Phase 2 Study of Sildenafil for the Treatment of Lymphatic Malformations
Phase: PHASE2
Conditions: Lymphatic Malformations, Lymphatic Diseases
Sponsor: Stanford University

 
 
 
 
Phase 2 Study of Sildenafil for the Treatment of Lymphatic Malformations   
Study Protocol and Statistical Analysis Plan 
NCT02335242 
June 6, 2016 

 
 
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Sildenafil for the treatment of lymphatic malformations  
 
 
 
 
Sponsor Name & Address:  
Joyce Teng, MD, PhD 
 
 
 
 
 
Stanford University School of Medicine 
 
 
 
 
 
Department of Pediatric Dermatology 
 
 
 
 
 
700 Welch Road, Suite 301 
 
 
 
 
 
Palo Alto, CA 94304 
 
 
 
Test Medication: 
Revatio® 
 
 
 
Protocol Version  
1, Original Issue, December 8, 2011 
2, Incorporating Amendment #1, March 6, 2012 
 
 
 
3, Incorporating Amendment #2, March 13, 2013 
 
 
 
4, Incorporating Amendment #3, September 10, 2013 
 
 
 
5, Incorporating Amendment #4, November 4, 2013 
 
 
 
6, Incorporating Amendment #5, February 23, 2015 
 
7, Incorporating Amendment #6, March 15, 2016 
 
8, Incorporating Amendment #7, June 6, 2016 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 

 
 
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Table of Contents 
TITLE PAGE  
1 
TABLE OF CONTENTS 
2 
1. LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
4 
2. SYNOPSIS 
5 
3. INTRODUCTION 
8 
3.1. 
BACKGROUND 
8 
3.2. 
RATIONALE 
11 
3.3. 
OBJECTIVE 
11 
4. TEST MEDICATION 
12 
4.1. 
IDENTIFICATION 
12 
4.2. 
PACKAGING AND LABELING 
12 
4.3. 
TEST MEDICATION ACCOUNTABILITY PROCEDURES 
12 
5. SUBJECTS 
13 
5.1. 
SUBJECT POPULATION 
13 
5.2. 
INCLUSION CRITERIA 
14 
5.3. 
EXCLUSION CRITERIA 
15 
5.4. 
SCREENING LOG 
16 
6. STUDY DESIGN 
16 
6.1. 
STUDY DESIGN 
16 
6.2. 
METHODS USED TO MINIMIZE BIAS 
19 
7. STUDY PROCEDURES 
19 
7.1. 
VISITS AND EXAMINATIONS 
20 
7.1.1. Prescreening communications 
20 
7.1.2. Visit 1 – Screening Visit [usually Day -7 to -1] 
20 
7.1.3. Baseline Study [Day 0 (medication dispensed) 
21 
7.1.4. Weeks 2, 8, and 16 [ ± 1 day] 
23 
7.1.5. Weeks 4 and 12 [ ± 14 days] 
23 
7.1.6. Week 20 [ ± 21] 
25 
7.1.7. End of Study 32 weeks [± 2 Weeks] 
27 
7.1.8. Baseline Active [Day 0 (medication dispensed) 
28 
7.1.9. Weeks 2 Active, 8 Active, and 16 Active [ ± 1 day] 
28 
7.1.10. Weeks 4 Active and 12 Active [ ± 14 days t] 
28 
7.1.11. Week 20 Active [End of Treatment, ± 21 days]                                                                         29 
7.1.12. Week 32 Active [ End of Study, ± 2 Weeks] 
29 
7.1.13. Early Exit 
29 
7.1.14. Unscheduled Visits 
29 
7.1.15. Concomitant Medications 
29 
7.2. 
DISCONTINUED SUBJECTS 
29 
7.3. 
SUBJECT PREGNANCY 
30 
7.3.1. Birth Control Measures 
30 
7.4. 
STUDY METHODS AND MEASUREMENTS 
31 
7.4.1. Demographic information 
31 

 
 
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7.4.2. Vital signs 
31 
7.4.3. Lymphatic malformation assessment 
31 
7.4.4. Photography methods 
31 
7.4.5. Laboratory tests 
32 
8.  DATA MANAGEMENT PLAN 
32 
9.  DATA SAFETY MONITORING BOARD 
33 
10. STATISTICAL DESIGN 
33 
10.1. 
EVALUABILITY 
33 
10.2. 
EFFICACY 
33 
10.2.1. Primary Efficacy 
33 
10.2.2. Secondary Efficacy 
34 
10.2.3. Exploratory Efficacy 
35 
10.3. 
SAFETY 
35 
11. SAMPLE SIZE JUSTIFICATION AND STATISTICAL ANALYSIS: 
35 
12. ADVERSE EVENTS 
36 
12.1. 
GENERAL INFORMATION 
36 
12.2. 
NON-SERIOUS ADVERSE EVENTS 
36 
12.3. 
SERIOUS ADVERSE EVENTS 
36 
12.4 
REPORTING OF SERIOUS ADVERSE EVENTS 
37 
12.4.1. Reporting to FDA 
37 
12.4.2. Reporting to IRB 
37 
12.4.3. Reporting to DSMB 
38 
12.5. 
ASSESSMENT OF ADVERSE EVENT 
38 
12.6. 
UNBLINDING OF TEST MEDICATION 
39 
12.7. 
FOLLOW-UP OF SUBJECTS WITH ADVERSE EVENTS 
39 
13. INVESTIGATOR OBLIGATIONS 
39 
14. INVESTIGATOR AND MONITOR RESPONSIBILITIES 
39 
15. REFERENCES 
40 
16. STUDY PLAN 
42 
17. APPENDICES 
43 
17.1. 
LABORATORY TESTS 
43 
17.2 
INSTRUCTIONS OF ORAL SUSPENSION FOR PHARMACIST 
43 
17.2.1 Instructions for Pharmacist (2 pages) 
44 
17.2.2 Pharmacist Instructions 
45 
18. DECLARATION OF HELSINKI 
47 
 
 
 

 
 
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1. 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS: 
 
Abbreviation  
Definition 
AE 
 
 
Adverse Event(s) 
AF 
 
 
Anchoring Fibrils 
ALT 
 
 
Alanine Transaminase 
AST  
 
Aspartate Transaminase 
BSA  
 
Body Surface Area 
BUN  
 
Blood Urea Nitrogen 
CBC  
 
Complete Blood Count 
CFR  
 
Code of Federal Regulation 
cGMP  
 
Cyclic Guanosine Monophosphate 
cm² 
 
 
Centimeters squared or square centimeters (area) 
CPK  
 
Creatine Phosphokinase 
CRF  
 
Case Report Form 
CT 
 
 
Computed Tomography 
CYP3A 
 
Cytochrome P450 3A 
DSMB  
 
Data Safety Monitoring Board 
EOS  
 
End of Study 
EOT  
 
End of Treatment 
FDA  
 
Food and Drug Administration 
GCP  
 
Good Clinical Practice 
HIPAA 
 
Health Insurance Portability and Accountability Act 
Hgb 
 
 
Hemoglobin 
IB 
 
 
Investigator’s Brochure 
ICH 
 
 
International Conference on Harmonization 
IEC 
 
 
Independent Ethics Committee 
IND 
 
 
Investigational New Drug 
IRB 
 
 
Institutional Review Board 
IUD 
 
 
Intrauterine Device 
LDH  
 
Lactate Dehydrogenase 
LM 
 
 
Lymphatic Malformation 
N/A 
 
 
Not Applicable 
MCV  
 
Mean Corpuscular Volume 
MCH  
 
Mean Corpuscular Hgb 
MCHC 
 
Mean Corpuscular Hgb Concentration 
MRI 
 
 
Magnetic Resonance Image 
RBC  
 
Red Blood Cells 
RDW  
 
RBC distribution width 
SAE  
 
Serious Adverse Event(s) 
SMP  
 
Safety Monitoring Plan 
SOP  
 
Standard Operating Procedures 
UP 
 
 
Unanticipated Problems 
UPT  
 
Urine Pregnancy Test 
WBC  
 
White Blood Cells 

 
 
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2. 
SYNOPSIS 
 
Study Phase:  
 
2 
 
Financial Disclosure Information for U.S. FDA Submission to be Obtained? 
Yes 
 
 
Test Medication: 
 
Sildenafil 20 mg tablets, 2.5mg/ml suspension (Revatio®)  
Control Medication:  
Placebo tablets or suspension resembling Revatio® 
 
Study Dosage  / Usage:  
Oral dosage of sildenafil. For pediatric patients 8 kg to 20 kg 
the suspension/tablets dose will be 10 mg/4ml three times a 
day (30 mg per day) and for patients > 20 kg the dose is 20 
mg/8ml three times a day (60 mg a day). Subjects less than 
8 kg will not be enrolled in the trial. 
 
Route of Administration: The medication will be given orally.  The subjects who will 
receive the 10 mg dose will be given an oral suspension  
(using dose calculation by the study pharmacist) or half a 
tablet. Subjects will have the option of taking tablets or 
receiving an oral suspension of the medication in 2.5mg per 
mL. 
 
Objective(s): 
The objectives of this study are to assess the safety and 
effectiveness of sildenafil taken orally to improve or resolve 
lymphatic malformations. 
 
Study Population: 
           Sixty Subjects (60) 
 
Subjects will be between the ages of 6 months to 10 years of 
age inclusive with lymphatic malformations (LM) that have a 
minimum diameter of 3 centimeters based upon MRI 
evaluation. Based on the patient numbers in pediatric 
dermatology clinics over the country, we expect that we will 
be able to screen 60 patients who will meet the inclusion 
criteria, and 55 patients will be enrolled in the study and 
begin medication. After 15 subjects are completed, an 
interim analysis will be performed to project effect size and 
estimate the total number of subjects required for the study. 
If after analysis of 15, 30 or 45 subjects we find that we are 
in the range of futility or efficacy, then we will notify the FDA 
as well as the DSMB, and begin to end the study by adding 
no additional subjects. 
 
Structure: 
Double-blind trial of placebo compared to sildenafil with an 
open label extension for subjects who received placebo.  
Two to one ratio of two sildenafil treated subjects who 

 
 
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receive active sildenafil to one placebo treated subject.  
During the twenty week evaluation visit, after completion of 
all evaluations, the randomization code will be broken and 
both the subject and investigator will know the results.  The 
subjects who have randomized to placebo will have the 
option to begin a twenty week course of sildenafil.  If the 
subjects who were on placebo elect to take active drug, the 
initiation visit can be completed at that time.  The subject will 
then be followed with clinic visits at weeks 4, 12, 20 and 32 
as indicated in the protocol.  We will call the subjects at 
weeks 2, 8 and 16 to inquire about any questions that the 
subjects may have or any concerns.  We will also request 
information on medication taken and their progress.   
 
The subject’s LMs will be categorized by the Pediatric 
Radiologist by the percent of the LM that is microcystic.  
Upon completion of the initial 15 subjects, the data will be 
evaluated in an interim analysis in order to determine if the 
percent of macrocystic component of the lesions suggests 
which subjects may have the best benefit.  The initial 15 
subjects will also be evaluated related to previous 
procedures, infections and other complications related to 
their lymphatic malformations.  If specific characteristics of 
the LM are identified that suggests beneficial effect of the 
sildenafil, the protocol will be changed to enroll those 
subjects who are projected to have the best benefit.  A new 
power analysis will be done to project the minimum numbers 
of subjects that should be enrolled further in the study.   
 
Duration of Treatment:  
20 weeks.  Placebo subjects will complete 20 weeks of 
placebo and then have an option for 20 weeks of active 
sildenafil.   
 
Duration of Assessment: 
The subjects will be evaluated for 20 weeks on therapy then 
followed for 12 weeks off therapy.   
 
