Conditions: NSCLC Stage IIIA (N2)
Keywords: Neoadjuvant Stage IIIA (N2) Cisplatin Gemcitabine Bevacizumab Non-Small Cell Lung Cancer NSCLC
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 7
Healthy volunteers: no

Brief summary:
Background:

* Surgical resection is the treatment of choice for patients with lung cancer, and cure after resection generally depends on whether lymph nodes are involved. A patient with Stage IIIA (N2) lung cancer has cancer in the lymph nodes involving the center of the chest (mediastinum).
* Studies have shown that surgery alone as a treatment for Stage IIIA (N2) lung cancer is not as effective as chemotherapy followed by surgery.
* Giving chemotherapy upfront may prevent the spread of Stage IIIA (N2) lung cancer tumors, and may shrink the tumors to allow adequate surgery to be performed. It is also thought that chemotherapy is usually better tolerated before major surgery than after, so higher doses can be given.

Objectives:

* To determine the effectiveness of the combination of three anti-cancer drugs (gemcitabine, cisplatin, and bevacizumab) given before surgery.
* To find out what effects this drug combination may have on the patient and the cancer.
* To determine if the combination of all three drugs given prior to surgery is more effective and as safe, safer, or less safe than other drug combinations given before surgery.

Eligibility:

* Patients with Stage IIIA (N2) lung cancer who have not had chemotherapy, radiation, or surgery to treat the cancer.

Design:

* Evaluations before the treatment period to determine eligibility:
* Physical examination, including vital signs and body weight checks, and pregnancy test for women who can become pregnant.
* Tests to evaluate heart and lung function, such as an echocardiogram.
* Blood and urine tests.
* Disease evaluation with computed tomography (CT), chest X-ray, positron emission tomography (PET) scans, and bronchoscopy/mediastinoscopy (examinations of the inside of the chest and lungs).
* Treatment with intravenous gemcitabine, cisplatin, and bevacizumab for three 21-day cycles.
* Cycles 1 and 2 - Gemcitabine on day 1 and day 8, cisplatin on day 1, bevacizumab on day 1.
* Cycle 3 - Gemcitabine on day 1 and day 8, cisplatin on day 1 (no bevacizumab).
* Physical examinations and tests will be conducted throughout each cycle.
* Surgery will take place 4 to 6 weeks after the last cycle if heart and lung functions are satisfactory and if the cancer remains stable.
* Chemotherapy (four 21-day cycles of cisplatin and etoposide treatments), further evaluations and examinations, and followup studies will take place 4 to 8 weeks after the surgery.

Detailed description:
Background:

* Stage IIIA-N2 is considered one of the most therapeutically challenging and controversial subsets of lung cancer. This heterogenous group of patients have tumors which range from minimal N2 (found incidentally during or after surgery) to multi-station bulky N2 disease. The extent of mediastinal involvement has an inverse correlation with survival.
* The 5-year survival ranges from 5-8% in patients with bulky N2 disease, to nearly 35% in patients with single station, microscopic N2 involvement.
* Neo-adjuvant chemotherapy and chemo-radiotherapy have been shown to be superior to surgery alone.
* Platinum-based induction chemotherapy in early and locally advanced non small cell lung cancer (NSCLC) results in a radiological down-staging in at least 50% of patients, and a pathological complete response rate of approximately 5%.
* Concurrent chemo-radiotherapy as an induction regimen increases the radiological and pathological down-staging rate, but at the cost of increasing the morbidity and mortality of a surgical intervention.
* Expectations have now turned towards a possible incremental effect of adding a targeted biological agent to a standard induction treatment.

Primary Objectives:

* To determine the safety of neo-adjuvant Gemcitabine/Cisplatin and Bevacizumab in stage IIIA-N2 non small cell lung cancer (NSCLC)
* To determine the pathological complete response rate
* To determine the resectability rate
* To determine the extent of surgery

Eligibility:

* Histologically confirmed stage IIIA-N2 NSCLC (non-squamous)
* No previous chemotherapy, radiotherapy, surgery or biological therapy for lung cancer
* Adequate organ and bone marrow function

Design:

* Multi-center, international (United States Of America (USA)/Croatia), open labeled phase II trial
* Following a Simon two-stage optimal design

Arms:
arm 1: Non-squamous cell non small cell lung cancer treated with 1250 mg/m\^2 gemcitabine dose for two doses on day 1 and day 8 every 21 days,80 mg/m\^2 cisplatin day 1 every 21 days for 3 cycles, 7.5 mg/kg bevacizumab on day 1 every 21 days for first 2 cycles only, and 100 mg/m\^2 intravenous, and 100 mg/m\^2 etoposide intravenous per day for consecutive 3 days on days 1 to 3 every 3 weeks for 4 cycles.

Interventions: intervention 1: Gemcitabine intervention 2: Cisplatin intervention 3: Bevacizumab intervention 4: Surgery intervention 5: Etoposide
Intervention descriptions: intervention 1: 1250 mg/m\^2 dose for two doses on days 1 and 8 intervention 2: 80 mg/m\^2 on day 1 intervention 3: 7.5 mg/m\^2 on day 1 every 21 days for first two cycles only intervention 4: thoracotomy with lobectomy/pneumonectomy and mediastinal lymph node dissection 4-6 weeks post completion of last cycle of cisplatin intervention 5: 100 mg/m\^2 intravenous per day for consecutive 3 days on days 1 to 3 every 3 weeks for 4 cycles.

Protocol document:
Prot_SAP_000.pdf: 
Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
1
PHASE II STUDY OF NEOADJUVANT GEMCITABINE, CISPLATIN 
AND BEVACIZUMAB IN STAGE IIIA (N2) NON-SQUAMOUS CELL 
NON-SMALL CELL LUNG CANCER 
 
Abbreviated Title: Neoadjuvant therapy in NSCLC 
 
Coordinating Center: 
 
Center for Cancer Research 
 
 
 
 
 
National Cancer Institute 
 
 
 
 
 
10 Center Drive 
 
 
 
 
 
Bethesda, MD 20892 
 
Principal Investigator: 
 
Giuseppe Giaccone, M.D., Ph.D, MOB/CCR/NCI 
 
 
 
 
 
Chief, Medical Oncology Branch 
 
 
 
 
 
NIH 
 
 
 
 
 
9000 Rockville Pike 
 
 
 
 
 
Bldg. 10, Room 12N226 
 
 
 
 
 
Bethesda, MD 20892 
 
 
 
 
 
Telephone: (301) 402-3415 
 
 
 
 
 
Fax: (301) 402-0172 
 
 
 
 
 
Email: giacconeg@mail.nih.gov 
 
 
 
Lead Associate Investigator: 
Ronan Joseph Kelly, M.D., M.B.A. 
 
 
 
 
 
National Cancer Institute 
 
 
 
 
 
10 Center Drive 
Bldg. 10, Room 13N230 
Bethesda, MD 20892 
Telephone: (301) 496-4916 
Email: kellyro@mail.nih.gov 
 
Associate Investigators: 
 
David Schrump, M.D., SB, CCR, NCI 
Jane Trepel, Ph.D, MOB/CCR/NCI* 
 
 
 
 
 
William Figg, Pharm D, CCR/NCI* 
 
 
 
 
 
David  Kohler, Pharm D, Pharmacy Dept, CC, NIH* 
 
 
 
 
 
Paul Meltzer ,M.D., GB/CCR/NCI* 
 
 
 
 
 
 
 
 
 
 
 
Arun Rajan, M.D., MOB/NCI 
 
 
 
 
 
Phil Dennis, M.D., Ph.D. MOB/NCI 
 
 
 
 
 
Eva Szabo, M.D., GB, CCR/NCI 
 
 
 
 
 
Peter Choyke, M.D.,MIP/CCR/NCI* 
 
 
 
 
 
King Kwong, M.D., SB,CCR, NCI 
 
 
 
 
 
Joseph Fontana, M.D., CCR,NHLBI 
 
 
 
 
 
Maria Merino, M.D., CCBB, CCR, NCI* 
 
 
 
 
 
Arlene Berman, RN, MOB, CCR, NCI 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
2
 
 
 
 
 
Corrine Keen, RN, MOB, CCR, NCI 
 
 
 
 
 
Michell Manu, RN SAIC-F, Inc. 
 
 
 
 
 
Ariel Lopez-Chavez, M.D., MOB, CCR, NCI 
 
 
*Not participating in routine patient care 
 
Statistician:   
 
 
Seth M. Steinberg, Ph.D., BDMS/CCR/NCI 
 
 
 
 
 
6116 Executive Blvd, Room 702 
 
 
 
 
 
Telephone: (301) 496-9502 
 
 
 
 
 
Fax: (301) 402-1259 
 
 
 
 
 
Email: steinbes@mail.nih.gov 
 
Responsible Research Nurse:  
Michell Manu, RN 
 
 
 
 
 
Medical Oncology Branch, 
 
 
 
 
 
National Cancer Institute 
 
 
 
 
 
9000 Rockville Pike 
NCI Bldg. 10, Room 12N226 
 
 
 
 
 
Bethesda, MD 20892 
 
 
 
 
 
Telephone: (301) 402-4423 
 
 
 
 
 
Fax: (301) 480-2590 
 
Participating Institution:  
University Hospital for Lung Diseases 
 ‘Jordanovac’, Zagreb, Croatia  
 
Principal Investigator:  
 
Professor Miroslav Samarzija, M.D., Ph.D. 
 
 
 
 
 
Medical Director 
 
 
 
 
 
University Hospital for Lung Diseases 
 
 
 
 
 
‘Jordanovac’ 
 
 
 
 
 
Jordanovac 104  
Zagreb 
Croatia 
Europe 
 
+385 1 2385 283 
 
 
 
miroslav.samarzija@zg.t-com.hr 
 
 
 
 
 
IRB Contact:  
 
 
Branko Sever, MD 
FWA number: 
 
 
FWA00013862 
 
 
 
 
 
University Hospital for Lung Diseases 
 
 
 
 
 
‘Jordanovac’ 
 
 
 
 
Jordanovac 104 
 
 
 
 
 
10 000 Zagreb  
 
 
 
 
 
Croatia 
 
 
 
 
 
Tel: + 385 1 2385 262 
 
 
 
 
 
e-mail: branko.sever@email.t-com.hr 
 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
3
Pharmacy Contact:  
 
Ruzica Samija, BscPharm 
 
 
 
 
 
University Hospital for Lung Diseases 
 
 
  
 
 
‘Jordanovac, Zagreb, Croatia 
 
 
 
 
 
+ 385 1 2385 257 
 
 
 
 
 
ljekarna.jordanovac@zg.t-com.hr 
 
 
 
 
 
Associate Investigators: 
 
 
University Hospital for  
Lung Diseases 
‘Jordanovac’ Croatia 
 
 
 
 
 
 
 
Marko Jakopovic, MD, PhD 
Sanja Plestina, MD, MSc 
Prof. Zoran Slobodnjak, MD, PhD 
 
 
 
 
 
Ass. Prof. Dinko Stancic – Rokotov, MD, PhD 
 
 
 
 
 
Zoran Janevski, MD 
 
 
 
 
 
Ass. Prof. Ivica Mazuranic, MD, PhD 
 
 
 
 
 
Ante Marusic, MD 
 
 
 
 
 
Antonija Balenovic, MD 
 
 
 
 
 
 
Eduard Vrdoljak, MD,PhD 
 
 
 
 
 
Simun Krizanac, MD,PhD 
 
 
 
 
 
Silvana Smojver – Jezek, MD, MSc 
 
 
 
 
 
Nabil Chalfe, MD 
 
 
 
 
 
Sonja Badovinac, MD 
 
 
 
 
 
Vida John, RN 
 
 
 
 
 
Tanja Zovko, RN 
 
 
 
 
 
Katherina Bernadette Sreter 
 
 
Participating Institution:  
 
National Naval Medical Center 
8901 Wisconsin Avenue, Bldg 8 
Bethesda, MD 20889-5600 
Phone:  301-435-5332 
Cell:  240-506-4307 
Fax:  301-295-0981 
 
 
 
Adjunct Principal Investigator: 
Corey A. Carter, MD 
National Naval Medical Center 
8901 Wisconsin Avenue, Bldg 8 
Bethesda, MD 20889-5600 
Phone:  301-435-5332 
Cell:  240-506-4307 
Fax:  301-295-0981 
Email:   corey.carter@med.navy.mil 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
4
 
 
 
 
 
Associate Investigator:  
Thurber, John S, MD  
 
Pharmacy Contact: 
Frank Grollmen 
National Naval Medical Center 
8901 Wisconsin Avenue, Bldg 8,  Room 3145 
Bethesda, MD 20889-5600 
Email:  frank.grollman@med.navy.mil 
 
 
Research Nurse: 
Veronica Salpeas 
National Naval Medical Center 
8901 Wisconsin Avenue, Bldg 8 
Bethesda, MD 20889-5600 
Phone: 301-435-2123 
Fax:  301-295-0981 
Email:  veronica.salpeas@med.navy.mil 
 
 
Regulatory Contact: 
Sheila Gaines 
Responsible Conduct of Research Service 
National Naval Medical Center 
8901 Wisconsin Avenue, Bldg 1 
Bethesda, MD 20889-5600 
Phone:  301-295-2275 
Fax:  301-295-1490 
 
IRB Address: 
Responsible Conduct of Research Service 
National Naval Medical Center 
8901 Wisconsin Avenue, Bldg 1 
Bethesda, MD 20889-5600 
Phone:  301-295-2275 
Fax:  301-295-1490 
 
FWA#  00000366 
DOD # 40001  
Protocol Version Date: 
 
December 22, 2010 
 
 
 
 
 
 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
5
Précis 
• Stage IIIA-N2 is considered one of the most therapeutically challenging 
and controversial subsets of lung cancer. This heterogenous group of 
patients, have tumors which range from minimal N2 (found incidentally 
during or after surgery) to multi-station bulky N2 disease. The extent of 
mediastinal involvement has an inverse correlation with survival.  
• The 5-year survival ranges from 5-8% in patients with bulky N2 disease, to 
nearly 35% in patients with single station, microscopic N2 involvement1. 
• Neo-adjuvant chemotherapy and chemo-radiotherapy have been shown to 
be superior to surgery alone. 
• Platinum-based induction chemotherapy in early and locally advanced 
NSCLC results in a radiological down-staging in at least 50% of patients, 
and a pathological complete response rate of approximately 5%2,3,4.  
• Concurrent chemo-radiotherapy as an induction regimen increases the 
radiological and pathological down-staging rate, but at the cost of 
increasing the morbidity and mortality of a surgical intervention.  
• Expectations have now turned towards a possible incremental effect of 
adding a targeted biological agent to a standard induction treatment.  
 
 
Primary Objectives 
• To determine the safety of neo-adjuvant Gemcitabine/Cisplatin and 
Bevacizumab in stage IIIA-N2 NSCLC 
• To determine the pathological complete response rate 
• To determine the resectability rate 
• To determine the extent of surgery 
 
Eligibility 
• Histologically confirmed stage IIIA-N2 NSCLC (non-squamous) 
• No previous chemotherapy, radiotherapy, surgery or biological therapy for lung 
cancer 
• Adequate organ and bone marrow function 
 
Design 
• Multi-center, International (USA/Croatia), open labeled phase II trial 
• Following a Simon  two-stage optimal design  
 
 
 
 
 
 
 


Protocol Number: 09-C-0107 
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Schema 
D1
D22
D43
Gem/Cis/Bev
Gem/Cis/Bev
Gem/Cis
Surgery
Cis/Etoposide
Cis/Etoposide
Cis/Etoposide
Cis/Etoposide
D71
Gemcitabine 1,250mg/m2 on days 1 & 8, Cisplatin 80mg/m2 on day 1 and Bevacizumab 7.5mg/Kg 
on day 1 every 21 days for 2 cycles only
D113
D134
D155
D176
Surgical resection at least 4 weeks post C3 Gemcitabine/Cisplatin and 7 weeks post last Bevacizumab
Cisplatin 80mg/m2 on day 1 & Etoposide 100mg/m2 per day x 3 days on days 1-3, every 21 days x4 cycles
Gemcitabine 1,250mg/m2 on days 1 & 8, Cisplatin 80mg/m2 on day 1 for one 21 day cycle
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Table of Contents  
 
 
 
 
 
Précis……………………………………………………………………….……............ 5 
 
Schema…………………………………………………………………………………..6 
 
Table of Contents………………………………………………………….................... 7 
 
1. Introduction 
1.1 
Primary protocol objectives…………………………………………… 9  
1.2 
Secondary protocol objectives………………………………………… 9 
 
2. Background 
 
2.1 
Non-small cell lung cancer……………………………………………. 9 
 
2.2 
Systemic and Local Therapy…………………………………………. 9 
 
2.3 
VEGF Inhibition………………………………………………............... 12 
 
2.4 
Correlative studies background………………………………………. 13 
 
2.5 
Rationale………………………………………………………………… 14 
 
3. Eligibility assessment and enrollment 
 
3.1 
Inclusion criteria………………………………………………………… 16 
 
3.2 
Exclusion criteria……………………………………………………….. 17 
 
3.3 
On-study research evaluation…………………………………............ 18 
 
3.4 
Patient registration and treatment…………………………………….. 19 
 
4. Study Implementation 
 
4.1 
Treatment plan…………………………………………………………. 20 
 
4.2 
Drug administration……………………………………………………. 21            
 
4.3 
Supportive care…………………………………………………………22 
                             
 
4.4 
Surgical guidelines…………………………………………………….. 23 
 
4.5 
Tissue sample acquisition and processing………………………….. 25 
 
4.6 
Protocol evaluation……………………………………………………. 26 
 
4.7 
Concurrent therapies………………………………………………….. 26 
 
4.8 
Reassessment…………………………………………………………. 27 
 
4.9 
Duration of therapy……………………………………………………. 27 
 
4.10 
Off study criteria……………………………………………………….. 27 
 
4.11 
Post study evaluation (follow up)…………………………………….. 28 
 
5. Dosing delays and dose modifications…………………………………….. ………28-31 
 
5.1 
Gemcitabine/Cisplatin and Etoposide - Hematologic toxicities 
 
 
5.1.1 Neutropenia/Thrombocytopenia/Anemia 
5.2 
Gemcitabine/Cisplatin and Etoposide - Non-Hematologic toxicities 
5.3 
Dose modifications for subsequent cycles of Gemcitabine/Cisplatin  
5.4 
Dose modifications in the adjuvant setting 
5.5 
Bevacizumab dose modifications 
 
 
6. Pharmaceutical information 
 
6.1 
Gemcitabine…………………………………………………………… 32 
6.2 
Cisplatin………………………………………………………………… 32  


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6.3 
Bevacizumab…………………………………………………….......... 32  
6.4 
Etoposide………………………………………………………………. 32 
 
 
7. Correlative studies 
 
7.1 
Angiogenesis studies………………………………………………….. 32 
 
7.2 
KRAS mutation status…………………………………………………. 34 
 
7.3 
Comparative Genomic Hybridization (CGH)…………………………34 
 
7.4 
Methylation micro array analysis…………………………………….. 35 
 
7.5 
ERCC1 and RRM1 polymorphism and expression analysis………. 35 
 
8. Study calendar……………………………………………………………………….. 37 
 
9. Measurement of effect 
 
9.1 
Definitions………………………………………………………………. 38 
 
9.2 
Guidelines for evaluation of measurable disease…………………… 39 
 
9.3 
Response criteria………………………………………………………. 40 
 
9.4 
Confirmatory measurement/ Duration of response…………………. 41 
 
9.5 
Progression-free survival……………………………………………… 42 
9.6 
Response review………………………………………………………. 42 
10. Regulatory and reporting requirements…………………………………………… 43 
 
 
11. Statistical considerations 
 
11.1 
Study design and endpoints…………………………………………… 46 
11.2 
Early Stopping Rule for Pulmonary Embolism (PE)………………… 48 
11.3 
Sample size/ accrual rate……………………………………………… 49 
 
11.4 
Stratification factors…………………………………………………… 49 
 
11.5 
Analysis of secondary endpoints……………………………………… 49 
 
11.6 
Reporting and exclusions……………………………………………… 49 
 
12. Human subjects protections 
 
12.1 
Rationale for subject selection………………………………………… 50 
 
12.2 
Justification for exclusion……………………………………………… 51 
 
12.3 
Participation of children……………………………………………….. 51 
 
12.4 
Evaluation of benefits and risks………………………………………. 51 
 
12.5 
Consent and assent process and documentation…………………... 52 
 
12.6 
Inclusion of women and minorities…………………………………… 52 
 
13. Data and safety monitoring 
 
13.1 
Multi-Institutional guidelines…………………………………………… 52 
 
13.2 
Data safety and monitoring plans…………………………………….. 53 
 
13.3 
Data collection…………………………………………………………. 54 
 
13.4 
Toxicity criteria…………………………………………………………. 54 
 
14. References………………………………………………………………………….. 55 
 
15.  Appendices………………………………………………………………………….62 
 
 
 


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1. Objectives 
 
1.1 Primary protocol objectives 
• 
Safety 
• 
Pathological complete response rate 
• 
Resectability rate 
• 
Extent of surgery (Lobectomy Vs Pneumonectomy) 
 
1.2 Secondary protocol objectives  
• To evaluate progression free survival, median survival (MS) and overall 
survival (OS) 
• Exploratory surrogate markers: (To be prioritized as follows) 
• Blood - Angiogenesis studies–CECs/CEPs, Myeloid subset analysis 
• Tissue 
1. Methylation microarray analysis 
2. KRAS mutation analysis 
3. Comparative genomic hybridization 
4. ERCC1 and RRM1 polymorphism and expression analysis 
 
2. Background 
 
2.1 Non-small cell lung cancer 
 
Lung cancer is the leading cause of cancer related death in Europe and in the 
USA. Non-small cell lung cancer (NSCLC) accounts for 80% of all lung cancers 
and approximately 15% of patients with NSCLC are diagnosed with stage IIIA-
N21. This subset is perhaps the most controversial and therapeutically 
challenging of all lung cancer stages. Stage IIIA-N2 represents a heterogenous 
group of patients, ranging from minimal N2 (found incidentally during or after 
surgery) to multi-station bulky N2 disease. The extent of mediastinal involvement 
has an inverse correlation with survival. The 5-year survival ranges from 5-8% in 
patients with bulky N2 disease, to nearly 35% in patients with single station, 
microscopic N2 invovlement1. 
 
2.2 Systemic and Local Therapy 
 
Platinum-based induction chemotherapy in early and locally advanced NSCLC 
results in radiological down-staging in at least 50% of patients, and a pathological 
complete response rate in only a small minority5,6,7. The simultaneous 
administration of chemotherapy and radiotherapy increases the radiological and 
pathological down-staging rate, but increases the morbidity and mortality of a 
surgical intervention, suggesting the gain in pathological response is lost by the 
operative mortality. In a meta-analysis, the combination of platinum-based 
chemotherapy and thoracic radiotherapy yielded a 5-year survival rate of 15% in 
locally advanced NSCLC5, and this combination has been considered a standard 
treatment for patients with stage IIIA-N2 tumors with unresectable disease. Local 


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10
and distant failure rates remain high in patients treated with definitive chemo-
radiation. Some authors continue to advocate in favor of the trimodality approach 
with surgical resection post chemo-radiation in selected patients with IIIA-N2 
disease6,7. Trials of neo-adjuvant therapy followed by surgery have used both 
chemotherapy and chemo-radiotherapy as induction regimens2,8. 
Many institutions routinely use induction chemotherapy followed by surgery as 
treatment for stage IIIA-N2 disease. This schedule is based on small randomized 
studies showing that surgery alone is inferior to peri-operative chemotherapy and 
surgery9,10. The European Organization for Research and Treatment of Cancer 
(EORTC) performed a large multicenter randomized trial (08941) to compare 
surgery with radiotherapy in patients with stage IIIA-N2 NSCLC who showed 
response to induction chemotherapy2. Of the planned patients included in the 
study, 87% received the planned three cycles of induction chemotherapy, with an 
overall response rate of 61%. A 5% pathologic complete response rate was seen 
in those patients randomized to the surgical arm. Down-staging to NO or N1 
disease was obtained in 41% of patients. There was no significant difference in 
median survival (17.5 months in the radiotherapy arm vs 16.4 months in the 
surgery arm), 5-year overall survival (14 vs 15.7%) or progression free survival. 
In a post hoc unplanned subgroup analysis on the surgical arm, 5-year survival 
was longer if a radical resection was performed, nodal down-staging was present 
or if a lobectomy was performed. Overall the author’s conclusions were that if 
patients have a radiologic response to induction chemotherapy, surgery did not 
improve survival compared with radiotherapy. 
 
In the US Intergroup trial 0139, patients with T1-3 pN2M0 NSCLC were 
randomized between induction chemo-radiotherapy followed by either surgery or 
consolidation radiotherapy to 61Gy8. Patients received two cycles of cisplatin and 
etoposide, concurrent with thoracic radiotherapy of 45Gy. Non-progressing 
patients then proceeded to either surgery or radiation and both arms received 
consolidation chemotherapy with two cycles of cisplatin/etoposide. Pathologic 
complete response was achieved in 15% of the patients. Progression-free 
survival was significantly better in the surgery group but overall survival did not 
differ, mainly due to postoperative mortality. Long term follow up confirms the 
significant improvement in progression-free survival, but not in overall survival, 
when surgery follows induction chemo-radiation. Three factors found in 
multivariate analysis to be associated with improved outcome were lobectomy, 
pathological down-staging and completeness of resection. Completeness of 
resection can only be defined post hoc, lymph node status is revised as part of 
pathological staging and no surgeon can be certain pre-operatively that a 
pneumonectomy will not be necessary for an individual patient with stage IIIA-N2 
disease. This has been shown by the high rates of pneumonectomy (28-44%) in 
selected surgical series11. This figure is similar to the rate of 46% observed in 
EORTC 089412. There are currently no comparative data showing that induction 
chemo-radiotherapy followed by surgery results in a better outcome than 
induction chemotherapy and surgery. Furthermore studies have shown that most 


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11
of the third-generation cytotoxic drugs have similar activity in locally advanced 
disease.  
 
An improvement in our understanding of the molecular anomalies that lead to the 
development of lung cancer has lead to a renewed emphasis in developing 
targeted therapy that can be combined with standard cytotoxic chemotherapy in 
order to improve response rates and survival of patients with advanced lung 
cancer. Expectations have turned towards possible incremental benefits of 
adding the targeted biological agent, bevacizumab, to a standard induction 
regimen. 
 
Bevacizumab is a novel targeted agent which has achieved proof of efficacy in 
combination with platinum-based doublet chemotherapy in NSCLC. A large 
phase III trial (Eastern Cooperative Oncology Group (ECOG) study 4599) 
evaluated bevacizumab plus chemotherapy in 878 treatment-naive patients with 
advanced nonsquamous NSCLC12.  Patients were randomized to receive 
carboplatin (AUC of 6) / paclitaxel (200 mg/m2) +/- bevacizumab (15 mg/kg) 
every 3 weeks for six cycles; bevacizumab monotherapy (15 mg/kg every 3 
weeks) was then continued until progressive disease or intolerable toxicity, or up 
to 1 year.  Patients receiving bevacizumab had significantly improved median 
overall survival (12.5 versus 10.2 months; P = 0.007), progression-free survival 
(6.4 versus 4.5 months; P < 0.0001), and response rates (27.2% versus 10.0%; 
P < 0.0001) compared with chemotherapy alone.  
 
Based on E4599 results, the bevacizumab/carboplatin/paclitaxel regimen used in 
the trial has been adopted as the new ECOG standard of care for the first-line 
treatment of advanced NSCLC.  The National Comprehensive Cancer Network 
has also recently incorporated bevacizumab (in combination with chemotherapy) 
into its treatment guidelines for NSCLC.   In October 2006, the Food and Drug 
Administration (FDA) granted approval for the use of bevacizumab in 
combination with carboplatin/paclitaxel as first-line treatment for patients with 
advanced non-squamous NSCLC.  
 
A large randomized phase III trial of cisplatin/gemcitabine +/- bevacizumab as 
first-line therapy in advanced non-squamous NSCLC (AVAiL) was performed in 
Europe13.  A total of 1,044 patients were randomized to three arms to receive 
cisplatin/gemcitabine with or without one of two doses of bevacizumab (either low 
dose 7.5 mg/kg or high dose 15 mg/kg every 3 weeks).  Preliminary analysis 
revealed that the 347 patients in the placebo arm had a median progression-free 
survival (PFS) time of 6.1 months, compared with 6.7 months for the 345 patients 
on low-dose bevacizumab, and 6.5 months for the 351 patients in the high-dose 
arm.  A statistically significant reduction in the risk of relapse was observed in 
patients treated with bevacizumab and chemotherapy, HR: 0.75 (CI: 0.62, 0.91) 
P< 0.002625 in the low-dose arm and a HR: 0.82 (CI: 0.68, 0.98) P < 0.0301 in 
the high-dose arm.  A statistically significant difference was found in the 
response rate (RR) observed in patients treated with bevacizumab and 


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12
chemotherapy, RR were 20%, 34% and 30% for placebo, low-dose 
bevacizumab, and high-dose arm, respectively.  No improvement in overall 
survival has been reported. 
 
Based on E4599 and AVAiL results, bevacizumab, was approved in August 
2007, for the first-line treatment of patients with advanced non-small cell lung 
cancer (NSCLC), in combination with platinum-based chemotherapy by the 
European Medicines Agency's (EMEA).  
 
The aim of this study is to evaluate neo-adjuvant bevacizumab in combination 
with cisplatin and gemcitabine in stage IIIA N2 NSCLC prior to surgical resection.  
 
2.3 VEGF Inhibition 
 
The pioneering work of Folkman and others have shown that tumors require 
angiogenesis in order to grow beyond 1-2 mm3 in size14.  When a tumor acquires 
the ability to establish its own vasculature, its behavior becomes more 
aggressive15.  The inhibition of new blood vessel growth has therefore become 
an important cancer control target.  Vascular Endothelial Growth Factor (VEGF) 
is a potent endothelial cell mitogen, which is normally seen in certain physiologic 
situations (fetal development, menstruation, wound healing).  High serum levels 
of circulating VEGF have been seen with a number of different tumor types.   
 
Bevacizumab is a recombinant humanized monoclonal IgG1 antibody that binds 
to and inhibits the biologic activity of human VEGF. Bevacizumab binds VEGF 
and prevents the interaction of VEGF to its receptors on the surface of 
endothelial cells. Two large randomized phase III clinical trials have shown a 
benefit in progression free survival, response rates and in one study overall 
survival when bevacizumab is added to a doublet of platinum based 
chemotherapy in the treatment of advanced non-small cell lung cancer12,13. 
 
There are limited data regarding the safety of peri-operative inhibition of VEGF.  
Roman, et al treated rats subjected to a lobectomy with SU5416, a VEGF flk-
1/KDR receptor tyrosine kinase inhibitor at doses that had achieved a clear 
decrease in vascular flow assays in a previous murine model16.  They observed 
no adverse effects on the animals’ recovery and on their post operative wound 
healing.  Additional experiments in different murine models suggest that there are 
likely enough differences between normal physiologic angiogenesis and 
neoplasm induced neo-angiogenesis to explain the fact that angiogenesis 
inhibition 
compromises 
tumor 
neo-vascularization 
sparing 
normal 
vascularization17.  
 
There are no studies to date investigating the safety and efficacy of bevacizumab 
added to gemcitabine and cisplatin in the neo-adjuvant setting in patients with 
resectable stage III NSCLC. The integration of novel effective cytotoxic biologic 
therapies with advanced surgical procedures has however transformed the 


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treatment of patients with colorectal cancer metastatic to the liver. In 
nonrandomized trials, the pre-operative administration of regimens containing 
chemotherapy in combination with bevacizumab appears to be both effective and 
safe. 
 
