Conditions: Lung Cancer
Keywords: Lung Cancer Non small cell lung cancer NSCLC Adenocarcinoma Squamous cell carcinoma BIBW 2992 Afatinib
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 2
Healthy volunteers: no

Brief summary:
The goal of this clinical research study is to learn if it is tolerable for patients with NSCLC to receive afatinib before surgery. The safety of this drug will also be studied.

Detailed description:
Study Drug Administration:

If you are found to be eligible to take part in this study, you will take afatinib by mouth 1 time a day for at least 14 days before your surgery. You should take it at least 1 hour before or 2 hours after a meal. You will sign a separate consent form that describes the surgery and its risks in more detail.

You will keep a diary of when you take the pills. You should bring the diary to each visit, along with your pill bottle so the study staff can count any remaining pills.

Some side effects, such as diarrhea and skin rash, will occur in almost all patients. If you have severe side effects, your dose may be lowered.

Study Visits:

One (1) time a week while you are taking afatinib:

* You will have a physical exam.
* Blood (about 3 teaspoons) will be drawn for routine tests.

Within a week before your surgery:

* You will have a physical exam.
* Blood (about 3 teaspoons) will be drawn for routine tests.
* You will have a PET-CT scan to check the status of the disease.
* You will have a MUGA scan to check your heart function.

On the day of surgery, blood (about 3 teaspoons) will be drawn for research tests, including looking for tumor cells that may be in the blood.

Leftover tissue from surgery will be used for biomarker testing.

Length of Treatment:

You will take your last dose of study drug within 24 hours before your surgery. You will no longer be able to take the study drug if the disease gets worse, if intolerable side effects occur, or if you are unable to follow study directions.

Your participation on the study will be over after the follow-up visit.

Follow-Up:

At about 30 days after surgery:

* You will have a physical exam.
* Blood (about 3 teaspoons) will be drawn for routine tests.

It is possible that the study staff will call you instead of the visit above. You will be asked how you are doing. The call should last about 5 minutes.

If you are having side effects from the study drug at the time of the follow-up visit or call, you may have additional follow-up if the doctor thinks it is needed. The follow-up tests, procedures, and schedule will be the doctor's decision depending on the side effects.

This is an investigational study. Afatinib is FDA approved and commercially available to be the first treatment for patients with a specific type of NSCLC that has spread. It is currently being used for research purposes only. The study doctor can explain how the study drug is designed to work.

Up to 20 participants will be enrolled in this study. All will take part at MD Anderson.

Arms:
arm 1: BIBW 2992 40 mg by mouth daily for a minimum of 14 days, and until the day of surgery.

Interventions: intervention 1: BIBW 2992
Intervention descriptions: intervention 1: 40 mg by mouth daily for a minimum of 14 days, and until the day of surgery.

Protocol document:
Prot_SAP_000.pdf: 
MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
 
The ATTAIN Lung Study 
A Therapeutic Trial of Afatinib in the Neoadjuvant Setting 
 
 
Molecular effects of Afatinib: A Window of Opportunity Trial In Early Stage NSCLC 
 
 
Sponsor: 
 
 
University of Texas MD Anderson Cancer Center 
 
 
 
George Simon, MD 
University of Texas MD Anderson Cancer Center 
1515 Holcombe Blvd, Unit 0432 
Houston, TX 77030 
Phone: 713-792-6363 
E mail: gsimon@mdanderson.org 
Fax: 713-792-1220 
 
 
 
 
 
 
 
 
 
Support provided by: 
BIPI (Boehringer Ingelheim Pharmaceuticals)GmbH 
Ingelheim, Germany 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
TABLE OF CONTENTS 
TABLE OF CONTENTS ............................................................................................................. 2 
Study Schema ............................................................................................................................ 4 
Abbreviations ............................................................................................................................. 5 
 
Introduction ......................................................................................................................... 7 
1
1.1 
Epidermal growth factor receptor expression and its significance in cancer ................ 7 
1.2 
The epidermal growth factor receptor (EGFR) mutations as a marker for 
treatment selection with EGFR tyrosine kinase inhibitors ........................................................ 8 
1.3 
The Responses to EGFR-TKI’s are transient and Development of Resistance 
to EGFR-TKI is universal ........................................................................................................ 9 
1.4 
EMT: significance, recognition, regulation and interaction with EGFR inhibition. ....... 10 
1.5 
BIBW 2992 (Afatinib) ................................................................................................ 11 
1.6 
Window of opportunity trial designs and recently reported window of 
opportunity studies................................................................................................................ 12 
1.7 
In Summary .............................................................................................................. 13 
 
Objectives ......................................................................................................................... 15 
2
2.1 
Primary objective ...................................................................................................... 15 
2.2 
Secondary Objective ................................................................................................. 15 
2.3 
Correlative Objectives ............................................................................................... 15 
 
Study Endpoints ................................................................................................................ 16 
3
3.1 
Definition of primary endpoint: .................................................................................. 16 
3.2 
Definition of secondary endpoint: .............................................................................. 16 
 
Study centers .................................................................................................................... 16 
4
 
Selection of Study Subjects ............................................................................................... 17 
5
5.1 
Overview ................................................................................................................... 17 
5.1.1 
Inclusion Criteria ................................................................................................... 17 
5.1.2 
Exclusion Criteria .................................................................................................. 17 
5.1.3 
Follow up and criteria for withdrawal from study. ................................................... 18 
5.2 
Study Plan ................................................................................................................ 19 
5.2.1 
REGISTRATION PROCEDURES ......................................................................... 19 
5.2.2 
General Guidelines ............................................................................................... 19 
5.2.3 
Study period .......................................................................................................... 19 
5.2.4 
Detailed treatment plan ......................................................................................... 19 
5.2.5 
General Concomitant Medication and Supportive Care Guidelines ....................... 20 
5.2.6 
Duration of Therapy .............................................................................................. 20 
5.2.7 
Evaluations During Treatment ............................................................................... 20 
Duration of Follow Up ........................................................................................................ 22 
5.2.8 
Table of Studies .................................................................................................... 23 
 
Correlative Studies ............................................................................................................ 24 
6
6.1.1 
Outline of correlative studies to be performed on tumor specimens ...................... 24 
6.1.2 
Assessment of Expression of EMT-associated genes ........................................... 25 
6.1.3 
Interpretation of results and correlation with clinical findings: ................................ 26 
 
Investigational Medicinal Product ...................................................................................... 27 
7
7.1 
NONCLINICAL STUDIES ......................................................................................... 27 
7.1.1 
In vitro pharmacological profile .............................................................................. 27 
7.1.2 
In vivo efficacy ...................................................................................................... 28 
7.1.3 
Single-agent efficacy in human cancer xenograft models in nude mice ................. 28 
7.1.4 
Activity of BIBW 2992 in breast cancer tumor models ........................................... 28 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
7.1.5 
Activity of BIBW 2992 in NCSLC tumor models resistant to first generation 
EGFR inhibitors. ................................................................................................................ 29 
7.1.6 
Distribution ............................................................................................................ 30 
7.1.7 
Safety ................................................................................................................... 30 
 
Dose and Schedule of Test Drug. ..................................................................................... 30 
8
8.1 
Dosing Delays/Dose Modifications ............................................................................ 31 
8.1.1 
Handling of Unused/Expired Investigational Product ............................................. 32 
8.2 
Additional Dose Delays and Dose Modifications ....................................................... 32 
8.3 
MANAGEMENT OF ADVERSE EVENTS ................................................................. 33 
8.3.1 
Suggested management of diarrhea following treatment with BIBW 2992 ............. 33 
8.3.2 
Management of nausea and vomiting following treatment with BIBW 2992 ........... 34 
8.3.3 
Management of rash following treatment with BIBW 2992 .................................... 34 
8.3.3.4  Management of mucositis/stomatitis ............................................................................ 36 
 
Assessment of Efficacy ..................................................................................................... 37 
9
9.1 
Efficacy parameters .................................................................................................. 37 
9.1.1 
Assessment methods to measure response and progression ............................... 37 
9.1.2 
Definition of measurable and non-measurable lesions according to RECIST ........ 37 
9.1.3 
Tumor response evaluation according to RECIST 1.1 ........................................... 37 
9.1.4 
Assessment of overall burden and measurable disease ........................................ 37 
9.1.5 
Baseline documentation of “Target” and “Non-Target” lesions .............................. 38 
9.1.6 
Evaluation of target lesions ................................................................................... 38 
9.1.7 
Evaluation of non-target lesions ............................................................................ 38 
9.1.8 
Evaluation of best overall response ....................................................................... 39 
9.1.9 
Evaluation according to PET Response Criteria in Solid Tumors (PERCIST), 
version 1.0. [55] ................................................................................................................. 39 
9.2 
Investigator Communication with Supporting Company for Safety analysis ................ 41 
9.3 
Investigator Communication with Supporting Company for Adverse Event 
Characteristics ...................................................................................................................... 43 
9.3.1 
Worsening of pre-existing conditions or underlying disease .................................. 43 
9.4 
Investigator Communication with Supporting Company for Reporting of SAE's .......... 44 
9.5 
Data Collection ......................................................................................................... 44 
 
Statistical Considerations .............................................................................................. 46 
10
 
Quality Control and Quality Assurance Procedures ...................................................... 47 
11
11.1 
Monitoring of the study and regulatory compliance ................................................... 47 
11.2 
Protocol modifications ............................................................................................... 47 
11.3 
Patient privacy .......................................................................................................... 47 
11.4 
Publication Policy ...................................................................................................... 47 
 
Ethical Considerations .................................................................................................. 48 
12
12.1 
Informed Consent ..................................................................................................... 48 
12.2 
Institutional Review Board......................................................................................... 48 
 
Data Handling and Record Keeping .............................................................................. 49 
13
13.1 
Data recording and quality control ............................................................................. 49 
 
Recruitment Procedure ................................................................................................. 50 
14
 
References ................................................................................................................... 51 
15
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
Study Schema 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recruitment:  n = 20. Untreated resectable Stage IA to IIIA NSCLC patients, PS 0 - 1 measurable disease. Patient must 
be medically operable and the tumor must be resectable. 
 
Diagnosis/Staging:   All patients will have a PET/CT scan, a biopsy of the primary, and mediastinal staging either by 
mediastinoscopy or by EBUS and/or EUS. Tissue is used for histopathological evaluation and for correlative studies. This 
specimen will be called specimen 1. 
 
Randomization:  Single arm trial where all patients will be treated with afatinib until the day of surgery and for a minimum 
of two weeks. 
 
Treatment:  Patients will receive treatment with afatinib 40mg orally daily. 
 
Clinical Objectives:  Determine whether pre-operative afatinib (BIBW 2992) treatment affects the primary tumor, as 
measured by a decrease is Standard Uptake Value (SUV) in PET-CT scanning. 
 
Determine the safety of this approach where the effects of neoadjuvant treatment with afatinib on surgical outcomes are 
assessed. Patients will be followed for 30 days after surgery. 
 
Correlative Objectives:   Determine total and phosphorylated EGFR to validate target inhibition and, in addition, assess 
the activation status of downstream signaling components, i.e., ERK1/2 and AKT. 
 
Determine the EMT status in afatinib treated tumors. This will include analysis of classical EMT markers and recently 
described markers. 
 
Follow-up:  Patients will be off study 30 days after surgery. Subsequent adjuvant treatments will administered as clinically 
indicated. 
 
 
Afatinib in patients with resectable Stage I to IIIA non-small cell lung cancer (NSCLC) 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
Abbreviations 
 
 
Abbreviations or Terms 
Definitions 
AE 
Adverse Event 
ALAT 
Serum Alanine Aminotransferase 
ANC 
Absolute Neutrophil Count 
ASAT 
Serum Aspartate Aminotransferase 
AQUA 
Accurate Quantitative Analysis of Protein Expression 
BID 
Twice a day 
BSA 
Body Surface Area 
CALGB 
Cancer and Leukemia Group B 
CBC 
Complete Blood Count 
CI 
Confidence Interval 
CNS 
Central Nervous System 
CR 
Complete Response 
CRF 
Case Report Form 
CT 
Computed Tomography 
CTCAE 
Common Terminology Criteria for Adverse Events v3.0 
D 
Day of cycle (d1 is the first day of the treatment cycle) 
D5W 
5 percent dextrose in water 
DDP 
Cisplatin 
DNA 
Deoxyribonucleic Acid 
EBUS 
Endoscopic Bronchial Ultrasound 
ECG 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
EGFR 
Epidermal Growth Factor Receptor 
EUS 
Endoscopic Ultrasound 
FDA 
Food & Drug Administration 
FSR 
Final Study Report 
GCP 
Good Clinical Practice 
G-CSF 
Granulocyte Colony Stimulating Factor 
HER2 
Human Epidermal Growth Factor Receptor 2 
i.m. 
Intramuscular 
i.v. 
Intravenous 
ICD 
Inform Consent Document 
ICH 
International Conference on Harmonization 
IEC 
Independent Ethics Committee 
IHC 
Immunohistochemistry 
IRB 
Institutional Review Board 
ITT 
Intent-To-Treat 
LCM 
Laser Capture Microdissection 
MoAb 
Monoclonal Antibody 
MRI 
Magnetic Resonance Imaging 
NCI 
National Cancer Institute 
NS 
Normal Saline 
NSCLC 
Non-Small-Cell Lung Cancer 
OS 
Overall Survival Time 
PD 
Progressive Disease 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
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PET 
Positron Emission Tomography 
PFS 
Progression Free Survival Time 
p.o. 
Per Os (by mouth) 
PR 
Partial Response 
PS 
Performance Status 
RECIST 
Response Evaluation Criteria in Solid Tumors 
RNA 
Ribonucleic Acid 
RR 
Response Rate 
RTPCR 
Reverse Transcriptase Polymerase Chain Reaction 
SAE 
Serious Adverse Event 
SAERF 
Serious Adverse Event Report Form 
SAP 
Statistical Analysis Plan 
SD 
Stable Disease 
SGOT 
Serum Glutamic Oxalo-Acetic Transaminase 
SGPT 
Serum Glutamic Pyruvic Transaminase 
SOP 
Standard Operating Procedure 
SWOG 
Southwest Oncology Group 
TID 
Three Times a Day 
TKI 
Tyrosine-Kinase Inhibitor 
UNL 
Upper Normal Limit for that institution 
VEGF 
Vascular Endothelial Growth Factor 
Vs 
Versus 
WBC 
White Blood Cell Count 
WHO 
World Health Organization 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
 Introduction  
1
 
Lung cancer is the second most common cancer diagnosed in the United States, with 
more than 212,000 new cases reported in 2010. Non-Small Cell Lung Cancer (NSCLC) 
accounts for approximately 85% of all incident lung cancer cases and predominantly 
encompasses the adenocarcinoma, squamous cell carcinoma and large cell carcinoma 
histologies. 
 
