A Phase III Randomized Trial for Patients With De Novo AML Using Bortezomib and Sorafenib (NSC# 681239, NSC# 724772) for Patients With High Allelic Ratio FLT3/ITD
Phase: PHASE3
Conditions: Acute Myeloid Leukemia, Leukemia Cutis, Myeloid Neoplasm, Myeloid Sarcoma
Sponsor: National Cancer Institute (NCI)

 
 
 
AAML1031 
 
Version Date: 04/24/2017 
 
1 
Activated: 
06/20/11 
Version Date: 
04/24/2017 
Closed: 
      
Amendment: 
#8a 
 
 
 
 
 
 
CHILDREN’S ONCOLOGY GROUP 
 
AAML1031 
 
A Phase III Randomized Trial for Patients with de novo AML using Bortezomib 
and Sorafenib (IND#114480; NSC# 681239, NSC# 724772) for Patients with High Allelic Ratio 
FLT3/ITD 
 
IND Sponsor for Bortezomib and Sorafenib: NCI 
 
NCI Supplied Agents: Bortezomib and Sorafenib (IND#114480; NSC# 681239, NSC# 724772)  
 
A Groupwide Phase II/III Study 
 
 
THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, AND SHOULD NOT BE COPIED, REDISTRIBUTED OR USED FOR 
ANY OTHER PURPOSE. MEDICAL AND SCIENTIFIC INFORMATION CONTAINED WITHIN THIS PROTOCOL IS NOT 
INCLUDED TO AUTHORIZE OR FACILITATE THE PRACTICE OF MEDICINE BY ANY PERSON OR ENTITY. RESEARCH 
MEANS A SYSTEMATIC INVESTIGATION, INCLUDING RESEARCH DEVELOPMENT, TESTING AND EVALUATION, 
DESIGNED TO DEVELOP OR CONTRIBUTE TO GENERALIZABLE KNOWLEDGE. THIS PROTOCOL IS THE RESEARCH 
PLAN DEVELOPED BY THE CHILDREN’S ONCOLOGY GROUP TO INVESTIGATE A PARTICULAR STUDY QUESTION OR 
SET OF STUDY QUESTIONS AND SHOULD NOT BE USED TO DIRECT THE PRACTICE OF MEDICINE BY ANY PERSON OR 
TO PROVIDE INDIVIDUALIZED MEDICAL CARE, TREATMENT, OR ADVICE TO ANY PATIENT OR STUDY SUBJECT. THE 
PROCEDURES IN THIS PROTOCOL ARE INTENDED ONLY FOR USE BY CLINICAL ONCOLOGISTS IN CAREFULLY 
STRUCTURED SETTINGS, AND MAY NOT PROVE TO BE MORE EFFECTIVE THAN STANDARD TREATMENT. ANY PERSON 
WHO REQUIRES MEDICAL CARE IS URGED TO CONSULT WITH HIS OR HER PERSONAL PHYSICIAN OR TREATING PHYSICIAN 
OR VISIT THE NEAREST LOCAL HOSPITAL OR HEALTHCARE INSTITUTION. 
 
 
 
 
 
STUDY CHAIR 
Richard Aplenc, MD, PhD 
Children’s Hospital of Philadelphia 
Pediatric Oncology/Stem Cell Transplant 
4018 CTRB 
3501 Civic Center Blvd 
Philadelphia, PA 19104-4318 
Phone: (267) 426-7252 
Fax: 
(267) 425-0013 
E-mail: aplenc@email.chop.edu  
 
 
 

 
 
 
AAML1031 
 
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2 
TABLE OF CONTENTS  
 
SECTION 
PAGE 
STUDY COMMITTEE 
6 
ABSTRACT 
9 
EXPERIMENTAL DESIGN SCHEMA FOR PATIENTS ENROLLED BEFORE 
ACCRUAL GOALS FOR ARMS A AND B HAVE BEEN MET 
11 
EXPERIMENTAL DESIGN SCHEMA FOR PATIENTS ENROLLED AFTER ACCRUAL 
GOALS FOR ARMS A AND B HAVE BEEN MET 
12 
1.0 
GOALS AND OBJECTIVES 
13 
1.1 
Primary Objectives 
13 
1.2 
Secondary Objectives 
13 
2.0 
BACKGROUND 
15 
2.1 
Rationale for Study Design 
15 
2.2 
Rationale for Bortezomib Feasibility, Definitive Efficacy Testing, and 
Pharmacokinetic Studies 
16 
2.3 
Rationale for Sorafenib Feasibility Determination 
17 
2.4 
Rationale for Sorafenib Maintenance for HR FLT3/ITD+ AML Patients 
19 
2.5 
Health Related Quality of Life and Parental Stress 
21 
2.6  
Dexrazoxane Use in Pediatric AML 
22 
2.7 
Rationale for Changes in GVHD Prophylaxis and SCT Conditioning Regimen 
22 
2.8 
Biology Correlative Studies 
23 
3.0 
STUDY ENROLLMENT AND PATIENT ELIGIBILITY 
33 
3.1 
Study Enrollment 
33 
3.2 
Patient Eligibility Criteria 
35 
3.3 
Definitions 
37 
3.4 
Pre-Enrollment Baseline Diagnostic Requirements 
39 
4.0 
TREATMENT PLAN 
40 
4.1 
Overview of Treatment Plan 
40 
4.2 
Concomitant Therapy Restrictions 
42 
4.3 
Dose Modifications for CNS Disease 
43 
4.4 
Evaluation of Marrow Status and Extramedullary Disease 
44 
4.5 
End of Induction I 
44 
4.6 
Progression to Subsequent Courses of Therapy 
44 
4.7 
Requirements to Start Each Sorafenib + Chemotherapy Course 
45 
4.8 
Induction I Arm A (ADE 10+3+5) 
45 
4.9 
Induction I Arm B (ADE 10+3+5+ Bortezomib) 
48 
4.10 
Induction I Arm C-Cohort 3 (ADE 10+3+5+ Sorafenib) 
52 
4.11 
Induction I Arm D (ADE 10+3+5) 
55 
4.12 
Induction II Arm A (ADE 8+3+5) – Low Risk Patients 
58 
4.13 
Induction II Arm B (ADE 8+3+5 + Bortezomib) – Low Risk Patients 
61 
4.14 
Induction II Arm A (MA) – High Risk Patients 
65 
4.15 
Induction II Arm B (MA + Bortezomib) – High Risk Patients 
68 
4.16 
Induction II Arm C - Cohort 3 (ADE 8+3+5 + Sorafenib) 
71 
4.17 
Intensification I Arm A (AE) 
74 
4.18 
Intensification I Arm B (AE + Bortezomib) 
77 
4.19 
Intensification I Arm C-Cohort 3 (AE + Sorafenib) 
80 

 
 
 
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4.20 
Intensification II Arm A (MA) – Low Risk Patients 
83 
4.21 
Intensification II Arm B (MA + Bortezomib) – Low Risk Patients 
86 
4.22 
Intensification II Arm A & B (HD ARAC/LASP) – High Risk Patients 
89 
4.23 
Intensification II Arm C-Cohort 3 (MA + Sorafenib) 
92 
4.24 
Allogeneic Stem Cell Transplantation 
96 
4.25 
Alternative Donor SCT 
101 
4.26 
Maintenance Arm C (Sorafenib) 
103 
5.0 
DOSE MODIFICATIONS FOR TOXICITIES 
106 
5.1 
Allergy 
106 
5.2 
Cardiac Toxicity 
106 
5.3 
Coagulopathy 
108 
5.4 
Hepatic Toxicity 
108 
5.5 
Neurologic Toxicity 
109 
5.6 
Pancreatitis 
110 
5.7 
Pulmonary Toxicity 
110 
5.8 
Palmar-Plantar Erythrodysesthesia Syndrome, Skin Pain that impacts ADLs or 
Rash Maculo-Papular 
111 
5.9 
Renal Toxicity 
113 
5.10 
Thrombosis 
113 
5.11 
Dose Reduction for Other Bortezomib-Associated Toxicities 
113 
5.12  
Dose Reductions for Other Sorafenib-Associated Toxicities 
114 
5.13 
Stem Cell Transplant Regimen Agents 
116 
6.0 
DRUG INFORMATION 
116 
6.1 
ASPARAGINASE (E. coli)       (07/01/15) 
116 
6.2 
ASPARAGINASE (ERWINIA CHRYSANTHEMI) 
118 
6.3 
BORTEZOMIB 
120 
6.4 
BUSULFAN INJECTION 
127 
6.5 
CYTARABINE – ALL ROUTES 
128 
6.6 
DAUNORUBICIN 
131 
6.7 
ETOPOSIDE INJECTION 
132 
6.8 
FLUDARABINE 
134 
6.9 
LYMPHOCYTE IMMUNE GLOBULIN 
137 
6.10 
METHOTREXATE-IV ONLY 
139 
6.11 
METHYLPREDNISOLONE 
140 
6.12 
MITOXANTRONE 
142 
6.13 
SORAFENIB TOSYLATE 
143 
6.14 
TACROLIMUS 
153 
7.0 
EVALUATIONS/MATERIAL AND DATA TO BE ACCESSIONED 
156 
7.1 
Required Clinical, Laboratory and Disease Evaluations 
156 
7.2 
Recommended Clinical, Laboratory and Disease Evaluations 
157 
7.3 
Required & Optional Observations for SCT Patients Only 
157 
7.4 
Optional Studies 
158 
7.5 
Follow-up Studies* 
159 
7.6 
Follow-up Reports 
159 
8.0 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY 
CRITERIA 
160 
8.1 
Criteria for Removal from Protocol Therapy 
160 
8.2 
Off Study Criteria 
160 

 
 
 
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9.0 
STATISTICAL CONSIDERATIONS 
161 
9.1 
Patient Accrual and Expected Duration of Trial 
161 
9.2 
Statistical Analysis Methods 
161 
9.3 
Interim Monitoring 
170 
9.4 
Gender and Minority Accrual Estimates 
172 
10.0 
EVALUATION CRITERIA 
172 
10.1 
Common Terminology Criteria for Adverse Events (CTCAE) 
172 
10.2 
Response Criteria for Patients with Acute Myeloid Leukemia 
172 
10.3 
Graft Failure following Allogeneic SCT 
173 
11.0 
ADVERSE EVENT REPORTING REQUIREMENTS 
174 
11.1 
Purpose 
174 
11.2 
Determination of reporting requirements 
174 
11.3 
Expedited Reporting Requirements – Serious Adverse Events (SAEs) 
174 
11.4 
Special Situations for Expedited Reporting 
175 
11.5 
Reporting Requirements for Specialized AEs 
177 
11.6 
Exceptions to Expedited Reporting 
177 
11.7 
Reporting Requirements - Investigator Responsibility 
178 
11.8 
General Instructions for Expedited Reporting via CTEP-AERS 
178 
11.9 
Reporting Table for Late Phase 2 and Phase 3 Studies – Table A 
179 
11.10 
Protocol Specific Additional Instructions and Reporting Exceptions 
180 
11.11 
Reporting of Adverse Events for commercial agents – CTEP-AERS abbreviated 
pathway 
180 
11.12 
Routine Adverse Event Reporting 
181 
11.13  Definition of Onset and Resolution of Adverse Events 
181 
12.0 
RECORDS AND REPORTING 
182 
12.1 
CDUS 
182 
12.2 
Data and Safety Monitoring Committee 
182 
12.3 
CRADA/CTA 
182 
13.0 
PATHOLOGY GUIDELINES AND SPECIMEN REQUIREMENTS 
184 
13.1 
Immunophenotyping Studies 
184 
13.2 
Cytomorphologic Studies 
185 
14.0 
FLT3 MOLECULAR GENETIC ANALYSIS GUIDELINES AND 
REQUIREMENTS 
187 
14.1 
NIH-Funded Laboratory for Mutation Analysis at Diagnosis 
187 
14.2 
FLT3 Mutation Analysis 
187 
14.3 
Specimen Requirements 
187 
14.4 
Shipping 
187 
14.5 
Specimens Shipping Options 
188 
15.0 
MRD ANALYSIS GUIDELINES AND REQUIREMENTS 
188 
15.1 
NIH-Funded Laboratory for MRD Testing at Diagnosis 
188 
15.2 
MRD Analysis 
188 
15.3 
Specimen Requirements 
189 
15.4 
Shipping 
189 
16.0 
CYTOGENETIC ANALYSIS GUIDELINES AND REQUIREMENTS 
190 
16.1 
Cytogenetic Analysis Overview 
190 
16.2 
Specimen Collection and Submission 
190 
17.0 
SPECIAL STUDIES SPECIMEN REQUIREMENTS 
192 

 
 
 
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17.1  
Pharmacokinetic and Pharmacodynamic Studies 
192 
17.2 
Leukemia Biology Studies 
194 
18.0 
QUALITY OF LIFE AND PARENTAL STRESS ASSESSMENTS 
196 
18.1 
Time points for Assessment 
196 
18.2 
Health Related Quality Of Life (HRQOL) and Parental Stress Questionnaires 
197 
19.0 
RADIATION THERAPY GUIDELINES 
198 
19.1 
Indications for Radiation Therapy 
199 
19.2 
Timing 
199 
19.3 
Emergency Radiation Therapy 
199 
19.4 
Equipment and Methods of Delivery and Verification 
199 
19.5 
Target Volumes 
200 
19.6 
Target Dose 
200 
19.7 
Treatment Technique 
201 
19.8 
Organs at Risk 
202 
19.9 
Dose Calculations and Reporting 
202 
19.10 
Quality Assurance Documentation 
203 
20.0 
HEMATOPOIETIC TRANSPLANT GUIDELINES 
205 
20.1 
Pre-SCT Conditioning 
205 
20.2 
Admission Criteria (see Section 7.3) 
205 
20.3 
Bone Marrow Harvest, Processing, Dose and Infusion 
205 
20.4 
Supportive Care Guidelines 
206 
20.5 
COG Stem Cell Committee Consensus Guidelines for Establishing Organ Stage and 
Overall Grade of Acute Graft versus Host Disease (GVHD) 
206 
APPENDIX I:  SUPPORTIVE CARE GUIDELINES 
213 
APPENDIX II:  SORAFENIB DOSING NOMOGRAM 
217 
APPENDIX III: INSTRUCTIONS FOR CHEMOTHERAPY DRUG PREPARATION, 
ADMINISTRATION AND SAFE HANDLING 
218 
APPENDIX IV: LIST CYP3A4 SUBSTRATES, INDUCERS AND INHIBITORS 
220 
APPENDIX V: SAMPLE SUBMISSION FOR CYTOGENETIC/FISH STUDIES 
222 
APPENDIX VI: BLOOD PRESSURE LEVELS FOR CHILDREN BY AGE AND HEIGHT 
PERCENTILE 
225 
APPENDIX VII: LEUKEMIA BIOLOGY & GENE POLYMORPHISM STUDIES 
227 
APPENDIX VIII: LEUKEMIA INITIATING CELL (LIC) STUDY 
228 
APPENDIX IX: PROTEIN EXPRESSION (RPPA) AND UNFOLDED PROTEIN 
RESPONSE (UPR) STUDY 
230 
APPENDIX X: SORAFENIB PHARMACOKINETIC (PK) STUDY 
232 
APPENDIX XI: SORAFENIB PIA STUDY 
235 
APPENDIX XII: YOUTH INFORMATION SHEETS 
236 
APPENDIX XIII: BIOMARKERS FOR THE PREDICTION OF GVHD STUDY 
238 
APPENDIX XIV: CTEP AND CTSU REGISTRATION PROCEDURES 
240 
APPENDIX XV: POSSIBLE DRUG INTERACTIONS 
242 
REFERENCES 
248 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
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Version Date: 04/24/2017 
 
6 
 
STUDY COMMITTEE 
 
STUDY CHAIR 
STUDY COMMITTEE MEMBERS 
Richard Aplenc, MD, PhD 
Michael Joseph Absalon, MD, PhD 
Children’s Hospital of Philadelphia 
Hematology/Oncology 
Pediatric Oncology/Stem Cell Transplant 
Cincinnati Children's Hospital Medical Center 
4018 CTRB 
MLC 7015 
3501 Civic Center Blvd 
3333 Burnet Avenue 
Philadelphia, PA  19104-4318 
Cincinnati, OH  45229 
Phone: (267) 426-7252 
Phone: (513) 636-2061 
Fax: 
(267) 425-0113 
Fax: 
(513) 636-3549 
E-mail: aplenc@email.chop.edu  
E-mail: michael.absalon@cchmc.org  
 
 
STUDY VICE CHAIR 
Lamia P. Barakat, PhD 
Lillian Sung, MD, PhD 
Behavioral Science 
Hematology/Oncology 
Children’s Hospital of Philadelphia 
Hospital for Sick Children 
Div. of Oncology, Dept. of Pediatrics 
Pediatrics 
3400 Civic Center Blvd.  
555 University Avenue 
CHOP North, Room 1483 
Toronto ON M5G 1X8 
Philadelphia, PA  19104 
Canada 
Phone: (267) 426-8135 
Phone: (416) 813-5287 
E-mail: barakat@email.chop.edu  
Fax: 
(416) 813-5327 
 
E-mail: lillian.sung@sickkids.ca  
Lisa A. Bayer, CPNP 
 
Nursing 
STUDY VICE CHAIR 
Weill Medical College of Cornell University 
Soheil Meshinchi, MD, PhD 
Division of Pediatric Hematology/Oncology 
Hematology/Oncology 
525 E. 68th Street, 
Seattle Children's Hospital 
Payson Building #695 
Fred Hutchinson Cancer Research Ctr. 
New York, NY  10065 
Clinical Research Division 
Phone: (212) 746-3400 
1100 Fairview Avenue North, D5-380 
Fax: 
(212) 746-8609 
Seattle, WA  98109-1024 
E-mail: lbayer@med.cornell.edu  
Phone: (206) 667-4077 
 
Fax: 
(206) 667-4310 
Patrick A. Brown, MD 
E-mail: smeshinc@fhcrc.org 
Hematology/Oncology 
 
Johns Hopkins University/Sidney Kimmel Cancer Center 
STUDY STATISTICIAN 
Pediatric Oncology 
Todd Alonzo, PhD 
1650 Orleans St. CRB 2M49 
Statistics 
Baltimore, MD  21231 
222 E. Huntington Dr, Suite 100 
Phone: (410) 614-4915 
Monrovia, CA 91016 
Fax: 
(410) 955-8897 
Phone: (626) 241-1522 
E-mail: pbrown2@jhmi.edu  
Fax: 
(626) 445-4334 
 
E-mail: talonzo@childrensoncologygroup.org 
John Kim Choi, MD, PhD 
 
Pathology 
STUDY COMMITTEE MEMBERS 
St. Jude Children’s Research Hospital 
Alan S. Gamis, MD, MPH 
Pathology  
Hematology/Oncology 
262 Danny Thomas Place, Mail Stop 250 
Children’s Mercy Hospitals & Clinics 
Memphis, TN 38105 
Department Hematology-Oncology 
Phone: (901) 595-5347 
2401 Gillham Road 
Fax: 
(901) 595-3100 
Kansas City, MO  64108 
E-mail: JohnKim.Choi@stjude.org 
Phone: (816) 302-6808 
 
Fax: 
(816) 855-1700 
 
E-mail: agamis@cmh.edu 
 

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Terzah M. Horton, MD, PhD 
Rajaram Nagarajan, MD 
Hematology/Oncology 
Hematology/Oncology 
Baylor College of Medicine 
Cincinnati Children's Hospital Medical Center 
Pediatrics 
Division of Hematology/Oncology 
1102 Bates Avenue, Suite 750  
3333 Burnet Avenue 
Houston, TX  77030 
MLC 7015; TCHRF 2092 
Phone: (832) 824-4269 
Cincinnati, OH  45229 
Fax: 
(832) 824-1206 
Phone: (513) 636-1248 
E-mail: tmhorton@txch.org 
Fax: 
(513) 636-3549 
 
E-mail: rajaram.nagarajan@cchmc.org  
Samir B. Kahwash, MD 
 
Pathology 
Susana C. Raimondi, PhD 
Nationwide Children's Hospital 
Cytogenetics 
Division of Laboratory Medicine 
St. Jude Children's Research Hospital 
700 Children's Dr 
Pathology 
Columbus, OH  43205 
262 Danny Thomas Place, MS 250 
Phone: (614) 722-5450 
Memphis, TN  38105-3678 
Fax: 
(614) 722-5308 
Phone: (901) 595-3537  
E-mail: Samir.Kahwash@nationwidechildrens.org  
Fax: 
(901) 595-3100 
 
E-mail: susana.raimondi@stjude.org  
John E. Levine, MD 
 
Stem Cell Transplantation 
Betsy Hirsch, PhD 
Mount Sinai Medical Center 
Cytogenetics 
Pediatric Hematology/Oncology/BMT 
University of Minnesota/Masonic Cancer Center 
Blood and Marrow Transplantation Program 
Division of Laboratory Medicine 
1 Gustave L. Levy Place, Box 1410 
420 Delaware St., SE 
New York, NY 10029 
MMC Box 609 
Phone: (212) 241-3429 
Minneapolis MN 55455 
Fax: 
(212) 659-5599 
Phone: (612) 273-4952 
E-mail: jelevine@mssm.edu  
Fax: 
(612) 273-4689 
 
E-mail: hirsc003@umn.edu  
Jessica A. Pollard, MD 
 
Hematology/Oncology 
Laura Louise Winter, PharmD 
Maine Children’s Cancer Program 
Pharmacy 
100 Campus Drive 
Seattle Children's Hospital 
Scarborough, ME  04074 
Pediatric Hematology/Oncology 
Phone:  (207) 396-7565 
4800 Sand Point Way NE 
Email:  jpollard@mmc.org 
MB.5.420 
 
Seattle, WA  98105-0371 
Thomas Merchant, DO, PhD 
Phone: (206) 987-2106 
Radiation Oncology 
Fax: 
(206) 729-3062 
St. Jude Children's Research Hospital 
E-mail: laura.winter@seattlechildrens.org 
Radiological Sciences  
 
262 Danny Thomas Place, MS 210 
Andrew Christopher Harris, MD  
Memphis TN 38105-3678 
Stem Cell Transplantation 
Phone: (901) 595-3604 
Primary Children's Hospital 
Fax: 
(901) 595-3113 
Pediatric Hematology/Oncology 
E-mail: thomas.merchant@stjude.org 
100 N. Mario Capecchi Drive, Suite 4100 
 
Salt Lake City, UT 84113 
 
Phone:  (801) 662-4700 
 
Fax:  (801) 662-4707 
 
Email:  andrew.harris@hsc.utah.edu 
 
 
 
 
 
 

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8 
STUDY COMMITTEE MEMBERS 
STUDY COMMITTEE MEMBERS 
Brian T. Fisher, DO, MSCE 
Jennifer Truong, MD MPH  
Epidemiology 
Clinical Research Associate 
Children’s Hospital of Philadelphia 
Floating Hospital for Children at Tufts Medical Center 
Pediatrics, Division of Infectious Diseases 
Pediatric Hem/Onc 
34th Street and Civic Center Boulevard 
800 Washington Street, Box 245 
CHOP North Room 1515 
Boston, MA 02111 
Philadelphia, PA  19104 
Phone: (617) 636-8885 
Phone:   (267) 426-7110 
Fax: (617) 636-8886 
Fax:  
 (215) 590-2017 
Email: jtruong@tuftsmedicalcenter.org 
Email:  fisherbria@email.chop.edu 
 
 
COG PROTOCOL COORDINATOR 
Michael G. Douvas, MD 
Jeannette Cassar 
Hematology/Oncology 
Children’s Oncology Group- Operations Center 
University of Virginia Cancer Center 
Study Development Office 
Internal Medicine 
222 E. Huntington Dr, Suite 100 
P.O. BOX 800716 
Monrovia, CA 91016  
Charlottesville, VA  22908-0716 
Phone: (626) 241-1532 
Phone:  434 982-6399 
Fax: 
(626) 445-4334 
Fax:  
434 243-6086 
E-mail: jcassar@childrensoncologygroup.org 
Email:  mgd9a@virginia.edu 
 
 
COG RESEARCH COORDINATOR 
Elizabeth Fox, MD  
Wendy Lee, LVN 
Hematology/Oncology 
Children’s Oncology Group 
Children's Hospital of Philadelphia 
Statistics and Data Center 
Pediatrics/Division of Oncology 
222 E. Huntington Dr, Suite 100 
3501 Civic Center Blvd. CTRB-4016 
Monrovia, CA 91016 
Philadelphia, PA 19104 
Phone : (626) 241-1762 
Phone:   (267) 425-3010 
Fax:      (626) 445-4334 
Fax:  
 (267) 425-0113 
Email: wlee@childrensoncologygroup.org 
Email:  foxe@email.chop.edu 
 
 
 
Gabriela Gheorghe, MD 
AGENT                                      NSC#                    IND# 
Pathology 
 
Midwest children’s Cancer Center 
Bortezomib (supplied by NCI)    NSC# 681239      IND# 114480 
CHW Department of Pathology 
Sorafenib  (supplied by NCI)      NSC#724772       IND# 114480 
9000 West Wisconsin Avenue  
 
Milwaukee, WI  53226 
Busulfan                                       NSC#750  
   Exempt 
Phone:   (414) 266-2530 
Cytarabine  
NSC#063878 
Exempt 
Fax:  
 (414) 266-2779 
Daunorubicin 
NSC#82151 
Exempt 
Email :  ggheorghe@mcw.edu 
Etoposide  
                     NSC#141540 
   Exempt 
 
Fludarabine  
NSC#312887 
Exempt 
 
L‘Asparaginase (E. Coli) 
NSC#109229 
Exempt 
 
L‘Asparaginase (Erwinia) 
NSC# 106977 
Exempt 
 
Lymphocyte Immune Globulin NSC#743145 
Exempt 
 
Methotrexate  
NSC#000740 
Exempt 
 
Methylprednisolone 
NSC#19987 
Exempt 
 
Mitoxantrone  
NSC#301739 
Exempt 
 
Tacrolimus  
NSC#717865 
Exempt 
 
 
 
IND Sponsor: NCI 
 
 
 
 
 
 
 
SEE SECTIONS 13-16 AND APPENDICES VII-XVII FOR SPECIMEN SHIPPING ADDRESSES. 
 
 

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9 
The Children's Oncology Group has received a Certificate of Confidentiality from the federal government, which will help us protect the privacy 
of our research subjects. The Certificate protects against the involuntary release of information about your subjects collected during the course of 
our covered studies. The researchers involved in the studies cannot be forced to disclose the identity or any information collected in the study in 
any legal proceedings at the federal, state, or local level, regardless of whether they are criminal, administrative, or legislative proceedings. 
However, the subject or the researcher may choose to voluntarily disclose the protected information under certain circumstances. For example, if 
the subject or his/her guardian requests the release of information in writing, the Certificate does not protect against that voluntary disclosure. 
Furthermore, federal agencies may review our records under limited circumstances, such as a DHHS request for information for an audit or program 
evaluation or an FDA request under the Food, Drug and Cosmetics Act. The Certificate of Confidentiality will not protect against mandatory 
disclosure by the researchers of information on suspected child abuse, reportable communicable diseases, and/or possible threat of harm to self or 
others. 
 
ABSTRACT 
Disease recurrence and treatment related toxicities still account for approximately 40% of deaths in 
pediatric patients with de novo Acute Myeloid Leukemia (AML) despite substantial progress made with 
various treatment modalities. Thus, the incorporation of new approaches to standard AML therapy that will 
further improve the overall outcome of patients with de novo AML by testing clinically relevant hypotheses 
that enhance better understanding of AML blast biology, more accurate patient risk stratification, and more 
effective supportive care practices is a high priority. Bortezomib, a proteasome inhibitor has been shown to 
selectively deplete the leukemic stem cells that are a source of resistance for AML. Despite limited pediatric 
data, adult and in vitro studies demonstrate that bortezomib can be safely combined with standard AML 
chemotherapy (without high dose cytarabine arabinoside), augmenting their anti-leukemic effects. Fms-like 
tyrosine kinase 3 (FLT3) which is an AML oncogene that plays a significant role in AML pathogenesis is 
a target of the multi-target tyrosine kinase inhibitor, sorafenib. Sorafenib has shown encouraging results 
with its use as a single agent in adults with relapsed FLT3 positive internal tandem duplication 
(FLT3/ITD+) AML. Despite limited pediatric experience of sorafenib in combination with AML 
chemotherapy, it has been safely combined with AML chemotherapy in younger adults with AML. This 
clinical trial seeks to determine the role of bortezomib in upfront therapy for pediatric AML, and to 
determine the safety of sorafenib in the treatment of patients with high allelic ratio FLT3/ITD+ (HR 
FLT3/ITD+) AML. In addition, bortezomib and sorafenib pharmacokinetic studies will be performed on a 
subset of patients. Bortezomib evaluation involved random allocation to treatment with standard pediatric 
AML therapy only (Arm A), or standard AML therapy with bortezomib (Arm B). With Amendment #7A, 
Arms A and B are closed to new patient enrollment as accrual goals have been met. Patients enrolled prior 
to Amendment #7A will continue treatment per their initially assigned arm. Arms A and B of AAML1031 
utilize a 3 or 4 course chemotherapy backbone. Patients with low risk disease receive 
cytarabine/daunorubicin/etoposide (ADE 10+3+5), cytarabine/daunorubicin/etoposide (ADE 8+3+5), 
cytarabine/etoposide (AE), and cytarabine/mitoxantrone (ARAC/Mitox). Patients with high risk disease 
receive 
3 
courses 
of 
chemotherapy: 
cytarabine/daunorubicin/etoposide 
(ADE 
10+3+5), 
cytarabine/mitoxantrone (ARAC/Mitox), and cytarabine/etoposide (AE), prior to best allogenic donor stem 
cell transplant (SCT). High risk patients without an appropriate allogenic donor will receive high dose 
cytarabine/L-asparaginase (HD ARAC/LASP) as a fourth chemotherapy course. Sorafenib evaluation will 
occur in three cohorts. Cohort 1-Arm C has determined a tolerable sorafenib dose in combination with 
standard AML chemotherapy in patients with HR FLT3/ITD+ mutations. With Amendment #3A, patients 
with HR FLT3/ITD+ will be allocated to sorafenib plus standard chemotherapy for additional feasibility 
and efficacy determination (Cohorts 2 and 3-Arm C) and offered an additional sorafenib maintenance phase. 
Cohort 2 patients received concomitant sorafenib and conventional chemotherapy whereas with Cohort 3 
(Amendment #6A) the dosing schedule of sorafenib during Induction II, Intensification I and Intensification 
II was changed given concerns of cardiac toxicity. With Amendment #6A, sorafenib was started after 
completion of conventional chemotherapy. With Amendment #7A, patients with known HR FLT3/ITD+ 
AML prior to study entry will be enrolled directly onto Arm C and receive three courses of chemotherapy 
in 
combination 
with 
sorafenib: 
cytarabine/daunorubicin/etoposide 
(ADE 
10+3+5), 
cytarabine/daunorubicin/etoposide (ADE 8+3+5), cytarabine/etoposide (AE), followed by best allogenic 
donor SCT. Patients with HR FLT3/ITD+ who do not have an appropriate allogenic donor will receive 
sorafenib with ARAC/Mitoxantrone as a fourth course of chemotherapy. Patients with unknown FLT/ITD 

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10 
allelic ratio prior to study entry will first enroll onto Arm D (standard pediatric AML Induction 
chemotherapy) until FLT/ITD results are determined. Patients found to have HR FLT/ITD+ will be treated 
per Arm C; patients without HR FLT/ITD+ will be removed from study. Risk stratification of patients in 
AAML1031 will utilize cytogenetics, molecular markers and multidimensional flow cytometry to allocate 
patients into high risk (HR) and low risk (LR) groups. This study will assess health related quality of life 
(HRQOL) and parental stress at multiple time points during and after therapy, for longitudinal assessment 
of QOL and parental stress. AAML1031 will also incorporate correlative studies aimed at contributing to 
the enhancement of future AML treatment parameters and assessment. These correlative studies include 
evaluation of the in vitro levels of wild type FLT3 in response to sorafenib, analyzing chromosomal 
abnormalities, complex karyotypes; molecular abnormalities of WT1, RUNX1, MLL-PTD and other novel 
AML associated genes, leukemic involvement of early progenitor cells, and GVHD biomarkers. 
 

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11 
 
EXPERIMENTAL DESIGN SCHEMA FOR PATIENTS ENROLLED BEFORE ACCRUAL 
GOALS FOR ARMS A AND B HAVE BEEN MET 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Risk Classification: Based on cytogenetics, molecular markers and MRD post-Induction I. See Section 3.3 for 
definitions.  
 
**Remission Assessment: Patients with ≥ 5% blasts or EMD will be off protocol therapy. 
 
# Consolidation Assignment 
- High risk patients receive SCT based on availability of appropriate donor. 
- Low risk patients receive chemotherapy only (based on initial treatment arm randomized to), without SCT. 
^Includes high-risk patients on both Arm A and Arm B. 
 
High allelic ratio FLT3/ITD+ patients 
- If appropriate donor available (MFD or MUD), patients receive best allogenic donor SCT regardless of 
cytogenetic risk group followed by maintenance sorafenib. 
- If no appropriate donor is available, patients receive a fourth course of chemotherapy followed by maintenance 
sorafenib, regardless of cytogenetic risk group  
 ## Sorafenib to be given in Induction I (after FLT3/ITD status is known) for Cohorts 2 and 3.  
Note: Patients enrolled prior to Amendment #3A activation and currently on therapy may move to Arm C prior 
to their next treatment course. Patients enrolled during suspension of Arm C may move to Arm C prior to their 
next treatment course as part of amendment 6a. 
 
See Section 18.0 for optional Quality of Life and Parental Stress Study. 
  
ADE = Cytarabine, Daunorubicin, Etoposide             ITD = Internal tandem duplication  
EMD = Extramedullary disease                                  AE = Cytarabine, Etoposide 
 
MFD = Matched family donor  
 
             SCT = Stem Cell Transplant 
ARAC/Mitox = Cytarabine, Mitoxantrone 
             MUD = Matched unrelated donor 
Intensification II 
ARAC/Mitox 
Best  
Allo SCT 
Best 
Allo 
SCT 
Any Donor 
No Donor 
Arm A 
Low Risk 
Intensification II 
ARAC/Mitox + 
Bortezomib 
Arm B 
Low Risk 
High Risk^  
+ Any Donor 
High Risk^ 
+ No Donor 
Intensification II 
HD ARAC 
Intensification II 
ARAC/Mitox 
+ 
Sorafenib 
Maintenance 
(Sorafenib) 
Intensification I 
AE 
Sorafenib 
Consolidation Assignment# 
OFF 
PROTOCOL 
THERAPY 
Arm A 
High & Low Risk 
Arm B 
High & Low Risk 
Intensification I 
AE  
Intensification I 
AE  
Bortezomib 
Consolidation Assignment# 
Remission Assessment** 
Induction II 
ADE 8+3+5 
Sorafenib 
≥ 5% blasts or 
EMD 
De novo AML 
Induction I 
ADE 10+3+5 
Bortezomib 
Risk Classification* 
Randomizatio
Induction I 
ADE 10+3+5 
Induction I## 
ADE 10+3+5 
Sorafenib 
Cohort 1 
Cohorts 2 and 3 
A 
B 
C 
High allelic ratio 
FLT3/ITD+ 
Arm A  
High Risk 
Arm B 
Low Risk 
Arm B  
High Risk 
Arm A 
Low Risk 
Induction II 
ADE 8+3+5 
Induction II 
ARAC/Mitox 
Induction II 
ADE 8+3+5 
Bortezomib
Induction II 
ARAC/Mitox + 
Bortezomib
Remission Assessment** 
Version Date: 02/04/16 

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12 
 
EXPERIMENTAL DESIGN SCHEMA FOR PATIENTS ENROLLED AFTER ACCRUAL 
GOALS FOR ARMS A AND B HAVE BEEN MET 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
≥ 5% blasts or 
EMD 
OFF 
PROTOCOL 
THERAPY 
Remission Assessment** 
Intensification I 
AE 
Sorafenib 
Consolidation Assignment# 
Any Donor 
No Donor 
Intensification II 
ARAC/Mitox 
+ 
Sorafenib 
Best Allo 
SCT 
Maintenance 
(Sorafenib) 
De novo AML 
D 
Unknown 
Induction I 
ADE 10+3+5 
High allelic ratio 
FLT3/ITD+ 
C 
Induction I## 
ADE 10+3+5 
Sorafenib
Induction II 
ADE 8+3+5 
Sorafenib 
High allelic 
ratio 
FLT3/ITD+ 
No high allelic ratio 
FLT3/ITD+  
(Or unknown FLT3/ITD 
status at End of Induction I) 
OFF STUDY 
Consent to 
Arm C 
treatment 
Decline 
Consent to 
Arm C 
treatment
 
**Remission Assessment: Patients with ≥ 5% blasts or EMD will be off protocol therapy. 
 
# Consolidation Assignment 
- High risk patients receive SCT based on availability of appropriate donor. 
- Low risk patients receive chemotherapy only, without SCT. 
 
High allelic ratio FLT3/ITD+ patients 
- If appropriate donor available (MFD or MUD), patients receive best allogenic donor SCT regardless of cytogenetic risk group followed by maintenance 
sorafenib. 
- If no appropriate donor is available, patients receive a fourth course of chemotherapy followed by maintenance sorafenib, regardless of cytogenetic risk group  
 ## Sorafenib to be given in Induction I (as soon as FLT3/ITD status is known).  
 
ADE = Cytarabine, Daunorubicin, Etoposide 
ITD = Internal tandem duplication 
EMD = Extramedullary disease  
 
AE = Cytarabine, Etoposide 
MFD = Matched family donor  
 
  
SCT = Stem Cell Transplant 
ARAC/Mitox = Cytarabine, Mitoxantrone 
 
MUD = Matched unrelated donor. 

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13 
 
 
1.0 
GOALS AND OBJECTIVES 
With Amendment #7A accrual goals for Arms A and B will have been met and there will be a sufficient 
number of patients enrolled in order to meet the following protocol objectives: 
 
Primary Objectives: 1.1.1, 1.1.2, 1.1.3 
Secondary Objectives: 1.2.2 - 1.2.6, 1.2.14 
 
1.1 
Primary Objectives 
 
1.1.1 
To compare event free survival (EFS) and overall survival (OS) in patients with de novo acute myeloid 
leukemia (AML) without high allelic ratio FLT3/ITD+ mutations who are randomized to standard therapy 
versus bortezomib/standard combination therapy. 
 
1.1.2 
To determine the feasibility of combining bortezomib with standard chemotherapy in patients with de novo 
AML. 
 
1.1.3 
To compare the OS and EFS of high risk patients treated with intensive Induction II with historical controls 
from AAML03P1 and AAML0531.  
 
1.1.4 
To determine the feasibility of administering sorafenib with standard chemotherapy and in a one year 
maintenance phase in patients with de novo high allelic ratio FLT3/ITD+ AML. 
 
1.2 
Secondary Objectives 
 
1.2.1  
To assess the anti-leukemic activity of sorafenib in patients with de novo high allelic ratio FLT3/ITD+ AML. 
 
1.2.2 
To compare the percentage of patients converting from positive MRD to negative MRD after Intensive 
Induction II with historical controls from AAML03P1 and AAML0531. 
 
1.2.3 
To compare OS, disease free survival (DFS), cumulative incidence of relapse, and treatment related mortality 
from end of Intensification I between patients allocated to best allogenic donor stem cell transplant (SCT) and 
comparable patients on AAML0531 who did not receive allogenic donor SCT. 
 
1.2.4  
To compare OS, DFS, cumulative incidence of relapse, treatment related mortality, and severe toxicity between 
patients allocated to matched family donor SCT on AAML1031 and AAML0531.  
 
1.2.5 
To assess the health-related quality of life (HRQOL) of patients treated with chemotherapy and stem cell 
transplant (SCT) for AML. 
 
1.2.6 
To evaluate bortezomib pharmacokinetics (PK) in patients receiving the combination regimen. 

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1.2.7 
To obtain sorafenib and metabolite steady state pharmacokinetics and pharmacokinetic-pharmacodynamic 
data in subjects with FLT3/ITD receiving sorafenib.  
 
1.2.8 
To compare the changes in shortening fraction/ejection fraction over time between patients treated with and 
without dexrazoxane. 
 
1.2.9 
To refine the use of minimal residual disease (MRD) detection with 4-color flow cytometry. 
 
 
1.2.10 
To evaluate the prognostic significance of molecular MRD and its contribution to risk identification with 
MDF-based MRD in patients with translocations amenable to quantitative RT-PCR (e.g., t (8;21), inv (16), 
t(9;11), WT1 expression). 
 
1.2.11 
To determine the leukemic involvement of the hematopoietic early progenitor cell and its role in defining 
response to therapy. 
 
1.2.12 
To define the leukemic stem cell population in patients with AML. 
 
 
1.2.13 
To determine the prevalence and prognostic significance of molecular abnormalities of WT1, RUNX1, MLL-
PTD, TET2, c-CBL, KIT and other novel AML associated genes in pediatric AML. 
 
1.2.14 
Correlate the expression of CD74 antigen as well as PSMB5 gene expression and mutation with response 
to bortezomib. 
 
1.2.15 
To evaluate the changes in protein expression and unfolded protein response (UPR) in patients with AML. 
 
1.2.16 
Determine the expression level of wild type FLT3, and correlate with outcome and in vitro sensitivity to 
FLT3 inhibition.  
 
1.2.17 
To collect biology specimens at diagnosis, treatment time points, and relapse for future biology studies. 
 
1.2.18 
To create a pediatric-specific algorithm to predict the occurrence of Grade 2-4 acute graft-versus-host 
disease (GVHD) prior to its clinical manifestations using a combination of pre-transplant clinical variables 
and serum GVHD biomarker concentrations in the first weeks after SCT. 
 
 
 

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15 
2.0 
BACKGROUND 
 
Despite substantial progress in the treatment of pediatric AML, approximately 40% of patients die from 
disease recurrence or treatment related toxicities.10 Further improvements in AML treatment response will 
require not only new, targeted therapies, but also an improved understanding of AML blast biology, more 
accurate patient risk stratification, and more effective supportive care practices. The AAML1031 protocol 
seeks to improve the overall outcome of patients with de novo AML by testing clinically relevant 
hypotheses in all of these areas.  
 
2.1 
Rationale for Study Design 
This 
trial 
(AAML1031) 
will 
use 
a 
4 
course 
standard 
therapy 
backbone 
of 
cytarabine/daunorubicin/etoposide (ADE 10+3+5), cytarabine/daunorubicin/etoposide (ADE 8+3+5), 
cytarabine/etoposide (AE), and cytarabine/mitoxantrone (ARAC/Mitox) for patients with low risk AML. 
These courses correspond to the first 4 courses of AAML0531. The final course of AAML0531, high dose 
cytarabine (HD ARAC), has been deleted from the therapy for low risk patients for 2 reasons. First, the 
available data from the MRC 12 pediatric trial that randomized patients to 4 versus 5 courses of therapy 
showed no benefit of a fifth course. Specifically, patients randomized to 4 courses had an overall survival 
(OS) of 81% while patient randomized to 5 courses had an OS of 80%.11 (Personal Communication, Gibson 
B 2008) Secondly, both the AAML03P1 and AAML0531 trials have had a 10% - 18% withdrawal rate for 
toxicity after Intensification II (Personal Communication, Alonzo TA 2009). The reported toxicities are 
primarily delayed count recovery with an attendant increase in infectious complication risk. Currently, 
patients removed from therapy after Intensification II do not have a decreased event free survival (EFS) or 
OS on either AAML03P1 or AAML0531 (Personal Communication, Alonzo TA 2009). Thus, the available 
data indicate that the fifth course (Intensification III) of therapy likely provides no additional benefit but 
increases toxicity risk.  
 
This trial will use an intensified Induction II regimen of cytarabine/mitoxantrone (ARAC/Mitox) for 
patients with high risk AML, while low risk patients will receive an Induction II regimen of 
cytarabine/daunorubicin/etoposide (ADE 10+3+5). For the high risk patients with persistent marrow 
disease (> 15%) after Induction I, recently released AAML0531 data shows that using ADE 8+3+5 during 
Induction II resulted in only a 36 - 40% CR rate (using either a flow-based or morphologic CR respectively) 
(personal communication, A Gamis, MD, 2010). As well, data from AAML03P1 demonstrate that patients 
with high risk AML have a very poor DFS. Specifically, using the same risk stratification that will be used 
in AAML1031, DFS at 3 years from Induction I was 68 ± 9% vs. 20 ± 16% for the low risk and high risk 
patients (p < 0.001), respectively.12 While the benefit of intensifying Induction therapy further remains 
debated, the poor outcome of high risk patients justifies evaluation of alternative chemotherapy strategies. 
COG’s extensive experience with ARAC/Mitox early in the relapsed setting (CCG-2951 and COG 
AAML00P2) indicates that intensifying Induction with ARAC/Mitox likely will be tolerated and may 
benefit patients. 
 
Patients with HR FLT3/ITD+ allocated to the sorafenib treatment arm will receive the first 3 courses of low 
risk 
therapy 
backbone 
followed 
by 
best 
allogenic 
donor 
SCT. 
These 
courses 
are: 
cytarabine/daunorubicin/etoposide (ADE 10+3+5), cytarabine/daunorubicin/etoposide (ADE 8+3+5), and 
cytarabine/etoposide (AE). Patients with HR FLT3/ITD+ without an appropriate allogenic donor will 
receive sorafenib in combination with ARAC/Mitox as a fourth course of chemotherapy. Patients allocated 
to the sorafenib treatment arm will not receive intensified Induction with ARAC/Mitox as the baseline rate 
of expected toxicities is not known for the intensified Induction regimen. The absence of baseline toxicity 
data substantively hinders assessment of sorafenib feasibility, which is the primary aim of the sorafenib 
treatment arm. 
 

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16 
When Arms A and B were open (NOTE: As of Amendment #7A accrual goals for Arms A and B have been 
met. No additional patients will be enrolled on Arms A or B of AAML1031), this study will use 
cytogenetics, molecular markers, and multidimensional flow cytometry to risk stratify patients into high 
risk (HR) and low risk (LR) groups to allocate patients to 1 of 3 treatment groups at diagnosis at the end of 
Induction I. Prior studies have demonstrated that FLT3 positive internal tandem duplication (FLT3/ITD+), 
particularly high allelic ratio (HR FLT3/ITD+), is an independent predictor of poor outcome. Likewise, 
pediatric and adult data have shown core binding factor AML, CEBPα mutations, and nucleophosmin 
(NPM) mutations as robust markers of good prognosis. Finally, recent work by Dr. Meshinchi has shown 
that minimal residual disease (MRD) may be used to identify high and low risk groups in patients with 
standard risk cytogenetic features. (Personal Communication, Meshinchi S 2009) Thus, the risk 
stratification procedure on this study will incorporate all of these factors. The data supporting MRD use are 
presented in the Biology Background (Section 2.7.1) below.  
 
2.2 
Rationale for Bortezomib Feasibility, Definitive Efficacy Testing, and Pharmacokinetic 
Studies 
Despite very intensive therapies, patients with AML still fare relatively poorly in comparison to many other 
pediatric cancers. Given the high intensity of AML therapy, the augmentation of chemotherapy with 
biologic agents will likely be necessary for further improvements in AML outcome. Bortezomib is a 
proteasome inhibitor that has single agent efficacy in the treatment of multiple myeloma13 and is currently 
under study in multiple bortezomib/chemotherapy combinations for patients with several malignancies. 
Bortezomib has been shown to selectively deplete the proposed AML leukemia stem cell population, a 
proposed source of resistance for AML, and may augment the anti-leukemic effect of standard 
chemotherapy.14 Adult trials have demonstrated that bortezomib may be safely combined with AML 
chemotherapy, although concerns exist about rare cases of acute respiratory distress syndrome (ARDS) in 
combination with HD AraC.15-18 Data from the ongoing CALGB10502 Phase I/II trial of bortezomib in 
older adults provides additional recent data demonstrating that bortezomib can be safely combined with 
standard AML chemotherapy (Personal Communication, Attar EC 2010). The CALGB trial enrolled 
98 patients, of whom 95 received bortezomib and 75 have complete Induction data. The trial defined the 
maximum tolerated dose (MTD) as 1.3 mg/m2, and did not observe idiosyncratic adult respiratory distress 
syndrome, although patients with pre-existing cardiac and pulmonary dysfunction were excluded from the 
study. Patients with greater or equal to Grade 2 peripheral neuropathy were also excluded. However, 
7 patients experienced Grade 3 or greater peripheral neuropathy with most toxicities resolving over time. 
In addition, 4 patients experienced autonomic neuropathy with orthostatic hypotension requiring IV fluids. 
Three of 4 patients have had a resolution of this toxicity, and 1 patient continues with unresolved symptoms. 
Remission Induction was achieved in 14 of the first 25 patients in Stage 1, and at least 25 of the 70 patients 
enrolled in Stage 2. Overall and event-free survival data are not yet available. The trial continues for those 
in complete remission (CR) and combines bortezomib on Days 1, 4, 8, and 11 during 2 courses with high 
dose cytarabine, 2 gm/m2 on Days 1 - 5. Data from this portion of the trial is pending. 
 
As of July 24, 2010, 20 evaluable patients have been treated on the ongoing COG protocol AAML07P1 
that combines bortezomib with standard AML chemotherapy. Of these, 14 evaluable patients have enrolled 
on Arm A of AAML07P1; interim analysis of Arm A efficacy data demonstrated that only 4 of 14 patients 
attained a CR or complete remission with partial recovery of platelet count (CRp). While an additional 4 
patients experienced a complete remission with incomplete blood count recovery (CRi) and 2 a partial 
response (PR), the study objectives were to assess only CR and CRp, and thus, Arm A has been closed to 
further accrual (Personal Communication, Alonzo TA 2010). Arm B is nearing completion of dose finding 
without seeing an episode of ARDS in the patients treated at a bortezomib dose of 1.3 mg/m2. Thus, while 
the available data on bortezomib in pediatric AML is limited, the in vitro and adult data demonstrate that 
bortezomib may be combined safely with AML chemotherapy and that bortezomib has potential for 
augmenting the efficacy of standard AML therapy.  
 

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Although the MTD of bortezomib both as a single agent and in combination with standard ALL induction 
therapy has been defined,19-21 very limited data exist on bortezomib pharmacokinetics. Specifically, of 
37 patients enrolled on these three trials, PK data are available on 5 patients treated with single agent 
bortezomib on the Phase I trial in refractory leukemia.20 Of these, only three patients were treated at the 
1.3 mg/m2 dose level. Thus, additional data are clearly needed to determine the pharmacokinetic properties 
of bortezomib.  
 
2.3 
Rationale for Sorafenib Feasibility Determination 
Sorafenib is a multi-target tyrosine kinase (TKI) inhibitor that targets FLT3, c-KIT, PDGF, VEGF, and the 
RAF/MEK/ERK pathway and is currently approved for the treatment of renal cell carcinoma.22 The current 
approved adult dose is 400 mg twice daily, and the ADVL0413 pediatric Phase I study has defined the 
MTD in solid tumor patients at 200 mg/m2 twice daily continuous exposure with dose-limiting toxicities 
(DLT) of hypertension and hand-foot syndrome. Children with refractory leukemias do not tolerate the 
solid tumor MTD, and therefore the recommended dose is 150 mg/m2/dose for this patient population. 
(Personal Communication, Widemann B, 2010) In addition, pharmacokinetic data indicate that that the half 
life (T½) is > 24 hours and that sorafenib exposure is not dose-proportional above 150 mg/m2 dosing.  
 
Sorafenib has shown encouraging results as a single agent in adults with relapsed FLT3/ITD+ AML.23-25 A 
very recent report from MD Anderson Cancer Center (MDACC) demonstrates that sorafenib can be safely 
combined with AML chemotherapy in younger adults with AML.26 Moreover, patients with FLT3/ITD+ 
AML treated with sorafenib had a significantly increased remission induction rate than either patients 
without FLT3/ITD or with FLT3/ITD+ patients treated with chemotherapy alone. However, no benefit in 
OS was observed in patients treated with sorafenib. 
 
Pediatric experience with sorafenib in combination with AML chemotherapy in children has been reported 
in 15 children in addition to the 10 evaluable patients in Arm C, Cohort 1.27,28 Data from these reports 
indicate that the MTD of sorafenib in combination with AML chemotherapy is 150 mg/m2 twice daily. Data 
from Arm C, Cohort 1, indicates that 200 mg/m2 once daily may be safely administered with COG standard 
AML therapy, and this dose will be taken forward for Arm C, Cohorts 2 and 3.  
 
2.3.1 
 Rationale for Modification of Sorafenib Dosing Schedule (Per Amendment #6A) 
As of the 04/2015 interim evaluation, higher than expected rates of cardiac toxicity were observed for 
Cohort 2 of Arm C. Specifically, 7/38 (18%) patients met criterion for cardiac toxicity that warranted 
permanent discontinuation of sorafenib treatment. Two patients experienced dose-limiting toxicity at 100 
mg/m2 dosing and five patients experienced dose limiting toxicity at 200 mg/m2 dosing but went off 
protocol therapy prior to a sorafenib dose reduction. In most children, cardiac toxicity was seen only by 
study required echocardiograms and the children had no clinical symptoms.  
 
In addition, prospective monitoring of cardiac toxicity on all arms of the study demonstrated that both 
shortening fraction (SF) and ejection fraction (EF) declined significantly more in patients treated with 
sorafenib than patients treated with standard chemotherapy. Specifically, the mean SF difference was 
- 1.96% (95% CI -3.02% - 0.9%, p = 0.003) and the mean EF difference was -3.57% (95% CI -5.21% - 
- 1.92%, p < 0.001) when comparing patients treated with standard chemotherapy plus sorafenib and 
patients treated with standard chemotherapy alone. 
 
Because of concerns for cardiotoxicity, a safety memo was released on 04/27/2015 that mandated a change 
in the sorafenib dosing schedule for patients during Induction II, Intensification I and, for the limited subset 
of patients without a SCT donor, Intensification II (as reflected in Amendment #6A). 
 
While the precise mechanisms for sorafenib related cardiotoxicity is not currently known, a number of 
mechanisms have been postulated based on preclinical models.29,30 VEGF is an important regulator of 

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18 
angiogenesis and VEGF/VEGFR-targeted therapeutics, including sorafenib, block endothelial proliferation 
and promote apoptosis causing regression of cardiac vasculature. Moreover, inhibition of the 
VEGF/VEGFR pathway impacts nitric oxide production by endothelial cells, resulting in hypertension.29 
Importantly, in patients with poorly controlled hypertension, inhibition of VEGF/VEGFR may have even 
greater sequelae. In a mouse model of increased pressure load, inhibition of angiogenesis resulted in 
reduction in myocardial capillary density promoting global contractile dysfunction.31,32 A second 
mechanism for cardiotoxicity may reflect sorafenib’s impact on the KIT receptor tyrosine kinase. KIT, the 
receptor for stem cell factor, is normally expressed on endothelial progenitor cells (EPCs) and proper 
functioning of this receptor is needed for mobilization of EPCs to sites of injury. As sorafenib inhibits KIT, 
homing to sites of cardiac injury after a myocardial event may be impaired in the context of sorafenib 
treatment, a finding supported by a mouse model of sorafenib induced cardiotoxicity4,30 PDGF may also be 
protective in the context of an ischemic heart and it remains of concern that inhibition of endogenous 
PDGFR signaling by receptor tyrosine kinases inhibitors, like sorafenib, may be detrimental.3 ,29 Finally, 
Raf family inhibition by sorafenib may also have deleterious cardiac effects. Raf-1 has an important role in 
cardioprotection, particularly in the context of pressure overload stress, and deletion of this serine/threonine 
kinase has been found to result in cardiomyocyte apoptosis and fibrosis.1  
 
Currently, the optimal schedule of TKIs such as sorafenib administration with standard AML chemotherapy 
is not known. Both sunitinib and tandutinib have been found to have synergistic effects in combination with 
both cytarabine and anthracyclines; in the context of tandutinib, this was sequence independent.8,9 
Importantly however, in vitro data of a third TKI, lestaurtinib, demonstrated that co-administration of both 
lestaurtinib and daunorubicin, both of which are normally protein bound, resulted in competition for protein 
binding sites and subsequently increased unbound levels of both drugs with resultant cytotoxicity.2  
 
While the initial clinical trials of sorafenib in combination with conventional chemotherapy included 
concomitant dosing, these treatments were characterized by short duration of sorafenib exposure and/or 
non-anthracycline regimens.6 ,26,27 Notably, an excess in cardiac toxicity was not observed with such 
regimens though final analysis of the de novo younger adult AML cohort treated with idarubicin/cytarabine 
and sorafenib did demonstrate that 6/62 (9.6%) patients experienced Grade 3 or higher cardiac toxicity or 
hypertension. One patient died of a massive MI during treatment though this was not considered related to 
sorafenib.6 A subsequent elderly AML trial studied sorafenib in a more sequential fashion. In this study by 
Serve et al, patients received (7 + 3) cytarabine/daunorubican followed by a 3 day washout and then single 
agent sorafenib until 3 days before the next chemotherapy course. Consolidation with intermediate dose 
cytarabine was followed by a similar sorafenib approach. For those who remained on study following 
Consolidation, an additional period of sorafenib maintenance (up until 1 year from start of treatment) was 
also possible. With this design, considerable Induction toxicity was observed for patients treated with 
sorafenib. Though toxicity was largely infectious in nature, Grade 3 or greater Induction cardiac toxicity 
was observed in 6/104 (5.8%) patients treated with sorafenib.5 A more recent abstract published by Rollig 
et al33 also utilized a treatment approach in which prolonged sorafenib exposure was delayed until after 
completion/washout from conventional chemotherapy, the latter of which included anthracyclines 
(daunorubicin and mitoxantrone). Reported toxicity data is limited to date but does not include reports of 
significant cardiac effects. Similarly, the Phase I pediatric trial of the alternative TKI quizartinib, in 
combination with cytarabine/etopside, utilized a dosing schema in which quizartinib was not initiated until 
after conventional chemotherapy completion.34 Using this design, there were no significant cardiac 
toxicities observed (Todd Cooper, personal communication).  
 
Since the precise mechanism of the observed cardiac toxicity is not fully understood, the impact of a 
sorafenib schedule change on cardiac toxicity risk is unknown. However, given the potential interaction of 
sorafenib with anthracyclines and limited cardiac toxicity reported by Serve et al and Rollig et al with 
sequential dosing of anthracyclines/sorafenib despite prolonged TKI exposure, the AAML1031 dosing 
schema was modified in Amendment #6A to avoid concomitant sorafenib/chemotherapy exposure and 

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ensure adequate washout between sorafenib and daunorubicin for Induction I and II. Given the low rate of 
cytarabine/etoposide associated cardiac toxicity, a washout period between cytarabine/etoposide and 
sorafenib was not included in Intensification I. 
 
2.3.2 
Rationale for Extending Study Accrual on Arm C and Creation of Arm D (Amendment #7A) 
Extending study accrual to Arm C is necessary to meet the protocol specified specific aims, particularly 
determining the feasibility of administering sorafenib with standard AML chemotherapy (Aim 1.1.4) and 
assessing the anti-leukemic activity of sorafenib (Aim 1.2.1). The current enrollment on Arm C is 
54 patients (12 patients in Cohort 1, 34 patients in Cohort 2, 5 patients rolling over to Cohort 3 upon 
reopening with Amendment #6A, and 3 patients starting therapy in Cohort 3) with a target sample size of 
80 patients in Cohort 2. The unexpected lower accrual on Arm C is due to multiple periods in which Arm C 
has been closed, particularly during the approval process for Amendment #4 that added a sorafenib 
maintenance treatment course. Additional enrollment to Arm C will substantially improve both the 
feasibility and efficacy data from the AAML1031 trial. In addition, extended accrual on the sequential 
chemotherapy/sorafenib administration schedule will enable a comparison of the different sorafenib dosing 
schedules used in the trial and facilitate more granular cardiac toxicity analyses. 
 
As Arms A and B are now closed, Arm D has been created in order to enroll patients on study whose 
FLT3/ITD allelic ratio is unknown prior to study entry. Patients who enroll on Arm D will receive ADE 
10+3+5 Induction therapy, which is the standard Induction regimen for children with de novo AML.34 
 
2.4 
Rationale for Sorafenib Maintenance for HR FLT3/ITD+ AML Patients 
 
2.4.1 
Overview 
Single agent sorafenib in the post-SCT period was initially reported in 3 adult AML patients with evidence 
of FLT3/ITD+ disease relapse during the first year following SCT. Despite lack of standardized dosing 
(100 - 400 mg/dose) sorafenib was reasonably well tolerated and CR observed in 3/3 patients, including 
one complete molecular remission. All patients were able to receive dosing for more than 75 days though 
the drug was held intermittently for marrow suppression.35 The drug was also used in a similar fashion in a 
4th reported patient, also with good effect.36 A subsequent abstract provided updated information regarding 
use of sorafenib post-SCT in 16 patients who recurred post-SCT. Patients received between 200 mg and 
800 mg sorafenib daily. In this group, there were 3 partial responses, 2 hematologic responses, 7 bone 
marrow responses and 4 complete molecular responses. In general, sorafenib was well-tolerated with Grade 
3/4 pancytopenia and thrombocytopenia the most significant, but manageable, side effects observed.37 In 
2011 Sharma et al described outcomes for n = 16 adult patients with relapsed FLT3/ITD+ AML following 
allogeneic SCT. In this series, patients were treated with either sorafenib alone (n = 8) or in combination 
with cytotoxic chemotherapy (n = 8). While the therapy was well-tolerated overall, there were no patients 
that survived beyond one year. This finding may reflect the very high risk nature of this study cohort.38 A 
more recent retrospective review of 65 adult patients with FLT3/ITD+ AML that were treated with 
sorafenib demonstrates more compelling results, particularly for the 29 patients treated with sorafenib 
following SCT. Sixty-three of 65 patients (96%) had relapsed or refractory disease suggesting this was a 
very high-risk group of patients and yet, overall, 25/65 (38%) achieved morphologic CR, complete 
morphologic remission with incomplete peripheral blood count recovery (CRi) or complete molecular 
response (CMR). Rates of CR/CRi/CMR were 11/36 (30%) for patients treated in the absence of SCT versus 
14/29 (48%) for patients who received sorafenib following transplantation. Notably, in the post-SCT cohort, 
7/29 (24%) patients achieved complete molecular response (CMR), a significantly higher rate than that 
observed in the setting of conventional chemotherapy (CMR 3/36 = 8%). Moreover, sorafenib induced 
remissions following HCT lasted, on average, significantly longer than patients treated with sorafenib + 
conventional chemotherapy. Specifically, 17/36 (47%) of patients without prior SCT developed sorafenib 
resistance after median treatment duration of 136 days whereas post-SCT patients developed sorafenib 
resistance less frequently (38%) and significantly later (median 197 days, P = .03). Three patients in the 

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post-SCT cohort have already survived more than 2 years without disease recurrence.39 Together these 
findings suggest that there is a potentially curative synergism between sorafenib and an allo-immune 
mediated anti-leukemic effect.39 In this study the median dose of sorafenib was 600 mg daily for the post-
SCT cohort (versus 486 mg daily in the chemotherapy group) and the median duration of therapy 74 days 
(range 1 - 270 days) for this subset of patients. The drug was overall well-tolerated though Grade 3/4 
pancytopenia was seen in 40/65 (62%) of the total cohort. Additional toxicities described for the entire 
study cohort included infection (n = 17), hand-foot syndrome (n = 8), rash (n = 12), mucositis (n = 7), 
hepatotoxicity (n = 5), hypertension (n = 4), cardiac decompensation (n = 2), GI perforation (n = 1), GI 
bleeding (n = 1), intracranial bleeding (n = 1), neurotoxicity (n = 1) and non-specific cardiac arrhythmia 
(n = 1). In 10 instances, such toxicities were fatal (n = 9 infections, n = 1 cardiac decompensation, n = 1 GI 
perforation, n = 1 intracranial bleed). For the post-HCT cohort, 1 case of severe liver GVHD and 1 case of 
severe skin GHVD were observed. An additional 5 patients developed mild (< Grade 2) skin GVHD.39  
 
At present there are 2 cooperative adult studies open to study this treatment approach in greater detail. The 
first study, conducted by the Dana-Farber Cancer Institute, is a Phase I study of sorafenib post-SCT for 
FLT3/ITD+ patients age 18 - 75 years. Patients initiate treatment Day 60 - 100 post-SCT and will receive 
treatment for 1 year. Three dose escalations and 1 de-escalation are planned. As of 9/2012, 7 patients had 
been enrolled without any DLTs to date and patients continued to be enrolled on the maximum dose planned 
(400 mg PO BID).(Personal Communication with Study PI, Dr Yi Bin Chen) A second post-SCT 
multicenter study is being conducted in Germany for FLT3/ITD+ patients > 18 years. This study is a 
randomization to +/- sorafenib. For patients on the treatment arm, sorafenib is initiated at Day 60 – 100 post-
SCT and is continued for 2 years. The starting dose of sorafenib is 400 mg PO daily (220 mg/m2/day) and 
assuming this dose is tolerated, the dose is increased over a period of 6 weeks to 800 mg PO daily 
(440 mg/m2/day). As of 04/2012 a total of 16 patients have been enrolled on this study. The dosing schema 
has been tolerated to date without significant adverse events and or GVHD observed. Notably, accrual has 
been significantly limited by the fact that treating physicians are not willing to accept randomization to the 
observation arm. (Personal Communication with Study PI, Dr Andreas Burchert) 
  
2.4.2  Pediatric Post-SCT Experience 
Given the encouraging results described above, sorafenib has been used in a subset of high-risk pediatric 
AML patients. A retrospective review of unpublished experience at several COG institutions, coupled with 
2 published series,27,28 suggests that this approach is feasible and has an acceptable toxicity profile. Of 
22 pediatric AML patients treated with sorafenib post SCT, the median dosing of drug used was 
200 mg/m2/day (range 110-400 mg/m2/day). Overall, the regimen was well tolerated. Specifically, 16/22 
(73%) patients had reported toxicity however Grade 3/4 toxicity was relatively low with n = 3 patients 
experiencing neutropenia, n = 1 rash/skin pain, n = 3 transaminitis, n = 1 hyperbilirubinemia and 
n =1  sepsis. One additional patient had Grade 4 cardiac toxicity that was possibly related to sorafenib, 
although additional confounding factors existed. Seven out of 22 (32%) patients who experienced toxicity 
had their sorafenib dose held and restarted at the same or a lower dose of drug without recurrence of 
symptoms. An additional 6 patients with toxicity resolved such toxicity without dose modification. Notably, 
of 5 patients with dose limiting toxicity, 3/5 were treated with exceptionally high doses of therapy 
(340 - 400 mg/m2/day). 
 
Of particular interest is the potential impact this therapeutic approach had on 15 pediatric FLT3/ITD+ 
patients treated with sorafenib following allogeneic SCT. Specifically, of 10 FLT3/ITD+ patients treated 
for relapse post-HCT (n = 8 morphologic, n = 2 with MRD), approximately 70% remain disease-free at a 
median of 12.5 months post start of therapy (range 2.5 - 48 months). Three additional FLT3/ITD+ patients 
received the drug prophylactically post-SCT given the high-risk nature of their disease and an additional 
2 patient received such treatment given MRD preceding, but not following, SCT. Of this cohort, 4/5 (80%) 
have remained disease-free for a median of 10 months (range 1 - 16 months). Interestingly, the 1 patient 

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who recurred had, at time of recurrence, absence of the FLT3/ITD+ clone, suggestive of clonal evolution 
and selection for a minor clone at time of disease recurrence.(Pollard et al. manuscript in preparation)      
 
The Seattle pediatric experience with single agent sorafenib post-SCT in FLT3/ITD+ AML suggests that 
the drug may facilitate clearance of MRD in the post-SCT setting. However, the initial dosing of sorafenib 
used to treat our patients is not standardized and drug toxicity/intolerance has necessitated doses far lower 
than that of the defined MTD for relapsed pediatric leukemias.40 Given limited data on post-SCT sorafenib 
use, its impact on pre-existing GVHD remains unclear. Together these findings suggest that a formal study 
to describe the feasibility of administering sorafenib following SCT is necessary, towards the goal of 
ultimately improving outcomes for this high-risk patient population.   
 
2.5 
Health Related Quality of Life and Parental Stress 
Health related quality of life (HRQOL) has become increasingly important in clinical trials of children 
undergoing cancer therapy and is of particular relevance in childhood AML. AML treatment clearly 
substantially impacts HRQOL. Short and long term complications following therapy can be quite extensive 
and are dependent on a variety of factors including chemotherapy regimen, radiation therapy, age, gender, 
and acute toxicities of therapy. Possible long term sequelae include cardiopulmonary toxicity, second 
malignancies, infertility, and endocrinopathies.41 In one study from the Childhood Cancer Survivor Study,42 
50% of long term AML survivors had a chronic physical health conditions and 16% had a significant health 
condition. We lack prospectively collected HRQOL data from large numbers of children with AML 
receiving homogeneous therapy and in particular, lack good data which examines HRQOL among children 
treated with stem cell transplant (SCT) and chemotherapy. The measurement of HRQOL is important for 
several reasons. First, it will help to better understand the expected consequences of therapy and to inform 
future interventional trials designed to improve HRQOL associated with both SCT and chemotherapy. 
Second, understanding and quantifying longitudinal changes in HRQOL associated with chemotherapy and 
SCT treatment will allow us to see how HRQOL changes and when interventions may be most beneficial. 
Finally, as an exploratory aim, the measurement of HRQOL will further clarify the overall impact of SCT 
on patients and the overall risk to benefit ratio of SCT. 
 
Despite this clear need, previous work in pediatric AML HRQOL has been very limited. In one of the larger 
studies by Nicholson et al,43 HRQOL was described in approximately 200 survivors of AML treated on 
COG trials. Median age at diagnosis was 3 years and age at HRQOL assessment (SF-36) was 19 years. One 
hundred and twenty four patients were treated with chemotherapy only, 54 with allogenic SCT and 28 with 
autologous SCT. HRQOL summary scores and sub-scale scores did not differ between those receiving 
chemotherapy only and those receiving SCT. However, this study was limited by the small number of 
patients receiving SCT and the cross-sectional nature of the study. Studies have been summarized by 
Redaelli and colleagues who examined 21 articles that reported on HRQOL in AML patients.44,45 Most 
studies were cross-sectional, post-treatment, and only included adult patients. Clarke et al.46 reviewed the 
literature regarding pediatric SCT and HRQOL; however, studies were small and utilized different 
assessments in various disease groups. Therefore, there is a lack of information on HRQOL from pediatric 
AML patients obtained prospectively that compares status during and following chemotherapy or SCT. 
Furthermore, almost nothing is known about the parenting stress of parents of children treated for pediatric 
AML. Parenting stress related to caring for a child with an illness can influence the family structure and 
cohesiveness and impact patient HRQOL.47-49 While this knowledge is less likely to contribute to decision-
making, it will help for anticipatory guidance and planning of future intervention trials. 
 
Thus, we believe that both patient HRQOL and parenting stress are important in pediatric AML. This study 
will provide a unique opportunity to prospectively assess HRQOL in comparable groups of AML patients 
on a prospective basis in order to definitely describe HRQOL in those receiving SCT and chemotherapy. 
In addition, longitudinal assessment of HRQOL and determination of predictors from demographic and 
treatment characteristics and pediatric parenting stress will allow for more accurate identification of 

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potentially modifiable risk factors for poorer HRQOL and determine how HRQOL changes over time. This 
in turn will inform future development and evaluation of early, targeted interventions to improve HRQOL 
and reduce pediatric parenting stress. For children 2 to 18 years of age, measures of HRQOL will be the 
Pediatric Quality of Life (PedsQL) 4.0 Generic Core Scale,50,51 the PedsQL 3.0 Cancer Module,52 and the 
Multidimensional Fatigue Scale.52,53 These have been found to be reliable and valid in this population.52 
For HRQOL assessments, parents will provide proxy assessments for all patients while for patients 
≥ 5 years of age, self-report also will be completed by the child (if able and agrees). Parental stress will be 
assessed using the Pediatric Inventory for Parents (PIP) scale.54,55 The PIP was developed to measure 
parenting stress related to caring for a child with an illness. PIP has been found to be a reliable and valid 
tool assessing parental stress in the pediatric oncology population.55 This instrument will only be completed 
by parents or guardians.  
 
2.6  
Dexrazoxane Use in Pediatric AML 
Patients treated with MRC based AML chemotherapy receive high cumulative anthracycline exposures and 
are at high risk for long term cardiac complications.56-58 Despite this, the available data on the risks and 
benefits of cardioprotection with dexrazoxane in pediatric AML patients are limited to a single institution 
case series. Sanchez-Medina et al59 reported on 50 patients treated according to the MRC10 protocol and 
appeared to benefit from the use of dexrazoxane. However, no control group was reported in this study, 
thus limiting the conclusions of this report. Since dexrazoxane is used by some centers for cardioprotection 
with AML, this study will prospectively collect data on dexrazoxane use and cardiac outcomes (shortening 
fraction and ejection fraction) at the end of each course of chemotherapy and in follow-up. These data will 
enable a comparison of cardiac complications in patients treated with and without dexrazoxane. 
Dexrazoxane use is per institutional preference and is NOT mandated by the AAML1031 protocol. 
 
2.7 
Rationale for Changes in GVHD Prophylaxis and SCT Conditioning Regimen 
A survival benefit, presumably due to graft-versus-leukemia effects, following family donor allogeneic 
SCT compared to chemotherapy only approaches, for children with AML has been shown in sequential 
randomized cooperative group studies.60,61 The benefit of allogeneic SCT for children with AML was 
confirmed in a recent meta-analysis, which included 1,373 pediatric patients with AML in first complete 
remission (CR1). In the intermediate-risk group, the estimated disease-free survival (DFS) at 8 years for 
patients who did not undergo transplantation was 39% ± 5%, whereas it was 58% ± 7% for family donor 
allogeneic SCT patients.62 In all of these analyses, some of the survival benefit was offset by increased 
treatment related mortality (TRM) in the SCT-treated patients. Transplant-related death is the culmination 
of a complex pathophysiology that includes conditioning regimen related effects, donor source, and graft-
versus-host disease (GVHD). Donor source selection is determined by factors outside investigator control, 
such as the availability of a family member match or unrelated donor. The 2 areas that can be readily 
incorporated into the treatment design are GVHD prophylaxis and conditioning regimen. 
 
The GVHD prophylaxis schema recently developed for ASCT0431 represents a consensus approach 
developed by the COG hematopoietic stem cell transplant (HSCT) committee covering diverse donor 
sources including matched family member, unrelated adult donor, and cord blood stem cell sources. It is 
logical, therefore, to include the ASCT0431 standard arm in this study (AAML1031) as the GVHD 
prophylaxis regimen. While the standard GVHD prophylaxis regimen does not attempt to improve upon 
TRM, incorporating this regimen in this study has the advantage of creating a standard approach and 
baseline for future comparisons across the 2 major indications for allogeneic SCT in children. The 
conditioning regimen for allogeneic SCT in children with AML (myeloablative doses of busulfan and high 
doses of cyclophosphamide) treated on POG/CCG/COG studies has not been updated in over 20 years, with 
the exception of the change from oral busulfan to intravenous (IV) busulfan and dosing based on 
pharmacokinetics in AAML0531. The combination of myeloablative busulfan and high doses of 
cyclophosphamide (200 mg/kg) has a well-documented track record, but this includes high rates of veno-
occlusive disease (VOD) at 20% - 50%,63,64 hemorrhagic cystitis (5% - 15%),65 and TRM. 

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Cyclophosphamide metabolism has been directly linked to VOD.66 Cyclophosphamide is included in the 
conditioning regimen primarily for its immunoablative effects. In recent years, fludarabine has been 
substituted for cyclophosphamide in order to avoid the cyclophosphamide toxicity with excellent results. 
Falling VOD rates after SCT in recent years can be attributed to the increasing use of fludarabine over 
cyclophosphamide in the conditioning regimen.63 Fludarabine, a nucleoside analog, has the attractive 
properties of potent immunosuppression as well as synergy with alkylating agents against leukemia.67 In 
fact, fludarabine, in combination with cytarabine and idarubicin, was used for its anti-AML effects in the 
predecessor study CCG2961. 
 
Most recently, a combination of fludarabine together with myeloablative doses of busulfan has been shown 
to be highly effective with rates of TRM ranging from 1% - 7% in adult patients with myeloid leukemias 
even when alternative donors, such as unrelated donors, were used.68,69 The lowest rates of TRM were seen 
when busulfan was administered as a once-daily IV dose for 4 days (FluBu4) and dose adjusted based on 
pharmacokinetics (PK). The graft failure rate was approximately 1%. Anti-thymocyte globulin (ATG) was 
used to facilitate engraftment in recipients of unrelated donors. In unpublished data from the University of 
Michigan, FluBu4 without ATG resulted in 100% engraftment in 56 patients receiving unrelated donor 
SCT. In order to compare the FluBu4 experience with BuCy, the MD Anderson group performed a Bayesian 
analysis of outcomes between nonrandomized patients (148 FluBu4, 67 BuCy). Both groups had 
comparable pretreatment characteristics, except that FluBu4 patients were older (46 versus 39 years, 
p < 0.01), more often had unrelated donors (47.3% versus 20.9%, p < 0.0003), and had shorter median 
follow-up (39.7 versus 74.6 months). Patients transplanted with FluBu4 in CR1 had a 3 year OS and EFS 
of 78% and 74%, respectively, whereas CR1 patients younger than age 41 years had a 3 year EFS of 83%. 
These results compared favorably to 3 year OS and EFS rates of 42% in the BuCy treated patients.70   
 
Fludarabine and busulfan conditioning regimens have been tested in pediatric populations. Pulsipher 
reported 2 year EFS of 40% with TRM of 11% in 47 children with very high risk malignancies who could 
not undergo a traditional myeloablative conditioning regimen for reasons that included prior myeloablative 
SCT.71 Excellent outcomes using fludarabine and busulfan have also been seen in children with both 
malignant and non-malignant diseases after related, unrelated, and cord blood SCT.72-75 Unpublished center 
for international blood and marrow transplant research (CIBMTR) data showed 1 year OS of 73% in 
40 children (age < 18 years with AML, sibling donor) conditioned myeloablative doses of 
fludarabine/busulfan compared to 63% in 200 children conditioned with BuCy (Mary Eapen M.D, personal 
communication). The data was unadjusted for any other risk factors, but does support the premise that 
FluBu4 can be considered at least roughly equivalent to BuCy, if not superior. Since 2005, children with 
AML under the age of 18 years have received myeloablative fludarabine/busulfan for SCT in 8% of cases 
reported to CIBMTR, making this regimen the third most common regimen after BuCy and total body 
irradiation (TBI) based conditioning regimens. Given the above data, and a compelling interest in reducing 
TRM and improving efficacy of SCT, the COG HSCT committee outlined a strategy in 2009 to support a 
transition from BuCy to FluBu4 to fludarabine/treosulfan in a sequential series of studies for children with 
AML. Revising the conditioning regimen in this study is in accordance with this aim. 
 
 
2.8 
Biology Correlative Studies 
 
2.8.1 
MRD Based Risk Stratification 
Utility of MRD in risk identification in childhood AML has been shown in legacy CCG2961.76 These 
findings have further been validated in a prospective study in AAML03P1, where post remission specimens 
were evaluated for the presence of disease by 4-color multidimensional flow cytometry (MDF), and the 
presence of disease was correlated with outcome (manuscript in preparation).77 End of Induction I 
specimens were evaluated for evidence of disease by MDF. Disease was detected in 69 of 222 evaluable 
patients (31%) at various MRD levels, ranging from 0.02% to 43% (median 1.5%). Two patients had MRD 

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levels < 0.1%, and 6 patients reported to be in morphologic CR had leukemia cells > 5% by MDF. Forty-
five of 191 patients (24%) in morphologic CR had a measurable MRD. At the end of Induction I, 27 patients 
were in PR (5% - 20% blasts, n = 15) or were refractory to initial Induction (> 20% blasts, n = 12). Disease 
assessment by MDF in these patients revealed that 40% of the patients with PR (5% - ≤ 20% blasts) had no 
evidence of disease by MRD, whereas, in those with refractory disease, all but one had disease by MDF. 
Thus, MDF identified residual disease in patients in morphologic CR as well as identified patients with 
reported morphologic disease who did not have immunophenotypic evidence of disease. Clinical 
implications of MRD were assessed in patients who had a response to initial chemotherapy (Induction I). 
Presence of MRD by MDF at the end of Induction I was correlated with relapse risk (RR) and DFS from 
end of Induction I. Patients with evidence of disease by MDF had a RR at 3 years of 64 ± 20%. In contrast, 
cumulative RR was 25 ± 11% in those without MRD (p < 0.001). Corresponding DFS at 3 years from initial 
Induction was 32 ± 14% for those with MRD compared to 65 ± 9% to those without MRD (p < 0.001). The 
impact of MRD on patients who were in morphologic CR were evaluated separately. Presence of MRD in 
patients in CR (n = 191) was associated with a RR of 59 ± 16% compared to that of 28 ± 8% in patients 
without MRD (p < 0.001). Corresponding DFS was 31 ± 15%vs. 65 ± 9%in those with and without MRD 
(p < 0.001). It was further evaluated whether presence of MRD beyond the Induction I carries clinical 
significance. One hundred and eighty-five patients had MRD data available at the end of Induction II of 
whom 36 patients (19.5%) had evidence of disease by MDF ranging from 0.1% to 50% (median 1.0%). 
Cumulative RR at 3 years from end of Induction II in patients with MRD was 68 ± 17% compared to 
28 ± 8% in those without MRD (p < 0.001) with a corresponding DFS of 28 ± 17% and 65 ± 9%respectively 
(p < 0.001). At the end of Intensification III (end of therapy), 7 of 91 patients (8%) were MRD positive. 
Patients with MRD at the end of therapy had a RR of 86 ± 26%, compared to that of 37 ± 11% for the MRD 
negative patients (p < 0.001) with a corresponding DFS of 14 ± 26% and 62 ± 11%, respectively (p < 0.001). 
It is of note that of the 7 patients who were MRD positive at the end of therapy, 3 had a previously 
documented MRD and in 4 patients, MRD emerged during therapy. We inquired whether clearance of 
initial MRD correlates with improved outcome. Ninety-one patients had MRD data available at the end of 
therapy, of which 7 (8%) were MRD positive and the remaining 84 were MRD negative. Of the 84 patients 
who were MRD-negative at the end of therapy, 22 patients had a previously documented MRD at the end 
of Induction I or II. The clinical outcome from end of therapy for MRD-negative patients with or without 
a previously documented MRD was evaluated. Relapse risk at 3 years from end of therapy for MRD positive 
patients was 86% ± 26% vs. 64 ± 20% for those with a history of MRD and RR of 25 ± 11% for those 
without previous MRD (p < 0.001).  
 
Prognostic Factors: Prognostic factors were evaluated for RR and DFS from end of Induction I. Cox 
regression analysis was used to evaluate MRD status, cytogenetic/molecular favorable risk (CBF AML, 
NPM and CEBPα mutations), unfavorable risk (–7, –5/del5q, HR FLT3/ITD+), and diagnostic WBC, as 
predictors of DFS and RR in a univariate model. In the univariate model, the presence of a MRD was a 
significant prognostic factor for higher relapse risk (HR 2.7, p < 0.001) and worse DFS with an HR of 
2.47 (p < 0.001). In separate univariate models, molecular high-risk patients had a worse DFS with a HR 
of 1.94 (p = 0.039), and those with favorable risk AML had an improved DFS (HR 0.58, p = 0.02) compared 
to those without standard risk AML. In a multivariate model that included the above-mentioned prognostic 
factors, the presence of MRD remained an independent prognostic factor for higher RR (HR = 2.43, 
p < 0.001) and lower DFS (HR = 2.41, p < 0.001). 
 
Implications of MRD in specific risk groups in AML: The clinical implications of MRD in specific risk 
classes identified by cytogenetic and molecular alterations was assessed. Of 206 patients with CR/PR at the 
end of Induction I, 195 patients had complete cytogenetic and molecular data available, 91 of which had 
favorable (CBF AML, NPM and CEBPα mutations, n=73) or unfavorable (HR FLT3/ITD+, -7, -5 or del5q, 
n = 18) features. The remaining 104 patients without favorable or unfavorable features were regarded 
standard risk, of whom 32 (31%) had MRD ranging from 0.02% to 22% (median 2%). Standard risk patients 
with MRD had a DFS at 3 years from end of Induction I of 34 ± 18% vs. 65 ± 13% for the MRD negative 

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patients (p = 0.006). Of the 73 patients with favorable risk features, 12 had MRD (16%) at the end of 
Induction I. In this favorable risk cohort, DFS at 3 years from CR for those with and without MRD was 
similar (p = 0.138). Eighteen patients were deemed high risk based on their cytogenetic or molecular 
features, of which 8 patients had MRD (44%). 
 
Implications of pre-transplant MRD: Hematopoietic cell transplantation (HCT) is utilized in the 
treatment of a subset of children with AML. Above it was demonstrated that the presence of MRD is 
associated with a high relapse rate in children with AML, however, the clinical implications of MRD prior 
to HCT have not previously been defined. We explored the clinical outcomes associated with the presence 
of morphologic or sub-morphologic disease prior to HCT.78 In the period of 1995 - 2007, 89 patients age 
1 - 18 years received myeloablative conditioning and allogeneic HCT from related (n = 36) or unrelated 
(n = 53) donors at Fred Hutchinson Cancer Research Center. At the time of HCT, 63 patients received 
transplants in CR and 26 had morphologic disease. Among those in morphologic CR, 43 were in CR1, 17 in 
second complete remission (CR2) and 3 were in second complete remission (CR3). All patients had bone 
marrow evaluation for MRD by MDF 2-4 weeks prior to HCT. MDF testing showed that 10 of 63 patients 
(16%) who received transplants in morphologic CR had MRD levels ranging from 0.3% to 12% (median 
3.7%) while the remaining 53 patients had no detectable MRD. The median follow up for the 38 survivors 
is 6 years (range 1 – 12 years). Actuarial relapse rate for those with MRD was 65% vs. 17% for those 
without MRD (p < 0.001). Corresponding OS for patients who received transplants in morphologic CR 
with MRD was 15% vs. 67% for those without MRD, p = 0.001. This data suggests that MRD data at the 
end of Intensification I would provide significant insight into the post-transplant outcome of patients who 
are to receive stem cell transplant.  
 
While MRD has prognostic significance for risk stratification at the end of Induction I, standard 
morphology criteria will be used to determine remission induction and relapse rate. Standard morphological 
remission criteria will be used for several reasons. First, morphology remains the standard measurement of 
disease response in all pediatric and adult cooperative groups. Thus, use of standard morphological criteria 
will facilitate comparisons of AAML1031 outcomes with other cooperative group trials. Second, 
AAML1031 standard therapy has omitted the fifth course of chemotherapy. Evaluation of the efficacy of 
the AAML1031 chemotherapy will require comparison with prior trials that have used morphologic criteria. 
Finally, additional work is needed to determine the reproducibility of centrally performed 4-color flow 
cytometry in other clinical laboratories. 
 
2.8.2 
Evaluation of the prognostic significance of molecular MRD and its contribution to risk 
identification with MDF based MRD in patients with translocations amenable to quantitative RT-PCR (e.g., 
t(8;21), inv(16), t(9;11), WT1 expression.  
Molecular markers have been considered candidates for post remission disease status assessment to be 
utilized for outcome prediction. Specific translocations including t(8;21), inv(16) and t(9;11) are common 
in childhood AML and provide for excellent tools for MRD assessment in a large cohort of patients. In 
addition, expression levels of WT1 gene have been associated with relapse risk in AML. Ribonucleic acid 
(RNA) extracted from remission specimens will be evaluated for quantitative expression of specific fusion 
transcripts as well as for WT1 expression levels. Molecular MRD will be correlated with MRD by MDF to 
determine whether molecular MRD provides any additional information to that obtained from MDF. 
 
2.8.3 
 Determination of the leukemic involvement of hematopoietic early progenitor  
We hypothesize that the extent of leukemic involvement of the early hematopoietic progenitors may be 
associated with response to chemotherapy, where those with leukemia limited to more differentiated 
progenitors would have improved outcome. In contrast, those with leukemic involvement of more primitive 
stem/progenitor population would be more resistant to conventional chemotherapy and may require more 
stem-cell targeted therapy (e.g., bortezomib) or stem cell transplantation. It has been demonstrated that 
early progenitor expression of the FLT3/ITD was associated with significantly worse outcome,79 compared 

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26 
to those where disease was limited to more differentiated cells. We will use early progenitor isolation and 
ex-vivo functional analysis, including stromal based culture, combined with molecular genotyping or clonal 
analysis based on expression of polymorphic X-linked genes in heterozygous females to determine early 
progenitor involvement and correlate it to response to therapy. 
 
2.8.4 
Definition of the Leukemia Stem Cell Population in Patients with AML 
The stem cell model proposes that AML arises from a biologically distinct subpopulation of cells referred 
to as leukemia initiating cells (LIC) with a capacity to self-renew, differentiate, and give rise to non-self-
renewing progeny. Additional data supports a key role for LIC in disease relapse. Murine models of AML 
have largely confirmed the observations made in primary human samples. While similar in some 
characteristics to normal hematopoietic stem cells (HSC), LIC have been shown to possess traits that are 
distinct from normal HSC including antigen expression.80,81 These differences allow them to be physically 
separated from normal HSC and may allow novel therapies to target LIC while sparing their normal HSC 
counterpart. Efforts to design therapies based on this model include drugs that target antigens on the surface 
of the LSC as well as agents that selectively deplete LSC, while sparing normal HSC.82-84 The underlying 
premise to the above studies is that the stem cell model is relevant to a majority of patients with AML in 
all stages of disease but there is little data that supports this assumption. The ability to identify and isolate 
the LIC populations from primary human AML samples has allowed the identification of several key 
molecular features of this population of leukemic cells. Dr. Becker and Dr. Jordan’s labs have identified 
LIC specific pathways using a genome wide approach.85-87 Expression profiles of highly enriched leukemic 
CD123CD34+CD38- cells and enriched normal HSC were analyzed and the expression profiles of leukemic 
and normal stem cell populations compared. This approach identified signaling pathways that are aberrantly 
regulated in LIC. Dr. Jordan’s lab demonstrated the aberrant activation of the NF-κB pathway in LIC and 
altered LIC response to changes in oxidative state.85 This data suggested that LIC may be more sensitive to 
bortezomib than HSC or the bulk leukemia population. Dr. Jordan’s lab demonstrated that AML stem cells 
are selectively sensitive to proteasome inhibition and that proteasome inhibitors are synergistic with 
cytotoxic AML agents such as idarubicin.88 Dr. Becker and his colleagues identified additional aberrantly 
regulated pathways in LIC, including the MAP kinase pathway, Wnt signaling, ribosomal proteins, the actin 
cytoskeleton and tight junction pathways.87 Several of the pathways identified by our analysis had not been 
previously implicated in the regulation of LIC function. These differences between normal and malignant 
stem cell compartments of the bone marrow represent potential targets to improve AML therapy for this 
deadly disease. However, it is critical to determine the frequency at which these pathways are disrupted in 
a cohort of patients with AML as well as determine if these findings are stable during treatment. To 
accomplish the task of studying LIC throughout the course of disease, Dr. Becker and Dr. Jordan’s labs 
have collaborated on the development of a flow cytometry platform that will permit the separation of 
potential LIC populations from the normal cell population at time of diagnosis, in remission and at relapse. 
The putative leukemia initiating cell-leukemia aberrant immunophenotype (LIC-LAIP) will be identified 
using a 10-color flow sorting strategy. It is not possible to enumerate LIC using 4-color flow cytometry. 
The published phenotype of CD123+CD45dimCD34+CD38- (LIC) has been shown to be sufficient to isolate 
a population of cells with LIC properties from many patients at time of high disease burden.81,89 In contrast 
to the study of de novo and relapsed samples, the above phenotype has been shown to be insufficient for 
the study of LIC in remission. Schuurhuis et al reported that by using a panel of antigens such as CLL-1, 
CD5, CD7, CD19 and CD56, he was able to identify leukemic (CD45dimCD34+CD38-) cells in the 
remission samples of patients undergoing treatment for AML.89,90 While an aberrant population of 
CD45dimCD34+CD38- cells was identified in the majority of patients, there was significant inter-patient 
heterogeneity in informative cell surface markers. Building upon this effort, we have characterized the 
surface 
antigen 
profile 
of 
over 
20 
different 
antigens 
on 
normal 
and 
leukemic 
CD123+CD45dimCD34+CD38- cells. These antigens were chosen based on prior published studies as well 
as data from expression profiling of LIC. AML samples used for this effort were obtained from patients at 
time of high disease burden to decrease the potential for residual normal marrow elements contamination. 
We found significant variability between patients with respect to surface antigen expression on the leukemic 

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27 
CD123+CD45dimCD34+CD38- 
population. 
In 
contrast 
the 
expression 
profile 
for 
normal 
CD123+CD45dimCD34+CD38- cells was conserved. Two antigens, BB9 and CD62L, expressed on normal 
CD123+CD45dimCD34+CD38- cells, were absent on same population for the majority of patients with 
AML. In addition to BB9 and CD62L, for many of the AML samples examined, aberrant expression of at 
least 1 additional antigen was identified. Using the gating strategy employed, we were able to identify a 
leukemia specific expression profile that may be employed to identify the LIC population in remission. 
 
