Conditions: Invasive Breast Carcinoma Triple-Negative Breast Carcinoma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 17
Healthy volunteers: no

Brief summary:
This phase II trial studies how well pegylated liposomal doxorubicin, bevacizumab, and everolimus work in treating patients with triple-negative breast cancer with tumors predicted insensitive to standard chemotherapy. Drugs used in chemotherapy, such as pegylated liposomal doxorubicin, work in different ways to stop the growth of tumor cells by stopping them from dividing. Bevacizumab may stop or slow breast cancer by blocking the growth of new blood vessels necessary for tumor growth. Everolimus may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Giving pegylated liposomal doxorubicin together with bevacizumab and everolimus may kill more tumor cells.

Detailed description:
PRIMARY OBJECTIVE:

I. Determine excellent clinical response rates (pathologic complete response \[pCR\]/residual cancer burden \[RCB\]-0 or minimal residual disease \[RCB-I\]) in patients with anthracycline-based chemotherapy insensitive, localized triple-negative breast cancer (TNBC) who receive 4 cycles of pegylated liposomal doxorubicin hydrochloride, bevacizumab, and everolimus (DAE) following anthracycline-based chemotherapy in the neoadjuvant setting.

SECONDARY OBJECTIVES:

I. Determine response rate after 4 cycles of DAE using radiographic imaging. II. Determine toxicity associated 4 cycles of DAE in the neoadjuvant setting. III. Pathologic response rates to 4 cycles of DAE in mesenchymal tumors versus (vs.) non-mesenchymal tumors.

V. Compare pathologic response rates in mesenchymal tumors to 4 cycles of DAE vs. 12 weeks of weekly paclitaxel (using data collected from standard of care treatment).

EXPLORATORY OBJECTIVES:

I. Determine the correlation between vimentin expression by immunohistochemistry (IHC) and the presence of mesenchymal gene signatures at the time of initial tumor biopsy prior to neoadjuvant chemotherapy (NACT).

II. Determine the correlation between mutations in PIK3CA, PTEN or NF2 or PTEN loss by IHC and the presence of mesenchymal gene signatures at the time of initial tumor biopsy prior to NACT.

III. Determine rates of pCR in patients with mesenchymal tumors identified by gene signatures and compare to pCR rates in non-mesenchymal tumors.

IV. Correlate pathologic response with degree of vimentin expression as measured by IHC.

V. Determine rates of pCR in patients whose tumors contain mutations in PIK3CA, PTEN or NF2 or PTEN loss by IHC and compare to pCR rates in patients whose tumors lacks mutations in these genes.

OUTLINE:

Patients receive pegylated liposomal doxorubicin hydrochloride intravenously (IV) over about 3 hours on day 1, bevacizumab IV over 90 minutes on day 1, and everolimus orally (PO) once daily (QD) on days 1-21. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Patients will not receive bevacizumab during cycle 4 of therapy. Patients then undergo surgery.

After completion of study treatment, patients are followed up within 30 days of surgery.

Arms:
arm 1: Patients receive pegylated liposomal doxorubicin hydrochloride IV over about 3 hours on day 1, bevacizumab IV over 90 minutes on day 1, and everolimus PO QD on days 1-21. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Patients will not receive bevacizumab during cycle 4 of therapy. Patients then undergo surgery.

Interventions: intervention 1: Bevacizumab intervention 2: Everolimus intervention 3: Laboratory Biomarker Analysis intervention 4: Pegylated Liposomal Doxorubicin Hydrochloride
Intervention descriptions: intervention 1: Given IV intervention 2: Given PO intervention 3: Correlative studies intervention 4: Given IV

Protocol document:
Prot_SAP_000.pdf: 
MDACC# 2015-0087 
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Women’s Triple-Negative First-Line Study: A Phase II Trial of Liposomal 
Doxorubicin, Bevacizumab and Everolimus (DAE) in Patients with 
Localized Triple-Negative Breast Cancer (TNBC) with Tumors Predicted 
Insensitive to Standard Neoadjuvant Chemotherapy (NACT) 
Principal Investigator:  Clinton Yam, MD 
Co-principal Investigator: Rashmi Murthy, MD 
Collaborating Statistician: Roland Bassett Jr. 
Clinical Collaborators: Debu Tripathy, MD; Jennifer Litton, MD; Nuhad Ibrahim, 
MD; Banu Arun, MD; Bora Lim, MD; Naoto Ueno, MD, PhD; Wei Yang, MD 
Laboratory Collaborators: Naoto Ueno, MD, PhD; Helen Piwnica-Worms, PhD; 
W. Fraser Symmans, MD
Department:  
Breast Medical Oncology 
Phone: 
713-792-2817
Fax: 
713-794-4385
Research Nurse: 
TBA 
Protocol Type: 
Standard Protocol 
Protocol Phase: 
Phase II 
Version Status: 
11 


 
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Table of Contents 
Study Schema: .............................................................................................................................................. 4 
List of abbreviations ................................................................................................................................. 5 
Glossary of terms .......................................................................................................................................... 6 
1.      Introduction ......................................................................................................................................... 8 
Introduction to investigational treatments and other study treatments ....................................11 
Overview of Everolimus ..........................................................................................................................11 
mTOR pathway and cancer ....................................................................................................................12 
Non-clinical experience ..........................................................................................................................12 
2.       Study Objectives………………………………………………………...…………………………..16 
3. 
Objectives ...........................................................................................................................................18 
4. 
Selection of Patients ...........................................................................................................................19 
 
Screening for hepatitis B and C ........................................................................................................22 
 
Registration Procedures ....................................................................................................................23 
5. 
Treatment Plan...................................................................................................................................23 
Everolimus Dosing in Special Populations ................................................................................................25 
       Drug Information including Adverse Drug Reactions (ADRs) ........................................................26 
Myelosuppression ........................................................................................................................................26 
Cardiac Toxicity ..........................................................................................................................................26 
Infusion reactions ........................................................................................................................................27 
Palmar-plantar erythrodysesthesia (PPE) / Hand-Foot syndrome (HFS) ..............................................27 
Nausea/Vomiting/Diarrhea .........................................................................................................................27 
Thromboembolism ......................................................................................................................................28 
Gastrointestinal (GI) Perforations and Wound Healing Complications ................................................28 
        Description of selected adverse drug reactions ......................................................................32 
      Therapy Administration and Dose Reductions ...................................................................................37 
Management of specific toxicities related to everolimus administration:...............................................37 
Management of skin toxicity .......................................................................................................................40 


 
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Management of hepatitis reactivation / flare…………………………………………………………….44 
6.     Concomitant medications....................................................................................................................47 
7.     Reporting of Adverse Events ..............................................................................................................50 
8. 
Scheduled evaluations ........................................................................................................................53 
9. 
Measurement of Effect ......................................................................................................................56 
 
Correlative Studies .............................................................................................................................57 
 
Statistical Considerations ..................................................................................................................57 
10. 
Protocol amendments, or changes in study conduct .......................................................................58 
REFERENCES: ..........................................................................................................................................59 
 
 


 
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Study Schema: 
 
 
 
 
 
 
 
 
*Bevacizumab will be omitted with the fourth cycle 
 
 
 
 
 
 
Alternate Study Schema for Patients not Participating on ARTEMIS (2014-0185): 
 
 
 
 
 
 
 
 
 
 
 
*Bevacizumab will be omitted with the fourth cycle 
Patients with 
localized 
TNBC who 
will receive 
neoadjuvant 
chemotherapy 
Pre-Treatment Ultrasound and Biopsy 
 
Anthracycline-
based 
chemotherapy 
x 4 cycles 
Ultrasound 
Chemo-
insensitive 
disease as 
per protocol 
2014-0815 
Ultrasound 
DAE x 4 
cycles 
administered 
every 21 
days* 
 
 
Surgery 
Patients with 
localized TNBC 
who will receive 
neoadjuvant 
chemotherapy 
Anthracycline-
based 
chemotherapy 
Ultrasound 
DAE x 4 
cycles 
administered 
every 21 
days* 
Ultrasound 
Surgery 


 
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List of abbreviations 
4E-BP1 
4E-binding protein 
AE 
Adverse event 
ALT 
Alanine aminotransferase/glutamic pyruvic transaminase/GPT 
ANC 
Absolute neutrophil count 
AST 
Aspartate aminotransferase/glutamic oxaloacetic transaminase/GOT 
AUC 
Area under the curve 
BAL 
Bronchoalveolar lavage 
BCG 
Bacillus Calmette-Guérin 
CDS 
Core data sheet 
CoA 
Coenzyme A 
CPK 
Creatine phosphokinase 
CRF 
Case Report Form 
CT 
Computer tomography 
CTCAE 
Common terminology criteria for adverse events 
CYP3A4 
Cytochrome P450 3A4 
DDI 
Drug-drug interaction 
DLCO 
Diffusing capacity of the Lung for Carbon Monoxide 
DNA 
Deoxyribonucleic acid 
DS&E 
Drug Safety and Epidemiology 
EOT 
End of treatment 
EU 
European Union 
FDA 
Food and drug administration 
GERD 
Gastroesophageal reflux disease 
HbA1c 
Hemoglobin A1c 
HBcAb 
Hepatitis B core antibody 
HbsAb 
Hepatitis B surface antibody 
HbsAg 
Hepatitis B surface antigen 
HBV 
Hepatitis B virus 
HCV 
Hepatitis C virus 
HMG 
3-hydroxy-3-methyl-glutaryl 
IB 
Investigator brochure 
INR 
International Normalized Ratio 
IRB 
Institutional Review Board 
IUD 
Intrauterine device 
IUS 
Intrauterine system 
IV 
Intravenous 
log10 
Decadic logarithm (common logarithm) 
MRI 
Magnetic resonance imaging 
mTOR 
Mammalian target of rapamycin 
NCI 
National Cancer Institute 
PCR 
Polymerase chain reaction 
PgP 
P-glycoprotein 
PFT 
Pulmonary function tests 
PI3K 
Phosphoinositide 3-kinase 
PNET 
Pancreatic neuroendocrine tumor 
RCC 
Renal cell carcinoma 
RMP 
Risk management plan 
RNA 
Ribonucleic acid 
SAE 
Serious Adverse Event 
SEGA 
Subependymal giant cell astrocytoma 
TS 
Tuberous sclerosis 
ULN 
Upper limit of normal 
US 
United States 
VEGF 
Vascular endothelial growth factor 


 
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WOCBP 
Women of child-bearing potential 
Glossary of terms 
 
Assessment 
A procedure used to generate data required by the study 
Baseline 
For efficacy evaluations, the baseline assessment will be the last available 
assessment before or on the date of randomization. 
For safety evaluations (i.e. laboratory assessments and vital signs), the 
baseline assessment will be the last available assessment before or on the 
start date of study treatment. 
The value obtained at baseline assessments, referred to as “baseline 
value” will be used as reference for the patient. 
Control drug 
A study treatment used as a comparator to reduce assessment bias, 
preserve blinding of investigational drug, assess internal study validity, 
and/or evaluate comparative effects of the investigational drug 
Dose level 
The dose of drug given to the patient (total daily or weekly etc.)  
Enrollment 
Point/time of patient entry into the study; the point at which informed 
consent must be obtained (i.e. prior to starting any of the procedures 
described in the protocol) 
Investigational drug 
The study treatment whose properties are being tested in the study; this 
definition is consistent with US CFR 21 Section 312.3 and is synonymous 
with “investigational new drug.” 
Investigational 
treatment 
Drug whose properties are being tested in the study as well as their 
associated placebo and active treatment controls (when applicable). This 
also includes approved drugs used outside of their indication/approved 
dosage, or that are tested in a fixed combination. Investigational treatment 
generally does not include other study treatments administered as 
concomitant background therapy required or allowed by the protocol when 
used in within approved indication/dosage 
Medication number 
A unique identifier on the label of each study treatment package which is 
linked to one of the treatment groups of a study 
Other study 
treatment 
Any drug administered to the patient as part of the required study 
procedures that was not included in the investigational treatment 
Patient  
A unique identifying number assigned to each patient/subject/healthy 
volunteer who enrolls in the study 
Period 
A subdivision of the study timeline; divides stages into smaller functional 
segments such as screening, baseline, titration, washout, etc. 
Premature  
patient withdrawal 
Point/time when the patient exits from the study prior to the planned 
completion of all study treatment administration and/or assessments; at this 
time all study treatment administration is discontinued and no further 
assessments are planned, unless the patient will be followed for 
progression and/or survival 
Stop study 
participation 
Point/time at which the patient came in for a final evaluation visit or when 
study treatment was discontinued whichever is later 


 
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Study treatment 
Includes any drug or combination of drugs in any study arm administered 
to the patient (subject) as part of the required study procedures, including 
placebo and active drug run-ins. 
In specific examples, it is important to judge investigational treatment 
component relationship relative to a study treatment combination; study 
treatment in this case refers to the investigational and non-investigational 
treatments in combination. 
Study  
treatment 
discontinuation 
Point/time when patient permanently stops taking study treatment for any 
reason; may or may not also be the point/time of premature patient 
withdrawal 
Supportive 
treatment 
Refers to any treatment required by the exposure to a study treatment, e.g. 
premedication 
of 
vitamin 
supplementation 
and 
corticosteroid 
for 
pemetrexed disodium. 
Variable 
Identifier used in the data analysis; derived directly or indirectly from data 
collected using specified assessments at specified time points 
 
 
 


 
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1.0 Introduction 
Patients with localized TNBC are preferably treated with systemic chemotherapy in the 
neoadjuvant setting (NACT) as this allows for close monitoring of response in the intact primary 
tumor and often results in ‘downstaging’ of tumors, which increases the feasibility of breast 
conserving surgery. The response to NACT at the time of surgical resection can be determined 
by measuring the amount of residual cancer remaining in the breast and draining lymph nodes 
during routine pathologic evaluation and is such a powerful indicator of prognosis that the Food 
and Drug Administration (FDA) has recognized significant improvement in complete response to 
neoadjuvant therapy as a pathway to drug approval. Investigators at MDACC have developed 
and validated a scoring system known as the Residual Cancer Burden (RCB) to quantify the 
extent of residual disease remaining after NACT and surgical resection.[2] Approximately 50% of 
patients with localized TNBC treated with standard taxane/anthracycline-based NACT will have 
either pathologic compete response (pCR/RCB-0) or minimal residual disease (RCB-I) at the time 
of surgical resection and those patients have identical and exceptionally good long-term 
prognosis (less than 10% risk of developing distant metastatic disease within 5 years). 
Unfortunately, those with more extensive residual disease (RCB-II or RCB-III) have a much worse 
prognosis, with 50%-80% of patients developing distant metastatic disease within 3 years of initial 
diagnosis.[3] Additionally, clinical trials of NACT in breast cancer have demonstrated that patients 
without response to their first chemotherapeutic regimen have very low chance (5%) of achieving 
pCR after their second neoadjuvant chemotherapy regimen.[4] However, this has not been the 
case with targeted regimens such as trastuzumab in HER2+ tumors, suggesting that intrinsic 
resistance to chemotherapy can be overcome with appropriate targeted therapy.[5] Though 
several targeted agents have been tested for treatment in TNBC, so far none have been 
successful. The underlying causes of this failure are commonly attributed to the molecular 
heterogeneity of tumors classified within the ‘catch all’ category of TNBC as well as the dilution 
effects of chemotherapy sensitive disease which requires clinical trials to enroll larger number of 
patients to show benefit of combined targeted therapy/chemotherapy regimens over standard 
chemotherapy. Additionally, clonal selection of resistant cells with escape mechanisms also likely 
develops. Recent advances in gene expression profiling have identified subgroups of triple-
negative breast cancer (TNBC) with distinct molecular features that, if appropriately selected, 
may be more responsive to targeted therapy with existing FDA-approved drugs, leading to rapid 
improvement of outcomes in this high-risk breast cancer population[1, 6-8].  
 
Prediction of chemosensitivity and molecular aberrations associated with TNBC subtypes: Our 
collaborator, Dr. Symmans, and his team have developed gene expression array-based 
predictive signatures of chemotherapy response using fresh 
primary tumor tissue obtained from a routine biopsy of breast 
cancer at the time of diagnosis or surgery. This approach has 
been retrospectively validated and tested for feasibility using a 
prospective registry study (MDACC clinical trial 2011-0007).[9] 
The proposed predictor was tested on an independent cohort of 
breast cancers irrespective of receptor status (N=198, 99% with 
clinical Stage II-III) who received neoadjuvant (N=180) or 
adjuvant 
(N=18) 
taxane-anthracycline 
chemotherapy. 
Predictions were accurate if ER+/HER2- (30% predicted 
sensitive, DRFS 97%, CI 91-100; ARR 11%, CI 0.1-21) or ER-
/HER2- (26% predicted sensitive, DRFS 83%, CI 68-100; ARR 
26%, CI 4-48) (Fig 1).[9] Predicted treatment sensitivity was 
significantly associated with lower relapse risk (HR 0.19, CI 
0.07-0.55) in a multivariate model including ER status, tumor 
and nodal stage, grade, age, and type of taxane treatment 
(paclitaxel or docetaxel). 
 
As important as predicting chemosensitivity may be, outcomes 
for will not be improved unless targeted therapy is developed for 
Fig 1: Distant RFS by genomic 
prediction of chemosensitivity in 
ER-/HER2- breast cancer 


 
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patients with chemoresistant TNBC. Recent advances in gene expression profiling have identified 
subsets of TNBC (Fig. 2) with distinct molecular features that, if appropriately selected, may be 
more responsive to targeted therapy with existing FDA approved 
drugs.[1, 7, 10, 11] Basal-like TNBCs (BL1 and BL2) are heavily 
enriched in cell cycle and cell division pathways. Gene expression 
profiling has revealed that these tumors have high expression of 
proliferation genes such as aurora kinases, MYC, NRAS and PLK1 
as well as elevated DNA damage response (BL1 subtype). These 
tumors may have higher rates of pCR to standard chemotherapy 
compared to other TNBC subtypes. The BL2 subset displays gene 
ontologies involving growth factor signaling such as EGFR and 
IGF1R pathways. Cell lines classified as basal-like had high rates 
of sensitivity to cisplatin and relative resistance to PI3K directed 
therapy in both cell culture and xenograft models. Though most 
triple-negative breast cancers are classified as basal-like (BL1 and 
BL2) by microarray analysis, approximately 30% of triple negative tumors are molecularly distinct 
from basal-like breast cancers as they display mesenchymal features, including enrichment in 
epithelial-to-mesenchymal transition (EMT) and stem-cell like characteristics. Subgroups with 
these features have been identified by independent investigators and have been termed 
mesenchymal (M), mesenchymal-stem cell like (MSL) and claudin-low. Mesenchymal-like TNBCs 
carry a high rate of molecular aberrations that activate the PI3K/Akt/mTOR axis suggesting that 
this subgroup may be responsive to therapeutic regimens targeting this pathway.[1, 6, 7] 
Approximately 10-15% of TNBC are associated with expression of androgen receptor (AR+ or 
LAR) and approximately 20-25% are immune modulatory (IM), expressing genes associated with 
immune activation. Approximately 10-20% of patients with TNBC are carriers of germline 
BRCA1/2 mutations. When treated with NACT, pCR rates similar to slightly higher than non-
carriers.[12] BRCA1 and BRCA2 are required for homologous recombination repair of DNA 
strand breaks leading to a defect in DNA repair in cancers harboring such mutations. As such, 
these tumors may be more sensitive to chemotherapy inducing DNA breaks or poly ADP-ribose 
polymerase (PARP) inhibitors.   
 
Notably, investigators at MDACC also determined that rates of pCR/RCB-I to standard NACT 
were not statistically different amongst the TNBC subtypes, though the lowest rates of pCR were 
seen in the BL-2 subtype and the highest rates of RCB-III disease was within the mesenchymal 
subtypes, further validating the need for both predictors of chemotherapy sensitivity as well as 
molecular characterization of predicted chemotherapy-insensitive disease to determine 
appropriate therapy for patients with localized TNBC.[13]  
 
Given the disparity of treatment outcomes from NACT for TNBC, a molecular triaging protocol 
(MDACC 2014-0185) has been 
developed and IRB approved as a 
diagnostic 
platform 
to 
identify 
patients whose tumors are likely or 
unlikely to achieve pCR or RCB-I, 
in 
order 
to 
direct 
predicted 
responders 
toward 
standard 
chemotherapy 
and 
to 
direct 
predicted 
chemotherapy 
insensitive 
patients 
toward 
potentially 
more 
effective 
experimental 
therapies 
within 
clinical trials (Figure 3). Previously 
untreated patients with localized 
TNBC who are candidates for 
standard NACT (anthracycline → 
taxane based therapy) will be 
Figure 2: Classification of 75 
TNBC samples at MDACC 
using signatures published by 
Pietenpol et al.[1] 
Fig. 3 Clinical Trial Schema for 2014-0185 


 
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enrolled into 2014-0185, a non-therapeutic, randomized trial where they will undergo biopsy of 
the primary tumor for molecular characterization within the MDACC CLIA certified diagnostic lab, 
including predicted sensitivity to chemotherapy using gene signatures developed at MDACC. 
Patients will be randomized 2:1 for themselves and their care team to either know or not know the 
results of the molecular characterization, which will be available within 4-6 weeks after biopsy. All 
patients will be treated the same except for the assignment of the randomization (Figure 3). The 
primary endpoint of this triage study is to determine whether molecular profiling improves the 
overall outcome when used over and above standard indices to identify patients for participation 
on clinical trials after the mid-point of NACT for those patients with predicted and/or apparent 
resistance to the first phase of NACT for TNBC. 
 
