A Phase I/II Trial of DFMO in Combination With Bortezomib in Patients With Relapsed or Refractory Neuroblastoma
Phase: PHASE1
Conditions: Neuroblastoma Recurrent
Sponsor: Giselle Sholler

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 1 of 81 
 
 
 
 
 
 
Protocol DFMO Phase I/II 
 
NMTRC 010B 
 
 
 
 
 
 
 
A Phase I/II Trial of DFMO in Combination with Bortezomib  
in Patients with Relapsed or Refractory Neuroblastoma 
 
 
 
 
 
Version 2.1     April 28, 2015 
 
 
 
 
 
 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 2 of 81 
 
Contact Information 
 
 
 
 
 
 
 
Study Chair:    
 
Kathleen Neville, MD, MS 
Children's Mercy 
Director, Experimental Therapeutics in Pediatric Oncology 
Program 
2401 Gillham Rd. 
Kansas City, MO  64108 
Tel: 816-234-3059 
Fax: 816-855-1958 
kaneville@cmh.edu 
 
 
 
Study Vice Chair:   
 
Giselle Sholler, MD  
NMTRC Chair 
Director, Haworth Innovative Therapeutics Clinic 
Helen DeVos Children’s Hospital 
100 Michigan Avenue NE  MC 272         
Grand Rapids, MI 49503 
Tel:  (616) 267-0332  
Fax: 616-391-2785 
giselle.sholler@helendevoschildrens.org 
 
 
 
 
 
Safety Officer:        
 
Stephen S. Roberts, MD 
Assistant Attending Physician, Neuroblastoma Program 
Memorial Sloan-Kettering Cancer Center 
1275 York Avenue 
New York, NY 10065 
Tel: 212-639-4034  
robertss@mskcc.org 
 
 
 
56B 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 3 of 81 
STUDY COMMITTEE 
 
STUDY CHAIRS: 
Kathleen Neville, MD, MS 
Children's Mercy 
Director, Experimental Therapeutics 
    in Pediatric Oncology Program 
2401 Gillham Rd. 
Kansas City, MO  64108 
 
 
Tel: 816-234-3059 
Fax: 816-855-1958 
kaneville@cmh.edu 
Giselle Sholler, MD  
NMTRC Chair 
Director, Haworth Innovative Therapeutics Clinic 
Helen DeVos Children’s Hospital 
100 Michigan Avenue NE  MC 272         
Grand Rapids, MI 49503 
 
Tel:  (616) 267-0332  
Fax: 616-391-2785 
giselle.sholler@helendevoschildrens.org 
 
 
STUDY COMMITTEE MEMBERS: 
 
André S. Bachmann, PhD 
Professor and Associate Chair for Research 
Department of Pediatrics and Human 
Development 
College of Human Medicine 
Michigan State University 
Cook-DeVos Center for Health Sciences 
301 Michigan Street, NE, Office 514  
Grand Rapids, Michigan 49503, USA 
 
Phone office: 1-616-331-5982 
E-mail: andre.bachmann@hc.msu.edu  
 
 
Genevieve Bergendahl, RN 
Clinical Program Director 
NMTRC 
100 Michigan Avenue NE  MC 272         
Grand Rapids, MI 49503 
 
 
 
Tel:  (616) 267-0335 
Fax: 616-391-2785 
E-Mail:  
Genevieve.bergendahl@helendevoschildrens.org  
 
 
Alyssa VanderWerff 
Clinical Program Coordinator 
NMTRC 
100 Michigan Avenue NE  MC 272         
Grand Rapids, MI 49503 
 
 
Tel:  (616) 267-0327  
Fax: 616-391-2785 
E-Mail:  
Alyssa.VanderWerff@helendevoschildrens.org  
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 4 of 81 
Max Wicha, MD 
University of Michigan  
Distinguished Professor of Oncology 
Director, UMCCC 
6302 CC 
1500 E. Medical Center Drive 
Ann Arbor, MI 48109 
 
Tel: 1-734-936-1831 
E-Mail: mwicha@umich.edu 
 
Takamaru Ashikaga, PhD 
Professor and Director of Medical 
Biostatistics 
University of Vermont 
Burlington, VT 05405 
 
(P)1-802-656-2526 
(F)1-802-656-3632 
Takamaru.Ashikaga@uvm.edu 
 
William Ferguson, MD  
Pediatric Hematology-Oncology  
Cardinal Glennon Children’s Medical Center  
Saint Louis University School of Medicine  
1465 S. Grand Blvd.  
Saint Louis, MO 63104 
 
Tel: (314) 577-5638  
Fax: (314) 268-4081  
Email: fergusws@slu.edu  
William Roberts, MD  
Pediatric Hematology/Oncology  
Rady Children's Hospital San Diego  
3020 Children’s Way MC5035  
San Diego, CA 92123-4282  
Tel: (858) 966-5811  
Fax: (858) 966-8035  
Email: wroberts@chsd.org  
Don Eslin, MD 
Arnold Palmer Hospital for Children 
Pediatric Hematology/Oncology 
50 W. Sturtevant St. 
Orlando, FL 32806 
Office: 321-841-8588 
E-Mail: Don.Eslin@orlandohealth.com 
Jacqueline M Kraveka, DO 
Assistant Professor of Pediatrics 
Medical University of South Carolina 
Division of Pediatric Hematology-Oncology 
135 Rutledge Avenue, Room 480 
MSC 558 
Charleston, SC 29425 
 
Office: 843-792-2957 
Pager: 843-792-2123 
Fax: 843-792-8912 
E-Mail: kravekjm@musc.edu 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 5 of 81 
Javier Oesterheld, MD 
Levine Children’s Hospital 
 
 
 
1000 Blythe Blvd 
 
 
 
 
Charlotte, NC 28203 
Phone-704-381-9900 
Fax-704-381-9901 
E-Mail: 
Javier.oesterheld@carolinashealthcare.org 
Deanna Mitchell, MD 
Medical Director, Coagulation Disorders 
Program 
Assistant Professor, Pediatrics 
Michigan State University 
Helen DeVos Children’s Hospital 
100 Michigan NE 
Grand Rapids, MI  49503 
 
Phone:  616-391-2086 
FAX:  616-391-8873 
E-Mail: Deanna.Mitchell@devoschildrens.org 
Nehal S. Parikh, MD 
Connecticut Children’s Medical Center 
Pediatric Hematology/Oncology 
282 Washington Street, Suite 2J 
Hartford, CT 06106 
Office: 860-545-9630 
Fax: 860-545-9622 
E-Mail: nparikh@connecticutchildrens.org 
Randal K. Wada, MD 
Associate Professor of Pediatrics and Nursing 
University of Hawaii 
Kapiolani Medical Center for Women and 
Children  
55 Merchant Street, 26th Floor 
Honolulu, HI 96813 
 
Office: 808-983-6000 
E-mail: randalw@hawaii.edu 
 
 
Devang Pastakia, MD 
Vanderbilt-Ingram Cancer Center 
397 Preston Research Building 
2220 Pierce Ave 
Nashville, TN 37232 
Phone: 615-875-6129 
Email: devang.pastakia@Vanderbilt.Edu 
Mark Fluchel, MD 
Primary Children's Hospital 
Division of Pediatric Hematology/Oncology 
100 North Mario Capecchi Drive, 4th Floor 
Salt Lake City, UT 84113 
 
 
 
Phone: 801-662-4700 
email: mark.fluchel@imail.org 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 6 of 81 
Valerie I. Brown, MD, PhD 
Associate Professor of Pediatrics 
Division of Pediatric Oncology/Hematology 
Clinical Director, Experimental Therapeutics 
Attending Physician, Hematopoietic Stem Cell 
Transplant Program 
Penn State Milton S. Hershey Medical Center 
and Children’s Hospital 
500 University Dr. 
P.O. Box 850, MC H085 
Hershey, PA  17033-0850 
 
 
Phone: 717-531-1042 
Email: vbrown1@hmc.psu.edu 
 
Francis Eshun, MD 
Center for Cancer and Blood Disorders 
Phoenix Children's Hospital 
1919 Thomas Road 
Phoenix Az 85016 
 
feshun@phoenixchildrens.com 
 
 
 
RESEARCH  LABORATORIES 
 
Ping Zhao 
Pediatric Oncology Translational Research 
Laboratory (POTRL) 
Helen DeVos Children’s Hospital 
Coopers Landing 
1345 Monroe Ave, Suite 121 
Grand Rapids, MI 49505 
Ph: 616-486-8645 
Ping.zhao@helendevoschildrens.org 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 7 of 81 
57BINVESTIGATOR SIGNATURE SHEET 
 
I have read the attached protocol and agree that it contains all the necessary details for 
performing the study. 
 
I will review copies of the protocol and of the preclinical and clinical information (Investigator’s 
Brochure) on the test article, which was furnished to me by the Neuroblastoma and 
Medulloblastoma Translational Research Consortium (NMTRC), to all members of the study 
team responsible to me who participate in the study.  I will discuss this material with them to 
assure that they are fully informed regarding the test article and the conduct of the study. 
 
Once the protocol has been approved by the Institutional Review Board (IRB)/Independent 
Ethics Committee (IEC), I will not modify this protocol without obtaining the prior approval of 
the NMTRC and of the IRB/IEC.  I will submit the protocol modifications and/or any informed 
consent form (ICF) modifications to the NMTRC and the IRB/IEC, and approval will be 
obtained before any modifications are implemented. 
 
I understand the protocol and will work according to it, the principles of Good Clinical Practice 
(GCP) [current International Conference of Harmonization (ICH) guidelines], and the 
Declaration of Helsinki (1964) including all amendments up to and including the Scotland 
revision (2000) and notes of clarification added in 2002 and 2004. 
 
 
 
 
 
 
Investigator's Signature 
 
Date 
 
 
 
Investigator’s Printed Name 
 
 
 
 
 
Investigational Site Name 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 8 of 81 
 
8B 
TABLE OF CONTENTS 
 
 
CONTACT INFORMATION ............................................................................................................................................ 2 
STUDY COMMITTEE ............................................................................................................................................. 3 
INVESTIGATOR SIGNATURE SHEET ................................................................................................................. 7 
TABLE OF CONTENTS ........................................................................................................................................... 8 
PROCEDURES AND ASSESSMENTS ............................................................................................................................. 17 
 
1.0 
PROTOCOL CONCEPT ................................................................................................................................. 18 
 
2.0 
STUDY OBJECTIVES ................................................................................................................................... 26 
 
3.0 
STUDY DESIGN .......................................................................................................................................... 27 
 
4.0 
SUBJECT SELECTION .................................................................................................................................. 30 
 
5.0 
STUDY DRUG ADMINISTRATION ..................................................................................................... 32 
5.1 DFMO ..................................................................................................................................................... 32 
5.1.1 DESCRIPTION, FORMULATION, AND STORAGE OF DFMO ................................................................. 32 
5.1.2 DFMO DOSING: PHASE I .................................................................................................................. 32 
5.1.3 DFMO DOSING: PHASE II................................................................................................................. 35 
5.1.4 ADMINISTRATION OF DFMO ............................................................................................................ 36 
5.1.5 SUBJECTS UNABLE TO SWALLOW TABLETS ...................................................................................... 36 
5.1.6 MISSED DOSES ................................................................................................................................. 36 
5.1.7 DFMO CLINICAL PHARMACOLOGY.................................................................................................. 37 
 
5.2 BORTEZOMIB ............................................................................................................................................ 39 
5.2.1 DOSE CALCULATION AND ADMINISTRATION OF BORTEZOMIB- ALL PHASES ................................... 39 
5.2.2 BORTEZOMIB (VELCADE) ................................................................................................................. 40 
 
5.3 GUIDELINES FOR DOSE MODIFICATIONS .................................................................................................. 42 
5.4 DOSE DELAY ............................................................................................................................................ 42 
5.5 DEFINITION OF DOSE-LIMITING TOXICITY (DLT) .................................................................................... 42 
5.6 DFMO DOSE MODIFICATION ................................................................................................................... 43 
5.7 BORTEZOMIB DOSE MODIFICATION ......................................................................................................... 43 
5.8 STUDY DRUG ACCOUNTABILITY .............................................................................................................. 46 
5.9 CONCOMITANT MEDICATIONS AND TREATMENTS .................................................................................... 46 
 
6.0 
STUDY PROCEDURES AND ASSESSMENTS .................................................................................... 46 
6.1 ENROLLMENT OF SUBJECTS ...................................................................................................................... 46 
6.2 SCREENING ............................................................................................................................................... 47 
6.3 TREATMENT PHASE – CYCLE 1 ................................................................................................................. 48 
6.4 TREATMENT PHASE – CYCLES 2-6 ............................................................................................................ 49 
6.5 OTHER SCHEDULES: ................................................................................................................................. 51 
6.6 PROTOCOL TREATMENT COMPLETION ..................................................................................................... 51 
6.7 SUBSEQUENT (MAINTENANCE) CYCLES ................................................................................................... 52 
6.8 OFF-THERAPY / 30 DAY FOLLOW-UP VISIT .............................................................................................. 53 
6.9 SURVIVAL FOLLOW-UP ............................................................................................................................. 54 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 9 of 81 
7.0 
EFFICACY ASSESSMENTS ........................................................................................................................... 54 
7.1 TUMOR ASSESSMENTS/SCANS .................................................................................................................. 54 
7.2 SCAN SUBMISSION: .................................................................................................................................. 54 
7.3 RESPONSE CRITERIA ................................................................................................................................. 55 
 
8.0 
ADVERSE EVENT REPORTING .................................................................................................................... 57 
8.1 DEFINITIONS ............................................................................................................................................. 57 
8.2 DOCUMENTING ADVERSE EVENTS ........................................................................................................... 58 
8.3 EXPEDITED REPORTING OF ADVERSE EVENTS .......................................................................................... 58 
8.4 GRADING AND RELATEDNESS OF ADVERSE EVENTS ................................................................................ 59 
8.4.1 GRADING OF SEVERITY OF AN ADVERSE EVENT ................................................................................... 59 
8.5 GRADING OF HEMATOLOGIC ADVERSE EVENTS IN SPECIAL POPULATIONS .............................................. 59 
8.6 RELATEDNESS TO STUDY DRUG ............................................................................................................... 60 
 
9.0 
SUBJECT WITHDRAWAL AND TRIAL DISCONTINUATION ........................................................................... 61 
9.1 CRITERIA FOR SUBJECT OFF-THERAPY .................................................................................................... 61 
9.2 CRITERIA FOR SUBJECT OFF-STUDY ......................................................................................................... 61 
 
10.0 
DATA ANALYSIS .................................................................................................................................. 62 
10.1 DATA QUALITY ASSURANCE .................................................................................................................. 62 
10.2 STATISTICAL ANALYSIS ......................................................................................................................... 62 
 
11.0 
ADMINISTRATIVE PROCEDURES ..................................................................................................... 64 
11.1 PATIENT INFORMED CONSENT ................................................................................................................ 64 
11.2 ETHICAL CONDUCT OF THE STUDY AND IRB/IEC APPROVAL ................................................................ 65 
11.3 DATA SAFETY MONITORING BOARD (DSMB) ....................................................................................... 65 
11.4 MONITORING AND AUDITING ................................................................................................................. 65 
11.5 PRE-STUDY DOCUMENTATION ............................................................................................................... 66 
11.6 CONFIDENTIALITY .................................................................................................................................. 66 
11.7 SOURCE DOCUMENTS ............................................................................................................................. 67 
11.8 RECORD RETENTION .............................................................................................................................. 67 
 
12.0 
BIOLOGICAL EVALUATION ........................................................................................................................ 67 
12.1 BIOLOGICAL CORRELATIVE STUDIES SAMPLE INSTRUCTIONS ................................................................ 69 
12.1.1 OPTIONAL URINE POLYAMINES COLLECTION: ................................................................................ 69 
12.1.2 OPTIONAL BLOOD COLLECTION ..................................................................................................... 70 
12.1.3 OPTIONAL BONE MARROW COLLECTION ....................................................................................... 71 
12.1.4 OPTIONAL TUMOR SAMPLE COLLECTION ....................................................................................... 72 
12.2 SAMPLE STORAGE AND DESTRUCTION ................................................................................................... 72 
 
 
APPENDIX I: PERFORMANCE STATUS/SCORES .......................................................................................................... 74 
 
APPENDIX II: LIST OF STRONG AND CLINICALLY RELEVANT MODERATE CYP3A4 
INDUCERS AND INHIBITORS ...................................................................................................................................... 76 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 10 of 81 
PROTOCOL SYNOPSIS 
PROTOCOL TITLE 
A Phase I/II Trial of DFMO in Combination with Bortezomib in 
Patients with Relapsed or Refractory Neuroblastoma  
PROTOCOL NUMBER 
NMTRC010B 
PHASE OF DEVELOPMENT 
Phase I/II 
OBJECTIVES 
Primary- Phase I  
• To determine the safety and tolerability of DFMO in combination 
with bortezomib at 3 dose levels of DFMO: 1500mg/m2 twice 
daily, 2000mg/m2 twice daily, and 2500mg/m2 twice daily  in 
subjects with relapsed or refractory neuroblastoma who receive 
one full cycle of this dose. 
 
Primary- Phase I and II 
To evaluate the activity of DFMO in combination with bortezomib 
in relapsed or refractory neuroblastoma based on: 
 Progression free survival (PFS)  
 Overall response rate (ORR)  
 
Secondary- Phase I and II 
• To determine the safety and tolerability of DFMO in combination 
with bortezomib in pediatric subjects with refractory or recurrent 
neuroblastoma. 
• For subjects followed with PET scan: comparison of changes in 
PET activity and correlation with PFS   
• Correlation of urinary polyamine levels with response and 
progression of disease in neuroblastoma. 
• Biological Correlates to evaluate or explore minimally include: 1) 
Urine: polyamine levels 2) Blood: Inflammatory markers (ESR, 
CRP, IL-6),  Biomarkers for Let 7 and SNPS, and explorative 
biomarker analysis, 3) Bone Marrow/Tumor biopsies (if biopsied 
per 
standard 
of 
care): 
research 
studies 
including 
Immunohistochemistry/Western Blot/qRT-PCR of bone marrow 
tumor cells or tumor to study Let-7, ODC, Lin28, MYCN, OKT-
4, BMI1, HMGA2, GLUT-4, p-AKT, NF-kB, SOCS3 will be 
performed in an explorative biomarker analysis. Studies will 
measure thymidine and polyamine levels. 4) In vitro research 
studies of tumor cells collected above will include: Genomic 
analysis of cells pre- and post- treatment (when applicable), cell 
viability assays to determine subject IC50 and correlation of in 
vitro response to in vivo response.  
• To determine the dose effect of DFMO on biological correlates 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 11 of 81 
STUDY DESIGN 
NMTRC010B is an open label, multicenter, study to evaluate the 
efficacy of DFMO in combination with Bortezomib in patients with 
relapsed or refractory neuroblastoma. 
Phase 1 
This portion of the study uses a standard 3+3 design in which 
cohorts of 3 patients will receive oral DFMO at a starting dose of 
1500 mg/m2 BID of a 21-day cycle.  Subjects that complete one 
cycle will be considered as having completed Phase I. The dose 
escalation scheme for subsequent cohorts and modifications for dose 
limiting toxicities (DLT) are detailed in the protocol.  The MTD of 
single agent therapy will be defined as the dose level below which 
DLTs are seen in ≥ two of six subjects dosed. 
 
Cycle 1 through 6: DFMO + Bortezomib 
Phase I: Subjects will receive oral DFMO twice daily at their 
assigned dose level on each day of this 21-day cycle. 
DFMO Dose 
Level 
Dose 
1 
1500 mg/m2 BID 
2 
2000 mg/m2 BID 
3 
2500 mg/m2 BID 
 
Phase II: The highest tolerated DFMO dose from the Phase I dose 
escalation will be used for the Phase II portion of the study. Subjects 
will receive oral DFMO twice daily on each day of this 21-day 
cycle. 
 
All Phases: Bortezomib will be given at 1.3mg/m2/dose  IV Push on 
Days 1, 4, and 8 of each 21-day cycle 
 
Phase I Subjects: 
The Phase I subjects on this study will be the first pediatric subjects 
to receive DFMO in combination with Bortezomib. If a Dose 
Limiting Toxicity (DLT) is seen in 2/6 subjects, this portion of the 
study will allow for a -1 dose level reduction (1000mg/m2/dose). If 
the DLT is seen in 2/6 subjects at the -1 dose level, a further 
reduction to dose level -2 (500mg/m2/dose) will be allowed.  
Enrollment will be held at the end of this phase of the study until all 
subjects within the cohort have completed one cycle and a safety 
analysis has been completed by the study committee and Data 
Safety and Monitoring Board (DSMB).  The study committee will 
then decide whether the study can continue to the next cohort and 
subsequently to the Phase II portion of the trial. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 12 of 81 
Phase I: At least three and up to six subjects per cohort, for an 
estimated three cohorts (based on safety) may be enrolled for a 
projected total of 12 to 24 subjects.   
 
Phase II: A total of 32-38 relapsed/refractory neuroblastoma subjects 
will be enrolled to ensure that there will be 32 subjects evaluable for 
efficacy. Phase 1 subjects assigned to the final dosing level that 
complete at least 2 cycles and re-evaluation will be eligible to 
continue onto the Phase II portion of the study and will be included 
in the total enrollment numbers. 
 
Response 
Response will be evaluated at the end of cycles 2, 4, and 6 with: 
• CT and/or MRI- same as baseline 
• MIBG or PET scan- same as baseline 
• Bone Marrow- if positive at study entry 
 
Maintenance Cycles 
Subjects that complete 6 cycles will be considered as having 
completed the protocol defined therapy, however they may continue 
on cycles of DFMO (at their current dose level) and bortezomib for 
as long as they are tolerating it well and not having progression. 
Subjects in maintenance cycles will have response evaluations done 
as per standard of care.  
 
