Phase I/II Study of T-DM1 Alone Versus T-DM1 and Metronomic Temozolomide in Secondary Prevention of HER2-Positive Breast Cancer Brain Metastases Following Stereotactic Radiosurgery
Phase: PHASE1
Conditions: Breast Cancer, Brain Metastasis, Brain Cancer
Sponsor: National Cancer Institute (NCI)

Abbreviated Title: TMZ in breast ca brain mets
Version Date: 06/06/2022
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Abbreviated Title: TMZ in breast ca brain mets
NIH Protocol: 17-C-0115
Version Date: 06/06/2022
NCT Number:  NCT03190967
Title: Phase I/II Study of T-DM1 alone versus T-DM1 and Metronomic Temozolomide in 
Secondary Prevention of HER2-Positive Breast Cancer Brain Metastases Following 
Stereotactic Radiosurgery
NCI Principal Investigator:
Stanley Lipkowitz, MD, PhD, WMB, CCR, NCI
Women’s Malignancies Branch
National Cancer Institute
Building 10, Rm 4B54
9000 Rockville Pike
Bethesda, MD 20892
Phone: 240-760-6129
E-mail: lipkowis@navmed.nci.nih.gov 
Investigational Agents:  None
Commercial Agents: T-DM1, Temzolomide

Abbreviated Title: TMZ in breast ca brain mets
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PRÉCIS 
Background:

Breast cancer is the most common cancer in women. In the HER2+ subtype, brain 
metastases can occur in up to 25-40% of patients.

The standard therapy for brain metastases continues to be surgery or stereotactic 
radiosurgery (SRS) and/or whole brain radiation therapy (WBRT).

Currently, independently of localized or systemic treatment modality, once brain 
metastases are established, options for treatment are limited, and the disease almost 
invariably progresses, limiting not only survival but also quality of life in most patients.

Preclinical literature suggests the hypothesis that preventing the formation of a metastasis 
by a drug may be more efficacious than attempting to shrink an established lesion.

Our group has shown in vitro and in vivo in animal models injected with a brain tropic 
MGMT+ cell line, that even in very low doses temozolomide (TMZ) administered in a 
prophylactic, metronomic fashion can significantly prevent development of brain 
metastases.

We propose a secondary-prevention clinical trial with oral TMZ given to HER2+ breast 
cancer patients with brain metastases after recent local treatment (SRS or surgical 
resection) in combination with the anti-HER2 agent T-DM1 for systemic control of disease.
Objectives:

Phase I (run in): to identify the maximum tolerated dose (MTD) of TMZ when used in 
combination with T-DM1.

Phase II: to determine if the combination regimen of T-DM1 and temozolomide improves 
the freedom from distant new brain metastases following stereotactic radiosurgery or 
surgical resection in HER2-positive breast cancer brain metastases, as compared to T-DM1 
alone, guided by one-year results as an important benchmark for measuring improvement.
Eligibility:
Phase I:

Histologically confirmed HER2+ breast cancer.

ECOG performance status 0-2 and adequate organ and marrow function.

Brain metastases, treated within 12 weeks of study entry with SRS, resection or WBRT.

Patients with leptomeningeal metastatic disease are ineligible.

Patients that are unable to complete a brain MRI with contrast are ineligible. 

Patients with breast tissue expanders must have those removed before enrollment.

HBV, HCV or HIV-positive patients are ineligible.

Patient with impaired cardiac function or clinically significant cardiac disease are 
ineligible.

Abbreviated Title: TMZ in breast ca brain mets
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
Corticosteroids will be allowed at enrollment and during the first month of treatment with 
T-DM1 after SRS, up to a dose of no more than 10mg of dexamethasone daily or 
equivalent. Patients that need to continue corticosteroids after the initial month will not be 
allowed to increase the dose after that period, and will be taken off protocol.
Phase II:

Histologically confirmed HER2+ breast cancer.

ECOG performance status 0-2 and adequate organ and marrow function.

1-10 brain metastases, by contrast MRI, treated within 12 weeks of study entry with SRS 
and/or resection.

Patients with leptomeningeal metastatic disease are ineligible.

Patients with history of WBRT are ineligible.

Patients that are unable to complete a brain MRI with contrast are ineligible. 

Patients with breast tissue expanders must have those removed before enrollment.

HBV, HCV or HIV-positive patients are ineligible.

Patient with impaired cardiac function or clinically significant cardiac disease are 
ineligible.

Corticosteroids will be allowed at enrollment and during the first month of treatment with 
T-DM1 after SRS, up to a dose of no more than 10mg of dexamethasone daily or 
equivalent. Patients that need to continue corticosteroids after the initial month will not be 
allowed to increase the dose after that period, and will be taken off protocol.
Design:

This is a Phase I/II open label study that will evaluate the potential benefit of TMZ in 
prevention of new brain metastases in patients with limited brain metastases from HER2+ 
breast cancer, previously treated with SRS or surgical resection of brain metastases.  

All patients will receive the standard second-line therapy for HER2+ metastatic breast 
cancer: T-DM1. During phase II patients will be randomized between T-DM1 plus TMZ 
versus T-DM1 alone.  

Phase I run in: T-DM1 3.6 mg/kg IV every 21 days plus TMZ 30, 40 or 50 mg/m2 daily. 

Phase II: T-DM1 3.6 mg/kg versus T-DM1 3.6mg/kg plus TMZ at recommended phase 2 
dose (RP2D).

Phase I will follow a standard 3+3 design. Thus, with 3 dose levels, up to 18 patients may 
be included in the initial safety evaluation.  

In the phase II portion of the trial, a total of 49 evaluable subjects per arm (98 total) will 
need to be randomized over a 3-year period and followed for an additional 2 years from 
the date of entry of the last patient, with occurrence of 79 total relapses in both arms 
combined, in order to have 80% power to compare the curves. 

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TABLE OF CONTENTS 
PRÉCIS............................................................................................................................................2
TABLE OF CONTENTS ................................................................................................................4
STATEMENT OF COMPLIANCE ................................................................................................9
1.
INTRODUCTION ...................................................................................................................9
1.1
Study Objectives............................................................................................................9
1.1.1
Primary Objectives: ...................................................................................................9
1.1.2
Secondary Objective(s):.............................................................................................9
1.1.3
Exploratory Objective(s): ..........................................................................................9
1.2
Background and Rationale ..........................................................................................10
1.2.1
Brain metastasis in HER2 positive breast cancer ....................................................10
1.2.2
Treatment of brain metastases .................................................................................10
1.2.3
Prevention of brain metastases ................................................................................12
1.3
Correlatives Background and Rationale......................................................................17
1.3.1
Cell free DNA (cfDNA) and primary tumor DNA sequencing...............................17
1.3.2
MGMT Status ..........................................................................................................19
1.3.3
Neuroinflammatory response and neuronal damage metrics...................................20
1.3.4
Exosomes.................................................................................................................21
1.3.5
Pharmacokinetics.....................................................................................................21
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT .......................................................21
2.1
Eligibility Criteria........................................................................................................21
2.1.1
Phase 1 Inclusion Criteria........................................................................................21
2.1.2
Phase 1 Exclusion Criteria.......................................................................................22
2.1.3
Phase 2 Inclusion Criteria........................................................................................24
2.1.4
Phase 2 Exclusion Criteria.......................................................................................25
2.1.5
Recruitment Strategies.............................................................................................26
2.2
Screening Evaluation...................................................................................................26
2.2.1
Screening activities performed prior to obtaining informed consent ......................26
2.2.2
Screening activities performed after a consent for screening has been signed........27
2.2.3
Pathology confirmation of diagnosis.......................................................................27
2.2.4
Imaging studies:.......................................................................................................27
2.2.5
Cardiology test: 2-D Echocardiogram or MUGA-scan...........................................27
2.2.6
Anti-HIV, anti-HCV, Hepatitis B Surface Ag.........................................................27
2.2.7
History and Physical examination: ..........................................................................27
2.2.8
Laboratory Studies:..................................................................................................27
2.2.9
Pregnancy Testing: ..................................................................................................27
2.3
Participant Registration and Status Update Procedures ..............................................28
2.3.1
Screen Failures.........................................................................................................28
2.4
Randomization (or Stratification) Procedures.............................................................28
2.5
Baseline Evaluation.....................................................................................................29
2.5.1
Clinical Evaluation: .................................................................................................29
2.5.2
Laboratory Evaluation: ............................................................................................30

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2.5.3
Neurocognitive and quality of life assessment:.......................................................30
2.5.4
Correlative tests evaluation: ....................................................................................30
3
STUDY IMPLEMENTATION .............................................................................................30
3.1
Study Design ...............................................................................................................30
3.1.1
Dose Limiting Toxicity............................................................................................30
3.1.2
Dose Escalation .......................................................................................................31
3.2
Drug Administration....................................................................................................32
3.2.1
T-DM1 .....................................................................................................................32
3.2.2
Temozolomide .........................................................................................................33
3.2.3
Self-Administered Study Drugs...............................................................................33
3.3
Dose Modifications and Management of Toxicities: ..................................................34
3.3.1
T-DM1 Dose Modifications: ...................................................................................34
3.3.2
Temozolomide Dose Modifications ........................................................................36
3.4
Questionnaires.............................................................................................................38
3.5
Study Calendar ............................................................................................................39
3.6
Cost and Compensation...............................................................................................41
3.6.1
Costs ........................................................................................................................41
3.6.2
Compensation ..........................................................................................................41
3.6.3
Reimbursement........................................................................................................41
3.7
Criteria for Removal from Protocol Therapy and Off Study Criteria .........................41
3.7.1
Criteria for removal from protocol therapy .............................................................41
3.7.2
Off-Study Criteria....................................................................................................41
3.7.3
Lost to Follow-up ....................................................................................................42
4
CONCOMITANT MEDICATIONS/MEASURES...............................................................42
4.1
T-DM1.........................................................................................................................42
4.1.1
Drug Interactions .....................................................................................................42
4.2
Temozolomide.............................................................................................................42
4.2.1
Drug Interactions .....................................................................................................42
4.2.2
General.....................................................................................................................42
5
BIOSPECIMEN COLLECTION...........................................................................................43
5.1
Correlative Studies for Research/Pharmacokinetic Studies ........................................43
5.2
Sample Collection .......................................................................................................45
5.2.1
Samples will be coded, linked in the BPC and sent for final analysis to: ...............46
5.2.2
Tumor, Blood Samples and CSF samples: ..............................................................46
5.3
Sample Storage, Tracking and Disposition .................................................................47
5.3.1
Participant sample protections.................................................................................47
5.3.2
Sample Storage, Tracking and Disposition .............................................................47
5.4
Samples for Genetic/Genomic Analysis......................................................................48
5.4.1
Description of the scope of genetic/genomic analysis.............................................48
5.4.2
Privacy and Confidentiality of medical information/biological specimens ............48

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5.4.3
A Certificate of Confidentiality will be obtained for the study as described in 
section 11.5.7.........................................................................................................................49
5.4.4
Management of Results ...........................................................................................49
5.4.5
Genetic counseling...................................................................................................49
6
DATA COLLECTION AND EVALUATION .....................................................................49
6.1
Data Collection............................................................................................................49
6.1.1
Source Documents...................................................................................................50
6.1.2
Case Report Forms ..................................................................................................50
6.1.3
Data Quality Assurance ...........................................................................................50
6.2
Data Sharing Plans ......................................................................................................50
6.2.1
Human Data Sharing Plan .......................................................................................50
6.2.2
Genomic Data Sharing Plan.....................................................................................51
6.3
Response Criteria ........................................................................................................51
6.3.1
RANO-BM Criteria for Evaluation of Brain Lesions..............................................51
6.3.2
RECIST for Systemic Evaluation............................................................................52
6.3.3
Duration of Response ..............................................................................................57
6.3.4
Relapse -Free Survival.............................................................................................58
6.3.5
Validation of Disease Assessment (Safety Mechanisms)........................................58
6.4
Toxicity Criteria ..........................................................................................................58
7
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN.....59
7.1
Definitions...................................................................................................................59
7.2
OHSRP Office of Compliance and Training / IRB  Reporting...................................59
7.2.1
Expedited Reporting ................................................................................................59
7.2.2
IRB Requirements for PI Reporting at Continuing Review ....................................59
7.3
NCI CLINICAL DIRECTOR REPORTING..............................................................59
7.4
NIH Required Data and Safety Monitoring Plan ........................................................59
7.4.1
Principal Investigator/Research Team.....................................................................59
7.4.2
Data Safety Monitoring Board (DSMB)..................................................................60
7.4.3
Corrective Action Plan ............................................................................................60
7.4.4
Independent Monitoring Committee (IMC) ............................................................60
8
SAFETY REPORTING CRITERIA TO THE PHARMACEUTICAL COLLABORATOR
60
9
STATISTICAL CONSIDERATIONS ..................................................................................61
9.1
Statistical hypotheses ..................................................................................................61
9.2
Sample size determination...........................................................................................61
9.3
Populations for analysis...............................................................................................62
9.4
Statistical analyses.......................................................................................................63
9.4.1
General approach.....................................................................................................63
9.4.2
Analysis of the primary safety and efficacy endpoints............................................63
9.4.3
Analysis of the secondary efficacy endpoints .........................................................63
9.4.4
Safety Analyses .......................................................................................................63
9.4.5
Baseline Descriptive Statistics.................................................................................63

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9.4.6
Planned interim analyses .........................................................................................63
9.4.7
Exploratory analyses................................................................................................64
10
COLLABORATIVE AGREEMENTS..................................................................................64
10.1
Clinical Trials Agreement (CTA)................................................................................64
11
HUMAN SUBJECTS PROTECTIONS................................................................................64
11.1
Rationale For Subject Selection ..................................................................................64
11.2
Participation Of Children ............................................................................................65
11.3
Participation of Subjects Unable to Give Consent ......................................................65
11.4
Evaluation of Benefits and Risks/Discomforts ...........................................................65
11.5
Risks/Benefits Analysis...............................................................................................65
11.5.1
Risks ........................................................................................................................65
11.5.2
Research Blood Collection Risks ............................................................................65
11.5.3
Risks of Echocardiogram.........................................................................................65
11.5.4
Risks of MUGA Scans.............................................................................................66
11.5.5
Risks of Questionnaires ...........................................................................................66
11.5.6
Lumbar Puncture for Research Purposes.................................................................66
11.5.7
Risks of exposure to ionizing radiation ...................................................................66
11.5.8
Risks of CT Scans....................................................................................................66
11.5.9
Risks of MRIs..........................................................................................................66
11.5.10 Other risks................................................................................................................66
11.5.11 Non-Physical Risks of Genetic Research ................................................................67
11.5.12 Certificate of Confidentiality...................................................................................67
11.5.13 Benefits....................................................................................................................67
11.5.14 Risks/Benefits Analysis...........................................................................................67
11.6
Consent Process and Documentation ..........................................................................67
11.6.1
Consent Process for Adults Who Lack Capacity to Consent to Research 
Participation...........................................................................................................................68
11.7
Request for Waiver of Consent for Screening Activities............................................68
12
REGULATORY AND OPERATIONAL CONSIDERATIONS..........................................69
12.1
STUDY DISCONTINUATION AND CLOSURE .................................................................69
12.2
QUALITY ASSURANCE AND QUALITY CONTROL........................................................69
12.3
CONFLICT OF INTEREST POLICY................................................................................70
12.4
CONFIDENTIALITY AND PRIVACY...............................................................................70
13
PHARMACEUTICAL INFORMATION .............................................................................71
13.1
Temozolomide.............................................................................................................71
13.1.1
Source ......................................................................................................................71
13.1.2
Formulation and preparation....................................................................................71
13.1.3
Storage and Stability................................................................................................72
13.1.4
Administration procedures.......................................................................................72
13.1.5
Pharmacokinetics.....................................................................................................72
13.1.6
Metabolism and Elimination....................................................................................72
13.1.7
Special Populations..................................................................................................73

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13.1.8
Incompatibilities and Toxicity.................................................................................73
13.2
T-DM1.........................................................................................................................75
13.2.1
Source ......................................................................................................................75
13.2.2
Formulation and Preparation ...................................................................................75
13.2.3
Supply and handling: ...............................................................................................76
13.2.4
Formulation and preparation....................................................................................77
13.2.5
Administration .........................................................................................................77
13.2.6
Pharmacokinetics.....................................................................................................77
13.2.7
Distribution..............................................................................................................78
13.2.8
Metabolism and Elimination....................................................................................78
13.2.9
Special populations..................................................................................................78
13.2.10 Incompatibilities and Toxicity.................................................................................81
14
REFERENCES ......................................................................................................................82
15
APPENDICES .......................................................................................................................90
15.1
Appendix A – Performance Status Criteria.................................................................90
15.2
Appendix B – List Of Drugs Interacting With CYP3A4 Isoenzyme..........................91
15.3
Appendix C – Oral Medication Diary .........................................................................92
15.4
Appendix D– Rano Criteria For CNS Metastasis .......................................................93

Abbreviated Title: TMZ in breast ca brain mets
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STATEMENT OF COMPLIANCE
The trial will be carried out in accordance with International Conference on Harmonisation Good 
Clinical Practice (ICH GCP) and the following: 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 
CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812) 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training.
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled.  Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study.  In addition, all changes to the consent form will be IRB-approved; an 
IRB determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form.
1. INTRODUCTION
1.1
STUDY OBJECTIVES
1.1.1
Primary Objectives:
Phase I (run in):

To identify the maximum tolerated dose (MTD) of temozolomide when used in 
combination with T-DM1.
Phase II:

To determine if the combination regimen of T-DM1 and temozolomide improves the 
freedom from distant new brain metastases following stereotactic radiosurgery or surgical 
resection in HER2-positive breast cancer brain metastases as compared to T-DM1 alone 
guided by one-year results as an important benchmark for measuring improvement.
1.1.2
Secondary Objective(s):

To evaluate the safety and tolerability of the combination of T-DM1 and temozolomide in 
HER2-positive breast cancer patients, previously treated for limited brain metastases. 

To assess time to whole brain radiation, and overall patient survival when treated with the 
combination regimen, compared to T-DM1 alone (control arm). 
1.1.3
Exploratory Objective(s):

To assess tumor genomic and neuroinflammatory biomarkers in the CSF and serum; the 
effects of treatment in those biomarkers; and the ability to predict relapses using those 
biomarkers; as described in the correlative studies background section (Section 1.3).To 
evaluate MGMT methylation status in primary tumor, CSF and serum; to compare it 
between patients that benefit and those that don’t benefit from treatment with 
temozolomide.

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
To assess neurotoxicity and neurocognitive effects in patients treated with the combination 
regimen compared to the control arm.

To assess between arm differences in symptom burden as measured by the M.D. Anderson 
Symptom Inventory-Brain Module (MDASI-BT). Specifically, it is hypothesized that the 
following subscales on the MDASI-BT (cognitive dysfunction, focal neurologic deficits 
and interference) will be higher in those receiving temozolomide alone due to differences 
in time to disease progression.

To assess if baseline MDASI-BT subscale scores (overall symptom burden, overall 
interference, cognitive dysfunction and focal neurologic deficits) along with the specific 
items of fatigue and change in appetite will be prognostic for time to distant metastases and 
for OS.

To assess if change scores over time in MDASI-BT subscale (overall symptom burden, 
overall interference, cognitive dysfunction, and focal neurologic deficits) along specific 
items (difficulty concentrating, fatigue, nausea, and headaches) were prognostic for OS, 
time to distant metastases, and neurocognitive decline.
1.2
BACKGROUND AND RATIONALE
1.2.1
Brain metastasis in HER2 positive breast cancer
Breast cancer is the most common cancer in women 1, and the second most common cause of brain 
metastases in the United States 2. The incidence of brain metastases varies amongst the different 
molecular subtypes of breast cancer, with high incidence in the HER2-positive and triple-negative 
breast cancers 3,4. In the HER2-positive group, the diagnosis of brain metastases became even more 
frequent – up to 25-40% 5-8 - after widespread treatment with trastuzumab, a monoclonal antibody 
that improved survival and control of systemic disease but has low central nervous system 
penetrance 9,10. New agents targeting HER2 have been evaluated since the introduction of 
trastuzumab, and, though several are now proven effective for systemic control of the disease, a 
major effect in decreasing brain metastases incidence in this group is still lacking.
1.2.2
Treatment of brain metastases
1.2.2.1
Local therapy
Radiation therapy modalities are currently the main options for treatment of brain metastases. 
In patients with limited number of brain metastases (one to five), current treatments include 
surgical resection, stereotactic radiosurgery (SRS), and/or whole-brain radiotherapy (WBRT) 11. 
Most prospective trials evaluating local treatment of brain metastases included mainly NSCLC 
patients and only a small proportion of breast cancer patients 12-14. Addition of WBRT to initial 
surgery or SRS has repeatedly demonstrated a decrease in intracranial disease recurrence but no 
difference in the overall survival of 7 to 10 months. However, WBRT has been reported to worsen 
quality of life and neurocognitive function, especially in patients with prolonged survival 15-17. In 
those cases, neurocognitive decline is progressive and untreatable. WBRT alone is the main 
indicated treatment for patients with higher numbers of brain metastatic lesions.