The First BEAT study evaluated the efficacy and safety of bevacizumab with 
standard first-line fluoropyrimidine-based chemotherapy in patients with metatatic 
colorectal cancer18. The authors report potential curative surgery was perfomed 
in 12% of patients. A low rate of surgery related grade 3 AEs or SAEs were 
reported (wound healing complications 1.3%; bleeding 0.4%).  
 
A second trial evaluated bevacizumab, capecitabine and oxalipaltin as neo-
adjuvant therapy for patients with potentially curable metastatic colorectal cancer. 
The authors conclude that bevacizumab can be safely administered until 5 weeks 
before liver resection in patients with metastatic CRC without increasing the rate 
of surgical or wound healing complications or severity of bleeding19. 
 
 
2.4 
Correlative studies background 
 
2.4.1 Angiogenesis studies 
 
Anti-angiogenic treatments for cancer, could be improved, if reliable surrogate 
markers of drug biological activity were available to help select and stratify the 
patients who are most likely to benefit from treatment. Many preclinical 
angiogenesis assays rely on the growth-factor-induced generation and 
quantification of new vessels at sites such as the cornea, skin or dorsal sac. 
Such surrogates are not adaptable to patients. To date the evaluation of 
microvessel density (MVD) in tumor biopsy samples has been used as a means 
of predicting and/or assessing the efficacy of anti-angiogenic therapies20. Another 
approach is the measurement of circulating levels of angiogenic growth factors, 
such as vascular endothelial growth factor (VEGF), basic fibroblast growth factor 
(BFGF), hepatocyte growth factor (HGF) and interleukin 8 (IL8), among others. 
Unfortunately no growth factor to date has been validated for predicting a 
response to anti-angiogenic therapies. Another possible approach to investigate 
anti-angiogenic activity is by utilizing functional imaging via dynamic contrast-
enhanced magnetic resonance imaging (DCE-MRI) to measure tumor blood flow 
and vascular permeability21. The effectiveness of this approach remains to be 
validated and its use requires expensive instrumentation that is limited to a small 
number of institutions.  
 
The possibility that the measurement of circulating endothelial cells (CEC’s) and 
circulating endothelial progenitors (CEP’s) might be exploited as surrogate 
markers of angiogenesis and anti-angiogenic drug activity has been studied at 
both the preclinical and clinical levels and will be evaluated in this trial. 
 


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Recently, much research has focused on a population of myeloid cells, identified 
by the expression of the cell surface markers CD11b, which include a variety of 
cell types such as neutrophils, immature dendritic cells, monocytes and early 
myeloid progenitors. Interest in these cells which includes a class of immune 
suppressive cells termed myeloid-derived suppressor cells (MDSC), relates to 
their ability to promote tumor progression. Tie2-expressing monocytes have also 
been reported to promote tumor growth through secretion of proangiogenic 
factors22 Recruitment of these cells may represent a cellular mechanism 
underlying the inherent refractoriness that tumors can develop in response to 
anti-VEGF therapy23.  This study will analyze CEC’s/CEP’s, MDSC, Tie2+ 
monocytes and VEGFR1+ hemangiocytes before treatment and on specified 
dates after administration of Gemcitabine/Cisplatin and Bevacizumab. 
 
 
2.4.2 Comparative Genomic Hybridization 
 
Chromosomal aberrations are thought to be critical events in human 
tumorigenesis, and several genomic regions frequently harboring DNA gains (3q, 
5p, 7q, 8q, 11q and 16p) and losses (3p, 4q, 5q, 6q, 8p, 9p and 13q, 17q) have 
been identified in NSCLC patients. Using array based comparative genomic 
hybridization (aCGH) and gene expression microarrays, DNA copy number 
changes and gene expression can be measured throughout the whole genome of 
tumor cells. We will combine the data from these analyses to obtain an integrated 
genome wide view of gene dosage aberrations and their effect on gene 
expression, which might help in identifying genes important in NSCLC. 
 
2.4.3 Methylation microarray analysis 
 
Epigenetic gene silencing is a molecular mechanism of silencing a gene by 
methylating its promoter region. Epigenetic silencing is involved in the initiation 
and progression of several types of cancer, including lung cancer24,25. The 
detection of epigenetic alterations with the use of methylation-specific 
polymerase-chain-reaction (PCR) assays may allow for the molecular staging of 
cancer. We will utilize methylation-specific PCR assays to define patterns of DNA 
methlyation that may delineate the behaviour of the primary tumor. 
 
2.4.4 ERCC1 and RRM1 IHC/SNP analysis 
 
Many published candidate gene association studies have assessed cancer risk 
by examining a single SNP per gene or a single locus at a time analysis 
approach. The ERCC1 gene encodes a subunit of the nucleotide excision repair 
complex required for the incision step of nucleotide excision repair (NER)26. 
Since the ERCC1 protein is essential for NER and influences genomic instability, 
polymorphisms in ERCC1 may play a role in carcinogenesis. A synonymous 
mutation at 500 (C>T) in the messenger RNA, both coding for asparagines (Asn, 
or N) at 118, was found to be correlated to important clinical endpoints of 


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15
platinum-based chemotherapy47,48. In general, the variant allele T was thought to 
result in decreased codon usage, which in turn compromises ERCC1 protein 
expression. Patients with T allele were found to respond to platinum-based 
chemotherapy better than those possessing C allele. In addition, ERCC1 
expression level in the tumors was suggested to have prognostic value for 
platinum-based chemotherapy49-52. Patients with low ERCC1 expression showed 
survival benefit from platinum-containing regimens. This study will examine 
whether the genotype of the germ line mutation ERCC1 N118N (500 C>T), 
and/or ERCC1 expression level in tumors could be used to predict a survival 
benefit of chemotherapy. 
 
RRM1, encodes the regulatory subunit of ribonucleotide reductase. It is located 
on chromosome segment 11p15.5, a region with frequent loss of heterozygosity 
in non small cell lung cancer27,28. Low levels of expression of the gene are 
associated with poor survival among patients with non small cell lung cancer29. 
An increase in the expression of the RRM1 protein increases the expression of 
the phosphatase and tensin homologue (PTEN), an inhibitor of cell proliferation; 
decreases the phosphorylation of focal adhesion kinase; and decreases cell 
migration and invasiveness30. RRM1 is also the predominant cellular determinant 
of 
the 
efficacy 
of 
the 
nucleoside 
analogue 
gemcitabine 
(2’,2’-
difluorodeoxycytidine)31,32. In addition to the gene expression, two genetic 
polymorphisms (-37 and -524) in the promoter region of RRM1 gene showed 
prognostic value for gemcitabine in patients with NSCLC55. The response rate 
was significantly higher in the patients carrying RR37AC-RR524CT genotype 
compared with the patients containing other genotypes (P = 0.039). 
 
Blood samples will be collected from each patient enrolled in this study to extract 
the genomic DNA for genotyping of ERCC1 polymorphism. In addition, tumor 
tissues, stromal cells surrounding the tumors and a small amount of normal 
tissue from each patient will be collected to be used in the immuno-staining 
study. 
 
 
2.5 
Rationale 
 
The combination of anti-VEGF therapies with platinum based doublets has been 
shown to improve overall survival in metastatic NSCLC. Neo-adjuvant 
chemotherapy utilizing the combination of Cisplatin and Gemcitabine has been 
shown to lead to a down-staging of stage IIIA N2 NSCLC and a pathological 
complete response rate in a small number of tumors. The addition of 
bevacizumab to this platinum based doublet in the neo-adjuvant setting has not 
previously been evaluated in a clinical study. It is hoped that this combination of 
cytotoxic chemotherapy with bevacizumab will be safe and effective in improving 
pathological complete response rates leading to improved resectability, 
progression free and overall survival. 
 


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3.0 
 PATIENT SELECTION 
3.1 
Inclusion Criteria 
 
3.1.1. Histologically or cytologically documented non squamous cell 
non-small cell lung cancer and confirmed by the pathological 
laboratories at participating centers.   
3.1.2 Patients must have measurable disease, defined as at least one 
lesion that can be accurately measured in at least one 
dimension (longest diameter to be recorded) as >20 mm with 
conventional techniques or as >10 mm with spiral CT scan.  See 
section 9.2 for the evaluation of measurable disease.  
3.1.3 Stage IIIA (N2) disease. All patients will require a baseline 
mediastinoscopy to ensure histological proof of N2 disease. 
(See appendix I for staging of non-small cell lung cancer). 
3.1.4 No prior treatment for lung cancer including chemotherapy, 
radiotherapy, surgery or biological therapy. 
3.1.5 Age ≥18 years (males or non-pregnant females).   
3.1.6 Life expectancy of greater than 3 months 
3.1.7 ECOG performance status 0-1 (Karnofsky >60%, see Appendix 
II) 
3.1.8 Adequate pulmonary and cardiovascular function to tolerate 
planned surgical resection: 
 
 
Pulmonary Function criteria:  
• paO2 >65 mmHg, paCO2 <45 mmHg on room air ABG 
• Anticipated post-op FEV1 > or equal to 40% predicted 
• Anticipated post-op DLCO > or equal to 40% predicted 
• If anticipated post-op FEV1 or DLCO < 40% predicted, 
must have VO2 >15ml/kg on oxygen consumption study 
 
 
Cardiac criteria: 
• LVEF > 40% 
• No pulmonary hypertension or RV dysfunction 
• No unstable angina 
3.1.9 Serum Creatinine ≤1.5mg/dl 
3.1.10 Hemoglobin (baseline) ≥ 10.0g/dl  
3.1.11 Absolute neutrophil count ≥ 1,500/m3 and platelets ≥ 100,000/m3 
3.1.12 AST/SGOT and ALT/SGPT ≤ 2.5 x ULN, total bilirubin ≤ 1.5 x 
ULN (In patients with evidence of Gilberts disease, elevated 
bilirubin should not be related to tumor or other liver diseases 
and should be less than or equal 2 x upper limit of normal ) 
3.1.13 The ability to understand and the willingness to sign a written 
informed consent document and the ability to comply with the 
requirements of the protocol. 
3.1.14 Women of childbearing potential must have a negative 
pregnancy test and both men and women must be willing to 


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17
consent to using effective contraception while on treatment and 
for at least 3 months thereafter 
 
3.2       Exclusion Criteria 
 
3.2.1 Squamous cell cancer or mixed tumors with small cell elements 
3.2.2 Tumor of any histology in close proximity to a major vessel or 
cavitation (Any tumor abutting an interlobar, main pulmonary 
artery, vena cava or major vein will be exluded). 
3.2.3 History of hemoptysis (bright red blood of ½ teaspoon or more 
[≥ 2.5 mL]) unrelated to any diagnostic procedure. (Patients who 
have a history of hemoptysis that occurred >3 months prior to 
study entry and that is assessed not to be related to tumor may 
be eligible) 
3.2.4 Patients with metastatic disease   
3.2.5 History of uncontrolled or labile hypertension, defined as blood 
pressure > 150/100mmHg (NCI CTCAE v.3.0 grade ≥ 2), 
systolic blood pressure > 180 mm Hg if diastolic blood pressure 
< 90 mm Hg, or diastolic blood pressure > 90 mm Hg, on at 
least 2 repeated determinations on separate days within 3 
months prior to study enrollment. Patients who have medication 
controlled hypertension are eligible for the study. 
3.2.6 Any of the following within 6 months prior to study enrollment: 
myocardial infarction, severe/unstable angina pectoris or 
uncontrolled angina pectoris, coronary/peripheral artery bypass 
graft, NYHA class III or IV congestive heart failure, clinically 
significant peripheral vascular disease (Grade II or greater)  
3.2.7 Psychiatric or neurologic illness that would limit compliance with 
study requirements. 
3.2.8 Patients with serious illness or medical condition 
3.2.9 Active infection within 14 days before beginning treatment. 
3.2.10 Patients may not be receiving any other investigational agents. 
3.2.11 History of a malignancy in the last five years other than in situ 
carcinoma of the cervix, or non-melanomatous skin cancers. 
3.2.12 Patients must not be on therapeutic anticoagulation or chronic 
daily treatment with aspirin 325mg/day within 10 days prior to 
day 1 on study. Prophylactic anticoagulation during peri-
operative period is acceptable.  Full dose aspirin post surgical 
resection is acceptable. Low dose aspirin 81mg/day and 
anticoagulation for line protection are allowed in the peri-
operative period and the adjuvant setting. 
3.2.13 Women who are breast feeding. 
3.2.14 History of stroke or transient ischemic attack within 6 months 
3.2.15 History of pulmonary embolism, deep venous thrombosis or 
other thrombo-embolic event within 6 months prior to study 


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18
3.2.16 Patients with a history of severe hypersensitivity reaction to 
compounds of similar chemical or biologic composition to 
cisplatin, gemcitabine, bevacizumab, etoposide or other agents 
used in the study. 
3.2.17 History of a major surgical procedure, open biopsy, or a 
significant traumatic injury within 35 days prior to commencing 
treatment, or the anticipation of the need for a major surgical 
procedure during the course of the study prior to the 
predetermined date of tumor excision. Fine needle aspirations, 
core biopsies or mediastinoscopies within 7 days prior to 
commencing treatment.  
3.2.18 History of abdominal fistula, gastrointestinal perforation, intra- 
abdominal abscess or tracheo-esophageal fistula  
3.2.19 Non-healing wound or ulcer 
3.2.20 Evidence of coagulopathic disorder or hemorrhagic diathesis. 
INR greater than 1.5. 
3.2.21 Patients with existing ototoxicity 
3.2.22 Pregnancy (positive pregnancy test) 
3.2.23 Urine protein: creatinine ratio ≥ 1.0 at screening. 
3.2.24 Patients known to be HIV-positive or have active hepatitis B/C 
(due to possible interaction between chemotherapy and HAART 
and antiviral medications used for treatment of active hepatitis 
B/C) 
3.2.25 Serious illness that may preclude adherence to the protocol. 
 
3.3 On-Study research eligibility evaluation  
3.3.1 Complete history and physical examination - including height, weight, vital 
signs and ECOG performance score (see appendix II). 
 
3.3.2 Imaging Studies (Baseline) - Every patient should have a baseline 
radiological evaluation with PET/CT scan, CT scan of chest and either MRI or 
contrast CT of brain. Imaging of other areas of known or suspected disease 
involvement should also be performed prior to receiving treatment. This must be 
completed within 28 days prior to enrollment. 
 
3.3.3 A baseline CXR,EKG, and arterial blood gas should be obtained within 14 
days prior to enrollment. Pulmonary function tests, Thallium stress test and Echo 
are also required as baseline investigations to determine suitability for surgery.  
 
3.3.4  Laboratory Evaluation [baseline is to be obtained within one week prior to 
enrollment]. 
3.3.4.1 Hematological Profile: Complete blood count (CBC) with differential and 
platelet count, Prothrombin time/International normalized ratio, activated partial 
thromboplastin time.  


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19
3.3.4.2 Biochemical Profile: Sodium, potassium, blood urea nitrogen (BUN), 
creatinine, glucose, aspartate aminotransferase (AST), alanine aminotransferase 
(ALT), 
bilirubin, 
calcium, 
phosphorous, 
albumin, 
magnesium, 
alkaline 
phosphatase, lactic acid dehydrogenase (LDH), chloride and bicarbonate. 
 
3.3.4.3 Serum or urine beta-hCG for female patients of childbearing age within  
7 days prior to therapy. 
 
3.3.4.4  Urinalysis for urinary protein or urinary protein creatinine (UPC) ratio 
 
3.3.5  Histologic confirmation: The initial pathological diagnosis will be performed 
by either the NCI laboratory of pathology or the pathology department in Zagreb 
Croatia. A block of primary tissue from the time of staging (mediastinoscopy + 
bronchoscopy) and the surgically resected specimen (post neo-adjuvant 
treatment) will be required from each patient and sent to the laboratory 
department in the NCI to confirm the diagnosis (N2 disease) and to perform 
correlative studies.  
 
3.4 
Patient Registration  
For patients at the NCI, CCR authorized staff must register an eligible candidate 
with the NCI Central Registration Office (CRO) within 24 hours of signing 
consent. 
A 
registration 
Eligibility 
Checklist 
from 
the 
web 
site 
(http://intranet.cancer.gov/ccr/welcome.htm) must be completed and faxed to 
301-480-0757. After confirmation of eligibility at Central Registration Office 
(CRO), CRO staff will call pharmacy to advise them of the acceptance of the 
patient on the protocol prior to the release of any investigational agents. 
Verification of Registration will be forwarded electronically via e-mail. Please 
note, it is very important for all registrars to acquire encrypted e-mail from NIH 
Help Desk, since the verification of registration includes patient’s information.  
 
All patients must be registered through the NCI Central Registration Office 
(CRO). The CRO is open from 8:30am to 5:30pm EST Monday through Friday, 
excluding federal holidays.  A protocol registration form and cover memo will be 
supplied by the Coordinating Center, NCI CCR and updates will be provided as 
needed. Subject eligibility and demographic information is required for 
registration. To register a subject, fax the completed registration checklist and 
cover memo to the CRO at 301-480-0757. Please indicate on the protocol 
registration form whether the patient is screening or is eligible to start treatment. 
The CRO will notify you either by e-mail or fax that the protocol registration form 
has been received. The CRO will assign a unique “900” patient/subject ID 
number for each subject that will be used to enter data into the C3D data base. 
Questions about eligibility should be directed to the Coordinating Center’s 


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20
Research Nurse, Michell Manu at 301-402-4423 or manumichell@mail.nih.gov.   
Technical questions about the form should be directed to the Central Registration 
Office (301-402-1732). 
 
Off-Study Procedure: Authorized staff must notify Central Registration Office 
(CRO) when a patient is taken off-study. An off-study form from the web site 
(http://intranet.cancer.gov/ccr/welcome.htm) main page must be completed and 
faxed to 301-480-0757. The coordinating center will provide sites with off study 
forms. 
 
4.0 
Study Implementation 
 
4.1 
Treatment Plan 
 
Cycle 1 and 2: 
Cisplatin 80mg/m2 day 1 every 21 days for 3 cycles + Gemcitabine 
1250mg/m2 dose for two doses on days 1 and day 8 every 21 days 
for 3 cycles + Bevacizumab 7.5 mg/kg on day 1 every 21 days for 
first 2 cycles only  
 
 
 
 
 
 
↓ 
 
Cycle 3: 
Cisplatin 80mg/m2 on day 1 + Gemcitabine 1250mg/m2·dose for 
two doses on days 1 and 8. No bevacizumab on 3rd cycle. 
 
 
 
 
 
 
↓ 
 
Re-staging and Response Evaluation following third cycle of 
chemotherapy, no more than 14 days prior to surgical resection 
 
 
 
 
 
↓ 
 
Surgery: 
4-6 
weeks 
post 
completion 
of 
last 
cycle 
of 
Cisplatin/Gemcitabine.  
 
 
 
 
 
↓ 
 
Adjuvant chemotherapy 4-8 weeks post surgery. All patients will  
Receive adjuvant chemotherapy irrespective of pathological staging 


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Post surgery. Cisplatin 80mg/m2 on day 1, every 3 weeks x 4 cycles 
+ Etoposide 100mg/m2 IV per day for consecutive 3 days, on days 1 
to 3 every 3 weeks for 4 cycles.  
 
 
4.2 Drug Administration 
 
4.2.1 Gemcitabine administration 
 
Gemcitabine will be diluted in 250 – 500 mL 0.9% Sodium Chloride Injection 
(0.9%NS) 
maintaining 
a 
concentration 
≥0.1 mg/mL, 
and 
administered 
intravenously before cisplatin at a fixed dose rate of 10 mg/m2·minute 
(600 mg/m2·hour). 
 
4.2.2  Cisplatin administration 
 
4.2.2.1 Hydration 
Euvolemic patients will receive hydration with 1000 mL 0.9%NS intravenously 
over 1 hour before receiving cisplatin. 
 
Patients who have received adequate hydration should receive Mannitol 
12.5 grams intravenously over 5 to 10 minutes just prior to starting cisplatin. 
• Osmotically-induced diuresis requires maintenance of adequate fluid input 
during and after mannitol administration. 
 
Post-cisplatin hydration with 1000 mL 0.9%NS should be administered 
intravenously over 1 to 2 hours after cisplatin administration is completed. In the 
adjuvant setting 1000 mL 0.9% NS over 1 to 2 hours should be administered 
after Etoposide administration is completed. 
 
• Additional IV fluids may be administered ad libitum. 
• Encourage ambulatory outpatients to continue liberally ingesting water, 
sports drinks and other non-alcoholic beverages for at least 24 hours after 
receiving cisplatin. 
 
4.2.2.2 
Administration 
Cisplatin will be diluted in 100 mL 0.9%NS and administered intravenously after 
gemcitabine over 60 minutes. 
 
4.2.3 Bevacizumab administration 
Bevacizumab will be diluted in a total volume of 100 mL 0.9%NS, and 
administered intravenously on day 1 after gemcitabine and cisplatin, every 21 
days ONLY during the first two cycles. 
 
• The initial Bevacizumab dose must be administered over at least 90 
(± 10) min. 


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• The second Bevacizumab dose may be given over 60 (±10) min if 
administration over 90 min was well tolerated. 
• In the event of an infusion-related event, bevacizumab administration 
should be interrupted until acute symptoms resolve. The PI or a medically 
responsible AI will be notified of the event at the time of the occurrence. 
After resolution of adverse signs and symptoms, bevacizumab 
administration may resume at a rate which increases the total planned 
infusion time by 30 minutes. For example, for a 60-minute infusion, the 
rate should be decreased to deliver the volume over 90 minutes (from 
1.7 mL/h to 1.1 mL/h). 
 
4.2.3.1   On days when bevacizumab is administered, the following evaluations 
should be performed: (Bevacizumab dose modifications see section 5.5) 
• review of systems pertinent to bleeding and thrombosis, 
• spot urine protein/creatinine ratio, & 
• blood pressure measurement. 
 
4.2.3.2 
Dose timing adjustments are listed in section 5.3. 
 
4.2.3.3 
If a patient’s weight changes by ≥ 10% during the course of the study, 
bevacizumab dose will be recalculated. 
 
4.2.4 Etoposide administration (adjuvant setting) 
If the calculated dose of etoposide is 100-200mg then dilute with 500ml of either 
5% dextrose or 0.9% normal saline. If the calculated dose is 201-400mg then 
dilute with 1000ml of either 5% dextrose or 0.9% normal saline. Administer 
etoposide IV over at least 60 minutes, daily for 3 consecutive days every 21 
days. 
 
4.3 
Supportive Care  
Prophylactic antiemetics, during and after, cisplatin administration will be as per 
standard practice in each participating center and the choice of agents 
administered is at the discretion of the principal investigator at each site. 
 
4.3.1 Antiemetics for cisplatin: (alternative antiemetic schedules are acceptable, 
at the discretion of the treating physician at each participating site). 
 
Acute and Delayed emesis prophylaxis will be delivered with cisplatin 
chemotherapy. Alternative drugs and dosing strategies are listed.  
Antiemetic Primary Prophylaxis: 
 
Day 1: a serotonin receptor (5-HT3) subtype antagonist + a high potency 
glucocorticoid + a neurokinin receptor (NK1) subtype antagonist before cisplatin 
administration. 
 


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23
• e.g., ondansetron 16 – 24 mg PO or 8 – 12 mg IV + dexamethasone 12 – 
20 mg PO or 10 – 12 mg IV + aprepitant 125 mg PO or fosaprepitant 
115 mg IV 
 
Days 2 & 3: a high potency glucocorticoid + a NK1 subtype antagonist. 
 
• e.g., dexamethasone 8 mg PO twice daily or 8 mg IV once daily + 
aprepitant 80 mg/day PO 
 
Other acceptable Anti-emetics (administered as per recommended guidelines) 
• 5-HT3 receptor antagonists: palonosetron, granisetron 
• D2 
receptor 
antagonists: 
metoclopramide, 
domperidone, 
prochloroperazine, thiethylperazine, metopimazine 
• Benzodiazepines: lorazepam, alprazolam 
 
4.3.2 Thrombocytopenia should be treated conservatively.  In the absence of 
bleeding or a planned invasive procedure, platelet transfusions should 
only be given for a platelet count below 10,000/μl.  If invasive procedures 
are planned or the patient develops bleeding, platelet transfusions should 
be administered in accordance with standard of practice, usually 
maintaining a platelet count ≥ 50,000/μl. 
 
4.3.3 Symptomatic anemia should be treated with appropriate red blood cell 
support and transfusion is recommended if the hemoglobin falls below 8 
g/dl.   
 
4.3.4 Central venous access devices such as a temporary internal jugular line, 
PICC lines via the brachial vein, semi-permanent HICKMAN®, 
GROSHONG®, or medi-port implanted devices are acceptable for this 
study.  All devices will have nursing supervision to include patient self-care 
and cleaning/flushing of the devices.   
 
4.3.5 Nutritional assessment and psychological support: Neoplasms are 
commonly complicated by malnutrition.  Patients with weight loss or 
evidence of wasting syndrome should have a nutritional consult.  Patients 
who are having emotional difficulties dealing with their treatment, and 
disease, or those patients who request assistance, will be referred to a 
Social Worker for evaluation and support. 
 
4.4 Surgical evaluation/management 
 
Patients with biopsy-proven or suspected primary lung cancers who are deemed 
potentially eligible for study will undergo comprehensive evaluation by thoracic 
surgery staff to determine/confirm tumor histology, pathologic stage, tumor 
resectability and operability.  Evaluation will consist of physical exam, blood work 
as listed in Section 3.3, chest X-RAY, CT scan of the chest, PET/CT scan, and 


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brain MRI scan or CT brain with contrast. Additional imaging studies (ie bone 
scan, plain films, CT or MR scans of extremities or spine) will be obtained if 
clinically indicated.  
 
Patients deemed to have clinical stage III disease will undergo bronchoscopy and 
cervical mediastinoscopy (CME) to confirm N2 disease and rule out N3 nodal 
metastases. CME will be considered complete if upper and lower right 
paratracheal (stations 2 and 4), left paratracheal (stations 2 and 4) and station 7 
are biopsied. Other techniques such as video-assisted thoracoscopic or 
endobronchial FNA techniques may be used to assess these stations if they 
cannot be reached by CME due to inflammation/adhesions, as well as stations 5 
and 6 (which cannot be assessed by standard CME) if clinically indicated for left-
sided lesions. Tissue from patients with stage IIIA (N2) disease will be obtained 
for aforementioned staging purposes as well as translational endpoints.. Patients 
who have no evidence of N2 metastases as well as those found to have N3 
(stage IIIB) disease will not be eligible for this study. 
 
In addition to the aforementioned pathologic staging studies, patients will 
undergo evaluation of cardiopulmonary reserve via pulmonary function testing 
(arterial blood gas, spirometry with DLCO, and oxygen consumption studies, if 
indicated) as well as cardiology evaluation (EKG and thallium stress test and 
ECHO). Additional studies such as cardiac CT/MR, and coronary angiography, 
will be performed, if indicated. Patients deemed to have acceptable 
cardiopulmonary reserve to tolerate resection as indicated in section 3.1.8 
(inclusion criteria) will undergo induction Cisplatin/Gemcitabine and Bevacizumab 
therapy as per protocol. Two to three weeks following completion of induction 
therapy patients will undergo repeat evaluation by Medical Oncology/Thoracic 
Surgery personnel to determine clinical response to therapy, and confirm 
potential tumor resectability and operability. Repeat staging studies will consist of 
CXR, CT scan of the chest, PET/CT scan and brain MR or CT brain with 
contrast, as well as additional imaging studies if clinically indicated. Any possible 
N3 or new sites of potentially distant disease will be evaluated by endo-bronchial 
FNA, CME, VATS, or CT-guided FNA techniques to rule-out inoperable disease 
prior to surgery. In addition, patients will undergo repeat pulmonary function tests 
with arterial blood gas, as well as EKG and ECHO to rule out potentially 
significant deterioration of cardiopulmonary status that could affect operability or 
peri-operative risk. All staging studies and pre-surgical tests obtained at outside 
participating institutions will be centrally reviewed by NCI Thoracic Surgery 
personnel to maintain consistency of surgical management. 
  
Patients meeting criteria for resection (clinically stable disease or tumor 
regression, no evidence of new sites of disease, and stable cardiopulmonary 
status) 
will 
undergo 
bronchoscopy 
and 
thoracotomy 
with 
lobectomy/ 
pneumonectomy and mediastinal lymph node dissection. All patients will have 
thoracic epidurals placed for post-operative analgesia, unless technically or 
medically contra-indicated. Bronchoplastic/ angioplastic techniques will be used if 


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25
possible to avoid pneumonectomy. All reasonable efforts will be made to assure 
microscopically-negative margins of resection by intra-operative frozen section 
analysis of bronchial as well as chest wall or parenchymal margins in the case of 
extended lobectomy. Mediastinal lymph node dissection will include stations 9, 8, 
7, 10, 4/3, and 2 for right-sided neoplasm, and stations 9, 8, 7, 10, 6, and 5 for 
left-sided lesions. Post-operatively, patients will be managed according to 
standard of care surgical guidelines regarding pulmonary hygiene, pain control, 
chest tube removal, etc. Patients will have routine beta-blocker or calcium 
channel antagonist prophylaxis for SVT, lovenox or heparin prophylaxis for DVT, 
acid-reduction regimen consisting of H2 antagonist or proton-pump inhibitor, and 
any other medications specifically indicated for co-morbidities. One month 
following surgery, patients will return to the clinic for evaluation by Thoracic 
Surgery staff prior to commencing post-operative chemotherapy per protocol.   
 
4.5 Tissue sample acquisition and processing  
 
4.5.1 At the time of biopsy of primary lung lesions, mediastinoscopy, and 
definitive lung cancer resections, tissue will be obtained for staging purposes. 
Additional tumor biopsies/aspirates will be obtained for evaluation of molecular 
endpoints. Tissue aspirates/biopsies will be immediately snap-frozen in liquid 
nitrogen and thereafter stored at -80°C..Tissues obtained from resections 
performed at the NCI will also be harvested in order to establish cell lines, and 
isolate cancer stem cells. 
  
All samples from the NCI will be codified and anonomized upon transport to the 
Thoracic Oncology Laboratory, (Building 10; Rm 3-5848), using the NCI Lab 
Matrix Database. Peripheral blood samples (10 ml) will be collected at baseline, 
immediately prior to surgery, 1month, and three months post-op, and at all 
subsequent scheduled follow-up appointments. Serum from these samples will 
be stored at -800C. Samples from Croatian patients will be coded (by using the 
Harris Orcan unique patient identifying number assigned at the time of NCI 
central registration) at the time of sampling, frozen, tracked and shipped via 
FedEx or World Courier to the Laboratory of Dr William Figg (See Appendix IX – 
NIH policy manual 1340-1, permits for import and export of biological materials). 
Application form 75-3 CDC for a permit to import or transport etiologic agents, 
hosts 
or 
vectors 
of 
human 
disease 
can 
be 
downloaded 
from  
http://dohs.ors.od.nih.gov/pdf/PHS%20Application%20to%20Import.pdf.  
(See appendix X - SOP describing all the procedures necessary to prepare 
biological samples for transport to the Clinical Pharmacology Program, Medical 
Oncology Branch, National Cancer Institute). 
Packaging and shipping will comply with IATAs dangerous goods regulations and 
with department of transport (DOT) regulations 49 CFR 171-178 which can be 
found at http://www.access.gpo.gov/nara/cfr/waisidx_07/49cfrv2_07.html. For 
information on packaging and shipping training, visit the DOHS website at 


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26
http://dohs.ors.od.nih.gov/Resources_main.htm.  A NIH commercial invoice form 
1884-1 is attached as appendix XII. 
Upon reaching the NCI, samples will be sent to the Lab of Dr William Figg,  
whereby, they will be codified, anonomized and stored for future analysis (See 
Appendix VII). Data will be entered as outlined in Appendix XI (SOP describes 
how to enter new sample data into LabSamples for the Clinical Pharmacology 
Program, Medical Oncology Branch, CCR, NCI). Thereafter, samples will be sent 
to the Laboratories of Dr Schrump, Dr Giaccone, Dr Meltzer and Dr Trepel. 
Tissues will be distributed to appropriate labs for micro-array, immuno-
histochemistry, and ELISA analysis of DNA methylation gene expression and 
gene expression profiling, analysis of k-ras mutation status and ERCC1/RRM1 
expression, and circulating VEGF levels.  
 
