Sirolimus for the Treatment of Severe Intestinal Polyposis in Patients With Familial Adenomatous Polyposis (FAP): a Pilot Study
Phase: PHASE2
Conditions: Adenomatous Polyposis Coli
Sponsor: Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)

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Sirolimus and FAP 
 
 
 
 
 
 
 
 
 
 
 
 
RESEARCH PROTOCOL 
 
‘Sirolimus for the treatment of severe intestinal 
polyposis in patients with familial adenomatous 
polyposis (FAP); a pilot study’ 
 
 
 
 
 
 
 
 
 
Correspondence to: 
Prof. dr. E. Dekker 
Department of gastroenterology and hepatology, C2 
Academic Medical Centre 
Meibergdreef 9 
1105 AZ Amsterdam 

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PROTOCOL TITLE ‘Sirolimus for the treatment of severe intestinal polyposis in patients with familial 
adenomatous polyposis (FAP), a pilot study’ 
Protocol ID 
NL55868.018.15 
Short title 
Sirolimus and FAP 
EudraCT number  
2015-005527-12 
Version 
1 
Date 
7-12-2015 
Coordinating investigator/project 
leader 
 
Prof. dr. E. Dekker 
Department of gastroenterology and hepatology, C2 
Academic Medical Centre 
Meibergdreef 9 
1105 AZ Amsterdam 
Principal investigator(s) (in Dutch: 
hoofdonderzoeker/ uitvoerder) 
 
Prof. dr. E. Dekker 
Department of gastroenterology and hepatology, C2 
Academic Medical Centre 
Meibergdreef 9 
1105 AZ Amsterdam 
Sponsor (in Dutch: 
verrichter/opdrachtgever) 
Department of gastroenterology and hepatology, C2 
Academic medical centre 
Meibergdreef 9 
1105 AZ Amsterdam 
Subsidising party 
Pfizer BV 
Rivium Westlaan 142 
2909 LD Capelle a/d IJssel 
Independent expert (s) 
Prof. dr. P. Fockens 
Department of gastroenterology and hepatology, C2 
Academic Medical Centre 
Meibergdreef 9 

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Sirolimus and FAP 
 
 
 
1105 AZ Amsterdam 
Laboratory sites  
Not applicable 
Pharmacy  
Not applicable 
 
PROTOCOL SIGNATURE SHEET 
 
Name 
Signature 
Date 
Head of Department: 
Prof. dr. P. Fockens 
 
 
 
[Coordinating Investigator/Project 
leader/Principal Investigator]: 
Prof. dr. E. Dekker 
 
 
 
 

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TABLE OF CONTENTS 
 
1. INTRODUCTION AND RATIONALE…………………………………………………………………………………………………..9 
2. OBJECTIVES ........................................................................................................................11 
3. STUDY DESIGN ....................................................................................................................12 
4. STUDY POPULATION .......................................................................................................... 123 
4.1 
Population (base)......................................................................................................13 
4.2 
Inclusion criteria .......................................................................................................13 
4.3 
Exclusion criteria ......................................................................................................13 
4.4 
Sample size calculation ..............................................................................................15 
5. 
TREATMENT OF SUBJECTS.................................................................................................16 
5.1  Investigational product/treatment ..................................................................................16 
5.2 
Use of co-intervention ...............................................................................................16 
5.3 
Escape medication ....................................................................................................16 
6. 
INVESTIGATIONAL PRODUCT .............................................................................................17 
6.1 
Name and description of investigational  product .........................................................17 
6.2 
Summary of findings from non-clinical studies .............................................................17 
6.3 
Summary of findings from clinical studies ....................................................................17 
6.4 
Summary of known and potential risks and benefits .....................................................17 
6.5 
Description and justification of route of administration and dosage ...............................20 
6.6 
Dosages, dosage modifications and method of administration .......................................20 
6.7 
Preparation and labelling of Investigational Medicinal Product ......................................20 
6.8 
Drug accountability ...................................................................................................21 
7. 
METHODS .......................................................................................................................22 
7.1 
Study parameters/endpoints .....................................................................................22 
7.1.1. 
Main study parameter/endpoint .........................................................................22 
 
Size of 5 marked polyps .............................................................................................22 
7.1.2. Secondary study parameters/endpoints (if applicable) ................................................22 
 
Number of polyps .....................................................................................................22 
7.2 
Study procedures ......................................................................................................22 
7.3 
Withdrawal of individual subjects ...............................................................................25 
7.4 
Replacement of individual subjects after withdrawal ....................................................25 
7.5 
Follow-up of subjects withdrawn from treatment .........................................................25 
7.6 
Premature termination of the study ............................................................................25 
8. 
SAFETY REPORTING ..........................................................................................................26 
8.1 
Temporary halt for reasons of subject safety ...............................................................26 
8.2 
AEs, SAEs and SUSARs ...............................................................................................26 
8.2.1 
Adverse events (AEs) ..........................................................................................26 
8.2.2 
Serious adverse events (SAEs) .............................................................................26 
8.2.3 
Suspected unexpected serious adverse reactions (SUSARs) ....................................27 
8.3 
Annual safety report .................................................................................................28 
8.4 
Follow-up of adverse events ......................................................................................28 
8.5 
Safety Committee .....................................................................................................28 

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9. 
STATISTICAL ANALYSIS ......................................................................................................30 
9.1 
Primary study parameter(s) .......................................................................................30 
9.2 
Secondary study parameter(s) ....................................................................................30 
9.3 
Interim analysis (if applicable) ....................................................................................30 
10. 
ETHICAL CONSIDERATIONS ............................................................................................31 
10.1 
Regulation statement ................................................................................................31 
10.2 
Recruitment and consent...........................................................................................31 
10.3 
Compensation for injury ............................................................................................31 
10.4 
Incentives (if applicable) ............................................................................................32 
11. 
ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION ...........................................33 
11.1 
Handling and storage of data and documents ..............................................................33 
11.2 
Monitoring and Quality Assurance ..............................................................................33 
11.3 
Amendments ...........................................................................................................33 
11.4 
Annual progress report ..............................................................................................34 
11.5 
Temporary halt and (prematurely) end of study report .................................................34 
11.6 
Public disclosure and publication policy .......................................................................34 
12. 
STRUCTURED RISK ANALYSIS ..........................................................................................35 
12.1 
Potential issues of concern ........................................................................................35 
12.2 
Synthesis .................................................................................................................37 
13. 
REFERENCES ................................................................................................................39 

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LIST OF ABBREVIATIONS AND RELEVANT DEFINITIONS  
 
ABR 
ABR form, General Assessment and Registration form, is the application form that is 
required for submission to the accredited Ethics Committee (In Dutch, ABR = Algemene 
Beoordeling en Registratie) 
AE 
Adverse Event 
AR 
Adverse Reaction 
CA 
Competent Authority 
CCMO 
 
CRC 
Central Committee on Research Involving Human Subjects; in Dutch: Centrale Commissie 
Mensgebonden Onderzoek 
Colorectal cancer 
CV 
Curriculum Vitae 
DSMB 
EKG 
Data Safety Monitoring Board 
Electrocardiography 
EU 
European Union 
EudraCT 
FAP 
European drug regulatory affairs Clinical Trials  
Familial adenomatous polyposis 
GCP 
HRQoL 
Good Clinical Practice 
Health related quality of life 
IB 
Investigator’s Brochure 
IC 
Informed Consent 
IMP 
Investigational Medicinal Product  
IMPD 
IPAA 
IRA 
LGI 
Investigational Medicinal Product Dossier  
Ileo-anal pouch anastomosis 
Ileo-rectal anastomosis 
Lower gastrointestinal 
METC  
Medical research ethics committee (MREC); in Dutch: medisch ethische toetsing 
commissie (METC) 
(S)AE 
(Serious) Adverse Event  
SPC 
Summary of Product Characteristics (in Dutch: officiële productinfomatie IB1-tekst) 
Sponsor 
The sponsor is the party that commissions the organisation or performance of the 
research, for example a pharmaceutical company, academic hospital, scientific 
organisation or investigator. A party that provides funding for a study but does not 
commission it is not regarded as the sponsor, but referred to as a subsidising party. 