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1.2.2.2
Systemic therapy
Systemic therapy for brain metastases, overall, has shown less efficacy than in systemic, non-CNS 
locations. Multiple clinical trials have documented few or no responses using agents with known 
activity in the metastatic setting 18-23. The reasons for this may be heterogeneous, but likely involve 
the blood-brain barrier (BBB), which prevents most substances from exiting the bloodstream and 
entering the brain parenchyma. Once a metastasis forms the BBB is transformed into a blood-
tumor barrier (BTB). In general, the BTB permits greater drug penetration than the BBB, but drug 
levels are ~a log less than those reached in systemic metastases and therefore ineffective 24. 
In the HER2 positive breast cancer patients, HER2 targeted agents beyond trastuzumab have 
been also evaluated for their potential therapeutic effect in brain metastases. Lapatinib is a small 
molecule tyrosine-kinase inhibitor of epidermal growth factor receptor (EGFR) and human 
epidermal growth factor type 2 (HER2), able to cross the BTB to a greater extent than paclitaxel 
24,25. A presurgical study documented heterogeneous levels of lapatinib in brain metastases from 
patients dosed pre-operatively for medically needed craniotomies26 .
As a single agent, lapatinib showed a few responses and a small non-significant diminution in 
size of brain metastatic lesions 27,28. The combination lapatinib plus capecitabine produced 
objective responses in approximately 30% of patients in phase II trials evaluating the combination 
treatment in patients previously treated with WBRT 28,29. The LANDSCAPE trial evaluated the 
combination in a single arm phase II design as first-line treatment for low-volume brain metastases 
with objective CNS responses of 65.9%, median time to CNS progression of 5.5 months, and 
median time to WBRT of 8.5 months 30. More recently, the MA.31 trial randomized 652 patients 
with HER2-positive breast cancer to treatment with lapatinib plus taxane or trastuzumab plus 
taxane as first line treatment of metastatic disease 31. The primary endpoint was PFS. The 
trastuzumab combination was superior to the lapatinib combination, 9.0 months and 11.3 months, 
respectively (HR 1.37, p=0.001). The incidence of brain metastases as first site of progression was 
28% for trastuzumab and 20% for lapatinib, with no difference in time to progression between the 
arms. In a brain metastasis prevention setting, a phase III trial of lapatinib plus capecitabine versus 
capecitabine alone in HER2-positive advanced breast cancer previously treated with an 
anthracycline, taxane, and trastuzumab was conducted.  4 (2%) patients developed symptomatic 
brain metastasis as an initial site of progression in the combination therapy arm compared to 13 
(6%) patients in the monotherapy group (p=0.045) 32.
Pertuzumab is a monoclonal antibody that targets HER2 extracellular dimerization domain and 
acts in synergy with trastuzumab. It was demonstrated to prolong survival when used with 
trastuzumab and docetaxel as first line treatment for metastatic HER2-positive breast cancer, 
compared to trastuzumab, docetaxel and placebo 33. An exploratory analysis of the trial evaluated 
the incidence of brain metastases as first site of disease progression, and found it to be similar in 
the pertuzumab arm and the placebo arm (13.7% and 12.6%)34.
Trastuzumab emtansine (T-DM1) is a newer anti-HER2 therapeutic agent, with case reports 
describing activity in CNS metastases 35,36. T-DM1 is an antibody–drug conjugate containing 
emtansine (DM1), a microtubule-inhibitory agent, linked to trastuzumab. Phase III trials have 
shown activity of T-DM1 in HER2-positive metastatic disease after previous lines of treatment 
including trastuzumab and lapatinib, with an increase in PFS and OS 37,38. T-DM1 is currently the 
standard therapy for HER2-positive breast cancer patients with recurrence or progression of 
disease after treatment with trastuzumab. The EMILIA trial randomized advanced HER2-positive 

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breast cancer patients previously treated with trastuzumab and taxanes, to receive either T-DM1 
or lapatinib plus capecitabine 38. Final results showed better PFS (9.6 months with T-DM1 versus 
6.4 months with lapatinib plus capecitabine - hazard ratio for progression or death from any cause, 
0.65; 95% confidence interval [CI], 0.55 to 0.77; P<0.001), and OS (30.9 months versus 25.1 
months; hazard ratio for death from any cause, 0.68; 95% CI, 0.55 to 0.85; P<0.001) for T-DM1. 
In a retrospective exploratory analysis of the EMILIA trial, the rate of CNS progression was similar 
between the two arms, with CNS metastases as the first site of relapse in 2% of T-DM1 treated 
patients and in 0.7% of lapatinib plus capecitabine treated patients, and progression of CNS disease 
known at baseline in 22.2% and 16%, respectively. However, in patients with treated 
asymptomatic CNS metastases at baseline, T-DM1 was associated with improved survival when 
compared to lapatinib plus capecitabine (26.8 versus 12.9 months, HR 0.38 p=0.008) 39. One report 
raised concerns about possible inflammatory interaction between T-DM1 and SRS-treated lesions 
with clinically symptomatic edema, not largely seen outside this report but it requires close 
monitoring 40.
Independently of localized or systemic treatment modality, once brain metastases are established, 
our options for treatment are currently limited and the disease almost invariably progresses, 
limiting not only survival but also quality of life in most patients.
1.2.3
Prevention of brain metastases
Preventing the development of brain metastases in high-risk breast cancer patients is a different 
way to tackle the problem clinically. Primary prevention refers to the initial development of a brain 
metastasis; secondary prevention refers to the development of additional brain metastases in 
patients with limited metastases treated with local therapy.
The preclinical literature suggests the hypothesis that preventing the formation of a metastasis 
by a drug may be more efficacious than attempting to shrink an established lesion. Multiple mouse 
models of brain metastasis of breast cancer have been developed. Many approved drugs and 
candidates have been tested in a prevention mode, where they were delivered early and 
continuously after tumor cell injection, or in a therapeutic setting, where brain lesions were 
permitted to form and then treatment began. As reviewed41, several drugs have shown statistically 
significant efficacy in preventing the formation of brain metastases. None have shown therapeutic 
efficacy, in keeping with the clinical literature. 
The use of prophylactic radiation therapy, as used in small-cell lung cancer, is one approach to 
prevent brain metastases in high risk patients. At least two trials, one in Europe (NCT00639366) 
and other in Canada (NCT00916877), recruited high-risk breast cancer patients to evaluate 
prophylactic radiation and prevention of brain metastases and results are still maturing. The 
increasing evidence of neurocognitive decline related to WBRT and the lack of initial reports 
showing major sign of positive results are discouraging though 42. There is increasing evidence of 
at least transient declines in memory, executive function, and processing speed in the first few 
months after WBRT in up to 40-60% patients. Based on the literature, additional progressive 
neurocognitive complications may be expected with time. 
In an attempt to evaluate prophylactic treatment against brain metastases as first site of relapse, 
the phase III CEREBEL trial assessed 501 women that were randomized to lapatinib plus 
capecitabine versus trastuzumab plus capecitabine 43. The incidence of brain metastases was 
overall low, 3% and 5% respectively, with no significant difference between the two arms.

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Considering the different subtypes of breast cancer, a retrospective analysis of 154 patients 
(56% HER2-positive) treated with SRS, evaluated their outcome in terms of new brain metastases, 
overall survival and death ultimately caused by progression in brain 44. Median overall survival 
was 16.7 months for HER2-positive patients and 8.4 months for HER2-negative patients 
(p<0.001). Brain metastasis progression was the cause of death in 46% of HER2-positive and 31% 
of HER2-negative patients (p=0.066). Freedom from distant brain failure at 1 year was 58% in 
HER2-positive as opposed to 40% in HER2-negative patients (p=0.034), however, the majority of 
those patients had also received WBRT in the past. Such analysis reinforces the findings that, once 
brain metastases are found, HER2-positive patients may have a better overall survival, but they 
are more prone to develop and to die from brain metastasis progression. Most interestingly, since 
brain metastatic disease frequently recurs after initial SRS, a secondary prevention strategy could 
be helpful at this point.
Temozolomide in brain metastases
Temozolomide (TMZ) is a cytotoxic alkylating agent with almost 100% oral bioavailability, 
known to penetrate the BBB and currently FDA approved for treatment of glioblastoma 
multiforme and recurrent anaplastic astrocytoma. Although not proven effective as single agent to 
treat established metastatic breast cancer 45, TMZ has been extensively evaluated in the treatment 
of established brain metastases in combination with other agents and/or radiation. therapy, 
showing 
mixed 
responses 
and 
good 
tolerability 
46-56. 
Our group has shown in models developed with brain tropic HER2–positive JIMT-1-BR3 (in 
vitro) and triple-negative 231-BR-EGFP (in vitro and in vivo in animal models) sublines, that even 
in very low doses TMZ administered in a prophylactic fashion can prevent development of brain 
metastases (Table 1) 57.  The brain tropic tumor cells were injected into left cardiac ventricle and 
on day 3 the mice were randomized to vehicle versus TMZ given by oral gavage for 5 days every 
week. At necropsy, brain metastases were quantified in step sections through one hemisphere, and 
Table 1. Prevention of experimental brain metastases by 
TMZ over a wide dose range.
Experiment:
Dose 
(mg/kg) 
Median number
 Metastases
Per Brain Section:
Large:
Micro:
1
0
2.0
63.3
50
0
0
2
0
2.6
86.4
50
0
0
25
0
0
3
0
6.5
143.3
25
0
0
10
0
0
5
0
0
4
0
2.3
101.1
1
0.9
40.1
0.5
1.2
58.0
Mice were injected with brain tropic MDAMB231-BR cells and 
treated from day 3 post-injection with the indicated dose of TMZ. At 
necropsy large (>300 um) and micrometastases were quantified in 
step sections through one brain hemisphere. Experiments 1-3, p< 
0.01. Results of four experiments are shown to demonstrate the 
efficacy of TMZ dose. 

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doses of TMZ from 5 to 50mg/kg significantly prevented brain metastases formation. TMZ was 
ineffective in the treatment (shrinking) of established brain metastases.  When mice injected with 
brain-tropic breast cancer cells were treated with a course of TMZ and then allowed to live 
untreated, TMZ extended survival, with early treatment better than later (Figure 1).  The ability 
of TMZ to prolong life more effectively when given earlier is consistent with its ability to prevent 
metastases but inability to treat established metastases.
Figure 1. MDA-MB231-BR cells were injected into nude mice; Mice were treated with vehicle or TMZ on the 
days post-injection indicated. Mice were allowed to age without further treatment. They were sacrificed upon 
signs of progression and a Kaplan-Meier graph of survival is shown.
Figure 2. Temozolomide is ineffective at preventing colonization of MGMT+ Jimt-1-BR3 cells. Top panel: 
Jimt-1-BR3 cells were transduced with two different MGMT-targeting shRNAs, along with a scrambled 
shRNA control.  Reduced MGMT level in Jimt-1-BR3 cells transduced with targeted shRNAs was confirmed 
by western blot. Expression level of α-tubulin served as loading control. Lower panel: Altered sensitivity to 
temozolomide following MGMT repression was assessed in clonogenic survival assays. Jimt-1-BR3 cells were 
seeded at single cell density in triplicate, allowed to attach for 24h, then treated with either vehicle or 
               

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temozolomide at 10, 50 or 100 µM final concentrations. Colonies were fixed, stained with crystal violet and 
counted at 14 days posttreatment. Colony counts are shown as mean +/- SEM; **P=.008, ***P
O6-Methylguanine-DNA methyltransferase (MGMT) is critical for repairing pro-mutagenic DNA 
bases and known to be contributory to tumor resistance to alkylating agents 58,59. Tumor response 
to TMZ has been shown to depend on low MGMT expression both in glioblastomas and in our 
preclinical breast cancer models as well (Figure 2) 57,60.  The correlation between primary breast 
tumor expression of MGMT and metastatic tissue expression of MGMT has not been largely 
investigated. Our group also evaluated 62 primary breast cancer tumor samples and their patient-
matched brain metastases (Figure 3). Primary breast tumor MGMT expression was not a reliable 
predictor of brain MGMT status, with 40% discordance between sites. In our sample, 60% of 
patients with breast cancer brain metastases showed low MGMT expression (Table 2), indicating 
that these patients are potentially susceptible to TMZ prevention of brain metastasis. A strong trend 
was observed for an association of HER2 overexpression and MGMT negativity in the HER2 
positive brain metastases (P = 0.089), suggesting the eligibility of this subset of patients for 
potential clinical trials (Table 3) 57.
Figure 3. MGMT expression in matched sets of human breast primary tumors and resected brain metastases. 
A- D, sixty-two patient-matched sets were collected from tumor banks in Poland and Germany. TMAs of the 
specimens were stained for MGMT and evaluated for the percentage of positively staining tumor cells 
(nuclear staining only), dichotomized at 5%. The number and percentage of specimens in each category is 
given below each representative photomicrograph

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Table 2. Cross-tabulation of MGMT IHC staining in matched primary breast tumors and resected brain 
metastases using two categoriesa.
Brain metastases
Primary tumor
<5% MGMT+
>5% MGMT+
Total
<5% MGMT +
27 (44%)
16 (26%)
43 (70%)
>5% MGMT +
9 (14%)
10 (16%)
19 (30%)
Total
36 (58%)
26 (42%)
62 (100%)
a The percentage of MGMT+ cells was scored by a pathologist, and grouped into four categories as listed. P=0.036 by 
Jonckheere-Terpstra trend test
TMZ has been administered in at least two doses and schedules. In its activity repairing O6-
methylguanine lesions, MGMT transfers the alkyl group from guanine to a cysteine moiety in its 
active site, thereby repairing the DNA. MGMT is irreversibly inactivated in this process and new 
MGMT protein synthesis is needed to restore MGMT activity 61,62.  In an attempt to overcome 
MGMT activity, trials evaluating the metronomic use of temozolomide were developed mainly for 
treatment of melanoma and brain tumors 63,64. MGMT enzyme activity was assayed in peripheral 
blood monocytes (PBMCs) collected at various time points during treatment and shown to be 
progressive and cumulatively decreased 65,66. More recently, at least three phase II clinical trials 
evaluated the continuous daily use of temozolomide (50mg/m2) in heavily pretreated brain tumors 
and demonstrated activity and safety of the regimen, even in non-methylated MGMT tumors 
54,67,68.
To our knowledge, the only published trial evaluating the combined use of temozolomide with 
an anti-HER2 agent in breast cancer brain metastases was the LAPTEM trial 50, combining 
temozolomide with lapatinib for treatment of established brain metastases, not prevention. The 
regimen showed a favorable toxicity profile, with main side effects being fatigue, diarrhea and 
constipation. Temozolomide was used in three dose levels: 100, 150 and 200 mg/m2/day, days 
1–5 with cycles of 28 days; lapatinib was given orally, once a day also at three dose levels: 1000, 
1250, 1500 mg/day. The MTD was not reached, per protocol. No cardiac toxicity events were 
observed. Of the 15 evaluable patients, 10 achieved stabilization of disease, with estimated median 
survival time of 10.94 months (95% CI: 1.09–20.79), and median progression-free survival time 
of 2.60 months [95% CI: 1.82–3.37].
We propose a secondary-prevention clinical trial with oral temozolomide for HER2-positive 
breast cancer patients with 1 to 3 brain metastases after recent local treatment (SRS or surgical 
resection), with the goal to decrease incidence of new metastatic lesions in the brain at 1 year. 
Temozolomide will be combined to the anti-HER2 agent T-DM1 for systemic control of disease. 

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Table 3Associations of primary tumor and brain metastasis MGMT expression with patient characteristics
1.3
CORRELATIVES BACKGROUND AND RATIONALE
Studies will address aspects of TMZ resistance, molecular alterations in brain metastatic tumor 
cells, the neuro-inflammatory response, and markers of cognition.
1.3.1
Cell free DNA (cfDNA) and primary tumor DNA sequencing
Few molecular tools exist to analyze brain metastasis progression other than MRI scans and 
neurocognitive testing. Recent work from Harvard demonstrated that brain metastases show 
unique mutational patterns as compared to primary tumors 69. An example is shown on Figure 4. 
These data were based on craniotomy samples, which will generally be unavailable in the current 
clinical study. Detecting DNA alterations in brain metastasis from patients’ systemic samples will 
likely be compromised by the contributions of systemic disease. We propose sequencing of cell 
free tumor DNA in the CSF as an alternative endpoint.
Recently several publications have reported the sequencing of cell free DNA (cfDNA) in CSF 
from patients with brain cancers and leptomeningeal disease from melanoma 70,71. The primary 
tumor tissue was subjected to DNA sequencing to identify specific alterations from a preselected 
targeted panel. In one report four CSF samples were analyzed by whole exome sequencing without 
prior knowledge of specific mutations; two of the four revealed mutant allele frequencies >10% 
that could be tracked 70. The presence or absence of cfDNA in CSF, or its levels and alterations 
was a correlate of clinical course and more informative than serum cfDNA71. Based on these data 
it is hypothesized that: (a) patients will have mutations that can be identified in the CSF in the 
secondary brain metastasis prevention trial; (b) alterations in the pattern or prevalence of mutations 
will correlate with clinical outcome in the secondary brain metastasis prevention trial and (c) that 
alterations in the pattern or prevalence of mutations or cfDNA levels in CSF will predict relapse 
before MRI imaging. In addition, the data will provide a landscape of the genetic mutations from 
cfDNA in CSF for brain metastasis of breast cancer, and a portrait of its evolution through 
progression. The CSF cfDNA sequence data will be compared to that of the primary tumor where 
available and serum cfDNA.  Comparison with the primary tumor may provide a portrait of 
mutations that are shared between the primary tumor and the brain metastasis as evidenced in 
cfDNA from CSF. Comparison with serum may identify events distinct between systemic and 
CNS progression.  

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Figure 4: Phylogenetic tree for a patient that developed a brain metastasis of HER2-positive breast cancer, as 
compared to the matched primary tumor. The phylogenetic tree is presented on the top, with the patient 
treatment history below. Primary tumor data is blue. All regions of the brain metastases (red) shared 
amplifications in EGFR and CCNE1 that were absent in the primary tumor. Heterogeneity was also observed 
in sequences from four different regions of the resected brain metastasis. In gray are mutational events 
shared by all samples. The timeline depicts the sequence of diagnosis, treatment, and tissue sampling, with 
chemotherapy treatment intervals denoted by grey rectangles, and treatment with specified targeted agents 
denoted by orange rectangles. Data developed by Drs. Brastianos and Carter.
This approach has been pioneered by Drs. Carter and Brastianos and is potentially groundbreaking. 
Drs. Brastianos and Carter have already subjected nearly 100 matched brain metastases, primary 
tumors and normal tissues to whole exome sequencing and demonstrated that in 53% of cases, 
oncogenic drivers were detected in the brain metastases that were not present in the clinically 
sampled primary tumor69. A case of a resected HER2+ brain metastasis is presented in Figure 4, 
showing that the brain metastasis was genetically divergent from the primary tumor biopsy and 
that multiple regions of the brain metastasis were relatively genetically homogeneous. Now they 
have developed techniques to analyze cfDNA in CSF69,72-74.
Figure 5: Genome-wide copy ratio results from low-pass whole-genome sequencing of cfDNA derived from 
CSF of a patient with metastatic HER2+ breast cancer.  Analysis of chromosomal aneuploidies in the sample 
indicates a tumor purity of 14% in the cfDNA.  Note that the ERBB2 amplicon is visible on chr17 (red 
arrow).
DNA will be subjected to solution-phase hybrid capture followed by Illumina sequencing to >100x 
mean coverage. Mutations and copy-number changes will be determined within the Firehose 
pipeline environment at the Broad Institute using a suite of existing tools, which include the 
published MuTect, Indelocator, GISTIC and MutSig algorithms72,73,75-79. To understand inter- and 
intratumoral heterogeneity, we will use computational tools developed by Dr. Carter to perform 
an integrative analysis of somatic mutations and copy-number alterations. This analysis, termed 
Absolute80, estimates the cancer-cell fraction (CCF) of each mutation, allowing parsimonious 
resolution of the clonal architecture of bulk cancer tissue samples. Dr. Carter also developed a 

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computational tool called Phylogic, which automates the inference of phylogenetic trees relating 
all cancer subclones identified in the cancer tissue samples of each individual patient69. Phylogic 
operates by analyzing the modeled absolute copy-numbers and mutation CCF estimates provided 
by ABSOLUTE. Figure 5 presents preliminary data developed by Drs. Brastianos and Carter, 
showing copy number alterations in the CSF of a HER2+ brain metastasis patient. 
We will characterize cfDNA from CSF samples and blood at diagnosis and during treatment, 
and bulk DNA from primary tumors using targeted and whole-exome sequencing (WES). All 
samples will be subjected to targeted sequencing and selected cases of adequate quality will be 
subjected to WES. This will allow us to characterize somatic point mutations, insertion-deletion 
events, and copy-number changes.
1.3.2
MGMT Status
 
O6-methylguanine-DNA methyltransferase (MGMT) is a DNA repair enzyme that confers 
resistance to TMZ. MGMT expression and activity have been determined by several methods in 
clinical tissues, most often by the DNA methylation status of its promoter, including methylation 
specific PCR (MSP), pyrosequencing and semi-quantitative MSP. Other techniques quantify total 
MGMT expression including IHC and QRT-PCR 81. When tumor tissue was assessed for MGMT 
status using MSP, low expression of MGMT generally correlated with response or better outcome 
to TMZ therapy in GBM82, TMZ combination therapy studies in GBM83,84, and other primary brain 
tumors85,86. MGMT studies have been conducted in other cancer types when TMZ was 
incorporated into the therapy, including lung cancer87, aerodigestive and colorectal cancers88, and 
melanoma89. These studies used tumor samples from biopsy or surgery. 
It is noteworthy that MGMT alterations occur in tissues other than tumor. Alterations were 
detected in stroma around tumor in breast cancer90. Similar findings have been reported for other 
cancers91.The data suggest that the microenvironment may also play a role in drug sensitivity or 
resistance. 
MGMT methylation has been measured in serum and compared to that in FFPE tumor blocks 
for glioma92. Circulating DNA was extracted from plasma using the QIAamp DNA Blood Mini 
kit. After bisulfite modification, an end point PCR assay, using primers specific to either 
methylated or unmethylated DNA, was used to determine MGMT promoter methylation status 
(Qiagen). The frequency of MGMT methylation was 60% in tumor and 41% in serum. Serum 
MGMT changed from baseline to 12 months. Both measurements predicted response to TMZ. 
Other studies have reported similar approaches93-95. CSF as a source of MGMT methylation data 
has only been reported in abstract form96 and a literature search revealed no analysis of MGMT in 
CTCs.
In preliminary studies in the Steeg laboratory, MGMT expression was determined by IHC in 
FFPE blocks of matched sets of primary breast tumors and resected brain metastases (n=62)97. 
Samples were dichotomized into low expression (<5% of tumor cells+) and high expression (>5%) 
categories by a pathologist. Overall concordance of primary tumor and brain metastasis MGMT 
expression was weak. Low MGMT expression was prevalent, in 58% of brain metastasis 
specimens. A strong trend was observed in brain metastases for an association of HER2 
overexpression and MGMT negativity (P = 0.089), suggesting the eligibility of this subset for 
potential clinical trials. 

