Records for each agent, strength, formulation and ordering investigator on this protocol. 
 
8.1.3 Investigator Brochure Availability 
 
The current versions of the IBs for the agents will be accessible to site investigators and research 
staff through the PMB OAOP application.  Access to OAOP requires the establishment of a 
CTEP IAM account and the maintenance of an “active” account status, a “current” password and 
active person registration status.  Questions about IB access may be directed to the PMB IB 
Coordinator via email. 
 

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8.1.4 Useful Links and Contacts 
 
• CTEP Forms, Templates, Documents:  http://ctep.cancer.gov/forms/ 
• NCI CTEP Investigator Registration:  RCRHelpDesk@nih.gov 
• PMB policies and guidelines: 
http://ctep.cancer.gov/branches/pmb/agent_management.htm  
• 
PMB Online Agent Order Processing (OAOP) application:  
https://ctepcore.nci.nih.gov/OAOP 
• CTEP Identity and Access Management (IAM) account: 
https://ctepcore.nci.nih.gov/iam/  
• CTEP IAM account help:  ctepreghelp@ctep.nci.nih.gov  
• IB Coordinator:  IBCoordinator@mail.nih.gov  
• PMB email:  PMBAfterHours@mail.nih.gov 
• PMB phone and hours of service: (240) 276-6575 Monday through Friday 
between 8:30 am and 4:30 pm (ET) 
 
8.2 
Commercial Agent 
 
8.2.1 Temozolomide (NSC 362856) 
 
Chemical Name:  3,4-dihydro-3-11 methyl-4-oxoimidazo[5,1-d]-as-tetrazine-8-carboxamide  
 
Other Names:  Temodar®, Temodal®, Temcad® 
 
Classification:  Alkylating Agent 
 
 
CAS Registry Number:  85622-93-1 
 
 
Molecular Formula:  C6H6N6O2                                                             M.W.: 194.15 
 
 
 
 
 
Mode of Action:  Temozolomide is not directly active but undergoes rapid nonenzymatic 
conversion at physiologic pH to the reactive compound 5-(3-methyltriazen-1-yl)-imidazole-4-
carboxamide (MTIC).  The cytotoxicity of MTIC is thought to be primarily due to alkylation of 
DNA.  Alkylation (methylation) occurs mainly at the O6 and N7 positions of guanine. 
 
How Supplied:  Temozolomide is commercially available.  Please refer to the FDA-approved 
package insert for this drug.   
 
Capsules are supplied in child-resistant sachets containing the following capsule 
strengths:  5 mg, 20 mg, 100 mg, 140 mg and180 mg..  The dose of temozolomide is based on 
body surface area (BSA) and then rounded off to the nearest 5 mg.   
 
Storage:  Store at 25°C (77°F); excursions permitted to 15°–30°C (59°–86°F).   
 
Stability:  The molecule is stable at acidic pH (<5) and labile at pH >7. 
 

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Route of Administration:  Oral 
 
Method of Administration:  Take each day’s dose of capsules at one time, with a full glass of 
water.  Temozolomide will be administered orally.  The capsules should be swallowed whole and 
never chewed.  The incidence of nausea and vomiting is decreased when temozolomide is taken 
on an empty stomach.  
 
 
9. 
STATISTICAL CONSIDERATIONS 
 
9.1 
Study Design/Endpoints 
 
9.1.1 Study Design 
 
A single arm, open label design will be used to determine the efficacy of the combination of 
olaparib and TMZ in patients of advanced uterine LMS. 
 
9.1.2 Primary Endpoint 
 
The primary endpoint of this study is the confirmed ORR (complete response + partial response) 
as measured by RECIST version 1.1 criteria.  Responses must occur within the first 6 months of 
study treatment for the purpose of evaluating the primary endpoint.  The ORR will be reported 
with a 95% confidence interval. 
 
FDA approved second-line and later line agents used in uterine LMS based on phase 3 clinical 
trial data include trabectedin (a DNA damaging cytotoxic agent) and pazopanib (an anti-
angiogenic receptor tyrosine kinase inhibitor).  A recent phase 3 clinical trial randomized 
patients with LMS and another sarcoma subtype (liposarcoma) to trabectedin or dacarbazine.  
Dacarbazine, an intravenous chemotherapeutic with an analogous mechanism of action to oral 
TMZ, has often been used as a control arm in phase 3 sarcoma studies, and was used by the 
European Organization for Research and Treatment of Cancer to establish benchmarks for 
assessing the activity of novel second line agents in STS (Van Glabbeke et al., 2002).  In the 
randomized phase 3 study of trabectedin versus dacarbazine, patients were required to have 
previously received an anthracycline-based regimen and there was no upper limit on the number 
of prior treatments received.  In a recently reported subset analysis of the uterine LMS cohort 
from this study, the ORR was 11% for trabectedin and 9% for dacarbazine and this difference 
was not statistically significant (p=0.82) (Demetri et al., 2016; Hensley et al., 2017).  Similarly, 
in an analysis of 318 LMS patients enrolled on a single-arm, open-label trabectedin extended 
access program available after progression on standard chemotherapy, the response rate was 
7.5% (Samuels et al., 2013).   
 
In another phase 3 study patients with several sarcoma subtypes who had received at least one 
regimen containing anthracycline and a maximum of four previous lines of systemic therapy 
were randomized to pazopanib versus placebo (van der Graaf et al., 2012).  In a recently 
published subset analysis of this study (and the preceding phase 2 study) limited to uterine 
sarcomas (90% had LMS), the response rate to pazopanib was 10% (Benson et al., 2016).  

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63 
 
In view of the above, we will consider a response rate of 10% to be inactive and unworthy of 
further study, whereas a response rate of 35% would be promising for further study among 
patients with advanced LMS treated with at least one prior systemic regimen.  A response rate of 
35% for the TMZ + PARPi combination would also be suggestive of superior efficacy over TMZ 
monotherapy in sarcoma.  As discussed above, dacarbazine, the IV analogue of TMZ, was 
associated with a response rate of 9% among LMS patients treated on the randomized phase 3 
study of trabectedin versus dacarbazine (Demetri et al., 2009).  Furthermore, in a phase 3 
randomized study of eribulin versus dacarbazine which included 75% LMS patients, the 
response rate to dacarbazine was 5% (Schoffski et al., 2016).  In a randomized study of 
gemcitabine and dacarbazine versus dacarbazine alone, the response rate to dacarbazine was 4% 
(Garcia-del-Muro et al., 2011).  
 
9.1.3 Analysis Plan 
 
A one-stage binomial design will be used evaluating an objective response rate of at most 10% 
(null hypothesis) versus at least 35% (alternative hypothesis).  The design calls for 22 patients.  
If 5 or more from the total sample of 22 respond, the treatment is considered worthy of further 
consideration.  This design yields 93% power and 1-sided type I error of 6% to test for a 
response rate of 10% vs. 35%.  The study team believes this design, and an observed response 
rate of 22.7%, would reflect a clinically meaningful finding worthy of further evaluation 
considering currently available treatment options and results of other studies as described above.  
A minimum of 22 to a maximum of 25 (22 + 3) patients will be required for the study, allowing 
for patients deemed ineligible or withdrawing consent prior to the first dose of study treatment 
(that is, 2-3 additional patients will be recruited to account for non-evaluable patients). 
 
The proposed endpoints are reflective of recently reported phase 2 studies conducted specifically 
in LMS.  Phase 2 studies of pembrolizumab (George et al., 2017), alisertib (Hyman et al., 2017), 
ixabepilone (Duska et al., 2014) and ziv-aflibercept (Mackay et al., 2012) conducted specifically 
in LMS used Simon 2 stage designs with objective response rate as the primary endpoint and a 
null hypothesis of 5% as compared an alternative hypothesis of between 20-25%, and none met 
this endpoint (Ben-Ami et al., 2017; Hyman et al., 2017; Duska et al., 2014; Mackay et al., 
2012).  After review of all recently published LMS-specific studies, the highest benchmarks for 
activity were used in phase 2 studies of trabectedin and sunitinib (10% considered inactive and 
30% active) (Monk et al., 2012; Hensley et al., 2009).  
 
9.2 
Sample Size/Accrual Rate 
 
Using the ECTCN network and recognizing that LMS is a relatively common sarcoma subtype, 
we expect to enroll approximately 2 patients per month across all participating centers.  Thus, we 
anticipate full accrual after approximately 10 months.   
 

NCI Protocol #: 10250 
Version Date: June 27, 2022 
 
64 
PLANNED ENROLLMENT REPORT 
Racial Categories 
Ethnic Categories 
Total 
Not Hispanic or Latino 
Hispanic or Latino 
 
Female 
Male 
Female 
Male 
 
American Indian/ Alaska 
Native 
0 
0 
0 
0 
0 
Asian 
1 
0 
0 
0 
1 
Native Hawaiian or 
Other Pacific Islander 
0 
0 
0 
0 
0 
Black or African 
American 
4 
0 
0 
0 
4 
White 
12 
0 
3 
0 
15 
More Than One Race 
2 
0 
0 
0 
2 
Total 
19 
0 
3 
0 
22 
PHS 398 / PHS 2590 (Rev. 08/12 Approved Through 8/31/2015)  
OMB No. 0925-0001/0002 
 
9.3 
Stratification Factors 
 
Not applicable.    
 
9.4 
Analysis of Secondary Endpoints 
 
9.4.1 Secondary Endpoints 
 
9.4.1.1 
Toxicity 
 
Adverse events will be recorded at each clinical visit and will be categorized according to NCI 
CTCAE version 5.0.  Adverse event rates will be reported as counts and percentages per adverse 
event by grade. 
 
9.4.1.2 
Progression-Free Survival 
 
PFS is defined as the time from first treatment with the study drug to the earliest of either disease 
progression or death from any cause.  Patients who are alive and progression free will be 
censored at the time of their last tumor assessment.  The Kaplan-Meier method will be used to 
evaluate time to event endpoints.  Median PFS will be reported with a 95% confidence interval. 

NCI Protocol #: 10250 
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65 
 
9.4.1.3 
Integrated Correlatives 
 
The association between ORR, PFS, and the results of integrated assays evaluating for presence 
of HR deficiency in the tumor will be evaluated. The two integrated assays are genomics for 
alterations in HR genes and RAD51 foci formation. Both of these assays report binary results. 
The rate of response will be compared between binary variables using the Fisher’s exact test.  
The log-rank test will be used to compare PFS between binary variables.  Additional results from 
whole exome sequencing and RNAseq analysis on study samples will be reported in a 
descriptive fashion. 
 
