Clinical trial NCT00827359
Conditions: Renal Cell Carcinoma Renal Cancer
Keywords: everolimus
Sponsor: Beth Israel Deaconess Medical Center
Start date: 2009-03-01; Completion date: 2018-06-01
Enrollment: 25 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this study is to determine if certain features of tumor specimens sampled prior to therapy can predict for the likelihood of responding to everolimus.

Detailed description:
* Participants will undergo a CT or ultrasound guided biopsy of an accessible tumor lesion before beginning the study medication.
* Everolimus tablets will be taken orally once a day. Participants will undergo a physical exam and will be asked questions about their general health and specific questions about any problems they might be having. Photographs will be taken of the tumor to assess the response to treatment. This will be done by a CT or MRI scan. Blood tests will be performed every 4 weeks. In addition, blood for research purposes will be done on day 1 of every other cycle. A urine test will be done every 4 weeks.

Arms: arm 1: This is a single-arm study. All patients will receive everolimus.
Interventions: intervention 1: Everolimus
Intervention descriptions: intervention 1: Tablet form taken orally once a day

Protocol documents:
Prot_SAP_000.pdf: 
 
 
 
 
PROTOCOL 08-313 
 
 
 
  
Closed to New Accrual  
 
 
 
 
 
 
 
 
 
 
Closure Effective Date:  12/09/13 
No new subjects may be enrolled in the study as described above.  
Any questions regarding this closure should be directed to the 
study’s Principal Investigator 
 
 
 
 


 
 
 
 
A Phase II Biomarker Trial of Everolimus in Patients with Advanced 
Renal Cell Carcinoma 
RAD001 
 
 
 
 
Principal Investigator: 
David McDermott, MD  
Version Date:  
October 03, 2014 
Co-Investigators: 
James Mier MD, Toni Choueiri MD ; Dana-Farber / 
Harvard Cancer Center 
Daniel George MD / Duke University Medical Center 
IND Number: 
103335 
DF/HCC Protocol Number: 
08-313 


 
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Table of contents 
1 
Introduction ...................................................................................................................... 5 
1.1 
Renal Cell Carcinoma .............................................................................................. 5 
1.2 
VEGF-Targeted Therapies....................................................................................... 6 
1.3 
RAD001 (everolimus) ............................................................................................. 7 
1.4 
Predictors Biomarkers of Response to mTOR Inhibitors ...................................... 14 
1.5 
Rationale for Study ................................................................................................ 16 
2 
Study objectives ............................................................................................................... 18 
3 
Investigational plan ......................................................................................................... 18 
3.1 
Overall study design .............................................................................................. 18 
3.2 
Study population .................................................................................................... 20 
3.3 
Treatments ............................................................................................................. 28 
3.4 
Visit schedule and assessments ............................................................................. 32 
4 
Protocol amendments, or changes in study conduct .................................................... 42 
5 
Registration Procedures .................................................................................................. 43 
5.1 
General Guidelines for DF/HCC Institutions ........................................................ 43 
5.2 
Registration Process for DF/HCC Institutions ...................................................... 43 
5.3 
General Guidelines for other Participating Institutions ......................................... 44 
5.4 
Registration Process for Other Participating Institutions ...................................... 44 
6 
Correlative Studies .......................................................................................................... 45 
6.1 
Studies proposed in tissue ...................................................................................... 45 
6.2 
Studies to performed on blood ............................................................................... 48 
7 
Data and safety management ......................................................................................... 46 
7.1 
Data collection ....................................................................................................... 46 
7.2 
Data and safety management ................................................................................. 49 
8 
Statistical methods ........................................................................................................... 50 
9 
References ........................................................................................................................ 52 
10 Procedures and instructions ........................................................................................... 56 
b. 
Ethics and Good Clinical Practice ......................................................................... 55 
Appendices  ............................................................................................................................. 58 
Appendix A: Tissue Shipping Form  .................................................................................... 58 
Appendix B: Blood Shipping Form ....................................................................................... 59 
Appendix C: DF/HCC Multi-Center Data and Safety Monitoring Plan…………………60 
Appendix D: Procedure for PBMC Isolation from CPT Tubes…………………………..81 
Appendix E: Eligibility Checklist………………………………………………………..TBA 
 


 
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List of abbreviations  
4E-BP1 
4E-binding protein 
ADR 
Adverse Drug Reaction 
AE 
adverse event 
ALT/SGPT 
alanine aminotransferase/glutamic pyruvic transaminase/Serum glutamic-
pyruvic transaminase 
AST/SGOT 
aspartate aminotransferase/glutamic oxaloacetic transaminase/Serum 
glutamic-oxaloacetic transaminase 
ATC 
Anatomical Therapeutic Chemical classification system 
AUC 
Area under the plasma-concentration time curve 
BAC 
Bronchoalveolar carcinoma 
Cmax 
Maximum plasma concentration 
CR 
Clinical research 
CRF 
Case report/Record form 
CRO 
Contract Research Organization 
CT 
Computer tomography 
CTC 
Common toxicity criteria 
CV 
Coefficient of Variation 
CYP3A4 
CytochromeP450 3A4 isoenzyme 
DLT 
Dose limiting toxicity 
ECG 
Electrocardiogram 
EGF 
Epidermal growth factor 
EGFR 
Epidermal growth factor receptor 
eIF-4E 
Eucariotic Initiation Factor 4E 
EPR 
Early progression rate 
FDG-PET 
Fluorine-18-2-fluoro-Deoxy-D-Glucose Positron Emission Tomography 
FKBP-12 
FK506-binding protein 12 
GF 
Growth factor 
HDL 
High-density lypoproteins 
HER 
Human Epidermal Receptor 
HUVECS 
human umbilical endothelial cells 
IC50 
Inhibitory concentration at 50% 
IEC 
Independent Ethics Committee 
IGF1-R 
Insulin-like Growth Factor 1 Receptor 
IHC 
Immunohistochemistry 
INN 
International Non-proprietary Name 
INR 
International Normal Ratio 
IRB 
Institutional Review Board 


 
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LC-MS 
liquid chromatography method with mass spectrometry 
LDL 
Low-density lypoproteins 
LLOQ 
Lower limit of quantification 
MAPK 
Mitogen Activated Protein Kinase 
mRNA 
messenger Ribonucleic acid 
mTOR 
mammalian Target of Rapamycin 
NIH/NCI 
National Institutes of Health/National Cancer Institute 
nM 
nano-molar 
NSCLC 
Non-small cell lung cancer 
OS 
overall survival 
P-AKT 
phosphor-AKT 
PD 
Pharmacodynamics 
PET 
Proton emission tomography 
PFS 
progression free survival 
P-gp 
P-glycoprotein 
PI3K 
Phosphoinositide 3-kinase 
PK 
Pharmacokinetics 
PK/PD model 
Pharmacokinetic/pharmacodynamic model 
PT/PTT 
prothrombin time 
PTEN 
Phosphatase and Tensin homolog deleted on chromosome 10 
RBC 
red blood cell count 
REB 
Research Ethics Board 
RR 
response rate 
S6K1 
S6 kinase 1 
SAE 
serious adverse event 
SCLC 
Small cell lung cancer 
STAT3 
Signal Transducer and Activator of Transcription 3 
TK 
Tyrosine kinase 
TSC2 
Tuberous Sclerosis Complex 2 
TUNNEL 
Terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-biotin 
Nick End Labeling 
ULN 
upper limit of normal 
VEGF 
Vascular Endothelial Growth Factor 
WBC 
total white blood cell count 
WHO 
World Health Organization 


 
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1 
Introduction 
 
1.1 
Renal Cell Carcinoma 
 
Renal cell carcinoma (RCC) is the eigth most common cancer with approximately 54,000 new 
cases and 13,000 deaths estimated in 2008 (1).  The incidence of RCC has been rising each 
year in the United States since 1970, with a 3:2 prevalence in men over women and a median 
age of diagnosis of 60 years (1).  While many patients present with surgically resectable 
disease, approximately 20-30% present with metastatic disease and 20-40% of patients 
undergoing nephrectomy for localized disease will develop metastases (2).  Traditionally, 
treatment for metastatic renal cell carcinoma has been limited.  Standard chemotherapeutic 
agents have been largely ineffective and cytokine-based treatments with interleukin-2 (IL-2) 
or interferon- (IFN) benefit a small proportion of patients.  Objective response rates to IL-2 
range from 10-20% with 5-10% of these patients having durable responses (3-5).  
Additionally, the toxicity of high-dose IL-2 has limited its widespread use.  Low dose IFN has 
produced response rates in the 10% range with several studies showing a modest survival 
benefit (6, 7).  There has thus been significant interest in developing more effective therapies 
for this group of patients.   
 
Many advances have been made in our understanding of the molecular biology of RCC.  Since 
1997, renal epithelial tumors have been classified into subtypes (clear cell, papillary type I, 
papillary type II, chromophobe, and oncocytoma), each with distinct morphology, genetic 
features, and cell of origin (8, 9).  Clear cell or conventional type renal cancer accounts for 
65% to 75 % of renal epithelial tumors.  It is now known that 75% to 80% of sporadic clear 
cell renal cancer cases possess bi-allelic somatic alterations in the Von Hippel Lindau (VHL) 
gene either via deletion, mutational inactivation, or silencing by hypermethylation (10, 11).  
The VHL gene encodes a tumor suppressor protein that under normoxic conditions forms a 
complex that binds to Hypoxia Inducible Factor (HIF)-1α and -2α in the presence of oxygen 
and targets them for proteasomal degradation.  Loss of VHL function results in inappropriate 
accumulation of both HIF-1α and HIF-2α and the subsequent activation of their target genes, 
including vascular endothelial growth factor (VEGF), platelet derived growth factor (PDGF), 
transforming growth factor-alpha (TGF-α), erythropoietin, GLUT-1, and CXCR4 (12-15).  
This accumulation of HIF-regulated proteins is believed to play a critical role in RCC 
tumorigenesis and RCC-mediated angiogenesis.  VEGF has been well established as having a 
central role in endothelial cell proliferation and survival (16).  PDGF is believed to play a role 
in endothelial stabilization. Disruption of PDGF signaling in perivascular cells has been 
shown to potentially enhance an anti-angiogenic response triggered by VEGFR inhibition 
(17).  The TGF-/EGFR pathway has been shown to be activated and critical for tumor 
progression in VHL-/- RCC tumor lines (18).  Thus, VHL dysfunction causing the 
inappropriate accumulation of HIF-1α and HIF-2α results in a cascade of signaling events 
favorable for RCC tumorigenesis and proliferation.  Given its central role in RCC 
development, the VHL-HIF pathway has emerged as perhaps the preeminent target in RCC 
therapy and several agents targeting elements of this pathway have demonstrated substantial 
clinical efficacy. 


 
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1.2 
VEGF-Targeted Therapies 
 
Recently, two multi-targeted kinase inhibitors (TKIs) have been approved by FDA for the 
therapy of metastatic RCC.  Sorafenib (BAY 43-9006, Nexavar) is an orally administered TKI 
originally discovered through a screen to discover inhibitors of Raf-kinase (19).  In addition to 
potent activity against both mutant and wild-type b-raf and c-raf, it was subsequently 
discovered that sorafenib also had inhibitory activity against a broad group of receptor 
tyrosine kinases including VEGFR2, PDGFR, c-KIT, p38α, and flt3 (20).  Sorafenib gained 
FDA approval based on a randomized, placebo-controlled trial of sorafenib conducted in 
patients with advanced RCC who had failed one prior therapy (21).  Overall, 903 patients 
were enrolled and randomized to placebo (n=452) versus sorafenib (n=451).  The primary 
end-point was overall survival with secondary end-points including progression free survival, 
response rate, and safety.  While the final analysis for overall survival has not been completed, 
the median progression free survival was found to be significantly longer in patients who 
received sorafenib versus placebo (24 weeks vs. 12 weeks; p<0.000001).  The objective 
response rate was only 2% on final analysis.  Drug-related adverse events (all grades) for 
sorafenib versus placebo included rash (34% vs. 13%), diarrhea (33% vs. 10%), hand-foot 
skin reaction (27% vs. 5%), fatigue (26% vs. 23%) and hypertension (11% vs. 1%). Any grade 
3 / 4 events were reported in 30% of patients on sorafenib versus 22% patients on placebo. 
Based on the promising prolongation of progression free survival and tolerability, sorafenib 
was approved by the FDA for therapy of patients with metastatic or unresectable RCC on 
December 20, 2005.   
 
Sunitinib (SU11248, Sutent) is an oral multi-targeted tyrosine kinase inhibitor of VEGFR, 
PDGFR and c-Kit (22).  Sutent has demonstrated promising efficacy in two independent 
single-agent phase II trials in patients with advanced RCC (23, 24). Sixty-three and 106 
previously treated patients were enrolled in the two trials, respectively, with a primary end-
point of response rate.  The overall response rate for the combined trials was approximately 
40% with a median PFS of 8.2 months.  Based on these findings, sunitinib received FDA 
approval for therapy of advanced RCC on January 26, 2006.  Sunitinib was also studied in the 
first-line setting in a randomized phase III trial comparing sunitinib to IFN-α (25).  Overall, 
750 patients were enrolled and randomized with 375 per treatment arm.  The objective 
response rate was 31% for sunitinib versus 6% for IFN-α (p<0.001) and the median PFS was 
11 months for sunitinib versus 5 months for IFN-α, corresponding to a hazard ratio of 0.42 
(95% confidence interval, 0.32 to 0.54; P<0.001).  At the time of analysis, the median overall 
survival had not yet been met in either group. 
 
Both sorafenib and sunitinib represent promising advancement in the therapy of metastatic 
RCC.  However, there are limitations to both agents.  While both drugs have been shown to 
significantly delay time to progression, objective responses have rarely been complete or 
maintained off therapy and all patients will eventually experience disease progression while 
on therapy.  It is possible that there may be limitations to what can be achieved therapeutically 
with agents that target the tumor endothelium and have primarily antiangiogenic effects.  
More robust responses may require agents which directly target oncogenic signaling pathways 


 
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in RCC tumor cells.  Fortunately, such agents are now emerging and demonstrating efficacy in 
RCC. 
 
1.3 
RAD001 (everolimus) 
RAD001 (everolimus) is a novel derivative of rapamycin. RAD001 has been in clinical 
development since 1996 as an immunosuppressant in solid organ transplantation. Since 2003, 
RAD001 is approved in Europe (trade name: Certican) via the Mutual Recognition 
Procedure (MRP) for the prevention of organ rejection in patients with renal and cardiac 
transplantation. Certican is also approved in Australia, South Africa, the Middle East, 
Central and South America, the Caribbean and some Asian countries. 
RAD001 is being investigated as an anticancer agent based on its potential to act  
 directly on the tumor cells by inhibiting tumor cell growth and proliferation  
 indirectly by inhibiting angiogenesis leading to reduced tumor vascularity (via potent 
inhibition of tumor cell VEGF production and VEGF-induced proliferation of endothelial 
cells)  
Figure  1 
Chemical structure of RAD001 
N
O
OH
C
H3
O
O
CH3
CH3
OH
C
H3
O
O
O
O
H
C
H3
O
CH3
O
C
H3
O
O
CH3
CH3
O
C
H3
 
1.3.1 
mTOR pathway and cancer 
At the cellular and molecular level, RAD001 acts as a signal transduction inhibitor. It 
selectively inhibits mTOR (mammalian target of rapamycin), a key protein kinase which 
regulates cell growth, proliferation and survival.  The mTOR is mainly activated via the PI3 
kinase pathway through AKT/PKB and the tuberous sclerosis complex (TSC1/2).  Mutations 
in these components or in PTEN, a negative regulator of PI3 kinase, may result in their 
dysregulation. Abnormal functioning of various components of the signaling pathways 
contributes to the pathophysiology of numerous human cancers.  Various preclinical models 
have confirmed the role of this pathway in tumor development (26). 
The main known functions of mTOR include the following (27): 
 mTOR functions as a sensor of mitogens, growth factors and energy and nutrient levels, 
facilitating cell-cycle progression from G1-S phase in appropriate growth conditions. 


 
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 The PI-3K (mTOR) pathway itself is frequently dysregulated in many human cancers, and 
oncogenic transformation may sensitize tumor cells to mTOR inhibitors. PI3-kinase 
mutations have been reported in the primary tumor in 10-20% of human colorectal cancers 
(28, 29). 
 The loss of PTEN protein, either through gene deletion or functional silencing (promoter 
hypermethylation), is reported in approximately 60% of primary human colorectal cancers 
(30).  
 The mTOR pathway is involved in the production of pro-angiogenic factors (i.e., VEGF) 
and inhibition of endothelial cell growth and proliferation. 
 Through inactivating eukaryotic initiation factor 4E binding proteins and activating the 
40S ribosomal S6 kinases (i.e., p70S6K1), mTOR regulates protein translation, including 
the HIF-1 proteins. Inhibition of mTOR is expected to lead to decreased expression of 
HIF-1. 
1.3.2 
Preclinical studies 
RAD001 inhibits the proliferation of a range of human tumor cell lines in-vitro including lines 
originating from lung, breast, prostate, colon, melanoma and glioblastoma.  IC50s range from 
sub/low nM to µM. RAD001 also inhibits the proliferation of human umbilical vein 
endothelial cells (HUVECS) in vitro, with particular potency against VEGF-induced 
proliferation suggesting that RAD001 may also act as an anti-angiogenic agent. The anti-
angiogenic activity of RAD001 was confirmed in vivo. RAD001 selectively inhibited VEGF-
dependent angiogenic response at well tolerated doses. Mice with primary and metastatic 
tumors treated with RAD001 showed a significant reduction in blood vessel density when 
compared to controls. 
The potential of RAD001 as an anti-cancer agent was shown in rodent models. RAD001 is 
orally bioavailable, residing longer in tumor tissue than in plasma in an s.c mouse xenograft 
model, and demonstrating high tumor penetration in a rat pancreatic tumor model.  The 
pharmacokinetic profile of RAD001 indicates sufficient tumor penetration, above that needed 
to inhibit the proliferation of endothelial cells and tumor cell lines deemed sensitive to 
RAD001 in vitro. 
RAD001 administered daily p.o. was a potent inhibitor of tumor growth, at well tolerated 
doses, in 11 different mouse xenograft models (including pancreatic, colon, epidermoid, lung 
and melanoma) and two syngeneic models (rat pancreatic, mouse orthotopic melanoma).  
These models included tumor lines considered sensitive and “relatively resistant” in vitro. In 
general, RAD001 was better tolerated in mouse xenograft models than standard cytotoxic 
agents (i.e., doxorubicin and 5-fluorouracil), while possessing similar anti-tumor activity.  
Additionally, activity in a VEGF-impregnated s.c. implant model of angiogenesis and reduced 
vascularity (vessel density) of RAD001-treated tumors (murine melanoma) provided evidence 
of in vivo effects of angiogenesis. 
It is not clear which molecular determinants predict responsiveness of tumor cells to RAD001. 
Molecular analysis has revealed that relative sensitivity to RAD001 in vitro correlates with the 
degree of phosphorylation (activation) of the AKT/PKB protein kinase and the S6 ribosomal 
protein; in some cases (i.e., glioblastoma) there is also a correlation with PTEN status.  


 
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In vivo studies investigating the anti-tumor activity of RAD001 in experimental animal tumor 
models showed that RAD001 monotherapy typically reduced tumor cell growth rates rather 
than produced regressions or stable disease. These effects occurred within the dose range of 
2.5 mg to 10 mg/kg, p.o. once a day. 
In preclinical models, the administration of RAD001 is associated with reduction of protein 
phosphorylation in target proteins downstream of mTOR, notably phosphorylated (p)-S6 (p-
S6) and p-4E-BP1, and occasionally with an increase in phosphorylated AKT, a protein 
upstream of mTOR signaling pathway. Study CRAD001A2107 explored MPD (molecular 
pharmacodynamic) changes in tumor at different doses and schedules of RAD001 (weekly 20 
mg, 50 mg and 70 mg or daily 5 mg and 10 mg). 
All significant adverse events observed in toxicology studies with RAD001 in mice, rats, 
monkeys and mini-pigs were consistent with its anticipated pharmacological action as an anti-
proliferative and immunosuppressant and at least in part reversible after a 2 or 4-week 
recovery period with the exception of the changes in male reproductive organs, most notably 
testes. 
1.3.3 
Clinical experience 
1.3.3.1 
RAD001 pharmacokinetics 
The pharmacokinetic characteristics of RAD001 have been extensively investigated in the 
context of the drug’s development as an immunosuppressant in solid organ transplantation 
where RAD001 was administered twice daily as a part of an immunosuppressant, multi-drug 
regimen consistently including cyclosporin A and glucocorticoids. Recent Phase I studies 
provide steady-state pharmacokinetics for both the weekly and daily schedules at varying dose 
levels in patients with advanced cancers. 
RAD001 is rapidly absorbed after oral administration, with a median time to peak blood levels 
(tmax) of 1-2 hours postdose. The extent of absorption is estimated at above 11%.  The area 
under the blood concentration-time curve (AUC) is dose-proportional over the dose range 
tested while maximum blood concentration Cmax appears to plateau at dose levels higher than 
20 mg. The terminal half-life in cancer patients averaged 30 hours, which is similar to that in 
healthy subjects. Inter-patient variability is moderate with the coefficient of variation (CV) of 
approximately 50%.  A high-fat meal altered the absorption of RAD001 with 1.3 hour delay in 
tmax, a 60% reduction in Cmax and a 16% reduction in AUC. In whole blood, approximately 
80% of RAD001 is contained in red blood cells. Of the fraction of drug contained in plasma, 
74% is protein-bound. The apparent distribution volume (Vz/F) after a single dose was 4.7 
L/kg. RAD001 is eliminated by metabolism, mainly by hydroxylation, then excreted into the 
feces >80%. 
RAD001 is mainly metabolized by CYP3A4 in the liver and to some extent in the intestinal 
wall. RAD001 is also a substrate of P-glycoprotein (P-gp). Therefore, absorption and 
subsequent elimination of systematically absorbed RAD001 may be influenced by medicinal 
products that interact with CYP3A4 and/or P-glycoprotein. In vitro studies showed that 
RAD001 is a competitive inhibitor of CYP3A4 and of CYP2D6 substrates, potentially 
increasing the concentrations of medicinal products eliminated by these enzymes. In two 
phase III clinical trials in patients following kidney transplantation, strong inhibitors of 


 
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CYP3A4 (azoles, antifungals, cyclosporine, erythromycin) have been shown to reduce the 
clearance of RAD001 therapy thereby increasing RAD001 blood levels. Similarly, Rifampin, 
a strong inducer of CYP3A4, increases the clearance of RAD001 thereby reducing RAD001 
blood levels. Caution should be exercised when co-administering RAD001 with CYP3A4 
inhibitors or inducers. 
Pharmacokinetic drug to drug interactions with cancer agents are being evaluated in ongoing 
phase Ib studies. Based on currently available results, gemcitabine (study 2101 part 2) and 
paclitaxel (study 2104) did not alter RAD001 pharmacokinetics to a clinically relevant extent 
whereas imatinib notably increased RAD001 exposure with a mean increase in AUC by a 
multiple of 3.7 for RAD001 administered weekly and two-fold for RAD001 administered 
daily (study 2206). Exposure to RAD001 in the presence of letrozole did not exceed that in 
monotherapy (study 2108). Co-administration of RAD001 did not influence pharmacokinetics 
of gemcitabine, imatinib or letrozole. Exposure to paclitaxel in the presence of RAD001 was 
slightly decreased (average by 23%). 
RAD001 pharmacokinetics in transplant patients was investigated in special populations such 
as subjects with hepatic or renal impairment, various ethnic groups and pediatric renal 
transplant patients. In subjects with mild–moderate hepatic impairment, mean AUC to 
RAD001 is increased by 3-fold whilst renal impairment does not affect the pharmacokinetics 
of RAD001. Age, weight (both over the adult range) and gender do not affect the 
pharmacokinetics of RAD001 to a clinically relevant extent. Also, pharmacokinetics does not 
alter in Japanese or Asian patients whereas black patients have 21% higher clearance 
compared to non-blacks. In children, the apparent clearance of RAD001 increases linearly 
with body surface. The clearance per square meter of body surface area is 12-fold higher 
compared with adult patients. 
The pharmacokinetic parameters derived for RAD001 given weekly are summarized in Table 
1-1. 
   Table  1-1 
Steady-state RAD001 pharmacokinetics (weekly dosing) 
Parameter 
5 mg 
10 mg 
20 mg 
30 mg 
50 mg 
70 mg 
N 
4 
4 
2 
5 
5 
6 
Tmax () 
1 (1-2) 
1 (1) 
1 (1) 
2 (1-2) 
1 (1-2) 
1 (1) 
Cmax (ng/mL) 
32 ± 15   
69 ± 8 
94 ± 0 
88 ± 20 
163 ± 63 
174 ± 49 
Cmax/Dose 
6.5 ± 3.1 
6.9 ± 0.8 
4.7 ± 0.0 
2.9 ± 0.7 
3.3 ± 1.2 
2.5 ± 0.7 
Ng/mL/mg 
 
 
 
 
 
 
AUC ss (ng-h/mL) 
283 ± 48 
573 ± 258 
1001 ± 301 
1798 ± 827 
2621 ± 633 3615 ± 1497
AUC ss/Dose 
57 ± 10 
57 ± 27 
50 ± 15 
60 ± 28 
52 ± 13 
52 ± 21 
(ng-h/mL/mg) 
 
 
 
 
 
 
T1/2 (h) 
26 ± 3 
38 ± 14 
31 ± 12 
37 ± 6 
27 ± 7 
26 ± 2 
Values are median (range) for tmax and mean ± standard deviation for all others. 
Reference:  RAD001 Investigator’s Brochure 2005 
 


 
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Cmax was achieved by 1 to 2 hours post dose.  While Cmax rose in roughly dose proportional 
manner from 5 to 20 mg/week, it appeared to increase less than proportionally at higher doses. 
Pharmacodynamic studies 
Pharmacokinetic/pharmacodynamic modeling based on inhibition in a peripheral biomarker 
(S6 kinase inhibition in peripheral blood mononuclear cells) suggests that 5-10 mg daily 
should be an adequate dose to produce a high-degree of sustained target inhibition. 
Furthermore, molecular pharmacodynamic (MPD) studies using IHC in biopsied tumor tissue 
assessed the degree of inhibition and its duration (for p-S6, p-4E-BP1 and p-Akt expression) 
with the daily and weekly dosing. The pathologist was blinded for the biopsy sequence. There 
was almost complete inhibition of p-S6 at all doses and schedules studied (p=0.001). 
Preliminary results suggest a dose-related decrease in p-4E-BP1 and increase in p-Akt 
expression with maximal effect at 10 mg daily and ≥ 50 mg weekly. The study results are 
provided in Table 1-1. 
Table  1-2 
p-S6, p-4E-BP1 and p-Akt expression at various doses of RAD001 
Dose of RAD001 
 
p-S6 inhibition 
(mean %) 
p-4E-BP1 inhibition 
(mean %) 
p-Akt activation  
(mean %) 
Daily 5 mg (n=3) 
100.0 
48.0 
22.2 
Daily 10 mg (n=6) 
92.5 
58.2 
45.5 
Weekly 20 mg (n=5) 
96.7 
5.9 
32.7 
Weekly ≥ 50 mg (n=6) 
100.0 
63.8 
63.1 
Reference:  RAD001 Investigator’s Brochure 2005 
1.3.3.2 
Phase I and II oncology studies 
Data are available from phase I clinical studies of RAD001 given as a single agent to 147 
patients with advanced solid tumors. Such studies included various doses and schedules 
(weekly dosing, range 5-70 mg and daily dosing 5-10 mg). Approximately, 46% of patients 
reported rash or erythema and 40% of the patients presented with stomatitis/mucositis. The 
most frequent adverse events suspected to be drug-related observed in three studies using 
RAD001 as a single agent are listed in Table 1-1. 


 
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Table  1-3 
Adverse events suspected to be drug-related in ≥10% of patients with 
advanced cancers reported in Phase I RAD001 monotherapy studies 
(C2101, C2102 and 2107)  
 
Weekly 
 
Daily 
 
Total 
n=147 
 
5-30 mg 
n=30 
50 mg
n=18 
70 mg
n=38 
 
5mg
n=16 
10 mg 
n=45 
 
No. Pts with AEs 
 
 
 
 
 
 
 
 
Any event 
23 (1) 
17 (2) 
38 (10) 
 
14 (1) 
43 (14) 
 
135 (28) 
By event 
 
 
 
 
 
 
 
 
- 
Rash  
5 
8 
18 
 
10 
27 (1) 
 
68 (1) 
- 
Stomatitis/mucositis 
6 
8 (2) 
16 (2) 
 
6 (1) 
23 (3) 
 
59 (8) 
- 
Fatigue 
8 
7 (1) 
14 (1) 
 
1 
17 (1) 
 
47 (3) 
- 
Nausea 
5 
4 
8 
 
2 
18 (1) 
 
37 (1) 
- 
Anorexia 
1 
6 
10 
 
3 
15 
 
35 
- 
Diarrhea 
1 
7 
7 
 
- 
9 
 
24 
- 
Vomiting 
4 
5 
5 
 
- 
10 
 
24 
- 
Headache 
7 
4 
6 
 
6 
4 
 
20 
- 
Pruritus 
2 
1 
6 
 
3 
4 
 
16 
- 
Infections1 
1 
3 
3 (1) 
 
1 
6 (2) 
 
14 (3) 
- 
Constipation 
- 
1 
2 
 
2 
9 
 
14 
The numbers of patients (by dose level and dose schedule) who have reported grade ≥31 toxicities is given in 
brackets. 
1. events included in brackets reached no more than grade 3 severity 
2 
Infections noted as drug-related included: 
 
 
Herpes simplex:  5 pts (1 at 50 mg/wk; 1 at 5mg/d; 3 at 10 mg/d) 
 
 
Oral candidiasis: 
5 pts (1 at 50 mg/wk; 3 at 70 mg/wk, 1 at 10 mg/d) 
 
 
Pneumonia (gr3)  1 pt (10 mg/d) 
 
 
Pustular rash 
1 pt (20 mg/wk) 
 
 
Rhinitis 
2 pts (50 mg/wk) 
 
 
URT Infection 
1 pt (50 mg/wk 
 
 
Urinary Tract Infect 1 pt (50 mg/wk) 
Reduced blood cell counts at the initiation of treatment are frequent but remain mostly within 
the normal range or limited to grade 1 although a grade 3 neutropenia was a DLT in one 
patient as was a grade 3 thrombocytopenia in a patient receiving RAD001 with letrozole 
where pharmacodynamic interaction is unlikely. This suggest that some patients may be 
particularly sensitive to the myelosuppressive effect of RAD001 making it necessary to 
monitor carefully blood cell counts at initiation of treatment. 
Metabolic changes (hyperlipidemia and hyperglycemia) may be observed during treatment 
with RAD001. Both events may be medically managed. Hyperlipidemia has been reported as 
an ADR in 10% of patients although review of the laboratory values suggests that as many as 
a quarter of patients develop grade 1-2 hyperlipidemia on treatment, mostly 
hypercholesterolemia. Hyperglycemia has been reported as an adverse event in 7% of patients. 
Grade 3 hyperglycemia has been observed, especially in diabetics receiving RAD001 
treatment. Therefore, patients with diabetes should have their blood glucose monitored 
carefully and their medications adjusted, as needed, to maintain adequate control of their 
blood glucose levels.  


