Clinical trial NCT03012477
Conditions: Triple-negative Metastatic Breast Cancer
Keywords: Triple-negative metastatic breast cancer
Sponsor: Dana-Farber Cancer Institute
Start date: 2017-01-18; Completion date: 2020-11-30
Enrollment: 34 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This research study is studying a combination of drugs as a possible treatment for triple-negative breast cancer that has spread to other areas of the body. The names of the study interventions involved in this study are:

* Cisplatin
* AZD1775

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

The FDA (the U.S. Food and Drug Administration) has not approved AZD1775 as a treatment for any type of cancer. Cisplatin is FDA approved for other cancers and has been shown to be an active treatment for breast cancer.

AZD1775 is a drug that is designed to block a protein called Wee-1 which may control the ability of certain cancer cells to grow or divide. Cisplatin works by damaging the DNA inside the cancer cells which prevents them from dividing. By combining AZD1775 and Cisplatin, cancer cells may potentially be more effectively killed.

In this research study, the investigators are looking to determine whether the combination of AZD1775 and cisplatin is an effective treatment for triple negative breast cancer that has spread to other parts of the body.

Arms: arm 1: Treatment will consist of one cycle of cisplatin monotherapy (cisplatin 75 mg/m2 IV x1) followed by combination therapy of AZD1775 plus cisplatin starting 21 days(1 cycle) later.

AZD1775 will be administered 200 mg as twice daily oral dosing predetermined dosing schedule, in combination with Cisplatin predetermined dosage every 21 days.

At least 10 patients will undergo a research biopsy within 5-48 hours after beginning cisplatin (Cycle 1 Day 1) and then again within 5-8 hours after the last dose of AZD1775 in cycle 2 (Cycle 2 Day 3).
Interventions: intervention 1: Cisplatin intervention 2: AZD1775
Intervention descriptions: intervention 1: chemotherapy intervention 2: Wee1 tyrosine kinase inhibitor

Protocol documents:
Prot_SAP_000.pdf: 
 
 
Page 1 
 
NCI Protocol #: 
N/A 
 
DF/HCC Protocol #: 16-264  
 
TITLE: A Phase II study of cisplatin + AZD1775 in metastatic triple-negative breast cancer and 
evaluation of pCDC2 as a biomarker of target response  
 
Coordinating Center:  Dana-Farber/Harvard Cancer Center   
 
 
 
*Principal Investigator (PI): 
Sara Tolaney, MD, MPH 
Dana-Farber Cancer Institute 
Brigham and Women’s Hospital 
450 Brookline Avenue  
Yawkey 1257  
Boston, MA 02215  
617-632-5743  
617-632-1930  
stolaney@partners.org   
 
Other Investigators: 
 
 
Eliezer Van Allen, MD, PhD 
 
Dana-Farber Cancer Institute 
 
450 Brookline Avenue 
 
Boston, MA 02215 
 
 
Geoffrey Shapiro  
Dana-Faber Cancer Institute 
450 Brookline Avenue  
Boston, MA 02215  
617-632-5743  
617-632-1930  
 
 
Supplied Agent(s):  AZD-1775 (AstraZeneca) 
Other Agent(s):  Cisplatin  
 
 
IND #: 130918 
IND Sponsor:  Sara Tolaney, MD MPH 
 
 
Protocol Type / Version # / Version Date: 
Amendment, Version 8, July 5, 2019 
 
 


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SCHEMA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. Patients have received 0 (limited to n = 20 patients) to 1 line of chemotherapy in the 
metastatic setting. 
2. All patients with tumor that is accessible to biopsy will undergo research biopsies. 
Cisplatin 
(cycle 1) 
 
Cisplatin  
+ 
AZD1775 
(cycle 2+) 
every 21 days 
until progression 
21 days 
Progression 
Off study 
Research Biopsy2 
Within 5-48hrs 
after monotherapy 
Research Biopsy2 
within 5-8hrs post the 
last dose of AZD1775 
Metastatic 
Triple-Negative 
Breast Cancer1 


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TABLE OF CONTENTS 
 
SCHEMA .........................................................................................................................................2 
1. 
OBJECTIVES ......................................................................................................................5 
1.1 
Study Design ............................................................................................................5 
1.2 
Primary Objectives...................................................................................................5 
1.3 
Secondary Objectives...............................................................................................5 
2. 
BACKGROUND .................................................................................................................6 
2.1 
Study Disease(s).......................................................................................................6 
2.2 
AZD1775 .................................................................................................................6 
2.3 
Cisplatin ...................................................................................................................7 
2.4 
Rationale ..................................................................................................................9 
2.5 
Correlative Studies Background ..............................................................................9 
3. 
PARTICIPANT SELECTION ...........................................................................................10 
3.1 
Inclusion Criteria ...................................................................................................10 
3.2 
Exclusion Criteria ..................................................................................................13 
3.3 
Inclusion of Women and Minorities ......................................................................14 
4. 
REGISTRATION PROCEDURES ...................................................................................15 
4.1 
General Guidelines for DF/HCC Institutions ........................................................15 
4.2 
Registration Process for DF/HCC Institutions .......................................................15 
5. 
TREATMENT PLAN ........................................................................................................15 
5.1 
Treatment Regimen ................................................................................................15 
5.2 
Pre-Treatment Criteria ...........................................................................................16 
5.3 
Agent Administration.............................................................................................16 
5.4 
General Concomitant Medication and Supportive Care Guidelines ......................17 
5.5 
Criteria for Taking a Participant Off Protocol Therapy .........................................21 
5.6 
Duration of Follow Up ...........................................................................................22 
5.7 
Criteria for Taking a Participant Off Study ...........................................................22 
6. 
DOSING DELAYS/DOSE MODIFICATIONS ...............................................................22 
7. 
ADVERSE EVENTS .........................................................................................................32 
7.1 
Adverse Event Characteristics ...............................................................................32 
7.2 
Expedited Adverse Event Reporting ......................................................................32 
7.3 
Expedited Reporting to the Food and Drug Administration (FDA) ......................32 
7.4 
Expedited Reporting to AstraZeneca .....................................................................33 
7.5 
Routine Adverse Event Reporting .........................................................................33 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................34 
8.1 
AZD1775 ...............................................................................................................34 
8.2 
Cisplatin .................................................................................................................35 


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9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................37 
9.1 
Biomarker Studies ..................................................................................................37 
9.2 
Laboratory Correlative Studies ..............................................................................39 
10. 
STUDY CALENDAR .......................................................................................................45 
11. 
MEASUREMENT OF EFFECT........................................................................................48 
11.1 
Antitumor Effect – Solid Tumors ..........................................................................48 
12. 
DATA REPORTING / REGULATORY REQUIREMENTS ...........................................55 
12.1 
Data Reporting .......................................................................................................55 
12.2 
Data Safety Monitoring..........................................................................................56 
13. 
STATISTICAL CONSIDERATIONS...............................................................................56 
13.1 
Study Design/Endpoints.........................................................................................56 
13.2 
Analysis of Primary Endpoints ..............................................................................57 
13.3 
Analysis of Secondary Endpoints ..........................................................................57 
14. 
PUBLICATION PLAN .....................................................................................................58 
REFERENCES ..............................................................................................................................59 
APPENDIX A 
PERFORMANCE STATUS CRITERIA41 ..............................................63 
 
APPENDIX B            NEW YORK HEART ASSOCIATION HEART HAILURE 
CLASSIFICATIONS.....................................................................................................................59 
APPENDIX C TISSUE AQUISITION GUIDELINES ................................................................60 
 
 


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1. OBJECTIVES 
 
1.1 
Study Design 
 
This is a single-arm, two-stage Phase 2 study assessing the efficacy of AZD1775, a Wee1 
tyrosine kinase inhibitor, given in combination with cisplatin chemotherapy.  The population to 
be studied will consist of approximately 35 patients with metastatic triple-negative breast cancer 
who have received 0 to 1 line of chemotherapy in the metastatic setting.  All patients must have 
measurable disease at baseline and have archival tissue available. Treatment will consist of  one 
cycle of cisplatin monotherapy (cisplatin 75 mg/m2 IV x1) followed by combination therapy of  
AZD1775 plus cisplatin starting 21 days later.  AZD1775 will be administered as twice daily oral 
dosing (AZD1775 200 mg po bid) x 5 doses over 2.5 days, in combination with cisplatin 75 
mg/m2 IV every 21 days.  At least 10 patients will undergo a research biopsy within 5-48 hours 
after cisplatin monotherapy and then again within 5-8 hours after the last dose of AZD1775 in 
cycle 2 of cisplatin +AZD1775.  Patients will undergo restaging scans every 6 weeks, those with 
complete responses, partial responses, and stable disease, will continue to receive study 
treatment.  Patients with progressive disease will be taken off study.   
 
1.2 
Primary Objectives 
 
The primary objective of the study is:  
 
1. To evaluate the activity of AZD1775 in combination with cisplatin, as defined by 
objective response rate (ORR) in patients with triple-negative metastatic breast cancer 
 
 
1.3 
Secondary Objectives 
 
The secondary objectives of the study are: 
 
1) To evaluate Progression Free Survival (PFS). 
 
2) To evaluate change in pCDC2 after therapy with AZD1775 in paired biopsies 
 
3) Evaluate incidence of p53 mutations in tumor tissue and correlate mutational status with 
response 
 
4) To evaluate change in markers for DNA damage (gamma-H2AX,  phospho-Histone 3, 
and caspase 3) after exposure to cisplatin + AZD1775 compared to cisplatin therapy 
alone in paired biopsy samples 
 
5) To evaluate the incidence BRCA1 and BRCA2 mutations, and correlate mutational status 
with response 
 


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6) To explore other possible gene mutations that may correlate with response. 
 
7) To correlate next generation sequencing of tumors with participant outcomes (ORR and 
PFS) in DFCI participants only.  
 
 
2. BACKGROUND 
 
2.1 
Study Disease(s) 
 
Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer 
death in American women.  Despite recent advances in breast cancer treatment, metastatic 
disease remains incurable.  One possible limitation of our therapies has been an inability to select 
subsets of patients most likely to benefit from specific therapies.  With the development of gene 
expression array technology, the heterogeneity of breast cancer has become clearer and the 
identification of novel cancer subtypes has reinvigorated the search for more specific and 
effective therapies.  Hierarchical clustering of genomic expression data from breast cancer 
specimens have demonstrated several distinct tumor subgroups with unique expression profiles, 
including a HER2-positive subgroup, an estrogen-receptor (ER)positive group, and a “basal-like” 
group.1  Hormonal therapies are only effective for ER or PR positive breast cancer, and the 
monoclonal antibody trastuzumab is effective only for tumors that have amplified HER2 genes.   
 
The basal-like tumors have a poor prognosis relative to other subtypes1, even with the best 
available chemotherapy.  Approximately 15% of women are diagnosed with this form of breast 
cancer, with a disproportionate distribution in younger women or BRCA1 mutation carriers. 
Little progress has been made in identifying specific molecular pathways associated with these 
refractory cancers that may be effectively targeted for therapeutic purposes. Thus, no proven, 
specific therapy exists for this tumor subtype. A common feature of tumors in the basal-like 
subgroup is the lack of expression of ER, PgR, and HER2 (hence the term ‘’triple-negative’’ 
breast cancer) as well as the expression of the Epidermal Growth Factor Receptor (EGFR) and 
certain cytokeratins (cytokeratin 5/6) that indicate a basal differentiation for these breast tumors2. 
The gene expression signature of the basal-like tumors shows high levels of expression of 
proliferation-associated genes and genes that are normally expressed in myoepithelial or basal 
cells of normal breast tissue, such as the basal keratins and smooth muscle actin. There are 
similarities between this subgroup and tumors with germline BRCA1 mutations, which also 
typically lack ER and PR receptors, are histologically high grade, and are reported to be positive 
for basal-like keratins3,4.  
 
2.2 
AZD1775 
 
Cytotoxic agents remain a key component of cancer therapy. Tumor cells rely on cell cycle 
checkpoints for repair of DNA damage induced by cytotoxic agents. Cytotoxic agents that induce 
DNA damage activate cell cycle checkpoints in proliferating cells. These checkpoints cause 
transient arrest at the G1-, S-, and G2-phase of cycling cells, allowing time to repair the DNA or 
initiate apoptosis if the DNA damage is too extensive. Human tumor cells are most sensitive to 


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chemotherapy during the phase of DNA replication (S-Phase) which is variable in length and 
lasts up to ~60 hrs in human tumors in-situ. While DNA checkpoints can protect normal cells 
from DNA damage, they also reduce the effectiveness of chemotherapy on tumor cells by 
allowing tumor cells to repair DNA damage induced by chemotherapy. Thus, selective inhibition 
of checkpoints in tumor cells is predicted to enhance the efficacy of DNA-damaging agents since 
mutations will not be repaired5–7.  
Wee1 is a tyrosine kinase that selectively phosphorylates the Tyr15 residue of cyclin-dependent 
kinase 1 (also known as CDC2) and inactivates its activity.8–11 AZD1775 is a highly selective, 
small-molecule, inhibitor of Wee1 kinase activity. The protein p53 regulates the G1 checkpoint, 
while the Wee 1 tyrosine kinase regulates the G2 checkpoint by selectively phosphorylating 
CDC2.  Phosphorylation of CDC2 inhibits its kinase activity, which abrogates G2 cell cycle 
arrest after DNA damage.  Therefore, p53 deficient tumor cells lacking the G1 checkpoint are 
dependent on the G2 checkpoint for survival following DNA damage.  G2 checkpoint abrogation 
is a therapeutic strategy designed to prevent cell cycle arrest in response to DNA damage, 
resulting in impaired DNA repair and increased tumor cell death5,6.  Because wild type p53 cells 
retain both the G1 checkpoint and back-up p53-dependent pathways at the G2 checkpoint, G2 
checkpoint abrogation in combination with DNA damage in p53 deficient cells is expected to 
selectively enhance cell death12.   
 
2.3 
Cisplatin  
 
Cisplatin and Breast Cancer 
Platinum was studied in breast cancer in the 1970s and was shown to be active when given early 
in the course of the disease, but it was not adopted, perhaps because of the superior therapeutic 
index of other drugs then under development (the taxanes). The drug was initially tested in 
patients with advanced breast cancer, both as a single agent and in combination with other drugs. 
Small studies demonstrated objective response rates ranging from 42% to 54% with the use of 
cisplatin as a single agent, but response rates were lower in women who had received prior 
chemotherapy for metastatic disease13–15. When cisplatin was given after other chemotherapy, 
the response rate fell to 0-9%16–20. 
Notably, these studies used cisplatin in patients regardless of ER, PgR, and HER2 status. Several 
combination regimens were also explored, particularly cisplatin combined with taxanes, but there 
seemed little reason to continue these combinations when the taxanes were found to be so active 
and relatively nontoxic21. There was also interest in the evaluation of combined treatment with 
docetaxel and platinum. In several studies in unselected cases of metastatic disease, the overall 
response rate with combination regimen was around 50%, even with prior adjuvant anthracycline 
therapy21. 
There has recently been renewed interest in cisplatin for the treatment of breast cancer, in part 
because of improved strategies for managing its side effects, particularly nausea. A 2004 phase 2 
study of preoperative paclitaxel and cisplatin demonstrated a 28% complete response rate and a 
63% partial response rate in patients enrolled without regard to ER, PgR, and HER2 status22. 
These rates are comparable to those for other active regimens. 


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Published data on response rates with cisplatin used as a single agent in women with metastatic 
breast cancer unselected for breast cancer subtype are summarized in Table 2.3.1.  Recent data 
from TBCRC009 demonstrated that platinum therapy (carboplatin or cisplatin) resulted in a 
response rate of 25.6% in the first or second line setting for metastatic triple-negative breast 
cancer, suggesting that these agents are active.  The Triple Negative Breast Cancer Trial (TNT) 
study directly compared single-agent platinum chemotherapy with taxane therapy in the first line 
treatment of metastatic triple-negative breast cancer.  Patients were randomized to carboplatin or 
docetaxel, and the objective response rate in the carboplatin arm was 31.4% compared to 35.6% 
in the docetaxel arm, which was not statistically different (p=0.44).  However, among the 43 
patients with a BRCA mutation, the objective response rate was 68% with carboplatin and 33% 
with docetaxel, which was statistically significant (p=0.03).   
 