 
9.4.1.4 
Exploratory Correlatives 
 
The association between ORR, PFS, and the exploratory assays will be evaluated in a 
preliminary fashion.  The exploratory assays include SLFN11 and MGMT expression by IHC. 
SLFN11 and MGMT mRNA expression may also be performed.   SLFN11 and MGMT 
expression are reported as a continuous variable.  Logistic regression will be used to estimate the 
odds of response for every unit increase in protein expression. Cox-regression will be used to 
evaluate the association between PFS and protein expression.  Graphical displays such as box 
plots and Kaplan-Meier plots will be used to visualize the data. 
 
9.5 
Reporting and Exclusions 
 
9.5.1 Evaluation of Toxicity 
 
All patients will be evaluable for toxicity from the time of their first dose of either study agent. 
 
9.5.2 Evaluation of Response 
 
All patients included in the study must be assessed for response to treatment, even if there are 
major protocol treatment deviations or if they are ineligible.  Each patient will be assigned one of 
the following categories:  1) complete response (CR), 2) partial response (PR), 3) stable disease, 
4) progressive disease, 5) early death from malignant disease, 6) early death from toxicity, 7) 
early death because of other cause, or 9) unknown (not assessable, insufficient data).  [Note:  By 
arbitrary convention, category 9 usually designates the “unknown” status of any type of data in a 
clinical database.] 
 
All patients who met the eligibility criteria (with the possible exception of those who received no 
study medication) should be included in the main analysis of the response rate.  Patients in 
response categories 4-9 should be considered to have a treatment failure (disease progression).  
Thus, an incorrect treatment schedule or drug administration does not result in exclusion from 
the analysis of the response rate.  Precise definitions for categories 4-9 will be protocol specific.  
 
All conclusions should be based on all eligible patients.  Sub analyses may then be performed on 
the basis of a subset of patients, excluding those for whom major protocol deviations have been 

NCI Protocol #: 10250 
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66 
identified (e.g., early death due to other reasons, early discontinuation of treatment, major 
protocol violations, etc.).  However, these sub analyses may not serve as the basis for drawing 
conclusions concerning treatment efficacy, and the reasons for excluding patients from the 
analysis should be clearly reported.  The 95% confidence intervals should also be provided.  
 
 
10. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 
following list of AEs (Section 10.1) and the characteristics of an observed AE (Sections 10.2 and 
10.3) will determine whether the event requires expedited reporting via the CTEP Adverse Event 
Reporting System (CTEP-AERS) in addition to routine reporting. 
 
10.1 
Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system. In addition to the comprehensive list, a subset, the 
Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and 
is identified with bold and italicized text. This subset of AEs (SPEER) is a list of events that are 
protocol specific exceptions to expedited reporting to NCI (except as noted below).  Refer to the 
'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for 
further clarification. Frequency is provided based on 3449 patients. Below is the CAEPR for 
Olaparib (AZD2281). 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses 
next to the AE in the SPEER.  If this CAEPR is part of a combination protocol using 
multiple investigational agents and has an AE listed on different SPEERs, use the lower 
of the grades to determine if expedited reporting is required. 
 
10.1.1 CAEPRs for Olaparib (AZD2281) (NSC747856) 
 
Version 2.5, July 1, 20211 
 
 Adverse Events with Possible  
 Relationship to Olaparib (AZD2281) 
 (CTCAE 5.0 Term) 
[n= 3449] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
Anemia 
 
 
 Anemia (Gr 4)  
 
 
Febrile neutropenia 
  
GASTROINTESTINAL DISORDERS 
  
 
Abdominal distension 
 
  
Abdominal pain 
 
 
 Abdominal pain (Gr 3) 
 
Constipation 
 
 Constipation (Gr 2) 
Diarrhea 
 
 
 Diarrhea (Gr 3) 

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67 
 
 Adverse Events with Possible  
 Relationship to Olaparib (AZD2281) 
 (CTCAE 5.0 Term) 
[n= 3449] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
 
Dyspepsia 
 
 Dyspepsia (Gr 2) 
 
                                                    
Mucositis oral 
 
  
Nausea 
 
 
 Nausea (Gr 3) 
Vomiting 
 
 
 Vomiting (Gr 3) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Edema limbs 
 
  
Fatigue 
 
 
 Fatigue (Gr 3) 
IMMUNE SYSTEM DISORDERS 
  
 
 
Allergic reaction 
  
INFECTIONS AND INFESTATIONS 
  
 
Upper respiratory infection 
 
  
 
Urinary tract infection 
 
  
INVESTIGATIONS 
  
 
Creatinine increased 
 
  
 
Neutrophil count decreased 
 
 Neutrophil count decreased 
(Gr 4) 
 
 
Platelet count decreased 
  
 
White blood cell decreased 
 
  
METABOLISM AND NUTRITION DISORDERS 
  
Anorexia 
 
 
 Anorexia (Gr 2) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
  
 
Back pain 
 
 Back pain (Gr 2) 
 
Muscle cramp 
 
  
 
Myalgia 
 
  
 
Pain in extremity 
 
  
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS)   
 
 
Leukemia secondary to 
oncology chemotherapy 
  
 
 
Myelodysplastic syndrome 
  
NERVOUS SYSTEM DISORDERS 
  
 
Dizziness 
 
 Dizziness (Gr 2) 
 
Dysgeusia 
 
 Dysgeusia (Gr 2) 
 
Headache 
 
 Headache (Gr 2) 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Cough 
 
 Cough (Gr 2) 
 
Dyspnea 
 
 Dyspnea (Gr 2) 
 
 
Pneumonitis 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
Rash maculo-papular 
 
  
 
 
Skin and subcutaneous tissue 
disorders - Other (angioedema) 
  
 
 
Skin and subcutaneous tissue 
disorders - Other (erythema 
nodosum) 
  
 
NOTE: New Primary Malignancies other than MDS/AML 

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68 
New primary malignancies have been reported in <1% of patients. There were other contributing 
factors/potential alternative explanations for the development of the new primary malignancy in all cases, 
including documented BRCA mutation, treatment with radiotherapy and extensive previous chemotherapy 
including carboplatin, taxanes, anthracyclines and other alkylating and DNA damaging agents. Most are 
not attributed to olaparib. 
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
 
 
Adverse events reported on olaparib (AZD2281) trials, but for which there is insufficient evidence 
to suggest that there was a reasonable possibility that olaparib (AZD2281) caused the adverse 
event: 
 
CARDIAC DISORDERS - Atrial fibrillation; Cardiac disorders - Other (nodal rhythm); Chest pain - cardiac; 
Sinus bradycardia; Sinus tachycardia 
EAR AND LABYRINTH DISORDERS - Tinnitus 
ENDOCRINE DISORDERS - Hypothyroidism 
GASTROINTESTINAL DISORDERS - Ascites; Colitis; Colonic obstruction; Dry mouth; Dysphagia; 
Enterocolitis; Esophageal stenosis; Flatulence; Gastroesophageal reflux disease; Gastrointestinal 
disorders - Other (gastrointestinal hemorrhage); Gastrointestinal disorders - Other (intestinal obstruction); 
Gastrointestinal disorders - Other (intestinal perforation); Ileus; Jejunal perforation; Obstruction gastric; 
Pancreatitis; Periodontal disease; Rectal hemorrhage; Small intestinal obstruction; Stomach pain 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Death NOS; Fever; Malaise; 
Non-cardiac chest pain 
IMMUNE SYSTEM DISORDERS - Immune system disorders - Other (systemic inflammatory response 
syndrome) 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Dermatitis radiation; Fracture; 
Gastrointestinal anastomotic leak; Injury, poisoning and procedural complications - Other (vena cava 
injury); Wound dehiscence 
INVESTIGATIONS - Alanine aminotransferase increased; Aspartate aminotransferase increased; Blood 
bilirubin increased; GGT increased; Hemoglobin increased; Lipase increased; Lymphocyte count 
decreased; Serum amylase increased; Weight loss 
METABOLISM AND NUTRITION DISORDERS - Dehydration; Hyperglycemia; Hypermagnesemia; 
Hypocalcemia; Hypokalemia; Hypomagnesemia; Hyponatremia 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Avascular necrosis; Bone pain; 
Generalized muscle weakness; Muscle weakness lower limb; Muscle weakness upper limb; Neck pain; 
Rotator cuff injury; Soft tissue necrosis lower limb 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Treatment 
related secondary malignancy; Tumor pain 
NERVOUS SYSTEM DISORDERS - Amnesia; Ataxia; Cognitive disturbance; Concentration impairment; 
Encephalopathy; Intracranial hemorrhage; Peripheral sensory neuropathy; Reversible posterior 
leukoencephalopathy syndrome; Stroke; Syncope; Transient ischemic attacks 
PSYCHIATRIC DISORDERS - Anxiety; Confusion; Delirium; Hallucinations; Insomnia 
RENAL AND URINARY DISORDERS - Acute kidney injury; Renal and urinary disorders - Other 
(decreased glomerular filtration rate); Renal and urinary disorders - Other (hydronephrosis); Urinary tract 
obstruction 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Vaginal hemorrhage 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Bronchopulmonary hemorrhage; 
Hypoxia; Oropharyngeal pain; Pleural effusion; Respiratory failure; Respiratory, thoracic and mediastinal 
disorders - Other (chronic obstructive pulmonary disease) 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Erythema multiforme; Pruritus 

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69 
VASCULAR DISORDERS - Arterial thromboembolism; Flushing; Hot flashes; Hypertension; Hypotension; 
Peripheral ischemia; Thromboembolic event 
 
 
 
 
Note: Olaparib (AZD2281) in combination with other agents could cause an exacerbation of any adverse 
event currently known to be caused by the other agent, or the combination may result in events never 
previously associated with either agent. 
 
 
10.1.2 Adverse Event List for TMZ 
 
Common Adverse Effects 
• Dermatologic: Alopecia (55% to 69%)  
• Gastrointestinal: Constipation (33%), Nausea and vomiting (42% to 53%)  
• Hematologic: Neutropenia (10%), Thrombocytopenia (14%) 
• Neurologic: Headache (41%), Seizure (23%)  
• Other: Fatigue 
 
For complete information on potential AEs for TMZ, please refer to the Temodar® Package 
insert. 
 
10.2 
Adverse Event Characteristics  
 
• CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
5.0 will be utilized for AE reporting.  All appropriate treatment areas should have access 
to a copy of the CTCAE version 5.0.  A copy of the CTCAE version 5.0 can be 
downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
• For expedited reporting purposes only:   
- 
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in the 
SPEER column, Section 10.1) should be reported through CTEP-AERS only if the 
grade is above the grade provided in the SPEER. 
- 
Other AEs for the protocol that require expedited reporting are outlined in Section 
10.3.4. 
 
• Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 

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70 
10.3 
Expedited Adverse Event Reporting 
 
10.3.1 CTEP-AERS 
 
Expedited AE reporting for this study must use CTEP-AERS (CTEP Adverse Event Reporting 
System), accessed via the CTEP Web site (https://eapps-ctep.nci.nih.gov/ctepaers).  The 
reporting procedures to be followed are presented in the “NCI Guidelines for Investigators: 
Adverse Event Reporting Requirements for DCTD (CTEP and CIP) and DCP INDs and IDEs” 
which can be downloaded from the CTEP Web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm).  
These requirements are briefly outlined in the tables below (Section 10.3.3). 
 
In the rare occurrence when Internet connectivity is lost, a 24-hour notification is to be made to 
CTEP by telephone at 301-897-7497.  Once Internet connectivity is restored, the 24-hour 
notification phoned in must be entered electronically into CTEP-AERS by the original submitter 
at the site. 
 
10.3.2 Distribution of Adverse Event Reports 
 
CTEP-AERS is programmed for automatic electronic distribution of reports to the following 
individuals:  Principal Investigator and Adverse Event Coordinator(s) (if applicable) of the 
Corresponding Organization or Lead Organization, the local treating physician, and the Reporter 
and Submitter.  CTEP-AERS provides a copy feature for other e-mail recipients.  
 
10.3.3 Expedited Reporting Guidelines 
 
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 
registration on all reports. 
 
Note:  A death on study requires both routine and expedited reporting, regardless of 
causality.  Attribution to treatment or other cause must be provided. 
 
Death due to progressive disease should be reported as Grade 5 “Disease progression” in the 
system organ class (SOC) “General disorders and administration site conditions.”  Evidence that 
the death was a manifestation of underlying disease (e.g., radiological changes suggesting tumor 
growth or progression: clinical deterioration associated with a disease process) should be 
submitted.  
 
Phase 1 and Early Phase 2 Studies:  Expedited Reporting Requirements for Adverse 
Events that Occur on Studies under an IND/IDE within 30 Days of the Last Administration 
of the Investigational Agent/Intervention 1, 2 
FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312) 
NOTE:  Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether or not 
they are considered related to the investigational agent(s)/intervention (21 CFR 312.64) 
An adverse event is considered serious if it results in ANY of the following outcomes:   
1) 
Death 
2) 
A life-threatening adverse event  

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71 
3) 
An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 
hours  
4) 
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions  
5) 
A congenital anomaly/birth defect.  
6) 
Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization 
may be considered serious when, based upon medical judgment, they may jeopardize the patient or 
subject and may require medical or surgical intervention to prevent one of the outcomes listed in this 
definition. (FDA, 21 CFR 312.32; ICH E2A and ICH E6). 
 
ALL SERIOUS adverse events that meet the above criteria MUST be immediately reported to the NCI via electronic 
submission within the timeframes detailed in the table below. 
Hospitalization 
Grade 1 and Grade 2 Timeframes 
Grade 3-5 
Timeframes 
Resulting in 
Hospitalization  
≥ 24 hrs 
10 Calendar Days 
24-Hour 5 Calendar 
Days 
Not resulting in 
Hospitalization  
≥ 24 hrs 
Not required 
NOTE:  Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific 
Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR. 
Expedited AE reporting timelines are defined as: 
o 
“24-Hour; 5 Calendar Days” - The AE must initially be submitted electronically within 24 hours of learning 
of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report. 
o 
“10 Calendar Days” - A complete expedited report on the AE must be submitted electronically within 10 
calendar days of learning of the AE. 
1Serious adverse events that occur more than 30 days after the last administration of investigational 
agent/intervention and have an attribution of possible, probable, or definite require reporting as follows:  
Expedited 24-hour notification followed by complete report within 5 calendar days for: 
• 
All Grade 3, 4, and Grade 5 AEs 
Expedited 10 calendar day reports for: 
• 
Grade 2 AEs resulting in hospitalization or prolongation of hospitalization 
2For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, 
rounded UP to the nearest whole day, after the agent/intervention was last administered.  Footnote “1” above 
applies after this reporting period. 
Effective Date:  May 5, 2011 
 
10.3.4 Olaparib Adverse Events of Special Interest 
 
AEs of special interest (AESI) are events of scientific and medical interest specific to the further 
understanding of olaparib’s safety profile and require close monitoring and rapid communication 
by the investigators to CTEP.  An AESI may be serious or non-serious.  The AESI for olaparib 
are the following Important Potential Risks: 
• MDS/AML 
• New primary malignancy (other than MDS/AML) 
• Pneumonitis 
• Cases of potential drug-induced liver injury (DILI) that include an elevated ALT 
or AST in combination with either an elevated bilirubin or clinical jaundice, as 
defined by Hy’s Law (see Appendix D) and based on the following observations:  
o Treatment-emergent ALT or AST >3×ULN (or >3× baseline value in 

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72 
disease states where LFTs may be elevated at baseline) in combination 
with total bilirubin >2×ULN (of which ≥35% is direct bilirubin).  
o Treatment-emergent ALT or AST >3×ULN (or >3× baseline value in 
disease states where LFTs may be elevated at baseline) in combination 
with clinical jaundice. 
 
Any event of MDS/AML, new primary malignancy, pneumonitis, or potential DILI should be 
reported in an expedited manner to CTEP via CTEP-AERS regardless of whether it is considered 
a non-serious AE (e.g., non-melanoma skin cancer) or SAE, and regardless of the investigator’s 
assessment of causality or knowledge of the treatment arm.  For cases of potential DILI, report 
all relevant laboratory abnormalities and related AEs using the appropriate CTCAE terms. 
 
Events of MDS, AML, or new primary malignancy occurring more than 30 days after the last 
study treatment must be reported via CTEP-AERS regardless of seriousness or causality.  
Investigators will be asked during the regular follow-up for OS if the patient has developed 
MDS/AML or a new primary malignancy and prompted to report any such cases. 
 
10.4 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions.  AEs reported 
expeditiously through CTEP-AERS must also be reported in routine study data 
submissions. 
 
Adverse event data collection and reporting, which are required as part of every clinical trial, are 
done to ensure the safety of patients enrolled in the studies as well as those who will enroll in 
future studies using similar agents.  AEs are reported in a routine manner at scheduled times 
during the trial using Medidata Rave.  For this trial the Adverse Event CRF is used for routine 
AE reporting in Rave. 
 
10.5 
Pregnancy 
 
Although not an adverse event in and of itself, pregnancy as well as its outcome must be 
documented via CTEP-AERS.  In addition, the Pregnancy Information Form included within 
the NCI Guidelines for Adverse Event Reporting Requirements must be completed and 
submitted to CTEP.  Any pregnancy occurring in a patient or patient’s partner from the time of 
consent to 90 days after the last dose of study drug must be reported and then followed for 
outcome.  Newborn infants should be followed until 30 days old.  Please see the “NCI 
Guidelines for Investigators: Adverse Event Reporting Requirements for DCTD (CTEP and CIP) 
and DCP INDs and IDEs” (at http://ctep.cancer.gov/protocolDevelopment/adverse_effects.htm) 
for more details on how to report pregnancy and its outcome to CTEP.  
 
10.6 
Secondary Malignancy 
 
A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., 
treatment with investigational agent/intervention, radiation or chemotherapy).  A secondary 
malignancy is not considered a metastasis of the initial neoplasm. 

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73 
 
CTEP requires all secondary malignancies that occur following treatment with an agent under an 
NCI IND/IDE be reported expeditiously via CTEP-AERS.  Three options are available to 
describe the event:  
 
• Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia 
[AML])  
• Myelodysplastic syndrome (MDS)  
• Treatment-related secondary malignancy  
 
Any malignancy possibly related to cancer treatment (including AML/MDS) should also be 
reported via the routine reporting mechanisms outlined in each protocol.  
 
10.7 
Second Malignancy 
 
A second malignancy is one unrelated to the treatment of a prior malignancy (and is NOT a 
metastasis from the initial malignancy).  Second malignancies require ONLY routine AE 
reporting unless otherwise specified. 
 
10.8 
Overdose 
 
There is currently no specific treatment in the event of overdose with olaparib and possible 
symptoms of overdose are not established.  Olaparib and Temozolomide must only be used in 
accordance with the dosing recommendations in this protocol.  Any dose or frequency of dosing 
that exceeds the dosing regimen specified in this protocol should be reported as an overdose.  
Adverse reactions associated with overdose should be treated symptomatically and should be 
managed appropriately. 
 
11. STUDY CALENDAR 
 
 
 
Pre-study1 
Cycle 12 
Cycle 22 
Cycle 3+2 
Pre-
POD 
Off  
Study3 
Wk 
1 
Wk 
2 
Wk 
3 
Wk 
4 
Wk 
5 
Wk 
6 
Wk 
7  
Wk 
8 
Wk 
9 
OlaparibA 
 
XA 
 
 
XA 
 
 
XA 
 
 
 
 
TMZB 
 
XB 
 
 
XB 
 
 
XB 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
 
Concurrent meds 
X 
X 
 
 
X 
 
 
X 
 
 
 
X 
Physical examC 
X 
X 
 
 
X 
 
 
X 
 
 
 
X 
Vital signsD 
X 
X 
 
 
X 
 
 
X 
 
 
 
X 
Height 
X 
 
 
 
 
 
 
 
 
 
 
X 
Weight 
X 
XK 
 
 
XK 
 
 
XK 
 
 
 
X 

NCI Protocol #: 10250 
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74 
 
Pre-study1 
Cycle 12 
Cycle 22 
Cycle 3+2 
Pre-
POD 
Off  
Study3 
Wk 
1 
Wk 
2 
Wk 
3 
Wk 
4 
Wk 
5 
Wk 
6 
Wk 
7  
Wk 
8 
Wk 
9 
Performance status 
X 
X 
 
 
X 
 
 
X 
 
 
 
X 
CBC w/diffE 
X 
XK 
XL 
XL 
XK 
XL 
XL 
XK 
 
XL 
 
X 
Serum chemistryE 
X 
XK 
 
 
XK 
 
 
XK 
 
 
 
X 
Coagulation factorsF 
X 
XK 
 
 
 
 
 
 
 
 
 
X 
Pregnancy testG 
X 
X 
 
 
X 
 
 
X 
 
 
 
X 
ECGH 
X 
 
 
 
 
 
 
 
 
 
 
X 
Adverse events 
X 
X----------------------------------------------------------------------------X 
 
