Clinical trial NCT03097328
Conditions: Renal Cell Carcinoma
Keywords: Renal Cell Carcinoma
Sponsor: Bradley A. McGregor, MD
Start date: 2017-08-01; Completion date: 2024-04-24
Enrollment: 39 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This research study is investigating a drug as a possible treatment for metastatic renal cell carcinoma. The intervention involved in this study is TAK-228.

Detailed description:
This research study is a Phase II clinical trial. Phase II clinical trials test the safety and effectiveness of an investigational intervention to learn whether the intervention works in treating a specific disease. "Investigational" means that the intervention is being studied.

The FDA (the U.S. Food and Drug Administration) has not approved TAK-228 as a treatment for any disease but it is being investigated as a treatment for advanced solid tumors, blood disorders, and inflammatory diseases. TAK-228 works to inhibit or interfere with cellular functions involved in cell growth and survival. TAK-228 specifically targets a type of protein that can make chemicals that trigger cell growth, including cancer cell growth. This protein may also cause cells to produce proteins that trigger the development of new blood vessels. Cancers need new blood vessels in order to grow. In some types of cancer, this type of protein (mTOR) is switched on, and it makes the cancer cells grow and produce new blood vessels. mTOR blockers (inhibitors) are a newer type of cancer growth blocker that can stop the growth of some types of cancer.

Researchers hope to learn how participants with previously treated mRCC will respond to treatment with TAK-228. Other goals of this study include assessing the types of side effects associated TAK-228 and whether there is a relationship between certain genetic mutations (changes to your DNA) and participant responses to the drug.

Arms: arm 1: * TAK-228 will be taken orally on a weekly basis for 4 weeks per cycle
* Dosage will be determined by the study team
Interventions: intervention 1: TAK-228
Intervention descriptions: intervention 1: TAK-228 works to inhibit or interfere with cellular functions involved in cell growth and survival. TAK-228 specifically targets a type of protein that can make chemicals that trigger cell growth, including cancer cell growth

Protocol documents:
Prot_SAP_000.pdf: 
 
 
 
 
 
TITLE:  A Phase II Study of TAK-228 in patients with previously treated metastatic renal cell carcinoma  
 
NCT Number: NCT03097328 
 
Protocol Version Date: December 20, 2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 




NCI Protocol: 
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SCHEMA 
 
 
 
*Pre-treatment biopsy will be mandatory in subjects who do not have available archival tissue 
collected within 18 months of enrollment.  
**Post-treatment biopsy, if feasible and safe, is mandatory only in subjects who experience a disease 
response as per RECIST 1.1 criteria followed by subsequent progression.  
+One Cycle is 28 Days 
 
 
 
 
 
 
 
 
 
 
 
 
Metastatic 
RCC 
-Clear cell 
and non 
clear cell 
histologies
-Progressed 
on at least 
one prior 
therapy
Pretreat-
ment 
Biopsy*
TAK228
Radiographic
Progression 
by RECIST 
1.1 
Post-
Treatment 
Biopsy**
Follow-up


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TABLE OF CONTENTS 
LIST OF ABBREVIATIONS AND GLOSSARY OF TERMS .................................... 2 
Schema ............................................................................................................................... 3 
1. 
Study Objectives and Endpoints.............................................................................6 
2.1 Objectives............................................................................................................................. 6 
2. 
Background and Rationale...................................................................................... 7 
1.1 
Renal Cell Carcinoma ..................................................................................................... 7 
1.2 
TAK-228 ......................................................................................................................... 7 
1.3 
Rationale ....................................................................................................................... 12 
1.4 
Correlative Studies Background ................................................................................... 15 
3. 
Eligibility Criteria. ..................................................................................................16 
3.1 
Inclusion Criteria .......................................................................................................... 16 
3.2 
Exclusion criteria .......................................................................................................... 18 
3.3 
Inclusion of Women and Minorities ............................................................................. 20 
4. 
Subject Registration.................................................................................................20 
4.1 
General Guidelines for DF/HCC Institutions ............................................................... 20 
4.2 
Registration Process for DF/HCC Institutions .............................................................. 21 
4.3 
General Guidelines for Other Investigative Sites ......................................................... 21 
4.4 
Registration Process for Other Investigative Sites........................................................ 21 
5. 
Treatment Plan .......................................................................................................22 
5.1 
Pre-medication and Hydration ...................................................................................... 22 
5.2 
TAK-228 Administration .............................................................................................. 22  
5.3 
Subject Evaluations ....................................................................................................... 23 
5.4 
Concomitant Medications ............................................................................................. 24 
5.5 
Criteria for Taking a Participant Off Protocol Therapy ................................................ 25 
5.6 
Duration of Follow Up .................................................................................................. 26 
5.7 
Criteria for Taking a Participant Off Study .................................................................. 26 
5.8 
Replacement .................................................................................................................. 26 
6. 
Toxicities and Dose Delays/Dose Modifications .................................................. 26 
6.1 
TAK-228 Dose Modifications ...................................................................................... 27 
6.2 
Dose Levels for Dose Reductions ................................................................................. 27 
7. 
Study Calendar & Evaluations ............................................................................. 38 
7.1 
Screening Evaluations ................................................................................................... 42 
7.2 
On Treatment Evaluations (± 3 days) ........................................................................... 42 
7.3 
Safety Follow-up Visit Evaluations .............................................................................. 47 
7.4 
Long Term Follow-up Evaluations ............................................................................... 48 
8. 
CORRELATIVE TISSUE and BLOOD ANALYSES ....................................... 48 
8.1 
TISSUE ANALYSES ................................................................................................... 48 
8.2 
BLOOD ANALYSES ................................................................................................... 50 
8.3 
Confidentiality of Biospecimens................................................................................... 50 
9. 
Criteria for Disease Evaluation ............................................................................ 50 
9.1 
Definitions..................................................................................................................... 50 
9.2 
Disease Parameters ....................................................................................................... 51 
9.3 
Methods for Evaluation of Disease ............................................................................... 52 
9.4 
Response Criteria .......................................................................................................... 52 
10. Drug Information ................................................................................................... 55 


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10.1 
TAK-228 ....................................................................................................................... 55 
10.2 
Supplier/How Supplied ................................................................................................. 56 
10.3 
Preparation .................................................................................................................... 56 
10.4 
Storage and Stability ..................................................................................................... 57 
10.5 
Handling and Disposal .................................................................................................. 57 
10.6 
Accountability ............................................................................................................... 57 
11. Adverse Events ....................................................................................................... 58 
11.1 
Expected Toxicities ....................................................................................................... 58 
11.2 
Adverse Event Characteristics ...................................................................................... 58 
11.3 
DF/HCC Expedited Adverse Event Reporting ............................................................. 59 
11.4 
Expedited Reporting to Millennium ............................................................................. 60 
 Definitions......................................................................................................................... 60 
11.5 
Expedited Reporting to the Food and Drug Administration (FDA) ............................. 63 
11.6 
Expedited Reporting to Hospital Risk Management .................................................... 63 
11.7 
Routine Adverse Event Reporting ................................................................................ 63 
12. Statistical Methods ................................................................................................. 64 
12.1 
Study Design ................................................................................................................. 64 
 Endpoints .............................................................................................................................. 64 
12.2............................................................................................................................................ 64 
12.3 
Sample Size and Accrual .............................................................................................. 64 
12.4 
Analysis Datasets .......................................................................................................... 65 
12.5 
Interim Analysis/Criteria for Stopping Study ............................................................... 67 
13. Data Reporting/Regulatory Requirements .......................................................... 67 
13.1 
Data Reporting .............................................................................................................. 67 
13.2 
Data Safety Monitoring................................................................................................. 67 
13.3 
Multicenter Guidelines.................................................................................................. 68 
13.4 
Data Quality Oversight Activities ................................................................................. 68 
13.5 
Compliance with Trial Registration and Results Posting Requirements ...................... 68 
14. Data Handling and Record Keeping .................................................................... 69 
14.1 
Data Management ......................................................................................................... 69 
14.2 
Case Report Forms and Submission ............................................................................. 69 
14.3 
Record Retention .......................................................................................................... 69 
14.4 
Confidentiality .............................................................................................................. 70 
15. Publication Plan ..................................................................................................... 70 
14 
References ............................................................................................................... 71 
APPENDIX A: PERFORMANCE STATUS CRITERIA........................................... 73 
APPENDIX B: Required Forms at Registration ......................................................... 74 
APPENDIX C: INFORMATION ON POSSIBLE DRUG INTERACTIONS .......... 75 
APPENDIX D: Subject Diary............................................................................................78 
APPENDIX E:Data Safety Monitoring Plan ................................................................ 78 
 


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1. 
STUDY OBJECTIVES AND ENDPOINTS 
1.1 
Objectives 
1.1.1 Primary Objective 
Assess the overall response rate (ORR) of TAK-228 in previously treated metastatic Renal Cell 
Carcinoma (RCC). 
 
1.1.2 Secondary Objectives 
1. Evaluate the progression-free survival (PFS) of TAK-228 in previously treated metastatic 
RCC. 
2. Evaluate overall survival (OS) of TAK-228 in previously treated metastatic RCC. 
3. Assess toxicity and safety of treatment with TAK-228.  
 
1.1.3 Correlative/Exploratory Objectives 
1. Assess the ORR of TAK-228 in subjects with mutations in genes involved in the mTOR 
pathway. 
2. Correlate ORR to TAK-228 to time on prior anti-cancer therapy, specifically prior rapalogs. 
3. Correlate ORR to TAK-228 with mutation status in RCC. 
4. Examine genetic mechanisms of resistance to TAK-228 in subjects who respond and then 
progress. 


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2. 
BACKGROUND AND RATIONALE 
 
2.1 
Renal Cell Carcinoma 
Metastatic RCC accounts for 14,000 deaths each year in the U.S. (1). It is a heterogeneous 
disease divided generally into two major groups: clear-cell RCC (ccRCC) (80%) and non-clear 
cell RCC (nccRCC). Despite the recent advances in the treatment of metastatic RCC, the median 
survival remained only 22 months in 2009(2).  
 
The introduction of molecularly targeted therapies has transformed the management of RCC. 
Since the first approval of sorafenib in December 2005, seven different drugs have been shown 
to provide clinical benefit for patients with RCC (2-4).  Agents targeting the VEGF pathway 
have emerged as the most robust therapeutic option, and are therefore the initial treatment choice 
for metastatic RCC. Sunitinib, sorafenib, pazopanib (VEGF receptors tyrosine kinase inhibitors 
(TKIs)) and bevacizumab (monoclonal antibody against VEGF ligand) are Food and Drug 
Administration (FDA)-approved in advanced RCC. Another class of targeted agents used in 
metastatic RCC are allosteric inhibitors of mTOR complex 1 (mTORC1).  Everolimus and 
temsirolimus, both sirolimus analogs (rapalogs), are also FDA-approved for use in the treatment 
of metastatic RCC based on large randomized phase III trials (3, 4). However, the clinical benefit 
from mTOR inhibitors is generally modest, with few partial responses (PRs) and very rare 
complete responses (CRs).  
 
2.2 
TAK-228 
Millennium has developed TAK-228, which is a novel, highly selective, orally bioavailable 
adenosine 5’ triphosphate (ATP)-competitive inhibitor of the serine/threonine kinase referred to 
as the mechanistic target of rapamycin (mTOR). TAK-228 (formerly INK128) targets 2 distinct 
mTOR complexes, mTORC1 and mTORC2. 
 
TAK-228 selectively and potently inhibits mTOR kinase (IC50 = 1.1 nM), inhibits mTORC1/2 
signaling, and prevents cellular proliferation. The mTOR is a kinase that regulates cell growth, 
translational control, angiogenesis, and cell survival by integrating nutrient and hormonal 
signals. mTOR kinase plays a key role in several pathways that are frequently dysregulated in 
human cancer. mTORC1 is best known as a key regulator of protein translation through 
phosphorylation of 4EBP1 (the eukaryotic translation Initiation Factor 4E-binding Protein 1) and 
ribosomal protein S6 (known as S6) kinase. mTORC2 is best known for its ability to fully 
activate protein kinase B (AKT) by phosphorylation on the S473 site, which regulates 
proliferation and survival pathways. 
 
The mTORC is an important therapeutic target that is a key intracellular point of convergence for 
a number of cellular signaling pathways. Inhibiting mTOR may inhibit abnormal cell 
proliferation, tumor angiogenesis, and abnormal cellular metabolism, thus providing the rationale 
for mTOR inhibitors as potential agents in the treatment of a number of indications including 
solid tumor and hematological malignancies, as either monotherapy or in combination with other 
chemotherapeutic agents. Like rapamycin, several newly approved rapalogs (temsirolimus and 
everolimus) are specific and allosteric inhibitors of mTORC1, and only partially inhibit 


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mTORC1 signaling pathways. They do not directly inhibit mTORC2, which has shown to be an 
emerging target in cancer research. TAK-228 was developed to address the incomplete inhibition 
of the mTOR pathway by rapalogs by targeting both mTORC1 and mTORC2. 
 
TAK-228 is being developed for both oncology and non-oncology indications. In oncology, 
TAK-228 is being investigated as a treatment for advanced solid tumors and hematologic 
malignancies, either as monotherapy or in combination with chemotherapy, other molecularly 
targeted therapies, or antihormonal agents. Non-oncology indications being investigated include 
fibrotic and inflammatory diseases. 
 
2.2.1 Pharmacology 
TAK-228 selectively and potently inhibits mTOR kinase (the concentration inhibiting 50% of 
enzyme activity [IC50] is 1.1 nM), inhibits mTORC1/2 signaling, and prevents cellular 
proliferation. 
 
TAK-228 inhibited phosphorylation of downstream modulators of mTORC1and mTORC2 in 
human U87 glioblastoma tumor xenograft models in mice and showed strong tumor growth 
inhibition (TGI) at tolerable oral (PO) doses in all 8 xenograft models tested (see IB Ed8 for 
details). 
 
TAK-228 has a low potential to affect the human ether-à-go-go related gene (hERG) potassium 
ion channel and did not affect cardiovascular (CV) parameters in vivo in 
telemeterized monkeys. 
 
2.2.2 Preclinical Studies  
Several preclinical studies have showed the superiority of TAK-228 over rapamycin and 
rapalogs in inhibiting tumor growth in several cancers, such as: breast and pancreatic cancer, 
glioblastoma, multiple myeloma and B-cell acute lymphoblastic leukemia (B-cell ALL).  
 
TAK-228 reduces p-4EBP1 (phosphorylated-eukaryotic translation initiation factor 4E binding 
protein 1) and p-S6K1 (phosphorylated-ribosomal S6 kinase 1), reflecting mTORC1 inhibition, 
as well as p-AKT (also known as protein kinase B) and p-NDRG1 (phosphorylated N-myc 
downstream-regulated gene 1) reflecting mTORC2 inhibition (5-7). In contrast, rapalogs only 
decrease phosphorylation of p-S6K1 with variable effects on p-4EBP1, and increases 
phosporylation of Akt (5, 7, 8). Akt phosphorylation due to rapalog treatment is due to feedback 
activation of the phosphatidylinositol 3-kinase (PI3K) /Akt pathway, and may contribute to the 
limited clinical benefit of rapalog mTORC1 inhibitors. Consistent with this model, TAK-228 
was found to be effective in cancer cells where the PI3K/Akt pathway has been upregulated, 
such as HER2 (human epidermal growth factor 2)-positive breast cancer cell lines resistant to 
HER2 inhibition (transtuzumab and lapatinib) (9). TAK-228 also inhibited cell proliferation in 
breast cancer cell lines harboring PIK3CA (phosphoinositide-3-kinase-catalytic-alpha), PTEN 
(phosphatase and tensin homolog), KRAS (Kirsten rat sarcoma viral oncogene homolog), and/or 
BRAF mutations as well as xenograft models that are both non- VEGF and VEGF-driven (6). 
 


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TAK-228 has a cytotoxic effect on several cancer cell lines through the induction of apoptosis, 
contrasting the cytostatic effect of rapamycin and rapalogs (5, 7).  It has also been shown to 
decrease the invasiveness of prostate cancer cell lines through the inhibition of translation of the 
genes that play a role in the invasion and metastasis potential, such as: YB1 (Y-box binding 
protein 1), MTA1 (metastatic associated 1), vimentin and CD44 (cluster of differentiation 44) 
(5). It also inhibits the VEGF-induced lung metastasis in xenografts models of breast cancer (6). 
In pancreatic cancer cell lines, TAK-228 also enhanced their radiosensitivity through the 
inhibition of deoxyribonucleic acid (DNA) repair (10). 
 
In a study directly comparing catalytic inhibitors to allosteric inhibitors of mTOR, TAK-228 
caused greater inhibition of mTORC1 signaling, mTORC2 signaling, cell cycle progression and 
translation in most cell lines compared to rapamycin (11).  Furthermore, its growth inhibitory 
effect was greater in cell lines and in vivo models that have either intrinsic or acquired resistance 
to rapamycin, highlighting its efficacy in resistant settings compared to rapamycin(11).  
 
TAK-228 (MLN0128) has also been shown to have a synergistic effect with several drugs, 
including: dasatinib in Philadelphia Chromosome-positive B –cell ALL cell lines, lapatinib in 
HER2-positive breast cancer cell lines, melphalan, doxorubicin, and dexamethasone in multiple 
myeloma cell lines (7-9). 
 
In RCC, a pre-clinical trial using patient-derived tissue slice graft (TSG) models derived from 
fresh primary RCC specimens was used to compare the effect of TAK-228 versus temsirolimus. 
TAK-228 consistently suppressed primary RCC growth up to two months whereas temsirolimus 
only transiently inhibited the growth of TSGs before resistance developed.  In addition, TAK-
228 was the only drug to reduce liver metastases lending strong support for the use of dual 
mTORC1/2 inhibitors in RCC (12). 
 
2.2.3 Clinical Studies  
 
2.2.3.1 Clinical trials: 
The pharmacokinetics (PK) and pharmacodynamic (PD) of TAK-228 have been evaluated in two 
phase I studies of TAK-228 as a single agent in patients with advanced solid malignancies (INK 
128-001), or refractory multiple myeloma (MM) and Waldenstorm’s macroglobulinemia (WM) 
(INK 128-002). They are also being evaluated in a phase I study of TAK-228 in combination 
with paclitaxel in patients with advanced solid tumors.  
 
 


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Table 1: Phase I clinical trials of TAK-228 
 
 
There are several ongoing phase I and II clinical trials of TAK-228 (13).  
TAK-228 is currently investigated in nine phase I clinical trials (one of which is completed), as a 
single agent and in combination with other drugs (paclitaxel, transtuzumab, MLN1117 (PI3K 
inhibitor), MLN2480 (A, B and C Raf inhibitor), bevacizumab, Ziv-Aflibercept) in patients with 
advanced solid tumours, recurrent glioblastoma as well as refractory MM or WM. A phase I 
study is currently evaluating the effect of a 40 mg single dose of TAK-228 on the 
electrocardiographic QT/QTc interval in participants with advanced solid tumors. Furthermore, 
there are 3 phase 1b/2 clinical trials, including one that is assessing the efficacy and the safety of 
TAK-228 with exemestane or fulvestrant in postmenopausal women with estrogen receptor 
positive (ER+)/Her2- metastatic breast cancer in patients who progressed on everolimus with 
exemestane or fulvestrant. The efficacy of TAK-228 is being investigated in 3 phase II clinical 
trials in patients with metastatic anaplastic thyroid cancer, metastatic castration-resistant prostate 
cancer as well as advanced squamous lung cancer harboring NFE2L2 (Nuclear Factor, Erythroid 
2-like 2) and KEAP1 (Kelch-Like ECH-Associated Protein 1) mutations. A pilot study of TAK-
228 given before and after surgery in patients with recurrent glioblastoma is also ongoing. 
 