Open Label Extension: 
Placebo subjects will have an option to enter an open label 
treatment after they have completed 20 weeks of placebo. 
 
 
 
 
 
Duration of treatment: Placebo 20 weeks 
 
Washout Between Periods: none 
 
Duration of Treatment: 20 weeks on active drug  
 
After the completion of 20 weeks of sildenafil and 12 weeks 
of follow up, the subjects will have the option to be followed 
through an IRB approved long-term follow up trial not 

 
 
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covered in this IND application.  That IRB trial would allow 
up to five years follow up on subjects and would only allow 
investigators to observe how the subject is doing long term, 
whichever treatment options the subject pursues in 
consultation with their regular doctor in that time. That 
planned follow up protocol will allow Stanford to contact the 
subjects several times a year in order obtain information 
about any therapy they may elect to follow, including 
sildenafil if their regular doctor prescribes it, and their 
response to any therapy.   
 
Multi-Center:  
 
Yes 
 
 
Number of Centers:  
Up to 4 
 
 
Blinding: 
 
 
Observer-Blind 
Yes 
 
 
 
 
Subject-Blind  
Yes 
 
 
 
 
 
Double-Blind  
Yes 
 
 
 
 
 
 
Randomization: 
Group Assignment Ratio: 2:1 randomization of two subjects 
who receive sildenafil to one subject who receives placebo.  
 
Concurrent Control: 
No other treatments for lymphatic malformation will be 
allowed except antibiotics and/or surgical drainage if the 
lesions become infected. Treatment for recurrent infections 
in the lymphatic malformation will be allowed and 
documented during the trial.  Concurrent medications will be 
documented.  Subjects who require sclerosing agents or 
excisional surgery of their lymphatic malformation will be 
withdrawn from the trial. 
 
Variable(s): 
PRIMARY: Change in lesion volume over twenty weeks of the test 
medication as evaluated by MRI examination.  Comparison 
of placebo to sildenafil treated subjects.   
 
 
SECONDARY: Change in lesion volume estimated using a soft tape 
measure to measure the length, width, and hemispheric 
measurement of each of the lymphatic malformations. (Berk, 
Berk et al. 2011) Completion of the form Lymphatic 
Malformation Measurements. 
 
 
Subject’s evaluation of the change in lesion clinical 
characteristics from baseline to 20 weeks by examining   
decreased discomfort, texture or thickness, distortion of 
normal anatomy or overall change obtained in the subject’s 

 
 
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completion of Subject’s Assessment of Lymphatic 
Malformation Change form. 
 
Physician’s evaluation of the lesion clinical characteristics on 
the day of the visit.  This includes color, tenseness and 
texture, superficial component, deep component, and 
distortion of anatomical landmarks.  This requires completion 
of the Lymphatic Malformation Assessment form for each LM 
site.   
 
Physician’s evaluation of the change in lesion clinical 
characteristics from baseline, such as change in texture or 
thickness, change in distortion of normal anatomy, and over 
change in lesions.  This requires completion of the 
Lymphatic Malformation Assessment of Change form for 
each LM site.   
 
Comparison of LM volume from MRI assessment to Body 
Surface Area (BSA) measurements before and after 20 
weeks of sildenafil. 
 
Blinded physician observer scored evaluation of clinical 
photographs taken prior to the initial dose of sildenafil or 
placebo and at the 20 week visit prior to the unblinding.   
Subjects who receive placebo and then enter the 20 week 
open label continuation will have additional photographs 
taken after 20 weeks of sildenafil.   
 
Presence, frequency or absence of infection during trial. 
 
Relationship of response to sildenafil to previous infections, 
sclerotherapy or surgery.   
 
 
SAFETY: Adverse events and frequency of lesion infections. 
 
Adverse Events: 
 
Both volunteered and elicited. 
 
3. 
INTRODUCTION 
3.1. 
BACKGROUND  
 
Lymphatic malformations (LMs) are uncommon, congenital vascular anomalies that 
arise due to developmental dysplasia of the lymphatic network in utero.(Blei 2008)  LMs 
are equally rare independent of sex or race.(Redondo, Aguado et al. 2011)  About 65% 
of LMs are detected at delivery, 80% by 1 year of age, and 90% by 2 years of age 

 
 
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emphasizing their childhood expression.(Redondo, Aguado et al. 2011)  The deeper 
ones may not be initially noticed but will become recognized as they increase in size or 
become infected.  Although histologically benign, they are often locally invasive and 
affect the skin and soft tissues, as well as nerve, muscle or bone in some cases.  Cystic 
hygromas are a specific type of congenital malformations of the lymphatic system that 
are commonly on the posterior neck.  (Gallagher, Mahoney et al. 1999)  They occur in 
about one in 1,775 live births (Howarth, Draper et al. 2005) to one in 2667 live births 
(Fisher, Partington et al. 1996) making them truly an orphan disease.  The incidence 
may be higher as they can be associated with other fetal abnormalities resulting in 
spontaneous or induced abortions.(Fisher, Partington et al. 1996)  In one series of 17 
live born infants with cystic hygroma, 15 survived the first year of life yielding a survival 
rate of 88%.(Fisher, Partington et al. 1996)  Lymphatic malformations often have 
considerable morbidity, associated with infection, bleeding and airway or vision 
obstruction as well as significant psychosocial concerns.  (Greene, Perlyn et al. 2011)  
When present on the extremities, they often bleed with physical activity, may inhibit 
movement and ambulation, and are at times painful.  
 
Clinical research in LMs has been largely neglected primarily due to the common 
misperception that only surgical and procedural interventions may help alleviate this 
disease. Unfortunately, despite the multiplicity of procedural therapies that exist, none 
are uniformly effective, all have the risk of significant adverse events, and no standard 
of care has been established.(Churchill, Otal et al. 2011; Greene, Perlyn et al. 2011) 
Sclerotherapy, surgical excision and laser ablation all require general anesthesia in the 
pediatric population, and even when initially effective, the LM may recur. In addition, 
many LMs are not resectable or able to be treated due to their infiltrative nature. 
Nonetheless, these lesions need to be treated due to risk of infection secondary to 
lymph stasis, acute enlargement as a reaction to infection or inflammation, 
disfigurement and pain. Unfortunately, active non-intervention is often the current 
recommendation for many patients with LMs due to the limitations of surgical and 
destructive modalities and lack of a disease-modifying medical therapy. Thus, many 
patients are forced to live with lesions which may inhibit movement and ambulation, can 
bleed and become infected, and are almost always of aesthetic and psychosocial 
concern.   
 
A recent patient observation within our institution brought the possibility of using 
sildenafil to treat LMs to our attention. A female infant was born with a venous and 
lymphatic malformation affecting the entire right arm and upper chest with pleural, 
paravertebral, and para-aortic involvement. Examination findings included massive 
enlargement of the affected arm and chest wall. MRI study at 2 months of age 
confirmed that the affected areas were infiltrated with small, abnormal lymphatic 
spaces. Due to the nature and extent of the malformation, treatment with sclerotherapy, 
laser or surgery was not an option, and the patient was simply observed. She was 
diagnosed with pulmonary hypertension at 9 months of age after repeated admissions 
for respiratory distress, heart failure and failure to thrive. Sildenafil was started for the 
pulmonary hypertension, and the patient’s mother noticed a decompression of the LM 
over the first 17 weeks of sildenafil. At 21 months of age, repeat MRI verified minimal 

 
 
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residual LM and continued severe pulmonary hypertension. Unfortunately, the patient 
was not able to be extubated after the study and she passed away due to cardiac and 
respiratory failure.  The family refused an autopsy.   
 
Sildenafil is well tolerated in both the adult and pediatric populations. It works by 
inhibiting phosphodiesterase isoform 5 (PDE5) and thus inhibits the breakdown of 
guanosine 3’,5’-cyclic monophosphate (cGMP). PDE5 is found in high concentrations in 
vascular smooth muscle, as well as in the corpus cavernosum, platelets, and retina.  
(Shekerdemian, Ravn et al. 2002; Wang, Wu et al. 2003)  It has also gained a second 
FDA approval for the treatment of patients with pulmonary arterial hypertension. (Pfizer 
2007)  Mortality associated with pulmonary hypertension is extremely high.  Thus, 
despite the fact that sildenafil does not have an indication for the pediatric population in 
the United States of America, it has been used for pulmonary hypertension in the 
pediatric population with a very good results, an exceedingly benign side effect profile, 
and an excellent safety record. (Abrams, Schulze-Neick et al. 2000; Karatza, Bush et al. 
2005; Barst, Ivy et al. 2012) 
 
The possible mechanism for the success of sildenafil treatment in lymphatic 
malformations seems congruent with our current knowledge of LM pathogenesis and 
sildenafil's mechanisms of action. Although the pathogenesis of lymphatic 
malformations is not completely elucidated, it has been postulated that primitive 
lymphatic sacs separate from the normal network of developing lymph vessels during 
embryogenesis. A thickened coat of muscle fibers line these cisterns, and rhythmic 
contractions of the muscles increase intramural pressures leading to dilation.(Whimster 
1976)  On histopathology a muscular lymphatic channel is often present. Potential 
explanations for the therapeutic effects of sildenafil include simple smooth muscle 
relaxation, which may open the primary overactive muscular fiber leading to decreased 
intramural pressures and decompression of the malformation. Alternatively, simple 
smooth muscle relaxation could lead to secondary lymphatic channels opening, allowing 
decompression of the malformation. Both of these explanations intuitively seem very 
plausible. There are also many other possible explanations why sildenafil may work in 
lymphatic malformations including sildenafil’s secondary effect on nitric oxide via its 
inhibition of cGMP as endothelial nitric oxide synthetase.   
 
We initially started an IRB approved clinical trial giving the subjects 12 weeks of 
sildenafil therapy.  We have currently enrolled 4 subjects in this trial.  One subject 
enrolled, but because of study visit conflicts elected to not receive sildenafil.  One 
subject had a suggestion of improvement at 8 weeks of treatment, but that subject had 
surgery on one of the lesions 8 weeks into the study and although the clinical lesion 
appeared improved the surgery decreased our ability to evaluate the results at the 
completion of the 12 week study.  One subject completed the study with no other 
interventions.  That subject had 25% to 50% improvement by the 12 week visit.  The 
sildenafil was stopped as planned at 12 weeks and follow up at 16 weeks (4 weeks off 
sildenafil) documented expansion of the lesion.  The parents of the first two children 
enrolled in the study requested continuation of the sildenafil and a prescription was 
given and follow up off the study was planned.  Those children are now in an IRB 

 
 
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approved long term follow up study. The initial IRB approved protocol was changed to 
20 weeks of sildenafil.  The final subject completed the enrolment and has completed 
12 weeks of sildenafil with 25% to 50% improvement.   
 
One of the problems that we have recognized in this study is the inaccuracy of physical 
examination as the method to evaluate the response to therapy.  The lesions seem to 
demonstrate improvement by first becoming soft when they were firm before.  The skin 
develops a sagging redundant feel to palpation but the measurements of the volume of 
the lesions are slow to change because of the elasticity of the skin and slow retraction 
of redundant skin.  In the proposed study, we will use MRI examinations to measure the 
volume change in the lesion over time as well as comparing subjects treated with 
sildenafil to subjects who initially receive placebo. 
 