4.5.2 Sample processing for angiogenesis studies 
 
Draw blood into 3 CPT citrate tubes (blue/black tops). Samples are required at 
baseline (cycle 1 day 1), cycle 1 day 8, cycle 1 day 22, day of surgery and 
approximately 72 hours post surgery. Spin samples as per manufacturer’s 
instructions within 3 hours of collection. Collect the following: 
 
(1) The top 1ml (plasma) per tube and store at -80°celcius or in liquid 
nitrogen.  
(2) The cells right above the gel (the cloudy interface between the plasma and 
the gel). Count the number of cells via a hemocytometer or a coulter 
counter and mix with cryomedium of approximately 5 x 106 per vial. 
 
Store the samples at -80°celcius in an isopropanol container overnight and 
transfer to liquid nitrogen the next day. 
 
Specimens that were not collected at the National Institutes of Health will be 
shipped to Lab of Dr William Figg as outlined above and then sent to the lab of 
Dr Jane Trepel (Building 10, Room 12N218).  
 
4.6 Protocol evaluation 
Baseline non-radiological evaluations are to be conducted within 1 week prior to 
start of study therapy. PET/CT and CT chest, abdomen and pelvis and either 
brain MRI or CT brain with contrast must be carried out within 28 days prior to 
the start of therapy.  
 
4.7 Concurrent therapies 
The combination of cisplatin, gemcitabine and bevacizumab is an approved 
chemotherapeutic drug combination in stage IV NSCLC, however, because there 
is a potential for interaction with other concomitantly administered drugs, the 
case report form must capture the concurrent use of all other drugs, over-the-
counter medications, or alternative therapies. Patients will be advised to discuss 


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27
taking any drugs, over-the-counter medications, or alternative therapies with a 
member of the research team.  
 
4.8 Reassessment 
Patients will be seen in clinic at least every 1 week while receiving neo-adjuvant 
therapy and 3 weekly while receiving adjuvant therapy. A history and physical 
with sphygmomanometry and a review of systems that documents coagulopathy-
related events must be charted in the medical record for each visit. PET/CT and 
CT/MRI scans will be obtained at baseline and within 2 weeks before surgery to 
monitor disease response. Measurable disease will be monitored as described in 
section 
9. 
Blood 
pressure 
monitoring 
will 
be 
based 
on 
published 
recommendations (NHLBI, JNC7). The PI will be notified of any abnormal 
measurement (any systolic BP over 140 or diastolic BP > 90). Treatment will be 
determined by the BP on the day of the clinic visit surrounding the treatment. 
Urinalysis every 3 weeks for proteinuria and calculation of a urine/protein 
creatinine ratio will be determined prior to each administration of bevacizumab 
(Bevacizumab dose modifications see section 5.5). 
 
4.9 Duration of therapy 
Patients will receive three 3-week cycles of neo-adjuvant chemotherapy leading 
to 63 days/9 week duration of therapy prior to surgery. There will then be a 4 to 6 
week period prior to surgery (7 to 9 weeks after completion of bevacizumab). 
Post-operatively (4-8 weeks) patients who are medically fit to receive adjuvant 
chemotherapy will receive up to 4 cycles of adjuvant chemotherapy (see section 
4.0). 
 
4.10 Off study criteria 
 
1. Progression of disease during treatment on study protocol. 
No less than 4 weeks/28 days post completion of last cycle of 
Cisplatin/Gemcitabine and 7 weeks/49 days post completion of second 
infusion of Bevacizumab. No more than 12 weeks/85 days from the start of 
therapy. Decision will be made at the time of restaging (restaging prior to 
surgery). However, if clinically indicated, a decision may be made following 
the first or second cycle, after obtaining the appropriate staging studies. 
 
2. Grade 3/4 adverse event lasting greater than 2 weeks or when therapy is 
judged detrimental to the patient’s health. 
 
3. Grade 4 hypersensitivity reaction to drug administration (anaphylaxis). 
 
4. Patient non-compliance or voluntary withdrawal. 
 
5. If a patient is deemed medically unfit to continue on study, at the discretion of 
the Principal Investigator. 
 


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28
Unacceptable toxicities that have not resolved at time of “off treatment” or “off 
study” must be followed until stabilization or resolution. 
 
4.11 Post study evaluation (Follow-up) 
 
Patients will be evaluated one month post adjuvant chemotherapy and then 
every 3 months for the first 2 years, every 6 months for 3 years and then yearly 
for 3 years. Follow up will include clinical evaluation, a chest x-ray and additional 
investigations when clinically indicated. 
 
5.0 
Dosing delays and dose modification 
 
5.1  Gemcitabine/Cisplatin/Etoposide - Hematologic toxicities 
 
5.1.1 Neutropenia/Thrombocytopenia 
Patients will have a complete blood count with differential checked prior to each 
dose of chemotherapy, on day 1 and on day 8 of neo-adjuvant therapy. Patients 
not eligible for treatment due to low neutrophil count or platelet count must return 
in one week for reassessment. 
 
• During cycle 1 (neoadjuvant setting), patients should not receive 
prophylactic filgrastim or pegfilgrastim to support their white blood cell 
count. 
• Any grade 4 neutropenia, or grade 3-4 neutropenia associated with fever 
(one reading of temperature ≥ 38.5° C or two readings of >38° C one hour 
apart), in addition to commencing recommended institutional antibiotic 
therapy may be treated with filgrastim or pegfilgrastim at the discretion of 
the treating physician.  If filgrastim or pegfilgrastim is used to support the 
neutrophil count, no dose reduction for neutropenia is required unless 
growth factor support is insufficient to prevent subsequent grade 3/4 
neutropenia. 
• Patients who experience grade 4 neutropenia on protocol (with or without 
fever), or require dose delay due to neutropenia, will receive prophylactic 
pegfilgrastim or filgrastim during cycle 2 and 3 of chemotherapy. 
• See Table 1 for dose adjustment criteria. 
 
 
Table 1: Day 1 Cisplatin/Gemcitabine/Bevacizumab 
 
Absolute neutrophil count  
 
Platelets 
Treatment 
≥ 1000/μl 
and
≥100,000/μl  
Treat 
<1000/μl 
or 
<100,000/μl 
Hold therapy until ANC 
≥1000/μl and platelets 
≥100,000/μl 


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29
 
 
Table 1: Day 8 Gemcitabine only 
 
Absolute neutrophil count  
 
Platelets 
Treatment 
>1000/μl 
 
750-1000/μl 
 
 
500-750/μl 
And 
 
 
And 
 
 
And 
 
100,000/μl 
 
75,000 - 
100,000/μl  
 
50,000 -
75,000/μl 
Treat with full dose 
 
25% dose reduction of 
Gemcitabine 
 
50% dose reduction of 
Gemcitabine  
<500/μl 
or 
<50,000/μl 
Hold Gemcitabine 
 
 
5.2 
Gemcitabine/Cisplatin/Etoposide – Non-Hematologic toxicities 
All non hematological toxicities should be resolved to grade 1 or less at the start 
of each cycle with the exception of alopecia. 
 
5.3      Dose modifications for subsequent cycles of Cisplatin/Gemcitabine 
 
• Non hematological grade 3 or 4 toxicities during the previous cycle will 
require a 25% dose reduction in the dose of both Cisplatin and 
Gemcitabine with the exception of: 
 
a. ototoxicity (grade 3/4) which will require substitution of Carboplatin 
for Cisplatin 
b. nephrotoxicity (grade 3/4) which will require substitution of 
Carboplatin for Cisplatin 
c. neurotoxicity (recurring or worsening grade 2) which will require 
substitution of Carboplatin for Cisplatin 
 
• Grade 3 or 4 toxicity of nausea and vomiting from a previous cycle will not 
require a dose reduction unless symptoms are refractory to antiemetic 
medications as outlined in section 4.3.1. 
 
5.4 In the adjuvant setting the same dose reductions and modifications apply  
          for Etoposide and Cisplatin as outlined above. 
 
5.5 
 Bevacizumab dose modifications 
 
1. Hypertension: Hypertension is one of the major toxicities that may be 
experienced with bevacizumab. All patients will have blood pressure measured 
and recorded weekly during the first 9 weeks of the study. Patients who have an 
asymptomatic increase > 20 mmHg (diastolic) or > 150/100mmHg recurrent or 


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30
persistent more than 24h: Antihypertensive therapy (or adding another category 
of antihypertensive drug if the patient already being treated for HTN) 
monotherapy will be initiated. Bevacizumab should be held for systolic BP (SBP) 
> 150 mmHg or diastolic BP (DBP) > 100 mmHg. If symptomatic, bevacizumab 
will be held until symptoms resolve. Bevacizumab should be discontinued for 
grade 4 hypertension. The presence of hypertension and proteinuria would favor 
the use of angiotensin-converting enzyme inhibitors or angiotensin receptor 
blockers, more so because angiotensin inhibitors restore nephrin expression.  
 
2. Hemorrhage/Bleeding: Bevacizumab administration is contingent upon 
assessment of any persistent bleeding. Active bleeding such as new petechiae, 
epistaxis, intermittent minimal hemoptysis or nasal secretions, or other grade 1 or 
greater bleeding events (excluding dipstick positive urine without red blood cells 
by microscopic exam) will require additional workup and subsequent risk 
assessment. Grade 2/3/4 hemorrhage: Bevacizumab will be stopped and not re-
introduced. 
 
3.Proteinuria: A spot UPC ratio should be performed prior to each bevacizumab 
dose. Repeat testing should be performed no sooner than 4 days. If 
bevacizumab is delayed for more than 2 weeks due to proteinuria, discontinue 
bevacizumab. 
 
Table 2: Bevacizumab dose modification (See appendix III) 
UPC RATIO 
BEVACIZUMAB DOSE MODIFICATION 
<2 
Continue Bevacizumab 
≥ 2 – 3.5 
Hold Bevacizumab and recheck UPC in 1 week. UPC must 
resolve <1.0 in order to resume Bevacizumab 
> 3.5  
Hold Bevacizumab and recheck UPC in 1 week. UPC must 
resolve <1.0 in order to resume Bevacizumab.  
 
 
4. Surgical or periodontal procedures: If there is a need for a major surgical or 
serious periodontal procedure, bevacizumab should be held for 4 weeks prior to 
the procedure and must not be resumed until 4 weeks after the surgical 
procedure. Longer delays may be necessary if clinically indicated in order to 
insure that adequate healing has taken place prior to bevacizumab resumption. 
Minor oral or periodontal procedures or surgical procedures may be done with no 
delay at the discretion of the PI. 
 
 
 
 


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31
5. Thrombosis 
 
Arterial Thromobsis: Patients will be taken off study in the event of arterial 
thrombosis. Arterial thrombosis includes CNS ischemia, cardiac ischemia, and 
any visceral or peripheral artery thrombosis. 
 
Venous Thrombosis: For venous thrombosis requiring systemic anticoagulation, 
patients will not receive further bevacizumab.    
 
6. Coagulopathy: Patients with grade 3-4 coagulopathy will be taken off study.  
 
7. Thrombocytopenia (platelets < 50,000/μl - grade 3 or greater): Bevacizumab 
should be held until thrombocytopenia resolves to grade 1 or better (platelet 
count ≥ 75,000/μl). If treatment is delayed for more than 2 weeks, discontinue 
therapy. Thrombocytopenia due to Cisplatin and Gemcitabine will require dose 
reductions of these agents. (see cisplatin and gemcitabine dose modifications, 
section 5.1.1). 
 
8. Infusion Reactions: Infusion reactions with the first dose of Bevacizumab are 
uncommon (<3%) and severe reactions can occur in 0.2% of patients. Infusion 
reactions reported in clinical trials include hypertension, hypertensive crises 
associated with neurologic signs and symptoms, wheezing, oxygen desaturation, 
NCI-CTC Grade 3 hypersensitivity, chest pain, headaches, rigors, and 
diaphoresis. Adequate information on re-challenge is not available. Patients who 
develop grade 2 allergic reactions with urticaria and dyspnea or any grade 3/4 
allergic/infusional reactions should have bevacizumab discontinued and not be 
re-challenged. Grade 1 Infusion reactions with transient flushing or rash canbe 
rechallenged 24 hours later after premedication with dexamethasone 20 mg IV 
30 minutes before the infusion. The infusion rate should be increased to 3 hours. 
If tolerated, the subsequent dose can be given with 50% of the steroid dose and 
a decreased duration of infusion from 3 hours → 90 minutes.  
 
9. Reversible posterior leukoencephalopathy syndrome (RPLS): Bevacizumab 
should be held in patients with signs and symptoms suggestive of reversible 
posterior leukoencephalopathy syndrome (RPLS), pending work-up and 
management, including control of blood pressure and MRI brain to rule out brain 
metastases. Bevacizumab should be discontinued upon diagnosis of RPLS. 
 
10. 
Bevacizumab should be withheld in the event of Grade 3 LFT elevations 
(Liver transaminases or alkaline phosphatase greater than 5.0 x upper limit of 
normal, total bilirubin greater than 3.0 x upper limit of normal), and should not 
resume until the abnormalities have recovered to grade 1 or lower.  If LFT 
elevations recur with retreatment, bevacizumab should be permanently 
discontinued. 
 
 


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32
6.0 
Pharmaceutical Information 
6.1 
Gemcitabine (see product information appendix VIII) 
6.2 
Cisplatin (see product information appendix VIII) 
6.3 
Bevacizumab (see product information appendix VIII) 
6.4 
Etoposide (see product information appendix VIII) 
 
 
7.0 
Correlative Studies 
Blood and tissue specimens collected in the course of this research project may 
be banked and used in the future to investigate new scientific questions related 
to this study.  However, this research may only be done if the risks of the new 
questions were covered in the consent document.  If new risks are associated 
with the research (e.g. analysis of germ line genetic mutations), the principal 
investigator must amend the protocol and obtain informed consent from all 
research subjects.  
 
Samples to be obtained for correlative studies (Section 4.5.1 for sample 
management): 
 
1. Block of formalin-fixed, paraffin-embedded primary tumor for  
--Immunohistochemistry for ERCC1 and RRM1 
--DNA extraction for CGH and methylation assays 
--KRAS mutation analysis 
 
2. Peripheral blood drawn into 3 CPT citrate tubes for CEC, CEP, MDSC,   Tie2+ 
monocytes, VEGFR1+ hemangiocytes (See section 4.5.2) 
 
 
7.1 Angiogenesis studies  
 
7.1.1 Method for identification of CEC and CEP  
 
Multiparameter flow cytometry is currently the best way to identify CEC and CEP 
cells33.  For this analysis, peripheral blood is drawn into 3 CPT citrate tubes 
(approximately 8 cc per tube) (See section 4.5.2 for sample processing).  
 
Mononuclear cells are isolated by centrifugation, washed with PBS, and FcR 
solution (Miltenyi) is added to block non-specific binding.  For identification of 
CECs and CEPs, cells are stained with FITC- conjugated anti-CD31 (BD), 
PerCP-conjugated anti-CD45 (BD), APC-conjugated anti-CD133 (Miltenyi) and 
PE-conjugated CD146 (Chemicon) for 30 min on ice.  For isotype controls, cells 
are incubated with FITC-conjugated IgG1, PerCP-conjugated IgG1, APC-
conjugated IgG1 and PE-conjugated IgG1.  After washing with 0.1% BSA in PBS, 
the cells are incubated with Hoechst 33258 dye as an indicator of cell viability 


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33
and analyzed by multiparametric flow cytometry on an LSR II flow cytometer (BD 
Biosciences), using LSR II-equipped digital data acquisition and FlowJo 
cytometric data analysis software. The CEC and CEP cell concentrations are 
calculated as a percentage of the total number of mononuclear cells or as the 
number of cells/microliter of whole blood after an evaluation of a minimum of 105 
cellular events, and preferable 106 cellular events.  CEC cells are defined by the 
co-expression, or absence of expression on a single cell of the following 
parameters: CD45-, CD31+, CD133- and CD146+, Hoechst 33258- (viable CEC) 
or CD45-, CD31+, CD133- and CD146+, Hoechst 33258+ (nonviable CEC).  
CEP cells are defined by the co-expression, or absence of expression on a single 
cell of the following parameters: CD45- or dim, CD31+, CD133+ and CD146-, 
Hoechst 33258- (viable CEP) or CD45- or dim, CD31+, CD133+ and CD146-, 
Hoechst 33258+ (nonviable CEP).  CEC and CEP markers may be modified or 
expanded in response to new studies in this rapidly developing field.  Additional 
parameters may be added specific to the targeted agent, i.e. flow cytometric 
analysis of p53 levels or the level of p53 target gene products in CEP and other 
progenitor cells.   
 
The assays will be performed by Dr. Min-Jung Lee and Dr. Yeong Sang Kim in 
Jane Trepel’s laboratory in the Medical Oncology Branch, Building 10, Room 
12N218.   This group has particular expertise in multiparametric flow cytometry 
pharmacodynamic assays34,35, including development of flow cytometric assays 
that were used for several published clinical trials36,37, and a patent in the 
National Phase of Foreign Filing on the use of multiparameter flow cytometry for 
pharmacodynamic analysis38. 
 
The outcome measures will be the number of CEC and CEP per 106 
mononuclear cells or per microliter of peripheral blood, analyzed in samples 
taken before and after treatment.  These numbers will then be examined for 
correlations with various parameters to assess their potential utility as surrogate 
biomarkers for drug activity, for establishing the optimal biologic dose, for patient 
stratification, and monitoring of therapy-related side effects.  
 
7.1.2 Myeloid Subset Analysis 
 
Peripheral blood will be analyzed for 3 myeloid subsets: MDSC, (myeloid-derived 
suppressor 
cells), 
Tie2+ 
proangiogenic 
monocytes, 
and 
VEGFR1+ 
hemangiocytes, using multiparameter flow cytometry. 
 
The markers to be used and the references for each subtype are included in 
table 3. 
 
Note that 3 CPT citrate tubes collected should be sufficient for the 3 myeloid 
subpopulations as well as CEC and CEP cells.  All analyses will be performed in 
accord with the number of cells available.  Markers may be modified as more 
detailed studies become available. 


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34
Table 3: Angiogenesis studies 
Sample 
Target population 
Marker 
Ref. 
PBMC  
1. CEC/CEP 
  
  
3 CPT citrate 
tubes 
(Becton 
Dickinson) 
  
  
  
  
2. MDSC  
lineage(CD3,14,19,56)- 39,40,41,42 
  
(Myeloid-derived suppressor cells)  
HLA-DR - 
  
  
  
CD33+ 
  
  
  
CD11b+ 
  
  
  
  
  
  
3. Tie2+ monocyte 
Tie2+ 
39,40,43,44,45
  
  
CD14 low 
  
  
  
CD16 + 
  
  
  
  
  
  
4. VEGFR1+ hemangiocyte 
VEGFR1+ 
39,40,46 
  
  
CD11b+ 
  
  
  
  
  
 
 
7.2 KRAS mutation analysis: 
Tissue (whether fresh or archival) for KRAS mutation status will be analyzed at 
the pathology department in the National Cancer Institute. 
 
7.3 Comparative Genomic Hybridization: 
As exploratory analyses, in collaboration with Dr. Paul Meltzer, we will utilize 
patient’s tumor tissue to determine if there is any correlation between 
chromosomal gains or losses in comparative genomic hybridization in non small 
cell lung carcinomas and clinical outcome.   
 
7.3.1 Collection of Specimen(s): 
Archival material:  A block of archival tumor material will be requested from each 
patient.  In addition, a recent resection sample or blocks of tissue from the 
original resection will be required (see section 4.5.1).   
 
 
7.3.2 Handling of Specimens(s):  
Comparative Genomic Hybridization (CGH) is a whole genome scanning method 
which can measure changes in copy number across the whole genome. This 
technique has the potential to uncover regions of the genome which undergo 
recurrent alteration during tumor progression.  Recent advances allow this 
technique to be performed at gene level resolution using microarrays.  Similarly, 
this technique can now be used to study the methylation status of thousands of 
sites in the genome.  CGH and methylation assays will be performed on DNA 
extracted from formalin fixed paraffin embedded tumor tissue (FFPE) using 
previously collected excess material which is not necessary for diagnostic 
purposes. Procedures will be carried out in the Clinical Molecular Profiling Core 


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lab.  One 5 micron section will be cut from the FFPE block and stained using 
hematoxylin and eosin to guide the collection of tumor tissue. If a suitable stained 
section is already available, that will be used instead. Using the stained section 
to identify the location of tumor within the block, a core of tissue will be collected 
using a 1mm punch. The block will then be stabilized by the insertion of a paraffin 
plug.  If the FFPE material is not of sufficient size for tissue collection by the 
punch method, 5 unstained slides will be cut from the FFPE block and the tumor 
tissue scraped from the slides.  DNA will be then be extracted from the FFPE 
tissue using the ATL tissue lysis buffer (Qiagen) and the DNeasy kit (Qiagen).  
900ng DNA will be labeled for hybridization to CGH and 500ng utilized for 
methylation microarrays using standard methods (Barrett et al.; Bibikova et al.).  
If insufficient DNA is unavailable, 10-20ng of DNA will be amplified using the 
WGA2 kit (Sigma) and 2.5 micrograms of the amplification product will be used 
for CGH.   
 
7.3.3  Site(s) Performing Correlative Study: 
CGH will be performed in collaboration with Dr. Paul Meltzer, Clinical Molecular 
Profiling Core lab, Bldg. 37 room 6138, tel. (301) 496-5266. 
 
7.4 
Methylation microarray analysis  
 
DNA and RNA will be isolated from tumor aspirates. Bisulfite modified DNA will 
be amplified using WGA procedures perfected in the Thoracic Oncology 
Laboratory. RNA will be amplified using established techniques. Genomic DNA 
methylation and gene expression signatures will be assessed by Illumina micro-
arrays, as well as customized arrays containing a variety of cancer-testis gene 
sequences, developed in the Thoracic Oncology Lab, Surgery Branch, NCI. 
Software assisted higher order analysis will be performed to examine if DNA 
methylation and /or gene expression signatures appear to be associated with 
response to therapy. These assays, will be performed by Thoracic Oncology lab 
personnel in collaboration with Dr. Paul Meltzer’s group at the NIH, are 
considered hypothesis generating; data from these preliminary studies may be 
further evaluated in a more formal manner in subsequent clinical trials.  
 
7.5  ERCC1 and RRM1 polymorphism and expression measurement: 
 
ERCC1 is the DNA repair gene involved in Nucleotide Excision Repair (NER) 
pathway that is mainly responsible for removing the DNA damage caused by 
cisplatin. A synonymous mutation at 500 (C>T) in the messenger RNA, both 
coding for asparagines (Asn, or N) at 118, was found to be correlated to 
important clinical endpoints of platinum-based chemotherapy47,48. In general, the 
variant allele T was thought to result in decreased codon usage, which in turn 
compromises ERCC1 protein expression. Patients with T allele were found to 
respond to platinum-based chemotherapy better than those possessing C allele. 
In addition, ERCC1 expression level in the tumors was suggested to have 
prognostic value for platinum-based chemotherapy49-52. Patients with low ERCC1 


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36
expression showed survival benefit from platinum-containing regimens. This 
study will examine whether the genotype of the germ line mutation ERCC1 
N118N (500 C>T), and/or ERCC1 expression level in tumors could be used to 
predict a survival benefit of chemotherapy. Ribonucleotide reductase M1, also 
known as RRM1, encodes the regulatory subunit of this enzyme and is a 
molecular target of gemcitabine. Gemcitabine-treated patients with high tumoral 
RRM1 expression generally signal poor prognoses53,54. In addition to the gene 
expression, two genetic polymorphisms (-37 and -524) in the promoter region of 
RRM1 gene showed prognostic value for gemcitabine in patients with NSCLC55. 
The response rate was significantly higher in the patients carrying RR37AC-
RR524CT genotype compared with the patients containing other genotypes (P = 
0.039). 
 
7.5.1 Collecting of Specimens(s): 
Blood samples will be collected from each patient enrolled in this study to extract 
the genomic DNA for genotyping of ERCC1 polymorphism. In addition, tumor 
tissues, stromal cells surrounding the tumors and a small amount of normal 
tissue from each patient will be collected to be used in the immuno-staining 
study. 
 
7.5.2 Handling of Specimens(s):  
Immuno-staining of ERCC1 will be performed using paraffin-embedded tumor 
samples from previously collected material. Specimens will be exposed to 10 mM 
citrate buffer (pH 6.0) and heated for 30 minutes in a water bath. Sections of 
tumors will be incubated for 60 minutes with a monoclonal antibody specific 
against the full-length human ERCC1 protein (mouse, clone 8F1, Neomarkers). 
Binding of the antibody will be determined using NovaRED as the substrate and 
Mayers hematoxylin as the counterstain56. The normal tissue sections and the 
stromal cells surrounding the tumor will be used as external and internal positive 
controls. Total RNA will be extracted using PicoPure RNA isolation kit (KIT0204; 
Arcturus, Mountain View, CA) for the measurement of RRM1 expression. 
Complementary DNA will be synthesized using Superscript II and oligo-dT from 
Invitrogen (Carlsbad, CA). Real-time quantitative RT-PCR gene analysis will be 
performed in triplicate per sample and gene in 96-well plates using ABI prism 
7700. Genotyping experiments will be performed using genomic DNA isolated 
from serum using the QIAmp DNA blood mini-kit (Qiagen, Inc, Valencia, CA). 
Polymerase chain reaction (PCR) will be performed using the Platinum Taq PCR 
Kit from Invitrogen (Carlsbad, CA) with gene-specific primers. Direct nucleotide 
sequencing PCR will be conducted using the Big Dye Terminator Cycle 
Sequencing Ready Reaction kit V3.1 (Applied Biosystems, Foster City, CA) and 
an ABI Prism 3130 Genetic Analyzer according to the manufacturers instructions. 
 
7.5.3 Site(s) Performing Correlative Study: 
These studies will be performed in collaboration with Dr. William Figg at the 
Medical Oncology Branch, CCR, NCI, Bldg 10 room 5A07, tel. (301) 451-5859. 
                                                                                  


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37
8.0   
Study calendar 
 
 
Parameter 
 
Prestudy1 
Before Each 
Neoadjuvant
Cycle2  
Prior to 
Surgery  
Before 
Each 
Adjuvant 
Cycle 
Follow
- 
Up5 
History  
X 
X 
X 
X 
X 
Physical examination  
X 
X 
X 
X 
X 
Height (Prestudy only) and Weight
X 
X 
X 
X 
X 
Measurement of tumor4 
X 
 
X 
 
X 
Performance status  
X 
X 
X 
X 
X 
CBC, differential, platelet count, 
Coagulation studies 
X 
X 
X 
X 
X 
Serum Chemistries (must include, 
bilirubin, Alk Phos, ALT and AST, 
Albumin, LDH) 
 
X 
 
X 
 
X 
            
X           
 
X 
Glucose and Electrolytes (Na, K, C, 
C1, CO2, BUN, glucose, calcium, 
phosphorous, magnesium, 
bicarbonate), urinalysis and UP/C, 24 
hr urine collection.7 
 
X 
 
X 
 
X 
 
 
X 
Beta HCG2,3 
X 
 
 
 
 
Tumor Imaging4 
X 
 
X 
 
 
Brain CT or MRI6 
X 
 
X 
 
 
CXR/EKG/PFT/ABG and Echo1 
X 
 
X 
 
 
Thallium Stress Test 
X 
 
 
 
 
 
 
1 Within 14 days before initiating chemotherapy and within 14 days prior to 
surgery 
 
2 Within 7 days prior to receiving chemotherapy 
 
3 For women of childbearing potential. 
 
4 This consists of a CT scan thorax through to the adrenals, and a PET/CT 
scan, within 28 days of initiation of therapy, and at the completion of neo-
adjuvant chemotherapy within 14 days prior to surgery. Restaging CT scans 
at the end of adjuvant chemotherapy and every 3 months for 2 years, every 
6 months for 3 years, then yearly for 3 years. 
 
 
5 Every 3 months for 2 years, every 6 months for 3 years, then yearly for 3 
years. 
 
6 At investigator’s discretion, depending on symptoms 
 
7 Please see Appendix III for determination of UP/C.  UP/C should be 
performed prior to all 3 cycles of neo-adjuvant therapy. 24 Hr. urine 
collection should be performed for all patients with a UP/C ≥ 2 
 
 
 


Protocol Number: 09-C-0107 
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38
9. 
MEASUREMENT OF EFFECT 
For the purposes of this study, patients should be re-evaluated for response at 
the end of treatment prior to surgery.   
9.1 Definitions 
Response and progression will be evaluated in this study using the new 
international criteria proposed by the Response Evaluation Criteria in Solid 
Tumors (RECIST) Committee. Changes in only the largest diameter (uni-
dimensional measurement) of the tumor lesions are used in the RECIST criteria. 
Note:  Lesions are either measurable or non-measurable using the criteria 
provided below. The term “evaluable,” in reference to measurability, will not be 
used because it does not provide additional meaning or accuracy. 
 
9.1.1 Measurable disease 
Measurable lesions are defined as those that can be accurately measured in at 
least one dimension (longest diameter to be recorded) as >20 mm with 
conventional techniques (CT, MRI, x-ray) or as >10 mm with spiral CT scan.  All 
tumor measurements must be recorded in millimeters (or decimal fractions of 
centimeters). 
 
9.1.2 Non-measurable disease 
All other lesions (or sites of disease), including small lesions (longest diameter 
<20 mm with conventional techniques or <10 mm using spiral CT scan), are 
considered non-measurable disease.  Bone lesions, leptomeningeal disease, 
ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonis, inflammatory 
breast disease, abdominal masses (not followed by CT or MRI), and cystic 
lesions are all non-measurable. 
 
9.1.3 Target lesions 
All measurable lesions up to a maximum of five lesions per organ should be 
identified as target lesions and recorded and measured at baseline.  Target 
lesions should be selected on the basis of their size (lesions with the longest 
diameter) and their suitability for accurate repeated measurements (either by 
imaging techniques or clinically).  A sum of the longest diameter (LD) for all 
target lesions will be calculated and reported as the baseline sum LD.  The 
baseline sum LD will be used as reference by which to characterize the objective 
tumor response. 
 


Protocol Number: 09-C-0107 
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39
9.1.4 
Non-target lesions 
All other lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Non-target lesions include measurable lesions that exceed 
the maximum numbers per organ.  Measurements of these lesions are not 
required, but the presence or absence of each should be noted throughout 
follow-up.  
9.2 
Guidelines for Evaluation of Measurable Disease 
All measurements should be taken and recorded in metric notation using a ruler 
or calipers.  All baseline evaluations should be performed as closely as possible 
to the beginning of treatment and never more than four weeks before the 
beginning of the treatment. 
 
 
The same method of assessment and the same technique should be used to 
characterize each identified and reported lesion at baseline and during follow-up. 
Imaging-based evaluation is preferred to evaluation by clinical examination when 
both methods have been used to assess the antitumor effect of a treatment. 
 
Clinical lesions.  Clinical lesions will only be considered measurable when they 
are superficial (e.g., skin nodules and palpable lymph nodes).  In the case of skin 
lesions, documentation by color photography, including a ruler to estimate the 
size of the lesion, is recommended.  
 
Chest x-ray.  Lesions on chest x-ray are acceptable as measurable lesions 
when they are clearly defined and surrounded by an aerated lung.  However, CT 
is preferable.  
 