 
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In Novartis-sponsored clinical trials, symptomatic non-infectious pneumonitis has been 
reported as a serious adverse event in less than 1% of patients out of approximately 1000 
cancer patients treated with RAD001 as of April 30, 2006. This adverse event has been noted 
in the Investigators’ Brochure. Corticosteroids were often administered to the patients with 
symptomatic pneumonitis.  
Novartis has recently received reports of low grade non-infectious pneumonitis in cancer 
patients treated with RAD001. Most of these reports involve patients with no respiratory 
symptoms (CTC grade 1 pneumonitis: radiographic findings only) or mild severity (CTC 
grade 2: symptomatic, not interfering activities of daily living), and were from two 
investigator-sponsored (private IND) trials, as follows: 
 In a study of patients with advanced renal cell carcinoma receiving 10 p.o. mg/day, 15/20 
patients reviewed by an independent radiologist were noted to have lung infiltrates 
consistent with pneumonitis on routine chest CT scans performed to follow the patients’ 
thoracic metastases. 
 In a study of patients with advanced breast cancer, 7/18 patients treated with RAD001 10 
mg/d and 2/16 patients treated with RAD001 70 mg/week, had findings consistent with 
pneumonitis. In this study, two patients, one on the daily RAD arm and one on the weekly 
RAD001 arm, developed severe (grade 3) pneumonitis which resolved after RAD001 was 
discontinued.  
In both studies, most patients had radiological changes with mild or no symptoms and have 
continued RAD001 treatment without developing symptoms. The reason for an increased rate 
of reported low-grade pneumonitis among oncology patients in these studies is unclear.  Both 
studies included serial chest CT scans allowing prolonged, detailed evaluation of the lung 
parenchyma; the dosage and drug exposure in these phase 2 trials is generally longer than in 
the phase 1 experience. In addition, the dosage of RAD001 used in the treatment of cancer 
patients is substantially higher than that given routinely in the organ transplant setting.  
Everolimus (RAD001) is approved at a daily dose of 0.75 mg twice a day guided by 
therapeutic drug monitoring (3-8 ng/ml) in combination with cyclosporine microemulsion in 
many regions of the world for renal and cardiac transplantation. In phase 3 trials investigating 
everolimus in renal and cardiac transplantation, the overall reported rate of pneumonitis 
ranged from 0.0 to 1.4%. The spontaneous reporting rate for pneumonitis following exposure 
to commercially available everolimus in transplantation is very low (0.08% or 84.4 
events/100,000 patient-years). Refer to the latest version of the RAD001 Investigator’s 
Brochure and safety letters (Investigator Notifications) for the most up to date information 
available. 
 
Everolimus has demonstrated promising activity in advanced renal cell carcinoma.  Results 
from a phase 2 trial of everolimus in previously treated patients with advanced RCC were 
recently presented (31).  Overall, 41 patients with metastatic RCC were enrolled and 37 were 
evaluable for response and toxicity.  12 patients (32%) showed an objective response and the 
median survival was over 11.5 months.  Based on these promising results, everolimus was 
studied in a large, randomized, phase 3 trial versus placebo in patients with metastatic RCC 
who had failed VEGF-targeted TKI (32).  Overall, 410 patients were randomized in a 2:1 
fashion to receive either everolimus at a dose of 10mg/day or best supportive care (272 pts 
everolimus, 138 pts placebo).  Everolimus resulted in a statistically and clinically significant 


 
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improvement in PFS over placebo with a favorable safety profile (PFS 4.0 vs. 1.9 months, 
p<0.0001).  The most common grade 3 or 4 adverse events reported for everolimus were 
stomatitis (36% grade 3, 4% grade 4), anemia (28% grade 3, 7% grade 4), and asthenia (28% 
grade 3, 2% grade 4).  Everolimus is now being studied in other settings and in combination 
with other molecularly targeted agents. 
 
 
1.4 
Predictors Biomarkers of Response to mTOR Inhibitors 
 
Concurrent with the development of molecularly targeted therapies in RCC has been the 
pursuit of biomarkers which might predict for response to these same therapies.  With many 
agents with distinct molecular targets currently available and even more on the horizon, 
identification of predictive biomarkers of response to these agents is a high priority for 
directing the most appropriate therapies to individual patients.  Unlike VEGF-targeted 
therapies which putatively target non-malignantly transformed tumor endothelial cells, the 
clinical benefit of mTOR inhibitors in RCC may be mediated through direct effects on tumor 
cells.  Therefore, mTOR inhibitors may be uniquely suited for the development of tumor-
based predictive molecular biomarkers of response.  One possible candidate biomarker is the 
pre-treatment activation status of the PI3-K/Akt/mTOR signaling pathway.  The hypothesis 
that this basal activity of the targeted pathway might predict for sensitivity to molecularly 
targeted agents is based on similar examples in other malignancies.  The link between 
response to the MEK inhibitor CI-1040 and the presence of an activating B-RAF mutation in 
melanoma is one example (33).   
 
Recently, pathologic surrogates of pre-treatment mTOR pathway activation were investigated 
in tumor specimens collected from a subset of patients treated with temsirolimus as part of a 
randomized phase 2 trial (34, 35).  Twenty pre-treatment tumor specimens from patients with 
metastatic RCC treated with temsirolimus were stained for expression of phospho-S6 (pS6) 
(Ser 235/236) ribosomal protein, a substrate downstream of mTOR.  At the same time, 19 
tumor specimens were stained for phospho-Akt (pAkt) (Ser 473), a substrate upstream of 
mTOR.  Higher pS6 expression was significantly correlated with objective response to 
temsirolimus (p=0.02) while there was a trend towards a significant correlation of pAkt with 
objective response (P=0.07).  No patient without high expression of either pAkt or pS6 
experienced an objective response.  Although this study has a small sample size, the findings 
serve as proof of principle that these surrogates of PI3-K/Akt pathway activation (in 
particular, S6 phosphorylation) are sufficiently stable in formalin-fixed tissue to yield 
reproducible data that may be predictive of response to molecularly targeted agents that block 
the PI3-K/Akt pathway. 
 
Despite the findings in this small retrospective analysis, there have been many concerns raised 
regarding the reliability of phosphoproteins as surrogates of signaling pathway activation in 
tumor specimens.  In particular, while there appears to be consensus that phospho-S6 is a 
particularly stable epitope, phospho-Akt appears quite variable due to rapid dephosphorylation 
(36).  As such, there are ongoing efforts to identify more reliable surrogates of Akt activation.  
Akt activation in the nucleus induces the translocation of the FOXO transcription factors into 
the cytoplasm (37).  As the detection of the intracellular location of FOXO is not dependent 


 
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upon a phospho-protein, it is possible that this would be a particularly stable marker of Akt 
activation in tumor specimens.  Akt also phosphorylates multiple other downstream substrates 
which may be more stable than phospho-Akt itself.   For example, PRAS40 (proline rich Akt 
substrate of 40 kd) is known to be directly phosphorylated by Akt and has recently been 
shown to potentially regulate mTOR activity by binding to raptor and competing with mTOR 
for binding to its substrates S6Kinase and 4EBP (38).  Preliminary work in paraffin-embedded 
tissue specimens suggests that phospho-PRAS40 may be a more stable epitope than phospho-
Akt (Ser 473) and therefore may serve as a more reliable biomarker of Akt activation.   
 
Although the mTOR is traditionally thought to be activated primarily by signaling through the 
PI3K/Akt pathway, alternate mechanisms of mTOR activation independent of Akt have 
recently been described.  For example, the tumor suppressor Promyelocytic Leukemia (PML) 
protein has recently been shown to play a critical role in the inhibition of mTOR and 
activation of FOXO transcription factors (39, 40).  Better known for its causative role in Acute 
Promyelocytic Leukemia, where its function is altered as a result of the (15;17) translocation 
and fusion with RARα (41), PML has more recently been shown to play a role in epithelial 
malignancies (e.g. breast, lung and prostate cancer) in which its function is frequently lost (42, 
43).  Loss of PML function would be expected to result in both the constitutive activation of 
mTOR independent of Akt and the nuclear activation of Akt independent of PI3-K signaling.  
Recent data has suggested that the expression and intranuclear distribution of PML is 
frequently altered in RCC (unpublished observations).  Similar to the loss of PML, activation 
of the MAP-Kinase (MAP-K) pathway may also result in the activation of mTOR independent 
of PI3-K/Akt signaling.  It has recently been shown that MAP-K regulated kinase Erk is 
capable of phosphorylating TSC2 at a specific residue (Ser664), resulting in inhibition of its 
GAP activity and subsequent downstream activation of mTOR (44).  It is possible that 
activation of mTOR through either of these pathways, PML loss or Erk activity, may represent 
oncogenic constitutive mTOR activation which is particularly sensitive to mTOR inhibition.  
The determination of the frequency and predictive value of these signaling events with respect 
to response to mTOR inhibitors is of great interest. 
 
Finally, there may be molecular characteristics within individual tumors which determine its 
susceptibility to the beneficial effects of mTOR inhibition, which are presumably at least in 
part mediated through the achievement of G1 phase cell cycle arrest.  mTOR mediates its 
control of translation by phosphorylating 4EBP, causing it to disassociate from eurkaryotic 
translation initiation factor 4E (eIF4E).  eIF4E binds to the 5’,7-methylguanosine cap structure 
of mRNAs, allowing them to associate with the eIF4F translation initiation complex, which 
then enables translation by scanning the 5’ UTR for the translation initiation codon.  It has 
recently become clear that individual mRNA vary widely in the ease with which they can be 
translated dependent upon the length and structure of their 5’ UTR (such as CG rich, high-
structured 5’ UTR) (45).  mRNA which are the most difficult to translate are therefore those 
which are most highly effected by the availability of eIF4E and include several well known 
growth and survival factors such as cyclin D1, c-myc, VEGF, and survivin.  The availability 
of eIF4E is dependent upon several factors such as activation of the ras and PI3-Kinase/Akt 
pathways.  However, eIF4E can also be overexpressed independent of the activity of these 
pathways in several tumor types (46).  Overexpression of eIF4E beyond the availability of 
4EBP is believed to potentially impart resistance to the growth inhibitory effects of mTOR 


 
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inhibition.  While the existence of such overexpression of eIF4E in RCC remains to be 
investigated, such baseline variability may be predictive of response to mTOR inhibitors.  
 
In addition to the levels of individual protein markers, the transcriptional expression profile of 
an individual RCC tumor may also be predictive of activation of the mTOR pathway and 
predict response to targeted mTOR inhibitors such as everolimus.  The Nevins laboratory at 
Duke University’s Institute for Genome Sciences & Policy has significant experience in 
performing these microarrays and analyzing the resulting data.  In our laboratory, microarray 
data from tumor cell lines have been used to generate genomic signatures to predict response 
to cytotoxic chemotherapy agents (48).  
 
Expression analysis of transcripts in peripheral blood mononuclear cells (PBMC) of patients 
with RCC have also proven informative.  In a prior study, 184 gene transcripts were found to 
be differentially expressed in PBMC of RCC patients compared to normal control patients 
(51).  In a separate study, PBMC expression signatures from RCC patients prior to treatment 
with temsirolimus were correlated with patient outcomes, including overall survival (52).  
Expression analysis of PBMC from patients enrolled in this study will evaluated with the goal 
of developing a signature that can predict response to mTOR inhibitor therapy.  During the 
study, PBMC will be collected at the beginning of every other cycle of therapy, and the data 
will be analyzed for changes in the PBMC expression signature during treatment with 
everolimus. 
 
1.5 
Rationale for Study 
 
Clinical experience with temsirolimus and everolimus has shown that only a subset of patients 
with advanced RCC derive substantial clinical benefit from mTOR inhibitors (31, 44).  The 
particular benefit of temsirolimus in patients with high-risk MSKCC prognostic features and 
in non-clear cell histology suggests that this subset of patients may be distinct from those 
responding to VEGF-targeted therapies (47).  The discovery of predictive biomarkers would 
allow the direction of mTOR inhibitors to those patients most likely to benefit and potentially 
identify those who should receive VEGF-targeted agents instead. 
 
It has been shown in a small retrospective study that certain markers of mTOR activation (e.g. 
Akt or S6 phosphorylation) may predict response to temsirolimus (35).  This study has several 
clear limitations which include small sample size, the retrospective nature of the analysis, and 
the use of mostly primary tumor (nephrectomy) specimens for biomarker determination.  The 
last issue may be particularly concerning as it is not clear if the expression of the biomarkers 
of interest will be the same in the primary lesion (sometimes resected several years prior to 
therapy) as in the metastatic lesions which are presumably being treated.  We therefore 
propose to validate these previously identified predictive biomarkers prospectively in 
metastatic lesions from patients treated with everolimus in a phase II trial.  This approach 
appears feasible as everolimus has demonstrated a robust objective response rate in prior 
phase II trials in advanced RCC, facilitating the correlation of biomarker expression with 
response.   
 


 
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In addition, there appear to baseline variations in RCC that may modulate the response to 
mTOR inhibitors.  Both loss of PML function and Erk-mediated phosphorylation of TSC2 are 
Akt-independent pathways of constitutive mTOR activation which may predict for a 
particularly robust response to mTOR inhibition.  Conversely, overexpression of eIF4E may 
predict for resistance to mTOR inhibition.  This phase II trial is an ideal setting to explore the 
frequency of these signaling events in metastatic RCC lesions as well as their predictive value 
with respect to response to mTOR inhibitors.  
 
Microarray expression analysis of the tumor samples that will be obtained during this study 
will be paired with individual patient response data, and used to develop a genomic expression 
pattern that could predict response to everolimus, thus rapidly and reproducibly identifying a 
subgroup of patients with renal cell carcinoma who are more likely to benefit from therapy 
with this agent (48, 50).  This signature could then be validated in future studies with 
additional tumor samples.  In addition, microarray data will be used to determine if gene 
products corresponding to potential biomarker proteins such as Erk, mTOR and S6 are 
overexpressed in these tumors. 
 
 
 


 
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2 
Study objectives 
Primary 
1. 
To prospectively validate the expression of phospho-Akt and phospho-S6 as 
predictive biomarkers of responsiveness to everolimus as determined by progression-
free survival in patients with advanced RCC using progression free survival as 
defined in sections 3.4.2.5, and 8.0. 
 
Secondary 
1. 
To estimate the progression-free survival in patients with advanced RCC treated with 
everolimus as defined in section 3.4.2.5 and 8.0. 
 
2. 
To determine the objective response rate to everolimus in patients with advanced 
RCC as defined in section 3.4.2.2 and 8.0. 
 
3. 
To assess in an exploratory fashion the predictive value of PML, phospho-TSC 
(S664), phospho-PRAS40, eIF4E, and FOXO expression with respect to response to 
everolimus. 
 
4. 
To develop a genomic predictor of response to everolimus based on microarray 
analysis of pretreatment biopsy samples. 
 
5.   To develop a peripheral blood cell signature to predict response to everolimus. 
 
 
3 
Investigational plan 
 
3.1 
Overall study design 
 
 
 
 
 
B 
I 
O 
P 
S
Y 
 
40 Patients 
with Advanced 
RCC 
 
Everolimus 
10 mg PO 
once daily 


 
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This will be an open-label, single-arm phase II trial of everolimus in patients with advanced 
RCC.  The primary objective of the protocol will be to prospectively validate pS6 and pAkt 
expression as predictive biomarkers of responsiveness to everolimus using progression free 
survival.  Forty patients total will be enrolled in the trial. Expected enrollment is 2-3 patients 
per months over 13-20 months. Patients may have had prior VEGF-targeted therapy (i.e. 
sorafenib, sunitinib, bevacizumab, or pazopanib) or prior cytokine-based therapy (i.e. IL-2).  
All patients will be required to undergo core needle biopsy or metastectomy of an accessible 
metastatic lesion prior to beginning therapy.  Enrollment, in general, will therefore be limited 
to patients who have safely accessible metastatic disease.  Safely accessible metastatic disease 
will be defined to include those lesions which are palpable with no overlying viscera and are 
at least 2cm in size (longest dimension).  Given the paucity of subcutaneous lesions in RCC, 
lesions which are felt safe to biopsy in the opinion of the investigator will also be allowed.  
These lesions will include pleural-based tumors, peripheral liver lesions, kidney lesions and 
bone lesions with exophytic soft tissue component.  As with palpable lesions, these other 
lesions should be at least 2cm in size (longest dimension) with no overlying viscera.  In 
addition to patients with safely accessible metastatic disease, patients who have undergone 
clinically indicated biopsy or surgical resection of metastatic lesions prior to enrollment will 
also be eligible provided that: 1) They were off any systemic therapy for at least 7 days prior 
to the biopsy or surgery; 2) They have not received any other systemic therapy since the 
biopsy or surgical resection; and 3) The tissue has been both paraffin-preserved and frozen as 
described in section 6.1. A subset of patients will be asked to undergo an on-treatment biopsy 
between days 7-14.  However, this will not be a requirement for participation in the protocol.  
For those patients who have undergone nephrectomy, the enrolling site will also be asked to 
submit tumor blocks or at least ten unstained paraffin-embedded slides of the primary tumor 
for analysis.         
 
All patients will begin everolimus at 10mg once daily.  One cycle will be defined as 28 days.  
Physician and laboratory assessments will occur every 28 days (+/- 2 days).  Disease 
assessment will occur every 2 cycles (q8 weeks +/- 1 week) by either CT or MRI.  Patients 
will continue on therapy until disease progression, intolerable toxicity, or they withdraw 
consent.  Patients discontinued from the treatment phase of the study for any reason will be 
evaluated ~30 days (28–42 days) after the decision to discontinue treatment (see Table 3-4 for 
details of off-study visit).  Patients will be followed for a total period of two years following 
registration.        
 
Dose selection for RAD001 
In phase 1 clinical studies of RAD001 as a monotherapy agent in oncology patients, the side-
effect profile is essentially mild to moderate adverse events with a low frequency of DLT at 
the daily dose of 10 mg/d (see Table 1-3). 
 
Based on the PK/PD model, a daily dose of 10mg RAD001 is assumed to provide a 
persistently high degree of target inhibition in the tumor [Investigators’ Brochure-Section 
5.3.1.1].  In addition, preliminary data from phase 1 studies, in which changes in molecular 
characteristics of tumor induced by treatment with RAD001 at the doses of 5 and 10 mg/d 
were investigated, confirm the pharmacodynamic activity predicted previously by PK/PD 
modeling [Table 1-2].  Therefore, a dose of 10 mg/d should ensure adequate drug target 


 
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inhibition for most patients, taking into consideration the known inter-patient variability in 
drug levels (CV of approx 50%). 
 
 
Tumor Sampling 
All patients who have not had prior biopsy or metastectomy will undergo either a core needle 
biopsy or metastectomy of an accessible metastatic lesion prior to beginning therapy.  Lesions 
for core needle biopsy will be limited to subcutaneous and cutaneous lesions, or those 
otherwise felt by the investigator to be safely accessible as defined above.  Core biopsies must 
be performed with at least a 20 gauge or larger (in size) biopsy needle.  Core biopsies can be 
performed under CT or ultrasound guidance by a radiologist.  Four biopsies will be taken of 
the same metastatic lesion and processed as described in the Correlative Science (Section 6.0).               
 
 
3.2 
Study population 
3.2.1 
Patient population 
A total of 40 patients with metastatic RCC will be enrolled on the study.  All patients will 
have ECOG performance status 0-1.  There will be no limit to number of prior therapies, but 
patients cannot have received prior mTOR inhibitors.   
3.2.2 
Inclusion and exclusion criteria 
Patients must have baseline evaluations performed prior to the first dose of study drug and 
must meet all inclusion and exclusion criteria. Results of all baseline evaluations, which 
assure that all inclusion and exclusion criteria have been satisfied, must be reviewed by the 
Principal Investigator or his/her designee prior to enrollment of that patient.  In addition, the 
patient must be thoroughly informed about all aspects of the study, including the study visit 
schedule and required evaluations and all regulatory requirements for informed consent. The 
written informed consent must be obtained from the patient prior to enrollment. The following 
criteria apply to all patients enrolled onto the study unless otherwise specified. 
Inclusion criteria  
 Patients must have at least one site of disease which in the opinion of the investigator is 
safely accessible by CT guided biopsy or metastectomy.  Safely accessible metastatic 
disease will be defined to include those lesions which are palpable with no overlying 
viscera and are at least 2cm in size (longest dimension).  Given the paucity of 
subcutaneous lesions in RCC, lesions which are felt safe to biopsy in the opinion of the 
investigator will also be allowed.  These lesions will include pleural-based tumors, 
peripheral liver lesions, kidney lesions and bone lesions with exophytic soft tissue 
component.  As with palpable lesions, these other lesions should be at least 2cm in size 
(longest dimension) with no overlying viscera.  
 In addition to patients with safely accessible metastatic disease, patients who have 
undergone clinically indicated biopsy or surgical resection of metastatic lesions prior to 
enrollment will also be eligible provided that: A) They were off systemic therapy at least 7 
days prior to the biopsy or surgical resection; B) They have not received any other 


 
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systemic therapy since the biopsy or surgical resection; C) the tissue specimens meet the 
following criteria: 1) All biopsies must be core needle biopsies; specimens obtained by 
fine needle aspiration are unacceptable. 2) At least one portion of the specimen must be 
preserved in paraffin.  3) At least one portion of the specimen must be flash frozen in 
liquid nitrogen. 
 Patients must have at least one measurable site of disease, other than the biopsy site, 
according to RECIST criteria that has not been previously irradiated.  If the patient has 
had previous radiation to the marker lesion(s), there must be evidence of progression since 
the radiation  
 Patients will be required to have metastatic renal cell carcinoma with histologic 
confirmation by the treating center of either the primary or a metastatic lesion.  Non-clear 
cell histologies will be allowed. 
 Age ≥ 18 years 
 Minimum of four weeks since any major surgery, completion of radiation, or completion 
of all prior systemic anticancer therapy (adequately recovered from the acute toxicities of 
any prior therapy). 
 ECOG performance status  1 
 Adequate bone marrow function as shown by: ANC ≥ 1.5 x 109/L, Platelets ≥ 100 x 109/L, 
Hb >9 g/dL 
 Adequate liver function as shown by: 
 serum bilirubin ≤ 1.5 x ULN 
 INR < 1.3  
 ALT and AST ≤ 2.5x ULN (≤ 5x ULN in patients with liver metastases) 
 Adequate renal function: serum creatinine ≤ 2.0 x ULN 
 Fasting serum cholesterol ≤ 300 mg/dL OR ≤ 7.75 mmol/L AND fasting triglycerides ≤ 
2.5 x ULN. NOTE: In case one or both of these thresholds are exceeded, the patient can 
only be included after initiation of appropriate lipid lowering medication. 
 Life expectancy greater than 6 months 
 Signed informed consent 
 As recent studies have shown that treatment with everolimus can result in reactivation of 
hepatitis B, all patients will undergo screening for hepatitis B infection, either chronic or 
resolved*.  Please see study calendar for screening studies. 
 PLEASE NOTE:  All patients must be off prior therapy at least 7 days prior to undergoing 
tumor biopsy on protocol.       
* ALL PATIENTS IN ACTIVE TREATMENT WHO ALREADY ENROLLED WILL 
ALSO BE SCREENED FOR HEPATITIS B INFECTION. 
Exclusion criteria 
 Prior treatment with any investigational drug within the preceding 4 weeks 
 Chronic treatment with systemic steroids or another immunosuppressive agent 


 
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 Patients should not receive immunization with attenuated live vaccines within one week of 
study entry or during study period.   
 Uncontrolled brain or leptomeningeal metastases, including patients who continue to 
require glucocorticoids for brain or leptomeningeal metastases.  Treated brain metastases 
will be allowed.  Treated brain metastases are defined as having no evidence of 
progression or hemorrhage after treatment and no ongoing requirement for 
dexamethasone, as ascertained by clinical examination and brain imaging (MRI or CT) 
during the screening period.  Anticonvulsants (stable dose) are allowed.  Treatment for 
brain metastases may include whole brain radiotherapy (WBRT), radiosurgery (RS; 
Gamma Knife, LINAC, or equivalent) or a combination as deemed appropriate by the 
treating physician.  Patients with CNS metastases treated by neurosurgical resection 
performed within 3 months prior to Day 1 will be excluded. 
 Other malignancies within the past 3 years except for adequately treated carcinoma of the 
cervix or basal or squamous cell carcinomas of the skin. 
 Patients who have any severe and/or uncontrolled medical conditions or other conditions 
that could affect their participation in the study such as: 
  unstable angina pectoris, symptomatic congestive heart failure, myocardial 
infarction ≤ 6 months prior to first study treatment, serious uncontrolled cardiac 
arrhythmia 
 severely impaired lung function  
  any active (acute or chronic) or uncontrolled infection/ disorders.   
  nonmalignant medical illnesses that are uncontrolled or whose control may be 
jeopardized by the treatment with the study therapy 
  liver disease such as cirrhosis, chronic active hepatitis or chronic persistent hepatitis 
 Uncontrolled diabetes mellitus as defined by fasting serum glucose >1.5 X ULN 
 A known history of HIV seropositivity.  Inhibitors of mTOR have been known to have 
immunosuppressive effects making its safety in the population of patients questionable. 
 Impairment of gastrointestinal function or gastrointestinal disease that may significantly 
alter the absorption of RAD001 (e.g., ulcerative disease, uncontrolled nausea, vomiting, 
diarrhea, malabsorption syndrome or small bowel resection) 
 Patients with an active, bleeding diathesis or on systemic anticoagulation (i.e. warfarin, 
heparin, lovenox, etc).  Aspirin is permitted. 
 Women who are pregnant or breast feeding, or women/men able to conceive and unwilling 
to practice an effective method of birth control. (Women of childbearing potential must 
have a negative urine or serum pregnancy test within 7 days prior to administration of 
RAD001). Oral, implantable, or injectable contraceptives may be affected by cytochrome 
P450 interactions, and are therefore not considered effective for this study. 
 Patients who have received prior treatment with an mTOR inhibitor (e.g. sirolimus, 
temsirolimus, everolimus). 
 Patients with a known hypersensitivity to RAD001 (everolimus) or other rapamycins 
(sirolimus, temsirolimus) or to its excipients 


 
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 History of noncompliance to medical regimens 
 Patients unwilling to or unable to comply with the protocol 
 
3.2.3 
Interruption, modification, or discontinuation of treatment 
 
For patients who are unable to tolerate the protocol-specified dosing schedule, dose 
adjustments are permitted in order to keep the patient on study drug.  If administration of 
RAD001 must be interrupted because of unacceptable toxicity, drug dosing will be interrupted 
or modified according to rules described in Table 3-1.  Toxicity will be assessed using the 
NIH-NCI Common Terminology Criteria for Adverse Events, version 3.0 (CTCAEv3.0, 
(http://ctep.cancer.gov/forms/CTCAEv3.pdf)). 
 
All patients will start therapy at 10mg orally once daily.  Patients will be permitted to have up 
to two reductions in therapy prior to discontinuing therapy.  These dose levels will be defined 
as: 
 
Dose Level I:  10mg PO once daily 
 
Dose Level II: 5mg PO once daily 
 
Dose Level III: 5mg PO QOD 
 
Toxicities which are intolerable at dose level III will require discontinuation of study 
medication.  Please see Table 3-1 for directions on holding of study drug.  Missed or vomited 
doses will not be made up. 
 
3.2.4 
Patients with history of resolved or inactive Hepatitis B infection 
 
Recent findings suggest that treatment of patients who been previously diagnosed with 
resolved or active Hepatitis B with everolimus may trigger reactivation of Hepatitis B.  
Therefore, all patients with a known history of resolved or active Hepatitis B should be treated 
with lamivudine for at least 14 days prior to beginning therapy on trial and continue treatment 
throughout duration of study drug treatment.  Patients with normal renal function should be 
treated with lamivudine 100mg PO once daily.  Patients with impaired renal function should 
be treated according to creatinine clearance as follows: CrCl 30-49 mL/min, 100 mg first dose 
then 50 mg once daily; CrCl 15-29 mL/min, 100 mg first dose then 25 mg once daily; CrCl 5-
14 mL/min, 35 mg first dose, then 15 mg once daily; CrCl less than 5 mL/min, 35 mg first 
dose then 10 mg once daily.  Please see attached package insert for potential toxicities 
associated with lamivudine administration.  Lamivudine will be charged to patients insurance 
company.  If not covered by insurance, cost of lamivudine will be covered by the sponsor. 


 
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Table 3-1 
Criteria for dose-modification in case of suspected RAD001 toxicity 
and re-initiation of RAD001 treatment 
Toxicity 
Actions 
Non-hematological toxicity 
 
Grade 2  
(except pneumonitis – refer to Table 3-2) 
If the toxicity is tolerable to the patient, 
maintain the same dose. If the toxicity is 
intolerable to patient, interrupt RAD001 until 
recovery to grade 1. Then reintroduce 
RAD001 at same dose. 
If event returns to grade 2, then  interrupt 
RAD001 until recovery to grade 1. Then 
reintroduce RAD001 at the lower dose level. 
Grade 3 
(except pneumonitis – refer to Table 3-2) 
Interrupt RAD001 until recovery to grade 1. 
Then reintroduce RAD001 at the lower dose 
level. For pneumonitis consider the use of a 
short course of corticosteroids. 
Grade 4 
Discontinue RAD001. 
Hematological toxicity 
 
Grade 2 Thrombocytopenia (platelets <75, ≥ 50x109/L)  
Interrupt RAD001 until recovery to grade 1 
(>75 x109/L). Then reintroduce RAD001 at 
initial dose. 
If thrombocytopenia again returns to grade 2,  
interrupt RAD001 until recovery to grade 1. 
Then reintroduce RAD001 at the lower dose 
level.  
Grade 3 Thrombocytopenia (platelets <50, ≥ 25 x109/L) 
Interrupt RAD001 until recovery to grade ≤1 
(platelets ≥ 75 x109/L).  Then resume  RAD001 
at one dose level lower.  If grade 3 
thrombocytopenia recurs, discontinue 
RAD001. 
Grade 4 Thrombocytopenia (platelets < 25 x109/L) 
Discontinue RAD001. 
Grade 3 Neutropenia (neutrophils <1, ≥0.5 x109/L) 
Interrupt RAD001 until recovery to grade 1 ( 
neutrophils ≥ 1.5 x 109/L). Then resume 
RAD001 at the initial dose.  If ANC again 
returns to Grade 3, hold RAD001 until the ANC 
≥ 1.5 x 109/L.  Then resume RAD001 dosing at 
the lower dose level.  Discontinue patient from 
study therapy for a third episode of grade 3 
neutropenia. 
Grade 4 Neutropenia (neutrophils < 0.5 x109/L) 
Interrupt RAD001 until recovery to grade  1  
(neutrophils ≥ 1.5 x 109/L). Then resume 
RAD001 at the lower dose level. If grade 3 or 
grade 4 neutropenia occurs despite this dose 
reduction, discontinue RAD001. 
Grade 3 febrile neutropenia (not life-threatening) 
Interrupt RAD001 until resolution of fever and 
neutropenia to grade ≤ 1. Hold further RAD001 
until the ANC ≥ 1,500/mm3 and fever has 
resolved. Then resume RAD001 at the lower 
dose level. If febrile neutropenia recurs, 
discontinue RAD001. 
Grade 4 febrile neutropenia (life-threatening) 
Discontinue RAD001. 