Table 2.3.1 Single-Agent Cisplatin in Metastatic Breast Cancer 
Cisplatin Dose 
Response Rate 
Reference No. 
No Prior chemotherapy 
 
 
30mg/m2/d x 4 d every 3 wk 
13/35 
5 
30mg/m2/d x 4 d every 3 wk 
5/12 
6 
30mg/m2/d x 4 d every 3 wk 
9/19 
7 
Total 
33/66(60%) 
 
 Prior chemotherapy 
 
 
35mg/m2/d x 5 d every 4 wk 
2/5 
8 
15mg/m2/d x 5 d every 4 wk 
100-120mg/m2 every  4 wk 
0/15 
2/13 
10 
60mg/m2  every 3-4 wk 
120mg/m2 every 3-4 wk 
0/18 
4/19 
9 
100mg/m2 every 3-4 wk 
2/17 
11 
20mg/m2/d x 5 d every 4 wk 
100mg/m2 every 3-4 wk 
0/14 
0/12 
12 
Total 
10/113(9%) 
 
Cisplatin and Basal-Like Breast Cancer 
Basal-like breast cancers share many molecular features with BRCA1-associated breast cancer, a 
subset which have recently been shown to be more sensitive to cisplatin.  Recent preclinical 
work has identified that platinum agents may be particularly active in a subset of triple-negative 


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breast cancer.23  Cytotoxic agents, such as cisplatin, induce DNA damage that activates cell cycle 
checkpoints. These checkpoints results in transient arrest at the G1-, S-, and G2- phases of 
cycling cells, allowing time to repair the DNA damage or to initiate apoptosis, if the DNA 
damage is too extensive.  While DNA checkpoints can protect normal cells from DNA damage, 
they also reduce the effectiveness of chemotherapy on tumor cells by allowing tumor cells to 
repair DNA damage induced by chemotherapy.   
 
 
  
2.4 
Rationale 
 
While only about 20% of breast cancer is p53 deficient, approximately 60-80% of triple-negative 
breast cancers appear to have p53 pathway deficiency24, suggesting that AZD1775 would be 
expected to have more selective chemosensitization effects for this tumor subtype.  In addition, 
in both in vitro and in vivo xenograft tumor models, AZD1775 in combination with gemcitabine 
or platinum chemotherapy caused significantly greater efficacy than gemcitabine or platinum 
alone12.  Additionally, we have treated 5 patients on protocol 001-07 (DF/HCC protocol 08-030) 
with metastatic triple-negative breast cancer with AZD1775+ cisplatin.  Of these 5 heavily 
pretreated patients, 1 had a PR and 3 had SD as their best response. 25  Additionally, in a 
randomized phase 2 study in women with TP-53 mutant ovarian cancer, AZD1775 plus 
paclitaxel and carboplatin was associated with a significant improvement in progression-free 
survival compared with chemotherapy alone, suggesting activity for this agent when given in 
combination with platinum-based chemotherapy (REF:  Oza et al ASCO 2015). 
 
We propose a trial to look at cisplatin in combination with AZD1775 for metastatic triple-
negative breast cancer. 
 
2.5 
Correlative Studies Background 
 
We plan to demonstrate target engagement in tumor tissue by analysis of changes in pCDC2.  
Changes in pCDC2 have been seen in skin biopsies of patients receiving AZD1775, 26  and 
recently has also been demonstrated in 3 of 5 paired biopsies in patients receiving AZD1775 as 
monotherapy in a phase 1 trial (REF: Do et al., JCO 2015). 
Patients will receive cisplatin monotherapy for 1 cycle upfront, followed by cisplatin + 
AZD1775 for subsequent cycles of therapy.  Any patient with tumor that is accessible to biopsy 
will undergo research biopsies after one dose of cisplatin, and after the combination therapy.   
We anticipate that pCDC2 will be present after cisplatin monotherapy.   After the combination, a 
reduction in pCDC2 relative to CDC2 is expected.  This should be accompanied by evidence of 
checkpoint bypass and entrance of tumor cells into mitosis, which will be assessed by an increase 
in phospho-Histone 3 after combination treatment compared to cisplatin monotherapy.  
Checkpoint bypass will result in greater DNA damage, which should cause an increase in 
gamma-H2AX after combination treatment.27 Finally, entrance of cells into mitosis without 
adequate DNA repair is frequently lethal and should result in increased apoptosis, which can be 
assessed with an increase in cleaved caspase 3 after combination treatment. 28   


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Historically, it has been challenging to study the molecular evolution of tumors over time and 
through progression on serial treatment regimens. However, emerging technology now permits 
whole exome sequencing from cell-free DNA (cfDNA) isolated from fresh blood. We aim to 
examine the utility of this approach for detecting molecular changes in individual patients’ tumor 
cell populations over time by performing serial cfDNA. 
 
We will access DNA sequencing data (where possible) on tumors from all DFCI participants 
who previously had tumor sequencing performed under the Dana-Farber Cancer Institute’s 
“Profile” targeted sequencing panel. MGH participants and any 16-264 participants who did not 
previously participate on or have sequencing performed under “Profile” will be excluded from 
any analysis. We will use these data to investigate candidate genomic correlates of response, 
including tumor mutation burden and alterations in genes involved in homologous 
recombination, DNA damage response, and cell cycle G1/S checkpoint signaling. Mutations in 
G1/S checkpoint genes, such as TP53, MYC, and CCNE1, may enhance reliance on the Wee1-
mediated G2/M checkpoint for accurate DNA repair and therefore make these tumors more 
susceptible to the combination of AZD1775 and cisplatin. Altogether, these existing DNA 
sequencing data may reveal preliminary response biomarkers to guide future DNA and RNA 
sequencing studies.     
 
 
3. PARTICIPANT SELECTION 
 
3.1 
Inclusion Criteria 
3.1.1 Participants must have histologically or cytologically confirmed invasive breast  
cancer, with either locally advanced or metastatic disease.  Patients without pathologic or 
cytologic confirmation of metastatic disease should have unequivocal evidence of 
metastasis from physical examination or radiologic evaluation. 
3.1.2 Either the primary invasive tumor and/or the metastasis must be triple-negative, 
defined as:  
• hormone-receptor poor, ER- and PR-negative, or staining present in <1% by 
immunohistochemistry (IHC) 
• HER2-negative: 0 or 1+ by IHC, or FISH<2.0 


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3.1.3 Participants must have at least one lesion that is not within a previously radiated 
field that is measurable on computerized tomography (CT) or magnetic resonance 
imaging (MRI) scan per RECIST version 1.1.  Bone lesions are not considered 
measurable by definition. See Section 11 for the evaluation of measurable disease.  
3.1.4 Prior chemotherapy: Patients may have received 0-1 prior chemotherapeutic 
regimen for metastatic breast cancer and must have been off treatment with 
chemotherapy for at least 21 days before enrollment in the study.  The number of 
patients with 0 prior chemotherapeutic regimen will be limited to a maximum of n = 
20.  
3.1.5 Prior biologic therapy: Patients must have discontinued all biologic therapy at least 
21 days before participation.  
3.1.6 Prior radiation therapy: Patients may have received prior radiation therapy in either 
the metastatic or early-stage setting.  Radiation therapy must be completed at least 
14 days prior to study participation and patients should have recovered from 
adverse effects of radiation to grade ≤1. 
3.1.7 Age  ≥18  
3.1.8 ECOG performance status ≤1  
3.1.9 Participants must have normal organ and marrow function as defined below: 
• Absolute neutrophil count ≥1500/mm3 
• Platelets ≥100,000/mm3 
• Hemoglobin ≥9 g/dL 
• Total Bilirubin ≤1.5 mg/dL 
• Serum creatinine ≤1.5 mg/dL OR measured creatinine clearance (CrCl) ≥45 
mL/min as calculated by the Cockcroft-Gault method OR 24-hour measured urine 
CrCl ≥45mL/min 
• 
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤2.5 times 
the upper limit of normal.  For patients with documented liver metastases, 
AST/ALT ≤ 5.0 times the upper limit of normal.     


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3.1.10 Patients on bisphosphonates may continue receiving bisphosphonate therapy during 
study treatment. 
3.1.11 Availability of a tissue block from initial breast cancer diagnosis and/or metastatic 
recurrence.  If a tissue block is not available, 10-20 unstained slides may be 
provided as an alternative.  If unstained slides will be provided, they should not be 
sent until specifically requested by the DFCI study coordinator.  If archival tumor 
tissue is not available, a fresh biopsy may be performed. 
3.1.12 All patients with biopsy-accessible disease must be willing to undergo paired 
research biopsies.  These biopsies will occur 5-48 hours after the C1D1 cisplatin 
dose (ie. C1D2or C1D3) and 5-8hrs (+/- 24hrs) after the last dose of AZD1775 on 
C2D3.  The exact timing of the biopsy relative to receipt of study treatment should 
be accurately recorded.   
• Biopsies may be done with local anesthesia or intravenous conscious sedation, 
according to standard institutional guidelines. 
• Research biopsies requiring general anesthesia are not allowed on this protocol 
unless a biopsy is being obtained simultaneously for clinical reasons, in the 
judgment of the patients’ treating physician. 
• Patients who undergo an attempted on-treatment research biopsy and in whom 
inadequate tissue is obtained are still eligible to continue protocol therapy. They 
will not be required to undergo a repeat biopsy attempt.  
• If dosing is delayed placing the biopsy outside of the allowable window, the 
biopsy should be rescheduled to be within the window.  If not feasible, the biopsy 
should be obtained as close to within the window as possible. 
• Fine needle aspirates (FNA) is not allowed 
3.1.13 Female subjects of childbearing potential must have a negative serum pregnancy 
test at screening. 
3.1.14 The effects of AZD1775 on the developing human fetus are unknown. Women of 
child-bearing potential and men must agree to use enhanced methods of 
contraception.  All women are considered to be of childbearing potential unless they 
fulfill one of the following criteria at screening: 
 
• Post-menopausal defined as age ≥50 and amenorrheic for at least 12 months  
OR  
Women  age <50 if they have been amenorrheic for at least 12 months and have a 
serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) level in the 
postmenopausal range (per institutional standards).   
• If women have documentation of irreversible surgical sterilisation by hysterectomy, 
bilateral oophorectomy, or bilateral salpingectomy, or bilateral tubal ligation, they are 
considered post-menopausal. 
 


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3.1.15 Appropriate contraception should be used from the time of screening, throughout 
the duration of study participation, and for four months after the last dose of 
AZD1775.  Acceptable methods of contraception include abstinence, tubal ligation, 
intra-uterine devices, and vasectomised partner.  All methods of contraception (with 
the exception of total abstinence) should be used in combination with the use of a 
condom by the male sexual partner for intercourse.  Should a woman become 
pregnant or suspect she is pregnant while she or her partner is participating in this 
study, the participants treating physician should be informed immediately.   
Additionally, male patients should refrain from donating sperm from the start of 
dosing until 6 months after discontinuing AZD1775.  If male patients wish to father 
children they should be advised to arrange for freezing of sperm samples prior to 
the start of study treatment. 
3.1.16 Participant must be able to swallow pills. 
3.1.17 Participant may not have a percutaneous endoscopic gastrostomy (PEG) tube or be 
receiving total parenteral nutrition (TPN). 
 
3.1.18 Ability to understand and the willingness to sign a written informed consent 
document. 
 
3.2 
Exclusion Criteria 
 
3.2.1 Participants who are receiving any other investigational agents within 21 days of 
the first dose of study drug.  
3.2.2 Major surgical procedures <28 days from beginning study treatment.   
3.2.3 Participants who have received a prior inhibitor of Wee1 kinase activity 
3.2.4 Participants who have received prior platinum chemotherapy 
3.2.5 Known brain metastases that are untreated, symptomatic, or require therapy to 
control symptoms.  Patients with a history of treated central nervous system (CNS) 
metastases are eligible.  Treated brain metastases are defined as those having no 
evidence of progression for ≥ 1 month after treatment, or hemorrhage for >/= 2 weeks 
after treatment and no ongoing requirement for corticosteroids, as ascertained by 
clinical examination and brain imaging (magnetic resonance imaging or CT scan) 
during the screening period.  Any corticosteroid use for brain metastases must have 
been discontinued without the subsequent appearance of symptoms for ≥2 weeks 
before the first study drug.  Treatment for brain metastases may include whole brain 
radiotherapy, radiosurgery, or a combination as deemed appropriate by the treating 
physician. Patients with CNS metastases treated by neurosurgical resection or brain 
biopsy performed within 1 month before day 1 of study treatment will be excluded. 
3.2.6 Patients with grade >1 neuropathy or grade >1 toxicity (except alopecia or 
anorexia) from prior therapy  
3.2.7 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to AZD1775 or Cisplatin. 
3.2.8 Participants receiving any medications, substances, or foods (ie, grapefruit juice) 
listed below are ineligible (Please refer to Section 5.4 for list of restricted co-
medications): 
 


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• prescription or non-prescription drugs or other products known to be 
sensitive CYP3A4 substrates or CYP3A4 substrates with a narrow 
therapeutic index, or to be moderate to strong inhibitors/inducers of 
CYP3A4 which cannot be discontinued prior to study start and 
withheld throughout the study until 2 weeks after the last dose of study 
drug. sensitive substrates of CYP2C8, CYP2C9, CYP2C19, or 
substrates of these enzymes with narrow therapeutic range 
• inhibitors or substrates of P-gp 
Because the lists of these agents are constantly changing, it is important to regularly 
consult a frequently-updated list such as 
http://medicine.iupui.edu/clinpharm/ddis/table.aspx; medical reference texts such as 
the Physicians’ Desk Reference may also provide this information.  As part of the 
enrollment/informed consent procedures, the patient will be counseled on the risk of 
interactions with other agents, and what to do if new medications need to be 
prescribed or if the patient is considering a new over-the-counter medicine or herbal 
product.      
3.2.9 Participants who have an uncontrolled intercurrent illness, including, but not limited 
to, ongoing or active infection, uncontrolled hypertension, unstable angina pectoris, 
uncontrolled cardiac arrhythmia, congestive heart failure-New York Heart 
Association Class III or IV (Appendix B), active ischemic heart disease, myocardial 
infarction within the previous six months, uncontrolled diabetes mellitus, gastric or 
duodenal ulceration diagnosed within the previous 6 months, chronic liver or renal 
disease, or severe malnutrition.  In addition, patients are ineligible if they have a 
psychiatric illness or a social situation that could limit their ability to comply with 
the study requirements. 
3.2.10 Participants who have refractory nausea and vomiting, chronic gastrointestinal 
diseases, or previous significant bowel resection that would preclude adequate 
absorption of AZD1775. 
3.2.11 Pregnant women are excluded from this study because AZD1775 is a Wee1 
inhibitor agent with the potential for teratogenic or abortifacient effects.   
3.2.12 Lactating or breastfeeding women are excluded because there is an unknown but 
potential risk for adverse events in nursing infants secondary to treatment of the 
mother with AZD1775, breastfeeding should be discontinued prior to being treated 
with AZD1775.  These potential risks may also apply to other agents used in this 
study. 
3.2.13 Known HIV-positive participants are ineligible because these participants are at increased 
risk of lethal infections when treated with marrow-suppressive therapy.   
3.2.14 Participant with mean resting corrected QT interval (specifically QTc calculated 
using the Fridericia formula [QTcF]) > 450 msec for males and > 470 msec for 
females, from 3 electrocardiograms (ECGs) performed within 2-5 minutes apart at 
study entry, or congenital long QT syndrome. 
  
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women of all races and ethnic groups are eligible for this trial. 


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4. REGISTRATION PROCEDURES 
 
4.1 
General Guidelines for DF/HCC Institutions 
 
Institutions will register eligible participants in the Clinical Trials Management System (CTMS) 
OnCore. Registrations must occur prior to the initiation of protocol therapy. Any participant not 
registered to the protocol before protocol therapy begins will be considered ineligible and 
registration will be denied. 
 