All patients will then initiate a planned 4 cycles of standard neoadjuvant anthracycline-based 
chemotherapy based upon physician’s choice (AC, dose-dense AC, FAC, EC or FEC are all 
allowed) with assessment of response by diagnostic imaging after 4 cycles of therapy (or at the 
time of progression in patients who develop clinical evidence of disease progression on 
chemotherapy). 
In 
our 
retrospective 
analysis 
of 
molecularly 
characterized 
patients 
with 
available 
diagnostic 
imaging, 
approximately 
10-15% 
of 
patients will have obvious, 
extreme discordance between 
volumetric measurement of 
tumor response by ultrasound 
after 4 cycles of NACT and 
response prediction by gene 
signature with the diagnostic 
imaging 
best 
predicting 
outcome in these extreme 
cases of response or lack thereof (parameters outlined in Fig. 3). As such, patients with 
discordant imaging/molecular predictor results will be advised of these results and counseled to 
proceed based upon imaging. After response assessment, all patients will be offered the option of 
continuing forward with standard taxane (paclitaxel or docetaxel) or participation in clinical trials 
(Figure 4). Molecular characterization of the tumor (if known) can also be used along with any 
other relevant factors by the treating physician to select for clinical trials within the BMO 
neoadjuvant clinical trials portfolio (Figure 4). 
 
Additionally, because of the 2:1 randomization in 2014-0185 (Figure 3), a subgroup of patients 
molecularly profiled will not know the results for decision making (control arm). Like the 
experimental arm, patients on the control arm will be allowed to choose between study 
participation or to receive standard chemotherapy with paclitaxel based regimen for 12 additional 
weeks based on standard clinical indices. Essentially, those who do not know the results of the 
molecular profiling are offered the same options as those who do, they simply will not have the 
molecular analysis to guide their decision making. Since all patients enrolled in 2014-0185 have 
biopsies for molecular characterization and diagnostic imaging, for research purposes all patients 
can be characterized as chemosensitive or chemoresistant and further subtyped into the TNBC 
molecular subtypes mentioned above. As such, those patients characterized with chemoresistant, 
subtype specific disease who receive standard NACT with taxane-based regimens can be 
compared with matched patients treated on clinical trials with phenotypically-matched targeted 
agents, such as DAE. Though this comparison will not be a randomized comparison, it will 
provide evidence as to whether patients treated on a single arm phase II trial of targeted therapy 
derive additional clinical benefit and the comparison can be used to provide more robust data for 
confirmatory phase III clinical trial design. Likewise, patients whose tumors do not have 
mesenchymal features can be enrolled on this protocol and receive DAE, which will allow a 
Figure 4: BMO Neoadjuvant Portfolio for Treatment of Chemotherapy 
Insensitive TNBC 


 
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control group of non-mesenchymal TNBCs to serve as a control to determine the predictive value 
of potential biomarkers to define the mesenchymal population.  
1.1 Introduction to investigational treatments and other study treatments 
Everolimus is a novel derivative of rapamycin. It has been in clinical development since 1996 as 
an immunosuppressant in solid organ transplantation. Everolimus is approved in Europe and 
other global markets (trade name: Certican®) for cardiac and renal transplantation, and in the 
United States (trade name: Zortress®) for the prevention of organ rejection of kidney 
transplantation. 
 
Afinitor® and was approved for adults with advanced renal cell carcinoma (RCC) after failure of 
treatment with sunitinib or sorafinib in 2009. In 2010, Afinitor® received United States (US) 
approval for patients with subependymal giant cell astrocytoma (SEGA) associated with tuberous 
sclerosis complex (TSC). Everolimus is also available as Votubia® in the European Union (EU) 
for patients with SEGA associated with TSC who require therapeutic intervention but are not 
candidates for curative surgical resection. Afinitor® was approved for “progressive pancreatic 
neuroendocrine tumor (PNET) in patients with unresectable, locally advanced, or metastatic 
disease” in 2011 in various countries, including the US and Europe. In 2012 Afinitor® received 
approval for the treatment of postmenopausal women with advanced hormone receptor-positive, 
HER2- negative breast cancer (advanced HR+ BC) in combination with exemestane, after failure 
of treatment with letrozole or anastrozole. Furthermore in 2012, Afinitor® received approval for 
the treatment of patients with TSC who have renal angiomyolipoma not requiring immediate 
surgery. 
 
Approximately 35,982 cancer patients have been treated with everolimus as of  31-Mar-2014: 
• 
19,668 patients in Novartis-sponsored clinical trials 
• 
2,394 patients in the individual patient supply program 
• 
More than 13,930 patients in investigator-sponsored studies. 
• 
In addition, healthy volunteer subjects and non-oncology hepatically impaired subjects have  
participated in the clinical pharmacology  studies as described in Section 7.2. 
The following is a brief summary of the main characteristics of Everolimus. More complete 
information can be obtained from the Everolimus Investigator’s Brochure (IB).  
1.2 Overview of Everolimus 
Everolimus is a derivative of rapamycin which acts as a signal transduction inhibitor (Table 1 and 
Figure 5). Everolimus selectively inhibits mTOR (mammalian target of rapamycin), specifically 
targeting the mTOR-raptor signal transduction complex. mTOR is a key serine-threonine kinase 
in the PI3K/AKT signaling cascade, which is known to be dysregulated in a wide spectrum of 
human cancers (Boulay and Lane 2007). 
Everolimus is being investigated as an anticancer agent based on its potential to act 
• 
directly on the tumor cells by inhibiting tumor cell growth and proliferation; 
• 
indirectly by inhibiting angiogenesis leading to reduced tumor vascularity (via potent inhibition 
of tumor cell VEGF (vascular endothelial growth factor) production and VEGF-induced 
proliferation of endothelial cells). 
 
Table 1: 
Everolimus - Drug substance 
Chemical name 
(1R,9S,12S,15R,16E,18R,19R,21R,23S,24E,26E,28E,30S,32S,35R)-
1,18-dihydroxy-12-{(1R)-2-[(1S,3R,4R)-4-(2-hydroxyethoxy)-3-
methoxycyclohexyl]-1-methylethyl}-19,30-dimethoxy-15,17,21,23,29,35-
hexamethyl-11,36-dioxa-4-aza-tricyclo[30.3.1.04,9]hexatriaconta-16,24, 
26,28-tetraene-2,3,10,14,20-pentaone 
International 
non-proprietary 
name 
Everolimus 


 
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1.2.1 Figure 5: Chemical structure of Everolimus 
 
1.2.2 mTOR pathway and cancer 
At the cellular and molecular level, Everolimus acts as a signal transduction inhibitor. It selectively 
inhibits mTOR (mammalian target of rapamycin), a key protein kinase which regulates cell 
growth, proliferation and survival. The mTOR kinase is mainly activated via the 
phosphatidylinositol 3-kinase (PI3-Kinase) pathway through AKT/PKB and the tuberous sclerosis 
complex (TSC1/2). Mutations in these components or in PTEN, a negative regulator of PI3-
kinase, may result in their dysregulation. Abnormal functioning of various components of the 
signaling pathways contributes to the pathophysiology of numerous human cancers. Various 
preclinical models have confirmed the role of this pathway in tumor development.[14] 
 
The main known functions of mTOR include the following [15]: 
• 
mTOR functions as a sensor of mitogens, growth factors and energy and nutrient levels; 
• 
Facilitating cell-cycle progression from G1-S phase in appropriate growth conditions; 
• 
The PI3K/mTOR pathway itself is frequently dysregulated in many human cancers, and 
oncogenic transformation may sensitize tumor cells to mTOR inhibitors; 
• 
PI3-kinase mutations have been reported in the primary tumor in 10-20% of human colorectal 
cancers [16, 17]; 
• 
The loss of PTEN protein, either through gene deletion or functional silencing (promoter 
hypermethylation), is reported in approximately 60% of primary human colorectal cancers 
[18]; 
• 
The mTOR pathway is involved in the production of pro-angiogenic factors (i.e., VEGF) and 
inhibition of endothelial cell growth and proliferation; 
• 
Through inactivating eukaryotic initiation factor 4E binding proteins and activating the 40S 
ribosomal S6 kinases (i.e., p70S6K1), mTOR regulates protein translation, including the HIF-
1 proteins. Inhibition of mTOR is expected to lead to decreased expression of HIF-1. 
 
1.2.3 Non-clinical experience 
Everolimus inhibits the proliferation of a range of human tumor cell lines in vitro including lines 
originating from lung, breast, prostate, colon, melanoma and glioblastoma. IC50s range from 
sub/low nM to µM. Everolimus also inhibits the proliferation of human umbilical vein endothelial 
cells (HUVECS) in vitro, with particular potency against VEGF-induced proliferation suggesting 
that Everolimus may also act as an anti-angiogenic agent. The anti-angiogenic activity of 
Everolimus was confirmed in vivo. Everolimus selectively inhibited VEGF-dependent angiogenic 


 
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response at well tolerated doses. Mice with primary and metastatic tumors treated with 
Everolimus showed a significant reduction in blood vessel density when compared to controls. 
The potential of Everolimus as an anti-cancer agent was shown in rodent models. Everolimus is 
orally bioavailable, residing longer in tumor tissue than in plasma in a subcutaneous mouse 
xenograft model, and demonstrating high tumor penetration in a rat pancreatic tumor model. The 
pharmacokinetic profile of Everolimus indicates sufficient tumor penetration, above that needed to 
inhibit the proliferation of endothelial cells and tumor cell lines deemed sensitive to Everolimus in 
vitro. 
 
Everolimus administered orally daily was a potent inhibitor of tumor growth, at well tolerated 
doses, in 11 different mouse xenograft models (including pancreatic, colon, epidermoid, lung and 
melanoma) and two syngeneic models (rat pancreatic, mouse orthotopic melanoma). These 
models included tumor lines considered sensitive and “relatively resistant” in vitro. In general, 
Everolimus was better tolerated in mouse xenograft models than standard cytotoxic agents (i.e., 
doxorubicin and 5-fluorouracil), while possessing similar anti-tumor activity. Additionally, activity in 
a VEGF-impregnated subcutaneous implant model of angiogenesis and reduced vascularity 
(vessel density) of Everolimus-treated tumors (murine melanoma) provided evidence of in vivo 
effects of angiogenesis. 
 
It is not clear which molecular determinants predict responsiveness of tumor cells to Everolimus. 
Molecular analysis has revealed that relative sensitivity to Everolimus in vitro correlates with the 
degree of phosphorylation (activation) of the AKT/PKB protein kinase and the S6 ribosomal 
protein; in some cases (i.e., glioblastoma) there is also a correlation with PTEN status. 
In vivo studies investigating the anti-tumor activity of Everolimus in experimental animal tumor 
models showed that Everolimus monotherapy typically reduced tumor cell growth rates rather 
than produced regressions. These effects occurred within the dose range of 2.5 mg to 10 mg/kg, 
orally once a day. 
 
In preclinical models, the administration of Everolimus is associated with reduction of protein 
phosphorylation in target proteins downstream of mTOR, notably phosphorylated S6 (p-S6) and 
p-4E-BP1, and occasionally with an increase in phosphorylated AKT, a protein upstream of 
mTOR signaling pathway. 
 
All significant adverse events observed in toxicology studies with Everolimus in mice, rats, 
monkeys and mini-pigs were consistent with its anticipated pharmacological action as an anti-
proliferative and immunosuppressant and at least in part reversible after a 2 or 4-week recovery 
period with the exception of the changes in male reproductive organs, most notably testes. 
In vitro genotoxicity studies covering relevant genotoxicity end-points showed no evidence of 
clastogenic or mutagenic activity. 
 
In male fertility studies in rats, testicular morphology was affected at 0.5 mg/kg and above, and 
sperm motility, sperm head count and plasma testosterone levels were diminished at 5 mg/kg 
which corresponded to 0.7 times the estimated clinical exposure at 10 mg/day, and caused a 
decrease in male fertility. There was evidence of reversibility. Female fertility was not affected, 
but everolimus caused an increase of pre-implantation loss in female rats at doses > 0.1 mg/kg, 
suggesting it could also potentially impact fertility in females.  Everolimus crossed the placenta 
and was toxic to the conceptus. In rats, everolimus caused embryo/fetotoxicity at systemic 
exposure below the planned therapeutic level comprising mortality and reduced fetal weight. The 
incidence of skeletal variations and malformations at 0.3 and 0.9 mg/kg (e.g. sternal cleft) was 
increased. In rabbits, embryo toxicity was evident by an increase in late resorptions. Effects of 
everolimus on the pre- and postnatal development of rats were limited to slightly affected body 
weight and survival in the F1-generation at ≥0.1 mg/kg, and did not indicate a specific toxic 
potential.  
 
The potential reproductive risk for humans is unknown. However, due to the observed 
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not be given to pregnant women unless the potential benefit outweighs the potential risk for the 
fetus. Women of childbearing potential should be advised to use highly effective contraception 
methods while they are receiving everolimus and up to 8 weeks after treatment has been 
stopped. It is not known whether everolimus is excreted in human milk. In animal studies, 
everolimus and/or its metabolites were readily transferred into the milk of lactating rats. Therefore 
women who are taking everolimus should not breastfeed. 
 
Further details can be found in the Everolimus Investigator’s Brochure. 
 
1.3 Rationale for DAE in claudin-low/mesenchymal/mesenchymal stem cell-like TNBC 
Though most TNBCs are classified as basal-like by gene expression array analysis, 
approximately 30% of triple-negative tumors are molecularly distinct from basal-like breast 
cancers as they display mesenchymal features, including enrichment in epithelial-to-
mesenchymal transition (EMT) and stem-cell like characteristics.[1, 11, 19]  TNBCs and TNBC 
cell lines with mesenchymal features have been identified by multiple independent investigators 
and have been labeled ‘claudin-low’, ‘mesenchymal’ and ‘mesenchymal stem cell-like’.[1, 11] 
Emerging data suggest that, in contrast to basal subtypes of TNBC, these mesenchymal TNBCs 
carry a high rate of molecular aberrations that activate the PI3K/Akt/mTOR axis suggesting that 
this subgroup may be responsive to therapeutic regimens targeting this pathway.[1, 6]  Cell lines 
characterized as mesenchymal/mesenchymal stem-like were noted to have a high rate of 
molecular aberrations that could result in activation of the PI3K/Akt/mTOR pathway and 
demonstrated response to PI3K-pathway inhibitors in both cell culture assays and xenograft 
models.[1]  
Many of these cell lines have also been classified as claudin-low. These features were not shared 
by the basal-like cell lines (BL1 and BL2), which were noted to have high proliferative rates, 
absence of mutations in PIK3CA, enhanced response to cisplatin and diminished sensitivity to the 
dual mTOR/PI3kinase inhibitor NVP-BEZ235.[1]  
Though evaluation using H&E staining/light microscopy cannot detect distinct morphological 
features that would distinguish most mesenchymal-like TNBCs from non-mesenchymal TNBCs, 
approximately 10-30% of tumors molecularly characterized as ‘claudin-low’ can be 
morphologically identified as metaplastic breast cancers using these conventional techniques.[6, 
11] Metaplastic breast cancers are commonly triple negative, considered refractory to standard 
therapy, and harbor a high rate of molecular aberrations that lead to activation of the PI3K- 
pathway.[6] Although genomic profiling, using unsupervised hierarchical clustering of patient 
samples, initially grouped metaplastic tumors within the spectrum of basal-like invasive ductal 
carcinomas (IDCs) some transcripts were found to be differentially expressed between 
metaplastic cancers and basal-like IDCs.[20] For example, DNA repair pathways such as BRCA1, 
PTEN and TOP2A were significantly down regulated in the metaplastic tumors compared to the 
basal-like IDCs.[20] Further genomic analyses by Hennessy et al. revealed that metaplastic 
tumors with mesenchymal features, such as sarcomatoid metaplasia, more closely resembled the 
claudin-low subtype of breast cancers rather 
than basal-like IDCs.[6] Like the mesenchymal/mesenchymal stem-like cell lines, metaplastic 
tumors with mesenchymal features have been associated with a high rate of mutations in PIK3CA 
(47%) and occasional mutations in PTEN (5%), which was noted to be much higher than the 8% 
(all PIK3CA) seen with non-metaplastic, TNBC.[6] Reverse-phase protein array (RPPA) 
confirmed elevations in the phosphorylation of phosphatidylinositol 3-kinase/Akt pathway proteins 
in metaplastic tumors (also noted to be higher than non-metaplastic TNBC tumors) further 
supporting the genomic profiling analyses and suggesting that agents which target the 
PI3K/mTOR pathway may be a viable option for the treatment of metaplastic breast cancer.[6] 
Metaplastic breast cancers have also been found to express high levels of vascular endothelial 
growth factor (VEGF) and hypoxia-induced factor (HIF-1), a transcription factor important for 
vasculogenesis and that signals through the mTOR pathway.[21, 22] Therefore, it is likely that 


 
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metaplastic tumors act as a morphologically identified ‘surrogate of response’ to evaluate the 
activity of targeted therapy regimens in mesenchymal-like TNBC.  
 
Based upon the molecular features of metaplastic breast cancer, 52 patients with metastatic, 
metaplastic breast cancer have been treated using a regimen using a combination of pegylated 
liposomal doxorubicin, bevacizumab and the mTOR inhibitors, temsirolimus (DAT) or everolimus 
(DAE). Most patients were treated on the Phase I trial that established the maximum tolerated 
dose (MTD) for this regimen.[23] The objective response rate (ORR) was 21% [complete 
response (CR)=4 (8%); partial response (PR)=7 (13%)] and 10 (19%) pts had stable disease 
(SD)≥6 months for a clinical benefit rate (CBR) of 40%.  One patient had a CR that remains 
durable for greater than 5 years on maintenance everolimus. Tissue was available for testing in 
43 pts and 32 (74%) had a PI3K-pathway activating aberration. PI3K-pathway activation was 
associated with a significant improvement in ORR (31 vs 0%; P=0.043). It is notable that 12 
patients with metastatic non-metaplastic TNBC were also treated with DAT, and only 1 patient 
had a response (CR/PR=1; SD≥6 months=0).[24]  
 
In this cohort, 13 patients were treated with DAE, with 9 patients being treated with liposomal 
doxorubicin 30mg/m2 IV Q3W, bevacizumab 15mg/kg IV Q3W and everolimus 7.5mg PO every 
day for 21 days. In these 9 patients, grade 3-4 toxicities included neutropenia (N=2; 22%), 
anemia (N=2; 22%), fatigue (N=2; 22%), thrombocytopenia (N=1; 11%), mucositis (N=1; 11%) 
and transaminitis (N=1; 11%). Grade 2 pulmonary toxicity was seen in one patient who was 
treated with DAE. Despite previous anthracycline exposure in approximately 85% of patients, no 
patients treated with DAE developed grade 3-4 heart failure. Although some patients required 
dose reduction and treatment interruptions due to toxicity, no patients discontinued treatment due 
to toxicity. 
 