3.2. 
RATIONALE 
Recently propranolol, a commonly used medication for hypertension, has been shown 
to have impressive efficacy in the treatment of infantile hemangiomas. (Leaute-Labreze, 
Dumas de la Roque et al. 2008)  The new indication for this “old” drug was discovered 
when two children with infantile hemangiomas and heart problems (one with cardiac 
myopathy, the other with increased cardiac output) were placed on propranolol. 
Unexpectedly, their hemangiomas involuted quickly and dramatically after the initiation 
of the medication. To verify the effect of propranolol on hemangiomas, 9 other infants 
with infantile hemangiomas but no heart disease were then treated with propranolol, 
and all had rapid resolution of their infantile hemangiomas. (Leaute-Labreze, Dumas de 
la Roque et al. 2008)  In addition, propranolol was well-tolerated and has a better side 
effect profile than oral corticosteroids, the traditional treatment for problematic 
hemangiomas. Additional studies have verified that hemangiomas respond quickly to 
propranolol, and the medication has been used successfully to treat not just infantile 
hemangiomas affecting the skin but of the airway and liver, as well as those 
complicated by ulceration.(Frieden and Drolet 2009; Sans, de la Roque et al. 2009; de 
Graaf, Breur et al. 2011; Fuchsmann, Quintal et al. 2011) After our own striking and 
serendipitous observation, we are hopeful to verify the effect of sildenafil on LMs. If 
successful, sildenafil has the potential to have just as large an impact in the treatment of 
LMs as propranolol has with hemangiomas. There is no effective nonsurgical treatment 
for this orphan disease.    
 
3.3. 
OBJECTIVE 
The objective in this study is to assess the safety and efficacy of sildenafil in reducing 
the volume and symptoms of lymphatic malformations when administered to subjects 
who have lymphatic malformations greater than 3 cm in diameter. 
 

 
 
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4. 
TEST MEDICATION  
4.1. 
IDENTIFICATION 
Test medication: 
Sildenafil (Revatio®) 20 mg tablets or suspension 
Control Medication: Placebo or suspension resembling Revatio® 
 
4.2. 
PACKAGING AND LABELING 
The test medications will consist of Sildenafil 20 mg tablets (Revatio®) and Placebo 
tablets that resemble Revatio®.  These medications will be shipped in bulk containers to 
the Lucile Packard Children’s Hospital (LPCH) Pharmacy where they will be stored.  
 
Each bottle will be labeled in accordance with Good Manufacturing Practice and will 
include the following information:  
• Study Acronym Name 
• Unique alpha-numeric identifier (Lot number) 
• Storage requirement 
• Investigational use and appropriate caution statements 
• Sponsor identification 
• Unique subject ID 
 
The LPCH Pharmacy will dispense the Revatio® or Placebo in bottles labeled with the 
subjects identification information based upon the randomized code.  The LPCH 
Pharmacist will compound an extemporaneously prepared oral suspension from 
Revatio® 20mg tablets or placebo tablets, depending on subject’s preference. 
Pharmacy staff will know if the subject is receiving Placebo or Revatio®.  Depending on 
subjects weight, the study pharmacist will formulate study drug into an oral suspension 
for 2.5mg per ml dosing volume.  
 
Subjects. who weigh 8kg – 20kg will receive a 4-week supply 10mg/4ml TID, and the 
treatment will be compounded into a 480ml dosing volume, and then transferred to four 
bottles of 120 ml each.   
 
Subjects weighing more than 20kg will receive a 4-week supply 20mg/8ml TID.  The 
subject and the research physician will be blinded to Placebo or Revatio® until 
completion of the 20 week study visit.  The code will also be broken in the situation of a 
Serious Adverse Event. 
4.3. 
TEST MEDICATION ACCOUNTABILITY PROCEDURES 
When a delivery of test medication is received at the investigational site, the 
Pharmacist, or a member of their staff specifically authorized and delegated by the 
Investigator, will check for accurate delivery and acknowledge receipt by signing (or 
initialing) and dating the required documentation and returning it as instructed. The 

 
 
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date, time, and condition of the package should also be documented at the time of 
receipt. A copy of this documentation will be retained for the Investigator file. 
 
The LPCH Pharmacist will compound Revatio® 20 mg film-coated tablets or placebo. 
The pharmacy instructions for compounding are listed in section 17.1.  
 
The packing list will indicate the expiry date for the material. Receipt and dispensing of 
the study treatment will be carefully recorded on appropriate accountability forms and 
made available for verification at each monitoring visit.  
 
Used medication containers will be retained until checked by study monitor, after which 
they will be discarded at the site. Unused medication will be accounted for at the end of 
the trial and appropriately discarded at the site. 
 
For study visits conducted at non-Stanford sites, medication will be prepared in the 
LPCH Pharmacy and shipped directly to the subject from Stanford for each visit.  
 
A study monitor will perform an accounting of all test medication supplies, used or 
unused, at the study centers. 
5. 
SUBJECTS 
5.1. 
SUBJECT POPULATION 
Subjects should be between the ages of six months and ten (10) years of age with the 
clinical diagnosis of lymphatic malformation that appears to be greater than 3 cm in 
diameter.  Subjects will have a minimal weight of 8 kg to enter the trial.  The diagnosis 
will be confirmed by an MRI examination performed within six (6) months of screening 
visit.  The MRI will confirm that the lesion at least 3 cm in diameter and the lesion is 
either: 
i. 
At least 50% of the lesion contains non-enhancing regions separated by septae,  
 
or 
ii. 
No vessels in the lesion, or only a few small vessels that traverse the lesion but 
are not intrinsically a portion of the lesion, and no flow voids or only a few small 
flow voids that traverse the lesion but are not intrinsically a portion of the lesion. 
iii. 
The volume of the total lesion will be calculated as well as the proportion of the 
lesion that is macrocystic will be calculated.   
 
The enrollment goal will be forty subjects who have completed the twenty weeks of 
therapy followed by an MRI.  We expect to enroll up to sixty (60) subjects.   
 
The upper age limit is ten years old because as patients age they may have recurrent 
infections and scarring which may decrease our ability to evaluate the response of the 
lymphatic malformation to sildenafil.  We will document previous therapies or 
interventions for the lymphatic malformation and previous infections in the lymphatic 
malformation.   
 

 
 
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5.2. 
INCLUSION CRITERIA 
Subjects will be considered qualified for enrollment if they meet the following criteria: 
 
1. 
Legally authorized representative of subjects willing and able to give consent.  
Assent will be obtained for subjects between the ages of 7 and 10 years old. 
 
2. 
Subjects will need to be 6 months of age to 10 years of age at the time of entry 
into the study.   
 
3.  
The minimum weight of a subject will need to be 8 kg at the time of enrollment.   
 
4. 
Subjects will be required to have the clinical diagnosis of lymphatic malformation 
that appears to be over 3 cm in greatest diameter in order to be evaluated for entry.  A 
review of a previous MRI examination may help confirm the entry criteria on subjects 
selected to come to Stanford for the MRI screening.  The MRI must be performed within 
six (6) months of the screening visit if used as a baseline measure. 
 
5. 
The lymphatic malformation should be causing enough disability for the subject 
requiring them to consider systemic therapy. 
 
6. 
Females must not be pregnant or breast-feeding.  
 
7.  
Female subjects of childbearing potential have negative urine-pregnancy test 
results. 
 
8. 
A parent or legally authorized representative must be willing and able to ensure 
subject is present for all required study visits. 
 
9. 
A parent or legally authorized representative must be able to follow instructions. 
 
10. 
During the initial screening evaluation portion of the trial the subjects MRI 
examination will be required to confirm that the lymphatic malformation is present and is 
greater than 3 cm in diameter in order for the subjects to receive medication.  MRI of 
less than six months is valid to use during screening with the discretion of the study 
radiologist. 
 
11.  
Subjects will have no contraindications for the use of sildenafil. 
 
12. 
Subjects will have a normal eye examination. 
 
13. 
Subjects will have normal liver and kidney function. 
 
14. 
Subjects will have no contraindication to MRI examinations such as metal 
implants, etc. 
 
15.  
Subject must not be a smoker. 

 
 
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5.3. 
EXCLUSION CRITERIA 
A participant will be ineligible if he/she meets any of the following criteria: 
 
1. 
The participant has a medically unstable health status that may interfere with 
his/her ability to complete the study. 
 
2.  
The participant presents with one or more of the following medical conditions: 
Hepatic impairment, severe renal impairment, lymphedema conditions such as Milroy 
disease, Meige lymphedema, Hennekam syndrome, Njolstad syndrome, Aagenaes 
syndrome, and Fabry disease, hypotension or at risk for hypotension, seizures or 
history of seizures, any significant cardiovascular risk factors and any condition which 
requires participants to use nitric oxide donors or nitrates in any form, underlying 
anatomic or vascular risk factor for developing non-arteritic anterior ischemic optic 
neuropathy (NAION) including low ocular cup to disc ratio, diabetes, hypertension, 
coronary artery disease, or hyperlipidemia  Participants with Down syndrome, Turner 
syndrome and Noonan syndrome will be considered on a case-by-case basis. 
 
3.  
The participant has received at least one of the following medications 
contraindicated in association with sildenafil within 15 days of inclusion: 
 
o Organic nitrates in any form, either regularly or intermittently -- Consistent with its 
known effects on the nitric oxide/cGMP pathway, sildenafil was shown to 
potentiate the hypotensive effects of nitrates. 
o Ritonavir and other Potent CYP3A Inhibitors  ---  Concomitant use of REVATIO 
with ritonavir and other potent CYP3A inhibitors is not recommended. 
o Alpha-blockers  ---  co-administering alpha-blockers with REVATIO because of 
additive blood pressure-lowering effects 
o Amlodipine 
o Cimetidine 
 
4.  
The participant requires concomitant use of potent cytochrome P450 3A4 
inhibitors (such as ketoconazole, itraconazole, erythromycin, saquinavir), or 
concomitant use of ritonavir.  Also excluded are concomitant use of organic nitrates, 
alpha-blockers, amlodipine, or cimetidine. 
 
5. 
The screening MRI cannot confirm that the lesion is a lymphatic malformation or 
the lymphatic malformation is less than 3 cm in its greatest diameter. 
 
6.  
The patient has had extensive prior surgery or sclerotherapy to treat LM such 
that scarring may interfere with evaluation and treatment effect of sildenafil. 
 
7. 
Patients who have had recurrent infection and significant scarring of the lesion 
secondary to infection to such an extent that the that scarring may interfere with 
evaluation and treatment effect of sildenafil 
 

 
 
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8. 
 Participant is currently pregnant or considering becoming pregnant in the next 
20 weeks. 
 
9.  
The participant is known to have an allergy to sildenafil. 
 
10.  
Ulcerated or currently infected LMs. 
 
11.  
Diagnosis of the soft tissue tumor as LM is not clinically certain. 
 
12.  
The participant is participating in another clinical study which may interfere. 
 
13.  
The participant has a history of priapism or is diagnosed with sickle cell anemia 
or any other disorder which may predispose to priapism. 
 
14. 
The Investigator may declare any subject ineligible for a valid medical reason. 
 
15. 
Sirolimus should not be taken or applied within the last six months. 
 
5.4. 
SCREENING LOG 
All screened subjects initially considered for inclusion in this study will be documented. 
Each study site will maintain a Pre-Screening Log of identified potential subjects for the 
trial.  Stanford will contact each potential subject for pre-screening procedures, detailed 
in section 7.1.1 on Page 18.  If a subject is excluded from the study, the reasons for 
exclusion will be documented in the subject's source documents and noted on the 
Screening Log at Stanford and in the Pre-Screening logs at each site. 
6. 
STUDY DESIGN 
6.1. 
STUDY DESIGN 
 
Figure 6.1-1: Study Design Schematic. Decision points are indicated in bold text.  
Treatment periods are indicated.  Double lined boxes indicate visits that will occur at the 
subject’s closest site, whether at Stanford or at a Cooperating Research Site (Denver, 
Chicago, Kansas City). 

 
 
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This will be a double blind placebo controlled trial with a ratio of 2 sildenafil subjects to 1 
placebo subject in the Initial Treatment Period. Sildenafil or placebo will be given for 20 
weeks.   
 