An investigator will confirm eligibility criteria and a member of the study team will complete the 
protocol-specific eligibility checklist. 
 
Following registration, participants may begin protocol therapy. Issues that would cause 
treatment delays should be discussed with the Overall Principal Investigator (PI). If a participant 
does not receive protocol therapy following registration, the participant’s registration on the 
study must be canceled. Registration cancellations must be made in OnCore as soon as possible.  
 
4.2 
Registration Process for DF/HCC Institutions 
 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed.   
 
5. TREATMENT PLAN 
 
5.1 
Treatment Regimen 
 
Treatment will consist of  one cycle (21 days) of cisplatin monotherapy ( cisplatin 75 mg/m2 IV) 
followed by combination therapy of AZD1775 plus cisplatin starting 21 days later.  AZD1775 
will be administered as twice daily oral dosing (AZD1775 200mg po bid) x 5 doses for 2.5 days, 
in combination with cisplatin 75 mg/m2 IV every 21 days.  Cycle length is 21 days long.  
Treatment will be administered on an outpatient basis.  Reported adverse events and potential 
risks are described in Section 7.  Appropriate dose modifications are described in Section 6.  No 
investigational or commercial agents or therapies other than those described below may be 
administered with the intent to treat the participant's malignancy. 
 
Regimen Description 
Agent 
Premedications; 
Precautions 
Dose 
Route*** 
Schedule 
Cycle 
Length 
AZD1775* 
See Section 5.4 
200 mg 
PO  
Twice daily  
 x 5 doses 
From Cycle 2 
21 days  
(3 weeks) 
 
 
 
Cisplatin 
See Section 5.3.2 75 mg/m2 IV  
60 minutes 
Days 1 
From Cycle 1 


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* The participant will be requested to maintain a medication diary of each dose of medication.  
The medication diary will be returned to clinic staff at the end of each cycle. 
 
5.2 
Pre-Treatment Criteria 
 
5.2.1 
Cycle 1, Day 1 
• ANC must be ≥ 1500/mm3 
• Hemoglobin must be ≥ 9mg/dl 
• Platelets must be ≥100,000/mm3 
• Serum creatinine < 1.5mg/dl OR measured creatinine clearance (CrCl) ≥45 mL/min as 
calculated by the Cockcroft-Gault method OR 24-hour measured urine CrCl ≥45mL/min 
• SGOT/SGPT must be ≤2.5 X ULN (≤5 X ULN if known liver metastases) 
• Total Bilirubin ≤1.5 mg/dL 
 
5.2.2 
Subsequent Cycles  
• ANC must be ≥ 1000/mm3 
• Hemoglobin must be ≥9mg/dl 
• Platelets must be ≥75,000/mm3 
• Serum creatinine ≤1.5 x ULN, or measured creatinine clearance (CrCl) ≥45 mL/min as 
calculated by the Cockcroft-Gault method or 24-hour measured urine CrCl ≥45mL/min 
• Transaminitis must return to ≤ grade 2 
• Diarrhea must be resolved ≤ grade 1. 
• Nausea and Vomiting must return to ≤ grade 1  
• Neurosensory must be ≤ grade 2 
• Other Treatment Related non-Hematologic Toxicity must return to ≤ grade 1  
 
5.3 
Agent Administration 
 
 
5.3.1 
AZD1775 
Dose: 200mg po bid x 5 doses  
AZD1775 will be administered bid for two and a half days starting concomitantly with the 
administration of cisplatin with cycle 2.  The patient will take the first dose of AZD1775 in 
clinic on cycle 2 day 1, and subsequent doses that cycle can be taken at home.  On cycle 2 
day 1 and subsequent day 1 visits, AZD1775 and cisplatin may be administered 
concurrently.  There is no preferential order of administration.  The subsequent 4 additional 
doses of AZD1775 are to be taken in approximately 12 hour increments.  Participants should 
take AZD1775on an empty stomach and should not have food 2 hours before or 2 hours 
after the dose.  If the participant misses a dose by < 6 hours from scheduled dose, the dose 
should be taken as soon as possible. If the participant misses a dose by ≥ 6 hours from 
scheduled dose, the dose should not be made up. If the participant vomits after the 
administration of AZD1775, the dose should not be readministered. AZD1775 should not be 
crushed, chewed or dissolved in water. 
 
Premedication:  


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All patients must receive a 5-HT3 antagonistprior to each dose of AZD1775.   In addition, 
dexamethasone 4 mg PO will be given with each AZD1775 dose as a minimum on the first day 
of dosing AZD1775 of every 3-5 days dosing period, unless contraindicated or not well-
tolerated. Dexamethasone or the 5-HT3 antagonist may be given by IV.   
 
 
5.3.2 
Cisplatin  
 
Administration 
• Dose: Cisplatin 75mg/m2 IVB q3 weeks (every 21 days, plus minus 3 days for 
scheduling issues).  Cisplatin may be administered according to institutional guidelines 
at participating sites. The preferred guidelines are as described below. 
• Infusion time: 60 minutes. 
• Pretreatment hydration: Hydration may be achieved by IV infusion of 1 liter of 
sodium chloride 0.9% (±potassium 20 meq) over 1-2 hours prior to Cisplatin infusion. 
• Pretreatment Magnesium Supplementation: As needed, give prior to Cisplatin, 
Magnesium Sulfate 2 GM IV×1. 
• Treatment: Ensure there is adequate urine output averaging at least 100cc/hr prior to 
Cisplatin infusion. As needed, give 12.5mg IVB of MANNITOL 25% 30 minutes prior 
to Cisplatin infusion. Mix Cisplatin in 100-500ml sodium chloride 0.9% and infuse IVB 
over 60 minutes. Post-treatment hydration: Participants should receive 1 liter of 
sodium chloride 0.9% (±potassium 20 meq) IV over 1-2 hours after Cisplatin 
administration. 
• Post-treatment hydration: Participants should receive 1 liter of sodium chloride 0.9% 
(±potassium 20 meq) IV over 1-2 hours after Cisplatin administration. 
 
Caregiver Precautions: 
• Qualified personnel who are familiar with procedures that minimize undue exposure to 
themselves and to environment should undertake the preparation, handling, and safe 
disposal of chemotherapeutic in a self-contained, protective environment. 
• Discard unused portions of infectable chemotherapeutic agents that do not contain a 
bacteriostatic agent or that are prepared with unpreserved diluents (i.e., sterile water for 
injection, USP, or 0.9% sodium chloride for injection, USP) within 8 hours of vital entry 
to minimize the risk of bacterial contamination. 
• The total administered dose of chemotherapy may be rounded up or down within a range 
of 5% of the actual calculated dose. 
 
 
5.4 
General Concomitant Medication and Supportive Care Guidelines 
 
The major pathway for metabolism of AZD1775 involves CYP3A4. Therefore AZD1775 may be 
prone to drug-drug interactions when co-administered with drugs that are known to be moderate 
or potent inhibitors/inducers or substrates of CYP3A4. 
 
Prohibited Medication 


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Patients may receive other medications that the investigator deems to be medically necessary, 
with the specific exception of non-protocol specified chemotherapy, radiotherapy, anti-neoplastic 
biological therapy or other investigational agents. Patients who require the use of any of the 
aforementioned treatments for clinical management should be removed from the study. 
 
Drugs known to be moderate or potent inhibitors/inducers of CYP3A4 or substrates of CYP3A4 
with narrow therapeutic windows are generally prohibited. However, some agents (e.g. 
midazolam, fentanyl, or any other agent used for anesthesia purposes) with which participants 
will have short term exposure are permissible. List of agents known to be moderate or strong 
inhibitors/inducers of CYP3A4 or substrates of CYP3A4 with narrow therapeutic widows 
includes: 
 
• 
Inhibitors of CYP3A4: azole antifungals (ketoconazole, iraconazole, fluconazole and 
voriconazole), macrolide antibiotics (erythromycin, clarithromysin), cimetidine, aprepitant, 
HIV protease inhibitors, and nefazodone 
 
• 
Inducers if CYP3A4: phenytoin, barbiturates and rifampicin 
 
• 
Substrates of CYP3A4: statins (lovastain, simvastain [Atorvastatin is also prohibited because 
of BCRP effect]), midazolam, terfenadine, astemizole, and cisapride 
 
Please refer to Table 5.5-1 for other concomitant medications including a list of inhibitors, 
inducers and substrates of CYP3A4. This list is not all inclusive, and, the Principal Investigator 
will determine if they are known to significantly influence CYP3A4. Supportive care with a 
CYP3A4 inhibitor / inducer / substrate according to institutional guidelines in the context of 
standard of care chemotherapy will be exempt in some cases provided it is administered within 
the guidance of the protocol (Please refer to Supportive Care below). Concomitant treatment 
with aprepitant is not allowable per protocol. 
Table 5.5-1 
DRUG INTERACTIONS 
TABLE OF CYP3A INHIBITORS, INDUCERS, AND SUBSTRATES 
 
EXAMPLES OF CYTOCHROME P450 ISOENZYME INHIBITORS AND INDUCERS 
Inhibitors 
Inducers 
amiodarone                   
aprepitant                      
cimetidine                     
ciprofloxacin                
clarithromycin              
delabiridine                   
dilitiazem                      
erythromycin     
fluconazole   
fluvoxamine 
gestodene  
grapefruit juice  
indinavir  
itraconazole 
ketoconazole 
mibefradil 
mifepristone 
nefazodone    
nelfinavir           
norfloxacin 
ritonavir 
saquinavir 
troleandmycin              
barbiturates 
carbamazepine 
efavirenz 
glucocorticoids 
modafinil 
nevirapine 
phenobarbital 
phenytoin 
rifampin 
St. John’s Wort 
troglitazone 


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http://medicine.iupui.edu/flockhart/ 
 
Classification of Substrates 
 
Examples of sensitive CYP3A substrates or CYP3A substrates with narrow therapeutic range 
Sensitive CYP3A substrates1 
CYP3A Substrates with Narrow therapeutic 
range2 
budesonide 
buspirone 
eplerenone 
eletriptan 
felodipine 
fluticasone 
lovastatin 
midazolam 
saquinavir 
sildenafil 
simvastatin 
triazolam 
vardenafil 
alfentanil 
astemizole(a) 
cisapride(a) 
cyclospotine 
diergotamine 
ergotamine 
fentanyl 
pimozide 
quinidine 
sirolimus 
tacrolimus 
terfenadine(a) 
Note that this is not an exhaustive list. 
 
1. Sensitive CYP3A4 substrates refers to drugs whose plasma AUC values have been shown to 
increase 5-fold or higher when co-administered with a known CYP2A inhibitor. 
2. CYP3A substrates with narrow therapeutic range refers to drugs whose exposure-response 
indicates that increases in their exposure levels by the concomitant use of CYP3A inhibitors may 
lead to serious safety concerns (e.g., Torsades de Pointes). 
(a) Not available in the United States. 
 
In light of in vitro data which suggests that AZD1775 may be a CYP2C8, CYP2C9, and 
CYP2C19 inhibitor, caution should be exercised with concomitant administration of AZD1775 
and agents that are sensitive substrates of CYP2C8, CYP2C9, CYP2C19, or substrates of these 
enzymes with narrow therapeutic range. Please refer to Table 5.5-2 for a list of sensitive 
substrates of CYP2C8, CYP2C9, and CYP2C19, or substrates of these enzymes with narrow 
therapeutic range. This list is not all inclusive, and for other concomitant medications, the 
Principal Investigator will determine if they are known to significantly influence CYP2C8, 
CYP2C9, and/or CYP2C19. 
 
Table 5.5-2 
DRUG INTERACTIONS 
TABLE OF CYP2C8, CYP2C9, AND CYP2C19 SENSITIVE SUBSTRATES 
 
Sensitive substrates of CYP2C8, CYP2C9, and CYP2C19 and  
substrates with a narrow therapeutic range for these enzymes 
Repaglinide, paclitaxel, warfarin, phenytoin, omeprazole, s-mephenytoin 
 Note that this is not an exhaustive list. 
 
In light of in vitro data which suggests that AZD1775 may be a substrate for human P-
glycoprotein (P-gp) caution should be exercised when agents that are inhibitors or substrates of 
P-gp are administered concomitantly with AZD1775. Please refer to Table 5.5-3 for a list of 
inhibitors or substrates of P-gp. This list is not all inclusive, and for other concomitant 
medications, the Principal Investigator will determine if they are known to significantly 


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influence P-gp. 
 
Table 5.5-3 
DRUG INTERACTIONS 
TABLE OF INHIBITORS OR SUBSTRATES OF P-GP 
 
Inhibitor of P-gp 
Substrates of P-gp 
ritonavir, cyclosporine, verapamil, 
erythromycin, ketoconazole, itraconazole, 
quinidine 
digoxin, fexodenadine, indinavir, vinctistine, 
colchicines, topotecan, paclitaxel 
 Note that this is not an exhaustive list. 
 
Supportive Care 
Patients should receive optimal supportive care throughout the study, including transfusions of  
blood and blood products, antibiotics, antiemetics, when appropriate. The reason(s) for 
treatment, dosage, and dates of treatment should be recorded. 
 
• 
Nausea/vomiting:  
All patients must receive a 5-HT3 antagonist prior to each dose of AZD1775. Additional 
doses of 5-HT3 antagonist may be used if needed.   In addition, dexamethasone 4 mg PO 
will be given with each AZD1775 dose as a minimum on the first day of dosing AZD1775 
of every 3-5 days dosing period, unless contraindicated or not well-tolerated. 
Dexamethasone may be continued on further days of dosing, potentially at a lower dose. 
Dexamethasone or the 5-HT3 antagonist may be given by IV.   
Promethazine (Phenergan), prochlorperazine (Compazine), and benzodiazepine may still be 
used as additional adjunctive treatments during AZD1775 therapy.   
Please note: aprepitant [Emend] and fosaprepitant are not permitted due to known DDIs. 
Patients should be strongly encouraged to maintain liberal oral fluid intake. 
Suitable alternative medications may be used, with adequate justification, where the use of 
any of the above medications might interfere with other study procedures or are deemed 
insufficient. 
 
• 
Diarrhea: Diarrhea should be treated promptly with appropriate supportive care, including 
administration of an anti-diarrheal agent according to standard practice guidelines. Anti-
diarrheal agents should not be taken prophylactically. Patients should be instructed to begin 
taking anti-diarrheal medication at the first sign of: 1) poorly formed or loose stool, 2) 
occurrence of more bowel movements than usual in one day or 3) unusually high volume of 
stool. Anti-diarrheal agents should be deferred if blood or mucus is present in the stool or if 
diarrhea is accompanied by fever. In this setting, appropriate diagnostic microbiologic 
specimens should be obtained to exclude an infectious etiology. Patients should  also be 
advised to drink liberal quantities of clear fluids to help prevent dehydration.  Octreotide can 
also be considered to aid with management of diarrhea.  If diarrhea is severe (ie. requiring 
IV hydration) and/or associated with fever or grade 3 or 4 neutropenia, broad spectrum 


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antibiotics should be considered.  Additionally, hospitalization for IV hydration and 
eletrolyte correction should be considered. 
Patients should be instructed to notify the Investigator or research staff for the occurrence of 
blood or black stools, symptoms of dehydration, fever, inability to take liquids by mouth, 
and inability to control diarrhea within 24 hours of using loperamide or other prescribed 
antidiarrheal medications. 
 
• 
Anemia: Transfusions and/or erythropoietin may be utilized as clinically indicated for the 
treatment of anemia, but should be clearly noted as concurrent medications. 
• 
Neutropenia: Colony-stimulating factors including G-CSF, pegylated G-CSF or  GM-CSF 
according to Institutional Standards. 
• 
Febrile Neutropenia: Patients experiencing febrile neutropenia with significant symptoms 
should be managed in a hospital setting according to standard procedures, with the urgent 
initiation of IV antibiotic therapy. Patients with febrile neutropenia without symptoms 
should be managed according to standard guidelines. 
• 
Thrombocytopenia: Transfusion of platelets may be used if clinically indicated. 
• 
Patients requiring radiation or surgery for palliation of a non-target lesion that have not 
measurably increased in size according to RECIST will be considered to have progressed. 
• 
Participants may receive intravenous fluids on study. 
• 
Bisphosphonates are allowed while on study. 
 
