A Phase II Trial of Cyclophosphamide, Topotecan, and Bevacizumab (CTB) in Patients With Relapsed/Refractory Ewing's Sarcoma and Neuroblastoma
Phase: PHASE2
Conditions: Neuroblastoma, Sarcoma
Sponsor: Memorial Sloan Kettering Cancer Center

  
 
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Pediatric Oncology Experimental Therapeutics Investigators’ Consortium (POETIC) 
 
A Phase II Trial of Cyclophosphamide, Topotecan, and Bevacizumab (CTB) in Patients 
with Relapsed/Refractory Ewing’s Sarcoma and Neuroblastoma 
 
Study Drug 
Bevacizumab (Avastin®) 
 
Support Provided By 
Genentech, Inc. 
 
Sponsor Investigator 
Tanya Trippett, M.D. 
Lia Gore, M.D. 
 
Sub-Investigators 
David Lyden, M.D., Ph.D. 
 
Aru Narendran, M.D., Ph.D. 
 
Research Nurse 
Geraldine Wright, RN 
 
Statistician 
     Irina Ostrovnaya, Ph.D. 
 
 
 
 
 
Study Number 
POE10-01 
 
Protocol History 
Version 1.0  
11/30/2011 
Version 2.0  
01/30/2013 
Version 3.0  
01/05/2016  
 
 
 
 
 
 
 

  
 
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Principal 
Investigator: 
 
 
Tanya Trippett, MD 
POETIC Data and Coordinating Center 
Memorial Sloan-Kettering Cancer Center 
1275 York Avenue 
New York, NY 10021 
Telephone     (212) 639-8267 
Fax                (212) 717-3239 
E-mail            Trippet1@mskcc.org  
Data Managers: 
 
Stephanie Limones 
POETIC Data and Coordinating Center 
Memorial Sloan-Kettering Cancer Center 
405 Lexington Avenue, Room 3-516 
New York, NY 10174 
 
Telephone         (646) 888-5714 
Fax                    (646) 888-5726 
E-mail                limoness@mskcc.org  
 
 
Co-Principal 
Investigators: 
Lia Gore, MD 
University of Colorado Health Sciences Center and 
The Children’s Hospital 
Box B115 
13123 East 16th Avenue 
Aurora, CO 80045 
Telephone   (720) 777-2879 
Fax              (720) 777-7289 
E-mail          lia.gore@ucdenver.edu  
 
Debra Schissel, RN 
University of Colorado Health Sciences Center 
and The Children’s Hospital 
Box B115 
13123 East 16th Avenue 
Aurora, CO 80045 
Telephone   (720) 777-2879 
Fax              (720) 777-7289 
Email           Debra.Schissel@Childrenscolorado.org 
Investigator(s): 
 
 
 
Jessica Boklan, MD 
Phoenix Children’s Hospital 
Center for Cancer and Blood Disorders 
1919 E. Thomas Road / Outpatient Bldg B 
Phoenix, AZ  85016-7710 
Telephone    (602) 546-0920 
Fax               (602) 546-0276 
E-mail           jboklan@phoenixchildrens.com  
Sam Chimienti 
Phoenix Children’s Hospital 
Center for Cancer & Blood Disorders 
1919 E. Thomas Road / Outpatient Bldg B 
 Phoenix, AZ  85016-7710 
 Telephone    (602) 546-5004 
 Fax               (602) 546-0211  
 E-mail           schimienti@phoenixchildrens.com 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

  
 
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Tony Truong, MD 
Alberta Children's Hospital 
2888 Shaganappi Trail NW 
Calgary, Alberta  T3B 6A8 
Telephone     (403) 955-2946 
Fax                (403) 955-2645 
E-mail        Tony.Truong@albertahealthservices.ca 
Karen Mazil, RN 
Alberta Children's Hospital 
2888 Shaganappi Trail NW 
Calgary, Alberta  T3B 6A8 
Telephone     (403) 955-2242 
Fax                (403) 955-7684 
E-mail            karen.mazil@albertahealthservices.ca 
 
 
Keith August, MD 
Children’s Mercy Hospitals and Clinics 
2401 Gillham Rd. 
Kansas City, MO, 64108 
Telephone     (816) 234-3059 
Fax                (816) 855-1958 
E-mail            kjaugust@cmh.edu 
Amber Jenkins MSc, CCRC 
Children’s Mercy Hospitals and Clinics 
2401 Gillham Rd. 
Kansas City, MO, 64108 
Telephone     (816) 302-6891 
Fax                (816) 302-9894 
E-mail            andempsey@chm.edu 
 
 
Lisa M. McGregor, MD, PhD 
Pennsylvania State University College of Medicine 
500 University Drive; MC H085 
 Hershey, PA  17033-0850 
Telephone     (717) 531-6012 
Fax                (717) 531-4789 
 E-mail            lmcgregor@hmc.psu.edu 
 
Kathryn Byrnes, BS, CCRP 
Pennsylvania State University College of Medicine 
500 University Drive; H085, Room C7830 
 Hershey, PA  17033-0850 
Telephone     (717) 531-3098 
Fax                (717) 531-0120 
 E-mail            kbyrnes@hmc.psu.edu 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

  
 
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TABLE OF CONTENTS 
                                                                         Page # 
1.0 BACKGROUND………………………………………………………………………....... 
8 
1.1 Disease Background ........................................................................................ 
8 
1.1.1 Rationale for Targeting VEGF in Pediatric Malignancies ...................  
8 
1.2 Bevacizumab Clinical Experience .................................................................... 
9 
1.2.1 Safety Profile ..................................................................................... 10 
1.3 Other Study Drug(s) Background ..................................................................... 18  
1.4 Study Rationale ............................................................................................... 19 
1.5 Rationale for Correlative Studies ..................................................................... 20 
1.5.1 Rationale for Investigating EPCs/HPCs .............................................  20 
1.5.2 Soluble markers of angiogenesis for the assessment of biological     
activity during bevacizumab based therapy .......................................  22 
1.5.3 Understanding tumor-related processes through metabolic profiling ..  22 
1.5.4 The impact of bevacizumab on growth and development in children.. 23 
2.0 OBJECTIVES ........................................................................................................ 23 
2.1  
Primary ................................................................................................... 23 
2.2  
Secondary ............................................................................................... 23 
2.3  
Exploratory .............................................................................................. 24 
3.0 STUDY DESIGN .................................................................................................... 24 
3.1 
Description of the Study ............................................................................. 24 
3.2 
Rationale for Study Design......................................................................... 24 
3.3 
Outcome Measures .................................................................................... 25 
3.3.1 Primary Outcome Measures .............................................................. 25 
3.3.2 Secondary Outcome Measures ......................................................... 25 
3.3.3 Safety Outcome Measures ................................................................ 25 
4.0 SAFETY PLAN ...................................................................................................... 25 
4.1 
General Plan to Manage Safety……………………………………………….. 
25 
5.0 STUDY SUBJECTS ............................................................................................... 27 
5.1 
Subject Selection ....................................................................................... 27 
5.2 
Inclusion Criteria ........................................................................................ 27 
5.3 
Exclusion Criteria ....................................................................................... 28 
6.0 STUDY DESIGN………………………………………………………………………… 
30 
6.1 
Treatment Plan .......................................................................................... 31 
6.2  
Number of Centers ..................................................................................... 31 

  
 
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6.3  
Number of Subjects.................................................................................... 31 
6.4  
Estimated Study Duration........................................................................... 32 
7.0 STUDY MEDICATION ........................................................................................... 32 
7.1 
Bevacizumab Dosage and Formulation  ..................................................... 32 
7.1.1 
Bevacizumab Administration ........................................................ 32 
7.1.2 
Bevacizumab Storage .................................................................. 32 
7.1.3 
Bevacizumab Dose Modification and Toxicity Management.........  33 
7.1.4 
Investigational Agent Management………………………………..... 36  
7.1.5 
Drug Accountability ...................................................................... 37 
7.1.6 
Disposition of Used Supplies ....................................................... 38 
7.1.7 
Inventory of Unused Supplies ...................................................... 38 
7.2 
Protocol-Specified Chemotherapy .............................................................. 39 
7.2.1 
Cyclophosphamide (Cytoxan) NSC #26271……………………….  39 
7.2.1.1   
Source and Pharmacology……………………………………  39 
7.2.1.2     Formulation………………………………………………… ......  39 
7.2.1.3     Storage……………………………………………………….....  39 
7.2.1.4      Reconstitution……………………………………………… ......  40 
7.2.1.5      Stability………………………………………………………… .  40 
7.2.1.6      Administration……………………………………………… ......  40 
7.2.1.7      Supplier………………………………………………………… .  40 
7.2.1.8      Safety profile… ................................................................... 40 
 
7.2.2          Topotecan, NSC #609699, IND #34494……… ............................  41 
7.2.2.1          Source and Pharmacology  ..............................................   41 
7.2.2.2          Formulation...................................................................... 41 
7.2.2.3          Storage ............................................................................ 41 
7.2.2.4          Reconstitution .................................................................. 41 
7.2.2.5          Stability ............................................................................  41 
7.2.2.6          Administration .................................................................. 42 
7.2.2.7          Supplier ........................................................................... 42 
7.2.2.8          Safety profile .................................................................... 42 
7.3 
Concomitant Medications ........................................................................... 43 
7.3.1 Prior Treatment ....................................................................................  43 
7.3.2 Permitted Treatment ............................................................................ 43 
8.0 CLINICAL AND LABORATORY EVALUATIONS ................................................... 44 

  
 
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8.1 
Pretreatment Evaluations ........................................................................... 44 
8.2 
Evaluations During Treatment .................................................................... 45 
8.3 
Post-Treatment Evaluations ....................................................................... 46 
8.4 
Study Termination Visit .............................................................................. 46 
8.5 
Overall Survival and Time To Progression .................................................  46 
8.6 
Criteria For Therapeutic Response/Outcome Assessment .........................  49 
8.6.1  Definition of Response in Patients ..................................................... 49 
8.6.1.1 Measureable Disease .................................................................. 49 
8.6.1.2 Non-Measureable Disease .......................................................... 49 
8.6.1.3 Target Lesions ............................................................................. 50 
8.6.1.4 Non-Target Lesions ..................................................................... 50 
8.6.1.5 Guidelines for Evaluation of Measurable Disease ........................  50 
8.6.2  Response Criteria .............................................................................. 51 
8.6.2.1       Evaluation of Target Lesions ................................................. 51 
8.6.2.2       Evaluation of Non-Target Lesions ..........................................  51 
8.6.3       Evaluation of Best Overall Response .............................................  52 
8.6.4       Confirmatory Measurement/Duration of Response .........................  52 
8.6.4.1 Confirmation ................................................................................ 52 
8.6.4.2 Duration of Response .................................................................. 52 
8.6.4.3 Duration of Stable Disease .......................................................... 53 
8.7 
Correlative Studies ..................................................................................... 53 
8.7.1 Pharmacokinetic Analysis..................................................................... 53 
8.7.2 Assessment of Angiogenic Profile ........................................................ 54 
8.7.3 Expression of Angiogenesis Associated Serum Biomarkers .................  55 
8.7.4 Metabolic Signature Analysis through Magnetic Resonance           
Spectroscopy ....................................................................................... 56 
8.7.5 Assessment of Impact of Bevacizumab on Growth and Development ..  57 
9.0  SUBJECT DISCONTINUATION ............................................................................ 57 
10.0 STUDY DISCONTINUATION ................................................................................ 58 
11.0 STATISTICAL METHODS ..................................................................................... 58 
11.1 Determination of Sample Size ....................................................................... 58 
11.2 Stratification of Accrual…………… ................................................................ 58 
11.3 Planned Efficacy Evaluations ........................................................................ 58 
11.3.1 
Primary Efficacy Variables .............................................................. 58 

  
 
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11.3.2 
Secondary Efficacy Variables ......................................................... 59 
11.3.3 
Methods of Analysis ....................................................................... 59 
11.4  Analysis of Correlative Studies...................................................................... 59 
12.0 SAFETY REPORTING OF ADVERSE EVENTS…. ...............................................  60 
12.1 Adverse Events Reporting and Definitions .................................................... 60 
12.2 Reporting of Serious Treatment Emergent Adverse Events ..........................  61 
12.2.1 Reporting of STEAE to Sponsor ......................................................... 63 
12.3 Safety Reporting Requirements for IND Holders ...........................................  64 
12.4 Safety Reporting Requirements for IND Exempt Studies ...............................  66 
13.0     RETENTION OF RECORDS .............................................................................. 66 
14.0     RECRUITEMENT PLAN/INFORMED CONSENT PROCEDURES .....................  66 
15.0 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION        
PROCEDURES .................................................................................................. 68 
15.1 Research Participant Registration .................................................................  69 
15.2  Randomization .............................................................................................. 69 
16.0   DATA MANAGEMENT ISSUES ........................................................................... 69 
16.1 Data and Coordinating Center ....................................................................... 69 
16.2 Site Research Staff ........................................................................................ 70 
16.3 Administrative Support ................................................................................... 71 
16.4 Additional IRB Correspondence ..................................................................... 72 
16.5 Quality Assurance ..........................................................................................  72 
16.6 Data and Safety Monitoring ........................................................................... 73 
16.7 Therapeutic Response Review ...................................................................... 74 
17.0   PROTECTION OF HUMAN SUBJECTS ............................................................... 74 
17.1 Privacy ........................................................................................................... 74 
 
 
REFERENCES 
 
APPENDICES  (Separate Documents) 
 
 
Appendix A: 
Study Flowchart 
Appendix B:  Informed Consent 
Appendix C: 
NCI Common Toxicity Criteria 
Appendix D: 
FDA MedWatch 3500a Form 
Appendix E: 
NYHA Guidelines 
Appendix F: 
Procedure for Obtaining a Urine Protein / Creatinine Ratio 

  
 
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Appendix G:  Blood Pressure Normal Values in Children 
Appendix H:  Serum Creatinine Normal Values in Children 
Appendix I:      Procedural Manual 
 
1.0 
BACKGROUND 
1.1 
Disease Background 
Angiogenesis, the formation of new blood vessels, is one of the key hallmarks of cancer 
and has been shown to be essential for tumor growth and metastasis.1  Amongst the 
tumor-associated growth factors and chemokines, vascular endothelial growth factor 
(VEGF) family members represent a prominent group of proangiogenic factors secreted 
by the majority of solid tumors, leukemias and lymphomas.2,3  The VEGF family proteins 
have several mechanistic properties responsible for enhancing the growth of tumors. 
Dvorak et al first identified this molecule as the vascular permeability factor (VPF), which 
resulted in the leakage of plasma proteins, growth factors, and platelets from the 
circulation to the tissue parenchyma in tumors and in distant organs.4,5 For a second 
mechanism of action, VEGF specific receptors were found on the surface of mature 
endothelial cells promoting the growth of new blood vessels. Folkman et al 
demonstrated that endothelial cell proliferation at the tips of established blood vessels 
formed branching of new blood vessels to the tumor site enabling the continued growth 
of the primary tumor.6 One member of this family, VEGF-A, was shown to  promote new 
blood vessel formation by its interaction with VEGF receptor 2 (VEGFR2) on endothelial 
cells.7 As an alternative explanation of new blood vessel formation, Lyden et al have 
shown that VEGF-A signals through two tyrosine kinase receptors, VEGFR1 and 
VEGFR2, expressed on bone marrow-derived stem and progenitor cells. Endothelial 
progenitor cells (EPCs) expressing VEGFR2 and hematopoietic progenitor cells (HPCs) 
expressing VEGFR1 were both required to form the earliest blood vessels 
(neovasculogenesis) in tumors. During early tumorigenesis, VEGF-A specifically 
promoted the proliferation and recruitment of VEGFR2+ EPCs to the primary tumor site. 
Similarly, VEGF-A promoted the production and mobilization of VEGFR1+ HPCs to the 
tumor as well. Although less well studied, VEGFR1+ HPCs appear to play a critical role 
in regulating the interactions, such as adhesive properties, between tumor cells, 
endothelial cells along with the adjoining inflammatory infiltrates. VEGFR1+ HPCs may 
also contribute to the perivascular cell network for the stabilization of blood vessels.  As 
a third mechanism, VEGF can mobilize VEGFR1+ HPCs to future sites of metastasis 
forming the “pre-metastatic niche” or the preconditioning necessary for a favorable 
microenvironment suitable for the arrival of incoming metastatic tumor cells8. In addition 
to VEGF-A, other VEGF family members, VEGF-B and PlGF (placental growth factor), 
can support the mobilization of VEGFR1+ HPCs to the primary tumor and to the pre-
metastatic sites. 
Besides its paracrine effects and as a fourth mechanism, VEGF-A and its receptors,  
VEGFR1 and VEGFR2, form an autocrine loop on certain tumor cells enabling the direct 
support of certain tumor cell growth. VEGF-A and its receptors are expressed in 
leukemia and lymphoma as well as pediatric sarcomas and neuroblastomas 9,10. Given 
the potential autocrine and paracrine effects of VEGF-A, it is not surprising that higher 
VEGF levels have been associated with worse prognosis in pediatric and adult patients 
with both liquid and solid tumors 11, 12, 13.   
 

  
 
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1.1.1 Rationale for Targeting VEGF in Pediatric Malignancies 
Pediatric cancers typically have a better cure rate than the majority of adult cancers. 
However, refractory disease and the potential for long-term morbidity from the use of 
conventional therapies necessitate the development of novel treatments for children.  
The promise of anti-angiogenic therapy includes reduced toxicity and the potential for 
efficacy predominantly by targeting the tumor’s blood supply.  Novel agents such as 
bevacizumab are easily administered with little or no significant toxicity. In fact, no MTD 
was established in the Phase I COG study of bevacizumab in refractory pediatric solid 
tumors.  Treatment was well tolerated with no DLTs observed. Adverse events including 
infusional reaction, rash, mucositis, proteinuria, and lymphopenia were Grade 1- 2 and 
did not meet the criteria for DLT.  Increases in systolic and diastolic blood pressure not 
meeting CTCAE version 3 pediatric-specific criteria for hypertension were observed. 
There was no hemorrhage or thrombosis reported. Growth pertubation was not detected 
in a limited sample over the first course.68 
 
The potential to prevent tumor growth and induce tumor shrinkage has been established 
in the adult setting as well as in pediatric tumor xenografts of neuroblastoma and 
sarcomas in the murine setting 14, 15.  The effect of targeting VEGF is enhanced when 
combined with traditional cytotoxic therapies and these findings provide evidence for 
combining VEGF with standard cytotoxic chemotherapeutic agents.  
 
1.2 
Bevacizumab Clinical Experience     
Bevacizumab has been studied in a multitude of Phase I, II, and III clinical trials in more 
than 5000 patients and in multiple tumor types. In addition, data are available from 3,863 
patients enrolled in two postmarketing studies in metastatic colorectal cancer (CRC).  
Approximately 130,000 patients have been exposed to bevacizumab as a marketed 
product or in clinical trials.  The following discussion summarizes bevacizumab’s safety 
profile and presents some of the efficacy results pertinent to this particular trial. Please 
refer to the bevacizumab Investigator Brochure for descriptions of all completed Phase I, 
II, and III trials reported to date. 
 
In a large phase III study (AVF2107g) in patients with metastatic colorectal cancer, the 
addition of bevacizumab, a monoclonal antibody directed against vascular endothelial 
growth factor (VEGF), to irinotecan/5-fluorouracil/leucovorin (IFL) chemotherapy resulted 
in a clinically and statistically significant increase in duration of survival, with a hazard 
ratio of death of 0.67 (median survival 15.6 vs. 20.3 months; p < 0.001).  Similar 
increases were seen in progression-free survival (6.2 vs. 10.6 months; p < 0.001), 
overall response rate (35% vs. 45%; p < 0.01) and duration of response (7.1 vs. 10.4 
months; p < 0.01) for the combination arm versus the chemotherapy only arm 
(bevacizumab Investigator Brochure, October 2005). 
 
Based on the survival advantage demonstrated in Study AVF2107g, bevacizumab was 
designated for priority review and was approved on 26 February 2004 in the United 
States for first-line treatment in combination with IV 5-FU−based chemotherapy for 
subjects with metastatic colorectal cancer.  
 
Additional data from Phase III trials in metastatic CRC (E3200), non−small cell lung 
cancer (NSCLC; E4599), and metastatic breast cancer (E2100) have also demonstrated 
clinical benefit from bevacizumab when added to chemotherapy.  In Study E3200, the 

  
 
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addition of bevacizumab to FOLFOX chemotherapy resulted in improved overall survival 
compared with FOLFOX alone (13.0 vs. 10.8 months, respectively, HR = 0.75; p < 0.01) 
in a population of previously treated CRC patients.   
 
There was also improved overall survival in first-line NSCLC patients (E4599) treated 
with carboplatin/paclitaxel + bevacizumab compared with chemotherapy alone (12.3 vs. 
10.3 months, respectively; HR = 0.80; p = 0.003).  The results from this trial were the 
basis 
for 
FDA 
approval 
of 
bevacizumab 
for 
use 
in 
combination 
with 
carboplatin + paclitaxel as first-line treatment of patients with unresectable, locally 
advanced, recurrent or metastatic, non-squamous NSCLC in October 2006.  Finally, 
patients with untreated metastatic breast cancer (E2100) who received bevacizumab in 
combination with weekly paclitaxel had a marked improvement in PFS compared with 
chemotherapy alone (13.3 vs. 6.7 months, respectively; HR = 0.48; p < 0.0001) (see the 
Bevacizumab Investigator Brochure for additional details). 
 
1.2.1. Safety Profile 
In the initial Phase I and II clinical trials, four potential bevacizumab-associated safety 
signals were identified: hypertension, proteinuria, thromboembolic events, and 
hemorrhage.  Additional completed Phase II and Phase III studies of bevacizumab as 
well as spontaneous reports have further defined the safety profile of this agent. 
Bevacizumab-associated adverse events identified in phase III trials include congestive 
heart failure (CHF) primarily in metastatic breast cancer, gastrointestinal perforations, 
wound healing complications, and arterial thromboembolic events (ATE). These and 
other safety signals are described in further detail as follows and in the bevacizumab 
Investigator Brochure. 
 
Hypertension: An increased incidence of hypertension has been observed in patients 
treated with bevacizumab.  Grade 4 and 5 hypertensive events are rare. Clinical 
sequelae of hypertension are rare but have included hypertensive crisis, hypertensive 
encephalopathy, and reversible posterior leukoencephalopathy syndrome (RPLS) 
(Ozcan et al., 2006; Glusker et al., 2006).  
 
There is no information on the effect of bevacizumab in patients with uncontrolled 
hypertension at the time of initiating bevacizumab therapy.  Therefore, caution should be 
exercised before initiating bevacizumab therapy in these patients.  Monitoring of blood 
pressure is recommended during bevacizumab therapy.  Optimal control of blood 
pressure according to standard public health guidelines is recommended for patients on 
treatment with or without bevacizumab.   
 