 
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Any hematological or non-hematological toxicity requiring 
interruption for ≥ 3 weeks 
Discontinue RAD001 
*Grade 2 hyperlipidemia (hypercholesterolemia and/or hypertriglyceridemia) should 
be managed using medical therapies. 
 
3.2.5 Monitoring of RAD001 suspected toxicities  
 
Patients whose treatment is interrupted or permanently discontinued due to an adverse event 
or abnormal laboratory value suspected to be related to RAD001 must be followed at least 
weekly until the adverse event or abnormal laboratory resolves or returns to grade 1.  If a 
patient requires a dose delay of > 21 days from the intended day of the next scheduled dose, 
then the patient must be discontinued from the study. 
 
3.2.6 
Known Undesirable Side Effects of RAD001 
 
Adverse events most frequently observed with RAD001 are rash, stomatitis/oral mucositis, 
fatigue, headache, anorexia, nausea, vomiting, diarrhea and infections.  Overall, the most 
frequently observed laboratory abnormalities include neutropenia, thrombocytopenia, 
hypercholesterolemia, and/or hypertriglyceridemia.  The majority of these AEs have been of 
mild to moderate severity (CTCAE 3.0 grade 1-2).  
 
Management of stomatitis/oral mucositis/mouth ulcers 
 
Stomatitis/oral mucositis/mouth ulcers due to RAD001 should be treated using local 
supportive care.  Please note that investigators in earlier trials have described the oral 
toxicities associated with RAD001 as mouth ulcers, rather than mucositis or stomatitis.  If 
your examination reveals mouth ulcers rather than a more general inflammation of the mouth, 
please classify the adverse event as such.  Please follow the paradigm below for treatment of 
stomatitis/oral mucositis/mouth ulcers: 
1. For 
mild 
toxicity 
(grade 
1), 
use 
conservative 
measures 
such 
as  
non-alcoholic mouth wash or salt water (0.9%) mouth wash several times a day until 
resolution. 
2. For more severe toxicity (grade 2 in which case patients have pain but are able to maintain 
adequate oral alimentation, or grade 3 in which case patients cannot maintain adequate 
oral alimentation), the suggested treatments are topical analgesic mouth treatments (i.e., 
local anesthetics such as, benzocaine, butyl aminobenzoate, tetracaine hydrochloride, 
menthol, or phenol) with or without topical corticosteroids, such as triamcinolone oral 
paste 0.1% (Kenalog in Orabase®). 
3. Agents containing hydrogen peroxide, iodine, and thyme derivatives may tend to worsen 
mouth ulcers.  It is preferable to avoid these agents. 
4. Antifungal agents must be avoided unless a fungal infection is diagnosed.  In particular, 
systemic imidazole antifungal agents (ketoconazole, fluconazole, itraconazole, etc.) should 
be avoided in all patients due to their strong inhibition of RAD001 metabolism, therefore 
leading to higher RAD001 exposures.  Therefore, topical antifungal agents are preferred if 


 
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Clinical study protocol 
 
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an infection is diagnosed.  Similarly, antiviral agents such as acyclovir should be avoided 
unless a viral infection is diagnosed. 
Management of hyperlipidemia and hyperglycemia  
Treatment of hyperlipidemia should take into account the pre-treatment status and dietary 
habits.  Blood tests to monitor hyperlipidemia must be taken in the fasting state. Grade 2 
hypercholesterolemia (>300 mg/dL or 7.75 mmol/L) or grade 2 hypertriglyceridemia (>2.5 x 
upper normal limit) should be treated with a statin or appropriate lipid-lowering medication, in 
addition to diet.  Atorvastatin and pravastatin have been shown to have no PK interactions 
with everolimus and are the preferred statins for this protocol.  Patients should be monitored 
clinically and through serum biochemistry for the development of rhabdomyolysis and other 
adverse events as required in the product label/data sheets for HMG-CoA reductase inhibitors. 
Note: Concomitant therapy with fibrates and an HMG-CoA reductase inhibitor is associated 
with an increased risk of a rare but serious skeletal muscle toxicity manifested by 
rhabdomyolysis, markedly elevated creatine kinase (CPK) levels and myoglobinuria, acute 
renal failure and sometimes death.  The risk versus benefit of using this therapy should be 
determined for individual patients based on their risk of cardiovascular complications of 
hyperlipidemia. 
Grade 3 hyperglycemia has been observed in patients receiving RAD001 therapy. In many 
cases the affected patients had an abnormal fasting glucose at baseline. Based on this finding, 
we suggest that optimal glucose control should be achieved before starting a patient on 
RAD001 and should be monitored during RAD001 therapy. 
Management of non-infectious pneumonitis 
Both asymptomatic radiological changes and symptomatic non-infectious pneumonitis have 
been noted in patients receiving RAD001 therapy.  Non-infectious pneumonitis has been 
associated with RAD001 and other mTOR inhibitors (33). In order to monitor for 
asymptomatic (grade 1) pulmonary infiltrates, a chest X-ray is required if a CT scan of chest is 
not used for bi-monthly disease evaluations. Additional chest X-rays/CT scans may be done, 
when clinically necessary. If non-infectious pneumonitis develops, consultation with a 
pulmonologist should be considered. Management of non-infectious pneumonitis suspected to 
be associated with RAD001 and dose modifications instructions are provided in Tables 3-1 
and 3-2.   


 
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Table 3-2 
Management of non-infectious pneumonitis 
Worst Grade 
Pneumonitis 
Required Investigations 
Management of 
Pneumonitis  
RAD001 Dose Adjustment 
Grade 1 
CT scans with lung 
windows. 
No specific 
therapy is 
required 
Administer 100% of RAD001 dose. 
Grade 2 
CT scan with lung windows.  
Consider pulmonary 
function testing includes: 
spirometry, DLCO, and room 
air O2 saturation at rest. 
Repeat each subsequent 
Cycle until return to within 
normal limits. Consider a 
bronchoscopy.  
Symptomatic 
only. Rule out 
infection. 
Prescribe 
corticosteroids if 
cough is 
troublesome. 
Reduce RAD001 dose until 
recovery to < grade 1. RAD001 may 
also be interrupted if symptoms 
are troublesome. Patients will be 
withdrawn from the study if they 
fail to recover to < grade 1 within 3 
weeks. 
Grade 3 
CT scan with lung windows 
and pulmonary function 
testing includes: spirometry, 
DLCO, and room air O2 
saturation at rest.; Repeat 
each subsequent Cycle until 
return to within normal 
limits. Bronchoscopy is 
recommended. 
Prescribe 
corticosteroids if 
infective origin is 
ruled out. Taper 
as medically 
indicated. 
Hold treatment until recovery to < 
grade 1. May restart protocol 
treatment within 3 weeks at a 
reduced dose (by one level) if 
evidence of clinical benefit. 
Grade 4 
CT scan with lung windows 
and required pulmonary 
function testing includes: 
spirometry, DLCO, and room 
air O2 saturation at rest. 
Repeat each subsequent 
Cycle until return to within 
normal limits. Bronchoscopy 
is recommended. 
Prescribe 
corticosteroids if 
infective origin is 
ruled out. Taper 
as medically 
indicated. 
Discontinue treatment. 
 
All interruptions or changes to study drug administration must be recorded. 
 
It will be documented whether or not each patient completed the clinical study.  If for any 
patient either study treatment or observations were discontinued the reason will be recorded. 
Reasons that a patient may discontinue participation in a clinical study are considered to 
constitute one of the following: 
1. adverse event(s) 
2. abnormal laboratory value(s) 
3. abnormal test procedure result(s) 
4. disease progression 
5. protocol violation 
6. subject withdrew consent 
7. lost to follow-up 
8. administrative problems 


 
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Clinical study protocol 
 
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9. death 
 
3.3 
Treatments 
 
3.3.1 
Investigational therapy 
 
The investigational therapy used in the course of this study is RAD001.  Study medication 
will be administered by the patients themselves.  During the study, RAD001 will be 
administered orally as once daily dose of 10mg continuously from study day 1 until 
progression of disease or unacceptable toxicity. 
 
Medication labels will comply with US legal requirements and be printed in English. They 
will supply no information about the patient.  The storage conditions for study drug will be 
described on the medication label. 
 
RAD001 will be provided by Novartis. RAD001 is formulated as tablets for oral 
administration of 5mg strength.  Tablets are blister-packed under aluminum foil in units of 10 
tablets, which should be opened only at the time of administration as drug is both hygroscopic 
and light-sensitive. 
 
RAD001 should be taken by the patient in a fasting state or with no more than a light fat-free 
meal.  Dietary habits around the time of RAD001 intake should be as consistent as possible 
throughout the study. 
 
3.3.2 
Concomitant therapy 
 
Patients must be instructed not to take any additional medications (including over-the-counter 
products) during the trial without prior consultation with the investigator. All medications 
taken within 30 days of screening should be recorded. If concomitant therapy must be added 
or changed, the reason and name of the drug/therapy should be recorded. 
 
In general, the use of any concomitant medication/therapies deemed necessary for the care of 
the patient are allowed, including drugs given prophylactically (e.g. antiemetics +/- steroids), 
with the following exceptions: 
 
 no other investigational therapy should be given to patients 
 no chronic treatment with systemic steroids or another immunosuppressive agent 
 no anticancer agents other than the study medications administered as part of this study 
protocol should be given to patients. If such agents are required for a patient then the 
patient must first be withdrawn from the study. 
 leukocyte growth factors (e.g.G-CSF and GM-CSF) are not to be administered 
systematically but may be prescribed by the investigator for severe neutropenia if this is 
thought to be appropriate.  
 no live vaccines should be administered to patient due to immunosuppressant potential of 
RAD001.    


 
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Clinical study protocol 
 
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 drugs or substances known to be inhibitors or inducers of the isoenzyme CYP3A should 
be avoided in association with RAD001 as these can alter metabolism. Strong inhibitors or 
inducers of the isoenzyme CYP3A should not be administered as systemic therapy (See 
Table 3-3).  Grapefruit juice should be avoided while on study. 
The investigator should instruct the patient to notify the study staff about any new medications 
he/she takes after the start of the study drug. All medications (other than study drug/s) and 
significant non-drug therapies (including physical therapy and blood transfusions) 
administered after the patient starts treatment with study drug/s must be recorded. 
 


 
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Table 3-3 Clinically relevant drug interaction: substrates, inducers and inhibitors of 
isoenzyme CYP3A.  
Substrates (competitive inhibition) 
 
Antibiotics1: 
 
clarithromycin* 
 
erythromycin  
 
telithromycin* 
Anti-arrhythmics: 
 
quinidine 
Benzodiazepines: 
 
alprazolam 
 
diazepam 
 
midazolam 
 
triazolam 
Immune Modulators: 
 
cyclosporine 
 
tacrolimus (FK506) 
HIV Protease Inhibitors: 
 
indinavir* 
 
ritonavir* 
 
saquinavir* 
Prokinetic: 
 
cisapride 
Antihistamines: 
 
astemizole 
 
chlorpheniramine  
Calcium Channel Blockers: 
 
amlodipine 
 
diltiazem 
 
felodipine 
 
nifedipine 
 
nisoldipine 
 
nitrendipine 
 
verapamil 
HMG CoA Reductase Inhibitors2:  
 
atorvastatin 
 
cerivastatin 
 
lovastatin 
 
simvastatin 
Miscellaneous: 
 
aprepitant 
 
buspirone 
 
haloperidol 
 
methadone 
 
pimozide  
 
quinine 
 
sildenafil 
 
tamoxifen 
 
trazodone 
 
vincristine 
Inducers 
Carbamazepine 
Phenobarbital 
Phenytoin* 
Rifabutin* 
Rifampin* 
St John’s wort 
Troglitazone 
Inhibitors 
Amiodarone 
Cimetidine 
Clarithromycin 
Delaviridine 
Diltiazem 
Erythromycin 
Fluvoxamine* 
Grapefruit juice 
Sevilla orange 
Indinavir 
Itraconazole* 
Ketoconazole* 
Voriconazole* 
Posaconazole* 
Mibefradil 
Nefazodone* 
Nelfinavir* 
Troleandomycin 
Verapamil 
Based on: Ingelman-Sundberg M, Human drug metabolising cytochrome P450 enzymes: properties and 
polymorphisms, Naunyn Schmiedebergs Arch Pharmacol. 2004 Jan;369(1):89-104.  and 
[http://www.medicine.iupui.edu/flockhart/clinlist.htm as of July 13, 2006] 
* asterisk denotes strong inhibition/ induction  
Please note: 
- 
strong inhibitor implies that it can cause ≥5-fold increase in AUC or ≥80% decrease in clearance of 
sensitive CYP substrates 
- 
moderate inhibitor implies that it can cause 2 to 5-fold increase in AUC values or 50-80% decrease in 
clearance  of sensitive CYP substrates. 
(Distinction is not always categorical as interaction can vary according to conditions). 
1. Macrolide antibiotics: 
Azithromycin is not a CYP3A substrate. It may therefore be employed where 


 
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antibiotherapy with a macrolide is desirable in a patient being treated with RAD001 
2. Statins: Atorvastatin and pravastatin may be associated with RAD001, since a PK interaction study has 
shown that there is no relevant PK interaction.  
 
3.3.3 
Treatment compliance 
Records of study medication used, dosages administered, and intervals between visits will be 
recorded during the study.  Drug accountability will be determined and noted by pill count and 
patients will be asked to return all unused study medication at the beginning of each cycle. 


 
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3.4 
Visit schedule and assessments 
3.4.1 
Visit schedule 
Table 3-4  Evaluation and visit schedule 
 
Table 3-4: Study Evaluation Calender 
 
 
 
Pre-
Studyh 
 
Wk 
1 
(+/- 2 
days) 
Wk 
2 
Wk 
3 
Wk 
4 
Wk 
5 
(+/- 2 
days) 
Wk 
6 
Wk 
7 
Wk 
8 
Wk 
9 
(+/- 2 
days) 
Wk 
10 
Wk 
11 
Wk 
12 
Wk 
13 
(+/- 2 
days) 
Off 
Studyg
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
X 
 
 
 
X 
 
   
 
X 
 
 
 
Q4wks 
 
 
Physical Exam 
X 
 
  X 
 
 
 
 
 
 
 
X 
 
 
 
 
X 
 
 
 
Q4wks 
X 
ECG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vital Signs 
X 
X 
 
 
 
 
X 
 
 
 
X 
 
 
 
Q4wks 
X 
 
Performance status 
X 
X 
 
 
 
 
X 
 
 
 
X 
 
 
 
Q4wks 
X 
CBC w/diff,  plts 
X 
X 
 
    
 
X 
 
 
 
X 
 
 
 
Q4wks 
 
Serum  chemistrya 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
Q4wks 
 
PT and INR 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
Q4wks 
 
Urinanalysis 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
Q4wks 
 
Hepatitis B ScreeningI 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum pregnancyb 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Bloodc 
X 
Xd 
 
 
 
X 
 
 
 
 
 
 
 
Q8wks 
 
Tumor Sampling 
Xe 
Xe,f 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse event evaluation 
X 
X -----------------------------------------------------------------------------------------------------------------
- 
X 
Tumor measurements 
X 
Tumor measurements are repeated every 8 weeks (+/- one week).  Documentation (radiological) 
must be provided for patients removed from study for progressive disease. 
X 
Radiologic evaluation 
X 
Radiologic measurements should be performed every 8 weeks.   If CT of chest is not done than 
recommend CXR q 8 wks 
X 
  
a. 
Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, 
sodium, potassium, total protein, SGOT [AST], SGPT [ALT], uric acid, magnesium, fasting (6 hours) serum cholesterol, 
fasting (6 hours) serum triglycerides. 
b. 
Within 72 hours prior to initiation of therapy for women of childbearing potential only. 
c. 
Submit one 7cc CPT tube 
d.     Pre-study blood can be submitted either during screening or on Day 1. 
e.     Either a core needle biopsy or metastectomy of an accessible metastatic lesion prior to beginning therapy. 
f.     Second biopsy optional 
g.    Off study visit should be between 28-42 days from day of discontinuation from the study. 
h.    All pre-study evaluations must be performed ≤ 28 days prior to the start of treatment. 
I.    Hepatitis screening labs should include: HepB surface Ab, HepB surface antigen, HepB Core Ab.  All active patients 
currently enrolled on this study will also need to be tested for hepatitis B infection. 


 
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3.4.2 
Duration of Follow-up 
 
For this protocol, all patients, including those who discontinue protocol therapy early, will be 
followed for response until progression and for survival for 2 years from the date of 
registration.  Following the off-study visit, the study team will update survival data every 6 
months for up to three years.     
 
Patients who have an ongoing everolimus-related Grade 4 or serious adverse event at the time 
of discontinuation from study treatment will continue to be followed until resolution of the 
event or until the event is considered irreversible.  Otherwise, there will no specific follow-up 
visits or studies following the off-study visit.   
 
3.4.3 
Efficacy assessments 
 
Tumor measurements will occur every 8 weeks (+/- 1 week) on study by either CT or MRI.  
RECIST criteria will be used to classify response. 
 
Patients who prematurely exit the study should have the required evaluations performed at the 
time study drug is discontinued and before initiation of any other treatment.  Physical 
examination, performance status (PS) determinations, and all laboratory tests should be 
repeated on the last day of study if these have not been evaluated within 14 days, inclusive, 
before discontinuation.  Repeat measurements or evaluations of all tumor sites should be 
performed if these have not been evaluated within 30 days, inclusive, before discontinuation. 
 
3.4.3.1 
Solid Tumor Response Criteria (RECIST) 
 
Malignant Disease Evaluation 
 
To assess objective response, it is necessary to estimate the overall tumor burden at baseline to 
which subsequent measurements will be compared. Measurable disease is defined by the 
presence of at least one measurable lesion. 
 
All measurements should be recorded in metric notation by use of a ruler or calipers. The 
same method of assessment and the same technique should be used to characterize each 
identified lesion at baseline and during follow-up. All baseline evaluations should be 


 
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performed as closely as possible prior to registration and never more than four weeks before 
registration. 
 
 
The term evaluable in reference to measurability will not be used because it does not provide 
additional meaning or accuracy.  At baseline, tumor lesions will be characterized as either 
measurable or non-measurable. 
 
Measurable  
 
Lesions that can be accurately measured in at least one dimension (longest diameter to be 
recorded) as > 20 mm (2.0 cm) with conventional techniques or as > 10 mm (1.0 cm) with 
spiral CT scan. 
 
If the measurable disease is restricted to a solitary lesion, its neoplastic nature should be 
confirmed by cytology/histology. 
 
Non-Measurable 
 
All other lesions, including small lesions [longest diameter < 20 mm (2.0 cm) with 
conventional techniques or < 10 mm (1.0 cm) with spiral CT scan] and truly non-measurable 
lesions. 
 
Lesions considered to be truly non-measurable include the following: bone lesions, 
leptomeningeal disease, ascites, pleural/pericardial effusion, inflammatory breast disease, 
lymphangitis cutis/pulmonis, abdominal masses that are not confirmed and followed by 
imaging techniques, and cystic lesions. 
 
3.4.3.2 
Definition of Response 
 
3.4.3.2.1 Target Lesions 
 
All measurable lesions up to a maximum of five lesions per organ and 10 lesions in total, 
representative of all involved organs. Target lesions should be selected on the basis of their 
size (those with the longest diameters) and their suitability for accurate repeated 
measurements 
 
The sum of the longest diameters of all target lesions will be calculated at baseline and 
reported as the baseline sum longest diameter. The sum longest diameter will be used to 
characterize the objective tumor response. For lesions measurable in 2 or 3 dimensions, 
always report the longest diameter at the time of each assessment. 
 
Complete Response (CR)  


 
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The disappearance of all target lesions. To be assigned a status of complete response, changes 
in tumor measurements must be confirmed by repeat assessments performed no less than four 
weeks after the criteria for response are first met. 
 
 
Partial Response (PR)  
At least a 30% decrease in the sum of the longest diameters of target lesions, taking as 
reference the baseline sum longest diameter. To be assigned a status of partial response, 
changes in tumor measurements must be confirmed by repeat assessments performed no less 
than four weeks after the criteria for response are first met. 
 
Progressive Disease (PD)   
At least a 20% increase in the sum of the longest diameters of target lesions, taking as 
reference the smallest sum longest diameter recorded since the baseline measurements, or the 
appearance of one or more new lesion(s). 
 
Stable Disease (SD)  
Neither sufficient shrinkage to qualify for partial response nor sufficient increase to qualify for 
progressive disease. To be assigned a status of stable disease, measurements must have met 
the stable disease criteria at least once after study entry at a minimum interval.  
 
3.4.3.2.2 Non-Target Lesions 
 
All other lesions or sites of disease not meeting definition of target lesions will be classified as 
non-target lesions. Measurements of these lesions are not required, but the presence or 
absence of each should be noted throughout follow-up. 
 
Complete Response (CR)  
The disappearance of all nontarget lesions and normalization of tumor marker levels, if 
applicable. To be assigned a status of complete response, changes in tumor measurements 
must be confirmed by repeat assessments performed no less than four weeks after the criteria 
for response are first met. 
 
Incomplete Response/Stable Disease (SD)  
The persistence of one or more nontarget lesion(s) and/or the maintenance of tumor marker 
levels above the normal limits. To be assigned a status of stable disease, measurements must 
have met the stable disease criteria at least once after study entry at a minimum interval at a 
minimum interval of 8 weeks. 
 
Progressive Disease (PD)  
Appearance of one or more new lesion(s) and/or unequivocal progression of existing non-
target lesions. 
 


 
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3.4.3.3 
Symptomatic Deterioration 
 
Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be classified as having 
symptomatic deterioration. 
 
3.4.3.4 
Evaluation of Patient’s Best Overall Response 
 
The best overall response is the best response recorded from registration until disease 
progression/recurrence, taking as reference for progressive disease the smallest measurements 
recorded since registration. The table below provides overall responses for all possible 
combinations of tumor responses in target and nontarget lesions, with or without new lesions. 
 
To be assigned a status of complete or partial response, changes in tumor measurements must 
be confirmed by repeat assessments performed no less than four weeks after the criteria for 
response are first met. 
 
To be assigned a status of stable disease, measurements must have met the stable disease 
criteria at least once after study entry at a minimum interval of eight weeks. 
 
Overall Response for all Possible Combinations of Tumor Response 
Target 
Lesions 
Nontarget 
Lesions 
New 
Lesions 
Overall 
Response 
CR 
CR 
No 
CR 
CR 
Incomplete 
response/SD 
No 
PR 
PR 
Non-PD 
No 
PR 
SD 
Non-PD 
No 
SD 
PD 
Any 
Yes or No 
PD 
Any 
PD 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
CR = complete response; PR = partial response; SD = stable disease; PD = 
progressive disease 
 
 
Documentation of Response 
The time between initiation of therapy and first documentation of PR or CR. 
 
Confirmation of Response 
To be assigned a status of complete or partial response, changes in tumor measurements must 
be confirmed by repeat assessments performed no less than four weeks after the criteria for 
response are first met. 
 


 
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3.4.3.5 
Duration of Response 
 
Duration of overall response – the period measured from the time that measurement criteria 
are met for complete or partial response (whichever status is recorded first) until the first date 
that progressive disease is objectively documented, taking as reference the smallest 
measurements recorded since treatment started. 
 
Duration of Complete Response 
The period measured from the time measurement criteria are met for complete response until 
the first date that progressive disease is objectively documented. 
 
Duration of Stable Disease 
The period measured from registration on to the study until the criteria for disease progression 
is met, taking as reference the smallest measurements recorded since registration. To be 
assigned a status of stable disease, measurements must have met the stable disease criteria at 
least once after study entry at a minimum interval of eight weeks.  
 
Survival 
Survival will be measured from the date of registration on to the study. 
 
Progression Free Survival 
Progression-free survival will be measured from the date of registration on to the study until 
the first date that progressive disease is objectively documented or death from any cause, 
whichever occurs first.  
 
3.4.3.6 
Methods of Measurement  
 
Imaging based evaluation is preferred to evaluation by clinical examination.  The same 
imaging modality must be used throughout the study to measure disease. 
 
CT and MRI 
CT and magnetic resonance imaging (MRI) are the best currently available and most 
reproducible methods for measuring target lesions. Conventional CT and MRI should be 
performed with contiguous cuts of 10 mm or less in slice thickness. Spiral CT should be 
performed by use of a 5 mm contiguous reconstruction algorithm. This specification applies to 
tumors of the chest, abdomen, and pelvis, while head and neck tumors, and those of the 
extremities require specific procedures. 
 
 


 
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3.4.4 
Safety assessments 
 
Please see the DF/HCC Multi-Center Data and Safety Monitoring Plan in Appendix C. Safety 
assessments will consist of monitoring and recording all adverse events and serious adverse 
events, the regular monitoring of hematology, blood chemistry and urine values, regular 
measurement of vital signs and the performance of physical examinations.  See multi-center 
Data Safety Monitoring Plan (Appendix C) for more details. 
These assessments should be performed within ±2 days of the scheduled day of assessment 
except for adverse events that will be evaluated continuously through the study. Safety and 
tolerability will be assessed according to the NIH/NCI CTCAE version 3.0 
http://ctep.cancer.gov/forms/CTCAEv3.pdf. 
 
3.4.4.1 
Adverse events 
 
Information about all adverse events, whether volunteered by the subject, discovered by 
investigator questioning, or detected through physical examination, laboratory test or other 
means, will be collected and recorded and followed as appropriate. 
 
An adverse event is the appearance or worsening of any undesirable sign, symptom, or 
medical condition occurring after starting the study drug even if the event is not considered to 
be related to study drug. Medical conditions/diseases present before starting study drug are 
only considered adverse events if they worsen after starting study drug. Abnormal laboratory 
values or test results constitute adverse events only if they induce clinical signs or symptoms, 
are considered clinically significant, or require therapy. 
 
The occurrence of adverse events should be sought by non-directive questioning of the patient 
at each visit during the study. Adverse events also may be detected when they are volunteered 
by the patient during or between visits or through physical examination, laboratory test, or 
other assessments. As far as possible, each adverse event should be evaluated to determine: 
 
1. the severity grade (grade 1: mild; grade 2: moderate; grade 3: severe; grade 4: life 
threatening; grade 5:fatal) 
2. attribution: the determination of whether an adverse event is related to a medical treatment 
or procedure 
Attribution categories: 
 
Definite: The adverse event is clearly related to the investigational agent(s).  
 
Probable: The adverse event is likely related to the investigational agent(s).  
 
Possible: The adverse event may be related to the investigational agent(s).  
 
Unlikely: The adverse event is doubtfully related to the investigational agent(s).  
 
Unrelated: The adverse event is clearly NOT related to the investigational agent(s) 
3. its duration (start and end dates or if continuing at final exam) 
4. action taken (no action taken; study drug dosage adjusted/temporarily interrupted; study 
drug permanently discontinued due to this adverse event; concomitant medication taken; 
non-drug therapy given; hospitalization/prolonged hospitalization) 


 
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5. whether it constitutes a serious adverse event (SAE) 
 
All adverse events should be treated appropriately. Such treatment may include changes in 
study drug treatment including possible interruption or discontinuation, starting or stopping 
concomitant treatments, changes in the frequency or nature of assessments, hospitalization, or 
any other medically required intervention. Once an adverse event is detected, it should be 
followed until its resolution, and assessment should be made at each visit (or more frequently, 
if necessary) of any changes in severity, the suspected relationship to the study drug, the 
interventions required to treat it, and the outcome. 
 
Information about common side effects already known about the investigational drug can be 
found in the Investigators’ Brochure or will be communicated between IB updates in the form 
of Investigator Notifications. This information will be included in the patient informed 
consent and should be discussed with the patient during the study as needed. 
3.4.4.2 
Serious adverse events 
Information about all serious adverse events will be collected and recorded. To ensure patient 
safety each serious adverse event must also be reported to the overall principal investigator 
within 24 hours of learning of its occurrence.  The overall principal investigator will then 
report the event to Novartis and to the Office for Human Research Studies (OHRS).  A serious 
adverse event is an undesirable sign, symptom or medical condition which: 
 is fatal or life-threatening 
 results in persistent or significant disability/incapacity 
 constitutes a congenital anomaly/birth defect 
 requires inpatient hospitalization or prolongation of existing hospitalization, unless 
hospitalization is for: 
 routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition (specify what this includes) 
 elective or pre-planned treatment for a pre-existing condition that is unrelated to the 
indication under study and has not worsened since the start of study drug 
 treatment on an emergency outpatient basis for an event not fulfilling any of the 
definitions of a SAE given above and not resulting in hospital admission 
 social reasons and respite care in the absence of any deterioration in the patient’s 
general condition 
 is medically significant, i.e., defined as an event that jeopardizes the patient or may require 
medical or surgical intervention to prevent one of the outcomes listed above 
 
3.4.5 
Reporting of Adverse Events 
The DFCI Institutional Review Board (IRB) requires the following events to be reported:  
 


 
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 
Grade 2 (moderate) and Grade 3 (serious) Events -- Only events that are 
Unexpected and Possibly, Probably or Definitely Related/Associated with the 
Intervention. 
 
ALL Grade 4 (life-threatening) events.  
 
ALL Grade 5 (Fatal) Events -- When subject is enrolled and actively 
participating in the trial or when event occurs within 30 days of the last study 
intervention. 
Full written SAE report must be submitted to the Office for Human Research Studies (OHRS) 
as soon as possible, but no later than 10 working days from notification of event.  DF/HCC 
institutions should electronically submit SAE reports via DFCI SAE reporting forms directly 
to the OHRS.  For participating institutions outside the DF/HCC, the overall principal 
investigator must be notified electronically of any events meeting the above requirements, 
even if they are not required to be reported by their local IRB.  All events should also be 
reported to the local IRB as per their respective requirements.       
 
 
If subject is in Long-Term Follow Up, death is reported at continuing review. 
 
3.4.6 
Instructions for rapid notification of serious adverse events 
 
The overall principal investigator has the obligation to report all serious adverse events to the 
FDA, DFCI IRB, and Novartis Pharmaceuticals Clinical Safety and Epidemiology 
Department (CS&E). 
 
All events reported to the FDA by the investigator are to be filed utilizing the Form FDA 
3500A (MedWatch Form).   This form can be downloaded at: 
 http://www.fda.gov/medwatch/REPORT/Mfg.htm[fordrugs/biologics] 
 
All events must be reported electronically to the overall principal investigator within 24 hours 
of learning of its occurrence.  The overall principal investigator will notify Novartis 
Pharmaceuticals CS&E Department by FAX (888-299-4565) also within 24 hours of learning 
of its occurrence. This includes serious, related, labeled (expected) and serious, related, 
unlabeled (unexpected) adverse experiences.  All deaths during treatment or within 30 days 
following completion of active protocol therapy must be reported within 5 working days. 
 
Any serious adverse event occurring after the patient has provided informed consent and until 
4 weeks after the patient has stopped study participation must be reported. This includes the 
period in which the study protocol interferes with the standard medical treatment given to a 
patient (e.g. treatment withdrawal during washout period, change in treatment to a fixed dose 
of concomitant medication). 
 