 
5.5 
Criteria for Taking a Participant Off Protocol Therapy 
 
Duration of therapy will depend on individual response, evidence of disease progression and 
tolerance. In the absence of treatment delays due to adverse event(s), treatment may continue 
until one of the following criteria applies: 
 
• 
Disease progression 
 
• 
Intercurrent illness that prevents further administration of treatment 
 
• 
Unacceptable adverse event(s) 
 
• 
Treatment delay of  > 21 days due to toxicity 
 
• 
Participant demonstrates an inability or unwillingness to comply with the medication 
regimen and/or documentation requirements 
 
• 
Participant decides to withdraw from the protocol therapy 
 
• 
General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the judgment of the treating investigator 
 


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Participants will be removed from the protocol therapy when any of these criteria apply.  The 
reason for removal from protocol therapy, and the date the participant was removed, must be 
documented in the case report form (CRF) and entered in the Clinical Trial Management System 
(OnCore). Alternative care options will be discussed with the participant. 
 
In the event of unusual or life-threatening complications, treating investigators must immediately 
notify Sara Tolaney, MD MPH at 617-632-3800. 
 
5.6 
Duration of Follow Up 
Participants will be followed on-study until progression or death, whichever occurs first.  
Participants removed from protocol therapy for unacceptable adverse event(s) will be followed 
until resolution or stabilization of the adverse event. 
 
The participant’s treatment status will be updated in OnCore at the time treatment with cisplatin 
and AZD1775 is discontinued. 
 
5.7 
Criteria for Taking a Participant Off Study 
 
Participants will be removed from study when any of the following criteria apply: 
• Disease Progression (in patients who come off treatment for reasons other than 
progressive disease) 
• Lost to follow-up 
• Withdrawal of consent for data submission 
• Death 
 
The reason for taking a participant off study, and the date the participant was removed, must be 
documented in the case report form (CRF) and Clinical Trial Management System (OnCore). 
 
 
6. DOSING DELAYS/DOSE MODIFICATIONS 
 
Dose delays and modifications will be made as indicated in the following table(s). The 
descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0 will be utilized for dose delays and dose modifications. A 
copy of the CTCAE version 4.0 can be downloaded from the CTEP website 
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
6.1 
Dose Delays and Modifications for AZD1775 
 
 
Participants can have a maximum of 2 dose modifications (if applicable) throughout the course 
of the study for toxicities. Participants who require more than 2 dose modifications may remain 
on study and continue with cisplatin monotherapy per investigator discretion. In the event that a 
participant is not willing to dose reduce AZD1775, they may continue with cisplatin 
monotherapy per investigator discretion.   
 


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In the event of toxicity, it is recommended that the investigator first modify the dose of 
AZD1775; however the investigator may choose to first modify the chemotherapy dose instead, 
in consultation with the Principal Investigator.   If a second dose reduction is necessary during 
combination therapy, the dose of chemotherapy or AZD1775 may be modified.  This decision 
should be made jointly by the treating physician and the Principal Investigator.  Participants who 
experience toxicity that the investigator finds attributable to AZD1775 will have their AZD1775 
dose reduced by 1 dose level as shown in Table 6-1. A participant’s dose may be re-escalated at 
the discretion of the principal investigator. 
 
If Day 1 dosing is delayed, all assessments will be delayed to accordingly. 
 
Table 6-1 
DOSE MODIFICATION OF AZD1775 
 
Dose Level 
AZD1775 Dose 
0 
200mg, twice daily x 5 doses 
-1 
175mg, twice daily x 5 doses 
-2 
150mg, twice daily x 5 doses 
-3 
125mg, twice daily x 5 doses 
  
 
 
Nausea 
Management/Next Dose for AZD1775 
≤ Grade 1 
No change in dose 
Grade 2 
Hold until ≤ Grade 1.  Resume at same dose level. 
Grade 3 
Hold* until < Grade 2.  Resume at one dose level lower, if indicated.** 
Grade 4 
Discontinue treatment and follow for disease progression 
*Participants requiring a delay of >3 weeks should discontinue AZD1775. 
**Participants requiring > two dose reductions should discontinue AZD1775 
All patients must receive a 5-HT3 antagonist prior to each dose of AZD1775. Additional doses 
of 5-HT3 antagonist may be used if needed.   In addition, dexamethasone 4 mg PO will be 
given with each AZD1775 dose as a minimum on the first day of dosing AZD1775 of every 3-5 
days dosing period, unless contraindicated or not well-tolerated. Dexamethasone may be 
continued on further days of dosing, potentially at a lower dose. Dexamethasone or the 5-HT3 
antagonist may be given by IV.   
Promethazine (Phenergan), prochlorperazine (Compazine), and benzodiazepine may still be 
used as additional adjunctive treatments during AZD1775 therapy.   
Please note: aprepitant [Emend] and fosaprepitant are not permitted due to known DDIs. 
Patients should be strongly encouraged to maintain liberal oral fluid intake. 
Suitable alternative medications may be used, with adequate justification, where the use of any 
of the above medications might interfere with other study procedures or are deemed 
insufficient. 
 
 
 


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Vomiting 
Management/Next Dose for AZD1775 
≤ Grade 1 
No change in dose 
Grade 2 
Hold until ≤ Grade 1.  Resume at same dose level. 
Grade 3 
Hold* until < Grade 2.  Resume at one dose level lower, if indicated.** 
Grade 4 
 Discontinue treatment and follow for disease progression 
*Participants requiring a delay of >3 weeks should discontinue AZD1775. 
**Participants requiring > two dose reductions should discontinue AZD1775. 
All patients must receive a 5-HT3 antagonist prior to each dose of AZD1775. Additional doses 
of 5-HT3 antagonist may be used if needed.   In addition, dexamethasone 4 mg PO will be 
given with each AZD1775 dose as a minimum on the first day of dosing AZD1775 of every 3-5 
days dosing period, unless contraindicated or not well-tolerated. Dexamethasone may be 
continued on further days of dosing, potentially at a lower dose. Dexamethasone or the 5-HT3 
antagonist may be given by IV.   
Promethazine (Phenergan), prochlorperazine (Compazine), and benzodiazepine may still be 
used as additional adjunctive treatments during AZD1775 therapy.   
Please note: aprepitant [Emend] and fosaprepitant are not permitted due to known DDIs. 
Patients should be strongly encouraged to maintain liberal oral fluid intake. 
Suitable alternative medications may be used, with adequate justification, where the use of any 
of the above medications might interfere with other study procedures or are deemed 
insufficient. 
 
. 
 
 
Diarrhea 
Management/Next Dose for AZD1775 
≤ Grade 1 
No change in dose 
Grade 2 
Hold until ≤ Grade 1.  Resume at same dose level. 
Grade 3 
Hold* until < Grade 2.  Resume at one dose level lower, if indicated.** 
Grade 4 
 Discontinue treatment and follow for disease progression 
*Participants requiring a delay of >3 weeks should discontinue AZD1775. 
**Participants requiring > two dose reductions should discontinue AZD1775. 
Recommended management:  Loperamide antidiarrheal therapy 
Dosage schedule:  4 mg at first onset, followed by 2 mg with each loose motion until diarrhea-
free for 12 hours (maximum dosage:  16 mg/24 hours) 
Adjunct anti-diarrheal therapy is permitted and should be recorded when used. 
Participants should be instructed to notify their research doctor for the occurrence of blood or 
black stools, symptoms of dehydration, fever, inability to take liquids by mouth, and inability to 
control diarrhea within 24 hours of using loperamide or other prescribed antidiarrheal 
medications. 
If associated with severe (Grade 3 or 4) neutropenia, broad-spectrum antibiotics must be 
prescribed.  Patients should be considered for hospitalization for IV hydration and correction of 
electrolytes. 
 
 


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Neutropenia 
Management/Next Dose for AZD1775 
≤ Grade 1 
No change in dose 
First occurrence 
Grade 2 
Hold* until ≤ Grade 1.  Resume at same dose level. 
Second or Third 
Occurrence Grade 2; 
Hold* until ≤ Grade 1.  Resume at one dose level lower, if indicated** 
First Occurrence 
Grade 3 or Second 
Occurrence Grade 3 
Hold* until ≤ Grade 1.  Resume at one dose level lower, if indicated** 
Grade 3 Febrile 
Neutropenia or 
Grade 3 Neutropenia 
with documented 
infection. 
Hold* until ≤ Grade 1.  Resume at one dose level lower, if indicated** 
Grade 4 or Second 
Occurrence Grade 4 
Hold* until ≤ Grade 1.  Resume at one dose level lower, if indicated** 
Grade 4 Febrile 
Neutropenia or 
Grade 4 Neutropenia 
with documented 
infection. 
Discontinue.  
*Participants requiring a delay of >3 weeks should discontinue AZD1775. 
**Participants requiring > two dose reductions should discontinue AZD1775. 
Note: Consider using G-CSF per institutional standards for neutropenia or febrile neutropenia. 
 
 
Thrombocytopenia 
Management/Next Dose for AZD1775 
≤ Grade 1 
No change in dose 
First Occurrence 
Grade 2 
Hold* until ≤ Grade 1.  Resume at same dose level. 
Second or Third 
Occurrence Grade 2 
Hold* until ≤ Grade 1.  Resume at one dose level lower, if indicated** 
First Occurrence 
Grade 3 or Second 
Occurrence Grade 3 
Hold* until ≤ Grade 1.  Resume at one dose level lower, if indicated** 
First or Second 
Occurrence Grade 4 
without any evidence 
of bleeding 
Hold* until ≤ Grade 1.  Resume at one dose level lower, if indicated** 
Thrombocytopenia 
haemorrhage (gross 
occult bleeding) 
associated with 
platelet count 
<50,000 uL 
Discontinue. 


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Thrombocytopenia 
Management/Next Dose for AZD1775 
*Participants requiring a delay of >3weeks should discontinue AZD1775. 
**Participants requiring > two dose reductions should discontinue AZD1775. 
 
 
 
 
6.2 
Dose Delays and Modifications for Cisplatin 
 
Cisplatin will be initially administered at a dosage of 75mg/m2 as an IV infusion given every 3 
weeks. Patients who experience a Grade 3 or 4 toxicity attributable to cisplatin will have their 
cisplatin dose reduced to per Table 6-2. Toxicities resulting in myelosuppression, renal 
insufficiency, ototoxicity, and marked nausea and vomiting are most commonly seen with  
cisplatin monotherapy. Assessments should be made immediately prior to the scheduled 
administration of the chemotherapy.  If patient needs to discontinue cisplatin therapy, patient can 
be treated on protocol with AZD1775 monotherapy. 
 
Table 6-2 
DOSE MODIFICATION OF CISPLATIN 
 
Dose Level 
Cisplatin Dose 
0 
75mg/m2 
-1 
60mg/m2 
-2 
50mg/m2 
 
Dose delays and modifications are summarized in the toxicity table in Table 6-6. 
 
No dose re-escalations are allowed on study, except where noted below. 
 
Other Non-
Hematologic 
Toxicities 
Management/Next Dose for AZD1775 
Grade 1 
No change in dose 
Grade 2^ 
Hold until ≤ Grade 1.  Resume at same dose level. 
Grade 3 
Hold until < Grade 2.  Resume at one dose level lower, if indicated. 
Grade 4 
Hold until < Grade 2.  Resume at one dose level lower, if indicated. 
• 
Dose modifications for AZD1775 non-hematologic toxicities should be based on toxicities occurring 
during the previous cycle.  
• 
For toxicities that lead to a dose reduction, the dose will not be re-escalated during subsequent cycles.  
• 
Any patient who develops a Grade 3 or 4 nonhematologic toxicity that does not resolve to ≤ Grade 1 
within 3 weeks should discontinue AZD1775, unless approved by the Principle Investigator.  
• 
Participants requiring > two dose reductions, should discontinue AZD1775.   
• 
^intolerable Grade 2 
 
 


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Expected toxicities for Cisplatin:  
 
Nephrotoxicity 
The major dose-limiting toxicity of cisplatin is cumulative nephrotoxicity. Tubular necrosis of 
both proximal and distal renal tubules has been noted in 28% to 36% of subjects treated with a 
single dose of 50mg/m2. It is first noted during the second week after a dose and is manifested by 
elevations in BUN and creatinine, serum uric acid and/or a decrease in creatinine clearance. 
Renal toxicity becomes more prolonged and severe with repeated courses of the drug. Renal 
function must return to normal before another dose of cisplatin can be given. Nephrotoxicity can 
be reduced by IV hydration and mannitol diuresis. 
 
Nausea and Vomiting 
Cisplatin causes moderate to severe nausea and vomiting in almost all subjects treated. Nausea 
and vomiting usually begin within 1 to 4 hours after treatment and last up to 24 hours. Various 
degrees of vomiting, nausea, and/or anorexia may persist for up to 1 week after the treatment. 
Delayed nausea and vomiting (beginning 24 hours or after chemotherapy) has occurred with 
complete emetic control on the day of cisplatin therapy. The use of prophylactic and continuing 
antiemetic medication reduces these adverse effects. 
 
Hypomagnesemia 
Hypomagnesemia has been reported in subjects treated with cisplatin and is probably related to 
renal tubular damage. It may become severe enough to cause tetany. Generally, serum 
electrolytes return to normal levels when cisplatin is discontinued and supplemental electrolytes 
are administered. 
 
Ototoxicity 
Ototoxicity has been observed in up to 31% of subjects treated with a single dose of cisplatin 
(50mg/m2) and is manifested by tinnitus and/or hearing loss in the high frequency range (4000 to 
8000 Hz). Decreased ability to hear normal conversational tones may occur occasionally. 
Ototoxicity can be more severe in children than in adults and more frequent and severe with 
repeated administration. Hearing loss can be unilateral or bilateral and is usually not reversible. 
During treatment with cisplatin, it is necessary to monitor hearing at each visit as part of a 
standard physical exam. 
 
Myelosuppression 
Myelosuppression occurs in 25 to 30% of subjects treated with cisplatin. The nadirs in 
circulating platelets and leukocytes occur between days 18 and 23, with most subjects recovering 
by day 39. Leukopenia and thrombocytopenia are more pronounced at higher doses (>50 
mg/m2). Anemia (a decrease in hemoglobin of 2 gm/100ml) occurs at approximately the same 
frequency and with the same timing as leukopenia and thrombocytopenia. 
 
Neurotoxicity 
Cisplatin neurotoxicity is characterized by peripheral neuropathies, which are sensory in nature 
but can also include motor difficulties such as reduced deep-tendon reflexes and leg weakness. 
The symptoms usually occur after prolonged therapy (4 to 7 months). Cisplatin therapy should 
be discontinued when serious neuropathy develops. The neuropathy, however, may progress 


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further even after discontinuation of treatment.  
 
Hematologic Toxicity 
Dose adjustment at the start of a subsequent cycle of therapy will be based on the neutrophil and 
platelet counts on day 1 of the cycle. ANC must be  ≥ 1.0×109/L and platelets  ≥  75×109/L 
before the start of each cycle. Treatment should be delayed to allow sufficient time for recovery. 
Upon recovery, if treatment is resumed, it should be accounting to the guidelines in Table 6-2 
with respect to nadir platelet and ANC values for subsequent cycles, except as noted below. A 
delay in treatment due to hematologic toxicity if more than 3 weeks will result in withdrawal 
from the study.  
 
The use of colony stimulating factors (filgrastim or pegfilgrastim) is permissible if recommended 
by the primary treating physician but should be clearly recorded in the medical record and case 
report form. Prophylactic use of GCSF is not recommended with the first cycle. 
 
If GCSF is initiated, then the required dose modification will be adjusted according to the 
guidelines in footnote of Table 6-3. 
 