Temporary interruption of bevacizumab therapy is recommended in patients with 
hypertension 
requiring 
medical 
therapy 
until 
adequate 
control 
is 
achieved.  
If hypertension cannot be controlled with medical therapy, bevacizumab therapy should 
be permanently discontinued.  Bevacizumab should be permanently discontinued in 
patients who develop hypertensive crisis or hypertensive encephalopathy. 
 
Reproductive System And Breast Disorders: Loss of the normal functioning of the 
ovaries in a woman that can result in temporary or permanent menopause; the impact 
on fertility (temporary or permanent) is unknown. 
 

  
 
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 Ovarian failure, defined as amenorrhea lasting 3 or more months with follicle-stimulating 
hormone (FSH) elevation (≥30 mIU/mL), was increased in patients receiving adjuvant 
bevacizumab plus mFOLFOX compared to mFOLFOX alone (34% vs. 2%).  After 
discontinuation of bevacizumab, resumption of menses and an FSH level <30 mIU/mL 
was demonstrated in 22% (7/32) of these women.  Long term effects of bevacizumab 
exposure on fertility are unknown. However, this risk is only applicable to female, 
premenopausal patients.  
 
Proteinuria:  An increased incidence of proteinuria has been observed in patients 
treated 
with 
bevacizumab 
compared 
with 
control 
arm 
patients. 
 
In 
the 
bevacizumab-containing treatment arms of clinical trials (across all indications), the 
incidence of proteinuria (reported as an adverse event) was up to 38% (metastatic CRC 
Study AVF2192g). The severity of proteinuria has ranged from asymptomatic and 
transient events detected on routine dipstick urinalysis to nephrotic syndrome; the 
majority of proteinuria events have been grade 1. NCI-CTC Grade 3 proteinuria was 
reported in up to 3% of bevacizumab-treated patients, and Grade 4 in up to 1.4% of 
bevacizumab-treated patients.  The proteinuria seen in bevacizumab clinical trials was 
not associated with renal impairment and rarely required permanent discontinuation of 
bevacizumab therapy.  Bevacizumab should be discontinued in patients who develop 
Grade 4 proteinuria (nephrotic syndrome). 
 
Patients with a history of hypertension may be at increased risk for the development of 
proteinuria when treated with bevacizumab.  There is evidence from the dose-finding, 
Phase II trials (AVF0780g, AVF0809s, and AVF0757g) suggesting that Grade 1 
proteinuria may be related to bevacizumab dose. 
 
Proteinuria will be monitored by urine protein:creatinine (UPC) ratio at least every 6 
weeks.  If the UPC ratio is not available, a dipstick urinalysis may be used to allow 
treatment to proceed. 
 
Thromboembolic Events: Both venous and arterial thromboembolic (TE) events, 
ranging in severity from catheter-associated phlebitis to fatal, have been reported in 
patients treated with bevacizumab in the colorectal cancer trials and, to a lesser extent, 
in patients treated with bevacizumab in NSCLC and breast cancer trials.  
 
Venous Thromboembolism (Including Deep Venous Thrombosis, Pulmonary 
Embolism, And Thrombophlebitis:  In the phase III pivotal trial in metastatic CRC, 
there was a slightly higher rate of venous TE events in patients treated with 
bevacizumab plus chemotherapy compared with chemotherapy alone (19% vs. 16%).  
 
In Study AVF2107g, a Phase III, pivotal trial in metastatic CRC, VTE events, including 
deep venous thrombosis, pulmonary embolism, and thrombophlebitis, occurred in 15.2% 
of patients receiving chemotherapy alone and 16.6% of patients receiving 
chemotherapy + bevacizumab.  
 
The incidence of NCI-CTC Grade ≥ 3 venous VTE events in one NSCLC trial (E4599) 
was higher in the bevacizumab-containing arm compared to the chemotherapy control 
arm (5.6% vs. 3.2%).  One event (0.2%) was fatal in the bevacizumab-containing arm; 
not fatal events were reported in the carboplatin/paclitaxel arm (see Bevacizumab 
Investigator Brochure).  In metastatic CRC clinical trials, the incidence of VTE events 

  
 
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was similar in patients receiving chemotherapy + bevacizumab and those receiving the 
control chemotherapy alone.  
 
In clinical trials across all indications the overall incidence of VTE events was 
2.8%−17.3% in the bevacizumab-containing arms compared with 3.2%−15.6% in the 
chemotherapy control arms.  The use of bevacizumab with chemotherapy does not 
substantially increase the risk of VTE event compared with chemotherapy alone.  
However, patients with metastatic CRC who receive bevacizumab and experienced a 
VTE event may be at higher risk for recurrence of VTE event. 
 
Arterial Thromboembotic Events:  An increased incidence of ATE events was 
observed in patients treated with bevacizumab compared with those receiving control 
treatment.  ATE events include cerebrovascular accidents, myocardial infarction, 
transient ischemic attacks (TIAs), and other ATE events.  In a pooled analysis of data 
from five randomized Phase II and III trials (mCRC [AVF2107g, AVF2192g, AVF0780g]; 
locally advanced or metastatic NSCLC [AVF0757g]; metastatic breast cancer 
[AVF2119g]), the incidence rate of ATE events was 3.8% (37 of 963) in patients who 
received chemotherapy + bevacizumab compared with 1.7% (13 of 782) in patients 
treated with chemotherapy alone.  ATE events led to a fatal outcome in 0.8% (8 of 963) 
of patients treated with chemotherapy + bevacizumab and 0.5% (4 of 782) of patients 
treated with chemotherapy alone.  Cerebrovascular accidents (including TIAs) occurred 
in 2.3% of patients treated with chemotherapy + bevacizumab and 0.5% of patients 
treated with chemotherapy alone.  Myocardial infarction occurred in 1.4% of patients 
treated with chemotherapy + bevacizumab compared with 0.7% of patients treated with 
chemotherapy alone (see the Bevacizumab Investigator Brochure for additional details). 
 
Aspirin is a standard therapy for primary and secondary prophylaxis of arterial 
thromboembolic events in patients at high risk of such events, and the use of aspirin ≤ 
325 mg daily was allowed in the five randomized studies discussed above. Use of 
aspirin was assessed routinely as a baseline or concomitant medication in these trials, 
though safety analyses specifically regarding aspirin use were not preplanned. Due to 
the relatively small numbers of aspirin users and arterial thromboembolic events, 
retrospective analyses of the ability of aspirin to affect the risk of such events were 
inconclusive. However, similarly retrospective analyses suggested that the use of up to 
325 mg of aspirin daily does not increase the risk of grade 1-2 or grade 3-4 bleeding 
events, and similar data with respect to metastatic colorectal cancer patients were 
presented at ASCO 2005 (Hambleton et al., 2005). Further analyses of the effects of 
concomitant use of bevacizumab and aspirin in colorectal and other tumor types are 
ongoing. 
 
Gastrointestinal Perforation: Patients with metastatic carcinoma may be at increased 
risk for the development of gastrointestinal perforation and fistula when treated with 
bevacizumab and chemotherapy. Bevacizumab should be permanently discontinued in 
patients who develop gastrointestinal perforation. A causal association of intra-
abdominal inflammatory processes and gastrointestinal perforation to bevacizumab 
treatment has not been established. Nevertheless, caution should be exercised when 
treating patients with intra-abdominal inflammatory processes with bevacizumab. 
Gastrointestinal perforation has been reported in other trials in non-colorectal cancer 
populations (e.g., ovarian, renal cell, pancreas, breast, and NSCLC) and may be higher 
in incidence in some tumor types. 

  
 
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Fistula:  Bevacizumab use has been associated with serious cases of fistulae including 
events resulting in death.  Fistulae in the GI tract are common (1%–10% incidence) in 
patients with metastatic CRC, but uncommon (0.1%−1%) or rare (0.01%–0.1%) in other 
indications.  In addition, fistulae that involve areas of the body other than the GI tract 
(e.g., tracheoesophageal, bronchopleural, urogenital, biliary) have been reported 
uncommonly (0.1%–1%) in patients receiving bevacizumab in clinical studies and 
postmarketing reports.  Events were reported at various time points during treatment, 
ranging from 1 week to > 1 year following initiation of bevacizumab, with most events 
occurring within the first 6 months of therapy. 
 
Permanently discontinue bevacizumab in patients with tracheoesophageal fistulae or 
any Grade 4 fistula.  Limited information is available on the continued use of 
bevacizumab in patients with other fistulae.  In cases of internal fistula not arising in the 
GI tract, discontinuation of bevacizumab should be considered. 
 
Wound healing complications: Wound healing complications such as wound 
dehiscence have been reported in patients receiving bevacizumab. In an analysis of 
pooled data from two trials in metastatic colorectal cancer, patients undergoing surgery 
28-60 days before study treatment with 5-FU/LV plus bevacizumab did not appear to 
have an increased risk of wound healing complications compared to those treated with 
chemotherapy alone (Scappaticci et al., 2005). Surgery in patients currently receiving 
bevacizumab is not recommended. No definitive data are available to define a safe 
interval after bevacizumab exposure with respect to wound healing risk in patients 
receiving elective surgery; however, the estimated half life of bevacizumab is 21 days. 
Bevacizumab should be discontinued in patients with severe wound healing 
complications. 
 
If patients receiving treatment with bevacizumab require elective major surgery, it is 
recommended that bevacizumab be held for 4-8 weeks prior to the surgical procedure.  
Patients undergoing a major surgical procedure should not begin or restart bevacizumab 
until 4 weeks after that procedure (in the case of high-risk procedures such as liver 
resection, thoracotomy, or neurosurgery, it is recommended that chemotherapy be 
restarted no earlier than 6 weeks and bevacizumab no earlier than 8 weeks after 
surgery). 
 
Hemorrhage: Overall, grade 3 and 4 bleeding events were observed in 4.0% of 1132 
patients treated with bevacizumab in a pooled database from eight phase I, II, and III 
clinical trials in multiple tumor types (bevacizumab Investigator Brochure, October 2005). 
The hemorrhagic events that have been observed in bevacizumab clinical studies were 
predominantly tumor-associated hemorrhage (see below) and minor mucocutaneous 
hemorrhage.  
 
Tumor-Associated Hemorrhage:  Major or massive pulmonary hemorrhage or 
hemoptysis has been observed primarily in patients with NSCLC.  Life-threatening and 
fatal hemoptysis was identified as a bevacizumab-related adverse event in NSCLC trials.  
These events occurred suddenly and presented as major or massive hemoptysis.  
Among the possible risk factors evaluated (including squamous cell histology, treatment 
with anti-rheumatic/anti-inflammatory drugs, treatment with anticoagulants, prior 
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tumor location, and cavitation of tumors during therapy), the only variables that showed 
statistically significant correlations with bleeding were bevacizumab therapy and 
squamous cell histology. 
 
In Study E4599, in which squamous cell carcinoma was excluded, the rate of any type of 
Grade ≥ 3 hemorrhage was 1.0% in the control arm (carboplatin and paclitaxel) versus 
4.1% in the carboplatin and paclitaxel + bevacizumab arm (Sandler et al. 2006).   
 
GI hemorrhages, including rectal bleeding and melena have been reported in patients 
with CRC, and have been assessed as tumor-associated hemorrhages. 
 
Tumor-associated hemorrhages were also seen rarely in other tumor types and 
locations, including a case of CNS bleeding in a patient with hepatoma with occult CNS 
metastases and a patient who developed continuous oozing of blood from a thigh 
sarcoma with necrosis. 
 
Mucocutaneous Hemorrhage:  Across all bevacizumab clinical trials, mucocutaneous 
hemorrhage has been seen in 20%-40% of patients treated with bevacizumab. These 
were most commonly NCI-CTC Grade 1 epistaxis that lasted less than 5 minutes, 
resolved without medical intervention and did not require any changes in bevacizumab 
treatment regimen.  
 
There have also been less common events of minor mucocutaneous hemorrhage in 
other locations, such as gingival bleeding and vaginal bleeding.  
 
Reversible Posterior Leukoencephalopathy Syndrome:  There have been rare 
reports of bevacizumab-treated patients developing signs and symptoms that are 
consistent with RPLS, a rare neurologic disorder that can present with the following 
signs and symptoms (among others):  seizures, headache, altered mental status, visual 
disturbance, or cortical blindness, with or without associated hypertension.  Brain 
imaging is mandatory to confirm the diagnosis of RPLS.  In patients who develop RPLS, 
treatment of specific symptoms, including control of hypertension, is recommended 
along with discontinuation of bevacizumab.  The safety of reinitiating bevacizumab 
therapy in patients previously experiencing RPLS is not known (Glusker et al. 2006; 
Ozcan et al. 2006).   
 
Congestive Heart Failure:  In clinical trials CHF was observed in all cancer indications 
studied to date, but predominantly in patients with metastatic breast cancer.  In the 
Phase III clinical trial of metastatic breast cancer (AVF2119g), 7 (3%) bevacizumab-
treated patients experienced CHF, compared with two (1%) control arm patients.  
These events varied in severity from asymptomatic declines in left ventricular ejection 
fraction (LVEF) to symptomatic CHF requiring hospitalization and treatment.  All the 
patients treated with bevacizumab were previously treated with anthracyclines 
(doxorubicin cumulative dose of 240−360 mg/m2).  Many of these patients also had prior 
radiotherapy to the left chest wall.  Most of these patients showed improved symptoms 
and/or left ventricular function following appropriate medical therapy (Miller et al. 2005). 
 
In a randomized, Phase III trial of patients with previously untreated metastatic breast 
cancer (E2100), the incidence of LVEF decrease (defined as NCI-CTC Grade 3 or 4) in 
the paclitaxel + bevacizumab arm was 0.3% versus 0% for the paclitaxel alone arm. 

  
 
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No information is available on patients with preexisting CHF of New York Heart 
Association (NYHA) Class II−IV at the time of initiating bevacizumab therapy, as these 
patients were excluded from clinical trials. 
 
Prior anthracyclines exposure and/or prior radiotherapy to the chest wall may be 
possible risk factors for the development of CHF.  Caution should be exercised before 
initiating bevacizumab therapy in patients with these risk factors. 
 
A Phase II trial in patients with refractory acute myelogenous leukemia reported 5 cases 
of cardiac dysfunction (CHF or LVEF decrease to < 40%) among 48 patients treated with 
sequential cytarabine, mitoxantrone, and bevacizumab.  All but 1 of these patients had 
significant prior exposure to anthracyclines as well (Karp et al. 2004).  
 
Other studies in patients with various tumor types and either a history of anthracycline 
exposure or concomitant use with bevacizumab are ongoing.  
 
Patients receiving concomitant anthracyclines or with prior exposure to anthracyclines 
should have a baseline MUGA scans or echocardiograms (ECHOs) with a normal LVEF. 
 
Neutropenia:  Increased rates of severe neutropenia, febrile neutropenia, or infection 
with severe neutropenia (including some fatalities) have been observed in patients 
treated with some myelotoxic chemotherapy regimens plus bevacizumab in comparison 
to chemotherapy alone (Sandler et al. 2006). 
 
Additional Adverse Events:  See the bevacizumab Investigator Brochure for additional 
details regarding the safety experience with bevacizumab. 
 
Likely ( > 20%) 
Less Likely ( ≤ 20%) 
Rare but Serious ( < 3%) 
• Hypertension 
• Reproductive 
system and breast 
disorders-
Other(ovarian 
failure)10 
• Thrombocytopenia 
• Lymphopenia 
• Anemia 
• Febrile neutropenia 
• Supraventricular tachycardia 
• Vertigo 
• Abdominal Pain 
• Colitis 
• Constipation 
• Diarrhea 
• Dyspepsia 
• Gastrointestinal hemorrhage2 
• Gastrointestinal obstruction3  
• Ileus 
• Mucositis oral 
• Nausea 
• Vomiting 
• Fatigue 
• Infusion related reaction 
• Non-cardiac chest pain  
• Pain 
• Allergic reaction 
• Infection6 
• Blood and lymphatic system 
disorders-Other (renal 
thrombotic microangiopathy) 
• Acute coronary syndrome 
• Heart failure 
• Left ventricular systolic       
 dysfunction 
• Myocardial infarction 
• Ventricular arrhythmia 
• Ventricular fibrillation 
• Gastrointestinal fistula1 
• Gastrointestinal perforation4 
• Gastrointestinal ulcer5 
• Anaphylaxis 
• Gastrointestinal anastomotic    
leak 
• Intracranial hemorrhage 
• Ischemia cerebrovascular 
• Reversible posterior  
leukoencephalopathy syndrome 
• Acute kidney injury 

  
 
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• Infections and infestations-Other 
(peri-rectal abscess) 
• Wound dehiscence 
• Alanine aminotransferase increased 
• Alkaline phosphatase increased 
• Aspartate aminotransferase 
increased  
• Blood bilirubin increased 
• Cardiac troponin I increased 
• Neutrophil count decreased  
• Weight loss 
• White blood cell decreased 
• Anorexia 
• Arthralgia 
• Musculoskeletal and connective 
tissue disorder-Other (bone 
metaphyseal dysplasia)7 
• Myalgia 
• Osteonecrosis of jaw8 
• Dizziness 
• Headache 
• Peripheral sensory neuropathy9 
• Syncope 
• Hematuria 
• Proteinuria 
• Vaginal hemorrhage 
• Allergic rhinitis  
• Cough  
• Dyspnea 
• Epistaxis 
• Hoarseness 
• Pruritus 
• Rash maculo-papular 
• Urticaria 
• Thromboembolic event  
• Renal and urinary disorders-
Other (Nephrotic Syndrome) 
• Urinary fistula 
• Vaginal fistula 
• Bronchopleural fistula, 
Bronchopulmonary hemorrhage 
• Respiratory thoracic and 
mediastinal disorders- Other 
(nasal-septal perforation)  
• Respiratory thoracic and 
mediastinal disorders- Other 
(tracheo-esophageal fistula) 
• Vascular disorders-Other 
(arterial thromboembolic 
event)**11 
• Cellulitis 
• Posterior reversible 
encephalopathy syndrome 
(PRES) 
• Non-mandibular osteonecrosis 
• Fetal abnormalities 
 
1Gastrointestinal fistula may include: Anal fistula, Colonic fistula, Duodenal fistula, Esophageal 
fistula, Gastric fistula, Gastrointestinal fistula, Rectal fistula, and other sites under the 
GASTROINTESTINAL DISORDERS SOC. 
 
2Gastrointestinal hemorrhage may include:  Colonic hemorrhage, Duodenal hemorrhage, 
Esophageal hemorrhage, Esophageal varices hemorrhage, Gastric hemorrhage, Hemorrhoidal 
hemorrhage, Intra-abdominal hemorrhage, Oral hemorrhage, Rectal hemorrhage, and other 
sites under the GASTROINTESTINAL DISORDERS SOC. 
 
3Gastrointestinal obstruction may include:  Colonic obstruction, Duodenal obstruction, 
Esophageal obstruction, Ileal obstruction, Jejunal obstruction, Rectal obstruction, Small 
intestinal obstruction, and other sites under the GASTROINTESTINAL DISORDERS SOC. 
 
4Gastrointestinal perforation may include:  Colonic perforation, Duodenal perforation, 
Esophageal perforation, Gastric perforation, Jejunal perforation, Rectal perforation, Small 
intestinal perforation, and other sites under the GASTROINTESTINAL DISORDERS SOC. 

  
 
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5Gastrointestinal ulcer may include:  Duodenal ulcer, Esophageal ulcer, Gastric ulcer, and other 
sites under the GASTROINTESTINAL DISORDERS SOC. 
 
6Infection may include any of the 75 infection sites under the INFECTIONS AND 
INFESTATIONS SOC. 
 
7Metaphyseal dysplasia was observed in young patients who still have active epiphyseal growth 
plates. 
 
8Cases of osteonecrosis of the jaw (ONJ) have been reported in cancer patients in association 
with bevacizumab treatment, the majority of whom had received prior or concomitant treatment 
with i.v. bisphosphonates. 
 
9Increased rate of peripheral sensory neuropathy has been observed in trials combining 
bevacizumab and chemotherapy compared to chemotherapy alone.  
 
10Ovarian failure, defined as amenorrhea lasting 3 or more months with follicle-stimulating 
hormone (FSH) elevation (≥30 mIU/mL), was increased in patients receiving adjuvant 
bevacizumab plus mFOLFOX compared to mFOLFOX alone (34% vs. 2%).  After 
discontinuation of bevacizumab, resumption of menses and an FSH level <30 mIU/mL was 
demonstrated in 22% (7/32) of these women.  Long term effects of bevacizumab exposure on 
fertility are unknown. 
 
11Arterial thromboembolic event includes visceral arterial ischemia, peripheral arterial ischemia, 
heart attack, and stroke. 
 
**In the AVF2107study [36, 37], there was a 1% incidence of arterial thromboembolic events 
(which include myocardial ischemia/infarction, transient ischemia attack, cerebrovascular 
accident/stroke and angina/unstable angina) in the IFL + placebo arm versus 3% in the IFL + 
bevacizumab arm. A pooled analysis of the rate of arterial TE events from 5 randomized studies 
showed that treatment with bevacizumab increased the risk of these events two-to-three fold (up 
to 5%). Furthermore, certain baseline characteristics, specifically age> 65 years and prior 
arterial TE event, conferred additional risk. 
 
Also reported on Bevacizumab (rhuMAb VEGF) trials but with the relationship to 
Bevacizumab (rhuMAb VEGF) still undetermined: 
 
- 
Blood and lymphatic system disorders - Other (idiopathic thrombocytopenia purpura) 
- 
Disseminated intravascular coagulation 
- 
Pericardial effusion 
- 
Gait disturbance 
- 
Sudden death NOS 
- 
Hepatic failure 
- 
Infections and infestations - Other (aseptic meningitis) 
- 
Platelet count decreased 
- 
Hyponatremia 
- 
Musculoskeletal and connective tissue disorder - Other (aseptic necrotic bone) 
- 
Musculoskeletal and connective tissue disorder - Other (myasthenia gravis) 
- 
Dysgeusia 

  
 
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- 
Peripheral motor neuropathy 
- 
Seizure 
- 
Confusion 
- 
Adult respiratory distress syndrome 
- 
Pneumonitis 
- 
Pneumothorax 
- 
Pulmonary hypertension 
- 
Palmar-plantar erythrodysesthesia syndrome 
- 
Skin ulceration 
 
Note: Bevacizumab (rhuMAb VEGF) in combination with other agents could cause an 
exacerbation of any adverse event currently known to be caused by the other agent, or 
the combination may result in events never previously associated with either agent 
 
1.3 
Other Study Drug(S) Background  
 
a. 
Cyclophosphamide And Topotecan 
As single agents, cyclophosphamide and topotecan are used in the treatment of a 
variety of pediatric tumors. The combination of cyclophosphamide and topotecan has 
been demonstrated to be an active chemotherapeutic regimen for treatment of 
relapsed/refractory Ewing sarcoma, rhabdomyosarcoma, neuroblastoma, Wilms’ tumor, 
germ cell tumors, and brain tumors.69 Cyclophosphamide plus topotecan has also shown 
activity in patients with untreated metastatic neuroblastoma. 25 This activity is attributed 
to synergistic stabilization of DNA-topoisomerase I adducts by topotecan which are 
formed after cyclophosphamide-induced DNA damage.  
 
