Treatment of Brain Metastases From Breast Cancer With Eribulin Mesylate
Phase: PHASE2
Conditions: Metastatic Breast Cancer, Brain Metastases
Sponsor: Case Comprehensive Cancer Center

 
 
 
 
 
 
 
 
 
 
 
                             
                               
 
 
 
 
                        Case Comprehensive Cancer Center 
11100 Euclid Avenue,  
Wearn 152 
Cleveland, Ohio  44106-5065 
 
 
 
 
 
 
 
 
 
 
 

CASE 7113 05.25.18 
 
2 
 
                                                  CASE COMPREHENSIVE CANCER CENTER 
__________________________________________________________________ 
 
STUDY NUMBER:   CASE 7113 
 
STUDY TITLE:   Treatment of Brain Metastases from Breast Cancer with Eribulin Mesylate. 
 
PRINCIPAL INVESTIGATOR: Paula Silverman, MD 
 
 
 
 
Case Comprehensive Cancer Center 
University Hospitals Cleveland Medical Center 
11100 University Hospitals Drive 
 
 
 
 
Cleveland, OH   44106 
Phone: (216)844-8510 
 
 
 
 
paula.silverman@uhhospitals.org 
 
CCF PRINCIPAL  
INVESTIGATOR: 
       
      Manmeet S. Ahluwalia, MD, FACP (CCF PI) 
                                                      Burkhardt Brain Tumor and Neuro-Oncology Center 
                                                      Neurological Institute, Cleveland Clinic 
                                                      9500 Euclid Ave, S73,  
                                                      Cleveland, OH, 44195, USA 
                                                      Phone: (216) 444-6145 
                                                      ahluwam@ccf.org 
 
 
 
 
 
CO- INVESTIGATORS  
 G. Thomas Budd, MD, FACP 
       Cleveland Clinic 
       Taussig Cancer Institute 
             9500 Euclid Avenue R35 
             Cleveland, OH 44195 
       Phone: (216)444-6480 
       buddg@ccf.org 
 
      Nicole Williams, MD 
      Division of Medical Oncology 
      The Ohio State University Wexner Medical Center 
      Telephone: (614) 293-3316 
                                                Nicole.Williams@osumc.edu 
 
STATISTICIAN:  
 
Cheryl Thompson, Ph.D, 
                                                      Department of Nutrition 
 
 
 
 
University Hospitals Cleveland Medical Center 
10900 Euclid Avenue  
 
 
 
Cleveland, OH   44106 
216-368-3956 

CASE 7113 05.25.18 
 
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SPONSOR:  
 
            Case Comprehensive Cancer Center 
 
 
 
 
Eisai Incorporated 
 
 
 
 
 
 
 
 
 
 
 
 
 
SUPPLIED AGENTS: 
            Eribulin mesylate 
 
 
 
 
  
 
 

CASE 7113 05.25.18 
 
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SCHEMA 
 
 
Treatment of Brain Metastases from Breast Cancer with Eribulin Mesylate 
 
Primary Objectives: 
To determine the 3-month central nervous system (CNS)-progression free survival (PFS) for patients with 
metastatic breast cancer with brain metastases treated with eribulin mesylate. 
 
 
 
 
 
             
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C1D1 
C1D8 
C2D1 
C2D8 
C3D1 
C3D8 
C4D1 
C4D8 
C4D21 
 
= MRI 
= Eribulin 1.4mg/m2 
   21 day cycles 

CASE 7113 05.25.18 
 
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TABLE OF CONTENTS 
 
1.0  
INTRODUCTION  
 
1.1 
Name of Study Disease/Stage 
1.2  
Name of Investigational Agent 
1.3       Clinical Data for Eribulin Mesylate 
1.4 
Study Rationale 
 
2.0 
OBJECTIVES 
2.1 
Primary Objective 
 
2.2  
Secondary Objectives 
 
3.0 
STUDY DESIGN 
3.1 
Design 
3.2 
Number of Subjects 
3.3 
Expected Duration of Subject Participation 
3.4 
Duration of Therapy 
3.5 
Duration of Follow up 
              3.6  
Replacement of Subjects 
  
4.0  
PATIENT SELECTION 
4.1 
Inclusion Criteria 
4.2  
Exclusion Criteria 
            4.3  
Inclusion of Women and Minorities 
 
5.0 
REGISTRATION  
5.1 
Registration 
 
6.0  
TREATMENT PLAN 
6.1 
Eribulin Mesylate administration  
6.2  
General Concomitant Medications and Supportive Care Guidelines 
 
7.0 
DOSE DELAYS / DOSE MODIFICATIONS 
7.1 
Dosing 
 
7.2 
Dose Modification 
 
8.0       ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS  
 
8.1        Adverse Events and Potential Risk List  
             8.1.1 Eribulin Mesylate 
8.2        Adverse events related to eribulin mesylate 
8.3        Adverse events related to MRI 
8.4        Reporting Procedures for All Adverse Events 
8.5 
 Serious Adverse Event Reporting Procedures 
8.6 
 FDA Reporting 
8.7 
Multi-center Trial Reporting  
8.8 
Data Safety Toxicity Committee 

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9.0       PHARMACEUTICAL INFORMATION  
9.1 
Eribulin Mesylate (Halaven®) 
 
 10.0 
STUDY PARAMETERS AND CALENDAR 
 10.1  
Screening/ Study Parameters 
 10.2  
Calendar 
 
 11.0 
MEASUREMENT OF EFFECT  
 11.1 
Antitumor Effect – Solid Tumors  
11.2   
Antitumor Effect – Non-CNS Metastases 
 
 12.0 
DATA REPORTING/REGULATORY CONSIDERATIONS 
 12.1 
Data Reporting 
 12.2 
Regulatory Considerations  
 
 13.0 
STATISTICAL CONSIDERATIONS 
13.1  
Methods to Address the Study Objectives 
 
REFERENCES 
 
 
APPENDICES        
 
 
 
 
APPENDIX A 
 
ECOG/Karnofksy Performance Status 
 
 
APPENDIX B 
 
Child-Pugh Classification of Severity of Liver Disease 

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1.0 
INTRODUCTION 
 
 
1.1 
Name of Study Disease/Stage: Breast cancer with brain metastases 
 
1.2 
Name of Investigational Agent: Eribulin Mesylate 
 
1.3 Clinical Data for Eribulin: 
Eribulin mesylate (Halaven®) is a microtubule inhibitor approved by FDA in metastatic breast 
cancer patients who have received at least two prior chemotherapy regimens for metastatic disease. 
Multiple phase 2 studies and one noteworthy phase 3 study have established the efficacy of 
eribulin mesylate (Halaven®) in patients with metastatic breast cancer (MBC) (1-4). The efficacy 
of eribulin mesylate has also been evaluated in other advanced solid tumors. These phase 2 studies 
have demonstrated that eribulin mesylate shows activity in patients with advanced non small cell 
lung cancer, prostate cancer, soft tissue sarcoma and platinum-susceptible ovarian, fallopian tube 
or peritoneal cancers. Eribulin mesylate was evaluated in a Phase 3, open label, randomized trial 
for patients with metastatic or locally recurrent breast cancer against the therapy of physician’s 
choice (TPC) (4). Eribulin mesylate 1.4mg/m2 was administered intravenously over 2-5 minutes on 
days 1 and 8 of 21 days cycles; the median duration of treatment was 3.9 months. TPC included 
chemotherapy (96% received single agent vinorelbine, gemcitabine, capecitabile, taxanes, or 
anthracyclines) or hormonal therapy. The median duration of treatment in the TPC arm was 2.1 
months for chemotherapy and 1 month for hormonal therapy. Participants had either received, 
responded poorly or became refractory to at least 2 prior chemotherapy treatments including an 
anthracycline and taxane unless contraindicated either the adjuvant or metastatic setting. Overall, 
16% of the patients had human epidermal growth factor receptor 2 (HER2)-positive disease and 
19% were estrogen receptor (ER), progesterone receptor (PR) and HER2- negative (triple-
negative). Although only 2 previous chemotherapy regimens were mandatory for enrollment, 9% 
of patients had received 4 or more chemotherapy regimens. For the 508 women treated with 
eribulin mesylate, the median overall survival (OS) was 13.1 months; the median OS was 10.6 
months in 254 women in the TPC arm (p = 0.041). A significantly higher overall response rate 
(ORR) was also found with eribulin mesylate compared to TPC (12% vs. 5%) (p = 0.002). Further 
analysis of the study results suggested that survival benefit with eribulin mesylate was independent 
of age without resulting in additional toxicity in older patients. Hence, it was recommended that 
age alone should not preclude older patients from receiving the drug regimen (5). Overall, this 
study demonstrated that eribulin mesylate was an effective agent associated with survival benefit 
compared to other standard regimens in heavily pretreated patients with locally advanced breast 
cancer or MBC.  This trial formed the basis for the 2010 United States Food and Drug 
Administration approval of eribulin mesylate for advanced breast cancer after two or more 
chemotherapy regimens. 
 