X 
Review pill diary 
 
X 
 
 
X 
 
 
X 
 
 
 
 
Imaging evaluation of 
disease statusI 
X 
 
 
 
 
 
 
X 
 
 
 
 
 
 
X 
 
Tumor Biopsy 
XM 
 
 
 
XM 
 
 
 
 
 
XN 
 
Blood collection for 
germline testingJ 
X 
 
 
 
 
 
 
 
 
 
 
 
1:     All pre-study screening procedures must be completed within 14 days of C1D1, except: informed consent must be completed within 21 
days of C1D1, and baseline radiologic evaluations of disease status must be completed within 21 days of C1D1.  Blood testing and 
imaging obtained as part of standard of care and which falls within this timeframe and otherwise meets protocol specifications need not be 
repeated. 
2:     A new cycle may begin ± 2 days from scheduled date. 
3:     Off-study evaluations must be performed within 21 days of the last dose of study drug.  
A: 
Olaparib:  200 mg PO BID on days 1-7 of a 21-day cycle.  Dosing window of ± 2 days at the start of each cycle is allowed; however both 
agents must begin dosing on the same day. 
B: 
TMZ: 75 mg/m2 PO daily on days 1-7 of a 21-day cycle.  Dose is based on weight at screening.  Dosing window of ± 2 days at the start of 
each cycle is allowed; however both agents must begin dosing on the same day.  TMZ dose is rounded to the nearest 5 mg increment.  
C:  A complete physical exam is performed at screening and end-of-study.  A limited, symptom based, physical exam is performed at other 
timepoints. For patients who remain on study as of 2/2023 and live distantly (more than 50 miles) from the site, in-person clinical visits 
are required every other cycle. During intervening cycles, a telephone or TeleHealth visit may be conducted instead of an in-person visit. 
Height, weight and vital signs may be omitted. Laboratory tests, except pregnancy test, must still be performed, and can be performed in a 
local laboratory, prior to the start of the new cycle.  
D:  Vital signs includes measurement of temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation (pulse oximetry). 
E: 
CBC with diff must include: hemoglobin, red blood cells [RBC], platelets, mean cell volume [MCV], mean cell hemoglobin concentration 
[MCHC], mean cell hemoglobin [MCH], white blood cells [WBC], absolute differential white cell count (neutrophils, lymphocytes, 
monocytes, eosinophils and basophils). 
         Serum chemistry must include: albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, GGT, 
glucose, LDH, magnesium, phosphorus, potassium, total protein, SGOT (AST), SGPT([ALT]), sodium. 
F: 
Coagulation factors include: aPTT, INR; required pre-study and as clinically indicated.  Patients who are on anti-coagulants should have 
coagulation studies monitored at more frequent intervals for safety - at least once per week for the first two cycles. Local laboratory 
testing is acceptable. 
G: 
Serum or urine pregnancy test (for women of childbearing potential) must be completed within 14 days of the start of study treatment, on 
C1D1 of the study prior to commencing treatment, at each subsequent visit during study treatment, and at the follow up visit.  Tests will 
be performed by the treating institution/hospital’s laboratory.  If results are positive the patient is ineligible and must be discontinued from 
study treatment immediately.  Details of the pregnancy tests must be recorded in the patient’s medical records. 
H  
A 12-lead ECG is performed at screening and end-of-study.  Additional ECGs are performed as clinically indicated. 
I:  
MRI or CT imaging to evaluate disease status is performed at baseline and once every 2 cycles (6 weeks) ± 3 days. For patients who 
continue beyond 12 cycles, MRI or CT imaging may be changed to once every 4 cycles (12 weeks) ± 3 days 
J:     See section 5.4.5 for details on sample collection.  
K:  Start- of cycle safety assessments may be performed up to 3 days prior to initiating treatment for a new cycle.  Local laboratory testing is  
          acceptable. 
L:  
Between cycle safety assessments may be performed ± 3 days from scheduled date.  Local laboratory testing is acceptable. If there is     
         a change in the patient’s clinical condition after the laboratory testing is complete but before dosing begins, testing should be  
         repeated.  
M::  Pre-study biopsy is performed within 14 days of C1D1.  On study biopsy is performed on day 3-5 of Cycle 2.  If the start of C2 is delayed, 
the biopsy should be delayed accordingly to match actual drug administration of C2 D3-5. See Correlative Studies section 5 for additional 
information.   
 N:    Selected patients undergo an optional third tumor biopsy in the event of radiographic progression after initial evidence of clinical benefit.     
        See Section 5.4.2 for details.  

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75 
TMZ=temozolomide; PO=oral administration, BID=twice per day, QD=once per day; BUN=blood urea nitrogen; 
GGT=gamma galactosyltransferase; LDH=lactic dehydrogenase; SGOT(AST)=serum glutamic oxaloacetic 
transaminase (aspartate transaminase); SGPT(ALT)=serum glutamic pyruvic transaminase (alanine transaminase); 
aPTT=activated partial thromboplastin time; INR=international normalized ratio; MRI=magnetic resonance 
imaging; CT=computerized tomography; ECG=electrocardiogram;  POD=progression of disease. 
 
All time windows refer to business days (e.g. exclude weekends and holidays).   
 
11.1 
Laboratory Assessments 
 
Full hematology assessments for safety (hemoglobin, red blood cells [RBC], platelets, mean cell 
volume [MCV], mean cell hemoglobin concentration [MCHC], mean cell hemoglobin [MCH], 
white blood cells [WBC], absolute differential white cell count (neutrophils, lymphocytes, 
monocytes, eosinophils and basophils) and absolute neutrophil count or segmented neutrophil 
count and band forms should be performed at each visit and when clinically indicated.  If 
absolute differentials are not available, please provide % differentials.   
 
Serum biochemistry assessments for safety include sodium, potassium, calcium, magnesium, 
fasting glucose, creatinine, total bilirubin, gamma galactosyltransferase (GGT), alkaline 
phosphatase (ALP), aspartate transaminase (AST), alanine transaminase (ALT), urea or blood 
urea nitrogen (BUN), total protein, albumin, and lactic dehydrogenase (LDH).  These 
assessments should be performed at every clinic visit and when clinically indicated.   
 
Coagulation (activated partial thromboplastin time [aPTT] and INR) will be performed at 
baseline and if clinically indicated unless the patient is receiving warfarin.  Patients taking 
warfarin may participate in this study; however, it is recommended that prothrombin time (INR 
and aPTT) be monitored carefully at least once per week for the first two cycles. 
 
Bone marrow or blood cytogenetic samples may be collected for patients with prolonged 
hematological toxicities as defined in Section 7.4.3.  Bone marrow analysis should include an 
aspirate for cellular morphology, cytogenetic analysis and flow cytometry, and a core biopsy for 
bone marrow cellularity.  If it is not possible to conduct cytogenetic analysis or flow cytometry 
on the bone marrow aspirate, then attempts should be made to carry out the tests on a blood 
sample.  Full reports must be provided by the investigator for documentation on the Patient 
Safety database.  These data are not required to be entered into CRF. 
Pregnancy tests on blood or urine samples will be performed for women of childbearing potential 
within 14 days prior to the start of study treatment, on Day 1 of the study prior to commencing 
treatment, at each subsequent visit during study treatment, and at the follow up visit.  Tests will 
be performed by the hospital’s local laboratory.  If results are positive the patient is 
ineligible/must be discontinued from study treatment immediately.  Details of the pregnancy 
tests must be recorded in the patient’s medical records. 
These tests will be performed by the hospital’s local laboratory.  Additional analyses may be 
performed if clinically indicated. Local laboratory testing is acceptable as indicated in the study 
calendar, except for pregnancy testing, which should be performed by the treating 
institution/hospital’s local laboratory. 
 

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76 
Any clinically significant abnormal laboratory values should be repeated as clinically indicated 
and recorded on the eCRF. 
 
In case a patient shows an AST or ALT ≥3×ULN or total bilirubin ≥2×ULN, please refer to 
Appendix F, “Actions Required in Cases of Combined Increase of Aminotransferase and Total 
Bilirubin – Hy’s Law”, for further instructions.  In addition, evaluate patients for potential drug-
induced liver injury (DILI) as described in Section 10.3.4. 
 
11.2 
ECG 
 
ECGs are required within 14 days prior to starting study treatment, at the end of study treatment, 
and when clinically indicated. 
 
Twelve-lead ECGs will be obtained after the patient has been rested in a supine position for at 
least 5 minutes in each case.  The investigator or designated physician will review the paper 
copies of each of the timed 12-lead ECGs on each of the study days when they are collected. 
ECGs will be recorded at 25 mm/sec.  All ECGs should be assessed by the investigator as to 
whether they are clinically significantly abnormal / not clinically significantly abnormal.  If there 
is a clinically significant abnormal finding, the Investigator will record it as an AE on the eCRF.  
The original ECG traces must be stored in the patient medical record as source data. 
 
 
12. MEASUREMENT OF EFFECT 
 
12.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, patients should be re-evaluated for response every 6 weeks.  In 
addition to a baseline scan, confirmatory scans should also be obtained 6 weeks (not less than 4) 
weeks following initial documentation of objective response. For patients who continue beyond 
12 cycles, MRI or CT imaging may be changed to once every 4 cycles (12 weeks) ± 3 days 
 
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1) (Eisenhauer et al., 2009).  Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph 
nodes are used in the RECIST criteria. 
 
12.1.1 Definitions 
 
Evaluable for toxicity.  All patients will be evaluable for toxicity from the time of their first 
treatment with olaparib. 
 
Evaluable for objective response.  Only those patients who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will 
be considered evaluable for response.  These patients will have their response classified 

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77 
according to the definitions stated below.  (Note:  Patients who exhibit objective disease 
progression prior to the end of cycle 1 will also be considered evaluable.) 
 
Evaluable Non-Target Disease Response.  Patients who have lesions present at baseline that are 
evaluable but do not meet the definitions of measurable disease, have received at least one cycle 
of therapy, and have had their disease re-evaluated will be considered evaluable for non-target 
disease.  The response assessment is based on the presence, absence, or unequivocal progression 
of the lesions.  
 
12.1.2 Disease Parameters 
 
Measurable disease.  Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as ≥20 mm (≥2 cm) by chest x-ray or as 
≥10 mm (≥1 cm) with CT scan, MRI, or calipers by clinical exam.  All tumor measurements 
must be recorded in millimeters (or decimal fractions of centimeters). 
 
Note:  Tumor lesions that are situated in a previously irradiated area are not to be considered 
measurable.   
 