With regard to CNS malignancies, cyclophosphamide is an active chemotherapeutic 
agent in medulloblastoma and is part of the first line chemotherapy regimen for 
ependymoma.26 However, some patients with recurrence will not have had prior 
exposure to this agent. Patients ≥ 3 years of age with standard risk medulloblastoma are 
often treated with vincristine, cisplatin and lomustine (without cyclophosphamide), and 
patients ≥ 3 years of age with completely resected ependymoma will not have received 
chemotherapy as part of their initial treatment regimen. Topotecan been demonstrated 
by St. Jude investigators to be active versus medulloblastoma in a phase II window 
study when administered as a 30 minute infusion daily x 5 days, as will be used in this 
study.27 Using a 72-hour infusion schedule of topotecan, Pediatric Oncology Group 
(POG) investigators reported that 5 of 17 patients with ependymoma achieved stable 
disease.28 Children’s Cancer Study Group (CCG) investigators performed a phase I 
study using a 21-day continuous infusion and reported that 2 of 3 patients with 
ependymoma achieved objective responses.29 
 
This study will focus primarily on the evaluation of the efficacy of the combination CTB in 
a restricted group of pediatric cancer patients, those with diagnoses of Ewing’s sarcoma 
and neuroblastoma. Prior data in patients with Ewing’s sarcoma and neuroblastoma 
have 
demonstrated 
efficacy 
in 
second 
line 
therapy 
with 
the 
combination 
cyclophosphamide and topotecan, both agents known to demonstrate single agent 
activity in these diseases. Importantly, objective response data has been published in 
children with neuroblastoma and Ewing’s sarcoma at the time point indicated in the 
primary study objective of this study, after 2 cycles of therapy, which can be used for 
comparison, 
Saylors 
et 
al 
reported 
response 
rates 
after 
2 
cycles 
of 

  
 
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cyclophosphamide/topotecan as 4/13 (30.8%) for neuroblastoma patients and 5/17 
(29.4%) Ewing’s sarcoma patients. Given the similar response rates (~30%) in   
historical phase II data with the chemotherapy backbone cyclophosphamide and 
topotecan, it was decided that the disease types neuroblastoma and Ewing’s sarcoma 
would be evaluated in a single cohort .69 Based upon this information, it is anticipated 
that the risk of encountering differing response rates in the disease groups will be 
minimal. Although the response rate that will determine the success of the combination 
of drugs in this trial will be based upon composite data from both disease groups, 
subpopulation response rates will be assessed. To safeguard against unequal 
proportions of patients from each of the disease group being enrolled on this study, the 
accrual of patients will be stratified. 
 
This study is intended for treatment in patients after first line treatment. Standard 
frontline chemotherapy for patients with Ewing’s sarcoma consists of the agents of 
vincristine, ifosfamide, doxorubicin, dactinomycin, and etoposide. Standard frontline 
chemotherapy 
for 
patients 
with 
neuroblastoma 
consists 
of 
the 
agents, 
cyclophosphamide, doxorubicin, vincristine, cisplatin, etoposide in combination with 
immunotherapy consisting of a monoclonal antibody directed to GD2. Given the limited 
overlap with first line therapy, it is anticipated that there will be activity as well in this trial. 
 
1.4 
Study Rationale 
 
This study will evaluate the safety and efficacy of the chemotherapeutic regimen 
cyclophosphamide and topotecan in combination with the novel agent bevacizumab 
(CTB). The schedule that will be used will be the 5-day infusion schedule every 21 days 
of cyclophosphamide and topotecan. The interest in incorporating bevacizumab with this 
standard salvage regimen is based upon preclinical data demonstrating activity in 
pediatric and adult solid tumors. Bevacizumab has been widely demonstrated to inhibit 
angiogenesis and tumor growth in numerous tumor models including breast, prostate, 
rhabdomyosarcoma, and Wilms’ tumor. Synergism with standard cytotoxic agents has 
been demonstrated including cyclophosphamide and topotecan. We hypothesize that 
the addition of bevacizumab to the standard regimen cyclophosphamide and topotecan 
will show enhanced clinical efficacy without additive toxicity.  
 
In this study, we propose a novel schedule of administration of bevacizumab which may 
enhance the effect of cytotoxic chemotherapy with cyclophosphamide and topotecan. 
Bevacizumab will be administered 3 days prior to administration of cytotoxic 
chemotherapy. The rationale for this approach is summarized as follows. Tumor 
vascular volume, microvessel density and interstitial fluid pressure are decreased in 
response to bevacizumab therapy.30 It has been proposed that blood vessel stabilization 
may occur given the decrease in interstitial fluid pressure, allowing for improved delivery 
of chemotherapy to tumor cells. This may explain the synergistic effects of this agent 
with conventional chemotherapy regimens.31, 
32 In animal models, Tong et al 
demonstrated that treatment with DC101 targeting anti-VEGF-R2 resulted in pruning of 
the vasculature, more uniform pericyte coverage of the remaining vessels, and a slight 
oncotic pressure gradiant facilitating transvascular delivery of macromolecules. 31 R. Jain 
et al demonstrated that bevacizumab is most effective when given several days prior to 
conventional chemotherapeutic delivery at a time when tumor blood vessel 
“normalization” and drug delivery are most optimal.33 This window of vessel 
normalization allows for greater influx or convection of chemotherapeutic agents into the 
tumor which is associated with a decrease in interstitial hypertension and peritumoral 

  
 
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edema and therefore a reduction in the efflux or convection out of the tumor of 
chemotherapy allowing for greater effect as well as growth factors, and cancer cells form 
the tumor margins reducing metastatic dissemination. The mechanism of normalization 
lies in that VEGF overexpression as occurs in most malignancies as discussed above 
results in highly abnormal vasculature with limited pericyte covering.  In fact a precise 
regulation of the spatial and temporal expression of VEGF is required for normal 
vasculature.  VEGF blockade has been shown to prune immature and leaky vessels with 
resultant decrease in interstitial hypertension, peri-tumor edema. Recent studies by 
Dickson et al corroborated these findings. 34 After a single dose of bevacizumab, a 
progressive decrease in tumor microvessel density in established orthotopic 
neuroblastoma xenografts was reported to < 30% of control was observed within 7 days. 
Assessment of the tumor microenvironment revealed a rapid, sustained decrease in both 
tumor vessel permeability and tumor interstitial fluid pressure, whereas intratumoral 
perfusion, as assessed by contrast-enhanced ultrasonography, was improved, although 
this latter change abated by 1 week. Intratumoral drug delivery mirrored these changes. 
Penetration of chemotherapy was improved by 81% when given 1-3 days after 
bevacizumab compared with when both drugs were given concomitantly or 7 days apart. 
Administration of topotecan to tumor-bearing mice 3 days after bevacizumab resulted in 
greater tumor inhibition (36% of control size) than with monotherapy (88% bevacizumab, 
54% topotecan) or concomitant administration of the two drugs (44%). These findings 
provide the rationale for the novel schedule of administration of bevacizumab proposed 
in this trial in which bevacizumab will administered 3 days prior to conventional 
chemotherapy. 
 
1.5 
Rationale For Correlative Studies 
This study will also include several mandatory exploratory biologic correlative studies to 
help determine the angiogenic profile of patients at baseline and following treatment with 
the bevacizumab-containing cytotoxic chemotherapy regimen. 
 
1.5.1 Rationale for Investigating EPCs/HPCs 
All tumors require their own blood supply through several means including angiogenesis-
cooption, branching from the existing vasculature, and vasculogenesis-recruitment of de 
novo single cells similar to processes observed in embryonic development.   
 
In response to VEGF-A and PlGF (placental growth factor, which signals via VEGFR1 
only) EPCs and HPCs proliferate and mobilize from the bone marrow into the circulation 
for recruitment to the primary tumor.35, 36 This “angiogenic switch”, supports an extensive 
vasculature network and has been shown to be associated with a worse prognosis.37, 38 
In particular, VEGFR1+ CD68+ stromal hemangiocytes within tumor tissue correlated with 
more aggressive subtypes of Non-Hodgkins lymphoma.39 Similarly, VEGFR1 and 
VEGFR2 expression with solid tumors has been associated with more aggressive stage 
(Ref).  Early myeloid HPCs as well as tumor-associated myeloid cells and macrophages 
(TAMs) have been shown to migrate along blood vessels promoting tumor cell 
extravasation and invasion into adjacent tissue. These myeloid cell infiltrates have been 
associated with higher stage tumors and worse prognosis. 36, 38 Moreover, HPCs may 
have additional roles in local invasion since these cells are commonly present at the 
peripheral rim of tumors, a site known as the invasive front.71  Because of their critical 
contribution to primary tumor growth and invasion, these bone marrow-derived 
progenitor cells may also participate in metastasis.   

  
 
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At distant sites of future metastasis, bone marrow-derived VEGFR1+ HPCs have been 
identified prior to evidence of tumor cell spread which establish a conducive 
microenvironment termed by Lyden et al as the “pre-metastatic niche”. 40 Following the 
arrival of tumor cells, VEGFR2+ EPCs contribute to new blood vessel formation in 
micrometastases leading to progression of the metastatic lesions.  
 
Conceivably, HPCs may support tumor cell homing in other niches, such as in the bone 
marrow microenvironment possibly favoring dormancy or promoting relapse of residual 
tumor cells.  As these bone marrow-derived cells are important in tumor invasion and 
metastasis, HPCs and EPCs can potentially represent prognostic indicators obtained not 
only from tissue samples, but also from the blood.  The biology of mobilization of HPCs 
and EPCs during tumorigenesis and metastasis therefore makes enumeration of these 
cells in circulation ideal surrogate markers to assess response to VEGF-A targeted 
therapies.   
 
VEGFR2+ circulating EPCs are elevated in the blood of patients in several adult cancers 
including breast cancer and lung cancer.41, 42 There have been reports that elevated 
levels of circulating EPCs and serum VEGF are correlated with poor overall survival in 
adult Non- Small Cell Lung Cancer. 41 In addition, these markers may have utility in 
gauging treatment response, as those patients that were poor responders to 
chemotherapy treatment had persistently elevated circulating EPC levels. 
42, 
43 
Furthermore, recent investigation has shown that the circulating endothelial progenitor 
marker CD133 can predict colon cancer recurrence. 44 Recently work has been 
performed in adult patients with non-Hodgkin’s lymphoma that demonstrated elevations 
in CEPs in patients compared to controls and these levels correlated with treatment 
response. 45 
 
There is limited information utilizing VEGFR1+ HPC levels as a biomarker for malignant 
disease. However, preclinical preliminary data from our laboratory shows that there is 
elevation in HPCs in pediatric patients with rhabdomyosarcoma and adult patients with 
breast cancer compared to healthy controls and these levels correlate with more 
advanced disease and treatment response (Figure 2 & Table 1).  Furthermore, recent 
work by Kosaka et al has demonstrated that a high-risk group of gastric cancer patients 
can be identified by vascular endothelial growth factor receptor-1 overexpression in the 
peripheral blood of these patients.46 Mononuclear cell-derived VEGFR1 mRNA was 
increased in those patients with advanced clinical stage, who either presented with local 
invasive disease beyond the muscularis propria or with distant metastases.  More 
importantly and in keeping with our findings that VEGFR1 may be a prognostic marker of 
metastatic progression, VEGFR1 mRNA was elevated in those patients that developed 
postoperative recurrence.  These findings suggest that this marker may be useful in 
determining risk of recurrence and may be useful in assessing treatment response by 
measuring VEGFR1+ HPC levels in pediatric patients with solid tumors receiving 
treatment with Bevacizumab and other anti-angiogenic agents.  We believe that using 
circulating VEGFR2+ EPCs and VEGFR1+ HPCs in combination will prove to be a 
powerful biomarker tool and guide risk stratification, treatment decisions and timing and 
duration of therapy.     
 
 

  
 
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Bone marrow-derived HPCs and EPCs play a critical role in the development of de novo 
tumor vasculature as well as in providing a supportive framework for tumor and 
metastatic progression.  HPCs may represent novel biomarkers not only for determining 
optimal biologic dosing and treatment response but also aid in patient stratification and 
identify those patients that may benefit most from targeted anti-angiogenic therapies. 
Determining the presence of these cells and other key molecular markers in the setting 
of targeted bevacizumab therapy will be studied.  These cellular and molecular markers 
can identify those patients that will benefit most from these anti-angiogenic therapies 
and the best approach to timing and duration of therapy.   Genetic analysis of these cells 
may also uncover new anti-angiogenic targets as well. 
  
1.5.2 Soluble Markers Of Angiogenesis For The Assessment Of Biological Activity   
          During Bevacizumab Based Therapy 
Tumor regression in response to agents such as bevacizumab is usually measured by 
conventional non-invasive imaging techniques such as computed tomography (CT) and 
magnetic resonance imaging (MRI). However, because of the cost and the patient 
inconvenience involved such techniques are not feasible for regular target modulation 
analysis. In contrast, the measurement of serum and plasma angiogenic biomarkers 
offers an alternative approach to assess biological responses during treatment.  
Previous studies have shown that several soluble molecules including VEGF, basic 
fibroblast growth factor (bFGF) and several endothelial cell-associated molecules 
provide an effective biomarker profile in response to targeted anti-angiogenic agents. 47-
49 This is based on the rationale that the concentration of these angiogenic factors in the 
plasma may reflect the hypoxic status of a tumor and may increase in response to 
effective blockade of VEGF receptors.  
 
Abnormalities in other plasma indices of angiogenesis, such as angiopoietins (Ang-1, 
Ang-2), as well as the soluble receptors Flt-1 (sFlt-1) and Tie 2 (sTie-2) have also been 
shown to correlate with a tumors response to the blockade of VEGF activity. 50, 51 In 
addition, tumors that are subjected to therapy have been shown to upregulate a number 
of other angiogenic growth factors, including placenta growth factor (PlGF), in a tumor-
specific pattern. Hence following the expression of PlGF in patients undergoing 
antiangiogenic treatment provides an avenue to identify treatment effectiveness. 52 
Though not comprehensive, we hypothesize that including the measurement of the 
expression of angiogenic factors (VEGF, bFGF), angiopoietins (Ang-1, Ang-2), 
angiogenesis modulators (sVEGFR, sTie-2) and angiogenesis enhancers (PlGF) will 
provide specific and sensitive biomarker profile on the action of bevacizumab and offer 
important clinical correlative analysis. 
 
1.5.3 Understanding Tumor-Related Processes Through Metabolic Profiling.   
Metabolic profiling can be used to differentiate between different cancer cell lines and to 
monitor metabolic processes in cancer cells during apoptosis.  Metabolomics has been 
used to study the changes in hypoxic regions of tumors that develop when a tumor 
outgrows its vasculature. 60 In such tumors, over-expression of hypoxia inducible factor 
(HIF-1) co-exists with increased glucose transporters, glycolytic enzymes and growth 
factors (such as VEGF).  The rate of glycolysis by NMR increases along with induction of 
angiogenesis.  Previous studies with anti-mitotic drugs show the decreased bioenergetic 
status of the tumor is accompanied by an increase in specific biomarkers. 61 With a novel 
targeted agent (imatinib for BCR-ABL inhibition, for example), the metabolic signature is 

  
 
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different from classic chemotherapeutic agents, indicating that these methods can be 
applied to different classes of therapeutics, work now performed in the Gore 
laboratory.53-66 
 
Additional 
studies 
will 
investigate 
the 
interaction 
between 
bevacizumab, 
cyclophosphamide and topotecan.  The results of the standard pharmacokinetic and 
pharmacodynamic variables, in conjunction with the parallel MRS metabolic information, 
will suggest the relative contribution that each individual agent makes within the 
treatment regimen.  Plasma levels of each drug will be determined at defined time points 
throughout protocol therapy.  At defined time-points, MRI scanning will be conducted in 
conjunction with blood sampling for MR spectroscopy.  Tumor and normal tissues /bone 
marrow can be used for Western blot and gene expression analysis, as is appropriate for 
normal clinical care of pediatric patients with refractory cancers.  For patients who do not 
require biopsies for their general clinical care, peripheral blood specimens can be 
evaluated. 
 
These experiments reveal how the combination of bevacizumab, cyclophosphamide and 
topotecan affects the bioavailability, metabolic and biochemical, and anti-tumor activity 
of each of the component drugs in vivo. MRI/NMR assessment will be of special interest, 
because at the current time, there are no data regarding non-invasive techniques for 
measuring metabolic response to treatment in pediatric tumors.   
 
1.5.4 The Impact Of Bevacizumab On Growth And Development In Children.  
Reversible skeletal lesions have been reported in the literature in an anecdotal case of a 
child with cutaneovisceral angiomatosis treated with a short course of bevacizumab.67 
Asymptomatic metaphyseal bone lesions were identified which resolved after 
discontinuation of the bevacizumab. To date, there have been additional cases reported 
following treatment with bevacizumab in children and adults; however, follow-up has 
been limited. In this study, patients will be monitored for changes in the growth plates 
related to treatment with bevacizumab. 
 
2.0 
OBJECTIVES 
 
2.1 
Primary 
 
2.1.1 To determine the efficacy of the bevacizumab in combination with 
cyclophosphamide and topotecan (CTB) in patients with relapsed/refractory 
Ewing’s Sarcoma and neuroblastoma as measured by objective response rate 
(CR/PR) after 2 cycles of treatment and duration of response. 
 
2.2 
Secondary 
 
2.2.1 To evaluate the safety and tolerability of bevacizumab in combination with   
           cyclophosphamide and topotecan. 
 
2.2.2 To determine the efficacy of combining bevacizumab with cyclophosphamide and  
           topotecan by measuring overall survival (OS) and time to progression (TTP). 
 
2.2.3 To determine the pharmacokinetic profile of bevacizumab when combined with  
           cyclophosphamide and topotecan. 

  
 
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2.3  
Exploratory 
2.3.1 To determine the expression of angiogenesis associated biomarkers in serum in  
            patients with relapsed/refractory Ewing’s sarcoma and neuroblastoma treated    
            with CTB. 
 
2.3.2 To determine the angiogenic profile of relapsed/refractory Ewing’s sarcoma and  
            neuroblastoma treated with CTB. 
 
2.3.3 To determine the magnetic resonance spectroscopy profile of changes induced  
            by CTB in peripheral blood mononuclear cells and tumor tissues compared to    
            baseline. 
 
2.3.4 To determine the impact of bevacizumab on growth and development in children.  
 
3.0 
STUDY DESIGN  
 
3.1 
Description of the Study 
This is a multi-center, open label phase II study evaluating the safety and efficacy of the 
novel combination of agents consisting of bevacizumab, cyclophosphamide, and 
topotecan. 
3.2 
Rationale for Study Design 
3.2.1  The study is designed to determine the efficacy and further evaluate the safety 
profile of bevacizumab given in combination with cyclophosphamide and topotecan.  The 
schedule of administration of bevacizumab will be unique in that the Bevacizumab will be 
administered 3 days prior to administration of cytotoxic chemotherapy based upon data 
by Jain et al demonstrating that bevacizumab is most effective when given several days 
prior to conventional chemotherapeutic delivery to allow for normalization of tumor blood 
vessels. The chemotherapy is then administered at a time when tumor blood vessel 
“normalization” and drug delivery are most optimal. This window of vessel normalization 
allows for greater influx or convection of chemotherapeutic agents into the tumor which 
is associated with a decrease in interstitial hypertension and peritumoral edema and 
therefore a reduction in the efflux or convection out of the tumor of chemotherapy 
allowing for greater effect as well as growth factors, and cancer cells form the tumor 
margins reducing metastatic dissemination. It is hoped that this schedule may impact 
ultimately on efficacy of this combination. This study will also incorporate bevacizumab 
at the standard dose established in adult and pediatric trials of 15 mg/Kg IV Q 3 weeks 
that was demonstrated to be safe.  In the event of inordinate toxicity, the dose of 
Bevacizumab will be eliminated. Cyclophosphamide and topotecan will be administered 
at a fixed dose according to the conventional 5-day schedule of administration. 
 
3.2.2 The tumor types to be evaluated in this study will incorporate tumors for which 
similar historical efficacy data is available including Ewing’s sarcoma and 
neuroblastoma.  
 
 

  
 
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3.3  
Outcome Measures  
3.3.1 Primary Outcome Measures 
The primary efficacy endpoint will be the objective response rate (CR/PR) after 2 cycles 
of treatment and duration of response according to the Revised RECIST guideline 
(version 1.1). Patients who experience progression of disease prior to receiving the 
second cycle of therapy will be considered a treatment failure. If appropriate, patients 
may be evaluated by other guidelines suitable for their disease (e.g., neuroblastoma). 
The variables will be the tumor measurements and assessment of non-target lesions by 
radiographic assessment.  
 
3.3.2 Secondary Outcome Measures 
Secondary efficacy endpoints will include time to tumor progression, progression-free 
survival, and evaluation of pharmacodynamic parameters. Duration of disease 
stabilization will also be assessed.  
 
3.3.3 Safety Outcome Measures 
Safety Assessment Methods 
Safety will be assessed by physical examination, interim history, and laboratory 
assessments. Adverse events will be graded according to the NCI-CTCAE, version 4.0  
 
Safety Laboratory Assessments  
The local laboratory of the institution where the trial is being conducted will be used to 
process the laboratory results. Clinically significant laboratory abnormalities (e.g., those 
that lead to some sort of intervention) are to be assessed as adverse events and 
recorded on the appropriate CRF.  
 
Patients will be considered evaluable for response if they have received at least 1 day of 
protocol therapy. Patients will be considered evaluable for toxicity if they have completed 
at least one cycle of treatment. 
 
4.0 
SAFETY PLAN 
See Section 4.1 for complete details of the safety evaluation for this study.  
 
4.1 
General Plan To Manage Safety  
a. Bevacizumab-Specific 
A number of measures will be taken to ensure the safety of patients participating in this 
trial.  These measures will be addressed through exclusion criteria (see Section 5.3) and 
routine monitoring as follows. 
 
Patients enrolled in this study will be evaluated clinically and with standard laboratory 
tests before and at regular intervals during their participation in this study.  Safety 
evaluations will consist of medical interviews, recording of adverse events, physical 
examinations, blood pressure, and laboratory measurements (performed by local 
laboratories, see Section 8.0).  Patients will be evaluated for adverse events (all grades), 
serious adverse events, and adverse events requiring study drug interruption or 
discontinuation at each study visit for the duration of their participation in the study.  

  
 
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Patients discontinued from the treatment phase of the study for any reason will be 
evaluated ~30 days (28–42 days) after the decision to discontinue treatment (see 
Section 7.1.3).   
 