Serious adverse events occurring more than 4 weeks after study discontinuation need only be 
reported if a relationship to the Novartis study drug (or therapy) is suspected.  
 


 
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For Comparator Drugs/Secondary Suspects (Concomitant Medications), all serious adverse 
experiences will be forwarded to the product manufacturer by the investigator. 
3.4.6.1 
Pregnancies 
Any pregnancy that occurs during study participation should be reported. To ensure patient 
safety each pregnancy must also be reported to Novartis within 24 hours of learning of its 
occurrence. The pregnancy should be followed up to determine outcome, including 
spontaneous or voluntary termination, details of birth, and the presence or absence of any birth 
defects, congenital abnormalities or maternal and newborn complications. 
3.4.6.2 
Laboratory evaluations 
Hematology 
Hematology must include hemoglobin, hematocrit, platelets, total white blood cell count 
(WBC) and differential. PT (INR) evaluation will be included for baseline evaluations. 
Blood chemistry 
Blood chemistry must include sodium, potassium, chloride, bicarbonate, calcium, glucose, 
creatinine, blood urea nitrogen, albumin, total protein, SGOT (AST), SGPT (ALT), total 
bilirubin, alkaline phosphatase, uric acid, phosphorus, magnesium, LDH, fasting serum 
triglycerides, and fasting total cholesterol, hepatitis B screening (HepB surface Ab, HepB 
surface antigen, HepB Core Ab). 
Because accurate serum glucose and lipid measurements are required, patients should be 
fasting at least 6 hours at the time of the blood sampling. 
ALL PATIENTS IN ACTIVE TREATMENT WHO ALREADY ENROLLED AND 
PATIENTS BEING SCREENED FOR THIS STUDY WILL BE TESTED FOR HEPATITIS 
B INFECTION. 
Urinalysis 
Standard urinalysis assessment (pH, protein, glucose, blood, ketones, and leukocytes) should 
be performed. This must be supplemented with laboratory quantification of any potentially 
relevant abnormalities.   
3.4.6.3 
Vital signs 
Vital sign assessment consists of height (first visit), pulse, blood pressure, respiration rate, 
temperature and weight. Blood pressure, pulse and respiration rate should be measured on 
patients after at least 3 minutes in the sitting position 
3.4.6.4 
Physical examination 
Physical examination will be performed which must comprise a total body examination 
(general appearance, skin, neck, including thyroid, eyes, ears, nose, throat, lungs, heart, 
abdomen, back, lymph nodes, extremities and basic nervous system). 


 
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Significant findings made after the start of study drug which meet the definition of an Adverse 
Event must be recorded. 
3.4.6.5 
ECG 
A standard 12 lead ECG is to be performed during screening and significant findings must be 
recorded. 
3.4.6.6 
Performance status 
Performance status will be assessed using the ECOG scale. 
3.4.7 
Drug levels and pharmacokinetic assessments 
None will be made 
 
4 
Protocol amendments, or changes in study conduct 
Any change or addition (excluding administrative) to this protocol requires a written protocol 
amendment that must be reviewed by Novartis and the investigator before implementation. 
Amendments significantly affecting the safety of subjects, the scope of the investigation or the 
scientific quality of the study require additional approval by the IRB at each study center.  A 
copy of the written approval of the IRB must be provided to Novartis. Examples of 
amendments requiring such approval are: 
1. increases in drug dose or duration of exposure of subjects, 
2. significant changes in the study design (e.g. addition or deletion of a control group), 
3. increases in the number of invasive procedures, 
4. addition or deletions of a test procedure required for monitoring of safety. 
These requirements for approval should in no way prevent any immediate action from being 
taken by the investigator or by Novartis in the interests of preserving the safety of all patients 
included in the trial.  If an immediate change to the protocol is felt to be necessary by the 
investigator and is implemented for safety reasons Novartis must be notified and the IRB at 
the center must be informed immediately.   Amendments affecting only administrative aspects 
of the study do not require formal protocol amendments or IRB approval but the IRB must be 
kept informed of such administrative changes. Examples of administrative changes not 
requiring formal protocol amendments and IRB approval include: 
1. 
changes in the staff used to monitor trials  
2. 
minor changes in the packaging or labeling of study drug. 
 


 
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5 
Registration Procedures 
5.1 
General Guidelines for DF/HCC Institutions 
Institutions will register eligible participants with the DF/HCC Quality Assurance Office 
for Clinical Trials (QACT) central registration system. Registration must occur prior to the 
initiation of therapy. Any participant not registered to the protocol before treatment begins 
will be considered ineligible and registration will be denied.  
A member of the study team will confirm eligibility criteria and complete the protocol-
specific eligibility checklist. 
 
Following registration, participants may begin protocol treatment. Issues that would cause 
treatment delays should be discussed with the Principal Investigator. If a participant does not 
receive protocol therapy following registration, the participant’s protocol status must be 
changed. Notify the QACT Registrar of participant status changes as soon as possible. 
5.2 
Registration Process for DF/HCC Institutions 
The QACT registration staff is accessible on Monday through Friday, from 8:00 AM to 5:00 
PM Eastern Standard Time. If a participant must be registered during off-hours or 
holidays, call the QACT registration line at 617-632-3761 and follow the instructions for 
registering participants after hours.   
The registration procedures are as follows: 
1. Obtain written informed consent from the participant prior to the performance of any 
study related procedures or assessments. 
2. Complete the protocol-specific eligibility checklist using the eligibility assessment 
documented in the participant’s medical/research record. To be eligible for 
registration to the study, the participant must meet each inclusion and 
exclusion criteria listed on the eligibility checklist.  
 
Reminder: Confirm eligibility for ancillary studies at the same time as eligibility for 
the treatment study. Registration to both treatment and ancillary studies will not be 
completed if eligibility requirements are not met for all studies.  
3. Fax the eligibility checklist(s) and all pages of the consent form(s) to the QACT at 
617-632-2295.  
 
exception: DF/PCC Affiliate sites must fax the entire signed consent form including 
HIPAA Privacy Authorization and the eligibility checklist to the Network Affiliate 
Office. The Network Affiliate Office will register the participant with the QACT.  


 
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4. The QACT Registrar will (a) validate eligibility, (b) register the participant on the 
study, and (c) randomize the participant when applicable.  
5. The QACT Registrar will send an email confirmation of the registration and/or 
randomization to the person initiating the registration immediately following the 
registration and/or randomization.  
 
5.3 
General Guidelines for other Participating Institutions 
 
Eligible participants will be entered on study centrally at the BIDMC by the Study 
Coordinator (Bryan Marion). All sites should call the Study Coordinator at [617-632-9271] 
to verify treatment availability. The required eligibility checklist can be found in 
Appendix D. 
Following registration, participants should begin protocol treatment within 72 hours or 
as soon as possible. Issues that would cause treatment delays should be discussed with the 
Principal Investigator. If a participant does not receive protocol therapy following 
registration, the participant’s protocol status must be changed. The Study Coordinator should 
be notified of participant status changes as soon as possible. 
 
Except in very unusual circumstances, each participating institution will order the study 
agent(s) directly from the supplier. A participating site may order the agent(s) only after 
the initial IRB approval for the site has been forwarded by the Coordinating Center to the 
supplier. 
Any other questions regarding the protocol can be addressed to the overall Principal 
Investigator:  David F. McDermott, MD (617-632-9250; dmcdermo@bidmc.harvard.edu). 
 
5.4 
Registration Process for Other Participating Institutions 
To register a participant, the following documents should be completed by the research 
nurse or data manager and faxed to (617-632-9260) or emailed to the Study 
Coordinator at (bmarion@bidmc.harvard.edu): 
 Copy of required laboratory tests 
 Signed study consent form 
 HIPAA authorization form 
 Other appropriate forms (e.g., Eligibility Screening Worksheet, Registration 
form) 
 
The research nurse or data manager at the participating site will then call (617-632-9271) 
or email the Study Coordinator at (bmarion@bidmc.harvard.edu) to verify eligibility. To 
complete the registration process, the Coordinator will: 
 Register the participant on the study with QACT 
 Fax or e-mail the participant study number, and if applicable the dose treatment 
level, to the participating site 


 
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 Call the research nurse or data manager at the participating site and verbally 
confirm registration 
6 
Correlative Studies 
 
Correlative studies appended to this clinical protocol include those proposed in tissue 
specimens and blood collected serially during treatment.   
 
 
6.1 
Studies proposed in tissue 
 
All patients who have not had prior biopsy of a metastatic lesion or metastectomy will 
undergo either a core needle biopsy or metastectomy of an accessible metastatic lesion prior to 
beginning everolimus.  A subset of patients will be asked to undergo an on-treatment biopsy 
of the same metastatic lesion between days 7-14 on-study medication.  This second biopsy 
will not be a requirement for participation in the protocol. These on-treatment biopsies will 
handled and analyzed identically to the pre-treatment biopsies (on-protocol) and will provide 
an opportunity to assess biologic target inhibition (i.e. suppression of S6 phosphorylation) and 
pharmacodynamic effects (i.e. changes in eIF4E phosphorylation and Cyclin D1 levels) of 
drug treatment.  We anticipate 6-10 patients will agree to undergo an on-treatment biopsy.  At 
teach time point, four core-needle biopsies will be taken of the same metastatic lesion.  One 
will be immediately placed in formalin, one will be promptly frozen in liquid nitrogen, and 
two will be placed in OCT and frozen.  Samples frozen in liquid nitrogen will ultimately be 
shattered and the powder dissolved equally into protein lysis buffer and trizol for RNA 
isolation (followed by RNAeasy cleanup, Qiagen).  Samples stored in OCT will be ultimately 
analyzed via microarray analysis.  If for some reason only one core biopsy can be obtained, 
preference will be given to formalin fixation for immunohistochemical studies. In cases of 
metastectomy, the specimen will be divided into thirds.  One piece will be placed in formalin 
and processed as decribed below.  Another piece will be stored in OCT and the final piece will 
be frozen separately in liquid nitrogen and stored at -80ºC.   
 
For patients who have undergone clinically indicated biopsy or surgical resection of metastatic 
lesions prior to enrollment, these specimens must meet the following criteria for these patients 
to be eligible: A) All biopsies must be core needle biopsies; specimens obtained by fine needle 
aspiration are unacceptable. B) At least one portion of the specimen must be preserved in 
paraffin.  C) At least one portion must be flash frozen in liquid nitrogen. 
 
Formalin fixed (or paraffin embedded) specimen should be shipped by overnight courier at 
room temperature to the DF/HCC RCC SPORE Pathology Core using the shipping form in 
Appendix A.  Frozen specimens should be shipped on dry ice also the DF/HCC SPORE 
Pathology CORE using the form in Appendix A.  Frozen specimens can also be stored at -
80ºC and batch shipped.     
 
For patients who have undergone nephrectomy, the enrolling site will be asked  to obtain and 
submit the tumor block or at least 10 unstained paraffin-embedded slides of the primary 


 
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tumor. These are not required for enrollment on the study and can be submitted at any point 
during study enrollment using the form in Appendix A. 
   
6.1.1 
Phospho-Akt and Phospho-S6 Expression 
5m thick sections will be prepared from formalin-fixed tumor specimens and stained with 
hematoxylin and eosin.  Sections will then be dewaxed, soaked in alcohol, and after 
microwave treatment in antigen unmasking solution for 10 minutes and then incubated in 3% 
hydrogen peroxide for 15 minutes to inactivate endogenous peroxidase.  Sections will next be 
incubated with the appropriate either the Phospho-Akt (Ser473) or Phospho-S6 
Ribosomal Protein (Ser235/236) antibodies from Cell Signaling Technology, Beverly, MA.  
Following this, detection of expression will be performed using DAKO EnVision™+ System 
horseradish peroxidase detection kit (Dako, Carpinteria).  Semi-quantitative assessment of 
antibody staining will be performed by a single pathologist blinded to the clinicopathologic 
variables.  Expression of phospho-S6 will be scored based on a composite of staining intensity 
(graded 0=1+, 1=2+, 2=2-3+, and 3=3+) and percentage of tumor cells staining positive (1=1-
29%, 2=30-69%, 3=70-100%).  Patients will then be classified as low (product of intensity 
and staining percentage score = 0-1), intermediate (2-3), and high (4-9) expressors of pS6.  
Phospho-Akt expression will be similarly scored based on a composite of intensity (graded 
0=1+, 1=1-2+, and 2= 2+ or 2-3+) and percentage of tumor cells positive (1=1-29%, 2=30-
69%, 3=70-100%).  Patients will then be classified as low (product of intensity and staining 
percentage score = 0), intermediate (1-2), and high (3-6) expressors of pAkt.  The expression 
of the markers will then be correlated with response to everolimus as determined by PFS.  
Detection of phospho-Akt and phospho-S6 by IHC will be verified by western blot from 
protein lysates.  Western blots will be performed once at the end of the study when all the 
biopsy specimens have been obtained and immunohistochemistry has been performed.  IHC 
studies will be performed with the guidance of the Pathology core of the DF/HCC RCC 
SPORE.  The same stains will also be performed in nephrectomy specimens collected.  The 
expression of the substrates in the metastatic and primary tumors will be compared.   
 
6.1.2 
Analysis of other biomarkers 
 
Slides will be prepared as above from formalin fixed samples.  PML expression will be 
analyzed by IHC using a commercially available antibody for PML (PGM3, Santa Cruz).  For 
the purpose of the correlative studies outlined below, PML expression/distribution will be 
categorized as absent, normal (particulate distribution), or increased (diffuse distribution).  
Phospho-TSC2 (Ser664) expression will be assayed both by IHC using an antibody provided by 
Dr. Piers Pandolfi.  For the purpose of correlative studies, phospho-TSC2 distribution will be 
categorized as low or high on IHC based on a composite of staining intensity and percentage 
of tumor cells positive for stain.  Phospho-PRAS40, eIF4E, and Cyclin D1 expression will be 
analyzed by IHC using commercially available antibodies (Cell Signaling, Beverly, MA).  
Expression will be scored as high or low based on a composite of staining intensity and 
percentage of tumor cells positive.  Localization of FOXO transcription factors will be 
assessed by IHC using a commercially available antibody (Cell Signaling).  FOXO will be 
classified as predominantly nuclear or cytoplasmic.  Expression of PML, phospho-TSC, 


 
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eIF4E, Cyclin D1, and phospho-PRAS will be verified by western blot from protein lystates.  
Expression of these biomarkers thus classified will then be correlated to response to 
everolimus.   
 
6.1.3 
Gene and micro-RNA expression studies 
 
Variations in gene expression patterns may provide insights into mechanisms of 
response/resistance to mTOR inhibitors.  For this reason, depending upon the availability of 
funding, transcriptional profiling using cDNA microarrays from RNA isolated from frozen 
specimens will be performed.  While these cDNA microarrays may provide part of the picture, 
it is becoming increasingly clear that post-transcriptional regulation by micro-RNA may play 
an important role in the ultimate expression of gene products at the translational level.  For 
this reason, also depending upon funding, micro-RNA expression profiling will be performed 
using RNA isolated from frozen specimens.        
 
In cases of on-study biopsy, three core biopses will be flash-frozen in liquid nitrogen and 
stored at -80ºC.  Samples will be de-identified of any patient data and will be listed by sample 
number only.  The code document linking the sample number to each individual patient will 
be stored in a locked cabinet in the principal investigator’s office.  Two of the three core 
needle frozen biopsies (or one-third of the metastectomy specimen) will be shipped in an 
insulated container on dry ice via commercial overnight delivery to:  
 
Ranjit Goudar, MD 
Nevins Laboratory 
CIEMAS Building, Room 2133 
101 Science Drive 
Durham, NC 27708 
919-684-8712 
 
 
Total RNA will be isolated from frozen tumors using Qiagen Rneasy Mini  Kit according to 
manufacturer’s recommendations (Qiagen, Valencia, CA) using approximately 1-2mg of wet 
tissue from each sample.  Total RNA will then be utilized for both cDNA microarrays as well 
as microRNA arrays.  50ng of total RNA from the qRT-PCR experiments above will be 
amplified.  There will be two rounds of amplification and Biotin-labeled aRNA is generated at 
the second in vitro transcription step.  15g of biotin-labeled aRNA is combined with the 
hybridization mix and loaded on to the Affymetrix Human Genome U133A GeneChip 
(Affymetrix, Santa Clara, CA).  After hybridization, the GeneChip will be washed, stained 
with Stepavidin/phycoerythrin conjugate and biotinylated antibody, and scanned according to 
the manufacturer’s recommendations.  Total RNA will also be sent to Exiqon Inc (Woburn, 
MA) for micro-RNA array analysis using the miRCURY™ LNA Array.   
 


 
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6.2 
Studies to performed on blood 
 
Blood samples will be collected pre-study (or cycle 1 day 1) and day 1 of every other cycle 
starting with C2 (i.e. C2D1, C4D1, etc).  One 7ml CPT tubes should be collected at each time 
point and submitted by overnight courier as instructed in Appendix B (include shipping form).  
The peripheral blood will be used in correlative studies investigating the angiogenic effects of 
treatment as well as surrogates of targeted pathway activation.   
 
6.2.1 
Angiogenesis 
RCC is known to be a highly vascular tumor type.  While mTOR inhibitors are believed to 
target the process of angiogenesis, the degree to which this effect may correlate with or 
contribute to tumor responses is unknown.  Therefore, studies investigating markers of 
angiogenesis in the blood before and during therapy are proposed. 
 
Plasma levels of circulating pro-angiogenic cytokines, VEGF, bFGF, TGF-, and TGF- will 
be measured in all patients at the selected time points.  These cytokines are chosen because 
they are prominent pro-angiogenic molecules that are secreted by renal cancer cells.   
 
In addition to more standard ELISA assays, circulating cytokines will be investigated using 
xMAP technology from Luminex Corporation (Austin, TX) in the Angiogenesis Monitoring 
Core Lab of the DF/HCC Renal Spore.  This is a novel bioassay system in which 
microspheres are made with internal dyes (red/infrared) and coated with a reagent specific to a 
certain bioassay (i.e. for circulating VEGF).  The internal dye mix is specific for the particular 
assay of interest and allows its identification based on its laser excitation pattern.  The reporter 
dye from the microsphere coating then allows for the detection and quantification of the 
protein of interest.  The Luminex technology allows for the rapid analysis of very small 
quantities of serum for simulataneous measurement of up to 100 different proteins of interest 
with sensitivity comparable to standard ELISA.  The access to such technology will allow the 
rapid exploration of more novel angiogenic cytokines such as SDF-1 and Angiopoietin-like 4 
in the context of these antiangiogenic therapies. 
 
6.2.2 
HIF activity 
 
Hypoxia-driven increase in HIF activity may be a mechanism of resistance to VEGF-targeted 
therapies.  As the extent to which increased HIF activity is present and effected by the 
everolimus is unknown, potential surrogates of HIF activity will be measured from serum at 
the selected time points.  Levels of serum erythropoietin and carbonic anhydrase IX will be 
measured and correlated with response to everolimus.   
 
 
 
6.2.3 
Peripheral blood cell signature 
 


 
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RNA will be isolated from PBMCs isolated from CPT tubes drawn pre-study.  PBMCs will be 
isolated as described in Appendix D, frozen viably in freezing media (95% Fetal Calf Serum, 
5% DMSO), and stored at -80°C or in liquid nitrogen.  RNA will be isolated from PBMCs 
using Trizol® reagent.  Briefly, frozen PBMCs will thawed, pelleted, washed once in PBS and 
pelleted again.  Cells will be lysed in 1ml of Trizol®  and incubated at room temperature for 5 
minutes.  200µl of chloroform will be added to each sample, which will then be shaken 
vigorously for 10-15 seconds, incubated at room temperature for 5 minutes, and centrifuged at 
no more than 12,000 G for 15 minutes at 2 to 8°C.  Following centrifugation, the mixture will 
separate into a lower red, phenol-chloroform phase, an interphase, and a colorless upper 
aqueous phase.  RNA remains exclusively in the aqueous phase.  The aqueous (clear) phase 
will be transferred to a separate tube and RNA precipitated by the addition of 0.5ml of 
isopropyl alcohol.  After addition of isopropyl alcohol, samples will be incubated at room 
temperature for 10 minutes, then centrifuged at no more than 12,000 G for 15 minutes at 2 to 
8°C.  The resulting pellets will be washed once with 70% ethanol, air-dried, dissolved in 
RNase-free water, and stored at -80°C.  At the conclusion of the study, RNA thus isolated 
should be batch shipped to for analysis: 
 
Ranjit Goudar, MD 
Nevins Laboratory 
CIEMAS Building, Room 2133 
101 Science Drive 
Durham, NC 27708 
919-684-8712 
 
50ng of total RNA will be utilized for microarray expression analysis.  The RNA is amplified 
twice, and biotin-labeled aRNA is generated at the second in vitro transcription step.  15g of 
biotin-labeled aRNA is combined with the hybridization mix and loaded on to the Affymetrix 
Human Genome U133 Plus 2.0 GeneChip (Affymetrix, Santa Clara, CA).  After 
hybridization, the GeneChip will be washed, stained with streptavidin/phycoerythrin 
conjugate and biotinylated antibody, and scanned according to the manufacturer’s 
recommendations. Expression data will be analyzed using published protocols (49, 50). 
 
 
7 
Data and safety management  
 
7.1 
Data collection 
 
Investigators or their designee must enter the information required by the protocol onto 
electronic Case Report Forms (eCRFs).  The QACT will collect, manage, and monitor for this 
study. 
  
7.2 
Data and safety management 
 


 
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Please see the full DF/HCC Multi-Center Data and Safety Monitoring Plan in Appendix C.  
This Phase II trial will be managed through the DF/HCC review and monitoring systems and 
therefore are subject to the Institutional Data and Safety Monitoring Plan (DSMP) that has 
been approved by NCI. This plan outlines the extensive Scientific Review Process, 
Institutional Review Board’s (IRB) review and monitoring of Adverse Events, and Internal 
Auditing.  A Data and Safety Monitoring Committee (DSMC) reviews patient safety data for 
high risk Phase II trials.  The risk level is determined with the help of the disease programs 
and the committee.  The DSMC has representatives from different modalities, disease 
programs and institutions.  The DSMB meetings occur semi-annually and the DSMC meetings 
occur quarterly for high-risk protocols. The committees will notify the Principal Investigator 
of safety issues that need to be addressed.  In the case of any unexpected safety problems, the 
PI and/or the DSMB or DSMC have the option to call an unscheduled meeting.  A summary 
of the DSMB and DSMC meetings is shared with the Clinical Investigations Policy and 
Oversight Committee (CLINPOC) and the IRB.  Details of the review are maintained in the 
Quality Assurance Office for Clinical Trials’ files.  
 
8 
Statistical methods 
 
This is a single-arm phase II study. Forty patients will be enrolled; expected enrollment is 2-3 
patients per month over 13-20 months. Patients will be followed for up to two years. 
 
The biomarkers of primary interest are pAkt and pS6. Expression of phospho-S6 and 
phospho-Akt will be classified as low, intermediate, or high based on a composite score of 
staining intensity and percentage of tumor cells staining positive as previously described for 
temsirolimus [35]. Based on prior analysis for temsirolimus we assume that approximately 
50% of patients will have tumors with high pS6 expression and/or high pAkt and therefore be 
classified in the favorable group. We assume 4 months median progression-free survival 
(PFS) in this cohort of patients.  The primary endpoint will be considered met if the median 
PFS of favorable versus unfavorable group is ≥ 4 months. 
  
 
When 26 events have been observed, a hazard ratio of 3.0 (2m vs. 6m median PFS) for 
biomarker low/intermediate (unfavorable) vs. high (favorable) groups would be detectable 
with 80% power (two-sided α=0.05) [George and Desu, 1974].  
 
Kaplan-Meier estimates of PFS distribution according to biomarker groups will be calculated, 
and Cox modeling used to estimate HRs and compare PFS between biomarker groups.  PML, 
pTSC2, pPRAS40, and FOXO localization will be analyzed similarly, though the expected 
proportions of absent/normal/increased PML or low/high pTSC2 are uncertain a priori. 
 
The tumor biopsy expression data will be analyzed to create a genomic predictor of 
everolimus response.  The genes whose level of expression are statistically significantly 
different between everolimus responders and nonresponders will be used to generate a 
metagene summary model.48  Leave-one-out cross-validation will be performed to strengthen 


 
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the metagene model.  Binary classification tree analysis will be used to predict a probability 
that a given subject will respond to everolimus.50  This signature can then be validated in an 
external data set. 
 
 


 
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9 
References 
1. 
Jemal A, Siegel R, Ward E, et al.  Cancer Statistics, 2008.  CA Cancer J Clin. 
58(2):71-96, 2008.    
2. 
Janzen NK, Kim HL, Figlin RA, Belldegrun AS: Surveillance after radical or partial 
nephrectomy for localized renal cell carcinoma and management of recurrent disease.  
Urol Clin North Am.  30: 843, 2003. 
3. 
Fyfe GA, Fisher RI, Rosenberg SA, Sznol M, Parkinson DR, Louie AC: Long-term 
response data for 255 patients with metastatic renal cell carcinoma treated with high-
dose recombinant interleukin-2 therapy.  J Clin Oncol. 14(8): 2410-1, 1996. 
4. 
Rosenberg S, Yang J, Top, Alian S, et al: Treatment of 283 patients with metastatic 
melanoma or renal cell cancer using high-dose bolus interleukin-2.  JAMA 271:907-
913, 1994. 
5. 
Yang JC, Sherry RM, Steinberg SM, et al:  Randomized Study of High-Dose and 
Low-Dose Interleukin-2 in Patients with Metastatic Renal Cancer.  J Clin Oncol.  
21:3127-3132, 2003. 
6. 
Pyrhonen S, Salminen E, Ruutu M, et al: Prospective randomized trial of interferon 
alfa-2a plus vinblastine versus vinblastine alone in patients with advanced renal cell 
cancer.  J Clin Oncol. 17(9): 2859-67, 1999. 
7. 
Medical Research Council and Collaborators: Interferon-alpha and survival in 
metastatic renal carcinoma: early results of a randomised controlled trial.  Lancet. 
353(9146):14-7, 1999. 
8. 
Kovacs G, Akhtar M, Beckwith BJ, et al: The Heidelberg classification of renal cell 
tumours. J Pathol 183:131-133, 1997. 
9. 
Reuter VE, Presti JC Jr.: Contemporary approach to the classification of renal 
epithelial tumors. Semin Oncol 27:124-137, 2000. 
10. Kenck C, Wilhelm M, Bugert P, Staehler G, Kovacs G: Mutation of the VHL gene is 
associated exclusively with the development of non-papillary renal cell carcinomas.  
J Pathol. 179(2):157-61, 1996. 
11. Foster K, Prowse A, van den Berg A, et al: Somatic mutations of the von Hippel-
Lindau disease tumour suppressor gene in non-familial clear cell renal carcinoma.  
Hum Mol Genet.  3(12): 2169-73, 1994. 
12. Jaakkola P, Mole DR, Tian YM, et al: Targeting of HIF-alpha to the von Hippel-
Lindau ubiquitylation complex by O2-regulated prolyl hydroxylation.  Science. 
292(5516): 468-72, 2001. 
13. Iliopoulos O, Kibel A, Gray S, Kaelin WG Jr.  Tumour suppression by the human 
von Hippel-Lindau gene product.  Nat Med.  1(8):822-6, 1995. 
14. de Paulsen N, Brychzy A, Fournier MC, Klausner RD, Gnarra JR, Pause A, Lee S: 
Role of transforming growth factor-alpha in von Hippel--Lindau (VHL)(-/-) clear cell 
renal carcinoma cell proliferation: a possible mechanism coupling VHL tumor 
suppressor inactivation and tumorigenesis.  Proc Natl Acad Sci U S A. 98(4): 1387-
92, 2000. 
15. Kondo K, Kico J, Nakamura E, Lechpammer M, Kaelin, W.  Inhibition of HIF is 
necessary for tumor suppression by the von Hippel-Lindau protein.  Cancer Cell.  1: 
237-46, 2002. 
16. Ferrara N. Molecular and biological properties of vascular endothelial growth factor. 
J Mol Med.  77:527-543, 1999. 