1.3.1 Clinical Pharmacokinetics of Eribulin: 
Eribulin mesylate when dosed at 1.4 mg/m2 as an intravenous bolus has been shown to be well 
tolerated at 2 dosing schedules: on days 1 and 8 of 21-day cycles and on days 1, 8, and 15 of 28-
day cycles in patients with MBC (1-4). Eribulin is a colorless, sterile solution for injection. Each 
vial contains 1 mg of eribulin as a 0.5-mg/mL solution in a 5:95 ratio of ethanol to water (6). 
Eribulin does not require pretreatment with corticosteroids or antihistamines (6) since its water 
solubility negates the requirement for a lipophilic vehicle such as polysorbate 80 (docetaxel) or 

CASE 7113 05.25.18 
 
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Cremophor (paclitaxel), which have the potential to cause a hypersensitivity reaction. Eribulin is 
freely soluble in water and various organic solvents including ethanol, benzyl alcohol, and 
dimethyl- sulfoxide (7). Eribulin vials should be stored at 25 degree Centigrade and should not be 
frozen (6). The pharmacokinetic profile of eribulin is linear and dose proportional. When 
administered intravenously, eribulin has a rapid and extensive volume of distribution, slow 
elimination phase, and biexponential plasma disposition (8-13).The mean plasma half-life of 
eribulin is approximately 37.8hours, which allows for prolonged drug exposure to exert the 
antimitotic action (11). Eribulin is eliminated primarily via theliver, where it is metabolized to 4 
monooxygenated metabolites by CYP3A4. The CYP3A4-mediated biotransformation of eribulin is 
slow, which results in delayed hepatic clearance (14). A minor amount of eribulin (~7%) is renally 
excreted as the parent compound (10). Dose adjustments for patients with moderate renal 
impairment, with creatinine clearance between 30 and 50 mL/min, are recommended (17). In a 
clinical setting, eribulin presents an insignificant risk for drug-drug interactions with CYP3A4 
inhibitors and inducers (17). Hepatic impairment decreases clearance and prolongs the elimination 
half-life of eribulin (15). Because of a significant risk of grade3/4 neutropenia, it is recommended 
to reduce the eribulin dose by half in patients with moderate hepatic impairment (16). 
 
1.4  
Study Rationale 
Brain metastases occur in 20-40% of all cancer patients (18) and account for more than half of all 
intra-cranial tumors in adults with approximately 170,000 new cases diagnosed annually in the United 
States alone (19). Breast cancer represents the primary tumor in 15-20% of patients with brain 
metastases (19). The risk of developing brain metastases from breast cancer varies with the underlying 
biology of the disease (20), stage of the disease and effectiveness of systemic therapy. Among women 
with advanced breast cancer, the long term cumulative risk for developing brain metastases from 
breast cancer is estimated at 10- 15% (21). The 5 year cumulative incidence of brain metastases in 
triple negative breast cancer has been reported as 10% (22) but has been reported to be 46 % following 
the diagnosis of metastatic breast cancer (23). In HER-2 positive disease, the incidence may be up to 
36% following the diagnosis of metastatic breast cancer (24, 25) and has been recently estimated as 
almost 50% based on data in long term follow up patients with both early and advanced HER-2 
positive disease (26). 
 
Brain metastases are associated with considerable morbidity and mortality. The most common 
presenting symptoms of brain metastases are headache, cognitive impairment and focal weakness, 
seizures and ataxia. Treatment of brain metastases are mainly palliative and typically include whole 
brain radiation therapy (WBRT), stereotactic surgery (SRS) or surgical resection. In patients with 
brain metastases from breast cancer the median survival depending on the subtype is 4-7.5 months 
(27) and median survival with SRS is 7-18 months (28, 29). 
 
Currently there is no approved drug therapy for brain metastases from metastatic breast cancer. 
Conventional cytotoxic drugs penetrate the brain poorly and intracranial response rates are low and of 
short duration. Paclitaxel which has become a standard of care for breast cancer has very little 
penetration across the blood-brain barrier (20) and has not demonstrated efficacy against breast 
metastases to brain. Targeted therapies such as lapatinib have been tested in HER 2 positive metastatic 
breast cancer with a response rate of 3-6% (31). Furthermore, the use of cytotoxic drugs is limited by 
systemic toxicity; restrictions imposed by blood brain barrier and the chemo sensitivity of the primary 
tumor. Patient outcomes with brain metastases are poor. Median survival following development of 

CASE 7113 05.25.18 
 
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brain metastases from triple negative breast cancer is approximately 4 months with combine modality 
of WBRT with chemotherapy (22). Outcomes are generally better for patients with HER 2 positive 
brain metastases (32) but when progression after cranial irradiation occurs, outcomes are similarly 
poor even after administration of a combination of capecitabine plus lapatinib. Given the poor 
prognosis of patients with brain metastases and the lack of effective drug treatment options, there is a 
need for development of new therapeutic agents and technology to evaluate early response to these 
therapeutic agents.   
Despite being approved in metastatic breast cancer treatment, eribulin mesylate’s therapeutic 
effectiveness on brain metastases from breast cancer has not been studied in a prospective clinical 
study. Matsuoka and colleagues described a case of a woman with brain metastases from breast cancer 
who had a significant response in brain that persisted for 4 months when treated with eribulin mesylate 
(33). 
Additionally two patients with brain metastases from breast cancer treated at University Hospitals 
Seidman Cancer Center showed marked response to eribulin. Based on these observations, we 
hypothesize that eribulin may have activity in patients with brain metastases from breast cancer.   
 
We propose to study a clinically meaningful endpoint, the 3-month CNS-progression free survival 
(PFS), of eribulin mesylate in breast cancer patients with brain metastases. 
 
2.0  
OBJECTIVES 
 
2.1  
Primary Objectives: 
            To determine the 3-month central nervous system (CNS)-progression free survival (PFS) 
for patients with metastatic breast cancer with brain metastases treated with eribulin 
mesylate. 
 
2.2 
Secondary Objective(s):  
 
2.2.1 Estimate CNS complete and partial response rates (CR and PR) and duration of CNS 
response in this patient population. 
 
2.2.2 Evaluate toxicity in patients with breast cancer with brain metastases treated with 
eribulin mesylate. 
 
2.2.3 Estimate clinical benefit rate (CBR) at 3 months in breast cancer patients with brain 
metastases treated with eribulin mesylate. (CBR is the sum of CR, PR and stable disease at 
3 months). 
 
2.2.4 To estimate systemic disease (extra cranial) response rate and duration of systemic 
response in this patient population. 
 
  
2.2.5 Overall survival in this patient population. 
 
 

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3.0  STUDY DESIGN 
 
3.1 Design: 
This is a phase II study that will require 20 patients to evaluate the primary objective (CNS PFS at 
3 months). Study patients will have a baseline brain MRI and a second MRI at 12 weeks to 
evaluate disease. 
 
3.2 
Number of Subjects: A total of 20 evaluable patients will be required for the study:  
 
3.3 
Expected Duration of Subject Participation: Death or disease progression or toxicity.  
 
3.4.   Duration of Therapy 
In the absence of treatment delays due to adverse events, treatment may continue on study until 
one of the following criteria applies: 
 
 Systemic or CNS disease progression, 
 Intercurrent illness that prevents further administration of treatment, 
 The investigator considers it, for safety reasons, to be in the best interest of the patient.  
 Unacceptable treatment related toxicity, NCI CTC AE version 4.0. Grade 3 or 4 that fails to 
recover to baseline or < Grade 2 in the absence of treatment within 4 weeks 
 General or specific changes in the patient’s condition render the patient unacceptable for 
further treatment in the judgment of the investigator,  
 Patient decision to withdraw from treatment (partial consent) or from the study (full consent), 
 Pregnancy during the course of the study  
 Death 
 
The date and reason for discontinuation must be documented.  Every effort should be made to 
complete the appropriate assessments.  
   
3.5 
Duration of Follow Up:  
 
30-Day Follow-Up: Patients will be followed for toxicity for 30 days after treatment has been 
discontinued or until death, whichever occurs first.  
 