Specific monitoring procedures are as follows: 
 
1. 
Hypertension: Hypertension will be monitored through routine evaluation of blood 
pressure prior to each bevacizumab treatment.  Optimal control of blood pressure 
according to standard public health guidelines is recommended for patients on treatment 
with or without bevacizumab. Patients who develop hypertension while on study, as 
defined by systolic BP ≥140 and/or diastolic BP ≥ 90 mmHg, or greater than 20% above 
upper limit of normal (ULN) for age, should be treated with appropriate medical therapy, 
initially with a single agent antihypertensive medication.  A second antihypertensive 
agent should be added if suboptimal control continues.  For controlled hypertension 
(sBP <140 and/or dBP < 90 mmHg or less than 20% above ULN for age), patients may 
continue study treatment without interruption. For persistent or symptomatic 
hypertension, defined as ≥ grade 2, despite optimal medication, bevacizumab must be 
held until hypertension is ≤ grade 1.  Patients with grade 4 hypertension (hypertensive 
crisis) or hypertension that persists despite optimal medical management will be 
discontinued from study treatment. Refer to Appendix G for normal values for blood 
pressure in children. 
 
2. 
Proteinuria:  Proteinuria will be monitored by urine protein: creatinine (UPC) ratio 
or dipstick at screening, Day 0 of therapy and every 2 cycles before the next dose of 
Bevacizumab. For patients with ≥ 2+ protein by dipstick (for younger patients refer to 
CTCAE V4.0 for values) on Day 0 and subsequent testing after initiation of study 
therapy, bevacizumab therapy will be held and a 24-hour urine collection will be 
performed for total protein analysis. If the 24-hour urine protein is < 2 g, then the patient 
may continue bevacizumab therapy at the same dose without interruption.  If the urine 
protein is 2-3 g/24 hours, bevacizumab therapy will be held for one week, and a 24-hour 
urine collection will be repeated.  Treatment with bevacizumab may be reinstituted after 
a one or two week delay if the 24 hour protein is < 2 g/24 hours. In instances in which 
the bevacizumab is held 1-2 weeks, all protocol therapy will be held to ensure that the 
bevacizumab is given prior to chemotherapy in order to test the hypothesis of this study.  
Patients will be discontinued from the study therapy if the 24-hour protein is > 3 g/24 
hours, if there is a second 24 hour urine protein > 2 g, or if the 24-hour urine protein 
does not decrease to < 2 g/24 hours after a 2 week delay of dosing. Patients will be 
discontinued from the study therapy if the 24-hour protein is > 3 g/24 hours, if there is a 
second 24 hour urine protein > 2 g, or if the 24-hour urine protein does not decrease to < 
2 g/24 hours after a 2 week delay of dosing. 
 
3. 
Elective major surgery: If patients on treatment with bevacizumab require elective 
major surgery, it is recommended that bevacizumab be held for 4-8 weeks prior to the 
surgical procedure. Patients undergoing a major surgical procedure should not 
begin/restart bevacizumab until 4 weeks after that procedure (in the case of high risk 
procedures such as liver resection, thoracotomy, or neurosurgery, it is recommended 
that treatment with the chemotherapy combination, CTB should be restarted no earlier 8 
wk after surgery). 
 

  
 
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b. Other Study Drug(s)-Specific 
Please see Section 7.1.3 for detailed instructions for the management of study drug–
related toxicities. 
 
5.0 
STUDY SUBJECTS 
 
5.1 
Subject Selection 
Investigators will be expected to maintain a screening log of all potential study 
candidates that includes limited information about the potential candidate (ie. age, sex, 
date) and the outcome of the screening process (ie. enrolled into study, reason for 
ineligibility, or refusal to participate).  
 
Screening Failures:  
Patients who fail to meet the inclusion and/or exclusion criteria are defined as screen 
failures. For all screen failures, the investigator will document the patient initials and 
reason(s) for screen failure in the screening log. A copy of the log should be retained in 
the investigator’s study files.  
 
5.2 
Inclusion Criteria 
Patients will be included in the study based on the following criteria:  
 
5.2.1 Patients must have histologically confirmed relapsed/refractory Ewing’s sarcoma 
or neuroblastoma.  
 
5.2.2 Patients must have measurable disease (Refer to Section 8.6.1.1 for the 
definition of measurable disease.) Patients with a diagnosis of neuroblastoma 
with MIBG avid disease only are permitted to enroll on this study. 
 
5.2.3 Patients must be ≤ 21 years of age at time of diagnosis 
 
5.2.4 Life expectancy ≥ 3 months 
 
5.2.5 Lansky or Karnofsky performance ≥ 70% 
 
5.2.6 Written informed consent 
 
5.2.7 Organ and marrow function defined as follows: 
Hematologic function, as follows 
- 
Absolute neutrophil count  ≥ 1000/µL  
- 
Platelets ≥ 100 x 109/L (without transfusion < 14 days before enrollment)  
- 
Hemoglobin ≥ 9 gm/dl 
 
Renal function, as follows:  
- 
Serum creatinine ≤ ULN for age. Refer to Appendix H for normal values for 
serum creatinine in children. 

  
 
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- 
If serum creatinine above these values, the calculated creatinine clearance or 
radioisotope GFR must be ≥ 60 ml/min/1.73 m2 
- 
Urinary protein < 2+ (unless total quantitative protein is < 500 mg protein/day 
as determined by 24 H urine collection). for pediatric patients please refer to 
the CTCAE V4.0 for values. 
Hepatic function, as follows:  
- 
Total bilirubin ≤ 1.5x ULN 
- 
AST and ALT ≤ 2.5x ULN for institution or ≤ 5x ULN for institution if 
clearly attributable to liver metastases 
- 
Albumin ≥ 2.5 g/dl. 
 
Coagulation: INR ≤ 1.5x ULN. 
 
5.2.8 Prior Treatment: Patients must have recovered from the acute toxic effects of all 
prior chemotherapy, immunotherapy, or radiation therapy prior to entry on study. 
Patients must have had at least one prior treatment regimen. Patients may have 
received 
treatment 
previously 
with 
cyclophosphamide, 
topotecan, 
or 
bevacizumab. 
Myelosuppressive chemotherapy: Two weeks must have elapsed since 
administration of previous chemotherapy.  
Biologic agents: At least 2 weeks must have elapsed since the completion of 
therapy with a monoclonal antibody. Seven days must have elapsed since the 
last dose of retinoids. 
Radiation therapy: For all patients, ≥ 4 weeks must have elapsed for local XRT; ≥ 
6 months must have elapsed if prior radiation to ≥ 50% of the pelvis or if 
substantial bone marrow irradiation.  Patients with a history of prior radiation with 
field including the heart (e.g. mantle) will be excluded. 
Stem cell transplant: Patients who have undergone prior stem cell transplantation 
will not be excluded from study entry. At least 3 months must have elapsed since 
autologous or allogeneic stem cell transplantation. Patients must have no 
evidence of active graft versus host disease.   
 
5.3  
Exclusion Criteria 
a. Disease-Specific Exclusions 
5.3.1 Disease-Specific Exclusions 
• 
Patients with centrally-located pulmonary or mediastinal primary tumors or 
metastases adjacent to or invading large blood vessels. 
• 
Prior left chest wall irradiation or a cumulative anthracycline dose of greater or 
equal to 300 mg/m2, unless the ejection fraction or fraction shortening is within 
normal institutional limits, in which case the patient can be enrolled. 
 

  
 
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b. General Medical Exclusions 
Subjects meeting any of the following criteria are ineligible for study entry:   
 
• 
Inability to comply with study and/or follow-up procedures 
• 
Life expectancy of less than 3 months 
• 
Current, recent (within 4 weeks of the first infusion of this study), or planned 
participation in an experimental drug study other than a Genentech-sponsored 
bevacizumab cancer study 
• 
Active second malignancy, other than superficial basal cell and superficial 
squamous (skin) cell, or carcinoma in situ of the cervix within last five years  
• 
History of other malignancies, except for other solid tumors curatively treated 
with no evidence of disease for > 3 years prior to enrollment. 
• 
Known infection with human immunodeficiency virus (HIV). 
c. Bevacizumab-Specific Exclusions 
• 
Uncontrolled hypertension (sBP >150 mmHg and/or diastolic BP > 100 mmHg, 
found on two consecutive measurements separated by a one week period of time 
despite adequate medical support). 
• 
Prior history of hypertensive crisis or hypertensive encephalopathy. 
• 
New York Heart Association (NYHA) Grade II or greater congestive heart failure 
(see Appendix E). 
• 
History of myocardial infarction or unstable angina within 6 months prior to Day -
3. 
• 
History of stroke or transient ischemic attack within 6 months prior to Day -3.  
• 
Known CNS disease, except for treated brain metastases. 
Treated brain metastases are defined as having no evidence of progression or 
hemorrhage after treatment and no ongoing requirement for dexamethasone, as 
ascertained by clinical examination and brain imaging (MRI or CT) during the 
screening period.  Anticonvulsants (stable dose) are allowed.  Treatment for 
brain metastases may include whole brain radiotherapy (WBRT), radiosurgery 
(RS; Gamma Knife, LINAC, or equivalent) or a combination as deemed 
appropriate by the treating physician.  Patients with CNS metastases treated by 
neurosurgical resection or brain biopsy performed within 3 months prior to Day -3 
will be excluded. 
• 
Significant vascular disease (e.g., aortic aneurysm, requiring surgical repair or 
recent peripheral arterial thrombosis) within 6 months prior to Day -3. 
• 
History of hemoptysis (≥ 1/2 teaspoon of bright red blood per episode) within 
1 month prior to Day -3. 
• 
Evidence of bleeding diathesis or significant coagulopathy (in the absence of 
therapeutic anticoagulation). 
 

  
 
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• 
Major surgical procedure, open biopsy, or significant traumatic injury within 
28 days prior to Day -3 or anticipation of need for major surgical procedure 
during the course of the study. (A major procedure constitutes an invasive 
procedure which requires general anesthetic support, hospitalization, and 
supportive care such as laparotomy, laminectomy, etc.) 
• 
Core biopsy or other minor surgical procedure, excluding placement of a vascular 
access device, within 7 days prior to Day 1. (Minor surgical procedures include 
minimally invasive procedures such as fine needle aspiration, core biopsy, etc 
requiring little if any supportive care excluding lumbar puncture and bone marrow 
aspiration/biopsy.) 
• 
History of abdominal fistula or gastrointestinal perforation within 6 months prior to 
Day -3. 
• 
Serious, non-healing wound, active ulcer, or untreated bone fracture. 
• 
Thrombolytics or treatment doses of warfarin within 28 days of initiating 
treatment.  Patients who require low dose warfarin for central venous catheter 
patency are allowed to enter if their dose is < 2 mg per day total AND their 
International Normalized Ratio (INR) is ≤ 1.5. 
• 
Patients requiring treatment doses of heparin for any reason.  The use of heparin 
flushes for maintenance of central venous catheters is permitted. 
• 
Patients requiring aspirin > 325 mg per day or non-steroidal anti-inflammatory 
medications known to inhibit platelet function.  Patients taking cyclooxygenase-2 
inhibitors (COX-2) inhibitors are allowed to enroll. 
• 
History or clinical evidence of deep venous thrombosis including pulmonary 
embolus within 6 months of treatment. 
• 
Patients with proteinuria > 1+ on urine dipstick or UPC ratio ≥ 1.0 at screening.  If 
>1+ proteinuria is detected on surveillance, a 24-hour collection must be 
performed if eligibility is desired.  Patients with a 24-hour urine protein content of 
≤ 500 mg are eligible. 
• 
Known hypersensitivity to any component of bevacizumab.  
• 
Pregnancy (positive pregnancy test) or lactation. (An effective means of 
contraception (men and women) in subjects of child-bearing potential must be 
used.) 
6.0 
STUDY DESIGN 
 
6.1 
Treatment Plan 
 
The treatment schedule for this study will consist of a 21-day cycle. Dose modification 
will only occur with administration of the investigational agent, bevacizumab.  
 
The schedule of administration is summarized as follows. Administration of bevacizumab 
will precede the administration of the cyclophosphamide and topotecan by 3 days (Day -
3) to allow for vascular stabilization prior to initiation of chemotherapy. Refer to Section 
7.1.1 for administration guidelines for bevacizumab. 

  
 
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The chemotherapy backbone will consist of cyclophosphamide and topotecan 
administered as follows: cyclophosphamide 250 mg/m2/day IV over 30 minutes  ± 5 
minutes on Days 0-4 followed by topotecan 0.75 mg/m2/day IV over 30 minutes  ± 5 
minutes on Day 0-4 of every cycle.  The dosing of cyclophosphamide and topotecan will 
be fixed.  
 
 
Dose Escalation Schema 
Dose Level 
Cyclophosphamide 
(mg/m2) 
daily x 5 Q 21 days 
Days 0-4 
Topotecan 
(mg/m2) 
daily x 5 Q 21 days 
Days 0-4 
Bevacizumab 
(mg/kg) Q 3 weeks 
Day -3 
-1 
250 mg 
0.75 mg 
- 
1 
250 mg 
0.75 mg 
15 mg 
 
Administration of Filgrastim will begin 24 hours after completion of chemotherapy (Day 
5) at a dose of 5 mcg/kg/dose subcutaneously until the ANC is ≥ 1,000/μL for 3 
consecutive days or ≥ 10,000/μL for 1 day. Administration of Neulasta is permitted. 
 
Patients can begin subsequent cycles of CTB once the following criteria have been met: 
1) after a minimum of 21 days since the start of the previous treatment cycle, 2) ANC ≥ 
1000/μL 48 hours after discontinuation of Filgrastim, and 3) platelet count ≥ 100,000/μL.  
  
In the event of development of the following toxicities defined as follows, treatment with 
bevacizumab will be withdrawn and therapy resumed with cyclophosphamide and 
topotecan alone:   
 
• 
If attribution of the event to bevacizumab is felt to be likely or definite 
• 
For any severe adverse event as outlined in Section 7.1.3, Table 1 
 
There will be no intra-patient dose escalation of bevacizumab.  
 
Response will be evaluated by Revised RECIST guideline (version 1.1) after every 2 
cycles of therapy (6 weeks). If the response is stable or better, the patient will continue 
on therapy up to a maximum duration of 1 year as long as their cancer continues to 
demonstrate response to treatment. 
 
Exploratory biologic correlative studies will be performed during the first and second 
cycle of treatment. See Section 8.6. 
 
6.2 
Number of Centers 
This trial will be conducted in the Pediatric Oncology Experimental Therapeutics Investigators’ 
Consortium (POETIC). Approximately 10 centers in the United States and Canada will 
participate in this study.  
 
6.3 
Number of Subjects 
 
 
The maximum sample size for this study is anticipated to be a total of 29 patients.  

  
 
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6.4 
Estimated Study Duration 
 
The accrual period is estimated to be approximately 1 ½ years. The maximum duration of the 
study will be approximately 2 years.  
 
7.0 
STUDY MEDICATION  
 
7.1  
Bevacizumab Dosage and Formulation 
Bevacizumab is a clear to slightly opalescent, colorless to pale brown, sterile liquid 
concentrate for solution for intravenous (IV) infusion.  Bevacizumab may be supplied in 
20-mL (400 mg) glass vials containing 16 mL bevacizumab, respectively (25 mg/mL).  
Vials contain bevacizumab with phosphate, trehalose, polysorbate 20, and Sterile Water 
for Injection (SWFI), USP.  Vials contain no preservative and are suitable for single use 
only. 
 
For further details and molecule characterization, see the bevacizumab Investigator 
Brochure. 
7.1.1 Bevacizumab Administration 
Bevacizumab will be diluted in a total volume of 100 mL of 0.9% Sodium Chloride 
Injection, USP.  Administration will be as a continuous IV infusion.  Anaphylaxis 
precautions should be observed during study drug administration.   It is not necessary to 
correct dosing based on ideal weight. 
 
The initial dose will be delivered over 90 ± 15 minutes. If the first infusion is tolerated 
without infusion-associated adverse events (fever and/or chills), the second infusion may 
be delivered over 60 ± 10 minutes.  If the 60-minute infusion is well tolerated, all 
subsequent infusions may be delivered over 30 ± 10 minutes.   
 
If a subject experiences an infusion-associated adverse event, he or she may be 
premedicated for the next study drug infusion; however, the infusion time may not be 
decreased for the subsequent infusion.  If the next infusion is well tolerated with 
premedication, the subsequent infusion time may then be decreased by 30±10 minutes 
as long as the subject continues to be premedicated. If a subject experiences an 
infusion-associated adverse event with the 60-minute infusion, all subsequent doses 
should be given over 90 ± 15 minutes.  Similarly, if a subject experiences an 
infusion-associated adverse event with the 30-minute infusion, all subsequent doses 
should be given over 60 ± 10 minutes. 
7.1.2 Bevacizumab Storage 
Upon receipt of the study drug, vials are to be refrigerated at 2°C-8°C  
(36°F-46°F) and should remain refrigerated until just prior to use.  DO NOT FREEZE.  
DO NOT SHAKE.   Vials should be protected from light. 
 
Opened vials must be used within 8 hours.  VIALS ARE FOR SINGLE USE ONLY.  
Vials used for 1 subject may not be used for any other subject.  Once study drug has 
been added to a bag of sterile saline, the solution must be administered within 8 hours. 

  
 
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7.1.3 Bevacizumab Dose and Toxicity Management 
There are no reductions in the bevacizumab dose. If adverse events occur that require 
holding bevacizumab, the dose will remain the same once treatment resumes. Any 
toxicities associated or possibly associated with bevacizumab treatment should be 
managed according to standard medical practice. Discontinuation of bevacizumab will 
have no immediate therapeutic effect. Bevacizumab has a terminal half-life of 21 days; 
therefore, its discontinuation results in slow elimination over several months. There is no 
available antidote for bevacizumab.  
 
Subjects should be assessed clinically for toxicity prior to, during, and after each 
infusion. If unmanageable toxicity occurs because of bevacizumab at any time during the 
study, treatment with bevacizumab should be discontinued.  
 
Infusion Reaction: Infusion of bevacizumab should be interrupted for subjects who 
develop dyspnea or clinically significant hypotension. Subjects who experience a NCI 
CTCAE v. 4.0 Grade 3 or 4 allergic reaction/hypersensitivity, adult respiratory distress 
syndrome, or bronchospasm (regardless of grade) will be discontinued from 
bevacizumab treatment. 
 
The infusion should be slowed to 50% or less or interrupted for subjects who experience 
any infusion-associated symptoms not specified above. When the subject’s symptoms 
have completely resolved, the infusion may be continued at no more than 50% of the 
rate prior to the reaction and increased in 50% increments every 30 minutes if well 
tolerated. Infusions may be restarted at the full rate during the next cycle.  
 
Adverse events requiring delays or permanent discontinuation of bevacizumab are listed 
below in Table 1.  
 
Regardless of the reason for holding study drug treatment, the maximum allowable 
length of treatment interruption is 2 months. 
Table1  
 
Bevacizumab Dose Management Due to Adverse Events 
 
Event 
Action to be Taken 
Hypertension 
No dose modifications for grade 1/2 events 
Grade 3 
If not controlled to 150/100 mmHg with medication, discontinue 
bevacizumab. 
Grade 4  
(including hypertensive 
encephalopathy) 
Discontinue bevacizumab. 
Hemorrhage 
No dose modifications for grade 1/2 non-pulmonary and non-CNS events 

  
 
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  Grade 3   
  Non-pulmonary and 
    non-CNS hemorrhage 
Subjects who are also receiving full-dose anticoagulation will be 
discontinued from receiving bevacizumab.   
All other subjects will have bevacizumab held until all of the following 
criteria  are met: 
• 
The bleeding has resolved and hemoglobin is stable. 
• 
There is no bleeding diathesis that would increase the risk 
of therapy. 
• 
There is no anatomic or pathologic condition that 
significantly increases the risk of hemorrhage recurrence. 
Subjects who experience a repeat Grade 3 hemorrhagic event will be 
discontinued from receiving bevacizumab. 
  Grade 4  
     non-pulmonary or  
    non-CNS hemorrhage 
Discontinue bevacizumab. 
   Grade 1 pulmonary or 
CNS hemorrhage 
Subjects who are also receiving full-dose anticoagulation will be 
discontinued from receiving bevacizumab.   
All other subjects will have bevacizumab held until all of the following 
criteria  are met: 
• 
The bleeding has resolved and hemoglobin is stable. 
• 
There is no bleeding diathesis that would increase the risk 
of therapy. 
• 
There is no anatomic or pathologic condition that 
significantly increases the risk of hemorrhage recurrence. 
 
Grade 2, 3, or 4 
pulmonary or CNS 
hemorrhage 
Discontinue bevacizumab. 
Venous Thrombosis 
No dose modifications for grade 1/2 events 
Table 1 
Bevacizumab Dose Management due to Adverse Events (continued) 
 
Grade 3 or 4 
Hold study drug treatment.  If the planned duration of full-dose 
anticoagulation is <2 weeks, bevacizumab should be held until the 
full-dose anticoagulation period is over.  If the planned duration of 
full-dose anticoagulation is >2 weeks, bevacizumab may be resumed 
during the period of full-dose anticoagulation if all of the following 
criteria  are met: 
• 
The subject must have an in-range INR (usually between 
2 and 3) if on warfarin; LMWH, warfarin, or other 
anticoagulant dosing must be stable prior to restarting 
bevacizumab treatment. 
• 
The subject must not have had a Grade 3 or 4 
hemorrhagic event while on anticoagulation. 

  
 
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Arterial Thromboembolic event 
(New onset, worsening, or unstable angina, myocardial infarction, transient ischemic attack, 
cerebrovascular accident, and any other arterial thromboembolic event) 
 Any grade 
Discontinue bevacizumab. 
Congestive Heart Failure (Left ventricular systolic dysfunction)  
No dose modifications for grade 1/2 events 
Grade 3 
Hold bevacizumab until resolution to Grade ≤ 1. 
Grade 4 
Discontinue bevacizumab. 
Proteinuria 
No dose modifications for grade 1/2 events 
Grade 3 
(UPC> 3.5, urine 
collection > 3.5 g/24 
hr)   
 
Hold bevacizumab treatment until ≤ Grade 2, as determined by either 
UPC ratio ≤ 3.5 or 24 hr collection ≤ 3.5 g 
 
Grade 4 (nephritic 
syndrome) 
Discontinue bevacizumab. 
GI Perforation 
 
Discontinue bevacizumab. 
Fistula  
 
Any grade (TE 
fistula) 
Discontinue bevacizumab. 
Grade 4 fistula 
Discontinue bevacizumab. 
Bowel Obstruction 
Grade 1 
 
Continue patient on study for partial obstruction NOT requiring medical 
intervention. 
Table 1  
Bevacizumab Dose Management due to Adverse Events (continued) 
 
Grade 2 
Hold bevacizumab for partial obstruction requiring medical intervention.  
Patient may restart upon complete resolution. 
Grade 3/4 
Hold bevacizumab for complete obstruction.  If surgery is necessary, 
patient may restart bevacizumab after full recovery from surgery, and 
at investigator’s discretion. 
Wound 
dehiscence 
Any grade (requiring 
medical 
or 
surgical 
therapy) 
Discontinue bevacizumab. 
Reversible Posterior Leukoencephalopathy   
Any grade 
(confirmed by MRI) 
Discontinue bevacizumab. 

  
 
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Other Unspecified Bevacizumab-Related Adverse Events 
Grade 3 
Grade 4 
Hold bevacizumab until recovery to ≤ Grade 1 
Discontinue bevacizumab. 
7.1.4 Investigational Agent Management 
FDA regulations require investigators to establish a record of the receipt, use, and 
disposition of all investigational agents.  The investigators in this study have the 
responsibility to assure the FDA that systems for agent accountability are being 
maintained by investigators in the clinical trials network.  Investigators may delegate 
responsibility for agent ordering, storage, accountability and preparation to a designee in 
their institutions.  However, the investigator is ultimately responsible for all agents 
shipped in his/her name.  The intent of agent accountability is to assure that supplied 
agents are only used for patients enrolled on this trial.  Investigational agents will not be 
shipped to a site unless all site and study specific regulatory documents have been 
received by the POETIC Data and Coordinating Center (DCC). The POETIC DCC will 
notify the site of their activation and provide clearance to order study drug from Fisher 
Clinical Sciences. 
 
Requests and Shipping 
 
Upon site activation by the POETIC DCC, the site will complete a Drug Shipment 
Authorization form and submit the document to the Fisher Clinical Sciences at the 
address listed below: 
 
Fisher Clinical Sciences 
Distribution Study Administration 
7554 Schantz Road 
Allentown, PA 18106 
Phone: 610-871-8300  
Fax:     610-871-8590 
E-mail: distribution.allentown@Thermofisher.com 
 
The information needed for completion Drug Shipment Authorization form is the POETIC 
protocol number, address, product information and quantity. The POETIC protocol, 
POE10-01, is included on the form. Investigational agents will only be shipped to the 
investigator’s designated shipping address.  All changes to the shipping address must 
be in writing and signed by the investigator or designee.   
 
Requests for investigational agents for new subjects should be submitted the day of 
registration and no less than 3 business days prior to the start of treatment.  Requests 
for subsequent cycles should be made a minimum of 1 week prior to treatment.  
Telephone requests will not be accepted. 
 
Investigational agents will only be shipped to the investigator’s designated shipping 
address.  All changes to the shipping address must be in writing and signed by the 
investigator or designee.  
 
 

  
 
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Upon receipt of the drug supply, the site must verify and document that correct agent(s), 
lot numbers, and quantity were received in adequate shipping conditions. Once verified 
the Packing Slip must be completed, signed and returned to Fisher Clinical Sciences to 
the following contact and FAX: AOR Administrator, FAX# 610-871-0775. If there are 
problems with the shipment, the Site must notify the AOR Administrator immediately.   
 
If there are any additional problems contact: 
 
Gregg J. Rieker 
Distribution Project Manager 
Thermo Fisher Scientific (Fisher Clinical Sciences) 
700 Nestle Way 
Breinigsville, PA 18031 
Phone: 484-538-2139    
Fax:     610-871-0711 
gregg.rieker@thermofisher.com  
 
7.1.5 Drug Accountability  
The study pharmacist at the site will be responsible for handling study drug, preparation 
of the appropriate dose to be administered, and completion of associated documentary 
paperwork. Documentation (receipt, transfer, dispensing, or return) will be maintained on 
the NCI Investigational Drug Accountability Record (DAR).  Alternative accountability 
records may be provided to meet study specific requirements (example – oral 
medication involving return of meds by patient) beyond the DAR form’s capability. A 
copy of the appropriate accountability record will be sent with the investigational agent. 
 
A DAR must be maintained at each location an agent is stored (example – main 
pharmacy, satellite, etc). A separate DAR will be maintained for each protocol. Protocols 
using more than one supplied agent or more than one strength or formulation of the 
same agent, each agent, strength, and formulation will be stored separately and a 
separate DAR maintained. Proper completion of the DAR is mandatory, failure to 
complete all fields as required may prevent future shipments until it is determined 
appropriate accountability can be maintained. Each time a dose is prepared for a patient, 
the following information must be recorded: the patient’s initials, the patient’s study 
number, the total dose prepared, the number of vials of drug product and diluent used, 
the number of the lot from which the dose was prepared, and the initials of the person 
preparing the dose. Audit of the DAR will be conducted at the end of the study and more 
often if needed. All investigational agents will be stored as per manufacturer 
recommendations in a secure location away from commercial drug stock that is only 
accessible to authorized personnel.  Each agent is to be stored and accounted for 
separately by protocol.  
 
Investigational agents requiring storage in refrigerator or freezer must be stored within 
the temperature range required by the manufacturer upon receipt.  The agents must be 
stored separately by protocol within the refrigerator/freezer. No food products may be 
stored within the refrigerator/freezer.  A thermometer or monitoring device must be 
utilized to monitor and record temperatures on a log posted on the equipment at a 
minimum of once daily.  Out of range temperatures must be documented with reason for 
situation and actions taken to correct.   
 

  
 
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Investigational agents must not be prepared until the subject is present, required testing 
completed, and the treating physician’s orders are received.  The investigator will 
administer the agent only to subjects registered to the study and under the investigator’s 
personal supervision or under the supervision of a sub-investigator responsible to the 
investigator. 
 
In addition to maintaining records of drug dispensation, an appropriate drug preparation 
log should also be maintained to document how the study drug solution was prepared. 
Calculations performed for preparation of the drug should be clearly recorded. If the site 
does not have such logs, Genentech will provide them. These logs are to be maintained 
by the study pharmacist in the pharmacy throughout the duration of the study and will be 
periodically verified by a representative of the Sponsor.  
 
7.1.6 Disposition of Used Supplies  
All used vials of study drug and diluent must be destroyed in an appropriate manner 
according to the standard practice at each study center. Destruction of such supplies will 
be documented, and a representative of the Sponsor will verify disposition records. No 
other utilization of bevacizumab study drug solution intended for use in this study is 
authorized by the Sponsor. The Principal Investigator or his/her designee will be 
responsible for the appropriate handling and disposition of residual study drug.  
 
7.1.7 Inventory of Unused Supplies  
Transfer of investigational agents between sites is prohibited unless approved by the 
DCC and the pharmaceutical management for drug distribution prior to the transfer. 
 
Investigational agents are not interchangeable with approved commercial agents.  
Correct stock must be used for all doses, if investigational agent is not available for a 
subject at the scheduled time the subject’s appointment must be changed. 
 
Every effort should be made to minimize the amount of agent ordered and returned 
unused.  Unused agents will either be returned or destroyed on-site as directed by the 
study staff when the study is completed or discontinued; agent is outdated, damaged or 
unfit for use.  Opened or partially used vials/bottles are not to be returned unless 
specifically requested otherwise in the protocol.  Broken vials are to be destroyed at the 
site, not returned.  
 
If return of investigational agent is not required, the agent will be treated as 
chemotherapy or biological hazardous waste as appropriate and disposed of in 
accordance to the policies for hazardous waste management at the Site.   
 
For agents destroyed on-site, the DAR must be completed and faxed to the POETIC 
DCC.  If the investigational agent is returned, the completed DAR must accompany the 
agent.   
 
Sites must maintain copies of all Requests for Drug Shipment, Packing Slips, and DARs 
on site, available for monitoring and auditing until final closure of the study.  After final 
closure of the study, forms may be stored off site as per the policy of the site. 

  
 
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Amended: 20-JAN-2016 
 
 
7.2 
Protocol Specified Chemotherapy 
 
7.2.1 Cyclophosphamide (Cytoxan) NSC #26271  
 
7.2.1.1 Source and Pharmacology:  
Cyclophosphamide 
is 
an 
alkylating 
agent 
related 
to 
nitrogen 
mustard. 
Cyclophosphamide is inactive until it is metabolized by P-450 isoenzymes (CYP2B6, 
CYP2C9 and CYP3A4) in the liver to active compounds. The initial product is 4-
hydroxycyclophosphamide (4-HC) which is in equilibrium with aldophosphamide which 
spontaneously releases acrolein to produce phosphoramide mustard. Phosphoramide 
mustard, which is an active bifunctional alkylating species, is 10 times more potent in 
vitro than is 4-HC and has been shown to produce interstrand DNA cross-linking 
analogous to those produced by mechlorethamine. Approximately 70% of a dose of 
cyclophosphamide is excreted in the urine as the inactive carboxyphosphamide and 5-
25% as unchanged drug. Cyclophosphamide is well absorbed orally with a bioavailability 
greater than 75%. The plasma half-life ranges from 4.1-16 hours after IV administration 
and 1.3-6.8 hours after oral administration. 
 
7.2.1.2 Formulation: 
Cyclophosphamide for Injection is available as powder for injection or lyophilized powder 
for injection in 500 mg, 1 gm and 2 gm vials. The powder for injection contains 82 mg 
sodium bicarbonate/100 mg cyclophosphamide and the lyophilized powder for injection 
contains 75 mg mannitol/100 mg cyclophosphamide.  
 
7.2.1.3 Storage: 
Storage at or below 25ºC (77ºF) is recommended. The product will withstand brief 
exposures to temperatures up to 30º C (86ºF). 
 
7.2.1.4 Reconstitution: 
Cyclophosphamide for Injection: Reconstitute with sterile water or Bacteriostatic water 
for injection (paraben preserved only) to a concentration of 20 mg/ml. If administered as 
undiluted drug at the 20 mg/ml concentration, reconstitute with NS only to avoid a 
hypotonic solution. Cyclophosphamide may be further diluted in dextrose or saline 
containing solutions for IV use. 
 
7.2.1.5 Stability: 
Reconstituted solution with preservative is stable for 24 hours at room temperature, or 6 
days if refrigerated. Solution reconstituted without preservative should be discarded after 
6 hours. 
 
7.2.1.6 Administration: 
In this study, cyclophosphamide will be administered intravenously over a 30 minute 
period + 5 minutes on 5 consecutive days. 
 
 

  
 
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7.2.1.7 Supplier: 
Commercially available from various manufacturers. See package insert for further 
information 
 
7.2.1.8 Safety Profile: 
 
Likely 
Less Likely 
Rare but Serious 
• 
Loss of appetite 
• 
Nausea 
• 
Vomiting 
• 
Fewer white blood cells in 
the blood. 
o A low number of white 
blood cells may make 
it easier to get 
infections. 
• 
Hair loss 
• 
Decreased ability of the 
body to fight infection 
• 
Absence or decrease in 
the number of sperm 
which may be temporary 
or permanent which may 
decrease the ability to 
have children 
 
• 
Abnormal hormone 
function which may lower 
the level of salt in the 
blood 
• 
Abdominal pain 
• 
Diarrhea 
• 
Fewer red blood cells and 
platelets in the blood 
o  A low number of red 
blood cells may make 
you feel tired and 
weak. 
o A low number of 
platelets may cause 
you to bruise and 
bleed more easily. 
• 
Bleeding and 
inflammation of the 
urinary bladder 
• 
Absence or decrease 
monthly periods which 
may be temporary or 
permanent and which 
may decrease the ability 
to have children 
• 
Temporary blurred vision 
• 
Nasal stuffiness at time of 
IV infusions 
• 
Skin rash 
• 
Darkening of areas of the 
skin and finger nails 
• 
Slow healing of wounds 
• 
 Infections 
• 
Metallic taste in mouth 
• 
Heart muscle damage 
which may occur with 
very high doses and 
which may be fatal 
• 
Abnormal heart rhythms 
• 
Damage and scarring of 
lung tissue which may 
make you short of breath 
• 
A new cancer or 
leukemia resulting from 
this treatment. 
• 
Damage or scarring of 
urinary bladder tissue 
• 
Severe allergic reaction 
which can be life 
threatening with 
shortness of breath, low 
blood pressure, rapid 
heart rate chills and fever 
• 
Infertility which is the 
inability to have children 
 
 
 
 
7.2.2 Topotecan, NSC #609699, IND #34494 
 
7.2.2.1 Source and Pharmacology:  
Topotecan is a semisynthetic analogue of camptothecin, an alkaloid derived from the 
camptothecin tree which grows widely throughout Asia. The drug is a specific 

  
 
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Topoisomerase-I inhibitor. Topotecan interferes with the repair activity of topoisomerase 
I by stabilizing the formation of a covalently bonded DNA-Topoisomerase I complex. 
Thus, the 5’-phosphoryl terminus of the enzyme catalyzed single strand DNA break 
remains bound to the tyrosine of the enzyme thereby interfering with replication. The 
drug exists as two species in equilibrium in aqueous solutions. One is a more active 
closed-ring lactone and the other a less active open ring form. Acidic conditions favor the 
closed ring lactone form while basic and physiologic pH favors the open ring form. In 
human plasma the lactone form is about 21% bound to plasma protein. The drug is 
excreted 39% in urine and the remainder in the stool, the latter is presumably via biliary 
excretion. In rats, over 90% of the radioactivity from [14C]topotecan was recovered in 
stool and urine in the first 96 hours. The half life for the lactone form is 180 minutes. 
 
7.2.2.2 Formulation: 
Topotecan is supplied as a lyophilized, light yellow powder in vials containing 4 mg 
Topotecan AS (as the base) and 48 mg mannitol and 20 mg tartaric acid, NF. The pH is 
adjusted to 3.0. It has a reverse magenta label for identification purposes.  
 
7.2.2.3 Storage: 
Unreconstituted vials are stored at room temperature, 15º-30ºC (59º-86ºF). 
 
7.2.2.4 Reconstitution: 
The contents of each 4 mg vial will be reconstituted with 4 mL Sterile Water for Injection, 
USP, yielding a 1 mg/mL solution of Topotecan AS. The vial can also be reconstituted 
with Bacteriostatic Water for Injection, USP.  
 
7.2.2.5 Stability:  
The vials reconstituted with Sterile Water for Injection, USP, contain no   antibacterial 
preservative and must be used within 8 hours. Those reconstituted with Bacteriostatic 
Water for Injection, USP, are stable for 21 days when stored in the refrigerator (2-8ºC). 
 
The reconstituted solution will be further diluted to concentrations of 10 mcg/mL to 500 
mcg/mL in Dextrose 5% in Water, Normal Saline, or Bacteriostatic Water for Injection, 
USP. Solutions for infusion in glass or plastic bags are stable at room temperature for 24 
hours if reconstituted with Dextrose 5% in Water or Normal Saline and are stable for 7 
days if reconstituted with Bacteriostatic Water for Injection, USP. No incompatibilities 
with other drugs have been described. The drug is stable in IV solutions as stated 
above. 
 
7.2.2.6 Administration: 
In this study, topotecan will be administered intravenously over a 30-minute +/- 5 
minutes on five consecutive days. The appropriate amount of drug should be diluted in 
D5W yielding a final volume of 25 mL. 
 
7.2.2.7 Supplier: 
Commercially available from various manufacturers. See package insert for further 
information. 
 

  
 
IRB#:11-183 A (2) 
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7.2.2.8 Safety Profile: 
 
Likely 
Less Likely 
Rare But Serious 
• 
Diarrhea  
• 
Nausea 
• 
Vomiting 
• 
Constipation 
• 
Fewer white blood cells, red 
blood cells and platelets in 
the blood. 
• 
A low number of white 
blood cells can make it 
easier to get infections 
• 
A low number of red blood 
cells can make you feel 
tired and weak 
• 
A low number of platelets 
causes you to bruise and 
bleed more easily 
• 
Fever including fever with a 
low white blood cell count 
which could indicate 
infection and may require 
hospitalization and 
treatment with antibiotics 
• 
Pain which may be in your 
abdomen, back or bones 
• 
A feeling of weakness 
and/or tiredness 
• 
Temporary hair loss 
• 
Loss of appetite 
• 
Elevation in the blood of certain 
enzymes or bilirubin found in the 
liver which could indicate liver 
irritation or damage 
• 
Headache 
• 
Rash, hives, itching or a red 
bumpy rash 
• 
A mild lowering of the blood 
pressure which usually does not 
require treatment 
• 
Inflammation and/or sores in the 
mouth, throat and/or esophagus 
• 
An infection in the blood which 
will require admission to the 
hospital and treatment with 
antibiotics 
• 
Numbness and tingling in the 
fingers and toes 
• 
Small amount of blood and/or 
protein in the urine or an 
elevation in blood creatinine 
which may indicate mild kidney 
damage 
• 
Shortness of breath 
• 
Muscle or joint aches and pains 
• 
Chest pain 
• 
Shaking chills 
• 
Severe allergic reaction 
which can be life 
threatening with shortness 
of breath, low blood 
pressure and a rapid heart 
rate 
• 
Severe allergic reaction 
which can be life 
threatening with rapid 
build-up of fluid under the 
skin, in the lining of the 
intestine and possibly in 
the throat or swelling of the 
tongue which could make it 
difficult to breath. 
• 
Bleeding into the tumor 
which may cause damage 
depending on the location 
of the tumor. 
 
 
 
 
 
 
 
7.3 
Concomitant Medications 
Low-dose aspirin (≤ 325 mg/d) may be continued in subjects at higher risk for arterial 
thromboembolic disease. Subjects developing signs of arterial ischemia or bleeding on 
study should be evaluated for possible bevacizumab discontinuation per Table 1, 
Bevacizumab Dose Management Due To Adverse Events. 
 
All concomitant medications administered within 14 days prior to and during the active 
study period are to be reported on the appropriate case report forms for each patient.  
 
7.3.1  Prior Treatment: 
Reasonable efforts will be made to collect information on all prior cancer treatments 
received by the patient (chemotherapy, radiotherapy, immunotherapy, biologics, etc.). 
The information must be recorded in the patient’s medical chart and on the patient’s 
CRF.  
 
All concomitant medications will be recorded on the appropriate case report forms. 

  
 
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7.3.2 Permitted Treatment: 
All routine and appropriate supportive care will be provided during this study, as clinically 
indicated, and in accordance with the standard of care practices. Clinical judgment 
should be utilized in the treatment of any adverse event experienced by the patient.  
 
Patients should receive full supportive care, including hematopoietic growth factors, 
transfusion of blood and blood products, aspirin, antibiotics, anti-emetics, as clinically 
appropriate.  Pre-medication (anti-emetics, hydration, antihistamines, etc.) should be 
administered according to institutional standards. Pneumocystis carinii prophylaxis is 
strongly recommended. 
 
Anti-platelet therapy (e.g. < 325 mg/day aspirin) should be considered for treatment of 
patients at high risk of developing arterial thromboembolic disease unless 
contraindicated. Low-dose aspirin (≤ 325 mg/d) may be continued in subjects at higher 
risk for arterial thromboembolic disease and are receiving aspirin at the time of study 
entry. Subjects developing signs of arterial ischemia or bleeding on study should be 
evaluated for possible bevacizumab discontinuation per Table 1, Bevacizumab Dose 
Management Due To Adverse Events. 
 
Patients may continue or be placed on oral contraceptives or hormone-replacement 
therapy as clinically indicated. 
 
Patients who experience infusion-associated symptoms may be treated symptomatically 
with acetaminophen, diphenhydramine, ranitidine, or other medications as clinically 
indicated. 
 
Patients with indwelling venous catheters may receive prophylaxis against catheter 
thrombosis in accordance with the local standard of care. Because bevacizumab has a 
half-life of approximately 21 days, elective major surgery with the exception of bone 
marrow biopsies should be delayed whenever possible. No data are available to define a 
safe interval. Re-initiation of bevacizumab following surgery requires documented 
approval from the Principal Investigator and Sponsor. 
 
Other medications considered necessary for the patient’s safety and well-being may be 
given at the discretion of the investigator. 
 
Information on all concomitant medications, blood products administered, as well as 
interventions occurring during the study period must be recorded on the patient’s CRF.  
 
8.0 
CLINICAL AND LABORATORY EVALUATIONS 
 
8.1 
Pre-Treatment Evaluations 
Informed consent must be obtained before study-specific screening evaluations are 
performed, unless performed as standard of care. The informed consent process should 
be documented in the patient’s chart. 
 

  
 
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The following procedures or evaluations will be performed within 7 days prior to 
treatment with the exception of screening radiologic studies appropriate for the disease 
which will be performed within 14 days of the start of treatment: 
• 
Complete medical and surgical history, including demographic data 
• 
Prior cancer history (including all prior therapy) 
• 
Complete physical examination 
• 
Vital Signs (temperature, heart rate, blood pressure and respiratory rate) 
• 
Lansky or Karnofsky performance status 
• 
Height and weight 
• 
Neurologic examination in patients with CNS tumors only 
• 
Laboratory studies 
o CBC (WBC with differential, hemoglobin, hematocrit, and platelets) 
o Serum chemistries (albumin, sodium, potassium, chloride, bicarbonate, 
BUN, creatinine, glucose, calcium, total bilirubin, total protein,  AST, ALT, 
alkaline phosphatase, phosphorus, and LDH) 
o Serum pregnancy test (for all females of childbearing potential) as per 
institutional guidelines 
o INR  
o Urine protein: creatinine ratio or urine dipstick (and 24 hour collection if 
indicated) 
• 
Radiologic studies appropriate for disease assessment (CT, MRI, MIBG, etc.)   
• 
EKG, echocardiogram, MUGA (as indicated)  
• 
CSF cell count and cytology if appropriate for disease assessment 
• 
Bone marrow aspiration(s) or biopsy if appropriate for disease assessment 
• 
To determine the impact of bevacizumab on growth and development in children. 
Baseline assessment of growth and development will consist of bone age films 
(left hand) and measurement of somatomedin C levels at baseline and at 
designated times during treatment. The evaluation will be conducted in all 
patients except for females who are post menarche or males who are Tanner 
Stage V. 
• 
Monitoring of protocol specified adverse events 
• 
Recording of concomitant medications 
 
8.2 
Evaluations During Treatment 
The following procedures or evaluations will be performed weekly during treatment 
except where designated in Table 2: Required Observations: 

  
 
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• 
Complete medical and surgical history, including demographic data 
• 
Complete physical examination 
• 
Vital Signs (temperature, heart rate, blood pressure and respiratory rate). Blood 
pressure monitoring will be performed weekly. 
• 
Lansky or Karnofsky performance status 
• 
Height and weight (to be collected prior to each cycle of treatment) 
• 
Neurologic examination every cycle as clinically indicated in patients with non-
CNS tumors. 
• 
Laboratory studies 
o CBC (WBC with differential, hemoglobin, hematocrit, and platelets) 
o Serum chemistries (albumin, sodium, potassium, chloride, bicarbonate, 
BUN, creatinine, glucose, calcium, total bilirubin ,total protein,  AST, ALT, 
alkaline phosphatase, phosphorus, and LDH) 
o Serum pregnancy test before each cycle (for females of childbearing 
potential only) 
o INR (for patients on warfarin only)  
o Urine protein: creatinine ratio or urine dipstick (and 24 hour collection if 
indicated) if indicated but otherwise every other dose. Screening urine 
protein cannot substitute for the day 0 time point, as the reason for the 
test is to see if there is a change from baseline, after bevacizumab has 
been given. 
• 
Radiologic studies appropriate for disease assessment (CT, MRI, MIBG, etc.) 
after every 2 cycles of therapy.  
• 
EKG, echocardiogram, MUGA (as indicated)  
• 
Monitoring of protocol specified adverse events 
• 
Recording of concomitant medications 
• 
To determine the impact of bevacizumab on growth and development in children. 
Baseline assessment of growth and development will consist of bone age films 
(left hand) and measurement of somatomedin C levels at baseline, 6 months and 
the end of treatment. 
 
