Clinical trial NCT05198843
Conditions: Anatomic Stage IV Breast Cancer AJCC v8 Metastatic Triple-Negative Breast Inflammatory Carcinoma
Sponsor: National Cancer Institute (NCI)
Start date: 2022-11-08; Completion date: 2023-12-20
Enrollment: 1 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This phase Ib/II tests the safety, side effects, and best dose of icosapent ethyl in combination with dasatinib and whether they work to shrink tumors in patients with triple-negative inflammatory breast cancer that has spread to other places in the body (metastatic). Triple-negative inflammatory breast cancer is a type of inflammatory breast cancer in which the tumor cells do not have estrogen receptors, progesterone receptors, or large amounts of HER2/neu protein on their surface. Dasatinib is in a class of medications called tyrosine kinase inhibitors. It works by blocking the action of an abnormal protein that signals cancer cells to multiply, which may help keep cancer cells from growing. Icosapent ethyl is an omega-3 fatty acid and in a class of medications called antilipemic or lipid-regulating agents. It may decrease the amount of triglycerides and other fats made in the liver. Preclinical studies have suggested that it may reduce the growth of triple negative inflammatory breast cancer cells. Combination therapy with dasatinib and icosapent ethyl may help shrink tumors in patients with triple-negative inflammatory breast cancer.

Detailed description:
PRIMARY OBJECTIVES:

I. To determine maximum tolerated dose (MTD) of icosapent ethyl (EPA) and dasatinib in patients with metastatic triple negative inflammatory breast cancer (mTN-IBC). (Phase 1b) II. To determine the overall response rate (ORR) of EPA and dasatinib therapy in patients with mTN-IBC. (Phase 2)

SECONDARY OBJECTIVES:

I. To determine the clinical benefit rate (CBR) of EPA and dasatinib therapy in patients with mTN-IBC.

II. To determine progression-free survival (PFS) at 1 year for patients with mTN-IBC who were enrolled in the study and received EPA and dasatinib therapy.

III. To determine overall survival (OS) at 2 years for patients with mTN-IBC who were enrolled in the study and received EPA and dasatinib therapy.

IV. To determine the induction of apoptosis by EPA and dasatinib therapy.

EXPLORATORY OBJECTIVES:

I. To determine the effect of EPA and dasatinib therapy on the expression of cholesterol transporter.

II. To determine the relationship between the expression of EphA2 and the treatment response to EPA and dasatinib therapy.

III. To determine the change in Ki67 by EPA and dasatinib therapy. IV. To evaluate the change in cholesterol homeostasis and tumor membrane rigidity after EPA and dasatinib therapy.

V. To investigate the effect of EPA and dasatinib therapy on the systemic inflammation.

OUTLINE: This is a phase Ib dose-escalation study of icosapent ethyl in combination with fixed dose dasatinib, followed by a phase II study.

Patients receive icosapent ethyl orally (PO) twice daily (BID) and dasatinib PO once daily (QD) in each treatment cycle. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.

After completion of the study treatment, patients will undergo in-clinic post-treatment evaluations 1 month after their last study treatment or before starting new treatment, whichever occurs first, subsequently, patients are followed every 3 months for 2 years.

Arms: arm 1: Patients receive icosapent ethyl PO BID and dasatinib PO QD in each treatment cycle. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity.
Interventions: intervention 1: Dasatinib intervention 2: Icosapent Ethyl
Intervention descriptions: intervention 1: Given PO intervention 2: Given PO

Protocol documents:
Prot_SAP_000.pdf: 
NCI Protocol #: 10480 
Version Date:  December 13, 2022 
 
 
i 
 
 
 
To:  
CTEP Protocol and Information Office  
From: 
Rachel Layman, M.D. 
Date:  
December 13, 2022 
Re: 
Response to Biobank Comments of Protocol #10480: “Phase Ib/II Study 
of EPA-based EphA2 Targeted Therapy for Patients with Metastatic 
Triple-Negative Inflammatory Breast Cancer” 
 
I. 
Protocol Revision 5 Summary of Change: 
 
# 
Section 
Comments 
1. 
Header 
Updated version date from April 27, 2022 to December 13, 2022. 
2. Protocol Title 
Page 
Local protocol number is added, Principle investigator is changed into 
Rachel Layman, add Study Coordinator Angela Alexander, protocol 
version is updated. 
Rationale: Dr. Naoto Ueno has left institution and Dr. Layman is the 
new PI assigned for this trial. Meanwhile, the local protocol number, 
study coordinator and protocol version are updated accordingly. 
3. 
Protocol 
Content 
There is no change to protocol content in this amendment except 
personnel change. 
 
 


NCI Protocol #: 10480 
Version Date:  December 13, 2022 
 
1 
 
 
 
NCI Protocol #: 
10480 
 
Local Protocol #: 
2022-0246 
 
ClinicalTrials.gov Identifier:   NCT05198843 
 
TITLE:  Phase Ib/II Study of EPA-based EphA2 Targeted Therapy for Patients with Metastatic 
Triple-Negative Inflammatory Breast Cancer 
 
Corresponding Organization: LAO-TX035 / University of Texas MD Anderson Cancer 
Center LAO 
 
Principal Investigator: 
Rachel Layman 
The University of Texas MD Anderson Cancer Center 
Dan L. Duncan Building (CPB5.3450) 
Houston, TX 77030-3721 
Phone: (713) 745-8401 
Fax: (713) 794-4385 
RLayman@mdanderson.org 
 
Co-Principal Investigator: 
Toshiaki Iwase 
The University of Texas MD Anderson Cancer Center 
Dan L. Duncan Building (CPB5.1354) 
Houston, TX 77030-3721 
Phone: (713) 294-1726 
Fax: (713) 794-4385 
tiwase@mdanderson.org 
 
Translational PI: 
Jangsoon Lee 
Zayed Research Building (Z12.5036) 
6565 MD Anderson Blvd. 
Houston, TX 77030-4009 
Phone: (713) 563-9221 
Fax: (713) 794-4385 
jslee@mdanderson.org  
 
Participating Organizations  
LAO-11030 / University Health Network Princess Margaret Cancer Center LAO 
LAO-CA043 / City of Hope Comprehensive Cancer Center LAO 
LAO-CT018 / Yale University Cancer Center LAO 
LAO-MA036 / Dana-Farber - Harvard Cancer Center LAO 
LAO-MD017 / JHU Sidney Kimmel Comprehensive Cancer Center LAO 


NCI Protocol #: 10480 
Version Date:  December 13, 2022 
 
2 
LAO-OH007 / Ohio State University Comprehensive Cancer Center LAO 
LAO-PA015 / UPMC Hillman Cancer Center LAO 
LAO-TX035 / University of Texas MD Anderson Cancer Center LAO 
LAO-NCI / National Cancer Institute LAO 
 
 
Interventional Radiologist:  
 
Statistician:  
Sanjay Gupta 
Ying Yuan 
University of Texas MD Anderson Cancer 
University of Texas MD Anderson Cancer  
Center 
Center 
T. Boone Pickens Academic Tower 
T. Boone Pickens Academic Tower  
(FCT14.6032) 
(FTC14.6034) 
1400 Pressler St. 
1400 Pressler St. 
Houston, TX 77030-4008 
Houston, TX 77030-4008 
Phone: (713) 794-4855 
Phone: (713) 563-4271 
Fax: (713) 792-4098 
Fax: (713) 563-4243 
sgupta@mdanderson.org  
yyuan@mdanderson.org 
 
Study Coordinator: 
 
 
 
Angela Alexander 
The University of Texas MD Anderson Cancer Center 
1155 Pressler Street 
Houston, TX 77030 
(CPB5.3443) 
Phone: (713) 792-9137 
Fax: (713) 563-0905 
AAlexand@mdanderson.org 
 
 
 
 
Responsible Research Nurse: 
Vivian Chiv 
University of Texas MD Anderson Cancer Center  
 1155 Pressler St. 
 Houston TX 77030 
(CPB5.3443) 
Phone: (713) 792-4157 
Fax: (713) 563-0905 
vychiv@mdanderson.org 
 
 
 
Responsible Data Manager:  
Megumi Kai 
University of Texas MD Anderson Cancer Center      
1155 Pressler St. 
Houston TX 77030 
(CPB5.3443) 


NCI Protocol #: 10480 
Version Date:  December 13, 2022 
 
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Phone: (713)792-3628 
Fax: (713)563-0905 
mkai@mdanderson.org 
 
NCI-Supplied Agent:  Dasatinib (BMS-354825, Sprycel) (NSC#732517) 
Commercial Agent:  Icosapent ethyl (EPA) (NSC#759597) 
 
 
IND Sponsor:  DCTD, NCI  
 
Protocol Type / Version # / Version Date: 
Original / July 21, 2021 
 
 
 
 
Revision 1 / October 13, 2021 
 
 
 
 
Revision 2 / December 14, 2021 
 
 
 
 
Revision 3a / January 28, 2022 
 
 
 
 
Revision 4 / March 03, 2022 
Amendment 1 / April 27, 2022 
Amendment 2/December 13, 2022 
 
 
 


NCI Protocol #: 10480
Version Date:  December 13, 2022
4
SCHEMA
This is a multicenter, single-arm, non-randomized phase 1b/2 trial of dasatinib (BMS-354825, 
Sprycel) and icosapent ethyl (EPA) combination therapy for patients with metastatic triple-
negative inflammatory breast cancer (mTN-IBC). All eligible patients will receive dasatinib and 
EPA combination therapy without randomization or stratification. The study design is 
summarized below.
Overview of phase 1b/2 trial of EPA-dasatinib combination therapy. 1 Cycle= 28 days.
Phase 1b Dose Escalation Schedule
Dose Level
Dose*
Dasatinib
(mg)
Icosapent ethyl 
(EPA)
(mg)
Cycle Length
Level 1*
100 mg, PO, QD
2000 mg, PO, BID
28 days
Level 2
100 mg, PO, QD
3000 mg, PO, BID
Level 3
100 mg, PO, QD
4500 mg, PO, BID
*Starting Dose Level. 
PO = Orally, QD = Once daily, BID = Twice a day
Phase 2
Agent
Dose
Route
Schedule
Cycle Length
Dasatinib
100 mg
PO
QD
28 days
Icosapent ethyl 
(EPA)
MTD/RP2D
PO
BID
28 days
MTD = Maximum tolerated dose, RP2D = Recommended phase 2 dose, PO = Orally, QD = 
Once daily, BID = Twice a day


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5 
TABLE OF CONTENTS 
 
SCHEMA 
......................................................................................................................4 
1. 
OBJECTIVES ......................................................................................................................8 
1.1 
Primary Objectives ...................................................................................................8 
1.2 
Secondary Objectives ...............................................................................................8 
1.3 
Exploratory Objectives ............................................................................................8 
2. 
BACKGROUND .................................................................................................................8 
2.1 
Study Disease ...........................................................................................................8 
2.2 
CTEP IND Agent .....................................................................................................9 
2.3 
Icosapent ethyl (EPA) ............................................................................................14 
2.4 
Rationale ................................................................................................................15 
2.5 
Correlative Studies Background ............................................................................20 
3. 
PATIENT SELECTION ....................................................................................................23 
3.1 
Eligibility Criteria ..................................................................................................23 
3.2 
Exclusion Criteria ..................................................................................................25 
3.3 
Inclusion of Women and Minorities ......................................................................27 
4. 
REGISTRATION PROCEDURES ...................................................................................27 
4.1 
Investigator and Research Associate Registration with CTEP ..............................27 
4.2 
Site Registration .....................................................................................................28 
4.3 
Patient Registration ................................................................................................31 
4.4 
General Guidelines .................................................................................................33 
5. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................33 
5.1 
Summary Table for Specimen Collection ..............................................................33 
5.2 
Summary Tables for Interventional Radiologist for Research Biopsies ................33 
5.3 
Specimen Procurement Kits and Scheduling .........................................................34 
5.4 
Specimen Tracking System Instructions ................................................................35 
5.5 
Specimen Collection ..............................................................................................39 
5.6 
Shipping Specimens from Clinical Site to the EET Biobank ................................41 
5.7 
Shipping of Specimens from Clinical Site to Other Laboratories .........................43 
5.8 
Biomarker Plan ......................................................................................................44 
5.9 
Integrated Correlative Studies ................................................................................49 
5.10 
Exploratory/Ancillary Correlative Studies ............................................................49 
6. 
TREATMENT PLAN ........................................................................................................53 
6.1 
Agent Administration .............................................................................................53 
6.2 
Definition of Dose-Limiting Toxicity ....................................................................55 
6.3 
General Concomitant Medication and Supportive Care Guidelines ......................55 
6.4 
Duration of Therapy ...............................................................................................58 
6.5 
Duration of Follow-Up ..........................................................................................59 


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7. 
DOSING DELAYS/DOSE MODIFICATIONS................................................................59 
7.1 
Dasatinib ................................................................................................................59 
7.2 
Icosapent ethyl (EPA) ............................................................................................61 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................62 
8.1 
CTEP Agent ...........................................................................................................63 
8.2 
Commercial Agent .................................................................................................65 
9. 
STATISTICAL CONSIDERATIONS...............................................................................67 
9.1 
Study Design/Endpoints.........................................................................................67 
9.2 
Sample Size/Accrual Rate ......................................................................................70 
9.3 
Stratification Factors ..............................................................................................71 
9.4 
Analysis of Secondary Endpoints ..........................................................................71 
9.5 
Analysis of Exploratory Endpoints ........................................................................71 
9.6 
Reporting and Exclusions ......................................................................................72 
10. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................73 
10.1 
Comprehensive Adverse Events and Potential Risks List (CAEPR) .....................73 
10.2 
Adverse Event Characteristics ...............................................................................78 
10.3 
Expedited Adverse Event Reporting ......................................................................78 
10.4 
Routine Adverse Event Reporting .........................................................................84 
10.5 
Pregnancy ...............................................................................................................84 
10.6 
Secondary Malignancy ...........................................................................................84 
10.7 
Second Malignancy ................................................................................................84 
11. 
STUDY CALENDAR .......................................................................................................85 
12. 
MEASUREMENT OF EFFECT........................................................................................87 
12.1 
Antitumor Effect – Solid Tumors ..........................................................................87 
13. 
STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS .............................................................................................................93 
13.1 
Study Oversight .....................................................................................................93 
13.2 
Data Reporting .......................................................................................................93 
13.3 
Data Quality Portal ................................................................................................96 
13.4 
CTEP Multicenter Guidelines ................................................................................96 
13.5 
Collaborative Agreements Language .....................................................................96 
13.6 
Genomic Data Sharing Plan ...................................................................................98 
13.7 
Incidental/Secondary Findings Disclosure Procedure ...........................................98 
14. 
REFERENCES ..................................................................................................................99 
APPENDIX A 
PERFORMANCE STATUS CRITERIA ................................................104 
APPENDIX B 
FORMULA TO ESTIMATE RENAL FUNCTION USING 
SERUM CREATININE ...................................................................................................105 


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APPENDIX C 
PATIENT CLINICAL TRIAL WALLET CARD ...................................106 
APPENDIX D 
PATIENT’S MEDICATION DIARY .....................................................107 
Appendix D1 .................................................................................. Patient Medication Diary for 
Dasatinib ..............................................................................................................107 
Appendix D2 ................................................................ Patient Medication Diary for Icosapent 
Ethyl .....................................................................................................................109 
APPENDIX E 
PRE-BIOPSY ASSESSMENT ................................................................111 
APPENDIX F 
TISSUE BIOPSY VERIFICATION .....................................................112 
APPENDIX G 
SUBSTANCES PROHIBITED DURING DASATINIB 
TREATMENT .................................................................................................................113 
APPENDIX H 
NCLN PHARMACODYNAMICS LABORATORY 
FROZEN BIOPSY COLLECTION PROCEDURE...................................................114 
 
 
 


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8 
1. 
OBJECTIVES 
 
1.1 
Primary Objectives 
 
1.1.1 Primary Objective (Phase 1b): To determine MTD/RP2D of EPA and dasatinib in 
patients with mTN-IBC.  
 
1.1.2 Primary Objective (Phase 2): To determine the overall response rate (ORR) of EPA and 
dasatinib therapy in patients with mTN-IBC.  
 
1.2 
Secondary Objectives 
 
1.2.1 To determine the clinical benefit rate (CBR) of EPA and dasatinib therapy in patients 
with mTN-IBC. 
 
1.2.2 To determine progression-free survival (PFS) at 1 year for patients with mTN-IBC who 
were enrolled in the study and received EPA and dasatinib therapy. 
 
1.2.3 To determine overall survival (OS) at 2 years for patients with mTN-IBC who were 
enrolled in the study and received EPA and dasatinib therapy 
 
1.2.4 To determine the induction of apoptosis by EPA and dasatinib therapy. 
 
1.3 
Exploratory Objectives 
 
1.3.1 To determine the effect of EPA and dasatinib therapy on the expression of cholesterol 
transporter. 
 
1.3.2 To determine the relationship between the expression of EphA2 and the treatment 
response to EPA and dasatinib therapy. 
 
1.3.3 To determine the change in Ki67 by EPA and dasatinib therapy. 
 
1.3.4 To evaluate the change in cholesterol homeostasis and tumor membrane rigidity after 
EPA and dasatinib therapy. 
 
1.3.5 To investigate the effect of EPA and dasatinib therapy on the systemic inflammation. 
 
2. 
BACKGROUND 
 
2.1 
Study Disease 
 
 
Triple-negative inflammatory breast cancer (TN-IBC) is the most aggressive subtype of breast 
cancer, which has poor outcomes (Masuda et al., 2013).  It is also associated with higher rates of 
recurrence and metastasis and a lower survival rate than non-IBC (Hance et al, 2005).  The 


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9 
incidence of IBC in the United States is 1.6–3.1 per 100,000 women with a higher incidence 
among black women and younger women, but owing to its aggressive nature, IBC represents 
approximately 8–10% of breast cancer deaths (Hance et al., 2005; Goldner et al., 2014). 
 
The inflammatory process contributes to the aggressiveness of IBC (Lim et al., 2018).  Recent 
studies have suggested that immune cells in the tumor microenvironment play a major role in 
regulating the malignant phenotype of IBC (Allen et al., 2016; Wolfe et al., 2016).  IBC is a rare 
tumor without specific treatment (Lim et al., 2018).  Further, IBC with a triple-negative 
molecular subtype lacks specific targeted therapy; chemotherapy is the main treatment choice 
and results in major toxicities.  These are compelling reasons for developing a novel treatment 
for TN-IBC. 
 
2.2 
CTEP IND Agent 
 
2.2.1 Dasatinib (BMS-354825, Sprycel) 
 
Dasatinib (BMS-354825, Sprycel), an aminothiazole analogue, is an orally administered (PO) 
protein tyrosine kinase (PTK) inhibitor with specificity for five kinases/kinase families that have 
been strongly linked to multiple forms of human malignancies (Hunter, 1997; Investigator’s 
Brochure, 2020; Lombardo et al., 2004).  These targets include:  BCR-ABL, c-SRc, c-KIT, 
PDGFβ receptor, and EPHA2.  In vivo and in vitro studies have established that dasatinib 
demonstrates potent antiproliferative activity in a wide spectrum of cancer cell lines/types, and 
clinical results suggest anticancer activity of dasatinib in chronic myelogenous leukemia (CML) 
and solid tumor patients (Demetri et al., 2009; Li et al., 2004; Schittenhelm et al., 2006; Wu et 
al., 2004).  
 
2.2.1.1 Mechanism of Action 
 
Dasatinib potently and selectively inhibits the five oncogenic PTKs/kinase families by 
competing with ATP for the ATP-binding sites in the kinases:  SRC family kinases (IC50:  SRC = 
0.55 nM, LCK = 1.1 nM, YES = 0.41 nM, FYN = 0.2 nM); BCR-ABL (<3 nM); c-KIT (13 nM); 
EPHA2 (17 nM) and PDGFE receptor (28 nM) (Investigator’s Brochure, 2020).  The agent was 
found to be less potent against unrelated PTKs and several serine/threonine kinases.  Dasatinib 
also demonstrates potent inhibition of VEGF- and bFGF-driven proliferation of human umbilical 
vein endothelial cells (HUVECs), with IC50 values of 43 and 248 nM, respectively. 
 
BCR-ABL, a constitutively active cytoplasmic tyrosine kinase, is present in >90% of all patients 
with CML and in 15-30% of adult patients with acute lymphoblastic leukemia (ALL).  The 
inhibition of BCR-ABL by imatinib, another PTK inhibitor, is effective in the management of 
CML thus providing proof-of-concept for targeting PTKs.  However, resistance to imatinib 
therapy associated with BCR-ABL gene mutation/over-expression and activation of selected 
SRC kinases has been increasingly encountered (Hochhaus and Hughes, 2004).  Dasatinib has 
activity in a number of imatinib-resistant tumors (Donato et al., 2004; Lee et al., 2004; Shah, 
2005; Shah et al., 2004; Talpaz et al., 2006) in addition to being 500-fold more potent than 
imatinib in inhibiting BCR-ABL.  The ability of dasatinib to inhibit imatinib-resistant forms of 
BCR-ABL is presumed to be due to its relaxed binding requirements because, unlike imatinib 


NCI Protocol #: 10480 
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10 
which binds only to the inactive conformation of the BCR-ABL kinase, dasatinib binds to both 
the active and inactive conformations (Tokarski et al., 2004).    
 
2.2.1.2 Nonclinical Studies 
 
2.2.1.2.1 Efficacy 
 
Dasatinib inhibits growth of multiple BCR-ABL-dependent leukemic cell lines and also shows 
activity against 14 of 15 imatinib-resistant BCR-ABL kinase mutants (Shah et al., 2004).  
Inhibition of CML cell lines established from patients who were resistant to imatinib therapy has 
also been reported (Wu et al., 2004).  Dasatinib potently inhibits wild-type (IC50:  1-10 nM) and 
mutant (IC50:  10-100 nM) KIT kinases in M07E cells and human mast cell leukemia cell lines, 
respectively (Schittenhelm et al., 2006).  Also of note, dasatinib selectively killed primary 
neoplastic bone marrow mast cells from patients with systemic mastocytosis while sparing other 
hematopoietic cells (Shah et al., 2005). 
 
Dasatinib demonstrated antiproliferative activity in a wide spectrum of solid tumor types, 
including mastocytoma, prostate, and breast cell lines with IC50 values ranging from 5.4-103 nM 
(Investigator’s Brochure, 2020).  The agent also inhibited stem cell factor-driven proliferation of 
three small cell lung cancer (SCLC) cell lines with IC50 values in the range of 114-220 nM and 
showed activity in head and neck squamous cell carcinoma and non-small cell lung cancer cell 
lines (Johnson et al., 2005). 
 
When dasatinib was administered twice daily (BID) on a 5-days-on/2-days-off schedule for a 
total of 14 to 25 days at doses of 10-50 mg/kg/dose, in vivo antitumor activity of dasatinib was 
seen in prostate, colon, breast, and pancreatic xenograft models (Investigator’s Brochure, 2020).  
Similarly, dasatinib was effective against K562 and imatinib-resistant K562-R human CML 
xenografts in SCID mice at doses as low as 2.5-5 mg/kg/day (Lee et al., 2004).  In combination 
with docetaxel, dasatinib produced antitumor effects against PC3 human prostate carcinoma 
xenografts that were substantially better than the effects of either single agent alone 
(Investigator’s Brochure, 2020). 
 
Dasatinib at 20 or 50 mg/kg inhibited the T-cell proliferation response in mice following the 
transfer of lymphocytes from allogeneic donor mice (Investigator’s Brochure, 2020).  In 
addition, treatment of mice with dasatinib 25 mg/kg BID inhibited the graft-versus-host response 
in a non-vascularized model of murine heart transplant.  The 5-days-on/2-days-off regimen 
almost completely eliminated immunosuppressive activity in this model. 
 
SRC kinase is known to play a major role in osteoclast function.  In short-term studies, dasatinib 
acted as a potent inhibitor of bone resorption as measured by its ability to reduce the release of 
45calcium into the culture medium by fetal rat long bones in vitro (IC50 = 2 nM).  Dasatinib also 
inhibited parathyroid hormone (PTH)-stimulated release of 45calcium in a dose-dependent 
manner with an apparent IC50 of 2 nM.  At 5 nM, dasatinib completely blocked PTH-stimulated 
bone resorption in thyro-parathyroidectomized rats.  The therapeutic utility of dasatinib in the 
treatment of cancer-related hypercalcemic syndromes has not been fully explored, and the long-
term effects of dasatinib on bone physiology are also unknown. 


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2.2.1.2.2 Nonclinical Pharmacokinetic and Pharmacodynamic Studies 
 
Nonclinical metabolic and pharmacokinetic (PK) studies were conducted with dasatinib in 
several species including mouse, rat, dog, and monkeys to assess the absorption, distribution, 
metabolism, and excretion of the compound in animals.  These studies showed that dasatinib has 
varying degrees of oral bioavailability, ranging from 15% in monkeys to 34% in dogs.  The 
permeability of dasatinib in the Caco-2 cell model is 102 nm/sec at pH 7.4, suggesting that it has 
the potential for good (>50%) oral absorption in humans.  The agent is highly bound to serum 
proteins (>91%) and has extensive extravascular distribution.  Dasatinib is principally eliminated 
by hepatic metabolism and excreted in feces.  The agent is primarily metabolized by the 
CYP3A4 enzyme to produce multiple metabolites.   
 
The value of phospho-SRC as a biomarker of dasatinib efficacy has been explored in nonclinical 
studies (Luo et al., 2005).  In nude mice bearing subcutaneous PC-3 tumors (human prostate), 
measurement of phospho-SRC by western blot in tumor and peripheral blood mononuclear cells 
(PBMCs) following treatment with a single dose of dasatinib (15 or 50 mg/kg) produced similar 
results in both tissues.  Levels of phospho-SRC were maximally inhibited at 3 hours post dose, 
then recovered partially between 7 and 17 hours and returned to the basal level by 24 hours after 
agent administration.  These results were quantitated by image scanning and compared to 
efficacy results when the agent was administered PO BID at 15-50 mg/kg/dose for 14 days on a 
5-days-on/2-days-off schedule.  Efficacy and phospho-SRC inhibition appeared to correlate, and 
this pharmacodynamic model permitted the authors to predict that the plasma concentration of 
dasatinib required to produce 90% inhibition of phospho-SRC would be 164 nM and 91 nM in 
PC-3 tumor and PBMCs, respectively.  Studies to evaluate the clinical utility of phospho-SRC as 
a biomarker are ongoing. 
 
2.2.1.2.3 Toxicology 
 
A range of toxicology studies have been conducted to support the oral administration of dasatinib 
in humans.  The oral studies indicated that dasatinib induced reversible toxicities of the 
gastrointestinal (GI) and lymphoid systems in rats and monkeys, and of the hematopoietic system 
in rats.  Embryofetal development studies in rats and rabbits indicated that dasatinib caused 
embryo lethality or skeletal malformations at doses that did not cause maternal toxicity, 
suggesting that it is a selective developmental toxicant.  An in vitro cytogenetics study in CHO 
cells indicated that it was clastogenic at concentrations >5 μg/mL, a level not achievable in vivo.  
The agent is nongenotoxic and did not show significant potential for undesirable functional 
activity in in vitro receptor/ion channel binding and enzyme assays.  In vitro potassium channel 
current (HERG/IKr) and Purkinje fiber assays suggested that dasatinib could potentially prolong 
cardiac ventricular repolarization (QT interval), and a single-dose cardiovascular study in 
monkeys demonstrated that the agent at a dose of 10 mg/kg caused a minimal increase in blood 
pressure for approximately 2 hours post dose.  There were no drug-related neurologic 
observations in rats or monkeys.  Dasatinib was found to be phototoxic in an in vitro assay in 
mouse fibroblasts. 
 


NCI Protocol #: 10480 
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12 
2.2.1.3 Clinical Experience 
 
Over 2000 subjects have received dasatinib, the majority with CML refractory or intolerant to 
imatinib (Investigator’s Brochure, 2020).  Studies conducted in healthy volunteers include the 
following:  PK; formulation comparisons; the effect of food; drug interactions; and supportive 
care.  Data are available from 11 phase 1 and phase 2 studies in patients with CML, Philadelphia 
chromosome-positive (Ph+) ALL, or solid tumors using different dosage regimens and designed 
to determine PK, pharmacodynamics, safety, and efficacy in these populations.  
 
2.2.1.3.1 Pharmacokinetics 
 
Pharmacokinetic (PK) studies were conducted using a single 100 mg dose of dasatinib 
administered to healthy volunteers in four different formulations:  50 mg clinical tablets x 2, 5 
mg clinical tablets x 20, 20 mg commercial tablets x 5, and 50 mg commercial tablets x 2.  The 
PK profile of the agent was similar in all four formulations.  The PK profile of dasatinib was also 
assessed in CML and Ph+ ALL patients providing data which showed that the PK parameters in 
the patient population appear to be similar to that in the healthy volunteers.  The agent was 
absorbed rapidly following oral administration; peak plasma concentrations were achieved in 
0.5-3 hours and dose-related increases in plasma concentrations were observed.  The mean 
terminal half-life (t1/2) of dasatinib was 4 hours.  Dosing interval exposures and t1/2 values were 
comparable regardless of whether the agent was administered on a once daily or twice daily 
(BID) 5-day-on/2-day-off schedule, or BID continuously. 
 
A phase 1 study has been initiated in solid tumor patients to determine the effect of the CYP3A4 
inhibitor ketoconazole on dasatinib PK.  In a study of 18 patients with solid tumors, 20 mg of 
dasatinib once daily coadministered with 200 mg of ketoconazole twice daily increased the 
dasatinib Cmax and AUC by four- and five-fold, respectively. 
 
2.2.1.3.2 Efficacy 
 
A phase I study treated patients with CML in chronic phase (CP) or advanced disease 
(accelerated phase or blast crisis) or Ph+ ALL who were intolerant or resistant to imatinib 
(Sawyers et al., 2005; Talpaz et al., 2006).  Dasatinib was administered once daily at doses 
ranging from 15 to180 mg/day or BID at doses ranging from 25 to 50 mg for 5-7 consecutive 
days each week.  Complete hematologic response was documented in 37 of 40 CP patients (92%) 
and the rate was similar with both schedules (once daily or BID).  Fourteen CP patients (35%) 
achieved a complete cytogenetic response and four (10%) experienced partial responses.  In 44 
patients with advanced CML or Ph+ ALL, 31 major hematologic responses were documented 
(70%).  Cytogenetic responses were documented in 25 advanced CML or ALL patients, 
including complete responses in 11 patients. 
 
A phase 1 study has been conducted in patients with refractory solid tumors in order to evaluate 
the safety, tolerability, and the pharmacologic profile of dasatinib (Demetri et al., 2009).  
Patients received escalating doses (25 to 120 mg) of dasatinib without food administered BID for 
5 consecutive days every week followed by 2 days of rest (5D2 schedule), or on a continuous 
daily dosing (CDD) schedule.  There were no objective responses on CT scans, but stable disease 


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(SD) was observed in 11 patients (16%), including three gastrointestinal stromal tumor (GIST) 
patients.  These 11 were comprised of seven (21%) of 33 patients on the 5D2 schedule and four 
(12%) of 34 patients on the CDD schedule.  The median duration of SD was 3.6 months (range 
1.7 – 23.6 months).  The investigators noted that the clinical benefits of the agent in a subset of 
imatinib-resistant GIST patients have been encouraging. 
 
In solid tumors, the recommended phase 2 dose for dasatinib was found to be 120 mg BID on the 
5D2 schedule, or 70 mg BID on the CDD regimen (Demetri et al., 2009).  In October 2010, 
dasatinib was approved by the FDA for treatment of chronic, accelerated, and blast phase CML 
and Ph+ ALL with resistance or intolerance to imatinib.  Results from two phase 3 dose-
optimization studies supported starting doses of 100 mg once/day for CP CML and 140 mg 
once/day for imatinib-resistant accelerated phase CML, myeloid or lymphoid blast phase CML, 
or Ph+ ALL.  A randomized phase 3 trial comparing dasatinib to imatinib led to FDA approval 
of dasatinib (100 mg once/day) for first-line therapy of newly diagnosed CML.  
 