1.4 Rationale for Everolimus 
 
Mesenchymal and mesenchymal stem cell-like tumors are hypothesized to develop from 
immature breast precursor cells, thus retaining cancer stem cell (CSC)-like features. Metaplastic 
and claudin-low cancers also closely resemble cancer stem cells (CSCs) and, given the role of 
the Akt pathway in stem cell maintenance, may be one reason metaplastic tumors are sensitive to 
mTOR inhibition. In preclinical studies, activation of PI3K/mTOR has been associated with CSC 
tumorigenicity, survival and capacity for self-renewal.[25, 26] Activation of this pathway is known 
to play an important role in breast cancer resistance to chemotherapy, HER2 targeted therapy 
and endocrine therapy as demonstrated in pre-clinical models [27-29] and confirmed in clinical 
trials [30-32]. The PI3K/mTOR pathway is involved in regulation of the signal transduction and 
activator of transcription (STAT3) pathway, which has been implicated in CSC survival.[26] 
Additionally, survival signaling by Notch1, a transmembrane protein involved in embryonic 
development and highly expressed in CSCs, is mediated through mTOR.[33] Inhibition of mTOR 
with rapamycin decreased breast CSC fractions in cell culture and impaired breast CSC 
tumorigenicity in mouse models.[26] Further, in pre-clinical studies, xenograft models of 
mesenchymal cells lines carrying PIK3CA mutations displayed partial or complete response with 
the mTOR/PI3kinase inhibitor NVP-BEZ235.[1] 
1.5 Rationale for Bevacizumab 
 
CSCs show high adaptability to inhospitable microenvironments or ‘tumor niches’. CSCs are able 
to survive in hypoxic conditions, presumably through the use of anaerobic glycolysis for 
generation of ATP, a process that involves activation of the PI3K pathway.[34-38]  Additionally, 
hypoxia has been implicated in CSC self-renewal, with increasing oxygen levels resulting in 
proliferation, maturation and exhaustion of the CSC pool[39]. Under hypoxic conditions, activated 
Akt promotes accumulation of hypoxia-induced factor (HIF-1), a transcription factor important for 
vasculogenesis, which is upregulated in stem cell promoting cell culture of breast cancer cell lines 
(Woodward, data not shown).[40, 41] CSCs also produce much higher levels of vascular 
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inhibited growth in tumors derived from CSC-positive cells but had no effect upon tumors derived 
from non-CSC cells in xenograft models[42].  More importantly, early evidence is emerging that 
suggests that CSCs may be dependent upon growth factors secreted by tumor vasculature.[43] 
Though most of the data concerning the CSC/vascular niche arises from brain tumors, data exist 
supporting the effects of the extracellular matrix in maintaining a breast CSCs phenotype, as well 
as, hypoxic conditions supporting self-renewal[44]. Interestingly, new data have emerged 
suggesting that treatment with bevacizumab induces intratumoral hypoxia which increases the 
population of CSCs in breast cancer xenografts.[45]  This increase in CSC population was 
associated with increased phosphorylation of Akt suggesting that treatment with bevacizumab 
may actually prime tumors with CSC like characteristics for response to temsirolimus. 
Additionally, under hypoxic conditions, activated Akt also promotes accumulation of hypoxia-
induced factor (HIF-1) a transcription factor important for vasculogenesis, which is up-regulated in 
stem cell promoting cell culture of breast cancer cell lines. As such, the combination of 
bevacizumab with temsirolimus could impact vasculogenesis by affecting both HIF-1 and VEGF 
production leading to increased tumor hypoxia.   
1.6 Rationale for Liposomal Doxorubicin 
 
The success of doxorubicin in the treatment of sarcoma suggests that other tumors with 
mesenchymal features may also be responsive to anthracyclines.[46] As confirmation, 
doxorubicin has shown response in sarcomatoid renal cell carcinoma.[47] Activation of the 
PI3K/mTOR pathway is known to play an important role in breast cancer resistance to 
chemotherapy, and it is possible that mTOR inhibition may be able to overcome resistance to 
anthracyclines. In a study of metastatic metaplastic TNBC patients conducted at MDACC, 23 
patients were treated with temsirolimus containing regimens. In patients treated with DAT or DT, 
the response rate was about 30%.[48] However, in the patients treated with paclitaxel or 
carboplatin in combination with temsirolimus, the response rate was 0%. Additionally, one patient 
was treated with temsirolimus alone, and no response was seen. This data suggests synergistic 
activity of mTOR inhibition with anthracycline therapy but not paclitaxel or carboplatin therapy in 
this subset of patients. In another study conducted at MDACC, patients with early stage TNBC 
treated with everolimus in combination with paclitaxel followed by anthracycline containing 
therapy in the neoadjuvant setting had no increase in pCR rates compared to patients treated 
with paclitaxel alone followed by anthracycline containing therapy.[49] As further proof of 
principle, doxorubicin but not paclitaxel was able to inhibit growth in PTEN knockout mammary 
cell lines, suggesting that anthracycline therapy may be more effective in cell lines exhibiting PI3K 
pathway activation.[50]  
 
2.0 Study Rationale / Purpose 
Based upon the above mentioned data, it is hypothesized that chemo-insensitive TNBCs with 
mesenchymal features will have higher rates of RCB-0 to RCB-1 with neoadjuvant DAE than 
historically seen with paclitaxel alone. 
 
2.1 Feasibility 
At MDACC, approximately 600 newly diagnosed TNBC patients are seen per year, and the 
majority will be eligible for screening for the triaging protocol. Of those, approximately 50% will be 
predicted chemo-insensitive based on molecular analysis performed on the pre-treatment biopsy 
and confirmed chemo-insensitive based on diagnostic imaging performed after four cycles of 
anthracycline-based therapy. As such, we estimate that there will be approximately 300 patients 
within the molecular triaging protocol who will be eligible for experimental therapies yearly. Of 
these, approximately 30% (90 patients yearly) are expected to have mesenchymal TNBCs. It is 
estimated that most of these patients will have evidence of some vimentin staining (~80%), which 
will identify these patients for enrollment in this trial. Additionally, some patients who will not have 
the results of their molecular profiling will also be recruited to this trial. Our study design requires 
37 patients to determine if there is sufficient efficacy data to move to a phase III registration trial. 
Assuming a 50% accrual rate, we anticipate completing accrual within 15 months with all patients 
undergoing surgery with assessment for pathologic complete response within 18 months. 


 
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2.2 Rationale for Correlative Studies 
Unfortunately, neither of the gene expression profiles used to identify claudin-low or 
mesenchymal/ mesenchymal stem cell-like TNBCs have been CLIA certified or are currently 
available as an assay that can be performed in formalin-fixed, paraffin-embedded (FFPE) tissue 
samples; however, staining for vimentin using immunohistochemistry (IHC) is a CLIA certified test 
that is routinely performed using FFPE tissue.   
 
Vimentin staining has been routinely 
used to identify cells of mesenchymal 
origin 
and 
has 
been 
used 
to 
characterize breast tumors or cell lines 
undergoing 
EMT. 
This 
assay 
is 
commercially available, available in or 
CLIA 
laboratory 
and 
vimentin 
is 
commonly expressed in non-tumor 
stroma, which can be used as a 
positive control when measuring for 
expression within cancer cells.  
Vimentin expression within breast 
cancer cells has been associated with 
a 
more 
aggressive 
triple-negative 
phenotype 
in 
retrospective 
analyses.[53, 54]  Claudin-low tumors 
are commonly vimentin-positive.[11] 
Though the Pietenpol group did not 
use vimentin staining to characterize  
the mesenchymal and mesenchymal 
stem-like cell lines, most of the lines 
identified by these signatures have 
been 
previously 
characterized 
as 
vimentin-positive (Table 2) and cell 
lines which have been characterized 
as mesenchymal or mesenchymal-
stem cell-like have demonstrated high 
levels 
of 
vimentin 
expression 
compared to basal-like cell lines 
(Figure 6, Ueno unpublished data). 
Interestingly, metaplastic tumors are 
almost always vimentin-positive (Table 
3).[55]  
Reproducibility and Potential Clinical 
Relevance of Vimentin Staining: 
To address concerns of reproducibility, 
tissue Microarrays (TMAs) of non-
metaplastic TNBCs (n=64 tumors) were 
stained x 3 sets of slides and scored for 
the presence or absence of vimentin in 
the epithelial carcinoma cells by two 
MDACC pathologists. Inter-pathologist 
reliability was assessed using standard 
metrics as defined in Table 4.  The first 
4 of these metrics are considered 
Table 2: Comparison of Vimentin Staining in Cell Lines 
Identified as Mesenchymal/Mesenchymal Stem-Like vs. Basal-
like Subtypes[51, 52] 
Cell Line 
Molecular 
Classification 
Vimentin 
CAL120 
Mesenchymal-like 
unknown 
CAL51 
Mesenchymal-like 
unknown 
MDAMB-157* 
Mesenchymal-like 
unknown 
MDAMB-231* 
Mesenchymal-like 
positive 
MDAMB-436* 
Mesenchymal-like 
positive 
SUM159* 
Mesenchymal-like 
positive 
HS578T* 
Mesenchymal-like 
positive 
BT549* 
Mesenchymal-like 
positive 
MDAMB-468 
Basal-like 1 
negative 
HCC2157, 
HCC1599, 
HCC1937, 
HCC1143, 
HCC3153, HCC38 
Basal-like 1 
unknown 
SUM149PT 
Basal-like 2 
negative 
HCC70 
Basal-like 2 
weakly positive 
(<10%) 
HCC1806 
Basal-like 2 
weakly positive 
(<10%) 
CAL851, HDQ-P1 
Basal-like 2 
unknown 
Table 3: Vimentin staining in human breast cancer TMAs 
(Gilcrease, unpublished data) 
Vimentin 
staining 
Metaplastic 
TNBC (n=52) 
Non-metaplastic 
TNBC (n=67) 
Any amount of 
tumor cell 
staining 
52 (100%) 
36 (54%) 
*indicates cell lines characterized as claudin-low 
Figure 6: Vimentin Expression in TNBC cell lines. 


 
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measures of association and the kappa statistic is a measure of agreement.  A generalized 
linear intercept only model was also fitted to the response data which contained a random 
subject effect assuming the subject effect had an exchangeable variance-covariance structure 
(which is the same as a compound symmetry). In this model, there were two observations 
(pathologist one and pathologist 2) for each unique slide (considered the subject for the 
model). This linear model was used to estimate the working correlation between paired 
responses and also to estimate the intra-class correlation.  All analyses suggested the inter-
pathologist reliability to be above 90%. 
 
To determine the intra-pathologist reliability as a surrogate for staining reproducibility, a 
generalized linear intercept only model was fitted to the response data which contained a random 
subject effect assuming the subject effect had an exchangeable variance-covariance structure.   
 
A model for each pathologist was fitted separately in 
which each subject was each specimen and thus 
there were three observations for each specimen 
(TN33, TN34, & TN35).   As such, each specimen 
represented a cluster or class. The linear model was 
used to estimate the working correlation within 
cluster and 
also 
to 
estimate the 
intra-class 
correlation.  An aggregate model was also fitted 
where 
each 
cluster 
was 
specimen 
within 
pathologists.  The estimates are presented in Table 
5. All analyses suggested a strong correlation further 
supporting the reproducibility of this assay 
 
 
Finally, as proof of principle, vimentin staining was 
performed on archived tissue samples from a subset 
of patients (n=4) with available tissue who carried a 
diagnosis of metastatic non-metaplastic TNBC and 
were treated with DAT. Eight additional patients had 
no archived tissue but were evaluated for response 
to therapy. Of the 12 unselected non-metaplastic 
TNBC, all but 1 patient exhibited PD as best response for a RR of 8%; however, of the 4 who 
had archived tissue available, only the tumor from the patient who developed a partial 
response had any evidence of vimentin staining. 
3. Objectives 
3.1 Primary Objective:  
Determine the rate of pCR/RCB-0 or RCB-I in patients with anthracycline-based chemotherapy 
insensitive, localized TNBC who receive 4 cycles of DAE following anthracycline-based 
chemotherapy in the neoadjuvant setting.  
 
3.2 Secondary Objectives: 
1. Determine response rate after 4 cycles of DAE using radiographic imaging. 
2. Determine toxicity associated 4 cycles of DAE in the neoadjuvant setting. 
3.  Pathologic response rates to 4 cycles of DAE in mesenchymal tumors vs. non-mesenchymal 
tumors.  
4. Compare pathologic response rates in mesenchymal tumors to 4 cycles of DAE vs. 12 weeks 
of weekly paclitaxel (using data collected from standard of care treatment). 
Table 4: Inter-pathologist Reliability 
Metric 
Value 
Kendall's tau 
0.9338 
Stuart's tau 
0.9095 
Pearson correlation 
0.9338 
Spearman correlation 
0.9338 
Kappa 
0.9338 
Working Correlation 
0.9363 
Intra-Class Correlation 
0.9341 
Table 5: Intra-pathologist reliability 
Model 
Working 
Correlation 
Intra-Class 
Correlation 
Pathologist 1 
0.9338 
0.9348 
Pathologist 2 
0.9558 
0.9565 
Both 
0.9448 
0.9452 


 
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3.3 Exploratory Objectives: 
1. Determine the correlation between vimentin expression by IHC and the presence of 
mesenchymal gene signatures at the time of initial tumor biopsy prior to NACT (using gene 
expression data obtained from protocol 2014-0185); if enrolled to this protocol prior to DAE. 
2. Determine the correlation between mutations in PIK3CA, PTEN or NF2 or PTEN loss by IHC 
and the presence of mesenchymal gene signatures at the time of initial tumor biopsy prior to 
NACT (using gene expression data obtained from protocol 2014-0185); if enrolled to this protocol 
prior to DAE. 
3. Determine rates of pCR in patients with mesenchymal tumors identified by gene signatures 
and compare to pCR rates in non-mesenchymal tumors. 
4. Correlate pathologic response with degree of vimentin expression as measured by IHC. 
5. Determine rates of pCR in patients whose tumors contain mutations in PIK3CA, PTEN or NF2 
or PTEN loss by IHC and compare to pCR rates in patients whose tumors lacks mutations in 
these genes. 
4.0 Selection of Patients 
Patients must have baseline evaluations performed prior to the first dose of study drug and must 
meet all inclusion and exclusion criteria. Results of all baseline evaluations, which assure that all 
inclusion and exclusion criteria have been satisfied, must be reviewed by the Principal 
Investigator or his/her designee prior to enrollment of that patient. In addition, the patient must be 
thoroughly informed about all aspects of the study, including the study visit schedule and required 
evaluations and all regulatory requirements for informed consent. The written informed consent 
must be obtained from the patient prior to enrollment. The following criteria apply to all patients 
enrolled onto the study unless otherwise specified. 
4.1 Inclusion Criteria  
1. Age ≥ 18 years. 
2. ECOG performance status of 0 or 1. 
3. Confirmed invasive triple-negative breast cancer defined as ER<10%; PR<10% by  
 immunohistochemistry (IHC) and HER2 0-1+ (by IHC) or 2+ (FISH < 2, gene copy 
number < 4). 
 
4. Primary tumor sample collected before NACT started and  
5. Undergone molecular testing for integral biomarkers including immunohistochemical 
staining. The tumor must have evidence of mesenchymal differentiation defined as 
metaplastic breast cancer, or vimentin >50% by IHC. 
 
 
 
 
 


 
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6. Received at least one dose of an anthracycline-based NACT. Patients are eligible if 
therapy was discontinued due to disease progression or therapy intolerance.  
7. At least 1.0 cm of measurable residual disease after neoadjuvant anthracycline-based 
chemotherapy.  
8. Baseline MUGA or echocardiogram showing LVEF ≥ 50% within 6 weeks prior to 
initiation of NACT.  
9. Adequate bone marrow function as shown by:  
              ANC ≥1.5 x 109/L,  
              Platelets ≥100 x 109/L,  
              Hb >9 g/dL; 
10. Adequate liver function as shown by: 
              Total serum bilirubin ≤2.0 mg/dL, 
              ALT and AST ≤2.5x ULN (≤5x ULN in patients with liver metastases), 
              INR ≤2; 
11. Adequate renal function as shown by: 
Serum creatinine ≤1.5x ULN; 
12. Fasting serum cholesterol ≤300 mg/dL OR ≤7.75 mmol/L, AND fasting triglycerides ≤2.5x 
ULN.  
NOTE: In case one or both of these thresholds are exceeded, the patient can only be 
included after initiation of appropriate lipid lowering medication; 
13. Signed informed consent obtained prior to any screening procedures. 
 
4.2 Exclusion Criteria 
1. Pregnant or lactating women. 
2. Presence of metastatic disease. 
3. Prior therapy with bevacizumab, liposomal doxorubicin, or everolimus. 
4. Prior radiation therapy of the primary breast carcinoma or axillary lymph nodes. 
5. Patients who have a history of another primary malignancy, with the exceptions of: non-
melanoma skin cancer, and carcinoma in situ of the cervix, uterus, or breast from which 
the patient has been disease free for <3 years; 
6. Prior cumulative dose of doxorubicin of greater than 360 mg/m2 or epirubicin of greater 
than 640 mg/m2.  
7. Any serious medical illness, other than treated by this study, which would limit survival to 
less than 1 month or psychiatric illness which would limit informed consent. 
8. Patients with history of serious cardiac events defined as: 
              New York Heart Association class 3 or 4 heart failure,  
              History of myocardial infarction,      
              Unstable angina, or CVA within 6 months of protocol registration. 
              History of PR prolongation or AV block. 


 
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9. Known intolerance or hypersensitivity to rapamycin analogs (e.g. sirolimus, temsirolimus). 
10. Known impairment of gastrointestinal (GI) function or GI disease that may significantly 
alter the absorption of oral Everolimus; 
11. Uncontrolled diabetes mellitus as defined by HbA1c >8% despite adequate therapy. 
Patients with a known history of impaired fasting glucose or diabetes mellitus (DM) may 
be included, however blood glucose and antidiabetic treatment must be monitored closely 
throughout the trial and adjusted as necessary; 
12.  Patients who have any severe and/or uncontrolled medical conditions such as: 
a. serious uncontrolled cardiac arrhythmia, or any other clinically significant cardiac 
disease 
b. active (acute or chronic) or uncontrolled severe infection, liver disease such as 
cirrhosis, decompensated liver disease, and active and chronic hepatitis (i.e. 
quantifiable HBV-DNA and/or positive HBsAg, quantifiable HCV-RNA), 
c. known severely impaired lung function (spirometry and DLCO 50% or less of 
normal and O2 saturation 88% or less at rest on room air), 
d. active, bleeding diathesis; 
e. Moderate or severe hepatic impairment (Child-Pugh B or C) 
13. Chronic treatment with corticosteroids or other immunosuppressive agents. Topical or 
inhaled corticosteroids are allowed; 
14. Known history of HIV seropositivity; 
15. Patients who have received live attenuated vaccines within 1 week of start of Everolimus 
and during the study. Patient should also avoid close contact with others who have 
received live attenuated vaccines. Examples of live attenuated vaccines include 
intranasal influenza, measles, mumps, rubella, oral polio, BCG, yellow fever, varicella 
and TY21a typhoid vaccines; 
16. Patients with a history of non-compliance to medical regimens or who are considered 
potentially unreliable or will not be able to complete the entire study; 
17. Patients who are currently part of or have participated in any clinical investigation with an 
investigational drug within 1 month prior to dosing; 
18.  Women of child-bearing potential (WOCBP), defined as all women physiologically 
capable of becoming pregnant, must use highly effective methods of contraception during 
the study and 8 weeks after. Highly effective contraception methods include combination 
of any two of the following: 
a. Placement of an intrauterine device (IUD) or intrauterine system (IUS); 
b. Barrier methods of contraception: condom or occlusive cap (diaphragm or 
cervical/vault caps) with spermicidal foam/gel/film/cream/ vaginal suppository; 
c. Total abstinence or; 
d. Male/female sterilization. 
     Note: Women are considered post-menopausal and not of child-bearing potential if they   
have had 12 months of natural (spontaneous) amenorrhea with an appropriate clinical profile 
(e.g. age appropriate, history of vasomotor symptoms) or have had surgical bilateral 
oophorectomy (with or without hysterectomy) or tubal ligation at least six weeks prior to 
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woman has been confirmed by follow up hormone level assessment is she considered not of 
child-bearing potential. 
19. Male patients whose sexual partner(s) are WOCBP who are not willing to use adequate 
contraception, during the study and for 8 weeks after the end of treatment. 
4.3 Screening for hepatitis B and C 
4.3.1   Hepatitis B 
Prior to start of Everolimus, the following three categories of patients should be tested for 
hepatitis B viral load and serologic markers, that is, HBV-DNA, HBsAg, HBs Ab, and HBc Ab: 
All patients who currently live in (or have lived in) Asia, Africa, Central and South America, 
Eastern Europe, Spain, Portugal and Greece. 
 
[http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-
travel/hepatitis-b.htm] 
Patients with any of the following risk factors: 
• 
known or suspected past hepatitis B infection, 
• 
blood transfusion(s) prior to 1990, 
• 
current or prior IV drug users, 
• 
current or prior dialysis, 
• 
household contact with hepatitis B infected patient(s), 
• 
current or prior high-risk sexual activity, 
• 
body piercing or tattoos, 
• 
mother known to have hepatitis B 
• 
history suggestive of hepatitis B infection, e.g., dark urine, jaundice, right upper 
quadrant pain. 
• 
Additional patients at the discretion of the investigator 
The management guidelines, in Section 5.5: Subsection: Therapy Administration and Dose 
Reductions are provided according to the results of the baseline assessment of viral load and 
serological markers for hepatitis B. 
 
4.3.2   Hepatitis C 
Patients with any of the following risk factors for hepatitis C should be tested using quantitative 
RNA-PCR: 
• 
known or suspected past hepatitis C infection (including patients with past interferon 
‘curative’ treatment), 
• 
blood transfusions prior to 1990, 
• 
current or prior IV drug users, 
• 
current or prior dialysis, 
• 
household contact of hepatitis C infected patient(s), 
• 
current or prior high-risk sexual activity, 
• 
body-piercing or tattoos. 


 
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• 
At the discretion of the investigator, additional patients may also be tested for hepatitis 
C. 
The management guidelines, in Section 5.5: Subsection: Therapy Administration and Dose 
Reductions are provided according to the results of the baseline assessment of hepatitis C viral 
load. 
 
4.4 Registration Procedures 
▪ 
Patients must not start protocol treatment prior to registration. 
▪ 
The following information will be requested: 
▪ 
Protocol Number  
▪ 
Investigator Identification  
• 
Investigator’s name 
▪ 
Patient Identification  
• 
Patient’s initials 
• 
Patient demographics 
▪ Sex 
▪ Birth date (mm/yyyy) 
▪ Race 
▪ Ethnicity 
Eligibility Verification  
Patients must meet all of the eligibility requirements listed in section 3. An eligibility checklist will 
be appended to the protocol.  
Additional Requirements  
All patients must be provided with a signed and dated, written informed consent form. 
 