Table 6-3 
Dose Adjustments for Cisplatin Based on Hematologic Values for Preceding Cycle 
 
Platelets (×109/L)                     ANC (×109/L)                                  Dose of Cisplatin  
≥75            and                 ≥1.0                                               75mg/m2* 
≥50                        or                   ≥ 0.5                                               60mg/m2*,# 
< 50                       or                   <0.5                                                50mg/m2*,@ 
Recurrence of grade 3 or 4 thrombocytopenia after 2 dose reductions        Withdraw subject from study 
or 
                                                                                                            continue on ADZ1775 
alone 
Recurrence of grade 3 or 4 neutropenia after 2 dose reductions                   Withdraw subject from study 
or 
                                                                                                            continue on ADZ1775 
alone 
* Treatment should be delayed until recovery of platelets to  ≥100×109/L and ANC to  
≥1.0×109/L. 
#  For ANC ≥0.5 treat at 75mg/m2 dose if initiating GCSF  
@ For ANC<0.5 treat at 60mg/m2 dose if initiating GCSF 
 
Non-Hematologic Toxicity 
For other grade 3 or higher non-hematologic effects (with the exception of grade 3 transaminase 
elevations and nausea or vomiting), treatment should be delayed until resolution (less than or 
equal to baseline). Treatment can be resumed at 60mg/m2, if deemed appropriate by the treating 
physician, for all subsequent cycles. 
 
Neurosensory Toxicity 


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Adjustments of the cisplatin dose in subjects with neurosensory toxicity are shown in Table 6-4. 
Cisplatin therapy should be held for grade 2 or higher neurosensory toxicity and should resume 
with a dose reduction once it has resolved to grade 1.   
 
 


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Table 6-4 
Dose Adjustments for Cisplatin Based on Neurosensory Toxicity 
 
CTCAE Grade                          Dose of Cisplatin  
0-1                                             100% of previous dose        
2                                                60mg/m2 
3-4                                             Withdraw participant from study or continue on AZD1775 
alone 
 
Tinnitus or Significant Hearing Loss 
In cases of tinnitus or significant hearing loss, cisplatin therapy should be reduced or stopped, at 
the discretion of the investigator. 
 
Nephrotoxicity 
Cisplatin dose adjustments in subjects with renal toxicity are shown in Table 6-5. Either serum 
creatinine or estimated creatinine clearance may be used. If a dose delay or dose reduction occurs 
due to nephrotoxicity, subsequent doses of cisplatin may be escalated based on the renal function 
on the day of treatment (+/- 3 days) and should be determined based on Table 6-5. 
 
Table 6-5 
Cisplatin Dose Adjustments for Renal Toxicity 
 
Creatinine(mg/dl)         OR       Creatine Clearance(cc/min)                  Dose of  Cisplatin 
<1.6                                             >50                                                         75mg/m2 
1.6-2                                                     10-50                                                      60mg/m2 
>2                                                         <10                                                     Delay one week 
 
Other Toxicity 
Patients who develop treatment-related grade 3 non-hematological toxicity (except grade 3  
transaminase elevations and nausea or vomiting ) should have cisplatin therapy delayed until 
toxicity has resolved to less than or equal to grade 1 or baseline. Cisplatin will be continued at  
60mg/m2 for subsequent cycles. For grade 3 nausea, vomiting, or transaminase elevation, 
treatment will be delayed until toxicity resolves to grade 1 or less, and treatment may resume at 
75 mg/m2 dose. If any toxicity, including those described above, results in a three week treatment 
delay, patients will be taken off protocol. Patients with grade 4 non-hematological toxicity 
attributed to cisplatin will come off study unless exception is given by the Protocol Chair. Prior 
to retreatment, toxicity must resolve to less than or equal to grade 1 or baseline. For ≥ grade 2 
Hgb toxicity, at the treating physician’s discretion, dose may be reduced by one dose level in 
addition to transfusions and/or growth factor support as clinically indicated, with the option to 
re-escalate at physician’s discretion. This should be documented in the medical record. 
 
 
Table 6-6: Cisplatin Toxicity Management and Dose Modification Summary Table 


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Toxicity Event 
Dose Modification 
Hematologic 
 
ANC > 1000/mm3 
None 
ANC  ≥ 500/mm3 
Delay until >1000/mm3 and reduce to 60mg/m2 
( treat at 75mg/mm2 if initiating GCSF) 
ANC <  500/mm3 
Delay until >1000/mm3 and reduce to 50mg/m2 
( treat at 60mg/mm2 if initiating GCSF) 
Grade 3 or 4 toxicity 
after 2 dose reduction 
Withdrawal from study or continue  
Plt >100,000/mm3 
None 
Plt >50,000/mm3 
Delay until >75,000/mm3 and reduce to 60mg/m2 
 
Plt <50,000/mm3 
Delay until >75,000/mm3 and reduce to 50mg/m2 
 
Grade 3 or 4 toxicity 
after dose reduction 
Withdrawal from study 
Gastrointestinal 
 
Diarrhea 
 
Grade 3/4 or 
requiring hospitalization 
Delay until resolution and reduce to 60mg/m2 
Vomiting,Nausea 
 
Grade 3/4 
Delay until ≤grade 1 or has returned to baseline and resume at 
75mg/m2 or with one dose reduction (Per investigator discretion) 
Transaminases 
 
Grade 3/4 
Delay until ≤grade 2 and with one dose reduction 
Neurological 
 
Neurosensory 
 
Grade 0-1 
None 
Grade 2 
Delay until resolves to ≤grade 1 and resume with one dose reduction 
Grade 3-4 
Withdrawal from study 
Ototoxicity 
 
Tinnitus or 
significant hearing loss 
Reduce dose or withdraw from study at investigator discretion 
Nephrotoxicity 
 
Cr <1.6 mg/dl or  
CrCl >50 cc/min 
None 
Cr 1.6-2 mg/dl or  
CrCl 10-50 cc/min 
50mg/m2 
Cr>2 mg/dl or  
CrCl <10-cc/min 
Delay one week 
Other Toxicity 
 
Grade 3 
Delay until ≤ grade 1 or has returned to baseline and resume at 
60mg/m2 


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Grade 4 
Withdraw from study, unless exception granted by the Principal 
Investigator 
 
 
7. ADVERSE EVENTS 
7.1 
Adverse Event Characteristics 
 
• CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
4.0 will be utilized for AE reporting.  All appropriate treatment areas should have access 
to a copy of the CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be 
downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
• For expedited reporting purposes only:   
- 
AEs for the agent(s) that are listed above should be reported only if the adverse event 
varies in nature, intensity or frequency from the expected toxicity information which 
is provided. 
 
• Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
7.2 
Expedited Adverse Event Reporting  
 
7.2.1 Investigators must report to the Overall PI any serious adverse event (SAE) that 
occurs after the initial dose of study treatment, during treatment, or within 30 days 
of the last dose of treatment on the local institutional SAE form.  
 
 
7.2.2 
DF/HCC Expedited Reporting Guidelines 
 
Investigative sites within DF/HCC will report AEs directly to the DFCI Office for 
Human Research Studies (OHRS) per the DFCI IRB reporting policy.  
 
 
7.3 
Expedited Reporting to the Food and Drug Administration (FDA) 
 
 
The Overall PI, as study sponsor, will be responsible for all communications with the FDA. The 
Overall PI will report to the FDA, regardless of the site of occurrence, any serious adverse event 
that meets the FDA’s criteria for expedited reporting following the reporting requirements and 
timelines set by the FDA. 


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7.4 
Expedited Reporting to AstraZeneca  
 
A serious adverse event is any adverse event occurring at any dose or during any use of 
AZD1775 that: 
 
• Results in death; 
• Is life-threatening; 
• Results in persistent or significant disability/incapacity; 
• Results in or prolongs an existing inpatient hospitalization; 
• Is a congenital anomaly/birth defect; 
• Is a new cancer (that is not a condition of the study); 
• Is associated with an overdose; 
• Is an other important medical event 
 
Serious adverse events that are ultimately related to disease progression do not need to be 
reported.  
 
SAE information will be sent via secure e-mail connection or via fax within 24 hours of learning 
of the event.  Medwatch 3500A report form with supporting relevant source documents (e.g. 
history and physical [H&P], hospital discharge summary, autopsy report when available, and 
results of relevant diagnostic tests completed to evaluate the event) will be attached and sent via: 
 
• Secure email: AEMailboxClinicalTrialTCS@astrazeneca.comor by  
• Fax: 1-302-886-4114 
Transmission of the SAE Report Form should be confirmed by the site personnel submitting the 
report. 
 
Follow-up information for SAEs and information on non-serious AEs that become serious should 
also be reported to AstraZeneca as soon as it is available; these reports should be submitted using 
the MedWatch 3500A Form.  The detailed SAE reporting process will be provided to the sites in 
the SAE reporting guidelines contained in the trial reference manual. 
 
Investigators must report SAEs and follow-up information to their responsible Institutional 
Review Board (IRB) according to the policies of the responsible IRB.  For fatal or life-
threatening AEs where important or relevant information is missing, active follow-up is 
undertaken immediately.  
 
7.5 
Routine Adverse Event Reporting 
 
All Grade 2 or higher Adverse Events must be reported in routine study data submissions to the 
Overall PI on the toxicity case report forms.  AEs reported through expedited processes (e.g., 
reported to the IRB, FDA, etc.) must also be reported in routine study data submissions. 


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8. PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational agents 
administered in this study can be found in Section 7.1. 
 
8.1 
AZD1775 
 
8.1.1 
Description 
 
 
Systematic chemical name (IUPAC) is 2-Allyl-1-[6-(1-hydroxy-1-methyl-ethyl)-2-pyridyl]-  
6-[4-(4-methylpiperazin-1-yl)anilino]pyrazolo[3,4- d]pyrimidin-3-one hemihydrate. Other names 
include: MK-1775 hemihydrate, AZD1775 hemihydrate, and AZ13737568 hemihydrate.  The 
molecular formula is C27H32N8O2 ∙ 0.5H2O and the relative molecular mass is 500.60. 
 
8.1.2 
Form 
 
AZD1775 will be provided by AstraZeneca as summarized in Table 8-1. 
 
Table 8-1 
 
Product Descriptions 
 
Product Name & Potency 
Dosage Form 
AZD1775  25mg 
Capsule 
AZD1775 100mg 
Capsule 
 
Supplies will be packaged in HDPE bottles. 
 
8.1.3 
Storage and Stability 
 
Investigational clinical supplies must be received by a designated person at the study site, 
handled and stored safely and properly, and  kept in a secured location to which only the 
investigator and designated assistants have access.  
 
Storage condition: do not store above 30°C. 


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The clinical supplies storage area at the site must be monitored by the site staff for 
temperature consistency with the acceptable storage temperature range specified in this 
protocol or in the product label attached to the protocol. Documentation of temperature 
monitoring should be maintained. 
 
8.1.4 
Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the agent in a self-contained and protective environment.  
 
In accordance with Good Pharmacy Practices, gloves should always be worn by study 
personnel if directly handling capsules that are returned (i.e. when counting returns). The 
Clinical Monitor should be contacted with any questions concerning investigational 
products where special or protective handling is indicated. 
 
8.1.5 
Availability 
 
AZD1775 will be provided by AstraZeneca.  
 
 
8.1.6 
Ordering 
 
Investigative sites will order their own agent. It is necessary to ensure that the pharmacy 
will be able to receive and store the agent. The IRB should be kept informed of who will 
supply the agent so that any regulatory responsibilities can be met in a timely fashion. 
 
8.1.7 
Accountability 
 
 
The investigator, or a responsible party designated by the investigator, should maintain a 
careful record of the inventory and disposition of the agent using the NCI Drug 
Accountability Record Form (DARF) or another comparable drug accountability form.  
(See the NCI Investigator’s Handbook for Procedures for Drug Accountability and 
Storage.) 
 
8.1.8 
Destruction and Return 
 
Unused materials will not be returned and should be destroyed according to institutional 
policy. 
 
8.2 
Cisplatin 
8.2.1 
Description 
 
The chemical name is cis-diamminedichloroplatinum(II).  The Chemical structure is (SP-


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4-2)-diamminedichloroplatinum platinum, diaminedichloro-, cis- (8CI). Cisplatin is also 
known as Platinol, CDDP. The molecular formula is Cl2H6N2Pt. The molecular weight is 
300.05.  
 
Following cisplatin doses of 20 to 120 mg/m^2, the concentrations of platinum are 
highest in liver, prostate, and kidney; somewhat lower in bladder, muscle, testicle, 
pancreas, and spleen; and lowest in bowel, adrenal, heart, lung, cerebrum, and 
cerebellum. Platinum is present in tissues for as long as 180 days after the last 
administration.  
 
Cisplatin does not undergo instantaneous and reversible binding to plasma protein that is 
characteristic of normal drug-protein binding. However, the platinum itself is capable of 
binding to plasma proteins, including albumin, transferrin, and gamma globulin. Three 
hours after a bolus injection and two hours after the end of a three-hour infusion, 90% of 
the plasma platinum is protein bound. 
 
The parent compound, cisplatin, is excreted in the urine. Although small amounts of 
platinum are present in the bile and large intestine after administration of cisplatin, the 
fecal excretion of platinum appears to be insignificant. 
 
Cisplatin decays monoexponentially with a half life of 20 to 30 minutes following 
administrations of 50 or 100 mg/m^2. Cisplatin has a plasma half-life of 30 minutes. The 
complexes between albumin and the platinum from cisplatin do not dissociate to a 
significant extent and are slowly eliminated with a minimum half-life of five days or 
more. 
 
The renal clearance of free (ultrafilterable) platinum also exceeds the glomerular 
filtration rate indicating that cisplatin or other platinum-containing molecules are actively 
secreted by the kidneys. The renal clearance of free platinum is nonlinear and variable 
and is dependent on dose, urine flow rate, and individual variability in the extent of active 
secretion and possible tubular reabsorption. 
 
8.2.2 
Form 
 
Commercially available cisplatin injection infusion (1mg/ml): Each ml of sterile, 
unpreserved solution contains: 1.0mg of cisplatin with 9 mg of sodium chloride and 1mg 
of  mannitol in water for injection. Hydrochloric acid is added to adjust the pH. Single-
dose glass vials of 10, 50, and 100mL contain 10, 50, and 100mg of cisplatin 
respectively.  
 
8.2.3 
Storage and Stability 
 
Vials of cisplatin injection, USP, are stored at room temperature between 15°C and 25°C. 
Do not refrigerate or freeze cisplatin solutions, since a precipitate will form. IV needles, 
syringes, or sets having aluminum components should not be used in preparing or 
administering cisplatin solutions. An interaction will occur between aluminum and 


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platinum from cisplatin, causing a black precipitate that is visible in cisplatin solution. 
 
8.2.4 
Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the chemotherapeutic agent in a self-contained and protective environment.  
 
8.2.5 
Availability 
 
    Cisplatin is commercially available.  
 
8.2.6 
Preparation 
Cisplatin should be prepared according to institutional guidelines. 
 
8.2.7 
Ordering 
 
Cisplatin is commercially available.  Check with the site Director of Pharmacy and/or the 
site research pharmacy to ensure that the agent is in stock. If the agent is not stocked, 
ensure that the agent can be ordered before the protocol is activated. 
 
 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
9.1 
Biomarker Studies 
 
All biomarker analyses completed on blood and tissue samples for correlative data will be 
exploratory.  
Wee1 kinase is a regulator of the G2/M checkpoint.  As Wee1 phosphorylates CDC2 in response 
to genotoxic insults, inhibition of CDC2 phosphorylation by a Wee1 inhibitor is considered a 
direct measure of target engagement.  Under normal conditions, pCDC2 levels in tissue is quite 
low.  Changes in pCDC2 is contingent upon pCDC2 induction by DNA damage.  Patients will 
therefore undergo tumor biopsies after one dose of cisplatin, and then again after a dose of 
cisplatin + AZD1775.   
Formalin-fixed, paraffin-embedded (FFPE) biopsy specimens will be subjected to 
immunohistochemical analyses using standard procedures for: (1) Total CDC2; (2) phospho-
CDC2; (3) gamma-H2AX; (4) phospho-Histone 3; and (5) cleaved caspase 3. 
 