Patients with early stage NSCLC are typically treated with surgical resection of their 
tumors. Adjuvant chemotherapy is now offered to patients with evidence of lymph node 
involvement or if the tumor is greater than 4 cm [1-3].   Relapses are common even after 
adjuvant chemotherapy and patients continue to succumb to their disease as a result of 
recurrence and metastasis. 
 
Greater understanding of the biological processes that occur within the tumor could help 
in the future development of newer more rationally designed drugs. Moreover, an 
understanding of the molecular events that lead to tumorogenesis and/or progression 
could provide investigators with an opportunity to intervene with appropriate agents if 
and when a tumor recurs. Additionally, such an understanding could lead to early 
interventions and perhaps a chance for prevention or delaying progression of tumors. 
 
1.1 Epidermal growth factor receptor expression and its 
significance in cancer 
 
The control of cell growth is mediated by a complex network of signaling pathways 
responsive to external influences, such as growth factors, as well as to internal controls 
and checks.  Epidermal growth factor (EGF) was one of the first growth factors to be 
described.  It was shown to be mitogenic, an effect mediated by the binding of EGF to a 
cell surface EGF receptor (EGFR), stimulating auto-phosphorylation of the intracellular 
tyrosine kinase domain of the receptor.  Subsequent investigations revealed EGFR to be 
one of a family of closely related receptors that includes EGFR (HER1), HER2, HER3, 
and HER4. 
 
EGFR and other HER family members are considered to be important in the 
development, progression, and aggressive behavior of human epithelial malignancies 
and to be relevant therapeutic targets.   A number of human malignancies are 
associated with aberrant or over expression of EGFR.  Stimulation of tumor cells via the 
EGFR is important for both tumor growth and tumor survival in vivo.  Over-expression of 
EGFR in certain human tumors, including NSCLC, has been correlated with both chemo-
resistance and poor prognosis [4-10]. Inhibitors of EGFR tyrosine kinase activity (EGFR 
TKI's) have been in development for a number of years, and although earlier compounds 
lacked specificity and potency, newer compounds have proven active in non-clinical and 
clinical studies [11, 12]. 
 
A number of EGFR inhibitors have been approved for use in cancer patients. Small 
molecules like gefitinib (Iressa™) and erlotinib (Tarceva™) are used for the treatment of 
NSCLC. The monoclonal antibody cetuximab (Erbitux™) has been approved for the 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
treatment of patients with colorectal and head/neck cancer. In general, EGFR inhibitors 
have shown a good safety profile with rash and diarrhea as the most common adverse 
events. Trastuzumab (Herceptin™), a monoclonal antibody approved for treatment of 
HER2-positive breast cancer is relatively well tolerated and is widely used in various 
settings of breast cancer. Lapatinib (TykerbTM), a dual EGFR and HER2 TKI was 
recently approved for the treatment of metastatic breast cancer. 
 
1.2 The epidermal growth factor receptor (EGFR) mutations 
as a marker for treatment selection with EGFR tyrosine 
kinase inhibitors 
 
As detailed above, the epidermal growth factor receptor (EGFR) is one of a family of 
receptors that has growth-promoting effects in NSCLC. EGFR is over expressed in 
about 40-80% of NSCLC [13]. Downstream signaling by the activated EGFR can be 
abrogated by small molecule inhibitors, such as erlotinib and gefitinib or by monoclonal 
antibodies directed towards the extracellular domain of EGFR, such as cetuximab. 
Potential markers evaluated for response to these targeted agents include EGFR 
expression by immunohistochemistry (IHC), amplification by fluorescence in situ 
hybridization (FISH) and EGFR mutations [14, 15]. 
 
Mutations in the tyrosine kinase domain of the EGFR receptor were first discovered and 
reported in 2004[16-18]. They are more prevalent in never-smoking patients with 
adenocarcinoma. In frame deletions in exon 19 and the L858R point mutation in exon 21 
are the two most commonly seen activating mutations in the ATP binding pocket of the 
EGFR TK domain.  The probability of response to an EGFR-TKI is very strongly 
correlated with the EGFR mutation status. In a seminal phase III trial, previously 
untreated, never or light smoking patients with advanced lung adenocarcinoma from 
East Asia were randomized to receive gefitinib (250 mg per day) (n = 609) or 
carboplatin-paclitaxel (n = 608).  A total of 261 patients were positive for the epidermal 
growth factor receptor mutations. The objective response rate was 71.2% with gefitinib 
versus 47.3% with carboplatin–paclitaxel in the mutation-positive subgroup (P<0.001) 
and 1.1% (one patient) versus 23.5%, respectively, in the mutation-negative subgroup 
(P=0.001). In patients with EGFR mutations, progression-free survival was significantly 
longer among those who received gefitinib than among those who received carboplatin-
paclitaxel (HR for progression or death, 0.48; 95% CI, 0.36 to 0.64; P<0.001), whereas 
in the subgroup of 176 patients who were negative for the mutation, progression-free 
survival was significantly longer among those who received carboplatin-paclitaxel (HR 
for progression or death with gefitinib, 2.85; 95% CI, 2.05 to 3.98; P<0.001) [19]. 
 
The recent discovery of the strong association between EGFR TKI therapy and EGFR 
mutations has helped clarify the role of FISH as a predictor of response to TKI’s. In two 
similarly designed studies that compared EGFR-TKI therapy versus placebo namely the 
BR.21 (erlotinib versus placebo) and ISEL (gefitinib versus placebo) showed an 
improved outcome with erlotinib and gefitinib respectively, in patients with high EGFR 
gene copy [20, 21]. The perceived ability of EGFR FISH to predict response to EGFR-
TKI may be secondary to the fact that there is significant overlap between FISH positivity 
and presence of EGFR mutations. In the aforementioned IPASS trial, FISH positive but 
mutation negative patients derived little or no benefit from gefitinib (essentially behaving 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
like mutation negative patients) in contrast to FISH positive and mutation positive 
patients, suggesting that EGFR mutation status is the primary determinant of response 
to gefitinib or erlotinib [22]. 
 
In phase II trials the Spanish Lung Cancer Study (SLCS) group evaluated the feasibility 
of large-scale screening for EGFR mutations in patients with advanced NSCLC and 
analyzed the association between the presence of these mutations and the outcome of 
patients treated with erlotinib. From April 2005 through November 2008, non-small cell 
lung cancers from 2105 patients in 129 institutions in Spain were screened in a central 
laboratory for EGFR mutations. Patients with tumors carrying EGFR mutations were 
eligible for erlotinib treatment. EGFR mutations were found in 350 of 2105 patients 
(16.6%). Mutations were more frequent in women (69.7%), in patients who had never 
smoked (66.6%), and in those with adenocarcinomas (80.9%) (P<0.001 for all 
comparisons). The mutations were deletions in exon 19 (62.2%) and L858R (37.8%). 
Median progression-free survival and overall survival for 217 patients who received 
erlotinib were 14 months and 27 months, respectively. [23]. Indeed erlotinib in now the 
preferred modality of treatment in patients known to harbor sensitizing EGFR mutations, 
in the United States. In Europe, gefitinib in now approved for the treatment of patients 
with EGFR mutations. 
 
Treatment with erlotinib yielded a similar response rate of 70.6% [23] in EGFR mutation 
positive patients, in a trial conducted in Europe. The consequent therapeutic implications 
of these data are that treatment with an EGFR-TKI is appropriate, especially as first-line 
treatment if the patient’s tumors are EGFR mutation positive. If the mutation status is 
unknown or negative chemotherapy with or without bevacizumab would be more 
appropriate. 
Thus, EGFR mutations significantly predict for both an increased response to TK therapy 
and a favorable prognosis in patients with advanced lung adenocarcinoma, thereby 
making the presence of EGFR mutations one of the most clinically validated prognostic 
and predictive marker in NSCLC [19, 21, 24-27] 
 
1.3 The Responses to EGFR-TKI’s are transient and 
Development of Resistance to EGFR-TKI is universal 
 
Despite the dramatic responses to TKI’s, most if not all patients will ultimately develop 
resistance to these agents. Several mechanisms of resistance have been described one 
of them being the emergence of resistance mutations known as the T790M mutation. 
Kobayashi et al described the presence of a second point mutation, resulting in 
threonine-to-methionine amino acid change at position 790 of EGFR tyrosine kinase 
domain that leads to biochemical and structural alteration leading to resistance to TKI 
therapy [28]. Presence of this and other mutations seen on exon 20 of the EGFR-TK 
domain predict for non-response to TKI therapy. This necessitated the development of 
novel EGFR TKI which would be active even in the setting of presence of resistance 
mutations. 
 
 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
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1.4 EMT: 
significance, 
recognition, 
regulation 
and 
interaction with EGFR 
inhibition. 
 
In cancer, Epithelial Mesenchymal Transition 
(EMT) has been associated with a poor 
prognosis and, resistance to anti-EGFR, 
chemo and radiation therapies, chemo-, 
radiation and anti-EGFR therapies, the 
acquisition of tumor-initiating cell properties, and increased cell migration and invasion 
[29-34]. At the transcriptional level, EMT is mediated by ZEB1 and 2, Snail, Slug, Twist 
and E12/E47 [29] [35] [36] [37], as well as by microRNAs, including the miR-200 family, 
which negatively regulates ZEB1 and 2 [38] (Fig. 1). Classic changes in gene expression 
include loss of epithelial markers, such as E-cadherin, and up regulation of 
mesenchymal markers (e.g., Vimentin, Fibronectin, N-cadherin). The detection of EMT 
features in lung tumors is variable, being dependent on the markers used and the 
strength of their association with the mesenchymal phenotype [39, 40]. In addition, EMT 
may occur preferentially at the tumor periphery [41] and in a transient manner. EMT can 
be induced by growth factors produced in the stromal compartment, such as TGFβ and 
hepatocyte growth factor [42]. In tumor cells, EGFR signaling promotes features 
associated with EMT, including migration, invasion and down-regulation of E-cadherin 
[31]. Conversely, EMT reduces the dependence on EGFR signaling for activation of 
downstream pathways leading to growth and survival (PI3K-AKT-mTOR and RAS-RAF-
ERK pathways). This has been clearly demonstrated in NSCLC cell lines [34, 43]. 
However, EGFR inhibition can also lead to some EMT-associated changes, which 
mechanistically appears to involve cross-talk between receptors. For instance, in the 
H1703 NSCLC cell line, EGFR inhibition by erlotinib leads to increased phosphorylation 
of PDGFRα, a receptor associated with the mesenchymal phenotype [44]. Similarly, 
erlotinib treatment has been shown to increase formation of EGFR/IGF-IR heterodimers 
and downstream IGF-1R signaling [45]. Whether EMT-associated changes in gene and 
protein expression occur in response to EGFR inhibition in patients is largely unknown. 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
In lung cancer cell lines, we and others have reported that EMT features and the loss of 
E-cadherin are most significantly linked to the expression of ZEB1 and 2 [46-48]. 
Recently, we found that EpCAM, ST14, ESRP1 and ESRP2 were among the top genes 
most significantly negatively-correlated with ZEB1 [46] (Table 1). In contrast, E-cadherin 
ranked number 31, although the R-value was still highly significant. We were able to 
demonstrate that the expression of all four genes was responsive to ZEB levels and that 
ZEB1 binds E-box elements in their upstream regulatory regions, thus confirming that all 
four are direct ZEB1 targets. Moreover, among 109 tumors 25% had lost expression of 
ST14 or E-cadherin, but not both, suggesting that ST14 is a useful adjunct to E-cadherin 
staining for the detection 
of EMT-associated 
changes. 
 
We therefore analyzed 
the expression of ST14, 
ZEB1 and E-cadherin in 
109 NSCLC tumors 
using a Tissue Micro 
Array (TMA). 
 
In 57% of human 
tumors, ZEB1 nuclear 
staining was detected in cells predominantly located in the stromal compartment in 57% 
of human tumors whereas only a very low number of ZEB1 positive cells were found in 
the tumor compartment (11% of tumors) (Fig. 5A). Similar results were obtained for Snail 
staining (Fig. 5B). In contrast, E-cadherin and ST14 were found in the tumor 
compartment in positive samples (78 and 90% respectively). 
 
While E-cadherin and ST14 staining were significantly associated (p = 0.004), 28 tumors 
stained negative for one but positive for the other. These results suggest that ST14 in 
addition to E-cadherin can be useful for detection of EMT-like changes in NSCLC, since 
over 35% of tumors showed EMT features using the combined markers. 
 
In summary, to assess the true EMT status of a tumor we may have to evaluate multiple 
markers simultaneously. Such a comprehensive assessment of markers may be a more 
accurate representation of the EMT status. 
 
1.5 BIBW 
2992 
(Afatinib) 
 
Afatinib is a potent, irreversible 
EGFR/HER2 inhibitor that displays anti-
tumor efficacy both in vitro and in vivo. As 
a small molecule EGFR/HER2 receptor 
tyrosine kinase inhibitor, afatinib offers the 
opportunity to control both recurrent as 
well as distant metastatic disease on an 
outpatient basis. Continuous treatment 


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Version Date January 2016 
 
 
 
 
with afatinib has the potential to provide significant benefit to patients with advanced 
malignancies by inducing tumor responses or slowing of tumor progression and 
metastasis. Due to its mechanism of action, treatment with afatinib will result in a more 
selective anti-tumor activity than classical cytotoxic chemotherapeutics, which have an 
indiscriminate effect on all proliferating cells. Afatinib has shown, in preclinical models, 
that it can effectively inhibit ligand-induced EGFR and constitutive HER2 
phosphorylation, resulting in tumor growth inhibition and regression. Afatinib has shown 
efficacy signals in clinical trials and thus may represent an excellent drug candidate for 
the treatment of a variety of cancers. 
 