4.4.1   Instructions for Patients who Do Not Start Assigned Protocol Treatment  
If a patient does not receive any assigned protocol treatment, baseline and follow-up data will still 
be collected and must be submitted. Document the reason for not starting protocol treatment on 
one of the baseline forms. Also report the date and type of the first non-protocol treatment that 
the patient receives. 
5 Treatment Plan 
5.1 Treatment 
Patients will initiate therapy with DAE at the doses and schedules listed in Table 6. Each cycle 
will be defined as 21 days of therapy (+/- 7days). Patients will undergo a planned 4 cycles of 
therapy prior to surgical resection. To reduce the rate of surgical complications, patients will not 
receive bevacizumab during cycle 4 of therapy.  Patients who are unable to receive 4 cycles of 
therapy due to reasons other than toxicity requiring discontinuation of study drug per protocol, or 
progression will be documented, and will be replaced for the efficacy analysis. Patients who 
develop disease progression during therapy, or discontinuation of study drug per protocol, due to 
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pCR/RCB-I. Patients who are unable to receive 4 cycles of therapy due to other reasons will have 
toxicity and efficacy recorded, however will be replaced for the efficacy analysis. 
Table 6: Administration description 
Agent 
Pre-medications 
Dose (IV) 
Route/Administration 
Bevacizumab 
 [Day 1] 
 
 10 mg/kg 
Zofran 8 mg in 50 ml NS 
IVPB 30 min prior to 
infusion 
*100cc NS  
Initial infusion over 90 minutes. May be 
shortened to 60 minutes if initial infusion 
well tolerated. 3rd and subsequent 
infusions may be shortened to 30 
minutes if 60 minute infusion well 
tolerated.  
Liposomal 
doxorubicin  
[Day 1] 
 
30mg/m2 
 
Solumedrol 20mg PO or 
IV; Diphenhydramine 50 
mg PO 30 min prior to 
infusion 
*250cc  
D5W 
1st (2) doses infused over 3 hours. 
Infusion duration may be shortened to 1 
hour if 1st two infusions well tolerated. 
Everolimus  
[Days 1-21] 
 
7.5 mg  
 
N/A 
N/A 
Oral - once daily.   
* Diluent / volume; dose prescribed per assigned dose level.  
 


 
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All patients will undergo surgical resection of their primary tumor unless they are deemed not fit 
for surgery after 4 cycles of therapy. Patients may undergo either lymph node sampling or 
complete axillary dissection as considered standard of care by their surgeon. In order to decrease 
wound complications from bevacizumab, patients will be recommended to wait 6 weeks after the 
last dose of bevacizumab before undergoing surgical resection.  
 
 
 
 
5.2 Schedule of Dosing: 
5.2.0 All dosages prescribed and dispensed to the patient and all dose changes during the study        
must be recorded. 
5.2.1 
Medication labels will comply with US legal requirements and be printed in English. They 
will supply no information about the patient. The storage conditions for Everolimus will be 
described on the medication label. 
5.2.2 
Everolimus is supplied by Novartis. Everolimus is formulated as tablets for oral 
administration of 2.5mg, 5mg, and 10mg strength. Tablets are blister-packed under 
aluminum foil, which should be opened only at the time of administration as drug is both 
hygroscopic and light-sensitive. Refer to label for expiration date and storage conditions. 
5.2.3 
The extent of absorption of everolimus through topical exposure is not known.  Therefore, 
caregivers are advised to avoid contact with suspensions of Afinitor Tablets.  Wash 
hands thoroughly before and after preparation of either suspension. 
5.2.4 
The investigator should promote compliance by instructing the patient to take the study 
drug exactly as prescribed and by stating that compliance is necessary for the patient’s 
safety and the validity of the study. The patient should be instructed to contact the 
investigator if he/she is unable for any reason to take the study drug as prescribed. 
5.2.5 
Everolimus should be administered orally once daily at the same time every day, either 
consistently with or consistently without food.   
5.2.6 
The tablets should be swallowed whole with a glass of water and should not be chewed 
or crushed. For patients unable to swallow tablets, the tablet(s) should be dispersed 
completely in a glass of water (containing approximately 30 mL) by gently stirring until the 
tablet(s) is fully disintegrated (approximately 7 minutes), immediately prior to drinking. 
The glass should be rinsed with the same volume of water and the rinse completely 
swallowed to ensure the entire dose is administered.  
5.2.7 
If vomiting occurs, no attempt should be made to replace the vomited dose. Patients 
should be instructed that if they miss a dose on one day, they must not take any extra 
dose the next day, but instead to immediately contact the study center as soon as 
possible to ask for advice.  
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• Geriatrics (≥ 65 years): No dosage adjustment is required. 
• Renal impairment: No dosage adjustment is required. 
• Ethnicity: Pharmacokinetic characteristics are similar for Caucasian and Japanese 
subjects. 
Pharmacokinetic studies in Black transplant patients have shown an average 20% higher 
clearance; however doses above 7.5 mg daily will not be administered as individual PK levels will 
not be evaluated on this trial. 
 
5.4 Drug Information including Adverse Drug Reactions (ADRs) 
 
5.4.1 Liposomal doxorubicin (Doxil®) 
Liposomal doxorubicin is pegylated liposomal doxorubicin hydrochloride (HCL). Doxorubicin is an 
anthracycline topoisomerase inhibitor that acts during the S1 phase of the cell cycle by 
intercalating irreversibly between DNA base pairs to form a complex that inhibits the progression 
of the enzyme topoisomerase II. Topoisomerase II functions to unwind the DNA double helix in 
preparation for transcription. Doxorubicin stabilizes the topoisomerase II complex after it has 
broken the DNA chain for replication, preventing the DNA double helix from being resealed and 
thereby stopping the process of replication. This leads to inhibition of mitotic activity and nucleic 
acid synthesis, induction of mutagenesis and tumor cell death[56]. Liposomal doxorubicin is 
doxorubicin HCL encapsulated in STEALTH® liposomes. Liposomes are microscopic vesicles 
composed of a phospholipid bilayer that are capable of encapsulating active drugs. The 
STEALTH® 
liposomes 
of 
liposomal 
doxorubicin 
are 
formulated 
with 
surface-bound 
methoxypolyethylene glycol (MPEG), a process referred to as pegylation, to protect liposomes 
from detection by the mononuclear phagocyte system (MPS) and to increase blood circulation 
time[57]. Liposomal doxorubicin has a half-life of approximately 55 hours in humans. They are 
stable in blood, and at least 90% of the drug remains liposome encapsulated during circulation. It 
is believed that because of their small size (~100nm) and persistence in the circulation, the 
pegylated liposomal doxorubicin liposomes are able to penetrate the altered and often 
compromised vasculature of tumors. After distribution to the tissue compartment, the 
encapsulated doxorubicin HCL becomes available[57]. Metabolism of liposomal doxorubicin is 
extensively metabolized in the liver and eliminated primarily as glucuronide or hydroxylated 
conjugates[56].  
The most common adverse reactions observed with liposomal doxorubicin are asthenia, fatigue, 
fever, nausea, stomatitis, vomiting, diarrhea, constipation, anorexia, hand-foot syndrome, rash 
and neutropenia, thrombocytopenia, and anemia[57]. The most clinically important adverse 
effects are discussed below: 
Myelosuppression 
Myelosuppression 
is 
the 
dose-limiting 
toxicity 
of 
liposomal 
doxorubicin. 
Signs 
of 
myelosuppression 
include 
pancytopenia, 
leukopenia, 
neutropenia, 
anemia, 
and 
thrombocytopenia. In ovarian cancer patients, leukopenia occurred in 42% of patients, 
neutropenia (ANC < 1000 cells/mm3) in 19—35%, anemia in 40.2%, and thrombocytopenia in 
24%. Severe neutropenia (ANC < 500 cells/mm3) occurred in 8% and severe thrombocytopenia 
(< 25,000 cells/mm3) occurred in 1%. Severe infection (1—5%) and sepsis have been seen in 
patients with doxorubicin-induced myelosuppression[56]. 
Cardiac Toxicity  
Special attention must be given to the risk of myocardial damage from cumulative doses of 
doxorubicin HCL. In particular, left ventricular failure may occur in patients who receive a 
cumulative dosage of doxorubicin exceeding the current recommended limit of 550mg/m2. Lower 
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or concomitant therapy with other potentially cardiotoxic agents such as cyclophosphamide. Prior 
use of other anthracyclines or anthracenediones should be included in calculations of total 
cumulative dosage. Cardiac function in patients suspected to have myocardial injury related to 
liposomal 
doxorubicin 
should 
be 
considered 
for 
multi-gated 
radionuclide 
scans 
or 
echocardiography[56]. 
Infusion reactions 
An infusion-associated reaction has been identified with liposomal doxorubicin. This reaction is 
due to the liposomes themselves or one of the surface components Patients who experience this 
reaction generally do so with the first liposomal doxorubicin dose and not with subsequent dosing. 
Liposomal doxorubicin should be administered at an initial rate of 1 mg/min to decrease the 
incidence of this reaction; if no symptoms occur, the infusion rate may be increased to complete 
the infusion within 1 hour. Symptoms include fever (9.1—21.3%), flushing, dyspnea, facial 
swelling, headache (5%), chills 1—5%), back pain (1—5%), tightness in the chest and throat, 
rash (unspecified) (22%), pruritus (1—5%), chest pain (unspecified) (1—5%), hypotension, 
syncope, sinus tachycardia, apnea, bronchospasm/wheezing, dyspnea(1—5%), cyanosis, and/or 
asthma. Serious and sometimes life-threatening or fatal anaphylactic shock/anaphylactoid 
reactions have been reported (1—5%)[56].  
Palmar-plantar erythrodysesthesia (PPE) / Hand-Foot syndrome (HFS) 
Hand and foot syndrome developed in 50.6% of patients treated for ovarian cancer dosed at 50 
mg/m2; 23.8% of these patients developed a severe reaction (i.e., Grade 3—4). The increased 
incidence in ovarian cancer patients is due to the higher doses used; liposomal doxorubicin® 
given at doses of > 20 mg/m2 or at shorter intervals than recommended are associated with an 
increased incidence. Among 318 patients with multiple myeloma who received liposomal 
doxorubicin at 30 mg/m2 every 3 weeks plus bortezomib, 19% had PPE; in contrast, < 1% of 318 
patients who received bortezomib monotherapy had the event. This syndrome usually occurs 
after the second or third cycle and is associated with the cumulative liposomal doxorubicin 
dose[56].  
Nausea/Vomiting/Diarrhea 
Nausea/vomiting occurs in 18-46% and 8-33% of patients treated with liposomal doxorubicin, 
respectively, and increases with increasing dose. Liposomal doxorubicin is not as emetogenic as 
conventional doxorubicin but premedication with antiemetics is still necessary. Stomatitis and 
mucositis occur more frequently with liposomal doxorubicin due to the longer half-life than 
conventional doxorubicin. In patients treated with higher doses, the incidence of stomatitis is 
increased (37%) and 7% of patients develop severe reactions. Diarrhea has been reported in 
20.9% and constipation in 30.1% of patients treated with liposomal doxorubicin[56].  
 
 
 
5.4.2 Bevacizumab (Avastin®) 
Bevacizumab is a recombinant humanized monoclonal antibody, specifically an IgG1 antibody 
that contains human framework regions and murine complementarity-determining regions. 
Bevacizumab binds to human vascular endothelial growth factor (VEGF) and prevents interaction 
of VEGF with its receptors (Flt-1, KDR) on the surface of endothelial cells. In vitro models of 
angiogenesis have shown that interaction of VEGF with its receptors may lead to endothelial cell 
proliferation and new blood vessel formation. Evidence from animal models has suggested that 
administration of an anti-VEGF monoclonal antibody (e.g., bevacizumab) may inhibit 
angiogenesis and thus may reduce microvascular growth of tumors and inhibit metastatic disease 
progression. Bevacizumab is metabolized and eliminated via the reticuloendothelial system[58]. 
The estimated half-life of the drug is approximately 20 days. Clearance of the drug is dependent 
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bevacizumab faster. In clinical trials, there has been no evidence of lesser efficacy in males or 
patients with a higher tumor burden as compared to females or patients with a lower tumor 
burden[59].  Adverse reaction data for bevacizumab are reported from clinical trial results. 
Because clinical trials are conducted under widely varying conditions, adverse reaction rates 
observed in the clinical trial of one drug cannot be directly compared to rates in the clinical trials 
of other drugs and may not reflect the rates observed in clinical practice[59].  
Thromboembolism  
Bevacizumab therapy is associated with an increased risk of arterial and venous 
thromboembolism in metastatic colon cancer and non-small cell lung cancer (NSCLC) patients. 
Additionally, in metastatic colon cancer patients, there is an increased risk of developing a 
second subsequent thromboembolic event in patients receiving bevacizumab plus chemotherapy 
versus chemotherapy alone. Among 53 patients who got bevacizumab and chemotherapy for 
metastatic colon cancer and received warfarin for a venous thromboembolic event, 11 had an 
additional thromboembolic event. In contrast, 1 of the 30 patients who got chemotherapy alone 
and received warfarin for a venous thromboembolic event had an additional thromboembolic 
event. A pooled analysis of randomized controlled clinical trials demonstrated an arterial 
thromboembolism rate of 4.4% in 963 patients treated with bevacizumab in combination with 
chemotherapy. Of these events, fatal outcomes occurred in 7 of 963 (0.7%) patients. Arterial 
thrombotic events have included cerebral infarction (stroke), transient ischemic attack (TIA), 
myocardial infarction, angina, and a variety of other arterial thromboembolic events. The 
incidences of both cerebrovascular arterial events and cardiovascular arterial events were 
increased in patients receiving bevacizumab (1.9% and 2.1%, respectively) as compared with 
chemotherapy alone (0.5% and 1%, respectively). In addition, there was a correlation between 
age (>= 65 years vs. < 65 years) and the increase in risk of thromboembolic events (8.5% vs. 
2.1%, respectively). In the clinical trial of patients with NSCLC, the incidence of venous 
thrombosis/embolism was 5% among patients who got bevacizumab and chemotherapy and 3% 
among chemotherapy alone recipients. An increased risk for a venous thromboembolic event was 
not found by a post-hoc analysis of data from 5 trials. Other thrombotic events reported during 
bevacizumab therapy have included axillary/subclavian vein occlusion, superior mesenteric 
thrombosis, phlebitis (thrombophlebitis), catheter thrombosis, and venous sclerosis. Bevacizumab 
should be permanently discontinued in patients who experience a severe arterial thromboembolic 
event[59]. 
Gastrointestinal (GI) Perforations and Wound Healing Complications 
GI perforation complicated by intra-abdominal abscesses or fistula formation occurred more 
frequently in patients receiving bevacizumab as compared to controls during clinical trials (range 
4-11%). In colorectal clinical trials, including single-agent bevacizumab and bevacizumab in 
combination with other chemotherapy agents, the incidence of GI perforation, fistula formation, 
and/or intra-abdominal abscess was 2.4%; in non-small cell cancer clinical trials the incidence 
was 0.9%. GI perforation, fistula (gastrointestinal fistula, enterocutaneous fistula, esophageal 
fistula, duodenal fistula, rectal fistula), and/or intra-abdominal abscess have also been reported 
during post-market reports and trials for colorectal cancer and other types of cancer. Of the 
reported events, 30% were fatal. GI perforation has occurred at various time points during 
bevacizumab therapy; most events occur within the first 50 days. Of 29 patients with limited-stage 
small cell lung cancer (SCLC) who were enrolled in a clinical trial, 2 developed a confirmed 
tracheoesophageal fistula. Information on the background rate of tracheoesophageal fistula is 
limited, and the presence of other risk factors for tracheoesophageal fistula in the patients is 
unknown. However, the estimated background rate of tracheoesophageal fistula in patients with 
limited-stage SCLC is estimated to be < 1%[59]. Two distinct patterns of bleeding have occurred 
in patients receiving bevacizumab. Minor or moderate bleeding occurs more frequently in patients 
treated with bevacizumab vs. those treated with chemotherapy alone. These events were 
generally mild and resolved without medical intervention. NCI-CTC Grade 3—5 hemorrhagic 
events occurred in 4.7% of non-small cell lung cancer (NSCLC) patients and 5.2% of metastatic 
colon cancer patients receiving bevacizumab. In a randomized study in patients with NSCLC 
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patients with squamous cell histology and 4% (2 of 53) bevacizumab-treated patients with non-
squamous cell histology experienced life-threatening or fatal pulmonary hemorrhage as 
compared to none of the 32 patients receiving chemotherapy alone. In another study the 
incidence of pulmonary hemorrhage requiring medical intervention was 2.4% (10 of 427) in 
patients receiving bevacizumab in combination with carboplatin and paclitaxel versus 0.5% (2 of 
441) in patients receiving chemotherapy alone. Seven deaths due to pulmonary hemorrhage 
have been reported. Of the patients experiencing events of life-threatening pulmonary 
hemorrhage, many had cavitation and/or necrosis of the tumor, either pre-existing or developing 
during bevacizumab therapy. The risk of CNS bleeding in patients with CNS metastases receiving 
bevacizumab has not been evaluated; patients with CNS metastases were excluded from 
bevacizumab studies after one such patient experienced CNS hemorrhage after receiving 
bevacizumab in a phase I trial[59]. A study of neoadjuvant bevacizumab in breast cancer patients 
did show in increase in early and delayed post-operative complications.[60] Serious adverse 
events in patients treated with bevacizumab included bleeding, thrombotic events and GI 
perforation. 
Hypertension 
The incidence of severe hypertension (NCI CTC Grade 3—4) across all bevacizumab clinical 
trials ranges from 8—18%. In patients with non-small cell lung cancer treated with bevacizumab, 
the incidence of hypertension was 8% vs. 0.7% in patients receiving chemotherapy alone. 
Development or worsening of hypertension can require hospitalization or require discontinuation 
of bevacizumab in 1.7% of patients. Severe hypertension complicated by subarachnoid 
hemorrhage or hypertensive encephalopathy has been reported and, in some cases, has been 
fatal. In post-market reports, acute increases in blood pressure have been associated with initial 
or subsequent infusions of bevacizumab.[59] 
Proteinuria  
Proteinuria (defined as urine dipstick reading >= 1+) occurs more frequently and is more severe 
in patients receiving bevacizumab as compared to those receiving chemotherapy alone; the 
incidence of severe proteinuria (> 3.5 g/24 hours) ranged up to 3% in bevacizumab-treated 
patients across clinical trials. In patients with non-small cell lung cancer treated with bevacizumab 
plus carboplatin/paclitaxel, the incidence of proteinuria was 3%. The safety of continued 
bevacizumab therapy or temporary suspension of the drug in patients with moderate to severe 
proteinuria has not been evaluated; such patients should be monitored regularly until 
improvement and/or resolution is observed. In most clinical studies, bevacizumab was interrupted 
for proteinuria exceeding 2 g per 24 hours and resumed when proteinuria declined below this 
level[59].  
Congestive Heart Failure 
Congestive heart failure (CHF), defined as NCI-CTC Grade 2-4 left ventricular dysfunction, was 
reported in 25 of 1459 (1.7%) patients receiving bevacizumab in manufacturer-sponsored trials. 
In a controlled trial in patients with breast cancer (non-FDA approved use), CHF occurred in 4% 
(13 of 299) of patients who received prior anthracyclines and/or left chest wall radiation therapy. 
The safety of continuation or resumption of bevacizumab therapy in patients with cardiac 
dysfunction has not been studied[59]. 
Infusion Reactions 
In clinical studies, infusion reactions with the first bevacizumab dose were uncommon (less than 
3%). Severe infusion reactions occurred in 0.2% of patients receiving bevacizumab. Infusion 
reactions include hypertension, hypertensive crises associated with neurologic manifestations, 
wheezing, oxygen desaturation, grade 3 hypersensitivity, chest pain, headaches, rigors, and 
diaphoresis[59].  
 