2.2.1.3.3 Safety 
 
Myelosuppression, probably attributable to suppression of the Ph+ clone, was the most frequent 
adverse event (AE) in the phase 1 study in CML or Ph+ ALL, while the most significant AE was 
grade 3/4 thrombocytopenia (28%) (Investigator’s Brochure, 2020).  Severe myelosuppression 
was reversible and easily managed with a short dose interruption; about 60% of patients required 
interruption of treatment, and the myelosuppression generally resolved within 3 months, often in 
association with a cytogenetic response (Talpaz et al., 2006).  Twenty-five percent of leukemia 
patients required a dose reduction.  In the phase 1 study in solid tumor patients, hematologic AEs 
were uncommon:  two patients on the 5D2 schedule with grade 1 or 2 anemia developed grade 3 
anemia while on study drug, whereas on the CDD schedule one patient developed grade 4 
neutropenia and another grade 3 anemia (Demetri et al., 2009).   
 
Non-hematologic AEs from the two phase 1 trials include GI intolerance (primarily diarrhea, 
nausea, and vomiting), GI hemorrhage, fatigue, dyspnea, anorexia, dehydration, fluid retention, 
pleural and pericardial effusion, a moderate increase in QTcF (with no QTcF >500 msec), 
elevated creatinine, depression, and tumor lysis syndrome.  In addition to these AEs, dasatinib 
treatment has the potential to produce skin rashes, other respiratory events, and CNS 
hemorrhage.  While neither immunosuppression nor osteoclast function abnormalities (e.g., 
osteoporosis) were observed in these short-term studies, SRC kinase inhibitors have the potential 
to cause these types of events.  
 
As of September 2010 in the overall population of 2840 subjects, a total of 740 (26%) deaths 
were reported in adult dasatinib-treated subjects with CML or Ph+ ALL.  Of these 740 deaths, 
296 occurred within 30 days of the last dose of study therapy.  Of the 740 deaths, 380 (51%) 
were due to disease progression and 11 (1.5%) have been positively attributed to study drug 
toxicity.  
 
2.2.1.4 Potential Drug Interactions 
 
Dasatinib is primarily metabolized by CYP3A4 and therefore, potent inhibitors of this enzyme 


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are contraindicated (Investigator’s Brochure, 2020).  Dasatinib is also a significant inhibitor of 
this hepatic enzyme but a weak inhibitor of other cytochrome enzymes, and the agent does not 
induce CYP3A4.  Thus, dasatinib may decrease the clearance of drugs that are significantly 
metabolized by the CYP3A4 enzyme, and caution should be used with concurrent use of such 
drugs or substances.  In a study in cancer patients, concomitant use of a potent CYP3A4 inhibitor 
(ketoconazole) produced >5-fold increase in exposure to dasatinib, while healthy subjects treated 
concurrently with dasatinib and a potent CYP3A4 inducer experienced a 5-fold decrease in 
dasatinib exposure.  When the CYP3A4 substrate simvastatin was studied in combination with 
dasatinib, increased simvastatin exposure resulted, indicating the necessity of caution when 
dasatinib is administered with CYP3A4 substrates with a narrow therapeutic margin (e.g., 
cyclosporine). 
 
2.3 
Icosapent ethyl (EPA) 
 
Icosapent ethyl is an ethyl ester of the omega-3 fatty acid eicosapentaenoic acid (EPA), and acts 
as a lipid-regulating agent (VASCEPATM package insert, 2019).  Studies suggest that EPA 
reduces hepatic very low-density lipoprotein triglycerides (VLDL-TG) synthesis and/or 
secretion, and enhances TG clearance from circulating VLDL particles.  The peak plasma 
concentrations of EPA are reached approximately 5 hours following oral doses of icosapent 
ethyl.  EPA is mainly metabolized by the liver via beta-oxidation similar to dietary fatty acids.  
Beta oxidation splits the long carbon chain of EPA into acetyl Coenzyme A, which is converted 
into energy via the Krebs cycle.  Cytochrome P450-mediated metabolism is a minor pathway of 
EPA elimination.  The total plasma clearance of EPA at steady state is 684 mL/hr and the plasma 
elimination half-life (t1/2) of EPA is approximately 89 hours.  Furthermore, icosapent ethyl does 
not undergo renal excretion. 
 
The potential mechanisms of action of icosapent ethyl include increased β-oxidation; inhibition 
of acyl-CoA:1,2-diacylglycerol acyltransferase (DGAT); decreased lipogenesis in the liver; and 
increased plasma lipoprotein lipase activity (VASCEPATM package insert, 2019).  The 
mechanisms of action contributing to reduction of cardiovascular events with icosapent ethyl are 
not completely understood but are likely multi-factorial.  Increased EPA lipid composition from 
carotid plaque specimens and increased circulating EPA/arachidonic acid ratio have been 
observed following EPA treatment.  EPA inhibits platelet aggregation under some ex vivo 
conditions.  However, the direct clinical meaning of these individual findings is not clear.   
 
Icosapent ethyl is indicated as an adjunct to maximally tolerated statin therapy to reduce the risk 
of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring 
hospitalization in adult patients with elevated TG levels (≥150 mg/dL) as well as (1) established 
cardiovascular disease or (2) diabetes mellitus and 2 or more additional risk factors for 
cardiovascular disease (VASCEPATM package insert, 2019).  Icosapent ethyl is also indicated as 
an adjunct to diet to reduce TG levels in adult patients with severe (≥500 mg/dL) 
hypertriglyceridemia.  However, the effect of icosapent ethyl on the risk for pancreatitis in 
patients with severe hypertriglyceridemia has not yet been determined and remains a limitation 
of its use.  For more information, see the package insert for VASCEPA™ (2019). 
 


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2.4 
Rationale 
 
Icosapent ethyl (EPA), a natural omega-3 polyunsaturated fatty acid found in fish oil and 
available as a dietary supplement, is a U.S. Food and Drug Administration (FDA)-approved 
agent (Vascepa, Amarin Pharmaceuticals) that has anti-inflammatory properties and the capacity 
to modulate lipid metabolism with a safe toxicological profile (mild diarrhea occurs in <2.5% of 
patients) (Bays et al., 2011).  EPA is an inhibitor of the delta-5-desaturase that produces 
arachidonic acid, which is necessary for the production of pro-inflammatory eicosanoids (Calder, 
2010).  Although most cancer prevention studies of EPA have not shown an improved outcome, 
EPA has demonstrated effects supportive of therapeutic activity.  In a randomized clinical trial in 
recurrent colorectal cancer, EPA treatment reduced plasma CCL2 levels, which predicted 
improved disease-free survival (DFS; hazard ratio [HR] = 0.32; P = 0.003) after surgery for 
resectable liver metastases (Volpato et al., 2016).  Also, in patients with newly diagnosed breast 
cancer, supplementation with EPA and docosahexaenoic acid maintained the serum levels of 
CD4+ T cells and high-sensitivity C-reactive protein, suggesting a beneficial effect on the 
immune system (Paixao et al., 2017).  Preliminary studies revealed the therapeutic potential of 
EPA in the preclinical setting; EPA reduced in vitro proliferation and in vivo tumor growth of 
TN-IBC cells by modulating cholesterol homeostasis (Torres-Adorno et al., 2019).  A single 
agent however is not sufficient to obtain a clinically relevant anti-tumor effect in TN-IBC. 
 
To identify a panel of kinase targets whose inhibition bolstered the anti-tumor activity of EPA in 
TN-IBC, a non-biased functional genomics screen was conducted.  This screen led to the 
identification of EphA2 (ephrin type-A receptor 2) as a potential therapeutic target in TN-IBC.  
A combination of EPA and inhibition of EphA2 showed the most effective anti-tumor activity 
among the targets identified.  Several EphA2-targeting agents, including multi-tyrosine kinase 
inhibitor dasatinib (Bristol-Myers Squibb) (Huang et al., 2014) and liposomal formulations of 
EphA2 siRNA, have demonstrated anti-tumor efficacy in preclinical studies (Landen et al. 
2005).  Although dasatinib as a single agent had a low tumor response rate in metastatic breast 
cancer and was not effective in a preclinical model (Pusztai et al., 2014), preclinical data for a 
response to EPA and dasatinib combination in TN-IBC mouse models is very compelling.  This 
study proposes to develop an EPA and dasatinib combination therapy for metastatic TN-IBC 
(mTN-IBC) and test its safety and efficacy in a phase 1b/2 trial.  As EphA2 is overexpressed in 
60% of TN-IBC xenografts (data not shown), successful translation of EPA and dasatinib 
combination therapy would hold significant clinical benefit for patients with EphA2+ mTN-IBC. 
 
A functional genomics screen identified EPA plus EphA2 inhibition as an enhanced 
combination therapy for TN-IBC.  
 
With the goal of developing a combination therapy, which includes EPA, for TN-IBC, a high-
throughput siRNA screen was conducted (Lee et al., 2015) to identify molecular targets that can 
improve EPA’s therapeutic activity without introducing bias.  By screening SUM149 TN-IBC 
cells using a siRNA “druggable gene” library that targets 939 genes, 20 targets were identified 
that, when inhibited, significantly enhanced the therapeutic potential of EPA; these targets 
included EphA2, FZD4, FZD8, GSK3B, and Src (Torres-Adorno et al., 2019).  Gene Ontology 
analysis of these 20 identified targets revealed enrichment in targets associated with the plasma 
membrane (P < 0.05), suggesting that functional changes within the cell that make EPA more 


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effective involve membrane biology.  Of these targets, 14 genes are associated with plasma 
membranes (Torres-Adorno et al., 2019).  EphA2 was selected for further evaluation on the basis 
of the following findings: 1) EphA2 mRNA levels in TNBC patient tumors (Fig. 1A) and EphA2 
protein levels in TNBC cell lines (Fig. 2A) were higher than in non-TNBC compartments; 2) 
EphA2 mRNA levels were significantly associated with short DFS in patients with TNBC (Fig. 
1B).  EphA2, a cell surface receptor tyrosine kinase, controls multiple signaling pathways 
regulating cell differentiation, migration, and proliferation (Ireton and Chen, 2005).  
 
EphA2 expression is elevated in patient samples and TNBC cell lines.  
 
The prevalence of EphA2 in 
breast cancer cell lines and 
patient samples was assessed.  
mRNA (data not shown) and 
protein (Fig. 2A) levels of 
EphA2 were higher in TNBC 
cells than in non-TNBC cells.  
Analysis of EphA2 mRNA 
levels in primary breast tumors 
in 3 datasets of more than 600 
patients consistently showed 
elevated levels in TNBC 
tumors (Fig. 1A). Importantly, 
EphA2 mRNA levels in untreated primary tumors were inversely correlated with poor DFS in 
breast cancer patients (Fig. 1B).  These data provide a solid rationale for targeting EphA2 in 
TNBC. 
 
EphA2 expression in subtypes of breast cancer 
 
TNBC is characterized by the distinct pathological feature that it lacks receptor targets (e.g., ER, 
PR, HER2 receptor).  Thus, identification and evaluation of new biomarkers and therapeutic 
agents constitute a highly mandated unmet medical need.  There are 3 major classification 
methods established for TNBC: the Vanderbilt, Baylor, and French subtypes (Masuda et al., 
2013).  These studies were performed using the Vanderbilt subtypes, which are based on gene 
expression analysis from 587 TNBC tumors. 
According to the original Vanderbilt 
classification, TNBC cells are classified into 7 
subtypes by their genetic context: basal-like 1 
(BL1), BL2, immunomodulatory (IM), 
mesenchymal (M), mesenchymal stem-like 
(MSL), luminal androgen receptor (LAR), and 
unstable (UNS)(12).  In 2016, these subtypes 
were refined to 4 subtypes (BL1, BL2, M, and 
LAR) (Lehmann et al., 2016).   
 
EphA2 protein expression was analyzed in 


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different molecular subtypes of breast cancer cell lines and 4 molecular subtypes of TNBC cell-
derived xenograft (CDX) tumors.  TNBC cells expressed higher levels of EphA2 than other 
subtypes of breast cancer cells (Fig. 2A).  Basal-like 2 (BL2) and mesenchymal (M) subtypes of 
TNBC CDX tumors had elevated EphA2 expression (Fig. 2B).  These results suggest that 
different TNBC molecular subtypes may have different responses to treatment with EPA and 
dasatinib combination therapy. 
 
EPA in combination with EphA2 inhibition drastically inhibits the growth of TN-IBC 
xenografts in vivo.  
 
To validate that EphA2 is an 
important target in the setting of 
EPA treatment, functional gene 
silencing using siRNA libraries 
was performed (Fig. 3A).  
siEphA2-treated SUM149 and 
TN-IBC cells were more 
sensitive to EPA treatment 
compared to the control siRNA 
treatment group (Fig. 3B).  For 
the further biological assay, 
dasatinib was selected, an SRC-
family tyrosine kinase, and 
EphA2 inhibitor, due to a lack 
of FDA-approved drug to 
targeting EphA2.  EphA2 
inhibition by dasatinib enhanced 
EPA’s therapeutic activity in 2 
EphA2+ TN-IBC cell lines, SUM149 and BCX010 (Fig. 3C).  BCX010 was derived from a TN-
IBC patient-derived xenograft (PDX) model that is chemotherapy resistant (McAuliffe et al., 
2015).  When these cells were treated with 
increasing doses of dasatinib and EPA at an 
IC50 of 50μM, high synergism was observed 
(combination index < 1 by the Chou- 
Talalay method [Chou 2010]).  Importantly, 
dasatinib did not show efficacy as a 
monotherapy or in combination with EPA in 
HCC38 TN-IBC cells, which express very 
low levels of EphA2 (Fig. 3C).  Moreover, 
restoration of Src gene expression did not 
rescue TN-IBC cells from the enhanced 
killing by EPA and dasatinib combination 
therapy (Fig. 4), suggesting that the 
mechanism of action requires EphA2 inhibition. 
 
To evaluate whether EPA-based EphA2-targeted combination therapy was effective in animal 


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models of TN-IBC, EphA2 activity was inhibited in vivo by 1) silencing EphA2 gene expression 
using shRNA or 2) treatment with EphA2 inhibitor dasatinib.  Silencing EphA2 gene expression 
was critical for assessing the effect of specifically targeting EphA2 because dasatinib can target 
multiple kinases besides Src.  Dasatinib was utilized, even though it can target multiple kinases, 
to demonstrate the translatability of this research to combination therapy in the clinic.  Two TN-
IBC cell lines were generated with doxycycline (Dox)-inducible shRNA (SUM149- shEphA2 
and BCX010-shEphA2) or non-silencing controls (Vector) using pTRIPZ lentiviral vectors.  
SUM149-shEphA2 or BCX010-shEphA2 cells were implanted into NSG mice (n=10/group).  
When tumors reached 100 mm3, the mice were switched to 1) normal diet, normal water 
(Control); 2) EPA diet (6 mg/kg), normal water; 3) normal diet, water containing Dox (to induce 
EphA2 knockdown); or 4) EPA diet and water containing Dox.  While both monotherapies (EPA 
treatment or Dox-induced EphA2 knockdown) slowed tumor growth, EPA and dasatinib 
combination therapy markedly prevented tumor growth (Fig. 3D).  Dox treatment had no effect 
on the growth of tumors derived from non-silencing controls, suggesting that the enhanced 
therapeutic effect was a result of the loss of EphA2. 
 
EPA and dasatinib combination therapy was further evaluated using SUM149 (chemo-sensitive) 
and BCX-010 (chemo- resistant) xenograft models.  When tumors reached 100 mm3, the mice 
were divided into 1) control; 2) EPA diet (6 mg/kg); 3) dasatinib (2.5 mg/kg); and 4) EPA and 
dasatinib groups.  Similarly, compared to treatment with monotherapies (EPA or dasatinib) or 
vehicle control, EPA and dasatinib combination therapy drastically reduced the growth of tumor 
xenografts of both cell lines (Fig. 3E).  Interestingly, EPA and dasatinib combination reduced 
tumor growth in both chemo-sensitive (SUM149) and chemo-resistant (BCX-010) TNBC-IBC 
xenografts.  This data indicated that EPA and dasatinib combination therapy could be considered 
as a novel treatment option for metastatic TNBC patients who received have previously received 
chemotherapeutic regimens.  Collectively, these results provide a rational basis for the 
development of EPA and dasatinib combination 
therapy for EphA2+ TN-IBC and demonstrate, by 
two independent methods, that inhibition of 
EphA2 drastically boosts the anti-tumor efficacy of 
EPA. 
 
EPA in combination with EphA2 inhibition 
increases TN-IBC cell membrane rigidity.  
 
Because EPA is incorporated into the cell 
membrane in TN-IBC (data not shown), the 
fluidity of TN-IBC cell membranes was assessed 
following treatment.  Membrane fluidity was 
assessed by measuring general polarization (GP), 
whereby higher GP indicates less fluidity (Fig. 
5A).  EphA2 silencing by Dox (Fig. 5B) or EphA2 
activity inhibition by dasatinib (Fig. 5C) did not 
alter the fluidity of SUM149 cell membranes, 
whereas when these treatments were combined 
with EPA, the cell membranes become rigid (Fig. 


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5B, 5C).  The same was observed in BCX010 cells (data not shown).  Collectively, these data 
suggest that EPA and dasatinib combination therapy increases cell membrane rigidity, leading to 
cell death. 
 
Cholesterol is a major 
modulator of cell 
membrane fluidity, and 
the intercalation of 
cholesterol into the 
phospholipid bilayer 
leads to increased 
rigidity of the cell 
membrane 
(Jaureguiberry et al., 
2014).  Because the 
level of cholesterol 
within the membrane in 
TN-IBC is higher than 
in other breast cancers 
(data not shown), it was hypothesized that a change in cholesterol homeostasis was the 
mechanism of EPA therapy’s efficacy.  Changes in GP of the plasma membrane in TN-IBC cells 
following exogenous cholesterol supplementation or cyclodextrin-based cholesterol depletion 
were assessed.  As expected, in TN-IBC cells treated with a combination of EPA with Dox or 
dasatinib, cholesterol supplementation elevated GP, whereas cholesterol depletion lowered GP 
(Fig. 6A).  Furthermore, the addition of exogenous reducing cholesterol content in these cells 
with rosuvastatin (a cholesterol biosynthesis inhibitor) partially blocked the effectiveness of 
dasatinib and EPA combination therapy (Fig. 6B).  
Conversely, reducing cholesterol content in these cells 
with rosuvastatin (a cholesterol biosynthesis inhibitor) 
partially blocked the effectiveness of EPA and 
dasatinib combination therapy (Fig. 6B).  These data 
suggest that EPA in combination with EphA2 
inhibition increases membrane rigidity through 
cholesterol accumulation in TN-IBC cell membranes, 
leading to cell apoptosis. 
 
ABCA1 is a critical mediator of cholesterol 
homeostasis.  
Cholesterol levels within the cell can be modulated 
through increased import, reduced export, and/or 
increased biosynthesis (Nandi et al., 2009; Miserez et 
al., 2002).  The expression levels of 4 major proteins 
(ABCA1, SREBP2, LDLR [low-density lipoprotein 
receptor], and HMGCR [3-hydroxy-3-methylglutaryl-
CoA reductase]) involved in cholesterol regulation 
was examined in both SUM149 and BCX010 cells.  


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ABCA1 is the membrane-bound cholesterol efflux protein that transports cholesterol from the 
cell cytosol, and SREBP2 is a transcription factor that regulates cholesterol and fatty acid 
biosynthesis for cellular cholesterol homeostasis (Fig. 7A).  If the cholesterol level is increased 
in the cells, SREBP2 loses transcriptional activity through inhibition of the formation of a 
complex with a transcription activator (Horton et al., 2002).  Compared to monotherapies (EPA 
or Dox/dasatinib) and untreated controls, EPA combined with Dox or dasatinib therapy 
diminished the expression of ABCA1 and mature SREBP2 but did not have any effect on the 
expression of LDLR and HMGCR (Fig. 7B). 
 
The reduced levels of ABCA1 may trigger the 
accumulation of cholesterol within cells, which 
could result in increased cell membrane polarity 
and cell death (Fig.7B).  To determine whether 
ABCA1 is critical to maintaining cell membrane 
polarity, gain/loss-of-expression studies were 
performed to assess the response of SUM149 
and BCX010 cells to combination treatment.  
Overexpression of ABCA1 significantly blocked 
GP induced by EPA and Dox combination 
therapy (P < 0.001) and subsequently prevented 
apoptosis (P < 0.05) when compared to controls 
(Fig. 8).  Furthermore, EPA and EphA2 
inhibition treatment dramatically reduced 
ABCA1 expression in the shEphA2-treated 
SUM149 and BCX010 tumor xenografts 
described above (Fig. 9).  These results provide 
proof of concept and efficacy that dasatinib and 
EPA combination therapy induces apoptosis in 
TN-IBC cells by impairing cholesterol export 
from the cell membrane by reducing ABCA1 
expression. 
 
Taken together, it is hypothesized that the combination of EPA and dasatinib, as EphA2 
inhibitor, synergistically inhibits the growth of mTN-IBC, by changing the membrane rigidity.  
Given previously shown the safety of both agents, the MTD for the combination will be 
determined and efficacy induced by MTD combination will be studied via this phase 1b/2 trail. 
 
2.5 
Correlative Studies Background 
 
2.5.1 Integrated Studies 
 
2.5.1.1 Apoptosis Multiplex Immunoassay, Luminex 
 
Biological rationale:  In SUM149PT and BCX010 tumor xenograft models, the combination of 
EPA and dasatinib significantly reduced Ki67 expression and increased cleaved caspase-3 
apoptosis marker by IHC.  Cleaved caspase-3 expression will be the main focus in the multiplex 


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immunoassay panel; however, the comprehensive immunoassay will assess the general change in 
apoptosis markers by EPA and dasatinib combination therapy.   
 
Hypothesis:  Patients who respond to EPA and dasatinib combination therapy will show a 
significant increase in the expression of apoptotic markers. 
 
2.5.2 Exploratory Studies 
 
2.5.2.1 DNA fragmentation 
 
Biological rationale:  Our preclinical results showed that the combination of EPA and dasatinib 
induced cancer cell apoptosis by altering cholesterol homeostasis. 
 
Preclinical and clinical data:  In the shEphA2 experiment described in Section 2.4, treatment 
with EPA and dasatinib in combination drastically reduced the growth of tumor xenografts of 
two TN-IBC cell lines by induction of apoptosis compared to treatment with monotherapies 
(EPA or dasatinib) or vehicle control. 
 
Hypothesis:  EPA and dasatinib combination therapy induces cancer cell apoptosis by altering 
cholesterol homeostasis.  
 
2.5.2.2 ABCA1 
 
Biological rationale:  Preclinical results showed that the cholesterol transporter, ABCA1, has an 
important role in regulating cholesterol homeostasis in the tumor cell membrane. 
 
Preclinical and clinical data:  Overexpression of ABCA1 significantly blocked the membrane 
GP induced by EPA and EphA2 shRNA in combination and subsequently prevented apoptosis (P 
< 0.05) when compared to controls (Fig. 6).  Furthermore, EPA and EphA2 inhibition 
dramatically reduced ABCA1 expression in the shEphA2-treated SUM149 and BCX010 tumor 
xenografts. 
 
Hypothesis:  EPA and dasatinib combination therapy induces breast cancer cell apoptosis via 
inhibiting ABCA1 function.   
 
2.5.2.3 EphA2 
 
Biological rationale:  The public gene dataset shows TNBC subtype has significantly higher 
gene expression of EphA2 compared with other subtypes, and the patients with EphA2 positive 
TNBC demonstrates poor survival outcome than those with EphA2 negative TNBC (Figures 1, 
3).  Thus, the expression of EphA2 is the critical indicator of the efficacy of the proposed 
treatment. 
 
Preclinical and clinical data:  For TN-IBC, our preclinical data strongly suggested that EPA in 
combination with dasatinib induced apoptosis by accumulating cholesterol in the cancer cell 
membrane.  Thus, expression of EphA2 may be a critical indicator of the efficacy of the 


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proposed treatment.   
 
Hypothesis:  EphA2 inhibition by EPA and dasatinib combination therapy induces apoptosis by 
accumulating cholesterol in the cancer cell membrane. 
 
2.5.2.4 Ki67 
 
Biological rationale:  In SUM149PT and BCX010 tumor xenograft models, the combination of 
EPA and dasatinib significantly reduced Ki67 expression and increased cleaved caspase-3 
apoptosis marker by IHC. 
 
Hypothesis:  Patients who respond to EPA and dasatinib combination therapy will show a 
significantly reduced Ki67 by IHC. 
 
2.5.2.5 Membrane rigidity 
 
Biological rationale:  Cholesterol is a major modulator of cell membrane fluidity, and the 
intercalation of cholesterol into the phospholipid bilayer leads to membrane stiffening 
(Jaureguiberry et al., 2014).  A preliminary preclinical study showed that EPA and dasatinib 
combination therapy enhanced anti-tumor activity and that this activity involved increased 
membrane rigidity through induction of cholesterol accumulation in tumor cell membranes 
(Torres-Adorno et al., 2019).  To examine whether EPA and dasatinib combination therapy 
inhibits tumor growth in patients through the same mechanism, its effects on cholesterol 
homeostasis will be assesses in snap-frozen tumor samples. 
 
Preclinical and clinical data:  Our data suggest that the combination of EPA and EphA2 
inhibition increased membrane rigidity through cholesterol accumulation in TN-IBC cell 
membranes, leading to apoptosis. 
 
Hypothesis:  EPA and dasatinib combination therapy increases cell membrane rigidity by altering 
cholesterol homeostasis. 
 
2.5.2.6 Cholesterol homeostasis in cell membrane 
 
Biological rationale:  Cholesterol is a major modulator of cell membrane fluidity as intercalation 
of cholesterol into the phospholipid bilayer leads to membrane stiffening.  
 
Preclinical and clinical data:  The likely mechanism of action of EPA-dasatinib combination 
therapy is inducing apoptosis by reduction of ABCA1 expression that increases cholesterol 
accumulation and membrane rigidity in cancer cells (Figures 5-9). 
 
Hypothesis:  EPA and dasatinib combination therapy alters cholesterol homeostasis. 
 
2.5.2.7 Multiplex cytokine panel 
 
Biological rationale:  IBC has numerous inflammatory processes that drives its aggressiveness 


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(Lim et al., 2018; Reddy et al., 2019).  The multiplex cytokine assay will be performed to 
determine the effect of EPA and dasatinib combination therapy on systemic inflammation. 
 
Preclinical and clinical data:  A previous preclinical study reported that EPA treatment 
decreased the tumoral expression of COX-2 (Ford et al., 2015).  In addition, membrane 
cholesterol efflux by IL-4–mediated reprogramming in tumor-associated macrophages (TAMs) 
was associated with tumor progression in a xenograft model (Goossens et al., 2019).  Further, 
inhibition of IL-4 and IL-13 decreased M2 polarization of macrophages by inhibition of STAT 
phosphorylation and resulted in increased efficacy of radiation in co-culture conditions with IBC 
cell lines (Rahal et al., 2018).  In a small randomized double-blind controlled trial, breast cancer 
patients who received EPA had a significantly reduced percentage of CD4+ T lymphocytes in 
peripheral blood (Paixao et al., 2017).  Recent studies have indicated that TAMs are a potential 
target for the treatment of solid tumors.  M1 macrophage cytokine IL-1β induces PD-L1 
expression in cancer cells (Zong et al., 2019), and inhibition of TAMs enhances the response to 
immune checkpoint inhibitors such as anti-PD-1, anti-PD-L1, or anti-CTLA-4 (Cassetta et al., 
2018).   We expect that EPA and dastinib combination therapy will inhibit TAMs by altering 
cholesterol homeostasis.   Overall, these results imply that EPA has an immunomodulatory effect 
on the tumor microenvironment (TME) and systemic anti-inflammatory effect. 
 
Hypothesis:  EPA and dasatinib combination therapy decreases M2 polarization of the 
macrophages represented by decreased M2 markers CD163 and CD206.  Dasatinib and EPA 
combination therapy decreases expression level of TAM-associated cytokines (IL-1β, IL-6, IL-8, 
IL-12, IL-23, IP-10, reactive oxygen intermediates, TNF-α, IL-10, TGF-β, CCL18, CCL22, and 
TNF-α) in the blood. 
 
3. 
PATIENT SELECTION 
 
3.1 
Eligibility Criteria  
 
3.1.1 Patients must have histologically confirmed mTN-IBC.  TNBC is defined as: 
a. <10% estrogen receptor and progesterone receptor expression by 
immunohistochemistry (IHC) 
b. Negative or 1+ for HER2 by IHC or negative by fluorescent in situ hybridization based 
on ASCO/CAP guideline) 
 
3.1.2 Patients must have had or currently have a clinical diagnosis of IBC according to the 
IBC-specific clinical manifestation as determined by a multidisciplinary team. 
 
3.1.3 Patients must have measurable disease by RECIST 1.1 for the phase 2 component of the 
study.  See Section 12 (Measurement of Effect) for the evaluation of measurable disease.  
Measurable disease is not a criterion for eligibility for the phase 1 component of the 
study. 
 
3.1.4 Patients must have minimum of one standard regimen exposure in a metastatic setting.  
 
3.1.5 Age ≥18 years.  Because no dosing or adverse event data are currently available on the 


NCI Protocol #: 10480 
Version Date:  December 13, 2022 
 
24 
use of dasatinib in combination with EPA in patients <18 years of age, children are 
excluded from this study. 
 
3.1.6 ECOG performance status: 0-2. 
 
3.1.7 Patients must have adequate organ and marrow function as defined below: 
 
 
absolute neutrophil count 
 
≥ 1,500/mcL 
 
platelets  
 
≥ 100,000/mcL 
 
total bilirubin 
 
≤ 1.5 × institutional upper limit of normal (ULN) 
 
AST(SGOT)/ALT(SGPT) 
 
≤ 2.5 × institutional ULN  
 
creatinine  
 
≤ 1.5 × institutional ULN 
 
glomerular filtration rate (GFR) ≥ 60 mL/min/1.73 m2 (see Appendix B) 
 
3.1.8 Patients with distant metastasis and/or local recurrence accessible for biopsy who are 
willing to undergo two mandatory biopsies.  Metastasis to brain, lung, and bone will be 
considered not accessible for safety reasons. 
 
3.1.9 Negative serum or urine pregnancy test for subjects with childbearing potential. 
 
3.1.10 Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral 
therapy with undetectable viral load within 6 months are eligible for this trial. 
 
3.1.11 For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral 
load must be undetectable on suppressive therapy, if indicated. 
 
3.1.12 Patients with a history of hepatitis C virus (HCV) infection must have been treated and 
cured.  For patients with HCV infection who are currently on treatment, they are eligible 
if they have an undetectable HCV viral load. 
 
3.1.13 Patients with a prior or concurrent malignancy whose natural history or treatment does 
not have the potential to interfere with the safety or efficacy assessment of the 
investigational regimen are eligible for this trial. 
 
3.1.14 Patients with known history or current symptoms of cardiac disease, or history of 
treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac 
function using the New York Heart Association Functional Classification.  To be eligible 
for this trial, patients should be of class 2B or better. 
 
3.1.15 The effects of dasatinib on the developing human fetus are unknown.  For this reason and 
because other therapeutic agents used in this trial are known to be teratogenic, women of 
child-bearing potential and men must agree to use adequate contraception (hormonal or 
barrier method of birth control; abstinence) prior to study entry and for the duration of 
study participation.  Should a woman become pregnant or suspect she is pregnant while 
she or her partner is participating in this study, she should inform her treating physician 
immediately.  Men treated or enrolled on this protocol must also agree to use adequate 


NCI Protocol #: 10480 
Version Date:  December 13, 2022 
 
25 
contraception prior to the study, for the duration of study participation, and 3 months 
after completion of dasatinib administration. 
 
