Combination of Bevacizumab, Irinotecan and Temozolomide for Relapsed or Refractory Neuroblastoma: A Phase II Study
Phase: PHASE2
Conditions: Neuroblastoma
Sponsor: Memorial Sloan Kettering Cancer Center

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Combination Of Bevacizumab, Irinotecan And Temozolomide For Relapsed 
Or Refractory Neuroblastoma: A Phase II Study 
 
MSKCC THERAPEUTIC/DIAGNOSTIC PROTOCOL 
Principal 
Investigator/Department: 
Shakeel Modak, MD 
Pediatrics 
 
 
 
 
Co-Principal 
Investigator(s)/Department: 
Nai-Kong V. Cheung, MD, PhD 
Pediatrics 
 
 
Investigator(s)/Department: 
Ellen Basu, MD, PhD 
Kim Kramer, MD 
Brian Kushner, MD 
Stephen Roberts, MD 
Li-Xuan Qin, PhD 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
Epidemiology & Biostatistics 
 
 
Consenting 
Professional(s)/Department: 
Ellen Basu, MD, PhD 
Shakeel Modak, MD 
Brian Kushner, MD 
Kim Kramer, MD 
Nai-Kong V. Cheung, MD, PhD 
Stephen Roberts, MD 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
 
 
 
 
 
 
Please Note: A Consenting Professional must have completed the mandatory Human 
Subjects Education and Certification Program. 
 
 
 
 
 
 
 
 
 
Memorial Sloan-Kettering Cancer Center 
1275 York Ave. 
New York, NY 10021 
 

 
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TABLE OF CONTENTS 
 
 
1.0 
PROTOCOL SUMMARY AND/OR SCHEMA ................................................................. 2 
2.0 
OBJECTIVES AND SCIENTIFIC AIMS ........................................................................... 2 
3.0 
BACKGROUND AND RATIONALE ................................................................................ 3 
4.0 
OVERVIEW OF STUDY DESIGN/INTERVENTION ................................................... 13 
4.1  DESIGN ................................................................................................................................. 13 
4.2 Intervention ......................................................................................................................... 14 
5.0 
THERAPEUTIC/DIAGNOSTIC AGENTS ...................................................................... 17 
6.0 
CRITERIA FOR SUBJECT ELIGIBILITY ...................................................................... 23 
6.1 
Subject Inclusion Criteria ............................................................................................... 23 
6.2 
Subject Exclusion Criteria .............................................................................................. 23 
7.0 
RECRUITMENT PLAN .................................................................................................... 24 
8.0 
PRETREATMENT EVALUATION ................................................................................. 25 
9.0 
TREATMENT/INTERVENTION PLAN ......................................................................... 25 
10.0 EVALUATION DURING TREATMENT/INTERVENTION ......................................... 31 
11.0 TOXICITIES/SIDE EFFECTS .......................................................................................... 31 
12.0 CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT................ 37 
13.0 CRITERIA FOR REMOVAL FROM STUDY ................................................................. 37 
14.0 BIOSTATISTICS .............................................................................................................. 38 
15.0 SUBJECT REGISTRATION AND RANDOMIZATION PROCEDURES ..................... 40 
15.1   Research Participant Registration ................................................................................... 40 
16.0 DATA  MANAGEMENT ISSUES ................................................................................... 41 
16.1 
Quality Assurance....................................................................................................... 41 
16.2 
Data and Safety Monitoring ....................................................................................... 41 
17.0 PROTECTION OF HUMAN SUBJECTS ........................................................................ 42 
17.1  Privacy ............................................................................................................................. 42 
17.2 Serious Adverse Event (SAE) Reporting .......................................................................... 42 
18.0 INFORMED CONSENT PROCEDURES ........................................................................ 45 
19.0 REFERENCE(S) ................................................................................................................ 46 
 

 
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1.0 
PROTOCOL SUMMARY AND/OR SCHEMA       
Neuroblastoma (NB) remains a fatal disease for a large percentage of patients, especially those 
with high-risk features including those that relapse or are resistant to conventional therapy. The 
combination of irinotecan and temozolomide is widely used as salvage chemotherapy for 
resistant NB both at MSKCC and nationwide. Although patients often have stabilization of their 
disease, response rates are relatively low and responses are usually not durable. The anti- 
vascular endothelial growth factor (VEGF) monoclonal antibody bevacizumab has been studied 
in children in a phase I study without dose-limiting toxicities (DLT) being encountered.  In 
preclinical studies, bevacizumab enhanced irinotecan-induced suppression of NB xenografts. In 
this phase II study, we will evaluate effectiveness of the combination of intravenous (IV) 
bevacizumab, IV irinotecan and oral temozolomide. Patients will be monitored for toxicity and 
changes in angiogenic profile will be assessed as a secondary objective. The overall schema for 
each cycle of chemotherapy is shown below in Table 1. 
 
Table 1: Schema for therapy for each cycle 
Day 
Intervention 
1 
Bevacizumab 15mg/kg IV 
4-8 
Irinotecan 50mg/m2/day+temozolomide 150mg/m2/day  
15 
Bevacizumab 15mg/kg IV 
 
If eligible for second cycle, above schema will be repeated starting between days 29-43 (Section 
9.8). Extent of disease evaluation will be carried out on day 15-35 of second cycle. If there is no 
progressive disease (PD) and the patient is found to be eligible for further treatment, the above 
schema will be repeated. Extent of disease evaluation will be performed after every two cycles. 
If patients continue to be eligible for therapy and do not have progressive disease, they may 
continue to receive therapy with bevacizumab, irinotecan and temozolomide for a maximum of 
two years.  
 
2.0 
OBJECTIVES AND SCIENTIFIC AIMS 
 
2.1 Primary Objectives 
• To evaluate tumor responses to combination of irinotecan, temozolomide 
and bevacizumab in patients with resistant NB. 
 
      
     2.2 Secondary Objectives 
• To determine the toxicity of the combination of irinotecan, temozolomide 
and bevacizumab in patients with resistant NB. 
 
• To evaluate changes in angiogenic markers after treatment with the 
combination of irinotecan, temozolomide and bevacizumab.  
 
• To measure time to progression in patients with resistant NB treated with 
the combination of irinotecan, temozolomide and bevacizumab.  

 
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3.0 
BACKGROUND AND RATIONALE 
 
3.1 Disease Background  
NB, the most common extracranial solid tumor of childhood accounts for 8% of pediatric 
malignancies. 50-60% of patients present with an unresectable primary tumor and metastases in 
bone marrow (BM). Intensive induction chemotherapy and aggressive surgery have improved 
remission rates in young patients. However, results have been less impressive in adolescents and 
adults in whom NB is especially resistant1-3. Myeloablative therapy (with stem-cell support) has 
been the most common approach for eradicating minimal residual disease in distant sites. 
Although the vitamin A derivative 13-cis-retinoic acid (isotretinoin) helped to prolong relapse-
free survival, the long-term relapse-free survival rate in the most recent national study was 
projected to be only ~20%4, 5. Furthermore, the ability to cure patients who relapse remains 
extremely low (<10%)6, 7. These results are compelling reasons for pursuing novel therapeutic 
approaches. 
 
3.2 Approaches to salvage therapy for resistant neuroblastoma 
Until recently the most common salvage regimen used for patients with relapsed and refractory 
disease was the combination of cyclophosphamide and topotecan8, 9. However, the Children’s 
Oncology Group, the only cooperative pediatric oncology group in the US, recently introduced 
this combination as an upfront “window” treatment for newly diagnosed patients, making it a 
less attractive proposition for use in a relapse/refractory setting for fear of chemoresistance. 
Current second line therapies include anti-GD2 immunotherapy for patients who have BM but no 
skeletal disease10, targeted endoradiotherapy (131I-MIBG or 131I-3F8)11 12 or phase I/II agents. 
However, these therapies have considerable limitations including poor response rates, short lived 
responses and in the case of targeted radiotherapy, the need for availability of stored autologous 
hematopoietic stem cells11 . Currently, the most widely used and well studied second line 
regimen for patients with refractory or relapsed NB is the combination of irinotecan and 
temozolomide13, 14.  
 
3.3 Irinotecan therapy of NB 
Irinotecan is a camptothecin prodrug activated by carboxylesterases to the active topoisomerase I 
inhibitor SN-38. Irinotecan was shown to have anti-NB in xenograft models15, 16. It subsequently 
underwent phase I and phase II testing in children with NB using various dosing schedules.17-19  
Toxicities included diarrhea (early and delayed), relatively modest myelosuppression, nausea, 
vomiting and asthenia. In general, although stabilization of disease was often observed, response 
rates were <5%20, 21.  At MSKCC, five-day courses of irinotecan alone were shown to be 
effective palliative therapy for patients (n=44) with resistant NB22 
 
 
3.4 Temozolomide therapy of NB 
Temozolomide, a methylating agent that is thought to act by generating O6-methylguanine in 
DNA has been shown to have activity against some NB xenografts23. In a phase II study in 
patients with NB, 5/23 patients showed objective responses24. In a further study for several 

 
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pediatric solid tumors, 2/16 patients with NB had objective responses25. Myelosuppression was 
the main toxicity encountered. 
 
3.5 Combination of irinotecan and temozolomide for NB 
Methylation of O6-guanine by temozolomide may lead to recruitment of topoisomerase I and 
potentially enhance the probability of inducing camptothecin-mediated damage. This forms the 
biochemical rationale for combining temozolomide with a camptothecin26. Furthermore the lack 
of overlapping major toxicities makes this an attractive combination for clinical use. A phase I 
study of the combination of temozolomide plus protracted irinotecan established toxicity profile 
in heavily pretreated patients. Toxicities included diarrhea and myelosuppression27. At MSKCC, 
we have treated thus far >80 patients with refractory or relapsed NB with irinotecan 
(50mg/m2/day x 5 days administered as a 1hr infusion) plus temozolomide (150mg/m2/day orally 
x 5 days). We reported on results on 49 patients who received 1 to 15 courses (median, 5)13. 
Gastrointestinal and myelosuppressive toxicities were readily managed. 2/19 patients treated for 
refractory NB and assessable for response had complete response (CR) and 1/17 patients treated 
for progressive disease showed partial response (PR). A further 9 patients had objective 
responses. Multiple courses entailed no cumulative toxicity and controlled disease for prolonged 
periods in many patients, including some who were unable to complete prior treatments because 
of hematologic, infectious, cardiac, or renal problems. Myelosuppression was manageable: in 
patients with pretreatment platelet counts more than 100,000/µL, courses could be started every 3 
weeks. In patients with pretreatment platelet counts of 32,000 to 85,000/µL, courses could be 
started every 3 to 5 weeks.  
 
3.6 Tumor angiogenesis in NB 
Recent studies have implicated angiogenesis as a significant regulator of NB growth. In a study 
of 50 untreated patients, tumor vascularity correlated with presence of metastases at diagnosis, 
MYCN amplification, unfavorable histology and poor survival probability28. Advanced stage 
tumors have an increased numbers of microvessels29, 30and a significant association between high 
levels of expression of the integrins αvβ3 and αvβ5, which are markers of active angiogenesis31. 
Expression of the pro-angiogenic vascular endothelial growth factor (VEGF) and its receptor 
(VEGFR) has been demonstrated in NB cell lines and in primary tumor samples 32. The 
coexpression of VEGF and VEGFR suggests the presence of an autocrine loop 32.  High levels of 
pro-angiogenic factors, including VEGF, VEGF-B, VEGF-C, basic fibroblast growth factor 
(bFGF), angiopoietin-2, transforming growth factor-α (TGF-α), and platelet derived growth 
factor-A (PDGF-A) were found in advanced-stage NB tumors. In addition, high expression of 
PDGF-A was significantly associated with decreased survival and has been associated with 
advanced stage in NB33, 34.The hypoxia inducible factors (HIF) may also play a key role in the 
angiogenic process35. NB cells and stroma secrete matrix metalloproteinases MMP-2 and MMP-
9 that degrade matrix and facilitate invasion and metastasis36-38. Because MYCN amplification is 
strongly associated with rapidly progressive malignant growth, many investigators have 
speculated that the MYCN oncogene may stimulate angiogenesis in NB by modulating the 
expression pattern of angiogenesis factors39. In support of this hypothesis, down-regulation of 
Activin A, a developmentally regulated anti-angiogenic TGF-family member has been observed 
in supernatants of SH-EP NB cells with exogenous MYCN expression40. Recently, interleukin-6 

 
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(IL-6) has also been shown to have anti-angiogenic activity and to be down-regulated in MYCN-
transfected NB cells41.  In contrast to high-risk NB, low risk-NB frequently have a stroma-rich 
component made up of mitotically quiescent Schwann cells. Schwann cells have been shown to 
produce the anti-angiogenic agents tissue inhibitors of metalloproteinase (TIMPs) and secreted 
protein acidic and rich in cysteine (SPARC) that may contribute to the relatively avascular nature 
of most stroma-rich low-risk NB42, 43.  
 
3.7 Anti-VEGF therapy for NB 
VEGF is considered to play a critical role in the initiation of tumor angiogenesis44, 45. In NB, 
expression of VEGF and VEGFR have been correlated by some investigators with higher stage 
NB46, 47 . Furthermore, VEGF may act as a growth factor for NB cells independent of its pro-
angiogenic action32, 48. Multiple anti-VEGF strategies including small molecule inhibitors such 
as tyrosine kinase inhibitors49, 50, decoy receptor51, methionine aminopeptidase-2 inhibitors (e.g. 
TNP470)52, cytokines53, chemotherapeutic agents54, 55 and antibodies have been used in 
preclinical NB models. In general, apart from conventional chemotherapeutic agents that have 
multiple mechanisms of action, these have at best only partially suppressed growth of established 
NB xenografts 49, 51, 56-58. Similarly in studies carried out in our laboratory (see Section 3.11), the 
anti-VEGFR antibody bevacizumab did not significantly suppress established NB xenografts. 
Though some preclinical studies suggest that bevacizumab may have some modest anti-NB 
activity in the minimal disease setting59, NB may have other mechanisms of sustaining blood 
supply including upregulation of proangiogenic factors60. This suggests that anti-VEGF therapy 
is best used in combination with other anti-NB agents. 
 