For total CDC2, phospho-CDC2, phospho-Histone 3 and cleaved caspase 3, 
immunohistochemical sections will be scored manually and the % positive cells will be 
annotated; a minimum of 200 cells will be counted.  Additionally, stained slides will be scanned 
using an Aperio ScanScope XT workstation (Aperio Technology, Inc., Vista, CA).  Images will 
be visualized and digitally annotated (as regions of interest, ROIs) using ImageScope software 
(version 10.0.35.1800, Aperio Technology).  The ROIs will then be analyzed using a standard 


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analysis algorithm to quantitate the proportion of area that is positive for staining (color 
deconvolution v9.0, Aperio Technology).  The expected result after cisplatin/AZD1775 
compared to cisplatin alone is preserved total CDC2 staining, reduced phospho-CDC2 staining, 
increased phospho-Histone 3 staining and increased cleaved caspase 3 staining.  In phase 1 
studies, in which skin biopsies were analyzed, a decrease of phospho-CDC2 in the presence of 
AZD1775 of at least 50% was considered to represent evidence of target engagement.1  In a 
study of AZD1775 monotherapy, increases in gamma-H2AX were seen in 3 of 5 paired 
biopsies.2  We will analyze changes in phospho-CDC2 (using this parameter alone); additionally, 
the change in ratio of phospho-CDC/total CDC2 will also be assessed when biopsies post-
cisplatin/AZD1775 and post-cisplatin alone are compared. 
 
Immunohistochemistry for gamma-H2AX [pSer139] will be scored manually with a 
determination of the percentage of cells containing at least 5 nuclear foci.3,4   It is expected that 
the percentage of foci-positive cells will be greater after cisplatin/AZD1775 compared to 
cisplatin alone.  This work will be performed in collaboration with Dr. Geoffrey Shapiro, who 
was the DF/HCC PI on the Phase I trial of chemotherapy combinations with AZD1775, and Dr. 
Alan D’Andrea, who is internationally recognized expertise in the assessment of DNA damage 
pathways, and with Dr. Scott Rodig, a pathologist in the DF/HCC Pathology Core at Brigham 
and Women’s Hospital, who has extensive experience with analysis of these markers. 
The study will obtain paired tumor biopsies for all patients enrolled with accessible disease (after 
cisplatin monotherapy and after cisplatin + AZD1775 combination therapy). The analysis will 
treat the quantification of pCDC2, gamma-H2AX, phospho-Histone 3, and cleaved caspase 3 as 
continuous variables. To evaluate change in these marker levels after the addition of AZD1775, 
descriptive statistics for the change will be generated. Paired t-tests or Wilcoxon signed rank test, 
whichever is appropriate considering the data distribution, will also be used to describe change in 
marker levels.     
 
Biopsy samples will also be subjected to whole exome sequencing (WES) to capture (1) BRCA 
reversion mutations as well as the mutation status of most genes involved with double strand 
break repair  (2) evidence of telometric allelic imbalance, a predictor of cytotoxic therapy 
response5, (3) overall mutational signature, and (4) cell cycle genes related to G1/S checkpoint, 
that may enhance reliance on Wee1-mediated G2/M checkpoint for proper DNA repair.6   
The prevalence of BRCA 1 and BRCA2 mutations is approximately 10-15% among patients 
with triple-negative breast cancer.37 Breast cancers with BRCA deficiency may be more 
susceptible to increases in DNA damage provoked by combination therapy with cisplatin and 
AZD1775.  For patients in whom BRCA status is unknown, anonymized blood samples will be 
undergo testing for BRCA 1 and 2. We will determine whether there is an association between 
germline BRCA deficiency and response to therapy. 
 
To evaluate the relationship between BRCA status and response, the data will be tabulated and 
Fisher’s exact test will be applied, recognizing that only large differences are detectable if the 
overall response rate is 30% (78% power to detect response rate of 83% among BRCA+ and 
20% among BRCA- assuming 15% of patients are deemed BRCA+ and data are available for all 
35 patients). 
 


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9.2 
Laboratory Correlative Studies 
 
Table 9-1 Biomarker sample collection schedule 
Sample 
Specimen 
Visit 
FFPE Archival 
Tumor 
Tumor 
Screening 
Research Biopsy   
Tumor 
Cycle 1 Day 1, 5-48hrs after  
Cisplatin Administration and  
Cycle 2 day 3, 5-8hrs (+/-24hrs)  
after AZD1775 administration 
cfDNA 
Blood (EDTA-purple top) 
Cycle 1 Day 1 
Restaging visits 
Time of Progression 
 
 
9.2.1 
Circulating cell free DNA Collection  
Blood will be collected at baseline, restaging visits and at time of progression for evaluation of cell-free 
DNA (cfDNA).  The cfDNA will be processed and banked in the DF/HCC Clinical Trials Core laboratory 
for future research purposes.  The banked samples will be used to analyze DNA, RNA and protein in 
future studies.   
 
After shipment to and storage within the DF/HCC Breast Bank, cfDNA plasma samples 
will be sent to the Broad Institute of MIT by the DFCI study team, under the care of Dr. 
Nikhil Wagle, for sequencing. Using standard lab software, the Broad Institute will 
create randomly generated barcode labels with a sample number. The DFCI study team 
will label the plasma specimens with the labels provided and complete an Excel 
spreadsheet that correlates the barcode label with the patient’s study ID and the 
timepoint of the sample. All samples will be de-identified and the Broad Institute, Dr. 
Wagle, and his staff, will not, in any way, be able to determine the identity of the 
patient.    
 
 
9.2.1.1 Collection of Specimen(s) 
 
20 ml of whole blood will be collected into 2 EDTA-containing purple top tubes.  The blood sample will be 
collected and processed at baseline, restaging visits and time of progression for evaluation of cfDNA.  Fill 
the tubes completely and immediately mix by gentle inversion 8 to 10 times.  Inadequate or delayed mixing 
may result in accurate results.  The banked samples will be used to analyze DNA, RNA and protein in future 


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studies. 
9.2.1.2 Handling of Specimens(s) 
 
 
20 ml of whole blood will be collected into 2 EDTA-containing purple top tubes.  The blood sample will be 
collected and processed at baseline, restaging visits and time of progression for evaluation of cfDNA.  Fill 
the tubes completely and immediately mix by gentle inversion 8 to 10 times.  Inadequate or delayed mixing 
may result in accurate results. 
 
9.2.1.3 Shipping of Specimen(s) 
 
Tubes must be delivered to DFCI for processing within 2 hours of collection at ambient temperature to: 
 
Dana-Farber Cancer Institute 
Attn: Laura Spetalnick, Krishan Taneja, Lynda Chichester 
Smith 9th Floor, Rm 948 
450 Brookline Avenue 
Boston, MA 02215 
dfcibreastbank@partners.org 
 
Email the blood bank (dfcibreastbank@partners.org) and the current Dana-Farber CRC with the sample 
information and tracking information the day before shipping specimens. 
 
Tube precautions: 
• Do not use tubes after expiration date. 
• Fill the tube completely; overfilling or underfilling of tubes will result in an incorrect blood-to-additive 
ratio and may lead to incorrect analytical results. 
 
Shipping Note:  Lavender tube samples are sent ambient.   
 
9.2.2 
Archival Tissue Collection 
 
Formalin-fixed, paraffin-embedded (FFPE) biopsy specimens will be subjected to immunohistochemical 
analyses using standard procedures for: (1) Total CDC2; (2) phospho-CDC2; (3) gamma-H2AX; (4) 
phospho-Histone 3; and (5) cleaved caspase 3 and other relevant markers.   
 
9.2.2.1 Collection of Specimen(s) 
Formalin-fixed, paraffin-embedded (FFPE) or 15 unstained slides will be collected from participants 
archival tissue.  
 
9.2.2.2 Shipping of Specimen(s) 
 
Ship within 24 hours of collection at ambient temperature to: 
 
Dana-Farber Cancer Institute 
Attn: Arielle Brackett 
Dana 157 
450 Brookline Avenue 
Boston, MA 02215 
Abrackett@partners.org 
 


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Email the current   Dana-Farber CRC with the sample information and tracking information the day 
before shipping specimens. 
 
9.2.2.3 Site(s) Performing Correlative Study   
DFCI/BWH 
 
9.2.3 
Biopsy Collection 
The study will obtain paired tumor biopsies for all patients enrolled with accessible disease (after 
cisplatin monotherapy and after cisplatin + AZD1775 combination therapy).  Paired biopsies will 
be used to evaluate changes in pCDC2, gamma-H2AX, phsopho-Histone 3, and cleaved caspase 
3 and other relevant markers.  Additionally, the biopsies will be subjected to whole exome 
sequencing (WES) to capture BRCA reversion mutations (and the mutation status of most genes 
involved with double strange break repair), evidence of telometric allelic imbalance, and overall 
mutational signature.  
 
After shipment to and storage within the DF/HCC Breast Bank, a portion of the paired biopsy 
samples will be sent to the Broad Institute of MIT by the DFCI study team, under the care of Dr. 
Elie Van Allen. Using standard lab software, the Broad Institute will create randomly generated 
barcode labels with a sample number. The DFCI study team will label the biopsy specimens with 
the labels provided and complete an Excel spreadsheet that correlates the barcode label with the 
patient’s study ID and the timepoint of the sample. All samples will be de-identified and the 
Broad Institute, Dr. Van Allen, and his staff, will not, in any way, be able to determine the 
identity of the patient.  
 
 
9.2.3.1 Scheduling and Feasibility of Research Biopsies 
 
The treating investigator will indicate the best lesion to target for potential biopsy, which 
will be ordered and scheduled per DFCI or BWH’s institutional guidelines. 
 
For research biopsies that are performed in the Cross-Sectional Interventional Radiology 
(CSIR) department, it will be expected that biopsy feasibility be reviewed within 24 
hours of the scheduled procedure. If the radiologist determines that the selected area is 
unsafe or inappropriate in any way, the Radiologist will page the ordering provider to 
discuss the best course of action.  
 
As biopsies for this trial may be occurring for research purposes only, with no additional 
clinical benefit to subjects, the threshold for determining safety and feasibility of the 
procedure must be lower than what might typically be used in determining safety and 
feasibility of a biopsy for clinical purposes. For this reason, the ordering provider will 
include information in the biopsy order comments that indicates that these biopsies are 
being performed for research purposes only and that the radiologist must use their best 
clinical judgement to determine if the procedure is unsafe. If at any point, a radiologist 
questions the safety of the procedure in question, they should not proceed.   
 


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9.2.3.2 Collection of Specimen(s) 
 
Biopsies will be collected at C1D1 5-48hrs after Cisplatin adminsitration and at C2D3 within 
5-8hrs (+/- 24hrs) after the last dose of AZD1775 administration.  If dosing is delayed placing 
the biopsy outside of the allowable window, the biopsy should be rescheduled to be within the 
window.  If not feasible, the biopsy should be obtained as close to within the window as possible. 
 
Tissue specimens will be collected from recurrent or metastatic lesions using standard institutional 
procedures. The amount of tissue collected will follow the guidelines listed below. If a participant 
has more than one site of disease, only one site needs to be biopsied in order to go on to the study 
and the site is left to the discretion of the patient and their treating physician. Fine need aspirates 
(FNA) is not allowed. Participants who undergo a research biopsy procedure for the purpose of this 
protocol, and in whom inadequate tissue is obtained, are still eligible and are not required to 
undergo a repeat biopsy in order to enter the study.   
 
Breast: A goal of 3-6 core biopsy specimens will be obtained using standard institutional 
guidelines for a diagnostic core biopsy of a breast mass. 
Skin/chest wall: A goal of 1-2 5-mm punch biopsies will be obtained. 
Lymph node: A goal of 3-6 core biopsy specimens will be obtained using an 18-gauge needle. 
 
Liver: A goal of 3-6 core biopsy specimens will be obtained using an 18-gauge needle. 
Lung: Because of the risk of pneumothorax associated with core needle biopsies of lung nodules, 
no core biopsies of lung nodules will be performed on this protocol, unless they are clinically 
indicated. 
 
Bone: Because the yield of malignant tissue from bone biopsies tends to be relatively low, if a 
participant has another accessible site of disease (i.e. skin, lymph node, liver), that site should be 
biopsied preferentially. If bone is the only biopsy-accessible site, then a goal of 3-6 core biopsy 
specimens will be obtained using an 11-13gauge needle. 
 
Pleural Fluid: A goal of 500 cc of pleural fluid will be obtained with a standard thoracentesis 
procedure, with or without image guidance, according to the clinical judgment of the treating 
physician and clinician performing the procedure. Less than the goal amount is acceptable, and 
should be based upon the clinical judgment of the Investigator and the clinician performing the 
procedure. If more than the goal amount of fluid is obtained, then the entire specimen (with the 
exception of what is needed for clinical purposes, if applicable) will be stored in the tissue bank. 
Ascites fluid: A goal of 500 cc of ascites fluid will be obtained with a standard paracentesis  procedure, 
with or without image guidance, according to the clinical judgment of the treating physician and 
clinician performing the procedure. Less than the goal amount is acceptable, and should be based 
upon the clinical judgment of the Investigator and the clinician performing the procedure.  If more 
than the goal amount of fluid is obtained, then the entire specimen (with the exception of what is 
needed for clinical purposes, if applicable) will be stored in the tissue bank. 
Please note that the above are guidelines for the amount of tissue to be obtained at the baseline 
biopsy, and are not meant to replace clinical judgment at the time the procedure is performed. 
Less than the goal quantity of tissue is accepted for each type of biopsy, and will be left to the 
clinical judgment of the physician performing the procedure. If ascites or pleural fluid is to be used as 
the investigational biopsy specimen, consideration should be given to confirming the malignant nature of 
the ascites or pleural fluid prior to study entry. 


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If a patient is undergoing resection of a lesion for clinical reasons (i.e. wedge resection  of a new 
lung lesion for confirmation of diagnosis or re-testing of hormone receptor or HER2 status;  or, 
resection of a chest wall lesion; or, resection of a lymph node), then the patient may opt to have a 
portion of that tissue stored for research at the time of the procedure  (provided that the tissue is 
processed as specified in Section 9.2.1.2 ), in which case, the participant would not be required to 
undergo a separate research biopsy for entry into this  protocol. 
 
9.2.3.3 Handling of Specimens(s) 
Core biopsy specimens will be handled and processed at the time of biopsy collection.  Ideally, sufficient 
core biopsy samples will be obtained to allow for some to be frozen (after embeding in OCT) and others 
to be fixed in formalin and subsequently embedded into paraffin blocks.  The specific instructions for 
handling core biopsy material is provided in Appendix C.  
 
9.2.3.4 Shipping of Specimen(s) 
 
 
Ship within 24 hours of collection overnight on dry ice to: 
 
Dana-Farber Cancer Institute 
Attn: Laura Spetalnick, Krishan Taneja, Lynda Chichester 
Smith 9th Floor, Rm 948 
450 Brookline Avenue 
Boston, MA 02215 
dfcibreastbank@partners.org 
 
Email the blood bank (dfcibreastbank@partners.org) and the current Dana-Farber CRC with the sample 
information and tracking information the day before shipping specimens. 
 
Genomic sequencing as described will be performed at the Broad Institute. 
 
9.2.3.5 Site(s) Performing Correlative Study 
 
Dana-Farber Cancer Institute 
 
9.2.3.6 Risks of Research Biopsy and Procedures for Minimizing Risk 
Potential risks according to site are: 
 
Breast (core biopsy): 
• Likely: local discomfort and minor bleeding. 
• Less likely: moderate or major bleeding, need for blood transfusion, hospitalization due to bleeding 
or other complications, infection, pneumothorax, damage to adjacent organs. 
 
Skin/chest wall (punch biopsy): 
• Likely: local discomfort and minor bleeding 
• Less likely: moderate or major bleeding, or infection 
 
Lymph node, liver, or bone (core needle biopsy): 
• Likely: local discomfort and minor bleeding 
• Less likely: moderate or major bleeding, need for blood transfusion, hospitalization due to bleeding 
or other complications, infection, damage to adjacent organs. Additional risks  may be present if 


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intravenous conscious sedation is required 
 
Pleural fluid (thoracentesis): 
• Likely: local discomfort and minor bleeding 
• Less likely: moderate or major bleeding, need for blood transfusion, hospitalization  
due to bleeding or other complications, infection, pneumothorax, damage to  adjacent organs 
 
Ascites fluid (paracentesis): 
• Likely: local discomfort and minor bleeding 
• Less likely: moderate or major bleeding, need for blood transfusion,  hospitalization  due to bleeding 
or other complications, infection, bowel perforation or damage to adjacent organs. In order to minimize 
the risk of a biopsy, only qualified personnel will perform these procedures. 
 