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a lymph 
node must be ≥15 mm (≥1.5 cm) in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm [0.5 cm]).  At baseline and in follow-up, 
only the short axis will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm [<1 cm] or pathological lymph nodes with ≥10 to <15 mm [≥1 to <1.5 cm] 
short axis), are considered non-measurable disease.  Bone lesions, leptomeningeal disease, 
ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
and abdominal masses (not followed by CT or MRI), are considered as non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not 
be considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, 
if they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions. 
 
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded 
and measured at baseline.  Target lesions should be selected on the basis of their size (lesions 
with the longest diameter), be representative of all involved organs, but in addition should be 
those that lend themselves to reproducible repeated measurements.  It may be the case that, on 
occasion, the largest lesion does not lend itself to reproducible measurement in which 
circumstance the next largest lesion which can be measured reproducibly should be selected.  A 
sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target 

NCI Protocol #: 10250 
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78 
lesions will be calculated and reported as the baseline sum diameters.  If lymph nodes are to be 
included in the sum, then only the short axis is added into the sum.  The baseline sum diameters 
will be used as reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 
 
Non-target lesions.  All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Measurements of these lesions are not required, but the presence, absence, 
or in rare cases unequivocal progression of each should be noted throughout follow-up.  
 
12.1.3 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment. 
 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam.  PET imaging is not typically used for the 
radiographic evaluation of soft tissue sarcoma with the possible exception of gastrointestinal 
stromal tumors.  In addition, olaparib is known to have effects on vascularity which could 
influence the results of PET and be of uncertain clinical significance.  Therefore, the use of PET 
(even with dedicated CT) imaging is not permitted for patients on this study. 
 
Clinical lesions  Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and ≥10 mm (≥1 cm) diameter as assessed using 
calipers (e.g., skin nodules).  In the case of skin lesions, documentation by color photography, 
including a ruler to estimate the size of the lesion, is recommended.  
 
Chest x-ray  Lesions on chest x-ray are acceptable as measurable lesions when they are clearly 
defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI  This guideline has defined measurability of lesions on CT scan based 
on the assumption that CT slice thickness is 5 mm (0.5 cm) or less.  If CT scans have slice 
thickness greater than 5 mm (0.5 cm), the minimum size for a measurable lesion should be twice 
the slice thickness.  MRI is also acceptable in certain situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which greatly 
impact image quality, lesion conspicuity, and measurement.  Furthermore, the availability of 
MRI is variable globally.  As with CT, if an MRI is performed, the technical specifications of the 
scanning sequences used should be optimized for the evaluation of the type and site of disease.  
Furthermore, as with CT, the modality used at follow-up should be the same as was used at 
baseline and the lesions should be measured/assessed on the same pulse sequence.  It is beyond 
the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all 

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79 
scanners, body parts, and diseases.  Ideally, the same type of scanner should be used and the 
image acquisition protocol should be followed as closely as possible to prior scans.  Body scans 
should be performed with breath-hold scanning techniques, if possible. 
 
PET-CT  The use of PET imaging is not permitted for the evaluation of disease status on this 
study.  If, prior to enrollment, a patient underwent PET with dedicated CT, the dedicated CT 
component may still be used as the baseline imaging study.  
 
Ultrasound  Ultrasound is not useful in assessment of lesion size and should not be used as a 
method of measurement.  Ultrasound examinations cannot be reproduced in their entirety for 
independent review at a later date and, because they are operator dependent, it cannot be 
guaranteed that the same technique and measurements will be taken from one assessment to the 
next.  If new lesions are identified by ultrasound in the course of the study, confirmation by CT 
or MRI is advised.  If there is concern about radiation exposure at CT, MRI may be used instead 
of CT in selected instances. 
 
Endoscopy, Laparoscopy  The utilization of these techniques for objective tumor evaluation is 
not advised.  However, such techniques may be useful to confirm complete pathological 
response when biopsies are obtained or to determine relapse in trials where recurrence following 
complete response (CR) or surgical resection is an endpoint. 
 
Tumor markers  Tumor markers alone cannot be used to assess response.  If markers are initially 
above the upper normal limit, they must normalize for a patient to be considered in complete 
clinical response.  Specific guidelines for both CA-125 response (in recurrent ovarian cancer) 
and PSA response (in recurrent prostate cancer) have been published (Rustin et al., 20004; 
Bubley et al., 1999; Scher et al., 2008).  In addition, the Gynecologic Cancer Intergroup has 
developed CA-125 progression criteria which are to be integrated with objective tumor 
assessment for use in first-line trials in ovarian cancer (Vergote et al., 2000). 
 
Cytology, Histology  These techniques can be used to differentiate between partial responses 
(PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as 
germ cell tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens 
during treatment when the measurable tumor has met criteria for response or stable disease is 
mandatory to differentiate between response or stable disease (an effusion may be a side effect of 
the treatment) and progressive disease. 
 
FDG-PET  The use of FDG PET imaging is not permitted for the evaluation of disease status on 
this study.  
 
12.1.4 Response Criteria 
 
12.1.4.1 
Evaluation of Target Lesions 
 

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80 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm (<1 cm). 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target lesions, 
taking as reference the baseline sum diameters. 
 
Progressive Disease (PD):  At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the 
smallest on study).  In addition to the relative increase of 20%, the sum must also demonstrate an 
absolute increase of at least 5 mm (0.5 cm).  (Note:  the appearance of one or more new lesions is 
also considered progressions). 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum diameters while on study. 
 
12.1.4.2 
Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and normalization of tumor 
marker level.  All lymph nodes must be non-pathological in size (<10 mm [<1 cm] short axis). 
 
Note:  If tumor markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response. 
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits. 
 
Progressive Disease (PD):  Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions.  Unequivocal progression should not normally trump 
target lesion status.  It must be representative of overall disease status change, not a single lesion 
increase. 
 
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the 
treating physician should prevail in such circumstances, and the progression status should be 
confirmed at a later time by the review panel (or Principal Investigator). 
 
12.1.4.3 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started).  The patient's best response assignment will 
depend on the achievement of both measurement and confirmation criteria. 
 
For Patients with Measurable Disease (i.e., Target Disease) 
 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response when 
Confirmation is Required* 

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81 
CR 
CR 
No 
CR 
≥4 wks. Confirmation** 
CR 
Non-CR/Non-
PD 
No 
PR 
≥4 wks. Confirmation** 
CR 
Not evaluated 
No 
PR 
PR 
Non-CR/Non-
PD/not 
evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/not 
evaluated 
No 
SD 
Documented at least once ≥4 
wks. from baseline** 
PD 
Any 
Yes or No 
PD 
no prior SD, PR or CR 
Any 
PD*** 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
 
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
**    Only for non-randomized trials with response as primary endpoint. 
***  In exceptional circumstances, unequivocal progression in non-target lesions may be 
accepted as disease progression. 
 
Note:  Patients with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
reported as “symptomatic deterioration.”  Every effort should be made to document the 
objective progression even after discontinuation of treatment. 
 
For Patients with Non-Measurable Disease (i.e., Non-Target Disease) 
 
Non-Target Lesions 
New Lesions 
Overall Response 
CR 
No 
CR 
Non-CR/non-PD 
No 
Non-CR/non-PD* 
Not all evaluated 
No 
not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 
 
‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign this 
category when no lesions can be measured is not advised 
 
 
12.1.5 Progression-Free Survival 
 
See Section 9.4.1.2. 
 
 
13. STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS 
 

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82 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 10 
(Adverse Events: List and Reporting Requirements). 
 
13.1 
Study Oversight 
 
This protocol is monitored at several levels, as described in this section.  The Protocol Principal 
Investigator is responsible for monitoring the conduct and progress of the clinical trial, including 
the ongoing review of accrual, patient-specific clinical and laboratory data, and routine and 
serious adverse events; reporting of expedited adverse events; and accumulation of reported 
adverse events from other trials testing the same drug(s).  The Protocol Principal Investigator and 
statistician have access to the data at all times through the CTMS web-based reporting portal.   
 
During the Phase 2 portion of the study, the Protocol Principal Investigator will have, at a 
minimum, quarterly conference calls with the Study Investigators and the CTEP Medical 
Officer(s) to review accrual, progress, and pharmacovigilance.   
 
All Study Investigators at participating sites who register/enroll patients on a given protocol are 
responsible for timely submission of data via Medidata Rave and timely reporting of adverse 
events for that particular study.  This includes timely review of data collected on the electronic 
CRFs submitted via Medidata Rave. 
 
All studies are also reviewed in accordance with the enrolling institution’s data safety monitoring 
plan. 
 
13.2 
Data Reporting 
 
Data collection for this study will be done exclusively through Medidata Rave.  Access to the 
trial in Rave is granted through the iMedidata application to all persons with the appropriate 
roles assigned in the Regulatory Support System (RSS).  To access Rave via iMedidata, the site 
user must have an active CTEP IAM account (check at https://ctepcore.nci.nih.gov/iam) and the 
appropriate Rave role (Rave CRA, Rave Read-Only, Rave CRA (Lab Admin), Rave SLA, or 
Rave Investigator) on either the LPO or participating organization roster at the enrolling site. To 
the hold Rave CRA role or Rave CRA (Lab Admin) role, the user must hold a minimum of an 
AP registration type.  To hold the Rave Investigator role, the individual must be registered as an 
NPIVR or IVR.  Associates can hold read-only roles in Rave.  
 
Upon initial site registration approval for the study in RSS, all persons with Rave roles assigned 
on the appropriate roster will be sent a study invitation e-mail from iMedidata.  To accept the 
invitation, site users must log into the Select Login (https://login.imedidata.com/selectlogin) 
using their CTEP-IAM user name and password, and click on the “accept” link in the upper 
right-corner of the iMedidata page.  Please note, site users will not be able to access the study in 
Rave until all required Medidata and study specific trainings are completed.  Trainings will be in 
the form of electronic learnings (eLearnings), and can be accessed by clicking on the link in the 
upper right pane of the iMedidata screen. 
 

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83 
Users that have not previously activated their iMedidata/Rave account at the time of initial site 
registration approval for the study in RSS will also receive a separate invitation from iMedidata 
to activate their account. Account activation instructions are located on the CTSU website, Rave 
tab under the Rave resource materials (Medidata Account Activation and Study Invitation 
Acceptance).  Additional information on iMedidata/Rave is available on the CTSU members’ 
website under the Rave tab or by contacting the CTSU Help Desk at 1-888-823-5923 or by e-
mail at ctsucontact@westat.com. 
 