Long term Follow-Up: Patients will be followed for survival every 3 months until death after 
discontinuation of study medications. 
 
The clinical course of each event will be followed until resolution, stabilization, or until it has been 
determined that the study treatment or participation is not the cause.  
 
Serious adverse events that are still ongoing at the end of the study period will necessitate follow-
up to determine the final outcome. Any serious adverse event that occurs after the study period and 
is considered to be possibly related to the study treatment or study participation will be recorded 
and reported immediately. 
 
 

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3.6 
Replacement of Subjects 
Subjects who do not obtain the two MRI scans (baseline and 12 weeks) will be considered not 
evaluable for response and will be replaced. 
 
4.0 
PATIENT SELECTION 
Each of the criteria in the checklist that follows must be met in order for a patient to be considered 
eligible for this study.  Use the checklist to confirm a patient’s eligibility.  The checklist must be 
completed for each patient and must be signed and dated by the treating physician.   
 
Patient’s Name _____________________________________________________________ 
 
Medical Record # ___________________________________________________________ 
 
Research Nurse /  
Study Coordinator Signature: _________________________________ 
Date __________ 
 
Treating Physician [Print] ____________________________________________________ 
 
Treating Physician Signature:  ________________________________ 
Date __________ 
 
4.1 
Inclusion Criteria 
 
_____ 4.1.1 Female with histologically confirmed breast cancer. 
 
_____ 4.1.2 Patients must have evidence of metastatic disease (non measurable disease is eligible). 
 
_____ 4.1.3 Radiologically confirmed metastatic brain lesion by MRI. 
 
_____ 4.1.4 
 Brain metastases from breast cancer with or without previous treatment. WBRT, 
STS or surgical resection permitted through progression. Progression must be documented in an at 
least one lesion untreated by SRS or in any site after surgery or WBRT. 
 
_____ 4.1.5 Patients must be neurologically stable and with stable dose steroids and anticonvulsants 
for at least 1 week prior to obtaining the baseline MRI of the brain, and/or at least 1 week prior to 
beginning study treatment. 
 
_____ 4.1.6 No presence of uncontrolled systemic disease or tumor related complication which, in 
opinion of the investigator, might restrict life expectancy to less than 3 months. 
 
_____ 4.1.7 Patients may not be on any cytotoxic chemotherapy or hormonal treatment for  breast 
cancer during protocol treatment. Trastuzumab is allowed in HER2 positive patients).   
 
_____ 4.1.8 Subject age ≥ 18 years 
 
_____ 4.1.9 Able to comprehend and willing to sign an Informed Consent Form (ICF) 
 
_____ 4.1.10   Karnofsky performance status ≥ 60 

CASE 7113 05.25.18 
 
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_____ 4.1.11   No brain radiation therapy > 4 weeks before planned start of protocol treatment. 
 
_____ 4.1.12_ No chemotherapy for > 3 weeks before planned start of protocol treatment.  
 
 
_____  4.1.13 Adequate bone marrow, renal, and hepatic function, per local reference laboratory 
ranges as follows: 
 
_____ 4.1.13.1 
Absolute neutrophil count (ANC) ≥ 1,500/mm3 
 
 
 
ANC= __________________ Date: ________________ 
 
_____ 4.1.13.2 
Platelet count ≥ 100,000/mm3 
 
 
 
Platelets= __________________ Date: ________________ 
 
_____ 4.1.13.3 
Hemoglobin ≥ 9 g/dL 
 
 
 
Hemoglobin= __________________ Date: ________________ 
 
_____ 4.1.13.4 
Calculated creatinine clearance (CrCl) ≥ 30mL/min (Cockcroft-
Gault method) 
 
 
 
Creatinine= __________________ Date: ________________ 
 
 
 
         Crcl = __________________ Date: ________________ 
 
_____ 4.1.13.5 
Patients with normal, mild or moderate hepatic dysfunction are 
eligible.  
 
 
 
 
 
Pugh-Child class= ____________ Date:____________ 
 
_____4.1.13.6 
Calcium <10.1 mg/dL (corrected to serum albumin as follows: 
Corrected Calcium = (0.8 x (4 - patient albumin)) + serum Ca  
 
 
 
Corrected calcium=___________ Date: ________________ 
 
_____4.1.14 Females of child-bearing potential must have a negative pregnancy test at screening 
and agree to take appropriate precautions to avoid pregnancy (double barrier 
method of birth control or abstinence) from screening through 3 months after the 
last dose of treatment 
 
____ 4.1.15    Able to undergo MRI evaluation with and without gadolinium contrast 
 
4.2 
Exclusion Criteria 
 
_____ 4.2.1 Patients with the presence of an active infection, abscess or fistula 
 
_____ 4.2.2 Known leptomeningeal disease or CNS midline shifts. 
 
_____ 4.2.3 Any evidence of severe or uncontrolled systemic disease such as clinically significant 
cardiovascular, pulmonary, hepatic, renal or metabolic disease. 
 

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_____ 4.2.4 Severe conduction abnormality including significant QTc prolongation >450ms. 
 
_____ 4.2.5 Patients with grade 3/4 peripheral neuropathy. 
 
_____ 4.2.6 Patients with pacemaker or an ICD devices. 
 
_____ 4.2.7 Previous treatment with eribulin mesylate. 
 
4.3 
Inclusion of Women and Minorities   
 
Women of all races and ethnic groups are eligible for this trial. 
 
5.0 
REGISTRATION  
 
All subjects who have been consented are to be registered in the OnCore Database. All subjects 
will be registered through Seidman Cancer Center CTU and will be assigned a study number by 
the study coordinator at 216-286-1086.   
 
6.0  
TREATMENT PLAN 
 
6.1 
Agent Administration: Eribulin 
 
 
TABLE 1:TREATMENT REGIMEN DESCRIPTION 
 
 
Agent 
 
 
Pre-medicate at 
the Treating 
Physician’s 
Discretion 
 
Dose 
 
Route 
 
Schedule 
 
Cycle 
Length 
Eribulin 
mesylate 
Zofran 8mg oral 
Decadron 8mg oral 
1.4 mg/m2 
(see section 7.1 
for details) 
IV over 
2-5 Min 
 
Days 1 & 8  
of each 21 day 
cycle 
21 days 
 
6.2 
General Concomitant Medications and Supportive Care Guidelines:  
Patient may receive trastuzumab if tumor is HER2 positive. No other cytotoxic or hormonal 
treatment is allowed while patient is on eribulin mesylate. Three weeks must elapse before 
beginning eribulin treatment (not protocol entry) after previous cytotoxic chemotherapy.  
 
7.0   
DOSING DELAYS / DOSE MODIFICATIONS:  
 
7.1.     Dosing 
The recommended starting dose of eribulin mesylate is 1.4 mg/m2 administered intravenously over 2 
to 5 minutes on Days 1 and 8 of a 21-day cycle. No calculation of Child-Pugh score is necessary for 
those without known hepatic impairment from hepatitis, cirrhosis or liver metastases. 
 

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7.1.1    The recommended dose of eribulin mesylate in patients with mild hepatic impairment (Child-
Pugh A) is 1.1 mg/m2 administered intravenously over 2 to 5 minutes on Days 1 and 8 of a 21-day 
cycle.  
 
7.1.2    The recommended dose of eribulin mesylate in patients with moderate hepatic impairment 
(Child-Pugh B) is 0.7 mg/m2 administered intravenously over 2 to 5 minutes on Days 1 and 8 of a 21-
day cycle.  
 
 7.1.3   The recommended dose of eribulin mesylate in patients with moderate renal impairment  
(creatinine clearance of 30-50 mL/min) is 1.1 mg/m2 administered intravenously over 2 to 5 minutes 
on Days 1 and 8 of a 21-day cycle. 
 
7.2  
Dose Modification  
 
Assess for peripheral neuropathy and obtain complete blood cell counts prior to each dose.  
 
It is not necessary to recalculate the BSA (Body Surface Area) for each treatment if the patient’s 
weight has not changed by more than 10% from baseline.  Prior to each administration of study drug, 
the nurse recalculates the BSA, the daily dose and the total dose of all chemotherapy treatment 
drug(s). A 5% variance rule is utilized between the ordered dose and the recalculated dose. As long as 
the recalculated dose is within 5%, it is acceptable to proceed. 
 
Recommended dose delays  
Do not administer eribulin mesylate on Day 1 or Day 8 for any of the following:  
ANC < 1,000/mm3  
Platelets < 75,000/mm3  
Grade 3 or 4 non-hematological toxicities.  
 