Afatinib combines EGFR and HER2-inhibiting properties and may exceed the efficacy of 
single EGFR-or HER2 inhibiting compounds. Objective responses to treatment so far 
have 
been observed in afatinib Phase I monotherapy and combination therapy trials in 
patients 
with non-small cell lung cancer (NSCLC), breast cancer, esophageal cancer and 
cholangiocarcinoma. Moreover, afatinib demonstrated clinical efficacy in Phase II trials in 
patients with NSCLC, HER2-positive Herceptin-refractory breast cancer and squamous 
cell 
cancer of the head and neck, and has demonstrated activity in a randomized Phase III 
trial in 
NSCLC. With the expected efficacy and safety profile of afatinib, the potential of 
significant 
1.6 benefit for cancer patients is anticipated. Currently 
afatinib is currently registered in the US for the first line 
treatment of metastatic NSCLC with common mutations 
Exon 19 deletions or Exon 21 (L858R) substitution 
mutations.  Window of opportunity trial designs and 
recently reported window of opportunity studies 
 
“Window of opportunity” trial designs in early stage NSCLC patients will allow for the 
evaluation of in vivo downstream effects of treatment with a specific compound with 
corresponding samples that otherwise might be difficult to obtain. There are a plethora of 
novel targeted agents currently under development in NSCLC. Universally, these 
compounds are used in the advanced stages of lung cancer, where, in most instances, 
biopsy specimens are very limited. This imposes an important limitation on correlative 
analyses and biomarker identification, while these compounds are undergoing 
development. Administering these compounds neoadjuvantly to surgically resectable 
patients allow for the examination of post-operative specimens for tumor status and 
possible treatment effects. In this proposal, we will administer BIBW 2992 (afatinib) to 
patients awaiting resection. The duration of treatment will extend from the time of 
enrollment to the day of surgery, which will be a minimum of two weeks given practical 
considerations of operating room and clinic scheduling. Hence, the curative resection will 
not be delayed. While most of these patients individually are unlikely to benefit directly 
from preoperative therapy, one goal is to obtain preliminary evidence for efficacy of 
EGFR/ERBB2 inhibition in early-stage patients, including those lacking EGFR activating 
mutations, which would have an impact on subsequent clinical trials with this agent. 


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Arguably, if a decrease in the standard uptake value (SUV) on the 18-fluorinated-
deoxyglucose positron emission tomography (FDG-PET) is documented then it can be 
reasonably assumed that the patient will have derived clinical benefit. In this proposal we 
will test the feasibility of this approach and attempt to discern the downstream 
consequences of treatment with afatinib (Please see correlative studies section). 
 
Several such window of opportunity studies has been reported. Haura et al conducted a 
trial of a brief course of preoperative gefitinib in early-stage NSCLC. Patient with early-
stage NSCLC received 4 weeks of gefitinib 250 mg daily before surgical resection. Pre- 
and post-treatment computerized tomography scans and positron emission tomography 
scans were used to assess clinical response. Gefitinib and surgical toxicity were 
evaluated. Tumor tissue was evaluated for gefitinib levels and was compared with 
plasma gefitinib levels. Activated signaling molecules including EGFR, STAT3, ERK, and 
AKT were examined in surgically resected tumor tissue. Twenty-three patients 
participated in the study, and all had surgical resection of tumors. No toxicities unrelated 
to known effects of gefitinib or surgery was encountered. Twenty-two patients had stable 
disease, and one had progression in tumor size. There was no correlation with positron 
emission tomography response and computerized tomography response. Tumor levels 
of gefitinib were approximately 40-fold higher than plasma levels, indicating potential 
tumor concentration of gefitinib. This study highlights feasibility and safety of this 
approach with 22 of 23 patients achieving stable disease and only one patient 
progressing on treatment. No increase in post-operative mortality was reported by these 
authors [49]. 
 
In a similarly designed trial, Lara-Guerra et al explored the use of preoperative gefitinib 
in clinical stage I NSCLC to assess tumor response, toxicity, and clinical and molecular 
predictors of response [50]. Patients were treated with gefitinib 250 mg/d for up to 28 
days, followed by mediastinoscopy and surgical resection in an open-label, single-arm 
study. Tumor response was evaluated by Response Evaluation Criteria in Solid Tumors. 
Blood samples and tumor biopsies were collected and analyzed for transforming growth 
factor α level, EGFR protein expression, EGFR gene copy number, and EGFR (exon 19 
to 21) and KRAS mutations. Thirty-six patients completed preoperative treatment 
(median duration, 28 days; range, 27 to 30 days). Median follow-up time is 2.1 years 
(range, 0.86 to 3.46 years). Three patients experienced grade 3 toxicities (rash, 
diarrhea, and elevated ALT). Tumors demonstrated EGFR-positive protein expression in 
83%, high gene copy number in 59%, EGFR mutations in 17%, and KRAS mutations in 
17%. Tumor shrinkage was more frequent among women and nonsmokers. Partial 
response was seen in four patients (11%), and disease progression was seen in three 
patients (9%). The strongest predictor of response was EGFR mutation. There was no 
peri-operative mortality. The authors concluded that preoperative window therapy with 
gefitinib is a safe and feasible regimen in early NSCLC and provides a trial design that 
may better inform predictors of treatment response or sensitivity [50]. 
 
1.7 In Summary 
 
In summary, in this protocol we will test the feasibility of administering BIBW 2992 in 
patients with early stage NSCLC awaiting a curative intent resection. This allows the 
patient to get a relatively non-toxic and well tolerated treatment while they await their 


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surgery. This approach also allows the investigators to discern the downstream 
molecular effects of treatment by analyzing the post-operative specimen, which in turn 
will enhance our understanding of the mechanisms of resistance and assist in future 
rational drug design. 
 
 


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 Objectives 
2
2.1 Primary objective 
 
The primary objective is to demonstrate the feasibility and tolerability of neoadjuvant 
treatment with BIBW 2992 in patients awaiting surgical resection. Patients will be 
monitored for toxicities and safety and will be followed for 30 days after surgery to 
assess post-operative morbidity. 
2.2 Secondary Objective 
 
Determine whether pre-operative BIBW 2992 treatment affects metabolic tumor labeling 
measured by PET-CT scanning according to PET Response Criteria in Solid Tumors 
(PERCIST), version 1.0 criteria. 
 
2.3 Correlative Objectives 
 
The correlative objectives are to discern the effects of BIBW 2992 treatment on the 
target, i.e. EGFR. Towards this goal our correlative aims are: 
 
• 
Both prior to and after surgery, measure the change in the total and 
phosphorylated EGFR to demonstrate target inhibition and assess the activation 
status of ERK1/2 and AKT by Western blots. 
 
• 
Determine the EMT status in BIBW 2992 treated tumors. This will include 
staining for ZEB1, Snail, E-cadherin, ST14, EpCAM, Vimentin and N-cadherin by 
immunohistochemistry (IHC), both within the tumor and at the boundary. Gene 
expression for these and other markers will be performed by quantitative real-
time RT-PCR (qRT-PCR). Microdissected tumor cells will be used for analysis of 
miR-200c levels. The met amplification status of the tumors will also be 
assessed. 
 
• 
To correlate any potential biological activity of BIBW 2992 with PET responses 
seen in the study subjects. 
 
A detailed analysis of the above mentioned parameters would enable us to 
comprehensively understand the downstream effects of treatment with BIBW 2992 and 
correlate these observations with the changes in the pre and post treatment PET-CT 
Scans. 
 
 
 
 
 
 
 


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 Study Endpoints 
3
 
This is a single arm, open-label, phase II trial to demonstrate the feasibility of 
neoadjuvant treatment with BIBW 2992 in resectable patients with NSCLC. 
 
3.1 Definition of primary endpoint: 
The primary endpoint will demonstrate feasibility of neoadjuvant treatment of BIBW 2992 
in patients with early stage (IA to IIIA) NSCLC awaiting surgical resection.  Feasibility will 
be assessed based on the ability to complete the treatment for each patient.  For our 
feasibility endpoint we will declare the treatment “completed” if a patient completes at 
least 14 days of treatment, had a thoracotomy for the planned surgical resection, and 30 
days of post operative care.  
 
3.2 Definition of secondary endpoint: 
To measure the absolute and the percentage change in SUV from pre to post operative 
PET-CT. 
 
 
 Study centers 
4
 
University of Texas MD Anderson Cancer Center will lead this study and all patients will 
be enrolled at this institution.  
 
 
 
 
 
 
 
 
 
 


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 Selection of Study Subjects 
5
5.1 Overview 
5.1.1 Inclusion Criteria 
• 
Histologically confirmed NSCLC, who are deemed to be surgical candidates by 
standard criteria.  Patients with all types of NSCLC (e.g., adenocarcinoma, 
squamous cell carcinoma) will be allowed to enroll. Patients with Stage IA to IIB 
disease.  Select patients with resectable stage IIIA disease (T3N1, T4N0, T4N1) 
will also be eligible if approved by the PI. 
• 
ECOG Performance Status 0-1 
• 
Measurable disease by RECIST 1.1 criteria  
• 
Mediastinoscopy and/or Endoscopic Bronchial Ultrasound (EBUS) and/or 
Endoscopic Ultrasound (EUS) for complete surgical staging when clinically 
indicated 
• 
Serious, active infections must be controlled. Patients may be enrolled while still 
on antibiotics as long as clinical signs of active infection have resolved. 
• 
A signed informed consent document (ICD) 
• 
Patients 18 years or older 
• 
Able and willing to take oral medications 
5.1.2 Exclusion Criteria 
• 
Known preexisting interstitial lung disease, interstitial pulmonary fibrosis, or 
connective tissue disorder associated lung disease.    
• 
Known N2 nodal disease or distant metastatic disease 
• 
History or presence of clinically relevant cardiovascular abnormalities such as 
uncontrolled hypertension, congestive heart failure NYHA classification of 3, 
unstable angina or poorly controlled arrhythmia. Myocardial infarction within 6 
months prior to randomization. 
• 
Patients with any of the following lab values at screening should be excluded: 
o Absolute neutrophil count (ANC) < 1500 / mm3 
o Platelet count < 100,000 / mm3 
o Serum creatinine ≥1.5 times the upper normal limit or 
calculated/measured creatinine clearance ≤60 mL/min 
o Bilirubin ≥1.5 mg/dL (>26 mol/L, SI unit equivalent) 
o Aspartate amino transferase (AST) or Alanine amino transferase (ALT) ≥ 
three (3) times the upper limit of normal.  
• 
Active hepatitis B infection, active hepatitis C infection or known HIV carrier. 
• 
Known or suspected active drug or alcohol abuse.   
• 
Significant or recent acute gastrointestinal disorders with diarrhea as a major 
symptom e.g. Crohn's disease, malabsorption or CTC grade ≥2 diarrhea of any 
etiology. 


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• 
Baseline (<1 month before treatment) cardiac left ventricular function with resting 
ejection fraction of less than 50% measured by multigated blood pool imaging of 
the heart (MUGA scan) or echocardiogram 
• 
Patients receiving other investigational agent.. 
• 
History of allergic reactions to anilinoquinazolins like gefitinib, erlotinib or BIBW 
2992 
• 
Uncontrolled intercurrent illness that would preclude a patient from undergoing 
surgery 
• 
Psychiatric illness/social situations that would limit compliance with study 
requirements. 
• 
Pregnant (positive pregnancy test) or lactating 
• 
Inability to comply with study and/or follow-up procedures 
• 
Patients who are not surgical candidates or refuse surgery 
 
5.1.3 Follow up and criteria for withdrawal from study. 
Patients will be followed for 30 days after surgery. After 30 days patients will be taken off 
study. Patients may receive adjuvant radiation therapy and chemotherapy as clinically 
indicated. Patient’s primary care giver will determine further follow up. 
 
Criteria for withdrawal from study are the following: 
 
• 
Completion of study and the requisite 30 day post-operative follow up 
• 
Withdrawal of consent 
• 
Investigator can withdraw patient from the trial if they feel it is not in the patient’s 
best interest to continue on study. If this is indeed the case the reason for 
withdrawal should be clearly documented. 
• 
Investigator can withdraw patient from the trial if the patients has missed more 
than 7 doses of the BIBW2992. 
• 
Patients will discontinue treatment if they experience deterioration in left 
ventricular cardiacfunction (LVEF) to CTCAE Grade ≥3. 
• 
Patients will discontinue treatment if they are diagnosed with ILD (Interstitial Lung 
Disease).  
 


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5.2 Study Plan 
5.2.1 REGISTRATION PROCEDURES 
5.2.2 General Guidelines 
 
Following registration, patients should begin protocol treatment within 2 weeks.  Issues 
that would cause treatment delays should be discussed with the Principal Investigator.  If 
a patient does not receive protocol therapy within 2 weeks following registration, the 
patient’s registration on the study may be canceled at the discretion of the study 
investigators and the patient will be considered a screen failure.  Research staff should 
be notified of cancellations as soon as possible. 
 
5.2.3 Study period 
The planned duration of the treatment will extend from the time of enrollment to the day 
of surgery, which will be between 2-3 weeks given practical considerations of operating 
room and clinic scheduling. The curative resection will not be delayed to participate in 
the study. 
 
The planned duration of the entire study per patient (enrollment period + the treatment 
period + a follow-up period of 30 days) is approximately 3 months. 
5.2.4 Detailed treatment plan 
 
BIBW 2992 Administration 
 
BIBW 2992 at a dose of 40 mg, orally daily will be taken by patients on an empty 
stomach (one hour prior to meals) at the same time every day.  
 
Patient will be treated for a minimum of 14 days and until the day of surgery. The 
timing should be such that BIBW 2992 is continued, in the absence of toxicities, until the 
day of surgery.    
 