5.4.3   Everolimus (Afinitor®) 


 
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The observed antitumor and immunosuppressive properties of rapamycin analogs are due to their 
ability to disrupt the mTOR-dependent signaling pathway. mTOR, a member of the 
phosphatidylinositide 3’-kinase (PI3K)-related family, is located predominantly in the nuclear 
fraction of both neoplastic and normal cells. mTOR activation triggers resting cells to increase the 
translation of a subset of mRNAs whose proteins are required for cell cycle progression from G1 
to S phase. mTOR regulates essential signal transduction pathways and is involved in the 
coupling of growth stimuli with cell cycle progression. Experimental data indicate that mTOR acts 
downstream of the PI3K/Akt-pathway and is phosphorylated in response to mitogenic signals. 
Early studies reported that mTOR was dedicated to initiating mRNA translation in response to 
favorable nutrient environments. In fact, cells treated with rapamycin undergo changes that are 
strikingly similar to those observed during conditions of starvation. These include mTOR 
inactivation, down regulation of translation, G1 arrest, accumulation of glycogen stores and 
altered transcription patterns. More recent studies have demonstrated that mTOR is involved in 
regulating many aspects of cell growth, including organization of the actin cytoskeleton, 
membrane traffic, protein degradation, protein kinase C (PKC) signaling, ribosome biogenesis, 
and transcription[61, 62]. 
Everolimus reacts with the ubiquitous intracellular FK506-binding protein 12 (FKBP12), forming a 
everolimus/FKBP12 complex that is a potent inhibitor of the highly conserved kinase mTOR. 
Inhibition of mTOR leads to suppression of several downstream signaling effectors, including the 
ribosomal subunit p70S6k and the eukaryotic initiation factor 4 binding protein 1 (4E-BP1). These 
two proteins play key roles in ribosomal biogenesis and cap-dependent translation, respectively. 
The extent of phosphorylation of these two downstream proteins (p70S6 kinase and 4E-BP1) may 
therefore serve as indicators of everolimus biologic activity in vivo[63]. Inhibition of the synthesis 
of ribosomal proteins and elongation factors, required to accelerate the process of cell division, 
are thought to contribute to the anti-proliferative effects of rapamycin analogs. While everolimus 
inhibits the translation of only a subset of mRNAs, inhibition of mTOR can lead to a substantial 
decrease (~15%) in overall protein synthesis[63]. The most common ADRs (incidence ≥1/10 and 
suspected to be related to treatment by the investigator) from the pooled safety data were (in 
decreasing order): stomatitis, rash, fatigue, diarrhea, infections, nausea, decreased appetite, 
anemia, dysgeusia, pneumonitis, hyperglycemia, weight decreased, pruritus, asthenia peripheral 
edema, hypercholesterolemia, epistaxis, and headache.[64].  
The most common grade 3/4 ADRs (incidence ≥1/100 to <1/10 and suspected to be related to 
treatment by the investigator) were stomatitis, anemia, hyperglycemia, fatigue, infections, 
pneumonitis, diarrhea, asthenia, thrombocytopenia, neutropenia, dyspnea, lymphopenia, 
proteinuria, hemorrhage, hypophosphatemia, rash, hypertension, aspartate aminotransferase 
(AST) increased, alanine aminotransferase (ALT) increased, and pneumonia. 
 
The below table presents the frequency category of ADRs reported in the pooled safety analysis. 
 
ADRs are listed according to MedDRA system organ class. Within each system organ class, the 
adverse reactions are ranked by frequency, with the most frequent reactions first. In addition, the 
corresponding frequency category using the following convention (CIOMS III) is also provided for 
each adverse reaction: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 
to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000) 
 
Infections and infestations 
Very common - Infections 
 
Blood and lymphatic system disorders 
Very common - Anemia,  
Common          - Thrombocytopenia, neutropenia, leukopenia, lymphopenia 
Uncommon      - Pancytopenia 
Rare 
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Immune system disorders 
Uncommon        - Hypersensitivity 
 
Metabolism and nutrition disorders 
Very common   - Decreased appetite, hyperglycemia, hypercholesterolemia 
Common          - Hypertriglyceridemia, hypophosphatemia, diabetes mellitus,    
                            Hyperlipidemia, hypokalemia, dehydration                                                                                  
Psychiatric disorders 
Common           - Insomnia 
 
Nervous system disorders 
Very common    - Dysgeusia, headache 
Uncommon        - Ageusia 
 
Cardiac disorders 
Uncommon        - Congestive cardiac failure 
 
Vascular disorders 
Common            - Hemorrhage, hypertension,  
Uncommon        - Deep vein thrombosis 
 
Respiratory, thoracic and mediastinal disorders 
Very common     - Pneumonitis, epistaxis,  
Common            - cough, dyspnea 
Uncommon         - Hemoptysis, pulmonary embolism 
Rare                - , acute respiratory distress syndrome 
 
Gastrointestinal disorders 
Very common    - Stomatitis, diarrhea, nausea 
Common          -   Vomiting, dry mouth, abdominal pain, oral pain, dyspepsia, and dysphagia 
 
Skin and subcutaneous tissue disorders 
Very common - Rash, pruritus 
Common           - Dry skin, nail disorder, acne, erythema, hand-foot syndrome 
Rare                 - Angioedema 
 
Musculoskeletal and connective tissue disorders 
Common            - Arthralgia 
 
Renal and urinary disorders 
Common             - Proteinuria, Renal failure 
Uncommon         - Increased daytime urination, acute renal failure 
 
Reproductive system and breast disorders 
Common            - Menstruation irregular  
Uncommon         - amenorrhea 
 
General disorders and administration site conditions 
Very common      - Fatigue, asthenia, peripheral edema,  
Common              - Pyrexia, mucosal inflammation 
Uncommon          - Non-cardiac chest pain,  
Rare                    - impaired wound healing 
 
Investigations 
Very common       - Weight decreased 


 
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Common               - aspartate aminotransferase increased, Alanine aminotransferase increased, 
blood creatinine increased.  
a Includes all reactions within the ‘infections and infestations’ system organ class including 
common: pneumonia and uncommon: herpes zoster, sepsis and isolated cases of opportunistic 
infections (e.g. aspergillosis, candidiasis and hepatitis B)  
b Includes different bleeding events not listed individually 
c Includes common: pneumonitis: interstitial lung disease, lung infiltration, and rare - alveolitis, 
pulmonary alveolar hemorrhage, and pulmonary toxicity 
d Includes very common: stomatitis; common: aphthous stomatitis, mouth and tongue ulceration; 
uncommon: glossitis, glossodynia 
e reported as palmar-plantar erythrodysesthesia syndrome 
f frequency is based upon number of women age 10 to 55 years of age in the safety pool 
 
Clinically relevant laboratory abnormalities 
 
In the pooled double-blind phase III safety database, the following new or worsening clinically 
relevant laboratory abnormalities were reported with an incidence of ≥1/10 (very common, listed 
in decreasing frequency). 
• 
Hematology: hemoglobin decreased, lymphocytes decreased, white blood cells 
decreased, platelets decreased, and neutrophils decreased (or collectively as 
pancytopenia); 
• 
Clinical chemistry: glucose (fasting) increased, cholesterol increased, triglycerides 
increased, AST increased, phosphate decreased, ALT increased, creatinine increased, 
and potassium decreased. 
Most of the observed abnormalities (> 1/100) were mild (grade 1) or moderate (grade 2). Grade 
3/4 hematology and chemistry abnormalities include: 
• 
Hematology: lymphocytes decreased, hemoglobin decreased,  (very common); 
neutrophils decreased, platelet count decreased, white blood cells decreased (all 
common). 
• 
Clinical chemistry: glucose (fasting) increased, phosphate decreased, potassium 
decreased, AST increased, ALT increased, creatinine increased cholesterol (total) 
increased, triglycerides increased (all common).  
 
Description of selected adverse drug reactions 
In clinical trials and post-marketing spontaneous reports, everolimus has been associated with 
serious cases of the following: 
• 
Hepatitis B reactivation, including fatal outcome. Reactivation of infections is an expected 
event during periods of immunosuppression.  
• 
Renal failure events (including fatal ones) and proteinuria. Monitoring of renal function is 
recommended. 
• 
Amenorrhea (including secondary amenorrhea). 
• 
Pneumocystis jiroveci pneumonia (PJP) some with a fatal outcome. 
• 
Angioedema has been reported with and without concomitant use of everolimus and ACE 
inhibitors 
 
The table below lists all fatal adverse events reported by investigators across all RAD001 studies 
as having a suspected causal relationship to everolimus and occurring on or before the cut-off 
date of 31-Mar-2014. 


 
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MedDRA system organ class 
Event 
Blood and lymphatic system disorders 
Thrombocytopenia 
Cardiac disorders 
Acute cardiopulmonary event, cardiogenic 
shock, cardio-respiratory arrest, myocardial 
infarction 
Gastrointestinal disorders 
Diarrhea, duodenal ulcer, GI hemorrhage, 
intestinal perforation, esophageal perforation, 
internal hernia 
General disorders/administration site conditions 
Cold sweat, concomitant disease progression, 
general physical health deterioration, multi-
organ failure, sudden death 
Infections and infestations 
Candidal sepsis, EBV pneumonia, neutropenic 
sepsis, pneumocystis jiroveci pneumonia, 
reactivation of Hepatitis B, septic shock, 
septicemia with massive Epstein-Barr viremia 
Injury, poisoning and procedural complications 
Bone fissure 
Metabolism and nutrition disorders 
Dehydration, ketoacidosis, hyperglycemia 
Neoplasms benign, malignant and unspecified 
(including cysts and polyps) 
Squamous cell carcinoma of skin 
Nervous system disorders 
Cerebral 
hemorrhage, 
embolic 
stroke, 
restlessness 
Renal and urinary disorders 
Renal tubular necrosis 
Respiratory thoracic and mediastinal disorders 
Acute cardiopulmonary event, acute respiratory 
distress syndrome, cardio-respiratory arrest, 
dyspnea, chronic obstructive pulmonary 
disease, interstitial pneumonia, pulmonary 
embolism, pulmonary edema, pneumonitis 
Vascular Disorders 
Cerebral hemorrhage, disseminated 
intravascular coagulation, embolic stroke, 
hemorrhage, hypovolemic shock, myocardial 
infarction, pulmonary hypertension 
 
The table below lists all serious, unexpected, life-threatening adverse events considered related 
to study drug, and reported on at least one occasion up to the cut-off date of 31-Mar-2014. It 
should be stressed that many of these SAE reports have been reported only on a single occasion 
making an accurate assessment of causality difficult, if not impossible. Due to the imprecision of 
causality, the causality assessments should not be assumed that all of these events are indeed 
the result of therapy with everolimus. Moreover, the assessment of causality is particularly difficult 
in critically ill patients where confounding factors are present relating mainly to complications of 
the underlying disease and to the use of prior therapy and/or concomitant medications. In addition 
to the SAE reports presented below, disease progression has on occasions been reported 
somewhat paradoxically as an SAE with a suspected causal relationship to everolimus and 
reported on at least one occasion. 
Individual events are presented for each MedDRA system organ class. 
 
MedDRA system organ 
class 
Event 
Blood and lymphatic 
system disorders 
Acute leukemia, anemia, bone marrow failure, disseminated intravascular 
coagulation, febrile neutropenia, hemorrhagic diathesis, leukemoid reaction, 


 
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leukocytosis, leukopenia, lymphadenopathy, lymphedema, lymphopenia, 
neutropenia, pancytopenia, platelet disorder, retroperitoneal lymphadenopathy, 
thrombocytopenia, white blood cell disorder, hemolytic uremic syndrome 
Cardiac disorders 
atrial fibrillation, atrioventricular block,  cardiorespiratory arrest, 
cardiopulmonary 
arrest, congestive cardiomyopathy, cyanosis, diastolic dysfunction, dilatation left 
atrial and left ventricular, hypertrophy, left ventricular hypertrophy, left ventricular 
dysfunction, myocardial infarction, myocardial ischemia, hypertensive heart 
disease, palpitations, pericardial effusion, right ventricular failure, sinus 
tachycardia, 
stress cardiopathy, supraventricular tachycardia, tachycardia, ventricular 
dysfunction 
Valve incompetence: mitral/pulmonary/tricuspid 
Ear and labyrinth 
disorders 
Vertigo, sudden hearing loss, deafness unilateral 
Endocrine disorders 
Hyperthyroidism , hyperglycemic non-ketotic syndrome, hypercalcemia, 
hypothyroidism 
Eye disorders 
Conjunctivitis, eyelid edema, scleral discoloration, ocular discomfort, ocular 
surface disease, ophthalmoplegia cranial nerve paralysis, papilloedema, 
photophobia, retinal artery thrombosis, retinal detachment, retinal hemorrhage, 
steroid Induced cataract, senile cataract, visual acuity reduced. 
Gastrointestinal 
disorders 
Abdominal abscess, abdominal adhesions, abdominal: 
discomfort/distension/pain/tenderness, anorectal discomfort, anal fissure, anal 
fistula, anastomotic leak, ascites, colitis, constipation, diarrhea, diverticulum, 
duodenal ulcer, dyspepsia, dysphagia, esophageal perforation, feces discolored, 
gastric perforation, gastric ulcer hemorrhage, gastric ulceration, gastrointestinal 
angiodysplasia, gastrointestinal ischemia,  gastrointestinal oedema, 
gastroenteritis, hemorrhoids, hematemesis, hematochezia, hiccups, ileus, 
intestinal perforation, melena, mesenteric vein thrombosis, mouth ulceration, 
nausea, pancreatitis, proctalgia, proctitis, recall phenomenon radiation enteritis, 
rectal discharge/hemorrhage, small intestinal obstruction, stomatitis, swollen 
tongue, vomiting, oral pain, enterovesical fistula, radiation esophagitis, necrotizing 
esophagitis, salivary gland calculus, small bowel thickness, thickened bowel Wall 
Gastritis: erosive/ hemorrhagic Lip: edema/swelling/ulceration 
Gastrointestinal: disorder/hemorrhage/sounds 
Mucosal: hemorrhage/inflammation 
General disorders and 
administration site 
conditions 
Application site erythema, asthenia, bloody discharge, calcinosis, chest 
discomfort/pain, chills, concomitant disease progression, condition aggravated, 
crepitations, death, discomfort, disease progression, drug ineffective, and drug 
withdrawal syndrome (asthenia and flushing) edema peripheral, face edema, 
facial pain, fatigue, feeling of body temperature change, general physical health 
deterioration, generalized edema, goiter, granuloma, hypertrophy, hypothermia, 
impaired healing, inflammation, influenza like illness, irritability, local swelling, 
malaise, mass, multi-organ failure, necrosis, non-cardiac chest pain, pain, 
performance status decreased, pitting edema, pyrexia, sudden death, swelling, 
tenderness, thirst 
Hepatobiliary disorders 
Cholecystitis, cholelithiasis, cholestasis, cytolytic hepatitis, hepatic cirrhosis, 
hepatic failure, hepatic function abnormal, hepatic necrosis, hepatorenal failure, 
hepatitis B and C reactivation, hepatomegaly, hyperbilirubinemia, jaundice, portal 
vein thrombosis 
Immune system 
disorders 
Acute disseminated encephalomyelitis, autoimmune disorder, cytokine release 
syndrome, Guillian Barre syndrome, hypersensitivity, immunosuppression, 
Stevens- Johnson syndrome 
Infections and 
infestations 
Bronchitis, bronchopneumonia, bronchopulmonary aspergillosis. candida sepsis, 
cellulitis, citrobacter sepsis, clostridium bacteremia, endocarditis, escherichia 
bacteremia, folliculitis, gastroenteritis, hepatitis fulminant. infected lymphocele, 
klebsiella sepsis, liver abscess, meningitis, herpes, nasopharyngitis, neutropenic 
sepsis, perirectal/anal abscess, pharyngitis, pneumococcal sepsis, pseudomonal 
bacteremia, purulent discharge, pyelonephritis, respiratory moniliasis, sepsis 
syndrome, septic shock, sinusitis, staphylococcal bacteremia, staphylococcal 
sepsis, streptococcal bacteremia, tonsillitis, tuberculosis, urosepsis 


 
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lnfection(s): alpha hemolytic streptococcal/atypical 
mycobacteriallbacteriallclostridiallenterobacter/enterococcal/epstein-barr virus/ 
escherichia/escherichia urinary tract/gastrointestinal/haemophilus/herpesvirus/ 
general/ localized/ morganella/ proteus/ skin/streptococcal/staphylococcal/urinary 
tract/ wound staphylococcal 
Injury, poisoning and 
Procedural 
complications 
Abdominal adhesion, anastomotic leak, bone fissure, collapse of lung, contusion, 
eschar, fall, head injury, lung injury, medical device complication, medication 
error, 
post procedural swelling, recall phenomenon radiation enteritis, surgical 
procedure 
repeated, vena cava injury, wound dehiscence/secretion 
Investigations 
Aspiration pleural cavity, antinuclear antibody positive, bleeding time prolonged, 
breath sounds abnormal, cardiac function test abnormal, chest X-ray abnormal, 
clostridium difficile toxin test positive, computerized tomogram abnormal, ejection 
fraction decreased, endoscopy upper gastrointestinal tract, general physical 
condition abnormal, granulocyte count decreased, hematocrit/hemoglobin 
decreased, hypophosphatemia, liver function test abnormal, neutrophil count 
abnormal/decreased, occult blood positive, oxygen saturation 
abnormal/decreased, 
peak expiratory flow rate decreased, protein urine present, QRS axis abnormal, 
urine output decreased, X-ray abnormal; Increased: alanine aminotransferase, 
ammonia, aspartate aminotransferase, aspartate aminotransferase, body 
temperature, C-reactive protein, eosinophil count, gamma-glutamyltransferase, 
international normalized ratio, lipase, red blood cell count, sedimentation rate, 
transaminases, troponin T, troponin Platelet count: 
abnormal/decreased/increased 
White blood cell(s): count abnormal/decreased/in urine Lymphocyte count: 
decreased/increased Blood: amylase increased/albumin decreased/alkaline 
phosphatase increased/bilirubin increased/creatine phosphokinase 
increased/creatinine increased/magnesium decreased/glucose increased/lactate 
dehydrogenase increased/potassium decreased/pressure diastolic 
decreased/pressure orthostatic abnormal/pressure systolic 
decreased/triglycerides increased/urea increased/urine present 
Electrocardiogram: T wave abnormal/T wave amplitude decreased/poor R-wave 
progression Weight: decreased/ increased 
Metabolism and 
nutrition disorders 
Acidosis, anorexia, appetite disorder, cachexia, Cushing’s syndrome, decreased 
appetite, dehydration, diabetes mellitus, diabetic ketoacidosis, electrolyte 
imbalance, failure to thrive, fluid overload/retention, food intolerance, glucose 
tolerance impaired, gout, hypothyroidism, malnutrition, metabolic acidosis, oral 
intake reduced, polydipsia, type 2 diabetes mellitus Hyper: 
cholesterolemia/glycemia/kalemia/lipidemia/calcemia uricemia/ 
triglyceridemia, glycemic non-ketotic syndrome 
Hypo: calcemia/glycemia/kalemia/magnesemia/natremia/ proteinemia/ 
hypophosphatemia 
Musculoskeletal and 
connective tissue 
disorders 
Arthritis, bone fissure, fistula, gout mobility decreased, joint effusion, 
rhabdomyolysis Pain: back/flank/musculoskeletal/musculoskeletal 
chest/extremity/neck Muscle: spasms/weakness; myalgia, arthralgia 
Osteoarthritis; Osteonecrosis, Osteoradionecrosis 
Neoplasms benign, 
malignant and 
unspecified (incl. cysts 
and polyps) 
Acute leukemia, adenocarcinoma of pancreas, Burkitt’s lymphoma, carcinoid 
syndrome, colon neoplasm, lung neoplasm, lymphoproliferative disorder, 
malignant 
neoplasm progression, malignant melanoma, malignant pleural effusion, 
pancreatic carcinoma, squamous cell carcinoma of skin, uterine leiomyoma 
Metastases: central nervous system/lung/lymph nodes/neoplasm; Tumor: 
hemorrhage/necrosis 
Nervous system 
disorders 
Acute disseminated encephalomyelitis, asterixis, ataxia, cerebrovascular 
accident, 
cognitive disorder, complex partial seizures, complex regional pain syndrome, 
convulsion, depressed level of consciousness, dizziness, dyslalia, encephalitis, 
encephalopathy, facial palsy, headache, hemiparesis, hemiplegia, hyperglycemic 
non-ketotic syndrome, hypersomnia, hypoglycemic coma, lethargy, loss of 
consciousness, ophthalmoplegia_cranial nerve paralysis, neuralgia, neuropathy 