 
Confidential 
Page 53 
Clinical study protocol 
 
October 3, 2014 
 
17. Bergers G, Song S, Meyer-Morse N, Bergsland E, Hanahan D: Benefits of targeting 
both pericytes and endothelial cells in the tumor vasculature with kinase inhibitors. J 
Clin Invest. 111(9):1287-95, 2003. 
18. Smith K, Gunaratnam L, Morley M, Franovic A, Mekhail K, Lee S.  Silencing of 
epidermal growth factor receptor suppresses hypoxia-inducible factor-2-driven VHL-
/- renal cancer.  Cancer Res 2005. 65(12): 5221-30. 
19. Lyons JF, Wilhelm S, Hibner B, Bollag G.  Discovery of a novel Raf kinase 
inhibitor.  Endocr Relat Cancer 2001; 8(3): 219-25. 
20. Wilhelm SM, Carter C, Tang L, et al.  BAY 43-9006 exhibits broad spectrum oral 
antitumor activity and targets the RAF/MEK/ERK pathway and receptor tyrosine 
kinases involved in tumor progression and angiogenesis.  Cancer Res 2004; 
64(19):7099-109. 
21. Escudier B, Eisen T, Stadler WM, et al.  Sorafenib in advanced clear cell renal cell 
carcinoma.  N Engl J Med 2007; 356(2):125-34.       
22. Mendel DB, Laird AD, Xin X, et al.  In vivo antitumor activity of SU11248, a novel 
tyrosine kinase inhibitor targeting vascular endothelial growth factor and platelet-
derived growth factor receptors: determination of a 
pharmacokinetic/pharmacodynamic relationship.  Clin Cancer Res 2003; 9(1):327-
37. 
23. Motzer RJ, Michaelson MD, Redman BG, et al.  Activity of SU11248, a 
multitargeted inhibitor of vascular endothelial growth factor receptor and platelet-
derived growth factor receptor, in patients with metastatic renal cell carcinoma.  J 
Clin Oncol 2006; 24(1): 16-24. 
24. Motzer RJ, Rini BI, Bukowski RM, et al.  Sunitinib in patients with metastatic renal 
cell carcinoma. 
JAMA. 2006; 295(21): 2516-24. 
25. Motzer RJ, Hudson TE, Tomczak P, et al.  Sunitinib versus interferon alfa in 
metastatic renal-cell carcinoma.  N Engl J Med. 2007; 356(2): 115-24. 
26. Cohen SJ, Cohen RB, Meropol N (2005) Targeting signal transduction pathways in 
colorectal cancer – more than skin deep.  J Clin Oncol; 23, 5374-5385. 
27. Bjornsti MA, Houghton PJ. (2004)  The TOR pathway: a target for cancer therapy.  
Nat Rev Cancer;  4, 335-48. 
28. Velho S, Oliveira C, Ferreira A, et al. (2005)  The prevalence of PIK3CA mutations 
in gastric and colon cancer.  Eur J Cancer; 41, 1649-54. 
29. Frattini M, Signoroni S, Pilotti S, et al. (2005) Letter to the Editor:  Phosphatase 
protein homologue to tensin expression and phosphatidylinositol-3 phosphase kinase 
mutations in colorectal cancer.  Cancer Res; 65, 11227. 
30. Goel A, Arnold CN, Niedzwiecki D, et al. (2004)  Frequent inactivation of PTEN by 
promoter hypermethylation in microsatellite instability-high sporadic colorectal 
cancers.  Cancer Res; 64, 3014-3021. 
31. Jac J, Giessinger S, Khan M, Willis J, Chiang S, Amato R.  A phase II trial of 
RAD001 in patients (Pts) with metastatic renal cell carcinoma (MRCC).  J Clin 
Oncol 2007 ASCO Annual Meeting Proceedings Part I; 25(18S): 5107. 
32. Motzer RJ, Escudier B, Oudard S, et al.  RAD001 vs placebo in patients with 
metastatic renal cell carcinoma (RCC) after progression on VEGFr-TKI therapy: 


 
Confidential 
Page 54 
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October 3, 2014 
 
Results from a randomized, double-blind, multicenter Phase-III study.  J Clin Oncol 
2008; 26(May 20 suppl): abstr LBA5026. 
33. Solit DB, Garraway LA, Pratilas CA, Sawai A, Getz G, Basso A, Ye Q, Lobo JM, 
She Y, Osman I, Golub TR, Seblot-Leopold J, Sellers WR, Rosen N. BRAF mutation 
predicts sensitivity to MEK inhibition. Nature 2006; 439: 358. 
34. Atkins MB, Hidalgo M, Stadler WM, Logan TF, Dutcher JP, Hudes GR, Park Y, 
Liou SH, Marshall B, Boni JP, Dukart G, Sherman ML.  Randomized phase II study 
of multiple dose levels of CCI-779, a novel mammalian target of rapamycin kinase 
inhibitor, in patients with advanced refractory renal cell carcinoma.  J Clin Oncol 
2004; 22(5):909-18. 
35. Cho D, Signoretti S, Dabora S, Regan M, Seeley A, Mariotti M, Youmans A, Polivy 
A, Mandato L, McDermott D, Stanbridge E, Atkins M.  Potential histologic and 
molecular predictors of response to temsirolimus in patients with advanced renal cell 
carcinoma.  Clin Genitourin Cancer 2007; 5(6):379-85. 
36. Baker AF, Dragovich T, Ihle NT, Williams R, Fenoglio-Preiser, Powis G.  Stability 
of phosphoprotein as a biological marker of tumor signaling.  Clin Cancer Res 2005; 
11(12): 4338-4340. 
37. Nicholson KM, Anderson NG: The protein kinase B / Akt signaling pathway in 
human malignancy.  Cell Signal.  14: 381-95, 2002. 
38. Wang L, Harris TE, Roth RA, Lawrence JC.  PRAS40 regulates mTORC1 kinase 
activity by functioning as a direct inhibitor of substrate binding.  J Biol Chem 2007; 
282(27):20036-44. 
39. Bernardi R, Guernah I, Jin D, Grisendi S, Alimonti A, Teruya-Feldstein J, Gordon-
Cardo C, Simon MC, Rafii S, Pandolfi PP. PML inhibits HIF-1α translation and 
neoangiogenesis through repression of mTOR. Nature 2006; 442: 779. 
40. Trotman LC, Alimonti A, Scaglioni PP, Koutcher JA, Cordon-Cardo C, Pandolfi PP. 
Identification of a tumour suppressor network opposing nuclear Akt function. Nature 
2006; 441: 523. 
41. Piazza F, Gurrieri C, Pandolfi PP. The theory of APL. Oncogene 2001; 20: 7216. 
42. Gurrieri C, Capodieci P, Bernardi R, Scaglioni PP, Nafa K, Rush LJ, Verbel DA, 
Cordon-Cardo C, Pandolfi PP. Loss of tumor suppressor PML in human cancers of 
multiple histologic origins. J Natl Cancer Inst 2004; 96: 269.  
43. Scaglioni PP, Yung TM, Cai LF, Erdjument-Bromage H, Kaufman AJ, Singh B, 
Teruya-Feldstein J, Tempst P, Pandolfi PP. A CK2-dependent mechanism for 
degradation of the PML tumor suppressor. Cell 2006; 126: 269. 
44. Ma L, Teruya-Feldstein J, Bonner P, Bernardi R, Franz DN, Witte D, Cordon-Cardo 
C, Pandolfi P.  Identification of S664 TSC2 phosphorylation as a marker for 
extracellular signal-regulated kinase mediated mTOR activation in tuberous sclerosis 
and human cancer.  Cancer Res 2007; 67(15): 7106-12. 
45. Graff JR, Konicek BW, Carter JH, Marcusson EG.  Targeting the eukaryotic 
translation initiation factor 4E for cancer therapy.  Cancer Res 2008; 68(30): 631-
634. 
46. De Benedetti A, Graff JR.  eIF4E expression and its role in malignancies and 
metastases.  Oncogene 2004; 23: 3189-99. 
47. Hudes G, Carducci M, Tomczak P, Dutcher J, Figlin R, Kapoor A, Staroslawska E, 
Sosman J, McDermott D, Bodrogi I, Kovacevic Z, Lesovoy V, Schmidt-Wolf IG, 


 
Confidential 
Page 55 
Clinical study protocol 
 
October 3, 2014 
 
Barbarash O, Gokmen E, O’Toole T, Lustgarten S, Moore L, Motzer RJ, Global 
ARCC Trial. Temsirolimus, interferon alfa, or both for advanced renal-cell 
carcinoma. N Eng J Med 2007; 356: 2271. 
48. Potti A, Dressman HK, Bild A, et al. Genomic signatures to guide the use of 
chemotherapeutics. Nat Med 2006;12(11):1294-1300. 
49. Bolstad BM, Irizarry RA, Astrand M, Speed TP. A comparison of normalization 
methods for high density oligonucleotide array data based on variance and bias. 
Bioinformatics 2003;19(2):185-193. 
50. Pittman J, Huang E, Nevins J, Wang Q, West M. Bayesian analysis of binary 
prediction tree models for retrospectively sampled outcomes. Biostatistics 2004; 
5(4):587-601. 
51. Twine NC, Stover JA, Marshall B, et al. Disease-associated expression profiles in 
peripheral blood mononuclear cells from patients with advanced renal cell 
carcinoma. Cancer Res 2003; 63(18):6069-6075. 
52. Witzig TE, Geyer SM, Ghobrial I, et al. Phase II trial of single-agent temsirolimus 
(CCI-779) for relapsed mantle cell lymphoma. J Clin Oncol 2005; 23(23):5347-5356. 
 
 
10 
Procedures and instructions 
i. Publication of results 
Any formal presentation or publication of data from this trial may be published after review and 
comment by Novartis and prior to any outside submission.  Novartis must receive copies of any 
intended communication in advance of publication (at least fifteen working days for presentational 
materials and abstracts and thirty working days for manuscripts).   These requirements acknowledge 
Novartis’ responsibility to provide peer input regarding the scientific content and conclusions of such 
publications or presentations.  Principal Investigation/Institution shall have the final authority to 
determine the scope and content of its publications, provided such authority shall be exercised with 
reasonable regard for the interests of Novartis and, in accord with the trial contract and shall not permit 
disclosure of Novartis confidential or proprietary information. 
ii. Disclosure and confidentiality 
The investigator agrees to keep all information provided by Novartis in strict confidence and to request 
similar confidentiality from his/her staff and the IRB/IEC/REB. Study documents provided by Novartis 
(investigators' brochures and other material) will be stored appropriately to ensure their confidentiality. 
The information provided by Novartis to the investigator may not be disclosed to others without direct 
written authorization from Novartis, except to the extent necessary to obtain informed consent from 
patients who wish to participate in the trial. 
iii. Discontinuation of study 
Novartis reserves the right to discontinue any study under the conditions specified in the clinical trial 
agreement. 


 
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b. Ethics and Good Clinical Practice 
This study must be carried out in compliance with the protocol and the principles of Good Clinical 
Practice, as described in Novartis standard operating procedures and: 
1. 
ICH Harmonized Tripartite Guidelines for Good Clinical Practice 1996. Directive 91/507/EEC, 
The Rules Governing Medicinal Products in the European Community. 
2. 
US 21 Code of Federal Regulations dealing with clinical studies (including parts 50 and 56 
concerning informed consent and IRB regulations). 
3. 
Declaration of Helsinki and amendments, concerning medical research in humans 
(Recommendations Guiding Physicians in Biomedical Research Involving Human Subjects). 
The investigator agrees to adhere to the instructions and procedures described in it and thereby to 
adhere to the principles of Good Clinical Practice that it conforms to. 
i. Institutional Review Board/Independent Ethics Committee 
Before implementing this study, the protocol, the proposed informed consent form and other 
information to subjects, must be reviewed by a properly constituted Institutional Review 
Board/Independent Ethics Committee/Research Ethics Board (IRB/IEC/REB). A signed and dated 
statement that the protocol and informed consent have been approved by the IRB/IEC/REB must be 
given to Novartis before study initiation. Any amendments to the protocol, other than administrative 
ones, must be reviewed by Novartis approved by this committee. 
ii. Informed consent 
The investigator must explain to each subject (or legally authorized representative) the nature of the 
study, its purpose, the procedures involved, the expected duration, the potential risks and benefits 
involved and any discomfort it may entail. Each subject must be informed that participation in the study 
is voluntary and that he/she may withdraw from the study at any time and that withdrawal of consent 
will not affect his/her subsequent medical treatment or relationship with the treating physician. 
This informed consent should be given by means of a standard written statement, written in non-
technical language. The subject should read and consider the statement before signing and dating it, 
and should be given a copy of the signed document. If the subject cannot read or sign the documents, 
oral presentation may be made or signature given by the subject’s legally appointed representative, if 
witnessed by a person not involved in the study, mentioning that the patient could not read or sign the 
documents. No patient can enter the study before his/her informed consent has been obtained. 
The informed consent form is considered to be part of the protocol, and must be submitted by the 
investigator with it for IRB/IEC/REB approval. 
iii. Declaration of Helsinki 
The investigator must conduct the trial in accordance with the principles of the Declaration of Helsinki. 
Copies of the Declaration of Helsinki and amendments will be provided upon request or can be 
accessed via the website of the World Medical Association at http://www.wma.net/e/policy/17-c_e.html. 
 
 
 
 
 
 


 
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Appendix A 
 
Phase II RAD001 Biomarker Trial RCC 
TISSUE SPECIMEN SHIPMENT FORM 
Instructions: Send overnight Sunday through Thursday to: 
DF/HCC Renal Cancer SPORE Tissue Bank 
c/o Sabina Signoretti, M.D.  Department of Pathology  
Brigham and Women’s Hospital 
Thorn Building 504A 
75 Francis Street 
Boston, MA 02115 
617-525-7438 (Michael Collins) 
PROTOCOL:  
 
 
 
 
 
 
 
Case No.:  00__  __  __ 
 
 
 
 
 
01 - BIDMC  
02 – DFCI 
03 - Duke 
 
 
Subject Initials __  __  __ (F,M,L) 
 
Site #:_______ 
 
 
 
 
 
Contact Name:   
 
 
______________________ 
 
Contact Phone:   
 
 
______________________ 
 
Date of Shipment: 
 
 
______________________ 
 
 
Shipping Conditions: 
 
______________________ 
(indicate dry ice, room temp, etc) 
Sample Sent:   
 
 
______________________ 
( indicate total amount: i.e. one core biospy) 
 
 
 
Surgical Path Report Enclosed: 
YES 
 
NO 
 
Nephrectomy Specimen 
 
YES 
 
NO 
 
Fomalin Fixed Biospy: 
 
YES 
 
NO    
 
 
Frozen Tissue Biopsy: 
 
YES 
 
NO     
 
 
Shipping Notes: 
Please fax form in advance to 617-264-5169 ATTN: Sabina Signoretti, M.D.   
Please include a copy of the form in the shipping container. 
BWH Staff Only:  
Specimen Received by:  
_______________________________ 
Date/Time Received: 
_______________________________ 


 
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Appendix B 
 
Phase II RAD001 Biomarker Trial RCC 
BLOOD SPECIMEN SHIPMENT FORM 
Instructions: Send overnight Sunday through Thursday to: 
DF/HCC Renal SPORE Immune Monitoring Core 
c/o David Panka, PhD 
330 Brookline Avenue; RW 571 
Boston, MA 02215 
617-667-0428 
PROTOCOL:  
 
 
 
 
 
 
 
Case No.:  00__  __  __ 
 
 
 
 
 
01 - BIDMC  
02 – DFCI 
03  - Duke 
 
Subject Initials __  __  __ (F,M,L) 
 
Site #:_______ 
 
 
 
 
 
Contact Name:   
 
______________________ 
 
Contact Phone:   
 
______________________ 
 
Date of Shipment: 
 
______________________ 
 
Shipping Conditions: 
Room Temperature_____ 
 
Sample Sent:  One CPT tube 
 
 
 
 
 
 
YES 
 
NO 
 
 
 
Shipping Notes: 
Please fax form in advance to 617 632-9260, ATTN:   Bryan Marion 
Please include a copy of the form in the shipping container. 
 
For IMC Staff Only: 
Specimen Received By: 
__________________________ 
 
Date/Time Received:  
__________________________ 
 
 


 
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APPENDIX C 
 
Dana-Farber/Harvard Cancer Center 
Multi-Center Data and Safety Monitoring Plan 
 
Protocol #: 08-313 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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Table of Contents 
 
1.0  Introduction ……………………………………………………………............ 62 
1.1  Purpose 
1.2  Data and Safety Monitoring Plan Components 
 
2.0     General Roles and Responsibilities …………………………………………  53 
  
2.1  Protocol Chair 
 
 
 
2.2  Coordinating Center 
 
 
 
2.3  Participating Institution 
 
 
 
3.0     DF/HCC Quality Assurance Office for Clinical Trials ………………..…..  65 
 
 
3.1  Organizational Structure 
 
  
4.0 Protocol Development ………………………………………………..………. 66 
 
 
  4.1   Activation of a Protocol 
 
 
 
 
  4.2   Coordinating Center Support Function 
 
 
 
  4.3 Training of DFCI Institutions and Participating Centers 
 
 
5.0   Protocol Management   …………………………………………………………67 
 
 
5.1 Protocol Distribution 
 
 
 
5.2 Protocol Revisions and Closures 
 
5.3 Informed Consent Requirements  
 
 
5.4 IRB Documentation 
 
 
 
5.5 IRB Re – Approvals 
 
 
 
5.6 Participant Confidentiality and Authorization 
 
 
5.7 Participant Registration 
 
 
 
5.8 DF/HCC Multi-center Protocol Case Number 
 
 
5.9 DF/HCC Multi-center Protocol Registration Policy 
 


 
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5.10 Schedule of Data Submission 
 
 
 
5.11 Data Form Review 
 
 
 
5.12 Missing and Deficient Memorandum 
 
 
6.0 Requisitioning Investigational Drug………………………………………….. 75 
 
6.1 CTEP Trial Routine Drug Requisitions 
 
 
 
     
 7.0   Safety Assessments and Toxicity Monitoring……………………………….. 75 
      
7.1 Serious Adverse Events 
 
 
 
7.2 Guidelines for Reporting Serious Adverse Events 
 
 
7.3 Guidelines for Processing IND Safety Reports 
 
 
 
 
8.0 Protocol Violations and Deviations ………………………………………….   77 
 
  
 
8.1 Definitions   
 
 
 
             8.2 Reporting Procedures 
 
 
 
9.0 Quality Assurance ...…………………………………………………………....  78 
 
        9.1 Ongoing Monitoring of Protocol Compliance 
 
 
            9.2 Evaluation of Participating Institution Performance 
 
 
            9.3 On-Site Auditing 
 
 
 
 
            9.4 Substandard Performance 
 
 
 
 
9.5 Scheduled Conference Calls


 
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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 a DF/HCC Multi-Center research protocol.  
 
1.1       Purpose 
 
To establish standards that will ensure that a Dana-Farber/Harvard Cancer Center 
(DF/HCC) Multi-center protocol will comply with Federal regulations (21 CFR Part 
11); Good Clinical Practice (GCP) Guidelines; and  Health Insurance Portability and 
Accountability Act (HIPAA) requirements in accordance with the CTEP Multi-center 
Guidelines.        
 
1.2      Multi-Center Data and Safety Monitoring Plan Components 
 
The Multi-Center Data and Safety Monitoring Plan includes the following 
components: 
 
DF/HCC Multi-center Protocol:  One or more outside institutions collaborating with 
Dana-Farber/Harvard Cancer Center on a research  protocol where DF/HCC is the 
Lead Institution. 
 
Lead Institution:  The BIDMC will be the Lead Institution and will be responsible for 
the coordination, development, submission, and approval of a protocol as well as its 
subsequent amendments per the DFCI IRB and the FDA.  
 
DF/HCC Contract Principal Investigator:  Dr. David McDermott located at the 
BIDMC will be charged with the responsibility of the administration of the DF/HCC 
Project.  
 
Protocol Chair:  The Protocol Chair is the Principal Investigator (Dr. David 
McDermott).  Dr. McDermott will be the single liaison with any regulatory agencies 
the FDA.  
 
Participating Institution:  A participating institution is an institution that desires to 
collaborate with DF/HCC and commits to accruing participants to a DF/HCC protocol.  
The participating institution acknowledges the Protocol Chair as having the ultimate 
authority and responsibility for the overall conduct of the study.    
 
Coordinating Center: The BIDMC is the Coordinating Center for the DF/HCC 
Multi-center Protocol. The Coordinating Center will provide the administrative 
support to the Protocol Chair in order that he/she may fulfill the responsibilities 
outlined in the DSMP and as specified in applicable regulatory guidelines (ie. CTEP 
Multi-Center Guidelines).  In addition to the Lead Institution, the Quality Assurance 
Office for Clinical Trials (QACT) provides support services to assist the Protocol 


 
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Chair.  
 
 
2.0      GENERAL ROLES AND RESPONSIBILITIES 
 
In accordance with the CTEP Multi-center Guidelines, the Protocol Chair (Dr. David 
McDermott), Coordinating Center (BIDMC), and the Participating Institutions will all agree to 
the general responsibilities as follows (specific procedures for these general responsibilities 
are detailed in the DSMP): 
 
2.1      Protocol Chair (DF/HCC Principal Investigator) 
 
Dr. Cho will accept responsibility for all aspects of the Multi-Center Data and Safety 
Monitoring Plan to: 
1) 
Oversee the coordination, development, submission, and approval of the protocol 
as well as subsequent amendments.    
2) 
Submit the Multi-Center Data and Safety Monitoring Plan as an inclusion to the 
protocol. 
3) 
Assure all participating institutions are using the correct version of the protocol. 
4) 
Monitor progress and overall conduct of the study at all participating institutions.  
5) 
Ensure all DFCI IRB, DF/HCC and FDA reporting requirements are met.  
6) 
Review data and maintain timely submission of data for study analysis.  
7) 
Act as the single liaison with the FDA (sponsor-investigator IND trials). 
8) 
Identify participating institutions and obtain accrual commitments. Dr. Cho will 
also submit a protocol attachment labeled as “Participating Investigators” to the 
DFCI IRB and FDA that provides the names and contact information for all 
participating institutions that perform the function of recruiting, enrolling, and 
treating participants for the protocol.  The Coordinating Center (BIDMC) must 
be designated on the title page. Revisions to the list will be submitted to the 
DFCI IRB and FDA as an administrative protocol amendment to reflect changes 
in staff and assignment of responsibility as they occur. 
 
    2.2   Coordinating Center (BIDMC) 
 
The Coordinating Center is the DF/HCC Lead Institution’s (BIDMC) study team. The 
BIDMC will ensure that all participating sites within the Multi-Center Protocol 
demonstrate their intent and capability of complying with Federal Regulations, GCPs 
and Health Insurance Portability and Accountability Act (HIPAA) requirements.   To 
assist the Protocol Chair in meeting his/her responsibilities as required by the DSMP, 
the BIDMC’s study team or designee will assume the following general 
responsibilities: 
 Assist in protocol review. 
 Maintain copies of Institutional Review Board (IRB) approvals. 
 Maintain FDA correspondence. 
 Maintain updated roster of participants.  


 
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 Verify eligibility. 
 Verify response. 
 Collect data on protocol specific CRFs. 
 Prepare all submitted data for review by the Protocol Chair. 
 Maintain documentation of Serious Adverse Event (SAE) reports 
submitted by Participating Institutions and submit to Protocol Chair for 
timely review.   
 Distribute external Serious Adverse Event safety reports.  
 Monitor and audit Participating Institutions either by on-site inspection 
of selected participant records and/or with submitted source documents 
and research records submitted to the Lead Institution.  
    
In addition to the Lead Institution, the DF/HCC Quality Assurance Office for Clinical 
Trials provides the following support services to assist the Protocol Chair: 
 Develop protocol specific case report forms (CRF/eCRFS). 
 QA/QC data of protocol specific CRFs.  
 Provide Central Participant Registration. 
 Confirm eligibility and consent.  
 Provide auditing services (funding and QACT approval required). 
 
    2.3   Participating Institution 
 
The Participating Institution(s) will be identified on the title page for each protocol.   
In addition, each participating institution will provide to the Lead Institution or 
designee a list of the key personnel assigned to the role for oversight of data 
management at their site. All sites must have office space, office equipment, and 
internet access that meet HIPAA standards. 
The general responsibilities for each participating institution are as follows: 
 
 Commit to accrual to the Lead Institution’s (DF/HCC) protocol. 
 Submit protocol and/or amendments to their local IRB. 
 Update Coordinating Center (Lead Institution or designee) with research staff 
changes on a timely basis. 
 Register participants through the QACT.  
 Submit source documents, research records, and CRFs per protocol specific 
submission guidelines to the Coordinating Center (Lead Institution or designee).  
 Submit Serious Adverse Event reports directly to the Coordinating Center (Lead 
Institution or designee).  
 Submit deviations and violations to the Coordinating Center (Lead Institution or 
designee). 


 
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 For protocols using investigational agents, the participating institution will order 
their own investigational agents regardless of the supplier (i.e. NCI, 
pharmaceutical company). 
 
3.0 DF/HCC QUALITY ASSURANCE OFFICE FOR CLINICAL TRIALS 
 
The DF/HCC QACT is a unit that has been developed to collect, manage, and monitor data for 
DF/HCC trials.  The DF/HCC QACT is located administratively in the office of the Senior 
Vice President for Clinical Research, at Dana-Farber Cancer Institute.  The QACT uses 
DF/HCC computerized institutional databases for participant registrations and for the 
management of trial data as well as a set of quality assurance programs designed to monitor 
DF/HCC trials.   
 
3.1      Organizational Structure 
 
The DF/HCC Quality Assurance Office for Clinical Trials administrative structure 
consists of: 
 
DF/HCC Quality Assurance Officer for Clinical Trials: Oversees the functions of 
the DF/HCC QACT. 
 
QACT Assistant Director for Data: Provides direct oversight to the QACT Data 
Analysts assigned to CRF design, data collection and computerization for DF/HCC 
trials.  
 
The DF/HCC QACT Data Analysts will be assigned on a protocol by protocol basis. 
Each protocol’s data analyst is responsible for database management, data entry, data 
quality assurance, and protocol specific correspondence related to the collection and 
quality assurance of data. 
 
QACT Assistant Director for Monitoring: Provides direct oversight to the QACT 
Protocol Registrars and Clinical Research Auditors. 
 
The DF/HCC Protocol Registrars are responsible for the confirmation of each 
participant’s eligibility and consent prior to protocol registration.  
 
If funded and QACT approved, the DF/HCC Clinical Research Auditors may assist the 
Lead Institution in their auditing responsibilities for multi-center trials. The QACT 
auditor is responsible for systematically evaluating participant safety, protocol 
compliance, institutional SOPs, ICH GCP and Federal regulation compliance, data 
accuracy and investigational drug handling to assure a high standard of quality for 
DF/HCC trials. 
 
 
 


 
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4.0  
PROTOCOL DEVELOPMENT 
 
4.1  
Activation of a Protocol 
 
Dr. Cho is responsible for the coordination, development, and approval of the protocol 
as well as its subsequent amendments, and reporting SAEs, violations and deviations 
per DFCI IRB guidelines and FDA.  Further, Dr. Cho will be the single liaison with 
the FDA. 
 
To meet these requirements, the Protocol Chair will be responsible for the following 
minimum standards: 
 
 Inclusion of the DF/HCC Multi-Center Data and Safety Monitoring Plan in 
the protocol as an appendix. 
 Identify participating institutions and obtain accrual commitments. The 
Protocol Chair will also submit a protocol attachment labeled as 
“Participating Investigators” to the DFCI IRB and FDA, that provides the 
names and contact information for all participating institutions that perform 
the function of recruiting, enrolling, and treating participants for the 
protocol. The Coordinating Center (BIDMC) must be designated on the 
title page.  
 Commit to the provision that the protocol will not be rewritten or modified 
by anyone other than the Protocol Chair. 
 Ensure that there is only one version of the Protocol and that all 
Participating Institutions use the correct version.  
 Oversee the development of data collection forms (case report forms) that 
are of common format for use at all the Participating Institutions.  
 
 4.2     Coordinating Center Support Function 
 
The BIDMC’s study staff or designee will provide administrative and clerical support 
to the Protocol Chair for the development and distribution of the protocol.  
 
The tasks to be performed by the BIDMC’s study staff or designee include: 
 
 Review of the protocol and consent to check for logistics, spelling, and 
consistency.  Provide the Protocol Chair a list of queries related to any 
inconsistencies. 
 Provide necessary administrative sections, including paragraphs related to 
registration logistics, data management schedules, and multi-center 
guidelines.  
 Maintenance of contact list of all participating institutions in the DF/HCC 


 
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Multi-center Protocol and the distribution of updates to the sites as 
needed.  
 Derivation of the study calendar, if applicable. 
 Assistance in preparation and maintenance of case report forms.  
 Maintain and document communication with all participating institutions.  
 
 
4.3 
Training at DF/HCC Sites and Participating Institutions 
 
Study initiation training will be conducted by the BIDMC Research Coordinator or 
designee by teleconference. 
 
 
5.0  
PROTOCOL MANAGEMENT 
 
The Coordinating Center (BIDMC) is responsible for assuring that each Participating 
Institution has the appropriate assurance on file with the Office of Human Research Protection 
(OHRP).   Additionally, the BIDMC or designee must maintain copies of all IRB approvals, 
for each participating institution.  
 
5.1 
Protocol Distribution 
 
The Coordinating Center (BIDMC) will distribute the final approved protocol and any 
subsequent amended protocols to all Participating Institutions.    
 
5.2 
Protocol Revisions and Closures 
 
The participating institutions will receive phone, fax, mail or e-mail notification of 
protocol revisions from the Lead Institution or designee.  It is the individual 
participating institution’s responsibility to notify its IRB of these revisions. 
 
 
5.2.1 Non life-threatening revisions  
 
Participating institutions will receive written notification of protocol revisions 
regarding non life-threatening events from the Lead Institution or designee. 
Non-life-threatening protocol revisions should be implemented within 90 
business days from receipt of the notification. 
 
5.2.2   Revisions for life-threatening Causes  
 
Participating institutions will receive telephone notification from the Lead 
Institution or designee concerning protocol revisions required to protect lives 
with follow-up by fax, mail or e-mail.  Life-threatening protocol revisions will 
be implemented immediately. 
 
5.2.3 Protocol Closures and Temporary Holds 


 
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Participating institutions will receive fax, e-mail, or phone notification of 
protocol closures and temporary holds, with follow-up by mail from the Lead 
Institution or designee. Closures and holds will be effective immediately.  In 
addition, the Lead Institution or designee will update the Participating 
institutions on an ongoing basis about protocol accrual data so that they will be 
aware of imminent protocol closures. 
 
5.3 
Informed Consent Requirements 
 
The Principal Investigator (PI) at each participating site will identify the physician 
members of the study team who will be obtaining consent and signing the consent 
form for therapeutic protocols. It is DF/HCC policy that Nurses and Fellows cannot 
obtain consent to greater than minimal risk trials 
 
5.4      IRB Documentation 
 
The following must be on file with the BIDMC prior to participant registration: 
 
 Activation Letter of the institution's IRB (An Expedited IRB first 
approval is NOT acceptable) 
 IRB approval for all amendments 
 
It is the individual institution's responsibility to notify its IRB of protocol revisions.  
Participating institutions will have 90 days from receipt to provide the BIDMC their 
IRB approval for Major Amendments* to a protocol.    
 
* DF/HCC defines a Major Amendment as: A substantive change in the study which 
may increase or decrease the risk to study participants.  Major revisions require full 
IRB approval.  The following criteria are examples of revisions to a protocol that are 
considered to be major amendments:  
 
 
 
 
 
Change of eligibility (inclusion/exclusion) criteria 
 
Change in design of protocol 
 
Change in statistical section 
 
Change in sample size/accrual (e.g., doubling the sample size) 
 
Change in informed consent 
 
Change of estimated dropout rate 
 
Change of treatment or intervention 
 
Change of device 
 
Change in primary objective evaluation process 
 
 
5.5      IRB Re-Approval 
 


 
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Annual IRB re-approval from the Participating institution is required in order to 
register participants onto a protocol.  There is no grace period for annual re-approvals. 
 
Protocol registrations will not be completed if a re-approval letter is not received by 
the DF/HCC Lead Institution or designee from the Participating Institutions on or 
before the anniversary of the previous approval date.   
 
5.6  
Participant Confidentiality and Authorization Statement 
 
 
The Health Insurance Portability and Accountability Act of 1996 contains,  as one of 
its six major components, the requirement to create privacy standards for health care 
information that is used or disclosed in the course of treatment, payment or health care 
operations.  The original Privacy Rule, as it has come to be known, was published in 
December 2000.  The Final Rule was published on August 14, 2002, which has 
modified the privacy rule in significant ways vis-à-vis research. 
 
In order for covered entities to use or disclose protected health information during the 
course of a DF/HCC Multi-Center Protocol the study participant must sign an 
Authorization.  This Authorization may or may not be separate from the Informed 
Consent.  The DF/HCC Multi-Center Protocol, with the approval from the DFCI IRB 
will provide an Informed Consent template, which covered entities (DF/HCC Multi-
Center Protocol participating institutions) must use.  
 
The DF/HCC Multi-Center Protocol 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 National Cancer Institute 
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.   
 
5.7  
Participant Registration  
 
To register a participant, the following documents should be completed by the 
DF/HCC Multi-Center Protocol participating site and faxed to or e-mailed to the 
Lead Institution or designee (Study Coordinator Bryan Marion): 
 
Copy of required tests (baseline CBC, baseline chemistries, pathology 
report, baseline radiographic study reports) 
 
Signed informed consent form 
 
HIPAA authorization form (if separate from the informed consent 
document) 
 
Eligibility Screening Checklist 
 
The research DF/HCC Multi-center Protocol participating site will then call or e-mail 
the BIDMC to verify eligibility. To complete the registration process, the Lead 
Institution or designee will: 


 
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 Register the participant on the study with the DF/HCC Quality Assurance 
Office for Clinical Trials (QACT) 
 Fax or e-mail the participant case number to the participating site 
 Call the research nurse or data manager at the participating site and 
verbally confirm registration 
 
5.8  
DF/HCC Multi-center Protocol Case Number 
 
Once eligibility has been established and the participant successfully registered, the 
participant is assigned a five digit protocol case number.  This number is unique to the 
participant on this trial and must be used for QACT CRF/eCRF completion and written 
on all data and QACT correspondence for the participant. 
 