3.1.16 Patients who are currently on bisphosphonate therapy should be able to temporarily stop 
bisphosphonate therapy for the duration of the study pending assessment of the need for 
calcium supplementation. 
 
3.1.17 Ability to understand and the willingness to sign a written informed consent document.  
Participants with impaired decision-making capacity (IDMC) who have a legally-
authorized representative (LAR) and/or family member available will also be eligible. 
 
3.2 
Exclusion Criteria 
 
3.2.1 Patients who have had chemotherapy or radiotherapy within 2 weeks (3 weeks for 
nitrosoureas or mitomycin C) prior to entering the study. 
 
3.2.2 Patients who are receiving any other investigational agents. 
 
3.2.3 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to dasatinib or icosapent ethyl or any of its components (tocopherol, gelatin, 
glycerin, maltitol, and sorbitol) or other agents used in study. 
 
3.2.4 Patients who have not recovered from adverse events due to prior anti-cancer therapies, 
(i.e.,  have residual toxicities > Grade 1) with the exception of alopecia. 
 
3.2.5 Patients with known active central nervous system metastases and/or carcinomatous 
meningitis.  Subjects with previously treated brain metastases may participate if they are 
stable, and have no evidence of new or enlarging brain metastases for at least 3 months, 
and are not using steroids for at least 7 days prior to trial treatment. 
 
3.2.6 Patients with an active autoimmune disease requiring systemic treatment within the past 3 
months or a documented history of clinically severe autoimmune disease, or a syndrome 
that requires systemic steroids or immunosuppressive agents.  Subjects with vitiligo or 
resolved childhood asthma/atopy would be an exception to this rule.  Subjects that require 
intermittent use of bronchodilators or local steroid injections would not be excluded from 
the study.  Subjects with hypothyroidism stable on hormone replacement or Sjorgen’s 
syndrome will not be excluded from the study. 
 
3.2.7 Patients with a history of (non-infectious) pneumonitis that required steroids or has a 
current diagnosis of pneumonitis. 
 
3.2.8 Patients with an active infection requiring systemic therapy. 
 
3.2.9 Patients with an allergy to fish, shellfish, or omega-3 unsaturated fatty acid. 
 
3.2.10 Patients who received a live vaccine within 30 days prior to the first dose of trial 


NCI Protocol #: 10480 
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26 
treatment. 
 
3.2.11 Patients receiving concurrent anti-cancer therapy for metastatic disease. 
 
3.2.12 Patients with uncontrolled intercurrent illness judged by the investigator to be unsafe for 
trial participation. 
 
 
3.2.13 Pregnant women are excluded from this study because Dasatinib is a protein tyrosine 
kinase (PTK) inhibitor agent with the potential for teratogenic or abortifacient effects.  
Because there is an unknown but potential risk for adverse events in nursing infants 
secondary to treatment of the mother with Dasatinib, breastfeeding should be 
discontinued if the mother is treated Dasatinib.  These potential risks may also apply to 
other agents used in this study. 
 
3.2.14 Patients with severe hypertriglyceridemia (>300 mg/dL -500 mg/dL) are at an unknown 
risk of developing pancreatitis following icosapent ethyl treatment. 
 
3.2.15 Patients with diabetes who are being treated with insulin.  Patients with oral medication 
and showing stable HbA1c <7% for the last three months will be eligible.  
 
3.2.16 Patients who require concurrent treatment with any medications or substances that are 
potent inhibitors or inducers of CYP3A4 are ineligible.  (See Appendix G for lists of 
specifically prohibited medications or substances.)  Efforts should be made to switch 
patients with gliomas or brain metastases who are taking enzyme-inducing anticonvulsant 
agents to other medications.  Patients who are on H2 blockers and proton pump inhibitors 
are ineligible. 
 
Because the lists of these agents are constantly changing, it is important to regularly 
consult a frequently-updated list such as 
http://medicine.iupui.edu/clinpharm/ddis/table.aspx; medical reference texts such as the 
Physicians’ Desk Reference may also provide this information.  As part of the 
enrollment/informed consent procedures, the patient will be counseled on the risk of 
interactions with other agents, and what to do if new medications need to be prescribed or 
if the patient is considering a new over-the-counter medicine or herbal product.   
 
3.2.17 Use of antithrombotic and/or anti-platelet agents (e.g., warfarin, heparin, low molecular 
weight heparin, aspirin, and/or ibuprofen).   
 
3.2.18 Patients with any condition (e.g., gastrointestinal tract disease resulting in an inability to 
take oral medication or a requirement for IV alimentation, prior surgical procedures 
affecting absorption, or active peptic ulcer disease) that impairs their ability to swallow 
and retain dasatinib and icosapent ethyl tablets are excluded. 
 
3.2.19 Patients may not have any clinically significant cardiovascular disease including the 


NCI Protocol #: 10480 
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27 
following: 
x myocardial infarction or ventricular tachyarrhythmia within 6 months 
x prolonged QTc ≥480 msec (Fridericia correction) 
x ejection fraction less than institutional normal 
x major conduction abnormality (unless a cardiac pacemaker is present). 
Patients with any cardiopulmonary symptoms of unknown cause (e.g., shortness of 
breath, chest pain, etc.) should be evaluated by a baseline echocardiogram with or 
without stress test as needed in addition to electrocardiogram (EKG) to rule out QTc 
prolongation.  The patient may be referred to a cardiologist at the discretion of the 
principal investigator.  Patients with underlying cardiopulmonary dysfunction should be 
excluded from the study. 
 
3.3 
Inclusion of Women and Minorities 
 
NIH policy requires that women and members of minority groups and their subpopulations be 
included in all NIH-supported biomedical and behavioral research projects involving NIH-
defined clinical research unless a clear and compelling rationale and justification establishes to 
the satisfaction of the funding Institute & Center (IC) Director that inclusion is inappropriate 
with respect to the health of the subjects or the purpose of the research.  Exclusion under other 
circumstances must be designated by the Director, NIH, upon the recommendation of an IC 
Director based on a compelling rationale and justification.  Cost is not an acceptable reason for 
exclusion except when the study would duplicate data from other sources.  Women of 
childbearing potential should not be routinely excluded from participation in clinical research.  
Please see http://grants.nih.gov/grants/funding/phs398/phs398.pdf. 
 
4. 
REGISTRATION PROCEDURES 
 
4.1 
Investigator and Research Associate Registration with CTEP 
 
Food and Drug Administration (FDA) regulations and National Cancer Institute (NCI) policy 
require all individuals contributing to NCI-sponsored trials to register and to renew their 
registration annually.  To register, all individuals must obtain a Cancer Therapy Evaluation 
Program (CTEP) Identity and Access Management (IAM) account at 
https://ctepcore.nci.nih.gov/iam.  In addition, persons with a registration type of Investigator 
(IVR), Non-Physician Investigator (NPIVR), or Associate Plus (AP) must complete their annual 
registration using CTEP’s web-based Registration and Credential Repository (RCR) at 
https://ctepcore.nci.nih.gov/rcr.    
 
RCR utilizes five person registration types. 
x IVR:  MD, DO, or international equivalent, 
x NPIVR:  advanced practice providers (e.g., NP or PA) or graduate level researchers (e.g., 
PhD), 
x AP:  clinical site staff (e.g., RN or CRA) with data entry access to CTSU applications 
such as the Roster Update Management System (RUMS), OPEN, Rave, acting as a 
primary site contact, or with consenting privileges, 


NCI Protocol #: 10480 
Version Date:  December 13, 2022 
 
28 
x Associate (A):  other clinical site staff involved in the conduct of NCI-sponsored trials, 
and 
x Associate Basic (AB):  individuals (e.g., pharmaceutical company employees) with 
limited access to NCI-supported systems. 
 
RCR requires the following registration documents: 
 
Documentation Required 
IVR NPIVR AP 
A 
AB 
FDA Form 1572 
✔ 
✔ 
 
 
 
Financial Disclosure Form 
✔ 
✔ 
✔ 
 
 
NCI Biosketch (education, training, employment, license, 
and certification) 
✔ 
✔ 
✔ 
GCP training 
✔ 
✔ 
✔ 
Agent Shipment Form (if applicable) 
✔ 
CV (optional) 
✔ 
✔ 
✔ 
 
An active CTEP-IAM user account and appropriate RCR registration is required to access all 
CTEP and Cancer Trials Support Unit (CTSU) websites and applications.  In addition, IVRs and 
NPIVRs must list all clinical practice sites and Institutional Review Boards (IRBs) covering their 
practice sites on the FDA Form 1572 in RCR to allow the following: 
 
x Addition to a site roster, 
x Assign the treating, credit, consenting, or drug shipment (IVR only) tasks in OPEN, 
x Act as the site-protocol Principal Investigator (PI) on the IRB approval, and 
x Assign the Clinical Investigator (CI) role on the Delegation of Tasks Log (DTL).  
 
In addition, all investigators acting as the Site-Protocol PI (Investigator listed on the IRB 
approval), consenting/treating/drug shipment investigator in OPEN, or as the Clinical 
Investigator (CI) on the DTL must be rostered at the enrolling site with a participating 
organization.  
 
Additional information is located on the CTEP website at 
https://ctep.cancer.gov/investigatorResources/default.htm.  For questions, please contact the 
RCR Help Desk by email at RCRHelpDesk@nih.gov. 
 
4.2 
Site Registration 
 
This study is supported by the NCI Cancer Trials Support Unit (CTSU). 
 
IRB Approval   
 
Sites participating with the NCI Central Institutional Review Board (NCI CIRB) must submit the 
Study Specific Worksheet (SSW) for Local Context to the CIRB using IRBManager to indicate 
their intent to open the study locally.  The NCI CIRB’s approval of the SSW is automatically 
communicated to the CTSU Regulatory Office, but sites are required to contact the CTSU 


NCI Protocol #: 10480 
Version Date:  December 13, 2022 
 
29 
Regulatory Office at CTSURegPref@ctsu.coccg.org to establish site preferences for applying 
NCI CIRB approvals across their Signatory Network.  Site preferences can be set at the network 
or protocol level.  Questions about establishing site preferences can be addressed to the CTSU 
Regulatory Office by email or calling 1-888-651-CTSU (2878). 
 
In addition, the Site-Protocol PI (i.e., the investigator on the IRB/REB approval) must meet the 
following criteria to complete processing of the IRB/REB approval record to be completed: 
x Holds an active CTEP status, 
x Active status at the site(s) on the IRB/REB approval (applies to US and Canadian sites 
only) on at least one participating organization’s roster, 
x If using NCI CIRB, active on the NCI CIRB roster under the applicable CIRB Signatory 
Institution(s) record, 
x Includes the IRB number of the IRB providing approval in the Form FDA 1572 in the 
RCR profile,  
x Lists all sites on the IRB/REB approval as Practice Sites in the Form FDA 1572 in the 
RCR profile; and 
x Holds the appropriate CTEP registration type for the protocol.  
 
Additional Requirements 
 
Additional site requirements to obtain an approved site registration status include: 
x An active Federalwide Assurance (FWA) number, 
x An active roster affiliation with the Lead Protocol Organization (LPO) or a Participating 
Organization (PO),  
x An active roster affiliation with the NCI CIRB roster under at least one CIRB Signatory 
Institution (US sites only); and 
x Compliance with all protocol-specific requirements (PSRs). 
 
4.2.1 Downloading Site Registration Documents 
 
Download the site registration forms from the protocol-specific page located on the CTSU 
members’ website.  Permission to view and download this protocol and its supporting documents 
is restricted to insitutions and its associated investigators and staff on a participating roster.  To 
view/download site registration forms:  . 
 
x Log in to the CTSU members’ website (https://www.ctsu.org) using your CTEP-IAM 
username and password, 
x Click on Protocols in the upper left of the screen 
o Enter the protocol number in the search field at the top of the protocol tree, or 
o Click on the By Lead Organization folder to expand, then select LAO-TX035, and 
protocol number 10480, 
x Click on Documents, Protocol Related Documents, and use the Document Type filter and 
select Site Registration, to download and complete the forms provided.  (Note:  For sites 
under the CIRB, IRB data will load automatically to the CTSU.)  
 


NCI Protocol #: 10480 
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30 
4.2.2 Protocol Specific Requirements For #10480 Site Registration 
 
x Specimen Tracking System Training Requirement: 
o All data entry users (Clinical Research Associate role) at each participating site will 
need to complete the Theradex-led training. 
o Theradex will provide a certificate of completion, which will need to be submitted to 
the CTSU through the Regulatory Submission Portal. 
o The training is a one-time only requirement per individual.  If an individual has 
previously completed the training for another ETCTN study, the training does not 
need to be completed again nor does the certificate of completion need to be 
resubmitted to the CTSU.  However, new versions of the Specimen Tracking System 
may require new training. 
o This training will need to be completed before the first patient enrollment at a given 
site. 
o Please contact STS Support at Theradex for the training 
(STS.Support@theradex.com, Theradex phone: 609-799-7580). 
 
4.2.3 Submitting Regulatory Documents 
 
Submit required forms and documents to the CTSU Regulatory Office using the Regulatory 
Submission Portal on the CTSU members’ website.  
 
To access the Regulatory Submission Portal, log on to the CTSU members’ website, go to the 
Regulatory section, and select Regulatory Submission. 
 
Institutions with patients waiting that are unable to use the Regulatory Submission Portal should 
alert the CTSU Regulatory Office immediately by phone or email: 1-866-651-CTSU (2878), or 
CTSURegHelp@coccg.orgin order to receive further instruction and support. 
 
Delegation of Tasks Log (DTL) 
 
Each site must complete a protocol-specific DTL using the DTL application in the Delegation 
Log section on the CTSU members’ website.  The Clinical Investigator (CI) is required to review 
and electronically sign the DTL prior to the site receiving an approved site registration status and 
enrolling patients to the study.  To maintain an approved site registration status the CI must re-
sign the DTL at least annually and when a new version of the DTL is released; and activate new 
task assignments requiring CI sign-off.  Any individual at the enrolling site on a participating 
roster may initiate the site DTL.  Once the DTL is submitted for CI approval, only the designated 
DTL Administrators or the CI may update the DTL.  Instructions on completing the DTL are 
available in the Help Topics button in the DTL application and include a Master Task List, 
which describes DTL task assignments, CI signature, and CTEP registration requirements. 
 
The individual initiating the DTL for the site should upload the above listed training 
documentation when making the task assignment.  The designated reviewer will accept or reject 
the documentation.  A note regarding rejection of any training documents will display on the Site 
DTL Browser next to the task assignment.  The DTL cannot be submitted for CI sign-off until 


NCI Protocol #: 10480 
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31 
the minimum number of persons are assigned to the task and have met the training requirements.   
 
4.2.4 Checking Site Registration Status 
 
Site’s registration status may be verified on the CTSU website.  
 
x Click on Regulatory at the top of the screen, 
x Click on Site Registration, and  
x Enter the site’s 5-character CTEP Institution Code and click on Go. 
o Additional filters are available to sort by Protocol, Registration Status, Protocol 
Status, and/or IRB Type. 
 
 
Note:  The status shown only reflects institutional compliance with site registration requirements 
as outlined within the protocol.  It does not reflect compliance with protocol requirements for 
individuals participating on the protocol or the enrolling investigator’s status with NCI or their 
affiliated networks. 
 
4.3 
Patient Registration 
 
4.3.1 OPEN / IWRS 
 
The Oncology Patient Enrollment Network (OPEN) is a web-based registration system available 
on a 24/7 basis.  OPEN is integrated with CTSU regulatory and roster data and with the LPOs 
registration/randomization systems or the Theradex Interactive Web Response System (IWRS) 
for retrieval of patient registration/randomization assignment.  OPEN or IWRS will populate the 
patient enrollment data in NCI’s clinical data management system, Medidata Rave. 
 
Requirements for OPEN access:   
 
x A valid CTEP-IAM account. 
x To perform enrollments or request slot reservations:  Must be on an LPO roster, ETCTN 
corresponding roster, or PO roster with the role of Registrar.  Registrars must hold a 
minimum of an Associate Plus (AP) registration type. 
x If a DTL is required for the study, the registrar must hold the OPEN Registrar task on the 
DTL for the site. 
x Have an approved site registration for the protocol prior to patient enrollment. 
 
To assign an Investigator (IVR) or Non-Physician Investigator (NPIVR) as the treating, 
crediting, consenting, drug shipment (IVR only), or receiving investigator for a patient transfer in 
OPEN, the IVR or NPIVR must list the IRB number used on the site’s IRB approval on their 
Form FDA 1572 in RCR.  If a DTL is required for the study, the IVR or NPIVR must be 
assigned the appropriate OPEN-related tasks on the DTL. 
 
Prior to accessing OPEN, site staff should verify the following: 
 


NCI Protocol #: 10480 
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32 
x Patient has met all eligibility criteria within the protocol stated timeframes, and  
x All patients have signed an appropriate consent form and Health Insurance Portability 
and Accountability Act (HIPAA) authorization form (if applicable). 
 
Note:  The OPEN system will provide the site with a printable confirmation of registration and 
treatment information.  IWRS system also sends an email confirmation of the registration.  You 
may print this confirmation for your records.  
 
Access OPEN at https://open.ctsu.org or from the OPEN link on the CTSU members’ website.  
Further instructional information is in the OPEN section of the CTSU website at 
https://www.ctsu.org or https://open.ctsu.org.  For any additional questions, contact the CTSU 
Help Desk at 1-888-823-5923 or ctsucontact@westat.com. 
 
Patient enrollment for this study will be facilitated using the Slot Reservation System in 
conjunction with the registration system in OPEN.  Prior to discussing protocol entry with the 
patient, all site staff must use the CTSU OPEN Slot Reservation System or the IWRS Slot 
Reservation System to ensure that a slot on the protocol is available to the patient.  Once a slot 
reservation confirmation is obtained, site staff may then proceed to enroll the patient to this 
study.  
 
4.3.2 Special Instructions for Patient Enrollment 
 
This Study will use the ETCTN Specimen Tracking System (STS).  
 
x All biospecimens collected for this trial must be submitted using the ETCTN Specimen 
Tracking System (STS) unless otherwise noted.   
x The system is accessed through Rave user roles:  “Rave CRA” and “Rave CRA 
(Labadmin)” for data entry at the treating institutions and “Biorepository” for users 
receiving the specimens for processing and storage at reference labs and the NCI Early-
Phase and Experimental Clinical Trials Biospecimen Bank (EET Biobank, formerly 
known as the ETCTN Biorepository).   
x Please refer to the Medidata Account Activation and Study Invitation Acceptance link on 
the CTSU website in the Data Management section under the Rave Home tab and then 
under Rave Resource Materials. 
x Important:  Failure to complete required fields in STS may result in a delay in 
sample processing.  Any case reimbursements associated with sample submissions will 
not be credited if samples requiring STS submission are not logged into STS. 
 
Detailed instructions on use of the STS can be found in Section 5.4. 
 
4.3.3 OPEN/IWRS Questions? 
 
Further instructional information on OPEN is provided on the OPEN link of the CTSU website 
at https://www.ctsu.org or at https://open.ctsu.org.  For any additional questions contact the 
CTSU Help Desk at 1-888-823-5923 or ctsucontact@westat.com.  
 


NCI Protocol #: 10480 
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33 
Theradex has developed a Slot Reservations and Cohort Management User Guide, which is 
available on the Theradex website:  http://www.theradex.com/clinicalTechnologies/?National-
Cancer-Institute-NCI-11. This link to the Theradex website is also on the CTSU website OPEN 
tab. For questions about the use of IWRS for slot reservations, contact the Theradex Helpdesk at 
855-828-6113 or Theradex main number 609-799-7580; CTMSSupport@theradex.com. 
 
4.4 
General Guidelines 
 
Following registration, patients should begin protocol treatment within 30 days.  Issues that 
would cause treatment delays should be discussed with the Principal Investigator.  If a patient 
does not receive protocol therapy following registration, the patient’s registration on the study 
may be canceled.  The Study Coordinator should be notified of cancellations as soon as possible. 
 
5. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
5.1 
Summary Table for Specimen Collection 
 
Time Point 
Specimen 
Send Specimens To: 
Baseline 
Phase 
1b 
and 
Phase 2 
x 1 tissue cores snap frozen (mandatory)1 
x 1 tissue core in formalin (mandatory)1 
x 20 mL blood in a red top tube, processed 
for serum and frozen (mandatory)  
EET Biobank 
 
 
x 1 fresh tissue core in X-VIVO™ 15 media 
(mandatory) 
x 1 tissue core snap frozen (mandatory)1 
Chapkin laboratory, Texas 
A&M University 
After completion of Cycle 2 (± 2 days) 
Phase 1b and 
Phase 2 
x 1 tissue cores snap frozen (mandatory)1 
x 1 tissue core in formalin (mandatory)1 
x 20 mL blood in a red top tube, processed 
for serum and frozen (mandatory) 
EET Biobank 
 
x 1 fresh tissue core in X-VIVO™ 15 media 
(mandatory) 
x 1 tissue core snap frozen (mandatory)1 
Chapkin laboratory, Texas 
A&M University 
1 For new biopsies, the Tissue Biopsy Verification Form (Appendix F), a copy of the 
radiology and/or operative reports from the tissue removal procedure and the diagnostic 
anatomic pathology report must be sent with the tissue to the EET Biobank. 
 
5.2 
Summary Tables for Interventional Radiologist for Research Biopsies 
 
Biopsy #:  1 
Trial Time Point:  Baseline 
IR Biopsy Definition:  Research – No Clinical Impact (All cores from a single biopsy 
procedure impact research goals, but do not directly impact patient care or benefit the patient). 


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34 
Core 
Priority 
Use in the 
Trial 
Biomarker 
Name(s) 
Tumor Content 
Required 
Post-Biopsy Processing 
1 
Integrated 
Apoptosis 
Multiplex 
Immunoassay, 
Luminex  
25-50% 
Fresh frozen 
2 
Exploratory 
Cholesterol 
homeostasis 
in cell 
membrane 
25-50% 
Fresh frozen 
3 
Exploratory 
DNA 
fragmentation, 
ABCA1, 
EphA2,  
Ki67 
25-50%  
Formalin 
4 
Exploratory 
Membrane 
rigidity 
25-50%  
Fresh in X-VIVO™ 15 media  
 
Biopsy #:  2 
Trial Time Point:  After completion of Cycle 2 (± 2 days) 
IR Biopsy Definition:  Research – No Clinical Impact (All cores from a single biopsy 
procedure impact research goals, but do not directly impact patient care or benefit the patient). 
Core 
Priority 
Use in the 
Trial 
Biomarker 
Name(s) 
Tumor 
Content 
Required 
Post-Biopsy Processing 
1 
Integrated 
Apoptosis 
Multiplex 
Immunoassay, 
Luminex  
25-50%  
Fresh frozen 
2 
Exploratory 
Cholesterol 
homeostasis in 
cell membrane 
25-50%  
Fresh frozen 
3 
Exploratory 
DNA 
fragmentation, 
ABCA1, 
EphA2,  
Ki67 
25-50% 
Formalin 
4 
Exploratory 
Membrane 
rigidity 
25-50% 
Fresh in X-VIVO™ 15 media 
 
Note:  Pre-biopsy assessments will be reported and tracked through a trial-specific Case Report 
Form (CRF) within the CTEP Medidata Rave system (see Appendix E).  
 
5.3 
Specimen Procurement Kits and Scheduling 
 


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35 
5.3.1 Specimen Procurement Kits  
 
Kits for the collection and shipment of tissue cores to the EET Biobank can be ordered online via 
the Kit Management system: (https://kits.bpc-apps.nchri.org).  
 
Users at the clinical sites will need to set up an account in the Kit Management system and select 
a specific clinical trial protocol to request a kit.  Please note that protocol may include more than 
one type of kit.  Each user may order two kits per kit type per day (daily max = 6 kits).  Kits are 
shipped ground, so please allow 5-7 days for receipt.  A complete list of kit contents for each kit 
type is located on the Kit Management system website. 
 
Note:  Kits or supplies are only provided for specimens shipped to the EET Biobank. 
Institutional supplies must be used for all other specimen collection and processing.  
 
5.3.2 Scheduling of Specimen Collections 
 
Please adhere to the following guidelines when scheduling procedures to collect tissue:  
x Tumor tissue specimens collected during biopsy procedures and fixed in formalin must 
be shipped on the same day of collection. 
 
x Tissue in formalin can be collected Monday through Wednesday and shipped overnight 
for arrival on Tuesday through Thursday at the EET Biobank at Nationwide Children’s 
Hospital. 
 
x Frozen tissue and serum can be collected on any day but must be stored frozen and 
shipped to the EET Biobank on Monday through Thursday.  In the event that frozen 
specimens cannot be shipped immediately, they must be maintained in a -70°C to -80°C 
freezer. 
 
 
5.4 
Specimen Tracking System Instructions 
 
5.4.1 Specimen Tracking System Overview and Enrollment Instructions 
 
For the ETCTN STS, the following information will be requested: 
x Protocol Number 
x Investigator Identification  
o Institution and affiliate name 
o Investigator’s name 
x Eligibility Verification:  Patients must meet all the eligibility requirements listed in 
Section 3. 
x Additional Requirements: 
o Patients must provide a signed and dated, written informed consent form. 
 
Upon enrolling a patient, IWRS will communicate with OPEN, assigning two separate and 
unique identification numbers to the patient, a Universal patient ID (UPID) and a Treatment 


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36 
patient ID.  The UPID is associated with the patient and used each and every time the patient 
engages with the portion of this or any other protocol that uses the ETCTN Specimen Tracking 
System.  The UPID contains no information or link to the treatment protocol.  IWRS will 
maintain an association between the UPID for ETCTN biobanking and molecular 
characterization and any treatment protocols the patient participates in, thereby allowing analysis 
of the molecular characterization results with the clinical data.   
 
Immediately following enrollment, the institutional anatomical pathology report for the diagnosis 
under which the patient is being enrolled must be uploaded into Rave.  The report must include 
the surgical pathology ID (SPID), collection date, block number, and the IWRS-assigned UPID 
and patient study ID for this trial.  For newly acquired biopsies, the radiology and operative 
report(s) must also be uploaded into Rave.  Important:  Remove any personally identifying 
information, including, but not limited to, the patient’s name, date of birth, initials, medical 
record number, and patient contact information from the institutional pathology report 
prior to submission. 
 
Additionally, please note that the STS software creates pop-up windows when reports are 
generated, so you will need to enable pop-ups within your web browser while using the software.   
 
For questions regarding the Specimen Tracking System, please contact STS Support at 
STS.Support@theradex.com. 
 
The Shipping List report must be included with all sample submissions. 
 
5.4.2 Specimen Labeling 
 
5.4.2.1 Blood Specimen Labels  
 
Include the following on blood specimens (including whole blood and frozen, processed blood 
products – like serum and plasma: 
x Patient Study ID 
x Universal Patient ID (UPID) 
x Specimen ID (automatically generated by Rave) 
x Time point 
x Specimen type (e.g., blood, serum) 
x Collection date (to be added by hand) 
 
5.4.2.2 Tissue Specimen Labels  
 
Include the following on all tissue specimens (e.g., frozen tissue) or containers (e.g., formalin 
jar):  
x Patient Study ID 
x Universal Patient ID (UPID) 
x Specimen ID (automatically generated by Rave)s 
x Time point 


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x
Specimen type (e.g., Formalin Fixed Tissue, Fresh Frozen Tissue, etc.)
x
Tissue type (P for primary, M for metastatic or N for normal)
x
Surgical pathology ID (SPID) number (when applicable)
x
Collection date (to be added by hand)
5.4.2.3
Example of Specimen Label Generated by STS
STS includes a label printing facility, accessed via the Print Label CRF in the All Specimens 
folder. A generated PDF is emailed to the user as a result of saving that form. 
The following image is an example of a tissue specimen label printed on a label that is 0.5” high 
and 1.28” wide.
The QR code in the above example is for the Specimen ID shown on the second line.  
Labels may be printed on a special purpose label printer, one label at a time, or on a standard 
laser printer, multiple labels per page. Theradex recommends the use of these low temperature 
waterproof labels for standard laser printers: https://www.labtag.com/shop/product/cryo-laser-
labels-1-28-x-0-5-cl-23-colors-available/
The last line item on the label includes the following data points joined together:
1. Tissue only: Primary (P), Metastatic (M), Normal (N) tissue indicated at the 
beginning of the specimen ID; this field is blank if not relevant (e.g., for blood)
2. Block ID or blank if not relevant
3. SPID (Surgical Pathology ID) or blank if none
4. An optional alpha-numeric code that is protocol specific and is only included if the 
protocol requires an additional special code classification
Space is provided at the bottom of the label for the handwritten date and optional time.  
The last line on the example label is for the handwritten date and optional time.
5.4.3
Overview of Process at Treating Site


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5.4.3.1 OPEN Registration 
 
All registrations will be performed using the Oncology Patient Enrollment Network (OPEN) 
system.  OPEN communicates automatically with the Interactive Web Response System (IWRS) 
which handles identifier assignments, any study randomization, and any prescribed slot 
assignments.  If specimen analysis is required to determine eligibility, the protocol will be setup 
with multi-step registration. 
 
Registration without eligibility specimen analysis:  
 
1. Site enters registration data into OPEN during one or more steps. 
2. IWRS receives data from OPEN, generates the Patient Study ID and the Universal Patient 
ID, both of which are sent back to OPEN. 
3. IWRS sends all applicable registration data directly to Rave at the end of the final 
registration step. 
 
 
5.4.3.2 Rave Specimen Tracking Process Steps 
 
Step 0: Log into Rave via your CTEP-IAM account, then navigate to the appropriate participant. 
 
Step 1:  Complete the Histology and Disease form (but do not upload reports until a specimen 
label can be applied to them) and the Baseline forms regarding Prior Therapies.  Enter the 
initial clinical specimen data:  
x Specimen Tracking Enrollment CRF:  Enter Time Point, Specimen Category, 
Specimen Type, Block number, Tissue type, Surgical Path ID, and number of labels 
needed (include extra labels to apply to reports to be uploaded).  CRF generates unique 
Specimen ID.  
 
Step 2:  Print labels using the Print Labels CRF located in the All Specimens folder, then 
collect specimen. 
x Label specimen containers and write collection date on each label.  After collection, store 
labeled specimens as described in Section 5.5. 
x Apply an extra specimen label to each report before scanning.  Return to the Histology 
and Disease form to upload any initial Pathology, Radiology, Molecular Reports (up to 
4), and Surgical (or Operative) reports.  Return to Specimen Tracking Enrollment CRF 
to upload any molecular report (one per specimen) and/or specimen specific pathology or 
related report (one per specimen) and/or the Tissue Biopsy Verification form (when 
applicable).  Uploaded reports should have protected health information (PHI) data, like 
name, date of birth, mailing address, medical record number or social security number 
(SSN), redacted.  Do not redact SPID, block number, diagnosis or relevant dates 
(such as collection date), and include the UPID and patient study ID on each 
document (either by adding a label or hand writing).  
 
Step 3:  Complete specimen data entry. 


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x Specimen Transmittal Form:  Enter collection date and time and other required 
specimen details. 
 
Step 4:  When ready to ship, enter shipment information. 
x Shipping Status CRF:  Enter tracking number, your contact information, recipient, 
number of sample containers and ship date once for the first specimen in a shipment. 
x Copy Shipping CRF:  In the specimen folders for additional specimens (if any) that will 
be shipped with the initial specimen, please use the Copy Shipping form to derive 
common data into additional Shipping Status forms. A few unique fields will still need 
to be entered in Shipping Status.   
Step 5:  Print shipping list report and prepare to ship.  
x Shipping List report is available at the site level. 
x Print two copies of the shipping list, one to provide in the box, the other for your own 
records. 
x Print pathology or other required reports to include in the box.  Be sure the printed copy 
includes the specimen label. 
 
Step 6:  Send email notification.  
x For only one of the specimens in the shipment, click “Send Email Alert” checkbox on the 
Shipping Status CRF to email recipient. 
 