13.2.1 Method 
 
This study will be monitored by the Clinical Trials Monitoring Service (CTMS).  Data will be 
submitted to CTMS at least once every two weeks via Medidata Rave (or other modality if 
approved by CTEP).  Information on CTMS reporting is available at:  
http://www.theradex.com/clinicalTechnologies/?National-Cancer-Institute-NCI-11.  On-site 
audits will be conducted on an 18-36 month basis as part of routine cancer center site visits. 
More frequent audits may be conducted if warranted by accrual or due to concerns regarding 
data quality or timely submission.  For CTMS monitored studies, after users have activated their 
accounts, please contact the Theradex Help Desk at 609-619-7862 or by email at 
CTMSSupport@theradex.com for additional support with Rave and completion of CRFs. 
 
 
13.2.2 Responsibility for Data Submission 
 
For ETCTN trials, it is the responsibility of the PI(s) at the site to ensure that all investigators at 
the ETCTN Sites understand the procedures for data submission for each ETCTN protocol and 
that protocol specified data are submitted accurately and in a timely manner to the CTMS via the 
electronic data capture system, Medidata Rave.   
 
Data are to be submitted via Medidata Rave to CTMS on a real-time basis, but no less than once 
every 2 weeks.  The timeliness of data submissions and timeliness in resolving data queries will 
be tracked by CTMS.  Metrics for timeliness will be followed and assessed on a quarterly basis.  
For the purpose of Institutional Performance Monitoring, data will be considered delinquent if it 
is greater than 4 weeks past due. 
 
Data from Medidata Rave and CTEP-AERS is reviewed by the CTMS on an ongoing basis as 
data is received.  Queries will be issued by CTMS directly within Rave.  The queries will appear 
on the Task Summary Tab within Rave for the CRA at the ETCTN to resolve.  Monthly web-
based reports are posted for review by the Drug Monitors in the IDB, CTEP.  Onsite audits will 
be conducted by the CTMS to ensure compliance with regulatory requirements, GCP, and NCI 
policies and procedures with the overarching goal of ensuring the integrity of data generated 
from NCI-sponsored clinical trials, as described in the ETCTN Program Guidelines, which may 
be found on the CTEP 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm)  and 
CTSU websites. 
 

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84 
An End of Study CRF is to be completed by the PI, and is to include a summary of study 
endpoints not otherwise captured in the database, such as (for phase 1 trials) the recommended 
phase 2 dose (RP2D) and a description of any dose-limiting toxicities (DLTs).  CTMS will 
utilize a core set of eCRFs that are Cancer Data Standards Registry and Repository (caDSR) 
compliant (http://cbiit.nci.nih.gov/ncip/biomedical-informatics-resources/interoperability-and-
semantics/metadata-and-models).  Customized eCRFs will be included when appropriate to meet 
unique study requirements.  The PI is encouraged to review the eCRFs, working closely with 
CTMS to ensure prospectively that all required items are appropriately captured in the eCRFs 
prior to study activation.  CTMS will prepare the eCRFs with built-in edit checks to the extent 
possible to promote data integrity. 
 
CDUS data submissions for ETCTN trials activated after March 1, 2014, will be carried out by 
the CTMS contractor, Theradex.  CDUS submissions are performed by Theradex on a monthly 
basis.  The trial’s lead institution is responsible for timely submission to CTMS via Rave, as 
above. 
 
Further information on data submission procedures can be found in the ETCTN Program 
Guidelines 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm). 
 
13.3 
CTEP Multicenter Guidelines 
 
N/A 
 
13.4 
Collaborative Agreements Language 
 
The agent(s) supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI 
under a Collaborative Agreement (CRADA, CTA, CSA) between the Pharmaceutical 
Company(ies) (hereinafter referred to as “Collaborator(s)”) and the NCI Division of Cancer 
Treatment and Diagnosis.  Therefore, the following obligations/guidelines, in addition to the 
provisions in the “Intellectual Property Option to Collaborator”  
(http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm) contained within the 
terms of award, apply to the use of the Agent(s) in this study: 
 
1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor can 
Agent(s) be transferred or licensed to any party not participating in the clinical study.  
Collaborator(s) data for Agent(s) are confidential and proprietary to Collaborator(s) and shall 
be maintained as such by the investigators.  The protocol documents for studies utilizing 
Agents contain confidential information and should not be shared or distributed without the 
permission of the NCI.  If a copy of this protocol is requested by a patient or patient’s family 
member participating on the study, the individual should sign a confidentiality agreement.  A 
suitable model agreement can be downloaded from: http://ctep.cancer.gov. 
 
2. For a clinical protocol where there is an investigational Agent used in combination with 
(an)other Agent(s), each the subject of different Collaborative Agreements, the access to and 

NCI Protocol #: 10250 
Version Date: June 27, 2022 
 
85 
use of data by each Collaborator shall be as follows (data pertaining to such combination use 
shall hereinafter be referred to as "Multi-Party Data”): 
 
a. NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NCI, the design of the 
proposed combination protocol, and the existence of any obligations that would tend to 
restrict NCI's participation in the proposed combination protocol. 
 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator 
to develop, obtain regulatory approval or commercialize its own Agent. 
 
c. Any Collaborator having the right to use the Multi-Party Data from these trials must 
agree in writing prior to the commencement of the trials that it will use the Multi-Party 
Data solely for development, regulatory approval, and commercialization of its own 
Agent. 
 
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement 
will be made available to Collaborator(s), the NCI, and the FDA, as appropriate and unless 
additional disclosure is required by law or court order as described in the IP Option to 
Collaborator (http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm).  
Additionally, all Clinical Data and Results and Raw Data will be collected, used and 
disclosed consistent with all applicable federal statutes and regulations for the protection of 
human subjects, including, if applicable, the Standards for Privacy of Individually 
Identifiable Health Information set forth in 45 C.F.R. Part 164. 
 
4. When a Collaborator wishes to initiate a data request, the request should first be sent to the 
NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them. 
 
5. Any data provided to Collaborator(s) for Phase 3 studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a 
DMC for this clinical trial. 
 
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the 
Group office for Cooperative Group studies or by the principal investigator for non-
Cooperative Group studies for immediate delivery to Collaborator(s) for advisory review and 
comment prior to submission for publication.  Collaborator(s) will have 30 days from the 
date of receipt for review.  Collaborator shall have the right to request that publication be 
delayed for up to an additional 30 days in order to ensure that Collaborator’s confidential and 
proprietary data, in addition to Collaborator(s)’s intellectual property rights, are protected.  
Copies of abstracts must be provided to CTEP for forwarding to Collaborator(s) for courtesy 
review as soon as possible and preferably at least three (3) days prior to submission, but in 
any case, prior to presentation at the meeting or publication in the proceedings.  Press 
releases and other media presentations must also be forwarded to CTEP prior to release.  
Copies of any manuscript, abstract and/or press release/ media presentation should be sent to: 

NCI Protocol #: 10250 
Version Date: June 27, 2022 
 
86 
 
Email:  ncicteppubs@mail.nih.gov 
 
The Regulatory Affairs Branch will then distribute them to Collaborator(s).  No publication, 
manuscript or other form of public disclosure shall contain any of Collaborator’s confidential/ 
proprietary information. 
 
 

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cancer genes identified frequent TP53 and ATRX mutations in leiomyosarcoma.  Am J Transl 
Res.  7(10):2072-81.  
 
Zhang, J., M.F. Stevens, T.D. Bradshaw.  (2012).  Temozolomide: mechanisms of action, repair 
and resistance.  Curr Mol Pharmacol.  5(1):102-14. 
 
 
 
 

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APPENDIX A 
PERFORMANCE STATUS CRITERIA 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 

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APPENDIX B 
PATIENT DRUG INFORMATION HANDOUT AND WALLET 
CARD 
 
Information for Patients, Their Caregivers, and Non-Study Healthcare Team on Possible 
Interactions with Other Drugs and Herbal Supplements  
 
The patient ____________________________ is enrolled on a clinical trial using the 
experimental study drug, olaparib in combination with an oral chemotherapy drug, 
temozolomide.  This clinical trial is sponsored by the National Cancer Institute.  This form is 
addressed to the patient, but includes important information for others who care for this patient.  
 
These are the things that you as a healthcare provider need to know: 
  
Olaparib interacts with certain specific enzymes in the liver and can affect the ability to process 
other medications, and other medications can affect the ability of your body to process olaparib. 
 
Olaparib interacts with a certain specific enzyme in your liver called CYP 3A4 isoenzymes.  The 
drug itself induces the CYP 3A4 isoenzymes, and olaparib is broken down by these enzymes and 
will be affected by other drugs that inhibit or induce this enzyme. 
 
To the patient: Take this paper with you to your medical appointments and keep the 
attached information card in your wallet.   
 
Olaparib may interact with other drugs which can cause side effects. For this reason, it is very 
important to tell your study doctors of any medicines you are taking before you enroll onto this 
clinical trial.  It is also very important to tell your doctors if you stop taking any regular 
medicines, or if you start taking a new medicine while you take part in this study.  When you talk 
about your current medications with your doctors, include medicine you buy without a 
prescription (over-the-counter remedy), or any herbal supplements such as St. John’s Wort. 
Grapefruit and grapefruit juice are prohibited while taking olaparib; Seville oranges and 
Seville orange juice should be avoided.  It is helpful to bring your medication bottles or an 
updated medication list with you. 
 
Many health care providers can write prescriptions.  You must tell all of your health care 
providers (doctors, physician assistants, nurse practitioners, pharmacists) you are taking part in a 
clinical trial.  
 
These are the things that you and they need to know:  
 
• Olaparib must be used very carefully with other medicines that use liver enzymes.  
Before you enroll onto the clinical trial, your study doctor will work with your regular 
health care providers to review any medicines and herbal supplements that are considered 
strong inducers/inhibitors or substrates of CYP 3A4 isoenzyme. 
• Your regular health care provider should check a frequently updated medical reference or 
call your study doctor before prescribing any new medicine or discontinuing any 
medicine.  Your study doctor’s name is  

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_____________________________________  
 
and he or she can be contacted at  
 
_____________________________________. 
 

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STUDY DRUG INFORMATION WALLET CARD   
You are enrolled on a clinical trial using the experimental study  
drug AZD2281 (Olaparib).  This clinical trial is sponsored by the NCI.  
AZD2281 (Olaparib) may interact with drugs that are processed by 
your liver, or use certain transport proteins in your body or affects 
the electrical activity of your heart.  Because of this, it is very 
important to: 
➢ Tell your doctors if you stop taking any medicines or if you start 
taking any new medicines. 
➢ Tell all of your health care providers (doctors, physician assistants, 
nurse practitioners, or pharmacists) that you are taking part in a 
clinical trial. 
➢ Check with your doctor or pharmacist whenever you need to use 
an over-the-counter medicine or herbal supplement. 
➢ AZD2281 (Olaparib) interacts with a specific liver enzyme called    
CYP3A4, and must be used very carefully with other medicines 
that interact with this enzyme. Avoid grapefruit/grapefruit juice. 
➢ Before you enroll onto the clinical trial, your study doctor will 
work with your regular health care providers to review any 
medicines and herbal supplements that are considered strong 
inducers/inhibitors or substrates of CYP3A4. 
➢ Before prescribing new medicines, your regular health care 
providers should go to a frequently-updated medical reference for 
a list of drugs to avoid, or contact your study doctor.   
➢ Your study doctor’s name is _____________________________ 
and can be contacted at _________________________________.  