 
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peripheral, presyncope, sinus headache, somnolence, speech disorder, tremor, 
vertigo Cerebral: hemorrhage/ infarction/ischemia; transient ischemic attack 
Psychiatric disorders 
Agitated depression, anxiety, confusional state, delirium, delusional disorder, 
disorientation, drug withdrawal syndrome, libido decreased insomnia, mental 
disorder/status changes, mood altered, persecutory type, personality disorder, 
neurosis, staring 
Renal and urinary 
disorders 
Acute renal failure, anuria, bladder tamponade, dysuria, hematuria, hemolytic 
uremic syndrome, hydronephrosis, leukocyturia, nephrolithiasis, oliguria, 
pollakiuria, 
polyuria, postrenal failure, renal failure/acute/impairment, urinary bladder 
hemorrhage, urinary incontinence, renal atrophy, renal colic, renal tubular 
necrosis 
Reproductive/breast 
disorders 
Azoospermia, endometrial hyperplasia, libido decreased, menorrhagia, pelvic 
pain, ovarian cyst, scrotal edema 
Respiratory, thoracic 
and mediastinal 
disorders 
Alveolitis, alveolitis allergic, asthma, atelectasis, bronchomalacia, bronchospasm, 
cough, cryptogenic organizing pneumonia, diffuse alveolar damage, dysphonia, 
dyspnea/dyspnea exertional, emphysema, epistaxis, hemoptysis, hydrothorax, 
hypercapnia, hypoxia, laryngeal edema, interstitial lung disease, laryngeal 
inflammation, pneumothorax, rales, sinus congestion, stridor, tachypnea, 
wheezing 
Acute: respiratory distress syndrome/respiratory failure 
Lung: consolidation/disorder/infiltration, obstructive airways disorder, orthopnea, 
pharyngolaryngeal pain, pleural disorder/effusion/pleurisy/pain; pneumonia 
aspiration, pneumonitis, pneumothorax, productive cough, rhinorrhoea 
Pulmonary: congestion/alveolar/hemorrhage/artery 
dilatation/cavitation/embolism/fibrosis/haemorrhage/hypertension/edema/toxicity 
Respiratory: arrest/disorder/distress/failure/gas exchange disorder 
Skin and subcutaneous 
tissue disorders 
Acute febrile neutrophilic dermatosis, Angioedema, blister, dermatitis, dermatitis 
acneiform, erythema, hyperhidrosis, leukocytoclastic vasculitis, night sweats, 
petechiae, photosensitivity reaction, pruritus, Stevens-Johnson syndrome 
Rash: erythematous/generalized/ maculo-papular/pruritic/skin 
disorder/exfoliation/lesion/reaction/ulcer/palmar plantar erythrodysesthesia/hand 
foot syndrome 
Surgical and medical 
procedures 
Abscess drainage, biliary drainage, bladder irrigation, catheter removal, chest 
tube 
insertion, cholecystectomy, debridement, endotracheal intubation, fistula repair, 
gastric ulcer surgery, gastrointestinal tube insertion, ileojejunal bypass, incisional 
drainage, laparotomy, mechanical ventilation, pleurodesis, sinus operation, 
surgery, 
thoracic cavity drainage, tracheostomy Pericardial: drainage/excision/operation 
Wound: closure/drainage/treatment 
Vascular disorders 
Capillary leak syndrome, circulatory collapse, embolism, flushing, gastrointestinal 
angiodysplasia, gastrointestinal ischemia, hemorrhoids, hematoma, hemodynamic 
instability, hemorrhage, hypertension, hypertensive angiopathy, hypertensive 
crisis, hypotension, lymphangiopathy, lymphedema, pallor, shock; transient 
ischemic attack, retinal hemorrhage, 
Thrombosis: deep vein/jugular vein 
*New events added to IB Editions 12 and 13 are noted in bold  
 
 


 
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5.5 Therapy Administration and Dose Reductions 
NOTE: All toxicities should be graded according to the NCI Common Toxicity Criteria 
(version 4.0) 
All patients will initiate therapy on dose level 1 (Table 7). In a currently accruing phase I study, a 
dosing schedule of everolimus 7.5mg PO on days 1-21, bevacizumab 15mg/kg IV day 1 and 
liposomal doxorubicin 30mg/m2 IV on day 1, every 21 days was well tolerated with no dose 
limiting toxicity. Although dose escalation within the phase I trial has demonstrated that higher 
doses of everolimus are feasible, there was a higher incidence of grade 3 mucositis, a known 
toxicity of both everolimus and liposomal doxorubicin. Since metaplastic patients who developed 
response were treated with 7.5mg everolimus, this has been the dose chosen to proceed forward 
in this clinical trial. 
Patients experiencing > grade 2 non-hematologic drug toxicity that is unresponsive to 
symptomatic support may undergo dose reduction of the responsible drug(s) as indicated in 
Table 7. Other drugs within the regimen can be continued at full dose per the treating physician’s 
discretion. If all three drugs are reduced to dose level -2, the patient will be withdrawn from study. 
Therapy with everolimus should be held in patients with absolute neutrophil count < 1000/mm3, 
hemoglobin < 8/mm3, platelet count <50,000/mm3 and/or > grade 3 mucositis and/or hand foot 
syndrome. Therapy may be resumed if neutrophil count improves to > 1000/mm3, hemoglobin 
improves to > 8/mm3, platelet count improves to >50,000/mm3 and/or mucositis and/or hand foot 
syndrome improve to grade 1. Neutrophils and platelets must have recovered to grade 2 prior to 
receiving subsequent cycles of therapy. Treatment may be held for up to 2 weeks for hematologic 
recovery, but therapy should be discontinued if >2 weeks is required for hematologic recovery. 
Elevation in blood pressure during therapy should be treated according to guidelines for 
bevacizumab induced hypertension. Urine dipstick protein values of 2 or higher should be 
confirmed by 24-hour collection of urine. For proteinuria > 3.5g/24 hours, bevacizumab should be 
discontinued. For proteinuria 1-3.5g/24 hours, bevacizumab should be held until proteinuria 
improves to < 2g/24 hours. If improvement to < 2g/24 hours is not seen in 4 weeks, bevacizumab 
should be discontinued. For proteinuria < 1g/24 hours, bevacizumab can be continued. Therapy 
will be administered as indicated in Table 7. 
5.5.1 Management of specific toxicities related to everolimus administration: 
Overall, safety data available from completed, controlled and uncontrolled studies indicate that 
everolimus is generally well tolerated at weekly or daily dose schedules. The safety profile is 
characterized by manageable adverse events (AEs). These AEs are generally reversible and 
non-cumulative. 
Adverse events most frequently observed with everolimus are stomatitis, rash, diarrhea, fatigue, 
infections, asthenia, nausea, peripheral edema, decreased appetite, headache, dysgeusia, 
epistaxis, mucosal inflammation, pneumonitis, weight decreased, vomiting, pruritus, cough, 
dyspnea, dry skin, nail disorder, and pyrexia.  Overall, the most frequently observed laboratory 
abnormalities include decreased hematology parameters including hemoglobin, lymphocytes, 
Table 7: Drug Dosing and Recommended Reductions for Toxicity* 
 
Everolimus 
Bevacizumab 
Liposomal 
Doxorubicin 
Dose level 1 
7.5mg PO on days 1-21 
10  mg/kg IV on day 1 
30 mg/m2 IV on day 1 
Dose level -1 
5 mg PO on days 1-21 
7.5 mg/kg IV on day 1 
25 mg/m2 IV on day 1 
Dose level -2 
2.5 mg PO on days 1-21 
5 mg/kg IV on day 1 
20 mg/m2 IV on day 1 
Dose level -3 
Discontinue 
Discontinue 
Discontinue 
*Decisions to reduce doses are made per individual drug based upon known toxicity profiles of each drug. 
As few as 1 and as many as 3 drugs may be reduced per investigator’s discretion upon evaluation of an 
individual patient’s symptoms, severity and likelihood of drug causation.  


 
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platelets, and neutrophils (or collectively as pancytopenia).; increased clinical chemistry 
parameters including cholesterol, triglycerides, glucose, aspartate transaminases, creatinine, 
alanine transaminases, and bilirubin; and decreased clinical chemistry parameters including 
phosphate and potassium.. The majority of these AEs have been of mild to moderate severity 
(NCI CTC grade 1-2).  
Table 8 - Dosing guidelines for Everolimus-related non-hematologic toxicities 
Toxicity 
Action 
Non-Infectious Pneumonitis 
Please refer to section below, including Table 12 
Reactivation of HBV or HCV flare 
Please refer to sections below, including Tables 14 and 15 
AST or ALT elevation 
Grade 1 (> ULN - 3.0 x ULN) 
Grade 2 (> 3.0 - 5.0 x ULN) 
Maintain current dose level 
AST or ALT elevation 
Grade 3 (> 5.0 - 20.0 ULN)* 
Interrupt Everolimus administration until resolution to ≤ grade 1 
(or ≤ grade 2 if baseline values were within the range of grade 
2). If resolution occurs ≤ 7 days, Everolimus should be re-started 
at the dose level prior to interruption. 
If resolution takes > 7 days, or if event recurs within 28 days, 
hold Everolimus until recovery to ≤ grade 1 or baseline grade / 
value and reintroduce Everolimus at one dose level lower, if 
available. 
AST or ALT elevation 
Grade 4 (> 20 x ULN)* 
 
 
 
Recurrence of grade 4 after dose 
reduction or toxicity requiring 
Everolimus interruption for > 28 
days 
Interrupt Everolimus administration until resolution to ≤ grade 1 
(or ≤ grade 2 if baseline values were within the range of grade 
2). If resolution occurs ≤ 7 days, Everolimus should be re-started 
at one dose level lower. If resolution takes > 7 days, discontinue 
Everolimus. 
Discontinue Everolimus. 
Intolerable grade 2 mucositis, or 
grade 3 AE, except hyperglycemia 
or hypertriglyceridemia or 
hypercholesterolemia (see below, 
including tables 10 and 11) 
Interrupt Everolimus administration until resolution to ≤ grade 1 
or baseline grade / value. 
If resolution occurs within ≤ 7 days, Everolimus should be re-
started at the dose level prior to interruption. 
If resolution takes > 7 days, or if event recurs within 28 days, 
hold Everolimus until recovery to ≤ grade 1 or baseline grade / 
value and reintroduce Everolimus at one dose level lower, if 
available. 
Patients will be withdrawn from the study if they fail to recover to 
 grade 1 or baseline grade / value within 28 days. 
Any other grade 4 
Hold Everolimus until recovery to grade  1 or baseline value 
Reintroduce Everolimus at one dose level lower, if available. 
Grade 3 or 4 clinical liver failure 
(asterixis or encephalopathy/coma) 
Discontinue Everolimus 
Recurrence of intolerable grade 2 
mucositis or grade 3 event after 
dose reduction 
Reduce dose to the next lower dose level, if available. The 
lowest possible dose level of Everolimus is 2.5 mg daily. Below 
this level, Everolimus must be discontinued. If toxicity recurs at 
Grade 3, consider discontinuation 
Recurrence of grade 4 after dose 
reduction 
Discontinue Everolimus 


 
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Table 9- Dosing guidelines for Everolimus-related hematologic toxicities 
Toxicity 
Action 
Grade 2 thrombocytopenia (platelets 
<75, ≥ 50x109/L) 
No action 
 
Grade 3 thrombocytopenia (platelets 
<50, ≥ 25 x109/L) 
Interrupt Everolimus until resolution to grade 1  
If resolution occurs ≤ 7 days, reintroduce Everolimus at the 
dose level prior to interruption. 
If resolution occurs > 7 days, or event occurs within 28 days, 
reintroduce Everolimus at one dose level lower, if available. 
Grade 4 thrombocytopenia (platelets 
< 25 x109/L) 
Interrupt Everolimus until recovery to grade  1. Then 
reintroduce Everolimus at one dose level lower, if available. 
Grade 3 neutropenia or anemia 
(neutrophil <1, ≥0.5 x109/L) 
Interrupt Everolimus until resolution to grade ≤1 or baseline 
value 
If AE resolution occurs ≤ 7 days, reintroduce Everolimus at 
the same dose level. 
If AE resolution occurs > 7 days, or event occurs within 28 
days, reintroduce Everolimus at one dose level lower, if 
available. 
Grade 4 neutropenia or anemia 
Interrupt Everolimus until recovery to grade  1 or baseline 
value. Reintroduce Everolimus at one dose level lower, if 
available.* 
Febrile neutropenia 
Interrupt Everolimus until resolution to grade  1 (or baseline 
value) and no fever. Reintroduce Everolimus at one dose 
level lower, if available.* 
Recurrence of grade 3 toxicity after 
dose reduction 
Reduce dose to the next lower dose level, if available. The 
lowest possible dose level of Everolimus is 5 mg every other 
day (2.5 mg daily). Below this level, Everolimus must be 
discontinued. 
*Recurrence of grade 4 toxicity 
(including febrile neutropenia) after 
dose reduction 
Discontinue Everolimus 
*Any hematologic toxicity requiring 
Everolimus interruption for > 28 
days 
Discontinue Everolimus 
 Management of infections 
Everolimus has immunosuppressive properties and may predispose patients to bacterial, fungal, 
viral or protozoal infections, including infections with opportunistic pathogens. Localized and 
systemic infections, including pneumonia, other bacterial infections, invasive fungal infections, 
such as aspergillosis or candidiasis and viral infections including reactivation of hepatitis B virus, 
have been described in patients taking Everolimus Some of these infections have been severe 
(e.g. leading to sepsis, respiratory or hepatic failure) and occasionally have had a fatal outcome. 
Physicians and patients should be aware of the increased risk of infection with Everolimus Treat 
pre-existing infections prior to starting treatment with Everolimus. While taking Everolimus, be 
Toxicity 
Action 
Any non-hematologic toxicity 
requiring Everolimus interruption 
for > 28 days 
Discontinue Everolimus 
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vigilant for symptoms and signs of infection; if a diagnosis of infection is made, institute 
appropriate treatment promptly and consider interruption or discontinuation of Everolimus. 
If a diagnosis of invasive systemic fungal infection is made, discontinue Everolimus and treat with 
appropriate antifungal therapy. 
Cases of pneumocystis jirovecii pneumonia (PJP), some with a fatal outcome, have been 
reported in patients who received everolimus. PJP may be associated with concomitant use of 
corticosteroids or other immunosuppressive agents.  Prophylaxis for PJP should be considered 
when concomitant use of corticosteroids or other immunosuppressive agents are required. 
 Management of skin toxicity 
For patients with grade 1 toxicity, no specific supportive care is usually needed or indicated. Rash 
must be reported as an AE. Patients with grade 2 or higher toxicity may be treated with the 
following suggested supportive measures at the discretion of the investigator: oral minocycline, 
topical tetracycline, topical clindamycin, topical silver sulfadiazine, diphenhydramine, oral 
prednisolone (short course), topical corticosteroids, or pimecrolimus. 
 Management of Hypersensitivity reactions 
Hypersensitivity reactions manifested by symptoms including, but not limited to, anaphylaxis, 
dyspnea, flushing, chest pain or angioedema (e.g. swelling of the airways or tongue, with or 
without respiratory impairment) have been observed with everolimus. 
 Angioedema with concomitant use of angiotensin-converting enzyme (ACE) inhibitors 
Patients taking concomitant ACE inhibitor therapy may be at increased risk for angioedema (e.g. 
swelling of the airways or tongue, with or without respiratory impairment). 
 Renal Failure Events 
Cases of renal failure (including acute renal failure), some with fatal outcome, occurred in patients 
treated with everolimus. Renal function of patients should be monitored particularly where 
patients have additional risk factors that may further impair renal function. 
Elevations of serum creatinine, usually mild, and proteinuria have been reported in patients taking 
everolimus. Monitoring of renal function, including measurement of blood urea nitrogen (BUN), 
urinary protein, or serum creatinine, is recommended prior to the start of everolimus therapy and 
periodically thereafter. 
 Management of stomatitis, oral mucositis, mouth ulcers 
Patients with a clinical history of stomatitis/mucositis/mouth ulcers and those with gastrointestinal 
morbidity associated with mouth/dental infections, irritation of esophageal mucosa e.g. 
gastroesophageal reflux disease (GERD) and pre-existing stomatitis/mucositis must be monitored 
even more closely. Patients should be instructed to report the first onset of buccal mucosa 
irritation/reddening to their study physician immediately. 
Stomatitis/oral mucositis/mouth ulcers due to Everolimus should be treated using local supportive 
care. Please note that investigators in earlier trials have described the oral toxicities associated 
with Everolimus as mouth ulcers, rather than mucositis or stomatitis. If your examination reveals 
mouth ulcers rather than a more general inflammation of the mouth, please classify the adverse 
event as such. The suggested paradigm for treatment of stomatitis/oral mucositis/mouth ulcers is 
as follows: 
1. For mild toxicity (grade 1), no dose adjustment required. Manage with non-alcoholic mouth 
wash or salt water (0.9%) mouth wash several times a day until resolution. 
2. For more severe toxicity (grade 2 in which case patients have pain but are able to maintain 
adequate oral alimentation, or grade 3 in which case patients cannot maintain adequate oral 
alimentation), the suggested treatments are topical analgesic mouth treatments (i.e., local 
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phenol) with or without topical corticosteroids, such as triamcinolone oral paste 0.1% 
(Kenalog in Orabase®). 
3. Agents containing alcohol, hydrogen peroxide, iodine, and thyme derivatives may tend to 
worsen mouth ulcers.  These agents should be avoided. 
4. Antifungal agents should be avoided unless a fungal infection is diagnosed. In particular, 
systemic imidazole antifungal agents (ketoconazole, fluconazole, itraconazole, etc.) should 
be avoided in all patients due to their strong inhibition of Everolimus metabolism, therefore 
leading to higher Everolimus exposures. Therefore, topical antifungal agents are preferred if 
an infection is diagnosed.  
Table 10: Management of stomatitis / oral mucositis / mouth ulcers 
Adverse Drug Reaction 
Severity 
Afinitor Dose Adjustment and Management 
Recommendations 
Stomatitis 
Grade 1 
(Minimal 
symptoms, 
normal diet) 
No dose adjustment required.  
Manage with non-alcoholic or salt water (0.9%) mouth 
wash several times a day. 
 
Grade 2 
(Symptomatic 
but can eat and 
swallow 
modified diet) 
Temporary dose interruption until recovery to grade 
≤1.  
Re-initiate Afinitor at the same dose. 
If stomatitis recurs at grade 2, interrupt dose until 
recovery to grade ≤1. Re-initiate Afinitor at a lower 
dose. 
Manage with topical analgesic mouth treatments (e.g. 
benzocaine, butyl aminobenzoate, tetracaine 
hydrochloride, menthol or phenol) with or without 
topical corticosteroids (i.e. triamcinolone oral paste)*. 
 
Grade 3 
(Symptomatic 
and unable to 
adequately eat 
or hydrate 
orally) 
Temporary dose interruption until recovery to grade 
≤1.  
Re-initiate Afinitor at lower dose. 
Manage with topical analgesic mouth treatments (i.e. 
benzocaine, butyl aminobenzoate, tetracaine 
hydrochloride, menthol or phenol) with or without 
topical corticosteroids (i.e. triamcinolone oral paste)* 
 
Grade 4 
(Symptoms 
associated with 
life-threatening 
consequences) 
Discontinue Afinitor and treat with appropriate medical 
therapy. 
* using agents containing alcohol, hydrogen peroxide, iodine, and thyme derivatives in 
management of stomatitis as they may worsen mouth ulcers. 
 Management of Diarrhea 
Appearance of grade 1-2 diarrhea attributed to study drug toxicity may be treated with supportive 
care such as loperamide, initiated at the earliest onset (for example 4 mg orally followed by 2 mg 
orally every 2 hours until resolution of diarrhea). 
 Management of Hyperlipidemia and Hyperglycemia 
Treatment of hyperlipidemia should take into account the pre-treatment status and dietary habits 
of the patient. Grade 2 or higher hypercholesterolemia (>300 mg/dL or 7.75 mmol/L) or grade 2 
hypertriglyceridemia or higher (>2.5x upper normal limit) should be treated with a 3-hydroxy-3-


 
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methyl-glutaryl (HMG)-CoA reductase inhibitor (e.g. atorvastatin, pravastatin, fluvastatin) or 
appropriate triglyceride-lowering medication, in addition to diet. 
Note: Concomitant therapy with fibrates and an HMG-CoA reductase inhibitor is associated with 
an increased risk of a rare but serious skeletal muscle toxicity manifested by rhabdomyolysis, 
markedly elevated creatine phosphokinase (CPK) levels and myoglobinuria, acute renal failure 
and sometimes death. The risk versus benefit of using this therapy should be determined for 
individual patients based on their risk of cardiovascular complications of hyperlipidemia. 
Dyslipidemia (including hypercholesterolemia and hypertriglyceridemia) has been reported in 
patients taking everolimus.  Monitoring of blood cholesterol and triglycerides prior to the start of 
everolimus therapy and periodically thereafter as well as management with appropriate medical 
therapy is recommended. 
Hyperglycemia has been reported in patients taking everolimus. Monitoring of fasting serum 
glucose is recommended prior to the start of Everolimus and periodically thereafter. More 
frequent monitoring is recommended when everolimus is co-administered with other drugs that 
may induce hyperglycemia. Optimal glycemic control should be achieved before starting a patient 
on Everolimus. 
Table 11: Management of hyperlipidemia and hyperglycemia 
Adverse Drug Reaction 
Severity 
Afinitor Dose Adjustment and Management 
Recommendations 
Metabolic events 
(e.g. 
hyperglycemia, 
dyslipidemia) 
Grade 1 
No dose adjustment required. 
Initiate appropriate medical therapy and monitor. 
 
Grade 2 
No dose adjustment required. 
Manage with appropriate medical therapy and 
monitor. 
 
Grade 3 
Temporary dose interruption. 
Re-initiate Afinitor at lower dose. 
Manage with appropriate medical therapy and 
monitor. 
 