The Day 8 dose may be delayed for a maximum of 1 week.  
If toxicities do not resolve or improve to ≤ Grade 2 severity by Day 15, omit the dose.  
If toxicities resolve or improve to ≤ Grade 2 severity by Day 15, administer eribulin mesylate at a 
reduced dose and initiate the next cycle no sooner than 2 weeks later.  
 
Recommended dose reductions:  If a dose has been delayed for toxicity and toxicities have recovered 
to Grade 2 severity or less, resume eribulin mesylate at a reduced dose as set out in Table 1. Do not re-
escalate Eribulin dose after it has been reduced.  
 

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8.0 
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS 
 
The following is a list of AEs (Section 8.1) and the reporting requirements associated with observed 
AEs (Sections 8.3 and 8.4).  
 
The clinical course of each event will be followed until resolution, stabilization, or until it has been 
determined that the study treatment or participation is not the cause.  
Serious adverse events that are still ongoing at the end of the study period will necessitate follow-up to 
determine the final outcome. Any serious adverse event that occurs after the study period and is 
considered to be possibly related to the study treatment or study participation will be recorded and 
reported immediately. 
 
8.1 
Adverse Events and Potential Risks  
 
8.1.1    Adverse Effects related to eribulin mesylate 
 
8.1.2    Neutropenia  
 Monitor complete blood counts prior to each dose, and increase the frequency of 
monitoring in patients who develop Grade 3 or 4 cytopenias. Delay administration and 
reduce subsequent doses in patients who experience febrile neutropenia or Grade 4 
neutropenia lasting longer than 7 days.  
 Severe neutropenia (ANC <500/mm3) lasting more than 1 week occurred in 12% 
(62/503) of patients. Patients with elevated liver enzymes >3 × ULN and bilirubin >1.5 × 
ULN experienced a higher incidence of Grade 4 neutropenia and febrile neutropenia than 
patients with normal levels.  
 Grade 3 and Grade 4 neutropenia occurred in 28% and 29%, respectively, of patients 
who received eribulin. Febrile neutropenia occurred in 5% of patients and two patients 
(0.4%) died from complications. 
Table 2: Recommended  
Dose Reductions Event Description  
Recommended  
Eribulin 
Dose  
Permanently reduce the 1.4 mg/m2 eribulin mesylate dose for 
any of the following:  
1.1 mg/m2  
ANC <500/mm3 for >7 days  
ANC <1,000 /mm3 with fever or infection  
Platelets <25,000/mm3  
Platelets <50,000/mm3 requiring transfusion  
Non-hematologic Grade 3 or 4 toxicities  
Omission or delay of Day 8 Eribulin dose in previous cycle for toxicity  
Occurrence of any event requiring permanent dose reduction while 
receiving 1.1 mg/m2  
0.7 mg/m2  
Occurrence of any event requiring permanent dose reduction while 
receiving 0.7 mg/m2  
Discontinue eribulin 
mesylate 

CASE 7113 05.25.18 
 
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8.1.3    Peripheral Neuropathy 
 Grade 3 peripheral neuropathy occurred in 8% of patients, and Grade 4 in 0.4% of 
patients who received eribulin. Delay administration of eribulin until resolution to Grade 
2 or less.  
 Neuropathy lasting more than 1 year occurred in 5% of patients. Twenty-two percent of 
patients developed a new or worsening neuropathy that had not recovered within a 
median follow-up duration of 269 days (range 25-662 days)  
 Peripheral neuropathy (5%) was the most common adverse reaction resulting in 
discontinuation  
8.1.4     Pregnancy Category D 
 
 Eribulin is expected to cause fetal harm when administered to a pregnant woman and 
patients should be advised of these risks  
8.1.5     QT Prolongation 
 In an uncontrolled ECG study in 26 patients, QT prolongation was observed on Day 8, 
independent of eribulin concentration, with no prolongation on Day 1. ECG monitoring 
is recommended for patients with congestive heart failure; bradyarrhythmias; 
concomitant use of drugs that prolong QT interval, including Class Ia and III 
antiarrhythmics; and electrolyte abnormalities.  
 Correct hypokalemia or hypomagnesaemia prior to initiating eribulin mesylate and 
monitor electrolytes periodically during therapy. Avoid in patients with congenital long 
QT syndrome.  
8.1.6     Hepatic and Renal Impairment 
For patients with mild (Child-Pugh A) or moderate (Child-Pugh B) hepatic and/or moderate 
(CrCl 30-50 mL/min) renal impairment, a reduction in starting dose is recommended. 
  
8.2  
MRI 
 
8.2.1       Adverse Events related to Magnetic Resonance Imaging (MRI) 
 
A known risk related to MRI examinations is that the MRI magnet could attract certain kinds of 
metal that may cause injury to the patient. In order to avoid that, patients will be screened for any 
hazardous metal object that they may have or is implanted inside their body which includes 
pacemakers, intracranial aneurysm clips, heart valve prostheses and other implanted devices that 
are not compatible with MRI. Although there is no risk from ionizing radiation with MRI, subjects 
will be exposed to strong magnetic fields and radio waves, neither of which are associated with 
any known detrimental health effects. 
For MR perfusion imaging we will use a contrast agent, gadolinium. This agent is approved by the 
FDA and commercially available. There is a risk of an allergic or nephrogenic systemic fibrosis (NSF) 
reaction. Allergic (anaphylactic) reactions to gadolinium contrast medium have occurred but are 

CASE 7113 05.25.18 
 
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extremely rare.  These severe reactions occur in about 1 in every 10,000 people who have 
gadolinium.NSF has not been reported in patients with normal kidney function. Patients at greatest 
risk for developing NSF after receiving gadolinium are those with impaired elimination of the drug, 
including patients with acute kidney injury (AKI) or chronic, severe kidney disease (with a glomerular 
filtration rate or GFR < 30 mL/min/1.73m2). Higher than recommended doses or repeat doses of 
GBCAs also appear to increase the risk for NSF.  
Generally, an injection of 10-20 ml IV of gadolinium contrast agent will be used, provided that the 
subject has no known reaction to contrast agents used in previous MRI scans. As with all such 
injections, bleeding, bruising, dizziness, fainting or infection may occur. Also, the injection may be 
painful but the discomfort should be brief and efforts will be made to minimize the pain.  
 
The MRI scanner makes a loud buzzing sound during the exam that could affect a patient’s 
hearing. In order to protect patient from this sound, they will be provided earplugs during the 
exam. There might also be some claustrophobia-related discomfort involved with being required to 
lie still in a small space. If this occurs, patients can signal the technologist attending the MRI who 
will terminate imaging. The subject will be removed from the MRI machine and regarded as being 
withdrawn from the study, with the exception of following the patient for any sign of adverse event 
to the injected study drug.  
 
8.3  
Reporting Procedures for All Adverse Events (AEs) 
All participating investigators will assess the occurrence of AEs throughout the subject’s participation 
in the study.  Subjects will be followed for toxicity for 30 days after treatment has been discontinued 
or until death, whichever occurs first.  The clinical course of each event will be followed until 
resolution, stabilization, or until it has been determined that the study treatment or participation is not 
the cause.   
 
The investigator is responsible for ensuring that all adverse events observed by the investigator or 
reported by the subject which occur after the subject has signed the informed consent are fully 
recorded in the subject’s case report form, subject’s medical records, and/or any other institutional 
requirement. Source documentation must be available to support all adverse events.  
 
A laboratory test abnormality considered clinically relevant (e.g., causing the subject to withdraw from 
the study), requiring treatment or causing apparent clinical manifestations, or judged relevant by the 
investigator, should be reported as an adverse event.   
 
The investigator will provide the following for all adverse events: 
 Description of the event 
 Date of onset and resolution 
 Grade of toxicity  
 Attribution of relatedness to the investigational agent 
 Action taken as a result of the event 
 Outcome of event 
 
 
 

CASE 7113 05.25.18 
 
18 
In this study, descriptions and grading scales found in the NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0 available at http://ctep.cancer.gov will be utilized for AE 
reporting.  
 
Investigative sites will report adverse events to their respective IRB according to the local IRB’s 
policies and procedures in reporting adverse events. 
 
8.4 
 
SAE Report Form 
SAEs will be recorded on the FDA Form 3500A (MedWatch) but should only be reported as 
instructed below.   The electronic FDA SAE reporting forms should not be used.   
 
8.5 
 
Reporting Procedures for Serious Adverse Events 
For the purposes of safety reporting, all adverse events will be reported that occur from day of 
registration  through 30 days after the final dose of study drug. Adverse events, both serious and non-
serious, and deaths that occur during this period will be recorded in the source documents. All SAEs 
should be monitored until they are resolved or are clearly determined to be due to a subject’s stable or 
chronic condition or intercurrent illness(es). Related AEs will be followed until resolution to baseline 
or grade 1 or stabilization.  
 
8.5.1 SAE Reporting Requirements 
 
Participating investigators (all sites) must report all serious adverse events to the Lead Site 
Principal Investigator (e.g. Sponsor-Investigator) within 24 hours of discovery or notification of the 
event. The participating investigator must also provide follow-up information on the SAE until final 
resolution.  
 
The Lead Site Principal Investigator will review the SAE and report the event to the FDA, 
external collaborator(s), and IRB as applicable. 
 
It is the Sponsor-Investigator’s responsibility (e.g. lead site PI) to ensure that ALL serious 
adverse events that occur on the study (e.g. ALL SAEs that occur at each enrolling institution) are 
reported to all participating sites. 
 
Institutional Review Board Reporting Requirements: 
 
Investigative sites will report adverse events to their respective IRB according to the local 
IRB’s policies and procedures in reporting adverse events.  
 
8.6 
SAEs and OnCore 
 
All SAEs will be entered into OnCore.   
 
A copy of the SAE form(s) submitted to the sponsor-investigator is also uploaded into Oncore. 
 
8.7  
Data Safety and Toxicity Committee 
It is the responsibility of each site PI to ensure that ALL SAEs occurring on this trial (internal or 
external) are reported to the Case Comprehensive Cancer Center’s Data and Safety Toxicity 
Committee. This submission is simultaneous with their submission to the sponsor and/or other 
regulatory bodies  
 

CASE 7113 05.25.18 
 
19 
The sponsor-investigator is responsible for submitting an annual report to the DSTC as per CCCC 
Data and Safety Monitoring Plan. 
  
8.8 
Data and Safety Monitoring Plan 
This protocol will adhere to the policies of the Case Comprehensive Cancer Center Data and Safety 
Monitoring Plan in accordance with NCI guidelines.  
 
9.0     PHARMACEUTICAL INFORMATION    
A list of the adverse events and potential risks associated with the investigational or commercial 
agents administered in this study can be found in Section 8.0.    
 
 
9.1 
Name of Agent:       Halaven® 
 
Chemical Name:      
Eribulin mesylate 
Other Names:         
None 
 
Classification:          
Antineoplastic drug 
 
Molecular Formula:  
C40H59NO11•CH4O3S 
 
Mode of Action:      
Microtubule Inhibitor 
 
Metabolism:    
Unchanged eribulin mesylate was the major circulating species in 
plasma following administration of 14C-eribulin to patients. 
Metabolite concentrations represented <0.6% of parent compound, 
confirming that there are no major human metabolites  
 
Product description:   
Eribulin mesylate is a microtubule inhibitor which is FDA approved 
for metastatic breast cancer in patients previously exposed to taxane 
and anthracycline  
 
Solution preparation:  
Each vial contains 1 mg of eribulin as a 0.5-mg/mL solution in a 5:95 
ratio of ethanol to water 
 
 
Storage requirements:   
Room temperature 
 
Stability:   
Soluble in water 
 
Route of administration:   IV 
 
The cost of this agent will be covered by a grant from Eisai, Incorporated.   
 
Drug Accountability: The investigator or designated study personnel are responsible for maintaining 
accurate dispensing records of the study drug. All study drugs must be accounted for, including study 
drug accidentally or deliberately destroyed. Under no circumstances will the investigator allow the 

CASE 7113 05.25.18 
 
20 
investigational drug to be used other than as directed by the protocol. If appropriate, drug storage, drug 
dispensing, and drug accountability may be delegated to the pharmacy section of the investigative site.  
 
Drug Destruction: At the completion of the study, there will be a final reconciliation of drug shipped, 
drug consumed, and drug remaining. This reconciliation will be logged on the drug reconciliation 
form, signed and dated. Any discrepancies noted will be investigated, resolved, and documented prior 
to return or destruction of unused study drug. Drug destroyed on site will be documented in the study 
files. 
 
 
10.0  STUDY PARAMETERS AND CALENDAR  
 
10.1 
Screening Evaluation   
Screening studies and evaluations will be used to determine the eligibility of each subject for study 
inclusion.  
Baseline imaging evaluations must be completed within 30 days prior to administration of protocol 
therapy. All other evaluations must be completed < 7 days prior to administration of protocol 
therapy.  
 
 Informed Consent 
 Demographics 
 Medical History  
 Complete physical examination  
 Height 
 Weight 
 Vital signs including: blood pressure, pulse, temperature, and respiratory rate 
 Concomitant Medications Assessment including prescription medications, OTC, and 
nutritional/herbal supplements.  
 Karnofsky Performance status 
  
 Baseline Symptoms Assessment 
 MRI of the brain with and without contrast 
 CT, chest abdomen and pelvis with IV contrast, or total body FDG PET scan 
 EKG 
 Laboratory Studies: 
 Complete Blood Count (CBC) with differential and platelets.  
 Serum Chemistries: albumin, alkaline phosphatase, total bilirubin, bicarbonate, 
BUN, calcium, chloride, creatinine, glucose,  potassium, total protein, SGOT 
[AST], SGPT [ALT], sodium 
 Prothrombin time/INR for calculation of Pugh-Child classification of hepatic 
dysfunction 
 ß-HCG for women of childbearing potential 
 Prothrombin time/INR  
 
 
 
 

CASE 7113 05.25.18 
 
21 
 
10.1.1 Treatment Period 
Treatment cycles are 21 days long.  
 
A visit window of up to 3 days before treatment is allowed for chemistry, coagulation and 
hematology labs. 
 
A visit window of + 7 days is allowed for 3 month MRI/CT scans and follow-up visits.  
 
Cycles 1-4 
Laboratory Studies: to be completed 0-3 days prior to Day 1 eribulin administration 
 Complete Blood Count (CBC) with differential and platelets.  
 Serum Chemistries: albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, 
calcium, chloride, creatinine, glucose,  potassium, total protein, SGOT [AST], SGPT 
[ALT], sodium, Mg 
 Calculated creatinine clearance will be done if creatinine and/or BUN are abnormal.    
 
Day 1 
Cycle 1, Day 1 evaluations do not need to be repeated if screening evaluations were conducted 
within 3 days prior to administration of protocol therapy.   
 Physical Examination  
 Weight 
 Vital signs including: blood pressure, pulse, temperature, and respiratory rate 
 Concomitant Medications Assessment including prescription medications, OTC, and 
nutritional/herbal supplements.  
 Karnofsky Performance status 
 
 Eribulin administration – 1.4mg/m2 (or adjusted dose for renal or hepatic insufficiency) 
 Baseline symptoms and adverse events assessment 
 
Cycles 1-4 
Laboratory Studies: to be completed 0-3 days prior to Day 8 eribulin administration 
 Complete Blood Count (CBC) with differential and platelets.  
 Serum Chemistries: albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, 
calcium, chloride, creatinine, glucose,  potassium, total protein, SGOT [AST], SGPT 
[ALT], sodium, Mg 
 Calculated creatinine clearance will be done if creatinine and/or BUN are abnormal.  
 
Day 8 
 Vital signs including: blood pressure, pulse, temperature, and respiratory rate 
 Karnofsky Performance status  
 
 Eribulin administration – 1.4mg/m2 (or adjusted dose for renal or hepatic insufficiency) 
 Adverse events assessment 
 
Cycles 4+  
Laboratory Studies: to be completed 0-3 days prior to Days 1 and 8 eribulin administration 

CASE 7113 05.25.18 
 
22 
 Complete Blood Count (CBC) with differential and platelets. ALC will be calculated from 
CBC and differential 
 Serum Chemistries: albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, 
calcium, chloride, creatinine, glucose,  potassium, total protein, SGOT [AST], SGPT 
[ALT], sodium, Mg 
 Calculated creatinine clearance will be done if creatinine and/or BUN are abnormal.    
 MRI of the brain with and without contrast every 12 weeks 
 CT, chest abdomen and pelvis with IV contrast, or total body FDG PET scan 
 
Days 1 and 8 
 Physical Exam (only day 1) 
 Vital signs including: blood pressure, pulse, temperature, and respiratory rate 
 Concomitant Medications Assessment including prescription medications, OTC, and 
nutritional/herbal supplements.  
 Adverse events assessment 
 Karnofksy Performance status 
 Eribulin administration – 1.4mg/m2 (or adjusted dose for renal or hepatic insufficiency) 
 
30-day follow-up 
 Physical Examination  
 Weight 
 Vital signs including: blood pressure, pulse, temperature, and respiratory rate 
 Concomitant Medications Assessment including prescription medications, OTC, and 
nutritional/herbal supplements.  
 Adverse events assessment 
 Complete Blood Count (CBC) with differential and platelets. ALC will be calculated from 
CBC and differential 
 Serum Chemistries: albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, 
calcium, chloride, creatinine, glucose,  potassium, total protein, SGOT [AST], SGPT 
[ALT], sodium, Mg 
 Calculated creatinine clearance will be done if creatinine and/or BUN are abnormal.    
 Karnofksy Performance status 
 
Long term follow-up (Every 3 months) 
 Physical Examination  
 Weight 
 Vital signs including: blood pressure, pulse, temperature, and respiratory rate 
 Concomitant Medications Assessment including prescription medications, OTC, and 
nutritional/herbal supplements.  
 Adverse events assessment 
 Complete Blood Count (CBC) with differential and platelets. ALC will be calculated from 
CBC and differential 
 Serum Chemistries: albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, 
calcium, chloride, creatinine, glucose,  potassium, total protein, SGOT [AST], SGPT 
[ALT], sodium, Mg 

CASE 7113 05.25.18 
 
23 
 Calculated creatinine clearance will be done if creatinine and/or BUN are abnormal.    
 Karnofksy Performance status 

CASE 7113 05.25.18 
 
24 
 
10.2 
Calendar  
 
Study Days 
Pre-
Study 
Cycles  
1-4 
Day 1 
Cycles 
1-4 
Day 8 
Cycles 4+ 
Days 1  
and 8 
 
30 Day 
Follow 
Up 
Long 
term 
Follow-
Up 
REQUIRED 
ASSESSMENTS 
 
 
 
 
 
 
Informed Consent 
X 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
Height  
X 
 
 
 
 
 
Weight  
X 
X 
 
Xc 
X 
X 
Vitals (blood pressure, pulse, 
temperature, and respiratory 
rate) 
X 
X 
X 
X 
X 
X 
Physical Examination 
X 
X 
 
Xc 
X 
X 
Concomitant Medication 
Assessment 
X 
X 
X 
Xc 
X 
X 
Karnofksy PS 
X 
X 
X 
X 
X 
X 
Baseline Symptoms 
X 
Xf 
 
 
 
 
Adverse Event Assessment 
 
X 
X 
X 
X 
X 
CBC / diff / platelets/b 
X 
Xb 
Xb 
Xb 
X 
X 
Serum Chemistry a,b 
X 
Xb 
Xb 
Xb 
X 
X 
PT/INR 
X 
 
 
 
 
 
ß-HCG,  women of 
childbearing potential 
X 
 
 
 
 
 
EKG 
X 
 
 
 
 
 
DISEASE ASSESSMENT 
 
 
 
 
 
 
MRI brain with and without 
contrast  
X 
 
 
Xd 
 
 
CT chest, abdomen and pelvis 
with IV contrast or total body 
FDG PET 
X 
 
 
Xe 
 
 
TREATMENT 
 
 
 
 
 
 
Eribulin mesylate 
 
X 
X 
X 
 
 
a: Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, 
potassium, total protein, SGOT [AST], SGPT [ALT], sodium, Mg.  Calculated creatinine clearance will be done if 
creatinine and/or BUN are abnormal.  
b: Laboratory Studies: to be completed 0-3 days prior to eribulin administration 
c: Day 1 only 
d: MRI brain to be completed every 12 weeks while on study eribulin mesylate 
e: CT chest/abd/pelvis or total body PET every 12 weeks in patients with systemic disease while on study eribulin 
mesylate. 
f:: cycle 1 day 1 only 
 

CASE 7113 05.25.18 
 
25 
 
11.0  MEASUREMENT OF EFFECT   
 
CNS and non-CNS disease will be followed during the course of the trial. The primary endpoint 
will be response in brain.  
 
11.1 
Antitumor Effect – CNS Metastases 
 
Patients will have a baseline MRI brain scan (within 30 days before initiation of therapy) and 
should be re-evaluated for response by MRI scan after 12 weeks of starting the study.   
 
Response and progression by MR will be evaluated in this study using WHO/modified 
McDonald’s criteria. 
 
11.1.1   Definitions 
 
Evaluable for toxicity All patients will be evaluable for toxicity from the time of registration to 
protocol.  
 
Evaluable for objective response Only those patients who have measurable disease present at 
baseline, have received eribulin as per the protocol, and have had their disease re-evaluated will be 
considered evaluable for response. These patients will have their response classified according to 
the definitions stated below.  (Note: Patients who exhibit objective disease progression prior to the 
end of cycle 1 will also be considered evaluable.) 
 
Evaluable Non-Target Disease Response Patients who have lesions present at baseline that are 
evaluable, but do not meet the definitions of measurable disease, have received at least one cycle 
of therapy, and have had their disease re-evaluated will be considered evaluable for non-target 
disease. The response assessment is based on the presence, absence, or unequivocal progression of 
the lesions.  
 
 
11.1.2  Disease Parameters  
 
Measurable Disease Measurable lesions are defined as brain lesions that can be accurately 
measured in at least one dimension) as > 10 mm by Gd-MRI. All tumor measurements must be 
recorded in millimeters. 
 
Note: Tumor lesions that are previously treated with stereotactic radiosurgery are not allowed as 
target lesion.  
 
Non-measurable disease All other lesions including small lesions (longest diameter < 10 mm are 
considered non-measurable disease.  
 
Note: Cystic lesions that meet the criteria for radiographically defined simple cysts should not be 
considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 

CASE 7113 05.25.18 
 
26 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions if 
they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions. 
 
Target lesions:  All measurable brain metastases > 10 mm should be identified as target lesions and 
recorded and measured at baseline. Target lesions should be selected on the basis of their size 
(lesions with the longest diameter but in addition should be those that lend themselves to 
reproducible repeated measurements. It may be the case that, on occasion, the largest lesion does 
not lend itself to reproducible measurement in which circumstance, the next largest lesion which 
can be measured reproducible should be selected. A sum of the diameters for all target lesions will 
be calculated and reported as the baseline sum diameters.  
 
Non-target lesions:  All other lesions should be identified as non-target lesions and should also be 
recorded at baseline. Measurements of these lesions are not required, but the presence, absence, or 
in rare cases unequivocal progression of each should be noted throughout follow-up. 
 
11.1.3 Methods for Evaluation of Measurable Disease 
All measurements should be taken and recorded in metric notation using calipers. All baseline 
evaluations should be performed within 30 days of initiation of 1st cycle of Chemotherapy.  
 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up.  
 
Conventional CT and MRI This guideline has defined measurability of lesions on CT scan based 
on the assumption that CT slice thickness is 5 mm or less.  If CT scans have slice thickness greater 
than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness.  MRI is 
also acceptable in certain situations (e.g., for body scans). 
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal resolution; 
however, there are many image acquisition variables involved in MRI which greatly impact image 
quality, lesion conspicuity, and measurement.  Furthermore, the availability of MRI is variable 
globally. As with CT, if an MRI is performed, the technical specifications of the scanning 
sequences used should be optimized for the evaluation of the type and site of disease. Furthermore, 
as with CT, the modality used at follow-up should be the same as was used at baseline and the 
lesions should be measured/assessed on the same pulse sequence. It is beyond the scope of the 
RECIST guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body 
parts, and diseases. Ideally, the same type of scanner should be used and the image acquisition 
protocol should be followed as closely as possible to prior scans. Body scans should be performed 
with breath-holding techniques, if possible.  
 
PET-CT At present, the low dose or attenuation correction CT portion of a combined PET-CT is 
not always of optimal diagnostic CT quality for use with RECIST measurements. However, if the 
site can document that the CT performed as part of a PET-CT is of identical diagnostic quality to a 
diagnostic CT (with IV contrast), then the CT portion of the PET-CT can be used for RECIST 
measurements and can be used interchangeably with conventional CT in accurately measuring 

CASE 7113 05.25.18 
 
27 
cancer lesions over time.  Note, however, that the PET portion of the CT introduces additional data 
which may bias an investigator if is not routine or serially performed. 
 
11.1.4 Response Criteria  
Measurement of Response  
Gadolinium-enhanced brain MRI will be checked at baseline, 12 weeks after after starting treatment, 
and every 12 weeks thereafter until progression. The slice thickness of MRI should be less than 5 mm 
throughout the brain (2 to 3 mm thickness is highly recommended). MR imaging will be collected 
electronically for ad hoc central review of responses. 
 
Response in the brain also will be measured using dimensional measurements (WHO/modified 
McDonald’s criteria). Systemic responses will be assessed using the revised Response Evaluation 
Criteria in Solid Tumors (RECIST) guideline (version 1.1) (Eisenhauer 2009). 
 
Time to CNS Progression 
Patients will be followed clinically and radiographically. The date at which the tumor is documented 
to have first enlarged (brain or systemic progression) by 25% from best response (steroid dose stable 
or increased, neurologically stable or worse) will be considered the date of tumor progression. Time to 
progression will be the interval between the date of study entry and the date of tumor progression. In 
the event of a discrepancy and for the purposes of analysis, the treating physician's date of tumor 
progression will be deemed to be correct. Tissue confirmation of CNS tumor progression by 
stereotactic biopsy or other surgical procedure is encouraged to rule out treatment effect as a cause of 
radiographic worsening. Ancillary imaging techniques such as PET imaging, perfusion MRI, or MR 
spectroscopy of all "recurrent” or “progressive” lesions of CNS is recommended for patients at centers 
with access to these technologies.   
 
Responses in the CNS and systemic compartments will be assessed by the same criteria in order to 
avoid confusion in the conduct of the trial. CNS disease will be imaged by MRI with gadolinium, and 
systemic disease will be imaged by CT scan with IV contrast. 
 
Definition of CNS response to eribulin mesylate 
Residual enhancing, non-enhancing, or minimally enhancing tumor: 
PR or CR should be confirmed at least 4 weeks after scan showing response. 
 
Complete Response (CR): shall be defined as the circumstance when the tumor is no longer seen by 
neuroimaging, with the patient off all steroids, or on adrenal maintenance only; CR will be coded only 
if confirmed by a second CT/MR scan performed a minimum of 4 weeks after the initial scan coding a 
response. 
 
Partial Response (PR): Decrease of >50% in the product of two diameters with the patient off all 
steroids, or on adrenal maintenance only; PR will be coded only if confirmed by a second CT/MR scan 
performed a minimum of 4 weeks after the initial scan. 
Stable Disease (SD): shall be defined as the circumstance when the scan shows no change. Patients 
should be receiving stable or decreasing doses of steroids. This will not need a confirmatory scan. 
 

CASE 7113 05.25.18 
 
28 
Progression (P): shall be defined as a > 25% increase in tumor area (two diameters) provided that the 
patient has not had his/her dose of steroids decreased since the last evaluation period. This will not 
need a confirmatory scan. A concomitant decrease in steroid dose will rule out a progression 
designation during the first two months after completion of XRT. (Note: Under exceptional 
circumstances disease progression may be declared in the absence of an increase in tumor size) 
 
11.1.4.1 
Evaluation of Target lesions by MRI using McDonalds criteria 
 
Response 
WHO/modified McDonald Criteria 
CR 
(complete 
response) 
Complete disappearance of all enhancing disease and off all steroids 
PR 
(partial 
response) 
≥ 50% reduction in the sum of products of the perpendicular 
diameters of up to 2 target lesions* plus no new lesion, no progression 
of non-measurable CNS lesion, no increasing steroid requirements, and 
no worsening of neurologic symptoms 
SD 
(stable 
disease) 
 
< 50% reduction in size or < 25% increase in size. 
PD† 
(progressive 
disease) 
 ≥ 25% increase of up to 2 target CNS lesions relative to nadir 
 New CNS lesions 
 unequivocal progression (defined below‡) 
 Tumor-related increase in steroid dose 
 New or worsening tumor-related neurologic symptoms 
 
11.1.4 Duration of Response 
 
Duration of overall response: The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that progressive disease is objectively documented. 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment until the 
criteria for progression are met, taking as reference the smallest measurements recorded since the 
treatment started, including the baseline measurements. 
 
 
 

CASE 7113 05.25.18 
 
29 
Evaluation of Best Overall Response 
The best overall response is the best response recorded from the start of the treatment until disease 
progression/recurrence (taking as reference for progressive disease the smallest measurements 
recorded since the treatment started). The patient’s best response assignment will depend on the 
achievement of both measurement and confirmation criteria. 
 
For Patients with Measurable Disease (i.e., Target Disease) 
 
Target 
lesions 
Non-Target 
Lesions 
New Lesions 
Overall 
Response 
Best 
Overall 
Response 
when 
Confirmation 
is 
Required* 
CR 
CR 
No 
CR 
> 4 wks. Confirmation ** 
 
CR 
 
Non-CR/Non-PD 
 
No 
 
 
PR 
 
 
> 4 wks. Confirmation ** 
CR 
Not evaluated 
No 
PR 
PR 
Non-CR/Non-
PD/not evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/not evaluated 
No 
SD 
Documented at least once 
 > 4 wks from baseline ** 
PD 
Any 
Yes or No 
PD 
 
No prior SD, PR or CR 
 
Any 
PD *** 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
*         See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
**       Only for non-randomized trials with response as primary endpoint. 
***     In exceptional circumstances, unequivocal progression in non-target lesions may be accepted as disease 
progression. 
 
Note:  Patients with a global deterioration of health status requiring discontinuation of treatment without objective 
evidence of disease progression at that time should be reported as “symptomatic deterioration.”  Every 
effort should be made to document the objective progression even after discontinuation of treatment.  
 
 
11.2  Antitumor Effect – Non-CNS Metastases 
 
Although non CNS response is not the primary endpoint of this trial, subjects with measurable disease 
will be assessed by standard criteria. For the purposes of this study, subjects should be re-evaluated 
every 4 cycles of treatment.  
 
Response and progression will be evaluated in this study using the new international criteria proposed 
by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1) [Eur J 
Ca 45:228-247, 2009]. Changes in the largest diameter (unidimensional measurement) of the tumor 
lesions and the shortest diameter in the case of malignant lymph nodes are used in the RECIST 
criteria.  
 
11.2.1 Definitions 
Evaluable for toxicity: All subjects will be evaluable for toxicity from the time of their first treatment 
with eribulin. 
  

CASE 7113 05.25.18 
 
30 
Evaluable for objective response: Only those subjects who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will be 
considered evaluable for response. These subjects will have their response classified according to the 
definitions stated below. 
 
Note: Subjects who exhibit objective disease progression prior to the end of cycle 1 will also be 
considered evaluable. 
 
Evaluable Non-Target Disease Response: Subjects who have lesions present at baseline that are 
evaluable, but do not meet the definitions of measurable disease, have received at least one cycle of 
therapy, and have had their disease re-evaluated will be considered evaluable for non-target disease. 
The response assessment is based on the presence, absence, or unequivocal progression of the lesions. 
 
11.2.2 Disease Parameters 
Measurable Disease: Measurable lesions are defined as those that can be accurately measured in at 
least one dimension (longest diameter for non-nodal lesions and short axis for nodal lesions to be 
recorded) as > 20 mm by chest x-ray, as > 10 mm with CT scan, or > 10 mm with calipers by clinical 
exam. All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters). 
 
Malignant lymph nodes: To be considered pathologically enlarged and measurable, a lymph node must 
be > 15 mm in short axis when assessed by CT scan (CT scan slice thickness recommended to be no 
greater than 5 mm). At baseline and in follow-up, only the short axis will be measured and followed. 
 
Non-measurable disease: All other lesions (or sites of disease), including small lesions (longest 
diameter < 10 mm or pathological lymph nodes with > 10 to < 15 mm short axis) are considered non-
measurable disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial effusions, 
lymphangitis cutis/pulmonitis, inflammatory breast disease, and abdominal masses (not followed by 
CT or MRI) are considered as non-measurable. 
 
Target lesions: All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total, 
representative of all involved organs, should be identified as target lesions and recorded and measured 
at baseline. Target lesions should be selected on the basis of their size (lesions with the longest 
diameter), be representative of all involved organs, but in addition should be those that lend 
themselves to reproducible repeated measurements. 
 
Non-target lesions: All other lesions (or sites of disease) including any measurable lesions over and 
above the 5 target lesions should be identified as non-target lesions and should also be recorded at 
baseline. Measurements of these lesions are not required, but the presence, absence, or in rare cases 
unequivocal progression of each should be noted throughout follow-up. 
 
11.2.3 Response Criteria 
 
Response Evaluation of Target Lesions 
Complete Response (CR): 
Disappearance of all target lesions. Any pathological lymph nodes (whether target or non-target) must 
have reduction in short axis to < 10 mm.  