2.8.5 
Prevalence and Prognostic Significance of Molecular Abnormalities of WT1, RUNX1, MLL-PTD, 
TET2, c-CBL, KIT and other novel AML Associated Genes in Pediatric AML 
As part of our continued efforts to identify molecular alteration in AML we will evaluate the prognostic 
significance of genes implicated in AML pathogenesis. Presence of these mutations will be correlated with 
clinical characteristics and outcome. We have documented the prevalence of numerous molecular 
alterations in genes involved in hematopoietic development. The list of genes and their overall prevalence 
is shown below. These genes are associated with regulation of normal hematopoiesis and the altered protein 
product as a result of genomic alteration may contribute to malignant transformation. Presence of some of 
these mutations may be associated with clinical outcome, and others may be potential targets for directed 
therapies. For example, N-RAS mutations are identified with a prevalence of 10% - 15% in childhood AML 
in an age dependent manner. Patients with N-RAS mutations have a constitutively activated 
RAS/RAF/MAP/ERK pathway, and although presence of N-RAS does not have prognostic significance, 
its presence may identify a pathway that may be amenable for targeting with specific small molecule 
inhibitors. Comprehensive mutation profiling in AML is essential for identification of patient populations 
with biologically distinct disease with altered disease response. As part of the integrated aims of this study 
we will create a complete genomic profile that will be used to correlate the information with specific patient 
demographics, disease characteristics and clinical outcome. Such a comprehensive genotypic profiling will 
allow more complete correlation of molecular alterations with clinical outcome. As part of complete 
profiling of specimens from AAML1031, we will screen all diagnostic specimens for disease-associated 
mutations that may impact disease initiation and progression and may act as targets for directed therapy. 
These include KIT mutations in CBF AML, WT1 mutations and WT1 single nucleotide polymorphisms 
(SNP), IDH1 mutations and IDH1 SNP, NRAS mutations, TET2 mutations and TET2 SNP, RUNX1 
mutations as well as novel mutations identified as disease associated alteration in AML. In addition to 
disease associated mutations, new data is emerging on the prognostic significance of common germline 
polymorphisms (whether synonymous or not) in disease outcome. 
 
N-RAS mutations (NRASmut): NRASmut occur in 10% - 20% of adult and pediatric patients with AML, 
however the prognostic significance remains disputed. We report on the incidence and prognostic 
significance of NRASmut in 1,241 pediatric AML patients treated on CCG2961 and AAML03P1. Of 
825 patients who underwent NRAS mutational analysis, 86 (10%) were positive. Gender, age, race, FAB 
subtype and cytogenetics were comparable between patients with and without NRASmut. FLT3/ITD were 
less common (2% vs. 9%, p = 0.03), while NPM mutations were more common in those with NRASmut 
(13% vs. 5%, p = 0.02), resulting an overall significant correlation with low risk disease (p = 0.04). NRASmut 
and non-mutated patients had identical CR rates of 79% following 2 courses of Induction and a similar rate 
of relapse. Five year EFS and OS were also comparable however NRASmut patients demonstrated a marked 
increase in treatment related mortality (TRM) (21% vs. 14%, p = 0.03). This increased TRM occurred 
exclusively for patients treated on CCG2961, which correlated with decreased OS and DFS. NRASmut did 
not contribute to increased disease recurrence in pediatric AML, but further study may identify a novel 
downstream target for directed therapy. 
 
KIT mutations: KIT receptor tyrosine kinase mutations are implicated as a prognostic factor in adults with 
core binding factor (CBF) AML. However, their prevalence and prognostic significance in pediatric CBF 
AML is not well established. We performed KIT mutational analysis (exon 8 and exon 17) on diagnostic 
specimens from 203 pediatric patients with CBF AML enrolled on 4 pediatric AML protocols.91 KIT 

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mutations were detected in 38 (19%) of 203 (95% CI, 14% - 25%) patient samples of which 20 (52.5%) of 
38 (95% CI, 36% - 69%) involved exon 8, 17 (45%) of 38 (95% CI, 29% - 62%) involved exon 17, and 
1 (2.5%; 95% CI, 0% - 14%) involved both locations. Patients with KIT mutations had a 5-year EFS of 
55% (± 17%) compared with 59% (± 9%) for patients with wild-type KIT (p = 0.86). Rates of CR, OS, DFS, 
or relapse were not significantly different for patients with or without KIT mutations. Location of the KIT 
mutation and analysis by cytogenetic subtype [t(8;21) vs inv(16)] also lacked prognostic significance. Our 
study shows that KIT mutations lack prognostic significance in a large series of pediatric patients with CBF 
AML.  
 
WT1 mutations (WT1mut): Recent studies of WT1 mutations in AML report conflicting associations with 
clinical outcome. We screened 842 patients treated on 3 consecutive pediatric AML trials for WT1 zinc-
finger mutations.92 Eighty-five mutations were detected in 70 of 842 patients (8.3%). Mutations occurred 
predominantly in exon 7 (n = 74), but were also found in exons 8 (n = 5) and 9 (n = 6). Normal karyotype 
was observed in 35.3% of WT1mut patients, while 27.5% WT1mut patients harbored favorable-risk 
cytogenetics. Patients with or without mutations had similar rates of CR after 1 course of Induction 
chemotherapy. Overall survival for patients with WT1 mutations was 41% vs. 54% for those without 
mutations (p = 0.016). Corresponding EFS was also significantly worse for those with WT1 mutations (28% 
vs. 42%, p = 0.01). FLT3/ITD was present in 36% of the WT1mut cohort. WT1mut patients without FLT3/ITD 
had similar OS (56% vs. 56% respectively, p = 0.8) and EFS (35% and 44% respectively, p = 0.34) to 
patients who were wild-type for both mutations. In current risk-stratification schemes incorporating 
cytogenetics and FLT3/ITD status, the presence of WT1 mutations has no independent prognostic 
significance in predicting outcome in pediatric AML. 
 
WT1 Single Nucleotide Polymorphism (SNP): A recent study in adult AML reported that the presence of 
the minor allele of the WT1 SNP rs16754 correlated significantly with improved survival outcomes. To 
determine the prevalence of the minor allele of SNP rs16754 in pediatric AML, we sequenced exon 7 of 
the WT1 gene in diagnostic marrow specimens from 562 children with de novo AML treated on the trial 
CCG2961. Presence of at least 1 copy of the minor allele was detected in 157 of 562 (28%) patients. Patients 
with or without the minor SNP allele did not differ significantly in terms of FAB class, diagnostic white 
blood cell count (WBC), or the concomitant presence CBF translocations or FLT3/ITD, CEBPα, or NPM 
mutations. Sixty percent of minor-allele positive patients were male, and 4 out of 5 patients with monosomy 
5 harbored the minor allele. Asian patients accounted for 6.1% of minor allele positive patients, vs. 1.9% of 
those without the minor allele (p = 0.020). Minor-allele positive patients were younger (median age 
9.2 years vs. 10.8 years, p = 0.021) than those with only the major allele. Rates of CR after 1 course of 
Induction therapy were similar between the 2 groups. However, minor allele positive patients had a 
significantly higher 5 year OS from study entry (62% vs. 44%, p = 0.004) than those with only the major 
allele. In addition, minor allele positive patients had a significantly higher OS from relapse (36% vs. 19%, 
p = 0.021) suggesting a higher rate of salvage success. The biologic mechanism explaining why the 
presence of a synonymous SNP correlates with favorable outcome remains to be determined. However, the 
high prevalence of this SNP in pediatric AML, and the strongly significant association with improved OS, 
identifies the minor allele of WT1 SNP rs16754 as an important molecular marker of prognosis that can be 
incorporated into the risk stratification schemes. 
 
WT1 expression: Expression level of WT1 gene has been implicated in disease pathogenesis and is 
suggested as a prognostic marker in AML,93 although comprehensive evaluation of WT1 expression in 
childhood AML is lacking.94 As part of our evaluation of the role of WT1 gene in AML pathogenesis, we 
have assessed WT1 expression by quantitative RT-PCR in patients treated on AAML03P1. In the initial 
100 specimens studied, WT1 expression varied over 4 log fold and there was no correlation with cytogenetic 
class. Those with highest WT1 expression had elevated blast percentage and had a higher incidence of 
FLT3/ITD (p = 0.042). We are investigating the correlation of WT1 expression level with WT1 mutation 
and SNP and clinical outcome. We are also evaluating the WT1 expression level in post remission 

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specimens and its correlation with flow based MRD as well as clinical outcome. In the context of 
AAML1031 we will evaluate the WT1 expression level and attempt to identify patient population in which 
WT1 expression level can be utilized for risk allocation 
 
IDH1 mutation and IDH1 SNP: Recent whole-genome sequencing efforts led to the identification of 
IDH1(R132) mutations in acute myeloid leukemia (AML) patients. We studied the prevalence and clinical 
implications of IDH1 genomic alterations in pediatric and adult AML.95 Diagnostic deoxy ribonucleic acid 
(DNA) from 531 AML patients treated on AAML03P1 (n = 257), and Southwest Oncology Group trials 
SWOG-9031, SWOG-9333 and SWOG-9500 (n = 274), were tested for IDH1 mutations. Codon R132 
mutations were absent in the pediatric cohort, but were found in 12 of 274 adult patients (4.4%, 95% CI 
2.3 - 7.5). IDH1(R132) mutations occurred most commonly in patients with normal karyotype, and those 
with FLT3/ITD and NPM mutations. Patients with IDH1(R132) mutations trended toward higher median 
diagnostic WBC (59.2 x 10(9) vs 29.1 x 10(9) per liter, p = 0.19) than those without mutations, but the 
2 groups did not differ significantly in age, bone marrow blast percentage, OS or relapse-free survival. 
Eleven patients (2.1%) harbored a novel V71I sequence alteration, which was found to be a germ-line 
polymorphism. In addition to the abovementioned mutations, 58 patients (12%) had silent G105G 
polymorphisms, 11 of which also harbored an additional, novel V71I sequence alteration. Recent studies 
have demonstrated that the presence of these synonymous SNP are associated with clinical outcome.96 As 
a result we inquired whether presence of SNP rs11554137 is associated with clinical outcome in pediatric 
and adult AML. Early studies from AAML03P1 demonstrated that presence of V71I was associated with 
improved outcome, where those with this polymorphism did not relapse. This data is being validated in a 
larger cohort of pediatric AML as well as adult patients treated on SWOG trials. 
 
RUNX1 mutations: The RUNX1 gene (previously AML1) encodes the alpha subunit of core binding factor 
(CBFα), which is implicated in normal and malignant hematopoiesis. Translocations involving RUNX1 
have been associated with favorable prognosis in acute leukemias (e.g., t(8;21) in AML and t(12;21) in 
ALL). Point mutations of RUNX1 have been identified in exon 3 and exon 8 of RUNX1 gene in a subset of 
AML patients and are most closely associated with myelodysplastic syndrome (MDS) associated AML and 
AML subtype M0. We evaluated the prevalence and prognostic significance of RUNX1 mutations in 
pediatric patients with de novo AML treated on pediatric AML trials CCG2941 and CCG2961. Initial 
evaluation of exon 3 and exon 8 of RUNX1 gene was conducted on a cohort of 100 randomly selected 
patient specimens. In this initial analysis, we identified 4 missense mutations of exon 3 that resulted in 
sequence alteration. No exon 8 mutations were identified. Subsequent molecular genotyping of the 
remaining 484 patient specimens were limited to exon 3. Of the 584 diagnostic specimens tested, missense 
mutations of exon 3 were detected in 19 patients (3.3%). All detected mutations were missense mutations 
at nucleotide 167 (T to C) causing a leucine to serine conversion at amino acid 56 (L56S). Two patients 
had silent mutations (G to A at base pair 182, G182G). Demographic, laboratory characteristics and clinical 
outcome was compared between those with and without RUNX1 mutations. There was no significant 
difference with regards to age, gender or race between these groups. Those with RUNX1 mutations had a 
significantly lower prevalence of organomegaly (11% vs. 32%, p < 0.05) and significantly higher rate of 
extramedullary disease (chloroma 26% vs. 10%, p < 0.05). There was no significant difference in 
association with other known cytogenetic abnormalities or risk groupings (standard, low, or high risk 
grouping on these studies). t(8;21) translocations were detected in 22% of those with RUNX1 mutations 
compared to 16% of those without mutation (p=0.6) and there was no RUNX1 mutation detected in patients 
with inv(16). Of the 85 patients with FLT3/ITD, NPM1 or CEBPα mutations, only 3 patients had the 
concomitant RUNX1 mutation (2 with FLT3/ITD and 1 with NPM1 mutation). Remission induction rate 
was compared between patients with and without RUNX1 mutations. Those with RUNX1 mutations had a 
similar CR rates to those without mutations (89% vs. 79%, p = 0.4). Overall survival from remission for 
patients with and without RUNX1 mutation was 38% and 60% respectively (p = 0.1) with a corresponding 
DFS of 34% vs. 49%. RUNX1 mutations may represent biologically distinct groups that are present in 3.3% 
of pediatric AML patients across different morphologic and cytogenetic populations. Alterations of RUNX1 

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are implicated in signal transduction pathway and may be exploited in defining a population for directed 
and risk based therapy. 
 
TET2 mutations: Deletions and rearrangements involving chromosome 4q24 in patients with 
myelodysplastic syndrome lead to the discovery that the TET2 gene found in this genomic region may be 
important to myeloid cancers. The function of TET2 is unknown although it is likely a tumor suppressor 
gene since full deletions of the gene have been demonstrated in some MDS patients. Further study has 
demonstrated that TET2 mutations are found in acute myeloid leukemia. Abdel-Wahab, et al.97 reported a 
prevalence of 12% (11 of 91 patients) in adults with primary AML. We tested a cohort or 172 pediatric 
patients treated on the study CCG2961. DNA was isolated from diagnostic bone marrow samples. All 
11 exons of the TET2 gene were amplified by PCR then sequenced for mutational analysis. Excluding 
synonymous mutations, mutations found in the single nucleotide polymorphism database (dbSNP) and 
mutations described as SNP by Abdel-Wahab, et al.97, there were 9 heterozygous missense mutations 
(K423R, N767D, R814H, E1010D, S1039L, A1443V, V1718L, H1817N and E1973K), 2 heterozygous 
nonsense mutations (Q958X and E1323X) and one heterozygous single base insertion (ins1870-1871) 
which caused a frame shift beginning with T624N and causing an early termination codon (E637X). Each 
mutation was found in a single patient sample except for 1 missense mutation (V1718L) which was found 
in 2 samples. Also, 1 patient sample had 2 missense mutations (E1010D and E1973K) and another patient 
sample contained both of the nonsense mutations. Therefore a total of 11 out of 172 samples (6.4%) had a 
TET2 mutation. 
 
c-CBL mutations: c-CBL encodes an ubiquitin ligase that targets multiple activated tyrosine kinases for 
degradation. Analysis of several series of patients with myeloid malignancies demonstrated mutations in 
the RING finger domain and linker domains (encoded by exons 8 and 9 of the c-CBL gene). Loh, et al98 
analyzed 157 samples from pediatric patients with juvenile myelomonocytic leukemia (JMML) for 
mutations in exons 8 and 9 of the c-CBL gene. They found c-CBL mutations in 27 of the 157 samples 
(17% prevalence). We sought to determine the prevalence of mutations in c-CBL exons 8 and 9 in pediatric 
patients with de novo AML. We analyzed 290 samples from pediatric patients treated on the study 
AAML03P1. DNA was isolated from diagnostic bone marrow samples. Exons 8 and 9 of the TET2 gene 
were amplified by PCR then sequenced for mutational analysis. One patient sample had a heterozygous 
splice site mutation (1,096 -1G > T). One patient sample had a homozygous missense mutation (C384S). 
Two samples each had a synonymous heterozygous mutation (P433P and I429I). We also found that 
3 samples had heterozygous insertions and deletions that included part of these exons. One sample had a 
121 base pair deletion that included 66 base pairs at the 3’ end of exon 8 and the first 55 base pairs of intron 
8. Another sample had complex insertion/deletions with deletion of 73 base pairs including 31 base pairs 
in intron 7 and 42 base pairs at the 5' end of exon 8 along with an insertion of 26 base pairs at the site of 
the deletion. A third sample had a 3 base pair duplication in exon 9 (1,382 - 1,383 ins TGA) with TGA 
repeated 7 rather than 6 times. Excluding the synonymous mutations, there were a total of 5 samples out of 
290 (1.7%) with c-CBL exon 8 or 9 mutations. Therefore c-CBL mutations in the RING finger and linker 
domains are rare in pediatric de novo AML compared to the previously reported prevalence in JMML. 
 
2.8.6 
Correlate the expression of CD74 antigen as well as PSMB5 gene expression and mutation with 
response to bortezomib 
 
CD74 expression determination: CD74 is a major histocompatibility complex molecule which signals 
thru NF-κB. In a study by Attar et al15 it was shown that CD74 expression level correlated with response to 
bortezomib. In this study CD74 was expressed at a 6-fold increase in patients who achieved a CR compared 
with patients who failed Induction (p = 0.06). As part of our diagnostic evaluations of marrow specimens 
by flow cytometry, we will evaluate CD74 expression level in all patients enrolled on AAML1031. CD74 
antibody can be included with ease into our diagnostic panel and expression level of CD74 on blast cells 
determined. CD74 expression will be subsequently correlated with CR and relapse rates in patients with 

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and without exposure to bortezomib to determine whether CD74 exposure correlates with response to 
bortezomib. 
 
PSMB5 mutations and expression: The ubiquitin-proteasome pathway plays an essential role in the 
degradation of cellular proteins. The C-terminal glycine residues of poly ubiquitin chains conjugate to 
specific lysine moieties on the protein targeted for degradation. The proteasome is a 26S enzyme complex 
that comprised of a core 20S catalytic complex and a 19S regulatory complex. Within the 20S core, proteins 
are degraded to small peptides. The 20S proteasome core has chymotrypsin- like, trypsin-like, and peptidyl 
glutamyl-like activities that are associated with three distinct units: b5, b2, b1, respectively. Chymotrypsin-
like activity at proteasome b5 subunit (PSMB5) is associated with the rate-limiting step of proteolysis. 
Recent data suggest that genomic alterations, SNPs and expression variations of PSMB5 gene may mediate 
response to bortezomib.99,100 Investigators created high levels of acquired resistance to bortezomib in THP1 
cells by exposure to increasing concentrations of bortezomib and demonstrated an Ala49Thr mutation 
residing in the bortezomib-binding pocket in the PSMB5 protein. 
 
2.8.7 
Evaluation of Protein Expression and Unfolded Protein Response in Patients with AML 
Understanding the changes in protein expression that occur in “bulk” leukemia cells and in leukemia 
initiating cells (LIC) in response to conventional and targeted chemotherapy is crucial to determining how 
LIC evade chemotherapy. We have recently developed the means to study protein expression and activation 
in small numbers of cells using reverse-phase protein lysate array (RPPA) technology. Using this technique 
we can globally assess the effects of targeted anti-cancer agents on the proteome by studying protein 
expression and phosphorylation of over 200 proteins using as few as 200,000 myeloblasts. We plan to use 
RPPA to identify protein pathways that correlate with bulk leukemia and LIC response to therapy. While 
previous work in adult AML has demonstrated that functional proteomic profiling can predict treatment 
response and survival,101 no functional proteomic profiling or unfolded protein response data are available 
in the pediatric AML population. We hypothesize that functional proteomic profiling and analysis of the 
unfolded protein response (UPR) will allow us to 1) further characterize the protein pathways associated 
with LIC and bulk leukemia cell response to bortezomib and sorafenib treatment, and 2) help to identify 
biomarkers of either clinical response or therapy resistance. Induction of the endoplasmic-reticulum (ER) -
mediated UPR and the triggering of autophagy may be important to targeting LIC. Properties that 
distinguish LIC from their normal counterparts have been characterized14,102 and these properties have been 
used to identify anti-LIC targets.101,103 Among these are the NF-B pathway and pathways controlled by 
the ubiquitin-proteasome pathway which regulate how rapidly AML cells multiply, die or mature.18 
Bortezomib is known to block NF-B activation, to trigger the UPR104 and to induce autophagy in many 
cell types105-107 suggesting that this may be a means of selectively enhance LIC targeting. Sorafenib also 
targets the LIC through its effects on FLT3 inhibition.101 
 
2.8.8 
Expression Levels of Wild Type FLT3 and it’s In Vitro Response to FLT3 Inhibitor Sorafenib. 
We have demonstrated that expression level of wild type FLT3 correlates with clinical outcome and those 
with high wild type FLT3 (WT-FLT3) expression are exquisitely sensitive to pro-apoptotic effects of FLT3 
inhibitors. We will prospectively evaluate the expression of FLT3 by flow cytometry (included in diagnostic 
flow platform) as well as by RT-PCR and define its impact on outcome. This approach may identify 
additional high risk patients who may benefit from therapy with FLT3 inhibitors. In addition, in vitro 
cytotoxicity will be performed on specimens identifed to have high versus low FLT3 expression in order to 
demonstrate correlation of in vitro response to FLT3 expression levels.  
 
2.8.9 
Sorafenib Pharmacokinetics and Pharmacodynamics 
The sorafenib dosing needed to achieve adequate mutant FLT3/ITD inhibition is poorly understood because 
of the very few patients treated with sorafenib/chemotherapy combinations and very limited data on the 
role of the sorafenib N-oxide metabolite. Thus, this trial will use a limited sampling approach to determine 
sorafenib and N-oxide metabolite exposure in plasma. Steady state PK sampling with each course of 

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Induction and Intensification and at various time points during the maintenance phase will provide 
information on systemic exposure to sorafenib and its N-oxide metabolite. These data can be compared to 
pharmacokinetic data obtained during ADVL0413 Phase I study of sorafenib in children and extension 
study in FLT3/ITD leukemia. In addition, the pharmacokinetic-pharmacodynamic relationship of 
FLT3/ITD inhibition will be studied using a plasma inhibitory assay (PIA) and trough plasma sorafenib and 
N-oxide metabolite concentrations. While standard PK assays accurately measure the concentration of total 
drug in plasma, they do not measure the amount of free drug, which varies widely depending upon the 
affinity of a drug for the various plasma proteins (e.g., albumin, alpha-1-acid glycoprotein (AGP) and the 
concentration of these proteins in an individual patient’s plasma. Since only the free, unbound fractions of 
sorafenib and the N-oxide metabolite are available to inhibit FLT3 in target cells, and since these 
compounds are known to be highly bound to plasma proteins, PK values cannot necessarily be used as a 
valid surrogate for biologic activity. The PIA assay is a pharmacodynamic (PD) assay can serve as a 
powerful surrogate for in vivo FLT3 inhibition in patients receiving sorafenib by measuring the amount of 
FLT3 inhibitory activity in plasma taken from patients just before and at various trough time points during 
sorafenib therapy. These data will be correlated with PK measurements from the same time points to 
determine the PK-PD relationship for sorafenib and its N-oxide metabolite. 
 
2.8.10  Serum Biomarkers for the Prediction of Graft-Versus-Host Disease in Children 
Approximately 45% of the children receiving allogeneic bone marrow transplants will develop GVHD of 
the skin, GI tract, or liver, of sufficient severity to warrant additional treatment despite advances in HLA-
matching techniques and GVHD prophylaxis strategies.108 Children experiencing moderate to severe 
GVHD (extensive rash, diarrhea, or jaundice) are twice as likely to die as those who experience no or mild 
GVHD [no more than a limited skin rash; relative risk = 1.96].108 Given the danger associated with GVHD 
and its treatment, there has been considerable interest in identifying patients at highest risk for GVHD. 
While clinical factors such as donor type (related, unrelated, cord) and HLA-match permit some calculation 
of GVHD risk,109 the choice of donor or HLA-match is typically constrained by limited availability. Recent 
research at the University of Michigan has identified several proteins in the bloodstream (biomarkers) that 
are associated with GVHD.110-112 Increased concentrations of one biomarker, TNFR1, measured 7 days 
post-SCT, correlated with GVHD risk in both pediatric (n = 82) and adult (n = 356) patients.113,114 These 
observations were extended to create a day 7 biomarker panel in primarily adult patients that included 4 
biomarkers: TNFR1, IL-2Rα, REG3α (a lower gastrointestinal-specific GVHD biomarker) and elafin (a 
skin-specific GVHD biomarker). The 4 protein panel identified GVHD after unrelated donor SCT with 
67% sensitivity and 50% specificity.115,116 We now have preliminary data that shows the combination of 
pre-SCT clinical factors (e.g. degree of HLA-match) and the 4 biomarker panel effectively predicts for 
GVHD following related donor SCT. Patients identified as high risk were twice as likely to develop GVHD 
(38% vs. 20%, p  < .001), which translated into significantly higher risk for non-relapse mortality (12% vs. 
3%, p = .001). 
 
The data from related and unrelated patients was mostly derived from adult patients. Therefore, the goal of 
this aim is to develop a pediatric specific algorithm using a similar strategy. There are several reasons why 
a pediatric algorithm will be different from adults. First, preliminary data showed that the absolute values 
of GVHD biomarker concentrations in 96 children were half the value of those in 456 adults. Predictive 
algorithms assign a specific weight to each clinical factor and biomarker concentration, thus biomarkers 
will be weighted differently in a pediatric algorithm. Furthermore, differences in clinical factors (e.g. more 
common use of cord blood as stem cell source) exist between the pediatric and adult population, and these 
differences will influence the predictive algorithm. A first step to developing a GVHD prediction algorithm 
in children is to study a fairly homogeneous population as is available on this protocol which involves 
patients with one underlying disease (AML), a preferred conditioning regimen and specified GVHD 
prophylaxis regimen. These results will form a baseline for future studies involving more heterogeneous 
populations.  
 

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2.8.11 Biology Specimen Collection at Diagnosis, Treatment Time Points, and Relapse 
The banking of biologic specimens is a requirement for innovative and potentially therapeutic biologic 
studies. Thus, this trial will strongly encourage banking of specimens at diagnosis, scheduled bone marrow 
evaluations, and relapse. 
 
 
 
3.0 
STUDY ENROLLMENT AND PATIENT ELIGIBILITY 
 
3.1 
Study Enrollment 
 
3.1.1 
Patient Registration  
Prior to enrollment on this study, patients must be assigned a COG patient ID number. This number is 
obtained via the OPEN (Oncology Patient Enrollment Network) system once authorization for the release 
of protected health information (PHI) has been obtained. The COG patient ID number is used to identify 
the patient in all future interactions with COG. If you have problems with the registration, please refer to 
the online help.  
 
In order for an institution to maintain COG membership requirements, every newly diagnosed patient needs to 
be offered participation in ACCRN07, Protocol for the Enrollment on the Official COG Registry, The 
Childhood Cancer Research Network (CCRN) or APEC14B1, Project:EveryChild. 
 
A Biopathology Center (BPC) number will be assigned as part of the registration process. Each patient will be 
assigned only one BPC number per COG Patient ID. For additional information about the labeling of specimens 
please refer to the Pathology and/or Biology Guidelines in this protocol.  
 
3.1.2 
IRB Approval 
Local IRB/REB approval of this study must be obtained by a site prior to enrolling patients. Sites must 
submit IRB/REB approvals to the NCI’s Cancer Trials Support Unit (CTSU) Regulatory Office and allow 
3 business days for processing. The submission must include a fax coversheet (or optional CTSU IRB 
Transmittal Sheet) and the IRB approval document(s). The CTSU IRB Certification Form may be submitted 
in lieu of the signed IRB approval letter. All CTSU forms can be located on the CTSU web page 
(https://www.ctsu.org). Any other regulatory documents needed for access to the study enrollment screens 
will be listed for the study on the CTSU Member’s Website under the RSS Tab. 
 
IRB/REB approval documents may be submitted via the online portal via www.ctsu.org in the members’ 
section) under the Regulatory Submission Portal, faxed (1-215-569-0206), E-mailed 
(CTSURegulatory@ctsu.coccg.org) or mailed to the CTSU Regulatory office. 
 
When a site has a pending patient enrollment within the next 24 hours, this is considered a “Time of Need” 
registration. For Time of Need registrations, in addition to marking your submissions as ‘URGENT’ and 
faxing the regulatory documents, call the CTSU Regulatory Helpdesk at: 1(866) 651-CTSU. For general 
(non-regulatory) questions call the CTSU General Helpdesk at: 1(888) 823-5923. 
 
3.1.3  Health Related Quality-of-Life and Parental Stress Assessments 
These studies are closed to new patient accrual as of 05-15-2015. 
Participation in the HRQOL and parental stress assessments is optional but strongly encouraged for patients 
between the ages of 2 years old and 18 years old (≥ 2 years and ≤ 18 years) with a parent/guardian who is 
able to speak and read English. Those under the age of 2 years and those 19 years old and over will not be 
eligible. For those who agree to the HRQOL and parental stress study, parents or alternative caregivers 
must provide assessments while children ≥ 5 years of age who can understand English will be given the 
opportunity to concurrently participate and provide self-report HRQOL data. The institutional CRA will be 

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34 
responsible for ensuring the quality of life and parental stress assessments are completed at the appropriate 
time points, and entry of responses into the COG eRDE system. See Section 18 for further details. 
 
3.1.4 
Study Enrollment 
Patients may be enrolled on the study once all eligibility requirements for the study have been met. Study 
enrollment is accomplished by going to the Enrollment application in the RDE system. If you have problems 
with enrollment, refer to online help in the Applications area of the COG website.  
 
3.1.5 
Timing 
Patients must be enrolled before treatment begins. The date protocol therapy is projected to start must be no 
later than five (5) calendar days after the date of study enrollment. Administration of IT chemotherapy is 
permitted before enrollment when administered as part of an initial diagnostic lumbar puncture. 
 
3.1.5.1 Cytogenetics 
Specimens for cytogenetics analysis are required, must be obtained prior to therapy initiation, and it 
is strongly recommended that they be sent to a COG-approved institutional cytogenetics laboratory 
(see Section 16.2). A listing of these laboratories may be found on the protocol web page as well as methods 
of attaining COG approval for local cytogenetics laboratories without COG approval. 
 
Because the chromosome analysis results should be finalized by the end of Induction I, and will be used for 
subsequent risk stratification and in order to guide therapy by Day 28 of a patient’s enrollment, the reports 
should be sent to the appropriate reviewer by Day 14 (see Appendix V). With Amendment #7A, only 
those patients with HR FLT3/ITD (AR > 0.4) who consent to Arm C should have cytogenetic data 
sent for Central Review. 
 
Results of cytogenetics are not required to be completed prior to enrollment, but samples must be collected 
prior to therapy initiation and submitted to a cytogenetics laboratory. 
 
3.1.5.2 FLT3, NPM and CEBPα Mutation Analysis 
Specimens for FLT3 (with ITD allelic ratio testing) mutation analysis will be used for risk assignment, 
must be obtained prior to therapy initiation, and must be performed at the Molecular Oncology 
Laboratory at the Seattle Cancer Care Alliance (SCCA). Testing is free of charge to the patient.  
 
With Amendment #7A, NPM1 and CEBPα testing will no longer be done as part of the clinical 
protocol but remain part of best clinical practice. 
 
Patients enrolled prior to Amendment #7A that do not have adequate specimens submitted will receive a 
risk assignment based upon other criteria. For patients enrolled after Amendment #7A, adequate specimen 
must be submitted in order to determine FLT3/ITD allelic ratio. Per Amendment #7A, patients with 
unknown FLT3/ITD status at End of Induction I on Arm D will be removed from study with no further 
data submission. See Section 14.0 for specimen collection and shipping details.  
 
Results of FLT3 testing are not required to be completed prior to enrollment, but samples must be collected 
prior to therapy initiation and submitted to the SCCA. 
 
3.1.5.3 MRD Analysis 
Specimens for MRD analysis at the end of Induction I are required, and must be obtained prior to 
start of Induction II. Samples must be sent to the central laboratory for MRD determination 
(Hematologics Inc.). The result of the MRD analysis will be used for risk assignment. All patients that do 
not have adequate specimens submitted will receive a risk assignment based upon other criteria. See 
Section 15.0 for specimen collection and shipping details.  

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3.1.6 
Clarification of Consent for Diagnostic Bone Marrow Samples 
It is recommended that patients initially provide consent for drawing and shipping extra bone 
marrow/peripheral blood. This may spare the child from having a second procedure. Investigators may use 
the sample consent for bone marrow sampling provided with this protocol or may use their own institutional 
consent for diagnostic bone marrow sampling. If an institutional consent is used, it should include within it 
that extra samples of bone marrow will be obtained and shipped for potential research studies should the 
diagnosis of AML be made. 
 
Once the diagnosis of acute leukemia is confirmed and AML is diagnosed, a separate consent must be 
completed prior to enrollment onto AAML1031. Permission to use the extra bone marrow samples for the 
performance of research studies will be obtained within this therapeutic study consent. The consent that 
pertains to the bone marrow sampling should permit the immediate shipment of the samples to the AML 
reference laboratory. This will maximize the viability of the samples. The samples will only be kept if the 
patient enrolls on AAML1031 and only if the patient’s family has approved their use as identified in the 
therapeutic study consent. In other words, the samples for those who do not enroll on AAML1031 for any 
reason will be destroyed. If, at any time, in the future, the patient wants banked tissue destroyed, the COG 
tissue bank must be notified immediately by the local institution and the RDE system will be updated and 
forwarded to the appropriate Reference Laboratory, who will destroy the tissue. Patients must be informed 
that their tissue can only be prospectively destroyed; that is, any research studies that have already been 
conducted prior to the date that they decided they wanted their tissue destroyed cannot be amended. 
 
3.1.7 
Inclusion of Women and Minorities 
Men, women and children of all races and ethnic groups are eligible for this study. To allow non-English 
speaking patients to participate in the study, bilingual health care services will be provided in the appropriate 
language. 
 
3.1.8 
Randomization 
As of Amendment #7A accrual goals for Arms A and B have been met and as such, there will be no 
randomization on AAML1031. Rather, patients enrolled after Amendment #7A with unknown FLT3 status 
at time of study enrollment will be offered treatment with standard induction chemotherapy treatment arm 
(Arm D, see Section 4.11.1) while FLT3 testing is being performed. 
 
Patients later determined to have HR FLT3/ITD+ AML, will be offered re-allocation from Arm D to the 
sorafenib treatment arm (Arm C, see Section 4.10.1), whereas patients determined not to have HR 
FLT3/ITD+ AML will be removed from study with no further data submission. Patients whose FLT3/ITD 
status is unknown at End of Arm D Induction I will be removed from study with no further data submission, 
as will  HR FLT3/ITD+ patients who decline  Arm C treatment.  
 
Patients with known HR FLT3/ITD+ AML prior to study enrollment will be offered to enroll directly onto 
the sorafenib treatment arm (Arm C). 
 
3.2 
Patient Eligibility Criteria 
Important note: The eligibility criteria listed below are interpreted literally and cannot be waived (per 
COG policy 7.12). All clinical and laboratory data required for determining eligibility of a patient 
enrolled on this trial must be available in the patient's medical/research record which will serve as the 
source document for verification at the time of audit.  
 
All clinical and laboratory studies to determine eligibility must be performed within 7 days prior to 
enrollment unless otherwise indicated. BMA/biopsy must be obtained within 2 weeks prior to start 
of protocol therapy (repeat the BMA/biopsy if necessary). 

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INCLUSION CRITERIA 
 
3.2.1 
Age 
Patients must be less than 30 years of age at the time of study enrollment. 
 
3.2.2 
Diagnosis 
Patients must be newly diagnosed with de novo acute myelogenous leukemia.  
 
3.2.2.1 
Patients with previously untreated primary AML who meet the customary criteria for AML with ≥ 20% 
bone marrow blasts as set out in the 2008 WHO Myeloid Neoplasm Classification are eligible.117 
 
Attempts to obtain bone marrow either by aspirate or biopsy must be made unless clinically prohibitive. In 
cases where it is clinically prohibitive, peripheral blood with an excess of 20% blasts and in which adequate 
flow cytometric and cytogenetics/FISH testing is feasible can be substituted for the marrow exam at diagnosis.  
 
3.2.2.2 
Patients with < 20% bone marrow blasts are eligible if they have:  
▪ 
A karyotypic abnormality characteristic of de novo AML (t(8;21)(q22;q22), inv(16)(p13q22) or 
t(16;16)(p13;q22) or 11q23 abnormalities,  
▪ 
The unequivocal presence of megakaryoblasts, or 
▪ 
Biopsy proven isolated myeloid sarcoma (myeloblastoma; chloroma, including leukemia cutis).  
 
3.2.3 
Performance Level  
Patients with any performance status are eligible for enrollment. 
 
3.2.4 
Prior Therapy 
Prior therapy with hydroxyurea, all-trans retinoic acid (ATRA), corticosteroids (any route), and IT cytarabine 
given at diagnosis is allowed. Hydroxyurea and ATRA must be discontinued prior to initiation of protocol 
therapy. Patients who have previously received any other chemotherapy, radiation therapy or any other 
antileukemic therapy are not eligible for this protocol.  
 
EXCLUSION CRITERIA 
 
3.2.5 
Excluded Constitutional Conditions 
Patients with any of the following constitutional conditions are not eligible:  
▪ 
Fanconi anemia  
▪ 
Shwachman syndrome 
▪ 
Any other known bone marrow failure syndrome 
▪ 
Patients with constitutional trisomy 21 or with constitutional mosaicism of trisomy 21  
 
Note: Enrollment may occur pending results of clinically indicated studies to exclude these conditions.  
 
3.2.6  Other Excluded Conditions 
Patients with any of the following oncologic diagnoses are not eligible: 
▪ 
Any concurrent malignancy 
▪ 
Juvenile myelomonocytic leukemia (JMML) 
▪ 
Philadelphia chromosome positive AML 
▪ 
Biphenotypic or bilineal acute leukemia  
▪ 
Acute promyelocytic leukemia 

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37 
▪ 
Acute myeloid leukemia arising from myelodysplasia 
▪ 
Therapy-related myeloid neoplasms 
 
Note: Enrollment may occur pending results of clinically indicated studies to exclude these conditions.  
 
3.2.7 
Pregnancy and Breast Feeding: 
 
3.2.7.1 
Female patients who are pregnant are ineligible since fetal toxicities and teratogenic effects have been noted 
for several of the study drugs. 
 
3.2.7.2 
Lactating females are not eligible unless they have agreed not to breastfeed their infants. 
 
3.2.7.3 
Female patients of childbearing potential are not eligible unless a negative pregnancy test result has been 
obtained. 
 
3.2.7.4 
Sexually active patients of reproductive potential are not eligible unless they have agreed to use an effective 
contraceptive method for the duration of their study participation and for 30 days after the last dose of 
sorafenib. 
 
REGULATORY  
 
3.2.8 
All patients and/or their parents or legal guardians must sign a written informed consent. 
 
3.2.9 
All institutional, FDA, and NCI requirements for human studies must be met. 
 
3.3 
Definitions 
 
3.3.1 
INITIAL WBC: The first WBC at the treating COG institution.  
 
3.3.2 
INITIAL PLATELET COUNT: The first platelet count at the treating COG institution, or the count before 
transfusion of platelets if transfused prior to arrival. 
 
3.3.3 
INITIAL HEMOGLOBIN: The first hemoglobin at the treating COG institution, or the hemoglobin prior 
to intravenous fluid or red cell transfusions, whichever occurred first. 
 
3.3.4 
CNS LEUKEMIA AT DIAGNOSIS: 
 
3.3.4.1 
CNS disease at diagnosis is defined as:  
 
Any number of blasts on a cytospin prep in an atraumatic (< 100 RBCs) lumbar puncture. 

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38 
 
Blasts in a traumatic tap in which the WBC/RBC ratio in the CSF is twice that in the peripheral blood. 
 
Clinical signs of CNS leukemia (such as facial nerve palsy, brain/eye involvement or 
hypothalamic syndrome). Extra-ocular orbital masses are not considered CNS leukemia. 
 
Radiographic evidence of an intracranial, intradural mass consistent with a chloroma. 
 
3.3.4.2 
METHOD OF EVALUATING INITIAL TRAUMATIC LUMBAR PUNCTURES: 
 
If the patient has leukemic cells in the peripheral blood and the lumbar puncture is traumatic and contains  
blasts, the following algorithm should be used to diagnose CNS disease: 
 
CSF WBC  
> 2X   
Blood WBC 
CSF RBC  
 
 
Blood RBC 
 
A patient with CSF blasts, whose CSF WBC/RBC is 2X greater than the blood WBC/RBC 
ratio, has CNS disease at diagnosis. Example: CSF WBC = 60/μL; CSF RBC = 1,500/μL; blood 
WBC = 46,000/μL; blood RBC = 3 X 106/μL: 
 
  60  = 0.04  
> 2X   
 46,000      = 0.015 
1,500   
 
 
3 X 106 
 
3.3.5 
RISK CATEGORY STRATIFICATION 
AAML1031 is utilizing stratification for relapse risk to guide both therapy and analyses. The section below 
outlines and defines the 2 risk categories – Low and High Risk. These classifications should be made no 
later than Day 1 of Induction II. 
 
HIGH RISK: 
1) FLT3/ITD+ with high allelic ratio > 0.4 (HR FLT3/ITD+) regardless of low risk features. 
 
2) Presence of monosomy 7, monosomy 5, or del5q, without inv(16)/t(16;16) or t(8;21) cytogenetics 
or NPM or CEBPα mutations. 
 
3) AML without inv(16)/t(16;16), t(8;21), NPM, CEPBα mutations, monosomy 7, monosomy 5, 
del5q, or HR FLT3/ITD+, but with evidence of residual AML (MRD ≥ 0.1%) at end of Induction I. 
 
4) AML without inv(16)/t(16;16), t(8;21), NPM, CEPBα mutations, monosomy 7, monosomy 5, 
del5q, or HR FLT3/ITD+, but with clinical or radiographic evidence of progressive extramedullary 
AML at end of Induction I. 
 
All patients in this category will receive SCT, if possible, after Intensification I. Those for whom no suitable 
alternative donor can be found should continue with their assigned chemotherapy regimen. 
 
LOW RISK: 
1) Presence of inv(16)/t(16;16) or t(8;21) cytogenetic features or NPM or CEBPα mutation regardless 
of monosomy 7, monosomy 5, or del5q and regardless of MRD at end of Induction I.  
 
2) Negative MRD (< 0.1%) at end of Induction I and no high risk disease features. 
 

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These patients do NOT receive SCT in first remission, regardless of whether a matched related donor is 
available.  
 
Note: Patients who do not have MRD data and have non-informative molecular studies (NPM, CEBP, 
and cytogenetics) will be classified as having Low Risk disease. Patients with multiple MRD measurements 
will be risk stratified based on the most recent MRD measurement.  
 
RISK ASSIGNMENT:  
Low Risk 
High Risk 
 
LR Group 1 
LR Group 2 
HR Group 1 
HR Group 2 
HR Group 3 
FLT3 ITD allelic ratio 
Low/Negative Low/Negative 
High 
Low/Negative 
Low/Negative 
Good risk molecular 
markers* 
Present 
Absent 
Any 
Absent 
Absent 
Poor risk cytogenetic 
markers** 
Any 
Absent 
Any 
Present 
Absent 
Minimal residual disease 
Any 
Negative 
Any  
Any 
Positive 
+ Groups are based upon combinations of risk factors which may be found in any individual patient 
*NPM1, CEBPa, t(8;21), inv(16) 
**Monosomy 7, Monosomy 5, del(5q) 
Bold indicates the overriding risk factor in risk group assignment 
 
3.4 
Pre-Enrollment Baseline Diagnostic Requirements 
See Section 7.0 for all required and recommended baseline pre-enrollment evaluations. 
 
 
 
 

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4.0 
TREATMENT PLAN 
 
 
 
 
 
 
4.1 
Overview of Treatment Plan 
With Amendment #7A, Arms A and B are closed to new patient enrollment as accrual goals have been met. 
Patients enrolled on AAML1031 prior to Amendment #7A who were randomized to either Arm A or Arm 
B received either a 3 or 4 course chemotherapy backbone. Patients with low risk AML will receive 
cytarabine/daunorubicin/etoposide (ADE 10+3+5), cytarabine/daunorubicin/etoposide (ADE 8+3+5), 
cytarabine/etoposide (AE), and cytarabine/mitoxantrone (ARAC/Mitox). Patients with high risk AML 
received 3 courses of chemotherapy followed by best allogenic donor SCT if available. These high risk 
AML patients received cytarabine/daunorubicin/etoposide (ADE 10+3+5), cytarabine/mitoxantrone 
(ARAC/Mitox), and cytarabine/etoposide (AE). Patients with high risk AML who did not have an 
appropriate allogenic donor received high dose cytarabine/L-Asparaginase (HD ARAC/LASP) as a fourth 
course.  
 
With Amendment #7A, patients with HR FLT3/ITD+ AML enrolled on the sorafenib treatment arm (Arm 
C) 
will 
receive 
3 
courses 
of 
chemotherapy 
in 
combination 
with 
sorafenib: 
cytarabine/daunorubicin/etoposide (ADE 10+3+5), cytarabine/daunorubicin/etoposide (ADE 8+3+5), 
cytarabine/etoposide (AE), followed by best allogenic donor SCT. Patients with HR FLT3/ITD+ who do 
not have an appropriate allogenic donor will receive sorafenib with ARAC/Mitox as a fourth course of 
chemotherapy. Finally, all patients allocated to the sorafenib treatment arm will be eligible to receive a one 
year sorafenib maintenance course.   
 
4.1.1 
Treatment Assignments 
Effective with Amendment #7A, Arms A and B are closed to new patient enrollment as accrual goals 
have been met; therefore, there will be no randomization on AAML1031 for patients enrolling after 
Amendment #7A. Patients enrolled prior to Amendment #7A will continue treatment per their 
initially assigned arm.  
 
Bortezomib safety analysis will be performed in an ongoing manner while patients are accrued. Formal 
interim bortezomib safety analysis will be performed (Section 9.3) in the first 100 patients without HR 
FLT3/ITD+ randomized to receive Arm B. Study suspension is not planned, but may be undertaken if 
needed, for this interim analysis. 
 
Patients with known HR FLT3/ITD+ status (from the SCCA central laboratory) at time of study entry will 
be enrolled onto the sorafenib treatment arm (Arm C). Should the patient decline treatment with sorafenib, 
the patient will not be enrolled on study.  
 
With Amendment #7A, patients with unknown FLT3/ITD allelic ratio prior to study entry will be offered 
enrollment on Arm D (standard pediatric AML Induction chemotherapy with ADE) while FLT3/ITD results 
are pending. Patients later found to have HR FLT3/ITD+ (prior to End of Arm D Induction I) will be offered 
treatment on the sorafenib treatment arm (Arm C). Patients with HR FLT3/ITD+ who decline participation 
in Arm C, patients without HR FLT3/ITD+, and patients with unknown FLT3/ITD status at End of Arm D 
Induction I will be removed from study with no further data submission. Patients enrolled prior to 
Amendment #7A, currently on therapy, and now found to have HR FLT3/ITD+ after initial randomization, 
will be offered participation in the sorafenib treatment arm (Arm C). Patients initially randomized to Arm B 
will stop bortezomib as soon as consent is obtained for participation in the sorafenib Arm C. 
Timing of protocol therapy administration, response assessment studies, and surgical interventions are based on 
schedules derived from the experimental design or on established standards of care. Minor unavoidable departures 
(up to 72 hours) from protocol directed therapy and/or disease evaluations (and up to 1 week for surgery) for valid 
clinical, patient and family logistical, or facility,  procedure and/or anesthesia scheduling issues are acceptable per 
COG administrative Policy 5.14 (except where explicitly prohibited within the protocol).  

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The sorafenib treatment arm entails 3 cohorts. Cohort 1 has been completed. Patients in Cohort 1 received 
sorafenib starting in Induction II and in the remaining chemotherapy courses. Cohort 1, which accrued and 
evaluated a total of 12 patients, determined that sorafenib at a dose of 200 mg/m2 daily given Day 1 to 
Day 28 is tolerable in combination with standard AML chemotherapy. Cohort 2, which accrued 34 patients, 
opened with Amendment #3a and later closed with Amendment #6A. Cohort 2 received 200 mg/m2 
sorafenib daily at the time of known HR FLT3/ITD+ (including in Induction I and concurrently with 
chemotherapy) until a safety memo was released on 04/27/2015 that resulted in subsequent sorafenib dosing 
being delayed until after conventional chemotherapy for a given course was complete. Cohort 3 opened 
with Amendment #6A and patients enrolled in Cohort 3 of Arm C receive sorafenib 200 mg/m2 daily. Per 
Amendment #6A, Cohort 3 sorafenib therapy starts on Day 11 of Induction I and continues until Day 28; 
Induction II and Intensification I, sorafenib starts on Days 9 and 6, respectively and is administered for a 
total of 28 days. While most Arm C patients proceed to hematopoietic stem cell transplant following 
Intensification I, should Intensification II treatment be administered, sorafenib would start on Day 7 and 
continue for 28 days. 
 
Any HR FLT3/ITD+ patient treated on Arm C will also be eligible for sorafenib maintenance. For Arm C 
patients who undergo SCT, sorafenib maintenance therapy must be started between Day 40 - 100 post-SCT 
and patients must meet baseline clinical criteria to initiate therapy (see Section 4.26). For Arm C patients 
who do not undergo SCT, sorafenib maintenance therapy must be started between Day 40 - 100 following 
Intensification II and patients must meet baseline clinical criteria to initiate therapy (see Section 4.26).  
 
4.1.2 
Stem Cell Transplant Assignments 
SCT allocation for patients will be based on risk stratification, to be determined no later than Day 1 of 
Induction II. Patients with low risk status will receive chemotherapy only and patients with high risk status 
will receive best allogenic donor SCT or alternative donor SCT depending on availability. All high risk 
patients without a suitable allogeneic or alternative donor will proceed to a final course of high dose 
cytarabine/L-Asparaginase (HD ARAC/LASP).  
 
All HR FLT3/ITD+ patients will receive best allogeneic donor SCT or alternative donor SCT depending 
on availability. Patients without a suitable allogeneic or alternative donor will proceed to a final course of 
cytarabine/mitoxantrone with sorafenib followed by 1 year of sorafenib maintenance. Enrollment on 
AAML05P1 will be permitted for patients with an available unrelated donor.  
 
4.1.3 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Participation in the HRQOL and parental stress assessments is optional but strongly encouraged for patients 
between the ages of 2 years old and 18 years old (≥ 2 years and ≤ 18 years) with a parent/guardian who is 
able to speak and read English. Those under the age of 2 years and those 19 years old and over will not be 
eligible. For those who agree to the HRQOL and parental stress study, parents or alternative caregivers 
must provide assessments while children ≥ 5 years of age who can understand English will be given the 
opportunity to concurrently participate and provide self-report HRQOL data.  
 
All eligible patients will be evaluated near diagnosis (within 14 days of Induction initiation), on or after 
Day 21 of Induction II but prior to start of Intensification I, and on or after Day 21 of Intensification I but 
prior to start of Intensification II. Patients assigned to chemotherapy in Intensification II will have 
evaluations 1 month (± 7 days) and 4 months (± 1 month) from the start of Intensification II, while patients 
assigned to SCT will have evaluations at 1 month (± 7 days) and 4 months (± 1 month) from the start of the 
preparative regimen. Evaluations 6, 7 and 8 occur at 12 (± 1 month), 24 (± 3 months) and 36 (± 3 months) 

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42 
months from diagnosis, respectively. Please see Section 18.0 for instructions on timing and specific test to 
be administered. 
4.1.4 
Standard Chemotherapy Dosing Guide 
Cytotoxic chemotherapy doses will be modified only for patients with a BSA < 0.6 m2. For patients with 
BSA < 0.6 m2, chemotherapy will be dosed in mg/kg, as specified in the treatment plan. 
 
Bortezomib and sorafenib will be dosed in mg/m2 for all patients.  
 
No chemotherapy dose modification will be made for obese patients except in stem cell transplant. 
These dosing guidelines are described in Section 4.24. 
 
Age and weight adjusted busulfan dosing guidelines are found in Section 4.24.3. 
 
4.2 
Concomitant Therapy Restrictions 
 
4.2.1 
Restrictions for all patients 
Myeloid growth factor support can be administered to patients in the following clinical scenarios: 
(1) prolonged neutropenia that is clinically significant; (2) clinical or culture proven bacteremia during 
neutropenia, or with invasive fungal infection. Growth factors should not be initiated before notification of 
the Study Chair. 
 
4.2.2 
Restrictions during Induction I, II and Intensification I (all treatment arms) 
Elimination of etoposide is partially mediated through cytochrome P450 3A4 (CYP3A4), CYP1A2 and 
2E1. The clinical outcome and significance of CYP450 interactions with etoposide is not clear. It is 
recommended to avoid concomitant administration with strong CYP3A4 inducers (refer to Appendix IV 
for a list of strong inducers for this protocol) when possible, given theoretical concerns for reduced clinical 
efficacy. Similarly, strong CYP3A4 inhibitors (refer to Appendix IV for a list of strong inhibitors for this 
protocol) should be avoided if possible. If concomitant administration is necessary, close monitoring for 
toxicity is recommended. Please consult frequently updated medical references for additional inducers or 
inhibitors of CYP450 isoenzymes.  
 
4.2.3 
Restrictions for patients receiving bortezomib  
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 avoided throughout therapy with 
bortezomib (refer to Appendix IV for a list of strong inducers for this protocol). 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 IV for a list of strong and clinically relevant moderate 
inhibitors for this protocol). Please consult frequently updated medical references for additional inducers 
or inhibitors of CYP450 enzymes. 
 
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.118,119 A more recent study 
has concluded that there is no interaction when plasma concentrations are commensurate with dietary oral 
intake.120 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 (e.g., vitamins, herbal 
supplements) be discontinued from at least 24 hours prior to the initiation of bortezomib through 72 hours 

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43 
after the last bortezomib dose. In addition, it is recommended that the total dietary intake of vitamin C not 
exceed the recommended daily allowance (RDA) for age (i.e., normally balanced diets are acceptable). 
 
 
 
4.2.4 
Restrictions for patients receiving sorafenib 
Sorafenib is primarily metabolized by cytochrome CYP3A4. While CYP3A4 inducers/inhibitors do not 
seem to substantially change sorafenib pharmacokinetics, levels of the N-oxide sorafenib metabolite are 
substantially altered by CYP3A4 inducers/inhibitors. Since the N-oxide metabolite has substantial activity 
against FLT3, concomitant administration of strong CYP3A4 inducers and inhibitors (including clinically 
relevant moderate inhibitors) is prohibited with the exception of voriconazole, fluconazole, and 
posaconazole in the sorafenib maintenance phase. Please refer to Appendix IV for a list of strong inducers 
and inhibitors for this protocol. Please consult frequently updated medical references for additional inducers 
or inhibitors of CYP450 enzymes. 
 
Sorafenib may increase systemic exposure to CYP2B6 or CYP2C8 substrates; caution is advised when 
substrates of CYP2B6 or CYP2C8 are used concomitantly with sorafenib. However, no CYP2B6 or 
CYP2C8 substrates are excluded.  
 
Sorafenib does not appear to affect the metabolism of warfarin (a CYP2C9 substrate) in vivo; however, 
infrequent bleeding events or elevations in the international normalized ratio (INR) have been reported in 
some patients receiving concomitant therapy with warfarin. Patients taking concomitant warfarin should be 
monitored regularly for changes in prothrombin time, INR or clinical bleeding episodes. 
 
4.3 
Dose Modifications for CNS Disease 
 
4.3.1 
Intrathecal Chemotherapy for CNS Disease 
 
CNS disease at diagnosis: Patients with CSF involvement will receive IT cytarabine twice weekly until 
the CSF is clear. A minimum of 4 intrathecal treatments must be given and a maximum of 6 intrathecal 
treatments may be given. Patients whose CSF is clear at the second spinal tap will receive 3 intrathecal 
treatments once the CSF is clear and all other patients will receive 2 intrathecal treatments once the CSF is 
clear. See Section 3.3.4 for definitions of CSF involvement.  
 
Patients with CNS chloromatous disease at diagnosis will receive 6 intrathecal treatments regardless of CSF 
blast count at diagnosis.  
 
CNS disease at the start of Induction II: If CSF involvement is present at start of Induction II but was not 
present at Induction I, patients will receive IT cytarabine twice weekly until the CSF is clear. A minimum 
of 4 intrathecal treatments must be given and a maximum of 6 intrathecal treatments may be given. Patients 
whose CSF is clear at the second spinal tap will receive 3 intrathecal treatments once the CSF is clear and 
all other patients will receive 2 intrathecal treatments once the CSF is clear. See Section 3.3.4 for definitions 
of CSF involvement.  
 
Patients with refractory CNS leukemia at the end of Induction I or Induction II will be taken Off Protocol 
Therapy for failure to attain remission. Patients with CNS disease at any time point after completion of 
Induction II will be taken Off Protocol Therapy for CNS relapse. See Section 10.2.2 and 10.2.3.  
 
4.3.2 
IT Chemotherapy Administration Timing 
The administration of subsequent IT chemotherapy in all courses of therapy after Induction I occurs on 
Day 1 of each course (except for the Intensification II course for high risk patients). It is permissible, to 
avoid additional sedation procedures, to administer this Day 1 dose of IT chemotherapy for Induction II, 
Intensification I, and Intensification II courses with the end of course bone marrow aspirations obtained for 
remission assessment at the end of the preceding course of therapy. 

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44 
 
 
4.4 
Evaluation of Marrow Status and Extramedullary Disease 
A bone marrow aspirate to assess remission status should be performed approximately 18 – 25 days after 
the last day of chemotherapy on each course. Bone marrow aspirate may be delayed beyond 25 days if 
adequate peripheral count recovery has not yet occurred. If the marrow is hypoplastic and/or there is little 
or no evidence of normal hematopoiesis, a repeat marrow should be performed after a further 7 – 21 days 
(based upon the peripheral blood count recovery and the clinician’s judgment) and remission status assessed 
at this later time point. If the bone marrow remains hypoplastic, then marrow studies should be repeated 
every 1 - 3 weeks (based upon the peripheral blood count recovery and the clinician’s judgment) until an 
accurate bone marrow status is ascertained.  
 
Differentiation between recovery bone marrow and AML blasts can be very difficult. Thus, repeat bone 
marrow examination in 7 - 10 days is strongly recommended when bone marrow blast percentage is ≥ 5% 
after each course.  
 
If clinically feasible, tissue biopsy should be used to determine extramedullary disease response. If tissue 
biopsy is not clinically appropriate, then radiographic studies should be used to determine extramedullary 
disease response. The differentiation between residual disease and residual scar tissue on radiographic 
studies may be difficult and the final determination of radiographic disease status should be made by the 
treating clinician in consultation with the local radiologist.  
 
Progression to the next course of therapy should await marrow and extramedullary disease response 
determination. Refer to Section 10.2 for the specific definitions of remission, persistent disease, refractory 
disease, and relapse. 
 
4.5 
End of Induction I 
All patients will proceed to Induction II regardless of remission status after Induction I. It is suggested, but 
not required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/μL, after chemotherapy-
induced count nadir, before proceeding with therapy.  
 
4.6 
Progression to Subsequent Courses of Therapy 
Patients should progress to the next course of therapy as soon as clinically acceptable to the treating 
institution. It is recommended but not required that the ANC > 1,000/μL and a platelet count > 75,000/μL 
be achieved before proceeding with therapy. Patients should have time for full or partial recovery (judged 
by the treating institution) from any toxicities experienced in the prior course(s) of therapy before 
proceeding to the next course. Disease status evaluations with bone marrow examination should be 
completed, where required, prior to proceeding to the next course of therapy. Administration of the next 
course’s intrathecal therapy at the time of these bone marrow evaluations is permitted to avoid additional 
sedation procedures.  
 
 

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45 
4.7 
Requirements to Start Each Sorafenib + Chemotherapy Course 
Patients must meet the following parameters before starting sorafenib in any sorafenib + chemotherapy 
course. Patients may start sorafenib as soon as these criteria are met: 
• 
Shortening fraction ≥ 28%, ejection fraction ≥ 55% 
• 
BP less than the 95th percentile for age, height and gender (antihypertensive therapy is allowed)  
• 
No concomitant treatment with CYP3A4 inducers/inhibitors listed in Section 4.2.4  
• 
No limitations in activities of daily living if a maculo-papular rash is present 
• 
Less than Grade 2 palmar-plantar erythrodysesthesia syndrome. 
 
Patients who experienced any of the following while on study may not start sorafenib in any subsequent 
courses of therapy (please refer to Sections 5.2 and 5.8 for additional details regarding the following 
toxicities as well as Section 5.12 for guidance regarding dose modifications): 
• 
Grade 4 hypertension 
• 
Any maculo-papular rash or palmar-plantar erythrodysesthesia syndrome that warranted permanent 
discontinuation of sorafenib in an earlier phase of treatment 
• 
Reduction in cardiac function to SF < 28% and/or EF < 55% on sorafenib 100 mg/m2/day (see 
Section 5.2) 
 
4.8 
Induction I Arm A (ADE 10+3+5) 
 
The following Induction I therapy guidelines are for patients who were randomized to Arm A of the study 
prior to Amendment #7A. Induction I lasts 28 days or longer.  
 
Note: Patients determined to be HR FLT3/ITD+ will be eligible to participate in sorafenib Arm C.  
During Arm C – Cohort 3: consenting patients begin sorafenib treatment in Induction I (see Section 4.10).  
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
Given at time of diagnostic lumbar puncture or Day 1. 
 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
For CNS positive patients: IT cytarabine is to be administered twice weekly until the CSF is clear. A 
minimum of 4 intrathecal treatments must be given and a maximum of 6 intrathecal treatments may be 
given. Patients whose CSF is clear at the second spinal tap will receive 3 intrathecal treatments once the 
CSF is clear and all other patients will receive 2 intrathecal treatments once the CSF is clear. See 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

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46 
Section 3.3.4 for definitions of CSF involvement. Patients with refractory CNS leukemia following 6 doses 
of therapy will be taken off protocol therapy. 
 
If IT cytarabine is given prior to diagnosis, a separate institutional consent must be obtained. 
 
Cytarabine (IV ARAC): IV over 1 - 30 minutes 
Days: 1 through 10. 
Dose: 100 mg/m2/dose, every 12 hours (i.e., 200 mg/m2/day, divided BID), or 
3.3 mg/kg/dose, every 12 hours (i.e., 6.6 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
DAUNOrubicin (DAUN): IV over 1 - 15 minutes 
Days: 1, 3 and 5.  
Dose: 50 mg/m2/dose or 
1.7 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Short infusion times may be lengthened slightly (and up to 60 minutes) if institutional policies 
mandate. It is suggested that DAUNOrubicin be administered through the tubing of rapidly infusing 
solution of D5W or 0.9% NaCl and that it is infused into a large vein. Protect from sunlight.  
 
Special precautions: Medication errors have occurred due to confusion between DAUNOrubicin and 
DOXOrubicin. DAUNOrubicin is available in a liposomal formulation (DAUNOrubicin citrate). The 
conventional and liposomal formulations are NOT interchangeable. 
 
Etoposide (ETOP): IV over at least 60 - 120 minutes 
Days: 1 through 5. 
Dose: 100 mg/m2/dose or 
3.3 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested.  
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the first 
evaluation time point can occur anytime within 14 days of the start of Induction I. See Section 18.0 for 
details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Induction I (Arm A) is on the next page.  
 
Following Induction I Arm A, Induction II Arm A (Section 4.12 or 4.14) starts on Day 29 or when blood 
count parameters and clinical condition are acceptable (whichever occurs later). This should not precede 
the end of course marrow exam.  
 
For patients without HR FLT3/ITD+: 
Continue treatment on Induction II Arm A therapy, see Section 4.12 or 4.14.  
 
For patients with HR FLT3/ITD+ disease (and who consent to participate in Arm C): 
Continue treatment on sorafenib Arm C-Cohort 3 starting in Induction I, see Section 4.10.  
 
Patients who decline participation on Arm C continue treatment on Induction II Arm A (high risk) therapy, 
see Section 4.14.  

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47 
 
4.8.1 Induction I Arm A (ADE 10+3+5)  
This therapy is for patients randomized to receive standard therapy only. 
___________________                            ______________________ 
Patient name or initials                                           DOB 
Induction I lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Sections 4.1 - 4.6 and 4.8. 
 
 
Ht______cm 
        Wt______kg  
         BSA______m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
ARAC IV 
____mg ____mg 
DAUN 
_____mg 
ETOP 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
Enter calculated dose above and actual dose administered below 
 
 
1 
1 
____mg# 
_____mg  _____mg 
____mg 
____mg 
a, c, d 
 
 
 
 
2 
 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
4 
____mg* 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
5 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
6 
 
_____mg  _____mg 
 
 
 
 
 
 
 
7 
 
_____mg  _____mg 
 
 
 
 
 
 
2 
8 
____mg* 
_____mg  _____mg 
 
 
 
 
 
 
 
9 
 
_____mg  _____mg 
 
 
 
 
 
 
 
10 
 
_____mg  _____mg 
 
 
 
 
 
 
 
11 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
3 
15 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
18 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
4 
28 
 
 
 
 
b, d 
 
 
 
 
29 
Start next course (Induction II Arm A, Section 4.12 or 4.14) on Day 29 or when blood count parameters and clinical condition are acceptable (whichever 
occurs later). This should not precede the end of course marrow exam.  
#  If IT ARAC is given at diagnosis (instead of Day 1), record the date of administration: ____________  
* Note: additional IT ARAC doses for CNS+ patients only. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine 
(IT ARAC) 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years) 
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Given at time of 
Diagnostic LP 
or Day 1 
 
If given prior to diagnosis, a separate 
institutional consent must be obtained.  
a. CBC, BUN/Creat, AST/ALT, bili (direct and total)  
b. BMA/clot section or biopsy, MRD 
c. HRQOL and Parental Stress Studies1 
d. Optional biology studies (see Section 7.4). 
 
See Section 7.1 for complete list of observations. 
 
1For patients enrolled on this study, evaluation can 
be obtained anytime within 14 days of starting 
Induction I (see Section 18.0 for details). 
 
OBTAIN OTHER STUDIES AS REQUIRED 
FOR GOOD PATIENT CARE 
Note: For CNS positive patients see Section 4.3.1 for details of additional doses of intrathecal ARAC needed. 
Cytarabine  
(IV ARAC) 
IV over 1 - 30 
minutes  
100 mg/m2/dose, every 12 hours  or  
3.3 mg/kg/dose, every 12 hours if 
BSA < 0.6 m2 
Days 1 - 10 
Total dose: 200 mg/m2/day, divided BID or 
6.6 mg/kg/day, divided BID if BSA < 0.6 m2 
DAUNOrubicin 
(DAUN) 
IV over 1 - 15 
minutes 
50 mg/m2/dose or 
1.7 mg/kg/dose if BSA < 0.6 m2 
Days 1, 3, 5 
 
Etoposide 
(ETOP)  
IV over 60 - 
120 minutes  
100 mg/m2/dose or  
3.3 mg/kg/dose if BSA < 0.6 m2 
Days 1 - 5 
 

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4.9 
Induction I Arm B (ADE 10+3+5+ Bortezomib)  
 
The following Induction I therapy guidelines are for patients who were randomized to Arm B of the study 
prior to Amendment #7A. Patients will receive bortezomib in addition to ADE therapy. Induction I lasts 
28 days or longer.  
 
Note: Patients determined to be HR FLT3/ITD+ will be eligible to participate in sorafenib Arm C.  
During Arm C–Cohort 3: consenting patients stop receiving bortezomib and continue treatment on Arm C-
Cohort 3, starting on Day 11 of Induction I (see Section 4.10).  
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
Given at time of diagnostic lumbar puncture or Day 1. 
 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
For CNS positive patients: IT cytarabine is to be administered twice weekly until the CSF is clear. A 
minimum of 4 intrathecal treatments must be given and a maximum of 6 intrathecal treatments may be 
given. Patients whose CSF is clear at the second spinal tap will receive 3 intrathecal treatments once the 
CSF is clear and all other patients will receive 2 intrathecal treatments once the CSF is clear. See 
Section 3.3.4 for definitions of CSF involvement. Patients with refractory CNS leukemia following 6 doses 
of therapy will be taken off protocol therapy. 
 
If IT cytarabine is given prior to diagnosis, a separate institutional consent must be obtained. 
 
Cytarabine (IV ARAC): IV over 1 - 30 minutes 
Days: 1 through 10. 
Dose: 100 mg/m2/dose, every 12 hours (i.e., 200 mg/m2/day, divided BID), or 
3.3 mg/kg/dose, every 12 hours (i.e., 6.6 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
DAUNOrubicin (DAUN): IV over 1 - 15 minutes 
Days: 1, 3 and 5.  
Dose: 50 mg/m2/dose, or 
1.7 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Short infusion times may be lengthened slightly (and up to 60 minutes) if institutional policies 
mandate. It is suggested that DAUNOrubicin be administered through the tubing of rapidly infusing 
solution of D5W or 0.9% NaCl and that it is infused into a large vein. Protect from sunlight.  
 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

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49 
Special precautions: Medication errors have occurred due to confusion between DAUNOrubicin and 
DOXOrubicin. DAUNOrubicin is available in a liposomal formulation (DAUNOrubicin citrate). The 
conventional and liposomal formulations are NOT interchangeable. 
 
Etoposide (ETOP): IV over at least 60 - 120 minutes 
Days: 1 through 5. 
Dose: 100 mg/m2/dose, or  
3.3 mg/kg/dose if BSA < 0.6 m2. 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested.  
 
Bortezomib (BORTEZ): IV bolus over 3 - 5 seconds 
Days: 1, 4 and 8. 
Dose: 1.3 mg/m2/dose. 
 
Special precautions: FOR INTRAVENOUS USE ONLY.  
The container or the syringe containing Bortezomib must be clearly labeled “For intravenous use only - 
Fatal if given by other routes.” Additional wording may be considered at the institution’s discretion.   
 
Note: Consecutive doses must be separated by at least 72 hours. Grapefruit and its juice should be avoided 
for the duration of treatment with bortezomib during each course. 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 (e.g., 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 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. 
 
On Days 1 and 4: administer after the end of the etoposide infusion. 
 
If bortezomib is not available on Day 1 of Induction I, then administer the first bortezomib dose as soon as 
possible. Subsequent bortezomib doses should be given after 72 and 144 hours. All doses must be at least 
72 hours apart. 
 
Bortezomib is supplied by Millennium Pharmaceuticals and distributed by the NCI DTCD. Do not 
use commercially available drug. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the first 
evaluation time point can occur anytime within 14 days of the start of Induction I. See Section 18.0 for 
details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Induction I (Arm B) is on the next page.  
 
Following completion of Induction I Arm B, Induction II Arm B (Section 4.13 or 4.15) starts on Day 29 or 
when blood count parameters and clinical conditions are acceptable (whichever occurs later). This should 
not precede the end of course marrow exam. 
 
 
For patients without HR FLT3/ITD+: 

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Continue treatment on Induction II Arm B therapy, see Section 4.13 or 4.15.  
 
For patients with HR FLT3/ITD+ disease (and who consent to participate in Arm C): 
Continue treatment on sorafenib Arm C-Cohort 3 starting in Induction I, see Section 4.10.  
 
Patients who decline participation on Arm C continue treatment on Induction II Arm B (high risk) therapy, 
see Section 4.15. 
 
 

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51 
4.9.1 Induction I Arm B (ADE 10+3+5 + Bortezomib)  
This therapy is for patients receiving standard therapy and bortezomib. 
___________________                            ______________________ 
Patient name or initials                                           DOB 
Induction I lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Sections 4.1 - 4.6 and 4.9. 
 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine 
(IT ARAC) 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years) 
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Given at time of 
Diagnostic LP or 
Day 1 
 
If given prior to diagnosis, a separate institutional 
consent must be obtained.  
a. CBC, BUN/Creat, AST/ALT, bili (direct 
and total), neurologic exam  
b. BMA/clot section or biopsy, MRD 
c. HRQOL and Parental Stress Studies1 
d. Optional biology studies (see Section 7.4) 
e. Pulse oximetry (prior to bortez) 
 
See Section 7.1 for complete list of 
observations. 
 
1For patients enrolled on this study, 
evaluation can be obtained anytime within 
14 days of starting Induction I (see 
Section 18.0 for details). 
 
OBTAIN OTHER STUDIES AS 
REQUIRED FOR GOOD PATIENT CARE 
Note: For CNS positive patients see Section 4.3.1 for details of additional doses of intrathecal ARAC needed. 
Cytarabine  
(IV ARAC) 
IV over 1 - 30 
minutes  
100 mg/m2/dose, every 12 hours or  
3.3 mg/kg/dose, every 12 hours if 
BSA < 0.6 m2 
Days 1 - 10 
Total dose: 200 mg/m2/day, divided BID or 
6.6 mg/kg/day, divided BID if BSA < 0.6m2  
DAUNOrubicin 
(DAUN) 
IV over 1 - 15 
minutes 
50 mg/m2/dose or 
1.7 mg/kg/dose if BSA < 0.6 m2 
Days 1, 3, 5 
 
Etoposide 
(ETOP)  
IV over 60 - 
120 minutes  
100 mg/m2/dose or  
3.3 mg/kg/dose if BSA < 0.6 m2 
Days 1 - 5 
 
Bortezomib 
(BORTEZ) 
IND# 114480 
IV over 3 - 5 
seconds 
1.3 mg/m2/dose 
Days 1, 4, 8 
Consecutive doses must be at least 72 hours apart.  
On Days 1 and 4: administer after the end of the 
etoposide infusion. 
 
Ht______cm 
        Wt______kg  
         BSA______m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
ARAC IV 
____mg ____mg 
DAUN 
_____mg 
ETOP 
____mg 
BORTEZ 
____mg 
Studies 
Comments (Include any held doses, 
or dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
 
1 
1 
____mg# 
_____mg  _____mg 
____mg 
____mg 
____mg 
a, c, d, e 
 
 
 
 
2 
 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
 
4 
____mg* 
_____mg  _____mg 
 
____mg 
____mg 
e 
 
 
 
 
5 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
 
6 
 
_____mg  _____mg 
 
 
 
 
 
 
 
 
7 
 
_____mg  _____mg 
 
 
 
 
 
 
 
2 
8 
____mg* 
_____mg  _____mg 
 
 
____mg 
e 
 
 
 
 
9 
 
_____mg  _____mg 
 
 
 
 
 
 
 
 
10 
 
_____mg  _____mg 
 
 
 
 
 
 
 
 
11 
____mg* 
 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
3 
15 
____mg* 
 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
 
18 
____mg* 
 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
4 
28 
 
 
 
 
 
b, d 
 
 
 
 
29 
Start next course (Induction II Arm B, Section 4.12 or 4.14) on Day 29 or when blood count parameters and clinical condition are acceptable (whichever 
occurs later). This should not precede the end of course marrow exam. 
#  If IT ARAC is given at diagnosis (instead of Day 1), record the date of administration: ____________  
* Note: additional IT ARAC doses for CNS+ patients only. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
52 
4.10 
Induction I Arm C-Cohort 3 (ADE 10+3+5+ Sorafenib)  
The following Induction I therapy guidelines are for patients with HR FLT3/ITD+ disease during the 
sorafenib feasibility part of the study (Cohort 3). Patients on Arm C-Cohort 3 will receive standard ADE 
therapy and sorafenib. Induction I lasts 28 days or longer.  
 
See Section 4.7 for requirements to start each sorafenib course.  
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
Given at time of diagnostic lumbar puncture or Day 1. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
For CNS positive patients: IT cytarabine is to be administered twice weekly until the CSF is clear. A 
minimum of 4 intrathecal treatments must be given and a maximum of 6 intrathecal treatments may be 
given. Patients whose CSF is clear at the second spinal tap will receive 3 intrathecal treatments once the 
CSF is clear and all other patients will receive 2 intrathecal treatments once the CSF is clear. See 
Section 3.3.4 for definitions of CSF involvement. Patients with refractory CNS leukemia following 6 doses 
of therapy will be taken off protocol therapy. 
 
If IT cytarabine is given prior to diagnosis, a separate institutional consent must be obtained. 
 
Cytarabine (IV ARAC): IV over 1 - 30 minutes 
Days: 1 through 10. 
Dose: 100 mg/m2/dose, every 12 hours (i.e., 200 mg/m2/day, divided BID), or 
3.3 mg/kg/dose, every 12 hours (i.e., 6.6 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
DAUNOrubicin (DAUN): IV over 1 - 15 minutes. 
Days: 1, 3 and 5.  
Dose: 50 mg/m2/dose, or 
1.7 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Short infusion times may be lengthened slightly (and up to 60 minutes) if institutional policies 
mandate. It is suggested that DAUNOrubicin be administered through the tubing of rapidly infusing 
solution of D5W or 0.9% NaCl and that it is infused into a large vein. Protect from sunlight.  
 
Special precautions: Medication errors have occurred due to confusion between DAUNOrubicin and 
DOXOrubicin. DAUNOrubicin is available in a liposomal formulation (DAUNOrubicin citrate). The 
conventional and liposomal formulations are NOT interchangeable. 

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Version Date: 04/24/2017 
 
53 
Etoposide (ETOP): IV over at least 60 - 120 minutes 
Days: 1 through 5. 
Dose: 100 mg/m2/dose if BSA, or  
3.3 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested.  
 
Sorafenib (SORAF): PO 
Days: 11 through 28. 
Dose: 200 mg/m2/dose daily, rounded to accommodate tablet size. The maximum dose will be 400 mg. 
Dose to be administered per dosing nomogram in Appendix II.  
 
Note: Sorafenib tablets should be taken at least 1 hour before or 2 hours after food. Tablets should be taken 
with clear liquids (approximately 2 to 4 ounces for children < 12 years and 4 to 8 ounces for ≥ 12 years). If 
taken with food, sorafenib should be taken with a moderate to low fat meal. Tablets should not be crushed, 
but should be swallowed whole. However, sorafenib tablets can be dispersed in water to facilitate the 
administration to subjects that cannot swallow tablets (see drug monograph in Section 6.12). Grapefruit and 
its juice should be avoided for the duration of treatment with sorafenib. 
 
Sorafenib is supplied by Bayer HealthCare Pharmaceuticals, and distributed by the NCI DTCD. Do 
not use commercially available drug. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the first 
evaluation time point can occur anytime within 14 days of the start of Induction I. See Section 18.0 for 
details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Induction I Arm C- Cohort 3 is on the next page.  
 
Following completion of Induction I, Induction II Arm C- Cohort 3 (Section 4.16) starts on Day 29 or when 
blood count parameters and clinical conditions are acceptable (whichever occurs later). This should not 
precede the end of course marrow exam. 
 

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54 
4.10.1 Induction I - Arm C-Cohort 3 (ADE 10+3+5 + Sorafenib)  
This therapy is for HR FLT3/ITD+ patients receiving standard therapy and sorafenib during sorafenib feasibility assessment. 
___________________                      _____________________ 
Patient name or initials                                           DOB 
Induction I lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Section 4.1-4.7 and 4.10. 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine 
(IT ARAC) 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years) 
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Given at time 
of Diagnostic 
LP or Day 1 
 
If given prior to diagnosis, a separate 
institutional consent must be obtained.  
a. CBC, BUN/Creat, AST/ALT, bili  (direct 
and total), BP, urinalysis 
b. BMA/clot section or biopsy, MRD 
c. HRQOL and Parental Stress Studies1 
d. Optional biology studies (see Section 7.4) 
e. Clinical cardiac examination 
See Section 7.1 for complete list of 
observations. 
 
1For patients enrolled on this study, evaluation can 
be obtained anytime within 14 days of starting 
Induction I (see Section 18.0 for details). 
OBTAIN OTHER STUDIES AS 
REQUIRED FOR GOOD PATIENT 
CARE 
Note: For CNS positive patients see Section 4.3.1 for details of additional doses of intrathecal ARAC needed. 
Cytarabine  
(IV ARAC) 
IV over 1 - 
30 minutes  
100 mg/m2/dose, every 12 hrs or  
3.3 mg/kg/dose, every 12 hrs if BSA < 0.6 m2 
Days 1 - 10 
Total dose: 200 mg/m2/day, divided BID or 
6.6 mg/kg/day, divided BID if BSA < 0.6 m2 
DAUNOrubicin 
(DAUN) 
IV over 1 - 
15 minutes 
50 mg/m2/dose or 
1.7 mg/kg/dose if BSA < 0.6 m2 
Days 1, 3, 5 
 
Etoposide 
(ETOP)  
IV over 60 - 
120 minutes  
100 mg/m2/dose or  
3.3 mg/kg/dose if BSA < 0.6 m2 
Days 1 - 5 
 
Sorafenib 
(SORAF) 
IND# 114480 
PO 
200 mg/m2/dose daily  
Days 11 - 28 
See Section 4.10 for administration guidelines. 
See Section 5.0 for dose modification plan. 
The maximum dose is 400 mg. 
Ht______cm 
        Wt______kg  
         BSA______m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
ARAC IV 
____mg ____mg 
DAUN 
_____mg 
ETOP 
____mg 
SORAF 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
 
1 
1 
______mg# 
_____mg  _____mg 
______mg 
______mg 
 
a, c, d, , e 
 
 
 
 
2 
 
_____mg  _____mg 
 
______mg 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
______mg 
______mg 
 
 
 
 
 
 
4 
______mg* 
_____mg  _____mg 
 
______mg 
 
 
 
 
 
 
5 
 
_____mg  _____mg 
______mg 
______mg 
 
 
 
 
 
 
6 
 
_____mg  _____mg 
 
 
 
 
 
 
 
 
7 
 
_____mg  _____mg 
 
 
 
 
 
 
 
2 
8 
______mg* 
_____mg  _____mg 
 
 
 
e 
 
 
 
 
9 
 
_____mg  _____mg 
 
 
 
 
 
 
 
 
10 
 
_____mg  _____mg 
 
 
 
 
 
 
 
 
11 
______mg* 
 
 
 
______mg 
 
 
 
 
 
 
12 
 
 
 
 
 
 
 
 
 
13 
 
 
 
 
 
 
 
 
 
14 
 
 
 
 
d 
 
 
 
3 
15 
______mg* 
 
 
 
e 
 
 
 
 
16 
 
 
 
 
 
 
 
 
 
17 
 
 
 
 
 
 
 
 
 
18 
______mg* 
 
 
 
 
 
 
 
 
21 
 
 
 
 
d 
 
 
 
4 
22 
 
 
 
 
e 
 
 
 
 
28 
 
 
 
 
b, d 
 
Start next course (Induction II Arm C, Section 4.16) on Day 29 or when blood count parameters and clinical condition are acceptable (whichever occurs later). This should not precede the end of 
course marrow exam. 
# If IT ARAC is given at diagnosis (instead of Day 1), record the date of administration: ____________ * Note: additional IT ARAC doses for CNS+ patients only. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
55 
4.11 
Induction I Arm D (ADE 10+3+5) 
The following Induction I therapy guidelines are for patients enrolled on study after implementation of 
Amendment #7A and whose FLT3/ITD status is unknown prior to study enrollment. Induction I lasts 28 
days or longer.  
 
Note: Patients determined to be HR FLT3/ITD+ will be eligible to participate in sorafenib Arm C.  
During Arm C–Cohort 3: consenting patients begin sorafenib treatment in Induction I (see Section 4.10).  
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
Given at time of diagnostic lumbar puncture or Day 1. 
 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
For CNS positive patients: IT cytarabine is to be administered twice weekly until the CSF is clear. A 
minimum of 4 intrathecal treatments must be given and a maximum of 6 intrathecal treatments may be 
given. Patients whose CSF is clear at the second spinal tap will receive 3 intrathecal treatments once the 
CSF is clear and all other patients will receive 2 intrathecal treatments once the CSF is clear. See 
Section 3.3.4 for definitions of CSF involvement. Patients with refractory CNS leukemia following 6 doses 
of therapy will be taken off protocol therapy. 
 
If IT cytarabine is given prior to diagnosis, a separate institutional consent must be obtained. 
 
Cytarabine (IV ARAC): IV over 1 - 30 minutes 
Days: 1 through 10. 
Dose: 100 mg/m2/dose, every 12 hours (i.e., 200 mg/m2/day, divided BID), or 
3.3 mg/kg/dose, every 12 hours (i.e., 6.6 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
DAUNOrubicin (DAUN): IV over 1 - 15 minutes 
Days: 1, 3 and 5.  
Dose: 50 mg/m2/dose or 
1.7 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Short infusion times may be lengthened slightly (and up to 60 minutes) if institutional policies 
mandate. It is suggested that DAUNOrubicin be administered through the tubing of rapidly infusing 
solution of D5W or 0.9% NaCl and that it is infused into a large vein. Protect from sunlight.  
 
Special precautions: Medication errors have occurred due to confusion between DAUNOrubicin and 
DOXOrubicin. DAUNOrubicin is available in a liposomal formulation (DAUNOrubicin citrate). The 
conventional and liposomal formulations are NOT interchangeable. 
 
Etoposide (ETOP): IV over at least 60 - 120 minutes 
Days: 1 through 5. 

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56 
Dose: 100 mg/m2/dose or 
3.3 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested.  
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Induction I (Arm D) is on the next page.  
 
For patients without HR FLT3/ITD+: 
Remove from study at the time of FLT3/ITD test results with no further data submission. See Section 7.1 
for required End of Therapy evaluations  
 
For patients with HR FLT3/ITD+ disease: 
Patients who consent to participate in Arm C will switch to the sorafenib treatment arm (Arm C-Cohort 3) 
starting with Induction I (see Section 4.10) at the time of FLT3/ITD test results. 
 
Patients who decline participation on Arm C are removed from study with no further data submission. See 
Section 7.1 for required End of Therapy evaluations  
 
For patients with unknown FLT3/ITD at End of Induction I: 
Remove from study with no further data submission. See Section 7.1 for required End of Therapy 
evaluations  
 
 

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Version Date: 04/24/2017 
 
57 
4.11.1 Induction I Arm D (ADE 10+3+5)  
This therapy is for patients enrolled on study with unknown FLT3/ITD status only enrolled after Amendment #7A. 
_______________________          ______________________ 
     Patient name or initials                              DOB 
 
Ht______cm 
        Wt______kg  
         BSA______m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
ARAC IV 
____mg ____mg 
DAUN 
_____mg 
ETOP 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
Enter calculated dose above and actual dose administered below 
 
 
1 
1 
____mg# 
_____mg  _____mg 
____mg 
____mg 
a, c 
 
 
 
 
2 
 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
4 
____mg* 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
5 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
6 
 
_____mg  _____mg 
 
 
 
 
 
 
 
7 
 
_____mg  _____mg 
 
 
 
 
 
 
2 
8 
____mg* 
_____mg  _____mg 
 
 
 
 
 
 
 
9 
 
_____mg  _____mg 
 
 
 
 
 
 
 
10 
 
_____mg  _____mg 
 
 
 
 
 
 
 
11 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
3 
15 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
18 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
4 
28 
 
 
 
 
b, c 
 
 
 
 
29 
Switch patients with HR FLT3/ITD+ to sorafenib treatment arm (Arm C-cohort 3, Section 4.10) after consenting them to Arm C treatment.  Patients without 
HR FLT3/ITD+, with unknown FLT3/ITD status at End of Induction I, or who do not consent to Arm C are Off Study. See Section 7.1 for required end of 
therapy evaluations 
#  
If IT ARAC is given at diagnosis (instead of Day 1), record the date of administration: ____________ 
* 
Note: additional IT ARAC doses for CNS+ patients only. 
SEE SECTION 5.0 FO R DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES.
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine 
(IT ARAC) 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years) 
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Given at time of 
Diagnostic LP or 
Day 1 
 
If given prior to diagnosis, a separate 
institutional consent must be obtained.  
a. CBC, BUN/Creat, AST/ALT, bili (direct and 
total)  
b. BMA/clot section or biopsy, MRD 
c. Optional biology studies (see Section 7.4). 
 
See Section 7.1 for complete list of observations. 
 
 
OBTAIN OTHER STUDIES AS REQUIRED 
FOR GOOD PATIENT CARE 
Note: For CNS positive patients see Section 4.3.1 for details of additional doses of intrathecal ARAC needed. 
Cytarabine  
(IV ARAC) 
IV over 1 - 30 
minutes  
100 mg/m2/dose, every 12 hours  or  
3.3 mg/kg/dose, every 12 hours if 
BSA < 0.6 m2 
Days 1 - 10 
Total dose: 200 mg/m2/day, divided BID or 
6.6 mg/kg/day, divided BID if BSA < 0.6 m2 
DAUNOrubicin 
(DAUN) 
IV over 1 - 15 
minutes 
50 mg/m2/dose or 
1.7 mg/kg/dose if BSA < 0.6 m2 
Days 1, 3, 5 
 
Etoposide 
(ETOP)  
IV over 60 - 
120 minutes  
100 mg/m2/dose or  
3.3 mg/kg/dose if BSA < 0.6 m2 
Days 1 - 5 
 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
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Version Date: 04/24/2017 
 
58 
4.12 
Induction II Arm A (ADE 8+3+5) – Low Risk Patients 
 
The following Induction II therapy guidelines are for low risk patients randomized to Arm A of the study. 
Arm A consists of the standard therapy. Induction II lasts 28 days or longer.  
 
All patients will proceed to Induction II regardless of bone marrow remission status after Induction I. 
Progression to Induction II should await disease response determination (MRD and extramedullary disease) 
in order to correctly assign risk stratum. Patients with high or low risk cytogenetic/molecular features may 
proceed on to Induction II therapy before disease response results are available. It is suggested, but not 
required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with 
therapy. By the beginning of Induction II, patients should have been classified as Low or High risk.  
 
Patients who were CSF positive at start of Induction I and are CSF positive at start of Induction II 
will be taken off protocol therapy (Section 8.1). 
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Induction II or with the bone marrow evaluation at the end of 
Induction I. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
For newly detected CNS positive patients who were CNS negative at diagnosis: IT cytarabine is to be 
administered twice weekly until the CSF is clear. A minimum of 4 intrathecal treatments must be given and 
a maximum of 6 intrathecal treatments may be given. Patients whose CSF is clear at the second spinal tap 
will receive 3 intrathecal treatments once the CSF is clear and all other patients will receive 2 intrathecal 
treatments once the CSF is clear. See Section 3.3.4 for definitions of CSF involvement. Patients with 
refractory CNS leukemia following 6 doses of therapy will be taken off protocol therapy. 
 
Cytarabine (ARAC IV): IV over 1 - 30 minutes 
Days: 1 through 8. 
Dose: 100 mg/m2/dose, every 12 hours (i.e., 200 mg/m2/day, divided BID), or 
 3.3 mg/kg/dose, every 12 hours (i.e., 6.6 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
DAUNOrubicin (DAUN): IV over 1 - 15 minutes 
Days: 1, 3, and 5.  
Dose: 50 mg/m2/dose, or 
1.7 mg/kg/dose if BSA < 0.6 m2. 
 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

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Version Date: 04/24/2017 
 
59 
Note: Short infusion times may be lengthened slightly (and up to 60 minutes) if institutional policies 
mandate. It is suggested that DAUNOrubicin be administered through the tubing of rapidly infusing 
solution of D5W or 0.9% NaCl and that it is infused into a large vein. Protect from sunlight.  
 