60 research subjects will be enrolled. 
 
There will be visits at Screening, Initial dose visit (includes a 2 hour observation period 
after initial dose), 4 weeks, 12 weeks, 20 weeks and 32 weeks visits.  MRI examination 
will be part of the screening visit and will be repeated prior to the completion of 
medication at the 20 week visit.  For subjects identified at Stanford, all visits will be 
conducted at Stanford University Medical Center.  For subjects identified at other sites, 
all Screening, Initial Dose Visit, and Week 20 visits will be conducted at Stanford, 
including both MRIs.  All other visits (weeks 4, 12, 32) will be conducted at the subject’s 
local site.  These subjects will be given the option to have the blood work for Screening 
done at their local site or at Stanford.  They will also be given the option to have the eye 
exams and hearing exams at Screening and Week 20 done at their local site or at 
Stanford.  Having these tests done locally at screening may make it easier to re-test if 
there is a change in vision or hearing while on sildenafil. 
 
At the completion of 20 weeks of medication or placebo the subject will be evaluated by 
MRI, and will undergo an eye exam and a hearing exam.  After the MRI, eye exam, and 

 
 
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hearing exam are completed, the subject will be evaluated by the investigator, and the 
subject will complete the self evaluation of response.  The Investigator will complete the 
physician evaluation forms.  After these evaluations are completed, the blind will be 
broken and the investigator and subject will know if the subject received placebo or 
sildenafil.  The subject will also be informed of the of the MRI results of the screening 
MRI and the 20 week MRI once that report is available.  Subjects who received placebo 
for the first 20 weeks will then have the option of starting 20 weeks on active drug.  
 
A second method to evaluate the volume of the MRI will be done in a blinded manner by 
a pediatric radiologist, assisted by a pediatric radiology fellow.  We will use 
segmentation to identify the surface area demonstrating LM involvement of multiple 
planes though the lesion.  By calculating the surface area of multiple planes and 
knowing the distance between planes, the volume of the LM can be calculated.  This is 
called segmentation analysis.  The research radiologist and fellow will evaluate multiple 
MRIs in groups at the same time, unaware of the date or the subject, therefore blinded 
to treatment, placebo, or pretreatment.  This evaluation will blinded in order to eliminate 
the bias of knowing who the subject is in the study.  Although this is a research 
procedure, the results will be reported in the subjects Radiology Report in the Medical 
Record as an addendum.  It will be signed by the research radiologist.  This evaluation 
will be available several weeks after the subject completes the 20 weeks of sildenafil 
and/or placebo.  The MRI will be read and the data recorded by the research radiologist 
without knowledge of the date the MRI was done.  Once the data is collected and 
recorded, the research radiologist will learn name of the subject and the date of the MRI 
in order to attach the correct volume calculation to the correct MRI when placing the 
volume data in the Medical Record.     
 
The volume data on the subject’s LM(s) relative to the subject’s BSA will then also be 
evaluated for any changes.  Since all subjects will be children under 10 years old, using 
the BSA measurement may help to adjust our volume assessment to accommodate the 
amount that a subject has grown over the course of the course of treatment. 
 
The process of screening will include an eye examination, hearing test, renal and liver 
function tests, and a MRI of the lesion.  If the screening tests meet the inclusion and 
exclusion criteria the subject will be then be randomized to receive either placebo or 
sildenafil and entered into the trial.  A hearing test can be difficult to accomplish if the 
child does not cooperate.  If the hearing test is not successful at screening, we will 
repeat the test at subsequent visits until we obtain a hearing test result that is 
satisfactory to the pediatric audiologist.  If the subject is referred from one of the 
cooperating research study sites, then we will give the subject the option to have the 
eye and hearing tests done at their closest cooperating research study site or at 
Stanford.  In addition, we will attempt to obtain the hearing test at the cooperating 
research study site if the test is not successful during the screening at Stanford.   
 
Initial dose of medication will be given in the dermatology clinic at Stanford before the 
two hour observation period.  The subjects will then have follow-up visits at 4 weeks 
after beginning medication, 12 weeks after beginning medication and 20 weeks after 

 
 
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beginning medication.  Subjects local to Stanford will be seen at Stanford for all visits.  
Subjects local to other cooperating study sites will be seen at Stanford for Screening, 
Initial Dose Visit, and Week 20, and at their local cooperating research study site for 
Week 4, Week 12, and Week 32.  These subjects will also be given the option to have 
their Week 20 eye and hearing exams done at the cooperating research study site or at 
Stanford. Laboratory tests will be conducted at Stanford for baseline and follow-up. The 
Stanford site will contact the subject by phone at 2 weeks, 8 weeks and 16 weeks.  
Subjects who received placebo during the first 20 weeks of evaluation will have the 
option at the twenty-week visit of commencing use of the active drug for the next twenty 
weeks.  If the subject who initially received placebo decides that they do not want to 
receive sildenafil for 20 weeks they will then complete the data collected at the 32 week 
visit in addition to the 20 week visit.  The subject will not need to return for the 32 week 
visit.  If the subject who initially received placebo selects to start the medication they will 
then be seen at the 4 week, 12 week and 20 week visit after commencing medication.  
Subjects local to other cooperating research study sites will attend the Week 4, Week 
12, and Week 32 visits at their local site and Week 20 at Stanford.  The medication will 
be stopped after the 20 week visit and the subject will be seen at Week 32, having been 
off medication for 12 weeks.  The subject will have an additional MRI done at Stanford 
at the completion of the twenty weeks of active medication.  Subjects on placebo who 
elect to receive the active drug will have three MRI examinations.  Subjects on active 
medication will be requested to stop the medication in order to be followed over the next 
twelve weeks with no medication (week 32).   
 
With the subject’s permission, we will send a report to the subject’s primary and 
specialty care physicians with the data that was obtained on the subject during the 
study, including the MRI LM research blinded segmentation results.  Subjects will be 
returned to their primary care physician or specialty care physicians for follow-up at 
completion of the study.  The subject can work with their local physician to decide to 
continue or not continue the sildenafil into the future independent of this research 
protocol and IND.  As part of a separate IRB approved follow up protocol independent of 
this IND and after informed consent, we will request the subject to allow us to contact 
them several times a year for the next five years to ask how their lymphatic 
malformation lesion has progressed or changed and what additional therapies they 
have received. 
 
6.2. 
METHODS USED TO MINIMIZE BIAS 
All subjects will have the option to receive 20 weeks of sildenafil in this open label 
extension study design. Subject assignment to sildenafil or placebo in the initial 
treatment period will be random. 
 
7. 
STUDY PROCEDURES 
For a summary of the required procedures by visit, refer to Table 17-1: Study 
Procedures by Treatment Day. 
 

 
 
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7.1. 
VISITS AND EXAMINATIONS 
7.1.1. Prescreening communications 
Authorization will be obtained by the Stanford Institutional Review Board (IRB) to screen 
subjects on the phone after they contact us.  Subjects from the cooperating research 
sites will be referred to contact the Stanford study staff where they will be prescreened 
by Stanford study staff and all prescreening records kept at Stanford.  The subjects will 
also obtain our contact information from ClinicalTrials.gov or through a local physician 
or community resource that is aware of our study.  Potential subjects who contact the 
coordinator will undergo a telephone screening, using a script approved by the Stanford 
IRB, to verify that they meet the initial inclusion criteria for this trial.  Potential subjects 
who meet the initial criteria will be mailed information about the study, including consent 
forms for their review.  We will also send and ask them to sign and send back to us a 
release to obtain and examine their medical records in order to have more details about 
their current condition.   
 
Once the prescreening communication documents that the patient is appropriate for the 
trial, the patient will be scheduled for a screening visit at the Stanford Dermatology 
Clinics.  All screening visits may be conducted at Stanford, even for patients identified at 
non-Stanford cooperating research study sites.  Patients identified at non-Stanford 
cooperating research study sites will be given the option to have the laboratory tests, 
ophthalmology evaluation and hearing test locally before coming to Stanford for the 
other screening tests.  If they opt to do these locally, they will sign a consent form at the 
cooperating research study site prior to these exams.  The visit at Stanford will be set 
up so that the subject can receive the screening evaluation, MRI, ophthalmology 
evaluation (if not done at the cooperating site), hearing test (if not done at the 
cooperating site), and laboratory tests (if not done at the cooperating site) during a two 
to three day visit to the Stanford site. 
 
7.1.2. Visit 1 – Screening Visit [usually Day -7 to -1] at Stanford 
NOTE: Any subject for whom an informed consent/assent has been obtained, but fails 
to meet the required entry criteria is considered to be a screen failure. All demographic 
information must be captured with the reason for screen failure specified. 
 
1. Explain the purpose and nature of the study, and have the subject’s parent or legally 
authorized representative, read, sign, and date the IRB-approved informed consent 
document. Even subjects who may have signed a consent form at the cooperating 
research study site prior to laboratory, eye and hearing exams will sign the Stanford 
consent form at this visit.  The subject’s assent to participate in the study will be 
obtained if the subject is between 7 and 10 years of age.  The informed consent 
document must be signed and dated by the individual who consents the subject. A 
photocopy of the signed informed consent document will be provided to the parent or 
legally authorized representative.  A copy of the informed consent will also be placed 
in the subject’s medical record.  The original copy will be maintained in the research 
files. 
 

 
 
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----- Do not proceed until consent has been obtained ----- 
 
2. Screen the subject against protocol inclusion and exclusion criteria (Sections 5.2, 
5.3). Subjects not meeting the criteria are screen failures and must exit the study at 
this point. 
 
3. Obtain demographic information and medical history, including information on all 
medications currently being taken at the time of signing the informed consent.  
Instruct the subject and/or caregiver of the excluded medications and give them a 
list.  Document previous treatments for the lymphatic malformation and previous 
infections in the lymphatic malformation.   
 
4. Review the subject’s previously obtained MRI, X-rays or CT scans and other 
laboratory test results with the subject. 
 
5. Perform a physical examination including heart and pulmonary auscultation, liver 
and spleen palpation, abdominal auscultation and palpation, and documentation of 
peripheral pulses.  Examine the characteristics of their lymphatic malformation to 
see that it meets the criteria for the trial. 
 
6. Obtain Vital Signs including height, weight, temperature, heart rate, blood pressure, 
respiratory rate, and oxygen saturation. 
 
7.  If the patient meets all the screening criteria then they will then be sent for an eye 
examination (if not done at the cooperating site), hearing test (if not done at the 
cooperating site), laboratory test evaluating a complete blood count (CBC) in 
addition to testing their liver and kidney function (if not done at the cooperating site) 
(see section 17.1), and an MRI.  We will also obtain a pregnancy test on females 
who have achieved menarche.   
 
 
7.1.3. Baseline Study [Day 0 (medication dispensed)] at Stanford 
This will usually be the day after the screening. 
 
1. Review inclusion and exclusion criteria with the subject, including the results of their 
laboratory data, eye examination, and MRI.  If subject no longer meets criteria for 
participation, exit the subject from the study as a screen failure. 
 
2. Obtain demographic information and medical history, including information on all 
medications currently being taken.  Document concomitant medications.  Instruct the 
subject and/or caregiver of the excluded medications and give them a list if they do 
not have their list that was previously given to them. 
 
3. Perform a physical examination including heart and pulmonary auscultation, liver 
and spleen palpation, abdominal auscultation and palpation, and documentation of 

 
 
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peripheral pulses.  Examine and describe the characteristics of their lymphatic 
malformation to see that it meets the criteria for the trial. 
 
4. Obtain Vital Signs including height, weight, temperature, heart rate, blood pressure, 
respiratory rate, and oxygen saturation. 
 