5.9 
DF/HCC Multi-center Protocol Registration Policy 
 
5.9.1   Initiation of Therapy: Participants must be registered with the DF/HCC QACT 
before receiving treatment.  Treatment may not be initiated until the site 
receives a faxed or e-mailed copy of the participant’s Registration 
Confirmation memo from the DF/HCC QACT. Therapy must be initiated per 
protocol guidelines.  The Protocol Chair and DFCI IRB must be notified of 
any exceptions to this policy.  
 
5.9.2  
Eligibility Exceptions: The DF/HCC QACT will make no exceptions to the 
eligibility requirements for a protocol without DFCI IRB approval. The 
DF/HCC QACT requires each institution to fully comply with this 
requirement. 
 
5.9.3  
Verification of Registration:  A registration confirmation memo for 
participants registered to DF/HCC Multi-Center Protocol will be faxed or 
emailed to the registering institution within one working day of the 
registration. Treatment may not be initiated until the site receives a faxed or 
e-mailed copy of the registration confirmation memo.  
 
5.9.4 
Confidentiality: All documents, investigative reports, or information relating 
to the participant are strictly confidential. Any participant specific reports 
(i.e. Pathology Reports, MRI Reports, Operative Reports, etc.) submitted to 
the Lead Institution or designee must have the participant’s full name & 
social security number “blacked out” and the assigned DF/HCC QACT case 
number and protocol number written in (with the exception of the signed 
informed consent document). Participant initials may only be included or 
retained for cross verification of identification. 
  
 
5.10  Schedule of Data Submission 
 


 
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The DF/HCC QACT will develop electronic case report forms, (CRF/eCRFs) for use 
with the DF/HCC Multi-Center Protocol.  These forms are designed to collect data for 
each study. DF/HCC QACT will require the forms to be submitted as follows: 
 
COMMON FORMS & REPORTS 
 
Eligibility Checklist, (Informed Consent/ Participant Authorization for 
the Release of Personal Health Information) 
 
On-study Form 
 
Baseline Assessment Form (Baseline disease assessment/measurement) 
 
Treatment Forms 
 
Adverse Event Forms 
 
Response 
Assessment 
Form 
(Follow-up 
disease 
assessment/Measurement) 
 
Off-Treatment/Off Study Form 
 
Follow-Up/Survival Forms 
 
Note: It is necessary to send only ONE copy of all paper Case Report Forms.  
   
5.10.1 Eligibility Checklist 
 
Purpose - Outlines protocol-specific eligibility criteria and includes the 
following: 
              
Participant Demographics (address, zip code, sex, race, ethnicity, initials, 
date of birth) 
9) Parameters for eligibility 
10) Parameters for exclusion 
11) Parameters for stratifications 
 
 
Schedule for Submission - Completed prior to participant registration. The 
Informed Consent/ Participant Authorization for the Release of Personal Health 
Information should be submitted with the Eligibility Checklist at the time of 
registration. 
 
5.10.2  On-study Form 
 
Purpose - documents the following items: 
 Demographic data 
 Prior therapy 
 Past medical and surgical history 
 Description of participant’s physical status at protocol registration 
 Disease site specific data 


 
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Schedule for Submission - Submitted to DF/HCC QACT within 14 days after 
registration. 
 
5.10.3  
Baseline Assessment Form 
 
Purpose – Documents objective and subjective disease status as defined by the 
protocol. Records all pertinent radiographic and laboratory measurements of 
disease utilized in determining response evaluations.  
 
Schedule of Submission – Submitted within 14 days after registration. 
 
5.10.4  
Treatment Form 
 
Purpose - Records the following information related to the time the participant 
receives protocol treatment: 
 
 
 Participant, Protocol, Affiliate information 
 Protocol treatment and supportive therapy per treatment cycle 
 Protocol specific laboratory values per treatment cycle 
 All medications other than protocol chemotherapy agents used to treat 
concomitant  diagnoses, if applicable 
 
Schedule for Submission – Submitted within 10 days after the last day of 
the cycle.   
 
5.10.5  Adverse Event Report Form  
 
Purpose – Documents adverse events that occur while the participant is 
receiving treatment and for up to 30 days after the last dose of treatment.  All 
adverse events are to be graded by number using the toxicity grading scale 
required by the protocol. This form is not for IRB submission, but for 
recording the AE in the research database. 
 
Schedule for Submission – Submitted within 10 days after the last day of 
the cycle. 
 
5.10.6  Response Assessment Form 
 
Purpose – Documents objective and subjective response as defined by the 
protocol. Records all pertinent radiographic and laboratory measurements of 
disease utilized in determining response evaluations.  
 
Schedule of Submission – Submitted within 10 days after the completion of  
the cycle required for response evaluation.  


 
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 5.10.7 Off Treatment/Off Study Form 
 
Purpose - The Off Treatment/Off Study Form is submitted when the 
participant is  
removed from the study or has completed all protocol treatment.  Note: If the 
participant dies while on protocol, the Off Study Form is the last form 
submitted. 
 
Schedule of Submission – Submitted within 14 days after completing 
treatment or taken off study for any reason. 
 
  5.10.8  Follow up / Survival Form 
 
Purpose - Summarizes participant status at a given point in time after being 
removed from treatment.  
 
Schedule of Submission – Submitted within 14 days after the protocol defined 
follow up visit date or call.    
 
 
 
 5.11  Data Form Review 
 
When data forms arrive at the DF/HCC QACT, they are reviewed for: 
  
Timeliness:  
Did the form arrive on time as specified in the protocol? 
 
 
 
 
Completeness:  
Is all the information provided as required per protocol? 
 
 
Participant Eligibility:  
Does the participant meet the eligibility requirements for the study based on the 
demographic data, lab values and measurements provided? 
 
Stratification:  
Are the stratification parameters consistent with what was given at the time of 
registration? 
 
Protocol Treatment Compliance:  
Are the body surface area (BSA) and drug dosage calculations correct?  The dose must 
be within 10% of the calculated protocol dose. 
  
Adverse Events (Toxicities):  


 
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Did the participant experience adverse events (toxicities or side effects) associated 
with the treatment? Was the treatment delayed due to the adverse event? What was the 
most severe degree of toxicity experienced by the participant? 
 
Notations concerning adverse events will address relationship to protocol treatment for 
each adverse event grade.  All adverse events encountered during the study will be 
evaluated according to the NCI Common Toxicity Criteria assigned to the protocol and 
all adverse events must be noted on the participant's Adverse Event (Toxicity) Forms. 
 
Response:  
Did the participant achieve a response?  What level of response did they achieve?  On 
what date did the participant achieve the response and how was the response 
determined? 
 
Response criteria are defined in the protocol.  A tumor assessment must be performed 
prior to the start of treatment and while the participant is on treatment as specified by 
the protocol.   
 
Objective responses must have documentation such as physical measurements, x-rays, 
scans, or laboratory tests.   
 
A subjective response is one that is perceived by the participant, such as reduction in 
pain, or improved appetite. 
 


 
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5.12 
Missing and Deficient Memorandum 
 
Data submissions are monitored for timeliness and completeness of submission. 
Participating institutions are notified of their data submission delinquencies in 
accordance with the following policies and procedures: 
 
Incomplete or Questionable Data 
 
If study forms are received with missing or questionable data, the submitting 
institution will receive a written query from the DF/HCC QACT Data Analyst.  
Responses to the query should be completed and returned within 14 days.  Responses 
may be returned on the written query or on an amended case report form. In both 
instances the query must be attached to the specific data being re-submitted in 
response.   
 
Missing Forms 
 
If study forms are not submitted on schedule, the participating institution will receive a 
Missing Form Report from the DF/HCC QACT noting the missing forms.  These 
reports are compiled by the DF/HCC QACT and distributed a minimum of three times 
a year.  
 
 
6.0 
REQUISITIONING INVESTIGATIONAL DRUG 
 
 
The ordering of investigational agent is specified in the protocol.  
 
Participating sites should order their own agent regardless of the supplier.  
 
If the agent is commercially available, check with the local Director of Pharmacy and/or the 
Research Pharmacy to ensure that the agent is in stock. If the agent is not stocked, ensure that 
the agent can be ordered once the protocol is approved by the local IRB. If the agent is 
investigational, ensure that the pharmacy will be able to receive and store the agent. The local 
IRB should be kept informed of who will supply the agent (i.e., NCI or a pharmaceutical 
company) so that any regulatory responsibilities can be met in a timely fashion.  
 
 
7.0  
SAFETY ASSESSMENTS AND TOXICITY MONITORING 
 
All participants receiving investigational agents 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 to the investigator 
by participants.  All toxicities encountered during the study will be evaluated according to 
the NCI criteria assigned to the protocol (CTCAE Version 3.0) and recorded prior to each 
course of therapy.  Life-threatening toxicities should be reported immediately to the Protocol 
Chair and Institutional Review Board (IRB).  


 
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Additional safety assessments and toxicity monitoring are outlined in the protocol. 
 
7.1 
Serious Adverse Events 
 
A serious adverse event (SAE) is any adverse drug experience at any dose that 
results  in any of the following outcomes: death, a life-threatening adverse drug 
experience, inpatient hospitalization or prolongation of existing hospitalization, a 
persistent or significant disability/incapacity, or a congenital anomaly/birth defect.  
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical 
judgment, they may jeopardize the participant or may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition.  Examples of 
such medical events include allergic bronchospasm requiring intensive treatment in 
an emergency room or at home, blood dyscrasias or convulsions in a participant who 
has never had seizure activity in the past that do not result in inpatient 
hospitalization, or the development of drug dependency or abuse. 
 
Unless otherwise specified in the protocol, the study will utilize the Cancer Therapy 
Evaluation Program (CTEP) Common Terminology Criteria for Adverse Events 
(CTCAE) Version 3.0 for Toxicity and Adverse Event reporting.  A copy of the CTC 
or CTCAE Criteria can be downloaded from the CTEP home page 
(http://ctep.info.nih.gov).   
 
7.2  
Guidelines for Reporting Serious Adverse Events  
 
Guidelines for reporting Serious Adverse Events (SAEs) will be followed as is 
delineated in the protocol. 
 
 
 
 
 
 
In addition, the Participating Institutions must report the serious adverse events to the 
Protocol Chair and the Coordinating Center (BIDMC) at the time SAEs are 
submitted.  
 
The Lead Institution will maintain documentation of all Adverse Event Reporting 
and be responsible for communicating all SAEs to all Participating sites. 
 
7.3 
Guidelines for Processing IND Safety Reports  
 
The U.S. Food and Drug Administration (FDA) regulations require sponsors of clinical 
studies to notify the FDA and all participating investigators of any serious and 
unexpected adverse experiences that are possibly related to the investigational agent.  
 
IND Safety Reports: Investigators will be sent a copy of expedited adverse events 
which have been sent to the FDA.  The investigators are to file a copy with their 
protocol file and send a copy to their IRB according to their local IRB’s policies and 
procedures. 


 
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8.0  
PROTOCOL VIOLATIONS AND DEVIATIONS 
 
Neither the FDA nor the ICH GCP guidelines define the terms “protocol violation” or 
“protocol deviation.”  All DF/HCC Protocol Chairs must adhere to those policies set by the 
DFCI IRB, the definitions for protocol violation and deviation as described by the DFCI 
IRB will be applied for reporting purposes for all institutions participating in the DF/HCC 
Multi-center Protocol.  
   
8.1 
Definitions 
 
Protocol Deviation: Any departure from the defined procedures set forth in the IRB-
approved protocol. 
 
 
 
Protocol Violation: Any protocol deviation that was not prospectively approved by 
the IRB prior to its initiation or implementation.  
 
 
8.2  
Reporting Procedures 
 
The Protocol Chair: is responsible for ensuring that clear documentation is 
available in the medical record to describe all protocol deviations and violations. 
  
The Protocol Chair will also be responsible for ensuring that all protocol 
violations/deviations are promptly reported per DFCI IRB guidelines.  
 
Participating Institutions: Protocol deviations require prospective approval from 
DFCI IRB. The Participating institution must submit the deviation request to the 
Protocol Chair and Lead Institution or designee, who will submit the deviation 
request to the DFCI IRB. Upon DFCI IRB approval the deviation should be 
submitted to the participating site’s own IRB, per its policy. 
 
Protocol violations occurring at a participating institution will be submitted to that 
site’s own IRB.   A copy of the participating institution’s IRB report and 
determination will be forwarded to the DF/HCC Lead Institution or designee by 
mail, facsimile, or via e-mail within 10 business days after the original submission.  
 
Coordinating Center:  Upon receipt of the violation/deviation report from the 
participating institution, the BIDMC will submit the report to the Protocol Chair 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.  
 
 
9.0  
QUALITY ASSURANCE 
 
The quality assurance process for a clinical trial research study requires verification of protocol 


 
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compliance and data accuracy. As the Coordinating Center, the BIDMC with the aid of the 
QACT provides quality assurance oversight for the DF/HCC Multi-center Protocol. 
 
9.1  
Ongoing Monitoring of Protocol Compliance 
 
 
All data submitted to the DF/HCC QACT will be monitored for timeliness of submission, 
completeness, and adherence to protocol requirements.  Monitoring will begin at the time 
of participant registration and will continue during protocol performance and completion.  
The BIDMC and if applicable QACT Data Analysts assigned to the Protocol will perform 
the ongoing protocol compliance monitoring with the support of the participating 
institution’s Coordinators, the Principal Investigators, and the Protocol Chair.  
 
9.2 
Evaluation of Participating Institution Performance 
 
9.2.1 
 Eligibility Checklist: Eligibility criteria are checked on a protocol-specific 
eligibility checklist and faxed to the DF/HCC QACT prior to registration on protocol.  
The checklist and informed consent document are reviewed by a DF/HCC QACT 
Protocol Registrar before the participant can be registered on a protocol.  The DF/HCC 
QACT cannot make exceptions to the eligibility requirements. 
 
9.2.5  Accrual of Eligible Participants: Annual accrual rates for eligible participants 
enrolled onto therapeutic clinical trials is calculated for each institution. Institutions are 
expected to maintain the minimum annual average accrual as defined by the protocol 
grant or contract.  
 
 
9.3  
On-Site Auditing 
 
 
9.3.1 NCI & DF/HCC Sponsored Trials 
 
For all DF/HCC sponsored protocols: 
 
The participating institutions may be required to submit subject source documents to 
the BIDMC for monitoring. Each participating institution will be subject to on-site 
monitoring conducted by the QACT. The first on-site audit will be conducted 
following the enrollment of the third participant at each participating institution.  
Further on-site audits will be determined as necessary by the results of this initial 
audit.  The BIDMC or designee will also require source documentation for review on 
1-2 patients at each participating institution every 6 months.  A report of these reviews 
will be filed in a separate monitoring binder at the lead institution (BIDMC).  
 
9.3.2  Participating Institution 
 
It is the participating institution’s responsibility to notify the BIDMC or designee of all 
scheduled audit dates (internal or NCI) and re-audit dates (if applicable), which 
involve the DF/HCC Multi-Center Protocol. The All institutions will forward a copy of 


 
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final audit and/or re-audit reports and corrective action plans (if applicable) to the 
BIDMC Research Coordinator (Bryan Marion) within 12 weeks after the audit date.  
 
9.3.3  Coordinating Center (BIDMC)  
 
The Protocol Chair (Dr. Cho) will review all DF/HCC Multi-Center Protocol Final 
Audit reports and corrective action plans if applicable. The Lead Institution or 
designee must forward these reports to the DF/HCC QACT per DF/HCC policy for 
review by the DF/HCC Audit Subcommittee. Based upon the audit assessments the 
DF/HCC Audit Subcommittee could accept or conditionally accept the audit rating and 
final report. Conditional approval could require the Protocol Chair to implement 
recommendations or require further follow-up.  For unacceptable audits, the Audit 
Subcommittee would forward the final audit report and corrective action plan to the 
Clinical Investigations Policy and Oversight Committee and the DFCI IRB as 
applicable. 
 
9.4  
Sub-Standard Performance 
 
The Protocol Chair, DFCI IRB and the NCI for CTEP trials, is charged with 
considering the totality of an institution’s performance in considering institutional 
participation in the DF/HCC Multi-Center Protocol. 
 
9.4.1  Corrective Actions  
 
 
 
Institutions that fail to meet the performance goals of accrual, submission of 
timely accurate data, and adherence to protocol requirements will 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. Institutions that fail to demonstrate 
significant improvement will be considered by the Protocol Chair for 
revocation of participation. 
 
9.5 
Scheduled Conference Calls 
 
Conference calls will be held once monthly involving the study staff from all DF/HCC 
and participating institutions to discuss protocol progress, accrual, side effects, and 
relevant regulatory issues. 
 
 
 
 
 
 


 
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Appendix D 
 
Collection of blood for both cytokine and for PBMC analysis will be performed as described 
below: 
 
Approximately 7 cc of venous blood will be collected into a BD Vacutainer CPT™ tube with 
Sodium Citrate  (Becton Dickinson product #362761).  The tube should be gently inverted 
several times to ensure mixing with the anticoagulant. Within 24 hours the CPT tube should 
be centrifuged at room temperature in a horizontal rotor for 25 minutes at 1600g.  After 
centrifugation, the mononuclear cells will be visible in a whitish layer just under the plasma 
(see figure below).  
 
Remove 2-3 mls of plasma (top layer) and aliquot into 3 tubes (1 ml cryotubes). Then remove 
mononuclear layer (1.5 ml) and put into cryotube #1. Then transfer half of mononuclear cells 
(750 microliters) to cryotube #2. Add 750 microliters of freezing media (RPMI-1640 media 
with 20% dimethyl sulfoxide) to PBMC cryotubes (#1 and #2). All cryotubes (plasma and 
PBMC containing tubes) should immediately be placed in a –80 degree freezer.   All samples 
should be labeled with the following: 
 
  
 
 
Patient Initials, ID number 
  
 
 
Protocol number 
  
 
 
Collection date 
  
 
 
Cells or plasma  
  
 
 
Institution 
 
Samples should be stored at -70° to -80°C. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure: The preparation of plasma and mononuclear cells using a CPT tube.  


 
 
 
 
 
 
 
Participant Identifier: ___________________________ 
Protocol # 08-313 
1. Missed or vomited doses will not be made up. 
2. Please keep drug in original container. 
3. You may either take everolimus on an empty stomach or after a low fat meal.  
Taking everolimus after large fatty meals is not advised because it will lower 
the amount of drug your body absorbs. Some examples of a low fat meal 
include: cereal with fat free milk, muffin/bagel with fat free spread, fruit salad, 
etc. 
 
Bring any unused study drug, all empty containers, and this diary to the next clinic visit. 
             
            Your MD______________________ Phone___________________ 
  
            Your RN______________________ Phone___________________ 
 
 
            STUDY DRUG INSTRUCTIONS: 
 
Study Drug: RAD001 
 
How Much: Your dose is:___________  
                    
How Often: You will take your medication everolimus (tablets) by mouth, 
once a day followed by a big glass of water 
 
When: You should take the drug about the same time each day 
 
SPECIAL INSTRUCTIONS: 
 
Study Participant  
Self-Administration 
Study Drug Diary 
Dana-Farber/Harvard Cancer Center 


 
DOSING LOG 
 
 
CYCLE:   
RAD001 
For each dose take:  
Please indicate the date, time, amount taken and any comments.  
Amount Taken 
 
Date 
AM dose  
PM dose  
Comments 
Ex: 
6/1/09 
8am - 1  
7:30pm - 1 
Vomited PM dose 
Day 1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
6 
 
 
 
 
7 
 
 
 
 
8 
 
 
 
 
9 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
13 
 
 
 
 
14 
 
 
 
 
15 
 
 
16 
 
 
 
 
17 
 
 
 
 
18 
 
 
 
 
19 
 
 
 
 
20 
 
 
 
 
21 
 
 
 
 
22 
 
 
 
 
23 
 
 
 
 
24 
 
 
 
 
25 
 
 
 
 
26 
 
 
 
 
27 
 
 
 
 
28 
 
 
 
 
 
 
 
 
 


SYMPTOMS/SIDE EFFECTS 
 
Please record any side effects experienced during this cycle. Include the date the particular symptom 
started and when it ended. Please evaluate the severity of the symptom according to the following 
scale: 
 
Mild: Awareness of sign or symptom; easily tolerated and did not affect ability to perform normal 
daily activities. Symptom did not require medication or therapeutic intervention. 
 
Moderate: Significant discomfort which interfered with ability to perform normal daily activities. 
Symptom was easily resolved with at home medication or simple therapeutic intervention. 
 
Severe: Marked discomfort with an inability to carry out normal daily activities. Symptom required 
new medication and/or therapeutic intervention in order to resolve.  
 
Please Note: The severity should reflect the most severe level experienced during the time period.  
 
Symptom 
Start Date 
End Date 
Severity 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
OTHER MEDICATIONS TAKEN 
 
If you take a daily medication (prescribed or otherwise), please use one line per drug and 
indicate the start and stop dates under the “Date(s) Taken” section (i.e., 6/2/09-6/5/09).  
 
Drug Name 
Dose 
Dates Taken 
Reason Taken 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Participant Initials __________  
 
Date _______________ 
 
 
 
FOR OFFICE USE 
 
Staff Initials:  
 
Date Dispensed:     
Date Returned:  
 
# pills/caps/tabs dispensed:  
# pills/caps/tabs returned:  
# pills/caps/tabs that should have been taken:  
 
Discrepancy Notes: 
 
 
 
 
 
Study Participant Signature: __________________________ 
Date ____________ 
 
Study Staff Signature: _____________________________  
Date ____________ 
 
    


 
1
HIGHLIGHTS OF PRESCRIBING INFORMATION 
These highlights do not include all the information needed to use EPIVIR 
safely and effectively. See full prescribing information for EPIVIR. 
EPIVIR (lamivudine) Tablets and Oral Solution 
Initial U.S. Approval: 1995 
WARNING: LACTIC ACIDOSIS, POSTTREATMENT 
EXACERBATIONS OF HEPATITIS B IN CO-INFECTED PATIENTS, 
DIFFERENT FORMULATIONS OF EPIVIR 
See full prescribing information for complete boxed warning 
• 
Lactic acidosis and severe hepatomegaly with steatosis, including 
fatal cases, have been reported with the use of nucleoside analogues. 
Suspend treatment if clinical or laboratory findings suggestive of 
lactic acidosis or pronounced hepatotoxicity occur. (5.1) 
• 
Severe acute exacerbations of hepatitis B have been reported in 
patients who are co-infected with hepatitis B virus (HBV) and 
human immunodeficiency virus (HIV-1) and have discontinued 
EPIVIR. Monitor hepatic function closely in these patients and, if 
appropriate, initiate anti-hepatitis B treatment. (5.2) 
• 
Patients with HIV-1 infection should receive only dosage forms of 
EPIVIR appropriate for treatment of HIV-1. (5.2) 
---------------------------RECENT MAJOR CHANGES -------------------- 
Dosage and Administration, Pediatric Patients (2.2)          February 2008 
----------------------------INDICATIONS AND USAGE--------------------- 
EPIVIR is a nucleoside analogue reverse transcriptase inhibitor indicated in 
combination with other antiretroviral agents for the treatment of HIV-1 
infection. Limitation of Use: The dosage of this product is for HIV-1 and not 
for HBV. (1) 
----------------------- DOSAGE AND ADMINISTRATION ---------------- 
• 
Adults and adolescents >16 years of age: 300 mg daily, administered as 
either 150 mg twice daily or 300 mg once daily. (2.1) 
• 
Pediatric patients 3 months up to 16 years of age: Dosage should be 
based on body weight. (2.2) 
• 
Patients With Renal Impairment: Doses of EPIVIR must be adjusted in 
accordance with renal function. (2.3) 
---------------------DOSAGE FORMS AND STRENGTHS -------------- 
• 
Tablets: 300 mg (3) 
• 
Tablets: Scored 150 mg (3) 
• 
Oral Solution: 10 mg/mL (3) 
-------------------------------CONTRAINDICATIONS------------------------ 
EPIVIR Tablets and Oral Solution are contraindicated in patients with 
previously demonstrated clinically significant hypersensitivity (e.g., 
anaphylaxis) to any of the components of the products. (4) 
----------------------- WARNINGS AND PRECAUTIONS ---------------- 
• 
Lactic acidosis and severe hepatomegaly with steatosis: Reported with 
the use of nucleoside analogues. Suspend treatment if clinical or 
laboratory findings suggestive of lactic acidosis or pronounced 
hepatoxicity occur. (5.1) 
• 
Severe acute exacerbations of hepatitis: Reported in patients who are co-
infected with hepatitis B virus and HIV-1 and discontinued EPIVIR. 
Monitor hepatic function closely in these patients and, if appropriate, 
initiate anti-hepatitis B treatment. (5.2) 
• 
Patients with HIV-1 infection should receive only dosage forms of 
EPIVIR appropriate for treatment of HIV-1. (5.2) 
• 
Co-infected HIV-1/HBV Patients: Emergence of lamivudine-resistant 
HBV variants associated with lamivudine-containing antiretroviral 
regimens has been reported. (5.2) 
• 
Emtricitabine should not be administered concomitantly with 
lamivudine-containing products. (5.3) 
• 
Hepatic decompensation (some fatal) has occurred in HIV-1/HCV 
co-infected patients receiving interferon and ribavirin-based regimens. 
Monitor for treatment-associated toxicities. Discontinue EPIVIR as 
medically appropriate and consider dose reduction or discontinuation of 
interferon alfa, ribavirin, or both. (5.4) 
• 
Pancreatitis: Use with caution in pediatric patients with a history of 
pancreatitis or other significant risk factors for pancreatitis. Discontinue 
treatment as clinically appropriate. (5.5) 
• 
Immune reconstitution syndrome (5.6) and redistribution/accumulation 
of body fat (5.7) have been reported in patients treated with combination 
antiretroviral therapy. 
------------------------------ ADVERSE REACTIONS ----------------------- 
• 
The most common reported adverse reactions (incidence ≥15%) in 
adults were headache, nausea, malaise and fatigue, nasal signs and 
symptoms, diarrhea, and cough. (6.1) 
• 
The most common reported adverse reactions (incidence ≥15%) in 
pediatric patients were fever and cough. (6.1) 
To report SUSPECTED ADVERSE REACTIONS, contact 
GlaxoSmithKline at 1-888-825-5249 or FDA at 1-800-FDA-1088 or 
www.fda.gov/medwatch. 
-------------------------------DRUG INTERACTIONS------------------------ 
Zalcitabine is not recommended for use in combination with EPIVIR. (7.2) 
----------------------- USE IN SPECIFIC POPULATIONS ---------------- 
• 
Pregnancy: Physicians are encouraged to register patients in the 
Antiretroviral Pregnancy Registry by calling 1-800-258-4263. (8.1) 
See 17 for PATIENT COUNSELING INFORMATION. 
Revised: April 2009 
EPV:2PI 
 
FULL PRESCRIBING INFORMATION: CONTENTS* 
WARNING: RISK OF LACTIC ACIDOSIS, EXACERBATIONS OF 
HEPATITIS B IN CO-INFECTED PATIENTS UPON 
DISCONTINUATION OF EPIVIR, DIFFERENT FORMULATIONS 
O  EPIVIR. 
F
1 
INDICATIONS AND USAGE 
2 
DOSAGE AND ADMINISTRATION 
2.1 
Adults and Adolescents >16 years of age 
2.2 
Pediatric Patients 
2.3 
Patients With Renal Impairmen  t
3 
DOSAGE FORMS AND STRENGTHS 
4 
CONTRAINDICATIONS 
5 
WARNINGS AND PRECAUTIONS 
5.1 
 Lactic Acidosis/Severe Hepatomegaly With 
teatosis 
S
5.2 
 Patients With HIV-1 and Hepatitis B Virus 
Co-infection 
5.3 
Use With Other Lamivudine- and 
mtricitabine-Containing Products 
E
5.4 
 Use With Interferon- and Ribavirin-Based 
Regimens 
5.5 
Pancreatitis 
5.6 
Immune Reconsti
tion Syndrome 
tu
5.7 
Fat Redistributio  
n
6 
AD ERSE REACTIONS 
V
6.1 
Clinical Trials Experience 
6.2 
Postmarketing Experience 
7 
DRUG INTERACTIONS 
7.1 
Interferon- and Ribavirin-Based Regimens 
7.2 
Zalcitabine 
7.3 
Trimethoprim/Sulfamethoxazole (TMP/SMX) 
7.4 
Drugs with No Observed Interactions With EPIVIR 
8 
USE IN SPECIFIC
OPULATIONS 
 P
8.1 
Pregnancy 
8.3 
Nursing Mothers 
8.4 
Pediatric Use 
8.5 
Geriatric Use 
8.6 
Patients With Impaired Renal Function 
10 
OVERDOSAGE 
11 
DESCRIPTION 
12 
CLINICAL PHARMACOLOGY 
12.1 
Mechanism of Action 
12.3 
Pharmacokinetics 
12.4 
Microbiology 
13 
NON LINICAL TOXICOLOGY 
C
13.1 
Carcinogenesis, Mutagenesis, Impairment of 
Fertility 
13.2 
Reproductive Toxicology Studies 
14 
CLINICAL STUDIES 
14.1 
Adults 
14.2 
Pediatric Patients 
16 
HOW SUPPLIED/STORAGE AND HANDLING 
17 
PATIENT COUNSELING INFORMATION 
17.1 
Advice for the Patient 
*Sections or subsections omitted from the full prescribing information are not listed. 


______________________________________________________________________ 
FULL PRESCRIBING INFORMATION 
WARNING: RISK OF LACTIC ACIDOSIS, EXACERBATIONS OF HEPATITIS B IN 
CO-INFECTED PATIENTS UPON DISCONTINUATION OF EPIVIR®, DIFFERENT 
FORMULATIONS OF EPIVIR. 
 
Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have 
been reported with the use of nucleoside analogues alone or in combination, including 
lamivudine and other antiretrovirals. Suspend treatment if clinical or laboratory findings 
suggestive of lactic acidosis or pronounced hepatotoxicity occur [see Warnings and 
Precautions (5.1)]. 
 
Severe acute exacerbations of hepatitis B have been reported in patients who are 
co-infected with hepatitis B virus (HBV) and human immunodeficiency virus (HIV-1) and 
have discontinued EPIVIR. Hepatic function should be monitored closely with both clinical 
and laboratory follow-up for at least several months in patients who discontinue EPIVIR 
and are co-infected with HIV-1 and HBV. If appropriate, initiation of anti-hepatitis B 
therapy may be warranted [see Warnings and Precautions (5.2)]. 
 