Twenty patients who are deemed to be appropriate surgical candidates will be enrolled. 
Pre treatment PET and CT will be obtained in addition to collecting pre-treatment tumor 
biopsies (prefer a core), mediastinoscopy in the appropriate patient (to appropriately 
stage patients), and pre-treatment, pre-surgery, and post surgery blood sample 
collection for other exploratory analysis.   Patients will then be treated with 40 mg/day of 
BIBW2992 for the duration specified above. The EGFR mutational status for all non-
squamous patients will be determined. Enrollment however will not be confined to non-
squamous patients and patients with all histologies will be allowed to enroll. Patients will 
then undergo surgical resection of their tumors at the end of this three-week treatment 
period. Prior to surgery, every patient will receive a second PET and CT scan in addition 
to collection of blood samples for exploratory analyses.  Pre-treatment biopsy sample 
and post surgery tumors will be tested for evidence of target protein/gene expression 


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inhibition. All tumor samples will be subject to tissue microarray construction and 
analysis. Every patient will serve as his/her own control using the pre treatment biopsy 
and blood sample as a control. 
5.2.5 General Concomitant Medication and Supportive Care 
Guidelines 
Because there is a potential for interaction of BIBW 2992 with other concomitantly 
administered drugs through the cytochrome P450 system, the case report forms must 
capture the concurrent use of all other drugs, over-the-counter medications, or 
alternative therapies.  The Principal Investigator should be alerted if the patient is taking 
any agent known to affect or with the potential to affect selected P450 isoenzymes. 
Please see Appendix 4. 
5.2.6 Duration of Therapy 
In the absence of treatment delays due to an adverse event(s), BIBW2992 treatment 
should continue up to surgery or until one of the following criteria applies: 
 
• 
Unacceptable adverse event(s), 
• 
Patient decides to withdraw from the study, or 
• 
Patient undergoes surgical resection. 
• 
If the patient is deemed unresectable then patient will be taken off study.  
5.2.7 Evaluations During Treatment 
 
Pre-Treatment Evaluation 
 
The following evaluations should take place within 14 days of enrollment unless 
otherwise indicated: 
• 
Informed Consent 
• 
CBC with differential and platelets 
• 
Serum Chemistry: potassium, calcium, sodium, bicarbonate, total protein, 
albumin, glucose, blood urea nitrogen, serum creatinine, and liver function tests 
including serum bilirubin, SGOT(AST), SGPT(ALT), and alkaline phosphatase 
• 
PT/PTT/INR 
• 
MUGA Scan within 4 weeks from study entry 
• 
PET-CT scan within 4 weeks from study entry 
• 
Medical History and Physical examination will be performed within 14 days of 
enrollment and will include performance status (refer to appendix 2), heart rate 
and blood pressure, weight, height, concurrent medications, review of systems, 
and adverse event evaluations. Smoking history information should also be 
obtained from the patient. See the enclosed smoking history questionnaire in 
Appendix 5. 
• 
B-HCG needs to be performed in sexually active premenopausal female patients 
• 
Tumor Biopsy (Obtain EGFR mutational status of the tumor, although mutational 
status is not needed to start treatment with the study agent).  Diagnostic biopsy is 
sufficient, provided there are at least 10 unstained slides available for analyses.  
If the initial diagnostic biopsy does not provide sufficient tissue, a core needle 
biopsy will be performed as part of the study 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
• 
Blood collection for correlative studies. 
Performed once a week while on BIBW2992 treatment 
• 
Medical History and Physical examination including performance status (refer to 
appendix 2), heart rate and blood pressure, weight, concurrent medications, and 
review of systems. 
• 
Adverse Event (with CTCAE v. 4 grading) recording/monitoring 
• 
Complete Blood Count with differential, platelets 
• 
Serum Chemistry: potassium, calcium, sodium, bicarbonate, total protein, 
albumin, glucose, blood urea nitrogen, serum creatinine and liver function tests 
including serum bilirubin, SGOT (AST), SGPT (ALT), and alkaline phosphatase 
• 
Review of patient’s BIBW2992 diary and pill count 
 
Pre-Surgical Evaluation (Within a Week of Surgery) 
• 
Medical History and Physical examination including performance status (refer to 
appendix 2), heart rate and blood pressure, weight, concurrent medications, and 
review of systems. 
• 
Adverse Event (with CTCAE v. 4 grading) recording/monitoring 
• 
CBC with differential and platelets 
• 
Serum Chemistry: potassium, calcium, sodium, bicarbonate, total protein, 
albumin, glucose, blood urea nitrogen, serum creatinine and liver function tests 
including serum bilirubin, SGOT (AST), SGPT (ALT), and alkaline phosphatase 
• 
PET-CT Scan 
• 
MUGA Scan 
• 
Review of patient’s BIBW2992 diary and complete pill count 
 
Surgery 
• 
Review of patient’s BIBW2992 diary and complete pill count. Patient’s last dose 
of BIBW2992 should be within 24 hours of time of surgery. All remaining 
investigational drug should be collected and returned to the investigational 
pharmacy to be reconciled with the drug accountability log. The patient’s drug 
diary should be collected and filed in the patient research record as source 
documentation. 
• 
Blood collection for correlative studies.  
• 
Assessment of concomitant medications 
• 
Intra-operative biopsy and tumor resection tissue collection for correlative 
studies.  
 
30-day Post-Surgery or End of Study Evaluations 
(to be completed thirty days after surgery or after resolution of all treatment related 
adverse effects whichever comes later) 
• 
Full physical exam with performance status, vital signs, weight, review of 
systems 
• 
CBC with differential and platelets 
• 
Serum Chemistry: potassium, calcium, sodium, bicarbonate, total protein, 
albumin, glucose, blood urea nitrogen, serum creatinine and liver function tests 
including serum bilirubin, SGOT (AST), SGPT (ALT), and alkaline phosphatase 
• 
Adverse Event (with CTCAE v.4 grading) related to study agent 
recording/monitoring until resolved to ≤ grade I 


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Duration of Follow Up 
Patients will be followed until resolution of all study related adverse events or 30 days 
after surgery, whichever comes later. 


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5.2.8 Table of Studies 
   
Pre-
Studyb 
Wk 
1 
Wk 
2 
Within 
a week 
prior to 
surgery 
Day of 
surgery 
Off Studyf 
 
Study agenta  (orally daily) 
 
 
 
X 
 
X 
 
X 
Last dose of 
BIBW 2992 
should be taken 
within 24 hrs of 
surgery 
 
 
Informed consent 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
 
Xh 
 
X 
 
X 
 
X 
 
 
 
X 
 
Physical exam and       
vital signs 
 
X 
 
X 
 
X 
 
X 
 
 
X 
 
Height 
 
X 
 
 
 
 
 
 
 
 
 
 
Weight 
 
X 
 
X 
 
X 
 
X 
 
 
X 
 
Performance status 
 
X 
 
X 
 
X 
 
X 
 
 
X 
Concomitant medication 
X 
X 
X 
X 
X 
 
 
CBC w/diff, platelets 
 
X 
 
 
 
X 
 
X 
 
 
X 
 
Serum chemistryc 
 
X 
 
X 
 
X 
 
X 
 
 
X 
 
B-HCGd 
 
X 
 
 
 
 
 
 
 
 
 
 
PT/PTT/INR 
X 
 
 
 
 
 
MUGA 
Xg 
 
 
X 
 
 
 
Adverse event evaluation 
X--------------------------------------------------------------------------- X 
Tissue collection 
(Required) 
X 
 
 
 
X 
 
Correlative Blood 
collection 
(Required) 
X 
 
 
 
X 
 
PET-CT Radiologic 
evaluatione 
X 
 
 
X 
 
 
a = BIBW 2992 (Afatinib) orally daily will be taken by patients on an empty stomach (one hour prior to 
meals) at the same time every day. The enrolling site must provide a drug diary to the patient and conduct a 
pill count and diary review each week during the patient’s visit. The diary should be collected and filed in the 
patient record as source documentation. 
b = Pre-study evaluations to be completed within 14 days of registration unless otherwise noted. 
c = Serum Chemistry: potassium, calcium, sodium, bicarbonate, total protein, albumin, glucose, blood urea 
nitrogen, serum creatinine and liver function tests including serum bilirubin, SGOT (AST), SGPT (ALT), and 
alkaline phosphatase. 
d = B-HCG needs to be performed in sexually active premenopausal female patients.                                                              
e = Screening includes PET-CT within 4 weeks of study entry. Prior to surgery a PET-CT should be 
repeated 
f = Thirty days +/- 10 business days after surgery or after resolution of all treatment related adverse effects 
whichever comes later. 
g= MUGA scan at time of screening can be done within 4 weeks of study entry.                                                         
h= At the time of patient screening, obtain smoking history information from patient. See Appendix 5. 


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 Correlative Studies 
6
 
Window of opportunity trial designs such as the one outlined in this proposal allow us to 
evaluate, in detail, the in vivo downstream effects of treatment with BIBW 2992. In 
addition to assessing tumoral response to treatment, we will subject the resected 
specimen to detailed analyses to evaluate the extent of target and pathway inhibition. 
The goals of the correlative components of the study are: 
 
1.  Determine total and phosphorylated EGFR to validate target inhibition and assess the 
activation status of ERK1/2 and AKT by Western blots. 
 
2.  Determine the Epithelial Mesenchymal Transition (EMT) status in BIBW 2992 treated 
tumors. This will include staining for specific markers that informs us about the EMT 
status of the tumor. These markers may include but not limited to, ZEB1, E-cadherin, 
Vimentin and N-cadherin, and will be evaluated by immunohistochemistry (IHC), both 
within the tumor and at the boundary. Gene expression for these and other markers will 
be performed by quantitative real-time RT-PCR (qRT-PCR). Microdissected tumor cells 
will be used for analysis of miR-200c levels. 
 
6.1.1 Outline of correlative studies to be performed on tumor 
specimens 
To contextually interpret the data obtained from the studies outlined above, we will test 
the post-resection specimen for sensitizing and resistant EGFR mutations, KRAS 
mutations and if negative for both and if the clinical circumstances warrant it, then for 
EML4-ALK translocation. 
 
The following tests to be performed in each of the tumor specimens: 
 
1. Pre treatment diagnostic biopsy specimen: this tissue is expected to be scant 
and it is anticipated that we will be able to run only one or two of the below 
specified markers on this specimen. The marker we will run on this specimen will 
be decided on a case-by-case basis based on the findings on the post treatment 
specimen. 
 
2. Intra-operative post-resection biopsy specimen: total and phosphorylated EGFR, 
ERK1/2 and AKT will be estimated by Western blots. Gene expression will be 
performed by qRT-PCR for ZEB1, Snail, E-cadherin, ST14, EpCAM, ESRP1, 
Vimentin and N-cadherin.  
 
3. Post clinical assessment residual specimen. EGFR mutations, KRAS mutations, 
BRAF, HER2, MET, EML4/ALK (if indicated) and FGFR; IHC staining for ZEB1, 
Snail, E-cadherin, ST14, EpCAM, Vimentin and N-cadherin within the tumor and 
at the boundary. Microdissected tumor cells will be used for analysis of miR-200c 
levels. 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
As part of the study, a tissue and blood sample repository will be created.  The objective 
of this tissue sample repository will be to provide material for future evaluations of other 
relevant biomarkers that may be associated with clinical outcomes. A written informed 
consent will be obtained from patients enrolled in this study so that these samples may 
be analyzed in the future for biomarkers not described in this protocol. 
 
Clinical parameters such as gender, smoking status and stage will be correlated with 
changes in SUV between the pre-treatment and post-treatment PET Scans and changes 
or status of the aforementioned biomarkers. Owing to the small sample size statistically 
significant associations are not expected. Please see the statistical section below for 
details of statistical assumptions for this trial. Additionally, for technical reasons, we may 
not be able to perform one or more of these assays. Inability to perform one or more of 
these assays WILL NOT be considered a protocol violation. 
 
In order to preserve the phosphorylation state of proteins, tumor specimens will be flash 
frozen. Antibodies that detect total and specific phosphorylation sites on EGFR, such as 
phospho-EGFR-Y1068, will be used for this analysis. Affects on downstream signaling 
pathways including ERK and AKT will be examined using anti-phospho-ERK1/2 
(T202/Y204) and anti-phospho-AKT-S473 antibodies, respectively. Positive and negative 
control lysates will be prepared from cultured NSCLC cell lines treated or not with BIBW 
2992. Antibodies detecting total phospho-tyrosine, phospho-actin (Tyr-53) or phospho-
tubulin (Tyr-272) will be utilized for comparisons.  
 
Total protein levels of ZEB1, Snail, E-cadherin, Vimentin, ST14, EpCAM and N-cadherin 
will be first measured by Western blot on post-operative biopsies. EMT markers will 
further be localized by IHC on formalin-fixed paraffin-embedded sections of tumors, 
including the tumor boundary, and normal adjacent tissues [46]. Stained slides will be 
scanned with the Aperio system (Aperio Technologies, Inc., Vista, CA) available through 
our Colorado SPORE collaborators, Drs. W. Franklin and D. Merrick. Samples will be 
scored (from 0 to 300) by multiplying the percentage of positive cells (0 to 100%) by the 
average level of staining intensity (0 to 3). 
6.1.2 Assessment of Expression of EMT-associated genes 
RNA and protein levels of EMT-associated genes will be measured from tissue samples 
prepared from biopsies and excised tumors. Total RNA will be extracted with TRIZOL 
that allows recovery of both mRNAs and microRNAs. cDNA will be prepared by reverse 
transcription and expression analysis for specific genes will be performed with an ABI-
7500 Fast machine with SYBR Green chemistry [51]. Ct values will be normalized using 
the geometric mean of 4 control housekeeping genes (GAPDH, HPRT1, RPL13A, 
YWHAZ) [52]. Splicing assays for six ESRP targets will be performed using RT-PCR 
combined with gel electrophoresis, as described [53]. 
 
MicroRNA miR-200c, a negative regulator of ZEB1 and ZEB2, will be quantified with the 
TaqMan MicroRNA assay from Applied Biosystems and standardized with the RNU6B 
control (Applied Biosystems). 
 
Protocols used for qRT-PCR and Immunohistochemistry is well established in the lab 
and we anticipate no substantial technical issues. 


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6.1.3 Interpretation of results and correlation with clinical 
findings: 
We will correlate the clinical observations, principally changes in the standard uptake 
value seen in the PET scan as a consequence of treatment with BIBW 2992 with 
changes in gene and protein expression. To further enable the contextual interpretation 
of data we will also assess MET amplification, EGFR and KRAS mutations status in the 
post-operative specimen. We expect that this overall tumor profiling will allow for a more 
comprehensive understanding of the molecular effects associated with BIBW 2992 
treatment. 
 