5. Clinical assessment of each lymphatic malformation including measuring the 
hemicircumference of the lesion by using a soft measuring tape placed on the skin 
over the area of the widest diameter of the lesion.  The length, and width, will then 
be calculated as described in Figure 2 of Berk et al.(Berk, Berk et al. 2011)  In order 
to document the site of the measurements a diagram will be drawn by hand or 
photographs will be taken of the methods.  Each clinic visit will try to duplicate the 
measurements methods used in the initial visit.   
 
6. Physician’s evaluation of the lesion clinical characteristics on the day of the visit.  
This includes color, tenseness and texture, superficial component, deep component, 
and distortion of anatomical landmarks.  This requires completion of the Lymphatic 
Malformation Assessment form for each LM site.   
 
7. Site investigator will acquire digital photographs of each lymphatic malformation as 
described in Section 7.4.4, and summarized as follows: 
o Subject will be seated on a chair.  If subject is an infant, then subject’s parent 
or guardian will be seated on a chair with subject sitting on his/her knees or in 
his/her arms. 
o All photographs will include a color chart in the field of view, held in the same 
plane as the target lymphatic malformation. 
o Distance and angle of each photograph relative to subject will be documented 
at baseline and repeated for all subsequent photographs. 
o Photograph 1: front-on view of each lymphatic malformation. 
o Photograph 2: side-on view of each lymphatic malformation (to visualize 
thickness). 
 
8. Review possible adverse events included in informed consent. 
 
9. Medication journals will be given and instructions reviewed. 
 
10. Study medication dose for 1 month will be calculated and obtained from the 
pharmacy. Subjects will receive an oral suspension of the study medication (see 
Section 18.2 for pharmacy instructions).  
 
11. The first dose of the medication will be consumed in the clinic. The subject will 
remain within the clinic area and temperature, heart rate, blood pressure, respiratory 
rate, and oxygen saturation will be repeated every 30 minutes for the initial 2 hours 
after the initial dose. 
 

 
 
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12. Instruction sheet will be given to the subjects documenting contact information for 
the research physicians and the foods and medications to be avoided while on 
sildenafil. 
 
13. If there are no safety issues identified during the 2 hours of observation, the 
participant or parent/guardian is dispensed enough study treatment until the next 
visit at Week 4 and the participant may leave the site. The subject and/or caregiver 
will again be instructed of the excluded medications and the list will again be 
reviewed.  The subject will be advised to stop medication and notify the study team 
immediately if they notice a change in vision or hearing or if they feel dehydrated. 
 
14. If a subject approves, we will send a copy of the dictated record for the study visit to 
their local primary care doctor and/or pediatric dermatologist and other specialty 
physicians that the subject requests.  If the subject is to be followed at one of the 
local cooperating research sites, a copy to the record will be sent to the center.  The 
MRI results, ophthalmology report, hearing test report and laboratory data will also 
be sent to the subject’s local cooperating research site.  We would like to be sure 
that the physicians in their home community are aware of the study and the subject’s 
participation in the study.   
 
7.1.4. Weeks 2, 8, and 16 [ ± 1 day] 
Study staff at Stanford will call the subject on the phone and query subject and/or 
caregiver regarding any changes in general health and the use of concomitant 
medications.  We will review previous and current concomitant medications.  We will 
instruct the subject and/or caregiver of the excluded medications and answer any 
question that the subject may have. 
 
7.1.5. Weeks 4 and 12 [ ± 14 days before or after scheduled visit] at subject’s 
cooperating research site or at Stanford if the subject is local to Stanford.   
 
1. If the subject is being seen at a cooperating research site the subject will need to 
review the purpose and nature of the study with the local investigator at the 
cooperating site.  If not already done before local laboratory tests, eye and hearing 
exams prior to the screening visit at Stanford, the subject’s parent or legally 
authorized representative must read, sign, and date the IRB-approved informed 
consent document for the local cooperating research site. The subject’s assent to 
participate in the study will be obtained if the subject is between 7 and 10 years of 
age.  The informed consent document must be signed and dated by the individual 
who consents the subject. A photocopy of the signed informed consent document 
will be provided to the parent or legally authorized representative.  A copy of the 
informed consent will also be placed in the subject’s medical record.  A copy will be 
sent the Stanford.  The original copy will be maintained in the research files.  This 
consent will document the cooperation of the Stanford site and the local cooperating 
research site. 
 

 
 
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2. Query subject and/or caregiver regarding any changes in general health and the use 
of concomitant medications.  Obtain demographic information and review interim 
medical history, including information on all medications currently being taken.  
Review previous concomitant medications and current concomitant medications.  
Instruct the subject and/or caregiver of the excluded medications and give them a list 
if they do not have their list with them. 
 
3. If any adverse events are observed or reported, they must be recorded as instructed 
in Section 13, Adverse Events. 
 
4. Review criteria for treatment discontinuation. If treatment must be permanently 
discontinued, proceed to Section 7.1.12 for Early Exit. 
 
5. Perform a physical examination including heart and pulmonary auscultation, liver 
and spleen palpation, abdominal auscultation and palpation, and documentation of 
peripheral pulses.  Examine and describe the characteristics of their lymphatic 
malformation. 
 
6. Obtain Vital Signs including height, weight, temperature, heart rate, blood pressure, 
respiratory rate, and oxygen saturation. 
 
7. Clinical assessment of each lymphatic malformation including measuring the 
hemicircumference of the lesion by using a soft measuring tape placed on the skin 
over the area of the widest diameter of the lesion.  The length, and width, will then 
be calculated as describe in Figure 2 of Berk et al (2011). In order to document the 
site of the measurements a diagram will be drawn by hand or photographs will be 
taken of the methods.  Each clinic visit will try to duplicate the measurements 
methods used in the initial visit.   
 
8. Completion of subject’s evaluation of the change in lesion clinical characteristics 
from baseline, such as decreased discomfort, texture or thickness, distortion of 
normal anatomy or overall change obtained in the subject’s completion of Subject’s 
Assessment of Lymphatic Malformation Change form. 
  
9. Completion of the physician’s evaluation of the lesion clinical characteristics on the 
day of the visit.  This includes color, tenseness and texture, superficial component, 
deep component, and distortion of anatomical landmarks.  This requires completion 
of the Lymphatic Malformation Assessment form for each LM site.   
 
10. Physician’s evaluation of the change in lesion clinical characteristics from baseline, 
such as change in texture or thickness, change in distortion of normal anatomy, and 
over change in lesions.  This requires completion of the Lymphatic Malformation 
Assessment of Change form for each LM site.   
 
11. Count study drug and perform compliance assessment; medication journal reviewed. 
 

 
 
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12. Study medication dose will be calculated based upon the weight of the subject 
during the visit. The Stanford site will be notified of the weight and dose.  The 
Stanford physician will notify the pharmacy of the subject number and proposed 
dose.  The Stanford pharmacy will dispense adequate study medication (sildenafil or 
placebo) to last until the next visit.  The medication will be shipped directly to the 
subject’s home. 
 
13. Review possible adverse events included in informed consent. 
 
14. New medication journals reviewed and instructions reviewed. 
 
15. Arrange a MRI examination to be done before the 20 week visit at Stanford. 
 
16. Instruction sheet will be given to the subjects documenting contact information for 
the research physicians and excluded medications and foods while on sildenafil if 
they do not have the instruction sheet previously given to them.   
 
17. If a subject approves, the Stanford site or the local cooperating research site will 
send a copy of the dictated record for the study visit to their local primary care doctor 
and/or pediatric dermatologist and other specialty physicians that the subject 
requests.  If the subject is to be followed at one of the local cooperating research 
sites, a copy to the record will be sent to the Stanford site.  We would like to be sure 
that the physicians in the subject’s home community are aware of the study and the 
subject’s participation in the study.   
 
7.1.6. Week 20 [ ± 21 days before or after scheduled visit] at Stanford 
End of Treatment for subjects treated with sildenafil.  Possible commencement of 
treatment for those subjects on placebo. 
 
1. Query subject and/or caregiver regarding any changes in general health and the use 
of concomitant medications.  Obtain demographic information and review interim 
medical history, including information on all medications currently being taken.  
Review previous concomitant medications and current concomitant medications.  
Instruct the subject and/or caregiver of the excluded medications and give them a list 
if they do not have their list with them. 
 
2. If any adverse events are observed or reported, they must be recorded as instructed 
in Section 13, Adverse Events. 
 
3. Ophthalmology evaluation, hearing exam, and blood draw performed.  Subjects from 
cooperating research study sites will have the option to do these tests at their local 
site or at Stanford. 
 
4. Perform a physical examination including heart and pulmonary auscultation, liver 
and spleen palpation, abdominal auscultation and palpation, and documentation of 

 
 
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peripheral pulses.  Examine and describe the characteristics of their lymphatic 
malformation. 
 
5. Obtain Vital Signs including height, weight, temperature, heart rate, blood pressure, 
respiratory rate, oxygen saturation. 
 
6. Clinical assessment of each lymphatic malformation including measuring the 
hemicircumference of the lesion by using a soft measuring tape placed on the skin 
over the area of the widest diameter of the lesion.  The length, and width, will then 
be calculated as describe in Figure 2 of Berk et al (2011).  In order to document the 
site of the measurements a diagram will be drawn by hand or photographs will be 
taken of the methods.  Each clinic visit will try to duplicate the measurements 
methods used in the initial visit.   
 
7. Photographs of the Lymphatic malformation will be taken using standardized 
procedures described in Baseline Visit.  
 
8.  Completion of subject’s evaluation of the change in lesion clinical characteristics 
from baseline, such as decreased discomfort, texture or thickness, distortion of 
normal anatomy or overall change obtained in the subject’s completion of Subject’s 
Assessment of Lymphatic Malformation Change form. 
  
9. Completion of the physician’s evaluation of the lesion clinical characteristics on the 
day of the visit.  This includes color, tenseness and texture, superficial component, 
deep component, and distortion of anatomical landmarks.  This requires completion 
of the Lymphatic Malformation Assessment form for each LM site.   
 
10. Physician’s evaluation of the change in lesion clinical characteristics from baseline, 
such as change in texture or thickness, change in distortion of normal anatomy, and 
over change in lesions.  This requires completion of the Lymphatic Malformation 
Assessment of Change form for each LM site.   
 
11. Collect study drug and perform compliance assessment; medication journal 
reviewed. 
 
12. Obtain a pregnancy test if the subject is has achieved menarche. 
 
13. The participant or parent/guardian and the investigator will complete the qualitative 
assessment of efficacy.  The subject’s evaluation of the response to the treatment 
will be reviewed. The results report of the MRI done at the twenty week visit will be 
shared with the subject and compared with the initial MRI reported results.  After that 
discussion the subject will be told if they were on sildenafil or placebo.  Subjects who 
received placebo will be given the option to start the sildenafil.  Subjects who 
received active medication will be requested to stop the sildenafil for the next twelve 
weeks and follow up at the 32 week visit to examine the response of the lesion off of 
the sildenafil. 

 
 
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14. If subject received placebo and decides to receive sildenafil at this time, the study 
medication dose will be calculated and obtained from the pharmacy for adequate 
study medication to last until the next visit in 4 weeks.  The 2 hour monitoring will be 
completed after the first dose as described in Baseline visit.  For more detail, see 
Section 7.1.7.  If the subject was on placebo and elects not to start sildenafil they will 
not need to return for the 32 week evaluation.   
 
15. If the subject received placebo and decides to not receive sildenafil they will end the 
study at this time and complete additional information needed for the End of study 
32 week visit described in 7.1.7. below.   
 
16. If a subject approves, we will send a copy of the dictated record for the study visit to 
their local primary care doctor and /or pediatric dermatologist so that the physicians 
in their home community are aware of the study and the subject’s participation in the 
study.   
 