3.8 Bevacizumab: preclinical studies 
Bevacizumab is a humanized monoclonal antibody61 binding all five isoforms of human VEGF 
that currently has FDA approval for the therapy of metastatic colorectal carcinoma and lung 
carcinoma. Its binding epitope62 and pharmacokinetic properties63 have been described. It has 
anti-tumor activities in murine xenograft models61 and its safety has been studied in cynomolgus 
monkeys64. Significant preclinical toxicities observed were as follows. (a) Physeal dysplasia of 
the distal femur:  these were zones of bone growth cessation in animals with open growth plates. 
These were dose-related and were reversible on cessation of bevacizumab. (b) Decrease in 
ovarian and uterine weights were observed in female monkeys along with absence of corpora 
lutea. These were also reversible on cessation of the agent61. (c) Wound healing: dermal wound 
healing was found to be impaired in a rabbit model65. (d) Proteinuria in mice: this was observed 
within 3 hours after IV administration and was associated with glomerular hypertrophy, 
endothelial detachment from glomerular basement membrane and disruption of slit diaphragms. 
This correlated with the decreased expression of glomerular slit diaphragm/podocyte-associated 
protein nephrin66.  
 
3.9 Bevacizumab: clinical studies in adults 
Bevacizumab has been studied in a multitude of Phase I, II, and III clinical trials in more than 
5000 patients and in multiple tumor types. In addition, data are available from 3,863 patients 
enrolled in two postmarketing studies in metastatic colorectal cancer (CRC).  Approximately 
130,000 patients have been exposed to bevacizumab as a marketed product or in clinical trials.   

 
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In a large phase III study (AVF2107g) 67 in patients with metastatic colorectal cancer, the 
addition of bevacizumab, a monoclonal antibody directed against vascular endothelial growth 
factor (VEGF), to irinotecan/5-fluorouracil/leucovorin (IFL) chemotherapy resulted in a 
clinically and statistically significant increase in duration of survival, with a hazard ratio of death 
of 0.67 (median survival 15.6 vs. 20.3 months; p < 0.001).  Similar increases were seen in 
progression-free survival (6.2 vs. 10.6 months; p < 0.001), overall response rate (35% vs. 45%; 
p < 0.01) and duration of response (7.1 vs. 10.4 months; p < 0.01) for the combination arm 
versus the chemotherapy only arm. Based on the survival advantage demonstrated in Study 
AVF2107g, bevacizumab was designated for priority review and was approved on 26 February 
2004 in the United States for first-line treatment in combination with IV 5-FU−based 
chemotherapy for subjects with metastatic colorectal cancer. There was also improved overall 
survival in first-line NSCLC patients (E4599) treated with carboplatin/paclitaxel + bevacizumab 
compared with chemotherapy alone (12.3 vs. 10.3 months, respectively; HR = 0.80; p = 0.003).  
The results from this trial were the basis for FDA approval of bevacizumab for use in 
combination with carboplatin + paclitaxel as first-line treatment of patients with unresectable, 
locally advanced, recurrent or metastatic, non-squamous non-small cell lung cancer (NSCLC) in 
October 200668. 
 
3.10 Bevacizumab: safety profile 
Common adverse events reported with the use of bevacizumab included reactions typically 
encountered with monoclonal antibody administration and included headache, fever, fatigue, 
nausea, vomiting, arthralgia and rash. In the initial Phase I and II clinical trials, four potential 
bevacizumab-associated safety signals were identified: hypertension, proteinuria, 
thromboembolic events, and hemorrhage.  Additional completed Phase II and Phase III studies of 
bevacizumab as well as spontaneous reports have further defined the safety profile of this agent. 
Bevacizumab-associated adverse events identified in phase III trials include congestive heart 
failure (CHF), gastrointestinal perforations, wound healing complications, and arterial 
thromboembolic events (ATE). These and other safety signals are described in further detail as 
follows and in the bevacizumab Investigator Brochure. 
 
3.10.1 Hypertension: Hypertension has been commonly seen in bevacizumab clinical 
trials to date and oral medications have been used to manage the hypertension when indicated. In 
two phase III studies, the incidence of hypertension (and of grade 3 hypertension) was reported 
to be increased67, 69 Grade 4 and 5 hypertensive events are rare. Clinical sequelae of hypertension 
are rare but have included hypertensive crisis, hypertensive encephalopathy, and reversible 
posterior leukoencephalopathy syndrome (RPLS) 70, 71. RPLS may include signs and symptoms 
of headache, altered mental function, seizures, and visual disturbances / cortical blindness and 
requires treatment, which should include control of hypertension, management of specific 
symptoms, and permanent discontinuation of bevacizumab.  There is no information on the 
effect of bevacizumab in patients with uncontrolled hypertension at the time of initiating 
bevacizumab therapy.  Therefore, caution should be exercised before initiating bevacizumab 
therapy in these patients.  Monitoring of blood pressure is recommended during bevacizumab 
therapy.  Optimal control of blood pressure according to standard public health guidelines is 
recommended for patients on treatment with or without bevacizumab.  Temporary interruption of 

 
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bevacizumab therapy is recommended in patients with hypertension requiring medical therapy 
until adequate control is achieved.  If hypertension cannot be controlled with medical therapy, 
bevacizumab therapy should be permanently discontinued.   
 
3.10.2 Proteinuria:  An increased incidence of proteinuria has been observed in patients 
treated with bevacizumab compared with control arm patients.  In the bevacizumab-containing 
treatment arms of clinical trials (across all indications), the incidence of proteinuria (reported as 
an adverse event) was up to 38% (metastatic CRC Study AVF2192g). The severity of proteinuria 
has ranged from asymptomatic and transient events detected on routine dipstick urinalysis to 
nephrotic syndrome; the majority of proteinuria events have been grade 1. NCI-CTC Grade 3 
proteinuria was reported in up to 3% of bevacizumab-treated patients, and Grade 4 in up to 1.4% 
of bevacizumab-treated patients.  The proteinuria seen in bevacizumab clinical trials was not 
associated with renal impairment and rarely required permanent discontinuation of bevacizumab 
therapy.  Bevacizumab should be discontinued in patients who develop Grade 4 proteinuria 
(nephrotic syndrome). Patients with a history of hypertension may be at increased risk for the 
development of proteinuria when treated with bevacizumab.  There is evidence from the dose-
finding, Phase II trials (AVF0780g, AVF0809s, and AVF0757g) suggesting that Grade 1 
proteinuria may be related to bevacizumab dose. 
 
3.10.3 Thromboembolic Events: Both venous and arterial thromboembolic (TE) events, 
ranging in severity from catheter-associated phlebitis to fatal, have been reported in patients 
treated with bevacizumab in the colorectal cancer trials and, to a lesser extent, in patients treated 
with bevacizumab in NSCLC and breast cancer trials. In the phase III pivotal trial in metastatic 
CRC, there was a slightly higher rate of venous TE events that was not statistically significant in 
patients treated with bevacizumab plus chemotherapy compared with chemotherapy alone (19% 
vs. 16%). The incidence of NCI-CTC Grade ≥ 3 venous TE (VTE) events in one NSCLC trial 
(ECOG4599) was higher in the bevacizumab-containing arm compared to the chemotherapy 
control arm (5.6% vs. 3.2%).  One event (0.2%) was fatal in the bevacizumab-containing arm; 
non- fatal events were reported in the carboplatin/paclitaxel arm (see Bevacizumab Investigator 
Brochure).  In clinical trials across all indications the overall incidence of VTE events was 
2.8%−17.3% in the bevacizumab-containing arms compared with 3.2%−15.6% in the 
chemotherapy control arms.  The use of bevacizumab with chemotherapy does not substantially 
increase the risk of VTE event compared with chemotherapy alone.  However, patients with 
metastatic CRC who receive bevacizumab and experienced a VTE event may be at higher risk 
for recurrence of VTE event. 
 
There was also a higher rate of ATE event (3% vs. 1%) such as myocardial infarction, 
transient ischemia attack, cerebrovascular accident/stroke and angina/unstable angina. A pooled 
analysis of the rate of ATE events from 5 randomized studies (1745 patients) showed that 
treatment with chemotherapy plus bevacizumab increased the risk of having an ATE event 
compared with chemotherapy alone (3.8% vs. 1.7%, respectively) 72. ATE events led to a fatal 
outcome in 0.8% (8 of 963) of patients treated with chemotherapy + bevacizumab and 0.5% (4 of 
782) of patients treated with chemotherapy alone.  Cerebrovascular accidents (including TIAs) 
occurred in 2.3% of patients treated with chemotherapy + bevacizumab and 0.5% of patients 

 
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treated with chemotherapy alone.  Myocardial infarction occurred in 1.4% of patients treated 
with chemotherapy + bevacizumab compared with 0.7% of patients treated with chemotherapy 
alone. Furthermore, subjects with certain baseline characteristics (age ≥ 65 years and/or a history 
of a prior ATE event) may be at higher risk of experiencing such an event. 69, 73. See the 
bevacizumab Investigator Brochure for additional information on risk factors. 
 
Aspirin is a standard therapy for primary and secondary prophylaxis of ATE events in 
patients at high risk of such events, and the use of aspirin ≤ 325 mg daily was allowed in the five 
randomized studies discussed above. Use of aspirin was assessed routinely as a baseline or 
concomitant medication in these trials, though safety analyses specifically regarding aspirin use 
were not preplanned. Due to the relatively small numbers of aspirin users and arterial 
thromboembolic events, retrospective analyses of the ability of aspirin to affect the risk of such 
events were inconclusive. However, similarly retrospective analyses suggested that the use of up 
to 325 mg of aspirin daily does not increase the risk of grade 1-2 or grade 3-4 bleeding events, 
and similar data with respect to metastatic colorectal cancer patients were presented at ASCO 
200574. Further analyses of the effects of concomitant use of bevacizumab and aspirin in 
colorectal and other tumor types are ongoing. 
 
3.10.4 Gastrointestinal (GI) perforation Patients with metastatic carcinoma may be at 
increased risk for the development of GI perforation when treated with bevacizumab and 
chemotherapy. Bevacizumab should be permanently discontinued in patients who develop 
gastrointestinal perforation. A causal association of intra-abdominal inflammatory process and 
gastrointestinal perforation to bevacizumab has not been established. Nevertheless, caution 
should be exercised when treating patients with intra-abdominal inflammatory processes with 
bevacizumab. GI perforation has been reported in other trials in non-colorectal cancer 
populations (e.g., ovarian, renal cell, pancreas, and breast) and may be higher in incidence in 
some tumor types. GI perforation was not correlated to duration of exposure to bevacizumab67. 
 
 
3.10.5 Fistula:  Bevacizumab use has been associated with serious cases of fistulae 
including events resulting in death.  Fistulae in the GI tract are common (1%–10% incidence) in 
patients with metastatic CRC, but uncommon (0.1%−1%) or rare (0.01%–0.1%) in other 
indications.  In addition, fistulae that involve areas of the body other than the GI tract (e.g., 
tracheoesophageal, bronchopleural, urogenital, biliary) have been reported uncommonly (0.1%–
1%) in patients receiving bevacizumab in clinical studies and postmarketing reports.  Events 
were reported at various time points during treatment, ranging from 1 week to > 1 year following 
initiation of bevacizumab, with most events occurring within the first 6 months of therapy. 
Permanently discontinue bevacizumab in patients with tracheoesophageal fistulae or any Grade 4 
fistula.  Limited information is available on the continued use of bevacizumab in patients with 
other fistulae.  In cases of internal fistula not arising in the GI tract, discontinuation of 
bevacizumab should be considered. 
 
3.10.6 Wound healing complications: Wound healing complications such as wound 
dehiscence have been reported in patients receiving bevacizumab. In an analysis of pooled data 

 
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from two trials in metastatic colorectal cancer, patients undergoing surgery 28-60 days before 
study treatment with 5-FU/LV plus bevacizumab did not appear to have an increased risk of 
wound healing complications compared to those treated with chemotherapy alone65 (Scappaticci 
et al., 2005). Surgery in patients currently receiving bevacizumab is not recommended. No 
definitive data are available to define a safe interval after bevacizumab exposure with respect to 
wound healing risk in patients receiving elective surgery; however, the estimated half life of 
bevacizumab is 20 days. Bevacizumab should be discontinued in patients with severe wound 
healing complications. If patients receiving treatment with bevacizumab require elective major 
surgery, it is recommended that bevacizumab be held for 4–8 weeks prior to the surgical 
procedure.  Patients undergoing a major surgical procedure should not begin or restart 
bevacizumab until 4 weeks after that procedure (in the case of high-risk procedures such as liver 
resection, thoracotomy, or neurosurgery, it is recommended that chemotherapy be restarted no 
earlier than 6 weeks and bevacizumab no earlier than 8 weeks after surgery). 
 
3.10.7 Hemorrhage: Overall, grade 3 and 4 bleeding events were observed in 4.0% of 
1132 patients treated with bevacizumab in a pooled database from eight phase I, II, and III 
clinical trials in multiple tumor types (Bevacizumab Investigator Brochure, October 2005). The 
hemorrhagic events that have been observed in bevacizumab clinical studies were predominantly 
tumor-associated hemorrhage (see below) and minor mucocutaneous hemorrhage.  
 
Tumor-associated hemorrhage – Major or massive pulmonary hemorrhage or hemoptysis 
has been observed primarily in patients with NSCLC.  Life-threatening and fatal hemoptysis was 
identified as a bevacizumab-related adverse event in NSCLC trials.  These events occurred 
suddenly and presented as major or massive hemoptysis.  Among the possible risk factors 
evaluated (including squamous cell histology, treatment with anti-rheumatic/anti-inflammatory 
drugs, treatment with anticoagulants, prior radiotherapy, bevacizumab therapy, previous medical 
history of atherosclerosis, central tumor location, and cavitation of tumors during therapy), the 
only variables that showed statistically significant correlations with bleeding were bevacizumab 
therapy and squamous cell histology.  In five of these cases, these hemorrhages were preceded 
by cavitation and/or necrosis of the tumor75. Tumor-associated hemorrhage was also seen rarely 
in other tumor types and locations, including central nervous system (CNS) bleeding in a patient 
with hepatoma with occult CNS metastases and continuous oozing of blood from a thigh 
sarcoma with necrosis. Serious GI hemorrhage has been reported in a phase II study for patients 
with colorectal cancer73. 
 
