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Abbreviated Title: Ph II Recurrent Ependymoma Version Date: 07/21/17 1 CC **Protocol \#:** 16CN005 Previous CERN Protocol\# 08-02 Amendment Letter: A Version Date: 07/21/2017 NCT Number: NCT00826241  
| Title: A Phase II Study of Dose-Dense Temozolomide and Lapatinib for Recurrent LowGrade and Anaplastic Supratentorial, Infratentorial and Spinal Cord Ependymoma  Principal Investigator: Mark Gilbert, MD, NOB, CCR, NCI E  9030 Old Georgetown Road, 82/225  Bethesda, MD 20892  Tel: 301-402-6298  Fax: 301-480-2246  Email: mark.gilbert@nih.gov NCI Associate Investigators: Terri S. Armstrong, PhD, ANP-BC, NOB, CCR, NCI E  Christine Bryla, RN, OCD, CCR, NCI E  Ann McCoy, RN, OCD, CCR, NCI E  Referral Contact: Christine Bryla, RN, OCD, CCR, NCI E  CCR Study Coordinator: Christine Bryla, RN, OCD, CCR, NCI E Non-NIH Associate  Investigators: Alvina Acquaye, MS, (Contractor) Columbus Technologies  & Services E,F Elizabeth Vera, MS, (Contractor) Columbus Technologies  & Services E,F  Miranda Brown, RN, (Contractor) Leidos Biomed E, F   Non-NIH  Collaborator(s): Ying Yuan, PhD, Biostatistician, MDACC F, G  Tito Mendoza, PhD, Biostatistician, MDACC F, G   |
|---|
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investigator roles

A. *Obtain information by intervening or interacting with living individuals for research* purposes B. *Obtaining identifiable private information about living individuals* C. *Obtaining the voluntary informed consent of individuals to be subjects* D. Makes decisions about subject eligibility E. *Studying, interpreting, or analyzing identifiable private information or data/specimens* for research purposes F. Studying, interpreting, or analyzing de-identified data or specimens for research purposes G. *Some/all research activities performed outside NIH*
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participating centers and principal investigators

| Marta Penas-Prado,                       | Elizabeth R.                                     | Antonio Omuro,                                                | Tobias Walbert,                                                 | Frances Collichio,                                    | H. Ian Robins MD                                                              |
|------------------------------------------|--------------------------------------------------|---------------------------------------------------------------|-----------------------------------------------------------------|-------------------------------------------------------|-------------------------------------------------------------------------------|
| MD                                       | Gerstner, MD                                     | MD                                                            | MD                                                              | M.D.                                                  |                                                                               |
| Massachusetts                            |                                                  |                                                               |                                                                 |                                                       |                                                                               |
| Center                                   | General Hospital/  Dana Farber Cancer  Institute | University of  Wisconsin School of  Medicine & Public  Health |                                                                 |                                                       |                                                                               |
| FWA00000363                              | FWA00001121                                      | FWA00004998                                                   | FWA00005846                                                     | FWA00004507                                           | FWA00005399                                                                   |
| Memorial Sloan  Kettering Cancer  Center | Henry Ford Health                                | University of                                                 |                                                                 |                                                       |                                                                               |
| System                                   | North Carolina at  Chapel Hill                   |                                                               |                                                                 |                                                       |                                                                               |
| Blvd, Houston, TX  77030                 | 55 Fruit Street,  Yawkey 9E Boston, MA 02114     | 1275 York  Avenue, New  York, NY 10065                        | 2799 W. Grand  Blvd, Pallister  Place T-139,  Detroit, MI 48202 | UNC Healthcare 101 Manning Dr  Chapel Hill, NC  27514 | K4/534, Box5664  Clinical Science  Center 600 Highland Ave  Madison, WI 53792 |
| 713-745-2164                             | 617-724-8770                                     | 212- 639-2000                                                 | 313-916-1784                                                    | 919-966-7890                                          | 608- 265-0861                                                                 |
| egerstner@mgh.harva                      | OmuroA@mskcc.                                    | Tmikkel1@hfhs.or                                              | collich@med.unc.                                                | hirobins@wisc.edu                                     |                                                                               |
| on.org                                   | rd.edu                                           | org                                                           | g                                                               | edu                                                   |                                                                               |  
Address: 1515 Holcombe  
Blvd, Houston, TX  
77030
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precis background

- Although relatively uncommon, ependymoma can occur at any age group although the tumors of the posterior fossa are much more common in the pediatric population and spinal cord tumors are more common in young to middle age adults. Anaplastic ependymomas are more common in adults
- There have only been a limited number of reports describing chemotherapy treatments for patients with recurrent ependymoma, either low grade or anaplastic. As a consequence, optimal therapy for this group remains unknown. Traditionally, combination chemotherapy regimens have been used, often containing either carboplatin or cisplatin. Many of these treatment programs were associated with a high incidence of moderate to severe toxicity
- Given the paucity of established treatments for recurrent ependymomas in adults, we propose a study that uses a combination of an established cytotoxic agent, temozolomide with a small molecule tyrosine kinase inhibitor. Temozolomide was chosen because it has an established track record in treating primary brain tumors, it has a good safety profile and recent data suggest that certain dosing schedules may modulate tumor cell resistance via the MGMT mechanism. Given the recent studies in glioblastoma that correlate MGMT methylation status with outcome, modulating MGMT activity may have a significant impact on response
- Additionally, we plan to target the ERBB1 and the ERBB2 pathways using lapatinib on a continuous daily dosing schedule
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objectives