Special precautions: Medication errors have occurred due to confusion between DAUNOrubicin and 
DOXOrubicin. DAUNOrubicin is available in a liposomal formulation (DAUNOrubicin citrate). The 
conventional and liposomal formulations are NOT interchangeable. 
 
Etoposide (ETOP): IV over at least 60 - 120 minutes 
Days: 1 through 5. 
Dose: 100 mg/m2/dose or 
3.3 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested.  
 
HRQOL and Parental Stress Studies  
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the 
second evaluation time is on or after Day 21 of Induction II, but prior to the start of Intensification I. See 
Section 18.0 for details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Induction II (Arm A, Low Risk) is on the next page. 
 
End of Induction II: Remission status at the end of Induction II will determine whether patients receive 
further protocol therapy. All patients in CR as defined in Section 10.2.1 will proceed to Intensification I. 
Patients with refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study. 
 
Following Induction II Arm A, the next course (Intensification I - Arm A, Section 4.17) starts on Day 29 
or when blood count parameters and clinical condition are acceptable (whichever occurs later). 
 

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60 
4.12.1 Induction II Arm A (ADE 8+3+5) – Low Risk Patients 
This therapy is for low risk patients randomized to receive standard therapy. 
___________________                            ______________________ 
Patient name or initials                                           DOB 
Induction II lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Section 4.1-4.6 and 4.12. All patients will proceed to Induction II regardless 
of remission status after Induction I. Progression to Induction II should await disease response determination so as to properly assign risk strata. It is suggested, but not required, that patients have an 
ANC > 1000/µL and a platelet count > 75 000/µL before proceeding with therapy.  
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine#   
(IT ARAC) 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years) 
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Day 1 
# May be performed with BM done at 
end of previous course.  
a. CBC, BUN/Creat, AST/ALT, bili (direct and 
total), Echo or MUGA and ECG 
b. BMA/clot section or biopsy 
c. Optional biology studies (see Section 7.4) 
d. HRQOL and Parental Stress Studies1   
 
See Section 7.1 for complete list of observations. 
 
1For patients enrolled on this study, evaluation 
can be obtained on or after Day 21 of 
Induction II, but prior to Intensification I (see 
Section 18.0 for details). 
 
OBTAIN OTHER STUDIES AS REQUIRED FOR 
GOOD PATIENT CARE 
Note: For CNS positive patients (initially CNS negative at diagnosis) see Section 4.3.1 for details of additional doses of intrathecal ARAC needed. 
Cytarabine 
(IV ARAC) 
IV over 1 - 30 minutes  
100 mg/m2/dose, every 12 hours or  
3.3 mg/kg/dose, every 12 hours if 
BSA < 0.6 m2 
Days 1 - 8 
Total dose: 200 mg/m2/day, divided BID 
or 6.6 mg/kg/day, divided BID if BSA 
< 0.6 m2 
DAUNOrubicin 
(DAUN) 
IV over 1 - 15 minutes 
50 mg/m2/dose or 
1.7 mg/kg/dose if BSA < 0.6 m2 
Days 1, 3, 5 
 
Etoposide  
(ETOP)  
IV over 60 - 120 
minutes  
100 mg/m2/dose or  
3.3 mg/kg/dose if BSA < 0.6 m2 
Days 1 - 5 
 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
ARAC IV 
____mg   ____mg  
DAUN 
____mg 
ETOP 
_____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
1 
1 
____mg#  
_____mg  _____mg 
____mg 
____mg 
a 
 
 
 
 
2 
 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
4 
____mg* 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
5 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
6 
 
_____mg  _____mg 
 
 
 
 
 
 
 
7 
 
_____mg  _____mg 
 
 
 
 
 
 
2 
8 
____mg* 
_____mg  _____mg 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
11 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
3 
15 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
18 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
21 
 
 
 
 
d 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
4 
28 
 
 
 
 
b, c 
 
 
 
 
29 
Remission status at the end of Induction II will determine whether patients receive further protocol therapy. All patients in CR as defined in Section 10.2.1 will 
proceed to Intensification I (AE). Patients with refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study.  Start next course 
(Intensification I Arm A, Section 4.17) on Day 29 or when blood count parameters and clinical condition are acceptable (whichever occurs later). 
# May be performed with BM done at end of previous course.  
 
*Note: additional IT ARAC doses for CNS+ patients only; those with no CNS disease at dx, but CNS disease present at start of Induction II (see Section 4.3).  
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
61 
4.13 
Induction II Arm B (ADE 8+3+5 + Bortezomib) – Low Risk Patients 
 
The following Induction II therapy guidelines are for low risk patients randomized to Arm B of the study. 
Patients will receive bortezomib in addition to ADE therapy. Induction II lasts 28 days or longer.  
 
All patients will proceed to Induction II regardless of bone marrow remission status after Induction I. 
Progression to Induction II should await disease response determination (MRD and extramedullary disease) 
in order to correctly assign risk stratum. Patients with high or low risk cytogenetic/molecular features may 
proceed on to Induction II therapy before disease response results are available. It is suggested, but not 
required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with 
therapy. By the beginning of Induction II, patients should have been classified as Low or High risk.  
 
Patients who were CSF positive at start of Induction I and are CSF positive at start of Induction II 
will be taken off protocol therapy (Section 8.1). 
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Induction II or with the bone marrow evaluation at the end of 
Induction I. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
For newly detected CNS positive patients who were CNS negative at diagnosis: IT cytarabine is to be 
administered twice weekly until the CSF is clear. A minimum of 4 intrathecal treatments must be given and 
a maximum of 6 intrathecal treatments may be given. Patients whose CSF is clear at the second spinal tap 
will receive 3 intrathecal treatments once the CSF is clear and all other patients will receive 2 intrathecal 
treatments once the CSF is clear. See Section 3.3.4 for definitions of CSF involvement. Patients with 
refractory CNS leukemia following 6 doses of therapy will be taken off protocol therapy. 
 
Cytarabine (IV ARAC): IV over 1 - 30 minutes 
Days: 1 through 8. 
Dose: 100 mg/m2/dose, every 12 hours (i.e., 200 mg/m2/day, divided BID), or 
3.3 mg/kg/dose, every 12 hours (i.e., 6.6 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
DAUNOrubicin (DAUN): IV over 1 - 15 minutes 
Days: 1, 3, and 5.  
Dose: 50 mg/m2/dose, or 
1.7 mg/kg/dose if BSA < 0.6 m2. 
 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
62 
Note: Short infusion times may be lengthened slightly (and up to 60 minutes) if institutional policies 
mandate. It is suggested that DAUNOrubicin be administered through the tubing of rapidly infusing 
solution of D5W or 0.9% NaCl and that it is infused into a large vein. Protect from sunlight.  
 
Special precautions: Medication errors have occurred due to confusion between DAUNOrubicin and 
DOXOrubicin. DAUNOrubicin is available in a liposomal formulation (DAUNOrubicin citrate). The 
conventional and liposomal formulations are NOT interchangeable. 
 
Etoposide (ETOP): IV over at least 60 - 120 minutes 
Days: 1 through 5. 
Dose: 100 mg/m2/dose, or 
3.3 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested.  
 
Bortezomib (BORTEZ): IV push over 3 - 5 seconds 
Days: 1, 4 and 8. 
Dose: 1.3 mg/m2/dose. 
 
Special precautions: FOR INTRAVENOUS USE ONLY.  
The container or the syringe containing Bortezomib must be clearly labeled “For intravenous use only - 
Fatal if given by other routes.” Additional wording may be considered at the institution’s discretion.   
 
Note: Consecutive doses must be separated by at least 72 hours. Grapefruit and its juice should be avoided 
for the duration of treatment with bortezomib during each course. 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 (e.g., 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 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. 
 
On Days 1 and 4: administer after the end of the etoposide infusion. 
 
Bortezomib is supplied by Millennium Pharmaceuticals and distributed by the NCI DTCD. Do not 
use commercially available drug. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the 
second evaluation time is on or after Day 21 of Induction II, but prior to the start of Intensification I. See 
Section 18.0 for details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Induction II (Arm B, Low Risk) is on the next page. 
 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
63 
End of Induction II: Remission status at the end of Induction II will determine whether patients receive 
further protocol therapy. All patients in CR as defined in Section 10.2.1 will proceed to Intensification I. 
Patients with refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study. 
 
Following Induction II Arm B, the next course (Intensification I - Arm B, Section 4.18) starts on Day 29 or 
when blood count parameters and clinical condition are acceptable (whichever occurs later). 
 
 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
64 
4.13.1 Induction II Arm B (ADE 8+3+5+ Bortezomib) – Low Risk Patients 
This therapy is for low risk patients receiving standard therapy and bortezomib. 
___________________                            ______________________ 
Patient name or initials                                                           DOB 
Induction II lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Sections 4.1-4.6 and 4.13. All patients will proceed to Induction II regardless of 
remission status after Induction I. Progression to Induction II should await disease response determination so as to properly assign risk strata. It is suggested, but not required, that patients have an 
ANC > 1000/µL and a platelet count > 75 000/µL before proceeding with therapy.  
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine#  
(IT ARAC) 
IT 
20 mg (age 0-0.99 years) 
30 mg (age 1-1.99 years) 
50 mg (age 2-2.99 years) 
70 mg (age ≥ 3 years) 
Day 1 
# May be administered with BM done at end 
of previous course.  
a. CBC, BUN/Creat, AST/ALT, bili (direct and 
total), neurologic exam, Echo or MUGA and 
ECG 
b. BMA/clot section or biopsy 
c. Optional biology studies (see Section 7.4)  
d. HRQOL and Parental Stress Studies1  
e.  Pulse oximetry (prior to bortez) 
f.  PK studies (see Appendices XII-XV, closed to 
new patients as of 6/25/13) 
 
See Section 7.1 for complete list of observations. 
1For patients enrolled on this study, evaluation can be 
obtained on or after Day 21 of Induction II, but prior to 
Intensification I (see Section 18.0 for details). 
OBTAIN OTHER STUDIES AS REQUIRED 
FOR GOOD PATIENT CARE 
Note: For CNS positive patients (initially CNS negative at diagnosis) see Section 4.3.1 for details of additional doses of intrathecal ARAC needed. 
Cytarabine 
(IV ARAC) 
IV over 1-30 minutes  
100 mg/m2/dose, every 12 hours 
or 3.3 mg/kg/dose, every 
12 hours if BSA < 0.6 m2 
Days 1-8 
Total dose: 200 mg/m2/day, divided BID or 
6.6 mg/kg/day, divided BID if BSA < 0.6 m2 
DAUNOrubicin 
(DAUN) 
IV over 1-15 minutes 
50 mg/m2/dose or 
1.7 mg/kg/dose if BSA < 0.6 m2 
Days 1, 3, 5 
 
 
Etoposide  
(ETOP)  
IV over 60-120 minutes  
100 mg/m2/dose or  
3.3 mg/kg/dose if BSA < 0.6 m2 
Days 1-5 
 
Bortezomib 
(BORTEZ) 
IND# 114480 
IV over 3-5 seconds 
1.3 mg/m2/dose 
Days 1, 4, 8 
Consecutive doses must be at least 72 hours 
apart. On Days 1 and 4: administer after the 
end of the etoposide infusion 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
ARAC IV 
____mg   ____mg  
DAUN 
____mg 
ETOP 
_____mg 
BORTEZ 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
 
1 
1 
____mg# 
_____mg  _____mg 
____mg 
____mg 
____mg 
a, e 
 
 
 
 
2 
 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
 
4 
____mg* 
_____mg  _____mg 
 
____mg 
____mg 
e 
 
 
 
 
5 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
 
6 
 
_____mg  _____mg 
 
 
 
 
 
 
 
 
7 
 
_____mg  _____mg 
 
 
 
 
 
 
 
2 
8 
____mg* 
_____mg  _____mg 
 
 
____mg 
e, f 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
 
11 
____mg* 
 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
3 
15 
____mg* 
 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
 
18 
____mg* 
 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
 
21 
 
 
 
 
 
d 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
4 
28 
 
 
 
 
 
b, c 
 
 
 
 
29 
Remission status at the end of Induction II will determine whether patients receive further protocol therapy. All patients in CR as defined in Section 10.2.1 will proceed to 
Intensification Course I (AE). Patients with refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study.  
Start next course (Intensification I – Arm B, Section 4.18) on Day 29 or when blood count parameters and clinical condition are acceptable (whichever occurs later). 
# May be performed with BM done at end of previous course. 
 
* Note: add’l IT ARAC doses for CNS+ pts only; those with no CNS disease at dx, but CNS disease present at start of Induction II (see Sect. 4.3).  
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES.

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
65 
4.14 
Induction II Arm A (MA) – High Risk Patients 
 
The following Induction II therapy guidelines are for high risk patients randomized to Arm A of the study. 
Induction II lasts 28 days or longer.  
 
All patients will proceed to Induction II regardless of bone marrow remission status after Induction I. 
Progression to Induction II should await disease response determination (MRD and extramedullary disease) 
in order to correctly assign risk stratum. Patients with high or low risk cytogenetic/molecular features may 
proceed on to Induction II therapy before disease response results are available. It is suggested, but not 
required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with 
therapy. By the beginning of Induction II, patients should have been classified as Low or High risk. If a 
patient is classified as High risk at the end of Induction I and no family HLA match is found, initiation 
of an unrelated donor search should occur. 
 
Patients who were CSF positive at start of Induction I and are CSF positive at start of Induction II 
will be taken off protocol therapy (Section 8.1). 
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Induction II or with the bone marrow evaluation at the end of 
Induction I. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
For newly detected CNS positive patients who were CNS negative at diagnosis: IT cytarabine is to be 
administered twice weekly until the CSF is clear. A minimum of 4 intrathecal treatments must be given and 
a maximum of 6 intrathecal treatments may be given. Patients whose CSF is clear at the second spinal tap 
will receive 3 intrathecal treatments once the CSF is clear and all other patients will receive 2 intrathecal 
treatments once the CSF is clear. See Section 3.3.4 for definitions of CSF involvement. Patients with 
refractory CNS leukemia following 6 doses of therapy will be taken off protocol therapy. 
 
High Dose Cytarabine (HD ARAC): IV over 1 - 3 hours 
Days: 1 through 4. 
Dose: 1000 mg/m2/dose, every 12 hours (i.e., 2000 mg/m2/day, divided BID) or 
33 mg/kg/dose, every 12 hours (i.e., 66 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
Suggested premedications and supportive care: Administer steroid eye drops (0.1% dexamethasone or 1% 
prednisolone ophthalmic solution), 2 drops to each eye every 6 hours, beginning immediately before the 
first dose and continuing for 24 hours after the last dose. If patient does not tolerate steroid eye drops, may 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
66 
administer artificial tears on an every 2-4 hour schedule. Patients in whom serum creatinine is > 2 mg/dL 
or > 2 x normal for age, must have a CrCl performed (Day 1) and doses of cytarabine adjusted as outlined 
in Section 5.9.1. 
 
MitoXANTRONE (MITOX): IV over 15 - 30 minutes 
Days: 3 through 6. 
Dose: 12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2.  
 
Note: Administer through the tubing of a rapidly infusing solution of D5W or 0.9% NaCl. Avoid 
extravasation; the use of a central line is suggested. On the Days 3 and 4, mitoXANTRONE should be given 
8 hours after the 5th and 7th high dose cytarabine infusions are complete. 
  
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the 
second evaluation time is on or after Day 21 of Induction II, but prior to the start of Intensification I. See 
Section 18.0 for details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Induction II (Arm A, High Risk) is on the next page. 
 
End of Induction II: Remission status at the end of Induction II will determine whether patients receive 
further protocol therapy. All patients in CR as defined in Section 10.2.1 will proceed to Intensification I. 
Patients with refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study. 
 
Following Induction II Arm A, the next course (Intensification I - Arm A, Section 4.17) starts on Day 29 
or when blood count parameters and clinical condition are acceptable (whichever occurs later). 
 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
67 
4.14.1 Induction II Arm A (MA) – High Risk Patients 
This therapy is for high risk patients randomized to receive standard therapy. 
___________________                            ______________________ 
Patient name or initials                                           DOB 
Induction II lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Section 4.1-4.6 and 4.14. All patients will proceed to Induction II regardless 
of remission status after Induction I. Progression to Induction II should await disease response determination so as to properly assign risk strata. It is suggested, but not required, that patients have an 
ANC > 1000/µL and a platelet count > 75 000/µL before proceeding with therapy.  
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine#   
(IT ARAC) 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years) 
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Day 1 
#  May be performed with BM done at end of 
previous course.  
a. CBC, BUN/Creat, AST/ALT, bili (direct and 
total), Echo or MUGA and ECG 
b. CrCl 
c. BMA/clot section or biopsy 
d. Optional biology studies (see Section 7.4) 
e. HRQOL and Parental Stress Studies1   
 
See Section 7.1 for complete list of observations. 
 
1For patients enrolled on this study, evaluation can 
be obtained on or after Day 21 of Induction II, but 
prior to Intensification I (see Section 18.0 for 
details). 
 
OBTAIN OTHER STUDIES AS REQUIRED 
FOR GOOD PATIENT CARE 
Note: For CNS positive patients (initially CNS negative at diagnosis) see Section 4.3.1 for details of additional doses of intrathecal ARAC needed. 
Cytarabine 
(HD ARAC) 
IV over 1 - 3 hours 
1000 mg/m2/dose, every 12 hours 
or 
33 mg/kg/dose, every 12 hours if 
BSA < 0.6 m2 
Days 1 - 4 
Total dose: 2000 mg/m2/day, divided BID or 
66 mg/kg/day, divided BID if BSA < 0.6 m2. 
Use eye drops as described in Section 4.1. 
MitoXANTRONE 
(MITOX) 
IV over 15 - 30 
minutes 
12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2 
Days 3 - 6 
See Section 4.14 for administration guidelines. 
On Days 3 and 4, administer 8 hours after the 
5th and 7th cytarabine infusions are completed. 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
HD ARAC 
____mg 
MITOX 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
1 
1 
____mg#  
_____mg    _____mg 
 
a, b+ 
 
 
 
 
2 
 
_____mg    _____mg 
 
 
 
 
 
 
3 
 
_____mg    _____mg 
____mg 
 
 
 
 
 
4 
____mg* 
_____mg    _____mg 
____mg 
 
 
 
 
 
5 
 
 
____mg 
 
 
 
 
 
6 
 
 
____mg 
 
 
 
 
 
7 
 
 
 
 
 
 
 
2 
8 
____mg* 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
11 
____mg* 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
3 
15 
____mg* 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
18 
____mg* 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
21 
 
 
 
e 
 
 
 
 
--- 
 
 
 
 
 
 
 
4 
28 
 
 
 
c, d 
 
 
 
 
29 
Remission status at the end of Induction II will determine whether patients receive further protocol therapy. All patients in CR as defined in Section 10.2.1 will 
proceed to Intensification I (AE). Patients with refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study.  Start next course 
(Intensification I Arm A, Section 4.17) on Day 29 or when blood count parameters and clinical condition are acceptable (whichever occurs later). 
# May be performed with BM done at end of previous course.    
* Note: add’l IT ARAC doses for CNS+ pts only; those with no CNS disease at dx, but CNS+ at start of Ind II (Sect. 4.3).  + For pts in whom serum Cr  is > 2 mg/dL or > 2 x normal for age. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
68 
4.15 
Induction II Arm B (MA + Bortezomib) – High Risk Patients 
 
The following Induction II therapy guidelines are for high risk patients randomized to Arm B of the study. 
Patients will receive bortezomib in addition to MA therapy. Induction II lasts 28 days or longer.  
 
All patients will proceed to Induction II regardless of bone marrow remission status after Induction I. 
Progression to Induction II should await disease response determination (MRD and extramedullary disease) 
in order to correctly assign risk stratum. Patients with high or low risk cytogenetic/molecular features may 
proceed on to Induction II therapy before disease response results are available. It is suggested, but not 
required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with 
therapy. By the beginning of Induction II, patients should have been classified as Low or High risk. If a 
patient is classified as High risk at the end of Induction I and no family HLA match is found, initiation 
of an unrelated donor search should occur. 
 
Patients who were CSF positive at start of Induction I and are CSF positive at start of Induction II 
will be taken off protocol therapy (Section 8.1). 
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Induction II or with the bone marrow evaluation at the end of 
Induction I. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
For newly detected CNS positive patients who were CNS negative at diagnosis: IT cytarabine is to be 
administered twice weekly until the CSF is clear. A minimum of 4 intrathecal treatments must be given and 
a maximum of 6 intrathecal treatments may be given. Patients whose CSF is clear at the second spinal tap 
will receive 3 intrathecal treatments once the CSF is clear and all other patients will receive 2 intrathecal 
treatments once the CSF is clear. See Section 3.3.4 for definitions of CSF involvement.  Patients with 
refractory CNS leukemia following 6 doses of therapy will be taken off protocol therapy. 
 
High Dose Cytarabine (HD ARAC): IV over 1 - 3 hours 
Days: 1 through 4. 
Dose: 1000 mg/m2/dose, every 12 hours (i.e., 2000 mg/m2/day, divided BID) or 
 33 mg/kg/dose, every 12 hours (i.e., 66 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
Suggested premedications and supportive care: Administer steroid eye drops (0.1% dexamethasone or 1% 
prednisolone ophthalmic solution), 2 drops to each eye every 6 hours, beginning immediately before the 
first dose and continuing for 24 hours after the last dose. If patient does not tolerate steroid eye drops, may 
administer artificial tears on an every 2-4 hour schedule. Patients in whom serum creatinine is > 2 mg/dL 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
69 
or > 2 x normal for age, must have a CrCl performed (Day 1) and doses of cytarabine adjusted as outlined 
in Section 5.9.1. 
 
MitoXANTRONE (MITOX): IV over 15 - 30 minutes 
Days: 3 through 6. 
Dose: 12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2 
 
Note: Administer through the tubing of a rapidly infusing solution of D5W or 0.9% NaCl. Avoid 
extravasation; the use of a central line is suggested. On Days 3 and 4, mitoXANTRONE should be 
given 8 hours after the 5th and 7th high dose cytarabine infusions are complete. 
 
Bortezomib (BORTEZ): IV over 3 - 5 seconds 
Days: 1, 4 and 8. 
Dose: 1.3 mg/m2/dose. 
 
On Day 4: Administer after the end of the mitoXANTRONE infusion. 
 
Special precautions: FOR INTRAVENOUS USE ONLY.  
The container or the syringe containing Bortezomib must be clearly labeled “For intravenous use only - 
Fatal if given by other routes.” Additional wording may be considered at the institution’s discretion.   
 
Note: at least 72 hours must have elapsed between doses. Grapefruit and its juice should be avoided for the 
duration of treatment with 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 (e.g., 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 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 is supplied by Millennium Pharmaceuticals and distributed by the NCI DTCD. Do not 
use commercially available drug. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the 
second evaluation time is on or after Day 21 of Induction II, but prior to the start of Intensification I. See 
Section 18.0 for details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Induction II (Arm B, High Risk) is on the next page. 
 
End of Induction II: Remission status at the end of Induction II will determine whether patients receive 
further protocol therapy. All patients in CR as defined in Section 10.2.1 will proceed to Intensification I. 
Patients with refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study. 
 
Following Induction II Arm B, the next course (Intensification I - Arm B, Section 4.18) starts on Day 29 or 
when blood count parameters and clinical condition are acceptable (whichever occurs later).  

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
70 
4.15.1 Induction II Arm B (MA+ Bortezomib) – High Risk Patients 
This therapy is for high risk patients receiving standard therapy and bortezomib. 
___________________                            ______________________ 
Patient name or initials                                           DOB 
Induction II lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Sections 4.1-4.6 and 4.15. All patients will proceed to Induction II 
regardless of remission status after Induction I. Progression to Induction II should await disease response determination so as to properly assign risk strata. It is suggested, but not required, that 
patients have an ANC > 1000/µL and a platelet count > 75 000/µL before proceeding with therapy.  
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine#  
(IT ARAC) 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years) 
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Day 1 
# May be administered with BM done at end 
of previous course.  
a. CBC, BUN/Creat, AST/ALT, bili (direct & 
total), neurologic exam, Echo or MUGA & ECG 
b.   CrCl 
c. BMA/clot section or biopsy 
d. Optional biology studies (see Section 7.4)  
e. HRQOL and Parental Stress Studies1  
f.   Pulse oximetry (prior to bortez)  
g.  PK studies (see Appendices XII-XV, closed to 
new patients as of 6/25/13) 
 
See Section 7.1 for complete list of observations. 
1For patients enrolled on this study, evaluation can 
be obtained on or after Day 21 of Induction II, but 
prior to Intensification I  (see Section 18.0). 
OBTAIN OTHER STUDIES AS REQUIRED FOR 
GOOD PATIENT CARE 
Note: For CNS positive patients (initially CNS negative at diagnosis) see Section 4.3.1 for details of additional doses of intrathecal ARAC needed. 
High dose 
Cytarabine 
(HD ARAC) 
IV over 1 - 3 hours 
1000 mg/m2/dose, every 12 hours 
or 33 mg/kg/dose, every 12 hours 
if BSA < 0.6 m2 
Days 1 - 4 
Total dose: 2000 mg/m2/day, divided BID or 
66 mg/kg/day, divided BID if BSA < 0.6 m2 
Use eye drops as described in Section 4.15. 
MitoXANTRONE 
(MITOX) 
IV over 15 - 30 
minutes 
12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2 
Days 3 - 6 
See Section 4.15 for administration guidelines. 
On Days 3 and 4, administer 8 hours after the 
5th and 7th cytarabine infusions are completed. 
Bortezomib 
(BORTEZ) 
IND# 114480 
IV over 3 - 5 seconds 
1.3 mg/m2/dose 
Days 1, 4, 8 
Consecutive doses must be at least 72 hours 
apart. On Day 4, administer after the end of 
the mitoXANTRONE infusion. 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
HD ARAC 
____mg  ____mg 
MITOX 
____mg 
BORTEZ 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
 
1 
1 
____mg# 
_____mg  _____mg 
 
______mg 
a, b+, f 
 
 
 
 
2 
 
_____mg  _____mg 
 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
______mg 
 
 
 
 
 
 
4 
____mg* 
_____mg  _____mg 
______mg 
______mg 
f 
 
 
 
 
5 
 
 
______mg 
 
 
 
 
 
 
6 
 
 
______mg 
 
 
 
 
 
 
7 
 
 
 
 
 
 
 
 
2 
8 
____mg* 
 
 
______mg 
f, g 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
11 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
3 
15 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
18 
____mg* 
 
 
 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
 
21 
 
 
 
 
e 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
4 
28 
 
 
 
 
c, d 
 
 
 
 
29 
Remission status at the end of Induction II will determine whether patients receive further protocol therapy. All patients in CR as defined in Section 10.2.1 will proceed 
to Intensification Course I (AE). Patients with refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study.  
Start next course (Intensification I – Arm B, Section 4.18) on Day 29 or when blood count parameters and clinical condition are acceptable (whichever occurs later). 
#May be performed with BM done at end of previous course.   *Note: add’l IT ARAC doses for CNS+ pts only; those with no CNS disease at dx, but CNS+ at start of Ind II (Sect. 4.3).   + For pts in whom serum Cr is > 2 mg/dL or 
> 2 x normal for age.   
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES.

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71 
4.16 
Induction II Arm C - Cohort 3 (ADE 8+3+5 + Sorafenib)  
The following Induction II therapy guidelines are for patients with HR FLT3/ITD+ disease during the 
sorafenib feasibility part of the study (Cohort 3). Patients on Arm C will receive standard ADE therapy and 
sorafenib. Induction II lasts 36 days or longer.  
 
All patients will proceed to Induction II regardless of bone marrow remission status after Induction I. 
It is suggested, but not required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL 
before proceeding with therapy. All patients with HR FLT3/ITD+ should have evaluation for a family 
HLA matched donor. If no family HLA match is found, initiation of an unrelated donor search should 
occur. 
 
Patients who were CSF positive at start of Induction I and are CSF positive at start of Induction II 
will be taken off protocol therapy (Section 8.1). 
 
See Section 4.7 for requirements to start each sorafenib course.  
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Induction II or with the bone marrow evaluation at the end of 
Induction I. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
For newly detected CNS positive patients who were CNS negative at diagnosis: IT cytarabine is to be 
administered twice weekly until the CSF is clear. A minimum of 4 intrathecal treatments must be given and 
a maximum of 6 intrathecal treatments may be given. Patients whose CSF is clear at the second spinal tap 
will receive 3 intrathecal treatments once the CSF is clear and all other patients will receive 2 intrathecal 
treatments once the CSF is clear. See Section 3.3.4 for definitions of CSF involvement. Patients with 
refractory CNS leukemia following 6 doses of therapy will be taken off protocol therapy. 
 
Cytarabine (IV ARAC): IV over 1 - 30 minutes 
Days: 1 through 8. 
Dose: 100 mg/m2/dose, every 12 hours (i.e., 200 mg/m2/day, divided BID), or 
3.3 mg/kg/dose, every 12 hours (i.e., 6.6 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
DAUNOrubicin (DAUN): IV over 1 - 15 minutes 
Days: 1, 3 and 5.  
Dose: 50 mg/m2/dose, or 
1.7 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Short infusion times may be lengthened slightly (and up to 60 minutes) if institutional policies 
mandate. It is suggested that DAUNOrubicin be administered through the tubing of rapidly infusing 
solution of D5W or 0.9% NaCl and that it is infused into a large vein. Protect from sunlight.  

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72 
 
Special precautions: Medication errors have occurred due to confusion between DAUNOrubicin and 
DOXOrubicin. DAUNOrubicin is available in a liposomal formulation (DAUNOrubicin citrate). The 
conventional and liposomal formulations are NOT interchangeable. 
 
Etoposide (ETOP): IV over at least 60 - 120 minutes 
Days: 1 through 5. 
Dose: 100 mg/m2/dose, or 
3.3 mg/kg/dose if BSA < 0.6 m2. 
 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested.  
 
Sorafenib (SORAF): PO 
Days: 9 through 36. 
Dose: 200 mg/m2/dose daily, rounded to accommodate tablet size. The maximum dose will be 400 mg. 
Dose to be administered per the dosing nomogram in Appendix II. 
 
Note: Sorafenib tablets should be taken at least 1 hour before or 2 hours after food. Tablets should be taken 
with clear liquids (approximately 2 to 4 ounces for children < 12 years and 4 to 8 ounces for ≥ 12 years). If 
taken with food, sorafenib should be taken with a moderate to low fat meal. Tablets should not be crushed, 
but should be swallowed whole. However, sorafenib tablets can be dispersed in water to facilitate the 
administration to subjects that cannot swallow tablets (see drug monograph in Section 6.12). Grapefruit and 
its juice should be avoided for the duration of treatment with sorafenib. 
 
Sorafenib is supplied by Bayer HealthCare Pharmaceuticals, and distributed by the NCI DTCD. Do 
not use commercially available drug. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the 
second evaluation time is on or after Day 21 of Induction II, but prior to the start of Intensification I. See 
Section 18.0 for details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Induction II Arm C-Cohort 2 is on the next page. 
 
End of Induction II: Remission status at the end of Induction II will determine whether patients receive 
further protocol therapy. All patients in CR as defined in Section 10.2.1 will proceed to Intensification I. 
Patients with refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study. 
 
Following Induction II Arm C - Cohort 3, the next course (Intensification I Arm C - Cohort 3, Section 4.19) 
starts on Day 37 or when blood count parameters and clinical condition are acceptable (whichever occurs 
later). 
 
 

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73 
4.16.1 Induction II Arm C-Cohort 3 (ADE 8+3+5 Sorafenib)  
This therapy is for HR FLT3/ITD+ patients receiving standard therapy and sorafenib during sorafenib feasibility assessment. 
___________________                 ______________________ 
Patient name or initials                                           DOB 
Induction II lasts 36 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Section 4.1-4.7 and 4.16. All patients will proceed to Induction II regardless of 
remission status after Induction I. It is suggested, but not required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with therapy.  
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine#   
(IT ARAC) 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years) 
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Day 1 
# May be performed with BM done at end of 
previous course.  
a. CBC, BUN/Creat, AST/ALT, bili (direct and 
total), Echo or MUGA and ECG, BP, urinalysis 
b. BMA/clot section or biopsy 
c. Optional biology studies (see Sect. 7.4)  
d. HRQOL and Parental Stress Studies1  
e. Clinical cardiac examination  
See Section 7.1 for complete list of observations. 
 
1For patients enrolled on this study, evaluation 
can be obtained on or after Day 21 of Induction 
II, but prior to Intensification I (see Sect. 18.0 for 
details) 
OBTAIN OTHER STUDIES AS REQUIRED FOR 
GOOD PATIENT CARE 
Note: For CNS positive patients (initially CNS negative at diagnosis) see Section 4.3.1 for details of additional doses of intrathecal ARAC needed. 
Cytarabine 
(IV ARAC) 
IV over 1 - 30 minutes  
100 mg/m2/dose, every 12 hours or  
3.3 mg/kg/dose, every 12 hours if BSA < 0.6 m2 
Days 1 - 8 
Total dose: 200 mg/m2/day, divided BID or 
6.6 mg/kg/day, divided BID if BSA < 0.6 m2 
DAUNOrubicin 
(DAUN) 
IV over 1 - 15 minutes 
50 mg/m2/dose or 
1.7 mg/kg/dose if BSA < 0.6 m2 
Days 1, 3, 5 
 
Etoposide  
(ETOP)  
IV over 60 - 120 minutes  
100 mg/m2/dose or  
3.3 mg/kg/dose if BSA < 0.6 m2 
Days 1 - 5 
 
Sorafenib 
(SORAF) 
IND# 114480 
PO 
200 mg/m2/dose once daily 
Days 9 - 36 
See Section 4.16 for administration guidelines. 
See Section 5.0 for dose modification plan. 
The maximum dose will be 400 mg. 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
ARAC IV 
____mg   ____mg  
DAUN 
____mg 
ETOP 
_____mg 
SORAF 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
 
1 
1 
____mg# 
_____mg  _____mg 
____mg 
____mg 
 
a, c, e 
 
 
 
 
2 
 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
 
4 
____mg* 
_____mg  _____mg 
 
____mg 
 
 
 
 
 
 
5 
 
_____mg  _____mg 
____mg 
____mg 
 
 
 
 
 
 
6 
 
_____mg  _____mg 
 
 
 
 
 
 
 
 
7 
 
_____mg  _____mg 
 
 
 
 
 
 
 
2 
8 
____mg* 
_____mg  _____mg 
 
 
 
e 
 
 
 
 
9 
 
 
 
 
______mg 
 
 
 
 
 
11 
____mg* 
 
 
 
 
 
 
 
 
14 
 
 
 
 
c 
 
 
 
3 
15 
____mg* 
 
 
 
e 
 
 
 
 
18 
____mg* 
 
 
 
 
 
 
 
 
21 
 
 
 
 
c, d 
 
 
 
4 
22 
 
 
 
 
e 
 
 
 
 
28 
 
 
 
 
c 
 
 
 
5 
29 
 
 
 
 
e 
 
 
 
6 
36 
 
 
 
 
b, c, e 
 
Remission status at the end of Induction II will determine whether patients receive further protocol therapy. All patients in CR as defined in Section 10.2.1 will proceed to Intensification I Arm C-Cohort 3 (AE). Patients with 
refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study.  
Start next course (Intensification I Arm C-Cohort , Section 4.19) on Day 37 or when blood count parameters and clinical condition are acceptable (whichever occurs later). 
# May be performed with BM done at end of previous course.  
* Note: additional IT ARAC doses for CNS+ patients only; those with no CNS disease at dx, but CNS+ at start of Induction II (see Section 4.3). 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 

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74 
4.17 
Intensification I Arm A (AE) 
 
The following Intensification I therapy guidelines are for patients randomized to Arm A of the study. Arm A 
consists of the standard therapy. Intensification I lasts 28 days or longer.  
 
All patients in CR as defined in Section 10.2.1 will proceed to Intensification I (AE). Patients with 
refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study. It is suggested, 
but not required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding 
with Intensification I therapy. 
 
Patients with high risk status will proceed to best allogenic donor SCT (see Section 4.24) or alternative 
donor SCT (see Section 4.25) following Intensification I. All high risk patients without a suitable donor 
will proceed to a final course of high dose cytarabine/L-Asparaginase (Section 4.22). Patients with low risk 
status will proceed to a final course of cytarabine/mitoxantrone (Section 4.20) regardless of the availability 
of a MFD (i.e., no SCT for these patients). Enrollment on AAML05P1 will be permitted for patients with 
an available unrelated donor. 
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Intensification I or with the bone marrow evaluation at the end 
of Induction II. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
High Dose Cytarabine (HD ARAC): IV over 1 - 3 hours 
Days: 1 through 5. 
Dose: 1000 mg/m2/dose, every 12 hours, (i.e., 2000 mg/m2/day, divided BID), or  
33 mg/kg/dose, every 12 hours (i.e., 66 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
Suggested premedications and supportive care: Administer steroid eye drops (0.1% dexamethasone or 1% 
prednisolone ophthalmic solution), 2 drops to each eye every 6 hours, beginning immediately before the 
first dose and continuing for 24 hours after the last dose. If patient does not tolerate steroid eye drops, may 
administer artificial tears on an every 2-4 hour schedule. Patients in whom serum creatinine is > 2 mg/dL 
or > 2 x normal for age, must have a CrCl performed (Day 1) and doses of cytarabine adjusted as outlined 
in Section 5.9.1. 
 
Etoposide (ETOP): IV over 60 - 120 minutes 
Days: 1 through 5. 
Dose: 150 mg/m2/dose, or 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

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75 
5 mg/kg/dose if BSA < 0.6 m2.  
 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested. Each dose of etoposide should immediately follow the 1st, 3rd, 5th, 7th and 9th doses of cytarabine. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the third 
evaluation time point is on or after Day 21 of Intensification I, but prior to Intensification II. See 
Section 18.0 for details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Intensification I (Arm A) is on the next page. 
 
End of Intensification I: Remission status at the end of Intensification I will determine whether patients 
receive further protocol therapy. Bone marrow exam after Intensification I must show continued complete 
remission. Patients not in remission as defined in Section 10.2.1 will be Off Protocol Therapy but not Off 
Study. All patients in remission will proceed on to Intensification II or SCT. 
 
Following Intensification I – Arm A, the next course (Intensification II – Arm A [Section 4.20 or 4.22], or 
SCT [Section 4.24 or 4.25 depending on availability of a suitable donor]) starts on Day 29 or when blood 
count parameters and clinical condition are acceptable (whichever occurs later). 
 

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76 
4.17.1 Intensification I Arm A (AE)  
This therapy is for patients randomized to receive standard therapy. 
___________________                            ______________________ 
Patient name or initials                                                     DOB 
Intensification I lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive details on treatment assignment are provided in Sections 4.1-4.6 and 4.17. It is suggested, but not 
required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with therapy.   
 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine* 
(IT ARAC) 
 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years)  
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
 
Day 1 
 
* May be performed with BM done at end of 
previous course.  
a. CBC, BUN/Creat, AST/ALT, bili (direct and 
total), Echo or MUGA and ECG 
b. CrCl 
c. BMA/clot section or biopsy. (For SCT patients: 
the end of therapy BMA/Biopsy is to be done 
within 1 month of ANC recovery.)  
d. Optional biology studies (see Section 7.4) 
e. HRQOL and Parental Stress Studies1 
 
See Section 7.1 for complete list of observations. 
 
1For patients enrolled on this study, evaluation 
can be obtained on or after Day 21 of 
Intensification I, but prior to Intensification II 
(see Section 18.0 for details). 
 
OBTAIN OTHER STUDIES AS REQUIRED FOR 
GOOD PATIENT CARE 
High dose 
Cytarabine 
(HD ARAC) 
IV over 1 - 3 
hours  
1000 mg/m2/dose, every 12 hours or  
33 mg/kg/dose, every 12 hours if 
BSA < 0.6 m2 
Days 1 - 5 
Total dose: 2000 mg/m2/day, divided BID or 
66 mg/kg/day, divided BID if BSA < 0.6 m2. 
Use eye drops as described in Section 4.17. 
 
Etoposide 
(ETOP) 
IV over 60 - 120 
minutes 
150 mg/m2/dose or  
5 mg/kg/dose if BSA < 0.6 m2 
Days 1 - 5 
Each dose of etoposide should immediately 
follow the 1st, 3rd, 5th, 7th and 9th doses of 
cytarabine. 
 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
HD ARAC 
____mg 
ETOP 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
1 
1 
____mg* 
_____mg  _____mg 
____mg 
a, b# 
 
 
 
 
2 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
4 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
5 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
3 
21 
 
 
 
e 
 
 
 
 
--- 
 
 
 
 
 
 
 
4 
28 
 
 
 
c, d 
 
 
 
 
29 
Remission status at the end of Intensification I will determine whether patients receive further protocol therapy. Patients not in remission as defined in 
Section 10.2.1 will be Off Protocol Therapy but not Off Study. All patients in remission will proceed on to Intensification II or SCT. 
Start next course (Intensification II – Arm A, Section 4.20 or 4.22) or SCT (Section 4.24 or 4.25) on Day 29 or when blood count parameters and clinical 
condition are acceptable (whichever occurs later). 
* May be performed with BM done at end of previous course. 
 
 
# For patients in whom serum creatinine is > 2 mg/dL or > 2 x normal for age. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 
 

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77 
4.18 
Intensification I Arm B (AE + Bortezomib)  
 
The following Intensification I therapy guidelines are for patients randomized to Arm B of the study. 
Patients on Arm B receive bortezomib in addition to AE therapy. Intensification I lasts 28 days or longer.  
 
All patients in CR as defined in Section 10.2.1 will proceed to Intensification I (AE). Patients with 
refractory disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study. It is suggested, 
but not required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding 
with therapy. 
 
Patients with high risk status will proceed to best allogenic donor SCT (see Section 4.24) or alternative 
donor SCT (see Section 4.25) following Intensification I. All high risk patients without a suitable donor 
will proceed to a final course of high dose cytarabine/L-Asparaginase (Section 4.22). Patients with low risk 
status will proceed to a final course of cytarabine/mitoxantrone (Section 4.21) regardless of the availability 
of a MFD (i.e., no SCT for these patients). Enrollment on AAML05P1 will be permitted for patients with 
an available unrelated donor. 
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Intensification I or with the bone marrow evaluation at the end 
of Induction II. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
High Dose Cytarabine (HD ARAC): IV over 1 - 3 hours 
Days: 1 through 5. 
Dose: 1,000 mg/m2/dose, every 12 hours (i.e., 2,000 mg/m2/day, divided BID), or 
33 mg/kg/dose, every 12 hours (i.e., 66 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
 
Suggested premedications and supportive care: Administer steroid eye drops (0.1% dexamethasone or 1% 
prednisolone ophthalmic solution), 2 drops to each eye every 6 hours, beginning immediately before the 
first dose and continuing for 24 hours after the last dose. If patient does not tolerate steroid eye drops, may 
administer artificial tears on an every 2-4 hour schedule. Patients in whom serum creatinine is > 2 mg/dL 
or > 2 x normal for age, must have a CrCl performed (Day 1) and doses of cytarabine adjusted as outlined 
in Section 5.9.1. 
 
Etoposide (ETOP): IV over at least 60 - 120 minutes 
Days: 1 through 5. 
Dose: 150 mg/m2/dose or 
5 mg/kg/dose if BSA < 0.6 m2.  
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

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78 
 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested. Each dose of etoposide should immediately follow the 1st, 3rd, 5th, 7th and 9th doses of cytarabine. 
 
Bortezomib (BORTEZ): IV over 3 - 5 seconds 
Days: 1, 4 and 8. 
Dose: 1.3 mg/m2/dose. 
 
Special precautions: FOR INTRAVENOUS USE ONLY.  
The container or the syringe containing Bortezomib must be clearly labeled “For intravenous use only - 
Fatal if given by other routes.” Additional wording may be considered at the institution’s discretion.   
 
Note: Consecutive doses must be separated by at least 72 hours. Grapefruit and its juice should be avoided 
for the duration of treatment with bortezomib during each course. 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 (e.g., 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 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. 
 
On Days 1 and 4: Administer after the end of the etoposide infusion. 
 
Bortezomib is supplied by Millennium Pharmaceuticals and distributed by the NCI DTCD. Do not 
use commercially available drug. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the third 
evaluation time point is on or after Day 21 of Intensification I, but prior to Intensification II. See 
Section 18.0 for details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Intensification I - Arm B is on the next page. 
 
End of Intensification I: Remission status at the end of Intensification I will determine whether patients 
receive further protocol therapy. Bone marrow exam after Intensification I must show continued complete 
remission. Patients not in remission as defined in Section 10.2.1 will be Off Protocol Therapy but not Off 
Study. All patients in remission will proceed on to Intensification II or SCT accordingly: 
 
Following Intensification I – Arm B, the next course (Intensification II – Arm B [Section 4.21 or 4.22] or 
SCT [see Section 4.24 or 4.25 depending on availability of a suitable donor]) starts on Day 29 or when 
blood count parameters and clinical condition are acceptable (whichever occurs later). 
 
 

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79 
4.18.1 Intensification I Arm B (AE + Bortezomib)  
This therapy is for patients randomized to receive bortezomib and standard therapy. 
___________________                            ______________________ 
Patient name or initials                                           DOB 
Intensification I lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive details on treatment assignment are provided in Sections 4.1-4.6 and 4.18. It is suggested, but not required, 
that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with therapy. 
 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine* 
(IT ARAC) 
 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years)  
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Day 1 
 
* May be performed with BM done at end 
of previous course.  
a. CBC, BUN/Creat, AST/ALT, bili (direct and total), 
neurologic exam, Echo or MUGA and ECG 
b. CrCl 
c. BMA/clot section or biopsy. (For SCT patients: the 
end of therapy BMA/Biopsy is to be done within 1 
month of ANC recovery.)   
d. Optional biology studies (see Section 7.4) 
e. HRQOL and Parental Stress Studies1 
f. Pulse oximetry (prior to bortez) 
 
See Section 7.1 for complete list of observations. 
 
1For patients enrolled on this study, evaluation can be 
obtained on or after Day 21 of Intensification I, but prior 
to Intensification II (see Section 18.0 for details). 
 
OBTAIN OTHER STUDIES AS REQUIRED FOR GOOD 
PATIENT CARE 
High dose 
Cytarabine 
(HD ARAC) 
IV over 1 - 3 
hours  
1,000 mg/m2/dose, every 12 hours 
or  
33 mg/kg/dose, every 12 hours if 
BSA < 0.6 m2 
Days 1 - 5 
Total dose: 2,000 mg/m2/day, divided BID 
or 66 mg/kg/day, divided BID if BSA 
< 0.6 m2. Use eye drops as described in 
Section 4.18. 
Etoposide 
(ETOP) 
IV over 60 - 120 
minutes 
150 mg/m2/dose or  
5 mg/kg/dose if BSA < 0.6 m2 
Days 1 - 5 
Each dose of etoposide should 
immediately follow the 1st, 3rd, 5th, 7th and 
9th doses of cytarabine. 
Bortezomib 
(BORTEZ) 
IND# 114480 
IV over 3 - 5 
seconds 
1.3 mg/m2/dose 
Days 1, 4, 8 
Consecutive doses must be at least 
72 hours apart. 
On Days 1 and 4: administer after the end 
of the etoposide infusion. 
 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
HD ARAC 
____mg 
ETOP 
____mg 
BORTEZ 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
 
1 
1 
____mg* 
_____mg  _____mg 
____mg 
____mg 
a, b#, f 
 
 
 
 
2 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
 
4 
 
_____mg  _____mg 
____mg 
____mg 
f 
 
 
 
 
5 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
2 
8 
 
 
 
____mg 
f 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
3 
21 
 
 
 
 
e 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
4 
28 
 
 
 
 
c, d 
 
 
 
 
29 
Remission status at the end of Intensification I will determine whether patients receive further protocol therapy. Patients not in remission as defined in 
Section 10.2.1 will be Off Protocol Therapy but not Off Study. All patients in remission will proceed on to Intensification II or SCT. 
Start next course (Intensification II – Arm B, Section 4.21 or 4.22) or SCT (Section 4.24 or 4.25) on Day 29 or when blood count parameters and clinical 
condition are acceptable (whichever occurs later). 
* May be performed with BM done at end of previous course. 
 
# For patients in whom serum creatinine is > 2 mg/dL or > 2 x normal for age. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 

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80 
4.19 
Intensification I Arm C-Cohort 3 (AE + Sorafenib)  
The following Intensification I therapy guidelines are for patients with HR FLT3/ITD+ disease during the 
sorafenib feasibility part of the study (Cohort 3). Intensification I lasts 33 days or longer.  
 
All patients in CR as defined in Section 10.2.1 will proceed to Intensification I (AE). Patients with refractory 
disease as defined in Section 10.2.2 are Off Protocol Therapy but not Off Study. It is suggested, but not 
required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with 
therapy. 
 
All HR FLT3/ITD+ patients will receive best allogeneic donor SCT (see Section 4.24) or alternative donor 
SCT (see Section 4.25) following Intensification I. Patients without a suitable donor will proceed to a final 
course of cytarabine/mitoxantrone with sorafenib. Enrollment on AAML05P1 will be permitted for patients 
with an available unrelated donor. 
 
See Section 4.7 for requirements to start each sorafenib course.  
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Intensification I or with the bone marrow evaluation at the end 
of Induction II. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
High Dose Cytarabine (HD ARAC): IV over 1 - 3 hours 
Days: 1 through 5. 
Dose:  1,000 mg/m2/dose, every 12 hours (i.e., 2,000 mg/m2/day, divided BID) or 
33 mg/kg/dose, every 12 hours (i.e., 66 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
Suggested premedications and supportive care: Administer steroid eye drops (0.1% dexamethasone or 1% 
prednisolone ophthalmic solution), 2 drops to each eye every 6 hours, beginning immediately before the 
first dose and continuing for 24 hours after the last dose. If patient does not tolerate steroid eye drops, may 
administer artificial tears on an every 2 - 4 hour schedule. Patients in whom serum creatinine is > 2 mg/dL 
or > 2 x normal for age, must have a CrCl performed (Day 1) and doses of cytarabine adjusted as outlined 
in Section 5.9.1. 
 
Etoposide (ETOP): IV over at least 60 - 120 minutes 
Days: 1 through 5. 
Dose: 150 mg/m2/dose or 
5 mg/kg/dose if BSA < 0.6 m2.  
 
Note: Slow rate of administration if hypotension occurs. The use of an in-line filter during the infusion is 
suggested. Each dose of etoposide should immediately follow the 1st, 3rd, 5th, 7th and 9th doses of cytarabine. 
 
 

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81 
Sorafenib (SORAF): PO 
Days: 6 through 33. 
Dose: 200 mg/m2/dose daily, rounded to accommodate tablet size. The maximum dose will be 400 mg.  
Dose to be administered per dosing nomogram in Appendix II. 
 
Note: Sorafenib tablets should be taken at least 1 hour before or 2 hours after food. Tablets should be taken 
with clear liquids (approximately 2 to 4 ounces for children < 12 years and 4 to 8 ounces for ≥ 12 years). If 
taken with food, sorafenib should be taken with a moderate to low fat meal. Tablets should not be crushed, 
but should be swallowed whole. However, sorafenib tablets can be dispersed in water to facilitate the 
administration to subjects that cannot swallow tablets (see drug monograph in Section 6.12). Grapefruit and 
its juice should be avoided for the duration of treatment with sorafenib. 
 
Sorafenib is supplied by Bayer HealthCare Pharmaceuticals, and distributed by the NCI DTCD. Do 
not use commercially available drug. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: For patients who consent and are enrolled on the HRQOL and parental stress studies, the third 
evaluation time point is on or after Day 21 of Intensification I, but prior to Intensification II. See Section 
18.0 for details of evaluation schedule. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Intensification I Arm C-Cohort 3 is on the next page. 
 
End of Intensification I: Remission status at the end of Intensification I will determine whether patients 
receive further protocol therapy. Bone marrow exam after Intensification I must show continued complete 
remission. Patients not in remission as defined in Section 10.2.1 will be Off Protocol Therapy but not Off 
Study. All patients in remission will proceed on to Intensification II or SCT accordingly: 
 
Following Intensification I Arm C - Cohort 3, the next course (Intensification II Arm C - Cohort 3 
[Section 4.23] or SCT [see Section 4.24 or 4.25 depending on availability of a suitable donor]) starts on 
Day 34 or when blood count parameters and clinical condition are acceptable (whichever occurs later). 
 

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82 
4.19.1 Intensification I Arm C-Cohort 3 (AE + Sorafenib)  
This therapy is for HR FLT3/ITD+ patients receiving standard therapy and sorafenib during sorafenib feasibility assessment. 
___________________                        ______________________ 
Patient name or initials                                           DOB 
Intensification I lasts 33 days or longer and this Therapy Delivery Map is on 1 page. Extensive details on treatment assignment are provided in Sections 4.1-4.7 and 4.18. It is suggested, but not required, 
that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with therapy.   
 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine* 
(IT ARAC) 
 
IT 
20 mg (age 0 - 0.99 years) 
30 mg (age 1 - 1.99 years)  
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Day 1 
 
* May be performed with BM done at end of 
previous course.  
a. CBC, BUN/Creat, AST/ALT, bili  (direct & 
total), BP, Echo or MUGA & ECG, urinalysis 
b. CrCl 
c. BMA/clot section or biopsy. (For SCT 
patients: the end of therapy BMA/Biopsy is to 
be done within 1 month of ANC recovery.)   
d. Optional biology studies (see Section 7.4) 
e. HRQOL and Parental Stress Studies1 
f. Clinical cardiac examination 
See Sect. 7.1 for complete list of observations. 
1For patients enrolled on this study, evaluation 
can be obtained on or after Day 21 of 
Intensification I, but prior to Intensification II 
(see Section 18.0 for details). 
OBTAIN OTHER STUDIES AS REQUIRED 
FOR GOOD PATIENT CARE 
High dose 
Cytarabine 
(HD ARAC) 
IV over 1 - 3 
hours  
1,000 mg/m2/dose, every 12 hours or  
33 mg/kg/dose, every 12 hours  if 
BSA < 0.6 m2 
Days  1 -5 
Total dose: 2,000 mg/m2/day, divided BID or 
66 mg/kg/day, divided BID if BSA < 0.6 m2. 
Use eye drops as described in Section 4.19. 
Etoposide 
(ETOP) 
IV over 60 - 120 
minutes 
150 mg/m2/dose or  
5 mg/kg/dose if BSA < 0.6 m2 
Days 1 - 5 
Each dose of etoposide should immediately follow 
the 1st, 3rd, 5th, 7th and 9th doses of cytarabine. 
Sorafenib 
(SORAF) 
IND# 114480 
PO 
200 mg/m2/dose once daily 
Days 6 - 33 
See Section 4.19 for administration guidelines.  
See Section 5.0 for dose modification plan. 
The maximum dose will be 400 mg. 
 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
HD ARAC 
____mg 
ETOP 
____mg 
SORAF 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
 
1 
1 
____mg* 
_____mg  _____mg 
____mg 
 
a, b#, f 
 
 
 
 
2 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
 
4 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
 
5 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
 
6 
 
 
 
_____mg 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
2 
8 
 
 
 
f 
 
 
 
 
14 
 
 
 
d 
 
 
 
3 
15 
 
 
 
f 
 
 
 
 
-- 
 
 
 
 
 
 
 
 
21 
 
 
 
d, e 
 
 
 
4 
22 
 
 
 
f 
 
 
 
 
28 
 
 
 
d 
 
 
 
5 
29 
 
 
 
f 
 
 
 
 
33 
 
 
 
c, d 
 
Remission status at the end of Intensification I will determine whether patients receive further protocol therapy. Patients not in remission as defined in Section 10.2.1 will be Off Protocol Therapy but 
not Off Study. All patients in remission will proceed on to Intensification II or SCT. 
Start next course (Intensification II Arm C-Cohort 3, Sect. 4.23) or SCT (Sect. 4.24 or 4.25) on Day 34 or when blood count parameters and clinical condition are acceptable (whichever occurs later). 
* May be performed with BM done at end of previous course. 
# For patients in whom serum creatinine is > 2 mg/dL or > 2 x normal for age. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 

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83 
4.20 
Intensification II Arm A (MA) – Low Risk Patients 
 
The following Intensification II therapy guidelines are for patients with low risk disease randomized to Arm 
A of the study. Arm A consists of the standard therapy. Intensification II lasts 28 days or longer.  
 
It is suggested, but not required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL 
before proceeding with therapy.  
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Intensification II or with the bone marrow evaluation at the 
end of Intensification I. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
High Dose Cytarabine (HD ARAC): IV over 1 - 3 hours 
Days: 1 through 4. 
Dose: 1,000 mg/m2/dose, every 12 hours (i.e., 2,000 mg/m2/day, divided BID) or 
33 mg/kg/dose, every 12 hours (i.e., 66 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
Suggested premedications and supportive care: Administer steroid eye drops (0.1% dexamethasone or 1% 
prednisolone ophthalmic solution), 2 drops to each eye every 6 hours, beginning immediately before the 
first dose and continuing for 24 hours after the last dose. If patient does not tolerate steroid eye drops, may 
administer artificial tears on an every 2-4 hour schedule. Patients in whom serum creatinine is > 2 mg/dL 
or > 2 x normal for age, must have a CrCl performed (Day 1) and doses of cytarabine adjusted as outlined 
in Section 5.9.1. 
 
MitoXANTRONE (MITOX): IV over 15 - 30 minutes 
Days: 3 through 6. 
Dose: 12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2.  
 
Note: Administer through the tubing of a rapidly infusing solution of D5W or 0.9% NaCl. Avoid 
extravasation; the use of a central line is suggested. On the Days 3 and 4, mitoXANTRONE should be given 
8 hours after the 5th and 7th high dose cytarabine infusions are complete. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: Patients assigned to chemotherapy- For patients who consent and are enrolled on the HRQOL 
and parental stress studies, the fourth and fifth evaluation time points occur at 1 month (± 7 days) and 
4 months (± 1 month) respectively, from the start of Intensification II. Evaluations 6, 7 and 8 occur at 12 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

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84 
(± 1 month), 24 (± 3 months) and 36 (± 3 months) months from diagnosis, respectively. See Section 18.0 
for complete details of evaluation schedules. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Intensification II (Arm A, Low Risk) is on the next page. 
 
 

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85 
4.20.1 Intensification II Arm A (MA) – Low Risk Patients  
This therapy is for low risk patients randomized to receive standard therapy. 
___________________                     ______________________ 
Patient name or initials                                DOB 
Intensification II lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Sections 4.1-4.6 and 4.20. It is suggested, but not 
required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with therapy. BM exam after Intensification I must show continued complete 
remission. 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine 
(IT ARAC) 
 
IT 
Age-based dosing: 
20 mg  (age 0 - 0.99 years) 
30 mg  (age 1 - 1.99 years)  
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
 
Day 1 
* May be performed with BM done at end of 
previous course.  
a. CBC, BUN/Creat, AST/ALT, 
bili (direct and total), Echo or 
MUGA and ECG 
b. CrCl 
c. HRQOL and Parental Stress 
Studies1 
 
See Section 7.1 for complete 
list of observations 
 
1For patients enrolled on this 
study, see Section 18.0 for 
details on evaluation time 
points 4, 5, 6, 7 and 8. 
 
OBTAIN OTHER STUDIES AS 
REQUIRED FOR GOOD 
PATIENT CARE 
Cytarabine 
(HD ARAC) 
IV over 1 - 3 
hours 
1,000 mg/m2/dose, every 12 hours 
or 
33 mg/kg/dose, every 12 hours if 
BSA < 0.6 m2 
 
Days 1 – 4 
Total dose: 2,000 mg/m2/day, divided BID or 
66 mg/kg/day, divided BID if BSA < 0.6 m2. 
Use eye drops as described in Section 4.20. 
MitoXANTRONE 
(MITOX) 
IV over 15 - 30 
minutes 
12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2 
 
Days 3 - 6 
See Section 4.20 for administration 
guidelines. On Days 3 and 4, administer 
8 hours after the 5th and 7th cytarabine 
infusions are completed. 
 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
HD ARAC 
____mg 
MITOX 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
1 
1 
____mg* 
_____mg  _____mg 
 
a, b# 
 
 
 
 
2 
 
_____mg  _____mg 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
4 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
5 
 
 
____mg 
 
 
 
 
 
6 
 
 
____mg 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
4 
28 
 
 
 
c 
 
See Section 7.1 for required end of therapy evaluations 
* May be performed with BM done at end of previous course 
 
# For patients in whom serum creatinine is > 2 mg/dL or > 2 x normal for age. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES.

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AAML1031 
Version Date: 04/24/2017 
 
86 
4.21 
Intensification II Arm B (MA + Bortezomib) – Low Risk Patients 
 
The following Intensification II therapy guidelines are for patients with low risk disease randomized to Arm 
B of the study. Patients on Arm B receive bortezomib in addition to MA therapy. Intensification II lasts 
28 days or longer. 
 
It is suggested, but not required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL 
before proceeding with therapy.  
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Intensification II or with the bone marrow evaluation at the 
end of Intensification I. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
High Dose Cytarabine (HD ARAC): IV over 1 - 3 hours 
Days: 1 through 4. 
Dose: 1,000 mg/m2/dose, every 12 hours (i.e., 2,000 mg/m2/day, divided BID) or 
33 mg/kg/dose, every 12 hours (i.e., 66 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
Suggested premedications and supportive care: Administer steroid eye drops (0.1% dexamethasone or 1% 
prednisolone ophthalmic solution), 2 drops to each eye every 6 hours, beginning immediately before the 
first dose and continuing for 24 hours after the last dose. If patient does not tolerate steroid eye drops, may 
administer artificial tears on an every 2 - 4 hour schedule. Patients in whom serum creatinine is > 2 mg/dL 
or > 2 x normal for age, must have a CrCl performed (Day 1) and doses of cytarabine adjusted as outlined 
in Section 5.9.1. 
  
MitoXANTRONE (MITOX): IV over 15 - 30 minutes 
Days: 3 through 6. 
Dose: 12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2 
 
Note: Administer through the tubing of a rapidly infusing solution of D5W or 0.9% NaCl. Avoid 
extravasation; the use of a central line is suggested. On Days 3 and 4, mitoXANTRONE should be 
given 8 hours after the 5th and 7th high dose cytarabine infusions are complete. 
 
Bortezomib (BORTEZ): IV over 3 - 5 seconds 
Days: 1, 4 and 8. 
Dose: 1.3 mg/m2/dose. 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

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87 
 
On Day 4: Administer after the end of the mitoXANTRONE infusion. 
 
Special precautions: FOR INTRAVENOUS USE ONLY.  
The container or the syringe containing Bortezomib must be clearly labeled “For intravenous use only - 
Fatal if given by other routes.” Additional wording may be considered at the institution’s discretion.   
 
Note: at least 72 hours must have elapsed between doses. Grapefruit and its juice should be avoided for the 
duration of treatment with 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 (e.g., 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 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 is supplied by Millennium Pharmaceuticals and distributed by the NCI DTCD. Do not 
use commercially available drug. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: Patients assigned to chemotherapy- For patients who consent and are enrolled on the HRQOL 
and parental stress studies, the fourth and fifth evaluation time points occur at 1 month (± 7 days) and 
4 months (± 1 month) respectively, from the start of Intensification II. Evaluations 6, 7 and 8 occur at 12 
(± 1 month), 24 (± 3 months) and 36 (± 3 months) months from diagnosis, respectively. See Section 18.0 
for complete details of evaluation schedules. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Intensification II (Arm B, Low Risk) is on the next page. 
 
 

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4.21.1 Intensification II Arm B (MA + Bortezomib) – Low Risk Patients 
This therapy is for low risk patients randomized to receive bortezomib and standard therapy. 
___________________                      ______________________ 
Patient name or initials                                       DOB 
Intensification II lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Sections 4.1-4.6 and 4.21. It is suggested, but not required, 
that patients have an ANC > 1000/µL and a platelet count > 75 000/µL before proceeding with therapy. BM exam after Intensification I must show continued complete remission. 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine* 
(IT ARAC) 
 
IT 
20 mg  (age 0 - 0.99 years) 
30 mg  (age 1 - 1.99 years)  
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Day 1 
 
*May be performed with BM done at end of 
previous course.  
a. CBC, BUN/Creat, AST/ALT, bili 
(direct and total), neurologic exam, 
Echo or MUGA and ECG 
b. CrCl 
c. Pulse oximetry (prior to bortez) 
d. HRQOL and Parental Stress Studies1 
 
See Section 7.1 for complete list of 
observations. 
 
1For patients enrolled on this study, see 
Section 18.0 for details on evaluation 
time points 4, 5, 6, 7 and 8. 
 
OBTAIN OTHER STUDIES AS 
REQUIRED FOR GOOD PATIENT 
CARE 
High dose 
Cytarabine 
(HD ARAC) 
IV over 1 - 3 hours 
1000 mg/m2/dose, every 12 hours 
or 
33 mg/kg/dose, every 12 hours if 
BSA < 0.6 m2 
 
Days 1 - 4 
Total dose: 2000 mg/m2/day, divided BID or 
66 mg/kg/day, divided BID if BSA < 0.6 m2 
Use eye drops as described in Section 4.21. 
MitoXANTRONE 
(MITOX) 
IV over 15 - 30 
minutes 
12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2 
Days 3 - 6 
See Section 4.21 for administration guidelines. 
On Days 3 and 4, administer 8 hours after the 
5th and 7th cytarabine infusions are completed. 
Bortezomib 
(BORTEZ) 
IND# 114480 
IV over 3 - 5 seconds 
1.3 mg/m2/dose 
Days 1, 4, 8 
Consecutive doses must be at least 72 hours 
apart. On Day 4, administer after the end of the 
mitoXANTRONE infusion. 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
HD ARAC 
____mg  ____mg 
MITOX 
____mg 
BORTEZ 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
1 
1 
____mg* 
_____mg  _____mg 
 
____mg 
a, b#, c 
 
 
 
 
2 
 
_____mg  _____mg 
 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
 
4 
 
_____mg  _____mg 
____mg 
____mg 
c 
 
 
 
 
5 
 
 
____mg 
 
 
 
 
 
 
6 
 
 
____mg 
 
 
 
 
 
 
7 
 
 
 
 
 
 
 
 
2 
8 
 
 
 
____mg 
c 
 
 
 
 
--- 
 
 
 
 
 
 
 
 
4 
28 
 
 
 
 
d 
 
See Section 7.1 for Required end of therapy observations. 
* May be performed with BM done at end of previous course. 
 
# For patients in whom serum creatinine is > 2 mg/dL or > 2 x normal for age. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 

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4.22 
Intensification II Arm A & B (HD ARAC/LASP) – High Risk Patients 
 
The following Intensification II therapy guidelines are for patients with high risk disease, randomized to 
Arm A or Arm B of the study, who do not have an appropriate donor for SCT. Intensification II lasts 28 days 
or longer.  
 
It is suggested, but not required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL 
before proceeding with therapy.  
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
High Dose Cytarabine (HD ARAC): IV over 3 hours 
Days: 1, 2 and 8, 9 
Dose: 3,000 mg/m2/dose, every 12 hours (i.e., 6,000 mg/m2/day, divided BID), or 
100 mg/kg/dose, every 12 hours (i.e., 200 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
Suggested premedications and supportive care: Administer steroid eye drops (0.1% dexamethasone or 1% 
prednisolone ophthalmic solution), 2 drops to each eye every 6 hours, beginning immediately before the 
first dose and continuing for 24 hours after the last dose. If patient does not tolerate steroid eye drops, may 
administer artificial tears on an every 2-4 hour schedule. Patients in whom serum creatinine is > 2 mg/dL 
or > 2 x normal for age, must have a CrCl performed (Days 1 and 8) and doses of cytarabine adjusted as 
outlined in Section 5.9.1. 
 
E. coli L-Asparaginase (LASP): IM 
Days: 2 and 9. To be given 6 hours after the start of the 4th and 8th dose of cytarabine (Hour 42).  
Dose: 6,000 International Units/m2/dose (200 International Units/kg/dose if BSA < 0.6 m2).  
 
If E.coli L-asparaginase (i.e., Elspar or Kidrolase) is not available, please use Erwinia asparaginase 
(Erwinaze) as follows:  
Erwinia L-asparaginase (Erwinaze): IM (may be given IV over 1 hour) 
Days: 2, 9 (one dose per day, 2 doses total for the entire course) 
Dose: 25,000 IU/m2 (830 IU/kg/dose if BSA < 0.6 m2) 
 
Note: Erwinia asparaginase should be given 6 hours after the start of cytarabine doses 4 and 8. 
If Erwinia asparaginase is not available, pegasparaginase should not be given. Rather, asparaginase should 
be omitted.  
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: Patients assigned to chemotherapy- For patients who consent and are enrolled on the HRQOL 
and parental stress studies, the fourth and fifth evaluation time points occur at 1 month (± 7 days) and 
4 months (± 1 month) respectively, from the start of Intensification II. Evaluations 6, 7 and 8 occur at 12 
(± 1 month), 24 (± 3 months) and 36 (± 3 months) months from diagnosis, respectively. See Section 18.0 
for complete details of evaluation schedules. 
 
NOTE: AS OF AMENDMENT #7A ACCRUAL FOR ARMS A AND B HAVE BEEN MET. NO 
ADDITIONAL PATIENTS WILL BE ENROLLED ON ARMS A OR B OF AAML1031. 

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90 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Intensification II (Arm A & B, High Risk) is on the next page. 
 
 

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91 
4.22.1 Intensification II Arm A & B (HD ARAC/LASP) – High Risk Patients  
This therapy is for high risk patients who do not have an appropriate donor for SCT. 
___________________                     ______________________ 
Patient name or initials                                           DOB 
Intensification II lasts 28 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Sections 4.1-4.6 and 4.22. It is suggested, but not 
required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with therapy. BM exam after Intensification I must show continued complete 
remission. 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine 
(HD ARAC) 
IV over 3 hours 
3,000 mg/m2/dose, every 12 hours 
or 100 mg/kg/dose, every 
12 hours if BSA < 0.6 m2 
 
Days 1, 2 and 8, 9 
Total dose: 6,000 mg/m2/day, 
divided BID or 200 mg/kg/day, 
divided BID if BSA < 0.6 m2.  
Use eye drops as described in 
Section 4.22. Check serum Cr. 
a. CBC, BUN/Cr, AST/ALT, 
bili (direct and total), Echo or 
MUGA and ECG 
b. CrCl 
c. HRQOL and Parental Stress 
Studies1 
 
See Section 7.1 for complete 
list of observations 
 
1For patients enrolled on this 
study, see Section 18.0 for 
details on evaluation time 
points 4, 5, 6, 7 and 8. 
 
OBTAIN OTHER STUDIES AS 
REQUIRED FOR GOOD 
PATIENT CARE 
E. coli  
L-Asparaginase 
(LASP) 
IM 
6,000 International Units/m2/dose 
(200 International Units/kg/dose 
if BSA < 0.6 m2)  
 
Day 2 and Day 9. To be given 
6 hours after the start of the 
4th and 8th dose of cytarabine 
(Hour 42). 
If E. Coli  version is not 
available use: 
Erwinia L-asparaginase 
(Erwinaze): 25,000 IU/m2 
(830 IU/kg/dose if BSA 
< 0.6 m2) on Days 2 and 9 
(2 doses total for the entire 
course). IM (may be given IV 
over 1 hour). See Section 4.22.  
 
 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date Due 
Date Given 
Week 
Day 
HD ARAC 
______mg 
LASP 
______units 
Studies 
Comments (Include any held doses, or 
dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below  
 
 
1 
1 
______mg   ______mg 
 
a, b* 
 
 
 
 
2 
______mg   ______mg 
______units 
 
 
 
 
 
--- 
 
 
 
 
 
 
 
8 
______mg   ______mg 
 
b* 
 
 
 
 
9 
______mg   ______mg 
______units 
 
 
 
 
 
--- 
 
 
 
 
 
 
4 
28 
 
 
c 
 
See Section 7.1 for required end of therapy evaluations. 
* For patients in whom serum creatinine is > 2 mg/dL or > 2 x normal for age. 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES. 

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92 
 
4.23 
Intensification II Arm C-Cohort 3 (MA + Sorafenib)  
The following Intensification II therapy guidelines are for patients with HR FLT3/ITD+ disease without a 
suitable donor for SCT, during the sorafenib feasibility part of the study (Cohort 3). Intensification II lasts 
34 days or longer. 
 
It is suggested, but not required, that patients have an ANC > 1,000/µL and a platelet count > 75,000/µL 
before proceeding with therapy.  
 
See Section 4.7 for requirements to start each sorafenib course. 
 
See the Parenteral Chemotherapy Administration Guidelines (CAGs) on the COG website at: 
https://members.childrensoncologygroup.org/_files/disc/Pharmacy/ChemoAdminGuidelines.pdf 
for 
special precautions and suggestions for patient monitoring during the infusions. As applicable, also see the 
CAGs for suggestions on hydration, or hydrate according to institutional guidelines. 
 
Intrathecal Cytarabine (IT ARAC): IT 
IT ARAC may be administered on Day 1 of Intensification II or with the bone marrow evaluation at the 
end of Intensification I. 
Age-based dosing: 
Age (yrs) 
Dose 
0 - 0.99  
20 mg 
1 - 1.99  
30 mg 
2 - 2.99  
50 mg 
≥ 3 
 
70 mg 
 
High Dose Cytarabine (HD ARAC): IV over 1-3 hours 
Days: 1 through 4. 
Dose: 1,000 mg/m2/dose, every 12 hours (i.e., 2,000 mg/m2/day, divided BID) or 
33 mg/kg/dose, every 12 hours (i.e., 66 mg/kg/day, divided BID) if BSA < 0.6 m2. 
 
Suggested premedications and supportive care: Administer steroid eye drops (0.1% dexamethasone or 1% 
prednisolone ophthalmic solution), 2 drops to each eye every 6 hours, beginning immediately before the 
first dose and continuing for 24 hours after the last dose. If patient does not tolerate steroid eye drops, may 
administer artificial tears on an every 2-4 hour schedule. Patients in whom serum creatinine is > 2 mg/dL 
or > 2 x normal for age, must have a CrCl performed (Day 1) and doses of cytarabine adjusted as outlined 
in Section 5.9.1. 
  
MitoXANTRONE (MITOX): IV over 15 - 30 minutes 
Days: 3 through 6. 
Dose: 12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2 
 
Note: Administer through the tubing of a rapidly infusing solution of D5W or 0.9% NaCl. Avoid 
extravasation; the use of a central line is suggested. On the Days 3 and 4, mitoXANTRONE should be given 
8 hours after the 5th and 7th high dose cytarabine infusions are complete. 
 
Sorafenib (SORAF): PO 
Days: 7 through 34. 
Dose: 200 mg/m2/dose daily, rounded to accommodate tablet size. The maximum dose will be 400 mg.  
Dose to be administered per dosing nomogram in Appendix II. 
 

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Note: Sorafenib tablets should be taken at least 1 hour before or 2 hours after food. Tablets should be taken 
with clear liquids (approximately 2 to 4 ounces for children < 12 years and 4 to 8 ounces for ≥ 12 years). If 
taken with food, sorafenib should be taken with a moderate to low fat meal. Tablets should not be crushed, 
but should be swallowed whole. However, sorafenib tablets can be dispersed in water to facilitate the 
administration to subjects that cannot swallow tablets (see drug monograph in Section 6.12). Grapefruit and 
its juice should be avoided for the duration of treatment with sorafenib. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: 
Patients assigned to chemotherapy- For patients who consent and are enrolled on the HRQOL and parental 
stress studies, the fourth and fifth evaluation time points occur at 1 month (± 7 days) and 4 months (± 1 
month) respectively, from the start of Intensification II. Evaluations 6, 7 and 8 occur at 12 (± 1 month), 24 
(± 3 months) and 36 months (± 3 months) from diagnosis, respectively. See Section 18.0 for complete 
details of evaluation schedules. 
 
Sorafenib is supplied by Bayer HealthCare Pharmaceuticals, and distributed by the NCI DTCD. Do 
not use commercially available drug. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Intensification II Arm C-Cohort 3 is on the next page. 
 
End of Intensification II:  
Arm C patients will complete protocol therapy after Intensification II if: 
1. They were unable to tolerate the sorafenib 100 mg/m2 dose level during any therapy phase to date,  
or  
2. They experienced Grade 4 hypertension.  
 
All other patients may proceed to Maintenance therapy (see Section 4.26). Maintenance therapy will begin 
between 40 - 100 days following Intensification II.   
 
 

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4.23.1 Intensification II Arm C – Cohort 3 (MA + Sorafenib)  
This therapy is for patients with HR FLT3/ITD+ disease without an appropriate SCT donor receiving standard therapy and 
sorafenib during sorafenib feasibility assessment. 
___________________                     _________________ 
Patient name or initials                                           DOB 
Intensification II lasts 34 days or longer and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in Sections 4.1-4.7 and 4.23. It is suggested, but not required, that patients 
have an ANC > 1,000/µL and a platelet count > 75,000/µL before proceeding with therapy. BM exam after Intensification I must show continued complete remission. 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Cytarabine* 
(IT ARAC) 
IT 
20 mg  (age 0 - 0.99 years) 
30 mg  (age 1 - 1.99 years)  
50 mg (age 2 - 2.99 years) 
70 mg (age ≥ 3 years) 
Day 1 
 
* May be performed with BM done at end of 
previous course.  
a. CBC, BUN/Creat, AST/ALT, bili (direct 
and total), Echo or MUGA and ECG, BP, 
urinalysis 
b. CrCl 
c. Optional biology studies (see Sect. 7.4) 
d. HRQOL and Parental Stress Studies1 
e. Clinical cardiac examination  
See Sect. 7.1 for complete list of 
observations. 
1For patients enrolled on this study, see 
Sect. 18.0 for details on evaluation time 
point 4. 
OBTAIN OTHER STUDIES AS 
REQUIRED FOR GOOD PATIENT CARE 
High dose 
Cytarabine 
(HD ARAC) 
IV over 1 - 3 
hours 
1,000 mg/m2/dose, every 12 hours or 
33 mg/kg/dose, every 12 hours if BSA 
< 0.6 m2 
Days 1 - 4 
Total dose: 2,000 mg/m2/day, divided BID or 
66 mg/kg/day, divided BID if BSA < 0.6 m2. 
Use eye drops described in Section 4.23. 
MitoXANTRONE 
(MITOX) 
IV over 15 - 30 
minutes 
12 mg/m2/dose or 
0.4 mg/kg/dose if BSA < 0.6 m2 
Days 3 - 6 
See Section 4.23 for administration guidelines. 
On Days 3 and 4, administer 8 hours after the 5th 
and 7th cytarabine infusions are completed. 
Sorafenib 
(SORAF) 
IND# 114480 
PO 
200 mg/m2/dose once daily 
Days 7 - 34 
See Section 4.23 for administration guidelines. 
See Section 5.0 for dose modification plan. The 
maximum dose will be 400 mg. 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Week 
Day 
ARAC IT 
____mg 
HD ARAC 
____mg  ____mg 
MITOX 
____mg 
SORAF 
____ mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
1 
1 
____mg* 
_____mg  _____mg 
 
 
a, b#, c, e 
 
 
 
 
2 
 
_____mg  _____mg 
 
 
 
 
 
 
 
3 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
 
4 
 
_____mg  _____mg 
____mg 
 
 
 
 
 
 
5 
 
 
____mg 
 
 
 
 
 
 
6 
 
 
____mg 
 
 
 
 
 
 
7 
 
 
 
_______mg 
 
 
 
 
2 
8 
 
 
 
e 
 
 
 
 
14 
 
 
 
c 
 
 
 
3 
15 
 
 
 
e 
 
 
 
 
21 
 
 
 
c 
 
 
 
4 
22 
 
 
 
e 
 
 
 
 
28 
 
 
 
c, d 
 
 
 
5 
29 
 
 
 
e 
 
 
 
 
34 
 
 
 
 
 
 
 
 
35 
 
 
 
 
 
 
See Section 7.1 for required evaluations. Arm C patients will complete protocol therapy after Intensification II if (1) they were unable to tolerate the sorafenib 100 mg/m2 dose level during any 
therapy phase to date, or (2) they experienced Grade 4 hypertension or Grade 3 maculo-papular rash during any therapy phase to date. All other patients may proceed to maintenance therapy (see 
Section 4.26). Maintenance therapy will begin between 40 - 100 days following Intensification II.   
* May be performed with BM done at end of previous course. 
 
# For patients in whom serum creatinine is > 2 mg/dL or > 2 x normal for age. 

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SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE GUIDELINES.  

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96 
4.24 
Allogeneic Stem Cell Transplantation 
Stem cell transplantation in this study will be utilized in those patients with high risk leukemia (see 
Section 3.3.5 for risk categorizations). All patients in whom low risk cytogenetics are present will NOT 
proceed to SCT. All high risk patients with a family match (see below) will proceed with a MFD SCT after 
Intensification I.  
 
All high risk patients in whom no MFD is available will proceed with an alternative donor SCT (see 
Section 4.25) after Intensification I. If the donor is not available after Intensification I, and the delay in the 
availability of the donor will exceed 8 weeks after count recovery, the patient should proceed with the 
chemotherapy according to the arm to which they were originally assigned. If the donor becomes available 
at a later date, the institution may proceed with the SCT. For those in whom donors later become available 
and in whom the subsequent Intensification course of therapy has been administered, the treating clinicians 
may choose to defer SCT altogether during CR. See Section 3.3.5 for further guidelines for high risk patients 
without a MFD.  
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: Patients assigned to stem cell transplant therapy- Patients who consent and are enrolled on the 
HRQOL and parental stress studies, will have their fourth and fifth evaluations at 1 month (± 7 days) and 
4 months (± 1 month) respectively, from the start of the preparative regimen. Evaluations 6, 7 and 8 occur 
at 12 (± 1 month), 24 (± 3 months) and 36 (± 3 months) months from diagnosis respectively. See 
Section 18.0 for complete details of evaluation schedules. 
 
4.24.1  
Bone marrow SCT must be performed at a COG certified SCT institution. Patients should begin their SCT 
preparative regimen following Intensification I (cytarabine and etoposide).  
 
4.24.2 MFD Donor Selection: 
1) 
HLA, A, B, C, DRB1, identical, or 1 antigen or allele mismatched family donor. 
2) 
HLA typing must be performed using molecular high resolution technique. 
3) 
All available first degree family members (parents and siblings) must be HLA typed. 
4) 
Use of syngeneic donors will NOT be permitted in this study 
 
4.24.3 MFD SCT Conditioning Regimen 
Dose adjustments will be made for obesity, defined as > 125% of IBW: 
Adjusted weight = 1.25*IBW  
 
Day –6  
Begin anti-seizure prophylaxis (lorazepam [phenytoin or levetiracetam can be used 
as alternatives]: see Section 4.24.4) 
Day –5 to –2 
Fludarabine 40 mg/m2/dose daily IV or 1.3 mg/kg/dose daily IV if < 10 kg 
Day –5 to –2 
Busulfan daily IV*  
• 
With age-based dosing (see Section 4.24.6.1)  
• 
With 1st dose pharmacokinetics (see Section 17.1.3) 
Day –2 
Begin Tacrolimus 
Day –1 
Rest 

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97 
Day 0  
Bone Marrow Infusion 
Day 1 
Methotrexate 5 mg/m2/dose IV 
Day 3  
Methotrexate 5 mg/m2/dose IV 
Day 6 
Methotrexate 5 mg/m2/dose IV 
 
Day 11 
Methotrexate 5 mg/m2/dose IV (mismatched family donors only, see 
Section 4.24.8.2). Matched sibling and UCB SCTs do not receive Day 11 MTX.  
 
 
* Divided dosing (4 times daily is permitted per institutional standard) 
 
 
4.24.4 Anti-seizure prophylaxis (Day –6) 
 
4.24.4.1 
Seizure prophylaxis is mandatory. The preferred regimen is lorazepam (0.02 - 0.05 mg/kg/dose, maximum 
dose: 2 mg) given 30 minutes prior to each busulfan dose and then continuing for at least 24 hours after last 
busulfan dose. Alternative acceptable regimens include phenytoin or levetiracetam beginning 12 hours 
prior to busulfan and continue at least 24 hours after completion of busulfan.  
 
4.24.4.2 
The dose of phenytoin is 2.5 mg/kg/dose PO BID (maximum dose: 150 mg). 
The dose of levetiracetam is 10 mg/kg/dose PO BID (maximum dose: 1,000 mg). 
 
4.24.4.3 
Loading dose and therapeutic monitoring are not necessary. For patients with a known seizure disorder, 
consider IV dosing with loading and therapeutic monitoring. 
 
4.24.4.4 
Phenytoin interacts with busulfan causing reduced plasma levels, whereas lorazepam and levetiracetam do 
not affect busulfan levels. Adjusting the busulfan dose based on 1st day pharmacokinetics is recommended.  
 
4.24.4.5 
Acetaminophen should be held for 72 hours before and during busulfan administration, but may be given 
per individual institutional standard policies if clinically necessary.  
 
4.24.5 Fludarabine (Day -5 to -2) 
 
4.24.5.1 
≥ 10 kg: Fludarabine 40 mg/m2 IV daily in 0.9% NaCl or D5W over 30 minutes on Days -5, -4, -3, -2 for a 
total of 4 doses. 
< 10 kg: Fludarabine 1.33 mg/kg IV daily in 0.9% NaCl or D5W over 30 minutes on Days -5, -4, -3, -2 for 
a total of 4 doses. 
 
4.24.6 Busulfan (Day -5 to -2) 
 
4.24.6.1 
Dosing of intravenous busulfan (BusulfexTM): 
Daily Dosing Schedule (Preferred Dosing Schedule) 
 
< 10 kg: 3.2 mg/kg/dose IV daily x 4 doses 

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98 
≥ 10 kg but < 4 years old: 4 mg/kg/dose IV daily x 4 doses 
> 4 years: 3.2 mg/kg/dose IV daily x 4 doses 
 
Q6 Hour Dosing Schedule: 
< 10 kg: 0.8 mg/kg/dose as a starting dose q 6 hours x 16 doses 
≥ 10 kg but < 4 years old: 1 mg/kg/dose as a starting dose q 6 hours x 16 doses 
      > 4 years: 0.8 mg/kg/dose as a starting dose q 6 hours x 16 doses 
 
Note: DOSING WILL BE ADJUSTED BASED ON 1ST DOSE PHARMACOKINETICS (see 
Section 17.1.3). 
 
4.24.6.2 Administration 
The preferred schedule is busulfan administered intravenously via a central venous catheter as a 3 hour 
infusion once daily for 4 consecutive days for a total of 4 doses. Institutional practice (divided dosing) is 
permitted. In this case, busulfan should be administered as a 2 hour infusion every 6 hours for 
16 consecutive doses. Please note that the timing of busulfan PK sample collection (Section 17.1.3) is based 
on whether a 2 our or 3 hour infusion is used. Refrain from using polycarbonate syringes or filter needles 
during busulfan preparation. 
 
4.24.7 Marrow Infusion (Day 0) 
Stem cells for allogeneic SCT is infused within 36 to 48 hours after the last dose of busulfan. A cell dose 
of at least 2 x 108 nucleated cells per kilogram should be given. Higher cell doses can be administered if 
donor size allows. For MFD SCT, the use of peripheral blood stem cells (PBSC) is not permitted on this 
study. 
 
 
4.24.8 GVHD Prophylaxis 
 
4.24.8.1 Tacrolimus Administration, Monitoring and Dose Adjustments  
Tacrolimus should be administered by continuous IV infusion until patients are able to take PO. Levels 
should be drawn at least twice per week while hospitalized, then weekly or monthly thereafter unless a 
change in medication (e.g. use of itraconazole) or renal function might result in an acute change in level. 
At that point, levels will be measured as clinically indicated. Levels sent when dosing by continuous 
infusion are not true trough concentrations, however, the same target range of drug levels will be used for 
both continuous IV and bolus PO routes of administration. 
 
The target serum trough level for tacrolimus is 5 - 12 ng/mL (8 - 12 ng/mL for mismatched or 
unrelated donors). Dose adjustments are based on clinical judgment of the treating physician after 
considering clinical toxicity, serum levels, GVHD, concomitant drug use and the rate of rise or decline of 
the serum level. For levels < 5 ng/mL, it is suggested that the dose of tacrolimus be increased by 
approximately 25% increments every 1 - 2 days, rounded to the nearest 0.5 milligram (when dosing is oral) 
until the target range is achieved (dose adjustments may vary from the suggested 25% as needed to achieve 
the therapeutic range based upon the measured level and the clinical status of the patient). Conversely, for 
levels > 12 ng/mL, it is suggested that the dose of tacrolimus be decreased by approximately 25% every 
1 - 2 days until the target level is achieved. For very high levels (> 20 ng/mL), tacrolimus may need to be 
held entirely for a period of time. This may be done as long as serum levels are monitored daily and the 
drug is restarted at an appropriate dosage when the level returns to the therapeutic range. 
 
4.24.8.2 Methotrexate Administration, Monitoring and Dose Adjustments  
“Mini-dose” methotrexate should be given at a dose of 5 mg/m2 on Days +1, 3, and 6 after transplant for 
matched sibling and cord blood donor sources and an additional dose at Day +11 after transplant for 
unrelated or “other” related marrow/PBSC donors (non-genotypically matched or partially mismatched 

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related donors). All doses of methotrexate should be administered as scheduled if possible, but centers may 
modify or hold methotrexate for significant toxicity (see Section 5.12.1 for methotrexate dose modification 
guidelines). 
 
4.24.8.3 Leucovorin Administration 
Leucovorin may be given at the physician’s discretion for patients at risk for methotrexate toxicity. 
Patients at risk for methotrexate toxicity include those with extravascular fluid collections (ascites, pleural 
effusions) or with decreased renal function (see Section 5.12.1). 
 
4.24.8.4 GVHD Prophylaxis Administration (the tacrolimus dose listed is a starting dose; doses should be 
adjusted to achieve target trough levels). 
 
Drug 
Route 
Dose 
Days 
Important Notes 
Tacrolimus 
IV, PO when able  0.02 mg/kg/day 
continuous 
infusion 
Begins Day -2  
Target levels  
5 - 12 ng/mL (8 - 12 ng/mL 
for mismatched or unrelated 
donors). Taper as per 
Section 4.23.9.3 
Methotrexate 
IV 
5 mg/m2/dose 
Days +1, +3, +6 
(matched sibling/cord 
blood donors) (Days 
+1, +3, +6 and 
+11(other related/ 
unrelated donors) 
Modify/hold for toxicity as 
per Section 5.12.1 
 
4.24.9 Tapering Immune Suppressive Medications 
 
4.24.9.1  Tapering immune suppression in patients with GVHD 
 
Patients who develop either acute or chronic GVHD will be treated according to institutional practice. 
 
 
4.24.9.2  Tapering immune suppression in patients without GVHD 
 
Tapering of Tacrolimus for Patients without GVHD 
Drug 
Stem cell source 
Taper Schedule 
Tacrolimus 
Matched Sibling 
Start Day +42 and taper over 8 weeks, off by Day +98. 
Tacrolimus 
“Other” Related, Unrelated, 
or Cord Blood 
Start Day +100, off by Day +180. 
 
4.24.9.3 Tacrolimus taper  
 
• Tacrolimus taper for patients receiving matched sibling donor allografts: 
In the absence of GVHD, patients receiving matched sibling donor allografts will taper tacrolimus starting 
on Day +42 over 8 weeks, tapering every 1 - 3 weeks depending on capsule sizes, and off by Day +98.  
 
• Tacrolimus taper for patients receiving “other” related or unrelated allografts (matched, mismatched, 
and cord blood): 
Patients receiving either “other” (non-genotypically matched) related or unrelated allografts or cord blood 
will start tapering tacrolimus at Day +100, tapering every 1 - 3 weeks depending on capsule sizes, and 
off by Day +180. 
 

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100 
 
4.24.10 
Patients who develop ≥ Grade 2 GVHD may be treated with steroids, antithymocyte globulin (ATG) or 
other agents according to local protocols. Tacrolimus therapy will continue during GVHD treatment and 
can be weaned per institutional guidelines. 
 
4.24.11 
Arm A & B Patients: Refer to End of Therapy evaluation requirements in Section 7.0. Patients enrolled on 
Arm C who are not eligible for Sorafenib Maintenance (Section 4.25) should also proceed to Section 7.0 
for end of therapy requirements. 
 