Grade 4 
Discontinue Afinitor and treat with appropriate 
medical therapy. 
 Management of non-infectious pneumonitis 
Non-infectious pneumonitis is a class effect of rapamycin derivatives. Cases of non-infectious 
pneumonitis (including interstitial lung disease) have also been described in patients taking 
Everolimus. Some of these have been severe and on rare occasions, a fatal outcome was 
observed. 
A diagnosis of non-infectious pneumonitis should be considered in patients presenting with non-
specific respiratory signs and symptoms such as hypoxia, pleural effusion, cough or dyspnea, 
and in whom infectious, neoplastic and other non-medicinal causes have been excluded by 
means of appropriate investigations. Opportunistic infections such as PJP should be ruled out in 
the differential diagnosis of non-infectious pneumonitis. Patients should be advised to report 
promptly any new or worsening respiratory symptoms. 
Patients who develop radiological changes suggestive of non-infectious pneumonitis and have 
few or no symptoms may continue Afinitor therapy without dose alteration. 
If symptoms are moderate (grade 2), consideration should be given to interruption of therapy until 
symptoms improve.  The use of corticosteroids may be indicated.  Afinitor may be reintroduced at 
a daily dose approximately 50% lower than the dose previously administered. 


 
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For cases of grade 3 non-infectious pneumonitis, interrupt Afinitor until resolution to less than or 
equal to grade 1.  Afinitor may be re-initiated at a daily dose approximately 50% lower than the 
dose previously administered depending on the individual clinical circumstances.  If toxicity recurs 
at grade 3, consider discontinuation of Afinitor.  For cases of grade 4 non-infectious pneumonitis, 
Afinitor therapy should be discontinued.  Corticosteroids may be indicated until clinical symptoms 
resolve. 
For patients who require use of corticosteroids for treatment of non-infectious pneumonitis, 
prophylaxis for pneumocystis jirovecii pneumonia (PJP) may be considered. The two compounds 
studied most extensively for prophylaxis against PJP have been trimethoprim-sulfamethoxazole, 
given orally, and pentamidine, given as an aerosol. 
If non-infectious pneumonitis develops, the guidelines in Table 12 should be followed. 
Consultation with a pulmonologist is recommended for any case of pneumonitis that develops 
during the study. 


 
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Table 12: Management of non-infectious pneumonitis 
Worst grade 
pneumonitis 
Suggested investigations 
Management of 
pneumonitis 
Everolimus dose adjustment 
Grade 1 
(Asymptomat
ic, 
radiographic 
findings only) 
CT scans with lung windows. 
No specific 
therapy is 
required 
No dose adjustment required.  
Initiate appropriate monitoring. 
Grade 2 
(Symptomati
c, not 
interfering 
with Activities 
of Daily 
Living) 
CT scan with lung windows. 
Consider pulmonary function 
testing includes: spirometry, 
DLCO, and room air O2 
saturation at rest. Consider a 
bronchoscopy with biopsy and/or 
BAL. Monitoring at each visit 
until return to ≤ grade 1. Return 
to initial monitoring frequency if 
no recurrence. 
Symptomatic 
only. Consider 
corticosteroids 
and/or other 
supportive 
therapy if 
symptoms are 
troublesome. 
Rule out infection and consider 
interruption of Everolimus until 
symptoms improve to Grade ≤ 
1. 
Re-initiate Everolimus at one 
dose level lower.  
Discontinue Everolimus if 
failure to recover within ≤ 28 
days. 
Grade 3 
(Symptomati
c, Interfering 
with Activities 
of Daily 
Living. 
O2 indicated 
CT scan with lung windows and 
pulmonary 
function 
testing 
includes: spirometry, DLCO, and 
room air O2 saturation at rest. 
Monitoring at each visit until 
return to ≤ grade 1. Return to 
initial monitoring frequency if no 
recurrence. Bronchoscopy with 
biopsy 
and/or 
BAL 
is 
recommended. 
Consider 
corticosteroids if 
infective origin is 
ruled out. Taper 
as 
medically 
indicated. 
Rule out infection and interrupt 
Everolimus until symptoms 
improve to Grade ≤ 1. 
Consider re-initiating 
Everolimus at one dose level 
lower (approximately 50% 
lower than the dose previously 
administered depending on 
individual clinical 
circumstances) 
Discontinue Everolimus if 
failure to recover within ≤ 28 
days. If toxicity recurs at Grade 
3, consider discontinuation 
Grade 
4 
(Life-
threatening, 
ventilator 
support 
indicated) 
CT scan with lung windows and 
required 
pulmonary 
function 
testing, if possible, includes: 
spirometry, DLCO, and room air 
O2 saturation at rest. Monitoring 
at each visit until return to ≤ 
grade 
1. 
Return 
to 
initial 
monitoring 
frequency 
if 
no 
recurrence. Bronchoscopy with 
biopsy 
and/or 
BAL 
is 
recommended if possible. 
Consider 
corticosteroids if 
infective origin is 
ruled out. Taper 
as 
medically 
indicated. 
Rule 
out 
infection 
and 
discontinue Everolimus. 
5.5.2 Management of hepatitis reactivation / flare 
Reactivation of Hepatitis B (HBV) has been observed in patients with cancer receiving 
chemotherapy.[65] Sporadic cases of Hepatitis B reactivation have also been seen in this setting 
with everolimus. Use of antivirals during anti-cancer therapy has been shown to reduce the risk of 
Hepatitis B virus reactivation and associated morbidity and mortality.[66] A detailed assessment 
of Hepatitis B/C medical history and risk factors must be done for all patients at screening, with 
testing performed prior to the first dose of everolimus.  
 Monitoring and prophylactic treatment for hepatitis B reactivation 


 
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Table 13 provides detail of monitoring and prophylactic therapy according to the screening results 
of viral load and serologic markers testing. 
Table 13: Action to be taken based on screening hepatitis B results 
Test 
Result 
Result 
Result 
Result 
Result 
HBV-DNA 
+ 
+ or - 
- 
- 
- 
HBsAg 
+ or - 
+ 
- 
- 
- 
HBsAb 
+ or - 
+ or - 
+ 
and no prior 
HBV vaccination 
+ or - 
- 
or + with prior 
HBV vaccination 
HBcAb 
+ or - 
+ or - 
+ or - 
+ 
- 
Recommendation 
Prophylaxis treatment 
should be started 1-2 
weeks prior to first dose of 
Everolimus 
 
Monitor HBV-DNA 
approximately every 4-8 
weeks 
 
 
No prophylaxis 
 
Monitor HBV-DNA 
approximately every 3-4 weeks  
No specific 
action 
Antiviral prophylaxis therapy should continue for at least 4 weeks after last dose of Everolimus. 
For HBV reactivation definition and management guidelines, see Table 14. 


 
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Table 14: Guidelines for the management of hepatitis B reactivation 
HBV reactivation (with or without clinical signs and symptoms)* 
For patients with baseline 
results:  
Positive HBV-DNA 
OR 
positive HBsAg 
-------------------------------------- 
reactivation is defined as: 
[Increase of 1 log in HBV-
DNA relative to baseline 
HBV-DNA value OR new 
appearance of measurable 
HBV-DNA] 
 
Treat: Start a second antiviral medication 
AND 
Interrupt Everolimus administration until resolution:  
• 
≤ baseline HBV-DNA levels 
If resolution occurs within ≤ 28 days, Everolimus should be re-
started at one dose lower, if available. (see Table 7 for dose levels 
available) If the patient is already receiving the lowest dose of 
Everolimus according to the protocol, the patient should restart at the 
same dose after resolution. Both antiviral therapies should continue at 
least 4 weeks after last dose of Everolimus.  
If resolution occurs > 28 days Patients should discontinue Everolimus 
but continue both antiviral therapies at least 4 weeks after last dose of 
Everolimus. 
For patients with baseline 
results: 
Negative HBV-DNA and 
HBsAg 
AND 
[Positive HBsAg (with no 
prior history of vaccination 
against HBV), OR positive 
HBcAb] 
------------------------------------- 
Reactivation is defined as: 
New appearance of 
measurable HBV-DNA 
Treat : Start first antiviral medication 
AND 
Interrupt Everolimus administration until resolution: 
• 
≤ undetectable (negative) HBV-DNA levels 
If resolution occurs within ≤ 28 days, Everolimus should be re-
started at one dose lower, if available (see Table 7 for dose levels 
available). If the patient is already receiving the lowest dose of 
Everolimus according to the protocol, the patient should restart at the 
same dose after resolution. Antiviral therapy should continue at least 4 
weeks after last dose of Everolimus. 
If resolution occurs > 28 days Patients should discontinue 
Everolimus but continue antiviral therapy at least 4 weeks after last 
dose of Everolimus. 
* All reactivations of HBV are to be recorded as grade 3 (e.g. CTCAE Version 3.0 - Investigations/Other: Viral 
Reactivation), unless considered life threatening by the investigator, in which case they should be recorded as grade 4. Date 
of viral reactivation is the date on which the rise or reappearance of HBV-DNA was recorded. 
 
 
 Monitoring for hepatitis C flare 
The following two categories of patients should be monitored every 4–8 weeks for HCV flare: 
• 
Patients with detectable HCV RNA-PCR test at screening. 
• 
Patients known to have a history of HCV infection, despite a negative viral load test at 
screening (including those that were treated and are considered ‘cured’) 
For definitions of HCV flare and actions to be taken in the event of a flare, please refer to Table 
15.  


 
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Table 15 Guidelines for the management of hepatitis C flare 
Baseline results 
HCV flare definition* 
HCV flare management 
Detectable HCV-RNA 
 
> 2 log10 IU/mL increase in HCV-RNA 
AND 
ALT elevation > 5 x ULN or 3 x baseline 
level, whichever is higher. 
Discontinue Everolimus 
Knowledge of past hepatitis C 
infection with no detectable 
HCV-RNA 
New appearance of detectable HCV-RNA 
AND 
ALT elevation > 5 x ULN or 3 x baseline 
level, whichever is higher. 
Discontinue Everolimus 
* All flares of HCV are to be recorded as grade 3 (e.g. CTCAE Version 3.0 - Investigations - Other: 
Viral Flare), unless considered life threatening by the investigator; in which case they should be 
recorded as grade 4. Date of viral flare is the date on which both the clinical criteria described above 
were met. (e.g., for a patient whose HCV-RNA increased by 2 logs on 01 JAN 2011 and whose ALT 
reached > 5 x ULN on 22 JAN 2011, the date of viral flare is 22 JAN 2011). 
 
6. Concomitant medications 
Patients must be instructed not to take any medications (over-the-counter or other products) 
during the protocol treatment period without prior consultation with the investigator. The 
investigator should instruct the patient to notify the study site about any new medications he/she 
takes after the start of study drug. All medications (other than study drug) and significant non-
drug therapies (including physical therapy and blood transfusions) taken within 28 days of starting 
study treatment through the 30-day safety follow up visit should be reported in the patient’s EMR. 
6.1 Permitted concomitant therapy 
All supportive measures consistent with optimal patient care should be given throughout the 
study. Exceptions include the use of erythropoietin to treat therapy induced anemia and use of 
myeloid growth factor support to treat neutropenia while taking everolimus. If everolimus is held 
for neutropenia, myeloid growth factors in the form of either GCSF or pegylated GCSF can be 
administered beginning on either day 2 or 3 of each cycle. The use of growth factor support 
should follow ASCO guidelines. 
6.2 Cytochrome P450 and P-glycoprotein inhibitors/inducers/substrates 
Co-administration with strong inhibitors of CYP3A4 or PgP should be avoided; and may cause 
increased everolimus concentrations. For a current table of Substrates, Inhibitors and Inducers 
please access the following website: 
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteraction
sLabeling/ucm093664.htm  
Everolimus is metabolized by CYP3A4 in the liver and to some extent in the intestinal wall. 
Therefore, the following are recommended: 
• 
Co-administration with strong inhibitors of CYP3A4 (e.g., ketoconazole, itraconazole, 
ritonavir) or P-glycoprotein (PgP) inhibitor should be avoided. 
• 
Co-administration with moderate CYP3A4 inhibitors (e.g., erythromycin, fluconazole) or PgP 
inhibitors should be used with caution. If a patient requires co-administration of moderate 
CYP3A4 inhibitors or PgP inhibitors, reduce the dose of everolimus by approximately 50%. 
Additional dose reductions to every other day may be required to manage toxicities. If the 
inhibitor is discontinued, the Everolimus dose should be returned to the dose used prior to 
initiation of the moderate CYP3A4/PgP inhibitor after a washout period of 2 to 3 days. 


 
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• 
TSC with SEGA: Everolimus trough concentrations should be assessed approximately 2 
weeks after the addition of a moderate CYP3A4/PgP inhibitor. If the inhibitor is discontinued 
the Afinitor dose should be returned to the dose used prior to initiation of the inhibitor and the 
everolimus trough concentration should be re-assessed approximately 2 weeks later. 
• 
Grapefruit, Seville oranges, and starfruit affect P450 and PgP activity. Concomitant use 
should be avoided. 
• 
If patients require co-administration of a strong CYP3A4 inducer, consider doubling the daily 
dose of Afinitor (based on pharmacokinetic data), using increments of 5 mg or less. This dose 
of Afinitor is predicted to adjust the AUC to the range observed without inducers. However, 
there are no clinical data with this dose adjustment in patients receiving strong CYP3A4 
inducers. If the strong inducer is discontinued, consider a washout period of at least 3 to 5 
days (reasonable time for significant enzyme de-induction), before the Afinitor dose is 
returned to the dose used prior to initiation of the strong CYP3A4 inducer. 
• 
TSC with SEGA Patients receiving concomitant strong CYP3A4 inducers (e.g., the enzyme 
inducing antiepileptic drugs carbamazepine, phenobarbital, and phenytoin) may require an 
increased Afinitor dose to attain trough concentrations of 3 to 15 ng/mL. Double the daily 
dose of Afinitor and assess tolerability. Assess the everolimus trough level two weeks after 
doubling the dose. Further adjust the dose if necessary to maintain the trough within the 3 to 
15 ng/mL range. If the strong inducer is discontinued, the Afinitor dose should be returned to 
the dose used prior to initiation of the strong CYP3A4 inducer and the everolimus trough 
concentrations should be assessed approximately 2 weeks later. 
• 
This dose adjustment of Everolimus is intended to achieve similar AUC to the range observed 
without inducers. However, there are no clinical data with this dose adjustment in patients 
receiving strong CYP3A4 inducers. If the strong inducer is discontinued the Everolimus dose 
should be returned to the dose used prior to initiation of the strong CYP3A4/PgP inducer. 
Please refer to Table 16 listing relevant inducers and inhibitors of CYP3A and Table 17 for a list 
of relevant substrates, inducers, and inhibitors of PgP. 
Table 16 Clinically relevant drug interactions: inducers, and inhibitors of isoenzyme 
CYP3A 
Inducers 
Strong inducers: 
avasimibe, carbamazepine, mitotane, phenobarbital, phenytoin, rifabutin, rifampin (rifampicin), St. 
John's wort 
(hypericum perforatum) 
Moderate inducers: 
bosentan, efavirenz, etravirine, genistein, modafinil, nafcillin, ritonavir, [talviraline], thioridazine, 
tipranavir 
Weak inducers: 
amprenavir, aprepitant, armodafinil (R-modafinil), bexarotene, clobazam, danshen, dexamethasone, 
Echinacea, 
garlic (allium sativum), gingko (ginkgo biloba), glycyrrhizin, methylprednisolone, nevirapine, 
oxcarbazepine, 
pioglitazone, prednisone, [pleconaril], primidone, raltegravir, rufinamide, sorafenib, telaprevir, 
terbinafine, 
topiramate, [troglitazone] , vinblastine 


 
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Inhibitors 
Strong inhibitors: 
boceprevir, clarithromycin, cobicistat, conivaptan, elvitegravir, indinavir, itraconazole, ketoconazole, 
lopinavir, 
mibefradil, nefazodone, nelfinavir, posaconazole [67], ritonavir, saquinavir, telaprevir, 
telithromycin, tipranavir, troleandamycin, voriconazole 
Moderate inhibitors: 
Amprenavir, aprepitant, atazanavir, casopitant, cimetidine, ciprofloxacin, cyclosporine, darunavir, 
diltiazem, 
dronedarone, erythromycin, fluconazole, fosamprenavir, grapefruit juice (citrus parasidi fruit juice), 
imatinib, 
schisandra sphenanthera, tofisopam, verapamil 
Table 17: Clinically relevant drug interactions: substrates, inducers, inhibitors of PgP and 
PgP/CYP3A dual inhibitors 
 
Substrates 
colchicine, digoxin, fexofenadine, indinavir, paclitaxel, talinolol, topotecan, vincristine, everolimus 
Inducers 
rifampin, St John’s wort 
PgP Inhibitors and PgP/CYP3A Dual Inhibitors 
amiodarone, azithromycin, captopril, carvedilol, clarithromycin, conivaptan, diltiazem, dronedarone, 
elacridar, 
erythromycin, felodipine, fexofenadine, fluvoxamine, ginkgo (ginkgo biloba), indinavir, itraconazole, 
lopinavir, 
mibefradil, milk thistle (silybum marianum), nelfinavir, nifedipine, nitrendipine, paroxetine, quercetin, 
quinidine, 
ranolazine, rifampin, ritonavir, saquinavir, Schisandra chinensis, St John’s wort (hypericum 
perforatum), talinolol, 
Telaprevir, telmisartan, ticagrelor, tipranavir, tolvaptan, valspodar, verapamil 
Reference: Internal Clinical Pharmacology Drug-drug interaction (DDI) memo, updated Oct. 2, 
2011,29-Oct-2012 
which summarizes DDI data from three sources including the FDA’s “Guidance for Industry, Drug 
Interaction 
Studies”, the University of Washington’s Drug Interaction Database, and Indiana University School of 
Medicine's 
Drug Interaction Table. 
 
6.3 Everolimus and drugs influencing CYP3A4 enzyme 
Everolimus is a substrate of CYP3A4, and a substrate and moderate inhibitor of the multidrug 
efflux pump, PgP (PgP, MDR1, and ABCB1). Therefore, extent of absorption and subsequent 
elimination of systemically absorbed everolimus may be influenced by products that are 
substrates, inhibitors, or inducers of CYP3A4 and/or PgP. Concurrent treatment with strong 
CYP3A4-inhibitors should be avoided. Refer to Table 16 for a comprehensive list of inducers and 
inhibitors of CYP3A4 and Table 17 for a list of relevant substrates, inducers and inhibitors of PgP. 
Inhibitors of PgP may decrease the efflux of everolimus from brain or tumor and therefore 
increase everolimus concentrations in these tissues. In vitro studies showed that everolimus is a 
competitive inhibitor of CYP3A4 and of CYP2D6, potentially increasing the concentrations of 
products eliminated by these enzymes. Thus, caution should be exercised when co-administering 
everolimus with CYP3A4 and CYP2D6 substrates with a narrow therapeutic index. Clinical 
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between everolimus and potential CYP3A modifiers (ketoconazole, verapamil, erythromycin, 
rifampin, midazolam, and HMGCoA reductase inhibitors (statins).  
6.4 Vaccinations 
Immunosuppressants may affect the response to vaccination and vaccination during treatment 
with Everolimus may therefore be less effective. The use of live vaccines should be avoided 
during treatment with Everolimus. For pediatric patients with SEGA that do not require immediate 
treatment, complete the recommended childhood series of live virus vaccinations prior to the start 
of therapy according to local treatment guidelines. Examples of live vaccines are: intranasal 
influenza, measles, mumps, rubella, oral polio, BCG, yellow fever, varicella, and TY21a typhoid 
vaccines. 
6.5 Prohibited concomitant therapy 
The concomitant use of therapeutic doses of anticoagulation is prohibited during treatment with 
bevacizumab. Patients requiring therapeutic doses of anticoagulation should discontinue 
bevacizumab, but may be allowed to continue liposomal doxorubicin and everolimus. The use of 
prophylactic anticoagulation is allowed, but indication must be carefully considered due to the risk 
of bleeding associated with bevacizumab administration.  
Growth factors should not be used for the treatment of anemia or thrombocytopenia as such use 
has been associated with decreased survival and increased thrombotic events in patients with 
breast cancer. 
7. Reporting of Adverse Events 
Definitions and reporting 
7.1 Adverse Events 
Adverse events that begin or worsen after informed consent should be recorded in the Adverse 
Events CRF. Conditions that were already present at the time of informed consent should be 
recorded in the Medical History page of the patient’s CRF. Adverse event monitoring should be 
continued for at least 30 days (or 5 half-lives, whichever is longer) following the last dose of study 
treatment. Adverse events (including lab abnormalities that constitute AEs) should be described 
using a diagnosis whenever possible, rather than individual underlying signs and symptoms. 
When a clear diagnosis cannot be identified, each sign or symptom should be reported as a 
separate Adverse Event. 
The occurrence of adverse events should be sought by non-directive questioning of the patient at 
each visit during the study. Adverse events also may be detected when they are volunteered by 
the patient during or between visits or through physical examination, laboratory test, or other 
assessments. As far as possible, each adverse event should be evaluated to determine: 
1. The severity grade (CTCAE Grade 1-4) 
2. Its duration (Start and end dates or if continuing at the Safety Follow-up Visit) 
3. Its relationship to the study treatment (Reasonable possibility that AE is related: No, Yes)  
4. Action taken with respect to study or investigational treatment (none, dose adjusted, 
temporarily interrupted, permanently discontinued, hospitalized, unknown, not applicable) 
5. Whether medication or therapy was given (no concomitant medication/non-drug therapy, 
concomitant medication/non-drug therapy) 
6. Outcome 
(not 
recovered/not 
resolved, 
recovered/resolved, 
recovering/resolving, 
recovered/resolved with sequela, fatal, unknown) 
7. Whether it is serious, where a serious adverse event (SAE) is defined as in the Serious 
Adverse Events subsection. 
All adverse events should be treated appropriately. Such treatment may include changes in study 
drug treatment including possible interruption or discontinuation, starting or stopping concomitant 
treatments, changes in the frequency or nature of assessments, hospitalization, or any other 
medically required intervention. Once an adverse event is detected, it should be followed until its 
resolution, and assessment should be made at each visit (or more frequently, if necessary) of any 
changes in severity, the suspected relationship to the study drug, the interventions required to 
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Information about common side effects already known about the investigational drug can be 
found in the [Investigators’ Brochure] and below. This information should be included in the 
patient informed consent and should be discussed with the patient during the study as needed. 
Adverse event monitoring should be continued for at least 30 days following the last dose of study 
treatment 
Laboratory test abnormalities 
Laboratory abnormalities that constitute an Adverse event in their own right (are considered 
clinically significant, induce clinical signs or symptoms, require concomitant therapy or require 
changes in study treatment), should be recorded on the Adverse Events CRF. Whenever 
possible, a diagnosis, rather than a symptom should be provided (e.g. anemia instead of low 
hemoglobin). Laboratory abnormalities that meet the criteria for Adverse Events should be 
followed until they have returned to normal or an adequate explanation of the abnormality is 
found. When an abnormal laboratory or test result corresponds to a sign/symptom of an already 
reported adverse event, it is not necessary to separately record the lab/test result as an additional 
event. 
Laboratory abnormalities, that do not meet the definition of an adverse event, should not be 
reported as adverse events. A Grade 3 or 4 event (severe) as per CTCAE does not automatically 
indicate a SAE unless it meets the definition of serious as defined below and/or as per 
investigator’s discretion. A dose hold or medication for the lab abnormality may be required by the 
protocol and is still, by definition, an adverse event. 
 