EPIVIR Tablets and Oral Solution (used to treat HIV-1 infection) contain a higher 
dose of the active ingredient (lamivudine) than EPIVIR-HBV® Tablets and Oral Solution 
(used to treat chronic HBV infection). Patients with HIV-1 infection should receive only 
dosage forms appropriate for treatment of HIV-1 [see Warnings and Precautions (5.2)]. 
1 
INDICATIONS AND USAGE 
 
EPIVIR is a nucleoside analogue indicated in combination with other antiretroviral 
agents for the treatment of human immunodeficiency virus (HIV-1) infection. Limitation of use: 
The dosage of this product is for HIV-1 and not for HBV. 
2 
DOSAGE AND ADMINISTRATION 
2.1 
Adults and Adolescents >16 years of age 
 
The recommended oral dose of EPIVIR in HIV-1-infected adults and adolescents 
>16 years of age is 300 mg daily, administered as either 150 mg twice daily or 300 mg once 
daily, in combination with other antiretroviral agents. If lamivudine is administered to a patient 
infected with HIV-1 and HBV, the dosage indicated for HIV-1 therapy should be used as part of 
an appropriate combination regimen [see Warnings and Precautions (5.2)]. 
2.2 
Pediatric Patients 
 
The recommended oral dose of EPIVIR Oral Solution in HIV-1-infected pediatric 
patients 3 months to 16 years of age is 4 mg/kg twice daily (up to a maximum of 150 mg twice a 
day), administered in combination with other antiretroviral agents. 
 
EPIVIR is also available as a scored tablet for HIV-1-infected pediatric patients who 
weigh ≥14 kg and for whom a solid dosage form is appropriate. Before prescribing EPIVIR 
 
2


Tablets, children should be assessed for the ability to swallow tablets. If a child is unable to 
reliably swallow EPIVIR Tablets, the oral solution formulation should be prescribed. The 
recommended oral dosage of EPIVIR Tablets for HIV-1-infected pediatric patients is presented 
in Table 1. 
 
Table 1. Dosing Recommendations for EPIVIR Tablets in Pediatric Patients 
Dosage Regimen Using Scored 150-mg Tablet 
Weight 
(kg) 
AM Dose 
PM Dose 
Total  
Daily Dose 
14 to 21 
½ tablet (75 mg) 
½ tablet (75 mg) 
150 mg 
>21 to <30 
½ tablet (75 mg) 
1 tablet (150 mg) 
225 mg 
≥30 
1 tablet (150 mg) 
1 tablet (150 mg) 
300 mg 
 
2.3 
Patients With Renal Impairment 
 
Dosing of EPIVIR is adjusted in accordance with renal function. Dosage adjustments are 
listed in Table 2 [see Clinical Pharmacology (12.3)]. 
 
Table 2. Adjustment of Dosage of EPIVIR in Adults and Adolescents (≥30 kg) in 
Accordance With Creatinine Clearance 
Creatinine Clearance 
(mL/min) 
Recommended Dosage of EPIVIR 
≥50 
150 mg twice daily or 300 mg once daily 
30-49 
150 mg once daily 
15-29 
150 mg first dose, then 100 mg once daily 
5-14 
150 mg first dose, then 50 mg once daily 
<5 
  50 mg first dose, then 25 mg once daily 
 
 
No additional dosing of EPIVIR is required after routine (4-hour) hemodialysis or 
peritoneal dialysis. 
 
Although there are insufficient data to recommend a specific dose adjustment of EPIVIR 
in pediatric patients with renal impairment, a reduction in the dose and/or an increase in the 
dosing interval should be considered. 
3 
DOSAGE FORMS AND STRENGTHS 
• EPIVIR Scored Tablets 
 
150 mg, are white, diamond-shaped, scored, film-coated tablets debossed with “GX CJ7” 
on both sides. 
• EPIVIR Tablets 
 
300 mg, are gray, modified diamond-shaped, film-coated tablets engraved with “GX EJ7” 
on one side and plain on the reverse side. 
• EPIVIR Oral Solution 
 
3


 
A clear, colorless to pale yellow, strawberry-banana flavored liquid, containing 10 mg of 
lamivudine per 1 mL. 
4 
CONTRAINDICATIONS 
 
EPIVIR Tablets and Oral Solution are contraindicated in patients with previously 
demonstrated clinically significant hypersensitivity (e.g., anaphylaxis) to any of the components 
of the products. 
5 
WARNINGS AND PRECAUTIONS 
5.1 
Lactic Acidosis/Severe Hepatomegaly With Steatosis 
 
Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been 
reported with the use of nucleoside analogues alone or in combination, including lamivudine and 
other antiretrovirals. A majority of these cases have been in women. Obesity and prolonged 
nucleoside exposure may be risk factors. Particular caution should be exercised when 
administering EPIVIR to any patient with known risk factors for liver disease; however, cases 
also have been reported in patients with no known risk factors. Treatment with EPIVIR should 
be suspended in any patient who develops clinical or laboratory findings suggestive of lactic 
acidosis or pronounced hepatotoxicity (which may include hepatomegaly and steatosis even in 
the absence of marked transaminase elevations). 
5.2 
Patients With HIV-1 and Hepatitis B Virus Co-infection 
 
Posttreatment Exacerbations of Hepatitis: In clinical trials in non-HIV-1-infected 
patients treated with lamivudine for chronic hepatitis B, clinical and laboratory evidence of 
exacerbations of hepatitis have occurred after discontinuation of lamivudine. These 
exacerbations have been detected primarily by serum ALT elevations in addition to 
re-emergence of HBV DNA. Although most events appear to have been self-limited, fatalities 
have been reported in some cases. Similar events have been reported from postmarketing 
experience after changes from lamivudine-containing HIV-1 treatment regimens to 
non-lamivudine-containing regimens in patients infected with both HIV-1 and HBV. The causal 
relationship to discontinuation of lamivudine treatment is unknown. Patients should be closely 
monitored with both clinical and laboratory follow-up for at least several months after stopping 
treatment. There is insufficient evidence to determine whether re-initiation of lamivudine alters 
the course of posttreatment exacerbations of hepatitis. 
 
Important Differences Among Lamivudine-Containing Products: EPIVIR Tablets 
and Oral Solution contain a higher dose of the same active ingredient (lamivudine) than 
EPIVIR-HBV Tablets and EPIVIR-HBV Oral Solution. EPIVIR-HBV was developed for 
patients with chronic hepatitis B. The formulation and dosage of lamivudine in EPIVIR-HBV are 
not appropriate for patients co-infected with HIV-1 and HBV. Safety and efficacy of lamivudine 
have not been established for treatment of chronic hepatitis B in patients co-infected with HIV-1 
and HBV. If treatment with EPIVIR-HBV is prescribed for chronic hepatitis B for a patient with 
unrecognized or untreated HIV-1 infection, rapid emergence of HIV-1 resistance is likely to 
result because of the subtherapeutic dose and the inappropriateness of monotherapy HIV-1 
 
4


treatment. If a decision is made to administer lamivudine to patients co-infected with HIV-1 and 
HBV, EPIVIR Tablets, EPIVIR Oral Solution, COMBIVIR® (lamivudine/zidovudine) Tablets, 
EPZICOM® (abacavir sulfate and lamivudine) Tablets, or TRIZIVIR® (abacavir sulfate, 
lamivudine, and zidovudine) Tablets should be used as part of an appropriate combination 
regimen. 
 
Emergence of Lamivudine-Resistant HBV: In non–HIV-1-infected patients treated 
with lamivudine for chronic hepatitis B, emergence of lamivudine-resistant HBV has been 
detected and has been associated with diminished treatment response (see full prescribing 
information for EPIVIR-HBV for additional information). Emergence of hepatitis B virus 
variants associated with resistance to lamivudine has also been reported in HIV-1-infected 
patients who have received lamivudine-containing antiretroviral regimens in the presence of 
concurrent infection with hepatitis B virus. 
5.3 
Use With Other Lamivudine- and Emtricitabine-Containing Products 
 
EPIVIR should not be administered concomitantly with other lamivudine-containing 
products including EPIVIR-HBV Tablets, EPIVIR Oral Solution, COMBIVIR 
(lamivudine/zidovudine) Tablets, EPZICOM (abacavir sulfate and lamivudine) Tablets, or 
TRIZIVIR (abacavir sulfate, lamivudine, and zidovudine) or emtricitabine-containing products, 
including ATRIPLA® (efavirenz, emtricitabine, and tenofovir), EMTRIVA® (emtricitabine), or 
TRUVADA® (emtricitabine and tenofovir). 
5.4 
Use With Interferon- and Ribavirin-Based Regimens 
 
In vitro studies have shown ribavirin can reduce the phosphorylation of pyrimidine 
nucleoside analogues such as lamivudine. Although no evidence of a pharmacokinetic or 
pharmacodynamic interaction (e.g., loss of HIV-1/HCV virologic suppression) was seen when 
ribavirin was coadministered with lamivudine in HIV-1/HCV co-infected patients [see Clinical 
Pharmacology (12.3)], hepatic decompensation (some fatal) has occurred in HIV-1/HCV 
co-infected patients receiving combination antiretroviral therapy for HIV-1 and interferon alfa 
with or without ribavirin. Patients receiving interferon alfa with or without ribavirin and EPIVIR 
should be closely monitored for treatment-associated toxicities, especially hepatic 
decompensation. Discontinuation of EPIVIR should be considered as medically appropriate. 
Dose reduction or discontinuation of interferon alfa, ribavirin, or both should also be considered 
if worsening clinical toxicities are observed, including hepatic decompensation (e.g., 
Child-Pugh >6). See the complete prescribing information for interferon and ribavirin. 
5.5 
Pancreatitis 
 
In pediatric patients with a history of prior antiretroviral nucleoside exposure, a history of 
pancreatitis, or other significant risk factors for the development of pancreatitis, EPIVIR should 
be used with caution. Treatment with EPIVIR should be stopped immediately if clinical signs, 
symptoms, or laboratory abnormalities suggestive of pancreatitis occur [see Adverse Reactions 
(6.1)]. 
5.6 
Immune Reconstitution Syndrome 
 
Immune reconstitution syndrome has been reported in patients treated with combination 
 
5


antiretroviral therapy, including EPIVIR. During the initial phase of combination antiretroviral 
treatment, patients whose immune system responds may develop an inflammatory response to 
indolent or residual opportunistic infections (such as Mycobacterium avium infection, 
cytomegalovirus, Pneumocystis jirovecii pneumonia [PCP], or tuberculosis), which may 
necessitate further evaluation and treatment. 
5.7 
Fat Redistribution 
 
Redistribution/accumulation of body fat including central obesity, dorsocervical fat 
enlargement (buffalo hump), peripheral wasting, facial wasting, breast enlargement, and 
“cushingoid appearance” have been observed in patients receiving antiretroviral therapy. The 
mechanism and long-term consequences of these events are currently unknown. A causal 
relationship has not been established. 
6 
ADVERSE REACTIONS 
6.1 
Clinical Trials Experience 
 
The following adverse reactions are discussed in greater detail in other sections of the 
labeling: 
• Lactic acidosis and severe hepatomegaly with steatosis [see Boxed Warning, Warnings and 
Precautions (5.1)]. 
• Severe acute exacerbations of hepatitis B [see Boxed Warning, Warnings and Precautions 
(5.2)]. 
• Hepatic decompensation in patients co-infected with HIV-1 and Hepatitis C [see Warnings 
and Precautions (5.4)]. 
• Pancreatitis [see Warnings and Precautions (5.5)]. 
 
Because clinical trials are conducted under widely varying conditions, adverse reaction 
rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical 
trials of another drug and may not reflect the rates observed in practice. 
 
Adults - Clinical Trials in HIV-1: The safety profile of EPIVIR in adults is primarily 
based on 3,568 HIV-1-infected patients in 7 clinical trials. 
 
The most common adverse reactions are headache, nausea, malaise, fatigue, nasal signs 
and symptoms, diarrhea and cough. 
 
Selected clinical adverse reactions in ≥5% of patients during therapy with EPIVIR 
150 mg twice daily plus RETROVIR® 200 mg 3 times daily for up to 24 weeks are listed in 
Table 3. 
 
6


Table 3. Selected Clinical Adverse Reactions (≥5% Frequency) in Four Controlled Clinical 
Trials (NUCA3001, NUCA3002, NUCB3001, NUCB3002) 
Adverse Reaction 
EPIVIR 150 mg 
Twice Daily 
plus RETROVIR 
(n = 251) 
RETROVIRa
(n = 230) 
Body as a Whole 
 
 
Headache 
35% 
27% 
Malaise & fatigue 
27% 
23% 
Fever or chills 
10% 
12% 
Digestive 
 
 
Nausea 
33% 
29% 
Diarrhea 
18% 
22% 
Nausea & vomiting 
13% 
12% 
Anorexia and/or decreased appetite 
10% 
7% 
Abdominal pain 
9% 
11% 
Abdominal cramps 
6% 
3% 
Dyspepsia 
5% 
5% 
Nervous System 
 
 
Neuropathy 
12% 
10% 
Insomnia & other sleep disorders 
11% 
7% 
Dizziness 
10% 
4% 
Depressive disorders 
9% 
4% 
Respiratory 
 
 
Nasal signs & symptoms 
20% 
11% 
Cough 
18% 
13% 
Skin 
 
 
Skin rashes 
9% 
6% 
Musculoskeletal 
 
 
Musculoskeletal pain 
12% 
10% 
Myalgia 
8% 
6% 
Arthralgia 
5% 
5% 
a Either zidovudine monotherapy or zidovudine in combination with zalcitabine. 
 
 
 
Pancreatitis: Pancreatitis was observed in 9 out of 2,613 adult patients (0.3%) who 
received EPIVIR in controlled clinical trials EPV20001, NUCA3001, NUCB3001, NUCA3002, 
NUCB3002, and NUCB3007 [see Warnings and Precautions (5.5)]. 
 
 
EPIVIR 300 mg Once Daily: The types and frequencies of clinical adverse reactions 
reported in patients receiving EPIVIR 300 mg once daily or EPIVIR 150 mg twice daily (in 
3-drug combination regimens in EPV20001 and EPV40001) for 48 weeks were similar. 
 
7


 
Selected laboratory abnormalities observed during therapy are summarized in Table 4. 
 
Table 4. Frequencies of Selected Grade 3-4 Laboratory Abnormalities in Adults in Four 
24-Week Surrogate Endpoint Studies (NUCA3001, NUCA3002, NUCB3001, NUCB3002) 
and a Clinical Endpoint Study (NUCB3007) 
 
24-Week Surrogate Endpoint 
Studiesa
Clinical Endpoint 
Studya
Test 
(Threshold Level) 
EPIVIR plus 
RETROVIR 
RETROVIRb
EPIVIR plus 
Current 
Therapy 
Placebo plus 
Current 
Therapyc
Absolute neutrophil count 
(<750/mm3) 
7.2% 
5.4% 
15% 
13% 
Hemoglobin (<8.0 g/dL) 
2.9% 
1.8% 
2.2% 
3.4% 
Platelets (<50,000/mm3) 
0.4% 
1.3% 
2.8% 
3.8% 
ALT (>5.0 x ULN) 
3.7% 
3.6% 
3.8% 
1.9% 
AST (>5.0 x ULN) 
1.7% 
1.8% 
4.0% 
2.1% 
Bilirubin (>2.5 x ULN) 
0.8% 
0.4% 
ND 
ND 
Amylase (>2.0 x ULN) 
4.2% 
1.5% 
2.2% 
1.1% 
a The median duration on study was 12 months. 
b Either zidovudine monotherapy or zidovudine in combination with zalcitabine. 
c Current therapy was either zidovudine, zidovudine plus didanosine, or zidovudine plus 
zalcitabine. 
ULN = Upper limit of normal. 
ND = Not done. 
 
 
The frequencies of selected laboratory abnormalities reported in patients receiving 
EPIVIR 300 mg once daily or EPIVIR 150 mg twice daily (in 3-drug combination regimens in 
EPV20001 and EPV40001) were similar. 
 
Pediatric Patients – Clinical Trials in HIV-1: EPIVIR Oral Solution has been studied 
in 638 pediatric patients 3 months to 18 years of age in 3 clinical trials. 
 
Selected clinical adverse reactions and physical findings with a ≥5% frequency during 
therapy with EPIVIR 4 mg/kg twice daily plus RETROVIR 160 mg/m2 3 times daily in 
therapy-naive (≤56 days of antiretroviral therapy) pediatric patients are listed in Table 5. 
 
 
8


Table 5. Selected Clinical Adverse Reactions and Physical Findings (≥5% Frequency) in 
Pediatric Patients in Study ACTG300 
Adverse Reaction 
EPIVIR plus 
RETROVIR 
(n = 236) 
Didanosine 
(n = 235) 
Body as a Whole 
 
 
Fever 
25% 
32% 
Digestive 
 
 
Hepatomegaly 
11% 
11% 
Nausea & vomiting 
8% 
7% 
Diarrhea 
8% 
6% 
Stomatitis 
6% 
12% 
Splenomegaly  
5% 
8% 
Respiratory 
 
 
Cough 
15% 
18% 
Abnormal breath sounds/wheezing 
7% 
9% 
Ear, Nose, and Throat 
 
 
Signs or symptoms of earsa
7% 
6% 
Nasal discharge or congestion 
8% 
11% 
Other 
 
 
Skin rashes 
12% 
14% 
Lymphadenopathy 
9% 
11% 
a Includes pain, discharge, erythema, or swelling of an ear. 
 
 
 
Pancreatitis: Pancreatitis, which has been fatal in some cases, has been observed in 
antiretroviral nucleoside-experienced pediatric patients receiving EPIVIR alone or in 
combination with other antiretroviral agents. In an open-label dose-escalation study 
(NUCA2002), 14 patients (14%) developed pancreatitis while receiving monotherapy with 
EPIVIR. Three of these patients died of complications of pancreatitis. In a second open-label 
study (NUCA2005), 12 patients (18%) developed pancreatitis. In Study ACTG300, pancreatitis 
was not observed in 236 patients randomized to EPIVIR plus RETROVIR. Pancreatitis was 
observed in 1 patient in this study who received open-label EPIVIR in combination with 
RETROVIR and ritonavir following discontinuation of didanosine monotherapy [see Warnings 
and Precautions (5.5)]. 
 
 
Paresthesias and Peripheral Neuropathies: Paresthesias and peripheral 
neuropathies were reported in 15 patients (15%) in Study NUCA2002, 6 patients (9%) in Study 
NUCA2005, and 2 patients (<1%) in Study ACTG300. 
 
Selected laboratory abnormalities experienced by therapy-naive (≤56 days of 
antiretroviral therapy) pediatric patients are listed in Table 6. 
 
 
9


Table 6. Frequencies of Selected Grade 3-4 Laboratory Abnormalities in Pediatric Patients 
in Study ACTG300 
Test 
(Threshold Level) 
EPIVIR plus 
RETROVIR 
Didanosine 
Absolute neutrophil count (<400/mm3) 
8% 
3% 
Hemoglobin (<7.0 g/dL) 
4% 
2% 
Platelets (<50,000/mm3) 
1% 
3% 
ALT (>10 x ULN) 
1% 
3% 
AST (>10 x ULN) 
2% 
4% 
Lipase (>2.5 x ULN) 
3% 
3% 
Total Amylase (>2.5 x ULN) 
3% 
3% 
ULN = Upper limit of normal. 
 
 
Neonates - Clinical Trials in HIV-1: Limited short-term safety information is available 
from 2 small, uncontrolled studies in South Africa in neonates receiving lamivudine with or 
without zidovudine for the first week of life following maternal treatment starting at Week 38 or 
36 of gestation [see Clinical Pharmacology (12.3)]. Selected adverse reactions reported in these 
neonates included increased liver function tests, anemia, diarrhea, electrolyte disturbances, 
hypoglycemia, jaundice and hepatomegaly, rash, respiratory infections, and sepsis; 3 neonates 
died (1 from gastroenteritis with acidosis and convulsions, 1 from traumatic injury, and 1 from 
unknown causes). Two other nonfatal gastroenteritis or diarrhea cases were reported, including 
1 with convulsions; 1 infant had transient renal insufficiency associated with dehydration. The 
absence of control groups limits assessments of causality, but it should be assumed that 
perinatally exposed infants may be at risk for adverse reactions comparable to those reported in 
pediatric and adult HIV-1-infected patients treated with lamivudine-containing combination 
regimens. Long-term effects of in utero and infant lamivudine exposure are not known. 
6.2 
Postmarketing Experience 
 
In addition to adverse reactions reported from clinical trials, the following adverse 
reactions have been reported during postmarketing use of EPIVIR. Because these reactions are 
reported voluntarily from a population of unknown size, estimates of frequency cannot be made. 
These reactions have been chosen for inclusion due to a combination of their seriousness, 
frequency of reporting, or potential causal connection to lamivudine. 
 
Body as a Whole: Redistribution/accumulation of body fat [see Warnings and 
Precautions (5.7)]. 
 
Endocrine and Metabolic: Hyperglycemia. 
 
General: Weakness. 
 
Hemic and Lymphatic: Anemia (including pure red cell aplasia and severe anemias 
progressing on therapy). 
 
Hepatic and Pancreatic: Lactic acidosis and hepatic steatosis, posttreatment 
exacerbation of hepatitis B [see Boxed Warning, Warnings and Precautions (5.1, 5.2)]. 
 
10


 
Hypersensitivity: Anaphylaxis, urticaria. 
 
Musculoskeletal: Muscle weakness, CPK elevation, rhabdomyolysis. 
 
Skin: Alopecia, pruritus. 
7 
DRUG INTERACTIONS 
 
Lamivudine is predominantly eliminated in the urine by active organic cationic secretion. 
The possibility of interactions with other drugs administered concurrently should be considered, 
particularly when their main route of elimination is active renal secretion via the organic cationic 
transport system (e.g., trimethoprim). No data are available regarding interactions with other 
drugs that have renal clearance mechanisms similar to that of lamivudine. 
7.1 
Interferon- and Ribavirin-Based Regimens 
 
Although no evidence of a pharmacokinetic or pharmacodynamic interaction (e.g., loss of 
HIV-1/HCV virologic suppression) was seen when ribavirin was coadministered with 
lamivudine in HIV-1/HCV co-infected patients, hepatic decompensation (some fatal) has 
occurred in HIV-1/HCV co-infected patients receiving combination antiretroviral therapy for 
HIV-1 and interferon alfa with or without ribavirin [see Warnings and Precautions (5.4), 
Clinical Pharmacology (12.3)]. 
7.2 
Zalcitabine 
 
Lamivudine and zalcitabine may inhibit the intracellular phosphorylation of one another. 
Therefore, use of lamivudine in combination with zalcitabine is not recommended. 
7.3 
Trimethoprim/Sulfamethoxazole (TMP/SMX) 
 
No change in dose of either drug is recommended. There is no information regarding the 
effect on lamivudine pharmacokinetics of higher doses of TMP/SMX such as those used to treat 
PCP. 
7.4 
Drugs with No Observed Interactions With EPIVIR 
 
A drug interaction study showed no clinically significant interaction between EPIVIR 
and zidovudine. 
8 
USE IN SPECIFIC POPULATIONS 
8.1 
Pregnancy 
 
Pregnancy Category C. There are no adequate and well-controlled studies of EPIVIR in 
pregnant women. Animal reproduction studies in rats and rabbits revealed no evidence of 
teratogenicity. Increased early embryolethality occurred in rabbits at exposure levels similar to 
those in humans. EPIVIR should be used during pregnancy only if the potential benefit justifies 
the potential risk to the fetus. 
 
Lamivudine pharmacokinetics were studied in pregnant women during 2 clinical studies 
conducted in South Africa. The study assessed pharmacokinetics in: 16 women at 36 weeks 
gestation using 150 mg lamivudine twice daily with zidovudine, 10 women at 38 weeks gestation 
using 150 mg lamivudine twice daily with zidovudine, and 10 women at 38 weeks gestation 
using lamivudine 300 mg twice daily without other antiretrovirals. These studies were not 
designed or powered to provide efficacy information. Lamivudine pharmacokinetics in pregnant 
 
11


women were similar to those seen in non-pregnant adults and in postpartum women. Lamivudine 
concentrations were generally similar in maternal, neonatal, and umbilical cord serum samples. 
In a subset of subjects, lamivudine amniotic fluid specimens were collected following natural 
rupture of membranes. Amniotic fluid concentrations of lamivudine were typically 2 times 
greater than maternal serum levels and ranged from 1.2 to 2.5 mcg/mL (150 mg twice daily) and 
2.1 to 5.2 mcg/mL (300 mg twice daily). It is not known whether risks of adverse events 
associated with lamivudine are altered in pregnant women compared with other HIV-1-infected 
patients. 
 
Animal reproduction studies performed at oral doses up to 130 and 60 times the adult 
dose in rats and rabbits, respectively, revealed no evidence of teratogenicity due to lamivudine. 
Increased early embryolethality occurred in rabbits at exposure levels similar to those in humans. 
However, there was no indication of this effect in rats at exposure levels up to 35 times those in 
humans. Based on animal studies, lamivudine crosses the placenta and is transferred to the fetus 
[see Nonclinical Toxicology (13.2)]. 
 
Antiretroviral Pregnancy Registry: To monitor maternal-fetal outcomes of pregnant 
women exposed to lamivudine, a Pregnancy Registry has been established. Physicians are 
encouraged to register patients by calling 1-800-258-4263. 
8.3 
Nursing Mothers 
 
The Centers for Disease Control and Prevention recommend that HIV-1-infected mothers 
in the United States not breastfeed their infants to avoid risking postnatal transmission of HIV-1 
infection. Because of the potential for serious adverse reactions in nursing infants and HIV-1 
transmission, mothers should be instructed not to breastfeed if they are receiving lamivudine. 
 
Lamivudine is excreted into human milk. Samples of breast milk obtained from 
20 mothers receiving lamivudine monotherapy (300 mg twice daily) or combination therapy 
(150 mg lamivudine twice daily and 300 mg zidovudine twice daily) had measurable 
concentrations of lamivudine. 
8.4 
Pediatric Use 
 
The safety and effectiveness of twice-daily EPIVIR in combination with other 
antiretroviral agents have been established in pediatric patients 3 months and older [see Adverse 
Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.2)]. 
8.5 
Geriatric Use 
 
Clinical studies of EPIVIR did not include sufficient numbers of subjects aged 65 and 
over to determine whether they respond differently from younger subjects. In general, dose 
selection for an elderly patient should be cautious, reflecting the greater frequency of decreased 
hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. In 
particular, because lamivudine is substantially excreted by the kidney and elderly patients are 
more likely to have decreased renal function, renal function should be monitored and dosage 
adjustments should be made accordingly [see Dosage and Administration (2.3), Clinical 
Pharmacology (12.3)]. 
8.6 
Patients With Impaired Renal Function 
 
12


 
Reduction of the dosage of EPIVIR is recommended for patients with impaired renal 
function [see Dosage and Administration (2.3), Clinical Pharmacology (12.3)]. 
10 
OVERDOSAGE 
 
There is no known antidote for EPIVIR. One case of an adult ingesting 6 g of EPIVIR 
was reported; there were no clinical signs or symptoms noted and hematologic tests remained 
normal. Two cases of pediatric overdose were reported in Study ACTG300. One case involved a 
single dose of 7 mg/kg of EPIVIR; the second case involved use of 5 mg/kg of EPIVIR twice 
daily for 30 days. There were no clinical signs or symptoms noted in either case. Because a 
negligible amount of lamivudine was removed via (4-hour) hemodialysis, continuous ambulatory 
peritoneal dialysis, and automated peritoneal dialysis, it is not known if continuous hemodialysis 
would provide clinical benefit in a lamivudine overdose event. If overdose occurs, the patient 
should be monitored, and standard supportive treatment applied as required. 
11 
DESCRIPTION 
 
EPIVIR (also known as 3TC) is a brand name for lamivudine, a synthetic nucleoside 
analogue with activity against HIV-1 and HBV. The chemical name of lamivudine is (2R,cis)-4-
amino-1-(2-hydroxymethyl-1,3-oxathiolan-5-yl)-(1H)-pyrimidin-2-one. Lamivudine is the 
(-)enantiomer of a dideoxy analogue of cytidine. Lamivudine has also been referred to as (-)2′,3′-
dideoxy, 3′-thiacytidine. It has a molecular formula of C8H11N3O3S and a molecular weight of 
229.3. It has the following structural formula: 
 
 
Lamivudine is a white to off-white crystalline solid with a solubility of approximately 
70 mg/mL in water at 20°C. 
 
EPIVIR Tablets are for oral administration. Each scored 150-mg film-coated tablet 
contains 150 mg of lamivudine and the inactive ingredients hypromellose, magnesium stearate, 
microcrystalline cellulose, polyethylene glycol, polysorbate 80, sodium starch glycolate, and 
titanium dioxide. 
 
Each 300-mg film-coated tablet contains 300 mg of lamivudine and the inactive 
ingredients black iron oxide, hypromellose, magnesium stearate, microcrystalline cellulose, 
polyethylene glycol, polysorbate 80, sodium starch glycolate, and titanium dioxide. 
 
EPIVIR Oral Solution is for oral administration. One milliliter (1 mL) of EPIVIR Oral 
 
13


Solution contains 10 mg of lamivudine (10 mg/mL) in an aqueous solution and the inactive 
ingredients artificial strawberry and banana flavors, citric acid (anhydrous), methylparaben, 
propylene glycol, propylparaben, sodium citrate (dihydrate), and sucrose (200 mg). 
12 
CLINICAL PHARMACOLOGY 
12.1 Mechanism of Action 
 
Lamivudine is an antiviral agent [see Clinical Pharmacology (12.4)]. 
12.3 Pharmacokinetics 
 
Pharmacokinetics in Adults: The pharmacokinetic properties of lamivudine have been 
studied in asymptomatic, HIV-1-infected adult patients after administration of single intravenous 
(IV) doses ranging from 0.25 to 8 mg/kg, as well as single and multiple (twice-daily regimen) 
oral doses ranging from 0.25 to 10 mg/kg. 
 
The pharmacokinetic properties of lamivudine have also been studied as single and 
multiple oral doses ranging from 5 mg to 600 mg/day administered to HBV-infected patients. 
 
The steady-state pharmacokinetic properties of the EPIVIR 300-mg tablet once daily for 
7 days compared with the EPIVIR 150-mg tablet twice daily for 7 days were assessed in a 
crossover study in 60 healthy volunteers. EPIVIR 300 mg once daily resulted in lamivudine 
exposures that were similar to EPIVIR 150 mg twice daily with respect to plasma AUC24,ss; 
however, Cmax,ss was 66% higher and the trough value was 53% lower compared with the 
150-mg twice-daily regimen. Intracellular lamivudine triphosphate exposures in peripheral blood 
mononuclear cells were also similar with respect to AUC24,ss and Cmax24,ss; however, trough 
values were lower compared with the 150-mg twice-daily regimen. Inter-subject variability was 
greater for intracellular lamivudine triphosphate concentrations versus lamivudine plasma trough 
concentrations. The clinical significance of observed differences for both plasma lamivudine 
concentrations and intracellular lamivudine triphosphate concentrations is not known. 
 
 
Absorption and Bioavailability: Lamivudine was rapidly absorbed after oral 
administration in HIV-1-infected patients. Absolute bioavailability in 12 adult patients was 
86% ± 16% (mean ± SD) for the 150-mg tablet and 87% ± 13% for the oral solution. After oral 
administration of 2 mg/kg twice a day to 9 adults with HIV-1, the peak serum lamivudine 
concentration (Cmax) was 1.5 ± 0.5 mcg/mL (mean ± SD). The area under the plasma 
concentration versus time curve (AUC) and Cmax increased in proportion to oral dose over the 
range from 0.25 to 10 mg/kg. 
 