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APPENDIX C 
PATIENT INFORMATION SHEET ON DIARRHEA 
MANAGEMENT 
 
Diarrhea is a common problem experienced by many patients and is a risk with olaparib.  If it is 
not controlled quickly, it can lead to dehydration. 
 
WHEN TO CALL YOUR DOCTOR TO REPORT DIARRHEA 
• Fever 100.5° or higher with diarrhea. 
• If you are experiencing diarrhea for the first time after starting therapy.  Based on questions 
answered during that phone call, we will advise starting with 2 milligrams (mg) of loperamide 
(Imodium) if it seems the symptoms are related to the treatment. 
• If you still have diarrhea 24 hours or more than 6 loose bowel movements after starting 
loperamide (Imodium) (your doctor may advise additional medications or want to 
evaluate you in person if there is a concern that you are becoming dehydrated). 
 
OVER THE COUNTER MEDICATION MANAGEMENT OF DIARRHEA 
• For diarrhea that occurs more than 2 episodes a day, use loperamide (Imodium).  We 
recommend that you have loperamide (Imodium) on hand at home before starting 
therapy. 
o 1st episode of diarrhea:  Take 2 caplets (4 mg). 
o During the day:  Take 1 caplet (2 mg) after each episode of diarrhea. 
o During the night:  Take 2 caplets (4 mg) at bedtime if you are still having diarrhea. 
o Do not take more than 8 tablets (16 mg) of loperamide in 24 hours. 
 
DRINK PLENTY OF FLUIDS 
• 
Drink 8 to 10 large glasses of liquids a day to replace those lost by diarrhea.  Drink small 
quantities at a time slowly. 
• 
AVOID caffeinated, very hot, or very cold fluids. 
Examples of acceptable fluids: 
o Water (should only be part of the 8 to 10 glasses a day) 
o Jello/gelatin 
o Gatorade  
o Clear soup or broth  
o Other non-caffeinated fluids 
 
EAT SMALL MEALS OFTEN 
• 
A good choice of foods for diarrhea is the BRAT diet: 
o B - bananas 
o R - rice 
o A - applesauce 
o T - toast 
• 
When these foods are being well tolerated, then you can add other bland low fiber foods 
such as: 
o Chicken (white meat without the skin), steamed rice, crackers, white bread, pasta 
noodles without sauce, and canned or cooked fruits without skins. 
o Foods high in potassium: bananas, apricots without skin, peach nectar, potatoes 

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without skin, broccoli, halibut, mushrooms, asparagus, non-fat milk. 
• 
Foods that can make diarrhea and cramping worse: 
o Fatty, fried, greasy, or spicy foods can cause more problems and discomfort. 
o High-fiber foods:  Bran, whole grain cereals, dried fruit, fruit skins, popcorn, nuts, 
and vegetables. 
o Foods that cause gas:  Beer, beans, cabbage, carbonated drinks. 
 
 

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APPENDIX D  
PATIENT MEDICATION DIARY - OLAPARIB 
 
PATIENT’S MEDICATION DIARY 
 
Today’s date _________________________ 
Agent _________Olaparib_________ 
Patient Name_________________________ (initials acceptable)  Patient Study ID________________________ 
 
INSTRUCTIONS TO THE PATIENT: 
1. 
Complete one form every three weeks. 
2. 
You will take ___ tablets each day, ___ in the morning and ___ in the evening.  You should take the tablets with 8 
oz. water.  Do not consume grapefruit, grapefruit juice, or Seville oranges while on olaparib therapy. 
        You can take the morning dose of olaparib together with the dose of temozolomide.  
3. 
If vomiting occurs shortly after the olaparib tablets are swallowed, you should only retake the dose if the intact 
tablets can be seen and counted.   
4. 
If you miss a scheduled dose for whatever reason (e.g., as a result of forgetting to take the tablets or vomiting), you 
can take the scheduled dose up to a maximum of 2 hours late.  If it is over 2 hours after the scheduled time, skip the 
dose.  Do not double the dose at the next scheduled time to make up for the missed dose. 
5. 
Record the date, the number of tablets you took, and when you took them.   
6. 
If you have any comments or notice any side effects, please record them in the Comments column.   
7. 
Please return the forms to your physician when you go for your next appointment. 
 
Day 
 
Date 
Time of 
morning dose 
# of tablets 
taken   
Time of evening 
dose 
# of tablets 
taken  
Comments 
1 
 
 
 
 
 
 
2 
 
 
 
 
 
 
3 
 
 
 
 
 
 
4 
 
 
 
 
 
 
5 
 
 
 
 
 
 
6 
 
 
 
 
 
 
7 
 
 
 
 
 
 
8 
Do not take olaparib days 8-21 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
Physician’s Office will complete this section: 
Date patient started protocol treatment_____________________________________________________________ 
Date patient was removed from study______________________________________________________________ 
Patient’s planned total daily dose_________________________________________________________________ 
Total number of tablets taken this month ___________________________________________________________ 
Physician/Nurse/Data Manager’s Signature _______________________________________________________ 
 
 
CTEP-assigned Protocol #   10250 
 
Local Protocol # ___________________ 

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Patient’s Signature____________________________________________________________________________ 
 
 

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APPENDIX E  
PATIENT MEDICATION DIARY – TEMOZOLOMIDE 
 
PATIENT’S MEDICATION DIARY  
 
     Today’s date _______________________________ 
Agent _________Temozolomide______ 
     Patient Name_________________________ (initials acceptable) Patient Study ID _____________________ 
 
INSTRUCTIONS TO THE PATIENT: 
1. 
Complete one form every three weeks. 
2. 
You will take ___ capsules each day.  You should take the capsules with 8 oz. water, without any food. 
3.     You should take ondansetron 8 mg immediately before temozolomide to help prevent nausea/vomiting, unless told 
not to. 
4. 
If vomiting occurs shortly after the temozolomide capsules are swallowed, you should not retake the dose.   
5. 
If you miss a scheduled dose for whatever reason (e.g., as a result of forgetting to take the capsules), you can take the 
scheduled dose up to a maximum of 12 hours late.  If it is over 12 hours after the scheduled time, skip the dose.  Do 
not double the dose at the next scheduled time to make up for the missed dose. 
6. 
Record the date, the number of capsules you took, and when you took them.   
7. 
If you have any comments or notice any side effects, please record them in the Comments column.   
8. 
Please return the forms to your physician when you go for your next appointment. 
 
Day 
 
Date 
 
Did you take 
ondansetron 8 
mg PO prior to 
your dose? 
What time was 
dose taken? 
# of capsules 
taken 
Comments 
1 
 
 
 
 
 
2 
 
 
 
 
 
3 
 
 
 
 
 
4 
 
 
 
 
 
5 
 
 
 
 
 
6 
 
 
 
 
 
7 
 
 
 
 
 
8 
Do not take temozolomide days 8-21. 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
Physician’s Office will complete this section: 
1. 
Date patient started protocol treatment_________________________________________________________ 
2. 
Date patient was removed from study__________________________________________________________ 
 
CTEP-assigned Protocol #    10250 
 
Local Protocol # ___________________ 

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3. 
Patient’s planned total daily dose_____________________________________________________________ 
4. 
Total number of pills taken this month (each size)________________________________________________ 
5.     Physician/Nurse/Data Manager’s Signature _____________________________________________________ 
    Patient’s Signature:____________________________________________________________________ 
 
 

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APPENDIX F 
ACTIONS REQUIRED IN CASES OF COMBINED INCREASE OF 
AMINOTRANSFERASE AND TOTAL BILIRUBIN – HY’S LAW 
 
Briefly, Hy’s Law cases have the following three components: 
 
The drug causes hepatocellular injury, generally shown by a higher incidence of 3-fold or 
greater elevations above the ULN of ALT or AST than the (non-hepatotoxic) control drug or 
placebo 
 
Among trial subjects showing such AT elevations, often with ATs much greater than 
3xULN, one or more also show elevation of serum TBL to >2xULN, without initial findings 
of cholestasis (elevated serum ALP) 
 
No other reason can be found to explain the combination of increased AT and TBL, such as 
viral hepatitis A, B, or C; preexisting or acute liver disease; or another drug capable of 
causing the observed injury 
 
Finding one Hy’s Law case in the clinical trial database is worrisome; finding two is considered 
highly predictive that the drug has the potential to cause severe drug induced liver injury (DILI) 
when given to a larger population. 
 
The following actions are required in cases of combined increase of aminotransferase and total 
bilirubin: 
 
1. Confirmation 
 
In general, an increase of serum AST/A:T to >3xULN should be followed by repeat testing 
within 48 to 72 hours of all four of the usual serum measures (ALT, AST, ALP, and TBL) to 
confirm the abnormalities and to determine if they are increasing or decreasing. There also 
should be inquiry made about symptoms. Serum AT may rise and fall quite rapidly, and waiting 
a week or two before obtaining confirmation of elevations may lead to a false conclusion that the 
initially observed abnormality was spurious. Of greater concern, delay in retesting may allow 
progression to severe worsening if the initial abnormality was the herald of a severe reaction to 
follow. The need for prompt repeat testing is especially great if AST/ALT is much greater than 
3xULN and/or TBL is greater than 2xULN. For outpatient trials, or trials in which subjects are 
far away from the trial site, it may be difficult for the subjects to return to the trial site promptly. 
In this case, the subjects should be retested locally, but normal laboratory ranges should be 
recorded, results should be made available to trial investigators immediately, and the data should 
be included in the case reports. If symptoms persist or repeat testing shows AST/ALT >3xULN 
for subjects with normal baseline measures or 2-fold increases above baseline values for subjects 
with elevated values before drug exposure, it is appropriate to initiate close observation to 
determine whether the abnormalities are improving or worsening. If close monitoring is not 
possible, the drug should be discontinued. 
 