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The hypothesis to be tested in this trial is that MGMT status, either at baseline or changes over 
time, will reflect secondary preventive activity of TMZ. A second hypothesis posits that alterations 
in MGMT may be an early sign of resistance to therapy and precede progression detectable on 
MRI.  In addition, we will determine the concordance of MGMT methylation from multiple 
sources (tissue, serum, CSF) and by two assays (methylation and IHC). MGMT status will be 
assayed from patient serum at baseline and on study, the primary FFPE tumor block as available, 
and CSF as available in this trial. MGMT methylation will be used for all samples. For the FFPE 
block, MGMT IHC will also be conducted as previously reported. 
1.3.3
Neuroinflammatory response and neuronal damage metrics. 
Brain metastases elicit a prominent neuro-inflammatory response including activated 
astrocytes, identified by GFAP positivity, and microglia98. Multiple preclinical studies indicate 
that the neuro-inflammatory milieu conducts cross-talk with tumor cells to augment metastatic 
colonization99. The hypothesis to be tested is that the extent of neuro-inflammatory response, either 
at baseline or through treatment, will correlate with secondary prevention efficacy of TMZ. Other 
goals of these studies are to determine the prevalence, magnitude and kinetics of the neuro-
inflammatory response in brain metastasis progression, which has not been addressed in the 
clinical literature. 
The neurocognitive sequelae of brain metastases derive from both the lesions and the 
treatments100-103. In preclinical studies brain metastases of breast cancer caused neuronal cell death 
104, which would be a contributor to neurocognitive dysfunction. Regional or systemic tests for 
neuro-inflammatory responses and neurocognitive sequelae have not been meaningfully 
incorporated into clinical research on brain metastasis, other than mental function testing. Several 
leads have been developed for other brain pathologies and will be tested in this trial:
a. The traumatic brain injury (TBI) field, another disease of the brain and BBB, has pioneered 
blood-based assays. Blood markers of neuro-inflammation (GFAP) and neuronal injury (UCH-L1) 
have been measured in patients with mild-severe TBI over time105-107. Serum levels were measured 
in duplicate using an ELISA assay (Banyan Biolarmers Inc.). Levels of each protein, or a ratio of 
the two were reported. Normal controls or trauma patients without TBI showed low levels of each 
marker. Serum levels were elevated in TBI patients and correlated with several indicators of 
outcome, need for treatments, and disease severity. The same markers have been infrequently 
reported in CSF108. Similar results have been reported for stroke109. 
Quantification of GFAP and UCH-L1 will be performed in serum and CSF samples from all 
patients on the trial. Validation experiments and the serum measurements from the trial will be 
conducted in the Steeg laboratory. The questions to be answered include: (a) what is the variation 
in baseline levels of brain metastasis patients? (b) what are the changes in time with and without 
progression? (c) Do changes in either level, or the ratio, correlate with preventive efficacy of TMZ? 
(d) Do changes predict clinical progression earlier than MRI?
b. MicroRNA-34c (miR-34c) has been studied in Alzheimer’s disease (AD) as a biological 
covariate of cognitive function110. miR-34c was identified as a miR enriched in the hippocampus 
of mice. It targets genes involved in axonogenesis, neuron projection neurogenesis, cell 
communication, neuronal activities, synaptic transmission, channel activity. Injection of miR-34c 
functionally improved learning in a mouse model of AD110. MiR-34c has been quantified in plasma 
of AD and healthy controls111. Of 110 AD and 123 normal control patients, RNA of sufficient 
integrity was extracted from 78 and 85, respectively. MiRNA extraction was completed using 

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plasma samples stored in RNAlater, subjected to Trizol/chloroform extraction and centrifugation. 
A Taqman miRNA reverse transcription kit was used to quantify miR-34c, using QPCR. A 30 ml 
blood sample was used, it is not known if smaller amounts can be used. Levels of miR-34c were 
elevated in AD patients compared to normal, or normal elderly controls, and correlated with mental 
function on Mini-Mental Status Examinations111.
Preclinical work will be performed in the Steeg lab to assay validate this technique, and to 
determine if an amplification will permit quantification of miR-34c from smaller plasma samples. 
If sufficient plasma is available from patients, miR-34c levels will be determined to answer the 
same questions posed in (a). If sufficient miRNA is obtained, a full miRNA profile may be 
obtained on the samples using a miRNA array112. 
1.3.4
Exosomes
Currently there is a lack of rapid and reliable methods for cancer detection, metastatic 
prediction and treatment response assessment. Dr. Lyden’s laboratory is developing non-invasive 
methods to predict patient outcome for site-specific metastasis and that can be used to monitor 
treatment responses. These methods are based on a simple blood test and rely on the isolation and 
characterization of tumor-derived exosomes from the plasma of cancer patients.
Exosomes are small membrane vesicles (30-100 nm in diameter) of endocytotic origin and 
secreted by most cells constitutively. These microvesicles contain cell type-specific proteins and 
genetic materials, including mRNAs, miRNAs and DNA, and can exert a functional influence once 
uptaken by recipient cells, therefore representing novel mediators of intercellular communication. 
Importantly, exosomes are shed from cancers and are readily isolated from the peripheral 
circulation. A growing body of evidence has shown that tumor-derived exosomes not only have a 
crucial role in regulating tumor growth and metastasis, but also provide a “treasure box” of novel 
non-invasive biomarkers for different types of cancers113.
We propose to use this “liquid biopsy” in this trial to evaluate the possibility of rapidly 
screening for metastatic disease detection, as well as for metastasis prediction and treatment 
response monitoring. Analysis of exosomes in blood samples will be performed in the Lyden lab 
at Weill Cornell Medical College. 
1.3.5
Pharmacokinetics 
Both temozolomide and T-DM1 are FDA approved drugs with established information on their 
pharmacokinetics. Since we are using temozolomide in new dose and schedule for this study, we 
will sample a cohort of patients in order to determine temozolomide exposure. 
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT 
2.1
ELIGIBILITY CRITERIA
2.1.1
Phase 1 Inclusion Criteria
2.1.1.1
Participants must have histologically confirmed HER2-positive breast cancer for which 
standard curative measures do not exist or are no longer effective. HER2 testing must 
have been performed in a laboratory accredited by the College of American Pathologists 
(CAP) or another accrediting entity.
2.1.1.2
Participants must have brain metastases, treated within 12 weeks of study entry with SRS, 

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resection or WBRT. A minimum interval of 3 weeks between completion of brain SRS 
and/or resection and 6 weeks for WBRT and the start of treatment in this trial will be 
observed to allow proper healing. The presence of concomitant extracranial metastatic 
disease is allowed for enrollment.
2.1.1.3
  Corticosteroids will be allowed at enrollment and during the first month of treatment 
with T-DM1 after SRS, up to a dose of no more than 10mg of dexamethasone daily or 
equivalent. Participants that need to continue corticosteroids after the initial month will 
be allowed to continue in the protocol treatment if no further increase in dose is necessary. 
Participants that need increase in dose of corticosteroid after initial month will be taken 
off protocol treatment.
2.1.1.4
  Age >18 years. Because breast cancer is not commonly found in pediatric population 
and no dosing or adverse event data are currently available on the use of temozolomide 
in combination with T-DM1 in participants <18 years of age, children are excluded from 
this study, but will be eligible for future pediatric trials.
2.1.1.5
ECOG performance status <2 (Karnofsky >60%, see Appendix A).
2.1.1.6
Participants must have adequate organ and marrow function as defined below: 
leukocytes
>3,000/mcL
absolute neutrophil count
>1,000/mcL
platelets
>100,000/mcL
total bilirubin
within normal institutional limits
AST(SGOT)/ALT(SGPT)
<3.0 X institutional upper limit of normal
creatinine
up to 1.5 upper institutional limits
OR
creatinine clearance
>60 mL/min/1.73 m2 for participants with 
creatinine levels above institutional normal.
2.1.1.7
Alkylating agents as well as other therapeutic agents used in this trial are known to be 
teratogenic, women of child-bearing potential and men must agree to use adequate 
contraception (hormonal or barrier method of birth control; abstinence) prior to study 
entry, for the duration of study participation and for 7 months (women) or 4 months (men) 
after treatment completion.  Should a woman become pregnant or suspect she is pregnant 
while she or her partner is participating in this study, she should inform her treating 
physician immediately.
2.1.1.8
Ability of subject to understand and the willingness to sign a written informed consent 
document.
2.1.2
Phase 1 Exclusion Criteria
2.1.2.1
Patients who are receiving any other investigational agents.
2.1.2.2
Patients unable to speak or understand English, since they cannot complete 
neurocognitive evaluation.

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2.1.2.3
Patients with known leptomeningeal metastatic disease.
2.1.2.4
Patients with major symptoms or impairments related to brain metastases, such as aphasia 
or severe confusion, will be excluded per PI discretion when those symptoms preclude 
proper neurocognitive evaluation during the study treatment. 
2.1.2.5
Patients who have received previous treatment with T-DM1 and had systemic progression 
of disease while on it, are ineligible. Patients receiving treatment with T-DM1 whose only 
site of disease progression was brain are allowed to enroll in this trial.
2.1.2.6
Patients who have received chemotherapy in the previous 3 weeks (6 weeks for 
nitrosoureas or mitomycin).
2.1.2.7
HBV (HBs Ag positive) or HCV (anti-HCV positive) patients are ineligible because of 
potential reactivation of hepatitis virus with temozolomide use.
2.1.2.8
Grade ≥3 peripheral neuropathy according to (NCI CTCAE) version 4.0.
2.1.2.9
Cerebral Vascular Accident (CVA) or Transitory Ischemic Attack (TIA) in the year 
before enrollment, or presence of residual symptoms from CVA that happened more than 
a year before. 
2.1.2.10 Pulmonary Embolism (PE) in the 3 months before enrollment. Anticoagulation is 
permitted. 
2.1.2.11 Impaired cardiac function or clinically significant cardiac disease including the 
following:
-
New York Heart Association grade III or IV congestive heart failure.
-
Myocardial infarction within the last 12 months.
-
Subjects with impaired LVEF (<50%).
2.1.2.12 Patients with inability to complete brain MRI studies with contrast. 
2.1.2.13 Patients with breast tissue expanders must have those removed before enrollment.
2.1.2.14 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to temozolomide or T-DM1. Patients who are tolerating TDM1 successfully 
with premedications and slower infusion will be allowed.
2.1.2.15 Patients receiving medications that are strong CYP3A4 inhibitors or inducers are 
ineligible. In vitro studies indicate that DM1, the cytotoxic component of T-DM1, is 
metabolized mainly by CYP3A4 and to a lesser extent by CYP3A5. Concomitant use of 
strong CYP3A4 inhibitors with T-DM1 should be avoided due to the potential for an 
increase in DM1 exposure and toxicity. Consider an alternate medication with no or 
minimal potential to inhibit CYP3A4. Lists including medications and substances known 
or with the potential to interact with CYP3A4 isoenzymes are provided in Appendix B.
2.1.2.16 Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, that 
would limit compliance with study requirements.
2.1.2.17 Pregnant women are excluded from this study because temozolomide is an alkylating 
agent with the potential for teratogenic or abortifacient effects.  Because there is an 

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unknown but potential risk for adverse events in nursing infants secondary to treatment 
of the mother with temozolomide and/or T-DM1, breastfeeding should be discontinued 
if the mother is treated with either of those agents.  These potential risks may also apply 
to other agents used in this study.
2.1.2.18 HIV-positive patients are excluded because these patients are at increased risk of lethal 
infections when treated with marrow-suppressive therapy.  
2.1.2.19 Patients with any other concomitant invasive malignancies are ineligible.  Prior invasive 
cancers treated with curative intent, and with no evidence of recurrent disease, may be 
eligible after PI evaluation.  Patients with treated limited stage basal cell or squamous cell 
carcinoma of the skin or carcinoma in situ of the breast or cervix are eligible.
2.1.3
Phase 2 Inclusion Criteria
2.1.3.1
Participants must have histologically confirmed HER2-positive breast cancer for which 
standard curative measures do not exist or are no longer effective. HER2 testing must 
have been performed in a laboratory accredited by the College of American Pathologists 
(CAP) or another accrediting entity.
2.1.3.2
Participants must have 1-10 brain metastases, by contrast MRI, treated within 12 weeks 
of study entry with SRS and/or resection. A minimum interval of 3 weeks between 
completion of brain SRS and/or resection and the start of treatment in this trial will be 
observed to allow proper healing. The presence of concomitant extracranial metastatic 
disease is allowed for enrollment.
2.1.3.3
  Corticosteroids will be allowed at enrollment and during the first month of treatment 
with T-DM1 after SRS, up to a dose of no more than 10mg of dexamethasone daily or 
equivalent. Participants that need to continue corticosteroids after the initial month will 
be allowed to continue in the protocol treatment if no further increase in dose is necessary. 
Participants that need increase in dose of corticosteroid after initial month will be taken 
off protocol treatment.
2.1.3.4
  Age >18 years. Because breast cancer is not commonly found in pediatric population 
and no dosing or adverse event data are currently available on the use of temozolomide 
in combination with T-DM1 in participants <18 years of age, children are excluded from 
this study, but will be eligible for future pediatric trials.
2.1.3.5
ECOG performance status <2 (Karnofsky >60%, see Appendix A).
2.1.3.6
Participants must have normal organ and marrow function as defined below: 
leukocytes
>3,000/mcL
absolute neutrophil count
>1,000/mcL
platelets
>100,000/mcL
total bilirubin
within normal institutional limits
AST(SGOT)/ALT(SGPT)
<3.0 X institutional upper limit of normal
creatinine
up to 1.5 upper institutional limits

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OR
creatinine clearance
>60 mL/min/1.73 m2 for participants with 
creatinine levels above institutional normal.
2.1.3.7
Alkylating agents as well as other therapeutic agents used in this trial are known to be 
teratogenic, women of child-bearing potential and men must agree to use adequate 
contraception (hormonal or barrier method of birth control; abstinence) prior to study 
entry, for the duration of study participation and for 7 months (women) or 4 months (men) 
after treatment completion.  Should a woman become pregnant or suspect she is pregnant 
while she or her partner is participating in this study, she should inform her treating 
physician immediately.
2.1.3.8
Ability of subject to understand and the willingness to sign a written informed consent 
document.
2.1.4
Phase 2 Exclusion Criteria
2.1.4.1
Patients who are receiving any other investigational agents.
2.1.4.2
Patients unable to speak or understand English, since they cannot complete 
neurocognitive evaluation.
2.1.4.3
Patients with known leptomeningeal metastatic disease.
2.1.4.4
Patients previously treated with whole brain radiation therapy (WBRT).
2.1.4.5
Patients with major symptoms or impairments related to brain metastases, such as aphasia 
or severe confusion, will be excluded per PI discretion when those symptoms preclude 
proper neurocognitive evaluation during the study treatment. 
2.1.4.6
Patients who have received previous treatment with T-DM1 and had systemic progression 
of disease while on it, are ineligible. Patients receiving treatment with T-DM1 whose only 
site of disease progression was brain are allowed to enroll in this trial.
2.1.4.7
Patients who have received chemotherapy in the previous 3 weeks (6 weeks for 
nitrosoureas or mitomycin).
2.1.4.8
HBV (HBs Ag positive) or HCV (anti-HCV positive) patients are ineligible because of 
potential reactivation of hepatitis virus with temozolomide use.
2.1.4.9
Grade ≥3 peripheral neuropathy according to (NCI CTCAE) version 4.0.
2.1.4.10 Cerebral Vascular Accident (CVA) or Transitory Ischemic Attack (TIA) in the year 
before enrollment, or presence of residual symptoms from CVA that happened more than 
a year before. 
2.1.4.11 Pulmonary Embolism (PE) in the 3 months before enrollment. Anticoagulation is 
permitted. 
2.1.4.12 Impaired cardiac function or clinically significant cardiac disease including the 
following:
-
New York Heart Association grade III or IV congestive heart failure.
-
Myocardial infarction within the last 12 months.

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-
Subjects with impaired LVEF (<50%).
2.1.4.13 Patients with inability to complete brain MRI studies with contrast. 
2.1.4.14 Patients with breast tissue expanders must have those removed before enrollment.
2.1.4.15 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to temozolomide or T-DM1. Patients who are tolerating TDM1 successfully 
with premedications and slower infusion will be allowed.
2.1.4.16 Patients receiving medications that are strong CYP3A4 inhibitors or inducers are 
ineligible. In vitro studies indicate that DM1, the cytotoxic component of T-DM1, is 
metabolized mainly by CYP3A4 and to a lesser extent by CYP3A5. Concomitant use of 
strong CYP3A4 inhibitors with T-DM1 should be avoided due to the potential for an 
increase in DM1 exposure and toxicity. Consider an alternate medication with no or 
minimal potential to inhibit CYP3A4. Lists including medications and substances known 
or with the potential to interact with CYP3A4 isoenzymes are provided in Appendix B.
2.1.4.17 Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, that 
would limit compliance with study requirements.
2.1.4.18 Pregnant women are excluded from this study because temozolomide is an alkylating 
agent with the potential for teratogenic or abortifacient effects.  Because there is an 
unknown but potential risk for adverse events in nursing infants secondary to treatment 
of the mother with temozolomide and/or T-DM1, breastfeeding should be discontinued 
if the mother is treated with either of those agents.  These potential risks may also apply 
to other agents used in this study.
2.1.4.19 HIV-positive patients are excluded because these patients are at increased risk of lethal 
infections when treated with marrow-suppressive therapy.  
2.1.4.20 Patients with any other concomitant invasive malignancies are ineligible.  Prior invasive 
cancers treated with curative intent, and with no evidence of recurrent disease, may be 
eligible after PI evaluation.
2.1.5
Recruitment Strategies
This protocol may be abstracted into a plain language announcement posted on NIH websites and 
on NIH social media platforms. Participants will be recruited from the current patient population 
at NIH. The study may be listed in patient advocacy websites such as the Army of Women. 
2.2
SCREENING EVALUATION
2.2.1
Screening activities performed prior to obtaining informed consent

Minimal risk activities that may be performed before the subject has signed a consent 
include the following: 

Email, written, in person or telephone communications with prospective subjects 

Review of existing medical records to include H&P, laboratory studies, etc.  

Review of existing MRI, x-ray, or CT images

Review of existing photographs or videos

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
Review of existing pathology specimens/reports from a specimen obtained for diagnostic 
purposes
A waiver of consent for these activities has been requested in Section 11.7.
2.2.2
Screening activities performed after a consent for screening has been signed
The following activities will be performed only after the subject has signed the study consent OR 
the consent for study 01-C-0129 (provided the procedure is permitted on that study) on which 
screening activities may also be performed. Assessments performed at outside facilities or on 
another NIH protocol within the timeframes below may also be used to determine eligibility once 
a participant has signed the consent.
Screening evaluations or tests will be done prior to enrollment within the following time frames:
Anytime:
2.2.3
Pathology confirmation of diagnosis.
Pathological confirmation of diagnosis and ER, PR and HER2 expression in the Laboratory of 
Pathology at NIH Clinical Center or Walter Reed National Military Medical Center at Bethesda. 
However, if no pathologic specimen is available, participants may enroll with a pathologist’s report 
showing a histologic diagnosis of HER2-positive breast cancer in a College of American 
Pathologists (CAP) accredited laboratory and a clinical course consistent with the disease.
Within 30 days: 
2.2.4
Imaging studies:

CT of chest/abdomen /pelvis (MRI may be substituted at investigator’s discretion) 

Bone scan

Contrast enhanced brain MRI
2.2.5
Cardiology test: 2-D Echocardiogram or MUGA-scan
2.2.6
Anti-HIV, anti-HCV, Hepatitis B Surface Ag
Within 10 days:
2.2.7
History and Physical examination:
Complete medical history (including prior therapy) and physical examination (including height, 
weight, vital signs, ECOG performance status and complete neurological exam). 
2.2.8
Laboratory Studies:  

CBC with differential, 

Biochemical profile: sodium, potassium, chloride, carbon dioxide, BUN, creatinine or 
measured creatinine clearance, glucose, AST, ALT, total bilirubin, calcium, total protein, 
albumin, alkaline phosphatase, magnesium.
2.2.9
Pregnancy Testing: 
For female subjects of childbearing potential, urine or serum HCG will be performed. Participants 
who are postmenopausal (age-related amenorrhea for 12 or more consecutive months, or 
documented FSH > 40 mIU/mL / Estradiol < 20mIU/mL), or who had undergone hysterectomy or 

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bilateral oophorectomy are exempt from pregnancy testing.
For baseline evaluations, please see Section 2.5.
2.3
PARTICIPANT REGISTRATION AND STATUS UPDATE PROCEDURES
Registration and status updates (e.g., when a participant is taken off protocol therapy and when a 
participant is taken off-study) will take place per CCR SOP ADCR-2, CCR Participant 
Registration & Status Updates found here.
2.3.1
Screen Failures
Screen failures are defined as participants who consent to participate in the clinical trial but are 
not subsequently assigned to the study intervention or entered in the study. A minimal set of screen 
failure information is required to ensure transparent reporting of screen failure participants, to meet 
the Consolidated Standards of Reporting Trials (CONSORT) publishing requirements and to 
respond to queries from regulatory authorities. Minimal information includes demography, screen 
failure details, eligibility criteria, and any serious adverse event (SAE).
2.4
RANDOMIZATION (OR STRATIFICATION) PROCEDURES
Cohorts
Number
Name
Description
1
Phase I Cohort
Subjects on phase I portion of study
2
Phase II Cohort
Subjects on phase II portion of study
Arms
Letter
Name
Description
1
Phase I
Phase I: T-DM1 + TMZ dose escalation
2A
Phase II arm A
Phase II: T-DM1 alone
2B
Phase II arm B
Phase II: T-DM1 + TMZ
Stratifications, Randomization and Arm Assignment
There are two stratification factors in the randomization: number of brain lesions (1 vs. 2-5 vs >5) 
and status of extracranial lesions (none/controlled. vs. progressing). 
Name
Distinct Options
Number of CNS lesions

1

2-5

>5
Status of extracranial lesions

None or controlled

Progressing
This results in six stratification groups:

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1. One brain lesion with no or controlled extracranial lesions
2. One brain lesion with progressing extracranial lesions
3. Two – three to five brain lesions with no or controlled extracranial lesions
4. Two – three to five brain lesions with progressing extracranial lesions
5. More than five brain lesions with no or controlled extracranial lesions
6. More than five brain lesions with progressing extracranical lesions
Within each of these six groups participants will be randomized at study entry to either arm 2A or 
arm 2B. Arm 2A will receive treatment with T-DM1 alone and Arm 2B will receive treatment with 
T-DM1 plus temozolomide. The Central Registration Office will be contacted via encrypted email 
at: ncicentralregistration-l@mail.nih.gov to determine the appropriate assignment for each 
participant. Once the NCI Central Registration Office receives subject stratification group 
assignment, randomization to treatment arms will be performed by the CRO.
Participants in cohort 1 will be directly assigned to arm 1.
Participants in cohort 2 will be randomized between arms 2A and 2B, stratified for number of CNS 
lesions and status of extracranial lesions.
2.5
BASELINE EVALUATION
The following procedures will be completed within 7 days before initiating of the treatment. Tests 
done at Screening do not need to be repeated on Baseline if performed in designated time frame. 
2.5.1
Clinical Evaluation: 

Review of concurrent medications 

Review of baseline adverse events  

Physical exam (including complete neurological exam, vital signs, weight and ECOG 
performance status) 
HER2+ Breast Cancer 
1-10 Brain metastases
SRS +/-  resection
(+/-WBRT  in phase I)
-1 brain lesion, no/controlled 
extracranial disease
-1 brain lesion, progressing 
extracranial disease
-2-5 brain lesion, no/controlled 
extracranial disease
-2-5 brain lesions, progressing 
extracranial disease
->5 brain lesion, no/controlled 
extracranial disease
->5 brain lesions, progressing 
extracranial disease
T-DM1 alone
T-DM1 plus 
Temozolomide
S
T
R
A
T
I
F
Y
R
A
N
D
O
M
I
Z
E

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2.5.2
Laboratory Evaluation:

CBC with differential and platelet count

Biochemical profile: (sodium, potassium, chloride, carbon dioxide, BUN, creatinine or 
measured creatinine clearance, glucose, AST, ALT, bilirubin, calcium, total protein, 
albumin, alkaline phosphatase, magnesium)

PT/INR/PTT

TSH 

Urinalysis

Pregnancy test for women of childbearing potential.
2.5.3
Neurocognitive and quality of life assessment:

Baseline MD Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) (Error! 
Reference source not found.).

Application 
of 
Patient-Reported 
Outcomes 
Measurement 
Information 
System 
(PROMIS®) cognitive questionnaire (Error! Reference source not found.).
2.5.4
Correlative tests evaluation:

Blood samples for correlative studies (will be collected at Day 1 of Cycle 1).

Lumbar puncture by Interventional Radiology for collection of CSF sample.

Primary tumor paraffin block and /or fresh frozen tissue from previous surgery will be 
requested from participants at baseline to perform comparative genomic analysis as part of 
correlative studies planned for this clinical trial.
3
STUDY IMPLEMENTATION
3.1
STUDY DESIGN
This is an open label Phase I/II trial, accruing initially one cohort to determine the safety and RP2D 
of Temozolomide combined to T-DM1 in participants with HER2-positive breast cancer metastatic 
to the brain after SRS or resection of those brain metastases (Phase I); and to examine the safety 
and clinical activity of the Temozolomide plus T-DM1 combination versus T-DM1 alone in the 
same group of participants (Phase II). In the Phase II portion, participants will be randomized 
between the two treatment arms. 
Participants will receive T-DM1 every 21-days, as per standard use recommendation. 
Administration of Temozolomide will be in daily dose by mouth. T-DM1 can be given up to 3 
days earlier or delayed up to 14 days due to holidays, inclement weather, conflicts, or similar 
reasons. The timing of subsequent administrations is then adjusted to maintain a 21 day-interval. 
Phase I: 
3.1.1
Dose Limiting Toxicity
The DLT period is one cycle, 21 days. DLT is defined as any of the following: 

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Non-Hematologic dose-limiting toxicity: 

Grade 3 or higher adverse events (AEs), excluding: 

Grade 3 hypertension controlled with anti-hypertensive therapy 

Grade 3 asymptomatic electrolytes imbalance with optimal and continuing 
repletion that downgrades to grade 1 or better within 3 days after onset of 
the event. 

Grade 3 endocrinopathy that is managed with or without hormone 
replacement therapy and the participant is asymptomatic. 