7.1.7. End of Study 32 weeks [± 2 Weeks] at subject’s cooperating research site or at 
Stanford if the subject is local to Stanford for subjects who are on active sildenafil for 
the initial twenty weeks of the trial 
 
1. Query subject and/or caregiver regarding any changes in general health and the use 
of concomitant medications.  Obtain demographic information and review interim 
medical history, including information on all medications currently being taken.  
Review previous concomitant medications and current concomitant medications.  
Instruct the subject and/or caregiver of the excluded medications and give them a list 
if they do not have their list with them. 
 
2. If any adverse events are observed or reported, they must be recorded as instructed 
in Section 13, Adverse Events. 
 
3. Perform a physical examination including heart and pulmonary auscultation, liver 
and spleen palpation, abdominal auscultation and palpation, and documentation of 
peripheral pulses.  Examine and describe the characteristics of their lymphatic 
malformation. 
 
4. Obtain Vital Signs including height, weight, temperature, heart rate, blood pressure, 
respiratory rate, and oxygen saturation. 
 
5. Clinical assessment of each lymphatic malformation including measuring the 
hemicircumference of the lesion by using a soft measuring tape placed on the skin 
over the area of the widest diameter of the lesion.  The length, and width, will then 
be calculated as describe in Figure 2 of Berk et al (2011). In order to document the 
site of the measurements a diagram will be drawn by hand or photographs will be 
taken of the methods.  Each clinic visit will try to duplicate the measurements 
methods used in the initial visit.   

 
 
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6. Completion of subject’s evaluation of the change in lesion clinical characteristics 
from baseline, such as decreased discomfort, texture or thickness, distortion of 
normal anatomy or overall change obtained in the subject’s completion of Subject’s 
Assessment of Lymphatic Malformation Change form. 
  
7. Completion of the physician’s evaluation of the lesion clinical characteristics on the 
day of the visit.  This includes color, tenseness and texture, superficial component, 
deep component, and distortion of anatomical landmarks.  This requires completion 
of the Lymphatic Malformation Assessment form for each LM site.   
 
8. Physician’s evaluation of the change in lesion clinical characteristics from baseline, 
such as change in texture or thickness, change in distortion of normal anatomy, and 
over change in lesions.  This requires completion of the Lymphatic Malformation 
Assessment of Change form for each LM site.   
 
9. If a subject approves, we will send a copy of the dictated record for the study visit to 
their local primary care doctor and/or pediatric dermatologist and other specialty 
physicians that the subject requests.  If the subject is to be followed at one of the 
local site cooperating research site, a copy to the record will be sent to Stanford.  
We would like to be sure that the physicians in their home community are aware of 
the study and the subject’s participation in the study.  By this visit the results of the 
segmentation analysis should be in the subjects Medical Record as an Addendum.  
Besides sharing this information with the subject, the information will be available for 
the subject’s physicians.   
 
10  After this visit the Stanford site will request the subject’s parent or guardian’s 
consent for a separate Stanford IRB-approved long term follow up protocol.  If the 
subject is between 7 and 10 years old, we will request their assent.  We will contact 
the subject on the phone if they are not at the Stanford site for the 32 week visit.   
 
7.1.8. Baseline Active [Day 0 (medication dispensed)] at Stanford for subjects who 
are on placebo for the initial twenty weeks of the trial 
For those subjects who were on placebo and request that they begin sildenafil, the first 
dose of the medication will be dispensed in the clinic, as described in the original 
baseline visit, Section 7.1.3.  This visit will follow the same procedures described in 
Section 7.1.3. 
7.1.9. Weeks 2 Active, 8 Active, and 16 Active [ ± 1 day] 
These phone calls will follow the same procedures described in Section 7.1.4. 
 
7.1.10. Weeks 4 Active and 12 Active [ ± 14 days before or after scheduled visit] at 
subject’s cooperating research site for subjects who are on placebo for the initial 
twenty weeks of the trial 
These visits will follow the same procedures described in Section 7.1.5. 

 
 
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7.1.11. Week 20 Active [End of Treatment, ± 21 days before or after scheduled visit] 
at Stanford for subjects who are on placebo for the initial twenty weeks of the trial 
This visit will follow the same procedures described in Section 7.1.6, except that there is 
no unblinding and no option to start a treatment period of active sildenafil. 
 
7.1.12. Week 32 Active [ End of Study, ± 2 Weeks] at subject’s cooperating research 
site for subjects who are on placebo for the initial twenty weeks of the trial 
This visit will follow the same procedures described in Section 7.1.7. 
 
7.1.13. Early Exit at subject’s cooperating research site or at Stanford 
In addition to the procedures required at the EOT visit: 
1. The subject will be exited from the study. 
2. Study medication will be collected.  The subject may elect to not return to Stanford 
or the cooperating research site for this visit.  In this case, we will have them mail the 
unused medication back to Stanford.  We will give them pre-addressed shipping 
forms.  If the subject does not return for this visit, we may also arrange to get the 
pregnancy test at a local hospital or local office.   
7.1.14. Unscheduled Visits at subject’s local site or at Stanford 
Unscheduled exams may be conducted at the discretion of the Investigator with all 
obtained information recorded in the source documents. Subjects will be requested to 
have their local physician also send us any information on visits they may have with 
their local physician related to the lymphatic malformation or lymphatic malformation 
treatment. 
7.1.15. Concomitant Medications 
A concomitant medication is any drug or substance administered from the signing of the 
informed consent for the study through the last study visit Items 3 and 4 in Section 5.3 
(Exclusion Criteria) list those medications that are not permitted during the study period. 
Investigational drugs or devices: The use of concomitant therapies must be documented 
in the subject's source documents.  
 
7.2. 
DISCONTINUED SUBJECTS 
Discontinued subjects are those who voluntarily discontinue participation, who are 
withdrawn for safety reasons or use of prohibited concomitant treatments, or who have 
missed a sufficient number of study visits, procedures or test medication doses as to be 
ineligible for further participation.  
 
All subjects who discontinue the study prior to completing the regularly scheduled visits 
must complete the EOT and Exit Visit procedures described in Section 7.1.11. Any 
changes in medical health and/or the use of concomitant treatments must be captured. 
If any adverse events were observed since the previous visit, they must be recorded 

 
 
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(refer to Section 13, Adverse Events). Finally, if appropriate, the Investigator also should 
advise the subject’s parent or legally authorized representative of subsequent therapy 
and/or procedures necessary for their medical condition. 
 
In the case of subjects who persistently fail to return for scheduled visits, three attempts 
must be made to contact the subject’s parent or legally authorized representative for the 
purpose of scheduling an Exit/EOS Visit. The third attempt should be via registered 
mail, return receipt requested.  
 
7.3. 
SUBJECT PREGNANCY 
Females of child-bearing potential (defined as post-menarche as documented in the 
medical history) are not excluded from the study, though we do not expect to enroll 
sexually active females since the upper age limit is 10 years old. However, if a subject 
becomes pregnant during the study, the investigators should be contacted immediately 
and the medication should be stopped. Pregnancy is not reportable as an adverse 
event; however, complications related to the pregnancy may be reportable as 
determined on a case-by-case basis. Pregnancy-related information will be collected 
until termination of the pregnancy.  The subject who becomes pregnant will be removed 
from the trial. 
 
7.3.1. Birth Control Measures 
Females of childbearing potential (those who are post-menarche as documented in the 
medical history) may participate in the study if they meet all of the following conditions: 
• they are not breast feeding; 
• they have a negative urine or serum pregnancy test at screening; 
• they agree to undertake a urine pregnancy test at the completion of week 20 of 
treatment or placebo 
• they agree to undertake a urine pregnancy test upon exiting the study if they 
elect to withdraw prior to the week 20 pregnancy test; 
• they do not intend to become pregnant during the study; 
• they are using adequate birth control methods and they agree to continue using 
those methods for the duration of the twenty (20) weeks of treatment or placebo. 
 
Adequate birth control methods are defined as: hormonal—topical, oral, implantable or 
injectable contraceptives; mechanical—spermicide in conjunction with a barrier such as 
a condom or diaphragm; IUD; or, surgical sterilization of partner. For non-sexually active 
females, abstinence may be regarded as an adequate method of birth control; however, 
if the subject becomes sexually active during the study, she must agree to use an 
adequate birth control method as described above for the remainder of the study.  Since 
the oldest age at entry for this trial is 10 years of age we expect all females who have 
completed menarche to not be sexually active but we will still discuss this topic during 
the visits in a sensitive way with the parent or guardian so that the child will not be 
embarrassed during the visit.  We will discuss this topic with the child in accordance 
with the wishes of the parent or guardian.   
 

 
 
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7.4. 
STUDY METHODS AND MEASUREMENTS 
7.4.1. Demographic information 
General demographic data include age, sex, race, and ethnicity. Location of the 
lymphatic malformation, age at diagnosis, confirmatory diagnostic tests (previous MRIs, 
biopsies, etc), family history of lymphatic malformation, and associated complications, 
e.g., infection, disability. 
7.4.2. Vital signs 
Vital sign measurements include measurement of temperature (oral or tympanic 
membrane), resting pulse rate, respiration rate, oxygen saturation, systolic and diastolic 
blood pressure; along with height and weight.  
7.4.3. Lymphatic malformation assessment 
The most precise method of lymphatic malformation evaluation will be the MRI 
examination.  Clinical assessment of each lymphatic malformation includes measuring 
the hemicircumference of the lesion by using a soft measuring tape placed on the skin 
over the area of the widest diameter of the lesion.  The investigators will be fully trained 
in the standardized methods to obtain these measurements.  We have found in our 
preliminary subjects that the investigators vary in their measurement of length, width 
and hemispheric measurement unless they practice these measurements together in 
order to standardize their methods.  The length, and width, will then be calculated as 
described in Figure 2 of Berk et al.(Berk, Berk et al. 2011)  We will use linear mixed 
model to compare the changes in volume over time between and within subjects who 
receive placebo and those who receive sildenafil.  In order to document the site of the 
measurements a diagram will be drawn by hand or photographs will be taken of the 
methods.  Each clinic visit will try to duplicate the measurements methods used in the 
initial visit.   
7.4.4. Photography methods 
The digital photographs of each lymphatic malformation in this study will be acquired by 
the site investigators. The investigators will be fully trained in the standardized 
acquisition procedures.  At least two digital photographs of the lymphatic malformation 
will be acquired for each subject at the baseline visit and the 20 week visit. Photographs 
may be taken at other visits but they will not be part of the final analysis.  The first 
photograph will be taken with the image plane parallel to the lymphatic malformation 
(front-on view) and the second photograph will be taken with the image plane at a 
different angle to that of the first photograph (side-on view) so that the thickness of the 
lesion can be clearly visualized. The subject will be sitting on a chair while photographs 
are taken.  If subject is an infant, subject’s parent or guardian will be sitting on a chair 
with the infant sitting on his/her knees, if possible, or in his/her arms.  In the field of 
view, all photographs will include a color chart for color and size calibration.  Patient 
identification information, date of the photograph and therapy information will not be 
visible on the photograph.  For each photograph acquisition, the color chart will be held 
in the same plane as the lymphatic malformation. The photographs will be acquired at a 
fixed distance from the patient at two different angles defined at baseline (one for 
Photograph 1 and one for Photograph 2). 

 
 
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The photographs will serve the following purposes: 
1: To identify the lymphatic malformation or malformations if the subject has more than 
one malformation. 
2: To qualitatively assess lymphatic malformation evolution between visits and to 
quantify the size and the color of the lymphatic malformation at baseline and Week 20. 
7.4.5. Laboratory tests 
The CBC and chemistry panel is detailed in Appendix 17. These are to be assessed at 
the Screening Visit and End of Treatment Visit (Week 20).   All required lab tests must 
have been completed.  At the discretion of the PI or designee, a topical lidocaine-based 
anesthetic (eg. Lidocaine 4% cream) may be used prior to clinical laboratory sample 
collection to decrease potential discomfort to the subject. A pregnancy test will be done 
at the end of treatment for females of childbearing potential. 
8.  
DATA MANAGEMENT PLAN 
Paper source documents will be prepared prior to study start.  These source documents 
will be used in clinic to collect data for the study. Data will be collected at study visits, 
using the prepared data collection forms.  All source documents will be retained in the 
subject’s study binder. Source documents can include, but are not limited to: 
• Signed informed consent documents 
• Data collection forms (source documents) 
• Laboratory reports  
• MRI reports  
• Dictations/summary reports 
  
REDCap, an electronic data capture (EDC) system, will be utilized in this study as an 
electronic case report form (eCRF).  REDCap is a HIPAA-secure database system 
available through Stanford at http://redcap.stanford.edu.This system can only be 
accessed by authorized users, and only users with permission to view identifiers will be 
able to view PHI.  Users must sign into REDCap using their Stanford University ID and 
password.  Additionally, users may only access the database from a Stanford IP 
address, or via a Virtual Private Network (VPN).  Prior to study start, a database will be 
designed for this study that incorporates the data points collected in the source 
documentation.  The Stanford site will receive a copy of the paper source documents 
from the local cooperating research sites after every visit of the subject at the local site.  
The Stanford site will place the information from the local site into REDCap.   
 
After each study visit, data will be transcribed from paper source documents into the 
electronic data capture (EDC) REDCap system. Hard copies of source documentation 
will also be retained and stored in the subject binder.  Photographs, laboratory reports, 
and dictations will be uploaded to REDCap.   
 
Study staff will be responsible for “cleaning” the source document data and EDC prior to 
monitoring at each site.  This includes but is not limited to: making sure that dates are 

 
 
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logical, reasons for concomitant medication have a corresponding adverse event, 
making sure that GCP is followed, etc. 
 
At monitoring visits at Stanford, the study monitor will verify that the data entered into 
REDCap matches the data recorded in the source documentation. REDCap data will be 
printed and the monitor will verify that this information is the same as in the source 
documentation. 
 
Data from REDCap will be exported to excel, SPSS, or SAS for analysis.  When 
exporting data, PHI will not be included in the dataset. 
9.  
DATA SAFETY MONITORING BOARD 
A DSMB will be developed to monitor the study.  The details of the DSMB are described 
in the Safety Monitoring Plan (SMP), in Item 10, section 2 of the IND application.  The 
independent DSMB will assure that this trial is performed to the highest scientific and 
ethical standards.  Prior to the start of the study, the DSMB will review the Clinical 
Protocol, Safety Monitoring Plan, Informed Consent forms, and proposed DSMB-
specific reporting forms.  Once the study has started, the DSMB will evaluate the 
scientific progress and safety of the trial, consider outside information that is relevant to 
the study, review proposed changes to the Clinical Protocol, ensure data integrity, 
ensure confidentiality of trial data and monitoring results, and make recommendations 
to the PI regarding the trial.  The DSMB will meet prior to the start of the trial and then at 
least twice annually until 1 year after the last subject completes the last Week 32 or 
Week 32-A visit.  Ad hoc or emergency meetings will occur as needed and the 
procedures for planning those meetings are described in detail in the Safety Monitoring 
Plan. 
10. STATISTICAL DESIGN 
 
10.1. EVALUABILITY 
All subjects who receive study medication will be evaluable for the safety analysis. All 
subjects who receive study medication will be evaluable for the intent-to-treat analysis.  
 
10.2. EFFICACY  
All subjects who receive study medication will be evaluated for efficacy. 
 
10.2.1. Primary Efficacy 
Summary statistics will be determined for change in lesion volume by a radiologist 
blinded to the time of the MRI and whether the patent was on treatment or placebo.  
The initial MRI will be compared to the MRI after 20 week of sildenafil or placebo.  If the 
subject on placebo elects to take sildenafil for 20 weeks the MRI used for comparison 
after 20 weeks of sildenafil will be the MRI taken after 20 weeks of placebo.   

 
 
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We will include in the interim analysis information about the characteristics of LMs.  We 
will do a sub-analysis looking at specifics of location, lesion type (microcystic, 
macrocystic, or mixed and percent macrocystic), as well as previous procedures, 
infections or other interventions.  If this process documents characteristics of lesions 
that do or do not respond to sildenafil, we will reconsider our study entry criteria and 
submit a protocol amendment for the IND and this grant, focusing more on specific 
characteristics of which type of lesion a subject should have in order to be enrolled in 
the trial. 
 
10.2.2. Secondary Efficacy 
The secondary efficacy variables will be change from baseline and at visits four weeks 
twelve weeks, twenty weeks and 32 weeks.   
 
These will include the changes in the soft tape measurements of the lesion by 
comparing the measurements of length, width, and hemispheric measurement.  The 
volume of the lymphatic malformation will be estimated based on these measurements.   
 
Statistical analysis of the Subject’s Assessment of Lymphatic Malformation Change 
form.  This will give data on the subject’s evaluation of the change in lesion clinical 
characteristics from baseline, such as decreased discomfort, texture or thickness, 
distortion of normal anatomy or overall change by correlating the data obtained in the 
subject’s completion of Subject’s Assessment of Lymphatic Malformation Change form. 
 
Statistical analysis of the Lymphatic Malformation Assessment form for each LM site.   
This will give data on the physician’s evaluation of the lesion clinical characteristics on 
the days of the visits.  This includes color, tenseness and texture, superficial 
component, deep component, and distortion of anatomical landmarks.   
 
Statistical analysis of the Lymphatic Malformation Assessment of Change form for each 
LM site.  This will give data on the physician’s evaluation of the change in lesion clinical 
characteristics from baseline, such as change in texture or thickness, change in 
distortion of normal anatomy, and over change in lesions.   
 
Change in LM volume from MRI assessments in relation to BSA will also be carried out.  
REDCap calculates the BSA from height and weight measurements at each visit.  Since 
growth can be non-linear, relating the LM volume to a subject’s BSA may help to explain 
why a small change to the LM (by MRI volume analysis) is assessed as moderate by 
the investigator and parents of the subject (i.e., the LM may have stayed the same size 
but the child grew quickly, so the LM appears smaller by visual assessment). 
 
The digital photographs of each lymphatic malformation in this study will be acquired by 
the site investigators. At least two digital photographs of the lymphatic malformation will 
be acquired for each patient at each scheduled study visit, a front-on view and a side-on 
view.  See Section 7.4.4.  The clinical photographs evaluated by blinded observers in a 
blinded manner by physicians not associate with this trial.  The observers of the 

 
 
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photographs will compare the baseline photographs and score the additional visits as 
worse, no change, 1-25%, 26-50%, 51-75%, 76-100% improvement.  We will also 
examine the potential value of 3D photography during the Baseline, 20 Week and 20-A 
Week visit.   
 
Presence, frequency or absence of infection during trial will be documented. 
 
10.2.3. Exploratory Efficacy 
Not applicable. 
 
10.3. SAFETY  
All subjects who receive study medication will be evaluable for the safety analysis. 
Summary statistics will be provided with respect to patients requiring discontinuation 
from treatment and from study (any reason and for safety reasons). AE summaries will 
focus on treatment-emergent AE and will summarize subject AE incidences by severity, 
seriousness, and relationship to treatment. Vital signs, laboratory tests, and concomitant 
medication usage will be displayed as listings by subject. 
11. SAMPLE SIZE JUSTIFICATION AND STATISTICAL ANALYSIS:  
This is an exploratory, descriptive study for an orphan disease. The sample size is 
based on the prevalence of the disease and the availability of the subjects for the study.  
Based on our clinic numbers and expected numbers of subjects who will travel for this 
study, we expect 60 subjects to qualify for the study.   
 
We will also perform analysis of responders vs. non-responders, taking multiple 
measurements for placebo patients into account, treating the patient as random effect, 
adjusting for age, sex and possibly other markers. 
 
One of the potential trigger points to stop this study will be if milestones are reached 
that document statistically significant beneficial effect of sildenafil requiring no additional 
placebo treated subjects, or possibly no beneficial effect.  We have reviewed the details 
of our study with our biostatistician.  Because this is a very early study, we are unable to 
estimate the response to therapy and develop an effect size.  For that reason we will do 
an interim analysis after completion of the first 15 subjects, 10 treated with sildenafil for 
the first 20 weeks and 5 treated with placebo for 20 weeks.  We will evaluate the first 15 
subjects for efficacy and futility and add to this analysis each additional 15 subjects as 
they complete the study.  We should be able to use the interim analysis to project effect 
size and estimate the total number of subjects required for the study. If after analysis of 
15, 30 or 45 subjects we find that we are in the range of futility or efficacy, then we will 
notify the FDA as well as the DSMB, and begin to end the study by adding no additional 
subjects.   
 
We will include in the interim analysis information about the characteristics of LMs.  We 
will do a sub-analysis looking at specifics of location, lesion type (microcystic, 

 
 
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macrocystic, or mixed and percent macrocystic), as well as previous procedures, 
infections or other interventions.  If this process documents characteristics of lesions 
that do or do not respond to sildenafil, we will reconsider our study entry criteria and 
submit a protocol amendment, focusing on specific characteristics of which type lesion a 
subject should have in order to be enrolled in the trial. 
12. ADVERSE EVENTS 
 
12.1. GENERAL INFORMATION 
Adverse event (AE): any untoward medical occurrence associated with the use of a 
drug in humans, whether or not considered drug related.  AEs include any new events 
not present during the pre-intervention period or events that were present during the 
pre-intervention period, which have increased in severity. 
 
All adverse events that occur during the course of the study will be recorded in the 
source documentation including the event’s onset and resolution date (if the event has 
resolved), the frequency and severity of the event, a summary of any action taken as a 
result of the event (both in regard to any treatment given and to any change in dosing 
with the test medication), and an assessment of the event’s relationship to the test 
medication. 
12.2. NON-SERIOUS ADVERSE EVENTS 
A nonserious adverse event is an adverse event that does not meet the requirements 
for a serious adverse event (see Section 13.3). Nonserious adverse events will be 
documented in study records and reported to the FDA in the annual IND report. All 
nonserious adverse events will be recorded in study documentation regardless of 
whether or not they are considered to be related to the test medication. 
12.3. SERIOUS ADVERSE EVENTS 
Life threatening AE: Any AE that places the subject, in the view of the investigator, at 
immediate risk of death.  It does not include an adverse event or suspected adverse 
reaction that, had it occurred in a more severe form, might have caused death. 
 
Serious Adverse Event (SAE): Any adverse event that, in the view of the investigator, 
results in any of the following outcomes: 
• Death 
• A life-threatening adverse event 
• Inpatient hospitalization 
• A persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions 
• A congenital anomaly/birth defect 
 
Important medical events that may not result in death, be life-threatening or require 
hospitalization may be considered serious when, based upon appropriate medical 
judgment, they may jeopardize the subject and may require medical or surgical 

 
 
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intervention to prevent one of the outcomes listed in this definition.  Examples of such 
medical events include allergic bronchospasm requiring intensive treatment in an 
emergency room or at home, blood dyscrasias or convulsions that do not result in 
inpatient hospitalization, or the development of drug dependency or drug abuse. 
 