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SUSAR 
ULN 
Suspected Unexpected Serious Adverse Reaction 
Upper limit of normal 
Wbp 
Personal Data Protection Act (in Dutch: Wet Bescherming Persoonsgevens) 
WMO 
Medical Research Involving Human Subjects Act (in Dutch: Wet Medisch-wetenschappelijk 
Onderzoek met Mensen 
 
 

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SUMMARY 
Rationale: Due to the presence of numerous colorectal polyps, nearly all patients with familial 
adenomatous polyposis (FAP) develop colorectal cancer (CRC) at an average age of 45 years, if left 
untreated. Therefore, a prophylactic colectomy is recommended. After surgery, adenomas are likely 
to reappear in the pouch or rectum. Recently, studies in APC-deficient mice have shown that the 
mTOR inhibitor sirolimus can cause intestinal tumour cells to undergo growth arrest and 
differentiation and could even lead to regression of polyps. In current practice, sirolimus is used as an 
immunomodulator for patients after renal transplantation. Sirolimus has never been investigated in 
patients with FAP. We hypothesize that sirolimus could lead to regression of intestinal polyps in 
patients with FAP.  
Objective: The aim of our study is to investigate the effect of sirolimus on the progression of 
intestinal adenomas in patients with FAP and to assess the safety of this treatment.  
Study design: A prospective phase II pilot study with a follow-up of 6 months. 
Study population: Five patients with FAP will be selected and invited for study participation. They 
need to be 18 years or older, have a genetically confirmed APC mutation with a classical FAP 
phenotype and a subtotal colectomy with an ileo-rectal anastomosis (IRA) or a total colectomy with 
an ileo-anal pouch anastomosis (IPAA) with severe polyposis.  
Intervention: All patients will receive sirolimus for the duration of the study, with a trough level 
target range of 5-8 ng/ml.   
Main study parameters/endpoints: The main study parameters are the effect of sirolimus on the 
size of 5 marked polyps and safety of this treatment. Safety outcomes will be assessed by summary 
analysis of adverse events, clinical laboratory abnormalities and regular physical examination. 
Additional parameters are the effect on the number of polyps, global polyp burden, histopathology 
and patient-reported quality of life. Cell proliferation and immunohistochemistry of mTOR targets in 
healthy intestinal mucosa and adenomatous tissue will be assessed.  
Nature and extent of the burden and risks associated with participation, benefit and group 
relatedness: At baseline and at three monthly visits a medical history will be taken and physical 
examinations will be performed, as well as laboratory tests and HRQoL questionnaires. Trough level 
testing of sirolimus will be measured at day 7 after start of the study drug and weekly until the 
therapeutic range has been achieved, after which the next trough level will be measured at 3 and 6 
months follow-up.  Finally, monthly telephone check-ups will be carried out. LGI endoscopies will be 
done at baseline and at 6 months. For this study, we include patients with severe rectal or pouch 
polyposis as they are expected to have an indication for invasive surgery on a short-term base and no 
other less invasive alternative therapy is available. 

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1. INTRODUCTION AND RATIONALE 
 
Familial adenomatous polyposis (FAP) is a syndrome caused by mutations in the adenomatous 
polyposis coli (APC) tumor suppressor gene. It follows an autosomal dominant pattern of inheritance 
and up to 25% of all cases are due to de novo mutations (1). This syndrome is characterized by the 
presence of numerous colorectal adenomas, usually more than hundred, from a young age (2).  If left 
untreated, colorectal cancer (CRC) develops in nearly 100% of all patients with a mean age at 
diagnosis of 45 years (3). Therefore, international guidelines recommend a prophylactic colectomy 
for these patients (4-7). After surgery, surveillance sigmoidoscopies are needed as adenomas are 
likely to reappear in the pouch or rectum (8, 9). In addition to colorectal adenomas, patients with 
FAP usually develop duodenal adenomas as well as extraintestinal manifestations, such as desmoid 
tumors and fundic gland polyps (10-12).  
 
In recent years several drug therapies have been investigated that aimed to decrease the number 
and size of polyps in patients with FAP, with none of them providing sufficient evidence of success 
(13). However, recently studies in APC-deficient mice demonstrated  that mTOR inhibitor sirolimus 
can cause intestinal tumour cells to undergo growth arrest and differentiation (14). Signalling 
through the mTOR pathway is required for epithelial cell proliferation and tumour growth (15, 16). It 
was shown that mTOR complex 1 (mTORC1) activity is required for the proliferation of APC-deficient 
enterocytes. This complex mediates inhibition of eEF2 kinase, which is needed for the proliferation of 
APC-deficient cells. Sirolimus targets eEF2 resulting in growth arrest and differentiation of tumour 
cells. The effect of sirolimus on colonic adenoma regression was confirmed in other mice studies, 
with one of them showing beneficial effects in the small bowel (17-22). Sirolimus seems to inhibit 
polyp formation and could even lead to regression of polyps (21, 23). Moreover, it seems to increase 
survival and time to progression to dysplasia (20, 21).  
 
Sirolimus has been widely investigated in human studies. It received FDA approval in 1999 as 
immunosuppressive agent for the treatment of patients with renal transplantations. Data on toxicity, 
contra-indications, interactions and dosing advice are available and based on data collected in 
patients with renal transplantations (24). Some of the most frequently (>10%) occurring side-effects 
are thrombocytopenia and anemia, hypertension, electrolyte disorders, urinary tract infections, 
hypercholesterolemia, hyperglycemia and abdominal pain. Less frequent, but more severe side-
effects are sepsis, deep venous thrombosis and skin cancer (Table 1).  

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This drug has not yet been evaluated in patients with FAP. In this pilot study (phase II), the possible 
polyp reducing effect of sirolimus will be investigated in a small number of patients with FAP, who 
suffer from severe intestinal polyposis. Patients who are expected to undergo rectal or pouch-related 
surgery on a short- term base (to avoid the development of cancer), will be selected and invited for 
study participation. Both rectal and pouch surgery are invasive and associated with a significant 
morbidity and mortality and neither does it prevent the development of adenomas in the remaining 
intestinal tissue as previously described. Therefore these patients could potentially benefit from a 
new and less invasive FAP related drug therapy to postpone, or eventually even prevent, surgery.  
 
The aim of our study is to investigate the effect of sirolimus on the progression of intestinal 
adenomas in patients with FAP and to assess the safety of this treatment.  