8.3 
Post-Treatment Evaluations / Off Study  
The following procedures or evaluations will be performed at the completion of study 
participation: 
• 
Complete medical and surgical history, including demographic data 

  
 
IRB#:11-183 A (2) 
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• 
Complete physical examination 
• 
Vital Signs (temperature, heart rate, blood pressure and respiratory rate) 
• 
Lansky or Karnofsky performance status 
• 
Height and weight 
• 
Neurologic examination for patients with CNS tumors only 
• 
Laboratory studies 
o CBC (WBC with differential, hemoglobin, hematocrit, and platelets) 
o Serum chemistries (albumin, sodium, potassium, chloride, bicarbonate, 
BUN, creatinine, glucose, calcium, phosphorus, total bilirubin ,total 
protein,  AST, ALT, alkaline phosphate, phosphorus, and LDH) 
o INR (for patients on warfarin)  
o Urine protein: creatinine ratio or urine dipstick (and 24 hour collection if 
indicated) 
• 
Radiologic studies appropriate for disease assessment (CT, MRI, MIBG, etc.)  
• 
EKG, echocardiogram, MUGA (as indicated)  
• 
Bone aspiration(s) or biopsy if appropriate for disease assessment 
• 
Monitoring of protocol specified adverse events 
• 
Recording of concomitant medications 
 
8.4 
Study Termination Visit 
A study termination visit should be scheduled for ~30 days (28–42 days) after the 
decision to discontinue study participation. The following evaluations and procedures will 
be performed at this visit: 
• 
Complete medical and surgical history, including demographic data 
• 
Complete physical examination 
• 
Vital Signs (temperature, heart rate, blood pressure and respiratory rate) 
• 
Lansky or Karnofsky performance status 
• 
Height and weight 
• 
Monitoring of protocol specified adverse events 
Recording of concomitant medications 
8.5 
Overall Survival (OS) and Time To Progression (TTP) 
Patients who complete or discontinue treatment will be followed for overall survival for up 
to 5 years and/or to the time of progression. This information will be requested by the 
Protocol Principal Investigator/POETIC Data and Coordinating Center via Email/Phone 
annually. Completion of case report forms is not required.  

  
 
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TABLE 2: REQUIRED OBSERVATIONS 
 
 
  
 
Pre- 
Stu
dy 
 
Wk 
1 
 
Wk 
2 
 
Wk 
3 
 
Wk 
4 
 
Wk 
5 
 
Wk 
6 
 
Wk 
7 
 
Wk 
8 
 
Wk 
9 
 
Wk 
10 
 
Wk 
11 
 
Wk 
12 
 
Off 
Study 
Study 
Termination 
Visit 
Bevacizumaba 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
Cyclophosphamide b 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
Topotecanb 
 
X 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
 
 
 
 
Informed consent 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Medical history 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Concurrent meds 
 
X 
 
X---------------------------------------------------------------------------------------------X 
X 
X 
 
Physical exam 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Vital signs (temp, HR, RR esp. BP) 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
Height/Weight  
 
X 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
X 
 
Performance Status 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
 
CBC w/diff, platelets 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
INR (For all weeks except 
baseline, collect only for Warfarin 
patient) 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Serum chemistryc 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
EKG, ECHO, MUGA 
(as indicated) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CSF ( as indicated ) 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
B-HCG 
 
Xd 
 
 
 
 
 
 
 
Xd 
 
 
 
 
 
Xd 
 
 
 
 
 
Xd 
 
 
 
 
 
 
 
 
Adverse event evaluation 
 
X 
 
X---------------------------------------------------------------------------------------------X 
X 
X 
 
 
Tumor measurements 
 
 
X 
 
Tumor measurements are repeated every ≥ 4 and < 6 weeks.  Documentation 
(radiologic) must be provided for patients removed from study for progressive 
disease. 
 
Xe 
 
 
Radiologic evaluation 
 
X 
 
Radiologic measurements should be performed every ≥ 4 and < 6 weeks. 
Xe 
 
Pharmacokinetics 
 
Xf  
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
Blood for angiogenic profile 
and serum angiogenic  
biomarkers 
 
Xg  
 
 
 
 
 
 
 
 
 
 
 
 
 
Somatomedin C 
Xi 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Bone age films 
Xi 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
Blood for Metabolic Signature  
Analysis 
 
 
 
Xh  
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine protein: creatinine ratio or 
dipstick 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 

  
 
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a:    Bevacizumab:  Administered on Day -3 of every 21 day cycle 
b:   Cyclophosphamide/Topotecan:  Administered on Days 0- 4 of every 21 day cycle 
c:   Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, potassium,     
      total protein, SGOT [AST], SGPT [ALT], sodium. 
d:   Serum pregnancy test will be preformed at the beginning of each cycle (Females of childbearing potential). 
e:   Off-study evaluation.   
f:    Pharmacokinetic Analysis: Samples will be collected pre and post treatment. See section 8.7.1 for schedule.   
g:   Angiogenic Profile and Serum Biomarkers: Day -3 ( prior to administration of bevacizumab), Day 0 (prior to administration of   
      cyclophosphamide), Day 7 and Day 18 (prior to the next scheduled dose of bevacizumab). 
h:   NMR analysis: Day -3 (prior to administration of bevacizumab), Day 0 (prior to administration of cyclophosphamide), and Day 7 of the    
      first cycle of therapy . 
i:    Bone age films and somatomedin C will be obtained at base line, every 6 months thereafter, and the end of treatment.                                              
 
Evaluations in patients who experience treatment delays 
In the event of a treatment delay, the timetable for the evaluations above will be modified 
so that studies are performed at the times appropriate relevant to drug administration.  
Height, weight, vital signs, and performance status will be checked and documented 
during weeks in which drug is administered.  Physical examinations will also be 
performed and documented during weeks in which drug is administered.  Laboratory 
studies as shown in the table will be performed on a weekly basis during weeks in which 
drug is administered and during the following rest week.  In the event of treatment delay, 
laboratory studies will be performed at additional time-points as needed for good patient 
care. Radiographic assessments will be performed after every 2 cycles of therapy.  
 
8.6    Criteria For Therapeutic Response/Outcome Assessment 
Patients with measurable disease will be assessed by standard criteria.  For the 
purposes of this study, all patients with solid tumors will be re-evaluated every 2 cycles 
(≥ 4 and < 6 weeks from the start of the first cycle of treatment).  In addition to a baseline 
scan, confirmatory scans will also be obtained 3 weeks following initial documentation of 
an objective response.  If a durable response is documented, response will be re-
assessed every 6 weeks. If treatment is delayed the radiologic imaging will be performed 
after every other cycle (which will result in a longer interval between imaging).   
 
8.6.1 Definition of Response in Patients  
Response and progression will be evaluated in this study using the international criteria 
Revised RECIST guideline (version 1.1) proposed by the Response Evaluation Criteria 
in Solid Tumors (RECIST) Committee [European Journal of Cancer 45:228-247, 2009].  
Changes in only the largest diameter (unidimensional measurement) of the tumor 
lesions are used in the RECIST criteria.  Note:  Lesions are either measurable or non-
measurable using the criteria provided below. The term “evaluable” in reference to 
measurability will not be used because it does not provide additional meaning or 
accuracy. 
 
8.6.1.1  Measurable Disease 
Measurable lesions are defined as those that can be accurately measured in at least one 
dimension (longest diameter to be recorded) as ≥ 20 mm with conventional techniques 
(CT, MRI, x-ray) or as ≥ 10 mm with spiral CT scan.  All tumor measurements must be 
recorded in millimeters (or decimal fractions of centimeters). 
 
 

  
 
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8.6.1.2  Non-measurable Disease 
All other lesions (or sites of disease), including small lesions (longest diameter < 20 mm 
with conventional techniques or <10 mm using spiral CT scan), are considered non-
measurable disease.  Bone lesions, leptomeningeal disease, ascites, pleural/pericardial 
effusions, lymphangitis cutis/pulmonis, inflammatory breast disease, abdominal masses 
(not followed by CT or MRI), and cystic lesions are all non-measurable. 
 
8.6.1.3 Target Lesions 
All measurable lesions up to a maximum of five lesions per organ and 10 lesions in total, 
representative of all involved organs, should be identified as target lesions and recorded 
and measured at baseline.  Target lesions should be selected on the basis of their size 
(lesions with the longest diameter) and their suitability for accurate repeated 
measurements (either by imaging techniques or clinically).  A sum of the longest 
diameter (LD) for all target lesions will be calculated and reported as the baseline sum 
LD.  The baseline sum LD will be used as a reference by which objective tumor 
response might be characterized. 
 
8.6.1.4 Non-target Lesions 
All other lesions (or sites of disease) should be identified as non-target lesions and 
should also be recorded at baseline.  Non-target lesions include measurable lesions that 
exceed the maximum numbers per organ or total of all involved organs as well as non-
measurable lesions.  Measurements of these lesions are not required, but the presence 
or absence of each should be noted throughout follow-up.  
 
8.6.1.5  Guidelines for Evaluation of Measurable Disease 
All measurements should be taken and recorded in metric notation using a ruler or 
calipers.  All baseline evaluations should be performed as closely as possible to the 
beginning of treatment and never more than 14 days before the beginning of the 
treatment.  Tumors in a previously irradiated area will be considered measurable. 
 
The same method of assessment and the same technique should be used to 
characterize each identified and reported lesion at baseline and during follow-up. 
Imaging-based evaluation is preferred to evaluation by clinical examination when both 
methods have been used to assess the antitumor effect of a treatment. 
 
Clinical lesions.  Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes).  In the case of skin lesions, 
documentation by color photography, including a ruler to estimate the size of the lesion, 
is recommended.  
 
Conventional CT and MRI.  These techniques should be performed with cuts of 10 mm 
or less in slice thickness contiguously.  Spiral CT should be performed using a 5 mm 
contiguous reconstruction algorithm.  This applies to tumors of the chest, abdomen, and 
pelvis.  Tumors of the head, neck and extremities usually require specific protocols. 
 
Ultrasound (US).  When the primary endpoint of the study is objective response 
evaluation, US should not be used to measure tumor lesions.  It is, however, a possible 
alternative to clinical measurements of superficial palpable lymph nodes, subcutaneous 

  
 
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lesions, and thyroid nodules.  US might also be useful to confirm the complete 
disappearance of superficial lesions usually assessed by clinical examination. 
 
Endoscopy, Laparoscopy.  The utilization of these techniques for objective tumor 
evaluation has not yet been fully and widely validated.  Their uses in this specific context 
require sophisticated equipment and a high level of expertise that may only be available 
in some centers.  Therefore, the utilization of such techniques for objective tumor 
response should be restricted to validation purposes in reference centers.  However, 
such techniques can be useful to confirm complete pathological response when biopsies 
are obtained. 
 
Cytology, Histology.  These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in 
tumor types such as germ cell tumors, where known residual benign tumors can 
remain). 
 
Because an effusion may be a side effect of treatment, cytological confirmation of the 
neoplastic origin of any effusion that appears or worsens during treatment (when the 
measurable tumor has met criteria for response or stable disease) is mandatory to 
differentiate between response, stable disease and progressive disease. 
 
       
8.6.2  Response Criteria  
8.6.2.1  Evaluation of Target Lesions 
 
Complete Response (CR): Disappearance of all target lesions 
 
Partial Response (PR): At least a 30% decrease in the sum of the longest diameter (LD) 
of target lesions, taking as reference the baseline sum LD. 
 
Progressive Disease (PD): 
At least a 20% increase in the sum of the LD of target 
lesions, taking as reference the smallest sum LD recorded since the treatment started 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 sum LD since the treatment started. 
 
8.6.2.2  Evaluation of Non-target Lesions 
 
Complete Response (CR): Disappearance of all non-target lesions and normalization of 
tumor marker level. 
 
Incomplete Response/Persistence of one or more nontarget lesion(s). 
 
Stable Disease (SD): or/and maintenance of tumor marker level above the normal limits. 
 
Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions. 
 

  
 
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Although a clear progression of “non-target” lesions only is exceptional, in such 
circumstances the opinion of the treating physician should prevail, and the progression 
status should be confirmed at a later time by the review panel (or study chair). 
 
If tumor markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response. 
 
8.6.3  Evaluation of Best Overall Response 
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started).  The patient's best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria. 
 
 
Target Lesions 
 
Non-target Lesions 
 
New Lesions 
 
Overall Response 
 
CR 
 
CR 
 
No 
 
CR 
 
CR 
 
Incomplete 
response/SD 
 
No 
 
PR 
 
PR 
 
Non-PD 
 
No 
 
PR 
 
SD 
 
Non-PD 
 
No 
 
SD 
 
PD 
 
Any 
 
Yes or No 
F 
PD 
 
Any 
 
PD 
 
Yes or No 
 
PD 
 
Any 
 
Any 
 
Yes 
 
PD 
 
Note: Patients with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
classified as having “symptomatic deterioration.”  Every effort should be made to 
document the objective progression, even after discontinuation of treatment. 
 
In some circumstances, it may be difficult to distinguish residual disease from normal 
tissue.  When the evaluation of complete response depends on this determination, it is 
recommended that the residual lesion be investigated (fine needle aspirate/biopsy) 
before confirming the complete response status. 
 
To be assigned a status of PR or CR, changes in tumor measurements must be 
confirmed by repeat evaluations (CT/MRI) 3 weeks after the criteria for response are first 
met. 
 
8.6.4 Confirmatory Measurement/Duration of Response  
 
8.6.4.1  Confirmation 
To be assigned a status of PR or CR, changes in tumor measurements must be 
confirmed by repeat assessments obtained 3 weeks after the criteria for response are 

  
 
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first met.  In the case of SD, follow-up measurements must meet the SD criteria at least 
once after study entry at a minimum interval of 6 weeks. 
 
8.6.4.2 Duration of Overall Response 
The duration of overall response is measured from the time measurement criteria are 
met for CR or PR (whichever is first recorded) until the first date that recurrent or 
progressive disease is objectively documented (utilizing as reference for progressive 
disease the smallest measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met 
for CR until the first date that recurrent disease is objectively documented. 
 
8.6.4.3 Duration of Stable Disease 
Stable disease is measured from the start of the treatment until the criteria for 
progression are met, utilizing as reference the smallest measurements recorded since 
the treatment started.  
 
8.7 
Correlative Studies 
The study will incorporate mandatory exploratory biologic correlative studies to evaluate 
the following:  
 
8.7.1  Pharmacokinetic Analysis 
These studies will be conducted under the direction of Dr. Aru Narendran at the 
University of Calgary in Alberta, Canada. 
 
Serum samples will be obtained before and at the end of each bevacizumab infusion.  
Pharmacokinetic serum samples will be obtained during the first and second cycles of 
treatment and at the first follow-up visit for response assessment.  
 
Cycle 1 (21 day cycle) 
 
Day -3 (Bevacizumab Dose 1): pre and immediate post infusion sample 
Day 7 ± 3 days: Trough  
Day 18 ±3 days: Trough 
 
Cycle 2 (21 day cycle) 
 
Day 7 ± 3 days: Trough  
Day 18 ± 3 days: Trough 
 
Trough at follow-up for the initial response assessment at 6 weeks after the start of 
treatment. 
 
Blood should be drawn from the contralateral arm to the infusion site using an indwelling 
catheter to avoid multiple needle sticks. If a catheter is used for blood collection, the fluid 
in the catheter should be completely withdrawn prior to sample collection and discarded. 
About 5 mL of blood will be collected in a red top tube at each time point, placed upright 
(30 minutes) and centrifuged 3,000 x g for 10 minutes at 4°C. Serum will be collected 
and stored at –70°C until analysis.  

  
 
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Samples should be batched and shipped to the following address: 
 
Aru Narendran, MD, PhD 
University of Calgary 
HRIC Building, Lab 2a34 
3280 Hospital Drive NW 
Calgary, Alberta T2N 4Z6 
CANADA 
Telephone: (403) 210-6402 
Fax: (403) 210-6418 
E-mail: anarendran@ucalgary.ca 
 
Bevacizumab concentrations will be determined using an enzyme-linked immunosorbent 
assay (ELISA) established by Genentech.  
 
8.7.2 Assessment of Angiogenic Profile 
In order to assess the angiogenic profile in patients enrolled in this study, the following 
analyses will be performed: 
 
Measurement of EPC and HPC 
Blood volumes collected will be based on the patient’s weight as outlined in the 
Procedural Manual (page 5). Blood will be collected in Cycle 1 only at the following time-
points: Day -3 (prior to bevacizumab therapy), Day 0 (prior to chemotherapy) and 7, and 
prior to next scheduled dose of bevacizumab.  Peripheral blood will be collected in an 
EDTA tube (purple top tube) and placed on ice. Specimens should be collected Monday 
through Thursday to allow for shipping and processing.  Blood will be centrifuged to 
collect plasma and then the cellular portion will be diluted and placed on a Ficoll-Opaque 
gradient to obtain the mononuclear cell layer. These cells will be stained for VEGFR1, 
VEGFR2, VEGFR3 along with stem/progenitor markers CD34, CD133 and cKIT.  HPCs 
will be defined as CD34+ VEGFR1+ cells and EPCs will be defined by VEGFR2 and 
CD133.  7-AAD staining will be used to assess the number of apoptotic cells. 
Mononuclear cells will also be collected and placed in 100 µl lysis solution for RNA 
extraction and quantification of mRNA levels in these circulating mononuclear cells.   
 
Furthermore, we will perform CD34 enrichment by using CD34 microbeads for flow 
cytometry and to obtain CD34 enriched population for RNA analysis in order to perform 
microarray analysis on CD34+ cells in pediatric lymphoma patients in order to better 
characterize this cell population.   
 
We also plan to measure VEGF-A, VEGF-B (signals through VEGFR1 alone), VEGF-C, 
PlGF (signals through VEGFR1 alone), FGF (fibroblast growth factor important in 
fibroblast activation and production of fibronectin the platform for circulating HPCs 
expressing the integrin VLA-4), SDF-1 (stromal derived factor-1 known to mobilize HPCs 
from the bone marrow), HGF/SC (hepatocyte growth factor/ scatter factor known to be 
elevated in many cancer types and plays a particularly important role in tumor invasion 
and spread) from the platelet-enriched plasma.  The plasma will be obtained after 
centrifugation of blood at 2000 rpm for 20 minutes. The collected plasma portion will be 
spun again at 6000 rpm in order to obtain the platelet enriched fraction.  
 

  
 
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If bone marrow cells are obtained during the course of treatment, similar studies to the 
blood studies will be performed on these cells as well as culturing of bone marrow 
lineage depleted cells in megakaryocyte specific chemokines in order to obtain profiling 
of megakaryocytes which are key regulators of VEGF storage and release in the bone 
marrow microenvironment. The methodology as noted above for the blood samples will 
also be used for the bone marrow samples.  
 
In addition to ELISA quantification of VEGF-A, VEGF-B and PlGF levels in plasma, 
Western blots will be performed for free VEGF and a non-denaturing gel will be used to 
evaluate VEGF bound to bevacizumab.  
 
Contact Information for Sample Shipment: 
 
David C. Lyden MD, PhD 
Stavros S. Niarchos Professor 
Department of Pediatrics, and Cell and Developmental Biology 
Weill Medical College of Cornell University 
413 E. 69th Street, Box 284 
New York, NY 10021 
Office: 646-962-6238  
Fax:    646-962-0574 
E-mail: dcl2001@med.cornell.edu 
8.7.3  Expression of Angiogenesis Associated Serum Biomarkers  
Plasma samples will be collected from patients before and after the initiation of treatment 
at scheduled intervals according to the treatment schema. Samples will be analyzed for 
levels of VEGF, bFGF, Ang-1, Ang-2, sFlt-1, sTie-2, and PlGF using commercially 
available ELISA kits (R&D Systems, Minneapolis, MN). Each sample will be assayed in 
triplicate. Technical steps will be carried out according to the instructions supplied by the 
manufacturer. Data will be analyzed using GraphPad Prism version 3.00 statistical 
software (GraphPad Software, San Diego, CA). Correlative analysis will be carried out 
with clinical parameters indicated in the protocol such as tumor type, grade, adverse 
events and treatment response. 
 
Five mL of peripheral blood drawn will be collected in EDTA containing tubes (purple top 
tube) in cycle 1 only at the following time-points: Day -3 (prior to administration of 
bevacizumab), Day 0 (prior to administration of cyclophosphamide), Day 7 and Day 18 
(prior to the next scheduled dose of bevacizumab) and centrifuged at 1200 rpm for 
approximately 10 minutes. Transfer collected plasma to Eppendorf tubes (maximum 1 ml 
per tube) and store at -200C until shipment on dry ice.  Samples can be batched and 
shipped. Please send samples by overnight only on Monday, Tuesday or Wednesday. If 
a sample to be collected on any other day, it can be kept in a -200C freezer until 
shipment. Please enclose the information for Canada Customs (attached).  
 
If possible, E-mail the shipment information to anarendran@ucalgary.ca and 
karen.mazil@albertahealthservices.ca. 
 
 
 
 

  
 
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The shipping address is as follows: 
 
Dr. Aru Narendran 
University of Calgary 
HRIC Building, Lab 2a34 
3280 Hospital Drive NW 
Calgary, Alberta T2N 4Z6 
CANADA 
Telephone: (403) 210-6402  
                   (403) 210-6418 
 
8.7.4  Metabolic Signature Analysis through Magnetic Resonance Spectroscopy 
Identification of the metabolic changes exhibited by cancer cells in response to a 
therapeutic agent can provide essential information with respect to drug activity as well 
as toxicity. In these experiments we will attempt to identify changes in metabolite levels 
in tumor tissues in response to the proposed treatment. The principles of the 
methodology have been reviewed previously.70 Briefly, aqueous metabolites will be 
extracted and proteins will be precipitated using a chloroform:methanol system (method 
of Bligh and Dyer) and an untargeted gas chromatography mass spectrometry (GC-MS) 
analysis will be performed following chemical derivatization. Multivariate statistical 
methods, namely principal component analysis (PCA) and partial least squares 
discriminant analysis (PLS-DA) will be performed to determine the clustering properties 
of the samples. Database matches will then be done to determine the identities of the 
most significant metabolites. Finally, the identities of the metabolites that change in 
response to treatment will be documented and analyzed. 
           
Tissue for Metabolic NMR Spectroscopy 
 
Optimal sample size is 50 mg of tissue *No formalin or other cold preservatives must be 
used except for the use of liquid nitrogen. Specimens must be harvested in the operating 
room or biopsy procedure room, with liquid nitrogen on site. 
 
1. Promptly remove the tissue of interest. 
2. Immediately place it in liquid nitrogen. 
3. Store frozen samples at -80 degrees Celsius. 
4. When a sample set is ready to be shipped for analysis, please ship the 
samples via FedEx (overnight) on sufficient dry ice to allow for 48 hours 
of storage.  Ship only on Mondays, Tuesdays, or Wednesdays to avoid 
weekend delays.  See below for shipping information. 
 
Human Whole Blood Collection for Metabolic NMR Spectroscopy 
 
Only heparin-preserved blood can be used for NMR analysis (please, no EDTA and no citrate 
coating).  The heparin tubes have green tops (sodium heparin) 5 mL whole blood is required 
and will be collected at the following time-points: Day -3 (prior to bevacizumab administration), 
Day 0 (prior to cyclophosphamide administration), and Day 7 of the first cycle of therapy. 
1. Collect minimum of 5 mL venous blood into a heparin-coated tube. 
2. Shake / vortex well. 
3. Immediately after collection, place the tube on ice for ~10 minutes. 
4. Store samples at -20 or -80 degrees Celsius. Samples can be batched. 

  
 
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5. When a sample set is ready to be shipped for analysis, please ship the samples 
via FedEx (overnight) on sufficient dry ice to allow for 48 hours of storage.  Ship 
only on Mondays, Tuesdays or Wednesdays to avoid weekend delays.  See 
below for shipping information. 
 
Shipping Instructions 
 
At least 24 hours prior to shipping samples, please contact Dr. Aru Narendran at the 
telephone number below and e-mail (anarendran@ucalgary.ca.) to inform about 
upcoming sample shipment.  Please provide (via email or inside the FedEx box) the 
exact sample study numbers/ identification, including the patient study number, source 
of sample, date and time of sample collection. 
 
SHIP SAMPLES ONLY ON MONDAYS, TUESDAYS, OR WEDNESDAYS. 
 
Contact Information for Sample Shipment: 
 
Dr. Aru Narendran 
University of Calgary 
HRIC Building, Lab 2a34 
3280 Hospital Drive NW 
Calgary, Alberta T2N 4Z6 
CANADA 
 
Telephone: (403) 210-6402  
                   (403) 210-6418 
 
8.7.5  Assessment of Impact of Bevacizumab on Growth and Development  
Baseline assessment of growth and development will consist of bone age films (left  
hand) and measurement of somatomedin C levels at baseline, 6 months and at the time 
that the patient is taken off study. The most useful information will be obtained from 
patients who have durable responses. 
 
9.0 
SUBJECT DISCONTINUATION 
Subjects who meet the following criteria should be discontinued from study treatment:  
• 
Grade 4 hypertension or Grade 3 hypertension not controlled with medication 
• 
Nephrotic syndrome 
• 
Grade 1 pulmonary or CNS hemorrhage for patients who are receiving full-
dose anticoagulation. 
• 
Grade ≥ 2 pulmonary or CNS hemorrhage; any Grade 4 hemorrhage 
• 
Symptomatic Grade 4 venous thromboembolic event (for lung protocols: any 
venous thromboembolic event requiring full dose warfarin or equivalent (i.e., 
unfractionated or low molecular weight heparin)  

  
 
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• 
Any grade arterial thromboembolic event 
• 
Grade 4 congestive heart failure 
• 
Gastrointestinal perforation  
• 
Tracheoesophageal fistula (any grade) or Grade 4 fistula 
• 
 Bowel obstruction that has not fully recovered despite medical or surgical 
intervention 
• 
Wound dehiscence requiring medical or surgical intervention 
• 
Unwillingness or inability of subject to comply with study requirements 
• 
Determination by the investigator that it is no longer safe for the subject to 
continue therapy 
• 
All Grade 4 events thought to be related to bevacizumab by the investigator 
Patients who have an ongoing bevacizumab-related Grade 4 or serious adverse event at 
the time of discontinuation from study treatment will continue to be followed until 
resolution of the event or until the event is considered irreversible (see Section 7.1.3). 
 
10.0 STUDY DISCONTINUATION  
Genentech has the right to terminate this study at any time. Reasons for terminating the 
study may include, but are not limited to, the following: 
• 
The incidence or severity of adverse events in this or other studies indicate a 
potential health hazard to patients. 
• 
Patient enrollment is unsatisfactory. 
• 
Data recording is inaccurate or incomplete. 
 
11.0 STATISTICAL METHODS 
11.1 
Determination of Sample Size  
It is anticipated that 1-2 patients per month will be accrued on this protocol.  Based on 
these estimates, a total of 29 patients will be enrolled on study with patient accrual 
completed in approximately 1 ½ years.   
 
11.2 
Stratification of Accrual 
To ensure that both disease groups are well represented, the accrual will be stratified. 
This measure will allow additional information about the response rates of each 
individual group to be obtained, however the success or failure of the combination, CTB, 
will be assessed based upon composite data from both disease groups combined. 
11.3 
Planned Efficacy Evaluations 
11.3.1 Primary Efficacy Variables 
The primary efficacy variables are objective response rate after 2 cycles of treatment 
and duration of response. Patients who experience early progression of disease prior to 
receiving the second cycle of therapy will be considered a treatment failure. 

  
 
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11.3.2 Secondary Efficacy Variables 
The secondary efficacy variables include time to progression The planned length of 
follow-up will be up to 5 years or until disease progression (Please refer to section 8.5 
for data requirements) 
11.3.3 Methods of Analysis 
In previous trials69, conducted in this population, the response rate (CR+ PR) for this 
patient population was approximately 0.30. A minimax Simon 2-stage design that 
differentiates between population response rates of 0.30 and 0.55 will be used. A total of 
29 patients will be accrued onto this study. We will enroll 14 patients in the first stage, 7 
patients from each disease group. If 4 or fewer responses are observed, then the trial is 
stopped. In that case, if there are at least 3 responses in one disease group, we will 
consider studying this treatment in another phase II study limited to that disease group. If 
at least 5 responses are observed, then 15 additional patients will be enrolled onto the 
study with at least 7 patients accrued from each disease group, for a total of 29 patients. 
In this scenario, even if all 5 responses are seen in one disease group, accrual will 
continue; however, this outcome is not likely even if the treatment is effective in only one 
group. (If the response rate in the neuroblastoma group is 55% and EWS 30%, the 
probability of having > 5/7 responders in NB and 0/7 in EWS is 3%. If NB has 55% 
response rate and EWS has 20%, the probability is 7%.) At the conclusion of the trial, if 
13 or more responses, the treatment will be considered successful. This design has 
power 0.88 for a population response proportion of 0.55 using a one-sided test with size 
0.07.   
 
At the conclusion of the study, overall survival and progression free survival probabilities 
over time will be computed using the Kaplan-Meier method. Subgroup response rates 
will be reported as well. In addition, a summary of the protein levels will be recorded at 
each time point, and the paired t-test or sign test will be used to determine if the pre and 
post protein levels within patient are equal.  
 
11.4 
Analysis of Correlative Studies 
Pharmacokinetic Analysis 
The pharmacokinetic parameters of bevacizumab (AUC, Cmax, t1/2) will be calculated 
using nonlinear mixed effects modeling (NONMEM, GloboMax® LLC, Hanover, MD).    
 
Analysis of Angiogenic Profile 
Blood samples will be collected at study entry and throughout the course of treatment as 
outlined above.  Categorical data will be compared using Fisher’s exact probability test 
and continuous data will be compared with Student’s test if the sample distribution is 
normal or with Mann-Whitney U test if the sample distribution is asymmetrical.  Kaplan-
Meier life-table curves will be constructed to estimate survival free of local-regional and 
distant recurrences and overall survival.  Data on patients who are alive and without 
evidence of disease at the end of five-year study will be considered censored. The 
comparison between survival functions for different strata will be assessed with the log-
rank statistics..  Differences will be considered significant when P < 0.05. Using these 
statistical methods, we will compare circulating HPC levels with treatment response and 
disease free survival.  Cutoff values of ‘positive’ circulating HPC levels will be 
established in order to test these values for discriminating power in predicting disease 

  
 
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outcome.  Once cutoffs are established as it has been in other tumor types, these values 
will be used to establish correlation with disease outcome.   
 
Analysis of Expression of Angiogenesis Associated Serum Biomarkers  
Each sample will be assayed in triplicate. Technical steps will be carried out according to 
the instructions supplied by the manufacturer. The quantity of individual cytokines 
(pg/ml) found in each sample and control normal plasma (n=20, investigator’s collection) 
will be analyzed as follows. The Wilcoxon signed ranks test or paired t-test will be used 
to compare pre and post treatment protein levels as appropriate. To examine differences 
between patients and controls, and at various time points with respect to treatment, 
Wilcoxon-Mann Whitney test or Student's t-test will be used.  The Spearman rank 
correlation test will be used to assess whether the levels of the measured cytokines 
correlated with clinical parameters indicated in the protocol such as tumor type, grade, 
adverse events and treatment response. All analyses will be performed by using SAS 
version 9.1, and, P-values less then .05 will be considered to be statistically significant.   
 
Analysis of Metabolic Profiling 
A descriptive analysis will be used to analyze the data obtained from the metabolic 
profiling analysis based upon the pattern of MRS. 
 
Analysis of Impact of Bevacizumab on Growth and Development  
A descriptive analysis will be used to describe the effect of bevacizumab on growth and 
development based upon the results of the serial measurements of Somatomedin C and 
bone age films.  
 
12.0 SAFETY REPORTING OF ADVERSE EVENTS 
 
12.1 
Adverse Event Reporting and Definitions 
In the event of an adverse event the first concern will be for the safety of the subject.   
 
The protocol principal investigator/ POETIC DCC are required to report to Genentech 
Drug Safety ANY serious treatment emergent adverse event (STEAE) as soon as 
possible.   
 
A STEAE is any sign, symptom or medical condition that emerges during Bevacizumab 
treatment or during a post-treatment follow-up period that (1) was not present at the start 
of Bevacizumab treatment and it is not a chronic condition that is part of the patient’s 
medical history, OR (2) was present at the start of Bevacizumab treatment or as part of 
the patient’s medical history but worsened in severity and/or frequency during therapy, 
AND that meets any of the following regulatory serious criteria: 
• 
Results in death  
• 
Is life-threatening  
• 
Requires or prolongs inpatient hospitalization  
• 
Is disabling  
• 
Is a congenital anomaly/birth defect  
• 
Is medically significant or requires medical or surgical intervention to prevent one 
of the outcomes listed above. 
 
 

  
 
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The following events will not be considered reportable: 
 
• 
Grade 3 or 4 Neutropenia for a duration < 7 days  
• 
Grade 3 or 4 Leukopenia for a duration < 7 days 
• 
Lymphopenia  
• 
Grade 3 or 4 Thrombocytopenia for a duration < 7 days 
• 
Anemia 
 
12.2 
Reporting of Serious Treatment Emergent Adverse Events  
The Protocol Chairman is responsible for monitoring the safety of patients who enroll in 
the study.  All AEs and SAEs occurring after consent has been signed and after any 
administration of the study drug regardless of drug attribution will be followed to the end 
of the study including 30 days after the last administration of study drug, as well as any 
SAEs designated possibly, probably or definitely related to treatment that occur greater 
than 30 days.  
 
The descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be used for adverse event and 
serious adverse event reporting.  All participating sites should have access to a copy of 
the CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be downloaded from the 
CTEP web site (http://ctep.cancer.gov/reporting/ctc.html).  
 
The Protocol Chairman is required to report all adverse events that occur during the 
clinical study starting when the patient signs consent throughout 30 days of stopping the 
investigational agent. Severe adverse events must be reported to the appropriate 
protocol-defined study sponsors. Serious adverse events must be reported  by email 
and/or telephone to the Protocol Chairman, Data and Coordinating Center at Memorial 
Sloan-Kettering Cancer Center, and local IRB within 24 hours of knowledge of their 
occurrence. A written SAE report including source documentation must be sent to the 
Protocol Chairman and Data and Coordinating Center within another 3 calendar days, 
using the Serious Adverse Event case report form and MedWatch 3500a form.  
 
Additionally, the Protocol Chairman is responsible for submitting follow-up reports for all 
SAEs regarding the patient’s subsequent course until the SAE has resolved or until the 
patient’s condition stabilizes (in the case of persistent impairment), or the patient dies.   
 
In the event of an adverse event the first concern will be for the safety of the subject.   
 
Investigators are required to report to the DCCANY serious treatment emergent adverse 
event (STEAE) as soon as possible.  The Protocol Chairman is responsible for reporting 
such STEAEs to Genentech Drug Safety. 
 
 
 
 
 
 
 
 

  
 
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Reporting Requirements for Adverse Events That Occur on Treatment and Within 30 
Days1 of the Last Dose of Study Drug 
 
 
 
Grade 1 
 
Grade 2 
 
Grade 2 
 
Grade 3 
 
Grade 3 
Grades 
4 & 5 
Unexpected  
and Expected 
with or with-out 
hospitalization 
        Unexpected 
Expected 
Unexpected 
Expected 
Unexpected  
and 
Expected 
With 
Hospitaliza
tion 
Without 
Hospitaliza
tion 
With 
Hospital 
zation 
Without 
Hospitaliz 
ation 
With 
Hospitaliza
tion 
Without 
Hospitaliza
tion 
With 
Hospitali 
ation 
Without 
Hospitaliza
tion 
Unrelated 
Unlikely 
Not 
Required 
SAE 
Report 
Required 
Not 
Required 
SAE 
Report 
Required 
Not 
Required 
SAE 
Report 
Required 
Not 
Required 
SAE 
Report 
Required 
Not 
Required 
SAE Report 
Required 
Possible 
Probable 
Definite 
Not 
Required 
SAE 
Report 
Required 
SAE 
Report 
Required 
SAE 
Report 
Required 
Not 
Required 
SAE 
Report 
Required 
SAE 
Report 
Required 
SAE 
Report 
Required 
Not 
Required 
SAE Report 
Required 
1     Adverse events with attribution of possible, probable, or definite that occur greater than 30 days after the last dose of study 
treatment require an SAE report as follows: 
• 
Grade 3 unexpected events with hospitalization or prolongation of hospitalization 
• 
Grade 4 unexpected events  
• 
Grade 5 expected events and unexpected events 
 
Initial notification for all STEAEs must include: 
• 
Grade of event 
• 
Date of event  
• 
A brief description of the event 
• 
Attribution to the protocol defined drug combination  
• 
Patient Status 
 
Relationship of any adverse event to protocol defined drug combination should use the following 
criteria:  
• 
Definite - The adverse event is clearly related to the drug combination 
• 
Probable - The adverse event is likely related to the drug combination. 
• 
Possible - The adverse event may be related to the drug combination. 
• 
Unlikely - The adverse event is doubtfully related to the drug combination. 
• 
Unrelated - The adverse event is clearly NOT related to the drug combination. 
 
STEAEs must be reported within 24 hours of the investigator’s knowledge by phone or 
e-mail to: 
• 
Data and Coordinating Center 
• 
Lead Principal Investigator of the protocol/Protocol Chairman - (Dr. Tanya 
Trippett) 
• 
Local IRB 
 
STEAE contact information for the Data and Coordinating Center is listed below:  
Memorial Sloan Kettering Cancer Center 
Pediatric & Allo Transplant Clinical Trials Office 
405 Lexington Avenue, room 3-512 
New York, NY 10174 
Phone: 646-888-5714/5715 
Fax: 646-888-5726 

  
 
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Contact information for the Protocol Principal Investigator is listed below:  
Tanya Trippett, MD 
Memorial Sloan-Kettering Cancer Center  
 1275 York Avenue 
 New York, NY 10065 
 Telephone (212) 639-8267 
 Fax (212) 717-3239 
 E-mail Trippet1@mskcc.org  
 
In the event of an AE, appropriate medical and supportive care will be administered. All   
efforts will be made to minimize the side effects and to support the patient until the 
toxicity resolves. 
 
12.2.1 Reporting of STEAE to Sponsor 
 
All STEAEs should be recorded on a MedWatch 3500a Form and faxed to: 
 
Data and Coordinating Center/Principal Investigator 
Tanya Trippett, MD 
Fax: 646-888-5726 
 
Reporting of STEAEs to the sponsor are to be handled by the Data and Coordinating 
Center at Memorial Sloan-Kettering Cancer Center. The DCC will fax all STEAEs to: 
 
Genentech Drug Safety  
Fax: 
(650) 225-4682 or (650) 225-5288 
 
MedWatch 3500a Reporting Guidelines: 
 
In addition to completing appropriate patient demographic and suspect medication 
information, the report should include the following information within the Event 
Description (section 5) of the MedWatch 3500a form: 
 
• 
Treatment regimen (dosing frequency, combination therapy) 
• 
Protocol description (and number, if assigned) 
• 
Description of event, severity, treatment, and outcome, if known 
• 
Supportive laboratory results and diagnostics 
• 
Investigator’s assessment of the relationship of the adverse event to each 
investigational product and suspect medication 
 
Follow-up information:   
 
Additional information may be added to a previously submitted report by any of the 
following methods: 
• 
Adding to the original MedWatch 3500a report and submitting it as follow-
up 
• 
Adding supplemental summary information and submitting it as follow-up 
with the original MedWatch 3500a form  

  
 
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• 
Summarizing new information and faxing it with a cover letter including 
subject identifiers (i.e. D.O.B. initial, subject number), protocol description 
and number, if assigned, suspect drug, brief adverse event description, 
and notation that additional or follow-up information is being submitted  
(The subject identifiers are important so that the new information is added 
to the correct initial report) 
 
Occasionally Genentech may contact the reporter for additional information, clarification, 
or current status of the subject for whom and adverse event was reported.  
 
Assessing Causality: 
 
Investigators are required to assess whether there is a reasonable possibility that 
bevacizumab caused or contributed to an adverse event.  The following general 
guidance may be used. 
 
Yes: 
If the temporal relationship of the clinical event to bevacizumab 
administration makes a causal relationship possible, and other drugs, therapeutic 
interventions or underlying conditions do not provide a sufficient explanation for 
the observed event. 
 
No: 
If the temporal relationship of the clinical event to bevacizumab 
administration makes a causal relationship unlikely, or other drugs, therapeutic 
interventions or underlying conditions provide a sufficient explanation for the 
observed event. 
 
12.3 
Safety Reporting Requirements for IND Holders 
For Investigator Sponsored IND Studies, there are some additional reporting 
requirements for the FDA in accordance with the guidance set forth in 21 CFR 312.32. 
Sponsor-investigators of studies conducted under an IND must comply with the following 
safety reporting requirements:  
 
a. Expedited IND Safety Reports: 
7 Calendar-Day Telephone or Fax Report:   
The Sponsor-Investigator is required to notify the FDA of any fatal or life-threatening 
adverse event that is unexpected and assessed by the investigator to be possibly 
related to the use of Bevacizumab.  An unexpected adverse event is one that is not 
already described in the Investigator Brochure.  Such reports are to be telephoned or 
faxed to the FDA and Genentech within 7 calendar days of first learning of the event.  
Each telephone call or fax transmission (see fax number below) should be directed to 
the FDA new drug review division in the Center for Drug Evaluation and Research or in 
the product review division for the Center for Biologics Evaluation and Research, 
whichever is responsible for the review of the IND. 
 
15 Calendar-Day Written Report:   
The Sponsor-Investigator is also required to notify the FDA and all participating 
investigators, in a written IND Safety Report, of any serious, unexpected AE that is 
considered possibly related to the use of bevacizumab.  An unexpected adverse event is 
one that is not already described in the Investigator Brochure. 

  
 
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Written IND Safety Reports should include an Analysis of Similar Events in accordance 
with regulation 21 CFR § 312.32.  All safety reports previously filed with the IND 
concerning similar events should be analyzed.  The new report should contain 
comments on the significance of the new event in light of the previous, similar reports.   
 
Written IND safety reports with Analysis of Similar Events are to be submitted to the 
FDA, Genentech Drug Safety, and all participating investigators within 15 calendar days 
of first learning of the event.  The FDA prefers these reports on a MedWatch 3500a 
Form but alternative formats are acceptable (e.g. summary letter). 
 
FDA fax number for IND Safety Reports: 
 
1 (800) FDA - 0178 
 
All written IND Safety Reports submitted to the FDA by the Sponsor-Investigator must 
also be faxed to: 
 
Genentech Drug Safety  
Fax: 
(650) 225-4682 or (650) 225-5288 
(Please use the safety reporting fax cover sheet attached to this document for your fax 
transmission) 
 
AND: 
 
Study Coordination Center/Principal Investigator 
Tanya Trippett, MD 
Fax: 646-888-5726 
 
For questions related to safety reporting, contact: 
 
Genentech Drug Safety 
Tel: 
1-888-835-2555 
         or 
Fax: 
(650) 225-4682 or (650) 225-5288 
(Please use the safety reporting fax cover sheet attached to this document for your fax 
transmission) 
 
b. IND Annual Reports 
In accordance with the regulation 21 CFR § 312.32, the Sponsor-Investigator shall within 
60 days of the anniversary date that the IND went into effect submit a brief report of the 
progress of the investigation.  Please refer to Code of Federal Regulations, 21 CFR § 
312.32 for a list of the elements required for the annual report.  All IND annual reports 
submitted to the FDA by the Sponsor-Investigator should be copied to Genentech.  
Copies of such reports should be mailed to: 
 
 
 
 

  
 
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Genentech, Inc. 
ATTN: Avastin IST Coordinator  
1 DNA Way, Mailstop 445-A 
South San Francisco, CA 94080-4990  
Tel: (650) 225-7121 (Oncology Hotline) 
 
PLEASE NOTE: Section 12.4 is mandatory if your site has received an IND 
Exemption Letter from the FDA 
 
12.4 
Safety Reporting Requirements for IND Exempt Studies 
For Investigator Sponsored IND Exempt Studies, there are some reporting 
requirements for the FDA in accordance with the guidance set forth in 21 CFR 314.80. 
 
Postmarketing 15-Day “Alert Report”: 
The Sponsor-Investigator is required to notify the FDA of any fatal or life-threatening 
adverse event that is unexpected and assessed by the investigator to be possibly 
related to the use of Bevacizumab. An unexpected adverse event is one that is not 
already described in the Investigator Brochure. Such reports are to be submitted to the 
FDA (2 copies) at the following address: Central Document Room, 12229 Wilkins 
Avenue, Rockville, MD 20852. 
 