Across all bevacizumab clinical trials, mucocutaneous hemorrhage has been seen in 20%-
40% of patients treated with bevacizumab. These were most commonly grade 1 epistaxis that 
lasted less than 5 minutes, resolved without medical intervention and did not require any changes 
in bevacizumab treatment regimen. There have also been less common events of minor 
mucocutaneous hemorrhage in other locations, such as gingival bleeding and vaginal bleeding. 
Grade 1 epistaxis occurred in 32% patients receiving bevacizumab plus combination 
chemotherapy as first line therapy for metastatic colon cancer69. 
 

 
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3.10.8 CHF: In clinical trials CHF was observed in all cancer indications studied to date, 
but predominantly in patients with metastatic breast cancer.  In the Phase III clinical trial of 
metastatic breast cancer (AVF2119g), 7 (3%) bevacizumab-treated patients experienced CHF, 
compared with two (1%) control arm patients.  These events varied in severity from 
asymptomatic declines in left ventricular ejection fraction (LVEF) to symptomatic CHF 
requiring hospitalization and treatment.  All the patients treated with bevacizumab were 
previously treated with anthracyclines (doxorubicin cumulative dose of 240−360 mg/m2).  Many 
of these patients also had prior radiotherapy to the left chest wall.  Most of these patients showed 
improved symptoms and/or left ventricular function following appropriate medical therapy 
(Miller et al. 2005). In a randomized, Phase III trial of patients with previously untreated 
metastatic breast cancer (E2100), the incidence of LVEF decrease (defined as NCI-CTC Grade 3 
or 4) in the paclitaxel + bevacizumab arm was 0.3% versus 0% for the paclitaxel alone arm No 
information is available on patients with preexisting CHF of New York Heart Association 
(NYHA) Class II−IV at the time of initiating bevacizumab therapy, as these patients were 
excluded from clinical trials.  Prior anthracyclines exposure and/or prior radiotherapy to the chest 
wall may be possible risk factors for the development of CHF.  Caution should be exercised 
before initiating bevacizumab therapy in patients with these risk factors.  A Phase II trial in 
patients with refractory acute myelogenous leukemia reported 5 cases of cardiac dysfunction 
(CHF or LVEF decrease to < 40%) among 48 patients treated with sequential cytarabine, 
mitoxantrone, and bevacizumab.  All but 1 of these patients had significant prior exposure to 
anthracyclines as well.76 Two additional studies investigated concurrent administration of 
anthracyclines and bevacizumab.  In 21 patients with inflammatory breast cancer treated with 
neoadjuvant docetaxel, doxorubicin, and bevacizumab, no patients developed clinically apparent 
CHF; however, patients had asymptomatic decreases in LVEF to < 40% 77.  In a small Phase II 
study in patients with soft tissue sarcoma, 2 of the 17 patients treated with bevacizumab and 
high-dose doxorubicin (75 mg/m2) developed CHF (one Grade 3 event after a cumulative 
doxorubicin dose of 591 mg/m2, one Grade 4 event after a cumulative doxorubicin dose of 
420 mg/m2); an additional 4 patients had asymptomatic decreases in LVEF 78Other studies in 
patients with various tumor types and either a history of anthracycline exposure or concomitant 
use with bevacizumab are ongoing. Patients receiving concomitant anthracyclines or with prior 
exposure to anthracyclines should have a baseline MUGA scans or echocardiograms (ECHOs) 
with a normal LVEF. 
 
3.10.9 Neutropenia: When combined with chemotherapy, bevacizumab increased the risk 
of neutropenia compared to chemotherapy alone.  In a phase 3 trial with IFL +/- bevacizumab in 
colorectal cancer, grade 3-4 neutropenia was 21% in the bevacizumab + IFL arm vs. 14% in the 
IFL arm (grade 4 neutropenia was 3% vs. 2%).  In a phase 3 trial with carboplatin and paclitaxel 
+/-  bevacizumab in NSCLC, the bevacizumab containing arm was associated with an increased 
rate of grade 4 neutropenia (27% vs 17%), febrile neutropenia (5.4%  vs. 1.8%), and an increased 
rate of infection with neutropenia (4.4% vs. 2.0%) with three fatal cases in the bevacizumab + 
chemotherapy arm vs. none in the chemotherapy control arm.                                                                                  
 

 
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3.10.10 RPLS:  There have been rare reports of bevacizumab-treated patients developing 
signs and symptoms that are consistent with RPLS, a rare neurologic disorder that can present 
with the following signs and symptoms (among others):  seizures, headache, altered mental 
status, visual disturbance, or cortical blindness, with or without associated hypertension.  Brain 
imaging is mandatory to confirm the diagnosis of RPLS.  In patients who develop RPLS, 
treatment of specific symptoms, including control of hypertension, is recommended along with 
discontinuation of bevacizumab.  The safety of reinitiating bevacizumab therapy in patients 
previously experiencing RPLS is not known70, 71 
 
Additional Adverse Events: are described in bevacizumab Investigator Brochure   
 
3.11 Pediatric experience with bevacizumab 
Pediatric experience with bevacizumab is limited. In the only published study, the Children’s 
Children’s Oncology Group recently reported on a phase I study of bevacizumab in 20 patients 
with resistant solid tumors (including 2 patients with NB). In this study, patients received 
bevacizumab as a single agent administered IV every two weeks followed by a two-week break 
before repeat administration. 18 patients were evaluable for toxicity. The maximum planned dose 
of 15mg/kg/dose was achieved without DLT being encountered. Non-DLTs included infusional 
reaction, rash, mucositis, proteinuria, mild hypertension and lymphopenia. There was no 
hemorrhage or thrombosis. The median clearance of BV was 4.1 mL/d/kg (range, 3.1 to 15.5 
mL/d/kg), and the median half-life was 11.8 days (range, 4.4 to 14.6 days). No objective 
responses were observed79. Other adverse events described in patients treated off study include 
RPLS80 and reversible skeletal changes81. At MSKCC we have treated 16 patients thus far on a 
phase I study (MSKCC IRB 06-072) of radioiodinated 3F8 plus bevacizumab in which the latter 
is administered at 15mg/kg/dose. We have encountered one grade 3 DLT: a patient developed GI 
perforation. However, skeletal changes have not been observed82 and in general, patients have 
tolerated therapy well. 
 
3.12 Rationale for combining anti-angiogenic therapy with chemotherapy 
Randomized control studies have confirmed the benefit of combining bevacizumab with 
cytotoxic therapy although the mechanism remains unclear. One hypothesis states that cytotoxic 
therapy releases VEGF which is then removed by bevacizumab leading to endothelial cell 
apoptosis and enhanced cancer cell death. Another proposes that bevacizumab selectively 
inhibits angiogenesis and “normalizes” intratumoral vasculature leading to a paradoxical 
improvement in perfusion and enhanced delivery of cytotoxic agents83. Both mechanisms may be 
involved in the anti-cancer effect of angiogenics. In our protocol, the first dose of bevacizumab 
injected prior to chemotherapy will avail of the latter hypothesis. It could be hypothesized that 
the second dose of bevacizumab injected 7 days after the last administration of chemotherapy 
may then remove VEGF released by the chemotherapeutic agents. 
3.13 Rationale for combining irinotecan and temozolomide with bevacizumab for NB 
In our laboratory we have recently observed bevacizumab-mediated enhancement of the anti-
tumor effect of irinotecan in NB bearing xenografts. NB xenografts using 4 cell lines (LAN-1, 
NMB7, SKNBE(2)C and SKNLP) were established in athymic nude mice by injecting 2-5 x 106 
cells subcutaneously in the flank. After tumor reached a diameter of 0.7-1cm, mice in groups of 

 
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4or 5 were either (a) left untreated, (b) treated with either irinotecan (0.75mg/kg IV daily Mon-
Fri x 10 doses), (c) bevacizumab  (5mg/kg IV twice weekly x 6 doses) alone or (d) combination 
of irinotecan and bevacizumab. Tumors were measured three times weekly and mice were 
sacrificed when tumors reached a diameter of 2cm. Tumor sizes were compared between groups 
using student t-test. Tumor growth curves are shown in Figure 1 below. Bevacizumab 
significantly enhanced the anti-tumor effect of irinotecan in all xenograft models:  p values for 
comparison between irinotecan and irinotecan+bevacizumab groups were 0.04 for NMB7 on day 
24, 0.005 for SKNLP on day 27, 0.05 on day 13 for LAN1.Tumor suppression resulted in a 
significantly enhanced survival in mice treated with the combination of bevacizumab and 
irinotecan when compared to control groups. 
 
 
 
 
Given the enhanced anti-NB activity of the combination of bevacizumab+ irinotecan compared 
to irinotecan alone, we propose to add bevacizumab to the established salvage regimen for NB 
and propose to study the combination of bevacizumab+irinotecan+temozolomide in patients with 
relapsed or refractory NB. This will be the first study of this combination in a predominantly 
pediatric population. 
LAN1 
50
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Figure 1. Bevacizumab enhances anti-NB effect of irinotecan in NB xenograft mouse models 

 
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3.14 Correlative biological studies 
The process of formation of new blood vessels for tumor growth has been termed vasculogenesis 
and involves the recruitment of two types of bone marrow-derived progenitor cells: endothelial 
progenitor cells expressing VEGF receptor 2 (VEGFR2) and hematopoietic progenitor cells 
expressing VEGF receptor 1 (VEGFR1)84. The latter is considered more important in the 
development of metastasis85. Placental derived growth factor (PlGF) is a chemokine that signals 
through VEGFR1 and determination of PlGF levels may serve as a surrogate marker to evaluate 
response to therapy86. Circulating bone marrow-derived cells that express VEGFR1 and 
VEGFR2 coexpress CD13387, 88, a possible cancer stem cell marker89. The integrin α4β1 (VLA-4) 
is also important in the movement of these progenitor cells and is coexpressed with VEGFR190. 
Genes belonging to HIF family are considered to be important regulators for the angiogenic 
switch that transcribes the downstream genes for angiogenesis. HIF1  subunit accumulates 
rapidly inside hypoxic cells due to the lack of ubiquitation and proteosomal degradation of the 
protein, which usually take place in normoxic cells. Both HIF-1  and -2  accumulation can 
drive tumor neovascularization by inducing further pro-angiogenic factors such as VEGF91, 92. 
   
4.0 
OVERVIEW OF STUDY DESIGN/INTERVENTION 
 
4.1  DESIGN  
This is a phase II study of the combination of irinotecan, temozolomide and bevacizumab in 
patients with resistant NB. Patients will initially receive bevacizumab IV at 15mg/kg/dose (this is 
defined as Day 1 Three days later (starting day 4), they will receive concurrently,  IV irinotecan 
at 50mg/m2/day x 5 days plus PO temozolomide 150mg/m2/day x 5 days. A second dose of 
bevacizumab will be administered 14 days after the first one(day 15).  Patients will be evaluated 
at least once weekly for toxicity. Patients will be evaluable for toxicity if they receive at least one 
dose of bevacizumab even if they have not received any irinotecan or temozolomide. If patients 
do not experience significant toxicity (described in Section 9.8), they will commence a second 
cycle 4-6 weeks after the first cycle. Extent of disease evaluation will be carried out after two 
cycles and if there is no progressive disease and patients do not experience significant toxicity 
(described in Section 9.9), they may receive combination therapy up to 2 years. Responses will 
be evaluated after every two cycles and will be compared to historical data for the combination 
of irinotecan + temozolomide. Early stopping rules will be established if undue toxicities or 
inadequate responses are observed. Correlative studies will include assessment of circulating BM 
angiogenic precursors and circulating VEGF and HIF1 alpha.  Schema for each cycle is shown 
below in Table 2. Plan for treating with more than one cycle is outlined in Figure 2. 
 
 
Table 2: Schema for each cycle. 
 
Day 
Intervention 
Treatment Schema for each cycle 
1 
Pre treatment blood draw for angiogenic profile*; bevacizumab 15mg/kg 

 
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4 
Blood draw for circulating angiogenic profile*; Irinotecan 50mg/m2/day+  
temozolomide 150mg/m2/day  
5-8 
Irinotecan 50mg/m2/day+temozolomide 150mg/m2/day. CBC and clinical 
chemistry including renal and liver function tests once a week. 
 
 
11-15 
CBC and clinical chemistry including renal and liver function tests once a week. 
15 
Blood draw for angiogenic profile* followed by bevacizumab 15mg/kg   
18-22 
CBC and clinical chemistry including renal and liver function tests once a week. 
22-35 
Blood draw for angiogenic profile*. 
22-42 
Evaluation for eligibility for second cycle (See Section 9.8) 
25-29 
CBC and clinical chemistry including renal and liver function tests once a week.  
30-36 
CBC and clinical chemistry including renal and liver function tests once a week. (if 
second cycle not started) 
37-42 
CBC and clinical chemistry including renal and liver function tests once a week. (if 
second cycle not started) 
*Blood draw for angiogenic profile are only done during cycle 1 and cycle 2 day 1. 
 
Patients will be removed from study if they suffer either PD or significant toxicities (as defined 
in Section 13). If life-threatening toxicity occurs in any patient, further accrual will be stopped 
pending review by the Principal Investigator. Patients may be eligible for further cycles of 
therapy up to a maximum of 2 years starting from first cycle. Patients who have a serious adverse 
event at the time of discontinuation from study treatment will continue to be followed. 
 
4.2 Intervention 
Each cycle consists of two doses of bevacizumab and five doses each of irinotecan and 
temozolomide (Table 2). Patients will be administered a dose of IV bevacizumab 15mg/kg on 
day 1 and 15 of study. Irinotecan 50mg/m2/day IV will be administered from day 4-8 
concurrently with temozolomide 150mg/m2/day orally. The treatment schedule may require 
minor adjustment as clinically indicated (e.g., due to PDH closure for holidays). 
 
Table 3: Treatment cycle 
 
Day 
Intervention 
1 
Bevacizumab 15mg/kg IV 
4-8 
Irinotecan 50mg/m2/day+temozolomide 150mg/m2/day  
15 
Bevacizumab 15mg/kg IV 
 
Monitoring for toxicities: Clinical observation for toxicity will be undertaken at weekly 
outpatient visits while the patient is on study. Biochemical testing for liver and kidney function 
and complete blood counts will be carried out at least weekly while the patient is on study.  
 