Prior to the procedure, the physician performing the procedure will discuss the risks with each study 
participant, answer any questions, and obtain separate procedure consent. Patients will b e  evaluated 
for comorbidities or concomitant medications that may increase the risk of potential complications. For 
biopsies of lesions that are not superficial and clearly palpable,  imaging studies such as CT or ultrasound 
will be used to guide the biopsy in order to minimize the risk of  damage to adjacent structures. After 
lymph node biopsies, patients will be observed a minimum of 2 hours (range 2-4 hours) after the 
procedure, or according to standard institutional guidelines. After liver biopsies, patients will be 
observed a minimum of 4 hours (range 4-6 hours) after the procedure, or according to standard 
institutional guidelines. Less than the goal quantity of tissue is accepted for each type of biopsy, and 
will be left to the clinical judgment of the physician performing the procedure. 
 
9.2.3.7 Risks of Anesthesia 
 
Local Anesthesia 
All biopsy procedures require local anesthesia using lidocaine, xylocaine, or related 
compounds. There is a small risk of an allergic reaction associated with these  drugs. In order 
to minimize the risk of local anesthesia, only qualified personnel  will perform the biopsy 
procedure. Patients will be queried if they have had previous allergic reactions to local 
anesthetics. 
 
Intravenous  Conscious  Sedation 
Certain biopsy  procedures, such as lymph node, liver, or bone biopsies, may require  intravenous  
conscious  sedation (IVCS). IVCS is a minimally depressed level of consciousness that retains the 
patient's ability to maintain a patent airway independently and continuously and respond 
appropriately to physical stimulation and verbal commands. 
 
The risks of intravenous conscious sedation include: inhibition of the gag reflex and concomitant  
risk of aspiration, cardiopulmonary complications (myocardial infarction, cardiac arrhythmias, 
hypoxemia), and allergic reactions to the sedative or analgesic medications. These risks are small but 
real; for example, in a prospective study of 14,149 patients undergoing IVCS during upper 
gastrointestinal endoscopies, the rate of immediate cardiopulmonary events was 2 in 100047. The 
30-day mortality was 1 per 2,000 cases. In this study, there was a strong association between lack of 
monitoring and use of high-dose benzodiazepines with adverse outcomes. There was also an 
association between the use of local anesthetic sprays to the oropharynx and the development of 
pneumonia. In order to minimize the risk of intravenous conscious sedation, only qualified personnel 
will be responsible for conscious sedation. A minimum of two individuals will be involved in the 
care of patients undergoing conscious sedation-the physician performing the biopsy procedure, and 


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the individual (M.D. or R.N.) who monitors the patients and his/her response to both the sedation 
and the procedure, and who is capable of assisting with any supportive or resuscitative measures. 
The room where the procedure utilizing IVCS takes place will have adequate equipment to provide 
supplemental oxygen, monitor vital signs, and maintain an  airway should this be necessary. An 
emergency cart will also be immediately accessible to the room where the procedure is to take place, 
and emergency support services will be available on page. Patients will be screened and evaluated 
for their fitness to undergo conscious sedation by a  trained physician. Patients with active cardiac 
disease are excluded from this study. No local anesthetic spray to the oropharynx will be necessary, 
given that endoscopy is not a planned procedure. Following the procedure, patients will be observed 
closely in the recovery room for a minimum of 2 hours. 
 
General Anesthesia 
Because of the higher risk of general anesthesia compared with local anesthesia or intravenous 
conscious sedation, biopsies that would require general anesthesia in order to be performed are not 
permitted on this protocol, unless they are being done for clinical reasons, and excess tissue that 
otherwise would  have been  discarded is then banked  for the purpose of this protocol. 
 
9.2.3.8 
Cyclic Immunofluorescence Analysis 
 
Cyclic immunofluorescence (cyCIF) will be performed on paired biopsy specimens to characterize 
immune cell (lymphocyte and myeloid) populations and their spatial relationship. There are a total of 
eight participants who have these tissues available in whom this analysis will be performed. De-
identified biopsy specimens will be shared with Harvard Medical School, specifically the laboratory 
of Peter Sorger, PhD. Any leftover specimens and all data generated from this will be returned to and 
become property of DF/HCC.  
9.2.3.8.1. Waiver of Consent 
 
When these participants initially consented to the trial, specimen and data sharing / future use was 
not a required part of the DF/HCC biomedical consent template and since that time has become a 
critical part of any external collaboration. Seven of eight participants whose tissue will be used for 
cyCIF analyses have passed away and cannot provide re-consent to these procedures. At this time, 
they are no longer human subjects. The eighth patient is currently lost to follow-up and the risk of 
privacy breach in trying to locate them is a greater risk that using their tissue for this analysis.   
 
 
 
10. STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 1 week prior to start of protocol therapy unless 
otherwise specified. Informed consent, scans and x-rays must be done <4 weeks prior to the start 
of therapy.  In the event that the participant’s condition is deteriorating, laboratory evaluations 
should be repeated within 48 hours prior to initiation of the next cycle of therapy.  
 
Assessments must be performed prior to administration of any study agent. Study assessments 
and agents should be administered within + 3 days of the protocol-specified date, unless 
otherwise noted. End of treatment assessments may be performed within 30 days of treatment 
discontinuation. 


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Baseline 
Cycle 1 
Day 1 
Cycle 2 
Day 1 
Cycle 2 
Day 21 
Cycle 3 
Day 1 
Cycle 4+ 
Day 1 
Cycle 4+ 
Day 21 
End of Treatment 
 
Follow-Upl 
AZD1775a 
 
 
X  
 
X  
X  
 
 
 
Cisplatinb 
 
X  
X  
 
X  
X  
 
 
 
Informed consent 
Xm 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
Physical exam 
X 
X 
X 
 
X 
X 
 
X 
 
Vital signsc 
X 
X 
X 
 
X 
X 
 
X 
 
Weightd 
X 
X 
X  
 
X 
X  
 
X 
 
Height 
X 
 
 
 
 
 
 
 
 
Performance status 
X 
X 
X  
 
X 
X  
 
X 
 
Adverse Event Assessment 
 
X 
X 
 
X 
X 
 
X 
 
CBC w/diff, plts 
X 
X 
X 
 
X 
X 
 
X 
 
Serum chemistrye 
X 
X 
X 
 
X 
X 
 
X 
 
B-HCGf 
X 
 
 
 
 
 
 
 
 
EKGg  
X 
 
 
 
 
 
 
X 
 
Radiologic evaluationh 
X  
 
 
X 
 
 
X 
 
X 
Archival tumor tissue 
X 
 
 
 
 
 
 
 
 
Research biopsyi 
 
X  
X  
 
 
 
 
 
 
cfDNA Blood collectionj 
X 
 
 
 
Xj 
Xj 
 
Xj 
 
Blood for genomic 
sequencingk 
 
X 
 
 
 
 
 
 
 
a. 
AZD1775:  200mg (PO) BID beginning with Cycle 2 Day 1.  The patient will take 5 doses of AZD1775 each cycle.  Day 1 dosing is to be done in 
the clinic; subsequent doses can be taken at home.  The 4 additional doses of AZD1775 are to be taken in approximately 12 hour increments.  
Patients should take AZD1775 either two hours before or two hours after a meal. 
b. 
Cisplatin:  75mg/m2 (IV) given on Day 1 of each 21-day cycle (+/- 3 days) 
c. 
Vital signs should be collected pre-dose on dosing days and are to include measurements of heart rate, respiratory rate, systolic and  diastolic  blood  
pressure  while  the  patient  is  in  a  seated  position,  and  oral  or  tympanic temperature. 
d. 
Weight adjustments for cisplatin will be done according to institutional standards. 
e. 
Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, potassium, total protein, 
SGOT [AST], SGPT [ALT], sodium, magnesium 
f. 
Serum pregnancy test (women of childbearing potential as defined in the eligibility criteria). 
g. 
A standard, triplicate12-lead EKG will be collected baseline. A standard, single EKG will be collected at the end of treatment. EKGs may be 
collected during protocol treatment if clinically indicated. 
h. 
 Radiologic measurements should be performed every 2 cycles/6 weeks (+/-7 days). Participants who have their treatment held or delayed will 
continue to have restaging scans that align with cycles of treatment received, rather than weeks on study. Participants taken off study for reasons 
other than progressive disease should continue to have radiologic assessments completed every 6-9 weeks until progression.   
i. 
All patients with tumors that is accessible to biopsy will undergo research biopsies 5-48 hours after cisplatin monotherapy (Cycle 1 Day 1) and after 
the combination therapy (Cycle 2 Day 3, 5-8hrs (+/- 24hr) after AZD1775). If dosing is delayed placing the biopsy outside of the allowable window, 
the biopsy should be rescheduled to be within the window.  If not feasible, the biopsy should be obtained as close to within the window as possible. 
j. 
At baseline, restaging visits, and at time of progression, two 10 mL blood samples will be drawn into EDTA-containing “purple top” test tubes or 
Streck Tubes for cfDNA analysis.  If sample collection is missed for any reason at baseline or at the time of progression then the sample should 
be drawn at a future appointment. 
k. 
Blood sample for genomic sequencing will be collected at Cycle 1 Day 1 
l. 
Participants will be contacted q 6 months for survival. 
m. 
Informed consent must be provided before any study-specific procedures are performed and within 28 days of registration.    
 
 


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11. MEASUREMENT OF EFFECT 
 
11.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, participants should be re-evaluated for response every 2 cycles of 
treatment or approximately every 6 weeks. .   
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1) 
[Eur J Ca 45:228-247, 2009].  Changes in the largest diameter (unidimensional measurement) of 
the tumor lesions and the shortest diameter in the case of malignant lymph nodes are used in the 
RECIST criteria. 
 
11.1.1 Definitions 
 
Evaluable for Target Disease response.  Only those participants who have measurable 
disease present at baseline, have initiated study treatment, and have had their disease re-
evaluated will be considered evaluable for target disease response.  These participants 
will have their response classified according to the definitions stated below.  (Note:  
Participants who exhibit objective disease progression prior to the end of cycle 1 will also 
be considered evaluable.) 
 
Evaluable Non-Target Disease Response.  Participants who have lesions present at 
baseline that are evaluable but do not meet the definitions of measurable disease, have 
received at least one cycle of therapy, and have had their disease re-evaluated will be 
considered evaluable for non-target disease.  The response assessment is based on the 
presence, absence, or unequivocal progression of the lesions.  
 
11.1.2 Disease Parameters 
 
Measurable disease.  Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter  to be recorded) as ≥ 20 mm by 
chest x-ray or ≥10 mm with CT scan, MRI, or calipers by clinical exam.  All tumor 
measurements must be recorded in millimeters (or decimal fractions of centimeters). 
 
Note: Tumor lesions that are situated in a previously irradiated area might be considered 
measurable if the investigator thinks it appropriate to include them. 
 
 Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a 
lymph node must be ≥15 mm in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm).  At baseline and in follow-up, only 
the short axis will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions 


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


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Clinical lesions. Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes) and ≥10 mm in diameter as 
assessed using calipers (e.g., skin nodules).  In the case of skin lesions, documentation by 
color photography, including a ruler to estimate the size of the lesion, is recommended.  
 
Chest x-ray.  Lesions on chest x-ray are acceptable as measurable lesions when they are 
clearly defined and surrounded by aerated lung; however, CT is preferable.  
 
Conventional CT and MRI. This guideline has defined measurability of lesions on CT 
scan based on the assumption that CT thickness is 5mm or less. If CT scans have slice 
thickness greater than 5 mm, the minimum size of a measurable lesion should be twice 
the slice thickness. MRI is also acceptable in certain situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which 
greatly impact image quality, lesion conspicuity, and measurement.  Furthermore, the 
availability of MRI is variable globally.  As with CT, if an MRI is performed, the 
technical specifications of the scanning sequences used should be optimized for the 
evaluation of the type and site of disease.  Furthermore, as with CT, the modality used at 
follow-up should be the same as was used at baseline and the lesions should be 
measured/assessed on the same pulse sequence.  It is beyond the scope of the RECIST 
guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body 
parts, and diseases.  Ideally, the same type of scanner should be used and the image 
acquisition protocol should be followed as closely as possible to prior scans.  Body scans 
should be performed with breath-hold scanning techniques, if possible. 
 
FDG-PET. While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible 'new' disease).  New lesions on the basis 
of FDG-PET imaging can be identified according to the following algorithm:  
(a) Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of 
PD based on a new lesion. 
(b)  No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive 
FDG-PET at follow-up corresponds to a new site of disease confirmed by CT, this is 
PD.  If the positive FDG-PET at follow-up is not confirmed as a new site of disease 
on CT, additional follow-up CT  scans are needed to determine if there is truly 
progression occurring at that site (if so, the date of PD will be the date of the initial 
abnormal FDG-PET scan).  If the positive FDG-PET at follow-up corresponds to a 
pre-existing site of disease on CT that is not progressing on the basis of the anatomic 
images, this is not PD. 
(c)  FDG-PET may be used to upgrade a response to a CR in a manner similar to a 
biopsy in cases where a residual radiographic abnormality is thought to represent 
fibrosis or scarring.  The use of FDG-PET in this circumstance should be 
prospectively described in the protocol and supported by disease-specific medical 
literature for the indication.  However, it must be acknowledged that both approaches 


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may lead to false positive CR due to limitations of FDG-PET and biopsy 
resolution/sensitivity. 
 
Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake 
greater than twice that of the surrounding tissue on the attenuation corrected image. 
 
PET-CT. At present, the low dose or attenuation correction CT portion of a combined 
PET-CT is not always of optimal diagnostic CT quality for use with RECIST 
measurements.  However, if the site can document that the CT performed as part of a 
PET-CT is of identical diagnostic quality to a diagnostic CT (with IV and oral contrast), 
then the CT portion of the PET-CT can be used for RECIST measurements and can be 
used interchangeably with conventional CT in accurately measuring cancer lesions over 
time.  Note, however, that the PET portion of the CT introduces additional data which 
may bias an investigator if it is not routinely or serially performed.   
MIBG (meta-iodobenzylguanidine).The following is recommended, to assure high 
quality images are obtained.  
Patient preparation: Iodides, usually SSKI (saturated solution of potassium iodide), 
are administered to reduce thyroidal accumulation of free radioiodine, preferably 
beginning the day prior to injection and continuing for 3 additional days (4 days 
total). For adults 3 drops t.i.d. Participants are asked about exposure to potential 
interfering agents. If none is noted, an indwelling intravenous line is established. The 
dose of MIBG is administered by slow intravenous injection over 90 seconds.  
Images from the head to the distal lower extremities should be obtained.  
I-123MIBG scintigraphy is performed to obtain both planar and tomographic images.  
Planar: Anterior and posterior views from the top of the head to the proximal lower 
extremities are obtained for 10 minutes at 24 hours and occasionally at 48 hours 
following injection of 10 mCi/1.7 square meters of body surface area (~150 μCi/kg, 
maximum 10 mCi). Anterior views of the distal lower extremities are adequate. A 
large field of view dual head gamma camera with low energy collimators is preferred.  
 
SPECT: Most participants receiving I-123 MIBG also undergo SPECT at 24 hours, 
using a single or multi-headed camera with a low energy collimator. The camera is 
rotated through 360 degrees, 120 projections at 25 seconds per stop. Data are 
reconstructed using filtered back projections with a Butterworth filter and a cut off 
frequency of 0.2-0.5. SPECT/CT may be performed at institutions with this capacity. 
 