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 Investigational Medicinal Product 
7
 
BIBW 2992 is a highly potent, irreversible inhibitor of the EGFR and HER2. It has shown 
in preclinical models that it can effectively inhibit ligand-induced EGFR and constitutive 
HER2 phosphorylation resulting in tumor growth inhibition and regression. BIBW 2992 
thus may represent an excellent drug candidate for the treatment of a variety of cancers 
and has shown efficacy signals in clinical trials. BIBW 2992 combines EGFR and HER2-
inhibiting properties and may exceed the efficacy of single EGFR-or HER2 inhibiting 
compounds. Objective responses to treatment so far have been observed in BIBW 2992 
phase I monotherapy and combination therapy trials in patients with NSCLC [54], breast 
cancer, esophageal cancer and cholangiocarcinoma. Moreover BIBW 2992 
demonstrated clinical efficacy in phase II trials in patients with NSCLC and HER2-
positive, Herceptin refractory breast cancer. With the expected efficacy and safety profile 
for BIBW 2992, there is the potential of significant benefit for NSCLC patients.  Afatinib is 
currently registered in the US for the first line treatment of metastatic NSCLC with 
common mutations Exon 19 deletions or exon 21 (L858R) substitution mutations.  
Please see Afatinib Investigator Brochure (version 14) for further details. 
7.1 NONCLINICAL STUDIES 
 
NONCLINICAL PHARMACOLOGY 
7.1.1 In vitro pharmacological profile 
BIBW 2992 potently inhibits the activity of the EGFR and HER2 kinases with IC50 values 
of 0.5 nM and 14 nM, respectively (U02-1351) and does not display any significant 
inhibitory activity in a larger panel of protein kinases and in receptor-ligand binding 
assays when tested at higher concentrations of 2 11M or beyond demonstrating high 
selectivity of this compound (U02-1083). The inhibitory activity of BIBW 2992 was 
confirmed at the cellular level (U02-1391) in short term receptor phosphorylation assays 
(EGFR: EC50 = 13 nM, A431cells; HER2: EC50 = 35 nM, BT-474 cells). In line with this 
data, BIBW 2992 inhibited proliferation ofBT-474 cells in a 72-hours assay with an EC50 
value of 12 nM. BIBW 2992 carries a Michael acceptor group to allow covalent binding to 
specific cysteine residues within the catalytic cleft of the targeted enzymes (Cys773 in 
EGFR and Cys805 in HER2: P02-07508). As expected, prolonged duration of action was 
observed in cellular washout experiments (U03-1 086): showing that A431 cells failed to 
respond to EGF stimulation 7 hours after compound removal whereas cells exposed to 
reversible inhibitors displayed full EGFR activation. Evaluation of the A431 response 24 
hours and 48 hours after compound removal showed that all treated cells could be 
stimulated with EGF, indicating that inhibition by BIBW 2992 is fully reversible 
presumably due to de novo receptor biosynthesis (R02-2291). 
 
In 2004, a series of novel activating mutations within the EGFR kinase domain were 
described in tumors from NSCLC patients who responded to erlotinib or gefitinib therapy 
(R06-1262). The mutant receptors EGFRL858R and the exon-19 deletions EGFR 
account for more than 85% of activating mutations. About 50% of patients who initially 
respond, but subsequently relapse on erlotinib/gefitinib treatment have acquired a 
secondary mutation (T790M) in the EGFR kinase domain (R06-1263, R06-1264). In vitro 


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Version Date January 2016 
 
 
 
 
experiments (U07-1338) using NSCLC cell lines with activating and resistance EGFR 
mutations (P06-08275, P06-08277, R06-2786 and R06-1267) revealed that BIBW 2992 
inhibits receptor activation and proliferation of all cells tested. The inhibitory activity of 
BIBW 2992 on the erlotinib/gefitinib resistant EGFR L858R/T790M double mutant was 
also observed in molecular kinase assays (U07-1338). In addition, BIBW 2992 inhibits 
growth of cells harboring other clinically relevant mutations of the EGFR receptor (e.g., 
EGFRvIII, D770_N77lins NPTG or H773_V774insH). Erlotinib was tested in parallel in 
these cellular models and was less potent if active at all. BIBW 2992 also inhibits the 
proliferation of NCI-HI781 NSCLC cells displaying wild type EGFR and mutated HER2 
receptors (G776VinsC). The clinical incidence ofHER2 mutations reported so far is low 
«5% of all NSCLC and around 10% in adenocarcinomas) but remains to be further 
explored. Taken together, our results and the published data using EGFR inhibitors 
(R06-1267) suggest that irreversible inhibition confers advantages over first generation 
reversible inhibitors. 
7.1.2 In vivo efficacy 
Several human tumor cell lines known for their sensitivity to monoclonal antibodies to 
EGFR (e.g. A431, R01-0007) or HER2 e.g. MDA-MB-453 (R03-0825) were used to 
establish subcutaneous tumor xenograft models in nude mice. Mice bearing established 
tumors were randomized into treatment and control groups. 
7.1.3 Single-agent efficacy in human cancer xenograft models in 
nude mice 
BIBW 2992 is bioavailable after oral administration in several species and, in mice, 
reaches efficacious plasma exposure with once daily dosing throughout the treatment 
period. In nude mouse xenograft models of human cancer, BIBW 2992 at tolerated 
doses induced regression of established subcutaneous tumors derived from four human 
cell lines known to co-express erbB receptors (A431 vulvar carcinoma (U02-1702), NCI-
N87 gastric carcinoma, SKOV-3 ovarian carcinoma, MDA-MB-453 breast carcinoma 
(U02-1614, U02-1660 and U02-1703 respectively). In these studies, the maximum 
plasma concentration of BIBW 2992 ranged between 80 and 285 nM with corresponding 
AUCO-24h between 0.6 and 3.2 flM*h at the MTD dose of 20 mg/kg. BIBW 2992 
exposure in this range should result in anti-tumor efficacy in patients, and initial clinical 
results seem to corroborate the preclinical assumption as objective responses have 
been observed in lung cancer patients, breast cancer patients and HNSCC patients at 
the targeted plasma exposure and below. 
7.1.4 Activity of BIBW 2992 in breast cancer tumor models 
In addition to the MDA-MB-453 data reported above (U02-1703) BIBW 2992 achieves 
full anti-tumor efficacy (TIC = 2%) in the BT-474 breast cancer xenograft model known to 
be driven in part by HER2 over-expression and to be responsive to Herceptin treatment 
(TIC 20%). The superior activity of BIBW 2992 in this model could in part be explained 
by the dual EGFR and HER2 inhibition concept as, in the same model, erlotinib 
treatment (selective EGFR inhibition) at MTD results in a TIC of 32%, suggesting a role 
for EGFR in this context. Additional preclinical data indicate that a subset of breast 
tumors might actually be driven by EGFR signaling. This concept is supported by data 
showing that BIBW 2992 achieves full anti-tumor efficacy (TIC = II %) in a HER2-positive 
but Herceptin-resistant tumor model (SUM-190) expressing high levels of EGF receptor 


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and EGFR ligands (U09-1455-0 1). Because the EGFR selective inhibitor erlotinib used 
at MTD (75 mg/kg/d) also showed activity (TIC = 20%) it is tempting to speculate that 
increased expression of EGFR and EGF ligands is involved in Herceptin resistance. The 
concept is further supported by published data showing increased EGFR and EGF 
ligand mRNA expression in the BT-474 HR breast cancer tumor model that has become 
resistant to Herceptin (R08-5278).  Further evidence for a role of EGFR signaling in 
breast cancer was obtained using SUM-149 xenografts. In this triple-negative breast 
cancer model (estrogen- and progesterone-receptor negative with low expression 
ofHER2) BIBW 2992 achieved full anti-tumour activity (TIC<10%) at MTD. Because 
Herceptin was completely ineffective and erlotinib was active in this preclinical model, 
the anti-tumor activity of BIBW 2992 in SUM-149 is most likely related 
to its EGFR inhibition. Consistently, a high expression of EGF-ligands (amphiregulin, 
epiregulin and TGF) was detected in SUM-149 tumors supporting the notion of 
EGFdependent proliferation in some breast cancer subtypes. Of note, high expression of 
EGF ligand and EGF receptor mRNA was observed in a subset of triple negative BC 
patients (approximately 5% of the mBC population) in a retrospective analysis combining 
data on 428 patients from different databases. This data combined with the preclinical 
observations (U09-1454-01) warrant testing of BIBW 2992 in triple-negative BC patients. 
 
7.1.5 Activity of BIBW 2992 in NCSLC tumor models resistant to 
first generation EGFR inhibitors. 
Based on the irreversible mode of binding and the available in vitro data, anti-tumour 
activity in NSCLC models harboring the EGFR L858RJT790M mutant was anticipated 
for BIBW 2992. In vivo testing of BIBW 2992 at maximum tolerated dose in the Hl975 
xenograft model expressing the EGFR L858RJT790M double mutant as well as in 
transgenic mice developing lung tumors upon induction of the EGFR L858RJT790M 
confirmed the hypothesis (P08-06904). 
 
 
At the time of data cut-off on 6 Ju12010 (8 Ju12010 for Study 1200.23), 1797 patients 
had been exposed to afatinib. Afatinib was administered to 100 healthy volunteers in an 
ADME study (1200.25), two bioavailability trials (1200.35 and 1200.80) and a drug-drug 
interaction study (1200.79). More than 150 patients have been treated in Phase I 
monotherapy trials. A total of 409 patients were treated in Phase I or II combination 
trials, including four trials with the combination of afatinib and BIBF 1120 (safety data 
from patients in these trials treated with BIBF 1120 alone are included in the BIBF 1120 
investigator's brochure). Phase II trials of afatinib have focused on non-small cell lung 
cancer (NSCLC), breast cancer, head and neck squamous cell carcinoma (HNSCC), 
and glioma. In Phase III trials, more than 800 patients have been treated (either with 
afatinib or control treatment). 
 
In addition to the Phase III trials in NSCLC, two more Phase III trials were close to 
beginning enrollment of patients at the time of data cutoff. Phase III Trial 1200.34 in 
NSCLC is similar to 1200.32: it is being conducted in different countries and uses a 
different comparator chemotherapy regimen (cisplatin-gemcitabine as opposed to 
cisplatin-pemetrexed). Study 1200.75 is a randomized Phase III trial in advanced breast 
cancer in patients pre-treated with trastuzumab comparing afatinib plus vinore1bine 
versus trastuzumab plus vinorelbine. 


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The following information is based on the data collected from eight Phase I dose 
escalation studies with BIBW 2992. 
 
Cancer Patients 
Afatinib Mean plasma concentration-time profiles were comparable for the individual 
dose groups tested, exhibiting at least biexponential disposition kinetics and increased 
with increasing doses (U I0-1153-0 1). A moderate to high variability was observed for 
the plasma concentrations e.g., for the 40 mg dose group with gCVs ranging from 50.8 
to 221 %. A similar variability range was observed in the other dose groups ranging from 
10 to 100 mg. (refer to UIO-1153-01). Maximum plasma concentrations mainly occurred 
at 2 to 5 hours after drug administration. Accumulation ratios based on AUC ranged from 
2.27 to 3.40 and were higher than the ratios based on Cmax (range of gMean values: 
1.68 to 2.67) - (refer to UIO-1153-01). Overall gMean pharmacokinetic parameters of 
afatinib in cancer patients from Trials 1200.1, 1200.2, 1200.3 and 1200.4 (dose range 10 
to 100mg) (refer to UIO-1153-01). Statistical analysis confirmed that steady state was 
attained after 8 days of afatinib treatment at the latest. It should be noted that there was 
no pre-dose plasma concentration data available before the 8th day due to the visit 
schedules in the analyzed studies. Afatinib trough values were stable over the observed 
treatment period and their intra-individual variability determined per dose group was 
moderate (gCVs ranging from 22.19% to 67.50%) (UIO-1153-01). 
7.1.6 Distribution 
Afatinib exhibited similar disposition characteristics after oral administration at all dose 
levels after single dose and at steady state, which could be described by at least 
biexponential disposition kinetics. In cancer patients afatinib showed a high apparent 
volume of distribution during the terminal phase both after single dose and at steady 
state (Vz/F and Vz/F,ss) which might indicate a high tissue distribution of the drug 
(U 10-1153-0 I). However, the respective values should be interpreted with caution as 
the absolute bioavailability (F) of afatinib in humans is not known. 
7.1.7 Safety 
All Phase I monotherapy trials with BIBW 2992 with a starting dose of 40mg have been 
reported.  Overall, 96.1% and 90.0% of patients receiving BIBW 2992 experienced 
diarrhea and skin rash-acne. Other common AE’s (regardless of assessment of 
relatedness) included stomatitis (72.1%), nail effect (58.8%), fatigue (30.1%), decreased 
appetite (30.6%), dry skin (31.4 %), vomiting (25.3%), epistaxis (17.9%), pruritus 
(21.4%), nausea (27.9%), cough (17.0%), headache (16.6%), constipation (16.2%), 
insomnia (16.2%), rhinorrhoea (17.0%), back pain, (15.7%), and weight decrease in 
18.8% of the patients were observed. The majority of these events were either CTCAE 
Grade 1 or 2. Grade 3 AE’s include diarrhea (153%), rash (16.2%), vomiting (4.4%), nail 
effect and fatigue (8.1%), stomatitis and decreased appetite (6.4%),, nausea (1.3%),.  
Grade 4 AE’s only included stomatitis (0.4%). 
 Dose and Schedule of Test Drug. 
8
 
BIBW 2992 will be administered once daily orally. The treatment will start from the time 
of enrollment to the day the patient goes to surgery. 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
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8.1 Dosing Delays/Dose Modifications 
 
The over arching guiding principal here is that every attempt will be made to avoid any 
delay in the surgical resection of the tumor. Although significant hematologic toxicities 
with this agent have not so far been reported, we will monitor hematologic parameters 
on a weekly basis and adjust drug administration accordingly. 
 
Only one dose level reduction will be allowed: 
 
 
Starting dose:  40 mg PO daily 
 
Level -1:  
30 mg PO daily 
 
There is no dose re-escalation in this protocol. 
 
Dose reduction scheme for BIBW 2992 based on 40mg daily.  In the event of 
treatment-related toxicities, the treatment with BIBW 2992 should be handled according 
to the schedule on next page. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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AE type and grade 
Action 
Dose reduction 
scheme 
Events related to study drug (except ILD and 
decreased LVEF which require special 
instructions below) : 
• 
Any drug related AE CTCAE Grade 
≥3. 
• 
CTCAE Grade ≥2 diarrhea persisting 
for 2 or more consecutive days (48 
hours) despite adequate anti-
diarrheal medication/hydration. 
• 
CTCAE Grade ≥2 nausea 
and/vomiting persisting for 7 or more 
consecutive days despite antiemetic 
treatment/hydration. 
• 
CTCAE Grade ≥2 worsening of renal 
function as measured by serum 
creatinine, newly developed 
proteinuria, or newly developed 
decrease in glomerular filtration rate 
of more than 50 % from baseline. 
Pause treatment with 
BIBW 2992 until patient 
has recovered to CTCAE 
Grade ≤ 1 or baseline1. 
 
Resume treatment at 
reduced dose according to 
dose reduction scheme in 
next column.  
 
If patient has not recovered 
to CTCAE Grade ≤ 1 or 
baseline within 14 days 
study treatment should be 
permanently discontinued. 
• If patient was 
receiving 40mg, 
resume treatment at 
a dose of 30mg. 
 
1 Baseline is defined as the CTCAE grade at the start of treatment 
 
Dose reduction should always follow a treatment pause. In the event of a treatment 
pause, subsequent visits/courses should not be delayed.  
 