- To determine the efficacy of the combination of temozolomide and lapatinib in recurrent brain ependymoma and anaplastic ependymoma as measured by median progression-free survival.
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eligibility

- Histologically proven ependymoma or anaplastic ependymoma. There must be pathologic or imaging confirmation of tumor progression or regrowth.  
- Patients must be on a steroid dose that has been stable or decreasing for at least 5 days.
- Karnofsky performance status ≥ 70
- Age ≥ 18 - No severe, active comorbidity
- No condition that impairs ability to swallow pills Design:  
- This is a phase II study to determine the efficacy of the combination of temozolomide and lapatinib in recurrent brain ependymoma and anaplastic ependymoma as measured by median progression-free survival.  
- Eligible patients will receive 2 cycles of the combination of temozolomide and lapatinib. The temozolomide will be administered at a dose of 125 mg/m2 as a single daily dose on days 1-7 and 15-21 of a 28-day cycle. The lapatinib will be given as a single daily dose of 1250 mg orally. Patients who do not experience any grade 1 or greater myelotoxicity will be eligible to have the temozolomide dose increased to 150 mg/m2 as a single daily dose on days 1-7 and 15-21 of a 28-day cycle. The lapatinib dose will not be increased.  
- Patients who exhibit response to protocol therapy and have not experienced any significant or intolerable toxicities may continue to receive protocol therapy up to a maximum number of 24 cycles.  
- Patients that are showing sustained Complete Response (CR), Partial Response
(PR) or Stable Disease (SD) may continue post protocol single agent therapy with lapatinib. Post-protocol lapatinib supply may be obtained through Glaxo SmithKline (GSK). Patients on post protocol single agent lapatinib will have follow up visits every 2 months for survival assessment and radiographic evaluation of disease per MRI or CT scan.
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study schema

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%&.5281'1'5721/( (shqgprpd

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³HSHQG\PRPD´DOVR FDOOHGD³:+2JUDGH,,HSHQG\PRPDDQGWKHPRUHPDOLJQDQWGHVLJQDWLRQ³DQDSODVWLF HSHQG\PRPD´DOVRFODVVLILHGDVD³:+2JUDGH,,,HSHQG\PRPD´.OHLKXHVDQG&DYHQHH The causes of ependymoma are not known. Although relatively uncommon, the disease can occur at any age group although the tumors of the posterior fossa are much more common in the pediatric population and spinal cord tumors are more common in young to middle age adults. Anaplastic ependymomas are more common in adults. A series of genetic changes have been reported in these tumors, although a wide variability between tumors has been reported. Furthermore, patients can be initially diagnosed with an anaplastic ependymoma or these malignant tumors can develop from the malignant transformation of the lower grade ependymoma. This underscores the importance of genetic changes in the formation of the disease, the biologic behavior including malignant transformation and the potential utilization of these characteristic molecular changes as treatment targets. The variable patterns of histology and clinical presentation of ependymoma, and the separation of pediatric and adult oncology services, have hindered efforts to coordinate clinical trials in this disease. As a result, no new therapeutic approaches have been identified to treat ependymoma during last 20 years and up to 40% of patients remain incurable](Brandes, Cavallo et al. 2005; Merchant and Fouladi 2005). Currently, the standard therapy for newly diagnosed low-grade ependymoma includes total surgical excision followed by radiation therapy. Complete surgical resection is often not possible because of the location of the tumor and the concern for damage to surrounding eloquent brain during surgery. The situation is even more critical for patients with anaplastic ependymomas because of the higher proliferative rate and greater propensity for tumor infiltration into surrounding normal brain, preventing any possibility of complete tumor removal by surgery. For patients with the more aggressive anaplastic ependymoma, chemotherapy is often administered either before or after the radiation in the hope that infiltrating tumor cells will be eliminated. Unfortunately, even for patients with low-grade ependymoma, survival can be poor when the tumor is not totally surgically resected. 1.2.2 Treatment of recurrent ependymoma There have only been a limited number of reports describing chemotherapy treatments for patients with recurrent ependymoma, either low grade or anaplastic. As a consequence, optimal therapy for this group remains unknown. Traditionally, combination chemotherapy regimens have been used, often containing either carboplatin or cisplatin. Many of these treatment programs were associated with a high incidence of moderate to severe toxicity. A recent publication by Brandes and colleagues underscores some of the limitations in determining the optimal treatment for recurrent disease(Brandes, Cavallo et al. 2005). They report on the treatment of 28 adults who had recurrent ependymoma (n = 17) or anaplastic ependymoma (n = 11) after initial treatment with surgery and radiation. Half of the patients had undergone multiple tumor resections. A wide variety of regimens were used ranging from single agent temozolomide to the "8 in 1" regimen that combines 8 different chemotherapy agents. For their analyses, they looked at the composite group as well as a comparison of patients treated with or without cisplatin. No overall differences were noted based on the use of cisplatin. Furthermore, the overall objective response rate was 20% (CR and PR). The 12 month progression free survival rate was 44% (95% CI, 29-68%). The median time to progression was 9.9 months. These data provide a benchmark for subsequent clinical trials evaluating treatments for adults with recurrent ependymomas. There have been anecdotal reports of response of ependymoma to temozolomide. The study by Brandes included 4 patients who received this either as single agent (n = 3) or in combination with cisplatin (n = 1)(Brandes, Cavallo et al. 2005). All patients were reported to have stable disease as their best response. A single case report describes a patient with recurrent anaplastic ependymoma with a greater than 10 year response to temozolomide therapy(Rehman, Brock et al. 2006). There is no published literature on the use of signal transduction modulating agents, save for a recent phase I study of the farnesyltransferase inhibitor lonafarnib in patients with recurrent primary pediatric brain tumors(Kieran, Packer et al. 2007). A single patient with a recurrent ependymoma did achieve stable disease with this regimen. Recent correlative laboratory studies have carefully examined the molecular profiles of both pediatric and adult ependymomas. Distinct profiles of gene expression were uncovered that were primarily based on tumor location, with less difference in expression pattern noted between the pediatric and adult tumor samples.
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1.2.3 potential molecular targets in