Conventional CT and MRI.  These techniques should be performed with cuts of 
10 mm or less in slice thickness contiguously.  Spiral CT should be performed 
using a 5 mm contiguous reconstruction algorithm.   
 
Ultrasound (US).  When the primary endpoint of the study is objective response 
evaluation, US should not be used to measure tumor lesions.  It is, however, a 
possible alternative to clinical measurements of superficial palpable lymph 
nodes, subcutaneous lesions, and thyroid nodules.  US might also be useful to 
confirm the complete disappearance of superficial lesions usually assessed by 
clinical examination. 
 
Cytology, Histology.  These techniques can be used to differentiate between 
partial responses (PR) and complete responses (CR) in rare cases. 
The cytological confirmation of the neoplastic origin of any effusion that appears 
or worsens during treatment when the measurable tumor has met criteria for 
response or stable disease is mandatory to differentiate between response or 


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40
stable disease (an effusion may be a side effect of the treatment) and 
progressive disease. 
 
9.3     Response Criteria 
 
9.3.1  Evaluation of target lesions 
 
Complete Response (CR): Disappearance of all target lesions 
 
Partial Response (PR): At least a 30% decrease in the sum of the longest 
diameter (LD) of target lesions, taking as reference the baseline sum LD. 
 
Progressive Disease (PD): At least a 20% increase in the sum of the LD of target 
lesions, taking as reference the smallest sum LD recorded since the treatment 
started or the appearance of one or more new lesions 
 
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum LD since the 
treatment started. 
 
9.3.2 Evaluation of non-target lesions 
Complete Response (CR): Disappearance 
of 
all 
non-target 
lesions 
and 
normalization of tumor marker level. 
 
Incomplete Response/Stable Disease (SD):  
Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits 
 
Progressive Disease (PD): Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions. Although a clear 
progression of “non-target” lesions only is exceptional, in such circumstances the 
opinion of the treating physician should prevail and the progression status should 
be confirmed at a later time by the review panel (or study chair). 
 
Note:  If tumor markers are initially above the upper normal limit, they must 
normalize for a patient to be considered in complete clinical response. 
9.3.3 Evaluation of best overall response 
The best overall response is the best response recorded from the start of the 
treatment until disease progression/recurrence (taking as reference for 
progressive disease the smallest measurements recorded since the treatment 
started).  The patient's best response assignment will depend on the 
achievement of both measurement and confirmation criteria (see section 9.3.1). 
 


Protocol Number: 09-C-0107 
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41
 
Target Lesions 
 
Non-Target 
Lesions 
 
New Lesions 
 
Overall 
Response 
 
CR 
 
CR 
 
No 
 
CR 
 
CR 
 
Incomplete 
response/SD 
 
No 
 
PR 
 
PR 
 
Non-PD 
 
No 
 
PR 
 
SD 
 
Non-PD 
 
No 
 
SD 
 
PD 
 
Any 
 
Yes or No 
 
PD 
 
Any 
 
PD 
 
Yes or No 
 
PD 
 
Any 
 
Any 
 
Yes 
 
PD 
 
Note: 
 
• Patients 
with 
a 
global 
deterioration 
of 
health 
status 
requiring 
discontinuation of treatment without objective evidence of disease 
progression at that time should be classified as having “symptomatic 
deterioration.”  Every effort should be made to document the objective 
progression, even after discontinuation of treatment. 
• In some circumstances it may be difficult to distinguish residual disease 
from normal tissue.  When the evaluation of complete response depends 
on this determination, it is recommended that the residual lesion be 
investigated (fine needle aspirate/biopsy) before confirming the complete 
response status. 
 
9.4  Confirmatory Measurement/Duration of Response 
 
9.4.1 Confirmation 
To be assigned a status of PR or CR, changes in tumor measurements must be 
confirmed by repeat assessments that should be performed four weeks after the 
criteria for response are first met.  In the case of SD, follow-up measurements 
must have met the SD criteria at least once after study entry and at a minimum 
interval of eight weeks   (see section 9.3.3). 


Protocol Number: 09-C-0107 
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42
 
9.4.2 Duration of overall response 
The duration of overall response is measured from the time measurement criteria 
are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented (taking as reference 
for progressive disease the smallest measurements recorded since the treatment 
started). 
 
The duration of overall CR is measured from the time measurement criteria are 
first met for CR until the first date that recurrent disease is objectively 
documented. 
 
9.4.3 Duration of Stable Disease 
Stable disease is measured from the start of the treatment until the criteria for 
progression are met, taking as reference the smallest measurements recorded 
since the treatment started.  
 
 
9.5  
Time to Progression and Overall Survival 
 
• Time to progression: The time between the first day of treatment to the 
day of disease progression as described in section 9.3. 
• Overall survival: The time between the first day of treatment to the days of 
death. 
 
9.6 
Response Review 
 
Patients with measurable disease will be assessed by standard criteria.  The 
purpose of tumor measurements will be to assess benefit to the patients from 
treatment and to determine appropriateness for continuing on study.  For the 
purposes of this study, patients should be re-evaluated after the third cycle of 
neo-adjuvant treatment and before surgery.  The response will be evaluated by 
the radiology departments at the Clinical Center Bethesda and in Zagreb Croatia. 
 
 
 
 
 
 
 
 


Protocol Number: 09-C-0107 
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43
10.0 REGULATORY AND REPORTING REQUIREMENTS 
Adverse Event Definitions 
 
10.1.1 Adverse Event 
An adverse event is defined as any reaction, side effect, or untoward event that 
occurs during the course of the clinical trial, whether or not the event is 
considered related to the treatment or clinically significant. For this study, AEs 
will include events reported by the patient, as well as clinically significant 
abnormal findings on physical examination or laboratory evaluation. A new 
illness, symptom, sign or clinically significant laboratory abnormality or worsening 
of a pre-existing condition or abnormality is considered an AE.  All AEs must be 
recorded on the AE case report form.   
 
All AEs, including clinically significant abnormal findings on laboratory 
evaluations, regardless of severity, will be followed until satisfactory resolution. 
AEs should be reported up to 30 days following the last dose of study drug.  AEs 
that are considered treatment related, expected, continuing, but not resolvable by 
30 days after treatment completion (e.g., alopecia) will not be followed after the 
30-day period.  
 
An abnormal laboratory value will be considered an AE if the laboratory 
abnormality is characterized by any of the following: 
• 
Results in discontinuation from the study 
• 
Is associated with clinical signs or symptoms  
• 
Requires treatment or any other therapeutic intervention 
• 
Is associated with death or another serious adverse event, 
including hospitalization.  
• 
Is judged by the Investigator to be of significant clinical 
impact 
• 
If any abnormal laboratory result is considered clinically 
significant, the investigator will provide details about the 
action taken with respect to the test drug and about the 
patient’s outcome. 
 
. 
10.1.2 Serious Adverse Event (SAE) 
 
Serious adverse drug experience (or SAE): Any adverse drug experience 
occurring during any study phase (treatment or follow-up) and at any dose that 
results in any of the following outcomes: 
•    
Death, 
•  
A life-threatening adverse drug experience 
•  
Inpatient 
hospitalization 
or 
prolongation 
of 
existing 
hospitalization 
•  
A persistent or significant disability/incapacity 
•  
A congenital anomaly/birth defect. 


Protocol Number: 09-C-0107 
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44
•  
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. 
 
Disability: A substantial disruption of a person’s ability to conduct normal life 
functions. 
 
Life-threatening adverse drug experience: Any adverse drug experience that 
places the patient or subject, in the view of the investigator, at immediate risk of 
death from the reaction as it occurred, i.e., it does not include a reaction that had 
it occurred in a more severe form, might have caused death. 
 
10.1.3 Unexpected adverse drug experience:  
 
Any adverse drug experience, the specificity or severity of which is not consistent 
with the current package insert. ‘‘Unexpected,’’ as used in this definition, refers 
to an adverse drug experience that has not been previously observed (e.g., 
included in the investigator brochure) rather than from the perspective of such 
experience not being anticipated from the pharmacological properties of the 
pharmaceutical product. 
 
 
10.2 NCI-IRB Adverse Event Reporting 
 
10.2.1  NCI-IRB Expedited Reporting of and Adverse Events and Deaths  
 
The Protocol PI will report to the NCI-IRB: 
• 
All serious adverse events (SAEs) that are not in the 
consent form, but are possibly, probably or definitely related to the 
research.  A SAE is defined as an untoward medical occurrence 
that 
o 
resulted in a death; 
o 
was life-threatening; 
o 
required or prolonged hospitalization; 
o 
caused persistent or significant disability/incapacity; 
o 
resulted in congenital anomalies or birth defects; or 
o 
required 
intervention 
to 
prevent 
permanent 
impairment or death. 
• 
All other deaths not included in the SAE category above, 
except deaths due to progressive disease.  


Protocol Number: 09-C-0107 
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45
• 
All deaths that occur within 30 days of the last dose of study 
drug or treatment, except deaths due to progressive disease.  
• 
All grade 3 and 4 (CTCAE) events that are not in the consent 
and that are possibly, probably or definitely related to the 
research. 
Reports must be received by the NCI-IRB within 7 working days via iRIS or for 
participating sites using form supplies in Appendix VI 
 
 
10.2.2 NCI-IRB Requirements for PI Reporting of Expected (In Consent) and 
Unexpected (Not in Consent) Adverse Events at Continuing Review 
The protocol PI will report to the NCI-IRB:  
• 
All Grade 2 events that are not in the consent form, but are 
possibly, probably or definitely related to the research;  
• 
All Grade 3 and 4 events that are possibly, probably or 
definitely related to the research;  
• 
All Grade 5 events regardless of attribution;  
• 
All Serious Events regardless of attribution.  
• 
NOTE: Grade 1 events are not required to be reported.  
 
The form for reporting to the FDA is the Voluntary MedWatch 3500 Form which 
can 
be 
found 
at: 
http://www.fda.gov/medwatch/how.html. 
Only 
serious, 
unexpected, and unrelated events will be reported to the FDA.  Outside sites will 
fill out the Voluntary MedWatch 3500 form and fax or email to the Coordinating 
Center. Forms can be faxed to Arlene Berman 301-480-2590 or emailed to 
arleneb@mail.nih.gov 
 
Confidentiality will be maintained as much as possible, consistent with applicable 
regulations.  Names of participants or identifying material will not be released 
without patient permission, except when such release is required by law.  No 
patient’s name or identifying information will be released in any publication or 
presentation.  Records are maintained according to current legal requirements, 
and are made available for review according to the requirements of the Food and 
Drug Administration (FDA) or other authorized user, only under guidelines 
established by the Federal Privacy Act. 
 
 
 
 
 


Protocol Number: 09-C-0107 
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46
11.0 STATISTICAL CONSIDERATIONS 
 
11.1 Study Design/Endpoints 
 
The primary objective of this study is to determine in patients with stage IIIA N2 
NSCLC if the combination of bevacizumab, gemcitabine, and cisplatin is able to 
result in a rate of pathologic complete responses (PCR) which is approximately 
double that of platinum and gemcitabine alone. 
 
The study will be conducted as an optimal two-stage phase II trial (Simon R, 
Controlled Clinical Trials 10:1-10, 1989), in order to rule out an unacceptably low 
5% PCR rate  (p0=0.05; that is, 5% which was observed for patients receiving 
platinum and gemcitabine alone)  in favor of a targeted, improved rate consistent 
with 15% (p1=0.15).  With alpha=0.10 (probability of accepting a poor 
regimen=0.10) and beta = 0.10 (probability of rejecting a good regimen=0.10), 
the study will initially enroll 28 evaluable patients, and if 0-1 of the 28 are able to 
have a PCR then no further patients will be accrued. If 2 or more of the first 28 
patients have a PCR, then accrual would continue until a total of 66 patients have 
been treated.   A temporary pause in the accrual to the trial may be necessary to 
ensure that enrollment to the second stage is warranted. If there are 2 to 5 
patients with a PCR in the total of 66 patients, then this would be an 
uninterestingly low rate, while if there were 6 or more patients of the 66 who have 
a PCR, this would be sufficiently interesting to warrant further study of this 
regimen in later trials. Under the null hypothesis (5% PCR rate), the probability of 
early termination is 59%. 
 
At present there are no published trials involving neoadjuvant bevacizumab in 
NSCLC. Unpublished studies have documented the potential for an increase in 
pulmonary hemorrhage or tracheosophageal fistula formation. These studies 
have either involved concurrent chemoradiation or used a higher dose of 
bevacizumab (15mg/Kg) or a greater number of induction bevacizumab 
treatments (3 cycles). In this study the dose of bevacizumab is 7.5mg/kg, 
patients will receive 2 doses of bevacizumab only and radiation will not be 
administered.  
 
An interim evaluation for safety will be performed. The incidence of grade 3 
toxicities 
will 
be 
compared 
to 
existing 
data 
involving 
neoadjuvant 
gemcitabine/cisplatin (see table 4, 5, 6, 7) .If more than one patient in the first 10 
enrolled is noted to have a fistula formation, or to have Grade 3 hemorrhaging 
within the first 10 patients enrolled, then the trial will be modified to reduce the 
likelihood of this occurring further. After 28 patients have been enrolled, a further 
evaluation of toxicities will take place and incidences noted of grade 3 toxicities 
will be compared to those associated with patients receiving standard 
chemotherapy (without bevacizumab). The magnitude of the noted toxicities 
relative to those associated with standard therapy will be used to guide further 


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47
treatment modifications if necessary. For example, if the associated lower 80% 
confidence interval bound for any individual toxicity incidence in this trial exceeds 
the actual rate known for the same type of toxicity in conventional treatment of 
similar patients, then this will trigger an evaluation to determine if modifications to 
the regimen are warranted. 
 
Table 4: Hematologic Toxicity (N=47) for Induction Gemcitabine and Cisplatin for 
patients with stage IIIA-N2 NSCLC57  
 
 
Grade 0 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
 
No. Pts       % 
No. Pts       %
No. Pts       %
No. Pts       % 
No. Pts       %
Leukocytes 
7            14.9.   10           21.3
16           34.0
14           29.8        --- 
Neutrophils 
16           34.0 
2              4.3
11           23.4
8             17.0 
10           21.3
Platelets 
2              4.3 
4              8.5
13           27.7
11           23.4 
17           36.2
Hemoglobin 
       --- 
13           27.7
27           57.5
6             12.8 
1              2.2
 
 
Table 5: Nonhematologic Toxicities (N=47) for Induction Gemcitabine and 
Cisplatin for patients with stage IIIA-N2 NSCLC57  
 
 
Grade 0 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
% G3/4  
Nausea 
10 
13 
17 
7 
     --- 
14.8% 
Vomiting 
14 
10 
18 
5 
     --- 
10.6% 
Headache 
36 
4 
1 
0 
0 
0 
Neuropathy 
37 
9 
0 
0 
0 
0 
Other 
neurotoxicity 
23 
8 
8 
3 
2 
10.6% 
Alopecia 
19 
8 
14 
5 
     --- 
10.6% 
Lethargy 
12 
16 
16 
3 
     --- 
6.4% 
Creatinine 
35 
9 
1 
      --- 
1 
2.1% 
Febrile 
neutropenia 
46 
      --- 
      --- 
1 
     --- 
2.1% 
Infection 
37 
      --- 
3 
1 
     --- 
2.1% 
Diarrhea 
38 
6 
2 
1 
     ---  
2.1% 
Hemorrhage 29 
11 
1 
1 
     --- 
2.1% 
Weight loss 
38 
4 
1 
1 
     --- 
2.1% 
Dyspnea 
36 
1 
      --- 
1 
     --- 
2.1% 
 
 
 
 
 
 
 
 


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48
Table 6: Hematologic Toxicity (N=136) for Induction Gemcitabine/Cisplatin and 
Docetaxel for patients with stage IIIA-N2 and IIIB (T4N0-1) NSCLC58  
 
 
Grade 0 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
 
No. Pts       % 
No. Pts       %
No. Pts       %
No. Pts       % 
No. Pts       %
Leukocytes 
17           12.5   21           15.4
38           27.9
50           36.8 
10             7.4 
Neutrophils 
19           14.0 
10             7.4
22           16.2
34           25.0 
51           37.5
Platelets 
5              3.7 
61           44.9
35           25.7
30           22.1 
5              3.7
Hemoglobin 
12             8.8 
71           52.2
41           30.1
9              6.6 
3              2.2
 
 
Table 7: Nonhematologic Toxicity (N=136) for Induction Gemcitabine/Cisplatin 
and Docetaxel for patients with stage IIIA-N2 and IIIB (T4N0-1) NSCLC58  
 
 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
% G3/4  
N/V 
37   27.2% 
39   28.7% 
13     9.6% 
0          0% 
 0        0% 
Neuropathy 
4       2.9% 
1      0.7% 
1       0.7% 
0          0% 
1       0.7% 
Alopecia 
25   18.4% 
37   27.2% 
0          0% 
0          0%   0          0% 
Creatinine 
0          0% 
1       0.7% 
0          0% 
0          0% 
0          0% 
Diarrhea 
14   10.3% 
11     8.1% 
7       5.1% 
3       2.2% 
10     7.4% 
Asthenia 
34   25.0% 
37   27.2% 
10     7.4% 
0          0% 
10     7.4% 
 
11.2 Early Stopping Rule for Pulmonary Embolism (PE) 
Following review by the Safety Monitoring Committee on August 4, 2010, an 
early stopping rule for pulmonary embolism (PE) will be implemented as follows:  
The study will continue to accrue patients until a total of 10 have been treated 
and evaluated for development of a PE.  The expected incidence of PE is 7%.  At 
present, 3 out of 7 patients have developed a PE.  If there are 3 patients with PE 
after 10 have been treated, the lower one-sided 97.5% CI bound (corresponding 
to a two-sided 95% CI) is 6.7%. The lower one-sided 95% CI bound is 8.7% with 
3/10. If the rate becomes 4/10, the lower one-sided 97.5% CI bound would be 
12.2% and the lower one-sided 95% CI bound would be 15.0%. Thus, if 4 
patients in the first 10 have a PE, this is likely to be in excess of what would be 
expected and accrual will stop pending re-evaluation of the treatments provided 
on the trial. Should accrual continue past 10 patients, the rate will be re-
examined again after each additional 5 patients have been enrolled and if any of 
the subsequent evaluations result in a lower one-sided 95% bound for PE 
incidence exceeding 10%, the trial would be stopped at that time. If accrual stops 
and treatment is modified as a result, the stopping rules will start over beginning 
with the patients treated under the modified regimen.  At this time there will be no 
prophylactic treatment for Pulmonary Embolisms but treatment will be 
determined on an individual basis. 


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49
 
11.3 Sample Size/Accrual Rate 
It is anticipated that up to 3 patients per month may be enrolled onto this trial, 
and thus up to two years may be required to enroll 66 evaluable patients. To 
allow for a small number of patients who may be in-evaluable, the accrual ceiling 
will be set at 70. 
 
11.4 Stratification Factors     - 
N/A 
 
11.5 Analysis of Secondary Endpoints 
For all evaluable patients, Kaplan-Meier analyses of time to progression 
and overall survival will also be performed. Appropriate confidence intervals at 
selected time points will also be provided. Since these will be considered 
secondary endpoints, the results will be reported as part of the descriptive report 
of the study. 
 
Toxicity will be tabulated by type and grade, for all types of toxicity identified as 
being at least possibly attributable to the agent. 
 
All molecular and other secondary evaluations will be considered exploratory 
analyses.  However, as an illustration for any given evaluation, if 10 paired 
results are available (before and after treatment); there is 80% power to declare 
an effect equal to one standard deviation of the change to be statistically 
significant at the 0.05 level with a two-tailed test. In general, it is anticipated that 
non-parametric analyses will generally be used for these evaluations because of 
the limited number of subjects.  In view of the exploratory nature of these 
analyses, any p-values reported will not be adjusted for multiple comparisons, 
and results of any such analyses will be stated carefully as being hypothesis 
generating, requiring additional confirmation 
 
11.6 Reporting and Exclusions 
 
11.6.1Evaluation of toxicity.  All patients will be evaluable for toxicity from the 
time of their first treatment with Gemcitabine, Cisplatin, Bevacizumab and 
Etoposide. 
 
11.6.2 Evaluation of response. All patients included in the study must be 
assessed for response to treatment, even if there are major protocol treatment 
deviations or if they are ineligible.  Each patient will be assigned one of the 
following categories:  1) complete response, 2) partial response, 3) stable 
disease, 4) progressive disease, 5) early death from malignant disease, 6) early 
death from toxicity, 7) early death because of other cause, or 9) unknown (not 


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50
assessable, insufficient data).  [Note:  By arbitrary convention, category 9 usually 
designates the “unknown” status of any type of data in a clinical database.] 
 
All of the patients who met the eligibility criteria (with the possible exception of 
those who received no study medication) will be included in the main analysis of 
the response rate.  Patients in response categories 4-9 will be considered as 
failing to respond to treatment (disease progression).  Thus, an incorrect 
treatment schedule or drug administration does not result in exclusion from the 
analysis of the response rate.   
 
All conclusions will be based on all eligible patients.  Sub analyses may then be 
performed on the basis of a subset of patients, excluding those for whom major 
protocol deviations have been identified (e.g., early death due to other reasons, 
early discontinuation of treatment, major protocol violations, etc.).  However, 
these sub analyses will not serve as the basis for drawing conclusions 
concerning treatment efficacy, and the reasons for excluding patients from the 
analysis will be clearly reported.  The 95% confidence intervals will also be 
provided.  
 
 
12.0 HUMAN SUBJECTS PROTECTIONS 
 
12.1 Rationale for Subject Selection 
 
This study will be open to all individual with stage IIIA N2 NSCLC regardless of 
gender, ethnicity, or race provided that the aforementioned inclusion and 
exclusion criteria are met.  For safety reasons, only pregnant women and 
children are excluded from this study. This study will be recruited through internal 
referral, our local physician referral base, and through physicians in Croatia. All 
individuals with newly diagnosed stage IIIA N2 NSCLC are eligible according to 
the eligibility criteria within section 3.  This is a Phase II trial designed to evaluate 
the safety and efficacy of Gemcitabine, Cisplatin and Bevacizumab in stage IIIA 
N2 NSCLC, study the side effect profile of the combination of drugs, characterize 
the pharmacokinetics, and assess several biological endpoints.  Patients should 
realize that we are hopeful that they may gain benefit from this study, but there is 
no objective evidence to support our optimism at this time.  Patients must not 
have received prior treatment for their lung cancer.  Subjects from both genders 
and all racial /ethnic groups are eligible for this study if they meet the eligibility 
criteria outlined in section 3.  To date, there is no information that suggests that 
differences in drug metabolism or disease response would be expected in one 
ethnic group compared to another.  Efforts will be made to extend accrual to 
each representative population, but in this preliminary study, a balance must be 
struck between patient safety considerations and limitations on the number of 
individuals exposed to potentially toxic and/or ineffective treatments on the one 


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hand and the need to explore racial/ethnic aspects of clinical research on the 
other hand.  If differences in outcome that correlate to ethnic identity are noted, 
accrual may be expanded or a follow-up study may be written to investigate 
those differences more fully. 
 
12.2 Justification for Exclusions 
Due to lack of knowledge of the effects of Gemcitabine, Cisplatin and 
Bevacizumab on the fetus or on infants, as well as the possibility of teratogenic 
effects, pregnant and nursing women will be excluded from this trial.  Patients 
with unstable or serious medical conditions (ongoing or active infection, 
symptomatic congestive heart failure (AHA Class II or worse), unstable angina 
pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would 
limit compliance with study requirements) are excluded due to the possibility that 
the combination of Gemcitabine, Cisplatin and Bevacizumab may worsen their 
condition and the likelihood that the underlying condition may obscure the 
attribution of adverse events with respect to this chemotherapeutic regimen. 
 
12.3 Participation of Children   
Patients under the age of 18 will be excluded from study because of the relative 
infrequence of NSCLC in this group. 
 
12.4 Evaluation of Benefits and Risks/Discomforts 
The potential benefit to a patient who enters study is a reduction in the bulk of 
his/her tumor, which may or may not have a favorable impact on extent of 
surgical resection and/or survival.  Potential risks include the possible occurrence 
of any of a range of side effects that are listed in the pharmaceutical section and 
the consent document.  The procedure for protecting against or minimizing risks 
will be to medically evaluate patients on a regular basis as described earlier. 
 
12.4.1 Risks/Benefits Analysis  
All care will be taken to minimize risks that may be incurred by tumor sampling.  
However, there are procedure-related risks (such as bleeding, infection and 
visceral injury) that will be explained fully during informed consent. If patients 
suffer any physical injury as a result of the biopsies, immediate medical treatment 
is available at the NIH’s Clinical Center in Bethesda, Maryland and the University 
hospital for lung diseases, Jordanovac, Zagreb, Croatia.  Although no 
compensation is available, any injury will be fully evaluated and treated in 
keeping with the benefits or care to which patients are entitled under applicable 
regulations. 
 


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12.5 Consent and Assent Process and Documentation 
An associate or principal investigator on the trial will inform patients of the 
purpose, alternatives, treatment plan, research objectives and follow-up of this 
trial.  The patient will be provided an IRB-approved consent for review and 
signature and his/her questions will be answered.  After a decision is made to 
enroll into the study, a signature will be obtained from the patient at a subsequent 
visit.  The original signed consent goes to Medical Records; copy placed in 
research record  
 
All patients must have a signed informed consent form and an on-study 
(confirmation of eligibility) form filled out and signed by a participating investigator 
before entering on study. 
 
12.6 Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible 
for this trial.  Every effort will be made to recruit women and minorities in this 
study. 
 
13.0 DATA AND SAFETY MONITORING PLAN 
13.1 Multi-Institutional guidelines 
 
13.1.1 IRB Approvals: The PI will provide the NCI IRB and Central 
Registration Office with a copy of the participating institution’s approved 
yearly continuing review.  Registration will be halted at any participating 
institution in which a current continuing approval is not on file at the NCI 
IRB.   
 
13.1.2 Amendments and Consents:  The CCR PI will provide the NCI 
IRB with copies of all amendments, consents and approvals from each 
participating institution.  
 
13.1.3 Data and Specimen Collection Procedures:  The PI will provide 
specific guidelines for quality assurance, data collection and format, and 
data receipt by the coordinating institution (recommend at least quarterly).  
It is recommended that data collection forms/system be consistent for all 
institutions. All adverse events from participating institutions must be 
submitted to the NCI IRB according to current NCI IRB policy.  
 
13.1.4 NCI Guidance for Reporting Serious Adverse Events for Multi-
Center Trials:  The reporting requirements for adverse events in multi-
center trials when the NCI PI is responsible for the research and the 
coordination of the other research sites is the same as with any NCI 


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intramural research protocol. Serious adverse event reports should be 
submitted from the participating centers along with a PI assessment of the 
event in the same time frame as adverse event reports that occur at the 
NCI. The review of the event should be submitted when available. If the 
NCI is a participating site, rather than the responsible site, then the 
serious adverse event report should be submitted per protocol  
 
13.1.5 Data Center Audits:  The PI will provide guidelines for audits of 
participating institutions.  Selected patient charts should be audited as well 
as the participating institutions Standard Operating Procedures (SOP) at 
the time of the visit.  Data from participating institutions should be 
available when the protocol is audited at the NCI. 
 
 
Drug Distribution:  Lead Associate Investigators will order drug as per local 
guidelines.  
 
Collection and Toxicity Reporting: Required data include, concurrent medications 
that are not disease related do not need to be entered into the NCI C3D 
database with the exception of steroids.  Participating institutions must submit 
ADRs as specified under section 10.0.  All data collection forms and the NCI IRB 
copy of the adverse event report must be submitted to the following address: 
Arlene Berman, RN, Building 10, Room 12N226, 10 Center Drive, Bethesda, MD 
20892. FAX# 301-480-2590. 
 
Data and Center Audits:  Participating centers will be audited at least every 1 
year.  Selected patient charts will be audited as well as the participating 
institutions Standard Operating Procedures (SOP) at the time of the visit.  Data 
from participating institutions should be available when the protocol is audited at 
the NCI. 
 
13.2 Data Safety and Monitoring Plan: 
 
This is an investigator initiated trial. The NCI PI will be responsible for patients 
enrolled at all institutions.  Serious adverse event reporting is outlined in section 
10.0. The participating sites will fax or email copies of SAEs to the Coordinating 
Center.  These will be reviewed by the Research Team.  Toxicity reports will be 
run quarterly to include data from all participating sites.  These reports will be 
reviewed by the Principal Investigator and communicated to the Lead Associate 
Investigator. A site visit to Croatia will be made prior to opening the study  to 
ensure understanding of protocol data collection requirements.  Audits will be 
conducted yearly to insure data integrity and to provide quality control. The site 
will perform ongoing quality assurance checks in the C3D data base to look for 
data discrepancies. Issues will be brought to the attention of the PI and the site 
PI.  
 


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13.3 Data Collection: 
 
The investigators will be responsible for the collection, maintenance, security and 
quality control of all study data.  Meetings chaired by the principal investigator 
and/or lead associate investigator will be held on a monthly basis to review the 
study data for quality, completeness, and interim analysis.  Data will be captured 
on the NCI C3D database. 
• 
All toxicities related to hemorrhage will be collected regardless of grade 
and captured in C3D 
• 
All toxicities related to wound healing will be collected regardless of grade 
and captured in C3D 
• 
All toxicities related to hypertension will be collected regardless of grade 
and captured in C3D 
• 
All toxicities related to proteinuria will be collected regardless of grade and 
captured in C3D 
• 
All grade 3, 4 events related to the research (possibly, probably and 
definitely) will be captured in the C3D data base 
• 
We will capture all grade 5 events 
Data from Croatia will be directly entered in to the C3D data base by staff in 
Croatia. All data will be kept secure. Personal identifiers will not be used when 
collecting and storing data. An enrollment log will be maintained in the regulatory 
binder/file which is the only location of personal identifiers with unique subject 
identification number. Source documents will be maintained in the patient 
medical record.  
 
13.4 Toxicity Criteria: 
The following adverse event management guidelines are intended to ensure the 
safety of each patient while on the study. Adverse events occurring during the 
study will be graded according to the NCI Common Terminology Criteria for 
Adverse 
Events 
version 
3.0 
(CTCAE 
v3.0) 
found 
at: 
http://ctep.cancer.gov/reporting/ctc_v30.html. 
 
 
 
 
 
 
 
 
 
 
 
 


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gemcitabine-based chemotherapy followed by resectional surgery. Clin 
Cancer Res. 2004 Jun 15: 10:4215s-9s 
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57. Van Zandwijk N, Smit E, Kramer G, et al. Gemcitabine and Cisplatin as 
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58. Garrido P, Gonzalez-Larriba J, Insa A, et al. Long-Term survival 
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Spanish Lung Cancer Group Trial 9901. J Clin Oncol 2007 25:4736-4742 
 
 
 
 
 
 
 
 


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Appendix I 


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Revision of the TNM Stage Groupings in the forthcoming (Seventh) Edition of the 
TNM Classification of Malignant Tumors. Adapted from Goldstraw et al: 
J.Thorac.Oncol., Volume 2(8).August 2007.706-714 
 
 
 
 
 
 
 


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


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Appendix III
Bevacizumab Dose Management Due to Adverse Events 
Event 
Action to be Taken 
 
Hypertension 
No dose modifications for grade 1/2 events 
Grade 3 
If not controlled with medication, discontinue the subject from the study. 
Grade 4 
Discontinue the subject from the study. 
Hemorrhage 
No dose modifications for grade 1/2 events 
Grade 3 
Subjects who experience pulmonary hemorrhage will be removed from the study. 
Subjects who are also receiving full-dose anticoagulation will be discontinued from the study.   
All other subjects will have study treatment held until all of the following criteria
  are met: 
• 
The bleeding has resolved and hemoglobin is stable. 
• 
There is no bleeding diathesis that would increase the risk of therapy. 
• 
There is no anatomic or pathologic condition that significantly increases the risk of 
hemorrhage recurrence. 
Subjects who experience a repeat Grade 3 hemorrhagic event will be discontinued from treatment. 
Grade 4 
Discontinue the subject from the study. 
Venous Thrombosis 
No dose modifications for grade 1/2 events 
Grade 3/ 
Asymptomatic Grade 
4 
Subjects with lung cancer placed on anticoagulant therapy for a thrombotic event should be discontinued 
from study. 
Symptomatic Grade 
4 
Discontinue the subject from the study. 
Arterial Thromboembolic event 
(Angina, myocardial infarction, transient ischemic attack, cerebrovascular accident, and any other arterial thromboembolic event) 
 Any grade 
Discontinue the subject from the study. 
Proteinuria 
Subjects who develop more than 2g/24 hr proteinuria, or a urine protein/creatinine > 2.0 will have their dose held until the Up/C < 1.0 
or the proteinuria is < 1g/24hr                                
Grade 3 
(>3.5 g/ 24 hr) 
Hold study drug treatment until ≤ Grade 2 
Grade 4 (nephrotic 
syndrome) 
Discontinue the subject from the study 
GI Perforation 
requiring medical or 
surgical therapy 
Discontinue the subject from the study. 
Wound dehiscence 
requiring medical or 
surgical therapy 
Discontinue the subject from the study. 


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Appendix IV 
 
MANAGEMENT OF ACUTE HYPERSENSITIVITY 
 
Severity of Symptoms 
Treatment Guidelines 
Mild symptoms: localized cutaneous reactions 
such as mild pruritus, flushing, rash. 
• 
Consider decreasing the rate of infusion until 
recovery from symptoms, stay at bedside and 
monitor patient 
• 
Then, complete chemotherapy infusion at the 
initial planned rate 
Moderate symptoms: any symptom that is not 
listed above (mild symptoms) or below (severe 
symptoms) such as generalized pruritus, flushing, 
rash, dyspnea, hypotension with systolic BP 80 mm 
Hg 
• 
Interrupt chemotherapy infusion 
• 
Give diphenhydramine 50 mg IV with or without 
dexamethasone 10mg IV; monitor patient until 
resolution of symptoms 
• 
Resume chemotherapy infusion after recovery 
of symptoms; depending on the physician’s 
assessment of the patient, chemotherapy 
infusion should be resumed at a slower rate, 
and then increased incrementally to the initial 
planned rate, (eg. Infuse at an 8 hour rate for 5 
minutes, then at a 4 hour rate for 5 minutes, 
then a 2 hour rate for 5 minutes, then finally, 
resume at the 1 hour infusion rate) 
• 
Depending on the intensity of the reaction 
observed, additional oral or IV premedication 
with an antihistamine should also be given for 
the next cycle of treatment, and the rate of 
infusion should be decreased initially and then 
increased back to the recommended 1 hour 
infusion, (eg, infuse at 8 hour rate for 5 
minutes, then at a 4 hour rate for 5 minutes, 
then at a 2 hour rate for 5 minutes, ad finally, 
administer at the 1 hour infusion rate). 
Severe symptoms: any reaction such as 
bronchospasm, generalized urticaria, systolic BP, 
80 mm Hg, angioedema 
• 
Immediately discontinue chemotherapy 
infusion 
• 
Give diphenhydramine 50 mg IV with or without 
dexamethasone 10 mg IV and/or epinephrine 
as needed; monitor patient until resolution of 
symptoms 
• 
The same treatment guidelines outlined under 
moderate symptoms (i.e. the third and fourth 
bullets) should be followed. 
Anaphylaxis(NCI grade 4 reaction) 
NO FURTHER STUDY DRUG THERAPY 
 
 
 
 
 
 
 
 
 
 
 


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Appendix V 
 
NIH Definitions: 
Adverse events  
Any unfavorable and unintended diagnosis, symptom, sign (including an abnormal 
laboratory finding), syndrome or disease which either occurs during the study, having been 
absent at baseline, or, if present at baseline, appears to worsen. 
Serious adverse events 
Any untoward medical occurrences that:  
 
(1) result in death,  
 
(2) are life threatening,  
 
(3) require (or prolong) hospitalization,  
 
(4) cause persistent or significant disability/incapacity,  
 
(5) result in congenital anomalies or birth defects, or  
(6) are other conditions which in the judgment of the investigators represent significant 
hazards.   
Expected Adverse Events 
For approved and marketed drugs or devices, those adverse events described in the 
approved Package Insert (Label).  For investigational new drugs or devices, those adverse 
events described in the FDA Investigator’s Brochure.  In clinical research studies, 
information on expected adverse events are also summarized in the protocol and in the 
consent form.   
Unexpected Adverse Events 
Those adverse events not described in the Package Insert, Investigator’s Brochure, in 
published medical literature, in the protocol, or in the informed consent document. 
Intensity or Severity of Adverse Events 
Assignment of the grade of adverse events or side-effects of interventions based on intensity 
of symptoms, degree of limitation of usual daily activities, or level of abnormality of 
objective clinical signs or laboratory parameters (schemes for assessing and monitoring 
adverse events can be drawn from existing models or those customized for use in particular 
protocols must be justified by the PI and approved by the IRB). 
Relatedness of Adverse Event  to an Intervention 
The best estimate of the PI at the time of reporting of the causal relationship between an 
experimental intervention and an adverse event; the degree of certainty about causality is 
graded as follows: 
Unrelated:  
Adverse event is clearly due to extraneous causes (e.g., underlying disease, environment) 
Unlikely (must have 2):  
Adverse event:  
(1) does not have temporal relationship to intervention,  
(2) could readily have been produced by the subject’s clinical state,  
(3) could have been due to environmental or other interventions,  
(4) does not follow known pattern of response to intervention,  
(5) does not reappear or worsen with reintroduction of intervention 
 
 


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Possible (must have 2):  
Adverse event:  
(1) has a reasonable temporal relationship to intervention,  
(2) could not readily have been produced by the subject’s clinical state,  
(3) could not readily have been due to environmental or other interventions,  
(4) follows a known pattern of response to intervention 
 
Probable (must have 3):  
Adverse event:  
(1) has a reasonable temporal relationship to intervention,  
(2) could not readily have been produced by the subject’s clinical state or have been 
due to environmental or other interventions,  
(3) follows a known pattern of response to intervention,  
(4) disappears or decreases with reduction in dose or cessation of intervention 
 
Definite (must have all 4):  
Adverse event:  
(1) has a reasonable temporal relationship to intervention,  
(2) could not readily have been produced by the subject’s clinical state or have been 
due to environmental or other interventions,  
(3) follows a known pattern of response to intervention,  
(4) disappears or decreases with reduction in dose or cessation of intervention and 
recurs with re-exposure 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix VI 
 
 


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Appendix VII 
 
 
General Considerations for Sample Handling for Research Samples at the 
NIH 
 
Shipment 
Samples from Croatian patients will be batch shipped via FedEx or World 
Courier Priority Overnight on dry ice to the Clinical Pharmacology Program 
(CPP) (Dr William Figg) at the following address: 
 
Dr. William D. Figg 
National Cancer Institute 
9000 Rockville Pike 
Bldg 10 Rm 5A01 
Bethesda, MD 20892 
USA 
Tel: 301-402-3622 
 
Samples will be batch shipped to the National Cancer Institute every TWO 
(2) months. Samples must be packaged in accordance with IATA 
regulations. The following documentation must be included with the 
shipment: a Simple Letter of Agreement (SLA) and a shipping manifest. 
The shipping manifest should include all relevant sample information: 
Harris Orcan patient registration number, sample ID, sample material type, 
sample collection date/time, date/time placed in freezer, protocol timepoint 
(Cycle 1 Day 1), and any processing or collection issues. The manifest 
should also include contact information for the person(s) shipping the 
samples, the protocol title/number, and the shipment date. Patient names 
and medical record numbers will not be included on the manifest. 
 
On the day of shipment, send an email notification to Dr. Figg at 
wdfigg@helix.nih.gov with the number of samples being shipped and the 
FedEx/World Courier tracking number. 
 
Storage/Tracking 
Research samples will be obtained from patients, as described in the 
protocol.  Patient samples will be coded in the laboratory of Dr. William 
Figg and stored either at 80°C or in a Liquid Nitrogen freezer in the case 
of samples viably frozen.  Records of sample acquisition will be held in the 
laboratory in Labrador (formerly known as LabSamples) a computerized 
database that is accessible by password. A limited number of laboratory 
staff will have access to identifying patient information.  Assays as noted 
above will be carried out on patient samples.  
 
 


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Protocol Completion/Sample Destruction 
Material remaining after completion of correlative studies will be returned 
to the laboratory of Dr. William Figg. These samples will be managed in 
accordance with the laboratory’s policies and procedures.  The PI will 
report any loss or destruction of samples to the IRB.  Any new use of the 
samples, specimens, or data will require prospective IRB review and 
approval. 
 
Labrador 
All samples will be barcoded, with data entered and stored in the Labrador 
system (formerly known as LabSamples) utilized by the CPP. This is a 
secure program, with access to the system limited to defined CPP 
personnel, who are issued individual user accounts. The program creates 
a unique barcode ID for every sample and sample box, which cannot be 
traced back to patients without Labrador access. The data recorded for 
each sample includes the patient ID, name, trial name/protocol number, 
time drawn, cycle time point, dose, material type, as well as box and 
freezer location. Patient demographics associated with the clinical center 
patient number are provided in the system. For each sample, there are 
notes associated with the processing method (delay in sample processing, 
storage conditions on the ward, etc.). For samples shipped from Croatia, 
any associated sample information sent with the shipment, such as the 
shipping manifest, will be scanned, uploaded, and attached to the 
sample(s) in Labrador. 
 
Barcoded samples are stored in barcoded boxes in a locked freezer at 
either -20, -80°C, or in liquid nitrogen according to stability requirements.  
These freezers are located onsite in the CPP and offsite at NCI Frederick 
Central Repository Services (Fisher Bioservices) in Frederick, MD. 
Samples will be stored until requested by Drs Giaccone, Schrump, 
Trepel and/or Meltzer. Samples will be brought to the requestor’s lab on 
dry ice in an appropriate container by a member of Dr. Figg’s laboratory 
with a copy of the shipping manifest. All requests are monitored and 
tracked in the Labrador system. All researchers are required to sign a form 
stating that the samples are only to be used for research purposes 
associated with this trial (as per the IRB approved protocol) and that any 
unused samples must be returned to the CPP. 
 
Following completion of this study, samples will remain in storage as 
detailed above. Access to these samples will only be granted following 
IRB approval of an additional protocol, granting the rights to use the 
material. 
 
If, at any time, a patient withdraws from the study and does not wish for 
their existing samples to be utilized, the individual must provide a written 
request. Following receipt of this request, the samples will be destroyed 


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(or returned to the patient, if so requested), and reported as such to the 
IRB. Any samples lost (in transit or by a researcher) or destroyed due to 
unknown sample integrity (i.e. broken freezer allows for extensive sample 
thawing, etc.) will be reported as such to the IRB. 
 
Sample barcodes are linked to patient demographics and limited clinical 
information. This information will only be provided to investigators listed on 
this protocol, via registered use of Labrador. It is critical that the sample 
remains linked to patient information such as race, age, dates of diagnosis 
and death, and histological information about the tumor, in order to 
correlate genotype with these variables. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix VIII 
 
1. 
Gemcitabine HCl 
 
Formulation 
Gemzar® is commercially available as a sterile, white, lyophilized powder in single-use vials. 
 
Ingredient 
Vial Sizes 
Gemcitabine HCl, equivalent to gemcitabine 
free base (+ 0–3% excess) 
200 mg 
1000 mg 
Mannitol, USP 
200 mg* 
1000 mg* 
Sodium acetate, ACS and USP 
12.5 mg* 
62.5 mg* 
* ± 10% 
 
Hydrochloric acid and sodium hydroxide may have been added to adjust product pH. 
 
Source 
Gemcitabine HCl will be purchased from commercial sources by the NIH Clinical Center Pharmacy 
Department. 
 
Preparation: 
Vials should be reconstituted with 5 mL (200-mg vials) or 25 mL (1000-mg vials) 0.9% Sodium Chloride 
Injection, USP (0.9% NS) to produce a solution with a concentration = 38 mg/mL.  The lyophilized powder 
adds a small amount to the total volume after reconstitution (200 mg gemcitabine/5.26 mL; 
1000 mg/26.3 mL). 
Reconstituted gemcitabine is suitable for direct administration or may be further diluted with 0.9%NS to 
concentrations as low as 0.1 mg/mL. 
 
Gemcitabine doses will be diluted in 250-500mL of 0.9% NS. 
 
Gemcitabine is compatible with either glass or PVC containers and PVC administration sets 
 
Stability 
Intact vials stored are labeled with the manufacturer’s expiration date. 
 
After reconstitution to a concentration of 38 mg/mL with either sterile Water for Injection, USP, or 0.9%NS in 
the original vials, gemcitabine was chemically and physically stable at 23°C (73.4°F) for at least 35 days.  
Crystalization occasionally occurred in vials stored under refrigeration for > 7 days.  The crystals did not 
redissolve when the solutions were warmed to room temperature and HPLC analysis revealed gemcitabine 
losses of 20 – 35% in samples which contained crystals.  Exposure or protection from fluorescent light did 
not affect gemcitabine stability. 
 
Storage 
Store intact vials at controlled room temperature (20° – 25°C [68° – 77°F]). 
Gemcitabine solutions were found to be stable without loss of potency after reconstitution to 38 mg/mL, and 
after dilution with 5% Dextrose Injection, USP, to concentrations of 10 mg/mL or 0.1 mg/mL and storage in 
PVC containers for 7 days at 32°C in the dark. Reconstituted gemcitabine solutions should not be 
refrigerated, as crystallization may occur. 
 
Dosage and Administration 
 
Fixed Dose-Rate Administration. 
Gemcitabine will be administered intravenously at a fixed dose-rate (FDR) of 10 mg/m2 per min 
(600 mg/m2·hour). 
• 
Experimental data have demonstrated that small increases in intracellular concentrations of 
gemcitabine’s active triphosphate metabolite profoundly affect its intracellular area under the curve, 
and that a fixed gemcitabine administration rate of 10 mg/m2 per min maximize the rate at which 
the metabolite accumulates in peripheral blood mononuclear cells. 


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• 
This observation is the basis for recent clinical trials with FDR gemcitabine administration which 
attempt to correlate increases in intracellular gemcitabine triphosphate concentrations with 
improved objective responses to treatment and survival. 
 
 
Toxicities 
Hematological Adverse Effects 
Myelosuppression is the primary dose-limiting effect of gemcitabine, and is characterized by 
thrombocytopenia with relative sparing of leukocytes without cumulative toxicity. Gemcitabine may also 
impair erythropoiesis, producing increased serum iron and ferritin, and a decrease in peripheral blood 
reticulocyte counts. 
Grades 3 and 4 anemia have been reported in 5% and up to 0.8% of patients, respectively, but has rarely 
been cause for discontinuing gemcitabine.  Anemia has tended to be more severe than leukopenia in some 
studies. 
 
Hemolytic uremic syndrome (HUS) has been reported in 0.015 – 0.25% of patients during and immediately 
following gemcitabine treatment.  Renal failure may be irreversible.  Thrombotic microangiopathy secondary 
to HUS has been described in three case reports of long- term therapy with gemcitabine.  A diagnosis of 
HUS should be considered if a patient develops anemia with evidence of microangiopathic hemolysis, 
increased serum bilirubin or LDH, reticulocytosis, severe thrombocytopenia, and/or evidence of renal failure 
(increased serum creatinine or BUN). Gemcitabine therapy should be discontinued immediately. Renal 
failure may not be reversible even with discontinuation of therapy and dialysis may be required. 
 
Respiratory Adverse Effects 
Dyspnea was reported in up to 10 – 23% of patients in clinical trials with gemcitabine; however, many 
patients with primary or metastatic lung cancer may have pre-existing pulmonary dysfunction prior to starting 
therapy.  Bronchospasm has also been observed during gemcitabine therapy. 
Parenchymal toxicity, including interstitial pneumonitis, pulmonary fibrosis, pulmonary edema, and acute 
respiratory distress syndrome (ARDS), has been reported rarely following one or more doses of 
gemcitabine.  Some patients experienced the onset of pulmonary symptoms up to two weeks after a dose of 
gemcitabine.  Respiratory failure and death occurred very rarely in some patients despite discontinuation of 
therapy. 
A patient developed acute respiratory distress after gemcitabine 900 mg/m2 over 90 minutes weekly for 
6 weeks, every 8 weeks.  Lung biopsy confirmed chemical interstitial injury which was believed to be related 
to gemcitabine treatment. ARDS has also been reported with gemcitabine 1200 – 1250 mg/m2 on days 1, 8, 
and 15 every four weeks.  Initial signs and symptoms including dyspnea, cough, and bilateral pulmonary 
infiltrates consistent with edema appeared after two to four cycles.  Among three patients who developed 
ARDS symptoms, one who showed temporary improvement with diuretics received three additional 
gemcitabine cycles before dying of rapidly progressing ARDS.  A second patient died within three days after 
initial presentation.  The survivor improved with steroids and received no further treatment with gemcitabine.  
Gemcitabine should be discontinued in the presence of unexplained, non-cardiogenic, acute or subacute 
pulmonary edema.  Other cases have been reported, with at least one fatality. 
 
Renal Adverse Effects 
Proteinuria and hematuria are common and have been described in up to 45% of patients in clinical trials. 
Azotemia and acute renal failure have been reported in association with gemcitabine treatment. 
A retrospective systematic review of case reports and clinical trials through December 2005, revealed data 
on 56 patients who developed gemcitabine-associated thrombotic microangiopathy (TMA), within a range of 
0.5 – 19 months (mean, 7.56 mo).  Twenty-four patients had received prior chemotherapy, and an estimated 
cumulative dose of gemcitabine in the range, 2000 – 70,000 mg (median, 22,480 mg).  Symptoms included 
worsening anemia, thrombocytopenia, increased serum creatinine and LDH, hypertension, dyspnea, 
peripheral edema, proteinuria, hematuria, neurological signs, and fragmented red blood cells.  Development 
of TMA secondary to hemolytic uremic syndrome (HUS) has been described in case reports of long-term 
therapy with gemcitabine. 
Deaths have been reported as a result of HUS or HUS-related complications in association with gemcitabine 
therapy.  The classic triad of acute uremia, microangiopathic hemolytic anemia, and thrombocytopenia was 
noted in all patients with HUS associated with gemcitabine. Hypertension was the other most common 
finding [see additional information about HUS in the Hematological Adverse Effects section (above)]. 
 
Dermatological Adverse Effects 
Generalized, erythematous, pruritic, maculopapular skin rashes (primarily affecting the neck and extremities) 
have been described in trials of gemcitabine (5 – 32% of patients).  Rashes are reversible with local 


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treatment and do not often require dosage reduction or drug discontinuation.  Antihistamines and topical 
steroids may also provide symptomatic improvement without having to alter or interrupt treatment.  
Gemcitabine may cause skin irritation and eye irritation after topical exposure, but it is not a vesicant drug.  
Up to 15% of patients treated with gemcitabine may experience hair loss. Alopecia and rashes seem to 
occur relatively frequently during gemcitabine therapy.  Cellulitis, pruritus, radiation recall dermatitis, 
erythema, skin ulcerations, and pseudolymphoma have been reported.  Skin desquamation and anal pruritis 
have been reported rarely.  More severe skin reactions have also been reported occasionally in patients 
treated with gemcitabine, including bullous skin ulceration and severe erythema resembling scalded-skin 
syndrome.  Radiation recall dermatitis has been reported in patients who received gemcitabine. 
 
 
Metabolic Adverse Effects 
Transient febrile episodes have been observed within 6 – 12 hours after a first dose in approximately 5 – 
60% of patients and are commonly associated with other flu-like symptoms. Fevers generally are responsive 
to acetaminophen and nonsteroidal anti-inflammatory drugs. 
 
Flu-like symptoms (with or without fever), including headache, malaise, myalgias, and rigors, are the most 
frequent adverse effects of gemcitabine, occurring in 20 – 100% of patients. Flu symptoms have been 
severe enough to be dose-limiting. 
 
Fatigue or lethargy, occurring alone or in conjunction with other flu-like symptoms, occur commonly. 
 
Hepatic Adverse Effects 
Transient grade II or III liver transaminase elevations were observed in 7% of patients with non-small-cell 
lung cancer treated with gemcitabine.  Gemcitabine has been associated with transiently increased serum 
transaminases in approximately 70% of patients.  There is no evidence that incidence of hepatic toxicity 
correlates with duration of exposure or total cumulative gemcitabine doses. 
 
Neurologic Adverse Effects 
Paresthesia has been reported in 10% of patients during clinical trials with gemcitabine. Mild-to-moderate 
somnolence has been reported in approximately 9.1 – 11% of patients who received gemcitabine.  In clinical 
trials, pain was reported by 48% of patients.  In the treatment of pancreatic cancer, pain was reported by 
6.8% and asthenia was observed in 6% of patients who received gemcitabine 1000 mg/m2·week.   
 
Cardiovascular Adverse Effects 
Systemic capillary leak syndrome has been suggested to be the pathogenic mechanism for the pulmonary 
toxicity of gemcitabine. 
Peripheral edema, usually mild, has been observed in 4% up to 20.3% of patients treated with gemcitabine, 
which was not associated with cardiac, hepatic, or renal failure. 
Isolated cases of severe hypertension, and rarely, atrial fibrillation, dysrhythmias (predominantly 
supraventricular), myocardial infarction, and congestive heart failure have been reported in association with 
gemcitabine either alone or in combination with other cytotoxic agents. 
 
Gastrointestinal Adverse Effects 
Gemcitabine as a single agent is associated with low emetic risk, but may produce mild nausea and 
vomiting.  Diarrhea and constipation have each occurred in patients during gemcitabine treatment.  
Stomatitis has been reported in 11% of patients who received gemcitabine, but G3 & G4 toxicity occurs 
infrequently. 
 
Reproductive Toxicity 
Gemcitabine is classified as a HAZARDOUS DRUG at the NIH Clinical Center. 
 
Drug Interactions 
Gemcitabine significantly increased systemic exposure to fluorouracil in 20 patients with advanced 
gastroenteric carcinoma. Patients who received the combination (with leucovorin) had a greater fluorouracil 
AUC and plasma half-life, and decreased mean total clearance and volume of distribution compared to 
controls.  The fluorouracil AUC in patients who received gemcitabine and fluorouracil was 
555 ±209 µg/mL·min and 244 ±89 in patients who did not receive gemcitabine. 
 
Preclinical and clinical studies have shown that Gemzar has radiosensitizing activity.  Toxicity associated 
with multimodality therapy is dependent on many different factors, including gemcitabine dose and 


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frequency of administration, dose of radiation, radiotherapy planning technique, the target tissue, and target 
volume. 
Significant toxicity was observed when gemcitabine 1000 mg/m2 was administered for up to 6 consecutive 
weeks in combination with thoracic radiation in patients with non-small cell lung cancer.  Severe and 
potentially life-threatening mucositis, particularly esophagitis and pneumonitis, were observed particularly in 
patients who received large radiation volumes (median, 4795 cm3). 
 
One case has been reported in which a 63-year-old male stabilized on warfarin experienced increased 
international normalized ratio (INR) values while receiving gemcitabine.  Repeated reductions in his warfarin 
dose were needed to maintain the INR in the target range.  The patient experienced no emesis or weight 
loss as a result of gemcitabine therapy, and no antiemetics were given.  After gemcitabine treatments were 
discontinued, the warfarin dose required an upward titration to its previous level. 
Although a pharmacokinetic interaction is unlikely, it is possible that gemcitabine decreased the metabolic 
function of the cytochrome P450 enzyme system and consequently, warfarin metabolism.  Hepatic toxicity 
associated with gemcitabine may also decrease clotting factors synthesis, resulting in a reduced warfarin 
requirement. 
 
2. 
Cisplatin 
 
Formulation & Source 
Cisplatin is commercially available in amber, multiple-dose vials containing 50, 100, or 200 mg cisplatin in 
solution.  Each milliliter of solution contains 1 mg of cisplatin and 9 mg sodium chloride in water for injection. 
HCl and sodium hydroxide may be added to adjust product pH. 
Cisplatin Injection, USP, will be purchased from commercial sources by the NIH Clinical Center Pharmacy 
Department. 
 
Preparation 
Each dose of cisplatin will be diluted in 100 mL 0.9% Sodium Chloride Injection, USP.  Protect diluted 
solutions from exposure to light. 
 
Stability 
Vials bear the manufacturer's expiration dating.  After reconstitution to a concentration of 1 mg/mL, cisplatin 
is stable at room temperature (80°F [27°C]) for 20 hours.  Further dilution to 0.05 or 0.5 mg/mL with 0.9%NS 
yields a solution that is stable for at least 24 hours at room temperature.  
 
Storage 
Intact vials and reconstituted solution should be maintained at room temperature. 
Store intact vials at 15° – 25°C (59° – 77°F).  Do not refrigerate cisplatin in vials or after dilution. 
Cisplatin that remains in an amber vial after initial entry is stable for 28 days if protected from light or for 
7 days under fluorescent room light. 
Large-volume solutions do not need to be protected from light if used within 6 hours after preparation. For 
longer time periods, light protection is recommended. Light protection is required for intensive lighting 
conditions; e.g., direct sunlight exposure. 
Although cisplatin slowly degrades to trichloroaminoplatinate (TCAP) on exposure to ambient lighting 
conditions, solution pH is the predominant factor affecting cisplatin stability.  Solution pH > 4.3 (especially 
> 6.3) was associated with loss of cisplatin and a more rapid formation of TCAP. 
 
Dosage and Administration 
Cisplatin will be diluted in 100 mL 0.9%NS and administered intravenously after gemcitabine over 60 
minutes. 
 
Adverse Effects 
The following ‘Black Box’ warnings appear in FDA approved product labeling for Cisplatin Injection, June 
2004. Bedford Laboratories™, Bedford, OH: 
 
Cisplatin injection should be administered under the supervision of a qualified physician 
experienced in the use of cancer chemotherapeutic agents. Appropriate management of therapy 
and complications is possible only when adequate diagnostic and treatment facilities are readily 
available. 
 
Cumulative renal toxicity associated with cisplatin is severe. Other major dose-related toxicities are 
myelosuppression, nausea, and vomiting. 


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Ototoxicity, which may be more pronounced in children, and is manifested by tinnitus, and/or loss 
of high frequency hearing and occasionally deafness, is significant. 
 
Anaphylactic-like reactions to cisplatin have been reported. Facial edema, bronchoconstriction, 
tachycardia, and hypotension may occur within minutes of cisplatin administration. Epinephrine, 
corticosteroids, and antihistamines have been effectively employed to alleviate symptoms. 
 
Exercise caution to prevent inadvertent cisplatin overdose. Doses greater than 100 mg/m2/cycle 
once every 3 to 4 weeks are rarely used. Care must be taken to avoid inadvertent cisplatin 
overdose due to confusion with carboplatin or prescribing practices that fail to differentiate daily 
doses from total dose per cycle. 
 
Renal Adverse Effects 
Renal toxicities are dose limiting and may be irreversible with high doses of cisplatin and repeated courses.  
The severity of toxicity correlates directly with the amount of cisplatin administered in individual and 
cumulative doses.  Manifestations include increased BUN and serum creatinine and uric acid, and 
decreased creatinine clearance.  Renal toxicity may be mitigated by delaying cisplatin administration in 
patients who are clinically dehydrated, by giving intravenous hydration during and after cisplatin 
administration with or without the use of diuretics (to maintain urine output of at least 100 mL/h), diluting 
cisplatin for administration in vehicle solutions which contain chloride concentrations > 0.225%, avoiding 
rapid administration (avoid rates > 1 mg cisplatin/kg·hour), and avoiding administration of other nephrotoxic 
drugs concomitantly. 
 
Electrolyte disturbances are a consequence of renal tubular damage, and may include hypomagnesemia, 
hypocalcemia, hyponatremia, hypokalemia, and hypophosphatemia.  Hypomagnesemia is a persistent and 
possibly permanent adverse effect of cisplatin. 
 
Decreased serum sodium concentrations has been observed within 24 – 72 hours following cisplatin 
infusion.  Serum sodium deficits may resolve, but chronic salt wasting and hyponatremia may persist after 
discontinuing cisplatin. 
Cisplatin-induced hyponatremia was associated with decreased mental awareness, episodic seizures, and 
decerebrate posturing. 
 
Hemolytic uremic syndrome has rarely been associated with cisplatin use. 
 
Neurologic Adverse Effects 
Peripheral neuropathy is a dose-limiting toxicity.  The features of neuropathy are uniform and consistent with 
damage primarily to large sensory fibers.  Numbness and tingling are often early symptoms; impaired 
reflexes, vibratory sensation, and proprioception are associated with progressive toxicity, and sensory ataxia 
generally occurs late.  Lhermitte sign is often present.  Pain and temperature sensation is usually preserved.  
The severity of neuropathy varies with the dose intensity and the total cumulative dose administered.  The 
onset of neuropathy may begin or progress after cisplatin has been discontinued. Neuropathy is often 
reversible at least in part, but recovery often follows a protracted course.  Persons with neuropathic 
symptoms due to diabetes, hereditary neuropathies, or prior exposure to neurotoxic chemotherapy may be 
at increased risk of neurotoxicity. 
 
Other neurotoxic effects reported include encephalopathy with or without seizures; reversible posterior 
leukoencephalopathy syndrome; and visual disturbances, including: optic neuritis, papilledema, retrobulbar 
neuritis, cortical blindness, blurred vision and altered color perception. 
 
Ototoxicity manifested by tinnitus or hearing loss occurs in up to 31% of patients who receive cisplatin 
50 mg/m2.  Severity correlates with the magnitude of individual doses and total cumulative dose 
administered, and toxicity appears to be irreversible. Risk factors for hearing loss include age > 40 years 
and preexisting hearing loss. Vestibular toxicity has also been observed following cisplatin therapy. 
 
Hypersensitivity Reactions 
Hypersensitivity reactions including anaphylactoid reactions may occur with cisplatin.  Cross-sensitivity 
among alternate platinating agents (cisplatin, carboplatin, oxaliplatin) may occur. 
 
 
 


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Gastrointestinal Adverse Effects 
Acute emetic risk is high according to current antiemetic guidelines, and vomiting occurs in > 99% of 
patients who do not receive primary antiemetic prophylaxis. Patients who receive cisplatin dosages 
≥ 50 mg/m2 also are at risk for delayed symptoms; i.e., nausea and emesis which occur > 24 h after cisplatin 
administration. 
 
Hematologic Adverse Effects 
Transient and moderate myelosuppression, including leukopenia, thrombocytopenia, and anemia in 25 – 
30% of patients. Leukocyte and platelet nadirs occur between 18 – 23 days after treatment and generally 
recover by day 39.  Leukopenia occurs most frequently (27% of patients treated) followed by 
thrombocytopenia (16%), and anemia (11%). Leukocyte counts < 2000/mm3 and platelet counts < 50,000 
platelets/mm3 are rare with intermittent doses of 50 – 60 mg/m2. 
 
Thromboembolic events associated with cisplatin treatment have included deep venous thrombosis, 
pulmonary embolism, arterial occlusions, and cerebrovascular accident.  Prophylactic anticoagulation should 
be considered for patients with risk factors for thromboembolic disease. 
 
Dermatologic Adverse Effects 
Moderately severe cellulitis and fibrosis following cisplatin extravasation has been observed in one patient. 
 
Hepatic Adverse Effects 
ALT/SGPT and AST/SGOT may be transiently increased after cisplatin administration. 
 
Cardiovascular Adverse Effects 
Ciosplatin administration has been associated with arrythmias, bradycardia, and has been etiologically 
implicated in cases of myocardial infarction, and angina pectoris with proven ischemia. 
 
Reproductive Adverse Effects 
Sperm concentrations, rates of azoospermia, and FSH and LH concentrations were found significantly 
altered in male patients who received cumulative cisplatin dosages > 400 mg/m2 for testicular germ cell 
tumors in comparison with patients who did not receive chemotherapy. 
 
Carcinogenicity, Mutagenicity, Genotoxicity 
Cisplatin is classified as a HAZARDOUS DRUG at the NIH Clinical Center. 
 
The incidence of secondary leukemias was 1.5% in a Pediatric Oncology Group study of 198 children (age 
< 3 y) with malignant brain tumors who received cyclophosphamide plus vincristine alternating with cisplatin 
and etoposide for two years.  The latency period between chemotherapy initiation and secondary 
malignancy ranged from 2.8 – 7.7 years. 
Of 28,971 patients with ovarian cancer, 96 developed a secondary leukemia while being treated with 
platinum-based chemotherapy.  The relative risk of developing a secondary leukemia for treatment with 
cisplatin was 3.3. 
A case-control study based on international population-based cancer registry data of 18,567 males with 
testicular cancer diagnosed between 1970 and 1993 determined that the adjusted relative risk of secondary 
leukemia with a cumulative cisplatin dose of 650 mg was 3.2 (95% CI, 1.5 – 8.4).  Investigators equated this 
relative risk with an excess of 16 leukemia cases per 10,000 patients over 15 years. The relative risk of 
leukemia was found correlated directly with cumulative cisplatin doses. 
Concomitant ionizing radiation therapy or melphalan administration with cisplatin further increase the relative 
risk of developing a secondary leukemia. 
 
Cisplatin is teratogenic and embryotoxic in animal models.  In humans, normal pregnancies have been 
reported following cisplatin use alone and in combination with other chemotherapeutic agents. 
 
Cisplatin exhibits mutagenic activity in vitro in the Ames microbial mutagenicity assay and embryotoxicity in 
animal models. 
 
Although the quantity of drug appearing in breast milk is likely to be small, cisplatin is inherently cytotoxic, 
and the risks to a breastfeeding infant are unknown. 
 
Breast (milk-to-plasma ratios = 0.1 and 1.1) have been reported. A conflicting report detected no cisplatin in 
the breast milk of a patient who received cisplatin 100 mg/m2 IV over 26 hours plus doxorubicin 70 mg/m2 IV 
over 15 min. Although doxorubicin was detected in milk samples, no platinum was found in six samples 


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collected between 0.25 – 71.25 hours after starting cisplatin administration. Although most of the platinum in 
breast milk may be bound to plasma proteins, no data are available on infant exposure to cisplatin through 
breast milk, and breastfeeding during cisplatin therapy is not recommended. 
 
Drug Interactions 
Hypersensitivity reactions have been reported in patients who received combination regimens containing 
sequential high dose aldesleukin and cisplatin. Erythema, pruritus, and hypotension has occurred within 
hours after chemotherapy administration. 
 
Aluminum reacts with carboplatin causing precipitation and loss of drug potency.  DO NOT PREPARE OR 
ADMINISTER cisplatin with needles, dispensing pins, administration sets that contain aluminum parts which 
may come into contact with the drug. 
 
Concomitant use of cisplatin and aminoglycosides (amikacin, gentamicin, streptomycin, tobramycin) 
has the potential to increase the risk of nephrotoxicity. 
 
Concomitant use of cisplatin was implicated in decreasing carbamazepine and valproic acid plasma 
concentrations to subtherapeutic ranges which resulted in seizure activity.  The mechanistic basis for the 
putative interaction is not know. 
 
In a study of patients with metastatic or advanced tumors, docetaxel in combination with cisplatin induced 
more severe neuropathic effects than either drug as a single agent in similar doses. 
 
In a retrospective study in a series of 23 patients, Cagnoni, et al. showed the mean area under the curve for 
both cyclophosphamide (76,600 vs 90,600 mg/mL per min, P = 0.001) and cisplatin (525 vs 648 mg/mL per 
min, P = 0.01) were significantly less in patients who received ondansetron in a combination antiemetic 
regimen than in 129 historical control patients who received an antiemetic regimen in which 
prochlorperazine was used instead of ondansetron. 
 
Combined therapy with cisplatin and phenytoin or fosphenytoin may cause decreased phenytoin 
concentrations and increased seizure activity and require compensatory increases in phenytoin dosages to 
maintain therapeutic plasma levels. 
 
Cisplatin may affect melphalan kinetics by inducing renal dysfunction and subsequently altering melphalan 
clearance. 
 
Cisplatin is physically incompatible in admixtures with mesna. 
 
In a phase I trial, sequential infusions of escalating doses of paclitaxel (110 – 200 mg/m2) and cisplatin (50 
or 75 mg/m2) caused more profound myelosuppression when paclitaxel was given after cisplatin than the 
alternate sequence of administration.  Paclitaxel clearance was decreased approximately 33% when 
paclitaxel was administered after cisplatin. 
 
In a randomized trial of cisplatin (37.5 mg/m2 or 75 mg/m2 IV, day 1) and altretamine (200 mg/m2 PO, 
days 8–21) with and without concurrent pyridoxine (300 mg/day PO. days 1–21) in patients with ovarian 
cancer, pyridoxine was implicated in multivariate analysis among factors that adversely affected response 
duration in previously untreated patients. Consequently, pyridoxine should not be administered concurrently 
with altretamine and cisplatin. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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3. 
Bevacizumab 
Formulation 
The commercial product (Avastin®) is packaged in single-use clear glass vials containing either 100 mg or 
400 mg bevacizumab solution in a uniform concentration of 25 mg/mL. The product is formulated in α,α-
trehalose dihydrate, sodium phosphate (monobasic, monohydrate), sodium phosphate (dibasic, anhydrous), 
polysorbate 20, and Water for Injection, USP. 
Source 
Bevacizumab will be provided by Genentech and Roche.  The supply of bevacizumab being administered to 
patients enrolled on this study is intended for use only in clinical trials.  It is expected to be very similar in 
safety and activity to the commercially marketed drug (Avastin®), but it is possible that some differences 
may exist. 
Preparation 
Withdraw from a vial an amount of bevacizumab sufficient to prepare a patient’s dose and add it to a volume 
of 0.9%NS sufficient to produce a total volume of (Q.S.) 100 mL in a PVC, polyolefin, or glass container.  
Gently invert the container to mix diluted bevacizumab solution. Discard unused bevacizumab that remains 
in a vial. 
DO NOT MIX bevacizumab with dextrose solutions. 
Storage and Stability 
Store intact vials under refrigeration at 2° – 8°C (35.6° – 46.4°F) and protect them from light.  DO NOT 
FREEZE solutions containing bevacizumab. 
DO NOT SHAKE intact vials or diluted solutions 
 
After dilution in 0.9%NS, bevacizumab was stable for up to 24 hours under the following conditions: 
 
Bevacizumab Concentrations (mg/mL) 
Storage Temperatures 
Container Composition 
0.9 
2.25 
3 
6.6 
7.5 
16.5 
30°C (86°F) 
PVC, polyolefin, glass 
1 
12.5 
25 (undiluted drug) 
2° – 8°C 
30°C 
Polyolefin 
 
 
Dosage and Administration 
DO NOT ADMINISTER bevacizumab by intravenous push or bolus injection 
Administer bevacizumab by intravenous infusion after chemotherapy.  The INITIAL DOSE is given over 
90 minutes.  If the first infusion is well tolerated, the administration duration may be decreased to 60 minutes 
during a second infusion.  If a 60-minute infusion was well tolerated, subsequent treatments may be 
administered over 30 minutes 
 
DO NOT ADMINISTER, mix, or flush bevacizumab with dextrose solutions 
Adverse Effects 
The following ‘Black Box’ warnings appear in FDA approved product labeling for Avastin® (Bevacizumab) 
For Intravenous Use, March 2008.  Genentech, Inc. South San Francisco, CA: 
 
 
 
 


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Gastrointestinal Perforations 
Avastin administration can result in the development of gastrointestinal perforation, in some 
instances resulting in fatality. Gastrointestinal perforation, sometimes associated with intra-
abdominal abscess, occurred throughout treatment with Avastin (i.e., was not correlated to duration 
of exposure). The incidence of gastrointestinal perforation (gastrointestinal perforation, fistula 
formation, and/or intra-abdominal abscess) in patients with colorectal cancer and in patients with 
non-small cell lung cancer (NSCLC) receiving Avastin was 2.4% and 0.9%, respectively. The 
typical presentation was reported as abdominal pain associated with symptoms such as 
constipation and vomiting. Gastrointestinal perforation should be included in the differential 
diagnosis of patients presenting with abdominal pain on Avastin. Avastin therapy should be 
permanently discontinued in patients with gastrointestinal perforation. 
 
Wound Healing Complications 
Avastin administration can result in the development of wound dehiscence, in some instances 
resulting in fatality. Avastin therapy should be permanently discontinued in patients with wound 
dehiscence requiring medical intervention. The appropriate interval between termination of Avastin 
and subsequent elective surgery required to avoid the risks of impaired wound healing/wound 
dehiscence has not been determined. 
 
Hemorrhage 
Fatal pulmonary hemorrhage can occur in patients with NSCLC treated with chemotherapy and 
Avastin. The incidence of severe or fatal hemoptysis was 31% in patients with squamous histology 
and 2.3% in patients with NSCLC excluding predominant squamous histology. Patients with recent 
hemoptysis (≥1/2 tsp of red blood) should not receive Avastin. 
 
Cardiovascular Adverse Effects 
Genentech, Inc. informed healthcare professionals of reports of several cases of microangiopathic hemolytic 
anemia (MAHA) in patients with solid tumors who received bevacizumab in combination with sunitinib 
malate.  Twenty-five patients were enrolled in a phase I dose-escalation study which included three 
treatment strata using a fixed dose of bevacizumab 10 mg/kg, IV every 2 weeks and escalating doses of 
sunitinib 25, 37.5, and 50 mg/day orally for four consecutive weeks followed by two weeks without sunitinib, 
every 6 weeks.  Five of 12 patients at the highest sunitinib dose level exhibited laboratory findings consistent 
with MAHA.  Two of these cases were considered severe with evidence of thrombocytopenia, anemia, 
reticulocytosis, reductions in serum haptoglobin, schistocytes on peripheral smear, modest increases in 
serum creatinine levels, and severe hypertension, reversible posterior leukoencephalopathy syndrome, and 
proteinuria. The findings in these two cases were reversible within three weeks after discontinuing both 
drugs without additional interventions. 
 <http://www.fda.gov/medwatch/safety/2008/MAHA_DHCP.pdf> 
 
Arterial thromboembolic events (ATE) (e.g., cerebral infarction, transient ischemic attacks, myocardial 
infarction, angina) have been reported more often in patients receiving bevacizumab plus chemotherapy 
compared to patients receiving chemotherapy alone. Resuming bevacizumab therapy following resolution of 
an ATE has not been studied. 
 
Bevacizumab increases the risk of hypertension, proteinuria, hypercoagulopathy, and arterial thrombosis by 
decreasing endothelial nitric oxide synthase activity, stimulating PAI-1 expression, and altering renal 
podocyte function and renal vasculature.  Angiotensin converting enzyme inhibitors, in addition to their 
primary antihypertensive activity, may also prevent arterial thrombosis by decreasing serum PAI-1 levels 
and bevacizumab-induced proteinuria. Therefore, ACE inhibitors may be the preferred antihypertensive 
agent in the management of bevacizumab- induced hypertension. 
 
In a single, open-label, randomized, multicenter study, congestive heart failure (G3 & G4 ) occurred in 2.2% 
of patients with metastatic breast cancer who received bevacizumab plus paclitaxel compared with 0.3% of 
patients who received paclitaxel alone.  The incidence of CHF was found to be increased in patients who 
received anthracyclines prior to bevacizumab or concurrently. 
Modest increases in diastolic and systolic blood pressures (BP) and clinical hypertension have are reported 
frequently during bevacizumab therapy (23 – 34% of patients).  In most cases, increased BP is mild or 
moderate and controlled with antihypertensives.  Severe hypertension has been reported more often in 
bevacizumab-treated patients compared to controls, with 8% to 18% of patients in clinical trials experiencing 
G3 or G4 hypertension.  Up to 1.7% of patients required hospitalization or discontinuation of bevacizumab 
as a result of developing or worsening hypertension. Additionally, hypertension may persist after 
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Bevacizumab-induced hypertension may result in complications including hypertensive encephalopathy, 
which may sometimes be fatal. 
 
Left ventricular dysfunction G2 – G4 was reported in 1.7% of patients who received bevacizumab in clinical 
studies. The safety of continuing or resuming bevacizumab therapy in patients with cardiac dysfunction has 
not been studied. 
Dermatologic Adverse Effects 
Alopecia. 
 
Impaired wound healing (see the Black Box warning, above).  The ideal interval between the termination of 
bevacizumab and elective surgery in order to avoid impaired wound healing or wound dehiscence has not 
been determined. In clinical studies, wound dehiscence was reported in 0.8% of patients who received 
chemotherapy plus bevacizumab, and has resulted in fatalities. The longest interval between a dose of 
bevacizumab and wound dehiscence was 56 days which occurred in a patient who received bolus 
irinotecan, fluorouracil, leucovorin, and bevacizumab.  Do not initiate bevacizumab for at least 28 days 
following major surgery, and ensure a surgical incision is entirely healed before commencing or resuming 
bevacizumab. 
 
Skin rashes (type unspecified) have been described in patients following bevacizumab infusion. 
 
Metabolic Adverse Effects 
In a randomized, open-label, clinical trial, G3 – G5 dehydration occurred in 10% of patients with metastatic 
colorectal carcinoma who received fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) plus bevacizumab, in 
6% of patients who received bevacizumab monotherapy, and in 5% of patients who received FOLFOX4 
only. 
 
In a multicenter, randomized, open-label stud, hyponatremia G3 – G5 occurred in 4% of patients with 
previously untreated locally advanced, metastatic or recurrent non-small cell lung cancer who received 
paclitaxel, carboplatin, and bevacizumab compared to 1% of patients who received paclitaxel and 
carboplatin only. 
 
Gastrointestinal Adverse Effects 
Abdominal pain G1 – G4 was reported in 50 – 61% of patients with metastatic colorectal carcinoma.  In a 
randomized, open-label, clinical trial, abdominal pain ≥G3 occurred in 8% of patients with metastatic 
colorectal carcinoma who received fluorouracil, leucovorin, oxaliplatin (FOLFOX4) and bevacizumab and in 
8% of patients receiving bevacizumab monotherapy compared with 5% of patients who received FOLFOX4 
only. 
 
Constipation, any grade was reported in 29 – 40% of patients with metastatic colorectal carcinoma.  
Constipation G3 & G4 was reported in 4% and 2% of patients who received bolus-IFL (irinotecan, 
fluorouracil, leucovorin) plus bevacizumab and IFL plus placebo arms, respectively. 
 
Diarrhea G≥3 has been reported in 2% of patients in association with bevacizumab monotherapy and up to 
34% of patients with metastatic colorectal carcinoma who received bevacizumab in combination with 
chemotherapy. 
Gastrointestinal hemorrhage in up to 24% of patients with metastatic colorectal carcinoma who received 
bevacizumab in association with chemotherapy. 
 
Gastrointestinal perforation, sometimes associated with intra-abdominal abscess, has been reported in 
patients receiving bevacizumab (see the Black Box warning, above). GI perforation did not correlate with 
duration of exposure and occurred at various points during therapy.  In pooled data, the incidence of GI 
perforation was up to 3.7%.  In clinical trials, GI perforation with or without intraabdominal abscess or fistula 
formation was reported in 2.4% of patients with colorectal cancer and 0.9% of patients with non-small cell 
lung cancer treated with bevacizumab plus chemotherapy compared with 0.3% and 0% of patients treated 
with chemotherapy alone. GI perforation was typically associated with abdominal pain, constipation, and 
emesis. 
In postmarketing analysis, cases of gastrointestinal perforation (approximately 30% being fatal) were 
reported in 1% of patients usually within 50 days after receiving bevacizumab (range, 1 wk to > 1 y). 
 
Anorexia (G1 – G4), nausea (low emetic risk/ASCO criteria), stomatitis, altered taste. 
 


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Tracheoesophageal (TE) fistula occurred in a study in which patients with limited-stage small cell lung 
cancer (SCLC) received four cycles of concurrent irinotecan, carboplatin, radiation therapy, and 
bevacizumab followed by maintenance bevacizumab for up to 6 months. 
Bevacizumab is not indicated for use in SCLC. 
Two confirmed serious events of TE fistula (one fatal) were reported in the first 29 study participants. A third, 
fatal event (upper aerodigestive tract hemorrhage and death of unknown cause), was also reported, in which 
TE fistula was suspected but not confirmed. All three events occurred during the maintenance phase of the 
study in the context of persistent esophagitis. As of March 22, 2007, six cases of TE fistula have also been 
reported in other lung and esophageal cancer studies involving the use of bevacizumab and chemotherapy 
alone or with concurrent radiation treatment. 
There is limited information in the published literature on the background rate of TE fistula in patients with 
limited-stage SCLC, but is estimated to be <1%, which was exceeded in the trial. Due to the small number of 
patients treated in the setting of limited-stage SCLC and the non-randomized nature of the trial, it was not 
possible to distinguish the toxicity observed in this trial from other risk factors for the development of TE.  
The study was closed to further accrual on March 12, 2007. 
A description of cases of gastrointestinal tract fistula formation in patients with colorectal cancer and other 
types of cancer treated with Avastin® in clinical studies and post-marketing reports is included in the current 
US prescribing information.  
[REF: Dear Healthcare Provider letter, entitled “IMPORTANT DRUG WARNING Regarding AVASTIN® 
(bevacizumab)” from Genentech, Inc., April 2007.  
Linked to the US FDA MedWatch site at  
www.fda.gov/medwatch/safety/2007/Avastin_DHCP_TEF_Final_April2007.pdf]. 
 
Hematologic Adverse Effects 
Severe and fatal hemorrhage occurred more frequently in bevacizumab-treated patients versus patients who 
received chemotherapy alone (see the Black Box warning, above).  Minor bleeding or hemorrhage (e.g., G1 
epistaxis) have been reported following the administration of bevacizumab. 
 
Administration of bevacizumab, in combination with chemotherapy, has been associated with serious 
hemorrhage and thromboembolic events. Other hematologic toxicities include neutropenia, febrile 
neutropenia, leukopenia, and thrombocytopenia.  Some data suggest that vascular endothelial growth 
factors (VEGFs) may play a role in maintaining endothelial integrity of the tumor microvasculature, and that 
receptor blockade by bevacizumab may initiate a coagulation cascade. 
 
Microangiopathic hemolytic anemia (MAHA) was reported in patients with solid tumors who received 
bevacizumab in combination with sunitinib malate. 
In a phase 1 dose-escalation study, patients received a fixed dose of bevacizumab 10 mg/kg, IV every 2 wks 
and escalating doses of sunitinib that included 25, 37.5, or 50 mg/day orally for 4 consecutive wks followed 
by 2 wks without sunitinib. Five of 12 patients at the highest sunitinib dose level exhibited laboratory findings 
consistent with MAHA.  Two cases were considered severe with evidence of thrombocytopenia, anemia, 
reticulocytosis, reductions in serum haptoglobin, schistocytes on peripheral smear, modest increases in 
serum creatinine, severe hypertension, reversible posterior leukoencephalopathy syndrome (RPLS), and 
proteinuria. 
The findings in these two cases were reversible within three weeks upon discontinuation of both drugs 
without additional intervention. The information above led to the closure of a Genentech-sponsored phase 2 
trial of sunitinib at 50 mg ± bevacizumab with a similar dosing schedule in which two of seven patients 
enrolled were found to have MAHA. 
Two additional Genentech-sponsored randomized, Phase 2 studies of Avastin in combination with sunitinib 
and chemotherapy in patients with solid tumors were also closed due to poor tolerability primarily due to 
myelosuppression, fatigue and gastrointestinal complications (e.g., diarrhea, anorexia, dehydration, 
stomatitis). No events of MAHA have been reported in these studies. 
Bevacizumab has not received FDA approval for use in combination with sunitinib malate, and is not 
recommended. 
[REF: Dear Healthcare Provider letter, entitled “IMPORTANT DRUG WARNING: Microangiopathic 
Hemolytic Anemia (MAHA) in Patients treated with Avastin® (bevacizumab) and sunitinib malate” from 
Genentech, Inc., July 2008. Linked to the US FDA MedWatch site at 
 www.fda.gov/medwatch/SAFETY/2008/MAHA_DHCP.pdf]. 
 
Neutropenia, including febrile neutropenia, has been reported more frequently in patients who received 
bevacizumab plus chemotherapy compared to patients who received chemotherapy alone. 
 
 


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Hypersensitivity (Infusion) Reactions 
In clinical trials and postmarketing surveillance, infusion reactions, including hypertension, hypertensive 
crises, wheezing, oxygen desaturation, G3 hypersensitivity, chest pain, headaches, rigors, and diaphoresis, 
have been observed during bevacizumab administration.  First dose infusion reactions have been reported 
in <3% of patients in clinical studies; 0.2% of patients reported a severe reaction.  Bevacizumab therapy 
should be interrupted and appropriate management instituted in patients who experience a severe reaction.  
There is no information available regarding rechallenge or identification of patients who can be safely treated 
following severe infusion reactions. 
 
Arthralgia has been reported occasionally after infusion with bevacizumab. 
 
Neurologic Adverse Effects 
Reversible posterior leukoencephalopathy syndrome (RPLS) has been reported in clinical trials (incidence 
<0.1%) and during postmarketing surveillance.  Clinical presentation included headache, lethargy, seizures, 
confusion, blindness, and other visual and neurologic disturbances. Onset of symptoms has ranged from 
16 h to 1 y after initiation of bevacizumab.  Although some patients have experienced ongoing neurologic 
sequelae, symptoms usually resolve or improve within days. The safety of resuming bevacizumab therapy 
following RPLS is not known. 
 
In a randomized, open-label, clinical trial, sensory neuropathy (G3 – G5) occurred in 17% of patients with 
metastatic colorectal carcinoma who received fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) plus 
bevacizumab and in 1% of patients who received bevacizumab alone compared with 9% of patients who 
received FOLFOX4 only.  In a single, open-label, randomized, multicenter study in patients with metastatic 
breast cancer, sensory neuropathy (G3 – G5) occurred in 24.2% of patients who received bevacizumab plus 
paclitaxel vs. 17.5% of patients receiving paclitaxel alone. 
 
Mild asthenia has been reported in up to 70% of patients during bevacizumab therapy.  In contrast, asthenia 
G3 and G4 occurred in 10% of patients with metastatic colorectal carcinoma who received bolus irinotecan, 
fluorouracil, and leucovorin (bolus-IFL) plus bevacizumab compared with 7% of patients who received IFL 
plus placebo. 
 
Headache, usually mild in severity, has been reported in up to 50% of patients receiving bevacizumab. In 
one study of patients being treated with bevacizumab for breast cancer, headache, with nausea and 
vomiting, was dose-limiting with bevacizumab 20 mg/kg·dose every 2 weeks. 
Dizziness (G1 – G4). 
 
Ophthalmologic Adverse Effects 
In a retrospective case series, retinal pigment epithelial tears (RPE) occurred in 2.2% of patients with 
neovascular age-related macular degeneration treated with intravitreally administered bevacizumab. 
 
Genitourinary Adverse Effects 
Bladder and vaginal fistula formation. 
 
Nephrotic syndrome and proteinuria have been reported in clinical trials at a higher rate in patients who 
received bevacizumab compared with control patients. In addition, proteinuria occurred at a higher rate in 
clinical trials in patients receiving bevacizumab compared with control patients. During these trials, 
bevacizumab was typically interrupted when urine protein was ≥2 grams/24 h, and subsequently resumed 
when urine protein levels returned to <2 g/24 h.  The safety of continued therapy in patients with moderate 
to severe proteinuria has not been studied and improvement and resolution should be appropriately 
monitored with 24-hr urine collections. Bevacizumab therapy should be discontinued in patients 
experiencing nephrotic syndrome. 
 
Respiratory Adverse Effects 
Fatal pulmonary hemorrhage and hemoptysis have been reported in patients with non-small cell lung cancer 
treated with bevacizumab and chemotherapy, with life-threatening or fatal hemoptysis occurring in 31% of 
patients with squamous histology and 2.3% of patients with non-squamous non-small cell lung cancer. 
 
In a randomized, double-blind, clinical trial, dyspnea (G1 – G4) occurred in 26% of patients with metastatic 
colorectal carcinoma who received bolus irinotecan, fluorouracil, and leucovorin (bolus-IFL) plus 
bevacizumab and 25% of patients received fluorouracil, leucovorin, and bevacizumab compared with 15% of 
patients who received IFL plus placebo. 
 


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In a randomized, double-blind, clinical trial, epistaxis (G1 – G4) occurred in 35% of patients with metastatic 
colorectal carcinoma receiving bolus irinotecan, fluorouracil, and leucovorin (bolus-IFL) plus bevacizumab 
and 32% of patients received fluorouracil, leucovorin, and bevacizumab compared with 10% of patients who 
received IFL plus placebo. 
 
Bronchopleural fistula formation, pulmonary hypertension, voice alteration. 
 
In clinical studies or postmarketing experience, nasal septum perforation has been reported in patients 
receiving bevacizumab. 
 
Reproductive Adverse Effects 
There is insufficient clinical experience with bevacizumab to confirm its safety in pregnancy. The potential to 
disrupt angiogenesis during fetal development following the administration of bevcizumab is likely to result in 
adverse effects on pregnancy.  Persons should be counseled after discontinuing bevacizumab use 
regarding prolonged exposure of the drug, given a half-life of approximately 20 days, and the possible 
effects on the fetus. 
No human studies of pregnancy outcomes after exposure to bevacizumab have been published, and there 
are no reports of outcomes following inadvertent exposure during pregnancy. Studies conducted in rabbits 
given twice the recommended human dose based on a mg/kg basis resulted in teratogenic effects, including 
decreases in fetal and maternal weights, increased fetal resorptions and an increased incidence of specific 
gross and skeletal alterations. 
 
It is not known whether bevacizumab is excreted into human breast milk and the potential for adverse 
effects in a nursing infant from exposure to the drug are unknown. It is not known if bevacizumab affects the 
quantity or composition of breast milk. 
 
Other Adverse Effects 
Fatigue, low-grade fever has been reported with variable frequency during bevacizumab therapy. 
 
4. 
Etoposide 
 
Formulation 
 
 
Etoposide Injection, USP, is commercially available in sterile, multiple-dose vials. 
The pH of the clear, nearly colorless to yellow liquid is 3 to 4.  Each milliliter of 
drug product contains 20 mg etoposide, USP; 2 mg citric acid; 30 mg benzyl 
alcohol; 80 mg modified polysorbate 80/tween 80; 650 mg polyethylene 
glycol 300; and 30.5% (v/v) alcohol. 
 
Etoposide Injection, USP, will be purchased from commercial sources by the 
NIHClinical Center Pharmacy Department. 
 
Stability 
Intact vials are stable for 24 months at room temperature (25°C, 77°F). 
 
The stability of etoposide is concentration dependent.  When diluted as described 
 (above) in either glass or plastic containers and stored at room temperature 
 under normal room fluorescent light, etoposide demonstrates stability as follows: 
 
 
solution concentration
Duration
of stability 
0.2 mg/mL 
96 hours 
0.4 mg/mL 
48 hours 
0.6 mg/mL  
12 hours 
1.0 mg/mL  
2 hours 
 
Storage 
Store intact vials and diluted solutions at controlled room temperatures, 15° – 
30°C (59° – 86°F).  DO NOT REFRIGERATE etoposide in vials or diluted 
solutions. 


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Preparation 
Etoposide Injection will be diluted in a volume of 5% Dextrose Injection, or 0.9% 
Sodium Chloride Injection, USP, sufficient to produce a concentration between 
0.2 – 0.4 mg/mL prior to administration: 
 
calculated dose 
Vehicle
solution volume 
100 – 200 mg 
500 mL 
201 – 400 mg 
1000 mL 
 
Dosage and Administration 
Administer etoposide intravenously over at least 60 minutes, daily for three 
consecutive days, every 21 days.  Longer infusion durations may be used if the 
volume of fluid to be administered is of concern, or if a patient experiences 
hypotension or evidence of hypersensitivity. 
 
Adverse Effects  
In general, toxicities are increased in patients with decreased serum albumin or 
hyperbilirubinemia due to decreased protein binding and an increased fraction of 
unbound etoposide, and in persons with renal impairment 
in whom elimination of etoposide and its metabolites is decreased. 
 
Hematological 
Myelosuppression is dose-related and dose-limiting. Leukopenia is the most 
common adverse effect associated with oral or intravenous etoposide. 
Granulocyte nadirs characteristically occur 7 – 14 days after etoposide 
administration, platelet nadirs occur 9 – 16 days after administration, and bone 
marrow recovery is usually complete by 20 days after etoposide administration.  
Cumulative myelosuppression has not been reported. 
 
 
Concurrent anemia is an independent risk factor for myelotoxicity, in part 
because it decreases the volume of distribution of epipodophyllotoxins and 
increases the circulating concentration of the unbound drug. 
Fever and infection have also been reported in patients with neutropenia. Death 
has been reported in association with myelosuppression. 
 
Acute leukemia with or without a preleukemic phase has been reported rarely in 
patients treated with etoposide in association with other antineoplastic agents. 
Secondary leukemia occurred from 9 – 68 months after diagnosis of the first cancer; treatment responses 
have been poor in most patients. 
 
Acute leukemia with or without a preleukemic phase has been reported rarely in 
patients treated with etoposide in association with other antineoplastic agents for 
acute lymphocytic leukemia (ALL) or solid tumors. The incidence of acute myeloid leukemias (AML) in three 
retrospective case series ranged from 0.37 – 8.1%. Patients with childhood ALL who received treatment 
containing etoposide have been found to develop an acute nonlymphocytic leukemia characterized by a 
translocation in chromosome 11 (11q23).  The site is the locus for the mixed-lineage leukemia gene which 
regulates pluripotent stem cell proliferation.  The secondary leukemic cells were found morphologically 
similar to acute monocytic or monomyelocytic leukemia cells. 
 
Etoposide-related leukemia is characterized by a short interval between the end 
of treatment and onset of leukemia (1 – 3 years) and the absence of a 
myelodysplastic period preceding leukemia, which distinguish it from a 4- to 5- 
year interval to secondary leukemias among patients who received treatment 
with alkylating agents. Ten of 205 patients who received treatment for ALL 
which included etoposide developed secondary AML. The risk of secondary AML at 4 years was 5.9 ±3.2% 
which suggests a strong link 
between etoposide use and secondary AML since none of the patients had 
received alkylating agents or irradiation. Patients who receive etoposide on 
weekly or twice-weekly schedules, with cumulative doses > 2000 mg/m2, may be 
at increased risk for developing a secondary leukemia. 


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Gastrointestinal 
The risk of nausea and vomiting after parenteral etoposide administration is low 
(approximately 15% of patients who do not receive antiemetic prophylaxis), but 
symptoms occur more frequently (up to 90% of patients) and may be the dose- 
limiting toxicity with oral administration.  In general, the severity of emetic 
symptoms is mild to moderate. 
 
Mucositis is directly related to etoposide dosage and the duration of exposure, 
and is reported in 1 – 6% of patients treated with etoposide at FDA approved 
 dosages and schedules. 
 
Diarrhea has been reported in 1 – 13% of patients receiving etoposide. 
 