ELIGIBILITY 
Inclusion Criteria 
1. Age: ≤ 21 years at the time of diagnosis. 
2. Diagnosis: Histologic verification at either the time of original 
diagnosis or relapse of neuroblastoma. 
3. Disease Status: For the purposes of this study, aggressive multidrug 
chemotherapy is defined as chemotherapy including 2 or more 
agents that must include an alkylating agent and a platinum-
containing compound. Patients must have ONE of the following: 
1)   Any episode of recurrent disease following completion 
of aggressive multi-drug frontline therapy. 
2)   Any episode of progressive disease during aggressive 
multi-drug frontline therapy. 
3)   Primary  resistant/refractory  disease  detected  at  the  
conclusion  of  at  least  4  cycles  of aggressive multidrug 
induction chemotherapy on or according to a high-risk 
neuroblastoma protocol (examples include Children’s 
Oncology Group trials: A3973, ANBL0532, ANBL09P1, 
etc.). 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 13 of 81 
4.  Measurable or evaluable disease, including at least one of the 
following: Measureable tumor by CT or MRI; or A positive 
MIBG or PET; or Positive bone marrow biopsy/aspirate. 
5. Current disease state must be one for which there is currently no 
known curative therapy or no additional therapies proven to 
prolong survival with an acceptable quality of life.    
6. A negative serum or urine pregnancy test is required for female 
subjects of child bearing potential (onset of menses or ≥13 years 
of age). 
7. Organ Function Requirements 
a. Subjects must have adequate liver function as defined by:  
• 
AST and ALT <5x upper limit of normal  
• 
Serum bilirubin must be ≤ 2.0 mg/dl 
 
b. Subjects must have adequate Bone Marrow function 
defined as: 
For patients without bone marrow involvement: 
• 
Peripheral absolute neutrophil count (ANC) ≥  
750/µL 
• 
Platelet count ≥ 50,000/µL (transfusion independent, 
defined as not receiving platelet transfusions within a 7 
day period prior to enrollment.  Exception: Patients 
that are platelet dependent due to previous extensive 
treatment- e.g. - MIBG therapy). 
• 
Hemoglobin ≥ 8.0 g/dL (may receive RBC 
transfusions) 
 
Patients known to have bone marrow involvement with 
neuroblastoma are eligible provided that minimum ANC 
and platelet count criteria are met but are not evaluable for 
hematological toxicity. 
 
Patients that do not have bone marrow involvement but that 
are transfusion dependent at study entry are eligible 
provided that minimum ANC and platelet count criteria are 
met but are not evaluable for platelet toxicity. 
 
 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 14 of 81 
c.  Subjects must have adequate renal function defined as: 
• 
Serum creatinine based on age/gender as follows: 
 Age 
Maximum Serum Creatinine (mg/dL) 
 Male  
Female  
1 month to < 6 months  
0.4 
0.4 
6 months to < 1 year  
0.5 
05 
1 to < 2 years  
0.6 
0.6 
2 to < 6 year 
0.8 
0.8 
6 to < 10 years  
1 
1 
10 to < 13 years  
1.2 
1.2 
13 to < 16 years  
1.5 
1.4 
≥ 16 years  
1.7 
1.4 
8. Informed Consent: All subjects and/or legal guardians must sign 
informed written consent. Assent, when appropriate, will be 
obtained according to institutional guidelines 
Exclusion Criteria 
9. Lansky score <50% 
10. BSA (m2) of  <0.25 
11. Prior Therapy- Patients must have fully recovered from the 
acute toxic effects of all prior anti- cancer chemotherapy and be 
within the following timelines: 
a.   Myelosuppressive chemotherapy: Must not have received 
within 2 weeks of enrollment onto this study (6 weeks if prior 
nitrosourea). 
b.   Hematopoietic  growth  factors:  At  least  5  days  since  
the  completion  of therapy with a growth factor. 
c.   Biologic (anti-neoplastic agent): At least 7 days since 
the completion of therapy with a biologic agent. For agents 
that have known adverse events occurring beyond 7 days 
after administration, this period must be extended beyond the 
time during which adverse events are known to occur. The 
duration of this interval must be discussed with the Study Chair. 
d.   Immunotherapy: At  least  6  weeks  since  the  completion  
of  any  type  of immunotherapy, e.g. tumor vaccines. 
e.   Monoclonal antibodies:  At least 7 days or 3 half-lives, 
whichever is longer, must have elapsed since prior treatment 
with a monoclonal antibody. 
f.    XRT: At least 14 days since the last treatment except for 
radiation delivered with palliative intent to a non-target site.  
g.   Stem Cell Transplant or Rescue: No evidence of 
active graft vs. host disease and ≥ 2 months must have 
elapsed since transplant. 
12. Investigational Drugs: Subjects who have received another 
investigational drug within the last 14 days are excluded from 
participation. 
13. Infection: Subjects who have an uncontrolled infection are not 
eligible until the infection is judged to be well controlled in the 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 15 of 81 
opinion of the investigator. 
14. Subjects who, in the opinion of the investigator, may not be able 
to comply with the safety monitoring requirements of the study, 
or in whom compliance is likely to be suboptimal, should be 
excluded.  
Additional criteria: 
Subjects willing to participate in the correlative biologic studies will 
sign an additional consent form to provide bone marrow, blood, 
urine, and tumor (if available) for analysis. 
ESTIMATED NUMBER OF 
SUBJECTS/GEOGRAPHIC 
REGIONS 
A projected total of 12 to 24 subjects for the Phase I and 32- 38 
subjects for the Phase II will be enrolled.  
A total of 38-62 subjects will be enrolled to complete the dose 
escalation and achieve 32 evaluable subjects for the Phase II.  
Up to 16 sites in the United States will participate. 
LENGTH OF STUDY 
Accrual to this study is estimated to be 2 years, with follow up for 
five years after last subject completion. 
INVESTIGATIONAL PRODUCT 
DOSE/ROUTE/REGIMEN 
DFMO is an oral agent that will be administered twice daily on 
every day of each 21-day cycle in combination with bortezomib 
given IV on Days 1, 4, and 8 of each 21-day cycle.   
STUDY ASSESSMENTS 
Refer to Table of Assessments for timing of study procedures. 
 
CRITERIA FOR EVALUATION 
Safety Measures:  
• Safety analysis will be conducted on all subjects who have 
received at least one dose of study drug, and will include the 
frequency and grade of all adverse events.  
Response Measures:  
• Overall Response Rate (ORR) 
 To determine the overall response rate (ORR) by the presence 
of radiologically assessable disease by cross-sectional imaging 
and in MIBG or PET scans. Response will be defined by 
criteria in section 9.0; or disappearance of abnormal MIBG or 
PET foci. 
 Duration of response, defined as the period of time from when 
measurement criteria are met for complete response (CR) or 
partial response (PR), whichever is first recorded, until the first 
date that recurrent or progressive disease (PD) is objectively 
documented (taking as reference for PD the smallest 
measurements recorded since the treatment started) 
 The assessment of response will include the initial measurable 
targets and will be performed after the second cycle, then after 
every other cycle. Serial results of bone marrow aspirates, and 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 16 of 81 
urinary catecholamines will be followed to confirm clinical 
response in subjects with stable disease.  
• A subject will be defined as a responder if CR/PR is observed at 
any time during the treatment.  
• Time to progression, defined as the period from the start of the 
treatment until the criteria for progression are met. 
• Survival will be recorded at all times during the study, and 
follow-up will be every three months for one year and then 
annually for five years.  
 
STATISTICS/SAMPLE SIZE 
ESTIMATE 
Statistics: 
All baseline subject characteristics will be summarized in a tabular 
format.  Safety data will be described for all subjects receiving at 
least one dose of DFMO.  Safety data will include all grade 2 or 
greater adverse events and reporting of DLT’s and MTD. The 
proportion of subjects experiencing adverse events, serious adverse 
events, and treatment delays will be summarized for each dosing 
cohort. 
 
Response data will be summarized as the proportion of subjects 
experiencing progressive disease, stable disease, partial responses or 
complete responses summarized in tabular format and supplemented 
with exact confidence intervals. Progression free survival and 
duration of any responses will also be summarized based on the 
Kaplan-Meier approach.   
 
Sample Size: 
Phase I:  A 3+3 design with 3 dose levels will be used. At least 
three and up to six subjects per cohort, for an estimated three cohorts 
(based on safety) may be enrolled for a projected total of 12 to 24 
subjects.   
 
Phase II: Primary endpoint of ORR, a sample size of n=32 (6 from 
Phase I MTD) will be required to test whether treatment with 
DFMO can result in an ORR of 10% (Reference Value set at ORR 
<= 1%) The sample size to detect this difference uses a two-stage 
test with 5% Type I error level and 80% power. 
 
Examination of the secondary endpoint of PFS will require a sample 
size of n = 23 subjects to test whether treatment with DFMO can 
prolong PFS by 48 days (from 42 days based on historical data in 
this subject population to 90 days). The sample size to detect this 
difference uses a two-stage test with 5% Type I error level and 80% 
power. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 17 of 81 
Procedures and Assessments 
 
a  Optional 
additional 
informed 
consent 
required 
b  At the end 
of cycle 2, 4, 
and 6, then 
every other 
cycle 
 
c  At the end 
of cycle 2 and 
6, then yearly 
 
^Standard of 
Care Bone 
Marrow. 
(Separate 
consent 
required for 
additional 
research 
samples per 
section 12.0) 
 
 
 
 
 
 
 
Screen 
Cycle 1 
Cycles 2 through 6 
Subsequent 
Cycles 
Follow 
Up 
 
 
Day 1 
Day 
4 
Day 
8 
Day 
15 
Day 16-
21 
Day 1 
Day 4 
Day 8 
Day 
15 
Day 
16-21 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical & surgical history, demographics
histologic evidence of malignancy 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
Prior therapy for malignancy 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Tumor Tissue (Pharmacogenomics)a 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Interval Medical History & Physical Exam 
 
X 
X 
X 
X 
 
X 
 
X 
X 
 
X 
X 
Vital signs including O2 saturation 
X 
X 
X 
X 
X 
 
X 
X 
X 
X 
 
X 
X 
ECOG or Lansky play status 
X 
 
 
 
 
 
X 
 
 
 
 
X 
X 
CBC and differential 
X 
 
 
X 
X 
 
X 
 
X 
X 
 
X 
X 
Serum chemistries 
X 
 
 
X 
X 
 
X 
 
 
X 
 
X 
X 
CRP, ESR, IL-6 (IL-6 is recommended) 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
Pregnancy test (urine) 
X 
 
 
 
 
 
X 
 
 
 
 
X 
 
Urinary VMA/HVA 
X 
 
 
 
 
 
X 
 
 
 
 
X 
X 
BSA calculation 
X 
 
 
 
 
 
X 
 
 
 
 
X 
 
Administration of Bortezomib 
 
X 
X 
X 
 
 
X 
X 
X 
 
 
X 
 
Administration of DFMO 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Dispense (and collect) drug dosing diary 
 
X 
 
 
 
 
X 
 
 
 
 
 
 
AE monitoring 
 
X 
X 
X 
X 
 
X 
X 
X 
X 
 
X 
X 
Concomitant medications 
X 
X 
X 
X 
X 
 
X 
X 
X 
X 
 
X 
X 
CT or MRI 
X 
 
 
 
 
 
 
 
 
 
Xb 
Xb 
Xb 
MIBG or PET scan 
X 
 
 
 
 
 
 
 
 
 
Xb 
Xb 
Xb 
Bone Marrow aspirate and biopsy ^  
(if + at enrollment) 
X 
 
 
 
 
 
 
 
 
 
Xb 
Xb 
Xb 
Audiogram 
X 
 
 
 
 
 
 
 
 
 
Xc 
Xc 
Xc 
Urine for biological correlatesa 
 
X 
 
 
X 
 
X 
 
 
 
 
 
 
Blood for biological correlatesa 
 
X 
 
 
X 
 
X 
 
 
 
 
 
 
Survival 
 
 
 
 
 
 
 
 
 
 
 
 
X 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 18 of 81 
1.0 
Protocol Concept 
High risk Neuroblastoma (NB) remains a challenge in pediatric oncology, accounting for 15% of 
all pediatric cancer deaths.  While most patients are able to attain remission, approximately 50% 
will relapse.  Once relapsed, there is currently no curative treatment for these children, and for 
these children the 5-year survival rate is <10%.  As such, new therapeutic approaches are needed 
to treat these children.  
  
These more aggressive forms of NB respond poorly to hormonal and chemotherapeutic 
approaches, and therefore, there is a great need for antineoplastic agents with novel mechanisms 
of action. The MYCN protein up-regulates ornithine decarboxylase (ODC), a gene encoding for 
the ODC enzyme that is pivotal in polyamine biosynthesis. High polyamine content and elevated 
ODC activities are commonly found in NB as well as many other tumors, and therefore, 
suppression of polyamines in cancer cells is an effective means to reduce tumor cell 
proliferation. We have shown ODC inhibition reverses the LIN28/Let7 pathway, an important 
pathway in cell differentiation and regulation of glycolytic metabolism.  In studying this 
pathway, it was found to be regulated as well by the NFkB pathway. We have therefore studied 
the combination of DFMO with Bortezomib and showing synergy of these medications in 
neuroblastoma in vitro and in vivo. This study will address this concept in children with relapsed 
or refractory neuroblastoma. 
 
 
Background and Preliminary Data 
1.1 
Previous Preclinical and Clinical Work  
Neuroblastoma (NB) is a tumor of the autonomous nervous system originating from the adrenal 
medulla and autonomous ganglia in the chest and abdomen. After leukemia and brain tumors, 
NB is the third most frequent malignant tumor of childhood. The incidence in the United States 
is approximately one in 7,000 children (Ater, Gardner et al. 1998). Therapy for NB is very 
intense, especially in advanced stages of the disease with widespread metastases to liver, bone, 
lymph nodes, and bone marrow. Current therapy includes chemotherapy, radiation, and high 
dose chemotherapy with subsequent bone marrow transplantation followed by differentiating 
therapy. More recently, immunotherapy has been added using monoclonal antibodies to the GD2 
glycolipid antigen that is heavily expressed by NB cells (Bosslet, Mennel et al. 1989; Cheung, 
Kushner et al. 1998). Over the last 30 years, significant therapeutic progress has been made with 
an increase in the five-year relative survival rate from approximately 25% to 55%. However, 
almost 50% of patients are estimated to die of their tumor, and over the past decade improvement 
in the five-year survival rate of NB patients has been slow (Harras 1996). NB has a particularly 
poor prognosis in patients older than 2 years at diagnosis, advanced stage disease and/or disease 
characterized by MYCN gene amplification (Seeger, Brodeur et al. 1985; Brodeur 2003). These 
more aggressive forms of NB respond poorly to chemotherapeutic approaches, and therefore, 
there is great need for a better understanding of the cellular regulation of MYCN-amplified NB 
tumors in an effort to search for alternative molecular drug targets. Although a role for the 
MYCN oncoprotein has been established in NB pathogenesis, the mechanism by which MYCN 
contributes to both the development of this disease and its poor prognosis is still unclear. The 
MYCN oncoprotein functions as a transcriptional regulator (Ben-Yosef, Yanuka et al. 1998) and 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 19 of 81 
thus may influence tumorigenesis and patient survival by regulating the expression of key genes 
involved in the NB malignant phenotype. MYCN regulates the expression of genes that encode 
ornithine decarboxylase (ODC), the multi-drug resistance-associated protein 1 (MRP1), and 
MDM2 (Slack, Chen et al. 2005). ODC is the rate-limiting enzyme in the production of 
polyamines (Marton and Pegg 1995). Although polyamines, and therefore ODC, are essential for 
normal cell proliferation, increased ODC activity can induce cellular transformation in vitro 
(Auvinen, Paasinen et al. 1992), and high ODC levels are associated with a variety of tumors, 
including those of the brain and prostate (Mohan, Challa et al. 1999; Ernestus, Rohn et al. 2001). 
Several studies have identified ODC as a target gene for the MYCN oncoprotein (Lutz, Stohr et 
al. 1996; Ben-Yosef, Yanuka et al. 1998; Lu, Pearson et al. 2003), and it is possible that ODC, 
and therefore polyamines, play a significant role in NB tumorigenesis. 
 
Role of polyamines in cancer 
The identification of novel inhibitors of enzymes involved in polyamine biosynthesis with 
antitumor activities has recently revived interest in polyamine homeostasis and in designing 
strategies of cancer chemotherapy (Mamont, Duchesne et al. 1978; Porter, Regenass et al. 1992; 
Seiler, Atanassov et al. 1998). Selective pharmacological interference with the synthesis of 
natural polyamines results in tumor cell growth inhibition under both in vitro and in vivo 
conditions (Mamont, Duchesne et al. 1978; McCann and Pegg 1992). Although the precise 
mechanism by which polyamines contribute to cell proliferation is not well known, it has been 
suggested that it may be a result of their ability to bind DNA and affect gene expression by 
bringing about structural changes in chromatin, thereby stimulating cell growth (Marton and 
Morris 1987). Furthermore, the dramatic increases in the activity of ODC in certain tumor cells 
have been linked to G1-S transition (Fuller, Gerner et al. 1977; Kahana and Nathans 1984; 
Kaczmarek, Calabretta et al. 1987). As mentioned above, an apparent molecular basis for this 
derives from the fact that ODC is among those genes, which can be regulated by c-Myc and 
MYCN (Bello-Fernandez, Packham et al. 1993; Pena, Reddy et al. 1993; Wagner, Meyers et al. 
1993; Lutz, Stohr et al. 1996; Lu, Pearson et al. 2003), both of which regulate entry into and exit 
from the cell cycle. Because cell growth is absolutely dependent on polyamines, interference 
with polyamine biosynthesis has long been considered a promising therapeutic approach against 
proliferative diseases, including various malignancies (Heby and Persson 1990; Auvinen, 
Paasinen et al. 1992; McCann and Pegg 1992). α-difluoromethylornithine (DFMO or 
eflornithine), a suicide substrate inhibitor of ODC (Metcalf, Bey et al. 1978; Poulin, Lu et al. 
1992), has been the prototype tool for the study of therapeutic effectiveness of polyamine 
depletion in experimental tumors (McCann and Pegg 1992; Meyskens and Gerner 1999) (Fig. 1). 
 
 
 
 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 20 of 81 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DFMO inhibits cell growth of many cancer cells including NB and induces cell differentiation 
(Chapman 1980; Melino, Farrace et al. 1988). These processes are accompanied by an apparent 
depletion of putrescine (Put) and spermidine (Spd) pools (Pegg 1988; Heby and Persson 1990; 
McCann and Pegg 1992). DFMO has also been shown to induce apoptosis and inhibit metastasis 
in a human gastric cancer model (Takahashi, Mai et al. 2000).  
 
Role of polyamines in NB cell differentiation   
The fluctuation in the levels of intracellular polyamines such as Put, Spd, and spermine (Spm) 
has been observed in association with cell differentiation (Heby 1981; Tabor and Tabor 1984; 
Pegg 1986), and inhibition of ODC by DFMO and reduction in polyamine pools stimulates 
various cancer cells including NB cells to differentiate (Chen, Nau et al. 1983; Melino, Farrace et 
al. 1988; Melino, Piacentini et al. 1991).  DFMO treatment of NB cells can change the triangular 
NB morphology by inducing a different phenotype; one which resembles elongated fibroblast-
like cells without typical neuritic processes. By comparison, treatment with retinoic acid (RA) 
induces neural differentiation of NB cells as indicated by the outgrowth of definite neurites 
(Melino, Farrace et al. 1988; Melino, Piacentini et al. 1991; Wainwright, Lasorella et al. 2001). 
The role of polyamines in cell differentiation has been studied for many years, and yet the 
precise role of polyamines at the cellular and molecular level is still not well understood and may 
play a key role in tumor regression. 
 
Effect of polyamine inhibitor DFMO in a transgenic neuroblastoma animal model 
Encouraging data by two groups (Hogarty, Norris et al. 2008; Rounbehler, Li et al. 2009) 
recently emerged and confirmed the effect of DFMO in vivo using the TH-MYCN NB mouse 
model, and DFMO in combination with cisplatin and cyclophosphamide increased the tumor-free 
survival of TH-MYCN homozygous mice (Fig. 2) (Hogarty, Norris et al. 2008). Additional 
studies have revealed that DFMO combined with SAM486A act synergistically and result in a 
significantly reduced tumor burden in TH-MYCN mice (56). 
Figure 1. Pathway of polyamine metabolism showing two target 
enzymes of the polyamine inhibitors DFMO and SAM486A. By 
inhibiting ODC, DFMO depletes putrescine (Put) and spermidine 
(Spd) pools, whereas it only modestly affects spermine (Spm) 
pools. By inhibiting AdoMetDC, SAM486A depletes Spd and 
Spm, whereas it markedly increases Put. The inhibitor 
combination lowers all three polyamine pools until cells stop 
growing and the pools are no longer diluted by cell division. SSAT 
and PAO work in concert to acetylate and oxidize polyamines 
during retro-conversion. SMO converts Spm back to Spd without 
the 
need 
for 
an 
acetylation 
step. 
AdoMetDC, 
S-
adenosylmethionine decarboxylase; MTA, methyl-thioadenosine; 
ODC, ornithine decarboxylase; PAO, polyamine oxidase; SAM, S-
adenosylmethionine; 
SMO, 
spermine 
oxidase; 
SSAT, 
spermidine/spermine N1-acetyltransferase 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 21 of 81 
 
 
Figure 2. Extended tumor-free survival in neuroblastoma-prone mice treated with DFMO. A, tumor-free survival 
curves for homozygous (TH-MYCN +/+) or hemizygous (TH-MYCN +/-) mice stratified by DFMO therapy. DFMO-
treated mice (dashed lines) received DFMO from birth onward (preemptive treatment trial). DFMO therapy was 
stopped at day 70 in tumor-free mice. B, delayed treatment trial: TH-MYCN homozygous and hemizygous mice 
were randomized to DFMO (dashed lines) or control (solid lines) following weaning at day 25. Tumor-free survival 
for TH-MYCN homozygous mice with advanced tumor from the time of treatment with (C) cisplatin alone (black 
line), cisplatin followed by DFMO (gray line), or cisplatin administered simultaneously with DFMO (dashed line) or 
(D) cyclophosphamide alone (solid line) or combined with DFMO (dashed line). P values using the method of 
Kaplan-Meier are shown (75). 
 