For patients enrolled on Arm C who are eligible for Sorafenib Maintenance, refer to Section 4.25 for 
additional monitoring in the context of sorafenib and Section 7.3 for additional post-SCT monitoring.  
 
 

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101 
4.25 
Alternative Donor SCT 
For patients with high risk AML (see Section 3.3.5 for high risk definition), SCT should be pursued after 
the completion of Intensification I. If a MFD is available, this donor should be utilized and the guidelines 
in Section 4.24 followed. For patients without an MFD, efforts should be made to identify an alternative 
donor for SCT. All high risk AML patients for whom a suitable alternative donor cannot be identified 
should continue with their assigned chemotherapy arm. 
 
HRQOL and Parental Stress Studies 
These studies are closed to new patient accrual as of 05-15-2015. 
Please note: Patients assigned to stem cell transplant therapy- Patients who consent and are enrolled on the 
HRQOL and parental stress studies, will have their fourth and fifth evaluations at 1 month (±7 days) and 
4 months (± 1 month) respectively, from the start of the preparative regimen. Evaluations 6, 7 and 8 occur 
at 12 (± 1 month), 24 (± 3 months) and 36 (± 3 months) months from diagnosis respectively. See Section 
18.0 for complete details of evaluation schedules. 
 
4.25.1 Timing of Alternative Donor SCT 
Bone marrow transplantation must be performed at a COG certified SCT institution. All patients with high 
risk disease should begin their transplant preparative regimen following Intensification I. If a suitable donor 
is unavailable at this time, they should continue with their assigned chemotherapy arm until such time a 
donor is identified and blood counts have recovered from their most recent course of chemotherapy. If no 
suitable alternative donor is found, they may continue to receive their assigned chemotherapy regimen 
without proceeding to SCT until such time that a donor becomes available.  
 
4.25.2 HLA Matching in Alternative Donor SCT 
It is strongly recommended that all children with AML are HLA-typed at high resolution at the time of 
study enrollment so that rapid donor search can be performed if the patient is categorized as high risk. 
Donor search should be performed as quickly as possible using the institutional criteria for optimal donor 
selection. Minimal criteria for donor selection are described below: 
1) HLA, A, B, C, DRB1, identical or 1 antigen or allele mismatched unrelated donor. 
2) HLA A, B, DRB1 4 of 6 antigen matched unrelated donor cord blood unit with an adequate 
cell dose. “Adequate” will be judged by institutional criteria, but is commonly considered to 
be a nucleated cell dose > 3.7x107/kg or CD34+ cell dose > 2x105/kg. 
3) Mismatched family member donor with at least one haplotype match, or 5 of 6 antigen 
phenotypic match. 
 
4.25.3 Graft Source for Alternative Donors 
Bone marrow and umbilical cord blood are the recommended stem cell sources for alternative donor SCT. 
Use of peripheral blood stem cells is discouraged but allowed. 
 
4.25.4 Transplant Conditioning Regimen  
The following conditioning regimen, GVHD prophylaxis, and supportive care plan, are based on the COG 
package and the COG’s broad experience with family donors. Although these guidelines are recommended 
for AAML1031 patients allocated to alternative donor SCT, use of institutional treatment standards for 
alternative donor SCT are acceptable.  
 
 
 

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102 
 
Dose adjustments will be made for obesity, defined as > 125% of IBW: 
Adjusted weight = 1.25*IBW  
 
 
Day –6  
Begin anti-seizure prophylaxis (lorazepam, [phenytoin or levetiracetam can be 
used as alternatives]: see Section 4.24.4) 
Day –5 to -2 
Fludarabine 40 mg/m2 /dose IV daily or 1.3mg/kg/dose daily IV if < 10 kg 
Day –5 to Day –2 
Busulfan daily IV*  
• 
With age-based dosing (see Section 4.24.6.1)  
• 
With 1st dose pharmacokinetics (see Section 17.1.3) 
Day –3 to -1 
ATGAM (Equine ATG) 30 mg/kg/dose IV daily 
Day –2 
Begin Tacrolimus 
Day 0  
Bone Marrow Infusion 
Day 1 
Methotrexate 5 mg/m2/dose IV 
Day 3  
Methotrexate 5 mg/m2/dose IV 
Day 6 
Methotrexate 5 mg/m2/dose IV 
Day 11  
Methotrexate 5 mg/m2/dose IV. UCB SCTs do not receive Day 11 MTX. 
*Divided dosing (4 times daily is permitted per institutional standard) 
 
4.25.5  
See Sections 4.24.4 through 4.24.10 with the following additions or exceptions. 
 
4.25.6 Equine Lymphocyte Immune Globulin 
Lymphocyte immune globulin equine (ATGAM) is utilized in addition to fludarabine and busulfan in 
patients with alternative donors as follows: 
ATGAM 30 mg/kg/dose IV over 6-8 hours on Days -3, -2, -1. Premedication will be given prior to infusion 
with diphenhydramine 1 mg/kg/dose, max 50 mg (or comparable anti-histamine) acetaminophen 10 - 15 
mg/kg (max 1,000 mg), and methylprednisone 1 mg/kg/dose. Premedications may be repeated or increased 
as needed to control allergic reactions, chills or fever. Patients who are unable to tolerate the equine product 
may receive rabbit antithymocyte globulin (thymoglobulin ) 2.5 mg/kg/day. 
 
4.25.7 Tacrolimus 
Follow the guidelines in Section 4.24.8.1. 
 
4.25.8 
Arm A & B Patients: Refer to End of Therapy evaluation requirements in Section 7.0. Patients enrolled on 
Arm C who are not eligible for Sorafenib Maintenance (Section 4.26) should also proceed to Section 7.0 
for end of therapy requirements. 
 
For patients enrolled on Arm C who are eligible for Sorafenib Maintenance, refer to Section 4.26 for 
additional monitoring in the context of sorafenib and Section 7.3 for additional post SCT monitoring.  
 

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103 
4.26 
Maintenance Arm C (Sorafenib)  
 
The following Maintenance therapy guidelines are for patients with HR FLT3/ITD+ disease who did not 
experience dose limiting toxicity on the Sorafenib 100 mg/m2 dose level during previous therapy.  
 
Maintenance therapy will begin between Days 40 - 100 post completion of Intensification II or stem cell 
transplant and continue for 1 year.  
 
Baseline Criteria for Initiation of Maintenance Therapy 
The following criteria must be met to initiate sorafenib maintenance therapy: 
• 
Adequate hematopoietic recovery (ANC > 1,000/µL and a platelet count > 75,000/µL)  
• 
No evidence of acute GVHD on physical examination 
• 
No evidence of relapse on baseline bone marrow examination post Intensification II or SCT 
• 
Shortening fraction ≥ 28% and ejection fraction ≥ 55% 
• 
Blood pressure less than the 95th percentile for age, height, and gender (anti-hypertensive therapy 
is allowed) 
• 
No history of Grade 4 hypertension  
• 
No history of maculo-papular rash or palmar plantar erythrodysesthesia syndrome that warranted 
permanent discontinuation of sorafenib in previous therapy cycles.  
 
 
Sorafenib (SORAF): PO 
Days: 1 through 364. 
Starting Dose: 100 mg/m2/dose daily, rounded to accommodate tablet size. Dose to be administered per 
dosing nomogram in Appendix II. See table below for guidelines for dose adjustment during maintenance. 
Refer to Appendix II for max dosing.  
 
Note: Sorafenib tablets should be taken at least 1 hour before or 2 hours after food. Tablets should be taken 
with clear liquids (approximately 2 to 4 ounces for children < 12 years and 4 to 8 ounces for ≥ 12 years). If 
taken with food, sorafenib should be taken with a moderate to low fat meal. Tablets should not be crushed, 
but should be swallowed whole. However, sorafenib tablets can be dispersed in water to facilitate the 
administration to subjects that cannot swallow tablets (see drug monograph in Section 6.12). Grapefruit and 
its juice should be avoided for the duration of treatment with sorafenib. 
 
 
 

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104 
 
Maintenance Sorafenib Dose Adjustment: 
Patient doses may change as described in Table 1 below over the course of maintenance with the exception 
that sorafenib doses may not be re-escalated in patients experiencing any grade of cardiac toxicities 
regardless of attribution or Grade 4 non-cardiac toxicities thought to be possibly, probably or definitely 
related to sorafenib by the treating physician.  
 
Table 1: Maintenance Sorafenib Dose Adjustment Guidelines  
Dose 
Toxicity* 
Timing of Dose 
Adjustment 
Dose Adjustment 
100 mg/m2/dose, once daily 
Dose limiting 
Immediate 
Hold dose and refer to dose 
modification guidelines. If 
further dose reduction mandated 
for toxicity then sorafenib 
should be discontinued 
permanently.  
100 mg/m2/dose, once daily 
No toxicity, or toxicities 
limited to ≤ Grade 2 that 
improve to ≤ Grade 1 
within one week 
After 28 days 
Increase dose to 200 mg/m2 
once daily 
200 mg/m2/dose, once daily 
Dose limiting 
Immediate 
Hold dose and adjust per dose 
modification guidelines. If dose 
reduction warranted, decrease 
dose to 100 mg/m2/dose, once 
daily  
200 mg/m2/dose, once daily 
No toxicity, or toxicities 
limited to ≤ Grade 2 that 
improve to ≤ Grade 1 
within one week 
After 28 days 
Increase dose to 
150 mg/m2/dose twice daily 
150 mg/m2/dose, TWICE 
daily 
Dose limiting 
Immediate 
Hold dose and adjust per dose 
modification guidelines. If dose 
reduction warranted, decrease 
dose to 200 mg/m2/dose, once 
daily  
150 mg/m2/dose, TWICE 
daily 
No toxicity, or toxicities 
limited to ≤ Grade 2 that 
improve to ≤ Grade 1 
within one week 
NA 
Maintain dose 
* Toxicity possibly, probably or definitely related to sorafenib.  
 
Sorafenib is supplied by Bayer HealthCare Pharmaceuticals, and distributed by the NCI DTCD. Do 
not use commercially available drug. 
 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I 
FOR SUPPORTIVE CARE GUIDELINES. 
 
The therapy delivery map (TDM) for Maintenance Arm C is on the next page. 
 

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105 
4.26.1 Maintenance Arm C (Sorafenib)  
This therapy is for patients with HR FLT3/ITD+ disease. 
__________________        __________ 
    Patient name or initials                   DOB 
Maintenance therapy lasts one year and this Therapy Delivery Map is on 1 page. Extensive treatment details are provided in 
Sections 4.1-4.7 and 4.26.  
 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Sorafenib 
(SORAF) 
IND# 114480 
PO 
Starting dose: 
100 mg/m2/dose 
once daily 
Days 1 - 364 
Baseline bone marrow evaluation 
is required prior to start of 
sorafenib maintenance. Evaluation 
can be done at any time in the post 
Intensification II or post SCT 
period, so long as it is prior to 
maintenance sorafenib treatment 
initiation. 
 
See Section 4.26 for administration 
guidelines and dose adjustment 
guidelines. 
 
See Section 5.0 for dose 
modification plan for toxicity.  
 
Refer to Appendix II for dosing 
nomogram and max dosing. 
a. History, PE, CBC, BUN, creatinine, 
AST, ALT, bili (direct & total), 
blood pressure, urinalysis, calcium, 
phosphorus, albumin  
b. Echo or MUGA and ECG 
c. BMA/clot section or biopsy 
d. Optional PK and PIA studies (also 
obtain within 2 weeks of dose 
adjustment; see Appendix X-XI) 
e. Clinical cardiac examination 
See Section 7.1 for complete list of 
observations. 
For patients enrolled on the HRQOL 
study, see Section 18.0 for details on 
evaluation time points 4-6. 
 
OBTAIN OTHER STUDIES AS 
REQUIRED FOR GOOD PATIENT 
CARE 
Enter Cycle # ____   
 
Ht_____cm 
        Wt_____kg 
 
         BSA____m2 
Date 
Due 
Date 
Given 
Day 
Month 
(circle one) 
SORAF 
_______ mg 
SORAF * 
(if given 2x daily 
enter 2nd dose) 
_______ mg 
Studies 
Comments (Include any 
held doses, or dose 
modifications) 
 
 
1 
1 / 5 / 9 / 13 
_______ mg 
_______ mg 
a, b, (c, d- month 1 only), e 
 
 
 
… 
 
 
 
 
 
 
 
8 
 
 
 
 
 
… 
 
 
 
 
 
15 
 
 
 
 
 
… 
 
 
 
 
 
22 
 
 
 
 
 
… 
 
 
 
 
 
29 
2 / 6 / 10 
_______ mg 
_______ mg 
a, (d- month 2, 6 only), e 
 
 
 
… 
 
 
 
 
 
 
 
36 
 
 
 
 
 
… 
 
 
 
 
 
43 
 
 
 
 
 
… 
 
 
 
 
 
50 
 
 
 
 
 
… 
 
 
 
 
 
57 
3 / 7 / 11 
_______ mg 
_______ mg 
a, e 
 
 
 
… 
 
 
 
 
 
 
 
64 
 
 
 
 
 
… 
 
 
 
 
 
71 
 
 
 
 
 
… 
 
 
 
 
 
78 
 
 
 
 
 
… 
 
 
 
 
 
85 
4 / 8 / 12 
_______ mg 
_______ mg 
a, d, e 
 
 
 
… 
 
 
 
 
 
 
 
92 
 
 
 
 
 
… 
 
 
 
 
 
99 
 
 
 
 
 
… 
 
 
 
 
 
106 
 
 
 
 
 
… 
 
 
 
 
 
112 
 
 
 
Repeat above therapy for a total of 3 cycles + one month (13). Then see Section 7.1 for required end of therapy evaluations. 
*If only given once daily cross out one of the two dose options 
SEE SECTION 5.0 FOR DOSE MODIFICATIONS BASED ON TOXICITIES. SEE APPENDIX I FOR SUPPORTIVE CARE 
GUIDELINES. 

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106 
 
5.0 
DOSE MODIFICATIONS FOR TOXICITIES 
 
5.1 
Allergy 
 
5.1.1 
Allergy to Asparaginase 
 
5.1.1.1 Local Reactions (Inflammation at Injection Site, Swelling): 
Continue asparaginase (E.coli or Erwinia) administration in the presence of Grade 1 allergic reaction 
(transient flushing or rash; drug fever < 38°C). Premedication with antihistamines to decrease the risk of 
overt allergy symptoms is strongly discouraged since anti-histamine use may mask the appearance of 
systemic allergy. Systemic allergy is associated with the presence of asparaginase neutralizing antibodies, 
which render asparaginase therapy ineffective.  
 
5.1.1.2 Anaphylaxis/Systemic Allergic Reactions: 
Discontinue asparaginase (E.coli or Erwinia) if the patient develops a systemic allergic reaction (urticaria, 
wheezing, laryngospasm, hypotension, etc). Should an allergy be diagnosed after the first dose given on 
Day 2 during Intensification II (for high risk patients), then the dose due on Day 9 should not be 
administered.  
 
5.1.2 
Allergy to Etoposide 
Etoposide allergic reactions may be managed with pre-medications such as diphenhydramine 1 mg/kg IV 
(maximum dose 50 mg) or an equivalent H-1 receptor antagonist, ranitidine 1 mg/kg IV (maximum dose 
50 mg) or an equivalent H-2 receptor antagonist, hydrocortisone 1 - 4 mg/kg IV, and by slowing the rate of 
the infusion OR etoposide phosphate may be substituted in the same dose and at the same rate. Pre-
medication for etoposide phosphate is recommended.  
 
5.2 
Cardiac Toxicity  
Note: Patients may be on ACE inhibitors at time of echocardiogram reassessment and still meet criteria for 
sorafenib re-initiation described below. However, patients would need to be off all ionotrophic support, 
including but not limited to oral digoxin, for a minimum of 7 days, before meeting echocardiogram/MUGA 
criteria for restarting sorafenib therapy described below. 
 
5.2.1 
Left Ventricular Systolic Dysfunction  
Daunorubicin, mitoxantrone, and sorafenib will be held if there is significant evidence of cardiac disease 
by echocardiogram or MUGA (shortening fraction < 28% or EF < 55%). Cardiac examination with 
echocardiogram (or MUGA) is required prior to the start of all chemotherapy courses, at the end of protocol 
therapy, and in follow up. Echocardiogram and cardiac biomarker evaluation (i.e. troponin) are also 
strongly recommended, particularly in clinical scenarios with potential or suspected cardiac dysfunction. 
Please see Section 7.5 for long-term follow-up monitoring.  
 
5.2.1.1 Daunorubicin and Mitoxantrone: 
Do not re-start anthracyclines if held for left ventricular shortening dysfunction that is not associated with 
a microbiologically proven bacteremia or sepsis. If the left ventricular shortening dysfunction occurred in 
the setting of microbiologically proven bacteremia or sepsis, then anthracyclines may be reinstituted at the 
treating clinician’s discretion once the shortening fraction has returned to ≥ 28% or EF ≥ 55%.  
 
5.2.1.2 Sorafenib in Combination with Chemotherapy: 
Sorafenib should be held for a shortening fraction of < 28% or EF < 55% regardless of attribution. Sorafenib 
should be restarted at a reduced dose (100 mg/m2) when the shortening fraction has returned to ≥ 28% or 
EF ≥ 55%. If SF decreases below 28% or EF decreases below 55% on 100 mg/m2, then sorafenib should 
be discontinued permanently. Sorafenib dose may not be re-escalated in combination with chemotherapy. 

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5.2.1.3 Sorafenib in Maintenance 
Sorafenib should be held for a shortening fraction of < 28% or EF < 55% regardless of attribution. Sorafenib 
should be restarted at 1 dose level lower when the shortening fraction has returned to ≥ 28% or EF ≥ 55%. 
Sorafenib may not be re-escalated during maintenance in patients experiencing a shortening fraction of 
< 28% or EF < 55% regardless of attribution. Patients experiencing a SF < 28% or EF < 55% at the 
100 mg/m2 dose level will permanently discontinue sorafenib.  
 
 
5.2.2 
Hypertension 
The table below will be used to manage hypertension possibly, probably or definitely related to sorafenib. 
Management of hypertension not related to sorafenib is at the treating clinician’s discretion. Should 
initiation of anti-hypertensive therapy be required, single agent therapy (such as amlodipine or nifedipine) 
should be started (see Appendix I) and the blood pressure should be monitored at least twice weekly until 
BP is within the 95th percentile for age, height, and gender per Appendix VI. For patients greater than 
age 18, rely on CTCAE v.4.0 grading of hypertension for consideration of dose adjustment. 
 
Grade 
(CTCAE v4.0) 
Antihypertensive 
Therapy 
Blood Pressure 
Monitoring 
 
Sorafenib Dose 
Grade 1  
(or Grade 2 lasting 
≤ 72 hours)  
None 
Routine 
No change 
Grade 2 lasting 
> 72 hours 
Initiate 
monotherapy 
 
Increase frequency and 
monitor (by health 
professional) at least 
twice/week until BP is within 
the 95th percentile for age, 
height, and gender. 
No change 
Grade 3 
Add additional 
agent(s) per 
institutional 
standards. 
 
Monitor every 2 days* until 
BP is within the 95th 
percentile for age, height, 
and gender; continue every 
other day monitoring after 
sorafenib restarted until BP 
is within the 95th percentile 
for age, height, and gender. 
1. Hold sorafenib until diastolic BP 
in range for age, height, and gender.  
2. If BP within the 95th percentile 
for age, height, and gender within 
14 days: 
• For patients receiving sorafenib + 
chemotherapy restart sorafenib at 
reduced dose (100 mg/m2/day). 
• For patients receiving sorafenib 
maintenance, refer to Table 1 in 
Section 4.26 and dose reduce 1 
dose level. 
 
3. If BP is not within the 95th 
percentile for age, height, weight 
within 14 days, or if hypertension 
occurred at 100 mg/m2 dose level 
discontinue sorafenib. 
Grade 4 
Discontinue sorafenib permanently. 
* May monitor q3 days over weekend, i.e., evaluation on Friday and Monday 

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108 
5.3 
Coagulopathy  
If symptomatic, omit Day 9 asparaginase and consider factor replacement (FFP, cryoprecipitate, factor 
VIIa). Do not hold asparaginase (E.coli or Erwinia) for abnormal laboratory findings without clinical 
symptoms. 
 
5.4 
Hepatic Toxicity 
 
5.4.1  Transaminases 
If the ALT or AST are > 10 x ULN, attempts should be made to identify the cause and notify the Study 
Chair. In most cases, the therapy will proceed without modification. 
 
5.4.2 
Hyperbilirubinemia 
If the direct bilirubin is > 3 mg/dL, notify the Study Chair. In some cases it may be necessary to proceed if 
the bilirubin elevation is a result of the leukemia itself. If the elevated direct bilirubin is not a result of the 
leukemia, modify the doses of daunorubicin, etoposide, mitoxantrone and bortezomib as follows below. 
For all cases in which the direct bilirubin is elevated at the point in time that the next course is to begin, 
consider delaying the course for 1 week to determine whether the direct bilirubin falls to an acceptable 
level. 
 
Asparaginase 
L-asparaginase has been associated with hepatic toxicity but dosing guidelines for hepatic toxicity are not 
available. Thus, asparaginase administration in the setting of hepatic toxicity is at the clinician’s discretion. 
 
Bortezomib  
Patients with mild hepatic impairment do not require dose adjustment of bortezomib. Patients with moderate 
or severe hepatic impairment should receive bortezomib at modified doses as outlined below:   
 
 
Direct Bilirubin Level 
Bortezomib Dose Modification  
Moderate  
> 1.5x – 3x upper limit of normal 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 
* No adjustment necessary for elevated SGOT (ALT). 
 
Daunorubicin, Etoposide and Mitoxantrone 
In severe liver dysfunction, the half-life of mitoxantrone is prolonged and the AUC may be more than 3-fold 
that of patients with normal hepatic function. However, there are no available dose adjustment guidelines 
in the literature. Therefore, similar dose reductions of mitoxantrone as outlined below for daunorubicin are 
utilized on this protocol.  
  
Direct Bilirubin 
Daunorubicin 
Etoposide 
Mitoxantrone 
> 2 and < 3 mg/dL 50% of the calculated 
dose 
50% of the calculated 
dose 
50% of the calculated 
dose 
> 3 and < 5 mg/dL 25% of the calculated 
dose 
25% of the calculated 
dose 
25% of the calculated 
dose 
> 5 mg/dL 
Hold dose and notify 
study chair 
Hold dose and notify 
study chair 
Hold dose and notify 
study chair 
Full dose of daunorubicin, etoposide and mitoxantrone may resume when the direct bilirubin has fallen to 
< 1.2 mg/dL.   
 
 

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5.5 
Neurologic Toxicity 
 
5.5.1 
Cytarabine 
Patients with > Grade 3 CTCAE v 4 nervous system disorders from high dose cytarabine should not receive 
further high dose cytarabine. The most common nervous system disorder is an acute cerebellar syndrome 
that may manifest itself as ataxia, nystagmus, dysarthria, or dysmetria. However, seizures and 
encephalopathy have also occurred following therapy with high dose cytarabine. If nervous system 
disorders > Grade 3 due to high dose cytarabine occurs during protocol therapy, the patient will go 
Off Protocol Therapy for toxicity.  
 
 
5.5.2 
Bortezomib-Related Peripheral Neuropathy 
Patients 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 v4.0. A complete neurological exam should be 
documented prior to the start of each course of therapy.  
 
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:  
 
Severity of peripheral 
sensory neuropathy 
Bortezomib modification 
Grades 1 - 2 with no pain 
Same dose as previous.  
Grade 1 with pain 
Decrease bortezomib to 1 mg/m2/dose 
Grade 2 with pain or any 
Grade 3  
Hold bortezomib treatment until 
symptoms have resolved to  Grade 1. Do 
not make up missed doses. When toxicity 
resolves, re-initiate bortezomib at 
1 mg/m2/dose 
Grade 4 
Discontinue bortezomib 
 
5.5.2.1 
If Grade 2 peripheral sensory neuropathy with pain or Grade 3 peripheral sensory neuropathy persists for 
> 2 weeks, bortezomib should be discontinued. Patients who discontinue bortezomib will continue with the 
standard chemotherapy regimen and will remain on protocol therapy.  
 
5.5.2.2 
Patients experiencing Grade 4 peripheral sensory neuropathy will discontinue bortezomib. Patients who 
discontinue bortezomib will continue with the standard chemotherapy regimen and will remain on protocol 
therapy.  
 
5.5.2.3 
If Grade 2 or 3 peripheral sensory neuropathy with pain recurs despite bortezomib dose reduction to 
1 mg/m2, the patient should discontinue bortezomib in Induction I. See Section 5.5.2.4 if peripheral 
neuropathy resolves before the start of Induction II. Patients who discontinue bortezomib will continue with 
the standard chemotherapy regimen and will remain on protocol therapy.  
 
5.5.2.4 
Patients whose peripheral sensory neuropathy resolves to ≤ Grade 1 or baseline within 2 weeks will receive 
bortezomib in Induction II at 1 mg/m2/dose.  
 

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5.6 
Pancreatitis  
Discontinue asparaginase (E.coli or Erwinia) in the presence of hemorrhagic pancreatitis or severe 
pancreatitis (abdominal pain > 72 hours and > Grade 3 amylase elevation (> 2.0 x ULN). In the case of 
mild pancreatitis after Day 2, Day 9 asparaginase may be given only if symptoms and signs subside, and 
amylase levels return to normal. Severe pancreatitis is a contraindication to additional asparaginase 
administration. 
 
5.7 
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 
patients receiving bortezomib. For this reason, pulmonary toxicity will be monitored carefully during the 
study. See Section 5.7.3 for management of new-onset dyspnea, hypoxia or chest infiltrates not explained 
by infection or other known cause. 
 
Bortezomib should be held in patients with ARDS that may be bortezomib related.  
 
5.7.1 
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 patients 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. See Section 5.7.3 for management of new-
onset dyspnea, hypoxia or chest infiltrates not explained by infection. 
 
5.7.2 
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. Patients that experience a Grade 4 pulmonary toxicity possibly, probably or definitely related 
to bortezomib (excluding hiccups and voice changes/laryngitis) will discontinue bortezomib. Patients who 
discontinue bortezomib will continue with the standard chemotherapy regimen and will remain on protocol 
therapy.  
 
Dose reduction within a course: 
If a patient experiences a Grade 3 or 4 bortezomib-related toxicity that does not require cessation of 
bortezomib (see above), and once this Grade 3 or 4 toxicity resolves to ≤ Grade 1, bortezomib can be 
restarted at a decreased dose of 1 mg/m2 for subsequent doses. Missed doses of bortezomib in a course 
should not be made up. Patients who have a Grade 3 pulmonary toxicity that worsens (i.e., > Grade 3) by 
the next scheduled dose of bortezomib should discontinue bortezomib. Patients who discontinue 
bortezomib will continue with the standard chemotherapy regimen and will remain on protocol therapy.  
 
Dose reduction between courses: 
The bortezomib dose will be decreased to 1 mg/m2 for qualifying Grade 3 or 4 toxicities (see above) that 
resolve to ≤ Grade 1 prior to the beginning of the next course. Doses reduced for an adverse event will not 
be increased, even if there is minimal or no toxicity at the reduced dose.  
 

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Patients re-experiencing the same bortezomib-related qualifying Grade 3 pulmonary toxicity following a 
single bortezomib dose reduction will discontinue bortezomib.  
 
 
5.7.3 
Management of Drug-induced Pulmonary Toxicity 
Both cytarabine and bortezomib have been associated with ARDS however, if a patient experiences 
dyspnea, hypoxia (oxygen saturation < 92%), or bilateral infiltrates on a CXR, other causes must be ruled 
out. Additional testing for infectious complications and congestive heart failure should be obtained. A CT 
scan is strongly recommended to evaluate for infectious complications. A repeat ECHO is advised since 
anthracyclines can be associated with sudden decreases in left ventricular function. In addition, formal 
consultation from a pediatric pulmonologist is strongly recommended. Bronchoscopy is encouraged if 
clinically indicated. In the absence of evidence of an infectious etiology or congestive heart failure, the 
following steroid therapy is recommended for patients with Grades 1 - 3 ARDS that may be related to 
bortezomib: 
Methylprednisolone 1 mg/kg IV daily.  
 
For patients with Grade 4 ARDS, the following steroid regimens may also be considered:  
Methylprednisolone 1 gram/m2 IV, followed by 500 mg/m2 IV daily, or 
Dexamethasone 6 mg/m2 IV q8 hrs, or 
Prednisone 40 mg/m2 PO daily divided BID. 
 
Other similar steroid regimens suitable for treatment of non-infectious pneumonitis may be used. It is 
recommended that steroids be rapidly tapered after 4 days based on the patient’s clinical status. Prolonged 
use of steroids is strongly discouraged to prevent an increased incidence in invasive fungal infections.  
 
5.8 
Palmar-Plantar Erythrodysesthesia Syndrome, Skin Pain that impacts ADLs or Rash 
Maculo-Papular  
 
The following tables detail sorafenib modifications for palmar-plantar erythrodysesthesia syndrome, skin 
pain that impacts ADLS, or rash maculo-papular. 
 
Grading for rash maculo-papular is performed solely on the basis of ADL limitation and not percentage of 
body surface area involved.  
 
Table 2: Palmar-Plantar Erythrodysesthesia Syndrome or Pain (in absence of rash) with impact on 
ADLs 
Grade 
Occurrence 
Dose Modification 
Grade 1 
Any 
Continue sorafenib. 
Topical therapy and supportive care measures. * 
Grade 2 
First 
1. Hold sorafenib. Institute topical therapy and supportive care measures. *  
2. If toxicity improves to < Grade 2 within 14 days, restart at same dose. 
3. If toxicity does not improve to < Grade 2 within 14 days, hold until toxicity resolved. 
• For patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 
100 mg/m2/day.  
• For patients receiving sorafenib maintenance, refer to Table 1 in Section 4.26 and 
dose reduce 1 dose level. 
• Discontinue sorafenib if toxicity occurred at 100 mg/m2 dose   
 
Second 
1. Hold sorafenib. Institute topical therapy and supportive care measures* 
2. If toxicity improves to < Grade 2 within 14 days: 
• 
patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 
100 mg/m2/day 

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• 
patients receiving sorafenib maintenance, refer to Table 1 in Section 4.26 and 
dose reduce 1 dose level  
• 
Discontinue sorafenib if toxicity occurred at 100 mg/m2 dose.  
3. Discontinue sorafenib if toxicity does not improve to < Grade 2 within 14 days. 
 
Third 
Institute topical therapy and supportive care measures.* 
Discontinue sorafenib permanently. 
Grade 3 
First 
1. Hold sorafenib. Institute topical therapy and supportive care measures. * 
2. If toxicity improves to < Grade 2 within 14 days: 
• 
patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 
100 mg/m2/day 
• 
patients receiving sorafenib maintenance, refer to Table 1 in Section 4.26 and 
dose reduce 1 dose level  
• 
Discontinue sorafenib if toxicity occurred at 100 mg/m2 dose.  
3. Discontinue sorafenib if toxicity does not improve to < Grade 2 within 14 days. 
 
Second 
Institute topical therapy and supportive care measures. * 
Discontinue sorafenib permanently. 
* see Appendix I  
 
 
Table 3: Rash, Maculo-Papular- Grade only for ADL Limitation  
Grade 
Occurrence 
Dose Modification 
Grade 1 
Any 
Continue sorafenib. 
Topical therapy and supportive care measures. * 
Grade 2 
First 
1. Hold sorafenib. Institute topical therapy and supportive care measures. *  
2. If toxicity improves to < Grade 2 within 14 days, restart at same dose. 
3. If toxicity does not improve to < Grade 2 within 14 days, hold until toxicity resolved. 
• For patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 
100 mg/m2/day.  
• For patients receiving sorafenib maintenance, refer to Table 1 in Section 4.26 
and dose reduce 1 dose level. 
• Discontinue sorafenib if toxicity occurred at 100 mg/m2 dose 
 
Second 
1. Hold sorafenib. Institute topical therapy and supportive care measures. * 
2. If toxicity improves to < Grade 2 within 14 days: 
• patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 
100 mg/m2/day.  
• patients receiving sorafenib maintenance, refer to Table 1 in Section 4.26 and 
dose reduce 1 dose level. 
• Discontinue sorafenib if toxicity occurred at 100 mg/m2 dose. 
3. Discontinue sorafenib if toxicity does not improve to < Grade 2 within 14 days. 
 
Third 
Institute topical therapy and supportive care measures.* 
Discontinue sorafenib permanently. 
Grade 3 
First 
1. Hold sorafenib. Institute topical therapy and supportive care measures. * 
2. If toxicity improves to < Grade 2 within 14 days: 
• patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 
100 mg/m2/day. 
• patients receiving sorafenib maintenance, refer to Table 1 in Section 4.26 and 
dose reduce 1 dose level. 
• Discontinue sorafenib if toxicity occurred at 100 mg/m2 dose. 
3. Discontinue sorafenib if toxicity does not improve to < Grade 2 within 14 days. 
 
Second 
Institute topical therapy and supportive care measures. * 
Discontinue sorafenib permanently. 
* see Appendix I  

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5.9 
Renal Toxicity 
 
5.9.1  Cytarabine 
Patients with nephrotoxicity secondary to antibiotics, or antifungals, may have prolonged excretion of 
cytarabine leading to more severe marrow and extramedullary toxicity. Patients with a serum creatinine 
> 2 mg/dL or > 2 x normal for age should be hydrated orally or intravenously. Following hydration, the 
patient must have a creatinine clearance ≥ 60 mL/min/1.73m² as measured preferably by a nuclear GFR 
Scan or timed urine collection for creatinine clearance before proceeding with high dose cytarabine therapy 
(doses of 1,000 mg/m2 or greater). If the CrCl is abnormal (< 60 mL/min/1.73m2) then high dose cytarabine 
should be reduced from twice daily to once daily dosing, at the same previously prescribed doses (e.g., 50% 
daily dose reduction). With this approach, previous research has shown the prevention of subsequent 
neurotoxicity in recipients of high dose cytarabine in the face of renal insufficiency.121 
 
 
5.9.2  Etoposide 
 
In patients with impaired renal function, the following initial dose modification of etoposide should be 
considered based on measured creatinine clearance: for CrCl > 60 mL/min give full dose, for CrCl of 
15 – 60 mL/min give 75% of the dose (25% dose reduction). For CrCl < 15 mL/min notify the Study Chair. 
(Please note: For dose adjustment in renal dysfunction for children, use the “corrected” value for creatinine 
clearance measured in mL/min/1.73 m2, which ‘corrects’ that value for the standardized values of CrCl in 
adults, measured in mL/min. The “corrected” value is loosely interpreted as being equivalent to creatinine 
clearance measured in an adult patient). Subsequent doses should be based on patient tolerance and clinical 
effect. 
 
5.10 
Thrombosis 
Discontinue asparaginase and treat with appropriate antithrombotic therapy, as indicated. Do not hold 
asparaginase for abnormal laboratory findings without clinical sequelae. For significant thrombosis, not 
line related, consider evaluation for inherited predisposition to thrombosis. 
 
 
5.11 
Dose Reduction for Other Bortezomib-Associated Toxicities 
 
5.11.1 Dose Reduction for Non-Hematological Toxicity (other than described above) 
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 (with the exception of fever, infection, hyperfibrinogenemia, or 
metabolic/laboratory abnormalities). Follow dose reduction guidelines detailed in Section 5.7.2. 
 
Bortezomib doses may not be re-escalated in patients with dose limiting toxicity. 
 
If a specific bortezomib-related toxicity recurs despite one dose reduction, patient will discontinue 
bortezomib. Patients who discontinue bortezomib will continue with the standard chemotherapy regimen 
and will remain on protocol therapy.  
 
5.11.2 Dose Reduction for Hematologic Toxicity 
Bortezomib will be dose reduced to 1 mg/m2 for patients experiencing persistent myelosuppression 
following chemotherapy. Persistent myelosuppression is defined as neutropenia (ANC < 500/µL) or 
thrombocytopenia (platelet count < 50,000/μL) lasting longer than 40 days in Induction I, Induction II, and 
Intensification I or longer than 75 days in Intensification II. Patients that have a recurrence of persistent 
neutropenia or thrombocytopenia despite 1 bortezomib dose reduction will discontinue bortezomib.  
 

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Bortezomib doses may not be re-escalated in patients with dose limiting toxicity. Patients who discontinue 
bortezomib will continue with the standard chemotherapy regimen and will remain on protocol therapy.  
 
5.12  
Dose Reductions for Other Sorafenib-Associated Toxicities  
 
Dose reductions for sorafenib-associated toxicities other than left ventricular shortening dysfunction 
(Section 5.2), hypertension (Section 5.2.2), and rash (maculo-papular or palmar plantar erythrodysesthesia 
syndrome, Section 5.8) or skin pain without rash that limits ADLs should be made according to the table 
below. There is a dose modification table for both the sorafenib/chemotherapy and sorafenib maintenance 
phases of the protocol. 
 
Sorafenib dose may not be re-escalated after de-escalation for dose limiting toxicity in the 
sorafenib/chemotherapy phase of the protocol. Patients should receive 100 mg/m2/day until 
maintenance, at which time dose-escalation may proceed according to Table 1 in Section 4.26. 
 
Sorafenib dose may be re-escalated after de-escalation for Grade 2 or 3 dose limiting toxicity in the 
sorafenib maintenance phase per Section 4.26.  
 
Dose re-escalation may not occur if the toxicity was Grade 4 and possibly, probably or definitely related to 
sorafenib, or for any grade of cardiac toxicity regardless of attribution.  
 
Non-Hematologic Toxicities (Possibly, Probably or Definitely) Related to Sorafenib: 
Grade  
Dose Modification 
Grade 1 
Continue same dose. 
Grade 2 
Continue same dose unless toxicity intolerable to the patient.  
If toxicity intolerant to the patient, dose adjust per Grade 3 dose adjustment guidelines. 
Grade 3 
Hold sorafenib until toxicity is Grade < 2. 
If toxicity improves to Grade < 2 within 14 days, resume at the same dose.  
If patient experiences a second Grade 3 toxicity or if resolution of the first takes > 14 days, 
hold sorafenib until toxicity is Grade < 2, then:  
• For patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 
100 mg/m2/day.  
• Discontinue sorafenib if toxicity occurred at 100 mg/m2/dose. 
Grade 4 
Hold sorafenib until toxicity is Grade < 2, then: 
• For patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 100 
mg/m2/day.  
• For patients receiving sorafenib maintenance, refer to Table 1 in Section 4.26 and dose 
reduce 1 dose level.  
• Discontinue sorafenib if toxicity occurred at 100 mg/m2/dose. 
If clinically indicated, sorafenib at 200 mg/m2 or 300 mg/m2 (150 mg/m2 BID) dose levels may 
be held indefinitely. 
 
Hematologic Toxicities (Possibly, Probably or Definitely) Related to Sorafenib + conventional 
chemotherapy phases (prior to maintenance therapy): 
Grade  
Dose Modification 
Grade 1 
Continue same dose.  
Grade 2 
Continue same dose. 
Grade 3 
Hold sorafenib until toxicity is Grade < 2. 
If toxicity improves to < Grade 2 within 14 days, resume at the same dose. 

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If patient experiences a second Grade 3 toxicity or if resolution of the first takes > 14 days, 
hold sorafenib until toxicity is Grade < 2, then: 
• For patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 
100 mg/m2/day.  
• Discontinue sorafenib if toxicity occurred at 100 mg/m2 dose   
Grade 4 
Hold sorafenib until toxicity is Grade < 2, then: 
• For patients receiving sorafenib (200 mg/m2/day) + chemotherapy, restart at 100 
mg/m2/day.  
• Discontinue sorafenib if toxicity occurred at 100 mg/m2/dose. 
If clinically indicated, sorafenib at 200 mg/m2 or 300 mg/m2 (150 mg/m2 BID) dose levels may 
be held indefinitely.  
 
Hematologic Toxicities (Possibly, Probably or Definitely) Related to Sorafenib Maintenance 
therapy: 
 
 
 
 
 
 
 
Grade  
Dose Modification 
Grade 1 
Continue same dose. 
Grade 2 
Continue same dose. 
Grade 3 
Hold sorafenib until toxicity is Grade < 2.  
If toxicity improves to < Grade 2 within 14 days, resume at the same dose.  
If patient experiences a second Grade 3 toxicity or if resolution of the first takes > 14 days, 
hold sorafenib until toxicity is Grade < 2, then:  
• 
Refer to Table 1 in Section 4.26 and dose reduce 1 dose level.  
Discontinue sorafenib if toxicity occurred at 100 mg/m2 dose 
Grade 4 
Hold sorafenib until toxicity is Grade < 2, then:  
• 
Refer to Table 1 in Section 4.26 and dose reduce 1 dose level.  
• 
Discontinue sorafenib if toxicity occurred at 100 mg/m2/dose. If clinically indicated, 
sorafenib at 200 mg/m2 or 300 mg/m2 (150 mg/m2 BID) dose levels may be held 
indefinitely. 
 
 
  
 

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5.13 
Stem Cell Transplant Regimen Agents  
 
5.13.1 Methotrexate Dose Adjustments 
Every attempt possible should be made to administer methotrexate as prescribed since dose reduction and 
omission have been associated with an increased incidence of acute GVHD. Not every impairment in renal 
function and not every increase in third space fluid are contraindications to the use of methotrexate. It may 
be advantageous to give methotrexate, possibly at a reduced dose (75%-50%), and offer rescue with 
leucovorin. Several studies have shown that this will reduce toxicity without increasing the risk of GVHD. 
Any questionable situation must be discussed with the Transplant Study Committee Representative and 
serum methotrexate levels determined. If methotrexate concentration is assessed and is greater than 0.1 µM 
at 24 hours, then leucovorin 10 mg/m2 IV q 6 hours should be initiated until resolution of elevated 
methotrexate levels. 
 
5.13.2 Tacrolimus 
Tacrolimus commonly causes mild/moderate hypertension and alopecia and less commonly kidney or liver 
dysfunction, transplant associated microangiopathy (TAM), and neurological changes associated with 
significant hypertension. When trough levels are kept in the therapeutic range and patients receive adequate 
hydration and magnesium replacement, most of these side effects can be minimized. Hypertension should 
be managed with single or combination antihypertensive therapy per institutional standards. Tacrolimus 
should be held for severe toxicities thought to be related to its administration (significant neurological 
changes/malignant hypertension, TAM, kidney failure, etc). Other immune suppressive medications may 
be substituted if tacrolimus is not tolerated (MMF, cyclosporine, etc). 
 
 
6.0 
DRUG INFORMATION  
 
Agents are listed alphabetically. 
 
6.1 
ASPARAGINASE (E. coli) 
 
 
 
 
 
 
(07/01/15) 
(E.coli L-asparaginase, EC 3.5.2.2, colaspase, L-asnase, Elspar, Kidrolase, Crasnitin,Leunase) 
NSC#109229    
 
 
 
 
 
 
 
 
 
 
Source and Pharmacology:   
L-asparagine is a nonessential amino acid synthesized by the transamination of L-aspartic acid by a reaction 
catalyzed by the enzyme L-asparagine synthetase. The ability to synthesize asparagine is notably lacking 
in malignancies of lymphoid origin. Asparaginase contains the enzyme L-asparagine amidohydrolase type 
EC-2, which is derived from Escherichia coli and depletes L-asparagine from leukemic cells (especially 
lymphoblasts) by catalyzing the conversion of L-asparagine to aspartic acid and ammonia. L-asparaginase 
is administered either intravenously or intramuscularly. The intramuscular route produces peak blood levels 
50% lower than the intravenous route, but the former may be less immunogenic and is more commonly 
used. L-asparaginase concentration in plasma is proportional to a total dose up to 200,000 IU/m2 and falls 
with a primary half-life of 14 to 22 hours after administration. Blood levels of the E. coli enzyme are 
detectable for 1 to 2 weeks after a single dose, and concentrations of L-asparagine fall below 1 mmol within 
minutes of enzyme injection and remain low for 7 to 10 days after completion of therapy. The half-life is 
independent of the dose administered, disease status, renal or hepatic function, age, or gender. Plasma t½ 
varies from 8 to 30 hours after IV administration and 39 to 49 hours after IM administration. L-asparaginase 
is cleared by the reticuloendothelial system and very little is excreted in the urine or bile. Cerebrospinal fluid 
levels are < 1% of plasma levels.  
 
 
 

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Toxicity: 
 
Common 
Happens to 21-100 children 
out of every 100 
Occasional 
Happens to 5-20 children 
out of every 100 
Rare 
Happens to < 5 children out of every 
100 
Immediate: 
Within 1-2 days 
of receiving 
drug 
Allergic reactions (total 
likelihood of local and/or 
systemic reaction), pain at 
injection site 
Rash  
Anaphylaxis, periorbital edema, chills, 
fever, myalgia, mild nausea & 
vomiting,  abdominal pain, somnolence, 
lethargy, headache, seizures 
(L),  hyperuricemia 
Prompt: 
Within 2-3 
weeks, prior to 
the next course 
Hyperammonemia (L), 
coagulation abnormalities 
with prolonged PTT, PT and 
bleeding times (secondary to 
decreased synthesis of 
fibrinogen, AT-III & other 
clotting factors) (L) 
Hyperglycemia, abnormal 
liver function tests  
Pancreatitis (L), hemorrhage (L), DIC, 
thrombosis,  anorexia, CNS ischemic 
attacks, edema, azotemia and decreased 
renal function, mild leukopenia and 
thrombocytopenia, coma and stupor, 
hypertriglyceridemia,  hyperlipidemia, 
Parkinson-like syndrome with tremor 
and increase in muscular tone, CNS 
changes including irritability, 
depression, confusion, EEG changes, 
hallucinations  
Delayed: 
Any time later 
during therapy, 
excluding the 
above conditions 
 
 
Renal failure 
Unknown 
Frequency and 
Timing: 
Fetal toxicities and teratogenic effects of asparaginase have been noted in animals. It is unknown 
whether the drug is excreted in breast milk. 
 (L) Toxicity may also occur later. 
 
Formulation and Stability:   
Asparaginase is a white lyophilized plug or powder supplied in a sterile 10 mL vial containing 10,000 IU 
of asparaginase and 80 mg mannitol, an inactive ingredient. The specific activity of asparaginase is at least 
225 IU per mg of protein. Store at 2º-8ºC (36º-46ºF). Asparaginase powder for injection is stable for at least 
48 hours at room temperature. 
 
Guidelines for Administration:  See Treatment and Dose Modifications sections of the protocol. 
 
For intramuscular use (IM): asparaginase is reconstituted by adding 1 or 2 mL of NS to the vial containing 
10,000 IU of asparaginase.  Rotate the vial to dissolve (shaking will cause excessive foaming making 
withdrawal of the entire contents difficult). It is suggested that no more than 2 mL should be given at any one 
injection site.   
 
For intravenous use (IV): Reconstitute a 10,000 units vial with 5mL of SWFI or with NS and used for direct 
intravenous infusion within 8 hours. Asparaginase may be further diluted in 50-250mL of D5W or NS and 
infuse within 8 hours, only if clear. 
 
Asparaginase does not contain a preservative. Unused, reconstituted solution should be discarded after eight 
hours or sooner if it becomes cloudy. 
 

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Occasionally a very small number of gelatinous, fiber-like particles may develop in asparaginase solutions on 
standing. These particles may be removed without loss of potency by filtration through a 5-micron filter. Some 
loss of potency has occurred with the use of a 0.2-micron filter. 
 
Have available during and after the infusion: antihistamine, epinephrine, oxygen, and IV 
corticosteroids. Observe patient for ONE hour after administration for signs of hypersensitivity 
reactions. 
 
Supplier:  US formulation of E.Coli Asparaginase, Elspar, has been discontinued.  
 
CANADIAN SITES: E.Coli Asparaginase is commercially available in Canada. See Canadian package 
insert for further information. 
 
6.2 
ASPARAGINASE (ERWINIA CHRYSANTHEMI)  
(Erwinia chrysanthemi, Erwinase®, ErwinazeTM, Crisantaspase)  
 
(10/10/2016) 
 
Source and Pharmacology: 
L-asparagine is a nonessential amino acid synthesized by the transamination of L-aspartic acid by a reaction 
catalyzed by the enzyme L-asparagine synthetase. Neoplastic cells associated with acute lymphoblastic 
leukemia, acute myeloid leukemia and lymphoblastic lymphosarcoma are asparagine-dependent but lack 
asparagine synthetase activity. The administration of L-asparaginase produces an anti-neoplastic effect by 
catalyzing asparagine into aspartic acid and ammonia. As a result, these cells lack the ability to produce the 
asparagine necessary for protein metabolism and survival. Deamination of glutamine may also play a role 
in the antineoplastic activity of asparaginase. 
 
Asparaginase Erwinia chrysanthemi (Erwinaze) is asparaginase derived from cultures of Erwinia 
chrysanthemi. L-asparaginase is a tetrameric enzyme; each of the four identical subunits has a molecular 
weight of approximately 35 kDa. Asparaginase Erwinia chrysanthemi is immunologically distinct from 
E. coli L-asparaginase and may allow continued asparaginase therapy when a hypersensitivity reaction 
occurs to Escherichia coli-derived asparaginase. The package labeling states that there is insufficient 
information to characterize the incidence of antibodies to asparaginase Erwinia chrysanthemi. Several 
factors are involved in immunogenicity assay results and the assessment of antibodies, including assay 
methodology, assay sensitivity and specificity, sample handling, timing of sample collection, concomitant 
medications, and the underlying disease state. The following data have been reported on each of the three 
preparations of asparaginase: 
 
Clinical Pharmacology 
of Asparaginase 
Formulation 
Elimination half-life (IM) 
% Anti-Asparaginase Antibody 
positive patients 
Native Escherichia Coli 
26-30 hours 
45-75 
Pegylated-asparaginase 
5.5-7 days 
5-18 
Erwinia Asparaginase 
16 hours (7-13 hrs package insert) 
30-50 
From: Avramis, V; Panosyan, E; Pharmacokinetic/Pharmacodynamic Relationships of Asparaginase Formulations: The Past, 
the Present and Recommendations for the Future. Clin Pharmacokinet 2005; 44 (4): 367-393. 
 
Effective asparaginase levels have been defined as activity of ≥ 0.1 International Units per mL. Clinical 
trials with asparaginase Erwinia chrysanthemi demonstrated that 100% of patients achieved effective 
asparaginase levels at 48 and 72 hours (n=35 and n=13, respectively) following the third total dose when 
given on a Monday, Wednesday, Friday schedule using the IM route of administration. In a multicenter 
study characterizing the pharmacokinetic profile of 25,000 International Units/m2 Erwinaze® given 
intravenously over one hour on the same dosing schedule of Monday, Wednesday, Friday for 2 consecutive 

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weeks, 83% (20/24) and 43% (9/21) of evaluable patients achieved an asparaginase activity level of ≥ 0.1 
International Units/mL at 48 post-dose 5 and 72 hours post-dose 6, respectively.. No formal drug interaction 
studies have been performed with asparaginase Erwinia chrysanthemi. 
 
Toxicity: 
 
Common 
Happens to 21-100 children 
out of every 100 
Occasional 
Happens to 5-20 children 
out of every 100 
Rare 
Happens to < 5 children out of every 100 
Immediate: 
Within 1-2 days 
of receiving drug 
 
Allergic reactions, 
anaphylaxis, urticaria 
Local injection site reactions, fever 
Prompt: 
Within 2-3 
weeks, prior to 
the next course 
 
 
Pancreatitis, glucose intolerance, 
thrombosis, hemorrhage, transient ischemic 
attack, disseminated intravascular 
coagulation, hyperbilirubinemia, alanine 
aminotransferase increased, aspartate 
aminotransferase increased, 
hyperglycemia, hyperammonemia, 
vomiting, nausea, abdominal pain, 
headache, diarrhea, seizure  
Unknown 
Frequency and 
Timing:  
Fetal toxicities and teratogenic effects of L-asparaginase have been noted in animals. It is 
unknown whether the drug is excreted in breast milk. Adequate, well-controlled studies of 
asparaginase Erwinia chrysanthemi have NOT been conducted. It is not known whether 
asparaginase Erwinia chrysanthemi will cause fetal harm or affect the ability to reproduce. It is 
not known if asparaginase Erwinia chrysanthemi is excreted into breast milk. The use of 
asparaginase Erwinia chrysanthemi should be avoided in pregnant or lactating patients. 
(L) Toxicity may also occur later. 
 
Formulation and Stability: 
Asparaginase Erwinia chrysanthemi is supplied as a sterile, white lyophilized powder for reconstitution in 
a clear glass vial with a 3 mL capacity. Each vial contains 10,000 International Units of asparaginase 
Erwinia chrysanthemi and the following inactive ingredients: glucose monohydrate (5.0 mg), sodium 
chloride (0.5 mg). Store intact vials between 2°C and 8°C (36° to 46ºF). Protect from light. 
 
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol. 
 
Erwinia asparaginase can be administered by intramuscular injection or by intravenous infusion. Use 
appropriate precautions for preparation of a hazardous agent. Visually inspect the powder in vial for foreign 
particles or discoloration prior to reconstitution. 
 
For intramuscular administration, the contents of each vial should be reconstituted by slowly adding 1 mL 
or 2 mL of sterile, preservative-free NS to the inner vial wall. The final concentration is 10,000 International 
Units per mL when using 1 mL for reconstitution or 5,000 International Units per mL when using 2 mL for 
reconstitution. Gently mix or swirl the contents to dissolve the contents of the vial. Do not shake or invert 
the vial. The resulting solution should be clear and colorless. Discard if any particulate matter or protein 
aggregates are visible. Withdraw the appropriate dosing volume into a polypropylene syringe within 
15 minutes of reconstitution. Polycarbonate luer-lok syringes from B-D (1 mL) are also acceptable 
(personal communication, EUSA Pharma). Discard any unused drug; do not save or use any unused drug 
remaining the in the vial. No more than 2 mL should be given at any one injection site. Doses larger than 2 
mL should be divided and given in separate administration sites. 
 
For intravenous use, slowly inject the appropriate volume of reconstituted solution into a Normal Saline 
100 mL infusion bag; do not shake or squeeze the bag.  Infuse Erwinia asparaginase over 1-2 hours. Do 

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120 
not infuse other intravenous drugs through the same intravenous line while infusing Erwinia 
asparaginase. 
 
Administer the dose within a 4 hour time period from reconstitution. If the dose is not used within this 
time period, discard the dose. Do not freeze or refrigerate the reconstituted solution.   
 
Have available during and after the infusion: antihistamine, epinephrine, oxygen, and IV corticosteroids. 
Observe patient for ONE hour after administration for signs of hypersensitivity reactions. 
 
Drug Ordering: 
In the United States, asparaginase Erwinia chrysanthemi (Erwinaze) is distributed by  McKesson Plasma 
and Biologics. Verify your institution has a contract with McKesson Plasma and Biologics before ordering. 
If not, contact McKesson at 877-625-2566 for assistance setting up an account. 
 
Orders may be placed online or via phone, fax, or email. 
1. Orders may be placed online via http://Connect.McKesson.com 
2. Orders may be submitted via fax to 888-752-7626 
3. Orders may be submitted via email or MPBOrders@McKesson.com 
4. Email all other information requests to MPB@McKesson.com 
5. Regular order hours: M-F 9:00 am – 7:30 pm EST; 
6. Emergency order after hours services (24/7/365): 877-625-2566 
Orders placed by 7:30 pm EST will ship the next day.  
 
 
CANADIAN SITES 
Asparaginase Erwinia chrysanthemi is commercially available in Canada. Canadian sites may purchase the 
Canadian commercial supply from EUSA via CGF Pharmatech, Montreal, Quebec, a subsidiary of EUSA 
(order desk phone: 1-514-343-0344 or 1-866-343-0344, fax: 1-514-343-0340). CGF requests that a site fax 
a Purchase Order number. There is no special fax order form. Shipments are sent Monday to Wednesday 
only and usually arrive at the site within 48-72 hours. 
 
6.3 
BORTEZOMIB 
(Velcade, N-Pyrazinecarbonyl-L-phenylalanine-L-leucine boronic acid, PS-341, MLN341, LDP-341) 
 
NSC# 681239, IND# 114480 
 
 
 
 
 
 
 
(08/04/14) 
 
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/m2 dose and 76 to 108 hours after the 1.3 mg/m2 dose. In vitro studies with human 
liver microsomes and human cDNA-expressed cytochrome P450 isozymes indicate that bortezomib is 

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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. 
 
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. Green tea constituents, 
in particular epigallocatechin gallate (EGCG) and other polyphenols with 1,2-benzenediol moieties, 
effectively prevented tumor cell death induced by bortezomib both in vitro and in vivo. In multiple myeloma 
cell lines or mouse xenografts, EGCG directly reacted with bortezomib and blocked its proteasome 
inhibitory function. As a result, bortezomib could not trigger endoplasmic reticulum stress or caspase-7 
activation and could not induce tumor cell death. A more recent study investigated whether clinically 
relevant levels of EGCG or ascorbic acid could inhibit the antitumor activity of bortezomib in murine 
xenograft tumors. The addition of EGCG to bortezomib demonstrated no effect on tumor growth inhibition 
at lower concentrations of EGCG that the investigators compare to human dietary intake. Similar results 
were found for ascorbic acid at normal daily doses. When bortezomib was given concurrently with much 
higher concentrations of EGCG, the investigators found that all antitumor activity was eliminated. The 
authors concluded that there is no interaction between EGCG or ascorbic acid when plasma concentrations 
are commensurate with dietary oral intake. 
 
Vitamin C, at concentrations achieved during vitamin supplementation, has also been shown to inhibit the 
activity of bortezomib both in vitro and in vivo. Direct binding between the hydroxyl group of vitamin C 
and the boronic acid of bortezomib reduced the affinity of the proteasome inhibitor for the chymotrypsin-
like subunit of the proteasome. In addition, it was noted that besides vitamin C, other natural agents carrying 
a hydroxyl group, such as flavonoid compounds (quercetin among others), bind and inhibit the activity of 
bortezomib in vitro.  
 
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 (e.g., 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 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. 
 
Toxicity: 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR) 
for 
PS-341 (Bortezomib, Velcade, NSC 681239) 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to Expedited 
Reporting (SPEER), appears in a separate column and is identified with bold and italicized text. This subset 
of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited reporting to NCI 
(except as noted below). Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf 
for 
further 
clarification. Frequency is provided based on 2084 patients. Below is the CAEPR for PS-341 (bortezomib, 
Velcade). 

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NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the 
AE in the SPEER. If this CAEPR is part of a combination protocol using multiple investigational agents 
and has an AE listed on different SPEERs, use the lower of the grades to determine if expedited 
reporting is required. 
 
Version 2.5, June 30, 201410 
 
 Adverse Events with Possible  
 Relationship to PS-341 (Bortezomib, Velcade) 
 (CTCAE 4.0 Term) 
[n= 2084] 
 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER) 
  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
Anemia 
 
 
 Anemia (Gr 3) 
CARDIAC DISORDERS 
  
 
 
Heart failure 
  
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 3) 
Constipation 
 
 
 Constipation (Gr 3) 
Diarrhea 
 
 
 Diarrhea (Gr 3) 
 
Dyspepsia 
 
 Dyspepsia (Gr 2) 
 
Gastrointestinal hemorrhage122 
 
  
 
 
 Gastrointestinal perforation11 
  
 
Ileus 
 
 Ileus (Gr 3) 
Nausea 
 
 
 Nausea (Gr 3) 
Vomiting 
 
 
 Vomiting (Gr 3) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Chills 
 
 Chills (Gr 2) 
 
Edema limbs 
 
 Edema limbs (Gr 3) 
Fatigue 
 
 
 Fatigue (Gr 3) 
Fever 
 
 
 Fever (Gr 3) 
INFECTIONS AND INFESTATIONS 
  
Infection123 
 
 
 Infection4 (Gr 3) 
INVESTIGATIONS 
  
 
Neutrophil count decreased 
 
 Neutrophil count decreased (Gr 
4) 
Platelet count decreased 
 
 
 Platelet count decreased  (Gr 4) 
 
Weight loss 
 
  
METABOLISM AND NUTRITION DISORDERS 
  
Anorexia 
 
 
 Anorexia (Gr 3) 
 
Dehydration 
 
  
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
 Arthralgia (Gr 2) 
 
Back pain 
 
 Back pain (Gr 2) 
 
Bone pain 
 
 Bone pain (Gr 2) 
 
Musculoskeletal and connective 
tissue disorder - Other (muscle 
spasms) 
 
  
 
Myalgia 
 
 Myalgia (Gr 3) 
 
Pain in extremity 
 
 Pain in extremity (Gr 2) 
NERVOUS SYSTEM DISORDERS 
  
 
Dizziness 
 
 Dizziness (Gr 3) 

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 Adverse Events with Possible  
 Relationship to PS-341 (Bortezomib, Velcade) 
 (CTCAE 4.0 Term) 
[n= 2084] 
 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER) 
  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
 
 
Headache 
 
 Headache (Gr 2) 
 
 
Leukoencephalopathy 
  
 
Neuralgia 
 
 Neuralgia (Gr 3) 
 
Paresthesia 
 
  
Peripheral motor neuropathy 
 
 
 Peripheral motor neuropathy (Gr 
3) 
Peripheral sensory neuropathy 
 
 
 Peripheral sensory neuropathy 
(Gr 3) 
 
 
Reversible posterior 
leukoencephalopathy syndrome 
  
PSYCHIATRIC DISORDERS 
  
 
Anxiety 
 
  
 
Insomnia 
 
 Insomnia (Gr 2) 
RENAL AND URINARY DISORDERS 
  
 
 
Acute kidney injury 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
 
Adult respiratory distress syndrome   
 
Cough 
 
 Cough (Gr 2) 
 
Dyspnea 
 
 Dyspnea (Gr 3) 
 
Pharyngeal mucositis 
 
 Pharyngeal mucositis (Gr 2) 
 
 
Pulmonary hypertension 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
Rash maculo-papular 
 
 Rash maculo-papular (Gr 3) 
VASCULAR DISORDERS 
  
 
Hypotension 
 
 Hypotension (Gr 3) 
1This table will be updated as the toxicity profile of the agent is revised. Updates will be distributed to all Principal 
Investigators at the time of revision. The current version can be obtained by contacting PIO@CTEP.NCI.NIH.GOV.  
Your name, the name of the investigator, the protocol and the agent should be included in the e-mail. 
 
2Gastrointestinal hemorrhage includes Anal hemorrhage, Cecal hemorrhage, Colonic hemorrhage, Duodenal 
hemorrhage, Esophageal hemorrhage, Esophageal varices hemorrhage, Gastric hemorrhage, Hemorrhoidal 
hemorrhage, Ileal hemorrhage, Intra-abdominal hemorrhage, Jejunal hemorrhage, Lower gastrointestinal 
hemorrhage, Oral hemorrhage, Pancreatic hemorrhage, Rectal hemorrhage, Retroperitoneal hemorrhage, and Upper 
gastrointestinal hemorrhage under the GASTROINTESTINAL DISORDERS SOC. 
 
3Gastrointestinal perforation includes Colonic perforation, Duodenal perforation, Esophageal perforation, Gastric 
perforation, Ileal perforation, Jejunal perforation, Rectal perforation, and Small intestinal perforation under the 
GASTROINTESTINAL DISORDERS SOC. 
 
4Infection includes all 75 sites of infection under the INFECTIONS AND INFESTATIONS SOC. 
 
Also reported on PS-341 (bortezomib, Velcade) trials but with the relationship to PS-341 (bortezomib, 
Velcade) still undetermined: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other (hematocrit 
low); Blood and lymphatic system disorders - Other (lymphadenopathy); Disseminated intravascular coagulation; 
Febrile neutropenia; Hemolytic uremic syndrome; Leukocytosis 

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CARDIAC DISORDERS - Acute coronary syndrome; Asystole; Atrial fibrillation; Atrial flutter; Atrioventricular 
block complete; Cardiac arrest; Cardiac disorders - Other (cardiac amyloidosis); Cardiac disorders - Other 
(cardiomegaly); Chest pain - cardiac; Left ventricular systolic dysfunction; Mobitz type I; Myocardial infarction; 
Palpitations; Pericardial effusion; Pericardial tamponade; Pericarditis; Right ventricular dysfunction; Sinus 
bradycardia; Sinus tachycardia; Supraventricular tachycardia; Ventricular arrhythmia; Ventricular fibrillation; 
Ventricular tachycardia 
EAR AND LABYRINTH DISORDERS - External ear inflammation; Hearing impaired; Tinnitus 
ENDOCRINE DISORDERS - Hypothyroidism 
EYE DISORDERS - Blurred vision; Conjunctivitis; Dry eye; Extraocular muscle paresis; Eye disorders - Other 
(chalazion); Eye disorders - Other (choroidal effusion); Eye disorders - Other (conjunctival hemorrhage); Eye 
disorders - Other (retinal hemorrhage with bilateral vision impairment); Keratitis; Watering eyes 
GASTROINTESTINAL DISORDERS - Abdominal distension; Ascites; Bloating; Colitis; Dry mouth; Duodenal 
ulcer; Dysphagia; Enterocolitis; Esophagitis; Flatulence; Gastritis; Gastroesophageal reflux disease; Gastrointestinal 
disorders - Other (colonic wall thickening); Gastrointestinal disorders - Other (early satiety); Gastrointestinal disorders 
- Other (eructation); Gastrointestinal disorders - Other (ileitis); Gastrointestinal disorders - Other (ischemic bowel); 
Gastrointestinal disorders - Other (mouth/tongue ulceration); Gastrointestinal disorders - Other (retching); 
Gastrointestinal pain; Gingival pain; Hemorrhoids; Mucositis oral; Oral pain; Pancreatitis; Small intestinal 
obstruction; Typhlitis 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Edema face; Flu like symptoms; 
Gait disturbance; General disorders and administration site conditions - Other (catheter related complication);General 
disorders and administration site conditions - Other (hepato-renal syndrome); Hypothermia; Injection site reaction; 
Malaise; Multi-organ failure; Non-cardiac chest pain; Pain; Sudden death NOS 
HEPATOBILIARY DISORDERS - Hepatic failure; Hepatobiliary disorders - Other (hepatitis); Hepatobiliary 
disorders - Other (portal vein thrombosis); Hepatobiliary disorders - Other (VOD) 
IMMUNE SYSTEM DISORDERS - Allergic reaction; Anaphylaxis; Cytokine release syndrome 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Bruising; Fall; Fracture; Vascular access 
complication 
INVESTIGATIONS - Activated partial thromboplastin time prolonged; Alanine aminotransferase increased; 
Alkaline phosphatase increased; Aspartate aminotransferase increased; Blood bilirubin increased; CD4 lymphocytes 
decreased; CPK increased; Carbon monoxide diffusing capacity decreased; Cardiac troponin I increased; Cardiac 
troponin T increased; Cholesterol high; Creatinine increased; Ejection fraction decreased; GGT increased; INR 
increased; Investigations - Other (albumin); Investigations - Other (BUN); Investigations - Other (low chloride); 
Investigations - Other (pancytopenia); Lipase increased; Lymphocyte count decreased; Serum amylase increased; 
Weight gain; White blood cell decreased 
METABOLISM AND NUTRITION DISORDERS - Acidosis; Hypercalcemia; Hyperglycemia; Hyperkalemia; 
Hyperuricemia; Hypoalbuminemia; Hypocalcemia; Hypoglycemia; Hypokalemia; Hypomagnesemia; Hyponatremia; 
Hypophosphatemia; Metabolism and nutrition disorders - Other (failure to thrive); Metabolism and nutrition disorders 
- Other (hypoproteinemia); Tumor lysis syndrome 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthritis; Avascular necrosis; Buttock 
pain; Chest wall pain; Generalized muscle weakness; Joint range of motion decreased; Muscle weakness lower limb; 
Musculoskeletal and connective tissue disorder - Other (cramping); Osteonecrosis of jaw 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Tumor pain 
NERVOUS SYSTEM DISORDERS - Acoustic nerve disorder NOS; Akathisia; Ataxia; Cognitive disturbance; 
Depressed level of consciousness; Dysesthesia; Dysgeusia; Dysphasia; Edema cerebral; Encephalopathy; Facial 
muscle weakness; Facial nerve disorder; Hypersomnia; Intracranial hemorrhage; Ischemia cerebrovascular; Lethargy; 
Memory impairment; Nervous system disorders - Other (autonomic neuropathy); Nervous system disorders - Other 
(Bell's palsy); Nervous system disorders - Other (cranial palsy); Nervous system disorders - Other (dysautonomia); 
Nervous system disorders - Other (L sided facial droop); Nervous system disorders - Other (paralysis); Nervous system 
disorders - Other (polyneuropathy); Nervous system disorders - Other (spinal cord compression); Nervous system 
disorders - Other (tongue paralysis); Presyncope; Seizure; Somnolence; Stroke; Syncope; Tremor; Vasovagal reaction 
PSYCHIATRIC DISORDERS - Agitation; Confusion; Delirium; Depression; Personality change; Psychosis 
RENAL AND URINARY DISORDERS - Bladder spasm; Chronic kidney disease; Cystitis noninfective; Hematuria; 
Proteinuria; Renal and urinary disorders - Other (bilateral hydronephrosis); Renal and urinary disorders - Other 
(calculus renal); Renal and urinary disorders - Other (glomerular nephritis proliferative); Urinary frequency; Urinary 
incontinence; Urinary retention; Urinary tract pain 

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RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Allergic rhinitis; Aspiration; Atelectasis; 
Bronchopulmonary hemorrhage; Bronchospasm; Epistaxis; Hiccups; Hypoxia; Laryngeal edema; Mediastinal 
hemorrhage; Pharyngolaryngeal pain; Pleural effusion; Pleuritic pain; Pneumonitis; Postnasal drip; Pulmonary edema; 
Respiratory failure; Respiratory, thoracic and mediastinal disorders - Other (obstructive airways disease); Respiratory, 
thoracic and mediastinal disorders - Other (pleurisy); Respiratory, thoracic and mediastinal disorders - Other 
(respiratory distress); Respiratory, thoracic and mediastinal disorders - Other (tachypnea); Tracheal mucositis; 
Tracheal stenosis; Voice alteration 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Bullous dermatitis; Dry skin; Erythema 
multiforme; Erythroderma; Hyperhidrosis; Pain of skin; Palmar-plantar erythrodysesthesia syndrome; Pruritus; 
Purpura; Rash acneiform; Skin and subcutaneous tissue disorders - Other (angioedema); Skin and subcutaneous tissue 
disorders - Other (leukoclastic vasculitis); Skin and subcutaneous tissue disorders - Other (Skin lesion NOS); Urticaria 
VASCULAR DISORDERS - Capillary leak syndrome; Flushing; Hematoma; Hypertension; Thromboembolic event; 
Vascular disorders - Other (trach site); Vasculitis 
 
Note: PS-341 (bortezomib; Velcade) in combination with other agents could cause an exacerbation of any 
adverse event currently known to be caused by the other agent, or the combination may result in events 
never previously associated with either agent. 
 
PLEASE NOTE: The potential risks listed in the CAEPR whose relationship to bortezomib is still 
undetermined are not required by CTEP to be described in the ICD; however, they may be communicated 
to patients according to local IRB requirements. 
 
Other Potential Risks: 
The CAEPR above lists “leukoencephalopathy” and “Reversible posterior leukoencephalopathy syndrome” 
as “Rare but Serious” adverse events with potential association to bortezomib. The prescribing information 
for bortezomib was updated in 2012 to include Progressive Multifocal Leukoencephalopathy (PML) as a 
specific adverse event noted in post-marketing reports. Institutions may use their discretion with adding 
this toxicity to the Informed Consent document.     
 
Effect in Pregnancy and Lactation: 
At ½ the clinical dose bortezomib was not teratogenic in non-clinical developmental toxicity studies in rats 
and rabbits. However, pregnant rabbits given bortezomib during organogenesis at a dose of 0.05 mg/kg (0.6 
mg/m2) experienced significant post-implantation loss and decreased number of live fetuses. Live fetuses 
from these litters also showed significant decreases in fetal weight. It is not known whether bortezomib is 
excreted in human milk. 
 
Formulation and Stability:  
Bortezomib is supplied as a lyophilized powder in sterile vials containing 3.5 mg and 35 mg mannitol, USP. 
Unopened vials may be stored at controlled room temperature 25ºC (77ºF); excursions permitted from 15ºC 
to 30ºC (59ºF to 86ºF). Retain in original package to protect from light. 
  
Reconstitute bortezomib with 3.5 mL normal saline, USP. Each milliliter of solution will contain 1 mg of 
bortezomib at a pH of approximately 5 to 6. The drug solution is clear and colorless. Bortezomib contains 
no antimicrobial preservative. When reconstituted as directed, bortezomib may be stored at 25°C (77°F). 
Reconstituted bortezomib should be administered within 8 hours of preparation. The reconstituted material 
may be stored in the original vial and/or the syringe prior to administration. The product may be stored for 
up to 8 hours in a syringe; however total storage time for the reconstituted material must not exceed 8 hours 
when exposed to normal indoor lighting.  
 
Guidelines for Administration:  
See Treatment and Dose Modification Sections of the Protocol. 

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Bortezomib is to be given without further dilution as an IV push over 3 to 5 seconds. Consecutive doses 
must be separated by at least 72 hours. Grapefruit and its juice should be avoided for the duration of 
treatment with bortezomib. 
 
Special precautions: FOR INTRAVENOUS USE ONLY.  
The syringe containing bortezomib should be clearly labeled “For intravenous use only. Fatal if given by 
other routes.” Additional wording may be considered at the institution’s discretion. Three fatalities have 
been reported following accidental intrathecal administration of bortezomib. Special precautions should be 
employed to ensure that intravenous bortezomib and intrathecal medications are not inadvertently 
interchanged. 
 
Supplier: Supplied by Millennium Pharmaceuticals and distributed by the NCI DTCD. Do not use 
commercially available drug. 
 
Obtaining the Agent 
Agent Ordering: 
NCI supplied agent may be requested by the Principal Investigator (or their authorized designee) at each 
participating institution. Pharmaceutical Management Branch (PMB) policy requires that agent be shipped 
directly to the institution where the patient is to be treated. PMB does not permit the transfer of agents 
between institutions (unless prior approval from PMB is obtained). The CTEP assigned protocol number 
must be used for ordering all CTEP supplied investigational agents. The responsible investigator at each 
participating institution must be registered with CTEP, DCTD through an annual submission of FDA form 
1572 (Statement of Investigator), Curriculum Vitae, Supplemental Investigator Data Form (IDF), and 
Financial Disclosure Form (FDF). If there are several participating investigators at one institution, CTEP 
supplied investigational agents for the study should be ordered under the name of one lead investigator at 
that institution. 
 
Active CTEP-registered investigators and investigator-designated shipping designees and ordering 
designees must submit agent requests through the PMB Online Agent Order Processing (OAOP) application 
< https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx >.  Access to OAOP requires the establishment of 
a CTEP Identity and Access Management (IAM) account < https://eapps-ctep.nci.nih.gov/iam/ > and the 
maintenance of an “active” account status and a “current” password. For questions about drug orders, 
transfers, returns, or accountability, call (240) 276-6575 Monday through Friday between 8:30 am and 4:30 
pm (ET) or email PMBAfterHours@mail.nih.gov anytime. 
 
Agent Accountability: 
Agent Inventory Records – The investigator, or a responsible party designated by the investigator, must 
maintain a careful record of the inventory and disposition of all agents received from DCTD using the NCI 
Drug 
Accountability 
Record 
Form 
(DARF). 
(See 
the 
CTEP 
home 
page 
at 
http://ctep.cancer.gov/protocolDevelopment/default.htm#agents_drugs for the Procedures for Drug 
Accountability and Storage and http://ctep.cancer.gov/forms/default.htm to obtain a copy of the DARF and 
Clinical Drug Request form.) 
 
Agent Returns: 
Investigators/Designees must return unused DCTD supplied investigational agent to the NCI clinical 
repository as soon as possible when: the agent is no longer required because the study is completed or 
discontinued and the agent cannot be transferred to another DCTD sponsored protocol; the agent is outdated 
or the agent is damaged or unfit for use. Regulations require that all agents received from the DCTD, NCI 
be returned to the DCTD, NCI for accountability and disposition. Return only unused vials/bottles. Do NOT 
return opened or partially used vials/bottles unless specifically requested otherwise in the protocol. See the 
CTEP 
web 
site 
for 
Policy 
and 
Guidelines 
for 
Investigational 
agent 
Returns 
at: 

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127 
http://ctep.cancer.gov/protocolDevelopment/default.htm#agents_drugs. The appropriate forms may be 
obtained at: http://ctep.cancer.gov/forms/docs/return_form.pdf. 
 
 
 
6.4 
BUSULFAN INJECTION 
(Busulfex®) 
 
 
 
 
NSC #750 
 
 
 
(07/01/15) 
Source and Pharmacology:   
Busulfan is a non-cell cycle specific bifunctional alkylating agent. In aqueous media, busulfan hydrolyzes to 
release methanesulfonate groups. This produces reactive carbonium ions that interact with cellular thiol 
groups and nucleic acids to form DNA cross-links. Busulfan injection is 100% bioavailable by definition of 
intravenous administration. The elimination of busulfan appears to be independent of renal function, 
presumably reflecting the extensive metabolism of the drug in the liver, since less than 2% of the 
administered dose is excreted in the urine unchanged within 24 hours. The drug is metabolized by enzymatic 
activity to at least 12 metabolites, among which tetrahydrothiophene, tetrahydrothiophene 12-oxide, 
sulfolane, and 3-hydroxysulfolane were identified. These metabolites do not have cytotoxic activity. 
Irreversible binding to plasma proteins (primarily albumin) is approximately 32.4%. Busulfan has a plasma 
terminal elimination half-life (t1/2) of about 2.6 hours and demonstrates linear kinetics. It is rapidly 
distributed into tissue and crosses the blood-brain and the placental barriers. CSF concentrations are 
approximately equal to those in plasma. Itraconazole reduced busulfan clearance by up to 25% in patients 
receiving itraconazole compared to patients who did not receive itraconazole. Higher busulfan exposure 
due to concomitant itraconazole could lead to toxic plasma levels in some patients. Fluconazole had no 
effect on the clearance of busulfan. 
 
Toxicities: 
 
Common 
Happens to 21-100 children out of 
every 100 
Occasional 
Happens to 5-20 children out 
of every 100 
Rare 
Happens to < 5 children out of every 100 
Immediate: 
Within 1-2 
days of 
receiving 
drug 
Nausea, vomiting, fever, electrolyte 
changes (hypokalemia, 
hypomagnesemia, hypocalcemia, 
hypophosphatemia, and 
hyponatremia), hyperglycemia, 
dizziness, rash, pruritus, urticaria, 
injection site pain and inflammation, 
back pain, tachycardia, chest pain, 
edema, insomnia, anxiety, depression, 
headache, abdominal pain, diarrhea 
(L) or constipation, anorexia, rectal 
discomfort, dyspnea, epistaxis 
Weight gain, confusion 
Seizures (rare with phenytoin prophylaxis), 
hematemesis, hyperuricemia, arrhythmias 
other than tachycardia, pleural effusion, 
alveolar hemorrhage 
Prompt: 
Within 2-3 
weeks 
Myelosuppression, asthenia, 
immunosuppression (L), mucositis, 
hyperbilirubinemia 
Hepatotoxicity, sinusoidal 
obstruction syndrome (SOS, 
formerly VOD) (L), mild 
alopecia (L), arthralgia, 
myalgia, hemorrhagic cystitis, 
hyperpigmentation (L), 
elevated creatinine and BUN 
Reduced adrenal function (L), esophagitis, 
radiation recall reactions  
Late: 
Any time 
after 
completion of 
treatment 
Infertility, testicular atrophy and 
azoospermia, amenorrhea, ovarian 
failure  
 
Secondary malignancy, breast enlargement, 
cataracts, idiopathic pulmonary syndrome 
(cough, dyspnea, pleural effusion, infiltrates, 
and hypoxemia), bronchopulmonary 
dysplasia with interstitial pulmonary fibrosis 
and pneumonitis, myocardial fibrosis, 
osteonecrosis 

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128 
Unknown 
Frequency 
and Timing: 
Fetal toxicities and teratogenic effects of busulfan and its solvent have been noted in animals. Toxicities include: 
multiple anomalies and low birth weight. It is unknown whether the drug or its solvent is excreted in breast milk. 
(L)Toxicity may also occur later 
 
Formulation and Stability:   
Each ampoule or vial of busulfan injection contains 60 mg (6 mg/mL) of busulfan, N,N-dimethylacetamide 
(DMA) 33% vol/vol and Polyethylene Glycol 400, 67% vol/vol. Store refrigerated at 2°-8°C, (36°-46°F). 
 
Guidelines for Administration: See Treatment and Dose Modifications sections of the protocol. 
 
Dilute busulfan injection to a final concentration of approximately 0.5 mg/mL with NS or D5W. The drug 
should not be infused with any other drug or IV solution other than NS or D5W. Always add the busulfan 
to the diluent, not the diluent to the busulfan injection. Mix thoroughly by inverting several times. Do not 
use polycarbonate syringes or filter needles with busulfan injection. Busulfan injection diluted in NS 
or D5W is stable at room temperature (25°C) for up to 8 hours but the infusion must be completed within 
that time. Busulfan injection diluted in NS is stable at refrigerated conditions 2°-8°C (36°-46°F) for up to 
12 hours but the infusion must be completed within that time.  
 
Busulfan injection contains N,N-dimethylacetamide, which is incompatible with many closed-system 
transfer devices (CSTDs); the plastic components of CSTDs may dissolve and result in subsequent leakage 
and potential infusion of dissolved plastic into the patient. 
 
Busulfan injection should be administered by IV infusion through a central venous catheter. Patients receiving 
busulfan in a conditioning regimen for bone marrow transplant must receive seizure prophylaxis. If phenytoin 
is used, it should be given 12 hours prior to the start of busulfan, then daily during busulfan administration 
and for 48 hours after completion of busulfan. In dose-finding studies of busulfan where patients received 
concomitant busulfan and phenytoin, phenytoin reduced busulfan plasma AUC by approximately 15%. Use 
of other anticonvulsants may result in higher busulfan plasma AUCs, and an increased risk of sinusoidal 
obstruction syndrome, (SOS, formerly VOD) or seizures. After an initial dose of busulfan injection, blood 
levels are monitored with bone marrow transplant patients in order to achieve a target area-under-the-curve 
(AUC) plasma concentration. 
 
Supplier:  Commercially available from various manufacturers. See package insert for further information. 
 
6.5 
CYTARABINE – ALL ROUTES 
(Cytosine arabinoside, Ara-C, Cytosar®) 
 
 
NSC #63878 
 
(07/13/15) 
Source and Pharmacology: 
Cytarabine appears to act through the inhibition of DNA polymerase. A limited, but significant, incorporation 
of cytarabine into both DNA and RNA has also been reported. It exhibits cell phase specificity, primarily 
killing cells undergoing DNA synthesis (S-phase) and under certain conditions blocking the progression of 
cells from the G1 phase to the S-phase. Cytarabine is metabolized by deoxycytidine kinase and other 
nucleotide kinases to the nucleotide triphosphate (Ara-CTP), an effective inhibitor of DNA polymerase. Ara-
CTP is inactivated by a pyrimidine nucleoside deaminase, which converts it to the nontoxic uracil derivative 
(Ara-U). It appears that the balance of kinase and deaminase levels may be an important factor in determining 
sensitivity or resistance of the cell to cytarabine. It has an initial distributive phase t½ of about 10 minutes, with 
a secondary elimination phase t½ of about 1 to 3 hours. Peak levels after intramuscular or subcutaneous 
administration of cytarabine occur about 20 to 60 minutes after injection and are lower than IV administration. 
Intrathecally administered doses are metabolized and eliminated more slowly with a t½ of about 2 hours. 
 
 
 

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129 
Toxicity: (Intravenous, SubQ, IM) 
 
Common 
Happens to 21-100 children 
out of every 100 
Occasional 
Happens to 5-20 children out 
of every 100 
Rare 
Happens to < 5 children out of every 
100 
Immediate: 
Within 1-2 days of 
receiving drug 
Nausea, vomiting, anorexia   
 
With High Dose: 
conjunctivitis  
Flu-like symptoms with fever, 
rash  
 
Ara-C syndrome (fever, myalgia, 
bone pain, occasionally chest pain, 
maculopapular rash, malaise, 
conjunctivitis), anaphylaxis, 
swelling, pain and redness at the site 
of the medication injection (SubQ or 
IM injection) 
 
With High Dose: cardiomyopathies 
(vasculitis, and pericarditis), cerebral 
and cerebellar dysfunction including: 
encephalopathy, aseptic meningitis, 
ataxia, dysphasia, nystagmus, a 
decreased level of consciousness, 
personality changes, somnolence, 
seizures  
Prompt: 
Within 2-3 weeks, prior 
to the next course 
Myelosuppression (anemia, 
thrombocytopenia, 
leukopenia, megaloblastosis, 
reticulocytopenia), stomatitis, 
alopecia 
Diarrhea, hypokalemia, 
hypocalcemia, hyperuricemia 
 
With High Dose: capillary 
pulmonary leak syndrome 
(RDS, pulmonary edema) 
Hepatotoxicity, sinusoidal 
obstruction syndrome (SOS, 
formerly VOD), urinary retention, 
renal dysfunction, pain and erythema 
of the palms and soles 
Delayed: 
Any time later during 
therapy, excluding the 
above conditions 
 
 
Asymptomatic nonoliguric 
rhabdomyolysis 
Unknown Frequency 
and Timing: 
Fetal toxicities and teratogenic effects of cytarabine have been noted in humans. It is unknown 
whether the drug is excreted in breast milk. 
 
Toxicity:  (Intrathecal) 
 
Common 
Happens to 21-100 
children out of every 100 
Occasional 
Happens to 5-20 children 
out of every 100 
Rare 
Happens to < 5 children out of 
every 100 
Immediate: 
Within 1-2 days of 
receiving drug 
Nausea, vomiting, fever, 
headache 
 
Arachnoiditis 
Rash, somnolence, meningismus, 
convulsions, paresis 
Prompt: 
Within 2-3 weeks, 
prior to the next 
course 
 
 
Myelosuppression, ataxia 
Delayed: 
Any time later during 
therapy, excluding 
the above condition 
 
 
Necrotizing leukoencephalopathy, 
paraplegia, blindness (in 
combination with XRT & systemic 
therapy) 
 
Formulation:  
Cytarabine for Injection is available in vials of 100 mg, 500 mg, 1 g, and 2 g containing a sterile powder for 
reconstitution. It is also available at a 20 mg/mL concentration with benzyl alcohol (25 mL per vial) or as a 
preservative free solution (5 mL, 50 mL per vial), and at a 100 mg/mL concentration with benzyl alcohol (20 
mL vial) or as preservative free solution (20 mL vial). Hydrochloric acid and/or sodium hydroxide may be 
added to adjust the pH. Store at 25°C (77°F); excursions permitted to 15°-30°C (59°-86°F). Cytarabine 
solutions should be protected from light. 

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130 
 
Guidelines for Administration:  See Treatment and Dose Modification sections of the protocol. 
 
IV Infusion: 
Reconstitute the lyophilized powder with Bacteriostatic Water for Injection or NS injection. Solution 
containing bacteriostatic agent should not be used for the preparation of doses > 200 mg/m2. May be further 
diluted with dextrose or sodium chloride containing solutions. May give by IV push injection, by IV infusion, 
or by continuous infusion.  
 
Low Dose (≤ 200 mg/m²/dose): For administration by IV push, reconstitute to a concentration of 20-
100 mg/mL. 
 
High Dose (≥ 1000 mg/m²/dose): Administer steroid eye drops (dexamethasone or prednisolone), 2 drops 
each eye q6h beginning immediately before the first dose and continuing 24 hours after the last dose. If patient 
does not tolerate steroid eye drops, administer artificial tears on a q2-4 hour schedule. 
 
Stability: When reconstituted with Bacteriostatic Water for Injection, cytarabine is stable for 48 hours at room 
temperature. Solutions reconstituted without a preservative should be used immediately. Discard if solution 
appears hazy. Diluted solutions in D5W or NS are stable for 8 days at room temperature; however, the diluted 
cytarabine should be used within 24 hours for sterility concerns.  
 
Intrathecal: 
For intrathecal administration, dilute with 5-10 mL (or volume per institutional practice) preservative free 
0.9% sodium chloride injection, lactated Ringer’s injection, Elliot’s B solution. The volume of CSF removed 
should be equal to at least ½ the volume delivered. 
 
Patient Age 
(years) 
Recommended 
volume 
10% CSF 
volume 
CSF Volume * 
1 – 1.99 
5–10 mL 
5 mL 
50 + 10 mL (babies) 
2 – 2.99 
5-10 mL 
8 mL 
80 + 20 mL (younger children) 
3 – 8.99 
5-10 mL 
10 mL 
100 + 20 mL (older children) 
9 or greater 
5-10 mL 
13 mL 
130 + 30 mL (adults) 
 
*Rieselbach, R.E. et.al. Subarachnoid distribution of drugs after lumbar injection; N Engl J Med. 1962 Dec 
20; 267:1273-8 
 
Of Note: Larger volumes approximating at least 10% of the CSF volume, isovolumetric delivery, with the 
patient remaining prone after the procedure may facilitate drug distribution. These procedures have not been 
validated in clinical trials. They are allowed but not mandated for patients on COG studies. 
 
Stability: Intrathecal cytarabine mixed in NS, lactated Ringer’s injection, or Elliot’s B solution is stable for 
24 hours at 25ºC but contains no preservative and should be administered as soon as possible after preparation. 
 
Supplier: Commercially available from various manufacturers. See package insert for further information. 
 
 
 

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131 
 
 
6.6 
DAUNORUBICIN  
(Daunomycin, rubidomycin, Cerubidine®) 
 
 
NSC #82151 
 
(05/09/11) 
 
Source and Pharmacology:  
Daunorubicin is an anthracycline antibiotic isolated from cultures of Streptomyces coeruleorubidus. 
Daunorubicin is closely related structurally to doxorubicin only differing in that the side chain of daunorubicin 
terminates in a methyl group rather than an alcohol. The cytotoxic effect of daunorubicin on malignant cells 
and its toxic effects on various organs are similar to those of doxorubicin and are thought to be related to 
nucleotide base intercalation and cell membrane lipid binding activities. Intercalation inhibits nucleotide 
replication and action of DNA and RNA polymerases. The interaction of daunorubicin with topoisomerase 
II to form DNA-cleavable complexes appears to be an important mechanism of cytocidal activity. 
Daunorubicin cellular membrane binding may affect a variety of cellular functions. Enzymatic electron 
reduction of daunorubicin by a variety of oxidases, reductases, and dehydrogenases generate highly reactive 
species including the hydroxyl free radical (OH•) which may lead to DNA damage or lipid peroxidation. 
Daunorubicin is metabolized more rapidly by aldoketoreductases to the active metabolite, daunorubicinol, 
than is doxorubicin. Daunorubicin hydrochloride is rapidly and widely distributed in tissues, with the 
highest levels in the spleen, kidneys, liver, lungs, and heart. Daunorubicin serum decay pattern is 
multiphasic. The initial t½ is approximately 45 minutes followed by a terminal t½ of 18.5 hours. By 1 hour 
after drug administration, the predominant plasma species is daunorubicinol, which disappears with a half-
life of 26.7 hours. Twenty five percent of an administered dose of daunorubicin is eliminated in an active 
form by urinary excretion and an estimated 40% by biliary excretion. 
 
Toxicity: 
 
Common 
Happens to 21-100 
children out of every 100 
Occasional 
Happens to 5-20 children out 
of every 100 
Rare 
Happens to < 5 children out of 
every 100 
Immediate: 
Within 1-2 days of 
receiving drug 
Nausea, vomiting, pink or 
red color to urine, sweat, 
tears, and saliva 
Hyperuricemia, sclerosis of 
the vein 
Diarrhea, anorexia, abdominal 
pain, extravasation (rare) but if 
occurs = local ulceration, 
anaphylaxis, fever, chills, rash, 
urticaria, acute arrhythmias  
Prompt: 
Within 2-3 weeks, 
prior to the next 
course 
Myelosuppression 
(leukopenia, 
thrombocytopenia, 
anemia), alopecia  
Mucositis (stomatitis and 
esophagitis), hepatotoxicity  
Radiation recall reactions, 
myocarditis-pericarditis 
syndrome, conjunctivitis and 
lacrimation 
Delayed: 
Any time later 
during therapy 
 
  
 
Cardiomyopathy1 
 (uncommon at cumulative 
doses ≤ 550 mg/m², 400 mg/m² 
with mediastinal radiation, 
300 mg/m² in children, or 
10 mg/kg in children < 2 yrs or 
0.5 m²) (L), hyper-pigmentation 
of nail beds 
Late: 
Any time after 
completion of 
treatment 
 
Subclinical cardiac 
dysfunction 
 
CHF (on long term follow up in 
pediatric patients), 
secondary malignancy (in 
combination regimens) 
Unknown 
Frequency and 
Timing:  
Fetal toxicities and teratogenic effects of daunorubicin have been noted in animals. It is 
unknown whether the drug is excreted in breast milk. 
1 Risk increases with cardiac irradiation, exposure at a young or advanced age.  
(L) Toxicity may also occur later. 

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132 
 
Formulation and Stability:  
Daunorubicin is available as red-orange lyophilized powder1 for injection in 20 mg single dose vials and a 
preservative free 5 mg/mL solution2 in 20 mg (4 mL) and 50 mg (10 mL) vials. 
¹  Each vial contains 21.4 mg of daunorubicin hydrochloride (equivalent to 20 mg of daunorubicin) and 
100 mg mannitol.                            
²  Each mL contains 5.3 mg daunorubicin hydrochloride (equivalent to 5 mg of daunorubicin), 9 mg of sodium 
chloride, sodium hydroxide or hydrochloric acid to adjust pH, and Sterile Water for Injection.  
 
Powder for Injection: 
Store unreconstituted vial at room temperature, 15°-30°C (59°-86°F). Protect from light. Retain in carton 
until contents are used. Reconstitute a 20 mg vial with 4 mL SWFI to a final concentration of 5 mg/mL. After 
adding the diluent, the vial should be shaken gently and the contents allowed to dissolve. The reconstituted 
solution is stable for 24 hours at room temperature and 48 hours refrigerated. Protect from exposure to 
sunlight.   
 
Aqueous Solution: 
Store refrigerated 2°-8°C, (36°-46°F). Protect from light. Retain in carton until contents are used. 
 
Guidelines for Administration: See Treatment and Dose Modifications sections of the protocol. 
Administer by IV side arm into a rapidly flowing infusion solution. Alternately, daunorubicin may be 
further diluted in saline or dextrose containing solutions and administered by infusion. Protect final 
preparation from light. To avoid extravasation, the use of a central line is suggested. 
 
Supplier: Commercially available from various manufacturers. See package insert for further information. 
 
6.7 
ETOPOSIDE INJECTION 
(Toposar®, VePesid®, Etopophos®,VP-16) 
NSC #141540   
 
(11/15/2016) 
 
Source and Pharmacology:  
A semisynthetic derivative of podophyllotoxin that forms a complex with topoisomerase II and DNA which 
results in single and double strand DNA breaks. Its main effect appears to be in the S and G2 phase of the 
cell cycle. The initial t½ is 1.5 hours and the mean terminal half-life is 4 to 11 hours. It is primarily excreted 
in the urine. In children, approximately 55% of the dose is excreted in the urine as etoposide in 24 hours. 
The mean renal clearance of etoposide is 7 to 10 mL/min/m² or about 35% of the total body clearance over 
a dose range of 80 to 600 mg/m². Etoposide, therefore, is cleared by both renal and non renal processes, 
i.e., metabolism and biliary excretion. The effect of renal disease on plasma etoposide clearance is not 
known. Biliary excretion appears to be a minor route of etoposide elimination. Only 6% or less of an 
intravenous dose is recovered in the bile as etoposide. Metabolism accounts for most of the non renal 
clearance of etoposide. 
 
The maximum plasma concentration and area under the concentration time curve (AUC) exhibit a high 
degree of patient variability. Etoposide is highly bound to plasma proteins (~94%), primarily serum 
albumin. Pharmacodynamic studies have shown that etoposide systemic exposure is related to toxicity. 
Preliminary data suggests that systemic exposure for unbound etoposide correlates better than total (bound 
and unbound) etoposide. There is poor diffusion into the CSF < 5%. 
 
Etoposide phosphate is a water soluble ester of etoposide which is rapidly and completely converted to 
etoposide in plasma. Pharmacokinetic and pharmacodynamic data indicate that etoposide phosphate is 
bioequivalent to etoposide when it is administered in molar equivalent doses. 
 
 

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Toxicity: 
 
Common 
Happens to 21-100 children out 
of every 100 
Occasional 
Happens to 5-20 children out of 
every 100 
Rare 
Happens to < 5 children out of every 
100 
Immediate: 
Within 1-2 days of 
receiving drug 
Nausea, vomiting 
Anorexia 
Transient hypotension during infusion; 
anaphylaxis (chills, fever, tachycardia, 
dyspnea, bronchospasm, hypotension) 
Prompt: 
Within 2-3 weeks, 
prior to next course 
Myelosuppression (anemia, 
leukopenia), alopecia 
Thrombocytopenia, diarrhea, 
abdominal pain, asthenia, 
malaise, rashes and urticaria 
Peripheral neuropathy, mucositis, 
hepatotoxicity, chest pain, 
thrombophlebitis, congestive heart 
failure, Stevens-Johnson Syndrome, 
exfoliative dermatitis 
Delayed: 
Any time later 
during therapy 
 
 
Dystonia, ovarian failure, amenorrhea, 
anovulatory cycles, hypomenorrhea, 
onycholysis of nails 
Late: 
Any time after 
completion of 
treatment 
 
 
Secondary malignancy (preleukemic 
or leukemic syndromes) 
 
Unknown 
Frequency and 
Timing:  
Fetal toxicities and teratogenic effects of etoposide have been noted in animals at 1/20th of the human dose. 
It is unknown whether the drug is excreted in breast milk. 
 
Formulation and Stability: 
Etoposide for Injection is available as a 20 mg/mL solution in sterile multiple dose vials (5 mL, 25 mL, or 
50 mL each). The pH of the clear, nearly colorless to yellow liquid is 3 to 4. Each mL contains 20 mg 
etoposide, 2 mg citric acid, 30 mg benzyl alcohol, 80 mg modified polysorbate 80/tween 80, 650 mg 
polyethylene glycol 300, and 30.5 percent (v/v) alcohol. Vial headspace contains nitrogen. Unopened vials 
of etoposide are stable until expiration date on package at controlled room temperature (20˚-25˚C or 68˚-
77˚F). 
 
Etoposide phosphate for injection is available for intravenous infusion as a sterile lyophilized powder in 
single-dose vials containing etoposide phosphate equivalent to 100 mg etoposide, 32.7 mg sodium citrate 
USP, and 300 mg dextran 40. Etoposide phosphate must be stored under refrigeration (2°-8°C or 36°-46°F). 
Unopened vials of etoposide phosphate are stable until the expiration date on the package. 
 
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol. 
 
Etoposide: 
Dilute etoposide to a final concentration ≤ 0.4 mg/mL in D5W or NS. Etoposide infusions are stable at 
room temperature for 96 hours when diluted to concentrations of 0.2 mg/mL; stability is 24 hours at room 
temperature with concentrations of 0.4 mg/mL. The time to precipitation is highly unpredictable at 
concentrations > 0.4 mg/mL. Use in-line filter during infusion secondary to the risk of precipitate 
formation. However, the use of an in-line filter is not mandatory since etoposide precipitation is unlikely at 
concentrations of 0.1-0.4 mg/mL. Do not administer etoposide by rapid intravenous injection. Slow rate 
of administration if hypotension occurs.  
 
Leaching of diethylhexyl phthalate (DEHP) from polyvinyl chloride (PVC) bags occurred with etoposide 
0.4mg/mL in NS. To avoid leaching, prepare the etoposide solution as close as possible, preferably within 
4 hours, to the time of administration or alternatively as per institutional policy; glass or polyethylene-lined 
(non-PVC) containers and polyethylene-lined tubing may be used to minimize exposure to DEHP. 
 
Etoposide Phosphate: 

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134 
Reconstitute the 100 mg vial with 5 or 10 mL of Sterile Water for Injection, D5W, NS, Bacteriostatic Water 
for Injection with Benzyl Alcohol, or Bacteriostatic Sodium Chloride for Injection with Benzyl Alcohol for 
a concentration equivalent to 20 mg/mL or 10 mg/mL etoposide equivalent (22.7 mg/mL or 11.4 mg/mL 
etoposide phosphate), respectively. Use diluents without benzyl alcohol for neonates and infants 
< 2 years of age or patients with hypersensitivity to benzyl alcohol.  
 
When reconstituted as directed, etoposide phosphate solutions can be stored in glass or plastic containers 
under refrigeration for 7 days. When reconstituted with a diluent containing a bacteriostat, store at 
controlled room temperature for up to 48 hours. Following reconstitution with SWFI, D5W, or NS store at 
controlled room temperature for up to 24 hours. 
 
Following reconstitution, etoposide phosphate may be further diluted to a concentration as low as 
0.1 mg/mL of etoposide with D5W or NS. The diluted solution can be stored under refrigeration or at 
controlled room temperature for 24 hours. 
 
Supplier:  
Commercially available from various manufacturers. See package insert for more detailed information. 
 
CANADIAN SITES 
Etoposide for Injection is available as a 20 mg/mL solution. 
 
Etopophos® (etoposide phosphate) is not commercially available in Canada. Sites may purchase and import 
the USA commercial supply from Bristol Laboratories via an International Distributor (Pharma Exports 
LLC, phone: 1-412-885-3700, fax: 1-412-885-8022, email: pharexp@aol.com) under the authority of the 
protocol’s No Objection Letter (NOL). Drug Accountability Log (DAL) must record Lot #’s and expiry 
dates of shipments received and doses dispensed. Sites may use their own DAL as long as it complies with 
all elements of ICH GCP and Division 5 of the Food and Drugs Act. Each site is responsible for the 
procurement (import +/- purchase) of Etoposide Phosphate (Etopophos). Sites may import and manage a 
single clinical trial supply for multiple protocols as long as each protocol has an NOL and the protocol the 
patient is registered on is recorded on the DAL.   
 
6.8 
FLUDARABINE  
(Fludara®, fludarabine phosphate, 2-fluoro-ara-AMP) NSC# 312887  
 
 
(05/09/11) 
 
Source and Pharmacology:  
Fludarabine phosphate is a synthetic purine nucleoside. It differs from the physiologic nucleosides, 
adenosine, in that the sugar moiety is arabinose instead of ribose, and by the addition of a fluorine atom to 
the purine base adenine. Fludarabine is also a fluorinated nucleotide analog the antiviral agent vidarabine, 
(ara-A). The addition of fluorine results in increased aqueous solubility and resistance to enzymatic 
degradation by adenosine deaminase. Fludarabine (2-fluoro-ara-A) is commercially available as the 
monophosphate salt (2-fluoro-ara-AMP). The monophosphorylation increases the drug's aqueous solubility 
while maintaining pharmacologic activity. The chemical name for fludarabine phosphate is 9H-Purin-6-
amine, 2-fluoro-9-(5-0-phosphono β-D-arabino-furanosyl) (2-fluoro-ara-AMP) and the molecular weight 
is 365.2.  
 
Fludarabine is a purine antagonist antimetabolite. In vivo, fludarabine phosphate is rapidly 
dephosphorylated to 2-fluoro-ara-A and then it is phosphorylated intracellularly by deoxycytidine kinase 
to the active triphosphate, 2-fluoro-ara-ATP. This metabolite appears to act by inhibiting DNA polymerase 
alpha, ribonucleotide reductase and DNA primase, thus inhibiting DNA synthesis. The mechanism of action 
of this antimetabolite is not completely characterized and may be multi-faceted. 
 

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135 
Phase I studies in humans have demonstrated that within several minutes after intravenous infusion, 
fludarabine phosphate is converted to the active metabolite, 2-fluoro-ara-A and becomes undetectable. 
Therefore, pharmacokinetics studies have focused on 2-fluoro-ara-A. Fludarabine phosphate 25 mg/m2 
infused intravenously over 30 minutes to adult cancer patients, showed a moderate accumulation of 2-
fluoro-ara-A. During a 5-day treatment schedule, 2-fluoro-ara-A plasma trough levels increased by a factor 
of about 2.  
Fludarabine is widely distributed. The volume of distribution at steady state (Vss) reported after daily 
administration of 25mg/m2 for 5 days to adults averaged at 96-98 L/m2. Tissue distribution studies in 
animals indicate that the highest concentrations of the drug are in liver, kidney, and spleen. Although the 
extent to which fludarabine and/or its metabolites distribute into the CNS in humans has not been 
determined to date, severe neurologic toxicity (e.g., blindness, coma) has been reported in patients receiving 
the drug, particularly in high dosages. There is evidence from animal studies that fludarabine distributes 
into the CNS and that a toxic metabolite (2-fluoroadenine, possibly formed by bacteria in the GI tract), can 
be absorbed systematically via enterohepatic circulation and distributed into CSF. According to in vitro 
data, about 19-29% of fludarabine is bound to plasma proteins.  
Following IV administration, fludarabine phosphate is dephosphorylated rapidly to fludarabine. Plasma 
concentrations of fludarabine decline in a linear, dose-independent manner. The elimination profile of 
fludarabine also has been reported to be either biphasic or triphasic; however, reported terminal elimination 
half-lives have been similar. In adult cancer patients receiving fludarabine 25 mg/m2 as a 30-minute IV 
infusion daily for 5 days, a terminal half-life of about 20 hours was reported. In a limited number of pediatric 
patients, the plasma concentration profile of fludarabine exhibited both monoexponential and biexponential 
decay, with a mean t1/2 of 10.5 hours in patients with monoexponential elimination and a t1/2 of 1.2-1.4 and 
12.4-19 hours, respectively, in patients with biexponential elimination.  
Renal clearance accounts for about 40% of the total body clearance of fludarabine. Renal elimination 
appears to become more important at high dosages of the drug. The dose of fludarabine needs to be adjusted 
in patients with moderate renal impairment. 
The use of fludarabine in combination with pentostatin is not recommended due to the risk of severe 
pulmonary toxicity. 
 
 
Toxicity: 
 
 
Common 
Happens to 21-100 
subjects out of every 100 
Occasional 
Happens to 5-20 subjects 
out of every 100 
Rare 
Happens to < 5 subjects out of every 
100 
Immediate: 
Within 1-2 days 
of receiving drug 
Fever, fatigue, weakness, 
pain, nausea, vomiting, 
anorexia, cough, dyspnea 
Edema including peripheral 
edema, chills, rash, diarrhea, 
rhinitis, diaphoresis, 
malaise, abdominal pain, 
headache, back pain, 
myalgia, stomatitis, flu-like 
syndrome 
Anaphylaxis, tumor lysis syndrome, 
dehydration*  
Prompt: 
Within 2-3 
weeks, prior to 
next course 
Myelosuppression 
(anemia, neutropenia, 
thrombocytopenia), 
infection (urinary tract 
infection, herpes simplex 
infection, pneumonia, 
upper respiratory) 
Weight loss, gastrointestinal 
bleeding, hemoptysis, 
paresthesia, allergic 
pneumonitis, bronchitis, 
pharyngitis, visual 
disturbance, hearing loss, 
hyperglycemia  
Sinusitis, dysuria, opportunistic 
infections and reactivation of latent 
viral infections like Epstein-Barr virus 
(EBV), herpes zoster and John 
Cunningham (JC) virus (progressive 
multifocal leukoencephalopathy 
[PML])L, EBV associated 
lymphoproliferative disorder, 
panycytopenia (can be prolonged), 

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136 
 
Common 
Happens to 21-100 
subjects out of every 100 
Occasional 
Happens to 5-20 subjects 
out of every 100 
Rare 
Happens to < 5 subjects out of every 
100 
pulmonary hypersensitivitya (dyspnea, 
cough, hypoxia, interstitial pulmonary 
infiltrate), pulmonary toxicity (acute 
respiratory distress syndrome [ARDS], 
pulmonary fibrosis, pulmonary 
hemorrhage, respiratory distress, 
respiratory failure), pericardial 
effusion, skin toxicity (erythema 
multiforme, Stevens-Johnson 
syndrome, toxic epidermal necrolysis, 
pemphigus), liver failure, renal failure, 
hemorrhage, transfusion-associated 
graft-versus-host disease has occurred 
following transfusion of nonirradiated 
blood products, phlebitis*, sleep 
disorder*, cerebellar syndrome*, 
depression*, mentation impaired*, 
alopecia*, pruritus*, seborrhea*, 
esophagitis*, constipation*, 
mucositis*, dysphagia*, hesitancy*, 
cholelithiasis*, abnormal liver function 
tests *, osteoporosis*, arthralgia*, 
abnormal renal function test*, 
proteinuria*, epistaxis*, hemorrhagic 
cystitis*, eosinophilia*  
Delayed: 
Any time later 
during therapy, 
excluding the 
above conditions 
 
 
Neurotoxicity (increased with high 
doses): seizures, agitation, confusion, 
weakness, visual disturbances, optic 
neuritis, optic neuropathy, photophobia, 
blindness, paralysis, coma, death, 
peripheral neuropathya); autoimmune 
phenomena: 
thrombocytopenia/thrombocytopenic 
purpura (ITP), Evans syndrome, 
hemolytic anemia, acquired hemophilia 
Late: 
Any time after 
completion of 
treatment 
 
 
Myelodysplastic syndrome/acute 
myeloid leukemia (mainly associated 
with prior or concomitant or subsequent 
treatment with other anticancer 
treatments), skin cancer (new onset or 
exacerbation) 
Unknown 
Frequency and 
Timing: 
Pregnancy Category D  
Based on its mechanism of action, fludarabine phosphate can cause fetal harm when 
administered to a pregnant woman. Fludarabine phosphate was embryolethal and teratogenic in 
both rats and rabbits. 
 (L) Toxicity may also occur later. 
* Reported in ≤ 3% of subjects. Since these are not considered life threatening they are not included in the consent. 
a These effects were not reported in children. 
 
Formulation and Stability: 
Fludarabine phosphate injection is available as sterile lyophilized powder and in solution. Each single-dose 
vial of powder contains 50 mg of the active ingredient fludarabine phosphate, 50 mg of mannitol, and 

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sodium hydroxide to adjust the pH to 7.7. After reconstitution, the pH range for the final product is 7.2-8.2. 
The single-dose solution vial contains 25 mg/mL, 2 mL of fludarabine phosphate. It may contain mannitol 
and is preservative-free.  
Fludarabine phosphate vials should be stored refrigerated at 2-8ºC (36-46ºF). 
 
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol. 
Prior to administration fludarabine phosphate powder should be reconstituted with Sterile Water for 
Injection and further diluted in D5W or NS to a concentration of 10 – 25 mg/mL. Fludarabine 25 mg/mL 
solution should be further diluted in the same manner. 
Fludarabine phosphate powder should be reconstituted with 2 mL of Sterile Water for Injection. The solid 
cake should fully dissolve in 15 seconds or less. The resulting concentration is 25 mg/mL. When 
reconstituted to a final concentration of 25 mg/mL, the drug is stable for at least 16 days at room temperature 
and normal light conditions. The manufacturer recommends that the solution be used within 8 hours after 
reconstitution. 
Prior to administration, fludarabine 25 mg/mL solution or the reconstituted 25 mg/mL solution should be 
further diluted in 100 mL or 125 mL of D5W or NS. When diluted to a final concentration of 1 mg/mL, 
fludarabine is stable for at least 16 days at room temperature and normal light conditions. The manufacturer 
recommends that the diluted solution be used within 8 hours after preparation. Parenteral drug products 
should be inspected visually for particulate matter and discoloration prior to administration. 
 
Supplier:  Commercially available from various manufacturers. See package insert for further information. 
 
6.9 
LYMPHOCYTE IMMUNE GLOBULIN  
(Antithymocyte globulin (equine), ATG, Atgam®) NSC# 743145 
 
 
(05/09/11) 
 
Source and Pharmacology:  
Lymphocyte immune globulin is a purified concentrated sterile gamma globulin (primarily monomeric IgG) from 
hyper immune serum of horses immunized with human thymus lymphocytes. It has a molecular weight of between 
150,000 to 160,000 Daltons. Lymphocyte immune globulin is a lymphocyte-selective immunosuppressant, 
demonstrated by its ability to reduce the number of circulating thymus-dependent lymphocytes that form rosettes with 
sheep erythrocytes. This anti-lymphocytic effect is believed to alter the function of lymphocytes which are responsible 
in part for cell mediated immunity and are involved in humoral immunity. When given in combination with other 
immunosuppressive therapy (antimetabolites and corticosteroids) the patient's antibody response to horse IgG is 
minimal. Lymphocyte Immune Globulin administered with other immunosuppressive therapy and measured as horse 
IgG has a serum half-life of 5.7 ±3 days. Peak plasma levels are reached after 5 days of infusions. These levels can 
vary depending on the individual's ability to metabolize foreign IgG. Distribution is poor into lymphoid tissues. 
Lymphocyte Immune Globulin binds to circulating lymphocytes, granulocytes, platelets, and bone marrow cells. 
Approximately 1% of the dose is excreted in the urine. 
 
Toxicity: 
 
Common 
Happens to 21-100 children 
out of every 100 
Occasional 
Happens to 5-20 children out of 
every 100 
Rare 
Happens to < 5 children out of every 100 
Immediate: 
Within 1-2 days of 
receiving drug 
Fever, rash, dyspnea 
Chills, apnea, pain (chest, back or 
flank), diarrhea, nausea, vomiting, 
pruritus, urticaria 
Anaphylaxis, laryngospasm, 
hypertension, hypotension, syncope, 
dizziness, tachycardia, pulmonary 
edema, diaphoresis, swelling, redness or 
phlebitis at the infusion site (peripheral 
veins), extravasation (rare) but if occurs 
= local ulceration headache, malaise, 
seizures, epigastric pain 
Prompt: 
Thrombocytopenia 
(transient) 
Leukopenia, infection, abnormal 
renal function tests  
Hemolysis (rarely clinically significant), 
hyperglycemia, sore mouth or throat, 
thrombosis, HSV or other viral infection, 

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138 
Within 2-3 weeks, 
prior to next 
course 
edema, eosinophilia, abnormal liver 
function test, CHF, vasculitis, arthralgia, 
myalgia, paresthesias 
Delayed: 
Any time later 
during therapy, 
excluding the 
above conditions 
 
Serum sickness (L ) which can 
have all or some of the following 
symptoms: glomerulonephritis, 
fever, myalgia, arthralgia and 
periorbital edema – incidence 
reduced with use with 
corticosteroid premedication 
GI bleeding or perforation, acute renal 
failure  
Unknown 
Frequency and 
Timing: 
Animal reproduction studies have not been conducted with lymphocyte immune globulin. It is not 
known whether lymphocyte immune globulin can cause fetal harm when administered to a pregnant 
woman or affect reproductive capacity.  It is unknown whether the drug is excreted in breast milk. 
(L) Toxicity may also occur later. 
 
Formulation and Stability: Each milliliter of Lymphocyte Immune Globulin contains 50 mg of horse 
gamma globulin stabilized in 0.3 molar glycine to a pH of approximately 6.8 (available in 5 mL vials). It 
may appear colorless to faintly pink or brown and is nearly odorless. It may develop a slight granular or 
flaky deposit during storage. Store in a refrigerator at 2°-8°C (36°-46°F). DO NOT FREEZE. 
 
 
Guidelines for Administration:  
Lymphocyte Immune Globulin (diluted or undiluted) should not be shaken because excessive foaming 
and/or denaturation of the protein may occur. Lymphocyte Immune Globulin may be added to NS or 
dextrose/saline containing solutions. Do not add to dextrose alone as low salt concentrations may result in 
precipitation. Add Lymphocyte Immune Globulin to an inverted bottle of sterile vehicle so the undiluted 
Lymphocyte Immune Globulin does not contact the air inside. The concentration should not exceed 
4 mg/mL. The diluted solution should be gently rotated or swirled to effect thorough mixing. Store diluted 
solution in the refrigerator until use. The diluted solution should be allowed to reach room temperature 
before infusion. Once diluted, Lymphocyte Immune Globulin has been shown to be physically and 
chemically stable for up to 24 hours at concentrations of up to 4 mg/mL. Lymphocyte Immune Globulin is 
appropriately administered into a vascular shunt, arterial venous fistula, or a high-flow central vein through 
an in-line filter with a pore size of 0.2 to 1.0 micron. The in-line filter should be used with all infusions to 
prevent the administration of any insoluble material that may develop in the product during storage. The 
use of high-flow veins will minimize the occurrence of phlebitis and thrombosis. Do not infuse a dose in 
less than 4 hours.  
 
Pretreat patient with an antipyretic, antihistamine, and/or corticosteroid to prevent chills, fever, itching, and 
erythema. Always keep appropriate resuscitation equipment at the patient’s bedside while Lymphocyte 
Immune Globulin is being administered. Observe the patient continuously for possible allergic reactions 
throughout the infusions. 
 
Skin Testing 
Before the first infusion of Lymphocyte Immune Globulin, Pharmacia & Upjohn Company strongly 
recommend that patients be tested with an intradermal injection of 0.1 mL of a 1:1,000 dilution (5 mcg 
horse IgG) of Lymphocyte Immune Globulin in NS and a contralateral NS injection control. Use only 
freshly diluted Lymphocyte Immune Globulin for skin testing. The patient, and specifically the skin test, 
should be observed every 15 to 20 minutes over the first hour after intradermal injection. A local reaction 
of 10 mm or greater with a wheal or erythema, or both, with or without pseudopod formation and itching 
or a marked local swelling should be considered a positive test. Note: The predictive value of this test has 
not been proved clinically. Allergic reactions such as anaphylaxis have occurred in patients whose skin test 
is negative. In the presence of a locally positive skin test, the risk to benefit ratio must be carefully weighed. 
 
Supplier: Commercially available from various manufacturers. See package insert for further information.  
 

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139 
 
6.10 
METHOTREXATE-IV ONLY  
(MTX, amethopterin) NSC #000740 
 
 
 
 
 
 
(02/29/12) 
 
Source and Pharmacology:  
A folate analogue which reversibly inhibits dihydrofolate reductase, the enzyme that reduces folic acid to 
tetrahydrofolic acid. Inhibition of tetrahydrofolate formation limits the availability of one carbon fragments 
necessary for the synthesis of purines and the conversion of deoxyuridylate to thymidylate in the synthesis of 
DNA and cell reproduction. The polyglutamated metabolites of MTX also contribute to the cytotoxic effect 
of MTX on DNA repair and/or strand breaks. MTX cytotoxicity is highly dependent on the absolute drug 
concentration and the duration of drug exposure. MTX is actively transported across cell membranes. At 
serum methotrexate concentrations exceeding 0.1 µmol/mL, passive diffusion becomes a major means of 
intracellular transport of MTX. The drug is widely distributed throughout the body with the highest 
concentration in the kidney, liver, spleen, gallbladder and skin. Plasma concentrations following high dose IV 
MTX decline in a biphasic manner with an initial half-life of 1.5-3.5 hours, and a terminal half life of 
8-15 hours. About 50% is bound to protein. MTX is excreted primarily by the kidneys via glomerular filtration 
and active secretion into the proximal tubules. Renal clearance usually equals or exceeds creatinine clearance. 
Small amounts are excreted in the feces. There is significant entero-hepatic circulation of MTX. The 
distribution of MTX into third-space fluid collections, such as pleural effusions and ascitic fluid, can 
substantially alter MTX pharmacokinetics. The slow release of accumulated MTX from these third spaces 
over time prolongs the terminal half-life of the drug, leading to potentially increased clinical toxicity.  
 
Toxicity: 
 
Common 
Happens to 21-100 
children out of every 100 
Occasional 
Happens to 5-20 children 
out of every 100 
Rare 
Happens to <5 children out of every 
100 
Immediate: 
Within 1-2 days of 
receiving drug 
Transaminase elevations 
Nausea, vomiting, 
anorexia 
Anaphylaxis, chills, fever, dizziness, 
malaise, drowsiness, blurred vision, 
acral erythema, urticaria, pruritis, 
toxic epidermal necrolysis, Stevens-
Johnson Syndrome, tumor lysis 
syndrome, seizures1, photosensitivity 
Prompt: 
Within 2-3 weeks, prior to 
the next course 
 
Myelosuppression, 
stomatitis, gingivitis, 
photosensitivity, fatigue 
Alopecia, folliculitis, acne, renal 
toxicity (ATN, increased 
creatinine/BUN, hematuria), enteritis, 
GI ulceration and bleeding, acute 
neurotoxicity1 (headache, drowsiness, 
aphasia, paresis, blurred vision, 
transient blindness, dysarthria, 
hemiparesis, decreased reflexes) 
diarrhea, conjunctivitis 
Delayed: 
Any time later during 
therapy, excluding the 
above conditions 
 
Learning disability1 (L) 
Pneumonitis, pulmonary fibrosis (L), 
hepatic fibrosis (L), osteonecrosis 
(L), leukoencephalopathy1 (L), 
pericarditis, pericardial effusions, 
hyperpigmentation of the nails 
Late: 
Any time after the 
completion of therapy 
 
 
Progressive CNS deterioration1 
Unknown Frequency and 
Timing:   
Methotrexate crosses the placenta. Fetal toxicities and teratogenic effects of methotrexate 
have been noted in humans. The toxicities include: congenital defects, chromosomal 
abnormalities, severe newborn myelosuppression, low birth weight, abortion, and fetal death.  
Methotrexate is excreted into breast milk in low concentrations. 
1 May be enhanced by HDMTX and/or cranial irradiation. 
 (L) Toxicity may also occur later. 

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140 
 
Formulation and Stability:  
Methotrexate for Injection is available as a lyophilized powder for injection in 1000 mg vials. The powder 
for injection contains approximately 7 mEq sodium in the 1000 mg vial. Methotrexate for Injection is also 
available as a 25 mg/mL solution in 2, 4, 8, 10, and 40 mL preservative free vials and 2 and 10 mL vials 
with preservative. The 2, 4, 8, 10, and 40 mL solutions contain approximately 0.43, 0.86, 1.72, 2.15, and 
8.6 mEq sodium per vial, respectively. The preserved vials contain 0.9% benzyl alcohol as a preservative. 
 
Sterile methotrexate powder or solution is stable at 20º-25ºC (68º-77ºF); excursions permitted to 15º-30ºC 
(59º- 86 Fº). Protect from light. 
 
Guidelines for Administration: See Treatment and Dose Modifications sections of protocol. Leucovorin 
rescue may be necessary with certain doses of methotrexate. 
 
For IV use: Powder for injection: Dilute 1000 mg vial with 19.4 mL of preservative free SWFI, D5W or 
NS to a 50 mg/mL concentration. The powder for injection may be further diluted in NS or dextrose 
containing solutions to a concentration of ≤ 25mg/mL for IV use. 
 
Do not use the preserved solution for high dose methotrexate administration due to risk of benzyl 
alcohol toxicity. Methotrexate dilutions are chemically stable for at least 7 days at room temperature but 
contain no preservative and should be used within 24 hours. Diluted solutions especially those containing 
bicarbonate exposed to direct sunlight for periods exceeding 4 hours should be protected from light. 
 
High dose Methotrexate requires alkalinization of the urine, adequate hydration and leucovorin rescue.  Avoid 
probenecid, penicillins, cephalosporins, aspirin, proton pump inhibitors, and NSAIDS as renal excretion of 
MTX is inhibited by these agents. 
 
Supplier: Commercially available from various manufacturers. See package insert for further information.  
 
6.11 
METHYLPREDNISOLONE(Solu-Medrol®, 
A-Methapred®, 
Medrol®) 
NSC 
#19987
 
(05/09/11) 
 
Source and Pharmacology:  
Methylprednisolone is a corticosteroid and the methyl derivative of prednisolone. Glucocorticoids produce 
widespread and diverse physiologic effects on carbohydrate, protein, and lipid metabolism, electrolyte and 
water balance, functions of the cardiovascular system, kidney, skeletal muscle, and the nervous systems. 
Glucocorticoids reduce the concentration of thymus-dependent lymphocytes (T-lymphocytes), monocytes, 
and eosinophils. Glucocorticoids selectively bind to the cortisol receptors on human lymphoid cells which 
are found in larger numbers on leukemic lymphoblasts. They also decrease binding of immunoglobulin to 
cell surface receptors and inhibit the synthesis and/or release of interleukins, thereby decreasing T-
lymphocyte blastogenesis and reducing expansion of the primary immune response. The specific cellular 
mechanisms that act to halt DNA synthesis are thought to be related to inhibition of glucose transport or 
phosphorylation, retardation of mitosis, and inhibition of protein synthesis. At the cellular level, 
corticosteroids appear to act by controlling the rate of protein synthesis. The half-life of methylprednisolone 
is approximately 2.5 hours; however, the metabolic effects at the tissue level persist for up to 20-30 hours. It 
is primarily metabolized in the liver and excreted by the kidneys. Methylprednisolone 4 mg has equivalent 
potency to prednisone 5mg.  
 
 
 

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141 
 
Toxicity: 
 
Common 
Happens to 21-100 children out 
of every 100 
Occasional 
Happens to 5-20 children 
out of every 100 
Rare 
Happens to <5 children out of every 
100 
Immediate: 
Within 1-2 days of 
receiving drug 
Insomnia, hyperphagia 
Gastritis 
Anaphylaxis, cardiac Arrhythmias, 
urticaria hyperuricemia,  
 
Prompt: 
Within 2-3 weeks, 
prior to the next 
course 
Immunosuppression, personality 
changes (mood swings, 
euphoria, anxiety, depression), 
pituitary-adrenal axis 
suppression, acne (L) 
Hyperglycemia, facial 
erythema, poor wound 
healing, infections 
(bacterial, fungal, 
parasitic, viral), edema 
 
Pancreatitis (L), electrolyte 
imbalance (Na retention, 
hypokalemia, hypocalcemia)(L), 
increased intraocular pressure (L), 
hypertension, psychosis, vertigo; 
headache 
Delayed: 
Any time later 
during therapy 
Cushing’s syndrome (moon 
facies, truncal obesity) 
striae and thinning of the 
skin, easy bruising, 
muscle weakness, 
osteopenia  
Spontaneous fractures (L), growth 
suppression, peptic ulcer and GI 
bleeding, pseudo tumor cerebri 
(increased intracranial pressure with 
papilledema, headache), aseptic 
necrosis of the femoral and humeral 
heads (L) 
Late: 
Any time after 
completion of 
treatment 
 
Cataracts (which may be 
reversible on 
discontinuation in 
children) 
 
Unknown 
Frequency and 
Timing: 
Fetal and teratogenic toxicities: Corticosteroids cross the placenta. In animal studies, large doses 
of cortisol administered early in pregnancy produced cleft palate, stillborn fetuses, and decreased 
fetal size. Chronic maternal ingestion during the first trimester has shown a 1% incidence of cleft 
palate in humans. Other studies have found no anomalies and neonatal adrenal insufficiency 
appears to be rare. Methylprednisolone is excreted into breast milk in humans; however, several 
studies suggest that amounts excreted in breast milk are negligible with methylprednisolone doses 
of < 8 mg/day.   
(L) Toxicity may also occur later. 
 
Formulation and Stability:  
Methylprednisolone is available for oral use in 2, 4, 8, 16, and 32 mg tablets. Inactive ingredients vary 
depending on manufacturer but tablet formulations may include: calcium stearate, corn starch, erythrosine 
sodium, lactose, mineral oil, sorbic acid, sucrose, croscarmellose sodium, lactose monohydrate, magnesium 
stearate, microcrystalline cellulose, polacrilin potassium, sodium starch glycolate, and stearic acid. 
 
Lyophilized Powder for Injection as methyprednisolone sodium succinate equivalent to methylprednisolone 
is available as: Dual chamber vials of 40 mg (1 mL), 125 mg (2 mL), 500 mg (4 mL), 1000 mg (8 mL) 
also containing mono, dibasic sodium phosphate and benzyl alcohol (diluent); Vials of 500 mg, 1 g, 2 g 
also containing monobasic and dibasic sodium phosphate with or without separate vials of diluent 
containing benzyl alcohol. Protect from light. 
 
Store unreconstituted product at controlled room temperature 20°- 25°C (68°- 77°F).  
 
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol. 
 
Only the sodium succinate formulation may be given intravenously. The acetate salt should NOT be given 
intravenously. 
 

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142 
Dilute lyophilized powder vials for injection with sufficient diluent to obtain a concentration of 
62.5 mg/mL. The manufacturer recommends the use of Bacteriostatic sterile water for injection containing 
benzyl alcohol. Use sterile water for injection without benzyl alcohol for neonates and infants < 2 years 
of age or patients with hypersensitivity to benzyl alcohol. 
 
Mix dual chamber vials as directed. Store solution at controlled room temperature 20°-25°C (68°-77°F). Use 
solution within 48 hours after mixing. 
 
May be further diluted in Saline or Dextrose containing solutions for intravenous administration.  
 
Supplier: Commercially available from various sources. See package insert for further information  
 
6.12 
MITOXANTRONE  
(Novantrone®, CL 232315, DAD, DHAD, Mitozantrone) NSC #301739  
 
(07/14/15) 
 
Source and Pharmacology: 
Mitoxantrone is a substituted alkylaminoanthraquinone and is a potent inhibitor of DNA and RNA synthesis 
in vitro and binds strongly to DNA. Mitoxantrone most likely acts through intercalation between base pairs 
of the DNA double helix causing crosslinks and strand breaks. In addition, it is a topoisomerase II inhibitor, 
an enzyme responsible for uncoiling and repairing damaged DNA. It has a cytocidal effect on both 
proliferating and non-proliferating cultured human cells, suggesting lack of cell cycle phase specificity. The 
drug disappears rapidly from plasma (drug found only in the 3-minute sample) and < 1% appears in the urine 
in 24 hours. The mean alpha half-life of mitoxantrone is 6 to 12 minutes, the mean beta half-life is 1.1 to 
3.1 hours and the mean gamma (terminal or elimination) half-life is 23 to 215 hours (median approximately 
75 hours). Primary excretion is biliary with 25% appearing in the feces; renal excretion accounting for only 
11% of the total dose. Mitoxantrone clearance is reduced by hepatic impairment. Patients with severe hepatic 
dysfunction (bilirubin > 3.4 mg/dL) have an AUC more than three times greater than that of patients with 
normal hepatic function receiving the same dose. Mitoxantrone is approximately 95% protein bound. 
 
 
Toxicity 
 
Common 
Happens to 21-100 children 
out of every 100 
Occasional 
Happens to 5-20 children out 
of every 100 
Rare 
Happens to < 5 children out of 
every 100 
Immediate: 
Within 1-2 days of 
receiving drug 
Nausea, vomiting, diarrhea, 
fever, anorexia, green blue 
discoloration of the urine 
and/or sclera 
Abdominal pain, back pain, 
headache, phlebitis, 
constipation 
Anaphylaxis, angioedema, cardiac 
arrhythmias1 (bradycardia), 
seizures, extravasation reactions 
rare but if occur can lead to: 
(erythema, swelling, pain, burning 
and/or blue discoloration of the 
skin and rarely tissue necrosis), 
tumor lysis 
Prompt: 
Within 2-3 weeks, prior to 
the next course 
Myelosuppression (L), 
mucositis /stomatitis, 
immunosuppression, 
alopecia, fatigue  
Transient elevation of LFTs, 
pruritus with desquamation of 
the skin due to progressive 
dryness 
Rash, conjunctivitis, (GI) 
hemorrhage, interstitial 
pneumonitis 
Delayed: 
Any time later during 
therapy 
Amenorrhea, menstrual 
disorders, temporary 
reduction in sperm count 
Cardiotoxicity (decreased 
LVEF)2 (L) 
CHF, hepatotoxicity 
Late: 
Any time after completion 
of treatment 
 
 
Secondary malignancy 

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143 
Unknown Frequency and 
Timing:  
Fetal toxicities and teratogenic effects of mitoxantrone have been noted in animals. Toxicities 
include: low birth weight and prematurity. Mitoxantrone is excreted in human milk and 
significant concentrations (18 ng/mL) have been reported for 28 days after the last 
administration. 
1 Rarely clinically significant. 
2 Risk increases with chest radiation and prior anthracycline dosage 
(L) Toxicity may also occur later. 
 
Formulation and Stability: 
The concentrate is a sterile, non-pyrogenic, non-preserved, dark blue aqueous solution containing 
mitoxantrone hydrochloride equivalent to 2 mg/mL mitoxantrone free base, with sodium chloride 
(0.80% w/v), sodium acetate (0.005% w/v), and acetic acid (0.046% w/v) as inactive ingredients with 
0.14 mEq of sodium per mL. Mitoxantrone is provided as 20 mg (10 mL), 25 mg (12.5 mL) and 30 mg 
(15 mL) vials. Store intact vials at 15°-25°C (59°-77°F). Undiluted mitoxantrone injection should be stored 
not longer than 7 days between 15°-25°C (59°-77°F) or 14 days under refrigeration. Refrigeration of the 
concentrate may result in a precipitate, which redissolves on warming to room temperature. DO NOT 
FREEZE.  
 
Guidelines for Administration: See Treatment and Dose Modifications sections of the protocol. 
 
Mitoxantrone must be diluted prior to injection. DO NOT GIVE IV PUSH. The dose of mitoxantrone 
should be diluted in at least 50 mL or to a concentration ≤ 0.5 mg/mL with either NS or D5W. The dilution 
is stable at room temperature for 48 hours with no loss of potency. Admixture with heparin may result in 
precipitation. Mitoxantrone is an irritant: Care should be taken to avoid extravasation; the use of a central 
line is suggested. If it is known or suspected that subcutaneous extravasation has occurred, it is 
recommended that intermittent ice packs be placed over the area of extravasation and that the affected 
extremity be elevated. Because of the progressive nature of extravasation reactions, the area of injection 
should be frequently examined and surgery consultation obtained early if there is any sign of a local 
reaction. 
 
Supplier: Commercially available. See package insert for more detailed information. 
 
Special precautions: Incompatible with heparin; precipitation may form 
 
 
6.13 
SORAFENIB TOSYLATE 
(BAY 43-9006 tosylate, BAY 54-9085 Nexavar®)  
NSC# 724772, IND#114480 
(03/05/2017) 
 
Source and Pharmacology: Sorafenib tosylate has the chemical name:  
4-(4-{3-[4-Chloro-3-(trifluoromethyl)phenyl]ureido}phenoxy)N2-methylpyridine-2-carboxamide 
4-methylbenzenesulfonate. Sorafenib is a kinase inhibitor that decreases tumor cell proliferation in vitro. 
Sorafenib was shown to inhibit multiple intracellular (CRAF, BRAF and mutant BRAF) and cell surface 
kinases (KIT, FLT-3, RET, VEGFR-1, VEGFR-2, VEGFR-3, and PDGFR-ß). Several of these kinases are 
thought to be involved in tumor cell signaling, angiogenesis, and apoptosis. Sorafenib inhibited tumor 
growth and angiogenesis of human hepatocellular carcinoma, human renal cell carcinoma, and several other 
human tumor xenografts in immunocompromised mice. 
 
In previously conducted clinical trials, sorafenib was predominantly administered as sorafenib tosylate 
(BAY 54-9085) tablets, however the dosage of sorafenib is expressed as free base sorafenib (BAY 43-
9006). The conversion factor between the free base sorafenib and the tosylate salt is 1.3705. No conversion 
should be used when calculating the dose in this clinical trial.  
 

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The mean relative bioavailability of sorafenib administered as an oral tablet was 38–49% when compared 
to an oral solution. Pharmacokinetics studies in adults who received oral sorafenib showed that sorafenib 
reaches peak plasma levels in approximately 3 hours. When given with a moderate-fat meal (30% fat; 700 
calories), the bioavailability was similar to that in the fasted state, however, with a high-fat meal (50% fat; 
900 calories), sorafenib bioavailability was reduced by 29% compared to administration in the fasted state. 
Therefore, it is recommended that sorafenib be administered without food.  
 
The mean maximum plasma concentration (Cmax) and area under the concentration curve (AUC) increased 
less than proportionally when doses greater than 400 mg are given orally twice daily. In vitro binding of 
sorafenib to human plasma proteins is 99.5%. 
 
Sorafenib is metabolized mainly in the liver through oxidation by cytochrome P-450 (CYP) isoenzyme 
3A4, and glucuronidation by uridine diphosphate-glucuronosyltransferase (UGT) 1A9. Sorafenib 
accounted for approximately 70–85% of the circulating analytes in plasma at steady state. Eight metabolites 
of sorafenib have been identified. The primary metabolite, a pyridine N-oxide derivative, is 
pharmacologically active, shows in vitro potency similar to that of sorafenib, and accounts for 
approximately 9-16% of total plasma concentrations of the drug. Approximately 77% of an oral dose of 
sorafenib is excreted in feces; 19% is eliminated in urine as glucuronidated metabolites. Unchanged 
sorafenib is recovered in feces and accounts for 51% of a single dose. No unchanged sorafenib is recovered 
in the urine. 
 
The mean elimination half-life of sorafenib is approximately 25 to 48 hours. Multiple dosing of sorafenib 
for 7 days resulted in a 2.5 to 7-fold accumulation compared to single dose administration. Steady-state 
plasma sorafenib concentrations are achieved within 7 days, with a peak-to-trough ratio of mean 
concentrations of less than 2.   
 
A study of the pharmacokinetics of sorafenib indicated that the mean AUC of sorafenib in Asians (N=78) 
was 30% lower than the mean AUC in Caucasians (N=40). In adult patients, gender and age do not appear 
to have a clinically meaningful effect on the pharmacokinetics of sorafenib. 
 
In children with refractory solid tumors or leukemias, single agent sorafenib pharmacokinetics were similar 
to adults. Significant interpatient variability was observed both on Day 1 and at steady state. Drug exposure 
increased only marginally with dose escalation from 150 to 200 mg/m2 for day 1 pharmacokinetics. The 
terminal half-life in children appeared to be prolonged (≥24 hours) but could not be estimated. Sorafenib 
accumulated after multiple doses and steady state appeared to be achieved after 5 to 7 days. Steady-state 
sorafenib concentrations (AUC0–12h/12) were 4.1 ± 2.1 μg/mL at the 150 mg/m2 and 5.4 ± 1.8 μg/mL at 200 
mg/m2 dose levels, respectively. The median apparent sorafenib clearance at the MTD was 56.0 mL/min/m2. 
The apparent sorafenib clearance increased with patient age. The observed single agent sorafenib MTD in 
pediatric patients was 200 mg/m2/dose twice daily for solid tumors and 150 mg/m2/dose twice daily for 
leukemias. 
 
The pharmacokinetics of sorafenib in patients with varying degrees of renal and hepatic impairment have 
been studied. No dose adjustment is necessary in patients with renal impairment or with mild to moderate 
hepatic impairment.   
 
Repeat dosing of sorafenib to young and growing dogs resulted in irregular thickening of the femoral growth 
plate at daily doses ≥ 600 mg/m2 (approximately 0.3 times the AUC at the recommended human dose), 
hypocellularity of the bone marrow adjoining the growth plate at 200 mg/m2/day (approximately 0.1 times 
the AUC at the recommended human dose), and alterations of the dentin composition at 600 mg/m2/day. 
Similar effects were not observed in adult dogs when dosed for 4 weeks or less. 
 

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Potential Drug Interactions:  Sorafenib is metabolized primarily by CYP3A4 during phase I metabolism 
(oxidation) and primarily by UGT1A9 in phase II (conjugation).  Co-administration of rifampin resulted in 
sorafenib AUC reduction of approximately 37%.  Therefore, use caution when co-administering with strong 
CYP3A4 inducers, such as St. John’s wort, phenytoin, carbamazepine, phenobarbital and dexamethasone 
as they can reduce sorafenib exposure.  CYP3A4 inhibitors are not expected to cause clinically relevant 
changes to sorafenib exposure. 
 
In vitro, sorafenib is a moderate inhibitor CYP2C19, 2D6, and 3A4 and a strong inhibitor of CYB2B6, 2C8, 
and 2C9.  It also inhibits pathway enzymes UGT1A1 and UGT1A9 in phase II conjugation.  Clinical data 
suggests sorafenib does not increase exposure of other drugs metabolized by CYP pathways and therefore 
does not appear to be clinically relevant. Use caution when co-administered with sensitive substrates of 
UGT1A1.  
 
While sorafenib solubility is pH dependent, co-administration with omeprazole did not result in clinically 
relevant change in sorafenib exposure. 
 
Sorafenib may prolong the QT/QTc interval.  Avoid concomitant drugs that may induce the QTc 
prolongation. 
 
Sorafenib also inhibited P-glycoprotein in vitro and could increase the concentrations of concomitantly 
administered drugs that are P-glycoprotein substrates. 
 
Concomitant use of docetaxel or doxorubicin with continuous sorafenib administration resulted in an 
increase in the AUC of both docetaxel and doxorubicin. With fluorouracil, both increases and decreases in 
AUC were seen. Therefore, caution is recommended when administering sorafenib with these 
chemotherapeutic drugs.  
 
Sorafenib does not appear to affect the metabolism of warfarin (a CYP2C9 substrate) in vivo, however, 
infrequent bleeding events or elevations of the International Normalized Ratio (INR) have been reported in 
some patients receiving concomitant therapy with warfarin. Patients taking concomitant warfarin should be 
monitored regularly for changes in prothrombin time, INR or clinical bleeding episodes. 
 
Patient Care Implications:  Hand-foot skin rash can be treated with topical emollients, high-potency 
topical steroids, or keratolytic cream (urea/salicyclic acid).   
 
Females of childbearing potential should avoid becoming pregnant while they or their male partners are 
taking sorafenib and should use effective contraception during and for at least 30 days after completion of 
therapy. 
 
Toxicity: 
Comprehensive Adverse Events and Potential Risks list (CAEPR) 
for 
Sorafenib (BAY 43-9006; Nexavar, NSC 724772) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported and/or 
potential adverse events (AE) associated with an agent using a uniform presentation of events by body system. In 
addition to the comprehensive list, a subset, the Specific Protocol Exceptions to Expedited Reporting (SPEER), 
appears in a separate column and is identified with bold and italicized text. This subset of AEs (SPEER) is a list of 
events that are protocol specific exceptions to expedited reporting to NCI (except as noted below).  Refer to the 
'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 

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http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf  for further clarification. 
Frequency is provided based on 2571 patients. Below is the CAEPR for Sorafenib (BAY 43-9006; Nexavar). 
 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the AE in 
the SPEER.  If this CAEPR is part of a combination protocol using multiple investigational agents and has 
an AE listed on different SPEERs, use the lower of the grades to determine if expedited reporting is 
required. 
Version 2.7, November 16, 20151 
 
 Adverse Events with Possible  
 Relationship to Sorafenib (BAY 43-9006; Nexavar) 
 (CTCAE 4.0 Term) 
[n= 2571] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
Anemia 
 
 
 Anemia (Gr 3) 
CARDIAC DISORDERS 
  
 
 
Acute coronary syndrome 
  
 
Chest pain - cardiac 
 
  
 
 
Heart failure 
  
 
 
Left ventricular systolic 
dysfunction 
  
 
 
Myocardial infarction 
  
GASTROINTESTINAL DISORDERS 
  
Abdominal pain 
 
 
 Abdominal pain (Gr 3) 
 
Ascites 
 
  
 
Constipation 
 
 Constipation (Gr 2) 
Diarrhea 
 
 
 Diarrhea (Gr 3) 
 
 Gastrointestinal hemorrhage2 
 
 Gastrointestinal hemorrhage2 (Gr 3) 
 
 
Gastrointestinal perforation3 
  
 
Mucositis oral 
 
  
Nausea 
 
 
 Nausea (Gr 3) 
 
Vomiting 
 
 Vomiting (Gr 3) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Edema limbs 
 
  
Fatigue 
 
 
 Fatigue (Gr 3) 
 
Fever 
 
 Fever (Gr 2) 
HEPATOBILIARY DISORDERS 
  
 
 
Hepatic failure 
  
IMMUNE SYSTEM DISORDERS 
  
 
 
Anaphylaxis 
  
INFECTIONS AND INFESTATIONS 
  
 
Infection4 
 
  
INVESTIGATIONS 
  
 
Activated partial thromboplastin 
time prolonged 
 
 Activated partial thromboplastin time 
prolonged (Gr 2) 
Alanine aminotransferase 
increased 
 
 
 Alanine aminotransferase increased (Gr 3) 
Alkaline phosphatase increased  
 
 Alkaline phosphatase increased (Gr 3) 
Aspartate aminotransferase 
increased 
 
 
 Aspartate aminotransferase increased (Gr 3) 
Blood bilirubin increased 
 
 
 Blood bilirubin increased  
(Gr 3) 

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 Adverse Events with Possible  
 Relationship to Sorafenib (BAY 43-9006; Nexavar) 
 (CTCAE 4.0 Term) 
[n= 2571] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
Creatinine increased 
 
 
 Creatinine increased (Gr 3) 
 
 
Electrocardiogram QT 
corrected interval prolonged 
  
 
GGT increased 
 
  
INR increased 
 
 
 INR increased (Gr 3) 
 
Investigations - Other 
(bicarbonate-serum low) 
 
  
Lipase increased 
 
 
 Lipase increased (Gr 3) 
Lymphocyte count decreased 
 
 
 Lymphocyte count decreased (Gr 3) 
 
Neutrophil count decreased 
 
 Neutrophil count decreased (Gr 4) 
Platelet count decreased 
 
 
 Platelet count decreased (Gr 4) 
Serum amylase increased 
 
 
 Serum amylase increased (Gr 3) 
Weight loss 
 
 
 Weight loss (Gr 2) 
White blood cell decreased 
 
 
 White blood cell decreased (Gr 4) 
METABOLISM AND NUTRITION DISORDERS 
  
Anorexia 
 
 
 Anorexia (Gr 3) 
 
Hypercalcemia 
 
  
Hyperglycemia 
 
 
 Hyperglycemia (Gr 3) 
 
Hyperkalemia 
 
 Hyperkalemia (Gr 3) 
 
Hypernatremia 
 
  
Hypoalbuminemia 
 
 
 Hypoalbuminemia (Gr 3) 
Hypocalcemia 
 
 
 Hypocalcemia (Gr 3) 
 
Hypoglycemia 
 
 Hypoglycemia (Gr 2) 
 
Hypokalemia 
 
 Hypokalemia (Gr 3) 
Hyponatremia 
 
 
 Hyponatremia (Gr 3) 
Hypophosphatemia 
 
 
 Hypophosphatemia (Gr 3) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
 Arthralgia (Gr 3) 
 
Back pain 
 
 Back pain (Gr 3) 
 
Bone pain 
 
  
 
Musculoskeletal and connective 
tissue disorder -  Other (muscle 
spasm) 
 
  
 
Myalgia 
 
  
 
Pain in extremity 
 
 Pain in extremity (Gr 3) 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND 
POLYPS) 
  
 
Treatment related secondary 
malignancy 
 
  
NERVOUS SYSTEM DISORDERS 
  
 
Dizziness 
 
  
 
Headache 
 
 Headache (Gr 3) 
 
 
Intracranial hemorrhage 
  
 
 
Reversible posterior 
leukoencephalopathy 
syndrome 
  
PSYCHIATRIC DISORDERS 
  
 
Insomnia 
 
  

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 Adverse Events with Possible  
 Relationship to Sorafenib (BAY 43-9006; Nexavar) 
 (CTCAE 4.0 Term) 
[n= 2571] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
RENAL AND URINARY DISORDERS  
  
 
Acute kidney injury 
 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Cough 
 
 Cough (Gr 2) 
 
Dyspnea 
 
 Dyspnea (Gr 3) 
 
Respiratory hemorrhage5 
 
  
 
Voice alteration 
 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
Alopecia 
 
 
 Alopecia (Gr 2) 
 
Dry skin 
 
 Dry skin (Gr 2) 
 
 
Erythema multiforme 
  
Palmar-plantar 
erythrodysesthesia syndrome 
 
 
 Palmar-plantar erythrodysesthesia syndrome 
(Gr 3) 
 
Pruritus 
 
 Pruritus (Gr 3) 
Rash maculo-papular 
 
 
 Rash maculo-papular (Gr 3) 
 
 
Stevens-Johnson syndrome 
  
 
 
Toxic epidermal necrolysis 
  
VASCULAR DISORDERS 
  
 
Hypertension 
 
 Hypertension (Gr 3) 
 
 
Thromboembolic event 
  
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all Principal 
Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should be 
included in the e-mail. 
 
2Gastrointestinal hemorrhage may include Anal hemorrhage, Cecal hemorrhage, Colonic hemorrhage, Duodenal 
hemorrhage, Esophageal hemorrhage, Esophageal varices hemorrhage, Gastric hemorrhage, Hemorrhoidal 
hemorrhage, Ileal hemorrhage, Intra-abdominal hemorrhage, Jejunal hemorrhage, Lower gastrointestinal 
hemorrhage, Oral hemorrhage, Pancreatic hemorrhage, Rectal hemorrhage, Retroperitoneal hemorrhage, and Upper 
gastrointestinal hemorrhage under the GASTROINTESTINAL DISORDERS SOC. 
 
3Gastrointestinal perforation may include Colonic perforation, Duodenal perforation, Esophageal perforation, 
Gastric perforation, Ileal perforation, Jejunal perforation, Rectal perforation, and Small intestinal perforation under 
the GASTROINTESTINAL DISORDERS SOC. 
 
4Infection may include any of the 75 infection sites under the INFECTIONS AND INFESTATIONS SOC. 
 
5Respiratory hemorrhage may include bronchopulmonary hemorrhage, epistaxis, laryngeal hemorrhage, mediastinal 
hemorrhage, pharyngeal hemorrhage, and pleural hemorrhage under the RESPIRATORY, THORACIC AND 
MEDIASTINAL DISORDERS SOC. 
 
6Febrile neutropenia is seen mostly in combination with other agents. 
 
Adverse events reported on sorafenib (BAY 43-9006; Nexavar) trials, but for which there is insufficient 
evidence to suggest that there was a reasonable possibility that sorafenib (BAY 43-9006; Nexavar) caused the 
adverse event: 
 

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149 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other 
(Thrombotic microangiopathy [e.g., TTP or HUS]); Febrile neutropenia6 
CARDIAC DISORDERS - Atrial fibrillation; Atrial flutter; Cardiac arrest; Palpitations; Pericardial effusion; 
Pericarditis; Right ventricular dysfunction; Sinus bradycardia; Sinus tachycardia; Supraventricular tachycardia; 
Ventricular arrhythmia; Ventricular tachycardia 
EAR AND LABYRINTH DISORDERS - Hearing impaired; Tinnitus 
ENDOCRINE DISORDERS - Adrenal insufficiency; Hyperthyroidism; Hypothyroidism 
EYE DISORDERS - Blurred vision; Cataract; Dry eye; Extraocular muscle paresis; Eye disorders - Other (color 
vision deficits); Eye disorders - Other (light to dark adaptation); Eye disorders - Other (retinal vein occlusion); Eye 
disorders - Other (retinal hemorrhage); Eye disorders - Other (visual field distortion); Flashing lights; Keratitis; 
Photophobia; Retinal detachment 
GASTROINTESTINAL DISORDERS - Abdominal distension; Anal fistula; Anal mucositis; Anal pain; Anal 
ulcer; Cheilitis; Colitis; Colonic obstruction; Colonic ulcer; Dry mouth; Duodenal ulcer; Dyspepsia; Dysphagia; 
Enterocolitis; Esophageal pain; Esophagitis; Flatulence; Gastric ulcer; Gastritis; Gastroesophageal reflux disease; 
Gastrointestinal disorders - Other (diverticulitis); Gastrointestinal disorders - Other (small bowel NOS fistula); 
Gastrointestinal fistula; Hemorrhoids; Ileal fistula; Ileus; Oral pain; Pancreatitis; Proctitis; Rectal fistula; Rectal 
mucositis; Rectal obstruction; Rectal pain; Small intestinal obstruction; Stomach pain 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Edema face; Facial pain; 
Flu like symptoms; Localized edema; Multi-organ failure; Non-cardiac chest pain; Pain 
HEPATOBILIARY DISORDERS - Cholecystitis; Hepatic hemorrhage; Hepatobiliary disorders - Other (biliary 
obstruction secondary to multiple biliary stones) 
IMMUNE SYSTEM DISORDERS - Allergic reaction; Cytokine release syndrome; Immune system disorders - 
Other (systemic inflammatory response syndrome) 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Arterial injury; Fall; Fracture; Hip 
fracture; Vascular access complication; Wound complication; Wound dehiscence 
INVESTIGATIONS - CPK increased; Cardiac troponin I increased; Cardiac troponin T increased; Cholesterol 
high; Ejection fraction decreased; Fibrinogen decreased; Investigations - Other (blood urea nitrogen high) 
METABOLISM AND NUTRITION DISORDERS - Acidosis; Alkalosis; Dehydration; Hypermagnesemia; 
Hypertriglyceridemia; Hyperuricemia; Hypomagnesemia; Tumor lysis syndrome 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthritis; Chest wall pain; Generalized 
muscle weakness; Joint range of motion decreased; Muscle weakness left-sided; Muscle weakness lower limb; 
Muscle weakness right-sided; Muscle weakness upper limb; Musculoskeletal and connective tissue disorders -  
Other (cramping); Myositis; Neck pain 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Leukemia 
secondary to oncology chemotherapy; Myelodysplastic syndrome; Neoplasms benign, malignant and unspecified 
(incl cysts and polyps) - Other (tumor hemorrhage); Tumor pain 
NERVOUS SYSTEM DISORDERS - Ataxia; Cognitive disturbance; Depressed level of consciousness; 
Dysgeusia; Dysphasia; Encephalopathy; Extrapyramidal disorder; Hydrocephalus; Ischemia cerebrovascular; 
Lethargy; Leukoencephalopathy; Memory impairment; Neuralgia; Peripheral motor neuropathy; Peripheral sensory 
neuropathy; Seizure; Stroke; Syncope; Tremor; Vasovagal reaction 
PSYCHIATRIC DISORDERS - Agitation; Anxiety; Confusion; Depression; Libido decreased; Personality 
change; Psychosis 
RENAL AND URINARY DISORDERS - Chronic kidney disease; Hematuria; Proteinuria; Renal and urinary 
disorders - Other (focal segmental glomerulosclerosis); Renal and urinary disorders - Other (nephrotic syndrome); 
Renal and urinary disorders - Other (right ureter rupture); Renal calculi; Renal hemorrhage; Urinary frequency; 
Urinary incontinence; Urinary retention; Urinary tract obstruction; Urine discoloration 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Erectile dysfunction; Gynecomastia; 
Hematosalpinx; Menorrhagia; Ovarian hemorrhage; Prostatic hemorrhage; Spermatic cord hemorrhage; Testicular 
hemorrhage; Uterine hemorrhage; Vaginal fistula; Vaginal hemorrhage 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Adult respiratory distress syndrome; 
Allergic rhinitis; Bronchospasm; Hiccups; Hoarseness; Hypoxia; Laryngeal mucositis; Pharyngeal mucositis; 
Pharyngolaryngeal pain; Pleural effusion; Pneumonitis; Pneumothorax; Pulmonary edema; Pulmonary fibrosis; 
Respiratory, thoracic and mediastinal disorders - Other (nasal septal perforation); Tracheal mucositis 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Erythroderma; Hyperhidrosis; Nail loss; Pain of skin; 
Purpura; Rash acneiform; Scalp pain; Skin and subcutaneous tissue disorders - Other (folliculitis); Skin and 

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subcutaneous tissue disorders - Other (non-life threatening squamous cell carcinoma of skin: keratoacanthoma type); 
Skin hyperpigmentation; Skin hypopigmentation; Skin ulceration; Urticaria 
VASCULAR DISORDERS - Flushing; Hematoma; Hot flashes; Hypotension; Phlebitis; Vascular disorders - Other 
(ruptured aortic aneurysm); Vascular disorders - Other (visceral arterial ischemia); Vasculitis 
 
Note: Sorafenib (BAY 43-9006; Nexavar) in combination with other agents could cause an exacerbation of any 
adverse event currently known to be caused by the other agent, or the combination may result in events never 
previously associated with either agent. 
 
The potential risks listed in the CAEPR whose relationship to sorafenib is still undetermined are not 
required by CTEP to be described in the ICD; however, they may be communicated to patients according 
to local IRB requirements.  The terminology for CTEP’s suggested lay terms may change periodically.   
 
Pregnancy and lactation:  
Pregnancy Category D. Sorafenib may cause fetal harm when administered to a pregnant woman. In rats 
and rabbits, sorafenib has been shown to be teratogenic and to induce embryo-fetal toxicity including 
increased post-implantation loss, resorptions, skeletal retardations, and retarded fetal weight. The effects 
occurred at doses considerably below the recommended human dose of 400 mg twice daily. Adverse 
intrauterine development effects were seen at doses ≥ 1.2 mg/m2/day in rats and 3.6 mg/m2/day in rabbits 
(approximately 0.008 times the AUC seen in cancer patients at the recommended human dose). There are 
no adequate and well-controlled studies in pregnant women using sorafenib. Women of childbearing 
potential should be advised to avoid becoming pregnant while on sorafenib. Men and women of 
childbearing potential should be instructed to use an effective method of birth control during treatment with 
sorafenib and for at least 2 weeks after stopping treatment. 
 
It is not known whether sorafenib is excreted in human milk. Following administration of radiolabeled 
sorafenib to lactating Wistar rats, approximately 27% of the radioactivity was secreted into the milk. The 
milk to plasma AUC ratio was approximately 5:1. 
 
Cardiac Toxicities in Arm C (per Amendment #6a) 
Per amendment #6a, The AAML1031 Study Committee has observed a higher than expected rate of cardiac 
toxicities in Cohort 2 of Arm C of the AAML1031 trial. The schedule of sorafenib administration for 
subjects enrolled on Arm C of this study has changed in response to these findings, as detailed in 
Section 2.3.1. 
 
Formulation and Stability: 
The tablets are available as 200 mg and 50 mg immediate release tablets.  The inactive ingredients for both 
tablets are microcrystalline cellulose, croscarmellose sodium, hydroxypropylmethyl cellulose, magnesium 
stearate, sodium lauryl sulfate, and a film- coat with hydroxypropylmethylcellulose, polyethylene glycol, 
titanium dioxide and red iron oxide. 
■ The commercially labeled 200 mg tablets are round, biconvex, red film-coated tablets, debossed 
with the “Bayer cross” on one side and “200” on the other side and packaged in HDPE bottles of 120 
tablets. 
■ The 50 mg tablets for pediatric studies are yellow orange color, 6 mm round shape weighing about 
87 mg and packaged in HDPE bottles containing 100 tablets. 
 
NOTE:  Sorafenib tablets may be repackaged in HDPE pharmacy dispensing bottle other than the original 
container with expiration date not to exceed 30 days. 
 
Storage:   Store intact bottles at controlled room temperature, not to exceed 25ºC. 
 

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If a storage temperature excursion is identified, promptly return sorafenib to controlled room 
temperature (not to exceed 25°C) and quarantine the supplies.  Provide a detailed report of the 
excursion (including documentation of temperature monitoring and duration of the excursion) to 
PMBAfterHours@mail.nih.gov for determination of suitability. 
 
Stability:   Stability studies are ongoing for investigationally-labeled supplies. Refer to package labeling for 
shelf life of commercially-labeled supplies.  
 
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol. 
Sorafenib tablets should be taken on an empty stomach (at least one hour before or two hours after food) or 
with a moderate fat meal. Ideally, tablets should be swallowed whole and should not be crushed. However, 
dispersion in water is allowed to facilitate administration to subjects that cannot swallow tablets (see 
below). Tablets should be taken with clear liquids (approximately 2 to 4 ounces for children < 12 and 4 to 
8 ounces for ≥ 12 years). If sorafenib tablets must be taken with food, they should be taken with a moderate 
to low fat meal. Grapefruit or its juice is not allowed for the duration of treatment with sorafenib. 
 
A suspension of sorafenib tosylate can be prepared by dispersing 50 mg and 200 mg tablets in drinking 
water. The volume of water depends on the dose and is presented in the table. 
 
Sorafenib dose range* 
Volume of drinking water 
Volume of rinsing water 
(total volume) 
50 mg to 199 mg 
30 mL (1 oz) 
90 mL (3 oz) 
200 mg to 400 mg 
60 mL (2 oz) 
180 mL (6 oz) 
*This represents each INDIVIDUAL dose. Doses should not be prepared in advance. 
 
Patient/caregiver instructions for preparation of the dispersed tablet may be found in Appendix III. 
Preparation instructions: 
1. First, choose a quiet working space away from food, windows, fans or heat ducts. 
2. Clean the working space with damp paper towels, and place a pad or paper towel on the clean 
working space. 
3. Next, place all needed items and your SORAFENIB tablets on the pad or paper towel.  
4. Then, wash your hands with soap and water before preparing this drug. The use of gloves and a 
mask for preparation of this drug is recommended. 
5. Fill a drinking glass with the volume of water appropriate for the dose as indicated in the table 
above. 
6. Place the number of tablets required for the dose into the specified amount of water. Record the 
time. 
7. Let the tablet(s) sit in the water for approximately 5 minutes, then begin stirring.  Stir the contents 
until all tablets are completely disintegrated (broken into tiny pieces).  You may see a thin film 
forming on the top of the water. This does not change the accuracy of your dose. The preparation 
(suspension) should be ready for administration after 10 minutes. 
8. Place dirty gloves, other dirty utensils (disposable spoon and cup), and the used pad or paper 
towel in the provided waste container or bag and seal.   
9. Wash your hands thoroughly. 
10. Administer the suspension immediately or within one (1) hour after preparation according to the 
steps that follow. 
 
Administration of the suspension 

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152 
1. Administer the suspension within one (1) hour of preparation. 
2. Swirl the suspension before taking it by mouth.  
3. Sorafenib should be taken once or twice a day on an empty stomach, at least one (1) hour before 
or two (2) hours after food. 
4. Refer to the table above to determine the appropriate amount of rinsing water per dose.  Rinse the 
glass with this additional water and drink this rinse water to capture all the remaining drugs. 
a. Do not drink grapefruit juice or eat grapefruit with this drug.  
b. If dose is skipped or missed, do not replace it. Wait for the next dose schedule to take the 
drug. 
Supplier: Supplied by Bayer HealthCare AG and distributed by PMB, CTEP, DCTD NCI. Do not use 
commercially available drug. 
 
Agent Ordering 
NCI supplied agent may be requested by the Principal Investigator (or their authorized designee) at each 
participating institution. Pharmaceutical Management Branch (PMB) policy requires that agent be shipped 
directly to the institution where the patient is to be treated. PMB does not permit the transfer of agents 
between institutions (unless prior approval from PMB is obtained).  The CTEP assigned protocol number 
must be used for ordering all CTEP supplied investigational agents. The responsible investigator at each 
participating institution must be registered with CTEP, DCTD through an annual submission of FDA form 
1572 (Statement of Investigator), Curriculum Vitae, Supplemental Investigator Data Form (IDF), and 
Financial Disclosure Form (FDF). If there are several participating investigators at one institution, CTEP 
supplied investigational agents for the study should be ordered under the name of one lead investigator at 
that institution. 
 
Active CTEP-registered investigators and investigator-designated shipping designees and ordering 
designees must submit agent requests through the PMB Online Agent Order Processing (OAOP) application 
< https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx >.  Access to OAOP requires the establishment of 
a CTEP Identity and Access Management (IAM) account < https://eapps-ctep.nci.nih.gov/iam/ > and the 
maintenance of an “active” account status and a “current” password. For questions about drug orders, 
transfers, returns, or accountability, call (240) 276-6575 Monday through Friday between 8:30 am and 4:30 
pm (ET) or email PMBAfterHours@mail.nih.gov anytime. 
 
Agent Accountability 
Agent Inventory Records:  
The investigator, or a responsible party designated by the investigator, must maintain a careful record of 
the receipt, dispensing and final disposition of all agents received from the PMB using the appropriate 
NCI Investigational Agent (Drug) Accountability Record (DARF) available on the CTEP forms page. 
Store and maintain separate NCI Investigational Agent Accountability Records for each agent, strength, 
formulation and ordering investigator on this protocol. 
 
Agent Returns 
Investigators/Designees must return unused DCTD supplied investigational agent to the NCI clinical 
repository as soon as possible when: the agent is no longer required because the study is completed or 
discontinued and the agent cannot be transferred to another DCTD sponsored protocol; the agent is outdated 
or the agent is damaged or unfit for use. Regulations require that all agents received from the DCTD, NCI 
be returned to the DCTD, NCI for accountability and disposition. Return only unused vials/bottles. Do NOT 
return opened or partially used vials/bottles unless specifically requested otherwise in the protocol. See the 
CTEP 
web 
site 
for 
Policy 
and 
Guidelines 
for 
Investigational 
agent 
Returns 
at: 

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153 
http://ctep.cancer.gov/protocolDevelopment/default.htm#agents_drugs. The appropriate forms may be 
obtained at: http://ctep.cancer.gov/forms/docs/return_form.pdf. 
 
Investigator Brochure Availability 
The current version(s) of the IB(s) for the agent will be accessible to site investigators and research staff 
through the PMB Online Agent Order Processing (OAOP) application. Access to OAOP requires the 
establishment of a CTEP Identity and Access Management (IAM) account and the maintenance of an 
“active” account status and a “current” password. Questions about IB access may be directed to the PMB 
IB coordinator via email. 
 
Useful Links and Contacts 
• 
CTEP Forms, Templates, Documents:  http://ctep.cancer.gov/forms/ 
• 
NCI CTEP Investigator Registration:  PMBRegPend@ctep.nci.nih.gov 
• 
PMB policies and guidelines: http://ctep.cancer.gov/branches/pmb/agent_management.htm  
• 
PMB Online Agent Order Processing (OAOP) application: https://eapps-
ctep.nci.nih.gov/OAOP/pages/login.jspx  
• 
CTEP Identity and Access Management (IAM) account: https://eapps-ctep.nci.nih.gov/iam/ 
• 
CTEP Associate Registration and IAM account help:  ctepreghelp@ctep.nci.nih.gov 
• 
PMB email: PMBAfterHours@mail.nih.gov 
• 
IB Coordinator: IBCoordinator@mail.nih.gov  
• 
PMB phone and hours of service: (240) 276-6575 Monday through Friday between 8:30 am and 
4:30 pm (ET) 
 
 
6.14 
TACROLIMUS  
(FK-506, Prograf®) NSC # 717865 
 
 
 
 
 
 
(05/10/11) 
 
Source and Pharmacology:  
Tacrolimus is a macrolide immunosuppressant produced by Streptomyces tsukubaensis. Tacrolimus is a 
potent immunosuppressive agent which prolongs the survival of the host and transplanted grafts in animal 
transplant models of liver, kidney, heart, bone marrow, small bowel and pancreas, lung and trachea, skin, 
cornea, and limb. Tacrolimus inhibits T-lymphocyte activation, although the exact mechanism of action is 
not known. Experimental evidence suggests that tacrolimus binds to an intracellular protein, FKBP-12. A 
complex of tacrolimus-FKBP-12, calcium, calmodulin, and calcineurin is then formed and the phosphatase 
activity of calcineurin inhibited. This effect may prevent the dephosphorylation and translocation of nuclear 
factor of activated T-cells (NF-AT), a nuclear component thought to initiate gene transcription for the 
formation of lymphokines (such as interleukin-2, gamma interferon). The net result is the inhibition of T-
lymphocyte activation (immunosuppression). Additionally, tacrolimus may inhibit cellular activities such 
as nitric oxide synthetase activation and apoptosis, and may potentiate the action of corticosteroids in these 
processes. Tacrolimus activity is primarily due to the parent drug. The plasma protein binding of tacrolimus 
is approximately 99% and is independent of concentration over a range of 5-50 ng/mL. Tacrolimus is bound 
mainly to albumin and alpha-1-acid glycoprotein, and has a high level of association with erythrocytes. The 
t½ in adult patients ranges from 11-19 hours.  
 

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154 
The pharmacokinetics of tacrolimus have been studied in pediatric liver transplant patients (0.7 to 13.2 years 
of age). Following the IV administration of a 0.037 mg/kg/day dose to 12 pediatric patients, mean terminal 
half-life, 
volume 
of 
distribution 
and 
clearance 
were 
11.5 ± 3.8 hours, 
2.6 ± 2.1 L/kg 
and 
0.138 ± 0.071 L/hr/kg, respectively. Following oral administration to 9 pediatric patients, the absolute 
bioavailability was 31 ± 21%. Whole blood trough concentrations from 31 patients less than 12 years old 
showed that pediatric patients needed higher doses than adults to achieve similar tacrolimus trough 
concentrations. Tacrolimus is extensively metabolized by the mixed-function oxidase system, primarily the 
cytochrome P-450 system (CYP3A) in the liver and to a lesser extent in the intestinal mucosa. The major 
metabolite identified in incubations with human liver microsomes is 13-demethyl tacrolimus. The main 
route of elimination is via the biliary tract and excretion in faeces. The mean clearance in renal dysfunction 
and mild hepatic dysfunction is the same as normal volunteers. Severe hepatic dysfunction (Pugh 
score > 10) led to a substantially decreased clearance. A retrospective comparison of Black and Caucasian 
kidney transplant patients indicated that Black patients required higher tacrolimus doses to attain similar 
trough concentrations; there were no gender-based differences. The absorption of tacrolimus from the 
gastrointestinal tract is incomplete and variable exhibiting large intra- and inter-patient variability. 
Administration with food significantly decreases the rate and extent of absorption Drugs that stimulate or 
inhibit hepatic p-450 enzymes will alter clearance of tacrolimus and close attention to potential drug 
interactions is crucial. 
 
Toxicity: 
 
Common 
Happens to 21-100 children 
out of every 100 
Occasional 
Happens to 5-20 children 
out of every 100 
Rare 
Happens to < 5 children out of 
every 100 
Immediate: 
Within 1-2 days of 
receiving drug 
Headache (L), hypertension 
(L), nausea, vomiting, 
anorexia, 
immunosuppression (L), 
diarrhea, constipation, fever 
Chest pain 
Anaphylaxis with the injection, 
allergic reaction, hypotension, 
asthma, dyspnea, increased cough, 
flu like syndrome, pleural effusion, 
seizure (L), tachycardia, angina 
Prompt: 
Within 2-3 weeks, prior 
to the next course 
Tremor (L), ), renal 
dysfunction (acute with 
decrease in GFR, impaired 
urinary concentrating 
ability, and sodium 
retention), elevated 
creatinine/BUN, anemia, 
insomnia, asthenia, pain 
(abdominal, back, pain), 
hyperglycemia, 
hypomagnesemia (L), 
hyper/hypokalemia (L), 
hypophosphatemia, 
paresthesia  
Alopecia, dizziness, 
elevated LFTs, UTI, 
peripheral edema, rash, 
pruritus, hyperlipidemia, 
hypercholesteremia 
Dyspepsia, dysphagia, gastritis, 
esophagitis, flatulence, CNS 
abnormalities (confusion (L), 
somnolence (L), depression (L), 
anxiety, anxiousness, abnormal 
dreams, emotional labiality, 
hallucinations, psychosis, 
hypertonia, incoordination, 
neuropathy, nervousness 
encephalopathy), coagulation 
disorder, leukopenia (L), 
thrombocytopenia, polycythemia, 
anemia, leukocytosis, infections 
(bacterial, fungal, viral –sepsis, 
cellulites, fungal dermatitis, herpes 
simplex, sinusitis, pharyngitis, 
abscess, pneumonia, bronchitis, 
peritonitis), hyperbilirubinemia (L), 
thrombosis, phlebitis, arthralgia, 
myalgia, electrolyte abnormalities 
Delayed: 
Any time later during 
therapy, excluding the 
above conditions 
 
 
Acne, exfoliative dermatitis, skin 
discoloration, photosensitivity 
reaction, skin ulcer, delayed wound 
healing, hirsutism (hypertrichosis) 
(L), gingival hyperplasia, abnormal 
vision, amblyopia, ear pain, otitis, 

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155 
tinnitus, GI hemorrhage, GI 
perforation, cholelithiasis, 
cholestatic jaundice, chronic renal 
dysfunction, renal failure, post-
transplant diabetes mellitus (L), 
myocardial hypertrophy, elevated 
liver function tests, liver damage, 
ascites 
Late: 
Any time after 
completion of treatment 
 
 
Lymphoproliferative disorders, skin 
malignancies 
Unknown Frequency 
and Timing:  
Fetal toxic effects of tacrolimus have been noted in animals. Tacrolimus is transported across 
the placenta and its use during pregnancy has been associated with neonatal hyperkalemia 
and renal dysfunction. Tacrolimus is excreted in human milk, nursing should be avoided. 
(L) Toxicity may also occur later. 
 
Formulation and Stability:  
Injection: 
Tacrolimus is available as a sterile solution (tacrolimus injection) containing the equivalent of 5 mg 
anhydrous tacrolimus per 1 mL. Each mL also contains polyoxyl 60 hydrogenated castor oil (HCO-60), 
200 mg, and dehydrated alcohol, USP, 80% v/v. Store between 5°C and 25°C (41°F and 77°F). 
 
Oral: 
Tacrolimus is available for oral administration as capsules containing the equivalent of 0.5 mg, 1 mg or 
5 mg of anhydrous tacrolimus. Inactive ingredients include lactose, hydroxypropyl methylcellulose, 
croscarmellose sodium, and magnesium stearate. The 0.5 mg capsule shell contains gelatin, titanium 
dioxide and ferric oxide, the 1 mg capsule shell contains gelatin and titanium dioxide, and the 5 mg capsule 
shell contains gelatin, titanium dioxide and ferric oxide. Store at 25°C (77°F); excursions permitted to 15°-
30°C (59°-86°F). 
 
Guidelines for Administration: See Treatment and Dose Modifications sections of the protocol. 
 
Injection: 
Tacrolimus Injection must be diluted with NS or D5W before use to a concentration between 0.004 mg/mL 
and 0.02 mg/mL. Diluted infusion solution should be stored in glass or polyethylene containers and should 
be discarded after 24 hours. The polyoxyethylated castor oil contained in the concentrate for intravenous 
infusion can cause phthalate stripping from PVC. It is strongly recommended that glass bottles and non-
PVC tubing be used to minimize patient exposure to DEHP. Due to the chemical instability of tacrolimus 
in alkaline media, tacrolimus injection should not be mixed or co-infused with solutions of pH 9 or greater 
(e.g., ganciclovir or acyclovir). 
 
Monitor closely for an acute allergic reaction for the first 30 minutes and at frequent intervals thereafter.  
 
Oral: Administer at a consistent time of day and at consistent intervals with regard to meals. Tacrolimus may 
be given with food as long as it is given the same way each time; however; administration with food 
significantly decreases the rate and extent of absorption. Grapefruit juice should be avoided during the 
entire course of tacrolimus administration. 
 
Supplier: Commercially available from various manufacturers. See package insert for further information.  
 
 

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156 
7.0 
EVALUATIONS/MATERIAL AND DATA TO BE ACCESSIONED 
 
 
 
 
 
 
 
All baseline studies must be performed prior to starting protocol therapy unless otherwise indicated below.  
 
7.1 
Required Clinical, Laboratory and Disease Evaluations  
Obtain prior to start of phase unless otherwise indicated.  
 
Baseline 
Each course of 
chemotherapy 
Arm C 
Maintenance*  
End of 
therapy 
Relapse/ 
Refractory 
History 
X 
 
Q month 
 
 
Physical Exam (Ht, Wt, BSA, & VS) 
X 
X1 
Q month1 
 
 
CBC 
X 
X 
Q month 
X 
X 
BUN and Creatinine 
X 
X2 
Q month 
 
 
AST, ALT, and bili (direct and total) 
X 
X 
Q month 
  
  
Calcium, phosphorus, albumin  
 
 
Q month 
 
 
Either Echo or MUGA, and ECG 
X 
Before Induction II 
Before Intensification I 
Before Intensification II 
Q 4 months 
X 
 
High Resolution HLA/DNA typing: 
patient, parents, siblings3 
X 
 
 
 
 
Biopsy and CT or MRI of chloroma4 
X 
 
 
 
X 
Blood Pressure5 
X  
X  
Q month 
X  
 
Pulse Oximetry (O2 saturation) 6 
X 
X6 
 
 
 
Neurologic Examination7 
X 
X7 
 
 
 
Urinalysis (Arm C only) 
X 
X 
Q month 
 
 
BMA/clot section (biopsy if aspirate 
unsuccessful) 8 
X 
After Induction I  
After Induction II 
After Intensification I  
Before 
Maintenance 
X9 
X 
BMA cytogenetics and FISH10 
X10 
 
 
  
X10 
LP-CSF for cell count, cytospin11 
X 
 
 
  
X 
BMA for MRD12 
X 
After Induction I  
 
 
 
BMA for FLT3 testing 
X13 
 
 
 
 
Pregnancy Test, if applicable 
X 
 
 
 
 
1 Patients on Arm C should have weekly clinical cardiac examinations performed while receiving sorafenib with chemotherapy. 
Patients on Arm C Maintenance must have at least monthly clinical cardiac examinations. A clinical cardiac examination should 
include a review of systems, vital sign assessment, pulse oximetry, and cardiac auscultation to identify signs and symptoms of 
cardiac dysfunction. 
2 Prior to HD AraC, obtain CrCl for patients with serum creatinine > 2 mg/dL or > 2 x normal for age. See Section 4 TDMs for 
timing. 
3 All AML patients will have HLA-typing at diagnosis. If an HLA-identical sibling is not identified at presentation, then high 
resolution typing of the patient should be performed at HLA-A, B, C and DRB1. If HLA typing is not able to be performed at 
diagnosis, then this should be pursued as soon as possible upon recovery from Induction I. 
4  For patients with granulocytic sarcomas (chloroma) only. Biopsy only required if other AML diagnostic methods are unsuccessful. 
5 Only for patients receiving sorafenib containing therapy. Blood pressure (BP) will be measured with an appropriate sized cuff at 
rest. Guidelines for the grading and management of hypertension are in Section 5.2.2, Appendix I. 
6 Only for patients randomized to receive bortezomib containing therapy. Prior to each bortezomib dose. 
7 Only for patients randomized to receive bortezomib containing therapy. Prior to each course of therapy. 
8 If it is unadvisable clinically to perform a BM at diagnosis or relapse, the use of peripheral blood may be substituted in cases 
where there are adequate numbers of blasts to conclusively make the diagnosis of AML. In these cases, peripheral blood should 
also be sent for all studies requested at diagnosis or relapse. Clot section is only required at diagnosis.  
9  For all patients. For Arm A or B SCT patients, the end of therapy BMA/Biopsy is to be done within 1 month of ANC recovery 
after SCT. For Arm C SCT patients, the end of therapy evaluation is within one month of completing sorafenib maintenance. 
Timing of protocol therapy administration, response assessment studies, and surgical interventions are based on 
schedules derived from the experimental design or on established standards of care. Minor unavoidable departures 
(up to 72 hours) from protocol directed therapy and/or disease evaluations (and up to 1 week for surgery) for valid 
clinical, patient and family logistical, or facility,  procedure and/or anesthesia scheduling issues are acceptable per 
COG administrative Policy 5.14 (except where explicitly prohibited within the protocol).  

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10 See Cytogenetics Section 16.0 for submission guidelines. Submit sample to local cytogenetics lab in green top tube.  
11  May be deferred if clinically indicated for patient safety. 
12 Extra marrow (or peripheral blood) is to be collected in a green top tube at time of disease status evaluation. See Section 15.0. 
13 See Section 14.0 for instructions regarding submission of FLT3 samples. Submit sample in purple top tube. 
* Patients receiving Maintenance post-SCT are referred to Section 7.3 for additional evaluations required/recommended post-SCT.  
This table only includes evaluations necessary to answer the primary and secondary aims. Obtain other studies as indicated for 
good clinical care. 
 
 
7.2 
Recommended Clinical, Laboratory and Disease Evaluations  
 
 
Baseline 
Each course of 
chemotherapy 
End of therapy* 
Relapse 
History and Physical 
per 7.1 
Weekly 
X 
X 
Urinalysis 
X 
X 
X 
X 
Electrolytes, Ca, Phos 
X 
X 
X 
X 
BUN/Cr 
per 7.1 
per 7.1 
X 
X 
LDH 
X 
 
 
X 
Uric Acid 
X 
 
 
X 
Quant. IgG 
X 
X (monthly) 
 
 
AST/ALT, bili (direct & total) 
per 7.1 
per 7.1  
X 
X 
CMV serology 
X 
 
 
 
Varicella serology 
X 
 
 
 
HSV serology 
X 
 
 
 
CXR 
 X 
 
 
 
Echo/EKG or MUGA 
per 7.1 
per 7.1 
per 7.1 
X 
PT/PTT, fib, FDP or d-dimers 
X 
 
 
 
Cr clearance or GFR 
X 
Prior to Intensification I  
 
 
*End of therapy evaluation for patients on Arm C who receive Sorafenib Maintenance will occur within 
1 month of completion of Sorafenib Maintenance.  
 
7.3 
Required & Optional Observations for SCT Patients Only 
 
Required: 
Pre-SCT  
Post- SCT 
Minimum Criteria to Proceed to SCT  
Pulmonary Function Tests (if able to perform; 
O2 saturation if unable to perform) 
X 
 
DLCO > 50% 
Echo/ECG 
X 
 
Shortening fraction > 28% or EF ≥ 55% 
Electrolytes 
X 
 
Within normal institutional limits 
Liver Function Tests 
X 
 
Transaminases < 2.5 x  normal;  
Total bilirubin < 2 mg/dL 
Creatinine Clearance or GFR 
X 
 
> 60 mL/minute/1.73m2 
BMA/clot section (biopsy if aspirate 
unsuccessful) 
X 
X** 
Documented remission 
LP-CSF for cell count, cytospin 
X 
 
No leukemic infiltrate 
HSV and CMV titers 
X 
 
Required Observations 
Hep B by surface antigen/ 
Hep C  by serology 
X 
 
Required Observations 
HIV by serology  
X 
 
Negative 
1st Dose Busulfan Pharmacokinetics* 
X 
 
To achieve an AUC for busulfan of 900 to 
1500 (micromole/liter)*minute. 
Optional:*** 
 
 
 
GVHD status 
 
X 
At onset of GVHD, Day +56 and Day +100 

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158 
* 
See Section 17.1.3. Note that laboratories may report busulfan pharmacokinetics as AUC or Css 
values. The target refers to results expressed as AUC. 
** 
BMA is required within 1 month after ANC recovery (> 500/µL). If patient is Arm A or B: also 
collect End of Therapy optional biology bone marrow sample if patients has consented to participate 
in optional biology studies. If patient is on Arm C: End of Therapy optional biology will be collected 
within one month of completing Sorafenib Maintenance. 
*** For patients that have consented to the optional GVHD predictor study. 
Note: Arm C patients: please also refer to Section 7.1 for Sorafenib Maintenance phase.  
7.3.1 
Required Busulfan Pharmacokinetic Studies* (See Section 17.1.3). 
 
For Single IV Dosing 
Time Following Start of 1st Dose 
3 hours 
3 hours 15 minutes 
4 hours 
5 hours 
6 hours 
8 hours 
 
* 
To be done on 1st dose only. 
 
For Q6 hour IV Dosing 
Time Following Start of 1st Dose 
2 hours 
2 hours 15 minutes 
2 hours 30 minutes 
3 hours 
4 hours 
5 hours 
6 hours 
* 
To be done on 1st dose only. 
 
7.3.2 
Recommended Clinical, Laboratory and Disease Evaluations During and Following SCT  
 
 
During 
Hospitalization 
Day 100 post 
SCT 
6 months post 
SCT 
9 months post 
SCT 
1 year post  
SCT 
Physical 
Examination 
Daily during 
hospitalization 
X 
X 
X 
X 
CBC 
Daily until APC is 
rising 
X 
X 
X 
X 
Electrolytes 
Weekly 
X 
X 
X 
X 
AST/ALT, bilirubin 
Weekly 
X 
X 
X 
X 
Donor Chimerism 
 
X 
X 
 
 
 
Note: Arm C patients: please also refer to Section 7.1 for specific monitoring post-SCT during Sorafenib 
Maintenance phase.  
 
 
 
 
7.4 
Optional Studies  
The following table lists samples to be obtained from patients who have provided consent for optional 
correlative studies. 

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159 
 
Baseline 
Each course of therapy 
End of 
therapy 
Relapse/ 
Refractory 
Special Tubes 
BMA for Leukemia Biology 
Studies #  
X# 
After Induction I # 
After Induction II # 
After Intensification I # 
X# 
X# 
3 - 10 mL/sample  
purple/lavender top 
BMA for Optional MRD @ 
 
After Induction II @  
After Intensification I @ 
X@ 
X@ 
2 - 4 mL/sample 
green top 
Peripheral blood for Gene 
Polymorphism studies^ 
X^ 
After Induction I only^ 
 
 
5 mL  
purple/lavender top 
Peripheral blood for 
UPR/RPPA§ studies 
 
During Induction I only 
§These studies have been 
completed per memo 2-17-2017 
 
 
3 mL/sample 
CellSave tube 
2mL/sample 
heparin tube 
Peripheral blood for Sorafenib 
PK studies+ 
 
During Induction I 
During Induction II 
During Intensification I 
During Intensification II 
During Maintenance  
 
 
3 mL/sample 
green top 
Peripheral blood for Sorafenib 
PIA studies& 
 
Per Amendment #6A, there are 
only pre-course and post-
chemotherapy samples. See 
Appendix XI   
 
 
3 mL/sample 
green top 
Bone Marrow for LIC studies* 
 
After Induction I 
After Induction II* 
 
 
5 mL/sample 
green top 
Peripheral blood for GVHD 
predictor study (for pts 
receiving SCT only)! 
 
Post-SCT on Days +7, +14, +28 
!These studies have been 
completed per memo 2-24-2017 
 
 
3 - 6 mL/sample  
red top  
HRQOL Studies (Closed to new 
patient accrual as of 05-15-15. 
COG memo posted on 05-08-15.) 
See Section 18.0 for specific evaluation time points 
 
 
# Extra marrow (or peripheral blood) is to be collected in purple/lavender top tube (green top preservative-free heparin tube if 
blood) at time of disease status evaluation. See Appendix VII for details on collection time points and send out guidelines.  
@ Extra marrow (or peripheral blood) is to be collected in green top tube (preservative-free heparin) at time of disease status 
evaluation. See Section 15.0 for send out guidelines. 
^  See Appendix VII for details on collection time points and send out guidelines. 
§  These studies have been completed per memo 2-17-2017. See Appendix IX.  
+  For patients on sorafenib Arm C only. See Appendix X for details on collection time points and send out guidelines. 
&  For patients on sorafenib Arm C only. See Appendix XI for details on collection time points and send out guidelines. 
*  See Appendix VIII for details on collection and send out guidelines. Submit Induction II sample only if patient is MRD+ at the 
end of Induction I. 
! These studies have been completed per memo 2-24-2017. See Appendix XIII. 
 
 
7.5 
Follow-up Studies* 
 
First 6 
months 
Second 6 
months 
Second Year 
Third Year 
Annually 
Thereafter 
PE & CBC 
Monthly 
Q other month 
Q 4 months 
Q 6 months 
Q year 
Echo (or MUGA)/ECG 
 
Once 
Yearly 
Yearly 
Q year 
* For patients who complete chemotherapy. Patients who go on to SCT will need, in addition to these 
items, further follow-up as required by their SCT institution. More frequent or additional studies should 
be pursued as clinically warranted.  
 
These studies are required until the patient is off study as defined in Section 8.2 and reported as defined in 
Section 7.6.  
 
 
7.6 
Follow-up Reports 
Follow-up data are expected to be submitted per the Case Report Forms (CRF) schedule. 
 

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160 
See COG Late Effects Guidelines for recommended post treatment follow-up: 
http://www.childrensoncologygroup.org/disc/LE/default.htm.  
 
 
8.0 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY 
CRITERIA  
 
8.1 
Criteria for Removal from Protocol Therapy 
 
a) Failure to attain or maintain remission following Induction II (≥ 5% malignant blasts or 
extramedullary disease). 
b) Relapse after Induction II of any site following remission. 
c) Refractory CNS leukemia following 6 doses of IT cytarabine therapy in Induction I or Induction II. 
d) CNS leukemia at start of Induction II after treatment for CNS leukemia in Induction I. 
e) Grade 3 or greater neurotoxicity from HD cytarabine or,  
f) Other intolerable or unacceptable toxicity secondary to the standard chemotherapy backbone. 
g) Refusal of further protocol therapy by patient/parent/guardian. 
h) Completion of planned therapy. 
i) Physician determines it is in patient’s best interest. 
j) Development of a second malignancy. 
k) Graft failure 
l) For patients enrolled on Arm C: Failure to meet required criterion for start of maintenance therapy. 
 
Patients who are off protocol therapy are to be followed until they meet the criteria for Off Study (see below). 
Follow-up data will be required unless consent was withdrawn.  
 
8.2 
Off Study Criteria 
 
a) Death. 
b) Lost to follow-up. 
c) Patient enrollment onto another COG study with tumor therapeutic intent (e.g., at recurrence).*  
d) Withdrawal of consent for any further data submission. 
e) Tenth anniversary of study entry. 
f) Excluded constitutional condition or oncologic diagnosis is indicated following enrollment (see 
Section 3.2.5 and Section 3.2.6). 
g) For patients enrolled after implementation of Amendment #7A: absence of FLT3/ITD or 
FLT3/ITD allelic ratio ≤ 0.4. 
h) For patients enrolled after implementation of Amendment #7A: FLT3/ITD status is unknown at 
End of Induction I. 
i) For patients enrolled after implementation of Amendment #7A: HR FLT3/ITD (AR > 0.4) and 
decline transition to Arm C chemotherapy. 
 
* For subsequent studies with a significant interval between enrollment and beginning of therapy 
(i.e., studies involving stem cell transplant where there will be an attempt to identify an adequate 
donor), the patient will come off AAML1031 at the time when therapy is initiated on the subsequent 
study (and not at time of enrollment onto that study). 
 
 
 

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9.0 
STATISTICAL CONSIDERATIONS 
 
9.1 
Patient Accrual and Expected Duration of Trial 
Since approximately 8% of eligible patients are expected to be HR FLT3/ITD+, enrollment of an additional 
500 patients post-amendment #7A should result in the enrollment of approximately 40 additional patients 
with HR FLT3/ITD+. Based on the current accrual estimate of 290 patients per year, it estimated that it will 
take approximately 1.7 years to accrue 500 patients post-amendment #7A which would result in total 
enrollment of up to 1,750 patients. Of these 1,750 patients, a total of approximately 100 patients are 
expected in Arm C (60 patients prior to Amendment 7A and 40 additional patients post-Amendment 7A). 
 
Extension of accrual to Arm C with Amendment 7A occurred for two reasons. First, accrual to Arm C 
during the main randomization substantively lagged behind expected accrual. Initial Arm C accrual 
estimates placed the total number of Arm C patients at approximately 80 patients. However, the extended 
closure of Arm C for Amendment 3 substantively decreased the time available for patient enrollment on 
Arm C. Second, Amendment 6, which changed the timing of sorafenib initiation to follow chemotherapy 
completion, has enrolled 14 patients. Since Cohort 3 patients are treated with a different sorafenib schedule, 
accrual of additional patients would enable more precise estimates of both toxicity, particularly left 
ventricular systolic dysfunction, and response. 
 
9.2 
Statistical Analysis Methods 
 
9.2.1 
Study Endpoints 
The primary outcome for Aim 1.1.1 is EFS, defined as the time on study to Induction failure, relapse or 
death. Secondary endpoints include OS, remission rate after 1 and 2 courses of therapy, the proportion of 
patients dying in each course of therapy, course duration, length of hospitalization, time to count recovery, 
relapse rate and treatment-related mortality, and frequency of toxicities, including infectious and cardiac 
complications. The safety of the combination of bortezomib and chemotherapy will be assessed by 
evaluating the proportion of patients experiencing Grade 3 or higher non-hematologic toxicities, infections, 
time to count recovery, and length of hospitalization (Aim 1.1.2).  
 
The feasibility of combining sorafenib with AML chemotherapy and in maintenance will be carried out as 
described in the analysis plan (Aim 1.1.4). Preliminary efficacy data will be obtained by comparing end of 
Induction I MRD clearance between HR FLT3/ITD patients who did and did not receive sorafenib in 
Induction I (Aim 1.1.4). In addition, OS and EFS from study entry will be estimated for patients who receive 
sorafenib in Induction I. OS and EFS will also be described separately for Arm C Cohort 1 patients, Cohort 
2 patients, and Cohort 3 patients. Given the small size of these patient groups, the OS and EFS analyses 
will be descriptive. 
 
The endpoints for the HRQOL aim will be the instruments as described in Section 18.0 and the PIP 
(Aim 1.2.5).  
 
9.2.2 
Analysis Plan 
Aim 1.1.1 
Patients determined to have HR FLT3/ITD+ will not contribute to or be included in analysis for Aim 1. The 
Kaplan-Meier method will be used to estimate OS, EFS, and DFS.126 The log-rank test will be used to 
compare survival between treatment groups. Comparison of EFS will occur when the total event horizon is 
reached. Comparison of OS will be performed only if a significant difference is found on EFS analysis. 
Cumulative incidence estimates that account for competing events will be used to estimate relapse rate, 
treatment-related mortality, and time to count recovery. The occurrence of a clinically important statistical 
interaction effect on outcomes for the main treatment comparisons is thought to be unlikely. Hence, power 
calculations are based on the assumption that the stratified analysis of either factor across levels of the other 

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162 
factor is valid. However, analysis of the study data will examine the validity of this assumption using a Cox 
regression model. If needed, separate analyses within strata of the factors will be performed but this will 
have limited power due to limited sample size. If the proportional hazards assumption is violated, alternative 
statistical methods will be employed. 
 
Aim 1.1.2 
Patients determined to have HR FLT3/ITD+ who are randomized to receive Bortezomib and elect to not 
participate in Arm C will be included in analysis for Aim 2. The proportion and corresponding confidence 
intervals of patients experiencing Grade 3 or higher non-hematologic toxicities and infections will be 
estimated. Descriptive statistics will be used to summarize length of hospitalization time. Cumulative 
incidence estimates that account for competing events will be used to estimate count recovery. Stopping 
rules for unacceptable bortezomib related toxicity are described in Section 9.3.1. 
 
Aim 1.1.3 
The Kaplan-Meier method will be used to estimate OS and EFS.126 We will assume the null hypothesis that 
the EFS experience from the end of Induction I for high risk children without HR FLT3/ITD+ treated on 
AAML03P1 and AAML0531 follows an exponential mixture cure model. Since AAML0531 data 
collection is still ongoing, the cure model parameters to be used in the one-sample log-rank test will be 
estimated at the time of the first interim analysis. We will assume the null hypothesis that the EFS 
experience on this study follows the exponential cure model. Cumulative incidence estimates that account 
for competing events will be used to estimate relapse rate, treatment-related mortality, and time to count 
recovery. 
 
Aim 1.1.4 
The proportion of patients experiencing Grade 3 or higher non-hematologic toxicities and infections will 
be estimated. Descriptive statistics will be used to summarize length of hospitalization time. Cumulative 
incidence estimates that account for competing events will be used to estimate count recovery. The Kaplan-
Meier method will be used to estimate OS and EFS for patients treated with sorafenib. 
 
Aim 1.2.2 
The proportion of high risk children without HR FLT3/ITD+ converting from positive MRD at end of 
Induction I to negative MRD at the end of Induction II will be estimated as well as the corresponding 
confidence interval. In addition, this proportion will be compared with the proportion for high risk children 
without HR FLT3/ITD+ treated on AAML03P1 and AAML0531. 
 
Aim 1.2.5 
The primary analysis will be the description of parent-report Generic Core Scale, Acute Cancer Module, 
and Multidimensional Fatigue Module summary and dimension scores of HRQOL and PIP at 4 months 
following start of SCT or Intensification II of chemotherapy; we will present mean values and their 95% 
CI. 
 
A secondary analysis will be the description of HRQOL and PIP outcomes over time in recipients of SCT 
or chemotherapy. This analysis will begin at the baseline assessment and we will describe summary 
measures at each time point as well as the overall trajectory over time. We also will perform a mixed linear 
regression model with repeated measures incorporating covariates as appropriate. Another secondary 
analysis will be the examination of concordance of parent and child measures using the intraclass 
correlation coefficient at each time point. 
 
As an exploratory analysis, we also will compare HRQOL and PIP between SCT and chemotherapy over 
time using a mixed linear regression model which includes an indicator variable for treatment and other 
covariates as appropriate. 

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Aim 1.2.6  
Bortezomib Pharmacokinetics Plasma concentration-time profiles on Day 8 of Induction II will be analyzed 
using descriptive statistics and will be graphically displayed by age group. PK data will be analyzed using 
methods such as nonlinear mixed effects modeling to estimate bortezomib clearance (Cl) and volume of 
distribution (Vd) with associated 95% confidence intervals in each age group (2-11 years and 12-16 years 
of age). To enable these analyses, data from this study will be combined with PK data collected on 
AALL07P1. Potential relationships between measures of bortezomib plasma exposure (eg, model-
estimated AUC0-last values) in individual patients and efficacy and/or safety endpoints may be examined 
graphically to guide exploratory assessment of exposure-response relationships. Up to 60 evaluable patients 
will be studied for bortezomib pharmacokinetic endpoints. Amendment #3A Update: This study was closed 
to new patient participation on June 25, 2013, as accrual goals were met.  
 
Aim 1.2.7  
Steady state pharmacokinetics of sorafenib and N-Oxide metabolite will be obtained in patients who receive 
sorafenib and provide consent/assent. Descriptive statistics will be used to summarize the systemic 
exposure of sorafenib and N-oxide metabolite for each course of induction and intensification (CL, Vd, 
Tmax½, AUC).  If sufficient data is available, comparison to steady state pharmacokinetic data from 
ADVL0413 will be performed using Wilcoxon Sign Rank Test. For PIA-PK correlations, a random effects 
linear regression model will be used to describe the relationship between PIA and PK levels for each of the 
trough plasma samples collected for each patient. Random effects are included to account for the potential 
correlation between observations from the same patient.  
 
Aim 1.2.8 
The proportion of patients treated with and without dexrazoxane will be estimated for each course of 
anthracycline containing chemotherapy. Shortening fraction/ejection fraction percentages and change over 
time will be analyzed by repeated measures ANOVA accounting for dexrazoxane exposure and other 
clinically relevant covariates, including age, gender, body mass index, risk group, and treatment arm. 
 
Given the ecologic study design, definitive conclusions about the impact of dexrazoxane on cardiac toxicity 
and relapse risk are not possible. Thus, the proposed analyses will serve as preliminary data to inform 
discussion of a randomized trial to evaluate the utility of dexrazoxane in pediatric AML therapy.  
 
Aim 1.2.18 
Serum concentrations of GVHD biomarker will be measured on samples collected on post-SCT Days 7, 14 
and 28. Samples will be excluded from analysis if collected after the onset of Grade 2-4 GVHD. The 
biomarker concentrations will be combined with the following two clinical variables: donor type (related 
versus unrelated versus cord blood donor) and HLA-match (matched versus mismatch). Logistic regression 
modeling will be used to assign individual weights to each individual biomarker and clinical variable in 
order to maximize sensitivity and specificity of a mathematical algorithm for the prediction of Grade 2-4 
GVHD occurring on or before Day 56 post-SCT. We will test whether algorithms using the Day 7 biomarker 
panel, the Day 14 biomarker panel, the Day 28 biomarker panel, or a combination of the biomarker panels 
at these different time points are most useful for the prediction of GVHD. We will compare the different 
algorithms on the basis of maximal specificity and sensitivity using the Akaike Information Criterion, which 
measures the tradeoff of accuracy for complexity.127 
 
A secondary analysis will explore the correlation of high and low risk profiles identified by the GVHD 
predictive algorithm with non-relapse mortality, relapse incidence and overall survival.  
 

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9.2.3 
Power Calculations 
 
9.2.3.1 Power Calculations Aim 1.1.1: EFS  
Power calculations are performed using a cure model assuming proportional hazards, the failure distribution 
contains a plateau corresponding to the proportion of patients who are cured, and those not cured have an 
exponential failure distribution.128 Based on this model with 1-sided testing and 2.5% type I error rate, there 
will be 80% power to detect a 9% difference in EFS plateaus (52% vs. 61%, hazard ratio = 0.78) between 
patients randomized to standard therapy versus bortezomib/standard combination therapy if the EFS at 1 
year is assumed to 69% for the group with inferior EFS. AML has a long term EFS of 52% with 90% of 
events observed by 1 year of follow-up. Thus enrollment of 1050 eligible patients without HR FLT3/ITD+ 
would be expected under the alternative hypothesis to generate 407 events by 1 year of follow-up. 
 
9.2.3.2 Power Calculations Aim 1.1.2: Feasibility of Combining Bortezomib with Standard Therapy 
Assuming 100 evaluable patients without HR FLT3/ITD+ are randomized to receive bortezomib, this study 
will provide a worst case precision of ± 9.8% at a prevalence of 50% of patients experiencing Grade 3 or 
higher non-hematologic toxicities. This precision will improve as the prevalence moves away from 50%, 
with a ± 7.8% precision at a prevalence of 10%.  
 
9.2.3.3 Power Calculations Aim 1.1.4: Feasibility of Combining Sorafenib with Standard Therapy 
The table below provides the probability of determining a dose de-escalation is needed (i.e. DLT rate of 
30% or more at any time after the enrollment of the first 2 and up to 10 patients enrolled) if the true 
probability a patient experiences a DLT varies from 0.05 to 0.4. Any patient who experiences a severe 
toxicity at any time during protocol therapy after receiving at least 1 dose of study drug is considered 
evaluable for toxicity. Patients without a severe toxicity who receive at least 85% of the prescribed dose 
per protocol guidelines are also considered evaluable for toxicity. In the dose finding phase, patients who 
are not evaluable for hematologic toxicity because of progressive disease will not be replaced. 
 
 
 
 
Probability of DLT 
Probability of determining 
dose de-escalation is needed 
Mean # of patients needed to 
make determination 
0.05 
0.16 
8.8 
0.1 
0.30 
7.8 
0.15 
0.43 
6.9 
0.2 
0.55 
6.0 
0.25 
0.67 
5.3 
0.3 
0.76 
4.6 
0.35 
0.82 
4.1 
0.4 
0.88 
3.6 
 
Given the concerns for cardiac toxicity in patients receving sorafenib with standard chemotherapy, the 
addition of approximately 40 patients to Arm C, cohort 3 will provide improved precision in the estimates 
of mean change in shortening and ejection fraction between the end of Induction I and end of therapy. The 
table below provides the decrease in half-width for 95% CI for the change in shorten fraction/ejection 
fraction for standard deviations of change ranging from 5 to 8.  
 
# of Arm C 
patients 
# evaluable 
for SF/EF 
95% CI half 
width 
SD = 5 
95% CI half 
width 
SD = 6 
95% CI half 
width 
SD = 7 
95% CI half 
width 
SD = 8 
14 
9 
3.8 
4.6 
5.4 
6.1 
54 
36 
1.7 
2.0 
2.4 
2.7 
 

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9.2.3.4 Power Calculation for Aim 1.1.3: Comparison of High Risk Outcome with Historical Controls  
Assuming that 25% of the children without HR FLT3/ITD+ will be high risk, this study will have 80% 
power (1-sided testing at the 5% level of statistical significance) to detect a relative risk of failure of 0.78 
(roughly a 9% improvement in EFS). 
 
9.2.3.5 Power Calculations Aim 1.2.1: Assessment of Anti-leukemic Activity of Sorafenib in HR 
FLT3/ITD+ 
Several analyses will be performed to assess the efficacy of sorafenib. First, minimal residual disease levels 
at the end of Induction I will be compared, using a test of proportions, between patients who receive 
sorafenib starting in Induction I (sorafenib cohorts 2 and 3) with those patients who receive sorafenib 
starting in Induction II (first sorafenib cohort). Since only 10 patients are expected to be enrolled in the first 
sorafenib cohort, this analysis may be exploratory. Second, prevalence of minimal residual disease at the 
end of Induction I and II will be compared, using tests of proportions, between patients treated with 
sorafenib in Cohorts 2 and 3 on AAML1031 with patients with HR FLT3/ITD+ enrolled on AAML0531 
(there are 64 patients with HR FLT3/ITD+ enrolled on AAML0531 as of September 27, 2010. (Todd 
Alonzo personal communication, 2010). Given the sample numbers of patients expected in Cohorts 2 and 
3, these analyses will be exploratory. Finally, OS and EFS from study entry will be compared, using log-
rank tests, for patients treated with sorafenib in the second and third cohorts on AAML1031 with patients 
with HR FLT3/ITD+ enrolled on AAML0531. These analyses will be exploratory.  
 
The table below summarizes the decrease in estimated half-width of the 95% CI with an additional 40 
patients enrolled on Arm C, Cohort 3 for MRD positivity at the end of Induction assuming MRD positivity 
of 50% (the MRD positivity with the greatest variability). 
 
# of Arm C patients 
# evaluable for MRD 
95% CI half-width 
14 
13 
28% 
54 
50 
15% 
 
9.2.3.6 Power Calculations for Aim 1.2.2: Comparison of MRD Conversion with Historical Controls 
Assuming that 25% of the children without HR FLT3/ITD+ will be high risk and 83% of them will be 
MRD+ at the end of Induction I, this study will have 80% power (2-sided testing at the 5% level of statistical 
significance) to detect between a 7% and 9% difference in MRD conversion rates. 
 
9.2.3.7 Power Calculations Aim 1.2.3: Comparison of SCT Outcome with Historical Controls 
Outcomes for high risk patients on AAML1031 who are assigned alternative SCT will be compared to 
comparable patients on AAML0531 who were not assigned alternative SCT. Specifically, OS and DFS 
from the end of Intensification I will be compared using the log-rank test and cumulative incidence of 
treatment related mortality (TRM) and relapse will be compared using Gray’s test. Given the small sample 
size, this analysis will be exploratory. 
 
9.2.3.8 Power Calculations Aim 1.2.4: Comparison of SCT Outcome with Historical Controls 
OS and DFS from the end of Intensification I will be compared, using the log-rank test, between 
AAML1031 patients assigned MFD SCT and AAML0531 patients assigned MFD SCT. In addition, the 
cumulative incidence of TRM, relapse, and severe toxicity will be compared using Gray’s test. As of 
September 27, 2010, approximately 100 AAML0531 patients have been assigned MFD SCT (Todd Alonzo 
personal communication, 2010). If we assume 77% of the non-HR FLT3/ITD+ patients will still be on 
protocol therapy at end of Intensification I (this is consistent with AML0531) and 25% of these are high 
risk, then there will be 202 high risk patients still on protocol therapy at the end of Intensification I. If 25% 
of these have a MFD, then about 50 will receive MFD SCT on protocol therapy. There will be 
approximately 80% power with 2-sided 5% type I error rate to detect a 23% difference in DFS plateaus 

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from the end of Intensification I (75% vs 52%, 0.44 hazard ratio) between patients assigned MFD SCT on 
AAML1031 and patients assigned MFD SCT on AAML0531 
 
9.2.3.9 Power Calculations Aim 1.2.5: HRQOL 
We have powered the study to ensure sufficient precision in HRQOL estimates at 4 months following start 
of SCT or Intensification II of chemotherapy separately. If we assume that there are 1050 non-HR 
FLT3/ITD+ subjects available, we estimate that 77%  will be between 2 and 18 years of age (derived from 
AAML0531), leaving 809 patients in the appropriate age range. If we assume that 70% of these patients 
would meet other eligibility criteria and consent to participate, this leaves 566 subjects that will be enrolled 
onto the HRQOL aim of the study. If we assume 70% of these patients will still be on study and event free 
at 4 months following start of SCT or Intensification II (consistent with AAML0531) and 25% of these are 
high risk, then there will be 99 high risk and thus assigned to SCT and 297 low risk patients and thus 
assigned to chemotherapy subjects still on protocol therapy at 4 months following SCT or Intensification 
II. Assuming a standard deviation of 20 points, the half-width of the 95% confidence interval for HRQOL 
will be 3.99 points and 2.28 points for patients assigned SCT and chemotherapy, respectively. In total, this 
approach would include 435 patients in the analysis for the time point at 4 months following start of SCT 
or Intensification II. This precision is sufficient for our purposes. Given the limited number of HR 
FLT3/ITD+ patients expected to be enrolled onto the HRQOL aim of the study, analysis of HRQOL for 
HR FLT3/ITD+ patients will be exploratory. 
 
9.2.3.10 Power Calculations for Aim 1.2.8: Changes in Cardiac Function with/without Dexrazoxane 
Since the prevalence of dexrazoxane use is not known, it is not possible to estimate the available study 
power for Aim 1.2.5. If the prevalence of dexrazoxane use is low, then the comparison of changes in 
shortening fraction over time between patients treated with and without dexrazoxane will be exploratory. 
 
9.2.3.11 Power Calculations Aim 1.2.9: Refinement of MRD Based Risk Stratification 
Outcomes for non HR FLT3/ITD+ subjects in morphologic remission at the end of Induction I will be 
compared for those with and without detectable leukemia by flow cytometry. OS from the end of the first 
course of therapy will be calculated as well as DFS and cumulative incidence of relapse. The Kaplan-Meier 
method will be used to calculate estimates of OS and DFS. Comparisons of outcomes will be accomplished 
using the log-rank test, Grey’s test, and multivariate Cox regressions that adjust for treatment arm, and 
clinical, demographic, and laboratory features, such as diagnostic WBC, cytogenetic class, and race. In 
addition, clinical outcome of the patients with minimal residual disease will be compared using varying 
levels of minimal residual disease and at various time points.  
 
If 85% of non HR FLT3/ITD+ subjects are in morphologic remission at the end of Induction I and 20% of 
these have detectable leukemia by flow cytometry, then this study will have 80% power to detect a 11% 
difference in plateaus for OS from end of Induction I (62% vs 73%, 1.5 hazard ratio) for those with and 
without detectable leukemia by flow cytometry. 
 
9.2.3.12 Power Calculations Aim 1.2.10: Prognostic significance of molecular MRD and its contribution to 
risk identification with MDF based MRD 
Molecular MRD and morphologic MRD will be assessed in non HR FLT3/ITD+ subjects with t(8;21), 
inv(16), and t(9;11). The proportions of these subjects in which each type of MRD is detected will be 
estimated along with corresponding confidence intervals. Assuming MRD results are available for 367 
(35%) non HR FLT3/ITD+ subjects with t(8;21), inv(16), and t(9;11), this study will provide a precision of 
± 4.1% at a prevalence of 20% of patients with MRD.  
 
9.2.3.13 Power Calculations Aim 1.2.11: Determine leukemic involvement of the hematopoietic early 
progenitor cell 

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Outcomes, e.g. DFS and time to relapse, will be compared for patients who achieve a MRD level of less 
than 1 in 10,000 versus those who fail to achieve a MRD level less than 1 in 10,000. The morphologic 
remission (< 5% myeloblasts) rates after induction I will also be compared. The Kaplan-Meier method will 
be used to calculate estimates of DFS while methods that account for competing events will be used to 
estimate cumulative incidence of relapse. Comparisons of outcomes will be accomplished using the log-
rank test, Grey’s test, and multivariate Cox regressions that adjust for treatment arm, and clinical, 
demographic, and laboratory features, such as diagnostic WBC, cytogenetic class, age, and race. Assuming 
MRD and morphology results are available for 200 patients (100 ADE and 100 ADE + Bortezomib) and 
40% of patients have MRD, then there will be 80% power to detect a 20% difference in DFS plateaus (46% 
vs 66%, 1.9 hazard ratio) between those with and without MRD collapsed across treatment arms. Analysis 
for a particular treatment arm will be 80% power to detect a 28% difference in DFS plateaus (41% vs 69%, 
2.4 hazard ratio) between those with and without MRD. This study will have 80% power to detect an 18% 
difference in CR rates after Induction I collapsed across treatment arms.  
 
9.2.3.14 Power Calculations Aim 1.2.12: Definition of the Leukemia Stem cell Population in Patients with 
AML 
Outcomes, e.g. DFS and time to relapse, will be compared for subjects who achieve a MRD level of less 
than 1 in 10,000 versus those who fail to achieve a MRD level less than 1 in 10,000. The Kaplan-Meier 
method will be used to calculate estimates of DFS while methods that account for competing events will 
be used to estimate cumulative incidence of relapse. Comparisons of outcomes will be accomplished using 
the log-rank test, Grey’s test, and multivariate Cox regressions that adjust for treatment arm, and clinical, 
demographic, and laboratory features, such as diagnostic WBC, cytogenetic class, and race. Assuming 
MRD results are available for 200 patients (100 ADE and 100 ADE + Bortezomib) and 40% of patients 
have MRD, then there will be 80% power to detect a 20% difference in DFS plateaus (46% vs 66%, 1.9 
hazard ratio) between those with and without MRD collapsed across treatment arms. Analysis for a 
particular treatment arm will be 80% power to detect a 28% difference in DFS plateaus (41% vs 69%, 2.4 
hazard ratio) between those with and without MRD.  
 
9.2.3.15 Power Calculations Aim 1.2.13: determine the prevalence and prognostic significance of 
molecular abnormalities of WT1, RUNX1, MLL-PTD, TET2, c-CBL, KIT, and other novel AML 
associated genes in pediatric AML 
The proportions of patients with WT1, RUNX1, MLL-PTD, TET2, c-CBL, KIT, and other abnormalities will 
be estimated along with corresponding confidence intervals. Assuming that 900 patients will have 
molecular results available, this study will provide a worst case precision of ±3.3% at a prevalence of 50%. 
This precision will improve as the prevalence moves away from 50%, with a ± 2.0% precision at a 
prevalence of 10%. The Kaplan-Meier method will be used to calculate estimates of OS, EFS, and DFS. 
Comparisons of outcomes will be accomplished using the log-rank test and multivariate Cox regressions 
that adjust for treatment arm, and clinical, demographic, and laboratory features, such as diagnostic WBC, 
cytogenetic class, and race. The table below provides the difference in EFS plateaus and hazard ratios (HR) 
this study will have 80% power to detect between those with and without the mutation if the specified 
prevalence of mutation is observed. 
 
Prevalence of Mutation 
Difference in EFS plateaus (HR) 
5% 
20% (1.74) 
10% 
15.5% (1.51) 
15% 
13% (1.45) 
20% 
11.25% (1.38) 
 
 
 

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9.2.3.16 Power Calculations Aim 1.2.14: Correlate the expression of CD74 antigen as well as PSMB5 
gene expression and mutation with response to Bortezomib 
Descriptive statistics will be used to summarize expression of CD74 antigen as well as PSMB5 gene 
expression and mutation. The Kaplan-Meier method will be used to calculate estimates of OS and DFS. 
Outcomes will be compared for subjects with expression levels above and below the median expression 
levels using, for example, the log-rank test and multivariate Cox regressions that adjust for treatment arm, 
and clinical, demographic, and laboratory features, such as diagnostic WBC, cytogenetic class, and race.  
 
9.2.3.17 Power Calculations Aim 1.2.15: Evaluation of Protein Expression and Unfolded Protein 
Response in Patients with AML 
Bulk leukemia cells were collected and analyzed from 35 of the initial 80 patients enrolled on study (43%). 
Based on this collection rate, with an enrollment of 1150 evaluable patients, we estimate that we will 
evaluate samples from 624 patients (312/treatment group). Leukemia initiation cells (LIC) isolation 
(CD34+CD38+) was successfully completed for 18 of the 35 evaluable samples. Based on this data, we 
conservatively estimate that we will successfully enrich for LIC in 25% of eligible patients (n=156, 
78/treatment group).  
 
9.2.3.17.1 Protein Expression: The objective of this biology aim is to provide a more global assessment of 
protein cell stress pathways and AML cell signaling following ADE +/- bortezomib treatments. Data in this 
analysis arise from a clinical trial with multiple arms, 3 sampling time points and 2 cellular subsets of 
individual samples (bulk tumor and LIC). Therefore, many different comparisons may be of interest.  
 
The statistical analysis will be performed in a stepwise manner: 
1) We will first look at dynamic changes in protein activations following chemotherapy in myeloblasts 
and AML-LIC cells. The purpose is to discover natural groupings based on proteomic data only, 
without any information about outcome, to compare those groups with other known classifications 
and then to perform bioinformatics analysis to identify pathways active in each of the newly 
identified clusters. 
2) Once clinical outcomes become available, we will analyze the difference in protein profiles 
between ADE and ADEB treatment groups as they relate to CR. This part will include different 
unsupervised methods and group comparisons. 
3) Finally, we will create a classifier(s) to predict clinical outcome. We will use outcome variables 
CR, MRD, relapse risk, and 2-year EFS. 
 
As with other high-dimensional data, RPPA data analysis will include low-level and high-level analysis: 
1)   In the low-level analysis, relative protein levels will be determined by interpolation of dilution 
curves 
from 
the 
global 
"standard 
curve" 
using 
the 
R 
package 
“SuperCurve”.52 
(http://bioinformatics.mdanderson.org/Software/OOMPA/Current/SuperCurve-manual.pdf). After 
normalization for protein loading and appropriate transformation, assessments of quality will be 
performed.  
2)  High-level analysis: To determine clusters (classes) with potentially different outcome or treatment 
targets based on protein expression and activation, we will use Hierarchical Clustering, Principal 
Component Analysis (PCA), Self Organizing Maps (SOM) and other class discovery methods.53 
Cluster stability will be accessed using reproducibility measures, including GAP,54 as well as 
robustness and discrepancy indices.55 Differentially expressed proteins will be found using paired 
t-test as well as repeated measures, mixed effect ANOVA and ANOVA with contrasts. We will use 
the Benjamini-Hockberg correction to account for multiple comparisons.56 To determine if dynamic 
changes in specific protein pathways predict chemoresistance, we will use different regression and 
classification methods: SOM (when no outcome is used), class prediction methods such as logistic 
regression, Support Vector Machine,57 Random Forest,58 Binary Tree Prediction, Bayesian 

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Compound 
Covariate 
Predictor, 
Discriminant 
analysis 
(http://linus.nci.nih.gov/techreport/Manual32.pdf), and finally, Cox proportional hazard models for 
survival analysis. We will use different boosting methods59 to combine different models for the 
purpose of producing more accurate classification and regression models. 
 
Comparison of protein expression profiles between responders and non-responders (e.g., CR after Induction 
I and EFS at 2 years) will also be assessed using an unpaired t-test in each group. We would expect to be 
able to detect fold changes as small as 1.54 (tumor cell group) and 1.86 (LIC group) between responders 
and non-responders at an alpha level of 0.05 and power of 80%.  
 
9.2.3.17.2 Unfolded protein response: We will assess UPR activity at baseline, before and after treatment, 
and across AML molecular subtypes. Differences in transcript expression will be compared using 2-sample 
t-tests, paired t-tests for pre-/post- treatment expression, or mixed-effects modeling when multiple post-
treatment measures are obtained. Baseline UPR activation, and UPR induction following treatment, will be 
compared between cytogenetic and molecular subtypes by analysis of variance. Fold-differences in Grp78 
and CHOP median expression, and between spliced and non-spliced sXBP1, will be reported for each 
common cytogenetic phenotype. Samples were collected and analyzed from 35 of the initial 80 patients 
enrolled (43%).  Based on this collection rate, with an enrollment of 1150 evaluable patients, we estimate 
that we will collect samples from 624 patients (312/treatment group). Because of the varying numbers of 
patients that are expected to be seen with each molecular abnormality, the power to detect differences will 
be dependent on the number of patients within each category. Chemotherapy responders and non-
responders will be compared within each treatment group using t-tests or a nonparametric analogue to 
compare baseline UPR activity or induction after treatment. While the UPR transcript expressions will be 
separately analyzed, we will look for any significant correlations between the transcripts. Given the 
projected sample numbers and using variability data from preliminary analyses, fold-changes as small as 
1.23 in the tumor cell group and 1.35 in the LIC group would be detectable using a conservative standard 
deviation of 1.0 (log-2 scale) at an alpha level of 0.05 and 80% power. 
 
9.2.3.17.3 Correlation of protein data with clinical variables: We expect to analyze 624 pediatric patients 
as a group to determine if RPPA provides prognostic/predictive information independent of known 
prognostic variables and information that is complementary to existing prognostic markers. 1) Determine 
if there is a protein classifier prognostic of clinical outcome:  After assignment of each patient to a training 
set or test set (n=312 each), supervised clustering analysis will be performed based on each clinical outcome 
variable, including CR, MRD, relapse risk and 2 year EFS. Multivariate analysis will be performed to 
determine if classifiers are independent predictors of response (or outcome) when controlling for known 
prognostic variables.  2) Determine if any of the protein classifiers are independent of known outcome 
predictors. Supervised clustering will be repeated for each prognostic variable in pediatric AML, including 
age (< 1y vs. > 1y), cytogenetics (low risk vs. high risk), WBC count (< 150,000 vs. > 150,000 cells/μL) 
and MRD status at the end of induction (< 0.1% = MRD negative, > 0.1% = MRD positive). This will 
determine if putative RPPA protein classifiers provide an independent assessment of either ADE response 
or relapse risk. 
 
9.2.3.18 Power Calculations Aim 1.2.16: Expression levels of wild type FLT3, and correlate with 
outcome and in vitro sensitivity to FLT3 inhibition 
Descriptive statistics will be used to summarize FLT3 expression in those without FLT3/ITD+. The Kaplan-
Meier method will be used to calculate estimates of OS, EFS, and DFS. Outcomes will be compared for 
subjects with expression levels above and below the median expression levels using, for example, the log-
rank test and multivariate Cox regressions that adjust for treatment arm, and clinical, demographic, and 
laboratory features, such as diagnostic WBC, cytogenetic class, and race. We will identify the 30-50 
subjects with highest wild type (WT) FLT3 expression and 30-50 subjects with lowest WT FLT3 
expression. In these patients we will investigate the ability of sorafenib to induce cell apoptosis and cell 

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death. The IC50 of sorafenib will be calculated for each case, and descriptive statistics will be used to 
characterize the IC50 for the high and low expression groups. Appropriate statistics will be used to compare 
these parameters between the two groups, and to test the hypothesis that cases with high FLT3 expression 
will be more sensitive (i.e., will have a lower IC50) than cases with low FLT3 expression. For example, with 
30 cases in each group, assuming a intragroup standard deviation of 10 nM, we will be able to detect an 
IC50 difference of 7.4 nM between groups (alpha of 0.05, power of 80%). 
 
9.2.3.19 Power Calculations Aim 1.2.18: Development of aGVHD Prediction Algorithm 
Simulation studies performed on the pilot data set indicate that a sample size of 250 patients will have 
appropriate statistical power to define the sensitivity and specificity of the prediction algorithm. 
Specifically, the mean and covariance matrix for the four (log-transformed) biomarker levels was estimated. 
Assuming a multivariate normal distribution for the measured biomarkers, a dataset of (log-transformed) 
biomarker levels for N hypothetical patients was created. Two-thirds of patients were randomly selected as 
a training set and the remaining one-third of patients as a validation set. A logistic regression model for the 
probability of developing aGVHD by Day 56 using the log-transformed biomarker levels was fit. 
Thresholds for the resulting fitted probabilities such that 50% of aGVHD- patients in the training set had a 
fitted probability no larger than that threshold, i.e. a specificity of 0.50, were set. The fitted logistic 
regression model and threshold was applied to the validation set to determine the specificity and sensitivity 
of in the validation set. This simulation was repeated 1,000 times to assess inherent variability. The 
following table displays the means sensitivity and specificity values with 95% confidence intervals across 
a range of sample sizes. Evaluating these test characteristics, a sample size of 250 was selected. 
 
 
 
Training Set 
Validation Set 
N 
Mean Specificity 
(95% CI) 
Mean Sensitivity 
(95% CI) 
Mean Specificity 
(95% CI) 
Mean Sensitivity 
(95% CI) 
200 
0.50 
n/a 
0.69 
(0.52, 0.84) 
0.47 
(0.31, 0.64) 
0.65 
(0.42, 0.86) 
250 
0.50 
n/a 
0.68 
(0.52, 0.82) 
0.48 
(0.32, 0.64) 
0.65 
(0.43, 0.84) 
300 
0.50 
n/a 
0.68 
(0.53, 0.80) 
0.48 
(0.32, 0.63) 
0.66 
(0.44, 0.82) 
 
9.3 
Interim Monitoring 
 
9.3.1 
Bortezomib Toxic Mortality and Adult Respiratory Distress Syndrome Monitoring 
Continuous monitoring of toxicity will be performed in the first 100 non- HR FLT3/ITD patients 
randomized to receive Bortezomib. It is expected that a small percentage of patients will experience toxic 
mortality (TM). Interim monitoring will be performed by determining the probability of observing the 
observed number of treatment related deaths out of the number of patients that have completed that phase 
of therapy, if the expected TM rate is the true rate. If this probability is smaller than 0.01 at an interim 
analysis, then treatment modification or study termination will be considered. The tables below provide the 
type I error rates and power of rejecting the null (expected) TM rate when the true incidence is that given 
in the Table below and a boundary of 0.06 is used in the final analysis that includes all 100 patients. 
 
Course 
Expected TM 
rate 
Type I error 
Excess TM rate 
Power 
Induction I 
2% 
0.063 
8% 
91.9% 
Induction II 
1% 
0.027 
7% 
91.3% 
Intensification I 
1% 
0.059 
7% 
92.7% 
Intensification II 
2% 
0.032 
8% 
69.1% 

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It is expected that a small percentage of patients will experience Grade 4 or higher ARDS. Continuous 
monitoring will be performed by determining the probability of observing the observed number of Grade 4 
or higher ARDS out of the number of patients that have completed that phase of therapy, if the expected 
ARDS rate is the true rate. If this probability is smaller than 0.01 at an interim analysis, then treatment 
modification or study termination will be considered. The tables below provide the type I error rates and 
power of rejecting the null (expected) ARDS rate when the true incidence is that given in the Table below 
and a boundary of 0.06 is used in the final analysis that includes all 100 patients. 
 
Course 
Expected ARDS 
rate 
Type I error 
Excess ARDS 
rate 
Power 
Induction I 
3% 
0.050 
10% 
89.7% 
Induction II 
1% 
0.027 
7% 
91.3% 
Intensification I 
1% 
0.059 
7% 
92.7% 
Intensification II 
3% 
0.043 
10% 
83.6% 
 
Update as of Amendment #3A: Interim monitoring after the 100 non-HR FLT3/ITD patients was completed 
and stopping rules for adult respiratory distress syndrome and treatment related mortality were not 
triggered. 
 
9.3.2 
Interim Monitoring for Bortezomib Efficacy 
Monitoring for efficacy with respect to EFS from study entry will utilize monitoring based on the Lan-
DeMets criterion with α-spending function αt2 (truncated at 3 standard deviations) and 2.5% type I error. 
The study will also be monitored for futility using lower boundaries based on testing the alternative 
hypothesis at the 0.005 level. Formal monitoring analyses will be performed every 12 months with the first 
analysis performed after 25% of the expected information has been observed. 
 
9.3.3 
Monitoring of Sorafenib Arm C 
 
9.3.3.1 Toxic Mortality for Sorafenib Patients during Chemotherapy Courses 
Sorafenib dose modification or termination will be considered if 3 or more of the first 10 patients enrolled 
on Arm C cohort 3 experience a toxic mortality (TM) during any of the four courses of chemotherapy. 
Sorafenib dose modification or termination will be considered with probability 0.10 if the true TM rate is 
10% and with probability 0.83 if the true TM rate is 40%. 
 
9.3.3.2 Toxic Mortality for Sorafenib Patients during Maintenance 
Sorafenib dose modification or termination during maintenance will be considered if 3 or more of the first 
10 patients enrolled on Arm C cohort 3 experience a toxic mortality (TM) during Sorafenib Maintenance 
therapy. Sorafenib dose modification or termination will be considered with probability 0.10 if the true TM 
rate is 10% and with probability 0.83 if the true TM rate is 40%. 
 
9.3.3.3 Sorafenib Discontinuation for Cardiac Toxicity 
Sorafenib dose modification or termination will be considered if 3 or more of the subsequent 10 patients 
enrolled on Arm C cohort 3 have permanent sorafenib discontinuation for cardiac toxicity during any phase 
of treatment. Sorafenib dose modification or termination will be considered with probability 0.07 if the true 
permanent discontinuation rate is 10% and with probability 0.83 if the true permanent discontinuation rate 
is 40%. 
 
 

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9.4 
Gender and Minority Accrual Estimates 
 
The gender and minority distribution of the study population is expected to be: 
 
Accrual Targets 
Ethnic Category 
Sex/Gender 
Females 
Males 
Total 
Hispanic or Latino 
174 
161 
335 
Not Hispanic or Latino 
706 
709 
1415 
Ethnic Category: Total of all subjects 
880 
870 
1,750 
Racial Category 
 
American Indian or Alaskan Native 
3 
3 
6 
Asian 
52 
41 
93 
Black or African American 
125 
99 
224 
Native Hawaiian or other Pacific Islander 
0 
3 
3 
White 
700 
724 
1424 
Racial Category: Total of all subjects 
880 
870 
1750 
This distribution was derived from AAML0531. 
 
 
10.0 
EVALUATION CRITERIA  
 
10.1 
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. Please note: ‘CTCAE v4.0’ 
is understood to represent the most current version of CTCAE v4.0 as referenced on the CTEP website (i.e., 
v4.02 and all subsequent iterations prior to version 5.0). 
 
All suspected or confirmed dose limiting toxicities should be reported to the Study Chair within 
24 hours of toxicity ascertainment. All suspected or dose limiting toxicities should also be submitted 
through the CTEP-AERS mechanism. Additionally, all reportable toxicities are to be submitted to 
eRDES on the appropriate case report forms. See Section 11. 
 
10.2 
Response Criteria for Patients with Acute Myeloid Leukemia 
 
The following definitions for response will be used: 
 
10.2.1 Complete Remission (CR)  
The bone marrow is regenerating normal hematopoietic cells and contains < 5% leukemic blasts by 
morphology and no evidence of extramedullary disease (EMD). This designation occurs at the end of 
Induction II. 
 

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10.2.2 Refractory Disease/Induction Failure (RD)  
Two  consecutive cellular bone marrow evaluations (separated by at least 2 weeks) that contain ≥ 5% 
leukemic blasts by morphology or evidence of EMD at the end of Induction II. Patients with CNS EMD at 
end of Induction I may stay on protocol therapy if CSF cytology is negative.   
 
Presence of CNS leukemia as determined by CSF examination after 6 intrathecal cytarabine treatments in 
either Induction I or Induction II. 
 
Presence of CNS leukemia as determined by CSF examination at the start of Induction II after treatment 
for CNS leukemia at start of Induction I. 
 
10.2.3 Relapse 
Morphologic relapse after CR is defined as a reappearance of leukemic blasts in the peripheral blood or 
≥ 5% blasts in the bone marrow not attributable to any other cause (e.g., bone marrow regeneration) after 
documented CR at end of Induction II. In the setting of recent treatment, if there are no circulating blasts 
and the bone marrow contains 5% to 20% blasts, a repeat bone marrow performed at least a week later 
is necessary to distinguish relapse from bone marrow regeneration. Should local flow cytometric analyses 
suggest relapse (by the reappearance of a similar immunophenotype to the original leukemia) in the 
presence of < 5% blasts, or ≥ 5% blasts in a regenerating marrow, a repeat bone marrow(s) performed 
at least a week later is necessary to confirm relapse by morphologic methods. In such instances the date 
of recurrence is defined as the first date that more than 5% leukemic blasts were observed in the marrow.  
 
Molecular and/or genetic relapse is characterized by reappearance of a cytogenetics or molecular 
abnormality after documented CR at end of Induction II. A bone marrow examination performed at least a 
week later is necessary to confirm cytogenetic or molecular relapse. 
 
Extramedullary disease relapse is defined as appearance of cytologically proven extramedullary disease 
after documented CR in Induction II. 
 
Recurrence of disease prior to the end of Induction II and still present at the end of Induction II will be 
considered refractory disease in accordance with Section 10.2.2. Recurrence of disease prior to the end of 
Induction II but absent at the end of Induction II would be classified as a complete remission in accordance 
with Section 10.2.1. 
 
10.2.4 Unevaluable 
Aplastic or severely hypocellular marrow with any blast percentage. In this instance, marrow evaluation 
should be repeated every 7 to 21 days until response determination can be made. 
 
10.3 
Graft Failure following Allogeneic SCT 
 
10.3.1 Primary Graft Failure: 
Failure to achieve an ANC > 500/µL by Day 28 post-HSCT (Day 42 for cord blood or haploidentical 
donors) and <20% donor cells as assessed by bone marrow chimerism studies and absence of leukemia 
relapse (which would be considered a relapse event). 
. 
 
10.3.2 Secondary Graft Failure: 
Hematopoietic recovery followed by severe neutropenia (ANC ≤ 500/µL) for 7 consecutive measurements 
on different days that is not caused by recurrent leukemia, active viral infection, or drugs. Improvement is 
defined as an ANC > 500/µL for 7 days.   

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Marrow or peripheral blood stem cell reinfusion carried out any time after Day 0 because of inadequate 
hematopoietic function will be considered graft failure regardless of ANC values and marrow cellularity. 
 
Acute and Chronic GVHD: 
The staging of acute GVHD will follow National Marrow Donor Program (NMDP) guidelines 
(Section 20.5) but will include weekly capture of symptoms for the first 100 days post transplant. Details 
regarding the definition and diagnosis of chronic GVHD are listed in Section 20.5.  
 
 
 
11.0 
ADVERSE EVENT REPORTING REQUIREMENTS  
 
11.1 
Purpose 
Adverse event (AE) data collection and reporting, which are required as part of every clinical trial, are done 
to ensure the safety of patients enrolled in the studies as well as those who will enroll in future studies using 
similar agents. Certain adverse events must be reported in an expedited manner to allow for timelier 
monitoring of patient safety and care. The following sections provide information about expedited 
reporting. 
 
11.2 
Determination of reporting requirements 
Reporting requirements may include the following considerations: 1) whether the patient has received an 
investigational or commercial agent; 2) the characteristics of the adverse event including the grade 
(severity), the relationship to the study therapy (attribution), and the prior experience (expectedness) of the 
adverse event; 3) the Phase (1, 2, or 3) of the trial; and 4) whether or not hospitalization or prolongation of 
hospitalization was associated with the event.  
 
An investigational agent is a protocol drug administered under an Investigational New Drug Application 
(IND). In some instances, the investigational agent may be available commercially, but is actually being 
tested for indications not included in the approved package label.  
Commercial agents are those agents not provided under an IND but obtained instead from a commercial 
source. The NCI, rather than a commercial distributor, may on some occasions distribute commercial agents 
for a trial. 
 
 
When a study includes both investigational and commercial agents, the following rules apply. 
• 
Concurrent administration: When an investigational agent is used in combination with a 
commercial agent, the combination is considered to be investigational and expedited 
reporting of adverse events would follow the guidelines for investigational agents. 
• 
Sequential administration: When a study includes an investigational agent and a commercial 
agent on the same study arm, but the commercial agent is given for a period of time prior to 
starting the investigational agent, expedited reporting of adverse events that occur prior to 
starting the investigational agent would follow the guidelines for commercial agents. Once 
therapy with the investigational agent is initiated, all expedited reporting of adverse events 
follow the investigational agent reporting guidelines. 
 
11.3 
Expedited Reporting Requirements – Serious Adverse Events (SAEs) 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be 
submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP 
Adverse Event Expedited Reporting System (CTEP-AERS). 
 

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Any AE that is serious qualifies for expedited reporting. An AE is defined as any untoward medical 
occurrence associated with the use of a drug in humans, whether or not considered drug related. A Serious 
Adverse Event (SAE) is any adverse drug event (experience) occurring at any dose that results in ANY of 
the following outcomes: 
 
1) Death. 
2) A life-threatening adverse drug experience. 
3) An adverse event resulting in inpatient hospitalization or prolongation of existing hospitalization 
(for ≥ 24 hours). This does not include hospitalizations that are part of routine medical practice. 
4) A persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
functions. 
5) A congenital anomaly/birth defect. 
6) Important Medical Events (IME) that may not result in death, be life threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon medical 
judgment, they may jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. 
 
11.4 
Special Situations for Expedited Reporting  
11.4.1 SAEs Occurring More than 30 Days After Last Dose of Study Drug 
Any Serious Adverse Event that occurs more than 30 days after the last administration of the investigational 
agent/intervention and has an attribution of a possible, probable, or definite relationship to the study therapy 
must be reported according to the CTEP-AERS reporting tables in this protocol.  
 
11.4.2 Persistent or Significant Disabilities/Incapacities 
Any AE that results in persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions (formerly referred to as disabilities), congenital anomalies or birth defects, must be 
reported via CTEP-AERS if it occurs at any time following treatment with an agent under a NCI IND/IDE 
since these are considered to be serious AEs. 
 
11.4.3 Death 
 
Reportable Categories of Death  
 
o Death attributable to a CTCAE term.  
o Death Neonatal: A disorder characterized by cessation of life during the first 28 days of life.  
o Sudden Death NOS: A sudden (defined as instant or within one hour of the onset of symptoms) 
or an unobserved cessation of life that cannot be attributed to a CTCAE term associated with 
Grade 5.  
o Death NOS: A cessation of life that cannot be attributed to a CTCAE term associated with grade 
5.  
o Death due to progressive disease should be reported as Grade 5 “Neoplasms benign, malignant 
and unspecified (incl cysts and polyps) - Other (Progressive Disease)” under the system organ 
class (SOC) of the same name. Evidence that the death was a manifestation of underlying disease 
(e.g., radiological changes suggesting tumor growth or progression: clinical deterioration 
associated with a disease process) should be submitted.  
 
Any death occurring within 30 days of the last dose, regardless of attribution to the investigational 
agent/intervention requires expedited reporting within 24 hours.  

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Any death occurring greater than 30 days after the last dose of the investigational agent/intervention 
requires expedited reporting within 24 hours only if it is possibly, probably, or definitely related to the 
investigational agent/intervention. 
 
11.4.4 Secondary Malignancy 
A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., treatment with 
investigational agent/intervention, radiation or chemotherapy). A metastasis of the initial neoplasm is not 
considered a secondary malignancy.  
 
The NCI requires all secondary malignancies that occur following treatment with an agent under an NCI 
IND/IDE be reported via CTEP-AERS. Three options are available to describe the event:  
• 
Leukemia secondary to oncology chemotherapy  
• 
Myelodysplastic syndrome  
• 
Treatment related secondary malignancy  
 
Any malignancy possibly related to cancer treatment (including AML/MDS) must also be reported via the 
routine reporting mechanisms outlined in this protocol. 
11.4.5 Second Malignancy 
A second malignancy is one unrelated to the treatment of a prior malignancy (and is NOT a 
metastasis from the initial malignancy). Second malignancies require ONLY routine reporting via 
CDUS unless otherwise specified. 
 
11.4.6 Pregnancy, Fetal Death, and Death Neonatal 
NOTE: When submitting CTEP-AERS reports for “Pregnancy”, “Pregnancy loss”, or “Neonatal 
loss”, the Pregnancy Information Form, available at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/PregnancyReportForm.
pdf, needs to be completed and faxed along with any additional medical information to (301) 230-
0159. The potential risk of exposure of the fetus to the investigational agent(s) or chemotherapy 
agent(s) should be documented in the “Description of Event” section of the CTEP-AERS report. 
 
11.4.6.1 Pregnancy 
Patients who become pregnant on study risk intrauterine exposure of the fetus to agents 
that may be teratogenic. For this reason, pregnancy needs to be reported in an expedited 
manner via CTEP-AERS as Grade 3 “Pregnancy, puerperium and perinatal 
conditions - Other (pregnancy)” under the Pregnancy, puerperium and perinatal 
conditions SOC. 
 
Pregnancy needs to be followed until the outcome is known. If the baby is born with 
a birth defect or anomaly, then a second CTEP-AERS report is required. 
 
11.4.6.2 Fetal Death 
Fetal death, defined in CTCAE as “A disorder characterized by death in utero; failure 
of the product of conception to show evidence of respiration, heartbeat, or definite 
movement of a voluntary muscle after expulsion from the uterus, without possibility of 
resuscitation”, needs to be reported expeditiously, as Grade 4 “Pregnancy, 
puerperium and perinatal conditions - Other (pregnancy loss)”. Do NOT report a 
fetal death as a Grade 5 event since CTEP-AERS recognizes any Grade 5 event as a 
patient death. 

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11.4.6.3 Death Neonatal  
Neonatal death, defined in CTCAE as “A disorder characterized by cessation of life 
occurring during the first 28 days of life” needs to be reported expeditiously, as Grade 
4 “General disorders and administration - Other (neonatal loss)” when the death is 
the result of a patient pregnancy or pregnancy in partners of men on study. Do 
NOT report a neonatal death resulting from a patient pregnancy or pregnancy in 
partners of men on study as a Grade 5 event since CTEP-AERS recognizes any Grade 
5 event as a patient death.  
 
11.5 
Reporting Requirements for Specialized AEs  
11.5.1 Baseline AEs 
Although a pertinent positive finding identified on baseline assessment is not an AE, when possible it is to 
be documented as “Course Zero” using CTCAE terminology and grade. An expedited AE report is not 
required if a patient is entered on a protocol with a pre-existing condition (eg, elevated laboratory value, 
diarrhea). The baseline AE must be re-assessed throughout the study and reported if it fulfills expedited AE 
reporting guidelines. 
 
a. If the pre-existing condition worsens in severity, the investigator must reassess the event to 
determine if an expedited report is required. 
b. If the AE resolves and then recurs, the investigator must re-assess the event to determine if an 
expedited report is required. 
c. No modification in grading is to be made to account for abnormalities existing at baseline. 
 
11.5.2 Persistent AEs 
A persistent AE is one that extends continuously, without resolution between treatment cycles/courses.  
ROUTINE reporting: The AE must be reported only once unless the grade becomes more severe in a 
subsequent course. If the grade becomes more severe the AE must be reported again with the new grade. 
EXPEDITED reporting: The AE must be reported only once unless the grade becomes more severe in the 
same or a subsequent course. 
 
11.5.3 Recurrent AEs 
A recurrent AE is one that occurs and resolves during a cycle/course of therapy and then reoccurs in a later 
cycle/course. 
ROUTINE reporting: An AE that resolves and then recurs during a subsequent cycle/course must be 
reported by the routine procedures. 
 
EXPEDITED reporting: An AE that resolves and then recurs during a subsequent cycle/course does not 
require CTEP-AERS reporting unless: 
1) The grade increases OR 
2) Hospitalization is associated with the recurring AE. 
 
11.6 
Exceptions to Expedited Reporting 
11.6.1 Specific Protocol Exceptions to Expedited Reporting (SPEER) 
SPEER: Is a subset of AEs within the Comprehensive Adverse Events and Potential Risks (CAEPR) that 
contains a list of events that are considered expected for CTEP-AERS reporting purposes. (Formerly 
referred to as the Agent Specific Adverse Event List (ASAEL).)  
 
AEs listed on the SPEER should be reported expeditiously by investigators to the NCI via CTEP-AERS 
ONLY if they exceed the grade of the event listed in parentheses after the event. If the CAEPR is part of a 

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combination IND using multiple investigational agents and has an SAE listed on different SPEERs, use the 
lower of the grades to determine if expedited reporting is required. 
 
11.6.2 Special Situations as Exceptions to Expedited Reporting 
An expedited report may not be required for a specific protocol where an AE is listed as expected. The 
exception or acceptable reporting procedures will be specified in the protocol. The protocol specific 
guidelines supersede the NCI Adverse Event Reporting Guidelines. These special situations are listed under 
the CTEP-AERS reporting Table A for this protocol. 
 
11.7 
Reporting Requirements - Investigator Responsibility 
Clinical investigators in the treating institutions and ultimately the Study Chair have the primary 
responsibility for AE identification, documentation, grading, and assignment of attribution to the 
investigational agent/intervention. It is the responsibility of the treating physician to supply the medical 
documentation needed to support the expedited AE reports in a timely manner.  
 
Note: All expedited AEs (reported via CTEP-AERS) must also be reported via routine reporting. Routine 
reporting is accomplished via the Adverse Event (AE) Case Report Form (CRF) within the study database.   
 
11.8 
General Instructions for Expedited Reporting via CTEP-AERS  
The descriptions and grading scales found in the NCI Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 will be utilized for AE reporting and are located on the CTEP website at:  
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. All appropriate treatment 
areas should have access to a copy of the CTCAE. 
 
An expedited AE report for all studies utilizing agents under an NCI IND/IDE must be submitted 
electronically to NCI via CTEP-AERS at: https://eapps-ctep.nci.nih.gov/ctepaers. 
 
In the rare situation where Internet connectivity is disrupted, the 24-hour notification is to be made to the 
NCI for agents supplied under a CTEP IND by telephone call to (301) 897-7497.  
In addition, once Internet connectivity is restored, a 24-hour notification that was phoned in must be entered 
into the electronic CTEP-AERS system by the original submitter of the report at the site.   
 
• 
Expedited AE reporting timelines are defined as: 
o 24-Hour; 5 Calendar Days - The AE must initially be reported via CTEP-AERS within 
24 hours of learning of the event, followed by a complete expedited report within 5 calendar 
days of the initial 24-hour report. 
o 7 Calendar Days - A complete expedited report on the AE must be submitted within 7 calendar 
days of the investigator learning of the event.  
 
• 
Any event that results in a persistent or significant incapacity/substantial disruption of the ability to 
conduct normal life functions, or a congenital anomaly/birth defect, or is an IME, which based upon 
the medical judgment of the investigator may jeopardize the patient and require intervention to prevent 
a serious AE, must be reported via CTEP-AERS if the event occurs following investigational agent 
administration.  
 
• 
Any death occurring within 30 days of the last dose, regardless of attribution to an agent/intervention 
under an NCI IND/IDE requires expedited reporting within 24 hours.  
• 
Any death occurring greater than 30 days of the last dose with an attribution of possible, probable, or 
definite to an agent/intervention under an NCI IND/IDE requires expedited reporting within 24 hours.  

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CTEP-AERS Medical Reporting includes the following requirements as part of the report: 1) whether the 
patient has received at least one dose of an investigational agent on this study; 2) the characteristics of the 
adverse event including the grade (severity), the relationship to the study therapy (attribution), and the 
prior experience (expectedness) of the adverse event; 3) the Phase (1, 2, or 3) of the trial; and 4) whether 
or not hospitalization or prolongation of hospitalization was associated with the event.  
 
Any medical documentation supporting an expedited report (eg, H & P, admission and/or notes, 
consultations, ECG results, etc.) MUST be faxed within 48-72 hours to the NCI. NOTE: English is 
required for supporting documentation submitted to the numbers listed below in order for the NCI 
to meet the regulatory reporting timelines.  
 
Fax supporting documentation for AEs related to investigational agents supplied under a CTEP IND 
to: (301) 230-0159 (back-up: (301) 897-7404).  
 
Also: Fax or email supporting documentation to COG for all IND studies (fax# (310) 640-9193; email:  
COGAERS@childrensoncologygroup.org; Attention: COG AERS Coordinator).  
 
• 
ALWAYS include the ticket number on all faxed documents. 
 
• 
Use the NCI protocol number and the protocol-specific patient ID provided during trial 
registration on all reports. 
 
11.9 
Reporting Table for Late Phase 2 and Phase 3 Studies – Table A 
Expedited Reporting Requirements for Adverse Events that Occur on Studies under an IND/IDE within 
30 Days of the Last Administration of the Investigational Agent/Intervention 1 
 
FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312)  
NOTE: Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether 
or not they are considered related to the investigational agent(s)/intervention (21 CFR 312.64).  
An adverse event is considered serious if it results in ANY of the following outcomes:  
1) Death.  
2) A life-threatening adverse event.  
3) Any AE that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 hours. 
This does not include hospitalizations that are part of routine medical practice. 
4) A persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
functions.  
5) A congenital anomaly/birth defect.  
6) Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization 
may be considered serious when, based upon medical judgment, they may jeopardize the patient or subject 
and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. 
(FDA, 21 CFR 312.32; ICH E2A and ICH E6.)  
 
ALL SERIOUS adverse events that meet the above criteria MUST be immediately reported to the NCI via 
CTEP-AERS within the timeframes detailed in the table below.   
Hospitalization 
Grade 1 
Timeframes 
Grade 2 
Timeframes 
Grade 3 
Timeframes 
Grade 4 & 5 
Timeframes 
Resulting in 
Hospitalization 
≥ 24 hrs 
 
7 Calendar Days 
 
 
24-Hour Notification 
5 Calendar Days 
Not resulting in 
 
 

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Hospitalization 
≥ 24 hrs 
Not Required 
7 Calendar Days 
NOTE: Protocol specific exceptions to expedited reporting of serious adverse events are found in the 
Specific Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR. Additional Special 
Situations as Exceptions to Expedited Reporting are listed below.  
 
Expedited AE reporting timelines are defined as:  
“24-Hour; 5 Calendar Days” - The AE must initially be reported via CTEP-AERS within 24 hours of learning 
of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour notification. 
“7 Calendar Days” - A complete expedited report on the AE must be submitted within 7 calendar days of 
learning of the AE.  
 
1SAEs that occur more than 30 days after the last administration of investigational agent/intervention and 
have an attribution of possible, probable, or definite require reporting as follows:  
Expedited 24-hour notification followed by complete report within 5 calendar days for:  
• 
All Grade 4, and Grade 5 AEs  
Expedited 7 calendar day reports for:  
• 
Grade 2 adverse events resulting in hospitalization or prolongation of hospitalization  
• 
Grade 3 adverse events  
 
 
11.10 Protocol Specific Additional Instructions and Reporting Exceptions 
The following toxicities DO NOT require expedited reporting on this trial: 
 
o Grades 
1-4 
hemoglobin, 
leukocytes, 
lymphocytes, 
neutrophils/granulocytes 
(ANC/AGC) or platelets, +/- hospitalization 
o Grade 3 nausea, vomiting, diarrhea, anorexia, or fatigue 
o Grade 3 alanine aminotransferase increased, aspartate aminotransferase increased 
that returns to Grade ≤ 1 or baseline within 35 days of the start of each course 
o Grade 3 hyperglycemia, hypokalemia, hypophosphatemia, hypomagnesemia 
o Grade 3 mucositis/stomatitis 
o Grade 1-4 fever, fever and neutropenia, or infection, +/- hospitalization, with the 
exception of zoster (varicella) or herpetic infections.  
 
The following toxicities DO require expedited reporting via the CTEP-AERS abbreviated pathway: 
o All suspected or dose limiting toxicities (as defined in Sections 4.7 and Section 5 
[toxicities related to bortezomib and sorafenib]) should be submitted through the CTEP-
AERS mechanism. 
 
11.11 Reporting of Adverse Events for commercial agents – CTEP-AERS abbreviated pathway 
 
The following are expedited reporting requirements for adverse events experienced by patients on study 
who have not received any doses of an investigational agent on this study. 
Commercial reporting requirements are provided in Table B.  
 
COG requires the CTEP-AERS report to be submitted within 7 calendar days of learning of the event. 
 
Table B  
Reporting requirements for adverse events experienced by patients on study who have NOT 
received any doses of an investigational agent on this study. 

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CTEP-AERS Reporting Requirements for Adverse Events That Occur During Therapy With a 
Commercial Agent or Within 30 Days1 
 
Attribution 
Grade 4 
Grade 5 
 
Unexpected 
Expected 
 
Unrelated or 
Unlikely 
 
 
CTEP-AERS 
Possible, 
Probable, Definite 
CTEP-AERS 
 
CTEP-AERS 
1This includes all deaths within 30 days of the last dose of treatment with a 
commercial agent, regardless of attribution.  Any death that occurs more than 
30 days after the last dose of treatment with a commercial agent that can be 
attributed (possibly, probably, or definitely) to the agent and is not due to 
cancer recurrence must be reported via CTEP-AERS. 
 
11.12 Routine Adverse Event Reporting 
 
Note: The guidelines below are for routine reporting of study specific adverse events on the COG case 
report forms and do not affect the requirements for CTEP-AERS reporting. 
 
Patients enrolled on Arm D (note enrolling on Arm C) do NOT require routine reporting of study 
specific adverse events.  
 
Patients enrolled on Arm C require routine reporting of study specific adverse events as outlined 
below. 
 
Routine reporting is accomplished via the Adverse Event (AE) Case Report Form (CRF) within the study 
database.  For this study, routine reporting will include: 
- 
All toxicities reported via CTEP-AERS,  
- 
All Grade 3 and higher non hematological Adverse Events,  
- 
All grades of the following cardiac events: left ventricular systolic dysfunction, heart failure, 
electrocardiogram QT corrected interval prolonged,  
- 
Dose limiting toxicities as defined in Section 5 [toxicities related to bortezomib and sorafenib]. 
- 
All grades of peripheral neuropathy and gastrointestinal ileus. 
 
11.13  Definition of Onset and Resolution of Adverse Events  
Note: These guidelines below are for reporting adverse events through eRDE and do not alter the guidelines 
for CTEP-AERS reporting.  
 
11.13.1 If an adverse event occurs more than once in a course (cycle) of therapy only the most severe grade 
of the event should be reported.  
 
11.13.2 If an adverse event progresses through several grades during one course of therapy, only the most 
severe grade should be reported.  
 
11.13.3 The duration of the AE is defined as the duration of the highest (most severe) grade of the Adverse 
Effects.  
 
11.13.4 The resolution date of the AE is defined as the date at which the AE returns to baseline or less than 
Grade 1, whichever level is higher (note that the resolution date may therefore be different from the date 

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at which the grade of the AE decreased from its highest grade). If the AE does not return to baseline the 
resolution date should be recorded as "ongoing."  
 
11.13.5 An adverse event that persists from one course to another should only be reported once unless the 
grade becomes more severe in a subsequent course. An adverse event which resolves and then recurs during 
a different course, must be reported each course it recurs. 
 
 
12.0 
RECORDS AND REPORTING 
The Case Report Forms and the submission schedule are posted on the COG web site with each protocol 
under “Data Collection/Specimens”.  
 
12.1 
CDUS 
This study will be monitored by the Clinical Data Update System (CDUS). Cumulative CDUS data will be 
submitted quarterly to CTEP by electronic means. Reports are due January 31, April 30, July 31 and October 
31. This is not a responsibility of institutions participating in this trial. 
 
12.2 
Data and Safety Monitoring Committee 
To protect the interests of patients and the scientific integrity for all clinical trial research by the Children’s 
Oncology Group, the COG Data and Safety Monitoring Committee (DSMC) reviews reports of interim 
analyses of study toxicity and outcomes prepared by the study statistician, in conjunction with the study 
chair’s report. The DSMC may recommend the study be modified or terminated based on these analyses.  
 
Toxicity monitoring is also the responsibility of the study committee and any unexpected frequency of 
serious events on the trial are to be brought to the attention of the DSMC. The study statistician is 
responsible for the monitoring of the interim results and is expected to request DSMC review of any 
protocol issues s/he feels require special review. Any COG member may bring specific study concerns to 
the attention of the DSMC.  
 
The DSMC approves major study modifications proposed by the study committee prior to implementation 
(e.g., termination, dropping an arm based on toxicity results or other trials reported, increasing target sample 
size, etc.). The DSMC determines whether and to whom outcome results may be released prior to the release 
of study results at the time specified in the protocol document. 
 
12.3 
CRADA/CTA 
The agent(s) supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI under a 
Collaborative Agreement (CRADA, CTA, CSA) between the Pharmaceutical Company(ies) (hereinafter 
referred to as “Collaborator(s)”) and the NCI Division of Cancer Treatment and Diagnosis. Therefore, the 
following obligations/guidelines, in addition to the provisions in the “Intellectual Property Option to 
Collaborator” (http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm) contained within 
the terms of award, apply to the use of the Agent(s) in this study: 
 
1. 
Agent(s) may not be used for any purpose outside the scope of this protocol, nor can Agent(s) be 
transferred or licensed to any party not participating in the clinical study. Collaborator(s) data for 
Agent(s) are confidential and proprietary to Collaborator(s) and shall be maintained as such by the 
investigators. The protocol documents for studies utilizing Agents contain confidential information 
and should not be shared or distributed without the permission of the NCI. If a copy of this protocol 
is requested by a patient or patient’s family member participating on the study, the individual 
should sign a confidentiality agreement. A suitable model agreement can be downloaded from: 
http://ctep.cancer.gov. 
 

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2. 
For a clinical protocol where there is an investigational Agent used in combination with (an)other 
Agent(s), each the subject of different Collaborative Agreements, the access to and use of data by 
each Collaborator shall be as follows (data pertaining to such combination use shall hereinafter be 
referred to as "Multi-Party Data”): 
 
a. 
NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NCI, the design of the 
proposed combination protocol, and the existence of any obligations that would tend to 
restrict NCI's participation in the proposed combination protocol. 
 
b. 
Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator to 
develop, obtain regulatory approval or commercialize its own Agent. 
 
c. 
Any Collaborator having the right to use the Multi-Party Data from these trials must agree 
in writing prior to the commencement of the trials that it will use the Multi-Party Data 
solely for development, regulatory approval, and commercialization of its own Agent. 
 
3. 
Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement will be 
made available to Collaborator(s), the NCI, and the FDA, as appropriate and unless additional 
disclosure is required by law or court order as described in the IP Option to Collaborator 
(http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm). 
Additionally, 
all 
Clinical Data and Results and Raw Data will be collected, used and disclosed consistent with all 
applicable federal statutes and regulations for the protection of human subjects, including, if 
applicable, the Standards for Privacy of Individually Identifiable Health Information set forth in 
45 C.F.R. Part 164. 
 
4. 
When a Collaborator wishes to initiate a data request, the request should first be sent to the NCI, 
who will then notify the appropriate investigators (Group Chair for Cooperative Group studies, or 
PI for other studies) of Collaborator's wish to contact them. 
 
5. 
Any data provided to Collaborator(s) for Phase 3 studies must be in accordance with the guidelines 
and policies of the responsible Data Monitoring Committee (DMC), if there is a DMC for this 
clinical trial. 
 
6. 
Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the Group 
office for Cooperative Group studies or by the principal investigator for non-Cooperative Group 
studies for immediate delivery to Collaborator(s) for advisory review and comment prior to 
submission for publication. Collaborator(s) will have 30 days from the date of receipt for review. 
Collaborator shall have the right to request that publication be delayed for up to an additional 30 
days in order to ensure that Collaborator’s confidential and proprietary data, in addition to 
Collaborator(s)’s intellectual property rights, are protected. Copies of abstracts must be provided 
to CTEP for forwarding to Collaborator(s) for courtesy review as soon as possible and preferably 
at least three (3) days prior to submission, but in any case, prior to presentation at the meeting or 
publication in the proceedings. Press releases and other media presentations must also be forwarded 
to CTEP prior to release. Copies of any manuscript, abstract and/or press release/ media 
presentation should be sent to: 
 
Email: ncicteppubs@mail.nih.gov 
 

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The Regulatory Affairs Branch will then distribute them to Collaborator(s). No publication, manuscript or 
other form of public disclosure shall contain any of Collaborator’s confidential/proprietary information. 
 
 
13.0 
PATHOLOGY GUIDELINES AND SPECIMEN REQUIREMENTS 
 
13.1 
Immunophenotyping Studies 
Immunophenotyping studies may be done at the local institution as part of the initial diagnostic work-up of 
acute leukemia. Although these immunophenotyping studies will be performed at multiple institutions and 
the nature of the technique and interpretation of results preclude the central review process, these data will 
be captured in this study as they are contributory to the diagnosis of AML. This information should be 
included in the bone marrow pathology report (to include the institutional morphologic assessment, 
immunophenotyping and cytochemistry). Flow cytometry immunophenotyping may be reported separately, 
if so, the complete flow cytometry report should be submitted. Immunophenotyping studies are essential in 
distinguishing AML from ALL. The 2008 world health organization (WHO) classification requires 
assessment of a certain set of cytoplasmic and surface antigens, with or without use of cytochemistry to 
define myeloid, lymphoid or mixed/ambiguous lineage (see Table 13.1.1). We strongly encourage the use 
of these markers:  
 
1) 
MPO (by cytochemistry, flow cytometry or immunohistochemistry) 
2) 
Cytoplasmic CD3 by flow cytometry 
3) 
CD19 (by flow cytometry), and at least 2 additional B-cell markers such as CD10, CD79a or 
cytoplasmic CD22. 
4) 
At least 3 markers of monocytic lineage: CD11c, CD14, CD64, lysozyme (by flow or 
immunohistochemistry) or NSE cytochemistry. 
 
Although no single myeloid-lineage-associated antigen is expressed by the leukemic blast cells in every 
patient with AML, the CD33 antigen is the most frequent, detectable in approximately 70%-80% of 
cases.129-131 Many patients with AML have blast cells that express other antigens associated with myeloid 
lineage differentiation (including CD11b, CD13, CD14, CD15, CD36, and glycoprotein 1b). However, a 
significant portion of patients with AML also express antigens associated with lymphoid-lineage 
differentiation.130-133 Use of the above recommended markers will aid in identifying acute leukemias with 
ambiguous or mixed myeloid/lymphoid lineages according to the WHO guidelines. Expression of certain 
antigens correlate with the morphologic subtype, such as CD11c, CD14, CD64, CD4, lysozyme in FAB 
M4 and M5 acute leukemias with monocytic differentiation, glycoprotein IIb/IIIa, glycoprotein Ib and 
Factor VIII antigen by megakaryoblastic leukemias (FAB M7)134,135 and glycophorin expression by 
erythroblastic leukemias (FAB M6).136  
 
In this study, AML blasts will be classified based upon the 2008 WHO morphologic, immunophenotypic, 
and genetic criteria.117 
 
 
 

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Table 13.1.1 
ASSIGNMENT OF LINEAGE IN MIXED PHENOTYPE ACUTE LEUKEMIA 
Lineage 
Criteria 
Myeloid lineage 
• 
Myeloperoxidase (by flow cytometry, immunohistochemistry or cytochemistry) 
OR 
• 
Monocytic differentiation (express at least 2 of the following: CD11c, CD14, 
CD64, lysozyme or NSE) 
T lymphoblastic 
• 
Cytoplasmic CD3 by flow cytometry 
OR 
• 
Surface CD3 (rare) 
B lymphoblastic 
• 
Strong CD19 and strong expression of at least one of the following: CD79a, 
cytoplasmic CD22 or CD10 
OR 
• 
Weak CD19 and strong expression of at least 2 of the following: CD79a, cytoplasmic 
CD22, CD10  
 
For Patients with Myeloid Sarcoma (Chloroma):  
If touch preps are able to be prepared from the tumor, the institutional pathologist should distribute/triage 
order(s) for FISH to be performed accordingly (e.g., RUNX1T1-RUNX1, CBFB). 
 
AML Reference Laboratory Immunophenotyping 
Research monoclonal antibody studies will be performed at the AML Reference Laboratory at the Fred 
Hutchinson Cancer Research Center in Seattle. The Reference Laboratory will help local institutions with 
immunophenotyping studies in difficult cases, but the Reference Laboratory does not have as its charge the 
routine immunophenotyping of all AML samples. 
 
13.2 
Cytomorphologic Studies 
 
13.2.1 Central Pathology Review 
The purpose of central review is to establish concordance between the institution and the designated 
reviewer, as well as possible evaluation of clinically and biologically important subsets that may be 
appropriate for subset specific therapy. For this study, acute myeloid leukemia will be classified according 
to the WHO criteria  
 
13.2.2 Instructions for Labeling Slides 
Bone Marrow Slides (aspirate smears, core biopsy, and clot section) - Please label bone marrow slides with 
the patient’s COG registration number and the surgical pathology identification (SPID) number (e.g. 
specific specimen number) from the matching bone marrow report. 
 
Peripheral Blood Slides (Smears) - If there is a procedure or report number on the institutional laboratory 
report, please label the peripheral blood slides with the patient’s COG Patient ID Number and the report 
(or procedure) number from the institutional report. If there is not a number on the report then please label 
the slide with the date the blood was drawn, patient initials and the COG Patient ID Number. 
 
13.2.3 Required Materials for Pathology Review 
Submit slides, all pertinent institutional reports and the AAML1031 pathology transmittal form to the 
Biopathology Center as described below. These samples should be submitted within 7 days of the 
procedure. 
 

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All Patients at the time of Disease Diagnosis Evaluation and Diagnosis of Refractory Disease or 
Relapse. 
 
The following materials are required for patients with bone marrow involvement*:  
1) A completed pathology report, bone marrow aspirate/biopsy report, and flow cytometry report. 
2) One (1) peripheral blood smear (Wright-Giemsa stained). 
3) A concurrent complete blood count including white blood cell differential (manual or automated) 
4) One (1) representative bone marrow aspirate smear (Wright-Giemsa stained).  
5) One (1) H&E stained slide from bone marrow clot section and/or one (1) stained slide from core 
biopsy. 
6) Four (4) unstained slides from aspirate smears. 
7) Four (4) unstained slides from clot section and/or core biopsy (preferably on charged slides). 
8) Cytogenetic report, and molecular testing for chromosomal translocations (if performed). 
 
RECOMMENDED ADDITIONAL MATERIALS: 
1) Additional aspirate smears (stained and/or unstained) 
2) Cytochemical stains (myeloperoxidase, non-specific esterase, PAS) 
3) Immunohistochemical stains (ex.CD34, CD74, CD117, myeloperoxidase) 
4) Tissue blocks  
 
For patients with myeloid sarcoma (chloroma) submit the following materials for central pathology 
review*:  
1) One (1) H&E stained slide and six (6) unstained recuts from the biopsy material of the myeloid 
sarcoma. Slides must be sent from a representative block with remaining diagnostic material. 
2) Immunohistochemistry stained slides that were used to establish the diagnosis (this is strongly 
recommended, but not required; these special stained slides will be sent back at the conclusion of 
review, if requested by contributor). 
3) A copy of pathology report (including results of special stains, flow cytometry and cytogenetics, if 
performed). 
 
* 
Patients can be included without these specimens on approval of the Chair or Vice-chair of the study. 
This approval will be contingent on the adequacy of alternate materials (e.g., peripheral blood) for 
performance of all tissue based techniques for the study.  
 
CENTRAL PATHOLOGY REVIEW MATERIALS WILL BE RETAINED BY COG AND WILL NOT 
BE RETURNED UNLESS OTHER WISE INDICATED ABOVE. 
 
Ship materials by regular mail or using your institution’s courier account to the Biopathology Center: 
 
COG Biopathology Center – AAML1031 
Nationwide Children’s Hospital 
700 Children’s Drive, WA1340** 
Columbus, OH 43205 
Phone: 614-722-2894 
Fax: 614-722-2897 
 
** Be sure to include the room number. Packages received without the room number may be returned to 
the sender. 
 
 

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14.0 
FLT3 MOLECULAR GENETIC ANALYSIS GUIDELINES AND REQUIREMENTS 
 
Specimens for mutation analysis must be obtained prior to therapy initiation. The result of the mutation 
analysis will be used for risk assignment. NPM and CEBPα testing will no longer be done as part of the 
protocol as per Amendment #7A but remain advised as part of good clinical practice. All patients that do 
not have adequate specimens submitted will remain in their strata based upon other criteria. 
 
For patients enrolled after Amendment #7A, adequate specimen must be submitted in order to determine 
ITD allelic ratio. Per Amendment #7A, patients with unknown FLT3/ITD status at End of Induction I on 
Arm D will be removed from study with no further data submission. 
 
Results of mutation analysis are not required to be completed prior to therapy initiation, but samples must 
be collected prior to therapy initiation. 
 
14.1 
NIH-Funded Laboratory for Mutation Analysis at Diagnosis 
In order to provide uniform mutation analysis that is used for risk-based therapy, all FLT3 mutation analysis 
will be performed as part of the protocol therapy at a single site through NIH funding by the Molecular 
Oncology Laboratory at Seattle Cancer Care Alliance (SCCA) free of charge to the patient.  
 
14.2 
FLT3 Mutation Analysis 
As previously described, diagnostic DNA samples from each patient will be used to amplify appropriate 
region of the gene of interest gene using specifically designed fluorescent labeled primers.137 PCR products 
will be resolved by microcapillary electrophoresis and the wild type and ITD products quantitated by 
GenescanTM or Genemapper software.138 The ITD allelic ratio is determined for each patient by dividing 
the ITD product peak by the wild type product peak. High Risk status is defined as an allelic ratio > 0.4. 
 
14.3 
Specimen Requirements 
Diagnostic bone marrow is required for FLT3 testing. Peripheral blood is only an acceptable alternative 
when bone marrow is unavailable. CEBPα and NPM1 testing remain advised but will need to be sent from 
the treating institution as a clinical test. 
 
Bone marrow aspirate: collect a minimum of 1 - 3 mL of bone marrow in an EDTA vacutainer 
(purple/lavender top). Clearly label tube as bone marrow aspirate (BMA) along with draw date and draw 
time, and the patient name and DOB. 
 
Peripheral blood (only if marrow specimen is not available): collect a minimum of 5 mL of whole blood in 
an EDTA vacutainer (purple/lavender top). Clearly label tube as blood (PB) along with draw date and draw 
time, and the patient name and DOB. Please state percent peripheral blast if a diagnostic specimen. 
 
Note: For patients with myeloid sarcoma, submit biopsy material (slides, paraffin block, etc), if available, 
in addition to the requirements described above.   
 
Follow shipping instructions on the SCCA Molecular Oncology Requisition form.  
 
14.4 
Shipping 
Samples should be shipped to SCCA at the address listed below. All specimens must be accompanied by a 
Molecular Oncology Requisition Form (see Specimen Shipping Forms on the protocol website). Diagnostic 
marrow/peripheral blood specimens are to be shipped priority overnight to the following address: 
 
 
 

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Molecular Oncology 
Seattle Cancer Care Alliance 
1100 Fairview Avenue North, Rm. D2-281 
Seattle, WA 98109 
Phone: (206) 667-2592 
Fax: (206) 667-6092 
 
See the AAML1031 Sample Submission Schedule posted on the protocol webpage for courier information. 
The Lab hours are Monday - Friday 8:00 am – 4:30 pm, closed on weekends and holidays. For Saturday 
deliveries, laboratory needs be informed of the shipment. Please see the Molecular Oncology Requisition 
Form for details regarding sample collection, handling and shipping, and include this form with every 
request for specimen testing. 
 
Please allow 5 - 7 business days for samples to be processed. Results will be communicated by fax. 
 
Storage: If sample cannot be shipped immediately (i.e., sample is drawn on a Saturday, Sunday or holiday), 
store sample at room temperature and ship on the next business day.  
 
14.5 
Specimens Shipping Options 
Diagnostic FLT3 mutational analysis specimens and optional biology research specimens (as described in 
Appendix VII) may be combined into one FedEx shipment at baseline. However, each specimen must be 
placed into separate biohazard bags (with the appropriate specimen transmittal form). Clearly label each 
bag with “Mutation analysis” or “AML Reference Lab” and send to SCCA lab address in Section 14.4.  
 
 
15.0 
MRD ANALYSIS GUIDELINES AND REQUIREMENTS 
 
Specimen submission for MRD analysis are required, must be obtained prior to therapy initiation as well as 
end of Induction I, and must be sent directly to Hematologics Inc. The result of the MRD analysis will be 
used for risk assignment. All patients that do not have adequate specimens submitted will remain in their 
strata based upon other criteria. 
 
Results of diagnostic MRD evaluations are not required to be completed prior to therapy initiation, but 
samples must be collected prior to therapy initiation. 
 
Submission of an additional sample at the end of Induction II, Intensification I, Intensification II and when 
a patient is determined to have relapsed/refractory disease is strongly encouraged. The results of these 
optional MRD analyses will not be returned.  
 
15.1 
NIH-Funded Laboratory for MRD Testing at Diagnosis 
In order to provide uniform MRD analysis that is used for risk-based therapy, MRD testing will be 
performed as part of the protocol therapy at a single site through NIH funding. MRD analysis will be 
performed by Hematologics Inc. free of charge to the patient.  
 
International sites should submit to Hematologics Inc. for MRD analysis. All samples will be processed 
free of charge, regardless of the country of origin.  
 
15.2 
MRD Analysis 
All diagnostic and post remission specimens will undergo immunophenotypic characterization with  

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4-color multidimensional flow cytometry (MDF). Presence of post remission residual disease will be 
determined by identification of population of cells with aberrant cell surface markers and quantified as 
percent of total nucleated cells present in the sample. This data will be used to stratify those with and 
without minimal residual disease (MRD) after induction therapy. 
 
15.3 
Specimen Requirements 
Bone marrow specimen is required for MRD testing. Peripheral blood is only an acceptable alternative 
when bone marrow is unobtainable.  
 
Bone marrow aspirate: collect a minimum of 2 - 4 mL of bone marrow in a preservative-free sodium heparin 
vacutainer (green top). Clearly label tube as bone marrow aspirate (BMA) along with draw date and draw 
time, and the patient name and DOB. In cases where specimen is expected to take more than 24 hours to 
arrive, please add equal volume of RPMI 1640 medium to the marrow specimen. 
 
Peripheral blood (only if marrow specimen is not obtainable): collect a minimum of 5 mL of whole blood 
in a preservative-free sodium heparin vacutainer (green top). Clearly label tube as blood (PB) along with 
draw date and draw time, and the patient name and DOB. Please state percent peripheral blast if a 
diagnostic specimen. 
 
Note: For patients with myeloid sarcoma, submit biopsy material (slides, paraffin block, etc) at diagnosis, 
if available, in addition to the requirements described above. For the end of Induction I time point, submit 
re-biopsy if available. Otherwise only submit samples as described above.   
 
Optional timepoints: Specimens submitted for the optional timepoints should be labelled with the COG # 
and date/time of specimen collection only.  
 
15.4 
Shipping 
Samples should be shipped to Hematologics Inc. Seattle, WA at the address listed below. All specimens 
sent to Hematologics Inc. must be accompanied by an MRD Requisition Form (see Specimen Shipping 
Forms on the protocol website). All specimens must be shipped priority overnight to the following address: 
 
Hematologics, Inc.  
3161 Elliot Ave. Suite 200 
Seattle, WA 98121 
Phone: (800) 860-0934 or (206) 223-2700 
Fax: (206) 223-5550 
Weekends and After Hours: (206) 264-4459 
 
See the AAML1031 Sample Submission Schedule posted on the protocol webpage for courier information. 
Weekend Specimens: The lab is staffed 6 days a week. For Saturday delivery, please use a Saturday 
delivery sticker and check the Saturday delivery box on the address label. Both sticker and checked box are 
necessary to insure proper handling.  
 
Please allow 2 - 4 business days for samples to be processed. Results will be communicated by fax and 
entered into eRDE. 
 
Storage: If sample cannot be shipped immediately (i.e., sample is drawn on a Saturday, Sunday or holiday), 
store sample with equal volume of RPMI medium at room temperature and ship on the next business day.  
 
 
 
 

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16.0 
CYTOGENETIC ANALYSIS GUIDELINES AND REQUIREMENTS 
 
16.1 
Cytogenetic Analysis Overview 
 
It is strongly recommended that all patients enrolled on AAML1031 have a cytogenetics study performed 
by a COG-approved laboratory at the time of initial diagnosis, relapse, and when refractory status is 
confirmed (for patients with normal diagnostic cytogenetic results: see Section 16.1.1). If the diagnostic 
cytogenetics/FISH findings are unknown/undetermined, the patient will be treated the same as patients with 
low risk cytogenetics. 
 
The institutional CRA must inform the cytogenetics laboratory that the patient has been enrolled in a COG 
Myeloid study and that the cytogenetics/FISH data must be submitted within 2 weeks after registration on 
the AAML1031 protocol. See Appendix V for cytogenetics procedures and for the Sample Authorization 
Form for reflexive FISH testing.  
 
Central cytogenetics review will only be performed for patients enrolled on Arm C after 
Amendment #7A. 
 
16.1.1 Cytogenetic Analysis for Refractory Patients 
Perform cytogenetic studies when patient is deemed refractory to protocol therapy only if diagnostic 
cytogenetics studies were normal. Note: Repeat the conventional G-banding cytogenetics study but no FISH 
unless indicated by new abnormality on G-banding. If there was FISH but no G-banding at diagnosis, then 
repeat G-banding, but not FISH unless FISH was abnormal. If no G-banding or FISH at diagnosis, both 
tests should be repeated.  
 
DIAGNOSIS: KARYOTYPE/FISH 
REFRACTORYDISEASE: KARYOTYPE/FISH 
ABNORMAL RESULT 
NOT NECESSARY TO REDO CYTOGENETICS 
NORMAL G-BANDING, NORMAL FISH  
YES G-BANDING, NO FISH 
NORMAL G-BANDING, ABNORMAL FISH 
YES G-BANDING, YES FISH 
NO G-BANDING, NORMAL FISH 
YES G-BANDING, NO FISH 
NO G-BANDING, NO FISH 
YES G-BANDING, YES FISH 
 
16.2 
Specimen Collection and Submission 
 
16.2.1 
It is strongly recommended that specimens for cytogenetic analysis be sent to a COG-approved institutional 
cytogenetics laboratory. If a COG institution does not have a COG-approved laboratory, the institution may 
send the samples for karyotyping/FISH studies to any COG-approved cytogenetics laboratory on a fee-for-
service basis. Prior arrangements for performing cytogenetics and/or FISH studies should be made with the 
laboratory. An authorization form for the reflexive FISH testing signed and dated (by the physician or designees 
just as with any order) sent to the cytogenetics laboratory with the sample will simplify and enhance the ability 
to obtain FISH testing and results. 
 
16.2.2 
A minimum of 2 mL (optimal volume, 3 mL) of fresh whole bone marrow aspirated through a needle into 
a syringe containing sodium heparin (preservative-free is preferable) is recommended in all cases. A first 
or second draw, or a draw from a repositioned needle, is best to ensure a sufficient number of leukemic 
cells in the aspirate. The specimens should be kept at room temperature and transported to the institutional 
cytogenetics laboratory as quickly as possible (always within 24 hours of collection). If shipping is done 

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by overnight courier to an approved laboratory, that laboratory should be contacted to obtain instructions 
on transport. Some laboratories request specimens to be transferred in a 15 mL conical tube filled with 
RPMI-1640 and 15% heat-inactivated fetal calf serum. Specimens should be kept at ambient temperature. 
 
16.2.3 
If bone marrow cannot be aspirated, a bone marrow core biopsy should be submitted. 
 
16.2.4 
Peripheral blood (3 - 5 mL) collected in sodium heparin should be submitted as a back-up to the bone 
marrow when the marrow sample is suboptimal or unobtainable, if more than 20% circulating blasts are 
identified, or when a constitutional abnormality (e.g., trisomy 21) is a possibility. For documenting a 
constitutional abnormality, a PHA stimulated blood study should be performed. 
 
For patients with myeloid sarcoma: 
In addition to the requirements described above, if touch preps are able to be prepared from the tumor, the 
institutional pathologist should distribute/triage order(s) for FISH to be performed accordingly (e.g., MLL, 
RUNX1T1-RUNX1, CBFB). 
 
16.2.5 
Results of these studies should be submitted electronically to the corresponding coordinator of the Myeloid 
COG cytogenetics committee for central review (see below). 
 
16.2.6 
Requirements for Data Submission 
The following are required for each case: a completed COG Cytogenetics/FISH Reporting Form (found on 
the eRDE) and 2 original karyotypes (different cells), with corresponding full-size metaphase spreads of 
each abnormal clone or 2 karyotypes of normal cells with corresponding full-size metaphase spreads in the 
case of normal cytogenetic analysis. This information must be sent to the appropriate coordinating 
cytogeneticist within 2 weeks after registration on the AAML1031 protocol (see Appendix V) and 
within 1 month of disease relapse, or confirmed refractory status (for patients with normal diagnostic 
cytogenetics results; see Section 16.1.1). Reports must be sent electronically (preferred as PowerPoint 
presentation). If the laboratory is unable to send an electronic file with the documentation, please contact 
the COG cytogenetics coordinator for your area for advice. Reporting forms must be filled out for all cases, 
whether or not the cytogenetic analyses were successful. A separate form is required for each specimen 
(i.e., bone marrow and blood) analyzed in each case. Published data on FISH screening report an overall 
incidence of occult aberrations in AML with normal karyotypes between 3% to 10%.139-141 Thus, for all 
cases with only normal karyotypes FISH must be performed to evaluate for inv(16)/t(16;16), t(8;21), 
t(15;17) and 11q23. However, if the sample did not yield sufficient quantity of metaphases for analysis, -7 
and -5/5q- should also be performed in addition to the inv(16)/t(16;16), t(8;21), t(15;17) and 11q23. 
Published data indicate that 10%-25% of patients who have one of these recurring translocations may have 
a concomitant deletion encompassing a region adjacent to the breakpoint on one of the involved derivative 
chromosomes. Such deletions may portend a less favorable prognosis.142-144 Thus, for all cases in which a 
recurring chromosomal abnormality [t(8;21), inv(16)/t(16;16), 11q23] is identified, it is recommended that 
FISH be performed with probes specific to that rearrangement, to evaluate any variant pattern that might 
include a deletion associated with a gene fusion. FISH forms should also be completed and sent to the 
coordinating cytogeneticist with images documenting the abnormal or normal FISH patterns. If the 
laboratory is not able to perform FISH, contact the COG cytogenetic coordinators for advice. Any 
discrepancies in interpretation between cytogenetics/FISH results from the laboratory and the coordinator 
will be discussed between the coordinators, with consult of additional cytogenetics committee members as 
necessary. The COG cytogenetics committee decision will prevail. 
 

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Cytogenetic Coordinators 
Please send above materials by e-mail (preferably as a PowerPoint file) to the following COG Cytogenetics 
Laboratories.  
WEST OF MISSISSIPPI RIVER  
(INCLUDE MINNESOTA AND WISCONSIN), 
AUSTRALIA, NEW ZEALAND, WESTERN CANADA 
EAST OF MISSISSIPPI RIVER 
 (EXCLUDE MINNESOTA AND WISCONSIN), 
EUROPE, EAST CANADA 
SEND TO:  
SEND TO: 
Betsy Hirsch, Ph.D. 
Susana C. Raimondi, Ph.D. 
Telephone: 612-273-4952/3171 
Telephone: 901-595-3537/3536 
E-mail: hirsc003@umn.edu 
E-mail: susana.raimondi@stjude.org 
Recommendations for Case Analysis by Institutional, COG-Approved Cytogenetics Laboratories  
See Appendix V. 
 
 
17.0 
SPECIAL STUDIES SPECIMEN REQUIREMENTS 
 
A Sample Submission Schedule is posted on the AAML1031 protocol website:https://members.childrens
oncologygroup.org/prot/AAML1031/AAML1031SampleSubmissionSchedule.pdf This document provides 
an overview of the AAML1031 sample submission requirements and shipping information. 
 
17.1  
Pharmacokinetic and Pharmacodynamic Studies 
 
17.1.1  Biology Aim 1.2.6: Pharmacokinetics of Bortezomib  
Blood draws for measurement of plasma bortezomib concentrations were performed on Day 8 of Induction 
II of therapy. The bortezomib PK study was open to patients 2 - 16 years of age, randomized to Arm B. 
This study was closed to new patient participation on June 25, 2013, as accrual goals were met. 
 
17.1.2  Biology Aim 1.2.7: Pharmacokinetics and Pharmacokinetic-Pharmacodynamics of Sorafenib 
 
17.1.2.1 Pharmacokinetics of Sorafenib and N-Oxide metabolite 
Steady state pharmacokinetics of sorafenib and N-oxide metabolite will be performed during Induction I, 
Induction II, Intensification I and Intensification II for all subjects receiving sorafenib who provide consent 
and assent. Additional samples will be collected during the maintenance sorafenib phase. The purpose of 
the pharmacokinetic study is to characterize the concentration x time profile and trough concentrations at 
steady state for sorafenib and the N-oxide metabolite in children and adolescents with AML receiving 
multiagent chemotherapy. The pharmacokinetic samples are separate from PK-PD study using the PIA 
assessment of FLT3. For adequate PK profiling at steady state, it is important to obtain one plasma sample 
prior to the administration of any sorafenib (during Induction I, prior to Day 10), and 3 additional samples 
during each Induction and Intensification course in subjects receiving sorafenib. All samples will be 
analyzed by HPLC MS/MS to quantify the sorafenib and N-oxide metabolite concentrations. This study is 
for research, no adjustment in individual patient dosing will be made based on the plasma concentrations. 
See Appendix X for collection, labelling and shipment instructions. 
 
 
17.1.2.2 PK-PD of Sorafenib by PIA Assay  
Plasma will be separated by centrifugation from blood samples collected during sorafenib administration 
and cryopreserved. Aliquots of 4 x 106 TF1/ITD cells (human AML cell line transfected with FLT3/ITD 
construct) will then be incubated for 1 hour with 0.5 mL of plasma from each time point. The cells will then 
be washed, lysed and analyzed for FLT3 phosphorylation by FLT3 immunoprecipitation and sequential 
immunoblotting with 4G10 anti-phosphotyrosine antibody and anti-FLT3 antibody. Densitometric analysis 
will be used to calculate the PIA (the percent inhibition of FLT3 phosphorylation of each time point relative 

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to the pre-treatment sample). These results will be used to determine whether a given dose of sorafenib is 
biologically active. Another 0.5 mL of plasma from the same time points will be collected for PK 
measurement to facilitate PK-PIA correlation. See Appendix XI for collection, labelling and shipment 
instructions. 
 
17.1.3 Pharmacokinetics for Busulfan Dose Adjustments 
 
17.1.3.1 1st Dose Pharmacokinetics 
Please note: Pharmacokinetic studies must be performed in a CLIA, NATA, IANZ-certified laboratory or 
equivalent authorized accrediting body for non-US sites. 
 
Target first dose pharmacokinetics should be performed in all patients regardless of busulfan dosing 
schedule.  
 
Daily dosing should target an area under the curve (AUC) of 3,600 to 6,000 (micromole/liter)*minute per 
dose.  
 
Every six hour dosing should target an AUC of 900 to 1,500 (micromole/liter)*minute.  
 
Instructions for Q24 hr dosing: Busulfex concentrations will be determined in plasma by collecting blood 
into a green top sodium heparin tube. Samples should be collected at the end of the first 3 hour infusion, 
195 minutes after start of infusion (or end of infusion plus 15 minutes), and 4, 5, 6, and 8 hours after the 
start of the first infusion. Samples should not be drawn from the lumen used to infuse busulfan. See table 
in Section 7.3.1. 
 
Institutional pharmacokinetic studies are acceptable. If pharmacokinetics cannot be performed at a local 
laboratory, samples can be shipped to the Seattle Cancer Care Alliance (as fee for service) or other regional 
laboratories experienced in this assay. Results are usually available in time for adjusting doses 3 and 4. 
 
Instructions for Q6hr dosing: Busulfex concentrations will be determined in plasma by collecting blood 
into a green top sodium heparin tube. Samples should be collected at the end of the first 2 hour infusion, 
135 minutes after start of infusion, 150 minutes after start of infusion, and 3, 4, 5, and 6 hours after the start 
of the first infusion. Samples should not be drawn from the lumen used to infuse busulfan. See table in 
Section 7.3.1. 
 
For Q6 hr infusion: In case infusion runs more or less than 2 hours, draw 1 sample immediately when 
infusion ends. Then, draw the next 2 samples 15 minutes apart and continue to draw 3, 4, 5, and 6 hours 
samples by counting from beginning of the infusion. 
 
Institutional pharmacokinetic studies are acceptable. If pharmacokinetics cannot be performed at a local 
laboratory, samples may be shipped to the Seattle Cancer Care Alliance (as fee for service) or other regional 
laboratories experienced in this assay. Results are usually available in time for adjusting doses 7 through 
16. Brief instructions are as follows: 
 
Collect 1 - 3 mL of blood into sodium heparin tubes (green top) according to the schedule above. Place 
labeled samples immediately on wet ice and refrigerate. Centrifuge samples as soon as possible at 4oC. 
Separate plasma from RBCs. Store plasma at –20°C. Plasma tubes must be labeled with the patient’s name, 
medical records number, and the date and actual clock time that the sample was drawn.  
 

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If using the SCCA Pharmacokinetics Laboratory, sample requisition form, collection schedule, and 
shipping instructions can also be found at: http://www.seattlecca.org/busulfan-lab-samples.cfm. Sites will 
be required to set up an institutional account with the SCCA PK laboratory for billing.  
 
17.1.3.3 Guidelines for Adjusting Busulfan Dosing Based on Results of First Dose Pharmacokinetic 
Results 
Once the results of the area under the curve (AUC) analysis of the first busulfan dose are available, 
subsequent 
doses 
will 
be 
adjusted 
to 
achieve 
an 
overall 
exposure 
target 
AUC 
of 
900 - 1,500 (micromole/liter)*minute. The amount by which the dose is increased or decreased should be 
decided by the patient’s attending physician in conjunction with the institutional toxicology laboratory 
director, or the Seattle Cancer Care Alliance Pharmacokinetics Laboratory (if using the SCCA laboratory). 
 
In cases where the pharmacokinetics are performed locally, a second AUC analysis should be performed 
after administration of the first modified dose, and further dose adjustments made accordingly, whenever 
feasible. 
 
17.2 
Leukemia Biology Studies 
 
17.2.1 Biology Aim 1.2.10:  
Evaluate the prognostic significance of molecular MRD and its contribution to risk identification with MDF 
based MRD in patients with translocations amenable to quantitative RT-PCR (e.g., t(8;21), inv(16), t(9;11), 
WT1 expression).  
As described in Section 2.7.2 transcripts for Inv(16), t(8;21), t(9;11) and WT1 gene will be quantified at 
the end of each course and correlated with MRD by MDF and clinical outcome. See Appendix VII for 
further details.  
 
17.2.2 Biology Aim 1.2.11:  
To determine the leukemic involvement of the hematopoietic early progenitor cell and its role in defining 
response to therapy. In order to assess the early progenitor involvement of the leukemia, diagnostic 
specimens from patients that have known molecular abnormalities (FLT3, KIT, RAS, etc) will be sorted 
for the CD34+/CD33- early progenitor population. DNA will be extracted from the flow sorted cells and 
subjected to mutation analysis. Based on this method we will define the early progenitor involvement of 
the specific mutations. Presence or absence of early progenitor involvement will be correlated with disease 
response. See Appendix VII for further details.  
 
17.2.3 Biology Aim 1.2.12:  
To define the leukemic stem cell population in patients with AML. 
In order to assess the ability of bortezomib to deplete the Leukemia Stem Cell (LSC) population in AML, 
diagnostic specimens will be sorted by 10-color flow to characterize an individualized leukemia initiating 
cell (LIC) population. The LIC population will be quantified at diagnosis and after the first course of 
treatment with either ADE or ADE + bortezomib. In patients with a sortable LIC population, RNA will be 
extracted from the flow sorted cells and subjected to low density TILDA mutation analysis. Based on this 
method we will determine the ability of bortezomib to deplete LSC in AML. If the patient is MRD+ after 
Induction I, a bone marrow sample should also be sent following Induction II. See Appendix VIII for further 
details.  
 
17.2.4 Biology Aim 1.2.13:  
To determine the prevalence and prognostic significance of molecular abnormalities of WT1, RUNX1, MLL-
PTD, TET2, c-CBL, KIT, and other novel AML associated genes in pediatric AML.  

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Functional regions of the abovementioned genes will be amplified and genomic alterations will be evaluated 
by direct sequencing or by capillary electrophoresis. Presence of mutations will be correlated with disease 
characteristics and outcome. See Appendix VII for further details.  
 
17.2.5 Biology Aim 1.2.14:  
Correlate the expression of CD74 antigen as well as PSMB5 gene expression and mutation with response 
to bortezomib. 
CD74 expression determination: Diagnostic marrow specimens from all patients enrolled on the study will 
be evaluated for CD74 expression by MDF. Expression level of CD74 will be subsequently correlated with 
CR and relapse rates in patients with and without exposure to bortezomib to determine whether CD74 
exposure correlates with response to bortezomib. 
PSMB5 mutations and expression: Diagnostic DNA from all consented patients will be subjected to 
amplification of individual exons for this gene and directly sequenced. All mutations will be confirmed and 
submitted to COG statistical office for future clinical correlation. RNA extracted from diagnostic specimens 
will be converted to cDNA and expression of PSMB5 gene will be assessed by TaqMan using commercially 
available primers and probes. All expression data will be normalized to that in normal bone marrow as a 
point of reference and presented as a ratio of expression in normal marrow. All PSMB5 expression data will 
be forwarded to COG statistical office for correlation with response to bortezomib. The aim is to evaluate 
sequence variations in PSMB5 gene in patients treated in AAML1031 and correlate the mutations with 
response to Bortezomib. See Appendix VII for further details.  
 
17.2.6 Biology Aim 1.2.15:  
To evaluate the changes in protein expression and unfolded protein response (UPR) in patients with HR 
AML. Consenting patients treated with ADE or ADE with bortezomib and with a peripheral blast count 
> 1,000 cells/L will have peripheral blood samples drawn prior to the start of therapy (Day 1, hour 0) and 
at 2 time points after the initiation of therapy (10 hours and 24 hours) to examine for changes in protein 
expression patterns using reverse phase protein lysate array (RPPA). Analysis will also assess cell stress 
pathways leading to myeloblast cell death, including analysis of the UPR proteins by RT-PCR, and analysis 
of autophagy by MDC flow cytometry. The goal is to determine if there are pre-treatment proteins 
predictive of either clinical response or proteins predictive of bortezomib drug resistance. See Appendix IX 
for collection, labelling and shipment instructions. 
 
17.2.7  Biology Aim 1.2.16:  
Determine the expression level of wild type FLT3, and correlate with outcome and in vitro sensitivity to 
FLT3 inhibition. 
The quantitative expression level of surface wild type FLT3 will be measured prospectively on the baseline 
MRD samples by including the CD135 antibody in the diagnostic panel (see Section 15.0). The quantitative 
expression level of FLT3 mRNA will be measured prospectively by qRT-PCR using RNA isolated from 
diagnostic marrow blasts in consenting patients. The in vitro cytotoxic response of high vs. low expressing 
blasts will be performed retrospectively on viably cryopreserved diagnostic marrow blasts in consenting 
patients. High vs. low expressors will be selected from the leukemia bank based on CD135 and/or qPCR 
expression. Vials of cryopreserved cells will be thawed, exposed to a dose range of sorafenib and assayed 
using WST-1 and annexin V binding assays. See Appendix VII for further details.  
 
17.2.8  Biology Aim 1.2.17:  
To collect biology specimens at diagnosis, treatment time points, and relapse for future biology studies. 
 
17.2.9 Biology Aim 1.2.18 
To create a pediatric-specific algorithm to predict the occurrence of Grade 2 - 4 acute graft-versus-host 
disease prior to its clinical manifestations. 

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A combination of pre-transplant clinical variables and serum GVHD biomarker concentrations in the first 
weeks after SCT will be used to create an algorithm for the prediction of GVHD. Consenting patients treated 
with stem cell transplant will have peripheral blood drawn post-SCT on Days +7, +14 and +28 and serum 
concentrations of GVHD biomarkers (e.g. IL-2Ra, TNFR1, REG3a, and Elafin) will be measured by 
ELISA. See Appendix XIII for collection, labelling and shipment instructions. 
 
 
18.0 
QUALITY OF LIFE AND PARENTAL STRESS ASSESSMENTS  
Closed to new patient accrual as of 05-15-2015. The COG memo posted on the study page 05-08-2015. 
 
Participation in the Health Related Quality of Life and parental stress assessments is optional but 
strongly encouraged for patients between the ages of 2 years old and 18 years old (≥ 2 years and 
≤ 18 years) with a parent/guardian who is able to speak and read English. Only the parent/guardian 
must be able to speak and read English to participate. That is, if the child does not speak or read English, 
the patient is still eligible for the HRQOL study and parents should complete the Parent-Proxy forms and 
the Pediatric Inventory for Parents (PIP). If both the parent/guardian and child speak and read English, both 
should complete their forms if the child agrees to self-report. Those under the age of 2 years and those 19 
years old and over will not be eligible. Assessments will be administered at multiple time-points in order 
to assess short and long-term HRQOL and parental stress. 
 
Measures of HRQOL will be the Pediatric Quality of Life (PedsQL) 4.0 Generic Core Scale,51,52 the 
PedsQL 3.0 Acute Cancer Module,52 and the PedsQL Multidimensional Fatigue Scale.52,53 These have been 
found to be reliable and valid in this population.52 For HRQOL assessments, parents or guardians will 
provide proxy assessments for all patients while for patient’s ≥ 5 years of age who can understand English, 
self-report also will be completed if the child is able and agrees. 
 
Parental stress will be assessed using the Pediatric Inventory for Parents (PIP) scale.54,55 The PIP was 
developed to measure parenting stress related to caring for a child with an illness. PIP has been found to be 
a reliable and valid tool assessing parental stress in the pediatric oncology population.55 This instrument 
will only be completed by parents or guardians who are able to speak and read English.  
 
See Section 18.1.1 for details of questionnaires used. 
 
18.1 
Time points for Assessment 
The HRQOL and parental stress assessments will be administered at multiple time-points in order to assess 
short and long-term HRQOL and parental stress. The first assessment will serve as a baseline and will be 
given within the first 2 weeks of treatment initiation. Although it would be optimal to obtain the baseline 
assessment prior to treatment initiation in Induction I, it is not feasible to reliably obtain such an assessment 
because the child may be ill at presentation and because treatment initiation often is a priority. The second 
and third assessments will be given on or after Day 21 of Induction II and Intensification I as one is 
recovering, to assess HRQOL prior to SCT and assess changes over time. To describe changes following 
consolidative therapy, assessments will be made 1 and 4 months following the start of Intensification II 
(chemotherapy only arm) or start of the preparative regimen for those who undergo SCT. 
 
At 12 months from diagnosis, assessments will be made and then yearly until 3 years from diagnosis. These 
time-points should give an overall assessment of HRQOL and parental stress following completion of 
therapy. We will also see how HRQOL and parental stress changes with continued follow-up and possible 
development of late-effects of therapy. 
 

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Note: If a patient is removed from protocol therapy prior to treatment completion, no additional 
assessments are required.  Patients that have completed planned therapy, continue to submit assessments 
until 3 years from diagnosis according to the schedule below.   
 
The assessment time points are: 
 
Time point 
Timing 
1 
Within 14 days of Induction initiation (will serve as baseline) 
2 
On or after Day 21 of Induction II but prior to the start of Intensification I. 
3 
On or after Day 21 of Intensification I but prior to the start of Intensification II 
4 
1 month (± 7 days) from start of Intensification II for chemotherapy arms or 
preparative regimen for SCT  
5 
4 months (± 1 month) from start of Intensification II for chemotherapy arms or 
preparative regimen for SCT  
6 
12 months (± 1 month) from date of diagnosis 
7 
24 months (± 3 months) from date of diagnosis 
8 
36 months (± 3 months) from date of diagnosis 
 
 
 
Assessments 
Age (Years) 
PedsQL - 
Generic 
PedsQL – 
Cancer Module 
PedsQL - 
Fatigue 
PIP 
2 - 4 
X 
X 
X 
X 
5 - 7 
X 
X 
X 
X 
8 - 12 
X 
X 
X 
X 
13 - 18 
X 
X 
X 
X 
Time to complete 
68 questions: 
15 - 20 minutes 
42 questions: 
8 - 12 minutes 
 
18.1.1 Assessment 
For all consenting participants, the appropriate questionnaires based on age will be determined and 
downloaded from the COG protocol web site by the institutional CRA.  
 
The assessments will be performed by the CRA and family at the appropriate time-points described above. 
Completed forms will be reviewed by the CRA for completeness. Responses will be entered through the 
RDE system and the original forms retained by the institution. Questionnaires will be logged. Families that 
do not submit a questionnaire (parental or child form) at a particular time point for any reason will still 
continue to participate in the remaining questionnaire time points. 
 
 
18.2 
Health Related Quality Of Life (HRQOL) and Parental Stress Questionnaires 
 
18.2.1 Pediatric Quality of Life Inventory (PedsQL) 
Quality of life (QOL) will be measured by the PedsQLTM Scales. This instrument is a modular instrument 
for measuring HRQOL in children and adolescents between the ages of 2 and 18 years of age. The 
PedsQLTM 4.0 Generic Core Scales are multidimensional child self-report and parent proxy-report scales 
developed as a generic core measure of QOL. The Generic Core Scales measure physical functioning, 
emotional functioning, social functioning, and school functioning. In addition, there is a cancer disease-
specific module that measures pain and hurt, nausea, procedural anxiety, treatment anxiety, worry, 
cognitive problems, perceived physical appearance, and communication. Validity of the PedsQLTM 4.0 

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Generic Core Scales and the Acute Cancer Module were established by known group comparisons and 
correlations with other measures of disease burden. Reliability was established by internal consistency 
reliability. Alpha coefficients for both self-report and proxy-report were greater than 0.90. Item response 
distributions were across the full-scale range, with no floor effects and minimal ceiling effects.145 
 
The PedsQLTM Multidimensional Fatigue Scale was designed to measure fatigue with the following scales: 
summary score, general fatigue, sleep/rest fatigue and cognitive fatigue. It has previously demonstrated 
good to excellent self-report measurement properties in pediatric patients ages 2 – 18 years with cancer 
(e.g., leukemia and brain tumor), as well as healthy children and adolescents. Across the ages, the PedsQL 
multidimensional fatigue scale total score for both child self-report and parent proxy-report approached or 
exceeded an alpha of 0.90. It has been recommended for individual patient analysis, making the PedsQL 
multidimensional fatigue scale total score a suitable outcome measure. It has recently been studied in the 
young adult population as well.51-53 
 
18.2.2 Pediatric Inventory for Parents (PIP) 
The Pediatric Inventory for Parents (PIP) is a 42 item parent self-report rating of stress associated with 
caring for a child with a medical illness. It was initially developed for the oncology population but its use 
has extended to other medical illnesses. The PIP has measures in 4 domains: communication, medical care, 
role functioning, and emotional functioning. Each item is rated on two 5 point Likert scales assessing the 
frequency of the stressor and the difficulty of the issue/stressor for the parent. It has been found to have 
adequate internal consistency (alpha = .80 – .96) and construct validity.54,55,146 
 
 
19.0 RADIATION THERAPY GUIDELINES  
 
 
 
Radiation therapy (RT) for patients on COG protocols can only be delivered at approved COG RT 
facilities (see Administrative Policy 3.9). 
 
General Guidelines 
The radiation therapy (RT) guidelines for this study were developed specifically for patients with AML 
who develop chloroma. RT is not required for any patient enrolled on this protocol; however, when RT 
may be indicated, care should be taken to use advanced treatment methods to ensure that the targeted 
volume receives the protocol specified dose and that normal tissue irradiation is limited and well 
documented. To achieve these goals, at a minimum, CT-based treatment planning is required. Patients who 
relapse after treatment on this protocol may eventually undergo total body irradiation. Knowledge of the 
dose administered to normal tissues will be essential to provide optimal care. 
 
Required Benchmark and Questionnaires 
RT using photons (either 3-D conformal [3-D CRT] or intensity modulated [IMRT]) and electrons will be 
allowed in this study. Protons are not allowed. Centers participating in this protocol using 3-D CRT are 
required to complete the 3-D benchmark; those using IMRT must complete the IMRT questionnaire and 
benchmark or phantom (QARC or RPC). Benchmark materials and questionnaires may be obtained from 
the Quality Assurance Review Center (www.qarc.org) and must be submitted before patients on this 
Timing of protocol therapy administration, response assessment studies, and surgical interventions are based on 
schedules derived from the experimental design or on established standards of care. Minor unavoidable departures 
(up to 72 hours) from protocol directed therapy and/or disease evaluations (and up to 1 week for surgery) for valid 
clinical, patient and family logistical, or facility, procedure and/or anesthesia scheduling issues are acceptable per 
COG administrative Policy 5.14 (except where explicitly prohibited within the protocol).  

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protocol can be evaluated. For information regarding the IMRT phantoms, please contact the RPC 
(http://rpc.mdanderson.org/rpc). 
 
Guidelines and Requirements for the Use of IMRT 
Investigators using IMRT will be required to comply with the guidelines developed for the use of IMRT in 
National Cancer Institute sponsored cooperative group trials. These guidelines are available through 
www.qarc.org. These guidelines require that the protocol explicitly state their requirements and methods 
for localization and immobilization; the use of volumetric imaging; target and organ motion management; 
nomenclature, definitions and rationale for targets and organs at risk; target volume coverage and normal 
tissue dose constraints; effects of heterogeneity in tissues; and quality assurance. 
 
19.1 
Indications for Radiation Therapy 
• 
No patient is required to receive radiation therapy on this protocol. 
• 
Radiation therapy may be considered for patients who present with a chloroma that may result in 
irreversible loss of function.  
 
19.2 
Timing  
• 
If the patient presents with chloroma that is producing or threatens to produce an irreversible 
neurologic deficit (e.g., visual impairment or myelopathy), radiation therapy may be given at the 
beginning of induction therapy. 
 
19.3 
Emergency Radiation Therapy 
Radiation therapy may be delivered on an emergent basis to patients with spinal cord compression, loss of 
vision or other function-threatening conditions. The decision to irradiate emergently should be made by the 
treating physicians. Although it is recommended to complete a continuous course of treatment once 
initiated, it will be the decision of the treatment team to deliver the entire course of the emergency 
radiotherapy or stop early if symptoms quickly resolve. 
 
19.4 
Equipment and Methods of Delivery and Verification  
 
Equipment 
Photons 
(any energy) 
Electrons 
(any energy) 
IMRT 
(4-10MV) 
Linear Accelerator* 
X 
X 
X 
* For tumors adjacent or included in lung tissue, photon beam energy should be < 10 MV. 
 
19.4.1 Treatment planning 
CT-treatment planning is required for all patients irradiated on this protocol. Slices no more than 0.5 cm 
thick (0.2 - 0.3 cm is recommended) shall be taken though out the extent of the irradiated volume. CT 
(volumetric) based planning is required to optimize dose to the PTV while protecting normal tissues. Organs 
within the irradiated volume should be contoured including those required by treatment site (Section 19.9). 
A DVH is necessary to determine target coverage and evaluate dose to normal tissues. In the event that a 
patient must start emergently with a non-volumetric treatment plan, a volumetric plan will be accomplished 
as soon as is reasonably possible and the previously utilized beams should be incorporated into the 
composite plan. 
 
19.4.2 In-room verification of spatial positioning  
2D or volumetric imaging may be used to verify correct patient positioning. 2D portal imaging using an 
electronic portal imaging device (MV or kV) is the most common method, particularly when the target 
volume possesses a fixed spatial relationship with visualized bony anatomy. Film is discouraged but is 
acceptable. For IMRT and 3-D CRT treatments, a pair of images (usually orthogonal AP and lateral) is 

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required to verify that the isocenter is in correct alignment relative to the treatment plan; these may be MV 
or kV images. Volumetric imaging for position verification may be in-room kV or MV cone beam or 
conventional CT imaging. 
 
19.4.3 Imaging submission requirements 
For 2D imaging, the portal and isocenter setup verification images should be submitted along with the 
digitally reconstructed radiographs from the treatment plan. Images should be sent in the form of screen 
captures or in hardcopy format. For volumetric imaging, submit representative axial slices showing the 
treatment scan registered to the planning scan and indicating correct positioning either by isocenter location 
or overlay of the isodoses. 
 
19.5 
Target Volumes 
19.5.1 Standard tumor and target volume definitions 
International Commission on Radiation Units and Measurements (ICRU) Reports 50 and 62 
(www.icru.org) define prescription methods and nomenclature that will be utilized for this study. Treatment 
planning will be based on the following definitions and applies to the treatment site: 
 
Photons 
• 
Gross tumor volume (GTV) is the volume at the first sign of visible or palpable disease.  
 
• 
Clinical target volume (CTV) includes the GTV and sites with potential occult tumor involvement 
including lymph nodes adjacent to the GTV that may be clinically involved. The CTV margin for 
this protocol will be 1cm. The CTV may be anatomically confined at barriers to tumor infiltration. 
 
• 
Planning target volume (PTV) is the CTV surrounded by a geometric margin to account for 
variability in set-up, breathing or motion during treatment. The PTV margin for cranial including 
head and neck sites will be 0.5cm. The PTV margin for extracranial sites should be 0.5 - 0.7 cm 
 
19.6 
Target Dose 
 
19.6.1 Dose Definition  
Photon dose is to be specified in centigray (cGy)-to-muscle.  
 
19.6.2 Prescribed dose and fractionation 
The protocol-specified dose per fraction is 150 or 200 cGy. The treatment should be limited to one fraction 
per day. Five fractions should be given per week. There may be an exception if a department is closed on a 
major holiday but an effort should be made to minimize days missed. The dose per fractionation may be 
reduced from 200 cGy to 150 cGy when large volumes are treated (i.e., whole abdomen and pelvis) or when 
tolerance is poor (i.e., mucositis or diarrhea). Changes to the fractionation regimen should be noted in the 
treatment record and submitted information. 
 
 
Table 19.6.2 Protocol-specified dose for chloroma  
Fractionation 
Total Dose (cGy) 
Gross disease (fractionation 200 cGy/day) 
2,000 
Gross disease (fractionation 150 cGy/day) 
2,050 
 

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19.6.3 Dose uniformity 
At least 95% of the protocol-specified dose should encompass 100% of the PTV and no more than 10% of 
the PTV should receive greater than 110% of the protocol dose as evaluated by DVH. The 100% isodose 
should be equal to the protocol specified dose. Wedges, compensators and other methods of generating 
more uniform dose distributions are encouraged. 
 
19.6.4 Tissue heterogeneity 
Calculations must take into account tissue heterogeneity and should be performed with CT-based treatment 
planning to generate dose distributions and treatment calculations from CT densities. When IMRT is used 
in lung, the heterogeneity correction algorithm must be approved by QARC. For questions about 
heterogeneity corrections or approved algorithms, please contact QARC (www.QARC.org). 
 
19.6.5 Environment of care - Interruptions, delays and dose modifications 
There will be no planned rests or breaks from treatment, and once radiation therapy has been initiated, 
treatment will not be interrupted except for any life-threatening infection or severe hematologic toxicity 
defined as ANC < 300/L or platelets < 40 000/L during the course of treatment. Under these 
circumstances, radiation therapy shall be delayed until the counts have recovered. Blood product support 
should be instituted according to institutional/protocol guidelines. The reason for any interruptions greater 
than 3 treatment days should be recorded in the patient’s treatment chart and submitted with the QA 
documentation. There should be no modifications in dose fractionation due to age or field size. 
 
19.7 
Treatment Technique 
 
19.7.1 Beam Configuration 
Every attempt should be made to minimize dose to organs at risk without compromising coverage of the 
target volume. Three-dimensional conformal therapy (coplanar or non-coplanar) or IMRT are required to 
minimize dose to normal tissues.  
 
19.7.2 Field Shaping  
Field shaping will be done with either customized cerrobend blocking or multileaf collimation.  
 
19.7.3 Simulation including patient positioning and immobilization 
 
19.7.3.1 Patient positioning  
Reproducible setups are critical and the use of immobilization devices is strongly encouraged. 
The patient may be treated in any appropriate, stable position. Consideration should be given to implications 
for inter- and intra-fraction motion when using non-standard positioning. 
 
19.7.3.2 Immobilization devices 
Standard immobilization devices for the torso, extremities or head and neck are to be used. 
For IMRT delivery approaches, the methods used for localization and immobilization of both patient and 
tumor are critical. The imaging studies should provide a clear assessment of the target volume with the 
patient in the treatment position.  
 
19.7.4 Special considerations  
Anesthesia or sedation may be required in certain patients, such as very young patients, to prevent 
movement during simulation and daily treatments.  
 
19.7.5 Motion Management and Margins to Account for Target Volume and Organ Motion 
Considering motion of normal tissues and target volumes is important. The internal target volume (ITV) is 
defined as the CTV surrounded by the internal motion (IM) component of the PTV and is meant to account 

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for potential motion of the CTV. The planning organ at risk volume (PRV) includes the organs at risk 
(OAR) surrounded by a margin to compensate for physiologic change in the target volume. If adequate 
clinical data do not exist to define the IM component of the PTV or the PRV margin, the following 
suggestions are provided: 
 
• 
A margin of at least 0.5 cm should be added to any OAR to form the PRV. 
• 
For a CTV susceptible to physiologic motion, a margin of at least 0.5 cm should be added to the 
CTV prior to PTV margin expansion or a PTV margin of 1.0 cm should be chosen. 
• 
For tumors of the thorax or abdomen, an assessment should be made to determine the extent of 
motion present. PTV margins should include this motion as a component.  
• 
IMRT may be used for tumors of the thorax only if the degree of tumor motion is assessed and can 
be limited to 0.5 cm in any direction. If required to achieve this goal, techniques for managing or 
suppressing tumor motion shall be applied. 
• 
A description of the method used and evidence (i.e., observed motion during fluoroscopy, motion 
of surrogate markers using camera systems, or analysis of 4-D CT) of the remaining tumor motion 
should be submitted on the Motion Management Reporting Form with the Quality Assurance 
Documentation materials as noted in Section 19.10. 
 
19.8 
Organs at Risk 
The organs at risk guidelines in this section are recommendations. If the recommended doses to the organs 
at risk are exceeded because of target volume coverage requirements or other conditions, an explanation 
should be included in the quality assurance documentation. In some cases, photon IMRT may be the 
preferred treatment method to meet these recommendations and the required target volume coverage 
guidelines. 
 
Table 19.8: Organs at risk dose recommendations 
 
Organ 
Volume (%) 
Dose (cGy) 
Single organs 
 
 
Lens 
100% 
600  
Paired organs  
 
 
Kidney (bilateral) 
50% 
2400 
Kidney (bilateral) 
100% 
1440 
Lung (bilateral) 
20% 
2000 
Lung (bilateral)  
100% 
1500 
Paired organs - % refers to one of the paired organs unless specified as bilateral (kidney, lung) in which 
both of the paired organs are included in the %. 
 
19.9 
Dose Calculations and Reporting 
 
19.9.1 Prescribed Dose 
The prescribed dose for each target volume and/or phase of treatment shall be calculated and submitted on 
the RT-1/IMRT Dosimetry Summary Form. If IMRT is used, the monitor units generated by the IMRT 
planning system must be independently checked prior to the patient’s first treatment. Measurements in a 
QA phantom can suffice for a check as long as the patient’s plan can be directly applied to a phantom 
geometry. The total prescribed dose shall be calculated and reported on the RT-2 Radiotherapy Total Dose 
Record.  
 

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19.9.2 Normal Tissue Dosimetry 
The total dose to the critical organs indicated should be calculated whenever they are directly included in a 
radiation field. The total dose shall be calculated and reported on the RT-2 Radiotherapy Total Dose Record 
form and the appropriate dose-volume histograms should be submitted. If IMRT is used, a DVH must be 
submitted for a category of tissue called “unspecified tissue,” which is defined as tissue contained within 
the skin, but which is not otherwise identified by containment within any other structure. 
 
Table 19.9.2: Required normal tissue DVH data according to primary treatment site(s)  
Treatment Area 
Required DVH 
Head 
Optic Nerve 
 
Optic Chiasm 
 
Pituitary  
 
Right and Left Cochlea 
Neck 
Thyroid 
Chest 
Lung 
 
Heart 
Abdomen 
Liver 
 
Right and Left Kidney 
Pelvis 
Bladder  
 
Rectum 
Spinal Cord 
Spinal Cord 
 
19.10 Quality Assurance Documentation 
 
Key Points 
• 
No on-treatment review will be required for this study. 
• 
Non-IMRT case: within 1 week of the completion of radiotherapy submit the forms indicated below 
and include information for each treated site(s). 
• 
IMRT case: within 1 week of the completion of radiotherapy submit forms indicated below and 
treatment data in digital format. 
 
IMRT ONLY 
 
Institutions are required to submit the treatment plan in digital format. An institution’s treatment planning 
system must have the capability of exporting data in 1 of 2 formats: 
• 
RTOG 
Data 
Exchange 
Format, 
Version 
3.20 
or 
later 
(specifications 
at 
http://itc.wustl.edu/exchange_files/tapeexch400.htm); or 
• 
DICOM 3.0 in compliance with the Advanced Technology Consortium's (ATC) DICOM 3.0 
Conformance Statement. A list of commercial systems that are known to have this capability are 
listed on the ATC Website (http://atc.wustl.edu/credentialing/atc_compliant_tps.html). 
• 
The data may be submitted on a CD or sent electronically via ftp to QARC. Instructions for digital 
submissions may be found on the QARC Website - www.qarc.org, under Digital Data, RT 
Treatment Planning. 
 
Please submit the following for the Treatment Volume: 
External Beam Treatment Planning System  
• 
Digitally reconstructed radiographs (DRR) or simulator films for each treatment field and 
orthogonal (anterior/posterior and lateral) images for isocenter localization for each group of 
concurrently treated beams. When using IMRT, orthogonal isocenter images are sufficient. 

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• 
Isodose distributions for the composite treatment plan in the axial, sagittal and coronal planes 
at the center of the treatment or planning target volume. The planning target volume, 
isocenter and the normalization method must be clearly indicated. 
• 
Dose volume histograms (DVH) for the composite treatment plan for all target volumes and 
required organs at risk. A DVH shall be submitted for the organs at risk specified in 
Section 19.8. When using IMRT, a DVH shall be submitted for a category of tissue called 
“unspecified tissue”. This is defined as tissue contained within the skin, but which is not 
otherwise identified by containment within any other structure. 
• 
Treatment planning system summary report that includes the monitor unit calculations, beam 
parameters, calculation algorithm, and volume of interest dose statistics. 
• 
Beams-eye-view (BEV) of portals showing collimator, beam aperture, target volume and 
critical structures are required when not using IMRT. 
 
Digital Data 
• 
Submission of the treatment plan in digital format is required. Please refer to 
www.QARC.org and click on "Digital Data" for guidelines regarding digital submission. All 
submissions, including those that are digital, require hard copy submission of the other items 
included in this list. If there are any problems with digital data submission, please contact 
QARC. 
 
Supportive Data 
• 
All diagnostic imaging used to plan the target volume. This includes CT or MRI PRIOR to 
attempted surgical resection of the primary tumor. Digital format is preferred. 
• 
Radiotherapy record (treatment chart) including prescription and daily and cumulative doses 
to all required areas and organs at risk. 
• 
Documentation of an independent check of the calculated dose when IMRT is used. 
• 
If the recommended doses to the organs at risk are exceeded, an explanation should be 
included for review by the QARC and the radiation oncology reviewers. 
• 
If emergency RT is administered, documentation should be provided in the form of the RT-2 
Total Dose Record Form and the radiotherapy record (treatment chart). 
 
Forms 
• 
RT1/IMRT Dosimetry Summary Form. 
• 
Motion Management Reporting Form (if applicable, see Section 19.7). 
• 
RT-2 Radiotherapy Total Dose Record Form. 
 
NON-IMRT 
Forms 
• 
RT-2 Radiotherapy Total Dose Record Form. 
• 
Radiotherapy record (treatment chart) including prescription and daily and cumulative 
doses to all required areas and organs at risk. 
 
These data should be forwarded to: 
Quality Assurance Review Center 
Building A, Suite 201 
640 George Washington Highway 
Lincoln, RI 02865-4207 
Phone: (401) 753-7600 
Fax: 
(401) 753 7601 
 

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Questions regarding the dose calculations or documentation should be directed to: 
COG Protocol Dosimetrist 
Building A, Suite 201 
Quality Assurance Review Center 
640 George Washington Highway 
Lincoln, RI 02865-4207 
 
 
20.0 
HEMATOPOIETIC TRANSPLANT GUIDELINES  
 
Timing of protocol therapy administration, response assessment studies, and surgical interventions are based 
on schedules derived from the experimental design or on established standards of care. Minor unavoidable 
departures (up to 72 hours) from protocol directed therapy and/or disease evaluations (and up to 1 week for 
surgery) for valid clinical, patient and family logistical, or facility, procedure and/or anesthesia scheduling 
issues are acceptable per COG administrative Policy 5.14 (except where explicitly prohibited within the 
protocol). 
 
All transplants performed on COG trials must occur at FACT-accredited SCT programs (see 
administrative policy 3.3).  
 
20.1 
Pre-SCT Conditioning 
Refer to Sections 4.24 - 4.25. 
 
20.2 
Admission Criteria (see Section 7.3)  
Documented remission after first intensification (BMA/Biopsy) 
7/8 or 8/8 allele HLA-match related donor 
Cardiac (Echo/ECG): Shortening fraction by echocardiogram ≥ 28% or ejection fraction ≥ 55% 
Electrolytes: Within normal institutional limits 
Pulmonary Function Tests if age allows: DLCO > 50% 
Renal: Creatinine Clearance / GFR  60 mL/minute/1.73m2 
Lumbar Puncture: No leukemic infiltrate 
Documented HSV and CMV titers  
Hepatitis B Surface Antigen Serology, and Hepatitis C Serology  
HIV by serology: Negative 
Hepatic: Transaminases < 2.5 x normal; Total Bilirubin < 2 mg/dL 
 
20.2.1 HLA Typing 
At the time of diagnosis, high resolution HLA typing at HLA-A, B, C and DRB1 should be performed on 
all patients, their biological parents, and is recommended for any full siblings. For full siblings in whom 
neither parent, recipient or donor are homozygous at one of the 4 loci, high resolution typing in that sibling 
may be deferred if not routinely done at an institution. High resolution typing is recommended at diagnosis 
for all children, even those with no siblings, so that it is available for rapid alternative donor search in case 
of induction failure, persistent disease after Induction I, high-risk cytogenetics, or relapse. 
 
20.3 
Bone Marrow Harvest, Processing, Dose and Infusion 
Bone marrow will be harvested and infused on Day 0. Peripheral blood stem cells are not permitted to be 
used with MFD SCT on this study. A minimum of 2 x 108 nucleated bone marrow cells/kg of the recipients’ 
ideal weight must be collected, but 4 x 108 nucleated bone marrow cells/kg is desirable. There will be no 
manipulation of the bone marrow to deplete T cells. Bone marrow should be processed to deplete red blood 
cells if there is a major ABO mismatch (e.g., O type in recipient and A type in donor) or plasma depleted 

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in the case of a minor ABO incompatibility (e.g., O type in donor and A type in patient) to avoid an acute 
hemolytic transfusion reaction. Bone marrow will be infused according to standard operating procedure. 
 
Donor bone marrow grafts should be assessed for quantity of total nucleated cells and reported. 
 
20.4 
Supportive Care Guidelines 
(Also see Appendix I) 
 
20.4.1 Blood Product Support 
Irradiated and leukodepleted packed red blood cell and platelet transfusions will be given as indicated 
clinically at the discretion of the managing attending physician. 
 
20.4.2 Infectious Prophylaxis 
Trimethoprim-sulfamethoxazole (TMP-SMX): 2-3 mg/kg/dose PO or IV BID to begin on day of admission 
through Day –2 daily, then twice weekly on consecutive days starting on Day 21 and continuing for 1 year. 
Dapsone or pentamidine may be used in patients who are allergic to TMP-SMX (Bactrim) or in patients 
with myelosuppression attributed to TMP-SMX (Bactrim). 
 
Fluconazole: 5 mg/kg dose, maximum of 400 mg/dose, daily QD IV or PO for the first 28 days. 
 
Acyclovir: Standard doses per institutional guidelines for 1 year after SCT. Acyclovir will be used in 
patients who have been exposed to HSV, VZV or CMV or whose donors have been infected by CMV. 
 
Weekly CMV screening from Day +14 through Day +100 and pre-emptive treatment with ganciclovir. 
 
20.5 
COG Stem Cell Committee Consensus Guidelines for Establishing Organ Stage and Overall 
Grade of Acute Graft versus Host Disease (GVHD) 
 
20.5.1 Reporting Requirements for Acute GVHD in COG Studies 
In an attempt to standardize reporting of acute GVHD, the COG Stem Cell Transplantation Committee has 
adopted a modification of guidelines that were originally developed at the University of Michigan.  
 
Table 1 outlines standard criteria for GVHD organ staging. However, confounding clinical syndromes (such 
as non-GVHD causes of hyperbilirubinemia) may make staging GVHD in a given organ difficult. In 
addition, timing of organ specific symptoms affects whether that symptom is more or less likely to be true 
GVHD. Please refer to Tables 2 and 3 to assist you in deciding whether to attribute these clinical findings 
to GVHD, especially in situations where a biopsy is not possible. For additional help, please see the text 
which follows the tables.  
 
Table 4 reviews the approach to assessing GVHD as acute, chronic, or the overlap between the two. 
 
Finally, engraftment syndrome will be reported separately from the GVHD scoring presented below. 
 
20.5.2 Engraftment Syndrome 
A clinical syndrome of fever, rash, respiratory distress, and diarrhea has been described just prior to 
engraftment in patients undergoing unrelated cord blood and mismatched transplantation. If in the judgment 
of the local investigator a patient experiences this syndrome, details of the event should be reported when 
requested in the study CRFs. 
 
Modified Glucksberg Staging Criteria for Acute Graft versus Host Disease 
 

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Table 1. Organ Staging (See tables and text below for details) 
Stage  
Skin  
Liver (bilirubin)  
Gut (stool output/day)  
0  
No GVHD rash  
< 2 mg/dL  
Adult: < 500 mL/day  
Child: < 10 mL/kg/day  
1  
Maculopapular rash  
< 25% BSA  
2 - 3 mg/dL 
Adult: 500 - 999 mL/day  
Child: 10 - 19.9 mL/kg/day 
Or persistent nausea, 
vomiting, or anorexia, with 
a positive upper GI biopsy.  
2  
Maculopapular rash  
25% – 50% BSA  
3.1 - 6 mg/dL  
Adult: 1,000 - 1,500 mL/day 
Child: 20 - 30 mL/kg/day  
3  
Maculopapular rash 
> 50% BSA  
6.1 - 15 mg/dL  
Adult: > 1,500 mL/day  
Child: > 30 mL/kg/day  
4  
Generalized 
erythroderma plus 
bullous formation and 
desquamation > 5% BSA  
> 15 mg/dL  
Severe abdominal pain with 
or without ileus, or grossly 
bloody stool (regardless of 
stool volume).  
For GI staging: The “adult” stool output values should be used for patients > 50 kg in weight. Use 
3 day averages for GI staging based on stool output. If stool and urine are mixed, stool output is 
presumed to be 50% of total stool/urine mix. 
 
For Stage 4 GI: the term “severe abdominal pain” will be defined as: 
(a) Pain control requiring institution of opioid use, or an increase in on-going opioid use, PLUS 
(b) Pain that significantly impacts performance status, as determined by the treating MD.  
 
If colon or rectal biopsy is +, but stool output is < 500 mL/day (< 10 mL/kg/day), then consider as 
GI Stage 0.  
 
There is no modification of liver staging for other causes of hyperbilirubinemia 
 
Overall Clinical Grade (based on the highest stage obtained):    
Grade 0: No Stage 1 - 4 of any organ  
Grade I:  Stage 1 - 2 skin and no liver or gut involvement  
Grade II: Stage 3 skin, or Stage 1 liver involvement, or Stage 1 GI 
Grade III: Stage 0 - 3 skin, with Stage 2 - 3 liver, or Stage 2 - 3 GI  
Grade IV: Stage 4 skin, liver or GI involvement  
 
 
 

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Table 2. Evaluating Liver GVHD in the Absence of Biopsy Confirmation 
 
Establishing liver GVHD with no skin or GI GVHD 
No Skin/GI GVHD 
Day 0 - 35 
Assume no liver GVHD unless proven by biopsy  
No Skin/GI GVHD  
Day 36 - 100 
If NO other etiology identified, NO 
improvement with stopping 
hepatotoxic medications/TPN: 
Stage as liver GVHD  
If other etiology identified or 
improves with stopping hepatotoxic 
drugs/TPN: 
 
Do not stage as liver GVHD  
Establishing liver GVHD with skin or GI GVHD and other cause of hyperbilirubinemia 
Skin and/or GI GVHD 
present  
Worsening bilirubin level (includes 
worsening just prior to onset of skin 
or GI tract GVHD) OR stable 
elevated bilirubin despite resolution 
of non-GVHD cause of increased 
bilirubin:  
Stage as liver GVHD  
Stable or improving bilirubin after 
diagnosis of skin or GI GVHD, 
irrespective of treatment:  
 
 
Do not stage as liver GVHD 
  
Changing liver GVHD stage with other cause of hyperbilirubinemia 
Skin and GI GVHD 
stable, improving, or 
absent  
Liver GVHD staging is carried forward without increase in stage until other 
disease process resolves (e.g., if TTP is diagnosed in the presence of Stage 2 
liver GVHD, the liver GVHD Stage 2 is carried forward despite rising 
bilirubin level until TTP is resolved. If there is no liver GVHD – Stage 0 – 
and new onset TTP, the Stage 0 is carried forward until TTP is resolved).  
Skin and/or GI GVHD 
worsening  
Liver GVHD is staged according to the Glucksberg criteria. The 
elevated bili is attributed to GVHD alone. 
 
Thus, when skin or GI GVHD is worsening, there is no downgrading of 
liver GVHD staging for other causes of hyperbilirubinemia. (e.g., if TTP is 
diagnosed in the presence of Stage 2 liver GVHD and worsening skin or GI 
GVHD, the liver is staged according to the actual bilirubin level even if 
some of the rise in bilirubin is attributed to TTP). 
 
Similarly, even if there is no liver GVHD at onset of a new process, (such 
as TPN cholestasis), but skin or GI GVHD worsen during that process, then 
liver GVHD is diagnosed and staged according to the height of the 
bilirubin. 
 
There is one exception to this: the diagnosis of TTP, with high LDH and 
unconjugated bilirubin precludes the diagnosis and staging of new liver 
GVHD in the absence of a confirmatory liver biopsy. 
 
 
 

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209 
Table 3. Evaluating GI GVHD in the Absence of Biopsy Confirmation  
 
Establishing GI GVHD with new onset diarrhea and no skin or liver GVHD 
No Skin/liver GVHD  
Day 0 through 
engraftment 
Assume no GI GVHD unless proven by biopsy  
 
No Skin/liver GVHD 
Engraftment through 
Day 100  
NO other etiology of diarrhea 
identified: 
Stage as GI GVHD  
Any other etiology of diarrhea 
identified: 
Do not stage as GI GVHD  
Establishing GI GVHD with pre-existing diarrhea and skin or liver GVHD 
Skin and/or liver GVHD 
present  
Worsening diarrhea (includes 
worsening just prior to onset of skin 
or liver GVHD) OR persistent 
diarrhea despite resolution of non-
GVHD cause: 
Stage as GI GVHD  
Improving diarrhea after the 
diagnosis of skin or liver GVHD 
(irrespective of treatment) OR 
persistent diarrhea without resolution 
of underlying non-GVHD cause: 
Do not stage as GI GVHD  
 
20.5.3 Differentiating Acute GVHD, Chronic GVHD, and Overlap Syndrome  
There is often confusion differentiating acute from chronic GVHD, especially in the setting of reduced 
intensity transplants, DLI and new prophylactic treatments. The NIH Working Group recently published 
new classifications for GVHD:  
 
Table 4. Acute GVHD, Chronic GVHD, and Overlap Syndrome 
Category  
Time of Symptoms 
after HCT or DLI  
Presence of Acute 
GVHD features  
Presence of Chronic 
GVHD features  
Acute GVHD  
 
 
 
Classic acute GVHD  
≤ 100 d  
Yes  
No  
Persistent, recurrent, or 
late-onset acute GVHD  
➢ 100 d  
Yes  
No  
Chronic GVHD  
 
 
 
Classic chronic GVHD  
No time limit  
No  
Yes  
Overlap syndrome  
No time limit  
Yes  
Yes  
 
• 
Scoring of acute GVHD may need to occur past Day 100. In particular, patients should continue to 
be scored for acute GVHD when classic acute GVHD symptoms (maculopapular rash, nausea, 
vomiting, anorexia, profuse diarrhea - particularly if bloody and ileus) persist past Day 100 or if 
identical symptoms previously scored as acute GVHD resolve and then recur within 30 days during 
immunosuppression taper but past Day 100. 
• 
Those patients being scored as having acute GVHD should NOT have diagnostic or distinctive 
signs of chronic GVHD. 
• 
Patients with both acute and chronic symptoms should be diagnosed as having Overlap Syndrome 
and scored according to their chronic GVHD score.  

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210 
20.5.4 Further Explanation of Criteria presented in Tables 2 and 3 
 
20.5.4.1 Assessment of Skin GVHD  
Presence or Absence of Skin GVHD: Skin GVHD will be considered present if a rash characteristic of 
acute GVHD develops after allogeneic marrow transplantation involving more than 25% of the body 
surface not clearly attributable to causes such as drug administration or infection. The extent of the body 
surface area involved can be estimated by the “Rule of Nines”. In estimating the extent of skin GVHD, the 
area involved is calculated for individual anatomic areas, such as the arm or leg, and then the total is 
derived from a simple summation. Areas that are non-blanching should not be considered involved 
regardless of the overlying color of the rash (red, brown, etc). Limited distribution erythema (with the 
exception of palms and soles) in the absence of associated rash elsewhere on the body will not be 
considered GVHD.  
 
20.5.4.2 Assessment of Liver GVHD  
Assessing for the Presence or Absence of Liver GVHD  
A. Hyperbilirubinemia (total bilirubin ≥ 2.0 mg/dL) in the absence of other signs of acute GVHD in 
the skin or GI tract:  
 
i) Day 0 - 35: If hyperbilirubinemia alone is present with no other signs of acute GVHD in other 
organ systems, acute GVHD will not be diagnosed based solely on laboratory abnormalities.  
Acute GVHD will be diagnosed if findings on histopathology studies of liver from a biopsy or 
autopsy are confirmatory.  
ii) Day 35 - 100: If hyperbilirubinemia (must be conjugated bilirubin) is not improving or is 
exacerbated (especially if serum alkaline phosphatase is increased), in the absence of acute 
GVHD in other organ systems, no other etiologies are identified, and does not improve with 
discontinuation of hepatotoxic drugs, acute GVHD will be diagnosed. However, it is 
distinctly unusual to develop ascites or a coagulopathy in the early stages of acute GVHD of 
the liver alone. In the absence of histopathology studies of liver from a biopsy or autopsy 
specimen, ascites or a coagulopathy secondary to liver dysfunction will be considered to 
indicate the presence of another disease process (e.g., veno-occlusive disease). 
Recommended non-invasive studies to define an etiology for hyperbilirubinemia are:  
a. Imaging of liver (CT or ultrasound)  
b. Hepatitis screen (only if ALT is elevated)  
c. PT  
d. Blood cultures  
e. Review of medication list for potentially hepatotoxic drugs  
f. 
Review of risk factors for viral liver infection (HSV, CMV, VZV, adenovirus, EBV, HBV, 
HCV)  
g. Hemolysis screen  
 
B. Pre-existing hyperbilirubinemia clearly attributed to an etiology other than acute GVHD in the 
presence of signs of acute GVHD in other organ systems.  
 
i) If pre-existing non-GVHD liver disease (documented clinically, by lab assessment, or by 
imaging studies) is stable or improving at the onset of signs of acute GVHD in other organs, 
then acute GVHD of the liver will not be considered to be present unless proven by liver 

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211 
biopsy or autopsy.  
ii) If hyperbilirubinemia worsens several days before or at the time of onset of signs of acute 
GVHD in other organ systems, GVHD will be considered to be present unless histopathology 
studies of liver are available and negative on a biopsy during that time interval or autopsy 
results exclude GVHD.  
iii) If hyperbilirubinemia persists and is not improving after resolution of a pre-existing non-
GVHD liver disease process (e.g. localized infection of liver, systemic sepsis, biliary tract 
obstruction) when signs of acute GVHD are present in other organ systems or no other 
intervening cause has been diagnosed, then acute GVHD will be considered to be present in 
the absence of a new, clearly identifiable cause of non-GVHD liver disease or unless a liver 
biopsy or autopsy specimen is negative.  
 
C. Prior acute GVHD in liver with new onset of a disease process that exacerbates pre-existing or 
recently resolved hyperbilirubinemia:  
 
i) If an etiology other than acute GVHD is clearly identified as causing or exacerbating 
hyperbilirubinemia and acute liver GVHD has been diagnosed and has been stable, improving, 
or resolved, then the liver will not be restaged for acute GVHD until the resolution or stabilizing 
of the concurrent disease process (i.e., the liver stage prior to the onset of the new disease 
process will be carried forward until the new disease process resolves). Example: Acute GVHD 
of the liver and gut is diagnosed on Day 20. Treatment of acute GVHD results in falling 
bilirubin levels to liver Stage 1. Sepsis or TTP develops with transient worsening of the 
hyperbilirubinemia. The liver stage is not increased, despite a higher bilirubin level, because 
the cause of worsening hyperbilirubinemia is attributed to sepsis or TTP.   
ii) If an etiology other than acute GVHD is clearly identified as causing or exacerbating 
hyperbilirubinemia in the presence of already worsening acute liver GVHD or GVHD of the 
skin or GI tract is simultaneously worsening, then the liver GVHD will be staged according to 
the actual bilirubin level, even though another cause of hyperbilirubinemia is present.  
 
20.5.4.3 Assessment of GVHD of the Gastrointestinal Tract  
Assessing for the Presence or Absence of GVHD of the Gastrointestinal Tract  
A. Diarrhea (≥ 500 mL/day in adults or > 10 mL/kg in pediatric patients) in the absence of other signs 
of acute GVHD in other organ systems  
 
i) Day 0 - engraftment: If diarrhea alone is present without other signs of acute GVHD in other 
organ systems, acute GVHD will not be considered present. Diarrhea will be attributed to acute 
GVHD if histopathology studies of gastrointestinal tract from a biopsy or autopsy are 
diagnostic.  
 
ii) Engraftment - Day 100: If diarrhea persists and is not improving, is exacerbated, or develops 
de novo in the absence of acute GVHD in other organ systems, histopathology studies of gut 
biopsies or from autopsy specimens are not available, and no other etiologies are clearly 
identified, acute GVHD will be considered to be the cause. A stool specimen should be 
examined to rule out infectious causes (e.g., rotavirus, adenovirus, and C. difficile toxin). It is 
recommended, if at all possible, that biopsies be obtained for diagnostic purposes.  

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212 
B. Pre-existing diarrhea clearly attributed to an etiology other than acute GVHD in the presence of 
signs of acute GVHD in other organ systems:  
 
i) If pre-existing diarrhea caused by a process other than GVHD has been documented clinically 
or by lab assessment and is stable or improving at the onset of signs of acute GVHD in the skin 
or liver, then acute GVHD of the intestine will not be considered to be present in the absence 
of biopsy confirmation or autopsy report.  
ii)  If diarrhea or gastrointestinal symptoms are already present, but worsen significantly at the 
time of onset of signs of acute GVHD in the skin or liver, GVHD will be considered present, 
unless biopsy or autopsy are negative.  
iii) If diarrhea persists after resolution of a pre-existing disease process with signs of acute GVHD 
present in other organ systems, GVHD will be considered present, unless biopsy or autopsy are 
negative.  
C. Prior or present acute GVHD in other organ systems with new onset of diarrhea:  
 
If diarrhea is clearly attributable to an etiology other than acute GVHD (e.g., infection) and a 
history of acute GVHD exists or acute GVHD is present in other organ systems and is stable, then 
the gastrointestinal tract will not be evaluable for acute GVHD until the resolution or stabilizing of 
the other disease process (e.g., infection) in the absence of biopsy or autopsy confirmation.  
D. Persistent anorexia, nausea or vomiting in the absence of signs of acute GVHD in other organ 
systems:  
 
Persistent anorexia, nausea or vomiting in the absence of other known causes of these symptoms 
will be considered Stage 1 acute GVHD if confirmed by endoscopic biopsy.  
 
If a biopsy is not possible (e.g., secondary to thrombocytopenia) but the clinical findings are 
compatible with acute GVHD, then the patient will be treated and recorded as having acute 
GVHD.  
Staging of the Gastrointestinal Tract for the Severity of Acute GVHD  
The severity of gastrointestinal tract GVHD will be staged according to modified Glucksberg criteria. 
To minimize errors caused by large day-to-day variation, diarrhea volume is measured as an average 
over 3 days and reported as the volume in ml per day. When urinary mixing is noted the stool volume 
will be considered half of the total volume unless nursing staff is able to give a better estimate from 
direct observation. Abdominal cramps are considered significant for staging if the severity results in a 
clinical intervention (e.g., analgesia, fasting, etc.). Blood in the stools is considered significant if the 
blood is visible or hematochezia/melena is present and not clearly attributed to a cause other than 
GVHD (e.g. epistaxis/hemorrhoids).  
 
 
 

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213 
APPENDIX I:  SUPPORTIVE CARE GUIDELINES 
 
General Guidelines 
The following guidelines are intended to give general direction for optimal patient care and to encourage 
uniformity in the treatment of this study population. They are provided for institutional consideration. Notify 
Study Chair of any unexpected or unusually severe complications. Please also see the COG Supportive Care 
Guidelines at: https://members.childrensoncologygroup.org/prot/reference_materials.asp 
 
Hospitalization/Hospital Environment 
Hospitalization following each course of chemotherapy is strongly recommended until the absolute 
phagocyte count (sum of the neutrophils, bands and monocytes) is rising for 2 successive days, and the 
patient is afebrile and clinically stable. An additional discharge criterion of an absolute neutrophil count 
(ANC) of at least 200/µL is also suggested. 
 
It is recommended that patients should be assigned to rooms with special air filtration systems such as high 
efficiency particulate air filters (HEPA) or clean-air rooms with constant positive pressure airflow if at all 
possible. 
 
Central Venous Access 
It is recommended that all patients have a double lumen central venous access line placed prior to the 
beginning of therapy. 
 
Hyperleukocytosis and Metabolic Derangement 
Patients with high peripheral blast counts (> 100,000/µL) may have increased problems related to metabolic 
abnormalities, bleeding, and hyperviscosity. Transfusion with packed red blood cells should be given very 
cautiously, since it may increase viscosity and increase the risk of leukostasis. In these patients, the platelet 
count should be maintained at least greater than 20,000/µL.147  
 
Continuation of AML Therapy 
AML therapy can proceed when there is documented evidence of response to antimicrobial therapy for 
infections complications, absence of fever or other signs or symptoms of infection, and other starting criteria 
have been met.  
 
Antiemetics 
Corticosteroids should not be used as antiemetics or to prevent infusional toxicity of Amphotericin B.  
 
Nutrition 
Active measures should be used to prevent weight loss of greater than 10% of pre-illness body weight. If 
possible, enteral feedings are preferred to parenteral. 
 
Chemotherapy dosing for obese patients should be based on actual body weight rather than ideal body 
weight or an adjusted body weight except in Sections 4.24.3 SCT conditioning.148 
 
Mucosal Evaluation and Care 
Mucositis is expected and may be severe; liberal use of pain medications for this condition is encouraged. 
For patients with poor oral hygiene, consultation by dentistry is recommended prior to initiating therapy.  
 

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214 
Suppression of Menstruation 
Menstruating females may receive depo-provera or another suppressant during the entire course of this 
protocol. Suppression of menses should be continued until the platelet count is 50 000/µL without 
transfusion support. 
 
Blood Product Support 
 
Irradiation 
Blood 
products 
should 
be 
irradiated 
following 
the 
current 
FDA 
guidelines 
found 
at: 
http://www.fda.gov/cber/gdlns/gamma.htm  
 
Investigators in Canadian institutions need to follow the CSA standards for Blood and Blood Components 
CAN/CSA-Z902-04 issued in March 2004 and available at http://www.shopcsa.ca. 
 
Infection Prophylaxis 
Management of Fever and Neutropenia 
Patients with an ANC < 500/µL (or < 1,000 /µL and falling) and an oral temperature > 38°C twice in 
12 hours or ≥ 38.3°C once, should have empiric systemic antibiotics initiated immediately. The specific 
choice of empiric antibiotics should be guided by the resistance patterns seen at the individual institution. 
However, the antibiotic regimen should contain activity against Gram negative organisms and 
Pseudomonas aeruginosa in particular.149 Examples of acceptable monotherapy directed at Gram negative 
organisms include ceftazidime and carbapenems. Acceptable combinations directed against Gram negative 
organisms include an anti-pseudomonal extended spectrum penicillin plus an aminoglycoside.  In addition, 
the initial regimen should include agents with activity against viridans group Streptococcus, as these 
organisms are a common cause of fulminant sepsis in children with AML.150,151 Examples of such 
antibiotics with anti-streptococcal coverage include beta lactams, first generation cephalosporins, 
clindamycin and vancomycin.  
 
Broad-spectrum antibacterial antibiotics, once started, should be continued until there is evidence of ANC 
recovery, or for a minimum of 14 days if there is no evidence of ANC recovery.149,152 Additional therapy 
will be dictated by the patient’s clinical status.  
 
Management of Possible or Documented Fungal Infection 
Patients with AML are at particularly high risk of invasive fungal infection and these organisms are a major 
cause of infection-related mortality.150 Antifungal prophylaxis can reduce morbidity and fungal infection-
related mortality in severely neutropenic chemotherapy recipients. Evidence for benefit is strongest for 
those with > 15% rate of systemic fungal infection, prolonged neutropenia and SCT recipients.153,154  
 
The persistence of fever for 5 days despite broad spectrum antibiotic therapy or the emergence of a new 
fever in neutropenic patients warrants the investigation for invasive fungal infection and initiation of 
empiric antifungal therapy.149  
 
Investigation of invasive fungal infection should include computerized tomography (CT) of sinuses and 
chest and imaging (CT or ultrasound) of the abdomen along with blood and urine cultures. Radiologic 
investigations in those with invasive fungal infections may be negative in the setting of profound 
neutropenia and, therefore, imaging at recovery of neutrophils also may be considered. 
 
In the event of suspected fungal lesions, biopsy whenever possible is strongly recommended in order to 
determine the causative organism. Antifungal options include Amphotericin B (convention or lipid 
products), caspofungin, voriconazole, and micafungin as well as combination therapy. The choice of 

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215 
specific agent(s) and length of therapy will be dictated by the suspected or confirmed fungal species, site 
of infection clinical status and concomitant drug restrictions (see Section 4.2). Consultation with Infectious 
Disease is recommended. 
 
Pneumocystis Prophylaxis 
The administration of trimethoprim-sulfamethoxazole 150 mg/m2/day trimethoprim or 5 mg/kg/day 
trimethoprim (maximum 320 mg/day trimethoprim) orally divided twice daily for 2 or 3 consecutive days 
per week is recommended to prevent infection with Pneumocystis jiroveci.155 
 
For children who are intolerant of trimethoprim-sulfamethoxazole, acceptable alternatives are dapsone 
(2 mg/kg/day, maximum 100 mg/day) orally once daily and aerosolized pentamidine for children old 
enough to cooperate with administration (≥ 5 years) (300 mg inhaled monthly). For children in whom 
trimethoprim-sulfamethoxazole, dapsone and inhaled pentamidine cannot be administered, intravenous 
pentamidine (4 mg/kg/dose intravenous every 2 to 4 weeks) should be given.155 
 
Prophylaxis against PCP should begin as soon as possible after the initiation of chemotherapy and continue 
for at least 3 months following discontinuation of chemotherapy. See the COG Supportive Care Guidelines 
for additional drugs. 
 
Prevention of Viral Infections 
It is suggested that physicians follow their institutional guidelines regarding the prevention and treatment 
of viral infections such as cytomegalovirus and herpes simplex virus in those undergoing initial 
chemotherapy and following SCT.  
 
Use of leuko-reduced and/or cytomegalovirus negative blood products for cytomegalovirus negative 
recipients are strongly encouraged. 
 
Prophylactic acyclovir can reduce the recurrence of mucocutaneous HSV infection in both 
immunocompetent and immunocompromised hosts. The efficacy of prophylactic acyclovir has primarily 
been restricted to reduction of recurrent mucocutaneous HSV infection and not with other clinical endpoints 
such as duration of fever, use of antibiotics and mortality.156  
 
Pulmonary Toxicity 
Cytarabine may result in pulmonary toxicity characterized by pulmonary infiltrates and shortness of breath 
similar to acute-respiratory distress syndrome (ARDS). Bortezomib has also been associated with 
pulmonary toxicity that resembles ARDS. Therefore, surveillance for pulmonary toxicity is extremely 
important, and aggressive intervention for pulmonary symptoms is indicated.  
 
If a patient should develop respiratory distress and/or oxygen saturation of < 92% on room air: 
 
• 
Infection, congestive heart failure, and other potential causes for respiratory distress should be 
evaluated. Consultation with a pulmonologist and bronchoscopy are encouraged if clinically indicated. 
• 
Repeat imaging using a PA/LAT CXR and a CT of the chest (with contrast if appropriate) is 
encouraged. 
• 
See Section 5.7 for dose modifications if pulmonary toxicity is considered drug induced. 
 
Treatment of sorafenib related Rash/Hand-foot syndrome 
Patients who develop hand-foot syndrome may receive topical emollients (such as Aquaphor) as well as 
topical or oral steroids or antihistamines if appropriate. Hand foot syndrome may include skin pain without 
rash that impacts activities of daily living. 
 

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216 
Oral administration of vitamin B 6 (pyridoxine) can also be used for these patients - BSA < 0.5m2: 50 mg 
per day; BSA 0.5 - 1.0 m2: 100 mg per day; BSA 1.1 - 1.5 m2: 200 mg per day, and BSA > 1.5m2: 300 mg 
per day. 
 
Treatment of sorafenib related hypertension. 
The algorithm used in Section 5.2.2 will be used to grade and manage sorafenib related hypertension for 
patients less than 18 years. For patients 18 years and older, refer to CTCAE v4 guidelines for grading of 
hypertension and utilize institutional standards to define BP normalization following medical management. 
Should initiation of antihypertensive therapy be required, single agent therapy (consider a calcium channel 
blocker such as amlodipine or nifedipine) should be started and the blood pressure should be monitored at 
least twice weekly until BP is within the 95th percentile for age, height and gender per Appendix VI. 
 
 
 

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217 
APPENDIX II:  SORAFENIB DOSING NOMOGRAM  
AAML1031 Sorafenib Dosing Nomogram 
BSA 
Range 
(m2) 
Dose Level 0 
100 mg/m2/day  
once daily 
(DOSE/WEEK) 
Dose Level 1 
200 mg/m2/day  
once daily 
(DOSE/WEEK) 
Dose Level 2 
300 mg/m2/day  
divided BID 
(DOSE/WEEK) 
≤ 0.35 
50 mg x 4 days/week,  
0 x 3 day/week 
(200 mg) 
50 mg x 5 days/week, 
100 mg x 2 days/week 
(450 mg) 
50 mg twice daily x 7 days/week 
(700 mg) 
0.36 - 0.4 
50 mg x 5 days/week,  
0 x 2 day/week 
(250 mg) 
50 mg x 4 days/week, 
100 mg x 3 days/week 
(500 mg) 
50 mg twice daily x 6 days/week +  
100 mg twice daily x 1 day/week 
(800 mg) 
0.41 - 0.45 
50 mg x 6 days/week,  
0 x 1 day/week 
(300 mg) 
50 mg x 2 days/week, 
100 mg x 5 days/week 
(600 mg) 
50 mg twice daily x 5 days/week +  
100 mg twice daily x 2 days/week 
(900 mg) 
0.46 - 0.55 
50 mg x 7 days/week 
(350 mg) 
100 mg x 7 days/week 
(700 mg) 
50 mg q AM +100 mg q PM   
x 7 days/week 
(1050 mg) 
0.56 - 0.6 
50 mg x 6 days/week,  
100 mg x 1 day/week 
(400 mg) 
100 mg x 6 days/week, 
200 mg x 1 day/week 
(800 mg) 
50 mg twice daily x 2 days/week +  
100 mg twice daily x 5 days/week 
(1200 mg) 
0.61 - 0.7 
50 mg x 5 days/week,  
100 mg x 2 days/week 
(450 mg) 
100 mg x 5 days/week, 
200 x 2 days/week 
(900 mg) 
100 mg twice daily x 7 days/week 
(1400 mg) 
0.71 - 0.8 
50 mg x4 days/week,  
100 mg x3 days/week 
(500 mg) 
150 mg x 7 days/week 
(1050mg) 
100 mg twice daily x 5 days/week + 
150 mg twice daily x 2 days/week 
(1600 mg) 
0.81 - 0.9 
50 mg x 2 days/week,  
100 mg x 5 days/week 
(600 mg) 
150 mg x 4 days/week, 
200 mg x 3 days/week 
(1200 mg) 
100 mg q AM + 150 mg q PM 
 x 7  days/week  
(1750 mg) 
0.91 - 1.05 
100 mg x 7 days/week 
(700 mg) 
200 mg x 7 days/week 
(1400 mg) 
150 mg twice daily x 7 days/week 
(2100 mg) 
1.06 - 1.2 
100 mg x 6 days/week,  
200 mg x1 day/week 
(800 mg) 
200 mg x 3 days/week, 
250 mg x 4 days/week 
(1600 mg) 
150 mg q AM + 200 mg q PM  
x 7 days/week 
(2450 mg)  
1.21 - 1.35 
100 mg x 5 days/week,  
200 mg x 2 days/week 
(900 mg) 
250 mg x 7 days/week 
(1750 mg) 
200 mg twice daily x 7 days/week 
(2800 mg) 
1.36 - 1.6 
100 mg x 4 days/week,  
200 mg x 3 days/week 
(1000 mg) 
300 mg x 7 days/week 
(2100 mg) 
200 mg q AM + 250 mg q PM 
x 7 days/week 
(3150 mg) 
1.61 - 1.7 
100 mg x 2 days/week,  
200 mg x 5 days/week 
(1200 mg) 
350 mg x 7 days/week 
(2450 mg) 
250 mg twice daily x 7 days/week 
(3500 mg) 
1.71 - 1.85 
100 mg x 1 day/week, 
200 mg x 6 days/week 
(1300 mg) 
350 mg x 3 days/week 
400 mg x 4 days/week 
(2650 mg) 
250 mg q AM + 300 mg q PM  
x 7 days/week 
(3850 mg) 
≥ 1.86 
200 mg x 7 days/week 
(1400 mg ) 
400 mg x 7 days/week 
(2800 mg) 
300 mg twice daily x 7 days /week 
(4200 mg) 

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APPENDIX 
III: 
INSTRUCTIONS 
FOR 
CHEMOTHERAPY 
DRUG 
PREPARATION, 
ADMINISTRATION AND SAFE HANDLING  
 
Patient Name: _________________    Cycle#/Course#: _____    Date Range: _______________ 
 
Sorafenib 
Sorafenib is a chemotherapeutic drug that requires safe 
handling. This information sheet will help you to safely 
prepare, administer, store, and dispose the drug. Please 
read the information before preparing and taking your 
drug. If you have any questions, please contact: 
__________________________________ 
 
WHAT DO I NEED?  
Your dose is:  
• 
Sorafenib _______ mg by mouth  
_______ time(s) per day  
on the following days:_________________ 
 
You should use the following combination of 
tablets for each dose: 
_______ of the 50 mg tablets 
_______ of the 200 mg tablets 
 
AND: 
 
• 
Sorafenib _______ mg by mouth  
_______ time(s) per day  
on the following days:_________________ 
 
You should use the following combination of 
tablets for each dose: 
_______ of the 50 mg tablets 
_______ of the 200 mg tablets 
Supplies:  
• 
Disposable pad or paper towels to cover the 
work area 
• 
Disposable gloves and mask 
• 
Disposable cup for mixing drug with water  
• 
Disposable spoon 
• 
A container to collect waste (zip top plastic 
bag or medical waste bag or container) 
• 
Tap or bottled water (drinking water)  
_______ mL of water for mixing  
_______ mL of water for rinsing 
(based on dose in table to the right) 
HOW DO I PREPARE THE DRUG?  
 
[Caution: If you are pregnant, could become pregnant, or are 
breast-feeding, we suggest that you DO NOT prepare or 
administer this drug without FIRST checking with your health 
care provider.] 
1. Choose a quiet working space away from food, 
windows, fans or heat ducts. 
2. Clean the working space with damp paper towels. 
3. Place a disposable pad or paper towel on the clean 
working space and place all needed items and drug on 
the pad or paper towel.  
4. Wash your hands with soap and water and dry 
thoroughly. 
5. It is suggested that you put on disposable gloves. 
 
Drug preparation instructions: 
(Refer to the section on “How do I Take/Give the Drug?” on 
the next page for specific instructions) 
1. Note: The suspension must be administered within one 
hour after preparation.  
2. Fill  the disposable cup with the volume of water 
appropriate for the dose as indicated in the table below: 
 
Sorafenib dose 
Amount of mixing 
water needed 
50 mg to 199 mg 
30 mL (1 oz) 
200 mg to 400 mg 
60 mL (2 oz) 
 
3. Place the number of tablets required for the dose into 
the water. Record the time. 
4. Begin stirring with the plastic spoon after approximately 
5 minutes. The tablets will begin to form a suspension.  
5. Continue stirring until the tablets are completely 
disintegrated (dissolved). The tablet coating may initially 
form a thin film; however, this has no impact on dosing 
accuracy. 
6. The suspension is ready for administration after about 
10 minutes. 
  
 
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219 
HOW DO I TAKE/GIVE THE DRUG? 
 
▪ 
Take/Give sorafenib at approximately the 
same time each day.   
▪ 
Take/Give sorafenib on an empty stomach, at 
least one hour before or two hours after food. 
▪ 
Do not consume grapefruit juice during this 
study as it interacts with sorafenib. 
▪ 
Just 
prior 
to 
administration, 
stir 
the 
suspension thoroughly and administer the 
dose to the patient. 
▪ 
After drinking the suspension, rinse the cup 
several times with the total volume of water 
indicated in the table below to capture all of 
the remaining drug particles, and administer to 
subject. 
Sorafenib dose 
Amount of rinsing 
water needed 
50 mg to 199 mg 
90 mL (3 oz) 
200 mg to 400 mg 
180 mL (6 oz) 
 
▪ 
When you are finished, place the dirty gloves, 
spoon, cup, and other tools used to mix the 
drug in a plastic zip top bag or the waste 
container 
provided 
by 
your 
nurse 
or 
pharmacist.  
▪ 
If a dose is skipped, DO NOT replace the 
skipped dose. Wait for the next dose to take 
the drug. Do not double the dose to catch up. 
▪ 
If the dose is vomited, do not take another 
dose. 
 
HOW DO I STORE THE DRUG BOTTLE?  
 
Store the medication in the bottle at room 
temperature away from food and out of the reach 
of children or pets. 
  
WHAT SHOULD I DO WITH LEFT-OVER DRUG 
AND USED SUPPLIES?  
 
If the patient could not take the dose or part of the 
dose, DO NOT keep or store the left-over portion. 
Place the remaining drug from this dose in the 
waste container and seal. Store the waste container 
out of the reach of children or pets. Return the waste 
container to the clinic at the next visit. Notify your 
study team at the next opportunity. 
 
WHAT DO I DO WITH THE EXPIRED OR NOT 
USED TABLETS?  
 
Return the unused drug to your study team at the 
clinic or hospital at the next visit. 
 
WHAT PRECAUTION/SAFETY MEASURES DO I 
NEED TO TAKE? 
 
If drug gets into eyes, hold eyelids open while 
flushing with water for at least 15 minutes. Call 
your doctor or nurse immediately at 
 
 ____________________________________  
 
 
and/or contact the Poison Control Center at 
 
 ____________________________________ 
  
If you spilled the drug on your skin, remove 
contaminated clothing. Wash area with soap and 
large amount of water. Seek medical attention 
(see contact information above) if the skin 
becomes red or irritated or if you are concerned. 
 
 
 
 
 
 
 
  
 
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220 
 
 
APPENDIX IV: LIST CYP3A4 SUBSTRATES, INDUCERS AND INHIBITORS  
This is not an inclusive list. Because the lists of these agents are constantly changing, it is important to 
regularly consult frequently updated medical references. 
 
 
CYP3A4 substrates  
Strong 
Inhibitors1 
Moderate 
Inhibitors 
Weak 
Inhibitors 
Inducers 
alfentanil4,5  
amiodarone4 
aprepitant5 
atorvastatin5 
benzodiazepines 
bortezomib 
brentuximab 
budesonide5 
buspirone5 
calcium channel blockers 
cisapride 
citalopram/escitalopram 
conivaptan5 
glucocorticoids2 
crizotinib 
cyclosporine4 
cyclophosphamide  
dapsone 
darifenacin5 
darunavir5 
dasatinib5 
dihydroergotamine 
docetaxel 
doxorubicin 
dronedarone5 
eletriptan5 
ergotamine4 
eplerenone5 
erlotinib 
esomeprazole 
estrogens 
etoposide 
everolimus5 
felodipine5 
fentanyl4 
fosaprepitant5 
gefitinib 
haloperidol 
HIV antiretrovirals 
HMG Co-A inhibitors5 
ifosfamide 
imatinib 
indinavir5 
atazanavir 
boceprevir 
clarithromycin 
cobicistat 
darunavir 
delavirdine 
grapefruit3 
grapefruit juice3 
indinavir 
itraconazole 
ketoconazole 
lopinavir/ritonavir 
nefazodone 
nelfinavir 
posaconazole 
ritonavir 
saquinavir 
telaprevir 
telithromycin 
voriconazole 
aprepitant 
conivaptan 
crizotinib 
diltiazem 
dronedarone 
erythromycin 
fluconazole 
fosamprenavir 
grapefruit3 
grapefruit juice3 
imatinib 
mifepristone 
nilotinib 
verapamil 
alprazolam 
amiodarone 
amlodipine 
atorvastatin 
bicalutamide 
cilostazol 
cimetidine 
ciprofloxacin 
cyclosporine 
fosaprepitant 
fluvoxamine 
isoniazid 
nicardipine 
propofol 
quinidine 
ranolazine 
 
 
 
armodafinil 
barbiturates 
bosentan 
carbamazepine 
deferasirox 
echinacea 
efavirenz 
etravirine 
fosphenytoin 
glucocorticoids2 
modafinil 
nafcillin 
nevirapine 
oxcarbazepine 
phenobarbital 
phenytoin 
pioglitazone 
primidone 
rifabutin 
rifampin 
rifapentin 
ritonavir 
St. John’s wort 
topiramate 
 

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221 
irinotecan  
itraconazole 
ketoconazole 
lansoprazole 
lapatinib 
losartan 
lovastatin5 
lurasidone5 
macrolide antibiotics 
maraviroc5 
medroxyprogesterone 
methadone 
midazolam5 
modafinil 
montelukast 
nefazodone 
nilotinib 
nisoldipine5 
omeprazole 
ondansetron 
paclitaxel 
pazopanib 
quetiapine5 
quinidine4  
saquinavir5 
sildenafil5 
simvastatin5 
sirolimus4,5 
sunitinib 
tacrolimus4,5  
telaprevir 
tamoxifen 
temsirolimus 
teniposide 
tetracycline 
tipranavir5 
tolvaptan5 
triazolam5 
trimethoprim 
vardenafil5 
vinca alkaloids 
zolpidem 
1 Certain fruits, fruit juices and herbal supplements (star fruit, Seville oranges, pomegranate, gingko, goldenseal) 
may inhibit CYP3A4 isozyme, however, the degree of that inhibition is unknown.  
2Dexamethasone is considered a weak CYP3A4 inducer. 
3The effect of grapefruit juice (strong vs moderate CYP3A4 inhibition) varies widely among brands and is 
concentration-, dose-, and preparation-dependent. 
4Narrow therapeutic range substrates 
5Sensitive substrates 
 

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222 
APPENDIX V: SAMPLE SUBMISSION FOR CYTOGENETIC/FISH STUDIES 
(A COPY OF THIS SECTION MUST BE SENT TO THE RECOMMENDED INSTITUTIONAL, 
COG-APPROVED CYTOGENETICS LABORATORY) 
 
CHROMOSOME ANALYSIS 
• 
Bone marrow should be studied by cytogenetics methods in all cases of acute myeloid leukemia. 
 
• 
A back-up blood specimen should be studied when the bone marrow aspirate or bone marrow core 
biopsy is inadequate or unobtainable (in which case short-term unstimulated cultures are 
established to examine spontaneously dividing [presumably leukemic] cells) or when a 
constitutional chromosomal abnormality is a possibility (phytohemagglutinin-stimulated cultures 
should be established to examine presumably nonleukemic [constitutional] lymphocytes). 
 
• 
Short-term (15 - 48 hours) unstimulated cultures are recommended for each bone marrow sample. 
Analysis of direct preparations is successful in some laboratories. Mitogen-stimulated cultures of 
bone marrow samples should not be initiated. 
 
• 
All preparations must be G-banded. (Q- or R-banding will not be accepted as a stand-alone banding 
method.) 
 
• 
Complete analysis of 20 G-banded metaphases is required for each case, except as noted below. 
Complete analysis is defined as follows: the chromosomes in each metaphase cell have been 
counted; each chromosome has been examined to determine whether the banding pattern is normal, 
and all abnormalities present in the cell have been defined. Analysis may be accomplished by 
examining metaphase spreads under the microscope or by imaging. Sometimes analysis of 20 
metaphases is not possible because of poor in vitro growth or a very limited quantity of specimen. 
However, limited characterization of the abnormal clone can still be informative. Such informative 
cases will be considered acceptable. A minimum analysis of 20 metaphases is required for a normal 
case. 
 
• 
Identification of clones will follow the criteria of the Second International Workshop on 
Chromosomes in Leukemia, as stated in the: General Report (Cancer Genet. Cytogenet 2:93-96, 
1980): at least 2 metaphases with identical structural abnormalities or extra chromosomes, or at 
least three metaphases with identical missing chromosomes will constitute a clone. Nonclonal 
abnormalities (excluding random loss) should also be recorded. 
 
• 
Karyotypes are to be designated according to the guidelines described in ISCN 2009, An 
International System for Human Cytogenetic Nomenclature (2009), LG Shaffer, ML Slovak and 
LJ Campbell (eds); S. Karger, Basel, 2009. 
 
FLUORESCENCE IN SITU HYBRIDIZATION (FISH) 
• 
FISH using commercially available probes will be required for the following cases A.) Normal 
B) Insufficient Quantity. C) Abnormal case with an inv(16)/t(16;16), t(8;21) or 11q23 (see below). 
The laboratory is expected to follow the standards and guidelines for FISH put forth by the 
American College of Medical Genetics. If the laboratory is unable to perform FISH tests, contact 
cytogenetics coordinators for advice. 
 
A) For all cases for which G-banding reveals a normal karyotype, FISH with RUNX1T1/RUNX1, 
CBFB, or CBFB-MYH11, PML-RARA and MLL (probes must be performed to rule out a cryptic 

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223 
t(8;21), inv(16) or t(16;16), t(15;17) and 11q23 abnormality. FISH testing should be performed on 
1 day cultures (unstimulated sample).  
 
B) For all cases with failed cytogenetics, FISH with RUNX1T1/RUNX1, CBFB or CBFB-MYH11, 
PML-RARA, MLL, 7 (LSI, D7Z1/D7S486), and 5 (LSI, EGR1/D5S23, D5S721). The threshold for 
a positive FISH finding for –7, -5/5q- will be >30%. If possible, morphologic and 
immunophenotypic data should be obtained as such data can be suggestive of a particular 
abnormality and thereby help the laboratory director to prioritize these studies.  
 
C) When G-banding reveals a known recurring chromosomal rearrangement, specifically one 
involving an t(8;21), inv(16)/t(16;16), or abnormal 11q23, FISH is recommended with a probe set 
targeting the involved loci (i.e., RUNX1T1/RUNX1,, CBFB or CBFB-MYH11, MLL) should be 
performed on metaphase or interphase cells to determine whether there is an associated deletion 
involving the regions 3’ or 5’ of the participating genes, and to establish the pattern that can be 
used to monitor this patient’s disease. When G-banding reveals an abnormality of 12p, FISH with 
a probe that can assess ETV6 status (ETV6 breakapart or ETV6-RUNX1) in order to detect ETV6 
rearrangement or deletion. 
 
CYTOGENETIC STUDY/FISH SUBMISSION 
Steps to obtain the FORMS by the institution’s CRA 
1. www.childrensoncologygroup.org 
2. COG members 
3. Protocols ►Protocol Reference Materials ►Generic Forms 
4. Under COG ►Cytogenetics Reporting/FISH Forms 
 
The COG Forms should be completed by the designated individual in the Cytogenetics Laboratory and 
signed by the Cytogenetics Director. It is highly recommended to scan the Forms and e-mail with the 
appropriate documentation (PowerPoint presentation preferred) to COG reviewers for the Myeloid 
Committee. If the laboratory is unable to send an electronic file with the documentation, please contact the 
COG cytogenetics coordinator for your area for advice 
 
Because the chromosome analysis results should be finalized and will be used for risk stratification and to 
guide therapy by Day 28 of a patient’s enrollment, the case should be sent to the appropriate reviewer 
by Day 14 but only for those patients identified as having HR FLT3/ITD (AR >0.4) who were 
consented to Arm C. As of Amendment #7A, cytogenetic review will not be conducted on those 
patients removed from protocol therapy after they were determined to be ineligible for Arm C. 
 
