A Phase I/II Study of Preoperative (Neoadjuvant) Combination of Letrozole (Femara), Everolimus (Afinitor), and TRC105 in Postmenopausal Women With Newly Diagnosed Local or Locally Advanced Potentially Resectable Hormone-Receptor Positive and Her2 Negative Breast Cancer
Phase: PHASE1
Conditions: Breast Cancer
Sponsor: University of Alabama at Birmingham

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COMPREHENSIVE CANCER CENTER 
UNIVERSITY OF ALABAMA AT BIRMINGHAM 
 
Local Protocol #: UAB 1514 
 
A Phase I/II Study of Preoperative (Neoadjuvant) Combination of Letrozole (Femara®), 
Everolimus (Afinitor®), and TRC105 in Postmenopausal Women with Newly Diagnosed Local 
or Locally Advanced Potentially Resectable Hormone-Receptor positive and Her2 negative 
Breast Cancer 
 
Brief Title: Letrozole, everolimus, and TRC105 in postmenopausal HR positive Breast Cancer  
 
Principal Investigators:      
 
 
 
 
 
 
 
 
 
Co-Investigator: 
Erica M. Stringer Reasor, M.D. 
Division of Hematology/Oncology 
Department of Medicine 
University of Alabama at Birmingham 
UAB Comprehensive Cancer Center 
1802 Sixth Avenue South 
North Pavilion 2501 
Birmingham, AL, 35294-3300 
email: esreasor@uabmc.edu 
 
Christos Vaklavas, M.D.  
cvaklava@yahoo.com 
 
 
 
 
 
 
Sub-investigators: 
Lisle M Nabell, M.D. 
Division of Hematology/Oncology 
Department of Medicine 
University of Alabama at Birmingham 
UAB Comprehensive Cancer Center 
1802 Sixth Avenue South 
North Pavilion 2540 
Birmingham, AL, 35294-3300 
Phone: (205) 934-3061 
Fax: (205) 975-9002 
email: lisle@uab.edu 
Carla I Falkson, M.D. 
Division of Hematology/Oncology 
Department of Medicine 
University of Alabama at Birmingham 
UAB Comprehensive Cancer Center 
1802 Sixth Avenue South 
North Pavilion 2540 
Birmingham, AL, 35294-3300 
Phone: (205) 975-2691 

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email: cfalkson@uab.edu 
 
 
Statistician: 
Study Coordinator:  
Kimberly V. Lamaster, RN, BSN 
Yufeng Li, Ph.D. 
Division of Preventive Medicine  
Department of Medicine 
University of Alabama at Birmingham 
1720 2nd Avenue South 
Medical Tower 644 
Birmingham, AL, 35294- 4410 
Phone: (205) 996-2866 and (205) 934-9520 
Fax: (205) 934-4262 
email: yufengli@uab.edu  
 
 
Data Manager: To Be Named 
 
NCI Supplied Agent: None  
 
Protocol Type / Version # / Version Date 
Amendment 1, version 2\ 6-29-2016 
                                                                              Amendment 2, version 3\ 7-25-19 
 
 
 
 

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PROTOCOL SYNOPSIS 
 
Title of Study: A Phase I/II Study of Preoperative (Neoadjuvant) Combination of Letrozole 
(Femara®), Everolimus (Afinitor®), and TRC105 in Postmenopausal Women with Newly 
Diagnosed Local or Locally Advanced Potentially Resectable Hormone-Receptor positive and 
Her2 negative Breast Cancer 
Brief Title: Letrozole, everolimus, and TRC105 in postmenopausal hormone receptor positive  
Breast Cancer 
Investigators:  
Erica M Stringer-Reasor, M.D., Christos Vaklavas, M.D.; (principal co-investigators) 
Lisle M Nabell, M.D., Carla I Falkson, M.D. (sub-investigators),  
Yufeng Li, Ph.D. (statistician) 
Phase: Pilot  
Type of Investigation: drug 
Study Center(s): UAB, Comprehensive Cancer Center 
Rationale: Our group has demonstrated in 2 different and independent studies that the addition 
of an anti-angiogenic agent to hormonal therapy in the neoadjuvant setting increased not only 
the proportion of patients with a pathologic complete remission (pCR) and near pCR (invasive 
residual disease less than 5 mm in the primary tumor) but also the proportion of patients that 
were down-staged (from stage 2 and 3 to 0 and 1)1,2 (a prognostic factor in neoadjuvant hormonal 
therapy). In addition, preclinical and clinical studies have shown that the addition of an mTOR 
inhibitor to hormonal therapy is able to reverse resistance to hormonal agents; these studies led 
to the approval of everolimus in combination with exemestane by the FDA for hormone receptor 
positive metastatic breast cancer3-6. However, preclinical studies have shown that mTOR 
inhibition results in VEGF inhibition which leads to overexpression of CD105 in the endothelial 
cells as a compensatory mechanism7,8. Thus, the addition of an anti-CD105 agent may increase 
the efficacy observed in the randomized trial of letrozole and everolimus in patients with stage 
2 and 3 breast cancer published by Baselga recently4.      
 
Background: The achievement of a pCR with neoadjuvant therapy in early-stage breast cancer 
has a favorable impact on long-term outcomes and is an excellent prognostic surrogate marker9-
13. Responses to neoadjuvant therapy however, are intrinsically dependent on the molecular 
subtype14 with the immunophenotypically luminal (hormone-receptor positive and HER2 
negative) breast cancers rarely achieving a pCR12.  Nonetheless, in the latter subgroup, 
downstaging to at least pathologic stage 1 or 0 is equally important as it has been associated 
with a significant low risk of recurrence15. With chemotherapy yielding similar benefits with 
hormonal therapy in the neoadjuvant setting16,17, the latter is generally preferred as it is 
associated with fewer adverse events and is overall better tolerated among postmenopausal 
women who frequently have other comorbidities18. In the neoadjuvant setting, aromatase 
inhibitors have been consistently shown to be superior over tamoxifen19-23, making the former 
the agents of choice in postmenopausal women with hormone-receptor positive [HR(+)] breast 
cancer. Despite the high rates of clinical and radiographic response achieved with hormonal 
therapy19-23, the rates of downstaging are still low15.  Collectively, there is a need to improve 
the efficacy of aromatase inhibitors in the neoadjuvant setting with minimal additional 
toxicities as it directly impacts clinical outcomes.  
 
Targeting angiogenesis in HR(+) breast cancer: Angiogenesis is an integral step in tumor 
progression24. In mouse xenograft models of HR(+) breast cancer, enhanced angiogenesis 

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accelerated tumor growth25, and overexpression of the Vascular Endothelial Growth Factor 
(VEGF) either by the tumor26 or stromal cells27 was associated with hormone independent 
growth and resistance to endocrine therapies.  
 
The concept of targeting angiogenesis to restore or enhance the efficacy of neoadjuvant 
hormonal therapy in breast cancer has been successfully translated in the clinical arena. The 
Translational Breast Cancer Research Consortium completed a study comparing preoperative 
letrozole versus letrozole plus bevacizumab in postmenopausal women with operable HR(+) 
breast cancer. The study (TBCRC002) showed that bevacizumab “deepened” the responses 
obtained with letrozole alone. Downstaging from stage 2/3 to 0/1 was achieved in 45% of 
patients in the letrozole-bevacizumab arm as compared to 25% in the letrozole-alone group. 
Remarkably, the combination induced a pCR in 11.1% of patients 1 (and 8% near pCR), 
comparable to the 12% pCR rate reported in a prior pilot single-institution study 2; no complete 
or near-complete pathologic remissions were observed in the letrozole-alone group. Taken 
together, enhanced angiogenesis is associated with hormone resistance and there is a 
successful clinical precedence of rationally combining an antiangiogenic agent with 
hormonal therapy that even led to an unprecedented pCR rate in an intrinsic subgroup 
where pCRs are rarely observed.  
 
Endoglin (CD105) as a rational target of malignant angiogenesis: Endoglin is a transmembrane 
accessory receptor for transforming growth factor-beta (TGF-β) that is predominantly expressed 
on proliferating endothelial cells in culture and on angiogenic blood vessels in vivo28. It diverts 
TGF-β downstream signaling toward proliferation and migration as well as transcription of pro-
angiogenic genes including endoglin itself29-31. Preclinical evidence suggests that CD105 is 
highly and exclusively or mainly expressed in de novo tumor vessels32,33, as opposed to the 
normal quiescent endothelium which has a very low turnover. In preclinical murine xenograft 
models of HR(+) breast cancer, anti-endoglin monoclonal antibodies selectively inhibited tumor 
angiogenesis and delayed the growth of established tumors, while sparing normal vasculature34.  
Endoglin expression has been investigated in multiple malignancies and has been consistently 
associated with adverse clinical outcomes31. This observation is in line with the premise that 
enhanced tumor vasculature correlates with adverse prognosis and the fact that endoglin is a 
marker of activated angiogenic endothelium31. Collectively, its exclusive expression in the 
activated endothelium and its pathophysiologic role in promoting angiogenesis make 
endoglin a rational target of tumor angiogenesis. 
 
Pharmacologic targeting of endoglin (CD105) with TRC105: TRC105 is a chimeric IgG1 
monoclonal antibody that binds with high avidity to CD105 (endoglin). It inhibits TGF-β 
mediated pro-angiogenic signaling and induces potent antibody-dependent cell-mediated 
cytotoxicity. In a phase I study, the maximum tolerated dose was determined at 10 mg/kg 
weekly; 15 mg/kg every two weeks was equally well tolerated and also resulted in continuous 
serum concentrations known to saturate CD105 binding sites on proliferating endothelium35. 
The most common adverse events associated with the investigational agent were infusion 
reactions that were successfully mitigated with pre-medications and prolongation of the infusion 
time, hemorrhages (mostly grade 1 and 2), headaches, and hypoproliferative anemia35. 
Importantly, the median age in this phase I clinical trial was 6335, making this study highly 
informative in terms of adverse events for the patient population intended to be used in our 
proposed study. Considering the non-overlapping toxicity profile with aromatase inhibitors 

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and the preclinical evidence highlighting malignant angiogenesis being in the core of 
hormone independence, there is an unprecedented potential of synergism between 
TRC105 and letrozole that is worth clinical investigation. 
 
Rationale for incorporating everolimus in the neoadjuvant setting: The phosphatidyl inositol-3 
kinase (PI3K)/ protein kinase B (AKT)/ mammalian target of rapamycin (mTOR) pathway is an 
intracellular signal transduction pathway downstream of receptor tyrosine kinases36. Class IA 
PI3K molecules are heterodimers composed of a regulatory subunit (p85) and a catalytic subunit 
(p110), the α isoform of which (encoded by PIK3CA) is widely mutated or amplified in human 
cancers37,38, including breast cancer39,40. Comprehensive genomic analyses of breast cancer 
samples in the context of The Cancer Genome Atlas Project also highlighted the high frequency 
of mutations along the PI3K/AKT/mTOR pathway41. In particular, activating mutations in the 
PIK3CA, inactivating mutations or loss of PTEN, and loss of INPP4B (a negative regulator of 
the PI3K/AKT pathway) were detected in 49%, 13%, and 9% (luminal A) and 32%, 24%, and 
16% (luminal B), respectively. At the preclinical level, breast cancer cells with upregulated 
PI3K/AKT/mTOR pathway were shown to be resistant to hormonal therapy and this resistance 
was restored by everolimus and other mTOR inhibitors 42,43. Taken together, the 
PI3K/AKT/mTOR pathway can be activated by various genetic events in HR (+) breast 
cancer and its inhibition with the FDA-approved agent everolimus has been proven at the 
clinical level to restore3 or enhance4 sensitivity to endocrine therapies. 
 
Synergism between TRC105 and everolimus. The molecular basis for combining antiangiogenic 
therapy with everolimus is provided by preclinical studies 44-46. In animal models, blocking 
mTOR was shown to reduce the VEGF levels and to inhibit significantly the response of 
endothelial cells to stimulation by VEGF 45. mTOR signaling was also shown to play a key role 
in hypoxia-triggered smooth muscle and endothelial cell proliferation and angiogenesis in vitro; 
this response (triggered by growth factors other than VEGF, such as FGF and PDGF) was 
abrogated with rapamycin, the prototypic mTOR inhibitor46. 
 
Moreover, VEGF inhibition leads to reactive upregulation of endoglin7 and large established 
CD105(+) vessels lying in the core of the tumors have been shown to be insensitive to VEGF 
inhibitors8. In those studies, CD105 expression was increased following inhibition of the VEGF 
pathway. CD105 expression increased more than two-fold in human pancreatic cancers grown 
in mice treated with an antibody that binds VEGF7. Similarly, treatment of human bladder 
cancers grown in mice with an antibody that blocks activation of the VEGF receptor increased 
CD105 expression within the core tumor vasculature8. Finally, a study of spontaneously 
occurring neuroendocrine tumors in RIP-Tag2 mice treated with antibody to VEGF indicated 
that TGF- β was the most highly upregulated factor, as determined by quantitative reverse 
transcriptase-polymerase chain reaction (RT-PCR)47. These studies indicate that the CD105 
pathway is a significant mechanism of escape from VEGF inhibitor therapy. 
 
Rationale for ovarian suppression with gonadotropin-releasing hormone analogs in 
premenopausal women. The IMPACT trial (Immediate Preoperative Anastrozole, Tamoxifen or 
Combined with Tamoxifen) established the superiority of aromatase inhibition over tamoxifen 
or tamoxifen + aromatase inhibition in the preoperative setting 48 . In addition, suppression of 
the proliferation marker Ki67 (which in itself has been shown to be predictive of favorable 
outcome) was statistically greater with anastrozole as compared with tamoxifen or the 

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combination 49. Aromarase inhibitors in premenopausal women are contraindicated as they may 
increase gonadotropin secretion because of the reduced feedback of estrogen to the 
hypothalamus and pituitary50. To that end, in order for premenopausal women to benefit from 
aromatase inhibition, they should become postmenopausal through ovarian suppression with 
gonadotropin-releasing hormone analogs. For this clinical trial goserelin subcutaneously q 4 
weeks will be used.  
 
Collectively, considering the non-overlapping toxicity profiles and the preclinical evidence 
highlighting malignant angiogenesis and the PI3K/AKT/mTOR pathway being in the core 
of resistance to and failure of endocrine therapies, there is an unprecedented potential of 
synergism among letrozole, TRC105, and everolimus that is worth clinical investigation. 
Primary Objective: Determine the tolerability and feasibility of combining everolimus and 
TRC105 with letrozole in postmenopausal women with newly diagnosed stage 2 and 3 (T2-T4a-
c, N0-2, M0; excluding patients with T4d or inflammatory breast cancer) estrogen and/or 
progesterone receptor positive, HER2/neu negative breast cancer, treated for 24 weeks in the 
preoperative (neoadjuvant) setting. 
Secondary Objective:  
1. Determine the efficacy of the combination of letrozole, everolimus, and TRC105 
2. Determine the pharmacokinetic parameters of everolimus and TRC105 when used in 
combination with letrozole. 
3. Determine the pharmacodynamic parameters of everolimus and TRC105 when used in 
combination with letrozole. 
Exploratory objective: Evaluate specific biomarkers of potential prognostic value and 
biomarkers potentially predictive of response or resistance to the combination of everolimus and 
TRC105 with letrozole. 
Primary Endpoint: Determine the maximum tolerated dose (MTD), the recommended phase 2 
dose (RP2D) and rates of adverse events associated with the combination of letrozole with 
everolimus and TRC105. 
Secondary Endpoints:  
1. Determine the rates of complete pathologic remission and downstaging achieved with the 
investigational treatment at the time of surgery.  
2. Determine the Cmax, Tmax, AUC, T½, clearance of everolimus and TRC105 when used in 
combination with letrozole. 
3. Determine the changes in tumor cell proliferation by means of changes in Ki67 expression 
and changes in serum concentration of markers of angiogenesis (VEGF-A, soluble 
VEGFR2, activin A and activin B, angiopoietin-1 and -2, TGF-β, soluble endoglin) before 
and after the investigational treatment and correlate with clinical, radiographic, and 
pathologic response. 
Exploratory Endpoints: 
1. Correlate the levels of PTEN immunostaining with response 
2. Correlate levels of phosphorylated AKT (pAKT) immunostaining with response 
3. Correlate expression of endothelial (CD105 and CD31/CD34) and pericyte (NG2, and 
MCAM [CD146]) markers in the initial diagnostic and final surgical specimens with 
response. 

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4. Determine translational (mRNA to protein) profiles by means of next-generation whole 
exome sequencing and sequencing of ribosome-protected mRNA associated with resistance 
to the investigational combination. 
Study Design: the study consists of 2 parts. 
 
The first part of the study will follow the conventional 3+3 dose escalation design. Up to 18 
patients will be enrolled. During the first part (phase I, dose escalation), the Maximum 
Tolerated  Dose  (MTD) and the Recommended Phase 2 Dose (RP2D) of the combination will 
be determined. The dose of letrozole will be kept the same for all cohorts (2.5 mg PO daily) 
(Table 1). The dose of everolimus will be escalated from 5 mg PO daily (cohort 1) to 10 mg PO 
daily (cohort 2, continuous arrow). The dose of everolimus will be de-escalated to 5 mg PO 
daily (cohort 1) if the dose of 10 mg PO daily is not well tolerated (dashed arrow). The dose of 
TRC105 will be 15 mg/kg q 2 weeks (cohorts 1 and 2, continuous arrow). The dose of TRC105 
will be de-escalated to 10 mg/kg q 2 weeks (cohort -1) if 15 mg/kg q 2 weeks in combination 
with everolimus 5 mg PO daily are not well tolerated (dashed arrow). Different doses of the 3 
agents evaluated in this trial have shown to be active against breast cancer in clinical trials.   
Premenopausal women at the time of study enrollment will receive goserelin 3.6 mg 
subcutaneously q 4 weeks to achieve ovarian suppression. 
 
Cohort 
TRC105 (mg/kg IV q 2 weeks) 
Everolimus (mg PO daily) 
1 
15 
5 
2 
15 
10 
-1 
10 
5 
  
The second part of the study (phase II, expansion phase), will ensue once the MTD and RP2D 
have been determined. In order to minimize exposure of patients to ineffective therapy, a 
Gehan’s two-stage design will be used51.  The study will enroll 10 patients first, and if no patient 
has pCR or downstaging, the study will close on the basis that it is unlikely (p=0.1074) that 0/10 
responses would occur if the true response rate were >20%. If at least one patient has pCR or 
downstaging, an additional 10 patients will be treated (total of 20). Accrual will be halted as a 
result of any grade ≥3 hemorrhage, cerebrovascular and vasovagal adverse events; the FDA will 
be contacted to discuss further accrual or potential need for protocol amendment. 
 

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Study Schema 
 
 
 
Study Procedures 
 
Premenopausal women at the time of study enrollment will receive goserelin 3.6 mg 
subcutaneously q 4 weeks to achieve ovarian suppression 
 
Drug Dose (doses, frequency, duration):  
Letrozole 2.5 mg PO daily, continuously until the day prior to surgery. TRC105 15 or 10 mg/kg 
IV every two weeks until 4 weeks prior to surgery. The first dose of TRC105 will be split into 
two doses; see Table 7-1 (Study Calendar) for additional details. Everolimus 5 or 10 mg PO 
daily, continuously until 4 weeks prior to surgery. Premenopausal women at the time of study 
enrollment will receive goserelin 3.6 mg subcutaneously q 4 weeks to achieve ovarian 
suppression. 
Main Criteria for Inclusion/Exclusion:  
Key Inclusion Criteria 
 
- Recent diagnosis of hormone receptor positive and HER2 negative breast cancer. 
- Stage 2 and 3 hormone receptor positive and HER2 negative breast cancer (stage T2-4 but not 
inflammatory, N0-2, M0). 

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- Histological grade I, II or III according to the modified Bloom Richardson scale52. 
- No prior treatment specific for breast cancer. 
- Menopausal status as defined by the National Comprehensive Cancer Network. Premenopausal 
women are eligible if ovarian suppression is achieved with goserelin 
- ECOG performance status < 2 (Karnofsky > 60%). 
- Must have signed study-specific informed consent. 
- Liver Function Tests < 2.5 times the upper normal limit (UNL). 
- Staging workup: medical/surgical/radiation therapy evaluation, CT scans and bone scan. 
- Lipid profile (cholesterol  and triglycerides). 
- ANC ≥ 1,500/mm3, platelets ≥ 100,000/mm3, Hemoglobin ≥ 10g%. 
- Renal function: serum creatinine < 1.5 institutional UNL or creatinine clearance > 40 cc/min. 
 
Key Exclusion Criteria 
- Inflammatory breast cancer. 
- Pregnancy. 
- Metastatic disease. 
- HER2 positive breast cancer by immunohistochemistry or FISH. 
- Triple negative breast cancer (hormone receptor and Her2 negative). 
- Disease that cannot be followed by imaging studies. 
Safety Assessments:  
 Vitals signs 
 Weight 
 ECOG performance status 
 Hematology 
 Chemistry 
 Lipid profile 
 Hepatitis panel 
 Adverse events 
 Concomitant medications  
Efficacy Assessments:  
 Physical examination 
 Imaging studies (mammography, 
breast ultrasound, breast magnetic 
resonance imaging)  
 Surgical Pathology 
 
Other Assessments: 
a. Pharmacokinetic (PK) studies. To investigate the pharmacokinetic interaction between 
TRC105 and everolimus, samples will be collected and concentrations of the agents measured 
on cycle 1 day 1 and cycle 2 day 1 at the following time points: pre-dose, 1, 2, 4, 6, and 24 hours 
and also cycle 1 day 4 predose. Pharmacokinetic parameters to be estimated include maximum 
serum concentration (Cmax), time of maximum serum concentration (Tmax), area under the serum 
concentration versus time curve (AUC), terminal half-life (T½), and clearance. Serum for 
assessment of TRC105 anti-product antibody formation will be collected before dosing on cycle 
1 day 1, every 4 weeks thereafter, 4 and 12 weeks following the last dose of TRC105 and 
concentrations will be determined by a validated ELISA53. 
 
b. Pharmacodynamic (PD) studies. Markers of angiogenesis (VEGF-A, soluble VEGFR2, 
activin A and activin B, angiopoietin-1 and -2, TGF-β, soluble endoglin) will be measured on 
samples collected pre-dose, cycle 1 day 15, cycle 2 day 1, and prior to surgery.  
 
c. Research biopsy. A research biopsy will be obtained at baseline, on cycle 2 day 1, and the 
time of the surgery. At least 2 core biopsies will be taken, one will be embedded in paraffin and 
the other one will be immediately frozen. Immunohistochemistry for pAKT and PTEN (markers 

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of the PI3K/AKT/mTOR pathway), CD105 and CD31/CD34 (pan-endothelial markers), and 
NG2 and MCAM/CD146 (pericyte markers) will be conducted on the research biopsies, and the 
final surgical specimen. Next Generation Sequencing. Determine translational (mRNA to 
protein) profiles by means of next-generation whole exome sequencing and sequencing of 
ribosome-protected mRNA associated with resistance to the investigational combination. 
Statistical Methods: this is a phase I study and primarily descriptive statistics will be used. 
 
(a) Sample size justification:   The dose escalation part of the study will follow a conventional 
3+3 dose escalation design according to the schema above. Up to 18 patients will be enrolled in 
this part anticipating that dose level 1 or 2 will be the RP2D. The number of patients to be 
enrolled ranges from 3 (≥2/3 DLTs in cohort 1) to 18 (enrollment of 6 patients in all cohorts). 
The sample size of 20 in Phase II part study is NOT determined by the statistical power but the 
feasibility and relative precision of estimate, e.g. standards error of the estimation is ≤10%. We 
will estimate the pCR of the combination to generate hypotheses for further clinical 
investigations. A Gehan’s two-stage design will be used51 which allows for the rapid rejection 
of an ineffective treatment at the end of the first stage, and provides an estimation of the success 
rate with a given precision, at the end of the second stage.  The study will enroll 10 patients first. 
If no patient has pCR or downstaging, it is unlikely (p=0.1074) that 0/10 responses would occur 
if the true response rate were >20% and the phase II portion will be closed.  If at least one patient 
has pCR or downstaging, an additional 10 patients will be treated (total of 20).  With an accrual 
of 20 patients to phase II portion of the study, estimated two-sided 95% confidence intervals 
(CI) would be 1.2%-31.7%, 5.7% -43.6% and 11.8%-54.3% if pCR is 10%, 20% or 30% 
respectively. The confidence intervals are calculated using the exact method Clopper-Pearson 
intervals54. Final analysis will include all patients enrolled in the trial.  
 
(b) Analytic plan for primary objective:  The rate of adverse events will be estimated at the 
end of the study along with two-sided 95% exact CIs (Clopper-Pearson intervals).  
 
(c) Analytic plan for secondary objectives:   
1. pCR or downstaging rate will be estimated along with two-sided 95% CIs with the exact 
method of Clopper-Pearson intervals. 
2. We will use descriptive statistics (mean, median, geometric mean, coefficient of variation, 
and 95% confidence intervals) and graphical displays to evaluate the pharmacokinetic 
parameters of the TRC105 and everolimus. 
3. We will use descriptive statistics (mean, median, geometric mean, coefficient of variation, 
and 95% confidence intervals) and graphical displays to analyze the changes in markers of 
proliferation and angiogenesis with the investigational treatment. 
4. Exploratory analysis will be conducted on the correlations between clinical outcomes and 
pharmacodynamic biomarkers or translation profiles. 
 
 
 

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TABLE OF ABBREVIATIONS 
 
4-EBP-1 
ACE 
AdEERS 
ADR 
AE 
ANC 
AUC 
AKT 
ALT 
APA 
AST 
BAL 
BCG 
BIRADS 
BUN 
Cmax 
CBC 
CC 
CD 
CD105 
CI 
CoA 
CPK 
CR 
CRF 
CT 
CTCAE 
CTEP 
CYP3A4 
DEXA 
DLCO 
DLT 
DM 
DS&E 
ECOG 
EKG 
ELISA 
ER 
FDA 
FGF 
FISH 
FSH 
GCP 
GERD 
GI 
4E Binding Protein 1 
Angiotensin-Converting Enzyme 
Adverse Event Expedited Reporting System 
Adverse Drug Reaction 
Adverse events 
Absolute Neutrophil Count 
Area Under the Curve 
Protein Kinase B 
Alanine aminotransferase/glutamic pyruvic transaminase/GPT 
Anti-Product (TRC105) Antibody 
Aspartate aminotransferase/glutamic oxaloacetic transaminase/GOT 
Bronchoalveolar lavage 
Bacillus Calmette-Guérin 
Breast Imaging Reporting and Data System 
Blood Urea Nitrogen 
Maximum Serum Concentration 
Complete Blood Count 
Craniocaudal 
Cluster of Differentiation 
Endoglin  
Confidence Intervals 
Coenzyme A 
Creatine Phosphokinase 
Complete Response 
Case Report Form 
Computed Tomography 
Common Terminology Criteria for Adverse Events 
Cancer Therapy Evaluation Program 
Cytochrome P450 3A4 
Dual-Energy X-ray Absorptiometry 
Diffusing capacity of the Lung for Carbon Monoxide 
Dose Limiting Toxicity 
Diabetes Mellitus 
Drug Safety and Epidemiology Department 
Eastern Cooperative Oncology Group 
Electrocardiogram 
Enzyme-linked Immunosorbent Assay 
Estrogen Receptor 
Food and Drug Administration 
Fibroblast Growth Factor 
Fluorescence in situ Hybridization 
Follicle Stimulating Hormone 
Good Clinical Practice 
Gastroesophageal Reflux Disease 
Gastrointestinal 

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GnRH 
HAMA 
HACA 
HbA1c 
HBcAb 
HbsAb 
HbsAg 
HBV 
HCV 
HHT-1 
HMG 
HR 
HUVEC 
IB 
ICH 
IgG1 
IHC 
IRB 
IUD 
IUS 
IV 
kg 
LD 
LH 
log10 
MedDRA 
mg 
MLO 
MMP-14 
MRI 
mRNA 
MTD 
mTOR 
MUGA 
NCI 
pAKT 
pCR  
PCR 
PD 
PD 
PDGF 
PET 
P-gp 
PHI 
PJP 
PNET 
PI3K 
Gonadotropin-releasing hormone 
Human Anti-Murine Antibody  
Human Anti-Chimeric Antibody 
Hemoglobin A1c 
Hepatitis B core antibody 
Hepatitis B surface antibody 
Hepatitis B surface antigen 
Hepatitis B virus 
Hepatitis C virus 
Hereditary Hemorrhagic Telangiectasia T1 (Rendu/Osler/Webber 
syndrome) 
3-hydroxy-3-methyl-glutaryl 
Hormone Receptor 
Human Umbilical Vein Endothelial Cells 
Investigator’s Brochure 
International Conference on Harmonization 
Immunoglobulin G1 
Immunohistochemistry 
Institutional Review Board 
Intrauterine Device 
Intrauterine System 
Intravenous 
kilogram 
Longest Diameter 
Luteinizing Hormone 
Decadic logarithm (common logarithm) 
Medical Dictionary for Regulatory Activities 
milligram 
Mediolateral Oblique  
Matrix Metalloproteinsae – 14 
Magnetic Resonance Imaging 
messenger RNA 
Maximum Tolerated Dose 
mammalian Target Of Rapamycin 
Multi Gated Acquisition Scan 
National Cancer Institute 
phosphorylated Protein Kinase B 
Pathologic Complete Remission  
Polymerase Chain Reaction 
Pharmacodynamic  
Progressive Disease 
Platelet Derived Growth Factor 
Positron-Emission Tomography 
P-glycoprotein 
Protected Health Information 
Pneumocystis jirovecii Pneumonia 
Pancreatic Neuroendocrine Tumor 

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PK 
PO 
PR 
PTEN 
RAD001 
RECIST 
RP2D 
RT-PCR 
SAE 
SD 
SEGA 
SUSARs 
T½  
Tmax 
TAC 
TBCRC 
TGF-β 
TGF-βR 
TSC 
UA 
ULN 
US 
VEGF 
VEGF-A 
VEGFR2 
WHO 
Phosphatidyl Inositol-3 Kinase 
Pharmacokinetic 
Oral 
Partial Response 
Phosphatase and Tensin Homolog 
everolimus 
Response Evaluation Criteria for Solid Tumors 
Recommended Phase 2 Dose 
Reverse Transcriptase-Polymerase Chain Reaction 
Serious Adverse Event 
Stable Disease 
Subependymal Giant cell Astrocytoma 
Suspected Unexpected Serious Adverse Reactions 
Half-life 
time of maximum serum concentration 
docetaxel 75 mg/m 2, doxorubicin 50 mg/m2, cyclophosphamide 500 
mg/m2 
Translational Breast Cancer Research Consortium 
Transforming Growth Factor-beta 
Transforming Growth Factor-beta Receptor 
Tuberous Sclerosis Complex 
Urinalysis 
Upper Level of Normal 
Ultrasound 
Vascular Endothelial Growth Factor 
Vascular Endothelial Growth Factor – A  
Vascular Endothelial Growth Factor Receptor 2 
World Health Organization 
 
 
 

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GLOSSARY OF TERMS 
 
Assessment 
A procedure used to generate data required by the study 
Baseline 
For efficacy evaluations, the baseline assessment will be the last available 
assessment before or on the date of randomization. 
For safety evaluations (i.e. laboratory assessments and vital signs), the 
baseline assessment will be the last available assessment before or on the 
start date of study treatment. 
The value obtained at baseline assessments, referred to as “baseline value” 
will be used as reference for the patient. 
Control drug 
A study treatment used as a comparator to reduce assessment bias, 
preserve blinding of investigational drug, assess internal study validity, 
and/or evaluate comparative effects of the investigational drug 
Dose level 
The dose of drug given to the patient (total daily or weekly etc.)  
Enrollment 
Point/time of patient entry into the study; the point at which informed 
consent must be obtained (i.e. prior to starting any of the procedures 
described in the protocol) 
Investigational 
drug 
The study treatment whose properties are being tested in the study; this 
definition is consistent with US CFR 21 Section 312.3 and is synonymous 
with “investigational new drug.” 
Investigational 
treatment 
Drug whose properties are being tested in the study as well as their 
associated placebo and active treatment controls (when applicable). This 
also includes approved drugs used outside of their indication/approved 
dosage, or that are tested in a fixed combination. Investigational treatment 
generally does not include other study treatments administered as 
concomitant background therapy required or allowed by the protocol 
when used in within approved indication/dosage 
Medication 
number 
A unique identifier on the label of each study treatment package which is 
linked to one of the treatment groups of a study 
Other study 
treatment 
Any drug administered to the patient as part of the required study 
procedures that was not included in the investigational treatment 
Patient  
A unique identifying number assigned to each patient/subject/healthy 
volunteer who enrolls in the study 
Period 
A subdivision of the study timeline; divides stages into smaller functional 
segments such as screening, baseline, titration, washout, etc. 
Premature  
patient withdrawal 
Point/time when the patient exits from the study prior to the planned 
completion of all study treatment administration and/or assessments; at 
this time all study treatment administration is discontinued and no further 
assessments are planned, unless the patient will be followed for 
progression and/or survival 

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Stop study 
participation 
Point/time at which the patient came in for a final evaluation visit or when 
study treatment was discontinued whichever is later 
Study treatment 
Includes any drug or combination of drugs in any study arm administered 
to the patient (subject) as part of the required study procedures, including 
placebo and active drug run-ins. 
In specific examples, it is important to judge investigational treatment 
component relationship relative to a study treatment combination; study 
treatment in this case refers to the investigational and non-investigational 
treatments in combination. 
Study  
treatment 
discontinuation 
Point/time when patient permanently stops taking study treatment for any 
reason; may or may not also be the point/time of premature patient 
withdrawal 
Supportive 
treatment 
Refers to any treatment required by the exposure to a study treatment, e.g. 
premedication of vitamin supplementation and corticosteroid for 
pemetrexed disodium. 
Variable 
Identifier used in the data analysis; derived directly or indirectly from data 
collected using specified assessments at specified time points 
 
 
 
 

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TABLE OF CONTENTS 
 
 
 
 
PROTOCOL SYNOPSIS 
TABLE OF ABBREVIATIONS 
GLOSSARY OF TERMS 
 
1. OBJECTIVES AND ENDPOINTS 
1.1 
Objectives 
1.2 
Endpoints 
 
2. BACKGROUND 
 
2.1.1    Rationale for improving outcomes with neoadjuvant treatment 
2.1.2    Rationale for incorporating everolimus in the neoadjuvant setting 
2.1.3    Background: Clinical studies with everolimus in HR+ breast cancer 
2.1.4    Rationale for incorporating antiangiogenic therapy in the neoadjuvant setting 
2.1.5    Background: Clinical studies with antiangiogenic agents in HR+ breast cancer                   
2.1.6    Rationale for targeting endoglin in cancer therapeutics 
2.1.7    Clinical studies with TRC105 
2.1.8    Synergism between TRC105 and everolimus 
2.1.9    Duration of neoadjuvant treatment 
2.1.10 Rationale for ovarian suppression with gonadotropin-releasing hormone analogs in  
 
 
premenopausal women 
2.2       Correlative Studies Background 
2.2.1    PI3K/AKT/mTOR pathway in breast cancer 
2.2.2    Regulation of gene expression at the translational level 
 
3. PATIENT SELECTION 
3.1  
Study Population 
3.2   
Eligibility Criteria  
3.3  
Exclusion Criteria 
3.4  
Inclusion of Women and Minorities 
3.5  
Subjects Who Fail to Meet the Eligibility Criteria. 
 
4. STUDY DESIGN 
4.1  
Phase I, dose escalation 
4.2  
Phase II, expansion phase 
4.3  
Study accrual and treatment considerations 
4.4  
Rationale for the Study Doses and Design 
4.5  
Rationale for the Preoperative Setting 
4.6  
Rationale for the Drug Combination 
4.7  
Rationale for Tumor Assessments by Both Physical Examination and Imaging 
4.8       Rationale for the duration of preoperative treatment 
 
5. TREATMENT PLAN 

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5.1  
Subject Selection and Registration 
5.2  
Study Medications 
5.2.1 Letrozole 
5.2.2 Everolimus 
5.2.3 TRC105 
5.2.4 Goserelin 
5.2.5 Concomitant Medications 
5.3  
Dose Modifications and Delays 
5.3.1    Dose modifications and delays with letrozole. 
5.3.2    Dose modifications and delays with everolimus 
5.3.3    Dose modifications and delays with TRC105 
5.3.4 Dose modifications and delays with goserelin 
5.4 
Study Procedures 
5.4.1    Screening phase 
5.4.2    Treatment Phase 
5.4.3    Safety Follow-up Phase 
5.5 
Study Termination 
5.6 
Subject Discontinuation 
 
6. STUDY DRUG PREPARATION AND DISPENSATION 
 
6.1  
Dosing Regimen and Schedule 
 
6.2  
Drug Formulations 
 
6.2.1 Letrozole Formulation 
 
6.2.2 Everolimus Formulation 
 
6.2.3 TRC105 Formulation 
 
6.2.4 Goserelin Formulation 
 
6.3  
Study Drug Storage and Handling 
 
6.4  
Study Drug Compliance 
 
6.5  
Study Drug Accountability 
 
7. VISIT SCHEDULE AND ASSESSMENTS 
7.1  
Study Flow and Visit Schedule 
7.2  
Measurement of Effect 
7.3   
Pharmacokinetic and Pharmacodynamic Studies and Research Biopsy  
 
8. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS 
8.1 
Adverse Events 
8.2 
Adverse Event Characteristics 
8.3 
Expedited Adverse Event Reporting 
8.4 
Routine Adverse Event Reporting 
8.5 
Serious Adverse Events 
8.6 
Adverse reactions with everolimus 
8.7  
Adverse reactions with TRC105 
 
9. DATA COLLECTION AND STUDY MANAGEMENT 
9.1 
Data Collection 
9.2 
Data Management 

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9.3 
Study Management 
 
10. STATISTICAL CONSIDERATIONS 
 
10.1 
Sample Size and Power Justification 
 
10.2 
Statistical Analysis 
 
10.3 
Stratification Factors 
11. PROTOCOL ADHERENCE 
11.1 
Amendments to the Protocol 
 
REFERENCES 
 
LIST OF FIGURES 
 
Figure A  
Genomic aberrations along the PI3K/AKT/mTOR pathway 
Figure B  
Results of the TBCRC002 study 
Figure C  
Interactions of endoglin with TGF-βR.    
 
Figure D  
Study design. 
Figure E  
Chemical structure of Everolimus 
Figure F  
Study Schema 
Figure G  
Timeline of the pharmacokinetic / pharmacodynamics studies and research biopsy 
 
LIST OF TABLES 
 
Table 4-1  
Cohorts and dose escalations of the phase I part of the study 
Table 4-2  
Dose escalation rules 
Table 5-1  
Everolimus - Drug substance 
Table 5-2  
Dosing guidelines for Everolimus-related non-hematologic toxicities 
Table 5-3  
Dosing guidelines for Everolimus-related hematologic toxicities 
Table 5-4   
Management of oral mucositis associated with everolimus. 
Table 5-5   
Management of hyperlipidemia and hypertriglycemia associated with everolimus. 
Table 5-6   
Recommendations for positive baseline results for hepatitis B. 
Table 5-7  
Guidelines for management of hepatitis B. 
Table 5-8  
Definitions and Guidelines for the management of Hepatitis C. 
Table 5-9  
Guidelines for the management of treatment-related non-infectious pneumonitis 
Table 5-10  
Guidelines for the management of infusion related reactions. 
      Table 5-11  
Drug interactions: inducers/inhibitors of isoenzyme CYP3A 
Table 5-12  
Drug interactions: inducers/inhibitors of P-gp and P-gp/CYP3A dual inhibitors 
Table 6-1  
Dosing regimen and schedule 
Table 7-1  
Study Calendar 
Table 8-1  
Adverse Drug Reactions associated with everolimus 
Table 8-2  
Fatal AE reported by investigators across all RAD001 studies as having a suspected 
causal relationship to everolimus as of 31-Mar-2014 
Table 8-3  
Serious, unexpected, life-threatening AE considered related to study drug, and 
reported on at least one occasion as of 31-Mar-2014. 
Table 10.1  
Probability of early termination and observing one response or at least one response 
at the first stage (N1=10) 
 

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APPENDICES 
 
APPENDIX A 
Performance Status Criteria 
APPENDIX B 
Drugs with potential interactions with everolimus 
APPENDIX C 
American College of Radiology Practice Guidelines for Imaging Studies of the Breast 
 
APPENDIX D 
National Cancer Institute Common Terminology Criteria for Adverse Events (NCI 
CTCAE) version 4.03 
 
APPENDIX E 
 
FDA MedWatch 3500A Form 
 
APPENDIX F 
  
SOP for Investigator INDs Held by Physician Members of the UAB CCC  
      APPENDIX G 
            Blood and Biopsy Procedures 
 
 
 
 
 
 

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1. OBJECTIVES AND ENDPOINTS 
 
1.1 
Objectives 
 
1.1.1 
Primary Objective 
 
Determine the tolerability and feasibility of combining everolimus and TRC105 with letrozole 
administered for 24 weeks in the preoperative (neoadjuvant) setting in postmenopausal women with 
newly diagnosed potentially resectable local or locally advanced (T2-T4a-c, N0-2, M0; excluding 
patients with T4d or inflammatory breast cancer) estrogen and/or progesterone receptor positive, 
Her2/neu negative breast cancer. 
 
1.1.2. 
Secondary Objectives 
 
a. Determine the efficacy of the combination of letrozole, everolimus, and TRC105 in 
postmenopausal women with newly diagnosed potentially resectable local or locally advanced 
estrogen and/or progesterone receptor positive, Her2/neu negative breast cancer. 
 
b. Determine the pharmacodynamic parameters of everolimus and TRC105 when used in 
combination with letrozole in the same patient population. 
 
c.   Determine the pharmacokinetic parameters of everolimus and TRC105 when used in combination 
with letrozole in the same patient population. 
 
1.1.3    Exploratory Objective 
 
Evaluate specific biomarkers of potential prognostic value and biomarkers potentially predictive of 
response or resistance to the combination of everolimus and TRC105 with letrozole. 
 
1.2  
Endpoints 
 
1.2.1 Primary Endpoint 
 
Determine the maximum tolerated dose (MTD), the recommended phase 2 dose (RP2D) and rates 
of adverse events associated with the combination of letrozole with everolimus and TRC105. 
 
1.2.2. 
Secondary Endpoints 
 
a. Determine the rates of complete pathologic remission and downstaging achieved with the 
investigational treatment at the time of surgery. 
 
b. Determine the changes in tumor cell proliferation by means of changes in Ki67 expression and 
changes in serum concentration of markers of angiogenesis (VEGF-A, soluble VEGFR2, activin A 
and activin B, angiopoietin-1 and -2, TGF-β, soluble endoglin) before and after the investigational 
treatment and correlate with clinical, radiographic, and pathologic response. 

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c. Determine the Cmax, Tmax, AUC, T½, clearance of everolimus and TRC105 when used in 
combination with letrozole.  
 
1.2.3   Exploratory Endpoint 
 
a. Correlate the levels of PTEN immunostaining with response. 
 
b. Correlate levels of phosphorylated AKT (pAKT) immunostaining with response. 
 
c. Correlate expression of endothelial (CD105 and CD31/CD34) and pericyte (NG2, and MCAM 
[CD146]) markers in the initial diagnostic and final surgical specimens with response. 
 
d. Determine translational (mRNA to protein) profiles by means of next-generation whole exome 
sequencing and sequencing of ribosome-protected mRNA associated with resistance to the 
investigational combination. 
 
2. BACKGROUND 
 
2.1  
Rationale and Background 
 
2.1.1 Rationale for improving outcomes with neoadjuvant treatment 
 
The achievement of a pathologic complete remission (pCR) with neoadjuvant (preoperative) therapy 
in early-stage breast cancer has an extremely favorable impact on long-term outcomes and is an 
excellent prognostic surrogate marker9-13,55,56. The Food and Drug Administration (FDA) has adopted 
the achievement of a pCR as an endpoint in neoadjuvant trials leading to accelerated approval of 
novel agents in breast cancer13,57.  
 
Responses to neoadjuvant therapy however, depend on the intrinsic molecular subtype14 with the 
immunophenotypically luminal (hormone-receptor positive and Her2 negative) breast cancers rarely 
achieving a pCR12.  Nonetheless, in this luminal subgroup, downstaging to at least pathologic stage 
1 is equally important as it has been associated with a low risk of recurrence15. In a preoperative 
study that compared 4 months of hormonal treatment with letrozole or tamoxifen (P024) in stage 2 
or 3 hormone receptor positive breast cancer, women whose disease shrunk to stage 1 or 0 (n=30) 
had a favorable long term outcome (no relapse with a median follow up of 61.2 months, one death 
due to unknown causes) as compared to the 30% relapse incidence among women whose disease was 
not preoperatively downstaged (n=175)15,19,21. An approach that intends to enhance or deepen the 
responses in luminal breast cancer is also supported by 2 large studies with response guided 
neoadjuvant chemotherapy58-60. After 2 cycles of neoadjuvant chemotherapy with docetaxel at 75 
mg/m 2, doxorubicin at 50 mg/m2, and cyclophosphamide at 500 mg/m2 (TAC), in women whose 
disease responded, the treatment was extended to a total of 8 cycles (versus standard 6 cycles)59 or 
alternatively, in women whose disease did not respond, the treatment was changed to a non-cross 
resistant regimen (capecitabine and vinorelbine versus continuation of TAC)60. In subsequent 
exploratory analyses, both disease-free and overall survival were better with a response guided 
approach58 despite the fact that the rates of pCR were not significantly improved. Moreover, at least 
in Luminal A breast cancers, the achievement of a pCR per se was not associated improved 

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outcomes58.  Taken together, although the achievement of pCR is not uniformly associated with 
improved clinical outcomes, a preoperative strategy that intends to enhance the responses in 
luminal breast cancer holds particular promise in yielding superior long term clinical 
outcomes. 
 
In the neoadjuvant setting for hormone receptor positive/Her2 negative breast cancer, chemotherapy 
and hormonal therapy have been shown to yield similar benefits in postmenopausal women16,17. 
While in one study the clinical response rates were higher (but not statistically significant) with 
neoadjuvant chemotherapy as opposed to hormonal therapy, by subgroup analysis, there was no 
difference in the efficacy of either intervention in postmenopausal women (57% vs. 52% clinical 
response rate with neoadjuvant chemotherapy vs. hormonal therapy, respectively)16. Of note, the 
pCR rate was low with either intervention (1/47 vs. 0/48 achieved a pCR with neoadjuvant 
chemotherapy vs. hormonal therapy, respectively)16.  In another study that compared the efficacy of 
neoadjuvant chemotherapy vs. hormonal therapy specifically in postmenopausal women, the 
outcomes were highly similar: rates of complete and partial clinical response were 62%, 67%, and 
63% for anastrozole, exemestane and chemotherapy, respectively17. In fact, neoadjuvant hormonal 
therapy was found to be associated with an increase in the proportion of patients suitable for breast 
conserving surgery17. Along these lines, hormonal therapy is generally preferred as it is associated 
with fewer adverse events and is overall better tolerated in this subgroup of patients who frequently 
have other comorbidities18. 
 
In the neoadjuvant setting, aromatase inhibitors have been consistently shown to be superior over 
tamoxifen19-23, making the former the agents of choice in postmenopausal women with hormone-
receptor positive breast cancer. Despite the high rates of clinical and radiographic response achieved 
with hormonal therapy alone19-23, the rates of downstaging are still low (approximately 15%15). 
Similarly, the rates of pCR are very low (less than 5%) 4,15,16. Collectively, there is a need to 
improve the efficacy of aromatase inhibitors in the neoadjuvant setting with minimal 
additional toxicities as it directly impacts clinical outcomes.  
 
2.1.2 Rationale for incorporating everolimus in the neoadjuvant setting 
 
The phosphatidyl inositol-3 kinase (PI3K)/ protein kinase B (AKT)/ mammalian target of rapamycin 
(mTOR) pathway is an intracellular signal transduction pathway downstream of receptor tyrosine 
kinases (figure A36). Class IA PI3K molecules are heterodimers composed of a regulatory subunit 
(p85) and a catalytic subunit (p110), the α isoform of which (encoded by PIK3CA) is widely mutated 
or amplified in human cancers37,38, including breast cancer39,40. Comprehensive whole-genome 
sequencing data indicate that the frequency of PIK3CA mutations in hormone receptor positive breast 
cancer is 41.3%36 (35.8% in a randomized clinical trial with everolimus where PIK3CA mutations 
were systematically evaluated4). Deletions were identified also in PTEN (7%), a negative regulator 
of the PI3K/AKT/mTOR pathway, as well as copy number aberrations and mutations in AKT (52% 
and 2%, respectively)36. Comprehensive genomic analyses of breast cancer samples in the context of 
The Cancer Genome Atlas Project also highlighted the high frequency of mutations along the 
PI3K/AKT/mTOR pathway41. In particular, activating mutations in the PIK3CA, inactivating 
mutations or loss of PTEN, and loss of INPP4B (a negative regulator of the PI3K/AKT pathway) 
were detected in 49%, 13%, and 9% (luminal A) and 32%, 24%, and 16% (luminal B), respectively. 
At the preclinical level, breast cancer cells with upregulated PI3K/AKT/mTOR pathway were shown 

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to be resistant to hormonal therapy and this resistance was restored by everolimus and other mTOR 
inhibitors42,43. The mechanistic connection between hormone resistance and PI3K/AKT/mTOR 
pathway activation relies on the ligand-independent activation of the estrogen receptor (ER) by 
downstream substrates of the mTOR complex5,6. Taken together, the PI3K/AKT/mTOR pathway 
can be activated by various genetic events in hormone receptor positive breast cancer and its 
inhibition with the FDA-approved agent everolimus can restore or enhance sensitivity to 
endocrine therapies. Moreover, inhibiting mTOR, a downstream signaling node where multiple 
pathways converge as opposed to blocking upstream mediators or individual surface receptors, has 
the potential to abrogate pleiotropic primary and escape tumor-promoting signaling cascades that 
mediate resistance to endocrine therapies. 
 
 
Figure A. Genomic aberrations along the PI3K/AKT/mTOR pathway. Genomic 
aberrations along the PI3K/AKT/mTOR pathway identified by comprehensive next-
generation sequencing in luminal breast cancer36 leading to constitutive signaling and evasion 
from hormone blockade. 
 
2.1.3 Background: Clinical studies with everolimus in HR positive breast cancer 
 
The elucidation of the mechanisms of resistance to endocrine therapies61 set the stage for many 
successful clinical trials where responses to endocrine therapies and aromatase inhibitors in particular 
were enhanced4 or restored3 with the addition of everolimus. Everolimus has been the prototypic 
agent which, in combination with aromatase inhibitors led to enhancement or restoration of 
responses to endocrine therapies in luminal breast cancer. Furthermore, its success in luminal 
breast cancer demonstrated that the strategy with the highest potential to successfully address the 
limitations of preoperative endocrine therapy is with rational combinations of novel agents 
capitalizing on the knowledge garnered in the preclinical arena. 
 
An upfront dual ER and mTOR co-targeting approach to enhance the responses of hormonal therapy 

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and/or circumvent de novo endocrine resistance62 is supported by a randomized placebo-controlled 
neoadjuvant clinical trial in postmenopausal women with ER-positive breast cancer, whereby the 
addition of everolimus to letrozole led to an increase in the clinical response rate (68.1% vs 59.1%)4. 
Although the benefit was greater in patients harboring PIK3CA mutations (especially in exon 9), 
patients with wild type PIK3CA still benefitted from the combination4. This observation suggests 
that everolimus inhibits alternative operational mechanisms of hormone resistance either within or 
outside the PI3K/AKT pathway, consistent with mTOR lying at a downstream signaling node where 
multiple pathways converge4.  
 
Two clinical trials evaluated the addition of everolimus to exemestane3 and tamoxifen63 in restoring 
resistance to hormone therapy in hormone-receptor positive, Her2 negative advanced or metastatic 
breast cancer. In both studies the clinical outcomes were significantly improved with the addition of 
everolimus. In the former study3 (which led to the approval of everolimus in postmenopausal women 
with advanced hormone receptor-positive, Her2-negative breast cancer in combination with 
exemestane after failure of treatment with letrozole or anastrozole), the addition of everolimus to 
exemestane led to a 6.5 month incremental improvement in the progression free survival (10.6 
months in the combination arm vs 4.1 months in the exemestane alone arm)3. There was however an 
increased incidence of adverse events in the combination arm with stomatitis (8% in the combination 
arm vs. 1% in the exemestane alone arm), anemia (6% vs <1%), dyspnea (4% vs. 1%), hyperglycemia 
(4% vs. <1%), fatigue (4% vs. 1%), and pneumonitis (3% vs. 0%) constituting the most frequent 
adverse events associated with the addition of everolimus3. 
 
Taken together, these clinical studies support the addition of everolimus to letrozole in 
enhancing the responses of hormonal therapy and/or circumventing de novo or acquired 
resistance to endocrine therapies.   
 
2.1.4 Rationale for incorporating anti-angiogenic therapy in the neoadjuvant setting 
 
Angiogenesis is an integral step in tumor progression24. Specifically in hormone-receptor positive 
breast cancer, enhanced angiogenesis accelerated tumor growth25, and overexpression of the 
Vascular Endothelial Growth Factor (VEGF) either by the tumor26,64 or stromal cells27 was associated 
with hormone-independent growth and resistance to endocrine therapies. An interplay between 
estrogens and angiogenic activity exists65,66 and VEGF is one of the genes whose expression is 
modulated by estrogens. Indeed, the presence of functional estrogen response elements in the VEGF 
gene67-69  underpin the transcriptional activation of VEGF by estrogens70. In mouse models of luminal 
breast cancer, overexpression of VEGF by human MCF-7 breast cancers not only enhanced estrogen 
dependent tumor growth, but also enabled estrogen independent tumor formation in vivo26. The 
stimulation of MCF-7 tumor growth by VEGF is through both a paracrine effect on tumor 
angiogenesis leading to neovascularization and an autocrine effect on tumor cell proliferation26. 
Tumor-released VEGF recruits stromal cells and promotes a desmoplastic microenvironment; 
stromal cells in turn, provide mitogenic and angiogenic growth factors stimulating both tumor and 
stromal cell growth64. Beside the breast cancer cells themselves, VEGF may be secreted by the 
activated stroma. In mouse models of xenografted ER-positive tumors, VEGF secreted by the stroma 
and acting cooperatively with other factors can substitute for estrogens and foster hormone-
independent growth of luminal tumors27. At the clinical level, in hormone-receptor positive breast 
cancer, elevated intratumoral levels of VEGF have been associated with suboptimal responses to 

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hormonal therapies and poorer clinical outcomes71-73 lending support to the hypothesis that VEGF 
and angiogenesis lie in the core of intrinsic resistance to endocrine therapies.  
 
Our studies in the UAB Breast Cancer Spore using the MCF-7 tamoxifen murine xenografts model 
by Dr. Fran Kern and collaborators indicate that paracrine effects of VEGF over-expression by ER+ 
breast cancer cells can reverse the effectiveness of tamoxifen as a cytostatic or cytotoxic agent64. In 
this MCF-7 model, they demonstrated that increased expression of VEGF causes an acquired 
Tamoxifen resistance and tumor loss of estrogen dependence in vivo.  MCF-7 cells with VEGF co-
expression (stably transfected or regulated expression) had in vitro tumor cell proliferation and 
estrogen dependence identical to non-transfected MCF-7, while MCF-7/VEGF cells in vivo 
displayed increased tumor growth rates, higher rates of metastases, and estrogen independence.  
These survival and proliferation signals may be an indirect effect of VEGF presumably reflecting the 
enhanced vascularity of tumors with secondary growth factor and signal pathway modulation.  
Reversal of VEGF over-expression in vivo returned tumors to estrogen dependent growth. 
 
Dr. Zhican Qu, Ph.D., a recipient of a career development award of the UAB-Breast SPORE in our 
group, conducted preclinical efficacy studies of tamoxifen and bevacizumab in combination for the 
treatment of breast cancer using a novel mouse model.  In her previous studies she showed that 
elevated levels of VEGF increases tumor growth, and promotes metastasis and tamoxifen resistance; 
thus, she hypothesized that a combination of agents targeting both ER and VEGF signaling may be 
a more effective treatment than the use of either drug alone.  She tested this hypothesis using a 
combination of tamoxifen and bevacizumab in a xenograft nude mouse model with regulated-VEGF 
expression.  The efficacy of the treatment was tested in two groups of mice, one with early and one 
with late stage ER-positive breast cancer.  All mice received orthotopic implantation of 107 tumor 
cells at mammary fat pat and a 17β-estradiol pellet supplement on Day 1.  Doxycycline was given to 
all mice to induce expression and secretion of VEGF from tumor cells.  Animals in the early stage 
group started therapy (tamoxifen or bevacizumab or placebo or tamoxifen-bevacizumab in 
combination) on Day 7 when the tumor size reached about 100 mm3.  The bevacizumab-tamoxifen 
combined treatment demonstrated better control of primary tumor growth than therapy with 
tamoxifen or bevacizumab alone.  The survival rate was superior in the group of mice treated with 
combination therapy compared with the groups treated with single agents or placebo.  Animals in the 
late stage group started therapy on Day 32 when the tumor size reached about 1000 mm3.  The 
combined treatment showed again a better reduction of tumor growth rate and a significant better 
survival.  83% of mice survived in the combined treatment group, while only about 50% of mice 
survived in the monotherapy groups.  These results demonstrated that the Avastin-tamoxifen 
combination is more effective on inhibiting tumor growth of ER positive breast cancer and increasing 
survival rate than either drug treatment alone (2005 AACR Annual Meeting, abstract #1091).   
 
 

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2.1.5 Background: Clinical studies with antiangiogenic agents in HR positive breast cancer 
 
These preclinical studies that support the role of angiogenesis in hormone-independent growth of 
luminal breast cancer set the stage for a pilot, single-institution (UAB) study of preoperative letrozole 
in combination with bevacizumab (a monoclonal antibody targeting VEGF, the prototypic 
proangiogenic factor and a crucial regulator of both normal and pathologic angiogenesis74) in 
postmenopausal women with hormone-receptor positive breast cancer2. In our study (n=25), 
preoperative letrozole and bevacizumab for 24 weeks resulted in a pCR rate of 12% (n=3), while the 
overall objective response rate was 68% (n=17). Additionally, 4% (n=1) achieved pCR in the breast 
but not in the lymph nodes and the rate of stage 0/1 attainment was 32%2. The treatment was overall 
well tolerated with a rate of discontinuation due to adverse events of 8% (n=2). With a median follow-
up of 55 months and 2 responders lost to follow up, none of the other 15 patients with objective 
response have relapsed. So far, 2 patients experienced a recurrence despite postoperative 
chemotherapy and hormonal therapy; these patients had achieved stable (SD) and progressive (PD) 
disease, respectively as their best response while on the investigational preoperative regimen. Our 
results are consistent with the concept that downstaging to at least pathologic stage 1 is equally 
important as achievement of a pCR and it has been associated with an extremely low risk of 
recurrence15. 
 
We conducted a separate, independent randomized open-label phase II study was conducted by the 
Translational Breast Cancer Research Consortium (TBCRC) comparing preoperative letrozole with 
or without bevacizumab in postmenopausal women with operable hormone receptor positive breast 
cancer1 (trial TBCRC002). The study showed that bevacizumab “deepened” the responses obtained 
with letrozole alone (figure B). Downstaging from stage 2/3 to 0/1 was achieved in 45% of patients 
in the letrozole-bevacizumab arm as compared to 25% in the letrozole-alone group. Remarkably, the 
combination induced a pCR in 11.1% of patients1, comparable to the 12% pCR rate reported in a 
prior pilot single-institution study2; no complete or near-complete remissions were observed in the 
letrozole-alone group. Of note, the addition of everolimus to letrozole has not led to such a high pCR 
rate: of the 246 patients who received letrozole +/- everolimus preoperatively for 4 months with 
available surgical excision specimens, only 3 achieved a pCR (2 in the combination arm versus 1 in 
the letrozole alone arm)4.  
 

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Figure B. Results of the TBCRC002 study. Waterfall plots of the pathologic responses 
(comparison of the tumor as assessed by imaging at the time of enrollment and tumor size at 
the time of surgery) achieved in the 2 arms (upper panel). Comparison between the pathologic 
responses in the letrozole arm and letrozole + bevacizumab arm (lower left panel). The table 
indicates the median and mean pathologic response between groups and the 95% confidence 
interval (CI) of the mean. 
 
Our study sets a successful clinical precedence of rationally combining an antiangiogenic agent 
with an aromatase inhibitor in postmenopausal women with hormone receptor-positive and 
Her2 negative breast cancer; this combination not only enhanced the response rate but even 
led to an unprecedented pCR rate in an intrinsic subgroup where pCRs are rarely seen.   
 
2.1.6 Rationale for targeting endoglin in cancer therapeutics 
 
Endoglin (CD105) is essential for normal vascular development75, and heterozygous expression of 
endoglin is associated with hereditary hemorrhagic telangiectasia type 1 (HHT-1,Rendu–Osler–
Webber syndrome), a human disease characterized by ectatic blood vessel formation76. In adults, 
endoglin is a marker of activated angiogenesis that is predominantly or exclusively expressed in de 
novo tumor vessels32,33, as opposed to the minimal expression in the normal quiescent endothelium 
which has a very low turnover28. Endoglin is a transmembrane accessory receptor for transforming 
growth factor-beta (TGF-β) receptor (TGF-βR) and diverts TGF-β downstream signaling toward 
proliferation and migration as well as transcription of proangiogenic genes including endoglin 
itself29-31. As TGF-β signaling can mediate diverse and opposing processes in endothelial cells, 
endoglin inhibits TGF-β-mediated endothelial quiescence (figure C 77,78). Indeed, in the absence of 
endoglin, TGF-β mediated endothelial cell quiescence is significantly enhanced28,79. The clinical 
implications of this observation is that targeting endoglin will selectively inhibit tumor 
angiogenesis and at levels below baseline.  
 

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Figure C. Interactions of endoglin with TGF-βR. Endoglin is a transmembrane 
accessory receptor for TGF-βR and diverts TGF-β downstream signaling toward 
proliferation, migration, and transcription of proangiogenic genes including endoglin, 
while in its absence, TGF-βR signaling mediates endothelial quiescence. 
 
In line with the premise that enhanced tumor vasculature correlates with adverse prognosis and the 
fact that endoglin is a marker of activated angiogenic endothelium, endoglin expression has been 
consistently associated with adverse clinical outcomes across multiple malignancies31. VEGF 
inhibition leads to reactive upregulation of endoglin7 and large established CD105(+) vessels lying 
in the core of the tumors have been shown to be insensitive to VEGF inhibitors8. In those studies, 
CD105 expression was increased following inhibition of the VEGF pathway. CD105 expression 
increased more than two-fold in human pancreatic cancers grown in mice treated with an antibody 
that binds VEGF7. Similarly, treatment of human bladder cancers grown in mice with an antibody 
that blocks activation of the VEGF receptor increased CD105 expression within the core tumor 
vasculature8. Finally, a study of spontaneously occurring neuroendocrine tumors in RIP-Tag2 mice 
treated with antibody to VEGF indicated that TGF- β was the most highly upregulated factor, as 
determined by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR)47. Taken 
together, these studies indicate that the CD105 pathway is a significant mechanism of escape from 
VEGF inhibitor therapy. 
 
Endoglin is extensively expressed in breast cancer80 and increased endoglin expression at baseline 
has been associated with poorer responses to neoadjuvant treatment81. In preclinical murine xenograft 
models of HR(+) breast cancer, anti-endoglin monoclonal antibodies inhibited selectively tumor 
angiogenesis and delayed the growth of established tumors, while sparing normal vasculature34. Of 
note, in these preclinical “proof-of-concept” studies, the antitumor efficacy of the monoclonal 
antibody may have been obscured by the fact that almost 60% of the malignant vasculature was 
murine to which the human investigational antibody had little affinity34. Collectively, endoglin is a 
rational target of tumor angiogenesis as it is exclusively expressed in the activated endothelium 
and plays a central pathophysiologic role in promoting angiogenesis. 
 
Endoglin is cleaved near the plasma membrane by membrane-anchored matrix metalloproteinase 

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(MMP)-14 to release a soluble form of endoglin (sEng) into the circulation82. Although membrane-
bound endoglin promotes angiogenesis, sEng antagonizes this process82 through multiple 
mechanisms including cell surface receptor downregulation and ligand sequestration83,84. The 
mechanism by which the novel monoclonal antibody intended to be used in the proposed study 
(TRC105) exerts its antiangiogenic effect is not clear in its details; however one of the proposed 
mechanisms involves enhanced endoglin shedding by stabilizing preformed endoglin/MMP-14 
complexes83. Indeed, results from the phase I trial reveal that there is a dramatic dose-dependent 
increase in sEng levels in patients treated with TRC10583. Enhanced shedding not only reduces the 
overall cell surface level of endoglin, but also the resulting product (sEng) exerts an antiangiogenic 
effect by itself83. 
 
2.1.7 Clinical studies with TRC105 
 
TRC105 was administered to 50 patients with solid tumors in the context of a phase 1 first-in-human 
dose escalation study following a 3+3 design35. The maximum tolerated dose was determined at 10 
mg/kg weekly; 15 mg/kg every two weeks was equally well tolerated and also resulted in continuous 
serum concentrations known to saturate CD105 binding sites on proliferating endothelium. 
Hypoproliferative anemia was the dose-limiting toxicity: above the maximum tolerated dose, at 15 
mg/kg weekly, all 3 patients that remained on study through cycle 2 developed dose-limiting grade 
3 anemia, and one of the three progressed to grade 4 anemia by cycle 3. Infusion reactions, including 
some that were serious, were observed following TRC105 administration, usually with the initial 
dose. Other adverse events most commonly observed with TRC105, either alone or in combination, 
include fatigue, mucocutaneous telangiectasia resulting in epistaxis and gingival bleeding, flushing, 
and headache. Classic toxicities associated with VEGF inhibition, including hypertension, 
proteinuria, and thrombosis, have been seen in isolation. In fact, 3 clinical trials combining TRC105 
with bevacizumab are currently ongoing (NCT01564914, NCT01648348, and NCT01332721). 
Multiple other phase Ib and phase II studies of TRC105 in combination with chemotherapy, with 
VEGF inhibitors, and as a single agent in patients with advanced prostate, sarcoma, renal cell 
carcinoma, choriocarcinoma, glioblastoma multiforme, and hepatocellular cancer are currently 
ongoing35,85. 
 
Collectively, TRC105 allows for the rational therapeutic targeting of malignant angiogenesis 
while sparing the cardiovascular toxicities of most contemporaneous antiangiogenic agents to 
which postmenopausal women with preexistent conditions may be particularly predisposed. 
 
Although the completed clinical trials with TRC105 were not designed to assess efficacy, several 
patients benefitted from the investigational drug. In the phase I study where TRC105 was 
administered as a single agent in patients with advanced metastatic malignancies and having received 
a median of 4 prior lines of therapy, 6/44 patients remained progression-free for longer than 4 
months35. 
 
2.1.8 Synergism between TRC105 and everolimus 
 
In animal models, mTOR inhibition was shown to reduce the levels of VEGF and downregulate 
significantly the response of endothelial cells to stimulation by VEGF45. mTOR signaling was also 
shown to play a key role in hypoxia-triggered smooth muscle and endothelial cell proliferation and 

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angiogenesis in vitro; this response (triggered by growth factors other than VEGF) was abrogated 
with mTOR inhibition46. On the other hand, VEGF inhibition leads to reactive upregulation of 
endoglin7 and large established CD105(+) vessels lying in the core of the tumors have been shown 
to be insensitive to VEGF inhibitors8. Other preclinical studies have also demonstrated that 
endoglin/CD105 represents a principal escape pathway from VEGF inhibition7,47. Collectively, 
mTOR inhibition with anti-CD105 targeted therapy is anticipated to represent a more inclusive 
antiangiogenic approach as opposed to anti-VEGF therapy alone as it inhibits signaling from 
alternative proangiogenic factors and targets malignant angiogenesis with inherent 
(preexistent CD105 expression) or acquired (reactive CD105 upregulation) resistance to VEGF 
inhibition. 
 
2.1.9 Duration of neoadjuvant treatment 
 
Most studies that prospectively evaluated preoperative hormonal therapy have limited the duration 
of treatment to 3-4 months14,15,19-21,23. Several studies however, suggest that extending neoadjuvant 
hormonal therapy beyond 3-4 months is safe and associated with further and sustained reductions in 
the tumor size leading to a higher proportion of breast conserving surgeries14,86,87. Indeed, in a 
prospective phase II clinical trial with preoperative letrozole treatment to maximum response, the 
mean time to first response was 3.9 months while the median time to maximum response was 4.2 
months87. It is noteworthy that approximately one third of the responders achieved maximum 
response beyond 6 months; however, very few responders were identified after 6 months and none 
from 8 to 12 months. The overall clinical response rate with preoperative letrozole was 76.8%87. 
Similarly, in a retrospective study of 182 patients treated preoperatively with letrozole, the rate of 
clinical complete or partial response rose from 69.8% at 3 months to 83.5% by extending letrozole 
treatment up to 24 months86. Moreover, continuing letrozole beyond 3 months increased the number 
of women who initially required mastectomy or had locally advanced breast cancer and subsequently 
became suitable for breast conserving surgery from 60% at 3 months to 72%86.  
 
Taken together, neoadjuvant endocrine therapy requires longer time to achieve responses as 
compared to cytotoxic chemotherapy. The majority of responders can be identified within the first 4 
months of treatment; however, some patients require longer durations of treatment to achieve their 
maximum response14. In luminal breast cancer, such sustained and increased reductions in the tumor 
size are associated with better long-term clinical outcomes.  
 
2.1.10 Rationale for ovarian suppression with gonadotropin-releasing hormone analogs in 
premenopausal women.  
 
The IMPACT trial (Immediate Preoperative Anastrozole, Tamoxifen or Combined with Tamoxifen) 
established the superiority of aromatase inhibition over tamoxifen or tamoxifen + aromatase 
inhibition in the preoperative setting.  Although the overall clinical response rate was not 
significantly different between the 3 arms, more patients classified as requiring mastectomy were 
eligible for breast conserving surgery on the anastrozole treatment arm48 . In addition, suppression 
of the proliferation marker Ki67 (which in itself has been shown to be predictive of favorable 
outcome) was statistically greater with anastrozole as compared with tamoxifen or the combination 
49. Aromarase inhibitors in premenopausal women are contraindicated as they may increase 
gonadotropin secretion because of the reduced feedback of estrogen to the hypothalamus and 

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pituitary50. To that end, in order for premenopausal women to benefit from aromatase inhibition, they 
should become postmenopausal through ovarian suppression with gonadotropin-releasing hormone 
analogs. Furthermore, ovarian suppression in combination with aromatase inhibition has been shown 
to be superior over tamoxifen in the adjuvant setting in premenopausal women 88 For this clinical 
trial goserelin subcutaneously q 4 weeks will be used to suppress ovarian function.  
 
 
2.2  Correlative Studies Background 
 
2.2.1  PI3K/AKT/mTOR pathway in breast cancer 
 
As outlined in section 2.1.2 and 2.1.3, the PI3K/AKT/mTOR pathway can be activated by various 
genetic aberrations at multiple nodes along the pathway leading to resistance to or evasion from 
hormone blockade. Loss of PTEN increases PI3K activity and increased phosphorylation, activation, 
or membrane translocation of signal transducers downstream of the PI3K including Akt, mTOR, S6 
kinase, and 4-EBP-189. Immunohistochemistry for the phosphorylated AKT (pAKT) is a surrogate 
for activation of the PI3K/AKT/mTOR pathway irrespective of the underlying genetic aberration; 
activating point mutations of signal transducers along the pathway can be captured by whole-exome 
sequencing.  
 
2.2.2         Regulation of gene expression at the translational level 
 
Over the recent years, significant progress has been made in understanding the mechanisms of 
transcriptional (DNA to RNA) regulation; however, little is known about the regulation of gene 
expression at the translational (mRNA to protein) level. Comprehensive analyses have shown that 
while mRNA and respective protein levels may correlate better than previously thought (still only at 
the level of R2=0.41), the abundance of a protein in a cell is predominantly determined at the level 
of translation90,91. Moreover, changes in translation have been shown to precede and be considerably 
more dramatic than changes in transcription in response to growth factor signaling modulation92. 
While mass spectrometry allows us to investigate translation at the protein level, it has its limitations 
(limitations in quantitation, incomplete and biased coverage93) and small changes in the expression 
of critical genes that cast a large shadow at multiple cellular levels may be missed. The advent of 
ribosomal profiling94-100 (deep sequencing of the ribosome protected mRNA fragments in parallel 
with mRNA-sequencing) harnesses the comprehensive and unbiased nature of massively parallel 
deep sequencing to provide a global genomic view of ribosome occupancy across the entire exome 
and is a good proxy of active protein production. There is a strong rationale in investigating 
ribosome occupancy across the exome as genes exert their functions by the protein products 
they encode. Ribosomal profiling provides “snapshots” of which mRNAs are being actively 
translated and how efficiently. It serves as a proxy of protein synthesis and currently, no other 
technology can capture which mRNAs are being actively translated as close as ribosomal profiling. 
Which mRNAs are actively translated and at what efficiency is a layer of complexity in gene 
expression which has not be captured in the currently completed comprehensive genomic analyses 
in breast cancer. 
 
3. PATIENT SELECTION 
 

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3.1  
Study Population 
 
Patients with newly diagnosed, potentially resectable (stage 2 or 3), local or locally advanced 
estrogen and/or progesterone receptor positive and HER2/neu negative breast cancer will be 
enrolled in this study 
 
3.2  
Eligibility Criteria  
 
Patients must have baseline evaluations performed prior to the first dose of study drug and must meet 
all inclusion and exclusion criteria. Results of all baseline evaluations, which assure that all inclusion 
and exclusion criteria have been satisfied must be reviewed by the Principal Investigator or his/her 
designee prior to enrollment of that patient. In addition, the patient must be thoroughly informed 
about all aspects of the study, including the study visit schedule and required evaluations and all 
regulatory requirements for informed consent. The written informed consent must be obtained from 
the patient prior to enrollment. The following criteria apply to all patients enrolled onto the study 
unless otherwise specified. 
 
3.2.1   Newly diagnosed, histologically confirmed breast cancer. 
 
 
3.2.2  hormone receptor positive and HER2 negative breast cancer 12,58; patients with Her2/neu 
positive tumors irrespective of their hormone receptor status will be excluded. At least 10% of tumor 
cell nuclei should be immunoreactive for hormone receptors (ER and/or PR) to be deemed eligible 
for the study101. Her2/neu negative is defined as102: 
 
a. Immunohistochemistry (IHC) score of 0 (no staining is observed or membrane staining that is 
incomplete and is faint/barely perceptible and within ≤ 10% of tumor cells) OR 
b. IHC score of 1 (incomplete membrane staining that is faint/barely perceptible and within <10% 
of tumor cells) OR 
c. Fluorescence in situ hybridization (FISH) HER2/CEP17 ratio of <1.8 or average HER2 gene 
copy number of <4 signals/nucleus for test systems without an internal control probe. 
d. Equivocal results for Her2/neu (defined as: IHC 2+ or FISH HER2/CEP17 ratio of 1.8-2.2 or 
average HER2 gene copy number 4-6 HER2 signals/nucleus for test systems without an internal 
control probe) should prompt reflex test (same specimen using an alternative method) or order a 
new test (new specimen if available, using IHC or FISH).  
 
3.2.3   Histological grade I,  II or III according to the modified Bloom Richardson scale52. 
 
3.2.4   Stage at diagnosis T2 through T4a-c, N0 through N2, and M0. Patients with inflammatory 
breast cancer or metastatic disease at diagnosis will be excluded. Patients with multicentric, 
multifocal, and/or bilateral disease are allowed to participate so long as all tumors meet the 
histologic criteria of the study. 
 
3.2.5    Determined menopausal status. Postmenopausal status is defined according to the National 
Comprehensive Cancer Network103 
  

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a. age >60 years old OR 
b. prior bilateral oophorectomy regardless of age 
c. if patient <60 years old and amenorrheic for >12 months in the absence of ovarian 
suppression, FSH and estradiol have to be in the postmenopausal range 
 
women who do not meet these criteria will be determined as non-postmenopausal and will 
require goserelin subcutaneously q 4 weeks to achieve ovarian suppression.  
 
3.2.6   No prior treatment with therapeutic intent for breast cancer.  
 
3.2.7   No life threatening parenchymal disease or rapidly progressing disease warranting cytotoxic 
chemotherapy. 
 
3.2.8   Patients must have disease that can be measured and followed by mammogram and/or breast 
ultrasound (in special cases a dedicated breast MRI may be clinically indicated). The target lesion 
must not have been previously irradiated. 
 
3.2.9 Resectable/Operable or potentially resectable/operable breast cancer as determined by the 
treating surgical oncologist. 
 
3.2.10  ECOG performance status <2 (Karnofsky >60%, see Appendix A) 
 
3.2.11  Life expectancy of greater than 6 months 
 
3.2.12 Patients must have normal organ and marrow function as defined below: 
 
- 
leukocytes  
 
>3,000/mcL 
-  absolute neutrophil count 
>1,500/mcL 
-  hemoglobin 
 
>10 gr/dL 
- 
platelets 
 
 
>100,000/mcL 
 
-     total bilirubin  
<2 X institutional ULN (except for known                 
Gilbert’s syndrome/familial non-hemolytic 
jaundice) 
             
- 
AST(SGOT)/ALT(SGPT) 
<2.5 X institutional upper limit of normal 
- 
creatinine  
 
Up to 1.5 UNL, or 
 
-  creatinine clearance                                       >40 mL/min/1.73 m2 for patients with  
 
 
  
 
 
 
creatinine levels above institutional normal 
-  INR 
 
 
< 2 
 
 
 
 
 
 
 
 
 
 
 
 
  
3.2.13  Fasting serum cholesterol ≤300 mg/dL OR ≤7.75 mmol/L AND fasting triglycerides ≤2.5x 
ULN. NOTE: In case one or both of these thresholds are exceeded, the patient can only be included 
after initiation of appropriate lipid lowering medication; 
 
3.2.14  Age >19 years.  Because no dosing or adverse event data are currently available on the use 
of TRC105 in patients <18 years of age85, children are excluded from this study. 
 

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3.2.15 No bleeding from gastrointestinal ulcers or other sites of bleeding. 
 
3.2.16 Ability to understand and willingness to sign a written informed consent document. 
 
3.2.17 Signed informed consent obtained prior to any screening procedures. 
 
3.3  
Exclusion Criteria 
 
3.3.1 Patients currently receiving anticancer therapies or who have received anticancer therapies 
within 4 weeks of the start of the investigational therapy (including chemotherapy, radiation 
therapy, antibody based therapy).  
 
3.3.2     Her2/neu positive102 or estrogen and progesterone receptor negative101 breast cancer. 
Patients with triple-negative breast cancer are also excluded.  
 
3.3.3     Metastatic breast cancer.  
3.3.4 Inflammatory (T4d) breast cancer. 
 
3.3.5 Patients may not be receiving any other investigational agents. If patients are currently part 
of or have participated in any clinical investigation with an investigational drug, the last 
administration of the investigational study should be at least 1 month prior to dosing. 
 
3.3.6  Inoperable breast cancer even after neoadjuvant treatment as assessed by the treating 
surgical oncologist. 
 
3.3.7  Undetermined or unknown menopausal status.  
 
3.3.8 Disease that cannot be measured and/or accurately followed by mammogram and/or breast 
ultrasound and/or dedicated breast MRI.  
 
3.3.9  Target lesion that has been previously irradiated. 
 
3.3.10 History of allergic reactions, intolerance or hypersensitivity attributed to compounds of 
similar chemical or biologic composition to TRC105 and/or everolimus or other rapamycin analogs 
(e.g. sirolimus, temsirolimus).  
 
3.3.11   Known impairment of gastrointestinal (GI) function or GI disease that may significantly alter 
the absorption of oral Everolimus 
 
3.3.12 Patients must have normal organ and marrow function. Patients with any of the following 
abnormal parameters will be excluded: 
 
- 
leukocytes 
<3,000/mcL 
- 
absolute neutrophil count 
<1,500/mcL 
-  hemoglobin 
<10 gr/dL 
- 
platelets  
<100,000/mcL 

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- 
total bilirubin 
>2 X institutional ULN (except for known                     
Gilbert’s syndrome/familial non-hemolytic 
jaundice)              
- 
AST(SGOT)/ALT(SGPT) 
>2.5 X institutional upper limit of normal 
- 
creatinine  
> 1.5 UNL, or 
- 
creatinine clearance 
<40 mL/min/1.73 m2 for patients with 
creatinine levels above institutional normal. 
-    INR 
 
 
≥2 
 
3.3.13 Uncontrolled diabetes mellitus as defined by HbA1c >8% despite adequate therapy. Patients 
with a known history of impaired fasting glucose or diabetes mellitus (DM) may be included, 
however blood glucose and antidiabetic treatment must be monitored closely throughout the trial and 
adjusted as necessary. 
 
3.3.14  Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric 
illness/social situations that would limit compliance with study requirements. Examples of 
uncontrolled medical conditions include:  
 
a. Unstable angina pectoris, symptomatic congestive heart failure, myocardial infarction ≤ 6 
months prior to start of Everolimus, serious uncontrolled cardiac arrhythmia, or any other 
clinically significant cardiac disease 
b. Symptomatic congestive heart failure of New York Heart Association Class III or IV 
c. Active (acute or chronic) or uncontrolled severe infection, liver disease such as cirrhosis, 
decompensated liver disease, and active and chronic hepatitis (i.e. quantifiable HBV-DNA 
and/or positive HbsAg, quantifiable HCV-RNA), 
d. Known severely impaired lung function (spirometry and DLCO 50% or less of normal and 
O2 saturation 88% or less at rest on room air), 
e. Active, bleeding diathesis. 
 
3.3.15  Chronic treatment with corticosteroids or other immunosuppressive agents. Topical or inhaled 
corticosteroids are allowed. 
 
3.3.16 Patients who have received live attenuated vaccines within 1 week of start of Everolimus and 
during the study. Patient should also avoid close contact with others who have received live 
attenuated vaccines. Examples of live attenuated vaccines include intranasal influenza, measles, 
mumps, rubella, oral polio, BCG, yellow fever, varicella and TY21a typhoid vaccines 
 
3.3.17 ECOG performance status >2 (Karnofsky <60%, see Appendix A) 
 
3.3.18  Pregnancy. Women of child-bearing potential, defined as all women physiologically capable 
of becoming pregnant, (including female pediatric patients who are menarcheal or who become 
menarcheal during the treatment) must use highly effective contraception during the study and for 8 
weeks after stopping treatment. Highly effective contraception is defined as either: 

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• 
Total abstinence: When this is in line with the preferred and usual lifestyle of the subject. 
[Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and 
withdrawal are not acceptable methods of contraception] 
• 
Female Sterilization: have had surgical bilateral oophorectomy (with or without hysterectomy), 
total hysterectomy or tubal ligation at least six weeks before taking study treatment. In case of 
oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow 
up hormone level assessment 
• 
Male partner sterilization: The vasectomized male partner should be the sole partner for that 
subject with the appropriate post-vasectomy documentation of the absence of sperm in the ejaculate.  
• 
Use of oral, injected or implanted hormonal methods of contraception or placement of an 
intrauterine device (IUD) or intrauterine system (IUS) or other forms of hormonal contraception that 
have comparable efficacy (failure rate <1%), for example, hormone vaginal ring or transdermal 
hormone contraception. In case of use of oral contraception women should have been stable on the 
oral agent for a minimum of 3 months before taking everolimus 
 
3.3.19  Known history of HIV seropositivity 
 
3.3.20 Need for concurrent treatment with medications that strongly interact with everolimus 
(CYP3A4 inducers or inhibitors, see Appendix B).   
 
3.3.21 History of another malignancy within the last five years except non-melanoma skin cancer, 
carcinoma in–situ of uterine cervix, uteri, and breast from which the patient has been disease free for 
at least 3 years.  Second primary breast cancers are allowed regardless of the number of years since 
they were first diagnosed.  
 
3.3.22  Major surgical procedure, open biopsy, or significant traumatic injury within 28 days prior to 
Day 0, anticipation of need for major surgical procedure during the course of the study. As an 
example, port placement or core biopsies are not considered major surgical procedures.   
 
3.4 Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this trial. 
Minority patients are particularly encouraged to participate. 
 
3.5  
Subjects Who Fail to Meet the Eligibility Criteria 
 
A subject may fail to meet entrance criteria because of an abnormal laboratory value, vital sign(s), 
or concurrent medications with strong interactions with the investigational combination. The 
abnormal screening test(s) may be repeated as soon as the investigator anticipates that it will be 
within acceptable range to meet eligibility criteria, but must be completed within the 4-week 
screening phase. Rescreening can be performed only once and the subject is not required to sign a 
new informed consent form. 
 
If the rescreening test(s) cannot be performed within the 4-week screening phase or return abnormal 
not meeting the entrance criteria, or the medical condition of the subject deteriorates so that she no 

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longer meets the eligibility criteria, the subject will be deemed a screen failure and withdrawn from 
the study. 
 
4. STUDY DESIGN 
 
The principal investigator will hold the IND for the trial (Appendix F).  This is a single-institution open-
label phase I/II study of preoperative treatment with the combination of letrozole, everolimus, and 
TRC105 in postmenopausal women with newly diagnosed potentially resectable local or locally 
advanced (T2-T4a-c, N0-2, M0; excluding patients with T4d or inflammatory breast cancer) estrogen 
and/or progesterone receptor positive, Her2/neu negative breast cancer. Accrual will be halted as a 
result of any grade ≥3 hemorrhage, cerebrovascular and vasovagal adverse events; FDA will be 
contacted to discuss further accrual or potential need for protocol amendment. Premenopausal 
women at the time of study enrollment will receive goserelin 3.6 mg subcutaneously q 4 weeks to 
achieve ovarian suppression. The study consists of 2 parts: a phase I and a phase II part (figure D). 
 
Figure D. Study design. 
 
 
 
4.1  Phase I, dose escalation 
  
The first part of the study will follow the conventional 3+3 dose escalation design. Up to 18 patients 
will be enrolled. During the first part (phase I, dose escalation), the Maximum Tolerated Dose 
(MTD) of the combination in terms of safety will be determined. The dose of letrozole will be kept 
the same for all cohorts (2.5 mg PO daily) (Table 4-1). The dose of everolimus will be escalated 
from 5 mg PO daily (cohort 1) to 10 mg PO daily (cohort 2). The dose of everolimus will be de-
escalated to 5 mg PO daily (cohort 1) if the dose of 10 mg PO daily is not well tolerated. The dose 
of TRC105 will be 15 mg/kg q 2 weeks (cohorts 1 and 2). The dose of TRC105 will be de-escalated 
to 10 mg/kg q 2 weeks (cohort -1) if 15 mg/kg q 2 weeks is not well tolerated. All doses that will be 
used in this trial have shown to be safe and active in clinical trials. Premenopausal women at the time 

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of study enrollment will receive goserelin 3.6 mg subcutaneously q 4 weeks to achieve ovarian 
suppression. 
 
Table 4-1. Cohorts and dose escalations of the phase I part of the study 
 
Cohort 
TRC105 (mg/kg IV q 2 weeks) 
Everolimus (mg PO daily) 
1 
15 
5 
2 
15 
10 
-1 
10 
5 
 
4.1.1 Definition of a Dose Limiting Toxicity (DLT) 
 
A dose-limiting toxicity (DLT) is defined as: 
 
a)  Any grade 3 or 4 non-hematologic toxicity except anorexia, alopecia, nausea (which is not 
refractory to antiemetics), fatigue, fever without neutropenia;  
b)  Failure to recover to baseline (except alopecia) after delaying the next dose by more than 14 
days;  
c)  Grade 3 or 4 neutropenia complicated by fever >38.5°C or infection, or grade 4 neutropenia of 
≥7 days duration; or  
 
d)  Grade 4 thrombocytopenia, or grade 3 thrombocytopenia complicated by hemorrhage. 
In addition, accrual will be halted as a result of any grade ≥3 hemorrhage, cerebrovascular and 
vasovagal adverse events; FDA will be contacted to discuss further accrual or potential need for 
protocol amendment. 
 
4.1.2    Dose escalation rule: 
 
Dose escalation will follow the decision rules shown in table 4-2. 
 
Table 4-2. Dose escalation rules 
 
Number of Patients with DLT at a 
Given Dose Level 
Escalation Decision Rule 
0 out of 3 
Enter 3 patients at the next dose level. 
1 out of 3 
Enter 3 additional patients in the same dose level (for a 
total of 6 patients at this dose level). 
If 0 of the 3 additional patients experience DLT, then 
proceed to the next dose level. 
If 1 or more of these additional patients experience DLT 
(i.e., ≥ 2 of 6 total patients), dose escalation will be 

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stopped. 
>2 out 3 
Dose escalation will be stopped.   
If  MTD not reached 
Cohort 2 will be selected for RP2D 
 
4.1.3   Definition of Maximum Tolerated Dose (MTD) 
 
The maximum tolerated dose (MTD) is defined as the highest dose at which 0 out of first 3 or 1 out 
of total of 6 patients experience DLT during the first cycle of therapy; this dose level will be 
recommended as RP2D in the second portion of the study.  If accrual to cohort 2 (highest dose of 
both everolimus and TRC105) is completed without reaching the MTD, this dose will be selected as 
the RP2D. In every cohort, patients withdrawn without receiving study treatment will be replaced, 
as will patients withdrawn before completing the first cycle of treatment for any reason other than 
DLT.   
 
4.2 Phase II, expansion phase 
 
The second part of the study (phase II, expansion phase), will ensue once the MTD and RP2D have 
been determined.  The objectives of the dose expansion phase is to estimate the rate of complete 
pathologic remission (pCR) or downstaging in addition to continue evaluation of the safety. In order 
to minimize exposure of patients to ineffective therapy, Gehan’s two-stage design will be used51.  
The study will enroll 10 patients first, and if no patient has pCR or downstaging, the study will close 
on the basis that it is unlikely (p=0.1074) that 0/10 responses would occur if the true response rate 
were >20%. If at least one patient has pCR or downstaging, an additional 10 patients will be treated 
(total of 20). For patients enrolled in Phase II, dose of everolimus can be de-escalated down to 2.5mg 
if needed. No further de-escalation is allowed. If 2.5mg not tolerated then the patient will be removed 
from study. 
 
4.3    Study accrual and treatment considerations 
 
It is anticipated that 26 – 38 patients will be enrolled in the study and accrual is expected to be 
completed in 24 months (see Section 10. STATISTICAL CONSIDERATIONS). Patients meeting 
the eligibility criteria and who have signed the consent form will start Letrozole 2.5 mg PO daily, 
Everolimus 5 or 10 mg PO daily, and TRC105 15 or 10 mg/kg IV every two weeks with the first 
infusion administered in 2 split doses on days 1 (3 mg/kg) and 4 (12 mg/kg or 7 mg/kg), respectively.  
Premenopausal women at the time of study enrollment will receive goserelin 3.6 mg subcutaneously 
q 4 weeks to achieve ovarian suppression. A cycle is defined as 4 weeks of treatment. Breast 
ultrasound, will be conducted upon completion of each cycle to complement clinical assessments of 
the size of the tumor(s). The duration of neoadjuvant therapy is 24 weeks or 6 cycles. No extensions 
of the neoadjuvant therapy beyond 6 months are allowed. After neoadjuvant therapy, patients will 
undergo surgical treatment and will receive adjuvant therapy (radiation therapy, chemotherapy, 
hormonal therapy) according to the standard of care or at the discretion of the treating physician.  The 
accrual rate is projected to be approximately 1-2 patients per month. Accrual will be halted as a result 
of any grade ≥3 hemorrhage, cerebrovascular and vasovagal adverse events; FDA will be contacted 
to discuss further accrual or potential need for protocol amendment. 

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4.4    Rationale for the Study Doses and Design 
 
The safety and efficacy of letrozole and everolimus for 4 months in the preoperative setting have 
been well established4, allowing the use of these agents in combination at their approved therapeutic 
doses. Nonetheless, the addition of everolimus at 10 mg PO daily was associated with an increase in 
the adverse events of any grade4 suggesting that extension of treatment to 6 months without dose 
reductions, delays, or interruptions may not be possible. To that end, a dose of everolimus at 5 mg 
PO daily is selected for cohort 1.  
 
The addition of an antiangiogenic agent with a non-overlapping pharmacokinetic and toxicity profile 
is anticipated to increase the proportion as well as the magnitude of responses achieved without a 
significant increment in the rate of adverse events. However, TRC105 has not been administered in 
combination with letrozole and everolimus before. To that end, the phase I portion of the study is 
designed to determine the MTD and RP2D. Because of a concern that a dose of 10 mg/kg every two 
weeks will not allow for continuous serum levels of TRC105 placing patients at risk for infusion 
reactions each time they receive TRC105, the starting dose for the latter was selected at 15 mg/kg q 
2 weeks. Provisions are made for a cohort -1 with a dose of TRC105 of 10 mg/kg in case the dose of 
15 mg/kg is not well tolerated. 
 
Preoperative treatment with an aromatase inhibitor has been shown to be superior over tamoxifen48. 
Premenopausal women cannot receive aromatase inhibitors50 and in order to benefit from the latter 
they should become postmenopausal. GnRH analogs can safely achieve ovarian suppression and in 
fact ovarian suppression in combination with an aromatase inhibitor has been shown already to be 
superior to tamoxifen in the adjuvant setting88. 
 
The primary objective of the study is to establish the safety and tolerability of combining everolimus 
and TRC105 with letrozole in the preoperative setting for 24 weeks. During the phase II part of the 
study we will continue to evaluate the safety and tolerability of the investigational combination as 
well as collect preliminary data about the activity of the regimen.  
 
4.5     Rationale for the Preoperative Setting 
 
The preoperative setting is increasingly utilized in the evaluation and development of novel 
investigational therapies that can potentially provide meaningful clinical benefits over the current 
standard of care in breast cancer104. Although the long term outcomes with adjuvant and neoadjuvant 
therapy may be similar, the most pertinent advantages of neoadjuvant therapy are summarized as 
follows: 
 
a. Neoadjuvant therapy allows for the clinical and radiographic evaluation of a regimen real-
time. In doing so, an ineffective therapy can be promptly discontinued sparing toxicities and 
time. 
b. The neoadjuvant setting allows for the evaluation of tumor tissue biomarkers predictive of 
response from the time of biopsy to the time of definitive breast surgery.  
c. The neoadjuvant setting allows for the utilization of endpoints that are indicative of clinical 
benefit and can be readily assessed (rates of pCR and downstaging) as opposed to endpoints 

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such as progression-free and overall survival which require considerably longer duration of 
follow-ups for their definitive assessment. 
d. Preoperative treatments permit breast conserving surgeries in patients who would otherwise 
require mastectomy (ies) and, therefore, may be more acceptable among patients potentially 
eligible for the proposed study.  
 
4.6      Rationale for the Drug Combination 
 
The proposed combination relies on preclinical evidence that has placed aberrant angiogenesis in the 
core of resistance to endocrine therapies and has elucidated the pathways that are operational in 
luminal breast cancer and can mitigate or completely abrogate the effect of aromatase inhibitors (see 
section 2. Background).  
 
In the clinical arena, the concept of targeting angiogenesis in the preoperative setting in luminal 
breast cancer was successfully translated into 2 independent clinical trials: a single-institution pilot 
study2 and a randomized, open-label phase 2 study conducted by the Translational Breast Cancer 
Research Consortium (TBCRC). In both studies, antiangiogenic therapies have been shown to 
significantly enhance the antitumor response to endocrine therapies1,2. Targeting the pathways that 
mediate de novo or acquired resistance to aromatase inhibitors in luminal breast cancer in the 
preoperative setting with everolimus has also been clinically validated in a large randomized phase 
II clinical trial4. The addition of everolimus to letrozole led to higher clinical response rates 
irrespective of the PIK3CA mutational status4. The clinical precedence set by these studies along 
with the preclinical evidence of potential synergism between everolimus and TRC105 provide the 
rationale of the proposed investigational therapy. 
 
 
 

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4.7      Rationale for Tumor Assessments by Both Physical Examination and Imaging 
 
It is anticipated that some tumors may not respond to the investigational therapy. With letrozole alone 
in the neoadjuvant setting, the rate of progressive disease has ranged between 2.2 and 12%1,17,86. In 
addition, certain tumors may not be well visualized or cannot be followed accurately with successive 
imaging studies.  
 
It is important to ensure accurate clinical and imaging assessment of the tumor to safeguard against 
progressive disease. In equivocal cases as well as cases of discrepancy between imaging modalities 
and physical examination, provisions will be made for the use of MRI. Altogether though, patients 
whose disease cannot be measured and/or accurately followed by mammogram and/or breast 
ultrasound and/or exceptionally dedicated breast MRI are not eligible for the study. As most 
responders to neoadjuvant hormonal therapy can be identified within the first 4 months14,87, patients 
with stable disease after 4 cycles or progressive disease at any time point will be promptly diverted 
to surgery or cytotoxic chemotherapy at the discretion of the treating physician. 
 
4.8      Rationale for the Duration of Preoperative Treatment 
 
The rationale for extending the preoperative investigational therapy beyond 3-4 months relies on 2 
prior clinical studies that have shown a sustained and continued benefit by extending neoadjuvant 
hormonal therapy to 6 months and beyond14,86,87. The efficacy and tolerability of letrozole in 
combination with bevacizumab has been established in 2 prior clinical trials1,2. Extension of 
preoperative treatment beyond 6 months is not allowed by the protocol. 
 
5. TREATMENT PLAN 
 
5.1  
Subject Selection and Registration  
 
At the time of study entry, the patient will be evaluated by a multidisciplinary team of medical 
oncologists, radiation oncologists, and surgical oncologists.  Before registration, investigators are 
required to indicate the type of operation they intend to perform.  Patients will be consented by the 
investigator and the coordinator of the trial. Patients will be registered in the Clinical Trials Network 
and Monitoring Office; the office will verify the inclusion/exclusion criteria in real time.  
 
5.2  
Study Medications 
 
5.2.1 Letrozole 
 
For this trial, patients will receive 2.5 mg PO daily until 1 day before surgery. The hormonal 
agent is commercially available and will not be provided by the study. 
 
Description of the drug: Letrozole (Femara®) is a nonsteroidal competitive inhibitor of the aromatase 
enzyme system, which is responsible for the synthesis of estrogens from androgenic substrates 
(specifically, the synthesis of estrone from the preferred substrate androstenedione and estradiol from 
testosterone)50.  It is an oral agent with a half-life approximating 48 hours allowing for a once-daily 
administration schedule50. 

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Pharmacokinetic properties: Letrozole is completely and rapidly absorbed from the gastrointestinal 
tract105. Absorption is not affected by food. Once absorbed, it is rapidly and extensively distributed 
into tissues (volume of distribution at steady state is ∼2 liters/kg). Letrozole is eliminated mainly by 
metabolism. The major metabolite, which does not inhibit aromatase, is 4′methanobisbenzonitrile. 
This metabolite is glucuronidated and excreted primarily in the urine. Neither renal impairment 
(creatinine clearance < 9 ml/min) nor moderate hepatic impairment (Child-Pugh classification A and 
B) significantly influences letrozole pharmacokinetic parameters. Letrozole pharmacokinetics are 
not altered by age (range 35 to >80 years); the effects of race have not been studied105.  
 
Pharmacodynamic properties: In postmenopausal patients with advanced breast cancer, daily 
letrozole doses of 0.1–5 mg suppress plasma concentrations of estradiol, estrone, and estrone sulfate 
by 75–95%, with maximal suppression within 2–3 days. Suppression is dose related, with doses of 
≥0.5 mg often reducing estrone and estrone sulfate levels to below the limit of detection. Estrogen 
suppression was maintained throughout treatment in all patients given ≥0.5 mg. At a clinically used 
dosage (2.5 mg PO daily), letrozole does not impair adrenal synthesis of glucocorticoids or 
aldosterone105. 
 
Adverse events: Adverse events associated with these medications are provided in the package insert 
(http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/020726s027lbl.pdf). The most frequent 
adverse events associated with letrozole include hot flashes, arthralgia/arthritis, night sweats, nausea, 
fatigue, myalgias, and edemas. Hypercholesterolemia grade 1 and 2 is frequent but grade 3 and 4 is 
rare (0.4%). Also, all aromatase inhibitors have been associated with osteoporosis. Formal 
assessment of bone density by means of DEXA scan relies at the discretion of the treating physician, 
as treatment for 6 months alone is not anticipated to incur clinically significant decreases in bone 
density. Following surgery, if patients proceed to adjuvant hormonal therapy with an aromatase 
inhibitor for 5 years, a DEXA scan is recommended as well as bone-strengthening medication(s) per 
institutional standards. 
 
5.2.2   Everolimus (Further details can be found in the Everolimus Investigator’s Brochure) 
 
For this trial, the dose for everolimus is 5 (cohort 1) or 10 (cohort 2) mg PO daily and it will be 
continued until 4 weeks prior to surgery. 
 
Everolimus is a novel derivative of rapamycin. It has been in clinical development since 1996 as an 
immunosuppressant in solid organ transplantation. Everolimus is approved in Europe and other 
global markets (trade name: Certican®) for cardiac and renal transplantation, and in the United States 
(trade name: Zortress®) for the prevention of organ rejection of kidney transplantation. 
 
Afinitor® was approved for adults with advanced renal cell carcinoma (RCC) after failure of 
treatment with sunitinib or sorafinib in 2009. In 2010, Afinitor® received United States (US) 
approval for patients with subependymal giant cell astrocytoma (SEGA) associated with tuberous 
sclerosis complex (TSC). Everolimus is also available as Votubia® in the European Union (EU) for 
patients with SEGA associated with TSC who require therapeutic intervention but are not candidates 
for curative surgical resection. Afinitor® was approved for “progressive pancreatic neuroendocrine 
tumor (PNET) in patients with unresectable, locally advanced, or metastatic disease” in 2011 in 
various countries, including the US and Europe. In 2012 Afinitor® received approval for the 

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treatment of postmenopausal women with advanced hormone receptor-positive, HER2- negative 
breast cancer in combination with exemestane, after failure of treatment with letrozole or anastrozole. 
Furthermore in 2012, Afinitor® received approval for the treatment of patients with TSC who have 
renal angiomyolipoma not requiring immediate surgery. Approximately 35,982 cancer patients have 
been treated with everolimus as of  31-Mar-2014 (19,668 patients in Novartis-sponsored clinical 
trials, 2,394 patients in the individual patient supply program, and more than 13,930 patients in 
investigator-sponsored studies). In addition, healthy volunteer subjects and non-oncology hepatically 
impaired subjects have participated in the clinical pharmacology studies. The following is a brief 
summary of the main characteristics of Everolimus. More complete information can be obtained from 
the Everolimus Investigator’s Brochure (IB).  
 
Description of the drug: Everolimus is an orally bioavailable derivative of rapamycin that acts as a 
signal transduction inhibitor (Table 5-1, Figure E). Everolimus selectively inhibits mTOR 
(mammalian target of rapamycin), specifically targeting the mTOR-raptor signal transduction 
complex. mTOR is a key serine-threonine kinase in the PI3K/AKT signaling cascade, which is 
known to be dysregulated in a wide spectrum of human cancers106. 
 
Everolimus is being investigated as an anticancer agent based on its potential to act directly on the 
tumor cells by inhibiting tumor cell growth and proliferation, and indirectly by inhibiting 
angiogenesis leading to reduced tumor vascularity (via potent inhibition of tumor cell VEGF 
(vascular endothelial growth factor) production and VEGF-induced proliferation of endothelial 
cells). 
Table 5-1: Everolimus – Drug substance 
Chemical name 
(1R,9S,12S,15R,16E,18R,19R,21R,23S,24E,26E,2
8E,30S,32S,35R)-1,18-dihydroxy-12-{(1R)-2-
[(1S,3R,4R)-4-(2-hydroxyethoxy)-3-
methoxycyclohexyl]-1-methylethyl}-19,30-
dimethoxy-15,17,21,23,29,35-hexamethyl-11,36-
dioxa-4-aza-tricyclo[30.3.1.04,9]hexatriaconta-
16,24, 26,28-tetraene-2,3,10,14,20-pentaone 
International non-proprietary name 
Everolimus 

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Figure E: Chemical structure of Everolimus 
 
 
mTOR pathway and cancer: At the cellular and molecular level, Everolimus acts as a signal 
transduction inhibitor. It selectively inhibits mTOR (mammalian target of rapamycin), a key protein 
kinase which regulates cell growth, proliferation and survival. The mTOR kinase is mainly activated 
via the phosphatidylinositol 3-kinase (PI3-Kinase) pathway through AKT/PKB and the tuberous 
sclerosis complex (TSC1/2). Mutations in these components or in PTEN, a negative regulator of PI3-
kinase, may result in their dysregulation. Abnormal functioning of various components of the 
signaling pathways contributes to the pathophysiology of numerous human cancers. Various 
preclinical models have confirmed the role of this pathway in tumor development107. The main 
known functions of mTOR include the following44: 
 
 mTOR functions as a sensor of mitogens, growth factors and energy and nutrient levels; 
 Facilitating cell-cycle progression from G1-S phase in appropriate growth conditions; 
 The PI3K/mTOR pathway itself is frequently dysregulated in many human cancers, and 
oncogenic transformation may sensitize tumor cells to mTOR inhibitors; 
 PI3-kinase mutations have been reported in the primary tumor in 10-20% of human colorectal 
cancers108,109; 
 The loss of PTEN protein, either through gene deletion or functional silencing (promoter 
hypermethylation), is reported in approximately 60% of primary human colorectal cancers110; 
 The mTOR pathway is involved in the production of pro-angiogenic factors (i.e., VEGF) and 
inhibition of endothelial cell growth and proliferation; 
 Through inactivating eukaryotic initiation factor 4E binding proteins and activating the 40S 
ribosomal S6 kinases (i.e., p70S6K1), mTOR regulates protein translation, including the HIF-1 
proteins. Inhibition of mTOR is expected to lead to decreased expression of HIF-1. 
 
Non-clinical experience: Everolimus inhibits the proliferation of a range of human tumor cell lines 
in vitro including lines originating from lung, breast, prostate, colon, melanoma and glioblastoma. 
IC50s range from sub/low nM to µM. Everolimus also inhibits the proliferation of human umbilical 
vein endothelial cells (HUVECs) in vitro, with particular potency against VEGF-induced 
proliferation suggesting that Everolimus may also act as an anti-angiogenic agent. The anti-

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angiogenic activity of Everolimus was confirmed in vivo. Everolimus selectively inhibited VEGF-
dependent angiogenic response at well tolerated doses. Mice with primary and metastatic tumors 
treated with Everolimus showed a significant reduction in blood vessel density when compared to 
controls. 
 
The potential of Everolimus as an anti-cancer agent was shown in rodent models. Everolimus is 
orally bioavailable, residing longer in tumor tissue than in plasma in a subcutaneous mouse xenograft 
model, and demonstrating high tumor penetration in a rat pancreatic tumor model. The 
pharmacokinetic profile of Everolimus indicates sufficient tumor penetration, above that needed to 
inhibit the proliferation of endothelial cells and tumor cell lines deemed sensitive to Everolimus in 
vitro. 
 
Everolimus administered orally daily was a potent inhibitor of tumor growth, at well tolerated doses, 
in 11 different mouse xenograft models (including breast, pancreatic, colon, epidermoid, lung and 
melanoma) and two syngeneic models (rat pancreatic, mouse orthotopic melanoma). These models 
included tumor lines considered sensitive and “relatively resistant” in vitro. In general, Everolimus 
was better tolerated in mouse xenograft models than standard cytotoxic agents (i.e., doxorubicin and 
5-fluorouracil), while possessing similar anti-tumor activity. Additionally, activity in a VEGF-
impregnated subcutaneous implant model of angiogenesis and reduced vascularity (vessel density) 
of Everolimus-treated tumors (murine melanoma) provided evidence of in vivo effects of 
angiogenesis. 
 
It is not clear which molecular determinants predict responsiveness of tumor cells to Everolimus. 
Molecular analysis has revealed that relative sensitivity to Everolimus in vitro correlates with the 
degree of phosphorylation (activation) of the AKT/PKB protein kinase and the S6 ribosomal protein; 
in some cases (i.e., glioblastoma) there is also a correlation with PTEN status. In vivo studies 
investigating the anti-tumor activity of Everolimus in experimental animal tumor models showed 
that Everolimus monotherapy typically reduced tumor cell growth rates rather than produced 
regressions. These effects occurred within the dose range of 2.5 mg to 10 mg/kg, orally once a day. 
In preclinical models, the administration of Everolimus is associated with reduction of protein 
phosphorylation in target proteins downstream of mTOR, notably phosphorylated S6 (p-S6) and p-
4E-BP1, and occasionally with an increase in phosphorylated AKT, a protein upstream of mTOR 
signaling pathway. 
 
All significant adverse events observed in toxicology studies with Everolimus in mice, rats, monkeys 
and mini-pigs were consistent with its anticipated pharmacological action as an anti-proliferative and 
immunosuppressant and at least in part reversible after a 2 or 4-week recovery period with the 
exception of the changes in male reproductive organs, most notably testes. In vitro genotoxicity 
studies covering relevant genotoxicity end-points showed no evidence of clastogenic or mutagenic 
activity. 
 
In male fertility studies in rats, testicular morphology was affected at 0.5 mg/kg and above, and sperm 
motility, sperm head count and plasma testosterone levels were diminished at 5 mg/kg which 
corresponded to 0.7 times the estimated clinical exposure at 10 mg/day, and caused a decrease in 
male fertility. There was evidence of reversibility. Female fertility was not affected, but everolimus 
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also potentially impact fertility in females.  Everolimus crossed the placenta and was toxic to the 
conceptus. In rats, everolimus caused embryo/fetotoxicity at systemic exposure below the planned 
therapeutic level comprising mortality and reduced fetal weight. The incidence of skeletal variations 
and malformations at 0.3 and 0.9 mg/kg (e.g. sternal cleft) was increased. In rabbits, embryo toxicity 
was evident by an increase in late resorptions. Effects of everolimus on the pre- and postnatal 
development of rats were limited to slightly affected body weight and survival in the F1-generation 
at ≥0.1 mg/kg, and did not indicate a specific toxic potential.  
 
The potential reproductive risk for humans is unknown. However, due to the observed malformations 
in rats, everolimus should be considered potentially teratogenic. Everolimus should not be given to 
pregnant women unless the potential benefit outweighs the potential risk for the fetus. Women of 
childbearing potential should be advised to use highly effective contraception methods while they 
are receiving everolimus and up to 8 weeks after treatment has been stopped. It is not known whether 
everolimus is excreted in human milk. In animal studies, everolimus and/or its metabolites were 
readily transferred into the milk of lactating rats. Therefore women who are taking everolimus should 
not breastfeed. 
 
Pharmacokinetic properties: Everolimus is rapidly absorbed after oral administration, with a median 
time to peak blood levels (tmax) of 1.3-1.8 hours post dose111. The extent of absorption is estimated 
at above 11%. The area under the blood concentration-time curve (AUC) is dose-proportional over 
the dose range tested while maximum blood concentration (Cmax) appears to plateau at dose levels 
higher than 20 mg. The elimination half-life in cancer patients averaged 30 hours, which is similar 
to that in healthy subjects. Inter-patient variability is moderate with the coefficient of variation of 
approximately 50%. In healthy subjects, high fat meals reduced systemic exposure to everolimus 10 
mg (as measured by AUC0-∞) by 22% and the peak plasma concentration Cmax by 54%. Light fat 
meals reduced AUC0-∞ by 32% and Cmax by 42%. Food, however, had no apparent effect on the 
post absorption phase concentration-time profile. Steady-state trough levels are highly predictive of 
AUC, with a coefficient of determination of 0.96, as has been reported in renal transplantation 
patients. Everolimus is mainly metabolized by the cytochrome P450 isoenzyme 3A4 (CYP3A4) in 
the liver and to some extent in the intestinal wall111. Everolimus is also a substrate of P-glycoprotein 
(P-gp). Therefore, absorption and subsequent elimination of systematically absorbed everolimus may 
be influenced by medicinal products that interact with CYP3A4 and/or P-gp. Strong CYP3A 
inhibitors (such as ketoconazole, itraconazole, ritonavir; Appendix B) and inducers (such as 
rifampicin, rifabutin; Appendix B) should be avoided.  
 
Everolimus, at a daily dose of either 5 mg or 10 mg, was added to the daily letrozole regimen of 2.5 
mg in breast cancer patients4. Letrozole is mainly metabolized by CYP3A4 and CYP2A6 with minor 
contribution of renal clearance. Due to the low affinity of letrozole to CYP3A4, the potential for 
pharmacokinetic interaction is remote. Pharmacokinetic profiles of letrozole were investigated before 
addition of everolimus and after everolimus reached steady state (day 15). Data suggested that, 
indeed, co-administration of everolimus with 2.5 mg/day letrozole did not influence the 
pharmacokinetics of letrozole. Pharmacokinetic characteristics are similar for Caucasian and 
Japanese subjects. Pharmacokinetic studies in Black transplant patients have shown an average 20% 
higher clearance. No dose adjustments are required for renal impairment or in geriatric 
populations but are required in hepatic impairment (see section 5.3.2). 

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Pharmacodynamic properties: The pharmacodynamic properties of everolimus have been 
investigated in a phase I study in patients with advanced solid tumors (including breast cancer) in 
peripheral blood mononuclear cells112. S6 kinase 1 activity (a substrate of mTOR) in peripheral-blood 
mononuclear cells was inhibited for at least 7 days at doses ≥20 mg/week. Duration of suppression 
lengthened with increasing dosage. 20 mg was presumed to be the minimum dose ensuring target 
inhibition over 7 days112. 
 
Adverse events. The addition of everolimus to letrozole has been associated with a higher rate of 
dose reductions or interruptions due to adverse events (52.9%) as well as discontinuations (18.8%) 
compared with letrozole alone (7.6% and 9.1%, respectively) in the neoadjuvant setting4. Grade 1 
and 2 adverse events were also more frequent in the combination arm (89.8% vs. 63.6% in the 
letrozole alone arm)4. The most frequent adverse events seen in higher frequency in the combination 
arm as compared to the letrozole alone group include stomatitis (36.5% vs. 6.1%), rash (20.4% vs. 
7.6%), asthenia  (17.5% vs. 9.8%), fatigue (12.4% vs. 4.5%), anorexia (12.4% vs. 3.8%), headache 
10.9% vs. 5.3%), pruritus (13.1% vs. none), dyspnea (7.3% vs. 1.5%), pneumonitis (2.9% vs. none). 
Laboratory abnormalities seen in higher frequency in the combination arm as compared with the 
control arm include hypercholesterolemia (16.1% vs. 6.1%), thrombocytopenia (18.2% vs. 0.8%), 
hyperglycemia (13.1% vs. 3%), increased ALT (11.7% vs. 3.8%), anemia (11.7% vs 0.8%), and 
neutropenia (9.5% vs. 1.5%).   
 
Grade 3 and 4 adverse events were also more frequent in the combination arm (22.6%) as opposed 
to the letrozole alone arm (3.8%). Stomatitis (2.2%), fatigue (1.5%), and pneumonitis (2.2%) were 
the most frequent grade 3 and 4 adverse events seen in more than 1 patients (n=137) associated with 
the addition of everolimus, while hyperglycemia (5.1%), increased ALT (1.5%), hypokalemia 
(1.5%), thrombocytopenia (1.5%) constituted the most frequent biochemical grade 3 and 4 adverse 
events. Serious adverse events associated with everolimus occurred in 7/137 patients: pneumonitis 
in three patients; pneumonia and mouth ulcers/stomatitis each in two patients; and dyspnea, 
neutropenia, and thrombocytopenia in one patient each. All three patient cases of pneumonitis 
resolved within 15 days of everolimus discontinuation. Among the placebo-treated patients, there 
was one serious adverse event of myocardial ischemia4. 
 
Overall, safety data available from completed, controlled and uncontrolled studies indicate that 
everolimus is generally well tolerated at weekly or daily dose schedules. The safety profile is 
characterized by manageable adverse events (AEs). These AEs are generally reversible and non-
cumulative. 
 
Adverse events most frequently observed with everolimus are stomatitis, rash, diarrhea, fatigue, 
infections, asthenia, nausea, peripheral edema, decreased appetite, headache, dysgeusia, epistaxis, 
mucosal inflammation, pneumonitis, weight decreased, vomiting, pruritus, cough, dyspnea, dry skin, 
nail disorder, and pyrexia. Overall, the most frequently observed laboratory abnormalities include: 
decreased hematology parameters including hemoglobin, lymphocytes, platelets, and neutrophils (or 
collectively as pancytopenia).; increased clinical chemistry parameters including cholesterol, 
triglycerides, glucose, aspartate transaminases, creatinine, alanine transaminases, and bilirubin; and 
decreased clinical chemistry parameters including phosphate and potassium. The majority of these 
AEs have been of mild to moderate severity. See section 8.6 Adverse reactions with everolimus 
for details regarding the reported adverse events associated with everolimus so far. The proceeding 

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sections summarize recommendations for dose interruption, reduction, or discontinuation of Afinitor 
in the management of adverse drug reactions (Table 5-2 and Table 5-3). General management 
recommendations are also provided as applicable. Clinical judgment of the treating physician should 
guide the management plan of each patient based on individual benefit/risk assessment. 

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Table 5-2: Dosing guidelines for Everolimus-related non-hematologic toxicities( see 4.2) 
Toxicity 
Action 
Non-Infectious Pneumonitis 
Please refer to Table 5-9. 
Reactivation of HBV or HCV flare 
Please refer to Table 5-7 and Table 5-8. 
AST or ALT elevation 
Grade 1 (> ULN - 3.0 x ULN) 
Grade 2 (> 3.0 - 5.0 x ULN) 
Maintain current dose level 
AST or ALT elevation 
Grade 3 (> 5.0 - 20.0 ULN)* 
- Interrupt Everolimus administration until resolution to ≤ grade 1 (or ≤ 
grade 2 if baseline values were within the range of grade 2). If 
resolution occurs ≤ 7 days, Everolimus should be re-started at the dose 
level prior to interruption. 
- If  resolution takes > 7 days, or if event recurs within 28 days, hold 
Everolimus until recovery to ≤ grade 1 or baseline grade / value and 
reintroduce Everolimus at one dose level lower, if available (for this 
trial if it was 2.5 mgs, then therapy will be discontinued).  
AST or ALT elevation 
Grade 4 (> 20 x ULN)* 
 
 
Recurrence of grade 4 after dose 
reduction or toxicity requiring 
Everolimus interruption for > 28 days 
Interrupt Everolimus administration until resolution to ≤ grade 1 (or ≤ 
grade 2 if baseline values were within the range of grade 2). If 
resolution occurs ≤ 7 days, Everolimus should be re-started at one dose 
level lower. If resolution takes > 7 days, discontinue Everolimus. 
Discontinue Everolimus. 
Intolerable grade 2 mucositis, or grade 
3 AE, except hyperglycemia or 
hypertriglyceridemia or 
hypercholesterolemia (see 
Section5.2.2.1) 
- Interrupt Everolimus administration until resolution to ≤ grade 1 or 
baseline grade / value. If resolution occurs within ≤ 7 days, Everolimus 
should be re-started at the dose level prior to interruption. 
- If resolution takes > 7 days, or if event recurs within 28 days, hold 
Everolimus until recovery to ≤ grade 1 or baseline grade / value and 
reintroduce Everolimus at one dose level lower, if available (for this 
trial if it was 2.5 mgs, then therapy will be discontinued). 
- Patients will be withdrawn from the study if they fail to recover to  
grade 1 or baseline grade / value within 28 days. 
Any other grade 4 
Hold Everolimus until recovery to grade  1 or baseline value 
Reintroduce Everolimus at one dose level lower, if available (for this 
trial if it was 2.5 mgs, then therapy will be discontinued). 
Grade 3 or 4 clinical liver failure 
(asterixis or encephalopathy/coma) 
Discontinue Everolimus 
Recurrence of intolerable grade 2 
mucositis or grade 3 event after dose 
reduction 
Reduce dose to the next lower dose level, if available. The lowest 
possible dose level of Everolimus is 2.5 mg daily. Below this level, 
Everolimus must be discontinued. If toxicity recurs at Grade 3, 
consider discontinuation 
Recurrence of grade 4 after dose 
reduction 
Discontinue Everolimus 
Any non-hematologic toxicity 
requiring Everolimus interruption for 
> 28 days 
Discontinue Everolimus 
* Should HCV flare be confirmed, the guidelines for flare must take precedence (please refer to Tables 5-7 and 
5-8) 

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Table 5-3: Dosing guidelines for Everolimus-related hematologic toxicities (see 4.2) 
Toxicity 
Action 
Grade 2 thrombocytopenia (platelets <75, 
≥ 50x109/L) 
No action 
 
Grade 3 thrombocytopenia (platelets <50, 
≥ 25 x109/L) 
- Interrupt Everolimus until resolution to grade 1  
- If resolution occurs ≤ 7 days, reintroduce Everolimus at the dose 
level prior to interruption. 
- If resolution occurs > 7 days, or event occurs within 28 days, 
reintroduce Everolimus at one dose level lower, if available (for 
this trial if it was 2.5mgs, then therapy will be discontinued). 
Grade 4 thrombocytopenia (platelets < 25 
x109/L) 
Interrupt Everolimus until recovery to grade  1. Then reintroduce 
Everolimus at one dose level lower, if available (for this trial if it 
was 2.5mgs, then therapy will be discontinued). 
Grade 3 neutropenia or anemia 
(neutrophil <1, ≥0.5 x109/L) 
- Interrupt Everolimus until resolution to grade ≤1 or baseline value 
- If AE resolution occurs ≤ 7 days, reintroduce Everolimus at the 
same dose level. 
- If AE resolution occurs > 7 days, or event occurs within 28 days, 
reintroduce Everolimus at one dose level lower, if available (for 
this trial if it was 2.5mgs, then therapy will be discontinued). 
Grade 4 neutropenia or anemia 
Interrupt Everolimus until recovery to grade  1 or baseline value. 
Reintroduce Everolimus at one dose level lower, if available (for 
this trial if it was 2.5mgs, then therapy will be discontinued).* 
Febrile neutropenia 
Interrupt Everolimus until resolution to grade  1 (or baseline 
value) and no fever. Reintroduce Everolimus at one dose level 
lower, if available (for this trial if it was 2.5mgs, then therapy 
will be discontinued).* 
Recurrence of grade 3 toxicity after dose 
reduction 
Reduce dose to the next lower dose level, if available. The lowest 
possible dose level of Everolimus is 2.5 mg every day. Below this 
level, Everolimus must be discontinued. 
*Recurrence of grade 4 toxicity 
(including febrile neutropenia) after 
dose reduction 
Discontinue Everolimus 
*Any hematologic toxicity requiring 
Everolimus interruption for > 28 days 
Discontinue Everolimus 
 
5.2.2.1 Management of stomatitis, oral mucositis, and mouth ulcers 
 
Patients with a clinical history of stomatitis/mucositis/mouth ulcers and those with gastrointestinal 
morbidity associated with mouth/dental infections, irritation of esophageal mucosa e.g. 
gastroesophageal reflux disease (GERD) and pre-existing stomatitis/mucositis must be monitored 
even more closely. Patients should be instructed to report the first onset of buccal mucosa 
irritation/reddening to their study physician immediately. 
 
Mouth ulcers, stomatitis and oral mucositis have been seen in patients treated with everolimus. 
Stomatitis/oral mucositis/mouth ulcers due to everolimus should be treated using local supportive 
care. If examination reveals mouth ulcers rather than a more general inflammation of the mouth, 

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please classify the adverse event as such. Please follow the paradigm below for treatment of 
stomatitis/oral mucositis/mouth ulcers (Table 5-4): 
 
1. For mild toxicity (grade 1) no dose adjustment required; use conservative measures such as non-
alcoholic mouth wash or salt water (0.9%) mouth wash several times a day until resolution. 
 
2. For more severe toxicity (grade 2 in which case patients have pain but are able to maintain adequate 
oral alimentation, or grade 3 in which case patients cannot maintain adequate oral alimentation), the 
suggested treatments are topical analgesic mouth treatments (i.e., local anesthetics such as 
benzocaine, butyl aminobenzoate, tetracaine hydrochloride, menthol, or phenol) with or without 
topical corticosteroids, such as triamcinolone oral paste 0.1% (Kenalog in Orabase®). 
 
3. Agents containing hydrogen peroxide, iodine, and thyme derivatives may tend to worsen mouth 
ulcers. It is preferable to avoid these agents. 
 
4. Antifungal agents must be avoided unless a fungal infection is diagnosed. In particular, systemic 
imidazole antifungal agents (ketoconazole, fluconazole, itraconazole, etc.) should be avoided in all 
patients due to their strong inhibition of everolimus metabolism, therefore leading to higher 
everolimus exposures. Therefore, topical antifungal agents are preferred if an infection is diagnosed. 
Similarly, antiviral agents such as acyclovir should be avoided unless a viral infection is diagnosed. 
 
Table 5-4: Management of oral mucositis (stomatitis) associated with everolimus. 
 
 
5.2.2.2 Management of Hyperlipidemia and Hyperglycemia 
Severity 
Everolimus  Dose Adjustment and Management Recommendations 
 (see 4.2) 
Grade 1 (Minimal symptoms, 
normal diet) 
No dose adjustment required.  
Manage with non-alcoholic or salt water (0.9%) mouth wash several times a 
day. 
Grade 2 (Symptomatic but can eat 
and swallow modified diet) 
- Temporary dose interruption until recovery to grade ≤1. Re-initiate 
everolimus at the same dose. 
- If stomatitis recurs at grade 2, interrupt dose until recovery to grade ≤1. Re-
initiate everolimus at a lower dose (for this trial if it was 2.5mgs, then 
therapy will be discontinued). 
Manage with topical analgesic mouth treatments (e.g. benzocaine,butyl 
aminobenzoate, tetracaine hydrochloride, menthol or phenol)with or without 
topical corticosteroids (i.e. triamcinolone oral paste). 
Grade 3 (Symptomatic and unable to 
adequately eat or hydrate orally) 
Temporary dose interruption until recovery to grade ≤1.  
Re-initiate everolimus at lower dose (for this trial if it was 2.5mgs, then 
therapy will be discontinued). 
Manage with topical analgesic mouth treatments (i.e. benzocaine,butyl 
aminobenzoate, tetracaine hydrochloride, menthol or phenol) with or without 
topical corticosteroids (i.e. triamcinolone oral paste)* 
Grade 4 (Symptoms associated with 
life-threatening consequences) 
Discontinue everolimus and treat with appropriate medical therapy. 

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Treatment of hyperlipidemia should take into account the pre-treatment status and dietary habits. 
Blood tests to monitor hyperlipidemia must be taken in the fasting state. Grade 2 or higher 
hypercholesterolemia (>300 mg/dL or 7.75 mmol/L) or grade 2 hypertriglyceridemia or higher 
(>2.5x upper normal limit) should be treated with a 3-hydroxy-3-methyl-glutaryl (HMG)-CoA 
reductase inhibitor (e.g. atorvastatin, pravastatin, fluvastatin) or appropriate triglyceride-lowering 
medication, in addition to diet. Note: Concomitant therapy with fibrates and an HMG-CoA reductase 
inhibitor is associated with an increased risk of a rare but serious skeletal muscle toxicity manifested 
by rhabdomyolysis, markedly elevated creatine phosphokinase (CPK) levels and myoglobinuria, 
acute renal failure and sometimes death. The risk versus benefit of using this therapy should be 
determined for individual patients based on their risk of cardiovascular complications of 
hyperlipidemia. 
 
Dyslipidemia (including hypercholesterolemia and hypertriglyceridemia) has been reported in 
patients taking everolimus.  Monitoring of blood cholesterol and triglycerides prior to the start of 
everolimus therapy and periodically thereafter as well as management with appropriate medical 
therapy is recommended. Hyperglycemia has been reported in patients taking everolimus. 
Monitoring of fasting serum glucose is recommended prior to the start of Everolimus and periodically 
thereafter. More frequent monitoring is recommended when everolimus is co-administered with other 
drugs that may induce hyperglycemia. Optimal glycemic control should be achieved before starting 
a patient on Everolimus. Hyperlipidemia and hypertriglyceridemia should be treated according to 
local best clinical practice (Table 5-5). Patients should be monitored clinically and through serum 
biochemistry for the development of rhabdomyolysis and other adverse events as required in the 
product label/data sheets for HMG-CoA reductase inhibitors (statins). 
 
Table 5-5. Management of hyperlipidemia/hypertriglycemia associated with everolimus 
 
Severity 
Everolimus Dose Adjustment and Management Recommendations 
Grade 1 
No dose adjustment required. Initiate appropriate medical therapy and monitor. 
Grade 2 
No dose adjustment required. Manage with appropriate medical therapy and monitor. 
Grade 3 
Temporary dose interruption. 
Re-initiate everolimus at lower dose (for this trial if it was 2.5mgs, then therapy will be 
discontinued). Manage with appropriate medical therapy and monitor. 
Grade 4 
Discontinue everolimus and treat with appropriate medical therapy. 
 
5.2.2.3 Management of Hepatitis reactivation 
 
Reactivation of Hepatitis B (HBV) has been observed in patients with cancer receiving 
chemotherapy113. Sporadic cases of Hepatitis B reactivation have also been seen in this setting with 
everolimus. Use of antivirals during anti-cancer therapy has been shown to reduce the risk of 
Hepatitis B virus reactivation and associated morbidity and mortality114. A detailed assessment of 
Hepatitis B/C medical history and risk factors must be done for all patients at screening, with testing 
performed prior to the first dose of everolimus. Hepatitis B. Table 5-6 provides details of monitoring 
and prophylactic therapy according to the baseline results of viral load and serologic markers testing. 
 
 

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Table 5-6. Recommendations for positive baseline results for hepatitis B 
 
Test 
Result 
Result 
Result 
Result 
Result 
HBV-DNA 
+ 
+ or - 
- 
- 
- 
HBsAg 
+ or - 
+ 
- 
- 
- 
HBsAb 
+ or - 
+ or - 
+ 
and no prior 
HBV vaccination 
+ or - 
- 
or + with prior HBV 
vaccination 
HBcAb 
+ or - 
+ or - 
+ or - 
+ 
- 
Recommendation 
Prophylaxis treatment should 
be started 1-2 weeks prior to 
first dose of Everolimus. 
Monitor HBV-DNA 
approximately every 4-8 
weeks 
No prophylaxis. Monitor HBV-
DNA approximately every 3-4 
weeks  
No specific action 
 
Antiviral prophylaxis therapy should continue for at least 4 weeks after last dose of study drug. 
Table 5-7 provides guidelines for definition and management of hepatitis B reactivation. 
 
Table 5-7: Guidelines for management of hepatitis B 
 
HBV reactivation (with or without clinical signs and symptoms): All reactivations of HBV are to be recorded as grade 
3 (e.g. CTCAE Version 3.0 - Investigations/Other: Viral Reactivation), unless considered life threatening by the 
investigator, in which case they should be recorded as grade 4. Date of viral reactivation is the date on which the rise 
or reappearance of HBV-DNA was recorded. 
For patients with baseline results: positive 
HBV-DNA, OR positive HBsAg 
 
Treat: Start a second antiviral AND interrupt everolimus 
administration until resolution: 
• ≤ grade 1 ALT (or baseline ALT, if > grade 1) and 
• ≤ baseline HBV-DNA levels 
- If resolution occurs within ≤ 28 days everolimus should be 
restarted at one dose lower, if available. (see 5.2.5.2) If the patient is 
already receiving the lowest dose of everolimus according to the 
protocol, the patient should restart at the same dose after resolution. 
Both antiviral therapies should continue at least 4 weeks after last 
dose of study drug. 
- If resolution occurs > 28 days patients should discontinue 
everolimus but continue both antiviral therapies at least 4 weeks after 
last dose of study drug. 
Reactivation is defined as: Increase of 1 
log in HBV-DNA relative to baseline, 
HBV-DNA value,  OR new appearance of 
measurable HBV-DNA 
 
For patients with baseline results: Negative 
HBV-DNA and HBsAg AND Positive HBs 
Ab (with no prior history of vaccination 
against HBV),  OR  Positive HBc Ab 
 
Treat : Start first antiviral medication AND interrupt study drug 
administration until resolution: ≤ baseline HBV-DNA levels 
- If resolution occurs within ≤ 28 days everolimus should be 
restarted at one dose lower, if available. (see 5.2.5.2) If the patient is 
already receiving the lowest dose of everolimus according to the 
protocol, the patient should restart at the same dose after resolution. 
Antiviral therapy should continue at least 4 weeks after last dose of 
study drug. 
- If resolution occurs > 28 days Patients should discontinue study 
drug but continue antiviral therapy at least 4 weeks after last dose of 
everolimus. 
Reactivation is defined as: 
New appearance of measurable HBV-DNA 
 

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Hepatitis C. The following two categories of patients should be monitored every 6 weeks for HCV 
reactivation: patients with detectable HCV RNA-PCR test at baseline, and patients known to have a 
history of HCV infection, despite a negative viral load test at baseline (including those that were 
treated and are considered ‘cured’). Table 5-8 provides definition and guidelines for the management 
of hepatitis C. 
 
Table 5-8: Definitions and Guidelines for the management of Hepatitis C 
 
Baseline results 
HCV flare definition* 
HCV flare management 
Detectable HCV-RNA 
 
> 2 log10 IU/mL increase in HCV-RNA 
AND 
ALT elevation > 5 x ULN or 3 x baseline 
level, whichever is higher. 
Discontinue Everolimus 
Knowledge of past hepatitis C 
infection with no detectable 
HCV-RNA 
New appearance of detectable HCV-RNA 
AND 
ALT elevation > 5 x ULN or 3 x baseline 
level, whichever is higher. 
Discontinue Everolimus 
* All flares of HCV are to be recorded as grade 3 (e.g. CTCAE Version 3.0 - Investigations - Other: Viral Flare), 
unless considered life threatening by the investigator; in which case they should be recorded as grade 4. Date of 
viral flare is the date on which both the clinical criteria described above were met. (e.g., for a patient whose 
HCV-RNA increased by 2 logs on 01 JAN 2011 and whose ALT reached > 5 x ULN on 22 JAN 2011, the date 
of viral flare is 22 JAN 2011). 
 
All reactivations of hepatitis B or C are considered grade 3 adverse events according to the NCI 
CTCAE version 4.03 unless associated with decompensated liver dysfunction in which case they are 
deemed grade 4. 
(http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf)  
 
5.2.2.4 Management of Non-infectious Pneumonitis 
 
Non-infectious pneumonitis is a class effect of rapamycin derivatives. Cases of non-infectious 
pneumonitis (including interstitial lung disease) have also been described in patients taking 
everolimus. Some of these have been severe and on rare occasions, a fatal outcome was observed. 
 
A diagnosis of non-infectious pneumonitis should be considered in patients presenting with non-
specific respiratory signs and symptoms such as hypoxia, pleural effusion, cough or dyspnea, and in 
whom infectious, neoplastic and other non-medicinal causes have been excluded by means of 
appropriate investigations. Opportunistic infections such as PJP should be ruled out in the differential 
diagnosis of non-infectious pneumonitis. Patients should be advised to report promptly any new or 
worsening respiratory symptoms. Diagnosis is generally suspected in individuals receiving mTOR 
inhibitors who develop these symptoms or in asymptomatic individuals in whom a routine chest CT 
scan reveals a new ground glass or alveolar infiltrate. 
 
The frequency of symptomatic pulmonary toxicity (all grades) was approximately 13% in a phase III 
study of everolimus in patients with metastatic renal cell carcinoma115. Severe (CTCAE grade 3) 
pneumonitis occurred in 4% of patients, and an occasional fatality was reported.  Similarly, in the 

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phase III study of everolimus in patients with advanced pancreatic neuroendocrine tumors 
symptomatic pulmonary toxicity was seen in 17% of patients with grade 3 or 4 pneumonitis seen in 
only 2%116. Lastly, in the clinical study that compared letrozole +/- everolimus in the neoadjuvant 
setting, grade 3 or 4 pneumonitis was seen in 2.2% of the patients in the everolimus (vs. none in the 
placebo) arm4. The lung toxicity was partly or completely reversible in the majority of cases with 
interventions including drug interruption, discontinuation and the use of corticosteroids. 
 
Patients who develop radiological changes suggestive of non-infectious pneumonitis and have few 
or no symptoms may continue Afinitor therapy without dose alteration. If symptoms are moderate 
(grade 2), consideration should be given to interruption of therapy until symptoms improve.  The use 
of corticosteroids may be indicated.  Afinitor may be reintroduced at a daily dose approximately 50% 
lower than the dose previously administered. For cases of grade 3 non-infectious pneumonitis, 
interrupt Afinitor until resolution to less than or equal to grade 1.  Afinitor may be re-initiated at a 
daily dose approximately 50% lower than the dose previously administered depending on the 
individual clinical circumstances.  If toxicity recurs at grade 3, consider discontinuation of Afinitor.  
For cases of grade 4 non-infectious pneumonitis, Afinitor therapy should be discontinued.  
Corticosteroids may be indicated until clinical symptoms resolve. For patients who require use of 
corticosteroids for treatment of non-infectious pneumonitis, prophylaxis for pneumocystis jirovecii 
pneumonia (PJP) may be considered. The two compounds studied most extensively for prophylaxis 
against PJP have been trimethoprim-sulfamethoxazole, given orally, and pentamidine, given as an 
aerosol. Individuals participating in this trial will be routinely questioned as to the presence of new 
or changed pulmonary symptoms consistent with lung toxicity. CT scans and pulmonary function 
test should be done, as clinically indicated, if there are symptoms that indicate that the patient has 
developed non-infectious pneumonitis. If non-infectious pneumonitis develops, the guidelines in 
Table 5-9 should be followed. Dose modification should be done as outlined in 5.2.5.2. Consultation 
with a pulmonologist is recommended for any case of pneumonitis that develops during the study. 
 
 
 
 
 
 
 
 
 
 
 
 
Table 5-9. Guidelines for the management of treatment-related non-infectious pneumonitis 

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Worst grade 
pneumonitis 
Suggested investigations 
Management of 
pneumonitis 
Everolimus dose adjustment 
Grade 1 
(Asymptomatic, 
radiographic 
findings only) 
CT scans with lung windows. 
No specific therapy is 
required 
No dose adjustment required.  
Initiate appropriate monitoring. 
Grade 2 
(Symptomatic, 
not interfering 
with Activities 
of Daily Living) 
CT scan with lung windows. 
Consider pulmonary function 
testing includes: spirometry, 
DLCO, and room air O2 saturation 
at rest. Consider a bronchoscopy 
with biopsy and/or BAL. 
Monitoring at each visit until return 
to ≤ grade 1. Return to initial 
monitoring frequency if no 
recurrence. 
Symptomatic only. 
Consider corticosteroids 
and/or other supportive 
therapy if symptoms are 
troublesome. 
Rule out infection and consider 
interruption of Everolimus until 
symptoms improve to Grade ≤ 1. 
Re-initiate Everolimus at one dose level 
lower (for this trial if it was 2.5 mgs, 
then therapy will be discontinued).  
Discontinue Everolimus if failure to 
recover within ≤ 28 days. 
Grade 3 
(Symptomatic, 
Interfering with 
Activities of 
Daily Living. 
O2 indicated 
CT scan with lung windows and 
pulmonary function testing includes: 
spirometry, DLCO, and room air O2 
saturation at rest. Monitoring at each 
visit until return to ≤ grade 1. Return 
to initial monitoring frequency if no 
recurrence. 
Bronchoscopy 
with 
biopsy 
and/or 
BAL 
is 
recommended. 
Consider corticosteroids 
if infective origin is ruled 
out. Taper as medically 
indicated. 
Rule out infection and interrupt 
Everolimus until symptoms improve to 
Grade ≤ 1. 
Consider re-initiating Everolimus at one 
dose level lower (approximately 50% 
lower than the dose previously 
administered depending on individual 
clinical circumstances) (for this trial if it 
was 2.5 mgs, then therapy will be 
discontinued). Discontinue Everolimus if 
failure to recover within ≤ 28 days. If 
toxicity recurs at Grade 3, consider 
discontinuation 
Grade 4 (Life-
threatening, 
ventlatory 
support 
indicated) 
CT scan with lung windows and 
required pulmonary function testing, 
if possible, includes: spirometry, 
DLCO, and room air O2 saturation 
at rest. Monitoring at each visit until 
return to ≤ grade 1. Return to initial 
monitoring 
frequency 
if 
no 
recurrence. 
Bronchoscopy 
with 
biopsy and/or BAL is recommended 
if possible. 
Consider corticosteroids 
if infective origin is ruled 
out. Taper as medically 
indicated. 
Rule 
out 
infection 
and 
discontinue 
Everolimus. 
 
5.2.2.3 Management of Infections 
 
From a historical perspective, everolimus has been in clinical development since 1996 initially in 
solid organ transplantation as a medication to prevent rejection. It has immunosuppressive properties 
and may predispose patients to bacterial, fungal, viral or protozoan infections, including infections 
with opportunistic pathogens. Localized and systemic infections, including pneumonia, other 
bacterial infections, invasive fungal infections, such as aspergillosis or candidiasis and viral 
infections including reactivation of hepatitis B virus, have been described in patients taking 
everolimus. Some of these infections have been severe (e.g. leading to respiratory or hepatic failure) 
and occasionally have had a fatal outcome. In the phase III study of everolimus in patients with 
advanced pancreatic neuroendocrine tumors, infectious complications of any grade were seen in 23% 
(predominantly in the upper respiratory tract; grade 3 or 4, 2%) in the investigational arm vs. 6% 
(grade 3 or 4, <1%) in the placebo arm116. On the other hand though, no infectious adverse events 
were reported in the clinical study that compared letrozole +/- everolimus in the neoadjuvant setting4. 

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Physicians and patients should be aware of the increased risk of infection with everolimus. Pre-
existing infections should be appropriately treated prior to starting the investigational therapy. While 
taking everolimus, the patient and the investigator should be vigilant for symptoms and signs of 
infection. If a diagnosis of infection is made, appropriate treatment should be instituted promptly 
and, if the infection is severe enough, interruption or discontinuation of everolimus should be 
considered. If a diagnosis of invasive systemic fungal infection is made, everolimus will be 
discontinued; the patient will be taken off study and treated with appropriate antifungal therapy. 
Cases of pneumocystis jirovecii pneumonia (PJP), some with a fatal outcome, have been reported in 
patients who received everolimus. PJP may be associated with concomitant use of corticosteroids or 
other immunosuppressive agents.  Prophylaxis for PJP should be considered when concomitant use 
of corticosteroids or other immunosuppressive agents are required. 
5.2.2.4 Management of skin toxicity 
For patients with grade 1 toxicity, no specific supportive care is usually needed or indicated. Rash 
must be reported as an AE. Patients with grade 2 or higher toxicity may be treated with the following 
suggested supportive measures at the discretion of the investigator: oral minocycline, topical 
tetracycline, topical clindamycin, topical silver sulfadiazine, diphenhydramine, oral prednisolone 
(short course), topical corticosteroids, or pimecrolimus. 
5.2.2.5 Management of Hypersensitivity reactions 
Hypersensitivity reactions manifested by symptoms including, but not limited to, anaphylaxis, 
dyspnea, flushing, chest pain or angioedema (e.g. swelling of the airways or tongue, with or without 
respiratory impairment) have been observed with everolimus. 
5.2.2.6 Angioedema with concomitant use of angiotensin-converting enzyme inhibitors 
Patients taking concomitant ACE inhibitor therapy may be at increased risk for angioedema (e.g. 
swelling of the airways or tongue, with or without respiratory impairment). 
5.2.2.7 Renal Failure Events 
Cases of renal failure (including acute renal failure), some with fatal outcome, occurred in patients 
treated with everolimus. Renal function of patients should be monitored particularly where patients 
have additional risk factors that may further impair renal function. Elevations of serum creatinine, 
usually mild, and proteinuria have been reported in patients taking everolimus. Monitoring of renal 
function, including measurement of blood urea nitrogen (BUN), urinary protein, or serum creatinine, 
is recommended prior to the start of everolimus therapy and periodically thereafter. 
 
 
 

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5.2.2.8 Management of diarrhea 
 
Appearance of grade 1-2 diarrhea attributed to study drug toxicity may be treated with supportive 
care such as loperamide, initiated at the earliest onset (for example 4 mg orally followed by 2 mg 
orally every 2 hours until resolution of diarrhea). 
 
5.2.2.9 Cytochrome P450 and P-glycoprotein inhibitors/inducers/substrates 
Co-administration with strong inhibitors of CYP3A4 or P-gp should be avoided; and may cause 
increased everolimus concentrations. For a current table of Substrates, Inhibitors and Inducers please 
access the following website:  
 
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractions
Labeling/ucm093664.htm.  
 
Everolimus is metabolized by CYP3A4 in the liver and to some extent in the intestinal wall. 
Therefore, the following are recommended: 
 
 Co-administration with strong inhibitors of CYP3A4 (e.g., ketoconazole, itraconazole, ritonavir) 
or P-glycoprotein (P-gp) inhibitor should be avoided. 
 
 Co-administration with moderate CYP3A4 inhibitors (e.g., erythromycin, fluconazole) or P-gp 
inhibitors should be used with caution. If a patient requires co-administration of moderate 
CYP3A4 inhibitors or P-gp inhibitors, reduce the dose of everolimus by approximately 50%. 
Additional dose reductions to every other day may be required to manage toxicities. If the 
inhibitor is discontinued, the Everolimus dose should be returned to the dose used prior to 
initiation of the moderate CYP3A4/P-gp inhibitor after a washout period of 2 to 3 days. 
 
 
Grapefruit, Seville oranges, and star fruit affect P450 and P-gp activity. Concomitant use should 
be avoided. 
 
 If patients require co-administration of a strong CYP3A4 inducer, consider doubling the daily 
dose of Afinitor (based on pharmacokinetic data), using increments of 5 mg or less. This dose of 
Afinitor is predicted to adjust the AUC to the range observed without inducers. However, there 
are no clinical data with this dose adjustment in patients receiving strong CYP3A4 inducers. If 
the strong inducer is discontinued, consider a washout period of at least 3 to 5 days (reasonable 
time for significant enzyme de-induction), before the Afinitor dose is returned to the dose used 
prior to initiation of the strong CYP3A4 inducer. 
 
 This dose adjustment of Everolimus is intended to achieve similar AUC to the range observed 
without inducers. However, there are no clinical data with this dose adjustment in patients 
receiving strong CYP3A4 inducers. If the strong inducer is discontinued the Everolimus dose 
should be returned to the dose used prior to initiation of the strong CYP3A4/P-gp inducer. 
 
Please refer to Table 5-11 listing relevant inducers and inhibitors of CYP3A and Table 5-12 for a 
list of relevant substrates, inducers, and inhibitors of P-gp. 

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Everolimus and drugs influencing CYP3A4 enzyme 
Everolimus is a substrate of CYP3A4, and a substrate and moderate inhibitor of the multidrug efflux 
pump, P-gp (P-gp, MDR1, and ABCB1). Therefore, extent of absorption and subsequent elimination 
of systemically absorbed everolimus may be influenced by products that are substrates, inhibitors, or 
inducers of CYP3A4 and/or P-gp. Concurrent treatment with strong CYP3A4-inhibitors should be 
avoided. Refer to Table 5-8 in section 6 for a comprehensive list of inducers and inhibitors of 
CYP3A4 and Table 5-9 for a list of relevant substrates, inducers and inhibitors of P-gp. Inhibitors of 
P-gp may decrease the efflux of everolimus from brain or tumor and therefore increase everolimus 
concentrations in these tissues. In vitro studies showed that everolimus is a competitive inhibitor of 
CYP3A4 and of CYP2D6, potentially increasing the concentrations of products eliminated by these 
enzymes. Thus, caution should be exercised when co-administering everolimus with CYP3A4 and 
CYP2D6 substrates with a narrow therapeutic index. Clinical studies have been conducted in healthy 
subjects to assess pharmacokinetic drug interactions between everolimus and potential CYP3A 
modifiers (ketoconazole, verapamil, erythromycin, rifampin, midazolam, and HMGCoA reductase 
inhibitors (statins).  
 
Table 5-11: Clinically relevant drug interactions: inducers, and inhibitors of isoenzyme CYP3A 
 
Inducers 
Strong inducers: avasimibe, carbamazepine, mitotane, phenobarbital, phenytoin, rifabutin, 
rifampin (rifampicin), St. John's Wort (hypericum perforatum) 
 
Moderate inducers: bosentan, efavirenz, etravirine, genistein, modafinil, nafcillin, ritonavir, 
[talviraline], thioridazine, tipranavir 
 
Weak inducers: amprenavir, aprepitant, armodafinil (R-modafinil), bexarotene, clobazam, 
danshen, dexamethasone, Echinacea, garlic (allium sativum), gingko (ginkgo biloba), glycyrrhizin, 
methylprednisolone, nevirapine, oxcarbazepine, pioglitazone, prednisone, [pleconaril], primidone, 
raltegravir, rufinamide, sorafenib, telaprevir, terbinafine, topiramate, [troglitazone] , vinblastine 
Inhibitors 
Strong inhibitors: boceprevir, clarithromycin, cobicistat, conivaptan, elvitegravir, indinavir, 
itraconazole, ketoconazole, lopinavir, mibefradil, nefazodone, nelfinavir, posaconazole117, 
ritonavir, saquinavir, telaprevir, 
telithromycin, tipranavir, troleandamycin, voriconazole 
 
Moderate inhibitors: Amprenavir, aprepitant, atazanavir, casopitant, cimetidine, ciprofloxacin, 
cyclosporine, darunavir, diltiazem, dronedarone, erythromycin, fluconazole, fosamprenavir, 
grapefruit juice (citrus parasidi fruit juice), imatinib, schisandra sphenanthera, tofisopam, 
verapamil 
 
 
 
 

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Table 5-12: Clinically relevant drug interactions: substrates, inducers,                                         
inhibitors of P-gp and P-gp/CYP3A dual inhibitors 
 
Substrates 
colchicine, digoxin, fexofenadine, indinavir, paclitaxel, talinolol, topotecan, vincristine, 
everolimus 
Inducers 
rifampin, St John’s Wort 
P-gp Inhibitors and P-gp/CYP3A Dual Inhibitors 
amiodarone, azithromycin, captopril, carvedilol, clarithromycin, conivaptan, diltiazem, 
dronedarone, elacridar, erythromycin, felodipine, fexofenadine, fluvoxamine, ginkgo (ginkgo 
biloba), indinavir, itraconazole, lopinavir, mibefradil, milk thistle (silybum marianum), 
nelfinavir, nifedipine, nitrendipine, paroxetine, quercetin, quinidine, ranolazine, rifampin, 
ritonavir, saquinavir, Schisandra chinensis, St John’s Wort (hypericum perforatum), talinolol, 
Telaprevir, telmisartan, ticagrelor, tipranavir, tolvaptan, valspodar, verapamil 
Reference: Internal Clinical Pharmacology Drug-drug interaction (DDI) memo, updated Oct. 2, 2011,29-Oct-
2012 which summarizes DDI data from three sources including the FDA’s “Guidance for Industry, Drug 
Interaction Studies”, the University of Washington’s Drug Interaction Database, and Indiana University School 
of Medicine's Drug Interaction Table. 
5.2.2.10 Vaccinations 
Immunosuppressants may affect the response to vaccination and vaccination during treatment with 
Everolimus may therefore be less effective. The use of live vaccines should be avoided during 
treatment with Everolimus. For pediatric patients with SEGA that do not require immediate 
treatment, complete the recommended childhood series of live virus vaccinations prior to the start of 
therapy according to local treatment guidelines. Examples of live vaccines are: intranasal influenza, 
measles, mumps, rubella, oral polio, BCG, yellow fever, varicella, and TY21a typhoid vaccines. 
 
5.2.3   TRC105 
 
 
Description of the drug. TRC105 is a chimeric anti-CD105 IgG1 antibody consisting of human Cκ 
and Cγ1 constant regions with murine Vκ and VH regions. TRC105 is composed of two light chains 
of 213 amino acids and two heavy chains of 448 amino acids and has an approximate molecular 
weight of 148 kDa. 
 
Manufacturing. A high producing CHO cell line using media that is free of animal derived 
components has been developed for production of TRC105. The TRC105 currently in use in all 
clinical studies is CHO-produced. The manufacturing process uses conventional purification and 
filtration steps and concludes with the formulation of TRC105 in  20 mM L-Histidine/L-Histidine 
Monohydrochloride, 240 mM Trehalose, 0.01% Polysorbate 20 Formulation (25 mg TRC105/mL)85. 
 
Pharmacokinetic properties. In the phase 1 first-in-human dose escalation study of TRC105, the 
medication was detectable at all dose levels immediately after intravenous infusion35. In patients 
enrolled at doses below 0.3 mg/kg every 2 weeks, circulating TRC105 was detectable but not 
measurable above the lower limit of quantitation of the assay (78 ng/mL). On an every 2-week 

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schedule, TRC105 was measurable above the target concentration that saturates CD105 receptors 
(200 ng/mL) for a duration of 4 hours at a TRC105 dose of 0.3 mg/kg, for 24 hours at 1 mg/kg, 120 
hours at 3 mg/kg, and 188 hours at 10 mg/kg (Fig. 1). The observed terminal T½ was considerably 
prolonged following a single dose of 15 mg/kg compared with 3 and 10 mg/kg. Serum concentrations 
expected to saturate CD105 binding sites (≥200 ng/mL) were achieved continuously at 15 mg/kg 
dosed every 2 weeks and 10 mg/kg dosed weekly. At doses above 1 mg/kg, AUC increased 
supraproportionally with dose, whereas the Cmax seemed to be dose proportional35. TRC105 
clearance was consistent with target mediated disposition, and decreased clearance at higher doses 
was related to target saturation85. 
 
Immunogenicity.. Neither Human anti-murine antibody (HAMA) nor Human anti-chimeric antibody 
(HACA) were detected in patients treated with CHO-produced TRC105 which was administered at 
the 0.3, 1, 3, 10 and 15 mg/kg dose levels35,85 and will be used in the proposed study. 
 
Pharmacodynamic properties. Please refer to the investigational brochure85 for nonclinical 
pharmacodynamics studies with TRC105.  
 
The dose for TRC105 is 15 (cohorts 1 and 2) or 10 (cohort -1) mg/kg IV every two weeks and it will 
be continued until 4 weeks prior to surgery.  
 
Adverse events. The most common adverse events associated with TRC105 are infusion reactions 
that are successfully mitigated with premedications and prolongation of the infusion time, 
hemorrhages (mostly grade 1 and 2), headaches, and hypoproliferative anemia35.  See section 8.3 for 
additional information regarding TRC105 adverse events. 
 
5.2.3.1 Management of Infusion Reactions 
 
Infusion reactions have been observed following TRC105 administration, usually with the initial 
dose (including a grade 4 vasovagal reaction that resolved without sequelae), and were commonly 
associated with one or more of the following signs or symptoms: hypertension, hypotension, dyspnea, 
bronchospasm, chills/rigors, chills, sweats, fever, nausea, tachycardia, bradycardia, EKG changes, 
flushing, urticaria, pruritus, and headache, generally of grade 1 and 2 severity. Hypersensitivity 
reactions with infusions are a potential risk for sensitized patients, and TRC105 should be used with 
caution in patients with known hypersensitivity to any component of the drug product.  Host anti-
TRC105 antibodies to the murine or human portions of CHO-produced TRC105 are rare.  In general, 
the risk of immunogenicity to therapeutic chimeric antibodies is small (<10%).  The presence of 
HAMA of HACA neither correlated nor predicted the development of infusion reactions.  
 
By extending the duration of the initial infusion from one to four hours and adding a glucocorticoid-
based premedication regimen prior to each dose, the frequency and severity of infusion reactions 
were reduced. At dose levels where continuous TRC105 serum levels were achieved, with 
subsequent infusions dexamethasone was safely discontinued and the infusion duration reduced to 
one hour. Table 5-10 provides guidelines for the definition and management of infusion related 
reactions. 
 

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To mitigate or avoid infusion reactions associated with TRC105, the following actions will be 
undertaken: 
 
a. The first dose of TRC105 will be split in two separate infusions to be infused over 4 hours each 
on days 1 (3 mg/kg) and 4 (12 mg/kg or 7 mg/kg if dose de-escalation occurs). If well tolerated, 
all subsequent infusions will be administered as a whole (i.e., 15 mg/kg or 10 mg/kg if dose de-
escalation occurs) in their scheduled times and infusion time will gradually be reduced to 2 hours 
and then to a minimum of 90 minutes. 
b. The following TRC105 premedications should be administered 2 hours to 30 minutes prior to the 
start of each infusion:   
1. Acetaminophen 650 mg p.o. x 1  
2. Methylprednisolone 100 mg i.v..  In the absence of any infusion reaction with the prior 
dose, methylprednisolone may be discontinued beginning with cycle 3. In addition, 
methylprednisolone will be given in the case of a delay of ≥ 18 days between any two 
doses or if the patient develops an infusion reaction during the immediate prior infusion.  
3. Famotidine 20 mg i.v. or p.o. (or similar H2 blocker) x 1. Famotidine (or similar H2 
blocker) may be discontinued starting with Cycle 2 in the absence of infusion reactions 
with the prior dose. 
4. Cetirizine 10 mg i.v. or p.o. x 1 (or similar oral or intravenous antihistamine). Cetirizine 
(or similar oral or intravenous antihistimine) may be discontinued starting with Cycle 2 
in the absence of infusion reactions with the prior dose. 
c. During the first (day 1 and 4) infusion, vital signs should be checked every 30 minutes and 
methylprednisolone 100 mg IV should be readily available for infusion. 
 
Table 5-10: Guidelines for the management of infusion related reactions 
 
Grade 
Signs or 
Symptoms 
Recommended Action 
Dose Adjustment or 
Modification 
Grade 1 
Mild transient 
reaction 
Mild increase in 
heart rate but <100 
bpm 
Mild increase in 
respiratory rate but 
<25 breaths per 
minute 
Interruption not 
indicated 
Intervention not 
indicated 
None 
Grade 2 
Infusion interruption 
indicated but 
responds promptly to 
symptomatic 
treatment 
Increase in heart 
rate but<120 bpm 
Increase in 
respiratory rate but 
<30 breaths per 
minute 
Skin rash or mild 
pruritus 
Withhold infusion until 
resolution of symptoms 
but no less than 30 
minutes.  
Administer 
methylprednisolone 100 
mg IV ± 
diphenhydramine 50 mg 
IV. 
None  
Premedications as per 
cycle 1. 
Do not shorten 
subsequent infusions 
until no infusion 
reactions are seen 

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Resume infusion once 
symptoms resolve 
Grade 3 
Prolonged recurrence 
of symptoms 
following initial 
improvement; 
hospitalization 
indicated 
Increase in heart 
rate >120 bpm, 
palpitations and 
sense of 
“impending 
doom” 
Diffuse skin rash 
and pruritus 
Tachypnea >30 
breaths per minute 
and mild wheezing 
Interrupt infusion and do 
not resume.  
Administer 
methylprednisolone 250 
mg IV and 
diphenhydramine 50 mg 
IV.  
Admit to the hospital for 
observation 
 
None  
Escalate 
premedications to 
dexamethasone 8 mg 
PO BID in the day 
before and day of 
chemotherapy. 
Do not shorten 
subsequent infusions 
until no infusion 
reactions are seen. 
If the reaction recurs 
the patient will be taken 
off study. 
Grade 4 
Life-threatening 
consequences 
Palpitations, 
tachycardia, 
dyspnea with 
stridor or 
wheezing, sense of 
“impending 
doom”, chest pain, 
diffuse rash with 
wheals and 
pruritus 
Interrupt infusion and 
admit to the MICU 
Administer 
methylprednisolone 250 
mg IV and 
diphenhydramine 50 mg 
IV. Administer pressors 
as indicated. 
 
Do not rechallenge with 
TRC105. The patient 
will be taken off study. 
 
5.2.3.2 Management of Hemorrhages 
 
Grade 3 or 4 hemorrhage with TRC105 is rare. In the phase I study, one patient developed dose-
limiting toxicity of grade 4 hemorrhage presenting as melena from a gastric ulcer within 5 days of 
the initial TRC105 infusion at 0.1 mg/kg35. TRC105 was withheld, the patient was transfused 2 units 
of packed red blood cells and the bleeding resolved with nonsurgical management by the time of 
upper endoscopy. Patients with bleeding gastrointestinal ulcers or other sources of bleeding will be 
excluded from the study unless there is documentation of healing.  
 
Subsequent bleeding associated with TRC105 has been limited to low grades including superficial 
gingival bleeding, epistaxis, and intermittent post-coital vaginal bleeding in a patient with uterine 
cancer recurrent at the vaginal cuff. Gingival bleeding and epistaxis are related to the development 
of mucocutaneous telangiectasia and represent on-target effects of TRC105 therapy. Patients with 
epistaxis may benefit from saline nasal gel. All patients treated with TRC105 should be monitored 
for signs of hemorrhage and the risks and benefits of drug treatment reevaluated in any patient with 
hemorrhage. 
 

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Cerebrovascular hemorrhage (grade 3) resulting in hemiparesis occurred in one patient with 
hepatocellular cancer who was thrombocytopenic (platelet count of 60,000/uL) in a study of TRC105 
with sorafenib. Patients in TRC105 protocols are required to have platelet counts of 100,000/µL. 
 
Accrual will be halted as a result of any grade ≥3 hemorrhage, cerebrovascular and vasovagal adverse 
events; FDA will be contacted to discuss further accrual or potential need for protocol amendment. 
 
5.2.3.3 Management of Anemia 
 
Hypoproliferative anemia was the dose-limiting toxicity in the phase I study35 and may be related to 
the action of TRC105 on proerythroblasts, the only cells in the bone marrow known to express high 
levels of CD105. When hemoglobin drops in a patient on the study, it is important to investigate for 
any ongoing blood loss. A reticulocyte count should be obtained to document the hypoproliferative 
nature of the anemia associated with TRC105. Anemia should be managed with standard supportive 
measures including transfusions of packed red blood cells if deemed necessary. If grade 3 or higher 
treatment related anemia develops, the dose of TRC105 should be reduced from 15 mg/kg to 10 
mg/kg or held if the assigned dose is 10 mg/kg until resolution of the anemia. 
 
5.2.3.4 Management of Headache 
 
Headaches (grade 1 to 3) have been observed following TRC105 treatment, generally within hours 
following completion of the initial infusion. Headaches are throbbing in nature, have not been 
associated with radiographic abnormalities, and have responded to treatment with non-steroidal anti-
inflammatory agents (including ketorolac) and to triptans. Extending the infusion to 4 hours or 
interrupting the infusion may also by tried to mitigate the headaches Nasal congestion and periorbital 
edema have been observed with TRC105. The edema has been transient in nature and treated with 
corticosteroids. Antihistamines are useful for nasal congestion. 
 
5.2.4  Goserelin 
 
Description of the drug: Goserelin (Zoladex®) is a synthetic decapeptide analog of endogenous 
gonadotropin-releasing hormone. GnRH regulates follicle-stimulating hormone (FSH) and 
luteinizing hormone (LH) synthesis and secretion by the anterior pituitary gland, which in turn 
stimulates the production of estrogens by the ovary. In response to GnRH, FSH and LH synthesis 
initially increases, causing a transient increase in circulating levels of sex hormones. These 
hormones are however, regulated by feedback loops, so further hormone release is suppressed. 
Chronic administration of goserelin leads to sustained suppression of pituitary gonadotropins FSH 
and LH as the pituitary gland down-regulates and desensitizes GnRH receptors.  
Pharmacodynamic properties: Within 3 weeks following initial administration of goserelin, serum 
estradiol is suppressed to levels similar to those observed in postmenopausal women. However, after 
suppression was attained, isolated elevations of estradiol were seen in up to 10% of the patients enrolled 
in clinical trials. Serum LH and FSH are suppressed to follicular phase levels within four weeks after 
initial administration of drug and are usually maintained at that range with continued use of goserelin. 
In 5% or less of women treated with goserelin, FSH and LH levels may not be suppressed to follicular 
phase levels on day 28 post treatment with a single 3.6 mg depot injection. 
Pharmacokinetic properties: Goserelin in its depot formulation is released slowly initially for the first 8 

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days, and then there is more rapid and continuous release for the remainder of the 28-day dosing period. 
Despite the change in the releasing rate of goserelin, administration of goserelin every 28 days resulted 
in testosterone levels that were suppressed to and maintained in the range normally seen in surgically 
castrated men. When goserelin 3.6 mg depot was used for treating male and female patients with 
normal renal and hepatic function, there was no significant evidence of drug accumulation. However, in 
clinical trials the minimum serum levels of a few patients were increased. These levels can be attributed 
to interpatient variation. The apparent volumes of distribution determined after subcutaneous 
administration of 250 μg aqueous solution of goserelin was 20.3 liters for females. The plasma protein 
binding of goserelin obtained from one sample is 27.3%.  
Metabolism of goserelin, by hydrolysis of the C-terminal amino acids, is the major clearance 
mechanism. All metabolites found in humans have also been found in toxicology species. Clearance of 
goserelin following subcutaneous administration of the solution formulation of goserelin is very rapid 
and occurs via a combination of hepatic metabolism and urinary excretion. More than 90% of a 
subcutaneous radiolabeled solution formulation dose of goserelin is excreted in urine. Approximately 
20% of the dose in urine is accounted for by unchanged goserelin. (AstraZeneca, Package Insert). 
 
Goserelin is generally safe to administer with other medications. Goserelin should be administered 
subcutaneously every 28 days into the anterior abdominal wall below the navel line using an aseptic 
technique under the supervision of a physician. 
 
5.2.5   Concomitant Medications 
 
The reason(s) for treatment dosage, and dates of treatment should be recorded in the source 
documents.  Concomitant medications should be reported to the investigator and will be recorded as 
instructed in the study specific case report forms.  Patients who experience TRC105-related 
temperature elevations or other infusion-related symptoms may be treated symptomatically with 
acetaminophen, dyphenhydramine, meperidine, or other medications as clinically indicated, 
including < 48 hours of treatment with corticosteroids.  Patients should receive full supportive care, 
including transfusions, antibiotics, anti-emetics, etc. when appropriate.  Pre-trial supportive care will 
continue. The following therapies are excluded during active protocol therapy: radiotherapy, 
hormonal therapy different from the agent prescribed in the protocol, cytotoxic chemotherapy, herbal 
medicines and cancer immunotherapy or other biologic agents. 
 
If the patient is on low dose aspirin at baseline he/she may continue it if medically indicated. If the 
patient is on NSAIDs on study should also receive peptic ulcer disease (PUD) prophylaxis with an 
H2 or proton pump blocker. 
 
Packed red blood cell, colony stimulating factors, and platelet transfusions should be administered 
as clinically indicated. 
 
 
5.3    Dose Modifications and Delays  
 
Dose modifications and delays are allowed. Determinations to reduce the dose, withhold, or delay 
the administration of a drug rely on the treating physician. The choice of the drug(s) (letrozole and/or 
everolimus and/or TRC105, or all three components) that need(s) to be withheld or dose reduced 
(everolimus or TRC105; delays but no dose reductions are allowed for letrozole) relies on the treating 

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physician and should be based on the nature of the observed adverse events. The justification for 
dose modifications and delays should be clearly documented. The maximum duration that a 
patient is allowed to withhold up to all three medications of the regimen is 7 days. Treatment can be 
resumed after 7 days at a lower dose level as outlined below for each individual component of the 
regimen. If treatment cannot be resumed within 7 days, the patient will be taken off study. 
 
5.3.1 Dose modifications and delays with letrozole 
 
Modifications. The dose of letrozole will not be modified (increased or decreased) in this protocol. 
Also letrozole cannot be substituted for another hormonal agent (e.g. anastrozole). Delays. The 
maximum duration that a patient is allowed to withhold letrozole due to adverse events is 7 days. If 
a patient cannot resume letrozole after 7 days or it is deemed necessary to withhold the medication 
again, the patient will be taken off study. 
 
 
5.3.2 Dose modifications and delays with everolimus in phase II portion 
 
Modifications. The dose for everolimus is 5 or 10 mg PO daily. In patients receiving 10 mg PO daily, 
dose reduction to 5 mg PO daily is allowed for adverse events or intolerance at the discretion of the 
treating physician. The reason for dose reduction must be clearly documented. Dose reductions at 
levels below 5 mg PO daily are allowed to 2.5 mg PO. No further reductions are allowed. Dose 
adjustments should be made if a patient’s hepatic (Child-Pugh) status changes during treatment. 
 Mild hepatic impairment (Child-Pugh A) – if the assigned dose was 5 or 10 mg PO daily, the 
recommended dose is 2.5 and 7.5 mg PO daily, respectively. 
 Moderate hepatic impairment (Child-Pugh B) – if the assigned dose was 10 mg PO daily, the 
recommended dose is 5 mg daily. If the assigned dose was 5 mg PO daily, withhold everolimus 
until resolution of hepatic impairment and resume at 5 mg PO daily. 
 Severe hepatic impairment (Child-Pugh C) – not recommended. If the desired benefit outweighs 
the risk, a dose of 2.5 mg daily must not be exceeded. 
 
Delays. The maximum duration that a patient is allowed to withhold everolimus due to adverse events 
is 7 days. If a patient cannot resume everolimus after 7 days or it is deemed necessary to withhold 
the medication again, the patient will be taken off study. 
5.3.3 Dose modifications and delays with TRC105 
 
Modifications. The dose for TRC105 is 10 or 15 mg/kg IV every two weeks and it will be continued 
until 4 weeks prior to surgery. Dose reductions to 10 mg/kg due to adverse events are allowed and 
the justification(s) should be documented. Dose reductions below 10 mg/kg are not allowed and if 
deemed necessary, the patient will be taken off study. 
 
Delays. All infusions of TRC105 should be administered within 3 days of the protocol-specified 
schedule. The maximum duration that a patient is allowed to withhold TRC105 due to adverse events 
is 14 days. If TRC105 is delayed > 3 days the first dose of TRC105 following the break needs to be 
split into two doses; 3 mg/kg should be given on the first day and the remainder of the dose (i.e., 12 
mg/kg, or 7 mg/kg in the case of a dose de-escalation) will be given 3 days later and the 

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methylprednisolone dose should be reinstituted. If a patient cannot resume TRC105 after 14 days or 
it is deemed necessary to withhold the medication again, the patient will be taken off study. 
Resumption at 10 mg/kg if the subject was receiving 15 mg/kg are allowed with the reinstitution of 
full premedication, as specified in Section 5.2.3.1. 
 
5.3.4 Dose modifications and delays with goserelin 
 
Modifications. No dose modifications are allowed with goserelin 
 
Delays: delays up to 3 days are allowed to accommodate for scheduling issues, inclement weather, 
or other extraneous circumstances. 
 
5.4    Study Procedures 
 
5.4.1 Screening phase 
 
Informed consent will be obtained before study-specific screening evaluations are performed.  
Screening evaluations must be performed within 4 weeks prior to day 0.  Results of tests or 
examinations done as standard of care prior to obtaining informed consent and within 56 days prior 
to day 0 may be used rather than repeating tests.  
 
The following evaluations and procedures will be performed during the screening phase:  
 
-  Signed informed consent. 
 
-  Clinical evaluations: medical history, demographics, weight and height, complete physical 
examination, vital signs and performance status.  
 
- 
Determination of the surgical procedure to be performed at the time of diagnosis without the 
neoadjuvant treatment by the surgical oncologist in the multidisciplinary team. Determinations 
include unresectable (for locally advanced disease that cannot be adequately resected unless 
tumor shrinkage is achieved), mastectomy, and lumpectomy.   
 
- 
Laboratory assessment: UA, CBC with differential and platelet count, serum chemistries 
(glucose, BUN, creatinine, total protein, albumin, bilirubin, calcium, alkaline phosphatase, AST, 
and ALT), serum electrolytes (Na, K, Cl), ferritin, and a lipid panel (cholesterol, triglycerides, 
HDL, and LDL) in a fasting state (at least 8 hours). 
 
- 
Determination of menopausal status: FSH, LH, and estradiol levels.  
 
- 
Pregnancy test in women with childbearing potential. 
 
- 
Research biopsy (core needle biopsy of the tumor) (required). 
 
-  Sentinel lymph node biopsy if required.  
 

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- 
Estrogen and Progesterone receptor status.  
 
- 
Her-2-neu by immunohistochemistry and or FISH (Negative: IHC 0, 1 or 2+ or non-amplified by 
FISH). 
 
- 
Tumor assessments: Mammogram and breast ultrasound are required.  PET/CT scan or CT scan 
of chest, abdomen, pelvis, with bone scan will be obtained.  If the scan shows disease outside the 
breast and/or the axilla, the patient will not be enrolled in the trial.   
 
- 
12-lead EKG. Evaluation of the ejection fraction with an echocardiogram or MUGA, if clinically 
indicated. 
 
-  Concomitant medication assessment. 
 
-  Patients who have satisfied basic eligibility criteria will be assigned with a study patient number 
and the patient can proceed to be consented.  
 
- 
Hepatitis B and C panels (see 5.2.2.3, table 5-2 and table 5-4 for Hepatitis B and C interpretation). 
 
5.4.1.1 Screening for hepatitis B 
 
Prior to initiation of Everolimus, the following three categories of patients should be tested for 
hepatitis B viral load and serologic markers, that is, HBV-DNA, HBsAg, HBs Ab, and HBc Ab: 
 
 All patients who currently live in (or have lived in) Asia, Africa, Central and South America, 
Eastern Europe, Spain, Portugal and Greece. 
[http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-
travel/hepatitis-b.htm] 
 
 Patients with any of the following risk factors: 
 known or suspected past hepatitis B infection, 
 blood transfusion(s) prior to 1990, 
 current or prior IV drug users, 
 current or prior dialysis, 
 household contact with hepatitis B infected patient(s), 
 current or prior high-risk sexual activity, 
 body piercing or tattoos, 
 mother known to have hepatitis B 
 history suggestive of hepatitis B infection, e.g., dark urine, jaundice, right upper quadrant 
pain 
 Additional patients at the discretion of the investigator. 
 
The management guidelines, in 5.2.2.3, are provided according to the results of the baseline 
assessment of viral load and serological markers for hepatitis B. 

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5.4.1.2 Screening for hepatitis C 
 
Patients with any of the following risk factors for hepatitis C should be tested using quantitative 
RNA-PCR: 
 
 known or suspected past hepatitis C infection (including patients with past interferon ‘curative’ 
treatment), 
 blood transfusions prior to 1990, 
 current or prior IV drug users, 
 current or prior dialysis, 
 household contact of hepatitis C infected patient(s), 
 current or prior high-risk sexual activity, 
 body piercing or tattoos 
 
At the discretion of the investigator, additional patients may also be tested for hepatitis C. The 
management guidelines, in 5.2.2.3, are provided according to the results of the baseline assessment 
of hepatitis C viral load. 
 
5.4.1.3 Pregnancy and assessments of fertility  
 
There are no adequate data from the use of everolimus and TRC105 in pregnant women. The safety 
of women of childbearing capacity cannot be implied for the existing data with TRC105. Studies 
with everolimus in animals have shown reproductive toxicity effects including embryo-toxicity and 
feto-toxicity. The potential risk for humans is unknown. Everolimus should not be given to pregnant 
women unless the potential benefit outweighs the potential risk to the fetus. If a pregnancy occurs 
while on study treatment, the newborn will be followed for at least 12 months. It is not known 
whether everolimus is excreted in breast milk. However, in animal studies everolimus and/or its 
metabolites readily passed into the milk of lactating rats. Women taking everolimus should therefore 
not breast-feed. 
 
Women of childbearing potential  
Women of child-bearing potential, defined as all women physiologically capable of becoming 
pregnant, must use highly effective contraception during the study and for 8 weeks after stopping 
treatment. Highly effective contraception is defined as either: 
 
 Total abstinence: When this is in line with the preferred and usual lifestyle of the subject. 
[Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and 
withdrawal are not acceptable methods of contraception] 
 Sterilization: have had surgical bilateral oophorectomy (with or without hysterectomy) or tubal 
ligation at least six weeks before taking study treatment. In case of oophorectomy alone, only 
when the reproductive status of the woman has been confirmed by follow up hormone level 
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 Male partner sterilization (with the appropriate post-vasectomy documentation of the absence 
of sperm in the ejaculate). [For female subjects on the study, the vasectomised male partner 
should be the sole partner for that subject]. 
 Use of a combination of any two of the following (a+b or a+c or b+c): 
a. Use of oral, injected, implanted or other hormonal methods of contraception 
b. Placement of an intrauterine device (IUD) or intrauterine system (IUS) 
c. Barrier methods of contraception: Condom or Occlusive cap (diaphragm or cervical/vault 
caps) with spermicidal foam/gel/film/cream/vaginal suppository 
 In case of use of oral contraception, women should have been stable on the oral agent before 
taking study treatment. 
 
Male Contraception  
 
Sexually active males must use a condom during intercourse while taking the drug and for 8 weeks 
after stopping treatment and should not father a child in this period. A condom is required to be used 
also by vasectomized men in order to prevent delivery of the drug via seminal fluid. Female partners 
of male patients must also be advised to use one of the following contraception methods: Use of (1) 
oral, injected, implanted or other hormonal methods of contraception, or (2) intrauterine device (IUD) 
or intrauterine system (IUS), or (3) prior male/female sterilization. 
 
Fertility  
 
The potential for everolimus and TRC105 to cause infertility in male and female patients is unknown. 
However, menstrual irregularities, secondary amenorrhea and associated luteinizing hormone 
(LH)/follicle stimulating hormone (FSH) imbalance has been observed with everolimus. Based on 
non-clinical findings, male and female fertility may be compromised by treatment with everolimus 
and TRC105. 
 
5.4.2 Treatment Phase 
 
The following evaluations and procedures will be performed during the treatment phase:  (All 
assessments should be performed within 5 working days of the protocol-specified date). 
 
-  Physical examination, vital signs, weight, and performance status on weeks 4, 8, 12, 16, 20 and 
24.   
 
- 
Laboratory assessments: CBC with differential and platelet count, serum chemistries (glucose, 
BUN, creatinine, total protein, albumin, bilirubin, calcium, alkaline phosphatase, AST, and 
ALT), and serum electrolytes (Na, K, Cl) on week 1 and at the beginning of each cycle until week 
24. 
 
- 
Lipid panel (cholesterol, triglycerides, HDL, and LDL) in a fasting state (at least 8 hours) should 
be obtained at least on cycle 2 and, if elevated, repeated on each cycle until recovery to baseline 
value or grade 1 (see 5.2.2.2 for management of hyperlipidemia and hyperglycemia). 
 

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Serum estradiol levels on weeks 4, 12, and 20 in women receiving goserelin. 
- 
Hepatitis panel as clinically indicated. 
 
- 
Research biopsy (core needle biopsy of the tumor) at week 4 (required). 
  
- 
Tumor assessments: Ultrasound of the breast will be obtained on week 4, 8, 12, 16, 20 and 24.  
Mammogram will be obtained on week 24.  Additional PET scans or CT of the chest, abdomen, 
and pelvis, or bone scans are not required during treatment phase except as clinically indicated 
(see section 7.2 Measurement of Effect).  MRI breast will be obtained at baseline, week 12 and 
24. 
 
- 
Evaluation of the ejection fraction with an echocardiogram/MUGA only as clinically indicated. 
 
-  Surgical evaluation at the end of neoadjuvant therapy.  There must be at least 4 weeks between 
the last dose of everolimus and TRC105 and surgery. Patients will continue letrozole until the 
day before surgery.  
 
- 
Concomitant medication assessment. 
 
- 
Assessment of adverse events.  
 
5.4.3 Safety Follow-up Phase 
 
Patients will complete participation in the protocol at the time of surgery and will not be followed 
unless the patient requires follow up of adverse events. The following evaluations and procedures 
will be performed at early termination. Every effort should be undertaken for the following 
procedures to be completed within 10 days.  
 
- 
Clinical evaluations: Weight, physical examination (complete), vital signs and performance 
status.  There must be a complete and clear documentation of objective response or disease 
progression using the RECIST criteria.  Reason(s) for discontinuation must be documented. 
 
- 
Laboratory assessment: UA, CBC with differential and platelet count, serum chemistries 
(glucose, BUN, creatinine, total protein, albumin, bilirubin, calcium, alkaline phosphatase, AST, 
and ALT), serum electrolytes (Na, K, Cl), and lipid panel (cholesterol, triglycerides, HDL, and 
LDL) in a fasting state (at least 8 hours).  
 
- 
Tumor assessments: Mammogram, breast ultrasound, and breast MRI. Spiral CT scans of chest, 
abdomen, and pelvis, bone scan, and any other procedure are not required per protocol but will 
be obtained if clinically indicated.  
 
-  Concomitant medication assessment. 
 
-  Assessment of adverse events.  If the patient has an ongoing toxicity, the patient should be 
followed until resolution or stabilization.  Serious and non-serious adverse events occurring 

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within 30 days of day 0 of the last treatment should be reported on the appropriate adverse event 
CRF.  
5.5  Study Termination 
 
The principal investigator retains the right to terminate study participation in consultation with the 
other investigators in the study. The principal investigator will notify the institutional review board 
and FDA in writing of the early termination or completion of the study and keep a copy of the 
notification in the regulatory file. Circumstances that may raise consideration for early termination 
include but are not limited to: inordinate toxicity of the proposed combination that is not amenable 
to protocol amendment, and slow accrual (rate of accrual of less than 1 patient in 6 months). 
 
5.6 Subject Discontinuation 
 
Patients may withdraw from this study at any time.  Any patient who withdraws will be encouraged 
to return to the study center for the post-dose evaluations.  The termination visit consists of all 
evaluations scheduled for the termination visit.  The primary reason(s) for discontinuation must be 
recorded on the appropriate CRF page.   
 
The PI may discontinue a patient from treatment.  Reasons may include, but are not limited to, the 
following: progressive disease, failure to obtain postmenopausal status (defined as serum estradiol 
levels any time during treatment in the premenopausal range) clinically significant deterioration, 
noncompliance, persistent grade 3 or 4 adverse event or any significant adverse event that 
compromises the patient’s ability to participate in the study, requirement of a significant surgical 
procedure or radiation therapy during the treatment period of the study, investigator’s determination 
that it is not in the patient’s best interest to continue participation, anemia greater than grade 4, 
persistent grade 3 mucositis despite maximal supportive care, development of brain metastases, 
pregnancy.   
 
Patients who have an ongoing grade 4 or serious adverse event at the time of discontinuation from 
study treatment will continue to be followed at least weekly for 4 weeks and at least monthly 
thereafter at the discretion of the investigator until resolution of the event or until the event is 
considered irreversible. 
 
 
 

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6.  STUDY DRUG PREPARATION AND DISPENSATION 
 
6.1 Dosing Regimen and Schedule 
 
Table 6-1: Dosing regimen and schedule 
 
Drug 
Formulation 
Dose and Route 
Frequency 
Letrozole 
Tablet for oral use 
2.5 mg PO 
Daily 
Everolimus 
Tablet for oral use 
5 or 10 mg PO 
Daily 
TRC105 
Solution for intravenous infusion 
10 or 15 mg/kg IV 
q 2 weeks* 
Goserelin** 
Depot for subcutaneous injection 
3.6 mg 
subcutaneously 
q 4 weeks 
* The first infusion of TRC105 will be split in 2 separate infusions to be administered on cycle 1 day 
1 (3 mg/kg) and cycle 1 day 4 (12 or 7 mg/kg). 
** when applicable 
6.1.2 TRC105 Preparation 
TRC105 will be prepared in the pharmacy and diluted into normal saline using appropriate aseptic 
technique.  TRC105 will be administered using an in-line 0.2 micron filter.  No incompatibilities 
between TRC105 and polyvinyl chloride or polyolefin bags have been observed.  Multiple vials 
will be required for a single dose.  The following formulae should be used to calculate the volume 
of TRC105 to be added to normal saline: 
 Patient weight (kg) × dose level (mg/kg) divided by TRC105 concentration (mg/mL) = 
volume of TRC105 (mL) to be administered. 
The volume of TRC105 that is to be administered can be rounded up or down to the nearest 1.0 
mL; in the case of an increment of 0.5 mL the volume should be rounded up.  The maximum 
weight that should be used for dose calculation in this study is 85 kg (note: there is not a 
weight restriction for enrollment purposes).  If the patient’s weight changes by > 10% during the 
study, the dose of TRC105 will be recalculated.  At that time a new baseline weight will be 
established such that subsequent weight changes by >10% from the new baseline weight would 
require further recalculation of the TRC105 dose.  The calculated volume of TRC105 will be 
diluted with normal saline.  Appropriate judgment should be exercised in withdrawing an adequate 
amount of saline necessary to permit injection of the appropriate volume of antibody into a normal 
saline bag in accordance with the dose needed.  The final TRC105 concentration must be between 
0.3 mg/mL and 10 mg/mL.  The prepared TRC105 must be gently inverted several times in order to 
ensure a homogeneous solution. The diluted infusion solution of TRC105 should be used within 8 
hours of preparation if stored at room temperature, or within 24 hours of dilution if stored at 2°C to 
8°C (36º to 46ºF). The expiration time should be labeled on the bag.  If the diluted infusion solution 
of TRC105 cannot be infused within 8 hours of preparation (i.e.: the prepared infusion is at room 
temperature for more than 8 hours), a second bag will be prepared that contains the balance of the 
planned dose that was not already delivered. The prepared solution should not be frozen. 
 
6.1.3 TRC105 Administration 

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Patients should be encouraged to drink abundant fluid (e.g. two eight ounce glasses of water or 
juice) prior to the first treatment.  Intravenous hydration prior to and during therapy is left to the 
discretion of the Investigator, but should be considered if the patient is thought to be volume 
depleted. 
The following TRC105 premedications should be administered 2 hours to 30 minutes prior to the 
start of each infusion:   
 Acetaminophen 650 mg p.o. x 1  
 Methylprednisolone 100 mg i.v. In the absence of any infusion reaction with the 
prior dose, methylprednisolone may be discontinued beginning with cycle 3.  In 
addition, methylprednisolone will be given in the case of a delay of ≥ 18 days 
between any two doses or if the patient develops an infusion reaction during the 
immediate prior infusion.  
 Famotidine 20 mg i.v. or p.o. (or similar H2 blocker) x 1. Famotidine (or similar H2 
blocker) may be discontinued starting with Cycle 2 in the absence of infusion 
reactions with the prior dose. 
 Cetirizine 10 mg i.v. or p.o. x 1 (or similar oral or intravenous antihistamine). 
Cetirizine (or similar oral or intravenous antihistimine) may be discontinued starting 
with Cycle 2 in the absence of infusion reactions with the prior dose. 
TRC105 will be administered intravenously utilizing an infusion pump.  TRC105 has been 
demonstrated to be compatible with polyethylene lined, non-DEHP infusion sets and polyvinyl 
chloride, non-DEHP infusion sets.  TRC105 is required to be administered with a 0.2 micron 
downstream filter.  The attachment of the infusion pump administration set to the i.v. bag and 
transport of the TRC105 study drug to the patient will be performed as per standard study site 
procedures.  
 
Following the appropriate premedication regimen, the patient will receive TRC105 on day 1 and 
day 15 of every cycle. The first TRC105 dose will be split with 3 mg/kg administered on cycle 1 
day 1 and infused over 4 hours (+/- 15 minutes) and 12 mg/kg (or 7 mg/kg if dose is de-escalated) 
administered on cycle 1 day 4 and infused over 2 hours (+/- 15 minutes), and then the full dose of 
15 mg/kg (or 10 mg/kg if dose is de-escalated) given on cycle 1 day 15 and every 2 weeks 
thereafter and will be administered over a minimum of 90 minutes.  The patient must complete at 
least one 4 hour infusion (+/- 15 minutes) without the development of any infusion reactions, in 
order to reduce the subsequent TRC105 infusion to 2 hours (+/- 15 minutes) and complete a 2 hour 
infusion (+/- 15 minutes) without the development of any infusion reactions in order to reduce 
subsequent TRC105 infusions to a minimum of 90 minutes.  If the patient develops infusion 
reactions of any kind they should be managed appropriately (see Section 5.3.2.1) and the patient is 
not permitted to reduce the duration of the next planned infusion. 
The rate of TRC105 infusion must not exceed 25 mg/min.  When the i.v. bag containing TRC105 is 
empty, flush the i.v. line with a 20 mL normal saline.  The dose level, time of transfer to i.v. bag, 
and the infusion start and stop times must be recorded in the source documents. 

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If the patient misses a TRC105 dose (i.e., ≥ 18 days between doses), the full premedication 
(including methylprednisolone) should be reinstituted as per the initial infusion and TRC105 dose 
should be administered over two days as was done for the initial dose. 
6.2 Drug Formulations 
All dosages prescribed and dispensed to the patient and all dose changes during the study must be 
recorded. Medication labels will comply with US legal requirements and be printed in English. They 
will supply no information about the patient. 
 
6.2.1 Letrozole Formulation 
 
Commercially available tablets of letrozole will be used in the study. Complete guidelines for the 
management and administration of letrozole can be found in the package insert 
(http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/020726s027lbl.pdf). Letrozole will not 
be provided from the study 
 
6.2.2 Everolimus Formulation 
 
Everolimus is formulated as tablets for oral administration of 2.5mg, 5mg, and 10mg strength. 
Tablets are blister-packed under aluminum foil, which should be opened only at the time of 
administration as drug is both hygroscopic and light-sensitive. Everolimus should be administered 
orally once daily at the same time every day, either consistently with or consistently without food.  
Refer to label for expiration date and storage conditions. 
 
The extent of absorption of everolimus through topical exposure is not known.  Therefore, caregivers 
are advised to avoid contact with suspensions of everolimus Tablets.  Hands should be washed 
thoroughly before and after preparation of either suspension. The blisters for everolimus tablets 
should be opened only at the time of administration as the formulation is both hygroscopic and light-
sensitive. Storage conditions for everolimus are described on the medication label 
(http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/022334s021s023s024,203985s002s004
s005lbl.pdf). The study drugs should be stored in a secure, locked area while under the responsibility 
of the principal investigator. Receipt and dispensing of study drug must be recorded by an authorized 
person at the investigator’s site.  
 
The tablets should be swallowed whole with a glass of water and should not be chewed or crushed. 
For patients unable to swallow tablets, the tablet(s) should be dispersed completely in a glass of water 
(containing approximately 30 mL) by gently stirring until the tablet(s) is fully disintegrated 
(approximately 7 minutes), immediately prior to drinking. The glass should be rinsed with the same 
volume of water and the rinse completely swallowed to ensure the entire dose is administered. If 
vomiting occurs, no attempt should be made to replace the vomited dose. Patients should be 
instructed that if they miss a dose on one day, they must not take any extra dose the next day, but 
instead to immediately contact the study center as soon as possible to ask for advice. Everolimus will 
be provided from the study. 
 
6.2.3 TRC105 Formulation 

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TRC105 is a sterile, clear colorless to slightly yellow opalescent solution for intravenous (IV) 
infusion. The solution may contain small amounts of visible particulates. TRC105 will be filtered 
through a 0.2 μm low protein binding filter at the clinical site prior to administration.  TRC105 will 
be supplied in 100 and 400 mg single-use vials in 20 mM L-Histidine/L-Histidine 
Monohydrochloride, 240 mM Trehalose, 0.01% Polysorbate 20 (25 mg TRC105/mL). Vials will be 
labeled with the following: 
TRC105 
NSC# 754227 
100 mg per vial (25 mg/mL, 4 mL per vial) 
Store refrigerated at 2-8˚C.      
For Intravenous Use Only.     Single-use vial. 
Lot:  XXXXXXX     Mfg Date: XX/XX/XXXX 
Caution: New Drug Limited by  
Federal (or United States) law to investigational 
use. 
TRACON Pharmaceuticals Inc., San Diego, CA 
92122 USA 
TRC105 
NSC# 754227 
400 mg per vial (25 mg/mL, 16 mL per vial) 
Store refrigerated at 2-8˚C.      
For Intravenous Use Only.     Single-use vial. 
Lot:  XXXXXXX     Mfg Date: XX/XX/XXXX 
Caution: New Drug Limited by  
Federal (or United States) law to investigational 
use. 
TRACON Pharmaceuticals Inc., San Diego, CA 
92122 US 
 
TRC105 will be provided by TRACON Pharmaceuticals, Inc. 
 
6.2.4 Goserelin Formulation 
 
Goserelin is supplied as a sterile, biodegradable product containing goserelin acetate equivalent to 
3.6 mg of goserelin. Goserelin is designed for subcutaneous injection with continuous release over a 
28-day period. Goserelin acetate is dispersed in a matrix of D,L-lactic and glycolic acids copolymer 
(13.3-14.3 mg/dose) containing less than 2.5% acetic acid and up to 12% goserelin-related substances 
and presented as a sterile, white to cream colored 1-mm diameter cylinder, preloaded in a special 
single use syringe with a 16-gauge x 36 +/- 0.5 mm siliconized needle with protective needle sleeve 
(SafeSystem™ Syringe) in a sealed, light and moisture proof, aluminum foil laminate pouch 
containing a desiccant capsule. Studies of the D,L-lactic and glycolic acids copolymer have indicated 
that it is completely biodegradable and has no demonstrable antigenic potential (AstraZeneca, 
Package Insert). 
 
6.3 Study Drug Storage and Handling 
 
Study treatments must be received by designated personnel at the study site, handled and stored 
safely and properly, and kept in a secured location to which only the investigator and designated 
site personnel have access. Upon receipt, the study treatment should be stored according to the 
instructions outlined in section 6.2. 
 
6.4 Study Drug Compliance 
 
The investigator should promote compliance by instructing the patient to take the study drug exactly 
as prescribed and by stating that compliance is necessary for the patient’s safety and the validity of 

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the study. The patient should be instructed to contact the investigator if he/she is unable for any 
reason to take the study drug as prescribed. 
 
Compliance will be assessed by the investigator and/or study personnel at each patient visit and 
information provided by the patient and/or caregiver. Records of study medication used, dosages 
administered, and intervals between visits and the completion of the study will be captured in the 
Drug Accountability Form. This information must be captured in the source document at each patient 
visit. 
 
On PK sampling days, compliance will be assured by administration of the study treatment under the 
supervision of investigator or his/her designee, and will be verified by determination of letrozole, 
everolimus, and TRC105 in serum. 
 
 
 

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6.5 Study Drug Accountability 
 
The investigator or designee must maintain an accurate record of the shipment and dispensing of 
study treatment in a drug accountability log. Patients will be asked to return all unused study 
treatment and packaging at the end of the study or at the time of study treatment discontinuation. 
 
At study termination, and, as appropriate during the course of the study, the investigator will return 
all used and unused study treatment, packaging, drug labels, and a copy of the completed drug 
accountability log to the Novartis and TRACON monitor or to the Novartis and TRACON address 
provided in the investigator folder at each site. 
 
7.  VISIT SCHEDULE AND ASSESSMENTS 
 
7.1 Study Flow and Visit Schedule 
 
Figure F and table 7-1 (following page) list all the assessments and indicate with an “x” the times 
they need to be performed.  
 
Baseline evaluations are to be conducted within 1week prior to start of protocol therapy. Imaging 
studies must be done within 4 weeks prior to the start of therapy.  In the event that the patient's 
condition is deteriorating, laboratory evaluations should be repeated within 48 hours prior to 
initiation of the next cycle of therapy. For all visits except day 1, there is a temporal window of ±3 
days to account for holidays, inclement weather or other extraneous circumstances. The temporal 
window does not apply for PK sampling, which needs to be undertaken at the specified time 
frames. Every effort must be undertaken to follow this schedule. 
 
In patients who discontinue their treatment early, all procedures outlined in 5.4.3 (5.4.3 Safety 
Follow-up Phase) must occur within 10 days. Patients who complete the protocol treatment and 
proceed to surgery as planned do not need to have an end of treatment visit. 
 
Figure F: Study Schema 
 
Premenopausal women at the time of study enrollment will receive goserelin 3.6 mg 
subcutaneously q 4 weeks to achieve ovarian suppression. 
 
7.2 Measurement of Effect 

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Although response is not the primary endpoint of this trial, patients with measurable disease will be 
assessed by standard criteria.  Patients must have disease that can be measured and followed by 
mammogram and/or breast ultrasound. Dedicated breast MRI evaluation will be done 
baseline, week 12 and 24. For the purposes of this study, patients should be re-evaluated every 4 
weeks.   
 
7.2.1 Antitumor Effect 
 
Response and progression will be evaluated in this study using the new international criteria proposed 
by 
the 
Response 
Evaluation 
Criteria 
in 
Solid 
Tumors 
(RECIST)118 
Committee  
(http://ctep.cancer.gov/protocolDevelopment/docs/recist_guideline.pdf)118.  Changes in only the 
largest diameter (one-dimensional measurement) of the tumor lesions are used in the RECIST 
criteria. 
 

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Table 7-1: Study Calendar (see 5.4 Study Procedures) 
 
SC 
Treatment Phase11, 13 
End of 
treatment7 
 
Follow up 
C1D1 
C1D4 
C1D15 
C2D1 
C2D15 
C3D1 
C3D15 
C4D1 
C4D15 
C5D1 
C5D15 
C6D1 
C6D15 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Past Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History Present Illness 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concurrent Medications 
       X----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------X 
Prior therapy 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physician Visits 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Physical Examination 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Performance status 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Vital Signs 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Height/Weight 
X 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
CBC and  differential 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
Chemistries/Electrolytes 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
FSH, LH,estradiol levels 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Estradiol levels15 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
Pregnancy test14 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lipid panel1 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Hepatitis panel2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urinalysis3 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
12-lead EKG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum ferritin level 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Everolimus serum level 
 
X10 
 
 
X10 
 
 
 
 
 
 
 
 
 
 
 
TRC105 serum level 
 
X10 
 
 
X10 
 
 
 
 
 
 
 
 
 
 
 
Anti-TRC105 antibodies 
(APA)11 
 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
X11 
VEGF-A serum12 
X 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
X 
 
sEng / TGf-β serum12 
X 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
X 
 
Angiopoietin-1/2 
serum12 
X 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
X 
 
Research Biopsy4 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
Adverse Events 
       X----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------X 

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Mammography 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Breast ultrasound 
X 
 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Breast MRI5 
X 
 
 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
Body CT/MRI/PET6 
(X) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Letrozole8 
                X- -------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------X 
Everolimus9 
                X-------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------X 
TRC1059 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Goserelin13 
 
X 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
 
Surgery 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 

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Notes: 
1. Cholesterol, triglycerides, HDL, and LDL in a fasting state (8 hours) should be obtained at least on cycle 2 and, if elevated, repeat on each cycle 
until recovery to baseline value or grade 1. 
2. Hepatitis panel should be obtained on screening and repeated as clinically indicated (HBV-DNA, HBsAg, HBs Ab, and HBc Ab, and  RNA-
PCR). 
3. Urinalysis should be obtained on screening and repeated as clinically indicated. 
4. Research biopsy (core needle biopsy of the tumor). 
5. Breast MRI is required by the protocol.  
6. As clinically indicated after baseline diagnosis. 
7. Within a week of surgery. 
8. Continuation until the day prior to surgery. 
9. Continuation no later than 4 weeks prior to surgery. 
10. Samples will be collected and concentrations of the agents measured on cycles 1 and 2 at the following time points: pre-dose, 1, 2, 4, 6, and 24, 
hours, and cycle 1 day 4 pre-dose.  
11. TRC105 anti-product antibodies (APA) will be collected before dosing on cycle 1 day 1, every 4 weeks thereafter, 4 and 12 weeks following 
the last dose of TRC105. 
12. Markers of angiogenesis (VEGF-A, soluble VEGFR2, activin A and activin B, angiopoietin-1 and -2, TGF-β, soluble endoglin) will be 
measured on samples collected pre-dose, cycle 1 day 15, cycle 2 day 1, and prior to surgery.  
13. Administered only if FSH, LH, and estradiol NOT within postmenopausal range at the time of enrollment.  
14.  In women with childbearing potential 
15. Only in women receiving goserelin 

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7.2.2 Definitions 
 
Evaluable for toxicity.  All patients who receive at least one dose of any or all of the drugs of the 
investigational regimen will be evaluable for toxicity from the time of their first treatment until 
discontinuation or completion of the investigational therapy. 
 
Evaluable for objective response.  Only those patients who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will be 
considered evaluable for response.  These patients will have their response classified according to 
the definitions stated below.  
 
7.2.3    Disease Parameters 
 
Measurable disease.  Measurable lesions are defined as those that can be accurately measured in at 
least one dimension (longest diameter to be recorded) as >20 mm with conventional techniques 
(mammogram, breast ultrasound, exceptionally MRI).  All tumor measurements must be recorded in 
millimeters (or decimal fractions of centimeters). Note:  Tumor lesions that are situated in a 
previously irradiated area should not be considered measurable.   
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <20 mm with conventional techniques), are considered non-measurable disease.  For this 
protocol it will be satellite lesions in the affected breast. 
 
Target lesions (not applicable for this trial).  All measurable lesions up to a maximum of 5 lesions 
per organ and 10 lesions in total, representative of breast(s) involved, 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 
reference by which to characterize the objective tumor response. 
 
Non-target lesions (not applicable for this trial.  All other lesions including any measurable lesions 
over and above the 10 target lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Measurements of these lesions are not required, but the presence or absence of 
each should be noted throughout follow-up.  
 
7.2.4    Evaluation of Response Reporting 
 
Studies in the neoadjuvant setting in breast cancer have used various endpoints in the assessment of 
response including rates of pCR12,59,60,119, radiographic response1, and clinical response4,14,17. 
Although these endpoints may have their limitations, the rates of pCR is the outcome measure least 
subject to serious errors of measurement and interpretation. All three outcome measures will the 
recorded and reported. The following definitions will be used: 
 
 
 

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a. Clinical response: the target lesion will be clinically assessed and measured using calipers on 
each visit. At least 2 dimensions will be measured and recorded. The maximum reduction in the 
maximum dimension of the tumor from baseline will be recorded as the best clinical response. 
 
b. Radiographic response: the target lesion(s) will be measured and recorded at least in 2 dimensions 
on mammograms, breast ultrasound, and MRI. RECIST will be used to assess the best 
radiographic response (see below 7.2.5 Methods for Evaluation of Measurable Disease). 
 
c. Pathologic response: the 2-dimensional size of the surgically excised residual tumor will be 
measured and compared to the radiographic size of the tumor at baseline. The maximum 
dimension will be used for comparison. 
 
Definition of pathologic complete remission (pCR): the definition adopted by the Center for Drug 
Evaluation and Research of the FDA104 will be used to define and report pCRs. According to the 
Center for Drug Evaluation and Research of the FDA, a pCR is defined as the absence of any residual 
invasive cancer on hematoxylin and eosin evaluation of the resected breast specimen and all sampled 
ipsilateral lymph nodes following completion of neoadjuvant systemic therapy (i.e., ypT0 ypN0 in 
the current AJCC staging system)104. For this protocol, near pCR will be considered if the breast 
residual disease is less or equal to 0.5 cm.  
 
7.2.5   Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment. 
 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Evaluation by clinical examination 
will always be complemented by imaging evaluation. See Appendix C for guidelines issued by the 
American College of Radiology for imaging studies of the breast. In cases of discrepancy between 
clinical and radiographic evaluation by >1 cm, a complementary imaging technique (breast 
ultrasound when the mammograms are inconclusive and breast MRI when both mammograms and 
breast ultrasound are inconclusive) will be used for the initial and subsequent assessments of the 
target lesion(s). 
 
7.2.5.1 Clinical Assessments 
 
Target lesion(s) in the breast or target ipsilateral lymph nodes will be measured using calipers and 
the size in two dimensions will be recorded on each clinical visit.  
 
7.2.5.2 Mammography 
 
Standard diagnostic mammograms will be used to identify and follow the target lesion(s) during the 
course of the protocol treatment. All mammograms will be obtained at the Kirklin Clinic which meets 
the requirements set forth by the Mammography Quality Standards Act (MQSA) final rule published 
by the Federal Drug Administration (FDA). 

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Technical considerations of diagnostic mammography (The American College of Radiology Practice 
Guideline 
for 
the 
Performance 
of 
Screening 
and 
Diagnostic 
Mammography, 
http://www.acr.org/~/media/3484ca30845348359bad4684779d492d.pdf): 
 
1. A diagnostic mammogram will include mediolateral oblique (MLO), craniocaudal (CC), and/or 
supplemental views to evaluate an area of clinical or radiographic concern. 
 
2. Supplemental mammographic views might include spot compression, spot compression with 
magnification, tangential views, or other special views. 
 
3. When selecting a view, the proximity of the area of concern to the image receptor should be 
considered. 
 
4. Diagnostic mammography should be performed under the immediate supervision of the 
interpreting physician. 
 
7.2.5.3 Breast Ultrasound 
 
Breast ultrasound (US) is particularly helpful in further delineating findings on mammography. All 
breast ultrasounds will be obtained at the Kirklin Clinic to complement diagnostic mammograms. 
 
Technical considerations of Breast Ultrasonography (The American College of Radiology Practice 
Guideline for the Performance of a Breast Ultrasound Examination,  
http://www.acr.org/~/media/52D58307E93E45898B09D4C4D407DD76.pdf) 
 
1. The breast sonogram should be correlated with clinical signs and/or symptoms and with 
mammographic and other appropriate breast imaging studies. If sonography has been performed 
previously, the current examination should be compared with prior sonograms. A lesion or any area 
of the breast being studied should be viewed in 2 perpendicular projections, and real-time scanning 
by the interpreter is encouraged. 
 
2. The size of a lesion should be determined by recording its maximal dimensions in at least 2 planes; 
orthogonal planes are recommended. At least 1 set of images of a lesion should be obtained without 
calipers. 
 
3. The images should be labeled as to right or left breast, location of lesions, and the orientation of 
the transducer with respect to the breast (e.g., transverse or longitudinal, radial or antiradial). The 
location of the lesion should be recorded using clock face notation and distance from the nipple, 
and/or shown on a diagram of the breast. The length of the transducer face (footprint), usually 
between 3.5 cm and 5 cm, can be used to estimate the distance from the nipple. Measurements should 
not be made from the edge of the areola, as areolar width is widely variable. 
 
4. Sonographic features are helpful in characterizing breast masses. These feature categories and their 
descriptors are listed and exemplified in the ACR Breast Imaging Reporting and Data System® 
(BIRADS®). The BI-RADS sonographic categories include size, shape, orientation, margin, 

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echogenicity, lesion boundary, attenuation (e.g., shadowing or enhancement), special cases, 
vascularity, and surrounding tissue120. 
 
5. Elastography, or tissue stiffness assessment, is among the new feature categories applicable to 
sonographic analysis of masses, to be included in the Associated Findings section in BI-RADS 
Ultrasound, edition 2. To minimize errors in communication or interpretation, if elastography is 
performed, the color scales should be annotated to denote hardness or softness. 
 
6. Mass characterization with ultrasonography is highly dependent on technical factors. Breast 
ultrasound should be performed with a high-resolution scanner. Gain settings, focal zone selections, 
and fields of view should be optimized to obtain high-quality images. The patient should be 
positioned to minimize the thickness of the portion of the breast being evaluated. For evaluation of 
lesions in, on, or just beneath the skin, a stand-off device or thick layer of gel may be helpful 
 
7.2.5.4 Breast Magnetic Resonance Imaging 
 
Breast Magnetic Resonance Imaging (MRI) is required by the protocol.  
 
Technical considerations of Breast MRI (The American College of Radiology Practice Guideline for 
the Performance of Contrast-Enhanced Magnetic Resonance Imaging [MRI] of the Breast, 
http://www.acr.org/~/media/2A0EB28EB59041E2825179AFB72EF624.pdf) 
 
1. Resolution, contrast, and field strength: Although a 1.5T magnet has traditionally been considered 
a minimum technical requirement because of the relationship between field strength and resolution, 
improvements in other components of the scanning process have resulted in improved scan quality 
at lower field strengths. High spatial and temporal resolutions are needed to detect and characterize 
small abnormalities on MRI. The slice thickness should be 3 mm or less, and in-plane pixel resolution 
should be 1 mm or less to minimize the problem of volume averaging effects. Optimized contrast 
between tumor and surrounding tissue is important. When high-resolution images are being obtained, 
chemical fat suppression is helpful as a method to reduce fat signal while preserving the signal-to-
noise ratio. Sole reliance on subtraction imaging for assessment of enhancement may result in 
misregistration due to patient motion; use of fat suppression is recommended on sequences used to 
assess contrast enhancement. Protocols may incorporate both fat suppression and subtraction. Motion 
correction may be helpful in reducing artifacts encountered with image subtraction. 
 
2. Contrast: Gadolinium contrast enhancement is generally needed in the evaluation of breast cancer. 
Gadolinium contrast should be administered as a bolus with a standard dose of 0.1 mmol/kg followed 
by a saline flush of at least 10 ml. 
 
3. Scan time: A pre-contrast scan should be obtained. Scan time in relation to contrast injection is 
extremely important for lesion characterization. Kinetic information should be reported, based on 
enhancement data determined at specified intervals separated by 4 minutes or less. Imaging sites 
should have adequately short temporal resolution for accurate capture of lesion kinetics. 
 
4. Examinations should be performed with a dedicated bilateral breast MRI coil. 
 

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Tumor markers.  Tumor markers alone cannot be used to assess response and will not be routinely 
obtained in the course of the study. Patients with stage III breast cancer will undergo imaging studies 
including imaging studies dedicated to identify skeletal metastases (bone scan and/or bone surveys) 
to confirm absence of metastatic disease.  
 
7.2.6 Response Criteria 
 
7.2.6.1  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 
 
7.2.6.2 
Evaluation of Non-Target Lesions 
 
Complete Response (CR): Disappearance of all non-target lesions. 
 
Incomplete Response/Stable Disease (SD): Persistence of one or more non-target lesion(s). 
 
Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal progression 
of existing non-target lesions 
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the treating 
physician should prevail in such circumstances, and the progression status should be confirmed at a 
later time by the review panel (or Principal Investigator). 
 
7.2.6.3  Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment until 
completion of protocol treatment, early termination, or 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 
Best Response for this 
Category Also Requires: 
CR 
CR 
No 
CR* 
NA for  this trial 

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CR 
Non-CR/Non-PD 
No 
PR** 
NA for this trial 
PR 
Non-PD 
No 
PR 
 
SD 
Non-PD 
No 
SD 
Documented at least once 
> 4 wk from baseline 
PD 
Any 
Yes or No 
PD 
No prior SD, PR or CR 
Any 
PD*** 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
*   For the definition of a pCR please refer to section 7.3.1.3. Definition of pathologic complete 
remission (pCR). No subsequent confirmation is required for pCR. ** Residual disease 
persistent in pathology specimen (near pCR if less than 0.5 cm residual disease in the breast) 
 
***In exceptional circumstances, unequivocal progression in non-target lesions may be accepted  as 
disease progression. 
 
Note: Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be reported as 
“symptomatic deterioration”.  Every effort should be made to document the objective 
progression even after discontinuation of treatment. 
 
7.2.7 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for clinical CR or PR (whichever is first recorded) until completion of 
protocol treatment or early termination or the first date that recurrent or progressive disease is 
objectively documented (taking as reference for progressive disease the smallest measurements 
recorded since the treatment started). 
 
The duration of overall clinical CR is measured from the time measurement criteria are first met for 
CR until the first date that recurrent disease is objectively documented. 
 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment until completion 
of protocol treatment or early termination or the criteria for progression are met, taking as reference 
the smallest measurements recorded since the treatment started.  
 
7.3 Pharmacokinetic and Pharmacodynamic Studies and Research Biopsy 
 
Figure G provides an outline of the planned pharmacokinetic and pharmacodynamics studies and 
the time or research biopsy. 
 
 
Figure G 

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7.3.1 Pharmacokinetic (PK) and Anti-Product Antibody (APA) studies 
 
To investigate the pharmacokinetic interaction between TRC105 and everolimus, samples will be 
collected and concentrations of the agents measured on cycle 1 day 1 and cycle 2 day 1 at the 
following time points: predose, 1, 2, 4, 6, 24 hours, and cycle 1 day 4 pre-dose. Pharmacokinetic 
parameters to be estimated include maximum serum concentration (Cmax), time of maximum serum 
concentration (Tmax), area under the serum concentration versus time curve (AUC), terminal half-life 
(T½), and clearance.  
 
Serum for assessment of TRC105 anti-product antibody (APA) formation will be collected before 
dosing on cycle 1 day 1, every 4 weeks thereafter, 4 and 12 weeks following the last dose of TRC105 
and concentrations will be determined by a validated ELISA53. 
 
7.3.2 Pharmacodynamic (PD) studies  
 
Markers of angiogenesis (VEGF-A, soluble VEGFR2, activin A and activin B, angiopoietin-1 and -
2, TGF-β, soluble endoglin) will be measured on  serum samples collected predose, cycle 1 day 15, 
cycle 2 day 1, and prior to surgery.  
 
7.3.3 Research biopsies  
 
Formalin-fixed paraffin embedded tissue blocks from the patient’s primary tumor collected for 
diagnostic purposes will be requested for all patients enrolled in the study at the time of registration. 
In addition, a research biopsy will be obtained at baseline, on cycle 2 day 1, and at the time of surgery 
if residual tumor. The goal is for 2-4 core biopsy specimens obtained using standard institutional 
guidelines for a diagnostic core biopsy of a breast mass. However, biopsy samples will preferably be 
obtained using a 14-18 gauge core needle. At least one core will be use to prepare a paraffin block 
(paraffin-embedded blocks or formalin fixed tissue) and at least one core will be immediately freeze 
(snap frozen individually for gene expression).  
 
Snap frozen research biopsies will be sent to UAB Tissue Procurement where biopsies will be stored 
for batching.  The batched biopsies will then be forwarded to HudsonAlpha Institute for 
Biotechnology.  All samples will be indelibly labeled with the appropriate study number, and date of 

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acquisition; these data will be correlated with clinical efficacy including complete response and 
objective response. All samples sent to HudsonAlpha Institute for Biotechnology for comprehensive 
genomic analysis will be labeled with the appropriate study number only. Frozen research biopsy 
will be used for comprehensive genomic analysis such as Next-GEN genomic analysis. “Next-GEN 
genomic analysis will be done at HudsonAlpha Institute for Biotechnology in Huntsville, Alabama 
(Shared Facility of the UAB Comprehensive Cancer Center) by Dr. Richard Myers’ group. No 
funding is necessary to conduct the evaluation in the laboratory at this time or macro-dissection; 
funds are needed only for shipping. 
 
Researchers at HudsonAlpha Institute for Biotechnology led by Dr. Richard M. Myers will obtain 
tissues from Drs. Erica M. Stringer- Reasor and Christos Vaklavas at UAB from patients enrolled in 
the pilot Study.  HudsonAlpha Institute for Biotechnology will analyze the tissues for several 
functional genomics features on a genome-wide scale, as well as whole exome DNA sequencing, to 
identify genetic variants. The functional genomics readout and genetic variation measurements will 
be assessed to help identify differences associated subtypes and/or responses to drug treatments.  The 
researchers at Hudson will utilize their expertise in applying six different genome-wide functional 
genomics measurements, as well as whole exome sequencing, whole genome sequencing and 
specialized array-based genotyping to measure genomic and genetic variants for cancers, brain 
diseases, autoimmune diseases and drug responses. The functional genomics measurements will 
include the use of ultrahigh throughput sequencing to measure mRNAs and long non-coding RNAs 
(RNA-seq), microRNAs (miRNA-seq), DNA methylation (a combination of two approaches, RRBS 
and Methyl1450 arrays), protein:DNA interations (ChIP-seq), chromatin markers (also ChIP-seq) 
and chromatin accessibility measurements (DNase-seq). 
 
To measure DNA sequence variation, two types of ultrahigh throughput DNA sequencing will be 
performed: whole exome sequencing, where all the exons and exon:intron boundaries in the human 
genome are sequenced deeply; and whole genome sequencing, to be used on a modest number of 
samples due to expense. A combination of exome and whole genome sequencing with inexpensive 
genotyping of 1 million or more polymorphic DNA markers around the genome may be used to 
supplement the DNA sequencing and to improve the ability to identify large DNA sequence variants 
known as copy number variants. 
 
Fifteen slides will be prepared from the paraffin blocks or formalin fixed tissue by Dr. Grizzle at 
UAB for analysis by conventional IHC of ER, PR, Her-2, EGFR, Ki67, apoptotic markers, and 
biomarkers of DNA repair such as H2AX and BRCA localization. All samples will be indelibly 
labeled with the appropriate study number, and date of acquisition; these data will be correlated with 
clinical 
efficacy 
including 
complete 
response 
and 
objective 
response. 
In 
addition, 
immunohistochemistry for pAKT and PTEN (markers of the PI3K/AKT/mTOR pathway), CD105 
and CD31/CD34 (pan-endothelial markers), and NG2 and MCAM/CD146 (pericyte markers) will be 
conducted on the diagnostic research tissue, the research biopsy, and the final surgical specimen.   
 
Any leftover study blood and tissue samples may be stored for future research studies.  The subjects 
will consent to the future use of samples in the consent form for the study.  Any samples will only 
be released for use in future studies after approval by the Principal Investigator and other regulatory 
bodies, as appropriate. 
 

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7.3.4 Ribosomal profiling on the final surgical specimen  
 
Fresh frozen, macrodissected surgical specimens collected and stored in RNAlater with the 
assistance of Tissue Procurement that meet criteria for expanded ribosomal profiling will undergo 
next-generation sequencing. We anticipate that small size of the residual tumor that is surgically 
excised will be the principal limiting factor in the conduction of this correlative study. Based on our 
previous experience1,2, we project that in the course of the study approximately 8 surgical specimens 
will undergo expanded ribosomal profiling. Three samples of previously untreated hormone receptor 
positive and Her2 negative breast cancer matched for clinical and demographic characteristics with 
the study samples and 3 samples of normal breast tissue resected for indications other than cancer 
will undergo expanded ribosomal profiling following the same protocol. Both samples of untreated 
luminal breast cancer and normal breast tissue will be obtained from patients who will not participate 
in the study. 
 
8. ASSESSMENT OF SAFETY 
 
8.1 Adverse Events Reporting and Definitions  
 
In the event of an adverse event the first concern will be for the safety of the subject.  Toxicities will 
be graded using the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 
(see http://ctep.cancer.gov/reporting/ctc.html - see Appendix D).Adverse events that begin or worsen 
after informed consent should be recorded. Conditions that were already present at the time of 
informed consent should be recorded in the Medical History page of the patient’s CRF. Adverse 
event monitoring should be continued for at least 30 days (or 5 half-lives, whichever is longer) 
following the last dose of study treatment. Adverse events (including lab abnormalities that constitute 
AEs) should be described using a diagnosis whenever possible, rather than individual underlying 
signs and symptoms. When a clear diagnosis cannot be identified, each sign or symptom should be 
reported as a separate Adverse Event. 
 
8.1.1 Adverse Events (AEs) 
 
Adverse events should be followed to resolution or stabilization, and reported as SAEs if they become 
serious. This also applies to patients experiencing AEs that cause interruption or discontinuation of 
investigational product or those experiencing AEs that are present at the end of their participation in 
the study. Such patients should receive post-treatment follow-up as appropriate as it has been 
described throughout the protocol. If an ongoing AE changes in its severity or in its perceived 
relationship to study drug, a new AE should be completed. 
 
The FDA has mandated that Novartis and TRACON be notified, at least one time per year, or at the 
agreed upon timeframe, of all non-serious adverse events that: (a) are grade 3-4 toxicity and (b) result 
in the subject’s premature discontinuation of the study. In addition, accrual will be halted as a result 
of “any grade ≥3 hemorrhage, cerebrovascular and vasovagal adverse events; FDA will be contacted 
to discuss further accrual or potential need for protocol amendment 
8.1.2 
Serious Adverse Event (SAEs)  
 

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SAEs require expeditious handling and reporting to UAB to comply with regulatory requirements. 
Investigators are required to report within 24 hours of investigator’s knowledge (MedWatch Form 
3500A) to the principal investigators (UAB – Erica M. Striger- Reasor), who will report to the FDA, 
UAB IRB, Novartis, and TRACON in accordance with regulatory requirements or contractual 
agreement ANY serious treatment emergent (occurring at any time during treatment, not present at 
baseline and related to study drug) adverse event (SAE) as soon as possible. SAEs must be reported 
to local IRB according to their institutional guidelines. All SAEs must be collected and reported until 
30 days following patient discontinuation of dosing; if only limited information is initially available, 
follow-up reports are required. The original SAE form must be kept on file at the study site.  
 
Any SAEs experienced after this 30 days period should only be reported to Novartis or TRACON 
pharmaceutical if the investigator suspects a causal relationship to the study drug. Recurrent 
episodes, complications, or progression of the initial SAE must be reported as follow-up to the 
original episode within 24 hours of the investigator receiving the follow-up information. A SAE 
occurring at a different time interval or otherwise considered completely unrelated to a previously 
reported one should be reported separately as a new event.  The end date of the first event must be 
provided. 
 
Follow-up information is sent to the same fax number as the original SAE Report Form was sent, 
using a new fax cover sheet, stating that this is a follow-up to the previously reported SAE, and 
giving the date of the original report. Each re-occurrence, complication, or progression of the original 
event should be reported as a follow-up to that event regardless of when it occurs. The follow-up 
information should describe whether the event has resolved or continues, if and how it was treated, 
whether the blind was broken or not (if applicable), and whether the patient continued or withdrew 
from study participation. 
 
A SAE is any sign, symptom or medical condition that emerges during treatment (with everolimus 
and TRC105) or during a post-treatment follow-up period that (1) was not present at the start of 
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 everolimus/TRC105 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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8.1.3 
Reporting of Serious Treatment Emergent Adverse Events  
 
All SAEs should be recorded on a MedWatch 3500A Form (can be accessed at: 
https://www.accessdata.fda.gov/scripts/MedWatch - see Appendix E) and faxed to: 
 
Pam Dixon 
 
 
 
 
 
Erica M. Sringer- Reasor 
Phone: 205-975-5387  
 
 
and 
Phone:  
Fax: 205-975-9875 
 
 
 
 
Fax: 205-995-9996 
 
Once forms are reviewed, UAB will report to: 
 
MedWatch 
 
 
 
 
 
Novartis 
5600 Fishers Lane 
 
 
 
 
Drug Safety 
Rockville, MD 20852-9787  
 
and 
Fax: 877-778-9739 
Fax: 1-800-FDA-0178 (1-800-332-0178) 
 
usdrugsafety.operations@novartis.com 
 
And 
 
UAB IRB  
 
and 
 
TRACON 
Drug safety 
Fax: (XXX) XXX-XXXX 
XXXX@XXXXXX 
 
E-mail:  
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 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 

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 Adding supplemental summary information and submitting it as follow-up with the original 
MedWatch 3500A form  
 Summarizing new information and faxing it with a cover letter including subject identifiers 
(i.e. D.O.B., initials, 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 the principal investigator and/or UAB may contact the reporter for additional 
information, clarification, or current status of the subject for whom an adverse event was reported.  
 
Assessing Causality: 
Investigators are required to assess whether there is a reasonable possibility that everolimus/TRC105 
caused or contributed to an adverse event.  The following general guidelines may be used. 
Yes: 
if the temporal relationship of the clinical event to everolimus/TRC105 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 everolimus/TRC105 administration makes 
a causal relationship unlikely, or other drugs, therapeutic interventions or underlying conditions 
provide a sufficient explanation for the observed event. 
 
Attribution of the AE: 
 Definite – The AE is clearly related to the study treatment. 
 Probable – The AE is likely related to the study treatment. 
 Possible – The AE may be related to the study treatment. 
 Unlikely – The AE is doubtfully related to the study treatment. 
 Unrelated – The AE is clearly NOT related to the study treatment. 
 
8.2       Adverse reactions with everolimus 
 
8.2.1    Clinical adverse reactions with everolimus 
The most common ADRs (incidence ≥1/10 and suspected to be related to treatment by the 
investigator) from the pooled safety data were (in decreasing order): stomatitis, rash, fatigue, 
diarrhea, infections, nausea, decreased appetite, anemia, dysgeusia, pneumonitis, hyperglycemia,  
weight decreased, pruritus, asthenia peripheral edema, hypercholesterolemia, epistaxis, and 
headache. The most common grade 3/4 ADRs (incidence ≥1/100 to <1/10 and suspected to be related 
to treatment by the investigator) were stomatitis, anemia, hyperglycemia, fatigue, infections, 
pneumonitis, diarrhea, asthenia, thrombocytopenia, neutropenia, dyspnea, lymphopenia, proteinuria, 
hemorrhage, hypophosphatemia, rash, hypertension, aspartate aminotransferase (AST) increased, 
alanine aminotransferase (ALT) increased, and pneumonia. Table 8-1 presents the frequency 
category of ADRs reported in the pooled safety analysis. 
 
Table 8-1: Adverse Drug Reactions associated with everolimus 

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Adverse Drug Reactions are listed according to MedDRA system organ class. Within each system organ class, the adverse reactions 
are ranked by frequency, with the most frequent reactions first. In addition, the corresponding frequency category using the 
following convention (CIOMS III) is also provided for each adverse reaction: very common (≥1/10); common (≥1/100 to <1/10); 
uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000) 
Infections and infestations 
Very common 
Infectionsa 
Blood and lymphatic system disorders 
Very common   
Common  
Uncommon  
Rare 
Anemia,  
Thrombocytopenia, neutropenia, leukopenia, lymphopenia 
Pancytopenia 
Pure red cell aplasia 
Immune system disorders 
Uncommon   
Hypersensitivity 
Metabolism and nutrition disorders 
Very common    
Decreased appetite, hyperglycemia, hypercholesterolemia 
Common 
Hypertriglyceridemia, hypophosphatemia, diabetes mellitus,    
hyperlipidemia, hypokalemia, dehydration                                               
Psychiatric disorders 
Common 
Insomnia 
Nervous system disorders 
Very common     
Dysgeusia, headache 
Uncommon 
Ageusia 
Cardiac disorders 
Uncommon 
Congestive cardiac failure 
Vascular disorders 
Common 
Hemorrhageb, hypertension, 
Uncommon 
Deep vein thrombosis 
Respiratory, thoracic and mediastinal disorders 
Very common      
Common  
Uncommon 
Rare 
Pneumonitisc, epistaxis,  
cough, dyspnea 
Hemoptysis, pulmonary embolism  
acute respiratory distress syndrome 
Gastrointestinal disorders 
Very common     
Common 
Stomatitisd, diarrhea, nausea 
Vomiting,  dry mouth, abdominal pain, oral pain, dyspepsia, 
dysphagia 
Skin and subcutaneous tissue disorders 
Very common 
Common  
Rare 
Rash, pruritus 
Dry skin, nail disorder, acne, erythema, hand-foot syndrome 
Angioedema 
Musculoskeletal and connective tissue disorders 
Common 
Arthralgia 
Renal and urinary disorders 
Common 
Uncommon      
Proteinuria, Renal failure 
Increased daytime urination, acute renal failure 
Reproductive system and breast disorders 
Common 
Uncommon  
Menstruation irregular f  
Amenorrhea 
General disorders and administration site conditions 
Very common       
Common   
Uncommon  
Rare   
Fatigue, asthenia,  peripheral edema  
Pyrexia, mucosal inflammation 
Non-cardiac chest pain 
impaired wound healing 
Investigations 
Very common        
Common    
Weight decreased  
aspartate aminotransferase increased, Alanine aminotransferase 
increased, blood creatinine increased 
a Includes all reactions within the ‘infections and infestations’ system organ class including common: pneumonia 

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and uncommon: herpes zoster, sepsis and isolated cases of opportunistic infections (e.g. aspergillosis, 
candidiasis and hepatitis B) 
b Includes different bleeding events not listed individually 
c Includes common: pneumonitis: interstitial lung disease, lung infiltration, and rare - alveolitis, pulmonary 
alveolar hemorrhage, and pulmonary toxicity 
d Includes very common: stomatitis; common: aphthous stomatitis, mouth and tongue ulceration; uncommon: 
glossitis, glossodynia 
e reported as palmar-plantar erythrodysaesthesia syndrome 
f frequency is based upon number of women age 10 to 55 years of age in the safety pool 
 
 
8.2.2    Clinically relevant laboratory abnormalities seen with everolimus 
 
In the pooled double-blind phase III safety database, the following new or worsening clinically 
relevant laboratory abnormalities were reported with an incidence of ≥1/10 (very common, listed in 
decreasing frequency). 
 
 Hematology: hemoglobin decreased, lymphocytes decreased, white blood cells decreased, 
platelets decreased, and neutrophils decreased (or collectively as pancytopenia); 
 
 Clinical chemistry: glucose (fasting) increased, cholesterol increased, triglycerides increased, 
AST increased, phosphate decreased, ALT increased, creatinine increased, and potassium 
decreased. 
 
Most of the observed abnormalities (> 1/100) were mild (grade 1) or moderate (grade 2). Grade 3/4 
hematology and chemistry abnormalities include: 
 
 Hematology: lymphocytes decreased, hemoglobin decreased,  (very common); neutrophils 
decreased, platelet count decreased, white blood cells decreased (all common). 
 
 Clinical chemistry: glucose (fasting) increased, phosphate decreased, potassium decreased, AST 
increased, ALT increased, creatinine increased cholesterol (total) increased, triglycerides 
increased (all common).  
 
  
8.2.3    Serious adverse events associated with everolimus 
 
Table 8-2 lists all fatal adverse events reported by investigators across all RAD001 studies as having 
a suspected causal relationship to everolimus and occurring on or before the cut-off date of 31-Mar-
2014. In clinical trials and post-marketing spontaneous reports, everolimus has been associated with 
serious cases of the following: 
 
 Hepatitis B reactivation, including fatal outcome. Reactivation of infections is an expected event 
during periods of immunosuppression.  
 Renal failure events (including fatal ones) and proteinuria. Monitoring of renal function is 
recommended. 
 Amenorrhea (including secondary amenorrhea). 
 Pneumocystis jirovecii pneumonia (PJP) some with a fatal outcome. 

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 Angioedema has been reported with and without concomitant use of everolimus and ACE 
inhibitors 
 
Table 8-2 
 
MedDRA system organ class 
Event 
Blood and lymphatic system disorders 
Thrombocytopenia 
Cardiac disorders 
Acute cardiopulmonary event, cardiogenic shock, 
cardio-respiratory arrest, myocardial infarction 
Gastrointestinal disorders 
Diarrhea, duodenal ulcer, GI hemorrhage, intestinal 
perforation, esophageal perforation, internal hernia 
General disorders/administration site conditions 
Cold sweat, concomitant disease progression, general 
physical health deterioration, multi-organ failure, 
sudden death 
Infections and infestations 
Candidal sepsis, EBV pneumonia, neutropenic sepsis, 
pneumocystis jiroveci pneumonia, reactivation of 
Hepatitis B, septic shock, septicemia with massive 
Epstein-Barr viremia 
Injury, poisoning and procedural complications 
Bone fissure 
Metabolism and nutrition disorders 
Dehydration, ketoacidosis, hyperglycemia 
Neoplasms benign, malignant and unspecified 
(including cysts and polyps) 
Squamous cell carcinoma of skin 
Nervous system disorders 
Cerebral hemorrhage, embolic stroke, restlessness 
Renal and urinary disorders 
Renal tubular necrosis 
Respiratory thoracic and mediastinal disorders 
Acute cardiopulmonary event, acute respiratory 
distress syndrome, cardio-respiratory arrest, dyspnea, 
chronic obstructive pulmonary disease, interstitial 
pneumonia, pulmonary embolism, pulmonary edema, 
pneumonitis 
Vascular Disorders 
Cerebral hemorrhage, disseminated intravascular 
coagulation, embolic stroke, hemorrhage, hypovolemic 
shock, myocardial infarction, pulmonary hypertension 
Table 8-3 lists all serious, unexpected, life-threatening adverse events considered related to 
everolimus, and reported on at least one occasion up to the cut-off date of 31-Mar-2014. It should 
be stressed that many of these SAE reports have been reported only on a single occasion making 
an accurate assessment of causality difficult, if not impossible. Due to the imprecision of 
causality, the causality assessments should not be assumed that all of these events are indeed 
the result of therapy with everolimus. Moreover, the assessment of causality is particularly difficult 
in critically ill patients where confounding factors are present relating mainly to complications of the 
underlying disease and to the use of prior therapy and/or concomitant medications. In addition to the 
SAE reports presented below, disease progression has on occasions been reported somewhat 
paradoxically as an SAE with a suspected causal relationship to everolimus and reported on at least 
one occasion. Individual events are presented for each MedDRA system organ class. 
 
Table 8-3 
 

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MedDRA 
system 
organ 
class 
Event 
Blood and lymphatic system 
disorders 
Acute leukemia, anemia, bone marrow failure, disseminated intravascular coagulation, 
febrile neutropenia, hemorrhagic diathesis, leukemoid reaction, leukocytosis, leukopenia, 
lymphadenopathy, lymphedema, lymphopenia, neutropenia, pancytopenia, platelet disorder, 
retroperitoneal lymphadenopathy, thrombocytopenia, white blood cell disorder, hemolytic 
uremic syndrome 
Cardiac disorders 
atrial fibrillation, atrioventricular block,  cardiorespiratory arrest, cardiopulmonary 
arrest, congestive cardiomyopathy, cyanosis, diastolic dysfunction, dilatation left atrial and 
left ventricular, hypertrophy, left ventricular hypertrophy, left ventricular dysfunction, 
myocardial infarction, myocardial ischemia, hypertensive heart 
disease, palpitations, pericardial effusion, right ventricular failure, sinus tachycardia, 
stress cardiopathy, supraventricular tachycardia, tachycardia, ventricular dysfunction 
Valve incompetence: mitral/pulmonary/tricuspid 
Ear and labyrinth disorders 
Vertigo, sudden hearing loss, deafness unilateral 
Endocrine disorders 
Hyperthyroidism , hyperglycemic non-ketotic syndrome, hypercalcemia, hypothyroidism 
Eye disorders 
Conjunctivitis, eyelid edema, scleral discoloration, ocular discomfort, ocular surface disease, 
phthalmoplegia_cranial nerve paralysis, papilloedema, photophobia, retinal artery 
thrombosis, retinal detachment, retinal hemorrhage, steroid Induced 
cataract, senile cataract, visual acuity reduced. 
Gastrointestinal disorders 
Abdominal abscess, abdominal adhesions, abdominal: 
discomfort/distension/pain/tenderness, anorectal discomfort, anal fissure, anal fistula, 
anastomotic leak, ascites, colitis, constipation, diarrhea, diverticulum, 
duodenal ulcer, dyspepsia, dysphagia, esophageal perforation, feces discolored, gastric 
perforation, gastric ulcer hemorrhage, gastric ulceration, gastrointestinal 
angiodysplasia, gastrointestinal ischemia,  gastrointestinal oedema, gastroenteritis, 
hemorrhoids,hematemesis, hematochezia, hiccups, ileus, intestinal perforation, melena, 
mesenteric vein thrombosis, mouth ulceration, nausea, pancreatitis, 
proctalgia, proctitis, recall phenomenon radiation enteritis, rectal discharge/hemorrhage, 
small intestinal obstruction, stomatitis, swollen tongue, vomiting, oral pain, enterovesical 
fistula, radiation esophagitis, necrotizing esophagitis, salivary gland calculus, small bowel 
thickness, thickened bowel Wall Gastritis: erosive/ hemorrhagic Lip: 
edema/swelling/ulceration 
Gastrointestinal: disorder/hemorrhage/sounds 
Mucosal: hemorrhage/inflammation 
General disorders and 
administration site conditions 
Application site erythema, asthenia, bloody discharge, calcinosis, chest discomfort/pain, 
chills, concomitant disease progression, condition aggravated, crepitations, death, 
discomfort, disease progression, drug ineffective, and drug withdrawal syndrome (asthenia 
and flushing) edema peripheral, face edema, facial pain, fatigue, feeling of body temperature 
change, general physical health deterioration, generalized edema, goiter, granuloma, 
hypertrophy, hypothermia, 
impaired healing, inflammation, influenza like illness, irritability, local swelling, malaise, 
mass, multi-organ failure, necrosis, non-cardiac chest pain, pain, 
performance status decreased, pitting edema, pyrexia, sudden death, swelling, tenderness, 
thirst 
Hepatobiliary disorders 
Cholecystitis, cholelithiasis, cholestasis, cytolytic hepatitis, hepatic cirrhosis, hepatic 
failure, hepatic function abnormal, hepatic necrosis, hepatorenal failure, hepatitis B and C 
reactivation, hepatomegaly, hyperbilirubinemia, jaundice, portal vein thrombosis 
Immune system disorders 
Acute disseminated encephalomyelitis, autoimmune disorder, cytokine release syndrome, 
Guillian Barre syndrome, hypersensitivity, immunosuppression, Stevens- Johnson syndrome 
Infections and infestations 
Abdominal abscess, aspergillosis, bacteremia, bronchitis, bronchitis viral, 
bronchopneumonia, bronchopulmonary aspergillosis, candida sepsis, candidiasis, 
cellulitis, citrobacter sepsis, clostridium bacteremia, endocarditis, escherichia 
bacteremia, folliculitis, gastroenteritis, gastroenteritis norovirus, hepatitis fulminant, 
herpes zoster, infected lymphocele, klebsiella sepsis, liver abscess, meningitis, 
herpes, nasopharyngitis, neutropenic sepsis, oral candidiasis, oral fungal infection, 
perirectal/anal abscess, pharyngitis, pneumococcal sepsis, pseudomonal 
bacteremia, purulent discharge, pyelonephritis, rectal abscess, respiratory 
moniliasis, sepsis, sepsis syndrome, septic shock, sinusitis, staphylococcal 

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bacteremia, staphylococcal sepsis, streptococcal bacteremia, tonsillitis, tuberculosis, 
urosepsis Infection(s): alpha hemolytic streptococcal/atypical 
mycobacterial/bacterial/clostridial/enterobacter/enterococcal/epstein-barr virus/ 
escherichia/escherichia urinary 
tract/gastrointestinal/haemophilus/herpesvirus/fungal/general/klebsiella/localized/low 
er respiratory tract lung/ morganella/pseudomonas/proteus/respiratory 
tract/skin/streptococcal/staphylococcal/urinary tract/wound/ wound staphylococcal 
Pneumonia: Pneumocystis jirovecii/general/bacterial/ streptococcal 
Injury, poisoning and 
Procedural complications 
Abdominal adhesion, anastomotic leak, bone fissure, collapse of lung, contusion, 
eschar, fall, head injury, lung injury, medical device complication, medication error, 
post procedural swelling, recall phenomenon radiation enteritis, surgical procedure 
repeated, vena cava injury, wound dehiscence/secretion 
Investigations 
Aspiration pleural cavity, antinuclear antibody positive, bleeding time prolonged, 
breath sounds abnormal, cardiac function test abnormal, chest X-ray abnormal, 
clostridium difficile toxin test positive, computerised tomogram abnormal, ejection 
fraction decreased, endoscopy upper gastrointestinal tract, general physical 
condition abnormal, granulocyte count decreased, hematocrit/hemoglobin 
decreased, hypophosphatemia, liver function test abnormal, neutrophil count 
abnormal/decreased, occult blood positive, oxygen saturation abnormal/decreased, 
peak expiratory flow rate decreased, protein urine present, QRS axis abnormal, 
urine output decreased, X-ray abnormal; Increased: alanine aminotransferase, ammonia, 
aspartate aminotransferase, aspartate aminotransferase, body temperature, C-reactive protein, 
eosinophil count, gamma-glutamyltransferase, international normalised ratio, lipase, red 
blood cell count, sedimentation rate, transaminases, troponin T, troponin Platelet count: 
abnormal/decreased/increased 
White blood cell(s): count abnormal/decreased/in urine Lymphocyte count: 
decreased/increased Blood: amylase increased/albumin decreased/alkaline phosphatase 
increased/bilirubin increased/creatine phosphokinase increased/creatinine 
increased/magnesium decreased/glucose increased/lactate dehydrogenase 
increased/potassium decreased/pressure diastolic decreased/pressure orthostatic 
abnormal/pressure systolic decreased/triglycerides increased/urea increased/urine present 
Electrocardiogram: T wave abnormal/T wave amplitude decreased/poor R-wave progression 
Weight: decreased/ increased 
Metabolism and 
nutrition disorders 
Acidosis, anorexia, appetite disorder, cachexia, cushing’s syndrome, decreased 
appetite, dehydration, diabetes mellitus, diabetic ketoacidosis, electrolyte imbalance, failure 
to thrive, fluid overload/retention, food intolerance, glucose tolerance impaired, gout, 
hypothyroidism, malnutrition, metabolic acidosis, oral intake reduced, polydipsia, type 2 
diabetes mellitus Hyper: cholesterolemia/glycemia/kalemia/lipidemia/calcaemia uricemia/ 
triglyceridemia, glycemic non-ketotic syndrome 
Hypo: calcemia/glycemia/kalemia/magnesemia/natremia/ proteinemia/ 
Hypophosphatemia 
Musculoskeletal and 
connective tissue disorders 
Arthritis, bone fissure, fistula, gout mobility decreased, joint effusion, rhabdomyolysis Pain: 
back/flank/musculoskeletal/musculoskeletal chest/extremity/neck Muscle: spasms/weakness; 
myalgia, arthralgia 
Osteoarthritis; Osteonecrosis, Osteoreadionecrosis 
Neoplasms benign, 
malignant and 
unspecified (incl cysts 
and polyps) 
Acute leukaemia, adenocarcinoma of pancreas, Burkitt’s lymphoma, carcinoid 
syndrome, colon neoplasm, lung neoplasm, lymphoproliferative disorder, malignant 
neoplasm progression, malignant melanoma, malignant pleural effusion, 
pancreatic carcinoma, squamous cell carcinoma of skin, uterine leiomyoma 
Metastases: central nervous system/lung/lymph nodes/neoplasm; Tumor: 
hemorrhage/necrosis 
Nervous system 
disorders 
Acute disseminated encephalomyelitis, asterixis, ataxia, cerebrovascular accident, 
cognitive disorder, complex partial seizures, complex regional pain syndrome, 
convulsion, depressed level of consciousness, dizziness, dyslalia, encephalitis, 
encephalopathy, facial palsy, headache, hemiparesis, hemiplegia, hyperglycemic 
non-ketotic syndrome, hypersomnia, hypoglycemic coma, lethargy, loss of 
consciousness, ophthalmoplegia_cranial nerve paralysis, neuralgia, neuropathy peripheral, 
presyncope, sinus headache, somnolence, speech disorder, tremor, 
vertigo Cerebral: hemorrhage/ infarction/ischemia; transient ischemic attack 
Psychiatric disorders 
Agitated depression, anxiety, confusional state, delirium, delusional disorder, 

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disorientation, drug withdrawal syndrome, libido decreased insomnia, mental 
disorder/status changes, mood altered, persecutory type, personality disorder, 
neurosis, staring 
Renal and urinary 
disorders 
Acute renal failure, anuria, bladder tamponade, dysuria, hematuria, hemolytic uremic 
syndrome, hydronephrosis, leukocyturia, nephrolithiasis, oliguria, pollakiuria, 
polyuria, postrenal failure, renal failure/acute/impairment, urinary bladder 
hemorrhage, urinary incontinence, renal atrophy, renal colic, renal tubular necrosis 
Reproductive/breast 
disorders 
Azospermia, endometrial hyperplasia, libido decreased, menorrhagia, pelvic pain, ovarian 
cyst, scrotal edema 
Respiratory, thoracic and 
mediastinal disorders 
Alveolitis, alveolitis allergic, asthma, atelectasis, bronchomalacia, bronchospasm, 
cough, cryptogenic organizing pneumonia, diffuse alveolar damage, dysphonia, 
dyspnea/dyspnea exertional, emphysema, epistaxis, hemoptysis, hydrothorax, 
hypercapnia, hypoxia, laryngeal edema, interstitial lung disease, laryngeal 
inflammation, pneumothorax, rales, sinus congestion, stridor, tachypnea, wheezing 
Acute: respiratory distress syndrome/respiratory failure 
Lung: consolidation/disorder/infiltration, obstructive airways disorder, orthopnoea, 
pharyngolaryngeal pain, pleural disorder/effusion/pleurisy/pain; pneumonia 
aspiration, pneumonitis, pneumothorax, productive cough, rhinorrhoea 
Pulmonary: congestion/alveolar/hemorrhage/artery 
dilatation/cavitation/embolism/fibrosis/haemorrhage/hypertension/edema/toxicity 
Respiratory: arrest/disorder/distress/failure/gas exchange disorder 
Skin and subcutaneous tissue 
disorders 
Acute febrile neutrophilic dermatosis, Angioedema, blister, dermatitis, dermatitis 
acneiform, erythema, hyperhidrosis, leukocytoclastic vasculitis, night sweats, 
petechiae, photosensitivity reaction, pruritus, Stevens-Johnson syndrome 
Rash: erythematous/generalized/ maculo-papular/pruritic/skin 
disorder/exfoliation/lesion/reaction/ulcer/palmar plantar erythrodysesthesia/hand foot 
syndrome 
Surgical and medical 
procedures 
Abscess drainage, biliary drainage, bladder irrigation, catheter removal, chest tube 
insertion, cholecystectomy, debridement, endotracheal intubation, fistula repair, 
gastric ulcer surgery, gastrointestinal tube insertion, ileojejunal bypass, incisional 
drainage, laparotomy, mechanical ventilation, pleurodesis, sinus operation, surgery, 
thoracic cavity drainage, tracheostomy Pericardial: drainage/excision/operation 
Wound: closure/drainage/treatment 
Vascular disorders 
Capillary leak syndrome, circulatory collapse, embolism, flushing, gastrointestinal 
angiodysplasia, gastrointestinal ischaemia, haemorrhoids, hematoma, hemodynamic 
instability, hemorrhage, hypertension, hypertensive angiopathy, hypertensive crisis, 
hypotension, lymphangiopathy, lymphedema, pallor, shock; transient ischemic attack, retinal 
haemorrhage, 
Thrombosis: deep vein/jugular vein 
*New events added to IB Editions 12 and 13 are noted in bold  
 
8.3       Adverse reactions with TRC105 
 
The most common adverse events associated with TRC105 are infusion reactions that are 
successfully mitigated with premedications and prolongation of the infusion time, 
hemorrhages (mostly grade 1 and 2), headaches, and hypoproliferative anemia. 
 
8.3.1    Hypoproliferative Anemia 
 
TRC105 was administered to 50 patients as part of a phase 1 first-in-human study of solid tumors. 
Dose escalation proceeded stepwise, and the majority of adverse events were grade 1 or 2. The MTD 
was 10 mg/kg weekly, and 15 mg/kg every two weeks was also well tolerated. At 15 mg/kg weekly, 
all 3 patients that remained on study through cycle 2 developed dose-limiting grade 3 anemia, and 
one of the three progressed to grade 4 anemia by cycle 3. In all three patients, the anemia resolved 
following discontinuation of treatment. Anemia has been observed in other trials of TRC105. 

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The dose-limiting anemia at 15 mg/kg weekly was associated with accumulation of TRC105 and 
characterized by a low reticulocyte production index. Additional laboratory and clinical evaluations 
excluded common causes of anemia including blood loss, hemolysis, plasma volume expansion, 
inadequate erythropoietin, iron deficiency, and vitamin B-12 or folate deficiency. Bone marrow 
aspiration attempts in the patient with grade 4 anemia yielded insufficient material to permit 
evaluation of the cause of anemia. 
 
The hypoproliferative anemia was believed to result from TRC105-mediated suppression of 
proerythroblasts, the only cells in the marrow known to express substantial levels of CD105. Anemia 
was manageable with standard supportive measures including erythropoietin and packed red blood 
cell transfusion. One patient dosed in study 105ST101 required dose reduction from 10 mg/kg to 7.5 
mg/kg weekly for grade 3 anemia at month 12 and further dose reduced to 6 mg/kg and continued 
treatment with a minor radiographic response for 20 months. All patients receiving TRC105 should 
be monitored for anemia and treated appropriately (including possible TRC105 dose reduction). 
 
8.3.2.  Infusion Reactions 
 
Infusion reactions were observed following TRC105 administration, usually with the initial dose, 
and included one or more of the following signs or symptoms: rigors, bronchospasm, urticaria, 
change in blood pressure, and change in heart rate. Grade 2 infusion reactions (requiring temporary 
interruption of the infusion) and grade 3 infusion reactions (requiring discontinuation of the infusion) 
were initially reported at the 0.3 and 1 mg/kg every 2 weeks in the absence of premedication. By 
extending the duration of the initial infusion from one to four hours and adding a dexamethasone-
based premedication regimen prior to each dose, the frequency and severity of infusion reactions 
were reduced and dose escalation continued to 15 mg/kg weekly. 
 
Infusion reactions were rare in patients re-dosed at the recommended phase 2 dose of 10 mg/kg 
weekly or 15 mg/kg every two weeks, where TRC105 serum levels known to saturate CD105 binding 
sites were present at the time of re-dosing. At dose levels where continuous TRC105 serum levels 
were achieved, dexamethasone was safely discontinued and the infusion duration reduced to one 
hour. All patients treated with TRC105 should receive appropriate premedication, be monitored 
during the TRC105 infusion, and be treated appropriately for infusion reactions (including possible 
TRC105 dose interruption). 
 
In a phase 2 study of TRC105 monotherapy in patients with hepatocellular carcinoma who progressed 
on sorafenib, one patient with coronary artery disease and prior bypass surgery dosed at 15 mg/kg 
TRC105 who received the required pre-medications, experienced an infusion reaction (Grade 3) with 
elevated heart rate, elevated blood pressure, shortness of breath and chest pain, and developed a non-
Q wave myocardial infarction, from which he recovered without sequellae. 
 
One patient participating in a phase 1/2 study of TRC105 for castrate-resistant prostate cancer in a 
NCI sponsored trial developed a serious adverse event of grade 4 vasovagal reaction. The patient 
was being treated with TRC105 at 15 mg/kg every 2 weeks and, after the appropriate premedication 
regimen, the patient fainted 17 mL into the initial infusion. He was treated with oxygen and i.v. fluids 
and completely recovered within 5 minutes. Vasovagal reaction, generally associated with volume 

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depletion, is a known adverse event that occurs in <1% of patients receiving therapeutic proteins like 
monoclonal antibodies. The risk of syncope can be minimized by encouraging patient hydration prior 
to the initial treatment with TRC105 and avoiding the treatment of patients who are volume depleted. 
 
Hypersensitivity reactions to therapeutic protein infusions are a potential risk for sensitized patients, 
and TRC105 should be avoided or used with caution in patients with known hypersensitivity to any 
component of the drug product. 
 
8.3.3. Hemorrhage 
 
One patient developed dose-limiting toxicity of grade 4 hemorrhage presenting as melena from a 
gastric ulcer within 5 days of the initial TRC105 infusion in the phase 1 monotherapy study at 0.1 
mg/kg. He discontinued TRC105 treatment, was transfused 2 units of packed red blood cells and the 
bleeding resolved with nonsurgical management by the time of upper endoscopy. Serious blood loss 
was not observed following protocol amendment to exclude patients with a history of peptic ulcer 
disease (unless healing was documented). Subsequent bleeding associated with TRC105 has been 
limited to low grades including superficial gingival bleeding, epistaxis, and intermittent post-coital 
vaginal bleeding in a patient with uterine cancer recurrent at the vaginal cuff. Gingival bleeding and 
epistaxis are related to the development of mucocutaneous telangiectasia that occur on TRC105 
therapy. Patients with epistaxis may benefit from saline nasal gel. All patients treated with TRC105 
should be monitored for signs of hemorrhage and the risks and benefits of drug treatment reevaluated 
in any patient with hemorrhage. 
 
Cerebrovascular hemorrhage (grade 3) resulting in hemiparesis occurred in one patient with 
hepatocellular cancer who was thrombocytopenic (platelet count of 60,000/uL) in a study of TRC105 
with sorafenib. Patients in TRC105 protocols are required to have platelet counts of 100,000/uL, with 
the exception of the hepatocellular cancer protocol, where patients with platelet counts as low as 
60,000/uL (without transfusion support in the past 30 days) are permitted due to the underlying 
cirrhotic liver disease that results in secondary thrombocytopenia. 
 
Mucocutaneous telangiectasia is observed routinely in patients treated with TRC105 as early as 2 
weeks after starting treatment. Telangiectasia is universally seen in patients with hereditary 
hemorrhagic telangiectasia (HHT), a disease of CD105 haplotype insufficiency. Patients with HHT 
are at risk of hemorrhage from abnormal blood vessels that could be exacerbated by treatment with 
TRC105, and are excluded from TRC105 trials. 
 
Additionally, Grade 5 intracranial hemorrhage occurred in one glioblastoma patient with markedly 
abnormal blood clotting parameters in a study of TRC105 with bevacizumab. 
 
8.3.4. Other Potential Risks 
 
Low grade fatigue is a commonly reported adverse event attributable to TRC105 although its cause 
is unclear and appears not to be caused by thyroid dysfunction. Headaches (grade 1 to 3) have been 
observed following TRC105 treatment, generally within hours following completion of the initial 
infusion. Headaches are throbbing in nature, have not been associated with radiographic 
abnormalities, and have responded to treatment with non-steroidal anti-inflammatory agents and to 

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triptans. Headaches were particularly prominent in patients treated with TRC105 in combination with 
bevacizumab. Headaches were more common and most severe when TRC105 and bevacizumab were 
initially dosed on the same day and were ameliorated when the first dose of TRC105 was dosed one 
week following bevacizumab and was given over two days. Nasal congestion and periorbital edema 
have been observed with TRC105 dosing, particularly when dosed in combination with bevacizumab. 
The edema has been transient in nature and treated with corticosteroids. Antihistamines are useful 
for nasal congestion. 
 
Flushing and rash (typically maculo-papular and erythematous) occasionally develop following 
infusion of TRC105. Low grade anorexia, nausea, and vomiting are seen infrequently. Isolated 
serious adverse reactions include grade 2 pancreatitis in a hepatocellular carcinoma patient in treated 
with TRC105 in combination with sorafenib and grade 3 infected skin lipoma/cyst observed in a 
phase 2 study of TRC105 as a single agent in patients with metastatic bladder cancer. Both resolved 
without sequellae. 
 
While thrombosis has not been frequent on TRC105 treatment, patients who develop arterial 
thrombosis or grade 3 or 4 venous thrombosis should discontinue TRC105 therapy. Those with 
uncomplicated grade 1 or 2 venous thrombosis and with normal platelet count and platelet function, 
who appear to be benefiting from TRC105 therapy, may be anticoagulated and continue on TRC105 
therapy at the discretion of the investigator. Patients with coagulation parameters above standard 
therapeutic levels (e.g., INR > 3) are at increased risk of hemorrhage and should therefore not receive 
TRC105. 
 
Transient Grade 3 hepatic encephalopathy occurred in one patient with cirrhosis and hepatocellular 
carcinoma who received TRC105 in combination with sorafenib.    
 
A patient with glioblastoma developed temporary confusion and slurred speech following treatment 
with TRC105 and bevacizumab that required hospitalization for observation.  Another patient with 
glioblastoma, who underwent resection and had a history of an abnormal collection of cerebral spinal 
fluid, developed a grade 2 cerebral spinal fluid leak. 
 
Grade 3 myocardial infarction (non-Q wave infarct associated with hypertension following an 
infusion reaction) was observed in a patient with hepatocellular cancer following treatment with 
TRC105 that resolved without sequelae.  In addition, a Grade 5 myocardial infarction occurred in a 
patient with coronary artery disease who received TRC105 in combination with sorafenib. Patients 
with evidence of active coronary artery disease are excluded from participation in this trial (see 
exclusion criteria).  
  
Adult respiratory distress syndrome that required temporary intubation occurred in one patient who 
received TRC105 with pazopanib, from which the patient recovered.  Of note, interstitial lung disease 
has been added as an adverse drug reaction and warning/precaution to the core safety information for 
pazopanib. 
 
Infections have been observed rarely. Grade 3 infected lipoma/cyst was observed in a Phase 2 study 
of TRC105 as a single agent in patients with metastatic bladder cancer. Grade 3 orbital cellulitis and 
grade 3 brain abscess were observed in patients treated with TRC105 and bevacizumab and 

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considered possibly related to TRC105.  Grade 1 and 2 gingivitis including infection and ulceration 
has also been observed.  Overall, infections have been observed in fewer than 5% of patients and 
have largely been considered unrelated to treatment with TRC105. 
 
9. DATA COLLECTION AND STUDY MANAGEMENT 
 
The study must be conducted as described in this approved protocol. Should amendments to the 
protocol be required, the amendments will be originated and documented by the Principal 
Investigator at UAB. The written amendment will be sent to the IRB at the investigator's site for 
approval. All revisions to the protocol will be provided to Novartis and TRACON by UAB. The 
Investigator should not implement any deviation or change to the protocol without prior review and 
documented approval/favorable opinion from the IRB of an Amendment, except where necessary to 
eliminate an immediate hazard(s) to study patients. Documentation of approval signed by the 
chairperson or designee of the IRB(s) must be sent to the UAB Clinical Protocols and Data manager 
Shared Facility Regulatory Office (Alfreda Lewis fax 205-). If the revision is an Administrative 
Letter, Investigator must inform their IRB(s)/IEC(s). 
 
Principal investigator will hold the IND for the trial. All patients must be registered with the Clinical 
Trials Network and Monitoring Office of the UAB Comprehensive Cancer Center (Pam Dixon, 
O.C.N.) before enrollment in study. Prior to initiation of therapy eligibility criteria must be 
confirmed. At the time of registration, a study identification number will be generated. All 
subsequent case report forms will use this study identification number. 
 
9.1   Data Collection 
 
The study will have electronic CRF in OnCore for each subject (UAB CCC). Entries made in the 
CRF must be verifiable against source documents; any discrepancies should be explained and 
documented. The investigator will be responsible for reviewing all data and CRF entries and will 
sign and date the designated pages in each subject's CRF, verifying that the information is true and 
correct. The investigator is responsible for the review and approval of all responses. Patients will be 
registered in the Clinical trial Network and Monitoring office of the UAB Comprehensive Cancer 
Center.  9.2   Data Management  
 
Data management will be performed from CRFs. All CRF data will be entered into a validated 
database. All data entry, verification, and validation will be performed in accordance with the current 
standard operating procedures of the Clinical Trials and Data Management Shared Facility of the 
UAB CCC. The database will be authorized for lock once all defined procedures are completed. 
 
9.3   Study Management  
 
9.3.1 Institutional Review Board Approval and Informed Consent 
 
Before study initiation, the Investigator must have written and dated approval/favorable opinion from 
the IRB for the protocol, consent form, patient recruitment materials/process (e.g., advertisements), 
and any other written information to be provided to patients.  The Investigator should provide the 
IRB with reports, updates, and other information (e.g., Safety Updates, Amendments, Administrative 

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Letters) according to regulatory requirements or Institution procedures. Copies of the initial IRB 
approval as well as annual re-approvals must be submitted to UAB. UAB will provide copies of IRB 
approval to Novartis and TRACON. 
 
It is expected that the IRB will have the proper representation and function in accordance with 
federally mandated regulations. In obtaining and documenting informed consent, the investigator 
should comply with the applicable regulatory requirement(s), and should adhere to Good Clinical 
Practice (GCP) and to ethical principles that have their origin in the Declaration of Helsinki. Before 
recruitment and enrollment onto this study, the patient will be given a full explanation of the study 
and will be given the opportunity to review the consent form. Each consent form must include all the 
relevant elements currently required by the FDA Regulations and local or state regulations. Once this 
essential information has been provided to the patient and the investigator is assured that the patient 
understands the implications of participating in the study, the patient will be asked to give consent to 
participate in the study by signing an IRB-approved consent form. 
 
Prior to a patient’s participation in the trial, the written informed consent form should be signed and 
personally dated by the patient or the patient’s legally acceptable representative, and by the person 
who conducted the informed consent discussion. Documentation of IRB approval must be on file 
before any patient can be registered. Registration begins with signed informed consent. 
 
9.3.2 Data confidentiality 
 
Information about study subjects will be kept confidential and managed under applicable laws and 
regulations. Those regulations require a signed subject authorization informing the subject of the 
following: 
 
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI. 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by regulation, 
retains the ability to use all information collected prior to the revocation of subject authorization. For 
subjects that have revoked authorization to collect or use PHI, attempts should be made to obtain 
permission to collect follow-up safety information (e.g. has the subject experienced any new or 
worsened AEs) at the end of their scheduled study period. The data collection system for this study 
uses built-in security features to encrypt all data for transmission in both directions, preventing 
unauthorized access to confidential participant information. Access to the system will be controlled 
by a sequence of individually assigned user identification codes and passwords, made available only 
to authorized personnel who have completed prerequisite training. 
 
9.3.3 Study Monitoring 
 
Data will be captured on electronic CRFs, and supporting documents will be faxed to the UAB 
Clinical Trials Network and Monitoring Office.  Personnel from the Clinical Trials Network and 
Monitoring office of the University of Alabama at Birmingham will monitor the trial in real time and 
will periodically visit the investigative site to ensure proper conduct of the trial and proper collection 

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of the data.  
 
The principal investigator will check the completeness of patient records, the accuracy of entries on 
the CRFs, the adherence to the protocol to Good Clinical Practice, the progress of enrollment, and to 
ensure that study treatment is being stored, dispensed, and accounted for according to specifications. 
Key study personnel must be available to assist the principal investigator in these periodic checks. 
 
The investigator must maintain source documents for each patient in the study, consisting of case 
and visit notes (hospital or clinic medical records) containing demographic and medical information, 
laboratory data, and the results of any other tests or assessments. All information recorded on CRFs 
must be traceable to source documents in the patient's file. The investigator must also keep the 
original signed informed consent form (a signed copy is given to the patient). 
Trial will be followed by the Clinical Trials Monitoring Committee and audited by the UAB CCC 
according to the institutional guidelines.  
 
9.3.4 Record Retention 
 
Study documentation includes all Case Report Forms, data correction forms or queries, source 
documents, Sponsor-Investigator correspondence, monitoring logs/letters, and regulatory documents 
(e.g., protocol and amendments, IRB correspondence and approved signed patient consent forms). 
Source documents include all recordings of observations or notations of clinical activities and all 
reports and records necessary for the evaluation and conduction of the clinical research study. 
Government agency regulations and directives require that all study documentation pertaining to the 
conduct of a clinical trial must be retained by the study investigator. In the case of a study with a 
drug pursuing regulatory approval and marketing, these documents shall be retained for at least two 
years after the last approval of marketing application in an International Conference on 
Harmonization (ICH) region. In all other cases, study documents should be kept on file until three 
years after the completion and final study report of this investigational study.  
If the Investigator withdraws from the study (e.g., relocation, retirement), the records shall be 
transferred to a mutually agreed upon designee (e.g., another Investigator, IRB). Notice of such 
transfer will be given in writing to NOVARTIS and TRACON Pharmaceuticals. Records of the 
patient’s participation in this study will be kept confidential so far as permitted by law.  However, 
the patient’s doctor and his/her staff, representatives of NOVARTIS and TRACON Pharmaceuticals, 
representatives of the U.S. Food and Drug Administration, and the IRB will be able to inspect patient 
records and have access to confidential information which identifies the patient by name.  Any 
publication of data will not identify the patient by name.  Should the patient’s medical record need 
to be reviewed by a foreign regulatory agency, a member of the IRB staff will observe the review so 
that the record is not removed, copied, or identifiable information recorded in any manner.  
 
9.3.5 Obligations of Investigators 
 
The Principal Investigator is responsible for the conduct of the clinical trial at the site in accordance 
with Title 21 of the Code of Federal Regulations and/or the Declaration of Helsinki. The Principal 
Investigator is responsible for personally overseeing the treatment of all study patients. The Principal 
Investigator must ensure that all study site personnel, including sub-investigators and other study 

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staff members, adhere to the study protocol and all FDA/GCP/NCI regulations and guidelines 
regarding clinical trials both during and after study completion. 
 
The Principal Investigator at each institution or site will be responsible for ensuring that all the 
required data will be collected and entered onto the Case Report Forms. Periodically, monitoring 
visits will be conducted and the Principal Investigator will provide access to his/her original records 
to permit verification of proper data entry. At the completion of the study, all case report forms will 
be reviewed by the Principal Investigator and will require his/her final signature to verify the 
accuracy of the data. 
 
10. STATISTICAL CONSIDERATIONS 
 
This is a phase I/II study with the primary objective to characterize the tolerability and feasibility of 
a novel combination of agents. The Primary Endpoint is defined as the determination of MTD and 
RP2D and rates of treatment-related toxicities. The secondary efficacy endpoints are rates of pCR or 
down-staging. The principal investigator will hold the IND for the trial (Appendix F).   
 
10.1   Sample Size and Power Justification 
 
A. The dose escalation part of the study will follow a conventional 3+3 dose escalation design 
according to the schema above. We anticipate that up to 18 patients will be enrolled in this part 
anticipating that dose level 1 or 2 will be the RP2D. The number of patients to be enrolled ranges 
from 3 (if ≥2/3 DLTs in cohort 1) to 18 (if enrollment of 6 patients in all cohorts).  
B. The sample size of 20 in Phase II part study is NOT determined by the statistical power but the 
feasibility and relative precision of estimate, e.g. standards error of the estimation is ≤10%. We will 
estimate the pCR of the combination to generate hypotheses for further clinical investigations. In 
order to minimize exposure of patients to ineffective therapy, Gehan’s two-stage design will be 
used51 which allows for the rapid rejection of an ineffective treatment at the end of the first stage, 
and provides an estimation of the success rate with a given precision, at the end of the second stage.  
The study will enroll 10 patients first, and if no patient has pCR or downstaging, it is unlikely 
(p=0.1074) that 0/10 responses would occur if the true response rate were >20%.  If responses were 
0/10, the phase II portion will be closed.  If at least one patient has pCR or downstaging, an additional 
10 patients will be treated (total of 20).  With an accrual of 20 patients to phase II portion of the 
study, estimated two-sided 95% confidence intervals (CI) would be 1.2%-31.7%, 5.7% -43.6% and 
11.8%-54.3% if pCR is 10%, 20% or 30% respectively. The confidence intervals are calculated using 
the exact method Clopper-Pearson intervals54. 
 
Table 10-1 shows the probability of early termination and observing one response or at least one 
response at the first stage (N1=10).  
 
Table 10.1: Probability of early termination and observing one response or at least one 
response at the first stage (N1=10) 
 
True ORR 
Probability of having 
zero response (x=0) 
Probability of having 
one response (x=1) 
Probability of having at 
least one response (x≥1) 

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0.1 
0.3486 
0.3874 
0.6513 
0.2 
0.1074 
0.2684 
0.8926 
0.30 
0.0282 
0.1211 
0.9718 
 
10.2 Statistical Analysis 
 
The primary analysis is of safety and will include any patients who receive at least one dose of the 
investigational regimen. The rate of adverse events will be estimated at the end of the study along 
with two-sided 95% exact CIs (Clopper-Pearson intervals). At the completion of the study, the 
secondary endpoint of pCR or downstaging rate will be estimated along with two-sided 95% CIs 
with the exact method of Clopper-Pearson intervals. Secondary endpoint analysis will be descriptive. 
Mean, median, geometric mean, range and coefficient of variation will be used to describe continuous 
demographic variables. Frequency and proportion will be used to describe categorical variables.  
 
We will use descriptive statistics (mean, median, geometric mean, coefficient of variation, and 95% 
confidence intervals) and graphical displays (mean concentration-time graphs, scatter plots, box 
plots or spaghetti plots) to evaluate the pharmacokinetic parameters of the TRC105 and everolimus. 
We will use descriptive statistics (mean, median, geometric mean, coefficient of variation, and 95% 
confidence intervals) and graphical displays (scatter plots, box plots, plots of PD parameters against 
PK data) to analyze the changes in markers of proliferation and angiogenesis with the 
investigational treatment. 
 
Exploratory analysis will be conducted on the correlations between clinical outcomes and 
pharmacodynamic biomarkers or translation profiles. Translational profiles will be analyzed between 
responders and non-responders and the differences between responders and non-responders will be 
presented in scatter plots along with corresponding 95% CI. Quartile normalization and logarithmic 
transformation will be conducted before analysis. Logistic regression analysis will be used to predict 
response with translational profiles or biomarkers with or without adjustment for covariates, e.g. age. 
Multivariate Cox proportional hazards model will be used to identify a set of biomarkers for 
prediction of response. Odds ratios with 95% CIs will be calculated for each significant biomarker 
in terms of predicting response. However, it is recognized that sample size may be too small for such 
analyses and these analyses are conducted only to generate hypotheses that will require further 
validation.   
 
10.3 Stratification Factors 
 
No a priori stratification of patients will be undertaken in this study. Subgroup analyses will be 
conducted a posteriori according to grade (grade II vs. III), stage (stage IIA and IIB vs. IIIA and 
IIIB) lymph node involvement (N0 vs. N1-2), age (as a continuous variable). It is recognized that 
sample size may be too small for such analyses and these analyses are exploratory to generate 
hypotheses and will require further validation. 
 
11. PROTOCOL ADHERENCE 

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Investigators ascertain they will apply due diligence to avoid protocol deviations. No authorized 
deviations are permitted. If an investigator feels a protocol deviation would improve the conduct of 
the study this must be considered a protocol amendment, and unless such an amendment is agreed 
upon by the principal investigator and approved by the IRB it cannot be implemented. All significant 
protocol deviations will be recorded and reported in the CSR. 
 
11.1  Amendments to the Protocol 
 
Any change or addition to the protocol can only be made in a written protocol amendment that must 
be approved by the IRB. Only amendments that are required for patient safety may be implemented 
prior to IRB approval. Notwithstanding the need for approval of formal protocol amendments, the 
investigator is expected to take any immediate action required for the safety of any patient included 
in this study, even if this action represents a deviation from the protocol. In such cases, the principal 
investigator should be notified of this action and the IRB should be informed no later than 10 working 
days. Novartis requests to review any significant changes, excluding administrative protocol 
amendments 
 
 

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REFERENCES 
 
1. 
Forero-Torres A, Rugo HS, Vaklavas C, et al. TBCRC 002: A phase II, randomized, open label trial 
of pre-operative letrozole vs. letrozole (LET) in combination with bevacizumab (BEV) in post-menopausal 
women with newly diagnosed stage II/III breast cancer.  presented at 2013 ASCO Meeting. Chicago, 
IL2013. 
2. 
Forero-Torres A, Saleh MN, Galleshaw JA, et al. Pilot trial of preoperative (neoadjuvant) letrozole 
in combination with bevacizumab in postmenopausal women with newly diagnosed estrogen receptor- or 
progesterone receptor-positive breast cancer. Clin Breast Cancer 2010;10:275-80. 
3. 
Baselga J, Campone M, Piccart M, et al. Everolimus in postmenopausal hormone-receptor-positive 
advanced breast cancer. N Engl J Med 2012;366:520-9. 
4. 
Baselga J, Semiglazov V, van Dam P, et al. Phase II randomized study of neoadjuvant everolimus 
plus letrozole compared with placebo plus letrozole in patients with estrogen receptor-positive breast cancer. 
J Clin Oncol 2009;27:2630-7. 
5. 
Yamnik RL, Digilova A, Davis DC, Brodt ZN, Murphy CJ, Holz MK. S6 kinase 1 regulates 
estrogen receptor alpha in control of breast cancer cell proliferation. J Biol Chem 2009;284:6361-9. 
6. 
Yamnik RL, Holz MK. mTOR/S6K1 and MAPK/RSK signaling pathways coordinately regulate 
estrogen receptor alpha serine 167 phosphorylation. FEBS Lett 2010;584:124-8. 
7. 
Bockhorn M, Tsuzuki Y, Xu L, Frilling A, Broelsch CE, Fukumura D. Differential vascular and 
transcriptional responses to anti-vascular endothelial growth factor antibody in orthotopic human pancreatic 
cancer xenografts. Clin Cancer Res 2003;9:4221-6. 
8. 
Davis DW, Inoue K, Dinney CP, Hicklin DJ, Abbruzzese JL, McConkey DJ. Regional effects of an 
antivascular endothelial growth factor receptor monoclonal antibody on receptor phosphorylation and 
apoptosis in human 253J B-V bladder cancer xenografts. Cancer Res 2004;64:4601-10. 
9. 
Esserman LJ, Berry DA, DeMichele A, et al. Pathologic complete response predicts recurrence-free 
survival more effectively by cancer subset: results from the I-SPY 1 TRIAL--CALGB 150007/150012, 
ACRIN 6657. J Clin Oncol 2012;30:3242-9. 
10. 
Houssami N, Macaskill P, von Minckwitz G, Marinovich ML, Mamounas E. Meta-analysis of the 
association of breast cancer subtype and pathologic complete response to neoadjuvant chemotherapy. 
European journal of cancer 2012;48:3342-54. 
11. 
Liedtke C, Mazouni C, Hess KR, et al. Response to neoadjuvant therapy and long-term survival in 
patients with triple-negative breast cancer. J Clin Oncol 2008;26:1275-81. 
12. 
von Minckwitz G, Untch M, Blohmer JU, et al. Definition and impact of pathologic complete 
response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. J Clin 
Oncol 2012;30:1796-804. 
13. 
Draft Guidance for Industry: Pathologic Complete Response in Neoadjuvant Treatment of High-
Risk Early-Stage Breast Cancer: Use as an Endpoint to Support Accelerated Approval. 2012. at 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM305501
.pdf.) 
14. 
Cardoso F. Neoadjuvant endocrine therapy: for whom, for how long? Clinical & translational 
oncology : official publication of the Federation of Spanish Oncology Societies and of the National Cancer 
Institute of Mexico 2012;14:81-2. 
15. 
Ellis MJ, Tao Y, Luo J, et al. Outcome prediction for estrogen receptor-positive breast cancer based 
on postneoadjuvant endocrine therapy tumor characteristics. J Natl Cancer Inst 2008;100:1380-8. 
16. 
Alba E, Calvo L, Albanell J, et al. Chemotherapy (CT) and hormonotherapy (HT) as neoadjuvant 
treatment in luminal breast cancer patients: results from the GEICAM/2006-03, a multicenter, randomized, 
phase-II study. Ann Oncol 2012;23:3069-74. 
17. 
Semiglazov VF, Semiglazov VV, Dashyan GA, et al. Phase 2 randomized trial of primary endocrine 
therapy versus chemotherapy in postmenopausal patients with estrogen receptor-positive breast cancer. 
Cancer 2007;110:244-54. 

                                                 UAB 1514 / Version 7-25-19                      
112 | P a g e  
 
18. 
Macaskill EJ, Renshaw L, Dixon JM. Neoadjuvant use of hormonal therapy in elderly patients with 
early or locally advanced hormone receptor-positive breast cancer. Oncologist 2006;11:1081-8. 
19. 
Eiermann W, Paepke S, Appfelstaedt J, et al. Preoperative treatment of postmenopausal breast 
cancer patients with letrozole: A randomized double-blind multicenter study. Ann Oncol 2001;12:1527-32. 
20. 
Cataliotti L, Buzdar AU, Noguchi S, et al. Comparison of anastrozole versus tamoxifen as 
preoperative therapy in postmenopausal women with hormone receptor-positive breast cancer: the Pre-
Operative "Arimidex" Compared to Tamoxifen (PROACT) trial. Cancer 2006;106:2095-103. 
21. 
Ellis MJ, Coop A, Singh B, et al. Letrozole is more effective neoadjuvant endocrine therapy than 
tamoxifen for ErbB-1- and/or ErbB-2-positive, estrogen receptor-positive primary breast cancer: evidence 
from a phase III randomized trial. J Clin Oncol 2001;19:3808-16. 
22. 
Ellis MJ, Coop A, Singh B, et al. Letrozole inhibits tumor proliferation more effectively than 
tamoxifen independent of HER1/2 expression status. Cancer Res 2003;63:6523-31. 
23. 
Smith IE, Dowsett M, Ebbs SR, et al. Neoadjuvant treatment of postmenopausal breast cancer with 
anastrozole, tamoxifen, or both in combination: the Immediate Preoperative Anastrozole, Tamoxifen, or 
Combined with Tamoxifen (IMPACT) multicenter double-blind randomized trial. J Clin Oncol 
2005;23:5108-16. 
24. 
Hanahan D, Folkman J. Patterns and emerging mechanisms of the angiogenic switch during 
tumorigenesis. Cell 1996;86:353-64. 
25. 
Zhang HT, Craft P, Scott PA, et al. Enhancement of tumor growth and vascular density by 
transfection of vascular endothelial cell growth factor into MCF-7 human breast carcinoma cells. J Natl 
Cancer Inst 1995;87:213-9. 
26. 
Guo P, Fang Q, Tao HQ, et al. Overexpression of vascular endothelial growth factor by MCF-7 
breast cancer cells promotes estrogen-independent tumor growth in vivo. Cancer Res 2003;63:4684-91. 
27. 
Pinto MP, Badtke MM, Dudevoir ML, Harrell JC, Jacobsen BM, Horwitz KB. Vascular endothelial 
growth factor secreted by activated stroma enhances angiogenesis and hormone-independent growth of 
estrogen receptor-positive breast cancer. Cancer Res 2010;70:2655-64. 
28. 
Lebrin F, Goumans MJ, Jonker L, et al. Endoglin promotes endothelial cell proliferation and TGF-
beta/ALK1 signal transduction. EMBO J 2004;23:4018-28. 
29. 
Bertolino P, Deckers M, Lebrin F, ten Dijke P. Transforming growth factor-beta signal transduction 
in angiogenesis and vascular disorders. Chest 2005;128:585S-90S. 
30. 
Blanco FJ, Santibanez JF, Guerrero-Esteo M, Langa C, Vary CP, Bernabeu C. Interaction and 
functional interplay between endoglin and ALK-1, two components of the endothelial transforming growth 
factor-beta receptor complex. Journal of cellular physiology 2005;204:574-84. 
31. 
Dallas NA, Samuel S, Xia L, et al. Endoglin (CD105): a marker of tumor vasculature and potential 
target for therapy. Clin Cancer Res 2008;14:1931-7. 
32. 
Minhajat R, Mori D, Yamasaki F, Sugita Y, Satoh T, Tokunaga O. Endoglin (CD105) expression in 
angiogenesis of colon cancer: analysis using tissue microarrays and comparison with other endothelial 
markers. Virchows Arch 2006;448:127-34. 
33. 
Fonsatti E, Altomonte M, Nicotra MR, Natali PG, Maio M. Endoglin (CD105): a powerful 
therapeutic target on tumor-associated angiogenetic blood vessels. Oncogene 2003;22:6557-63. 
34. 
Takahashi N, Haba A, Matsuno F, Seon BK. Antiangiogenic therapy of established tumors in 
human skin/severe combined immunodeficiency mouse chimeras by anti-endoglin (CD105) monoclonal 
antibodies, and synergy between anti-endoglin antibody and cyclophosphamide. Cancer Res 2001;61:7846-
54. 
35. 
Rosen LS, Hurwitz HI, Wong MK, et al. A phase I first-in-human study of TRC105 (Anti-Endoglin 
Antibody) in patients with advanced cancer. Clin Cancer Res 2012;18:4820-9. 
36. 
Ellis MJ, Ding L, Shen D, et al. Whole-genome analysis informs breast cancer response to 
aromatase inhibition. Nature 2012;486:353-60. 
37. 
Higgins MJ, Baselga J. Targeted therapies for breast cancer. J Clin Invest 2011;121:3797-803. 
38. 
Karakas B, Bachman KE, Park BH. Mutation of the PIK3CA oncogene in human cancers. Br J 

                                                 UAB 1514 / Version 7-25-19                      
113 | P a g e  
 
Cancer 2006;94:455-9. 
39. 
Bachman KE, Argani P, Samuels Y, et al. The PIK3CA gene is mutated with high frequency in 
human breast cancers. Cancer Biol Ther 2004;3:772-5. 
40. 
Saal LH, Holm K, Maurer M, et al. PIK3CA mutations correlate with hormone receptors, node 
metastasis, and ERBB2, and are mutually exclusive with PTEN loss in human breast carcinoma. Cancer Res 
2005;65:2554-9. 
41. 
TCGA. Comprehensive molecular portraits of human breast tumours. Nature 2012;490:61-70. 
42. 
Beeram M, Tan QT, Tekmal RR, Russell D, Middleton A, DeGraffenried LA. Akt-induced 
endocrine therapy resistance is reversed by inhibition of mTOR signaling. Ann Oncol 2007;18:1323-8. 
43. 
deGraffenried LA, Friedrichs WE, Russell DH, et al. Inhibition of mTOR activity restores 
tamoxifen response in breast cancer cells with aberrant Akt Activity. Clin Cancer Res 2004;10:8059-67. 
44. 
Bjornsti MA, Houghton PJ. The TOR pathway: a target for cancer therapy. Nature reviews Cancer 
2004;4:335-48. 
45. 
Guba M, von Breitenbuch P, Steinbauer M, et al. Rapamycin inhibits primary and metastatic tumor 
growth by antiangiogenesis: involvement of vascular endothelial growth factor. Nature medicine 
2002;8:128-35. 
46. 
Humar R, Kiefer FN, Berns H, Resink TJ, Battegay EJ. Hypoxia enhances vascular cell proliferation 
and angiogenesis in vitro via rapamycin (mTOR)-dependent signaling. FASEB journal : official publication 
of the Federation of American Societies for Experimental Biology 2002;16:771-80. 
47. 
Sennino B, Ishiguro-Oonuma T, Wei Y, et al. Suppression of tumor invasion and metastasis by 
concurrent inhibition of c-Met and VEGF signaling in pancreatic neuroendocrine tumors. Cancer discovery 
2012;2:270-87. 
48. 
Smith IE, Dowsett M, Ebbs SR, et al. Neoadjuvant treatment of postmenopausal breast cancer with 
anastrozole, tamoxifen, or both in combination: the Immediate Preoperative Anastrozole, Tamoxifen, or 
Combined with Tamoxifen (IMPACT) multicenter double-blind randomized trial. J Clin Oncol 
2005;23:5108-16. 
49. 
Dowsett M, Smith IE, Ebbs SR, et al. Short-term changes in Ki-67 during neoadjuvant treatment of 
primary breast cancer with anastrozole or tamoxifen alone or combined correlate with recurrence-free 
survival. Clin Cancer Res 2005;11:951s-8s. 
50. 
Smith IE, Dowsett M. Aromatase inhibitors in breast cancer. N Engl J Med 2003;348:2431-42. 
51. 
Gehan EA. The determinatio of the number of patients required in a preliminary and a follow-up 
trial of a new chemotherapeutic agent. J Chronic Dis 1961;13:346-53. 
52. 
Elston CW, Ellis IO. Pathological prognostic factors in breast cancer. I. The value of histological 
grade in breast cancer: experience from a large study with long-term follow-up. Histopathology 
1991;19:403-10. 
53. 
Shiozaki K, Harada N, Greco WR, et al. Antiangiogenic chimeric anti-endoglin (CD105) antibody: 
pharmacokinetics and immunogenicity in nonhuman primates and effects of doxorubicin. Cancer Immunol 
Immunother 2006;55:140-50. 
54. 
Clopper C, Pearson ES. The use of confidence or fiducial limits illustrated in the case of the 
binomial. Biometrika 1934;26:404-13. 
55. 
Rastogi P, Anderson SJ, Bear HD, et al. Preoperative chemotherapy: updates of National Surgical 
Adjuvant Breast and Bowel Project Protocols B-18 and B-27. J Clin Oncol 2008;26:778-85. 
56. 
Cortazar P, Zhang L, Untch M, et al. Pathological complete response and long-term clinical benefit 
in breast cancer: the CTNeoBC pooled analysis. Lancet 2014. 
57. 
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm370393.htm. FDA, 2013. 
(Accessed 10/01/2013, at 
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm370393.htm.) 
58. 
von Minckwitz G, Blohmer JU, Costa SD, et al. Response-guided neoadjuvant chemotherapy for 
breast cancer. J Clin Oncol 2013;31:3623-30. 
59. 
von Minckwitz G, Kummel S, Vogel P, et al. Intensified neoadjuvant chemotherapy in early-

                                                 UAB 1514 / Version 7-25-19                      
114 | P a g e  
 
responding breast cancer: phase III randomized GeparTrio study. J Natl Cancer Inst 2008;100:552-62. 
60. 
von Minckwitz G, Kummel S, Vogel P, et al. Neoadjuvant vinorelbine-capecitabine versus 
docetaxel-doxorubicin-cyclophosphamide in early nonresponsive breast cancer: phase III randomized 
GeparTrio trial. J Natl Cancer Inst 2008;100:542-51. 
61. 
Johnston SR. New strategies in estrogen receptor-positive breast cancer. Clin Cancer Res 
2010;16:1979-87. 
62. 
Dees EC, Carey LA. Improving endocrine therapy for breast cancer: it's not that simple. J Clin 
Oncol 2012;31:171-3. 
63. 
Bachelot T, Bourgier C, Cropet C, et al. Randomized phase II trial of everolimus in combination 
with tamoxifen in patients with hormone receptor-positive, human epidermal growth factor receptor 2-
negative metastatic breast cancer with prior exposure to aromatase inhibitors: a GINECO study. J Clin 
Oncol 2012;30:2718-24. 
64. 
Qu Z, Van Ginkel S, Roy AM, et al. Vascular endothelial growth factor reduces tamoxifen efficacy 
and promotes metastatic colonization and desmoplasia in breast tumors. Cancer Res 2008;68:6232-40. 
65. 
Losordo DW, Isner JM. Estrogen and angiogenesis: A review. Arteriosclerosis, thrombosis, and 
vascular biology 2001;21:6-12. 
66. 
Hyder SM, Stancel GM. Regulation of angiogenic growth factors in the female reproductive tract by 
estrogens and progestins. Molecular endocrinology (Baltimore, Md 1999;13:806-11. 
67. 
Hyder SM, Nawaz Z, Chiappetta C, Stancel GM. Identification of functional estrogen response 
elements in the gene coding for the potent angiogenic factor vascular endothelial growth factor. Cancer Res 
2000;60:3183-90. 
68. 
Buteau-Lozano H, Ancelin M, Lardeux B, Milanini J, Perrot-Applanat M. Transcriptional regulation 
of vascular endothelial growth factor by estradiol and tamoxifen in breast cancer cells: a complex interplay 
between estrogen receptors alpha and beta. Cancer Res 2002;62:4977-84. 
69. 
Mueller MD, Vigne JL, Minchenko A, Lebovic DI, Leitman DC, Taylor RN. Regulation of vascular 
endothelial growth factor (VEGF) gene transcription by estrogen receptors alpha and beta. Proceedings of 
the National Academy of Sciences of the United States of America 2000;97:10972-7. 
70. 
Applanat MP, Buteau-Lozano H, Herve MA, Corpet A. Vascular endothelial growth factor is a 
target gene for estrogen receptor and contributes to breast cancer progression. Advances in experimental 
medicine and biology 2008;617:437-44. 
71. 
Foekens JA, Peters HA, Grebenchtchikov N, et al. High tumor levels of vascular endothelial growth 
factor predict poor response to systemic therapy in advanced breast cancer. Cancer Res 2001;61:5407-14. 
72. 
Linderholm B, Grankvist K, Wilking N, Johansson M, Tavelin B, Henriksson R. Correlation of 
vascular endothelial growth factor content with recurrences, survival, and first relapse site in primary node-
positive breast carcinoma after adjuvant treatment. J Clin Oncol 2000;18:1423-31. 
73. 
Linderholm B, Tavelin B, Grankvist K, Henriksson R. Vascular endothelial growth factor is of high 
prognostic value in node-negative breast carcinoma. J Clin Oncol 1998;16:3121-8. 
74. 
Ferrara N, Davis-Smyth T. The biology of vascular endothelial growth factor. Endocrine reviews 
1997;18:4-25. 
75. 
Li DY, Sorensen LK, Brooke BS, et al. Defective angiogenesis in mice lacking endoglin. Science 
1999;284:1534-7. 
76. 
Lenato GM, Guanti G. Hereditary Haemorrhagic Telangiectasia (HHT): genetic and molecular 
aspects. Current pharmaceutical design 2006;12:1173-93. 
77. 
Hinck AP, Archer SJ, Qian SW, et al. Transforming growth factor beta 1: three-dimensional 
structure in solution and comparison with the X-ray structure of transforming growth factor beta 2. 
Biochemistry 1996;35:8517-34. 
78. 
Huse M, Chen YG, Massague J, Kuriyan J. Crystal structure of the cytoplasmic domain of the type I 
TGF beta receptor in complex with FKBP12. Cell 1999;96:425-36. 
79. 
Warrington K, Hillarby MC, Li C, Letarte M, Kumar S. Functional role of CD105 in TGF-beta1 
signalling in murine and human endothelial cells. Anticancer research 2005;25:1851-64. 

                                                 UAB 1514 / Version 7-25-19                      
115 | P a g e  
 
80. 
Bodey B, Bodey B, Jr., Siegel SE, Kaiser HE. Over-expression of endoglin (CD105): a marker of 
breast carcinoma-induced neo-vascularization. Anticancer research 1998;18:3621-8. 
81. 
Beresford MJ, Harris AL, Ah-See M, Daley F, Padhani AR, Makris A. The relationship of the neo-
angiogenic marker, endoglin, with response to neoadjuvant chemotherapy in breast cancer. Br J Cancer 
2006;95:1683-8. 
82. 
Hawinkels LJ, Kuiper P, Wiercinska E, et al. Matrix metalloproteinase-14 (MT1-MMP)-mediated 
endoglin shedding inhibits tumor angiogenesis. Cancer Res 2010;70:4141-50. 
83. 
Kumar S, Pan CC, Bloodworth JC, et al. Antibody-directed coupling of endoglin and MMP-14 is a 
key mechanism for endoglin shedding and deregulation of TGF-beta signaling. Oncogene 2013. 
84. 
Castonguay R, Werner ED, Matthews RG, et al. Soluble endoglin specifically binds bone 
morphogenetic proteins 9 and 10 via its orphan domain, inhibits blood vessel formation, and suppresses 
tumor growth. J Biol Chem 2011;286:30034-46. 
85. 
Investigational Brochure; Chimeric Anti-CD105 Monocloncal Antibody TRC105, TRACON 
Pharma 2013. 
86. 
Dixon JM, Renshaw L, Macaskill EJ, et al. Increase in response rate by prolonged treatment with 
neoadjuvant letrozole. Breast Cancer Res Treat 2009;113:145-51. 
87. 
Llombart-Cussac A, Guerrero A, Galan A, et al. Phase II trial with letrozole to maximum response 
as primary systemic therapy in postmenopausal patients with ER/PgR[+] operable breast cancer. Clinical & 
translational oncology : official publication of the Federation of Spanish Oncology Societies and of the 
National Cancer Institute of Mexico 2012;14:125-31. 
88. 
Pagani O, Regan MM, Walley BA, et al. Adjuvant exemestane with ovarian suppression in 
premenopausal breast cancer. N Engl J Med 2014;371:107-18. 
89. 
Keniry M, Parsons R. The role of PTEN signaling perturbations in cancer and in targeted therapy. 
Oncogene 2008;27:5477-85. 
90. 
Schwanhausser B, Busse D, Li N, et al. Corrigendum: Global quantification of mammalian gene 
expression control. Nature 2011;495:126-7. 
91. 
Schwanhausser B, Busse D, Li N, et al. Global quantification of mammalian gene expression 
control. Nature 2011;473:337-42. 
92. 
Rajasekhar VK, Viale A, Socci ND, Wiedmann M, Hu X, Holland EC. Oncogenic Ras and Akt 
signaling contribute to glioblastoma formation by differential recruitment of existing mRNAs to polysomes. 
Mol Cell 2003;12:889-901. 
93. 
Bantscheff M, Schirle M, Sweetman G, Rick J, Kuster B. Quantitative mass spectrometry in 
proteomics: a critical review. Anal Bioanal Chem 2007;389:1017-31. 
94. 
Hsieh AC, Liu Y, Edlind MP, et al. The translational landscape of mTOR signalling steers cancer 
initiation and metastasis. Nature 2012;485:55-61. 
95. 
Ingolia NT. Genome-wide translational profiling by ribosome footprinting. Methods in enzymology 
2010;470:119-42. 
96. 
Ingolia NT, Brar GA, Rouskin S, McGeachy AM, Weissman JS. The ribosome profiling strategy for 
monitoring translation in vivo by deep sequencing of ribosome-protected mRNA fragments. Nat Protoc 
2012;7:1534-50. 
97. 
Ingolia NT, Ghaemmaghami S, Newman JR, Weissman JS. Genome-wide analysis in vivo of 
translation with nucleotide resolution using ribosome profiling. Science 2009;324:218-23. 
98. 
Ingolia NT, Lareau LF, Weissman JS. Ribosome profiling of mouse embryonic stem cells reveals 
the complexity and dynamics of mammalian proteomes. Cell 2011;147:789-802. 
99. 
Michel AM, Choudhury KR, Firth AE, Ingolia NT, Atkins JF, Baranov PV. Observation of dually 
decoded regions of the human genome using ribosome profiling data. Genome research 2012;22:2219-29. 
100. 
Ingolia NT, Brar GA, Rouskin S, McGeachy AM, Weissman JS. Genome-wide annotation and 
quantitation of translation by ribosome profiling. Curr Protoc Mol Biol 2013;Chapter 4:Unit 4 18. 
101. 
Hammond ME, Hayes DF, Dowsett M, et al. American Society of Clinical Oncology/College Of 
American Pathologists guideline recommendations for immunohistochemical testing of estrogen and 

                                                 UAB 1514 / Version 7-25-19                      
116 | P a g e  
 
progesterone receptors in breast cancer. J Clin Oncol 2010;28:2784-95. 
102. 
Wolff AC, Hammond ME, Hicks DG, et al. Recommendations for human epidermal growth factor 
receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American 
Pathologists clinical practice guideline update. J Clin Oncol 2013;31:3997-4013. 
103. 
NCCN Breast Cancer, Version 3.2014. 2014. (Accessed Spetember 21, 2014, at www.nccn.org.) 
104. 
Draft Guidance for Industry: Pathologic Complete Response in Neoadjuvant Treatment of High-
Risk Early-Stage Breast Cancer: Use as an Endpoint to Support Accelerated Approval. 2012. at 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM305501
.pdf.) 
105. 
Cohen MH, Johnson JR, Li N, Chen G, Pazdur R. Approval summary: letrozole in the treatment of 
postmenopausal women with advanced breast cancer. Clin Cancer Res 2002;8:665-9. 
106. 
Boulay A, Lane HA. The mammalian target of rapamycin kinase and tumor growth inhibition. 
Recent results in cancer research Fortschritte der Krebsforschung Progres dans les recherches sur le cancer 
2007;172:99-124. 
107. 
Cohen HT, McGovern FJ. Renal-cell carcinoma. N Engl J Med 2005;353:2477-90. 
108. 
Frattini M, Signoroni S, Pilotti S, et al. Phosphatase protein homologue to tensin expression and 
phosphatidylinositol-3 phosphate kinase mutations in colorectal cancer. Cancer Res 2005;65:11227. 
109. 
Velho S, Oliveira C, Ferreira A, et al. The prevalence of PIK3CA mutations in gastric and colon 
cancer. European journal of cancer 2005;41:1649-54. 
110. 
Goel A, Arnold CN, Niedzwiecki D, et al. Frequent inactivation of PTEN by promoter 
hypermethylation in microsatellite instability-high sporadic colorectal cancers. Cancer Res 2004;64:3014-
21. 
111. 
Kirchner GI, Meier-Wiedenbach I, Manns MP. Clinical pharmacokinetics of everolimus. Clin 
Pharmacokinet 2004;43:83-95. 
112. 
O'Donnell A, Faivre S, Burris HA, 3rd, et al. Phase I pharmacokinetic and pharmacodynamic study 
of the oral mammalian target of rapamycin inhibitor everolimus in patients with advanced solid tumors. J 
Clin Oncol 2008;26:1588-95. 
113. 
Yeo W, Lam KC, Zee B, et al. Hepatitis B reactivation in patients with hepatocellular carcinoma 
undergoing systemic chemotherapy. Ann Oncol 2004;15:1661-6. 
114. 
Loomba R, Rowley A, Wesley R, et al. Systematic review: the effect of preventive lamivudine on 
hepatitis B reactivation during chemotherapy. Annals of internal medicine 2008;148:519-28. 
115. 
Motzer RJ, Escudier B, Oudard S, et al. Efficacy of everolimus in advanced renal cell carcinoma: a 
double-blind, randomised, placebo-controlled phase III trial. Lancet 2008;372:449-56. 
116. 
Yao JC, Shah MH, Ito T, et al. Everolimus for advanced pancreatic neuroendocrine tumors. N Engl 
J Med 2011;364:514-23. 
117. 
Krishna G, Moton A, Ma L, et al. Effects of oral posaconazole on the pharmacokinetic properties of 
oral and intravenous midazolam: a phase I, randomized, open-label, crossover study in healthy volunteers. 
Clinical therapeutics 2009;31:286-98. 
118. 
Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: 
revised RECIST guideline (version 1.1). European journal of cancer 2009;45:228-47. 
119. 
von Minckwitz G, Eidtmann H, Rezai M, et al. Neoadjuvant chemotherapy and bevacizumab for 
HER2-negative breast cancer. N Engl J Med 2012;366:299-309. 
120. 
Mendelson EB, Berg WA, Merritt CR. Toward a standardized breast ultrasound lexicon, BI-RADS: 
ultrasound. Seminars in roentgenology 2001;36:217-25. 
 
APPENDIX A 
Performance Status Criteria 
 
 

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

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APPENDIX B 
Drugs with potential interactions with everolimus 
 
CYP3A4 inhibitors 
CYP3A4 inducers 
Alosetron                  Aprepitant 
Atorvastatin              boceprevir 
Bosentan            buprenorphine 
Buspirone           carbamazepine 
clarithromycin           conivaptan 
Coumadin              cyclosporine 
Diazepam                Valdecoxib 
dihydroergotamine mesylate 
diltiazem                    docetaxel 
dofetilide                   efavirenz 
eplerenone                estazolam 
fentanyl            fosamprenavir 
galantamine                gefitinib 
grapefruit juice            imatinib 
indinavir                itraconazole 
ketoconazole 
  lopinavir/ritonavir 
lovastatin                methadone 
mibefradil,            mifepristone 
nefazodone,              nelfinavir 
paclitaxel                   pimozide 
propafenone        posaconazole 
quinidine                  ranolazine 
rifampin                      rifabutin 
ritonavir                   saquinavir 
simvastatin                sirolimus 
solifenacin                 succinate 
tacrolimus                telaprevir, 
telithromycin            tinidazole 
valdecoxib                valdenafil 
vinorelbine 
voriconazole 
zonisamide 
Alosetron            Aprepitant 
Bexarotene     uprenorphine 
Buspirone        cyclosporine 
diltiazel 
docetaxel 
efavirenze 
erlotinib 
estazolam 
exemestane 
fosamprenavir 
galantamine 
gefitinib 
imatinib 
irinotecan 
itraconazole 
lopinavir/ritonavir 
methadone 
mifepristone 
modafinil 
nisoldipine 
paclitaxel 
pimozide 
quinidine 
sirolimus 
solifenacin succinate 
sunitinib 
tacrolimus 
tramadol 
tinidazole 
valdecoxib 
voriconazole 
zonisamide 
 

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APPENDIX C 
 
American College of Radiology (ACR) Practice Guidelines for Imaging Studies of the Breast 
 
The ACR Practice Guideline for the Performance of Screening and Diagnostic Mammography, 
http://www.acr.org/~/media/3484ca30845348359bad4684779d492d.pdf 
 
The ACR Practice Guideline for the Performance of a Breast Ultrasound Examination, 
http://www.acr.org/~/media/52D58307E93E45898B09D4C4D407DD76.pdf 
 
The ACR Practice Guideline for the Performance of Contrast-Enhanced MRI of the Breast, 
http://www.acr.org/~/media/2A0EB28EB59041E2825179AFB72EF624.pdf 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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APPENDIX D 
 
NCI Common Terminology Criteria for Adverse Events (NCI CTCAE) version 4.03  
http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_ 8.5x11.pdf  
 
 

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APPENDIX E 
 
FDA MedWatch 3500A Form 
http://www.accesdata.fda.gov/scripts/MedWatch 
 
 

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APPENDIX F 
 
SOP for Investigator INDs Held by Physician Members of the UAB CCC 
(Available upon request; Pam Dixon 205- 975-5387) 
 
 

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APPENDIX G 
 
Blood and Biopsy Procedures 
 
 

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UAB 1514 - Blood Draw and Biopsy Schedule 
 
Paraffin blocks to UAB 
Frozen biopsies to UAB 
Blood for Serum Collection (PK, PD, APA)  
 
 
 
A. UAB - Paraffin blocks (all patients) 
 
Pre-therapy paraffin blocks and  core research biopsies (all patients) will be obtained and 
prepared. Time points include baseline, cycle 2 day  1 and at the time of surgery.  Formalin-fixed 
paraffin embedded tissue blocks from the patient’s primary tumor collected for diagnostic purposes 
will be requested for all patients enrolled in the study at the time of registration. For the research 
cores, the goal is for 2-4 core biopsy specimens obtained using standard institutional guidelines for 
a diagnostic core biopsy of a breast mass. However, biopsy samples will preferably be obtained using 
a 14-18 gauge core needle. At least one core will be used to prepare a paraffin block (paraffin-
embedded blocks or formalin fixed tissue) and at least one core will be immediately frozen (snap 
frozen individually for gene expression).  
 
Snap frozen research biopsies will be sent to UAB Tissue Procurement where biopsies will be stored 
for batching.  The batched biopsies will then be forwarded to HudsonAlpha Institute for 
Biotechnology.  These biopsies should be labeled with an indelible marker to include: 
 
1. The clinical trial identification number (UAB 1514) 
2. The subject’s study number  
3. The date of acquisition 
 
 Fifteen slides will be prepared from the paraffin blocks or formalin fixed tissue by Dr. Grizzle 
at UAB for analysis by conventional IHC of ER, PR, Her-2, EGFR, Ki67, apoptotic markers, and 
biomarkers of DNA repair such as H2AX and BRCA localization. 
 
 
 
B. UAB – Snap-Frozen research biopsies (all patients) 
 
.   
 
All cryovials (NALGENE® Cryoware™ 5000-0000) will be labeled with an indelible marker 
to include: 
 
1. The study identification number (UAB 1514);  
2. The subject’s study number;  
3. The date of acquisition 
 
 
 
 

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            Ed Acosta’s Lab 
 
Lab Contact: Kevin J. Ryan 
 
University of Alabama at Birmingham 
 
CCC PK/PD Core Laboratory 
 
1670 University Blvd, Volker Hall, Lab 175 
 
Preparing Tissue in Frozen Cryovials  
 
Snap Freezing: Do not Cut the tissue and simply ship as is. Place each core of tissue into a labeled 
individual 2.0 ml   NALGENE® Cryoware™ cryovials.  The label should contain the UAB clinical 
trial number (UAB 1514) followed by the subject’s study number, as well as the date the specimen 
was collected.  Do not place the patient’s name or medical record number on the label.  The container 
will become very cold.  Do not handle with unprotected hands.  Safety goggles should be use 
throughout the procedure. Snap freeze samples in liquid nitrogen.  If not available, you may use an 
alcohol/dry ice bath.   Fill pan about 1-2 inches deep with methanol.  The depth should be enough to 
cover the height of the vial.  Slowly add crushed dry ice until the boiling stops.  The bath is now 
ready for use.  Drop the sealed vials directly into the liquid nitrogen (LN2) carefully.  Leave the vials 
in the liquid nitrogen for at least one minute.  Once frozen, transfer the samples using tongs or a large 
spoon to remove the vials from the liquid nitrogen and transfer to a –80 C freezer until shipped.   
 
C. Serum (PK, PD, APA) 
 
1. Blood samples for the assays will be taken at the times described in the protocol.  Serum will 
be obtained in red top serum separator tubes and will be sent to Ed Acosta’s Lab. Dr.  
Acosta’s lab should be notified of these samples. The laboratory address is: 
 
 
Ed Acosta’s Lab 
Lab Contact: Kevin J. Ryan 
University of Alabama at Birmingham 
CCC PK/PD Core Laboratory 
1670 University Blvd, Volker Hall, Lab 175 
 
2. PK: A 5 mL blood sample will be collected pre-dose and 1, 2, 4, 6 and 24 hours post-
dose on the days indicated within Table 7-1: Study Calendar.  Samples will be separated 
and stored at approximately -70 °C.  
 
Ed Acosta’s Lab 
Lab Contact: Kevin J. Ryan 
University of Alabama at Birmingham 
CCC PK/PD Core Laboratory 
1670 University Blvd, Volker Hall, Lab 175 
 
APA: Anti-Product Antibody (APA) will be collected will be collected before dosing on 
cycle 1 day 1, every 4 weeks thereafter, 4 and 12 weeks following the last dose of TRC105 

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(Table 7-1: Study Calendar). Concentrations will be measured using validated ELISA 
methods.  APA concentrations will be evaluated in the context of pharmacokinetic 
parameters and AE profiles. Samples will be separated and stored at approximately -
70 °C.   
Ed Acosta’s Lab 
Lab Contact: Kevin J. Ryan 
University of Alabama at Birmingham 
CCC PK/PD Core Laboratory 
            1670 University Blvd, Volker Hall, Lab 175