 
 

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2. Close Observation 
 
It is critical to initiate close observation immediately upon detection and confirmation of early 
signals of possible DILI, and not to wait until the next scheduled visit or monitoring interval. A 
threshold of aminotransferase levels greater than 3xULN seems reasonable, as lesser elevations 
are common and nonspecific. If additional testing, beyond that specified in the trial protocol, is 
carried out, it is important that the subject’s information be added to the case report forms and 
database. 
Close observation includes: 
 
Repeating liver enzyme and serum bilirubin tests two or three times weekly. Frequency of 
retesting can decrease to once a week or less if abnormalities stabilize or the trial drug has been 
discontinued and the subject is asymptomatic. 
Obtaining a more detailed history of symptoms and prior or concurrent diseases. 
Obtaining a history of concomitant drug use (including nonprescription medications and herbal 
and dietary supplement preparations), alcohol use, recreational drug use, and special diets. 
Ruling out acute viral hepatitis types A, B, C, D, and E; autoimmune or alcoholic hepatitis; 
NASH; hypoxic/ischemic hepatopathy; and biliary tract disease. 
Obtaining a history of exposure to environmental chemical agents. 
Obtaining additional tests to evaluate liver function, as appropriate (e.g., INR, direct bilirubin). 
Considering gastroenterology or hepatology consultations. 
 
3. Decision to Stop Drug Administration 
 
It has been observed that de-challenge (stopping drug administration) does not always result in 
immediate improvement in abnormal lab values. Abnormal test values and symptoms may 
progress for several days or even weeks after discontinuation of the drug that caused the 
abnormality.  For example, rising TBL usually follows serum AT increases by a few days to 
weeks.  The primary goal of close observation is to determine as quickly as possible whether 
observed abnormal findings are transient and will resolve spontaneously or will progress.  For 
most DILI, no specific antidotes are available (except N-acetylcysteine for acute acetaminophen 
overdose if given promptly, and, possibly, intravenous carnitine for valproic acid hepatotoxicity). 
 
Promptly stopping the offending drug usually is the only potentially effective therapy. 
 
Because transient fluctuations of ALT or AST are common, and progression to severe DILI or 
acute liver failure is uncommon, automatic discontinuation of trial drug upon finding a greater 
than 3xULN elevation of ALT or AST may be unnecessary.  For most people, the liver appears 
capable of adapting to injury by foreign chemical substances, which may render a person tolerant 
to the drug despite continued exposure. Stopping a drug at the first hint of mild injury does not 
permit learning whether adaptation will occur, as it does for drugs such as tacrine, which cause 
liver injury but do not cause severe DILI.  On the other hand, continuing drug appears 
unacceptably dangerous if there is marked serum aminotransferase elevation or evidence of 
functional impairment, as indicated by rising bilirubin or INR, which represent substantial liver 
injury.  Although there is no published consensus on exactly when to stop a drug in the face of 
laboratory abnormalities and the decision will be affected by information on related drugs, the 

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accumulating clinical experience, the clinical status of the patient, and many other factors, the 
following can be considered a basic guide.  Discontinuation of treatment should be considered if: 
 
ALT or AST >8xULN 
ALT or AST >5xULN for more than 2 weeks 
ALT or AST >3xULN and (TBL >2xULN or INR >1.5) 
ALT or AST >3xULN with the appearance of fatigue, nausea, vomiting, right upper quadrant 
pain or tenderness, fever, rash, and/or eosinophilia (>5%) 
 
It should be noted that although these guidelines have not been evaluated systematically in a 
prospective fashion, they represent an approach that is similar to current practice. 
 
4. Evaluating Data for Alternative Causes 
 
An important purpose of close observation is to gather additional clinical information to seek 
other possible causes of the observed liver test abnormalities, such as one of the following 
common causes: 
 
Acute viral hepatitis. The usual onset of hepatocellular DILI is indistinguishable from acute viral 
hepatitis A or B. Hepatitis C is much less often acute in its onset and tends to be insidious, but it 
sometimes can resemble acute DILI. The presence of acute viral hepatitis A, B, and C should be 
evaluated by serological markers. Viral hepatitis D (requires concomitant hepatitis B infection) 
and E are relatively rare in the United States. Hepatitis E is more common in developing 
countries, including Southeast Asia, and should be considered in recent travelers to those 
countries and in patients in trials conducted in those countries. Also rare are hepatocellular liver 
injuries caused by Epstein-Barr virus, cytomegalovirus, herpes simplex virus, toxoplasmosis, 
varicella, and parvovirus, although these infections are seen more typically in immuno- 
suppressed individuals. Adolescent and young adult patients with possible DILI should be tested 
for Epstein-Barr virus. Hepatitis is common among transplant patients with cytomegalovirus 
disease. 
 
Alcoholic and autoimmune hepatitis. Acute alcoholic hepatitis usually is recurrent, with a history 
of binging exposure to alcohol preceding episodes, and it has some characteristic features, such 
as associated fever, leukocytosis, right upper quadrant pain and tenderness, hepatomegaly, and 
AST >ALT, that may help distinguish it from other causes of liver injury. Other features of the 
physical examination may include the presence of stigmata of cirrhosis, such as spider nevi, 
palmar erythema, estrogenic changes in males, and Dupuytren’s contractures. Alcoholic and 
autoimmune hepatitis should be assessed by history, physical examination, and laboratory 
testing, including serologic testing (e.g., antinuclear or other antibodies). 
 
Hepatobiliary disorders. Biliary tract disease, such as migration of gallstones or intrahepatic 
lesions, more often causes cholestatic injury initially and should be investigated with gall bladder 
and ductal imaging studies, especially if ALP is increased. Malignant interruption of the biliary 
tract also should be considered. 
 

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NASH. NASH may be seen in obese, hyperlipoproteinemic, and/or diabetic patients and may be 
associated with fluctuating aminotransferase levels, and hepatic and sometimes splenic 
enlargement. It is sometimes associated with cirrhosis and portal hypertension. 
 
Cardiovascular causes. Cardiovascular disease, especially right heart failure and hypotension or 
any cause of impaired oxygenation of the liver, may cause acute centrilobular hypoxic cell 
necrosis (ischemic hepatitis) with rapid and sometimes spectacular increases of serum AT (e.g., 
AT >10,000 U/L). Cardiovascular dysfunction or impaired liver oxygenation, including 
hypotension or right heart failure, should be assessed by physical examination and history. 
 
Concomitant treatments. It is critical to discover concomitant treatments, including exposure to 
nonprescription and dietary supplement products that might be responsible for injury. Many 
people take multiple drugs, perhaps less often in controlled clinical trials because of exclusion 
criteria, but subjects may not report taking disallowed drugs or other agents. The possible 
exposure to potentially toxic herbal or dietary supplement mixtures (sometimes of unknown 
composition), nonprescription medications such as acetaminophen, or to occupational chemical 
agents may not be volunteered unless subjects are specifically questioned. 
 
5. Follow-Up to Resolution 
 
All trial subjects showing possible DILI should be followed until all abnormalities return to 
normal or to the baseline state. DILI may develop or progress even after the causative drug  has 
been stopped. Results should be recorded on the case report form and in the database. Note that 
longer follow-up can sometimes reveal an off-drug repetition of what had appeared to be DILI, 
indicating that liver injury was related to underlying liver disease. 
 
6. Re-challenge 
 
Whether or not to re-challenge a subject who showed mild DILI is a difficult decision. Re- 
exposure may initiate a sometimes explosive and more severe reaction, as was observed with 
halothane several decades ago. Some cases of DILI show indicators of immunological reaction 
such as eosinophilia, rash, fever, or other symptoms or findings, and it is possible that such cases 
are more prone to recur with re-exposure. Re-challenge may not be considered negative unless 
the subject is exposed to and tolerates the same dose and treatment duration that preceded the 
original reaction. A negative re-challenge does not necessarily allow a conclusion that the drug 
did not cause the injury. Most people can adapt to xenobiotic substances, including new drugs, 
and develop tolerance for them. This has been observed even for drugs that can cause severe 
injury, such as isoniazid. The large majority of people showing hepatocellular injury while 
taking isoniazid recover fully or recover while continuing to take the drug, and some, but not all, 
can resume or continue taking the drug without further adverse consequence. If such tolerance 
has developed, the use of re-challenge to verify drug causation would give a false negative result. 
 
Generally, re-challenge of subjects with significant AT elevations (>5xULN) should not be 
attempted. If such subjects are re-challenged, they should be followed closely. Re-challenge can 
be considered if the subject has shown important benefit from the drug and other options are not 
available or if substantial accumulated data with the test drug do not show a potential for severe 

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injury. The subject should be made aware of the potential risk, and consent to the re-challenge, 
and the PI consulted. 
 

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APPENDIX G 
ACCEPTABLE BIRTH CONTROL METHODS 
 
Women of childbearing potential and their partners, who are sexually active, must agree to the 
use of two highly effective forms of contraception in combination as listed below.  This should 
be started from the signing of the informed consent and continue throughout the period of taking 
study treatment and for at least 1 month after last dose of study drugs, or they must totally/truly 
abstain from any form of sexual intercourse (see below). 
Acceptable Non-hormonal birth control methods include: 
• Total/True abstinence: When the patient refrains from any form of sexual intercourse and this 
is in line with their usual and/or preferred lifestyle; this must continue for the total duration 
of the trial and for at least 1 month after the last dose of study drug.  [Periodic abstinence 
(e.g., calendar, ovulation, symptothermal, post-ovulation methods, or declaration of 
abstinence solely for the duration of a trial) and withdrawal are not acceptable methods of 
contraception]  
• Vasectomised sexual partner PLUS male condom.  With participant assurance that partner 
received post-vasectomy confirmation of azoospermia. 
• Tubal occlusion PLUS male condom  
• IUD PLUS male condom.  Provided coils are copper-banded 
Acceptable hormonal methods: 
• Normal and low dose combined oral pills PLUS male condom  
• Cerazette (desogestrel) PLUS male condom.  Cerazette is currently the only highly 
efficacious progesterone based pill. 
• Hormonal shot or injection (eg., Depo-Provera) PLUS male condom 
• Etonogestrel implants (e.g., Implanon, Norplant) PLUS male condom  
• Norelgestromin / EE transdermal system PLUS male condom  
• Intrauterine system [IUS] device (eg., levonorgestrel releasing IUS -Mirena®) PLUS male 
condom  
• Intravaginal device (e.g., EE and etonogestrel) PLUS male condom  
 
 

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APPENDIX H 
SCHEMA OF BIOMARKER SAMPLE COLLECTION AND 
PROCESSSING