Safety: A number of measures will be taken to ensure the safety of patients participating in this 
trial.  These measures will be addressed through (a) exclusion criteria (see Section 6.2), (b) early 
stopping rules (see Section 13.0) and (c) clinical and laboratory evaluations at weekly intervals. 

 
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Safety evaluations will consist of medical interviews, recording of adverse events, physical 
examinations, blood pressure, and laboratory measurements.  
Specific bevacizumab-related monitoring procedures are as follows: 
• Hypertension will be monitored through routine evaluation of blood pressure prior to 
each bevacizumab treatment.  Optimal control of blood pressure according to standard 
public health guidelines is recommended for patients on treatment with or without 
bevacizumab. 
• Proteinuria will be monitored by urine protein: creatinine ratio at least every 4 weeks 
while on study.  
• If patients on treatment with bevacizumab require elective major surgery, it is 
recommended that bevacizumab be held for 4-8 weeks prior to the surgical procedure. 
Patients undergoing a major surgical procedure should not begin/restart bevacizumab until 4 
weeks after that procedure (in the case of high risk procedures such as liver resection, 
thoracotomy, or neurosurgery, it is recommended that chemotherapy be restarted no earlier 
than 6 wk and bevacizumab no earlier than 8 wk after surgery). 
Patients who are withdrawn for the study due to toxicity will be evaluated at least once 28-42 
days after withdrawal. 
 
Tumor response:  Disease status will be evaluated after every two cycles. Patients who are 
withdrawn from study after one cycle will also have disease status evaluated if feasible. 
 
Angiogenic profile: will be assessed on serial blood draws during cycle 1 on days 1, 4, 15 and 
once between days 22-35. Then during cycle 2 on day 1. 
 
 
 

 
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Plan for treatment with more than one cycle is shown in Figure 2. 
 
 
 
 
 
 
 
Treatment with one cycle of bevacizumab+irinotecan+temozolomide 
Observation for toxicities for up to 42 
days 
Significant toxicities requiring 
discontinuation of therapy* 
No significant toxicities*  
Discontinue treatment; 
patient withdrawn from study 
Further cycle of bevacizumab+ irinotecan+ temozolomide if 
eligible for >1 cycle** 
Observation for toxicities for up to 42 days; extent of 
disease evaluation 15-35 days after cycle2 
Significant toxicities or progression of 
disease * 
Discontinue treatment; pt 
withdrawn from study 
No significant toxicities* and no progression of disease  
Further cycles of bevacizumab+ irinotecan+ temozolomide up 
to a maximum of 2 years if eligible for >1 cycle** 
Figure 2: Algorithm for continuing treatment. * Significant toxicities requiring discontinuation of 
therapy are defined in Section 13.0. **Eligibility for >1cycle is defined in Section 9.8 

 
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5.0 
THERAPEUTIC/DIAGNOSTIC AGENTS 
 
5.1  
Irinotecan (Camptosar, CPT-11)  
 
 
Please refer to the package for comprehensive information. 
 
5.1.1 Chemistry: Irinotecan hydrochloride trihydrate (CPT-11) is a topoisomerase I inhibitor. 
 
5.1.2 Formulation: The drug is supplied in two forms: 2 mL vials containing 40 mg of drug  
and 5 mL vials containing 100 mg of drug. The drug is supplied in brown vials and 
appears as a pale-yellow-to-yellow crystalline powder and pale yellow transparent 
solution when reconstituted. 
 
5.1.3 Administration: Irinotecan will be diluted with D5W to a total volume of up to 100 ml  
 
 
and infused IV over 60 minutes.  
 
5.1.4 Storage and Stability: Irinotecan vials must be stored in a cool, dry place, protected from 
light in a locked space. It is stable to the expiration date on its labeling. After 
reconstitution with D5W, irinotecan is stable refrigerated for 14 days or at room 
temperature for 24 hours.  
 
5.1.5 Adverse Events: Phase I and II studies of irinotecan have reported neutropenia and/or late 
diarrhea (diarrhea occurring more than 8 hours after irinotecan administration) as the 
dose-limiting toxicities (depending upon the schedule). Other commonly observed 
adverse events include nausea and vomiting, anorexia, abdominal cramping, alopecia, 
asthenia, lymphocytopenia, and anemia. Dehydration has occurred as a consequence of 
diarrhea, particularly when associated with severe vomiting.  Patients may have an acute 
syndrome of lacrimation, diaphoresis, abdominal cramping, and diarrhea (early diarrhea) 
during or shortly after irinotecan administration; this syndrome is thought to be 
cholinergically mediated.  Prophylactic or therapeutic administration of atropine should 
be considered in patients experiencing cholinergic symptoms. Loperamide should be 
readily available to begin treatment for late diarrhea (generally occurring more than 24 
hours after administration of irinotecan). Sporadic cases of pulmonary toxicity, 
manifested as shortness of breath, non productive cough, and transient infiltrates on chest 
X-ray have been reported. Infrequent occurrences of mucositis or colitis (sometimes with 
gastrointestinal bleeding) have been observed.  Occasionally, abnormalities of serum 
creatinine, hepatic enzymes, or thrombocytopenia have been observed. Irinotecan may 
cause local irritation at infusion sites.   
 
5.1.6 Supply: Commercially available.  
 
5.2  
Temozolomide (Temodar) 
 
 
Please refer to the package insert for comprehensive information. 
 

 
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5.2.1 Formulation: Temozolomide is supplied in white opaque, preservative-free, two-piece, 
hard gelatin capsules of the following p.o. dosage strengths: 5 mg, 20 mg, 100 mg, 140 mg, 
180 mg, and 250 mg. Each capsule contains drug substance in combination with lactose, 
anhydrous NF, colloidal silicon dioxide NF, sodium starch glycolate NF, tartaric acid NF, 
and stearic acid NF. The capsule shells contain gelatin NF, titanium dioxide USP, and 
sodium lautyl sulfate NF. 
 
5.2.2 Mode of Action: Alkylating agent of imidazotetrazinone class. 
 
5.2.3 Storage and Stability: The capsules are packaged in Type I amber glass bottles (30 
capsules/bottle) and should be stored at room temperature. Capsules are stable for at least 30 
months when stored in amber glass bottle at this temperature. 
 
5.2.4 Supply: Commercially available. 
 
5.2.5 Administration: Temozolomide is administered orally.  
 
5.2.5 Pharmacokinetics: Temozolomide is rapidly and completely absorbed after oral 
administration; peak plasma concentrations occur in 1 hour. Temozolomide is rapidly 
eliminated with a mean elimination half-life of 1.8 hours and exhibits linear kinetics over the 
therapeutic dosing range. Temozolomide has a mean apparent volume of distribution of 0.4 
L/kg (%CV=13%). It is weakly bound to human plasma proteins; the mean percent bound of 
drug-related total radioactivity is 15%. 
 
5.2.6 Metabolism and Elimination: Temozolomide is spontaneously hydrolyzed at physiologic 
pH to the active species, 3-methyl-(triazen-1-yl) imidazole-4-carboxamide (MTIC) and to 
temozolomide acid metabolite. MTIC is further hydrolyzed to 5-amino-imidazole-4-
carboxamide (AIC), which is known to be an intermediate in purine and nucleic acid 
biosynthesis and to methylhydrazine, which is believed to be the active alkylating species. 
Cytochrome P450 enzymes play only a minor role in the metabolism of temozolomide and 
MTIC. Relative to the AUC of temozolomide, the exposure to MTIC and ACI is 2.4% and 
23% respectively. About 38% of the administered temozolomide total radioactive dose is 
recovered over 7 days; 37.7% in urine and 0.8% in feces. The majority of the recovery of 
radioactivity in urine is as unchanged temozolomide (5.6%), AIC (12%), temozolomide acid 
metabolite (2.3%), and unidentified polar metabolites(s) (17%). Overall clearance of 
temozolomide is about 5.5 L/hr/m2. 
 
5.2.7 Known Potential Adverse Events: (a) Hematologic: Thrombocytopenia, leukopenia, 
myelodysplastic syndrome (b) Gastrointestinal: Nausea, vomiting, anorexia (c) Hepatic: 
Elevated liver enzymes (reversible) (d) Skin: Rash. (e) Other: Constipation, diarrhea, 
stomatitis, fatigue, decreased performance status, headache 
 
5.2.8 Pregnancy: Temozolomide is potentially mutagenic and should be handled with 
appropriate precautions by both staff and patients.  Procedures for proper handling and 

 
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disposal of anticancer drugs should be considered. Temozolomide may cause fetal harm 
when administered to a pregnant woman. There are no adequate and well-controlled studies 
in pregnant women. If this drug is used during pregnancy, or if the patient becomes pregnant 
while taking this drug, the patient should be apprised of the potential hazard to the fetus. 
Women of childbearing potential should be advised to avoid becoming pregnant during 
therapy with temozolomide. Men receiving temozolomide should be directed to use effective 
contraception while they are being treated.  
 
5.3 Bevacizumab (Avastin) 
Please refer to the bevacizumab Investigator Brochure for further details and molecular 
characterization. 
 
5.3.1 Formulation: :Bevacizumab is a clear to slightly opalescent, colorless to pale brown, 
sterile, pH 6.2 solution for IV infusion. It is supplied in 100 mg and 400 mg preservative-
free, single-use vials to deliver 4 mL or 16 mL of bevacizumab (25 mg/mL). It contains 
α-trehalose dihydrate sodium phosphate (monobasic, monohydrate), sodium phosphate 
(dibasic, anhydrous), polysorbate 20, and Water for Injection, USP. Vials are for single 
use only. Bevacizumab being administered in this study is intended for use only in 
clinical trials. It is expected to be very similar in safety and activity to the commercially 
marketed drug (Avastin), but it is possible that some differences may exist. 
 
5.3.2  Storage: Upon receipt of the study drug, vials are to be refrigerated at 2°C–8°C  
(36°F–46°F) and should remain refrigerated until just prior to use.  DO NOT FREEZE.  
DO NOT SHAKE.   Vials should be protected from light.  Opened vials must be used 
within 8 hours.  VIALS ARE FOR SINGLE USE ONLY.  Vials used for 1 subject may 
not be used for any other subject.  Once study drug has been added to a bag of sterile 
saline, the solution must be administered within 8 hours. 
 
5.3.3 Preparation of bevacizumab infusion: The necessary amount of bevacizumab should be 
withdrawn and diluted in 0.9% Sodium Chloride Injection, USP to make a final volume 
of 100 mL. Unused portion left in the vial should be discarded, as the product contains no 
preservatives. Vials are for single use only.  Bevacizumab infusions should not be 
administered or mixed with dextrose solutions. Diluted bevacizumab solutions for 
infusion may be stored at 2-8°C (36-46°F) for up to 8 hours. 
 

 
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5.3.4 Administration: Administration will be as a continuous IV infusion.  Anaphylaxis 
precautions should be observed during study drug administration.   The initial dose will 
be delivered over 90±15 minutes.  If the first infusion is tolerated without 
infusion-associated adverse events (fever and/or chills), the second infusion may be 
delivered over 60±10 minutes.  If the 60-minute infusion is well tolerated, all subsequent 
infusions may be delivered over 30±10 minutes.  If a subject experiences an infusion–
associated adverse event, he or she may be premedicated for the next study drug infusion; 
however, the infusion time may not be decreased for the subsequent infusion.  If the next 
infusion is well tolerated with premedication, the subsequent infusion time may then be 
decreased by 30±10 minutes as long as the subject continues to be premedicated.  If a 
subject experiences an infusion-associated adverse event with the 60-minute infusion, all 
subsequent doses should be given over 90±15 minutes.  Similarly, if a subject 
experiences an infusion-associated adverse event with the 30-minute infusion, all 
subsequent doses should be given over 60±10 minutes. It should not be administered as  
IV push or  bolus. Bevacizumab infusion should be interrupted in all patients with severe 
reactions and appropriate medical therapy administered. The line should be flushed after 
infusion is complete. 
5.3.5 Toxicity: Bevacizumab toxicities are described in detail in section 3.8 and are also 
summarized below in Table 4. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Table 4: Bevacizumab toxicities 
Likely 
(>20% Frequency) 
Less Likely 
(≤ 20%) 
Rare 
(<3% Frequency) 
reproductive system and 
breast disorders - other 
(ovarian failure)j; 
hypertension 
anemia, febrile neutropenia; 
supraventricular tachycardia; 
vertigo; abdominal pain, colitis, 
constipation, diarrhea, dyspepsia, 
gastrointestinal hemorrhageb, 
gastrointestinal obstructionc, ileus; 
mucositis oral, nausea, vomiting; 
fatigue, infusion related reaction, 
non-cardiac chest pain, pain; 
allergic reaction; infectionf, 
infection and infestations- 
other(peri-rectal abscess); wound 
dehiscence; alanine 
aminotransferase increased, 
alkaline phosphatase increased, 
aspartate aminotransferase 
increased, blood bilirubin 
increased, cardiac troponin I 
increased, neutrophil count 
decreased, weight loss, white 
blood cell decreased; anorexia; 
arthralgia, musculoskeletal and 
connective tissue-disorder-other 
(bone metaphyseal dysplasia)g, 
myalgia, osteonecrosis of jawh; 
dizziness, headache, peripheral 
sensory neuropathyi, syncope; 
hematuria, proteinuria; vaginal 
hemorrhage; allergic rhinitis, 
cough, dyspnea, epistaxis, 
hoarseness; pruritus, rash maculo-
papular, urticaria; 
thromboembolic event 
blood and lymphatic system 
disorders - other (renal 
thrombotic microangiopathy); 
acute coronary syndrome, heart 
failure, left ventricular systolic 
dysfunction, myocardial 
infarction, ventricular 
arrhythmia, ventricular 
fibrillation; gastrointestinal 
fistulaa, gastrointestinal 
perforationd, gastrointestinal 
ulcere; anaphylaxis; 
gastrointestinal anastomotic 
leak; intracranial hemorrhage, 
ischemia cerebrovascular, 
reversible posterior 
leukoencephalopathy syndrome; 
acute kidney injury, renal and 
urinary disorders- 
other(nephrotic syndrome), 
urinary fistula; vaginal fistula; 
bronchopleural fistula, 
bronchopulmonary hemorrhage, 
respiratory, thoracic and 
mediastinal disorders - other 
(nasal-septal perforation), 
respiratory, thoracic and 
mediastinal disorders - Other 
(tracheo-esophageal fistula); 
vascular disorders - Other 
(arterial thromboembolic event)k  
a Gastrointestinal fistula may include: Anal fistula, Colonic fistula, Duodenal fistula, Esophageal fistula, Gastric 
fistula, Gastrointestinal fistula, Rectal fistula, and other sites under the GASTROINTESTINAL DISORDERS SOC. 
 
b Gastrointestinal hemorrhage may include:  Colonic hemorrhage, Duodenal hemorrhage, Esophageal hemorrhage, 
Esophageal varices hemorrhage, Gastric hemorrhage, Hemorrhoidal hemorrhage, Intra-abdominal hemorrhage, Oral 
hemorrhage, Rectal hemorrhage, and other sites under the GASTROINTESTINAL DISORDERS SOC. 
 

 
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Amended: 04/04/14 
 
cGastrointestinal obstruction may include:  Colonic obstruction, Duodenal obstruction, Esophageal obstruction, Ileal 
obstruction, Jejunal obstruction, Rectal obstruction, Small intestinal obstruction, and other sites under the 
GASTROINTESTINAL DISORDERS SOC. 
 
dGastrointestinal perforation may include:  Colonic perforation, Duodenal perforation, Esophageal perforation, 
Gastric perforation, Jejunal perforation, Rectal perforation, Small intestinal perforation, and other sites under the 
GASTROINTESTINAL DISORDERS SOC. 
 
eGastrointestinal ulcer may include:  Duodenal ulcer, Esophageal ulcer, Gastric ulcer, and other sites under the 
GASTROINTESTINAL DISORDERS SOC. 
 
fInfection may include any of the 75 infection sites under the INFECTIONS AND INFESTATIONS SOC. 
 
gMetaphyseal dysplasia was observed in young patients who still have active epiphyseal growth plates. 
 
hCases of osteonecrosis of the jaw (ONJ) have been reported in cancer patients in association with bevacizumab 
treatment, the majority of whom had received prior or concomitant treatment with i.v. bisphosphonates. 
 
iIncreased rate of peripheral sensory neuropathy has been observed in trials combining bevacizumab and 
chemotherapy compared to chemotherapy alone.  
jOvarian failure, defined as amenorrhea lasting 3 or more months with follicle-stimulating hormone (FSH) elevation 
(≥30 mIU/mL), was increased in patients receiving adjuvant bevacizumab plus mFOLFOX compared to mFOLFOX 
alone (34% vs. 2%).  After discontinuation of bevacizumab, resumption of menses and an FSH level <30 mIU/mL 
was demonstrated in 22% (7/32) of these women.  Long term effects of bevacizumab exposure on fertility are 
unknown. 
kArterial thromboembolic event includes visceral arterial ischemia, peripheral arterial ischemia, heart attack, and 
stroke. 
 
Also reported on Bevacizumab (rhuMAb VEGF) trials but with the relationship to Bevacizumab 
(rhuMAb VEGF) still undetermined: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other 
(idiopathic thrombocytopenia purpura); Disseminated intravascular coagulation 
CARDIAC DISORDERS - Pericardial effusion 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Gait disturbance; 
Sudden death NOS 
HEPATOBILIARY DISORDERS - Hepatic failure 
INFECTIONS AND INFESTATIONS - Infections and infestations - Other (aseptic meningitis) 
INVESTIGATIONS - Platelet count decreased 
METABOLISM AND NUTRITION DISORDERS - Hyponatremia 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Musculoskeletal and 
connective tissue disorder - Other (aseptic necrotic bone); Musculoskeletal and connective tissue disorder 
- Other (myasthenia gravis) 
NERVOUS SYSTEM DISORDERS - Dysgeusia; Peripheral motor neuropathy; Seizure 
PSYCHIATRIC DISORDERS - Confusion 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Adult respiratory distress 
syndrome; Pneumonitis; Pneumothorax; Pulmonary hypertension 

 
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SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Palmar-plantar erythrodysesthesia syndrome; 
Skin ulceration 
 
 
5.3.6 Source: Bevacizumab will be supplied by Genentech. Patients will not be charged for this 
agent.  
 
 
 
6.0 
CRITERIA FOR SUBJECT ELIGIBILITY 
Patients with relapsed or refractory neuroblastoma will be eligible for the study. 
 
6.1 
Subject Inclusion Criteria 
• 
Patients must have the diagnosis of NB in accordance with the International Criteria, 
i.e., either histopathology (confirmed by the MSKCC Department of Pathology) or BM 
involvement plus elevated urinary catecholamines. 
• 
Must have a history of tumor progression or recurrence or failure to achieve complete 
response with standard therapy. 
• 
Patients must have evaluable (microscopic marrow metastasis, MIBG or PET scans) or 
measurable (CT, MRI) disease.  
• 
Patients of all ages are eligible.   
• 
Prior Therapy: At least 2 weeks should have elapsed since any biologic therapy. Three 
weeks should have elapsed since last dose of chemotherapy. 
• 
Minimum life expectancy of eight weeks. 
• 
Signed informed consent indicating awareness of the investigational nature of this 
program. 
 
6.2 
Subject Exclusion Criteria 
• Severe major organ toxicity. Renal, cardiac, hepatic, pulmonary, gastrointestinal and 
neurologic toxicity should all be grade 2 or less (per NCI CTC version 4.0 criteria). 
Specifically, serum creatinine should be ≤3 x upper limit of normal (ULN), serum AST 
and ALT ≤5 x ULN, serum bilirubin ≤ 3 x ULN, LV shortening fraction should be ≥15%. 
• Patients with myelosuppression are not excluded if ANC ≥ 500/uL. Platelet count should 
be > 35,000/ul and hemoglobin should be > 8gm/dl. Patients should not have received 
filgrastim, platelet or red blood cell transfusions for 2 days prior to achieving the above 
ANC, platelet and hemoglobin levels. 
• Patients with documented chronic non-healing wound, ulcer or bone fracture  
• Surgical procedures.  
o Patients who have undergone major surgery <28 days prior to beginning 
therapy with bevacizumab are excluded.  
o Patients must be least 24 hours from having after surgical procedures such as 
placement of central catheter.  

 
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o Patients <7days from minor surgeries (e.g. fine needle or core biopsies) and/or 
the unhealed wounds from these procedures are excluded. 
o Patients will be excluded if major surgery (e.g. abdominal or thoracic surgery 
for resection of tumor) is anticipated during the course of the study. 
• Known bleeding diathesis or coagulopathy (in the absence of therapeutic anticoagulation) 
• Thrombosis: patients must not have had a deep venous or arterial thrombosis (non-central 
venous catheter related) within the last three months prior to study entry. Patients with 
cerebrovascular accident or transient ischemic attack within 6 months of therapy are 
excluded. Patients with history of peripheral vascular disease, myocardial infarction or 
unstable angina are excluded.  
• History of abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess 
within 6 months prior to study entry. 
• Known CNS metastases, except for treated brain metastasis. Treated brain metastases are 
defined as having no evidence of progression or hemorrhage after treatment and no 
ongoing requirement except for dexamethasone, as ascertained by clinical examination 
and brain imaging (MRI or CT) during the screening period.  Anticonvulsants 
(stable dose) are allowed.  Treatment for brain metastases may include radiotherapy, 
chemotherapy or immunotherapy Patients with CNS metastases treated by neurosurgical 
resection or biopsy performed within 3 months of treatment will be excluded 
• Proteinuria:  Urine protein: creatinine ratio ≥ 1.0 
• Uncontrolled (lasting >24 hrs on antihypertensive medication) hypertension as defined by 
age-appropriate criteria. Hypertension is defined as average systolic blood pressure 
and/or diastolic blood pressure that is 95th percentile for gender, age, and height on 3 
occasions93. 95th percentiles for gender, age and height are provided in Appendix A. For 
patients ≥18 years of age, hypertension is defined as systolic blood pressure >150mmHg 
and/or diastolic blood pressure >100mmHg.  
• Prior history of hypertensive crisis or hypertensive encephalopathy 
• History of hypersensitivity to any component of bevacizumab  
• History of hemoptysis (≥ 1/2 teaspoon of bright red blood per episode) within 1 month 
prior to Day 1 
• Active serious infections not controlled by antibiotics. 
• Pregnant women are excluded for fear of danger to the fetus. Therefore negative 
pregnancy test is required for all women of child-bearing age, and appropriate 
contraception is used during the study period.  
• Inability or unwillingness to comply with protocol requirements. 
 
7.0 
RECRUITMENT PLAN 
Patients will be offered the opportunity to participate in this trial if they have NB and fulfilled 
the eligibility criteria. The opportunity to participate will be offered to all patients, including 
females and minority groups. Pregnant women will be excluded for fear of danger to the fetus. 
Informed consent will be obtained from the patients or their legal guardians by an investigator 
authorized to obtain consent. Patients will not receive any payment for their participation in 
this study. 

 
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8.0 
PRETREATMENT EVALUATION 
• Complete history including history of prior thromboembolic episodes, stroke, non-
healing ulcers or fractures,  myocardial infarction, surgical procedures 
• Physical examination including blood pressure measurement 
• CBC with differential and platelet count 
• Urine testing for proteinuria 
• CT or MRI of head with contrast 
• Clinical chemistry (including serum sodium, potassium, chloride, bicarbonate, 
 
calcium,) 
• Liver function tests including ALT, AST and serum bilirubin 
• Renal function tests including BUN and serum creatinine 
• Echocardiogram 
• Serum Beta-HCG in females of child-bearing age 
• Investigations for evaluating disease possibly including: BM aspirations and biopsy, 
CT or MRI of suspected sites of disease, bone scan, MIBG scan, PET scan and/or 
urine catecholamines 
• BM testing for quantifying residual disease by reverse transcriptase polymerase chain 
reaction (RT-PCR) (research studies; only if BM studies were done as part of pre-
treatment disease.) 
 
Pretreatment evaluation should be carried out within 6 weeks (preferably within 4 weeks) of 
patient being enrolled on study. 
 
 
9.0 
TREATMENT/INTERVENTION PLAN 
 
9.1 
General Outline 
This is a phase II study of the combination of irinotecan, temozolomide and bevacizumab in 
patients with resistant NB. Patients will initially receive bevacizumab at 15mg/kg/dose IV 
(defined as Day1). Three days later (starting day 4), they will receive concurrently,  IV irinotecan 
at 50mg/m2/day x 5 days plus PO temozolomide 150mg/m2/day x 5 days. A second dose of 
bevacizumab will be administered 14 days after the first one (day 15). Patients will be evaluated 
at least once weekly for toxicity. Patients will be evaluable for toxicity if they receive at least one 
dose of bevacizumab even if they have not received any irinotecan or temozolomide. If patients 
do not experience significant toxicity (described in Section 9.8), they will commence a second 
cycle 4-6 weeks after the first cycle. Extent of disease evaluation will be carried out after two 
cycles and if there is no progressive disease and patients do not experience significant toxicity 
(described in Section 9.9), they may continue to receive therapy up to a maximum of two years. 
Responses will be evaluated after every two cycles and will be compared to historical data for 
the combination of irinotecan + temozolomide. Enrollment on the study will be halted if undue 
toxicities or inadequate responses are observed (described in Section 14.2). Correlative studies 
will include assessment of circulating BM angiogenic precursors and circulating VEGF and 

 
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HIF1 alpha.  Schema for each cycle is shown below in Table 5. Plan for treating with more than 
one cycle is outlined in Figure 2. 
 
Table 5: Schema for each cycle 
 
Day 
Intervention 
Treatment Schema for each cycle 
1 
Pre treatment blood draw for angiogenic profile*; bevacizumab 15mg/kg 
4 
Blood draw for circulating angiogenic profile* 
4-8 
Irinotecan 50mg/m2/day+temozolomide 150mg/m2/day. CBC and clinical 
chemistry including renal and liver function tests once a week. 
11-15 
CBC and clinical chemistry including renal and liver function tests once a 
week. 
15 
Blood draw for angiogenic profile* followed by bevacizumab 15mg/kg   
18-22 
CBC and clinical chemistry including renal and liver function tests once a 
week. 
22-35 
Blood draw for angiogenic profile*. 
22-42 
Evaluation for eligibility for second cycle (See Section 9.8) 
25-29 
CBC and clinical chemistry including renal and liver function tests once a 
week.  
30-36 
CBC and clinical chemistry including renal and liver function tests once a 
week. (if second cycle not started) 
37-42 
CBC and clinical chemistry including renal and liver function tests once a 
week. (if second cycle not started) 
*Blood draws for angiogenic profile for research purposes and are done only during cycle 1 and 
cycle 2 day 1. 
 
 
Patients will be removed from study if they suffer either progressive disease or significant 
toxicities (as defined in Section 13). If life-threatening toxicity occurs in any patient, further 
accrual will be stopped pending review by the Principal Investigator. Patients may be eligible for 
further cycles of therapy up to a maximum of two years. Patients who have a serious adverse 
event at the time of discontinuation from study treatment will continue to be followed until 
resolution of the event or until the event is considered irreversible. 
 
9.2 Treatment schedule 
The following treatment schedule will be followed for each cycle of therapy. 
 
Table 6: Treatment cycle 
 
Day 
Intervention 
1 
Bevacizumab 15mg/kg IV 
4-8 
IV Irinotecan 50mg/m2/day+oral temozolomide 150mg/m2/day  

 
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15 
Bevacizumab 15mg/kg IV 
The treatment schedule may require minor adjustment by ±1 day as clinically indicated (e.g. due 
to PDH closure for holidays or due to inclement weather). 
 
9.3 Administration of bevacizumab 
The dose of bevacizumab is fixed at 15mg/kg/dose. For each cycle, two doses will be 
administered IV on each of days 1 and 15.  Each dose will be administered over 30 to 90 minutes 
as described in Section 5.2.    
 
9.4 Administration of irinotecan 
Irinotecan will be administered as an IV infusion over 60±15 minutes. Anti-emetics will be 
administered as necessary. 
Irinotecan may be administered at a location more convenient for the patient. In such cases, 
adequate documentation must be sent to MSKCC in a timely fashion and in compliance with all 
study guidelines and requirements.  
 
Documentation will include: 
• Patient Name 
• Patient Date of Birth 
• Dates of Treatment 
• Dosage of Treatment 
• Facility Name 
• Clinician Signature and Name 
 
9.5 Administration of temozolomide 
Temozolomide will be administered orally. The dose of temozolomide will be adjusted such that 
it can be administered using available capsules i.e. will be rounded off to the nearest 5 mg. If the 
patient vomits within approximately 30 minutes after receiving temozolomide, the treatment 
dose may be re-administered.  
9.6 Angiogenic profile 
Blood draws for angiogenic profile are for research purposes and are optional. The following 
parameters of angiogenesis will be monitored in patients’ blood samples: 
 
• Circulating BM derived progenitor cells expressing CD133, VEGFR1 and VEGFR2, 
and  integrin α4β1 by immunocytology 
• Plasma VEGF and PlGF and HIF1α using ELISA assays 
• RNA and DNA will be extracted and stored for subsequent testing for other 
angiogenic markers 
 
Blood will be sampled during cycle 1 on days 1, 4, 15, and once between days 22 and 35 where 
feasible. Blood will also be sampled during cycle 2 day 1 where feasible. Samples on days 1 and 
15 will be obtained before bevacizumab administration. Tests for angiogenic profile will be 

 
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carried out in Dr Nai-Kong Cheung’s laboratory (Z-727G). Blood draws for angiogenic profile 
are optional and specific consent will be obtained from the patient. 
 
9.7 Toxicities requiring discontinuation of therapy 
The following toxicities will necessitate discontinuation of therapy for a particular patient 
o Grade 4 toxicity, other than myelosuppression (and its sequelae namely 
thrombocytopenia-related bleeding and infection), clearly attributable to 
irinotecan, temozolomide or bevacizumab. 
o wound dehiscence requiring medical or surgical intervention,  
o arterial thromboembolic event,  
o GI perforation,  
o CNS hemorrhage,  
o reversible posterior encephalopathy (confirmed by MRI)  
o tracheo-esophageal fistula. 
o ≥Grade 3 allergic reaction,  
o ≥Grade 3 hypertension,  
o ≥Grade 3 venous thromboembolism 
o grade 1 pulmonary hemorrhage  
o nephrotic syndrome  
o grade ≥ 3 bowel obstruction that has not fully recovered despite medical or 
surgical intervention 
o >grade 2 congestive cardiac failure 
 
9.8  Eligibility for second cycle of therapy 
Patients will be eligible for a second cycle of chemotherapy if they fulfill the following criteria:  
(a) They do not experience any of the toxicities defined in Section 9.7 until day 42 of therapy or 
until recovery from myelosuppression (myelosuppression is defined as ANC<500/uL and 
platelet count <20,000/uL) whichever is earlier. Based on our prior experience with the 
combination of irinotecan+temozolomide, subsequent cycles could be commenced 3-5 weeks 
apart even in patients whose pre-treatment platelet counts were <30,000/uL. Therefore, we do 
not expect prolonged myelosuppression. However, if patients have not recovered from 
myelosuppression by day 42, they will not be eligible for further therapy.  
(b) They continue to not have any major organ toxicity as evaluated by clinical examination and 
blood draws between days 22-42. Specifically: serum creatinine should be ≤3 x upper limit of 
normal (ULN), serum AST and ALT ≤5 x ULN, serum bilirubin ≤ 3 x ULN, ANC ≥ 500/uL, 
platelet count > 35,000/ul, hemoglobin > 8gm/dl and urine protein: creatinine ratio < 1.0. (c) 
They continue to meet eligibility criteria defined in Section 6, with the exception that patients 
who are found to be in remission after an extent of disease evaluation may continue on treatment 
for up to 2 years. Second and subsequent cycles can only be commenced at a minimum of 14 and 
a maximum of 28 days after the previous dose of bevacizumab i.e. the second cycle cannot 
commence before day 29 or after day 43. 
 
9.9 Eligibility for continuing therapy beyond second cycle 

 
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Patients who do not have disease progression as evaluated on day 15-35 after the second cycle 
and continue to meet eligibility criteria defined in section 9.8 can continue to receive 
bevacizumab plus irinotecan and temozolomide for a maximum of two years. The algorithm 
shown in figure 3 will continue to be followed. Extent of disease evaluations will be performed 
after every two cycles. Subsequent cycles can only be commenced at a minimum of 14 and a 
maximum of 28 days after the previous dose of bevacizumab i.e. the second cycle cannot 
commence before day 29 or after day 43. 
 
 
 

 
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9.10 Use of G-CSF  
G-CSF (5-10ug/kg) may be used as clinically indicated.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
9.11 Concomitant Medications  
 
Patients may receive radiation therapy to sites of disease that are not being assessed for disease 
or response evaluation, at the discretion of the PI. 
 
 
 
Treatment with one cycle of  bevacizumab+irinotecan+temozolomide 
Observation for toxicities for up to 42 
days 
Significant toxicities requiring 
discontinuation of therapy* 
No significant toxicities*  
Discontinue treatment; 
patient withdrawn from study 
Further cycle of bevacizumab+ irinotecan+ temozolomide if 
eligible for >1 cycle** 
Observation for toxicities for up to 42 days; extent of 
disease evaluation 15-35 days after cycle2 
Significant toxicities or progression of 
disease * 
Discontinue treatment; pt 
withdrawn from study 
No significant toxicities* and no progression of disease  
Further cycles of bevacizumab+ irinotecan+ temozolomide up 
to a maximum of 2 years if eligible for >1 cycle** 
Figure 3: Algorithm for continuing treatment. * Significant toxicities requiring discontinuation of 
therapy are defined in Section 13.0. **Eligibility for >1cycle is defined in Section 9.8 

 
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10.0 EVALUATION DURING TREATMENT/INTERVENTION 
The following evaluations will be carried out during treatment: 
 
Table 7: Evaluations during treatment 
Evaluation 
Timing 
A. Pretreatment evaluation 
 
Clinical history and exam including blood pressure 
Within 6 weeks of enrollment 
CBC 
Urine testing for proteinuria 
Clinical chemistry (including serum sodium, potassium, 
chloride, bicarbonate,  calcium) 
Liver function tests including ALT, AST and serum 
bilirubin 
Renal function tests including BUN and serum creatinine 
Tests for disease evaluation possibly including BM, MIBG, 
Bone scan, PET scan CT/MRI and/or LDH 
CT or MRI of head 
Echocardiogram 
Serum Beta-HCG in females of child-bearing age; 
BM testing for quantifying residual disease by RT-PCR 
(research studies) 
B. Evaluations while on treatment 
 
Clinical exam including blood pressure 
Weekly 
CBC 
Weekly  
Serum electrolytes, BUN, creatinine, ALT, total bilirubin, 
AST 
Weekly 
Urine protein to creatinine ratio 
Every four weeks while on study 
X-ray knee 
At end of therapy  
Tests for disease evaluation possibly including BM, MIBG, 
Bone scan, PET scan CT/MRI and/or LDH 
After two cycles of  therapy and then 
after every two cycles until a 
maximum of two years 
BM studies for minimal residual disease evaluation by RT-
PCR 
At times of BM testing as above 
C. Evaluations after protocol treatment is completed  
Xray knee 
Once three to six months after therapy 
Tests for disease evaluation 
As indicated 
11.0 
TOXICITIES/SIDE EFFECTS 
This combination has not been previously administered to children and there are limited data on 
the use of bevacizumab in children. Toxicities are graded using the NCI Scale CTCAE (Version 
4.0).  
 
11.1 
 Toxicities associated with irinotecan  
 

 
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Common/expected: Diarrhea that may lead to dehydration, abdominal cramping, nausea and 
vomiting, anorexia, sweating and flushing, alopecia, asthenia, myelosuppression, lacrimation nd 
diaphoresis as part of a cholinergically mediated syndrome 
 
Rare: interstitial lung disease, nephrotoxicity, hepatotoxicity, mucositis, colitis,gastrointestinal 
bleeding, local irritation at infusion sites.   
 
11.2 
Toxicities associated with temozolomide 
 
Common/expected: Nausea, vomiting, anorexia, headache, constipation, fatigue, 
myelosuppression 
Rare: seizures, opportunistic infection, secondary malignancy, hepatotoxicity, hepatic failure, 
rash, constipation, diarrhea, and mucositis. 
 
11.3 Toxicities associated with bevacizumab 
Bevacizumab toxicities are described in detail in Section 3.8 and summarized in Table 8 below. 
Acute toxicities reported with bevacizumab are those expected with administration of a 
humanized monoclonal antibody and include headache, fever, fatigue, nausea, vomiting, 
arthralgia and rash.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 8: Bevacizumab toxicities 
Likely 
(>20% Frequency) 
Less Likely 
(≤ 20%) 
Rare 
(<3% Frequency) 

 
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reproductive system and 
breast disorders - other 
(ovarian failure)j; 
hypertension 
anemia, febrile neutropenia; 
supraventricular tachycardia; 
vertigo; abdominal pain, colitis, 
constipation, diarrhea, dyspepsia, 
gastrointestinal hemorrhageb, 
gastrointestinal obstructionc, ileus; 
mucositis oral, nausea, vomiting; 
fatigue, infusion related reaction, 
non-cardiac chest pain, pain; 
allergic reaction; infectionf, 
infection and infestations- 
other(peri-rectal abscess); wound 
dehiscence; alanine 
aminotransferase increased, 
alkaline phosphatase increased, 
aspartate aminotransferase 
increased, blood bilirubin 
increased, cardiac troponin I 
increased, neutrophil count 
decreased, weight loss, white 
blood cell decreased; anorexia; 
arthralgia, musculoskeletal and 
connective tissue-disorder-other 
(bone metaphyseal dysplasia)g, 
myalgia, osteonecrosis of jawh; 
dizziness, headache, peripheral 
sensory neuropathyi, syncope; 
hematuria, proteinuria; vaginal 
hemorrhage; allergic rhinitis, 
cough, dyspnea, epistaxis, 
hoarseness; pruritus, rash maculo-
papular, urticaria; 
thromboembolic event 
blood and lymphatic system 
disorders - other (renal 
thrombotic microangiopathy); 
acute coronary syndrome, heart 
failure, left ventricular systolic 
dysfunction, myocardial 
infarction, ventricular 
arrhythmia, ventricular 
fibrillation; gastrointestinal 
fistulaa, gastrointestinal 
perforationd, gastrointestinal 
ulcere; anaphylaxis; 
gastrointestinal anastomotic 
leak; intracranial hemorrhage, 
ischemia cerebrovascular, 
reversible posterior 
leukoencephalopathy syndrome; 
acute kidney injury, renal and 
urinary disorders- 
other(nephrotic syndrome), 
urinary fistula; vaginal fistula; 
bronchopleural fistula, 
bronchopulmonary hemorrhage, 
respiratory, thoracic and 
mediastinal disorders - other 
(nasal-septal perforation), 
respiratory, thoracic and 
mediastinal disorders - Other 
(tracheo-esophageal fistula); 
vascular disorders - Other 
(arterial thromboembolic event)k  
 
a Gastrointestinal fistula may include: Anal fistula, Colonic fistula, Duodenal fistula, Esophageal fistula, Gastric 
fistula, Gastrointestinal fistula, Rectal fistula, and other sites under the GASTROINTESTINAL DISORDERS SOC. 
 
b Gastrointestinal hemorrhage may include:  Colonic hemorrhage, Duodenal hemorrhage, Esophageal hemorrhage, 
Esophageal varices hemorrhage, Gastric hemorrhage, Hemorrhoidal hemorrhage, Intra-abdominal hemorrhage, Oral 
hemorrhage, Rectal hemorrhage, and other sites under the GASTROINTESTINAL DISORDERS SOC. 
 
cGastrointestinal obstruction may include:  Colonic obstruction, Duodenal obstruction, Esophageal obstruction, Ileal 
obstruction, Jejunal obstruction, Rectal obstruction, Small intestinal obstruction, and other sites under the 
GASTROINTESTINAL DISORDERS SOC. 
 

 
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dGastrointestinal perforation may include:  Colonic perforation, Duodenal perforation, Esophageal perforation, 
Gastric perforation, Jejunal perforation, Rectal perforation, Small intestinal perforation, and other sites under the 
GASTROINTESTINAL DISORDERS SOC. 
 
eGastrointestinal ulcer may include:  Duodenal ulcer, Esophageal ulcer, Gastric ulcer, and other sites under the 
GASTROINTESTINAL DISORDERS SOC. 
 
fInfection may include any of the 75 infection sites under the INFECTIONS AND INFESTATIONS SOC. 
 
gMetaphyseal dysplasia was observed in young patients who still have active epiphyseal growth plates. 
 
hCases of osteonecrosis of the jaw (ONJ) have been reported in cancer patients in association with bevacizumab 
treatment, the majority of whom had received prior or concomitant treatment with i.v. bisphosphonates. 
 
iIncreased rate of peripheral sensory neuropathy has been observed in trials combining bevacizumab and 
chemotherapy compared to chemotherapy alone.  
jOvarian failure, defined as amenorrhea lasting 3 or more months with follicle-stimulating hormone (FSH) elevation 
(≥30 mIU/mL), was increased in patients receiving adjuvant bevacizumab plus mFOLFOX compared to mFOLFOX 
alone (34% vs. 2%).  After discontinuation of bevacizumab, resumption of menses and an FSH level <30 mIU/mL 
was demonstrated in 22% (7/32) of these women.  Long term effects of bevacizumab exposure on fertility are 
unknown. 
kArterial thromboembolic event includes visceral arterial ischemia, peripheral arterial ischemia, heart attack, and 
stroke. 
 
Also reported on Bevacizumab (rhuMAb VEGF) trials but with the relationship to Bevacizumab 
(rhuMAb VEGF) still undetermined: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other 
(idiopathic thrombocytopenia purpura); Disseminated intravascular coagulation 
CARDIAC DISORDERS - Pericardial effusion 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Gait disturbance; 
Sudden death NOS 
HEPATOBILIARY DISORDERS - Hepatic failure 
INFECTIONS AND INFESTATIONS - Infections and infestations - Other (aseptic meningitis) 
INVESTIGATIONS - Platelet count decreased 
METABOLISM AND NUTRITION DISORDERS - Hyponatremia 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Musculoskeletal and 
connective tissue disorder - Other (aseptic necrotic bone); Musculoskeletal and connective tissue disorder 
- Other (myasthenia gravis) 
NERVOUS SYSTEM DISORDERS - Dysgeusia; Peripheral motor neuropathy; Seizure 
PSYCHIATRIC DISORDERS - Confusion 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Adult respiratory distress 
syndrome; Pneumonitis; Pneumothorax; Pulmonary hypertension 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Palmar-plantar erythrodysesthesia syndrome; 
Skin ulceration 
Note: Bevacizumab (rhuMAb VEGF) in combination with other agents could cause an exacerbation of 
any adverse event currently known to be caused by the other agent, or the combination may result in 
events never previously associated with either agent. 

 
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11.4 Management of toxicity associated with bevacizumab.  
There are no reductions in the bevacizumab dose.  Dose management of bevacizumab due to 
adverse events is described in Table 9, section 11.5. 
Any toxicities associated or possibly associated with bevacizumab treatment should be managed 
according to standard medical practice. Discontinuation of bevacizumab will have no immediate 
therapeutic effect. Bevacizumab has a terminal half-life of 21 days; therefore, its discontinuation 
results in slow elimination over several months. There is no available antidote for bevacizumab.  
Infusion Reaction: Emergency support for possible anaphylaxis will be available.  Infusion of 
bevacizumab should be interrupted for subjects who develop dyspnea or clinically significant 
hypotension. Subjects who experience a NCI CTCAE v. 4.0 Grade 3 or 4 allergic reaction will 
be discontinued from treatment.  The infusion should be slowed to 50% or less or interrupted for 
subjects who experience any infusion-associated symptoms not specified above. When the 
subject’s symptoms have completely resolved, the infusion may be continued at no more than 
50% of the rate prior to the reaction and increased in 50% increments every 30 minutes if well 
tolerated. Infusions may be restarted at the full rate during the next cycle. Adverse events 
requiring delays or permanent discontinuation of bevacizumab are listed in Table 10.  Regardless 
of the reason for holding study drug treatment, the maximum allowable length of treatment 
interruption is 2 months. 
 
11.5 All serious adverse events will be reported to the Institutional Review Board of MSKCC, 
FDA, Genentech Drug Safety. 
 
 
Table 9: Bevacizumab Dose Management Due to Adverse Events 
 
Event 
Action to be Taken 
Allergic reaction 
 
Grade1/2 
No modifications 
Grade 3/4 
Discontinue bevacizumab; patient withdraws from study 
Hypertension 
 
Grade 1/2 events 
No modifications 
Grade 3 
If not controlled to age-appropriate levels with 
medication, discontinue bevacizumab 
Grade 4 
Discontinue bevacizumab; patient withdraws from study 
Hemorrhage 
 
CNS hemorrhage (any grade) 
Discontinue bevacizumab; patient withdraws from study 
Grade ≥ 2 pulmonary  hemorrhage 
Discontinue bevacizumab; patient withdraws from study 
Grade 1 pulmonary or ≥ grade 2 non 
pulmonary hemorrhage 
No dose modifications 
≥ Grade 3 non-pulmonary, non-CNS 
hemorrhage 
Discontinue bevacizumab; patient withdraws from study 
Venous Thrombosis 
 

 
Memorial Sloan-Kettering Cancer Center 
IRB Protocol 
IRB:# 10-015 A(8) 
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Grade 1/2 
No dose modifications 
Grade 3/4 
Discontinue bevacizumab; patient withdraws from study 
Arterial Thromboembolic event  
(Angina, myocardial infarction, 
transient ischemic attack, 
cerebrovascular accident, and any 
other arterial thromboembolic event) 
Any grade 
Discontinue bevacizumab; patient withdraws from study 
Congestive Heart Failure (Left 
ventricular systolic dysfunction) 
 
1/2 events 
No dose modifications  
Grade 3/4 
Discontinue bevacizumab; patient withdraws from study 
Proteinuria 
 
Grade 1/2  
No dose modifications 
Grade 3 
(UPC> 3.5, urine collection > 3.5 
g/24 hr, or dipstick 4+)   
 
Hold bevacizumab treatment until ≤ Grade 2, as 
determined by either UPC ratio ≤ 3.5 or 24 hr collection 
≤ 3.5 g 
 
Grade 4 (nephrotic syndrome) 
Discontinue bevacizumab; patient withdraws from study 
Bowel Obstruction 
 
Grade 1 
Continue patient on study for partial obstruction NOT 
requiring medical intervention. 
Grade 2 
Hold bevacizumab for partial obstruction requiring 
medical intervention.  Patient may restart upon complete 
resolution. 
Grade 3/4 
Hold bevacizumab for complete obstruction.  If surgery 
is necessary, patient may restart bevacizumab after full 
recovery from surgery, and at investigator’s discretion. 
Fistula 
 
TE fistula any grade 
Discontinue bevacizumab; patient withdraws from study 
Grade 4 fistula 
Discontinue bevacizumab; patient withdraws from study 
Wound dehiscence requiring medical 
or surgical therapy 
Discontinue bevacizumab; patient withdraws from study 
Reversible Posterior 
Leukoencephalopathy confirmed 
by MRI any grade 
Discontinue bevacizumab; patient withdraws from study 
Other Unspecified Bevacizumab-
Related Adverse Events 
 
Grade 3 
Hold bevacizumab until recovery to ≤ Grade 1 
Grade 4 
Discontinue bevacizumab. 
 
 

 
Memorial Sloan-Kettering Cancer Center 
IRB Protocol 
IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
12.0 
CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT 
12.1 Response duration is calculated from the first day of treatment with bevacizumab. 
 
12.2  Patients developing progressive disease will be considered a treatment failure under this 
protocol. 
 
 
12.3 Therapeutic response in patients with NB will be assessed using the International 
Neuroblastoma Response Criteria94 which are shown below.  
  
International Neuroblastoma Response Criteria:    
• Complete remission/response:  Complete disappearance of all evidence of disease.  
• Very good partial remission/response:  >90% decrease in volume of primary tumor 
and in all other markers of disease, except bone scan (if initially abnormal) stable or 
improved; BM must be free of disease 
• Partial remission/response:  50 to 90% decrease in measurable, and no new, lesions, 
except bone scan stable or improved (if initially abnormal).  Bones and BM: no more 
than 1 positive BM site allowed. 
• Mixed response (MR):  No new lesions; >50% reduction of any measurable lesion 
(primary or metastases) with <50% reduction in any other; <25% increase in any 
existing lesion. 
• No response (NR; stable disease):  <50% reduction in all tumor markers; no new 
lesions; <25% increase in any existing lesion. 
• Progressive disease (PD):  Any new lesion; increase of any measurable lesion by 
>25%; previous negative marrow positive for tumor. 
 
13.0 
CRITERIA FOR REMOVAL FROM STUDY 
Patients will come off study at any time if disease progression is observed. If patients are 
removed from study, further patients will not be added as replacements. 
 
13.1Patients will be withdrawn from study if the following toxicities occur: 
  
13.1.1 If at any time the patient develops life-threatening grade 4 toxicity, other than 
myelosuppression, clearly attributable to irinotecan, temozolomide or bevacizumab, 
he/she will be removed from study. 
 
 If the patient develops any grade of the following toxicities, the patients 
will be removed from study:  
 wound dehiscence requiring medical or surgical intervention,  
 arterial thromboembolic event,  
 GI perforation,  
 CNS hemorrhage,  
 reversible posterior encephalopathy (confirmed by MRI)  
 tracheo-esophageal fistula. 

 
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IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
 ≥Grade 3 allergic reaction,  
 ≥Grade 3 hypertension,  
 ≥Grade 3 venous thromboembolism  
 > grade 1 pulmonary hemorrhage 
 nephrotic syndrome 
 >grade 2 congestive cardiac failure.  
 grade ≥ 3 bowel obstruction that has not fully recovered despite 
medical or surgical intervention 
 ANC<500/uL and/or platelet count <20,000/uL on day 43 of treatment 
 
13.2 Patients who are removed from the study due to adverse events will be treated and followed 
according to established, accepted medical practice. Patients who have an ongoing 
bevacizumab-related Grade 4 or serious adverse event at the time of discontinuation from 
study treatment will continue to be followed until resolution of the event or until the event is 
considered irreversible. All pertinent information concerning the outcome of such treatment 
will be entered in the Case Report Form or on the Serious Event Report, as applicable. 
 
 
13.3 If at any time the patient is found to be ineligible for the protocol as designated in the 
section on Criteria for Patient/Subject Eligibility (i.e., a change in diagnosis), the patient will 
be removed from the study  
 
13.4 Withdrawal of consent. The patient’s desire to withdraw from the study may occur at any 
time. The investigator should carefully consider whether the patient’s withdrawal of consent is 
due to an adverse event, and if so, record the adverse event as the reason for withdrawal. 
 
13.5 If at any time the patient is non-compliant with therapy or requests withdrawal from the 
study, he/she will be removed from study. 
 
13.6 If at any time, the principal investigator determines that it is no longer safe for the subject to 
continue therapy, the subject will be removed from study 
 
 
14.0 
BIOSTATISTICS 
This is a phase II study of the combination of irinotecan, temozolomide and bevacizumab in 
patients with resistant NB. The primary endpoint is response rate (CR+PR) by INSS response 
criteria. The secondary endpoints are toxicity, time to progression, and post-treatment angiogenic 
markers. 
 
14.1 Study Design and Sample Size 
 
The Simon’s optimal two-stage design will be used for this phase II study. The primary endpoint 
is response rate (CR+PR) by INSS response criteria. Response assessment will be based on the 
best response over the course of four cycles. The undesirable response rate is set at 20% based on 

 
Memorial Sloan-Kettering Cancer Center 
IRB Protocol 
IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
prior studies. The desirable response rate is set at 35%. The type I error is set at 10%, and type II 
error at 10%. In the first stage 27 patients will be enrolled: if response (CR+PR) is observed in 
≤5 patients, the combination of irinotecan, temozolomide and bevacizumab will be considered 
ineffective and the study will be stopped. If response (CR+PR) is observed in ≥6 patients, the 
study will continue to the next stage and an additional 34 patients will be enrolled. The 
combination will be considered effective if ≥17/63 patients show response. If disease progresses 
in patients prior to their completing four cycles, treatment will be considered to have failed. Such 
patients will not be replaced on study. 
 
 
14.2 Stopping Rules for Toxicity 
 
Since the combination of irinotecan, temozolomide and bevacizumab has not been previously 
used in children, we have inserted early stopping rules to avoid undue toxicity. Toxicity will be 
graded using CTC version 4.0. 
 
 In our previous reports, grade 4 myelosuppression and grade 3 diarrhea were expected 
complications of treatment with irinotecan and temozolomide. 1/49 patients also developed grade 
3 hepatic transaminitis. In our previous experience with the combination of irinotecan and 
temozolomide, we were able to administer successive cycles 3-5 weeks apart even in heavily 
pretreated patients with pre treatment platelet counts <35,000/uL.  
 
In order to reduce patient risk, the study design includes early stopping during the first cycle of 
treatment in the event of excessive (1) grade 4 diarrhea, or (2) severe myelosuppression defined 
as failure to reach ANC ≥500/uL and/or platelet count >20,000 by day 43 (day 1 is defined as 
each cycle), (3) grade 3 or 4 toxicity (other than myelosuppression, infection secondary to 
myelosuppression or diarrhea) clearly related to the combination of irinotecan, temozolomide 
and bevacizumab. The stopping rules for excessive toxicity and the corresponding power 
calculations are given in the table below. 
 
Table 10: Stopping Rules 
Toxicity Type 
Number of toxicities needed 
to stop the study 
Probability of 
toxicity type 
Probability of early 
study stopping 
Grade 4 diarrhea 
4 within the first 12 patients 
6 within the first 27 patients 
8 within the first 44 patients 
11 within 63 patients 
0.1 
0.11 
0.2 
0.80 
Severe 
myelosuppression 
4 within the first 12 patients 
6 within the first 27 patients 
8 within the first 44 patients 
11 within 63 patients 
0.1 
0.11 
0.2 
0.80 

 
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IRB Protocol 
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Amended: 04/04/14 
 
Other grade 3 or 
4 toxicity 
4 within the first 12 patients 
6 within the first 27 patients 
8 within the first 44 patients 
11 within 63 patients 
0.1 
0.11 
0.2 
0.80 
 
 
14.3 Patient Accrual 
 
Review of accrual patterns from previous neuroblastoma studies indicates that 1-2 patients per 
month may be accrued.  This will permit completion of the first phase of the study in 
approximately two years.  If the study proceeds to the second phase, it is anticipated that an 
additional four years will be required to complete the entire study. 
 
14.4 Analysis Plan 
Overall response rate (CR+PR) will be calculated and its 90% confidence interval provided. 
Toxicity events will be listed. Time to progression will be estimated using the Kaplan-Meier 
curve. The 95% confidence interval will be provided for 3-year time to progression. Angiogenic 
profile will be assessed by measuring plasma VEGF, HIF1 alpha and PIGF levels, and circulating 
CD133 positive cells in the blood, before and after treatment with bevacizumab. The average 
before vs. after treatment change will be estimated for each angiogenic marker and will be 
evaluated using the Wilcoxon signed rank test. The analysis of correlative markers will only be 
embarked upon if the study proceeds to the second stage. 
 
Patients will be included for toxicity assessment as long as they have received one dose of 
bevacizumab. Patients will be evaluable for response if they have received at least two doses of 
bevacizumab and 5 doses each of irinotecan and temozolomide. If patients receive only one 
cycle of therapy, response evaluation will be carried out prior to their coming off study. Patients 
who do not complete at least one cycle of therapy and therefore not evaluable for response will 
be replaced on study. 
 
15.0 
SUBJECT REGISTRATION AND RANDOMIZATION PROCEDURES 
 
15.1   Research Participant Registration 
 
Confirm eligibility as defined in the section entitled Criteria for Patient/Subject 
Eligibility. 
 
Obtain informed consent, by following procedures defined in section entitled Informed 
Consent Procedures. 
 
During the registration process registering individuals will be required to complete a 
protocol specific Eligibility Checklist. 
 

 
Memorial Sloan-Kettering Cancer Center 
IRB Protocol 
IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
All participants must be registered through the Protocol Participant Registration (PPR) 
Office at Memorial Sloan-Kettering Cancer Center. PPR is available Monday through 
Friday from 8:30am – 5:30pm at 646-735-8000. Registrations must be submitted via the 
PPR Electronic Registration System (http://ppr/).  The completed signature page of the 
written consent/RA, a completed Eligibility Checklist and other relevant documents must 
be uploaded via the PPR Electronic Registration System. 
 
 
16.0 
DATA  MANAGEMENT ISSUES 
A Research Study Assistant (RSA) will be assigned to the study.  The responsibilities of 
the RSA include project compliance, data collection, abstraction and entry, data 
reporting, regulatory monitoring, problem resolution and prioritization, and coordinate 
the activities of the protocol study team. The data collected for this study will be entered 
into a secure database. Source documentation will be available to support the 
computerized patient record. 
 
16.1 
Quality Assurance 
Weekly registration reports will be generated to monitor patient accruals and 
completeness of registration data.  Routine data quality reports will be generated to assess 
missing data and inconsistencies.  Accrual rates and extext and accuracy of evaluations 
and follow-up will be monitored periodically throughout the study period and potential 
problems will be brought to the attention of the study team for discussion and action 
 
Random-sample data quality and protocol compliance audits will be conducted by the 
study team, at a minimum of  two times per year, more frequently if indicated. 
 
16.2 
Data and Safety Monitoring 
The Data and Safety Monitoring (DSM) Plans at Memorial Sloan-Kettering Cancer Center 
were approved by the National Cancer Institute in September 2001.  The plans address the 
new policies set forth by the NCI in the document entitled “Policy of the National Cancer 
Institute for Data and Safety Monitoring of Clinical Trials” which can be found at:  
http://cancertrials.nci.nih.gov/researchers/dsm/index.html.   The DSM Plans at MSKCC were 
established and are monitored by the Office of Clinical Research.  The MSKCC Data and 
Safety Monitoring Plans can be found on the MSKCC Intranet at: 
http://mskweb2.mskcc.org/irb/index.htm 
 
There are several different mechanisms by which clinical trials are monitored for data, safety 
and quality.  There are institutional processes in place for quality assurance (e.g., protocol 
monitoring, compliance and data verification audits, therapeutic response, and staff education 
on clinical research QA) and departmental procedures for quality control,  plus there are two 
institutional committees that are responsible for monitoring the activities of our clinical trials 
programs.  The committees: Data and Safety Monitoring Committee (DSMC) for Phase I and 
II clinical trials, and the Data and Safety Monitoring Board (DSMB) for Phase III clinical 
trials,  report to the Center’s Research Council and Institutional Review Board.   

 
Memorial Sloan-Kettering Cancer Center 
IRB Protocol 
IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
 
During the protocol development and review process, each protocol will be assessed for it’s 
level of risk and degree of monitoring required.  Every type of protocol (e.g., NIH sponsored, 
in-house sponsored, industrial sponsored, NCI cooperative group, etc.) Will be addressed and 
the monitoring procedures will be established at the time of protocol activation 
 
17.0 
PROTECTION OF HUMAN SUBJECTS 
The investigator agrees to conduct this study in accordance with the International Conference 
on Harmonization (ICH) principles of Good Clinical Practice and with the Declaration of 
Helsinki (1989).  The investigator will conduct all aspects of this study in accordance with all 
national, state, and local laws of the applicable regulatory agencies. 
 
Most patients will be children, adolescents, and young adults because of the nature of these 
tumors.  Patients of both sexes and all ethnic backgrounds are eligible for this study.  
Alternative treatments are available and will be discussed with patient or legal guardian.  
Patients are responsible for the costs of physician visits and usual laboratory tests, 
hospitalizations, and outpatient care.  If there is an injury as a result of this research study, 
emergency care, hospitalization, and outpatient care will be made available by Memorial 
Hospital and billed to the patient as part of the medical expenses.  No money will be provided 
by Memorial Hospital as compensation for research-related injury.   
 
Patients will not be billed for bevacizumab, but as part of standard care for this medical 
condition, the patient will be charged for: 
• 
any needed hospitalization 
• 
doctor’s care 
• 
any other drugs (including irinotecan and temozolomide) besides bevacizumab 
needed for treatment. 
• 
laboratory tests 
• 
radiographic studies 
• 
clinic visits 
 
17.1  Privacy 
 
MSKCC’s Privacy Office may allow the use and disclosure of protected health information 
pursuant to a completed and signed Research Authorization form.  The use and disclosure of 
protected health information will be limited to the individuals described in the Research 
Authorization form.  A Research Authorization form must be completed by the Principal 
Investigator and approved by the IRB and Privacy Board. 
 
17.2 Serious Adverse Event (SAE) Reporting 
 

 
Memorial Sloan-Kettering Cancer Center 
IRB Protocol 
IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
Any SAE must be reported to the IRB/PB as soon as possible but no later than 5 calendar 
days. The IRB/PB requires a Clinical Research Database (CRDB) SAE report be submitted 
electronically to the SAE Office at sae@mskcc.org  containing the following information: 
Fields populated from the CRDB: 
• Subject’s name (generate the report with only initials if it will be sent outside of  
 
MSKCC) 
• Medical record number 
• Disease/histology (if applicable) 
• Protocol number and title 
 
Data needing to be entered: 
• The date the adverse event occurred 
• The adverse event 
• Relationship of the adverse event to the treatment (drug, device, or intervention) 
• If the AE was expected 
• The severity of the AE 
• The intervention 
• Detailed text that includes the following information: 
o A explanation of how the AE was handled 
o A description of the subject's condition 
o Indication if the subject remains on the study 
o If an amendment will need to be made to the protocol and/or consent form 
 
The PI’s signature and the date it was signed are required on the completed report. 
All SAE reports must also be forwarded as soon as possible to: 
 
Genentech Drug Safety  
Fax: 
(650) 225-4682 or (650) 225-4683 
 
Occasionally Genentech may contact the reporter for additional information, clarification, or 
current status of the subject for whom and adverse event was reported.  
 
17.2.1  Genentech Adverse Event Reporting Definitions 
 
In the event of an adverse event the first concern will be for the safety of the subject. 
A SAE is any sign, symptom or medical condition that emerges during treatment or during a 
post-treatment follow-up period that (1) was not present at the start of treatment and is not a 
chronic condition that is part of the patient’s medical history, OR (2) was present at the start 
of treatment or as part of the patient’s medical history but worsened in severity and/or 
frequency during therapy, AND that meets any of the following regulatory serious criteria: 
 
• Results in death  

 
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IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
• Is life-threatening  
• Requires or prolongs inpatient hospitalization (except hospitalization required as part of 
radiation safety precautions) 
• Is disabling  
• Is a congenital anomaly/birth defect  
• Is medically significant or requires medical or surgical intervention to prevent one of the 
outcomes listed above. 
•  Is grade 3 or 4 toxicity excluding myelosuppression. 
 
Assessing Causality: 
 
Investigators are required to assess whether there is a reasonable possibility that bevacizumab 
and/or irinotecan and/or temozolomide caused or contributed to an adverse event.  The following 
general guidance may be used. 
Yes: 
if the temporal relationship of the clinical event to bevacizumab and/or irinotecan and/or 
temozolomide administration makes a causal relationship possible, and other drugs, therapeutic 
interventions or underlying conditions do not provide a sufficient explanation for the observed 
event. 
 
No: 
if the temporal relationship of the clinical event to bevacizumab and/or irinotecan and/or 
temozolomide administration makes a causal relationship unlikely, or other drugs, therapeutic 
interventions or underlying conditions provide a sufficient explanation for the observed event. 
 
17.3 Safety Reporting Requirements for IND Exempt Studies 
For investigator sponsored IND exempt studies, there are reporting requirements for the FDA in 
accordance with guidance set forth in 21 CFD 314.80 
 
Postmarketing 15 -Day Alert Report   
The Sponsor-Investigator is also required to notify the FDA of any fatal or life-threatening 
adverse event that is unexpected and assessed by the investigator to be possibly related to the use 
of bevacizumab.  An unexpected adverse event is one that is not already described in the 
Investigator Brochure. Such reports are to be submitted to the FDA at the following address: 
Central Document Room, 12229 Wilkins Avenue, Rockville, MD 20852. 
 
 
 
All Post-marketing 15-Day alert Reports submitted to the FDA by the Sponsor-Investigator must 
also be faxed to: Genentech Drug Safety  
 
Fax: 
(650) 225-4682 or (650) 225-4683  
 
For questions related to safety reporting bevacizumab, contact: 
 

 
Memorial Sloan-Kettering Cancer Center 
IRB Protocol 
IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
Genentech Drug Safety 
Tel: 
1-888-835-2555 
         or 
Fax: 
(650) 225-4682 or (650) 225-4683 
 
18.0 
INFORMED CONSENT PROCEDURES 
 
Before protocol-specified procedures are carried out, consenting professionals will 
explain full details of the protocol and study procedures as well as the risks involved to 
participants prior to their inclusion in the study. Participants will also be informed that 
they are free to withdraw from the study at any time. All participants must sign an 
IRB/PB-approved consent form indicating their consent to participate. This consent form 
meets the requirements of the Code of Federal Regulations and the Institutional Review 
Board/Privacy Board of this Center. The consent form will include the following:  
 
1. The nature and objectives, potential risks and benefits of the intended study.  
2. The length of study and the likely follow-up required. 
3. Alternatives to the proposed study. (This will include available standard and 
investigational therapies. In addition, patients will be offered an option of 
supportive care for therapeutic studies.) 
4. The name of the investigator(s) responsible for the protocol. 
5. The right of the participant to accept or refuse study interventions/interactions and 
to withdraw from participation at any time.  
Before any protocol-specific procedures can be carried out, the consenting professional 
will fully explain the aspects of patient privacy concerning research specific information.  
In addition to signing the IRB Informed Consent, all patients must agree to the Research 
Authorization component of the informed consent form. 
Each participant and consenting professional will sign the consent form. The participant 
must receive a copy of the signed informed consent form. 
 

 
Memorial Sloan-Kettering Cancer Center 
IRB Protocol 
IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
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adolescents and adults: The Memorial Sloan-Kettering experience. Med Pediatr Oncol 2003:in 
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2. 
Kushner BH, LaQuaglia MP, Bonilla MA, et al. Highly effective induction therapy for 
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Franks LM, Bollen A, Seeger RC, Stram DO, Matthay KK. Neuroblastoma in adults and 
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Villablanca JG, Khan AA, Avramis VI, et al. Phase I trial of 13-cis-retinoic acid in 
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Matthay KK, Villablanca JG, Seeger RC, et al. Treatment of high-risk neuroblastoma 
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Lau L, Tai D, Weitzman S, Grant R, Baruchel S, Malkin D. Factors influencing survival 
in children with recurrent neuroblastoma. J Pediatr Hematol Oncol 2004;26:227-32. 
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Castel V, Canete A, Melero C, et al. Results of the cooperative protocol (N-III-95) for 
metastatic relapses and refractory neuroblastoma. Med Pediatr Oncol 2000;35:724-6. 
8. 
Kushner BH, Kramer K, Modak S, Cheung NK. Camptothecin analogs (irinotecan or 
topotecan) plus high-dose cyclophosphamide as preparative regimens for antibody-based 
immunotherapy in resistant neuroblastoma. Clin Cancer Res 2004;10:84-7. 
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Saylors RL, 3rd, Stewart CF, Zamboni WC, et al. Phase I study of topotecan in 
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Kushner BH, Kramer K, Cheung NKV. Phase II trial of the anti-G(D2) monoclonal 
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Matthay KK, Yanik G, Messina J, et al. Phase II study on the effect of disease sites, age, 
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Cheung NK, Kushner BH, LaQuaglia M, et al. N7: a novel multi-modality therapy of 
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Kushner BH, Kramer K, Modak S, Cheung NK. Irinotecan plus temozolomide for 
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Rodriguez-Galindo C, Crews KR, Stewart CF, et al. Phase I study of the combination of 
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Thompson J, Zamboni WC, Cheshire PJ, et al. Efficacy of oral irinotecan against 
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Vassal G, Terrier-Lacombe MJ, Bissery MC, et al. Therapeutic activity of CPT-11, a 
DNA-topoisomerase I inhibitor, against peripheral primitive neuroectodermal tumour and 
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Memorial Sloan-Kettering Cancer Center 
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IRB:# 10-015 A(8) 
Amended: 04/04/14 
 
17. 
Blaney S, Berg SL, Pratt C, et al. A phase I study of irinotecan in pediatric patients: a 
pediatric oncology group study. Clin Cancer Res 2001;7:32-7. 
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Mugishima H, Matsunaga T, Yagi K, et al. Phase I study of irinotecan in pediatric 
patients with malignant solid tumors. J Pediatr Hematol Oncol 2002;24:94-100. 
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Vassal G, Doz F, Frappaz D, et al. A phase I study of irinotecan as a 3-week schedule in 
children with refractory or recurrent solid tumors. J Clin Oncol 2003;21:3844-52. 
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Bomgaars LR, Bernstein M, Krailo M, et al. Phase II trial of irinotecan in children with 
refractory solid tumors: a Children's Oncology Group Study. J Clin Oncol 2007;25:4622-7. 
21. 
Vassal G, Giammarile F, Brooks M, et al. A phase II study of irinotecan in children with 
relapsed or refractory neuroblastoma: a European cooperation of the Societe Francaise 
d'Oncologie Pediatrique (SFOP) and the United Kingdom Children Cancer Study Group 
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22. 
Kushner BH, Kramer K, Modak S, Cheung NK. Five-day courses of irinotecan as 
palliative therapy for patients with neuroblastoma. Cancer 2005;103:858-62. 
23. 
Middlemas DS, Stewart CF, Kirstein MN, et al. Biochemical correlates of temozolomide 
sensitivity in pediatric solid tumor xenograft models. Clin Cancer Res 2000;6:998-1007. 
24. 
Rubie H, Chisholm J, Defachelles AS, et al. Phase II study of temozolomide in relapsed 
or refractory high-risk neuroblastoma: a joint Societe Francaise des Cancers de l'Enfant and 
United Kingdom Children Cancer Study Group-New Agents Group Study. J Clin Oncol 
2006;24:5259-64. 
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