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2. OBJECTIVES 
 
Primary objective:  
 
To evaluate the effect of sirolimus on the size of 5 marked polyps in 5 patients with FAP and a 
large intestinal polyp burden 
 
To assess safety outcomes by summary analysis of adverse events, clinical laboratory 
abnormalities and regular physical examination. 
 
Secondary Objectives: 
 
To evaluate the effect on number of polyps  
 
To evaluate the effect on global polyp burden (see definition in chapter 7.2) 
 
To evaluate the effect on histology (tubular, tubulovillous or villous histology and degree of 
dysplasia) 
 
To evaluate patient reported quality of life using health related quality of life (HRQoL) 
questionnaires (EORTC QLQ-C30, SF-36, CR29 and EQ-5D-5L) 
 
To measure the rate of cell proliferation in healthy intestinal mucosa and adenomatous 
tissue 
 
To assess immunohistochemistry of mTOR targets (such as eEF2 kinase, phospho-S6)  in 
healthy intestinal mucosa and adenomatous tissue 

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3. STUDY DESIGN 
 
This is a prospective phase II pilot study that will take place at the Academic Medical Center (AMC). 
Five patients with FAP will be invited for study participation. The total study duration will be 6 
months. At baseline and at 6 months follow-up all included patients will undergo a lower 
gastrointestinal (LGI) endoscopy. Safety outcomes will be assessed by laboratory tests, physical 
examinations and telephone check-ups. Sirolimus trough levels will be measured regularly and if 
needed dosing adjustments will be made.  
 
 
 
Baseline 
· Medical history & physical examination (including vital signs) 
· Laboratory tests (hematology1, chemistry2, pregnancy test, urine specimen) 
· HRQoL questionnaires 
· LGI endoscopy 
· Day 7: Trough level testing of sirolimus on day 7 after start study drug and weekly until the 
therapeutic range has been achieved  
Month 6 
· Monthly telephone check-ups to assess the occurrence of (non-)serious adverse events  
· Medical history & physical examination (including vital signs) 
· Laboratory tests (hematology1, chemistry2, pregnancy test, urine specimen) 
· HRQoL questionnaires 
· LGI endoscopy 
· Trough level testing of sirolimus  
 Month 7 
. Additional telephone check-up to assess the occurrence of (non-)serious adverse events 
1. Hb, leukocytes, thrombocytes 2. ALAT, ASAT, AF, GGT, AF, LDH, chol, triglyc, potassium, phosphate, 
creatinine,  glucose, calcium, albumin 
Month 1 & 2 
· Monthly telephone check-ups to assess the occurrence of (non-)serious adverse events  
Month 3 
· Monthly telephone check-ups to assess the occurrence of (non-)serious adverse events  
· Medical history & physical examination (including vital signs) 
· Laboratory tests (hematology1, chemistry2, pregnancy test, urine specimen) 
· HRQoL questionnaires 
· Trough level testing of sirolimus and weekly until the therapeutic range has been achieved    
Month 4 & 5 
· Monthly telephone check-ups to assess the occurrence of (non-)serious adverse events  

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4. STUDY POPULATION 
 
4.1 Population (base)  
Five patients with FAP will be selected and invited for study participation. These patients must 
have severe rectal or pouch polyposis for which surgery is expected within a few years. These 
patients are selected from our large cohort of patients with FAP (n≈200).  Selection will not be 
based on sex and age.  
 
4.2 Inclusion criteria 
 
In order to be eligible to participate in this study, a subject must meet all of the following criteria: 
 
- ≥ 18 years 
 
-A genetically confirmed APC mutation 
-Classical FAP phenotype (100-1000 colorectal adenomatous polyps) 
-Subtotal colectomy with ileorectal anastomosis (IRA) or total colectomy with ileo-anal pouch 
anastomosis (IPAA) 
-Severe rectal or pouch polyposis, defined as having >25 polyps amenable to complete removal 
(InSiGHT 2011 Staging System score of 3, see below)  
-Fertile patients must use effective contraception during study treatment and until 12 weeks after 
study treatment 
 
 
InSiGHT 2011 Staging System (InSiGHT Meeting 2011, San Antonio, TX) 
Stage  
Polyp description 
0 
0-10 polyps, all <5mm 
1 
10-25 polyps, most <5mm, none > 1cm 
2 
10-25 polyps, any >1 cm, amenable to complete removal 
3 
>25 polyps amenable to complete removal, or any incompletely removed sessile polyp, or any 
prior evidence of high grade dysplasia, even if completely excised 
4 
>25 polyps not amenable to complete removal, or any incompletely excised sessile polyp 
showing high grade dysplasia; any invasive cancer 
 
4.3 Exclusion criteria 
A potential subject who meets any of the following criteria will be excluded from participation in 
this study: 
 
General exclusion criteria: 

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-Inability to give informed consent 
 
-Participation in another interventional clinical trial 
 
Medical history: 
-Subjects who are pregnant or breast-feeding, proved with a negative pregnancy test if female of 
child-bearing potential 
-Prior pelvic irradiation 
-Invasive malignancy in the past 5 years 
-Subjects who are HIV positive 
-Subjects with severe systemic infections, current or within 2 weeks prior to study start 
-Subjects with known severe restrictive or obstructive pulmonary disorders 
-Known sucrase insufficiency, isomaltase insufficiency, fructose intolerance, glucose 
malabsorption, galactose malabsorption, galactose intolerance or Lapp-lactase deficiency  
 
-History of pulmonary embolism or deep venous thrombosis 
 
-Major surgery less than or equal to 2 weeks prior to enrollment or any planned surgery within 
treatment period 
 
-Active post-operative complication, e.g. infection, delayed wound healing 
 
Co-medication: 
-History of hypersensitivity to sirolimus or to drugs of similar chemical classes 
-Regular NSAID use (defined as more than twice a week for 4 consecutive weeks) within 3 months 
prior to baseline 
-Use of other FAP directed drug therapies (accepted if discontinued 3 months prior to start of the 
study) 
-Subjects requiring systemic anticoagulation 
-Co-medication that could interact with sirolimus 
 
Lab results: 
 
-Abnormal laboratory results (assessed within 14 days prior to start of study drug): 
 
 
-Significant abnormalities in hepatic function 
 
 
 
-ALAT, ASAT, GGT, AF, LDH: > 1.5 times ULN 
 
 
-Significant hematologic abnormalities 
 
 
 
-Hb: <7.0 mmol/L 
 
 
 
-Thrombocytes: <100 10E9/L 
 
 
 
-Leukocytes: <4.0 10E9/L 

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-Increased fasting serum cholesterol or triglyceride (whether or not on lipid-
lowering therapy) 
 
 
 
-Serum cholesterol: >7.8 mmol/L 
 
 
 
-Serum triglycerides: >4.5 mmol/L 
 
 
-Increased glucose (venous, fasting): >6.4 mmol/L 
 
 
-Electrolyte abnormalities  
 
 
 
-Total serum calcium (corrected for albumin): <2.0 mmol/L 
 
 
 
-Potassium: <3.0 mmol/L 
 
 
 
-Phosphate: <1.3 mmol/L 
 
 
-Calculated glomerular filtration rate (GFR) less than 40 mL/min/1.73m2 
 
 
using the simplified Modification of Diet in Renal Disease (MDRD) formula 
 
-Urine specimen: 
 
 
-Spot urine protein to creatinine ratio (UPr/Cr) greater than or equal to 0.5 
 
 
 
4.4 Sample size calculation 
As this is a pilot study that has not been performed in humans previously, no sample size 
calculation is being done. We believe a number of 5 patients is sufficient for the explorative 
purpose of our study.  
 