Anorexia has been reported in approximately 10 – 13% of patients treated with 
either intravenous or oral etoposide 
 
Hypotension 
Transient hypotension following rapid intravenous administration has been 
reported in 1 – 2% of patients, and may be avoided by slow intravenous 
administration over at least 30 minutes.  Hypotension has not been associated 
with cardiac toxicity or ECG changes.  Delayed hypotension has not been noted 
If hypotension occurs, it usually responds to interrupting etoposide. 
administration and, if necessary, administration of fluids or other supportive 
therapy as appropriate.  When resuming intravenous administration after a 
hypotensive event, a slower rate should be used. 
 
Hypersensitivity 
Anaphylactoid reactions characterized by chills, fever, tachycardia, hypotension, 
bronchospasm, flushing, exanthema, dyspnea, tightness, cyanosis, and 
hypertension have been reported in 0.7 – 2% of patients who receive etoposide 
intravenously and in < 1% of patients treated with etoposide capsules 
administered orally.  Hypersensitivity reactions often respond promptly to the 
cessation of etoposide administration and administration of pressor agents, 
glucocorticoids, antihistamines, or volume expanders as appropriate; however, 
fatal reactions have occurred.  Hypertension and flushing have also been 
reported.  Blood pressure usually normalizes within a few hours after 
discontinuing intravenous etoposide administration.  Anaphylactoid reactions 
have been observed during initial exposure to etoposide. 
 
Although an immunological basis for hypersensitivity cannot be excluded, 
hypersensitivity reactions are reported to occur less frequently with orally 
administered etoposide and etoposide phosphate which, unlike formulations of 
etoposide for parenteral administration, do not contain polysorbate 80. 
Face and tongue swelling, coughing, diaphoresis, cyanosis, throat tightness, 
laryngospasm, back pain, and loss of consciousness have sometimes occurred 
in association with other hypersensitivity reactions.  An apparent hypersensitivity- 
associated apnea has been reported rarely. 
 
Rash, urticaria, and pruritus have infrequently been reported at FDA approved 
dosages and schedules. 
 
Skin and Integument 
Reversible alopecia occurs commonly (8 – 93% of patients) and may progress to 
total baldness. Ultraviolet light-induced ‘recall’ dermatoses, 
StevensJohnson syndrome, rashes, cutaneous eruptions, urticaria and pruritis, exfoliative dermatitis, 
erythrodysesthesia, and onycholysis have been associated with etoposide use. 
 
Chemical phlebitis has been reported during etoposide use, and is thought to be due to solvent components 
in the drug formulation.  Rarely, extravasation has been associated with necrosis and venous induration. 
 
Pulmonary 
Bronchospasm, pneumonitis, pulmonary toxicity, dyspnea and apnea have been 


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described with etoposide use. 
 
Hepatotoxicity 
Hepatotoxicity has been reported in up to 3% of patients who received etoposide, 
and is particularly evident after high-dose treatment. Hepatotoxicity may include 
hepatitis with transiently increased hepatic enzymes (alkaline phosphatase, total 
bilirubin, ALT), hepatocellular necrosis, hyperammonemia, hyperbilirubinemia, 
and ascites.  Hepatocellular necrosis has been reported following high 
dose etoposide (600 – 2400 mg/m2). 
 
Reproduction, Fertility, and Gestation 
Ovarian failure, amenorrhea, anovulatory cycles, and hypomenorrhea have been 
described in association with etoposide therapy.  Etoposide is potentially gonadotoxic and should be used 
with caution in young females. 
Etoposide is teratogenic and may increase the risk of congenital malformations if 
given during the first trimester of pregnancy. 
Etoposide is categorized among Hazardous Drugs at the NIH Clinical Center. 
 
Other Adverse Effects 
The following adverse reactions have been infrequently reported: abdominal 
pain, aftertaste, constipation, dysphagia, asthenia, fatigue, malaise, somnolence, 
transient cortical blindness, optic neuritis, fever, and seizure (occasionally 
associated with allergic reactions). 
Although rare, cerebral edema due to a capillary leak syndrome, angina pectoris, myocardial infarction, and 
congestive heart failure have been described with etoposide in clinical use. 
 
 
Drug Interactions 
Cytochrome P450 (CYP) CYP3A4 inhibition by aprepitant or fosaprepitant 
theoretically may result in increased concentrations of etoposide in plasma and potentially increased 
etoposide side effects. 
 
Vaccination with live virus vaccines (mumps, poliovirus, rotavirus, rubella, 
rubeola, varicella, variola, yellow fever virus) and live bacteria vaccines (BCG, 
typhoid) in patients with immunity compromised by chemotherapeutic agents has 
resulted in severe and fatal infections.  At least three months should elapse between the discontinuation of 
chemotherapy and vaccination with a live vaccine. 
 
Coadministration of etoposide and cyclosporine may increase etoposide serum 
concentrations and risk of adverse reactions. 
 
Glucosamine induced resistance to the topoisomerase II inhibitors etoposide 
and doxorubicin in in vitro experiments.  It is currently not known whether oral glucosamine administration 
concurrent with etoposide may 
compromise the latter drug’s antineoplastic effect.  Therefore, the combination 
should be avoided. 
 
Concomitant grapefruit juice ingestion decreased the bioavailability of etoposide 
by a mean 26% in a randomized crossover trial. The effect may be attributable to grapefruit juice induction of 
P-glycoprotein and enhanced extracellular transport of etoposide into the gut lumen.  Concomitant use of 
etoposide and grapefruit juice and grapefruit products should be avoided. 
 
Etoposide is a substrate for metabolism by CYP3A4 and extracellular transport 
by P-glycoprotein (MDR1, ABCB1). St. John's Wort induces CYP3A4 and P- 
glycoprotein and, consequently, may decrease the effectiveness of etoposide 
while potentially increasing the formation of leukemogenic etoposide metabolites 
via CYP3A4. Use of St. John's Wort should be avoided in patients who receive treatment with etoposide. 
 
 
Combined use of valspodar with chemotherapeutic regimens containing 
etoposide has resulted in significant decreases in etoposide clearance (40 – 
60%), associated with significant increases in the etoposide area under the 
plasma concentration-vs-time curve and elimination half-life and a reduced 
volume of distribution.  Dose reductions of etoposide of up to 66% have been 


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required to minimize toxicity. 
 
In patients who receive warfarin, concomitant etoposide may increase the 
International Normalized Ratio (INR) and bleeding.  Monitor INR closely and for signs of bleeding when 
warfarin and etoposide are used concomitantly 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix IX 
 
NIH POLICY MANUAL 
1340-1 - Permits for Import or Export of Biological Materials 
Issuing Office: OD/OM/ORS/DOHS (301) 496-2960 
Release Date: 02/01/08 
 
1. Explanation of Material Transmitted: This manual chapter describes the NIH 
policy and procedures concerning the requirements for the importation or 
shipment of etiological agents, their vectors, animals, and plants and for the 
exportation of biological materials.  This chapter is being revised to update 
organizational references and to add 2 new required sections:  Records Retention 
and Management Controls.  
2. Filing Instructions:  
Remove: NIH Manual 1340-1, dated 11/15/96  
Insert: NIH Manual 1340-1 dated 02/01/08 
PLEASE NOTE: For information on:  
• 
Content of this chapter, contact the issuing office listed above.  
• 
On-line information, enter this URL: 
http://www1.od.nih.gov/oma/manualchapters/  
• 
To sign up for e-mail notification of future changes, please go to the NIH Manual 
Chapters LISTSERV Web page.  
 
A. Purpose: 
This chapter describes the NIH policy and procedures concerning the requirements for 
permits for the importation or shipment of etiological agents, their vectors, animals and 
plants, and for the exportation of biological materials. This chapter is being revised to 
comply with the requirement that chapters be reviewed every 5 years.  In addition, 2 new 
sections have been added (a) Records Retention and (b) Management Controls.    
B. Background:  
In recent years, the concern over the safe and secure transport of hazardous material has 
intensified in an effort to ensure personal and public safety during transport of etiological 


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agents, their vectors, animals and plants, and for the exportation of biological materials.  
In the United States, all hazardous material packages that are offered for domestic 
transport are subject to the DOT regulations.  All hazardous material packages shipped 
internationally are subject to the requirements established by the United Nations 
International Civil Aviation Organization (ICAO) whose guidelines are adopted by the 
International Air Transport Association (IATA).  Both regulatory bodies establish 
definitions and requirements for the classification, packaging, marking, labeling, and 
documentation of hazardous material packages. Personal, civil and criminal penalties 
have been established for willful violation of these regulations.   
Failure to comply with import and export requirements may result in shipment release 
delays or shipment confiscation and destruction by the Quarantine Officer at the port of 
entry. 
C. Policy:  
NIH will conform to all applicable laws and regulations for the importation and shipment 
of etiological agents and vectors. 
It is the policy of the NIH to ensure that all packages being offered for transport comply 
with all Federal and international regulations for ground and air transport in order to 
protect the safety of the laboratory staff, support staff, the environment, and the public.   
No person at NIH shall make arrangements to receive or ship an etiological agent, vector, 
animal, or plant before ascertaining the necessity for a permit and obtaining a permit 
when required. 
Etiological agents and vectors of human or animal disease cannot be transported in a 
privately owned vehicle (POV).  To transport via land, a government vehicle may be 
used.  All applicable packaging requirements of the U. S. Department of Transportation 
(DOT) regulations must be followed (49 CFR Parts 171- 178). 
Any person at the NIH wanting to personally transport etiological agents and/or vectors 
of human or animal disease via air must have the material packaged by an appropriately 
trained and certified individual, following IATA packaging instructions.  The material 
must be declared prior to departure.    
 
No person at NIH shall transfer PHS-permitted materials to another laboratory or facility 
within NIH or to another Federal or private facility without prior authorization by the 
Division of Occupational Health and Safety, Quarantine Permit Service Office (QPSO). 
NIH Policy Manual 1340-1 sets forth the responsibilities and specific requirements for 
acquiring appropriate import and export permits for shipping hazardous materials.  All 
hazardous materials shipped from the NIH Bethesda campus must be shipped through the 
Office of Logistics and Acquisitions Operations, Freight Forwarding Team.  Remote NIH 


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facilities must establish site specific requirements for the transport of hazardous material 
packages to facilitate compliance with this policy. 
D. References: Legislative Sources:  
1.  Department of Health and Human Services, Public Health Service quarantine 
regulations task the Centers for Disease Control and Prevention (CDC) with 
management of human etiological agent import/transfer program.  The regulation 
states: "A person may not import into the United States, nor distribute after 
importation, any etiological agent or any arthropod or other animal host or vector 
of human disease, or any exotic living arthropod or other animal capable of being 
a host or vector of human disease unless accompanied by a permit issued by the 
Director." (42 CFR 71.54).   
2. U.S. Department of Agriculture (USDA) regulations state: "No organisms or 
vectors shall be imported into the United States or transported from one State or 
Territory or the District of Columbia to another State or Territory or the District 
of Columbia without a permit issued by the Secretary and in compliance with the 
terms thereof....” (9 CFR 122.2).  
Note: The USDA will not permit the importation of cell cultures, monoclonal antibodies, 
ascites fluid or bovine serum from countries where rinderpest and foot-and-mouth disease 
are present unless the imported materials are determined to be virus-free. 
3. Similar USDA regulations are concerned with agents and vectors of plant disease 
(7 CFR 330). These regulations seldom affect the work of biomedical 
investigators but are applicable. 
4. The United States Fish and Wildlife Service (USFWS), U.S. Department of 
Interior, is responsible for regulations involving the prevention and control of 
wildlife diseases and for the importation of wildlife and eggs thereof (50 CFR 23). 
In addition, the USFWS represents the United States to the Convention on 
International Trade in Endangered Species of Wild Fauna and Flora (CITES).   If 
biomedical investigators wish to use biological materials or tissues derived from 
fauna or flora listed in Appendices I, II or III of the convention, a CITES permit is 
required (50 CFR 23). The USFWS has granted the NIH a Designated Port 
Exemption permit to allow for the importation of materials transiting through 
Washington Dulles International Airport, however, the importation of certain 
animals and birds is prohibited.  
5. The U. S. Department of Commerce (DOC), Bureau of Industry and Security, is 
responsible for implementing and enforcing the Export Administration 
Regulations (EAR), which regulate the export and re-export of most commercial 
items. 
6. Biological materials and etiological agents are subject to packaging and shipping 
requirements of various Federal and International regulations.  Proper packaging 


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is the primary consideration and of utmost importance in the safe transportation of 
hazardous materials.  The DOT regulations (49 CFR 171 – 178) and IATA’s 
Dangerous Goods Regulations dictate the proper packaging requirements 
necessary for most biological materials.  
E. Delegation:  
The Centers for Disease Control and Prevention (CDC) Etiological Agent Import Permit 
Program Atlanta, Georgia, has authorized NIH to issue permits for the importation of 
etiological agents and vectors of human disease into NIH laboratories. It is a condition of 
this authorization that NIH maintains a record of each permit issued and documents the 
transfer of all PHS-permitted material.  
 
NIH has established the Quarantine Permit Service Office (QPSO), Division of 
Occupational Health and Safety (DOHS), Office of Research Services (ORS), Building 
13, Room 3K04  for matters involving the import or export of biological materials.  
Permit information is available by calling (301) 496-2960 or by going online at 
http://dohs.ors.od.nih.gov/shipping_biological_material.htm.  
F. Responsibilities:  
1. The NIH Quarantine Permit Service Office is responsible for:  
a. Providing information and guidance to NIH components on the requirements for 
import or export of biological materials. 
b. Issuing PHS import/transfer permits or letters of non-infectious import for biological 
materials arriving to the NIH. 
c. Executing export declarations for biological materials leaving the United States. 
d. Maintaining records and the submission of reports to regulatory agencies.  
Note: In some cases, more than one permit may be required for the import/transfer or 
export of a biological material.  Although the QPSO does not issue USDA or USFWS 
permits, the office will provide assistance in obtaining these permits.  Should QPSO 
determine a DOC validated license is required for the export or re-export of a biological 
material, the office will notify the investigator and apply directly to the DOC on his/her 
behalf. 
The transfer of select agents and toxins is managed by the NIH Select Agent Program, 
following the regulations promulgated in 42 CFR 73, “Select Agents and Toxins”.  The 
QPSO requires that a request for permit to import an etiological agent requiring Biosafety 
Level 3 (BSL3) or Biosafety Level 4 (BSL4) containment be submitted with the written 
concurrence of the IC Scientific Director. 


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2. IC Scientific Directors are responsible for: 
a. Providing written concurrence for the import of an etiological agent requiring 
Biosafety Level 3 (BSL3) or Biosafety Level 4 (BSL4). 
b. Ensuring staff compliance with QPSO policy and regulations involving the import and 
export of etiological agents, disease vectors, animals and plants, and other biological 
materials. 
G. Procedures:  
1. Imports: 
 
a. To ascertain the need for a permit to import or transfer a human etiological 
agent, vector of human or animal disease, animal or plant, contact the QPSO at 
least six weeks before the date of shipment in order to allow adequate time for 
processing the permit request. 
 
b. A person wishing to import biological material, or  transfer previously 
permitted material to another NIH/PHS laboratory, must obtain a PHS import 
permit by submitting the application, Form CDC 75-3, "Application for Permit to 
Import or Transport Agents or Vectors of Human Disease" to the QPSO via fax 
(301) 480-0671.  This form is available on the DOHS website at 
http://dohs.ors.od.nih.gov/forms.htm.  The QPSO will determine whether a PHS 
permit or letter of non-infectious import is required.   
 
c. A person wanting to apply for an import/export/re-export permit of wildlife 
samples and/or biomedical samples collected from an endangered species must 
complete USFWS Form 3-200-29, “Import, Export, Re-export of Wildlife 
Samples and/or Biomedical Samples”.  This permit application is submitted 
directly to USFWS and is available online at: http://www.fws.gov/permits/ .  
Applicants should be prepared to wait 60-90 days for a determination and be 
aware that an application fee applies.  Once approval is granted, a copy of the 
USFWS permit must be forwarded to the QPSO.  
 
d. A person wanting to apply for a USDA Animal and Plant Health Inspection 
Service (APHIS) permit must submit the permit application directly to the USDA 
using the ePermit system available at http://www.aphis.usda.gov/permits/. Both 
USDA and PHS permits may be required for the importation of some biological 
materials.  An application fee applies.  Once approval is granted, a copy of the 
USDA permit must be forwarded to the QPSO.  Applicants must contact the 
QPSO prior to shipment if live animals are to be received at the Washington 
Dulles International Airport under the NIH designated port exemption.  
 
e. No person at the NIH shall distribute a permitted etiological agent or vector of 


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human disease unless the intended recipient provides a copy of the appropriate 
permit authorizing the receipt of the material.    
2. Exports:  
 
a. In general, biological materials may be exported to most countries under the 
provisions of the Export Administration Regulations (EAR), DOC.  A person 
wanting to export a biological material must submit Form NIH-2388, 
“Declaration for Exportation of Biologic Materials”, to the QPSO.  This form is 
available on the NIH Forms website at 
http://forms.nih.gov/adobe/procurement/NH2388.PDF and can be faxed to (301) 
480-0671.  Authorization is dependent upon the nature of the biological agent or 
material, recipient, proposed country of destination, and commercial value of the 
shipment.   
 
b. The recipient’s country may impose import restrictions or require that the 
recipient obtain an import permit from the appropriate issuing agency in the 
recipient’s country.  If an import permit is required, the permit number or a copy 
of the import permit must be included with the “Declaration for Exportation of 
Biologic Materials”, and provided to the QPSO. 
3. Interstate Shipments:  
 
In general, indigenous etiological agents and vectors are not subject to control by 
Federal or other agencies for U.S. interstate shipments, however there are 
exceptions (e.g., establishment of a colony of Aedes aegypti mosquitoes, interstate 
transport of plant pests, blue tongue virus, etc.). Contact the QPSO for guidance 
before transporting etiological agents that may be subject to interstate shipment 
restrictions. 
4. Packaging Requirements:    
Biological materials, including diagnostic specimens, are subject to packaging 
requirements described in the DOT regulations (49 CFR 171 – 178) and the International 
Air Transport Association (IATA) Dangerous Goods Regulations.  Shipments known or 
suspected to contain a pathogen or toxin are subject to additional packaging and shipping 
requirements described in these regulations.  
Only a person that has been properly trained may package hazardous materials for 
shipping.  All packaging must follow DOT and IATA regulations.  For information on 
packaging and shipping training, visit the DOHS website at 
http://dohs.ors.od.nih.gov/Resources_main.htm.  
H. Records Retention and Disposal: 
For this chapter, records pertaining to NIH Permits For Import or Export of Biological 
Materials are retained and disposed of under the authority of NIH Manual 1743 "Keeping 


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and Destroying Records," Appendix 1, "NIH Records Control Schedule," Item 1300-B-3, 
safety management subject files. 
NIH e-mail messages.  NIH e-mail messages (messages, including attachments, that are 
created on NIH computer systems or transmitted over NIH networks) that are evidence of 
the activities of the agency or have informational value are considered Federal records.  
These records must be maintained in accordance with current NIH Records Management 
guidelines.  Contact your IC Records Officer for additional information.  
All e-mail messages are considered Government property, and, if requested for a 
legitimate Government purpose, must be provided to the requester.  Employees’ 
supervisors, NIH staff conducting official reviews or investigations, and the Office of the 
Inspector General may request access to, or copies of, e-mail messages.  E-mail messages 
must also be provided to Congressional oversight committees, if requested, and are 
subject to Freedom of Information Act requests.  Since most e-mail systems have back-up 
files that are retained for significant periods of time, e-mail messages and attachments are 
likely to be retrievable from a back-up file after they have been deleted from an 
individual’s computer.  The back-up files are subject to the same request as the original 
messages. 
 
I. Management Controls:  
The purpose of this Manual Chapter is to establish the NIH policy and procedures 
concerning the requirements for permits for the importation, transfer, export or shipment 
of etiological agents, their vectors, animals and plants.  
1. Office Responsible for Reviewing Management Controls Relative to this 
Chapter (Issuing Office): Through this Manual Chapter, the Quarantine Permit 
Service Office (QPSO), Division of Occupational Health and Safety (DOHS), 
Office of Research Services (ORS) is responsible for the method used to ensure 
that management controls are implemented and working. 
2. Frequency of Review:  Annual review 
3. Method of Review:  The QPSO, DOHS will maintain oversight and ensure 
compliance with this policy.  
The QPSO shall maintain a registry of all NIH personnel who have completed the 
DOHS sponsored Shipping Infectious Substances training course.  The QPSO 
shall also maintain files of all export declarations and import/transfer permits 
issued.  In addition, the QPSO shall maintain a database of all shipping related 
incidents which are reported to the DOHS. 
4. Review Reports are sent to:   


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The QPSO is required to submit an annual summary report to the CDC regarding 
the total number of imports/transfers of biological material. 
The QPSO will provide an annual report at the end of the calendar year of the 
issued import/transfer permits, export declarations and shipping incidents 
investigated to the Director, DOHS, the Associate Director for Research Services 
and the Deputy Director for Management.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix X 
 
 
SOP No.  6 
Version 3 
 
 
 
 
Inception Date: 12/15/04 
 
 
 
Title:  Preparation and shipping of biohazard  
 
Filename:  NCI10B.10_G1:Group:Clinical Pharmacology:SOPs:SOP No_6 Sample 
HandlingV3.doc 
 
This SOP describes all the procedures necessary to prepare biological samples for 
transport in the Clinical Pharmacology Program, Medical Oncology Branch, National 
Cancer Institute. 
 
Version No. 
Date Revised  
Revision Summary 
 
1. 
 
12/15/04 
 
Original 
2.  
 
3/26/07 
 
Updated titles and names 
3. 
 
9/30/08 
 
Updated to comply with new CFR-49  and IATA 
regulations 
 
 
 
Inception by: 
 
William D. Figg, Head, CPP, MOB, CCR, NCI 
Signature: ____________________________________ Date:  __________ 
 
Erin Gardner, CPP, SAIC-F 
Signature: ____________________________________ Date:  __________ 
 
Kathryn Compton, CPP, SAIC-F 
Signature: ____________________________________ Date:  __________ 
 
 
 
4 pages 
 
Approval of this page indicates approval of all pages of this SOP. 
 
Approval Signature:  _____________________________________  Date:  ___________ 
 
 


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Annual Review Signature and Date: 
_______________________________ 
 
______________________________ 
_______________________________ 
 
______________________________ 
_______________________________ 
 
______________________________ 
 
 
 
 
 
 
SOP No.  6 
Version  3 
 
 
 
 
Inception Date: 12/15/04 
 
 
 
 
1.0 
Scope and Application 
 
This is a Standard Operating Procedure (SOP) outlining the procedures, which 
should be carried out in order to prepare biological samples for shipment or transport 
off campus.  
 
 
It complies with federal regulations outlined in 42 CFR 72.2 and 49 CFR. 
 
2.0 
Responsibility 
 
All laboratory employees who pack samples for shipment or transport off campus 
are responsible for ensuring that sample packaging complies with federal 
regulations. A one day Shipping Biological Materials certificate course is offered by 
the NIH and should be attended by all personnel who will regularly be packaging 
biological samples for shipment.  
 
3.0 
Definitions 
3.1 
Biohazard label – OSHA Biohazard Label Marking is required to be used on 
the outside of the package per 29 CFR part 1910.1030 for blood borne 
pathogens requirements. 
3.2 
Carbon Dioxide, Solid (Dry Ice) – produced by expanding liquid carbon 
dioxide to vapour and “snow” in presses that compact the product into 
blocks. Used primarily for cooling (~ -79°C) and can cause severe burns to 
skin upon direct contact. As it converts to gaseous carbon dioxide, it takes in 
heat from its surroundings. The resulting gas is heavier than air and can 
cause suffocation in confined areas as it displaces the air. Packages 
containing this must be designed and constructed so as to prevent build-up of 
pressure due to the release of carbon dioxide. 
3.3 
Category B – an infectious substance which does not meet the criteria for 
inclusion in Category A. These substances must be assigned to UN 3373. 


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3.4 
Infectious Substances – substances which are known or reasonably expected 
to cintain pathogens. 
3.5 
Overpack – an enclosure used by a single shipper to cintain one or more 
packages and to form one handling uint for convenience of handeling and 
stowage. Dangerous goods packages contained in the overpack, must be 
properly packed, marked, labelled and in proper condition as required by 
these Regulations. 
3.6 
Pathogens – micro-organisms (including bacteria, viruses, rickettsiae, 
parasites, fungi)  and other agents such as prions, which can cause disease in 
humans or animals. 
3.7 
Patient Specimens – those collected directly from humans or animals, 
including, but not limited to, excreta, secreta, blood or its components, tissue 
and tissue fluid swabs, and body parts being transported for purposes such as 
research, diagnosis, investigational activities, disease treatment and 
prevention. 
3.8 
UN Number – the four-digit number assigned by the Unite Nations 
Committee of Experts on the Transport of Dangerous Goods to identify a 
substance or a particular group of substances. (The prefix “UN” must always 
be used on conjunction with these numbers.) 
 
 
4.0 
Procedure 
 
 
4.1 Unless otherwise known, all samples must be treated as hazardous. 
 
4.2 Federal requirements for biological samples as contained in 42 CFR 72.2 and 
49 CFR must be followed. 
 
4.2.1 Primary Containment – sample must be within a sealed container. In 
most cases, a sample vial will be the primary containment.  
4.2.1.1 Category A specimens - primary container volume must not 
exceed 50 ml. 
4.2.1.2 Category B specimens – primary container volume must 
not exceed 1 liter. 
 
4.2.2 Secondary Containment – the primary container must be placed 
within a sealed secondary container. This can take the form of a sealed 
plastic bag or other plastic container suitable for containing the sample in 
the case of thawing and/or breakage of the primary container. 
 
4.2.3 Absorbent Material – absorbent material must be enclosed between 
the primary and secondary containers, for any liquid samples (including 
those that are frozen). This material must be able to absorb the total 
volume held in the primary container. 
 
4.2.4 Itemized List – an itemized list of the contents must be enclosed 
between the secondary container and the outer shipping container. 


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4.2.5. Outer shipping Container – this container will enclose the secondary 
container(s). The outer shipping container must contain no more than 4 
liters. 
 
4.2.6 If dry ice is to be used, it must be between the secondary container 
and the outer shipping container. The outer shipping container must be 
designed to permit the release of carbon dioxide gas and to prevent the 
buildup of pressure. A means of support must be used to maintain the 
secondary container in its original position to prevent movement as dry ice 
dissipates. 
 
4.2.7 The shipping container must have appropriate labels and markings 
for biohazard agents and dangerous goods. 
 
4.2.7.1 Category A specimens – UN2814 marking and “Infectious 
substances, affecting humans” marking 
 
4.2.7.2 Category B specimens – UN3373 marking and “Biological 
substance, Category B” marking  
 
4.2.7.3 Dry Ice – “Dry Ice UN1845” marking and Class 9 label 
 
 
4.3 Specific instructions for packaging of boxes containing cryovials 
 
 
4.3.1 These will be packaged following regulations in Section 3.2.  
 
 
 
4.3.2 Place each box within a resealable biohazard bag.  
 
e.g.  
LabGuard Reclosable Biohazard Bags 
 
 
 
 
 
Size: 20.3 x 25.4 (8 x 10) 
 
 
 
 
 
VWR catalog # 56766-372 
 
 
 
4.3.3 Insert an absorbent strip into each bag and seal. 
 
 
 
 
e.g.  
Saf-T-Pak STP-152  
 
 
 
 
12 in, 250 ml absorbent strip 
 
 
 
 
www.saf-t-pak.com 
4.3.4 Place all bags inside a box with a Styrofoam cooler and surround 
with sufficient dry ice to keep samples frozen. 
 
4.3.5 Affix biohazard label to outside of box. 
 
 
 
 
 
 
 
 
 
 
 
Date of  
Preparatio
n:   
Master 
Reference 
Standard 
Compoun
d Name:
Manufactu
rer of 
Master 
Reference 
Standard:
Manufactu
rer's Lot # 
of Master 
Reference 
Standard:
Compoun
d % 
Purity: 
First 
Aliquot& 
Tech: 
Second 
Aliquot & 
Tech: 
Balance  
Manufactu
rer: 
Balance 
Model: 
Diluted 
with: 
Manufactu
rer: 
Manufactu
rer's Lot #: 
Volume 
Added to  
Second 
Aliquot: 
If pipette 
used 
record its 
name, 
serial #
Standard 
Concentrati
on Made: 
Expiration 
Date: 
(if stability 
has not 
been 
establishe
d write
First 
Standard 
Second 
Standard 
Area 
Count 
Inject 1 
Inject 1 
Inject 2 
Inject 2 
Inject 3 
Inject 3 
Inject 4 
Inject 4 
Inject 5 
Inject 5 
Mean std 
1 
Mean std 
2 
#DIV/0! 
% 
Difference  
between      
std1 & 
std2 
#DIV/0! 
Passes for 
use in 
laboratory 
if  
Failed if > 
5% 
Difference 
in the 
mean
Make third 
standard if 
1&2 fail. 
Technicia
n(s) 
Signature: 
________
Master 
Refere
nce 
Standar
Observed 
Balance 
Weight 
Observed 
Balance 
Weight 
Upon 
filling out 
this 
worksheet
copy and
the 
coumpoun
d's 
validation 
workbook
Stocksol
n 
 tab. 
#DIV/0! 
 Volume 
Added to 
First  
Aliquot: 
Area 
Count 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
103
Appendix XI 
 
 
SOP No. 4 
Version 2 
 
 
 
 
Inception Date: 11/23/04 
 
 
 
Title: Entering Sample Data into the Patient Sample Data Management System 
 
Filename:  Group Drive: Clinical Pharmacology/SOPs/SOP No_4 Sample Data Entry 
v2.doc 
 
This SOP describes how to enter new sample data into LabSamples for the Clinical 
Pharmacology Program, Medical Oncology Branch, CCR, NCI. 
 
Version No. 
Date Revised  
Revision Summary 
 
1. 
 
11/23/04 
 
Original Approved SOP 
2. 
 
3/26/07 
 
Updated titles and names 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inception by: 
 
W. D. Figg, Head, CPP, MOB, CCR, NCI  
Signature:   _____________________________________ Date:  __________ 
 
Erin Gardner, CPP, SAIC-F  
Signature:    _____________________________________ Date:  __________ 
 
Kathy Compton, CPP, SAIC-F 
Signature:   _____________________________________ Date:  __________ 
 
 
3 pages 
 
Approval of this page indicates approval of all pages of this SOP. 
 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
104
Approval Signature:  ____________________________________ Date:  _________  
 
 
Annual Review Signature and Date: 
_______________________________ 
 
______________________________ 
_______________________________ 
 
______________________________ 
_______________________________ 
 
______________________________ 
 
SOP No. 4 
Version 1 
 
 
 
 
Inception Date: 10/21/04 
 
 
 
 
1.0 
Scope and Application 
 
This SOP describes how to enter new sample data into LabSamples.  
 
2.0 
Responsibility 
 
2.1 
All laboratory employees are required to follow this SOP when using 
LabSamples.    
 
3.0 
Procedure 
 
3.1 
Log into LabSamples (Refer to SOP 3 Sample System Access – 3.0 
Procedure to Log on to Sample System). 
 
3.2 
Select ‘Enter New Sample’ button from main menu. 
 
3.3 
After ‘Create Sample Data’ screen loads, type in the patient’s last name in 
the ‘Last Name’ field or, if known, the Patient ID and hit return on the 
keyboard. 
 
3.4 
If there is more than one patient with that last name (e.g. Smith) then a list 
of all patients Dr. Figg’s lab has access to will appear in a new window 
‘Patient Search Results’. 
 
3.5 
If the correct first name appears in the list, click on the name to highlight it 
and then choose the ‘Select Record’ button. 
 