 
Relevance of ODC in patients with neuroblastoma 
Further evidence of the importance of ODC in NB tumorigenesis is available from our recent 
studies with human NB tumors. We analyzed the expression levels of ODC mRNA from 88 NB 
patients and found significant correlations between ODC expression and the overall survival 
probability. High levels of ODC were predictive of low survival probability and vice versa (Fig. 
3A). Most surprisingly, ODC was also predictive in tumors without MYCN amplification (Fig. 
3B), thus suggesting that ODC also plays a role in NB tumorigenesis independent of MYCN 
amplification (57). These findings were independently confirmed by two other groups (Hogarty, 
Norris et al. 2008; Rounbehler, Li et al. 2009). 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 22 of 81 
A                                                        B 
 
 
Figure 3. Correlation of ODC gene expression with NB patient survival prognosis. A, Kaplan-Meier graphs 
representing the survival prognosis of 88 NB patients based on high or low expression levels of ODC. Survival 
probability of NB patients (follow-up over 196 months) with low ODC expression is significantly higher than of 
patients with high ODC expression. B, Kaplan-Meier graphs representing the survival prognosis based on high or 
low expression levels of ODC stratified for patients without MYCN amplification. The survival probability of NB 
patients with low ODC expression is significantly higher than of patients with high ODC expression (80). 
 
 
Combination of DFMO and Bortezomib targeting LIN28/Let7 axis and glycolytic 
metabolism. 
Overexpression of LIN28 correlates with poor outcome in neuroblastoma (NB) [1].   The 
LIN28/Let-7 axis affects many cellular processes including cell differentiation and glycolytic 
metabolism [2-4]. The LIN28/Let-7 axis also 
affects MYCN, which is often overexpressed 
in high risk NB [5, 6]. Studies in colon 
cancer 
have 
shown 
that 
ornithine 
decarboxylase (ODC) inhibition decreases 
LIN28 
levels, 
thereby 
reversing 
the 
LIN28/Let-7 axis [7].    
 
Our preliminary studies demonstrate that 
therapy 
targeting 
ODC 
reverses 
the 
LIN28B/Let-7 axis in NB and decreases 
MYCN protein expression (Figure 4).  Our 
studies show that cells overexpressing 
LIN28B also have greater sensitivity to 
difluoromethylornithine (DFMO) treatment, 
which inhibits ODC and decreases cellular 
polyamines [8].  
 
 
 
 
 
Figure 4: DFMO treatment reverses the LIN28/Let-7 axis in NB. A) 
Western blot analysis showed that DFMO treatment reduces LIN28B 
and MYCN protein levels in NB cells lines. B) qRT-PCR analysis 
showed increased Let-7 miRNA levels in BE(2)-C and SMS-KCNR 
cell lines with DFMO treatment.  

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 23 of 81 
Many cancer cells are reprogramed to produce ATP primarily via glycolytic metabolism as 
opposed to oxidative phosphorylation, a phenomenon termed the “Warburg effect” [9-13]. This 
phenomenon is well documented in NB [14]. 
Our studies showed a decrease in ATP/cell with 
DFMO treatment in NB, indicating a decrease 
in glycolytic metabolic activity (data not 
shown).  Patient observations in our Phase I 
study with DFMO and in vivo xenograft studies 
using PET scans further validated the findings 
that 
DFMO 
treatment 
reduces 
glycolytic 
metabolism in NB (Figure 2).  
 
Recent studies have shown that the LIN28/Let-7 
and metabolism pathways are important in 
cancer stem cell (CSC) regulation. Our 
collaborator, Dr. Max Wicha, has demonstrated 
the importance of these pathways in breast 
CSCs. His studies show that elevated glycolytic 
metabolism is a characteristic of CSCs [15] and  
suggests that the  LIN28/Let-7 axis is of critical  
importance in CSCs [16]. Additionally, his 
research has demonstrated the importance of 
SOCS3 and the NF-kB/IL-6 inflammatory loop 
in CSCs [17]. The NF-kB/IL-6 inflammatory loop is linked to the LIN28/Let-7 axis [3]; 
therefore, to further inhibit this pathway, we studied bortezomib (Velcade). Bortezomib 
inactivates NF-kB through proteasome inhibition. NF-kB binds and enhances expression at the 
LIN28 promoter [3], therefore inhibition by 
bortezomib reduces LIN28.  Downstream 
effects of this include inhibition of the insulin 
receptor and GLUT-4 and decrease in 
glycolytic metabolism [2].  Proteosome 
inhibition also results in an increase in SOCS3 
which in turn inhibits the JAK/STAT pathway 
and decreases IL-6 [17] (Figure 3). Our 
preliminary studies show synergy between 
DFMO and bortezomib in NB. 
 
This combination was tested in in vitro and in 
vivo studies and shown to be well tolerated 
and effective together. A mice xenograft 
model treated with the combination with 
DFMO and bortezomib resulted in a decrease 
in tumor growth (Figure 5).   
 
 
 
Figure 5: DFMO treatment reduces glycolytic metabolism in 
NB. A) Patient PET scans before and after one cycle of DFMO 
treatment. B) Average SUVmax (measure of metabolism) was 
lower in mice treated with DFMO compared to untreated. C) 
PET scans of one untreated and one DFMO-treated mouse at 
baseline, day 19, and day 32 of treatment.  
Figure 3:  Pathways of importance in CSCs. Combined treatment 
with DFMO and Bortezomib targets multiple points of the ODC-
LIN28 pathways and IL-6 inflammatory loop.  

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 24 of 81 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 5. SMS-KCNR Xenograft treated with DFMO and Botrezomib 
 
 
1.2 
Clinical Work 
 
Summary of Phase I Neuroblastoma Trial (NTC01059071) 
 
NTC01059071 was a multi-center, investigator initiated dose escalation study that was 
completed in 2013. The following dose levels of DFMO (CPP-1X) were investigated: 500 
mg/m2, 750 mg/m2, 1000 mg/m2 and 1500 mg/m2. Cycles were 21 days, with CPP-1X given 
days 1-21 for all cycles and for cycles 2 and greater, etoposide is given on days 1-14 of each 
cycle. Subjects must complete the first 2 cycles of treatment (cycle 1 CPP-1X alone, cycle 2 
CPP-1X with 50 mg/m2/dose etoposide) in order to be included in the dose limiting toxicity 
assessment. Subjects who did not complete 2 cycles were replaced in the cohort. Subjects are 
considered to have completed the study if they have received 5 cycles of treatment. They may 
continue treatment if there are no safety concerns, there is no disease progression, and/or there is 
an indication of clinical benefit. 
 
At the close of the study 21 subjects had received at least one dose of DFMO, with 3 evaluable 
subjects at 500 mg/m2, 3 evaluable subjects at 750 mg/m2, 3 evaluable subjects at 1000 mg/m2, 
and 6 evaluable subjects at 1500 mg/m2. All subjects were multiple relapsed/refractory, with 14 
males and 7 females, mean age 9, range (1-17), and 60% White/Caucasian. 
 
There were no DLT’s reported during this study and no serious adverse events. The most 
prevalent adverse events were low hemoglobin, neutropenia and thrombocytopenia. The majority 
of the events were considered unrelated to treatment.  
 
Nine subjects completed at least 5 cycles of therapy therefore completing study defined protocol 
therapy. Time on study ranged from 1 to 43 cycles, with 4 subjects on therapy 1 year or more. 
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Baseline
Day 7
Day 14
cm3 
Average Tumor Volume 
Vehicle
DFMO
Velcade
Combo

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 25 of 81 
 
Summary of Phase II Neuroblastoma Prevention Trial  
 
NCT01586260 is a multi-center, open label, single agent study that was opened in 2012 for 
children with neuroblastoma that is in remission. The dose level of DFMO being investigated is: 
1000 mg/m2 twice daily. Cycles are 28 days, with DFMO given days 1-28 for all cycles. Subjects 
are considered to have completed the study if they have received 27 cycles of treatment (2 years) 
without a remission.  
 
To date 51 subjects had received at least one dose of DFMO, with 44 subjects remaining on 
study at this time.  All subjects had neuroblastoma that is in remission, with 33 males and 18 
females, mean age 9, range (1-17), and 69% White/Caucasian.  There have been no related 
SAE’s reported during this study to date.  
 
Summary of Dosing and Schedule Development for Bortezomib 
 
Bortezomib (Velcade®, IND #58443) is an FDA approved proteasomal Inhibitor for the 
treatment of multiple myeloma and mantle cell lymphoma.  Pre-clinical studies have 
demonstrated anti-tumor activity of bortezomib in pediatric cancers, including leukemia, non-
Hodgkin lymphoma, neuroblastoma, rhabdomyosarcoma, and Ewing’s sarcoma.   Bortezomib 
has been studied in one phase 1 and three phase 2 Children’s Oncology Group (COG) studies 
and is currently under investigation in a phase 3 study.  The Phase 1 study was combined with 
Vorinostat and the MTD for bortezomib was 1.3mg/m2 IV on D1, 4, 8 and 11 of a 21 day cycle.  
On this trial, one child developed grade 4 neuropathy late in treatment.  Due to this, the phase 2 
trials have used bortezomib at either 1.2 mg/m2 or 1.3mg/m2 on D1, 4 and 8 of a 21 day cycle.  
The one trial using the 1.2mg/m2 combined bortezomib with more myelosuppressive therapy 
(Ifosfamide/Vinorelbine). The remaining COG trails, including the current phase 3 trial, have use 
the dose of Bortezomib at 1.3mg/m2 IV on D1, 4 and 8 of a 21 day cycle.  This dose and 
schedule of Bortezomib is chosen for this study as the standard of care dose in pediatrics. 
 
Summary 
In summary, our studies show that DFMO reverses the LIN28/Let-7 pathway, reverses MYCN 
overexpression and decreases cellular ATP and PET activity in NB cells. These pathways, in 
addition to the proteasome pathway, have been shown to be important in CSCs but have yet to be 
linked to CSCs in NB.  Given the high rate of relapse in NB, targeting of the CSC is important to 
prevent relapse. We believe that our preliminary study lays the framework for an investigation of 
the effects of ODC-Lin 28/Let-7 inhibition in NB using DFMO and bortezomib in children with 
relapsed/refractory neuroblastoma. 
  
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 26 of 81 
2.0 
Study Objectives 
2.1 
Primary Objective- Phase I  
2.1.1 To determine the safety and tolerability of DFMO in combination with 
bortezomib at 3 dose levels of DFMO: 1500mg/m2 twice daily, 
2000mg/m2 twice daily, and 2500mg/m2 twice daily  in subjects with 
relapsed or refractory neuroblastoma who receive one full cycle of this 
dose. 
 
2.2 
Primary- Phase I and II 
2.2.1 To evaluate the activity of DFMO as a single agent and in combination 
with bortezomib in relapsed or refractory neuroblastoma based on: 
Progression free survival (PFS)  
Overall response rate (ORR)  
 
2.3 
Secondary Objectives: 
2.3.1 To determine the safety and tolerability of DFMO in combination with 
bortezomib in pediatric subjects with refractory or recurrent 
neuroblastoma. 
2.3.2 For subjects followed with PET scan: comparison of changes in PET 
activity and correlation with PFS  
2.3.3 Correlation of urinary polyamine levels with response and progression of 
disease in neuroblastoma. 
2.3.4 Biological Correlates to evaluate or explore minimally include: 1) Urine: 
polyamine levels 2) Blood: Inflammatory markers,  Biomarkers for Let 7 
and SNPS, and explorative biomarker analysis, 3) Bone Marrow/Tumor 
biopsies (if biopsied per standard of care): research studies including 
Immunohistochemistry/Western Blot/qRT-PCR of bone marrow tumor 
cells or tumor to study Let-7, ODC, Lin28, MYCN, OKT-4, BMI1, 
HMGA2, GLUT-4, p-AKT, NF-kB, SOCS3 will be performed in an 
explorative biomarker analysis. Studies will measure thymidine and 
polyamine levels. 4) In vitro research studies of tumor cells collected 
above will include: Genomic analysis of cells pre- and post- treatment 
(when applicable), cell viability assays to determine subject IC50 and 
correlation of in vitro response to in vivo response. 
2.3.5 To determine the dose effect of DFMO on biological correlates 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 27 of 81 
3.0 
Study Design 
 
NMTRC010B is an open label, multicenter, study to evaluate the efficacy of DFMO in 
combination with bortezomib in subjects with relapsed or refractory neuroblastoma. 
 
3.1 
Cycles 1-6 
 
3.1.1 DFMO- Phase I 
 
Subjects will receive six (6) cycles of oral DFMO twice daily at their assigned 
dose level on each day of this 21-day cycle. 
 
DFMO Dose 
Level 
Dose 
1 
1500 mg/m2 BID 
2 
2000 mg/m2 BID 
3 
2500 mg/m2 BID 
 
DFMO is provided as 250mg tablets.   
 
 
3.1.2 DFMO- Phase II 
 
The highest tolerated DFMO dose from the Phase I dose escalation will be used 
for the Phase II portion of the study. Subjects will receive oral DFMO twice daily 
on each day of this 21day cycle. 
  
DFMO is provided as 250mg tablets.   
 
3.1.3 Bortezomib 
 
Bortezomib will be given at 1.3mg/m2/dose IV Push on Days 1, 4, and 8 of each 
21-day cycle 
 
The Phase I subjects on this study will be the first pediatric subjects to receive 
DFMO in combination with Bortezomib. If a Dose Limiting Toxicity (DLT) is 
seen in 2/6 subjects, this portion of the study will allow for a -1 dose level 
reduction (1000mg/m2/dose). If the DLT is seen in 2/6 subjects at the -1 dose 
level, a further reduction to dose level -2 (500mg/m2/dose) will be allowed.  
Enrollment will be held at the end of this phase of the study until all subjects 
within the cohort have completed one cycle and a safety analysis has been 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 28 of 81 
completed by the study committee and Data Safety and Monitoring Board 
(DSMB).  The study committee will then decide whether the study can continue 
to the next cohort and subsequently to the Phase II portion of the trial. 
 
3.2 
 Response Evaluations  
At the times indicated in Section 6.0 and the Table of Procedures and Assessments, scans will be 
obtained to evaluate response for subjects enrolled in this study.  Response will be assessed 
according to criteria outlined in Section 7.0 to evaluate the potential benefit of DFMO in this 
subject population.   
 
3.3 
Biological Studies 
Subjects will have an opportunity to participate in additional correlative biological studies on a 
voluntary basis collecting urine, blood, bone marrow and tumor (if a standard of care sample is 
being collected).  These samples will be sent to the POTRL at Helen DeVos Children’s Hospital 
and University of Arizona for studies described in Section 12.  The studies will evaluate the 
effect of DFMO and bortezomib on neuroblastoma. These studies will include evaluation of the 
ODC-Lin28/Let-7 pathway, glycolytic metabolism and inflammation. These biologic studies 
may be able to contribute to our knowledge of molecular profiles or biomarkers of response to 
therapy to help guide future treatment studies.  
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 29 of 81 
 
Protocol Design Schema 
 
Initial Evaluation 
 
DFMO at assigned dose twice daily for  
every day of a 21-day cycle 
+  
Bortezomib 1.3mg/m2 IV push days 1, 4, 8  
of a 21-day cycle 
 
End of Cycle 2 Re-evaluation 
Continue Protocol Therapy for 6 Total Cycles 
Re-evaluation at end of every 2 cycles 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 30 of 81 
4.0 
Subject Selection  
 
4.1 
Inclusion Criteria: 
 
1. Age: ≤ 21 years at the time of diagnosis. 
2. Diagnosis: Histologic verification at either the time of original diagnosis or relapse of 
neuroblastoma. 
3. Disease Status: For the purposes of this study, aggressive multidrug chemotherapy is defined as 
chemotherapy including 2 or more agents that must include an alkylating agent and a platinum-
containing compound. Patients must have ONE of the following: 
1)   Any episode of recurrent disease following completion of aggressive multi-drug 
frontline therapy. 
2)   Any episode of progressive disease during aggressive multi-drug frontline therapy. 
3)   Primary  resistant/refractory  disease  detected  at  the  conclusion  of  at  least  4  
cycles  of aggressive multidrug induction chemotherapy on or according to a high-risk 
neuroblastoma protocol (examples include Children’s Oncology Group trials: A3973, 
ANBL0532, ANBL09P1, etc.). 
4. Measurable or evaluable disease, including at least one of the following: Measureable tumor 
by CT or MRI; or A positive MIBG or PET scan; or Positive bone marrow biopsy/aspirate.  
5. Current disease state must be one for which there is currently no known curative therapy or 
no additional therapies proven to prolong survival with an acceptable quality of life.   
6. A negative serum or urine pregnancy test is required for female subjects of child bearing 
potential (onset of menses or ≥13 years of age). 
7. Organ Function Requirements: 
a. Subjects must have adequate liver function as defined by:  
• AST and ALT <5x upper limit of normal  
• Serum bilirubin must be ≤ 2.0 mg/dl 
 
b. Subjects must have adequate Bone Marrow function defined as: 
For patients without bone marrow involvement: 
• Peripheral absolute neutrophil count (ANC) ≥ 750/µL 
• 
Platelet count ≥ 50,000/µL (transfusion independent, defined as not receiving 
platelet transfusions within a 7 day period prior to enrollment.  Exception: 
Patients that are platelet dependent due to previous extensive treatment- e.g. - 
MIBG therapy). 
• Hemoglobin ≥ 8.0 g/dL (may receive RBC transfusions) 
 
Patients known to have bone marrow involvement with neuroblastoma are 
eligible provided that minimum ANC and platelet count criteria are met but are 
not evaluable for hematological toxicity. 
 
Patients that do not have bone marrow involvement but that are transfusion 
dependent at study entry are eligible provided that minimum ANC and platelet 
count criteria are met but are not evaluable for platelet toxicity. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 31 of 81 
 
c.  Subjects must have adequate renal function defined as: 
Serum creatinine based on age/gender as follows: 
 
 Age 
Maximum Serum Creatinine 
(mg/dL) 
 Male  
Female  
1 month to < 6 
months  
0.4 
0.4 
6 months to < 1 year  
0.5 
05 
1 to < 2 years  
0.6 
0.6 
2 to < 6 year 
0.8 
0.8 
6 to < 10 years  
1 
1 
10 to < 13 years  
1.2 
1.2 
13 to < 16 years  
1.5 
1.4 
≥ 16 years  
1.7 
1.4 
 
8. Informed Consent: All subjects and/or legal guardians must sign informed written consent. 
Assent, when appropriate, will be obtained according to institutional guidelines. 
 
4.2 
Exclusion Criteria: 
 
1. Lansky score <50% 
2. BSA (m2) of  <0.25 
3. Prior Therapy- Patients must have fully recovered from the acute toxic effects of all prior 
anti- cancer chemotherapy and be within the following timelines: 
a.   Myelosuppressive chemotherapy: Must not have received within 2 weeks of enrollment 
onto this study (6 weeks if prior nitrosourea). 
b.   Hematopoietic  growth  factors:  At  least  5  days  since  the  completion  of therapy 
with a growth factor. 
c.   Biologic (anti-neoplastic agent): At least 7 days since the completion of therapy 
with a biologic agent. For agents that have known adverse events occurring beyond 7 days 
after administration, this period must be extended beyond the time during which adverse 
events are known to occur. The duration of this interval must be discussed with the Study 
Chair. 
d.   Immunotherapy: At  least  6  weeks  since  the  completion  of  any  type  of 
immunotherapy, e.g. tumor vaccines. 
e.   Monoclonal antibodies:  At least 7 days or 3 half-lives, whichever is longer, must have 
elapsed since prior treatment with a monoclonal antibody. 
f.    XRT: At least 14 days since the last treatment except for radiation delivered with 
palliative intent to a non-target site.  
g.   Stem Cell Transplant or Rescue: No evidence of active graft vs. host disease and 
≥ 2 months must have elapsed since transplant. 
4. Investigational Drugs: Subjects who have received another investigational drug within the 
last 14 days are excluded from participation. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 32 of 81 
5. Infection: Subjects who have an uncontrolled infection are not eligible until the infection is 
judged to be well controlled in the opinion of the investigator. 
6. Subjects who, in the opinion of the investigator, may not be able to comply with the safety 
monitoring requirements of the study, or in whom compliance is likely to be suboptimal, 
should be excluded.  
 
Additional criteria: 
Subjects willing to participate in the correlative biologic studies will sign an additional consent 
form to provide bone marrow, blood, urine and tumor (if available) for analysis. 
 
5.0 
STUDY DRUG ADMINISTRATION 
5.1 
DFMO 
 
5.1.1 
Description, Formulation, and Storage of DFMO 
DFMO (eflornithine hydrochloride is an inhibitor of ornithine decarboxylase (ODC) designated 
chemically as 2-(difluoromethyl)-DL-ornithine monohydrochloride monohydrate.   
 
The dosage form to be used in this study are provided as a convex tablet containing 250 mg of 
eflornithine HCl, monohydrate.  The tablets are packaged and sealed in opaque white HDPE 
bottles, and each bottle contains 100 tablets.  The DMFO tablets are supplied by KC Pharma. 
 