Grade 3 asymptomatic increase in AST (SGOT), ALT (SGPT), that 
downgrades to grade 1 or better within 7 days after onset of the event. 

Transient (lasting less than<48 hrs.) nausea/emesis/diarrhea if corrected 
with conservative measures within 24-48 hours.

Persistent (>14 days) non-hematologic Grade 2 AEs despite optimal medical management 
and temozolomide treatment delay > 14 days. 
Hematologic Toxicity:

Grade 4 neutropenia of ≥ 7 days duration, grade 3 or 4 neutropenia of any duration with 
fever or documented infection (febrile neutropenia). 

Grade ≥ 3 thrombocytopenia.

All other grade 4 hematologic toxicities, excluding: 

Grade 4 lymphopenia, or leukopenia in the absence of grade 3 or higher 
neutropenia. 
Note: Participants in use of corticosteroids that require increase in dose of corticosteroid after 
initial month of treatment in this clinical trial will be taken off protocol treatment given potential 
of tumor necrosis post SRS and will not be considered as DLT.
3.1.2
Dose Escalation
Dose escalation will follow the classical ‘3+3’ trial design. If none of the first three participants in 
a cohort experiences a dose-limiting toxicity during one cycle of treatment, another three 
participants will be treated at the next higher dose level. However, if one of the first three 
participants experiences a dose-limiting toxicity during first cycle of treatment, three more 
participants will be treated at the same dose level. Dose escalation continues until the final dose 
level meets safety criteria or at least two participants among a cohort of three to six participants 
experience dose-limiting toxicities (i.e., ≥33% of participants with a dose-limiting toxicity at that 
dose level). 
Dose Escalation Schedule
Dose Level
T-DM1 mg/kg IV every 21 days
Temozolomide mg/m2 PO daily
Level 1
3.6
30
Level 2
3.6
40

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Level 3
3.6
50
Dose escalation will follow the rules outlined in the Table below.
Number of Participants 
with DLT
at a Given Dose Level
Escalation Decision Rule
0 out of 3
Enter up to 3 participants at the next dose level
> 2
Dose escalation will be stopped.  This dose level will 
be declared the maximally administered dose 
(highest dose administered).  Up to 3 additional 
participants will be entered at the next lowest dose 
level if only 3 participants were treated previously at 
that dose.
1 out of 3
Enter up to 3 more participants at this dose level.

If 0 of these 3 participants experience DLT, 
proceed to the next dose level.

If 1 or more of this group suffer DLT, then dose 
escalation is stopped, and this dose is declared 
the maximally administered dose.  Up to 3 
additional participants will be entered at the next 
lowest dose level if only 3 participants were 
treated previously at that dose.
<1 out of 6 at highest dose 
level below the maximally 
administered dose
This is the MTD and is generally the recommended 
Phase II dose.  At least 6 participants must be entered 
at the recommended Phase II dose.
During the Phase I DLT time period (first 21 days), no decrease or delay for toxicity reasons in 
dose of T-DM1 is allowed. If participants develop side effects considered mainly related to T-
DM1 that would require dose reductions leading to discontinuation of that drug, they should be 
taken off protocol treatment and substituted by another participant. During the Phase II portion of 
this trial, dose reductions should be done as described in 3.3.1.
Phase II:
The phase II portion of this trial will randomize participants between treatment with T-DM1 alone 
at standard recommended dose (3.6 mg/kg IV every 21 days) or the combination of T-DM1 at 
standard dose and Temozolomide. The Temozolomide recommended dose for phase II trial will 
be considered the maximum tolerated dose determined from the lead-in phase I trial.
3.2
DRUG ADMINISTRATION
3.2.1
T-DM1
See section 13.2.4 for preparation instructions. T-DM1 will be administered intravenously to all 
participants in the study. T-DM1 will be administered at standard recommended dose (3.6 mg/kg), 
once every 21 day cycle until disease progression, participant withdrawal or toxicities. The 

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infusion site will be closely monitored for possible subcutaneous infiltration during drug 
administration. First infusion will be administered approximately 90 minutes. Participants should 
be observed during the infusion and for at least 90 minutes following the initial dose for fever, 
chills, or other infusion related reactions. Subsequent infusions will be administered approximately 
30 minutes if prior infusions were well tolerated. Participants should be observed during the 
infusion and for at least 30 minutes after infusion. If the infusion is interrupted, the reason for 
interruption will be documented in the clinical record. Administration of T-DM1 may be given 3 
days earlier or delayed up to 14 days due to holidays, inclement weather, conflicts, or similar 
reasons. The timing of subsequent administrations is then adjusted to maintain a 21 days-interval. 
Participants will be monitored before and after the infusion with assessment of vital signs at the 
times specified in the Study Calendar (Section 3.5).  In the event of a ≤grade 2 infusion-related 
reactions (IRR), the infusion rate of study drug may be decreased by 50% or interrupted until 
resolution of the event (up to 4 hours) and re-initiated at 50% of the initial rate until completion of 
the infusion. For subjects with a ≤grade 2 infusion related reaction, subsequent infusions may be 
administered at 50% of the rate at which the IRR occurred. Acetaminophen and/or an antihistamine 
(e.g., diphenhydramine) or equivalent medications may be administered at the discretion of the 
investigator. T-DM1 will be given until disease progression, participant withdrawal or toxicities. The 
start of the first cycle will be scheduled within 7 days of registration. In the event of G3 or G4 
IRR, treatment should be stopped and not repeated in the future.
3.2.2
Temozolomide
During Phase I all participants will receive temozolomide and T-DM1. During Phase II only 
participants randomized to the combination treatment arm, will receive temozolomide and T-DM1. 
Temozolomide at the appropriate dose level will be given orally continuously once a day, every 
day during the 21 cycle. Temozolomide will be given in combination with T-DM1 until disease 
progression, participant withdrawal or toxicities. Temozolomide will be dispensed at the start of 
each cycle. Participants will be provided with a pill diary (Appendix C), instructed in its use, and 
asked to bring it with them to each appointment. The dose will be determined using the body 
surface area (BSA) calculated at the beginning of each cycle unless significant (> 3 kg) weight 
loss or gain is observed. The BSA will be calculated from the height obtained at the pretreatment 
visit and from the weight obtained at the visit before each odd cycle. Capsules of temozolomide 
will be available in 5, 20, and 100 mg for this study. The daily dose will be rounded to the nearest 
5 mg. The exact dose administered should be recorded in the CRF. Each daily dose should be given 
with the least number of capsules. Prior to each treatment cycle with temozolomide a complete 
blood count (CBC) will be obtained (within 72 hours prior to dosing). 
3.2.3
Self-Administered Study Drugs
The Temozolomide used in this study is a self-administered investigational agent. Such agents are 
dispensed from the pharmacy to a participant or to a Patient Care Unit for self-medication and a 
record of the dispensed investigational agent is generated and kept by the dispensing pharmacy. 
Participants will be instructed to fast at least 2 hours before and 1 hour after temozolomide 
administration. Water is allowed during the fast period. Participants will be instructed to swallow 
the capsules whole, in rapid succession, without chewing them. If vomiting occurs during the 
course of treatment, no re-dosing of the participant is allowed before the next scheduled dose. 
Antiemetic prophylaxis with a 5-HT3 antagonist is strongly recommended and should 
administered 30 to 60 minutes before temozolomide administration.

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As indicated above, participants will be asked to keep a medication diary and bring it with them 
on each study visit. Participants will also bring any remaining pills to each study visit. The 
Research Nurse reviews and validates the completeness and accuracy of the participant’s diary 
with the participant. 
If a participant goes off study while at home, the Research Nurse will ensure and document the 
return of the unused oral investigational agents from the participant. Unused investigational agent 
will be destroyed per dispensing pharmacy procedure. 
3.3
DOSE MODIFICATIONS AND MANAGEMENT OF TOXICITIES:

In the case of toxicity, appropriate medical treatment should be used (including anti-emetics, 
anti-diarrheals, etc.). 

Once a participant has a dose reduction for toxicity, the dose will not be increased. 

Participants continuing to experience toxicity at the off-study visit will be contacted for 
additional assessments until the toxicity has resolved or is deemed irreversible. Participants 
must remain on the study to have additional assessment. 

For AEs that are unrelated to the study drugs, study drug may be held for up to 14 days at the 
discretion of the PI. 
3.3.1
T-DM1 Dose Modifications:
If a planned dose is delayed or missed, administer as soon as possible; do not wait until the next 
planned cycle. Adjust the schedule of administration to maintain a 3-week interval between doses. 
Administer the infusion at the dose and rate the participant tolerated in the most recent infusion. 
Management of increased serum transaminases, hyperbilirubinemia, left ventricular dysfunction, 
thrombocytopenia, pulmonary toxicity or peripheral neuropathy may require temporary 
interruption, dose reduction or treatment discontinuation of T-DM1 as per guidelines provided in 
the tables below.
Recommended dose reductions for AEs during Phase II part of the trial.
Dose level
Dose
Starting dose
3.6 mg/kg
Dose reduction -1
3.0 mg/kg
Dose reduction -2
2.4 mg/kg
Stop treatment
No treatment
Dose Modification Guidelines for Infusion Related Reactions
Grade  ≤ 2
Grade ≥3 
Reduce rate of infusion to 50% of the rate at 
which the toxicity occurred
Permanently discontinue T-DM1 
Dose Modification Guidelines for Increased Serum Transaminases (AST/ALT)
Grade 2 (< 3 to ≤ 5 X ULN)
Grade 3 (< 5 to ≤ 20 X ULN) 
Grade 4 (>20 X ULN)
Treat at same dose level
Do not administer T-DM1 until 
AST/ALT recovers to Grade ≤ 
2, and then reduce one dose 
level. 
Permanently discontinue T-
DM1

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ALT = alanine transaminase; AST = aspartate transaminase; ULN = upper limit of normal. 
Dose Modification Guidelines for Hyperbilirubinemia
Grade 2 (>1.5 to ≤ 3 X ULN) 
Grade 3 (>3 to ≤ 10 X ULN)
Grade 4 (>10 X ULN)
Do not administer T-DM1 until 
total bilirubin recovers to Grade 
≤ 1, and then treat at same dose 
level. 
Do not administer T-DM1 until 
total bilirubin recovers to Grade 
≤ 1, and then reduce one dose 
level.
Permanently discontinue T-
DM1.
Permanently discontinue T-DM1 treatment in participants with serum transaminases > 3 x ULN 
and concomitant total bilirubin > 2 X ULN. 
Permanently discontinue T-DM1 in participants diagnosed with nodular regenerative hyperplasia 
(NRH).
Dose Modifications for Left Ventricular Dysfunction
Symptomatic 
CHF
LVEF <40%
LVEF 40% to ≤ 
45% and 
decrease is ≥ 
10% points from 
baseline
LVEF 40% to ≤ 
45% and 
decrease is < 
10% points from 
baseline
LVEF >45%
Discontinue T-
DM1
Do not administer 
T-DM1. 
Repeat LVEF 
assessment within 
3 weeks. If LVEF 
< 40% is 
confirmed, 
discontinue T-
DM1.
Do not administer 
T-DM1.
 
Repeat LVEF 
assessment within 
3 weeks. If the 
LVEF has not 
recovered to 
within 10% points 
from baseline, 
discontinue T-
DM1. 
Continue 
treatment with T-
DM1.
 
Repeat LVEF 
assessment within 
3 weeks. 
Continue 
treatment with T-
DM1
CHF = Congestive Heart Failure; LVEF = Left Ventricular Ejection Fraction
Dose Modification Guidelines for Thrombocytopenia
Grade 3
Grade 4
PLT 25.000/L to <50.000/L
PLT <25.000/L
Do not administer T-DM1 (hold up to 4 weeks) 
until platelet count recovers to ≤ Grade 2 
(50,000/L to < 75,000/L) , and then treat at same 
dose level, or reduce one dose level at the 
discretion of the investigator. If not resolved after 
4 weeks, then stop.
Do not administer T-DM1 (hold up to 4  weeks) 
until platelet count recovers to ≤ Grade 2 
(50,000/L to < 75,000/L), and then reduce one 
dose level. If not resolved after 4 weeks, then 
stop.
PLT = platelets
Dose modification for Interstitial Lung Disease:
Monitor participants for signs and symptoms of pneumonitis or ILD (new onset or worsening 

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shortness of breath or cough). Participants should be evaluated with imaging and/or pulmonary 
function tests including other diagnostic procedures as described below. Initial work-up may 
include clinical evaluation, monitoring of oxygenation via pulse oximetry (resting and exertion), 
laboratory work-up and high-resolution CT scan. Permanently discontinue T-DM1 in participants 
diagnosed with interstitial lung disease (ILD) or pneumonitis.
Dose modification for Peripheral Neuropathy:
Temporarily discontinue T-DM1 in participants experiencing Grade 3 or 4 peripheral neuropathy 
until resolution to ≤ Grade 2.
3.3.2
Temozolomide Dose Modifications
Dosing is based on adverse events (AEs) during the prior treatment cycle. If multiple AEs are seen, 
the dose administered should be based on the dose reduction required for the most severe grade of 
any single AE. 
Dose Level
Dose mg/m2 daily
Comments
0
RP2D
Starting dose for cycle 1 of 
phase II
-1
RP2D -10
Reduction if prior AE
-2
RP2D -20
Reduction if prior AE
Temozolomide will be started at a dose recommended for phase 2 after completion of phase 1 
portion of this study. 
 
Planned delay: 
On day 1 of each cycle (within the prior 72 hours), if ANC ≤ 1.0 x 109 /L, platelet count ≤ 75 x 
109 /L and until all grade 2, 3 or 4 non-hematologic AEs (except for alopecia, nausea, and 
vomiting) have resolved to grade ≤ 1. 
If AEs persists, treatment should be delayed by 1 week for up to 4 consecutive weeks. If, after 4 
weeks of delay, all treatment related AEs have still not resolved (to grade ≤ 1): then any further 
treatment with temozolomide should be stopped. 
Dose reductions: If any treatment related non-hematologic AE observed was grade > 2 (except 
alopecia, lymphopenia, nausea and vomiting) and/or if platelets < 50 x 109 /L and/or ANC < 1 x 
109 /L, then the dose should be reduced by one dose level. Participants who require more than two 
dose reductions will have treatment stopped. If any treatment-related non-hematologic AE 
observed was grade 4 (except alopecia, lymphopenia, nausea and vomiting) then temozolomide 
treatment should be stopped. 
Any dose reductions of temozolomide will be determined according to: (1) non-hematologic AE 
during the preceding treatment cycle, as well as (2) the lowest ANC and platelets observed. No 
dose escalation should be attempted. 
Important: If the dose was reduced or delayed for AEs, there will be no dose re-escalation in 
subsequent treatment cycles. 
Summary of Dose Modifications or Discontinuation for Temozolomide-Related Adverse Events 

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Worst Treatment-Related Non-Hematologic AE (except for alopecia, nausea, and vomiting) During the 
Previous Cycles
Grade
Dose modification
0-2
No dose modifications for non-hematologic AEs. Dose reductions based on ANC and 
platelet counts are applicable. 
3
Reduce by one dose level (except alopecia, nausea, and vomiting). 
4
Stop (except alopecia, nausea, and vomiting). Dose modifications based on ANC and 
platelet counts are not applicable. 
Worst Treatment-Related Hematologic AE During the Previous Cycle 
Platelets
Worst AE
≥75.000 /L 
50 – 75.000 /L 
< 50.000 /L 
≥ 1.5 x 109 /L 
Dose unchanged
Dose unchanged
Reduce 1 dose 
level
≥1 & ≥ 1.5 x 109 /L
Dose unchanged
Dose unchanged
Reduce 1 dose 
level
ANC
< 1 x 109 /L 
Reduce 1 dose 
level
Reduce 1 dose 
level
Reduce 1 dose 
level
Note: A complete blood count must be performed on days 14 and 28 (± 72 hours) after the first 
daily dose of each treatment cycle. 
Hematologic AE on Day 1 of Each Cycle (within the prior 72 hours before Day 1)
AE
Delay
ANC< 1.000/L 
Delay up to 4 weeks until resolved. If not resolved after 4 weeks, then 
stop. If resolved, dose delay/reductions based on non-hematologic AEs 
are applicable. 
Platelet count < 50,000 /L
Delay up to 4 weeks until resolved to grade 2 or better (≥ 50,000 /L), 
then continue with same dose, or ability to dose reduce per 
investigator discretion. If resolved, dose delay/reductions based on 
non-hematologic AEs are applicable. If not resolved after 4 weeks, 
then stop.
Non-Hematologic AE (except for alopecia, nausea, and vomiting) On Day 1 of Each Cycle (within the 
prior 72 hours)
Grade
Delay
2-4
Delay up to 4 weeks until all resolved (to grade ≤ 1). If not resolved 
after 4 weeks, then stop. If resolved, dose delay/reductions based on 
ANC and platelets are applicable. 
Instructions on Missed Doses:
Participants should be instructed to take the medication as soon as it is remembered. 
The next due dose should be taken no sooner than 12 hours after the previous dose, and the time 
of administration of the subsequent doses should be adjusted until it is back on its regular “am or 
pm” schedule. 

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3.4
QUESTIONNAIRES 
The MDASI-BT (Error! Reference source not found.) and the PROMIS® (Error! Reference 
source not found.) will be utilized for this portion of the study. Full instruments are provided in 
the appendix. Both questionnaires will be filled by the participants at the same timepoint where 
they have scheduled brain MRIs scheduled, before the appointment with the physician. In addition, 
information regarding demographics and treatment history will be collected as part of the larger 
study and used in this analysis. 
The MDASI-BT consists of 23 symptoms rated on an 11-point scale (0 to 10) to indicate the 
presence and severity of the symptom, with 0 being “not present” and 10 being “as bad as you can 
imagine.” Each symptom is rated at its worst in the last 24 hours. Symptoms included on the 
instrument include those commonly associated with cancer therapies, those associated with 
increased intracranial pressure, and those related to focal deficits. The questionnaire also includes 
ratings of how much symptoms interfered with different aspects of a participant’s life in the last 
24 hours. These interference items include: general activity, mood, work (includes both work 
outside the home and housework), relations with other people, walking, and enjoyment of life. The 
interference items are also measured on 0 - 10 scales. The average time to complete these 
instruments is 5 minutes. The MDASI-BT or SP has been translated into 18 languages 114.
The PROMIS® assess patient-perceived functional abilities with regard to cognitive tasks 
including the perception that one’s cognitive ability with regard to the domain of inquiry (e.g. 
concentration, memory) has not changed. (http://www.healthmeasures.net/explore-measurement-
systems/promis) The applied cognition abilities is universal rather than disease specific. Each 
question has five response options ranging in value from one to five. To find the total raw score 
for a short form with all questions answered, sum the values of the response to each question. 
Using rigorous methods, PROMIS® has developed item banks (a collection of items that assess a 
specific trait, e.g., pain). These instruments are available to researchers free of cost. PROMIS® can 
be applied as computerized tests or on paper and have been translated into languages other than 
English 115.

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3.5
STUDY CALENDAR
Procedure
Screening 15 Baseline
Day 1 of 
each 
Cycle13, 15
End of 
treatment 
visit14
Long Term 
Follow-up
T-DM11
X
Temozolomide2
X
History 
X
Pathology confirmation
X
Height
X
PE3
X
X
X
NIH Advanced Directives Form4
X
HIV, HCV, HepB
X
Cardiology Assessments at screening 
and every 3 months (ECHO)5
X
X
CT of chest/abdomen /pelvis and Brain 
MRI6
X
X
Bone scan
X
CBC with differential 
X
X
X
Biochemical profile 7
X
X
X
CD4 T cell count
X
PT/INR/PTT 17
X
X
TSH
X
X
Urinalysis
X
X
Pregnancy testing8
X
X
X
X
Concomitant Medications
X
X
Adverse events
X
X
X
MDASI-BT assessment9
X
X
PROMIS9
X
X
Blood samples for Correlative Research 
Studies 
X16
Tumor block10
X
Fresh frozen tissue11
X
X
CSF sample / lumbar puncture by IR12
X
X
Phone call or e-mail for survival/new 
cancer treatments every 3 months once 
off treatment
X
1 Participants will receive 3.6 mg/kg T-DM1 IV on Day 1 of each cycle. One cycle is 21 days. 
Allowance for scheduling changes: Brief interruption and delay in the 21-day cycle (- 3/ +14 days) 
may occasionally be required due to travel delays, airport closure, inclement weather, family 
responsibilities, security alerts and government holidays, etc. This can also extend to complications 
of disease not attributable to disease progression or protocol therapy. These delays will not be 
considered protocol deviation. 

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2 During Phase I all patents will receive Temozolomide in a dose according to escalation schedule 
from 30 to 50 mg/m2 PO daily. During Phase II patents, randomized to Arm B will receive 
Temozolomide according to dose estimated during Phase I
3Weight, vital signs, ECOG performance status and complete neurological exam
4 As indicated in section 11.3, all subjects will be offered the opportunity to complete an NIH 
advanced directives form. This should be done preferably at baseline but can be done at any time 
during the study as long as the capacity to do so is retained. The completion of the form is strongly 
recommended, but is not required
5 Cardiology assessments: 2-D Echocardiogram or MUGA-scan; to be repeated every 3 months 
(+/- 2 weeks to adjust to participant visits) 
6 During Year 1, CT of chest/abdomen/pelvis and contrast brain MRI will be repeated every 6 
weeks (- 3/ +14 days).  Beginning with Year 2, imaging may be completed every 12 weeks (- 3/ 
+14 days) at the discretion of the PI.
7 Sodium, potassium, chloride, carbon dioxide, BUN, creatinine or measured creatinine clearance, 
glucose, AST, ALT, bilirubin total and direct, calcium, total protein, albumin, alkaline 
phosphatase, magnesium
8 Urine or serum HCG
9 On baseline and every Odd Numbered Cycle, to be completed within +/- 1week of the MRI 
assessment date. Optional for people who do not speak English. 
10 Primary tumor paraffin block or unstained slides (minimum of 20 slides) will be requested at 
enrollment to perform comparative genomic analysis as part of correlative studies planned for this 
clinical trial.
11 Only applies to participants that have undergone tumor resection at recurrence or prior to study 
enrollment.
12 LP guided by fluoroscopy at Baseline and C3D1 are mandatory, three LP guided by 
fluoroscopy after C3 are optional.
13 Tests done at Baseline do not need to be repeated on Day 1 of Cycle 1 if performed during 72 
hours before C1D1. Tests can be done 72 hours before Day 1 of every cycle.
14 End of treatment visit will occur approximately 30 days after the last dose of study drug. If the 
participant cannot return to the Clinical Center for this visit, a request will be made to collect 
required clinical labs from a local physician or laboratory. If this is not possible, participants may 
be assessed by telephone for symptoms.
15 Screening and Day 1 cycle visits for Cycle 3 and beyond may be completed by remote visit 
with a member of the study team (e.g., if the participant is not able to return to the NIH CC). 
Remote visits will be conducted in compliance with NIH guidelines and FDA regulations.  A 
participant may be referred to their local provider for pre-treatment assessment, T-DM1 IV 
treatment, and lab tests, or asked to come to the NIH CC for an in-person assessment, if 
clinically indicated, and at the discretion of the PI.  In the case of any visits with participants’ 
local providers, records will be obtained. There is no variation among labs for tests being 
performed; they are all standardized tests. In the event that the participant is unable to return to 
the NIH Clinical Center during a follow up visit, imaging may be delayed, but will be completed 

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as soon as feasible. Collection of research blood, CSF or urine will be omitted or collected in a 
delayed fashion.
16 Pharmacokinetics samples will be collected one time only, Phase I only. See Section 5.1.
17 Every effort will be made to collect PT/ INR and aPTT baseline and as clinically indicated. 
Routine testing may resume when tubes become available.
3.6
COST AND COMPENSATION
3.6.1
Costs
NIH does not bill health insurance companies or participants for any research or related clinical 
care that participants receive at the NIH Clinical Center.  If some tests and procedures performed 
outside the NIH Clinical Center, participants may have to pay for these costs if they are not covered 
by insurance company.  Medicines that are not part of the study treatment will not be provided or 
paid for by the NIH Clinical Center.    
3.6.2
Compensation
Participants will not be compensated on this study.
3.6.3
Reimbursement 
The NCI will cover the costs of some expenses associated with protocol participation.  Some of 
these costs may be paid directly by the NIH and some may be reimbursed to the 
participant/guardian as appropriate.  The amount and form of these payments are determined by 
the NCI Travel and Lodging Reimbursement Policy.
3.7
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY CRITERIA
Prior to documenting removal from study, effort must be made to have all subjects complete a 
safety visit approximately 30 days following the last dose of study therapy.
3.7.1
Criteria for removal from protocol therapy

Progressive disease (distant brain metastases or systemic disease progression)

Necessity to increase dose of corticosteroid

Participant requests to be withdrawn from active therapy

Unacceptable Toxicity as defined in sections 3.1 and 3.3

Investigator discretion

Positive pregnancy test
3.7.2
Off-Study Criteria

Participant requests to be withdrawn from study

Death

Investigator discretion 

PI decision to end the study

Screen failure

Lost to follow-up

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3.7.3
Lost to Follow-up
A participant will be considered lost to follow-up if he or she fails to return for 4 scheduled visits 
and is unable to be contacted by the study site staff. 
The following actions must be taken if a participant fails to return to the clinic for a required 
study visit:

The site will attempt to contact the participant and reschedule the missed visit within 14 
days, counsel the participant on the importance of maintaining the assigned visit 
schedule. and ascertain if the participant wishes to and/or should continue in the study.