CASE 7113 05.25.18 
 
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Partial Response (PR): 
At least a 30% decrease in the sum of diameters of target lesions, taking as reference the baseline sum 
of diameters.  
 
Progressive Disease (PD): 
At least a 20% increase in the sum of diameters of target lesions, taking as reference the smallest sum 
on study (this includes the baseline sum if that is the smallest on study). In addition to the relative 
increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm.  
Note: the appearance of one or more new lesions is also considered progression. 
 
Stable Disease (SD)” 
Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as 
reference the smallest sum diameters while on study. 
 
Evaluation of Non-Target lesions 
Response Evaluation of Non-Target Lesions 
 
Complete Response (CR)  
Disappearance of all non-target lesions and normalization of tumor marker level. All lymph nodes 
must be non-pathological in size (< 10 mm short axis). 
Note: If tumor markers are initially above the upper normal limit, they must normalize for a subject to 
be considered in complete clinical response. 
 
Non-CR/ Non-PD[Incomplete response/Stable Disease (SD)] 
Persistence of one or more non-target lesion(s) and/or maintenance of tumor marker level above the 
normal limits. 
 
Progressive Disease (PD) 
Appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions. 
Unequivocal progression should not normally trump target lesion status. It must be representative of 
overall disease status change, not a single lesion increase. Although a clear progression of ‘non-target’ 
lesions only is exceptional, the opinion of the treating physician should prevail in such circumstances, 
and the progression status should be confirmed at a later time by the review panel (or Principal 
Investigator). 
 
11.2.4  Evaluation of Best Overall Response 
The best overall response is the best response recorded from the start of the treatment until disease 
progression/recurrence (taking as reference for progressive disease the smallest measurements 
recorded since the treatment started). The subject’s best response assignment will depend on the 
achievement of both measurement and confirmation criteria. 
 
 
 
 
 
 

CASE 7113 05.25.18 
 
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12.0 
RECORDS TO BE KEPT / REGULATORY CONSIDERATIONS  
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 8.0 
(Adverse Events: List and Reporting Requirements). 
 
12.1 
Data Reporting  
The OnCore Database will be utilized, as required by the Case Comprehensive Cancer Center, to 
provide data collection for both accrual entry and trial data management.  OnCore is a Clinical 
Trials Management System housed on secure servers maintained at Case Western Reserve 
University.  OnCore properly used is compliant with Title 21 CFR Part 11.  Access to data through 
OnCore is restricted by user accounts and assigned roles.  Once logged into the OnCore system 
with a user ID and password, OnCore defines roles for each user which limits access to appropriate 
data. User information and password can be obtained by contacting the OnCore Administrator at 
oncore-registration@case.edu. 
 
OnCore is designed with the capability for study setup, activation, tracking, reporting, data 
monitoring and review, and eligibility verification. This study will utilize electronic Case Report 
Form completion in the OnCore database.  A calendar of events and required forms are available in 
OnCore. 
 
12.2 
Regulatory Considerations 
The study will be conducted in compliance with ICH guidelines and with all applicable federal 
(including 21 CFR parts 56 & 50), state or local laws.  
12.2.1 Written Informed consent 
Provision of written informed consent must be obtained prior to any study-related procedures.  The 
Principal Investigator will ensure that the subject is given full and adequate oral and written 
information about the nature, purpose, possible risks and benefits of the study as well as the subject’s 
financial responsibility.  Subjects must also be notified that they are free to discontinue from the study 
at any time.  The subject should be given the opportunity to ask questions and allowed time to consider 
the information provided.  
The original, signed written Informed Consent Form must be kept with the Research Chart in 
conformance with the institution’s standard operating procedures. A copy of the signed written 
Informed Consent Form must be given to the subject. 
12.2.2 Subject Data Protection 
In accordance with the Health Information Portability and Accountability Act (HIPAA), a subject 
must sign an authorization to release medical information to the sponsor and/or allow the sponsor, a 
regulatory authority, or Institutional Review Board access to subject’s medical information that 
includes all hospital records relevant to the study, including subjects’ medical history. 
 
 
 

CASE 7113 05.25.18 
 
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12.2.3  Retention of records 
The Principal Investigator of The Case Comprehensive Cancer Center supervises the retention of all 
documentation of adverse events, case report forms, source documents, records of study drug receipt 
and dispensation, and all IRB correspondence for as long as needed to comply with national and 
international regulations and the institution in which the study will be conducted, or for the period 
specified by the sponsor, whichever is longer. No records will be destroyed until the Principal 
Investigator confirms destruction is permitted.  
 
12.2.4  Audits and inspections  
Authorized representatives of the sponsor, a regulatory authority, an Independent Ethics Committee 
(IEC) or an Institutional Review Board (IRB) may visit the Center to perform audits or inspections, 
including source data verification.  The purpose of an audit or inspection is to systematically and 
independently examine all study-related activities and documents to determine whether these activities 
were conducted, and data were recorded, analysed, and accurately reported according to the protocol, 
Good Clinical Practice (GCP), guidelines of the International Conference on Harmonization (ICH), 
and any applicable regulatory requirements.   
12.2.5 Data Safety and Monitoring Plan 
This protocol will adhere to the policies of the Case Comprehensive Cancer Center Data and Safety 
Monitoring Plan in accordance with NCI regulations.  
 
13.0     STATISTICAL CONSIDERATIONS 
 
Overview 
This is a prospective, single arm Phase II study to determine the 3-month CNS –progression fee 
survival for patients with breast cancer with brain metastases treated with eribulin mesylate, 
which is the primary objective of the study. To detect treatment response of brain metastases we 
will enroll 20 patients and use standard imaging modality, MRI, at baseline and 12 weeks.  
 
Sample size and study duration 
Clinically, in this population of breast cancer with brain metastases, we expect that a therapy 
would induce a 35% 3-month PFS rate.  A 15% rate would not be considered meaningful, and thus 
anything statistically significant > 15% would be considered a positive study. The 3-month CNS 
PFS of 35% as an indicator of efficacy was based on studies of chemotherapy in brain metastases, 
which demonstrated 3-month CNS PFS rates in the range of 22%–50% (34-36). If 8 or more 
patients (out of 20) remain progression free at three months this will be taken as evidence that 
eribulin may have a positive impact on PFS, as the estimate of the proportion of patients with PFS 
would be 40%, and the 95% CI would be 18.5-61.5%, which does not include 15%.  Thus, we 
have determined that a total of 20 evaluable patients will be required for the study. 
 
In terms of availability of patients to enroll in this study, the proposed institution for this trial is the 
Case Comprehensive Cancer Center, a collaboration that includes clinical research activities at 
both University Hospitals Siedman Cancer Center and the Cleveland Clinic Foundation. 
Approximately 9000 new cancer patients are seen at Case Comprehensive Cancer Center annually 
of which 30-40 patients have brain metastases from metastatic breast cancer in Seidman network 

CASE 7113 05.25.18 
 
34 
alone. The anticipated accrual rate is 20 patients per year. We have the predefined response on 
eribulin mesylate which will be assessed by CNS RECIST 1.1 criteria using MRI scan.  
 
Evaluability  
To be evaluable for inclusion in the primary objective and secondary objectives, patients must 
have baseline and week 12 MRI. 
 
13.1 Methods to address the study objectives 
Primary Objective:  CNS PFS at 3 months 
We will assess the proportion of subjects without CNS progression at 3 months. We hypothesize 
that this will be at least 35%. We will generate a Kaplan- Meier curve of CNS PFS and estimate 
the PFS and 95% CI of the PFS. 
 
Secondary Objective 2.2.1: Objective RR 
We will calculate the proportion (and 95% CI) of the patients with complete and partial response 
and duration of CNS response. 
 
Secondary Objective 2.2.2: Toxicity 
We will evaluate rates (and 95% CI) of toxicity in patients treated with eribulin. 
 
Secondary Objective 2.2.3: CBR at 12 weeks 
We will sum the proportion of the patients with complete response, partial response and stable 
disease at 12 weeks (CBR).  We will then calculate the proportion (and 95% CI) of patients with 
CBR at 12 weeks. 
 
Secondary Objective 2.2.4: Systemic Disease RR 
For this objective, we will estimate systemic disease response rate (and 95% CI) and perform a 
Kaplan-Meier analysis for systemic response in this patient population 
 
Secondary Objective 2.2.5: Overall Survival 
We will generate a Kaplan-Meier curve of OS. Point estimates (and standard error) of OS will be 
calculated. 
 

CASE 7113 05.25.18 
 
35 
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Appendix A 
 
                                                              

CASE 7113 05.25.18 
 
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Appendix B