Step 7:  Ship the specimen(s). 
 
Step 8: Monitor the Receiving Status form located in each specimen folder for acknowledgment 
of receipt and adequacy. 
 
5.5 
Specimen Collection  
 
Proper tissue embedding and orientation are necessary in order to support the sample and prevent 
tissue damage or loss during sectioning (as well as preserve diagnostic histological features). 
Improperly embedded tissue (e.g., needle cores) can provide incomplete information if 
diagnostic material is not properly sectioned in a timely manner. Improper orientation of certain 
samples (e.g., skin tumors) can prevent the evaluation of histological features that may affect 
survival or recurrence, like depth of tumor invasion and involvement of surgical margins of 
resection. In order to prevent tissue embedding and orientation errors, refer to the guidelines in 
Appendix I. 
 
5.5.1 Fresh Tumor Biopsies 
 
1. Label 2OZ sterile specimen container (Cat. 14-375-152C, Fisher Scientific) according to 
instructions in Section 5.4.2. 
2. Fill with 50 ml of X-VIVO™ 15 Chemically Defined, Serum-free Hematopoietic Cell 
Medium (Cat. 04-744Q, Lonza). 
3. Obtain 2 16-gauge or 18-gauge core needle biopsy specimens, and transfer to containers. 
4. Secure the container lids and package containers into the shipping kit according to 


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instructions in Section 5.7.  Keep containers at cold temperature by ice-pack until 
shipment to the Dr. Chapkin’s lab via FEDEX overnight shipping.  
 
5.5.2 Formalin-Fixed Tumor Biopsies  
 
1. Label formalin-filled containers according to instructions in Section 5.4.2.  
2. Obtain one 16-gauge or 18-gauge core needle biopsy specimens, and place one core in 
each cassette.  
3. Snap the cassette lids closed and place cassettes into a formalin-filled pre-labeled 
container as soon as possible after collection to prevent air drying.  Up to two cassettes 
may be placed in one formalin jar. 
4. Secure the container lids and package containers into the shipping kit according to 
instructions in Section 5.6.  Keep tissue in formalin jars at room temperature until 
shipment to the EET Biobank.  
 
5.5.3 Collection of Snap-Frozen Biopsies 
 
1. Follow step 5.3.1 to request specimen procurement kits for frozen sample collection 
before scheduled biopsy collection. 
2. Biopsy specimens should be collected into pre-chilled 1.5mL Sarstedt, O-ring screw cap 
tubes (VWR, Cat#: 83009-010).  
a. Label Sarstedt tube(s) according to instructions in Section 5.4.2, prior to pre-
chilling. 
3. It is imperative that biopsies are flash frozen within 2 minutes of collection in order to 
preserve key pharmacodynamic biomarkers. 
4. As described in Appendix H, place the tissue in a pre-chilled cryovial and freeze the tube 
in liquid nitrogen or dry ice/ethanol bath.  Keep frozen at -80 ºC or lower until shipment 
to the EET Biobank. 
 
Sites are strongly encouraged to contact the NCLN PD Laboratory at 
NCI_PD_Support@mail.nih.gov to initiate training and clarify biopsy collection procedure.  
 
5.5.4 Blood Collection  
 
5.5.4.1 Collection of Blood in Red Top Tube for Serum Processing 
 
1. Label two 10 mL red-top tubes according to the instructions in Section 5.4.2.  
2. Collect 20 mL of blood in red-top tubes.  
3. Gently invert the tube 8-10 times and allow blood to clot upright at room temperature for 
at least 30 minutes (maximum 60 minutes) prior to processing.  If the blood is not 
immediately processed after the clotting period, then tubes should be stored (after the 30-
60 minutes of clotting time) at 4°C for no longer than 4 hours.  Process serum from red 
top tubes by centrifuging for 10 minutes at 1,200 × g at room temperature. 
4. Using a clean transfer pipette, aliquot serum into the labeled (using the label printed 
from the ETCTN Specimen Tracking System or following the instructions in Section 
5.4.2) cryovials at an aliquot volume of 1 mL per tube.  Collect from the middle of the 


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41 
plasma layer to avoid picking up red blood cells when aliquoting, keeping the pipet above 
the red blood cell layer and leaving a small amount of serum in the tube.  Tightly secure 
the cap of the vials before storage.  Aliquoting and freezing of serum specimens should 
be completed within 1 hour of centrifugation. 
5. Store serum cryovials upright in a specimen box or rack in an -70°C to -90°C or colder 
freezer prior to delivering to laboratory.  Do not allow specimens to thaw after freezing. 
 
5.6 
Shipping Specimens from Clinical Site to the EET Biobank  
 
5.6.1 General Shipping Information 
 
When kits are provided, the shipping container sent with kit contents should be used to ship 
specimens to the EET Biobank.  In winter months, please include extra insulation, such as bubble 
wrap, inside the shipping container with the ambient specimens. 
 
5.6.1.1 Required Forms for Specimen Submissions: 
 
Each document submitted with the specimen must be labeled with a label printed from the 
STS, or the Universal ID and Patient Study ID.  
 
Tissue  
Required Forms 
New Biopsy 
1. Shipping List 
2. Tissue Biopsy Verification Form 
3. Diagnostic Pathology Report  
4. Surgical and/or Radiology Report 
Serum 
1. Shipping List 
 
5.6.2 Specimen Shipping Instructions 
 
Tissue in formalin must be shipped on the day of collection.  Collect and ship on Monday 
through Wednesday. 
 
Frozen specimens may be shipped on Monday through Thursday.  
 
5.6.2.1 Shipping Frozen and Ambient Specimens in a Dual-Chamber Kit  
 
The Dual Chambered Specimen Procurement Kit is constructed to allow the shipment of frozen 
(on dry ice) and ambient (room temperature) specimens in the same container.  Dry ice may be 
placed in either compartment of the kit but should not be put in both.  The dual chambered 
kit is only used for shipments that contain both frozen and ambient specimens.  If formalin-fixed 
tissue is shipped separately (not in the same shipment as frozen specimens), then it must be 
shipped using institutional shipping supplies.    
 


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42 
Supplies for the collection of frozen serum are not provided, but serum may be shipped to the 
EET Biobank in the kit with the tissue cores. 
 
1. Before packaging specimens, verify that each specimen is labeled according to the 
instructions in 5.4.2 and that lids of all primary receptacles containing liquid are tightly 
sealed.  
2. Pre-fill one of the kit chambers about 1/3 with dry ice. 
3. Prepare the frozen specimens for shipment: 
a. Place the specimens into zip-lock bags.  
b. Place the zip-lock bags into a biohazard envelope containing absorbent material.  
Expel as much air as possible before sealing the biohazard envelope. 
c. Put each biohazard envelope into a Tyvek envelope.  Expel as much air as possible 
and then seal the Tyvek envelope. 
4. Quickly place the Tyvek envelope containing frozen specimens in the kit compartment 
that is pre-filled with dry ice.  Place the Tyvek envelope on top of the dry ice.  Cover the 
specimens with additional dry ice until the compartment is almost completely full.   
5. Place the Styrofoam lid on top to secure specimens during shipment.  Do not tape the 
inner chamber shut. 
6. Prepare the ambient specimens for shipment: 
a. Seal the lids of the formalin jars with parafilm.  Place absorbent material around 
the primary container of each liquid specimen.  Place the specimens into zip-lock 
bags. 
b. Place specimens inside the secondary pressure vessel with bubble wrap.  
c. Secure the lid on the secondary pressure vessel and set it inside the kit chamber. 
7. Insert a copy of the required forms in the kit chamber with the ambient specimens. 
8. Place the Styrofoam lid on top of the kit compartment to secure specimens during 
shipment.  Do not tape the inner chamber shut. 
9. Close the outer lid of the Specimen Procurement Kit and tape it shut with durable sealing 
tape.  Do not completely seal the container. 
10. Complete a FedEx air bill and attach to top of shipping container. 
11. Complete a dry ice label. 
12. Attach the dry ice label and an Exempt Human Specimen sticker to the side of the 
shipping container. 
13. Ship specimens via overnight courier to the address below.  FedEx Priority Overnight is 
strongly recommended to prevent delays in package receipt.  
 
5.6.3 Shipping Address 
 
Ship to the address below.  Ship formalin-fixed specimens the same day of specimen collection.  
Do not ship specimens the day before a holiday. 
 
EET Biobank 
The Research Institute at Nationwide Children's Hospital 
700 Children's Drive, WA1340 
Columbus, Ohio 43205 
PH: (614) 722-2865 


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43 
FAX: (614) 722-2897 
E-mail: BPCBank@nationwidechildrens.org 
 
FedEx Priority Overnight service is very strongly preferred.   
 
NOTE:  The EET Biobank FedEx Account will not be provided to submitting institutions. There 
is no central Courier account for this study.  Sites are responsible for the cost of shipments to the 
EET Biobank. 
 
5.6.4 Contact Information for Assistance 
 
For all queries, please use the contact information below: 
 
EET Biobank  
Toll-free Phone: (800) 347-2486 
E-mail:  BPCBank@nationwidechildrens.org 
 
5.7 
Shipping of Specimens from Clinical Site to Other Laboratories  
 
5.7.1 Shipping of Specimens to Chapkin laboratory, Texas A&M University  
 
5.7.1.1 Specimen Shipping Instructions 
 
Containers in the shipping kits should be kept at cold temperature by ice-pack until shipment to 
the Chapkin laboratory via FEDEX overnight shipping. 
 
5.7.1.2 Shipping Address 
 
Department of Biochemistry and Biophysics, Texas A&M University 
Attn: Dr. Robert Chapkin 
Dept of Nutrition 
373 Olsen Blvd., 112 Cater-Mattil Hall; 2253 TAMU 
College Station, TX 77843 
Texas A&M University 
Tel: 979.845.0419 |  
Fax: 979.458.3129 
E-mail: r-chapkin@tamu.edu 
 
5.7.1.3 Contact Information for Assistance 
 
Dr. Robert Chapkin 
Tel: 979.845.0419 |  
Fax: 979.458.3129 
E-mail: r-chapkin@tamu.edu 
 


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5.8 
Biomarker Plan  
 
 


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45 
List of Biomarker Assays in Order of Priority 
Note for participating sites: Please see Section 5.1 for details on specimens to collect.  The specimens tested are not always the 
same specimens that are submitted by the site, as processing of blood and tissue will occur at the Biobank prior to testing.  
Priority 
Biomarker 
Name 
Assay 
(CLIA:  Y/N) 
Use in the Trial and 
Purpose 
Specimens 
Tested 
Collection Time 
Points 
Mandatory 
or 
Optional 
Assay Laboratory and 
Lab PI 
Tissue-based Biomarkers 
1 
Apoptosis 
Multiplex 
Immunoassay, 
Luminex 
Luminex, 
 
Priority #1: 
Panel 3: BCL-
XL:BAK 
heterodimer, 
cleaved caspase 
3, MCl1:BAK 
heterodimer, 
survivin 
 
If remaining 
tissue: 
 
Panel 1:  BAX, 
BAK, Lamin B 
(Intact and 45 
KDa cleaved 
fragment), 
SMAC 
 
Panel 2: BAD, 
BAX: BCL2 
heterodimer, 
BCL-XL, BIM, 
MCL1  
 
 
 
CLIA:  N 
Integrated 
 
Response assessment 
 
To identify biomarkers 
of response 
Frozen tumor 
tissue from 
primary or 
metastatic site 
Phase 1b and 
Phase 2: 
 
Baseline and after 
completion of 
Cycle 2 (±2 days) 
 
M 
NCLN PD Assay 
Laboratory at Molecular 
Pathology Laboratory 
Network, Inc. 
 
Kate Ferry-Galow 
 
ferrygalowkv@mail.nih.gov  
2 
DNA 
fragmentation  
TUNEL assay 
 
Exploratory 
 
Unstained slides 
from FFPE tumor 
Phase 1b and 
Phase 2: 
M 
Department of Breast 
Medical Oncology, MD 


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Priority 
Biomarker 
Name 
Assay 
(CLIA:  Y/N) 
Use in the Trial and 
Purpose 
Specimens 
Tested 
Collection Time 
Points 
Mandatory 
or 
Optional 
Assay Laboratory and 
Lab PI 
CLIA:  N 
Hypothesis generation 
 
To evaluate 
biomarkers of 
response 
tissue from 
primary or 
metastatic site 
 
Baseline and after 
completion of 
Cycle 2 (±2 days) 
Anderson Cancer Center 
(MDACC) 
 
Jangsoon Lee 
 
jslee@mdanderson.org  
3 
ABCA1 
IHC 
 
CLIA:  N 
Exploratory 
 
Hypothesis generation 
 
To evaluate 
biomarkers of 
response 
Unstained slides 
FFPE from tumor 
tissue from 
primary or 
metastatic site 
Phase 1b and 
Phase 2: 
 
Baseline and after 
completion of 
Cycle 2 (±2 days) 
M 
Department of Pathology, 
MD Anderson Cancer 
Center (MDACC) 
 
Savitri Krishnamurthy 
 
skrishna@mdanderson.org  
4 
EphA2 
IHC 
 
CLIA:  N 
Exploratory 
 
Hypothesis generation 
 
To evaluate 
biomarkers of 
response 
Unstained slides 
from FFPE tumor 
tissue from 
primary or 
metastatic site 
Phase 1b and 
Phase 2: 
 
Baseline and after 
completion of 
Cycle 2 (±2 days) 
M 
Department of Pathology, 
MD Anderson Cancer 
Center (MDACC) 
 
Savitri Krishnamurthy 
 
skrishna@mdanderson.org 
5 
Ki67 
IHC 
 
CLIA:  N 
Exploratory 
 
To evaluate 
biomarkers of 
response 
Unstained slides 
from FFPE tumor 
tissue from 
primary or 
metastatic site 
Phase 1b and 
Phase 2: 
 
Baseline and after 
completion of 
Cycle 2 (±2 days) 
M 
Department of Breast 
Medical Oncology, MD 
Anderson Cancer Center 
(MDACC) 
 
Jangsoon Lee 
 
jslee@mdanderson.org 
6 
Membrane 
rigidity 
Cholesterol 
assay 
 
CLIA:  N 
Exploratory 
 
Hypothesis generation 
 
To identify biomarkers 
of response 
Fresh tumor 
tissue in VIVOTM 
15 media from 
primary or 
metastatic site 
Phase 1b and 
Phase 2: 
 
Baseline and after 
completion of 
Cycle 2 (±2 days) 
M 
Department of 
Biochemistry and 
Biophysics, Texas A&M 
University 
 
Robert S Chapkin 
 
r-chapkin@tamu.edu  


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Priority 
Biomarker 
Name 
Assay 
(CLIA:  Y/N) 
Use in the Trial and 
Purpose 
Specimens 
Tested 
Collection Time 
Points 
Mandatory 
or 
Optional 
Assay Laboratory and 
Lab PI 
7 
Cholesterol 
homeostasis in 
cell membrane 
Cholesterol 
assay 
 
CLIA:  N 
Exploratory 
 
Hypothesis generation 
 
To identify biomarkers 
of response 
Frozen tumor 
tissue from 
primary or 
metastatic site 
Phase 1b and 
Phase 2: 
 
Baseline and after 
completion of 
Cycle 2 (±2 days) 
M 
Department of 
Biochemistry and 
Biophysics, Texas A&M 
University 
 
Robert S Chapkin 
 
r-chapkin@tamu.edu 
Blood-based Biomarkers 
1 
Multiplex 
cytokine panel 
Invitrogen 
Immune 
Monitoring 65-
Plex Human 
ProcartaPlex™ 
Panel 
 
M1 
macrophage-
derived pro-
inflammatory 
cytokines (IL-
1β, IL-6, IL-8, 
IL-12, IL-23, 
IP-10, TNF-α) 
 
M2 
macrophage-
derived anti-
inflammatory 
cytokines (IL-
10, CCL22) 
 
Pro-
inflammatory 
markers (TNF-
α, IL-1β) 
 
Exploratory 
 
Response assessment 
Serum  
Phase 1b and 
Phase 2: 
 
Baseline and after 
completion of 
Cycle 2 (±2 days) 
M 
Department of 
Hematopathology, MD 
Anderson Cancer Center 
(MDACC) 
 
James M Reuben 
 
jreuben@mdanderson.org  


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48 
Priority 
Biomarker 
Name 
Assay 
(CLIA:  Y/N) 
Use in the Trial and 
Purpose 
Specimens 
Tested 
Collection Time 
Points 
Mandatory 
or 
Optional 
Assay Laboratory and 
Lab PI 
CLIA:  N 
 


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49 
 
5.9 
Integrated Correlative Studies 
 
5.9.1 Apoptosis Multiplex Immunoassay, Luminex 
 
5.9.1.1 Specimen(s) Receipt and Processing at the EET Biobank 
 
Frozen tissue will be barcoded and stored in a liquid nitrogen vapor phase freezer. 
 
5.9.1.2 Site(s) Performing Correlative Study  
 
This study will be conducted at the NCLN PD Assay Laboratory at Molecular Pathology 
Laboratory Network, Inc. under the supervision of Kate Ferry-Galow, Ph.D. 
(ferrygalowkv@mail.nih.gov). 
 
5.9.1.3 Shipment of Specimens from the EET Biobank to Site Performing Correlative Study  
 
Specimens will be shipped from the EET Biobank to: 
 
NCLN PD Assay Laboratory at Molecular Pathology Laboratory Network, Inc. 
Attention: Donald Henley 
Molecular Pathology Laboratory Network, Inc. 
250 E Broadway Ave. 
Maryville, TN 37804 
Tel:  865-380-9746 
 
5.9.1.4 Contact Information for Notification of Specimen Shipment 
 
lab@geneuity.com 
 
5.10 Exploratory/Ancillary Correlative Studies 
 
5.10.1 DNA fragmentation 
 
5.10.1.1 Specimen(s) Receipt and Processing at the EET Biobank  
 
Tissue received in formalin will be processed and embedded in paraffin and stored as an FFPE 
tissue block.  FFPE tissue blocks are stored at room temperature until sectioning unstained slides 
for analysis.  Ten (10) slides per patient will be needed including an extra 5 μM air-dried 
positively charged slide. 
 
5.10.1.2 Site(s) Performing Correlative Study 
 
This study will be conducted at the Department of Breast Medical Oncology, MD Anderson 
Cancer Center (MDACC) under the supervision of Jangsoon Lee, Ph.D. 
(jslee@mdanderson.org). 


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50 
 
5.10.1.3 Shipment of Specimens from the EET Biobank to Site Performing Correlative Study  
 
Specimens will be shipped from the EET Biobank to: 
 
Department of Breast Medical Oncology, MD Anderson Cancer Center (MDACC) 
Attention: Dr. Jangsoon Lee 
Z12.5036, Breast Medical Oncology, Unit 1354 
6565 MD Anderson Blvd., Houston, TX 77030 
Tel: 713-563-9221 
Email: jslee@mdanderson.org 
 
5.10.1.4 Contact Information for Notification of Specimen Shipment: 
 
Dr. Jangsoon Lee 
Tel: 713-563-9221 
Email: jslee@mdanderson.org 
 
5.10.2 ABCA1 
 
5.10.2.1 Specimen(s) Receipt and Processing at the EET Biobank  
 
Tissue received in formalin will be processed and embedded in paraffin and stored as an FFPE 
tissue block.  FFPE tissue blocks are stored at room temperature until sectioning unstained slides 
for analysis.  Ten (10) slides per patient will be needed including an extra 5 μM air-dried 
positively charged slide. 
 
5.10.2.2 Site(s) Performing Correlative Study   
 
This study will be conducted at the Department of Pathology, MD Anderson Cancer Center 
(MDACC) under the supervision of Savitri Krishnamurthy, M.D. (skrishna@mdanderson.org). 
 
5.10.2.3 Shipment of Specimens from the EET Biobank to Site Performing Correlative Study  
 
Specimens will be shipped from the EET Biobank to: 
 
Department of Pathology, MD Anderson Cancer Center (MDACC) 
Attention: Dr. Savitri Krishnamurthy 
G3.3749, Hematopathology - Rsch, Unit 0053 
1515 Holcombe Blvd., Houston, TX 77030 
Tel: 713-794-5625  
 
5.10.2.4 Contact Information for Notification of Specimen Shipment: 
 
Dr. Savitri Krishnamurthy  
Tel: 713-794-5625 


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51 
Email: skrishna@mdanderson.org 
 
5.10.3 EphA2 
 
5.10.3.1 Specimen(s) Receipt and Processing at the EET Biobank  
 
Tissue received in formalin will be processed and embedded in paraffin and stored as an FFPE 
tissue block.  FFPE tissue blocks are stored at room temperature until sectioning unstained slides 
for analysis.  Ten (10) slides per patient will be needed including an extra 5 μM air-dried 
positively charged slide. 
 
5.10.3.2 Site(s) Performing Correlative Study   
 
This study will be conducted at the Department of Pathology, MD Anderson Cancer Center 
(MDACC) under the supervision of Savitri Krishnamurthy, M.D. (skrishna@mdanderson.org). 
 
5.10.3.3 Shipment of Specimens from the EET Biobank to Site Performing Correlative Study  
 
Specimens will be shipped from the EET Biobank to: 
 
Department of Pathology, MD Anderson Cancer Center (MDACC) 
Attention:  Dr. Savitri Krishnamurthy 
G3.3749, Hematopathology - Rsch, Unit 0053 
1515 Holcombe Blvd., Houston, TX 77030 
Tel: 713-794-5625  
 
5.10.3.4 Contact Information for Notification of Specimen Shipment:  
 
Dr. Savitri Krishnamurthy 
Tel: 713-794-5625 
Email: skrishna@mdanderson.org 
 
5.10.4 Ki67 
 
5.10.4.1 Specimen(s) Receipt and Processing at the EET Biobank  
 
Tissue received in formalin will be processed and embedded in paraffin and stored as an FFPE 
tissue block.  FFPE tissue blocks are stored at room temperature until sectioning unstained slides 
for analysis.  Ten (10) slides per patient will be needed including an extra 5 μM air-dried 
positively charged slide. 
 
5.10.4.2 Site(s) Performing Correlative Study   
 
This study will be conducted at the Department of Breast Medical Oncology, MD Anderson 
Cancer Center (MDACC) under the supervision of Jangsoon Lee, Ph.D. 
(jslee@mdanderson.org). 


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52 
 
5.10.4.3 Shipment of Specimens from the EET Biobank to Site Performing Correlative Study  
 
Specimens will be shipped from the EET Biobank to: 
 
Department of Breast Medical Oncology, MD Anderson Cancer Center (MDACC) 
Attn.: Dr. Jangsoon Lee 
Z12.5036, Breast Medical Oncology, Unit 1354 
6565 MD Anderson Blvd., Houston, TX 77030 
Tel: 713-563-9221 
Email: jslee@mdanderson.org 
 
5.10.4.4 Contact Information for Notification of Specimen Shipment: 
 
Dr. Jangsoon Lee 
Tel: 713-563-9221 
Email: jslee@mdanderson.org 
 
5.10.5 Membrane rigidity 
 
5.10.5.1 Specimen(s) Receipt and Processing at Chapkin Laboratory Texas A&M University.  
 
Fresh tumor tissue will be received at Chapkin lab for the membrane rigidity assay. 
 
5.10.5.2 Site(s) Performing Correlative Study   
 
This study will be conducted at the Department of Biochemistry and Biophysics, Texas A&M 
University under the supervision of Robert S. Chapkin, Ph.D. (r-chapkin@tamu.edu). 
 
5.10.5.3 Shipment of Specimens to Site Performing Correlative Study  
 
See Section 5.7.1. 
 
5.10.5.4 Contact Information for Notification of Specimen Shipment: 
 
See Section 5.7.1. 
 
5.10.6 Cholesterol homeostasis in cell membrane 
 
5.10.6.1 Specimen(s) Receipt and Processing Chapkin Laboratory Texas A&M University.  
 
Fresh tumor tissue will be received at Chapkin lab for the cholesterol homeostasis in cell 
membrane assay. 
 
5.10.6.2 Site(s) Performing Correlative Study   
 


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53 
This study will be conducted at the Department of Biochemistry and Biophysics, Texas A&M 
University under the supervision of Robert S. Chapkin, Ph.D. (r-chapkin@tamu.edu). 
 
5.10.6.3 Shipment of Specimens to Site Performing Correlative Study  
 
See Section 5.7.1. 
 
5.10.6.4 Contact Information for Notification of Specimen Shipment:  
 
See Section 5.7.1. 
 
5.10.7 Multiplex cytokine panel 
 
5.10.7.1 Specimen(s) Receipt and Processing at the EET Biobank  
 
Frozen aliquots of serum will be barcoded and stored in a -80°C freezer until distribution for 
analysis. 
 
5.10.7.2 Site(s) Performing Correlative Study   
 
This study will be conducted at the Department of Hematopathology, MD Anderson Cancer 
Center (MDACC) under the supervision of James M. Reuben, Ph.D. (jreuben@mdanderson.org). 
 
5.10.7.3 Shipment of Specimens from the EET Biobank to Site Performing Correlative Study  
 
Specimens will be shipped from the EET Biobank to: 
 
Department of Hematopathology, MD Anderson Cancer Center (MDACC) 
Attn.: Dr. Evan Cohen 
Y4.6041, Hematopathology  
1515 Holcombe Blvd., Houston, TX 77030 
Tel: 713-745-2132 
Email: encohen@mdanderson.org 
 
5.10.7.4 Contact Information for Notification of Specimen Shipment: 
 
Dr. Evan Cohen 
Tel: 713-745-2132 
Email: encohen@mdanderson.org 
 
 
6. 
TREATMENT PLAN 
 
6.1 
Agent Administration 
 
Treatment will be administered on an outpatient basis.  Reported adverse events and potential 


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54 
risks are described in Section 10.  Appropriate dose modifications are described in Section 7.  No 
investigational or commercial agents or therapies other than those described below may be 
administered with the intent to treat the patient's malignancy. 
 
Phase 1b Dose Escalation Schedule 
Dose Level 
Dose*# 
Dasatinib 
(mg) 
Icosapent ethyl 
(EPA) 
(mg) 
Cycle Length 
Level 1* 
100 mg, PO, QD 
2000 mg, PO, BID 
28 days 
Level 2 
100 mg, PO, QD 
3000 mg, PO, BID 
Level 3 
100 mg, PO, QD 
4500 mg, PO, BID 
*Starting Dose Level.  
PO = Orally, QD = Once daily, BID = Twice a day 
#Following registration, patients should begin protocol treatment within 30 days. 
 
Phase 2 
Agent 
Dose 
Route 
Schedule 
Cycle Length 
Dasatanib 
100 mg 
PO 
QD 
28 days 
Icosapent ethyly 
(EPA) 
MTD/RP2D 
PO 
BID 
28 days 
MTD = Maximum tolerated dose, RP2D = Recommended phase 2 dose, PO = Orally, QD = 
Once daily, BID = Twice a day 
 
 
6.1.1 Dasatinib 
 
Dasatinib tablets may be taken with or without food as desired, but should be swallowed with at 
least 8 ounces (240 mL) of water.  Taking dasatinib with grapefruit juice is prohibited.  Each 
participant will receive the first doses of dasatinib at the clinical site and be monitored for 2 
hours to accommodate safety observations.  Each participant will self-administer all subsequent 
doses.  A light meal is not required, but may improve gastric tolerance for dasatinib.  Tablets 
must be swallowed whole and may not be broken.  If vomiting occurs within 30 minutes of 
swallowing the tablet(s), the dose may be replaced if the tablets can be seen and counted.  Four 
weeks (28 days) constitutes one cycle of treatment. 
 
Patients will be provided with a Medication Diary for dasatinib (Appendix D), instructed in its 
use, and asked to bring the diary with them to each appointment.  A new copy of the Medication 
Diary will be given to patients whose dose is reduced due to adverse events. 
 
If a dose is missed, then the patient should take the next dose on the next day and in the pre-
specified amount.  The patient needs to record the missed dose and date in the medication diary.  


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The patient must not take any more than the pre-specified amount. 
 
If tablets are accidentally crushed or broken, caregivers should wear disposable chemotherapy 
gloves.  Pregnant women should avoid exposure to crushed and/or broken tablets.  
 
6.1.2 Icosapent ethyl (EPA) 
 
Icosapent ethyl capsules are administered orally (PO) twice daily (BID) with or following a 
meal.  The capsules are to be swallowed whole and cannot be broken, crushed, dissolved, or 
chewed.  If one dose of the daily two dose schedule is missed, the capsule should be taken as 
soon as possible within the same day.  In the case where both doses of the daily two dose 
schedule are omitted, the capsules should not be doubled the next day.  If vomiting occurs within 
30 minutes of swallowing the capsules, then the dose may be replaced if the capsules can be seen 
and counted. 
 
Patients will be provided with a Medication Diary for EPA (Appendix D), instructed in its use, 
and asked to bring the diary with them to each appointment.  A new copy of the Medication 
Diary will be given to patients whose dose is reduced due to adverse events. 
 
6.2 
Definition of Dose-Limiting Toxicity 
 
For dose-finding, DLT is defined as an inability to maintain the prescribed doses during the first 
28 days as a result of treatment-related toxicity, as follows: 
 
1. Grade 3 or 4 non-hematological toxicities >2 days while on optimal therapy 
2. Grade 4 neutropenia >3 days, or grade 3 or 4 neutropenia with sepsis/fever 
3. Grade 4 thrombocytopenia or bleeding requiring platelet transfusion.  
 
Management and dose modifications associated with the above adverse events are outlined in 
Section 7. 
 
Dose escalation will proceed within each cohort according to the scheme presented in Section 
9.1.  Dose-limiting toxicity (DLT) is defined above.   
 
The MTD is defined as the highest dose level at which <33% of the dose cohort (0 of 3 or 1 of 6) 
experience a DLT in the first cycle.  Up to 3 additional patients (maximum enrollment 6) will be 
added at the MTD level to more fully characterize the safety of the drug combination.  If <33% 
(2) patients in this expanded cohort experience a DLT, this will be declared the MTD, and thus 
the RP2D.  If 2 or more patients experience a DLT, we will adopt this dose level as the 
maximum administered dose (MAD) and drop to the dose level immediately below, for the MTD 
and the RP2D. 
 
6.3 
General Concomitant Medication and Supportive Care Guidelines 
 
Because there is a potential for interaction of dasatinib with other concomitantly administered 
drugs, the case report form must capture the concurrent use of all other drugs, over-the-counter 


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56 
medications, or alternative therapies.  The Principal Investigator should be alerted if the patient is 
taking any agent known to affect or with the potential for drug interactions.  The study team 
should check a frequently-updated medical reference for a list of drugs to avoid or minimize use 
of.  A patient wallet card listing the study agents will be provided (Appendix C). 
 
6.3.1 Dasatinib 
 
Dasatinib is indicated for the treatment of the following: 
• Newly diagnosed adults with Philadelphia chromosome-positive (Ph+) chronic 
myeloid leukemia (CML) in chronic phase.  
• Adults with chronic, accelerated, or myeloid or lymphoid blast phase Ph+ CML with 
resistance or intolerance to prior therapy including imatinib.  
• Adults with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ 
ALL) with resistance or intolerance to prior therapy. 
• Pediatric patients with Ph+ CML in chronic phase. 
 
The proposed research involves a change to the subject population (mTN-IBC). Since the 
proposed research will combine dasatinib with EPA, it may increase the risks associated with 
using the product.  To ensure safety, the maximum tolerated dose for EPA and dasatinib in 
combination will be determined in phase 1b.  Dasatinib is not being promoted for off-label use. 
 
6.3.1.1 Agents or substances that strongly induce or inhibit CYP3A4 are prohibited during 
dasatinib treatment because the patient’s exposure to dasatinib is significantly affected 
by such materials.  For CYP3A4 inhibitors, a washout period of >7 days is required 
prior to starting dasatinib.  The washout period should be based on the half-life of the 
particular CYP 3A4 inhibitor which can be substantially longer than 7 days in some 
cases (e.g., amiodarone).  The Principal Investigator should be alerted if the patient is 
taking any agent known to affect or with the potential to affect selected P450 
isoenzymes.  See Appendix G for a list of specifically prohibited CYP3A4 inhibitors 
and inducers.   
 
6.3.1.2 Patients should be advised not to consume grapefruit or grapefruit juice during dasatinib 
treatment. 
 
6.3.1.3 Because systemic antacids (H2 inhibitors, proton pump inhibitors) decrease dasatinib 
absorption, patients who require antacids should use short-acting, locally-active agents 
(e.g., Maalox®, Mylanta® etc.).  However, these agents should not be taken within either 
2 hours before or 2 hours after the dasatinib dose. 
 
6.3.1.4 Use of agents with proarrhythmic potential is not permitted during the study, and a 
washout period of ≥7 days is required prior to starting dasatinib.  The washout period 
should be based on the half-life of the particular proarrhythmic agent which can be 
substantially longer than 7 days in some cases (e.g., amiodarone).  See Appendix G for 
a list of proarrhythmic agents that are specifically prohibited during dasatinib treatment.  
A comprehensive list of agents with the potential to cause QTc prolongation (≤450 


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57 
milliseconds) can be found at http://torsades.org. 
 
6.3.1.5 Thrombocytopenia and hemorrhagic events can occur with dasatinib treatment.  For this 
reason, patients may not take anticoagulants or medications that inhibit platelet function 
while on study including therapeutic warfarin or heparin.  All such medications must 
have been stopped ≥7 days prior to starting dasatinib to allow an appropriate washout 
period.  If the patient requires any surgical (including dental) procedure while on study, 
dasatinib should be stopped 1 day before the procedure and not reinstituted until 1 to 2 
days afterward or until adequate hemostasis is achieved. 
 
6.3.1.6 Bisphosphonate therapy should be withheld for the first 8 weeks of treatment in patients 
receiving such treatment pending assessment of the need for calcium supplementation 
(see below).  If patient’s serum calcium levels remain above the lower limit of normal, 
patients on prior bisphosphonate therapy may be restarted with caution at the 
investigator’s discretion. 
 
6.3.1.7 Calcium supplements (e.g., calcium carbonate, 500 mg PO three times daily) may be 
required to maintain serum calcium levels above the lower limit of normal during 
dasatinib treatment.  Vitamin D supplements (e.g., ergocalciferol, 400 IU PO daily) may 
be appropriate for persistent hypocalcemia.  Bisphosphonate therapy should be deferred 
in the presence of hypocalcemia. 
 
6.3.1.8 The nausea, vomiting, and diarrhea that may occur with dasatinib administration can 
generally be managed through the use of appropriate supportive measures (anti-emetics 
- e.g., 5-HT3 antagonists, benzodiazepines, prochlorperazine, and anti-diarrheal 
medications - e.g., loperamide).  Granisetron, an antiemetic that does not prolong QTc 
intervals, should be considered early in treatment. 
 
6.3.1.9 Fluid retention, including pleural effusions, should be controlled by early institution of 
diuresis (e.g., furosemide, 20-40 mg PO daily and/or spironolactone, 25-50 mg PO, 
titrated to symptoms).  Pleural effusions that remain or become symptomatic despite 
diuresis should be managed with thoracentesis.  Steroid treatment may also be effective 
for pleural effusion.  Chest discomfort may be related to a pericardial effusion; and an 
echocardiogram should be performed to investigate this possibility in such cases. 
 
6.3.1.10 Inflammation (e.g., pneumonitis, colitis, skin rash) may be appropriately managed with 
dasatinib interruption and short-term steroid treatment (e.g., 5-7 days 
methylprednisolone with rapid taper).  Concurrent antibiotics are appropriate if there is 
clinical suspicion of infection.   
 
6.3.1.11 Therapeutic use of hematopoietic growth factors is permitted at the investigator’s 
discretion and should follow American Society of Clinical Oncology guidelines for 
their use (Ozer et al., 2000). 
 
6.3.1.12 Symptoms of pulmonary arterial hypertension (PAH) include dyspnea, fatigue, hypoxia, 
and edema.  Since other medical conditions may also cause these symptoms, non-


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58 
invasive procedures (including echocardiogram) should be done first to rule out more 
the common etiologies of these symptoms, such as pleural effusion, pulmonary edema, 
anemia, and lung infiltration. 
 
6.3.1.13 Right heart catheterization can confirm the diagnosis of PAH.  Hypertension is “pre-
capillary” and not a consequence of left heart failure or chronic lung disease if there is 
normal pulmonary capillary wedge pressure (<15 mm Hg) but elevated pulmonary 
artery pressure (mean pulmonary artery pressure >25 mm Hg).  Since PAH may be 
reversible upon discontinuation of dasatinib, a diagnostic approach of interruption of 
dasatinib treatment may be considered at the discretion of the treating physician; 
however, if PAH is confirmed, dasatinib should be permanently discontinued. 
 
6.3.2 Icosapent ethyl (EPA) 
 
Icosapent ethyl was associated with an increased risk of atrial fibrillation or atrial flutter 
requiring hospitalization in a double-blind, placebo-controlled trial of statin-treated patients with 
established cardiovascular disease (CVD) or diabetes plus an additional risk factor for CVD.  
The incidence of atrial fibrillation was greater in patients with a previous history of atrial 
fibrillation or atrial flutter.  Thus, patients with diabetes or hypothyroidism should be monitored. 
 
The effect of icosapent ethyl on the risk for pancreatitis in patients with severe 
hypertriglyceridemia has not been determined.  Furthermore, icosapent ethyl has not been 
studied in patients with renal or hepatic impairment. 
 
6.3.2.1 Drug Interaction Studies 
 
In drug-drug interaction studies, icosapent ethyl (4 g/day) at steady-state did not significantly 
change: 
x the steady-state AUCτ or Cmax of omeprazole when co-administered at 40 mg/day to 
steady-state 
x the single dose AUC or Cmax of rosiglitazone at 8 mg 
x the single dose AUC or Cmax of R- and Swarfarin or the anti-coagulation 
pharmacodynamics of warfarin when co-administered as racemic warfarin at 25 mg 
x the steady-state AUCτ or Cmax of atorvastatin, 2-hydroxyatorvastatin, or 4-
hydroxyatorvastatin when co-administered with atorvastatin 80 mg/day at steady-state 
 
6.4 
Duration of Therapy 
 
In the absence of treatment delays due to adverse event(s), treatment may continue until one of 
the following criteria applies: 
 
x 
Disease progression 
 
x 
Intercurrent illness that prevents further administration of treatment 
 
x 
Unacceptable adverse event(s) 


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59 
 
x 
Patient decides to withdraw from the study 
 
x 
General or specific changes in the patient's condition render the patient unacceptable for 
further treatment in the judgment of the investigator 
 
x 
Clinical progression 
 
x 
Patient non-compliance 
 
x 
Pregnancy 
 
o All women of child bearing potential should be instructed to contact the investigator 
immediately if they suspect they might be pregnant (e.g., missed or late menstrual 
period) at any time during study participation. 
 
o The investigator must immediately notify CTEP in the event of a confirmed 
pregnancy in a patient participating in the study. 
 
x 
Termination of the study by sponsor 
 
x 
The drug manufacturer can no longer provide the study agent 
 
The reason(s) for protocol therapy discontinuation, the reason(s) for study removal, and the 
corresponding dates must be documented in the Case Report Form (CRF). 
 
6.5 
Duration of Follow-Up 
 
Patients will undergo in-clinic post-treatment evaluations 1 month after their last study treatment 
or before starting new treatment, whichever occurs first, and 3 months after their last study 
treatment.  The 1-month and 3-month follow-up visits can be done by phone if patients prefer.  
Patients will then be followed by phone every 3 months for up to 2 years after removal from 
study or until death, whichever occurs first.  Patients removed from study for unacceptable 
adverse event(s) will be followed until resolution or stabilization of the adverse event. 
 
7. 
DOSING DELAYS/DOSE MODIFICATIONS 
 
7.1 
Dasatinib 
 
The dose levels and the general approach to dose modification of dasatinib on this trial are 
shown below.  Adverse events (AEs) should be treated with the appropriate maximum supportive 
care, and dose reductions should be clearly documented in the case report form. 
 
Patients will be withdrawn from the study if they fail to recover to CTCAE grade 0-1 or tolerable 
grade 2 (or within 1 grade of starting values for pre-existing laboratory abnormalities) from a 
treatment-related toxicity within 14 days OR they experience agent- related adverse events 


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60 
requiring dose modification despite two previous dose reductions (i.e., would require a third dose 
reduction) unless the investigator and CTEP senior investigator agree that the patient should 
remain on the study because of evidence that the patient is/may continue deriving benefit from 
continued study treatment. 
 
Dose Level 
Dasatinib Dose 
-2 
50 mg PO QD 
-1 
80 mg PO QD 
0 
100 mg PO QD 
 
7.1.1 Dosage Modification for Dasatinib 
 
7.1.1.1 Selected Hematologic and Non-Hematologic Adverse Events 
 
Event 
AE Grade or 
Observation 
Dose modification 
Neutropenia 
Grade 1 or 2 
Maintain dose 
Grade 3 or 4 1 
Hold dasatinib until < grade 2, then reduce 1 
dose level and resume treatment  
Thrombocytopenia 
Grade 1 or 2 
Maintain dose 
Grade 3 or 4 1 
Hold dasatinib until < grade 2, then reduce 1 
dose level and resume treatment 
Hemorrhage/Bleeding/ 
Coagulopathy 
(without 
thrombocytopenia) 
Grade 1 
No interruption in treatment; maintain current 
dose. 
Monitor as clinically indicated 
Grade 2 
Hold dasatinib until AE resolved to < grade 1; 
reduce dose to next lower dose level, and 
continue treatment.  
 
If grade 2 or greater hemorrhage/ bleeding recurs 
following dose reduction, stop dasatinib and 
remove patient from study.  
 
Follow up per protocol (Section 6.5) if patient is 
removed from the study. 
Grade 3 or 4 
Discontinue treatment and withdraw subject from 
study. 
Follow up per protocol (see Section 6.5). 
QTc Prolongation 
>480 but 
<550 msec 
Review patient’s concomitant medications for 
QT interval-prolonging agents.  Correct any 
electrolyte abnormalities. 
Continue dasatinib at current dose level and 
repeat ECG. 
>550 msec 
Stop dasatinib and any other QT interval-
prolonging agents immediately.  Correct any 


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61 
electrolyte abnormalities, then 
1. If there is a plausible explanation 
for AE other than dasatinib 
treatment, resume dasatinib at 
current dose level. 
2. If dasatinib may have 
contributed to the AE: 
x Reduce 2 dose levels and restart dasatinib. 
x If QTc remains <480 msec after 14 days at 
reduced dose, increase one dose level and 
continue dasatinib. 
1 
Recurrent grade 3 events require dose reduction; recurrent grade 4 events require 
study removal. 
 
 
7.1.1.2 General Management Guidelines for Agent-Related Non-Hematologic Toxicity 
 
Severity 
Management 
Grade 2 
1st event: Institute supportive therapy.  May hold dasatinib, or continue 
without dose reduction, or reduce by one dose level 
2nd event: Hold dasatinib and maximize supportive therapy.  Decrease dose 
by one dose level  
3rd event: Hold dasatinib.  May discontinue if AE poorly controlled. 
Grade 3 
1st event: Hold dasatinib.  Institute supportive therapy.  Restart dasatinib with 
reduction by one dose level allowed. 
2nd event: Hold dasatinib.  Maximize supportive therapy.  Dasatinib may be 
restarted or discontinued if dose already reduced. 
Grade 4 
1st event: Hold dasatinib.  Maximize supportive therapy.  Dasatinib may be 
restarted with dose reduction by one dose level or discontinued. 
 
7.2 
Icosapent ethyl (EPA) 
 
EPA is a basically nutritional agent, and we do not expect severe adverse effects from the 
treatment. Previous clinical trials showed arthralgia was the most frequent adverse effect, but the 
incidence rate was less than 5%. The dosing escalation for EPA will follow the BOIN design. In 
case the patient had uncommon side effects, PI and clinical stuff will discuss the event and 
determine which drug should be reduced dosing. The table below describes the summary of dose 
modification and criteria for treatment interruption and re-initiation.  
 
 
EPA Dose 
First Dose 
Reduction (Dose 
Level -1) 
Second Dose 
Reduction (Dose 
Level -2) 
2000 mg PO BID 
Discontinue EPA 
Discontinue EPA 
3000 mg PO BID 
2000 mg 
Discontinue EPA 


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62 
4500 mg PO BID 
3000 mg 
2000 mg 
 
 
Dose Modifications for EPA 
Worst toxicity (CTCAE 5.0 
Grade) 
EPA Dose Modifications 
Arthralgia 
Grade 1 or 2 
Maintain dose level 
Grade 3 
Omit dose until resolved to ≤ Grade 1, then decrease 1 dose 
level 
Grade 4 
Permanently discontinue patient from EPA 
Coagulation abnormalities 
Grade 1 or 2 
Maintain dose level 
Grade 3 
Omit dose until resolved to ≤ Grade 1, then decrease 1 dose 
level 
Grade 4 
Permanently discontinue patient from EPA 
Pancreatitis 
Grade 1 
Maintain dose level 
Grade 2 
Omit dose until resolved to ≤ Grade 1, then decrease 1 dose 
level 
Grade 3 
Permanently discontinue patient from EPA 
High triglycerides 
Grade 1 or 2 
Maintain dose level 
Grade 3 
Omit dose until resolved to ≤ Grade 1, then decrease 1 dose 
level 
Grade 4 
Permanently discontinue patient from EPA 
 
 
8. 
PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational or commercial 
agent administered in this study can be found in Section 10.1. 


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63 
 
8.1 
CTEP Agent 
 
8.1.1 Dasatinib (NSC #732517) 
 
Other names: BMS-354825, Sprycel® 
 
Chemical Name:  N-(2-Chloro-6-methylphenyl)-2-[[6-[4-(2-hydroxyethyl)-1-piperazinyl]-2 
methyl-4-pyrimidinyl]amino]-5-thiazolecarboxamide, monohydrate 
 
Mechanism of Action:  Dasatinib is a potent, broad spectrum ATP-competitive inhibitor of 5 
critical oncogenic tyrosine kinase families:  BCR-ABL, SRC family kinases, c-KIT, ephrin (EP) 
receptor kinases, and PDGFβ receptor.  Overexpression or activation of these kinases plays 
critical roles in the etiology of various cancer types. 
 
Molecular Formula:  C22H26CIN7O2S· H20 MW:  Dasatinib monohydrate: 506.02 daltons  
 
Approximate Solubility:  Dasatinib’s solubility ranged from 18.42 mg/mL at pH 2.6 to < 0.001 
mg/mL at pH 7. 
 
How Supplied:  BMS supplies and CTEP, NCI, DCTD distributes dasatinib. Dasatinib is 
available in the following tablet/bottle sizes: 
 
x 20 mg biconvex, round, white to off-white film-coated tablets.  
x 50 mg biconvex, oval, white to off-white film-coated tablets.  The tablet is debossed with 
“50” on one side and “528” on the other side.  
   
Inactive ingredients include lactose monohydrate, microcrystalline cellulose, croscarmellose 
sodium, hydroxypropyl cellulose, magnesium stearate.  The film-coating contains 
hypromellulose, titanium dioxide and polyethylene glycol. 
 
Tablets are supplied in high-density polyethylene (HDPE) bottles with desiccant and cotton. The 
bottles are heat-induction sealed with child-resistant caps. 
 
Storage:  Store the intact bottles at controlled room temperature (15°C-25°C) and protect from 
light.   
 
Stability:  Stability studies are ongoing.  
 
Route of Administration:  Oral. Tablets may be taken with or without food.   They should be 
swallowed whole and not crushed or broken.  
 
Potential Drug Interactions:  Dasatinib is primarily metabolized by the human CYP3A4 
enzyme; therefore, potent CYP3A4 inducers and inhibitors are prohibited on dasatinib trials. 
 
Concomitant use of dasatinib and a CYP3A4 substrate may increase exposure to the CYP3A4 


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64 
substrate. Therefore, caution is warranted when dasatinib is coadministered with CYP3A4 
substrates of narrow therapeutic index. 
 
Systemic antacids (both H2 receptor antagonists and proton pump inhibitors) are prohibited on 
dasatinib trials.  Locally acting antacids can be given up to two hours prior or two hours 
following dasatinib administration.   
 
Dasatinib may prolong the QT/QTc interval.  Use caution when administering dasatinib with 
other potential QTc-prolonging medications. 
 
Due to the possibility of CNS, gastrointestinal, cardiac, and cutaneous hemorrhage, use caution 
in patients who require medications that inhibit platelet function or anticoagulants.  
 
Special Handling:  Dasatinib tablets consist of a core tablet (containing the active drug) 
surrounded by a film coating to prevent exposure to the active drug substance.  If tablets are 
accidentally crushed or broken, caregivers should wear disposable chemotherapy gloves. 
Pregnant women should avoid exposure to crushed and/or broken tablets.  
 
Availability 
 
Dasatinib is an investigational agent supplied to investigators by the Division of Cancer 
Treatment and Diagnosis (DCTD), NCI. 
 
Dasatinib is provided to the NCI under a Collaborative Agreement between the Pharmaceutical 
Collaborator and the DCTD, NCI (see Section 13.5). 
 
8.1.2 Agent Ordering and Agent Accountability 
 
8.1.2.1 NCI-supplied agents may be requested by eligible participating Investigators (or their 
authorized designee) at each participating institution.  The CTEP-assigned protocol 
number must be used for ordering all CTEP-supplied investigational agents.  The 
eligible participating investigators at each participating institution must be registered 
with CTEP, DCTD through an annual submission of FDA Form 1572 (Statement of 
Investigator), NCI Biosketch, Agent Shipment Form, 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 
participating investigator at that institution. 
 
 Study agents must be ordered after a patient is registered since no starter supplies are 
being provided.  Normal order processing time is two business days.  Expedited 
orders may be shipped overnight when a site provides expedited courier information. 
Submit agent requests 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, a “current” password, and active person registration status.  For questions 
about drug orders, transfers, returns, or accountability, call or email PMB any time.  


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65 
Refer to the PMB’s website for specific policies and guidelines related to agent 
management.   
 
8.1.2.2 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. 
 
8.1.3 Investigator Brochure Availability 
 
The current version of the dasatinib IB will be accessible to site investigators and research staff 
through the PMB OAOP application.  Access to OAOP requires the establishment of a CTEP 
IAM account and the maintenance of an “active” account status, a “current” password and active 
person registration status.  Questions about IB access may be directed to the PMB IB 
Coordinator via email. 
 
8.1.4 Useful Links and Contacts 
x CTEP Forms, Templates, Documents:  http://ctep.cancer.gov/forms/ 
x NCI CTEP Investigator Registration:  RCRHelpDesk@nih.gov 
x PMB policies and guidelines: 
http://ctep.cancer.gov/branches/pmb/agent_management.htm  
x 
PMB Online Agent Order Processing (OAOP) application: 
https://ctepcore.nci.nih.gov/OAOP   
x CTEP Identity and Access Management (IAM) account: https://ctepcore.nci.nih.gov/iam/  
x CTEP IAM account help:  ctepreghelp@ctep.nci.nih.gov  
x IB Coordinator:  IBCoordinator@mail.nih.gov  
x PMB email:  PMBAfterHours@mail.nih.gov 
x PMB phone and hours of service: (240) 276-6575 Monday through Friday between 8:30 
am and 4:30 pm (ET) 
 
8.2 
Commercial Agent  
 
8.2.1 Icosapent ethyl (EPA, VASCEPA) 
 
Product description:  Icosapent ethyl (EPA, VASCEPA), a lipid-regulating agent, is supplied as 
either a 0.5 gram or a 1 g amber-colored, liquid-filled soft gelatin capsule for oral use.  Each 
icosapent ethyl (EPA, VASCEPA) capsule contains either 0.5 grams of icosapent ethyl (in a 0.5 
g capsule) or 1 gram of icosapent ethyl (in a 1 g capsule).  Icosapent ethyl is an ethyl ester of the 
omega-3 fatty acid eicosapentaenoic acid (EPA).  The empirical formula of icosapent ethyl is 
C22H34O2 and the molecular weight is 330.51.  The chemical name for icosapent ethyl is ethyl 
all-cis-5,8,11,14,17-icosapentaenoate with the following chemical structure: icosapent ethyl 
(EPA, VASCEPA) capsules also contain the following inactive ingredients: tocopherol, gelatin, 
glycerin, maltitol, sorbitol, and purified water.  
 


NCI Protocol #: 10480 
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66 
Absorption:  After oral administration, icosapent ethyl (EPA, VASCEPA) is de-esterified 
during the absorption process and the active metabolite EPA is absorbed in the small intestine 
and enters the systemic circulation mainly via the thoracic duct lymphatic system.  Peak plasma 
concentrations of EPA were reached approximately 5 hours following oral doses of icosapent 
ethyl (EPA, VASCEPA).  Icosapent ethyl (EPA, VASCEPA) was administered with or 
following a meal in all clinical studies; no food effect studies were performed.  Therefore, it is 
recommended to take icosapent ethyl (EPA, VASCEPA) with or following a meal.  
 
Distribution:  The mean volume of distribution at steady state of EPA is approximately 88 liters.  
The majority of EPA circulating in plasma is incorporated in phospholipids, triglycerides and 
cholesteryl esters, and <1% is present as the unesterified fatty acid.  Greater than 99% of 
unesterified EPA is bound to plasma proteins.  
 
Elimination 
Metabolism 
EPA is mainly metabolized by the liver via beta-oxidation similar to dietary fatty acids.  Beta 
oxidation splits the long carbon chain of EPA into acetyl Coenzyme A, which is converted into 
energy via the Krebs cycle.  Cytochrome P450-mediated metabolism is a minor pathway of 
elimination of EPA. 
 
Excretion 
The total plasma clearance of EPA at steady state is 684 mL/hr.  The plasma elimination half-life 
(t1/2) of EPA is approximately 89 hours. icosapent ethyl (EPA, VASCEPA) does not undergo 
renal excretion. 
 
Route of administration:  The dose of icosapent ethyl (EPA, VASCEPA) is as assigned per 
Section 6.1, taken twice daily with food.  Patients are advised to swallow capsules whole.  Do 
not break open, crush, dissolve, or chew capsules. 
 
Prior to initiation of icosapent ethyl (EPA, VASCEPA), assess lipid levels.  Identify other causes 
(e.g., diabetes mellitus, hypothyroidism, or medications) of high triglyceride levels and manage 
as appropriate.  Patients should engage in appropriate nutritional intake and physical activity 
before receiving icosapent ethyl (EPA, VASCEPA), which should continue during treatment. 
 
Storage:  Store the product bottle at 20º to 25ºC (68º to 77ºF); excursions permitted to 15º to 
30ºC (59º to 86ºF). 
 
Agent Ordering:  Icosapent ethyl (VASCEPA®) is commercially available.  Given that 
icosapent ethyl (VASCEPA®) is a dietary supplement, it will not be covered by insurance.  The 
participating sites will purchase EPA, one of the study drugs, if it is not already in their 
institution’s formulary.  For a participating site to be reimbursed a fee-for-service agreement 
through Purchase Order (PO) will be established between the participating sites and the lead site 
(MD Anderson Cancer Center).  Participating sites will invoice MD Anderson for the EPA costs 
for their enrolled patients. 
 
For additional information, please refer to the package insert. 


NCI Protocol #: 10480 
Version Date: April 27, 2022 
 
67 
 
9. 
STATISTICAL CONSIDERATIONS 
 
9.1 
Study Design/Endpoints 
 
This is a multicenter, single-arm, non-randomized phase 1b/2 trial of dasatinib (BMS-354825, 
Sprycel) and icosapent ethyl (EPA) combination therapy for patients with metastatic triple-
negative inflammatory breast cancer (TN-IBC).  All eligible patients will receive dasatinib and 
EPA combination therapy without randomization or stratification.  The primary objectives of this 
study are: 1) To determine the MTD/RP2D for dasatinib and EPA combination therapy in 
patients with mTN-IBC (phase 1b) and 2) To determine the ORR of dasatinib and EPA 
combination therapy for patients with mTN-IBC (phase 2). 
 
Phase 1:  
The primary objective of the phase 1b trial is to determine the MTD/RP2D for dasatinib and 
EPA combination therapy in patients with mTN-IBC.  In the phase 1b part of the study, Bayesian 
Optimal Interval Combination Design (BOIN), with the 3+3 design run-in, will be used to 
determine the MTD for the combination of EPA and dasatinib.  The target DLT rate in the phase 
Ib part is ɸ = 0.25, and the maximum sample size for the dose-finding is 18.  We will enroll and 
treat patients in cohorts of 3.  The BOIN design uses the following rule, optimized to minimize 
the probability of incorrect dose assignment, to guide dose escalation/de-escalation: 
• 
if the observed DLT rate at the current dose is ≤ 0.197, escalate the dose to the next higher 
dose level; 
• 
if the observed DLT rate at the current dose is > 0.298, de-escalate the dose to the next lower 
dose level; 
• 
otherwise, stay at the current dose. 
 
The 3+3 design run-in will be applied to override the above decision rule when the number of 
patients treated at the current dose is 3.  That is, we will escalate the dose if 0/3 DLT, stay at the 
current dose if 1/3 DLT, and de-escalate the dose if >= 2/3 DLTs.  For the purpose of overdose 
control, doses ݆ and higher levels will be eliminated from further examination if Pr(݌௝> 0.25 | 
data) > 0.75 and at least 3 evaluable patients have been treated at dose level ݆, where ݌௝ is the 
true DLT rate of dose level ݆, ݆= 1,⋯, 3.  This posterior probability is evaluated based on the 
beta-binomial model ݕ௝∣݌௝∼binomial(݌௝) with ݌௝∼uniform(0,1), where ݕ௝ is the number of 
patients experienced DLT at dose level ݆.  When the lowest dose is eliminated, stop the trial for 
safety.  The above dose escalation/de-escalation and elimination rule can be equivalently 
presented in Table 1, which will be used to conduct the trial. 
 
The steps to conduct the trial are described as follows: 
 
1. The dose-escalation starts by treating patients in the first cohort at dose level 1 (dasatinib 
= 100 mg/day; EPA = 2,000 mg twice per day).   
2. To assign a dose to the next cohort of patients, we will conduct dose escalation/de-
escalation according to the rule displayed in Table 1.   
x When a dose is eliminated, the dose is automatically de-escalated to the next 
lower level.  When the lowest dose is eliminated, stop the trial for safety.  


NCI Protocol #: 10480 
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68 
x If none of the actions is triggered, treat the new patients at the current dose.   
x If the current dose was the lowest dose and the rule indicates dose de-escalation, 
treat the new patients at the lowest dose unless the number of DLTs reaches the 
elimination boundary, at which point terminates the trial for safety.   
x If the current dose was the highest dose and the rule indicates dose escalation, we 
will treat the new patients at the highest dose.   
3. We will repeat the above steps until the maximum sample size of 18 is reached or stop 
the trial if the number of patients treated at the current dose reaches 9 and the decision, 
according to Table 1 is to stay at the current dose. 
 
Table 1. Dose escalation/de-escalation rule for the BOIN design. 
 
Actions 
The number of patients treated at the 
current dose 
3 
6 
9 
12 
Escalate if # of DLT <=  
0 
1 
1 
2 
De-escalate if # of DLT >= 
2* 
2 
3 
4 
Eliminate if # of DLT >= 
2 
2 
3 
4 
Note. “# of DLT” is the number of patients with at least 1 DLT.  When none of the actions (i.e., 
escalate, de-escalate or eliminate) is triggered, stay at the current dose for treating the next cohort 
of patients.  “NA” means that a dose cannot be eliminated before treating 3 evaluable patients. 
“*" indicates the 3+3 design run-in. 
 
After the trial is completed, the MTD is selected based on isotonic regression, as specified in the 
previous report (Liu and Yuan, 2015).  Specifically, the dose is selected as the MTD for which 
the isotonic estimate of the toxicity rate is closest to the target toxicity rate.  If there are ties, the 
higher dose level is selected when the isotonic estimate is lower than the target toxicity rate; the 
lower dose level is selected when the isotonic estimate is greater than or equal to the target 
toxicity rate.  The RP2D will be selected based on the safety, efficacy, and the totality of the 
data. The RP2D may be the MTD or a dose lower than the MTD. 
 
The dose-finding part of the study was designed and will be conducted using the BOIN Design 
Desktop Program v1.0.7.  Table 2 shows the operating characteristics of the trial design based on 
1000 simulations of the trial using shiny app “BOIN” (BOIN V2.6.4.0) available at 
http://www.trialdesign.org. 
 
Table 2. Operating characteristics of the BOIN design. 
 
 
 
Dose Level 
 
 
 
 
1 
2 
3 
Number of 
Patients 
% Early 
Stopping 
Scenario 1 
 
 
 
 
 
True DLT Rate 
0.25 
0.43 
0.62 
 
 
Selection % 
44 
8 
0.1 
 
47.9 
% Pts Treated 
63.6 
30.3 
6.1 
10.5 
 


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69 
Scenario 2 
 
 
 
 
 
True DLT Rate 
0.11 
0.25 
0.39 
 
 
Selection % 
42.1 
35.9 
10 
 
12 
% Pts Treated 
39.6 
38.8 
21.6 
14.7 
 
Scenario 3 
 
 
 
 
 
True DLT Rate 
0.05 
0.11 
0.25 
 
 
Selection % 
13 
43.3 
41.4 
 
2.3 
% Pts Treated 
25.4 
36.6 
38 
16 
 
  Note: “% Early Stopping”" refers to early stopping due to excessive DLT. 
 
 
Phase 2: 
The primary objective of the phase 2 trial is to determine the ORR of dasatinib and EPA 
combination therapy, administered at the RP2D determined in phase 1 part, for patients with 
mTN-IBC.  Once the MTD/RP2D has been determined in phase 1b, the trial will move to phase 
2 using Bayesian optimal phase II (BOP2) design with the null hypothesis H0: ORR = 5% vs. the 
alternative hypothesis H1: ORR = 25%.  In the first stage, 9 patients will be enrolled; if 1 or more 
responses are observed, an additional 8 patients will be enrolled.  The treatment is regarded as 
promising if 3 or more responses out of 17 patients are observed.  This design yields 81% power 
while controlling the one-sided type I error rate at 0.05.  Under our setting, BOP2 is the same as 
Simon optimal two-stage design.  Table 3 shows the operating characteristics of the design based 
on 10,000 simulations using the BOP2 web application, which is available at 
http://www.trialdesign.org. 
 
Table 3. Operating characteristics for 10,000 simulations. 
 
True ORR 
 
Early 
stopping (%) 
Claim 
promising (%) 
 
Sample size 
0.05 
63.02 
4.66 
12.0 
0.10 
38.74 
22.34 
13.9 
0.20 
13.42 
66.31 
15.9 
0.25 
7.51 
81.22 
16.4 
0.30 
4.04 
90.45 
16.7 
 
During the phase 2 part, the dose elimination rule of the BOIN design will be used to monitor 
toxicity. That is, if Pr(݌௝> 0.25 | data) > 0.75, the trial may be terminated for safety based on 
the totality of safety data.  This corresponds to the following stopping boundaries:  
x halt the accrual for possible trial termination if  (# of toxicity) / (# of patients) >= 2/3, 3/6, 
4/11 and 6/17.  
Below shows the operating characteristics of the safety monitoring rule. 
 
Toxicity rate 
0.1 
0.2 
0.3 
0.4 
0.5 
Early stopping (%) 
4.6 
22.9 
50.4 
74.5 
90.7 


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70 
Sample size 
16.5 
14.6 
11.7 
8.9 
6.5 
 
9.2 
Sample Size/Accrual Rate 
 
A maximum total of 18 patients will be enrolled in the phase 1b part of the study to determine 
the MTD/RP2D for the combination of EPA and dasatinib, and a maximum of 17 patients will be 
enrolled to the phase 2 portion of the study.  The maximum sample sizes for this phase 1b/2 
study will be 35 in total.  An estimated 1-2 patients will be accrued per month.  Total accrual 
duration is estimated to take 13 months for the phase 1b trial and approximately 11 months for 
the phase 2 trial (the duration of total accrual within 24 months). 
 
Year 
1 
2 
3 
4 
Quarter 
1 
2 
3 
4 
1 
2 
3 
4 
1 
2 
3 
4 
1 
2 
3 
4 
Establish 
Phase II 
Dose 
  
  
  
  
  
 
  
 
  
  
  
  
  
  
  
  
Regulatory 
Approval 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Enroll Phase 
lb 
  
  
 
 
 
 
  
  
  
  
  
  
  
  
  
  
Enroll Phase 
ll 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
  
  
Treatment 
duration 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Biomarker 
Analysis 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Follow-up 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Statistical 
Analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Final 
deliberative 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PLANNED ENROLLMENT REPORT 
 
 
 
DOMESTIC PLANNED ENROLLMENT REPORT (TREATMENT) 
Racial Categories 
Ethnic Categories 
Total 
Not Hispanic or Latino 
Hispanic or Latino 
Female 
Male 
Female 
Male 
American Indian/ 
Alaska Native 
1 
0 
0 
0 
1 
Asian 
1 
0 
0 
0 
1 
Native Hawaiian or 
Other Pacific 
Islander 
0 
0 
0 
0 
0 
Black or African 
American 
4 
0 
0 
0 
4 
White 
25 
0 
2 
0 
27 
More Than One 
Race 
0 
0 
2 
0 
2 
Total 
31 
0 
4 
0 
35 
 


NCI Protocol #: 10480 
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71 
PHS 398 / PHS 2590 (Rev. 03/20 Approved Through 2/28/2023)  
OMB No. 0925-0001/0002 
 
9.3 
Stratification Factors 
 
N/A 
 
9.4 
Analysis of Secondary Endpoints 
 
The secondary objectives of the phase 2 trial are: 1) To determine the clinical benefit rate (CBR) 
of dasatinib and EPA combination therapy for patients with mTN-IBC and 2) To determine the 
survival benefit of dasatinib and EPA combination therapy for patients with mTN-IBC.  The 
definition of CBR will be the proportion of the patients with static disease (SD) ≥24 weeks, 
complete response (CR), and partial response (PR).  The survival benefit will be determined by 
the progression-free survival (PFS) rate at 1 year and the overall survival rate at 2 years.  PFS at 
1 year is defined as the rate of patients without the progression of disease or loss to follow-up at 
1 year after initiating the EPA and dastinib combination therapy.  Overall survival at 2 years is 
the survival rate at 2 years after initiating the EPA and dasatinib combination therapy.   
 
CBR will be estimated along with a 95% exact confidence interval.  PFS and OS will be 
estimated using the methods of Kaplan and Meier.   
 
Tumor apoptosis will be measured by using the Luminex Apoptosis multiplex immunoassay 
panel (cleaved caspase-3) as well as TUNEL assay.  For the Luminex Apoptosis multiplex 
immunoassay panel, Panel 3, which includes cleaved caspase, will be prioritized.  The tumor 
cells/section will be counted for apoptotic index (3,000 cells).  The apoptotic index is a 
percentage of the number of cells displaying apoptotic bodies, scoring 0 if <0.5%, +1 if between 
0.5% and 2%, and +3 if >2% (Lipponen et al., 1994).  The correlation between the apoptotic 
index by cleaved caspase-3 IHC expression and treatment response (ORR) will be evaluated 
using Pearson’s correlation test.  For the TUNEL assay, the apoptotic cells will be counted and 
the correlation between those apoptotic cells and ORR will be determined.  Given the sample 
size of 17 patients, we have 82% power to detect an effect size of 0.16 in ORR across three 
apoptotic index groups (with score of 0, 1 and 3) at the significance level of 0.1 using Chi-square 
test.  The effect size is defined as the variance of ORR across three apoptotic index groups, 
standardized by the variance of the average ORR.  In addition, given 17 patients, we have 80% 
power to detect 1.5 SD difference in the number of apoptotic cells between respondents and non-
respondents, assuming ORR=0.25 (i.e., 4 respondents and 13 non-respondents), at the 1-sided 
significance level of 0.05. 
 
 
9.5 
Analysis of Exploratory Endpoints 
 
Changes in biomarkers corresponding to the EPA and dasatinib combination therapy will be 
determined in correlative studies.  Cholesterol homeostasis, and cholesterol transporter in the 
tumor cell membrane, the tumor microenvironment, and pro-inflammatory cytokines will be 
assessed and analyzed using descriptive statistics.  Continuous value before/after treatment will 
be compared by utilizing the Wilcoxon signed-rank test and paired t-test. 


NCI Protocol #: 10480 
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72 
 
ABCA1 will be measured not only in tumor cells but also in immune cells, especially in M1 and 
M2 macrophages since ABCA1 is known to promote cholesterol efflux in macrophages (Tall et 
al., 2002).  Changes in expression levels of ABCA1 in tumors are an indicator of unbalanced 
cholesterol metabolism.  The intensity of the staining and percentage of stained cells will be 
scored by H-score following the formula: H Score = summation (1+i) pi, where i is the intensity 
score and pi is the percentage of cells with that intensity.  H-score will be analyzed using 
descriptive statistics, including mean, standard deviation and 95% confidence interval.  
 
EphA2-IHC positivity will be defined from 0 to 3+ by modifying the ASCO/CAP HER2 testing 
clinical practice guideline because EphA2 protein expressed in tumor membrane is targeted 
(Wolff et al., 2018).  The modified pathological evaluation of the EphA2-IHC positivity will be 
as follows:1) 0 (negative) No staining is observed or membrane staining that is incomplete and is 
faint/barely perceptible, 2) 1+ (negative) Incomplete membrane staining that is faint/barely 
perceptive, 3) 2+ (equivocal) Weak to moderate complete membrane staining observed in >10% 
of tumor cells, and 4) 3+ (positive) Circumferential membrane staining that is complete, intense 
and in >10% of tumor cells.  After the completion of the phase 2 part, the association between 3 
levels of EphA2-IHC expression (negative, equivocal, and positive) and ORR will be analyzed 
using Fisher’s exact test and logistic regression.  
 
The effects of EPA and dasatinib combination therapy on membrane rigidity of tumor cells will 
be determined and analyzed as described previously (Torres-Adorno et al., 2019).  Higher 
general polarization values are indicative of increased polarization or rigidity.  Increases in 
cholesterol levels in cell membranes will indicate membrane stiffness in response to the 
combination treatment.  For quantitative analysis of cholesterol in individual cells in situ, images 
will be opened in NIH ImageJ software, converted to Tiff files, and a custom macro used to 
quantify the average fluorescent intensity of cholesterol (Salinas et al., 2020).  As an internal 
control to assess variability, serial sections of one sample will be used for staining and imaging.  
A minimum of 20 random regions of each sample will be acquired for quantification. 
 
To visualize effects of EPA and dasatinib combination therapy on cholesterol homeostasis, tissue 
sections stained with filipin (which labels unesterified cholesterol) and Draq5 (which labels 
nuclei) will be imaged using confocal microscopy, and fluorescent intensity will be quantified as 
previously described (Salinas et al., 2020). 
 
For the cytokine/chemokine assay, the correlation between ORR and levels of cytokine and 
immune cell markers will be analyzed by Fisher’s exact test and logistic regression (Harano et 
al., 2017). 
 
9.6 
Reporting and Exclusions 
 
9.6.1 Evaluation of Toxicity 
 
All patients will be evaluable for toxicity from the time of their first treatment with dasatinib. 
 


NCI Protocol #: 10480 
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73 
9.6.2 Evaluation of Response 
 
All patients included in the study must be assessed for response to treatment, even if there are 
major protocol treatment deviations.  Each patient will be assigned one of the following 
categories:  1) complete response, 2) partial response, 3) stable disease, 4) progressive disease, 5) 
early death from malignant disease, 6) early death from toxicity, 7) early death because of other 
cause, or 9) unknown (not assessable, insufficient data).  [Note:  By arbitrary convention, 
category 9 usually designates the “unknown” status of any type of data in a clinical database.] 
 
All of the patients who met the eligibility criteria (with the possible exception of those who 
received no study medication) should be included in the main analysis of the response rate.  
Patients in response categories 4-9 should be considered to have a treatment failure (disease 
progression).  Thus, an incorrect treatment schedule or drug administration does not result in 
exclusion from the analysis of the response rate.  Precise definitions for categories 4-9 will be 
protocol specific.  
 
All conclusions should be based on all eligible patients.  Sub-analyses may then be performed on 
the basis of a subset of patients, excluding those for whom major protocol deviations have been 
identified (e.g., early death due to other reasons, early discontinuation of treatment, major 
protocol violations, etc.).  However, these sub-analyses may not serve as the basis for drawing 
conclusions concerning treatment efficacy, and the reasons for excluding patients from the 
analysis should be clearly reported.   
 
10. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 
following list of AEs (Section 10.1) and the characteristics of an observed AE (Sections 10.2 and 
10.3) will determine whether the event requires expedited reporting via the CTEP Adverse Event 
Reporting System (CTEP-AERS) in addition to routine reporting. 
 
10.1 Comprehensive Adverse Events and Potential Risks List (CAEPR) 
 
10.1.1 CAEPRs for CTEP IND Agent 
 
10.1.1.1 CAEPR for Dasatinib 
 
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 2937 patients. Below is the CAEPR for 
dasatinib (BMS-354825, Sprycel).  


NCI Protocol #: 10480 
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74 
 
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, September 10, 20181 
 
 Adverse Events with Possible  
 Relationship to Dasatinib (BMS-354825, Sprycel) 
 (CTCAE 5.0 Term) 
[n= 2937] 
 
 
 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) 
 
Febrile neutropenia 
 
  
CARDIAC DISORDERS 
  
 
 
Heart failure 
  
 
 
Left ventricular systolic 
dysfunction 
  
 
 
Myocardial infarction 
  
 
Pericardial effusion 
 
  
GASTROINTESTINAL DISORDERS 
  
 
Abdominal distension 
 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 3) 
 
Anal mucositis 
 
  
 
Constipation 
 
  
Diarrhea 
 
 
 Diarrhea (Gr 3) 
 
Dyspepsia 
 
  
 
Gastrointestinal 
hemorrhage2 
 
  
 
Mucositis oral 
 
  
Nausea 
 
 
 Nausea (Gr 3) 
 
Rectal mucositis 
 
  
 
Small intestinal mucositis  
  
 
Vomiting 
 
 Vomiting (Gr 3) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Edema limbs 
 
  
Fatigue 
 
 
 Fatigue (Gr 3) 
 
Fever 
 
 Fever (Gr 2) 
 
General disorders and 
administration site 
conditions - Other 
(superficial edema) 
 
 General disorders and 
administration site conditions - 
Other (superficial edema) (Gr 2) 
 
Generalized edema 
 
  
 
Non-cardiac chest pain 
 
  
 
Pain 
 
  
INFECTIONS AND INFESTATIONS 
  
 
Infection3 
 
 Infection3 (Gr 3) 
INVESTIGATIONS 
  
 
Alanine aminotransferase 
increased 
 
  


NCI Protocol #: 10480 
Version Date: April 27, 2022 
 
75 
 
 Adverse Events with Possible  
 Relationship to Dasatinib (BMS-354825, Sprycel) 
 (CTCAE 5.0 Term) 
[n= 2937] 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
 
Aspartate 
aminotransferase 
increased 
 
  
 
 
Electrocardiogram QT 
corrected interval prolonged 
  
Neutrophil count decreased  
 
 Neutrophil count decreased (Gr 4) 
Platelet count decreased 
 
 
 Platelet count decreased (Gr 4) 
 
Weight gain 
 
  
 
Weight loss 
 
  
 
White blood cell decreased  
 White blood cell decreased (Gr 3) 
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
 Anorexia (Gr 3) 
 
Hypocalcemia 
 
  
 
Hypokalemia 
 
  
 
Hypophosphatemia 
 
 Hypophosphatemia (Gr 3) 
 
 
Tumor lysis syndrome 
  
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
  
 
 
 Growth suppression4 
  
 
 
Musculoskeletal and 
connective tissue disorder - 
Other (epiphyses delayed 
fusion)4 
  
 
 
Musculoskeletal and 
connective tissue disorder - 
Other (osteopenia)4 
  
Myalgia 
 
 
 Myalgia (Gr 2) 
NERVOUS SYSTEM DISORDERS 
  
 
Dizziness 
 
  
Headache 
 
 
 Headache (Gr 3) 
 
 
Intracranial hemorrhage 
  
 
 
Leukoencephalopathy 
  
 
 
Reversible posterior 
leukoencephalopathy 
syndrome 
  
REPRODUCTIVE SYSTEM AND BREAST DISORDERS  
  
 
 
Gynecomastia4 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Cough 
 
  
Dyspnea 
 
 
 Dyspnea (Gr 3) 
 
Laryngeal mucositis 
 
  
 
Pharyngeal mucositis 
 
  
Pleural effusion 
 
 
 Pleural effusion (Gr 3) 
 
Pneumonitis 
 
  
 
 
Pulmonary hypertension 
  
 
Tracheal mucositis 
 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
Alopecia 
 
  


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76 
 
 Adverse Events with Possible  
 Relationship to Dasatinib (BMS-354825, Sprycel) 
 (CTCAE 5.0 Term) 
[n= 2937] 
 
 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
 
 
Erythema multiforme 
  
 
Pruritus 
 
  
 
Rash acneiform 
 
  
Rash maculo-papular 
 
 
 Rash maculo-papular (Gr 2) 
 
 
Stevens-Johnson syndrome   
 
 
Toxic epidermal necrolysis   
VASCULAR DISORDERS 
  
 
Flushing 
 
  
 
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. 
 
3Infection includes all 75 sites of infection under the INFECTIONS AND INFESTATIONS SOC. 
 
4Effects on growth and development have been observed in pediatric patients and may include epiphyses delayed 
fusion, osteopenia, growth retardation, and gynecomastia. 
 
5Gastrointestinal ulcer includes Anal ulcer, Colonic ulcer, Duodenal ulcer, Esophageal ulcer, Gastric ulcer, Ileal 
ulcer, Jejunal ulcer, Rectal ulcer, and  Small intestine ulcer under the GASTROINTESTINAL DISORDERS SOC. 
 
 
 Adverse events reported on Dasatinib (BMS-354825, Sprycel) trials, but for which there is insufficient 
evidence to suggest that there was a reasonable possibility that Dasatinib (BMS-354825, Sprycel) caused the 
adverse event:  
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other 
(pancytopenia) 
CARDIAC DISORDERS - Atrial fibrillation; Cardiac disorders - Other (cardiomegaly); Cardiac disorders - Other 
(heart rate increased); Chest pain - cardiac; Myocarditis; Palpitations; Pericarditis; Sinus tachycardia; Ventricular 
tachycardia 
CONGENITAL, FAMILIAL AND GENETIC DISORDERS - Congenital, familial and genetic disorders - Other 
(Keratosis follicular) 
EAR AND LABYRINTH DISORDERS - Ear pain; Middle ear inflammation; Tinnitus; Vertigo 
EYE DISORDERS - Blurred vision; Dry eye; Eye disorders - Other (optic nerve neuritis); Periorbital edema 
GASTROINTESTINAL DISORDERS - Anal fissure; Ascites; Colitis; Dry mouth; Dysphagia; Esophagitis; 
Flatulence; Gastritis; Gastrointestinal disorders - Other (enteritis); Gastrointestinal disorders - Other (oral soft tissue 
disorder); Gastrointestinal disorders - Other (tongue eruption); Gastrointestinal ulcer5; Ileus; Oral pain; Pancreatitis; 
Periodontal disease; Stomach pain 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Edema face; Edema trunk; 
Flu like symptoms; Gait disturbance; General disorders and administration site conditions - Other (temperature 
intolerance); Localized edema; Malaise 
HEPATOBILIARY DISORDERS - Cholecystitis; Hepatobiliary disorders - Other (cholestasis) 


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77 
IMMUNE SYSTEM DISORDERS - Anaphylaxis 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Bruising 
INVESTIGATIONS - Alkaline phosphatase increased; Blood bilirubin increased; Cardiac troponin T increased; 
CD4 lymphocytes decreased; CPK increased; Creatinine increased; Electrocardiogram T wave abnormal; GGT 
increased; Investigations - Other (bone densitometry); Investigations - Other (thermometry abnormal); Lymphocyte 
count decreased; Lymphocyte count increased 
METABOLISM AND NUTRITION DISORDERS - Dehydration; Hyperkalemia; Hyperuricemia; 
Hypoalbuminemia; Hypomagnesemia; Hyponatremia 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthritis; Back pain; Bone pain; Chest 
wall pain; Generalized muscle weakness; Muscle cramp; Musculoskeletal and connective tissue disorder - Other 
(muscle stiffness); Musculoskeletal and connective tissue disorder - Other (nuchal rigidity); Musculoskeletal and 
connective tissue disorder - Other (tendonitis); Myositis; Osteoporosis; Pain in extremity; Rhabdomyolysis 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Neoplasms 
benign, malignant and unspecified (incl cysts and polyps) - Other (hemangiomatosis) 
NERVOUS SYSTEM DISORDERS - Acoustic nerve disorder NOS; Amnesia; Cognitive disturbance; 
Concentration impairment; Dysarthria; Dysgeusia; Ischemia cerebrovascular; Lethargy; Peripheral motor 
neuropathy; Peripheral sensory neuropathy; Seizure; Somnolence; Syncope; Transient ischemic attacks; Tremor 
PSYCHIATRIC DISORDERS - Anxiety; Confusion; Depression; Insomnia; Libido decreased; Suicidal ideation 
RENAL AND URINARY DISORDERS - Acute kidney injury; Proteinuria; Urinary frequency 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS – Irregular menstruation 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Adult respiratory distress syndrome; 
Bronchospasm; Epistaxis; Hypoxia; Oropharyngeal pain; Pulmonary edema; Sore throat 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Bullous dermatitis; Dry skin; Hair color changes; 
Hyperhidrosis; Nail loss; Pain of skin; Palmar-plantar erythrodysesthesia syndrome; Photosensitivity; Purpura; Skin 
and subcutaneous tissue disorders - Other (acute febrile neutrophilic dermatosis); Skin and subcutaneous tissue 
disorders - Other (panniculitis); Skin ulceration; Urticaria 
VASCULAR DISORDERS - Hematoma; Hot flashes; Hypertension; Hypotension; Phlebitis; Superficial 
thrombophlebitis; Thromboembolic event; Vasculitis 
 
 
Note: Dasatinib (BMS-354825, Sprycel) 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. 
 
10.1.2 Adverse Event List for Commercial Agent 
 
10.1.2.1 Adverse Event List for Icosapent Ethyl 
 
Common adverse reactions (incidence ≥3% on icosapent ethyl and ≥1% more frequent than 
placebo) in a double-blind, randomized, placebo-controlled cardiovascular outcomes trial 
included musculoskeletal pain, peripheral edema, constipation, gout, and atrial fibrillation.   
 
In two randomized, double-blind, placebo-controlled hypertriglyceridemia trials, adverse 
reactions reported with icosapent ethyl at an incidence ≥1% more frequent than placebo (based 
on pooled data) included arthralgia and oropharyngeal pain. 
 
Additional adverse reactions identified during post-approval use of icosapent ethyl include: 
x Diarrhea 
x Blood triglycerides increased 
x Abdominal discomfort 
x Pain in the extremities 


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78 
 
Please review the icosapent ethyl package insert for the comprehensive lists of adverse events. 
 
10.2 Adverse Event Characteristics  
 
x CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
5.0 will be utilized for AE reporting.  All appropriate treatment areas should have access 
to a copy of the CTCAE version 5.0.  A copy of the CTCAE version 5.0 can be 
downloaded from the CTEP website 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
x For expedited reporting purposes only:   
- 
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in the 
SPEER column, Section 10.1) should be reported through CTEP-AERS only if the 
grade is above the grade provided in the SPEER. 
- 
Other AEs of special interest (AESIs) for the protocol that require expedited reporting 
are outlined in Section 10.3.4. 
 
x Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
10.3 Expedited Adverse Event Reporting 
 
10.3.1 Rave-CTEP-AERS Integration 
 
The Rave Cancer Therapy Evaluation Program Adverse Event Reporting System (CTEP-
AERS) integration enables evaluation of Adverse Events (AEs) entered in Rave to 
determine whether they require expedited reporting and facilitates entry in CTEP-AERS 
for those AEs requiring expedited reporting.  Sites must initiate all AEs for this study in 
Medidata Rave.  
 
Treatment-emergent AEs:  All AEs that occur after start of treatment are collected in 
Medidata Rave using the Adverse Event form, which is available for entry at each 
treatment course or reporting period and is used to collect AEs that start during the period 
or persist from the previous reporting period.  AEs that occur 30 Days after the Last 
Administration of the Investigational Agent/Intervention are collected using the Late 
Adverse Event form. 
 
Prior to sending AEs through the rules evaluation process, site staff should verify the 
following on the Adverse Event form in Rave: 
 


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79 
x The reporting period (course/cycle) is correct, and 
x AEs are recorded and complete (no missing fields) and the form is query-free.  
 
The CRA reports AEs in Rave at the time the Investigator learns of the event.  If the CRA 
modifies an AE, it must be re-submitted for rules evaluation. 
 
Upon completion of AE entry in Medidata Rave, the CRA submits the AE for rules 
evaluation by completing the Expedited Reporting Evaluation form.  Both NCI and 
protocol-specific reporting rules evaluate the AEs submitted for expedited reporting.  A 
report is initiated in CTEP-AERS using information entered in Medidata Rave for AEs 
that meet reporting requirements.  The CRA completes the report by accessing CTEP-
AERS via a direct link on the Medidata Rave Expedited Reporting Evaluation form.  
Contact the CTSU Help Desk at 1-888-823-5923 or by email at ctsucontact@westat.com 
if you have any issues submitting an expedited report in CTEP-AERS. 
 
 
In the rare occurrence that internet connectivity is lost, a 24-hour notification is to be 
made to CTEP by telephone at 301-897-7497.  Once internet connectivity is restored, the 
24-hour notification that was phoned in must be entered immediately into CTEP-AERS 
using the direct link from Medidata Rave. 
 
Additional information about the CTEP-AERS integration is available on the CTSU 
members’ website: 
 
x Study specific documents:  Protocols > Documents > Protocol Related 
Documents> Adverse Event Reporting , and 
x Additional resources:  Resources > CTSU Operations Information > User Guides 
& Help Topics. 
 
NCI requirements for SAE reporting are available on the CTEP website:  
 
x NCI Guidelines for Investigators:  Adverse Event Reporting Requirements is 
available at 
https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguid
elines.pdf. 
 
10.3.2 Distribution of Adverse Event Reports 
 
CTEP-AERS is programmed for automatic electronic distribution of reports to the following 
individuals:  Principal Investigator and Adverse Event Coordinator(s) (if applicable) of the 
Corresponding Organization or Lead Organization, the local treating physician, and the Reporter 
and Submitter.  CTEP-AERS provides a copy feature for other e-mail recipients.  
 
10.3.3 Expedited Reporting Guidelines 
 
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 


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80 
registration on all reports. 
 
Note:  A death on study requires both routine and expedited reporting, regardless of 
causality as long as the death occurred within 30 days after the last administration of the 
investigational agent.  Attribution to treatment or other cause must be provided. 
 
Death due to progressive disease should be reported as Grade 5 “Disease progression” in the 
system organ class (SOC) “General disorders and administration site conditions.”  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.  
 
Phase 1 and Early Phase 2 Studies:  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, 2 
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) 
An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 
hours  
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 electronic 
submission within the timeframes detailed in the table below. 
Hospitalization 
Grade 1 and Grade 2 Timeframes 
Grade 3-5 
Timeframes 
Resulting in 
Hospitalization  
≥ 24 hrs 
10 Calendar Days 
24-Hour 5 Calendar 
Days 
Not resulting in 
Hospitalization  
≥ 24 hrs 
Not required 
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. 
Expedited AE reporting timelines are defined as: 
o 
“24-Hour; 5 Calendar Days” - The AE must initially be submitted electronically within 24 hours of learning 
of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report. 
o 
“10 Calendar Days” - A complete expedited report on the AE must be submitted electronically within 10 
calendar days of learning of the AE. 
1Serious adverse events 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: 
x 
All Grade 3, 4, and Grade 5 AEs 


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81 
Expedited 10 calendar day reports for: 
x 
Grade 2 AEs resulting in hospitalization or prolongation of hospitalization 
2For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, 
rounded UP to the nearest whole day, after the agent/intervention was last administered.  Footnote “1” above 
applies after this reporting period. 
Effective Date:  May 5, 2011 
 
10.3.4 Biopsy-related Adverse Events 
 
Adverse Events related to the biopsy component of the study should be captured in Rave as they 
occur and should be reported expeditiously according to the table above.  Four of these AEs are 
not currently part of the CTCAE and must be reported in Rave/CTEP-AERS using the term: 
Injury, poisoning and procedural complications - Other, specify.  The Biopsy-related Adverse 
EventsTerms and Grading Table below (Section 10.3.4.1) lists the terms and their grading.  The 
Biopsy-related Reporting Table (Section 10.3.4.2) provides instruction on how to record these 
events in Rave/CTEP-AERS. 


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82 
10.3.4.1 Biopsy-related Adverse Events Terms and Grading 
Biopsy-related Adverse Events Terms and Grading 
AE 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 
Definition 
Biopsy-related 
hemorrhage 
Symptomatic 
hematoma requiring 
medications 
Any hematoma 
(symptomatic or 
asymptomatic) requiring 
unplanned observation with 
less than 24 hours of 
hospitalization 
Hemorrhage requiring 
transfusion, radiologic, 
endoscopic or surgical 
intervention or greater than 24 
hours of hospitalization 
Hemorrhage with life-
threatening consequences; 
urgent intervention indicated 
Death 
 
 
A disorder characterized by 
bleeding related to a biopsy 
procedure. 
Biopsy-related 
nerve injury 
Symptomatic nerve 
pain or injury 
requiring medications 
Any nerve injury requiring 
unplanned observation with 
less than 24 hours of 
hospitalization 
Any nerve injury requiring 
surgical intervention or 
greater than 24 hours of 
hospitalization 
Nerve injury with life-
threatening consequences; 
urgent intervention indicated  
Death 
A finding of damage to a nerve 
related to a biopsy procedure. 
Biopsy-related 
organ injury 
Symptomatic organ 
pain or injury 
requiring medications 
Any organ injury requiring 
unplanned observation with 
less than 24 hours of 
hospitalization 
Any organ injury that requires 
radiologic, endoscopic or 
surgical intervention or 
greater than 24 hours of 
hospitalization 
Organ injury with life-
threatening consequences; 
urgent intervention indicated 
Death 
A finding of damage to an organ 
related to a biopsy procedure. 
Biopsy-related 
anesthesia (local 
or moderate 
sedation) effects 
Symptomatic 
anesthesia effects 
requiring medications 
Any biopsy-related 
anesthesia effects requiring 
medical intervention for 
reversal of symptomatic 
effects and/or requiring 
unplanned observation with 
less than 24 hours of 
hospitalization 
Any anesthesia effects 
requiring intervention for 
reversal or treatment of 
symptomatic effects and/or 
requiring greater than 24 
hours of hospitalization 
Anesthesia effects with life-
threatening consequences; 
urgent intervention indicated 
Death 
A disorder characterized by 
reactions related to the 
administration of local or 
moderate sedation given for a 
biopsy procedure. 
Pneumothorax 
Asymptomatic; 
clinical or diagnostic 
observations only; 
intervention not 
indicated 
Symptomatic; intervention 
indicated 
Sclerosis and/or operative 
intervention indicated; 
hospitalization indicated 
Life-threatening consequences; 
urgent intervention indicated 
Death 
A disorder characterized by 
abnormal presence of air in the 
pleural cavity resulting in the 
collapse of the lung. 
Pain 
Mild pain 
Moderate pain; limiting 
instrumental ADL 
Severe pain; limiting self care 
ADL 
- 
- 
A disorder characterized by the 
sensation of marked discomfort, 
distress or agony. 
Wound infection 
Localized, local 
intervention indicated 
Oral intervention indicated 
(e.g., antibiotic, antifungal, 
or antiviral) 
IV antibiotic, antifungal, or 
antiviral intervention 
indicated; invasive 
intervention indicated 
Life-threatening consequences; 
urgent intervention indicated 
Death 
A disorder characterized by an 
infectious process involving the 
wound. 
Allergic reaction 
Systemic intervention 
not indicated 
Oral intervention indicated 
Bronchospasm; 
hospitalization indicated for 
clinical sequelae; intravenous 
intervention indicated 
Life-threatening consequences; 
urgent intervention indicated 
Death 
A disorder characterized by an 
adverse local or general response 
from exposure to an allergen. 


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83 
10.3.4.2 Biopsy-related Adverse Events Reporting 
 
Biopsy-related Adverse Events Reporting 
AE Term 
CTCAE term to Select 
Other, specify language to record: 
Pneumothorax* 
Pneumothorax 
N/A 
Pain* 
Pain 
N/A 
Wound infection* 
Wound infection 
N/A 
Allergic reaction* 
Allergic reaction 
N/A 
Biopsy-related hemorrhage** 
Injury, poisoning and procedural 
complications - Other, specify 
Biopsy-related hemorrhage 
Biopsy-related nerve injury** 
Injury, poisoning and procedural 
complications - Other, specify 
Biopsy-related nerve injury 
Biopsy-related organ injury** 
Injury, poisoning and procedural 
complications - Other, specify 
Biopsy-related organ injury 
Biopsy-related anesthesia (local or moderate 
sedation) effects** 
Injury, poisoning and procedural 
complications - Other, specify 
Biopsy-related anesthesia (local or moderate 
sedation) effects 
 
*Select the indicated current CTCAE Term. 
 
**Select CTCAE term, “Injury, poisoning and procedural complications - Other, specify” and fill in the ‘Specify’ with the AE term 
when prompted in Rave.   
 
For example, if the subject experienced a biopsy-related hemorrhage, select Injury, poisoning and procedural complications - Other, 
specify and write in ‘Biopsy-related hemorrhage’ when prompted in Rave and/or CTEP-AERS. 
 


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84 
10.4 Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions.  AEs reported 
expeditiously through CTEP-AERS must also be reported in routine study data 
submissions. 
 
Adverse event 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.  AEs are reported in a routine manner at scheduled times 
during the trial using Medidata Rave.  For this trial the Adverse Event CRF is used for routine 
AE reporting in Rave. 
 
10.5 Pregnancy 
 
Although not an adverse event in and of itself, pregnancy as well as its outcome must be 
documented via CTEP-AERS.  In addition, the Pregnancy Information Form included within 
the NCI Guidelines for Adverse Event Reporting Requirements must be completed and 
submitted to CTEP.  Any pregnancy occurring in a patient or patient’s partner from the time of 
consent to 90 days after the last dose of study drug must be reported and then followed for 
outcome.  Newborn infants should be followed until 30 days old.  Please see the “NCI 
Guidelines for Investigators: Adverse Event Reporting Requirements for DCTD (CTEP and CIP) 
and DCP INDs and IDEs” (at http://ctep.cancer.gov/protocolDevelopment/adverse_effects.htm) 
for more details on how to report pregnancy and its outcome to CTEP.  
 
10.6 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 secondary 
malignancy is not considered a metastasis of the initial neoplasm. 
 
CTEP requires all secondary malignancies that occur following treatment with an agent under an 
NCI IND/IDE be reported expeditiously via CTEP-AERS.  Three options are available to 
describe the event:  
 
x Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia [AML])  
x Myelodysplastic syndrome (MDS)  
x Treatment-related secondary malignancy  
 
Any malignancy possibly related to cancer treatment (including AML/MDS) should also be 
reported via the routine reporting mechanisms outlined in each protocol.  
 
10.7 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 AE 
reporting unless otherwise specified. 


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85 
 
11. STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 1 week prior to start of protocol therapy.  Scans 
and x-rays must be done <4 weeks prior to the start of therapy.  All assessments may have a +/- 2 
day window.  In the event that the patient’s condition is deteriorating, laboratory evaluations 
should be repeated within 48 hours prior to initiation of the next cycle of therapy. 
 
 
Pre- 
Study 
Cycle 1 
Cycle 2 
Cycle 3+ 
Off Studya 
Wk 
1 
Wk 
2 
Wk 
3 
Wk 
4 
Wk 
1 
Wk 
2 
Wk 
3 
Wk 
4 
Wk 
9 
Wk 
10 
Wk 
11 
Wk 
12 
Dasatinib 
 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
 
Icosapent ethyl (EPA) 
 
B 
B 
B 
B 
B 
B 
B 
B 
B 
B 
B 
B 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concurrent meds 
X 
X---------------------------------------------------------------------------------------------X 
 
Physical exam 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Vital signs 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Performance status 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC w/diff, plts 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
Serum chemistryb 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 PT w/INR & PTT 
X 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 Amylase and Lipase 
X 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 Lipid panel 
X 
 
 
 
 
X 
 
 
 
X 
 
 
 
X 
EKGg (at baseline and as 
indicated thereafter) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECHO or MUGA (at baseline 
and as indicated thereafter) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse event evaluation 
 
X---------------------------------------------------------------------------------------------X 
X 
Tumor measurements 
X 
Tumor measurements are repeated every 2 cycles.  Documentation (radiologic) must 
be provided for patients removed from study for progressive disease. 
X 
Radiologic evaluation 
X 
Radiologic measurements should be performed every 2 cycles. 
X 
Pregnancy testd 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Biopsy for research 
Xe 
 
 
 
 
 
 
 
Xf 
 
 
 
 
 
Blood collection for research 
Xe 
 
 
 
 
 
 
 
Xf 
 
 
 
 
 
HbA1c 
 Xh 
 
 
 
 
 
 
 
 
 
 
 
 
 
HIV, HBV, HCV viral load 
 Xh 
 
 
 
 
 
 
 
 
 
 
 
 
 
A: 
Dasatinib:  100 mg PO QD. 
B: 
Icosapent ethyl (EPA):  Dose as assigned, PO BID. 
a: 
Off-study evaluations within 1 month after and 3 months after final study treatment. 
b: 
Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, potassium, 


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86 
total protein, SGOT [AST], SGPT [ALT], sodium. 
d: 
Pregnancy test for women of childbearing potential. 
e:  
Baseline biopsy and blood collection to be performed within 1 week before starting study treatment. 
f:  
Second biopsy and blood collection to be performed ± 2 days after completing the 2nd cycle. 
g.      EKG at baseline is required and later checkup will be as clinically indicated as standard of care. 
h.      HbA1C at baseline for patients taken antidiabetic medication while A1c is not available only, HIV, HBV, HCV viral load for patients 
who have known history of positive tests/on treatment only. 
 
 
 


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87 
12. MEASUREMENT OF EFFECT 
 
12.1 Antitumor Effect – Solid Tumors 
 
For the purposes of this study, patients should be re-evaluated for response every 8 weeks.  In 
addition to a baseline scan, confirmatory scans should also be obtained 4 weeks following initial 
documentation of objective response. 
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1) [Eur J Ca 45:228-247, 2009].  Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph 
nodes are used in the RECIST criteria. 
 
12.1.1 Definitions 
 
Evaluable for Toxicity.  All patients will be evaluable for toxicity from the time of their first 
treatment with dasatinib. 
 
Evaluable for Objective Response.  Only those patients who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will 
be considered evaluable for response.  These patients will have their response classified 
according to the definitions stated below.  (Note:  Patients who exhibit objective disease 
progression prior to the end of cycle 1 will also be considered evaluable.) 
 
Evaluable Non-Target Disease Response.  Patients who have lesions present at baseline that are 
evaluable but do not meet the definitions of measurable disease, have received at least one cycle 
of therapy, and have had their disease re-evaluated will be considered evaluable for non-target 
disease.  The response assessment is based on the presence, absence, or unequivocal progression 
of the lesions.  
 
12.1.2 Disease Parameters 
 
Measurable Disease.  Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as ≥20 mm (≥2 cm) by chest x-ray or as 
≥10 mm (≥1 cm) with CT scan, MRI, or calipers by clinical exam.  All tumor measurements 
must be recorded in millimeters (or decimal fractions of centimeters). 
 
Note:  Tumor lesions that are situated in a previously irradiated area might or might not be 
considered measurable.   
 
Malignant Lymph Nodes.  To be considered pathologically enlarged and measurable, a lymph 
node must be ≥15 mm (≥1.5 cm) in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm [0.5 cm]).  At baseline and in follow-up, 
only the short axis will be measured and followed. 
 


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Non-Measurable Disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm [<1 cm] or pathological lymph nodes with ≥10 to <15 mm [≥1 to <1.5 cm] 
short axis), are considered non-measurable disease.  Bone lesions, leptomeningeal disease, 
ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
and abdominal masses (not followed by CT or MRI), are considered as non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not 
be considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, 
if they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions. 
 
Target Lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded 
and measured at baseline.  Target lesions should be selected on the basis of their size (lesions 
with the longest diameter), be representative of all involved organs, but in addition should be 
those that lend themselves to reproducible repeated measurements.  It may be the case that, on 
occasion, the largest lesion does not lend itself to reproducible measurement in which 
circumstance the next largest lesion which can be measured reproducibly should be selected.  A 
sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target 
lesions will be calculated and reported as the baseline sum diameters.  If lymph nodes are to be 
included in the sum, then only the short axis is added into the sum.  The baseline sum diameters 
will be used as reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 
 
Non-Target Lesions.  All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Measurements of these lesions are not required, but the presence, absence, 
or in rare cases unequivocal progression of each should be noted throughout follow-up.  
 
12.1.3 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment. 
 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam. 
 
Clinical Lesions.  Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and ≥10 mm (≥1 cm) diameter as assessed using 
calipers (e.g., skin nodules).  In the case of skin lesions, documentation by color photography, 


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including a ruler to estimate the size of the lesion, is recommended.  
 
Chest X-Ray.  Lesions on chest x-ray are acceptable as measurable lesions when they are clearly 
defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI.  This guideline has defined measurability of lesions on CT scan 
based on the assumption that CT slice thickness is 5 mm (0.5 cm) or less.  If CT scans have slice 
thickness greater than 5 mm (0.5 cm), the minimum size for a measurable lesion should be twice 
the slice thickness.  MRI is also acceptable in certain situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which greatly 
impact image quality, lesion conspicuity, and measurement.  Furthermore, the availability of 
MRI is variable globally.  As with CT, if an MRI is performed, the technical specifications of the 
scanning sequences used should be optimized for the evaluation of the type and site of disease.  
Furthermore, as with CT, the modality used at follow-up should be the same as was used at 
baseline and the lesions should be measured/assessed on the same pulse sequence.  It is beyond 
the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all 
scanners, body parts, and diseases.  Ideally, the same type of scanner should be used and the 
image acquisition protocol should be followed as closely as possible to prior scans.  Body scans 
should be performed with breath-hold scanning techniques, if possible. 
 
PET-CT.  At present, the low dose or attenuation correction CT portion of a combined PET-CT 
is not always of optimal diagnostic CT quality for use with RECIST measurements.  However, if 
the site can document that the CT performed as part of a PET-CT is of identical diagnostic 
quality to a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be 
used for RECIST measurements and can be used interchangeably with conventional CT in 
accurately measuring cancer lesions over time.  Note, however, that the PET portion of the CT 
introduces additional data which may bias an investigator if it is not routinely or serially 
performed.   
 
Ultrasound.  Ultrasound is not useful in assessment of lesion size and should not be used as a 
method of measurement.  Ultrasound examinations cannot be reproduced in their entirety for 
independent review at a later date and, because they are operator dependent, it cannot be 
guaranteed that the same technique and measurements will be taken from one assessment to the 
next.  If new lesions are identified by ultrasound in the course of the study, confirmation by CT 
or MRI is advised.  If there is concern about radiation exposure at CT, MRI may be used instead 
of CT in selected instances. 
 
Endoscopy, Laparoscopy.  The utilization of these techniques for objective tumor evaluation is 
not advised.  However, such techniques may be useful to confirm complete pathological 
response when biopsies are obtained or to determine relapse in trials where recurrence following 
complete response (CR) or surgical resection is an endpoint. 
 
Tumor Markers.  Tumor markers alone cannot be used to assess response.  If markers are 
initially above the upper normal limit, they must normalize for a patient to be considered in 


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complete clinical response.  Specific guidelines for both CA-125 response (in recurrent ovarian 
cancer) and PSA response (in recurrent prostate cancer) have been published [JNCI 96:487-488, 
2004; J Clin Oncol 17, 3461-3467, 1999; J Clin Oncol 26:1148-1159, 2008].  In addition, the 
Gynecologic Cancer Intergroup has developed CA-125 progression criteria which are to be 
integrated with objective tumor assessment for use in first-line trials in ovarian cancer [JNCI 
92:1534-1535, 2000]. 
 
Cytology, Histology.  These techniques can be used to differentiate between partial responses 
(PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as 
germ cell tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens 
during treatment when the measurable tumor has met criteria for response or stable disease is 
mandatory to differentiate between response or stable disease (an effusion may be a side effect of 
the treatment) and progressive disease. 
 
FDG-PET.  While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible 'new' disease).  New lesions on the basis of 
FDG-PET imaging can be identified according to the following algorithm:  
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD 
based on a new lesion. 
b. No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive FDG-
PET at follow-up corresponds to a new site of disease confirmed by CT, this is PD.  If the 
positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, 
additional follow-up CT scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-
PET scan).  If the positive FDG-PET at follow-up corresponds to a pre-existing site of 
disease on CT that is not progressing on the basis of the anatomic images, this is not PD. 
c. FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy in 
cases where a residual radiographic abnormality is thought to represent fibrosis or 
scarring.  The use of FDG-PET in this circumstance should be prospectively described in 
the protocol and supported by disease-specific medical literature for the indication.  
However, it must be acknowledged that both approaches may lead to false positive CR 
due to limitations of FDG-PET and biopsy resolution/sensitivity. 
 
Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake greater 
than twice that of the surrounding tissue on the attenuation corrected image. 
 
12.1.4 Response Criteria 
 
12.1.4.1 Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm (<1 cm). 
 


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Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target lesions, 
taking as reference the baseline sum diameters. 
 
Progressive Disease (PD):  At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the 
smallest on study).  In addition to the relative increase of 20%, the sum must also demonstrate an 
absolute increase of at least 5 mm (0.5 cm).  (Note:  the appearance of one or more new lesions is 
also considered progressions). 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum diameters while on study. 
 
12.1.4.2 Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and normalization of tumor 
marker level.  All lymph nodes must be non-pathological in size (<10 mm [<1 cm] short axis). 
 
Note:  If tumor markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response. 
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits. 
 
Progressive Disease (PD):  Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions.  Unequivocal progression should not normally trump 
target lesion status.  It must be representative of overall disease status change, not a single lesion 
increase. 
 
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the 
treating physician should prevail in such circumstances, and the progression status should be 
confirmed at a later time by the review panel (or Principal Investigator). 
 
12.1.4.3 Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started).  The patient's best response assignment will 
depend on the achievement of both measurement and confirmation criteria. 
 
For Patients with Measurable Disease (i.e., Target Disease) 
 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response when 
Confirmation is Required* 
CR 
CR 
No 
CR 
≥4 wks. Confirmation** 
CR 
Non-CR/Non-
PD 
No 
PR 
≥4 wks. Confirmation** 


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


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12.1.6 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression or death, 
whichever occurs first. 
 
12.1.7 Response Review 
 
The Quantitative Imaging Analyzing Core (QIAC) at MD Anderson Cancer Center will 
independently evaluate the treatment response based on the imaging results. 
 
13. STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 10 
(Adverse Events: List and Reporting Requirements). 
 
13.1 Study Oversight 
 
This protocol is monitored at several levels, as described in this section.  The Protocol Principal 
Investigator is responsible for monitoring the conduct and progress of the clinical trial, including 
the ongoing review of accrual, patient-specific clinical and laboratory data, and routine and 
serious adverse events; reporting of expedited adverse events; and accumulation of reported 
adverse events from other trials testing the same drug(s).  The Protocol Principal Investigator and 
statistician have access to the data at all times through the CTMS web-based reporting portal.   
 
For the Phase 1 portion of this study, all decisions regarding dose escalation/expansion/de-
escalation require sign-off by the Protocol Principal Investigator through the CTMS/IWRS.  In 
addition, for the Phase 1 portion, the Protocol Principal Investigator will have at least monthly 
conference calls with the Study Investigators [and, if needed, the CTEP Medical Officer(s)] to 
review accrual, progress, and adverse events and unanticipated problems.  
 
For a Phase 1/2 trial, enrollment to the Phase 2 portion of the trial will not begin until a protocol 
amendment has been submitted which summarizes the Phase 1 results, the recommended Phase 2 
dose, and the rationale for selecting it.  The amendment must be reviewed and approved by 
CTEP before enrollment to the Phase 2 portion can begin. 
 
All Study Investigators at participating sites who register/enroll patients on a given protocol are 
responsible for timely submission of data via Medidata Rave and timely reporting of adverse 
events for that particular study.  This includes timely review of data collected on the electronic 
CRFs submitted via Medidata Rave. 
 
All studies are also reviewed in accordance with the enrolling institution’s data safety monitoring 
plan. 
 
13.2 Data Reporting 
 


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Medidata Rave is a clinical data management system being used for data collection for this 
trial/study.  Access to the trial in Rave is controlled through the CTEP-IAM system and role 
assignments.   
Requirements to access Rave via iMedidata: 
 
x 
A valid account, and  
x 
Assigned a Rave role on the LPO or PO roster at the enrolling site of:  Rave CRA, Rave 
Read Only, Rave CRA (LabAdmin), Rave SLA, or Rave Investigator.   
Rave role requirements: 
 
o Rave CRA or Rave CRA (Lab Admin) role, must have a minimum of an 
Associate Plus (AP) registration type, 
o Rave Investigator role, must be registered as an Non-Physician Investigator 
(NPIVR) or Investigator (IVR), and 
o Rave Read Only role, site staff must have at a minimum an Associates (A) 
registration type. 
x 
Refer to https://ctep.cancer.gov/investigatorResources/default.htm for registration types 
and documentation required. 
 
If the study has a DTL, individuals requiring write access to Rave must also be assigned the 
appropriate Rave tasks on the DTL. 
 
Upon initial site registration approval for the study in Regulatory Support System (RSS), all 
persons with Rave roles assigned on the appropriate roster will be sent a study invitation email 
from iMedidata.  To accept the invitation, site staff must either click on the link in the email or 
log in to iMedidata via the CTSU members’ website  under Data Management > Rave Home and 
click to accept the invitation in the Tasks pane located in the upper right-corner of the iMedidata 
screen.  Site staff will not be able to access the study in Rave until all required Medidata and 
study specific trainings are completed.  Trainings will be in the form of electronic learnings 
(eLearnings) and can be accessed by clicking on the eLearning link in the Tasks pane located in 
the upper right corner of the iMedidata screen.  If an eLearning is required for a study and has 
not yet been taken, the link to the eLearning will appear under the study name in the Studies 
pane located in the center of the iMedidata screen; once the successful completion of the 
eLearning has been recorded, access to the study in Rave will be granted, and a Rave EDC link 
will replace the eLearning link under the study name.  
 
Site staff that have not previously activated their iMedidata/Rave account at the time of initial 
site registration approval for the study in RSS will receive a separate invitation from iMedidata 
to activate their account.  Account activation instructions are located on the CTSU website in the 
Data Management section under the Rave resource materials (Medidata Account Activation and 
Study Invitation Acceptance).  Additional information on iMedidata/Rave is available on the 
CTSU members’ website in the Data Management > Rave section at www.ctsu.org/RAVE/ or by 
contacting the CTSU Help Desk at 1-888-823-5923 or by email at ctsucontact@westat.com.   
 
13.2.1 Method 
 


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This study will be monitored by the Clinical Trials Monitoring Service (CTMS).  Data will be 
submitted to CTMS at least once every two weeks via Medidata Rave (or other modality if 
approved by CTEP).  Information on CTMS reporting is available at 
http://www.theradex.com/clinicalTechnologies/?National-Cancer-Institute-NCI-11.  On-site 
audits will be conducted three times annually (one annual site visit and two data audits).  For 
CTMS monitored studies, after users have activated their accounts, please contact the Theradex 
Help Desk at (609) 619-7862 or by email at CTMSSupport@theradex.com for additional support 
with Rave and completion of CRFs. 
 
13.2.2 Responsibility for Data Submission 
 
For ETCTN trials, it is the responsibility of the PI(s) at the site to ensure that all investigators at 
the ETCTN Sites understand the procedures for data submission for each ETCTN protocol and 
that protocol specified data are submitted accurately and in a timely manner to the CTMS via the 
electronic data capture system, Medidata Rave.   
 
Data are to be submitted via Medidata Rave to CTMS on a real-time basis, but no less than once 
every 2 weeks.  The timeliness of data submissions and timeliness in resolving data queries will 
be tracked by CTMS.  Metrics for timeliness will be followed and assessed on a quarterly basis.  
For the purpose of Institutional Performance Monitoring, data will be considered delinquent if it 
is greater than 4 weeks past due. 
 
Data from Medidata Rave and CTEP-AERS is reviewed by the CTMS on an ongoing basis as 
data is received.  Queries will be issued by CTMS directly within Rave.  The queries will appear 
on the Task Summary Tab within Rave for the CRA at the ETCTN to resolve.  Monthly web-
based reports are posted for review by the Drug Monitors in the IDB, CTEP.  Onsite audits will 
be conducted by the CTMS to ensure compliance with regulatory requirements, GCP, and NCI 
policies and procedures with the overarching goal of ensuring the integrity of data generated 
from NCI-sponsored clinical trials, as described in the ETCTN Program Guidelines, which may 
be found on the CTEP 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm)  and 
CTSU websites. 
 
CTMS will utilize a core set of eCRFs that are Cancer Data Standards Registry and Repository 
(caDSR) compliant (http://cbiit.nci.nih.gov/ncip/biomedical-informatics-
resources/interoperability-and-semantics/metadata-and-models).  Customized eCRFs will be 
included when appropriate to meet unique study requirements.  The PI is encouraged to review 
the eCRFs, working closely with CTMS to ensure prospectively that all required items are 
appropriately captured in the eCRFs prior to study activation.  CTMS will prepare the eCRFs 
with built-in edit checks to the extent possible to promote data integrity. 
 
CDUS data submissions for ETCTN trials activated after March 1, 2014, will be carried out by 
the CTMS contractor, Theradex.  CDUS submissions are performed by Theradex on a monthly 
basis.  The trial’s lead institution is responsible for timely submission to CTMS via Rave, as 
above. 
 


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Further information on data submission procedures can be found in the ETCTN Program 
Guidelines 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm). 
 
13.3 Data Quality Portal 
 
The Data Quality Portal (DQP) provides a central location for site staff to manage 
unanswered queries and form delinquencies, monitor data quality and timeliness, 
generate reports, and review metrics.  
 
The DQP is located on the CTSU members’ website under Data Management.  The Rave 
Home section displays a table providing summary counts of Total Delinquencies and 
Total Queries.  DQP Queries, DQP Delinquent Forms, DQP Form Status and the DQP 
Reports modules are available to access details and reports of unanswered queries, 
delinquent forms, forms with current status and timeliness reports.  Review the DQP 
modules on a regular basis to manage specified queries and delinquent forms. 
 
The DQP is accessible by site staff that are rostered to a site and have access to the CTSU 
website.  Staff that have Rave study access can access the Rave study data using a direct 
link on the DQP. 
 
To learn more about DQP use and access, click on the Help icon displayed on the Rave 
Home, DQP Queries, DQP Delinquent Forms modules, DQP Form Status, and DQP 
Reports. 
 
13.4 CTEP Multicenter Guidelines 
 
N/A 
 
13.5 Collaborative Agreements Language 
 
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 


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97 
member participating on the study, the individual should sign a confidentiality agreement.  A 
suitable model agreement can be downloaded from: http://ctep.cancer.gov. 
 
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.  


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98 
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 
 
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. 
 
13.6 Genomic Data Sharing Plan 
 
N/A 
 
13.7 Incidental/Secondary Findings Disclosure Procedure 
 
N/A 
 
 


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Calder, P.C.  (2010).  Omega-3 fatty acids and inflammatory processes.  Nutrients.  2(3):355-
374. 
 
Cassetta, L. and T. Kitamura.  (2018).  Targeting Tumor-Associated Macrophages as a Potential 
Strategy to Enhance the Response to Immune Checkpoint Inhibitors.  Front Cell Dev Biol.  6:38. 
 
Chou, T.C.  (2010).  Drug combination studies and their synergy quantification using the Chou-
Talalay method.  Cancer Res.  70(2):440-446. 
 
Demetri, G.D., P. Lo Russo, I.R.J. MacPherson, et al.  (2009).  Phase I dose-escalation and 
pharmacokinetic study of dasatinib in patients with advanced solid tumors.  Clin Cancer Res.  
15:6232-6240. 
 
Donato, N.J., J. Wu, L.Y. Kong, et al.  (2004).  The SRC/ABL inhibitor BMS-354825 
overcomes resistance to imatinib mesylate in chronic myelogenous leukemia cells through 
multiple mechanisms.  Blood.  104:A1989. 
 
Ford, N.A., E.L. Rossi, K. Barnett, et al.  (2015).  Omega-3-Acid Ethyl Esters Block the 
Protumorigenic Effects of Obesity in Mouse Models of Postmenopausal Basal-like and Claudin-
Low Breast Cancer.  Cancer Prev Res (Phila).  8(9):796-806. 
 
Goldner, B., C.E. Behrendt, H.F. Schoellhammer, et al.  (2014).  Incidence of inflammatory 
breast cancer in women, 1992-2009, United States.  Ann Surg Oncol.  21(4):1267-1270. 
 
Goossens, P., J. Rodriguez-Vita, A. Etzerodt, et al.  (2019).  Membrane Cholesterol Efflux 
Drives Tumor-Associated Macrophage Reprogramming and Tumor Progression.  Cell Metab.  
29(6):1376-1389. 
 
Hance, K.W., W.F. Anderson, S.S. Devesa, et al.  (2005).  Trends in inflammatory breast 
carcinoma incidence and survival: the surveillance, epidemiology, and end results program at the 
National Cancer Institute.  J Natl Cancer Inst.  97(13):966-975. 
 
Harano, K., T. Kogawa, J. Wu, et al.  (2017).  Thrombocytosis as a prognostic factor in 
inflammatory breast cancer.  Breast Cancer Res Treat.  166(3):819-832. 
 
Hochhaus, A., and T. Hughes.  (2004).  Clinical resistance to imatinib:  Mechanisms and 


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implications.  Hematol Oncol Clin North Amer.  18:641-656. 
 
Horton, J.D., J.L. Goldstein, and M.S. Brown.  (2002).  SREBPs: activators of the complete 
program of cholesterol and fatty acid synthesis in the liver.  J Clin Invest.  109(9):1125-1131. 
 
Huang, J., W. Hu, J. Bottsford-Miller, et al.  (2014).  Cross-talk between EphA2 and BRaf/CRaf 
is a key determinant of response to Dasatinib.  Clin Cancer Res.  20(7):1846-1855. 
 
Hunter, T.  (1997).  Oncoprotein networks.  Cell.  88:333-346. 
 
Investigator's Brochure.  (2020).  Dasatinib.  BMS-354825.  Bristol-Myers Squibb. Version No:  
20.  Version Date:  June 2020.  
 
Ireton, R.C. and Chen, J.  (2005).  EphA2 receptor tyrosine kinase as a promising target for 
cancer therapeutics.  Curr Cancer Drug Targets.  5(3):149-157. 
 
Jaureguiberry, M.S., M.A. Tricerri, S.A. Sanchez, et al.  (2014).  Role of plasma membrane lipid 
composition on cellular homeostasis: learning from cell line models expressing fatty acid 
desaturases.  Acta Biochim Biophys Sin (Shanghai).  46(4):273-282. 
 
Johnson, F.M., B. Saigal, M. Talpaz, and N.J. Donato.  (2005).  BMS-354825 tyrosine kinase 
inhibitor suppresses invasion and induces cell cycle arrest and apoptosis of head and neck 
squamous cell carcinoma (HNSCC) and non-small cell lung cancer (NSCLC) cells.  Clin Cancer 
Res.  11:6924-6932. 
 
Landen, C.N. Jr., A. Chavez-Reyes, C. Bucana, et al.  (2005).  Therapeutic EphA2 gene targeting 
in vivo using neutral liposomal small interfering RNA delivery.  Cancer Res.  65(15):6910-6918. 
 
Lee, F.Y., L. Lombardo, R. Borzilleri, et al.  (2004).  BMS-354825 - A potent dual SRC/ABL 
kinase inhibitor possessing curative efficacy against imatinib sensitive and resistant human CML 
models in vivo.  Proc Am Assoc Cancer Res.  45:A3987. 
 
Lee, J., R. Galloway, G. Grandjean, et al.  (2015).  Comprehensive Two- and Three-Dimensional 
RNAi Screening Identifies PI3K Inhibition as a Complement to MEK Inhibitor AS703026 for 
Combination Treatment of Triple-Negative Breast Cancer.  J Cancer.  6(12):1306-1319. 
 
Lehmann, B.D., B. Jovanovic, X. Chen, et al.  (2016).  Refinement of Triple-Negative Breast 
Cancer Molecular Subtypes: Implications for Neoadjuvant Chemotherapy Selection.  PLoS One.  
11(6):e0157368. 
 
Li S., Y. Hu, S.J. Swerdlow, et al.  (2004).  Simultaneous targeting of SRC and BCR-ABL 
kinases by BMS-354825 cures Ph+ acute lymphoblastic leukemia in mice.  Blood.  104:Abstr. 
1976. 
 
Lim, B., W.A. Woodward, X. Wang, et al.  (2018).  Inflammatory breast cancer biology: the 
tumour microenvironment is key.  Nature Rev Cancer.  18(8):485-499. 


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Lipponen, P., S. Aaltomaa, V.M. Kosma, et al.  (1994).  Apoptosis in breast cancer as related to 
histopathological characteristics and prognosis.  Eur J Cancer.  30A(14):2068-2073. 
 
Liu, S., and Y. Yuan.  (2015).  Bayesian optimal interval designs for phase I clinical trials. 
Journal of the Royal Statistical Society Applied Statistics Series C.  64(3):507-523. 
 
Lombardo, L.J., F.Y. Lee, P. Chen, et al.  (2004).  Discovery of N-(2-chloro-6-methyl-phenyl)-2-
(6-(4-(2-hydroxyethyl)-piperazin-1-yl)-2-methylpyrimidin-4-ylamino)thiazole-5-carboxamide 
(BMS-354825), a dual Src/Abl kinase inhibitor with potent antitumor activity in preclinical 
assays.  J Med Chem.  47:6658-6661. 
 
Luo F.R., Z. Yang, A. Camuso, et al.  (2005).  Pharmacodynamic biomarker.  Proc Am Assoc 
Cancer Res. 46:A4183. 
 
Masuda, H., K.A. Baggerly, Y. Wang, et al.  (2013).  Comparison of molecular subtype 
distribution in triple-negative inflammatory and non-inflammatory breast cancers.  Breast 
Cancer Res.  15(6):R112. 
 
McAuliffe, P.F., K.W. Evans, A. Akcakanat, et al.  (2015).  Ability to Generate Patient-Derived 
Breast Cancer Xenografts Is Enhanced in Chemoresistant Disease and Predicts Poor Patient 
Outcomes.  PLoS One.  10(9):e0136851. 
 
Miserez, A.R., P.Y. Muller, L. Barella, et al.  (2002).  Sterol-regulatory element-binding protein 
(SREBP)-2 contributes to polygenic hypercholesterolaemia.  Atherosclerosis.  164(1):15-26. 
 
Nandi, S., L. Ma, M. Denis, et al.  (2009).  ABCA1-mediated cholesterol efflux generates 
microparticles in addition to HDL through processes governed by membrane rigidity.  J Lipid 
Res.  50(3):456-466. 
 
Ozer H., J.O. Armitage, C.L. Bennett, et al., for the American Society of Clinical Oncology 
Growth Factors Expert Panel.  (2000).  2000 update of recommendations for the use of 
hematopoietic colony-stimulating factors:  Evidence-based, clinical practice guidelines.  J Clin 
Oncol.  18:3558-3585.  
 
Paixao, E., A.C.M. Oliveira, N. Pizato, et al.  (2017).  The effects of EPA and DHA enriched 
fish oil on nutritional and immunological markers of treatment naive breast cancer patients: a 
randomized double-blind controlled trial.  Nutr J.  16(1):71. 
 
Pusztai, L., S. Moulder, M. Altan, et al.  (2014).  Gene signature-guided dasatinib therapy in 
metastatic breast cancer.  Clinical Cancer Res.  20(20):5265-5271. 
 
Rahal, O.M., A.R. Wolfe, P.K. Mandal, et al.  (2018).  Blocking Interleukin (IL)4- and IL13-
Mediated Phosphorylation of STAT6 (Tyr641) Decreases M2 Polarization of Macrophages and 
Protects Against Macrophage-Mediated Radioresistance of Inflammatory Breast Cancer.  Int J 
Radiat Oncol Biol Phys.  100(4):1034-1043. 


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Reddy, S.M., A. Reuben, S. Barua, et al.  (2019).  Poor Response to Neoadjuvant Chemotherapy 
Correlates with Mast Cell Infiltration in Inflammatory Breast Cancer.  Cancer Immunol Res.  
7(6):1025-1035. 
 
Salinas, M.L., N.R. Fuentes, R. Choate, et al.  (2020).  AdipoRon Attenuates Wnt Signaling by 
Reducing Cholesterol-Dependent Plasma Membrane Rigidity.  Biophys J.  118(4):885-897 
 
Sawyers, C.L., N.P. Shah, H.M. Kantarjian, et al.  (2005).  A phase I study of BMS-354825 in 
patients with imatinib-resistant and intolerant accelerated and blast phase chronic myeloid 
leukemia (CML):  Results from CA180002.  Proc Am Soc Clin Oncol.  24:A6520. 
 
Schittenhelm, M., S. Shiraga, F.Y. Lee, and M.C. Heinrich.  (2006).  Dasatinib (BMS-354825), a 
dual SRC/ABL kinase inhibitor, inhibits the kinase activity of wild-type, juxtamembrane, and 
activation loop mutant KIT isoforms associated with human malignancies.  Cancer Res.  66:473-
481. 
 
Shah, N.P.  (2005).  Loss of response to imatinib:  Mechanisms and management.  Hematology 
Am Soc Hematol Educ Program.  183-187. 
 
Shah, N.P., F.Y. Lee, R. Luo, et al.  (2005).  Dasatinib (BMS-354825) inhibits KITD816V, an 
imatinib-resistant activating mutation that triggers neoplastic growth in the majority of patients 
with systemic mastocytosis.  Blood.  108:286-291. 
 
Shah, N.P., C. Tran, F.Y. Lee, and C.L. Sawyers.  (2004).  BMS-354825 is a novel orally 
bioavailable small molecule ABL tyrosine kinase inhibitor that successfully and safely inhibits 
the kinase activity of multiple imatinib-resistant BCR-ABL isoforms in vitro and in vivo.  Proc 
Am Assoc Can Res.  45:A5624. 
 
Tall, A.R., P. Costet, and N. Wang.  (2002).  Regulation and mechanisms of macrophage 
cholesterol efflux.  J Clin Invest.  110(7):899-904. 
 
Talpaz, M., N.P. Shah, H. Kantarjian, et al.  (2006).  Dasatinib in imatinib-resistant Philadelphia 
chromosome-positive leukemias.  N Engl J Med.  354:2531-2541.  
 
Tokarski, J.S., J. Newitt, F.Y. Lee, et al.  (2004).  The crystal structure of Abl kinase with BMS-
354825, a dual SRC/ABL kinase inhibitor.  Blood.  104:A553. 
 
Torres-Adorno, A.M., H. Vitrac, Y. Qi, et al.  (2019).  Eicosapentaenoic acid in combination 
with EPHA2 inhibition shows efficacy in preclinical models of triple-negative breast cancer by 
disrupting cellular cholesterol efflux.  Oncogene.  38(12):2135-2150. 
 
VASCEPA (package insert).  Bridgewater, NJ: Amarin Pharma, Inc.; 2019. 
 
Volpato, M., S.L. Perry, G. Marston, et al.  (2016).  Changes in plasma chemokine C-C motif 
ligand 2 levels during treatment with eicosapentaenoic acid predict outcome in patients 


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undergoing surgery for colorectal cancer liver metastasis.  Oncotarget.  7(19):28139-28150. 
 
Wolfe, A.R., N.J. Trenton, B.G. Debeb, et al.  (2016).  Mesenchymal stem cells and 
macrophages interact through IL-6 to promote inflammatory breast cancer in pre-clinical models.  
Oncotarget.  7(50):82482-82492. 
 
Wu, J.Y., N.J. Donato, D.S. Hong, et al.  (2004).  The SRC/ABL kinase inhibitor BMS-354825 
induces apoptosis and overcomes imatinib resistance in chronic myelogenous leukemia cell lines 
and patient specimens.  Proc Am Assoc Can Res.  45:A3850. 
 
Zong, Z., J. Zou, R. Mao, et al.  (2019).  M1 Macrophages Induce PD-L1 Expression in 
Hepatocellular Carcinoma Cells Through IL-1beta Signaling.  Front Immunol.  10:1643. 
 
 
 


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APPENDIX A 
PERFORMANCE STATUS CRITERIA 
 
ECOG Performance Status Scale 
Grade 
Descriptions 
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
1 
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
2 
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
5 
Dead. 
 
 
 


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APPENDIX B FORMULA TO ESTIMATE RENAL FUNCTION USING SERUM 
CREATININE 
 
Formulas to estimate renal function using serum creatinine provided by the NCI’s Investigational Drug 
Steering Committee (IDSC) Pharmacological Task Force in table below. 
 
1. Estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology 
Collaboration (CKD-EPI) (Levey et al., 2009). 
 
Formulae: 
 
Race and 
Sex 
Serum Creatinine (SCr), 
μmol/L (mg/dL) 
Equation 
Black 
 
 
Female 
≤62 (≤0.7) 
GFR = 166 × (SCr/0.7)−0.329 × (0.993)Age 
 
>62 (>0.7) 
GFR = 166 × (SCr/0.7)−1.209 × (0.993)Age 
Male 
≤80 (≤0.9) 
GFR = 163 × (SCr/0.9)−0.411 × (0.993)Age 
 
>80 (>0.9) 
GFR = 163 × (SCr/0.9)−1.209 × (0.993)Age 
 
 
 
White or 
other 
 
 
Female 
≤62 (≤0.7) 
GFR = 144 × (SCr/0.7)−0.329 × (0.993)Age 
 
>62 (>0.7) 
GFR = 144 × (SCr/0.7)−1.209 × (0.993)Age 
Male 
≤80 (≤0.9) 
GFR = 141 × (SCr/0.9)−0.411 × (0.993)Age 
 
>80 (>0.9) 
GFR = 141 × (SCr/0.9)−1.209 × (0.993)Age 
 
SCr in mg/dL; Output is in mL/min/1.73 m2 and needs no further conversions. 
 
2. eGFR using the Modification of Diet in Renal Disease (MDRD) Study (Levey et al., 2006). 
 
175 x SCr–1.154 × age–0.203 × 0.742 (if female) × 1.212 (if black) 
Output is in mL/min/1.73 m2 and needs no further conversions. 
3. Estimated creatinine clearance (ClCr) by the Cockcroft-Gault (C-G) equation (Cockcroft and 
Gault, 1976). 
 
 
Followed by conversion to a value normalized to 1.73 m2 with the patient’s body surface area 
(BSA). 
 
References 
1. Levey, A.S., L.A. Stevens, C.H. Schmid, et al.  (2009).  A new equation to estimate glomerular 
filtration rate.  Ann Inter Med.  150:604-612. 
2. Levey, A.S., J. Coresh, T. Greene, et al.  (2006).  Using standardized serum creatinine values in the 
modification of diet in renal disease study equation for estimating glomerular filtration rate.  Ann 
Intern Med.  145:247-254. 
3. Cockcroft, D.W. and M.H. Gault.  (1976).  Prediction of creatinine clearance from serum 
creatinine.  Nephron.  16:31-41. 
 


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APPENDIX C
PATIENT CLINICAL TRIAL WALLET CARD
CLINICAL TRIAL WALLET CARD
Show this card to all of your 
healthcare providers and keep 
it with you in case you go to 
the emergency room.
Patient Name:  
Diagnosis:  
Study Doctor: 
Study Doctor Phone #: 
NCI Trial #:  10480
Study Drug(S):  
Dasatinib
Icosapent ethyl
For more information: 1-800-4-CANCER
cancer.gov | clinicaltrials.gov


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APPENDIX D
PATIENT’S MEDICATION DIARY
Appendix D1
Patient Medication Diary for Dasatinib
PATIENT’S MEDICATION DIARY
Today’s date _________________________
Agent __Dasatinib___ Dose __________________
Patient Name_________________________ (initials acceptable)  Patient Study ID ________________________
INSTRUCTIONS TO THE PATIENT:
1.
Complete one form for each cycle of treatment (4 weeks).
2.
You will take ___ 20 mg tablets and ____ 50 mg tablets once at the same time each day.  You should take 
the tablets with 8 oz. water.  You may take the tablets with or without food as you wish.  
3.
Tablets must be swallowed whole and may not be broken.  
4.
If vomiting occurs within 30 minutes of swallowing the tablet(s), the dose may be replaced if the tablets can 
be seen and counted.
5.     If a dose is missed, then take your next dose on the next day and in the pre-specified amount. You need to 
record the missed dose and date on the medication diary.  Do not take any more than the pre-specified 
amount.
6.
Record the date, the number of tablets you took, and when you took them.  
7.
If you have any comments or notice any side effects, please record them in the Comments column.  
8.
Please bring this form and your bottles of dasatinib tablets when you return for each appointment.
Day
Date
Time of dose
# of 20 mg 
tablets taken
# of 50 mg 
tablets taken
Comments
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
CTEP-assigned Protocol #_10480____
Local Protocol # ___________________


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24 
 
 
 
 
 
25 
 
 
 
 
 
26 
 
 
 
 
 
27 
 
 
 
 
 
28 
 
 
 
 
 
 
Patient’s Signature_____________________________________________________________________________ 
Physician’s Office will complete this section: 
1. 
Date patient started protocol treatment______________________________________________________ 
2. 
Date patient was removed from study_______________________________________________________ 
3. 
Patient’s planned total daily dose___________________________________________________________ 
4. 
Total number of tablets taken this month ____________________________________________________ 
5. 
Physician/Nurse/Data Manager’s Signature __________________________________________________ 
 
 
 


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109 
Appendix D2 
Patient Medication Diary for Icosapent Ethyl 
 
 
 
 
PATIENT’S MEDICATION DIARY 
 
Today’s date _________________________ 
Agent _ Icosapent ethyl_ Dose __________________ 
Patient Name_________________________ (initials acceptable)  Patient Study ID ________________________ 
 
INSTRUCTIONS TO THE PATIENT: 
1. 
Complete one form for each cycle of treatment. 
2. 
You will take icosapent ethyl (VASCEPA) capsules twice each day with food about 12 hours apart.   
 
Morning dose:  take ___500 mg capsules and ___ 1000 mg capsules. 
 
Evening dose:  take ___ 500 mg capsules and ___ 1000 mg capsules.  
3. 
The capsules are to be swallowed whole and cannot be broken, crushed, dissolved, or chewed.   
4. 
If one dose of the daily two dose schedule is missed, the capsule should be taken as soon as possible 
 
within the same day.  In the case where both doses of the daily two dose schedule are omitted, the 
 
capsules should not be doubled the next day. 
5.      If vomiting occurs within 30 minutes of swallowing the capsules, then the dose may be replaced if the 
capsules can be seen and counted. 
3. 
Record the date, the number of capsules of each size of capsule that you took, and when you took them.   
5. 
If you have any comments or notice any side effects, please record them in the Comments column.   
6. 
Please bring this form and your bottles of icosapent ethyl (VASCEPA) capsules when you return for each 
appointment. 
 
Day 
 
Date 
Time of 
morning 
dose 
# of capsules taken 
Time of 
evening 
dose 
# of capsules taken 
Comments 
 
500 mg 
 
1000 mg 
 
500 mg 
 
1000 mg 
 
1 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
3 
 
 
 
 
 
 
 
 
4 
 
 
 
 
 
 
 
 
5 
 
 
 
 
 
 
 
 
6 
 
 
 
 
 
 
 
 
7 
 
 
 
 
 
 
 
 
8 
 
 
 
 
 
 
 
 
9 
 
 
 
 
 
 
 
 
10 
 
 
 
 
 
 
 
 
11 
 
 
 
 
 
 
 
 
12 
 
 
 
 
 
 
 
 
13 
 
 
 
 
 
 
 
 
14 
 
 
 
 
 
 
 
 
15 
 
 
 
 
 
 
 
 
16 
 
 
 
 
 
 
 
 
17 
 
 
 
 
 
 
 
 
18 
 
 
 
 
 
 
 
 
19 
 
 
 
 
 
 
 
 
20 
 
 
 
 
 
 
 
 
21 
 
 
 
 
 
 
 
 
22 
 
 
 
 
 
 
 
 
23 
 
 
 
 
 
 
 
 
24 
 
 
 
 
 
 
 
 
25 
 
 
 
 
 
 
 
 
 
CTEP-assigned Protocol #_10480____ 
 
Local Protocol # ___________________ 


NCI Protocol #: 10480 
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110 
26 
 
 
 
 
 
 
 
 
27 
 
 
 
 
 
 
 
 
28 
 
 
 
 
 
 
 
 
 
Patient’s signature     ___________________________________________________________________________ 
 
Physician’s Office will complete this section: 
1. 
Date patient started protocol treatment____ _________________ _________________________________ 
2. 
Date patient was removed from study________________________________________________________ 
3. 
Patient’s planned total daily dose________________________ ___________________________________ 
4. 
Total number of capsules taken this month ____________________________________ _______________ 
5. 
Physician/Nurse/Data Manager’s Signature ___________________________________________________ 
 
 


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APPENDIX E 
PRE-BIOPSY ASSESSMENT 
 
A pre-biopsy lesion assessment can increase trial safety and efficiency.  By agreement between 
all investigators, an attempt at biopsy will be made if the clinical trial team determines that a 
biopsy poses minimal relative risk, provides potential clinical gain to the participant, and will 
likely yield sufficient tissue for analysis.   
 
Pre-biopsy assessments will be reported and tracked through a trial-specific CRF within the 
CTEP Medidata Rave system.  Additional information can be found in the Investigational 
Radiology SOP available at:   
https://ctep.cancer.gov/initiativesPrograms/docs/ETCTN_IR_Research_Biopsy_SOP.pdf.  
 
Individual Patient Pre-Biopsy Assessment.  IR co-investigators are encouraged to apply this 
pre-biopsy scoring and correlation system to assist in the determination of biopsy 
appropriateness. 
 
x IR co-investigators assign a subjective score of 1-3 based on likelihood of success due to 
lesion characteristics.  
 
1.  Biopsy should not be done  
A. Due to safety concerns 
B. Due to lack of suitable lesion for biopsy 
 
2.  Uncertainty about success  
A. Due to access path to lesion 
B. Due to lesion characteristics  
 
3.  Likely successful  
 
x Lesion characteristics to be considered 
x Size (small) (<2 cm) 
x Location/path to lesion 
x Morphologic features (necrosis, sub-solid, sclerosis, ill-defined/infiltrative) 
x PET (+/-), avidity  
x Organ/site (sclerotic bone is low yield; fine needle aspiration to be used) 
 


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APPENDIX F 
TISSUE BIOPSY VERIFICATION 
 
A copy of the diagnostic pathology report must be shipped with all tissue specimens sent to the 
EET Biobank. 
 
If the corresponding pathology report is not available for the biopsy, then a copy of the 
radiology report or operative report from the biopsy procedure and the diagnostic 
pathology report must be sent to the EET Biobank. A completed copy of this appendix 
(i.e., Tissue Biopsy Verification) must also be submitted to the EET Biobank. 
 
Note: If this information is not provided with the biopsy specimen, then it will not be accepted 
by the EET Biobank. 
 
 
 
Please have the Clinician* responsible for signing out this patient’s case complete the following: 
 
ETCTN Universal Patient ID:  
 
 
ETCTN Patient Study ID:   
 
 
Date of Procedure (mm/dd/yyyy):   
 
 
Tissue Type (circle one): 
Primary 
Metastatic 
 
Time point (circle one):  Baseline 
Completion of Cycle 2 (±2 days)  
 
Site Tissue Taken From:   
 
 
Diagnosis:   
 
 
I agree that this tissue may be released for research purposes only and that the release of this 
tissue will not have any impact on the patient’s care. 
 
 
 
Clinician Signature 
Date 
 
 
 
Clinician Printed Name 
 
*Note: For the purposes of this form, Clinician could include the Nurse Practitioner, Registered Nurse, Pathologist, 
Radiologist, Interventional Radiologist, Surgeon, Oncologist, Internist, or other medical professional responsible for 
the patient’s care.  
 
Version: 1 


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APPENDIX G 
SUBSTANCES PROHIBITED DURING DASATINIB 
TREATMENT 
 
CYP3A4 Inhibitors: 
x itraconazole, ketoconazole, miconazole, voriconazole 
x amprenavir, atazanavir, fosamprenavir, indinavir, nelfinavir, ritonavir 
x ciprofloxacin, clarithromycin, diclofenac, doxycycline, enoxacin, imatinib, isoniazid, 
ketamine nefazodone, nicardipine, propofol, quinidine, telithromycin 
 
CYP3A4 Inducers: 
x aminoglutethimide, primidone, rifabutin, rifampin, St. John’s wort 
x carbamazepine, nevirapine, oxcarbazepine, rifapentine 
x fosphenytoin, pentobarbital, phenobarbital, phenytoin 
 
Agents with Proarrhythmic Potential 
x quinidine, procainamide, disopyramide, amiodarone, sotalol, ibutilide, dofetilide 
x erythromycins, clarithromycin 
x chlorpromazine, haloperidol, mesoridazine, thioridazine, pimozide 
x cisapride, bepridil, droperidol, methadone, arsenic, chloroquine, domperidone, 
halofantrine, levomethadyl, pentamidine, sparfloxacin, lidoflazine 
 
Systemic antacids  
x Both H2 receptor antagonists and proton pump inhibitors are prohibited on dasatinib 
trials.  Locally acting antacids can be given up to two hours prior or two hours following 
dasatinib administration.   
 
 


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114 
 
APPENDIX H 
NCLN PHARMACODYNAMICS LABORATORY FROZEN 
BIOPSY COLLECTION PROCEDURE 
 
 


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Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 2 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
 
 
TABLE OF CONTENTS 
 
1.0 
PURPOSE ..................................................................................................................................................... 3 
2.0 
SCOPE .......................................................................................................................................................... 3 
3.0 
ABBREVIATIONS ...................................................................................................................................... 3 
4.0 
INTRODUCTION ........................................................................................................................................ 3 
5.0 
ROLES AND RESPONSIBILITIES ............................................................................................................ 3 
6.0 
MATERIALS AND EQUIPMENT REQUIRED ......................................................................................... 4 
7.0 
OPERATING PROCEDURES ..................................................................................................................... 5 
8.0 
SHIP TO EET BIOBANK ............................................................................................................................ 9 
APPENDIX 1: BIOPSY COLLECTION RECORD ........................................................................................................ 12 
 
 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 3 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
 
1.0 
PURPOSE 
Standardize the method for collecting, handling, and shipping frozen needle tumor biopsies to EET Biobank 
to enable measurement of pharmacodynamic (PD) markers following treatment with anti-cancer agents.  
 
2.0 
SCOPE 
This procedure applies to all personnel involved in the collection and handling of frozen needle tumor 
biopsies for use in PD marker assays during clinical trials. The goal of this SOP and associated training is to 
ensure consistency in tumor needle biopsy collection and handling between clinical sites.. 
 
3.0 
ABBREVIATIONS 
 
DCTD 
= Division of Cancer Treatment and Diagnosis 
EET Biobank 
= NCI Early-Phase and Experimental Clinical Trials Biospecimen Bank, 
also referred to as the Nationwide Biorepository or ETCTN 
Biorepository 
FNLCR 
= Frederick National Laboratory for Cancer Research 
ID 
= Identification / Identifier 
IQC 
= Internal Quality Control 
LHTP 
= Laboratory of Human Toxicology and Pharmacology 
PADIS 
= Pharmacodynamics Assay Development & Implementation Section 
PD 
= Pharmacodynamic 
SOP 
= Standard Operating Procedure 
 
4.0 
INTRODUCTION 
Specimen handling, shipping, and storage procedures (pre-analytical variables) can have a significant impact 
on the reliability of biomarker measurements in the laboratory. Following detailed steps for sample collection 
and handling procedures and recording any deviations from this procedure allow retrospective identification 
of artifactual changes in biomarker readout and increases the reliability of the data and validity of the 
analytical results.  
 
5.1 
ROLES AND RESPONSIBILITIES 
Laboratory Director/Supervisor: The Laboratory Director/Supervisor directs laboratory operations, supervises technical 
personnel and reporting of findings, and is responsible for the proper performance of all 
laboratory procedures. Oversees the personnel who follow the SOPs in the laboratory 
and is responsible for ensuring the personnel are certified and have sufficient experience 
to handle clinical samples.  


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 4 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
Certified Assay Operator and/or PK/PD Support Lab Personnel: An assay operator and/or PK/PD Support Lab 
personnel may be a Laboratory Technician/Technologist, Research 
Associate, or Laboratory Scientist who has been trained by DCTD personnel 
on this SOP. Working under the guidance of the Laboratory 
Director/Supervisor, this person performs laboratory procedures and 
examinations in accordance with the current SOP(s), as well as any other 
procedures conducted by a laboratory, including maintaining equipment and 
records and performing quality assurance activities related to performance. 
5.2 
It is the responsibility of the Laboratory Director/Supervisor to ensure that all personnel 
have documented training and qualification on this SOP prior to the actual handling and 
processing of samples from clinical trial patients. The Laboratory Director/Supervisor is 
responsible for ensuring the assay operator running the SOP has sufficient experience to 
handle and analyze clinical samples. To become proficient with this SOP, sites are 
highly encouraged to reach out to NCI_PD_Support@mail.nih.gov for additional training 
materials. 
5.3 
It is the responsibility of the assay operator to confirm scheduled specimen collection 
time points, pre-print all labels, request access to NCI Medidata Rave (ETCTN 
Specimen Tracking System), check documentation for accuracy, request sample shipping 
kits from the EET Biobank and verify that the required collection tubes, supplies, and 
equipment are available for successful collection and handling of biopsy samples. 
5.4 
It is the responsibility of the assay operator to conduct the specimen collection and 
handling procedures following this SOP and complete the required tasks and associated 
documentation. The Biopsy Collection Record (Appendix 1) must be completed for each 
patient sample collection and filed with the study patient’s other records. 
5.5 
The responsible personnel are to check the DCTD Biomarkers Web site 
(http://dctd.cancer.gov/ResearchResources/ResearchResources-biomarkers.htm) to verify 
that the latest SOP version is being followed. 
 
6.1 
MATERIALS AND EQUIPMENT REQUIRED 
6.2 
Stopwatch, total time in minutes and seconds required 
6.3 
1.5-mL Sarstedt o-ring screw cap, conical bottomed tubes (Sarstedt, Cat#: 72.703.416) 
6.4 
Disposable, fine-tipped tweezers (e.g., VWR, Cat#: 83009-010). Tweezer tips need to 
easily fit to the bottom of a 1.5-mL Sarstedt tube 
6.5 
Printable microcentrifuge tube labels or BSI labeling system 
6.6 
81-place freezer boxes (e.g., Fisher Scientific, Cat#: 12-565-182) 
6.7 
Thermoflask cooler or polystyrene foam container 
6.8 
Ice bucket 
6.9 
Liquid nitrogen or dry ice/ethanol bath 
6.10 
-80°C freezer (or colder) 
6.11 
Specimen shipping kit from EET Biobank 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 5 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
 
7.1 
OPERATING PROCEDURES 
7.2 
This SOP uses NCI Medidata Rave for sample tracking, please review the following 
training videos for NCI Medidata Rave before you start: 
7.2.1 
General RAVE training: 
https://www.youtube.com/watch?app=desktop&v=ZRX0lSqs5zo 
7.2.2 
Label Printing training: 
https://www.youtube.com/watch?app=desktop&v=9_Q6_k-KHHs 
7.3 
Sample Shipping Kits 
Sample shipping kits should be requested prior to enrolling the first biopsy patient from  
EET Biobank by emailing BPCBank@nationwidechildrens.org. For current customers, 
the kits can be requested through the EET Biobank (kit management system: 
https://kits.bpc-apps.nchri.org/Auth/Login?ReturnUrl=%2f). Please allow 5-7 business 
days for kit shipment. 
7.4 
Labels 
7.4.1 
Prepare enough pre-printed specimen labels in NCI Medidata Rave by 
following steps 7.3.1.1- 7.3.1.5: 
7.4.1.1 
Log into NCI Medidata Rave and go to Enrollment folder and 
confirm the Histology and Disease form is complete. 
7.4.1.2 
Go to All Specimens folder. 
7.4.1.3 
Complete the Specimen Consent form. 
7.4.1.4 
Complete the Specimen Tracking Enrollment form for each 
specimen. 
7.4.1.5 
Complete the Print Labels form. Labels will be sent to user’s email 
address. For tissue specimens, apply appropriately coded label to each 
pass of the biopsy (see below). 
Note: Five labels will be printed by default when you enter “1” in the 
“How many labels are needed” field. The first four will be 
designated with A, B, C and D to represent different passes of the 
biopsy procedure. Please use those accurately to label the specimens; 
pass A should be for the first pass, B for the second, etc. The fifth label 
will have no pass designation and can be used on reports to be 
uploaded into RAVE. See an example of pre-printed label for frozen 
tissue biopsy below.  
 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 6 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
7.5 
Tumor Needle Biopsy Collection and Handling 
7.5.1 
The research nurse is to notify the laboratory of scheduled PD sample 
collections, preferably giving at least 24 hours of notice. Arrive at the biopsy 
collection site early enough to allow sufficient time to set up laboratory supplies, 
collect relevant clinical information, and ensure rapid transport of frozen 
specimens from the procedure area to the laboratory, where they will be placed 
into storage at -80ºC (or colder). 
7.5.2 
Prior to biopsy, the lesion should be assessed as to whether or not the biopsy 
should be performed and yield a successful outcome. Fill out the Pre-Biopsy 
Lesion Score form in NCI Medidata Rave using inputs from interventional 
radiologists and/or oncologists. 
7.5.3 
Bring all necessary lab supplies to the biopsy collection site, including: 
disposable tweezers, a minimum of four 1.5-mL Sarstedt tubes pre-cooled on 
liquid nitrogen or dry ice/ethanol in an insulated bucket (Sarstedt tubes will be 
provided in the sample shipping kit from EET Biobank; please use one tube for 
each whole biopsy core), the label with no pass designation to give to the 
research nurse for the patient record, and a printout of Appendix 1. 
Note: Pre-chill additional 1.5-mL Sarstedt tubes for specimen collection in case  
the interventional radiologist collects additional passes, or if one of the tubes is 
compromised prior to collection. 
7.5.4 
The total time elapsed between biopsy collection and placement into the pre- 
chilled tube is of key importance to biomarker analysis; this time should be 
documented in NCI Medidata Rave for each biopsy pass. It is important to 
note that all biopsies should be frozen within 2 minutes of collection. The 
interventional radiologist will eject the biopsy onto a sterile slide (for optimal 
analyte recovery the slide should be pre-chilled). Start a stopwatch at this point 
(or note the time in Appendix 1) and immediately walk the slide to the sample 
preparation table for transfer to the pre-chilled Sarstedt tube. 
7.5.5 
Immediately snap freeze the biopsy by placing the tube in liquid nitrogen or a dry 
ice/ethanol bath (stop the stopwatch at this point). Note: DO NOT let the tubes 
tip over in the liquid nitrogen or dry ice/ethanol bath. 
7.5.6 
Calculate the total time elapsed from biopsy collection to biopsy freezing and 
record the total number of minutes and seconds (Appendix 1). 
7.5.7 
Note the specific needle type used and location of each biopsy pass collected 
(e.g., spleen, large left upper quadrant splenic mass) (Appendix 1). 
7.5.8 
Note the protocol biopsy timepoint in Appendix 1. 
7.5.9 
Return to the sample processing laboratory and transfer the frozen biopsy 
specimen(s) to -80°C (or colder) for storage until shipment to the EET Biobank. 
7.5.10 After biopsy collection, complete sample tracking documentation in NCI 
Medidata Rave according to notes recorded in Appendix 1. 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 7 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
7.5.11 Fill out Biopsy Report form in the All Specimen folder. 
Note: It is very important to record the site of the biopsy to the Tumor Site Location field as shown below. 
 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 8 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
7.5.12 Complete the Specimen Transmittal form in the All Specimen folder. 
Note: It is important to fill out the time from collection to frozen for each pass in 
the Specimen Transmittal form by following the instructions below. 
Pass A time will be recorded in the appropriate fields as shown below: 
 
 
Times elapsed for passes B, C and D will be recorded in the Comment field near the bottom of the 
Specimen Transmittal form as shown below. Biopsy passes not collected will also be recorded in the 
Comment field as shown below. 
 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 9 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
 
8.1 
SHIP TO EET BIOBANK 
8.2 
When specimens are ready to be shipped, complete shipment documentation in NCI 
Medidata Rave. 
8.2.1 
Complete the Shipping Status form. 
8.2.1.1 
Each field in the Shipping Status form should be completed as shown 
below and Number Sent (circled below) should equal the number of 
biopsy passes in the shipment. 
8.2.1.2 
Email Alert (circled below) is only checked for the last specimen in a 
shipment if multiple specimens are shipped together. 
 
 
 
 
 
 
 
 
 
 
8.2.2 
If there are other specimens to be shipped with the frozen biopsies, use the Copy 
Shipping utility form (shown below) in the other specimens’ folder. 
 
 
 
8.2.3 
Print the Shipping List report and place it in the box with the specimens. 
8.2.3.1 
The Shipping List report is found in the report panel at the bottom of 
the window at the site level (an example shown below) since specimens 
from multiple patients can be included in a single shipment. 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 10 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
 
 
 
8.2.3.2 
Shipment should include a hard copy (printed copy) of the Shipping 
List. An example is shown below. 
 
8.2.3.3 
Shipment should also include a hard copy of the TISSUE BIOPSY 
VERIFICATION form found in the appendices of corresponding 
protocols. 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 11 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
8.3 
Specimen shipment to EET Biobank 
8.3.1 
Follow the Shipping Specimens from Clinic Site to the EET Biobank/ETCTN 
Biorepository section of the clinical protocol for general instructions of sample 
shipment to EET Biobank. 
8.3.2 
Frozen biopsies should be shipped in kits provided by EET Biobank. The 
shipping container sent with kit contents should be used to ship specimens to 
EET Biobank. Note: It’s important to include sufficient dry ice to keep the 
biopsy frozen for at least 96 hours. 
8.3.3 
Frozen specimens may be shipped on Monday through Thursday to the following 
address: 
EET Biobank 
The Research Institute at Nationwide Children's Hospital 700 Children's Drive, 
WA1340 
Columbus, Ohio 43205 
PH: (614) 722-2865 
FAX: (614) 722-2897 
 
Note: FedEx Priority Overnight service is the required shipping method. The EET Biobank FedEx account 
will not be provided to submitting institutions. 
Sites are responsible for all costs for shipments to the EET Biobank, so the overnight express shipment 
should be billed directly to the shipping institution/site. 
8.4 
Useful contacts for Specimen Collection, Handling and Shipment: 
8.4.1 
Send all questions related to this SOP or PD- assay support questions to: 
NCI_PD_Support@mail.nih.gov 
8.4.2 
Send all technical questions about the Specimen Tracking System to: 
STS.Support@theradex.com 
8.4.3 
EET Biobank queries (kit inquiries and sample shipping): 
BPCBank@nationwidechildrens.org 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 12 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
APPENDIX 1: BIOPSY COLLECTION RECORD 
 
Note: This document lists important information to be recorded during the biopsy collection process for later 
documentation in NCI Medidata Rave. The completed document should be filed with the study patient’s 
other records at a predetermined location according to local policy for managing clinical trial information. 
Please do not include the document in the shipment to EET Biobank. 
 
Certified Assay Operator:   
 
Facility/Clinic Collecting Specimens:   
 
Clinical Protocol Number:   
 
Patient ID:   
 
 
 
 
1. Biopsy Collection Information: 
Note: Information collected in the table below will be entered in Medidata RAVE. 
Note: Record times using military time (24-h designation); for example, specify 16:15 to indicate 4:15 PM. 
 
 
Pass A 
Pass B 
Pass C 
Pass D 
Specimen ID 
 
Protocol timepoint of biopsy 
(Cycle, Day, and Hours post 
dose, if post treatment) 
 
Needle type 
 
Site of biopsy (complete for all 
passes or note “same” for 
replicate cores) 
 
Required: 
Time elapsed from collection to 
placement in tube 
 
 
 
min 
sec 
min 
sec 
min 
sec 
min 
sec 
Date biopsy collected 
 
Time biopsy collected 
: 
: 
: 
: 
Time biopsy placed in tube 
: 
: 
: 
: 


DCTD Standard Operating Procedures (SOP) 
 
Title: 
Tumor Frozen Needle Biopsy Specimen Collection, Handling and Shipment to EET 
Biobank 
Page 13 of 13 
Doc. #: 
SOP340567 
Revision: 
- 
Effective Date: 
10/08/2021 
 
2. Notes, including any deviations from the SOP: 
 
 


NCI Protocol #: 10480 
Version Date:  April 27, 2022 
 
128 
APPENDIX I 
EMBEDDING NEEDLE BIOPSIES 
 
If your study has sites embedding formalin fixed tissue from needle biopsies in paraffin, include 
this Appendix.  Customize the protocol text and reference this appendix in the body of the 
protocol. 
 
Embedding needle biopsies (FFPE processing):  
y These types of specimens are very thin and delicate. 
y Lift gently with forceps and avoid pinching too roughly to prevent fragmentation and 
crush artifact. 
y Because these specimens are typically very thin (diameter) it is absolutely essential that 
they be orientated for optimal sectioning. 
y They must be embedded in the same plane, as flat as possible (including tips of long 
strings). 
y Please select the mold size that is most suitable and will be easiest for the histotechnician 
to eventually position multiple FFPE tissue sections on the glass slides. 
y Dipping the needle core biopsies in methylene blue or eosin renders the samples more 
readily visible in the tissue block (helps when tissue sections are being oriented during 
embedding and eventually cut following FFPE processing). 
y Arrange the specimens in a horizontal plane or diagonal plane to reduce the distance that 
the knife blade travels across the specimen- this may reduce folds and compression. 
 
Adequate – horizontal 
 
 
Avoid – no orientation 
 
Adequate – diagonal 
 
 
 


 
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