Several studies have been performed examining the spectrum of molecular profiles in ependymoma. These studies often examine a wide variety of tumors including grade II and III ependymomas, myxopapillary ependymomas. These series often include pediatric and adult tumors as well as those from spinal cord, posterior fossa and supratentorial locations. Most studies demonstrate specific molecular patterns that distinguish tumors by location with the largest differences noted between tumors arising within the spinal cord compared with those of brain origin. There are reports that find some distinct changes in comparing supra- from infratentorial tumors however this is much less striking. Cytogenetic studies report aberrations on chromosome 22 in a high percentage of tumors, with either monosomy or 22q deletion (Lamszus, Lachenmayer et al. 2001; Suarez-Merino, Hubank et al. 2005). Intracranial tumors are reported to have a gain of 1q and chromosomal losses on 6q, 9 and 13(Korshunov, Neben et al. 2003). In comparison, spinal cord ependymomas have been reported to have gains on chromosome 7(Korshunov, Neben et al. 2003). Specific microarray analysis has shown increased expression of putative oncogenes such as WNTSA, as well as genes involved in cell cycle regulation, cell adhesion and proliferation(Suarez-Merino, Hubank et al. 2005). More recently, promoter methylation analysis has been performed on ependymoma cells uncovering that genes involved in apoptosis, such as TRAIL, are frequently methylated(Michalowski, de Fraipont et al. 2006). However, these studies also show that the MGMT gene is not commonly methylated, which may impact sensitivity of ependymoma to alklyating agent chemotherapies. Recent, comparative genomic hybridization studies demonstrated that 90% of ependymomas had increased expression of EGFR(Gilbertson, Bentley et al. 2002). Furthermore, immunohistochemical analysis showed increased levels of intracellular EGFR in nearly 60% of intracranial ependymoma and this was highly correlated with a poorer prognosis (P = 0.002). Interestingly, although the rate of high expression of EGFR was the same in spinal cord tumors, there was no correlation with outcome. These studies suggest that EGFR may be a suitable target for treating intracranial ependymomas. Additional studies have shown increased expression of ERBB2 and ERBB4 in pediatric intracranial ependymomas(Gilbertson, Bentley et al. 2002). Also, a polymorphism has been detected in the promoter region of the PDGFRα gene that alters the binding of the transcription factor, ZNF-148, suggesting that the PDGFR pathway may be important in the development of some ependymomas(De Bustos, Smits et al. 2005). Therefore, the PDGFR pathway may also be a potential therapeutic target.
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1.2.4 study proposal

Given the paucity of established treatments for recurrent ependymomas in adults, we propose a study that uses a combination of an established cytotoxic agent, temozolomide with a small molecule tyrosine kinase inhibitor. Temozolomide was chosen because it has an established track record in treating primary brain tumors, it has a good safety profile and recent data suggest that certain dosing schedules may modulate tumor cell resistance via the MGMT mechanism. Given the recent studies in glioblastoma that correlate MGMT methylation status with outcome, modulating MGMT activity may have a significant impact on response. Prolonged dosing of temozolomide using a dose-dense schedule has been shown to reduce MGMT activity in peripheral blood mononuclear cells(Tolcher, Gerson et al. 2003). Therefore, this strategy which has shown potential benefit in recurrent malignant glioma, may enhance the activity of temozolomide in ependymoma. In recurrent glioblastoma, response (as measured by 6-month progression free survival)l to conventional dosing of temozolomide was 21% (Yung, Albright et al. 2000). In comparison, a "week-on, week-off" schedule resulted in a 46% 6-month progression free survival rate(Wick, Felsberg et al. 2007). A similar dosing schedule is proposed for this study. Additionally, we plan to target the ERBB1 and the ERBB2 pathways using lapatinib on a continuous daily dosing schedule. Given the recent results described above demonstrating a high percentage of ependymomas expressing high levels of EGFR (ERBB1) as well as ERBB2, these are logical targets. The concept of potential additive or synergistic benefit of combining a cytotoxic agent with a cytostatic agent has been established in brain tumor treatments. Conventional dosing of temozolomide shows better response when combined with either isotretinoin (6-month PFS = 31%) or marimastat (6-month PFS = 42%)(Groves, Puduvalli et al. 2002; Jaeckle, Hess et al. 2003). Recently, studies have been performed on tumor tissues from patients with glioblastoma who were treated with EGFR inhibitors (either erlotinib or gefitinib). Two studies demonstrated a correlation of response with either EGFR overexpression or the presence of the EGFRVIII mutation, but only when the PTEN gene or protein was present(Haas-Kogan, Prados et al. 2005; Mellinghoff, Wang et al. 2005). It is not known whether these results are translatable to ependymoma. Therefore, in addition to the clinical trial, a correlative study will be performed. Tumor tissue will be analyzed for the following markers:
MGMT methylation status EGFR amplification EGFR vIII mutation PI3K pathway activation This correlative study may help define the tumors that are optimally treated with the combination of temozolomide and lapatinib. Furthermore, this study will further define the frequency of these molecular changes in adult ependymoma. Temozolomide, an oral alkylating agent with good penetration of the central nervous system, has been evaluated in patients with glial malignancies. Initial studies evaluated the efficacy of temozolomide in patients with recurrent glioblastoma and anaplastic glioma. A large, randomized phase II study by Yung and colleaguestreated patients with recurrent glioblastoma with either temozolomide (200 mg/m2 days 1-5 of a 28-day cycle) or procarbazine (150 mg/m2 28 day-on, 28-day off schedule) (Yung, Albright et al. 2000). The study demonstrated only a modest objective response rate for both regimens (approximately 5%), but a superior 6-month progression-free survival rate for temozolomide (21% vs. 9%) was found. In the pre-radiation setting, a phase II study demonstrated a good objective response rate (complete plus partial response = 41%) in patients with glioblastoma during the four monthly cycles of treatment, using 200 mg/m2 on days 1 to 5 of a 28-day cycle. However, the responses were not durable in many cases and the median progression-free survival rate was 3.8 months. Overall survival for patients on this study was 13.1 months, similar to most reports of treatment in newly diagnosed patients. This suggests that the neoadjuvant temozolomide chemotherapy likely had little overall benefit. However, these results did demonstrate definite activity of temozolomide for glioblastoma.(Gilbert, Friedman et al. 2002) Stupp and colleagues performed a phase III trial in patients with newly diagnosed glioblastoma, administering a daily lower dose (75 mg/m2) of temozolomide every day during the course of radiation therapy, followed by 6 months of adjuvant chemotherapy at the standard single-agent dose of 200 mg/m2 for days 1 to 5 of a 28-day cycle.(Stupp, Mason et al.  
2005) This study, performed by the EORTC and the NCIC, randomized patients with newly diagnosed glioblastoma to receive either radiation therapy alone or concurrent radiation and temozolomide followed by 6 months of adjuvant temozolomide. The study demonstrated a statistically significant improvement in median survival for the combination treatment arm (12.1 vs. 14.6 months) as well as a significant increase in 2-year survival (10% vs 26%). Eighty-eight percent of the patients received the full course of concurrent temozolomide with radiation. Approximately 40% of patients received the full 6 cycles of temozolomide after the completion of the radiation (adjuvant therapy). Tumor progression was the most prominent cause of treatment cessation. The chemoradiation treatment was well tolerated, with an incidence of grade 3 or 4 hematologic toxicity of < 4%. This chemoradiation regimen has been widely accepted as the new standard of care for patients with newly diagnosed glioblastoma. As described above, incorporation of a dose-dense strategy for recurrent primary brain tumors is supported by the results of a recently reported clinical trial that treated patients with recurrent malignant glioma with the week on/week off dosing schedule of temozolomide at a dose of 150 mg/m2 /day. This study reported a 6-month progression free survival rate of 46%,
which compares favorably with the 6-month PFS rate of 21% reported with conventional 5 day of a 28 day cycle of temozolomide (Yung, Albright et al. 2000; Wick, Felsberg et al. 2007).
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1.2.6 lapatinib overview

Lapatinib acts as a dual inhibitor of both ErbB1(EGFR) and ErbB2 (HER2) tyrosine kinase activity. As a member of the 4-anilinoquinazoline class of kinase inhibitors, Lapatinib is thought to react with the ATP binding site of EGFR/ErbB2, resulting in inhibition of autophosphorylation and subsequent proliferative signaling (Shewchuk, Hassell et al. 2000). The ErbB family consists of four closely related growth factor receptor tyrosine kinases. The family is comprised of ErbB1 (EGFR/HER), ErbB2 (HER2/neu), ErbB3 (HER3), and ErbB4 (HER4). All members of the ErbB family share a common extracellular ligand-binding domain, a single membrane-spanning region and a cytoplasmic tyrosine kinase domain (reviewed in (Yarden and Sliwkowski 2001) and (Burgess, Cho et al. 2003)). A ligand for ErbB2 has not been identified, while ErbB3 lacks tyrosine kinase activity. Ligand binding to EGFR, ErbB3 or ErbB4 induces these inactive monomers to undergo an array of homo- or heterodimerization with other members of the ErbB family. ErbB2 is the preferred heterodimeric partner for all ErbB receptors, resulting in a complex that is endocytosed at one half to one third the rate of other EGFR dimers (Graus-Porta, Beerli et al. 1997; Hendriks, Opresko et al. 2003). ErbB dimerization leads to receptor autophosphorylation and subsequent activation of the tyrosine kinase domain. The signaling characteristics of the ErbB family are thought to be strongly interdependent. EGFR expression by tumor cells has been linked with aggressive tumor growth, disease progression, poor survival, and poor response to therapy. Overexpression of EGFR has been reported in a number of epithelium-derived carcinomas including head and neck, colorectal, lung, esophageal, gastric, and breast carcinoma. In a similar manner, ErbB2 has been reported to be overexpressed in 15-30% of invasive ductal breast cancer and has been associated with increased proliferation, poor clinical outcome, and altered responsiveness to various adjuvant therapies (Allred, Mohsin et al. 2001) Activation of either EGFR or ErbB2 initiates a series of signaling cascades that includes mitogen-activated protein kinase (MAPK), phosphoinositide 3-kinase (PI3K), Akt, and p70S6K.
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1.2.6.1 mechanism of action

Lapatinib has been shown to be a potent and selective dual inhibitor of EGFR (ErbB1) and ErbB2 tyrosine kinase activity with IC50 values of 10.2 and 9.8 nM, respectively(Rusnak, Lackey et al. 2001). Lapatinib has demonstrated selective growth inhibition of human cell lines (head and neck, breast, and gastric) in vitro (IC90 values <2.26 µM or 1313 ng/mL) with no outgrowth observed up to 18 days following cessation of treatment. Growth inhibition corresponded with the ability of Lapatinib to inhibit phosphorylation of Akt. These studies suggested that inhibition of EGFR by Lapatinib resulted preferentially in cell growth arrest, while inhibition of ErbB2 led to cell growth arrest and apoptosis after 72 hours. Treatment with Lapatinib leads to arrest of tumor cell growth and/or apoptosis, even in the presence of saturating concentrations of epidermal growth factor (EGF). Treatment of tumor xenografts resulted in inhibition of activation of EGFR, erbB2, Erk1/2, and Akt (Xia, Mullin et al. 2002).
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1.2.6.2 preclinical studies

The ability of Lapatinib to inhibit the growth of EGFR-overexpressing cell lines (IC50 <0.16 µM) was observed to be equal to that of other EGFR inhibitors being tested in clinical trials (e.g.  
gefitinib/IressaTM or erlotinib/TarcevaTM). With the exception of ErbB4, Lapatinib was >300-fold more selective towards ErbB2 and EGFR kinase inhibition than to other kinases tested. Lapatinib demonstrated potent growth inhibition of human breast ductal (BT474) and head and neck (HN5) tumor xenografts in mice. A dose response inhibition was observed in both models receiving Lapatinib (30 or 100 mg/kg twice daily orally for 21 days). Complete inhibition of tumor growth was seen in mice receiving 100 mg/kg (Rusnak, Lackey et al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2.1.1.4 Patients must be able to undergo brain or spine MRI scans with intravenous gadolinium, based on tumor location(s) within 14 days prior to registration.  
2.1.1.5 Patients must be on a steroid dose that has been stable or decreasing for at least 5 days. If the steroid dose is increased between the date of imaging and registration, a new baseline MRI is required.
2.1.1.6 Karnofsky performance status ≥ 70 2.1.1.7 Age ≥ 18 2.1.1.8 CBC/differential obtained within 14 days prior to registration, with adequate bone marrow function defined as follows:  
- Absolute neutrophil count (ANC) ≥ 1,500/mm3
- Platelets ≥ 100,000 cells/mm3
- Hemoglobin ≥ 10.0 gm/dL (Note: The use of transfusion or other intervention to achieve Hgb ≥ 10.0 is acceptable)
- White blood cell count (WBC) ≥ 3,000/mcL.  
- Adequate liver function within 14 days prior to registration, defined as follows:
SGPT (ALT) < 2.5 times the upper limit of normal, Bilirubin ≤ 1.6 mg/dL
- Adequate renal function within 14 days prior to registration, defined as follows:
Creatinine < 1.7 mg/dL
2.1.1.9 Patients must have recovered from the toxic effects of prior therapy, and there must be a minimum time of:
- 28 days from the administration of any investigational agent
- 28 days from administration of prior cytotoxic therapy with the following exceptions:
- 14 days from administration of vincristine
- 42 days from administration of nitrosoureas
- 21 days from administration of procarbazine  
- 7 days from administration of non-cytotoxic agents [e.g., interferon, tamoxifen, thalidomide, cis-retinoic acid, etc. (radiosensitizer does not count)].  
- 28 days from prior radiation therapy.  
2.1.1.10 Patients must have recovered from the effects of surgery and a minimum of 14 days must have elapsed from the day of surgery to the day of registration. For core or needle biopsy, a minimum of 7 days must have elapsed prior to registration.  
2.1.1.11 Residual disease following resection of recurrent tumor is not mandated for eligibility into the study. To best assess the extent of residual disease post-operatively, an MRI should be done no later than 96 hours in the immediate postoperative period or at least 4 weeks postoperatively, within 14 days prior to registration. If the "within 96-hour of surgery" scan is more than 14 days before registration, the scan needs to be 2.1.1.12 Patients must sign study-specific informed consent and authorization for the release of their protected health information prior to registration. Patients must be registered in the prior to treatment with study drug.  
2.1.1.13 Women of childbearing potential must have a negative β-HCG pregnancy test documented within 14 days prior to registration.  
2.1.1.14 Women of childbearing potential and male participants must practice adequate contraception.  
2.1.1.15 All patients must have an LVEF measurement of at least 50% by Echo or MUGA (if clinically indicated) within 14 days prior to registration. The method used for LVEF assessment in an individual subject must be the same throughout the trial 2.1.2 Exclusion Criteria 2.1.2.1 Prior invasive malignancy that is not the ependymoma (except non-melanomatous skin cancer or carcinoma in situ of the cervix) unless the patient has been disease free and off therapy for that disease for a minimum of 3 years.  
2.1.2.2 Severe, active comorbidity, defined as follows:
- Transmural myocardial infarction or unstable angina within 3 months prior to study registration
- Evidence of recent myocardial infarction or ischemia by the findings of S-T
elevations of ≥ 2 mm using the analysis of an EKG performed within 14 days prior to registration
- New York Heart Association grade II or greater congestive heart failure requiring hospitalization within 12 months prior to registration
- History of stroke or transient ischemic attack within 3 months prior to registration.  
- Inadequately controlled hypertension (systolic blood pressure > 150 mm Hg and/or diastolic blood pressure > 90 mm Hg despite antihypertensive medication)
- History of cerebral vascular accident (CVA) within 3 months prior to registration.  
- Serious and inadequately controlled cardiac arrhythmia
- Significant vascular disease (e.g., aortic aneurysm, history of aortic dissection)
- Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
- Acquired immune deficiency syndrome (AIDS) based upon current CDC definition; note, however, that HIV testing is not required for entry into this protocol. The need to exclude patients with AIDS from this protocol is necessary because the treatments involved in this protocol may be significantly immunosuppressive.  
2.1.2.3 Patients cannot be receiving HAART (Highly Active Anti-Retroviral Therapy)
therapy.  
2.1.2.4 Pregnant or nursing women because of concern of fetal/infant exposure to these
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| 3.3.1.2                                                   | Summary of dose modifications  Dermatologic                                                                                                                                                                                                                   | Hold dose.  - Re-evaluate at least weekly  until AE resolved to < 1 or  tolerable Grade 2.  - Re-treat at a one dose level  reduction  - If AE persists > 4 weeks,  remove patient from study  Patients with Grade 4 AEs related  to agent should be taken off study.   |
|-----------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Rash - acne/acneiform - Intolerable Grade 2 &  Grades 3-4 | Note: Grade 2 lapatinib related rash  may not automatically require dose  reduction. However, for Grade≥ 3  rash or recurrent intolerable Grade  2 rash, reduce 1 dose level.                                                                                 |                                                                                                                                                                                                                                                                         |
| Gastrointestinal Diarrhea - Grade 1                       | No intervention required  Loperamide (4 mg at first onset,  followed by 2 mg every 2–4 hrs  until diarrhea free for 12 hrs)                                                                                                                                   |                                                                                                                                                                                                                                                                         |
| - Grade 2 - Grade 3, 4 or  intolerable Grade 2:           | - Hold dose.  - Loperamide, hold agent until  recovery to < Grade 1 and then  reduce 1 dose level - If AE persists > 4 weeks,  remove patient from study - Patients with Grade 4 AEs  related to agent may be taken  off study at investigator's  discretion. |                                                                                                                                                                                                                                                                         |
| Ocular/Visual Keratitis                                   | - Preservative-free artificial tears,  ointments, and/or other therapies  as clinically indicated, with a  follow-up examination within  2 weeks1 .  - Dose reduction not required.                                                                           |                                                                                                                                                                                                                                                                         |
| - Grade 1                                                 |                                                                                                                                                                                                                                                               |                                                                                                                                                                                                                                                                         |  
Abbreviated Title: Ph II Recurrent Ependymoma  
Version Date: 07/21/17 22  
| Version Date: 07/21/17                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      | 22                                                                                                                                      |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------|
| - Manage as for Grade 1 keratitis1 .  - Grade 2 persistent (>14 days) or  Grade 3: Hold dose. Re-treat at a  reduced dose after resolution or  amelioration of AE to < Grade 1  at the discretion of the  investigator. - Persistent Grades 2 or 3: Remove  patient from study for persistent  Grade >2 keratitis after dose held  for 14 days. Ophthalmologic F/U  should be scheduled at a  frequency determined by the  ophthalmologist                                                                  |                                                                                                                                         |
| Pulmonary/Upper Respiratory - Grade 2 or 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | Patient should be thoroughly  evaluated, closely monitored, and  supported as clinically indicated.                                     |
| Signs and symptoms of  Interstitial Pneumonitis                                                                                                                                                                                                                                                                                                                                                                                                                                                             | Hold dose pending diagnosis Permanently discontinue lapatinib if  diagnosis is confirmed and considered possibly related to  lapatinib. |
| All other non-hematologic adverse events  Hold dose. - Re-treat at a reduced dose after  resolution or amelioration of AE  to < Grade 1 If AE persists > 4 weeks , remove  patient from study Any Grade 2 of concern (e.g., prolonged cardiac,  Hold dose.  - Re-evaluate until AE  resolved to < Grade 1 (or  tolerable Grade 2).  - If AE persists >4 weeks,  remove patient from study  - Patients with Grade 4 AEs  related to agent may be  taken off study at  investigator's discretion.Grade 3 or 4 |                                                                                                                                         |  
