Phase 2 Trial of Sirolimus and Methotrexate in Relapsed/Refractory Lymphoblastic Leukemia and Lymphoma
Phase: PHASE2
Conditions: Cancer, Leukemia, Lymphoma
Sponsor: Children's Hospital of Philadelphia

 
 
 
Protocol No. CHP-948 
 
 
 
i
Title: 
A PHASE 2 TRIAL OF SIROLIMUS WITH METHOTREXATE IN 
RELAPSED/REFRACTORY LYMPHOBLASTIC LEUKEMIA AND 
LYMPHOMA 
Study Key Name 
Key Name  
Protocol No: 
CHP-948 
Drug or Device 
Name(s): 
Sirolimus, Methotrexate 
FDA IND 
N/A 
Protocol Date: 
4/16/10  
Amendment 1 Date: 02/25/11 
Amendment 4 Date:  
Amendment 2 Date: 
Amendment 5 Date: 
Amendment 3 Date: 
Amendment 6 Date: 
Sponsor  
 
The Leukemia & Lymphoma Society  
1311 Mamaroneck Ave.  
White Plains, NY 10605 
STUDY PRINCIPAL INVESTIGATOR 
 
 Susan R. Rheingold, MD 
The Children’s Hospital of Philadelphia 
Division of Oncology 
34th Street and Civic Center Blvd. 
Wood Building, 4th Floor 
Philadelphia, PA 19104 
Phone: (215) 590-2801 
Fax: (215) 590-4183 
e-mail: rheingold@email.chop.edu 
 
RESEARCH COORDINATOR 
Nancy Sacks, MS, RD, LDN 
The Children’s Hospital of Philadelphia 
Division of Oncology 
34th Street and Civic Center Blvd. 
Phone: (267) 426-5613 
Fax: (267) 426-2822 
e-mail: sacks@email.chop.edu 

 
 
 
Protocol No. CHP-948 
 
 
 
ii 
CO-INVESTIGATORS 
 
Charles Bailey, MD,PhD 
The Children’s Hospital of Philadelphia 
Division of Oncology 
34th Street and Civic Center Blvd. 
Wood Building, 4th Floor 
Philadelphia, PA 19104 
Phone: (267) 426-3184 
Fax: (215) 590-4183 
e-mail: baileyc@email.chop.edu 
 
Valerie I. Brown, MD,PhD 
The Children’s Hospital of Philadelphia 
CTRB, Room 3004 
3501 Civic Center Blvd. 
Phone: (267) 426-5073 
Fax: (215) 590-3770 
e-mail: brownv@email.chop.edu 
 
Stephen A. Grupp, MD,PhD 
The Children’s Hospital of Philadelphia 
CTRB, Room 3006 
3501 Civic Center Blvd. 
Phone: (215) 590-5475 
Fax: (215) 590-3770 
e-mail: grupp@email.chop.edu 
 
David Teachey, MD 
The Children’s Hospital of Philadelphia 
CTRB, Room 3008 
3501 Civic Center Blvd. 
Phone: (267) 426-5802 
Fax: (215) 590-3770 
e-mail: teachey@email.chop.edu 
 
Richard Aplenc, MD 
The Children’s Hospital of Philadelphia 
Abramson Research Center, 916G 
34th Street and Civic Center Blvd. 
Phone: (267) 426-7252 
Fax: (215) 590-3770 
e-mail: aplenc@email.chop.edu 
 
 
 

 
 
 
Protocol No. CHP-948 
 
 
 
iii 
Table of Contents...................................................................................................................
iii 
Abbreviations and Definitions of Terms............................................................................ vii-viii 
Protocol Synopsis............................................................................................................
ix--x 
Table 1: Schedule of Clinical and Laboratory Studies......................................................
xi 
  
  
BACKGROUND INFORMATION AND RATIONALE..................................................................
1 
1.1        Introduction.......................................................................................................................
1 
1.2        Name and Description of Investigational Product or Description of Intervention..............
1 
1.3        Findings from Non-Clinical and Clinical Studies...............................................................
2 
1.3.1 Pre-Clinical data on mTOR Inhibitors (MTI)……………………..…….....…............
2-3 
1.3.2 Pre-clinical data on temsirolimus combined with chemotherapy.............................
3-6 
1.3.3 Adult Neoplastic Studies……………………………………..………......…….............
6 
1.3.4 Pediatric Neoplastic Studies………………………………………….…….….............
7 
1.3.5 Combination therapy of MTIs and methotrexate..…………….…….……...…..........
7 
1.4        Selection of Drugs and Dosages..................................................................................
7 
1.4.1 Sirolimus.................................................................................................................
7 
1.4.2 Methotrexate.…………………………………………………….…..............................
7 
1.5       Compliance Statement………………………………...…….…............................................
8 
1.6        Pharmacokinetics of Sirolimus…………….……...…….......….…...……………................
8 
  
  
2    STUDY OBJECTIVES.............................................................................................................
9 
2.1        Primary Objective (or Aim).…………….……...…………………………..…........................
9 
2.2        Secondary Objectives (or Aim) …………….……...………………………………................
9 
  
  
3    INVESTIGATIONAL PLAN…………………….……………………..……................................
9 
3.1       General Schema of Study Design………......………........………………..……...................
10 
3.1.1 Screening Phase....................................................................................................
11 
3.1.2 Treatment Phase....................................................................................................
11 
3.1.3 Follow-up Phase....................................................................................................
11 
3.2       Randomization and Blinding...........................................................................................
11 
3.3       Study Duration, Enrollment and Number of Sites...........................................................
11 
3.3.1 Duration of Study.…………………………………………..…....................................
11 
3.3.2 Total Number of Study Sites/Total Number of Subjects Projected.........................
12 
3.4       Study Population……………...………………..…….........................................................
12 
3.4.1 Inclusion Criteria………………......…………………................................................
12 
3.4.2 Organ Function Requirement....………………..……..............................................
12 
3.4.2.1 Bone Marrow Function...................................................................................
3.4.2.2 Adequate Renal Function……………………..……………...............…..…..…......
      12 
 12-13 
3.4.2.3 Adequate Liver Function….…………………………………….…....…...............…
13 
3.4.2.4 Adequate Cardiac Function……....……………..….……..…………......................
13 
3.4.2.5  Adequate Pulmonary Function……….….………….….…........…........................
13 
3.4.3   Exclusion Criteria……………….………………………..…..….….…......................
13-15 
  
  

 
 
 
Protocol No. CHP-948 
 
 
 
iv
4    STUDY PROCEDURES…………………….………………………….......................................
15 
4.1        Pre-Study / Screening Visit…………………………………………………...………….....….
15 
4.2        Treatment Plan…………………………………………...……………………......……...........
15 
4.3        Definition of cycle……………..…………………………………………………..……............
16 
4.4        Required Observations/Material And Data To Be Accessioned During Study…...….......
17 
4.5        Changes to the study protocol……………………………………………………..................
18 
4.6        Study visits for all cohorts - Cycle 1 and subsequent cycles.......................................
18 
4.6.1 Planned follow-up Visits will be scheduled according to the roadmap................…
18 
4.6.2 Unscheduled Visits…………………………………………………….........................
18 
4.7        Supportive Care/Concomitant Therapy……………………………………..........….…........
18 
4.7.1 General…………………………………………………………..….........………………
18 
4.7.2 Tumor Lysis Syndrome……………….....……………………………..……………….
18 
4.7.3 Growth Factor……………………………………………………….............…………..
18 
4.7.4 Hypercholesteremia/Hypertriglyceridemia……...…….…………………............……
19 
4.7.5 Interactions………………………………………………………….………........………
19 
4.7.6 PCP Prophylaxis……………………………………………………………........………
19 
4.8        Extramedullary Disease……………………………………………………….................……
19 
4.9        Dose Modifications…………………………………………………........................……….
19 
4.9.1 Myelosuppression……………………………………………………….....….....…….
20 
4.9.2 Aplastic marrow………………………………………………………………..…….…
20 
4.9.3 Organ system toxicity………………………………………..………………..…….…
20 
4.9.4 Stomatitis………………………………………………………..………………...….…
20 
4.9.5 Liver Dysfunction……………………………………………….………………...….…
20 
4.10      Rescue Medication Administration……………………………………….............….……….
21 
4.11      Subject Completion Withdrawal….…………………………………….…............…………..
21 
4.11.1 Early Termination Study Visit……………………….…..............……………..……..
21 
  
  
5   STUDY ENDPOINTS AND EVALUATIONS…………………….…………..................……......
21 
5.1        Primary Endpoint……………………………………………….…….................……….….…
21 
5.2        Secondary Endpoints…....………………………………………..............…..……….…….…
21 
5.3        Screening and Baseline and On-study Evaluation….........………………......................…
21 
5.3.1  Physical Examination and current medication………………..…......…………........ 21-22 
5.3.2  Demographic information collected…………………………….……….…….….…...
22 
5.3.3  Vital Signs……………………………………….........………………….....…….………
22 
5.3.4  Laboratory Evaluations…………………………......…………………………….…….
22 
5.4        Efficacy Evaluations…………………………………………....………............……….…….
22 
5.4.1  Response criteria (Leukemia)…………………………………....………….…….…… 22-23 
5.4.2  Response criteria (for NHL patients)…………………………...……….........….…… 23-24 
5.4.3  Response Assessment………………………………………....…………..…..….……
24 
      5.4.3.1 Quantification of Disease Burden…............………........…...………… 
24 
      5.4.3.2 Complete Response (CR)……….………..………..................…………
24 
5.4.3.3 Partial Response (PR) ……………………………………….…........……
24 
5.4.3.4 Progressive Disease (PD) …………………………………....….…..…....
24 

 
 
 
Protocol No. CHP-948 
 
 
 
v
5.4.3.5 Stable Disease (SD) ………………………………………….....…..……..
24 
5.4.3.6 Response Assessment ……………………………………...............……
24 
5.4.3.7 Best Response …………………………………………….…............……
24-25 
5.5        Pharmacokinetic Evaluation…………………………………………………….…..............…
25 
5.5.1  Description of Assay…………………………………..………………………......……
25 
5.5.2  Sampling Schedule……………………………………………….………................... 25-26 
5.5.3  Sample Collection and Handling Instructions……………………………............….
26 
5.6        Biology Studies. ……………………………………………………………………………...….
26 
5.6.1  Peripheral Blood Mononuclear Cells/ Peripheral Blood Lymphoblast….…...…….
26 
5.6.2  Bone Marrow ……………………………………………………………………......…..
26 
5.6.3  Collection of Bone Marrow or Peripheral Blood………….…...................………… 26-27 
5.6.4  Documenting specimen delivery …………………………………….....……………..
27 
  
  
6   STATISTICAL CONSIDERATIONS……….…………..................……..................................... 
27 
6.1        Sample Size and Study duration………………………………………..…………….............
28 
6.2        Statistical Analysis………………………………………..…………….................................
28 
6.2.1  Clinical Trial Analysis…………………........……………………..………………..…..
28 
6.2.2  Biology Study Analysis …………………………………..………............…….………
28 
6.3        Definitions……………………………………………………………………..........…….………
29 
6.3.1  Evaluable for Toxicity………………………………………………................……….
29 
6.4        Inclusion of Women and Minorities…………………………………….……......……………
29 
6.5        Statistical Methods………………………………………………………..............................
29 
6.5.1  Baseline Data……………….............................................................................
29 
6.5.2  Efficacy Analysis - Clinical Trials Analysis…….................................................
29 
6.5.3  Pharmacokinetic Analysis………………….........................................................
29 
6.5.4  Biology Study / Pharmacodynamic Analysis……….……….................................
29 
6.5.5  Safety Analysis…………………..…..................................................................
30 
  
  
7   STUDY MEDICATION…………………………...……………………………............................... 
30 
7.1       Sirolimus…………………………..................……………......…………………………………
30 
7.1.1 Toxicity……………………………………………..................………………………… 31-32 
7.1.2 Formulation and Stability……………………………………………………............…
7.1.3 Sirolimus Administration, Monitoring and Dose Adjustments...............................
32-33 
33 
7.2        Methotrexate…………………………………………………………………...................…….
34 
7.2.1 Toxicity………………………………………………………………..................……….
34-35 
7.2.2 Formulation and Stability………………………………………………….....……….… 35-36 
7.3        Drug Accountability………………….........………………………………………….…………
36 
  
  
8   SAFETY MANAGEMENT…….........…………………………………………………….................
36 
  
  
8.1        Clinical Adverse Events………………….........………………………………………….…..…
36 
8.2        Adverse Event Reporting………………….........……………………………………….……..
36 
8.2.1 General Guidelines For All Adverse Events…………………………..……….……… 36-37 

 
 
 
Protocol No. CHP-948 
 
 
 
vi
8.2.2 Persistent Adverse Events………………………………………...…………….……...
37 
8.2.3 Baseline Adverse Events………………………….....………………………….………
37 
8.3        Definition of an Adverse Event……………………….............……………………….……… 37-38 
8.4        Definition of a Serious Adverse Event (SAE)……….…………………….............…………
38 
8.4.1 Relationship of SAE to study drug or other intervention……….…....…….…………
38 
8.5        IRB/IEC Notification of SAEs……………………………………….………........….…………
39 
             8.5.1 Follow-up Report............................................................................................
8.6        Investigator Reporting of a Serious Adverse Event to Sponsor..................................
38-39 
39 
8.7        Medical Emergencies…………………………………………………………..................……
39 
  
  
9   STUDY ADMINISTRATION……………………………………………………….....………………
39 
  
  
9.1        Treatment Assignment Methods…………………………………………............…….………
39 
9.2        Data Collection and Management……………………………………...........………….…..… 39-40 
9.3        Regulatory and Ethical Considerations……………………………………...................……
40 
9.3.1 Data and Safety Monitoring Plan………………………………......…………...………
40 
9.3.2 Risk Assessment…………………………………………………..............…….………
41 
9.3.3 Potential Benefits of Trial Participation …………………………....................………
41 
9.3.4 Risk-Benefit Assessment ……………………………………………...............………
41 
9.4        Recruitment Strategy……………………………………………………………….......………
41-42 
9.5        Informed Consent/Assent………………………………………………...............……………
42 
9.6        Payment to Subjects/Families………………………………….....................……….………
42 
  
  
10   PUBLICATION……………………………………………………........……………………..………
42 
  
  
Appendix I: Eligibility Criteria Form……………………………………...............…………….……… 43-44 
Appendix II: Roadmap for Therapy……………………………………….................………………… 45-46 
Appendix III: Medication Diary..............................................................................................
Appendix IV: Relevant Drug Iinteractions...............................................................................
47-48 
49 
Appendix V: Karnofsky/Lansky..............................................................................................
 