Cytogenetic Coordinators 
Please send above materials by e-mail (preferably as PowerPoint file) to the following COG Cytogenetics 
Laboratories:  
 
WEST OF MISSISSIPPI RIVER  
(INCLUDE MINNESOTA AND WISCONSIN), 
AUSTRALIA, NEW ZEALAND, WESTERN 
CANADA 
EAST OF MISSISSIPPI RIVER  
(EXCLUDE MINNESOTA AND 
WISCONSIN), EUROPE, EAST CANADA 
SEND TO:  
SEND TO: 
Betsy Hirsch, Ph.D. 
Susana C. Raimondi, Ph.D. 
Telephone: 612-273-4952/3171 
Telephone: 901-595-3537/3536 
E-mail: hirsc003@umn.edu 
E-mail: susana.raimondi@stjude.org 
 
 

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224 
CYTOGENETICS REVIEW 
The region’s cytogenetics coordinator will review each case when it is submitted. She/he will determine 
whether each case is adequate in terms of the numbers of metaphase cells analyzed, quality of banding, and 
interpretation of the karyotypes. If the coordinator agrees with the submitting laboratory, the results of the 
study will be entered into the appropriate eRDE. If the coordinator does not agree and the results are 
significant for patient stratification, she/he will send the case to another member of the COG Cytogenetics 
Review Committee for rapid review. If the coordinator does not agree with the submitting laboratory but 
the results are not significant for patient stratification, the case will be taken to the next central review 
session to be reviewed there. If the case is determined as not adequate it will be registered as unknown 
cytogenetics.  
 
(A SIGNED AND DATED COPY OF THIS AUTHORIZATION FORM FOR REFLEXIVE FISH 
TESTING MUST BE SENT TO THE CYTOGENETICS LABORATORY, TOGETHER WITH 
THE BONE MARROW SAMPLE) 
 
AUTHORIZATION FORM FOR REFLEXIVE FISH TESTS 
Patients are stratified for AAML1031 treatment by cytogenetic groups. To achieve the most accurate 
diagnosis/subgrouping. 
 
A). REQUIRED FISH if a case is cytogenetically normal or inadequate  
t(8;21)    
 
[RUNX1T1/RUNX1] 
inv(16)/t(16;16)  
[CBFB or CBFB-MYH11] 
t(15;17) 
 
[PML-RARA] 
11q23    
 
[MLL] 
 
B). REQUIRED FISH if a case is cytogenetically inadequate  
-7: 
  
 
[LSI, D7Z1/D7S486] 
-5/5q-:    
 
[LSI, EGR1/D5S23, D5S721] 
t(8;21)    
 
[RUNX1T1/RUNX1] 
inv(16)/t(16;16)  
[CBFB or CBFB-MYH11] 
t(15;17) 
 
[PML-RARA] 
11q23    
 
[MLL] 
 
C). RECOMMENDED FISH if a case has a cytogenetically detectable  
 
t(8;21)   
 
[RUNX1T1/RUNX1] 
 
inv(16)/t(16;16)  
[CBFB or CBFB-MYH11] 
 
11q23  
 
[MLL] 
              Abnormality of 12p      [ETV6 breakapart or ETV6-RUNX1] 
 
It is authorized to perform reflexive FISH testing to rule-out cryptic aberrations and/or to evaluate 
molecular deletions. 
 
Patient Registration #  __________________________________________ 
 
___________________________________________________________ 
Print Name of Attending Physician 
 
_____________________________________________________________ 
Print Name of Institution and City, State 
 
Signature of attending physician or designee: ________________________  
 
Date: ______________________ 
 
 

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225 
APPENDIX VI: BLOOD PRESSURE LEVELS FOR CHILDREN BY AGE AND HEIGHT 
PERCENTILE 
 
 
BLOOD PRESSURE (BP) LEVELS FOR BOYS AGED 1-17 YEARS 
 
 
Systolic Blood Pressure, mm Hg 
Diastolic Blood Pressure, mm Hg 
Age 
BP 
Percentile of Height 
Percentile of Height 
(years) 
Percentile 
5th 
10th 
25th 
50th 
75th 
90th 
95th 
5th 
10th 
25th 
50th 
75th 
90th 
95th 
1 
95th 
98 
99 
101 
103 
104 
106 
106 
54 
54 
55 
56 
57 
58 
58 
2 
95th 
101 
102 
104 
106 
108 
109 
110 
59 
59 
60 
61 
62 
63 
63 
3 
95th 
104 
105 
107 
109 
110 
112 
113 
63 
63 
64 
65 
66 
67 
67 
4 
95th 
106 
107 
109 
111 
112 
114 
115 
66 
67 
68 
69 
70 
71 
71 
5 
95th 
108 
109 
110 
112 
114 
115 
116 
69 
70 
71 
72 
73 
74 
74 
6 
95th 
109 
110 
112 
114 
115 
117 
117 
72 
72 
73 
74 
75 
76 
76 
7 
95th 
110 
111 
113 
115 
117 
118 
119 
74 
74 
75 
76 
77 
78 
78 
8 
95th 
111 
112 
114 
116 
118 
119 
120 
75 
76 
77 
78 
79 
79 
80 
9 
95th 
113 
114 
116 
118 
119 
121 
121 
76 
77 
78 
79 
80 
81 
81 
10 
95th 
115 
116 
117 
119 
121 
122 
123 
77 
78 
79 
80 
81 
81 
82 
11 
95th 
117 
118 
119 
121 
123 
124 
125 
78 
78 
79 
80 
81 
82 
82 
12 
95th 
119 
120 
122 
123 
125 
127 
127 
78 
79 
80 
81 
82 
82 
83 
13 
95th 
121 
122 
124 
126 
128 
129 
130 
79 
79 
80 
81 
82 
83 
83 
14 
95th 
124 
125 
127 
128 
130 
132 
132 
80 
80 
81 
82 
83 
84 
84 
15 
95th 
126 
127 
129 
131 
133 
134 
135 
81 
81 
82 
83 
84 
85 
85 
16 
95th 
129 
130 
132 
134 
135 
137 
137 
82 
83 
83 
84 
85 
86 
87 
17 
95th 
131 
132 
134 
136 
138 
139 
140 
84 
85 
86 
87 
87 
88 
89 
Instructions for using this BP Chart: 
1. Measure the patient’s blood pressure using an appropriate size cuff. 
2. Select appropriate chart for a female or male patient. 
3. Using the “age” row and “height” column determine if the BP is within the ULN. 
4. See Section 5.2.2 for definition of dose-limiting hypertension, management and grading of 
hypertension, and Appendix I for medical treatment of sorafenib related hypertension.  
 
This table was taken from “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High 
Blood Pressure in Children and Adolescents”.157  
 

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226 
BLOOD PRESSURE (BP) LEVELS FOR GIRLS AGED 1-17 YEARS  
 
 
Systolic Blood Pressure, mm Hg 
Diastolic Blood Pressure, mm Hg 
Age 
BP 
Percentile of Height 
Percentile of Height 
(years) 
Percentile 
5th 
10th 
25th 
50th 
75th 
90th 
95th 
5th 
10th 
25th 
50th 
75th 
90th 
95th 
1 
95th 
100 
101 
102 
104 
105 
106 
107 
56 
57 
57 
58 
59 
59 
60 
2 
95th 
102 
103 
104 
105 
107 
108 
109 
61 
62 
62 
63 
64 
65 
65 
3 
95th 
104 
104 
105 
107 
108 
109 
110 
65 
66 
66 
67 
68 
68 
69 
4 
95th 
105 
106 
107 
108 
110 
111 
112 
68 
68 
69 
70 
71 
71 
72 
5 
95th 
107 
107 
108 
110 
111 
112 
113 
70 
71 
71 
72 
73 
73 
74 
6 
95th 
108 
109 
110 
111 
113 
114 
115 
72 
72 
73 
74 
74 
75 
76 
7 
95th 
110 
111 
112 
113 
115 
116 
116 
73 
74 
74 
75 
76 
76 
77 
8 
95th 
112 
112 
114 
115 
116 
118 
118 
75 
75 
75 
76 
77 
78 
78 
9 
95th 
114 
114 
115 
117 
118 
119 
120 
76 
76 
76 
77 
78 
79 
79 
10 
95th 
116 
116 
117 
119 
120 
121 
122 
77 
77 
77 
78 
79 
80 
80 
11 
95th 
118 
118 
119 
121 
122 
123 
124 
78 
78 
78 
79 
80 
81 
81 
12 
95th 
119 
120 
121 
123 
124 
125 
126 
79 
79 
79 
80 
81 
82 
82 
13 
95th 
121 
122 
123 
124 
126 
127 
128 
80 
80 
80 
81 
82 
83 
83 
14 
95th 
123 
123 
125 
126 
127 
129 
129 
81 
81 
81 
82 
83 
84 
84 
15 
95th 
124 
125 
126 
127 
129 
130 
131 
82 
82 
82 
83 
84 
85 
85 
16 
95th 
125 
126 
127 
128 
130 
131 
132 
82 
82 
83 
84 
85 
85 
86 
17 
95th 
125 
126 
127 
129 
130 
131 
132 
82 
83 
83 
84 
85 
85 
86 
Instructions for using this BP Chart: 
1. Measure the patient’s blood pressure using an appropriate size cuff. 
2. Select appropriate chart for a female or male patient. 
3. Using the “age” row and “height” column determine if the BP is within the ULN. 
4. See Section 5.2.2 for definition of dose-limiting hypertension, management and grading of 
hypertension, and Appendix I for medical treatment of sorafenib related hypertension.  
 
This table was taken from “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High 
Blood Pressure in Children and Adolescents”.157 
 
 

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227 
 
APPENDIX VII: LEUKEMIA BIOLOGY & GENE POLYMORPHISM STUDIES 
 
Leukemia Biology Studies and Specimen Banking:  
Submit 3 - 10 mL of bone marrow in EDTA containing tubes (purple/lavender top tubes) at the times 
specified in Section 7.4. Peripheral blood in the same amount (i.e., 3–10 mL) may be substituted if bone 
marrow is unobtainable. When marrow is unattainable for mutation analysis, peripheral blood should be 
obtained in preservative-free heparin tubes (green top tubes). 
 
Gene Polymorphism Study: 
Submit 5 mL of peripheral blood in purple/lavender top tubes at sent at the time of diagnosis and at the time 
of the bone marrow exam at the end of Induction I.  
 
Shipping: Samples should be sent to:  
Fred Hutchinson Cancer Research Center  
1100 Fairview Ave. N., D2-367 
Seattle, WA 98109 
(206) 667-2286 
Contact person: Sommer Castro  
Email: scastro@fhcrc.org 
Director: Irwin Bernstein, M.D. 
Email:  ibernste@fhcrc.org 
 
See the AAML1031 Sample Submission Schedule posted on the protocol webpage for courier information. 
Saturday deliveries are permissible; Sunday deliveries are not permissible. Note: If a Saturday delivery is 
planned, please notify Sommer Castro at the number listed above and clearly mark the package “For 
Saturday Delivery.” 
 
Ship each serial specimen individually by overnight air freight on the day of its harvest. Maximum time 
from sample collection to shipment should be no greater than 24 hours.  
 
Exceptions:  
1) Samples collected on weekends or holidays should be shipped the first working day following 
collection.  
2) Although diagnostic marrow samples should be sent in as soon as possible, diagnostic samples will 
be accepted if they are later than 24 hours from sample collection to shipment (only post-Induction 
samples require the 24-hour time limit). 
 
Store and ship samples at room temperature. Send fresh. If delay in shipment is not avoidable, please add 
equal volume of RPMI medium (1 mL RPMI for 1 mL of specimen). 
 
Labelling: Label the tubes with the patient’s COG ID number, protocol ID number, BPC #, date and time 
of collection, phase of therapy, and source of material (i.e., bone marrow or blood). No refrigeration is 
necessary, with the exception of the Day 1 samples collected for protein expression array. Utilize AML 
Specimen Transmittal forms specific for AAML1031. PACK TUBES CAREFULLY! Wrap in an 
absorbable material, place in an airtight container (i.e., ziplock bag), and place entire specimen into an 
appropriate shipping container.   
 
Peripheral Blood/Genotyping studies: These samples will be stored for future use if the patient/family 
consents to the use of lab samples for future studies on cancer or unrelated diseases. 
 
Banking Specimens: If the patient consents, any specimens left over on this study after required tests are 
performed will be banked for future research studies.  
 

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228 
APPENDIX VIII: LEUKEMIA INITIATING CELL (LIC) STUDY 
 
Sample collection time point: End Induction I 
 
NOTE: If a patient is MRD+ at the end of Induction I, a second 5 cc sample should be sent to the 
University of Rochester for LIC assessment after Induction II. 
 
Specimen Requirements: 
 
• 
Collect 5 cc BM into a syringe and transfer the specimen immediately into a 10 mL green heparin 
tube. 
• 
Mix well by inverting several times immediately after injecting into tube. Up to 5 mL of BM can 
be placed in one 10 mL green top tube.  
• 
Use multiple syringes and tubes as necessary. Reposition the bone marrow aspirate needle at least 
once during the diagnostic procedure to ensure the maximum quality of bone marrow. 
• 
Label each tube with Patient ID, Patient’s initials, Protocol number (AAML1031), date of sample 
collection, institution and type of specimen (bone marrow). 
• 
Each sample should be clearly labeled to include the 6 digit COG number as well as the 4 digit 
treatment accession number; the study number (AAML1031), date and time sample was drawn. 
• 
Store in refrigerator until shipment. 
 
▪ 
Shipping Requirements: 
 
• 
Prior to sample collection, please contact Dr. Michael Becker at (585) 273-3083 or a Becker Lab 
representative at (585) 273-5548 to notify them of pending collection. If time is available the 
Becker lab will send a shipping container prior to collection of the end of Induction I bone marrow.  
• 
In the absence of a shipping box from the Becker lab, place collection tubes in a container and place 
the container in a Styrofoam box. 
 
o The sample must be placed in a leak proof primary receptacle (e.g.: vacutainer).  
o Multiple fragile primary receptacles must be individually wrapped or separated to prevent 
contact.  
o The primary receptacle must be placed into a leak proof secondary container (e.g.: ziplock 
bag) in such a way that under normal conditions of transport, they cannot break or leak. 
Please place each sample in a separate secondary container to prevent cross-
contamination. 
o Absorbent material, such as paper towels or absorbent pads or pillows, must be placed in 
the secondary container with sufficient capacity to absorb the entire contents of the primary 
receptacle(s).  
o The secondary containers must be placed into an outer package with suitable cushioning 
material and the total amount of diagnostic specimen must not exceed 4 L (liquid) or 4 kg 
(solid) per package.  
o The secondary packaging must be labeled with the universal biohazard symbol.  
o The outer packaging must be clearly and durably marked with the words "Diagnostic 
Specimen"  
o The outer packaging must be marked with the name, address, and phone number of both 
the sender and recipient.  
o In addition to the above list of requirements for ground transportation, the following 
requirements apply when shipping via FedEx or other air courier:  
 

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229 
a. All packages shipped via aircraft must display a 2 inch diamond with "UN3373" inside 
of the diamond. 
b. Outer packages must be rigid (bags and envelopes are not allowed).  
c. The outer packaging must be at least 4 inches in the smallest overall external 
dimension.  
 
• 
Please ship the sample with an ice pack placed in either the shipping container provided 
by the Becker lab or the Styrofoam box. During the non-winter months (April - October) 
add an additional ice pack to assure the samples stays cold during shipment.  
 
• 
Package sample as appropriate for biologic material. 
 
o For all samples: 
 
a. Include a copy of the AAML1031 LIC Specimen Transmittal Form (posted on the 
protocol website) with each shipment. 
b. DocuSAM a recent bone marrow immunophenotype report with the first 
peripheral blood sample. If this is not possible, please send the report that day via fax 
(585) 276-2596 or email to Dr. Becker at Michael_becker@urmc.rochester.edu. 
(Please strip unnecessary identifiers) 
 
o Ship the sample on the same day it was obtained by Federal Express Priority 
Overnight delivery to: 
 
Dr. Michael W. Becker c/o Susan Murray 
J.P. Wilmot Cancer Center, Room 30852 
575 Elmwood Avenue 
Rochester, NY, 14620 
 
o See the AAML1031 Sample Submission Schedule posted on the protocol webpage for 
courier information. 
o Notify Dr. Michael Becker at (585) 273-3083 or a Becker Lab representative at (585) 273-
5548 prior to sample shipment 
o Do not ship samples for delivery on a weekend or holiday. If samples are collected on 
a Friday, refrigerate over the weekend and ship on Monday.  
o Samples must be shipped within 24 hours (except for samples collected on Friday, see 
above). 
 
 

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230 
APPENDIX IX: PROTEIN EXPRESSION (RPPA) AND UNFOLDED PROTEIN RESPONSE 
(UPR) STUDY 
As of 2/17/2017, the number of required specimens for analysis of RPPA and Unfolded Protein Response 
(UPR) has been met. No samples should be submitted. (See memo from 02/17/2017 
https://cogmembers.org/site/News/newsitem.aspx?lid=18690) 
 
Eligible samples: 
Sample should be sent to the Horton lab only if the patient samples meet the following criteria: 
 
Eligible patients must have an initial absolute blast count of at least 1,000 myeloblasts/µL. To calculate 
the absolute blast percentage, multiply the total WBC by the % peripheral blasts: 
 
(WBC)(% blast)(1,000) = absolute blast count/µL 
 
As an example, if the patient has a WBC of 10 and 50% blasts, the absolute blast count is: 
(10)(.5)(1,000) = 5,000/µL 
 
If the initial % blasts is unknown, send samples only if the total WBC is more than 10,000 and notify 
the Horton lab of the % blast as soon as available (contact info provided below). 
 
The Horton lab can accept Saturday shipments if we are contacted ahead of time. Please contact Gaye 
Jenkins or Dr Horton (832-824-4676 or 832-824-4269) for alternative address and shipping information for 
Saturday delivery. 
 
Sample collection time points: 
 
Day 1, Hour 0 
Day 1, Hour 10 
Day 1, Hour 24 
Peripheral Blood 
(Induction 1 only) 
5 mL* 
(before start of systemic 
chemotherapy) 
5 mL*  
5 mL* 
(collected 24 hours after 
the start of the 
chemotherapy infusion) 
* 
Sample Collection: Divide 5 mL sample into the CellSave tubes (3 mL) and heparin tubes (2 mL). Either lithium heparin 
or sodium heparin is acceptable (however please do not use heparin tubes with plasma separator gel, i.e., plasma separator 
tubes or PST tubes). Hour 10 samples should be collected 10 hours after the start of systemic chemotherapy.  
 
Shipping Note: Although not preferred, samples collected on Saturday and Sunday can be shipped Monday 
for Tuesday arrival. See below for information on obtaining and shipping samples in ThermoSafe 
containers. 
 
▪ 
Specimen Requirements: 
• Store samples in refrigerator until shipment. 
• CellSave tubes will be provided by the Horton lab to each institution upon IRB approval.   
o To obtain more CellSave tubes, contact the Horton lab at the numbers provided below. 
o If the CellSave tubes are not available, submit entire 5 mL sample in heparin tubes. Note that 
the sample integrity is greatly enhanced by the use of CellSave tubes.  
• Each sample should be clearly labeled to include the 6 digit COG number as well as the 4 digit 
treatment accession number; study number (AAML1031), date and time sample was drawn.  
• On the AAML1031 Specimen Transmittal Form in the RDE system record the exact time and date 
that the sample is drawn along with the exact start time for administration of systemic 
chemotherapy. 
• Please note the WBC and % blasts on the specimen transmittal form. 

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231 
• The institutional immunophenotype report should be submitted via the eRDEs Document Imaging 
System (DocuSAM).  
Note: it is acceptable for blood to be collected from a central line. 
 
Shipping Requirements:  
Prior to sample collection, please contact Dr. Horton at (832) 824-4269 or Gaye Jenkins/Horton lab at (832) 
824-4676 for ThermoSafe shipping containers. These containers maintain biology samples at a constant 
temperature and are recommended, but not required, for biology sample shipment. Shipment of peripheral 
blood samples should not be delayed for receipt of shipping containers.   
 
If Thermo-Safe shipping container is not available: 
• 
Place collection tubes in a primary container. Wrap each collection tube separately to protect 
from breakage during shipment. Place the container in a Styrofoam box.  
• 
Please place an ice pack in the primary container. During the non-winter months (April-
October) add additional ice packs to the Styrofoam box to assure the samples stays cold during 
shipment.  
• 
Package sample as appropriate for biologic material. 
 
For all samples, including those in ThermoSafe containers: 
• 
Include a small ice pack in the ThermoSafe container in the space provided. 
• 
Include a copy of the AAML1031 Specimen Transmittal Form (as a CRF in RDE) with each 
shipment. 
• 
If possible, please DocuSAM the bone marrow immunophenotype report with the first 
peripheral blood sample. If this is not possible, please send the report that day via fax 
(832-825-1206) or email to Dr. Horton at tmhorton@txccc.org and Gaye Jenkins at 
gnjenkin@txccc.org (Please strip unnecessary identifiers) 
• 
Ship the sample by Federal Express Priority Overnight delivery to: 
 
Dr. Terzah Horton c/o Gaye Jenkins 
Feigin Center, Suite 760.01 
1102 Bates St. 
Baylor College of Medicine 
Houston, TX  77030 
832-824-4676 
 
• 
See the AAML1031 Sample Submission Schedule posted on the protocol webpage for 
courier information. 
• 
Notify Gaye Jenkins or Horton lab representative prior to shipment of the sample. Phone: 
(832) 824-4676 or (832) 824-1236. Please email the Fed-Ex tracking number to the email 
addresses above if prior notification is not possible. 
• 
If possible, do not ship samples for delivery on a weekend or holiday. Please contact the 
Horton lab for special instructions if samples are collected on a Friday.  
 
 

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232 
APPENDIX X: SORAFENIB PHARMACOKINETIC (PK) STUDY 
 
Sample collection time points: 
Baseline  
(Any Day 1 - 10) 
3 mL prior to any sorafenib therapy 
Induction I 
(Day 21 + 3) 
3 mL  
pre-sorafenib dose 
3 mL  
3-4 hours post sorafenib dose 
3 mL  
6-8 hours post sorafenib dose 
Induction II 
(Day 21 + 3)  
3 mL  
pre-sorafenib dose 
3 mL   
3-4 hours post sorafenib dose 
3 mL  
6-8 hours post sorafenib dose 
Intensification I 
(Day 21 + 3)  
3 mL  
pre-sorafenib dose 
3 mL  
3-4 hours post sorafenib dose 
3 mL  
6-8 hours post sorafenib dose 
Intensification II 
(Day 21 + 3)  
3 mL  
pre-sorafenib dose 
3 mL  
3-4 hours post sorafenib dose 
3 mL  
6-8 hours post sorafenib dose 
 
Maintenance: 
Baseline (pre-sorafenib), Month 2*, 4*, 6*, 8*, 12*  
Also obtain specimen within 2 weeks (±5 days) of dose adjustment 
* 
± 2 weeks 
 
Note: Days are counted from the start of each course of therapy and correspond with TDM day; steady state 
PK samples should be obtained as outlined in Appendix X, at approximately Day 21 (+3 days) of the 
indicated treatment cycles.. PK should only be collected on days that sorafenib is administered. 
 
Specimen Requirements: 
• 
Peripheral blood samples: 3 mL of whole blood will be collected in a heparinized tube (Becton 
Dickinson 6334 Green Top). If blood samples are taken via an indwelling central venous cannula, 
an appropriate amount of fluid should be removed from the cannula to clear the line before each 
blood sample is taken. 
• 
Plasma: should be separated by centrifugation (10 minutes at 1,000 g or 2,500 rpm) within 6 hours 
after collection. Transfer separated plasma to a standard freezer tube/cryovial and label tube with 
the registration number, subject COG ID number, date and time of sampling, and sample number. 
Plasma samples should be frozen and stored in the dark at -70°C. 
 
Shipping Requirements:  
Frozen plasma samples may be batched for shipment. Frozen samples must be packed in dry ice sufficient 
to last at least 3 days, and shipped via FedEx or other express courier from Monday through Thursday 
along with the pharmacokinetic worksheet (below) to: 
Ganesh Moorthy, PhD 
Alternate contact:  
Division of Clinical Pharmacology & Therapeutics 
Elizabeth Fox, MD   
The Children’s Hospital of Philadelphia 
Email: foxe@email.chop.edu 
CTRB-4200 
Phone: 267-425-3010 
3501 Civic Center Blvd 
Fax: 267-425-0113 
Philadelphia, PA 19104 
Page: 877-314-9558 
Email: moorthyg@email.chop.edu 
Cell: 267-648-1274 
Phone: 215-590-0142 
 
See the AAML1031 Sample Submission Schedule posted on the protocol webpage for courier information. 
Dr. Moorthy or Fox should be notified by phone or e-mail prior to the day of the shipment to facilitate sample 
tracking and receipt.  

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233 
PK SPECIMEN COLLECTION WORKSHEET: 
COG Registration #:  
Study ID: AAML1031 
BASELINE PK sample in ALL PATIENTS who consent to PK (Blank PK sample) 
Sample # 
Prior to Start of Any Sorafenib 
Hour 
Target Date/Time 
Date/Time Obtained 
IND I-1 
Induction I 
Pre-sorafenib  
 
 
 
Induction I (Obtain samples on one day between day 21-24)    Sorafenib Dose (mg/m2):_____BSA (m2): ____ 
Sample # 
Day 
Hour 
Target Date/Time 
Date/Time Obtained 
 
Day Prior to PK: Sorafenib  Dose Administered (mg)  :  
Date Time 
IND1-2 
Day 21 (+3) 
Pre-sorafenib dose 
 
 
 
Day of PK: Sorafenib  Dose Administered (mg)  : 
Date Time 
IND1-3 
Day 21 (+3) 
3-4 hr post dose 
 
 
IND1-4 
Day 21 (+3) 
6-8 hr post dose 
 
 
 
Induction II (Obtain samples on one day between day 21-24)    Sorafenib Dose (mg/m2):_____BSA (m2): ___ 
Sample # 
Day 
Hour 
Target Date/Time 
Date/Time Obtained 
 
Day Prior to PK: Sorafenib Dose Administered (mg): 
Date Time 
IND2-1 
Day 21 (+3) 
Pre-sorafenib dose 
 
 
Day of PK: Sorafenib Dose Administered (mg): 
Date Time 
IND2-2 
Day 21 (+3) 
3-4 hr post dose 
 
 
IND2-3 
Day 21 (+3) 
6-8 hr post dose 
 
 
 
Intensification I (Obtain samples on one day between day 21-24)    Sorafenib Dose (mg/m2):____BSA (m2):  
Sample # 
Day 
Hour 
Target Date/Time 
Date/Time Obtained 
 
Day Prior to PK: Sorafenib Dose Administered (mg) 
Date Time 
INT1-1 
Day 21 (+3) 
Pre-sorafenib dose 
 
 
Day of PK: Sorafenib Dose Administered (mg) 
Date Time 
INT1-2 
Day 21 (+3) 
3-4 hr post dose 
 
 
INT1-3 
Day 21 (+3) 
6-8 hr post dose 
 
 
 
IntensificationII (Obtain samples on one day between day 21-24)    Sorafenib Dose (mg/m2):____BSA(m2):  
Sample # 
Day 
Hour 
Target Date/Time 
Date/Time Obtained 
 
Day Prior to PK: Sorafenib  Dose Administered (mg)  : 
Date Time 
INT2-1 
Day 21 (+3) 
Pre-sorafenib dose 
 
 
Day of PK: Sorafenib  Dose Administered (mg)  : 
Date Time 
INT2-2 
Day 21 (+3) 
3-4 hr post dose 
 
 
INT2-3 
Day 21 (+3) 
6-8 hr post dose 
 
 
 
 
 

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234 
PK SPECIMEN COLLECTION WORKSHEET (con’t): 
 
COG Registration #:  
Study ID: AAML1031 
 
Maintenance (All samples are obtained as troughs, prior to dose of sorafenib) 
 
Sample # 
Month 
 
Sorafenib dose PRIOR   
to PK sample 
Sample Obtained 
 
 
 
Dose Level 
(mg/m2) 
Actual Dose (mg) BSA 
(m2) 
Date & time 
prior dose 
Date/Time  
 
MNT M1 
Month 1 
Pre-sorafenib 
dose  
 
 
 
 
 
MNT M2 
Month 2 ± 
2 weeks 
Pre-sorafenib 
dose  
 
 
 
 
 
MNT M4 
Month 4 ± 
2 weeks 
Pre-sorafenib 
dose  
 
 
 
 
 
MNT M6 
Month 6 ± 
2 weeks 
Pre-sorafenib 
dose  
 
 
 
 
 
MNT M8 
Month 8 ± 
2 weeks 
Pre-sorafenib 
dose  
 
 
 
 
 
MNT 
M12 
Month 12 
± 2 weeks 
Pre-sorafenib 
dose 
 
 
 
 
 
DM 
Date of Dose 
Modification:__________
_ New Dose Level 
(mg/m2/day):  _________ 
Dose (mg) admin. prior to 
sample:_______ 
 
 
 
 
 
 
 
 

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235 
 
 
APPENDIX XI: SORAFENIB PIA STUDY 
 
NOTE: ALL “POST-COURSE” SAMPLES SHOULD BE DRAWN JUST BEFORE SCHEDULED 
DOSES OF SORAFENIB (I.E., AT TROUGH TIME POINTS) 
 
 
Sample Collection Time Points for Sorafenib + Chemotherapy Courses: 
 
 
Course 
 
Days 
Pre-Course 
During 
chemotherapy 
Post-Chemotherapy 
Induction I 
1 
Deleted per 
Amendment #6A 
Deleted per 
Amendment 
#6A 
 
 
14 ± 1 
21±3  
28 ± 1 
Induction II 
1 
14 ± 1 
21±3  
28 ± 1 
Intensification I 
1 
14 ± 1 
21±3 
28 ± 1 
Intensification II 
1 
14 ± 1 
21±3 
28 ± 1 
Note: Numbers above refer to treatment day according to treatment delivery maps (TDMs) 
 
 
Pre-Course 
Months 
Maintenance  
1 
2, 4*, 6*, 8*, 12* 
Also obtain specimen within 2 weeks of dose adjustment 
* ± 2 weeks.   
 
Specimen Requirements: 
• 
Peripheral Blood: At each time point, 3 mL of blood must be drawn into green-top (sodium heparin) 
vacutainer(s).  
• 
Each blood collection tube must be labeled as “Course ___ (IND1/IND2/INT1/INT2), Day: ____ 
PK/PIA sample” with patient initials, COG ID number, sample date and collection time recorded 
to the nearest minute using a 24-hour clock. A completed Specimen Transmittal Form must 
accompany the sample(s) when shipped.  
• 
Any missing samples, and samples not drawn, must be noted on the Specimen Transmittal Form.  
 
Shipping Requirements:  
Samples should be maintained at room temperature (no refrigeration or icing of samples is necessary) and 
shipped via overnight courier service to: 
Dr. Patrick Brown 
Johns Hopkins Oncology 
Cancer Research Building I, Room 262 
1650 Orleans Street 
Baltimore, MD 21231 
Laboratory phone: (410) 955-8688 
Pager no: (410) 434-0732 
E-mail: pbrown2@jhmi.edu 
 
See the AAML1031 Sample Submission Schedule posted on the protocol webpage for courier information. 
Samples can be shipped 7 days a week. Saturday deliveries are permissible. If a Saturday delivery is 
required, please notify Dr. Brown of the planned shipment via email or pager prior to the time of shipment 
and clearly mark the package “For Saturday Delivery”. 
 
 

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236 
APPENDIX XII: YOUTH INFORMATION SHEETS 
 
INFORMATION SHEET REGARDING RESEARCH STUDY AAML1031 
(for children from 7 - 12 years of age) 
_____________________________________________________________________________________________________________________________________ 
A Study of Adding Sorafenib to the Usual Treatment in Children 
 with AML (Acute Myeloid Leukemia) 
 
1. We have been talking with you about your illness, acute myeloid leukemia (AML). AML is a type 
of cancer that grows in the center of your bones. The center of your bones is called bone marrow. 
It is where your body makes blood. After doing tests, we have found that you have this type of 
cancer.  
 
2. We are asking you to take part in a research study because you have AML. A research study is 
when doctors work together to try out new ways to help people who are sick. In this study, we are 
trying to learn more about how to treat AML.  
 
3. All children who are part of this study will get the usual treatment for AML. The normal treatment 
is cancer-fighting medicines. Sometimes a stem cell transplant is also done. A stem cell transplant 
is done to replace blood cells that are killed by cancer treatment. If a test finds you have a lot of a 
certain change in a gene in your cancer cells you may switch to getting a different medicine, called 
sorafenib in addition to the usual treatment for AML. A gene is one of the building blocks of DNA. 
Your doctor will tell you which group you are in. We do not know if treatment with the extra 
medicine will be better than the usual treatment. That is why we are doing this study.  
 
4. Sometimes good things can happen to people when they are in a research study. These good things 
are called “benefits”. We hope that a benefit to you of being part of this study is a better chance of 
getting rid of the leukemia for as long as possible. But, we do not know for sure if there is any 
benefit of being part of this study. 
 
5. Sometimes bad things can happen to people when they are in a research study. These bad things 
are called “risks”. There is a risk that you will have more bad effects from the medicines if you are 
treated with sorafenib along with the usual medicines. If this happens, you may need treatment for 
the bad effects. Other things may happen to you that we do not yet know about. 
 
6. Your family can choose to be part of this study or not. Your family can also decide to stop being 
in this study any time. There may be other treatments for your illness that your doctor can tell you 
about. Make sure to ask your doctors any questions you have. 
 
7. We are asking your permission to collect additional blood and bone marrow. We want to see if 
there are ways to tell how the cancer will react to treatment. Almost all of these samples will be 
taken when other standard blood tests and bone marrow tests are done. You would need some extra 
blood tests done on the days you take the experimental medicine, as well as for some of the special 
biology tests, so there would only be a few extra needle sticks. We would also like to save any 
leftover samples for other research tests in the future. You can still take part in this study even if 
you do not allow us to collect the extra blood or bone marrow samples or save the leftover samples 
for research.  

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237 
INFORMATION SHEET REGARDING RESEARCH STUDY AAML1031 
(for teens from 13 - 17 years of age) 
 
A Study of Adding Sorafenib to Standard Treatment in Children and Teens with AML (Acute Myeloid 
Leukemia) 
 
1. We have been talking with you about your illness, acute myeloid leukemia (AML). AML is a 
type of cancer that grows in the center of your bones. The center of your bones is called bone 
marrow. It is where your body makes blood. After doing tests, we have found that you have 
this type of cancer.  
 
2. Now we want to ask you to take part in a research study because you have just been diagnosed 
with AML. A research study is when doctors work together to try out new ways to help people 
who are sick. In this study, we are trying to find better ways to treat children and teens with 
AML.  
 
3. All children and teens that are part of this study will be treated with the usual treatment for 
AML. The usual treatment includes chemotherapy (anti-cancer medicine). Sometimes it also 
includes a stem cell transplant. A stem cell transplant is done to replace blood cells that are 
killed by cancer treatment. If you are found to have a high amount of a certain change in one 
of the genes in your cancer cells, you may switch to getting a different medicine, called 
sorafenib in addition to the usual chemotherapy for AML. Study doctors want to find out if 
adding sorafenib to the usual chemotherapy will be better for treating leukemia. That is why 
we are doing this study.  
 
4. Sometimes good things can happen to people when they are in a research study. These good 
things are called “benefits”. We hope that a benefit to you of being part of this study is a better 
chance at getting rid of the leukemia for as long as possible. However, we do not know for sure 
if there is any benefit of being part of this study. 
 
5. Sometimes bad things can happen to people when they are in a research study. These bad things 
are called “risks”. There is a risk of more side effects from the chemotherapy if you are treated 
with sorafenib in addition to the usual chemotherapy. If this happens, you may need treatment 
for the side effects. Some risks of taking sorafenib are tiredness, diarrhea and painful hands or 
feet. Study doctors will check you closely to see if any side effects are happening. Other things 
may happen to you that we do not yet know about. 
 
6. Your family can choose to be part of this study or not. Your family can also decide to stop 
being in this study at any time once you start. There may be other treatments for your illness 
that your doctor can tell you about. Make sure to ask your doctors any questions you have.  
 
7. We are asking your permission to collect additional blood and bone marrow. We want to see if 
there are ways to tell how the cancer will respond to treatment. Almost all of these samples 
will be taken when other standard blood tests and bone marrow tests are done. You would need 
some extra blood tests done on the days you take the experimental medicine sorafenib, as well 
as for some of the special biology tests, so there would only be a few extra procedures. If there 
is any blood or bone marrow left over from tests done for this study, we would like to save 
them for other research tests in the future. You can still take part in this study even if you do 
not allow us to collect the extra blood or bone marrow samples or save the leftover samples for 
research.  

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238 
APPENDIX XIII: BIOMARKERS FOR THE PREDICTION OF GVHD STUDY 
 
As of 2-24-2017, the funding to collect and analyze the optional samples for Biomarkers for the 
Prediction of GVHD study (Appendix XIII) has been depleted. Samples for this optional study should no 
longer be submitted. Please see memo dated 2/24/2017 (https://members.childrensoncology group.
org/prot/AAML1031/AAML1031Mem2_24_17.pdf). 
 
Participation in the GVHD prediction study is limited to patients receiving stem cell transplant on 
AAML1031. This study is optional and patient consent is required. 
 
Sample Collection Schedule: Day +7, Day +14, and Day +28 following SCT infusion (Day 0).  
 
Sample Collection Instructions: 
• 
Collect 3 - 6 mL of peripheral blood in a red top tube (no reagent). 
• 
Place sample upright in a rack for 30 minutes at room temperature. 
• 
Label sample with the COG ID, study ID (AAML1031), date of collection, Day post SCT (i.e., 
Day +7, Day +14, and Day +28).  
• 
Sample should be collected Monday through Thursday. Avoid collecting samples on Fridays, 
weekends or holidays. It is permissible to collect sample ± 2 days from the target day in order to 
accommodate the Monday through Thursday schedule and the restriction of weekend deliveries.   
 
Shipping Instructions: 
• 
Ship each sample on the day of collection.  
• 
Complete aGVHD Biomarker Specimen Transmittal Form (see Specimen Shipping Forms on the 
AAML1031 protocol website) and include a copy of the transmittal form with each shipment. 
• 
Ship sample at room temperature via overnight delivery only on Monday through Thursday, 
excluding holidays.  
• 
Ship specimen using the courier account provided in the sample submission schedule on the 
AAML1031 protocol website. 
• 
Please ship the sample at room temperature in the Styrofoam box. 
• 
Package sample as appropriate for biologic material. 
• 
The sample must be placed in a leak proof primary receptacle (e.g.: red top tube). 
• 
If multiple primary receptacles are to be shipped in the same package, please wrap each receptacle 
separately. 
• 
The primary receptacle must be placed into a leak proof secondary container (e.g.: zip-lock bag) 
in such a way that under normal conditions of transport, they cannot break or leak. Please place 
each sample in a separate secondary container to prevent cross contamination. 
• 
Absorbent material, such as paper towels or absorbent pads or pillows, must be placed in the 
secondary container with sufficient capacity to absorb the entire contents of the primary 
receptacle(s). 
• 
The secondary containers must be placed into an outer package with suitable cushioning material 
and the total amount of diagnostic specimen must not exceed 4 L (liquid) or 4 kg (solid) per 
package. 
• 
The secondary packaging must be labeled with the universal biohazard symbol. 
• 
The outer packaging must be marked with the name, address, and phone number of both the sender 
and recipient. 

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• 
In addition to the above list of requirements for ground transportation, the following requirements 
apply when shipping via FedEx or other air courier: 
a. All packages shipped via aircraft must display a 2 inch diamond with "UN3373" inside of the 
diamond. 
b. Outer packages must be rigid (bags and envelopes are not allowed). 
c. The outer packaging must be at least 4 inches in the smallest overall external dimension. 
 
Shipping Address: 
Dr. Andrew Harris c/o Joel Whitfield 
4725 Med Sci 2 
1150 West Medical Center Drive 
Ann Arbor, MI 48109 
Tel:  
(734) 647-9524 
(no fax; please scan and email documents if necessary) 
 
Laboratory Contact:  
Joel Whitfield 
Email: jrwhitf@umich.edu 
Tel: 
(734) 647-9524 
(no fax; please scan and email documents if necessary) 
 
Questions regarding the GVHD Prediction Study may be directed to: 
Email: andrew.harris@hsc.utah.edu 
Phone: (801) 662-4700 
Pager: (801) 914-6184 
Fax: 
(801) 662-4707 
 

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APPENDIX XIV: CTEP AND CTSU REGISTRATION PROCEDURES 
 
CTEP Investigator Registration Procedures 
 
Food and Drug Administration (FDA) regulations and National Cancer Institute (NCI) policy require all 
investigators participating in any NCI-sponsored clinical trial to register and to renew their registration 
annually. 
 
Registration requires the submission of: 
 
• 
a completed Statement of Investigator Form (FDA Form 1572) with an original signature 
• 
a current Curriculum Vitae (CV) 
• 
a completed and signed Supplemental Investigator Data Form (IDF) 
• 
a completed Financial Disclosure Form (FDF) with an original signature 
 
Fillable PDF forms and additional information can be found on the CTEP website at 
<http://ctep.cancer.gov/investigatorResources/investigator_registration.htm>.  For questions, please 
contact the CTEP Investigator Registration Help Desk by email at <pmbregpend@ctep.nci.nih.gov>. 
 
CTEP Associate Registration Procedures / CTEP-IAM Account 
 
The Cancer Therapy Evaluation Program (CTEP) Identity and Access Management (IAM) application is 
a web-based application intended for use by both Investigators (i.e., all physicians involved in the conduct 
of NCI-sponsored clinical trials) and Associates (i.e., all staff involved in the conduct of NCI-sponsored 
clinical trials). 
 
Associates will use the CTEP-IAM application to register (both initial registration and annual re-
registration) with CTEP and to obtain a user account. 
 
Investigators will use the CTEP-IAM application to obtain a user account only. (See CTEP Investigator 
Registration Procedures above for information on registering with CTEP as an Investigator, which must 
be completed before a CTEP-IAM account can be requested.) 
 
An active CTEP-IAM user account will be needed to access all CTEP and CTSU (Cancer Trials Support 
Unit) websites and applications, including the CTSU members’ website. 
 
Additional information can be found on the CTEP website at 
<http://ctep.cancer.gov/branches/pmb/associate_registration.htm>.  For questions, please contact the 
CTEP Associate Registration Help Desk by email at <ctepreghelp@ctep.nci.nih.gov>. 
 
CTSU REGISTRATION PROCEDURES 
 
This study is supported by the NCI Cancer Trials Support Unit (CTSU). 
 
Submit completed forms along with a copy of your IRB Approval to the CTSU Regulatory Office, where 
they will be entered and tracked in the CTSU RSS.  
 
 
 

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Submitting Regulatory Documents: 
ONLINE: www.ctsu.org  (members’ section) → Regulatory Submission Portal 
EMAIL: CTSURegulatory@ctsu.coccg.org (for regulatory document submission only) 
FAX: 215-569-0206 
MAIL:  CTSU Regulatory Office 
             1818 Market Street, Suite 1100 
             Philadelphia, PA 19103 
 
Checking Your Site’s Registration Status: 
Check the status of your site’s registration packets by querying the RSS site registration status page of the 
members’ section of the CTSU website.  (Note: Sites will not receive formal notification of regulatory 
approval from the CTSU Regulatory Office.) 
▪ 
Go to https://www.ctsu.org and log in to the members’ area using your CTEP-IAM username and 
password 
▪ 
Click on the Regulatory tab at the top of your screen 
▪ 
Click on the Site Registration tab 
▪ 
Enter your 5 character CTEP Institution Code and click on Go 
 
 

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APPENDIX XV: POSSIBLE DRUG INTERACTIONS 
 
The lists below do not include everything that may interact with chemotherapy. Study Subjects and/or 
their Parents should be encouraged to talk to their doctors before starting any new medications, using 
over-the-counter medicines, or herbal supplements and before making a significant change in diet. 
 
Bortezomib 
Drugs that may interact with bortezomib 
• Antibiotics  
o Clarithromycin, erythromycin, nafcillin, rifabutin, rifampin, telithromycin, tetracycline 
• Antidepressants and antipsychotics  
o Aripiprazole, citalopram, clozapine, escitalopram, fluoxetine, nefazodone, sertraline 
• Antifungals  
o Fluconazole, itraconazole, ketoconazole, posaconazole, voriconazole 
• Antiretrovirals and antivirals  
o Atazanavir, boceprevir, darunavir, delaviridine, efavirenz, etravirine, fosamprenavir, 
indinavir, lopinavir, nelfinavir, nevirapine, ritonavir, saquinavir, telaprevir 
• Anti-seizure medications  
o Carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone 
• Heart medications  
o Amiodarone, clopidogrel, diltiazem, nicardipine, verapamil 
• Some chemotherapy (be sure to talk to your doctor about this) 
• Many other drugs, including the following: 
o Aprepitant, bosentan, cimetidine, cyclosporine, deferasirox, esomeprazole, haloperidol, 
ivacaftor, lomitapide, mifepristone, omeprazole, pimozide 
 
Food and supplements that may interact with bortezomib** 
• 
Echinacea  
• 
Grapefruit, grapefruit juice, Star fruit, Seville oranges 
• 
Green tea or a major component of green tea called ECGC 
• 
St John’s Wort  
• 
Vitamin C, ascorbic acid, or multivitamins/minerals containing vitamin C or ascorbic acid 
• 
Drinks, food, supplements, or vitamins containing “flavonoids” or other “antioxidants” 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, 
or dried herbs. All forms should be avoided. 
 
Sorafenib 
Drugs that may interact with sorafenib 
• Antibiotics  
o Ciprofloxacin, levofloxacin, moxifloxacin, clarithromycin, erythromycin, nafcillin, 
rifabutin, rifampin, telithromycin 
• Antidepressants and antipsychotics  

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o Aripiprazole, citalopram, clozapine, escitalopram, nefazodone, paliperidone, paroxetine, 
quetiapine, risperidone, sertraline, thioradizine, trazodone, ziprasidone 
• Antifungals  
o Itraconazole, ketoconazole, posaconazole, voriconazole, terfenadine 
• Arthritis medications  
o Leflunomide, tofacitinib 
• Antiretrovirals and antivirals  
o Atazanavir, boceprevir, darunavir, delaviridine, efavirenz, etravirine, fosamprenavir, 
indinavir, lopinavir, nelfinavir, nevirapine, rilpivirine, ritonavir, saquinavir, Stribild, 
telaprevir, tipranavir 
• Anti-seizure medications  
o Carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone 
• Heart and cholesterol medications  
o Amiodarone, clopidogrel, digoxin, dronedenarone, fenofibric acid, fluvastatin, 
gemfibrozil, irbesartan, losartan, procainamide, sotalol 
• Some chemotherapy (be sure to talk to your doctor about this) 
• Many other drugs, including the following: 
o Acetaminophen, bosentan, chlorpromazine, granisetron, haloperidol, methadone, 
mifepristone, natalizumab, omeprazole, pentamidine, pimozide, pioglitazone, tacrolimus, 
rosiglitazone, treprostinil, warfarin 
 
Food and supplements that may interact with sorafenib** 
• 
Echinacea  
• 
Grapefruit, grapefruit juice, Seville oranges, star fruit 
• 
Milk thistle 
• 
St. John’s Wort 
• 
Drinks, food, supplements, or vitamins containing “flavonoids” or other “antioxidants” 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, 
or dried herbs. All forms should be avoided.  
 
Busulfan 
Drugs that may interact with busulfan 
• Acetaminophen 
• Itraconazole  
• Metronidazole 
• Thioguanine  
• Fosphenytoin or phenytoin (in some cases these drugs are used with busulfan on purpose) 
 
Food and supplements that may interact with busulfan** 
• Drinks, food, supplements, or vitamins containing “flavonoids” or other “antioxidants” 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, 
or dried herbs. All forms should be avoided.  
 

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Cytarabine IV 
Drugs that may interact with cytarabine 
• Clozapine 
• Digoxin  
• Flucytosine 
• Leflunomide 
 
Food and supplements that may interact with cytarabine** 
• 
Echinacea 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, 
or dried herbs. All forms should be avoided. 
 
Daunorubicin 
Drugs that may interact with daunorubicin 
• 
Some antibiotics and antifungals (clarithromycin, erythromycin, itraconazole, ketoconazole) 
• 
Some antiepileptics (carbamazepine, phenobarbital, phenytoin, fosphenytoin) 
• 
Some antiretrovirals (darunavir, lopinavir; nelfinavir, ritonavir, saquinavir, telaprevir, 
tenofovir, tipranavir) 
• 
Some heart medications (amiodarone, carvedilol, digoxin, dronedarone, nicardipine, 
propranolol, verapamil) 
• 
Other agents, such as atorvastatin, clozapine, cyclosporine, dexamethasone, ivacaftor, 
leflunomide, natalizumab, nefazodone, progesterone, rifampin, tacrolimus, tofacitinib, and 
trazodone 
 
Food and supplements that may interact with daunorubicin** 
• 
Echinacea 
• 
Grapefruit, grapefruit juice, Seville oranges, star fruit 
• 
St. John’s Wort 
• 
Drinks, food, supplements, or vitamins containing “flavonoids” or other “antioxidants” 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, 
or dried herbs. All forms should be avoided. 
 
Etoposide 
Drugs that may interact with etoposide 
• 
Antibiotics  
o Clarithromycin, erythromycin, nafcillin, rifabutin, rifampin, telithromycin 
• 
Antidepressants and antipsychotics  
o Aripiprazole, clozapine, nefazodone 
• 
Antifungals  
o Fluconazole, itraconazole, ketoconazole, posaconazole, voriconazole 
• 
Arthritis medications  
o Leflunomide, tofacitinib 
• 
Anti-rejection medications 

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o Cyclosporine, tacrolimus 
• 
Antiretrovirals and antivirals  
o Atazanavir, boceprevir, darunavir, delaviridine, efavirenz, etravirine, fosamprenavir, 
indinavir, lopinavir, nelfinavir, nevirapine, ritonavir, saquinavir, Stribild, telaprevir, 
tipranavir 
• 
Anti-seizure medications  
o Carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone 
• 
Heart medications  
o Amiodarone, dronedenarone, verapamil 
• 
Some chemotherapy (be sure to talk to your doctor about this) 
• 
Many other drugs, including the following: 
o Atovaquone, bosentan, sitaxentan, aprepitant, dexamethasone, mifepristone, natalizumab, 
pimozide, ivacaftor, deferasirox, lomitapide 
 
Food and supplements that may interact with etoposide** 
• 
Echinacea 
• 
Glucosamine 
• 
St. John’s Wort 
• 
Grapefruit, grapefruit juice, Seville oranges, star fruit 
**Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, or 
dried herbs. All forms should be avoided. 
 
Fludarabine 
Drugs that may interact with fludarabine 
• Clozapine 
• Leflunomide 
• Natalizumab 
• Pentostatin 
• Tofacitinib  
 
Food and supplements that may interact with fludarabine** 
• 
Echinacea 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, 
or dried herbs. All forms should be avoided. Talk to your doctor before starting any new medications 
or herbal supplements and before making a significant change in your diet. 
 
Methotrexate 
Drugs that may interact with methotrexate 
• Some antibiotics (amoxicillin, Bactrim, chloramphenicol, ciprofloxacin, penicillin, piperacillin, 
tetracycline) 
• Some anti-inflammatory drugs (aspirin, acetaminophen, ibuprofen, naproxen, ketorolac) 
• Some heartburn medications (esomeprazole, lansoprazole, omeprazole, pantoprazole) 

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• Several other specific agents, including the following: amiodarone, clozapine, cyclosporine, 
eltrombopag, leflunomide, phenytoin, pimecrolimus, probenecid, pyrimethamine, retinoids, 
theophylline, warfarin 
 
Food and supplements that may interact with methotrexate** 
• Alcohol 
• Echinacea 
• Some vitamins, including those that contain folic acid or high doses of vitamin C 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, 
or dried herbs. All forms should be avoided. 
 
Methylprednisolone 
Drugs that may interact with methylprednisolone 
• Antibiotics  
o Azithromycin, clarithromycin, erythromycin, telithromycin, rifampin 
• Antidepressants and antipsychotics  
o Aripiprazole, nefazodone 
• Antifungals  
o Fluconazole, itraconazole, ketoconazole, posaconazole, voriconazole 
• Arthritis medications  
o Leflunomide, tofacitinib 
• Antiretrovirals and antivirals  
o Atazanavir, boceprevir, darunavir, delaviridine, fosamprenavir, indinavir, lopinavir, 
nelfinavir, ritonavir, saquinavir, telaprevir 
• Anti-seizure medications  
o Carbamazepine, phenobarbital, phenytoin, primidone 
• Some chemotherapy (be sure to talk to your doctor about this) 
• Many other drugs, including the following: 
o Aprepitant, cyclosporine, deferasirox, lomitapide, mifepristone, natalizumab, warfarin  
 
Food and supplements that may interact with methylprednisolone** 
• 
Echinacea 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, 
or dried herbs. All forms should be avoided. 
 
Mitoxantrone 
Drugs that may interact with mitoxantrone 
• Aripiprazole 
• Clozapine 
• Cyclosporine 
• Dofetilide 
• Leflunomide  
• Natalizumab 

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• Pimozide 
• Tofacitinib  
 
Food and supplements that may interact with mitoxantrone** 
• 
Echinacea 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, or 
dried herbs. All forms should be avoided. 
 
Tacrolimus 
Drugs that may interact with tacrolimus 
• 
Antibiotics  
o Clarithromycin, erythromycin, nafcillin, rifabutin, rifampin, telithromycin 
• 
Antidepressants and antipsychotics  
o Citalopram, clozapine, escitalopram, fluvoxamine, lurasidone, nefazodone, paliperidone, 
quetiapine, thioridizine, ziprasidone 
• 
Antifungals  
o Fluconazole, itraconazole, ketoconazole, posaconazole, voriconazole 
• 
Anti-inflammatory, arthritis, or pain medications  
o Leflunomide, tofacitinib 
• 
Anti-rejection medications 
o Cyclosporine, sirolimus  
• 
Antiretrovirals and antivirals  
o Atazanavir, boceprevir, darunavir, delaviridine, efavirenz, etravirine, fosamprenavir, 
indinavir, lopinavir, nelfinavir, nevirapine, ritonavir, saquinavir, Stribild, telaprevir, 
tipranavir 
• 
Anti-seizure medications  
o Carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone 
• 
Heart medications  
o Amiodarone, dronedenarone, disopyramide, procainamide, sotalol, verapamil 
• 
Kidney medications  
o Amiloride, spironolactone, triamterene 
• 
Stomach and reflux medications 
o Dexlansoprazole, esomeprazole, lansoprazole, omeprazole 
• 
Some chemotherapy (be sure to talk to your doctor about this) 
• 
Many other drugs, including the following: 
o Ambrisentan, bosentan, sitaxentan, aprepitant, colchicine, dexamethasone, mifepristone, 
natalizumab, pimozide  
 
Food and supplements that may interact with tacrolimus** 
• 
Echinacea 
• 
St. John’s Wort 
• 
Grapefruit, grapefruit juice, Seville oranges, star fruit 
** Supplements may come in many forms, such as teas, drinks, juices, liquids, drops, capsules, pills, or 
dried herbs. All forms should be avoided.  

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REFERENCES 
1. 
Yamaguchi O, Watanabe T, Nishida K, et al: Cardiac-specific disruption of the c-raf-1 gene induces 
cardiac dysfunction and apoptosis. J Clin Invest 114:937-43, 2004 
2. 
Levis M, Pham R, Smith BD, et al: In vitro studies of a FLT3 inhibitor combined with 
chemotherapy: sequence of administration is important to achieve synergistic cytotoxic effects. 
Blood 104:1145-50, 2004 
3. 
Chintalgattu V, Ai D, Langley RR, et al: Cardiomyocyte PDGFR-beta signaling is an essential 
component of the mouse cardiac response to load-induced stress. J Clin Invest 120:472-84, 2010 
4. 
Duran JM, Makarewich CA, Trappanese D, et al: Sorafenib cardiotoxicity increases mortality after 
myocardial infarction. Circ Res 114:1700-12, 2014 
5. 
Serve H, Krug U, Wagner R, et al: Sorafenib in combination with intensive chemotherapy in elderly 
patients with acute myeloid leukemia: results from a randomized, placebo-controlled trial. J Clin 
Oncol 31:3110-8, 2013 
6. 
Ravandi F, Arana Yi C, Cortes JE, et al: Final report of phase II study of sorafenib, cytarabine and 
idarubicin for initial therapy in younger patients with acute myeloid leukemia. Leukemia 28:1543-
5, 2014 
7. 
Ravandi F, Cortes JE, Jones D, et al: Phase I/II Study of Combination Therapy With Sorafenib, 
Idarubicin, and Cytarabine in Younger Patients With Acute Myeloid Leukemia. J Clin Oncol, 2010 
8. 
Yee KW, Schittenhelm M, O'Farrell AM, et al: Synergistic effect of SU11248 with cytarabine or 
daunorubicin on FLT3 ITD-positive leukemic cells. Blood 104:4202-9, 2004 
9. 
Schittenhelm MM, Kampa KM, Yee KW, et al: The FLT3 inhibitor tandutinib (formerly MLN518) 
has sequence-independent synergistic effects with cytarabine and daunorubicin. Cell Cycle 8:2621-
30, 2009 
10. 
Woods WG: Curing childhood acute myeloid leukemia (AML) at the half-way point: Promises to 
keep and miles to go before we sleep. Pediatr Blood Cancer 46:565-9, 2006 
11. 
Gibson BE, Wheatley K, Hann IM, et al: Treatment strategy and long-term results in paediatric 
patients treated in consecutive UK AML trials. Leukemia 19:2130-8, 2005 
12. 
Alonzo T HP, Gerbing R, Gamis A, Raimondi S, Hirsch B, Cooper T, Franklin J, Pardo L, Loken 
M, Meshinchi S: Combination of conventional cytogenetics, molecular profiling and flow 
cytometric response data allows creation of a two-tier risk group system for risk-based therapy 
allocation in childhood AML – a report from Children’s Oncology Group. [Abstract]. Blood 
16(21):761, 2010 
13. 
Richardson PG, Mitsiades C, Schlossman R, et al: Bortezomib in the front-line treatment of 
multiple myeloma. Expert Rev Anticancer Ther 8:1053-72, 2008 
14. 
Guzman ML, Swiderski CF, Howard DS, et al: Preferential induction of apoptosis for primary 
human leukemic stem cells. Proc Natl Acad Sci U S A 99:16220-5, 2002 
15. 
Attar EC, De Angelo DJ, Supko JG, et al: Phase I and pharmacokinetic study of bortezomib in 
combination with idarubicin and cytarabine in patients with acute myelogenous leukemia. Clin 
Cancer Res 14:1446-54, 2008 
16. 
Horton TM, Gannavarapu A, Blaney SM, et al: Bortezomib interactions with chemotherapy agents 
in acute leukemia in vitro. Cancer Chemother Pharmacol 58:13-23, 2006 
17. 
Minderman H, Zhou Y, O'Loughlin KL, et al: Bortezomib activity and in vitro interactions with 
anthracyclines and cytarabine in acute myeloid leukemia cells are independent of multidrug 
resistance mechanisms and p53 status. Cancer Chemother Pharmacol 60:245-55, 2007 
18. 
Pigneux A, Mahon FX, Moreau-Gaudry F, et al: Proteasome inhibition specifically sensitizes 
leukemic cells to anthracyclin-induced apoptosis through the accumulation of Bim and Bax pro-
apoptotic proteins. Cancer Biol Ther 6:603-11, 2007 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
249 
19. 
Blaney SM, Bernstein M, Neville K, et al: Phase I study of the proteasome inhibitor bortezomib in 
pediatric patients with refractory solid tumors: a Children's Oncology Group study (ADVL0015). 
J Clin Oncol 22:4804-9, 2004 
20. 
Horton TM, Pati D, Plon SE, et al: A phase 1 study of the proteasome inhibitor bortezomib in 
pediatric patients with refractory leukemia: a Children's Oncology Group study. Clin Cancer Res 
13:1516-22, 2007 
21. 
Messinger Y, Gaynon P, Raetz E, et al: Phase I study of bortezomib combined with chemotherapy 
in children with relapsed childhood acute lymphoblastic leukemia (ALL): a report from the 
therapeutic advances in childhood leukemia (TACL) consortium. Pediatr Blood Cancer 55:254-9, 
2010 
22. 
Wilhelm S, Carter C, Lynch M, et al: Discovery and development of sorafenib: a multikinase 
inhibitor for treating cancer. Nat Rev Drug Discov 5:835-44, 2006 
23. 
Lee SH, Paietta E, Racevskis J, et al: Complete resolution of leukemia cutis with sorafenib in an 
acute myeloid leukemia patient with FLT3-ITD mutation. Am J Hematol 84:701-2, 2009 
24. 
Metzelder S, Wang Y, Wollmer E, et al: Compassionate use of sorafenib in FLT3-ITD-positive 
acute myeloid leukemia: sustained regression before and after allogeneic stem cell transplantation. 
Blood 113:6567-71, 2009 
25. 
Safaian NN, Czibere A, Bruns I, et al: Sorafenib (Nexavar) induces molecular remission and 
regression of extramedullary disease in a patient with FLT3-ITD+ acute myeloid leukemia. Leuk 
Res 33:348-50, 2009 
26. 
Ravandi F, Cortes JE, D J, et al: Phase I/II Study of Combination Therapy With Sorafenib, 
Idarubicin, and Cytarabine in Younger Patients With Acute Myeloid Leukemia. J Clin Oncol, 2010 
27. 
Inaba H, Rubnitz JE, Coustan-Smith E, et al: Phase I pharmacokinetic and pharmacodynamic study 
of the multikinase inhibitor sorafenib in combination with clofarabine and cytarabine in pediatric 
relapsed/refractory leukemia. J Clin Oncol 29:3293-300, 2011 
28. 
Watt TC, Cooper T: Sorafenib as treatment for relapsed or refractory pediatric acute myelogenous 
leukemia. Pediatr Blood Cancer 59:756-7, 2012 
29. 
Chen MH, Kerkela R, Force T: Mechanisms of cardiac dysfunction associated with tyrosine kinase 
inhibitor cancer therapeutics. Circulation 118:84-95, 2008 
30. 
Force T, Krause DS, Van Etten RA: Molecular mechanisms of cardiotoxicity of tyrosine kinase 
inhibition. Nat Rev Cancer 7:332-44, 2007 
31. 
Izumiya Y, Shiojima I, Sato K, et al: Vascular endothelial growth factor blockade promotes the 
transition from compensatory cardiac hypertrophy to failure in response to pressure overload. 
Hypertension 47:887-93, 2006 
32. 
Shiojima I, Sato K, Izumiya Y, et al: Disruption of coordinated cardiac hypertrophy and 
angiogenesis contributes to the transition to heart failure. J Clin Invest 115:2108-18, 2005 
33. 
Rollig C, Muller-Tidow C, Huttmann A, et al: Sorafenib versus placebo in addition to standard 
therapy in younger patients with newly diagnosed acute myeloid leukemia: results from 267 
patients treated in the randomized placebo-controlled SAL-Sorami Trial. Blood 124 (21), 2014 
34. 
Todd Michael Cooper, Jemily Malvar, Jeannette Cassar, et al: A Phase I Study Of AC220 
(Quizartinib) In Combination With Cytarabine and Etoposide In Relapsed/Refractory Childhood 
ALL and AML: A Therapeutic Advances In Childhood Leukemia & Lymphoma (TACL) Study. 
Blood 122 (21), 2013 
35. 
Metzelder S, Wang Y, Wollmer E, et al: Compassionate use of sorafenib in FLT3-ITD-positive 
acute myeloid leukemia: sustained regression before and after allogeneic stem cell transplantation. 
Blood 113:6567-71, 2009 
36. 
Winkler J, Rech D, Kallert S, et al: Sorafenib induces sustained molecular remission in FLT3-ITD 
positive AML with relapse after second allogeneic stem cell transplantation without exacerbation 
of acute GVHD: A case report. Leukemia Research 34:e270-e272, 2010 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
250 
37. 
Metzelder S, Finck A, Fey M, et al: Sorafenib Monotherapy Is Effective In Relapsed and 
RefractoryFlt3-ITD Positive Acute Myeloid Leukemia, Particularly After Allogenic Stem Cell 
Transplantation. ASH Annual Meeting Abstracts 116:3314-, 2010 
38. 
Sharma M, Ravandi F, Bayraktar UD, et al: Treatment of FLT3-ITD-positive acute myeloid 
leukemia relapsing after allogeneic stem cell transplantation with sorafenib. Biol Blood Marrow 
Transplant 17:1874-7, 2011 
39. 
Metzelder SK, Schroeder T, Finck A, et al: High activity of sorafenib in FLT3-ITD-positive acute 
myeloid leukemia synergizes with allo-immune effects to induce sustained responses. Leukemia, 
2012 
40. 
Widemann BC, Kim A, Fox E, et al: A phase I trial and pharmacokinetic study of sorafenib in 
children with refractory solid tumors or leukemias: a Children's Oncology Group Phase I 
Consortium report. Clin Cancer Res 18:6011-22, 2012 
41. 
Leung W, Hudson MM, Strickland DK, et al: Late effects of treatment in survivors of childhood 
acute myeloid leukemia. J Clin Oncol 18:3273-9, 2000 
42. 
Mulrooney DA, Dover DC, Li S, et al: Twenty years of follow-up among survivors of childhood 
and young adult acute myeloid leukemia: a report from the Childhood Cancer Survivor Study. 
Cancer 112:2071-9, 2008 
43. 
Nicholson HS, Zhou T, Chen Z, et al: Quality of Life in Survivors of Childhood and Adolescent 
Acute Myelogenous Leukemia (AML) Does Not Differ by Treatment (Bone Marrow Transplant 
(BMT) vs. Chemotherapy). A Report from the Children's Oncology Group (COG). ASH Annual 
Meeting Abstracts 106:701, 2005 
44. 
Redaelli A, Stephens JM, Brandt S, et al: Short- and long-term effects of acute myeloid leukemia 
on patient health-related quality of life. Cancer Treat Rev 30:103-17, 2004 
45. 
Watson M, Buck G, Wheatley K, et al: Adverse impact of bone marrow transplantation on quality 
of life in acute myeloid leukaemia patients; analysis of the UK Medical Research Council AML 10 
Trial. Eur J Cancer 40:971-8, 2004 
46. 
Clarke SA, Eiser C, Skinner R: Health-related quality of life in survivors of BMT for paediatric 
malignancy: a systematic review of the literature. Bone Marrow Transplant 42:73-82, 2008 
47. 
Kazak AE, Barakat LP: Brief report: parenting stress and quality of life during treatment for 
childhood leukemia predicts child and parent adjustment after treatment ends. J Pediatr Psychol 
22:749-58, 1997 
48. 
Vannatta K, Zeller M, Noll RB, et al: Social functioning of children surviving bone marrow 
transplantation. J Pediatr Psychol 23:169-78, 1998 
49. 
Barrera M, Boyd-Pringle LA, Sumbler K, et al: Quality of life and behavioral adjustment after 
pediatric bone marrow transplantation. Bone Marrow Transplant 26:427-35, 2000 
50. 
Varni JW, Seid M, Knight TS, et al: The PedsQL 4.0 Generic Core Scales: sensitivity, 
responsiveness, and impact on clinical decision-making. J Behav Med 25:175-93, 2002 
51. 
Varni JW, Seid M, Kurtin PS: PedsQL 4.0: reliability and validity of the Pediatric Quality of Life 
Inventory version 4.0 generic core scales in healthy and patient populations. Med Care 39:800-12, 
2001 
52. 
Varni JW, Burwinkle TM, Katz ER, et al: The PedsQL in pediatric cancer: reliability and validity 
of the Pediatric Quality of Life Inventory Generic Core Scales, Multidimensional Fatigue Scale, 
and Cancer Module. Cancer 94:2090-106, 2002 
53. 
Varni JW, Burwinkle TM, Szer IS: The PedsQL Multidimensional Fatigue Scale in pediatric 
rheumatology: reliability and validity. J Rheumatol 31:2494-500, 2004 
54. 
Streisand R, Kazak AE, Tercyak  KP: Pediatric-Specific Parenting Stress and Family Functioning 
in Parents of Children Treated for Cancer. Children's Health Care 32:245 - 256, 2003 
55. 
Streisand R, Braniecki S, Tercyak KP, et al: Childhood illness-related parenting stress: the pediatric 
inventory for parents. J Pediatr Psychol 26:155-62, 2001 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
251 
56. 
van der Pal HJ, van Dalen EC, Hauptmann M, et al: Cardiac function in 5-year survivors of 
childhood cancer: a long-term follow-up study. Arch Intern Med 170:1247-55, 2010 
57. 
Tukenova M, Guibout C, Oberlin O, et al: Role of cancer treatment in long-term overall and 
cardiovascular mortality after childhood cancer. J Clin Oncol 28:1308-15, 2010 
58. 
Reulen RC, Winter DL, Frobisher C, et al: Long-term cause-specific mortality among survivors of 
childhood cancer. JAMA 304:172-9, 2010 
59. 
Sanchez-Medina J, Gonzalez-Ramella O, Gallegos-Castorena S: The effect of dexrazoxane for 
clinical and subclinical cardiotoxicity in children with acute myeloid leukemia. J Pediatr Hematol 
Oncol 32:294-7, 2010 
60. 
Woods WG, Neudorf S, Gold S, et al: A comparison of allogeneic bone marrow transplantation, 
autologous bone marrow transplantation, and aggressive chemotherapy in children with acute 
myeloid leukemia in remission. Blood 97:56-62, 2001 
61. 
Lange BJ, Smith FO, Feusner J, et al: Outcomes in CCG-2961, a children's oncology group phase 
3 trial for untreated pediatric acute myeloid leukemia: a report from the children's oncology group. 
Blood 111:1044-53, 2008 
62. 
Horan JT, Alonzo TA, Lyman GH, et al: Impact of disease risk on efficacy of matched related bone 
marrow transplantation for pediatric acute myeloid leukemia: the Children's Oncology Group. J 
Clin Oncol 26:5797-801, 2008 
63. 
McDonald GB: Hepatobiliary complications of hematopoietic cell transplantation, 40 years on. 
Hepatology 51:1450-60, 2010 
64. 
Ozkaynak MF, Weinberg K, Kohn D, et al: Hepatic veno-occlusive disease post-bone marrow 
transplantation in children conditioned with busulfan and cyclophosphamide: incidence, risk 
factors, and clinical outcome. Bone Marrow Transplant 7:467-74, 1991 
65. 
Sencer SF, Haake RJ, Weisdorf DJ: Hemorrhagic cystitis after bone marrow transplantation. Risk 
factors and complications. Transplantation 56:875-9, 1993 
66. 
McDonald GB, Slattery JT, Bouvier ME, et al: Cyclophosphamide metabolism, liver toxicity, and 
mortality following hematopoietic stem cell transplantation. Blood 101:2043-8, 2003 
67. 
Gandhi V, Plunkett W: Cellular and clinical pharmacology of fludarabine. Clin Pharmacokinet 
41:93-103, 2002 
68. 
Bornhauser M, Thiede C, Platzbecker U, et al: Dose-reduced conditioning and allogeneic 
hematopoietic stem cell transplantation from unrelated donors in 42 patients. Clin Cancer Res 
7:2254-62, 2001 
69. 
de Lima M, Couriel D, Thall PF, et al: Once-daily intravenous busulfan and fludarabine: clinical 
and pharmacokinetic results of a myeloablative, reduced-toxicity conditioning regimen for 
allogeneic stem cell transplantation in AML and MDS. Blood 104:857-64, 2004 
70. 
Andersson BS, de Lima M, Thall PF, et al: Once daily i.v. busulfan and fludarabine (i.v. Bu-Flu) 
compares favorably with i.v. busulfan and cyclophosphamide (i.v. BuCy2) as pretransplant 
conditioning therapy in AML/MDS. Biol Blood Marrow Transplant 14:672-84, 2008 
71. 
Pulsipher MA, Boucher KM, Wall D, et al: Reduced-intensity allogeneic transplantation in 
pediatric patients ineligible for myeloablative therapy: results of the Pediatric Blood and Marrow 
Transplant Consortium Study ONC0313. Blood 114:1429-36, 2009 
72. 
Resnick IB, Aker M, Tsirigotis P, et al: Allogeneic stem cell transplantation from matched related 
and unrelated donors in thalassemia major patients using a reduced toxicity fludarabine-based 
regimen. Bone Marrow Transplant 40:957-64, 2007 
73. 
Bradley MB, Satwani P, Baldinger L, et al: Reduced intensity allogeneic umbilical cord blood 
transplantation in children and adolescent recipients with malignant and non-malignant diseases. 
Bone Marrow Transplant 40:621-31, 2007 
74. 
Iravani M, Evazi MR, Mousavi SA, et al: Fludarabine and busulfan as a myeloablative conditioning 
regimen for allogeneic stem cell transplantation in high- and standard-risk leukemic patients. Bone 
Marrow Transplant 40:105-10, 2007 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
252 
75. 
Horn B, Baxter-Lowe LA, Englert L, et al: Reduced intensity conditioning using intravenous 
busulfan, fludarabine and rabbit ATG for children with nonmalignant disorders and CML. Bone 
Marrow Transplant 37:263-9, 2006 
76. 
Sievers EL, et al: Immunophenotypic evidence of leukemia after induction therapy predicts relapse: 
results from a prospective Children's Cancer Group study of 252 patients with acute myeloid 
leukemia. Blood 101(9):3398-406, 2003 
77. 
Meshinchi S, et al: Minimal Residual Disease Detection by Four-Color Multidimensional Flow 
Cytometry Identifies Pediatric AML Patients at High Risk of Relapse. ASH Annual Meeting 
Abstracts 110(11):1429, 2007 
78. 
Rosenberg AR, al e: Sub-Morphologic Evidence of Disease Prior to Stem Cell Transplantation 
Correlates with Inferior Post Transplant Outcome in Childhood Acute Myeloid Leukemia. ASH 
Annual Meeting Abstracts 114(22):328, 2009 
79. 
Pollard JA, Alonzo TA, Gerbing RB, et al: FLT3 internal tandem duplication in CD34+/CD33- 
precursors predicts poor outcome in acute myeloid leukemia. Blood 108:2764-9, 2006 
80. 
Bonnet D, Dick JE: Human acute myeloid leukemia is organized as a hierarchy that originates from 
a primitive hematopoietic cell. Nat Med 3:730-7, 1997 
81. 
Jordan CT, Upchurch D, Szilvassy SJ, et al: The interleukin-3 receptor alpha chain is a unique 
marker for human acute myelogenous leukemia stem cells. Leukemia 14:1777-84, 2000 
82. 
Majeti R, Chao MP, Alizadeh AA, et al: CD47 is an adverse prognostic factor and therapeutic 
antibody target on human acute myeloid leukemia stem cells. Cell 138:286-99, 2009 
83. 
Frankel A, Liu JS, Rizzieri D, et al: Phase I clinical study of diphtheria toxin-interleukin 3 fusion 
protein in patients with acute myeloid leukemia and myelodysplasia. Leuk Lymphoma 49:543-53, 
2008 
84. 
Yalcintepe L, Frankel AE, Hogge DE: Expression of interleukin-3 receptor subunits on defined 
subpopulations of acute myeloid leukemia blasts predicts the cytotoxicity of diphtheria toxin 
interleukin-3 fusion protein against malignant progenitors that engraft in immunodeficient mice. 
Blood 108:3530-7, 2006 
85. 
Guzman ML, Neering SJ, Upchurch D, et al: Nuclear factor-kappaB is constitutively activated in 
primitive human acute myelogenous leukemia cells. Blood 98:2301-7, 2001 
86. 
Guzman ML, Upchurch D, Grimes B, et al: Expression of tumor-suppressor genes interferon 
regulatory factor 1 and death-associated protein kinase in primitive acute myelogenous leukemia 
cells. Blood 97:2177-9, 2001 
87. 
Majeti R, Becker MW, Tian Q, et al: Dysregulated gene expression networks in human acute 
myelogenous leukemia stem cells. Proc Natl Acad Sci U S A 106:3396-401, 2009 
88. 
Guzman ML, Swiderski CF, Howard DS, et al: Preferential induction of apoptosis for primary 
human leukemic stem cells. Proc Natl Acad Sci U S A 99:16220-5, 2002 
89. 
van Rhenen A, Moshaver B, Kelder A, et al: Aberrant marker expression patterns on the 
CD34+CD38- stem cell compartment in acute myeloid leukemia allows to distinguish the 
malignant from the normal stem cell compartment both at diagnosis and in remission. Leukemia 
21:1700-7, 2007 
90. 
Bakker AB, van den Oudenrijn S, Bakker AQ, et al: C-type lectin-like molecule-1: a novel myeloid 
cell surface marker associated with acute myeloid leukemia. Cancer Res 64:8443-50, 2004 
91. 
Pollard JA, et al: Prevalence and prognostic significance of KIT mutations in pediatric patients with 
core binding factor AML enrolled on serial pediatric cooperative trials for de novo AML. Blood 
115(12):2372-9, 2010 
92. 
Pollard JA, et al: Prevalence and Prognostic Implications of WT1 Mutations in Pediatric AML A: 
Report from Children's Oncology Group. ASH Annual Meeting Abstracts 112(11):143, 2008 
93. 
Lapillonne H, et al: High WT1 Expression After Induction Therapy Predicts High Risk of Relapse 
and Death in Pediatric Acute Myeloid Leukemia. J Clin Oncol 24(10):1507-1515, 2006 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
253 
94. 
Noronha SA, et al: WT1 expression at diagnosis does not predict survival in pediatric AML: a 
report from the Children's Oncology Group. Pediatr Blood Cancer 53(6):1136-9, 2009 
95. 
Ho PA, et al: Molecular alterations of the IDH1 gene in AML: a Children's Oncology Group and 
Southwest Oncology Group study. Leukemia, 2010 
96. 
Wagner K, et al: Impact of IDH1 R132 Mutations and an IDH1 Single Nucleotide Polymorphism 
in Cytogenetically Normal Acute Myeloid Leukemia: SNP rs11554137 Is an Adverse Prognostic 
Factor. J Clin Oncol, 2010 
97. 
Abdel-Wahab O, Mullally A, Hedvat C, et al: Genetic characterization of TET1, TET2, and TET3 
alterations in myeloid malignancies. . Blood 114:144-147, 2009 
98. 
Loh ML, Sakai DS, Flotho C, et al: Mutations in CBL occur frequently in juvenile myelogenous 
leukemia. Blood 114:1859-1863, 2009 
99. 
Lu S, et al: Overexpression of the PSMB5 gene contributes to bortezomib resistance in T-
lymphoblastic lymphoma/leukemia cells derived from Jurkat line. Exp Hematol 36(10):1278-84, 
2008 
100. 
Lu S, et al: Different mutants of PSMB5 confer varying bortezomib resistance in T lymphoblastic 
lymphoma/leukemia cells derived from the Jurkat cell line. Exp Hematol 37(7):831-7, 2009 
101. 
Mori S, Cortes J, Kantarjian H, et al: Potential role of sorafenib in the treatment of acute myeloid 
leukemia. Leuk.Lymphoma 49:2246-2255, 2008 
102. 
Guzman ML, Neering SJ, Upchurch D, et al: Nuclear factor-kappaB is constitutively activated in 
primitive human acute myelogenous leukemia cells. Blood 98:2301-7, 2001 
103. 
Guzman ML, Jordan CT: Considerations for targeting malignant stem cells in leukemia. Cancer 
Control 11:97-104, 2004 
104. 
Richardson PG, Hideshima T, Mitsiades C, et al: Proteasome inhibition in hematologic 
malignancies. Ann.Med 36:304-314, 2004 
105. 
Obeng EA, Carlson LM, Gutman DM, et al: Proteasome inhibitors induce a terminal unfolded 
protein response in multiple myeloma cells. Blood 107:4907-4916, 2006 
106. 
Ding WX, Ni HM, Gao W, et al: Linking of autophagy to ubiquitin-proteasome system is important 
for the regulation of endoplasmic reticulum stress and cell viability. Am.J.Pathol 171:513-524, 
2007 
107. 
Fels DR, Ye J, Segan AT, et al: Preferential cytotoxicity of bortezomib toward hypoxic tumor cells 
via overactivation of endoplasmic reticulum stress pathways. Cancer Res 68:9323-9330, 2008 
108. 
Davies SM, Wang D, Wang T, et al: Recent decrease in acute graft-versus-host disease in children 
with leukemia receiving unrelated donor bone marrow transplants. Biol Blood Marrow Transplant 
15:360-6, 2009 
109. 
Jagasia M, Arora M, Flowers ME, et al: Risk factors for acute GVHD and survival after 
hematopoietic cell transplantation. Blood 119:296-307, 2012 
110. 
Ferrara JL, Harris AC, Greenson JK, et al: Regenerating islet-derived 3-alpha is a biomarker of 
gastrointestinal graft-versus-host disease. Blood 118:6702-8, 2011 
111. 
Paczesny S, Braun TM, Levine JE, et al: Elafin is a biomarker of graft-versus-host disease of the 
skin. Sci Transl Med 2:13ra2, 2010 
112. 
Paczesny S, Krijanovski OI, Braun TM, et al: A biomarker panel for acute graft-versus-host 
disease. Blood 113:273-8, 2009 
113. 
Choi SW, Kitko CL, Braun T, et al: Change in plasma tumor necrosis factor receptor 1 levels in 
the first week after myeloablative allogeneic transplantation correlates with severity and incidence 
of GVHD and survival. Blood 112:1539-42, 2008 
114. 
Kitko CL, Mineishi S, Braun T, et al: Day 7 TNFR1 levels following reduced intensity allogeneic 
hematopoietic stem cell transplant (HCT) predict for acute GVHD (abstract). Biol Blood Marrow 
Transpl. In press, 2009 
115. 
Paczesny S, Braun T, Lugt MV, et al: Three Biomarker Panel at Day 7 and 14 Can Predict 
Development of Grade II IV Acute Graft Versus Host Disease. Blood 116(21):296-7, 2010 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
254 
116. 
Levine JE, Paczesny S, Sarantopoulos S: Clinical applications for biomarkers of acute and chronic 
graft-versus-host disease. Biol Blood Marrow Transplant 18:S116-24, 2012 
117. 
Vardiman JW, Thiele J, Arber DA, et al: The 2008 revision of theWorld Health Organization 
(WHO) classification of myeloid neoplasms and acute leukemia: rationale and important changes. 
Blood 114:937-95, 2009 
118. 
Golden EB, Lam PY, Kardosh A, et al: Green tea polyphenols block the anticancer effects of 
bortezomib and other boronic acid-based proteasome inhibitors. Blood 113:5927-37, 2009 
119. 
Perrone G, Hideshima T, Ikeda H, et al: Ascorbic acid inhibits antitumor activity of bortezomib in 
vivo. Leukemia 23:1679-86, 2009 
120. 
Bannerman B, Xu L, Jones M, et al: Preclinical evaluation of the antitumor activity of bortezomib 
in combination with vitamin C or with epigallocatechin gallate, a component of green tea. Cancer 
Chemother Pharmacol, 2011 
121. 
Smith GA, Damon LE, Rugo HS, et al: High-dose cytarabine dose modification reduces the 
incidence of neurotoxicity in patients with renal insufficiency. J Clin Oncol 15(2):833-839, 1997 
122. 
Gastrointestinal hemorrhage includes Anal hemorrhage, Cecal hemorrhage, Colonic hemorrhage, 
Duodenal hemorrhage, Esophageal hemorrhage, Esophageal varices hemorrhage, Gastric 
hemorrhage, Hemorrhoidal hemorrhage, Ileal hemorrhage, Intra-abdominal hemorrhage, Jejunal 
hemorrhage, Lower gastrointestinal hemorrhage, Oral hemorrhage, Pancreatic hemorrhage, Rectal 
hemorrhage, Retroperitoneal hemorrhage, and Upper gastrointestinal hemorrhage under the 
GASTROINTESTINAL DISORDERS SOC.,  
123. 
Infection includes all 75 sites of infection under the INFECTIONS AND INFESTATIONS SOC.,  
124. 
Gastrointestinal hemorrhage may include Anal hemorrhage, Cecal hemorrhage, Colonic 
hemorrhage, Duodenal hemorrhage, Esophageal hemorrhage, Esophageal varices hemorrhage, 
Gastric hemorrhage, Hemorrhoidal hemorrhage, Ileal hemorrhage, Intra-abdominal hemorrhage, 
Jejunal hemorrhage, Lower gastrointestinal hemorrhage, Oral hemorrhage, Pancreatic hemorrhage, 
Rectal hemorrhage, Retroperitoneal hemorrhage, and Upper gastrointestinal hemorrhage under the 
GASTROINTESTINAL DISORDERS SOC.,  
125. 
Infection may include any of the 75 infection sites under the INFECTIONS AND INFESTATIONS 
SOC.,  
126. 
Kaplan EL, Meier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 
53:457-481, 1958 
127. 
Burnham KP, Anderson DR: Multimodel inference - understanding AIC and BIC in model 
selection. Sociol Method Res. 33(2):261-304, 2004 
128. 
Sposto R, Sather HN: Determining the duration of comparative clinical trials while allowing for 
cure. . J Chron Dis 38:683-690, 1985 
129. 
Kuerbitz SJ, Civin CI, Krischer JP, et al: Expression of myeloid-associated and lymphoid-
associated cell-surface antigens in acute myeloid leukemia of childhood: a Pediatric Oncology 
Group study. J Clin Oncol 10:1419-29, 1992 
130. 
Smith FO, Lampkin BC, Versteeg C, et al: Expression of lymphoid-associated cell surface antigens 
by childhood acute myeloid leukemia cells lacks prognostic significance. Blood 79:2415-22, 1992 
131. 
Creutzig U, Harbott J, Sperling C, et al: Clinical significance of surface antigen expression in 
children with acute myeloid leukemia: results of study AML-BFM-87. Blood 86:3097-108, 1995 
132. 
Pui CH, Dahl GV, Melvin S, et al: Acute leukaemia with mixed lymphoid and myeloid phenotype. 
Br J Haematol 56:121-30, 1984 
133. 
Cross AH, Goorha RM, Nuss R, et al: Acute myeloid leukemia with T-lymphoid features: a distinct 
biologic and clinical entity. Blood 72:579-87, 1988 
134. 
Ruiz-Arguelles GJ, Marin-Lopez A, Lobato-Mendizabal E, et al: Acute megakaryoblastic 
leukaemia: a prospective study of its identification and treatment. Br J Haematol 62:55-63, 1986 
135. 
van der Reijden HJ, van Rhenen DJ, Lansdorp PM, et al: A comparison of surface marker analysis 
and FAB classification in acute myeloid leukemia. Blood 61:443-8, 1983 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
255 
136. 
Villeval JL, Cramer P, Lemoine F, et al: Phenotype of early erythroblastic leukemias. Blood 
68:1167-74, 1986 
137. 
Meshinchi S, Woods WG, Stirewalt DL, et al: Prevalence and prognostic significance of Flt3 
internal tandem duplication in pediatric acute myeloid leukemia. Blood 97:89-94, 2001 
138. 
Thiede C, Steudel C, Mohr B, et al: Analysis of FLT3-activating mutations in 979 patients with 
acute myelogenous leukemia: association with FAB subtypes and identification of subgroups with 
poor prognosis. Blood 99:4326-4335, 2002 
139. 
Stark B, Jeison M, Gabay LG, et al: Classical and molecular cytogenetic abnormalities and outcome 
of childhood acute myeloid leukaemia: report from a referral centre in Israel. Br.J.Haematol 
126:320-337, 2004 
140. 
Cuneo A, Bigoni R, Cavazzini F, et al: Incidence of cryptic chromosome aberrations detected by 
fluorescent in situ hybridization in acute myeloid leukemia with normal karyotype. Leukemia 
16:745-751, 2002 
141. 
Frohling S, Skelin S, Liebisch C, et al: Comparison of cytogenetic and molecular cytogenetic 
detection of chromosome abnormalities in 240 consecutive adult patients with acute myeloid 
leukemia. J Clin Oncol 20:2480-2485, 2002 
142. 
Huntly BJ, Bench AJ, Delabesse E, et al: Derivative chromosome 9 deletions in chronic myeloid 
leukemia: poor prognosis is not associated with loss of ABL-BCR expression, elevated BCR-ABL 
levels, or karyotypic instability. Blood 99:4547-4553, 2002 
143. 
Huntly BJ, Guilhot F, Reid AG, et al: Imatinib improves but may not fully reverse the poor 
prognosis of patients with CML with derivative chromosome 9 deletions. Blood 102:2205-2212, 
2003 
144. 
Morel F, Ka C, Le Bris MJ, et al: Deletion of the 5'ABL region in Philadelphia chromosome 
positive chronic myeloid leukemia: frequency, origin and prognosis. Leuk Lymphoma 44:1333-
1338, 2003 
145. 
Varni JW, Seid M, Kurtin PS: Measurement model for the Pediatric Quality of Life Inventory  
Version 4.0. Mapi Research Institute, 1998 
146. 
Logan DE, Radcliffe J, Smith-Whitley K: Parent factors and adolescent sickle cell disease: 
associations with patterns of health service use. J Pediatr Psychol 27(5):475-84, 2002 
147. 
Avvisati G, Tirindelli MC, Annibali O: Thrombocytopenia and hemorrhagic risk in cancer patients. 
Crit Rev Oncol Hematol 48:S13-6, 2003 
148. 
Rogers PC, Meacham LR, Oeffinger KC, et al: Obesity in pediatric oncology. Pediatr Blood 
Cancer, 2005 
149. 
Hughes WT, Armstrong D, Bodey GP, et al: guidelines for the use of antimicrobial agents in 
neutropenic patients with cancer. Clin Infect Dis 34:730-51, 2002 
150. 
Feusner JH, Alonzo TA, Dinndorf P, et al: Infectious Complications of Intensive Chemotherapy 
on Children's Cancer Group Protocol 2961 for Pediatric Acute Myeloid Leukemia, American 
Society of Clinical Oncology. Chicago. . 2003 
151. 
Gamis AS, Howells WB, DeSwarte-Wallace J, et al: Alpha hemolytic streptococcal infection 
during intensive treatment for acute myeloid leukemia: a report from the Children's cancer group 
study CCG-2891. J Clin Oncol 18:1845-55, 2000 
152. 
Rubin M, Hathorn JW, Pizzo PA: Controversies in the management of febrile neutropenic cancer 
patients. Cancer Invest 6:167-84, 1988 
153. 
Bow EJ, Laverdiere M, Lussier N, et al: Antifungal prophylaxis for severely neutropenic 
chemotherapy recipients: a meta analysis of randomized-controlled clinical trials. Cancer 94:3230-
46, 2002 
154. 
Kanda Y, Yamamoto R, Chizuka A, et al: Prophylactic action of oral fluconazole against fungal 
infection in neutropenic patients. A meta-analysis of 16 randomized, controlled trials. Cancer 
89:1611-25, 2000 

THIS PROTOCOL IS FOR RESEARCH PURPOSES ONLY, SEE PAGE 1 FOR USAGE POLICY 
AAML1031 
Version Date: 04/24/2017 
 
256 
155. 
American Academy of Pediatrics Red book: Report of the committee on infectious diseases (ed 
26th). Elk Grove Village, IL, American Academy of Pediatrics. . 2003 
156. 
Bergmann OJ, Mogensen SC, Ellermann-Eriksen S, et al: Acyclovir prophylaxis and fever during 
remission-induction therapy of patients with acute myeloid leukemia: a randomized, double-blind, 
placebo-controlled trial. J Clin Oncol 15:2269-74, 1997 
157. 
Adolescents NHBPEPWGoHBPiCa: The Fourth Report on the Diagnosis, Evaluation, and 
Treatment of High Blood Pressure in Children and Adolescents. Pediatrics 14:555-576, 2004