3.3.1.3 Liver Chemistry Stopping and Follow-up Criteria  
3.3.1.3.1 Liver Chemistry Stopping Criteria 3.3.1.3.1.1 Liver chemistry stopping and follow up criteria have been designed to assure subject safety and evaluate liver event etiology. All subjects who meet liver chemistry criteria requiring permanent discontinuation of lapatinib must continue to be followed for the study assessments and procedures as defined in Section 3.7.6and Appendix 12.5If a subject experiences ALT >3 × ULN and total bilirubin >2.0 × ULN (>35% direct; bilirubin fractionation required*), then the following actions must be taken:
- immediately and permanently discontinue investigational product;
- complete the SAE data collection tool, and the clinical evaluation CRF;
- in addition to the liver event follow up assessments defined below, the following are suggested: specialist or hepatology consultation; anti-nuclear antibody, antismooth muscle antibody, and Type 1 anti-liver kidney microsomal antibodies; and liver imaging and/or liver biopsy to evaluate liver disease;
- promptly report the event to NCI CCR within 24 hours of learning of its occurrence
(refer to Section 7.4);
- monitor every week until liver chemistries resolve, stabilize or return to within baseline values;
- do not re-challenge with lapatinib.  
- **NOTE**: bilirubin fractionation should be performed if testing is available. If testing is unavailable and a subject meets the criterion of total bilirubin >2.0 × ULN, then the aforementioned actions must still be performed.  
3.3.1.3.1.2 If a subject experiences:
- ALT >8 × ULN or
- ALT >5 × ULN persisting for ≥2 weeks: retest within 3 days from the first occurrence and then weekly to determine if ALT elevation persists or
- ALT >3 × ULN with signs or symptoms of hepatitis or hypersensitivity (the appearance or worsening of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, or eosinophilia),
- Total Bilirubin > 2 x ULN in absence of Gilbert's Syndrome
then hold investigational product for 2 weeks, repeat liver chemistry testing in 2 weeks, and then call the Study Chair (Dr. Mark Gilbert) to discuss the possibility of re-challenging with investigational product.  
3.3.1.3.1.3 If the treatment is exhibiting efficacy and the subject wants to continue for potential benefit of lapatinib therapy after being informed of the results of liver chemistry testing, then the lapatinib may be re-started at the reduced dose agreed upon by the investigator and the Study Chair. The liver event CRF should be completed and liver chemistries and aforementioned signs and symptoms should
be monitored at a minimum of every 2 weeks until resolution, stabilization, or a return to baseline values, at which point monitoring should be continued per protocol.  
3.3.1.3.1.4 If a subject experiences ALT >3 × ULN but <5 × ULN and total bilirubin ≤2 ×
ULN, without signs or symptoms of hepatitis or hypersensitivity, and who can be monitored weekly, then the following actions should be taken:
- continue investigational product;
- monitor weekly until liver chemistries resolve, stabilize, or return to within baseline, then monitor liver chemistries as per protocol assessment schedule;
- if ALT >3 and < 5 × ULN for > 4 weeks , discontinue the treatment; - if at any time this subject meets any of the aforementioned liver chemistry stopping criteria, then proceed as described above.  
3.3.1.3.2 Liver Chemistry Follow up Criteria 3.3.1.3.2.1 For all subjects who meet any of the liver chemistry criteria described above, make every attempt to carry out the liver follow up assessments described below:
- Viral hepatitis serology including:
- Hepatitis A IgM antibody;
- Hepatitis B surface antigen and Hepatitis B Core Antibody (IgM);
- Hepatitis C RNA;
- Cytomegalovirus IgM antibody;
- Epstein-Barr viral capsid antigen IgM antibody (or if unavailable, obtain heterophile antibody or monospot testing);
- Hepatitis E IgM antibody (if subject resides or has travelled outside USA or Canada in past 3 months);
- Serum creatine phosphokinase (CPK) and lactate dehydrogenase (LDH);  
- Complete blood count with differential to assess eosinophilia;
- Record the appearance or worsening of clinical symptoms of hepatitis, or hypersensitivity, fatigue, decreased appetite, nausea, vomiting, abdominal pain, jaundice, fever, or rash as relevant on the AE report form;
- Record use of concomitant medications, acetaminophen, herbal remedies, other over the counter medications, or putative hepatotoxins, on the concomitant medications report form;
- Record alcohol use on the liver clinical evaluation case report form.  
- Refer to Appendix **12.5** for a liver safety algorithm detailing stopping and follow up criteria.
3.3.1.4.1 Cardiac Definitions  
3.3.1.4.1.1 Cardiac Death is defined as either:
- Cardiac death due to heart failure, myocardial infarction, or arrhythmia.  
- Probable cardiac death defined as sudden, unexpected death within 24 hours of a definite or probable cardiac event.  
3.3.1.4.1.2 Severe symptomatic CHF is defined as New York Heart Association (NYHA)
Class III or IV (Class III defined as being not capable of climbing one flight of stairs and class IV defined as having symptoms at rest) and a drop in LVEF of more than 10 points from the baseline and to below 50%. In these cases there is no need to perform a confirmatory second LVEF assessment. The method used for the LVEF assessment must be the same method as used for the baseline assessment.  
3.3.1.4.1.3 Asymptomatic (NYHA I) or mildly symptomatic (NYHA II) is defined as a significant drop in LVEF, confirmed by a second LVEF assessment within approximately three weeks showing also a significant drop in LVEF. A significant drop is defined as an absolute decrease of more than 10 points below the baseline LVEF and to below 50%. The method used for LVEF assessment must be the same method used for the first (baseline) assessment.
untitled h1
new york heart association functional