11   References……………………………………………………………………………………..........
50 
 
51-53 
 
 
 
 
 
 
 
 

 
 
 
Protocol No. CHP-948 
 
 
 
vii 
ABBREVIATIONS AND DEFINITIONS OF TERMS 
AE 
Adverse event 
ALL 
Acute Lymphoblastic Leukemia 
AML 
Acute Myelogenous Leukemia 
ANC 
Absolute Neutrophil Count 
AUC 
Area under the curve 
BM 
Bone Marrow 
BMI 
Body Mass Index 
BMT 
Bone Marrow Transplant 
BSA 
Body Surface Area 
Ca++ 
Calcium 
CBC 
Complete Blood Count 
CFR 
Code of Federal Regulations 
CHOP 
The Children’s Hospital of 
Philadelphia 
CCG 
Children's Cancer Group 
CCI-779 
Temsirolimus 
cc 
Cubic centimeter 
Cmax 
Maximum Concentration 
CNS 
Central Nervous System 
Cr 
Creatinine 
CR 
Complete Response 
CRA 
Clinical Research Assistant 
CRp 
C-Reactive Protein 
CSF 
Cerebrospinal fluid 
CT 
Computed tomography 
CTC v3 
Common Terminology Criteria 
Version 3 
DEX 
Dexamethason 
DHFR 
dihydrofolate reductase 
DLT 
Dose limiting toxicity 
EDTA 
Diaminoethanetetraacetic acid 
EFS 
Event free survival 
ELISA 
Enzyme-linked immunosorbent 
assay 
ENT 
Ears, nose and throat 
°F 
Degrees Fahrenheit 
FK506 
Tacrolimus  
5-FU/LCV 
5-Fluorouracil and Leucovorin  
G-CSF 
Growth Colony Stimulating 
Factor 
GVHD 
Graft verses host disease 
GI 
Gastrointestinal  
g/dl 
Grams per deciliter 
HDMTX 
High dose methotrexate 
Hgb 
Hemoglobin 
HPLC 
High-performance (pressure) 
liquid chromatography 
HPLC-MS 
High pressure liquid 
chromatography - conduction 
microcalorimetry  
HSCT 
Hematopoetic stem cell 
transplant 
Ht 
Height 
ICH 
International Conference on 
Harmonisation 
ID 
Identification 
IRB 
Institutional Review Board 
IT 
Intrathecal 
IV 
Intravenous 
kg 
Kilogram 
LD 
longest diameter 
LFT's 
Liver function tests 
M1 
<5% blasts in BM 
M2 
5-25% blasts in BM 
m2 
Meter squared 
mEq 
Milliequivalents 
mg 
Milligram 
Mg++ 
Magnesium 
MRD 
MRI 
Minimal Residual Disease 
Magnetic Resonance Imaging 
MTD 
Maximum tolerated dose 
MTI 
Mammalian target  inhibitors 
mTOR 
Mammalian target of rapamycin 
MTX 
Methotrexate 
NG / NJ 
Nasogastric / Nasojejunal 
Ng/ml 
Nanogram per millileter 
NHL 
Non Hodgkins Lymphoma 
NIH 
National Institute of Health 
PD 
Progressive Disease 
PI 
Principal Investigator 
PK 
Pharmakokinetic 
PLT 
platelet 
PO 
Per Os (Oral) 

 
 
 
Protocol No. CHP-948 
 
 
 
viii 
PO4 
phosphorous 
POG 
Pediatric Oncology Group 
RNAs 
Riboneucleic Acid 
Rapa 
Rapamycin 
SAE 
Severe Adverse Event 
SCT 
Stem cell transplant 
SOC 
Standard of Care 
SD 
Stable disease 
ULN 
Upper limit of normal 
μL 
Microliter 
VCR 
Vincristine 
VS 
Vital signs 
Wt 
Weight 
XRT 
Radiation 

 
 
 
Protocol No. CHP-948 
 
 
 
ix
PROTOCOL SYNOPSIS 
Study Title 
 A PHASE 2 TRIAL OF SIROLIMUS WITH METHOTREXATE IN 
RELAPSED/REFRACTORY LEUKEMIA AND NON-HODGKIN’S 
LYMPHOMA 
Sponsor 
Leukemia/Lymphoma Society Translational Research Grant 
Clinical Phase 
Phase 2 
Study Rationale 
 
At present children who have bone marrow or combined bone 
marrow and extramedullary relapses of acute leukemia while on 
therapy have 5-20% of long-term survival.  
 
Newer, targeted agents need to be identified and integrated into 
the present cytotoxic chemotherapy regimens. Biologically 
targeted cancer agents, including signal transduction inhibitors 
like mammalian target of rapamycin inhibitors (MTIs), have 
shown great promise in treating hematologic malignancies.  
 
A Phase 1 trial of sirolimus (an MTI) alone performed at CHOP 
has been well tolerated with no DLTs and has evidence of hitting 
the biologic target. 
 
While signal transduction inhibitors may be efficacious as single 
agents, it is more likely that these targeted agents will 
demonstrate greater efficacy in combination with other cytotoxic 
agents. 
 
Based upon pre-clinical mouse models we propose to study the 
toxicity and efficacy of adding sirolimus to oral methotrexate in 
relapsed and refractory patients. 
 
 
Study 
Objective(s) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary 
Objectives 
 
 
 
 
Secondary 
Objectives 
 
 
 
 
Determine the efficacy of oral sirolimus when given 
in combination with methotrexate in children with 
refractory/relapsed ALL or NHL. 
 
Determine the safety and tolerability of oral 
sirolimus given in combination with methotrexate. 
 
To characterize the trough levels produced by 
administration of oral sirolimus in children with 
refractory/relapsed lymphoblastic leukemia or 
lymphoma. 
 
To evaluate the effect of sirolimus on intracellular 
targets, including ribosomal protein s6 (a marker of 
mTOR inhibition), AKT, P27kip1, DHFR, cyclin D1, 
Rb, and STAT5 in peripheral blood mononuclear 
cells, peripheral blood lymphoblasts, and bone 
marrow lymphoblasts. 

 
 
 
Protocol No. CHP-948 
 
 
 
x
Test Article(s) 
(if applicable) 
Sirolimus  
 
Study Design 
 
 
Phase 2 study looking at efficacy and toxicity of oral sirolimus in 
combination with methotrexate. 
 
Subject 
Population 
Key criteria for 
inclusion and 
exclusion: 
 
 
Inclusion Criteria: 
 
Patients  25 years, at time of enrollment, with second or greater 
relapse of ALL or NHL.  
 
Patients with lymphoblastic lymphoma or peripheral T-cell 
lymphoma must have radiologic or physical evidence of 
recurrence.   
Standard exclusion criteria for oncology protocols will be used. 
Number of 
Subjects/Sites  
 
9 to 17 enrollees primarily at CHOP, possible extension to other sites.  
Study Duration 
 
Total study duration is expected to be 2-2.5 years. 
Study Phases 
 
Subject participation will be for a 28 day cycle. They can be enrolled for 
subsequent cycles as long as they maintain stable disease or better. 
Follow-up for 30 days once therapy is stopped or upon enrollment on 
another study. 
Efficacy 
Evaluations 
The day 28 bone marrow in the initial cycle will determine response. If a 
patient has stable disease or better, at day 28 of cycle 1, they may 
continue to receive subsequent cycles as long as they maintain a stable 
disease or better. The fall in absolute peripheral blasts count will also be 
monitored.  
Pharmacokinetic 
Evaluations 
Trough levels of sirolimus. 
 
Safety 
Evaluations 
SAE’s as delineated in the protocol will be reported to the IRB.  
Statistical and 
Analytic Plan 
This study will be conducted using a two staged Simon design.  
Data and Safety 
Monitoring Plan 
An independent medical monitor will review SAE’s and response data at 
least twice yearly with the study team. 

 
 
 
Protocol No. CHP-948 
 
 
 
xi
Table 1: Schedule of Clinical and Laboratory Studies 
All entry/eligibility studies must be performed within 1 week prior to entry onto the 
trial (unless otherwise specified).  Imaging studies are required within 1 month prior 
to study entry. 
STUDIES TO BE OBTAINED 
Pre-
Study 
Cycle 1 
Subsequent Cycles 
Off 
Study 
Informed Consent/Assent 
X 
 
 
 
Demographics/Medical History 
X 
 
 
 
Physical Exam (Ht, Wt, BSA, VS) 
X 
Weekly 
Once a cycle 
X 
Performance Status 
X 
Once a cycle 
Once a cycle 
X 
CBC, differential, platelets1 
X 
Weekly 
Once a cycle 
X 
Review Eligibility Criteria 
X 
 
 
 
TROUGH sirolimus Level2 
 
 
Day 5-8, then 
weekly 
Day 1 of a cycle, or 
with any addition of a 
CYP3A4 agonist 
 
Prior/Concomitant Medications 
X 
X 
X 
 
Urinalysis 
X 
 
 
 
Electrolytes including Ca++, PO4, Mg++, 
Cr, ALT, AST, Total bilirubin3  
X 
1-3 X per 
week 
Once a cycle 
X 
Cholesterol/Triglyceride levels 
X 
X 
Once a cycle 
X 
Pregnancy Test4 
X 
 
 
 
Tumor Disease Evaluation  
X 
D 28 
End of every other 
cycle 
X 
Bone Marrow Aspirate or Biopsy 
(Response)5 
X 
D 28 
X 
X 
Spinal Tap5 
X 
 
 
 
Echocardiogram6 
X 
 
 
 
Bone Marrow Biology Studies7 
X 
Day 28 
X 
X 
Peripheral Blood Biology Studies7 
X 
D 1, 8, 28 
X 
X 
Oral Drug Diary 
 
Once a cycle 
Once a cycle 
 
Adverse Event/Serious Adverse Event 
Assessment 
 
X 
X 
X 
OBTAIN OTHER STUDIES AS NEEDED FOR GOOD PATIENT CARE  
1 These are the minimum labs required for the study. CBCs and Chemistries should be obtained as frequently  
   as dictated by good medical care.  
2 See Section  4.10 for timing of sirolimus levels. Trough levels w ill also be checked 5-8 days after any dose   
  adjustments are made. 
3Tumor lysis labs (electrolytes, BUN, Cr, Ca, PO4, and uric acid) should be obtained tw o times in the first w eek  
  (Section 4.7.2). If there is no evidence of tumor lysis, obtain chemistries as outlined above. On subsequent   
  cycle chemistries should be obtained at least once per cycle but more as dictated by good patient care. 
4 Patients of childbearing potential require a negative pregnancy test prior to starting treatment and per  
  institutional standards. 
5 Response w ill be evaluated at day 28 of cycle 1 and then at the end of every 28 day cycle until a  
CR/CRp is obtained. (Section 5.4)  If a patient obtains a CR or CRp on the cycle 1, day 28 bone marrow , bone     
marrow s only need to be performed if there is suspicion/evidence of relapse. The on-study bone marrow  and 
LP may be up to 14 days prior to enrollment. 
6 On study echocardiogram needs to be obtained w ithin 6 months of study initiation. 
7 Section 5.6 for timing of biology studies 

 
 
Protocol No. XXXXX 
 
 
 
1
BACKGROUND INFORMATION AND RATIONALE 
1.1 Introduction 
Children with acute leukemia, the most common pediatric malignancy, have 
benefited greatly from dramatic advances in therapy over the past two decades. 
Stepwise improvements in treatment have led to five-year event free survival rates 
approaching, and in some cases exceeding, eighty percent 1-4. However, one in five 
children will develop recurrent disease despite strategies of risk stratification and 
modern intensified chemotherapy, and their prognosis is poor 5, 6. At present 
children who have bone marrow or combined bone marrow and extramedullary 
relapses while on therapy have a 5-20% of long term survival 5. For children whose 
disease relapses off therapy the prognosis is marginally improved with a 20-50% 
rate of long-term survival 5. In addition, as therapy for initial disease is intensified, 
there is concern that recurrent disease may be more difficult to treat, and be more 
refractory to traditional chemotherapy. The number of children with relapsed acute 
leukemia equals or exceeds the incidence of most other pediatric tumors 7, 8. Only 
newly diagnosed cases of ALL, astrocytoma and neuroblastoma exceed the number 
of patients with recurrent acute leukemia.  
The primary modality of treatment for childhood NHL is intensive multiagent 
chemotherapy. The outcome in childhood NHL has improved significantly over the 
past two decades, especially in those with disseminated disease (Stage III/IV 
Murphy classification and/or Group B/C – FAB Classification) (80-90% 2 year EFS) 
9-13. Unfortunately, the long-term survival rate in children with relapsed NHL is 
dismal, with less than 20% achieving long term survival 11, 14. New treatment 
modalities are additionally required to improve the reinduction rate and durability of 
response in children with relapsed NHL. 
Thus, effective therapy for relapsed acute leukemia has emerged as one of the top 
therapeutic priorities for pediatric oncologists. Newer, targeted agents need to be 
identified and integrated into the present cytotoxic chemotherapy regimens. 
Biologically targeted cancer agents, including signal transduction inhibitors like 
mammalian target of rapamycin inhibitors (MTIs), have shown great promise in 
treating hematologic malignancies 15-17. While signal transduction inhibitors may be 
efficacious as single agents, it is more likely that these targeted agents in will 
demonstrate greater efficacy in combination with other cytotoxic agents. 
1.2 Name and Description of Investigational Product or Description of 
Intervention 
Sirolimus was initially developed as an immunosuppressive agent because it 
inhibits T-lymphocyte proliferation that occurs in response to antigenic and cytokine 
stimulation. 
In 
vivo, 
sirolimus 
binds 
to 
other 
proteins 
to generate an 
immunosuppressive complex that binds to and inhibits the activation of the 
mammalian target of sirolimus (mTOR). The inhibition of mTOR’s protein kinase 
activity inhibits a variety of signal transduction pathways including production of 
proteins that regulate the cell cycle. Sirolimus inhibits the progression of 

 
 
Protocol No. XXXXX 
 
 
 
2
Single-agent rapamycin extends mean 
survival in leukemic mice from 10 to 30 days
analysis tim e (d ays)
0
2 0
4 0
60
8 0
0 .00
0 .25
0 .50
0 .75
1 .00
untreated
treated
analysis tim e (d ays)
0
2 0
4 0
60
8 0
0 .00
0 .25
0 .50
0 .75
1 .00
0 .00
0 .25
0 .50
0 .75
1 .00
untreated
treated
p<.0001
lymphocytes from the G1-to-S phase. This may provide synergy with other cytotoxic 
agents which inhibit activity at alternative points in the cell cycle. Preclinical data 
show that sirolimus inhibits the growth of B-precursor ALL lines in vitro and has 
activity in a murine model of leukemia/lymphoma. A Phase 1 study of sirolimus 
alone has shown evidence of stable disease, but use with combined therapy needs 
to be studied. 
1.3 Findings from Non-Clinical and Clinical Studies 
1.3.1 Pre-Clinical data on mTOR Inhibitors (MTI) 
The mammalian target of rapamycin (mTOR) is a serine/threonine kinase involved 
in signal transduction pathways which regulate cell growth and proliferation 16, 18. Its 
activation triggers resting cells to increase the translation of a subset of messenger 
RNAs whose proteins are required for cell-cycle progression from the G1 to S 
phase of the cell cycle (reviewed in 16, 18). While mTOR itself has not been found to 
be mutated directly, constitutive activation of signal transduction proteins related to 
the mTOR pathway (AKT, S6K1, PI3-K) or loss of proteins linked to mTOR (PTEN) 
are found in numerous malignancies 18, 19. Studies have shown that MTIs inhibit 
growth of B-precursor ALL lines in vitro, inducing apoptosis in both primary cell 
cultures 15 and NOD/SCID xenograft models 17. Testing of the mTOR inhibitor 
sirolimus by the Pediatric Preclinical Testing Program in vitro showed maximal 
inhibition of 5 ALL cell lines ranging from 23-77%, with all 3 T-cell ALL lines having 
maximal inhibition greater than 70% 20. In vivo rapamycin induced significant EFS 
differences in 5 of 8 ALL xenografts, including 2 of 2 T-cell ALL xenografts 20. 
Sirolimus has also been found to reverse glucocorticoid resistance in resistant 
lymphoid cell lines 21. Present MTI’s under study include sirolimus, temsirolimus, 
everolimus, and deforolimus. The MTI sirolimus was chosen for use in this study as 
it is already FDA approved in children, comes in both a liquid and tablet oral 
formulation, and has readily available trough levels at all Children’s Hospitals.  
Work at CHOP using sirolimus in precursor B cell malignancies and both human 
and murine pre-B ALL cell lines have shown both inhibition of growth in culture as 
well as induction of apoptosis in these cells. The active drug concentration in these 
studies was well below 
the 
achievable 
serum 
level 
in 
patients. 
Furthermore, sirolimus is 
active as a single agent 
in a murine model of B-
precursor 
leukemia/ 
lymphoma. 
 
