Conditions: Recurrent Oral Cavity Adenoid Cystic Carcinoma Recurrent Salivary Gland Carcinoma Salivary Gland Adenoid Cystic Carcinoma Stage III Major Salivary Gland Cancer AJCC v7 Stage III Oral Cavity Adenoid Cystic Carcinoma AJCC v6 and v7 Stage IVA Major Salivary Gland Cancer AJCC v7 Stage IVA Oral Cavity Adenoid Cystic Carcinoma AJCC v6 and v7 Stage IVB Major Salivary Gland Cancer AJCC v7 Stage IVB Oral Cavity Adenoid Cystic Carcinoma AJCC v6 and v7 Stage IVC Major Salivary Gland Cancer AJCC v7 Stage IVC Oral Cavity Adenoid Cystic Carcinoma AJCC v6 and v7 Tongue Carcinoma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 30
Healthy volunteers: no

Brief summary:
This phase II trial studies how well vorinostat works in treating patients with adenoid cystic carcinoma that has come back (recurrent) or that has spread from where it started to nearby tissue or lymph nodes (locally advanced) or has spread to other places in the body (metastatic). Vorinostat may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.

Detailed description:
PRIMARY OBJECTIVES:

I. To evaluate the efficacy by means of response rate (based on Response Evaluation Criteria in Solid Tumors \[RECIST\] 1.1 criteria) of vorinostat in the treatment of patients with locally advanced, recurrent or metastatic adenoid cystic carcinoma (ACC).

SECONDARY OBJECTIVES:

I. To characterize the safety and tolerability of vorinostat in this patient population.

II. To assess the time to tumor response (TTR). III. To assess the response duration (RD). IV. To evaluate progression free survival (PFS). V. To assess overall survival (OS).

TERTIARY OBJECTIVES:

I. To assess the association between a metabolic response by positron emission tomography (PET)/computed tomography (CT) after one cycle of chemotherapy and subsequent best tumor response according to standard anatomic response evaluation criteria (RECIST).

II. To assess the association between a metabolic response by PET/CT after the first and second chemotherapy cycle and PFS.

III. To assess flow sort diploid, aneuploid, and tetraploid populations of tumor cells from formalin fixed, paraffin-embedded (FFPE) tissue blocks from patients who benefited from suberoylanilide hydroxamic acid (SAHA) therapy and from patients who did not demonstrate a durable benefit.

IV. Profile the genomes of each cell population using oligonucleotide comparative genomic hybridization (CGH) arrays.

V. Perform whole exome analysis of the sorted tumor population and matching germ line sample for each of the patients selected.

VI. To assess stable disease duration (SDD). VII. To assess the association between response to vorinostat treatment and RAD23 homolog B (HR23B) on tumor paraffin blocks.

VIII. Retrospectively compare volumetric density (viable tumor volume = VTV) with pre-determined RECIST of target lesions in cross sectioning imaging (CT/magnetic resonance \[MR\]) already obtained.

IX. Correlate VTV, RECIST and treatment response (partial response, stable disease, progressive disease and stable disease over 6 months).

OUTLINE:

Patients receive vorinostat orally (PO) once daily (QD) on days 1-28. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

After completion of study therapy, patients are followed up for 180 days.

Arms:
arm 1: Patients receive vorinostat PO QD on days 1-28. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

Interventions: intervention 1: Laboratory Biomarker Analysis intervention 2: Vorinostat
Intervention descriptions: intervention 1: Correlative studies intervention 2: Given PO

Protocol document:
Prot_SAP_000.pdf: 


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SUMMARY OF CHANGES 
 
For Protocol Amendment # 17 to:  A Phase 2 Study of Suberoylanilide Hydroxamic Acid 
(SAHA) in Subjects with Locally Advanced, Recurrent or Metastatic Adenoid Cystic Carcinoma 
(ACC) (IND 71976) 
 
NCI Protocol #: 8474 
Local Protocol #: 2009-165 
 
Protocol Date: 05/12/2016 
 
 
 
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There are no consent form revisions. 


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NCI Protocol # 8474
 
 
Local Protocol # 2009-165
 
 
Version Date: 08/16/16 
NCI Protocol #: 8474 
 
Local Protocol #:  
2009-165 
 
TITLE:  A Phase 2 Study of Suberoylanilide Hydroxamic Acid (SAHA) in Subjects with 
Locally Advanced, Recurrent or Metastatic Adenoid Cystic Carcinoma (ACC) (IND 71976)  
 
Coordinating Center: 
 
Barbara Ann Karmanos Cancer Institute/Wayne State 
University 
 
Principal Investigator: 
      Patricia Mucci LoRusso, DO 
      Associate Director of Innovative Medicine 
      Yale Cancer Center 
      333 Cedar Street, WWW217 
      P.O. Box 208028 
      New Haven, CT 06520-8028 
      Phone: (203) 785-5944 
      Fax:  (203) 785-4116 
      E-mail:  patricia.lorusso@yale.edu  
 
Co-Investigators: 
     Ulka Vaishampayan, M.D.- KCI Site Principal Investigator 
 
     Karmanos Cancer Institute, HW04HO 
 
     4100 John R Street, Detroit, MI 48201 
 
     Phone: (313) 576-8718 
 
     Fax: (313) 576-8487 
 
     E-mail: vaishamu@karmanos.org 
 
 
      Priscila Hermont Goncalves, MD  
      National Cancer Institute, National Institutes of Health 
      10 Center Drive, Building 10, Room 6N110 
      Bethesda, MD, 20892 
      Phone: 301-402-1541 
                  Email: priscila.goncalves@nih.gov 
 
 
 
       
 
      Dr. Jeffrey Trent 
 
      445 N 5th Street, Suite 600 
 
      Phoenix, AZ  85004 
 
      jtrent@tgen.org 
 
      602-343-8419 
 
      602-343-8448 FAX 
      (Note: Dr. Trent is not participating in patient care for this study) 
 
 
      Dr. Michael Barrett 
 
      13208 E. Shea Blvd. 
 
      Scottsdale, Arizona 85259 


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      mbarrett@tgen.org 
 
      602- 358-8383 
 
      602- 358-8360 FAX 
     (Note: Dr. Barrett is not participating in patient care for this study) 
 
      
 
 
 
 
 
 
 
 Panayiotis (Panos) Savvides, MD, PhD, MPH (site PI) 
Department of Medicine 
University Hospitals of Cleveland 
Case Western Reserve University 
11100 Euclid Avenue 
Cleveland, OH 44106 
Phone: 216-844-5946 
Fax: 216-844-1721 
Email: psavvides@case.edu   
 
 
Joel Saltzman, MD  
Lake University – Ireland Cancer Center (LUICC) 
9485 Mentor Avenue 
Mentor, OH 44060 
Phone:  440-205-5755  
Fax:  440-205-5792 
Email: jns70@yahoo.com 
    
 
Mark Bergman, MD  
Lake University – Ireland Cancer Center (LUICC) 
9485 Mentor Avenue 
Mentor, OH 44060 
Phone:  440-205-5755  
Fax:  440-205-5792  
Mark.Bergman@uhhospitals.org  
 
Vinay Gudena, MD    
Ireland Cancer Center at Firelands Regional Medical Center 
701 Tyler Street 
Sandusky, OH 44870 
Phone: 419-557-7480 
Fax: 419-557-7533 
Vinay.Gudena@uhhospitals.org 
 
Amy Reese, MD 
 Ireland Cancer Center at Firelands Regional Medical Center 
701 Tyler Street 
Sandusky, OH 44870 
Phone: 419-557-7480 


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Fax: 419-557-7533 
Amy.Reese@uhospitals.org 
 
Joseph Bokar, MD 
Department of Medicine 
University Hospitals of Cleveland 
VA Hospitals of Cleveland 
Case Comprehensive Cancer Center 
11100 Euclid Avenue 
Cleveland, OH 44106 
Email: Joseph.Bokar@uhHospitals.org   
 
Afshin Dowlati, MD 
Department of Medicine                   
University Hospitals of Cleveland   
Case Comprehensive Cancer Center  
11100 Euclid Avenue 
Cleveland, OH 44106   
Email: Afshin.Dowlati@uhHospitals.org 
 
Charles Nock, MD 
Department of Medicine  
University Hospitals of Cleveland  
Case Comprehensive Cancer Center 
11100 Euclid Avenue 
Cleveland, OH 44106 
Email: Charles.Nock@uhHospitals.org 
 
Joseph Chao M.D.  
City of Hope Comprehensive Cancer Center 
     Medical Office Building 
    1500 E. Duarte Road 
    Duarte, CA 91010 
Phone: 626-471-9200 
Fax: 626-301-8233 
Email: jchao@coh.org 
 
 
 
 
 
      Stephen Shibata, MD 
      City of Hope National Medical Center 
      Department of Medical Oncology 
      Medical Office Building 
      1500 E. Duarte Road 
      Duarte, CA 91010 
      Phone: 626-359-811 X1 
 
 
Email: sshibata@coh.org 
 


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    Alice Chen, MD 
    
 
 
 
    Medical Oncology Branch 
    National Cancer Institute 
    31 Center Drive 
    Bldg 31 Room 3A44 
    Bethesda, MD 20892 
    Phone: 301-496-4291 
    Fax: 301-496-0826 
 
    Email: chenali@mail.nih.gov    
 
Stephen Koehler, MD 
City of Hope Medical Group, Inc., 
209 Fair Oaks Avenue 
South Pasadena, CA 91030 
Phone:  626/396-2900 
Fax:  626/799/2770 
Email:  Skoehler@cohmg.com 
 
Ammar Sukari M.D. 
            Karmanos Cancer Institute 
4100 John R, HW04HO 
Detroit, MI 48201 
Phone: 313-576-8751 
     
Fax: 313-576-8702 
Email: sukaria@karmanos.org 
 
Alan L. Ho M.D., Ph.D. 
Memorial Sloan-Kettering Cancer Center 
Department of Medicine, Solid Tumor Service 
1275 York Avenue, Schwartz 1210B 
New York, New York 10065 
Phone : 212-639-3311 
Fax : 212-717-3278 
Email : hoa@mskcc.org 
 
Lillian L Siu, FRCPC, MD 
Princess Margaret Hospital/Ontario Cancer Institute (OCI) 
610 University Avenue, Suite 5-718 
Toronto, Ontario 
M5G 2M9 
Canada 
Tel: 416-946-2911 
Fax: 416-946-4467 
Email: lillian.siu@uhn.on.ca 
 


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Aaron Hansen, MD 
Princess Margaret Cancer Centre 
610 University Ave 
Toronto, Ontario, M5G 2M9 
Canada 
T: +1 416-946-4501 ext 3426 
F: +1 416-946-2890 
 
Les Folio, DO DO, MPH, FAOCR 
Col (ret), USAF, MC, SFS 
Physician Lead for Computed Tomography, 
Radiologist, Body Imaging; 
Radiology and Imaging and Sciences 
Clinical Center, National Institutes of Health 
  
Clinical Professor, Radiology, George Washington University 
Hospital 
  
NIH address: 
National Institutes of Health 
10 Center Drive; Building 10; Room 1C 340 
Bethesda, MD, 20892 
Voice 301.435 8622  
Cell 240.281.8832 
Fax 301.480.2229  
Email: les.folio@nih.gov 
(Note: Dr. Folio is not participating in patient care for this study) 
 
 
 
Statisticians:  
 
Lance K. Heilbrun, Ph.D 
Assistant Director, Biostatistics Core 
Karmanos Cancer Institute 
Office: Mid Med Building, 3rd Floor 
87 East Canfield 
Detroit, MI 48201 
E-mail: heilbrun@karmanos.org 
phone: 313 / 576-8652 
FAX: 313 / 576-8656 
 
 
Daryn Smith, M.S.    
Karmanos Cancer Institute 
Office: Mid Med Building, 3rd Floor 
87 East Canfield 
Detroit, MI 48201 


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Version Date: 08/16/16 
Phone: 313-576-8649 
Email: smithda@karmanos.org 
 
 
 
Responsible Data Manager: Kelly Schneider, BS, CCRP 
 
Karmanos Cancer Institute, Clinical Trials Office 
 
4100 John R Street, Detroit, MI, 48201 
Phone: 313 576-9749 
Fax: 313 576-9684 
Email: schneidk@karmanos.org  
NCI Supplied Agent: Suberoylanilide Hydroxamic Acid (SAHA); NSC 701852, IND 71976    
Protocol Version Date: 
November 08, 2009 (Original) 
 
June 17, 2010 (Amendment 1) 
 
September 11, 2010 (Amendment 2) 
 
November 16, 2010 (Amendment 3) 
 
February 18, 2011 (Amendment 4) 
 
April 25, 2011 (Amendment 5) 
 
June 23, 2011 (Amendment 6) 
 
January 24, 2012 (Amendment 7) 
 
June 8, 2012 (Amendment 8) 
 
June 4, 2013 (Amendment 9) 
 
July 1, 2013 (Amendment 9 revised) 
 
December 23, 2013 (Amendment 10) 
 
March 7, 2014 (Amendment 11) 
 
August 8, 2014 (Amendment 12) 
 
September 25, 2014 (Amendment 13) 
 
October 1, 2014 (Amendment 14)  
 
July 23, 2015 (Amendment 15) 
May 12, 2016 (Amendment 16) 
August 16, 2016 (Amendment 17) 
 


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SCHEMA 
 
Treatment Plan: 
Pre-treatment Period 
Screening assessments will be performed as described below:  
 
Days -21 to-1: (within 21 days prior to start of treatment). Informed consent; medical history; 
physical exam (PE) with vital signs, including height and weight; ECOG performance status and 
review of concomitant medications and electrocardiogram (EKG) will be ordered. Tumor tissue 
from a previous paraffin block will be obtained for correlative studies. 
  
Days -14 to -1: (within 14 days of start of treatment). PE with vital signs and weight; review of 
any new events in medical history and medication; ECOG performance status will be repeated. 
Assessment and tumor imaging (CT scans and optional PET/CT scans) will also be obtained.  
 
Day -7 to day 1 prior to study drug start: Hematology, comprehensive metabolic chemistry 
profile, coagulation profile and urinalysis will be obtained. Women of childbearing potential will 
have a serum pregnancy test done. 
 
Treatment Period:  
Vorinostat will be administered orally once daily continuously at 400 mg. Each treatment cycle 
will consist of 4 weeks of daily treatment.  
 
Study visits will be conducted on weeks 2 and 4 (±1 day) for the first cycle, then for the second 
cycle on week 5 and 7, (±1 day); then from week 9 on, every four weeks (±1 day) thereafter for 
the remainder of the study. Patient medical histories, physical examinations, laboratory tests, 
assessments of compliance with study medication and recording of adverse events will be 
conducted during study visits. Further blood may be drawn for research correlatives. For patients 
that have been on study longer than 2 years, office visits can be done every 12 weeks (±7 days), 
with medical history, concurrent meds, physical exam, vital signs, weight, performance status, 
and adverse events evaluation done also at that time. For patients that have been on study longer 
than 2 years, hematology labs and serum chemistry can be done every 6 weeks (±7 days). 
 
 
The severity duration and relationship to vorinostat will be determined for each adverse 
experience (AE) (Section 11). 
 
Blood will be drawn on days 1 prior to first drug intake, and on days 7 (+- 1 day) and 28 (+-
1day), prior to drug intake, to assess for correlative studies.  
 
Patients will have radiological tumor assessment by computed tomography (CT) scan (or 
magnetic resonance imaging - MRI) on days -14 to -1 (prior to the start of vorinostat) and day 56 
(±3 days). They will be followed with CT scans or MRI every 2 cycles / 8 weeks (± 1 week) 
thereafter. Patients may receive scans every 3 cycles/12 weeks (± 1 week) after completing 6 
months of treatment on study.  Patients that have been on study longer than 2 years can have 
tumor measurements (CT scans or MRI) done every 24 weeks (±10 days). 


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Predicated on obtaining funding, additional scans (optional) will be performed.  These will 
include PET/CT scans prior to treatment, Day 28 (±3 days), and Day 56 (±3 days).  An 
additional CT scan or MRI will also be performed on Day 28 (±3 days) for comparison purposes. 
The Day 28 CT/MRI and the PET/CT scans will be optional studies- due to financial issues 
(funding). 
 
Vorinostat will be withheld for any possible or probable drug related grade 3 to 4 adverse event. 
.Patients will be allowed to have 2 dose reductions (from 300mg/day D1-7 to 300mg/day D1-5) 
due to grade 3 nausea, emesis or diarrhea (not controlled by appropriate supportive care 
measures); due to other drug-related grade 3/4 non-hematological toxicity; due to grade 3/4 
neutropenia associated with fever and/or grade 4 neutropenia and/or grade 4 thrombocytopenia 
(section 6). In the event a patient is experiencing clinical benefit from vorinostat and requires 
further dose reduction, a discussion between CTEP and PI will ensue. 
 
Patients who cannot be retreated within 3 weeks (21 days) of the end of the previous cycle 
should be removed from study, unless they are deriving benefit. In the later case, a discussion 
with the PI and/or CTEP senior investigator will also ensue. 
 
Patients who experience either stable disease, complete response, or partial response by RECIST 
criteria will be allowed to continue on vorinostat as long as they are experiencing benefits 
without intolerable/life-threatening side effects. 
 
Post-treatment Period: 
Patients with progression of disease (PD), unacceptable toxicity, or uncontrolled intercurrent 
illness will be taken off the trial. Other criteria for discontinuation will include: patient 
withdrawal of consent, noncompliance with study medication or visits, or any change that would 
render the patient ineligible for further treatment. In those cases, patients will be entered on the 
post-treatment period. The end of study visit should occur within 30 days of the last dose of the 
study drug. Patient medical histories, physical examinations and laboratory tests will be obtained. 
Tumor imaging if not done in the last 30 days, will be ordered at this time. The investigator or 
designee will obtain follow-up information on the patient at 180 days after the last dose of the 
study drug or until death (if before 180 days). 
 
Correlative Studies: 
The correlative portion of this trial is described the Laboratory Correlates section (appendix D). 
In a retrospective pilot study, CT and or MRI scans already obtained from all the patients in the 
trial will be re-reviewed. RECIST imaging will be compared to volumetric density (viable tumor 
volume VTV) CT and MR measurements. The objective is to establish whether volumetric 
density/percent necrosis algorithms such as VTV more accurately assess the extent of the disease 
and response to therapy than standard RECIST criteria.  
 
 
 
 
 


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Table of Contents 
SUMMARY OF CHANGES ........................................................................................................... I 
SCHEMA ........................................................................................................................................ 7 
1. 
OBJECTIVES ........................................................................................................................ 11 
1.1. 
 Primary Objectives ........................................................................................................ 11 
1.2 Secondary Objectives.......................................................................................................... 11 
1.3 Exploratory Objectives ....................................................................................................... 11 
2. 
BACKGROUND ................................................................................................................... 11 
2.1 
 Adenoid Cystic Carcinoma ........................................................................................... 11 
2.2 
Suberoylanilide Hydroxamic Acid (SAHA) .................................................................. 12 
2.3  FDG PET/CT ..................................................................................................................... 17 
2.4 
Rationale......................................................................................................................... 20 
3. 
PATIENT SELECTION ........................................................................................................ 22 
3.1 
 Eligibility Criteria ......................................................................................................... 22 
3.2 
 Exclusion Criteria .......................................................................................................... 24 
4. 
REGISTRATION PROCEDURES ....................................................................................... 25 
4.1 General Guidelines.............................................................................................................. 25 
4.2 Registration Process ............................................................................................................ 25 
5. 
TREATMENT PLAN............................................................................................................ 26 
5.1 
Vorinostat Administration .............................................................................................. 26 
5.2 Supportive Care Guidelines ................................................................................................ 26 
5.3 
Duration of Therapy ....................................................................................................... 27 
5.4 Duration of Follow Up ........................................................................................................ 27 
6.  
DOSING DELAYS/DOSE MODIFICATIONS ............................................................... 27 
6.1 Retreatment Criteria ............................................................................................................ 27 
6.2 Dose Modification Guidelines ............................................................................................ 28 
7. 
PHARMACEUTICAL INFORMATION ............................................................................. 29 
7.1 
Suberoylanilide Hydroxamic Acid (NSC 701852) ......................................................... 29 
7.2 Agent Availability ............................................................................................................... 34 
7.3 
Agent Ordering ............................................................................................................... 34 
7.4 
Agent Accountability ..................................................................................................... 34 
8.  CORRELATIVE STUDIES .................................................................................................... 34 
9.  STUDY CALENDAR ............................................................................................................. 39 
10. 
MEASUREMENT OF EFFECT........................................................................................ 41 


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10.1 Definitions......................................................................................................................... 41 
11. 
REGULATORY AND REPORTING REQUIREMENTS ............................................... 48 
11.1 
Expedited Adverse Event Reporting .......................................................................... 49 
11.2 Data Reporting .................................................................................................................. 50 
11.3 CTEP Multicenter Guidelines ........................................................................................... 51 
11.4 Cooperative Research and Development Agreement (CRADA)/Clinical Trials Agreement 
(CTA) ........................................................................................................................................ 52 
12. 
STATISTICAL CONSIDERATIONS............................................................................... 54 
12.1 Study Design/Endpoints.................................................................................................... 54 
12.2  Sample Size/Accrual Rate ................................................................................................ 55 
12.3  Stratification Factors ........................................................................................................ 55 
Phase II Study:   Stage 1 / Stage 2 Accrual Estimates .............................................................. 55 
12.4  Analysis of Secondary Endpoints .................................................................................... 55 
12.5 Reporting and Exclusions ................................................................................................. 58 
REFERENCES ............................................................................................................................. 59 
APPENDIX A Performance Status Criteria ............................................................................. 64 
APPENDIX B PET Imaging Acquisition Parameters and Image Data Analysis ..................... 65 
APPENDIX C CT Acquisition Parameters and Image Data Analysis ..................................... 68 
APPENDIX D -Correlative Studies .......................................................................................... 73 
APPENDIX E- PD Generic SOP: Storage and Shipping ......................................................... 80 
APPENDIX F- Enzyme inducing anti-convulsants .................................................................. 83 
APPENDIX G- PATIENT’S MEDICATION DIARY (300 mg)............................................. 84 
APPENDIX H- PATIENT’S MEDICATION DIARY (400 mg)............................................. 85 
APPENDIX I - VOLUMETRIC TUMOR MEASUREMENT………………………………87 
 


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1. OBJECTIVES 
 
1.1.  Primary Objectives  
• To evaluate the efficacy by means of response rate (based on RECIST 1.1 
criteria) of vorinostat in the treatment of patients with locally advanced, 
recurrent or metastatic adenoid cystic carcinoma (ACC). 
 
     1.2 Secondary Objectives 
• To characterize the safety and tolerability of vorinostat in this patient 
population. 
• To assess the time to tumor response (TTR). 
• To assess the response duration (RD). 
• To evaluate progression free survival (PFS). 
• To assess overall survival (OS). 
 
1.3 Exploratory Objectives 
• To assess the association between a metabolic response by PET/CT after one 
cycle of chemotherapy and subsequent best tumor response according to 
standard anatomic response evaluation criteria (RECIST). 
• To assess the association between a metabolic response by PET/CT after the 
first and second chemotherapy cycle and PFS. 
• Flow sort diploid, aneuploid, and tetraploid populations of tumor cells from 
FFPE tissue blocks from patients who benefited from SAHA therapy and from 
patients who did not demonstrate a durable benefit.  
• Profile the genomes of each cell population using oligonucleotide CGH 
arrays. This will confirm the identification of tumor populations in each 
sample and provide genomic landmarks for NGS analysis.  
• Perform whole exome analysis of the sorted tumor population and matching 
germ line sample for each of the patients selected 
• To assess stable disease duration (SDD)  
• To assess the association between response to vorinostat treatment and 
HR23B on tumor paraffin blocks 
• Retrospectively compare volumetric density (viable tumor volume=VTV) 
with pre-determined RECIST of target lesions in cross sectioning imaging 
(CT/MR) already obtained 
• Correlate VTV, RECIST and treatment response (partial response, stable 
disease, progressive disease and stable disease over 6 months) 
 
 
2. BACKGROUND 
 
2.1 
 Adenoid Cystic Carcinoma 
 
Tumors of the salivary gland comprise 3 to 6% of all head and neck neoplasms in adults; the 


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Version Date: 08/16/16 
 
incidence is one to three per 100,000 people per year (1) Of the several types of salivary gland 
cancer, adenoid cystic carcinoma is the second most common type, accounting for 22% of cases 
in some series (2). ACC is an indolent cancer with 5-year survival rates as high as 50-90% and 
up to 25% 15-year survival rates. Surgery with wide resection is the main modality of treatment 
for localized ACC. Adjuvant radiation therapy is reserved for patients with poor prognostic 
factors, such as close or positive margins, vascular or perineural invasion, lymph node metastasis 
or high grade tumors. Loco-regional recurrence and distant metastasis especially to the lung are 
not uncommon. A watch and wait approach is appropriate if a patient has metastasis but has few 
or no symptoms due to the indolent nature of the tumor. 
 
Response to chemotherapy agents is around 20% with single agents and 50% with   
combination therapy (3-10). There is no evidence that combination therapy is better than single 
agents and it is unknown if survival is improved with chemotherapy. Active single agents 
include cisplatin, 5-FU, doxorubicin, mitoxantrone and vinorelbine. New agents have also been 
studied, but so far their use remains investigational. In the largest study utilizing  imatinib in 
patients with ACC that overexpressed c-kit, no partial or complete responses were seen, stable 
disease was achieved in 9 patients, some of them over 12 months (11). In a phase 2 study of 
trastuzumab in salivary gland tumors that overexpressed Her-2, a partial response was seen in 1 
out of 14 patients (12). Another phase 2 trial utilizing lapatinib, a pan-Erb inhibitor (EGFR and 
HER-2) showed promising activity with 79% of ACC patients with stable disease, 47% of more 
than 6 months (13). A phase 2 trial of gefitinib showed no responses but stable disease in 68% of 
the patients (14). The use of cetuximab also showed no response, but stable disease in 50% of the 
patients with salivary gland tumors (15). A combination trial investigated the use of  bortezomib 
and doxorubicin. Bortezomib was given until progression in patients with metastatic ACC. 
Doxorubicin was added at time of progression. There were no responses to single agent 
bortezomib, however, 64% of patients had stable disease (16).  
 
Stable disease duration has been described in several trials (11,13,15,17,18) as so far partial 
or complete responses have been rarely obtained with the current regimens or experimental 
therapies. It is unclear if stable disease duration represents a marker of drug activity or only the 
indolent nature of this tumor. However, most phase II studies report stable disease duration for 6 
months or more as an endpoint, therefore, especially in view of tumors that were progressing 
prior to study entry, this may be a relevant exploratory endpoint. 
 
There is no established standard chemotherapy for the treatment of ACC. Therefore there is a 
need to perform high quality clinical trials in this setting. Multicenter cooperative trials should be 
included in order to maximize patient’s resources due to the rarity of this cancer. 
 
 
2.2 
Suberoylanilide Hydroxamic Acid (SAHA) 
 
Suberoylanilide hydroxamic acid (SAHA; NSC 701852) is a small molecule inhibitor of 
histone deacetylase (HDAC) that binds directly in the enzyme’s active site in the presence of a 
zinc ion (19). Because aberrant HDAC activity has been implicated in a variety of cancers, 
development of HDAC inhibitors is a rational approach to the design of targeted anticancer 


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therapeutics. Several HDAC inhibitors from multiple chemical classes have been developed and 
are currently in clinical trials. Trichostatin and butyric acid were among the first HDAC 
inhibitors to be administered to patients, but these were found to be clinically unsuitable due to 
potency and formulation issues (20,21). Depsipeptide was originally selected for clinical study 
based on its antiproliferative effects; subsequently it was discovered to antagonize HDACs (22) 
and was the first HDAC inhibitor to demonstrate clinical efficacy (23).  Of the three classes of 
HDACs, SAHA targets most human Class 1 (related to the yeast transcriptional regulator Rpd3) 
and Class 2 (similar to the yeast Hda1) enzymes (24,25); the third class of HDACs (homologues 
of yeast sir2) requires NAD+ for activity and is not inhibited by SAHA.  Among those currently 
in clinical trials, SAHA is the most potent HDAC inhibitor that can be administered orally with 
excellent bioavailability.   
 
 
Mechanism of Action 
 
The HDACs exert their targeted action during post-translational acetylation of core 
nucleosomal histones, which affects chromatin structure, thereby regulating gene expression.  
DNA that is wrapped around condensed, non-acetylated histones is transcriptionally inactive, 
whereas acetylation of N-terminal histone lysine residues exposes DNA to important 
transcription factors that promote transcriptional activity (26,27)The dynamic equilibrium 
between histone acetylation and deacetylation is regulated by histone acetyltransferases (HATs) 
and HDACs.  The action of HDACs on nucleosomal histones leads to tight coiling of chromatin 
and silencing of expression of various genes, including those implicated in the regulation of cell 
survival, proliferation, differentiation, and apoptosis (28).  The effects of HDACs are not limited 
to histone deacetylation.  HDACs also act as members of a protein complex to recruit 
transcription factors to the promoter region of genes, including those of tumor suppressors, and 
they affect the acetylation status of specific cell cycle regulatory proteins (27)  
 
Nonclinical Activity 
 
SAHA was identified originally by its ability to induce differentiation of murine 
erythroleukemia cells at micromolar concentrations (29,30). Subsequently, it was found to 
induce differentiation or arrest growth of a wide variety of human carcinoma cells.  To date, 
SAHA activity has been reported in transformed hematopoietic cells, such as multiple myeloma 
(MM) (31-33), acute promyelocytic leukemia (APL) (34), acute lymphocytic leukemia (35), 
chronic myelogenous leukemia (36,37), Waldenstrom’s macroglobulinemia (33), and cutaneous 
T-cell lymphoma (CTCL) (38).  Activity has also been reported in cell lines representing other 
tumor types including bladder transitional cell carcinoma (39), breast cancer (40-42), prostate 
cancer (43), head and neck squamous carcinoma (44), and colon carcinoma (45). 
 
The antitumor activity of SAHA was demonstrated in several in vivo models of cancer, 
including a xenograft model of human CWR22 prostate cancer cells (43), a mouse model of APL 
containing the promyelocytic leukemia zinc-finger-retinoic acid receptor α fusion gene (PLZF-
RARα) (46), and an N-methylnitrosourea-induced mammary tumor model in rodents (47).  


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SAHA has also showed activity when administered daily by intraperitoneal (IP) injections in the 
CWR22 and PLZF-RARα models and by oral (PO) administration in the carcinogen-induced 
mammary tumor model. 
 
SAHA Combination Studies 
 
Accumulating evidence has demonstrated the effectiveness of HDAC inhibitors in 
combination with several other agents in vitro.  The combination of SAHA and DNA 
hypomethylating agents (5-azacytidine or decitabine) acts synergistically to induce apoptosis, 
differentiation, and/or cell growth arrest in various cancer cell lines (48,49).  When SAHA was 
combined with the anti-metabolite 5-fluorouracil, a supra-additive to additive antiproliferative 
effect in wild type and mutant-p53 colorectal cancer cells was observed (50).  SAHA with 
imatinib mesylate (Gleevec®) may be effective in chronic myelogenous leukemia (CML) cells 
that resist imatinib mesylate through increased Bcr-Abl expression (36,37).  Minimally toxic 
concentrations of the proteasome inhibitor bortezimib combined with SAHA resulted in 
increased apoptosis in human leukemia cells (37).  In cells from RARα-PLZF/RARα-PLZF 
transgenic mice and in cells harboring t(15;17) (RARα-PML fusion genes), SAHA induced 
significant apoptosis and growth inhibition, effects that were increased by adding all-trans 
retinoic acid (46). Pre-treating four human cancer cell lines (including a brain tumor line) with 
SAHA increased the killing efficiency of etoposide, ellipticine, doxorubicin, or cisplatin, but not 
of the topoisomerase I inhibitor camptothecin (51).  However, treating cells in the reverse order 
(anticancer drug followed by SAHA) was no more cytotoxic than the anticancer drug alone.  
Finally, overexpression of Bcl-2 or Bcl-XL in leukemia and MM cell lines abolished SAHA-
induced apoptosis but did not affect its differentiation or cell cycle regulatory effects (45,52,53).  
This suggests that agents blocking Bcl-2 expression or function could be effectively combined 
with SAHA.  Studies done with other HDACs have suggested that a consequence of HDAC 
inhibitor-induced heat shock protein 90 (Hsp 90) acetylation is depletion of the Hsp 90 client 
protein Her-2 and increased apoptosis of breast cancer cell lines induced by taxotere, 
trastuzumab, epothilone B, and gemcitabine (54,55).  In addition to these potentially additive or 
synergistic interactions between SAHA or other HDACs and various anticancer drugs, SAHA 
has shown synergistic activity when combined with radiotherapy in prostate cancer cell 
spheroids (56). 
 
Phase 1 Clinical Experience 
 
A phase 1 study evaluated vorinostat administered intravenously (IV) to patients with 
advanced solid tumors and hematologic malignancies (57).  Vorinostat was administered using 
two schedules:  2-hour IV infusion daily x 3 q21d, or daily x 5 for 1 to 3 weeks.  No dose-
limiting toxicities (DLTs) were observed in eight patients administered vorinostat daily x 3 q21d 
at doses of 75, 150, 300, 600, and 900 mg/m²/day.  One solid tumor patient given 900 mg/m² on 
the daily x 5 schedule for 3 weeks developed acute respiratory distress and grade 3 hypotension.  
Among five other patients at this dose, no additional DLTs were observed.  Among 12 
hematologic and 17 solid tumor patients enrolled on the daily x 5 schedule (300, 600, and 900 
mg/m²/day), therapy was delayed for 1 week for grade 3/4 leukopenia and/or thrombocytopenia 
in two of five patients with hematologic malignancies given 600 mg/m² for 3 weeks.  The 


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maximum tolerated dose (MTD) for hematologic malignancy patients was 300 mg/m² daily x 5 
for 3 weeks.  An MTD for solid tumors was not determined because the study was terminated 
when an oral formulation became available. The mean terminal half-life (t1/2) ranged from 21 - 
58 minutes, and the dose was linearly proportional to the area under the concentration versus 
time curve (AUC).  Acetylated histones were detected in peripheral blood mononuclear cells 
(PBMCs) up to 4 hours post-infusion at higher dose levels.  This observation was confirmed by 
immunohistochemical analyses of post-therapy tumor biopsies.  Four patients, including two 
with lymphoma and two with bladder cancer, experienced objective tumor regression with 
clinical improvement in tumor-related symptoms. 
 
As of 29-May-2009 the clinical safety of vorinostat is supported by data from 854 
patients (858 patient-exposures) who have been treated in Merck & Co., Inc sponsored 
Phase I, II, and III studies (Investigator’s Brochure, 2009) conducted in patients with both 
hematologic malignancies and solid tumors. An additional 290 patients were enrolled in a 
randomized, blinded study where patients are randomized in a 1:1 fashion to vorinostat or 
placebo. Merck & Co., Inc., including Banyu (Japan), has sponsored 30 vorinostat studies that 
are completed (11),closed (3), or ongoing (14). The NCI is working in collaboration with Merck 
& Co., Inc. to further evaluate vorinostat. The NCI-sponsored studies of vorinostat are in 
progress or are planned in a variety of different indications both in hematologic malignancies as 
well as solid tumors. To date, 1,230 patients have received vorinostat as either monotherapy or 
combination chemotherapy in 43 studies sponsored by the NCI. 
 
In addition, vorinostat is also being evaluated in studies initiated and sponsored 
by independent Investigators, both as monotherapy and as combination chemotherapy. As of 29-
May-2009, 44 of these Investigator initiated studies have enrolled 326 patients. These active 
studies are enrolling and additional studies are planned. 
 
Therefore, over 2,574 patients have received at least one dose of vorinostat in 
studies sponsored by either Merck and Co., Inc., the NCI or independent Investigators. 
 
The total daily doses studied ranges from 200 mg to 900 mg. The tolerability of 
oral vorinostat appears to be determined by total daily dose and the length of consecutive days of 
dosing. The maximum tolerated dose (MTD) for continuous daily dosing without a rest period is 
400 mg daily or 200 mg BID. The MTD for intermittent dosing is 300 mg BID x 3 consecutive 
days per week, or 250 mg TID x 14 consecutive days followed by a 7-day rest. Dose-limiting 
toxicities (DLTs) of single agent vorinostat were mainly non-hematologic (anorexia, 
dehydration, diarrhoea, and fatigue); hematologic toxicities are primarily anaemia and 
thrombocytopenia, most of which were mild to moderate. The majority of these DLTs occurred 
within the first month on oral vorinostat. The DLTs were manageable because these toxicities 
resolved quickly after drug administration 
was interrupted. The optimal dose, dose frequency, and dose duration remains under active 
investigation. 
 
The pharmacokinetics and toxicokinetics of vorinostat have been evaluated in 


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mice, rats, dogs and humans. Rapid oral absorption has been noted in all species studied. 
Vorinostat (0.5 to 50 µg/mL) exhibited moderate reversible binding to plasma proteins. In human 
plasma, vorinostat appears to bind primarily to human serum albumin; however, some binding of 
vorinostat was also observed in solutions of human α1-acid glycoprotein. 
 
Vorinostat is excreted exclusively as metabolites, the majority of metabolites are 
derived from glucuronidation and hydrolysis with β-oxidation pathway metabolites accounting 
for the rest. As vorinostat is not eliminated via cytochrome P450 pathways, it is anticipated that 
vorinostat will not be subject to drug-drug interactions when co-administered with drugs that are 
known to be CYP inhibitors. Although vorinostat was not a potent reversible inhibitor of the 
cytochrome P450 isozymes (IC50 >75 µM), gene expression studies detected some potential for 
suppression of CYP2C9 and CYP3A4 activities at ≥10 µM vorinostat however, these changes 
were observed at concentrations higher than the pharmacologically relevant serum concentration 
of 2 µM (Cmax). 
 
Pharmacokinetic analysis of 26 patients has indicated that the bioavailability of oral 
vorinostat is approximately 46%.  Vorinostat doses in the range of 200 - 600 mg produced 
maximum concentration (Cmax) and drug exposure (AUC) curves that were linearly proportional.  
The t1/2 of oral vorinostat ranges from 92 to 150 minutes, and preliminary data suggest that 
administration of vorinostat with food does not appear to substantially alter the rate or extent of 
absorption.  Inhibition of HDAC activity was achieved in PBMCs at the 200 mg dose level.  At 
dose levels of 400 and 600 mg, the duration of HDAC inhibition lasted >10 hours.  
 
Significant antitumor activity has been observed among members of the above patient 
trial population.  In a phase 1 study of oral vorinostat, seven patients with heavily pre-treated 
diffuse large B-cell lymphoma were entered.  Among these patients, one complete response (CR) 
and one partial response (PR) were observed.  In addition, one patient has had a significant PET 
scan response.  The PR lasted 5 months, the PET scan response lasted 6 months, and the CR was 
ongoing with a duration >12 months at last report.  Decrease in tumor mass, pleural effusion, and 
improvement of tumor-related pain or shortness of breath have also been observed in patients 
with mesothelioma.  In an ongoing phase 2 study of vorinostat in patients with heavily pretreated 
CTCL or peripheral T-cell lymphoma, objective responses have been observed (including PRs in 
5 of 13 patients), and 8 of 10 patients reported decreased pruritus.  
 
Zolinza® (vorinostat) was approved by the U.S. Food and Drug Administration (FDA) 
on 06-Oct-2006 for the treatment of cutaneous manifestations in patients with cutaneous T-cell 
lymphoma (CTCL) who have progressive, persistent or recurrent disease on or following two 
systemic therapies. Phase I and II clinical studies of Vorinostat sponsored by Merck & Co., Inc., 
Banyu (Japan), and the NCI have emonstrated confirmed anti-tumor activity in patients with 
acute myeloid leukemia (AML), advanced multiple myeloma, B-cell non-Hodgkin's lymphoma, 
squamous cell laryngeal carcinoma, thyroid carcinoma, breast carcinoma, non-small cell lung 
carcinoma, glioblastoma multiforme, and myelodysplastic syndrome. 
 
 


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Potential for Drug Interactions 
 
Vorinostat has a low propensity to cause or be affected by drug-drug interactions. In vivo 
animal models and in vitro human systems have demonstrated that the major 
pathways of metabolism of vorinostat involve glucuronidation, and hydrolysis 
followed by β-oxidation (Investigator’s Brochure, 2009). As vorinostat is not eliminated via 
cytochrome P450 (CYP) pathways, it is anticipated that vorinostat will not be subject to drug-
drug interactions when co-administered with drugs that are known to be CYP inhibitors or 
inducers. Since vorinostat was neither a potent inhibitor nor an inducer of CYP enzymes, drug-
drug interactions caused by vorinostat are not anticipated. Additionally, vorinostat is not 
recovered intact in urine to any appreciable extent. Therefore, compounds known to affect renal 
elimination are not expected to affect the pharmacokinetics of vorinostat. 
 
Prolongation of prothrombin time (PT) and International Normalized Ratio (INR) were 
observed in patients receiving vorinostat concomitantly with  coumarin-derivative 
anticoagulants. Physicians should carefully monitor PT and INR in patients concurrently 
administered vorinostat and coumarin derivatives. 
 
Vorinostat should not be administered concomitantly with other HDAC inhibitors (e.g., 
valproic acid) as class-specific adverse reactions may be additive. Severe (Grade 4) 
thrombocytopenia with associated gastrointestinal bleeding and anaemia has been reported with 
the concomitant use of vorinostat and valproic acid. 
 
Patients who have received HDAC inhibitors or compounds with HDAC inhibitor like 
activity, such as valproic acid, for anti-neoplastic therapy should not enroll in vorinostat oncology 
trials. Patients who have received such agents for other indications, e.g epilepsy, may enroll on 
vorinostat trials after a 30-day wash-out period. 
 
 
2.3  FDG PET/CT 
 
Assessment of tumor response to therapy plays a central role in drug development as well 
as clinical patient management.  Currently response is mainly evaluated by measuring tumor size 
in CT and classifying tumor shrinkage according to standard criteria, such as those of the World 
Health Organization (WHO) or Response Evaluation Criteria for Solid Tumors (RECIST) 1.1 
criteria (58-60).  However, response rates as assessed by these criteria are not well correlated 
with patient survival. Furthermore, response is evaluated not earlier than 2-3 months after start of 
therapy.  This represents a significant clinical problem, since many treatment regimens are only 
active in the minority of the patients, meaning that the majority of patients undergo prolonged 
therapy without benefits.  Several studies have suggested that positron emission tomography 
(PET) with the glucose analog fluorodeoxyglucose (FDG) may be used to monitor tumor 
response very early in the course of therapy.  Quantitative changes in tumor FDG uptake 2-3 
weeks after start of therapy have been shown to correlate well with subsequent tumor shrinkage 
and patient survival in some tumor types (table 1). Conversely, the absence of a measurable 
decrease in tumor FDG uptake after the first chemotherapy cycle has been found to predict lack 


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of tumor shrinkage and poor patient survival. 
 
 
 
 
 
 
 
Table 1: Prognostic relevance of quantitative changes in tumor FDG uptake during 
chemo- or chemoradiotherapy 
Tumor 
Author 
Year
N 
criteria
median survival 
p-value 
 
responder non-responder
Esophagus
Weber(61) 
2001
37 
-35% 
>48 
20 
0.04 
 
Wieder(62) 
2004 22**
-30% 
>38 
18 
0.011 
Gastric 
Ott(63) 
2002
35 
-35% 
>48 
17 
0.001 
Head and
Neck 
Brun(64) 
2002 47** median*
>120 
40 
0.004 
Ovarian 
Avril (65) 
2005
33 
-20% 
38 
23 
0.008 
Lung 
Weber(65) 
2003
57 
-20% 
9 
5 
0.005 
 
Hoekstra (66) 2005
56 
-35% 
43 
18 
0.04 
* Median metabolic rate at the time of the follow-up study.  
** Chemoradiotherapy, otherwise chemotherapy. 
 
Thus, FDG-PET has the potential to improve patient management by signaling the need 
for early therapeutic changes in non-responders, thereby avoiding the side effects and costs of 
ineffective treatment.  Furthermore, as an early indicator of clinical benefit, FDG-PET may also 
facilitate oncologic drug development by shortening Phase II trials and detecting clinical benefit 
earlier in Phase III investigations.   
 
An exploratory objective of this study (pending funding) will be to assess the association 
between a metabolic response after one and two cycles of chemotherapy and subsequent best 
tumor response according to standard anatomic response evaluation criteria (RECIST 1.1). The 
PET studies will be optional. 
 


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Rationale for Studying the Time Course of Tumor FDG Uptake During 
Chemotherapy 
 
To the best of our knowledge, there is very few data published on the use of PET scans to 
monitor response in ACC (67,68). Non small cell lung cancer (NSCLC) was chosen as a model 
because the data on this tumor type is more mature and abundant. 
 
A previous study has indicated that, in patients with advanced NSCLC, changes in tumor 
FDG uptake after one cycle of chemotherapy are well correlated with patient survival (65).  In 
addition, a study evaluating neoadjuvant chemotherapy has also shown that metabolic activity 
after one chemotherapy cycle is highly predictive of patient survival (66).  A second study in 
patients undergoing neoadjuvant chemoradiotherapy retrospectively analyzed PET scans of 
patients with locally advanced NSCLC imaged after three cycles of induction chemotherapy and 
after completion of chemoradiotherapy (45 Gy) (69).  Changes in tumor FDG uptake at both time 
points were predictive of patient survival.  However, most of the patients underwent only two 
and not three PET studies.  There are some data in locally advanced breast and esophageal 
cancer that PET imaging after one cycle of chemotherapy may be a slightly better predictor of 
patient survival than PET after 2-6 cycles (62,70,71).  
 
Both patients treated in the NCI protocol 8057 (section 2.4) experienced subjective 
clinical and/or laboratorial improvement around 2-3 weeks after starting treatment with 
vorinostat. Therefore, this trial will measure changes in tumor FDG uptake after one and two 
cycles of chemotherapy. 
 
Definition of a Metabolic Response in FDG-PET 
 
Based on the reproducibility of the FDG-signal in untreated tumors, relative changes of 
approximately 20% are very unlikely to be due to measurement errors or spontaneous 
fluctuations of tumor metabolic activity (72,73).  These data establish the minimal effect of 
treatment on tumor metabolic activity that can be assessed by FDG-PET.  However, a 
measurable change in metabolic activity does not necessarily imply that treatment has a 
beneficial effect for the patient.  A recent study evaluated the prognostic implications of a 
measurable change in tumor glucose utilization in patients with advanced NSCLC, who were 
treated with palliative platinum-based chemotherapy.  A "metabolic response" in PET was 
prospectively defined as decrease of the SUV of the primary tumor by at least 20%.  A total of 
57 patients were included in the study and 28 tumors showed a metabolic response after the first 
chemotherapy cycle.  Median progression-free survival of metabolic nonresponders was only 1.8 
months versus 5.9 months for metabolic responders.  Median overall survival of metabolic 
responders was 8.4 months and only 5.0 months for metabolic nonresponders (65).  The 
sensitivity and specificity of a metabolic response for prediction of best response according to 
RECIST criteria were 95% and 74%, respectively. 
 
These data indicate that a measurable change in tumor FDG uptake after the first cycle of 
chemotherapy is associated with a palliative effect of therapy.  These data and the data on the 
test-retest reproducibility of FDG-PET suggest that a 20% decrease in tumor FDG uptake may be 


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used to define a metabolic response in patients with NSCLC.  However, we will use slightly 
stricter criteria for a metabolic response in the present study and define a metabolic response as a 
decrease of tumor FDG uptake by 25%.  The rationale for this definition is that the test/retest 
reproducibility of FDG-PET in a multicenter trial may be lower than previously reported in 
single-center studies.  Therefore, a 20% threshold may not be robust enough for a multicenter 
trial.  Defining a metabolic response as a 25% decrease of tumor FDG uptake makes this study 
also consistent with previous recommendations by the EORTC (74).  
 
Although data in the literature support the use of a 25% decrease in tumor FDG uptake as 
a criterion for a metabolic response, we cannot exclude that other threshold values may allow a 
better prediction of patient outcome.  Therefore, receiver operating characteristic (ROC) curves 
will be calculated for prediction of best response by quantitative changes in FDG uptake after 
one and two cycles of chemotherapy.  Predictive accuracy will be evaluated through 95% 
confidence intervals for the area under the ROC curve (75) 
 
All PET/CT data will follow the guidelines specified in appendices B and C (76) .  
 
 
2.4 Rationale 
  
Case Reports 
Two patients with ACC were treated in the NCI protocol 8057 (Phase I and 
pharmacokinetic study of vorinostat for solid tumors and lymphomas in patients with varying 
degrees of hepatic dysfunction) at the Karmanos Cancer Institute (KCI), Detroit, MI. Both 
patients displayed significant subjective clinical and/or laboratorial improvement. One patient 
also experienced partial response on the liver metastasis. Based on those cases, we propose to 
investigate the activity of vorinostat in patients with ACC. A brief summary of those cases is 
described below. 
 
Case 1 
40 year old Caucasian female with a diagnosis of ACC stage III of the right parotid in 
1997. Patient underwent right neck dissection and total parotidectomy on 11/03/97. Adjuvant 
radiation therapy to the left maxilla and mandible at 6200cGY was delivered. Metastatic disease 
to the bone, lung and liver were diagnosed in August of 2006. Palliative radiation therapy to the 
bone was delivered from T9 to L1 (30Gy) and from L3 to S2 (30Gy). Patient opted for a watch 
and wait approach until January of 2008. 
 
Previous treatments included a phase 1 trial utilizing a hedgehog inhibitor from 01/22/08 
to 03/24/08. Treatment was discontinued due to progression of disease. Patient subsequently 
enrolled on another phase 1 trial utilizing a telomerase inhibitor from 05/15/08 to 06/16/08, 
discontinued due to progression of disease in the liver. 
 
Patient enrolled on the liver dysfunction NCI protocol 8057 on 07/24/08. A flat dose of 
400mg of vorinostat was given on day -6 (07/24/08), followed by a 200mg daily dose starting on 
07/31/08. At the time of enrollment, patient’s liver enzymes and bilirrubin levels placed her on 


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the moderate liver dysfunction cohort (see table below). On 08/21/08, a decrease in bilirrubin 
levels was observed as well as a minor decrease in alanine aminotransferase (ALT). Decrease in 
the liver span and firmness on physical examination were noticed. Patient reported improvement 
in symptoms, such as less bloating since the start of treatment. CT scans done at the end of 8 
weeks of treatment showed stable disease, but on cycle 3 day 1 (09/11/08), ALT level was 
normal, AST was only mildly elevated (grade 1) and bilirrubin was normal. On 10/02/08, due to 
complete normalization of liver enzymes, vorinostat dose was increased from 200mg to 400mg 
(normal dose cohort). Patient’s CT scans showed partial response in the liver after 5 months into 
the trial, with stable disease in the lung. Liver enzymes (AST and ALT) and bilirrubin return to 
normal limits (table 2). Patient was taken off trial on April 30, 2009 due to interstitial 
pneumonitis (possibly drug related). 
 
Adverse events observed included pulmonary embolism (probably drug related), grade 1 
elevation of hemoglobin and alkaline phosphatase. Patient also experienced grade 2 
thrombocytopenia, completely resolved. Patient also experienced adrenal insufficiency, needing 
steroids replacement and had 3 episodes of hospitalization due to aspiration pneumonia. 
 
 
Table 2 – Laboratory values according to vorinostat cycle 
 
07/24/08
(D-6) 
07/31/08
(C1D1) 
08/21/08
(C2D1) 
09/11/08
(C3D1) 
10/02/08
(C4D1) 
02/10/09 
(C10D13)
03/12/09
AST 
219 
160 
200 
64 
27 
27 
23 
ALT 
173 
137 
120 
45 
33 
25 
20 
Bilirrubin 
4.0 
1.9 
1.4 
0.8 
0.5 
0.3 
0.3 
Alkaline 
phosphatase 
1421 
1305 
1418 
1103 
774 
232 
208 
 
 
 
 
 
 
 
 
 
 
Case 2  
40 year old Caucasian male with a diagnosis of ACC stage IVB of the left nasopharynx in 
January 2003.  Patient was treated with a LeFort I approach resection through the sphenoid sinus 
and pterigopalatine fossa on the same month. Tumor was not totally resected, due to extension to 
carotid artery. He subsequently received adjuvant radiation therapy by intensity-modulated 
external beam radiation therapy (IMRT) to the nasal cavity and sinus (at a dose of 50.4Gy) as 
well as radiosurgery boost to the residual sinus lesion (10Gy). Radiation therapy was completed 
in May of 2003. Patient developed metastatic lung disease in May of 2006. Lung biopsy 
confirmed metastatic ACC. At the same time, a renal mass was found in his left kidney. Biopsy 
was performed and it was positive for chromophobe renal cell carcinoma. It was surgically 
resected by left radical nephrectomy in August 29, 2006 with no evidence of recurrence from this 
cancer until the present moment.   
 
Patient was treated with sorafenib from May 2007 to June 2007. Treatment was 
discontinued upon patient’s request; no evaluation for response was performed. Re-irradiation to 
the recurrent disease on the left pterygopalatine fossa, left trigeminal nerve and cavernous sinus 


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at a dose of 34Gy was performed from August 08, 2007 to August 20, 2007. 
 
Previous treatments included a phase 1 trial utilizing a hedgehog inhibitor from 11/19/07 
to 02/14/08. Treatment was discontinued due to progression of disease and worsening of 
symptoms. Patient subsequently enrolled on another phase 1 trial utilizing a telomerase inhibitor 
from 03/24/08 to 05/2708, discontinued due to progression of disease. He underwent another 
phase 1 trial with a vascular disrupting agent from 07/07/08 to 08/18/08. Treatment was 
discontinued due to intolerable side effects. 
 
Treatment on the NCI protocol 8057 with vorinostat at 400mg orally daily (normal dose 
cohort) was started on 10/09/08. Clinical benefit was noted within the first month of treatment 
with vorinostat, as demonstrated by decrease in facial pain, increase in energy levels and weight 
gain. CT thorax after 8 weeks of treatment showed decrease in the size of the lung metastasis in 
the range of 10-20%. Significant adverse events included grade 2 asymptomatic elevation of 
creatinine, which after a 5-day discontinuation of the drug returned to the patient’s baseline. 
Grade 1 decrease in hemoglobin and platelets were also observed. Patient remained on the study 
until 01/12/09, off study due to progression of disease. 
  
 
3. PATIENT SELECTION 
 
3.1  
Eligibility Criteria 
 
3.1.1 Patients must have histologically or cytologically confirmed locally advanced, 
recurrent or metastatic adenoid cystic carcinoma. 
 
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 by chest x-ray, as >10 mm with CT scan, or >10 mm 
with calipers by clinical exam.  All tumor measurements must be recorded in 
millimeters (or decimal fractions of centimeters). See section 10.1 for the 
evaluation of measurable disease.  
 
 
3.1.3 Patients must have locally advanced and/or recurrent and/or metastatic disease 
not amenable to potentially curative surgery or radiotherapy. Any prior 
number of chemotherapy regimens is allowed. A minimum of at least 4 weeks 
since prior chemotherapy or radiation therapy should have elapsed, 6 weeks if 
the last regimen included BCNU or mitomycin C.  
 
3.1.4 Age ≥18 years.  Because no dosing or adverse event data are currently 
available on the use of vorinostat in patients <18 years of age, children are 
excluded from this study but will be eligible for future pediatric single-agent 
trials, if applicable. 
 
3.1.5 Life expectancy of greater than 12 weeks. 


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3.1.6 ECOG performance status 0−2 (Karnofsky ≥60%; see Appendix A). 
 
3.1.7 Patients must have normal organ and marrow function as defined     below: 
 
• leukocytes 
>3,000/mcL 
• absolute neutrophil count 
>1,500/mcL 
• platelets 
>100,000/mcL 
• total bilirubin 
within normal institutional limits(WNL)  
• AST(SGOT)/ALT(SGPT) 
≤2.5 X institutional upper limit of 
 
 
 
 
 
 
 
 
 
Normal (ULN) 
• creatinine 
within normal institutional limits 
 
 
OR 
 
 
creatinine clearance 
>60 mL/min/1.73 m2 for patients with 
creatinine levels above institutional 
normal 
 
3.1.8 Eligibility of patients receiving any medications or substances known to affect 
or with the potential to affect the activity or pharmacokinetics of vorinostat 
will be determined following review of their case by the Principal 
Investigator.   
 
3.1.9 No other diagnosis of malignancy unless non-melanoma skin cancer, 
carcinoma in situ of the cervix, or a malignancy diagnosed ≥ 5 years 
previously and currently with no evidence of disease.  HOWEVER - if the 
patient has had a previously diagnosed Stage I/II malignancy of another type, 
consideration for recruitment may be made by the CTEP senior investigator 
after discussion with local PI and patient’s physician 
 
3.1.10 Confirmed availability of tumor tissue (either fresh or from paraffin block) 
from the primary tumor or metastatic site to be available to use on correlative 
studies (see Section 8 for details).  
 
3.1.11 The effects of vorinostat on the developing human fetus at the recommended 
therapeutic dose are unknown. For this reason and because HDAC inhibitors 
are known to be teratogenic, women of child-bearing potential and men must 
agree to use adequate contraception (hormonal or barrier method of birth 
control; abstinence) prior to study entry and for the duration of study 
participation. Should a woman become pregnant or suspect she is pregnant 
while participating in this study, she should inform her treating physician 
immediately. 
 


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3.1.12 Ability to understand and the willingness to sign a written informed consent 
document. 
 
3.1.13 If the patient’s tumor can be easily accessed, a pre-treatment biopsy will be 
mandatory. 
 
3.2  
Exclusion Criteria 
 
3.2.1 Patients who have had chemotherapy or radiotherapy within 4 weeks (6 weeks 
for nitrosoureas or mitomycin C) prior to entering the study or those who have 
not recovered from adverse events due to agents administered more than 4 
weeks earlier. More than 21 days from major surgery should have elapsed 
before the first dose of the study drug. 
 
3.2.2 Patients may not be receiving any other investigational agents or have 
received vorinostat in the past. Patients should not have taken valproic acid 
for at least 4 weeks prior to enrollment. 
 
3.2.3 Inability to take oral medications on a continuous basis. 
 
3.2.4 Patients with active brain metastases should be excluded from this clinical 
trial because of their poor prognosis and because they often develop 
progressive neurologic dysfunction that would confound the evaluation of 
neurologic and other adverse events. Patients with previous brain metastases 
will be eligible if condition is treated and stable for ≥ 1 month 
 
3.2.5 History of allergic reactions attributed to compounds of similar chemical or 
biologic composition to SAHA. 
 
3.2.6 Uncontrolled intercurrent illness including, but not limited to, ongoing or 
active infection, symptomatic congestive heart failure, unstable angina 
pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would 
limit compliance with study requirements.  
 
3.2.7 Pregnant women are excluded from this study because SAHA is a HDAC 
inhibitor agent with the potential for teratogenic or abortifacient effects.  
Because there is an unknown but potential risk for adverse events in nursing 
infants secondary to treatment of the mother with vorinostat, breastfeeding 
should be discontinued if the mother is treated with vorinostat. 
 
3.2.8 Patient is unable or unwilling to abide by the study protocol and to cooperate 
fully with the investigator or designee. 
 
3.2.9 Patient on current therapy with enzyme-inducing anticonvulsants (see 
Appendix G) 


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Version Date: 08/16/16 
 
 
  
3.3 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this 
trial.   
 
4. REGISTRATION PROCEDURES 
 
4.1 General Guidelines 
 
Eligible patients will be entered on study centrally at the Karmanos Cancer Institute by the 
Study Coordinator.  All sites should call the Study Coordinator at 313-576-9369 to verify agent 
availability.   
 
Following registration, patients should begin protocol treatment within 72 hours.  Issues that 
would cause treatment delays should be discussed with the Principal Investigator.  If a patient 
does not receive protocol therapy following registration, the patient’s registration on the study 
may be cancelled.  The Study Coordinator should be notified of cancellations as soon as 
possible. 
 
Except in very unusual circumstances, each participating institution will order DCTD-
supplied agents directly from CTEP.  Agents may be ordered by a participating site only after the 
initial IRB approval for the site has been forwarded by the Coordinating Center to the CTEP PIO 
(PIO@ctep.nci.nih.gov) except for Group studies. 
 
 
4.2 Registration Process 
 
To register a patient, the following documents should be completed by the research nurse or 
data manager and faxed to (313) 576-8365 or e-mailed (casettal@karmanos.org ) to the Study 
Coordinator: 
• Copy of required laboratory tests 
• Signed patient consent form 
• HIPAA authorization form (signed by patient) 
• Eligibility screening worksheet 
• Registration form 
 
The research nurse or data manager at the participating site will then call (313) 576-9369 
or e-mail (casettal@karmanos.org ) the Study Coordinator to verify eligibility.  To complete the 
registration process, the Coordinator will 
• assign a patient study number 
• register the patient on the study 
• fax or e-mail the patient study number and dose to the participating site 
• call the research nurse or data manager at the participating site and verbally 
confirm registration. 


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Version Date: 08/16/16 
 
 
 
5. TREATMENT PLAN 
 
         5.1 Vorinostat Administration 
 
Treatment will be administered on an outpatient basis.  Reported adverse events and potential 
risks are described in Section 7.  Appropriate dose modifications for vorinostat are described in 
Section 6.  No investigational or commercial agents or therapies other than those described 
below may be administered with the intent to treat the patient’s malignancy. 
 
On Day 1 of the first cycle of vorinostat will be initiated on a continuous daily oral regimen 
at 400mg PO. The dose may be reduced for individual patients in subsequent cycles depending 
on toxicity (See Section 6.2.2). Each treatment cycle will consist of 28 days of therapy. 
 
Vorinostat can be taken with food. Patients need to swallow each capsule whole with a full 
glass of water. Capsules should not be chewed or opened. If a capsule is broken and the powder 
of the capsules gets on skin, patients should be instructed to wash the exposed area with copious 
amounts of water and to inform investigator or nurse of the fact.  
 
Patients are required to record their daily dose in a “pills diary”. Missed/ skipped pills or 
vomited doses should not be re-taken. Patients should be instructed to record those pills as missed 
doses in the diary and to inform investigator or nurse if that happens.  
 
5.2 Supportive Care Guidelines 
 
Patients will be permitted to receive appropriate supportive care measures as deemed 
necessary by the treating physician. The use of prophylactic granulocyte growth factors is not 
permitted for the first cycle of therapy. 
 
Patients should maintain adequate fluid and food intake because the dose-limiting toxicities 
related to vorinostat are anorexia, dehydration, diarrhea, and fatigue. In the setting of dysgeusia, 
popsicles and Gatorade have been found to be useful by some investigators to maintain adequate 
hydration. Antiemetics, particularly after the first 3 days of therapy, may be required. Patients 
should also be encouraged to seek a nutritional consult. 
 
Diarrhea: Treat diarrhea promptly with appropriate supportive care, including loperamide. 
Instruct patients to begin taking loperamide at the first signs of: 1) poorly formed or loose stool, 
2) occurrence of more bowel movements than usual in one day, or 3) unusually high volume of 
stool. Loperamide should be taken in the following manner: 4 mg at first onset of diarrhea, then 
2 mg after each unformed stool. Daily dose should not exceed 16 mg/day. Loperamide should 
not be taken prophylactically. Advise patients to drink plenty of clear fluids to help prevent 
dehydration caused by diarrhea. Avoid loperamide if there is the presence of blood or mucus in 
the stool or if diarrhea is accompanied by fever. If grade 3 or 4 diarrhea develops, discontinue 
further treatment with vorinostat. 


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Version Date: 08/16/16 
 
 
 
5.3 Duration of Therapy 
 
In the absence of treatment delays due to adverse event(s), treatment may continue for until 
one of the following criteria applies: 
• Disease progression, 
• Intercurrent illness that prevents further administration of treatment, 
• Unacceptable adverse event(s), 
• Patient decides to withdraw from the study, or 
• General or specific changes in the patient’s condition render the patient 
unacceptable for further treatment in the judgment of the investigator. 
• If a female patient gets pregnant during the study 
 
Patients will be removed from study when any of the criteria listed above applies.  The 
reason for study removal and the date the patient was removed must be documented in the Case 
Report Form. 
 
5.4 Duration of Follow Up 
 
Patients will be followed for 180 days after removal from study or until death, whichever 
occurs first.  Patients removed from study for unacceptable adverse events will be followed until 
resolution or stabilization of the adverse event. 
 
 
6.  DOSING DELAYS/DOSE MODIFICATIONS 
 
6.1 Retreatment Criteria 
 
Prior to administration of each new cycle following cycle one, patients must have   recovered 
the following organ function: 
•  absolute neutrophil count ≥1.5 x 109/L 
•  platelets ≥100 x 109/L 
• creatinine ≤1.5 x upper limit of normal (ULN) 
• other drug related toxicity must have recovered to ≤ grade 1 (excluding alopecia, 
controllable hypertension, leukopenia and lymphopenia) 
•  total bilirubin WNL 
•  AST(SGOT)/ALT(SGPT) ≤2.5 X ULN 
 
 
 
 
 
 
 
 
 
 
Patients not fulfilling these criteria should have treatment delayed by 1 week to allow for 
recovery of organ function. Patients who cannot be retreated within 3 weeks (21 days) of the end 
of the previous cycle should be removed from study, unless they are deriving benefit. In the later 
case, a discussion with the PI and/or CTEP senior investigator will ensue. 
 


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Version Date: 08/16/16 
 
6.2 Dose Modification Guidelines 
 
6.2.1 During the Course of a Cycle: 
 
The dose of vorinostat will be held during the course of the cycle for one or more of the 
following events: 
•  Grade 4 neutropenia lasting > 7 days 
• Grade 4 thrombocytopenia 
• Any grade 4 non-hematological toxicity 
• Grade 3 non-hematological toxicity that cannot be controlled with appropriate supportive 
care measures. 
 
Treatment can be restarted with a reduction in dose (refer to table 3) once the toxicity 
resolves to severity of grade 1 or less. Inability to start the next cycle within 3 weeks (21 days) of 
the scheduled start due to toxicity will result in removal of the patient from the study, unless the 
patient is deriving benefit. In the later case, a discussion with the PI and/or CTEP senior 
investigator will ensue. 
 
6.2.2 Dose Modification for Subsequent Cycles 
 
Laboratory parameters should be obtained within 72 hours prior to initiation of the next cycle 
of therapy.  
 
 
Table 3- Dose Reduction for Toxicity (based on events from previous cycle) 
 
Toxicity 
Dose Reduction*, †
Grade 3/4 Neutropenia associated with 
fever 
and/or 
Grade 4 neutropenia 
and/or 
Grade 4 thrombocytopenia 
 
1st occurrence: 
Reduce by 100 mg/day – 300mg/day (D1-7) 
2nd occurrence: 300mg/day (D1-5), with 2 days 
of rest 
3rd occurrence: Off study 
 
Grade 3 nausea, emesis or diarrhea (not 
controlled by appropriate supportive care 
measures) 
 
1st occurrence:  
Reduce dose by 100 mg/day- 300mg/day (D1-7) 
2nd occurrence: 300mg/day (D1-5), with 2 days 
of rest 
3rd occurrence: Off study 
 
 
Other drug-related grade 3/4 non-
hematological 
toxicity** 
 
1st occurrence: 
Reduce dose by 100 mg/day – 300mg/day (D1-
7) 
2nd occurrence: 300mg/day (D1-5), with 2 days 


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Version Date: 08/16/16 
 
of rest 
3rd occurrence: Off study 
 
* If a patient is experiencing benefits from vorinostat and needs further dose reduction, a 
discussion will occur between CTEP and the PI. 
**  Since fatigue can be a symptom of underlying malignancy, dose reductions will only 
be done if  fatigue can be attributed to vorinostat. No dose reductions will be done for alopecia. 
† Note: “D1-7” means for 7 contiguous days in a week for ALL the weeks that the patient 
will be on treatment (i.e, 300mg/day everyday from D1-28, without any days of rest). “D1-5” 
means for 5 days out of 7 days (i.e., 5 days on treatment/ 2 days of rest in a week) for a cycle of 
28 days.  
 
 
7. PHARMACEUTICAL INFORMATION 
 
7.1 Suberoylanilide Hydroxamic Acid (NSC 701852) 
 
Chemical Name: N-hydroxy-N’-phenyl-octane-1,8-diotic acid diamide;  
N-hydroxyl-N’-phenyl (9CI) octanediamide  
 
Other Names:  
SAHA, Vorinostat, L-001079038, WIN 64652, MSK390, AP390, 
Zolinza™. 
 
Classification:  
Antineoplastic 
 
CAS Registry Number: 149647-78-9 
 
Molecular Formula: 
C14H20N203 
 
M.W.: 264 
 
Approximate Solubility:  Water < 5 mg/mL 
 
Description:  
Histone deacetylase (HDAC) inhibitor  
 
Mode of Action:  Histone deacetylases (HDACs) are a family of enzymes that regulate 
chromatin remodeling and gene transcription via the dynamic 
process of acetylation and deacetylation of core histones. 
 
Suberoylanilide hydroxamic acid, a potent inhibitor of HDAC 
activity, binds directly to the catalytic pocket of HDAC enzymes. 
SAHA causes G1 or G2 phase cell-cycle arrest, apoptosis, or 
differentiation in cultured transformed cells. 
 
How Supplied:  
Suberoylanilide hydroxamic acid is supplied by Merck and Co., Inc. 
and distributed by the CTEP, DCTD, NCI.  Suberoylanilide 
hydroxamic acid is supplied in the following strength: 


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NCI Protocol #: 8474 
 
 
Local Protocol #: 2009-165 
 
 
Version Date: 08/16/16 
 
1. a white, opaque gelatin capsule containing 100 mg (size 3 
capsule) of suberoylanilide hydroxamic acid  
 
The 
inactive 
ingredients 
contained 
in 
each 
capsule 
are 
microcrystalline cellulose, sodium croscarmellose, and magnesium 
stearate.  
 
Suberoylanilide hydroxamic acid 100 mg capsules are supplied in 
bottles of 120 capsules.  
 
Storage:  
Store suberoylanilide hydroxamic acid capsules at room temperature, 
15 to 30 ºC (59 to 86 ºF).  Do not store above 30 ºC .Avoid exposure 
to excessive moisture. 
 
Stability: 
Shelf life stability studies of the intact bottles are ongoing. 
 
Route of Administration:  
Orally 
 
Method of Administration:  Unless otherwise stated in the protocol, suberoylanilide 
hydroxamic acid capsules must be administered whole. 
The 
absolute 
bioavailability 
of 
suberoylanilide 
hydroxamic acid under fasted or fed conditions is 
approximately 46%. Oral administration with food does 
not appear to substantially alter the rate or extent of 
absorption. 
 
Potential Drug Interactions: Vorinostat has a low propensity to cause or be affected by 
drug-drug interactions. In vivo animal models and in 
vitro human systems have demonstrated that the major 
pathways 
of 
metabolism 
of 
vorinostat 
involve 
glucuronidation, and hydrolysis followed by β- oxidation. 
As vorinostat is not eliminated via cytochrome P450 
(CYP) pathways, it is anticipated that vorinostat will not 
be 
subject 
to 
drug-drug 
interactions 
when 
co-
administered with drugs that are known to be CYP 
inhibitors or inducers. Additionally, vorinostat is not 
recovered intact in urine to any appreciable extent. 
Therefore, compounds known to affect renal elimination 
are not expected to affect the pharmacokinetics of 
vorinostat. Prothrombin time and INR prolongation have 
been reported in patients taking vorinostat concomitantly 
with coumadin derivatives anticoagulants. Monitor these 
patients more frequently in their coagulation parameters.  
 
Special Handling: 
SAHA is an anticancer drug. Powder spills from SAHA 


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Local Protocol #: 2009-165 
 
 
Version Date: 08/16/16 
 
capsules due to damaged or broken capsules should be 
cleaned up carefully so as to minimize inhalation. The 
affected area must be washed with copious amounts of  
water. 
 
Patient Care Implications: Because vorinostat’s dose limiting toxicities are anorexia, 
dehydration, diarrhea, and fatigue, patients should 
maintain adequate fluid and food intake. Encourage 
patients to seek a nutritional consult. 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR) 
for 
Vorinostat (SAHA, Zolinza, NSC 701852) 
 
The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI via CTEP-AERS (except as noted below).  Refer to the 'CTEP, NCI Guidelines: Adverse 
Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for further 
clarification. Frequency is provided based on 702 patients. Below is the CAEPR for vorinostat (SAHA, 
Zolinza). 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the 
AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple investigational 
agents and has an AE listed on different SPEERs, use the lower of the grades to determine if 
expedited reporting is required. 
Version 2.7, February 28, 20131 
 Adverse Events with Possible  
 Relationship to Vorinostat (SAHA, Zolinza) 
 (CTCAE 4.0 Term) 
[n= 702] 
 Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious 
(<3%) 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
 
Anemia 
 
 
Anemia (Gr 2) 
GASTROINTESTINAL DISORDERS 
 
 
Abdominal pain 
 
 
 
Constipation 
 
Constipation (Gr 2) 
Diarrhea 
 
 
Diarrhea (Gr 2) 
 
Dry mouth 
 
Dry mouth (Gr 2) 
 
Dyspepsia 
 
Dyspepsia (Gr 2) 
Nausea 
 
 
Nausea (Gr 2) 
Vomiting 
 
 
Vomiting (Gr 2) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS  
Fatigue 
 
 
Fatigue (Gr 2) 
 
Fever 
 
 


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Version Date: 08/16/16 
 
INFECTIONS AND INFESTATIONS 
 
 
Infection2
 
 
INVESTIGATIONS 
 
 
Alanine aminotransferase 
increased 
 
Alanine aminotransferase 
increased (Gr 2) 
 
Alkaline phosphatase 
increased 
 
 
 
Aspartate aminotransferase 
increased 
 
Aspartate aminotransferase 
increased (Gr 2) 
 
Blood bilirubin increased 
 
 
 
Creatinine increased 
 
Creatinine increased (Gr 2) 
 
Lymphocyte count decreased  
Lymphocyte count decreased (Gr 
2) 
 
Neutrophil count decreased 
 
Neutrophil count decreased (Gr 2)
Platelet count 
decreased 
 
 
Platelet count decreased (Gr 2) 
 
Weight loss 
 
Weight loss (Gr 2) 
 
White blood cell decreased 
 
White blood cell decreased (Gr 2)
METABOLISM AND NUTRITION DISORDERS 
 
Anorexia 
 
 
Anorexia (Gr 2) 
 
Dehydration 
 
Dehydration (Gr 2) 
 
Hyperglycemia 
 
Hyperglycemia (Gr 2) 
 
Hypoalbuminemia 
 
 
 
Hypocalcemia 
 
 
 
Hypokalemia 
 
 
 
Hyponatremia 
 
 
 
Hypophosphatemia 
 
Hypophosphatemia (Gr 2) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
 
 
Musculoskeletal and 
connective tissue disorder -  
Other (muscle spasms) 
 
 
 
Muscle weakness3
 
Muscle weakness3 (Gr 2)
NERVOUS SYSTEM DISORDERS 
 
 
Dizziness 
 
Dizziness (Gr 2) 
 
Dysgeusia 
 
Dysgeusia (Gr 2) 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
 
 
Cough 
 
Cough (Gr 2) 
 
Dyspnea 
 
 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
 
 
Alopecia 
 
 
 
 
Skin and subcutaneous 
tissue disorders - Other 
(skin necrosis) 
 
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
2Infection includes all 75 sites of infection under the INFECTIONS AND INFESTATIONS SOC. 
3Muscle weakness includes Generalized muscle weakness, Muscle weakness left-sided, Muscle 
weakness lower limb, Muscle weakness right-sided, Muscle weakness trunk, and Muscle weakness upper 
limb under the MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS SOC. 


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Version Date: 08/16/16 
 
 
4Prolongation of prothrombin time and International Normalized Ratio have been observed in patients 
using vorinostat concomitantly with coumarin-derivative anticoagulants.  
 
Also reported on vorinostat (SAHA, Zolinza) trials but with the relationship to vorinostat (SAHA, 
Zolinza) still undetermined: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Febrile neutropenia 
CARDIAC DISORDERS - Atrial fibrillation; Atrial flutter; Chest pain - cardiac; Left ventricular systolic 
dysfunction; Myocardial infarction; Palpitations; Pericardial effusion; Sinus bradycardia; Sinus 
tachycardia; Ventricular fibrillation 
EAR AND LABYRINTH DISORDERS - Tinnitus; Vertigo 
EYE DISORDERS - Blurred vision 
GASTROINTESTINAL DISORDERS - Abdominal distension; Anal hemorrhage; Bloating; Cheilitis; Colitis; 
Dysphagia; Esophageal hemorrhage; Esophagitis; Flatulence; Gastric hemorrhage; Gastritis; Gingival 
pain; Lower gastrointestinal hemorrhage; Mucositis oral; Oral hemorrhage; Small intestinal obstruction; 
Stomach pain; Upper gastrointestinal hemorrhage 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Death NOS; Edema 
limbs; Gait disturbance; General disorders and administration site conditions - Other (angioedema); 
General disorders and administration site conditions - Other (failure to thrive); Malaise; Multi-organ failure; 
Non-cardiac chest pain; Pain 
HEPATOBILIARY DISORDERS - Hepatic failure 
INFECTIONS AND INFESTATIONS - Infections and infestations - Other (Herpes zoster) 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Bruising; Vascular access complication; 
Wound dehiscence 
INVESTIGATIONS - Activated partial thromboplastin time prolonged4; Cardiac troponin I increased; 
Electrocardiogram QT corrected interval prolonged; GGT increased; INR increased4; Investigations - 
Other (elevated LDH); Lipase increased 
METABOLISM AND NUTRITION DISORDERS - Acidosis; Hypercalcemia; Hyperkalemia; 
Hypermagnesemia; Hypernatremia; Hypoglycemia; Hypomagnesemia; Tumor lysis syndrome 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthralgia; Back pain; Chest wall 
pain; Myalgia; Neck pain; Pain in extremity 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Neoplasms 
benign, malignant and unspecified (incl cysts and polyps) - Other (tumor hemorrhage); Tumor pain 
NERVOUS SYSTEM DISORDERS - Ataxia; Cognitive disturbance; Depressed level of consciousness; 
Dysphasia; Encephalopathy; Facial muscle weakness; Facial nerve disorder; Headache; Intracranial 
hemorrhage; Ischemia cerebrovascular; Lethargy; Memory impairment; Nervous system disorders - Other 
(Guillain-Barre syndrome); Nervous system disorders - Other (head injury); Nervous system disorders - 
Other (polyneuropathy); Paresthesia; Peripheral motor neuropathy; Peripheral sensory neuropathy; 
Seizure; Syncope; Tremor 
PSYCHIATRIC DISORDERS - Agitation; Anxiety; Confusion; Depression; Insomnia; Personality change; 
Psychosis 
RENAL AND URINARY DISORDERS - Acute kidney injury; Hematuria; Proteinuria; Urinary frequency; 
Urinary incontinence; Urinary retention; Urinary tract pain 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Pelvic pain; Uterine hemorrhage 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Bronchopulmonary hemorrhage; 
Epistaxis; Hypoxia; Nasal congestion; Pharyngeal mucositis; Pharyngolaryngeal pain; Pleural effusion; 
Pleuritic pain; Pneumonitis 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Dry skin; Hyperhidrosis; Nail loss; Palmar-plantar 
erythrodysesthesia syndrome; Pruritus; Purpura; Rash maculo-papular 
VASCULAR DISORDERS - Flushing; Hematoma; Hot flashes; Hypertension; Hypotension; 
Thromboembolic event; Vascular disorders - Other (arterial thrombosis); Vasculitis 
 
 


34 
 
NCI Protocol #: 8474 
 
 
Local Protocol #: 2009-165 
 
 
Version Date: 08/16/16 
 
Note: Vorinostat (SAHA, Zolinza) in combination with other agents could cause an exacerbation of any 
adverse event currently known to be caused by the other agent, or the combination may result in events 
never previously associated with either agent. 
 
7.2 Agent Availability 
 
Vorinostat is an investigational agent supplied to investigators by the Division of Cancer 
Treatment and Diagnosis (DCTD), NCI. 
 
 
     Vorinostat is provided to the NCI under a Collaborative Agreement between Merck and 
Co., Inc. and the DCTD, NCI (see Section 11.4). 
 
7.3 
Agent Ordering 
NCI supplied agents may be requested by the Principal Investigator (or their authorized 
designee) at each participating institution.  Pharmaceutical Management Branch (PMB) policy 
requires that agent be shipped directly to the institution where the patient is to be treated.  PMB 
does not permit the transfer of agents between institutions (unless prior approval from PMB is 
obtained.)  The CTEP assigned protocol number must be used for ordering all CTEP supplied 
investigational agents.  The responsible investigator at each participating institution must be 
registered with CTEP, DCTD through an annual submission of FDA form 1572 (Statement of 
Investigator), Curriculum Vitae, Supplemental Investigator Data Form (IDF), and Financial 
Disclosure Form (FDF).  If there are several participating investigators at one institution, CTEP 
supplied investigational agents for the study should be ordered under the name of one lead 
investigator at that institution. 
 
Active CTEP-registered investigators and investigator-designated shipping designees and 
ordering designees can submit agent requests through the PMB Online Agent Order Processing 
(OAOP) application < https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx >.  Access to 
OAOP requires the establishment of a CTEP Identity and Access Management (IAM) account < 
https://eapps-ctep.nci.nih.gov/iam/ > and the maintenance of an “active” account status and a 
“current” password.   For questions about drug orders, transfers, returns, or accountability, call 
(240) 276-6575 Monday through Friday between 8:30 am and 4:30 pm (ET) or email 
PMBAfterHours@mail.nih.gov anytime. 
 
7.4 Agent Accountability 
 
The Investigator, or a responsible party designated by the investigator, must maintain a 
careful record of the inventory and disposition of all agents received from DCTD using the NCI 
Drug Accountability Record Form.  See the CTEP web site for Policy and Guidelines for 
Accountability and Storage of Investigational Drugs (http://ctep.cancer.gov). 
 
 
8.  CORRELATIVE STUDIES 
 
A detailed description of all the planned/optional (pending funding) correlative studies is 
described in appendicies D, E, and F. 


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NCI Protocol #: 8474 
 
 
Local Protocol #: 2009-165 
 
 
Version Date: 08/16/16 
 
 
Archival paraffin blocks of formalin-fixed diagnostic tumor biopsy specimens will be 
requested for each patient from the participating centers. If a paraffin block cannot be provided, 
twenty-five slides containing 5µm sections from an archival block, mounted onto Superfrost 
slides suitable for immunostaining can alternatively be submitted.  If twenty-five slides are not 
available, a lesser amount may be acceptable after discussion with the study Principal 
Investigator, Dr. Patricia LoRusso.  
 
 
Methods 
 
Samples 
Barbara Ann Karmanos Cancer Institute (KCI) has a set of formalin-fixed paraffin embedded 
(FFPE) tumor blocks or slides from individual ACC patients who were treated with SAHA. A 
high number of patients had stable disease on treatment over 6 months (median and range), and 
we observed a partial response in 2 of the patients in this trial. These FFPE samples are well 
annotated with clinical follow-up and represent highly favorable samples to exploit for 
advancing improved outcomes in ACC. 
This study will use previously collected FFPE tissue blocks or slides from 10 patients (all  
available samples may be used at a later point) who achieved some benefit from SAHA and  
patients whose tumors did not demonstrate a therapeutic response. If an entire FFPE block is not 
available, PI's will request up to 20 unstained slides (10 microns).  A deidentified, coded copy of 
the pathology report will also be sent with the FFPE block or slides. 
Whole blood was also collected on most of the patients at the time of enrollment in the original 
study.  Karmanos will send white blood cells from the blood to TGen to serve as patient matched 
germline DNA.  If no blood exists from a selected patient, or the blood was of poor quality, 
Karmanos study personnel will recontact the patient to obtain new informed consent and draw a 
new blood sample. 
Blood samples will be spun down to remove the white blood cells from the red blood cells.  The 
white blood cell pellet will be snap frozen using liquid nitrogen and stored at -80° until shipping 
on dry ice to TGen. 
 
All samples and data will be de-identified and coded with a unique study code assigned by 
Karmanos study personnel.  A key linking the patient name to the study code will be maintained 
and stored by Karmanos study personnel.  TGen will not receive any patient identifiable 
information before, during or after this study is conducted. 
 
Sample Shipment 
 
Initial sample were shipped as specified below to Karmanos Cancer Institute. 
Shipping of paraffin blocks/slides should be done with a padded envelope. Paraffin 
blocks should be wrapped in a plastic bag before placement in the envelope.  Slides 


36 
 
NCI Protocol #: 8474 
 
 
Local Protocol #: 2009-165 
 
 
Version Date: 08/16/16 
 
should be put in an appropriate slide case before placement in the envelope.  
 
Attention: Richard Wiegand 
Barbara Ann Karmanos Cancer Institute 
Wayne State University 
4100 John R, 531 HWCRC 
Detroit, MI 48201 
Office: 313-576-8244 
Fax: 313-576-8266 
Email: wiegandr@karmanos.org 
 
 
All samples will be shipped to: 
The TGen Barrett Laboratory 
 
 
 
 
 
C/O Elizabeth Lenkiewicz 
13208 E. Shea Blvd. 
Scottsdale, Arizona 85259 
602- 358-8839 
 
FFPE Blocks or Slides 
 
When shipping the FFPE block, place the block in a ziplock bag and wrap in bubble wrap 
or another type of padded material prior to shipping.  The zip lock bag can be placed into 
a FedEx envelope or small shipping box. 
 
If sending slides, pack the labeled slides into plastic slide cassette(s). Tape plastic slide 
cassettes shut and wrap in bubble wrap or another type of padded material prior to 
shipping.  Place the slide cassettes into an outer shipping box. 
 
White Blood Cell Pellets 
Place container with frozen specimen in a ziplock bag.  Place 2-3 inches of dry ice in the 
bottom of a Styrofoam cooler.  Place bag in the center of the cooler on top of the dry ice, 
and then fill the cooler the rest of the way with dry ice (preferably pelleted). Place a 
single paper-towel or piece of paper across top of ice, then put lid on the cooler and tape 
the lid tightly to the cooler, sealing all the way around the lid.  Ship Monday through 
Wednesday only unless prior notification is made is made with TGen.  Do not ship 
the day before a U.S. Holiday. 
 
 
Laboratory 
Each 50 µm section will be dewaxed and the nuclei extracted in the presence of DAPI. These 
nuclei suspensions will then be sorted with an Influx flow cytometer equipped with a UV and a 
488 nm laser. For each sample, we will simultaneously collect each diploid, aneuploid, and 
tetraploid population present in the tissue. Our sorting techniques can collect up to 4 
simultaneous streams, thus optimizing the use of clinical samples for genomic studies. Sorting 


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gates out cellular and tissue debris that is typically present in FFPE samples and provides highly 
purified tumor material for genomic analysis. The DNA from each sorted fraction will be 
extracted and then amplified using our established protocols. This linear amplification extends 
the use of each purified sample and allows deep genomic profiling including NGS of each tumor 
population of interest. In addition, we will save aliquots of unamplified genomic DNA from each 
sample for PCR-based validation studies. For each of the tumors in this study, we will initially 
profile sorted populations of interest with high-density aCGH to identify the tumor population(s) 
in each FFPE sample that will be processed for NGS. These data also will define the landmarks 
(focal amplicons, homozygous deletions, and breakpoints) of each tumor genome. We will then 
interrogate the DNA from each sorted tumor cell population in parallel with patient matched 
germline DNA with whole exome NGS.  
 
 Site(s) Performing Correlative Studies   
 
Dr. Michael Barrett 
 
13208 E. Shea Blvd. 
 
Scottsdale, Arizona 85259 
 
mbarrett@tgen.org 
 
602- 358-8383 
 
602- 358-8360 FAX 
 
 
Volumetric Tumor Assesment (refer to appendix I for details)_ 
RECIST criteria uses 2D-proxies (single maximum diameter on axial images) to estimate 
tumor volumes. RECIST is limited in that it only assess tumor response in terms of 
change in maximal axial diameter of selected target lesions.  
 
Recent studies in metastatic cancer have demonstrated the added value of accounting for 
tumor density and volume using size and attenuation CT (SACT), mass attenuation, size 
and structure (MASS), or modified versions of the original Choi CT response criteria, 
beyond RECIST.  
 
We propose a retrospective comprehensive assesment of tumor response, using total 
viable tumor volume (VTV) to quantify the change in viable versus necrotic tumor 
volumes across all lesions through volumetric characterization of density distribution 
throughout all parts of measurable tumors.  
 
In this retrospective study, imaging already obtained (CT and/or MRI) from patients with 
locally advanced, recurrent or metastastic adenoid cystic carcinoma treated on this trial 
will be   re-reviewed.  
 
Target lesions will be volumetric segmented by a research assistant blinded to clinical 
status withing PACS (Carestream VuePACS v12.0, Rochester, NY).  
 


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RECIST imaging from selected CT and/or MRIs from all the patients treated on this trial 
will be compared to volumetric size and viable tumor volume (VTV).  
 
No patient-related decisions will be made based on this assesment. Off-study patients will 
not be reconsented for retrospective data analysis.  
 
CT and/or MRI will be re-reviewed at the National Cancer Institutes by Dr. Les Folio team.


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9.  STUDY CALENDAR 
Baseline evaluations are to be conducted within 1 week prior to administration of 
protocol therapy.  Scans and x-rays must be done 2 weeks prior to the start of therapy.  In the 
event that the patient’s condition is deteriorating, laboratory evaluations should be repeated 
within 48 hours prior to initiation of the next cycle of therapy.  
   
Pre- 
Study 
(D-21 
to D-1)
W
k 
1 
W
k 
2 
W
k 
3 
 
Wk
4 
W
k 
5 
W
k 
6 
W
k 
7 
 
Wk
8 
W
k 
9 
Wk 
10-12 
 
 
 
Wk
13 
 
Off 
Study 
Vorinostata 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Informed consent  
X b 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics  
X b 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history n  
X b, c 
 
Xe
 
Xe
Xe
 
Xe
 
Xe
 
Xe
X 
Concurrent meds n
X b, c
Xe
Xe 
Xe 
 
Xe 
 
Xe 
 
Xe 
X 
Physical exam n  
X b, c 
 
Xe
 
Xe
Xe
 
Xe
 
Xe
 
Xe
X 
Vital signs n 
X b, c 
 
Xe
 
Xe
Xe
 
Xe
 
Xe
 
Xe
X 
Height  
X b 
 
 
 
 
 
 
 
 
 
 
 
 
Weight n 
X b, c 
 
Xe
 
Xe
Xe
 
Xe
 
Xe
 
Xe
X 
Performance status 
(ECOG) n
X b, c 
 
Xe
 
Xe
Xe
 
Xe
 
Xe
 
Xe
X 
Hematology labs  d,o
Xc 
 
Xe
 
Xe
Xe
 
Xe
 
Xe
 
Xe
X 
Serum chemistry  f,o 
Xc 
 
Xe
 
Xe
Xe
 
Xe
 
Xe
 
Xe
X 
EKG  
Xb 
 
Urinalysis
Xc
B-HCG  g 
Xc 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse events 
evaluation n
 
 
Xe
 
Xe 
Xe
 
Xe
 
Xe
 
Xe 
X 
 
Tumor 
measurements p  
 
Xc 
Tumor measurements are repeated every 8 weeks (± 1 week) 
for the first 6 cycles. After 6 months on study, can be 
performed every 12 weeks (± 1 week). Documentation 
(radiologic) must be provided for patients removed from 
study for progressive disease. Objective responses should be 
confirmed within 4 weeks.
 
Xh 
Archival 
tumor 
tissue collected
Xb
 
Blood 
for 
correlative studies 
j, m 
 
X 
 
X 
 


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PET/CT L
Xc
 
 
 
Xi
 
 
 
Xi 
 
 
 
 
 
 
a- Vorinostat:  continuous oral dose 400mg/day (or other dosage if drug reduction required). 
b- Days -21 to day -1: informed consent, physical examination and medical history; vital signs including weight 
and height; review of concurrent medication; ECG; collection of archival tumor tissue. 
c- Days -14 to day -1: limited physical examination with vital signs (including weight); review of new events on 
history; review of medication; performance status; tumor measurement (by CT or MRI) and PET/CT (optional). 
Laboratory tests, pregnancy test (if appropriate) and urinalysis should be done within 7 days from first drug 
intake. 
d- CBC with differential and platelets; PTT, PT and INR. 
e- Study visits assessments to be done on weeks 2 and 4 (±1 day) for the first cycle, then for the second cycle on 
week 5 and 7, (±1 day); then from week 9 on, every four weeks (±1 day) thereafter.  
f- Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, 
LDH, phosphorus, potassium, total protein, AST, ALT, sodium, magnesium. 
g- Serum pregnancy test (women of childbearing potential). 
h- Off-study evaluation.   
i- PET/CT to be done on days -14 to -1; D28±3 days and D56±3 days (optional). 
j- Blood for correlative studies on days 1 (prior to first dose of vorinostat), 7 (+-1day) and 28 (+-1day)  
k- A tumor biopsy will be done if the tumor can be easily accessed. 
L – PET/CT scans are optional and will be performed based on the availability of funding 
m- If no blood exists from a selected patient, or the blood was of poor quality, Karmanos study personnel will 
recontact the patient to obtain new informed consent and draw a new blood sample. 
n- For patients that have been on study longer than 2 years, office visits can be done every 12 weeks (±7 days), 
with medical history, concurrent meds, physical exam, vital signs, weight, performance status, and adverse 
events evaluation done also at that time  
o- For patients that have been on study longer than 2 years, hematology labs and serum chemistry can be done 
every 6 weeks (±7 days) 
p- For patients that have been on study longer than 2 years, tumor measurements can be done every 24 weeks 
(±10 days) 
 


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10. 
MEASUREMENT OF EFFECT 
For the purposes of this study, patients should be re-evaluated for response every 8   weeks. 
Patients may receive scans every 3 cycles/12 weeks (± 1 week) after completing 6 months of 
treatment on study.  Patients that have been on study longer than 2 years can have tumor 
measurements (CT scans or MRI) done every 24 weeks (±10 days). In addition to a baseline 
scan, confirmatory scans should also be obtained 4 (not less than 4) weeks following initial 
documentation of objective response.  
 
10.1 Definitions 
Response and progression will be evaluated in this study using the new international 
criteria proposed by the revised Response Evaluation Criteria in Solid Tumors 
(RECIST) guideline (version 1.1) (58).  Changes in the largest diameter 
(unidimensional measurement) of the tumor lesions and the shortest diameter in the 
case of malignant lymph nodes are used in the RECIST criteria. 
 
10.1.1 Definitions 
Evaluable for toxicity.  All patients will be evaluable for toxicity from the time of 
their first treatment with vorinostat. 
 
Evaluable for objective response.  Only those patients who have measurable 
disease present at baseline, have received at least one cycle of therapy, and have 
had their disease re-evaluated will be considered evaluable for response.  These 
patients will have their response classified according to the definitions stated 
below.  (Note:  Patients who exhibit objective disease progression prior to the end 
of cycle 1 will also be considered evaluable.) 
 
Evaluable Non-Target Disease Response.  Patients who have lesions present at 
baseline that are evaluable but do not meet the definitions of measurable disease, 
have received at least one cycle of therapy, and have had their disease re-
evaluated will be considered evaluable for non-target disease.  The response 
assessment is based on the presence, absence, or unequivocal progression of the 
lesions.  
 
10.1.2 Disease Parameters 
Measurable disease.  Measurable lesions are defined as those that can be 
accurately measured in at least one dimension (longest diameter to be recorded) as 
>20 mm by chest x-ray, as >10 mm with CT scan, or >10 mm with calipers by 
clinical exam.  All tumor measurements must be recorded in millimeters (or 
decimal fractions of centimeters). 
 
Note:  Tumor lesions that are situated in a previously irradiated area might or 
might not be considered measurable.  
 
Malignant lymph nodes.  To be considered pathologically enlarged and 
measurable, a lymph node must be >15 mm in short axis when assessed by CT 


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scan (CT scan slice thickness recommended to be no greater than 5 mm).  At 
baseline and in follow-up, only the short axis will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small 
lesions (longest diameter <10 mm or pathological lymph nodes with ≥ 10 to <15 
mm short axis), are considered non-measurable disease.  Bone lesions, 
leptomeningeal disease, ascites, pleural/pericardial effusions, lymphangitis 
cutis/pulmonitis, inflammatory breast disease, and abdominal masses (not 
followed by CT or MRI), are considered as non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple 
cysts should not be considered as malignant lesions (neither measurable nor non-
measurable) since they are, by definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as 
measurable lesions, if they meet the definition of measurability described above. 
However, if non-cystic lesions are present in the same patient, these are preferred 
for selection as target lesions. 
 
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ 
and 5 lesions in total, representative of all involved organs, should be identified as 
target lesions and recorded and measured at baseline.  Target lesions should be 
selected on the basis of their size (lesions with the longest diameter), be 
representative of all involved organs, but in addition should be those that lend 
themselves to reproducible repeated measurements.  It may be the case that, on 
occasion, the largest lesion does not lend itself to reproducible measurement in 
which circumstance the next largest lesion which can be measured reproducibly 
should be selected.  A sum of the diameters (longest for non-nodal lesions, short 
axis for nodal lesions) for all target lesions will be calculated and reported as the 
baseline sum diameters.  If lymph nodes are to be included in the sum, then only 
the short axis is added into the sum.  The baseline sum diameters will be used as 
reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 
 
Non-target lesions.  All other lesions (or sites of disease) including any 
measurable lesions over and above the 5 target lesions should be identified as 
non-target lesions and should also be recorded at baseline.  Measurements of 
these lesions are not required, but the presence, absence, or in rare cases 
unequivocal progression of each should be noted throughout follow-up.  
 
10.1.3 Methods 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 4 weeks before the beginning of 
the treatment. 


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The same method of assessment and the same technique should be used to 
characterize each identified and reported lesion at baseline and during follow-up. 
Imaging-based evaluation is preferred to evaluation by clinical examination 
unless the lesion(s) being followed cannot be imaged but are assessable by 
clinical exam. 
 
Clinical lesions  Clinical lesions will only be considered measurable when they 
are superficial (e.g., skin nodules and palpable lymph nodes) and ≥10 mm 
diameter as assessed using calipers (e.g., skin nodules).  In the case of skin 
lesions, documentation by color photography, including a ruler to estimate the 
size of the lesion, is recommended.  
 
Chest x-ray  Lesions on chest x-ray are acceptable as measurable lesions when 
they are clearly defined and surrounded by aerated lung.  However, CT is 
preferable.  
 
Conventional CT and MRI  This guideline has defined measurability of lesions on 
CT scan based on the assumption that CT slice thickness is 5 mm or less.  If CT 
scans have slice thickness greater than 5 mm, the minimum size for a measurable 
lesion should be twice the slice thickness.  MRI is also acceptable in certain 
situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and 
temporal resolution; however, there are many image acquisition variables 
involved in MRI, which greatly impact image quality, lesion conspicuity, and 
measurement.  Furthermore, the availability of MRI is variable globally.  As with 
CT, if an MRI is performed, the technical specifications of the scanning 
sequences used should be optimized for the evaluation of the type and site of 
disease.  Furthermore, as with CT, the modality used at follow-up should be the 
same as was used at baseline and the lesions should be measured/assessed on the 
same pulse sequence.  It is beyond the scope of the RECIST guidelines to 
prescribe specific MRI pulse sequence parameters for all scanners, body parts, 
and diseases.  Ideally, the same type of scanner should be used and the image 
acquisition protocol should be followed as closely as possible to prior scans.  
Body 
scans should be performed with breath-hold scanning techniques, if possible. 
 
PET-CT  At present, the low dose or attenuation correction CT portion of a 
combined PET-CT is not always of optimal diagnostic CT quality for use with 
RECIST measurements.  However, if the site can document that the CT 
performed as part of a PET-CT is of identical diagnostic quality to a diagnostic 
CT (with IV and oral contrast), then the CT portion of the PET-CT can be used 
for RECIST measurements and can be used interchangeably with conventional 
CT in accurately measuring cancer lesions over time.  Note, however, that the 


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PET portion of the CT introduces additional data which may bias an investigator 
if it is not routinely or serially performed.   
 
Ultrasound  Ultrasound is not useful in assessment of lesion size and should not 
be used as a method of measurement.  Ultrasound examinations cannot be 
reproduced in their entirety for independent review at a later date and, because 
they are operator dependent, it cannot be guaranteed that the same technique and 
measurements will be taken from one assessment to the next.  If new lesions are 
identified by ultrasound in the course of the study, confirmation by CT or MRI is 
advised.  If there is concern about radiation exposure at CT, MRI may be used 
instead of CT in selected instances. 
 
Endoscopy, Laparoscopy  The utilization of these techniques for objective tumor 
evaluation is not advised.  However, such techniques may be useful to confirm 
complete pathological response when biopsies are obtained or to determine 
relapse in trials where recurrence following complete response (CR) or surgical 
resection is an endpoint. 
 
Tumor markers  Tumor markers alone cannot be used to assess response.  If 
markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response.  Specific guidelines for 
both CA-125 response (in recurrent ovarian cancer) and PSA response (in 
recurrent prostate cancer) have been published [JNCI 96:487-488, 2004; J Clin 
Oncol 17, 3461-3467, 1999; J Clin Oncol 26:1148-1159, 2008].  In addition, the 
Gynecologic Cancer Intergroup has developed CA-125 progression criteria which 
are to be integrated with objective tumor assessment for use in first-line trials in 
ovarian cancer [JNCI 92:1534-1535, 2000]. 
 
Cytology, Histology  These techniques can be used to differentiate between 
partial responses (PR) and complete responses (CR) in rare cases (e.g., residual 
lesions in tumor types, such as germ cell tumors, where known residual benign 
tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears 
or worsens during treatment when the measurable tumor has met criteria for 
response or stable disease is mandatory to differentiate between response or stable 
disease (an effusion may be a side effect of the treatment) and progressive 
disease. 
 
FDG-PET  While FDG-PET response assessments need additional study, it is 
sometimes reasonable to incorporate the use of FDG-PET scanning to 
complement CT scanning in assessment of progression (particularly possible 'new' 
disease).  New lesions on the basis of FDG-PET imaging can be identified 
according to the following algorithm:  
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a 


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sign of PD based on a new lesion. 
b. No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the 
positive FDG-PET at follow-up corresponds to a new site of disease 
confirmed by CT, this is PD.  If the positive FDG-PET at follow-up is not 
confirmed as a new site of disease on CT, additional follow-up CT  scans 
are needed to determine if there is truly progression occurring at that site 
(if so, the date of PD will be the date of the initial abnormal FDG-PET 
scan).  If the positive FDG-PET at follow-up corresponds to a pre-existing 
site of disease on CT that is not progressing on the basis of the anatomic 
images, this is not PD. 
c. FDG-PET may be used to upgrade a response to a CR in a manner similar 
to a biopsy in cases where a residual radiographic abnormality is thought 
to represent fibrosis or scarring.  The use of FDG-PET in this 
circumstance should be prospectively described in the protocol and 
supported by disease-specific medical literature for the indication.  
However, it must be acknowledged that both approaches may lead to false 
positive CR due to limitations of FDG-PET and biopsy 
resolution/sensitivity. 
  
 Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an 
uptake greater than twice that of the surrounding tissue on the attenuation 
corrected image. 
 
10.1.4 Response Criteria 
 
10.1.4.1 
Evaluation of Target Lesions 
 
Complete Response (CR): 
Disappearance of all target lesions.  Any 
pathological lymph nodes (whether target or 
non-target) must have reduction in short axis 
to <10 mm. 
 
Partial Response (PR): 
At least a 30% decrease in the sum of the 
diameters of target lesions, taking as 
reference the baseline sum diameters 
 
Progressive Disease (PD): 
At least a 20% increase in the sum of the 
diameters of target lesions, taking as 
reference the smallest sum on study (this 
includes the baseline sum if that is the 
smallest on study).  In addition to the 
relative increase of 20%, the sum must also 
demonstrate an absolute increase of at least 
5 mm.  (Note:  the appearance of one or 
more new lesions is also considered 


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progressions). 
 
Stable Disease (SD): 
Neither sufficient shrinkage to qualify for 
PR nor sufficient increase to qualify for PD, 
taking as reference the smallest sum 
diameters while on study 
 
10.1.4.2 
Evaluation of Non-Target Lesions 
 
Complete Response (CR): 
Disappearance of all non-target lesions and 
normalization of tumor marker level.  All 
lymph nodes must be non-pathological in 
size (<10 mm short axis) 
 
Note:  If tumor markers are initially above 
the upper normal limit, they must normalize 
for a patient to be considered in complete 
clinical response. 
 
Non-CR/Non-PD:  
Persistence of one or more non-target 
lesion(s) and/or maintenance of tumor 
marker level above the normal limits 
 
Progressive Disease (PD): 
Appearance of one or more new lesions 
and/or unequivocal progression of existing 
non-target lesions.  Unequivocal progression 
should not normally trump target lesion 
status.  It must be representative of overall 
disease status change, not a single lesion 
increase.     
Although a clear progression of “non-target” lesions only is exceptional, 
the opinion of the treating physician should prevail in such circumstances, 
and the progression status should be confirmed at a later time by the 
review panel (or Principal Investigator). 
 
10.1.4.3 
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. 
 
For Patients with Measurable Disease (i.e., Target Disease) 
 


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


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Duration of stable disease:  Stable disease is measured from the start of the 
treatment until the criteria for progression are met, taking as reference the 
smallest measurements recorded since the treatment started, including the baseline 
measurements.  
 
10.1.6 Progression-Free Survival 
Progression-Free Survival (PFS) is defined as the duration of time from start of 
treatment to time of progression or death, whichever occurs first. 
 
10.2 
Other Response Parameters 
10.2.1 Time to Response (TTR) 
TTR is measured from the start of the treatment until the RECIST measurement 
criteria are met for CR or PR (whichever is first recorded).   TTR only applies to 
the patients achieving either PR or CR, and involves no censoring. 
 
10.2.2 Overall Survival (OS) 
OS is measured from the start of treatment until death from any cause. OS is 
subject to censoring. 
 
10.3  Response Review 
We do not routinely mark scans and will encourage all sites that submit radiographic 
images to submit unmarked images. After the initial patient recruitment, we will use 
an outside radiologist to review the scans prior to going to the second phase. If the 
decision is made to proceed to the second phase, an outside radiologist will look at all 
images at protocol completion. 
 
 
 
11. REGULATORY AND REPORTING REQUIREMENTS 
 
Expedited adverse event (AE) reporting for this study is via CTEP-AERS (CTEP 
Adverse Event Reporting System ), accessed via the secure CTEP web site(https://eapps-
ctep.nci.nih.gov/ctepaers).  The reporting procedures to be followed are presented in the “CTEP, 
NCI Guidelines: Adverse Event Reporting Requirements”” which can be downloaded from the 
CTEP web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm).  
 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0 will be utilized for adverse event reporting.  All 
appropriate treatment areas should have access to a copy of the CTCAE version 4.0.  A copy of 
the CTCAE version 4.0 can be downloaded from the CTEP web site (http://ctep.cancer.gov). 
 
A list of adverse events that have occurred or might occur (Comprehensive Adverse Events 
and Potential Risks list) can be found in Section 7 (Pharmaceutical Information).  A copy of the 


49 
 
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current Agent-Specific Adverse Event List (ASAEL) is sent with LOI approval letters.  The 
ASAEL is updated periodically; copies of the updated list are available on request via e-mail 
from aemd@tech-res.com.   
 
11.1 Expedited Adverse Event Reporting 
(AE; formerly known as Adverse Drug Reaction) 
 
Expedited reports are submitted to CTEP via the secure CTEP-AERS application 
accessed via the CTEP web site (https://eapps-ctep.nci.nih.gov/ctepaers).  Those AEs that do not 
require expedited reporting must be reported in routine (CDUS) study data submissions.  AEs 
reported through CTEP-AERS must also be reported in routine study data submissions. In the 
rare event when Internet connectivity is disrupted a 24-hour notification is to be made to NCI by 
telephone at:  301-897-7497, or 301-897-7402 for CIP studies.  An electronic report MUST be 
submitted immediately upon re-establishment of internet connection.  Please note that all paper 
CTEP-AERS forms have been removed from the CTEP website and will NO LONGER be 
accepted.   
 
 
11.1.1 Expedited Reporting Guidelines –  
Phase 2 studies with investigational agents (including hospitalization defined in bullet 1 
below) 
 
CTEP-AERS Reporting Requirements for Adverse Events that occur within 30 Days1 of the 
Last Dose of the Investigational Agent on Phase 2 and 3 Trials 
 
Phase 2 and 3 Trials
 
Grade 1 
Grade 2 
Grade 2 
Grade 3 
Grade 3 
Grades
4 & 52 
Grades
4 & 52 
Unexpected 
and 
Expected 
Unex-
pected 
 
Expected
Unexpected
Expected
Unex- 
pected  
Expected 
with 
Hospitali-
zation 
without 
Hospitali- 
zation 
with 
Hospitali-
zation 
without 
Hospitali-
zation 
Unrelated
Unlikely 
Not 
Required 
Not 
Required
Not 
Required
10 
Calendar 
Days 
Not 
Required 
10 
Calendar
Days 
Not 
Required 
10 
Calendar 
Days 
10 
Calendar 
Days 
Possible
Probable
Definite 
Not 
Required 
10 
Calendar
Days 
Not 
Required
10 
Calendar 
Days 
10 
Calendar 
Days 
10 
Calendar
Days 
Not 
Required 
24-Hour; 
5 Calendar 
Days 
10 
Calendar 
Days 
1 Adverse events with attribution of possible, probable, or definite that occur greater than 30 days after the last 
dose of treatment with an agent under a CTEP IND require reporting as follows: 
CTEP-AERS 24-hour notification followed by complete report within 5 calendar days for: 
• 
Grade 4 and Grade 5 unexpected events  
 
CTEP-AERS 10 calendar day report: 
• 
Grade 3 unexpected events with hospitalization or prolongation of hospitalization 
• 
Grade 5 expected events 
2 Although an CTEP-AERS 24-hour notification is not required for death clearly related to progressive disease, a full report 
is required as outlined in the table. 
December 15, 2004
 


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Note:  All deaths on study require both routine and expedited reporting regardless of causality.  
Attribution to treatment or other cause must be provided. 
 
• 
Expedited AE reporting timelines defined: 
 “24 hours; 5 calendar days” – The investigator must initially report the AE via 
CTEP-AERS within 24 hours of learning of the event followed by a complete 
CTEP-AERS report within 5 calendar days of the initial 24-hour report. 
 “10 calendar days” - A complete CTEP-AERS report on the AE must be 
submitted within 10 calendar days of the investigator learning of the event.  
 
• 
Any medical event equivalent to CTCAE grade 3, 4, or 5 that precipitates 
hospitalization (or prolongation of existing hospitalization) must be reported 
regardless of attribution and designation as expected or unexpected with the 
exception of any events identified as protocol-specific expedited adverse event 
reporting exclusions.   
 
• 
Any event that results in persistent or significant disabilities/incapacities, 
congenital anomalies, or birth defects must be reported via CTEP-AERS if the 
event occurs following treatment with an agent under a CTEP IND. 
 
• 
Use the NCI protocol number and the protocol-specific patient ID assigned during 
trial registration on all reports.   
 
11.1.2 Expedited Adverse Event Reporting Exclusions 
 
 
 
N/A 
 
Note:  All deaths on study must be reported using expedited reporting regardless of 
causality.  Attribution to treatment or other cause should be provided. 
 
11.1.3 Secondary AML/MDS 
 
Investigators are required to report cases of secondary AML/MDS occurring on or 
following treatment on NCI-sponsored chemotherapy protocols through CTEP-AERS. If Please 
refer to the CTEP, NCI Guidelines (available at htpp://ctep.cancer.gov) for additional 
information about secondary AML/MDS reporting. 
 
Second malignancies and non-AML/MDS secondary malignancies (e.g., endometrial cancer 
in a breast cancer patient receiving tamoxifen) should NOT be reported via CTEP-AERS but 
should be submitted as part of the study results via routine CDUS reporting. 
 
11.2 Data Reporting 
 
This study will be monitored by the Clinical Data Update System (CDUS) version 3.0.  
Cumulative CDUS data will be submitted quarterly to CTEP by electronic means.  Reports are 


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Version Date: 08/16/16 
 
due January 31, April 30, July 31, and October 31. 
 
 
11.3 CTEP Multicenter Guidelines 
 
If an institution wishes to collaborate with other participating institutions in performing a 
CTEP sponsored research protocol, then the following guidelines must be followed. 
 
Responsibility of the Protocol Chair  
• The Protocol Chair will be the single liaison with the CTEP Protocol and Information 
Office (PIO).  The Protocol Chair is responsible for the coordination, development, 
submission, and approval of the protocol as well as its subsequent amendments.  The 
protocol must not be rewritten or modified by anyone other than the Protocol Chair.  
There will be only one version of the protocol, and each participating institution will use 
that document.  The Protocol Chair is responsible for assuring that all participating 
institutions are using the correct version of the protocol. 
• The Protocol Chair is responsible for the overall conduct of the study at all participating 
institutions and for monitoring its progress.  All reporting requirements to CTEP are the 
responsibility of the Protocol Chair.  
• The Protocol Chair is responsible for the timely review of Adverse Events (AE) to assure 
safety of the patients. 
• The Protocol Chair will be responsible for the review of and timely submission of data 
for study analysis. 
 
Responsibilities of the Coordinating Center 
• Each participating institution will have an appropriate assurance on file with the Office 
for Human Research Protection (OHRP), NIH.  The Coordinating Center is responsible 
for assuring that each participating institution has an OHRP assurance and must maintain 
copies of IRB approvals from each participating site.  
• Prior to the activation of the protocol at each participating institution, an OHRP form 310 
(documentation of IRB approval) must be submitted to the CTEP PIO. 
• The Coordinating Center is responsible for central patient registration.  The Coordinating 
Center is responsible for assuring that IRB approval has been obtained at each 
participating site prior to the first patient registration from that site. 
• The Coordinating Center is responsible for the preparation of all submitted data for 
review by the Protocol Chair. 
• The Coordinating Center will maintain documentation of AE reports.  There are two 
options for AE reporting: (1) participating institutions may report directly to CTEP with a 
copy to the Coordinating Center, or (2) participating institutions report to the 
Coordinating Center who in turn report to CTEP.  The Coordinating Center will submit 
AE reports to the Protocol Chair for timely review. 
• Audits may be accomplished in one of two ways:  (1) source documents and research 
records for selected patients are brought from participating sites to the Coordinating 
Center for audit, or (2) selected patient records may be audited on-site at participating 


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sites.  If the NCI chooses to have an audit at the Coordinating Center, then the 
Coordinating Center is responsible for having all source documents, research records, all 
IRB approval documents, NCI Drug Accountability Record forms, patient registration 
lists, response assessments scans, x-rays, etc. available for the audit. 
 
Inclusion of Multicenter Guidelines in the Protocol 
• The protocol must include the following minimum information:  
 The title page must include the name and address of each participating institution and the 
name, telephone number and e-mail address of the responsible investigator at each 
participating institution. 
 The Coordinating Center must be designated on the title page. 
 Central registration of patients is required.  The procedures for registration must be stated 
in the protocol. 
 Data collection forms should be of a common format.  Sample forms should be submitted 
with the protocol.  The frequency and timing of data submission forms to the 
Coordinating Center should be stated. 
 Describe how AEs will be reported from the participating institutions, either directly to 
CTEP or through the Coordinating Center.  
 
Agent Ordering 
• Except in very unusual circumstances, each participating institution will order DCTD-
supplied investigational agents directly from CTEP.  Investigational agents may be 
ordered by a participating site only after the initial IRB approval for the site has been 
forwarded by the Coordinating Center to the CTEP PIO.  
 
 
11.4 Cooperative Research and Development Agreement (CRADA)/Clinical Trials 
Agreement (CTA) 
 
The agent(s), supplied by CTEP, DCTD, NCI, used in this protocol is/are provided to the 
NCI under a Collaborative Agreement (CRADA, CTA) between the Merck Pharmaceutical 
Company [hereinafter referred to as Collaborator] and the NCI Division of Cancer Treatment 
and Diagnosis.  Therefore, the following obligations/guidelines, in addition to the provisions in 
the Intellectual Property Option to Collaborator contained within the terms of award, apply to 
the use of Agent(s) in this study: 
 
1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor can 
Agent(s) be transferred or licensed to any party not participating in the clinical study.  
Collaborator(s) data for Agent(s) are confidential and proprietary to Collaborator(s) and shall be 
maintained as such by the investigators.  The protocol documents for studies utilizing 
investigational agents contain confidential information and should not be shared or distributed 
without the permission of the NCI.  If a copy of this protocol is requested by a patient 
participating on the study or patient’s family member, the individual should sign a confidentiality 
agreement.  A suitable model agreement can be downloaded from http://ctep.cancer.gov. 
 


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2. For a clinical protocol where there is an investigational Agent used in combination with 
(an)other investigational Agent(s), each the subject of different collaborative agreements, the 
access to and use of data by each Collaborator shall be as follows (data pertaining to such 
combination use shall hereinafter be referred to as "Multi-Party Data”.): 
 
a. NCI must provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NIH, the design of the proposed 
combination protocol, and the existence of any obligations that would tend to restrict NCI's 
participation in the proposed combination protocol. 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator to 
develop, obtain regulatory approval, or commercialize its own investigational agent. 
c. Any Collaborator having the right to use the Multi-Party Data from these trials must 
agree in writing prior to the commencement of the trials that it will use the Multi-Party Data 
solely for development, regulatory approval, and commercialization of its own investigational 
agent. 
 
3. .Clinical Trial Data and Results and Raw Data developed under a Collaborative 
Agreement will be made available exclusively to Collaborator(s), the NCI, and the FDA, as 
appropriate and unless additional disclosure is required by law or court-order. Additionally, all 
Clinical Trial Data and Results and Raw Data will be collected, used and disclosed consistent 
with all applicable federal statutes and regulations for the protection of human subjects, 
including, if applicable, the Standards for Privacy of Individually Identifiable Health Information 
set forth in 45 C.F.R. Part 164. 
 
4. When a Collaborator wishes to initiate a data request, the request should first be sent to 
the NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them. 
 
5. Any data provided to Collaborator(s) for phase 3 studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a DMC 
for this clinical trial. 
 
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP 
for immediate delivery to Collaborator(s) for advisory review and comment prior to submission 
for publication.  Collaborator(s) will have 30 days from the date of receipt for review.  
Collaborator shall have the right to request that publication be delayed for up to an additional 30 
days in order to ensure that Collaborator’s confidential and proprietary data, in addition to 
Collaborator(s)’s intellectual property rights, are protected.  Copies of abstracts must be provided 
to CTEP for forwarding to Collaborator(s) for courtesy review as soon as possible and preferably 
at least three (3) days prior to submission, but in any case, prior to presentation at the meeting or 
publication in the proceedings.  Press releases and other media presentations must also be 
forwarded to CTEP prior to release.  Copies of any manuscript, abstract, and/or press release/ 
media presentation should be sent to: 
 


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Version Date: 08/16/16 
 
 
Regulatory Affairs Branch, CTEP, DCTD, NCI 
6130 Executive Boulevard, Suite 7111 
Rockville, MD  20852 
FAX 301-402-1584 
 
  E-mail: ncicteppubs@mail.nih.gov 
 
The Regulatory Affairs Branch will then distribute them to Collaborator(s).  No 
publication, manuscript or other form of public disclosure shall contain any of Collaborator’s 
confidential/proprietary information. 
 
 
12. 
STATISTICAL CONSIDERATIONS 
 
12.1 Study Design/Endpoints 
 
12.1.1. Study Design: 
We will use a 2-stage Simon (1989) optimal design to minimize the number of patients to 
be treated.  Complete + partial (CR+PR) rate will be the primary statistical endpoint.  We wish to 
distinguish response rate regions of at most 5% vs. at least 20%.   For this 2-stage design its 
Stage 1 will require 12 response-evaluable (r-e) patients.  At least 1 responder in Stage 1 will be 
needed to justify continuing to Stage 2, which will require 17 more r-e patients (i.e., maximum of 
N=29 r-e patients for the study). If ≥ 3 responders are observed among the final 29 r-e patients, 
then vorinostat will be considered promising.   If < 3, conclude that vorinostat has insufficient 
efficacy to justify further study.     This design specifies significance level = 0.15, and power = 
0.90, and has a probability of early termination (PET) = 0.540 under the null hypothesis.  Alpha 
is relaxed in this design since there are no effective therapies available, but beta is limited to 0.10 
to better ensure that we identify vorinostat as a promising therapy, if it truly is one. 
 
In ACC, late responses (by RECIST) may occur; hence we anticipate the need to suspend 
accrual after 12 r-e patients have been enrolled for Stage 1. Among stable disease patients still on 
vorinostat treatment, responses could occur as long as one year after treatment started. Should 
vorinostat have little efficacy, disease progression among the Stage 1 patients will be more rapid, 
thus limiting the time until study termination can be justified based on the Stage 1 response 
results.    
 
12.1.2 Study Endpoints: 
The primary endpoint is objective response based on RECIST 1.1 criteria.  Response 
criteria and categories are defined in detail in Sections 10.1.1-10.1.4. 
 
Secondary endpoints include toxicity, time to response (TTR), response duration (RD), 
progression free survival (PFS), and overall survival (OS).   Definition, assessment, and 
reporting of toxicity (adverse events) may be found in Sections 6.1, or 10.   TTR, RD, PFS, and 
OS are defined in Sections 10.2.1, 10.1.5, 10.1.6, and 10.2.2, respectively. 


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Exploratory endpoints include metabolic response by PET/CT scan, and several laboratory 
biomarkers listed in Section 1.3 (Exploratory Objectives), and described in Section 8 and in the 
Appendix D. 
 
12.2  Sample Size/Accrual Rate 
We anticipate an accrual rate of 1-2 ACC patients/month from the 10 organ dysfunction 
working group institutions combined.  That would yield an expected combined accrual rate of 
12-24 patients/year.  At that rate, 12 r-e patients should be accrued in 6-12 months.  Allowing for 
up to 12 additional months for the discovery of late responders, a Stage 1 interim analysis result 
should be obtainable within 18-24 months from the time the first patient begins treatment. 
 
If Stage 2 is needed (i.e., an additional 17 r-e patients), that should take an additional 9-17 
months of accrual, plus up to 12 additional months for the discovery of late responders.  Thus, a 
final analysis result at the end of Stage 2 (if Stage 2 is needed) should be obtainable within 39-54 
months from the time the first patient begins treatment.     
 
12.3  Stratification Factors 
None, as this is a single sample Phase II trial.   Any stratification of interest can be performed 
at the time of statistical analysis, after the study data have been collected. 
 
12.3.1  Gender and Minority Accrual Estimates 
 
 
  Phase II Study:   Stage 1 / Stage 2 Accrual Estimates     
Ethnic Category 
Sex/Gender 
Females 
Males 
Total 
Hispanic or Latino 
0 
+
0 
=
0 
Not Hispanic or Latino 
7 / 18 
+
5 / 11 
=
12 / 29 
Ethnic Category: Total of all subjects 
7 / 18   (A1) 
+
5 / 11   (B1) 
=
12 / 29 
(C1) 
Racial Category 
 
American Indian or Alaskan Native 
0 
+
0 
=
 
Asian 
0 
+
0 
=
 
Black or African American 
1 / 2 
+
0 
=
   1 /  2 
Native Hawaiian or other Pacific Islander 
0 
+
0 
=
 
White 
                6  /  16 
+
           5  /  11 
=
11  /  27 
Racial Category: Total of all subjects 
       7 /   18   (A2) 
+
 5  /  11   (B2) 
=
12  /  29 
 (C2) 
 
(A1 = A2) 
(B1 = B2) 
(C1 = C2) 
 
 
 
12.4  Analysis of Secondary Endpoints 
 


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There are 5 Secondary Objectives: 
 
1) To characterize the safety and tolerability of vorinostat in this patient population 
 
2) To assess the time to response (TTR) 
 
3) To assess the response duration (RD) 
 
4) To evaluate progression free survival (PFS) 
 
5) To assess overall survival (OS) 
 
  
 
Secondary Objective 1 concerns toxicity and adverse events, hence will involve 
categorical variables.   They will be tabulated via frequency distributions, and also dichotomized 
to report the proportion (and percentage) of patients experiencing a specified level (e.g., Grade 3-
4) of toxicity.   Analysis of these proportions (i.e., rates) will include both point and 90% 
confidence interval (CI) estimates, with the CI estimates calculated via Wilson’s method.   The 
90% confidence level is appropriate for either the Stage 1 sample size (n=12) or even the Stage 2 
sample size (n=29) planned for this Phase II trial. 
 
Secondary Objective 2 concerns TTR, which is a continuous variable not subject to 
censoring.   It will be summarized descriptively, reporting N, median, mean, standard deviation 
(SD), standard error (SE), minimum, maximum, and 90% CI for the mean calculated from the 
SE and asymptotic Normal distribution theory. 
 
Secondary Objectives 3-5 concern censored time-to-event (TTE) endpoints.   Their 
distribution will be estimated using standard survival analysis techniques, and the Kaplan-Meier 
(K-M) method.   From the K-M life tables, both point and 90% CI estimates of various statistics 
of interest can be calculated (e.g., median, 6-month event-free rate, 12-month event-free rate, 
etc.).  Statistical graphs of each K-M curve (with 90% CI lines) will be generated for visual 
display of these censored TTE endpoints. 
 
 
There are 7 Exploratory Objectives: 
 
1) To assess the association between a metabolic response by PET/CT after one cycle of 
chemotherapy and subsequent best tumor response according to standard anatomic response 
evaluation criteria (RECIST). 
 
2) To assess the association between a metabolic response by PET/CT after the first and second 
chemotherapy cycle and PFS. 
 
3) Flow sort diploid, aneuploid, and tetraploid populations of tumor cells from FFPE tissue 
blocks from patients who benefited from SAHA therapy and from patients who did not 
demonstrate a durable benefit.  
 
4) Profile the genomes of each cell population using oligonucleotide CGH arrays. This will 
confirm the identification of tumor populations in each sample and provide genomic landmarks 


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for NGS analysis.  
 
5) Perform whole exome analysis of the sorted tumor population and matching germ line sample 
for each of the patients. The combined aCGH and exome data will be mined to identify genes 
and pathways that are targeted by select somatic events in each of the patient subsets 
 
6)  To assess stable disease duration (SDD). 
 
7)  To assess the association between response to vorinostat treatment and HR23B on tumor 
paraffin blocks. 
 
 
Exploratory Objective 1 concerns the potential association of PET/CT response 
(magnitude of decrease in SUV after 1 treatment cycle) with clinical response by RECIST 1.1 
criteria.   Percent change in SUV (∆SUV) is a continuous variable, whereas objective response is 
a categorical (typically, binary) variable.   First, we will use receiver operator characteristic 
(ROC) curve analysis to determine the optimal cutoff in the distribution of ∆SUV, in relationship 
to objective response (yes/no).   That will allow us to define “PET response”.  We will also 
compare the descriptive statistics of the ∆SUV distribution in the RECIST responders vs non-
responders. At Stage 1 (n=12), the association of ∆SUV with subsequent best tumor response 
will be explored in a simple 2 x 2 contingency table, with point and 90% CI estimates of 
objective response rates among the patients with vs. without PET response. Descriptively only, 
we can then examine the point and CI estimates to see if there is a hint of any association. At 
Stage 2 (n=29), we would repeat the same descriptive, exploratory investigation, and then 
determine what, if any, additional statistical analysis might be appropriate.   For example, that 
might involve exact logistic regression to model the log-odds of later objective response as a 
function of only one predictor:  early PET response (yes/no).   This exact logistic modeling 
investigation would still be viewed as exploratory only, but would yield a point and 90% CI 
estimate of the odds ratio for response. 
 
Exploratory Objective 2 concerns the potential association of PET/CT response 
(magnitude of decrease in SUV after 1 treatment cycle) with censored PFS. “PET response” 
(yes/no) will be determined as just described above for Exploratory Objective 1. At Stage 1 
(n=12), to explore the potential association of PET/CT response with length of censored PFS, we 
will use the Cox proportional hazards model.   This analysis will focus on the length of PFS after 
the second PET/CT scan, and will be exploratory only.   The goal would be to determine if there 
is any hint of a potential positive association in the hypothesized direction, i.e., is the hazard 
ratio (HR) < 1 or not for patients with an early PET/CT response. At Stage 2 (n=29), we would 
repeat the same Cox model investigation, but pay more attention to the magnitude of (HR), its 
precision (i.e., half-width of it 90% CI), but not its statistical significance (i.e., p-value). Again, 
this Cox modeling investigation would still be viewed as exploratory only. A similar analysis 
will be performed utilizing the third PET/CT scan, taken after 2 treatment cycles, at day 56. 
 
 


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Exploratory Objectives 3, 4 and 5 are strictly exploratory and will be reported as 
descriptive results 
 
            Exploratory Objective 6 concerns yet another time-to-event endpoint (SDD), which is 
defined in Section 10.1.5.    The analysis of the censored SDD distribution will use the same 
approach as described above for Secondary Objectives 3-5.  
 
Exploratory Objective 7 concerns a biomarker (HR23B), measured by 
immunohistochemistry (IHC).  Its expression level will be recorded as:  0,  1+,  2+,  or 3+.   In 
light of the small to modest sample sizes for this Phase II trial (either n=12 after Stage 1, or n=29 
after Stage 2), we will dichotomize the total staining score (TSS) of HR23B into ≥ 6 (“positive”) 
or < 6 (“negative”). 
 At Stage 1 (n=12), the association of  HR23B’s dichotomized expression level 
(absence/presence) to objective response (yes/no) can be explored via a simple 2 x 2 contingency 
table. From the table we can compute the point and 90% CI estimates of response rates among 
the patients who do vs. those who do not “express” HR23B.  The most basic exploratory 
observation will be the direction of the association, i.e., whether the point-estimate of response 
rate is higher (or lower) among expressers of HR23B.     We can also observe the precision in the 
estimate of the response rate via its CI.    
 At Stage 2 (n=29), we would repeat the same descriptive, exploratory investigation, and 
then determine what, if any, additional statistical analysis might be appropriate. For example, 
that might involve exact logistic regression to model the log-odds of later objective response as a 
function   “expression” of HR23B (yes/no). This exact logistic modeling investigation would still 
be viewed as exploratory only, but would yield a point and 90% CI estimate of the odds ratio for 
response. 
 
 
12.5 Reporting and Exclusions 
 
12.5.1 Evaluation of Toxicity.   
All patients will be evaluable for toxicity from the time of their first treatment with 
vorinostat. 
 
12.5.2 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 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) should be included in the main analysis of the response rate.  
Patients in response categories 4-9 should be considered as failing to respond to treatment 
(disease progression).  Thus, an incorrect treatment schedule or drug administration does not 


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result in exclusion from the analysis of the response rate.  Precise definitions for categories 4-9 
will be protocol specific.  
 
All conclusions should 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 may not serve as the 
basis for drawing conclusions concerning treatment efficacy, and the reasons for excluding 
patients from the analysis should be clearly reported.  The 95% confidence intervals should also 
be provided.  
 
REFERENCES 
 
1. 
Ward, M., Levine, PA. (1998) Salivary gland tumors. In: Essentials of Head and Neck Oncology, 1st 
edition ed., Thieme, New York, NY  
2. 
Spiro, R. H. (1986) Head Neck Surg 8, 177-184 
3. 
Airoldi M, P. F., Succo G et al. (1991) Cancer 91, 541-547 
4. 
Licitra, L., Marchini, S., Spinazze, S., Rossi, A., Rocca, A., Grandi, C., and Molinari, R. 
(1991) Cancer 68, 1874-1877 
5. 
Airoldi, M., Fornari, G., Pedani, F., Marchionatti, S., Gabriele, P., Succo, G., and 
Bumma, C. (2000) Anticancer Res 20, 3781-3783 
6. 
Gilbert, J., Li, Y., Pinto, H. A., Jennings, T., Kies, M. S., Silverman, P., and Forastiere, 
A. A. (2006) Head Neck 28, 197-204 
7. 
Alberts, D. S., Manning, M. R., Coulthard, S. W., Koopmann, C. F., Jr., and Herman, T. 
S. (1981) Cancer 47, 645-648 
8. 
Creagan, E. T., Woods, J. E., Schutt, A. J., and O'Fallon, J. R. (1983) Cancer 52, 2007-
2010 
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Dreyfuss, A. I., Clark, J. R., Fallon, B. G., Posner, M. R., Norris, C. M., Jr., and Miller, 
D. (1987) Cancer 60, 2869-2872 
10. 
Veenok AP, T. A., Meyers FJ et al. (1987) J Clin Oncol  5, 951-955 
11. 
Hotte, S. J., Winquist, E. W., Lamont, E., MacKenzie, M., Vokes, E., Chen, E. X., 
Brown, S., Pond, G. R., Murgo, A., and Siu, L. L. (2005) J Clin Oncol 23, 585-590 
12. 
Haddad, R., Colevas, A. D., Krane, J. F., Cooper, D., Glisson, B., Amrein, P. C., Weeks, 
L., Costello, R., and Posner, M. (2003) Oral Oncol 39, 724-727 
13. 
Agulnik, M., Cohen, E. W., Cohen, R. B., Chen, E. X., Vokes, E. E., Hotte, S. J., 
Winquist, E., Laurie, S., Hayes, D. N., Dancey, J. E., Brown, S., Pond, G. R., Lorimer, I., 
Daneshmand, M., Ho, J., Tsao, M. S., and Siu, L. L. (2007) J Clin Oncol 25, 3978-3984 
14. 
Glisson BS, B. G., Francisco M et al. . (2005) J Clin Oncol 23 
15. 
Locati, L. D., Bossi, P., Perrone, F., Potepan, P., Crippa, F., Mariani, L., Casieri, P., 
Orsenigo, M., Losa, M., Bergamini, C., Liberatoscioli, C., Quattrone, P., Calderone, R. 
G., Rinaldi, G., Pilotti, S., and Licitra, L. (2009) Oral Oncol 45, 574-578 
16. 
Argiris A, G. M., Burtness B et al. . (2006) A Phase II of PS-341 (bortezomib) followed 
by the addition of doxorubicin at progression in incurable adenoid cystic carcinoma of 
the head and neck: and Eastern Cooperative Oncology Group study. . in ASCO Ann Meet 
Proc  


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chromosomes & cancer 51, 805-817 
 
 


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


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APPENDIX B 
PET Imaging Acquisition Parameters and Image Data Analysis 
 
 
Additional information for PET Imaging Acquisition Parameters and Analysis are available on 
the ACRIN web site at (www.acrin.org/6678_protocol.aspx).(76)   
 
Acquisition and Analysis of FDG-PET/CT Scans 
FDG-PET/CT scans will be performed according to the guidelines for NCI-sponsored studies as 
recently published by Shankar et al. (77). 
 
1. Participant Preparation  
Participants must fast for a minimum of 4 hours prior to the injection of FDG for the PET scan. 
However, they will be encouraged to drink water to ensure adequate hydration. 
• Upon arrival at the PET facility, the participant’s weight and height will be measured and 
recorded.  Serum glucose should be measured to determine that the blood glucose 
concentration is within the normal range.  
• If the serum glucose concentration is found to be greater than 150 mg/dL, the study should 
be rescheduled.  The referring oncologist or the primary physician of the patient will be 
contacted to optimize blood glucose control. 
• The participant should be placed in a comfortable position, either supine or semi-
recumbent.  A large-bore intravenous line (21-gauge or greater) should be placed in an 
arm or hand vein.  The room should be kept warm to avoid shivering and temperature 
effects that may increase muscular or fat uptake.  The participant should move as little as 
possible and should not talk more than necessary in the first 30 min following FDG 
injection. 
• Prior to positioning the participant on the PET scanner the participant should be asked to 
urinate.  
 
2. Injection of [18F] Fluorodeoxyglucose (FDG) 
• The dose of FDG to be administered should be 10 to 20 millicuries (mCi), adjusted 
according to weight as suggested by the scanner manufacturer.   
• FDG will be synthesized and prepared in accordance with USP compendial standards.  
• The exact time of calibration of the dose should be recorded and the exact time of 
injection noted to permit correction of the administered dose for radioactive decay.  In 
addition, the dose remaining in the tubing or syringe, or that was spilled during injection 
should be recorded. The injection should be performed through an intravenous catheter.  
 
3. FDG-PET/CT Imaging 


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• PET scanning must begin 60 ± 10 minutes after FDG injection.  The time between 
injection and the start of the PET scanning for the second and third scans should be 
matched as closely as possible to that for the first scan (less than 10 min difference in 
uptake times). 
• Participants will generally be positioned in the PET/CT scanner with their arms raised 
above the head.  If participants cannot tolerate this position for the duration of the PET/CT 
study, a different participant positioning may be chosen.  However, arms should be 
positioned in the same way at the baseline and the follow-up studies. 
• A low-dose CT scan will be acquired for attenuation correction and anatomical 
localization of findings in the PET scan.  
• The acquisition parameter for the low-dose CT scan for attenuation correction should be:  
kV = 120-140; effective mAs = 30-120 (patient dependent); gantry rotation time ≤ 0.8 sec; 
maximum reconstructed width = 3-5 mm without overlap; standard reconstruction 
algorithm, minimum reconstruction diameter = outer arm to outer arm; and without 
iodinated contrast (78). 
• The axial field of view of the CT scan for attenuation correction will range from the mid 
thighs to the base of the skull.  Arm positioning will be the same as for the PET scan, 
typically above the head. 
• The CT scan will be performed during "shallow breathing" as described previously 67.  No 
respiratory gating will be applied. 
• After the CT scan, a PET scan covering the same axial field of view will be performed.  
This scan will start at the mid thighs.  The number of bed positions and the acquisition 
time per bed position will be scanner specific.  Typical parameters are 6 bed positions and 
an acquisition of 2-5 min per bed position. 
 
4. Image Reconstruction 
• The PET data will be corrected for dead time, scatter, randoms and attenuation using 
standard algorithms provided by the scanner manufacturers.  
• Image reconstruction will be performed. 
 
5. Image Analysis  
• Activity concentrations in the attenuation-corrected PET images will be converted to 
standardized uptake values (SUVs) by dividing the activity concentrations by the decay-
corrected injected dose and multiplying with the body weight of the participant. 
• A circular region of interest (ROI) with a diameter of 0.75 to 1.5 cm will be centered at 
the site of maximum FDG uptake within this lesion.  ROIs of the same size will be placed 
in the slices immediately above and below, at the same transverse location.  


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• The average SUV within the volume encompassed by these three ROIs will be 
determined and recorded.  This approach for definition of ROIs has been successfully 
used for assessment of tumor response in patients with advanced NSCLC 63.   
• In most patients the primary tumor will show the highest FDG uptake.  However, in a 
small subgroup of participants the primary tumor may be small (< 2cm) and show only 
low FDG uptake in PET or it may have been resected.  In this case, the metastatic lesion 
with the highest FDG uptake will be used for analysis.   
• For quality control purposes, a large circular ROI (diameter >= 5 cm) will be placed in 
normal liver tissue.  The mean SUV in this ROI will be recorded. 
• In the case of multiple liver metastases, it may not be feasible to place one large ROI in 
normal liver tissues.  In this case, several small ROIs, including the same number of 
pixels as one 5-cm ROI, may be placed in normal liver tissue.  FDG uptake within these 
lesions will be averaged and used for further analysis. 
• If the mean SUV within the liver changes by more than 1.0 between two scans, the SUV 
calculation will be checked for errors.  Specifically, the scanner cross calibration, the 
decay correction of the injected activity, and the participant's body weight will be 
checked (see checklist below for details) 
 
6. Image Interpretation 
• Describe the location of the primary tumor and of metastatic lesions if present. 
• Measure and record the maximum SUV in the primary tumor and most active metastatic 
lesion.   
• If the diameter of the primary tumor is less than 2 cm or the primary tumor demonstrates 
only low FDG uptake, measure the maximum SUV of the lesion with the highest FDG 
uptake. 
• Measure and record the mean SUV in the liver as described in Section 5 above.  


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APPENDIX C 
CT Acquisition Parameters and Image Data Analysis 
 
Additional Information for the CT Acquisition Parameters and Volumetric Analyses are also 
available on the ACRIN web site at (www.acrin.org/6678_protocol.aspx).   
 
Acquisition and Analysis of the CT Scans 
The CT scans serve three purposes: (a) attenuation correction and registration with PET scans for 
anatomic localization of FDG uptake; (b) response assessment using RECIST; and (c) high 
spatial quality data sets for central volumetric analyses of lung lesions.  Depending upon 
considerations of workflow and the need for intravenous contrast, individual institutions may 
have different processes for completing the chest CT scans used for RECIST and tumor 
volumetric assessments.  The following are potential scenarios: 
 Single Platform: fusion PET/CT scanner: All studies are performed on a fusion PET/CT 
scan, including the PET/CT scanner, and one single inspiratory CT without contrast for 
both RECIST criteria and tumor volumetry.   
 Single Platform: fusion PET/CT scanner: All studies are performed on a fusion PET/CT 
scan, including the PET/CT scanner, an inspiratory CT with contrast for RECIST criteria, 
and an inspiratory CT without contrast for tumor volumetry. 
 Dual Platforms:  Fusion PET/CT scanner used to perform a PET/CT scan and an 
inspiratory CT without contrast for tumor volumetry as well as a dedicated, standalone 
CT scanner to perform a CT with contrast for RECIST criteria. 
 
1.  CT Volumetry 
1.1  Image Acquisition 
To ensure the level of spatial quality necessary for tumor volumetric analyses, the scanner 
platforms must be able to perform prospective reconstructions of a single helical sequence at 
different slice thicknesses.  The following are representative PET/CT systems:  
 
 Siemens Biograph PET/CT (CT scanners 6,16, 64-slice); Siemens Medical Solutions | 
Malvern, PA. 
 GE Discovery PET/CT scanners; GE Healthcare Technologies | Waukesha, WI, USA 
 Philips Gemini PET/CT scanners (Brilliance CT: 6, 10, 16, 40-slice; 40 and 64 channel); 
Philips Medical Systems | Andover, MA, USA  
 
All CT scans for an individual participant should be performed on the same platform throughout 
the trial.  In the rare instance of equipment malfunction, follow-up scans on an individual 
participant can be performed on the same type of platform.  
 
Each scanner platform has slightly different technical specifications and user inputs for imaging 
parameters.  The following table provides specifications for the acquisition and reconstruction 
parameters for the CT series  performed for tumor volumetry.   


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Table 1. Parameters for the CT scans used to measure tumor volume. 
 
Parameter
Diagnostic CT Scan 
for Tumor Volumetry 
KV
120 
Gantry rotation time
≤ 0.5 sec 
Scanner Effective mAs 
(Regular-large size patient)
100-260 
Maximum scan | breath-hold time (40 cm long thorax) 
≤ 15 sec 
Number of active channels (N)
≥ 6 
Maximum Reconstructed slice width
1-1.5 mm 
Reconstruction interval
0 – 20% overlap 
Reconstruction algorithm
Standard 
Reconstruction diameter (dFOV)
outer rib to outer rib 
Intravenous contrast media
None 
Arm positioning
Above the head 
Parameters for tumor volumetry should provide an in-plane voxel size of 0.55-0.75 mm. 
  
 
2. Tumor Response Evaluation According To RECIST 
2.1 Image Acquisition 
Response assessment using RECIST criteria will be performed on all CT scans during the trial. 
Scans will be performed after administration of oral and IV contrast agents according to 
institutional practices.   
 
Iodinated intravenous (IV) contrast media may be administered for diagnostic CT scans per 
standard institutional practice, unless contraindicated.  The decision not to use IV contrast for 
CT is at the discretion of the performing radiologist.  If IV contrast is not administered for these 
scans, then these non-contrast CT series can be used for both RECIST and volumetric 
measurements by prospectively reconstructing the image data into both thick (2.5 to 5 mm) and 
thin-section (1 to 1.25 mm) series, respectively..   
 
The CT scan with contrast is obtained with arms elevated above the head and at suspended 
maximal inspiration to provide optimal relative contrast of lung lesions within aerated lung. 
Typical parameters for image acquisition and reconstruction are shown in Table 2.  
 
 
 


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Table 2: Parameters for the CT scans used to assess tumor response according to RECIST 
Parameter
Dedicated CT for RECIST
KV
120
Gantry rotation time
≤ 0.5 sec
Scanner Effective mAs (Regular-large size patient)
100-260
Maximum scan | breath-hold time (40 cm long thorax) 
≤ 15 sec
Number of active channels (N)
≥ 6
Maximum Reconstructed slice width
3 mm1
Reconstruction interval
0-20% overlap
Reconstruction algorithm
Standard
Reconstruction diameter (dFOV)
outer rib to outer rib
Intravenous contrast media
Per institution practice | indication2
Arm positioning
Above the head
1 If the inspiratory scan of the PET/CT is non-contrast, it also should be used for tumor volumetry, and 
prospectively reconstructed at 1-1.25 (volumetry) and 2.5-5 mm (diagnostic interpretation using RECIST) slice 
thicknesses. 
2. Intravenous contrast should be administered according to standard practices with respect to amount, flow rates, 
and timing with respect to image acquisition, depending upon the body parts imaged.  The same method of 
contrast administration should be followed with all subsequent scans.   
 
2.2 Image Data Analysis 
2.2.1 The following categories of disease will be used in determining response to treatment by 
RECIST: 
 Measurable disease:  The presence of at least one measurable lesion.  If the measurable 
disease is restricted to a solitary lesion, its neoplastic nature should be confirmed by cytology 
| histology. 
 Measurable lesions:  Lesions that can be accurately measured in at least one dimension with 
longest diameter ≥ 10 mm with helical CT. 
 Non-measurable lesions:  all other lesions, including small lesions (longest diameter < 20 
mm with conventional techniques or < 10 mm with helical CT scan), i.e., bone lesions, 
leptomeningeal disease, Ascites, pleural/pericardial effusion, inflammatory breast disease, 
lymphangitic cutis | pulmonis, cystic lesions, and also abdominal masses that are not 
confirmed and followed by imaging techniques.  
 
All measurements will be taken and recorded in metric notation on a calibrated diagnostic 
imaging workstation at full resolution using electronic calipers.  The baseline measurements will 
be performed within one week of the start of treatment; measurements obtained following 
chemotherapy cycles will be obtained on scans performed within 1-3 days of the next cycle of 
treatment.  The same method of assessment and the same technique will be used to characterize 
each identified and reported lesion at baseline and during follow-up.  Lung lesions will be 


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evaluated on lung windows; mediastinal and or soft tissue lesions will be evaluated on soft tissue 
windows.  The acquisition parameters provided above serve as guidelines for CT technique. 
 
“Target” and “Non-Target” lesions will be documented according to the following guidelines: 
 All measurable lesions up to a maximum of five lesions per organ and 10 lesions total, 
representative of all involved organs, should be identified as target lesions and recorded and 
measured at baseline.   
 Target lesions should be selected on the basis of their size (lesions with the longest diameter 
and their suitability for accurate repeated measurements. 
 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. 
 All other lesions (or sites of disease) should be identified as non-target lesions and should 
also be recorded at baseline.  Measurements of these lesions are not required, but the 
presence or absence of each should be noted throughout follow-up. 
 
The following summarizes the categories of response: 
 
Response Criteria
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 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 treatment 
start
 
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 lesions(s) or/and maintenance of 
tumor marker level  above the normal limits
Progressive disease
Appearance of one or more new lesions and/or unequivocal progression 
of existing non-target lesions (1)
(1) 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 later on by follow-up imaging. 
   
Evaluation of Best Overall Response:  The best overall response recorded from the start of the 
treatment until disease progression | recurrence (taking as reference for PD the smallest 
measurements recorded since the treatment started).  In general, the participant’s best response 
assignment will depend on the achievement of both measurement and confirmation criteria. 
 


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Target Lesions
Non-Target Lesions 
Evaluation of Non-
Target 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 
 
Confirmation:   
 To be assigned the status of PR or CR, changes in tumor measurements must be confirmed 
by repeat assessments that should be performed no less than 4 weeks after the criteria for 
response are first met.  Longer intervals as determined by the study protocol may also be 
appropriate. 
 To be assigned the status of SD, follow-up measurements must have met the SD criteria at 
least once after study entry at a minimum interval (in general, not less than 6-8 weeks) that is 
defined in the study protocol. 
 
Duration of Overall Response:  This is measured from the time measurement criteria are met 
for CR or PR (whichever status is recorded first) until the first date that recurrence or PD is 
objectively documented, taking as reference for PD the smallest measurements recorded since 
the treatment started.  
 
Duration of Stable Disease:   Stable disease is measured from the start of the treatment until the 
criteria for disease progression are met, taking as reference the smallest measurements recorded 
since the treatment started.  The clinical relevance of the duration of SD varies for different 
tumor types and grades.   
 


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APPENDIX D -Correlative Studies 
 
Background 
 
The mainstay of treatment for patients with adenoid cystic carcinomas (ACC) has unfortunately 
not advanced over the last several years. Outside of local disease control, which includes surgery 
and radiotherapy, systemic therapy has not demonstrated significant benefit in terms of either 
response rate or overall survival. Studies have shown that ACC genomes are characterized by 
multiple copy number aberrations and recurring gene translocations (79). In addition recent 
studies have started to catalog the mutational landscape of these genomes (80). Despite these 
recent advances, there is an urgent need to study the genomic basis of therapeutic benefit 
(response and stable disease rates) and clinical behaviors of this disease. In order to address this 
current unmet need, we are proposing a novel study of ACC genomes in patients who have been 
treated with the histone deacetylase inhibitor, suberoylanilide hydroxamic acid (SAHA).  
 
Dr. Michael Barrett (TGen) has recently validated the use of DNA content-based sorting 
strategies with clinical FFPE samples. These methods allow the identification and purification of 
distinct and pure populations of tumor cells from each sample of interest. In addition, TGen has 
optimized methods to use the DNA from each sorted population for whole genome and whole 
exome analysis, and we have established a highly efficient pipeline to process next generation 
sequencing (NGS) data and to extract clinically actionable results from patient samples during 
clinical trials.  
 
HR23B was identified as a candidate cancer biomarker through a genome-wide loss-of-function 
screen (81). It sensitizes osteosarcoma cells to HDAC inhibitor-dependent cell death. Depletion 
of HR23B in CTCL (cutaneous T cell lymphoma) cell lines reduced sensitivity to apoptosis of 
these cells upon SAHA treatment (add pearsson ref). Skin biopsies from patients with CTCL 
enrolled in a SAHA phase 2 study were evaluated for pre and post treatment quantitative HR23B 
levels (82) The total staining score (TSS) was compared to clinical response. The positive 
predictive value of HR23B in this clinical setting was 68.8%. Lack of response or progression of 
disease also correlated with initial absence or disappearance of HR23B in pre and post-treatment 
biopsies respectively. 
 
Specific Aims 
 
The fundamental hypothesis of our study is that distinct genomic aberrations including 
amplifications, mutations, and gene translocations that target specific genes and signaling 
pathways will distinguish those tumors that had a meaningful response to SAHA. We propose 
that our comprehensive study of the genomic landscape of this patient population, specifically 
looking at the differences in therapeutic benefit, will provide a unique data set that can be 
exploited for advancing effective targeted therapy for patients with disease. To accomplish our 
study we will complete the following Aims:  
 


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SPECIFIC AIMs 
 
- Flow sort diploid, aneuploid, and tetraploid populations of tumor cells from FFPE tissue blocks 
from each of 5 patients who benefited from SAHA therapy and from each of 5 patients who did 
not demonstrate a durable benefit.  
 
- Profile the genomes of each cell population using oligonucleotide CGH arrays. This will 
confirm the identification of tumor populations in each sample and provide genomic landmarks 
for NGS analysis.  
 
-Perform whole exome analysis of the sorted tumor population and matching germ line sample 
for each of the 10 patients. The combined aCGH and exome data will be mined to identify genes 
and pathways that are targeted by select somatic events in each of the patient subsets. 
 
Methods FFPE Sample Preparation and Flow Sorting: Excess paraffin is removed with a 
scalpel from individual 40-60µm scrolls which are then washed with 1ml Xylene for 5 minutes 
to remove remaining paraffin.  Each sample is rehydrated in sequential ethanol washes (100% 5 
minutes x2, then 95%, 70%, 50% and 30% ethanol) and washed 2 times in 1ml 1mM EDTA pH 
8.0. A 1ml aliquot of 1mM EDTA pH 8.0 is added to the samples which are then incubated at 
95oC for 80 minutes to facilitate the removal of protein cross-links.  Samples are cooled to room 
temperature for > 5 minutes, followed by addition of 300µl PBS 7.4 and gentle centrifugation for 
2 minutes.  The pellet is washed 3 times with 1ml PBS 7.4/0.5mM CaCl2 to remove EDTA. 
Each sample is digested overnight (6-17 hours) in 1ml of enzymatic cocktail containing 50 
units/ml of collagenase type 3, 80 units/ml of purified collagenase, and 100 units/ml of 
hyaluronidase in PBS ph7.4/0.5mM CaCl2 buffer. Following overnight digestion 500µl NST 
buffer is added and samples are centrifuged for 5 minutes at 3000rcf, after which pellets are 
resuspended in 750µl of NST/10% fetal bovine serum and then passed through a 25g needle 10-
20 times. The samples are filtered through a 35µm mesh and collected into a 5ml polypropylene 
round bottom tube. The mesh is rinsed with an additional 750µl of NST/10% fetal bovine serum 
and placed on ice while processing remaining samples.  An equal volume of 20µg/ml DAPI is 
added to each tube to achieve a final concentration of 10µg/ml DAPI prior to flow sorting with 
an Influx cytometer with ultraviolet excitation (Becton-Dickinson, San Jose, CA). Optimal 
settings for sorting FFPE samples are: Drop formation is achieved with piezzo amplitude of 6-10 
volts and a drop frequency of 30khertz. The sort mode is set to purity yield with a drop delay of 
31.5-32. Sheath fluid pressure is typically 17-18psi with a 100µm nozzle. For single parameter 
DNA content assays DAPI emission is collected at > 450nm. DNA content and cell cycle are 
then analyzed using the software program MultiCycle (Phoenix Flow Systems, San Diego, CA). 
 
DNA Extraction and Amplification: DNA from sorted nuclei is extracted using an amended 
protocol for QIAamp® DNA Micro Kit from Qiagen.  Briefly each sorted sample is resuspended 
in 180µl buffer ATL and 20µl proteinase K, and then incubated for 3 hours at 56°C for complete 
lysis.  Samples are bound and washed according to supplier's instructions, eluted into 50µl of 
H20, and then precipitated overnight with 5ul sodium acetate and 180µl 100% EtOH.  Each 
sample is then centrifuged for 30 minutes at 20,000 x g, washed in 1ml of 70% EtOH for 30 
minutes at 20,000 x g. The DNA pellet is dried then resuspended in a small volume (e.g. 10-


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50µl) of H20 for final concentrations suitable for accurate quantization. Genomic DNA from 
sorted FFPE samples is amplified using Ovation® WGA FFPE System (NuGEN® Technologies, 
San Carlos CA) with an alternate fragmentation step.  Resulting amplified products are used as 
template for aCGH. In all cases the amplification product quality is assessed by gel 
electrophoresis. 
 
Array CGH: For each flow sorted tumor sample of interest we will label 1 µg of tumor DNA and 
1 µg of reference DNA according to our published protocols (83). These will be hybridized to 
Agilent 60mer oligonucleotide CGH arrays. All microarray slides will be scanned using an 
Agilent 2565C DNA microarray scanner. Microarray images will be analyzed using Agilent 
Feature Extraction software version 11.0 (FE 11.0) using default settings according to the 
supplier’s recommendations. Log2 ratios of fluorescent signals and corresponding log2 ratio 
errors, as calculated from the log10 output of FE 11.0, will be analyzed in Genome Workbench 
6.7. All aCGH experiments will be evaluated using a series of quality control (QC) metrics. 
These include background noise, signal intensities and signal to noise ratios for each dye-specific 
channel, the reproducibility of a series of replicate control probes on the arrays, and a measure of 
the spread of the distribution of the log2 ratios reported in each experiment. The data from arrays 
that pass the QC metrics will then be analyzed using an aberration detection algorithm (ADM2) 
(84). The latter identifies all aberrant intervals in a given sample with consistently high or low 
log ratios based on the statistical score derived from the average normalized log ratios of all 
probes in the genomic interval multiplied by the square root of the number of these probes. 
Aberration calling thresholds for ADM2 will be determined based on hybridizations with normal 
46XY and 46XX DNA derived from sorted control tissues. We will use the distribution of log2 
ratios for autosome probes and the corresponding chromosome X probes from control 
experiments to determine the error rates in our experiments and select the statistical threshold for 
calling aberrant genomic intervals in the PDA samples.  
 
NGS Template and Exome Sampling: For each sample of interest we will generate double 
stranded (ds) DNA template using our published methods and the Ovation® WGA FFPE System 
(85). Each sample selected for NGS will be assayed for final QC metrics including size range 
and concentration of dsDNA prior to exome sampling and sequencing. Patient matched germline 
DNAs will be processed in parallel. All exome sampling and NGS data generation will be done 
in TGen’s Collaborative Sequencing Center (CSC).  
 
NGS Analyses Workflow: Once exome sequencing data is generated, we will leverage our 
substantial bioinformatics and statistics skills, experience, and large-scale computational 
capabilities to carry out research-objective-specific customized data-analyses. We have several 
automated workflows that consist of both published and internally developed data analyses tools 
for processing sequenced data to generate interpretation-ready results. This includes germline 
results, such as detecting variants, comparisons with a variety of publically available variants 
datasets (e.g., dbSNP, 1000 genomes, etc.), functional annotation, Ti/Tv ratios, target sequencing 
efficiency, etc. Further, when both tumor and normal sequencing data is available, we have well-
tested sophisticated workflows for somatic variant detection with detailed comparisons with 
publically available datasets (e.g., COSMIC). Both germline and somatic variants are 
comprehensively annotated for functional consequences, such as non-synonymous mutations, 


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frame-shift insertion-deletions. Our workflows are compatible with standard, platform-
independent input sequencing data format (e.g., FASTQ format), generate detailed QC and 
several additional statistical metrics at various stages of data processing, and deliver results that 
conform to standard output formats, such as BAM (alignments), VCF (variant calls), functional 
annotation, etc.  
 
HR23B protein levels will be measured by immunohistochemistry (IHC) using published 
protocols (86). We will use a single thin section slide for all IHC experiments. All assays will be 
done through TGen’s Macromolecular Analyte and Processing Center (MAPC) pending 
additional funding. In addition a second slide from each patient will be used for further 
validation of the recurring t(6:9) MYB-NFIB translocation using conventional fluorescent in situ 
hybridization (FISH) (87). A semiquantitative analysis based upon intensity and frequency of 
HR23B staining and the type of dermal and epidermal infiltrate will be performed on each 
biopsy(87). A total staining score (TSS) will be determined out of 13, where a score of greater 
than or equal to 6 will be considered to be strong HR23B staining. The threshold for 
differentiating between positive and negative immunostaining will be set at at TSS of equal or 
higher than 6. This optimal cutoff was determined by the receiver operating characteristic curve 
(ROC) distribution analysis. 
 
Samples 
Barbara Ann Karmanos Cancer Institute (KCI) has a set of formalin-fixed paraffin embedded 
(FFPE) tumor slides/blocks from individual ACC patients who were treated with SAHA. A high 
number of patients had stable disease on treatment over 1 year (median and range), and we 
observed partial responses in two of the patients in this trial. These FFPE samples are well 
annotated with clinical follow-up and represent highly favorable samples to exploit for 
advancing improved outcomes in ACC. 
This study will use previously collected FFPE tissue blocks from 10 patients; 5 patients who 
achieved durable benefit from SAHA and 5 patients whose tumors did not demonstrate 
therapeutic response. If an entire FFPE block is not available, PI's will request up to 20 unstained 
slides (10 microns).  One or two 5 micron slides will be requested and used for validations. of the 
recurring t(6:9) MYB-NFIB translocation and measurement of HR23B protein levels  A 
deidentified, coded copy of the pathology report will also be sent with the FFPE block or slides. 
Whole blood was also collected on most of the patients at the time of enrollment in the original 
study.  Karmanos will send white blood cells from the blood to TGen to serve as patient matched 
germline DNA.  If no blood exists from a selected patient, or the blood was of poor quality, 
Karmanos study personnel will recontact the patient to obtain informed consent and to draw a 
new blood sample. 
Blood samples will be spun down to remove the white blood cells from the red blood cells (see 
Blood Sample Collection below).  The white blood cell pellet will be snap frozen using liquid 
nitrogen and stored at -80° until shipping on dry ice to TGen. 
 
Blood Sample Collection 
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The procedures for Processing Peripheral Blood Mononuclear Cells (PBMC) are described 
below: 
 
Equipment 
• One BD Vacutainer CPT Cell Preparation Tube with sodium heparin 
• 15 ml size plastic conical centrifuge tubes with caps 
• Transfer pipettes 
• Temperature-controlled centrifuge with swinging bucket rotor and adapters for  
16 X 125 mm tube size 
• Coulter counter or hemocytometer 
 
Reagents  
• Phosphate Buffered Saline (PBS) without Ca++ or Mg++ 
• 0.4% Trypan blue 
• BioRad BioPlex Cell Lysis Kit (BioRad, Cat # 171-304011) 
 
Procedures 
Blood Collection 
1. Samples will be collected into 1BD Vacutainer CPT tube with sodium heparin. These will be 
kept at room temperature (18-26oC) and properly labeled with patient information and study 
number. . 
2.  Once blood is collected, the tubes will be inverted approximately 8-10 times to ensure that 
the whole blood is mixed thoroughly with the anticoagulant. 
3. The tubes will be centrifuged within 2 hr of collection at room temperature for 30 min at 
1700 RCF (relative centrifugal force). 
 
 
Note: The tube will be checked to be in the proper centrifuge adapter.  Excessive 
centrifuge speed (over 2000 RCF) may cause tube breakage, exposure to blood and 
possible injury.  To calculate the correct centrifuge speed for a given RCF, the following 
formula is used: 
 
  
The variable “r” is the radial distance in centimeters from the centrifuge center post to the 
tube bottom, when the tube is positioned horizontally. RCF is the desired relative 
centrifugal force, 1700 in this case. (2.5cm = 1 inch). 
4. After centrifugation, mononuclear cells and platelets will be in a whitish layer just under the 
plasma layer (see below figure).  


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5. The plasma layer will be removed, taking care not to disturb the PBMC layer, and discarded. 
6. The PBMCs will be washed with ice-cold PBS, centrifuging at 300RCF for 10 min. Before 
centrifuging, an aliquot of 20uL will be taking for counting in a cell counter or by 
hemocytometer. 
7. The cells will be counted and the cell number will be recorded on the label which is to be 
placed on the cryovial. When the centrifugation is finished, the supernatant will be taken off 
and discarded. 
8. The bottom of the centrifuge tube will be flicked to resuspend the cells and 1 mL of BioRad 
BioPlex cell wash buffer will be added. The tube will be centrifuged again at 300 RCF for 10 
minutes. The supernatant will be removed by transfer pipet and the last bit of supernatant 
removed using a micropipetter. 
9. The lysates will be prepared by adding BioRad BioPlex lysis buffer. The cell counts will be 
used to determine the quantity to use. For example, if the cell counts ar > 10 x 106 , 75 uL 
will be used. If the cell number is > 2.5 x 106 but < 10 x 106 , 50 uL will be used; and if the 
cell number is < 2.5 x 106 , 25 uL will be used. The cells will be incubated with the lysis 
buffer for 30 minutes at 4 oC. 
10. The cells will be sonicated on ice for 3 seconds at setting 6 and the cell lysate will be frozen 
at -70oC or -80 oC. 
 
 
All samples and data will be de-identified and coded with a unique study code assigned by 
Karmanos study personnel.  A key linking the patient name to the study code will be maintained 
and stored by Karmanos study personnel.  TGen will not receive any patient identifiable 
information before, during or after this study is conducted. 
 
 
Sample Shipment 
 


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All samples will be shipped to: 
The TGen Barrett Laboratory 
 
 
 
 
 
C/O Elizabeth Lenkiewicz 
13208 E. Shea Blvd. 
Scottsdale, Arizona 85259 
602- 358-8839 
 
FFPE Blocks or Slides 
 
When shipping the FFPE block, place the block in a ziplock bag and wrap in bubble wrap 
or another type of padded material prior to shipping.  The zip lock bag can be placed into 
a FedEx envelope or small shipping box. 
 
If sending slides, pack the labeled slides into plastic slide cassette(s). Tape plastic slide 
cassettes shut and wrap in bubble wrap or another type of padded material prior to 
shipping.  Place the slide cassettes into an outer shipping box. 
 
White Blood Cell Pellets 
Place container with frozen specimen in a ziplock bag.  Place 2-3 inches of dry ice in the 
bottom of a Styrofoam cooler.  Place bag in the center of the cooler on top of the dry ice, 
and then fill the cooler the rest of the way with dry ice (preferably pelleted). Place a 
single paper-towel or piece of paper across top of ice, then put lid on the cooler and tape 
the lid tightly to the cooler, sealing all the way around the lid.  Ship Monday through 
Wednesday only unless prior notification is made is made with TGen.  Do not ship 
the day before a U.S. Holiday. 
 
 
 
   


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APPENDIX E- PD Generic SOP: Storage and Shipping 
 
PD Sample Storage 
Archival Tissue:  
• Shipping of paraffin blocks/slides should be done with a padded envelope and shipped to 
KCI. Paraffin blocks should be wrapped in a plastic bag before placement in the 
envelope.  Slides should be put in an appropriate slide case before placement in the 
envelope.  
 
 
PD Sample Shipping 
• When to ship out the sample? 
• How to pack the frozen sample? 
- 
Verify each specimen is labeled properly.  
- 
Verify spread sheet for the box contents is accurate, so that individual samples 
can rapidly identified. 
- 
Place box into a large biohazard bag with absorbent strip.  Seal bag completely.  
- 
Insert sealed biohazard bag into white “Saf-T-Pak” envelope. 
- 
Place copies of spread sheet of box contents into the “Saf-T-Pak” envelope, 
between the plastic biohazard bag and envelope. Place the envelopes containing 
storage box inside cooler 
- 
Fill cooler completely with dry ice. 
- 
Place cover on the cooler.  (Do Not Tape Cooler Closed). 
- 
Place cooler in the fiberboard container, close the cardboard flaps and secure with 
tape. 
- 
Complete Shipper’s Information on the outside of kit box (name, address, and 
phone). 
- 
Affix completely filled-out airbill on top of kit box in designated area.  
 
 
Ship Frozen Samples no Later Than Wednesday 
 
• Complete the following items on the airbill: 
- 
1. Address as provided in the study protocol 
- 
2.a Shipment date 
- 
2.b Verify the box is checked for “Yes. Shippers Declaration not required” 
 
- 
2.c Check the box for “dry ice”, record the # of packages and record the weight of 
dry ice. 
- 
3. Enter the total weight of the package- this cannot be pre-printed and must be 
filled in by the sender. 
 
 
• Affix completely filled-out air bill on top of the box in designated area. 
 


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Completing Dry Ice Information 
• Complete and affix the dry ice label on the outside of the shipping container. 
• Contact the local Federal Express office to arrange for diagnostic specimen pick up.    
• Pick-up must be the same day as packaging.  Do not leave the box for pick-up the 
next day, as this may severely compromise testing. 
 


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Notify the Recipient about the Shipment 
• Please email the respective recipient when the samples are shipped 
- 
WSU Pharmacology Laboratory Contact:  
• Richard Wiegand (wiegandr@karmanos.org) 
- 
TGen Contact: (602) 343 8839 
- 
Elizabeth Lenkiewicz (Elenkiewicz@tgen.org) 
 
• Inform which samples that are included in the shipment and FedEx tracking number in 
the email 
 
 
 
 
 
Shippers declaration not 
required 
Part B is required 
Dry ice amount must be in 
kilograms 
Note 2.2 lbs = 1 kg 
Airbills must have the 
following: 
 
“Dangerous Goods 
shippers declaration 
not required” 
 
•Dry Ice; 9; UN1845 
 
k III
Recipient address
DRY ICE _________kg
UN1845
Shippers name and address 
_______________________ 
_______________________ 
_______________________


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APPENDIX F- Enzyme inducing anti-convulsants 
 
The following agents are potential hepatic enzyme inducing antiepileptic drugs (EIAEDs): 
Carbamazepine (Tegretol, Tegretol XR, Carbatrol) 
Oxcarbazepine (Trileptal) 
Phenytoin (Dilantin, Phenytek) 
Fosphenytoin (Cerebyx) 
Phenobarbital 
Pentobarbital 
Primidone (Mysoline) 
 
 
The following agents are non (non- IAEDs): 
Valproic acid (Depakote, Depakene, Depacon) 
Gabapentin (Neurontin) 
Lamotrigine (Lamictal) 
Topiramate (Topamax) 
Tiagabine (Gabitril) 
Zonisamide (Zonegran) 
Levetriacetam (Keppra) 
Clonazepam (Klonopin) 
Clonozam (Frisium) 


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APPENDIX G- PATIENT’S MEDICATION DIARY (300 mg) 
 
300mg Suberoylanilide Hydroxamic Acid (SAHA)/Vorinostat 
Today’s Date _____________________ 
  
  
Patient Name_____________________(initials acceptable)  
 Patient Study ID __________________ 
 
   INSTRUCTIONS  
1. 
Complete one form for each cycle of treatment. 
2. 
You will take three 100mg vorinostat capsules each day (300 mg total dose), once a day, at 
approximately the same time, continuously over a 28 day period.  
3. 
Swallow each capsule whole with a full glass of water.  Do not chew or open the capsules.  If capsule is 
broken and the powder of the capsules gets on skin, wash the exposed area with as much water as 
necessary. Inform investigator or nurse if that occurs. 
4. 
Record the date and time you took the capsule.   
5. 
If you have any comments or notice any side effects, please record them in the Comments column.   
6. 
Please bring this form and your bottle of vorinostat when you return for your Day 28 appointment. 
7. 
In case of errors, please place a single slash mark through the error and initial it.  Please do not 
white out any error or scribble it out with ink.  Please do not write the correct information directly 
over the error, but on a separate line next to the error. 
 
Day 
Date 
Time of Dose  
Comments 
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Patient’s signature:  ___________________________________________________________________ 
CTEP-assigned Protocol #___________ 
 
Local Protocol # ___________________ 


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Version Date: 08/16/16 
 
 APPENDIX H- PATIENT’S MEDICATION DIARY (400 mg) 
 
400mg Suberoylanilide Hydroxamic Acid (SAHA)/Vorinostat 
Today’s Date _____________________ 
  
  
Patient Name_____________________(initials acceptable)  
 Patient Study ID __________________ 
 
   INSTRUCTIONS  
8. 
Complete one form for each cycle of treatment. 
9. 
You will take four 100mg vorinostat capsules each day (400 mg total dose), once a day, at 
approximately the same time, continuously over a 28 day period.  
10. Swallow each capsule whole with a full glass of water.  Do not chew or open the capsules.  If capsule is 
broken and the powder of the capsules gets on skin, wash the exposed area with as much water as 
necessary. Inform investigator or nurse if that occurs. 
11. Record the date and time you took the capsule.   
12. If you have any comments or notice any side effects, please record them in the Comments column.   
13. Please bring this form and your bottle of vorinostat when you return for your Day 28 appointment. 
14. In case of errors, please place a single slash mark through the error and initial it.  Please do not 
white out any error or scribble it out with ink.  Please do not write the correct information directly 
over the error, but on a separate line next to the error. 
 
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Date 
Time of Dose  
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Patient’s signature:  ___________________________________________________________________ 
CTEP-assigned Protocol #___________ 
 
Local Protocol # ___________________ 


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Local Protocol #: 2009-165 
 
 
Version Date: 08/16/16 
 
 
APPENDIX I: THERAPEUTIC RESPONSE ASSESSMENT USING VOLUMETRIC 
DENSITY 
 
Department of Radiology and Imaging Sciences investigator Dr. Les Folio and colleagues will 
retrospectively evaluate CT and/or MRI of patients treated in the current trial. These cross 
sectioning imaging (CT/MR) have already been obtained. No new imaging will be performed. 
 
All the CTs and/or MRI will be evaluated at the National Cancer Institute, under Dr. Folio and 
colleagues.   
 
All pre-specified target lesions will be assessed at specific time-points: baseline, date of best 
response, a mid-treatment time point and most recent imaging.  
 
The specific aims are to:  
1. Retrospectively compare VTV (all lesions; volume/density) vs. pre-determined RECIST (axial 
only)  
2. Correlate VTV, RECIST, and treatment response (partial response, progressive disease, stable 
disease and stable disease over 6 months) 
 
Registration and Lesion Management Application (algorithm/ software):  
Automated registration and semi-automatic segmentation of all target lesions will be performed 
on serial CT scans or MRI using PACS (Picture Archiving and Communication System) . 
 
Lesion Management Algorithm radiology imaging software (Carestream vue PACS v12, 
Rochester, NY).  
First, each scan is manually opened and globally registered to align axial planes between the two 
scans. The global registration algorithm employs a fully automated volumetric voxel-based rigid 
registration algorithm.1 Second, tumors are manually located, which is performed by singly 
clicking on tumors, or by extending a measurement markup across conglomerated or abutting 
lesions. The PACS software then performs a refined registration by modifying the initial global 


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Version Date: 08/16/16 
 
registration dataset to enhance localization of the selected metastatic tumor across serial exams.2 
Next, the software automatically segments the target tumor on both CT and/or MR scans using 
enhanced tumor edge detection (not necessarily defining separate lesions). 3 Finally, the PACS 
software automatically couples segmentation and tumor measurement, providing longest axial 
tumor length, perpendicular to longest axial length, short axis, mean HU density, and tumor 
volume of interest (VOI) in the segmented area. Observers then edit the typical segmentation 
outline using a freeform segmentation tool to exclude non-tumoral components.  
 
1 Hawkes DJ. Algorithms for radiological image registration and their clinical application. J. 
Anat. (1998) 193, pp. 347-361.  
2 Hong H, Lee J, Yim Y. Automatic lung nodule matching on sequential CT images. Comput 
Biol Med. 2008 May;38(5):623-34. Epub 2008 Apr 15.  
3 Maintz JBA, Viergever MA. A survey of medical image registration. Med Image Anal 1998; 
2:1–36.  
All volume, size, and volumetric density measurements of the target tumors will be recorded on 
both the baseline and follow-up CT scans. All measurements will be performed by two observers 
(college graduates with no formal medical training) under other authors with over 10 years of 
experience in CT as body radiologists. The radiologists will verify observer segmentations, in 
consensus, when needed.