 

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5. TREATMENT OF SUBJECTS 
 
5.1  Investigational product/treatment 
Participants will be given sirolimus tablets. The starting dose is 2 mg once daily which will be given in 
1mg tablets. On day 7 the first trough level is measured (using the LC-MS/MS method) and if not 
within the target range of 5-8ng/ml, dosing adjustments are made. In case of dosing adjustments, the 
next trough level is measured seven days later and this is repeated weekly until the target range is 
achieved. In case trough levels are within the target range, the next trough level measurement is at 
month 3, after which dosing adjustments are made if necessary, and at month 6. The maximum daily 
dose is 40mg. No placebo is given.  
We estimate that a total number of 2000 tablets of 1mg are needed: 2 tablets a day for 6 months for 
5 patients resulting in approximately 1800 tablets, plus 200 additional tablets in case of loss or if 
dosing adjustments are needed.  
 
5.2 Use of co-intervention  
Female participants who are sexually active must use adequate contraception as confirmed by three 
monthly pregnancy tests and male patients need to use adequate contraception as well. Adequate 
contraception needs to be continued until 12 weeks after therapy. Furthermore, any new concurrent 
medication that is started during the study needs to be reported. If known to have an interaction 
with sirolimus, an additional trough level measurement needs to be done. Patients will visit the AMC 
at baseline, month 3 and month 6 for the interventions as mentioned in chapter 1 ‘Study design’ 
(physical examinations, laboratory tests, pregnancy test, urine specimen , questionnaires) and weekly 
for sirolimus trough level testing until the target range has been achieved. Moreover, monthly 
telephone check-ups will be performed.  
Endoscopies that take place at baseline and at 6 months follow-up are not considered co-
interventions, as these are performed in a frequency that is consistent with our practice guidelines. 
Tattoos that are placed during these procedures are considered additional interventions and biopsies 
that are done can partly be considered as additional interventions, as some of these would have 
been done in routine care: 5 biopsies of normal mucosa are additional, 5 biopsies of adenomatous 
tissue are part of routine care. 
 
5.3 Escape medication  
In case of pain due to any cause, the use of paracetamol is recommended instead of NSAIDS.  

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6. INVESTIGATIONAL PRODUCT  
 
6.1 Name and description of investigational  product 
The investigational product is sirolimus. Please see the SPC text of sirolimus for further 
information.  
 
6.2 Summary of findings from non-clinical studies 
Please see the SPC text of sirolimus. The text is based on an indication (immunotherapy in 
patients who received a renal transplantation) that is different than the indication we will 
investigate. This drug has not yet been tested in patients with FAP. Our hypothesis of the polyp 
reducing effect of sirolimus is based on mouse model studies. As described in the introduction, 
recently it was shown that the mTOR inhibitor sirolimus can cause tumour cells to undergo 
growth arrest and differentiation in APC-deficient mice (14). Signalling through the mTOR 
pathway is necessary for epithelial cell proliferation and tumour growth (15, 16). It was shown 
that mTOR complex 1 (mTORC1) activity is required for the proliferation of APC-deficient 
enterocytes. This complex mediates inhibition of eEF2 kinase, which is needed for the 
proliferation of APC-deficient cells. Sirolimus targets eEF2 resulting in growth arrest and 
differentiation of tumour cells. The effect of sirolimus on colonic adenoma regression was 
confirmed in other mice studies, with one of them showing beneficial effects in the small bowel 
(17-22). Sirolimus seems to inhibit polyp formation and could even lead to regression of polyps 
(21, 23). Moreover, it seems to increase survival and time to progression to dysplasia (20, 21). 
  
6.3 Summary of findings from clinical studies 
Please see the SPC text of sirolimus. This drug has not yet been tested in patients with FAP. 
Therefore findings from clinical human studies investigating the effect of sirolimus for our 
hypothesized indication cannot be reported. Since February 2014 an American center has been 
recruiting 15 participants for a pilot study aiming to investigate if mTor pathway activation 
decreases in patients with surgically-resectable desmoid tumors which are removed following 
pre-operative treatment with sirolimus. That study is being conducted in children and young 
adults (up to 29 years), which includes patients with FAP. Results are expected in 2016 (25).  
 
6.4 Summary of known and potential risks and benefits 
Please see the SPC text of sirolimus. Some of the most frequently (>10%) occurring side-effects 
are thrombocytopenia and anemia, hypertension, electrolyte disorders, urinary tract infections, 

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hypercholesterolemia, hyperglycemia and abdominal pain. Some of the less frequent, but more 
severe side-effects are sepsis, deep venous thrombosis and skin cancer and self-limiting oral 
stomatitis. All known side-effects can be found in the Table 1. The incidence of several of these 
side-effects can increase by an increasing trough level of sirolimus. By applying a relatively low 
dosing range and frequent trough level testing, we believe these risks have  been minimized in 
our study.   
 
Side-effects of sirolimus as reported in the SPC text apply to patients with a renal transplantation. 
Most of these side-effects were reported in patients who used sirolimus in combination with 
other immunosuppressive drugs. We exclude patients who use other immunosuppressive 
therapy. Moreover, compared to patients with FAP, patients with a renal transplantation more 
frequently have (severe) comorbidities and additionally, sirolimus will be given for a short amount 
of time (6 months). Therefore, side-effects of sirolimus might be less frequently found in our 
participants.   
 
We will use tattoos with SPOTTM for marking the polyp sites, which has been used for many years 
in colonoscopy practice (26). No side-effects of SPOT have been described in literature.  
Furthermore, colonic biopsies are accompanied by a minimal risk of perforation, bleeding and 
infection. These complications have been described in some case reports after hot biopsy but 
mostly in patients with pre-existent ulcerative colitis or infectious colitis. Bleeding after hot biopsy 
has been reported to occur in up to 0.26% and perforation in up to 0.01% after hot biopsy. During 
our study only cold biopsies will be obtained. Only case reports have reported on complications 
after cold biopsy (27, 28). These potential complications are cited in the written patient 
information.  
 
As described in chapter 6.2, a significant polyp reducing effect of sirolimus is to be expected. The 
patients that will be included, are likely to undergo a subtotal colectomy with ileoanal pouch 
anastomosis or an end ileostomy on a short term base due to the severity of polyposis. These 
invasive types of surgery are accompanied with a significant risk of comorbidities (29). Even after 
surgery, patients will develop polyps in the remaining intestinal tissue and therefore surveillance 
sigmoidoscopies are needed to prevent the development of cancer (5, 30-32). There is currently 
no alternative treatment available for these patients. Therefore, a medical treatment to postpone 
or even prevent surgery could be beneficial. If a polyp reducing effect is shown, this therapy could 
possibly also be beneficial in postponing a preventive colectomy in patients with FAP who have 
their colon in situ and in postponing a duodenectomy in patients with severe duodenal polyposis.  