Eμ-Ret 
transgenic mice are a 
model of precursor B cell 
malignancy. These mice 
develop 
B-precursor 
malignancies between 4 
and 7 months of life as a 

 
 
Protocol No. XXXXX 
 
 
 
3
result of the activated tyrosine kinase expressed in the B lineage. In these 
experiments, leukemic mice with significant disease burdens were treated with 
sirolimus. When compared to untreated littermates, sirolimus-treated mice survived 
almost 3 fold longer (see Kaplan-Meier analysis of survival in treated and untreated 
mice in Figure above). In addition to extending survival, sirolimus also normalized 
the significantly elevated peripheral white blood cell counts in treated mice.  There 
was no statistically significant difference between treated and untreated mice with 
respect to the hemoglobin or platelet counts. 
1.3.2 Pre-clinical data on temsirolimus combined with chemotherapy  
In preclinical studies, ALL cells lines treated with the temsirolimus or sirolimus 
showed synergism as determined by Chou and Talalay mathematical synergy 
models with methotrexate, dexamethasone, L-asparaginase, etoposide and 
doxorubicin 22 (Figure 1). ALL cell lines treated with vincristine or cytarabine showed 
neither additive benefit nor antagonism. The combination of methotrexate and either 
sirolimus or temsirolimus was tested in 9 ALL cell lines (pre-B and T) and was 
synergistic in all cell lines (Combination Indices <1). NOD/SCID mice xenografted 
with primary human ALL were treated with either placebo, weekly MTX alone (5 -10 
mg/kg), 
weekly 
temsirolimus 
alone 
(20mg/kg), 
temsirolimus 
5 
days/wk 
(5mg/kg/dose) or a combination of the two using both temsirolimus doses 22. 
Kaplan-Meyer analysis of time to progression demonstrated a statistically significant 
difference, comparing all treatment arms to control (p <0.01), and comparing the 
combination of drugs to methotrexate only and MTI.  

 
 
Protocol No. XXXXX 
 
 
 
4
Figure 1. 
 
 
Figure 1. MTIs can be effectively combined w ith chemotherapy. Aliquots of 2 x 104 cells from 3 ALL lines 
were treated with sirolimus (rap) and 7 chemotherapeutics. Figure 1a depicts MTT data for each drug 
combination in 1 representative cell line. Grey bars represent untreated, slashed bars represent MTI 
alone, black bars represent cytotoxic alone, and dotted bars represent combined effect. All data is 
normalized to untreated baseline (=1) with a value >1 representing relative cell proliferation and <1 
inhibition. Each group of 4 bars represents a combination with a different cytotoxic agent. MTIs had at 
least an additive effect when combined with methotrexate (MTX), dexamethasone (DEX), L-
asparaginase (L-ASP), etoposide (VP-16), and doxorubicin (DOX). The combination of MTIs with 
vincristine (VCR) and Ara-C (cytarabine) did not add a benefit over either single agent alone. Doses 
depicted in figure: sirolimus (0.3ng/ml), MTX (5nM), DEX (5uM), L-ASP (1ug/ul), VP-16 (1nM), DOX 
(1nM), VCR (1nM), ARA-C (0.1ug/ml).  Next, aliquots of cells from 6 ALL lines were treated with 
methotrexate and 2 MTIs (temsirolimus (CCI) and sirolimus).  Figure 1b depicts MTT data for 
temsirolimus and methotrexate in 1 cell line (289), demonstrating a synergistic effect at multiple drug 
doses.  The other cell lines tested showed similar results. 
 

 
 
Protocol No. XXXXX 
 
 
 
5
Figure 2. A majority of mice treated with MTX + temsirolimus were cured of their 
disease, while only short-term disease control was seen with either drug alone. 
Figure 2. 
 
Figure 2.  Temsirolimus and methotrexate are synergistic and produce durable remission. NOD/SCID mice 
w ere xenografted w ith human ALL from patient samples. After establishment of ALL, mice w ere randomiz ed to 
treatment w ith vehicle, temsirolimus (CCI), methotrexate, or a combination of temsirolimus and methotrexate. 
Temsirolimus w as dosed with two schedules, 5mg/kg 5 days a w eek and 20mg/kg w eekly.  Disease was evaluated at 
w eekly intervals by FACS of peripheral blood for anti-human CD19 and anti-human CD45. Figure 2A depicts 
comparison of arms from xenografts generated from sample 359 show ing w eekly changes in blast count (WBC in 
mm3 x % blasts). As similar results w ere found for both dosing schedules only the 20mg/kg w eekly dosing is 
depicted in figure 2A. Each series of vertical bars represents average blast count in animals for a particular treated 
arm at a given timepoint. Control animals died after 3 w eeks. Mice treated w ith temsirolimus or methotrexate alone 
had improvement in disease but eventual progression. Mice treated w ith both drugs had complete resolution of 
peripheral blasts by Day 21. After 49 days (depicted by black arrow in figure 2B) all drugs w ere stopped. One half of 
the mice w ere sacrificed and no mouse receiving combination therapy had measurable disease.  The remaining mice 
w ere followed for 2 months and sacrificed. Figure 2B depicts time to progression on different arms by Kaplan-Meier 
analysis from sample 359 (top) and 240 (bottom). Figure 2C depicts immunoblots of splenocytes from sample 240 
mice treated w ith temsirolimus (“Treated”) or vehicle control (“Control”) for varying lengths of time, show ing 
decreased cyclin D1 (top row ), DHFR (second row), and phospho-S6 (pS6) (third row ), comparing treated to control 
animals. In addition, mice that w ere treated w ith temsirolimus until relapse (“Treated after Relapse”) had increased 
expression of cyclin D1 after relapse.  Depicted 240 samples in 2C from left to right: Control 7 days, Control 14 days, 
Control 21 days, Control 30 days, Treated 7 days, Treated 14 days, Treated 21 days, and Treated 30 days. 

 
 
Protocol No. XXXXX 
 
 
 
6
MTIs have been shown to prevent activation and increase degradation of cyclin-
dependent kinases, including cyclin D1 
23. Cyclin D1 is involved in Rb 
phosphorylation and release E2Fs which are involved in dihydrofolate reductase 
(DHFR) synthesis 24-26. Resistance to methotrexate has been shown in tumors that 
have high DHFR expression 27, 28. MTIs were demonstrated to increase the 
sensitivity of ALL to methotrexate by decreasing cyclin D1, which in turn decreased 
DHFR (Figure 2C). 
1.3.3 Adult Neoplastic Studies 
 
In a Phase I trial of single agent temsirolimus in adults with solid tumors doses 
ranged from 7.5 to 220mg/m2, with no MTD identified 29. At the 34mg/m2 and 
45mg/m2 doses one patient in each dose level had Grade 3 dose limiting toxicities 
(DLT) of thrombocytopenia; one also neutropenia and hypophosphatemia; the other 
had asthenia and diarrhea. Dose escalation continued to 220mg/m2 where the 
DLTs included grade 3 stomatitis, manic-depressive syndrome, transaminase 
elevation, and asthenia. At all dose levels temsirolimus (and its hydrolysis product 
sirolimus) were in the range that inhibits cancer cell proliferation in vitro 29.  
 
A variety of  MTI’s have been studied in combination with other therapies; including 
interferon in renal cell carcinoma 30, hormonal agents in breast cancer 31, 5-FU/LCV 
32, imatinib in gastrointestinal stromal tumors, gemcitabine, and sorafanib in adult 
tumors. Early data on MTI/chemotherapy combinations may have shown potential 
enhancement of expected toxicities when compared to single agent use in patients 
with solid tumors. In the 5-FU/LCV/Temsirolimus study, grade IV 
mucositis/stomatitis was observed at the 45mg/m2 level 32. Grade 3 toxicities noted 
in adult trials with temsirolimus (solo and in combination) have been rash, 
nausea/vomiting, cytopenias, hypophosphatemia, hypokalemia, hyperglycemia, 
asthenia/neuropathy, fatigue, mucositis, hypercholesteremia / hypertriglyceridemia, 
and dyspnea 29-34. 
 
The only published combination trial of an MTI and high-dose chemotherapy in 
leukemia is an adult AML Phase 1 dose escalation trial of oral daily sirolimus on a 
backbone of standard adult AML therapy consisting of 5 days each of mitoxantrone 
(8mg/m2/d), cytarabine (1gm/m2/d) and etoposide (100mg/m2/d). This trial did not 
demonstrate an increased toxicity rate with the MTI/chemotherapy combination. 
One patient had a DLT attributed to prolonged aplasia (120 days) at a sirolimus 
dose of 15mg load and 5mg daily. In the prior 4 dose levels the median time to ANC 
>500 was 27 days (range 16-38). Overall sirolimus was well tolerated and did not 
increase non-hematologic toxicity of the backbone chemotherapy 35. 
 
 
 

 
 
Protocol No. XXXXX 
 
 
 
7
1.3.4 Pediatric Neoplastic Studies 
To date 9 children have been enrolled in a sirolimus only Phase 1 study at CHOP 
(CHP-755). Four of 7 patients on Dose level 1(9mg/m2 load, 3mg/m2 daily) were 
evaluable for toxicity and none had a DLT. One of 2 patients on Dose level 2 
(12mg/m2 load, 4mg/m2 daily) have been evaluable for toxicity. There have been 
no DLT’s to date on any cycle. Average trough levels for the 3mg/m2 daily dose 
level on day 7 and 22 were 10.9 and 8.5. At the 4mg/m2 daily level (2 pts) the 
trough at day 7 and 22 were 16.1 and 7.6 
A Phase I trial of single agent once weekly IV temsirolimus in children with 
advanced solid tumors had an MTD of 75mg/m2. The DLT at the 150mg/m2 dose 
was grade 3 anorexia (1 pt) and grade 4 thrombocytopenia < 7 days (1 pt). Seven 
pts had   grade 3 treatment-related adverse events: neutropenia, leukopenia, 
anemia, anorexia, thrombocytopenia, and increased ALT. Cmax was comparable to 
adult pts; temsirolimus area under the curve (AUC) was higher in children. Greater 
exposure to parent drug appeared balanced by shorter half-life and commensurate 
lower AUC of the sirolimus metabolite. Western blot analysis of phosphorylated S6 
and Akt proteins in peripheral blood mononuclear cells confirmed temsirolimus 75 
mg/m2 significantly inhibited Akt pathway signaling in vivo 34. Inhibition was also 
seen at the 10 and 25mg/m2 dose levels (personal communication, S. Grupp). 
1.3.5 Combination therapy of MTIs and methotrexate.  
A combination of the mTOR inhibitor everolimus and methotrexate was studied in a 
randomized placebo-controlled trial in patients with rheumatoid arthritis. One-
hundred twenty-one patients were randomized to receive everolimus and 
methotrexate (mean methotrexate dose 17.5mg) or methotrexate and placebo. The 
combination was found to be effective and well tolerated. Only 2 SAEs were 
reported in the combination therapy arm (1 patient developed epiglottis and 
obstructive airway disorder and the second developed cardiac failure). One patient 
on the combination arm died of a myocardial infarction. The SAEs and death were 
not thought to be caused by the combination of agents. Mucositis was rare, 
transient, and low grade (I-II) (9 patients in combination arm and 2 in methotrexate 
alone). 36 
1.4 Selection of Drugs and Dosages 
1.4.1 Sirolimus - The dose of sirolimus is based upon the approved daily dose used 
for pediatric solid organ transplant patients (9 mg/m2 bolus day 1 and 3 mg/m2/day) 
and the lack of toxicity seen in our single agent Phase 1 trial at similar dose levels. 
Dose will then be altered to maintain a sirolimus trough level between ≥ 8 and ≤ 13.  
1.4.2 Methotrexate - The starting dose of oral methotrexate is the once weekly dose 
of methotrexate used in children with ALL during their maintenance therapy on 
present day COG trials. 37 

 
 
Protocol No. XXXXX 
 
 
 
8
1.5 Compliance Statement 
This study will be conducted in full accordance all applicable Children’s Hospital of 
Philadelphia Research Policies and Procedures and all applicable Federal and state 
laws and regulations including 45 CFR 46, 22 CFR Parts 50, 54, 56, 312, 314 and 
812 and the Good Clinical Practice: Consolidated Guideline approved by the 
International Conference on Harmonisation (ICH). Any episode of noncompliance 
will be documented. 
The investigators will perform the study in accordance with this protocol, will obtain 
consent and assent, and will report adverse events in accordance with The 
Children’s Hospital of Philadelphia IRB Policies and Procedures and all federal 
requirements. Collection, recording, and reporting of data will be accurate and will 
ensure the privacy, health, and welfare of research subjects during and after the 
study.  
1.6 Pharmacokinetics of Sirolimus 
 
The pharmacokinetics of sirolimus has been studied in healthy subjects, pediatric 
dialysis patients, hepatically-impaired adult patients, and adult renal transplant 
patients 38, 39. Oral doses of both liquid and solid sirolimus are rapidly, though 
variably, absorbed. Mean time-to-peak concentrations range from 1 hour in healthy 
subjects to 2 hours in renal transplant recipients. Half-life is upwards of 2½ days. 
Metabolism is by the intestinal and hepatic CYP3A4 enzyme family and 91% of the 
elimination of the drug is via the GI tract. The AUC correlates well with trough and 
peak concentrations. Patients who ingested the drug after a high fat breakfast did 
have delayed Cmax and it is recommended to consistently take sirolimus with or 
without food. 
In a Phase I pharmacokinetic study conducted in renal transplant patients doses 
ranging from 0.5 to 6.5 mg/m2 were administered every 12 hours 38. Phase III 
studies to date have had concomitant use of cyclosporine, steroid, or both. At a 
dose of 2 mg/day the sirolimus trough concentration was 8.58 +/- 4.0ng/ml and at 
5mg/day the trough was 17.3 +/- 7.4 ng/ml. Sirolimus concentrations in stable renal 
transplant patients are dose proportional between 3 and 12 mg/m2. Also, in this 
population a loading dose of 3 times the maintenance dose provided near steady-
state concentrations within 1 day in most patients. Stable renal transplant recipients 
have received single doses of up to 22mg/m2. No toxicity has been observed in any 
of several single dosing studies with sirolimus doses ranging from 3-22 mg/m2. 
In pediatric dialysis patients, young patients 5-11 years exhibited greater oral 
clearances and shorter half-lives. This suggests that they may need higher doses 
per body weight or surface area than adults. Patients 12 to 18 years had similar PK 
parameters as adult renal transplant patients. The variability of bioavailability in the 
pediatric group may be overcome by obtaining trough serum levels, which are 
readily available at CHOP.  

 
 
Protocol No. XXXXX 
 
 
 
9
2 
STUDY OBJECTIVES 
2.1   Primary Objectives 
 To determine the efficacy of oral sirolimus when given in combination with 
oral methotrexate in children with refractory/relapsed lymphoblastic leukemia 
or lymphoma. 
 To determine the safety and tolerability of oral sirolimus when given with oral 
methotrexate. 
2.2  Secondary Objectives 
 To characterize the trough levels produced by administration of oral sirolimus 
in children with refractory/relapsed lymphoblastic leukemia or lymphoma. 
 To evaluate the effect of sirolimus on intracellular targets, including ribosomal 
protein s6 (a marker of mTOR inhibition), AKT, P27kip1, cyclin D1, DHFR, 
Rb, and STAT5 in peripheral blood mononuclear cells, peripheral blood 
lymphoblasts, and bone marrow lymphoblasts. 
3 INVESTIGATIONAL PLAN 
This is a Phase 2 study of a daily regimen of oral sirolimus combined with once 
weekly oral methotrexate in patients with relapsed and refractory ALL and NHL. 
Patients will receive a loading dose of sirolimus followed by daily dosing through 
day 28. This will be combined with oral methotrexate weekly starting on day 2.  
 
To evaluate the primary aim of this study, the efficacy of sirolimus and 
methotrexate, when given in combination, patients will have disease evaluations 
performed after their initial 28 day cycle and then every other cycle of therapy. 
Disease response will be assessed according to Section 5.4. If there is evidence of 
efficacy in at least one of the first 9 patients the study will enroll 8 more patients. If 3 
or more patients respond of the full 17 (or original 9) then the combination will be 
considered effective.  
 

 
 
Protocol No. XXXXX 
 
 
 
10
3.1.1 
 
Sirolimus Daily: (Days: 2- 28)  PO 
3mg/m 2 
MTX Dose: (Days: 2, 9, 16, 23)  PO 
20mg/m 2 weekly 
3.1  General Schema  CHP-948 Study Design 
Do not alter daily dose 
if the trough level 
remains ≥ 8 ug/L and ≤ 13ug/L 
 
 
If there is evidence of efficacy in at least 
one of the first 9 patients the study will 
enroll 8 more patients. 
 
If 3 or more patients respond of the full 17 
(or original 9) then the combination will be 
considered effective. 
Increase daily 
dose by         
1 mg/m
2/day 
and re-check 
trough level in 
5-8 days 
Decrease daily 
dose by         
1 mg/m
2/day 
and re-check 
trough level in 
5-8 days 
> 13 ug/L 
   ≥ 8 ug/L and ≤ 13ug/L 
< 8 ug/L 
Sirolimus Day 1 Load 
PO 9 mg/m 2 
Check Day 5-8 Sirolimus trough level (ug/L) 
Adjust daily dose based on trough levels 
Check Sirolimus trough level weekly. 
 
Adjust daily dose based  
on trough levels as indicated above. 
Evaluate Disease 
Response on Day 28 

 
 
Protocol No. XXXXX 
 
 
 
11
  
3.1.1  Screening Phase 
Potential subjects will be identified through weekly Oncology patient meetings, 
clinicians and the study coordinator. Physicians may also contact the PI directly if 
they feel they have an appropriate patient. The subjects will be screened using the 
protocol inclusion and exclusion criteria. If they are found to be eligible, the CRA will 
provide the appropriate consent forms and study worksheets to the consenting 
physician.  The attending on service or the primary oncologist will approach the 
patient/family about the study. 
Parental/guardian permission (informed consent) and, if applicable, child assent, will 
be obtained prior to any study related procedures being performed. Bone marrow 
samples drawn as SOC for determining relapse will be requested for biology testing 
once the family consents to the study.  Blood samples will be drawn to confirm 
eligibility based on clinical laboratory parameters.   
3.1.2 Treatment Phase 
Once eligibility criteria are met the patient will receive the loading dose of oral 
sirolimus (9mg/m2) on day 1, followed by daily sirolimus at 3mg/m2/day. The dose of 
sirolimus will then be altered to maintain a sirolimus trough level between 8 –13. If 
the trough is < 8, the daily oral dose will be escalated by 1mg/m2/day with a repeat 
trough checked 5-8 days later. If the trough is >13, the daily oral dose will be de-
escalated by 1mg/m2/day. Once weekly oral methotrexate at 20mg/m2 will be 
started on day 2 and continued weekly.  
To evaluate the primary aim of this study, the efficacy of sirolimus and methotrexate 
given in combination, patients will have disease evaluations performed after their 
initial 28 day cycle and then every 28 days. Disease response will be assessed 
according to Section 5.4. If there is evidence of objective response in at least one of 
the first 9 patients the study will enroll 8 more patients. If 3 or more patients respond 
of the full 17 (or original 9) then the combination will be considered effective.  
 
3.1.3 Follow-up Phase 
To be eligible for the follow-up phase, subjects must have been enrolled on study 
and received at least one dose of medication. The follow-up phase will continue for 
up to 30 days after the last day medication is received or until enrollment on another 
study, whichever comes first.   
3.2 Randomization and Blinding 
None 
3.3 Study Duration, Enrollment and Number of Sites 
3.3.1 Duration of Study 
Historically 4-8 patients with relapsed ALL enroll in Phase 1 or 2 trials at CHOP 
each year. Based upon toxicity and dose levels the study is projected to run 2-3 
years. NHL patients will also be eligible and patients can be referred from other 

 
 
Protocol No. XXXXX 
 
 
 
12
sites for enrollment, possibly decreasing the maximum duration of the study to < 2 
years. 
3.3.2 Total Number of Study Sites/Total Number of Subjects Projected 
The study will initially open only a CHOP, but may open subsequently at several 
pediatric oncology centers. The maximum number of evaluable subjects enrolled 
will be 17.  
3.4 Study Population 
3.4.1 Inclusion Criteria 
1) Males or females  25 years at the time of study entry.  
2) Girls who have experienced menarche must have a negative urine/serum 
pregnancy test and must use an acceptable method of contraception, 
including abstinence, a barrier method (diaphragm or condom), Depo-
Provera, or an oral contraceptive, for the duration of the study. 
3) Parental/guardian permission (informed consent) and if appropriate, child 
assent. 
4) Histologic Diagnosis 
Patients must have documented recurrent or refractory acute lymphoblastic 
leukemia (ALL) with  10 % blasts in the marrow. Patients with recurrent or 
refractory lymphoblastic lymphoma or peripheral T-cell lymphoma must have 
radiologic or physical evidence of recurrence measurable by RECIST criteria. 
 
5) Patient must have experienced their second or greater relapse.  
6) Patient must have a disease for which there is no known curative therapy. 
7) Karnofsky  50% for patients >10 years of age and Lansky  50 for children  
10 years of age (Appendix V). 
8) Patient must be able to consume oral medication in the form of tablets or 
solution. 
3.4.2 Organ Function Requirements 
3.4.2.1 Bone Marrow Function Defined As: 
 Patients with ALL and NHL patients with tumor metastatic to bone 
marrow, who have granulocytopenia, anemia, and/or thrombocytopenia 
are eligible, but will not be evaluable for hematological toxicity.  
 
3.4.2.2 Adequate Renal Function Defined As: 
 Creatinine clearance or radioisotope GFR  70ml/min/m2  OR 

 
 
Protocol No. XXXXX 
 
 
 
13
 A serum creatinine based on age /gender as follows: 
 
3.4.2.3  Adequate Liver Function Defined As: 
 Total bilirubin  1.5 x normal for age, and 
 SGPT (ALT)  5 x normal for age and albumin  2 g/dL. 
3.4.2.4  Adequate Cardiac Function within 6 months of enrollment defined as: 
 Shortening fraction of  28% by echocardiogram, or 
 Ejection fraction of  50% by gated radionuclide study. 
3.4.2.5  Adequate Pulmonary Function Defined As: 
 Pulse ox > 94% 
3.4.3  Exclusion Criteria 
1)   Pregnancy or Breast-Feeding 
Pregnancy tests must be obtained in females of childbearing potential. 
Pregnant or lactating patients are ineligible for this study due to the unknown 
human fetal or teratogenic toxicities of sirolimus. Males or females of 
reproductive age may not participate unless they have agreed to use an 
effective contraceptive method. 
 
2)  Patients With An Uncontrolled Infection 
Patients must have any active infection under control. Fungal disease must be 
stable for at least 2 weeks before enrollment. Patients with bacteremia must 
have a documented negative blood culture prior to initiating drug.  
 
3)   Patients Who Do Not Meet Organ Function Requirements per Section 
3.4.2. 
 
4)   Patients Currently Receiving Other Investigational Anti-Neoplastic Drugs 
 

 
 
Protocol No. XXXXX 
 
 
 
14
5)   Patients who have a known allergy to sirolimus, FK506, or other mTOR 
inhibitors are not eligible. 
 
6)   Patients who relapsed after receiving sirolimus GVHD prophylaxis post-
HSCT. 
 
7)   Parents/guardians or subjects who, in the opinion of the Investigator, may 
be non-compliant with study schedules or procedures.   
 
8)   Any investigational anti-neoplastic drug use within 14 days prior to 
enrollment. 
 
9)   Subjects that do not meet all of the enrollment criteria may not be enrolled. 
Any violations of these criteria will be reported in accordance with IRB Policies 
and Procedures. 
 
 
10)  Prior Therapy 
 Patients must have fully recovered from the acute toxic effects of all 
prior chemotherapy, immunotherapy, or radiotherapy prior to entering 
this study. Patients must have recovered from the non-hematologic 
toxic effects of all prior therapy before entry into this trial. Recovery is 
defined as a toxicity grade < 2 as defined by the Common 
Terminology Criteria Version 3 (CTC v3) unless otherwise specified in 
the Inclusion and Exclusion criteria. 
 Myelosuppressive chemotherapy: Must not have been received within 
14 days of entry onto this study (28 days if prior nitrosourea). Patients 
may have received hydroxyurea OR corticosteroids if they have had 
stable or rising peripheral blast counts for three days.  
 Biologic (anti-neoplastic agent): At least 14 days since the completion 
of therapy with a biologic agent. 
 XRT:  2 wks for local palliative XRT (small port);  4 weeks must 
have elapsed if prior craniospinal XRT or if  50% radiation of pelvis;  
4 wks must have elapsed if other substantial BM radiation.  
 Bone Marrow Transplant (BMT)/Stem Cell Transplant (SCT): No 
evidence of active graft vs. host disease.  For allogeneic BMT/SCT,  
3 months must have elapsed. 
 Concomitant Medications (see also Section 4.7):  
o Hematopoietic growth factor(s): Must not have received 
within 1 week of entry onto this study except for 
erythropoietin. 

 
 
Protocol No. XXXXX 
 
 
 
15
o Steroids: Patients may have received corticosteroids within 
two weeks of entry if they have had stable or rising 
peripheral blast counts for three days. If corticosteroids 
were administered for life threatening superior vena cava 
syndrome or spinal cord compression, the patient may 
enroll when medically stable. 
 
o Hydroxyurea: Patients may have received hydroxyurea if 
they have had stable or rising peripheral blast counts for 
three days.  
 
4 STUDY PROCEDURES - TREATMENT PROGRAM 
4.1 Pre-Study/Screening Visit 
Patients must meet the eligibility criteria as indicated on the eligibility/exclusion 
criteria worksheet. (see Appendix I). All entry/eligibility studies must be performed 
within 1 week prior to entry onto the trial with the exception of imaging studies and 
echocardiograms which are required within 1 month prior to study entry and bone 
marrows/spinal taps required within 14 days. 
4.2 Treatment Plan 
 
Sirolimus Loading Dose: PO 9mg/m2 on Day 1 only. 
 
Sirolimus Daily Dose: PO 3mg/m2 on Day 2-28.  
 
Day 5-8 check trough level.  
If trough level ≥ 8 ug/L and ≤ 13 ug/L, do not alter daily dose and 
recheck level weekly.  
If < 8 ug/L increase daily dose by 1mg/m2/day and re-check trough 
level in 5-8 days.  
If > 13 ug/L decrease daily dose by 1mg/m2/day and re-check trough 
level in 5-8 days.  
Continue to modify daily sirolimus daily dose to keep trough levels ≥ 8 
ug/L and ≤ 13 ug/L. See Section 5.5.1 for information on how to obtain 
a trough level. 
 
Methotrexate: PO 20 mg/m2/week on Days 2, 9, 16, 23.  

 
 
Protocol No. XXXXX 
 
 
 
16
4.3 Definition of cycle 
One cycle is described as 28 days of therapy. Subsequent cycles will start on day 
28 of the prior cycle. There is no limit to the number of cycles a patient may receive 
as long as the patient has at least stable disease. 
 

 
 
Protocol No. XXXXX 
 
 
 
17
4.4  REQUIRED OBSERVATIONS/MATERIAL AND DATA TO BE 
ACCESSIONED DURING STUDY 
STUDIES TO BE OBTAINED 
Pre-
Study 
Cycle 1 
Subsequent Cycles 
Off 
Study 
Informed Consent/Assent 
X 
 
 
 
Demographics/Medical History 
X 
 
 
 
Physical Exam (Ht, Wt, BSA, VS) 
X 
Weekly 
Once a cycle 
X 
Performance Status 
X 
Once a cycle 
Once a cycle 
X 
CBC, differential, platelets1 
X 
Weekly 
Once a cycle 
X 
Review  Eligibility Criteria 
X 
 
 
 
TROUGH sirolimus Level2 
 
 
Day 5-8, then 
w eekly 
Day 1 of a cycle, or w ith 
any addition of a CYP3A4 
agonist 
 
Prior/Concomitant Medications 
X 
X 
X 
 
Urinalysis 
X 
 
 
 
Electrolytes including Ca++, PO4, Mg++, 
Cr, ALT, AST, Total bilirubin3  
X 
1-3 X per 
w eek 
Once a cycle 
X 
Cholesterol/Triglyceride levels 
X 
X 
Once a cycle 
X 
Pregnancy Test4 
X 
 
 
 
Tumor Disease Evaluation  
X 
D 28 
End of every other cycle 
X 
Bone Marrow  Aspirate or Biopsy 
(Response)5 
X 
D 28 
X 
X 
Spinal Tap5 
X 
 
 
 
Echocardiogram6 
X 
 
 
 
Bone Marrow  Biology Studies7 
X 
Day 28 
X 
X 
Peripheral Blood Biology Studies7 
X 
D 1, 8, 28 
X 
X 
Oral Drug Diary 
 
Once a cycle 
Once a cycle 
 
Adverse Event/Serious Adverse Event 
Assessment 
 
X 
X 
X 
OBTAIN OTHER STUDIES AS NEEDED FOR GOOD PATIENT CARE 
 
1 These are the minimum labs required for the study. CBCs and Chemistries should be obtained as frequently  
   as dictated by good medical care.  
2 See Section 4.10 for timing of sirolimus levels. Trough levels w ill be checked 5-8 days after any does 
adjustments. 
3Tumor lysis labs (electrolytes, BUN, Cr, Ca, PO4, and uric acid) should be obtained tw o times in the first w eek  
  (Section 4.7.2). If there is no evidence of tumor lysis, obtain chemistries as outlined above. On subsequent   
  cycle chemistries should be obtained at least once per cycle but more as dictated by good patient care. 
4 Patients of childbearing potential require a negative pregnancy test prior to starting treatment and per  
  institutional standards. 
5 Response w ill be evaluated at day 28 of cycle 1 and then at the end of every 28 day cycle until a  
  CR/CRp is obtained. (Section 5.4) If a patient obtains a CR or CRp on the cycle 1, day 28 bone marrow , bone 
marrow s only need to be performed if there is suspicion/evidence of relapse. The on-study bone marrow  and 
LP may be up to 14 days prior to enrollment. Patients w ith lymphoma and no bone marrow  involvement at 
diagnosis do not need repeat bone marrow s. 
6 Echocardiogram needs to be obtained w ithin 6 months of study initiation. 
7 Section 5.6 for timing of biology studies 

 
 
Protocol No. XXXXX 
 
 
 
18
4.5 Changes to the study protocol 
It is acceptable to have a 3 day window for required specimens/tests if the 
scheduled study day falls on a weekend or holiday or when schedule changes are 
necessary for patient care.  
4.6  
Study visits for all cohorts - Cycle 1 and subsequent cycles  
4.6.1 Planned follow-up Visits will be scheduled according to the roadmap.  
4.6.2 Unscheduled Visits - the oncology outpatient clinic sees all sick patients 
Monday- Friday from 8am to 4pm. After those hours and on weekends a child is 
referred to the CHOP Emergency Department and the case is reviewed with the 
oncologist-on-call.  
4.7 
Supportive Care/Concomitant Therapy 
All prior and concomitant medications used within 7 days prior to the drug initiation 
visit and through the end of the study will be recorded. Use of hydroxyurea or 
corticosteroids will be documented up to 30 days prior to drug initiation. The dates 
of administration, dosage, and reason for use will be included.  
Concomitant medications will be recorded for a period of 30 days after patients are 
no longer on study or until they are enrolled on another study.  
4.7.1 General 
Medically indicated use of antibiotics, anti-fungals, blood products, antiemetics, and 
general supportive care should be used as indicated. 
4.7.2 Tumor Lysis Syndrome 
It is recommended, but not mandated, that all subjects start allopurinol 150mg/m2 
divided TID or urate oxidase (0.1mg/kg IV) prior to the first dose of sirolimus. Serum 
chemistries, including electrolytes, BUN, Cr, and uric acid, should be monitored at 
least 2 times per week for the first week. If there is no evidence of tumor lysis the 
patients may then get routine chemistry labs as described in Section 4.4. If a 
patient’s peripheral leukemic blast count is  20,000 or if they have bulk 
lymphomatous disease it is highly recommended, although not mandated, that they 
are admitted to the hospital for IV hydration and close monitoring for metabolic 
abnormalities and renal insufficiency due to tumor lysis syndrome. 
4.7.3 Growth Factor 
Routine prophylactic use of sargramostim (GM-CSF), filgrastim (G-CSF), or peg-
filagrastim is not permitted. Therapeutic use in patients with serious neutropenic 
complications such as sepsis syndrome, fungal infection, etc., may be considered at 
the investigator’s discretion.  Sirolimus and methotrexate should be held if growth 
factor is required.  
 

 
 
Protocol No. XXXXX 
 
 
 
19
4.7.4 Hypercholesteremia/Hypertriglyceridemia 
If cholesterol and /or triglyceride levels are elevated in patients who have completed 
at least 4 cycles of therapy, and remain in a PR, CRp, or CR, the patient may be 
started on HMG-CoA inhibitors at the discretion of the treating physician. 
4.7.5 Interactions (see Appendix IV) 
Medications which may interact with the study drug (CYP3A4 modulators) are not 
allowed. Ketoconazole, tacrolimus, cyclosporine, Rifampin, and diltiazem may not 
be used while the patient is taking sirolimus. Fluconazole and voriconazole may be 
used at standard doses, but a sirolimus trough level must be checked within 5-7 
days of initiation 
4.7.6 PCP Prophylaxis 
Patients should remain on PCP prophylaxis while on study.  
4.8     Extramedullary Disease 
Patients with CNS and bone marrow involvement of ALL, or CNS involvement of 
NHL, may receive concomitant weekly intrathecal chemotherapy with IT cytarabine 
and IT hydrocortisone starting at day 8. If intrathecal chemotherapy was given with 
the on-study LP or as part of routine relapse therapy when the relapse was 
discovered the child remains eligible for enrollment. Radiation therapy should not be 
administered, except for emergent situations or persistent extramedullary disease 
with resolution of bone marrow disease (until the patient is in a CRp or CR). 
4.9 
Dose Modifications 
The daily dose of sirolimus will be modified to maintain a sirolimus trough level ≥ 8 
and ≤ 13.  
 
Sirolimus Daily Dose: PO 3mg/m2 on Day 2-28.  
 
Day 5-8: Check trough level.  
If trough level ≥ 8 ug/L and ≤ 13 ug/L, do not alter daily dose and 
recheck level weekly. 
If < 8 ug/L increase daily dose by 1mg/m2/day and re-check trough 
level in 5-8 days.  
If > 13 ug/L decrease daily dose by 1mg/m2/day and re-check trough 
level in 5-8 days.  
Continue to modify daily sirolimus daily dose to keep trough levels ≥ 8 
ug/L and ≤ 13 ug/L. See Section 5.5.1 for information on how to obtain 
a trough level. 
 
Methotrexate: PO 20 mg/m2/week on Days 2, 9, 16, 23.  

 
 
Protocol No. XXXXX 
 
 
 
20
4.9.1 Myelosuppression: If a patient with NHL non-metastatic to the marrow, or a 
patient with acute leukemia who obtains a complete remission (CR) has Grade IV 
neutropenia, Grade IV anemia, or Grade IV thrombocytopenia, oral sirolimus and 
methotrexate should be held until count recovery occurs.  All drugs should be re-
initiated at 50% dosing, and escalated by 25% increments weekly for ANC > 1,000 
and platelet count > 100.  If cytopenia persists > 14 days a bone marrow aspirate 
should be performed to evaluate for BM involvement of disease. If the cytopenia 
resolves and then re-occurs, and the patient has reached a CR, drugs can be held 
again and dose reduced by another 25%. 
 
4.9.2 Aplastic marrow: If at day 28 of the first cycle a patient has an aplastic marrow 
(spicules present) with no evidence of leukemic blasts, a second cycle may be 
initiated. If at the end of 2 cycles the marrow remains aplastic all sirolimus and 
methotrexate should be held until marrow recovery occurs, or disease become 
evident. If recovery occurs myelosuppressive therapy (methotrexate, sirolimus) may 
be re-initiated with a 50% dose reduction.  
 
4.9.3 Organ system toxicity: Drug-related irreversible (within 4 weeks of drug 
administration) Grade 3 or 4 renal, hepatic, cardiac, central nervous system toxicity 
that persists > 14 days after cessation of sirolimus and methotrexate will result in 
the patient being off protocol therapy. Sirolimus and methotrexate should be held at 
the time the toxicity is identified and if resolved within 2 weeks restarted with a 50% 
dose reduction. See section 4.9.5 for transaminitis or hyperbilirubinemia. 
 
4.9.4 Stomatitis: A sirolimus trough should be obtained when Grade II or greater 
stomatitis is identified, and drug dosage altered accordingly.  Patients with Grade III 
or greater stomatitis that does not improve in 7 days without intervention, or 
requires IV hydration or IV pain medication, should have sirolimus and methotrexate 
held until symptoms improve. Patient may re-initiate drugs with a 50% dose 
reduction of both sirolimus and methotrexate when the stomatitis resolves to Grade 
<2. Evaluate for presence of herpes simplex if indicated. 
 
4.9.5   Liver Dysfunction: For increase in hepatic transaminases (SGPT/ALT or 
SGOT/AST) to greater than 5x ULN consistent with Grade 3 toxicity, obtain Total 
bilirubin.  
 
Continue full dose therapy unless either of the following occurs: 
1) Total bilirubin > 2.0 mg/dL 
2) SGPT/ALT or SGOT/AST > 20x ULN (consistent with Grade 4 toxicity) on 
two determinations at least one week apart. 
 
If either of these occurs, hold MTX and monitor labs as above, weekly. Restart at 
full dose therapy when the transaminase is less than 5x ULN, and/or  Total bilirubin 
is normal. 

 
 
Protocol No. XXXXX 
 
 
 
21
4.10 
Rescue Medication Administration   
Routine prophylactic use of sargramostim (GM-CSF), filgrastim (G-CSF), or peg-
filagrastim is not permitted. Therapeutic use in patients with serious neutropenic 
complications such as sepsis syndrome, fungal infection, etc., may be considered at 
the investigator’s discretion.  Sirolimus and methotrexate should be held if growth 
factor is required.  
4.11 
Subject Completion/Withdrawal 
Subjects may withdraw from the study at any time without prejudice to their care.  
They may also be discontinued from the study at the discretion of the Investigator 
for lack of adherence to study treatment or visit schedules, AEs, or due to 
progression of disease. The Investigator may also withdraw subjects who violate the 
study plan, or to protect the subject for reasons of safety or for administrative 
reasons.  It will be documented whether or not each subject is evaluable. If the 
Investigator becomes aware of any serious, related adverse events after the subject 
completes or withdraws from the study, they will be recorded in the source 
documents and on the CRF. 
4.11.1 Early Termination Study Visit 
A CBC with differential will be documented at the time of study 
withdrawl/termination.  
5 STUDY ENDPOINTS AND EVALUATIONS 
5.1 Primary Endpoints 
 Efficacy of combination as determined by having at least 3 CR’s in the first 
17 evaluable patients enrolled (17% CR rate). 
 Safety and tolerability of sirolimus in combination with methotrexate   
5.2 Secondary Endpoints 
 Sirolimus median dose required to keep trough levels > 8 and ≤ 13. 
 Biology (To evaluate the effect of sirolimus on intracellular targets, 
including p70/S6 kinase (a marker of mTOR inhibition), phosphoAKT, 
P27kip1, and STAT5 in peripheral blood mononuclear cells, peripheral 
blood lymphoblasts, and bone marrow lymphoblasts.) 
5.3 Screening, Baseline and On-study Evaluations 
5.3.1 Physical Examination and current medical history will include:  
 
History of Present Illness: duration, signs, symptoms  
 
Constitutional: fever, chills, fatigue, wt. change (↑ or ↓) appetite 
change, sleep  

 
 
Protocol No. XXXXX 
 
 
 
22
 
ENT: mucositis, dental , swallowing  
 
Respiratory: cough, pneumonia Cardiovascular: chest pain, SOB  
 
GI: constipation, diarrhea, abdominal pain, nausea, vomiting  
 
Musculoskeletal: pain, h/o fracture  
 
Heme/Lymph: bruising, petechiae, bleeding  
 
Other: dehydration, electrolyte abnormality. Please explain. 
 
Infection: source/type 
 
Performance Status (Karnofsky, Lansky) 
5.3.2 Demographic Information collected includes: 
 
Age at enrollment on study 
 
Race 
 
Gender 
 
Ethnicity 
 
Diagnosis 
 
Previous Treatment Protocols (chemotherapy and radiation) 
 
Baseline toxicity present when enrolled on study.   
5.3.3  The following vital signs and anthropometric measurements will be performed 
as per Nursing Standards at The Children's Hospital of Philadelphia: 
 
Blood Pressure 
 
Respiratory Rate 
 
Heart Rate  
 
Temperature 
 
Weight and Length/Height Measurements 
5.3.4 Laboratory Evaluations obtained (Please see section 4.4) 
5.4   Efficacy Evaluations of disease status – done on Day 28 
5.4.1 Response criteria (Leukemia): 
 Complete Response (CR) - M1 bone marrow (<5% blasts) with adequate 
bone marrow cellularity, no evidence of circulating blasts or 
extramedullary disease and normalization of peripheral blood counts 
(neutrophil count =1,000/µL and platelets =100,000/ µL). 
 Complete Response in the absence of total platelet recovery (CRp) - M1 
bone marrow (<5% blasts) with adequate bone marrow cellularity, no 
evidence of circulating blasts or extramedullary disease and 

 
 
Protocol No. XXXXX 
 
 
 
23
normalization of peripheral blood counts except for platelets (neutrophil 
count =1,000/µL, platelets < 100,000uL).  
 Partial Response (PR) - M2 bone marrow (5% but <25% blasts), with no 
evidence of circulating blasts or extramedullary disease and 
normalization of peripheral blood counts (neutrophil count =1,000/µL and 
platelets =100,000/µL). A response of PR may not be assigned to a 
patient that has < 25% blasts (M3) marrow at diagnosis. 
 Stable Disease (SD) - Patient meeting neither the requirements for a PR 
or progressive disease.  
 Progressive Disease – An increase of at least 25% in the absolute 
number of leukemic cells in peripheral blood or bone marrow, the 
development of extramedullary disease, or other evidence of increased 
tumor burden. 
5.4.2 Response Criteria (for NHL patients) 
This study will use the (RECIST) Response Evaluation Criteria in Solid 
Tumors from the NCI.  Patients may be enrolled with evaluable disease 
but not measurable disease. These patients will not be evaluated for 
response. Initial disease response evaluation is at day 28 of cycle 1. If a 
patient has obtained a PR or SD they should continue to be imaged at the 
end of every 28 day cycle. Once a CR is obtained, imaging of the primary 
will be every other cycle. 
 Measurable Disease - The presence of at least one lesion that can be 
accurately measured in at least one dimension with the longest diameter 
at least 20 mm.  With spiral CT scan, lesions must be at least 10 mm.  
The investigator will identify up to 10 measurable lesions to be followed 
for response. 
 Serial measurements of lesions are to be done with CT or MRI.  The 
same method of assessment is to characterize each identified and 
reported lesion at baseline and during follow-up. 
 Quantification of Disease Burden - The sum of the longest diameter (LD) 
for all target lesions will be calculated and reported as the disease 
measurement. 
 Complete Response (CR) - Disappearance of all target lesions.  If 
immunocytology is available, no disease must be detected by that 
methodology. 
 Partial Response (PR) - At least a 30% decrease in the disease 
measurement, taking as reference the disease measurement done to 
confirm measurable disease at study entry. 

 
 
Protocol No. XXXXX 
 
 
 
24
 Progressive Disease (PD) - At least a 20% increase in the disease 
measurement, taking as reference the smallest disease measurement 
recorded since the start of treatment; or the appearance of one or more 
new lesions. 
 Stable Disease (SD) - Neither sufficient shrinkage to qualify for PR nor 
sufficient increase to qualify for PD taking as reference the smallest 
disease measurement since the treatment started. 
5.4.3   Response Assessment  
Serial measurements of lesions are to be done with CT or MRI on Day 28.  
The same method of assessment is to characterize each identified and 
reported lesion at baseline and during follow-up. 
5.4.3.1 Quantification of Disease Burden -The sum of the longest diameter (LD) for 
all target lesions will be calculated and reported as the disease 
measurement. 
5.4.3.2 Complete Response (CR) -Disappearance of all target lesions. If 
immunocytology is available, no disease must be detected by that 
methodology. 
5.4.3.3 Partial Response (PR) - At least a 30% decrease in the disease 
measurement, taking as reference the disease measurement done to 
confirm measurable disease at study entry. 
5.4.3.4 Progressive Disease (PD) - At least a 20% increase in the disease 
measurement, taking as reference the smallest disease measurement 
recorded since the start of treatment; or the appearance of one or more 
new lesions. 
5.4.3.5 Stable Disease (SD) - Neither sufficient shrinkage to qualify for PR nor 
sufficient increase to qualify for PD taking as reference the smallest disease 
measurement since the treatment started. 
5.4.3.6 Response Assessment - Each patient will be classified according to their 
“best response” for the purposes of analysis of treatment effect. Best 
response is determined from the sequence of the objective statutes 
described above. 
5.4.3.7 Best Response - Two objective status determinations of CR before 
progression are required for best response of CR.  Two determinations of 
PR or better before progression, but not qualifying for a CR, are required for 
a best response of PR.  Two determinations of stable/no response or better 
before progression, but not qualifying as CR or PR are required for a best 
response of stable/no response; if the first objective status is unknown, only 
one such determination is required.  Patients with an objective status of 
progression on or before the second evaluations (the first evaluation is the 

 
 
Protocol No. XXXXX 
 
 
 
25
first radiographic evaluation after study drug has been administered) will 
have a best response of increasing disease.  Best response is unknown if 
the patient does not qualify for a best response of increasing disease and if 
all objective statuses after the first determination and before progression 
are unknown. 
Use of the definition is illustrated in Table 1 with several sequences of 
objective statuses and the corresponding best response. The best response 
is the same if these sequences are preceded by the objective statuses of 
unknown or stable or if unknowns separate the first objective status from 
the second. 
Table 1.  Sequences of objective statuses with corresponding best response. 
1st Status 
2nd Status 
3rd Status 
Best Response 
Progression 
Stable, PR, CR 
Unk 
Stable 
Stable, Unk 
Stable, Unk 
PR 
PR 
PR, CR 
CR 
Unknown 
 
Progression 
Progression 
Stable  
PR, CR 
Unknown 
PR 
CR 
Unknown 
CR 
Stable 
 
 
 
Progression 
Progression 
Progression 
Progression 
Progression 
Progression 
Progression 
Progression 
Increasing Disease 
Increasing Disease 
Increasing Disease 
Stable 
Stable 
Unknown 
PR 
PR 
Unknown 
CR 
Stable 
 
5.5 Pharmacokinetic Evaluation 
5.5.1 Description of Assay 
Plasma sirolimus levels will be determined by commercially available assay. Trough 
levels should be obtained 20-24 hours from the prior dose. Patients should be 
advised NOT to take the sirolimus in the morning prior to the clinic appointment 
when trough levels are going to be obtained. 
5.5.2  Sampling Schedule 
Sirolimus levels should be obtained prior to the dose on days 5-8 and then weekly if 
target trough level is met. If the sirolimus dose level is modified a repeat trough 

 
 
Protocol No. XXXXX 
 
 
 
26
should be obtained in 5-8 days. If the drug is held for toxicity a level should be sent 
at the time the drug is held. In subsequent cycles levels should be obtained weekly 
and modified as described in section 4.9.  If drugs that are metabolized through 
CYP 4A3 are added to the patient’s regimen a trough level should be obtained 
within 5-7 days.  
5.5.3 Sample Collection and Handling Instructions 
3-4 cc in a purple top (EDTA) tube to be sent to central dispatch for shipment to the 
commercial assay laboratory. Record the exact time that the sample is drawn along 
with the exact time that the drug was administered. This should be a TROUGH 
level: patients should be advised NOT to take the sirolimus prior to the clinic 
appointment. 
5.6  
Biology Studies  
5.6.1 Peripheral Blood Mononuclear Cells/ Peripheral Blood Lymphoblasts 
Peripheral blood mononuclear cells will be collected on Days 1, 8, and 28.  If a 
patient is removed from study due to progressive disease peripheral blood should 
also be sent on the day that they are withdrawn. 
5.6.2 Bone Marrow 
 
Bone marrow will be collected prior to study and on day 28.  The day 28 marrow 
may be replaced by peripheral blood if peripheral leukemic blast count is >5,000ul. 
If a patient with NHL has a negative bone marrow at enrollment they do not require 
repeat bone marrows. 
 
5.6.3 Collection of Bone Marrow or Peripheral Blood: 
 
Bone marrow aspiration: 
 Collect 5 mL of bone marrow in preservative free heparin (100 units heparin/1 
mL of bone marrow) by aspiration. 
Peripheral blood collection: 
 Collect peripheral blood (15 mL in children >10 kg weight, 10 mL in children   
≤10 kg weight) in 1-3 green top (sodium heparin) tubes. 
 
Shipment Of Peripheral Blood or Bone Marrow: 
 Place bone marrow or peripheral blood in polypropylene screw top tube(s). 
 Label tube with patient’s registration number, the study ID (CHP X), and date 
and time it was drawn. 
 Place tube(s) in container. 
 Place the container with the conical tube in styrofoam box.  
 Package sample as appropriate for biologic material. 
 Ship the sample on the same day it was obtained with Federal Express 
overnight priority delivery to: 

 
 
Protocol No. XXXXX 
 
 
 
27
 
Dr. Stephen Grupp’s lab 
The Children's Hospital of Philadelphia 
CTRB, Room 3006 
 
 3501 Civic Center Blvd. 
Philadelphia, PA 19104 
 
Attention: David Teachey, MD 
Phone: Yueh Chang (215)-590-6118 
  
Phone: David Teachey, MD (267) 426-5802, pager 15386  
 Samples must be received within 24 hours of obtaining the sample. 
 Do not ship samples for delivery on a weekend or holiday 
 
5.6.4  Documenting specimen delivery 
All specimens (blood and bone marrow) will be delivered and labeled with the 
patient ID number upon arrival in the lab. Any patient identifying information will be 
removed upon arrival. The research assistant will deliver the specimens to Dr. 
Grupp’s lab and all specimens will be signed for including the following information:  
 type of specimen 
 amount (cc and number of tubes) 
 date and time specimen obtained 
 person delivering 
 person accepting 
 date delivered 
 time delivered 
 
6 STATISTICAL CONSIDERATIONS  
To evaluate the primary aim of this study, the efficacy of sirolimus and methotrexate 
when given in combination, patients will have disease evaluations performed after 
their initial 28 day cycle and then every cycle of therapy as indicated by peripheral 
counts.  
 
The following Simon’s two stage design will be used:  
 
Cumulative Number of Responses Decision: 
 
Stage 1: Enter 9 patients  
 
responses 
 
0  
 
 
Terminate the trial: agent ineffective 
 
1 CR/CRp or 2 PRs Inconclusive result, continue trial (proceed to stage 2) 
 
 
 
Stage 2: Enter 8 additional patients  

 
 
Protocol No. XXXXX 
 
 
 
28
 
responses 
 
2 or less  
Terminate the trial: agent ineffective 
 
3 or more  
Terminate the trial: agent effective 
 
We will consider sirolimus/methotrexate not of sufficient interest for further 
evaluation if the true response rate is 5% and of sufficient activity/interest if the true 
response rate is 25%. The optimal two-stage design to test the null hypothesis that 
P<=0.050 versus the alternative that P>=0.250 has an expected sample size of 
11.96 and a probability of early termination of 0.630. If the drug is actually not 
effective, there is a 0.047 probability of concluding that it is. If the drug is actually 
effective, there is a 0.188 probability of concluding that it is not. After testing the 
drug on 9 patients in the first stage, the trial will be terminated if 0 respond. If there 
has been no responses when patient  9 enrolls, further enrollment will be 
suspended until that patient is fully evaluable. The second tier will not enroll until the 
medical monitor and study committee meet and certify responses and toxicity. If the 
trial goes on to the second stage, a total of 17 patients will be studied. If the total 
number responding is less than or equal to 2, the drug combination is rejected. 
 
6.1   Sample Size and Study Duration 
Total number of evaluable patients enrolled will be 17.  Historically 4-8 patients with 
relapsed ALL enroll in Phase 1 or 2 trials at CHOP each year. Based upon toxicity 
and dose levels the study is projected to run 2-2.5 years. NHL patients will also be 
eligible and patients can be referred from other sites for enrollment, possibly 
decreasing the maximum duration of the study to < 2 years. 
6.2 
Statistical Analysis 
6.2.1  Clinical Trial Analysis 
Patient characteristics such as age, gender, ethnicity, disease, and disease status, 
will be tabulated with descriptive statistics.  All severe adverse events will be 
tabulated.  The overall and disease specific percentage of patients responding will 
be calculated with 95% confidence intervals. Kaplan-Meier analysis will be used to 
describe the time to disease progression for patients receiving sirolimus. 
6.2.2  Biology Study Analysis 
The presence of p70/S6 kinase, phospho-AKT, p27kip1 and STAT5 will be assayed 
in leukemic blasts at day 0, day 8, (if peripheral blasts remain present) and day 28 
from the bone marrow. DHFR, cyclin D1 and Rb will also be evaluated. They will 
also be evaluated at time of progression. These signaling intermediates will also be 
assessed in peripheral blood mononuclear cells.  Expression levels of these 
molecules will be quantified by gel densitometry and described with summary 
statistics.  Levels of expression will be compared with paired t-tests. 
 
 

 
 
Protocol No. XXXXX 
 
 
 
29
6.3 
Definitions 
6.3.1 Evaluable For Toxicity 
Any patient who receives at least one dose of sirolimus will be evaluable for 
Adverse Effects.  
 
6.4 
Inclusion Of Women And Minorities 
The study is open to all participants regardless of gender or ethnicity.  Review of 
accrual to past COG studies of new agents demonstrates the accrual of both 
genders and all NIH-identified ethnicities to such studies.  The small number of 
patients entered into this trial will obviate any analysis of variation in toxicity profile 
or response rate with gender or ethnicity. 
6.5 
Statistical Methods 
6.5.1 Baseline Data  
Baseline and demographic characteristics will be summarized by standard 
descriptive summaries (e.g. means and standard deviations for continuous 
variables such as age and percentages for categorical variables such as gender). 
6.5.2 Efficacy Analysis - Clinical Trial Analysis 
The primary analysis will be based on an intention to treat approach and will include 
all subjects who complete 1 cycle of therapy.  
Patient characteristics such as age, gender, ethnicity, disease, and disease status, 
will be tabulated with descriptive statistics.  All severe adverse events will be 
tabulated.  The overall and disease specific percentage of patients responding will 
be calculated with 95% confidence intervals. Kaplan-Meier analysis will be used to 
describe the time to disease progression for patients receiving sirolimus. 
6.5.3 Pharmacokinetic Analysis 
Mean and median serum trough levels will be determined for each patient on study. 
Correlation between trough levels and toxicity will be analyzed. Trough levels will 
also be correlated to response data in a descriptive manner 
6.5.4 Biology Study / Pharmacodynamic Analysis 
The presence of ribosomal protein s6, AKT, p27kip1 and STAT5 will be assayed in 
leukemic blasts at day 0, day 8 (if peripheral blasts remain present) and day 28 
bone marrow and peripheral blood. DHFR, cyclin D1 and Rb will also be evaluated. 
They will also be evaluated at time of progression. These signaling intermediates 
will also be assessed in peripheral blood mononuclear cells. Changes in protein 
levels will be quantified by gel densitometry and described with summary statistics.  
Relative changes in protein expression will be compared using the paired student t-
test. 

 
 
Protocol No. XXXXX 
 
 
 
30
6.5.5 Safety Analysis 
Example: All subjects entered into the study at Visit 1 will be included in the safety 
analysis. The frequencies of AEs by type, body system, severity and relationship to 
study drug will be summarized. SAEs (if any) will be described in detail. 
AE incidence will be summarized along with the corresponding exact binomial 95% 
two-sided confidence intervals. 
7   STUDY MEDICATION 
7.1 Description - Source and Pharmacology:  Sirolimus (Rapamune®, 
rapamycin) 
 
Approved roadmap abbreviation:  SIR 
NSC#226080  
SIROLIMUS (AY-22989, rapamycin, Rapamune®) NSC# 226080 (01/17/08) 
 
Source and Pharmacology: Sirolimus is a macrocyclic lactone produced by 
Streptomyces hygroscopicus. Sirolimus is a potent immunosuppressive agent which 
prolongs the survival of the host and transplanted grafts in animal transplant models 
of kidney, heart, skin, islet, small bowel, pancreatico-duodenal, and bone marrow. In 
rodent models of autoimmune disease, sirolimus suppresses immune-mediated 
events associated with systemic lupus erythematosus, collagen-induced arthritis, 
autoimmune type I diabetes, autoimmune myocarditis, experimental allergic 
encephalomyelitis, graft-versus-host disease, and autoimmune uveoretinitis. 
Sirolimus inhibits T lymphocyte activation and proliferation that occurs in response 
to antigenic and cytokine (Interleukin {Altman,  #65}-2, IL-4, and IL-15) stimulation 
by a mechanism that is distinct from that of other immunosuppressants. Sirolimus 
also inhibits antibody production. In cells, sirolimus binds to the immunophilin, FK 
Binding Protein-12 (FKBP-12), to generate an immunosuppressive complex. The 
sirolimus: FKBP-12 complex has no effect on calcineurin activity. This complex 
binds to and inhibits the activation of the mammalian Target Of Rapamycin (mTOR), 
a key regulatory kinase. This inhibition suppresses cytokine-driven T-cell 
proliferation, inhibiting the progression from the G1 to the S phase of the cell cycle. 
In some studies, the immunosuppressive effect of sirolimus lasts up to 6 months 
after discontinuation of therapy. The plasma protein binding of sirolimus is 
approximately 92% mainly to albumin, alpha-1-acid glycoprotein and lipoproteins 
and has a high level of association with erythrocytes. Following administration of 
sirolimus oral solution, sirolimus is rapidly absorbed, with a mean time-to-peak 
concentration of approximately 1 hour (range 1-3 hours). The systemic availability of 
sirolimus was estimated to be approximately 14% after the administration of 
sirolimus oral solution. The mean bioavailability of sirolimus after administration of 
the tablet is about 27% higher relative to the oral solution. Sirolimus oral tablets are 
not bioequivalent to the oral solution; however, clinical equivalence has been 
demonstrated at the 2-mg dose level. Sirolimus is extensively metabolized by O-
demethylation and/or hydroxylation to at least seven major metabolites. The parent 
drug contributes to more than 90% of the immunosuppressive activity. The main 

 
 
Protocol No. XXXXX 
 
 
 
31
route of elimination is through the feces (91%). The mean t 1/2 increased from 79 ± 
12 hours in subjects with normal hepatic function to 113 ± 41 hours in patients with 
impaired hepatic function. Males have a 12% lower clearance of sirolimus than 
females after oral solution administration. No differences were demonstrated 
between black and non-blacks. After administration of the oral solution and tablets 
with a high fat meal, the maximum concentration was reduced, and the time to 
maximum concentration was increased. The total exposure to drug (AUC) was also 
increased. Sirolimus is a substrate for both cytochrome P450 IIIA4 (CYP3A4) and 
P-glycoprotein (P-gp). Sirolimus is extensively metabolized by the CYP3A4 isozyme 
in the intestinal wall and liver and undergoes counter-transport from enterocytes of 
the small intestine into the gut lumen by the P-gp drug efflux pump. Sirolimus is 
potentially recycled between enterocytes and the gut lumen to allow continued 
metabolism by CYP3A4. Therefore, absorption and subsequent elimination of 
systemically absorbed sirolimus may be influenced by drugs that affect these 
proteins. Drugs that stimulate or inhibit p-450 enzymes will alter clearance of 
sirolimus and close attention to potential drug interactions is crucial. 
 
7.1.1 SIROLIMUS: 
Toxicity 
 
Common 
Happens to 21-100  
children out of every 
100 
 
 
Occasional 
Happens to 5-20 
children out of every 
100 
Rare 
Happens to <5 children out of 
every 100 
 
Immediate 
Within 1-2 
days of 
receiving 
drug 
 
Headache (L), 
hypertension (L), 
nausea, 
immunosuppression 
(L), diarrhea, 
constipation, fever 
Chest pain, insomnia, 
dyspepsia, vomiting, 
dyspnea 
Hypotension, asthma, 
increased cough, flu like 
syndrome, tachycardia, 
anorexia, sensitivity reactions 
 
Prompt 
Within 2-3 
weeks, prior 
to the next 
course 
Tremor (L), renal 
dysfunction, elevated 
creatinine/BUN, 
anemia, asthenia, pain 
(abdominal, back, 
pain), hyperlipidemia, 
hypercholesteremia, 
hypertrigylceridemia, 
hyperglycemia, 
peripheral edema, 
weight gain, arthralgia 
 
Elevated LFTs, UTI, 
URIs, mild 
thrombocytopenia, 
leukopenia, 
hyper/hypokalemia 
(L), 
hypophosphatemia, 
rash, hives, pruritis, 
hyperuricemia, 
delayed wound 
healing, 
hypomagnesaemia (L) 
 
Gastritis, esophagitis, 
flatulence, CNS 
abnormalities: (confusion (L), 
somnolence (L), depression 
(L), anxiety, anxiousness, 
paresthesias, emotional 
labiality, hypo/hypertonia, 
dizziness, neuropathy, 
hypesthesia, nervousness), 
infections (bacterial, fungal, 
viral-sepsis, cellulitis, 
herpes simplex & zoster, EBV, 
mycobacterial, sinusitis, 
pharyngitis, abscess, 
pneumonia, bronchitis, 
peritonitis), pleural effusions, 

 
 
Protocol No. XXXXX 
 
 
 
32
pleural edema, hypoxia 
thrombosis, thrombophlebitis, 
myalgia, delayed wound 
healing, 
 
Delayed 
Any time 
later during 
therapy, 
excluding 
the above 
conditions 
Acne 
 
Skin ulcer, hirsutism 
(hypertrichosis) (L), 
gingival hyperplasia, abnormal 
vision, ear pain, cataracts, 
otitis, tinnitus, hemorrhage, 
ileus, chronic renal 
dysfunction, renal tubular 
necrosis, post transplant 
diabetes mellitus (L), CHF, 
ascites, thrombocytopenic 
purpura (hemolyticuremic 
syndrome), arthrosis, bone 
necrosis, osteoporosis 
Late 
Any time 
after 
completion 
of treatment 
 
 
Lymphoproliferative disorders, 
skin malignancies 
 
Unknown 
Frequency 
and Timing 
Sirolimus was embryo/feto-toxic in rats at dosages of 0.1mg/kg and above 
(approximately 0.2 to 0.5 the clinical doses adjusted for body surface area). 
Embryo/feto toxicity was manifested as mortality and reduced fetal weights (with 
associated delays in skeletal ossification). Sirolimus is excreted in trace amounts 
in milk of lactating rats.  It is not known whether sirolimus is excreted in human 
milk. 
 
7.1.2 Formulation and Stability: 
Sirolimus is available as an oral solution containing 1 mg/mL sirolimus. Sirolimus is 
also available as a white, triangular-shaped tablet containing 1-mg sirolimus, and as 
a yellow to beige triangular-shaped tablet containing 2-mg sirolimus. The inactive 
ingredients in sirolimus oral solution are Phosal 50 PG ® (phosphatidylcholine, 
propylene glycol, mono- and di-glycerides, ethanol, soy fatty acids, and ascorbyl 
palmitate) and polysorbate 80. Sirolimus oral solution contains 1.5%-2.5% ethanol. 
 
The inactive ingredients in sirolimus tablets include sucrose, lactose, polyethylene 
glycol 8000, calcium sulfate, microcrystalline cellulose, pharmaceutical glaze, talc, 
titanium dioxide, magnesium stearate, povidone, poloxamer 188, polyethylene 
glycol 20,000, glyceryl monooleate, carnauba wax, and other ingredients. The 2 mg 
dosage strength also contains iron oxide yellow 10 and iron oxide brown 70. 
Sirolimus oral solution should be stored protected from light and refrigerated at 2°C 
to 8°C (36°F to 46°F). Once the bottle is opened, the contents should be used 
within one month. If necessary, the patient may store the bottles at room 
temperatures up to 25°C (77°F) for a short period of time (e.g., not more than 15 
days for the bottles). Amber syringes and caps are provided for dosing and the 

 
 
Protocol No. XXXXX 
 
 
 
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product may be kept in the syringe for a maximum of 24 hours at room 
temperatures up to 25°C (77°F) or refrigerated at 2°C to 8°C (36°F to 46°F). The 
syringe should be discarded after one use. After dilution, the preparation should be 
used immediately. Sirolimus oral solution provided in bottles may develop a slight 
haze when refrigerated. If such a haze occurs allow the product to stand at room 
temperature and shake gently until the haze disappears. The presence of this haze 
does not affect the quality of the product. Sirolimus tablets should be stored at 20°-
25°C (68°-77°F). Use cartons to protect blister cards and strips from light. Dispense 
in a tight, light-resistant container as defined in the USP.  
 
7.1.3 Guidelines for Administration:  
Sirolimus Administration, Monitoring and Dose Adjustments –  
Sirolimus is available in pill or liquid form. Because the liquid has a bitter taste, pills 
have generally been better tolerated and are preferred. If administration of the liquid 
is necessary, the drug can be mixed with water or orange juice or given through an 
NG/NJ tube (do not give with grapefruit juice). If enteral tubes are used they must 
be primed with sirolimus prior to administration of the medication. Levels of 
sirolimus should be drawn at least twice per week while hospitalized, then weekly or 
monthly thereafter unless a change in medication (e.g. use of itraconazole) or liver 
function might result in an acute change in level. At that point, levels will be 
measured as clinically indicated. Levels of sirolimus must be assayed by HPLC or 
HPLC-MS. If ELISA or other immunoassays are used, laboratories must have 
performed standardization titers compared to HPLC methods and dosing targeting 
and reporting must be adjusted to conform to the HPLC standard. 
 
Administer at a consistent time of day and at consistent intervals with regard to 
meals. Sirolimus may be given with food as long as it is given the same way each 
time; however, administration with food significantly alters the rate and extent of 
absorption. The amber oral dose syringe should be used to withdraw the prescribed 
amount of sirolimus oral solution from the bottle. In order to improve palatability, it is 
recommended that the correct amount of sirolimus from the syringe be emptied only 
into a glass or plastic container holding at least two (2) ounces (1/4 cup, 60 mL) of 
water or orange juice. No other liquids, including grapefruit juice, should be 
used for dilution. Stir vigorously and drink or administer at once. Refill the 
container with an additional volume (recommended minimum of four 40 ounces (1/2 
cup, 120 mL) of water or orange juice, stir vigorously, and drink or administer at 
once to assure delivery of all of the medication. Small children may not be able to 
consume the recommended volumes of water or orange juice suggested for dilution 
and may need lesser volumes. 
 
See Treatment and Dose Modifications sections of the protocol. 
 
Supplier: Commercially available. See package insert for further information. 
 
Concomitant Medications/Drug Interactions: Sirolimus is a CYP 3A4 inhibitor 
and a P-glycoprotein substrate. Because of this, patients on medications that are 

 
 
Protocol No. XXXXX 
 
 
 
34
CYP 3A4, 5, or 7 substrates or inhibitors may have an increase in sirolimus level 
(see table below). Conversely, patients who start taking CYP 3A4, 5, or 7 inducers 
may have a decrease in sirolimus levels. Any patient on any of the medications 
listed (See Appendix V) needs to have careful monitoring of sirolimus to keep 
the levels in the therapeutic range. 
 
7.2 
METHOTREXATE (MTX, amethopterin, Trexall®) NSC #000740 (102006) 
 
Source and Pharmacology: A folate analogue which reversibly inhibits dihydrofolate 
reductase, the enzyme that reduces folic acid to tetrahydrofolic acid. Inhibition of 
tetrahydrofolate formation limits the availability of one carbon fragments necessary 
for the synthesis of purines and the conversion of deoxyuridylate to thymidylate in 
the synthesis of DNA and cell reproduction. The polyglutamated metabolites of MTX 
also contribute to the cytotoxic effect of MTX on DNA repair and/or strand breaks. 
MTX cytotoxicity is highly dependent on the absolute drug concentration and the 
duration of drug exposure. MTX is actively transported across cell membranes. At 
serum methotrexate concentrations exceeding 0.1μmol/mL, passive diffusion 
becomes a major means of intracellular transport of MTX. The drug is widely 
distributed throughout the body with the highest concentration in the kidney, liver, 
spleen, gallbladder and skin. Plasma concentrations following high dose IV MTX 
decline in a biphasic manner with an initial half-life of 1.5-3.5 hours, and a terminal 
half life of 8-15 hours. About 50% is bound to protein. After oral administration, 
approximately 60% of a 30 mg/m2 dose is rapidly absorbed from the GI tract, with 
peak blood levels at 1 hour. At doses >30mg/m² absorption decreases significantly. 
Even at low doses absorption may be very erratic, varying between 23% and 95%. 
The elimination of MTX from the CSF after an intrathecal dose is characterized by a 
biphasic curve with half-lives of 4.5 and 14 hours. After intrathecal administration of 
12mg/m², the lumbar concentration of MTX is ~ 100 x’s higher than in plasma. 
(Ventricular concentration is ~ 10% of lumbar concentration). MTX is excreted 
primarily by the kidneys via glomerular filtration and active secretion into the 
proximal tubules. Renal clearance usually equals or exceeds creatinine clearance. 
Small amounts are excreted in the feces. There is significant entero-hepatic 
circulation of MTX. The distribution of MTX into third-space fluid collections, such as 
pleural effusions and ascitic fluid, can substantially alter MTX pharmacokinetics. 
The slow release of accumulated MTX from these third spaces over time prolongs 
the terminal half-life of the drug, leading to potentially increased clinical toxicity. 
 
7.2.1 Toxicity: 
 
 
 
Common 
Happens to 22-
100 children 
out of every 
100 
Occasional 
Happens to 5-20 
children out of 
every 100 
Rare 
Happens to < 5 children 
out of every 100 
Immediate: 
Within 1-2 
Transaminase 
elevations 
Nausea, vomiting, 
anorexia, 
Anaphylaxis, chills, fever, dizziness, 
Malaise, drowsiness, blurred vision, 

 
 
Protocol No. XXXXX 
 
 
 
35
days of 
receiving 
drug 
 
 
 
 
acral erythema, urticaria, pruritis, 
toxic epidermal necrolysis, Stevens-
Johnson Syndrome, tumor lysis 
syndrome, Seizures1, 
photosensitivity 
Prompt: 
Within 2-3 
weeks, prior 
to the next 
course 
 
 
Myelosuppression, 
stomatitis, 
Gingivitis, 
photosensitivity, 
Fatigue 
 
Alopecia, folliculitis, acne, renal 
toxicity (ATN, increased 
creatinine/BUN, hematuria), 
enteritis, GI ulceration and bleeding, 
acute neurotoxicity1 (headache, 
drowsiness, aphasia, pareisis, 
blurred vision, transient blindness, 
dysarthria, hemiparesis, decreased 
reflexes) Diarrhea, conjunctivitis 
Delayed: 
Any time 
later during 
therapy 
 
 
Learning 
disability1 (L) 
 
Pneumonitis, pulmonary fibrosis(L), 
Hepatic fibrosis (L), osteonecrosis 
(L), leukoencephalopathy1 (L), 
pericarditis, Pericardial effusions, 
hyperpigmentation of the nails 
Late: 
Any time 
after 
completion 
of treatment 
 
 
 
Progressive CNS deterioration1 
 
Unknown 
Frequency 
and Timing: 
 
Methotrexate crosses the placenta. Fetal toxicities and teratogenic effects 
of methotrexate have been noted in humans. The toxicities include: 
congenital defects, chromosomal abnormalities, severe newborn 
myelosuppression, low birth weight, abortion, and fetal death. Methotrexate 
is excreted into breast milk in low concentrations 
 1 May be enhanced by HDMTX and/or cranial irradiation. 
(L) Toxicity may also occur later. 
 
7.2.2 Formulation & Stability 
Methotrexate for oral use is available as 2.5mg, 5.0mg, 7.5mg, 10mg and 15 mg 
tablets. Inactive ingredients vary depending on manufacturer but tablet formulations 
may include: anhydrous lactose, crospovidone, hydroxypropyl methylcellulose, 
magnesium stearate, microcrystalline cellulose, polyethylene glycol, polysorbate 80, 
pregelatinized starch, sodium carbonate monohydrate, talc and titanium dioxide and 
various dyes. Store at controlled room temperature 15°-30°C (59°-86°F) and protect 
from light. 
 
Methotrexate for Injection is available as a lyophilized powder for injection in 20 mg 
and 1 gm vials. The powder for injection contains approximately 0.14 mEq sodium 
in the 20 mg vial; 7 mEq sodium in the 1 g vial. Methotrexate for Injection is also 
available as a 25mg/mL solution in 2,4,8,10,20 and 40mL preservative free vials 
and 2 and 10mL vials with preservative. The 2, 4, 8, 10, 20, and 40 mL solutions 
contain approximately 0.43, 0.86, 1.72, 2.15, 4.3, and 8.6 mEq sodium per vial, 

 
 
Protocol No. XXXXX 
 
 
 
36
respectively. The preserved vials contain 0.9% benzyl alcohol as a preservative and 
must not be used for intrathecal or high dose therapy. 
 
Sterile methotrexate powder or solution is stable at 20 to 25 Cº (68 to 77 Fº); 
excursions permitted to 15 to 30 Cº (59 to 86 Fº). Protect from light 
 
Guidelines for Administration: See Treatment and Dose Modification sections of the 
protocol. 
 
Oral administration: Food delays absorption and reduces peak concentration. MTX 
for oral use should preferentially be given on an empty stomach, 1 hour before or 2 
hours after a meal and at the same time each day. Oral methotrexate solution may 
be substituted for the oral tablet dosage form.  
Supplier: Commercially available from various manufacturers. See package insert 
for further information 
7.3  
Drug Accountability 
Patients, or their guardian, will be provided a prescription of the daily dose of 
sirolimus. They will receive the initial loading dose in the oncology clinic or as an 
inpatient. A prescription for the assigned methotrexate dose will also be provided to 
the patient/family. A daily drug diary will be provided to the families to document all 
oral, at home, doses of study medications.  
8.0 
SAFETY MANAGEMENT 
8.1 
Clinical Adverse Events 
Clinical adverse events (AEs) will be monitored throughout the study.  
8.2 
Adverse Event Reporting 
The Investigator is responsible for recording and reporting unanticipated problems 
related to research that occur during and after study treatment.  The plan for 
Adverse Event reporting should be consistent with the CHOP IRB Guidelines. For 
example: “All on-site SAEs (CHOP or related sites) will be reported to the IRB in 
accordance with CHOP IRB policies. AEs that are not serious will be summarized in 
narrative or other format and submitted to the IRB at the time of continuing review.” 
8.2.1 General Guidelines For All Adverse Events 
Adverse event collection and reporting is a routine part of every clinical trial.  The 
first step is to identify the event using the Common Toxicity Criteria (CTC) V3. ALL 
serious adverse events (SAEs) will be reported to the IRB. 
A copy of the Common Terminology Criteria (CTC) version V3 can be downloaded 
from the CTEP home page (http://ctep.info.nih.gov).  All appropriate treatment areas 
should have access to a copy of the CTC version 3.0.   The severity of the event 
should then be graded using the CTC criteria.  Next, determine if the adverse event 

 
 
Protocol No. XXXXX 
 
 
 
37
is related to the medical treatment or procedure (attribution).  If so, determine 
whether the adverse event is expected or unexpected.  With this information and 
the adverse event reporting section in each protocol, the investigator can determine 
whether an adverse event should be reported to the IRB as an expedited report or a 
routine report. 
8.2.2 Persistent Adverse Events 
An adverse event that persists from one course (cycle) to another should only be 
reported once unless the grade becomes more severe in a subsequent course.  An 
adverse event, which resolves and then re-occurs during a different course (cycle) 
must be reported each course (cycle) it re-occurs. 
A patient experiences Grade 3 thrombocytopenia during cycle one.  During cycle 
two the adverse event persists but the severity remains unchanged.  During cycle 
three the adverse event persists but increases in severity to Grade 4.  The following 
should be submitted as expedited reports: 
Cycle One – Grade 3 Thrombocytopenia 
Cycle Two – No Report 
Cycle Three – Grade 4 Thrombocytopenia 
8.2.3 Baseline Adverse Events 
An adverse event should NOT be reported if a patient is entered on a study with a 
pre-existing condition (e.g., elevated laboratory value).  If the adverse event 
increases in severity, the investigator should re-assess the event to determine if the 
event should be reported.  No modification in grading should be made to account for 
abnormalities noted at baseline.  For example: 
A patient enters a trial with an AST equivalent to Grade 1.  If the AST remains 
unchanged at the end of cycle one, the adverse event should NOT be reported.  If 
the AST increases to a Grade 3 level, the adverse event should be re-assessed and 
reported if it fulfills the other adverse event reporting criteria.  The AST would be 
reported at Grade 3 with no adjustment for the baseline AST equivalent to Grade 1. 
A patient enters a study with diarrhea equivalent to Grade 2.  The diarrhea resolves 
during the first cycle of therapy.  If, during a subsequent cycle the patient 
experienced Grade 2 diarrhea, the adverse event should be re-assessed and 
reported if it fulfills adverse event reporting guidelines. 
8.3 
Definition of an Adverse Event 
An adverse event is any untoward medical occurrence in a subject who has 
received an intervention (drug, biologic, or other intervention).  The occurrence does 
not necessarily have to have a causal relationship with the treatment.  An AE can 
therefore be any unfavorable or unintended sign (including an abnormal laboratory 

 
 
Protocol No. XXXXX 
 
 
 
38
finding, for example), symptom, or disease temporally associated with the use of a 
medicinal product, whether or not considered related to the medicinal product. 
All AEs (including serious AEs) will be noted in the study records and on the case 
report form with a full description including the nature, date and time of onset, 
determination of non-serious versus serious, intensity (mild, moderate, severe), 
duration, causality, and outcome of the event. 
8.4 
Definition of a Serious Adverse Event (SAE) 
An SAE is any adverse drug experience occurring at any dose that results in any of 
the following outcomes:  
 death, 
 a life-threatening event (at risk of death at the time of the event),  
 requires inpatient hospitalization or prolongation of existing hospitalization, 
 a persistent or significant disability/incapacity, or 
 a congenital anomaly/birth defect in the offspring of a subject.   
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug event when, based upon 
appropriate medical judgment, they may jeopardize the subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this 
definition. 
A distinction should be drawn between serious and severe AEs. A severe AE is a 
major event of its type.  A severe AE does not necessarily need to be considered 
serious.  For example, nausea which persists for several hours may be considered 
severe nausea, but would not be an SAE.  On the other hand, a stroke that results 
in only a limited degree of disability may be considered a mild stroke, but would be 
an SAE.  
8.4.1 Relationship of SAE to study drug or other intervention 
The relationship of each SAE to the study intervention should be characterized 
using one of the following terms in accordance with CHOP IRB Guidelines: 
definitely, probably, possibly, unlikely or unrelated.  
8.5 
IRB/IEC Notification of SAEs 
The Investigator is responsible for promptly notifying the IRB of all study on-site 
SAEs and other unanticipated problems related to research using the CHOP 
Internal SAE reporting form and in accordance with the following timeline.  
Type of Internal Adverse 
Event 
Initial Notification  
(Phone, Email, Fax) 
Written Report 

 
 
Protocol No. XXXXX 
 
 
 
39
Internal (on-site) SAEs 
Death or Life 
Threatening  
24 hours 
Within 2 calendar days 
Internal (on-site) SAEs 
Unexpected and Related  
7 days 
Within 7 business days 
Unanticipated Problems 
Related to Research 
7 days  
Within 7 business days 
All other SAEs 
N/A 
Summary of SAEs Reported 
at Time of Continuing 
Review 
8.5.1 Follow-up report 
If an SAE has not resolved at the time of the initial report, a follow-up report 
including all relevant new or reassessed information (e.g., concomitant medication, 
medical history) will be submitted to the IRB. All SAE will be followed until either 
resolved or stable.  
8.6 
Investigator Reporting of a Serious Adverse Event to Sponsor 
Reporting will be in accordance with regulatory requirements. 
8.7 
Medical Emergencies 
Any child on trial will be evaluated emergently as needed in the outpatient oncology 
clinic or emergency department as indicated.  
9.0 
STUDY ADMINISTRATION 
9.1 
Treatment Assignment Methods - None 
9.2 
Data Collection and Management-  
 Confidentiality will be maintained by providing a de-identified patient ID 
number. This number will be used in the database. All specimens from The 
Children's Hospital of Philadelphia will be sent with patient labels. Once the 
assays are run, the information will be reported using the de-identified patient 
ID number.  The statistical analysis will only contain de-identified ID 
numbers.   
 A master list containing PHI and subject ID will be kept in the study binder 
separate from data forms that have only a study ID number. The master list 
will be on a separate computer in the study coordinator's office which will be 
locked.  
 