Ultrasound. Ultrasound is not useful in assessment of lesion size and should not be used 
as a method of measurement. Ultrasound examinations cannot be reproduced in their 
entirety for independent review at a later data and, because they are operator dependent, it 


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cannot be guaranteed that the same technique and measurements will be taken from one 
assessment to the next. If new lesions are identified by ultrasound in the course of the 
study, confirmation by CT or MRI is advised. If there is concern about radiation exposure 
from CT, MRI may be used instead of CT in selected instances.  
 
Endoscopy, Laparoscopy. The utilization of these techniques for objective tumor 
evaluation is not advised. However, such techniques may be useful to confirm complete 
pathological response when biopsies are obtained or to determine relapse in trials where 
recurrence following complete response (CR) or surgical resection is an endpoint. 
 
Tumor markers. Tumor markers alone cannot be used to assess response. If markers are 
initially above the upper normal limit, they must normalize for a participant to be 
considered in complete clinical response.  Specific guidelines for both CA-125 response 
(in recurrent ovarian cancer) and PSA response (in recurrent prostate cancer) have been 
published [JNCI 96:487-488, 2004; J Clin Oncol 17, 3461-3467, 1999; J Clin Oncol 
26:1148-1159, 2008].  In addition, the Gynecologic Cancer Intergroup has developed 
CA-125 progression criteria which are to be integrated with objective tumor assessment 
for use in first-line trials in ovarian cancer [JNCI 92:1534-1535, 2000]. 
 
Cytology, Histology. These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor 
types, such as germ cell tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or 
stable disease is mandatory to differentiate between response or stable disease (an 
effusion may be a side effect of the treatment) and progressive disease. 
 
11.1.4 Response Criteria 
 
 
11.1.4.1 
Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological 
lymph nodes (whether target or non-target) must have reduction in short axis to <10 
mm. 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target 
lesions, taking as reference the baseline sum diameters. 
 
Progressive Disease (PD):  At least a 20% increase in the sum of the diameters of 
target lesions, taking as reference the smallest sum on study (this includes the 
baseline sum if that is the smallest on study).  In addition to the relative increase of 
20%, the sum must also demonstrate an absolute increase of at least 5 mm.  (Note:  
the appearance of one or more new lesions is also considered progressions). 
 


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Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum diameters while on 
study. 
 
11.1.4.2 
Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and normalization 
of tumor marker level.  All lymph nodes must be non-pathological in size (<10 mm 
short axis). 
 
Note:  If tumor markers are initially above the upper normal limit, they must 
normalize for a patient to be considered in complete clinical response. 
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal limits. 
 
Progressive Disease (PD):  Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions.  Unequivocal progression 
should not normally trump target lesion status.  It must be representative of overall 
disease status change, not a single lesion increase.     
 
Although a clear progression of “non-target” lesions only is exceptional, the opinion 
of the treating physician should prevail in such circumstances, and the progression 
status should be confirmed at a later time by the review panel (or Principal 
Investigator). 
 
11.1.4.3 
Evaluation of New Lesions 
 
The finding of a new lesion should be unequivocal (i.e. not due to difference in 
scanning technique, imaging modality, or findings thought to represent something 
other than tumor (for example, some ‘new’ bone lesions may be simply healing or 
flare of pre-existing lesions). However, a lesion identified on a follow-up scan in an 
anatomical location that was not scanned at baseline is considered new and will 
indicate PD. If a new lesion is equivocal (because of small size etc.), follow-up 
evaluation will clarify if it truly represents new disease and if PD is confirmed, 
progression should be declared using the date of the initial scan on which the lesion 
was discovered. 
 
11.1.4.4 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started).  The patient's best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria. 
 


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


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death due to any cause. Participants without events reported are censored at the last 
disease evaluation). 
 
Duration of overall complete response: The duration of overall CR is measured from the 
time measurement criteria are first met for CR until the first date that progressive disease 
is objectively documented, or death due to any cause. Participants without events 
reported are censored at the last disease evaluation. 
 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment 
until the criteria for progression are met, taking as reference the smallest measurements 
recorded since the treatment started, including the baseline measurements.  
 
11.1.6 Survival 
 
 
Overall Survival: Overall Survival (OS) is defined as the time from randomization (or 
registration) to death due to any cause, or censored at date last known alive. 
 
Progression-Free Survival: Progression-Free Survival (PFS) is defined as the time from 
randomization (or registration) to the earlier of progression or death due to any cause. 
Participants alive without disease progression are censored at date of last disease 
evaluation. 
 
Time to Progression: Time to Progression (TTP) is defined as the time from 
randomization (or registration) to progression, or censored at date of last disease 
evaluation for those without progression reported. 
 
11.1.7 Response Review 
 
Central Review will be conducted by the DF/HCC Tumor Imaging Metric Core for 
DF/HCC Institutions. 
 
12. DATA REPORTING / REGULATORY REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements). 
 
12.1 
Data Reporting 
 
 
12.1.1 Responsibility for Data Submission 
 
Investigative sites within DF/HCC or DF/PCC are responsible for submitting data and/or 
data forms to the ODQ according to the schedule set by the ODQ. 
 


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12.2 
Data Safety Monitoring 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity 
and accrual data from this study. The committee is composed of clinical specialists with 
experience in oncology and who have no direct relationship with the study. Information that 
raises any questions about participant safety will be addressed with the Overall PI and study 
team. 
 
The DSMC will review each protocol up to four times a year or more often if required to review 
toxicity and accrual data. Information to be provided to the committee may include: up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or higher 
unexpected adverse events that have been reported; summary of all deaths occurring with 30 
days of intervention for Phase I or II protocols; for gene therapy protocols, summary of all deaths 
while being treated and during active follow-up; any response information; audit results, and a 
summary provided by the study team. Other information (e.g. scans, laboratory values) will be 
provided upon request.  
 
13. STATISTICAL CONSIDERATIONS 
 
 
13.1 
Study Design/Endpoints 
 
This is a single-arm, two-stage phase 2 study to evaluate the response to AZD1775 in 
combination with cisplatin in patients with triple-negative breast cancer. The primary endpoint is 
to investigate objective response rate, and secondary endpoint will examine changes in pCDC2, 
as well as markers of checkpoint bypass, DNA damage and apoptosis in tumor tissue. Patients 
may have received 0-1 prior chemotherapeutic regimen for metastatic breast cancer.  The number 
of patients with 0 prior chemotherapeutic regimen will be limited to a maximum of n = 20. 
 
There is data to suggest that in patients with ≤1 prior chemotherapy for triple-negative disease, 
response to ranges from 10-37%.   A recent study that looked at the activity of platinum therapy 
for first or second line treatment of metastatic triple-negative disease found an overall response 
rate of 25.6%.  The response rate in the first line setting was 29% and in the second line setting 
was 12%.39 Another study, found a response rate of 10.3% to cisplatin monotherapy in patients 
who had received ≤ 1 prior line of chemotherapy.40  
  
Based on the maximum enrollment of patients receiving first line chemotherapy for metastatic 
triple-negative breast cancer, aa rate response of no more than 20% to cisplatin alone would be 
anticipated.  A response rate of 40% would be of clinical interest for the combination of cisplatin 
with AZD1775. 
 
The study uses a Simon optimal two-stage design with a one-sided type I error of 0.1 and type II 
error of 0.1 (90% power) to detect the difference between null (20%) and alternative (40%) 
objective response rates. In the first stage, 17 patients will be entered.  If there are at least 4 


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responses, the study will continue to stage 2 where another 20 patients will be enrolled.  If there 
are 10 or fewer responses among the 37 patients, the regimen will be declared not worthy of 
further study.  If there are 11or more responses (>30%), the regimen will be declared worthy of 
further study in a randomized setting for patients with metastatic triple-negative breast cancer 
comparing cisplatin to cisplatin + AZD1775.   If the true response rate is 20%, the chance the 
regimen is declared ineffective is approximately 90% (exact alpha=0.095).  If the true response 
rate is 40%, the chance that the regimen is falsely declared ineffective is 10% (exact 
power=0.903).  
 
 
13.2 
Analysis of Primary Endpoints 
 
For this phase II trial, the analysis population is all patients who initiate protocol regimen. All 
patients who receive at least one dose of protocol regimen will be evaluable for objective 
response every 6 weeks from the time of their first treatment. The primary analysis will evaluate 
the objective response rate per RECIST 1.1.  We will estimate this percentage and a 
corresponding 95% confidence interval (CIs) will be calculated. 
 
13.3 
Analysis of Secondary Endpoints 
 
PFS is defined as the time from enrollment until disease progression or death, whichever occurs 
first. Patients alive and free from disease progression will be considered censored. PFS will be 
estimated by the method of Kaplan and Meier.  
 
The study requires paired biopsies from all patients with accessible tumor.  With a sample size of 
37 and assuming that 50% of them either without accessible lesions or assay failure, paired 
biopsy assessment are available for 18 patients. Assuming the percent of pCDC2 positive cells 
decreases 50% in the presence of AZD1775 and the standard deviation of pCDC2 equals to the 
difference, using t statistics with 1-sided alpha of 0.05, there will be 99% power to detect the 
change in pCDC2 pre- and post-treatment.  The calculation was done using East v6.3 (Cytel Inc). 
Analysis plan for all biomarker data was written in section 9.1. 
 
Difference of % CDC2 
positive cells in paired 
samples 
S.d. of paired difference 
Power 
0.5 
0.5 
99% 
0.5 
0.75 
86% 
0.5 
1 
65% 
 
Descriptive statistics will be used to characterize the tumor genomic profiles available for DFCI 
participants by disease response to therapy (response assessed by RECIST 1.1). PFS and ORR 
will be estimated using Kaplan-Meier methods among patients with and without certain gene 
mutations, respectively. The Benjamini-Hochberg procedure will be used to control the false 
discovery rate and address multiple comparisons. 
 
 


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13.4 
Reporting and Exclusions 
 
13.4.1 Evaluation of Toxicity 
 
All participants who have received at least one dose of study medication will be evaluable for 
toxicity from the time of their first treatment. 
 
13.4.2 Evaluation of Response 
 
All participants who have received at least one dose of study medication will be assessed for 
response. 
 
Patients would be replaced if she/he withdraws study consent prior to initiation of protocol 
therapy.  
 
 
 
 
14. PUBLICATION PLAN 
 
The results should be made public within 24 months of reaching the end of the study. The end of 
the study is the time point at which the last data items are to be reported, or after the outcome 
data are sufficiently mature for analysis, as defined in the section on Sample Size, Accrual Rate 
and Study Duration. If a report is planned to be published in a peer-reviewed journal, then that 
initial release may be an abstract that meets the requirements of the International Committee of 
Medical Journal Editors. A full report of the outcomes should be made public no later than three 
(3) years after the end of the study.  
 
 


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40.  
Baselga J SS, Pego A, Change A, Goeminne JC, Graas MP, Kennedy J, Ciruelos G, Zubel 
A, Groos J, Kia U SA. Cetuximab + Cisplatin in Estrogen Receptor-Negative, 
Progesterone Receptor-Negative, HER2-Negative (Triple-Negative) Metastatic Breast 
Cancer: Results of the Randomized Phase II BALI-1 Trial. Cancer Res. 2010;70:Abstract 
PD01-01.  
41. Oken M, Creech R, Tormey D, et al. Toxicity and response criteria of the Eastern 
Cooperative Oncology Group.Am J Clin Oncol. 1982;5:649-655. 
 
 


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APPENDIX A 
PERFORMANCE STATUS CRITERIA41 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
 
 
 
 
 
 
 


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APPENDIX B New York Heart Association Heart Failure Classifications 
 
Class 
Patient Symptoms 
I 
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, 
dyspnea (shortness of breath). 
II 
Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, 
palpitation, dyspnea (shortness of breath). 
III 
Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, 
palpitation, or dyspnea. 
IV 
Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest.  If any 
physical activity is undertaken, discomfort increases. 
 


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APPENDIX C: Tissue Acquisition Guidelines 
Core needle tumor biopsies (18-gauge) will be acquired with 3-6 cores each at the following timepoints: 
 
• 
Cycle 1 Day 1 5-48hrs after Cisplatin administration 
• 
Cycle 2 Day 3 5-8hrs (+/- 24hrs) after AZD1775 administration 
 
The order of specimen collection should be: 
• 
First core: Frozen OCT 
• 
Second core: Frozen OCT 
• 
Third core: Frozen OCT 
• 
Fourth core: 10% neutral buffered formalin 
• 
Fifth core: Frozen OCT 
• 
Sixth core: Frozen OCT 
• 
Seventh core: 10% neutral buffered formalin 
 
Supplies: 
o Tissue-Tek Cryomold,  
 
Standard size 25x20x5mm (#4557), Fisher Scientific Cat# NC9511236 
-OR- 
 
Intermediate size 15x15x5mm (#4566), Fisher Scientific Cat# NC9542860 
o Tissue-Tek O.C.T. Compound, 4oz (#4583): Fisher Scientific Cat# NC9638938 
o Small specimen bag: Fisher Cat# 01-002-37 (or equivalent) 
o Forceps: Fisher Cat# NC9832137 (or equivalent) 
o Dry Ice and Cooler 
o Cryoware Pen: Fisher Cat# 13-382-88 
o 10mL – 10% Formalin: Fisher Cat#032-065 
 
Procedure for Freezing samples in OCT: 
 
• 
Prepare cryomolds ahead of time: Squeeze small amount of OCT into cyromolds* – enough 
for there to be a thin layer covering the bottom let settle on a flat surface for a minute or two. 
It is crucial for future sectioning that these core biopsies are placed on a very flat OCT 
surface, so the best way to make sure these mold are flat is the freeze the bottom layer on a -
80 freezer shelf.  
*If time permits, the cryomolds can be placed onto the dry-ice once a thin layer of 
OCT has been put it but before the tissue is put in. Once this is frozen or begins to 
freeze, the tissue can be placed on top of the now frozen OCT and then covered with 
more liquid OCT and then placed back onto the dry ice to freeze completely.  
• 
Bring all supplies needed to the biopsy as the tissue needs to be frozen immediately.  
• 
As soon as the specimen is ready, use disposable forceps to gently place only 1 core into each 
cryomold. Gently pick up the tissue with the forceps from one end of the core biopsy, being 
careful not to crush the tissue and immediately lay out the fresh biopsy tissue onto the center 
of the mold. Be sure to lay the tissue as flat to the mold, and as straight as possible. Keep 
molds on dry ice at all times. 
• 
You should ideally collect between 3 and 6 separate cores. 
• 
Once the specimen is in the cryomold, cover with more OCT making sure the tissue is 


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entirely submerged.  
• 
Immediately place cryomold with OCT and tissue onto dry-ice making sure the cryomold is 
level and will not tip over.  
• 
The OCT will freeze into a solid white block within 5-10 minutes 
o Once the blocks have completely frozen they can be put into a specimen bag and 
sealed. More than one block can be put into a bag. 
o The bag should be labeled with: 
 
Patient name 
 
DFCI Study #:  
 
DFCI MRN # 
 
Date of biopsy 
 
Time Point 
 
Number of blocks in the bag 
o Samples should be kept on dry ice at all times until they can be placed in a -80oC 
freezer. Samples should remain frozen at -80oC until shipment. 
 
All biopsy samples should be brought to the Clinical Trials Core Lab: 
 
Dana-Farber Cancer Institute 
Attn: Laura Spetalnick, Krishan Taneja, Lynda Chichester 
Smith 9th Floor, Rm 948 
450 Brookline Avenue 
Boston, MA 02215 
dfcibreastbank@partners.org  
 
Procedure for Samples Placed in Formalin: 
• 
Immediately place the specimen in a container of 10mL formalin. 
• 
The container and/or bag should be labeled with: 
 
Patient name 
 
DFCI Study #:  
 
DFCI MRN # 
 
Date of biopsy 
 
Time Point 
 
Number of blocks in the bag 
 
All biopsy samples should be brought to the Clinical Trials Core Lab to be processed into 
formalin fixed paraffin embedded blocks (FFPE): 
 
Dana-Farber Cancer Institute 
Attn: Laura Spetalnick, Krishan Taneja, Lynda Chichester 
Smith 9th Floor, Rm 948 
450 Brookline Avenue 
Boston, MA 02215 
dfcibreastbank@partners.org