7.2 Serious Adverse Events 
A serious adverse event is an undesirable sign, symptom or medical condition which: 
• 
is fatal or life-threatening 
• 
results in persistent or significant disability/incapacity 
• 
constitutes a congenital anomaly/birth defect 
• 
requires inpatient hospitalization or prolongation of existing hospitalization, unless 
hospitalization is for: 
• 
routine treatment or monitoring of the studied indication, not associated with any deterioration 
in condition (specify what this includes) 
• 
elective or pre-planned treatment for a pre-existing condition that is unrelated to the indication 
under study and has not worsened since the start of study drug 
• 
treatment on an emergency outpatient basis for an event not fulfilling any of the definitions of 
a SAE given above and not resulting in hospital admission 
• 
social reasons and respite care in the absence of any deterioration in the patient’s general 
condition 
• 
is medically significant, i.e., defined as an event that jeopardizes the patient or may require 
medical or surgical intervention to prevent one of the outcomes listed above 
Reporting 
The principal investigator has the obligation to report all serious adverse events to the FDA and 
IRB. If the SAE is deemed definitely, probably or possibly related to everolimus, the investigator is 
obligated to notify Novartis Pharmaceuticals Drug Safety and Epidemiology Department (DS&E) . 
 
All events reported to the FDA by the investigator are to be filed utilizing the Form FDA 3500A 
(MedWatch Form).  
 
To ensure patient safety, every SAE, regardless of suspected causality, occurring 
• 
after the patient has provided informed consent and until at least 30 days after the patient has 
stopped study treatment/participation 
• 
after protocol-specified procedures begin (e.g., placebo run-in, washout period, double-blind 
treatment, etc.) and 30 days after the patient has stopped study treatment 
• 
after the start of any period in which the study protocol interferes with the standard medical 
treatment given to a patient (e.g., treatment withdrawal during washout period, change in 


 
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treatment to a fixed dose of concomitant medication) and until 30 days after the patient has 
stopped study treatment 
 
must be reported to Novartis within 24 hours of learning of its occurrence (fax: 877-778-9739). 
This includes serious, related, labeled (expected) and serious, related, unlabeled (unexpected) 
adverse experiences. All deaths during treatment or within 30 days following completion of active 
protocol therapy must be reported within 5 working days. 
 
Any SAEs experienced after this 30 days period should only be reported to Novartis if the 
investigator suspects a causal relationship to the study drug. Recurrent episodes, complications, 
or progression of the initial SAE must be reported as follow-up to the original episode within 24 
hours of the investigator receiving the follow-up information. A SAE occurring at a different time 
interval or otherwise considered completely unrelated to a previously reported one should be 
reported separately as a new event.  The end date of the first event must be provided. 
 
The original copy of the SAE Report and the fax confirmation sheet must be kept within the Trial 
Master File at the study site. 
 
Follow-up information is sent to the same fax number as the original SAE Report Form was sent, 
using a new fax cover sheet, stating that this is a follow-up to the previously reported SAE, and 
giving the date of the original report. Each re-occurrence, complication, or progression of the 
original event should be reported as a follow-up to that event regardless of when it occurs. The 
follow-up information should describe whether the event has resolved or continues, if and how it 
was treated, whether the blind was broken or not (if applicable), and whether the patient 
continued or withdrew from study participation. 
 
If the SAE is not previously documented in the Everolimus Investigator Brochure or Package 
Insert (new occurrence) and is thought to be related to the Novartis study drug, a DS&E associate 
may urgently require further information from the investigator for Health Authority reporting. 
Novartis may need to issue an Investigator Notification (IN), to inform all investigators involved in 
any study with the same drug that this SAE has been reported. Suspected Unexpected Serious 
Adverse Reactions (SUSARs) will be collected and reported to the competent authorities and 
relevant ethics committees in accordance with Directive 2001/20/EC or as per national regulatory 
requirements in participating countries. 
 
For Comparator Drugs/Secondary Suspects (Concomitant Medications), all serious adverse 
experiences will be forwarded to the comparator drug company by the investigator. 
 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. All events 
occurring during the conduct of a protocol and meeting the definition of a SAE must be reported 
to the IRB in accordance with the timeframes and procedures outlined in “University of Texas M. 
D. Anderson Cancer Center Institutional Review Board Policy on Reporting Serious Adverse 
Events”.  Unless stated otherwise in the protocol, all SAEs, expected or unexpected, must be 
reported to ORERM, regardless of attribution (within 5 working days of knowledge of the event). 
All life-threatening or fatal events, expected or unexpected, and regardless of attribution to the 
study drug, must have a written report submitted within 24 hours (next working day) of knowledge 
of the event to the Safety Project Manager in ORERM. The MDACC “Internal SAE Report Form 
for Prompt Reporting” will be used for reporting to ORERM. Serious adverse events will be 
captured from the time the patient signs consent until 30 days after the last dose of drug. Serious 
adverse events must be followed until clinical recovery is complete and laboratory tests have 
returned to baseline, progression of the event has stabilized, or there has been acceptable 
resolution of the event. Serious adverse events will be forwarded to FDA by the Safety Project 
Manager ORERM according to 21 CFR 312.32. 


 
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7.3 Pregnancy 
Preclinical data regarding reproductive toxicity is described in the most recent Investigator 
Brochure. The potential reproductive risk for humans is unknown.  Women of childbearing 
potential should be advised to use highly effective contraception methods while they are receiving 
everolimus and up to 8 weeks after treatment has been stopped.   
To ensure patient safety, each pregnancy occurring while the patient is on study treatment must 
be reported to Novartis within 24 hours of learning of its occurrence. The pregnancy should be 
followed up to determine outcome, including spontaneous or voluntary termination, details of the 
birth, and the presence or absence of any birth defects, congenital abnormalities, or maternal 
and/or newborn complications. The newborn will be followed for at least 12 months. 
Pregnancy should be recorded on a Clinical Trial Pregnancy Form and reported by the 
investigator to the oncology Novartis Drug Safety and Epidemiology Department (DS&E). 
Pregnancy follow-up should be recorded on the same form and should include an assessment of 
the possible relationship to the study treatment and any pregnancy outcome. Any SAE 
experienced during pregnancy must be reported on the SAE Report Form. 
 
7.4. Duration of Therapy  
Patients will receive protocol therapy unless: 
▪ 
Patient experiences unacceptable drug toxicity.  
▪ 
Patient withdraws consent. 
▪ 
Patient has progression of disease as defined in section 9.0.2 
▪ 
The patient completes the required 4 cycles of therapy. 
Duration of Follow-up  
For this protocol, all patients, including those who discontinue protocol therapy early, will be 
followed until 1 month after surgical resection of the tumor.  Date of last follow up clinic visit 
should be within 30 days (+/- 10 days) of surgical resection. Investigators also collect data on 
recurrence 2 years after surgical resection of the tumor. 
Protection of human subjects 
All current FDA, NCI, state federal and institutional regulations concerning informed consent will 
be followed.  
In order to protect confidential patient information, all study participants will be assigned a study 
ID number.  Specimens will be assigned a separate specimen ID number.  All study information 
will be stored in locked file cabinets and in password-protected computer files.  Only authorized 
study personnel will have access to these files. 
 
 
 
 
8. Scheduled evaluations 
 
 


 
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8.0 Study Calendar: 
 
 
8.1 Pretreatment Evaluation  
• 
History and physical examination.  
• 
Laboratory studies: CBC with differential, sodium, potassium, chloride, bicarbonate, BUN, 
creatinine, glucose, calcium, magnesium, albumin, alkaline phosphatase, total bilirubin, 
SGOT [AST], SGPT [ALT], Cholesterol, Triglycerides.  
• 
Urinalysis includes analysis (protein, glucose, ketones, blood, and specific gravity).  
• 
Urine pregnancy test (WOCBP). 


 
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• 
Viral Screening: HBV-DNA, HBsAb, HBsAg, HBcAb, HCV-Ab, HCV-RNA for patients with 
known Hepatitis B or C, or patients who fall into the potential risk category, or at the 
physician’s discretion. 
• 
Radiologic evaluation of measurable disease within 4 weeks prior to start of treatment.  
• 
Patient must sign IRB-approved informed consent prior to any study-specific procedures 
unless such procedures are part of the standard of care. 
8.2 Evaluation during Study  
▪ 
Physical examination (including vital signs, weight, performance status): on day 1 of (or 
up to 3 days prior to) each treatment cycle.  
▪ 
CBC with differential, sodium, potassium, chloride, bicarbonate, BUN, creatinine, 
glucose, calcium, magnesium, albumin, alkaline phosphatase, total bilirubin, ALT, 
AST, urine pregnancy test within 48 hours prior to starting each cycle of therapy. 
▪ 
Blood pressure and urinalysis for evidence of proteinuria within 48 hours of starting each 
cycle of therapy. 
▪ 
Patients will undergo repeat imaging, +/- 7 days, (mammogram, ultrasound and/or MRI, 
as clinically indicated) of the involved breast and axillary nodal basin as standard of 
care prior to surgical resection (after 4 cycles of therapy) or at the time of clinically 
suspected disease progression. 
8.3 Pregnancy and assessments of fertility 
There are no adequate data from the use of everolimus in pregnant women. Studies in animals 
have shown reproductive toxicity effects including embryo-toxicity and feto-toxicity. The potential 
risk for humans is unknown. Everolimus should not be given to pregnant women unless the 
potential benefit outweighs the potential risk to the fetus. If a pregnancy occurs while on study 
treatment, the newborn will be followed for at least 12 months. 
It is not known whether everolimus is excreted in breast milk. However, in animal studies 
everolimus and/or its metabolites readily passed into the milk of lactating rats. Women taking 
everolimus should therefore not breast-feed. 
Women of child-bearing potential, defined as all women physiologically capable of becoming 
pregnant, must use highly effective contraception during the study and for 8 weeks after stopping 
treatment. Highly effective contraception is defined as either: 
• 
Total abstinence: When this is in line with the preferred and usual lifestyle of the subject. 
[Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and 
withdrawal are not acceptable methods of contraception] 
• 
Sterilization: have had surgical bilateral oophorectomy (with or without hysterectomy) or tubal 
ligation at least six weeks before starting study treatment. In case of oophorectomy alone, 
only when the reproductive status of the woman has been confirmed by follow up hormone 
level assessment 
• 
Male partner sterilization (with the appropriate post-vasectomy documentation of the absence 
of sperm in the ejaculate). [For female subjects on the study, the vasectomised male partner 
should be the sole partner for that subject]. 
• 
Use of a combination of any two of the following (a+b, or a+c, or b+c): 
a. Use of oral, injected, implanted or other hormonal methods of contraception 


 
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b. Placement of an intrauterine device (IUD) or intrauterine system (IUS) 
c. Barrier methods of contraception: Condom or Occlusive cap (diaphragm or 
cervical/vault caps) with spermicidal foam/gel/film/cream/vaginal suppository 
• 
In case of use of oral contraception, women should have been stable on the oral agent before 
taking study treatment. 
8.4 Male Contraception 
• 
Sexually active males must use a condom during intercourse while taking the drug and for 8 
weeks after stopping treatment and should not father a child in this period. 
• 
A condom is required to be used also by vasectomised men in order to prevent delivery of the 
drug via seminal fluid. 
• 
Female partners of male patients must also be advised to use one of the following 
contraception methods: Use of (1) oral, injected, implanted or other hormonal methods of 
contraception, or (2) intrauterine device (IUD) or intrauterine system (IUS), or (3) prior 
male/female sterilization. 
8.5 Fertility 
The potential for everolimus to cause infertility in male and female patients is unknown. However, 
menstrual irregularities, secondary amenorrhea and associated luteinizing hormone (LH)/follicle 
stimulating hormone (FSH) imbalance has been observed. Based on non-clinical findings, male 
and female fertility may be compromised by treatment with everolimus. 
 
9. Measurement of Effect 
9.0.1 Pathologic response 
The RCB is a continuous variable derived from the primary tumor dimensions, cellularity of the 
tumor bed, and axillary nodal burden. RCB can be divided into four classes (RCB-0 to RCB-III) 
and will be collected as part of the study. 
 
RCB-0 (pCR), Minimal RCB (RCB-I), Moderate RCB (RCB-II), and Extensive RCB (RCB-III) 
 
The following parameters are required from pathologic examination in order to calculate 
Residual Cancer Burden (RCB) after neoadjuvant treatment: 
 
▪ 
The largest two dimensions (mms) of the residual tumor bed in the breast (largest tumor 
bed if multicentric disease) 
 
▪ 
Submission of the entire largest cross-sectional area of the residual tumor bed for 
histologic mapping, with specific identification of those slides in the pathology report (e.g. 
"the largest cross-sectional area of primary tumor bed was submitted in cassettes A5 - 
A9") 
 
▪ 
If the residual tumor is large (i.e. largest diameter > 5 cm), then at least 5 representative 
cassettes from the largest cross-sectional area are sufficient, but should be identified in 
the original pathology report (e.g. "representative sections from the largest cross- 
sectional area of primary tumor bed were submitted in cassettes A5 - A9") 
 
▪ 
Histologic assessment of the percentage of the tumor bed area that contains carcinoma 
(all carcinoma, i.e. invasive and in situ), select one of the following: 
 
o 
0%, 1%, 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% 
 


 
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▪ 
To assess cellularity it is helpful to scan across the sections of tumor bed and then 
estimate the average cellularity from the different microscopic fields. 
 
▪ 
When estimating percentage cancer cellularity in any microscopic field, compare the 
involved area with obvious standards, e.g. more or less than half, one quarter, one fifth, 
one tenth, one twentieth, etc. 
 
▪ 
Expect there to be variable cellularity within the cross section of any tumor bed, but 
estimate the overall cellularity from the average of the estimates in different microscopic 
fields of the tumor bed. 
 
o 
e.g. if cellularity in different fields of the tumor bed were estimated as 20%, 10%, 
20%, 0%, 20%, 30%, then an average estimate of overall cellularity would be 
20%. 
 
▪ 
Histologic estimate of the percentage of the carcinoma in the tumor bed that is in situ, 
select one of the following: 
 
o 
0%, 1%, 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100% 
 
▪ 
The number of positive (metastatic) lymph nodes 
 
▪ 
The largest diameter (mm) of the largest nodal metastasis 
 
9.0.2 Radiographic Imaging 
Radiographic criteria of response will be based on the on regional ultrasound examination 
(decrease in size of the primary tumor and/or fatty replacement in regional lymph nodes) 
▪ 
A decrease in size of the product of the two largest dimensions should =/> 50% will be 
considered a partial response. 
▪ 
Complete disappearance of the primary tumor by physical exam and or ultrasound and 
normalization of the lymph nodes by ultrasound will be considered a complete clinical 
response. 
▪ 
Progression of disease will be defined as 30% increase in the size of the primary tumor 
and/or lymph nodes by ultrasound. 
 
    9.2 Correlative Studies 
All molecular correlative studies will involve molecular profiling data generated through biopsy of 
the primary breast tumor and profiled within the existing BMO molecular triaging protocol that is 
currently IRB approved (MDACC 2014-0185), for patients who participated on that trial. Potential 
biomarkers of response will be correlated with pathologic response to DAE using appropriate 
statistical analyses for the biomarker of interest (see Section 9). 
9.3Statistical Considerations 
9.3.1   Primary/Secondary Objectives: 
This is a non-randomized open label phase II study. Counting pCR (RCB-0) or RCB-I as 
response, a two-stage Gehan-type design will be employed with 14 patients in the first stage. If at 
least one patient responds, 23 more patients will be added for a total of 37 patients. This design 
has a 49% chance of terminating after the first stage if the true response rate is 0.05, 23% 
chance if the true rate is 0.10, 10% if the true rate is 0.15 and 4% if the true rate is 0.20. If accrual 


 
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continues to the second stage and a total of 37 patients are enrolled, the 95% confidence interval 
for a 0.20 response rate will extend from 0.10 to 0.35. For patients who complete 4 cycles of 
DAE, the proportion of patients with pCR (RCB-0) or RCB-I as the response rate along with a 
Wilson (score) 95% confidence interval (CI) will be estimated.  
Radiographic response rate (partial response + complete clinical response) will be estimated, and 
reported with a 95% CI. 
Toxicity will be measured according to CTCAE v4.0.  Adverse events and serious adverse events 
will be summarized in order of prevalence, with the highest grade experienced by each patient 
reported for each adverse event.   
PFS will be estimated using the Kaplan-Meier method from the date of enrollment onto this study 
until the date of progression or death without evidence of progression. Patients alive and disease-
free at the latest clinical evaluation will be censored for PFS at the date of that evaluation. PFS 
will be reported with a 95% CI. 
9.3.2 Correlative Studies: 
Potential biomarkers of response will be correlated with pathologic response to DAE (this 
protocol) versus paclitaxel, using appropriate statistical analyses for the biomarker of interest.  
It is anticipated that mesenchymal gene signatures currently under development may predict 
response to therapy and response will be correlated in tumors categorized as mesenchymal 
using these signatures. 
Similarly, it is anticipated that vimentin staining will also be correlated with response. Protein 
expression will be graded 0, 1+, 2+ or 3+ by IHC by a single collaborating pathologist. Degree of 
expression will then be correlated with presence of mesenchymal signatures as well as response 
to therapy. 
Presence of mutations in PIK3CA, PTEN and NF2 will also be correlated with response. Further, 
multivariate logistic regression models will be fitted to the data that include three explanatory 
variables; namely dichotomous variables for treatment (DAE vs paclitaxel), gene mutation, and 
the interaction.  The interaction will be examined to investigate if the relationship between gene 
mutation status and pathologic response (RCB-0 or 1) is different for the two treatments. We are 
interested in fitting three such models; specifically, one for mutations PIK3CA, PTEN and NF2 
10. Protocol amendments, or changes in study conduct 
Any change or addition (excluding administrative) to this protocol requires a written protocol 
amendment that must be reviewed by Novartis and the investigator before implementation. 
Amendments significantly affecting the safety of subjects, the scope of the investigation or the 
scientific quality of the study require additional approval by the IRB at each study center.  A copy 
of the written approval of the IRB must be provided to Novartis. Examples of amendments 
requiring such approval are: 
1. increases in drug dose or duration of exposure of subjects, 
2. significant changes in the study design (e.g. addition or deletion of a control group), 
3. increases in the number of invasive procedures, 
4. additions or deletions of a test procedure required for monitoring of safety. 
These requirements for approval should in no way prevent any immediate action from being 
taken by the investigator or by Novartis in the interests of preserving the safety of all patients 
included in the trial.  If an immediate change to the protocol is felt to be necessary by the 
investigator and is implemented for safety reasons Novartis must be notified and the IRB at the 
center must be informed immediately.   Amendments affecting only administrative aspects of the 
study do not require formal protocol amendments or IRB approval but the IRB must be kept 
informed of such administrative changes. Examples of administrative changes not requiring 
formal protocol amendments and IRB approval include: 
1. 
changes in the staff used to monitor trials  
2. 
minor changes in the packaging or labeling of study drug. 


 
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