12.4 REPORTING OF SERIOUS ADVERSE EVENTS 
 
12.4.1. Reporting to FDA 
For serious adverse events (SAE), a MedWatch Form FDA 3500A containing all 
available information must be sent to the FDA within 15 days of the Investigator's 
knowledge of the event; new information should be reported by telephone or fax as 
soon as it becomes available.  Fatal or life-threatening SAEs will be reported to the FDA 
within 7 days of the Investigator’s knowledge of the event.  We will also inform Pfizer, 
the manufacturer of sildenafil (Revatio®), about the SAE.  SAEs at any given site will be 
communicated to Stanford immediately by phone or email and reported to the FDA by 
Stanford on the timelines described above.  All coordinating sites will be informed of 
SAEs promptly. 
 
A MedWatch Form FDA 3500A must be completed for all serious adverse events and 
forwarded to the FDA within 15 days of the Investigator's knowledge of the event and to 
the Institutional Review Board/Independent Ethics Committee, according to their 
requirements. When new significant information is obtained as well as when the 
outcome of an event is known, the Investigator must inform FDA by telephone or fax. 
Fatal or life-threatening SAEs will be reported to the FDA within 7 days of the 
Investigator’s knowledge of the event 
 
12.4.2. Reporting to IRB 
Unexpected deaths or life-threatening experiences related to the research must be 
reported to the IRB within 5 working days from the when the site’s PI learns of the 
event. All SAEs (as defined in section 13.3) will be reported to the IRB within 10 working 
days from when the site’s PI learns of the event. 
 
Unanticipated problems involving risks to participants or others, or Internal Events that 
are unexpected and related to the research should be reported to the IRB within 10 
working days from when the site’s PI learns of the event or new information, or receives 
assessment from monitoring entity. 
 
Additional reportable events include: unanticipated problems (UPs) involving risks to 
participants or others (including internal or external events, deaths, life-threatening 
experiences, injuries, breaches of confidentiality, or other problems) that occur any time 
during or after the research study. 
 
Additional Reportable information: 

 
 
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• New information that indicates a change to the risks or potential benefits of the 
research, in terms of severity or frequency 
• Protocol deviation.  Protocol deviations/violations are to be reported only if: 
o Intended to eliminate apparent immediate hazard to a research 
participant, or 
o Harmful, or 
o Possible serious or continued noncompliance 
• Complaint that is unresolved by the research team, or that indicates increased or 
unexpected risks 
• Incarceration when, in the opinion of the PI, it is in the best interest of the 
participant to remain on the study 
 
12.4.3. Reporting to DSMB 
Reporting to the DSMB is described in detail in the Safety Monitoring Plan, under Item 
10, section 2 of the IND application.  In brief, SAEs will be reported as soon as possible 
to the DSMB Safety Officer, who will determine if it is necessary to convene the entire 
DSMB, and any other events that are potentially reportable to other regulatory agencies 
will also be reported to the DSMB. 
 
12.5. ASSESSMENT OF ADVERSE EVENT SEVERITY, CAUSALITY, AND 
EXPECTEDNESS 
Unexpected AE: Any adverse event, the specificity or severity of which is not consistent 
with the risk information described in the Investigator’s Brochure. 
 
Severity: Severity of the AE will be determined by the investigator.  Severity may be 
mild, moderate, or severe: 
• Mild – An event is mild if the subject is aware of, but can easily tolerate the sign 
or symptom 
• Moderate – An event is moderate if the sign or symptom results in discomfort 
significant enough to cause interference with the subject’s usual activities 
• Severe – An event is severe if the sign or symptom is incapacitating and results 
in the subject’s inability to work or engage in their usual activities 
 
In addition, the Investigator will determine if the adverse event is may have been 
caused by the test product. The following circumstances would be considered to be 
possibly related: 
• A single occurrence of an event that is uncommon and known to be strongly 
associated with drug exposure (e.g., angioedema, hepatic injury, Stevens-
Johnson Syndrome). 
• One or more occurrences of an event that is not commonly associated with drug 
exposure, but is otherwise uncommon in the population exposed to the drug 
(e.g., tendon rupture). 
• An aggregate analysis of specific events observed in a clinical trial (such as 
known consequences of the underlying disease or condition under investigation 

 
 
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or other events that commonly occur in the study population independent of drug 
therapy) that indicates those events occur more frequently in the drug treatment 
group than in a concurrent or historical control group. 
 
In source documentation, causality will be recorded using the following definitions: 
• Not Related – An event is considered to be not related to the use of the test 
medication when the event is DEFINITELY UNRELATED or UNLIKELY to have 
any relationship to the use of the test medication 
• Possibly Related – An event is considered to be possibly related to the use of the 
test medication when there is a REASONABLE POSSIBILITY that the test 
medication caused the adverse event 
 
12.6. UNBLINDING OF TEST MEDICATION 
If a subject develops an adverse reaction that requires withdrawal from the study we will 
document whether they are receiving placebo or active medication.  The treatment 
assignment will also be unblinded during the twenty week visit after the MRI 
examination is completed. 
 
12.7. FOLLOW-UP OF SUBJECTS WITH ADVERSE EVENTS 
For subjects who are experiencing ongoing unresolved adverse events at the time of 
their study completion or early discontinuation from the study, the Investigator will 
schedule an appropriate follow-up visit in order to determine the outcome of the event.  
 
13. INVESTIGATOR OBLIGATIONS 
The Principal Investigator will comply with the commitments outlined in the Statement of 
Investigator (Form FDA 1572), with current Good Clinical Practice (GCP), and with all 
applicable regulatory requirements as outlined in Appendix 18.2 of this protocol.  
Additional information on Investigator Obligations is listed in Item 10, section 1 of the 
IND application. 
 
14. INVESTIGATOR AND MONITOR RESPONSIBILITIES 
The Investigator will designate a monitor to conduct the appropriate site visits 
monitoring at the appropriate intervals. The clinical investigation will be monitored to 
ensure that: the rights and well being of the subjects are protected; the reported data 
are accurate, complete, and verifiable from the source documents; and the study is 
conducted in compliance with the current approved protocol, with current GCP, and with 
applicable regulatory requirements. 
 

 
 
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 Monitoring will be conducted periodically while the clinical study is ongoing. Monitoring 
methods may include site visits, telephone, written and fax correspondence. The study 
monitor will contact the site at appropriate intervals.  
 
15. REFERENCES 
Abrams, D., I. Schulze-Neick, et al. (2000). "Sildenafil as a selective pulmonary 
vasodilator in childhood primary pulmonary hypertension." Heart 84(2): E4. 
Barst, R. J., D. D. Ivy, et al. (2012). "A randomized, double-blind, placebo-controlled, 
dose-ranging study of oral sildenafil citrate in treatment-naive children with 
pulmonary arterial hypertension." Circulation 125(2): 324-334. 
Berk, D. R., E. J. Berk, et al. (2011). "A novel method for calculating the volume of 
hemangiomas." Pediatr Dermatol 28(4): 478-482. 
Blei, F. (2008). "Congenital lymphatic malformations." Ann N Y Acad Sci 1131: 185-194. 
Churchill, P., D. Otal, et al. (2011). "Sclerotherapy for lymphatic malformations in 
children: a scoping review." J Pediatr Surg 46(5): 912-922. 
de Graaf, M., J. M. Breur, et al. (2011). "Adverse effects of propranolol when used in the 
treatment of hemangiomas: A case series of 28 infants." J Am Acad Dermatol 
65(2): 320-327. 
Fisher, R., A. Partington, et al. (1996). "Cystic hygroma: comparison between prenatal 
and postnatal diagnosis." J Pediatr Surg 31(4): 473-476. 
Frieden, I. J. and B. A. Drolet (2009). "Propranolol for infantile hemangiomas: promise, 
peril, pathogenesis." Pediatr Dermatol 26(5): 642-644. 
Fuchsmann, C., M. C. Quintal, et al. (2011). "Propranolol as first-line treatment of head 
and neck hemangiomas." Arch Otolaryngol Head Neck Surg 137(5): 471-478. 
Gallagher, P. G., M. J. Mahoney, et al. (1999). "Cystic hygroma in the fetus and 
newborn." Semin Perinatol 23(4): 341-356. 
Greene, A. K., C. A. Perlyn, et al. (2011). "Management of lymphatic malformations." 
Clin Plast Surg 38(1): 75-82. 
Howarth, E. S., E. S. Draper, et al. (2005). "Population-based study of the outcome 
following the prenatal diagnosis of cystic hygroma." Prenat Diagn 25(4): 286-291. 
Karatza, A. A., A. Bush, et al. (2005). "Safety and efficacy of Sildenafil therapy in 
children with pulmonary hypertension." Int J Cardiol 100(2): 267-273. 
Leaute-Labreze, C., E. Dumas de la Roque, et al. (2008). "Propranolol for severe 
hemangiomas of infancy." N Engl J Med 358(24): 2649-2651. 
Pfizer. (2007). "Revatio Patient Information Sheet."   Retrieved November 29, 2011, 
2011, from 
http://www.accessdata.fda.gov/drugsatfda_docs/label/2007/021845s004lbl.pdf. 
Redondo, P., L. Aguado, et al. (2011). "Diagnosis and management of extensive 
vascular malformations of the lower limb: part I. Clinical diagnosis." J Am Acad 
Dermatol 65(5): 893-906; quiz 907-898. 
Sans, V., E. D. de la Roque, et al. (2009). "Propranolol for severe infantile 
hemangiomas: follow-up report." Pediatrics 124(3): e423-431. 

 
 
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Shekerdemian, L. S., H. B. Ravn, et al. (2002). "Intravenous sildenafil lowers pulmonary 
vascular resistance in a model of neonatal pulmonary hypertension." Am J Respir 
Crit Care Med 165(8): 1098-1102. 
Wang, P., P. Wu, et al. (2003). "Identification and characterization of a new human type 
9 cGMP-specific phosphodiesterase splice variant (PDE9A5). Differential tissue 
distribution and subcellular localization of PDE9A variants." Gene 314: 15-27. 
Whimster, I. W. (1976). "The pathology of lymphangioma circumscriptum." Br J 
Dermatol 94(5): 473-486. 
 
 

 
 
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16. STUDY PLAN 
 
Table 16-1: Study Procedures by Treatment Day 
 
 

 
 
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17. APPENDICES 
 
17.1. LABORATORY TESTS 
Laboratory tests will be obtained upon entry (baseline) and end of treatment into the 
clinical trial. The exams will include: 
 
• Complete Blood Count: 
Hematocrit 
Hemoglobin 
White Blood Cell Count (WBC) 
WBC differential 
Red Blood Cell Count (RBC) 
MCV (Mean Corpuscular Volume) 
MCH (Mean Corpuscular Hgb) 
MCHC (Mean Corpuscular Hgb Concentration) 
RDW (RBC distribution width) 
Stained Red Cell examination (Peripheral Smear) 
Platelet Count 
 
• Complete Metabolic Panel: 
Albumin 
Alkaline Phosphatase Total 
ALT 
AST 
Urea Nitrogen 
Calcium 
Chloride 
CO2 Content 
Creatinine 
Glucose 
Globulin 
Potassium 
Sodium 
Total Bilirubin 
Total Protein 
Anion Gap 
 
• Urine Pregnancy if required (See Schedule of Events) 
 
17.2 INSTRUCTIONS OF ORAL SUSPENSION FOR PHARMACIST 
 
 

 
 
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17.2.1 Instructions for Pharmacist (2 pages) 
 
page 1: 
 
 
 
 
 
 
 
 
 
 

 
 
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page 2: 
 
 
 
17.2.2 Pharmacist Instructions for Oral Suspension of 10mg and 20mg 
 
 
 
 
 

 
 
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Subjects taking 20mg/8ml 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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Subjects taking 10mg/4ml 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
18. DECLARATION OF HELSINKI 
This clinical study will be performed in compliance with the ethical principles of the 
Declaration of Helsinki and Good Clinical Practice (GCP).