The tablets are to be stored at room temperature (20-250C). 
 
 
5.1.2 
DFMO Dosing: Phase I 
 
Subjects will be given oral DFMO twice daily at their assigned dose level on each day of this 21-
day cycle. Upon enrollment subjects will be assigned a DFMO dose level by NMTRC staff. 
Dosing will be per Dose level charts below. Doses are rounded to the nearest whole tablet.  
 
The dose of DFMO will be recalculated at the beginning of each cycle based on BSA using a weight 
and height obtained up to 5 days prior to the cycle start date. 
 
 
 
DFMO Dose 
Level 
Dose 
1 
1500 mg/m2 BID 
2 
2000 mg/m2 BID 
3 
2500 mg/m2 BID 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 33 of 81 
DFMO Dose Table for Dose Level 1 - 1500 mg/m2 BID: 
 
BSA (m2) 
Tablets to be Dispensed for 
each dose 
Total Tablets 
Per Day 
Actual 
Mg/m2 
>1.5 
Nine (9) tablets orally twice a day 
Eighteen (18) 
1500 and 
down per dose 
1.3 to 1.5 
Eight (8) tablets orally twice a day 
Sixteen (16) 
1539 to 1333 
per dose 
1.1 to 1.2 
Seven (7) tablets orally twice a day 
Fourteen (14) 
1458 to 1591 
per dose 
1.0  
Six (6) tablets orally twice a day 
Twelve (12) 
1500 per dose 
0.8 to 0.9 
Five (5) tablets orally twice a day 
Ten (5) 
1389 to 1563 
per dose 
0.6 to 0.7 
Four (4) tablets orally twice a day 
Eight (8) 
1429 to 1667 
per dose 
0.5 
Three (3) tablets orally twice a day 
Six (6) 
1500 per dose 
0.3 to 0.4 
Two (2) tablets orally twice a day 
Four (4) 
1250 to 1667 
per dose 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 34 of 81 
DFMO Dose Table for Dose Level 2 - 2000 mg/m2 BID: 
 
BSA (m2) 
Tablets to be Dispensed for 
each dose 
Total Tablets 
Per Day 
Actual 
Mg/m2 
1.5 to >1.5 
Twelve (12) tablets orally twice a 
day 
Twenty-four 
(24) 
2000 and 
down per dose 
1.4  
Eleven (11) tablets orally twice a 
day 
Twenty-two 
(22) 
1964 per dose 
1.2 to 1.3 
Ten (10) tablets orally twice a day 
Twenty (20) 
1923 to 2083 
per dose 
1.1   
Nine (9) tablets orally twice a day 
Eighteen (18) 
2046 per dose 
1.0  
Eight (8) tablets orally twice a day 
Sixteen (16) 
2000 per dose 
0.9  
Seven (7) tablets orally twice a day 
Fourteen (14) 
1944 per dose 
0.7 to 0.8 
Six (6) tablets orally twice a day 
Twelve (12) 
1875 to 2143 
per dose 
0.6 
Five (5) tablets orally twice a day 
Ten (10) 
 2083 per dose 
 0.5  
Four (4) tablets orally twice a day 
Eight (8) 
2000 per dose 
 0.4  
Three (3) tablets orally twice a day 
Six (6) 
1875 per dose 
 0.3 
Two (2) tablets orally twice a day 
Four (4) 
1667 per dose 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 35 of 81 
DFMO Dose Table for Dose Level 3 - 2500 mg/m2 BID: 
 
BSA (m2) 
Tablets to be Dispensed for each 
dose 
Total Tablets 
Per Day 
Actual 
Mg/m2 
1.5 to >1.5 
Fifteen (15) tablets orally twice a day 
Thirty (30) 
2500 and 
down per dose 
1.4  
Fourteen (14) tablets orally twice a day 
Twenty-eight 
(28) 
2500 per dose 
1.3  
Thirteen (13) tablets orally twice a day 
Twenty-six (26) 
2500 per dose 
1.2 
Twelve (12) tablets orally twice a day 
Twenty-four 
(24) 
2500 per dose 
1.1   
Eleven (11) tablets orally twice a day 
Twenty-two 
(22) 
2500 per dose 
1.0  
Ten (10) tablets orally twice a day 
Twenty (20) 
2500 per dose 
0.9  
Nine (9) tablets orally twice a day 
Eighteen (18) 
2500 per dose 
0.8  
Eight (8) tablets orally twice a day 
Sixteen (16) 
2500 per dose 
0.7 
Seven (7) tablets orally twice a day 
Fourteen (14) 
2500 per dose 
0.6 
Six (6) tablets orally twice a day 
Twelve (12) 
2500 per dose 
 0.5  
Five (5) tablets orally twice a day 
Ten (10) 
2500 per dose 
 0.4  
Four (4) tablets orally twice a day 
Eight (8) 
2500 per dose 
 0.3 
Three (3) tablets orally twice a day 
Six (6) 
2500 per dose 
 
 
5.1.3 
DFMO Dosing: Phase II 
 
The highest tolerated DFMO dose from the Phase I dose escalation will be used for the Phase II 
portion of the study. Subjects will receive oral DFMO twice daily on each day of this 21-day 
cycle per dosing chart above for appropriate dose level. Doses are rounded to the nearest whole 
tablet. 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 36 of 81 
5.1.4 
Administration of DFMO 
 
Treatment will be administered on an outpatient basis unless hospitalization is required for 
another reason. 
 
Each entire dose of DFMO tablets should be swallowed.  
 
Subjects will be advised (but not required) to maintain a low Polyamine diet during the duration 
of this study. A handout will be provided to subjects with foods they should avoid while on this 
study.  
 
Subjects will be given a ‘patient instruction sheet’ for home administration.   
 
Subjects will be given a ‘dosing diary’ to keep track of doses given at home.  
 
 
5.1.5 
Subjects Unable to Swallow Tablets 
For subjects unable to swallow tablets, DFMO tablets may be chewed or crushed in a teaspoon 
and administered with a small amount of liquid. Note; tablets may not completely dissolve. 
 
Recommended liquids for mixing (to cover taste)- Lemonade, Apple, Cranberry, Grape, or 
Pineapple 
 
DFMO may NOT be mixed in high polyamine juices such as orange or grapefruit juice. 
 
Crushed DFMO tablets may also be mixed in 1-2 tablespoons of chocolate syrup, applesauce, or 
other food.  The DFMO tablets will not dissolve, and this is acceptable.  This technique is simply 
to mask the flavor. 
 
 
5.1.6 
Missed Doses 
If a subject vomits or misses a dose they should skip the missed dose and continue the drug at the 
next dose.  Do not make up missed doses.  
 
 
 
 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 37 of 81 
5.1.7 
DFMO Clinical Pharmacology 
DFMO (Eflornithine hydrochloride) is a member of the following drug classes: 1) inhibitor of 
ornithine decarboxylase (ODC), 2) hirsutism (excess hair growth) retardant, and 3) 
antiprotozoals. Eflornithine is FDA approved as a cream for treatment of female hirsutism, and 
in intravenous form for treatment of trypanosomiasis. The oral tablet form is not available 
outside of the clinical trial setting in the U.S., and the formulation used in this trial is similar to 
that used in the Phase III colon adenoma clinical trial in combination with sulindac (Meyskens et 
al., 2008). 
Contraindications:  Prior hypersensitivity to eflornithine.  
 
Common side effects:   
Overall, the most frequently reported AEs in NCI, DCP-sponsored chemoprevention studies 
were diarrhea (9.0%), headache (7.5%), nausea (6.5%), hearing loss (5.6%), tinnitus (4.3%) and 
asthenia (4.7%). Other common toxicities (each accounting for 2 to 3% of all AEs reported) were 
epigastric pain, flatulence, dyspepsia, anemia, dizziness and skin rash. Less common toxicities 
(each accounting for 1 to 2% of all AEs reported) were: stomatitis, rhinitis, insomnia, infections, 
vomiting, vasodilation, dry mouth, constipation, dry skin, menstrual disorders, pharyngitis, 
emotional lability, pruritis, myalgia, and pain (miscellaneous). The most significant adverse 
effects associated with clinical administration of DFMO in chemoprevention trials are loss of 
hearing acuity and tinnitus. These effects have generally been found to be reversible when 
DFMO treatment is stopped. Patients who receive a cumulative oral dose of DFMO below 150 
g/m2 experience minimal ototoxicity. 
 
Infrequent side effects:  Hearing loss/change by audiometry testing has been reported in 8.4% 
of patients on high dose eflornithine.  Rash and alopecia have been reported in 3% of patients.  
Anorexia and abdominal pain have been reported in 2% of patients treated with eflornithine. 
Rare but serious side effects include dizziness (1%), headaches (2%), and seizures (8%), have 
been reported in patients on intravenous eflornithine.  Myelosuppression (including leukopenia, 
[37%], anemia [55%], and thrombocytopenia [14%]) has been reported at high intravenous 
doses. 
Pregnancy and Lactation:  Pregnancy category C. It is unknown if eflornithine crosses the 
placenta.  Case reports in humans along with animal studies (mice, rats) indicate potential for 
fetotoxicity.  Experiments in rodents indicate that eflornithine blocks yolk sac formation and 
trophoblast differentiation, affecting processes such as vasculogenesis and steriodgnesis (Lopez-
Garcia, et al., 2008).  The World Health Organization has not determined a breast feeding rating 
for eflornithine due to insufficient data. The Thompson lactation rating is that infant risk cannot 
be ruled out.  No studies investigating the safety of lactation after eflornithine administration 
have been conducted, nor are there data to determine drug levels in breast milk after drug 
administration.  
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 38 of 81 
Toxicity for DFMO Potential Risk: 
Likely 
Happens to 10-30  patients out 
of every 100 
Less Likely 
Happens to 3-10 patients out of 
every 100 
Rare  
Happens to fewer than 3 patients 
out of every 100 
• 
Fewer red and white 
blood cells  
o a low number of red 
blood cells can make 
you feel tired and 
weak and may 
require transfusion. 
o a low number of 
white blood cells can 
make it easier to get 
infections 
• Decrease in the number 
of platelets made in the 
bone marrow 
• Nausea  
• Hearing Loss 
• Ringing in ears 
• Diarrhea 
• Headache 
• Weakness 
• Loss of appetite 
• Abdominal Pain 
• Flatulence (gas) 
• Dizziness 
•  
• Skin Rash 
• Seizures 
• Sores in the mouth 
• Runny nose 
• Difficulty sleeping 
• Infections 
• Dry mouth 
• Constipation 
• Dry skin 
• Menstrual disorders 
• Sore throat 
• Vomiting 
• Vasodilation (the 
relaxation of blood 
vessels possibly causing 
low blood pressure) 
• Emotional ups and downs 
• Itchiness 
• Body aches 
• Pain  
 
Four particular areas of concern have been identified with regard to the safety of subjects 
participating in this study and an attempt to address each of them is outlined below: The main 
considerations are: thrombocytopenia, hearing loss, gastrointestinal and non-G.I. side effects. 
 
a) 
DFMO Specific Adverse Events 
(1) 
Hearing loss. 
Although hearing loss has been a problem at higher doses (see below), clinical changes in 
hearing have been uncommon (one of 123 subjects in the phase IIb trial) and reversible in the 
doses proposed for this trial (62). An extended analysis of these observations is in press (65). 
There was no statistically significant shifts in distortion product otoacoustic emission levels. For 
auditory pure tone thresholds, there was a subtle 2-3 dB decrease in hearing sensitivity for the 
two higher DFMO doses (0.2 and 0.4 gm/M2/day), but only for the two lowest frequencies at 250 
and 500 HZ. However in two phase I trials using lower doses of DFMO, done by other 
investigators, no audiometric changes were seen after approximately 6 months of DFMO therapy 
at 0.50Gm/m2/d (total dose 90Gm) although some changes were seen at higher doses (79). 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 39 of 81 
Hearing loss may occur in association with DFMO administration at high doses. In a meta-
analysis of previous studies, (64), it was reported that less than 10% of the subjects who received 
cumulative doses below 150 Gm/m2 developed a demonstrable hearing deficit, while hearing 
losses were observed in up to 75% of subjects who received cumulative doses above 250 Gm/m2. 
This side effect was thought to be totally reversible upon drug discontinuation.  Some study 
participants taking DFMO at doses similar to those used in this study have experienced mild 
decreases in hearing soft sounds. These changes have been uncommon and usually subclinical 
(that is, noticeable on special hearing tests called audiograms, but not in normal conversation or 
daily activities). Although an affected participant's level of hearing usually returns to its usual 
state when drug is stopped, in a small percentage of cases (occurring in less than 5% of 
participants taking the drug) effects have persisted even after drug was stopped. These changes 
are most, likely not reversible in all subjects.  However, in a recently completed phase IIb trial of 
DFMO audiologic changes that were clinically significant were not detected, even in the highest 
dose group (0.4Gm/m2/day) (extended analysis, 65). It is probable that at low doses of DFMO 
ongoing recovery of inner ear polyamines occurs and clinical hearing loss will be rarely, if ever, 
seen. Since hearing loss is usually totally reversible after drug discontinuation, this approach 
appears safe and cost effective. 
(2) 
Thrombocytopenia (low platelets)  
Thrombocytopenia has been reported predominantly in studies using doses of DFMO 
(>3Gm/m2/day) and primarily in cancer patients who had previously undergone chemotherapy or 
patients with compromised bone marrow.  Other side effects ascribed to DFMO have been rare 
and, to date, seen only at high doses. 
(3)  
Other 
Skin rash, anemia, and neutropenia have also been seen with DFMO administration 
(4) 
GI 
Abdominal pain, loss of appetite, diarrhea have been reported.  
 
 
5.2 
Bortezomib 
 
5.2.1 
Dose Calculation and Administration of Bortezomib- All Phases 
 
Bortezomib will be given at 1.3mg/m2/dose IV Push on Days 1, 4, and 8 of each 21-day 
cycle. 
 
Doses should be rounded per institutional standard.  
 
The dose of bortezomib will be recalculated at the beginning of each cycle based on BSA 
using a weight and height obtained up to 5 days prior to cycle start date. 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 40 of 81 
5.2.2 
Bortezomib (Velcade) 
Formulation and Stability: Bortezomib is a commercially available product and will not be 
supplied for this study. Bortezomib should be stored and dispensed per institutional standards 
and product insert. 
Source and Pharmacology: Bortezomib (PS - 341) is a reversible inhibitor of the chymotrypsin 
-like activity of the 26S proteasome (a multicatalytic protease present in all eukaryotic cells). 
The 26S proteasome is a large protein complex that degrades proteins that have been conjugated 
to ubiquitin. The ubiquitin-proteasome pathway plays an essential role in regulating the 
intracellular concentration of specific proteins, and constitutes the major mechanism for 
intracellular protein degradation (80%). Those intracellular proteins which maintain homeostasis 
within cells include numerous regulatory proteins involved in cellular integrity, such as cell-
cycle control, cellular apoptosis, transcription factor activation, and tumor growth via ATP-
dependent processes. Inhibition of the 26S proteasome prevents this targeted proteolysis, which 
can affect multiple signaling cascades within the cell. This disruption of normal homeostatic 
mechanisms can lead to cell death. The binding of bortezomib to human plasma proteins 
averages 83% over a concentration range of 100 to 1000 ng/mL. The mean elimination half- 
life of bortezomib after multiple dosing ranged from 40 to 193 hours after the 1 mg/m 2 dose and 
76 to 108 hours after the 1.3mg/m2 dose. In vitro studies with human liver microsomes and 
human cDNA-expressed cytochrome P450 isozymes indicate that bortezomib is primarily 
oxidatively metabolized via cytochrome P450 enzymes 3A4, 2C19, and 1A2.  Bortezomib 
metabolism by CYP 2D6 and 2C9 enzymes is minor. The major metabolic pathway is  
deboronation to form 2 deboronated metabolites that subsequently undergo hydroxylation to 
several  metabolites. Deboronated bortezomib metabolites are inactive as 26S proteasome 
inhibitors. 
 
Bortezomib is metabolized by multiple cytochrome P450 (CYP) enzymes, with CYP3A4 being 
the primary contributor, and with only minor contributions of CYPs 2C19, 1A2, 2C9 and 2D6. It 
is a weak inhibitor of CYP2C19 and does not inhibit CYP1A2, 2C9, 2D6, and 3A4 at clinically 
relevant concentrations (IC50 > 30 μM). Co-administration of strong CYP3A4 inducers should 
be discussed with pharmacy prior to use throughout therapy with bortezomib (refer to Appendix 
II for a list of strong inducers). Co-administration of strong and clinically relevant moderate 
CYP3A4 inhibitors should be avoided until 72 hours beyond administration of Day 8 bortezomib 
for each course (exception: administration of prophylactic fluconazole may begin ≥ 24 hours 
after the Day 8 bortezomib dose). Similarly, patients receiving strong and clinically relevant 
moderate inhibitors should discontinue use of these agents 72 hours prior to start of Day 1 
bortezomib in all courses (refer to Appendix II for a list of strong and clinically relevant 
moderate inhibitors). Additional inducers or inhibitors of CYP450 enzymes can be found at 
http://medicine.iupui.edu/clinpharm/ddis. 
 
In vitro and in vivo studies showed that green tea compounds, ascorbic acid (vitamin C) and 
other antioxidants, have the potential to significantly inhibit the activity of bortezomib. To avoid 
the risk of any possible interaction it is recommended that green tea containing products and any 
supplemental products containing vitamin C, flavonoids or other antioxidants (eg, vitamins, 
herbal supplements) be discontinued from at least 24 hours prior to the initiation of bortezomib 
through 72 hours after the last bortezomib dose. Injectable multivitamins used as a component of 
parenteral nutrition should also be avoided during this time period to minimize the risk of direct 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 41 of 81 
vitamin C inactivation of bortezomib. In addition, it is recommended that the total dietary intake 
of vitamin C not exceed the RDA for age. Normally balanced diets are acceptable; 
supplementation with high doses of vitamin C or injectable vitamin C should be avoided. 
 
Bortezomib Risks: 
 
 
 
 
 
 
Risks and side effects related to Bortezomib include those which are: 
 
Likely 
Happens to 10-30  
patients out of every 
100 
Less Likely 
Happens to 3-10 patients out of every 100 
Rare  
Happens to fewer than 
3 patients out of every 
100 
• A feeling of 
weakness and/or 
tiredness 
• Nausea and/or 
vomiting 
• Constipation or 
diarrhea 
• Loss of appetite 
• Fever 
• Fewer red blood cells 
and platelets in the 
blood  
o a low number of 
red blood cells 
can make you feel 
tired and weak 
o a low number of 
platelets causes 
you to bruise and 
bleed more easily 
• Fluid retention and 
build-up in the arms 
and legs leading to 
swelling and an 
increase in weight 
• Infection 
• Nerve damage that 
may cause pain, 
burning, numbness, 
and tingling in the 
hands and feet and 
may affect the ability 
to perform tasks that 
require fine 
movements 
• Nerve damage that 
may cause muscle 
weakness or 
paralysis in the 
hands and feet and 
may affect the ability 
to perform tasks that 
require fine 
movements 
• Low blood pressure  
• Dizziness  
• Fainting 
• Difficulty sleeping or falling asleep 
• Chills including shaking chills 
• Skin rash with the presence of macules (flat 
discolored area) and papules (raised bump) 
• Excessive loss of water from the body 
• Acid or upset stomach (heartburn) 
• Pain which may be in the abdomen (belly), 
back, bone, head, joints, arms and legs, 
muscles, and nerves 
• Headache or head pain 
• Cough 
• Shortness of breath 
• Fewer white blood cells in the blood 
o a low number of white blood cells can 
make it easier to get infections 
• Low numbers of white blood cells called 
lymphocytes that may last a long time and 
make it easier to get infections which may be 
life threatening 
• A stoppage (or blockage) of the intestine 
which may require treatment 
• Inflammation and/or sores in the mouth 
and/or throat that may make swallowing 
difficult and are painful (painful mouth sores) 
• Bleeding in the gut that may show in the 
stools 
• Nose bleed 
• Fever with a low white blood cell count which 
could indicate infection and may require 
hospitalization and treatment with antibiotics 
• Infection caused by hard to treat bugs 
including bacteria, virus, and fungus 
• Muscle weakness of the whole body 
• Anxiety 
• Blurred vision 
• Fluid build-up in the lungs that can make you 
feel short of breath 
• A hole in the 
intestines which 
would cause leakage 
into the abdomen 
(belly) with pain and 
infection 
• Damage to the brain 
associated with high 
blood pressure 
which may lead to 
difficulty thinking, 
carrying out normal 
tasks, headache, 
seizures 
(convulsions), 
difficulty seeing, 
blindness, or other 
visual changes, 
which if caught early 
can be reversed 
• Severe damage to 
the brain tissue 
which could lead to 
difficulty carrying out 
normal daily tasks or 
could lead to coma 
• Severe kidney 
damage (which may 
be permanent) 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 42 of 81 
5.3 
Guidelines for Dose Modifications 
Toxicities and dose modifications will be monitored in all cycles.  Adjustments to the doses of 
study drug will be based upon toxicity, graded according to the NCI Common Toxicity Criteria 
(CTC), Version 4.0, if these were normal at baseline. Events that are not described in the NCI 
criteria will be assigned grades according to the criteria provided in Section 8.0.  Criteria for 
determining the relatedness of clinical adverse events to treatment (Section 8.5) should be 
utilized to determine the relationship of adverse events to the treatment.  
  