8.1.1 Handling of Unused/Expired Investigational Product 
Any unused and expired investigational product will be disposed of per institutional  
policy. 
 
 
8.2 Additional Dose Delays and Dose Modifications 
 
Hematologic toxicities: Hematological toxicities are not anticipated with BIBW 2992. 
 
For any Grade 3 toxicity, hold drug until resolution to grade ≤ 1 or baseline, and 
then restart at 40 mg daily dose. 
 
For any Grade 4 toxicity, discontinue administration of the study agent. 


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Non- Hematologic toxicities(refer to section 8.3 for management of diarrhea, nausea, 
and vomiting: 
 
For Grade 3 and 4 rash:  Treatment with BIBW 2992 should be paused until 
recovery to CTCAE grade </= 1.  Treatment should be resumed at a reduced 
dose.  If CTCAE > 3 rash does not resolve to CTCAE Grade </= 1 within 14 days 
of stopping BIBW 2992 treatment and despite optimal supportive care, the 
patient should not receive any further treatment with BIBW 2992 and the End of 
treatment visit should be followed.  For Grade 3 diarrhea (refer to Section 8.3.1): 
First occurrence: Follow table instructions above. 
 
Second Occurrence: Discontinue drug administration. 
 
For the first occurrence of all other Grade 3 and 4 non- hematologic toxicities not 
related to study agent: Hold drug until resolution of the toxicity to Grade ≤ 2, then 
restart at 40 mg daily dose. In case of the second occurrence we will discontinue 
drug administration and they will be discontinued from the study but will be 
followed until resolution of AE. 
 
8.3 MANAGEMENT OF ADVERSE EVENTS 
 
8.3.1 Suggested management of diarrhea following treatment 
with BIBW 2992 
Close monitoring and proactive management of diarrhea is essential for successful 
treatment of patients with BIBW 2992. Early and appropriate intervention can prevent the 
development of more severe diarrhea. In most cases, loperamide controls diarrhea 
caused by BIBW 2992. Loperamide should be available at the start of therapy and kept 
with the patient at all times; it is therefore advisable that patients be given a prescription 
at the time of initiating treatment with BIBW 2992. 
 
The recommendations for management are as follows: 
 
• 
If any diarrhea is experienced (CTCAE Grade 1), two 2 mg loperamide 
tablets should be taken immediately, followed by one 2 mg tablet with 
every loose bowel movement, up to a maximum daily dose of 10 tablets 
(20 mg).   
 
• 
In the event of diarrhea patients should be advised to avoid lactose-
containing products or any foods known to aggravate diarrhea. 
 
• 
Oral hydration is essential regardless of severity; appropriate rehydration 
(1.5 l/m2/day plus  equivalent of actual fluid loss) and electrolyte 
replacement has to be ensured in the event of CTCAE Grade 2 and 
Grade 3 adverse events. 
 
• 
For CTCAE Grade 3 diarrhea or CTCAE Grade 2 diarrhea lasting ≥ 2 
days (48 hours) despite adequate antidiarrhoeal treatment, BIBW 2992 


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must be paused until recovery to CTCAE ≤ Grade 1. Upon recovery, 
BIBW 2992 should be resumed at a reduced dose according to the dose 
reduction scheme. 
 
If despite optimal supportive care and a treatment pause, diarrhea does not resolve to 
CTC Grade ≤1 within 14 days, the patient must not receive any further BIBW 2992 
treatment. 
 
8.3.2 Management of nausea and vomiting following treatment 
with BIBW 2992 
Nausea and vomiting may significantly affect patients’ adherence to the treatment and 
their quality of life. In order to reduce the occurrence and the intensity of emesis, the 
patients should be treated with an aggressive antiemetic program such as the following: 
 
CTCAE Grade 
Antiemetic treatment 
Nausea = grade 0 
and 
Vomiting = grade 0 
No antiemetic prophylactic treatment 
Nausea = grade 1 
and 
Vomiting = grade 0 
No antiemetic treatment 
Nausea = grade 2 
and 
Vomiting = grade 0 
Nausea = grade 0, 1 or 2 
and 
Vomiting = grade 1 or 2 
Antiemetic treatment1 
Pause BIBW 2992 treatment if grade 2 
vomiting or grade 2 nausea persist for 7 or 
more consecutive days despite optimal 
supportive care. Resume treatment when 
CTCAE grade ≤ 1. 
Vomiting ≥ grade 3 
or 
Nausea ≥ grade 3 
Antiemetic treatment1 
Pause BIBW 2992 treatment until return to 
CTCAE grade ≤ 1 or baseline2. 
1 Antiemetic treatment should follow the recommendations given in the Consensus 
Statement of the Antiemetic Subcommittee of the Multinational Association of 
Supportive Care in cancer (MASCC): Prevention of chemotherapy- and radiotherapy-
induced emesis: Results of the Perugia Consensus Conference 
2 Baseline is defined as the CTCAE grade at the start of treatment 
 
After a treatment pause the dose of BIBW 2992 should be reduced according to the 
dose reduction scheme table. 
 
In case of nausea and/or vomiting ≥ CTCAE grade 2, appropriate hydration (1.5 
L/m2/day plus hydration deficit) must be ensured. 
 
8.3.3 Management of rash following treatment with BIBW 2992 
A proactive and early approach to management of rash is crucial. Rash can be managed 
by a variety of treatment options to relieve symptoms and reduce the rash. 
The recommendations for management are as follows: 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
• 
General/Prevention: strict sun protection; use of a sunscreen of Sun Protection 
Factor 15 (SPF 15) or higher, preferably containing zinc oxide; use of a thick, 
alcohol-free emollient cream;  avoid harsh detergents, avoid using a solarium. 
 
Grade specific treatment recommendations of skin reactions to afatinib 
Severity  
(CTCAE Grading) 
Description 
  
Specific intervention 
ACNEIFORM RASH 
Mild (Grade 1) 
Macular or papular eruptions or 
erythema without associated 
symptoms 
Consider topical antibiotics, e.g. 
clindamycin 2% or topical erythromycin 
1% cream of metronidazole 0.75% or 
topical nadifloxacin 1%; 
Isolated scattered lesion: cream preferred 
Multiple scattered areas: lotion preferred 
Moderate (Grade 2) 
Macular or papular eruptions with 
pruritus or other associated 
symptoms; localized desquamation 
or other lesions covering <50% of 
BSA  
Topical treatment as for Grade 1  
plus short term topical steroids, e.g. 
prednicarbate cream 0.02% plus 
an oral antibiotic (for at least 2 weeks) e.g. 
Doxycycline 100mg b.i.d. or Minocycline 
hydrochloride 100mg b.i.d 
Severe (Grade 3) 
Severe, generalized erythroderma or 
macular, popular or vesicular 
eruption; desquamation covering ≥ 
50% of BSA; associated with pain, 
disfigurement, ulceration or 
desquamation 
Topical and systemic treatment as for   
Grade 2. 
Consider referral to dermatologist 
Consider systemic steroids 
Life threatening 
(Grade 4) 
Generalized exfoliative, ulcerative, 
or bullous dermatitis 
See Grade 3 
Systemic steroids are recommended 
EARLY AND LATE XEROTIC SKIN REACTIONS - PRURITUS 
Mild (Grade 1) 
Mild or localized 
Topical polidocanol cream. 
Consider oral antihistamines, e.g. 
diphenhydramine, dimethindene, 
cetirizine, levocetirizine, desloratidine, 
fexofenadine or clemastine) 
Moderate (Grade 2) 
Intense or widespread 
See Grade 1 plus oral antihistamines; 
Consider topical steroids, e.g. topical 
hydrocortisone 
Severe (Grade 3) 
Intense or widespread and 
interfering with activities of daily 
living (ADL) 
See Grade 2. 
XEROSIS (DRY SKIN) 
Mild (Grade 1) 
Asymptomatic 
Soap-free shower gel and/or bath oil. 
Avoid alcoholic solutions and soaps. 
Urea- or glycerin-based moisturizer. 
In inflammatory lesions consider topical 
steroids (e.g. hydrocortisone cream) 


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Moderate (Grade 2) 
Symptomatic, not interfering with 
ADL 
See Grade 1. 
In inflammatory lesions consider topical 
steroids (e.g. hydrocortisone cream) 
Severe (Grade 3) 
Symptomatic, 
interfering with ADL 
See Grade 2. 
Topical steroids of higher potency (e.g. 
prednicarbate, mometasone furoate) 
Consider oral antibiotics 
8.3.3.4  Management of mucositis/stomatitis 
Treatment is supportive and aimed at symptom control.  These may include atraumatic 
cleansing and rinsing with non-alcoholic solutions such as normal saline, diluted salt and 
baking soda solution (e.g. one-half teaspoon of salt and one teaspoon of baking soda in 
one quart of water every four hours); avoidance of agents containing iodine, thyme 
derivatives and prolonged use of hydrogen peroxide; dietary manoeuvres such as 
promotion of soft, non-irritating foods like ice-creams, mashed/cooked vegetables, 
potatoes and avoidance of spicy, acidic or irritating foods such as peppers, curries, 
chillies, nuts, and alcohol.  If the patient is unable to swallow foods or liquids, parenteral 
fluid and/or nutritional support may be needed.   
Grade specific treatment recommendations of study-drug related 
mucositis/stomatitis 
Severity  
(CTCAE 
grading) 
Description  
Treatment recommendations 
Intervention concerning 
afatinib treatment/ dose 
modification 
Mild (Grade 1) 
Minimal 
symptoms; 
normal diet  
Oral rinses with agents such as 
non-alcoholic 
mouth 
wash,  
normal saline, diluted salt and 
baking soda solution . 
No change . 
Moderate (Grade 
2) 
Symptomatic, 
but can eat 
and 
swallow 
modified diet 
Addition of topical analgesic 
mouth 
treatments, 
topical 
corticosteroids, 
antiviral 
therapy if herpetic infection 
confirmed, antifungal therapy 
preferably topical on a case by 
case basis. 
Maintain 
dose 
if 
tolerable; Hold dose 
if 
intolerable 
until 
recovery 
to 
grade 
≤1, then restart at 
the same dose. 
Severe (Grade 3)  
Symptomatic 
and unable to 
adequately 
aliment 
or 
hydrate orally 
Same as for Grade 2; institute 
additional symptomatic therapy 
(topical 
or 
systemic) 
as 
clinically indicated . 
Hold 
dose 
until 
recovery to grade ≤1 
or 
baseline, 
then 
restart 
at 
the 
reduced 
dose 
according to Section 
4.1.4. 
Life threatening 
(Grade 4) 
Symptoms 
associated 
with 
life-
threatening 
consequences  
Same as for Grade 2; institute 
additional symptomatic therapy 
(topical 
or 
systemic) 
as 
clinically indicated 
Hold 
dose 
until 
recovery to grade ≤1 
or 
baseline, 
then 
restart 
at 
the 
reduced 
dose 


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according to Section 
4.1.4 
 Assessment of Efficacy 
9
9.1 Efficacy parameters 
9.1.1 Assessment methods to measure response and progression 
Radiographic studies in form of a CT scan, PET scan, or other assessment methods as 
deemed appropriate by the treating physician will be used to assess response and 
progression. The same assessment used at baseline should be repeated at the time of 
response evaluation. The tumor measurements will be documented and reported as 
defined by RECIST 1.1 criteria and PET Response Criteria in Solid Tumors (PERCIST), 
version 1.0. 
9.1.2 Definition of measurable and non-measurable lesions 
according to RECIST 
At baseline, tumor lesions will be categorized as: measurable: lesions that can be 
accurately measured in at least one dimension (longest diameter to be recorded) as > 20 
mm with conventional techniques or as 10 mm with spiral CT scan (See 
http://ctep.info.nih.gov/protocolDevelopment/docs/Recist_Guideline.pdf). 
• 
Non-measurable: all other lesions, including small lesions (longest diameter < 20 
mm with conventional techniques or < 10 mm with spiral CT scan) and truly non-
measurable lesions. 
• 
The term “evaluable” in reference to measurability is not recommended and will 
not be used because it does not provide additional meaning or accuracy. 
• 
All measurements should be recorded in metric notation, using a ruler or calipers.  
All baseline evaluations should be performed as close as possible to the 
treatment start and never more than 4 weeks before the beginning of the 
treatment. 
 
9.1.3 Tumor response evaluation according to RECIST 1.1 
9.1.4 Assessment of overall burden and measurable disease 
To assess objective response, it is necessary to estimate the overall tumor burden at 
baseline and use this as a comparator for subsequent measurements.  Only patients 
with measurable disease at baseline should be included in this protocol.  Measurable 
disease is defined by the presence of at least one measurable lesion.  If the measurable 
disease is restricted to a solitary lesion, its neoplastic nature could be confirmed by 
cytology/histology at the discretion of the investigator, sub-investigator, or treating 
physician. 
 
 
 
 
 


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9.1.5 Baseline documentation of “Target” and “Non-Target” 
lesions 
All measurable lesions should be identified as target lesions and will be 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 repetitive 
measurements (either by imaging techniques or clinically).  A sum of the longest 
diameter (LD) for all target lesions will be calculated and reported as the baseline sum 
LD.  The baseline sum LD will be used as reference to further characterize the objective 
tumor response of the measurable dimension of the disease. 
 
All other lesions (or sites of disease) should be identified as non-target lesions and 
should also be recorded at baseline. Measurements are not required and these lesions 
should be followed as “present” or “absent”. 
 
9.1.6 Evaluation of target lesions 
Complete Response (CR): disappearance of all target lesions. 
 
Partial Response (PR): at least a 30% decrease in the sum of LD of target lesions taking 
as reference the baseline sum LD. 
 
Progression (PD): at least a 20% increase in the sum of LD of target lesions taking as 
references the smallest sum LD recorded since the treatment started or the appearance 
of one or more new lesions, and evidence of a 5 mm absolute increase. 
 
Stable Disease (SD): neither sufficient shrinkage to qualify for PR nor sufficient increase 
to qualify for PD taking as references the smallest sum LD since the treatment started. 
9.1.7 Evaluation of non-target lesions 
Complete Response (CR): disappearance of all non-target lesions. 
 
Non-Complete Response (non-CR) / Non-Progression (non-PD): persistence of one or 
more non-target lesion or/and maintenance of tumor marker level above the normal 
limits. 
 
Progression (PD): appearance of one or more new lesions.  Unequivocal progression of 
existing non-target lesions. 
 