The accumulation ratio of lamivudine in HIV-1-positive asymptomatic adults with 
normal renal function was 1.50 following 15 days of oral administration of 2 mg/kg twice daily. 
 
 
 
Effects of Food on Oral Absorption: An investigational 25-mg dosage form of 
lamivudine was administered orally to 12 asymptomatic, HIV-1-infected patients on 2 occasions, 
once in the fasted state and once with food (1,099 kcal; 75 grams fat, 34 grams protein, 72 grams 
carbohydrate). Absorption of lamivudine was slower in the fed state (Tmax: 3.2 ± 1.3 hours) 
compared with the fasted state (Tmax: 0.9 ± 0.3 hours); Cmax in the fed state was 40% ± 23% 
(mean ± SD) lower than in the fasted state. There was no significant difference in systemic 
 
14


exposure (AUC∞) in the fed and fasted states; therefore, EPIVIR Tablets and Oral Solution may 
be administered with or without food. 
 
 
Distribution: The apparent volume of distribution after IV administration of 
lamivudine to 20 patients was 1.3 ± 0.4 L/kg, suggesting that lamivudine distributes into 
extravascular spaces. Volume of distribution was independent of dose and did not correlate with 
body weight. 
 
Binding of lamivudine to human plasma proteins is low (<36%). In vitro studies showed 
that over the concentration range of 0.1 to 100 mcg/mL, the amount of lamivudine associated 
with erythrocytes ranged from 53% to 57% and was independent of concentration. 
 
 
Metabolism: Metabolism of lamivudine is a minor route of elimination. In man, the 
only known metabolite of lamivudine is the trans-sulfoxide metabolite. Within 12 hours after a 
single oral dose of lamivudine in 6 HIV-1-infected adults, 5.2% ± 1.4% (mean ± SD) of the dose 
was excreted as the trans-sulfoxide metabolite in the urine. Serum concentrations of this 
metabolite have not been determined. 
 
 
Elimination: The majority of lamivudine is eliminated unchanged in urine by active 
organic cationic secretion. In 9 healthy subjects given a single 300-mg oral dose of lamivudine, 
renal clearance was 199.7 ± 56.9 mL/min (mean ± SD). In 20 HIV-1-infected patients given a 
single IV dose, renal clearance was 280.4 ± 75.2 mL/min (mean ± SD), representing 71% ± 16% 
(mean ± SD) of total clearance of lamivudine. 
 
In most single-dose studies in HIV-1-infected patients, HBV-infected patients, or healthy 
subjects with serum sampling for 24 hours after dosing, the observed mean elimination half-life 
(t½) ranged from 5 to 7 hours. In HIV-1-infected patients, total clearance was 
398.5 ± 69.1 mL/min (mean ± SD). Oral clearance and elimination half-life were independent of 
dose and body weight over an oral dosing range of 0.25 to 10 mg/kg. 
 
Special Populations: Renal Impairment: The pharmacokinetic properties of 
lamivudine have been determined in a small group of HIV-1-infected adults with impaired renal 
function (Table 7). 
 
Table 7. Pharmacokinetic Parameters (Mean ± SD) After a Single 300-mg Oral Dose of 
Lamivudine in 3 Groups of Adults With Varying Degrees of Renal Function 
 
Creatinine Clearance Criterion 
(Number of Subjects) 
 
Parameter 
>60 mL/min 
(n = 6) 
10-30 mL/min 
(n = 4) 
<10 mL/min 
(n = 6) 
Creatinine clearance (mL/min) 
111 ± 14 
28 ± 8 
6 ± 2  
Cmax (mcg/mL) 
2.6 ± 0.5 
3.6 ± 0.8 
5.8 ± 1.2 
AUC∞ (mcg•hr/mL) 
11.0 ± 1.7 
48.0 ± 19 
157 ± 74 
Cl/F (mL/min) 
464 ± 76 
114 ± 34 
36 ± 11 
 
 
Exposure (AUC∞), Cmax, and half-life increased with diminishing renal function (as 
 
15


expressed by creatinine clearance). Apparent total oral clearance (Cl/F) of lamivudine decreased 
as creatinine clearance decreased. Tmax was not significantly affected by renal function. Based on 
these observations, it is recommended that the dosage of lamivudine be modified in patients with 
renal impairment [see Dosage and Administration (2.3)]. 
 
Based on a study in otherwise healthy subjects with impaired renal function, 
hemodialysis increased lamivudine clearance from a mean of 64 to 88 mL/min; however, the 
length of time of hemodialysis (4 hours) was insufficient to significantly alter mean lamivudine 
exposure after a single-dose administration. Continuous ambulatory peritoneal dialysis and 
automated peritoneal dialysis have negligible effects on lamivudine clearance. Therefore, it is 
recommended, following correction of dose for creatinine clearance, that no additional dose 
modification be made after routine hemodialysis or peritoneal dialysis. 
 
It is not known whether lamivudine can be removed by continuous (24-hour) 
hemodialysis. 
 
The effects of renal impairment on lamivudine pharmacokinetics in pediatric patients are 
not known. 
 
 
Hepatic Impairment: The pharmacokinetic properties of lamivudine have been 
determined in adults with impaired hepatic function. Pharmacokinetic parameters were not 
altered by diminishing hepatic function; therefore, no dose adjustment for lamivudine is required 
for patients with impaired hepatic function. Safety and efficacy of lamivudine have not been 
established in the presence of decompensated liver disease. 
 
 
Pediatric Patients: In Study NUCA2002, pharmacokinetic properties of lamivudine 
were assessed in a subset of 57 HIV-1-infected pediatric patients (age range: 4.8 months to 
16 years, weight range: 5 to 66 kg) after oral and IV administration of 1, 2, 4, 8, 12, and 
20 mg/kg/day. In the 9 infants and children (range: 5 months to 12 years of age) receiving oral 
solution 4 mg/kg twice daily (the usual recommended pediatric dose), absolute bioavailability 
was 66% ± 26% (mean ± SD), which was less than the 86% ± 16% (mean ± SD) observed in 
adults. The mechanism for the diminished absolute bioavailability of lamivudine in infants and 
children is unknown. 
 
Systemic clearance decreased with increasing age in pediatric patients, as shown in 
Figure 1. 
 
 
16


Figure 1. Systemic Clearance (L/hr•kg) of Lamivudine in Relation to Age 
 
 
 
After oral administration of lamivudine 4 mg/kg twice daily to 11 pediatric patients 
ranging from 4 months to 14 years of age, Cmax was 1.1 ± 0.6 mcg/mL and half-life was 
2.0 ± 0.6 hours. (In adults with similar blood sampling, the half-life was 3.7 ± 1 hours.) Total 
exposure to lamivudine, as reflected by mean AUC values, was comparable between pediatric 
patients receiving an 8-mg/kg/day dose and adults receiving a 4-mg/kg/day dose. 
 
Distribution of lamivudine into cerebrospinal fluid (CSF) was assessed in 38 pediatric 
patients after multiple oral dosing with lamivudine. CSF samples were collected between 2 and 
4 hours postdose. At the dose of 8 mg/kg/day, CSF lamivudine concentrations in 8 patients 
ranged from 5.6% to 30.9% (mean ± SD of 14.2% ± 7.9%) of the concentration in a 
simultaneous serum sample, with CSF lamivudine concentrations ranging from 0.04 to 
0.3 mcg/mL. 
 
Limited, uncontrolled pharmacokinetic and safety data are available from administration 
of lamivudine (and zidovudine) to 36 infants up to 1 week of age in 2 studies in South Africa. In 
these studies, lamivudine clearance was substantially reduced in 1-week-old neonates relative to 
pediatric patients (>3 months of age) studied previously. There is insufficient information to 
establish the time course of changes in clearance between the immediate neonatal period and the 
age-ranges >3 months old [see Adverse Reactions (6.1)]. 
 
 
Geriatric Patients: The pharmacokinetics of lamivudine after administration of 
EPIVIR to patients over 65 years of age have not been studied [see Use in Specific Populations 
(8.5)]. 
 
 
Gender: There are no significant gender differences in lamivudine pharmacokinetics. 
 
 
Race: There are no significant racial differences in lamivudine pharmacokinetics. 
 
Drug Interactions: Interferon Alfa: There was no significant pharmacokinetic 
interaction between lamivudine and interferon alfa in a study of 19 healthy male subjects [see 
Warnings and Precautions (5.4)]. 
 
17


 
 
Ribavirin: In vitro data indicate ribavirin reduces phosphorylation of lamivudine, 
stavudine, and zidovudine. However, no pharmacokinetic (e.g., plasma concentrations or 
intracellular triphosphorylated active metabolite concentrations) or pharmacodynamic (e.g., loss 
of HIV-1/HCV virologic suppression) interaction was observed when ribavirin and lamivudine 
(n = 18), stavudine (n = 10), or zidovudine (n = 6) were coadministered as part of a multi-drug 
regimen to HIV-1/HCV co-infected patients [see Warnings and Precautions (5.4)]. 
 
 
Trimethoprim/Sulfamethoxazole: Lamivudine and TMP/SMX were coadministered 
to 14 HIV-1-positive patients in a single-center, open-label, randomized, crossover study. Each 
patient received treatment with a single 300-mg dose of lamivudine and TMP 160 mg/SMX 
800 mg once a day for 5 days with concomitant administration of lamivudine 300 mg with the 
fifth dose in a crossover design. Coadministration of TMP/SMX with lamivudine resulted in an 
increase of 43% ± 23% (mean ± SD) in lamivudine AUC∞, a decrease of 29% ± 13% in 
lamivudine oral clearance, and a decrease of 30% ± 36% in lamivudine renal clearance. The 
pharmacokinetic properties of TMP and SMX were not altered by coadministration with 
lamivudine [see Drug Interactions (7.3)]. 
 
 
Zidovudine: No clinically significant alterations in lamivudine or zidovudine 
pharmacokinetics were observed in 12 asymptomatic HIV-1-infected adult patients given a 
single dose of zidovudine (200 mg) in combination with multiple doses of lamivudine (300 mg q 
12 hr) [see Drug Interactions (7.4)]. 
12.4 Microbiology 
 
Mechanism of Action: Intracellularly, lamivudine is phosphorylated to its active 
5′-triphosphate metabolite, lamivudine triphosphate (3TC-TP). The principal mode of action of 
3TC-TP is the inhibition of HIV-1 reverse transcriptase (RT) via DNA chain termination after 
incorporation of the nucleotide analogue into viral DNA. 3TC-TP is a weak inhibitor of 
mammalian DNA polymerases α, β, and γ. 
 
Antiviral Activity: The antiviral activity of lamivudine against HIV-1 was assessed in a 
number of cell lines (including monocytes and fresh human peripheral blood lymphocytes) using 
standard susceptibility assays. EC50 values (50% effective concentrations) were in the range of 
0.003 to 15 µM (1 μM = 0.23 mcg/mL). HIV-1 from therapy-naive subjects with no amino acid 
substitutions associated with resistance gave median EC50 values of 0.429 µM (range: 0.200 to 
2.007 µM) from Virco (n = 92 baseline samples from COLA40263) and 2.35 µM (1.37 to 
3.68 µM) from Monogram Biosciences (n = 135 baseline samples from ESS30009). The EC50 
values of lamivudine against different HIV-1 clades (A-G) ranged from 0.001 to 0.120 µM, and 
against HIV-2 isolates from 0.003 to 0.120 μM in peripheral blood mononuclear cells. Ribavirin 
(50 μM) decreased the anti-HIV-1 activity of lamivudine by 3.5 fold in MT-4 cells. In 
HIV-1-infected MT-4 cells, lamivudine in combination with zidovudine at various ratios 
exhibited synergistic antiretroviral activity. Please see the full prescribing information for 
EPIVIR-HBV for information regarding the inhibitory activity of lamivudine against HBV. 
 
Resistance: Lamivudine-resistant variants of HIV-1 have been selected in cell culture. 
Genotypic analysis showed that the resistance was due to a specific amino acid substitution in 
 
18


the HIV-1 reverse transcriptase at codon 184 changing the methionine to either isoleucine or 
valine (M184V/I). 
 
HIV-1 strains resistant to both lamivudine and zidovudine have been isolated from 
patients. Susceptibility of clinical isolates to lamivudine and zidovudine was monitored in 
controlled clinical trials. In patients receiving lamivudine monotherapy or combination therapy 
with lamivudine plus zidovudine, HIV-1 isolates from most patients became phenotypically and 
genotypically resistant to lamivudine within 12 weeks. In some patients harboring 
zidovudine-resistant virus at baseline, phenotypic sensitivity to zidovudine was restored by 
12 weeks of treatment with lamivudine and zidovudine. Combination therapy with lamivudine 
plus zidovudine delayed the emergence of mutations conferring resistance to zidovudine. 
 
Lamivudine-resistant HBV isolates develop substitutions (rtM204V/I) in the YMDD 
motif of the catalytic domain of the viral reverse transcriptase. rtM204V/I substitutions are 
frequently accompanied by other substitutions (rtV173L, rtL180M) which enhance the level of 
lamivudine resistance or act as compensatory mutations improving replication efficiency. Other 
substitutions detected in lamivudine-resistant HBV isolates include: rtL80I and rtA181T. Similar 
HBV mutants have been reported in HIV-1-infected patients who received 
lamivudine-containing antiretroviral regimens in the presence of concurrent infection with 
hepatitis B virus [see Warnings and Precautions (5.2)]. 
 
Cross-Resistance: Lamivudine-resistant HIV-1 mutants were cross-resistant to 
didanosine (ddI) and zalcitabine (ddC). In some patients treated with zidovudine plus didanosine 
or zalcitabine, isolates resistant to multiple reverse transcriptase inhibitors, including lamivudine, 
have emerged. 
 
Genotypic and Phenotypic Analysis of On-Therapy HIV-1 Isolates From Patients 
With Virologic Failure: Study EPV20001: Fifty-three of 554 (10%) patients enrolled in 
EPV20001 were identified as virological failures (plasma HIV-1 RNA level ≥400 copies/mL) by 
Week 48. Twenty-eight patients were randomized to the lamivudine once-daily treatment group 
and 25 to the lamivudine twice-daily treatment group. The median baseline plasma HIV-1 RNA 
levels of patients in the lamivudine once-daily group and lamivudine twice-daily group were 
4.9 log10 copies/mL and 4.6 log10 copies/mL, respectively. 
 
Genotypic analysis of on-therapy isolates from 22 patients identified as virologic failures 
in the lamivudine once-daily group showed that isolates from 0/22 patients contained 
treatment-emergent amino acid substitutions associated with zidovudine resistance (M41L, 
D67N, K70R, L210W, T215Y/F, or K219Q/E), isolates from 10/22 patients contained 
treatment-emergent amino acid substitutions associated with efavirenz resistance (L100I, K101E, 
K103N, V108I, or Y181C), and isolates from 8/22 patients contained a treatment-emergent 
lamivudine resistance-associated substitution (M184I or M184V). 
 
Genotypic analysis of on-therapy isolates from patients (n = 22) in the lamivudine 
twice-daily treatment group showed that isolates from 1/22 patients contained 
treatment-emergent zidovudine resistance substitutions, isolates from 7/22 contained 
treatment-emergent efavirenz resistance substitutions, and isolates from 5/22 contained 
 
19


treatment-emergent lamivudine resistance substitutions. 
 
Phenotypic analysis of baseline-matched on-therapy HIV-1 isolates from patients 
(n = 13) receiving lamivudine once daily showed that isolates from 12/13 patients were 
susceptible to zidovudine; isolates from 8/13 patients exhibited a 25- to 295-fold decrease in 
susceptibility to efavirenz, and isolates from 7/13 patients showed an 85- to 299-fold decrease in 
susceptibility to lamivudine. 
 
Phenotypic analysis of baseline-matched on-therapy HIV-1 isolates from patients 
(n = 13) receiving lamivudine twice daily showed that isolates from all 13 patients were 
susceptible to zidovudine; isolates from 3/13 patients exhibited a 21- to 342-fold decrease in 
susceptibility to efavirenz, and isolates from 4/13 patients exhibited a 29- to 159-fold decrease in 
susceptibility to lamivudine. 
 
 
Study EPV40001: Fifty patients received zidovudine 300 mg twice daily plus 
abacavir 300 mg twice daily plus lamivudine 300 mg once daily and 50 patients received 
zidovudine 300 mg plus abacavir 300 mg plus lamivudine 150 mg all twice daily. The median 
baseline plasma HIV-1 RNA levels for patients in the 2 groups were 4.79 log10 copies/mL and 
4.83 log10 copies/mL, respectively. Fourteen of 50 patients in the lamivudine once-daily 
treatment group and 9 of 50 patients in the lamivudine twice-daily group were identified as 
virologic failures. 
 
Genotypic analysis of on-therapy HIV-1 isolates from patients (n = 9) in the lamivudine 
once-daily treatment group showed that isolates from 6 patients had an abacavir and/or 
lamivudine resistance-associated substitution M184V alone. On-therapy isolates from patients 
(n = 6) receiving lamivudine twice daily showed that isolates from 2 patients had M184V alone, 
and isolates from 2 patients harbored the M184V substitution in combination with zidovudine 
resistance-associated amino acid substitutions. 
 
Phenotypic analysis of on-therapy isolates from patients (n = 6) receiving lamivudine 
once daily showed that HIV-1 isolates from 4 patients exhibited a 32- to 53-fold decrease in 
susceptibility to lamivudine. HIV-1 isolates from these 6 patients were susceptible to zidovudine. 
 
Phenotypic analysis of on-therapy isolates from patients (n = 4) receiving lamivudine 
twice daily showed that HIV-1 isolates from 1 patient exhibited a 45-fold decrease in 
susceptibility to lamivudine and a 4.5-fold decrease in susceptibility to zidovudine. 
13 
NONCLINICAL TOXICOLOGY 
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility 
 
Long-term carcinogenicity studies with lamivudine in mice and rats showed no evidence 
of carcinogenic potential at exposures up to 10 times (mice) and 58 times (rats) those observed in 
humans at the recommended therapeutic dose for HIV-1 infection. Lamivudine was not active in 
a microbial mutagenicity screen or an in vitro cell transformation assay, but showed weak 
in vitro mutagenic activity in a cytogenetic assay using cultured human lymphocytes and in the 
mouse lymphoma assay. However, lamivudine showed no evidence of in vivo genotoxic activity 
in the rat at oral doses of up to 2,000 mg/kg, producing plasma levels of 35 to 45 times those in 
 
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humans at the recommended dose for HIV-1 infection. In a study of reproductive performance, 
lamivudine administered to rats at doses up to 4,000 mg/kg/day, producing plasma levels 47 to 
70 times those in humans, revealed no evidence of impaired fertility and no effect on the 
survival, growth, and development to weaning of the offspring. 
13.2 Reproductive Toxicology Studies 
 
Reproduction studies have been performed in rats and rabbits at orally administered doses 
up to 4,000 mg/kg/day and 1,000 mg/kg/day, respectively, producing plasma levels up to 
approximately 35 times that for the adult HIV dose. No evidence of teratogenicity due to 
lamivudine was observed. Evidence of early embryolethality was seen in the rabbit at exposure 
levels similar to those observed in humans, but there was no indication of this effect in the rat at 
exposure levels up to 35 times those in humans. Studies in pregnant rats and rabbits showed that 
lamivudine is transferred to the fetus through the placenta. 
14 
CLINICAL STUDIES 
 
The use of EPIVIR is based on the results of clinical studies in HIV-1-infected patients in 
combination regimens with other antiretroviral agents. Information from trials with clinical 
endpoints or a combination of CD4+ cell counts and HIV-1 RNA measurements is included 
below as documentation of the contribution of lamivudine to a combination regimen in 
controlled trials. 
14.1 Adults 
 
Clinical Endpoint Study: NUCB3007 (CAESAR) was a multi-center, double-blind, 
placebo-controlled study comparing continued current therapy (zidovudine alone [62% of 
patients] or zidovudine with didanosine or zalcitabine [38% of patients]) to the addition of 
EPIVIR or EPIVIR plus an investigational non-nucleoside reverse transcriptase inhibitor 
(NNRTI), randomized 1:2:1. A total of 1,816 HIV-1-infected adults with 25 to 
250 CD4+ cells/mm3 (median = 122 cells/mm3) at baseline were enrolled: median age was 
36 years, 87% were male, 84% were nucleoside-experienced, and 16% were therapy-naive. The 
median duration on study was 12 months. Results are summarized in Table 8. 
 
Table 8. Number of Patients (%) With at Least One HIV-1 Disease Progression Event or 
Death 
Endpoint 
Current Therapy 
(n = 460) 
EPIVIR plus 
Current Therapy 
(n = 896) 
EPIVIR plus an 
NNRTIa plus Current 
Therapy 
(n = 460) 
HIV-1 progression or death 
90 (19.6%) 
86 (9.6%) 
41 (8.9%) 
Death 
27 (5.9%) 
23 (2.6%) 
14 (3.0%) 
a An investigational non-nucleoside reverse transcriptase inhibitor not approved in the United 
States. 
 
 
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Surrogate Endpoint Studies: Dual Nucleoside Analogue Studies: Principal clinical 
trials in the initial development of lamivudine compared lamivudine/zidovudine combinations 
with zidovudine monotherapy or with zidovudine plus zalcitabine. These studies demonstrated 
the antiviral effect of lamivudine in a 2-drug combination. More recent uses of lamivudine in 
treatment of HIV-1 infection incorporate it into multiple-drug regimens containing at least 
3 antiretroviral drugs for enhanced viral suppression. 
 
 
Dose Regimen Comparison Surrogate Endpoint Studies in Therapy-Naive 
Adults: EPV20001 was a multi-center, double-blind, controlled study in which patients were 
randomized 1:1 to receive EPIVIR 300 mg once daily or EPIVIR 150 mg twice daily, in 
combination with zidovudine 300 mg twice daily and efavirenz 600 mg once daily. A total of 
554 antiretroviral treatment-naive HIV-1-infected adults enrolled: male (79%), Caucasian (50%), 
median age of 35 years, baseline CD4+ cell counts of 69 to 1,089 cells/mm3 
(median = 362 cells/mm3), and median baseline plasma HIV-1 RNA of 4.66 log10 copies/mL. 
Outcomes of treatment through 48 weeks are summarized in Figure 2 and Table 9. 
 
Figure 2. Virologic Response Through Week 48, EPV20001ab (Intent-to-Treat) 
 
 
a Roche AMPLICOR HIV-1 MONITOR. 
b Responders at each visit are patients who had achieved and maintained HIV-1 RNA 
<400 copies/mL without discontinuation by that visit. 
 
 
22


Table 9. Outcomes of Randomized Treatment Through 48 Weeks (Intent-to-Treat) 
Outcome 
EPIVIR 300 mg 
Once Daily 
plus RETROVIR 
plus Efavirenz 
(n = 278) 
EPIVIR 150 mg 
Twice Daily 
plus RETROVIR 
plus Efavirenz 
(n = 276) 
Respondera
67% 
65% 
Virologic failureb
8% 
8% 
Discontinued due to clinical progression 
<1% 
0% 
Discontinued due to adverse events 
6% 
12% 
Discontinued due to other reasonsc
18% 
14% 
a Achieved confirmed plasma HIV-1 RNA <400 copies/mL and maintained through 48 weeks. 
b Achieved suppression but rebounded by Week 48, discontinued due to virologic failure, 
insufficient viral response according to the investigator, or never suppressed through Week 
48. 
c Includes consent withdrawn, lost to follow-up, protocol violation, data outside the 
study-defined schedule, and randomized but never initiated treatment. 
 
 
The proportions of patients with HIV-1 RNA <50 copies/mL (via Roche Ultrasensitive 
assay) through Week 48 were 61% for patients receiving EPIVIR 300 mg once daily and 63% 
for patients receiving EPIVIR 150 mg twice daily. Median increases in CD4+ cell counts were 
144 cells/mm3 at Week 48 in patients receiving EPIVIR 300 mg once daily and 146 cells/mm3 for 
patients receiving EPIVIR 150 mg twice daily. 
 
A small, randomized, open-label pilot study, EPV40001, was conducted in Thailand. A 
total of 159 treatment-naive adult patients (male 32%, Asian 100%, median age 30 years, 
baseline median CD4+ cell count 380 cells/mm3, median plasma HIV-1 RNA 
4.8 log10 copies/mL) were enrolled. Two of the treatment arms in this study provided a 
comparison between lamivudine 300 mg once daily (n = 54) and lamivudine 150 mg twice daily 
(n = 52), each in combination with zidovudine 300 mg twice daily and abacavir 300 mg twice 
daily. In intent-to-treat analyses of 48-week data, the proportions of patients with HIV-1 RNA 
below 400 copies/mL were 61% (33/54) in the group randomized to once-daily lamivudine and 
75% (39/52) in the group randomized to receive all 3 drugs twice daily; the proportions with 
HIV-1 RNA below 50 copies/mL were 54% (29/54) in the once-daily lamivudine group and 67% 
(35/52) in the all-twice-daily group; and the median increases in CD4+ cell counts were 
166 cells/mm3 in the once-daily lamivudine group and 216 cells/mm3 in the all-twice-daily 
group. 
14.2 Pediatric Patients 
 
Clinical Endpoint Study: ACTG300 was a multi-center, randomized, double-blind study 
that provided for comparison of EPIVIR plus RETROVIR (zidovudine) with didanosine 
monotherapy. A total of 471 symptomatic, HIV-1-infected therapy-naive (≤56 days of 
 
23


antiretroviral therapy) pediatric patients were enrolled in these 2 treatment arms. The median age 
was 2.7 years (range: 6 weeks to 14 years), 58% were female, and 86% were non-Caucasian. The 
mean baseline CD4+ cell count was 868 cells/mm3 (mean: 1,060 cells/mm3 and range: 0 to 
4,650 cells/mm3 for patients ≤5 years of age; mean: 419 cells/mm3 and range: 0 to 
1,555 cells/mm3 for patients >5 years of age) and the mean baseline plasma HIV-1 RNA was 
5.0 log10 copies/mL. The median duration on study was 10.1 months for the patients receiving 
EPIVIR plus RETROVIR and 9.2 months for patients receiving didanosine monotherapy. 
Results are summarized in Table 10. 
 
Table 10. Number of Patients (%) Reaching a Primary Clinical Endpoint (Disease 
Progression or Death) 
Endpoint 
EPIVIR plus RETROVIR 
(n = 236) 
Didanosine 
(n = 235) 
HIV-1 disease progression or death (total) 
15 (6.4%) 
37 (15.7%) 
Physical growth failure 
7 (3.0%) 
6 (2.6%) 
Central nervous system deterioration 
4 (1.7%) 
12 (5.1%) 
CDC Clinical Category C 
2 (0.8%) 
8 (3.4%) 
Death 
2 (0.8%) 
11 (4.7%) 
 
16 
HOW SUPPLIED/STORAGE AND HANDLING 
 
EPIVIR Scored Tablets, 150 mg 
 
White, diamond-shaped, scored, film-coated tablets debossed with “GX CJ7” on both 
sides. 
 
Bottle of 60 tablets (NDC 0173-0470-01) with child-resistant closure. 
 
EPIVIR Tablets, 300 mg 
 
Gray, modified diamond-shaped, film-coated tablets engraved with “GX EJ7” on one 
side and plain on the reverse side. 
 
Bottle of 30 tablets (NDC 0173-0714-00) with child-resistant closure. 
 
Recommended Storage: 
 
Store EPIVIR Tablets at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) 
[see USP Controlled Room Temperature]. 
 
EPIVIR Oral Solution, 10 mg/mL 
 
A clear, colorless to pale yellow, strawberry-banana-flavored liquid, contains 10 mg of 
lamivudine in each 1 mL. 
 
Plastic bottle of 240 mL (NDC 0173-0471-00) with child-resistant closure. This product 
does not require reconstitution. 
 
Recommended Storage: 
 
Store in tightly closed bottles at 25°C (77°F) [see USP Controlled Room Temperature]. 
 
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17 
PATIENT COUNSELING INFORMATION 
17.1 Advice for the Patient 
 
Information About Therapy With EPIVIR: EPIVIR is not a cure for HIV-1 infection 
and patients may continue to experience illnesses associated with HIV-1 infection, including 
opportunistic infections. Patients should remain under the care of a physician when using 
EPIVIR. Patients should be advised that the use of EPIVIR has not been shown to reduce the risk 
of transmission of HIV-1 to others through sexual contact or blood contamination. 
 
Patients should be advised that the long-term effects of EPIVIR are unknown at this time. 
 
Patients should be advised of the importance of taking EPIVIR with combination therapy 
on a regular dosing schedule and to avoid missing doses. 
 
EPIVIR should not be coadministered with drugs containing lamivudine or emtricitabine, 
including COMBIVIR (lamivudine/zidovudine) Tablets, EPZICOM (abacavir sulfate and 
lamivudine) Tablets, TRIZIVIR (abacavir sulfate, lamivudine, and zidovudine), ATRIPLA 
(efavirenz, emtricitabine, and tenofovir), EMTRIVA (emtricitabine) or TRUVADA 
(emtricitabine and tenofovir) [see Warnings and Precautions (5.3)]. 
 
Redistribution/Accumulation of Body Fat: Patients should be informed that 
redistribution or accumulation of body fat may occur in patients receiving antiretroviral therapy, 
including EPIVIR, and that the cause and long-term health effects of these conditions are not 
known at this time [see Warnings and Precautions (5.7)]. 
 
Differences in Formulations of EPIVIR: Patients should be advised that EPIVIR 
Tablets and Oral Solution contain a higher dose of the same active ingredient (lamivudine) as 
EPIVIR-HBV Tablets and Oral Solution. If a decision is made to include lamivudine in the 
HIV-1 treatment regimen of a patient co-infected with HIV-1 and HBV, the formulation and 
dosage of lamivudine in EPIVIR (not EPIVIR-HBV) should be used [see Warnings and 
Precautions (5.2)]. 
 
Co-infection With HIV-1 and HBV: Patients co-infected with HIV-1 and HBV should 
be informed that deterioration of liver disease has occurred in some cases when treatment with 
lamivudine was discontinued. Patients should be advised to discuss any changes in regimen with 
their physician [see Warnings and Precautions (5.2)]. 
 
Risk of Pancreatitis: Parents or guardians should be advised to monitor pediatric 
patients for signs and symptoms of pancreatitis [see Warnings and Precautions (5.5)]. 
 
Sucrose Content of EPIVIR Oral Solution: Diabetic patients should be advised that 
each 15-mL dose of EPIVIR Oral Solution contains 3 grams of sucrose [see Description (11)]. 
 
COMBIVIR, EPIVIR, EPIVIR-HBV, EPZICOM, and TRIZIVIR are registered trademarks of 
GlaxoSmithKline. ATRIPLA, EMTRIVA, and TRUVADA are trademarks of their respective 
owners and are not trademarks of GlaxoSmithKline. The makers of these brands are not 
affiliated with and do not endorse GlaxoSmithKline or its products. 
 
 
25


 
GlaxoSmithKline 
Research Triangle Park, NC 27709 
 
Manufactured under agreement from 
Shire Pharmaceuticals Group plc 
Basingstoke, UK 
 
©2009, GlaxoSmithKline. All rights reserved. 
 
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