5.4 
Dose Delay  
Subjects without bone marrow metastases must have an ANC > 500/μl before starting Day 1 of 
each cycle. Subjects experiencing any related toxicity specified in 5.5 or any intolerable toxicity 
on a scheduled treatment day will have their dose of study drug held per Sections 5.6 and 5.7. If 
toxicity is encountered on Day 1 of any cycle, the day of resolution and administration of the 
dose will be considered Day 1 of that cycle. Treatment may be delayed no more than 14 days to 
allow recovery from related toxicity. 
 
5.5 
Definition of Dose-Limiting Toxicity (DLT) 
DLT will be defined as any of the following events that are possibly, probably or definitely 
attributable to DFMO or bortezomib.  
 
Dose limiting hematologic and non-hematologic toxicities are defined differently. 
 
5.5.1 Non-Hematologic Dose-Limiting Toxicity 
5.5.1.1 Any Grade 3 or Grade 4 non-hematological toxicity attributable to the 
investigational drug with the specific exclusion of: 
 
 Grade 3 nausea, vomiting, diarrhea unless > 3 days despite optimal 
treatment with antiemetics 
 ALT/AST elevation > 10x ULN that returns to Grade ≤ 2 or 
baseline prior to the time for the next treatment cycle. Note: For 
the purposes of this study the ULN for ALT/AST is defined as 50 
U/L. 
 
Direct Bilirubin level > 1.5x – 3x upper limit of normal 
 Grade 3 fever 
 Grade 3 infection 
 Grade 3 hypophosphatemia, hypokalemia, hypocalcemia or 
hypomagnesemia responsive to oral supplementation. 
 Grade 2 allergic reactions that results in discontinuation of study 
drug 
 
5.5.1.2 A peripheral neuropathy that results in a discontinuation of the bortezomib 
dose (See Section 5.7). 
 
5.5.1.3 Non-hematological toxicity that causes a delay of  >14 days between 
treatment cycles. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 43 of 81 
 
5.5.2 Hematological dose limiting toxicity (for bone marrow negative patients only). 
 
Hematological dose limiting toxicity is defined as: 
 Grade 4 neutropenia for > 7 days  
 Grade 4 thrombocytopenia for > 14 days  (excluding special populations 
defined in 8.4.2) 
 Myelosuppression that causes a delay of >14 days between treatment 
cycles. 
 
**Any suspected or confirmed dose-limiting toxicity should be reported immediately 
(within 24 hours of discovery of the event) to the NMTRC and Study Chair.** 
 
5.6 
DFMO Dose Modification  
Subjects experiencing any dose limiting toxicity (DLT) specified above (Section 5.5) attributable 
to DFMO or any other intolerable toxicity will have their dose of DFMO held until toxicities 
have reverted to ≤ Grade 2 toxicity. Upon resolution of the toxicity, subjects will receive a -1 
dose reduction of DFMO to one step down on the dosing table in section 5.1.2  Example- If the 
subject is currently taking 3 tabs twice a day they will step down to the weight range/dose 
directly below the one they are at and take 2 tabs twice a day. Subjects that are currently only 
taking one tablet per dose BID will be dose reduced to one tablet per day (QD).   
 
Subjects will be allowed to dose reduce for subsequent toxicities one more time to a -2 dose 
level.  At that point if they experience another dose reducing toxicity (as defined here) they will 
be required to go off protocol therapy.  
 
If there is no resolution of above toxicity attributable to DFMO to ≤Grade 2 by 14 days, DFMO 
should be discontinued, and subjects should be discontinued from the study.   
 
.  
For subjects entering this trial with bone marrow disease and for subjects entering this trial with 
platelet transfusion dependency, modifications will not be made based on platelet count.  
 
 
5.7 
Bortezomib Dose Modification 
 
Subjects experiencing any dose limiting toxicity (DLT) specified above (Section 5.5) attributable 
to bortezomib or any other intolerable toxicity will have their dose of bortezomib held until 
toxicities have reverted to ≤ Grade 2 toxicity.  Upon resolution of the toxicity, subjects will have 
bortezomib restarted per recommendations below. 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 44 of 81 
Bortezomib-Related Hepatotoxicity 
Subjects with mild hepatic impairment do not require dose adjustment of bortezomib. 
Subjects with severe hepatic impairment should receive bortezomib at modified doses as outlined 
below: 
 
 
 
 -No adjustment necessary for elevated SGOT (ALT). 
 
 
Bortezomib-Related Peripheral Neuropathy 
Subjects with bortezomib-related neurotoxicity will remain on protocol therapy but have 
bortezomib dose de-escalated or held as specified below. Peripheral neuropathy will be 
closely monitored during each course of treatment and toxicities graded using CTCAE v 4.0.  
 
Peripheral sensory neuropathy grading should be based on the maximum toxicity occurring 
during the previous course. All dose modifications should be based on the worst preceding 
toxicity. Bortezomib dose will be decreased for sensory peripheral neuropathy as follows: 
 
 
 
If Grade 3 peripheral sensory neuropathy persists for > 2 weeks, bortezomib should be 
discontinued. Subjects who discontinue bortezomib will be off protocol therapy. 
 
If Grade 3 peripheral sensory neuropathy recurs despite bortezomib dose reduction to 1 
mg/m2, the subject should discontinue bortezomib.  Subjects who discontinue bortezomib 
will be off protocol therapy. 
Direct Bilirubin Level 
Bortezomib Dose Modification 
Moderate* 
> 1.5x – 3x upper limit of normal 
* Will not be considered a DLT 
Reduce bortezomib to 0.7 mg/m2 for all doses in the 
cycle in which hepatotoxicity is present. Consider 
dose escalation to 1 mg/m2 if transaminitis resolves 
and is not possibly, probably or definitely related to 
bortezomib. 
Severe 
> 3x upper limit of normal 
Severity of peripheral 
sensory neuropathy 
Bortezomib modification 
Grade 1 without pain  
None 
Grade 1 with pain or 
Grade 2 without pain* 
Decrease bortezomib to the next lower dose level. 
For patients receiving 1.0 mg/m2/day bortezomib 
decrease to 0.7 mg/m2/day. 
* Will not be considered a DLT 
Grade 2 with pain or 
Grade 3* 
Hold bortezomib treatment until symptoms have 
resolved to < Grade 1. When toxicity resolves, 
reinitiate bortezomib at the next lower dose level. 
For patients receiving 1.0 mg/m2/day bortezomib, 
decrease to 0.7 mg/m2/day. 
*Will not be considered a DLT 
Grade 4* 
Discontinue bortezomib 
*DLT 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 45 of 81 
Pulmonary Toxicity  
There have been rare reports of acute diffuse infiltrative pulmonary disease of unknown etiology 
such as pneumonitis, interstitial pneumonia, lung infiltration and acute respiratory distress 
syndrome (ARDS) in subjects receiving bortezomib. For this reason, pulmonary toxicity will be 
monitored carefully during the study. Bortezomib should be held in subjects with ARDS that 
may be bortezomib related. 
 
Monitoring  
Pulmonary function will be monitored by pulse oximetry. Measurement of pulse oximetry should 
be documented within 12 hours prior to each dose of bortezomib. A chest radiograph should be 
performed with the development of respiratory symptoms. In the absence of identifiable causes 
of respiratory stress, all subjects should demonstrate oxygen saturation on room air of ≥ 94% at 
sea level (> 90% at high altitude) prior to each bortezomib dose. Pulmonary toxicity due to 
bortezomib is frequently delayed and can occur up to 3 weeks after the final dose of bortezomib 
is administered.  
Pulmonary symptoms such as increased respiratory rate may indicate toxicity related to 
bortezomib and pulse oximetry should be checked for persistent, unexplained hyperpnea. 
Respiratory symptoms such as cough, hypoxia and dyspnea should be aggressively evaluated. 
 
Dose Reductions and Discontinuation of Bortezomib for Pulmonary Toxicity  
Bortezomib will be dose reduced to 1 mg/m2 for any resolving Grade 3 pulmonary toxicity 
(excluding hiccups or voice changes/laryngitis), including hypoxia that is possibly, probably or 
definitely related to bortezomib. Subjects that experience a Grade 4 pulmonary toxicity possibly, 
probably or definitely related to bortezomib (excluding hiccups and voice changes/laryngitis) 
will discontinue bortezomib. Subjects who discontinue bortezomib will be removed from 
protocol therapy.  
Subjects re-experiencing the same bortezomib-related qualifying Grade 3 pulmonary toxicity 
following a single bortezomib dose reduction will be removed from protocol therapy. 
 
 
Dose Reduction for Other Bortezomib-Associated Toxicities  
Bortezomib will be dose reduced to 1 mg/m2 for non-hematological severe toxicities (other than 
those described above) that are possibly, probably or definitely related to bortezomib. A severe 
toxicity is defined as any Grade 3 or 4 toxicity as described in Section 5.5. 
For subjects entering this trial with stable platelets between 50,000-100,000/ μl (those with poor 
bone marrow recovery after previous treatment) study drug should be held if platelets are Grade 
3 as defined in Section 8.4.2. For subjects entering this trial with platelet transfusion dependent, 
modifications will not be made based on platelet count. 
Bortezomib doses may not be re-escalated in subjects with dose limiting toxicity.  
If a specific bortezomib-related toxicity recurs despite one dose reduction, subject will 
discontinue study. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 46 of 81 
5.8 
Study Drug Accountability  
Study drug must only be used for subjects enrolled in the trial. The investigational site staff must 
maintain a careful inventory of study drug.  Drugs will be distributed to investigational site staff 
and subjects using FDA guidelines for distribution of investigational agents. Study drug use will 
be recorded on a Study Drug Inventory Form.   This form will contain the following information: 
• 
Subject number and initials for each subject receiving study drug 
• 
Date and quantity of DFMO received by the site 
• 
Date and quantity of DFMO dispensed 
• 
Date and quantity of DFMO returned 
At each monitoring visit, the clinical monitor will reconcile with the actual inventory of study 
drug at each site.   
 
5.9 
 Concomitant Medications and Treatments 
All intercurrent medical conditions will be treated at the discretion of the Investigator according 
to acceptable community standards of medical care.  All concomitant medications and treatments 
will be documented on the appropriate case report form. 
The following medications are not permitted during the trial: 
• 
Any cytotoxic chemotherapy 
• 
Any other investigational treatment  
• 
Any other systemic anti-neoplastic therapy including, but not limited to, immunotherapy, 
hormonal therapy, targeted therapies, anti-angiogenic therapies, or monoclonal antibody 
therapy 
• 
Any radiotherapy, including systemically administered radioisotopes, unless administered 
with palliative intent; another site of disease must be available for response evaluation. 
 
Erythropoietin, blood products, anti-emetics, steroids, and transfusions may be administered at 
the discretion of the Investigator based on established criteria  
 
6.0 
STUDY PROCEDURES AND ASSESSMENTS 
6.1 
Enrollment of Subjects 
Prior to consent of the subject, the research coordinator at the lead site will be contacted (via e-
mail). This coordinator will then reply with study space availability. If the subject fits all 
enrollment criteria, the site will again contact the coordinator at the lead site for official 
enrollment confirmation and unique subject identifier and dose level assignment. In addition, a 
study enrollment form will be faxed to the coordinator at the lead site. This determination will be 
made based on subject data (subject qualifies for study) and current subjects enrolled in trial (i.e. 
how many subjects are currently enrolled).  A subject may NOT be enrolled on trial until official 
approval from the lead site is received. 
 
All subjects (or subjects’ legal representatives) must provide written informed consent before 
any study specific assessments may be performed. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 47 of 81 
6.2 
Screening 
The Investigator is responsible for keeping a record of all subjects screened for entry into the 
study and subsequently excluded. 
 
The following screening procedures must be performed within 21 days prior to the first dose of 
study drug.  Studies must be done after last previous treatment for malignancy: 
1. Signed informed consent form.  All subjects (or subjects’ legal representatives) must 
provide written informed consent before any study specific assessments may be 
performed.  Signed informed consent form for voluntary participation in correlative 
biologic analysis will also be obtained;  
2. CT or MRI of measurable disease sites; 
3. MIBG or PET scan;  
4. Audiogram; 
5. Bilateral bone marrow aspirate and biopsy; 
6. Additional Optional Bone Marrow-for subjects with additional informed consent bone 
marrow samples for biological correlatives per section 12.0). 
The following screening procedures must be performed up to 5 days prior to the first dose 
of study drug. 
1. Complete medical and surgical history, including documentation of the histologic 
evidence of malignancy and prior treatments for cancer.  Include all other pertinent 
medical conditions and a careful history of all prior medical treatments 
2. Demographics; 
3. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation;  
4. BSA calculation (from body weight and height); 
5. ECOG Performance status/Lansky Play status (Appendix I);  
6. CBC with differential; 
7. Serum electrolytes, blood urea nitrogen (BUN), creatinine, bilirubin, LDH, ALT, AST 
and ferritin; 
8. C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) and IL-6 level (IL-6 
recommended).  
9. Urine for Vanillylmandelic Acid (VMA) & Homovanillic Acid (HVA); 
10. Serum or Urine pregnancy test for female subjects of child bearing potential (onset of 
menses or ≥13 years of age); 
11. Concomitant medications/therapies; 
12. Confirmation of inclusion and exclusion requirements; 
 
Following completion of all required screening procedures and certification of all inclusion and 
exclusion criteria by the Investigator, the lead site will be contacted (via e-mail or phone call), at 
which time the subject will be enrolled in the trial and a unique subject number and drug dose 
assigned.  The lead site will act as the central coordinating body.  The subject may not start on 
study until the lead site has provided official approval of enrollment.  

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 48 of 81 
6.3 
Treatment Phase – Cycle 1 
The first cycle will be 21 days in duration.  The following procedures must be completed: 
Cycle 1 Day 1 (procedures listed here must be done on Day 1):  
1. Physical examination (including body weight), including documentation of an update of 
all previous abnormalities, any new abnormalities, and a detailed neurological exam  
2. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation;  
3. Review and recording of concomitant medications;  
4. Monitoring and documentation of all AEs and review of concurrent illnesses  
5. Optional: Urine for Biological Correlates per section 12.0 (additional consent required); 
6. Optional: Blood for Biological Correlates per section 12.0 (additional consent required); 
7. Dispense drug dosing diary; 
8. DFMO dosing begins; 
9. Bortezomib administration. 
 
Cycle 1 Day 4 (+/- 1 day window) 
Subjects will return to the clinic on Cycle 1 Day 4 for Bortezomib and evaluations. The 
following evaluations will be conducted: 
 
1. History and Physical exam; 
2. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation; 
3. Monitoring and documentation of all AEs and review of concurrent illnesses; 
4. Review and recording of concomitant medications; 
5. DFMO dosing continues daily; 
6. Bortezomib administration. 
 
Cycle 1 Day 8 (+/- 1 day window) 
Subjects will return to the clinic on Cycle 1 Day 8 for evaluations. The following evaluations 
will be conducted: 
1. History and Physical exam;  
2. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation; 
3. CBC with differential; 
4. Serum electrolytes, BUN, creatinine, bilirubin, ALT, AST; and LDH; 
5. Monitoring and documentation of all AEs and review of concurrent illnesses; 
6. Review and recording of concomitant medications; 
7. DFMO dosing continues daily; 
8. Bortezomib administration. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 49 of 81 
Cycle 1 Day 15 (+/- 3 day window) 
Subjects will return to the clinic on Cycle 1 Day 15 for evaluations. The following evaluations 
will be conducted: 
1. History and Physical exam; 
2. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation; 
3. CBC with differential; 
4. Serum electrolytes, BUN, creatinine, bilirubin, ALT, AST; and LDH; 
5. Review and recording of concomitant medications; 
6. Monitoring and documentation of all AEs and review of concurrent illnesses; 
7. DFMO dosing continues daily; 
8. Optional: Urine for Biological Correlates per section 12.0 (additional consent required); 
9. Optional: Blood for Biological Correlates per section 12.0 (additional consent required). 
6.4 
Treatment Phase – Cycles 2-6 
 
All Cycles will be 21 days in duration.  The following procedures must be completed: 
Cycle 2-6 Day 1 (+/- 3 day window to start Day 1 treatment)  
The following procedures may be performed up to 5 days prior to starting treatment/Day 1 
unless otherwise indicated:  
1. History and Physical examination (including body weight), including documentation of 
an update of all previous abnormalities, any new abnormalities, and a detailed 
neurological exam (same day); 
2. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation (same 
day); 
3. Review and recording of concomitant medications; 
4. Monitoring and documentation of all AEs and review of concurrent illnesses (same day); 
5. BSA calculation (from body weight and height); 
6. ECOG Performance status/Lansky Play status (Appendix I);  
7. CBC with differential; 
8. Serum electrolytes, blood urea nitrogen (BUN), creatinine, bilirubin, LDH, ALT, and 
AST; 
9. C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR), IL-6 level (IL-6 
recommended); 
10. Urine for Vanillylmandelic Acid (VMA) & Homovanillic Acid (HVA); 
11. Optional: Urine for Biological Correlates per section 12.0 (additional consent required); 
12. Optional: Blood for Biological Correlates per section 12.0 (additional consent required); 
13. Collection of previous cycle drug dosing diary and dispensing of new drug dosing diary; 
14. Serum or Urine pregnancy test for female subjects of child bearing potential (onset of 
menses or ≥13 years of age); 
15. DFMO dosing continues daily; 
16. Bortezomib administration. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 50 of 81 
 
Cycle 2-6 Day 4 (+/- 1 day window) 
Subjects will return to the clinic on Cycle 1 Day 4 for Bortezomib and evaluations. The 
following evaluations will be conducted: 
 
1. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation; 
2. Monitoring and documentation of all AEs and review of concurrent illnesses; 
3. Review and recording of concomitant medications; 
4. DFMO dosing continues daily; 
5. Bortezomib administration. 
 
Cycle 2-6 Day 8 (+/- 1 day window) 
Subjects will return to the clinic on Cycle 1 Day 8 for evaluations. The following evaluations 
will be conducted: 
 
1. History and Physical exam; 
2. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation; 
3. CBC with differential; 
4. Monitoring and documentation of all AEs and review of concurrent illnesses; 
5. Review and recording of concomitant medications; 
6. DFMO dosing continues daily; 
7. Bortezomib administration. 
 
Cycle 2-6 Day 15 (+/- 3 day window) 
Subjects will return to the clinic on Cycle 1 Day 15 for evaluations. The following evaluations 
will be conducted: 
 
1. History and Physical exam; 
2. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation; 
3. CBC with differential; 
4. Serum electrolytes, BUN, creatinine, bilirubin, ALT, AST;  
5. Review and recording of concomitant medications; 
6. Monitoring and documentation of all AEs and review of concurrent illnesses.  
7. DFMO dosing continues daily. 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 51 of 81 
End of Cycles 2, 4, and 6, then every 2 cycles thereafter while on study drug 
1. MIBG or PET scan (use same as baseline) 
2. CT/MRI (use same radiologic method  as baseline); 
3. Bone marrow biopsy and aspirate if positive at study entry  (If the subject has signed 
informed consent for the use of tissue in the correlative biologic study please send 
additional samples per section 12.0); 
 
End of Cycles 2, 6, then yearly thereafter 
1. Audiogram  
(Audiogram should also be done at any time point for any suspected hearing loss) 
 
6.5 
Other Schedules: 
1. Additional imaging or assessments may be done if clinically indicated.  Type of imaging, 
type of assessment and timing should be recorded as well as reason for imaging and/or 
assessment. 
2. Survival will be monitored on an ongoing basis during the study, then every 3 months 
from the time the subject is off-treatment for a period of 1 year, then yearly for up to five 
years.  
 
6.6 
Protocol Treatment Completion 
Subjects who receive 6 total 21-day treatment cycles will be considered as having completed the 
protocol. Additional treatment cycles may be delivered in a maintenance setting if there are no 
safety concerns and there is no disease progression.  Maintenance monitoring will be conducted 
as described for Subsequent Cycles (Section 6.7). 
 
 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 52 of 81 
6.7 
Subsequent (Maintenance) Cycles (for subjects that have completed the 6 
protocol treatment cycles) 
Drug administration will be according to guidelines with premedication as specified. The 
following evaluations will be performed on the days of each cycle as indicated.  Evaluations will 
be performed prior to dosing unless otherwise indicated.   
 
All Cycles will be 21 days in duration.  The following procedures must be completed: 
Day 1 (+/- 3 day window to start Day 1 treatment)  
The following procedures may be performed up to 5 days prior to starting treatment/Day 1 
unless otherwise indicated:   
1. History and Physical examination (including body weight), including documentation of 
an update of all previous abnormalities, any new abnormalities, and a detailed 
neurological exam (same day); 
2. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation (same 
day); 
3. Review and recording of concomitant medications; 
4. Monitoring and documentation of all AEs and review of concurrent illnesses  
(same day); 
5. BSA calculation (from body weight and height); 
6. ECOG Performance status/Lansky Play status (Appendix I);  
7. CBC with differential; 
8. Serum electrolytes, blood urea nitrogen (BUN), creatinine, bilirubin, LDH, ALT, and 
AST; 
9. Urine for Vanillylmandelic Acid (VMA) & Homovanillic Acid (HVA); 
10. Serum or Urine pregnancy test for female subjects of child bearing potential (onset of 
menses or ≥13 years of age). 
11. DFMO dosing continues daily; 
12. Bortezomib administration. 
 
Day 4 (+/- 1 day window) 
Subjects will return to the clinic on Cycle 1 Day 4 for Bortezomib and evaluations. The 
following evaluations will be conducted: 
 
1. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation; 
2. Monitoring and documentation of all AEs and review of concurrent illnesses; 
3. Review and recording of concomitant medications; 
4. DFMO dosing continues daily; 
5. Bortezomib administration. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 53 of 81 
 
Cycle Day 8 (+/- 1 day window) 
Subjects will return to the clinic on Cycle 1 Day 8 for evaluations. The following evaluations 
will be conducted: 
 
1. History and physical exam; 
2. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation; 
3. CBC with differential; 
4. Monitoring and documentation of all AEs and review of concurrent illnesses; 
5. Review and recording of concomitant medications; 
6. DFMO dosing continues daily; 
7. Bortezomib administration. 
 