 
 
 
 
 
 
 
 


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9.1.8 Evaluation of best overall response 
The best overall response is the best response recorded from the start of the treatment 
until the date of surgery(taking as reference for progressive disease the smallest 
measurements recorded since the treatment started).  In general the patient’s best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria. 
 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
CR 
CR 
No 
CR 
CR 
Non-CR/Non-PD 
No 
PR 
PR 
Non-PD 
No 
PR 
SD 
Non-PD 
No 
SD 
PD 
Any 
Yes or No 
PD 
Any 
PD 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
Note:  Patients with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
reported as “symptomatic deterioration”.  Every effort should be made to document the 
objective progression even after discontinuation of treatment. 
In some circumstances it may be difficult to distinguish residual disease from normal 
tissue.  When the evaluation of complete response depends upon this determination, it is 
recommended that the residual lesion be investigated (fine needle aspirate/biopsy) 
before confirming the complete response status. 
 
9.1.9 Evaluation according to PET Response Criteria in Solid 
Tumors (PERCIST), version 1.0. [55] 
 
Complete Metabolic Response (CMR): 
o 
Complete resolution of F-FDG uptake within measurable target lesions so 
that it is less than mean liver activity and indistinguishable from surrounding 
background blood-pool levels.  
o 
Disappearance of all other lesions to background blood-pool levels.  
o 
Percentage decline in SUV should be recorded from measurable region, as 
well as (ideally) time in weeks after treatment was begun (i.e. CMR -90, 4).  
o 
No new F-FDG-avid lesions in pattern typical of cancer. If progression by 
RECIST, must verify with follow-up. 
 
Partial Metabolic Response (PMR):  
o 
Reduction of minimum of 30% in target measurable tumor F-FDG SUV peak. 
Absolute drop in SUL must be at least 0.8 SUV units as well.  
o 
Measurement is commonly in same lesion as baseline but can be another 
lesion if that lesion was previously present and is the most active lesion after 
treatment. Region of Interest (ROI) dose not have to be in precisely same 
areas a baseline scan, through typically it is.  


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o 
No increase, > 30% in SUV or size of target or nontarget lesions (i.e., no PD by 
RECIST or IWC) (if PD anatomically, must verify with follow-up). Reduction in 
extent of tumor F-FDG uptake is not a requirement for PMR. Percentage 
decline in SUL should be recorded, as well as (ideally) time from start of most 
recent therapy, in weeks after treatment was begun (i.e. PMR -40, 3).  
o 
No new lesions. 
 
Stable Metabolic Disease (SMD): 
o 
Not a CMR, PMR, or PMD. 
o 
SUV peak in metabolic target lesion should be recorded, as well as (ideally) 
time from start of most recent therapy, in weeks (i.e. SMD -15, 7). 
 
Progressive Metabolic Disease (PMD): 
o 
> 30% increase in F-FDG SUV peak, with > 0.8 SUV unit increase in tumor 
SUV peak from baseline scan in pattern typical of tumor and not of 
infection/treatment effect; OR, 
o 
Visible increase in extent of F-FDG tumor uptake (75% in TLG volume with no 
decline in SUV; OR, 
o 
New F-FDG-avid lesions that are typical of cancer and not related to treatment 
effect of infection. PMD other than new visceral lesions should be confirmed on 
follow-up study within 1 month unless PMD also is clearly associated with 
progressive disease by RECIST 1.1. 
o 
PMD should be reported to include percentage change in SUV peak, (ideally, 
time after treatment, in weeks) and whether new lesions are present/absent 
and their number (i.e., PMD, +35, 4, new: 5). Because SUV is continuous 
variable, dividing response criteria into limited number of somewhat arbitrary 
response categories loses much data. For this reason, PERCIST preserves 
percentage declines in SUV peak in each reported category. Because rapidity 
with which scan normalizes is important (faster appears better), PERCIST asks 
for time from start of treatment as part of reporting. For example, CMR 90, 1, is 
probably superior to CMR 90, 10, especially if latter patient were SMD 20,1.  
o 
More than one measurement of PET response may be needed at differing 
times, and it may be treatment type-dependent, PERCIST 1.0 evaluated SUV 
peak of only hottest tumor. This is possible limitation of approach, but lesions 
and their responses are highly correlated in general. Additional data are 
required to determine how many lesions should be assessed over 1. A 
suggested option is to include the 5 hottest lesions, or the 5 observed on 
RECIST 1.1 that are most measurable. Percentage change in SUV can be 
reported for single lesion with largest increase in uptake or smallest decline in 
uptake. Additional studies will be needed to define how many lesions are 
optimal for assessment. 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
Assessment of Safety/Toxicity 
9.2 Investigator Communication with Supporting Company 
for Safety analysis 
 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS 
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial. All 
serious adverse events that are considered certainly, probably, or possibly related to 
afatinib treatment must be recorded and sent within 24 hours to Boehringer Ingelheim of 
research site staff notification of event.  SAE reports will include the name/number of the 
protocol; a description of the event, severity, treatment and outcome if known; supportive 
laboratory results and diagnostics; and investigators assessment of the relationship of 
the adverse event to the investigational product.  All adverse events, serious and non-
serious, occurring during the course of the clinical trial (i.e., from signing the informed 
consent onwards through the trial defined follow-up period) will be collected, 
documented, and reported by the investigator. For each adverse event, the investigator 
will provide the onset date, end date, intensity, treatment required, outcome, 
seriousness, and action taken with the investigational drug. The investigator will 
determine the relationship of the investigational drug to all AE’s as defined within the 
Boehringer Ingelheim’s (BI’s) Investigator Brochure for the BIBW2992.  
The Investigator or physician designee is responsible for verifying and providing source documentation for 
all adverse events and assigning the attribution for each event for all subjects enrolled on the trial 
 
For this protocol adverse events will be captured and recorded in the medical record and case 
report form according to the Recommended Adverse Event Recording for Phase II Protocols 
 
Recommended Adverse Event Recording Guidelines 
 
Attribution 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 
Unrelated 
Phase I 
Phase I 
Phase I 
Phase II   
 
Phase I 
Phase II   
Phase III 
Phase I  
Phase II   
Phase III 
Unlikely 
Phase I 
Phase I 
Phase I  
Phase II   
Phase I 
Phase II   
Phase III 
Phase I 
Phase II   
Phase III 
Possible 
Phase I 
Phase II   
Phase I 
Phase II   
Phase III 
Phase I 
Phase II   
Phase III 
Phase I 
Phase II   
Phase III 
Phase I 
Phase II   
Phase III 
Probable 
Phase I 
Phase II  
 
Phase I 
Phase II   
Phase III 
Phase I 
Phase II   
Phase III 
Phase I 
Phase II   
Phase III 
Phase I 
Phase II   
Phase III 
Definitive 
Phase I 
Phase II  
  
Phase I 
Phase II   
Phase III 
Phase I 
Phase II   
Phase III 
Phase I 
Phase II  
Phase III  
Phase I 
Phase II   
Phase III 
 
For this protocol we will capture and record AEs that are determined to be related to the 
surgical procedure. 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
Adverse event 
An adverse event (AE) is defined as any untoward medical occurrence, including an 
exacerbation of a pre-existing condition, in a patient in a clinical investigation who 
received a pharmaceutical product. The event does not necessarily have to have a 
causal relationship with this treatment. 
 
Serious adverse event 
A serious adverse event (SAE) is defined as any AE which results in death, is 
immediately life-threatening, results in persistent or significant disability / incapacity, 
requires or prolongs patient hospitalisation, is a congenital anomaly / birth defect, or is to 
be deemed serious for any other reason if it is an important medical event when based 
upon appropriate medical judgement which may jeopardise the patient and may require 
medical or surgical intervention to prevent one of the other outcomes listed in the above 
definitions. 
Patients may be hospitalised for administrative or social reasons during the trial (e.g. 
days on which infusion takes place, long distance from home to site). These and other 
hospitalisations planned at the beginning of the trial do not need to be reported as an 
SAE. 
In addition, all reports of spontaneous abortion, abuse and/or drug dependency shall be 
considered as SAEs for regulatory reporting purposes. 
As part of the exchange of SAEs any non-serious AEs occurring at the same time and/or 
which are medically related to the SAE have to be included.  
 
 
Important medical events may be considered a serious adverse drug experience when, 
based upon appropriate medical judgment, they may jeopardize the patient or subject 
and may require medical or surgical intervention to prevent one of the outcomes listed in 
this definition. Examples of such medical events include allergic bronchospasm requiring 
intensive treatment in an emergency room or at home, blood dyscrasias or convulsions 
that do not result in inpatient hospitalization, or the development of drug dependency or 
drug abuse (21 CFR 312.32). 
 
 
All events occurring during the conduct of a protocol and meeting the definition of a SAE 
must be reported to the IRB in accordance with the timeframes and procedures outlined 
in “The University of Texas M. D. Anderson Cancer Center Institutional Review Board 
Policy for Investigators on Reporting Unanticipated Adverse Events for Drugs and 
Devices”.  
 
• 
  
Serious adverse events will be captured from the time of the first protocol-specific 
intervention, until 30 days after the last dose of drug, unless the participant withdraws 
consent. Serious adverse events must be followed until clinical recovery is complete and 
laboratory tests have returned to baseline, progression of the event has stabilized, or 
there has been acceptable resolution of the event. 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
 
It is the responsibility of the PI and the research team to ensure serious adverse events 
are reported according to the Code of Federal Regulations, Good Clinical Practices, the 
protocol guidelines, the sponsor’s guidelines, and Institutional Review Board policy. 
 
 
9.3 Investigator Communication with Supporting Company 
for Adverse Event Characteristics 
• 
CTCAE term (AE description) and grade:  The descriptions and grading scales 
found in the revised NCI Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 will be utilized for AE reporting.  All appropriate treatment 
areas should have access to a copy of the CTCAE version 4.0.  A copy of the 
CTCAE version 4.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov). 
• 
Causal relationship of adverse event: 
Medical judgment should be used to determine the relationship, considering all 
relevant factors, including pattern of reaction, temporal relationship, de-challenge 
or re-challenge, confounding factors such as concomitant medication, 
concomitant diseases and relevant history. Assessment of causal relationship 
must be recorded for each adverse event.  
Causality will be reported as either “Yes” or “No”. 
Yes:    There is a reasonable causal relationship between the investigational 
product administered and the AE.  
No:     There is no reasonable causal relationship between the investigational 
product administered and the AE.  
If an SAE is reported from a still blinded trial, the causal relationship must be 
provided by the investigator for the study medication and study design. 
9.3.1 Worsening of pre-existing conditions or underlying disease 
A pre-existing condition present at baseline, which remains unchanged during the trial, 
does not need to be recorded as adverse event. Any worsening of any pre-existing 
baseline condition or deterioration of the underlying disease should be reported as an 
adverse event. Examples of worsening of a preexisting condition that should be 
recorded as an AE are given below; 
• 
Worsening of condition meets the criteria for an SAE 
• 
Action is taken with the investigational drug (i.e. dose is reduced or treatment is 
discontinued) 
• 
Treatment is required (concomitant medication is added or changed) 
Other changes in vital signs, ECG, physical examination and laboratory test results will 
be recorded as an AE in the CRF only if they are judged clinically relevant by the 
investigator. 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
 
 
 
 
 
 
9.4 Investigator Communication with Supporting Company 
for Reporting of SAE's 
 
Adverse events classified as serious require expeditious handling and reporting to 
University of Texas MD Anderson Cancer Center and the pharmaceutical company/BI. 
SAE reporting should occur for: 
 
• 
Any SAE that occurs while a patient is on study or within 30 days of the last study 
drug administration, regardless of any opinion as to the relationship of the SAE to 
the study drug; or 
• 
Any SAE that the investigator feels is related to the study drug occurs later than 
30 days after the last study drug administration.   
 
 
All initial and follow-up reports of serious adverse events will be reported and 
documented on the Boehringer Inglehiem Investigator Initiated Study Serious Adverse 
Event Reporting Form and faxed to: 
 
Boehringer Ingelheim Pharmaceuticals, Inc 
Boehringer Ingelheim Pharmaceuticals, Inc. 
900 Ridgebury Road 
Ridgefield, CT  06877 
  
Fax: 1-203-837-4329  
E-mail:casefile.rdg@boehringer-ingelheim.com 
 
If no confirmation of receipt received from BI within 1 working day, the investigator must 
resend SAE report 
 
The following timelines for submission of initial/follow-up reports apply:  
- within 5 calendar days: cases with 1 or more fatal/life-threatening events  
- within 10 calendar days: all other SAEs 
9.5 Data Collection 
 
Electronic CRFs will be provided for the recording of data.  Protocol specific data and 
adverse event will be entered into PDMS/CORe.  PDMS/CORe will be used as the 
electronic case report form for this protocol. All data should be substantiated by clinical 
source documents organized within a patient research record. ICH Good Clinical 
Practices are to be followed.During the course of the study, data quality will be 
monitored by random inspection of the completed forms by a designated monitor.  Any 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
problems detected will be discussed with the PI. If necessary, re-training of data 
collectors will be conducted. 
 
Data quality will be monitored by random inspection of the completed forms by an 
auditor external to the research team.  Any problems detected will be discussed with the 
PI. If necessary, re-training of data collectors will be conducted. 
 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
 Statistical Considerations 
10
 
The primary endpoint is feasibility of neoadjuvant treatment of BIBW 2992 in patients 
with early stage (IA to IIIA) NSCLC awaiting surgical resection. We will recruit 20 
evaluable patients for pre and post BIBW 2992 measurement of tumor response and 
protein activity.  Feasibility will be assessed based on the ability to complete the 
treatment for each patient.  For our feasibility endpoint, we will declare the treatment 
“completed” if a patient completes at least 14 days of treatment, had a thoracotomy for 
the planned surgical resection, and 30 days post-operative care.  . Our null hypothesis is 
that the treatment will be feasible for 50% of patients versus the alternative that it will be 
feasible in 80%. A Simon two-stage design will be used in which 9 patients will initially 
be enrolled.  If 6 or more have complete (i.e., feasible) treatment, an additional 11 
patients will be enrolled for a total sample size of 20.  If 14 or more of 20 patients 
complete treatment, then we will conclude that the treatment regimen is feasible. This 
design has an alpha level of 0.048 and power of 87% to detect this difference. 
 