All Postmarketing 15-Day “Alert Reports” submitted to the FDA by the Sponsor-
Investigator must also be faxed to: Genentech Drug Safety  
 
Fax: 
(650) 225-4682 or (650) 225-5288 (Please use the safety reporting fax cover 
sheet attached to this document for your fax transmission) 
 
For questions related to safety reporting, contact: 
 
Genentech Drug Safety 
Tel: 
1-888-835-2555 
         or 
Fax: 
(650) 225-4682 or (650) 225-5288 
(Please use the safety reporting fax cover sheet attached to this document for your fax 
transmission) 
 
13.0 RETENTION OF RECORDS 
U.S. FDA regulations (21 CFR 312.62[c] and the ICH Guidelines for GCP require that 
records and documents pertaining to the conduct of this study and distribution of the 
bevacizumab including CRFs, consent forms, laboratory test results, documentation of 
adverse events, medication inventory records, and all IRB correspondence must be 
retained by the Principal Investigator for at least 2 years after the investigation is 
completed. 
14.0 RECRUITMENT PLAN/INFORMED CONSENT PROCEDURES 
14.1 
Patients will be offered the opportunity to participate in this trial if they meet all 
eligibility criteria. There will be no discrimination against females or minorities. Informed 
consent will be obtained from the patient, or if they are non-emancipated minors, their 

  
 
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parent or legal guardian. Consent will be obtained by an investigator authorized to obtain 
consent. Patients will not receive any payment for their participation in this study. 
 
14.2  Patients or their parent/legal guardian will be required to sign an IRB approved 
statement of informed consent indicating the investigational nature of this study, 
indicating their consent to participate. 
 
This consent form meets the requirements of the Code of Federal Regulations and the 
Institutional Review Board/Privacy Board of this Center. The consent form will include 
the following:  
1. The nature and objectives, potential risks and benefits of the intended 
study.  
2. The length of study and the likely follow-up required. 
3. Alternatives to the proposed study. (This will include available standard 
and investigational therapies. In addition, patients will be offered an 
option of supportive care for therapeutic studies.) 
4. The name of the investigator(s) responsible for the protocol. 
5. The 
right 
of 
the 
participant 
to 
accept 
or 
refuse 
study 
interventions/interactions and to withdraw from participation at any time.  
Before any protocol-specific procedures can be carried out, the consenting professional will fully 
explain the aspects of patient privacy concerning research specific information.  In addition to 
signing the IRB Informed Consent, all patients must agree to the Research Authorization 
component of the informed consent form. 
 
14.3 
The investigators listed on the cover page and their qualified designees at each 
institution as listed on the FDA 1572 for this study may obtain consent and care for the 
patients according to good clinical practice and protocol guidelines. 
 
14.4 
One to three copies of the informed consent will be signed and dated by the 
patient, parent or the patient's legally authorized representative and by the physician 
obtaining informed consent, as per institutional guidelines. If institutional guidelines 
mandate that only one original copy is signed, the following sentences will refer to 
photocopies of the original. One copy will be given to the patient/parent/legal guardian to 
be retained for their personal records. One copy will be maintained on file at the Data 
and Coordinating Center. The third copy will be confidentially maintained by the 
participating institution.  
 
14.5 
A note will be placed in the medical record documenting that informed consent 
was obtained for this study, and that the patient and/or his/her parents, to the degree of 
their understanding, acknowledge and accept the risk of participation in this study. 
 
14.6 
Written consent must be documented on the appropriate consent form approved 
by the Institutional Review Board at the individual participating center. Attainment of the 
written consent must be verified by the Data and Coordinating Center (or equivalent 
entity) of the participating institution prior to entry on study. A copy of the consent form, 
along with the eligibility checklist, and Health Insurance Portability and Accountability 
Agreement (HIPAA) must be submitted to the Clinical Trials Office at the Data and 
Coordinating Center prior to enrollment of any subject on this study. Verification of 
subject enrollment on this study will be sent by email to the participating center 
immediately on receipt of the required documents.  

  
 
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14.7 
Every effort will be made to include women, children of both sexes and minorities 
in the study population for this trial. No patient will be excluded from participation in this 
trial on the basis of gender, ethnicity, or race. Review of accrual to past pediatric 
multicenter 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. 
 
Data from the institutions participating in this trial have been reviewed with respect to 
enrollment of patients of different races and genders. It is anticipated that enrollment of 
the current study will follow the same pattern.  
Institution 
Number of 
Patients 
White 
Non-Hispanic 
(%) 
Black 
Non-Hispanic 
(%) 
Hispanic 
(%) 
Other 
(%) 
MSKCC 
147 
61.0 
19.0 
15.0 
5.0 
JHMC 
77 
73.0 
21.0 
1.0 
5.0 
UCS/TCH 
204 
62.0 
0.0 
34.0 
4.0 
MDACC 
146 
60.0 
5.0 
29.0 
6.0 
DFCI 
250 
81.3 
4.7 
0.5 
9.2 
PCH 
137 
65.7 
< 0.1 
27.7 
6.5 
CHM 
184 
71.0 
12.0 
13.0 
4.0 
MDACCO 
90 
50 
9 
26 
15 
PSH 
85 
81 
6 
0 
13 
 
15.0 RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION 
PROCEDURES 
15.1 
Research Participant Registration 
All patients must be centrally registered at the POETIC Data and Coordinating Center 
(DCC) located at Memorial Sloan-Kettering Cancer Center.  Registrations will be 
handled by the RSA at the POETIC DCC.  The contact telephone number is (646) 888-
5714/5715 and the fax number is (646) 888-5726.  Registrations will occur between 9:00 
am and 5:00 pm Eastern Standard Time (EST), Monday through Friday and will include 
review of the signed consent form, HIPAA research authorization form, eligibility 
checklist, eligibility source documentation and Patient Enrollment form.  The RSA will 
also verify, via a FAX/email copy, that the written informed consent is obtained and 
dated prior to subject entry on the study.  

  
 
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The participating sites must contact the Research Study Assistant (RSA) at the POETIC 
DCC and the Protocol Principal Investigator to reserve a slot on the protocol when a 
patient is being considered for a trial. To begin a registration the participating site must 
fax/email the signed consent form and HIPAA research authorization to the RSA within 
48 hours of the patient signing consent. To complete the registration, the completed 
eligibility checklist, patient eligibility source documentation and the Patient Enrollment 
form must be faxed/emailed to the RSA at MSKCC prior to protocol treatment or any 
research tests. 
 
All research participants are registered through the Protocol Participant Registration 
(PPR) Office at Memorial Sloan-Kettering Cancer Center by the DCC RSA.  PPR is 
available Monday through Friday from 8:30am - 5:30 pm. Registrations must be faxed to 
the POETIC DCC and the Research Study Assistant (RSA) at MSKCC will verify 
eligibility and complete the registration with the PPR Office.   
 
Once eligibility has been established and the participant is registered, the participant will 
be assigned an MSKCC Clinical Research Database (CRDB) number (protocol 
participant number). This number is unique to the participant and must be written on all 
data and correspondence for the participant. This protocol participant number will be 
relayed back to study staff at the registering site via e-mail and will serve as the 
enrollment confirmation. 
 
The registration procedure is summarized below. 
 
Confirm that the patient has received the Notice of Privacy Practice if local institutional 
requirement.  This must be obtained before the eligibility confirmation and obtaining of 
the research informed consent. 
Confirm eligibility as defined in the section entitled Criteria for Patient/Subject Eligibility. 
 
Obtain written informed consent, by following procedures defined in Section 14.0, 
Recruitment Plan/ Informed Consent Procedures. 
 
15.2 Randomization 
 
This study does not include randomization. 
 
16.0 DATA  MANAGEMENT ISSUES 
16.1    Data and Coordinating Center (DCC) 
The Research Study Assistant (RSA) at POETIC DCC will be assigned to the study. The 
responsibilities of the RSA include project compliance, data collection, abstraction and 
entry, data reporting, regulatory monitoring, problems and prioritization. The Clinical 
Research Coordinator, CRS, is responsible for coordination between the RSA and 
Research Staff at the following member institutions: Alberta Children’s Hospital, 
Memorial Sloan-Kettering Cancer Center, Phoenix Children’s Hospital, Children’s 
Hospital of Colorado, Children’s Mercy Hospital and Clinics, and Pennsylvania State 
University College of Medicine, is necessary in order for a complete process. The CRS 

  
 
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at the POETIC DCC will also serve as the liaison among all staff involved including the 
principal investigators, attending physicians, and nurses. 
 
Case report forms will be drafted in a standard format and will be provided to each 
participating institution by the DCC. The participating Site PI is responsible for ensuring 
these forms are completed accurately and legibly. The Site PI is also responsible for 
ensuring that all CRFs and corresponding source documentation is submitted within one 
week of the end of a treatment cycle. Required study tools for each protocol including 
correlative studies, vital signs, drug administration and protocol evaluations will also be 
provided to each participating institution by the DCC. Case report forms, study tools and 
source documentation are required to be submitted to the DCC one week after the 
completion of each cycle. The data collected for this study will be entered into a secure 
database by the RSA at the POETIC DCC. Data will be collected, stored, and monitored 
at an institutional level via the Clinical Research Database (CRDB) system. Data will be 
provided from CRDB to protocol-defined sponsors (CTEP, FDA, etc.) as required, 
through the Data Management Resource Division, a division of the Office of Clinical 
Research. 
 
Source documentation will be available to support the computerized patient record and 
must be submitted with the case report forms and required study tools. Case report forms 
will not be considered source documentation.  
 
• 
Variables that will be recorded include the patient's birth date, date of diagnosis, 
date of study entry and histologic diagnosis.  
• 
The results of the pretreatment and end of therapy evaluations, including the 
extent of disease evaluation (history, physical examination and imaging studies), 
baseline laboratory values, renal and hepatic function, as defined per protocol, 
will be recorded.  
• 
All study related treatment data and concomitant drugs will be recorded.  
• 
The presence of toxicity at baseline, during and for 30 days after administration 
of the investigational agent will be monitored and recorded.  
• 
The results of the extent of disease evaluation (history, physical examination and 
imaging studies) following each course of treatment will be recorded.  
• 
The patient's disease status and last follow-up will be recorded. If disease 
progresses or recurs, the results of the repeat extent of disease evaluation will be 
recorded. 
 
16.2 Site Research Staff 
Research staff will be assigned at Alberta Children’s Hospital, Memorial Sloan-Kettering 
Cancer Center, Phoenix Children’s Hospital, Children’s Hospital of Colorado, Children’s 
Mercy Hospital and Clinics, and Pennsylvania State University College of Medicine. 
Their responsibilities will include project compliance, data collection, abstraction and 
entry, data reporting, regulatory monitoring, problems and prioritization, maintaining file 
documentation of data for the clinical trial, pharmacokinetic or other biologic correlative 
study collection, and analysis as outlined for each patient enrolled on study. They will 
also be responsible for maintaining a regulatory binder for each protocol. The designated 
research staff will also be responsible for submitting the data on a weekly basis by fax or 
mail to the RSA at the DCC. Case report forms and required study tools along with 

  
 
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supporting source documentation should be faxed/emailed or mailed to the address 
below, one week after the completion of each study cycle: 
 
 
 
 
POETIC Data and Coordinating Center 
Memorial Sloan Kettering Cancer Center 
Pediatric & Allo Transplant Clinical Trials Office 
405 Lexington Avenue, Room 3-512 
New York, NY 10174 
Phone: 646-888-5714/5715 
Fax: 646-888-5726 
 
16.3 Administrative Support 
The protocol will be conducted as a single research study effort and data from each 
participating institution will be included in the analysis of results. 
 
The Protocol Chairman will be responsible for the conduct of the study, monitoring of the 
progress of the study, and review of all case report forms from each participating 
institution.  
 
Failure to submit required forms in the timelines requested will result in suspension of 
accrual privileges at a given site until data is updated, and/or withholding of contract 
payments if applicable.   
 
Initial Protocol Submission 
Prior to implementing the protocol, informed consent form, HIPAA authorization and any 
other information pertaining to participants must be approved by the MSKCC IRB/PB. 
Prior to implementing this protocol at the participating centers, approval must be 
obtained from the participating center’s Local IRB of Record. The following documents 
must be provided to MSKCC before the participating site can be initiated and begin 
enrolling participants: 
• 
Local IRB of Record approval(s) for the protocol, appendices, informed consent 
      form and HIPAA authorization 
• 
Local IRB approved consent form 
• 
Local IRB of Record membership 
• 
Local IRB of Record’s Federal Wide Assurance number and OHRP Registration 
      number 
• 
Curriculum vitae and medical license for each investigator and consenting 
      professional 
• 
Documentation of Human Subject Research Certification and HIPAA training for 
      investigators and key staff members 
• 
Signed and dated FDA Related Forms 1572/1571 (if applicable) 
• 
Lab Certifications and Reference Ranges for each lab listed on the 1572 
• 
Appropriate financial disclosure forms. 
 
Protocol Amendments/Status Changes 
Each change to the protocol must be organized and documented by the POETIC DCC. 
After IRB approval at the lead institution, the POETIC DCC will distribute the amendment 
to the participating institutions, for approval by their local IRB within 60 days of the 

  
 
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amendment date. The participating sites will ensure that documentation for all IRB 
approved amendments are sent to the DCC and are maintained in the regulatory binder. 
This documentation will include the IRB approval letter referencing the protocol version 
date and amendment number, IRB approved protocol, IRB approved appendices and 
IRB approved consent forms. 
 
The amendment will be written so that no other institution will need to reformat the 
information but can simply copy and distribute. An amendment memo as well as 
highlighted and clean copies of the protocol, appendices and consent forms will be 
distributed to the participating sites. The consent form will be a sample which may be 
edited in order to adhere to local IRB guidelines. The amendment must be submitted at 
each site to the IRB for review and approval before patients can be enrolled on the study 
and within 60 days of the amendment version date. The amendment number and 
version date will also be displayed on each amendment. 
 
16.4  Additional IRB Correspondence 
Annual re-approval 
Annual continuing review reports from a participating center’s Local IRB of Record must 
be submitted to MSKCC at the time re-approval is granted. The most current approved 
version of the consent form should also be submitted to MSKCC at that time. Failure to 
submit the reapproval will result in suspension of accrual privileges. 
 
Deviations and Violations 
If a deviation from the protocol is proposed for a potential or existing participant at a 
participating site, approval from the MSKCC IRB/PB is required prior to the action. 
For all protocol violations, the participating site should report the violation to Dr. Tanya 
Trippett the Director of the POETIC DCC, as soon as possible. Dr. Trippett will in turn 
the report of the violation to the MSKCC IRB/PB. Participating sites should report 
deviations 
and 
violations 
to 
the 
Local 
IRB 
of 
Record 
as 
they 
occur. 
Approvals/acknowledgments from the Local IRB of Record for protocol deviations and 
violations should be submitted to POETIC DCC as received. 
 
Other correspondence 
Participating sites should submit other correspondence to their local IRB of Record 
according to local guidelines, and submit copies of that correspondence to MSKCC. 
 
16.5 Quality Assurance 
Quality assurance is a central responsibility of the POETIC DCC and it will be achieved 
by frequent review, constant oversight and input from objective advisors.  Each project 
will maintain a steering committee which will meet in conference call on a weekly basis 
to critically review the scientific progress of the clinical trial. The steering committee will 
include the principal investigators, research staff and the biostatistical support team 
under the direction of Dr. Irina Ostrovnaya. Conference calls will also occur bi-weekly 
between the DCC and the Protocol Chair to discuss the trial. 
  
Case Report Forms with accompanying source documents must be provided to the DCC 
to ensure that real-time monitoring can be accomplished. Queries will be generated by 
the DCC as needed if questions arise, and prompt responses are requested back to the 

  
 
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DCC. Internal audits will be conducted by the DCC. Audits may be accomplished in one 
of two ways: (1) source documents and research records for selected patients are 
brought from participating sites to the DCC for audit, or (2) selected patient records may 
be audited on-site at participating sites. These audits will be performed by persons who 
are qualified by training and experience to monitor the progress of the investigation. 
During these audits the following activities will take place: 
• 
Review regulatory binders for protocol documentation; 
• 
Ensure that case report forms are source data verified according to the 
       monitoring plan 
• 
Verify drug accountability is complete and accurate; and 
• 
Verify compliance to GCPs, ICH guidelines, FDA regulations, and applicable 
      SOPs. 
 
If the sponsor chooses to have an audit at the DCC, then the DCC is responsible for 
having all source documents, research records, all IRB approval documents, Drug 
Accountability Record Forms, patient registration lists, response assessments scans, x-
rays, etc. available for the audit. Alternatively, an external auditor would be designated 
for this study through a contract with MSKCC. 
 
 
16.6 
 Data and Safety Monitoring 
The Data and Safety Monitoring Committee (DSMC) under the direction of Dr. Robert 
Motzer and Bonnie Edelman, Manager, will be responsible for monitoring the data safety 
of the protocols sponsored by POETIC. The DSMC meets quarterly, and will review data 
from phase I, II, I/II, pilot and non-phase trials that are not being monitored by an 
industrial sponsor at least every 6 weeks, and which meet the NCI definition of a Clinical 
Trial.. A copy of the MSKCC Data and Safety Monitoring Plan is on file at the Data and 
Coordinating Center. The DSMC reports to MSKCC Research Council and Institutional 
Review Board. 
 
The Data and Safety Monitoring (DSM) Plans at Memorial Sloan-Kettering Cancer 
Center were approved by the National Cancer Institute in September 2001. The DSM 
Plans at MSKCC were established and are monitored by the Office of Clinical Research.   
The plans address the new policies set forth by the NCI in the document entitled “Policy 
of the National Cancer Institute for Data and Safety Monitoring of Clinical Trials” which 
can be found at: http://cancertrials.nci.nih.gov/clinicaltrials/conducting/dsm-guidelines.  
 
During the protocol development and review process, each protocol will be assessed for 
its level of risk and degree of monitoring required. Risk levels are as follows: 
  
Low Risk: Probability of harm or discomfort not greater than daily life or routine 
physical/psychological exams.  
 
Moderate Risk: Intervention commensurate with those inherent in their expected 
medical, social, or education situations. Risks are reasonable in relation to anticipated 
benefits and the importance of knowledge expected to result.  
 
High Risk: Pose greater than minimal risk which may or may not have direct benefit to 
the participant.  
 

  
 
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High risk trials are monitored once per quarter, moderate risk twice per year and low risk 
once annually. 
  
16.7 
 Therapeutic Response Review  
The Therapeutic Response Review Committee (TRRC) is MSKCC’s independent 
response review committee which annually evaluates therapeutic responses for 
participants in IRB/PB approved clinical trials where therapeutic efficacy is a stated 
primary objective, typically phase II and III trials. The process, done in an unbiased 
blinded fashion, ensures the data from the institution’s therapeutic trials clinical research 
program is verified and vetted. Studies monitored by the TRRC include NCI-NIH, in-
house, industrial trials, and multi-center trials where MSKCC is the coordinating center, 
which are not reviewed by an outside independent therapeutic response review board. 
 
MSKCC’s TRRC review will serve as the committee that may review and confirm 
responses of POETIC patients. The TRRC will possibly randomly select cases on an 
annual basis. If a patient is selected to be reviewed by the TRRC, the clinical site will be 
notified by the DCC with the required materials to be submitted to the committee and 
timeframe of submission. 
 
17.0 PROTECTION OF HUMAN SUBJECTS 
 
17.1 
 Privacy 
All institutional, FDA, and NCI requirements for human subjects must be met.  This study 
will be carried out in compliance with the regulations of the Health Insurance Portability 
and Accountability Act (HIPAA).  Each participating institution will have an appropriate 
assurance on file with the Office for Human Research Protection (OHRP), NIH.  The 
Data and Coordinating Center is responsible for assuring that each participating 
institution has an OHRP assurance and must maintain copies of IRB approvals from 
each participating site. The Data and Coordinating Center is responsible for assuring 
that IRB approval has been obtained at each participating site prior to the first patient 
registration from that site. 
 
The risks and benefits of participation in this study will be reviewed with the patient 
and/or parent/legal guardian. 
 
Enrollment on this study is on a voluntary basis and every effort will be made to maintain 
privacy and confidentiality.  The patient's records will be confidential. Only authorized 
individuals or agencies may inspect the records.  No identifying information will be used 
in reports or publications resulting from this study. 
 
The following section is a Mandatory Section that pertains to MSKCC only: 
It is the responsibility of the Research Staff to ensure that protocol subjects received the 
Center’s Notice of Privacy Practices.  If the subject has not received one, MSK 
personnel must provide a Notice of Privacy Practices and obtain acknowledgment before 
the subject participates in the study. 
 

  
 
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MSKCC’s Privacy Office may allow the use and disclosure of protected health 
information pursuant to a completed and signed Research Authorization form.  The use 
and disclosure of protected health information will be limited to the individuals described 
in the Research Authorization form.  A Research Authorization form must be completed 
by the Principal Investigator and approved by the IRB and Privacy Board. 
 
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70. Griffin, JL, Shockcor JP. Metabolic profiles of cancer cells. Nat Rev Cancer. 2004 
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71. Figure provided by Dr. David Lyden on page 76 of the Appendix (Figure 1). 
 
 
 
 
 
Figure 1. 
 
 
 
 
 
 
Figure 1: Peripheral rim of tumor with blue Dapi staining nuclei and green 
fluorescent protein expressing cells are bone marrow-derived and localize to 
the invasive front of the tumor.   

  
 
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Figure 2. 
 
Normal Patient Control mononuclear cells stained for CD45, CD34 and VEGFR1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Breast Cancer Patient  mononuclear cells stained for CD45, CD34 and VEGFR1 

  
 
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Table 3 
 
 
Table3: Levels of CD34+/VEGFR1- HSC/HPCs, CD34+/VEGFR1+ HPCs, and CD34-
/VEGFR1+ macrophages were measured in Normal Controls (n=6), patients with a new 
diagnosis of rhabdomyosarcoma (n=4) and in remission (n=6).  Patients with new 
diagnosis had the highest HPCs and there was a reduction in these levels in patients 
who were with no evidence of disease after completion of therapy. 
 
 
Normal 
Controls 
(n=6) 
Std. 
Dev. 
New 
Diagnosis 
(n=4) 
Std. 
Dev. 
Remission 
(n=6) 
Std. 
Dev. 
CD34+/VEGFR1- HSC/HPCs 
0.41 
0.33 
 0.46 
0.37 
0.368 
0.368 
CD34+/VEGFR1+ HPCs 
1.205 
0.713  2.77 
0.869 
0.79 
0.824 
CD34-/VEGFR1+ Mature 
monocytes 
19.191 
6.182  20.446 
7.992 
42.6 
17.865 
CD133+/VEGFR2+ EPCs 
0.28 
0.14 
 0.83 
0.45 
0.46 
0.38