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Table 1. Side-effects of sirolimus (SPC) 
System/organ 
Very frequent 
(1/10) 
 
Frequent 
(1/100 to <1/10) 
Less frequent 
(1/1000 to <1/100) 
Seldom 
(1/10.000 to <
Infections  
Pneumonia 
Fungal infection 
Viral infection 
Bacterial infection 
Herpes simplex infection 
Urinary tract infection 
 
 
Sepsis 
Pyelonephritis 
CMV infection 
Herpes zoster infection 
Clostridium difficile 
colitis Mycobacterial 
infection (incuding 
tuberculosis) 
EBV viral infection  
 
Neoplasms, benign, malignant and 
non-specified (including cysts and 
polyps) 
 
Skin cancer 
Lymphoma/ post-
transplantation 
lymphoproliferative 
conditions 
 
Blood and lymphatic disorders 
Thrombocytopenia 
Anemia 
Leukopenia 
 
Hemolytic-uremic syndrome 
Neutropenia 
Pancytopenia 
Thrombotic 
thrombocytopenic 
purpura 
 
 
 
Hepatic and biliary disorders 
 
 
Hepatic failure 
 
Immune system disorders 
 
Hypersensitivity disorders such as 
anaphylactic/anaphylactoid 
reactions, angio-edema 
 
 
Feeding and metabolic disorders 
 
Hypokalemia 
Hypophosphatemia  
Hyperlipidemia (such as 
Hypercholesterolemia) 
Hyperglycemia 
Hypertriglyceridemia 
Diabetes mellitus 
 
 
 
Nervous system disorders* 
Headache 
 
 
 
Cardiac disorders 
Tachycardia 
Pericard effusion 
  
 
Vascular disorders 
Lymphocele 
Hypertension 
Venous thrombosis (such as deep 
venous thrombosis) 
Lymphedema 
 
Respiratory, chest and mediastinal 
disorders 
 
Pulmonary embolism 
Pneumonitis 
Pleural effusion 
Epistaxis 
Pulmonary hemorrhage 
Alveolar protein
Gastrointestinal disorders 
Abdominal pain 
Diarrhea 
Constipation 
Nausea 
Pancreatitis 
Stomatitis 
Ascites 
 
 
Cutaneous and subcutaneous 
disorders 
Rash 
Acne 
 
Expholiative dermatitis 
Hypersensitive 
Musculoskelatal and connective 
tissue disorders 
Arthralgia 
 
Osteonecrosis 
 
 
Renal and urinary system disorders 
Proteinuria 
 
Nephrotic syndrome 
Focal segmental 
glomerulosclerosis 
 

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System/organ 
Very frequent 
(1/10) 
 
Frequent 
(1/100 to <1/10) 
Less frequent 
(1/1000 to <1/100) 
Seldom 
(1/10.000 to <
Reproductive system disorders and 
breast disorders 
Menstruation disorders 
(including amenorrhea, 
menorrhagia 
Ovarial cysts 
 
 
General disrders and disorders at 
administration site 
Edema 
Peripheral edema 
Pyrexia 
Pain 
Disturbed wound healing 
Disturbed wound healing 
Edema 
 
 
 
Laboratory testing disorders 
Increased LDH 
Increased creatinin 
Increased liver function 
tests (such as increased 
ASAT and ALAT) 
 
 
 
* Side-effect of unknown frequency: posterior reversible encephalopathy syndrome 
 
6.5 Description and justification of route of administration and dosage 
In patients with a renal transplantation, the starting dose is 6 mg orally and then 2 mg once daily. 
After a week a first trough level assessment is done.  The aim in these patients is to obtain a 
trough level of 12-20 ng/ml in full blood (24). The current practice in the AMC is a target dose of 
5-8 ng/ml for patients with a renal transplantation as this results in less adverse events compared 
to a trough level of 12-20 ng/ml but still results in a clinical effect. As safety and efficacy of this 
drug has not yet been assessed in patients with FAP, the target range in this study is therefore set 
at 5-8 ng/ml as recommended by an AMC renal transplantation expert. The starting dose is 2 mg 
once daily. On day 7 the first trough level is measured and if not within the target range, dosing 
adjustments are made. In case of dosing adjustments, the next trough level is measured seven 
days later and this is repeated weekly until the target range is achieved. In case trough levels are 
within the target range, the next trough level measurement is at month 3, after which dosing 
adjustments are made if needed, and at month 6. The maximum daily dose is 40 mg.  
 
6.6 Dosages, dosage modifications and method of administration 
 
See chapter 6.5 
 
6.7 Preparation and labelling of Investigational Medicinal Product 
Sirolimus will be provided free of charge by Pfizer. Labelling of sirolimus will be done by the AMC 
Hospital Pharmacy according to GCP guidelines (GCP and GMP-annex 13).  The registered product 
Sirolimus will be used, meaning that the accessory label text of the producer will be used. This 
will be added with another label that indicates: name of the study, name of the principal 
investigator, name of the sponsor (AMC, Meibergdreef 9, 1105 AZ Amsterdam, tel 020-5669111), 

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“uitsluitend ten behoeve van klinisch onderzoek”, “Buiten bereik van kinderen bewaren”, 
“Gebruiken volgens voorschrift studieprotocol”, patient number, patient name. 
 
 
6.8 Drug accountability 
As described in chapter 6.7, sirolimus will be delivered at the AMC Hospital Pharmacy by 
Pfizer. Sirolimus will be stored and dispensed on a patient named basis by the AMC Hospital 
Pharmacy and drug accountability of receipt, dispensed, returned and destroyed medication will 
be kept conform GCP guidelines. 
 

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7. METHODS 
7.1 Study parameters/endpoints 
7.1.1. Main study parameter/endpoint 
 
Size of 5 marked polyps in 5 patients with FAP and a large intestinal polyp burden 
 
Safety outcomes reported by summary analysis of adverse events , clinical laboratory 
abnormalities and regular physical examination 
 
   7.1.2. Secondary study parameters/endpoints (if applicable) 
 
Number of polyps  
 
Global polyp burden (see definition in chapter 7.2) 
 
Histology (tubular, tubulovillous or villous histology and degree of dysplasia) 
 
Patient reported quality of life using HRQoL questionnaires 
 
Rate of cell proliferation in healthy intestinal mucosa and adenomatous tissue 
 
Immunohistochemistry of mTOR targets (such as eEF2 kinase, phospho-S6)  in healthy 
intestinal mucosa and adenomatous tissue 
 
7.2 Study procedures 
 
 
Baseline and follow-up measurements and monitoring  
-Medical history and physical examination (including vital signs) at baseline and at three monthly 
visits 
-Lab testing at baseline and at three monthly visits: pregnancy test, urine specimen, hemoglobin, 
thrombocytes, cholesterol, triglycerides, glucose, potassium, phosphate, calcium, LDH, ALAT, 
ASAT, GGT, AF, leukocytes, creatinine, albumin.  
 
-Three monthly HRQoL questionnaires 
-Trough level testing of sirolimus (using the LC-MS/MS method) on day 7 after start study drug 
and weekly until the therapeutic range has been achieved, after which the next trough level will 
be measured at three months   
 
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-LGI endoscopies at baseline and at six months. Endoscopic procedures will be performed after 
bowel preparation with sedation according to the standard of care by experienced endoscopists. 
 
Baseline LGI endoscopy 
A video record will be made of the endoscopic examination, which will be conducted in a spiral 
fashion. Disease stage will be assessed according to the IPSS stage. Polyps >10mm and other 
relevant polyps can be managed at the discretion of the endoscopist. In all patients, 5 polyps 
between 3-10 mm will be photographed (with an open biopsy forceps visible), measured (using 
the open biopsy forceps), and marked using tattoo dye (using SPOTTM 1 cm from the polyp at 9 
o’clock, without NaCL and a maximum of 0.5cc SPOTTM), photographed with ink marking, and 5 
biopsies of normal mucosa and one biopsy of 5 other adenomatous polyps (other than those 
marked for the primary outcome measure) will be taken in order to evaluate histology and to 
measure the rate of cell proliferation and immunohistochemistry. The 5 marked polyps need to 
have an endoscopic adenomatous appearance, as sirolimus is expected to cause regression of 
adenomas (and not hyperplastic lesions) (14, 17). There is no evidence concerning the minimum 
or maximum size of adenomas that could be influenced by sirolimus. We chose not to include 
adenomas >10mm as we would usually resect them due to an increased risk of developing cancer 
(33). We chose a minimum size of 3mm as it is our experience that these patients tend to have 
many small (1-2mm) polyps and by choosing to mark these small polyps, it might be difficult to 
recognize the marked polyp amongst the adjacent small polyps.  
 
Follow-up LGI endoscopy: 
A video record will be made of the endoscopic examination, which will be conducted in a spiral 
fashion. Disease stage will be assessed according to the IPSS stage. The follow-up LGI endoscopy 
will be conducted in a similar fashion to the baseline examination. All marked polyps will be 
photographed and measured. Five biopsies of normal mucosa and biopsies of 5 adenomatous 
polyps (other than those marked for the primary outcome measure) will be taken in order to 
evaluate histology and to measure the rate of cell proliferation and immunohistochemistry.  
At the end of the study, histology of adenomatous polyps will be reviewed by an expert GE 
pathologist.  
 
The above endoscopies are part of routine care. However, extra biopsies that are taken and the 
tattoos are study related.  

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Assessment of degree of polyposis  
For the primary outcome measure, the size of polyps will be measured as follows: 
 
1. Size of polyps: 
The polyp-size is estimated by the endoscopist using the open biopsy forceps (the most reliable 
method currently available). Two independent reviewers will also assess polyp size of marked 
polyps at the LGI endoscopy by viewing matching still images per patient on dual monitors. They 
are blinded for timing of endoscopy (baseline or follow-up). The mean size per polyp is calculated 
from the assessments of the three reviewers. If the assessment of the reviewers differs by more 
than 3mm from the assessment of the endoscopist, consensus is needed.  
 
For the secondary outcome measures, the degree of polyposis will be measured as follows: 
 
2. Number of polyps: 
During endoscopy, the number of polyps is estimated by the endoscopist. At a later phase, two 
independent reviewers will also assess the number of polyps seen (categorized per 10 polyps) by 
viewing both videos (before and after treatment) per patient, blinded for the order. The mean 
number of polyps is calculated as a mean of all 3 assessments. If the assessment between 
reviewers differs by more than 10 polyps from the assessment of the endoscopist, consensus is 
needed.  
 
3. Global polyp burden: 
During endoscopy, the global polyp burden is estimated by the endoscopist. At a later phase, two 
independent reviewers will also globally assess polyp burden by viewing both videos per patient, 
blinded for order. The second video in the pair could take the value of −2 (much better), −1 
(better), 0 (same), 1 (worse) or 2 (much worse) relative to the first video. Mean scores are 
calculated for each subject and averaged for the three reviewers.  If the assessment of the 
reviewers differs by more than 1 point from the assessment of the endoscopist, consensus is 
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7.3 Withdrawal of individual subjects 
If they wish to do so, subjects can leave the study at any time for any reason without any 
consequences. The investigator can decide to withdraw a subject from the study for urgent 
medical reasons. 
 
 
7.3.1 Specific criteria for withdrawal  
 
Participants will be withdrawn from treatment under the following circumstances: 
 
-If any of the exclusion criteria apply during the study 
 
7.4 Replacement of individual subjects after withdrawal 
If participants are withdrawn from the study due to any reason they will not be replaced.  
 
7.5 Follow-up of subjects withdrawn from treatment 
All participants that have been using sirolimus for at least 1 month and who are withdrawn for 
any reason, will undergo another sigmoidoscopy within 6 weeks after withdrawal. If patients 
withdraw due to side-effects of sirolimus, these patients will be contacted by telephone weekly 
until symptoms have disappeared. 
 
7.6 Premature termination of the study 
There are no criteria for early termination, as sirolimus has been investigated previously and 
therefore unknown adverse events (resulting in premature termination of the study) are not to be 
expected.  
 
 
 
 

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8. SAFETY REPORTING 
8.1 Temporary halt for reasons of subject safety 
In accordance to section 10, subsection 4, of the WMO, the sponsor will suspend the study if 
there is sufficient ground that continuation of the study will jeopardise subject health or safety.  
The sponsor will notify the accredited METC without undue delay of a temporary halt including 
the reason for such an action. The study will be suspended pending a further positive decision by 
the accredited METC. The investigator will take care that all subjects are kept informed.  
 
8.2 AEs, SAEs and SUSARs 
8.2.1 Adverse events (AEs) 
Adverse events are defined as any undesirable experience occurring to a subject during the 
study, whether or not considered related to the investigational product. All adverse events 
reported spontaneously by the subject or observed by the investigator or his staff will be 
recorded. 
 
8.2.2 Serious adverse events (SAEs) 
A serious adverse event is any untoward medical occurrence or effect that  
- 
results in death; 
- 
is life threatening (at the time of the event); 
- 
requires hospitalisation or prolongation of existing inpatients’ hospitalisation; 
- 
results in persistent or significant disability or incapacity; 
- 
is a congenital anomaly or birth defect; or 
- 
any other important medical event that did not result in any of the outcomes listed 
above due to medical or surgical intervention but could have been based upon 
appropriate judgement by the investigator. 
An elective hospital admission will not be considered as a serious adverse event. 
 
Subjects will be instructed to contact the investigator to report any symptom and the 
investigator will question each subject regarding symptoms at the time of each contact 
moment (at least monthly). All adverse events, including duration and severity, will be 
captured in the case report forms.  
 
 

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The investigator will report all SAEs to the sponsor without undue delay after obtaining 
knowledge of the events.  
 
The sponsor will report the SAEs through the web portal ToetsingOnline to the accredited 
METC that approved the protocol, within 7 days of first knowledge for SAEs that result in 
death or are life threatening followed by a period of maximum of 8 days to complete the 
initial preliminary report. All other SAEs will be reported within a period of maximum 15 days 
after the sponsor has first knowledge of the serious adverse events. 
 
8.2.3 Suspected unexpected serious adverse reactions (SUSARs) 
Adverse reactions are all untoward and unintended responses to an investigational product 
related to any dose administered. 
 
Unexpected adverse reactions are SUSARs if the following three conditions are met: 
1. the event must be serious (see chapter 9.2.2); 
2. there must be a certain degree of probability that the event is a harmful and an 
undesirable reaction to the medicinal product under investigation, regardless of the 
administered dose; 
3. the adverse reaction must be unexpected, that is to say, the nature and severity of the 
adverse reaction are not in agreement with the product information as recorded in: 
- 
Summary of Product Characteristics (SPC) for an authorised medicinal product; 
- 
Investigator’s Brochure for an unauthorised medicinal product. 
 
The sponsor will report expedited the following SUSARs through the web portal 
ToetsingOnline  to the METC: 
 
SUSARs that have arisen in the clinical trial that was assessed by the METC; 
 
SUSARs that have arisen in other clinical trials of the same sponsor and with the same 
medicinal product, and that could have consequences for the safety of the subjects 
involved in the clinical trial that was assessed by the METC. 
The remaining SUSARs are recorded in an overview list (line-listing) that will be submitted 
once every half year to the METC. This line-listing provides an overview of all SUSARs from 
the study medicine, accompanied by a brief report highlighting the main points of concern.  
 

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The expedited reporting of SUSARs through the web portal Eudravigilance or 
ToetsingOnline is sufficient as notification to the competent authority. 
 
The sponsor will report expedited all SUSARs to the competent authorities in other 
Member States, according to the requirements of the Member States.  
 
The expedited reporting will occur not later than 15 days after the sponsor has first 
knowledge of the adverse reactions. For fatal or life threatening cases the term will be 
maximal 7 days for a preliminary report with another 8 days for completion of the report.  
 
8.3 Annual safety report 
In addition to the expedited reporting of SUSARs, the sponsor will submit, once a year throughout 
the clinical trial, a safety report to the accredited METC, competent authority, and competent 
authorities of the concerned Member States. 
This safety report consists of: 
 
a list of all suspected (unexpected or expected) serious adverse reactions, along with an 
aggregated summary table of all reported serious adverse reactions, ordered by organ system, 
per study; 
 
a report concerning the safety of the subjects, consisting of a complete safety analysis and an 
evaluation of the balance between the efficacy and the harmfulness of the medicine under 
investigation. 
 
8.4 Follow-up of adverse events 
All AEs will be followed until they have abated, or until a stable situation has been reached. 
Depending on the event, follow up may require additional tests or medical procedures as 
indicated, and/or referral to the general physician or a medical specialist. 
SAEs need to be reported till end of study within the Netherlands, as defined in the protocol. 
 
8.5 Safety Committee 
All investigators involved in this study (prof. dr. E. Dekker, Prof. dr. G.R. van den Brink, Dr. F. 
Bemelman and a PhD candidate) are the safety committee. As previously described, safety of this 
treatment will be monitored by performing regular lab and trough level testing, physical 
examinations and monthly telephone contacts. All serious and non-serious adverse events that 
are collected by the PhD candidate will immediately be reported to the safety committee. The 

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safety committee will decide whether it is a serious or non-serious adverse event, the toxicity 
grade of this event, the relatedness to the study drug and subsequent measures to be taken. This 
safety committee is needed as sirolimus has not been investigated previously for the indication as 
being used in this study.  

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9. STATISTICAL ANALYSIS 
Descriptive statistics will be used to describe the study population, characteristics and changes in 
outcome measures during follow-up. SPSS for Windows software (Chicago, IL, USA) version 21.0. will 
be used for these analysis.  
 
9.1 Primary study parameter(s) 
 
Descriptive statistics will be used to describe the changes in outcome measures during follow-up. 
 
9.2 Secondary study parameter(s)  
 
Descriptive statistics will be used to describe the changes in outcome measures during follow-up. 
 
9.3 Interim analysis (if applicable) 
 
Not applicable.  

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10. ETHICAL CONSIDERATIONS 
10.1 Regulation statement 
The study will be conducted according to the principles of the Declaration of Helsinki (18th WMA 
General Assembly, Helsinki, Finland, June 1964), which was amended by the 64th WMA General 
Assembly, October 2013, Fortaleza, Brazil) and in accordance with the Medical Research Involving 
Human Subjects Act (WMO). The protocol of this study will be submitted to the Medical Ethical 
Committee of the Academic Medical Center and will not start before formal approval has been 
granted. All patients are required to sign an informed consent form. The study will also be 
conducted in accordance with ICH Good Clinical Practice (GCP) and all applicable subject privacy 
requirements. 
 
10.2 Recruitment and consent 
Participants will be given oral and written explanation about the study, before they give written 
informed consent.  Participants will be given as much time as possible to make a decision. 
Subjects are allowed to withdraw informed consent at any time for any reason if they wish to do 
so without providing arguments. The results will be published in a peer-reviewed scientific 
journal. Subjects will be approached for participation by the investigator or colleagues. This 
invitation could take place at the outpatient clinic or during telephonic contact. Participants will 
not be compensated for their travel costs.  
 
10.3 Compensation for injury 
The sponsor/investigator has a liability insurance, which is in accordance with article 7 of the 
WMO. The sponsor also has an insurance, which is in accordance with the legal requirements in 
the Netherlands (Article 7 WMO and the Measure regarding Compulsory Insurance for Clinical 
Research in Humans of 23th June 2003). The insurance applies to the damage that becomes 
apparent during the study or within 4 years after the end of the study: 
1. € 650.000,-- (i.e. six hundred and fifty thousand Euro) for death or injury for each subject 
who participates in the Research; 
2. € 5.000.000,-- (i.e. five million Euro) for death or injury for all subjects who participate in 
the Research;  
3. € 7.500.000,-- (i.e. seven million five hundred thousand Euro) for the total damage 
incurred by the organisation for all damage disclosed by scientific research for the 
Sponsor as ‘verrichter’ in the meaning of said Act in each year of insurance coverage. 
 

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The insurance applies to the damage that becomes apparent during the study or within 4 years 
after the end of the study. 
 
10.4 Incentives (if applicable) 
Participants will not receive any reimbursements.

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ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION 
10.5 Handling and storage of data and documents 
Endoscopically collected material of adenomatous tissue, as part of routine care, will be stored 
according to regulations of the department of pathology in the AMC. Slides of this adenomatous 
tissue, used for the assessment of immunohistochemistry and cell proliferation rates, and 
endoscopically collected material of healthy intestinal mucosa, will be analysed and stored at the 
Tytgat institute. Source documents and CRFs will be stored by the project leader for 15 years after 
closure of the trial. Data of the subjects will be coded in order of participation. The code and the 
data are stored in different locations. The code can only be seen by the investigators. Qualified 
authorities can get insight in the code and data, but only when accompanied by the investigators.  
Informed consent forms are kept in separate files, to ensure the data security. The handling of 
personal data will comply with the Dutch Personal Data Protection Act (in Dutch: De Wet 
Bescherming Persoonsgegevens, Wbp). 
 
10.6 Monitoring and Quality Assurance  
 
Not applicable.  
 
10.7 Amendments  
A ‘substantial amendment’ is defined as an amendment to the terms of the METC application, or 
to the protocol or any other supporting documentation, that is likely to affect to a significant 
degree: 
- the safety or physical or mental integrity of the subjects of the trial; 
- the scientific value of the trial; 
- the conduct or management of the trial; or 
- the quality or safety of any intervention used in the trial. 
 
All substantial amendments will be notified to the METC and to the competent authority. 
 
Non-substantial amendments will not be notified to the accredited METC and the competent 
authority, but will be recorded and filed by the sponsor.  
 

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10.8 Annual progress report 
The sponsor/investigator will submit a summary of the progress of the trial to the accredited 
METC once a year. Information will be provided on the date of inclusion of the first subject, 
numbers of subjects included and numbers of subjects that have completed the trial, serious 
adverse events/ serious adverse reactions, other problems, and amendments.  
 