The secondary objective is to determine whether pre-operative BIBW 2992 treatment 
affects metabolic tumor labeling, as measured by PET-CT scanning. We will measure 
the absolute and the percentage change in SUV from baseline to follow-up.  Graphical 
displays will be used to demonstrate changes.  We will test the hypothesis that the mean 
difference is less than 0 versus greater than 0 using a one-sided paired t-test with alpha 
of 0.05.  With 20 patients, we can detect a change of 0.6 standard deviations with 83% 
power.  For this stage of research, an effect size of 0.6 is deemed to be appropriate. 
 
Our correlative objectives are: 
 
1. To measure the change in the total and phosphorylated EGFR inhibition and 
assess the activation status of ERK1/2 and AKT from baseline biopsy to resected 
tumor by Western blots. 
2. Determine the EMT status in BIBW 2992 treated tumors. This will include 
staining for ZEB1, Snail, E-cadherin, ST14, EpCAM, Vimentin and N-cadherin by 
immunohistochemistry (IHC), both within the tumor and at the boundary. If E-
cadherin  levels are high and Vimentin levels are low then the EMT status will be 
classified as epithelial.  If the E-cadherin levels are low and the Vitmentin levels 
are high then the EMT status will be classified as mesenchymal.  Gene 
expression for these and other markers will be performed by quantitative real-
time RT-PCR (qRT-PCR). Microdissected tumor cells will be used for analysis of 
miR-200c levels. The met amplification status of the tumors will also be 
assessed. 
3. To correlate any potential biological activity of BIBW 2992 with PET responses 
seen in the study subjects. 
 
We will use the same approach for analyzing changes from pre to post treatment in gene 
expression measures as outlined for the secondary endpoint above.  Correlations 
between change in SUV and gene expression (baseline expression and change in 
expression) will be estimated using linear regression.  Graphical displays will be used to 
assess the linearity of the relationship and demonstrate associations. For the correlative 
studies the sample size may be less than 20 due to lack of biopsy tissue at baseline.  
This is recognized and these analyses are considered exploratory. 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
 Quality Control and Quality Assurance Procedures 
11
11.1  Monitoring of the study and regulatory compliance 
 
The Principal Investigator and the Clinical Research Coordinator assigned to the case 
will be primarily responsible for maintaining all study related documents including the 
clinical research forms.  All CRF entries will be verified with source documentation. The 
review of medical records will be done in a manner to assure that patient confidentiality 
is maintained. Reports will be sent to the IRB as and when serious adverse effects 
occur.  
 
11.2 Protocol modifications 
 
No modifications will be made to the protocol without the agreement of the investigators. 
Changes that significantly affect the safety of the patients, the scope of the investigation, 
or the scientific quality of the study will require Institutional Review Board approval prior 
to implementation, except where the modification is necessary to eliminate apparent 
immediate hazard to human subjects.  Any departures from the protocol must be fully 
documented in the case report form and the source documentation. 
11.3  Patient privacy 
 
In order to maintain patient confidentiality, all case report forms, study reports and 
communications relating to the study will identify patients by initials and assigned patient 
numbers.  The US Food and Drug Administration (FDA) may also request access to all 
study records, including source documentation for inspection. 
11.4  Publication Policy 
 
The Investigators plan to publish and present the information obtained from the study. 
The data will be shared with the sponsors and they will be given adequate time to 
preview the abstracts and documents that will be submitted for publication. 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
 Ethical Considerations 
12
12.1  Informed Consent 
 
The investigator will obtain written informed consent from all participating patients or 
their authorized representatives.  The form must be signed and dated.  The consent will 
contain all the Essential Elements of Informed Consent set forth in Title 21, Code of 
Federal Regulations, Part 50 for the centers enrolling in the United States.  Copies of the 
signed document will be given to the patient and filed in the Investigator’s study file, as 
well as the patient’s medical record if in conformance with the institution’s Standard 
Operating Procedures. 
12.2  Institutional Review Board 
 
The trial will not be initiated without approval of the appropriate Institutional Review 
Board (IRB).  All administrative requirements of the governing body of the institution will 
be fully complied with.  This protocol, consent procedures, and any amendments must 
be approved by the IRB in compliance with current regulations of the Food and Drug 
Administration.  A letter of approval will be sent to the institution(s) funding the study 
prior to initiation of the study and when any subsequent modifications are made.  The 
IRB will be kept informed by the Investigator as to the progress of the study as well as to 
any serious or unusual adverse events. 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
 Data Handling and Record Keeping 
13
13.1  Data recording and quality control 
 
Case Report Forms 
 
Electronic case report forms (CRFs) will be used for this study, stored under M. D. 
Anderson’s database.  In addition, PDMS/CORe will be used as the electronic case 
report form (eCRF) for this protocol.  Adverse events and protocol specific data will be 
entered into PDMS/CORe. 
 
            Study Files and Patient Source Documents 
The investigator must maintain adequate and accurate records to enable the 
conduct of the study to be fully documented and the study data to be 
subsequently verified.  These documents include investigators’ Study Files and 
original patient clinical source documents generated at the study site.  The term 
“original” means the first recording of the data. 
The investigator will ensure the Study Files are maintained, including the CRFs 
and query forms, protocol/amendments, IRB and regulatory approvals with 
associated correspondence, informed consents, study drug records, staff 
curriculum vitae, all correspondence, and other appropriate documents. 
Patient clinical source documents may include, but are not limited to, patient 
hospital/clinic records, physicians’ and nurses’ notes, appointment books, 
laboratory reports, ECGs, radiographs, pathology and special assessment 
reports, and consultant letters.  The investigator must assure that all original 
source documents are available to support monitoring activities. 
 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
 Recruitment Procedure 
14
 
All patients referred to or seeking surgery for stage IA to IIIA NSCLC will be offered this 
trial. 
 
Women and men will be recruited, and are anticipated to be equally represented in the 
trial. 
 
Persons equal to or over the age of 18 are eligible for trial participation if they have a 
performance status of 0 or 1, thus by NIH criteria, children are eligible for trial 
participation.  However, the median age of persons with NSCLC is 71 years, and thus 
the vast majority of participants will be above the age of 21. 
 
Minority participation will be especially encouraged.  
 
Patients with psychiatric illness/social situations that would limit compliance with study 
requirements will not be allowed to enroll on the trial owing to the possible need for an 
invasive procedure, which will need the cooperation and compliance of the individual. 
 
 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
Version Date January 2016 
 
 
 
 
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counteract the antitumor action of erlotinib. Cancer Res, 2006. 66(20): p. 10100-
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Gemmill, R.M., et al., ZEB1-responsive genes in non-small cell lung cancer. 
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transition (EMT) gene, suppresses anchorage-independent cell growth of lung 
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cancer to assess intratumor drug concentration and pathways mediating primary 
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Lara-Guerra, H., et al., Phase II study of preoperative gefitinib in clinical stage I 
non-small-cell lung cancer. J Clin Oncol, 2009. 27(36): p. 6229-36. 
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Yin, J.L., et al., Real-time reverse transcriptase-polymerase chain reaction (RT-
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fluorogenic probes or SYBR Green I. Immunol Cell Biol, 2001. 79(3): p. 213-21. 
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Vandesompele, J., A. De Paepe, and F. Speleman, Elimination of primer-dimer 
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RT-PCR. Anal Biochem, 2002. 303(1): p. 95-8. 


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53. 
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regulators of FGFR2 splicing. Mol Cell, 2009. 33(5): p. 591-601. 
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after breast cancer among women of working age: a 2-year follow-up study. J 
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Wahl, R.C., et.al. From RECIST to PERCIST: Evolving Considerations for PET 
 
Response Criteria in Solid Tumors. The Journal of Nuclear Medicine, May 2009. 
 
50 (5): p.122S - 150S. 
 
 
 
 


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7th Edition – Staging of NSCLC 
T (Primary Tumor) 
TX  
Primary tumor cannot be assessed, or tumor proven by the presence of 
malignant cells in sputum or bronchial washings but not visualized by imaging or 
bronchoscopy 
T0  
No evidence of primary tumor 
Tis  
Carcinoma in situ 
T1  
Tumor _3 cm in greatest dimension, surrounded by lung or visceral pleura, 
without bronchoscopic evidence of invasion more proximal than the lobar 
bronchus (i.e., not in the main bronchus) 
T1a  
Tumor _2 cm in greatest dimension 
T1b  
Tumor _2 cm but _3 cm in greatest dimension 
T2  
Tumor _3 cm but _7 cm or tumor with any of the following features (T2 tumors 
with these features are classified T2a if _5 cm) 
Involves main bronchus, _2 cm distal to the carina 
Invades visceral pleura 
Associated with atelectasis or obstructive pneumonitis that 
extends to the hilar region but does not 
involve the entire lung 
T2a  
Tumor _3 cm but _5 cm in greatest 
dimension 
T2b  
Tumor _5 cm but _7 cm in greatest 
dimension 
T3  
Tumor _7 cm or one that directly invades 
any of the following: chest wall (including 
superior sulcus tumors), diaphragm, 
phrenic nerve, mediastinal pleura, 
parietal pericardium; or tumor in the main 
bronchus _2 cm distal to the carinaa but 
without involvement of the 
carina; or associated atelectasis or 
obstructive pneumonitis of the entire lung 
or separate tumor 
nodule(s) in the same lobe 
T4  
Tumor of any size that invades any of the 
following: mediastinum, heart, great 
vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina; 
separate tumor nodule(s) in a different ipsilateral lobe 
N (Regional Lymph Nodes) 
NX  
Regional lymph nodes cannot be assessed 
N0  
No regional lymph node metastasis 
N1  
Metastasis in ipsilateral peribronchial and/or ipsilateral hilar 
lymph nodes and intrapulmonary nodes, including 
involvement by direct extension 
N2 
Metastasis in ipsilateral mediastinal and/or subcarinal lymph 
node(s) 
N3 
Metastasis in contralateral mediastinal, contralateral hilar, 
ipsilateral or contralateral scalene, or supraclavicular 
lymph node(s) 
 
Descriptors, Proposed T and M 
Categories, and Proposed Stage 
Groupings 
T/M              N0            N1             
N2             N3 
T1a IA IIA IIIA IIIB 
T1b IA IIA IIIA IIIB 
T2a IB IIA IIIA IIIB 
T2b IIA IIB IIIA IIIB 
T3 IIB IIIA IIIA IIIB 
T3 invasion IIB IIIA IIIA IIIB 
T4 (same lobe nodules) IIB IIIA IIIA 
IIIB 
T4 (extension) T4 IIIA IIIA IIIB IIIB 
M1 (ipsilateral lung) IIIA IIIA IIIB IIIB 
T4 (pleural effusion) M1a IV IV IV IV 
M1 (contralateral lung) IV IV IV IV 
M1 (distant) M1b IV IV IV IV 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
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M (Distant Metastasis) 
MX 
 Distant metastasis cannot be assessed 
M0  
No distant metastasis 
M1  
Distant metastasis 
M1a  Separate tumor nodule(s) in a contralateral lobe; tumor with 
pleural nodules or malignant pleural (or pericardial) 
effusionb 
M1b  Distant metastasis 
a The uncommon superficial spreading tumor of any size with its invasive component 
limited to the bronchial wall, which may extend proximally to the main bronchus, 
is also classified as T1. 
b Most pleural (and pericardial) effusions with lung cancer are due to tumor. In a 
few patients, however, multiple cytopathologic examinations of pleural (pericardial) 
fluid are negative for tumor, and the fluid is nonbloody and is not an exudate. Where 
these elements and clinical judgment dictate that the effusion is not related to the tumor, 
the effusion should be excluded as a staging element and the patient should be staged 
as if the patient didn’t have a pleural effusion. 
 
 
 


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Appendix 2 
 
ECOG PERFORMANCE STATUS 
Grade ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all selfcare but unable to carry out any work 
activities. Up and about more than 50% of waking hours 
3 
Capable of only limited selfcare, confined to bed or chair more than 50% of 
waking hours 
4 
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or 
chair 
5 
Dead 
* As published in Am. J. Clin. Oncol.: 
Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: 
Toxicity And Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 
5:649-655, 1982.  


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
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Appendix 3 
 
 
Common Terminology Criteria for Adverse Events (CTCAE) v4.0 
 
This study will utilize the Common Terminology Criteria for Adverse Events v4.0 
(CTCAE) for grading of toxicity and adverse event reporting.  It can be downloaded from 
the CTEP home page (http://ctep.cancer.gov). 
 
NCI CTEP Help Desk: 
Telephone:  301-840-8202 
Fax:  301-948-2242 
e-mail:  ncictephelp@ctep.nci.nih.gov 
 
All appropriate treatment areas will have access to a copy of the CTCAE v4.0. 
 
 
 


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Appendix 4 
 
P-GLYCOPROTEIN INHIBITORS AND INDUCERS 
 
List of potent inhibitors and inducers of P-glycoprotein (MDR1): 
 
Inhibitors 
Inducers 
Amiodarone 
Azithromycin 
Captopril 
Carvedilol 
Clarithromycin  
Conivaptan 
Cyclosporine  
Diltiazem 
Dronedarone 
Erythromycin 
Felodipine 
Itraconazole 
Ketoconazole 
Lopinavir 
Nelfinavir 
Ritonavir 
Quinidine 
Ranolazine 
Saquinavir 
Tacrolimus 
Ticagrelor 
Verapamil 
Carbamazepine 
Phenytoin 
Rifampicin 
St John’s Wort 
Phenobarbital Salt 
Tipranavir 
Ritonavir 
 
 
 
 
 


MDACC Protocol 2013-0305: The ATTAIN Lung Study (Simon) 
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Appendix 5 
The ATTAIN Lung Study 
 
PATIENT SMOKING HISTORY QUESTIONNAIRE 
VERSION November 3, 2011 
 
 
Patient interviewed: ________________________________ 
 
Signature of person conducting interview: _______________________ 
 
Date completed: __________________________________ 
 
 
 
1) Do you currently smoke cigarettes?  
 
 Yes                         Numbers cigarettes per day? ________________ 
 
 
 
 No, I have quit 
  Age when started: _______  Age when quit: _____ 
 
 
 No, I never smoked.  
 
2) Do you currently use any other form of tobacco? 
 
 
 Yes                          Select Type:  
 
 
 
 
    Pipe      Cigar      Smokeless 
                                       Other (please specify):________ 
 
 
 
 
 
  Amount per day? ________________ 
 
 
 
 No, I have quit 
  Age when started: _______  Age when quit: _____ 
 
 
 No, I never used other forms of tobacco. 
 
3) Please answer this if you are a non-smoker. Have you ever lived for an extensive 
amount of time with a person who smoked cigarettes (e.g. parent, spouse, etc.) 
 
 
 Yes  
Describe: 
 
 
 
 No 
 
Comments: