Discovery of Sirolimus Sensitive Biomarkers in Blood
Phase: PHASE2
Conditions: Lymphangioleiomyomatosis
Sponsor: National Heart, Lung, and Blood Institute (NHLBI)

 
 Protocol with Statistical Analysis Plan Cover Page:   
 
Official Title: 
 
Discovery of Sirolimus Sensitive Biomarkers in Blood 
NCT number: 
 
NCT03304678 
Document Type:  
Protocol with Statistical Analysis Plan (SAP)  
Document Date: 
November 1, 2021 
 
 

18-H-0003 
Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
1
 
 
 
      
 
 
 
 
 
 
 
CLINICAL RESEARCH PROJECT      
 
 
 
 
     Protocol # 18-H-0003 
 
 
 
 
 
 
 
 
 
IND/IDE: N/A 
 
Protocol Title:  Discovery of Sirolimus Sensitive Biomarkers in Blood 
 
Abbreviated Title: Sirolimus Sensitive Biomarkers 
  
Principal Investigator:  
Joel Moss, M.D., Ph.D., PB, NHLBI (E), phone #301-496-1597, Bldg. 10, Rm. 6D05 
 
 
 
 
  
Accountable and Medically Responsible Investigator: 
Joel Moss, M.D., Ph.D., PB, NHLBI (E), phone #301-496-1597, Bldg. 10, Rm. 6D05 
 
 
Subjects of study: 
 
 
Number 
Sex 
 
Age range 
                                              
   
  33 
     
F            
18 to 90 
 
 
 
Project involves ionizing radiation? 
 
 
No 
 
Off site project? 
 
 
 
 
No 
 
 
 
 
Multi-Institutional project? 
 
 
 
Yes (Reliance Agreement(s): Brigham &  
Women’s Hospital, University of Pennsylvania 
Medical Center, University of Cincinnati) 
 
 
DSMB involvement?  
 
 
 
No 
 
 
 
Tech Transfer: CRADA, MTA 
 
 
Yes 
 
 
 
 
Non- NIH Non-Enrolling Multi-Site Individuals: 
Brigham & Women Hospital, Boston, MA 
Site PI: 
Elizabeth Henske, M.D. 
 
University of Pennsylvania Medical Center, Philadelphia, PA 
Site PI: 
Vera Krymskaya, Ph.D. 
 
University of Cincinnati, Cincinnati, OH 
Site PI: 
Francis X McCormack, M.D. 
 
 
 
 

18-H-0003 
Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
2
 
Table of Contents 
1.0 
Précis: ..................................................................................................................................... 3 
2.0 
Objectives............................................................................................................................... 3 
3.0 
Background ........................................................................................................................... 3 
3.1 
Treatment Options ............................................................................................................... 3 
3.2 
Clinical and Scientific justification ..................................................................................... 3 
4.0 
Subject Recruitment and Registration................................................................................ 3 
5.0 
Study Design .......................................................................................................................... 4 
6.0 
Eligibility Assessment ........................................................................................................... 4 
6.1 
Inclusion Criteria ................................................................................................................. 4 
6.2 
Exclusion criteria................................................................................................................. 5 
7.0 
Sample Collection, Storage, and Biospecimen and Data Management Plan................... 5 
7.1 
Intended use......................................................................................................................... 7 
8.0 
BIOSTATISTICAL CONSIDERATIONS ......................................................................... 7 
9.0 
Data and Safety Monitoring and Reporting ....................................................................... 7 
9.1 
Assessment of Safety ......................................................................................................... 8 
9.2 
Adverse Event Management ............................................................................................ 8 
9.3 
NIH Intramural-IRB and CD reporting ......................................................................... 8 
10.0 Human Subjects Protection ................................................................................................. 8 
10.1 
Rationale for Subject Selection .................................................................................... 8 
10.2 
Participation of children ............................................................................................... 9 
10.3 
Risks and Discomforts ................................................................................................... 9 
10.4 
Informed Consent Processes and Procedures ............................................................. 9 
11.0 Conflict of Interest ................................................................................................................ 10 
12.0 Compensation ....................................................................................................................... 10 
13.0 References ............................................................................................................................. 10 
 
 
 
 

18-H-0003 
Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
3
1.0 
Précis: 
Sirolimus (rapamycin), which acts as a targeted inhibitor of the protein mechanistic target of rapamycin 
(mTOR), has been shown to be effective in patients with lymphangioleiomyomatosis (LAM). It stabilizes 
lung function, resolves chylous effusions and lymphangioleiomas and shrinks angiomyolipomas. The 
current study is to understand better the short-term action of the drug by following the effects on potential 
biomarkers in blood and urine. Patients with LAM will have samples taken prior to administration of first 
dose of the drug, at 1 hr and then at 23 hours after the drug (trough level). At 3 and 9 months, samples will 
be obtained at trough and 1 hour after the dose. Molecular and cellular analyses will be performed to look 
for potential biomarkers.  
 
2.0 
Objectives 
To determine the levels of sirolimus required to suppress known and candidate biomarkers of mTORC1 
inhibition in LAM patients. 
 
3.0 
Background 
Lymphangioleiomyomatosis (LAM) is a cystic lung disease characterized by proliferation of cells with 
mutations in the tuberous sclerosis complex (TSC) which leads to activation of the mTORC pathway (1). In 
LAM ~70% of patients have increased levels of VEGF-D which serves as a biomarker for diagnosis and 
potentially for therapeutic response (2). Additional biomarkers are needed. We have previously shown that 
Sirolimus regulates microRNA levels in vitro and in vivo. One of these “RapamiRs” is miR-21 is also 
regulated in vivo (3).  
 
The central question of this research proposal is to identify if miRNA are responsive to sirolimus in patients 
with LAM, which will serve as a marker of therapeutic efficiency and dosing of sirolimus in patients.  
 
3.1 
Treatment Options  
Sirolimus is an FDA-approved medication for the treatment of LAM. We plan to use sirolimus in our studies.  
 
3.2 
Clinical and Scientific justification 
Sirolimus is an effective suppressive therapy for LAM that must be used chronically for sustained benefit. In 
a disease where therapy with a toxic drug is expected to be lifelong, determining the minimal effective dose 
is critical. Therefore, there remains an urgent unmet clinical need for biomarkers of response to Rapalogs 
and other targeted agents to streamline clinical trial design and enable personalized dosing. This project will 
investigate potential biomarkers of sirolimus response in humans, including microRNA, circulating LAM 
cells, mTOR pathway suppression, and lymphangiogenic factors. 
 
MicroRNA (miRNA) are small RNA molecules that regulate gene expression. We have found that sirolimus 
regulates the expression of microRNA (3). miRNA are highly stable and many can be detected in 
the blood. MicroRNA have been identified as biomarkers of many human diseases, including COPD and 
several types of cancer. Therefore, biomarkers can be used to establish personalized sirolimus dosing levels, 
ultimately allowing therapeutic efficacy to be maximized while minimizing the adverse effects of continuous 
treatment (4). There is already evidence that lower doses may be sufficient but currently there is no proven 
metric other than lung function testing (which is inherently variable and slow to reflect changes) to guide 
optimal dosing. Our long-term goal is to correlate the impact of sirolimus on serum microRNA, 
lymphangiogenic factors, circulating LAM cells, and indicators of mTORC1 activity with the effect of 
sirolimus on VEGF-D, leading to the preliminary design of a combinatorial biomarker score of sirolimus 
efficacy in LAM and enabling future studies of personalized dosing. 
 
4.0 
Subject Recruitment and Registration 
Recruitment: Subjects will be recruited from investigative sites (University of Cincinnati, Brigham and 
Women’s Hospital, University of Pennsylvania). In addition, the study will be listed on clinicaltrials.gov, 

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Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
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Clinical Center research studies, the NHLBI patient recruitment websites. Patients will also be recruited 
through direct calls to LAM Clinic Directors in the largest cities, direct mailings to physicians, postings on 
the LAM Foundation and Tuberous Sclerosis Web site, and by mailings and eBlasts from the LAM 
Foundation. Currently the LAM Foundation Clinic Network comprises 30 LAM clinics in the US, and 19 
international LAM clinics with a total of about 2750 LAM patients. It is expected that approximately 8 
patients will be recruited per year for 3 years, drawing on existing patients who are already enrolled plus 
additional recruitments. 
 
5.0 
Study Design 
Patients with LAM, whose treating physicians have decided that they need to start treatment with sirolimus 
will be referred to the NIH Clinical Center for these studies. This is a single center study with all subjects 
being enrolled at the NIH Clinical Center. The extracted LAM cells and serum, and other samples and data 
will be sent to the non-NIH associate investigators to identify the LAM biomarkers. 
 
The first dose of sirolimus given will be a 2mg tablet per day. This is the typical starting dose as established 
by the Multicenter International Efficacy of Sirolimus (MILES) study (5). Once daily dosing is typical for 
sirolimus, which has a half-life of 60 hrs.  
 
The amount of blood that may be drawn from adult patients (i.e., those persons 18 years of age or older) for 
research purposes shall not exceed 10.5 mL/kg or 550 mL (approximately 2 cups), whichever is smaller, at 
each study visit. 
 
Each patient will have three study visits (0, 3, and 9  months from the start of therapy). Three blood samples 
will be drawn at Visit #1 and two samples at Visit #2 and Visit #3, totaling 7 samples/patient. Urine will also 
be collected during these visits. Urine or blood pregnancy test (if of childbearing potential) will be verified 
at the time of each visit. 
 
Visit#1 (Month 0): Urine or blood pregnancy test.  Three blood samples will be drawn: a) a pretreatment 
level, b) 1 hr (± 15 min) after the first dose of 2 mg of sirolimus, representing a Cmax timepoint when we 
expect to see repression of mTORC1 targets, and c) 23 hr (± 15 min) after the first dose of 2 mg sirolimus, 
representing a trough level to look for de-repression of mTORC1 targets. Urine will be collected pretreatment 
and approximately 23 hours (± 1 hr) after the first dose of sirolimus. Subjects will be asked to complete a 
drug diary to document taking sirolimus.  
 
Visit #2 (Month 3 ± 2 weeks): Urine or blood pregnancy test.  Two blood samples will be drawn: a) 23 hrs 
(± 15 min) after the prior dose of 2 mg of sirolimus, b) 1 hr (± 15 min) after the next dose of 2 mg. Urine will 
be collected approximately 23 hours (± 1 hr) after the prior does of sirolimus.  
 
Visit #3 (Month 9 ± 2 weeks):  Urine or blood pregnancy test.  Two blood samples will be drawn: a) 23 hrs 
(± 15 min) after the prior dose of 2 mg of sirolimus, b) 1 hr (± 15 min) after the next dose of 2 mg. Urine will 
be collected approximately 23 hours (± 1 hr) after the prior does of sirolimus..  Subjects will be considered 
off study after the completion of Visit 3. 
 
The protocol involves no more than minimal risk, since it only includes blood draws, since initiation of 
rapamycin is clinically indicated. Information gathered from other NIH Intramural IRB approved 
protocols that subjects may have participated in, may be used as part of this study. 
                 
6.0 
Eligibility Assessment 
 
6.1 
Inclusion Criteria 
1- Female 18 to 90 years of age 

18-H-0003 
Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
5
2- Diagnosis of LAM 
3- Initiation of sirolimus therapy (2mg daily) based on standard-of-care pulmonary indications and 
the advice of the patient’s local physician 
 
6.2 
Exclusion criteria 
1- Unable to travel to the NIH 
2- Unable to provide informed consent 
3- Advanced stage of a pulmonary or a systemic illness in which the risk of the study is judged to be 
significant even in the absence of a clear contraindication to the procedures. 
4- Women who are pregnant or lactating 
 
 
7.0 
Sample Collection, Storage, and Biospecimen and Data Management Plan   
 
Biospecimen Management:  Specimens and their derivatives (e.g., genomic material, cell lines) will be 
coded and stored in conformity with DIR Policy (e.g., BSI). Coded biospecimens may be sent to collaborators 
outside of the NIH with IRB approval in accordance with applicable NIH and DIR Policy for sharing research 
resources, including an executed material transfer agreement. Biospecimens with subject personal identifiers 
may be sent to associate investigators and collaborators outside of the NIH only after approvals of both 
NHLBI and local IRBs, an executed reliance agreement with  NIH Intramural IRB, or an extension of the 
NIH’s FWA through an Individual Investigator Agreement. 
 
Data Management:  The principal investigator, associate investigators, and research nurses will assist with 
the data management efforts. Data will be abstracted from Clinical Center progress notes as well as intake 
forms. Laboratory data from NIH will be reviewed using CRIS. The principal investigator and associate 
investigators/research nurses will assist with the data management efforts to ensure that data is verifiable and 
evaluable. Data will be abstracted from Clinical Center progress notes as well as from progress notes 
forwarded from the subjects’ home physician. 
 
The PI will be responsible for overseeing entry of data into an in-house password protected electronic system 
and ensuring data accuracy, consistency and timeliness. Laboratory values from referring home physicians 
will not be entered into the system. The principal investigator and associate investigators/research nurses will 
assist with the data management efforts to ensure that data are verifiable and evaluable.   
 
Any pertinent supplementary information obtained from outside laboratories, outside hospitals, radiology 
reports, laboratory reports, or other patient records will be used as additional sources for data collection. 
 
We will maintain the confidentiality of identifiable private information collected in this clinical trial and 
protect the privacy of the individual human subjects. Primary data containing individually identifiable 
information obtained during the conduct of the protocol will be kept in secure network drives or in approved 
alternative sites that comply with NIH information security standards. Identifiable data will not be sent 
outside NIH without prior IRB approval or appropriate conditions for disclosure outlined in the executed 
CTA or MTA. 
 
Storage: All samples will be stored in the laboratory of Dr. Moss. Collected samples will be de-identified 
prior to storage in the laboratory of the principal investigator following current NHLBI DIR BSI Policy. 
Efforts to ensure protection of patient information include; 
• 
Each sample is assigned a unique number.  
• 
Vials holding patient samples are labeled with the sequential laboratory accession ID number that 
does not contain any personal identifier information. 
• 
An electronic database is used to store patient information related to the coded samples.  

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Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
6
• 
The laboratory is located in a controlled access building and laboratory doors are kept locked. 
Visitors to the laboratory are required to be accompanied by laboratory staff at all times.   
• 
Hard copy records or electronic copies of documents containing patient information are kept in the 
locked laboratory or other controlled access locations. 
 
Intended use: During the course of participating on this study, blood and data may be collected for correlative 
laboratory research studies.  Specimens collected strictly for research purposes will not be read by a 
pathologist. 
 
Tracking: Samples will be ordered and tracked through the CRIS Research Screens.  Should a CRIS screen 
not be available, the NIH form 2803-1 will be completed and will accompany the specimen and be filed in 
the medical record.  Samples will not be sent outside NIH without appropriate institutional approval and an 
executed MTA or CTA. 
 
End of study procedures: At a minimum, data collected at the NIH will be stored in locked cabinets and in 
a password protected network servers until it is no longer of scientific value. The study will remain open so 
long as sample or data analysis continues.  Samples from consenting subjects will be stored until they are no 
longer of scientific value or if a subject withdraws consent for their continued use, at which time they will be 
destroyed.  A file note will be made to document the withdrawal / destruction, and existing data will not be 
used in future studies. 
 
Loss or destruction of data/samples:  Should we become aware that a major breech in our plan to protect 
subject confidentiality and trial data has occurred, the Institutional Review Board (IRB) will be notified. 
 
Publication Policy:  Given the research mandate of the NIH, patient data including the results of testing and 
responses to treatment will be entered into an NIH-authorized and controlled research database. Any future 
research use will occur only after appropriate human subject protection and institutional approval.  
 
Privacy and Confidentiality:  All efforts, within reason, will be made to keep subjects’ protected health 
information (PHI) and private identifiable information (PII) private.  Using or sharing (“disclosure”) such 
data must follow federal privacy rules.  Under certain circumstances, the United States Office of Human 
Research Protections (OHRP), and the NIH Intramural Institutional Review Board (IRB), will be able to 
inspect and copy confidential study-related records which identify participants by name.  Therefore, absolute 
confidentiality cannot be guaranteed. 
 
Data sharing and future use of data  
Research data may be shared with qualified non-collaborator recipients following publication of the primary 
research results after removal of PII and  an executed MTA, and or DTA..  Future research use of data not 
defined in the research protocol may occur only after the appropriate institutional approval and an executed 
MTA and or DTA.  Refusal of a research subject participant to permit future use of data--other than required 
in the protocol --will be honored.  Limitations in data sharing and future use of data due to contractual 
obligations (e.g., CRADAs) or intellectual property proceedings (such as patent filings) will be honored. 
 
Future use of biospecimens  
Following analyses of biospecimens for primary research purposes, remaining samples suitable for future 
research will be stored in manner that conforms with DIR policy (such as BSI) or in a publicly accessible 
research biospecimen repository following IRB or OHSRP approval, as applicable. Biospecimens may be 
destroyed only when permitted by the Clinical Director and the IRB. 
 

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Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
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Any future research use of biospecimens not defined in the protocol in which NHLBI investigators are 
engaged in research (e.g., they are undertaking research activities and hold the key that identifies research 
subjects) requires IRB review and approval. Coded biospecimens (NHLBI investigators hold the key that 
identifies research subjects) to be shared outside of NIH for future research use requires IRB review and 
approval (for research collaborations), and an executed transfer agreement. Unlinked biospecimens (no key 
to identify research subjects exists) to be shared outside of NIH for future research use requires appropriate 
institutional approval and an executed transfer agreement. There are a few types of biospecimens that do not 
require IRB or OHSRP approval for future research use outside of NIH, such as specimens from deceased 
individuals (refer to OHSRP SOP5, Appendix 1 for complete list); an executed transfer agreement is required 
in these special cases.  Refusal of a research subject participant to allow for future use of identifiable 
biospecimens--other than required in the protocol or for appropriate regulatory purposes --will be honored. 
 
Reliance Agreements are in the process of being executed between the external research sites associated 
with the protocol and NHLBI for identifiable data and samples to be sent for analysis in accordance with 
the U01 grant. Sample and data analysis will only address those questions pertaining to the primary and 
secondary objectives/endpoints of the study.  The review of samples and data with identifiers will only start 
upon execution of a reliance agreement.  Until such time, the external sites may receive deidentified 
samples upon execution of an MTA at each site. 
 
7.1 
Intended use 
Biomarkers including miRNA, VEGF-D, circulating LAM cells, peripheral lymphocyte phosphor-S6 and 
phospho-S6K will be drawn.  
 
8.0 
BIOSTATISTICAL CONSIDERATIONS 
 
microRNA. In a pilot study, we profiled 185 serum microRNA in 5 women with LAM (2 sporadic LAM and 
3 TSC-LAM) and 5 healthy controls using the miRCURY LNA RT microRNA PCR Serum/plasma Panel. 
Based on this five sample/group pilot experiment, a power-analysis was performed. If we assume that at least 
a similar level of difference in microRNA will be observed with sirolimus treatment vs. the prior comparison 
of LAM patients vs. healthy women, the top nine miRNA should be validated with 18 samples per group 
(p=0.05 after B-H correction, 95% confidence interval). For this project, we will test 24 women treated with 
sirolimus. Therefore, we should have sufficient statistical power to detect sirolimus-dependent changes in 
microRNA. 
 
Lymphangiogenic factors. In the MILES trial, VEGF-D levels decreased more than 2 folds with sirolimus 
treatment. Our planned enrollment of 24 women with LAM will ensure that a two-sided test with α=0.05 has 
80% power to detect a 2-fold change using a paired Wilcoxon signed-ranked test. 
 
9.0 
 Data and Safety Monitoring and Reporting 
 
Safety Monitoring: 
Accrual and safety data will be monitored by the Principal Investigator who provides oversight to the conduct 
of this study, Joel Moss, M.D., Ph.D. 
 
NIH Intramural IRB: Accrual and safety data will also be monitored and reviewed annually by the IRB.  
Prior to implementation of this study, the protocol and the proposed subject consent form will be reviewed 
and approved by the properly constituted IRB operating according to 45 CFR 46. This committee will 
approve all amendments to the protocol or informed consent and conduct continuing annual review so long 
as the protocol is open to accrual, follow-up of subjects, or data analysis continues. 
 

18-H-0003 
Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
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9.1 
Assessment of Safety 
 
Definitions 
Please refer to Policy 801 for current definitions. 
 
9.2 
Adverse Event Management 
 
The following adverse event management guidelines are intended to ensure the safety of each patient while 
on the study.  The AEs will be attributed (unrelated, unlikely, possibly, probably or definitely) to study 
procedure and graded by severity utilizing CTC version 4.0.  A copy of the criteria can be downloaded from 
the CTEP home page at http://ctep.cancer.gov/reporting/ctc.html. 
 
Patients entered onto this protocol will only be subject to blood and urine collection.. Therefore any observed 
or volunteered adverse events not related to these research study procedures will NOT captured in the 
research data base.  
 
Adverse events that are deemed possibly, probably or definitely related to the subject’s underlying disease(s), 
prior therapies, or concurrent non-protocol treatments will be  captured in the subject’s medical records, but 
will not be captured in the research database.  
 
9.3 
NIH Intramural-IRB and CD reporting 
 
Only adverse events, SAEs, and UPs that occur solely as a result of participation in this research study, such 
as those due to blood draws, will be captured in the research database.  
 
NIH Intramural IRB and CD reporting:   
Expedited Reporting:   
 
Events requiring expedited reporting will be submitted to the IRB per Policy 801 “Reporting Research 
Events”. 
 
Reports to the IRB at the time of Continuing Review: 
The PI or designee will refer to HRPP Policy 801 “Reporting Research Events”, to determine IRB reporting 
requirements. 
 
Reports to the CD: 
The PI or designee will refer to NHLBI DIR guidelines to determine CD reporting requirements. 
 
Data reporting: 
The following Adverse Events will captured in the subject’s medical records, but will not be captured in the 
research database.. 
• 
Adverse events that are deemed possibly, probably or definitely related to the subject’s underlying 
disease(s), prior therapies, or concurrent non-protocol treatments.  
• 
Phlebotomy: Transient discomfort, minor bleeding and/or bruising may occur at the phlebotomy 
site. Vasovagal symptoms can occur during blood drawing. 
 
10.0 
Human Subjects Protection 
 
 
10.1 
Rationale for Subject Selection 
 

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Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
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Study population:  Female patients ages 18 to 90 will be considered for the protocol. No patient will be 
excluded from participation based on race or ethnicity.  Patients may self refer, be recruited through the NIH 
office of recruitment and may include patients participating on NIH Clinical Center Protocols and NIH 
employees and/or children of NIH employees.  Women who are pregnant or lactating are excluded due to the 
risk to the developing fetus or nursing babies.  
 
10.2 
Participation of children 
 
We are limiting the protocol to participants who are 18 to 90 years old because LAM is primarily a disease 
of young to older women but not children.   
 
10.3 
Risks and Discomforts  
 
Risks associated with phlebotomy and/or blood draws include symptoms related to a fear of blood drawing, 
temporary lowering of blood pressure, dizziness, lightheadedness, fainting, and rarely seizures.   
 
10.4 
Informed Consent Processes and Procedures 
Informed consent will be conducted following OHSRP Policy 301- Informed Consent. 
An IRB-approved consent form will be provided to the participant electronically or by hard copy 
for review prior to consenting. The initial consent process as well as re-consent, when required, 
may take place in person or remotely (e.g., via telephone or other NIH approved platforms). The 
investigational nature and objectives of this trial, the procedures, and their attendant risks and 
discomforts and potential benefits will be carefully explained to the participant in a private setting. 
The participant will be given as much time as they need to review the document and to consult 
with their family, friends, and personal health care providers. In addition, a study team member 
will be available to answer any questions. 
 
A signed and dated informed consent document will be obtained by any investigator authorized to 
consent (See Key Study Personnel Page) prior to entry onto the study. Consent may be obtained 
with required signatures on the hard copy of the consent  or on the electronic document.   
When a document that is in electronic format is used for obtaining  consent, this study may use the 
iMed platform which is 21 CFR, Part 11 compliant, to obtain the required signatures. 
During the consent process, participants and investigators may view the same approved consent 
document simultaneously when participant is being consented in person at the Clinical Center or 
both may view individual copies of the approved consent document on screens in their respective 
locations remotely. Signatures may be obtained either by both directly signing on the device that 
the consenting investigator is using (when in person) or through iMed Mobile Signature Capture  
(remotely) which allows texting or emailing a link to the participant. That link allows the 
participant to review the consent, then proceed to sign on the device they are using. 
 
Whether hard copy or electronic, both the investigator and the participant will sign the document 
with a hand signature using a pen (if using hard copy), finger, stylus, or mouse (if electronic). 
When done remotely, if the participant prefers to sign a hard copy, they may be instructed to sign 
and date the consent document during the discussion and mail, secure email or fax the signed 
document to the consenting investigator. 
 
Whether in person or remotely, the privacy of the participant will be maintained. 

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Nov. 01, 2021 (Amendment I/9) 
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Finally, the fully signed informed consent document will be stored in the electronic medical 
record, and the participant will receive a copy of the signed informed consent document. 
 
11.0 
Conflict of Interest 
The National Institutes of Health reviews NIH staff researchers at least yearly for conflicts of interest. The 
following link contains details on this process http://ethics.od.nih.gov/forms/Protocol-Review-Guide.pdf. 
 
None of the members of the research team reported a potential conflict of interest. 
 
This protocol may have investigators who are not NIH employees.  Non-NIH investigators are expected to 
adhere to the principles of the Protocol Review Guide but are not required to report their personal financial 
holdings to the NIH. Investigators at Brigham and Women’s Hospital, University of Cincinnati, and 
University of Pennsylvania Medical Center will have a Reliance Agreement with the NIH.  
 
12.0 
Compensation  
 
Subjects will not be paid for their participation in this study. 
 
 
 
 
Reimbursement for Travel 
  
Reimbursement for travel will be in accordance with NHLBI travel policy. Reimbursement for food and 
lodging will be consistent with NIH and NHLBI guidelines. 
 
13.0 
References 
 
1. 
Carsillo T, Astrinidis A, & Henske EP (2000) Mutations in the tuberous sclerosis complex 
gene TSC2 are a cause of sporadic pulmonary lymphangioleiomyomatosis.  Proc Natl 
Acad Sci U S A 97:6085-6090. 
2. 
Young L, Lee HS, Inoue Y, Moss J, Singer LG, Strange C, Nakata K, Barker AF, 
Chapman JT, Brantly ML, Stocks JM, Brown KK, Lynch JP, 3rd, Goldberg HJ, Downey 
GP, Swigris JJ, Taveira-DaSilva AM, Krischer JP, Trapnell BC, & McCormack FX (2013) 
Serum VEGF-D a concentration as a biomarker of lymphangioleiomyomatosis severity 
and treatment response: a prospective analysis of the Multicenter International 
Lymphangioleiomyomatosis Efficacy of Sirolimus (MILES) trial.  Lancet Respir Med 
1:445-452. 
3. 
Trindade AJ, Medvetz DA, Neuman NA, Myachina F, Yu J, Priolo C, & Henske EP 
(2013) MicroRNA-21 is induced by rapamycin in a model of tuberous sclerosis (TSC) and 
lymphangioleiomyomatosis (LAM).  PLoS One 8:e60014. 
4. 
Trelinska J, Dachowska I, Kotulska K, Fendler W, Jozwiak S, & Mlynarski W (2015) 
Complications of mammalian target of rapamycin inhibitor anticancer treatment among 
patients with tuberous sclerosis complex are common and occasionally life-threatening.  
Anticancer Drugs 26:437-442. 
5. 
McCormack FX, Inoue Y, Moss J, Singer LG, Strange C, Nakata K, Barker AF, Chapman 
JT, Brantly ML, Stocks JM, Brown KK, Lynch JP, 3rd, Goldberg HJ, Young LR, Kinder 
BW, Downey GP, Sullivan EJ, Colby TV, McKay RT, Cohen MM, Korbee L, Taveira-
DaSilva AM, Lee HS, Krischer JP, & Trapnell BC (2011) Efficacy and safety of sirolimus 
in lymphangioleiomyomatosis.  N Engl J Med 364:1595-1606.

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Appendix I: Drug Diary 
18-H-0003: Discovery of Sirolimus Sensitive Biomakers in Blood 
Study Drug Diary 
Version 2.0 
 
UO1: Discovery of Sirolimus Sensitive Biomarkers in Blood 
Study Drug Diary 
Participant: 
Local ID: 
Please complete this Study Drug Log daily while on Sirolimus providing the date it was taken, the time of day, reason if medication was not 
taken and any symptoms related to taking Sirolimus. Please report any changes to dosage or if you need to stop the medication. 
 
Date (MM/DD/YYYY) 
Time (circle AM or PM) 
Dosage 
Reason if medication not taken 
Report any symptoms related to taking 
Sirolimus 
  
/ 
/  
 
  
 AM or PM 
  
2mg  
 
  
/ 
/  
 
  
 AM or PM 
  
2mg  
 
  
/ 
/  
 
  
 AM or PM 
  
2mg  
 
  
/ 
/  
 
  
 AM or PM 
  
2mg  
 
  
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18-H-0003 
Joel Moss, M.D., Ph.D. 
Nov. 01, 2021 (Amendment I/9) 
12
  
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Signature of staff member reviewing form:  
Date  
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