Before a participant is deemed lost to follow-up, the investigator or designee will make 
every effort to regain contact with the participant (where possible, 3 telephone calls and, 
if necessary, an IRB approved certified letter to the participant’s last known mailing 
address or local equivalent methods). These contact attempts should be documented in 
the participant’s medical record or study file. 

Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up.
4
CONCOMITANT MEDICATIONS/MEASURES
4.1
T-DM1
4.1.1
Drug Interactions
No formal drug-drug interaction studies with T-DM1 have been conducted. In vitro studies 
indicate that DM1, the cytotoxic component of T-DM1, is metabolized mainly by CYP3A4 and to 
a lesser extent by CYP3A5. Concomitant use of strong CYP3A4 inhibitors (e.g., ketoconazole, 
itraconazole, clarithromycin, atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, 
telithromycin, and voriconazole) with T_DM1 should be avoided due to the potential for an 
increase in DM1 exposure and toxicity (Appendix B). Consider an alternate medication with no 
or minimal potential to inhibit CYP3A4. If concomitant use of strong CYP3A4 inhibitors is 
unavoidable, consider delaying T-DM1 treatment until the strong CYP3A4 inhibitors have cleared 
from the circulation (approximately 3 elimination half-lives of the inhibitors) when possible. If a 
strong CYP3A4 inhibitor is coadministered and T-DM1 treatment cannot be delayed, participants 
should be closely monitored for adverse reactions.
4.2
TEMOZOLOMIDE
4.2.1
Drug Interactions
Administration of valproic acid decreases oral clearance of temozolomide by about 5% and should 
be avoided in this study participants.
4.2.2
General
All supportive therapy for optimal medical care will be given during the study period at the 
discretion of the attending physician(s) within the parameters of the protocol and documented on 
each site’s source documents as concomitant medication. 

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Platelet support: Prophylactic use of platelet is only used when Platelet count < 20 x 109 /L. Platelet 
transfusion is provided for active bleeding participants with thrombocytopenia to keep platelet 
count above 50 x 109 /L. 
Corticosteroids: Corticosteroids will be allowed at enrollment and during the first month of 
treatment with T-DM1 after SRS, up to a dose of no more than 10 mg of dexamethasone daily or 
equivalent. Participants that need to continue corticosteroids after the initial month will not be 
allowed to increase the dose after that period. Participants requiring dose increase will be off 
protocol.
G-CSF administration: Routine prophylactic use is not permitted. However, therapeutic use in 
participants with complications (severe neutropenia with fever), may be considered at the 
investigator’s discretion.
Febrile Neutropenia: It may be managed according to the local institution's Infectious Disease 
guidelines. Measures may include appropriate laboratory testing, including blood and urine 
cultures and the institution of broad-spectrum antibiotics. If a source for the fever is not identified 
or the fever resolves when the neutrophil count recovers, antibiotics may be discontinued and the 
participant observed. 
Pneumocystis Pneumonia Prophylaxis: recommended to participants in use of temozolomide and 
CD4 counts <200/mm3.
Antiemetics:  Prophylactic and therapeutic use is allowed. Other concomitant medications and the 
therapies considered necessary for the well-being of the participant may be given at the discretion 
of the treating physician. All concomitant medications must be recorded. 
Bisphosphonates, regardless of indication, provided subjects have been on stable doses for at least 
2 weeks prior to randomization. Stable dose should be maintained during the investigational 
product treatment period. Subjects requiring initiation of bisphosphonate treatment, during the 
course of this study, should be discontinued due to progressive disease unless disease progression 
can be completely ruled out and clearly documented in the subject’s source documentation.
Other anticancer experimental therapies: No other anticancer therapy (including chemotherapy, 
radiation, hormonal treatment or immunotherapy) of any kind is permitted during the study period. 
No other antitumor drugs under investigation may be used concomitantly with the study drug. 
5
BIOSPECIMEN COLLECTION
5.1
CORRELATIVE STUDIES FOR RESEARCH/PHARMACOKINETIC STUDIES
Correlative studies rationale is discussed in detail in section 1.3 of this protocol. Studies will 
address aspects of TMZ resistance, molecular alterations in brain metastatic tumor cells, the neuro-
inflammatory response, and markers of cognition. Biospecimen collection and storage protocols 
are summarized below.

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Test/assay
Volume 
(approx.)
Type of 
tube***
Collection point 
Location of 
specimen analysis
Whole genome 
sequence
Tumor 
sample
if participant 
undergoes surgery 
immediately before 
enrollment or at the 
time of disease 
progression. 
Primary tumor 
paraffin block or 
unstained slides
Brastianos Lab at 
MGH or Carter 
Lab at Harvard
MGMT Analysis
Tumor 
sample
if participant 
undergoes surgery 
immediately before 
enrollment or at the 
time of disease 
progression. 
Primary tumor 
paraffin block or 
unstained slides
Steeg Lab at NCI
MGMT Analysis
CSF, 2 ml
2 ml in 
plypropylene 
tubes
C1D1, C3D1, every 
Odd Numbered 
Cycle after C3*
Steeg Lab at NCI
Cell free DNA for 
sequencing
CSF, 10 ml
Streck Cell-
Free DNA 
Blood 
Collection 
Tube (BCT
C1D1, C3D1, every 
Odd Numbered 
Cycle after C3*
Brastianos Lab at 
MGH or Carter 
Lab at Harvard
Neuroinflammatory 
marker analysis
CSF, 2 ml
2 ml in 
polypropylene 
tubes
C1D1, C3D1, every 
Odd Numbered 
Cycle after C3*
Steeg Lab at NCI
Cell free DNA for 
sequencing
Plasma, 10 
ml 
Two Streck 
Cell-Free 
DNA BCTs 
or 
BD 
Vacutainer 
EDTA tubes
D1 of each cycle
Brastianos Lab at 
MGH or Carter 
Lab at Harvard
MGMT analysis
Plasma, 10 
ml
Two Streck 
Cell-Free 
DNA BCTs 
or 
BD 
Vacutainer 
EDTA tubes
D1 of each cycle
Steeg Lab at NCI

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Test/assay
Volume 
(approx.)
Type of 
tube***
Collection point 
Location of 
specimen analysis
Exosome analysis
Plasma, 5-
10 ml
EDTA (purple 
top) tubes
D1 of each cycle
Lyden Lab at 
Weill Medical 
College
Neuroinflammatory 
marker analysis
Blood, 10 
ml
Serum 
separation 
tube without 
separator gel
D1 of each cycle
Steeg Lab at NCI
MicroRNA-34c 
(miR-34c)
Blood, 5 
ml
Serum 
separation 
tube without 
separator gel
D1 of each cycle
Steeg Lab at NCI
PK samples
Blood, 3 
ml
Sodium 
heparin 
collection 
tubes (green 
top)
Pre dose,1, 2, 3, 4 
and 8 hours post 
Temozolomide **
Figg Lab at NCI
*CSF at Baseline and C3D1 are mandatory, every Odd Numbered Cycle after C3 is optional
**PK  blood will be collected in a sample of the phase I study subjects in order to determine 
exposure to temozolomide, in one day, at schedule determined in the table.  In this instance, PK 
data will be collected in the C1 PK CRF regardless of the time point of collection.
*** Please note that tubes and media may be substituted based on availability with the 
permission of the PI or laboratory investigator.
5.2
SAMPLE COLLECTION
Please e-mail NCIBloodcore@mail.nih.gov at least 24 hours before transporting samples (the 
Friday before is preferred).
For sample pickup, page 102-11964.
For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 
240-760-6190 (main clinical pharmacology lab number).
For questions regarding sample processing, contact NCIBloodcore@mail.nih.gov
The samples will be processed, barcoded, and stored in Dr. Figg’s lab until requested by the 
investigator.
All samples sent to the Blood Processing Core (BPC) will be barcoded, with data entered and 
stored in Labmatrix utilized by the BPC. This is a secure program, with access to Labmatrix limited 
to defined Figg lab personnel, who are issued individual user accounts. Installation of Labmatrix 
is limited to computers specified by Dr. Figg. These computers all have a password restricted login 
screen. 
Labmatrix creates a unique barcode ID for every sample and sample box, which cannot be traced 
back to participants without Labmatrix access. The data recorded for each sample includes the 
participant ID, name, trial name/protocol number, time drawn, cycle time point, dose, material 

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type, as well as box and freezer location. Participant demographics associated with the clinical 
center participant number are provided in the system. For each sample, there are notes associated 
with the processing method (delay in sample processing, storage conditions on the ward, etc.).
5.2.1
Samples will be coded, linked in the BPC and sent for final analysis to: 
Brastianos Lab
Priscilla K. Brastianos, MD
Central Nervous System Metastasis Program
Division of Neuro-Oncology, Massachusetts General Hospital
55 Fruit Street, Yawkey 9E
Boston, MA 02115
Phone: 617-643-1938 
Fax: 617-643-2591 
Email: pbrastianos@mgh.harvard.edu 
Lyden Lab
David C. Lyden, MD, PhD
Stavros S. Niarchos Professor
Department of Pediatrics, and Cell and Developmental Biology
Weill Medical College of Cornell University
413 E. 69th Street, Box 284
New York, NY 10021
Phone: 646-962-6238
Fax: 646-962-0574
e-mail: dcl2001@med.cornell.edu
Steeg Lab
1. Patricia S. Steeg, Ph.D. 
a.
Email: steegp@mail.nih.gov
b. Phone: 301-402-2732
2. Brunilde Gril, Ph.D.
a.
Email: grilbrun@mail.nih.gov 
b. Phone: 301-451-6445
Building 37, Room 1126
NIH, Bethesda, MD 20892
5.2.2
Tumor, Blood Samples and CSF samples:
Fresh frozen brain tumor tissue will be requested from participants undergoing surgery 
immediately before enrollment or at the time of disease progression.
The slides and tissue blocks are stored indefinitely. All specimens are catalogued and retrieved 
utilizing the laboratory information systems. The use of any stored specimens for research 
purposes is only allowed when the appropriate IRB approval has been obtained. In some cases, 
this approval has been obtained via the original protocol on which the participant was enrolled. 

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Blood samples will be collected at Day 1 of each cycle.
CSF, guided by fluoroscopy done at Baseline and C3D1 are mandatory, every Odd Numbered 
Cycle after C3 is optional. 
Effective with Amendment (version date 07/12/2021):  PK blood samples will be collected per 
designated time points (pre dose, 1, 2, 3, 4, and 8 hours post Temozolomide) in one day only, in a 
sample of the participants remaining in the Phase I portion of the study.
The collection will follow as: collect 3mL of blood into 4ml (green top) sodium heparin collection 
tubes.  Mix by gently inverting 6 times.  Place the tubes immediately on wet ice-water bath after 
collection. Centrifuge samples within 1 hour after collection at 1300 x g for 10 minutes at 
4°C.  Place the centrifuged tubes on wet ice.  Separate the plasma from the blood into a labeled 
polpropylene freezer vial.  The samples should be processed to plasma within 30 minutes from 
centrifugation and the pH adjusted to <4 with the use of 8.5% phosphoric acid (15µL of 8.5% 
phosphoric acid per 0.5mL of plasma).  Plasma should then be stored frozen at -70°C until 
subsequent batch analysis. The collection and analysis will be perfomed by the Figg lab at NCI.
5.2.2.1
MGMT methylation in tumor and blood samples.
MGMT methylation will be tested at protein level by IHC and at mRNA level by methylation-
dependent PCR in the Steeg laboratory. For DNA methylation analysis, a procedure previously 
published will be utilized 92. For IHC, the previously published procedure will be utilized 57.
5.2.2.2
Neuroinflammatory response and neuronal damage metrics in tumor and blood samples.
Analysis of GFAP, UCH-L1 and MicroRNA-34c (miR-34c) levels in serum and CSF will be 
performed by the Steeg Lab.
5.3
SAMPLE STORAGE, TRACKING AND DISPOSITION
5.3.1
Participant sample protections
Each participant sample set will be coded with a unique participant identifier. No participant 
specific information is encoded in this identifier. The protocol scientific investigators handling 
samples will be blinded as to as to the participant identification, participant data and outcome. 
The amount of blood that may be drawn from adult participants (i.e., those persons 18 years of age 
or older) for research purposes shall not exceed 10.5 mL/kg or 550 mL, whichever is smaller, over 
any eight-week period.
5.3.2
Sample Storage, Tracking and Disposition
Samples will be ordered in CRIS and tracked through a Clinical Trial Data Management system.  
Should a CRIS screen not be available, the CRIS downtime procedures will be followed.  Samples 
will not be sent outside NIH without appropriate approvals and/or agreements, if required. 
Barcoded samples are stored in barcoded boxes in a locked freezer at either -20° or -80° C 
according to stability requirements.  These freezers are located onsite in the BPC and offsite at 
NCI Frederick Central Repository Services in Frederick, MD. Visitors to the laboratory are 
required to be accompanied by laboratory staff at all times. 
Access to stored clinical samples is restricted. Samples will be stored until requested by a 
researcher named on the protocol. All requests are monitored and tracked in Labmatrix. All 
researchers are required to sign a form stating that the samples are only to be used for research 

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purposes associated with this trial (as per the IRB approved protocol) and that any unused samples 
must be returned to the BPC. It is the responsibility of the NCI Principal Investigator to ensure that 
the samples requested are being used in a manner consistent with IRB approval.
Following completion of this study, samples will remain in storage as detailed above. Access to 
these samples will only be granted following IRB approval of an additional protocol, granting the 
rights to use the material. 
If, at any time, a participant withdraws from the study and does not wish for their existing samples 
to be utilized, the individual must provide a written request. Following receipt of this request, the 
samples will be destroyed (or returned to the participant, if so requested). The PI will record any 
loss or unanticipated destruction of samples as a deviation. Reporting will be per the requirements 
of section 7.2.
Sample barcodes are linked to participant demographics and limited clinical information. This 
information will only be provided to investigators listed on this protocol, via registered use of the 
Labmatrix. It is critical that the sample remains linked to participant information such as race, age, 
dates of diagnosis and death, and histological information about the tumor, in order to correlate 
genotype with these variables.
All specimens obtained in the protocol are used as defined in the protocol. Any specimens that are 
remaining at the completion of the protocol will be stored in the conditions described below. The 
study will remain open so long as sample or data analysis continues. Samples from consenting 
subjects will be stored until they are no longer of scientific value or if a subject withdraws consent 
for their continued use, at which time they will be destroyed.
If the participant withdraws consent the participants data will be excluded from future 
distributions, but data that have already been distributed for approved research use will not be able 
to be retrieved.
5.4
SAMPLES FOR GENETIC/GENOMIC ANALYSIS
5.4.1
Description of the scope of genetic/genomic analysis

Tumor whole-exome sequencing will be performed in collaboration with the Brastianos 
and Carter’ laboratories at Harvard.

Tumor cfDNA and primary tumor DNA sequencing in collaboration with Brastianos and 
Carter Laboratories

We plan to characterize cfDNA from CSF samples and blood at enrollment and during 
treatment. All samples will be subjected to targeted sequencing and selected cases of 
adequate quality will be subjected to WES. This will allow us to characterize somatic point 
mutations, insertion-deletion events, and copy-number changes.

Exosomes analysis in collaboration with Dr. Lyden’s laboratory at Weill Cornell Medical 
College.
5.4.2
Privacy and Confidentiality of medical information/biological specimens
Fresh tumor and blood samples will be stored in a minus 80-degree freezer. The samples of each 
participant will be barcoded. At no time will participant’s names be used on the blood and tissue 
samples. Sometimes, because a group collaboration or journal policy requires it, a subject’s genetic 
data may be deposited in a database such as dbGaP. Although there is controlled access to such a 

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database, such a submission carries theoretical risks of revealing the identity of the subject. This 
is discussed in the consent.
5.4.3
A Certificate of Confidentiality will be obtained for the study as described in section 
11.5.12. 
5.4.4
Management of Results
Subjects will be contacted if a clinically actionable gene variant is discovered. Clinically 
actionable findings for the purpose of this study are defined as disorders appearing in the 
American College of Medical Genetics and Genomics recommendations for the return of 
incidental findings that is current at the time of primary analysis. (A list of current guidelines is 
maintained on the CCR intranet: 
https://ccrod.cancer.gov/confluence/display/CCRCRO/Incidental+Findings+Lists).  Subjects will 
be contacted at this time with a request to provide a blood sample to be sent to a CLIA certified 
laboratory.  
5.4.5
Genetic counseling
If the research findings are verified in the CLIA certified lab, the subject will be offered the 
opportunity to come to NIH (at our expense) to have genetic education and counseling with the 
NCI Genetics Branch to explain this result.  If the subject does not want to come to NIH, a referral 
to a local genetic healthcare provider will be provided (at their expense). This is the only time 
during the course of the study that incidental findings will be returned. No interrogations regarding 
clinically actionable findings will be made after the primary analysis.
6
DATA COLLECTION AND EVALUATION 
6.1
DATA COLLECTION
The PI will be responsible for overseeing entry of data into a 21 CFR Part 11-compliant data 
capture system provided by the NCI CCR and ensuring data accuracy, consistency and timeliness. 
The principal investigator, associate investigators/research nurses and/or a contracted data 
manager will assist with the data management efforts. Primary and final analyzed data will have 
identifiers so that research data can be attributed to an individual human subject participant.
All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event.
Document AEs from the first study treatment, Study Day 1, through 30 days after the subject 
received the last administration of the study agent.
An abnormal laboratory value will be recorded in the database as an AE only if the laboratory 
abnormality is characterized by any of the following:

Results in discontinuation from the study

Is associated with clinical signs or symptoms 

Requires treatment or any other therapeutic intervention

Is associated with death or another serious adverse event, including hospitalization. 

Is judged by the Investigator to be of significant clinical impact

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
If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the 
participant’s outcome.
End of study procedures: Data will be stored according to HHS, FDA regulations and NIH 
Intramural Records Retention Schedule as applicable. 
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, this will be reported expeditiously per 
requirements in section 7.2.1. 
6.1.1
Source Documents 
Source documents are defined as original documents, data and records. This may include hospital 
records, clinical and office charts, laboratory data/information, patients' diaries or evaluation 
checklists, pharmacy dispensing and other records, recorded data from automated instruments, 
microfiches, photographic negatives, microfilm or magnetic media, X-rays. The investigator will 
permit trial-related monitoring, audits, IRB review, and regulatory inspection(s), providing direct 
access to source documents. 
6.1.2
Case Report Forms 
Data may be entered from the source documents directly into eCRFs for each participant enrolled 
in this study. The principal investigator or research nurse will review the eCRFs for completeness 
and accuracy. Independent audits may also be conducted by NCI personnel to ensure completeness 
and accuracy of data in study database.
6.1.3
Data Quality Assurance
The research team will monitor each participant’s dataset throughout the study. Source document 
review will be made against entries on the eCRF and a quality assurance check will be performed 
to ensure that the investigator is complying with the protocol and regulations. In addition, after the 
research team (data managers) completes the CRFs a research nurse or physician at the NCI will 
review and verify the data.
6.2
DATA SHARING PLANS
6.2.1
Human Data Sharing Plan
What data will be shared?
I will share human data generated in this research for future research as follows:

Coded, linked data in an NIH-funded or approved public repository.  

Coded, linked data in BTRIS (automatic for activities in the Clinical Center)

Coded, linked or identified data with approved outside collaborators under appropriate 
agreements.
Data will be shared through:

An NIH-funded or approved public repository: clinicaltrials.gov.

BTRIS (automatic for activities in the Clinical Center)

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
Approved outside collaborators under appropriate individual agreements.

Publication and/or public presentations.
Data will be shared: 

Before publication.

At the time of publication or shortly thereafter.
6.2.2
Genomic Data Sharing Plan
Unlinked genomic data will be deposited in public genomic databases such as dbGaP in 
compliance with the NIH Genomic Data Sharing Policy.
6.3
RESPONSE CRITERIA
For the purposes of this study, participants should be re-evaluated for response every 6 weeks.  In 
addition to baseline images, confirmatory images should also be obtained 3 weeks following initial 
documentation of objective response. 
6.3.1
RANO-BM Criteria for Evaluation of Brain Lesions
The primary endpoint of this study, however, is 12-month freedom from distant brain metastases 
after initial SRS or surgery. A combination of the neurological examination and MRI brain scan 
will be used to define progression. Due to improvements in neuroimaging and the fact that tumor 
growth in certain regions of the CNS is without immediate neurologic signs and symptoms, greater 
reliance is placed on neuroimaging to define progression. Brain MRI assessment for CNS disease 
progression will be done every 6 weeks. Time to distant brain CNS failure will be scored from the 
date of randomization to the date of diagnosis of a new focus of contrast enhancement outside the 
prior SRS region. Any lesions that cannot be undoubtedly classified as new or increasing tumor 
will have to be confirmed to be present on two consecutive MRI scans and growing, following 
recommendations of The Response Assessment in Neuro-Oncology Brain Metastases (RANO-
BM) 116. (Appendix D)
Participants with questionable progression or recurrence of tumor in areas of brain previously 
treated by SRS, that cannot be differentiated from necrosis post SRS without biopsy, will be 
continued in protocol treatment and follow-up, as long as no local treatment is recommended by 
their primary physicians (oncology or radiation therapy). In the instance wherein a lesion is found 
retrospectively and pre-dated study therapy, that lesion or lesions may receive local treatment if 
deemed in the best interest of the partcipant.  Participants indicated to receive WBRT or new SRS 
because of local recurrence in brain will be off protocol and censored for analysis. Participants 
with systemic progression with no CNS new lesions will also be off protocol and censored for 
analysis. Participants with new brain tumor lesions away from previously treated (by SRS or 
surgery) are the ones considered progression of disease, independently of the systemic status of 
disease and/or concomitant recurrence in brain areas previously treated by SRS/surgery. They will 
be off protocol for progression with distant brain metastases and will be accounted for in the 
statistical analysis.
6.3.1.1
Definitions of Response 
Measurable Disease: 
Bi-dimensionally measurable lesions with clearly defined margins by MRI scan. 