2.2.3.2 Drug Metabolism and Pharmacokinetics 
TAK-228 was rapidly absorbed after PO administration to mice, rats, dogs, and monkeys, with 
high oral bioavailability. [14C] TAK-228 was rapidly and widely distributed throughout the body 
in Long-Evans rats; radioactivity was eliminated from most tissues at 48 hours post dose. TAK-
228 displayed dose-proportional plasma exposures, a moderate propensity to cross the blood-
brain barrier, and was modestly bound (70.5%) to human plasma proteins. TAK-228 distributed 
mainly to the plasma of human blood. There was no obvious concentration-dependent red blood 
cell (RBC) distribution of TAK-228 in human blood. 
 


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TAK-228 did not inhibit P-glycoprotein, but did inhibit breast cancer-resistance protein (BCRP), 
organic cation transporter (OCT)1 and OCT2. 
 
M1, the single metabolite (monohydroxylation product) observed in human microsomal 
incubations, was also observed in rats and monkeys.  
 
Recently completed in vitro metabolism experiments in human hepatocytes using 14C-labeled 
TAK-228 suggest that TAK-228 is metabolized primarily via CYP1A2 (approximately 31%-
40%), with a minor contribution from CYP3A4 (approximately 11%-22%). These data suggest 
that TAK-228 is also metabolized by direct glucuronidation (approximately 22%) and an 
unidentified non-uridine diphosphate glucuronosyl transferase pathway (approximately 18%). 
The new data differ from the previous in vitro CYP phenotyping data obtained using 
recombinant CYP enzymes, which suggested the involvement of CYP2C9 (approximately 35%), 
CYP2C19 (approximately 28%), and CYP3A4 (approximately 28%) in TAK-228 metabolism. In 
addition, physiologically based PK modeling and simulation using the new metabolism data for 
TAK-228 suggest that the risk for a metabolism-based drug-drug interaction with TAK-228 
appears to be low. Therefore, strong CYP1A2 inhibitors and CYP inducers should be 
administered with caution and at the discretion of the investigator during the study. 
 
Especially given clinical exposures observed to date after administration of the highest 
anticipated therapeutic dose to be used in the clinic in oncology indications (total maximum 
plasma concentration [Cmax] of 0.48 µM [free Cmax of 0.14 µM] at 30 mg once weekly [QW]).  
 
2.2.3.3 Pharmacodynamics 
In INK128-001, the pharmacodynamic effect of TAK-228 was measured in surrogate tissue 
(skin) to explore the downstream effectors of mTOR complex-1 inhibition (pS6 and p4EBP1) 
and mTOR complex-2 inhibition (pAKT (S473), pNDRG1, and pPRAS40 (proline-rich Akt 
substrate of 40 kDa)). Preliminary data demonstrate reduction of the levels of pS6, p4EBP1, 
pNDRG1, and pPRAS40 in skin at TAK-228 doses of ≥4 mg. pAKT (S473) had high variability 
in the staining rendering the results inconclusive.  
 
2.2.3.4 Updated Manufacturing Process 
A new TAK-228 (MLN0128) capsule containing milled active pharmaceutical ingredient (API) 
is available for new clinical studies in 1 mg, 3 mg and 5 mg strengths. In this study, the 5 mg 
capsules will be provided. 
 
The milled API, may result in faster absorption profile with possibly higher maximum 
concentration (Cmax), which could result in a different safety profile compared to the previous 
unmilled API capsules. Therefore, ongoing studies (C31001, C31002 and , TAK-228 
(MLN0128)-1004 –A Phase I, open label study to evaluate the safety, tolerability, and 
pharmacokinetics of TAK-228 (MLN0128) as a single agent and in combination with 
paclitaxel in adult patients with advanced non-hematological malignancies-), with the new 
milled API will determine the recommended phase 2 dose (RP2D) for single agent TAK-228 


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(MLN0128) (QD and QW) and QD×3days per week in combination with paclitaxel, as well as 
the effect of high-fat meal on the PK of milled API. 
 
The selected dose of 30 mg TAK-228 QW is based on the findings from 2 studies: Study 
INK128-001 and Study MLN0128-1004. Study INK128-001was the first-in-human study of 
TAK-228. This was an open-label study designed to determine the maximum tolerated dose 
(MTD) and to identify dose-limiting toxicities (DLTs) for oral administration of single-agent 
unmilled TAK-228, and to characterize the safety and tolerability of escalating doses of TAK-
228 in patients with advanced solid tumors. In this study, 116 patients with advanced solid 
tumors received TAK-228 (2 – 40 mg via 4 dosing schedules: QD [once a day] (31 patients), 
QDx3 QW [3 days per week] (33 patients), QDx5 QW [5 days per week] (22 patients), and 
QW [once a week] (30 patients).) in the dose escalation phase. Doses of 40 mg QW, 30 mg 
QW and 5 mg QD were further evaluated in an additional 82 patients in the expansion phase.  
 
Improved tolerability, including a reduced frequency of TEAEs leading to dose interruptions 
and modifications, respectively (30 mg QW: 24% and 41%, versus 40 mg QW: 19% and 77%) 
and longer duration of clinical benefit favored 30 mg QW dosing as a RP2D and schedule for 
further development.  
 
Scale-up manufacturing of TAK-228 capsules required the introduction of a physical milling 
step during the granulation process to control for particle size distribution of TAK-228 drug 
substance. In order to observe whether this milling step altered the safety and PK profile of 
TAK-228, the recommended dose of 30 mg milled TAK-228 QW was further evaluated and 
confirmed in Study MLN0128-1004 in which a total of 14 patients were enrolled and assigned, 
sequentially, to 2 QW dosing cohorts: 20 mg QW and 30 mg QW milled TAK-228 (see Table 
2 below). 
 
Table 2: Dose-Limiting Toxicity Observed with milled TAK-228 QW in Study  
MLN0128-1004 
 
Dose of Milled TAK-228  
Number of Evaluable Patients  Patients with DLTs observed 
in Cycle 1  
20 mg QW  
6  
None  
30 mg QW  
6  
None  
DLT = dose-limiting toxicity; QW = once weekly.  
 
 
1.3 
Rationale 
The PI3K/Akt/mTOR pathway is involved in most cancer development, including RCC.  The 
mTOR pathway plays a major role in cell growth, survival and migration. mTOR is the central 
component of 2 multi-protein complexes: mTORC1 and mTORC2.  
 
mTORC1 is a heterotrimeric protein kinase that consists of the mTOR catalytic subunit and two 
associated proteins, raptor (regulatory-associated protein of mTOR) and mLST8 (mammalian 
lethal with SEC13 protein 8, also known as GβL (G-protein beta-subunit like)) (14).  Activation 
of mTORC1 leads to the phosphorylation of S6K1, 4E-BP1, and numerous other protein targets 
(14) (Fig. 1). S6K1 phosphorylates ribosomal protein S6 and is a key regulator in cell growth. 


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Furthermore, S6K1 represses the PI3K–Akt pathway by inhibiting IRS1 (insulin receptor 
substrate 1) and IRS2 expression (14) (Fig. 1). Therefore, mTORC1 inhibition leads to feedback 
activation of the PI3K/Akt pathway implicated in cell growth (15). Phosphorylation of 4E-BP1 
inhibits its binding to eukaryotic initiation factor 4E (eIF4E), which enables the cap-dependent 
translation of complex mRNAs such as Bcl-2 (B-cell lymphoma 2) and VEGF, thereby 
increasing cell proliferation, survival and angiogenesis (14).  
 
mTORC2 consists of mTOR and mLST8, as well as rictor (rapamycin-insensitive companion of 
mTOR) and mSin1 (mammalian stress-activated protein kinase [SAPK]-interacting protein, also 
known as mitogen-activated-protein-kinase-associated protein 1), that are not part of mTORC1 
(14). Activated mTORC2 phosphorylates Akt at Serine (Ser) 473, as well as several other protein 
targets, leading to enhanced cell survival, proliferation, and cell migration (14) (Fig. 1). 
Rapamycin and its analogs (rapalogs) inhibit mTORC1 by binding to the rapamycin-binding 
protein FKBP12, which then binds to mTORC1 (14).  Rapamycin has different degrees of 
inhibition for different substrates of mTORC1.  It potently inhibits S6K1 phosphorylation, but 
has more variable effects on 4EBP1 phosphorylation and cap-dependent translation. In addition, 
rapalogs lead to feedback activation of Akt - as a result of inhibition of the S6K/IRS-1 feedback 
loop- decreasing its beneficiary effect as an anticancer drug (11, 15). In PTEN-deficient 
glioblastoma patients treated with rapamycin, Akt hyperactivation was associated with a shorter 
time to progression (TTP) (15). Therefore, targeting Akt activation as with mTORC2 inhibition 
may provide superior clinical benefit. 
 
Rapalogs, such as everolimus and temsirolimus are currently used in the management of mRCC. 
However, their clinical benefit is limited with very rare CRs and few PRs. Therefore, it is 
essential to investigate drugs that have a potential increased clinical effect. Novel drugs have 
been developed to inhibit both mTORC1 and mTORC2. TAK-228 (or INK128) is an ATP-
competitive dual mTORC1/2 inhibitor. In contrast to the competitive inhibitors of the mTOR 
catalytic site, rapamycin and rapalogs (temsirolimus and everolimus) are allosteric inhibitors of 
mTOR and result in a partial inhibition of the mTOR pathway through the inhibition of 
mTORC1 complex solely. 
 
Furthermore, competitive dual mTORC1/2 inhibitors such as TAK-228 are thought to be 
superior to rapalogs in the inhibition of mTOR pathway as well as in anti-tumor activity as it has 
the advantage of inhibiting the PI3K/Akt pathway. Several pre-clinical studies have 
demonstrated the superiority of TAK-228 over rapamycin and its analogs, particularly in RCC 
and in settings of rapamycin resistance (11, 12). Therefore, the evidence suggests that TAK-228 
may have benefit for RCC patients who have progressed on rapalogs. 
 


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Figure 1. TSC Protein Complex, mTOR Complex 1, and Downstream Effects. The tuberous 
sclerosis complex (TSC) proteins, which include TSC1, TSC2, and TBC1D7, are negatively 
regulated by phosphorylation (+P) by AKT, ERK, and RSK, which are all core kinases that are 
activated during growth signaling. This complex is activated under hypoxia and on 
phosphorylation by AMPK in response to energy stress and functions as a GTPase-activating 
protein to negatively regulate RHEB, a Ras family member GTPase. RHEB-GTP activates 
mechanistic target of rapamycin (mTOR) complex 1 (mTORC1), which is also regulated by 
intracellular amino acid levels and has multiple direct kinase targets and even more secondary 
targets of phosphorylation. In some cases, the mechanism of regulation is not completely 
understood (as indicated by a dashed line). In aggregate, these transcription factors, translation 
factors, and enzymes lead to biosynthesis of ribosomes and other components that are needed for 
efficient translation, including ATP and amino acids, as well as lipid precursors, NADPH, 
nucleotides, RNA, and DNA, to enable an increase in cell size and growth. Arrows indicate 
stimulatory events, which at times are mediated by phosphorylation; blocked lines indicate 


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inhibitory effects. Biallelic (complete) loss of TSC1 or TSC2 leads to the loss of negative 
regulatory effects of the TSC protein complex and constitutive activation of mTORC1. CAD 
denotes carbamoyl-phosphate synthetase 2, aspartate transcarbamoylase, dihydroorotase; EIF4E 
eukaryotic translation initiation factor 4E; 4EBP1 eukaryotic translation initiation factor 4E 
binding protein 1; G6PD glucose-6-phosphate dehydrogenase; HIF1A hypoxia-inducible factor 1
α; PPP pentose phosphate pathway; SREBP1 sterol regulatory element-binding protein 1; and 
S6K1/2 ribosomal protein S6 kinase 1 and 2 (16). 
 
 
1.4 
Correlative Studies Background 
As described above, TAK-228 is a dual inhibitor of mTORC1/2 signaling, thus it inhibits 
phosphorylation of their downstream modulators. TAK-228 has been shown to downregulate p-
4EBP1,p-S6k, HIF1α (Hypoxia-inducible factor 1α) and MTA1 downstream of mTORC1 as 
well as AKT, c-Myc  and NDRG1 downstream of mTORC2 (5-7, 12, 14).  
 
Acquired secondary mutations in MTOR are one mechanism of resistance to rapalogs, as was 
demonstrated in a patient with anaplastic thyroid cancer (17). Whole exome sequencing was 
performed on a tumor sample from a patient who progressed after an impressive 18 months 
response. A missense mutation in MTOR (F2108L (G>T)) was found only in the biopsy 
performed at the time of resistance, and not in the pre-treatment tumor. In vitro studies showed 
that this mutation conferred resistance of mTORC1 to rapalog treatment, but not to mTOR 
kinase inhibitors, specifically a tool compound Torin1 (11). 
 
Furthermore, it has also been suggested that eIF4E amplification may also be a mechanism of 
resistance to mTOR inhibitors. eIF4E is an essential component of the eIF4F complex that 
recruits the mRNA to the ribosome to initiate translation thereby promoting cell growth, survival 
and angiogenesis. 4E-BPs (4E-binding proteins) are a family of small translational repressors 
which sequester eIF4E, thereby impeding the assembly of the eIF4F complex. 4E-BP1 is 
phosphorylated by mTORC1 activation, inhibiting its binding to eIF4E. Alain et al. have shown 
that a higher eIF4E/4E-BP ratio is predictive of resistance to catalytic mTOR inhibitors (18). 
Similarly, in a study by Cope et al., amplification of eIF4E has been shown to confer resistance 
to AZD8005 -a catalytic mTOR inhibitor- with ribonucleic acid interference (RNAi)-mediated 
knockdown of eIF4E reversing the acquired resistance (19).  
 
Several genes have been found to be significantly mutated in clear cell RCC including HIF1α, 
HIF1β, PBRM1 and SETD2. Additionally, the cancer genome atlas research network have 
identified and validated 19 significantly mutated genes (SMGs) in ccRCC with VHL, PBRM1, 
SETD2, KDM5C, PTEN, BAP1, MTOR and TP53 being the most significant(20). In 
chromophobe RCC, the SMGs included TP53, PTEN, mTOR, NRAS, TSC1 and TSC2(21). 22% 
(15/66) of the somatic alterations occurred in the genetic components affecting the mTOR 
pathway, indicating its role in chromphobe RCC. 
 






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• For men: 
o Even if surgically sterilized (ie, status post-vasectomy), they must agree to 
practice highly effective barrier contraception during the entire study 
treatment period and through 120 days after the last dose of study drug, 
OR 
o Agree to practice true abstinence, when this is in line with the preferred 
and usual lifestyle of the subject (Periodic abstinence [e.g, calendar, 
ovulation, symptothermal, postovulation methods for the female partner] 
and withdrawal, spermicides only, and lactational amenorrhea are not 
acceptable methods of contraception. Female and male condoms should 
not be used together.) 
o Agree not to donate sperm during the course of this study or 120 days after 
receiving their last dose of study drug. 
 
3.2 
Exclusion criteria 
 
1. Subjects with a history of deep vein thrombosis (DVT) or pulmonary embolism (PE) 
within 6 months of study treatment initiation. 
2. Receipt of any type of small molecular kinase inhibitor (including investigational 
kinase inhibitors) within 2 weeks of enrollment or receipt of any anti-cancer therapy 
(including investigational therapy, monoclonal antibodies, cytokine therapy) within 3 
weeks of enrollment. 
3. Treatment with any investigational products within 3 weeks before the first dose of 
study drug. 
4. Radiation therapy for bone metastases within 2 weeks, other external radiation 
therapy within 4 weeks of enrollment.  
5. Received prior hemibody external radiotherapy.  
6. Known brain metastases or cranial epidural disease unless adequately treated with 
radiotherapy, radiosurgery, or surgery and stable for at least 4 weeks prior to 
enrollment as documented by magnetic resonance imaging (MRI) or computed 
tomography (CT) imaging. Treated brain metastases are defined as having no ongoing 
requirement for steroids and no evidence of progression or hemorrhage after treatment 
for at least 4 weeks prior to enrollment as documented by MRI or CT imaging.  
7. Imminent or established spinal cord compression based on clinical and/or imaging. In 
subjects with untreated imminent or established spinal cord compression, treatment 
with standard of care as clinically indicated should be completed at least 4 weeks 
before enrollment. 
8. The subject has a history of any of the following within the last 6 months before 
administration of the first dose of the drug: 
• Ischemic myocardial event, including angina requiring therapy  and artery 
revascularization procedures   
• Ischemic cerebrovascular event, including transient ischemic attack and artery 
revascularization procedures 


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• Requirement for inotropic support (excluding digoxin) or serious 
(uncontrolled) cardiac arrhythmia (including atrial flutter/fibrillation, 
ventricular fibrillation or ventricular tachycardia)  
• Placement of a pacemaker for control of rhythm  
• New York Heart Association (NYHA) Class III or IV heart failure  
• Significant active cardiovascular or pulmonary disease including: 
o Uncontrolled hypertension defined as sustained BP >160 mm Hg 
systolic or > 95 mm Hg diastolic despite optimal antihypertensive 
treatment.  
o Pulmonary hypertension   
o Uncontrolled asthma or O2 saturation < 90% by arterial blood gas 
analysis or pulse oximetry on room air    
o Significant valvular disease; severe regurgitation or stenosis by 
imaging independent of symptom control with medical intervention, 
or history of valve replacement   
o History of arrhythmia requiring an implantable cardiac defibrillator 
o Medically significant (symptomatic) bradycardia   
9. Poorly controlled diabetes mellitus defined as glycosylated hemoglobin (HbA1c) > 
7%; subjects with a history of transient glucose intolerance due to corticosteroid 
administration may be enrolled in this study if all other inclusion/exclusion criteria 
are met 
10. Active gastrointestinal (GI) disorders including those associated with a high risk of 
perforation or fistula formation. Subjects with  enteric stomata (such as ileostomy, 
colostomy) are also excluded: 
• Tumors invading the GI-tract, active peptic ulcer disease, inflammatory bowel 
disease, diverticulitis, cholecystitis, symptomatic cholangitis or appendicitis, 
acute pancreatitis or acute obstruction of the pancreatic or biliary duct, or 
gastric outlet obstruction.  
• Abdominal fistula, gastrointestinal perforation, bowel obstruction, or 
intraabdominal abscess within 12 weeks before enrollment. NOTE: Complete 
healing of an intra-abdominal abscess must be confirmed before enrollment. 
11. Clinically significant hematemesis or hemoptysis of > 0.5 teaspoon (2.5 ml) of red 
blood, or other history of significant bleeding (such as pulmonary hemorrhage) within 
4 weeks of enrollment. 
12. Other clinically significant disorders such as: 
• Known active infection requiring systemic treatment, infection with human 
immunodeficiency virus (HIV) or acquired immunodeficiency syndrome 
(AIDS)-related illness, chronic hepatitis B or known or suspected active 
hepatitis C infection. 
• Serious non-healing wound or ulcer. 
• Malabsorption syndrome. 
• Symptomatic hypothyroidism. 
• Moderate to severe hepatic impairment (Child-Pugh B or C). 
• Requirement for hemodialysis or peritoneal dialysis. 
• History of solid organ transplantation. 


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13. Major surgery (such as GI surgery) within 6 weeks of enrollment. However, subjects 
who have had a nephrectomy may be enrolled 4 weeks after surgery, providing there 
are no wound-healing complications. Subjects with clinically relevant ongoing 
complications from prior surgery are not eligible. The following are not considered to 
be major procedures: Thoracentesis, paracentesis, port placement, laparoscopy, 
thoracoscopy, bronchoscopy, endoscopic ultrasonographic procedures, 
mediastinoscopy, skin biopsies, incisional biopsies, imaging-guided biopsy for 
diagnostic purposes, and routine dental procedures. 
14. QTcF (Fridericia formula for the QT interval correction for the heart rate) > 480 msec 
within 4 weeks of enrollment. If the initial QTcF is found to be > 480 msec, two 
additional electrocardiograms (EKGs) separated by at least 3 minutes should be 
performed. If the average of these three consecutive results for QTcF is ≤ 480 msec, 
the subject meets eligibility in this regard. Subjects with history of congenital long 
QT syndrome, or torsades de pointes, are not allowed. 
15. Pregnant or lactating females. 
16. Inability to swallow tablets or capsules. 
17. Previously identified allergy or hypersensitivity to components of the study treatment 
formulations. 
18. Malignancies other than RCC within 5 years of first study treatment with the exception of 
those with negligible risk of metastases or death (carcinoma in situ of the cervix, basal or 
squamous cell skin cancer, localized prostate cancer, ductal carcinoma in situ of the 
breast, non-muscle invasive urothelial carcinoma).  
19. Any serious medical or psychiatric illness that could, in the site investigator’s 
opinion, potentially interfere with the completion of treatment according to this 
protocol. 
20. Daily or chronic use of a proton pump inhibitor (PPI) and/or having taken a PPI 
within 7 days before receiving the first dose of study drug. 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women of all races and ethnic groups are eligible for this trial. 
 
 
4. 
SUBJECT REGISTRATION 
4.1 
General Guidelines for DF/HCC Institutions 
 
Institutions will register eligible participants in the Clinical Trials Management System (CTMS) 
OnCore. Registrations must occur prior to the initiation of protocol therapy. Any participant not 
registered to the protocol before protocol therapy begins will be considered ineligible and 
registration will be denied. 
 
An investigator will confirm eligibility criteria and a member of the study team will complete the 
protocol-specific eligibility checklist. 


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Following registration, participants may begin protocol therapy. Issues that would cause 
treatment delays should be discussed with the Overall Principal Investigator (PI). If a participant 
does not receive protocol therapy following registration, the participant’s registration on the 
study must be canceled. Registration cancellations must be made in OnCore as soon as possible.  
 
4.2 
Registration Process for DF/HCC Institutions 
 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed.   
 
4.3 
General Guidelines for Other Investigative Sites 
 
Eligible participants will be entered on study centrally at the DFCI by the Project Manager.  All 
sites should call the Project Manager to verify treatment availability.  
 
Following registration, participants should begin protocol therapy within 5 days.  Issues that 
would cause treatment delays should be discussed with the Overall PI.  If a participant does not 
receive protocol therapy following registration, the participant’s registration on the study must be 
canceled.  The Project Manager should be notified of cancellations as soon as possible. 
 
4.4 
Registration Process for Other Investigative Sites 
 
To register a participant, the following documents should be completed by the research nurse or 
data manager and emailed/faxed to the Project Manager: 
 
• Informed consent 
• HIPAA authorization form (if not included in consent form). 
• Medical History  
• Diagnosis and staging assessment 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• ECG 
• Laboratory Testing 
• Documentation of at least one prior anti-cancer therapy 
• Eligibility Checklist 
 
The research nurse or data manager at the participating site will then e-mail the Project Manager 
to verify eligibility. To complete the registration process, the Project Manager will follow 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) and register the participant on the protocol.  The Project 


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Manager will fax or e-mail the participant study number, and if applicable the dose treatment 
level, to the participating site.  The Project Manager will also call the research nurse or data 
manager at the participating site and verbally confirm registration. 
 
5. 
TREATMENT PLAN 
5.1 
Pre-medication and Hydration 
Prophylactic use of anti-emetic, anti-nausea, and anti-diarrheal medications are encouraged and 
may be used prior to first dose of TAK-228, and as needed throughout the study prior to each 
dosing and as clinically indicated per standard practice. When selecting an anti-emetic agent, 
drugs that do not have an effect on the QT interval are preferred.  Subjects should be encouraged 
to drink at least 18-24 oz of liquids a day. 
 
5.1.1 
Antiemetic Recommendations: These guidelines are strongly recommended to prevent 
treatment associated nausea but will not constitute deviations if not followed. 
  
Cycle 1 Day 1: IV Palonosetron (Aloxi) 0.25 mg infusion administered in clinic prior to first 
TAK-228 administration (dosing of study drug may be done outside of clinic). 
• 
Recommend prescribing prochlorperazine 10 mg orally as needed every 6 hours and 
lorazepam 0.5 mg as needed every 6 hours for nausea following study drug 
administration. Encourage the patient to alternate between the two anti-emetics if nausea 
persists. 
 
Cycle 1 Day 8 (and subsequent dosing days): If first dose of TAK-228 was tolerated well with 
IV palonosetron and as needed anti-emetics, subsequent dosing will include only oral antiemetic 
prophylaxis prior to TAK-228 dosing. 
• 
Recommend prescribing ondansetron 8mg and instruct patient to take ondanesetron orally 
at least 30-60 minutes prior to TAK-228 dosing. 
• 
If nausea after TAK-228 dosing persists, recommend providing patient with 
prochlorperazine 10 mg every 6 hours and lorazepam 0.5 mg every 4-6 hours as needed. 
Alternating between the two anti-emetics is recommended if nausea persists.  
5.2 
TAK-228 Administration 
Eligible subjects will be registered and will receive treatment with TAK-228 at a dose of 30 mg 
by mouth weekly on Day 1, Day 8, Day 15 and Day 22. Each cycle will be 4 weeks (28 days) in 
duration.   
 
TAK-228 capsules should not be opened, dissolved or crushed. TAK-228 capsules should be 
swallowed whole on an empty stomach. Subjects should be instructed to refrain from eating and 
drinking (except for water and prescribed medications) for 2 hours before and 1 hour after each 
dose.    If the subject chews or sucks the capsules by error, the subject should drink a large glass 


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of water (~8 oz).  Direct contact with the powder in TAK-228 capsules with skin or mucous 
membranes should be avoided. If such contact occurs, the subject should wash thoroughly with 
water. 
 
Subjects should be instructed to take their study medication at approximately the same time on 
each scheduled dosing day and not to take more than the prescribed dose at any time. If a subject 
does not take his or her TAK-228 dose within the time frame specified (± 24 hours of the QW 
scheduled dosing time), then the dose should be skipped and considered a missed dose. Subjects 
should record any missed doses in their diary and resume drug administration at the next 
scheduled time with the prescribed dosage. Under no circumstance should a subject repeat a dose 
or double-up doses.  The subject will be asked to bring their diary and pill bottle to their clinic 
visits. 
 
If severe emesis or mucositis prevents the subject from taking scheduled doses, that dose will be 
skipped. If emesis occurs after study medication ingestion, the dose will not be re-administered 
and subjects should resume dosing at the next scheduled time with the prescribed dosage. 
Subjects should record the occurrence of the emesis in their dosing diaries. Under no 
circumstance should a subject repeat a dose or double-up doses. 
 
TAK-228 Administration  
Drug 
Dose 
Route1 
Schedule 
Cycle Length2 
TAK-228 
30 mg 
(six 5 mg capsules) 
Orally 
Day 1, Day 8,  
Day 15 and Day 22 
4 weeks/28 days) 
 
1 Capsules should be taken whole with water. No food should be consumed within 2 hours before and one 
hour after the dose. Capsules should not be chewed, crushed or dissolved. If vomited, the capsules should not 
be retaken. 
2 A window of ± 3 days may be applied to all study visits to accommodate observed holidays, inclement 
weather, scheduling conflicts etc. Date and time of each drug administration should be clearly documented in 
subject’s chart and electronic case report forms (eCRFs). 
 
 
5.2.1 Prior to Cycle 1 Day 1, the following parameters must be met: 
• ANC ≥ 1500/mm3. 
• Platelet count ≥ 100,000/mm3. 
• Hemoglobin ≥ 9 g/dL (transfusions allowed).  
 
5.2.2 Subsequent cycles  
No specific parameters to be met for subsequent cycles. 
 
5.3 
Subject Evaluations 
Subjects will be evaluated clinically every week for Cycle 1, every 2 weeks for Cycles 2-3, and 
then every 4 weeks for subsequent cycles. On the days that a subject is seen in clinic, subjects are 
not required to physically dose in clinic.  There is no in-clinic dosing requirement. 
 


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Subjects will undergo disease assessments with imaging every 8 weeks relative to the C1D1 visit  
and continue on study therapy until radiographic progression, unacceptable toxicity or 
withdrawal.  
 
Subjects that do not have archived tissue from the previous 18 months available will undergo one 
mandatory biopsy at screening.  The pretreatment biopsy must occur within 28-days prior to 
initiation of therapy. In subjects who have an objective disease response as per RECIST version 
1.1 and then subsequently progress, a second biopsy at time of progression will be mandatory if 
feasible and safe. Subjects should continue study treatment until the day prior to the progression 
biopsy. Progression biopsy must occur within 28-days of determination of disease progression. 
 
5.4 
Concomitant Medications 
All prescription and over-the-counter medications, including influenza vaccines, taken by a 
subject within 30 days before the first study drug administration will be recorded on the 
designated CRF. 
 
5.4.1 Allowed Concomitant Medications 
• Histamine H2 receptor antagonists may be allowed, if needed provided that the histamine 
H2 receptor antagonist is not taken within 12 hours before and within 6 hours after study 
drug administration. Subjects receiving histamine H2 receptor antagonists before 
enrollment must stop using these medications for at least 24 hours before their first dose 
of study drug. Examples of histamine H2 receptor antagonists include ranitidine, 
famotidine, and nizatidine.  Cimetidine, a moderate cytochrome P450 (CYP)1A2 
inhibitor, is not recommended as a first choice H2 receptor antagonist. 
• Low molecular weight heparin (LMWH) is allowed 
• Palliative XRT to pre-existing lesion is allowed 
• Other medications considered necessary for the subject’s safety and well-being may be 
given at the discretion of the site investigator. Any concomitant medications added or 
discontinued during the study should be recorded on the Case Report Forms (CRF). 
• Neutralizing antacid preparations (acid neutralizers) and calcium supplements are not 
permitted during Cycle 1 on study drug administration days, but may be taken as needed 
on non-TAK-228 administration days. However, for all other cycles of the study 
administration of neutralizing antacids and calcium preparations is permitted except from 
4 hours before until 2 hours after TAK-228 administration. Some anti-gas preparations 
may also have antacid properties, and should also not be permitted from 4 hours before 
until 2 hours after study drug administration 
 
5.4.2 Prohibited Concomitant Medications 
The following medications/therapies are prohibited during the study: 
• Other investigational agents or mTOR inhibitors. 
• Other anticancer therapies including chemotherapy, immunotherapy, 
radioimmunotherapy, targeted agents, radiation or surgery (subjects can have palliative 
radiation or surgery in the study for pre-existing lesions). 


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• Systemic corticosteroids (either IV or oral steroids, excluding inhalers or intraarticular, 
intraocular steroids) unless necessary for treatment of TAK-228 related AE (such as, 
rash). 
• Anti-epileptic drugs for subjects with treated brain metastasis. 
• Concomitant administration of any PPI is not permitted during the study. Subjects 
receiving PPI therapy before enrollment must stop using the PPI for 7 days before their 
first dose of study drugs. Examples of PPIs include omeprazole, esomeprazole, 
pantoprazole, lansoprazole, and rabeprazole. 
• Strong CYP1A2 inhibitors and CYP inducers should be administered with caution, at the 
discretion of the investigator (see Appendix C). Alternative treatments, if available, 
should be considered. 
• Use of concomitant medications that are known to prolong the QTc interval is strongly 
discouraged. If use is medically indicated, caution is advised with increased EKG for 
QTc monitoring. 
 
5.4.3 Supportive Care 
Subjects should receive full supportive care, including transfusions of blood and blood products, 
antibiotics, anti-emetics, etc., when appropriate. Subjects who require therapeutic anticoagulation 
with low molecular weight heparin (e.g., enoxaparin and tinzaparin) at study entry will be 
eligible for enrollment. In addition, subjects requiring therapeutic anticoagulation with these 
agents during study participation will be allowed to remain on study therapy. 
 
5.5 
Criteria for Taking a Participant Off Protocol Therapy 
Duration of therapy will depend on individual response, evidence of disease progression and 
tolerance. In the absence of treatment delays due to adverse event(s), treatment may continue 
until one of the following criteria applies: 
 
• 
Disease progression 
• 
Intercurrent illness that prevents further administration of treatment 
• 
Unacceptable adverse event(s) 
• 
Participant demonstrates an inability or unwillingness to comply with the oral 
medication regimen and/or documentation requirements 
• 
Participant decides to withdraw from the protocol therapy 
• 
Investigator determines a change of therapy would be in the best interest of the 
subject 
• 
Female subject becomes pregnant 
• 
General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the judgment of the treating investigator 
• 
Study Termination 
 
Participants will be removed from the protocol therapy when any of these criteria apply.  The 
reason for removal from protocol therapy, and the date the participant was removed, must be 
documented in the case report form (CRF). Alternative care options will be discussed with the 
participant. 


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An ODQ Treatment Ended/Off Study Form will be filled out when a participant is removed from 
protocol therapy. This form can be found on the DF/HCC website at 
http://www.dfhcc.harvard.edu/research/clinical-research-support/document-library-forms-sops-
etc/. 
 
In the event of unusual or life-threatening complications, treating investigators must immediately 
notify the Overall PI, 
  
 
5.6 
Duration of Follow Up 
Subjects will be followed for safety for 90 days following the last dose of study treatment or 
until receipt of another anticancer therapy, whichever comes first. Subjects who have an ongoing 
study treatment-related AE upon study completion or at discontinuation from the study will be 
followed until the event has resolved to baseline grade, the event is assessed by the site 
investigator as stable, new anticancer treatment is initiated, the subject is lost to follow-up, the 
subject withdraws consent, or until it has been determined that study treatment or participation is 
not the cause of the AE.   
 
After progression/treatment discontinuation, subjects will be followed for survival and receipt of 
next line therapies every 6 months until death or 2 years after treatment discontinuation Follow-
up will be via phone calls and through review of medical records.  
 
5.7 
Criteria for Taking a Participant Off Study 
Participants will be removed from study when any of the following criteria apply: 
• Lost to follow-up 
• Withdrawal of consent for data submission 
• Death 
 
The reason for taking a participant off study, and the date the participant was removed, must be 
documented in the case report form (CRF). 
 
For Decentralized Subject Registrations, the research team updates the relevant Off 
Treatment/Off Study information in OnCore.  
 
5.8 
Replacement  
A subject who discontinues study participation prematurely for any reason is defined as a 
“dropout” if the subject has already been assigned to treatment or administered at least one dose 
of the study drug. Subjects who have dropped out will not be replaced. 
 
6. 
TOXICITIES AND DOSE DELAYS/DOSE MODIFICATIONS 
Measures will be taken to ensure the safety of subjects participating in this trial, including the 
use of stringent inclusion and exclusion criteria and close monitoring. Eligibility criteria were 


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selected to guard the safety of subjects in this trial. Safety will be evaluated in this study through 
the monitoring of all serious and non-serious AEs, defined and graded according to CTCAE v4.  
Subjects will be assessed for safety (including laboratory values). General safety assessments 
will include serial interval histories, physical examinations, and specific laboratory studies, 
including serum chemistries and blood counts all serious adverse events (SAEs) and protocol 
defined events of special interest will be reported in an expedited fashion. In addition, the site 
investigators will review and evaluate observed AEs on a regular basis. 
 
The descriptions and grading scales found in the revised CTCAE v4 will be utilized for dose 
delays. A copy of the CTCAE v4 can be downloaded from the Cancer Therapy Evaluation 
Program (CTEP) website 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.    
 
6.1 
TAK-228 Dose Modifications 
TAK-228 administration should be withheld for treatment-related adverse events that are Grade 
3 or higher, despite supportive treatment per standard clinical practice. If the event resolves to 
Grade 1 or Grade 2 for hyperglycemia or rash or to baseline values within 2 weeks of 
interrupting treatment, then the subject may resume study treatment at a dose reduced by 1 level 
(see Table below). If study drug administration is delayed for more than 4 weeks (28 consecutive 
days) due to non-resolving study drug-related grade 3 toxicity despite supportive treatment per 
standard clinical practice, or more than 3 dose reductions of study drug are required in a subject, 
then study drug treatment should be stopped, the subject discontinued from the study, and the 
EOT visit completed within 30 days (±7) after the last dose of study drug.  
 
If study drug administration is delayed for more than 6 weeks (42 consecutive days) due to non-
treatment related adverse events, then study drug treatment should be discontinued, and EOT 
visit completed within 30 days (± 7 days) after the last dose of study drug  
 
If study drug is delayed for either less than 4 weeks (28 consecutive days) due to non-resolving 
study drug-related grade 3 toxicity or less than 6 weeks (42 consecutive days) due to non-
treatment related adverse events, subjects should skip the dosing cycles missed and when if 
treatment is resume, this should be at the next scheduled dosing cycle.  
6.2 
Dose Levels for Dose Reductions 
 
Table 4: Dose Modifications for Single-Agent TAK-228 
Dose Level 
Dose Regimen  
TAK-228 Capsules: Number and Strength 
Starting Dose 
Level 
30 mg QW 
Six 5-mg capsules   
−1 
20 mg QW 
Four 5-mg capsules   
−2 
15 mg QW 
Three 5-mg capsule  
−3 
10 mg QW 
Two 5-mg capsules  
QW=once weekly. 
 


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It is not mandatory to hold treatment in the absence of optimal supportive care for toxicities of 
nausea and diarrhea.  Optimal supportive care is defined as an anti-emetic regimen that employs 
a 5-HT3 antagonist.  If nausea and diarrhea persist despite optimal supportive care, treatment 
should be held until the subject returns to baseline. 
 
In the case that a patient experiences persistent grade 1 or 2 toxicity, treatment with TAK-228 
may be withheld at the discretion of the treating investigator. Once toxicity resolves in the case 
of grade 1 toxicity or resolves or at least improves to grade 1 in the case of grade 2 toxicity, 
treatment with TAK-228 may be resumed at the current dose level. If persistent grade 1 or 2 
toxicity recurs, treatment with TAK-228 can again be held withheld at the discretion of the 
treating investigator. Once toxicity resolves in the case of grade 1 toxicity or resolves or at least 
improves to grade 1 in the case of grade 2 toxicity, treatment with TAK-228 may be resumed but 
at a reduced dose by one level. 
 
 
6.3 
Management of Clinical Events 
6.3.1 Management of Hyperglycemia 
 
Guidance for TAK-228 dose management in the event of hyperglycemia is provided in the table 
below. 
 
Table 5: Management of Hyperglycemia 
Grade 
Description 
Treatment 
TAK-228 Dose Modification 
1 
Fasting blood sugar 
> ULN–160 mg/dL 
Continue close monitoring of 
blood sugars. 
Consider initiation of oral 
hypoglycemic agent and/or 
insulin if not well controlled on 
oral agent. 
None. 
2 
Fasting blood sugar 
> 160–250 mg/dL 
Initiate oral hypoglycemic 
agent and/or insulin if not well 
controlled on oral agent. 
None. 
≥3 
Fasting blood sugar 
> 250 mg/dL 
Initiate oral hypoglycemic 
agent and/or insulin. 
Hold drugs until ≤ Grade 2. 
Resume TAK-228 based on timing of 
recovery: 
≤ 1 week:  resume at same dose and 
schedule; 
>1 but ≤2 weeks: reduce TAK-228 by 
1 dose level 
>2 weeks: discontinue subject from 
study  
Prevention/Prophylaxis 
• 
Follow fasting serum glucose levels during clinic visits. 
• 
Monitor home glucometer test results. 
• 
Check HbA1c levels every 3 months during therapy. 


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• 
Life-style modifications, as appropriate (balanced diet, limit alcohol consumption, increase 
physical activity). 
• 
Most episodes of Grade 1 and 2 hyperglycemia respond quickly to oral metformin. 
• 
Early initiation of therapy is recommended to prevent higher grade hyperglycemia. 
• 
Fasting blood glucose levels ≥ 150 mg/dL by glucometer should be followed by closer monitoring 
of serum glucose and possible intervention. 
Abbreviations:  dL = deciliters; mg = milligrams; ULN = upper limit of normal. 
 
On the basis of the clinical experience in TAK-228 trials, most episodes of hyperglycemia 
observed occurred within the first 60 days after initiation of treatment with TAK-228 and have 
been either Grade 1 or Grade 2, and have responded quickly to oral metformin. Hyperglycemia 
has not been dose-limiting since the institution of a standard regimen for early treatment of 
hyperglycemia.  
 
All subjects developing hyperglycemia during the study should have their glucose closely 
monitored by study staff. The site investigator may choose to continue close monitoring of 
subjects who develop Grade 1 hyperglycemia (fasting glucose >ULN ≤160 mg/dL) or, 
alternatively, consider initiating treatment with an oral hypoglycemic agent, such as metformin. 
All subjects with ≥Grade 2 hyperglycemia (fasting glucose >160 mg/dL) must be treated 
aggressively with oral hypoglycemic agents and/or insulin as clinically indicated. The site 
investigator should consult an endocrinologist, if needed, to aid in optimizing the subject’s 
hyperglycemia treatment plan. 
 
It is recommended that subjects be initially treated with a fast acting insulin sensitizer such as 
metformin at 500 mg orally QD, and titrate up to a maximum of 1000 mg orally BID as needed. 
Concurrent addition to metformin of DPP-4 inhibitors (eg, sitagliptin or vildagliptin) and/or 
insulin should also be considered. Oral sulfonylureas (eg, glipizide or glyburide) should be used 
with caution, due to the higher risk of inducing hypoglycemia in subjects. The dose of oral 
hypoglycemic agents should be adjusted in subjects with renal insufficiency. In addition, subjects 
should be encouraged to follow a low carbohydrate diet once hyperglycemia is first observed. 
If any fasting serum glucose reading performed at the site indicates hyperglycemia (>ULN or 
≥110 mg/dL), the study staff should first confirm that the subject was fasting at the time of blood 
specimen collection (ie, nothing by mouth for at least 8 hours before collection). 
 
In-Home Daily Fasting Glucose Monitoring 
In addition to obtaining fasting glucose levels at the clinic visits as outlined in the Schedule of 
Events, all subjects receiving TAK-228 will be given a glucometer to monitor their daily FBG 
levels at home. The level should be collected daily, predose on dosing days, and at 
approximately the same time each day. 
 
Prior to initiating treatment, the subject will be provided an in-home glucometer. Subjects will be 
trained on proper use of the glucometer and instructed to collect a daily FBG level every 
morning (predose on dosing days), starting on Cycle 1 Day 2. Subjects will be instructed to bring 
the glucometer with them to each study visit so that the data collected can be reviewed and 
recorded in the source documents. Site investigators will be responsible for reviewing the home 
glucose monitoring logs for hyperglycemia. 


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The subject will be instructed to contact the site immediately if the value is abnormal (ie, ≥150 
mg/dL) for further instructions on the management of their hyperglycemia. Hyperglycemia 
observed during home glucose monitoring should be confirmed in the clinic.  If no irregularities 
in the fasting blood glucose level are observed during a minimum of 2 consecutive months, then 
the frequency of in-home fasting blood glucose testing can be reduced to a minimum frequency 
of once weekly, depending on the site investigator’s judgment and approval. Subjects will 
continue to notify the site investigator of fasting blood glucose levels that exceed 150 mg/dL 
and, if blood glucose levels are not well controlled, or if the subject requires either oral 
hypoglycemic agents or insulin to control blood glucose levels, then the frequency of in-home 
testing of FBG levels will be reinstated to daily. 
6.3.2 Management of Noninfectious Pneumonitis 
Guidance for TAK-228 dose management in the event of noninfectious pneumonitis is shown in 
the table below.   
 
Table 6: Management of Non-infectious Pneumonitis 
Grade 
Description 
Treatment 
TAK-228 Dose Modification 
1 
Asymptomatic: 
Radiographic findings only 
Rule out infection and 
closely monitor. 
None. 
2 
Symptomatic: 
Not interfering with ADLs 
Rule out infection and 
consider treatment with 
corticosteroids until 
symptoms improve to 
≤ Grade 1. 
Interrupt TAK-228 treatment: 
When symptoms ≤ Grade 1, re-
initiate TAK-228 treatment at a 
dose reduction  
Discontinue TAK-228 treatment if 
failure to recover within 4 weeks. 
3 
Symptomatic: 
Interfering with ADLs; 
Requires administration of 
O2 
Rule out infection and 
consider treatment with 
corticosteroids until 
symptoms improve to 
≤ Grade 1. 
Interrupt TAK-228 treatment until 
symptoms resolve to ≤ Grade 1. 
Consider re-initiating TAK-228 
treatment at a dose reduction  
If toxicity recurs at Grade 3, 
discontinue TAK-228 treatment. 
. 
4 
Life-threatening: 
Ventilatory support 
indicated 
Rule out infection and 
consider treatment with 
corticosteroids. 
Discontinue TAK-228 treatment. 
Abbreviations:  ADL = activities of daily living; O2 = oxygen gas. 
 
 
6.3.3 Management of Hyperlipidemia 
Guidance for TAK-228 dose management in the event of hyperlipidemia is shown in the table 
below.  


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Table 7: Management of Hyperlipidemia 
Grade 
Description 
Treatment 
TAK-228 Dose Modification 
1 
Cholesterol: 
> ULN - 300 mg/dL 
Triglycerides: 
> 150 - 300 mg/dL 
None. 
None. 
2 
Cholesterol: 
> 300 – 400 mg/dL 
Triglycerides: 
> 300 - 500 mg/dL 
Treat hyperlipidemia 
according to standard 
guidelines. 
Triglycerides ≥ 500 mg/dl 
should be treated urgently 
due to risk of pancreatitis. 
Maintain dose if tolerable. 
 
If toxicity becomes intolerable, 
interrupt TAK-228 dosing until 
recovery to ≤ Grade 1.  Reinitiate at 
same dose. 
3 
Cholesterol: 
> 400 - 500 mg/dL 
Triglycerides: 
> 500 - 1000 mg/dL 
Same as for Grade 2. 
Hold dose until recovery to ≤ Grade 
1, then restart at a dose reduction  
4 
Cholesterol: 
> 500 mg/dL 
Triglycerides: 
> 1000 mg/dL 
Same as for Grade 2. 
Same as for Grade 3. 
Prevention/Prophylaxis 
• 
Life-style modifications, as appropriate (balanced diet, limit consumption of alcoholic beverages, 
increase physical activity). 
Abbreviations:  dL = deciliters; mg = milligrams; ULN = upper limit of normal. 
 
 
6.3.4 Management of Oral Mucositis 
Guidance for TAK-228 dose management in the event of oral mucositis is provided in the table 
below.  
Table 8:   Management of Oral Mucositis 
Grade 
Description 
Treatment 
TAK-228 Dose Modification 
1 
Asymptomatic or mild 
symptoms 
Non-alcoholic mouth wash or 
0.9% salt water rinse; 
Consider topical 
corticosteroids at earliest 
signs of mucositis. 
None. 
2 
Moderate pain, not 
interfering with oral 
intake 
 
Modified diet indicated 
Topical analgesic mouth 
treatments; 
Topical corticosteroids; 
Initiate antiviral or antifungal 
therapy, if indicated. 
Maintain dose if tolerable. 
If toxicity becomes intolerable, 
interrupt TAK-228 dosing until 
recovery to ≤ Grade 1.  Reinitiate at 
same dose. 
3 
Severe pain, interfering 
with oral intake 
Same as for Grade 2; 
Consider intra-lesional 
corticosteroids. 
Hold dose until recovery to ≤ Grade 1, 
then restart at a dose reduction 


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4 
Life-threatening 
consequences 
Same as for Grade 2. 
Consider intra-lesional 
corticosteroids. 
Discontinue treatment. 
Prevention/Prophylaxis 
• 
Consider initiation of a non- alcoholic mouth wash or 0.9% salt water rinses 4-6 times daily with 
start of therapy before signs of mucositis develop. 
• 
Avoid using agents containing hydrogen peroxide, iodine, and thyme derivatives in management of 
stomatitis as they may worsen mouth ulcers. 
 
 
 


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6.3.5 Management of Rash 
Guidance for TAK-228 dose adjustment for the event of rash is provided in the table below 
 
 
Subjects who develop Grade 4 rash should permanently discontinue study treatment, unless they 
derive clinical benefit as determined by the site investigator, in which case they may be retreated 
at a reduced dose level after recover to ≤ Grade 1 severity. Grade 4 rash is defined as rash 
acneifom and/or papulopustular with papules and/or pustules covering any % body surface area, 
which may or may not be associated with symptoms of pruritus or tenderness, AND are 
associated with extensive superinfection requiring with intravenous (IV) antibiotics indicated; 
life threatening consequences (NCI CTCAE Version 4.03, effective date 14 June 2010). 
 
Prevention/Prophylaxis: 
Rash should be managed aggressively. The site investigator should consider consulting a 
dermatologist or other specialist, if needed.  A skin biopsy at the site of rash should be 
considered as soon as possible after the initial episode. 
 
 
Table 9: Management of Rash 
Grade Description 
Treatment 
TAK-228 Dose Modification 
≤ 2 
Macules/papules 
covering ≤ 30% body 
surface area with or 
without symptoms 
Consider treatment 
with topical steroid 
cream/ointment 
and/or oral anti-
histamines or 
antibiotics. 
None. 
≥ 3 
Macules/papules 
covering > 30% body 
surface area with or 
without symptoms 
Consider treatment 
with topical steroid 
cream/ointment, 
oral antihistamines, 
oral antibiotics, 
and/or pulsed 
steroids. 
Hold until ≤ Grade 2; 
Resume TAK-228 based on 
timing of recovery and severity 
of symptoms: 
≤ 3 weeks: reduce dose  by 1 
dose level; 
> 3 weeks and severely 
symptomatic: stop TAK-228 
and discontinue subject from the 
study. 


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6.3.6 Management of Nausea and/or Vomiting 
Guidance for TAK-228 dose adjustment for the event of nausea and/or vomiting is provided in 
the table below. 
  
 
6.3.7 Management of Cardiac Events 
6.3.7.1 Management of Cardiac Instability 
For subjects showing signs of cardiac instability after TAK-228 dosing, additional monitoring 
onsite before clinic discharge should be considered. 
 
6.3.7.2  Management of Left Ventricular Dysfunction 
Guidance for TAK-228 dose adjustment for the event of left ventricular dysfunction is provided 
in the table below. 
 
Table 11: Management of Left Ventricular Dysfunction 
Grade 
Description 
TAK-228 Dose Modification 
1 
Asymptomatic decline in 
LVEF > 15% from baseline values OR; 
LVEF > 10%-15% from baseline values and is 
below institution’s LLN 
No change; continue TAK-228 at same dose 
and schedule. 
≥ 2 
Symptomatic cardiac dysfunction/congestive 
heart failure 
Discontinue treatment. 
Abbreviations:  LLN = lower limit of normal; LVEF = left ventricular ejection fraction. 
 
Table 10: Management of Nausea and/or Vomiting 
Grade 
Description 
Treatment 
TAK-228 Dose Modification 
≤ 2 
Loss of appetite with or without 
decreased oral intake; 
1-5 episodes of vomiting within 
24 hours 
Maximize anti-emetic 
therapy; 
Consider IV fluid 
hydration. 
None. 
≥ 3 
Inadequate oral intake; 
≥ 6 episodes of vomiting within 
24 hours 
Maximize anti-emetic 
therapy; 
Initiate tube feeding, 
IVF, or TPN. 
If experienced for ≤72 hours, hold 
TAK-228 until ≤ Grade 1, then 
resume TAK-228 without dose 
modification. If experienced for >72 
hours despite optimal therapy, hold 
TAK-228 until ≤ Grade 1, then 
resume treatment with the dose of 
TAK-228 reduced by 1 level. 
Prevention/Prophylaxis 
Prophylactic use of anti-emetic, anti-nausea, and anti-diarrheal medications are encouraged and may be used 
before each dose of TAK-228 as needed throughout the study. 
Abbreviations:  IV = intravenous; IVF = intravenous fluids; TPN = total parenteral nutrition 


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6.3.7.3 Management of QTc Prolongation 
Guidance for TAK-228 dose adjustment for the event of QTcF prolongation is provided in the 
table below. 
 
Table 12: Management of QTc Prolongation 
Grade 
Description 
Treatment 
TAK-228 Dose Modification 
2 
480 ms < QTcF  
< 501 ms 
Evaluate for other possible causes (eg, 
electrolyte disturbance, concomitant 
medication, etc.) 
None; continue TAK-228 at the same 
dose and schedule. 
≥ 3 
QTcF ≥ 501 ms 
Evaluate for other possible causes (eg, 
electrolyte disturbance, concomitant 
medication)a; 
Consider a formal consult by a 
cardiologist; 
Notify the study doctor; 
Additional ECGs may be performed at 
intervals that the treating physician 
deems clinically appropriate until 
repeated QTc measurements fall or are 
below the threshold interval that 
triggered the repeat measurement. 
TAK-228 should be interrupted. 
 
Subjects who experience persistent 
symptomatic Grade 3 or Grade 4 QTc 
prolongation without another cause 
should permanently discontinue study 
treatment. 
Abbreviations:  ECG = electrocardiogram; IV = intravenous; ms = milliseconds; QTc = QT interval 
corrected for heart rate 
a A list of medications known to prolong QTc can be found at www.torsades.org and www.QTdrugs.org. 
6.3.8 Management of Aspartate Aminotransferase/Alanine Aminotransferase Elevations 
Table 14: Management of Aspartate Aminotransferase/Alanine Aminotransferase 
Elevations 
Grade Description 
Treatment 
Dose Modification 
1 
>ULN to 3×ULN 
None 
None 
2 
Asymptomatic with levels 
3 to 5×ULN; >3×ULN with 
the appearance of 
worsening fatigue, nausea, 
vomiting, right upper 
quadrant pain or tenderness, 
fever, rash, or eosinophilia. 
• 
Closely monitor LFTs at 
least weekly or more 
frequently as indicated. 
• 
Assess subject for other 
causes of transaminitis (eg, 
past medical history, 
concomitant medications). 
None 
3 
>5 to 20×ULN; >5×ULN 
for >2 weeks 
Same as for Grade 2. 
Hold TAK-228 until ≤Grade 1; 
Restart TAK-228 at the same 
dose. Permanently discontinue 
study treatment if in 
combination with Grade 2 total 
bilirubin elevation when 
alternative causes cannot be 
identified (ie, Hy’s Law); 
4 
>20×ULN 
Same as for Grade 2. 
Stop TAK-228 and discontinue 
subject from the study. 


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Table 14: Management of Aspartate Aminotransferase/Alanine Aminotransferase 
Elevations 
Grade Description 
Treatment 
Dose Modification 
Permanently discontinue study 
treatment if in combination 
with Grade 2 total bilirubin 
elevation when alternative 
causes cannot be identified (ie, 
Hy’s Law). 
Prevention/Prophylaxis: 
Ensure proper screening of subjects for study participation. 
LFTs=liver function tests, ULN=upper limit of normal. 
Patients meeting Hy’s Law criteria regardless of attribution or of alternative etiology, must discontinue 
treatment. 
 
 
 


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6.3.9 Management of Other Non-Hematologic Toxicities 
Guidance for TAK-228 dose management in the event of non-hematologic toxicities is provided 
in the table below. 
 
Table 13: Management of Other Non-Hematologic Toxicities (including asthenia, weakness and 
fatigue) 
Grade 
Description 
Treatment 
Dose Modification 
1 
Mild; asymptomatic or 
mild symptoms; clinical or 
diagnostic observations 
only; intervention not 
indicated. 
Initiate appropriate 
medical therapy and 
monitor. 
If tolerable, then no adjustment 
is required. 
2 
Moderate; minimal, local 
or noninvasive intervention 
indicated. 
Initiate appropriate 
medical therapy and 
monitor. 
• 
If tolerable, no adjustment 
required. 
• 
If toxicity becomes 
intolerable, hold TAK-228 
until recovery to ≤Grade 1, 
then reinitiate at same 
dose.  
≥ 3 
Severe or medically 
significant but not 
immediately life-
threatening; hospitalization 
or prolongation of 
hospitalization indicated 
 
Hold TAK-228 until recovery 
to ≤ Grade 1. Reinitiate TAK-
228 at dose reduced by 1 level. 
Subjects who develop Grade 4 
non-hematological toxicities 
(with the exception of isolated 
non-clinically significant 
laboratory values) should 
permanently discontinue study 
treatment, unless they derive 
clinical benefit as determined 
by PI, in which case they may 
be retreated at a reduced dose 
level after recovery to ≤ Grade 
1 severity.  






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6: Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects are required to fast overnight (nothing except water and/or 
medications after midnight or for a minimum of 8 hours before the assessment) for each of these measurements. In-home glucose monitoring will 
begin on Cycle 1 Day 2 and is required daily for the first two months of treatment. If levels remain stable, monitoring can be decreased to once a 
week after the first two cycles, otherwise it is required daily until the last dose of study drug. In-home glucose monitoring is not required on the 
days that subjects will be getting fasting serum glucose testing in clinic. Please see the Management of Hyperglycemia section for details. 
 
7: Subjects with ≥ 2+ protein on dipstick urinalysis must undergo 24-hour urine collection for protein 
 
8: Diagnostic CT chest and CT or MRI of the abdomen and pelvis should be obtained at screening and at every 8 week imaging assessment 
relative to the C1D1 visit. If doses are held due to toxicity, scans should continue on this every 8 week interval relative to C1D1. 
 
9: MRI of the brain with and without contrast is preferred. If a subject is not able to obtain an MRI, CT imaging with contrast is acceptable. If a 
subject is not able to receive contrast, CT head without contrast is acceptable. 
 
10: Archival tissue needs to be requested and received prior to therapy initiation if available. 
 
11: Baseline fresh tumor biopsies are MANDATORY for subjects that do not have archival tissue available from the previous 18 months.  
Screening tumor biopsies must be collected within 28 days prior to initiation of study therapy.  Progression tumor biopsies are MANDATORY 
ONLY in subjects who experience an initial disease response per RECIST 1.1 criteria and then subsequent progression, if feasible and safe.   
 
12: MANDATORY: Blood for germline DNA analysis will be collected prior to C1D1 treatment. MANDATORY: Research blood samples for 
biomarker analysis to be collected prior to C1D1 treatment and every 8 weeks until off treatment. If off treatment collection is within 2 weeks of 
prior collection, research samples do not need to be collected.  
 
13: Subjects who discontinue study treatment will return for a treatment discontinuation visit around 30 days (± 7 days) after the last study 
treatment.  The visit at which a response assessment shows progressive disease may be used as the treatment discontinuation visit. 
 
14: After a subject discontinues from study treatment, they will continue to be followed for survival and subsequent anti-cancer therapy every 6 
months until death or 2 years after study treatment discontinuation.  Follow up may be accomplished via clinic visit, phone call, or other avenues 
as appropriate. 
 
 
 
 


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7.1 
Screening Evaluations 
 
Within 28 days prior to registration for protocol therapy 
• Informed consent 
• Medical History  
• Diagnosis and staging assessment 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• ECG 
• Cardiac Echo or MUGA 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile  
o PT/INR and aPTT 
o Thyroid Function Tests (TSH) 
o Pregnancy Test (urine or serum) for WOCBP 
o Fasting Lipid Profile (fasting is defined as nothing except water and/or 
medications after midnight or for a minimum of 8 hours before the assessment). 
o HbA1c 
o LDH 
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
• Disease assessments (imaging with contrast is preferred unless contraindicated) 
o CT of Chest 
o CT or MRI of Abdomen and Pelvis 
o MRI Brain with/without contrast preferred; other options include: CT imaging 
with contrast or CT without contrast if the subject cannot receive contrast.  CT 
head without contrast is acceptable 
• Research Testing to be done after confirmation of eligibility 
o Archival tissue will be requested and received prior to C1D1.  Formalin-fixed, 
paraffin-embedded (FFPE) tumor tissue block is preferred.  Alternatively, a 
minimum of 20unstained, charged, paraffin coated slides will suffice.  Fine-
needle aspiration, brushings, cell pellet from pleural effusion, bone marrow 
aspirate/biopsy are not acceptable.   
o MANDATORY: Pre-treatment biopsy should take place prior to initiation of 
protocol therapy C1D1 following confirmation of eligibility if the subject does 
not have archival tissue from the previous 18 months available.  
 
7.2 
On Treatment Evaluations (± 3 days) 
 
Cycle 1 Day 1 


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• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• ECG 
• In home glucose monitoring: 
o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight (nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment) for each of these 
measurements. In-home glucose monitoring will begin on Cycle 1 Day 2 and is 
required daily for the first two months of treatment. If levels remain stable, 
monitoring can be decreased to once a week after the first two cycles, otherwise it 
is required daily until the last dose of study drug. In-home glucose monitoring is 
not required on the days that subjects will be getting fasting serum glucose testing 
in clinic. 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile  
o PT/INR and aPTT 
o Thyroid Function Tests (TSH) 
o Fasting Lipid Profile (fasting is defined as nothing except water and/or 
medications after midnight or for a minimum of 8 hours before the assessment). 
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
• MANDATORY: Research Blood Samples prior to initiation of protocol therapy C1D1 
o Germline DNA analysis 
o Blood biomarker analysis 
• Medication Administration: TAK228 (D1, D8, D15, D22) 
 
Cycle 1 Day 8 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• In home glucose monitoring: 
o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight (nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment) for each of these 
measurements. In-home glucose monitoring will be required daily for the first two 
months of treatment. In-home glucose monitoring is not required on the days that 
subjects will be getting fasting serum glucose testing in clinic. 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile  
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 


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• Medication Administration: TAK228 (D1, D8, D15, D22) 
 
Cycle 1 Day 15 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• In home glucose monitoring: 
o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment) for each of these 
measurements. In-home glucose monitoring will be required daily for the first two 
months of treatment. In-home glucose monitoring is not required on the days that 
subjects will be getting fasting serum glucose testing in clinic. 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile  
o TSH 
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
• Medication Administration: TAK228 (D1, D8, D15, D22) 
 
Cycle 1 Day 22 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• In home glucose monitoring: 
o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight (nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment) for each of these 
measurements. In-home glucose monitoring is not required on the days that 
subjects will be getting fasting serum glucose testing in clinic. 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile  
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
• Medication Administration: TAK228 (D1, D8, D15, D22) 
 
Cycle 2 Day 1 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• In home glucose monitoring: 


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o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight (nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment) for each of these 
measurements. In-home glucose monitoring is not required on the days that 
subjects will be getting fasting serum glucose testing in clinic. 
• ECG 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile  
o PT/INR and aPTT 
o Thyroid Function Tests (TSH) 
o Fasting Lipid Profile (fasting is defined as nothing except water and/or 
medications after midnight or for a minimum of 8 hours before the assessment). 
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
• Medication Administration: TAK228 (D1, D8, D15, D22) 
 
Cycle 2 Day 15 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• In home glucose monitoring: 
o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight (nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment) for each of these 
measurements. In-home glucose monitoring is not required on the days that 
subjects will be getting fasting serum glucose testing in clinic. 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile 
o TSH 
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
• Medication Administration: TAK228 (D1, D8, D15, D22) 
 
Cycle 3 Day 1 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• In home glucose monitoring: 
o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight (nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment) for each of these 


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measurements In-home glucose monitoring is not required on the days that 
subjects will be getting fasting serum glucose testing in clinic. 
• ECG 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile  
o PT/INR and aPTT 
o HbA1c 
o Fasting Lipid Profile (fasting is defined as nothing except water and/or 
medications after midnight or for a minimum of 8 hours before the assessment). 
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
• Medication Administration: TAK228 (D1, D8, D15, D22) 
 
Cycle 3 Day 15 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• In home glucose monitoring: 
o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight (nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment for each of these 
measurements. If levels remain stable after 2 months of treatment, monitoring can 
be decreased to once a week after the first two cycles, otherwise it is required 
daily until the last dose of study drug. In-home glucose monitoring is not required 
on the days that subjects will be getting fasting serum glucose testing in clinic. 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile 
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
• Medication Administration: TAK228 (D1, D8, D15, D22) 
 
Cycle 4 Day 1 and subsequent Cycles 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• In home glucose monitoring: 
o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight (nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment) for each of these 
measurements. If levels remain stable after 2 months of treatment, monitoring can 
be decreased to once a week after the first two cycles, otherwise it is required 


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daily until the last dose of study drug. In-home glucose monitoring is not required 
on the days that subjects will be getting fasting serum glucose testing in clinic. 
• ECG 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile 
o PT/INR and aPTT 
o HbA1c 
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
o Fasting Lipid Profile (fasting is defined as nothing except water and/or 
medications after midnight or for a minimum of 8 hours before the assessment). 
• Medication Administration: TAK228 (D1, D8, D15, D22) 
 
Every 8 weeks (± 7 days) 
• Laboratory 
o Fasting Lipid Profile 
o Blood for biomarker analysis 
• In home glucose monitoring: 
o Fasting serum glucose will be measured in the clinic at each clinic visit. Subjects 
are required to fast overnight (nothing except water and/or medications after 
midnight or for a minimum of 8 hours before the assessment) for each of these 
measurements. If levels remain stable after 2 months of treatment, monitoring can 
be decreased to once a week after the first two cycles, otherwise it is required 
daily until the last dose of study drug. In-home glucose monitoring is not required 
on the days that subjects will be getting fasting serum glucose testing in clinic. 
• Disease assessments- scans are done every 8 weeks relative to the C1D1 visit (imaging 
with contrast is preferred unless contraindicated) 
o CT of Chest 
o CT or MRI of Abdomen and Pelvis 
 
7.3 Safety Follow-up Visit Evaluations 
Subjects discontinued from the treatment phase of the study for any reason will be evaluated 30 
days (± 7) after the last dose of study drug. Discuss the sequence of events that should occur 
during the visit, e.g., review of medications, assessment of adverse events, etc. These should be 
consistent with the Study Calendar. 
• Physical Examination including review of medications (over-the-counter or prescribed) 
and side effects the subject is experiencing 
• Vital signs (including temperature, heart rate, blood pressure, weight, height and oxygen 
saturation) and ECOG performance status 
• ECG 
• Laboratory Testing 
o CBC with differential and platelet count 
o Comprehensive Metabolic Profile  
o Thyroid Function Tests (TSH) 


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o Fasting Lipid Profile (fasting is defined as nothing except water and/or 
medications after midnight or for a minimum of 8 hours before the assessment). 
o Urinalysis (Subjects with ≥ 2+ protein on dipstick urinalysis at baseline must 
undergo 24-hour urine collection for protein) 
• Progression tumor biopsies are MANDATORY ONLY in subjects who experience an 
initial disease response per RECIST 1.1 criteria and then subsequent progression, if 
feasible and safe. 
 
7.4 
Long Term Follow-up Evaluations 
After a subject discontinues from study treatment, they will continue to be followed for survival 
and subsequent anti-cancer therapy every 6 months until death or 2 years after study treatment 
discontinuation.  Follow up may be accomplished via clinic visit, phone call, or other avenues as 
appropriate. 
 
8. 
CORRELATIVE TISSUE AND BLOOD ANALYSES  
 
8.1 
TISSUE ANALYSES 
A DFCI mutation screen analysis of 300 cancer genes (Oncopanel), including all those involved 
in regulation of mTOR will be performed on pre-treatment biopsies in all subjects to correlate 
with response to TAK-228(22). Data will be analyzed using standard pipeline tools for the CLIA 
use of this mutation analysis to identify sequence variants present in the tumor and not in the 
normal DNA sample, as well as tools to identify regions of significant copy number variation 
across the genome. 
 
Immunoblotting and IHC will performed on pre and post-treatment biopsies to analyze the 
downstream targets of mTORC1 and mTORC2 and correlate with the clinical response to TAK-
228. The downstream targets are the following: S6, p-S6, S6K1, p-S6K1, 4EBP1, p-4EBP1, Akt-
S473 and p-AKT-S473. 
 
In responding subjects who subsequently progress, the post-treatment biopsy will be used for 
genetic studies to determine the mechanism of resistance. A DFCI mutation screen (Oncopanel) 
as well as whole exome sequencing will be performed on pre and post-treatment biopsies to 
understand the mechanism of resistance. 
 
8.1.1 Archival Tissue Correlative Studies 
Archival tissue, preferred to have been collected within 18 months of enrollment otherwise, will 
be obtained prior to study treatment if available.  This tissue will be used to assess response to 
TAK-228, and evaluate mechanisms of acquired resistance to therapy. Mutation profiling will be 
performed using massively parallel sequencing technology (Oncopanel) and/or whole exome 
sequencing.  In addition, nucleic acid purification will be performed on the specimens. 
 


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The archival specimen must contain adequate viable tumor tissue and be overall representative of 
the whole tumor (i.e. containing predominant and highest Fuhrman grade areas). Formalin-fixed 
paraffin-embedded tumor tissue blocks are preferred and should contain tumor areas that 
measure at least 1 cm square in aggregate. Alternatively, a minimum of 20 unstained 4-micron-
thick sections (on charged slides) can be provided. The unstained slides should be coated with 
paraffin. Surgical specimens are preferred with order of preference being 1) nephrectomy 
specimens and 2) metastatectomy specimens. If surgical specimens are not available, core-needle 
biopsy specimens are acceptable. Fine-needle aspiration, brushings, cell pellet from pleural 
effusion, bone marrow aspirate/biopsy are not acceptable.  
 
8.1.2 Fresh Tissue Correlative Studies 
 
8.1.2.1 Pre-Treatment  
If subjects do not have archival tissue from within the previous 18 months available, they will 
undergo one mandatory biopsy prior to study treatment. The pretreatment biopsy must occur 
within 28-days prior to initiation of study therapy.  
 
8.1.2.2 Progression 
In subjects who experience an objective response as defined by RECIST version 1.1 and then 
subsequent progression as defined by RECIST 1.1, a biopsy will be mandated at the time of 
disease progression from a site of metastasis, if feasible and safe. Subjects should continue study 
treatment until the day prior to the progression biopsy. Progression biopsy must occur within 28-
days of determination of disease progression.   
 
The metastatic sites need to be safely accessible as deemed by the site investigator and 
interventional radiologist. During the core needle biopsy procedure, four core samples will be 
collected: one will be placed in formalin for routine histology and immunohistochemistry (IHC) 
studies and the remaining three will be frozen in liquid nitrogen. Two of the cores will be utilized 
for genomic analysis and the remaining core will be used for IHC and immunoblot analysis.  In 
addition, nucleic acid purification will be performed on the specimens. 
 
Biopsies will be obtained in a manner that minimizes risk and will be taken only if there is no 
intervening condition (e.g., thrombocytopenia or neutropenia) that, in the opinion of the site 
investigator, increases the likelihood of procedural complications to an unacceptable level.  
 
Biopsies should be performed per institutional standards and/or operator preference. Blood 
samples will be drawn within 2 weeks of the biopsy to document an acceptable coagulation 
profile (INR ≤ 1.5, PTT ≤ 60, platelets > 50,000). Aspirin, clopidogrel, and NSAIDS should be 
discontinued 5 days prior to the biopsy.  
 
Preferred biopsy sites include: lymph nodes, peripheral based liver lesions, exophytic soft tissue 
components associated with bone lesions, subcutaneous nodules, pleural-based lesions, and 
kidney lesions. An 18 gauge needle or larger is preferred when possible. For each tissue 


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collection procedure, the intent is to acquire at a minimum of 4 cores and up to 6 cores. Though 
the size of the biopsy cores is variable, to optimize tumor capture, larger cores are preferred.  
 
8.2 
BLOOD ANALYSES 
 
8.2.1 Blood for Germline DNA 
• This sample will be collected once prior to C1D1. 
• Five (5) mL of blood will be collected   
 
8.2.2 Blood for cfDNA Biomarker Research  
• This sample will be collected prior to C1D1 treatment and every 8 weeks until off 
treatment. If off treatment collection is within 2 weeks of prior collection, research 
samples do not need to be collected. 
• 10 mL of blood will be collected  
 
8.3 
Confidentiality of Biospecimens 
Samples that are collected will be identified by a subject’s study number assigned at the time of 
registration to the trial. Any material issued to collaborating researchers will be anonymized and 
only identified by the subject’s study number. 
 
9. 
CRITERIA FOR DISEASE EVALUATION 
For the purposes of this study, subjects should be re-evaluated for response every 8 weeks. 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1) 
(23). 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. 
 
9.1 
Definitions 
Evaluable for Target Disease response.  Only those subjects 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 target disease response.  These subjects will have their 
response classified according to the definitions stated below.  (Note:  Subjects who exhibit 
objective disease progression prior to the end of cycle 1 will also be considered evaluable.) 
 
Evaluable Non-Target Disease Response.  Subjects 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.  
 


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9.2 
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 by chest x-ray or ≥10 mm 
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 in short axis when assessed by CT scan (CT scan slice thickness 
recommended to be no greater than 5 mm).  At baseline and in follow-up, only the short axis will 
be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), are considered 
non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, pleural/pericardial 
effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, abdominal masses (not 
followed by CT or MRI), and cystic lesions are all considered 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 subject, 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. 
 


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9.3 
Methods for Evaluation of Disease 
All measurements should be taken and recorded in metric notation using a ruler, calipers, or a 
digital measurement tool.  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 in diameter as assessed using calipers 
(e.g., skin nodules).  In the case of skin lesions, documentation by color photography, including a 
ruler to estimate the size of the lesion, is recommended.  
Conventional CT and MRI. This guideline has defined measurability of lesions on CT scan based 
on the assumption that CT thickness is 5mm or less. If CT scans have slice thickness greater than 
5 mm, the minimum size of 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. 
 
9.4 
Response Criteria 
 
9.4.1 Evaluation of Target Lesions 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm. 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target lesions, 
taking as reference the baseline sum 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 


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absolute increase of at least 5 mm.  (Note:  the appearance of one or more new lesions is also 
considered progressions). 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum diameters while on study. 
 
9.4.2 Evaluation of Non-Target Lesions 
Complete Response (CR):  Disappearance of all non-target lesions and normalization of tumor 
marker level.  All lymph nodes must be non-pathological in size (<10 mm short axis). 
 
NOTE:  If tumor markers are initially above the upper normal limit, they must normalize for a 
subject 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 site 
investigator should prevail in such circumstances, and the progression status should be 
confirmed at a later time by the review panel (or sponsor investigator). 
 
9.4.3 Evaluation of New Lesions 
The finding of a new lesion should be unequivocal (i.e. not due to difference in scanning 
technique, imaging modality, or findings thought to represent something other than tumor (for 
example, some ‘new’ bone lesions may be simply healing or flare of pre-existing lesions). 
However, a lesion identified on a follow-up scan in an anatomical location that was not scanned 
at baseline is considered new and will indicate PD. If a new lesion is equivocal (because of small 
size etc.), follow-up evaluation will clarify if it truly represents new disease and if PD is 
confirmed, progression should be declared using the date of the initial scan on which the lesion 
was discovered. 
 
9.4.4 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 subject's best response assignment will 
depend on the achievement of both measurement and confirmation criteria. 
 
For Subjects with Measurable Disease (i.e., Target Disease) 
 
Table 17: Definition of clinical response for subjects with measurable disease  


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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** 
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. 
***      In exceptional circumstances, unequivocal progression in non-target lesions may be 
            accepted as disease progression. 
 
Note:  Subjects 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 Subjects with Non-Measurable Disease (i.e., Non-Target Disease) 
 
Table 18: Definition of clinical response for subjects with non-measurable 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 
 
9.4.5 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 


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disease the smallest measurements recorded since the treatment started, or death due to any 
cause. Subjects without events reported are censored at the last disease evaluation). 
 
Duration of overall complete response: 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, or death due to any cause. Subjects without events reported are 
censored at the last disease evaluation. 
 
 
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.  
 
9.4.6 Response Review 
Tumors will be assessed for response and progression by RECIST version 1.1 by central 
radiology review.  
 
 
10. 
DRUG INFORMATION 
Please refer to the current version of the Investigator’s Brochure (IB) for additional information 
regarding this drug. 
 
10.1 
TAK-228 
The chemical name and structure for the active form of TAK-228 are provided in the following:  
• Research Name: TAK-228 
                           INK128 
                     I-119 
• Chemical Names: 3-(2-amino-1,3-benzoxazol-5-yl)-1-(propan-2-yl)-1H-pyrazolo [3, 4-d] 
pyrimidin-4-amine 
• Molecular Formula: C 15 H 15 N 7 O 
• CAS Registry Number: 1224844-38-5 
• CAS Registry Name: 1H-Pyrazolo[3,4-d]pyrimidin-4-amine,3-(2-amino-5-
benzoxazolyl)-1-(1-methylethyl)- 
• Molecular Weight: 309.3 g/mol 
• Chemical Structure:  
 


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The milled API, may result in faster absorption profile with possibly higher maximum 
concentration (Cmax), which could result in a different safety profile compared to the previous 
unmilled API capsules. Therefore, ongoing studies (C31001, C31002 and , TAK-228-1004 –A 
Phase I, open label study to evaluate the safety, tolerability, and pharmacokinetics of TAK-228 
as a single agent and in combination with paclitaxel in adult subjects with advanced non-
hematologuical malignancies-), with the new milled API will determine the recommended 
phase 2 dose (RP2D) for single agent TAK-228 (QD and QW) and QD×3days per week in 
combination with paclitaxel, as well as the effect of high-fat meal on the PK of milled API. 
 
Overall, PK data from Studies INK128-001, INK128-002, and INK128-003 indicate that TAK-
228 exhibits fast oral absorption (time to reach the maximal concentration (Cmax) [tmax 
],generally between 1-4 hours after dosing); has dose-linear PK, with a mean plasma half-life of 
approximately 8 hours; and does not accumulate meaningfully in plasma when dosed as 
frequently as once daily and under any of 4 tested dosing regimens (1.once daily, 2. once daily 
for 3 consecutive days followed by a 4-day dosing holiday every week, 3.once daily for 5 
consecutive days followed by a 2-day dosing holiday every week, 4.once weekly). The PK of 
TAK-228 was generally consistent, with no appreciable differences across the clinical studies 
that measured PK. Neither paclitaxel nor TAK-228 appeared to alter the PK of the other agent 
when co-administered. 
Clinical Drug-Drug Interaction (DDIs) studies have not been conducted with TAK-228. At this 
time, there are no known drug interactions. In vitro data, including CYP induction/inhibition and 
transporter inhibition studies conducted for TAK-228, suggest a low risk for TAK-228 to 
precipitate a drug-drug interaction. Although potential DDIs with TAK-228 cannot be ruled out 
based on the known metabolism characteristics of TAK-228, the potential risk is considered low. 
 
10.2 
Supplier/How Supplied 
Millennium will supply TAK-228 at no charge to subjects participating in this clinical trial.  
 
TAK-228 drug substance is a white to off-white crystalline powder. The values of acid 
dissociation constant in logarithmic scale (pKa) were determined to be 2.9 and 4.1. 
TAK-228 drug product has been developed as an immediate-release capsule for oral 
administration. The drug product contains a mixture of drug substance, microcrystalline 
cellulose, and magnesium stearate encapsulated in size 2 hard-gelatin capsules. Clinical trial 
materials are supplied as capsules in 1.0- (white, opaque), 3.0- (swedish orange, opaque), and 5.0 
mg (gray, opaque) dosage strengths. 
 
10.3 
Preparation  
TAK-228 study drug will be provided in 60 cc high-density polyethylene (HDPE) bottles with 
polypropylene, child-resistant caps and induction seal. Study drug will be dispensed with dosing 
instructions for home use, including the requirement that capsules are stored in their original 
containers and that capsules be swallowed whole and not opened, chewed, or manipulated in any 
way. Materials provided by the sponsor should be dispensed to subjects with clear administration 
instructions from the site investigator. 


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TAK-228 is an anticancer drug and, as with other potentially toxic compounds, caution should be 
exercised when handling TAK-228 capsules. 
 
10.4 
Storage and Stability 
TAK-228 capsules are packaged either in blister packs or in induction-sealed, high-density 
polyethylene bottles equipped with child-resistant caps. TAK-228 drug product is stable when 
stored in its original packaging between 15°C to30°C, with allowed short-term excursions 
between 2°C to 40°C.  
 
All temperature excursions will be reported for assessment and authorization for continued use. 
All investigational supplies must be stored in a secure area with controlled access and will be 
stored in original packaging. All drug supplies should be used before the retest expiry date. 
 
10.5 
Handling and Disposal 
TAK-228 drug product is an anticancer drug. As with other anticancer compounds, caution 
should be exercised when handling TAK-228. It is recommended that gloves and protective 
garments be worn during preparation when dispensed in the clinic. Please refer to published 
guidelines regarding the proper handling and disposal of anticancer agents. Because TAK-228 is 
an investigational agent, it should be handled with due care. In case of contact with broken 
capsules, raising dust should be avoided during the clean-up operation. The product may be 
harmful if inhaled, ingested, or absorbed through the skin. Gloves and protective clothing should 
be worn during the clean-up operation. The area should be ventilated and the spill site washed 
after material pick-up is complete. The spilled material should be disposed of as hazardous 
medical waste in compliance with federal, state, and local regulations. In case of contact with the 
powder (eg, from a broken capsule), skin should be washed immediately with soap and copious 
amounts of water for at least 15 minutes. In case of contact with the eyes, copious amounts of 
water should be used to flush the eyes for at least 15 minutes. Medical personnel should be 
notified. 
 
Drug should be destroyed at the site, after the site investigator approves the drug destruction 
policy at the site. Drug will not be returned to Millennium. Destruction will be documented in 
the Drug Accountability Record Form. 
 
10.6 
Accountability 
Accountability for investigational product is the responsibility of the site investigator. The study 
site must maintain accurate records demonstrating dates and amount of investigational product 
received, to whom dispensed (subject by subject accounting), and accounts of any investigational 
product accidentally or deliberately destroyed. At the end of the study, reconciliation must be 
made between the amount of investigational product supplied, dispensed, and subsequently 
destroyed. At the time of delivery of investigational product to the site, the site investigator, 
designee, or pharmacist (where appropriate) will confirm that the supplies for the study have 


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been received. This following information will be confirmed: lot numbers, quantities 
shipped/delivered, and date of receipt. 
 
 
11. 
ADVERSE EVENTS 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 
following list of reported and/or potential AEs (Section 11.1) and the characteristics of an 
observed AE (Section 11.2) will determine whether the event requires expedited reporting in 
addition to routine reporting. 
 
11.1 
Expected Toxicities 
 
11.1.1 Adverse Event List 
 
11.1.1.1 Adverse Event List for TAK-228 
 
Among the 335 subjects who had received ≥1 dose of study drug as of the clinical data cutoff 
date (09 December 2014), 18 deaths had occurred within 30 days of the last dose, including 7 in 
Study INK128-001, 2 in Study INK128-002, and 9 in Study INK128-003.  One death 
(ventricular fibrillation and cardiac arrest; Study INK128-001) was considered related to TAK-
228. At least 1 treatment-emergent SAE, regardless of causality, had been reported in 125/335 
subjects (37%). Across the studies and regardless of causality or dosing regimen, the most 
common treatment emergent adverse events (TEAEs) included nausea, fatigue, hyperglycemia, 
vomiting, diarrhea, stomatitis, and decreased appetite. 
 
 
11.2 
Adverse Event Characteristics  
• CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
4.0 will be utilized for AE reporting.  All appropriate treatment areas should have access 
to a copy of the CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be 
downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic applications/ctc.htm. 
 
• For expedited reporting purposes only:   
- 
AEs for the agent(s) that are listed above should be reported only if the adverse event 
varies in nature, intensity or frequency from the expected toxicity information which 
is provided. 
- 
Other AEs for the protocol that do not require expedited reporting are outlined in the 
next section (Expedited Adverse Event Reporting) under the sub-heading of Protocol-
Specific Expedited Adverse Event Reporting Exclusions. 


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• 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. 
 
 
11.3 
DF/HCC Expedited Adverse Event Reporting  
 
11.3.1 Investigators must report to the Overall PI any serious adverse event (SAE) that occurs 
after the initial dose of study treatment, during treatment, or within 30 days of the last 
dose of treatment on the local institutional SAE form.  
 
11.3.2 For multi-institution studies where a DF/HCC investigator is serving as the Overall 
Principal Investigator, each participating institution must abide by the reporting 
requirements set by the DF/HCC. This applies to any medical event equivalent to an 
unexpected grade 2 or 3 with a possible, probable or definite attribution, grade 4 
toxicities, and grade 5 (death) regardless of study phase or attribution. 
 
11.3.3 DF/HCC Expedited Reporting Guidelines 
 
Investigative sites within DF/HCC will report AEs directly to the DFCI Office for 
Human Research Studies (OHRS) per the DFCI IRB reporting policy.  
 
Other investigative sites will report AEs to their respective IRB according to the local 
IRB’s policies and procedures in reporting adverse events. A copy of the submitted 
institutional AE form should be forwarded to the Overall PI within the timeframes 
detailed in the table below.   
 
 
 
 
Attribution 
DF/HCC Reportable AEs 
Gr. 2 & 3 AE 
Expected 
Gr. 2 & 3 AE 
Unexpected 
Gr. 4 AE Expected 
Gr. 4 AE 
Unexpected 
Gr. 5 AE Expected 
or Unexpected 
Unrelated 
Unlikely 
Not required 
Not required 
5 calendar days# 
5 calendar days 
24 hours* 
Possible 
Probable 
Definite 
 
Not required 
 
5 calendar days 
 
5 calendar days# 
 
5 calendar days 
 
24 hours* 
# If listed in protocol as expected and not requiring expedited reporting, event does not need to be reported. 
 
* For participants enrolled and actively participating in the study or for AEs occurring within 30 days of the last intervention, 
the AE should be reported within 1 business day of learning of the event. 


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The Overall PI will submit AE reports from outside institutions to the DFCI OHRS 
according to DFCI IRB policies and procedures in reporting adverse events 
 
11.4 
Expedited Reporting to Millennium 
 
11.4.1 Definitions 
11.4.1.1 Serious Adverse Event (SAE) 
A SAE is an adverse event that: 
• Results in death. NOTE: Death due to disease progression should not be reported as a 
SAE, unless it is attributable by the site investigator to the study drug(s) 
• Is life-threatening (defined as an event in which the subject was at risk of death at the 
time of the event; it does not refer to an event which hypothetically might have caused 
death if it were more severe) 
• Requires inpatient hospitalization for >24 hours or prolongation of existing 
hospitalization. NOTE: Hospitalization for anticipated or protocol specified procedures 
such as administration of chemotherapy, central line insertion, metastasis interventional 
therapy, resection of primary tumor, or elective surgery, will not be considered serious 
adverse events. 
• Results in persistent or significant disability/incapacity 
• Is a congenital anomaly or birth defect 
• Is an important medical event (defined as a medical event(s) that may not be immediately 
life-threatening or result in death or hospitalization but, based upon appropriate medical 
and scientific judgment, may jeopardize the subject or may require intervention (e.g., 
medical, surgical) to prevent one of the other serious outcomes listed in the definition 
above). Examples of such events include, but are not limited to, intensive treatment in an 
emergency room or at home for allergic bronchospasm; blood dyscrasias or convulsions 
not resulting in hospitalization; or the development of drug dependency or drug abuse. 
 
11.4.1.2 Unexpected Adverse Event 
For this study, an AE is considered unexpected when it varies in nature, intensity or frequency 
from information provided in the current IB, prescribing information or when it is not included in 
the informed consent document as a potential risk. Unexpected also refers to AEs that are 
mentioned in the IB as occurring with a class of drugs or are anticipated from the 
pharmacological properties of the drug, but are not specifically mentioned as occurring with the 
particular drug under investigation.   
 
11.4.2 Requirements for Reporting SAEs to Millennium 
Adverse Events may be spontaneously identified by the patient and/or in response to an open 
question from study personnel or revealed by observation, physical examination, or other 


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diagnostic procedures.  Any clinically relevant deterioration in laboratory assessments or other 
clinical finding is considered an AE.  When possible, signs and symptoms indicating a common 
underlying pathology should be noted as one comprehensive event.   
Adverse Events which are serious must be reported to Takeda Pharmacovigilance (or designee) 
from the time of consent up to and including 30 days after administration of the last dose of 
TAK-228. Any SAE that occurs at any time after completion of TAK-228 treatment or after the 
designated follow-up period that the sponsor-investigator and/or sub-investigator considers to be 
related to any study drug must be reported to Takeda Pharmacovigilance (or designee).  In 
addition, new primary malignancies that occur during the follow-up periods must be reported, 
regardless of causality to study regimen, for a minimum of two years after the last dose of the 
investigational product, starting from the first dose of study drug. All new cases of primary 
malignancy must be reported to Takeda Pharmacovigilance (or designee). 
Planned hospital admissions or surgical procedures for an illness or disease that existed before 
the patient was enrolled in the trial are not to be considered AEs unless the condition deteriorated 
in an unexpected manner during the trial (e.g., surgery was performed earlier or later than 
planned).  All SAEs should be monitored until they are resolved or are clearly determined to be 
due to a patient’s stable or chronic condition or intercurrent illness (es). 
Since this is an investigator-initiated study, the principal investigator Dr. Bradley McGregor also 
referred to as the sponsor-investigator, is responsible for reporting serious adverse events (SAEs) 
to any regulatory agency and to the sponsor- investigator’s EC or IRB.    
Regardless of expectedness or causality, all SAEs must also be reported in English to Takeda 
Pharmacovigilance or designee: 
Fatal and Life Threatening SAEs within 24 hours of the sponsor-investigator’s 
observation or awareness of the event 
All other serious (non-fatal/non life threatening) events within 4 calendar days of the 
sponsor-investigator’s observation or awareness of the event 
The Sponsor will send all SAE reports to Takeda Pharmacovigilance (or designee) within 24 
hours but no later than 4 calendar days as per any agreements. 
See below for contact information for the reporting of SAEs to Millennium Pharmacovigilance. 
The sponsor-investigator must fax or email the SAE Form per the timelines above. A sample of 
an SAE Form will be provided. 
The SAE report must include at minimum: 
• Event term(s) 
• Serious criteria 
• Intensity of the event(s): Sponsor-investigator’s or sub-investigator’s determination.  
Intensity for each SAE, including any lab abnormalities, will be determined by using the 
NCI CTCAE version specified in the protocol, as a guideline, whenever possible.  The 
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Hospitalization for elective surgery or routine clinical procedures that are not the result of an AE 
(e.g., surgical insertion of central line) should not be recorded as an AE.  
 
Disease progression should not be recorded as an AE, unless it is attributable to the study 
regimen by the site investigator. 
 
12. 
STATISTICAL METHODS 
 
12.1 
Study Design 
This is an open-label, single-arm phase II study of TAK-228 (the ATP-competitive inhibitor of 
the serine/threonine kinase mTOR) at recommended phase II dosing of 30 mg orally once per 
week, in subjects with previously treated advanced RCC. The study consists of a two-stage 
design. The first stage will assess futility when half of the planned patients are enrolled and have 
had their first (8 week) imaging assessment to determine their response status. The second stage 
will assess the overall response after all patients are enrolled. 
 
12.2 
Endpoints 
12.2.1 Definition of Primary Endpoint 
Objective Response (OR): Confirmed CR or PR as best overall response according to RECIST 
version 1.1 by central review. Objective response will be determined by the best overall 
confirmed response designation recorded between the date of first dose of trial therapy and the 
date of objectively documented disease progression or cessation of trial therapy, whichever 
occurs first. For subjects without documented progression or cessation of trial therapy, all 
available response designations will contribute to the objective response determination. 
 
12.2.2 Definition of Secondary Endpoints 
• Safety and tolerability according to NCI CTCAE version 4.0 
• Progression-free survival (PFS):  time from registration to the earlier of (radiographic) 
progression based on RECIST 1.1 or death due to any cause. Subjects alive without 
disease progression are censored at date of last disease evaluation.  
• Overall survival (OS): time from registration to death due to any cause, or censored at 
date last known alive.  
 
12.3 
Sample Size and Accrual 
 
Forty subjects with metastatic RCC will be enrolled for a goal of 38 evaluable subjects (assuming 5% 
not evaluable). ,The two-stage single arm phase II study is designed to detect an improvement in 
response rate from 5% to 20%. Assuming a type I error of 0.05 and targeting 90% statistical 
power, 20 patients will be accrued (for 19 evaluable) in the first stage. The first interim analysis 
will occur when the first 8 week imaging assessment for response data is available for all 20 


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patients. If 1 or more responses are observed, the accrual will continue to the second stage. 
Twenty (for 19 evaluable) additional patients will be accrued in the second stage. TAK-228 will 
be declared ineffective in this study if <5 responses are observed. It will be considered worthy of 
further study if more than 4 (≥5) responses are observed. 
 
The design operating characteristics are as follows: 
 
Hypothesis 
#s responses  
at stage I 
Prob(stop at 
first stage 
Overall # 
responses 
Prob(Rx declared 
inactive) 
Design Statistics 
Ho: ORR=0.05 
<1 
38% 
≤4 
96% 
True type I error 
0.04 
Ha: ORR=0.2 
<1 
1.4% 
≤4 
10% 
 
Power: 90% 
 
 
The 90% confidence intervals for the response rate in a two-stage phase II design are 
summarized as below. The calculation employed the method of Atkinson and Brown (1985) 
Biometrics 741-744 
 
Observed # of responses 
Response rate 
90% CI 
4/38 
0.105 
(0.04, 0.23) 
5/38 
0.13 
(0.05, 0.26) 
6/38 
0.16 
(0.07, 0.29) 
7/38 
0.18 
(0.09, 0.32) 
 
The accrual is expected to be 3 subjects every month for 14 months to complete enrollment with 
additional follow-up to 2 years for disease progression or survival.  The study is expected to last 
approximately 40 months.  
  
12.4 
Analysis Datasets 
 
Population 
Definition 
Enrolled 
This will comprise all subjects who meet the 
eligibility criteria and are registered onto the study. 
 
Evaluable 
 
Subjects who receive at least one dose of trial drug 
TAK-228 and have at least one response assessment 
or die before any evaluation. 
   
Safety 
All subjects receiving at least one dose of TAK-
228 will be included in analysis unless otherwise 
specified.  
 
 


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12.4.1 Analysis Plans for Primary Objective  
ORR is defined as the proportion of subjects who achieve objective response, as defined in 
Section 12.2.1.  ORR and its 90% exact confidence interval (CI) using the method of Atkinson 
and Brown (1985) will be provided based on the evaluable population. Best overall response 
(BOR) will also be summarized. In addition, tumor burden data will be summarized by waterfall 
plot showing the maximum tumor shrinkage and spider plot showing individual subject tumor 
burden over time. 
 
12.4.2 Analysis Plans for Secondary Objectives 
Safety and Tolerability: All adverse events recorded during the trial will be summarized for the 
safety population. The incidence of events that are new or worsening from the time of first dose 
of treatment will be summarized according to system organ class and/or preferred term, severity 
(based on CTCAE version 4.0 grade), type of adverse event, and relation to study treatment. 
Deaths reportable as SAEs and non-fatal serious adverse events will be listed by subject and 
tabulated by primary system organ class, and type of adverse event. 
 
PFS and OS: PFS and OS will each be summarized using the product-limit method of Kaplan-
Meier. Median times for each endpoint will be presented with two-sided 90% confidence 
intervals estimated using log(-log(survival)) methodology. Kaplan-Meier estimates of PFS at 6 
or 12 months after treatment initiation may also be presented with two-sided 90% confidence 
intervals. 
 
12.4.3 Analysis Plans for Exploratory Objectives 
It’s expected that 80% of the trial samples will have adequate specimens for the correlative study 
and the evaluable samples for the correlative analyses will be 32 (80% of 40 subjects). 
 
A DFCI mutation screen analysis of 300 cancer genes (Oncopanel), including all those involved 
in regulation of mTOR, will be performed on pre-treatment biopsies in all subjects.  
 
The mutation profiling will be performed using next generation sequencing via Oncopanel in all 
cases and whole exome sequemcing in a subset of subjects. 
 
The sample size/power justification is focused on the primary objective of assessing the 
association between ORR and mTOR pathway mutation status (defined as mutation(s) observed 
in 1 gene or several genes belonging to mTOR pathways). To examine the response (or ORR) by 
the mutation status (mutated or non-mutated), the evaluable samples will be divided 
retrospectively according to objective response or non-response. Pre-treatment mutation status 
will be summarized descriptively for the response/non-response groups.  
 
The trial’s targeted ORR rate was 0.2. Based on our experience (submitted for publication) the 
mutation rate for a cohort of mRCC subjects treated with mTOR inhibitors was 20% (16/79), we 
assumed a mTOR pathway gene mutations rate of 0.25 for the power estimation, as it is 
suggested that “23-38% of subjects likely have alteration in the mTOR pathway. 
 


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With an evaluable correlative sample size of 32, the study has 80% power to detect a 48% 
increase (one-sided alpha=0.05) in response probability of 56% in subjects with mutations as 
compared to that of 8% in subjects without mutations.  
The proportion of subjects with objective response according to pre-treatment (baseline) nutation 
status will also be summarized with two-sided 90% exact binomial CI. Kaplan-Meier estimates 
will be used to assess the distribution of PFS according to mutation status. Medians of time to 
PFS will be shown with two-sided 90% CIs. 
 
12.5 
Interim Analysis/Criteria for Stopping Study 
There are no formal interim efficacy analyses planned for this study. 
 
13. 
DATA REPORTING/REGULATORY REQUIREMENTS  
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 11 
(Adverse Events) 
 
13.1 
 Data Reporting 
13.1.1 Method 
 
The Office of Data Quality (ODQ) will collect, manage, and perform quality checks on    the 
data for this study. 
 
13.1.2 Responsibility for Data Submission 
 
Investigative sites within DF/HCC or DF/PCC are responsible for submitting data and/or data 
forms to the Office of Data Quality in accordance with DF/HCC SOPs. 
 
13.2 
Data Safety Monitoring 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity 
and accrual data from this study. The committee is composed of clinical specialists with 
experience in oncology and who have no direct relationship with the study. Information that 
raises any questions about participant safety will be addressed with the Overall PI and study 
team. 
 
The DSMC will review each protocol up to four times a year or more often if required to review 
toxicity and accrual data. Information to be provided to the committee may include: up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or higher 
unexpected adverse events that have been reported; summary of all deaths occurring with 30 
days of intervention for Phase I or II protocols; for gene therapy protocols, summary of all deaths 
while being treated and during active follow-up; any response information; audit results, and a 


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summary provided by the study team. Other information (e.g. scans, laboratory values) will be 
provided upon request 
 
13.3 
 Multicenter Guidelines 
 
This protocol will adhere to the policies and requirements of the DF/HCC Multi-Center Data and 
Safety Monitoring Plan.  The specific responsibilities of the Overall PI, Coordinating Center, and 
Participating Institutions and the procedures for auditing are presented in Appendix E. 
 
• The Overall PI/Coordinating Center is responsible for distributing all IND Action Letters 
or Safety Reports to all participating institutions for submission to their individual IRBs 
for action as required. 
 
• Mechanisms will be in place to ensure quality assurance, protocol compliance, and 
adverse event reporting at each site. 
 
• Except in very unusual circumstances, each participating institution will order the study 
agent(s) directly from supplier.  A participating site may order the agent(s) only after the 
initial IRB approval for the site has been forwarded to the Coordinating Center. 
 
13.4 
Data Quality Oversight Activities  
 
Validation of  data will be completed on a continual basis throughout the life cycle of the study.  
A summary report (QC Report) of these checks together with any queries resulting from manual 
review of the eCRFs will be generated for each site and transmitted to the site and the site 
monitor. Corrections will be made by the study site personnel.  
 
There will be at least one routine visit per site per year for sites that have accrued.  Additional for 
cause visits may occur as necessary. Source documents will be reviewed for verification of 
agreement with data entered into InForm.  It is important for the site investigator and their 
relevant personnel to be available for a sufficient amount of time during the monitoring visits or 
audit, if applicable. The site investigator and institution guarantee access to source documents by 
the sponsor/investigator or its designee. 
 
The trial site may also be subject to quality assurance audit by Millennium or its designee as well 
as inspection by appropriate regulatory agencies. 
 
13.5 
Compliance with Trial Registration and Results Posting Requirements 
Under the terms of the Food and Drug Administration Modernization Act (FDAMA) and the 
Food and Drug Administration Amendments Act (FDAAA), the sponsor-investigator of the trial 
is solely responsible for determining whether the trial and its results are subject to the 
requirements for submission to the Clinical Trials Data Bank, http://www.clinicaltrials.gov. All 
results of primary and secondary objectives must be posted to CT.gov within a year of 


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completion.  Information posted will allow subjects to identify potentially appropriate trials for 
their disease conditions and pursue participation by calling a central contact number for further 
information on appropriate trial locations and study site contact information.   
 
14. 
DATA HANDLING AND RECORD KEEPING 
 
14.1 
Data Management 
The Dana-Farber Cancer Clinical Trials Office will provide Project Management and Monitoring 
services for this trial. Data will be collected through the web based clinical research platform, 
InForm , a system compliant with Good Clinical Practices and Federal Rules and Regulations 
created by the Clinical Trials Research Informatics Office (CTRIO).  All data will be collected 
and entered into InForm  by study site personnel from participating institutions.   
 
14.2 
Case Report Forms and Submission 
Generally, clinical data will be electronically captured in InForm  and correlative results will be 
captured in spreadsheets  or other secure database(s). If procedures on the study calendar are 
performed for standard of care, at minimum, that data will be captured in the source document. 
Select standard of care data will also be captured in InForm, according to study-specific 
objectives.  
 
The completed dataset is the sole property of the sponsor-investigator’s institution and should 
not be exported to third parties, except for authorized representatives of appropriate 
Health/Regulatory Authorities, without permission from the sponsor-investigator . 
 
14.3 
Record Retention 
To enable evaluations and/or audits from Health Authorities, the site investigator agrees to keep 
records, including the identity of all subjects (sufficient information to link records; e.g., hospital 
records), all original signed informed consent forms, copies of all source documents, and detailed 
records of drug disposition. All source documents are to remain in the subject’s file and retained 
by the site investigator in compliance with the site contract. .  No records will be destroyed until 
the sponsor/investigator confirms destruction is permitted. 
 
 
 


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14.4 
Confidentiality 
There is a slight risk of loss of confidentiality of subject information. All records identifying the 
subjects will be kept confidential and, to the extent permitted by the applicable laws and/or 
regulations, will not be made publicly available. Information collected will be maintained on 
secure, password protected electronic systems. Paper files that contain personal information will 
be kept in locked and secure locations only accessible to the study site personnel.  
 
Subjects will be informed in writing that some organizations including the sponsor-investigator 
and his/her research associates, Millennium, IRB, or government agencies, like the FDA, may 
inspect their medical records to verify the information collected, and that all personal 
information made available for inspection will be handled in strictest confidence and in 
accordance with local data protection laws. 
 
If the results of the study are published, the subject’s identity will remain confidential. 
 
15. 
PUBLICATION PLAN 
The data will be collected by the investigators and analyzed by the co-principal investigators and 
the statistical team at DFCI. It is anticipated that the results will be made public within 12 
months of the end of data collection. A report is planned to be published in a peer-reviewed 
journal, however initial release may be an abstract that meets the requirements of the 
International Committee of Medical Journal Editors. 
 in consultation with 
 
 as well as outside investigators will decide on the authorship orders for 
abstracts and manuscripts from the trial. 
 
 


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14 
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APPENDIX A: PERFORMANCE STATUS CRITERIA 
 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active 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. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX B: REQUIRED FORMS AT REGISTRATION 
 
Please notify the lead clinical research coordinator at the time a participant is identified or 
consented to the study.  The DFCI coordinator will register the participant once the below 
documentation is finalized using the DFCI OnCore registration system.  Non-DF/HCC 
participating sites will send the documents to the DFCI research coordinator to complete 
registration.  Please allow a one-week turn-a-round time for the DFCI research team to determine 
participant eligibility. The following documentation is required prior to participant registration: 
 
• Current IRB approved consent form signed by participant and Investigator (MD 
only) 
• HIPAA authorization form (if separate from the informed consent document) 
• Signed and dated DFCI eligibility checklist (signed by MD and RN) 
• The following source documentation is typically required:  
• Please note: Additional documentation may be required by the lead institution. 
o Documentation of prior treatments/procedures performed to treat RCC  
o Reports documenting disease status 
 MRI or CT Brain  
 Chest CT 
 CT or MRI Abdomen and Pelvis 
o Pathology Report  
o Concomitant medication list 
o Progress note or equivalent documentation of consenting visit 
o Progress note documenting medical history and oncologic history 
o Screening Labs 
 Complete blood count with differential  
 Comprehensive Metabolic Profile (CMP) 
 Fasting Lipid Profile 
 PT/INR and aPTT 
 TSH 
 Hb1c 
 On home daily fasting glucose monitoring 
 Pregnancy test 
 Urinalysis 
o Screening visit note with vital signs, weight, height, ECOG performance 
status, physical examination 
o Screening ECG 
o Screening ECHO or MUGA 
 
 
PLEASE NOTE: ADDITIONAL DOCUMENTATION MAY BE REQUIRED BY THE LEAD 
INSTITUTION. 
 
 
 


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APPENDIX C: INFORMATION ON POSSIBLE DRUG INTERACTIONS 
 
     Strong Inhibitors and Strong Inducers of CYP2C9, CYP2C19, and CYP3A4 
 
List of Relevant Cytochrome P450 Inhibitors and Inducers 
Strong CYP2C19 Inhibitors 
Fluconazole 
fluvoxamine 
ticlopidine 
Moderate CYP3A4 Inhibitors 
amprenavir  
darunavir/ritonavir 
fosamprenavir  
Aprepitant 
Diltiazem 
grapefruit juice (a) 
Atazanavir 
erythromycin 
imatinib 
Ciprofloxacin 
 
Fluconazole 
 verapamil 
Strong CYP3A4 Inhibitors 
Boceprevir 
ketoconazole 
ritonavir 
Clarithromycin 
lopinavir/ritonavir 
saquinavir 
Conivaptan 
mibefradil (b) 
telaprevir 
grapefruit juice (a) 
nefazodone 
telithromycin 
Indinavir 
Nelfinavir 
voriconazole 
Itraconazole 
posaconazole 
 
Clinically Significant Enzyme Inducers 
Carbamazepine 
Rifabutin 
St. Johns Wort 
Phenobarbital 
Rifampin 
 
phenytoin 
rifapentine 
 
 
Note that these lists are not exhaustive.   
a. The effect of grapefruit juice varies widely among brands and is concentration-, dose-, 
and preparation-dependent.  Studies have shown that it can be classified as a “strong 
CYP3A inhibitor” when a certain preparation was used (eg, high dose, double strength) 
or as a “moderate CYP3A inhibitor” when another preparation was used (eg, low dose, 
single strength). 
b. Withdrawn from the United States market because of safety reasons. 
 
 


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Information on Possible Interactions with Other Agents for Subjects and Their Caregivers 
and Non-Study Healthcare Team 
 
TAK-228 interacts with many drugs that are processed by your liver.  Because of this, it is very 
important to tell your study doctors about all of your medicine before you start this study.  It is 
also very important to tell them if you stop taking any regular medicine, or if you start taking a 
new medicine while you take part in this study.  When you talk about your medicine with your 
study doctor, include medicine you buy without a prescription at the drug store (over-the-counter 
remedy), or herbal supplements such as St. John’s wort.  
 
Many health care prescribers can write prescriptions.  You must also tell your other prescribers 
(doctors, physicians’ assistants or nurse practitioners) that you are taking part in a clinical trial. 
Bring this paper with you and keep the attached information card in your wallet.   
 
These are the things that you and they need to know:  
• TAK-228 interacts with certain specific enzymes in your liver.  
• The enzymes in question are CYP2C9, CYP2C19 and CYP3A4, and TAK-228 is broken 
down by these enzymes in order to be cleared from your system.  
• TAK-228 must be used very carefully with other medicines that need these liver enzymes 
to be effective or to be cleared from your system.   
• Other medicines may also affect the activity of the enzyme.   
o Substances that increase the enzyme’s activity (“inducers”) could reduce the 
effectiveness of the drug, while substances that decrease the enzyme’s activity 
(“inhibitors”) could result in high levels of the active drug, increasing the chance 
of harmful side effects. 
o  TAK-228 is considered a weak “inhibitor” of the enzyme, meaning that it can 
affect the levels of other drugs that are processed by that enzyme.  This can lead 
to harmful side effects and/or reduce the effectiveness of those medications.    
• You and healthcare providers who prescribe drugs for you must be careful about adding or 
removing any drug in this category.  
• Before you start the study, your study doctor will work with your regular prescriber to 
switch any medicines that are considered “strong inducers/inhibitors or substrates of 
CYP2C9, CYP2C19 and CYP3A4. 
• Your prescribers should look at this web site 
http://medicine.iupui.edu/clinpharm/ddis/table.aspx or consult a medical reference to see 
if any medicine they want to prescribe is on a list of drugs to avoid.   
• Please be very careful!  Over-the-counter drugs have a brand name on the label—it’s 
usually big and catches your eye.  They also have a generic name—it’s usually small and 
located above or below the brand name, and printed in the ingredient list.  Find the 
generic name and determine, with the pharmacist’s help, whether there could be an 
adverse interaction.   
• Be careful:  
o If you take acetaminophen regularly:  You should not take more than 4 grams a 
day if you are an adult or 2.4 grams a day if you are older than 65 years of age.  
Read labels carefully!  Acetaminophen is an ingredient in many medicines for 
pain, flu, and cold. 


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o If you drink grapefruit juice or eat grapefruit:  Avoid these until the study is over.  
o If you take herbal medicine regularly:  You should not take St. John’s wort while 
you are taking TAK-228. 
 
Other medicines can be a problem with your study drugs.  
• You should check with your doctor or pharmacist whenever you need to 
use an over-the-counter medicine or herbal supplement.  
• Your regular prescriber should check a medical reference or call your 
study doctor before prescribing any new medicine for you.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
INFORMATION ON POSSIBLE DRUG INTERACTIONS  
You are enrolled on a clinical trial using the experimental agent TAK-
228.  This clinical trial is sponsored by the NCI.  TAK-228 interacts 
with drugs that are processed by your liver.  Because of this, it is very 
important to: 
 Tell your doctors if you stop taking regular medicine or if you start 
taking a new medicine. 
 Tell all of your prescribers (doctor, physicians’ assistant, nurse 
practitioner, and pharmacist) that you are taking part in a clinical 
trial. 
 Check with your doctor or pharmacist whenever you need to use 
an over-the-counter medicine or herbal supplement. 
TAK-228 interacts with a specific liver enzyme called CYP2C9, 
CYP2C19 and CYP3A4, and must be used very carefully with other 
medicines that interact with this enzyme.  
 Before you start the study, your study doctor will work with your 
regular prescriber to switch any medicines that are considered 
“strong inducers/inhibitors or substrates of CYP2C9, CYP2C19 and 
CYP3A4.” 
 Before prescribing new medicines, your regular prescribers should 
go to http://medicine.iupui.edu/clinpharm/ddis/table.aspx for a 
list of drugs to avoid, or contact your study doctor.   
 


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APPENDIX D: SUBJECT DIARY 
 
Protocol Number: 16-527 
 
Name: ________________________ 
Date: ________________ 
Cycle:  ______ 
 
Drug Strength: ___ mg capsules 
Dose: ___ mg (# ___ capsules) 
Schedule: Once per week in the morning at approximately the same time (e.g. Day 1, 8, 15, and 22) 
 
Dosing Instructions: The TAK-228 capsules will be supplied at the start of each cycle.  You will take 
your doses on an empty stomach in the morning with water.  You should not have anything to eat for at 
least 2 hours before and 1 hour after you take your dose.  Please do not crush, chew, dissolve, or open 
your TAK-228 capsules.  If you come into contact with the powder from the capsule, wash your skin 
thoroughly with soap and water. If you do not take your TAK-228 dose within the time frame specified (± 
24 hours of the weekly scheduled dosing time), then the dose should be skipped and considered a missed 
dose.  Resume the dose when your next scheduled dose is due, and mark the dose as missed on your study 
diary.  If you vomit a dose, do not make up the dose, and mark this on your study diary.  If you can’t 
remember whether you missed a dose, consider the dose missed, and resume dosing at your next 
scheduled dose. 
 
 
On day 1 of each cycle, please bring this completed diary and any unused or empty study bottles to your 
visit and return it to your study team.  If you are having new or worsening symptoms, please contact your 
study nurse.   
 
At-home Blood Glucose Monitoring Instructions: You will be provided with a kit for at-home blood 
glucose monitoring.  You will be required to measure your daily blood glucose levels while you are on 
this study. Please measure your glucose level when you are in a fasting state (no food or drink, except 
water/medication, for at least 8 hours).  We recommend you measure your blood glucose level first thing 
in the morning when you wake up.  Please write your blood glucose levels in the spaces provided on your 
diary below.  If any fasting blood glucose levels are greater than or equal to 150 mg/dL please contact 
your study team as soon as possible. On days when you are scheduled to come into clinic, you will not be 
required to check your fasting blood glucose level at home beforehand as your study team will be 
checking it in the clinic. 
 
Page Operator (Holidays, Weekends, and Non-Business Hours): 
_________________; ask for your site investigator to be paged. 
 
Research Nurse: ________________  Phone: _______________ 
 
 
 
 
 
 
 
Day 
Date 
Time (AM) 
Number of 
Capsules 
Fasting blood glucose 
level 
Time (AM) 


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Day 1* 
 
 
 
 
 
Day 2 
 
 
 
 
 
Day 3 
 
 
 
 
 
Day 4 
 
 
 
 
 
Day 5 
 
 
 
 
 
Day 6 
 
 
 
 
 
Day 7 
 
 
 
 
 
Day 8* 
 
 
 
 
 
Day 9 
 
 
 
 
 
Day 10 
 
 
 
 
 
Day 11 
 
 
 
 
 
Day 12 
 
 
 
 
 
Day 13 
 
 
 
 
 
Day 14 
 
 
 
 
 
Day 15* 
 
 
 
 
 
Day 16 
 
 
 
 
 
Day 17 
 
 
 
 
 
Day 18 
 
 
 
 
 
Day 19 
 
 
 
 
 
Day 20 
 
 
 
 
 
Day 21 
 
 
 
 
 
Day 22* 
 
 
 
 
 
Day 23 
 
 
 
 
 
Day 24 
 
 
 
 
 
Day 25 
 
 
 
 
 
Day 26 
 
 
 
 
 
Day 27 
 
 
 
 
 
Day 28 
 
 
 
 
 
*Suggested days to take your dose within a cycle 
 
 
 


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DFCI IRB Protocol #: 16-527 
 
 
 
 
 
APPENDIX E 
 
Dana-Farber/Harvard Cancer Center 
Multi-Center Data and Safety Monitoring Plan 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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1.0 
INTRODUCTION 
The Dana-Farber/Harvard Cancer Center Multi-Center Data and Safety Monitoring Plan 
(DF/HCC DSMP) outlines the procedures for conducting a DF/HCC Multi-Center research 
protocol. The DF/HCC DSMP should serve as a reference for any sites external to DF/HCC that 
will be participating in the research protocol. 
 
1.1 
Purpose 
To establish standards that will ensure that a Dana-Farber/Harvard Cancer Center Multi-Center 
protocol will comply with Federal Regulations, Health Insurance Portability and Accountability 
Act (HIPAA) requirements and applicable DF/HCC Standard Operating Procedures  
 
1.2 Multi-Center Data and Safety Monitoring Plan Definitions 
DF/HCC Multi-Center Protocol:  A research protocol in which one or more outside institutions 
are collaborating with Dana-Farber/Harvard Cancer Center where a DF/HCC investigator is the 
sponsor. DF/HCC includes Dana-Farber/Partners Cancer Care (DF/PCC) Network Clinical Trial 
Affiliates.  
 
Lead Institution:  One of the Dana-Farber/Harvard Cancer Center consortium members (Dana-
Farber Cancer Institute (DFCI), Massachusetts General Hospital (MGH), Beth Israel Deaconess 
Medical Center (BIDMC), Children’s Hospital Boston (CHB), Brigham and Women’s Hospital 
(BWH)) responsible for the coordination, development, submission, and approval of a protocol 
as well as its subsequent amendments per the DFCI IRB and applicable regulatory guidelines 
(Food and Drug Administration (FDA)).  The Lead Institution is typically the home of the 
DF/HCC Sponsor. The Lead Institution also typically serves as the Coordinating Center for the 
DF/HCC Multi-Center Protocol.   
 
DF/HCC Sponsor:  The person sponsoring the submitted Multi-Center protocol.  Within 
DF/HCC, this person is the Overall Principal Investigator (sponsor-investigator) who takes 
responsibility for initiation, management and conduct of the protocol at all research locations. In 
applicable protocols, the DF/HCC Sponsor will serve as the single liaison with any regulatory 
agencies (i.e. FDA). The DF/HCC Sponsor has ultimate authority over the protocol and is 
responsible for the conduct of the study at DF/HCC and all Participating Institutions. In most 
cases the DF/HCC Sponsor is the same person as the DF/HCC Principal Investigator; however, 
both roles can be filled by two different people.  
 
Participating Institution:  An institution that is outside the DF/HCC and DF/PCC consortium 
that is collaborating with DF/HCC on a protocol where the sponsor is a DF/HCC Investigator. 
The Participating Institution acknowledges the DF/HCC Sponsor as having the ultimate authority 
and responsibility for the overall conduct of the study.    
 
Coordinating Center: The entity (i.e. Lead Institution, Medical Monitor, Contract Research 
Organization (CRO), etc) that provides administrative support to the DF/HCC Sponsor in order 
that he/she may fulfill the responsibilities outlined in the protocol document and DSMP, and as 
specified in applicable regulatory guidelines (i.e. CTEP Multi-Center Guidelines). In general, the 
Lead Institution is the Coordinating Center for the DF/HCC Multi-Center Protocol. 


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DF/HCC Office of Data Quality (ODQ): A group within DF/HCC responsible ensuring high-
quality standards are used for data collection and the ongoing management of clinical trials, 
auditing, and data and safety monitoring. ODQ also coordinates quality assurance efforts related 
to multi-center clinical research. 
 
DF/HCC Clinical Trials Research Informatics Office (CTRIO): A group within DF/HCC 
responsible for providing a comprehensive data management platform for managing clinical trial 
data. 
 
2.0 
GENERAL ROLES AND RESPONSIBILITIES 
For DF/HCC Multi-Center Protocols, the DF/HCC Sponsor, the Coordinating Center, and the 
Participating Institutions are expected to adhere to the following general responsibilities:  
 
2.1 
DF/HCC Sponsor 
The DF/HCC Sponsor, Bradley McGregor, MD, will accept responsibility for all aspects of 
conducting a DF/HCC Multi-Center protocol which includes but is not limited to:  
• Oversee the coordination, development, submission, and approval of the protocol as well 
as subsequent amendments.  
• Ensure that the investigators, study team members, and Participating Institutions are 
qualified and appropriately resourced to conduct the protocol.   
• Include the Multi-Center Data and Safety Monitoring Plan as an appendix to the protocol. 
• Ensure all Participating Institutions are using the correct version of the protocol. 
• Ensure that each participating investigator and study team receives adequate protocol 
training and/or a Site Initiation Visit prior to enrolling participants and throughout trial’s 
conduct as needed. 
• Ensure the protocol will be provided to each participating site in a language 
understandable to all site personnel when English is not the primary language.  
• Monitor progress and overall conduct of the study at all Participating Institutions.  
• Ensure all DFCI Institutional Review Board (IRB), DF/HCC and other applicable (FDA) 
reporting requirements are met.  
• Review data and maintain timely submission of data for study analysis.  
• Act as the single liaison with the FDA (investigator-held IND trials) as applicable. 
• Ensure compliance with all requirements as set forth in the Code of Federal Regulations, 
applicable DF/HCC requirements, HIPAA requirements, and the approved protocol. 
• Commit to the provision that the protocol will not be rewritten or modified by anyone 
other than the DF/HCC Sponsor and approved by Millennium Pharmaceuticals. 
• Identify and qualify Participating Institutions and obtain accrual projections prior to 
extending the protocol to that site. 
• Monitor accrual and address Participating Institutions that are not meeting their accrual 
requirements. 
 


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2.2 
Coordinating Center  
The general responsibilities of the Coordinating Center may include but are not limited to: 
• Assist in protocol development.  
• Maintain FDA correspondence, as applicable. 
• Review registration materials for eligibility and register participants from Participating 
Institutions in the DF/HCC clinical trial management system (CTMS). 
• Distribute protocol and informed consent document updates to Participating Institutions 
as needed. 
• Oversee the data collection process from Participating Institutions. 
• Maintain documentation of Serious Adverse Event (SAE) reports and 
deviations/violation submitted by Participating Institutions and provide to the DF/HCC 
Sponsor for timely review and submission to the DFCI IRB, as necessary.   
• Distribute serious adverse events reported to the DF/HCC Sponsor that fall under the 
DFCI IRB Adverse Event Reporting Policy to all Participating Institutions. 
 
• Provide Participating Institutions with information regarding DF/HCC requirements that 
they will be expected to comply with. 
• Carry out plan to monitor Participating Institutions either by on-site or remote 
monitoring. 
• Maintain Regulatory documents of all Participating Institutions which includes but is not 
limited to the following: local IRB approvals/notifications from all Participating 
Institutions, confirmation of Federal wide Assurances (FWAs) for all sites, all SAE 
submissions, Screening Logs for all sites, IRB approved consents for all sites 
• Conduct regular communications with all Participating Institutions (conference calls, 
emails, etc.) and maintain documentation all relevant communications 
 
2.3 
Participating Institution 
Each Participating Institution is expected to comply with all applicable Federal Regulations and 
DF/HCC requirements, the protocol and HIPAA requirements.  
 
The general responsibilities for each Participating Institution may include but are not limited to: 
• Document the delegation of research specific activities to study personnel. 
• Commit to the accrual of participants to the protocol. 
• Submit protocol and/or amendments to their local IRB. 
• Maintain site regulatory files as per DF/HCC Sponsor/ Coordinating Center 
requirements.  
• Provide the Coordinating Center with regulatory documents or source documents as 
requested. 
• Participate in protocol training prior to enrolling participants and throughout the trial as 
required (i.e. teleconferences). 
• Update Coordinating Center with research staff changes on a timely basis. 
• Register participants through the Coordinating Center prior to beginning research related 
activities.  
• Submit Serious Adverse Event (SAE) reports to IRB per local requirements and to the 
Coordinating Center, in accordance with protocol requirements.  


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• Submit protocol deviations and violations to IRB per local requirements and  in 
accordance with study requirements. 
• Order, store and dispense investigational agents and/or other protocol mandated drugs per 
federal guidelines and protocol requirements. 
• Have office space, office equipment, and internet access that meet HIPAA standards. 
• Participate in any quality assurance activities and meet with DFCI monitors or DFCI 
ODQ auditors at the conclusion of a visit to review findings. 
• Promptly provide follow-up and/or corrective action plans for any monitoring queries or 
audit findings. 
 
3.0 
DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS 
The following section will clarify DF/HCC Requirements and further detail the expectations for 
participating in a DF/HCC Multi-Center protocol.  
 
3.1 
Protocol Distribution 
The Coordinating Center, DFCI, will distribute the final DFCI IRB approved protocol and any 
subsequent amended protocols to all Participating Institutions.    
 
3.2 
Protocol Revisions and Closures 
The Participating Institutions will receive notification of protocol revisions and closures from the 
Coordinating Center.  It is the individual Participating Institution’s responsibility to notify its 
IRB of these revisions. 
 
• Non life-threatening revisions: Participating Institutions will receive written notification 
of protocol revisions regarding non life-threatening events from the Coordinating Center. 
Non-life-threatening protocol revisions must be IRB approved and implemented within 
90 days from receipt of the notification. 
• 
Revisions for life-threatening causes: Participating Institutions will receive immediate 
notification from the Coordinating Center concerning protocol revisions required to 
protect lives with follow-up by fax, mail, e-mail, etc.  Life-threatening protocol revisions 
will be implemented immediately followed by IRB request for approval. 
• 
Protocol closures and temporary holds: Participating Institutions will receive 
notification of protocol closures and temporary holds from the Coordinating Center. 
Closures and holds will be effective immediately.  In addition, the Coordinating Center, 
will update the Participating Institutions on an ongoing basis about protocol accrual data 
so that they will be aware of imminent protocol closures. 
 
3.3 
Informed Consent Requirements 
The DF/HCC approved informed consent document will serve as a template for the informed 
consent for Participating Institutions. The Participating Institution consent form must follow the 
consent template as closely as possible and should adhere to specifications outlined in the 
DF/HCC Guidance Document on Model Consent Language for PI-Initiated Multi-Center 
Protocols.  This document will be provided separately to each Participating Institution. 
 
Participating Institutions are to send their version of the informed consent document and HIPAA 
authorization, if a separate document, to the Coordinating Center for review and approval prior 


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to submission to their local IRB. The approved consent form must also be submitted to the 
Coordinating Center after approval by the local IRB. 
 
The Principal Investigator (PI) at each Participating Institution will identify the physician 
members of the study team who will be obtaining consent and signing the consent form for 
therapeutic protocols. Participating institutions must follow the DF/HCC requirement that only 
attending physicians obtain informed consent and re-consent to interventional trials (i.e. drug 
and/or device trials).   
 
3.4 
IRB Documentation 
The following must be on file with the Coordinating Center: 
 
• Initial approval letter of the Participating Institution's IRB.  
• Copy of the Informed Consent Form(s) approved by the Participating Institution’s IRB.  
• Participating Institution’s IRB approval for all amendments. 
• Annual approval letters by the Participating Institution's IRB. 
 
It is the Participating Institution's responsibility to notify its IRB of protocol amendments.  
Participating Institutions will have 90 days from receipt to provide the Coordinating Center their 
IRB approval for amendments to a protocol.    
 
 
3.5 
IRB Re-Approval 
Verification of IRB re-approval from the Participating Institutions is required in order to 
continue research activities.  There is no grace period for continuing approvals. 
 
The Coordinating Center will not register participants if a re-approval letter is not received from 
the Participating Institution on or before the anniversary of the previous approval date.   
 
 
3.6 
Participant Confidentiality and Authorization Statement 
In 1996, congress passed the first federal law covering the privacy of health information known 
as the Health Insurance Portability and Accountability Act (HIPAA). Any information, related to 
the physical or mental health of an individual is called Protected Health Information (PHI). 
HIPAA outlines how and under what circumstances PHI can be used or disclosed.  
 
In order for covered entities to use or disclose protected health information during the course of a 
study, the study participant must sign an Authorization.  This Authorization may or may not be 
separate from the informed consent document.  The Coordinating Center, with the approval from 
the DFCI IRB.  
 
The DF/HCC Sponsor will use all efforts to limit its use of protected health information in its 
trials.  However, because of the nature of these trials, certain protected health information must 
be collected per NCI requirements. These are the primary reasons why DF/HCC has chosen to 
use Authorizations, signed by the participant in the trial, rather than limited data sets with data 
use agreements. 


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3.6.1 DF/HCC Multi-Center Protocol Confidentiality 
All documents, investigative reports, or information relating to the participant are strictly 
confidential. Whenever reasonably feasible, any participant specific reports (i.e. Pathology 
Reports, MRI Reports, Operative Reports, etc.) submitted to the Coordinating Center should be 
de-identified. It is recommended that the assigned protocol case number (as described below) be 
used for all participant specific documents. Participant initials may be included or retained for 
cross verification of identification.  
 
3.7 
DF/HCC Multi-Center Protocol Registration Policy 
 
• Informed consent must be obtained from subjects before they can be screened. A patient 
will be considered “in screening” when he/she has signed the IRB approved Informed 
Consent Form. 
• Each patient screened must be documented on the Potential Patient/Pre‐Screening Log or 
equivalent site form/software. The Potential Patient Log/Pre‐Screening Log is to aid in 
fulfilling the ICH requirement of maintaining a confidential list of patient names. It 
should be stored in the site study files. 
• Eligibility Criteria Worksheet is provided as a tool for registration. 
• Once the investigator verifies the patient is eligible, the lead site (DFCI) will formally 
register the patient in the DF/HCC Clinical Trail Management System (CTMS)    and 
enter the On Study Date. The sequence number used at screening will remain the same 
for the remainder of the study to identify the enrolled patient. 
• Subjects must be registered prior to starting protocol therapy and begin therapy within 
five business days of the lead site (DFCI) entering the On Study Date into the DF/HCC 
Clinical Trail Management System (CTMS).    
 
3.7.1 Participant Registration   
All subjects must be registered by the lead site (DFCI) through the DF/HCC Clinical Trail 
Management System (CTMS)    in accordance with section 4 of the protocol.  A subject is 
considered registered when an “On Study” date is entered into OnCore. 
• To register a participant, the following documents should be completed by the 
Participating Institution and maintained in the Participating Institutions’ records: 
o Signed informed consent document 
o HIPAA authorization form (if separate from the informed consent document) 
o Other appropriate forms (See Section 4 of the Protocol)  
The Coordinating Center will review the submitted documents in order to verify 
eligibility and consent. To complete the registration process, the Coordinating Center 
will: 
• Register the participant on the study with the DF/HCC Clinical Trial Management 
System (CTMS). 
• Upon receiving confirmation of registration, the Coordinating Center will inform 
the Participating Institution and provide the study specific participant case number, 
and, if applicable, assigned treatment and/or dose level 
 


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Treatment may not begin without confirmation from the Coordinating Center that the 
participant has been registered. 
 
Registration can only occur during normal business hours, Monday through Friday from 8:00 AM 
to 5:00 PM Eastern Standard Time. 
 
 
3.7.2 Initiation of Therapy 
Participants must be registered with the DF/HCC CTMS before the initiation of treatment or 
other protocol-specific interventions. Treatment and other protocol-specific interventions may 
not be initiated until the Participating Institution receives confirmation of the participant’s 
registration from the Coordinating Center. The DF/HCC Sponsor and DFCI IRB must be notified 
of any violations to this policy 
 
3.7.3 Eligibility Exceptions 
 No exceptions to the eligibility requirements for a protocol without DFCI IRB approval will be 
permitted. All Participating Institutions are required to fully comply with this requirement.  
 
3.8 
DF/HCC Protocol Case Number  
At the time of registration, Coordinating Center requires the following identifiers for all subjects: 
initials, date of birth, gender, race and ethnicity. Once eligibility has been established and the 
participant successfully registered, the participant is assigned a unique sequence number.  
Participating Institutions should submit all de-identified subsequent communication and 
documents to the Coordinating Center, using this sequence number to identify the subject.   
 
3.8.1  Protocol Deviations, Exceptions and Violations 
Federal Regulations require an IRB to review proposed changes in a research activity to ensure 
that researchers do not initiate changes in approved research without IRB review and approval, 
except when necessary to eliminate apparent immediate hazards to the participant. DF/HCC 
requires all departures from the defined procedures set forth in the IRB approved protocol to be 
reported to the DF/HCC Sponsor, who in turn is responsible for reporting to the DFCI IRB. 
 
For reporting purposes, DF/HCC uses the terms “violation”, “deviation” and “exception” to 
describe departures from a protocol. All Participating Institutions must adhere to these 
requirements for reporting to the DF/HCC Sponsor and will follow their institutional policy for 
reporting to their local IRB. 
 
3.8.2 Definitions 
Protocol Deviation: Any departure from the defined procedures set forth in the IRB-approved 
protocol which is prospectively approved prior to its implementation. 
 
Protocol Exception:  Any protocol deviation that relates to the eligibility criteria, e.g. enrollment 
of a participant who does not meet all inclusion/exclusion criteria. 
  
 
Protocol Violation: Any protocol departure that was not prospectively approved by the IRB prior 
to its initiation or implementation.  
 


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3.8.3  Reporting Procedures 
DF/HCC Sponsor: is responsible for ensuring that clear documentation is available in the 
medical record and/or regulatory documents to describe all protocol deviations occurring at their 
site. The DF/HCC Sponsor will also be responsible for ensuring that all protocol deviations are 
promptly reported per DFCI IRB guidelines.  
 
Participating Institutions: Protocol deviations require prospective approval from the DFCI IRB. 
The Participating Institution must submit the deviation request to the Coordinating Center who 
will then submit the deviation request to the DFCI IRB. Upon DFCI IRB approval the deviation is 
submitted to the Participating Institution IRB, per institutional policy. A copy of the Participating 
Institution’s IRB report and determination will be forwarded to the Coordinating Center within 10 
business days after the original submission.  The deviation may not be implemented without all 
required approvals. 
 
All protocol violations must be sent to the Coordinating Center in a timely manner. The 
Coordinating Center will provide training for the requirements for the reporting of violations. 
 
Coordinating Center: Upon receipt of the violation/deviation report from the Participating 
Institution, the Coordinating Center will submit the report to the DF/HCC Sponsor for review. 
Subsequently, the Participating Institution’s IRB violation/deviation report will be submitted to 
the DFCI IRB for review per DFCI IRB reporting guidelines. DF/HCC will forward all violation 
reports to CTEP via an internal DF/HCC process, as applicable. 
 
3.9 
Safety Assessments and Toxicity Monitoring 
The study teams at all participating institutions are responsible for protecting the safety, rights 
and well-being of study participants. Recording and reporting of adverse events that occur during 
the course of a study help ensure the continuing safety of study participants.  
 
All participants receiving investigational agents and/or other protocol mandated treatment will be 
evaluated for safety. The safety parameters include all laboratory tests and hematological 
abnormalities, physical examination findings, and spontaneous reports of adverse events reported 
by participants.  All toxicities encountered during the study will be evaluated according to the 
NCI criteria specified in the protocol. Life-threatening toxicities must be reported to the DF/HCC 
Sponsor within 1 business days of becoming aware of the event.  
 
Additional safety assessments and toxicity monitoring is outlined in the protocol. 
 
 
 


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3.9.1 Guidelines for Reporting Serious Adverse Events  
Guidelines for reporting Adverse Events (AEs) and Serious Adverse Events (SAEs) are detailed 
in protocol Section 11. 
 
 
 
 
 
 
Participating Institutions must report the SAEs to the Coordinating Center according to the 
protocol.  
 
The Coordinating Center will maintain documentation of all Participating Institution Adverse 
Event reports and be responsible for communicating to all participating investigators, any 
observations reportable under the protocol requirements.  Participating Institutions will review 
and submit to their IRB according to their institutional policies and procedures 
 
3.9.2 Guidelines for Processing IND Safety Reports  
The DF/HCC Sponsor will review all IND Safety Reports and ensure that all IND Safety Reports 
are distributed to the Participating Institutions. Participating Institutions will review and submit 
to their IRB according to their institutional policies and procedures. 
 
3.10 
Data Management 
Data will be handled and recorded in accordance with Section 14 of the protocol. 
 
3.10.1 Data Forms Review 
 
Data submissions are monitored for timeliness and completeness of submission. If study forms 
are received with missing or questionable data, the submitting institution will receive a written or 
electronic query from the DF/HCC Office of Data Quality, Coordinating Center, or designee. 
 
Responses to all queries should be completed and submitted within 14 calendar days.   
 
Responses may be returned on the written query or on an amended paper case report form, or in 
the case of electronic queries, within the electronic data capture (eDC) system. In the case of a 
written query for data submitted on a paper case report form, the query must be attached to the 
specific data being re-submitted in response.   
 
If study forms are not submitted on schedule, the Participating Institution will periodically receive 
a Missing Form Report from the Coordinating Center noting the missing forms.  
 
 
4.0 REQUISITIONING INVESTIGATIONAL DRUG  
Investigational Drug (TAK-228) will be provided by Millennium Pharmaceuticals. 
 
5.0 MONITORING: QUALITY CONTROL 
The quality control process for a clinical trial requires verification of protocol compliance and data 
accuracy. The Coordinating Center, with the aid of the DF/HCC Office of Data Quality, provides 
quality control oversight for the protocol. 
 
 


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5.1 
Ongoing Monitoring of Protocol Compliance 
The Participating Institutions may be required to submit participant source documents to the 
Coordinating Center for monitoring. Participating Institutions may also be subject to on-site 
monitoring conducted by the Coordinating Center.  
 
DFCI will implement ongoing monitoring activities to ensure that Participating Institutions are 
complying with regulatory and protocol requirements, data quality, and participant safety. 
Monitoring will occur during protocol performance and through study completion. Additional 
monitoring practices may include but are not limited to; source verification, review and analysis 
of the following: eligibility requirements, informed consent procedures, adverse events and all 
associated documentation, study drug administration/treatment, regulatory files, protocol 
departures, pharmacy records, response assessments, and data management.  
 
Participating institutions will be required to participate in monthly Coordinating Center initiated 
teleconferences.  
 
Remote Monitoring  
Data will be monitored remotely throughout the study both manually and electronically.  Data 
will be assessed for completeness and correctness by DFCI monitoring  staff.  A Missing Forms 
Report (MFR) will be  run on a regular basis, and queries will be issued based on the results to 
site personnel.  Site personnel will make all corrections and/or notations as appropriate. 
 
On-Site Monitoring will occur per section 13 of the protocol 
 
5.2 
Monitoring Reports 
 
The DF/HCC Sponsor will review all monitoring reports to ensure protocol compliance. The 
DF/HCC Sponsor may increase the monitoring activities at Participating Institutions that are 
unable to comply with the protocol, DF/HCC Sponsor requirements or federal and local 
regulations.  
 
 
5.3 
Accrual Monitoring 
Prior to extending a protocol to an external site, the DF/HCC Sponsor will establish accrual 
requirements for each participating institution. Accrual will be monitored for each participating 
institution by the DF/HCC Sponsor or designee. Sites that are not meeting their accrual 
expectations may be subject to termination. 
 
6.0 AUDITING: QUALITY ASSURANCE 
Auditing is a method of Quality Assurance. Its main focus is to measure whether standards and 
procedures were followed. Auditing is the systematic and independent examination of all trial 
related activities and documents.  Audits determine if evaluated activities were appropriately 
conducted and whether data was generated, recorded and analyzed, and accurately reported per 
the protocol, Standard Operating Procedures (SOPs), and the Code of Federal Regulations 
(CFR). 
 


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6.1 
DF/HCC Internal Audits 
All Participating Institutions are subject to audit by the DF/HCC Office of Data Quality (ODQ). 
Typically, approximately 3-4 participants would be audited at the site over a 2 day period. If 
violations which impact participant safety or the integrity of the study are found, more 
participant records may be audited. 
 
6.1.1 Audit Notifications 
 
It is the Participating Institution’s responsibility to notify the Coordinating Center of all 
scheduled audit dates (internal or NCI) and re-audit dates (if applicable), which involve this 
protocol. All institutions will forward a copy of final audit and/or re-audit reports and corrective 
action plans (if applicable) to the Coordinating Center, within 12 weeks after the audit date.  
 
6.1.2 Audit Reports  
 
The DF/HCC Sponsor will review all final audit reports and corrective action plans, if 
applicable. The Coordinating Center, must forward any reports to the DF/HCC ODQ per 
DF/HCC policy for review by the DF/HCC Audit Committee. For unacceptable audits, the 
DF/HCC Audit Committee would forward the final audit report and corrective action plan to the 
DFCI IRB as applicable. 
 
6.2 
Participating Institution Performance 
 
The DF/HCC Sponsor, and DFCI IRB, is charged with considering the totality of an institution’s 
performance in considering institutional participation in the protocol. 
 
Participating Institutions that fail to meet the performance goals of accrual, submission of timely 
and accurate data, adherence to protocol requirements, and compliance with state and federal 
regulations, may be recommended for a six-month probation period. Such institutions must 
respond with a corrective action plan and must demonstrate during the probation period that 
deficiencies have been corrected, as evidenced by the improved performance measures. 
Participating Institutions that fail to demonstrate significant improvement will be considered by 
the DF/HCC Sponsor for revocation of participation. A DF/HCC Sponsor and/or the DFCI IRB 
may terminate a site’s participation if it is determined that a site is not fulfilling its 
responsibilities as described above.