10.9 Temporary halt and (prematurely) end of study report 
The sponsor will notify the accredited METC and the competent authority of the end of the study 
within a period of 90 days. The end of the study is defined as the last patient’s last visit.  
 
The sponsor will notify the METC immediately of a temporary halt of the study, including the 
reason of such an action. 
 
In case the study is ended prematurely, the sponsor will notify the accredited METC and the 
competent authority within 15 days, including the reasons for the premature termination. 
 
 Within one year after the end of the study, the investigator/sponsor will submit a final study 
report with the results of the study, including any publications/abstracts of the study, to the 
accredited METC and the Competent Authority.  
 
10.10 Public disclosure and publication policy 
This study will be executed by the following team: prof. dr.  E. Dekker (gastroenterologist), prof. 
dr. G.R. van den Brink (gastroenterologist), dr. F. Bemelman (nephrologist), dr. L. Koens 
(pathologist) , a PhD candidate and a research nurse.  
 

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11. STRUCTURED RISK ANALYSIS  
 
11.1 Potential issues of concern 
 
a. Level of knowledge about mechanism of action 
Recently it was shown that the mTOR inhibitor sirolimus can cause tumour cells to undergo 
growth arrest and differentiation in APC-deficient mice (14). Signalling through the mTOR 
pathway is necessary for epithelial cell proliferation and tumour growth (15, 16). It was shown 
that mTOR complex 1 (mTORC1) activity is required for the proliferation of APC-deficient 
enterocytes. This complex mediates inhibition of eEF2 kinase, which is needed for the 
proliferation of APC-deficient cells. Sirolimus targets eEF2 resulting in growth arrest and 
differentiation of tumour cells. The effect of sirolimus on colonic adenoma regression was 
confirmed in other mice studies, with one of them showing beneficial effects in the small bowel 
(17-22). Sirolimus seems to inhibit polyp formation and could even lead to regression of polyps 
(21, 23). Moreover, it seems to increase survival and time to progression to dysplasia (20, 21).  
 
b. Previous exposure of human beings with the test product(s) and/or products with a similar 
biological mechanism 
As previous described, sirolimus is a registered drug for patients who have undergone a renal 
transplantation. Details about the exposure of human beings with sirolimus are clearly described 
in the SPC text. Sirolimus has never been investigated in patients with FAP. However, since 
February 2014 an American center has been recruiting 15 participants for a pilot study aiming to 
investigate if mTor pathway activation decreases in patients with surgically-resectable desmoid 
tumors that are removed following pre-operative treatment with sirolimus. That study is being 
conducted in children and young adults (up to 29 years), which includes patients with FAP. Results 
are expected in 2016 (25).  
 
c. Can the primary or secondary mechanism be induced in animals and/or in ex-vivo human cell 
material? 
As far as we know, sirolimus has never been investigated in ex-vivo human cell material of FAP 
patients. However, as written in chapter 12.1a the primary outcome and some of the secondary 
outcomes were found effective in mouse models.  
 
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See the SPC text and chapter 12.1a for explanations of working mechanisms. Known side-effects 
can be found in chapter 6.2 and all other drugs that could interact with sirolimus can be found in 
Table 1.   
 
e. Analysis of potential effect 
See chapter 6.2 for side-effects of sirolimus. The incidence of side-effects increases at a rising 
trough level of sirolimus. The dosing regimen as nationally recommended for patients with a renal 
transplantation reaches blood level concentrations sufficient to achieve a clinical result. As our 
proposed dosing regimen is similar to that but on the lower side, we believe effect on the 
intestinal mucosa can be expected with a limited risk of side-effects. No data from human studies 
is available on the required level of sirolimus in full blood to achieve intestinal effects. See chapter 
6.4 for further risks and benefits.  
 
f. Pharmacokinetic considerations 
See the SPC text for pharmacokinetics of sirolimus.  
 
g. Study population 
The study population consists of patients with FAP, which is a potentially life threatening disease. 
The patients that will be included are likely to undergo a subtotal colectomy with ileoanal pouch 
anastomosis or an end ileostomy on a short term due to the severe degree of polyposis. These 
invasive types of surgery are accompanied with a significant risk of comorbidities (29). Even after 
surgery, patients will develop polyps in the remaining intestinal tissue and therefore surveillance 
sigmoidoscopies are needed to prevent the development of cancer (5, 30-32). There is currently 
no alternative treatment available for these patients. Therefore, a medical treatment to postpone 
or even prevent surgery could be beneficial. If a polyp reducing effect is shown in the intestinal 
tissue, this therapy could possibly also be beneficial in postponing a preventive colectomy in 
patients with FAP who have their colon in situ and in postponing a duodenectomy in patients with 
severe duodenal polyposis.  
 
h. Interaction with other products 
See the SPC text for interactions of sirolimus with other products. To avoid these interactions, the 
use of any of these products is not allowed when enrolling in this study (see exclusion criteria). If 
any of these products are started during the study, additional trough level testing will be done or 
patients will be withdrawn from this study (depending on the expected interaction).    
 

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i. Predictability of effect 
The combination of endoscopic measurements and laboratory measurements will provide 
relevant data, both clinical and translational, that will help answering the research question. If no 
effects on polyp size are seen, laboratory measurements will provide us with useful translational 
information. If, for example, an effect is seen in cell proliferation or mTOR targets and the chosen 
dosing regimen is safe, a future study could evaluate the effect of a higher dose for a longer 
period of time.  
 
j. Can effects be managed? 
A renal transplantation physician, working at the AMC, is actively involved in this study. She is 
experienced in treating patients with sirolimus and therefore she will assist us if needed. Patients 
will be given contact details of the investigating team and in case of emergencies when the 
investigating team cannot be contacted, the patient can contact the gastroenterologist that is on 
call.    
 
11.2 Synthesis 
To reduce the risk of side-effects related to sirolimus, a relatively low trough level will be 
managed. Furthermore, regular telephonic contact, trough level testing, laboratory testing and 
physical examination will lead to an early detection of any side-effects. We believe this could help 
patients, who would otherwise need surgery on a short term. As of today no strict 
contraindications exist for the use sirolimus. However, we exclude patients using medications that 
could interact with sirolimus. Furthermore, patients with specific laboratory abnormalities as well 
as patients with specific conditions (such as a deep venous thrombosis or sucrose insufficiency) 
that could deteriorate due to the use of sirolimus or that could influence the effect of sirolimus 
are excluded.  
 
We will use tattoos with SPOTTM for marking the polyp sites, which has been used for many years 
in colonoscopy practice (26). No side-effects of SPOT have been described in the literature.  
Furthermore, colonic biopsies are accompanied by a minimal risk of perforation, bleeding and 
infection. These complications have been described in some case reports after hot biopsy but 
mostly in patients with pre-existent ulcerative colitis or infectious colitis. Bleeding after hot biopsy 
has been reported to occur in up to 0.26% and perforation in up to 0.01% after hot biopsy. During 
our study only cold biopsies will be obtained. Only case reports have reported on complications 
after cold biopsy (27, 28). These complications are cited in the written patient information.  
 

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In our opinion, treatment with sirolimus could help patients, who would otherwise need surgery 
on a short term base associated with a significant risk of morbidity and mortality. By applying the 
above risk management, we believe this treatment is justified. Results of this pilot study could 
help in creating a future trial assessing the effect of sirolimus in patients with FAP.  
 

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