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Objective Status, To Be Recorded at Each Evaluation: 
If there are too many measurable lesions to measure at each evaluation, choose the largest two to 
be followed before a patient is entered on study. The remaining lesions will be considered 
evaluable for the purpose of objective status determination. Unless progression is observed, 
objective status can only be determined when ALL measurable and evaluable sites and lesions are 
assessed. 
Response Criteria 
Stable/No Progression: No evidence of new measurable lesions on MR imaging. The designation 
of Stable/No Progression requires a minimum of 12 weeks duration. All measurable and evaluable 
sites must be assessed using the same techniques as baseline. 
Partial response: ≥ 50% reduction in the sum of products of all measurable lesions over baseline 
sum observed using the same techniques as baseline. The patient must be on a stable or decreased 
dose of corticosteroids to be evaluable for response. 
Complete response: Complete resolution of all lesions. The patient cannot be on any 
corticosteroids with the exception of adrenal replacement doses. 
Progression: 25% increase in the sum of products of all measurable lesions over smallest sum 
observed (over baseline if no decrease) using the same techniques as baseline, OR clear worsening 
of any evaluable disease, OR appearance of any new lesion/site, OR failure to return for evaluation 
due to death or deteriorating condition (unless clearly unrelated to this cancer). 
Unknown: Progression has not been documented and one or more measurable or evaluable sites 
have not been assessed. 
6.3.2
RECIST for Systemic Evaluation
Systemic response and progression will be evaluated in this study using the new international 
criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1) [Eur J Ca 45:228-247, 2009].  Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph nodes 
are used in the RECIST criteria.
If participant develop additional systemic lesions without CNS progression and require new 
therapy, they will be taken off the trial. This group will be followed separately to determine their 
RFS. Additional participant will be accrued to meet the 49 goal with one year of follow up. 
6.3.2.1
Definitions
Evaluable for toxicity:  All participant will be evaluable for toxicity from the time of their first 
treatment with Temozolomide and/or T-DM1.
Evaluable for objective response: Only those participant who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will 
be considered evaluable for response.  These participant will have their response classified 
according to the definitions stated below.  (Note:  Participant who exhibit objective disease 
progression prior to the end of cycle 1 will also be considered evaluable.)
Evaluable Non-Target Disease Response:  Participant who have lesions present at baseline that are 
evaluable but do not meet the definitions of measurable disease, have received at least one cycle 

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of therapy, and have had their disease re-evaluated will be considered evaluable for non-target 
disease.  The response assessment is based on the presence, absence, or unequivocal progression 
of the lesions. 
6.3.2.2
Disease Parameters
Measurable disease:  Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as:

By chest x-ray: >20 mm; 

By CT scan: 
o
Scan slice thickness 5 mm or under: as >10 mm
o
Scan slice thickness >5 mm: double the slice thickness 

With calipers on clinical exam: >10 mm.  
  All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters).
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a lymph node 
must be >15 mm in short axis when assessed by CT scan (CT scan slice thickness recommended 
to be no greater than 5 mm).  At baseline and in follow-up, only the short axis will be measured 
and followed.
Non-measurable disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), are considered 
non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, pleural/pericardial 
effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, and abdominal masses (not 
followed by CT or MRI), are considered as non-measurable.
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not be 
considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts.
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, if 
they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions.
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded and 
measured at baseline.  Target lesions should be selected on the basis of their size (lesions with the 
longest diameter), be representative of all involved organs, but in addition should be those that 
lend themselves to reproducible repeated measurements.  It may be the case that, on occasion, the 
largest lesion does not lend itself to reproducible measurement in which circumstance the next 
largest lesion which can be measured reproducibly should be selected.  A sum of the diameters 
(longest for non-nodal lesions, short axis for nodal lesions) for all target lesions will be calculated 
and reported as the baseline sum diameters.  If lymph nodes are to be included in the sum, then 
only the short axis is added into the sum.  The baseline sum diameters will be used as reference to 
further characterize any objective tumor regression in the measurable dimension of the disease.
Non-target lesions.  All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 

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recorded at baseline.  Measurements of these lesions are not required, but the presence, absence, 
or in rare cases unequivocal progression of each should be noted throughout follow-up. 
6.3.2.3
Methods for Evaluation of Measurable Disease
All measurements should be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment.
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam.
Clinical lesions:  Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and 10 mm diameter as assessed using calipers 
(e.g., skin nodules).  In the case of skin lesions, documentation by color photography, including a 
ruler to estimate the size of the lesion, is recommended. 
Chest x-ray:  Lesions on chest x-ray are acceptable as measurable lesions when they are clearly 
defined and surrounded by aerated lung.  However, CT is preferable. 
Conventional CT and MRI:  This guideline has defined measurability of lesions on CT scan based 
on the assumption that CT slice thickness is 5 mm or less.  If CT scans have slice thickness greater 
than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness.  MRI is 
also acceptable in certain situations (e.g. for body scans).  
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal resolution; 
however, there are many image acquisition variables involved in MRI, which greatly impact image 
quality, lesion conspicuity, and measurement.  Furthermore, the availability of MRI is variable 
globally.  As with CT, if an MRI is performed, the technical specifications of the scanning 
sequences used should be optimized for the evaluation of the type and site of disease.  Furthermore, 
as with CT, the modality used at follow-up should be the same as was used at baseline and the 
lesions should be measured/assessed on the same pulse sequence.  It is beyond the scope of the 
RECIST guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body 
parts, and diseases.  Ideally, the same type of scanner should be used and the image acquisition 
protocol should be followed as closely as possible to prior scans.  Body scans should be performed 
with breath-hold scanning techniques, if possible.
PET-CT:  At present, the low dose or attenuation correction CT portion of a combined PET-CT is 
not always of optimal diagnostic CT quality for use with RECIST measurements.  However, if the 
site can document that the CT performed as part of a PET-CT is of identical diagnostic quality to 
a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be used for 
RECIST measurements and can be used interchangeably with conventional CT in accurately 
measuring cancer lesions over time.  Note, however, that the PET portion of the CT introduces 
additional data which may bias an investigator if it is not routinely or serially performed.  
Ultrasound:  Ultrasound is not useful in assessment of lesion size and should not be used as a 
method of measurement.  Ultrasound examinations cannot be reproduced in their entirety for 
independent review at a later date and, because they are operator dependent, it cannot be 

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guaranteed that the same technique and measurements will be taken from one assessment to the 
next.  If new lesions are identified by ultrasound in the course of the study, confirmation by CT or 
MRI is advised.  If there is concern about radiation exposure at CT, MRI may be used instead of 
CT in selected instances.
Endoscopy, Laparoscopy:  The utilization of these techniques for objective tumor evaluation is not 
advised.  However, such techniques may be useful to confirm complete pathological response 
when biopsies are obtained or to determine relapse in trials where recurrence following complete 
response (CR) or surgical resection is an endpoint.
Tumor markers:  Tumor markers alone cannot be used to assess response.  If markers are initially 
above the upper normal limit, they must normalize for a patient to be considered in complete 
clinical response.  Specific guidelines for both CA-125 response (in recurrent ovarian cancer) and 
PSA response (in recurrent prostate cancer) have been published [JNCI 96:487-488, 2004; J Clin 
Oncol 17, 3461-3467, 1999; J Clin Oncol 26:1148-1159, 2008].  In addition, the Gynecologic 
Cancer Intergroup has developed CA-125 progression criteria which are to be integrated with 
objective tumor assessment for use in first-line trials in ovarian cancer [JNCI 92:1534-1535, 2000].
Cytology, Histology:  These techniques can be used to differentiate between partial responses (PR) 
and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as germ cell 
tumors, where known residual benign tumors can remain).
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens 
during treatment when the measurable tumor has met criteria for response or stable disease is 
mandatory to differentiate between response or stable disease (an effusion may be a side effect of 
the treatment) and progressive disease.
FDG-PET:  While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in assessment 
of progression (particularly possible 'new' disease).  New lesions on the basis of FDG-PET imaging 
can be identified according to the following algorithm: 
a.
Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD 
based on a new lesion.
b. No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive FDG-
PET at follow-up corresponds to a new site of disease confirmed by CT, this is PD.  If 
the positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, 
additional follow-up CT scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-
PET scan).  If the positive FDG-PET at follow-up corresponds to a pre-existing site of 
disease on CT that is not progressing on the basis of the anatomic images, this is not 
PD.
c.
FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy 
in cases where a residual radiographic abnormality is thought to represent fibrosis or 
scarring.  The use of FDG-PET in this circumstance should be prospectively described 
in the protocol and supported by disease-specific medical literature for the indication.  
However, it must be acknowledged that both approaches may lead to false positive CR 
due to limitations of FDG-PET and biopsy resolution/sensitivity.

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 Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake greater 
than twice that of the surrounding tissue on the attenuation corrected image.
6.3.2.4
Response Criteria
6.3.2.4.1 Evaluation of Target Lesions
Complete Response (CR): Disappearance of all target lesions.  Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm.
Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, taking 
as reference the baseline sum of diameters.
Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest 
on study).  In addition to the relative increase of 20%, the sum must also demonstrate an absolute 
increase of at least 5 mm.  (Note:  the appearance of one or more new lesions is also considered 
progressions).
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum of diameters while on study.
6.3.2.4.2 Evaluation of Non-Target Lesions
Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor 
marker level.  All lymph nodes must be non-pathological in size (<10 mm short axis).
Note:  If tumor markers are initially above the upper normal limit, they must normalize for a patient 
to be considered in complete clinical response.
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits.
Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal progression 
of existing non-target lesions.  Unequivocal progression should not normally trump target lesion 
status.  It must be representative of overall disease status change, not a single lesion increase.    
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the treating 
physician should prevail in such circumstances, and the progression status should be confirmed at 
a later time by the review panel (or Principal Investigator).
6.3.2.4.3 Evaluation of Best Overall Response
The best overall response is the best response recorded from the start of the treatment until disease 
progression/recurrence (taking as reference for progressive disease the smallest measurements 
recorded since the treatment started).  The patient's best response assignment will depend on the 
achievement of both measurement and confirmation criteria.

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For Participant with Measurable Disease (i.e., Target Disease)
Target 
Lesions
Non-Target 
Lesions
New 
Lesions
Overall 
Response
Best Overall Response when 
Confirmation is Required*
CR
CR
No
CR
>4 wks. Confirmation**
CR
Non-
CR/Non-PD
No
PR
CR
Not 
evaluated
No
PR
PR
Non-
CR/Non-
PD/not 
evaluated
No
PR
>4 wks. Confirmation**
SD
Non-
CR/Non-
PD/not 
evaluated
No
SD
Documented at least once >4 
wks. from baseline**
PD
Any
Yes or 
No
PD
Any
PD***
Yes or 
No
PD
Any
Any
Yes
PD
no prior SD, PR or CR
*
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion.
**
Only for non-randomized trials with response as primary endpoint.
***
In exceptional circumstances, unequivocal progression in non-target lesions may be accepted as 
disease progression.
Note:
Participant with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be reported as “symptomatic 
deterioration.”  Every effort should be made to document the objective progression even after 
discontinuation of treatment.
For Participant with Non-Measurable Disease (i.e., Non-Target Disease)
6.3.3
Duration of Response
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started).
Non-Target Lesions
New Lesions
Overall Response
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PD*
Not all evaluated
No
not evaluated
Unequivocal PD
Yes or No
PD
Any
Yes
PD
*  ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is increasingly used 
as an endpoint for assessment of efficacy in some trials so to assign this category when no lesions can be 
measured is not advised

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The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that progressive disease is objectively documented.
Duration of stable disease:  Stable disease is measured from the start of the treatment until the 
criteria for progression are met, taking as reference the smallest measurements recorded since the 
treatment started, including the baseline measurements. 
6.3.4
Relapse -Free Survival
RFS is defined as the duration of time from start of treatment to time of progression or death, 
whichever occurs first.
6.3.5
Validation of Disease Assessment (Safety Mechanisms) 
The following practices will ensure accuracy in disease assessment:
Dr. Ritu Shah, Neuroradiolgist, or her designee will be provided with a list of patients scheduled 
for imaging by a member of the WMB team approximately 4-5 days in advance of clinic except in 
cases where urgent imaging is warranted. In the case of urgent scans, a member of the WMB team 
will make every effort to contact Dr. Shah with as much notice as the clinical situation allows prior 
to and/or after the urgent imaging as been performed.
The electronic medical record (EMR) protocol order set for Brain MRIs has been modified to 
include the following language provided by the Neuroradiology Leadership, “Comment on any 
new lesions relative to baseline. Any enhancing lesion 5 x 5mm or greater described for the FIRST 
time is to be called as a NEW lesion, even if it can be seen in retrospect on older studies. For 
comparison, use Baseline scan of _________.” Should additional clarity or requests be made by 
Neuroradiology regarding order language, we will continue to amend the orders in a timely 
manner. Every effort will be made that each brain MRI will be initially read by neuroradiologist 
on call the day scans are performed or on the day patient(s) present to clinic; this review is to rule 
out any major finding requiring immediate attention. To review specific imaging findings related 
to the study, Dr. Shah will meet with Dr Zimmer to review the images within 7 days, optimally 
within 24-48 hours. Dr. Zimmer will document the patient respective findings in the EMR then 
route for Dr. Shah’s co-signature. In the absence of Dr. Shah, she may delegate her responsibilities 
to a Neuroradiology colleague.
6.4
TOXICITY CRITERIA
The following adverse event management guidelines are intended to ensure the safety of each 
patient while on the study.  The descriptions and grading scales found in the revised NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE 
reporting.  All appropriate treatment areas should have access to a copy of the CTCAE version 
4.0.  A copy of the CTCAE version 4.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40). 

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7
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN
7.1
DEFINITIONS
Please refer to definitions provided in Policy 801: Reporting Research Events found at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&Guidance-
800Series-ComplianceandResearchEventReportingRequirements.
7.2
OHSRP OFFICE OF COMPLIANCE AND TRAINING / IRB  REPORTING
7.2.1
Expedited Reporting
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 
802 Non-Compliance Human Subjects Research found at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&Guidance-
800Series-ComplianceandResearchEventReportingRequirements.
7.2.2
IRB Requirements for PI Reporting at Continuing Review
Please refer to the reporting requirements in Policy 801: Reporting Research Events found at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&Guidance-
800Series-ComplianceandResearchEventReportingRequirements. 
7.3
NCI CLINICAL DIRECTOR REPORTING 
Problems expeditiously reported to the OHSRP in iRIS will also be reported to the NCI Clinical 
Director.  A separate submission is not necessary as reports in iRIS will be available to the Clinical 
Director.
In addition to those reports, all deaths that occur within 30 days after receiving a research 
intervention should be reported via email to the Clinical Director unless they are due to progressive 
disease.  
To report these deaths, please send an email describing the circumstances of the death to the 
Clinical Director/designee at NCICCRQA@mail.nih.gov within one business day of learning of 
the death.
7.4
NIH REQUIRED DATA AND SAFETY MONITORING PLAN
7.4.1
Principal Investigator/Research Team 
The clinical research team will meet or have a teleconference every other week when participants 
are being actively treated on the trial to discuss each patient. Decisions about dose level enrollment 
and dose escalation if applicable will be made based on the toxicity data from prior participants. 
All data will be collected in a timely manner and reviewed by the principal investigator or a lead 
associate investigator. Events meeting requirements for expedited reporting as described in section 
7.2.1 will be submitted within the appropriate timelines.
The principal investigator will review adverse event and response data on each patient to ensure 
safety and data accuracy. The principal investigator will personally conduct or supervise the 
investigation and provide appropriate delegation of responsibilities to other members of the 
research staff. 

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7.4.2
Data Safety Monitoring Board (DSMB)
This protocol requires monitoring by the NCI CCR Data Safety Monitoring Board (DSMB) as 
described in Section 9.4.6.  Interim outcome results will not be revealed to the investigators of the 
trial; results will be presented to the investigators prior to final accrual to the trial only if the DSMB 
recommends early termination of the trial. 
7.4.3
Corrective Action Plan
The study has implemented a corrective action plan to assure timely and accurate disease 
assessment. Please reference Section 6.3.5 Validation of Disease Assessment (Safety 
Mechanisms).
Additionally, the study will undergo oversight by an Independent Monitoring Committee (7.4.4). 
7.4.4
Independent Monitoring Committee (IMC)
Additional oversight for this study will be provided by an Independent Monitoring Committee 
consisting of the Principal Investigator and two qualified investigators who are independent of the 
study team. The committee meetings will be conducted annually for the duration of time that 
participants are having disease response evaluations per protocol.  Ad hoc meetings may be called 
at more frequent intervals for cause at the request of the PI or the independent reviewers.
During these meetings, the committee will review the results of the findings from the procedures 
described in Section 6.3.5 Validation of Disease Assessment (Safety Mechanisms) to ensure 
disease assessment is managed accurately in accordance with protocol requirements.  These results 
will be provided to the IMC by the PI or designee.
The PI will be responsible for promptly alerting the independent reviewers of any missed disease 
assessments identified during the validation process. Event reporting and event management will 
be submitted for appropriate adjudication and reported promptly to the IRB.
8
SAFETY REPORTING CRITERIA TO THE PHARMACEUTICAL 
COLLABORATOR
Principal Investigator shall report any SAE, SUSAR, Medical Device Event, Device Deficiency 
or Incident information, including, but not limited to, all initial and follow-up information 
involving any Study subject in the Study. 
Serious Adverse Event and Suspected Unexpected Serious Adverse Reaction, Medical Device 
Event, Potential Incident, Device Deficiency or Incident Reporting:  Principal Investigator shall 
report any SAE, SUSAR, Medical Device Event, Device Deficiency or Incident information, 
including, but not limited to, all initial and follow-up information involving any Study subject in 
the Study.  Notification shall be in the form of a completed CIOMS I/MedWatch (or other mutually 
agreed upon format) within two (2) business days of learning of the information.  This information 
shall be transmitted to Merck GS using the contact information provided below or such other 
modified contact information as provided by Merck in writing.  All information shall be 
transmitted in the English language and contain the reporter’s name and the Study subject identifier 
code.   SUSAR information will be reported unblinded if the Study Drug has been blinded in the 
Study.  Randomization codes for all other SAEs will be provided to Merck GS at end of Study if 
the Study Drug has been blinded in the Study.

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 Merck may define certain Non-Serious Events of Interest.  If any Non-Serious Events of Interest 
are defined, Merck will provide such information in writing to Principal Investigator at the time 
of Protocol approval, execution of the CTA or anytime thereafter.  Reporting of any defined Non-
Serious Events of Interest will be handled in the same manner as SAEs unless mutually agreed 
otherwise in writing by the parties. 
All reports of Study Drug exposure during pregnancy or lactation (including a female partner of a 
male Study subject using the Study Drug), whether associated with an AE or not, must be reported 
to Merck GS in accordance with the timelines and contact information for an SAE.  Principal 
Investigator shall follow pregnancies to term to obtain the outcome of the pregnancy.  The outcome 
of the pregnancy shall be forwarded to Merck GS.
The Principal Investigator shall fully comply with all of their respective reporting obligations to 
the applicable regulatory authorities with respect to any AE, SAE or SUSAR that arises from the 
Study.
SAE reports and any other relevant safety information are to be forwarded to Merck GS facsimile 
number:  215-993-1220.
A MedWatch form available at http://www.fda.gov/medwatch/  
9
STATISTICAL CONSIDERATIONS  
9.1
STATISTICAL HYPOTHESES
Primary efficacy endpoints: 
Safety: Determination of the MTD assessed at the completion of cycle 1 (21 days)
Efficacy: Freedom from distant new brain metastases following stereotactic radiosurgery or 
surgical resection at 1 year, measured by rate of brain relapse free survival (RFS) for temozolomide 
and TDM-1 vs. TDM-1 alone assessed at approximately 12-24 months after the last participant 
starts treatment. 
Secondary Efficacy endpoints:
Number of participants with DLTs at each dose level assessed at the completion of cycle 1 (21 
days)
Tabulated counts of adverse events assessed through 30 days after the completion of study therapy 
Time to whole brain irradiation compared between the two arms assessed at time of whole brain 
irradiation
Overall survival compared between the two arms assessed at death
9.2
SAMPLE SIZE DETERMINATION
Phase I:
The initial safety evaluation will be done using a standard 3+3 design. Thus, with 3 dose levels, 
up to 18 participants may be included in the initial safety evaluation.
Phase II:

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Following a safety evaluation, the primary objective of the trial is to determine if the addition of 
temozolomide to TDM-1 will be associated with an increase in new brain metastases Relapse Free 
Survival (brain RFS) among participants with breast cancer and resection of brain metastases. 
While there are no published reports on participants with HER2+ disease and SRS without WBRT, 
one paper indicated that the 12 month brain RFS is approximately 51% in participants with breast 
cancer and resected brain metastases that are treated with SRS alone 117. This will be used  to help 
estimate the sample size. The goal would be to determine if this can be increased by a modest 
amount with the addition of temozolomide.  T-DM1 will be used as the backbone systemic 
treatment. Initially, a small (3 dose level) phase I-type run-in for safety will be needed for 
evaluation of T-DM1 and temozolomide combination. 
In the main, randomized cohort of the trial, Kaplan-Meier curves and a one-tailed log-rank test 
will be the primary analysis methods. Assuming exponential brain RFS curves, the hazard rate for 
TDM-1 associated with a 50% 12 month brain RFS is 0.0578: approximately a 5.8% probability 
of relapsing each month when the 12 month brain RFS probability is 50%. If we assume that the 
addition of temozolomide will increase brain RFS to 65% at 12 months, this corresponds to a 
hazard rate of 0.0359 and the resulting hazard ratio for the comparison of the two overall actuarial 
curves would be 1.61. Following the principles of a phase 2.5 trial, to compare these curves and 
detect a difference with a 0.10 significance level one-tailed log-rank test, a total of 49 evaluable 
subjects per arm (98 total) will need to be randomized over a 3-year period and followed for an 
additional 2 years from the date of entry of the last participant, with occurrence of 79 total relapses 
in both arms combined, to have 80% power to compare the curves. It should also be noted that if 
the true 12 month brain RFS probability without temozolomide were closer to 55%, that 49 
participants per arm would provide 83% power for a comparison with 70%, using otherwise 
identical parameters.
Participants will be randomized to receive TDM-1 or TDM-1 + temozolomide after being 
registered onto the study, and will be stratified prior to randomization for characteristics potentially 
associated with relapse: 1 brain lesion in the absence of extracranial disease or presence of stable 
extracranial disease, 2-5 brain lesions in the absence of extracranial disease or stable extracranial 
disease, >5 brain lesions in the absence of extracranial disease or stable extracranial disease, 1 
brain lesion and progressive extracranial disease, 2-5 brain lesions and progressive extracranial 
disease, >5 brain lesions and progressive extracranial disease. If participants develop additional 
systemic lesions and require new therapy, they will be taken off treatment. This group will be 
followed separately to determine their brain RFS. Additional participants will be accrued to meet 
the 49 goal with one year of follow up. 
It is expected that approximately 30 to 40 participants per year can be accrued onto this trial, and 
thus accrual to both phases of the trial will be completed in approximately 3-4 years. Allowing for 
a very small number of inevaluable participants, the accrual ceiling will be set at 125 participants 
to permit up to 18 participants in the initial dose escalation phase and 98 randomized evaluable 
participants.
9.3
POPULATIONS FOR ANALYSIS
Phase I: all participants who received at least one dose of the agents
Phase II: Modified intention to treat analysis (all participants who received at least one dose of the 
agents)

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9.4
STATISTICAL ANALYSES
9.4.1
General approach
Safety data will be tabulated and reported per arm.
Kaplan-Meier curves will be created for each of the randomized arms and compared using a two-
tailed log-rank test, with a one-sided 0.10 significance level of interest to be detected.
9.4.2
Analysis of the primary safety and efficacy endpoints
The MTD will be identified based on being the dose level at which 0 or 1 participant in 6 has a 
DLT.
Brain RFS curves will be created using the Kaplan-Meier method based on all participants 
considered to be evaluable based on having received protocol treatment, and compared using a 
one-tailed log-rank test, with a one-sided 0.10 significance level of interest to be detected.
9.4.3
Analysis of the secondary efficacy endpoints
Number of participants with DLTs at each dose level: tabulated counts
Toxicity data: tabulated counts
Time to whole brain irradiation compared between the two arms: Kaplan-Meier curves constructed 
with a two-tailed log-rank test used to compare the arms.
Overall survival compared between the two arms Kaplan-Meier curves constructed with a two-
tailed log-rank test used to compare the arms.
9.4.4
Safety Analyses
Toxicity data: tabulated counts and adverse events will be evaluated descriptively.
9.4.5
Baseline Descriptive Statistics
Demographic and clinical characteristics of participants on both arms will be tabulated.
9.4.6
Planned interim analyses
This study will be monitored by the NCI/CCR Data Safety and Monitoring Board, both for toxicity 
as well as futility and efficacy with respect to the primary brain RFS endpoint.
Beginning in the year after twenty total participants have been randomized and treated on the trial, 
the study will be monitored by a DSMB on an annual basis to evaluate the safety of the two arms. 
The SAEs (typically grade 3 toxicities, or greater) will be reported according to type of toxicity, 
and maximal grade noted per participant, for toxicities with at least a possible attribution to the 
therapy provided on that arm. Comparisons will be made between the two arms using a Cochran-
Armitage test for trend, or other appropriate methods, to determine if there is increased toxicity 
associated with either arm.
In addition, at the first DSMB meeting held following the point at which half of the required total 
subjects have been enrolled and followed for a minimum of 12 months (that is, after 49 participants 
have been enrolled, and the most recent of those 49 participants were randomized at least 12 
months prior to the date of the DSMB evaluation), a single evaluation for futility will be 
undertaken. The futility evaluation will be performed as follows: based on the full data available 
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arm (that is, if the HR=1.0 or greater favoring TDM-1 alone), or at the discretion of the DSMB if 
results are not clearly defined for other reasons, such as the appearance of the interim Kaplan-
Meier curves, then the trial will end accrual at that time if this is directed by the DSMB.
Monitoring for efficacy will take place on an annual basis, also beginning after 49 participants 
have been randomized and followed potentially for a minimum of 6 months. This will be 
performed using a Lan-DeMets alpha spending function approach based on an O’Brien-Fleming 
boundary associated with the results of the log-rank test related to the comparison of OS curves.
9.4.7
Exploratory analyses
As described in the correlative studies section of the protocol, biomarkers in the CSF and serum 
will be measured, as well as their changes with treatment. The biomarkers will be evaluated in an 
exploratory fashion to predict relapse. 
MGMT methylation status will be analyzed in primary tumor, CSF and serum, as described in the 
correlative studies section in the protocol. Findings at baseline and changes at different points 
during the treatment will be compared between participants that benefit and those participants that 
don’t benefit from temozolomide treatment, applying non-parametric tests.
In the same manner, questionnaires regarding cognitive and quality of life aspects will be applied 
and analyzed in an exploratory fashion. The analysis should include: 
1. Neurotoxicity and neurocognitive effects between the two arms
2. MDASI-BT subscale (cognitive dysfunction, focal neurologic deficits, and interference) 
differences between the two arms
3. Baseline MDASI-BT subscales (overall symptom burden, overall interference, cognitive 
dysfunction) as well as fatigue and change of appetite as prognostic for time to distant metastases 
and for OS
4. Changes in score over time in select MDASI-BT subscales as prognostic for OS, time to distant 
metastases, and neurocognitive decline
10 COLLABORATIVE AGREEMENTS 
10.1 CLINICAL TRIALS AGREEMENT (CTA)
The study agent, Temozolomide is provided by MERCK & Co., Inc. under a Clinical Trials 
Agreement (CTA). Results or study data may be communicated to CTA partner, according to the 
terms of the NIH- Advanced Accelerator Applications SA CTA.
11 HUMAN SUBJECTS PROTECTIONS 
11.1 RATIONALE FOR SUBJECT SELECTION
Subjects from all racial and ethnic groups are eligible for this trial if they meet the eligibility 
criteria. Efforts will be made to extend the accrual to a representative population. If differences in 
outcome that correlate to racial or ethnic identity are noted, accrual may be expanded or additional 
studies may be performed to investigate those differences more fully.

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We are excluding non-English speakers because part of our study objectives is to evaluate 
neurocognitive effects of disease and treatment. The evaluation of neurocognitive effects relies in 
tests and questionnaires that require clear comprehension of the language used to apply them. 
Failures in comprehension of the language could jeopardize the tests results and interpretation.
11.2 PARTICIPATION OF CHILDREN 
The age group for enrollment on this trial is 18 or more years of age. Because no dosing or adverse 
event data are currently available on the use of T-DM1 or temozolomide in participants < 18 years 
of age, children are excluded from this study.
11.3 PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT
Adults unable to give consent are excluded from enrolling in the protocol.  However, re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (section 11.5), all subjects will be offered the opportunity to fill in their 
wishes for research and care, and assign a substitute decision maker on the “NIH Advance 
Directive for Health Care and Medical Research Participation” form so that another person can 
make decisions about their medical care in the event that they become incapacitated or cognitively 
impaired during the course of the study. Note: The PI or AI will contact the NIH Ability to Consent 
Assessment Team (ACAT) for evaluation to assess ongoing capacity of the subjects and to identify 
an LAR, as needed.  
Please see section 11.6.1 for consent procedure.
11.4 EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS
The primary risk to participants participating in this research study is from the toxicity of 
Temozolomide and T-DM1, or both drugs. Temozolomide is an investigational agent in the 
prevention of breast cancer brain metastases. T-DM1 is an approved agent for treatment of 
metastatic HER2-positive breast cancer. The protocol provides for detailed and careful monitoring 
of all participants to assess for toxicity. Toxicity data from the phases I and II dose levels will be 
collected and reviewed to ensure that there were no severe toxicities that would preclude further 
participant enrollment. Participants will be treated with therapeutic intent and response to the 
therapy will be closely monitored. 
11.5 RISKS/BENEFITS ANALYSIS
11.5.1 Risks 
11.5.2 Research Blood Collection Risks
Risks of blood draws include pain and bruising in the area where the needle is placed, 
lightheadedness, and rarely, fainting. When large amounts of blood are collected, low red blood 
cell count (anemia) can develop. 
11.5.3 Risks of Echocardiogram
Other than the possibility of some mild discomfort during the test, there are no known risks to an 
echocardiogram.

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11.5.4 Risks of MUGA Scans
In addition to the risks of radiation exposure, the primary risk associated with MUGA scans is an 
allergic reaction to the contrast material. 
11.5.5 Risks of Questionnaires
These contain questions that may be sensitive in nature. Subjects are instructed that they may 
refuse to answer any question that makes them feel uncomfortable, and theat if they have concerns 
after completing the questionnaire, they are encouraged to contact the study team. 
11.5.6 Lumbar Puncture for Research Purposes
Risks of lumbar puncture include headache, tenderness or pain in the lower back and bleeding near 
the puncture site; and pain and numbness that shoots down in the legs. In rare cases, people 
experience brainstem herniation, which is the movement of brain tissue from its normal position 
in the skull.
11.5.7 Risks of exposure to ionizing radiation 
Study participants will be exposed to radiation from the following sources within a one-year 
period:

Up to 5 lumbar punctures guided by fluoroscopy

Up to 8 CT scans

1 technetium bone scan

Up to 4 MUGA scans
The amount of radiation exposure from these procedures is equal to approximately 11.19 rem. This 
is equal to roughly the same amount of radiation as 37.3 years’ worth of background radiation. 
About 40 out of 100 people (40%) will get cancer during their lifetime, and 20 out of 100 (20%) 
will die from cancer. The risk of getting cancer from the radiation exposure in this study is 1.1 out 
of 100 (1.1%) and of getting a fatal cancer is 0.6 out of 100 (0.6%).
Note:  MRIs will be performed for participants who are unable to tolerate the CT contrast.
11.5.8 Risks of CT Scans
In addition to the radiation risks discussed above, risks associated with CT scans include allergic 
reaction to and kidney damage from the contrast dye, nausea, vomiting, and anxiety.
11.5.9 Risks of MRIs
The risks of MRI include anxiety as well as the risks associated with the gadolinium contrast 
material, which are metallic taste, headache, nausea, and allergic reaction; and in participants with 
kidney disease, nephrogenic systemic fibrosis (NSF).
11.5.10
Other risks
Risks include the possible occurrence of any of a range of side effects which are listed in the 
Consent Document or this protocol document. Frequent monitoring for adverse effects will help 
to minimize the risks associated with administration of the study agents. 

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11.5.11
Non-Physical Risks of Genetic Research
11.5.11.1
Risk of receiving unwanted information
Anxiety and stress may arise as a result of the anticipation that unwanted information regarding 
disease related DNA sequencing or disease tendencies, or misattributed paternity. Participants will 
be clearly informed that the data related to DNA sequencing and genetic analysis is coded, 
investigational and will not be shared with participants, family members or health care providers.
11.5.11.2
Risk related to possibility that information may be released
This includes the risk that data related to genotype, DNA sequencing or risk for disease tendency 
or trait can be released to members of the public, insurers, employers, or law enforcement agencies. 
Although there are no plans to release results to the participants, family members or health care 
providers, this risk will be included in the informed consent document.
11.5.11.3
Risk to family or relatives
Family members or relatives may or may not want to be aware of familial tendencies or genetic 
risks of disease which may cause anxiety about possible future health problems. As previously 
noted, participants will be given the option in the consent document to be notified of any medically 
significant and actionable incidental findings. 
11.5.12
Certificate of Confidentiality
As part of study efforts to provide confidentiality of subject information, this study has a Certificate 
of Confidentiality which helps to prevent forced disclosure of personally identifiable research 
information.  The Certificate of Confidentiality allows investigators on this trial to refuse to 
disclose identifying information related to the research participants, should such disclosure have 
adverse consequences for subjects or damage their financial standing, employability, insurability 
or reputation.  The informed consent includes the appropriate coverage and restrictions of the 
Certificate of Confidentiality.
11.5.13
Benefits 
The potential benefit to a participant on this study is a reduction or stability in the volume of their 
tumor systemically or outside of the brain, as well as potentially the prevention or delay in 
development of new metastatic lesions in the brain, which may or may not have favorable impact 
on symptoms and/or survival. 
11.5.14
Risks/Benefits Analysis
The potential benefits from this therapy are stabilization or shrinkage of disease outside the brain 
and a reduction in chances of developing new tumor lesions in the brain, with decrease of 
symptoms caused by the brain tumor such as neurological deficits and headache. Given the efforts 
to minimize risk with the administration of this combination, this protocol involves greater than 
minimal risk, but presents the potential for direct benefit to individual subjects.
11.6 CONSENT PROCESS AND DOCUMENTATION
The informed consent document will be provided as a physical or electronic document to the 
participant or consent designee(s) as applicable for review prior to consenting.  A designated study 
investigator will carefully explain the procedures and tests involved in this study, and the 
associated risks, discomforts and benefits. In order to minimize potential coercion, as much time 

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as is needed to review the document will be given, including an opportunity to discuss it with 
friends, family members and/or other advisors, and to ask questions of any designated study 
investigator. A signed informed consent document will be obtained prior to entry onto the study.
The initial consent process as well as re-consent, when required, may take place in person or 
remotely (e.g., via telephone or other NIH approved remote platforms used in compliance with 
policy, including HRPP Policy 303) per discretion of the designated study investigator and with 
the agreement of the participant/consent designee(s).  Whether in person or remote, the privacy of 
the subject will be maintained. Consenting investigators (and participant/consent designee, when 
in person) will be located in a private area (e.g., clinic consult room). When consent is conducted 
remotely, the participant/consent designee will be informed of the private nature of the discussion 
and will be encouraged to relocate to a more private setting if needed.
Consent will be documented with required signatures on the physical document (which includes 
the printout of an electronic document sent to participant) or as described below, with a manual 
(non-electronic) signature on the electronic document.  When required, witness signature will be 
obtained similarly as described for the investigator and participant.
Manual (non-electronic) signature on electronic document:
When a manual signature on an electronic document is used for the documentation of consent at 
the NIH Clinical Center, this study will use the following to obtain the required signatures:

Adobe platform (which is not 21 CFR Part 11 compliant); or, 

iMedConsent platform (which is 21 CFR Part 11 compliant)
During the consent process, participants and investigators will view individual copies of the 
approved consent document on screens at their respective locations (if remote consent); the same 
screen may be used when in the same location but is not required.
Both the investigator and the subject will sign the document using a finger, stylus or mouse. 
Note: Refer to the CCR SOP PM-2, Obtaining and Documenting the Informed Consent 
Process for additional information (e.g., verification of participant identity when obtaining 
consent remotely) found at 
https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=73203825.
11.6.1 Consent Process for Adults Who Lack Capacity to Consent to Research Participation
For participants addressed in section 11.3, an LAR will be identified consistent with Policy 403 
and informed consent obtained from the LAR, as described in Section 11.6.
11.7 REQUEST FOR WAIVER OF CONSENT FOR SCREENING ACTIVITIES
Prior to the subject signing the consent for this study pre-screening activities listed in section 2.2.1 
may be performed. 
We request a waiver of consent for these activities as they involve only minimal risk to the subjects.  
A waiver will not adversely affect the rights and welfare of the subjects given that the activities 
are only intended to determine suitability for screening for participation in research protocols.  
These activities could not practicably be carried out without the wavier as central recruiting 
services, utilized in the NIH Clinical Center, perform pre-screening activities for multiple studies 
and obtaining consent for each one is beyond their resources.  The subjects will be provided with 

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additional pertinent information after participation as they will be informed whether or not they 
are eligible to sign a consent for additional screening.
12 REGULATORY AND OPERATIONAL CONSIDERATIONS  
12.1
STUDY DISCONTINUATION AND CLOSURE
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause.  Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to study participants, 
investigator, funding agency, and regulatory authorities.  If the study is prematurely terminated or 
suspended, the Principal Investigator (PI) will promptly inform study participants, the Institutional 
Review Board (IRB), and sponsor and will provide the reason(s) for the termination or suspension.  
Study participants will be contacted, as applicable, and be informed of changes to study visit 
schedule.
Circumstances that may warrant termination or suspension include, but are not limited to:

Determination of unexpected, significant, or unacceptable risk to participants

Demonstration of efficacy that would warrant stopping   

Insufficient compliance to protocol requirements

Data that are not sufficiently complete and/or evaluable

Determination that the primary endpoint has been met

Determination of futility
Study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the sponsor, IRB and as applicable, Food and Drug Administration (FDA).
12.2
QUALITY ASSURANCE AND QUALITY CONTROL
The clinical site will perform internal quality management of study conduct, data and biological 
specimen collection, documentation and completion.  An individualized quality management plan 
will be developed to describe a site’s quality management.
Quality control (QC) procedures will be implemented beginning with the data entry system and 
data QC checks that will be run on the database will be generated. Any missing data or data 
anomalies will be communicated to the site(s) for clarification/resolution.
Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical 
trial is conducted and data are generated and biological specimens are collected, documented 
(recorded), and reported in compliance with the protocol, International Conference on 
Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory requirements (e.g., 
Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)). 
The investigational site will provide direct access to all trial related sites, source data/documents, 
and reports for the purpose of monitoring and auditing by the sponsor, and inspection by local and 
regulatory authorities.

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12.3
CONFLICT OF INTEREST POLICY
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical.  Therefore, any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and 
managed. Furthermore, persons who have a perceived conflict of interest will be required to have 
such conflicts managed in a way that is appropriate to their participation in the design and conduct 
of this trial.  The study leadership in conjunction with the National Cancer Institute has established 
policies and procedures for all study group members to disclose all conflicts of interest and will 
establish a mechanism for the management of all reported dualities of interest.
12.4
CONFIDENTIALITY AND PRIVACY
Participant confidentiality and privacy is strictly held in trust by the participating investigators, 
their staff, and the sponsor(s). This confidentiality is extended to cover testing of biological 
samples and genetic tests in addition to the clinical information relating to participants. Therefore, 
the study protocol, documentation, data, and all other information generated will be held in strict 
confidence. No information concerning the study or the data will be released to any unauthorized 
third party without prior written approval of the sponsor. 
All research activities will be conducted in as private a setting as possible.
The study monitor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and 
records required to be maintained by the investigator, including but not limited to, medical records 
(office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical 
study site will permit access to such records.
The study participant’s contact information will be securely stored at the clinical site for internal 
use during the study. At the end of the study, all records will continue to be kept in a secure location 
for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor 
requirements.
Study participant research data, which is for purposes of statistical analysis and scientific reporting, 
will be transmitted to and stored at the NCI CCR. This will not include the participant’s contact or 
identifying information. Rather, individual participants and their research data will be identified 
by a unique study identification number. The study data entry and study management systems used 
by the clinical site and by NCI CCR research staff will be secured and password protected. At the 
end of the study, all study databases will be archived at the NIH.
To further protect the privacy of study participants, a Certificate of Confidentiality has been issued 
by the National Institutes of Health (NIH).  This certificate protects identifiable research 
information from forced disclosure. It allows the investigator and others who have access to 
research records to refuse to disclose identifying information on research participation in any civil, 
criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local 
level. By protecting researchers and institutions from being compelled to disclose information that 
would identify research participants, Certificates of Confidentiality help achieve the research 
objectives and promote participation in studies by helping assure confidentiality and privacy to 
participants.

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13 PHARMACEUTICAL INFORMATION
There will be no IND obtained for the use of any of the commercial agents used in this study. 
This study meets the criteria for exemption for an IND as this investigation is not intended to 
support a new indication for use or any other significant change to the labeling; the drugs are 
already approved and marketed and the investigation is not intended to support a significant change 
in advertising; and the investigation does not involve a route of administration or dosage level in 
use in a patient population or other factor that significantly increases the risks (or decreases the 
acceptability of the risks) associated with the use of the drug product.  
13.1 TEMOZOLOMIDE 
13.1.1 Source
Temozolomide is commercially available. It will be provided by MERCK & Co., Inc. for this study 
under the agreement described in section 10.1.
NOTE:  Effective with Amendment F (version date 06/08/2020):  Merck discontinuned production 
of the Temozolomide 5mg and 20mg capsules, so Merck will purchase those doses from Myonex 
for delivery to the NIH pharmacy. Merck will continue to provide the 100mg capsules per the 
original agreement.
13.1.2 Formulation and preparation
Temozolomide is an imidazotetrazine derivative. The chemical name of temozolomide is 3,4-
dihydro-3-methyl-4-oxoimidazo[5,1-d]-as-tetrazine-8-carboxamide. The structural formula is:
The material is a white to light tan/light pink powder with a molecular formula of C6H6N6O2 and 
a molecular weight of 194.15. The molecule is stable at acidic pH (<5) and labile at pH >7; hence 
Temozolomide can be administered orally and intravenously. The prodrug, temozolomide, is 
rapidly hydrolyzed to the active 5-(3-methyltriazen-1-yl) imidazole-4-carboxamide (MTIC) at 
neutral andalkaline pH values, with hydrolysis taking place even faster at alkaline pH.
Other Names: methazolastone, Temodar
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, 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. 

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Mode of Action 
Alkylating agent of imidazotetrazinone class. 
13.1.3 Storage and Stability 
The 5-mg, 20-mg, 100-mg, 140-mg, and 180-mg capsule strengths are available in 5- count and 
14-count packages. The 250-mg capsule strength is available in a 5-count package. Each strength 
of Temozolomide must be dispensed in a separate vial or in its original package (one strength per 
one container). 
Follow the instructions below: 
Based on the dose prescribed, determine the number of each strength of Temozolomide capsules 
that are needed. Label each container with the appropriate number of capsules to be taken each 
day. Dispense to the participant, making sure each container lists the strength (mg) per capsule and 
that he or she understands to take the appropriate number of capsules of Temozolomide from each 
package or vial to equal the total daily dose prescribed by the physician. Temozolomide is store at 
25°C, excursions permitted to 15-30°C.
Repackaging of Temozolomide for dispensing may occur per guidance provided in manufacturer's 
product labeling. 
13.1.4 Administration procedures 
Participants should take each day’s dose with a full glass of water at the same time each day. 
Taking the medication on an empty stomach or at bedtime may help ease nausea. If participants 
are also taking anti-nausea or other medications to relieve the side effects associated with 
Temozolomide, they should be advised to take these medications 30 minutes before they take 
Temozolomide. Temozolomide causes the rapid appearance of malignant tumors in rats. 
Participants SHOULD NOT open or split the capsules. If capsules are accidentally opened or 
damaged, rigorous precautions should be taken with the capsule contents to avoid inhalation or 
contact with the skin or mucous membranes. The medication should be kept away from children 
and pets. The Temozolomide capsules should be swallowed whole and NEVER CHEWED.
13.1.5 Pharmacokinetics 
Temozolomide is rapidly and completely absorbed after oral administration; peak plasma 
concentrations occur in 1 hour. Food reduces the rate and extent of temozolomide absorption. 
Mean peak plasma concentration and AUC decreased by 32% and 9%, respectively, and Tmax 
increased 2-fold (from 1.1 to 2.25 hours) when temozolomide was administered after a modified 
high-fat breakfast. 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%. 
13.1.6 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 
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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.
13.1.7 Special Populations 
Creatinine Clearance: Population pharmacokinetic analysis indicates that creatinine clearance over 
the range of 36-130 mL/min/m2 has no effect on the clearance of temozolomide after oral 
administration. The pharmacokinetics of temozolomide have not been studied in participants with 
severely impaired renal function (CLcr < 36 mL/min/m2). Caution should be exercised when 
temozolomide is administered to participants with severe renal impairment. Temozolomide has 
not been studied in participants on dialysis. 
Hepatically Impaired Participants: In a pharmacokinetic study, the pharmacokinetics of 
temozolomide in participants with mild to moderate hepatic impairment (Child’s-Pugh Class I-II) 
were similar to those observed in participants with normal hepatic function. Caution should be 
exercised when temozolomide is administered to participants with severe hepatic impairment. 
Gender: Population pharmacokinetic analysis indicates that women have an approximately 5% 
lower clearance (adjusted for body surface area) for temozolomide than men. Women have higher 
incidences of grade 4 neutropenia and thrombocytopenia in the first cycle of therapy than men. 
Population pharmacokinetic analysis indicates that age (range 19-78 years) has no influence on the 
pharmacokinetics of temozolomide. In the anaplastic astrocytoma study population, participants 
70 years of age or older had a higher incidence of grade 4 neutropenia and grade 4 
thrombocytopenia in the first cycle of therapy than participants under 70 years of age. In the entire 
safety database, however, there did not appear to be a higher incidence in participants 70 years of 
age or older. 
13.1.8 Incompatibilities and Toxicity
Drug-Drug Interactions: In a multiple dose study, administration of temozolomide with ranitidine 
did not change the Cmax or AUC values for temozolomide or MTIC. Population analysis indicates 
that administration of valproic acid decreases the clearance of temozolomide by about 5%. The 
clinical implication of this effect is not known. Population analysis failed to demonstrate any 
influence of co-administered dexamethasone, prochlorperazine, phenytoin, carbamazepine, 
ondansetron, H2- receptor antagonists, or phenobarbital on the clearance of orally administered 
temozolomide.
Known Potential Adverse Events 
Hematologic: Thrombocytopenia, leukopenia, myelodysplastic syndrome 
Gastrointestinal: Nausea, vomiting, anorexia 
Hepatic: Elevated liver enzymes (reversible) 
Skin: Rash 
Neurologic: Convulsions, weakness on one side of the body, abnormal coordination, paralysis