6.8 
Off-Therapy / 30 Day Follow-up Visit 
Subjects will return to the clinic 30 (+7) days after the last dose of DFMO, and the following 
evaluations will be conducted: 
1. History and Physical examination (including body weight), including documentation of 
an update of all previous abnormalities, any new abnormalities, and a detailed 
neurological exam; 
2. ECOG Performance status/Lansky Play status (Appendix I); 
3. Vital signs, including temperature, pulse rate, blood pressure, and O2 saturation; 
4. CBC with differential; 
5. Serum electrolytes, BUN, creatinine, bilirubin, LDH, ALT, AST; 
6. Urine for Vanillylmandelic Acid (VMA) & Homovanillic Acid (HVA); 
7. Review and recording of concomitant medications; 
8. Monitoring of AEs and review of concurrent illnesses;  
9. Collect previous cycles drug dosing diaries (if early withdrawal); 
10. MRI/CT; MIBG or PET scan; if not already obtained within the previous two cycles.  
11. Bone marrow biopsy and aspirate (if positive at study entry); if not already obtained 
within the previous two cycles; 
12. Audiogram (if clinically indicated). 
 
Any subject with a suspected study drug-related toxicity at the follow-up visit must be 
followed until the related event(s) has resolved to baseline or ≤ grade 2.  This may require 
additional clinical assessments and laboratory tests.  The follow-up results will be recorded 
on the appropriate page of the CRF, as well as in the subject's source documentation. 
Subjects that have started a new anti-cancer treatment since going off DFMO will be 
censored from any further new AE collection at the date of starting the new therapy but will 
continue survival follow up. 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 54 of 81 
6.9 
Survival Follow-up 
Subjects will be followed for long term survival by contact with parent or treating institution to 
confirm survival at the following time points (time from last dose of study drug): 
− 3 months 
− 6 months 
− 9 months 
− 1 year 
− Then Yearly after (up to 5 years total) 
 
Follow up will continue for five (5) years or until subject death or subject is lost to follow up 
(per definition in section 9.0). The follow-up results including date of any progression of disease, 
survival status or date of death will be recorded on the appropriate page of the CRF, 
as well as in the subject's source documentation. 
 
 
7.0 Efficacy Assessments 
 
7.1 
Tumor Assessments/Scans 
Tumor assessments/imaging studies must be obtained at baseline and at the end of the second 
and fourth cycles, and again after every other cycle.   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. 
All radiological images must be available for source verification.  Images may be submitted for 
extramural review for final assessment of antitumor activity. 
Subjects who come off study for any reason should have a final end of study disease-specific 
assessment done. 
 
7.2 
Scan Submission:  
All required study scans (CT’s, MRI’s, and MIBG’s) will be reviewed by central radiology.  All 
study required scans should be sent on disc.  Scans will be sent as a batch at the end of each 
subject’s therapy or sooner if any concern for progression to: 
Alyssa VanderWerff 
NMTRC 
Clinical Program Coordinator 
100 Michigan Avenue NE  MC 272         
Grand Rapids, MI 49503 
Tel:  (616) 267-0327  
E-Mail:  Alyssa.VanderWerff@helendevoschildrens.org  
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 55 of 81 
7.3 
Response Criteria 
 
Overall response rate (ORR) in subjects with radiologically assessable disease will be 
determined by CT or MRI by cross-sectional imaging, by MIBG or PET scans, and/or bone 
marrow assessment.  
Response Assessment: Each subject will be classified according to their “best response” for the 
purposes of analysis of treatment effect. Best response is determined from the sequence of the 
objective status described below. 
Response Criteria for Subjects with Solid Tumors: This study will use the (RECIST) 
Response Evaluation Criteria in Solid Tumor (version 1.1) from the NCI. Key points are that a 
maximum of 5 target lesions are identified and that changes in the largest diameter (uni-
dimensional measurement) of the tumor lesions are used in the RECIST v1.1 criteria. 
• Measurable disease: The presence of at least one lesion that can be accurately measured in at 
least one dimension with the longest diameter at least 10 mm (CT scan slice thickness no 
greater than 5 mm). The investigator will identify up to 5 measurable lesions to be followed 
for response. Previously irradiated lesions must demonstrate clear evidence of progression to 
be considered measurable. 
• Measurable Disease Response will be assessed at end of Cycle 2 and then at least every other 
cycle 
• Serial measurements of lesions are to be done with CT or MRI, using the same method of 
assessment is to be used to characterize each identified and reported lesion at baseline and 
during follow-up. 
• Quantification of Disease Burden: The sum of the longest diameter (LD) for all target lesions 
will be calculated and reported as the disease measurement.   
• Complete Response (CR): Disappearance of all target and non-target lesions. 
• Very Good Partial Response (VGPR): Greater than 90% decrease of the disease 
measurement for CT/MRI lesions, taking as reference the disease measurement done to 
confirm measurable disease at study entry. Non-target CT/MRI lesions stable to smaller in 
size. 
• Partial Response (PR): At least a 30% decrease in the disease measurement, taking as 
reference the disease measurement done to confirm measurable disease at study enrollment. 
No new lesions or progression of any non-target measurable lesion.  
• Stable Disease (SD): Neither sufficient decrease to qualify for PR or sufficient increase to 
qualify for PD taking as reference the smallest disease measurement since the treatment 
started. 
• Progressive Disease (PD):  At least a 20% increase in the sum of the disease measurements 
for measurable lesions, taking as reference the smallest disease measurement recorded since 
the start of treatment (nadir), or the appearance of one or more new lesions. 
 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 56 of 81 
Response Criteria for Subjects with Bone Marrow Disease:  
• Those subjects with morphologic evidence of neuroblastoma by routine H and E staining 
(NSE staining only is not evaluable) will be evaluable to assess bone marrow response. 
• Complete response: No tumor cells detectable by routine morphology on two consecutive 
bilateral bone marrow aspirates and biopsies done at least three weeks apart after study entry. 
• Progressive disease: Tumor seen on morphology on two consecutive bilateral bone marrow 
aspirates and biopsies done at least three weeks apart in subjects who had NO tumor in bone 
marrow at study entry. (Note: Subject may be declared as progressive disease in bone marrow 
after only one diagnostic bone marrow at the discretion of the treating physician after 
discussion with the study chair.) 
• Stable disease: Persistence of any amount of tumor in the bone marrow by morphology that 
does not meet criteria for either complete response or progressive disease. 
 
Response Criteria for Subjects with MIBG/PET Positive Lesions 
• Subjects who have a positive MIBG or PET scan at the start of therapy will be evaluable for 
MIBG/PET response. The use of I123 for MIBG imaging is recommended for all scans. If this 
radioisotope is unavailable at the treating institution, the use of the same radioisotope for all 
MIBG scans for an individual subject is strongly encouraged.  
• Complete response = complete resolution of all MIBG/PET positive lesions 
• Partial response = resolution of at least one MIBG/PET positive lesion, with persistence of 
other MIBG/PET positive lesions. 
• Stable disease = no change in MIBG/PET scan in number of positive lesions (includes 
subjects who have same number of positive lesions but decreased intensity) 
• Progressive disease = Development of new MIBG/PET positive lesions 
 
The intensity of MIBG/PET uptake is not to be considered in the above institutional evaluation. 
 
 
Duration of response: 
Duration of response is defined as the period of time from when measurement criteria are met for 
complete response (CR) or partial response (PR), whichever is first recorded, until the first date 
that recurrent or progressive disease (PD) is objectively documented (taking as reference for PD 
the smallest measurements recorded since the treatment started) 
The assessment of response will include the initial measurable targets and will be performed 
after the first and second cycle, then after every other cycle. Serial results of bone marrow 
aspirates, biopsies and urinary catecholamines will be reviewed for responding subjects to 
confirm response or lack of progression.   
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 57 of 81 
8.0 
Adverse Event Reporting  
 
Common Terminology Criteria for Adverse Events (CTCAE) 
This study will utilize the version 4.0 of the CTCAE of the National Cancer Institute (NCI) for 
toxicity and performance reporting. A copy of the CTCAE version 4.0 can be downloaded from 
the NCI website at: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
8.1 
Definitions 
8.1.1 Adverse Event 
An adverse event is any untoward medical occurrence in a patient or clinical investigation 
subject administered a pharmaceutical product and which does not necessarily have to have a 
causal relationship with this treatment.  An adverse event can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding, for example), symptom, or disease 
temporally associated with the use of a medicinal product, whether or not considered related to 
the medicinal product. 
 
An untoward medical event which occurs outside the period of follow-up as defined in the 
protocol will not be considered an adverse event unless related to study drug.  Worsening of a 
medical condition for which the efficacy of the study drug is being evaluated will not be 
considered an adverse event. 
 
8.1.2 Unexpected Adverse Event 
An unexpected adverse event is one for which the nature or severity of the event is not 
consistent with the applicable product information, e.g., the investigator’s brochure. 
 
8.1.3 Serious Adverse Event 
A serious adverse event is any untoward medical occurrence that at any dose: 
• 
Results in death 
• 
Is life-threatening (an event in which the subject was at risk of death at the time of the 
event; it does not refer to an event which hypothetically might have caused death if it were 
more severe) 
• 
Requires in-patient hospitalization or prolongation of existing hospitalization 
• 
Results in persistent or significant disability/incapacity 
 
• 
Is a congenital anomaly or birth defect 
• 
Other important medical events that may not be immediately life-threatening or result in 
death or hospitalization but may jeopardize the subject or may require intervention to 
prevent one of the other outcomes listed above.  Examples of such events are intensive 
treatment in an emergency room for allergic bronchospasm; blood dyscrasias or 
convulsions that do not result in hospitalization; or development of drug dependency or 
drug abuse. 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 58 of 81 
The term “severe” is often used to describe the intensity (severity) of an event; the event itself 
may be of relatively minor medical significance (such as a severe headache).  This is not the 
same as “serious”, which is based on subject/event outcome or action criteria usually associated 
with events that pose a threat to a subject’s life or functioning. 
 
8.2 
Documenting Adverse Events  
The Investigator should elicit information regarding the occurrence of adverse events through 
open-ended questioning of the subject, physical examination and review of laboratory results.   
 
All Grade 2 or higher (per CTCAE version 4.0) adverse events, whether serious or not, will be 
described in the source documents and the adverse event page of the case report form.  All new 
events (Grade 2 or higher), as well as those that worsen in intensity or frequency relative to 
baseline, which occur after administration of study drug through the period of protocol-specified 
follow-up, must be captured. 
 
Information to be reported in the description of each adverse event includes: 
• 
A medical diagnosis of the event (if a medical diagnosis cannot be determined, a 
description of each sign or symptom characterizing the event should be recorded)  
• 
The date of onset of the event  
• 
The date of resolution of the event and whether the event is serious or not 
• 
Action taken; drug treatment required; non-drug treatment required; hospitalization or 
prolongation of hospitalization required; diagnostic procedure performed; subject 
discontinued from the study 
• 
Outcome:  complete recovery or return to baseline; unknown/lost to follow-up; adverse 
event persisting; subject died (notify lead site immediately, and complete the Serious 
Adverse Event page and the Final Visit section of the case report form)   
 
Adverse events, regardless of suspected cause, will be collected for 30 days following the last 
treatment or until a new treatment is started. Suspected study drug-related toxicity at the 30 day 
follow-up visit must continue to be followed until resolution to baseline or ≤ Grade 2 or 
stabilization of the event. 
 
8.3 
Expedited Reporting of Adverse Events 
All fatal, life–threatening, or dose limiting adverse events must be reported to the lead site 
immediately by telephone, fax, or e-mail within 24 hours of discovery as well as to the 
appropriate regulatory authorities (local IRB). The lead site, NMTRC, will then report directly to 
the safety officer, FDA if required, and KC Pharma as appropriate. If full information is not 
known, additional follow-up by the Investigator will be required. 
 
All other serious adverse events must be reported to the lead site by telephone, fax, or e-
mail within 5 days of discovery as well as to the appropriate regulatory authorities (local IRB). 
The lead site will then report directly to the safety officer, FDA if required, and KC Pharma as 
appropriate.  

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 59 of 81 
The Investigator must report all serious adverse events reported to regulatory authorities in an 
expedited manner to the local IRB or IEC.  All serious adverse events must be followed until 
resolution or stabilization.  
 
NMTRC Reporting Contact 
 
Please report all expedited reports to: 
 
Alyssa VanderWerff and Genevieve Bergendahl, RN 
NMTRC 
Tel:  (616) 267-0327  
E-Mail:  Alyssa.VanderWerff@helendevoschildrens.org 
E-Mail:  Genevieve.Bergendahl@helendevoschildrens.org 
   
8.4 
Grading and Relatedness of Adverse Events 
8.4.1 Grading of Severity of an Adverse Event 
Each adverse event (Grade 2 or higher) will be graded for severity per the National Cancer 
Institute Common Terminology Criteria for Adverse Events (CTCAE V 4.0), and these criteria 
must be used in grading the severity of adverse events.  The criteria can be found at: 
http://ctep.cancer.gov/reporting/ctc.html. 
 
Grading of Severity of an Adverse Event Not Listed in Published Criteria: 
For those adverse events which are not listed as part of the NCI CTCAE V 4.0, the same grading 
system should be used, where: 
• 
Mild corresponds to an event not resulting in disability or incapacity and which resolves 
without intervention 
• 
Moderate corresponds to an event not resulting in disability or incapacity but which 
requires intervention 
• 
Severe corresponds to an event resulting in temporary disability or incapacity and which 
requires intervention 
• 
Life-threatening corresponds to an event in which the subject was at risk of death at the 
time of the event 
• 
Fatal corresponds to an event that results in the death of the subject 
 
 
8.5 
Grading of Hematologic Adverse Events in special populations 
Subjects who are platelet transfusion dependent at study entry will not have grading of platelet 
levels. 
 
Subjects who have bone marrow involvement at study entry will not have grading of any 
hematologic levels. 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 60 of 81 
 
8.6 
Relatedness to Study Drug 
The Investigator must attempt to determine if an adverse event is in some way related to the use 
of the study drug and define an attribution category. This relationship should be described as 
follows: 
 
RELATIONSHIP 
ATTRIBUTION 
DESCRIPTION 
Unrelated to 
investigational 
agent/intervention 
 
Unrelated 
The AE is clearly NOT related to the intervention. 
The event is clearly due to causes distinct from the use of the 
study drug, such as a documented pre-existing condition, the 
effect of a concomitant medication, or a new condition which, 
based on the pathophysiology of the condition, and the 
pharmacology of the study drug, would be unrelated to the use 
of the study drug. 
Unlikely 
The AE is doubtfully related to the intervention. 
Adverse event does not have temporal relationship to 
intervention, could readily have been produced by the 
subject’s clinical state, could have been due to environmental 
or other interventions, does not follow known pattern of 
response to intervention, does not reappear or worsen with 
reintroduction of intervention. 
Related to 
investigational 
agent/intervention 
 
Possible 
The AE may be related to the intervention. 
The event follows a reasonable temporal sequence from 
administration of the study drug and the event follows a 
known response pattern to the study drug BUT the event could 
have been produced by an intercurrent medical condition 
which, based on the pathophysiology of the condition, and the 
pharmacology of the study drug, would be unlikely related to 
the use of the study drug OR the event could be the effect of a 
concomitant medication. 
Probable 
The AE is likely related to the intervention. 
The event follows a reasonable temporal sequence from 
administration of the study drug, the event follows a known 
response pattern to the study drug AND the event cannot have 
been reasonably explained by an intercurrent medical 
condition OR the event cannot be the effect of a concomitant 
medication. 
Definite 
The AE is clearly related to the intervention. 
The event follows a reasonable temporal sequence from 
administration of the study drug, the event follows a known 
response pattern to the study drug and based on the known 
pharmacology of the study drug, the event is clearly related to 
the effect of the study drug.  The adverse event improves upon 
discontinuation of the study drug and reappears upon repeat 
exposure. 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 61 of 81 
9.0 
Subject Withdrawal and Trial Discontinuation 
9.1 
Criteria for Subject Off-Therapy 
Subjects may be withdrawn from the study treatment for the following reasons: 
• 
Subject completes all protocol defined therapy- 6 cycles  
• 
Progressive neoplastic disease  
• 
Subject or guardian withdraws consent to continue study drug 
• 
Subject develops an intercurrent illness that precludes further participation, or requires a 
prohibited concomitant treatment 
• 
The Investigator withdraws the subject in the subject’s best interests 
• 
Subject is lost to follow-up (defined as the inability to contact the subject on 3 separate 
occasions over a period of 2 weeks) 
• 
Administrative reasons (e.g., the subject is transferred to hospice care) 
• 
An adverse event, which in the opinion of the Investigator, precludes further trial 
participation or fulfills the protocol requirements for withdrawal (e.g., the development of 
dose limiting toxicity despite a reduction in protocol therapy for a previous episode of dose 
limiting toxicity) 
• 
Death 
 
9.2 
Criteria for Subject Off-Study 
Subjects may be withdrawn from the study completely which includes withdrawal from 
survival follow-up for the following reasons: 
• 
Subject or guardian withdraws consent to continue in the trial 
• 
Subject is lost to follow-up (defined as the inability to contact the subject on 3 separate 
occasions over a period of 2 weeks) 
• 
Subject completes all protocol defined therapy including all follow-up time points. 
• 
Death 
 
9.3 
Trial Discontinuation 
The lead site may discontinue the trial as a whole or at an individual investigational site at any 
time.  Reasons for early trial discontinuation may include, but are not limited to, unacceptable 
toxicity of study drug, a request to discontinue the trial from a regulatory authority, protocol 
violations at an investigational site, violations of good clinical practice at an investigational site, 
or poor enrollment.  The lead site will promptly inform all Investigators in the event of 
premature study discontinuation and provide all Investigators with instructions regarding the 
disposition of subjects still on study.  Should the study be terminated prematurely, all unused 
study drug, case report forms and any other study material will be returned to the lead site. 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 62 of 81 
10.0 DATA ANALYSIS 
10.1 Data Quality Assurance 
Electronic case report forms (CRF) will be checked for correctness against source document data 
by the monitor.  If any entries into the CRF are incorrect, incomplete or illegible, the monitor 
will ask the Investigator or the study site staff to make appropriate corrections.   
10.2 Statistical Analysis 
 
This is an open label, single agent, multicenter, study for subjects with relapsed or refractory 
neuroblastoma. 
 
The following data sets will be used in this study: 
• All enrolled and eligible subjects (ITT) population: All eligible subjects who have a signed 
informed consent form. 
• All treated and eligible subjects (Safety evaluable) population: All subjects who received at 
least one dose of study drug 
• All eligible subjects treated to first evaluable time point with evaluation completed (generally 
2 cycles) (as Treatment Efficacy) population, unless subjects have reached the study endpoint 
of progression of disease at an earlier time point. 
 
Efficacy analyses will be performed on the Treatment evaluable population. Safety analysis will 
be performed on the Safety and Efficacy evaluable population. 
 
All baseline patient characteristics will be summarized in a tabular format.  Safety data will be 
described for all subjects receiving at least one dose of DFMO.  Safety data will include values 
for hematology, serum chemistry, vital signs, and adverse events. The proportion of subjects 
experiencing adverse events, serious adverse events, dose limiting toxicities and treatment delays 
will be summarized.  Enrollment to study will not pause at interim analysis time points. 
 
Sample Size and Analysis: 
 
The primary outcome measure is the Overall Response Rate (ORR).  A two-stage minimax test 
for a single binomial population using a directional 5% Type I error level of the null hypothesis 
that the Overall Response Rate is <=1% versus the alternative hypothesis of the Overall 
Response Rate being 10% will require 32 evaluable subjects to achieve an 80% power for each 
of the subject stratum..  The two-stage decision rule for each strata is as follows: 
 
Stage 1- When 20 evaluable subjects have been entered into the study and observed for Overall 
Response, the study will terminate and accept the null hypothesis of a <=1% Overall Response 
Rate if none (0) of these 20 subjects show a Complete Response or Partial Response (i.e. stop 
due to futility).  If 1 or more of the 20 evaluable subjects show an Overall Response, then the 
study will continue to Stage 2. 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 63 of 81 
Stage 2- When the full 32 evaluable subjects have been entered into the study and observed for 
an Overall Response, the study would terminate and accept the null hypothesis of an Overall 
Response Rate <=1% if 1 or fewer of the 32 subjects show a Complete Response or Partial 
Response.  If 2 or more of the 32 evaluable subjects show an Overall Response, the study will 
terminate and will result in the rejection of the null hypothesis and conclude that the 10% Overall 
Response Rate is more likely. 
  
 
Total subjects: Assuming that approximately 10% of subjects will be non-evaluable, the actual 
sample size needed will be n =35 per stratum. 
 
The secondary outcome measure is Progression Free Survival (PFS) at 100 days.  The sample 
size discussion that follows mimics the two-stage design approach used for the primary outcome 
measure, ORR.  However, since this sample size and decision rule description relate to PFS at 
100 days, this section is illustrative only and will not be used to impact on study accrual.   
 
Assuming an exponential model with the null hypothesis median Progression Free Survival of 42 
days and an alternative median Progression Free Survival of 82 days, then one would expect the 
proportion of subjects who are progression free at 100 days of follow-up to be19.2% under the 
null value of 42 days and 42.9% under the alternative value of 82 days.  Shorter follow-up time 
frames would increase the proportion of progression free subjects while a longer follow-up 
would decrease these proportions. 
 
Rationale for the null hypothesis effect size is derived from recent Children’s Oncology Group 
reports in multiply relapsed NB patients.  Forty-two days was selected as the standard for 
comparison because it is the median time to progression for a control population of NB patients 
recently treated on other Phase I and II trials (CCG-8607, ANBL00321, NANT-0103, CCG-
0926, and CCG-0961).  
 
Progression Free Survival (PFS) is defined as the period from the first day of administration of 
study drug (DFMO) until the criteria for progression are met taking as reference the screening 
measurements. The definition of “progression” as applied to this control population will include 
deaths from any cause.   From the control patients in the COG study (n=136), the 42 day PFS 
rate was 50% ± 4%.  Day 42 corresponds to the time at which most patients will have completed 
2 courses of study therapy (assuming no delays, 21 days per course for 2 courses is 42 days). An 
assessment of disease will be required after the completion of 2 courses. Therefore, the standard 
for comparison, which DFMO/Velcade is anticipated to exceed, has been set at a median time to 
progression of 42 days.  
 
Using a one sample exact binomial test of the 19.2% versus the 42.9% progression free survival 
values at 100 days, the overall sample size would be n = 23 using a two-stage minimax test with 
directional 5% Type I error level and 80% power 
The two-stage decision rule is as follows: 
 
Stage 1- When 18 evaluable subjects have been entered into the study and observed for at least 
100 days, the study will terminate and accept the null hypothesis of 19.2% progression free 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 64 of 81 
survival if 5 or fewer of the 18 subjects are progression free at 100 days of follow-up (i.e. stop 
due to futility).  If 6 or more of the 18 evaluable subjects are progression free, then the study will 
continue to Stage 2. 
 
Stage 2- When 23 evaluable subjects have been entered into the study and observed for at least 
100 days, the study would terminate and accept the null hypothesis of 19.2% progression free 
survival if 7 or fewer of the 23 subjects are progression free at 100 days of follow-up.  If 8 or 
more of the 23 evaluable subjects are progression free, the study will terminate and will result in 
the rejection of the null hypothesis and conclude that the 42.9% progression free survival at 100 
days is more likely. 
 
It is thus clear that the analysis of PFS will be able to progress without difficulty if the full 
sample size of 32 evaluable subjects per stratum is achieved for the ORR primary outcome 
evaluation.  It is also clear that even with an early termination for futility for the ORR outcome at 
n = 20 subjects at Stage I in either of the subject strata, that the PFS secondary outcome should 
be testable although with slightly lower power.  
 
 
11.0 ADMINISTRATIVE PROCEDURES 
11.1 Patient Informed Consent 
No study related procedures will be performed until a patient or a patient’s legal representative 
has given written informed consent.  The lead site will provide to the site Investigators a sample 
informed consent document that conforms to all the requirements for informed consent according 
to ICH GCP and US FDA guidelines (21 CFR 50).  However, it is up to each site Investigator to 
provide a final informed consent that may include additional elements required by the 
Investigator’s institution or local regulatory authorities.  The IRB/EC for each investigational site 
must approve the consent form document prior to study activation; changes to the consent form 
during the course of the study may also require IRB/EC approval.  The informed consent 
document must clearly describe the potential risks and benefits of the trial, and each prospective 
participant must be given adequate time to discuss the trial with the Investigator or site staff and 
to decide whether or not to participate.  Each patient who agrees to participate in the trial and 
who signs the informed consent will be given a copy of the signed dated and witnessed 
document.  The original copy of the signed, dated, and witnessed informed consent document 
will be retained by the Investigator in the study files. 
 
The Investigator must also obtain authorization from the patient to use and/or disclose protected 
health information in compliance with the Health Insurance Portability and Accountability Act 
(HIPAA).  Written HIPAA authorization may be obtained as part of the informed consent 
process.   
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 65 of 81 
11.2 Ethical Conduct of the Study and IRB/IEC Approval 
The study will be conducted according to the principles of the 2004 version of the Declaration of 
Helsinki, the International Conference on Harmonization Guidance on Good Clinical Practice 
and the requirements of all local regulatory authorities regarding the conduct of clinical trials and 
the protection of human subjects.  
 
The Investigator will submit the protocol, the Investigator’s Brochure, the informed consent and 
any other material used to inform patients about the trial to the local IRB/IEC for approval prior 
to enrolling any patient into the trial.  The IRB/IEC should be duly constituted according to 
applicable regulatory requirements.  Approval must be in the form of a letter signed by the 
Chairperson of the IRB/IEC or the Chairperson’s designee, must be on IRB/IEC stationary and 
must include the protocol by name and/or designated number.  If an Investigator is a member of 
the IRB/IEC, the approval letter must stipulate that the Investigator did not participate in the final 
vote, although the Investigator may participate in the discussion of the trial.  The Investigator 
will also inform the IRB/IEC of any serious adverse events that are reported to regulatory 
authorities and will provide to the IRB/IEC a final summary of the results of the trial at the 
conclusion of the trial. 
 
Any amendments to the protocol will be done at the lead site, and will be submitted to the 
IRB/IEC for review and written approval before implementation. These approved changes will 
then be forwarded to sites for review by their local IRB/IEC.  Written approval from sites will be 
forwarded to the lead site. 
 
11.3 Data Safety Monitoring Board (DSMB) 
An independent Data Safety and Monitoring Board (DSMB) will oversee the conduct of the 
study.  The members of this Board will receive database summaries, including adverse event 
reports, and will convene either in person or via teleconference every 6 months or for any study 
drug related Grade 5 toxicity occurring on study, whichever occurs first. The Board will be 
responsible for recommendations regarding possible termination and/or early reporting of the 
study. 
 
Study will be on hold for safety monitoring by DSMB review when: 
 
1. Any deaths deemed related to the study drug by the treating PI while on study or 
occurring less than 30 days after medications ended or 2 serious adverse events 
possibly related to protocol within 60 days. 
2. Any Life threatening hemorrhage requiring hospitalization  
3. Any intracerebral hemorrhage 
4. Any other reason that the NMTRC feels it is in the best safety interest of the subjects. 
 
11.4 Monitoring and Auditing 
A clinical monitor will make regularly scheduled trips to the investigational site to review the 
progress of the trial as defined in the Monitoring Plan.  The actual frequency of monitoring trips 
will depend on the enrollment rate and performance at each site.  At each visit, the monitor will 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 66 of 81 
review various aspects of the trial including, but not limited to, screening and enrollment logs; 
compliance with the protocol and with the principles of Good Clinical Practice; completion of 
case report forms; source data verification; study drug accountability and storage; facilities and 
staff data quality; regulatory documentation; and study integrity. In addition the site may be 
audited by representatives of KC Pharma and/or government inspectors who must be allowed 
access to CRFs, source documents and other study files.  The site must promptly notify the study 
chair of any inspections scheduled by regulatory authorities, and also forward copies of the 
inspection reports to the study chair. The study chair will promptly forward this information to 
KC Pharma as required. 
 
 
During scheduled monitoring visits, the Investigator and the investigational site staff must be 
available to meet with the study monitor in order to discuss the progress of the trial, make 
necessary corrections to case report form entries, respond to data clarification requests and 
respond to any other trial-related inquiries of the monitor. 
 
 
11.5 Pre-Study Documentation 
Prior to initiating the trial, the Investigators at each site will provide to the Lead site the 
following documents: 
• 
A signed FDA Form 1572 
• 
A current curriculum vitae for the Principal Investigator and each sub-investigator listed on 
the FDA Form 1572 
• 
A copy of the Investigator’s medical license from the state in which the study is being 
conducted 
• 
A letter from the IRB or EC stipulating approval of the protocol, the informed consent 
document and any other material provided to potential trial participants with information 
about the trial (e.g., advertisements) 
• 
A copy of the IRB- or EC-approved informed consent document 
• 
Current IRB membership list for IRB’s without a multiple project assurance number or an 
IRB 
organization 
number 
under 
the 
Federal 
Wide 
Assurance 
program 
(www.ohrp.osophs.dhhs.gov).   
• 
A signed Investigator Protocol Agreement 
• 
A completed financial disclosure form for each person listed in box 6 of the FDA form 
1572. 
• 
Current laboratory certification for the reference laboratory 
• 
A list of current laboratory normal values for the reference laboratory 
 
11.6 Confidentiality 
It is the responsibility of the investigator to insure that the confidentiality of all subjects 
participating in the trial and all of their medical information is maintained.  Case report forms 
and other documents submitted must never contain the name of a trial participant.  Each subject 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 67 of 81 
in the trial will be identified by a unique identifier that will be used on all CRF’s and any other 
material submitted to the lead site.  All case report forms and any identifying information must 
be kept in a secure location with access limited to the study staff directly participating in the trial. 
 
The results of the study may be presented in reports, published in scientific journals or presented 
at medical meetings; however, subject names will never be used in any reports about the study. 
 
11.7 Source Documents 
The Investigator will maintain source records separate from the case report forms in the form of 
clinical charts, medical records, original laboratory, radiology and pathology reports, pharmacy 
records, etc.  The Investigator will document in the clinic chart or medical record the name and 
number of the trial and the date on which the subject signed informed consent prior to the 
subject’s participation in the trial.  Source documents must completely reflect the nature and 
extent of the patient’s medical care, and must be available for source document verification 
against entries in the case report forms when the monitor visits the investigational site.  All 
information obtained from source documents will be kept in strict confidentiality. 
11.8 Record Retention 
The Investigator will retain the records of the study for 15 years, or for 2 years following the date 
that a marketing application for the study drug is approved, or if no marketing application is 
filed, or if such an application is not approved, for 2 years after the IND has been closed.  The 
lead site will notify Investigators when retention of study records is no longer required.  All 
study records must be maintained in a safe and secure location that allows for timely retrieval, if 
needed. 
 
Study records that must be retained include copies of case report forms, signed informed 
consents, correspondence with the IRB or IEC, study drug dispensing and inventory records, 
source documents, clinic charts, medical records, laboratory results, radiographic reports) and 
screening/enrollment logs. 
 
Should the Investigator relocate or retire, or should there be any changes in the archival 
arrangements for the study records, the lead site must be notified.  The responsibility for 
maintaining the study records may be transferred to another suitable individual, but the lead site 
must be notified of the identity of the individual assuming responsibility for maintaining the 
study records and the location of their storage.   
 
12.0 Biological Evaluation  
A major challenge in the development of cancer therapeutics is an absence of understanding the 
relationship of the disease to response to therapy, and the ability to predict which subjects are 
most likely to respond to any particular agent. Emerging technologies including ability to 
establish primary tumor cells in culture, evaluate pharmacogenomics and explore biomarkers 
may provide a way to explore relationships between clinical benefit and treatment.  
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 68 of 81 
Urine Sample Analysis: 
 
Decarboxylated S-adenosylmethionine (dcSAM) Performed by Dr. Bachmann (section 12.1.1): 
 Adenine and its derivatives are known to react with 2-chloroacetaldehyde to form highly 
fluorescent tricyclic derivatives. This reaction gives a sensitive and specific method for 
measuring dc-SAM in urine and plasma samples. The reaction mixture will be incubated at 40°C 
overnight. An aliquot of this mixture will be injected onto an Altex Ultrosphere column for 
chromatographic separation. Detection will be accomplished using a Perkin-Elmer LS-4 
spectrofluorometer, as described by others.[77] 
 
Polyamines Performed by Dr. Bachmann (section 12.1.1) 
 High performance liquid chromatography (HPLC) and other methods will be used, as per 
previous studies ([4, 77]), to detect  putrescine, spermidine, spermine, monoacetylspermidine and 
monoacetylspermine and diacetylspermine.  Samples will be adjusted to 0.2N perchloric acid and 
analyzed directly.  Acid hydrolysis methods will be employed to remove acetyl groups, and thus 
measure diacetylated amines.  The detection level will be 1-10 pmol.  Sources of error associated 
with these measures in colonic tissue have been previously reported ([78]).  Urinary creatinine 
levels will also be determined, using a commercial kit (Oxford Biochemical Research), to 
normalize urinary polyamines.  In the method, picric acid reacts with creatinine and other urinary 
components to produce an orange color, which can be quantified spectrophotometrically at 490 
nm at alkaline pH.  The creatinine reaction degrades rapidly when acidified. The difference in 
optical density is a direct measure of the creatinine concentration.   
 
Blood and Bone Marrow Samples Analysis 
 
ODC SNP analysis –Performed by Pediatric Oncology Translational Research Laboratory 
(Section 12.1.2) 
The ODC G316A single nucleotide polymorphism (SNP) was associated with polyamine 
contents in prostate and colorectal mucosal biopsies. The lowest levels of polyamines are found 
in colorectal mucosal tissues from individuals homozygous for the A allele, with highest levels 
observed among carriers of the GG-genotype. There is no relationship between ODC G316A 
allele genotype and colorectal content of histamine, an amine not dependent on ODC for its 
synthesis. We wish to determine the effects of DFMO treatment on polyamine levels in patients 
with each ODC genotype. Results from our recent clinical trial suggest that ototoxicity 
associated with DFMO therapy is restricted to a small fraction of people with the ODC 316AA 
genotype. These clinical trial results are corroborated by clinical translational studies that are 
based on molecular epidemiology investigations and have been replicated by three independent 
groups in humans showing that a polymorphism affecting the expression of ODC, the DFMO 
target protein, is highly associated with metachronous colon adenomas and sporadic breast 
cancer. In addition, two independent groups have reported that this same polymorphism is 
associated with prostate cancer progression and colon cancer survival. In order to develop 
algorithms predicting who will benefit, and who will have side effects of DFMO treatment, we 
will determine the ODC G263T and G316A types of all study participants, by analyzing DNA 
obtained from nucleated blood cells using established methods. We will also assess levels of 
micro RNAs in serum (Gilad S, Meiri E, Yogev Y, Benjamin S, Lebanony D, Yerushalmi N, 
Benjamin H, Kushnir M, Cholakh H, Melamed N, Bentwich Z, Hod M, Goren Y, Chajut A. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 69 of 81 
Serum microRNAs are promising novel biomarkers PLoS One. 2008 Sep 5;3(9):e3148) as 
predictive markers of DFMO effect. We have evidence in both human cancer cells and 
apparently normal rectal tissue from humans that DFMO modulates cell and tissue contents of 
specific micro RNAs.  
 
Neuroblastoma Tumor Cell Analysis –Performed by Pediatric Oncology Translational Research 
Laboratory (Section 12.1.2)  Studies will be performed to determine the dose effect of DFMO on 
biological correlates. Biological Correlates will include an analysis of neuroblastoma cells 
isolated from bone marrow and from tumor biopsies. Cells will be grown in culture as well as in 
mice xenograft models. Research studies will include immunohistochemistry, western blot, qRT-
PCR of bone marrow tumor cells or tumor to study Let-7, ODC, Lin28, MYCN, OKT-4, BMI1, 
HMGA2, GLUT-4, p-AKT, NF-kB, SOCS3. Studies will measure thymidine and polyamine 
levels. In vitro research studies of tumor cells collected above will include: Genomic analysis of 
cells pre- and post- treatment, cell viability assays to determine subject IC50 and correlation of in 
vitro response to in vivo response.  
 
 
12.1   Biological Correlative Studies Sample Instructions 
 
12.1.1 Optional Urine Polyamines Collection:  
On Days 1 and 15 of Cycle 1 and on Day 1 of cycles 2-6 urine polyamines 
will be collected. 
A. 
First morning void urines will be collected using a clean catch 
method in containers and placed at 4oC until transported to the 
laboratory. Collection of 15ml is ideal, but lab can accept amounts 
down to a minimum of 1 (one) ml.  
B. 
Specimens will be transferred to 15ml polypropylene conical tubes 
(use multiple 15ml tubes as needed)  and stored at -80oC until 
analysis for the dc-SAM and polyamines. Samples should be kept 
at 4oC (either in refrigerator or on ice pack during shipping) until 
frozen and must be frozen within 48 hours from collection time. If 
unable to freeze within 48 hours please note this on the container 
along with time before frozen. 
Samples will be batch shipped on a Monday (send after 
approximately 20 samples are collected) and sent on dry ice 
to: Ping Zhao 
Pediatric Oncology Translational Research Laboratory  
Coopers Landing  
1345 Monroe Ave., Suite 121  
Grand Rapids, MI 49505  
Ph: 616-486-8645  
Ping.zhao@helendevoschildrens.org  

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 70 of 81 
 
12.1.2 Optional Blood Collection 
 
1. Sample One- 5ml of blood in purple-top (EDTA) tube(s) will be 
collected 
 
A. 
On Days 1 and 15 of Cycle 1 and on Day 1 of cycles 2-6 
  
B. 
The specimen should be placed on ice immediately upon draw and 
sent on an ice pack immediately via FED-EX overnight along with 
sample 2 below. (If Friday collection site may store in refrigerator 
and ship on Monday)- 
 
Tube(s) will go to:  
Ping Zhao 
Pediatric Oncology Translational Research Laboratory  
Coopers Landing  
1345 Monroe Ave., Suite 121  
Grand Rapids, MI 49505  
Ph: 616-486-8645  
Ping.zhao@helendevoschildrens.org  
 
 
 
 
2. Sample Two- 5ml of blood in purple-top (EDTA) tube(s) will be 
collected 
 
A. 
On Days 1 and 15 of Cycle 1 and on Day 1 of cycles 2-6 
 
B. 
The specimen should be placed on ice immediately upon draw and 
sent on an ice pack immediately via FED-EX overnight. (If Friday 
collection site may store in refrigerator and ship on Monday)- 
 
Tube(s) will go to:  
Ping Zhao 
Pediatric Oncology Translational Research Laboratory 
Coopers Landing 
1345 Monroe Ave, Suite 121 
Grand Rapids, MI 49505 
Ph: 616-486-8645 
Ping.zhao@helendevoschildrens.org 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 71 of 81 
12.1.3 Optional Bone Marrow Collection 
 
If subject agrees to optional biology portion of study, additional bone marrow 
samples should be sent at the following time points: 
(Please note that if subject has also signed to protocol NMTRC 00B, these 
samples may be sent under that study instead): 
 
All Subjects- At Enrollment, End of cycle 2, 4, and 6, and Early Withdrawal (if 
indicated). 
 
 
Sample Collection-  
 
Send green top (sodium heparin) tube(s) with a minimum of 2cc and preferably 
5cc of bone marrow aspirate in them.    The bone marrow samples should be 
shipped room temperature- but needs to be sent out same day priority overnight 
(must get there within 24 hours of the draw).   Shipments are only accepted 
Monday through Friday, so Bone Marrow draw needs to be done and shipped out 
on Monday through Thursday only please.  
Please contact the lab at the number below to let them know of pending arrival. 
 
 
Bone marrow 2-5cc in green top (sodium heparin) tube(s) at room temperature 
and will be shipped FED-EX overnight to:  
 
Ping Zhao 
Pediatric Oncology Translational Research Laboratory 
Coopers Landing 
1345 Monroe Ave, Suite 121 
Grand Rapids, MI 49505 
Ph: 616-486-8645 
Ping.zhao@helendevoschildrens.org 
 
 
 
 
 
 
 
 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 72 of 81 
12.1.4 Optional Tumor Sample Collection 
If subject agrees to optional biology portion of study, and undergoes a standard of 
care tumor biopsy, tumor samples should be sent as follows: 
 
Sample Collection-  
 
Contact Ping Zhao as below for collection materials (kit). Collection instructions 
can be found in REDCap.  To be shipped out on Monday through Thursday only.  
 
A. 
Viable, fresh tumor > 0.2 grams should be placed in tissue culture 
media using sterile technique for cell line generation- ambient. 
B. 
Remaining Tumor collected in RNA later- ambient. 
C. 
Remaining Tumor flash frozen samples in cryovials on dry ice. 
 
  
 
Record sample information on sample collection form found in REDCap and ship 
form along with samples (2 packages- one ambient, one on dry ice) via FED-EX 
overnight to:  
 
Ping Zhao 
Pediatric Oncology Translational Research Laboratory 
Coopers Landing 
1345 Monroe Ave, Suite 121 
Grand Rapids, MI 49505 
Ph: 616-486-8645 
Ping.zhao@helendevoschildrens.org 
 
 
 
12.2 Sample Storage and Destruction 
Samples collected for any studies performed in this protocol may be stored in a 
safe and confidential laboratory area indefinitely to research future scientific 
questions related to cancer and/or study drugs. Samples will be frozen and stored 
in a carefully controlled deep freezer.  The samples that are stored for future 
research may only be used by Dr. Sholler and the other investigators who are 
participating in this study or other NMTRC studies.  There is no way to predict 
exactly what research tests will be performed with the stored samples at this time. 
Because these tests are for research only, results will not be shared with the 
subject or their physician. In the unlikely event that the research testing finds 
important information about the subject’s current or future health, the researchers 
may contact the primary treating oncologist about what the research test results 
might mean. Only the primary treating oncologist will be notified and the 
information will not become part of the subject’s medical record. The primary 
treating oncologist may discuss this unexpected finding with the subject, and may 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 73 of 81 
recommend that they see a genetic counselor and/or repeat testing in a clinical 
(not research) laboratory if needed.  
 
Samples will be stored with a unique identifier and date of collection only; 
samples will not contain names or any other identifying information. No 
information that identifies the subject will be used for any of the future research 
tests and studies. Samples will not be traceable from the lab to the subject. Only 
the enrolling site will hold the key to the sample identification between the unique 
code and the subject. The subject retains the right to have the sample material 
destroyed at any time by contacting the principal investigator. 
60B 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 74 of 81 
Appendix I: Performance Status/Scores 
 
 
 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 75 of 81 
APPENDIX II: LIST OF STRONG AND CLINICALLY RELEVENT MODERATE CYP3A4 
INDUCERS AND INHIBITORS 
 
 
 
A list of additional, less potent inducers or inhibitors of CYP450 isoenzymes can be found at 
http://medicine.iupui.edu/clinpharm/ddis/ 
 
 
Strong CYP3A4 Inducers: 
Generic Name 
Common Trade Name 
Carbamazepine 
Tegretol 
Phenobarbital 
Luminal 
Phenytoin 
Dilantin 
Rifampin 
Rifadin 
St. John’s wart 
N/A 
Systemic dexamethasone 
Decadron 
Strong* and clinically relevant moderate CYP3A4 
Inhibitors: 
Generic Name 
Common Trade Name 
Aprepitant 
Emend 
Clarithromycin* 
Biaxin 
Erythromycin 
Eryc, EryPed 
Fluconazole 
Diflucan 
Grapefruit and its juice 
N/A 
Itraconazole* 
Sporanox 
Ketoconazole* 
Nizoral 
Voriconazole 
VFend 
Posaconazole* 
Noxafil 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 76 of 81 
 
References  
 
1. 
Ater JL, Gardner KL, Foxhall LE, Therrell BL, Jr., Bleyer WA. Neuroblastoma screening in the United 
States: results of the Texas Outreach Program for neuroblastoma screening. Cancer 1998; 82(8):1593-
602. 
2. 
Bosslet K, Mennel HD, Rodden F, et al. Monoclonal antibodies against epitopes on ganglioside GD2 
and its lactones. Markers for gliomas and neuroblastomas. Cancer Immunol Immunother 1989; 
29(3):171-8. 
3. 
Cheung NK, Kushner BH, Yeh SD, Larson SM. 3F8 monoclonal antibody treatment of patients with 
stage 4 neuroblastoma: a phase II study. Int J Oncol 1998; 12(6):1299-306. 
4. 
Harras A. Cancer Rates and Risks. National Cancer Institute, NIH Publication. 1996:96-691. 
5. 
Brodeur GM. Neuroblastoma: biological insights into a clinical enigma. Nat Rev Cancer 2003; 3(3):203-
16. 
6. 
Seeger RC, Brodeur GM, Sather H, et al. Association of multiple copies of the N-myc oncogene with 
rapid progression of neuroblastomas. N Engl J Med 1985; 313(18):1111-6. 
7. 
Ben-Yosef T, Yanuka O, Halle D, Benvenisty N. Involvement of Myc targets in c-myc and N-myc 
induced human tumors. Oncogene 1998; 17(2):165-71. 
8. 
Slack A, Chen Z, Tonelli R, et al. The p53 regulatory gene MDM2 is a direct transcriptional target of 
MYCN in neuroblastoma. Proc Natl Acad Sci U S A 2005 Jan 18; 102(3):731-6. Epub 2005 Jan 11. 
9. 
Marton LJ, Pegg AE. Polyamines as targets for therapeutic intervention. Annu Rev Pharmacol Toxicol 
1995; 35:55-91. 
10. 
Auvinen M, Paasinen A, Andersson LC, Holtta E. Ornithine decarboxylase activity is critical for cell 
transformation. Nature 1992; 360(6402):355-8. 
11. 
Ernestus RI, Rohn G, Schroder R, et al. Polyamine metabolism in brain tumours: diagnostic relevance of 
quantitative biochemistry. J Neurol Neurosurg Psychiatry 2001; 71(1):88-92. 
12. 
Mohan RR, Challa A, Gupta S, et al. Overexpression of ornithine decarboxylase in prostate cancer and 
prostatic fluid in humans. Clin Cancer Res 1999;5(1):143-7. 
13. 
Lu X, Pearson A, Lunec J. The MYCN oncoprotein as a drug development target. Cancer Lett 2003; 
197(1-2):125-30. 
14. 
Lutz W, Stohr M, Schurmann J, Wenzel A, Lohr A, Schwab M. Conditional expression of N-myc in 
human neuroblastoma cells increases expression of alpha-prothymosin and ornithine decarboxylase and 
accelerates progression into S-phase early after mitogenic stimulation of quiescent cells. Oncogene 
1996; 13(4):803-12. 
15. 
Mamont PS, Duchesne MC, Grove J, Bey P. Anti-proliferative properties of DL-alpha-difluoromethyl 
ornithine in cultured cells. A consequence of the irreversible inhibition of ornithine decarboxylase. 
Biochem Biophys Res Commun 1978; 81(1):58-66. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 77 of 81 
16. 
Porter CW, Regenass U, Bergeron RJ. Polyamine inhibitors and analogs as potential anticancer agents. 
In: Dowling RH, Folsch UR, Loser C, editors. Falk symposium on polyamines in the gastrointestinal 
tract. Dordrecht, the Netherlands: Kluwer Academic Publishers; 1992. p. 301-22. 
17. 
Seiler N, Atanassov CL, Raul F. Polyamine metabolism as target for cancer chemoprevention (review). 
Int J Oncol 1998; 13(5):993-1006. 
18. 
McCann PP, Pegg AE. Ornithine decarboxylase as an enzyme target for therapy. Pharmacol Ther 1992; 
54(2):195-215. 
19. 
Marton LJ, Morris DR. Molecular and cellular functions of polyamines. In: McCann PP, Pegg AE, 
Sjoerdsma A, editors. Inhibition of Polyamine Metabolism: Biological Significance and Basis for New 
Therapies. New York: Academic Press; 1987. p. 79-105. 
20. 
Fuller DJ, Gerner EW, Russell DH. Polyamine biosynthesis and accumulation during the G1 to S phase 
transition. J Cell Physiol 1977; 93(1):81-8. 
21. 
Kaczmarek L, Calabretta B, Ferrari S, de Riel JK. Cell-cycle-dependent expression of human ornithine 
decarboxylase. J Cell Physiol 1987; 132(3):545-51. 
22. 
Kahana C, Nathans D. Isolation of cloned cDNA encoding mammalian ornithine decarboxylase. Proc 
Natl Acad Sci U S A 1984; 81(12):3645-9. 
23. 
Bello-Fernandez C, Packham G, Cleveland JL. The ornithine decarboxylase gene is a transcriptional 
target of c-Myc. Proc Natl Acad Sci U S A 1993; 90(16):7804-8. 
24. 
Pena A, Reddy CD, Wu S, et al. Regulation of human ornithine decarboxylase expression by the c-
Myc.Max protein complex. J Biol Chem 1993; 268(36):27277-85. 
25. 
Wagner AJ, Meyers C, Laimins LA, Hay N. c-Myc induces the expression and activity of ornithine 
decarboxylase. Cell Growth Differ 1993; 4(11):879-83. 
26. 
Heby O, Persson L. Molecular genetics of polyamine synthesis in eukaryotic cells. Trends Biochem Sci 
1990; 15(4):153-8. 
27. 
Metcalf BW, Bey P, Danzin C, Jung MJ, Casara P, Vevert JP. Catalytic irreversible inhibition of 
mammalian ornithine decarboxylase (E.C. 4.1.1.17) by substrate and product analogs. J Am Chem Soc 
1978; 100:2551-3. 
28. 
Poulin R, Lu L, Ackermann B, Bey P, Pegg AE. Mechanism of the irreversible inactivation of mouse 
ornithine decarboxylase by alpha-difluoromethylornithine. Characterization of sequences at the inhibitor 
and coenzyme binding sites. J Biol Chem 1992; 267(1):150-8. 
29. 
Meyskens FL, Jr., Gerner EW. Development of difluoromethylornithine (DFMO) as a chemoprevention 
agent. Clin Cancer Res 1999; 5(5):945-51. 
30. 
Chapman SK. Antitumor effects of vitamin A and inhibitors of ornithine decarboxylase in cultured 
neuroblastoma and glioma cells. Life Sci 1980; 26(16):1359-66. 
31. 
Melino G, Farrace MG, Ceru MP, Piacentini M. Correlation between transglutaminase activity and 
polyamine levels in human neuroblastoma cells. Effect of retinoic acid and alpha-
difluoromethylornithine. Exp Cell Res 1988; 179(2):429-45. 
32. 
Pegg AE. Polyamine metabolism and its importance in neoplastic growth and a target for chemotherapy. 
Cancer Res 1988; 48(4):759-74. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 78 of 81 
33. 
Takahashi Y, Mai M, Nishioka K. alpha-difluoromethylornithine induces apoptosis as well as anti-
angiogenesis in the inhibition of tumor growth and metastasis in a human gastric cancer model. Int J 
Cancer 2000; 85(2):243-7. 
34. 
Carbone PP, Pirsch JD, Thomas JP, et al. Phase I chemoprevention study of difluoromethylornithine in 
subjects with organ transplants. Cancer Epidemiol Biomarkers Prev 2001;10(6):657-61. 
35. 
Eskens FA, Greim GA, van Zuylen C, et al. Phase I and pharmacological study of weekly administration 
of the polyamine synthesis inhibitor SAM 486A (CGP 48 664) in patients with solid tumors. European 
Organization for Research and Treatment of Cancer Early Clinical Studies Group. Clin Cancer Res 
2000; 6(5):1736-43. 
36. 
Fabian CJ, Kimler BF, Brady DA, et al. A phase II breast cancer chemoprevention trial of oral alpha-
difluoromethylornithine: breast tissue, imaging, and serum and urine biomarkers. Clin Cancer Res 2002; 
8(10):3105-17. 
37. 
Levin VA, Hess KR, Choucair A, et al. Phase III randomized study of postradiotherapy chemotherapy 
with combination alpha-difluoromethylornithine-PCV versus PCV for anaplastic gliomas. Clin Cancer 
Res 2003; 9(3):981-90. 
38. 
Levin VA, Uhm JH, Jaeckle KA, et al. Phase III randomized study of postradiotherapy chemotherapy 
with alpha-difluoromethylornithine-procarbazine, N-(2-chloroethyl)-N'-cyclohexyl-N-nitrosurea, 
vincristine (DFMO-PCV) versus PCV for glioblastoma multiforme. Clin Cancer Res 2000; 6(10):3878-
84. 
39. 
Paridaens R, Uges DR, Barbet N, et al. A phase I study of a new polyamine biosynthesis inhibitor, 
SAM486A, in cancer patients with solid tumours. Br J Cancer 2000 Sep; 83(5):594-601. 
40. 
Pless M, Belhadj K, Menssen HD, et al. Clinical efficacy, tolerability, and safety of SAM486A, a novel 
polyamine biosynthesis inhibitor, in patients with relapsed or refractory non-Hodgkin's lymphoma: 
results from a phase II multicenter study. Clin Cancer Res 2004 Feb 15; 10(4):1299-305. 
41. 
Siu LL, Rowinsky EK, Hammond LA, et al. A phase I and pharmacokinetic study of SAM486A, a novel 
polyamine biosynthesis inhibitor, administered on a daily-times-five every-three-week schedule in 
patients with Advanced solid malignancies. Clin Cancer Res 2002; 8(7):2157-66. 
42. 
van Zuylen L, Bridgewater J, Sparreboom A, et al. Phase I and pharmacokinetic study of the polyamine 
synthesis inhibitor SAM486A in combination with 5-fluorouracil/leucovorin in metastatic colorectal 
cancer. Clin Cancer Res 2004 Mar 15; 10(6):1949-55. 
43. 
Chopra S, Wallace HM. Induction of spermidine/spermine N1-acetyltransferase in human cancer cells in 
response to increased production of reactive oxygen species. Biochem Pharmacol 1998 Apr 1; 
55(7):1119-23. 
44. 
Wallace HM, Fraser AV, Hughes A. A perspective of polyamine metabolism. Biochem J 2003; 376(Pt 
1):1-14. 
45. 
Wang Y, Devereux W, Woster PM, Stewart TM, Hacker A, Casero RA, Jr. Cloning and characterization 
of a human polyamine oxidase that is inducible by polyamine analogue exposure. Cancer Res 2001 Jul 
15; 61(14):5370-3. 
46. 
Heby O. Role of polyamines in the control of cell proliferation and differentiation. Differentiation 1981; 
19(1):1-20. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 79 of 81 
47. 
Pegg AE. Recent advances in the biochemistry of polyamines in eukaryotes. Biochem J 1986; 
234(2):249-62. 
48. 
Tabor CW, Tabor H. Polyamines. Annu Rev Biochem 1984; 53:749-90. 
49. 
Chen KY, Nau D, Liu AY. Effects of inhibitors of ornithine decarboxylase on the differentiation of 
mouse neuroblastoma cells. Cancer Res 1983; 43(6):2812-8. 
50. 
Melino G, Piacentini M, Patel K, Annicchiarico-Petruzzelli M, Piredda L, Kemshead JT. Retinoic acid 
and alpha-difluoromethylornithine induce different expression of neural-specific cell adhesion 
molecules in differentiating neuroblastoma cells. Prog Clin Biol Res 1991; 366:283-91. 
51. 
Wainwright LJ, Lasorella A, Iavarone A. Distinct mechanisms of cell cycle arrest control the decision 
between differentiation and senescence in human neuroblastoma cells. Proc Natl Acad Sci U S A 2001; 
98(16):9396-400. 
52. 
Wallick CJ, Gamper I, Thorne M, et al. Key role for p27Kip1, retinoblastoma protein Rb, and MYCN in 
polyamine inhibitor-induced G1 cell cycle arrest in MYCN-amplified human neuroblastoma cells. 
Oncogene 2005 Aug 25;24(36):5606-18. 
53. 
Koomoa DL, Yco LP, Borsics T, Wallick CJ, Bachmann AS. Ornithine decarboxylase inhibition by 
alpha-difluoromethylornithine activates opposing signaling pathways via phosphorylation of both 
Akt/protein kinase B and p27Kip1 in neuroblastoma. Cancer Res 2008 Dec 1; 68 (23):9825-31. 
54. 
Hogarty MD, Norris MD, Davis K, et al. ODC1 is a critical determinant of MYCN oncogenesis and a 
therapeutic target in neuroblastoma. Cancer Res 2008 Dec 1; 68(23):9735-45. 
55. 
Rounbehler RJ, Li W, Hall MA, Yang C, Fallahi M, Cleveland JL. Targeting ornithine decarboxylase 
impairs development of MYCN-amplified neuroblastoma. Cancer Res 2009; 69(2):547-53. 
56. 
AACR 2009, Abstract #3203 
57. 
AACR 2009, Abstract #3208 
58. 
Dorr RT, Liddil JD, Gerner EW. Modulation of etoposide cytotoxicity and DNA strand scission in 
L1210 and 8226 cells by polyamines. Cancer Res 1986 Aug; 46(8):3891-5. 
59. 
Meyskens FL, Jr., McLaren CE, Pelot D, et al. Difluoromethylornithine plus sulindac for the prevention 
of sporadic colorectal adenomas: A randomized placebo-controlled, double-blind trial. Cancer Prev Res 
2008; 1(1):32-8. 
60. 
Boyle JO, Meyskens FL, Jr, Garewal HS, Gerner EW: Polyamine contents in rectal and buccal mucosae 
in humans treated with oral difluoromethylornithine. Cancer Epidemiology, Biomarkers & Prevention. 
1:131-135, 1992 
61. 
Meyskens, FL, Emerson SS, Pelot D, Meshkinpour L, et al.: Dose de-escalation chemoprevention trial 
of 2 difluoromethylornithine in patients with colon polyps. J Natl Cancer Inst 86: 1122-1130, 1994 
62. 
Meyskens FL, Gerner E, Emerson S, Pelot D, Durbin T, Doyle K, Lagerberg W: A Randomized Double-
Blind Placebo Controlled Phase IIb Trial of Difluoromethylornithine for Colon Cancer Prevention. 
Journal of the National Cancer Institute, 90(16)1212-1218,1998 
63. 
Love RR, Jacoby R, Newton MA, Tutsch KD, Simon K, Pomplun M, Verma AK. A randomized, 
placebo-controlled trial of low-dose alpha-difluoromethylornithine in individuals at risk for colorectal 
cancer. Cancer Epidemiol Biomarkers Prev. 1998 Nov;7(11):989-92. 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 80 of 81 
64. 
Croghan MK, Aickin MG, Meyskens FL. Dose-related alpha-difluoromethylornithine ototoxicity. Am J 
Clin Oncol. 1991 Aug;14(4):331-5. 
65. 
 Doyle KJ, McLaren CE, Shanks JE, Galus C, Meyskens FL Jr:. Effects of DFMO chemoprevention on 
audiometry thresholds and otoacoustic emissions. Arch. Otolaryngology Head and Neck Surgery, 
127:553-558, 2001 
 
66. 
Brant LJ, Gordon-Salant S, Pearson JD, Klein LL, Morrell CH, Metter EJ, Fozard JL. Risk 
factors related to age-associated hearing loss in the speech frequencies. J Am Acad Audiol. 1996 
Jun;7(3):152-60. 
 
67. 
Cruickshanks KJ, Tweed TS, Wiley TL, Klein BE, Klein R, Chappell R, Nondahl DM, Dalton 
DS. The 5-year incidence and progression of hearing loss: the epidemiology of hearing loss 
study. Arch Otolaryngol Head Neck Surg. 2003 Oct;129(10):1041-6. 
68. 
Bradford MM. A rapid and sensitive method for the quantitation of microgram quantities of protein 
utilizing the principle of protein-dye binding. Anal Biochem. 1976 May 7;72:248-54. 
 
69. 
Gilbert RS, Gonzalez GG, Hawel L 3rd, Byus CV. An ion-exchange chromatography procedure 
for the isolation and concentration of basic amino acids and polyamines from complex biological 
samples prior to high-performance liquid chromatography. Anal Biochem. 1991 Nov 
15;199(1):86-92. 
 
 
70. 
Wallick CJ, Gamper I, Thorne M, Feith DJ, Takasaki KY, Wilson SM, Seki JA, Pegg AE, Byus 
CV, Bachmann AS. Key role for p27Kip1, retinoblastoma protein Rb, and MYCN in polyamine 
inhibitor-induced G1 cell cycle arrest in MYCN-amplified human neuroblastoma cells. 
Oncogene. 2005 Aug 25;24(36):5606-18. 
 
71. 
Inoue H, Fukunaga K, Munemura S, Tsuruta Y. Simultaneous determination of free and N-
acetylated polyamines in urine by semimicro high-performance liquid chromatography using 4-
(5,6-dimethoxy-2-phthalimidinyl)-2-methoxyphenylsulfonyl chloride as a fluorescent labeling 
reagent. Anal Biochem. 2005 Apr 15;339(2):191-7. 
 
72. 
Schiavetti A, Varrasso G, Maurizi P, Cappelli C, Clerico A, Properzi E, Castello MA. Ten-day 
schedule oral etoposide therapy in advanced childhood malignancies J Pediatr Hematol Oncol. 
22(2):119-24, 2000. 
 
73. 
Kushner BH, Kramer K, Cheung NV, Oral Etoposide for Refractory and Relapsed 
Neuroblastoma, JCO, 17(10): 3221-3225, 1999. 
 
74. 
Koomoa DT, Borsics T, Feith DJ, Coleman CS, Wallick CJ, Gamper I, Pegg AE, Bachmann 
AS: Inhibition of S-adenosylmethionine decarboxylase by the competitive inhibitor SAM486A 
connects polyamine metabolism with p53-Mdm2-Akt/PKB regulation and apoptotic cell death 
in neuroblastoma, Molecular Cancer Therapeutics, 8(7): 2067-2075, 2009. 
 

Clinical Protocol NMTRC010B 
 
NMTRC 010B Version 2.1 Issued 28 April 2015             Confidential 
 Page 81 of 81 
75. 
Hogarty MD, Norris MD, Davis K, Liu X, Evageliou NF, Hayes CS, Pawel B, Guo R, Zhao H, 
Sekyere E, Keating J, Thomas W, Cheng NC, Murray J, Smith J, Sutton R, Venn N, London 
WB, Buxton A, Gilmour SK, Marshall GM, Haber M. ODC1 is a critical determinant of MYCN 
oncogenesis and a therapeutic target in neuroblastoma. Cancer Res. 2008 Dec 1;68(23):9735-45. 
 
76. 
Therasse P, Arbuck SG, Eisenhauer EA, Wanders J, Kaplan RS, Rubinstein L, Verweij J, Van 
Glabbeke M, van Oosterom AT, Christian MC, Gwyther SG. New guidelines to evaluate the 
response to treatment in solid tumors. European Organization for Research and Treatment of 
Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J 
Natl Cancer Inst. 2000 Feb 2;92(3):205-16. 
 
77. 
Haegele, K.D., et al., Decarboxylated-S-adenosylmethionine excretion: a biochemical marker of 
ornithine decarboxylase inhibition by alpha-difluoromethylornithine. Cancer Res, 1987. 47(3): p. 
890-5. 
 
78. 
Hixson, L.J., et al., Sources of variability in estimating ornithine decarboxylase activity and 
polyamine contents in human colorectal mucosa. Cancer Epidemiol Biomarkers Prev, 1994. 3(4): 
p. 317-23. 
 
79. 
Pasic TR, Heisey D, Love RR, alpha-difluoromethylornithine ototoxicity. Chemoprevention 
clinical trial results. Arch Otolaryngol Head Neck Surg. 1997 Dec;123(12):1281-6. 
 
80. 
Geerts D, Koster J, Albert D, Koomoa DL, Feith DJ, Pegg AE, Volckmann R, Caron H, Versteeg 
R, Bachmann AS. The polyamine metabolism genes ornithine decarboxylase and antizyme 2 
predict aggressive behavior in neuroblastomas with and without MYCN amplification. Int J 
Cancer. 2009 Dec 3. [Epub ahead of print]. PMID: 19960435 [PubMed - as supplied by 
publisher]. 
 
81. 
Santana E, Furman W, McGregor L, Billups C. Disease control intervals in high-risk 
neuroblastoma.  Cancer, 2008. 112 (12): 2796-2801. 
 
82. 
Yu, A. et al. Anti-GD2 Antibody with GM-CSF, Interleukin-2, and Isotretinoin for 
Neuroblastoma. New England Journal of Medicine, 2010. 363 (14): 1324-1334.