 All data and records generated during this study will be kept confidential in 
accordance with Institutional policies and HIPAA. Investigator and other site 

 
 
Protocol No. XXXXX 
 
 
 
40
personnel will not use such data and records for any purpose other than 
conducting the study. All records will be kept in a locked filing cabinet in the 
office of the Research Coordinator.  
 All files will be password protected on a computer that will be password 
protected as well. 
1. Security.  A copy of the password-protected file will be on the research 
coordinator's computer in a locked office along with the original file which will 
be stored in one of the Hospital’s secure servers. 
2. Anonymization, de-identification or destruction.  The identifiers for all patients 
will be destroyed after publication.  The other data will be retained for three 
years.  The laboratory maintains a file drawer specifically for such archives, 
each folder labeled “Destroy by a certain date,” with the earliest dates at the 
front.”   
9.3 
Regulatory and Ethical Considerations 
9.3.1 Data and Safety Monitoring Plan 
The Principal Investigator will monitor the study regularly and review all evaluations 
of patients’ eligibility, evaluability, and dose limiting toxicities in the study database. 
If of the first 6 patients enrolled, DLTs of the combination are noted in at least 2, the 
study will be temporarily closed and either modified or terminated as the dose 
combination is considered too toxic.  
 
At least every 6 months the PI will meet with 2 of the other co-chairs of the study 
committee and the medical monitor, Frank Balis, MD, to review all potential DLTs 
and assign proper attribution. They will also determine official response based upon 
the criteria in Section 5.4. 
The study PI and medical monitor will also independently review all serious, 
unexpected, (possibly) related SAEs and all other unanticipated problems involving 
risks to research subjects or others. 
 
After 9 patients have enrolled and had response based criteria the Review 
Committee will meet to decide progression to Stage 2 or Study termination if the 
combination is deemed ineffective. 
 
All SAE’s that are unexpected and related will be reported to the IRB as outlined in 
Section 8.5 by the PI and the study coordinator. All other significant events will be 
summarized at the time of continuing review. 
 
 
9.3.2 Risk Assessment -  
Medication: 

 
 
Protocol No. XXXXX 
 
 
 
41
 Sirolimus – see Section 7.1.1 above for a list of medication toxicities 
 Methotrexate - see Section 7.2 above for a list of medication toxicities 
Procedures: 
 Bone Marrow Aspirate- minor increase above minimal risk, often being 
performed as standard of care. 
 Peripheral blood draw (through Broviac, port, peripheral IV)- minimal risk, 
often being performed as standard of care. 
Risks are a minor increase above minimal or greater than minimal and have a 
prospect for direct benefit. The major risk to the patient enrolled on trial is the 
individual and combined drug toxicities which are being defined in the study. The 
risk of the study related procedures are minimal and are often standard of care for 
patients with refractory and relapsed ALL/NHL.  
9.3.3 Potential Benefits of Trial Participation –  
The potential benefit of the combination treatment with sirolimus and methotrexate 
is that it may cause patients cancer to stop growing or to decrease production for a 
period of time. It may lessen the symptoms, such as pain, that are caused by the 
disease. We know that methotrexate is effective in treating ALL and NHL in newly 
diagnosed patients and in relapsed patients.  Because there is no information about 
this combination’s effect on cancer in humans, we do not know if there will be any 
direct benefit from participating in this study. Information learned from this study 
may help future patients with ALL/NHL 
 
9.3.4 Risk-Benefit Assessment 
Patients enrolling on this trail have been refractory to multiple first and second line 
drug combinations to treat ALL/NHL. If untreated, the patient will die of disease. 
This drug combination involves greater than minimal risk to participants, but the 
risks are reasonable when balanced with the prospect for benefit and the alternative 
outcome.  
9.4 
Recruitment Strategy 
Eligible subjects will be identified during weekly meetings where potential 
candidates are discussed. The primary oncologist for the patient can request 
information about the study from the Principal Investigator to determine if the study 
is appropriate and the patient is eligible. An eligibility checklist will be sent to the 
attending physician to screen for eligibility. If the patient is eligible, their primary 
doctor will review the study with the parents (patient if appropriate) during a clinic 
visit or if they are inpatient, a meeting will be set up to see if they are interested in 
participating. Patients will come from The Children's Hospital of Philadelphia and 
other hospitals who have eligible patients. The subjects may be the investigator's 
patients or from other care providers.  

 
 
Protocol No. XXXXX 
 
 
 
42
9.5 
Informed Consent/Assent 
The primary oncologist or member of the study team will approach the family to 
discuss the protocol and obtain consent and assent.  
9.6 
Payment to Subjects/Families 
There will be no payment to subjects or families. 
10    
PUBLICATION 
It is planned that the results of this study will be published in the appropriate cancer 
journal.  

 
 
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43
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appendix I: Eligibility Criteria Form  
 

 
 
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APPENDIX I: Pre-screening - Eligibility/Exclusion Criteria Worksheet 
 
Phase 2 Trial of Sirolimus with Methotrexate in Relapsed/Refractory Lymphoblastic Leukemia and Lymphoma 
 
Patient ID:__________Patient Initials:__________ 
 
1.  Is the patient age 25 or younger? 
 
                            
□Yes              □ No  
2.  ALL:  Histologic diagnosis with >10% blasts in the marrow?   
□Yes              □ No  
     NHL: Radiologic evidence of Relapse?   
 
 
 
□Yes              □ No  
3.  Is this the patient’s second or greater relapse?  
 
 
□Yes              □ No  
4.  Lansky  50% if  age 10? 
 
 
  
            
□Yes              □ No  
     Karnofsky  50% if   age 10? 
 
 
 
 
□Yes              □ No  
5.  Pregnancy Test Negative?   
 
 
 
 
□Yes              □ No 
6.  Creatinine clearance or radioisotope GFR  70ml/min/m2 OR   
□Yes              □ No 
     a serum creatinine based on age /gender as identified in 
     Protocol section 3.4.2.2? 
 
 
 
 
 
□Yes              □ No 
7.  Pulse ox >94%? 
 
 
 
 
 
 
□Yes              □ No 
8   Uncontrolled infection?  
 
 
 
 
 
□Yes              □ No 
     If yes: 
     Patients with fungal disease: stable for 14 days? 
 
 
□Yes              □ No 
□ N/A 
     Patients with bacteremia: negative blood culture? 
 
 
□Yes              □ No  
□ N/A 
9.  Total Bilirubin <1.5 x normal for age?  
            
 
□Yes              □ No   
     ALT < 5 x normal for age? 
 
 
            
 
□Yes              □ No   
     Albumin  2g/dL? 
    
 
 
 
 
 
□Yes              □ No   
10. Shortening fraction by echo  28% OR  
 
          
 
□Yes              □ No   
      Ejection fraction  50% by gated radionuclide study 
      within 6 months? 
            
 
 
          
 
□ Yes             □ No   
11. Patient is not taking other investigational anti-neoplastic drugs? 
□Yes              □ No  
12. Patient does not have known allergies to sirolimus,  
      FK-506 or mTOR inhibitors.   
 
 
 
 
□Yes              □ No  
13. Has no existing non-hematologic toxicities > grade 2?  
 
□Yes              □ No  
 
14. Patient received no myelosuppressive chemo within 14 days? 
□Yes              □ No  
      (2 if prior nitrosourea.) 
 
 
 
 
  
15. The PI has been contacted if the patient has had Hydroxyurea  
      OR Corticosteroids within 14 days of enrollment? 
 
 
□Yes              □ No  
16. Patient has not taken any biologic agents within 14 days? 
 
□Yes              □ No 
17.  14 days have elapsed since local palliative XRT (small port) 
□Yes              □ No  
       28 days since prior craniospinal XRT or 50% radiation of pelvis? 
□Yes              □ No  
       28 days if other substantial BM radiation?  
 
  
□Yes              □ No  
18.  For BMT/SCT - no evidence of active GVHD. 
 
 
□Yes              □ No  
       For Allogeneic BMT/SCT,  3 months must have elapsed. 
 
□Yes              □ No  
19.  No Hematopoietic growth factors within 7 days of entry? 
 
□Yes              □ No  
       (except erythropoietin.) 
20.  Does the patient have Extramedullary Disease? 
 
 
□Yes              □ No           □ N/A 
22.  Does the patient have bone marrow Involvement? 
 
 
□Yes 
          □ No           □ N/A 
22.  Signed informed consent?  
 
 
 
 
□Yes 
          □ No 
 
 
 
 
 
. 
    
      Clinician Name ___________________________________________   
    
      Clinician Signature___________________________________   Date____________  
 
 
      PI signature__________________________________________ Date____________  
 
 
 
 

 
 
Protocol No. XXXXX 
 
 
 
45
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                                       Appendix II: Roadmap for Therapy  

 
 
Protocol No. XXXXX 
 
 
 
46
Last Name _________________   First Name__________________  MRN: ______________  PH # _________                                                      
Cycle # _______      Wt               .     kg       Ht               .    cm      BSA     .          m2                           
Methotrexate 
OBSERVATIONS - Description
(MTX) - oral
Trough Level 
≥ 8 and ≤ 13ug/L
 Due
Given
D A Y
Actual Dose Given
Trough Level
OBSERVATIONS 
1
  ______  mg LOAD
See above
1,2,3,4,5,6,8 (blood),9
2
____mg DAILY
_   __mg
3
___mg
4
4
___mg
5
___mg
4
6
___mg
7
___mg
8
___mg
1,3,4,5,7,8 (blood)
9
___mg
_   __mg
10
___mg
11
___mg
12
___mg
4
13
___mg
14
___mg
15
___mg
1,3,4,5,7
16
___mg
_   __mg
17
___mg
18
___mg
19
___mg
4
20
___mg
21
___mg
22
___mg
1,3,4,5,7
23
___mg
_   __mg
24
___mg
25
___mg
4
26
___mg
27
___mg
28
___mg
1,3,4,8 (blood&BM),9
Day 1:             Loading Dose - 9 mg/m² 
< 8ug/L 
increase daily dose by 1 mg/m²/day
Days 2-28:     Daily Dose - 3 mg/m² 
Sirolimus - oral 
CHP-948: A PHASE 2 TRIAL OF SIROLIMUS WITH MTX IN RELAPSED/REFRACTORY LYMPHOBLASTIC LEUKEMIA AND LYMPHOMA
Adjusted Total Daily Dose/m2
>13 ug/L
decrease daily dose by 1 mg/m²/day
no change
 Check trough level 5-8 days after starting daily dose
Days 2,9,16,23 
PATIENT LABEL
recheck in 5-8 days
recheck weekly
SIROLIMUS dose
recheck in 5-8 days
DATE
MTX  dose
20 mg/m²
Set 1: History, PE(Ht,Wt,VS)                                             
Set 2: Pregnancy Test/Perfermance Scale                            
Set 3: CBC, differential, platelets                                         
Set 4: Tumor lysis labs, electrolytes (Sect 4.2)                      
Set 5: ALT, AST, Total Bilirubin                                           
Set 6: Cholesterol/Triglycerides                                           
Set 7: Sirolimus Trough Levels                                            
Set 8: Biology Studies (Sect 5.6)                                         
Set 9: Tumor Disease Evaluation & BM
Trough
Dose

 
 
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47
 

 
 
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48
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appendix III- Medication Diary 

 
 
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49
 

 
 
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50
 
Appendix IV - relevant drug interactions 

 
 
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51
Appendix V: Performance Status Scales/Scores 
PERFORMA NCE STATUS CRITERIA 
Karnofsky and Lansky performance scores are intended to be multiples of 10 
ECOG (Zubrod) 
Karnofsky 
Lansky* 
Score 
Description 
Score 
Description 
Score 
Description 
0 
Fully active, able to 
carry on all pre-
disease performance 
w ithout restriction. 
100 
Normal, no complaints, 
no evidence of disease 
100 
Fully active, normal. 
90 
Able to carry on normal 
activity, minor signs or 
symptoms of disease. 
90 
Minor restrictions in 
physically strenuous 
activity. 
1 
Restricted in 
physically strenuous 
activity but 
ambulatory and able 
to carry out w ork of a 
light or sedentary 
nature, e.g., light 
housew ork, office 
w ork. 
80 
Normal activity w ith 
effort; some signs or 
symptoms of disease. 
80 
Active, but tires more 
quickly 
70 
Cares for self, unable to 
carry on normal activity 
or do active w ork. 
70 
Both greater restriction 
of and less time spent 
in play activity. 
2 
Ambulatory and 
capable of all self-
care but unable to 
carry out any w ork 
activities.  Up and 
about more than 50% 
of w aking hours 
60 
Required occasional 
assistance, but is able to 
care for most of his/her 
needs. 
60 
Up and around, but 
minimal active play; 
keeps busy w ith 
quieter activities. 
50 
Requires considerable 
assistance and frequent 
medical care. 
50 
Gets dressed, but lies 
around much of the 
day; no active play, 
able to participate in all 
quiet play and 
activities. 
3 
Capable of only 
limited self-care, 
confined to bed or 
chair more than 50% 
of w aking hours.  
40 
Disabled, requires 
special care and 
assistance. 
40 
Mostly in bed; 
participates in quiet 
activities. 
30 
Severely disabled, 
hospitalization indicated.  
Death not imminent. 
30 
In bed; needs 
assistance even for 
quiet play. 
4 
Completely disabled.  
Cannot carry on any 
self-care. Totally 
confined to bed or 
chair. 
20 
Very sick, hospitalization 
indicated.  Death not 
imminent. 
20 
Often sleeping; play 
entirely limited to very 
passive activities. 
10 
Moribund, fatal 
processes progressing 
rapidly. 
10 
No play; does not get 
out of bed. 
 
 
 

 
 
Protocol No. XXXXX 
 
 
 
52
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