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Other: Constipation, diarrhea, stomatitis, fatigue, decreased performance status, headache 
Likely (occurring in more than 20% of participants)
Fatigue
Alopecia
Constipation
Headache
Nausea
Anorexia
Seizures
Vomiting
Common (occurring in 3-20% of participants)
Dizziness
Depression
Weight gain
Abnormal muscle movements/ 
coordination
Difficulty sleeping
Loss of urinary control
Abnormal gait
Drowsiness
Urinary tract infection
Hemiplegia or partial paralysis
Skin rash
Frequent urination
Upper and/or lower extremity 
edema
Pruritus
Abnormal vision
Weakness (such as weakness on 
one side of the body)
Dry skin
Blurry vision
Tickling/tingling sensation
Mucositis
Diplopia or double vision
Pain (such as in the abdomen, 
joints, back, and/or muscles)
Dysphagia
Fever
Breast pain in females
Dysgeusia or taste changes
Head cold
Confusion
Diarrhea
Cough
Memory problems
Excess steroid in the body 
(possible bruising and/or 
increase in size of the face 
and/or neck)
Sore throat
Anxiety
Viral infection
Sinusitis
Dyspnea
Allergic reaction
Temozolomide may commonly cause low blood cell counts (white blood cells, red blood cells, 
and platelets). This means that while you take the drug, there is more of a chance of getting an 
infection, including pneumonia. You may become anemic and/or have problems with bleeding, 
bruising, fatigue, and/or shortness of breath. You may need a blood transfusion.
Rare but serious (occurring in fewer than 3% of participants)
Bone marrow disease where not 
enough blood cells are made
New occurrence of cancer 
(including myeloid leukemia)
Steven-Johnson Syndrome
Hallucinations
Allergic skin reaction
Damage from radiation (such as 
skin damage)
Nervous system disease 
(possible pain and/or weakness)
Severe skin damage with loss of 
a large portion of skin 
Pneumonitis (lung 
inflammation)
Neuropathies (nerve damage- 
possible numbness, tingling, and 
pain)
Weight loss
Flu-like symptoms
Hyperglycemia (possible 
diabetes)
Fever due to low white blood 
cell counts
Injection site reactions (skin 
redness, irritation, pain, itching, 
swelling, and/or warmth)

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Hypokalemia (possible 
weakness)
Bruising
Opportunistic infection
Severe allergic reaction
Hemorrhage
Herpes infection causing painful 
skin rash (shingles)
The following side effects have been reported in research studies with temozolomide. It is 
unclear if these side effects were caused by temozolomide, but they may be:
BUN blood level increase
Death
Cholecystitis
Creatinine blood elevated
Hypoxia
Pancreatitis
Lymphopenia
Weight loss
GI perforation
Thrombocytopenia
Epistaxis
Dehydration
Neutropenia
Sepsis
Temozolomide is potentially mutagenic and should be handled with appropriate precautions by 
both staff and participants. Capsules should not be opened. If capsules are accidentally opened or 
damaged, rigorous precautions should be taken with the capsule contents to avoid inhalation or 
contact with the skin or mucous membranes. Procedures for proper handling and disposal of 
anticancer drugs should be considered. 
Contraindications: Temozolomide is contraindicated in participants who have a history of a 
hypersensitivity reaction to any of its components or to DTIC. 
Pregnancy Category D 
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 participant becomes pregnant while taking this drug, the participant 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. 
Treatment of a man with temozolomide may increase the risk of birth defects if he causes a woman 
to become pregnant while he is taking temozolomide. Men treated with temozolomide may have 
difficulty causing a woman to become pregnant after their treatment is completed. Men receiving 
temozolomide should be directed to use effective contraception while they are being treated. There 
is insufficient data to know what the risk of subsequent problems with fertility will be. Similarly, 
women who are treated with temozolomide may have difficulty becoming pregnant in the future 
and may at be at increased risk of having children with birth defects. There is insufficient evidence 
to determine what the risk of these complications will be. 
13.2 T-DM1 
13.2.1 Source
T-DM1 will be used in its standard approved indication by the FDA. 
T-DM1 will be purchased from commercial sources by the NIH CC Pharmacy.
13.2.2 Formulation and Preparation
T-DM1 (ado-trastuzumab emtansine) is a HER2-targeted antibody-drug conjugate (ADC) which 
contains the humanized anti-HER2 IgG1, trastuzumab, covalently linked to the microtubule 

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inhibitory drug DM1 (a maytansine derivative) via the stable thioether linker MCC (4-[N-
maleimidomethyl] cyclohexane-1-carboxylate). Emtansine refers to the MCC-DM1 complex. 
The antibody trastuzumab, is a well characterized recombinant monoclonal antibody product 
produced by mammalian (Chinese hamster ovary) cells, and the small molecule components (DM1 
and MCC) are produced by chemical synthesis. Ado-trastuzumab emtansine contains an average 
of 3.5 DM1 molecules per antibody. Ado-trastuzumab emtansine has the following chemical 
structure:
Note: The bracketed structure is DM1 plus MCC which represents the emtansine component. The n is, on 
average, 3.5 DM1 molecules per trastuzumab (Mab) molecule.
T-DM1 (ado-trastuzumab emtansine) is a sterile, white to off-white preservative free lyophilized 
powder in single-use vials. Each vial contains 100 mg or 160 mg ado-trastuzumab emtansine. 
Following reconstitution, each single-use vial contains ado-trastuzumab emtansine (20 mg/mL), 
polysorbate 20 [0.02% (w/v)], sodium succinate (10 mM), and sucrose [6% (w/v)] with a pH of 
5.0 and density of 1.026 g/mL. The resulting solution containing 20 mg/mL ado-trastuzumab 
emtansine is administered by intravenous infusion following dilution.
13.2.3 Supply and handling:
T-DM1(ado-trastuzumab emtansine) is supplied as: one 100 mg vial, single use vial or one 160 
mg vial, single use vial per carton.
Store vials in a refrigerator at 2°C to 8°C (36°F to 46°F) until time of reconstitution. Do not freeze 
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13.2.4 Formulation and preparation 
In order to prevent medication errors, it is important to check the vial labels to ensure that the drug 
being prepared and administered isT-DM1 (ado-trastuzumab emtansine) and not trastuzumab. 
Lyophilized powder in single-use vials: 100 mg per vial or 160 mg per vial of ado-trastuzumab 
emtansine.
13.2.5 Administration 
Administer T-DM1 as an intravenous infusion only with a 0.2 or 0.22 micron in-line 
polyethersulfone (PES) filter. Do not administer as an intravenous push or bolus. Do not mix T-
DM1, or administer as an infusion, with other medicinal products. In order to improve traceability 
of biological medicinal products, the tradename and the batch number of the administered product 
should be clearly recorded (or stated) in the patient file. 
13.2.5.1 Reconstitution 
Use aseptic technique for reconstitution and preparation of dosing solution. Appropriate 
procedures for the preparation of chemotherapeutic drugs should be used. 
Using a sterile syringe, slowly inject 5 mL of Sterile Water for Injection into the 100 mg T-DM1 
vial, or 8 mL of Sterile Water for Injection into the 160 mg T-DM1 vial to yield a solution 
containing 20 mg/mL. Swirl the vial gently until completely dissolved. Do not shake. Inspect the 
reconstituted solution for particulates and discoloration. 
The reconstituted solution should be clear to slightly opalescent and free of visible particulates. 
The color of the reconstituted solution should be colorless to pale brown. Do not use if the 
reconstituted solution contains visible particulates or is cloudy or discolored. 
The reconstituted lyophilized vials should be used immediately following reconstitution with 
Sterile Water for Injection. If not used immediately, the reconstituted T-DM1 vials can be stored 
for up to 24 hours in a refrigerator at 2ºC to 8ºC (36°F to 46°F); discard unused T-DM1 after 24 
hours. Do not freeze. 
The reconstituted product contains no preservative and is intended for single-use only. 
13.2.5.2 Dilution
Determine the correct dose (mg) of T-DM1.
Calculate the volume of the 20 mg/mL reconstituted T-DM1 solution needed. 
Withdraw this amount from the vial and add it to an infusion bag containing 250 mL of 0.9% 
Sodium Chloride Injection. Do not use Dextrose (5%) solution. 
Gently invert the bag to mix the solution in order to avoid foaming. 
The diluted T-DM1 infusion solution should be used immediately. If not used immediately, the 
solution may be stored in a refrigerator at 2°C to 8°C (36°F to 46°F) for up to 24 hours prior to 
use. This storage time is additional to the time allowed for the reconstituted vials. Do not freeze or 
shake. 
13.2.6 Pharmacokinetics 
The pharmacokinetics of T-DM1 was evaluated in a phase 1 study and in a population 
pharmacokinetic analysis for the ado-trastuzumab emtansine conjugate (ADC) using pooled data 

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from 5 trials in participants with breast cancer. A linear two-compartment model with first-order 
elimination from the central compartment adequately describes the ADC concentration-time 
profile. In addition to ADC, the pharmacokinetics of total antibody (conjugated and unconjugated 
trastuzumab), DM1 were also determined. The pharmacokinetics of T-DM1 are summarized 
below. 
13.2.7 Distribution 
Maximum concentrations (Cmax) of ADC and DM1 were observed close to the end of infusion. 
In Study 1, mean (SD) ADC and DM1 Cycle 1 Cmax following KADCYLA administration was 
83.4 (16.5) µg/mL and 4.61 (1.61) ng/mL, respectively. 18 of 24 
In vitro, the mean binding of DM1 to human plasma proteins was 93%. In vitro, DM1 was a 
substrate of P-glycoprotein (P-gp). Based on population pharmacokinetic analysis, the central 
volume of distribution of ADC was 3.13 L. 
13.2.8 Metabolism and Elimination 
In vitro studies indicate that DM1, the small molecule component of T-DM1, undergoes 
metabolism by CYP3A4/5. DM1 did not inhibit or induce major CYP450 enzymes in vitro. In 
human plasma, ado-trastuzumab emtansine catabolites MCC-DM1, Lys-MCC-DM1, and DM1 
were detected at low levels. 
Based on population pharmacokinetic analysis, following intravenous infusion of T-DM1, the 
clearance of the ADC was 0.68 L/day and the elimination half-life (t1/2) was approximately 4 
days. No accumulation of T-DM1 was observed after repeated dosing of intravenous infusion 
every 3 weeks. 
Based on population pharmacokinetic analysis (n=671), body weight, sum of longest diameter of 
target lesions by RECIST, HER2 extracellular domain (ECD) concentrations, AST, albumin, and 
baseline trastuzumab concentrations were identified as statistically significant covariates for ado-
trastuzumab emtansine clearance. However, the magnitude of effect of these covariates on ado-
trastuzumab emtansine exposure suggests that, with the exception of body weight, these covariates 
are unlikely to have a clinically meaningful effect on T-DM1 exposure. Therefore, the body weight 
based dose of 3.6 mg/kg every 3 weeks without correction for other covariates is considered 
appropriate. 
Drug to drug interaction: No formal drug-drug interaction studies with T-DM1 have been 
conducted. In vitro studies indicate that DM1, the cytotoxic component of T-DM1, is metabolized 
mainly by CYP3A4 and to a lesser extent by CYP3A5. Concomitant use of strong CYP3A4 
inhibitors (e.g., ketoconazole, itraconazole, clarithromycin, atazanavir, indinavir, nefazodone, 
nelfinavir, ritonavir, saquinavir, telithromycin, and voriconazole) with T-DM1 should be avoided 
due to the potential for an increase in DM1 exposure and toxicity. Consider an alternate medication 
with no or minimal potential to inhibit CYP3A4. If concomitant use of strong CYP3A4 inhibitors 
is unavoidable, consider delaying T-DM1 treatment until the strong CYP3A4 inhibitors have 
cleared from the circulation (approximately 3 elimination half-lives of the inhibitors) when 
possible. If a strong CYP3A4 inhibitor is coadministered and T-DM1 treatment cannot be delayed, 
participants should be closely monitored for adverse reactions.
13.2.9 Special populations
 Pregnancy:

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There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to 
T-DM1 during pregnancy. Encourage women who receive T-DM1 during pregnancy or within 7 
months prior to conception, to enroll in the MotHER Pregnancy Registry by contacting 1-800-690-
6720 or visiting http://www.motherpregnancyregistry.com/. 
In addition, there is a pregnancy pharmacovigilance program for T-DM1. If T-DM1 is 
administered during pregnancy, or if a participant becomes pregnant while receiving T-DM1 or 
within 7 months following the last dose of T-DM1, health care providers and participants should 
immediately report T-DM1 exposure to Genentech at 1-888-835-2555. 
T-DM1 can cause fetal harm when administered to a pregnant woman. There are no available data 
on the use of T-DM1 in pregnant women. Cases of oligohydramnios and oligohydramnios 
sequence manifesting as pulmonary hypoplasia, skeletal abnormalities, and neonatal death were 
observed in the postmarketing setting in participants treated with trastuzumab, the antibody 
component of T-DM1. Based on its mechanism of action, the DM1 component of T-DM1 can also 
cause embryo-fetal harm when administered to a pregnant woman. Apprise the participant of the 
potential risks to a fetus. There are clinical considerations if T-DM1 is used in a pregnant woman, 
or if a participant becomes pregnant within 7 months following the last dose of T-DM1.
The estimated background risk of major birth defects and miscarriage for the indicated population 
is unknown. In the U.S. general population, the estimated background risk of major birth defects 
and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. 
Fetal/Neonatal Adverse Reactions Monitor women who received T-DM1 during pregnancy or 
within 7 months prior to conception for oligohydramnios. If oligohydramnios occurs, perform fetal 
testing that is appropriate for gestational age and consistent with community standards of care. 
Human Data There are no available data on the use of T-DM1 in pregnant women. In the post-
marketing setting, cases of oligohydramnios, and of oligohydramnios sequence, manifesting in the 
fetus as pulmonary hypoplasia, skeletal abnormalities and neonatal death were observed after 
treatment with trastuzumab during pregnancy. These case reports described oligohydramnios in 
pregnant women who received trastuzumab either alone or in combination with chemotherapy. In 
some case reports, amniotic fluid index increased after trastuzumab was stopped. In one case, 
trastuzumab therapy resumed after amniotic index improved, and oligohydramnios recurred. 
Animal Data There were no reproductive and developmental toxicology studies conducted with 
ado-trastuzumab emtansine. DM1, the cytotoxic component of T-DM1, disrupts microtubule 
function. DM1 is toxic to rapidly dividing cells in animals and is genotoxic, suggesting it has the 
potential to cause embryotoxicity and teratogenicity. In studies where trastuzumab was 
administered to pregnant cynomolgus monkeys during the period of organogenesis at doses up to 
25 mg/kg given twice weekly (about 7 times the clinical dose), trastuzumab crossed the placental 
barrier during the early (Gestation Days 20 to 50) and late (Gestation Days 120 to 150) phases of 
gestation. The resulting concentrations of trastuzumab in fetal serum and amniotic fluid were 15 
of 24 approximately 33% and 25%, respectively, of those present in the maternal serum but were 
not associated with adverse developmental effects. 
Lactation 
There is no information regarding the presence of ado-trastuzumab emtansine in human milk, the 
effects on the breastfed infant, or the effects on milk production. DM1, the cytotoxic component 
of T-DM1, may cause serious adverse reactions in breastfed infants based on its mechanism of 

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action. Advise women not to breastfeed during treatment and for 7 months following the last dose 
of T-DM1. 
There were no animal lactation studies conducted with ado-trastuzumab emtansine or the cytotoxic 
component of T-DM1 (DM1). In lactating cynomolgus monkeys, trastuzumab was present in 
breast milk at about 0.3% of maternal serum concentrations after pre- (beginning Gestation Day 
120) and post-partum (through Post-partum Day 28) doses of 25 mg/kg administered twice weekly 
(about 7 times the clinical dose of T-DM1). Infant monkeys with detectable serum levels of 
trastuzumab did not exhibit any adverse effects on growth or development from birth to 1 month 
of age. 
Verify the pregnancy status of females of reproductive potential prior to the initiation of T-DM1. 
Contraception 
Females T-DM1 can cause embryo-fetal harm when administered during pregnancy. Advise 
females of reproductive potential to use effective contraception during treatment and for 7 months 
following the last dose of T-DM1 
Males Because of the potential for genotoxicity, advise male participants with female partners of 
reproductive potential to use effective contraception during treatment with T-DM1 and for 4 
months following the last dose. 
Infertility Based on results from animal toxicity studies, T-DM1 may impair fertility in females 
and males of reproductive potential. It is not known if the effects are reversible 
Geriatric Use 
Of 495 participants who were randomized to T-DM1 in the randomized trial, 65 participants (13%) 
were ≥ 65 years of age and 11 participants (2%) were ≥ 75 years of age. In participants ≥ 65 years 
old (n=138 across both treatment arms) the hazard ratios for progression-free survival (PFS) and 
Overall Survival (OS) were 1.06 (95% CI: 0.68, 1.66) and 1.05 (95% CI: 0.58, 1.91), respectively. 
Population pharmacokinetic analysis indicates that age does not have a clinically meaningful effect 
on the pharmacokinetics of ado-trastuzumab emtansine 
Renal Impairment 
No dedicated renal impairment trial for T-DM1 has been conducted. Based on the population 
pharmacokinetics, as well as analysis of Grade 3 or greater adverse drug reactions and dose 
modifications, dose adjustments of T-DM1 are not needed in participants with mild (creatinine 
clearance [CLcr] 60 to 89 mL/min) or moderate (CLcr 30 to 59 mL/min) renal impairment. No 
dose adjustment can be recommended for participants with severe renal impairment (CLcr less 
than 30 mL/min) because of the limited data available.
Hepatic Impairment 
No adjustment to the starting dose is required for participants with mild or moderate hepatic 
impairment. T-DM1 was not studied in patients with severe hepatic impairment. Closely monitor 
participants with hepatic impairment due to known hepatotoxicity observed with T-DM1.

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13.2.10
Incompatibilities and Toxicity
Incompatibilities are addressed in Section 4.1.1
Known Potential Adverse Events 
Hematologic: Thrombocytopenia, neutropenia, anemia 
Gastrointestinal: Nausea, vomiting, diarrhea 
Hepatic: Elevated liver enzymes  
Skin: Rash, pruritus
Neurologic: headache, peripheral neuropathy
Other: fatigue, decreased performance status 
Likely (occurring in more than 25% of participants)
Fatigue
Hemorrhage
Increased transaminases
Nausea
Thrombocytopenia
Constipation
Musculoskeletal pain
Headache
Epistaxis
Common (occurring in 3-25% of participants)
Blood alkaline phosphatase 
increased
Dysgeusia
Dyspnea 
Hypokalemia
Dizziness
Cough
Myalgia
Insomnia
Pruritus
Arthralgia
Rash
Hypertension
Increased bilirubin
Rare but serious / G3-4 (occurring in fewer than 3% of participants)
Hypokalemia
Musculoskeletal pain
Peripheral neuropathy
Hemorrhage
Hypertension
Hepatic failure has been observed in two participants (0.2%) with HER2-positive metastatic breast 
cancer in clinical trials (n=884) with T-DM1 as single-agent.

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

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15.2 APPENDIX B – LIST OF DRUGS INTERACTING WITH CYP3A4 ISOENZYME
CYP3A4 INHIBITORS 
Strong Inhibitors 
(prohibited) 
Moderate Inhibitors 
(use with caution, avoid if 
possible) 
Weak Inhibitors 
(use with caution, avoid if 
possible) 
Amprenavir1 
Atazanavir1 
Clarithromycin 
Conivaptan1 
Delavirdine1 
Fosamprenavir1 
Fospropofol1 
Imatinib1 
Indinavir 
Isoniazid1 
Itraconazole 
Ketoconazole 
Miconazole1 
Nefazodone 
Nelfinavir 
Nicardipine1 
Posaconazole1 
Propofol1 
Quinidine1 
Ritonavir 
Saquinavir2 
Telithromycin 
Amiodarone1 
Aprepitant 
Cimetidine1 
Clotrimazole1 
Cyclosporine1 
Desipramine1 
Doxycycline1 
Efavirenz1 
Erythromycin 
Fluconazole 
Fosaprepitant1 
Grapefruit juice 
Haloperidol1 
Lidocaine1 
Metronidazole1 
Norfloxacin1 
Sertraline1 
Tetracycline1 
Verapamil 
Voriconazole1 
Chloramphenicol2 
Ciprofloxacin2 
Diethyldithiocarbamate2 
Fluvoxamine2 
Gestodene2 
Mibefradil2 
Mifepristone 
Norfluoxetine2 
Star fruit2 
Troleandomycin2 
1 Cited in Cytochrome P450 Enzymes: Substrates, Inhibitors, and Inducers. In: Lacy CF, Armstrong LL, Goldman MP, Lance LL, eds. Drug Information Handbook 20th ed. 
Hudson, OH; LexiComp Inc. 2011-2012: 1810-1818 
2 Cited in Flockhart DA. Drug Interactions: Cytochrome P450 Drug Interaction Table. Indiana University School of Medicine (2007). 
http://medicine.iupui.edu/clinpharm/ddis/table.asp. Accessed Nov 2011.  Note: Drugs without a superscript are cited in both the Lacy and Flockhart references.

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15.3 APPENDIX C – ORAL MEDICATION DIARY
TEMOZOLOMIDE
Today’s Date ________________________________ Cycle #__________ 
Patient Name_______________________________ Patient Study ID ___________________ 
(initials acceptable for patien’s name)
INSTRUCTIONS TO THE PATIENT: 
1. Complete one form for each cycle (21 days). 
2. You will take ___ (number capsule(s)), total _______ mg (dosage) each day.
3. Please, do not eat anything for at least 2 hours before and 1 hour after temozolomide 
administration.  
4. Record the date, the number of pills you took, and when you took them. 
5. If you have any comments or notice any side effects, please record them in the Comments column. 
6. Please bring your pill bottle and this form to your physician when you go for your next 
appointment. 
# pills and when 
taken: 
temozolomide 
# pills and when 
taken: 
temozolomide
Date Day 
Dose
Time
Comments Date Day 
Dose
Time
Comments 
1 
12 
2 
13 
3 
14 
4 
15 
5 
16 
6 
17 
7 
18 
8 
19 
9 
20 
10 
21 
11 
Study Team will complete this section:
1. Date patient started protocol treatment_____________________
2. Date patient was removed from study _____________________
3. Patient’s planned daily dose______________________________
4. Total number of pills taken this month ______________________
Physician/Nurse’s Signature: ______________________________________________________

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15.4 APPENDIX D– RANO CRITERIA FOR CNS METASTASIS
Lin NU, Lee EQ, Aoyama H, et al. Response assessment criteria for brain metastases: proposal from the RANO group. Lancet Oncology 2015; 16(6): E270-E8

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Lin NU, Lee EQ, Aoyama H, et al. Response assessment criteria for brain metastases: proposal from the RANO group. Lancet Oncology 2015; 16(6): E270-E8