3.6 
If unsure, double-check the record by selecting it and verifying the correct 
trial on the next screen (Patient Data Screen). If you are still unsure, do not 
enter the sample data into the system. Check with the research nurse and 
other blood processing personnel to find out the correct patient name. 
 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
105
3.7 
Once the correct record is found and selected, the ‘Create Sample Data’ 
window will appear again with the selected Patient Information. Be sure 
that the correct protocol for the blood sample is shown in the ‘Protocol’ 
drop down menu. If the protocol is not listed, double check the patient 
data to ensure the name is correct. 
 
3.8 
Select the correct type of sample from the ‘Sample Type’ drop down menu 
(i.e. Plasma for green top tube, Serum for red top tubes, etc.). 
 
3.9 
The Integrity of the Sample should be set to ‘Unknown at Present’, if you 
are entering data before the sample has been processed. Otherwise, please 
choose the best descriptor, and make a note if necessary (see section 3.16). 
 
3.10 
The ‘Sample Drawn’ date/time should be entered as the day and time the 
research nurse gave as the sample draw time. They normally place this 
information on the tube or the bag the tube was in. If no time is given, the 
research nurse needs to be contacted to find the correct time. Do not 
estimate the draw time. (Note: most tube labels state the draw time as 
8AM. This is generally incorrect and should not be used as the draw time.) 
 
3.11 
The ‘Placed in Freezer’ date/time should be set as the current date/time. 
 
3.12 
Unless otherwise noted, all samples should be listed as ‘On Study’ in the 
‘Relationship to Protocol’ field. 
 
3.13 
In the ‘Number of Aliquots’ field, select the correct number of aliquots to 
be created – typically two. 
 
3.14 
While the LabSamples does not require ‘Storage Information’ to be given 
in order to save data, all blood samples must be placed in boxes before 
data is saved. Select the correct freezer box to place the sample in from the 
‘Box’ drop down menu. 
 
3.15 
If the correct box is unknown, locate the current ‘box list’ next to the main 
blood processing computer to check and/or look for the most current 
boxes in the -80°C freezer 7. 
 
3.16 
Information about pharmacokinetic samples must be entered into the 
‘Sample Notes’ screen (i.e. Pre/Post drug infusion hour information). This 
is located under a tab at the top left side of the window. A ‘Subject’ and 
‘Sample Note’ must be entered. Then click on the ‘Add to List’ button and 
save.  
 
3.17 
Any other uncharacteristic information about that particular blood sample 
should be noted in the sample notes. (Such as any possible human error 
when entering into LabSamples or an unknown blood draw time.) 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
106
 
3.18 
Select ‘Save’ from the buttons at the bottom of the window. 
 
3.19 
Select ‘Print Barcodes’. 
 
3.20 
Once barcodes are printed, cancel out of windows and enter the next 
sample. If entering samples for the same patient, select the ‘Copy Info’ 
button. This prevents superfluous data entry. 
 
This process needs to be completed for each blood tube received 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
107
 
Appendix XII 
 
 
 
 
 
 


Protocol Number: 09-C-0107 
Version Date 12/22/10 
 
108
 

ICF_001.pdf: 
 
 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
   MEDICAL RECORD 
               •  Adult Patient or     •  Parent, for Minor Patient 
 
 
INSTITUTE: 
National Cancer Institute 
 
 
STUDY NUMBER: 
09-C-0107 
PRINCIPAL INVESTIGATOR:  Giuseppe Giaccone, MD, PhD 
 
 
STUDY TITLE: 
A Phase II Study of Neo-Adjuvant Gemcitabine, Cisplatin and Bevacizumab in Stage IIIA (N2) 
Non-Squamous Cell Non-Small Cell Lung Cancer 
 
 
Initial Review Approved by the IRB on 01/26/09  
 
 
 
Date Posted to Web: 03/20/09 
Standard 
 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL 
 
RESEARCH STUDY 
 
•   Adult Patient or    •   Parent, for Minor Patient 
 
NIH-2514-1 (4-97) 
 
P.A.: 09-25-0099 
 
File in Section 4:  Protocol Consent (1) 
 
 
INTRODUCTION 
 
We invite you to take part in a research study at the National Institutes of Health (NIH). 
 
First, we want you to know that: 
 
 
Taking part in NIH research is entirely voluntary. 
 
 
You may choose not to take part, or you may withdraw from the study at any time.  In either case, you will not 
lose any benefits to which you are otherwise entitled.  However, to receive care at the NIH, you must be taking 
part in a study or be under evaluation for study participation. 
 
 
You may receive no benefit from taking part.  The research may give us knowledge that may help people in the 
future. 
 
Second, some people have personal, religious or ethical beliefs that may limit the kinds of medical or research treatments 
they would want to receive (such as blood transfusions).  If you have such beliefs, please discuss them with your NIH 
doctors or research team before you agree to the study. 
 
Now we will describe this research study.  Before you decide to take part, please take as much time as you need to ask 
any questions and discuss this study with anyone at NIH, or with family, friends or your personal physician or other health 
professional. 
 
Why is this study being done?  
 
The purpose of this study is to determine the effectiveness of the combination of three anti-cancer drugs given before 
your surgery, and to find out what effects, good and/or bad, these drugs may have on you and your cancer. The three 
drug combination consists of (1) Gemcitabine (2) Cisplatin and (3) Bevacizumab given prior to surgery (neo-adjuvant 
setting) in an attempt to shrink the size of your lung tumor so as to allow your surgeon to remove it completely. 
Gemcitabine, Cisplatin and Bevacizumab are all approved by the United States Food and Drug Administration (FDA) and 
the European Medicines Agency (EMEA) for the treatment of many cancers including lung cancer. This study will help to 
determine if the combination of all three drugs given up front prior to surgery is more effective and as safe, safer, or less 
safe than other drug combinations given in the neo-adjuvant setting (chemotherapy given before surgery).  
 
We will also look at how well this drug combination works against cancer cells in tumors by evaluating the tumor cells in 
your original biopsy specimen prior to chemotherapy and then in the resected tumor cells after surgery has been 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  2  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
performed (post chemotherapy). This study will also look at how these drugs may affect the cancer by measuring 
different proteins in your blood and in the tumor.  
 
Using these drugs together is experimental. Although we hope this therapy will decrease the size of your tumor prior to 
surgery, we cannot promise the benefits of the treatment at this time. The expected benefit with this drug combination is 
that your tumor will decrease in size allowing your surgeon to perform more extensive and complete surgery. The 3 drugs 
used in this combination have known side effects that will be reviewed with you by your medical team before you sign the 
consent form.  
 
Why are you being asked to take part in this study? 
 
You have been diagnosed with Stage IIIA (N2) lung cancer. Approximately 15% of people who are diagnosed with Non 
Small Cell Lung cancer have Stage IIIA (N2) disease. “Staging” your cancer is the process for looking to see how far the 
cancer has spread into the body, and is important in determining your treatment options. Stage III lung cancer lies 
between stage II which is considered operable and stage IV which is considered inoperable. Surgical resection is the 
treatment of choice for patients with lung cancer. Cure after resection depends on whether lymph nodes are involved. 
Once a patient is shown to have cancer in the lymph nodes involving the center of the chest (mediastinum) they are 
defined as having stage IIIA (N2) disease. Many hospitals use upfront chemotherapy followed by surgery as treatment for 
stage IIIA (N2) disease. This schedule is based on data from clinical studies showing that surgery alone is inferior to 
chemotherapy upfront followed by surgery. It is proposed that giving chemotherapy upfront may prevent spread of the 
tumor outside of your chest and may shrink your tumor to allow adequate surgery to be performed. It is also thought that 
chemotherapy is usually better tolerated before major surgery than after, therefore, allowing greater administration of the 
chemotherapeutic drugs. 
 
How many people will take part in this Study?  
 
Up to 70 patients will take part in this study. 
 
Description of Research Study 
 
What will happen if you take part in this research study?   
 
Before you begin the study 
 
You will need to have the following examinations, tests, or procedures to find out if you can be in the study.  These 
examinations, tests, or procedures are part of your regular lung cancer care and should be done by your health care team 
even if you do not join the study.  If you have had them recently, they may not need to be repeated.  This will be up to 
your study doctor. 
 
If you decide that you would like to participate in this study, you will be asked to sign this consent form.  . You will then 
have the examinations, tests, and procedures listed below to see if you are eligible to participate further in this study (this 
is called the screening/baseline evaluation). Invasive procedures such as bronchoscopy or mediastinoscopy (see below) 
will not need to be repeated once adequate tissue is available.   
 
• 
A complete medical history. 
• 
A physical examination (including height, weight, blood pressure, pulse, temperature). 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  3  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
• 
The following standard blood tests (requiring about 3 teaspoons of blood) - Complete Blood Count (CBC), which 
includes: white blood cell count, red blood cell count, platelet count, hemoglobin (oxygen-carrying pigment in red 
blood cells), and hematocrit (measures the amount of space red blood cells take up in the blood);  blood 
chemistry (which measures the levels of a number of chemical substances that are released from various tissues 
in the body to evaluate the function of the liver and kidneys); coagulation profile (measures how quickly your 
blood clots); urinalysis. 
• 
A blood test or a urine test to check for pregnancy for women who are able to become pregnant. 
• 
Urine test to check the level of protein excreted by your kidneys 
• 
EKG and ECHO (tests to evaluate your heart) 
• 
Chest x-ray 
• 
Pulmonary function tests (to check your lung function) 
• 
PET/CT scan, CT scan of chest and either MRI or contrast CT of brain 
• 
Bronchoscopy and Mediastinoscopy. These are standard procedures that are used to both diagnose and 
adequately stage lung cancer. During these procedures the doctor can look directly at your tumor and can also 
take biopsies (tiny pieces of tissue) to send to the pathology lab for diagnosis. You will be given anesthesia and 
then a small, flexible tube with a light on the end of it is put into the lungs (bronchoscopy), or through a small 
incision in your chest (mediastinoscopy).. You will be asked to sign a separate consent for these procedures and 
the doctor performing this procedure will describe it in more detail.  
 
During the study 
After you are accepted for this study and you choose to take part, you will begin taking the study drugs. For some study 
procedures we will need you to come to the Clinical Center. You will also have tests performed because you are in the 
study to see how the study drugs are affecting your body. This will include imaging studies (eg CT scans and PET scans) 
prior to chemotherapy and after chemotherapy to find out if your cancer has responded. The combination of drugs will be 
given in cycles. All cycles are 21 days long. Now, we will describe what will happen during each cycle. 
 
Cycle 1: 
• 
Gemcitabine will be given on day 1 and day 8 through a vein for 1 hour 
• 
Cisplatin will be given on day 1 through a vein for 1 hour with normal saline administered through a vein before 
and after cisplatin administration 
• 
Bevacizumab will be given on day 1 through a vein for 60-90 minutes 
 
 
Cycle 2: 
• 
Gemcitabine will be given on day 1 and day 8 through a vein for 1 hour 
• 
Cisplatin will be given on day 1 through a vein for 1 hour with normal saline administered through a vein before 
and after cisplatin administration 
• 
Bevacizumab will be given on day 1 through a vein for 60 minutes 
 
 
Cycle 3: 
• 
Gemcitabine will be given on day 1 and day 8 through a vein for 1 hour 
• 
Cisplatin will be given on day 1 through a vein for 1 hour with normal saline administered through a vein before 
and after cisplatin administration 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  4  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
Treatment Plan: 
 
Cycle 1 and 2 (each cycle lasts for 21 days) 
 
Cisplatin given on day 1 every 21 days + Gemcitabine for two doses on days 1 and day 8 every 21 days  
+ Bevacizumab on day 1 every 21 days for first 2 cycles only  
 
 
 
 
 
↓ 
Cycle 3 
Cisplatin on day 1 + Gemcitabine for two doses on days 1 and 8. No bevacizumab on 3rd cycle. 
 
 
 
 
 
↓ 
                    Re-imaging scans following third cycle of chemotherapy 
 
 
 
 
↓ 
         Surgery: 4-6 weeks post completion of last cycle (cycle 3) of chemotherapy  
        (If your disease is stable or smaller and heart and lung function is satisfactory) 
 
 
 
 
↓ 
Chemotherapy 4-8 weeks post surgery. Cisplatin on day 1, every 21 days x 4 cycles + Etoposide for  
consecutive 3 days, on days 1 to 3 every 21 days for 4 cycles.  
 
Re-staging and Response Evaluation: 
 
Two to three weeks following the third cycle of chemotherapy and no more than 14 days prior to your planned operation 
you will undergo repeat evaluation by Medical Oncology/Thoracic Surgery personnel to determine the clinical response of 
your tumor to the chemotherapy, and to confirm if your tumor is resectable. Repeat imaging studies will consist of a chest 
x-ray, CT scan of the chest, PET/CT scan and either a brain MRI or CT brain with contrast. If your doctor feels that there 
are new lymph nodes in your chest or there are new sites of potentially distant disease then you will need to be further 
evaluated by either repeat biopsy by either a bronchoscopy (as previously outlined), a mediastinoscopy (as previously 
outlined) or a biopsy performed under CT guidance. These investigations may be required to rule-out inoperable disease 
prior to surgery. After you have completed the chemotherapy your surgeon will also ask you to undergo repeat pulmonary 
function tests (to check your lung function) as well as an EKG and an ECHO (to check your heart function). These tests 
are performed prior to surgery to rule out any potentially significant deterioration of heart and lung function that could 
affect your ability to survive a large operation.  
 
Surgery: 
 
• 
If your surgeon feels that your tumor has either stayed the same size or has got smaller and your heart/lung 
function is satisfactory then you will proceed to surgery. Surgery will take place 4-6 weeks post completion of the 
last cycle of chemotherapy. If your tumor has increased in size or new sites of disease have appeared then you 
will not have surgery and you will be taken off study and treated with standard of care medicines. If your cancer 
can be removed by surgery, and you decide to have surgery, your doctor will discuss the details of the operation 
with you, including the location of your tumor, the type of surgery to be performed, and the risks of surgery. After 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  5  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
your surgery you may go to the ICU for additional monitoring. You will be given pain medicines after the 
operation to make you more comfortable. You will be given specific information from the doctor and nurses about 
what to expect after your operation. 
 
Chemotherapy after surgery: 
• 
4-8 weeks post surgery patients will receive chemotherapy which is a standard treatment approach. 
• 
Cisplatin will be given on day 1 through a vein for 1 hour with normal saline administered through a vein before 
and after cisplatin administration. Cisplatin is given on Day 1 every 21 days for 4 cycles.  
• 
Etoposide will be given through a vein for 1 hour for 3 consecutive days, on days 1 to 3 every 21 days for 4 
cycles.  
 
Study Chart 
 
 
Parameter 
 
Prestudy 
Before Each  
Upfront 
Cycle of 
Chemo  
Prior to 
Surgery  
Before 
Each  
Cycle of 
Chemo 
after 
surgery 
Follow- 
Up 
History (Dr will ask you questions) 
X 
X 
X 
X 
X 
Physical examination  
X 
X 
X 
X 
X 
Weight 
X 
X 
X 
X 
X 
Measurement of tumor 
X 
 
X 
 
X 
Performance status (Your ability 
to perform normal daily activities) 
X 
X 
X 
X 
X 
Complete blood count 
X 
X 
X 
X 
X 
Blood test assessing kidney and 
liver function 
 
X 
 
X 
 
X 
          
X         
 
X 
Urine analysis and assessment of 
protein level in urine 
 
X 
 
X 
 
X 
 
 
X 
Pregnancy test 
X 
 
 
 
 
Tumor Imaging (CT and PET/CT) 
X 
 
X 
 
 
Brain CT or MRI 
X 
 
X 
 
 
Assessment of heart and lung 
function via EKG, breathing tests 
and Echo 
X 
 
X 
 
 
 
When you are finished taking the drugs (treatment) 
You will be seen in the clinic with repeat imaging every 3 months for 2 years then every 6 months for 3 years and then 
yearly for 3 years. 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  6  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
What does this study involve? 
 
Treatments covered under this study include a combination of medications (chemotherapy) given before surgery, surgery, 
and then a combination of medicines (chemotherapy) after surgery. The treatment drugs individually are not experimental 
and all are approved by the United States Food and Drug Administration (FDA) but the combination of the three drugs 
given before surgery is experimental. Your doctors will describe your treatment plan to you in detail before asking you to 
sign this consent form. You may be asked to sign a separate consent form for any treatment procedures not outlined in 
this consent. This study will also look at how well this drug combination works against cancer cells in tumors by evaluating 
the tumor cells in your original biopsy specimen prior to chemotherapy and then in the resected tumor cells after surgery 
has been performed (post chemotherapy). This study will also look at how these drugs may affect the cancer by 
measuring different proteins in your blood and in the tumor. Research blood samples are required at baseline (cycle 1 day 
1), cycle 1 day 8, cycle 1 day 22, on the day of surgery and approximately 72 hours post surgery. 
 
Birth Control 
 
If you are a woman who is breast feeding or pregnant, you may not take part in the study because we don’t know how 
the combination of these medicines would affect your baby or your unborn child. If you are a woman who can become 
pregnant, or are the partner of a woman who can become pregnant, you will need to practice an effective form of birth 
control before starting study treatment, during study treatment, and for 3 months after you finish study treatment.  If you 
think that you or your partner is pregnant, you should tell your study doctor or nurse at once.   
Effective forms of birth control include: 
 
• 
Abstinence  
• 
intrauterine device (IUD) 
• 
hormonal [birth control pills, injections, or implants] 
• 
tubal ligation 
• 
vasectomy 
 
Alternative Approaches or Treatments 
 
What other choices do I have if I do not take part in this study?  
 
Instead of being in this study, you have these options  
 
• 
Getting treatment or care for your cancer without being in a study 
• 
Taking part in another study 
• 
Getting comfort care, also called palliative care.  This type of care helps reduce pain, tiredness, appetite problems 
and other problems caused by the cancer.  It does not treat the cancer directly.  Instead, it tries to improve how 
you feel.  Comfort care tries to keep you as active and comfortable as possible. 
 
Please talk to your doctor about these and other options. 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  7  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
Risks or Discomforts of Participation 
 
What side effects or risks can I expect from being in this study?  
 
Risks and side effects related to Gemcitabine: 
 
Likely 
Less likely 
Rare but serious 
Swelling, pain, fever, sleepiness, rash, 
hair loss, severe itching, nausea/vomiting, 
constipation, diarrhea; anemia (decreased 
number of red blood cells), inflammation 
of the mouth, leukopenia/neutropenia 
(decreased number of white blood cells, 
decreased number of platelets (cell 
fragments in your blood), bleeding,; 
increased liver enzymes, proteins and 
blood in the urine, difficulty breathing, 
increased nitrogen in the blood (sign of 
kidney infection), flu-like syndrome, 
infection, absence of menstrual periods or 
abnormal/irregular  menstrual periods  
Injection site reactions, abnormal 
sensation/itching, increased 
creatinine (metabolic waste), 
bronchospasm (contraction of the 
air passage of the lung)  
Adult respiratory distress syndrome 
(inflammation of the lungs), severe 
allergic reaction, eating disorder, 
abnormal heart rhythm, skin 
infection, inflammation 
(redness/swelling) of body tissue, 
stroke (sudden loss of brain 
function), heart disease, chills, 
cough, shedding of skin, increased 
sweating, decay of body tissue, 
headache, hemolytic uremic 
syndrome (decrease in blood cells 
and kidney disease), hepatotoxic 
reaction (liver damage from 
chemicals), increase blood tension, 
problems sleeping, lung disease, 
liver failure, feeling faint, heart 
attack, inflammation 
(redness/swelling) of blood vessels, 
petechiae (small purplish spots), 
swelling in the lungs, water in the 
lungs, scarring of the lungs, severe 
skin reaction, kidney failure, 
inability to breath, inflammation of 
the nose blood infection, weakness  
 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  8  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
Risks and side effects related to Cisplatin: 
 
Likely 
Less Likely  
Rare but serious 
Peripheral neuropathy (disease of the 
nerve cells leading to pain and 
numbness), mild hair loss, nausea and 
vomiting, myelosuppression (decrease in 
the number of blood cells made), 
increased liver enzymes, nephrotoxicity 
(kidney toxicity), ototoxicity (ear toxicity), 
absence of menstrual periods or 
abnormal/irregular  menstrual periods   
Diarrhea, local tissue irritation  
Severe allergic reaction, abnormal 
heart rhythm, blurred vision, slow 
heart rate, blindness, hemolytic 
anemia (destruction of red blood 
cells), increased liver enzymes, , 
mouth sores, optic neuritis 
(inflammation of the nerve cells 
connected to the eye), 
papilledema (swelling of the area 
near the nerve cells connected to 
the eye), low concentration of 
potassium in the blood, low 
concentration of magnesium in the 
blood, kidney failure, increased 
creatinine (metabolic waste), 
azotemia (large amounts of 
nitrogen waste in the blood), 
temporary pain at tumor, 
temporary autoimmune disorders 
(conditions in which the immune 
system attacks healthy body 
tissues)  
 
Risk and side effects related to Bevacizumab: 
 
Likely 
Less Likely  
Rare but serious  
High blood pressure 
Tiredness 
Loss of appetite 
Constipation 
Diarrhea 
Heartburn 
Nose bleed 
Bleeding from gut 
Pain in abdomen 
Headache 
Runny nose 
Voice changes 
Low white blood cells, low blood 
pressure, fever, shakes/chills, 
weight loss, rash, skin ulcers, 
hives, cough, shortness of breath, 
pain in chest, pain in joints, pain 
in muscles 
 
Impaired wound healing 
 
Inflammation of gut (colitis) or 
mouth (mucositis), Nausea, 
Vomiting 
 
Blood clots in arteries or veins 
 
Liver damage 
 
Severe allergic reaction, abnormal 
heart rhythm, heart attack, 
weakened heart muscle, very high 
blood pressure, confusion or other 
neurological changes because of 
high blood pressure,  wheezing 
 
Formation of an abnormal 
connection (fistula) between your 
trachea (wind-pipe) and 
esophagus (gullet) called a 
tracheosophageal fistula or 
between your bowel and another 
organ or the skin  
 
 
 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  9  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
Kidney damage 
Protein spillage from kidney into 
urine 
 
Infection of soft tissue/skin 
 
Acute infusion reaction 
(flushing, low blood pressure, 
dizziness, shortness of breath, 
swelling) 
Formation of a hole in the 
intestines that may allow material 
to spill into the abdomen which 
can make you very ill 
(perforation) 
 
Bleeding from lung (hemoptysis) 
Bleeding in head 
Bleeding from vagina, rectum or 
from bladder 
Stroke 
ReversiblePosterior 
Leukoencephalopathy Syndrome 
(RPLS) (described below) 
 
 
Fistulas/Perforations: Some previous studies of lung cancer patients that have been treated with bevacizumab have shown 
higher fistula and perforation rates than what would be expected. 
 
Reversible Posterior Leukoencephalopathy Syndrome (RPLS): RPLS is a medical condition related to the leakiness of blood 
vessels in the brain and can cause confusion, blindness or vision changes, seizure and other symptoms, as well as 
changes in brain scans.  This condition is usually reversible, but in rare cases, it is potentially life-threatening and may 
have long-term effects on brain function. 
 
Bevacizumab is the common name for the commercial drug Avastin.  The bevacizumab used in this trial, however, is for 
use in research studies only and may be made at locations different from those where Avastin is made.   Although some 
differences may exist, bevacizumab for research use and the commercial drug, Avastin, are manufactured by a similar 
process, meet similar standards for final product testing, and are expected to be very similar in safety and effectiveness. 
For more information about risks and side effects, ask your study team. 
 
Risks and side effects related to Etoposide: 
 
Likely 
Less Likely  
Rare but serious 
Nausea and vomiting, diarrhea, loss of 
appetite, hair loss or thinning, dizziness, 
feeling tired or sleepy, fever, high 
temperature, stomach pain or discomfort, 
constipation, myelosuppression (decrease 
in the number of blood cells made) 
Inflammation of the mouth 
(mucositis), local tissue irritation, 
rash, ovarian failure, absence of 
menstrual periods or 
abnormal/irregular  menstrual 
periods  
Severe allergic reaction (flushing, 
low blood pressure, dizziness, 
shortness of breath, swelling) 
 
Acute Leukemia (cancer of the 
blood) 
 
Low blood pressure, rash, hives, 
itching, shortness of breath, liver 
damage, abdominal pain, 
aftertaste, constipation, difficulty 
swallowing, transient blindness, 
optic neuritis (inflammation of the 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  10  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
nerve cells connected to the eye), 
fever, seizures, chest pain, heart 
attack, heart failure  
 
Potential Benefits of Participation 
 
Are there benefits to taking part in this study?  
 
The aim of this study is to see if this experimental treatment will cause your tumors to shrink.  We hope that you will get 
personal medical benefit from taking part in this study, but we cannot be certain.  These potential benefits could include 
shrinking of your tumor or lessening of your symptoms, such as pain, that are caused by the cancer.  Because there is not 
much information about the drug’s effect on your cancer, we do not know if you will benefit from taking part in this study, 
although the knowledge gained from this study may help others in the future who have cancer.   
 
Research Subject’s Rights 
 
What are the costs of taking part in this study?  
 
If you choose to take part in the study, the following will apply, in keeping with the NIH policy: 
• 
You will receive study treatment at no charge to you. This may include surgery, medicines, 
laboratory testing, x-rays or scans done at the Clinical Center, National Institutes of Health 
(NIH), or arranged for you by the research team to be done outside the Clinical Center, NIH if 
the study related treatment is not available at the NIH.  
• 
There are limited funds available to cover the cost of some tests and procedures performed 
outside the Clinical Center, NIH.  You may have to pay for these costs even if they are not 
covered by your insurance company. 
• 
Medicines that are not part of the study treatment will not be provided or paid for by the Clinical 
Center, NIH. 
• 
Once you have completed taking part in the study, medical care will no longer be provided by 
the Clinical Center, NIH. 
 
Stopping Therapy  
 
Your doctor may decide to stop your therapy for the following reasons: 
• 
if he/she believes that it is in your best interest 
• 
if your disease comes back during treatment 
• 
if you have side effects from the treatment that your doctor thinks are too severe 
• 
if new information shows that another treatment would be better for you 
 
In this case, you will be informed of the reason therapy is being stopped. 
 
You can stop taking part in the study at any time. However, if you decide to stop taking part in the study, we would like 
you to talk to the study doctor and your regular doctor first. 


 
 
  
CONTINUATION SHEET for either: 
  MEDICAL RECORD 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
 
STUDY NUMBER:  
09-C-0107 
CONTINUATION:  page  11  of  12  pages 
 
 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
 
NIH-2514-1 (10-84) 
 
NIH-2514-2 (10-84) 
 
P.A.: 09-25-0099 
 
 
 
Conflict of Interest 
 
The National Institutes of Health (NIH) reviews NIH staff researchers at least yearly for conflicts of interest.  The following 
link contains details on this process http://ethics.od.nih.gov/procedures/COI-Protocol-Review-Guide.pdf.  You may ask 
your research team for a copy of the Protocol Review Guide or for more information.  Members of the research team who 
do not work for NIH are expected to follow these guidelines but they do not need to report their personal finances to the 
NIH. 
 
Members of the research team working on this study may have up to $15,000 of stock in the companies that make 
products used in this study.  This is allowed under federal rules and is not a conflict of interest.  
 
Optional Studies  
 
We would like to keep some of the tissue and blood that are collected for future research.  These specimens will be 
identified by a number and not your name.  The use of your specimens will be for research purposes only and will not 
benefit you.  It is also possible that the stored specimens may never be used.  Results of research done on your 
specimens will not be available to you or your doctor.  It might help people who have cancer and other diseases in the 
future.   
 
If you decide now that your tissue and blood can be kept for research, you can change your mind at any time. Just 
contact us and let us know that you do not want us to use your tissue or blood.  Then any tissue or blood that remains 
will be destroyed.  
 
Please read each sentence below and think about your choice. After reading each sentence, circle and initial the answer 
that is right for you.  No matter what you decide to do, it will not affect your care. 
 
1. My tissue and blood specimens may be kept for use in research to learn about, prevent, or treat cancer.  
 
Yes              No               Initials_________ 
 
2. My specimens may be kept for use in research to learn about, prevent or treat other health problems (for example: 
diabetes, Alzheimer's disease, or heart disease).  
 
Yes              No               Initials_________ 
 
3. Someone may contact me in the future to ask permission to use my specimen(s) in new research not included in this 
consent.  
 
Yes              No               Initials_________ 
 


 
  
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
   MEDICAL RECORD 
•  Adult Patient or    •  Parent, for Minor Patient 
 
STUDY NUMBER: 
09-C-0107 
CONTINUATION:  page  12  of  12  pages 
 
 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL 
 
RESEARCH STUDY (Continuation Sheet) 
 
•  Adult Patient or   •  Parent, for Minor Patient 
 
NIH-2514-1 (12-08) 
 
P.A.: 09-25-0099 
 
FAX TO:  (301) 480-3126 
 
File in Section 4:  Protocol Consent 
 
 
OTHER PERTINENT INFORMATION 
 
1. Confidentiality.  When results of an NIH research study are reported in medical journals or at scientific meetings, 
the people who take part are not named and identified.  In most cases, the NIH will not release any information about 
your research involvement without your written permission.  However, if you sign a release of information form, for 
example, for an insurance company, the NIH will give the insurance company information from your medical record.  This 
information might affect (either favorably or unfavorably) the willingness of the insurance company to sell you insurance. 
 
The Federal Privacy Act protects the confidentiality of your NIH medical records.  However, you should know that the Act 
allows release of some information from your medical record without your permission, for example, if it is required by the 
Food and Drug Administration (FDA), members of Congress, law enforcement officials, or other authorized people. 
 
2. Policy Regarding Research-Related Injuries.  The Clinical Center will provide short-term medical care for any 
injury resulting from your participation in research here.  In general, no long-term medical care or financial compensation 
for research-related injuries will be provided by the National Institutes of Health, the Clinical Center, or the Federal 
Government.  However, you have the right to pursue legal remedy if you believe that your injury justifies such action. 
 
3. Payments.  The amount of payment to research volunteers is guided by the National Institutes of Health policies.  In 
general, patients are not paid for taking part in research studies at the National Institutes of Health.  Reimbursement of 
travel and subsistence will be offered consistent with NIH guidelines. 
 
4. Problems or Questions.  If you have any problems or questions about this study, or about your rights as a research 
participant, or about any research-related injury, contact the Principal Investigator, Giuseppe Giaccone, M.D., Building 10, 
Room 12N226, Telephone: 301-402-3415.  If you have any questions about the use of your tissue for futures research 
studies, you may also contact the Office of the Clinical Director, Telephone: 301-496-4251 
 
You may also call the Clinical Center Patient Representative at (301) 496-2626. 
 
5. Consent Document.  Please keep a copy of this document in case you want to read it again. 
 
COMPLETE APPROPRIATE ITEM(S) BELOW: 
 
A. Adult Patient’s Consent 
B. Parent’s Permission for Minor Patient. 
I have read the explanation about this study and have been given the 
opportunity to discuss it and to ask questions.  I hereby consent to take 
part in this study. 
I have read the explanation about this study and have been given the 
opportunity to discuss it and to ask questions.  I hereby give permission 
for my child to take part in this study.   
(Attach NIH 2514-2, Minor’s Assent, if applicable.) 
 
 
 
  
 
 
  
 
Signature of Adult Patient/Legal Representative 
Date 
Signature of Parent(s)/Guardian 
Date 
C. Child’s Verbal Assent (If Applicable) 
The information in the above consent was described to my child and my child agrees to participate in the study. 
 
 
 
 
  
 
 
Signature of Parent(s)/Guardian 
Date 
 
THIS CONSENT DOCUMENT HAS BEEN APPROVED FOR USE  
FROM JANUARY 26, 2009 THROUGH JANUARY 25, 2010. 
 
 
 
  
 
 
  
 
Signature of Investigator 
Date 
Signature of Witness 
Date