| I   | No Symptoms and no limitations in ordinary physical activity.                                                  |
|-----|----------------------------------------------------------------------------------------------------------------|
| II  | Mild Symptoms and slight limitation during ordinary activity. Comfortable at rest.                             |
| III | Marked limitation in activity due to symptoms, even during  less-than-ordinary activity.  Comfortable at rest. |
| IV  | Severe limitations. Experiences symptoms even while at rest.                                                   |
untitled h1
- stopping rule

Treatment with any of the treatment regimens defined for this study will be permanently stopped if a patient develops a symptomatic cardiac event or an asymptomatic event confirmed by repeat evaluation. However, patients will remain in the study and all efforts will be made to complete all assessments as planned.
untitled h1
- treatment

It is strongly recommended that patients who have symptomatic decreases in LVEF or those who meet the criteria for stopping treatment seek cardiologic consultation for advice on potential treatment for their cardiac dysfunction. 3.3.2 Temozolomide 3.3.2.1 Dosing is based on adverse events (AEs) during the prior treatment cycle. If multiple AEs are seen, the dose administered should be based on the dose reduction required for the most severe grade of any single AE.  
| Dose Level   | Dose mg/m2   | Remarks                                                                                                                                                                        |
|--------------|--------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| - 2          | 75           | Reduction if prior AE                                                                                                                                                          |
| -1           | 100          | Reduction if prior AE Starting dose for cycle 1and 2,  increase to 150 mg/m2 for cycle 3  and beyond if non hematologic toxicity ≤ grade 2 and  hematologic toxicity ≤ grade 1 |
| 0            | 125          |                                                                                                                                                                                |
| +1           | 150          | Highest possible dose level                                                                                                                                                    |  
3.3.2.1.1 First and Second Cycle: Temozolomide will be started at a dose of 125mg/m2/day.  
3.3.2.1.2 Third Cycle: The dose of temozolomide will be determined according to: (1)
treatment related non-hematologic AE during the preceding treatment cycle, as well as (2) the worst ANC and platelet counts.  
3.3.2.1.3 Delay: On day 1 of each cycle (within the prior 72 hours), ANC ≥ 1.5 x 109/L,
platelet count ≥ 100 x 109/L and all grade 2, 3 or 4 non-hematologic AEs (except for alopecia, nausea, and vomiting) must have resolved (to grade ≤ 1).  
3.3.2.1.4 If AEs persists, treatment should be delayed by 1 week for up to 4 consecutive weeks. If, after 4 weeks of delay, all treatment related AEs have still not resolved (to grade ≤ 1): then any further treatment with temozolomide should be stopped.
3.3.2.1.5 Dose Escalations and Reductions: If, during the first and second cycle, all hematologic AEs observed were ≤ grade 1 and treatment related non-hematologic AEs observed were grade ≤ 2 (except alopecia, lymphopenia, nausea and vomiting) then the temozolomide dose should be escalated to dose level 1 and this dose should be used as the starting dose for subsequent cycles. If treatment after cycles 1and 2 temozolomide has to be delayed because of ongoing non-hematologic AEs of grade ≥ 2, then no escalation is possible. If the dose was not escalated at cycle 3, then the dose should not be escalated in further cycles (4-24).  
3.3.2.1.5.1 Dose reductions: If any treatment related non-hematologic AE observed was grade
> 2 (except alopecia, lymphopenia, nausea and vomiting) and/or if platelets < 50 x 109/L and/or ANC < 1 x 109/L, then the dose should be reduced by one dose level.  
Patients who require more than two dose reductions will have treatment stopped.  
If any treatment-related non-hematologic AE observed was grade 4 (except alopecia, lymphopenia, nausea and vomiting) then temozolomide treatment should be stopped.  
Abbreviated Title: Ph II Recurrent Ependymoma Version Date: 07/21/17 27 3.3.2.1.5.2 Subsequent cycles (4-24): Any dose reductions of temozolomide will be determined according to: (1) non-hematologic AE during the preceding treatment cycle, as well as (2) the lowest ANC and platelets observed. No dose escalation should be attempted. The same dose reductions as for the second cycle should be applied. *Important:* If the dose was reduced or delayed for AEs, there will be no dose re-escalation in subsequent treatment cycles.  
3.3.2.2 Summary of Dose Modifications or Discontinuation for Temozolomide-Related Adverse Events  
| Worst Treatment-Related Non-Hematologic AE (except for alopecia, nausea,  and vomiting) During the Previous Cycles   |                                                                                                                        |
|----------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------|
| Grade                                                                                                                | Dose Modification                                                                                                      |
| 0-2                                                                                                                  | No dose modifications for non-hematologic AEs. Dose reductions based on  ANC and platelet counts are applicable.       |
| 3                                                                                                                    | Reduce by one dose level (except alopecia, nausea, and vomiting).                                                      |
| 4                                                                                                                    | Stop (except alopecia, nausea, and vomiting). Dose modifications based on  ANC and platelet counts are not applicable. |  
3.3.2.3 Worst Treatment-Related Hematologic AE During the Previous Cycle  
| Worst AE      | Platelets        |                  |                         |                  |
|---------------|------------------|------------------|-------------------------|------------------|
| ≥100 x 109/L  | 50 - 99 x 109/L  | < 50 x 109/L     |                         |                  |
| ≥ 1.5 x 109/L | Dose unchanged   | Dose unchanged   | Reduce by 1 dose  level |                  |
| ANC           | ≥1 & <1.5 x      | Dose unchanged   | Dose unchanged          | Reduce by 1 dose |
| 109/L         | level            |                  |                         |                  |
| < 1 x 109/L   | Reduce by 1 dose | Reduce by 1 dose | Reduce by 1 dose        |                  |
| level         | level            | level            |                         |                  |  
Note: A complete blood count must be performed on days 14 and 28 (± 72 hours) after the first daily dose of each treatment cycle.  
| before Day 1)                                                                                                                                                                                                                              |       |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------|
| AE                                                                                                                                                                                                                                         | Delay |
| Delay up to 4 weeks until all resolved. If  unresolved after 4 weeks then stop. If resolved,  dose delay/reductions based on non-hematologic  AEs are applicable. If treatment has to be delayed  for AEs, then no escalation is possible. |       |
| ANC< 1.5 x 109/L                                                                                                                                                                                                                           |       |
| and/or Platelet count <  100 x 109/L                                                                                                                                                                                                       |       |  
| Non-Hematologic AE (except for alopecia, nausea, and vomiting)  On Day 1 of Each Cycle (within the prior 72 hours)   |       |
|----------------------------------------------------------------------------------------------------------------------|-------|
| Grade                                                                                                                | Delay |  
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3.8.3 off study procedure

For participating CERN sites: When a subject is taken off-study, notify CCR study coordinator via encrypted email. (Christine Bryla email: christine.bryla@nih.gov )
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3.8.4 post protocol therapy and

Patients that are showing sustained Complete Response (CR), Partial Response (PR) or Stable Disease (SD) may continue Post protocol single agent therapy with lapatinib. Post protocol lapatinib supply may be obtained through Glaxo Smith-Kline (GSK), using the same drug ordering mechanism as detailed in section 10.2.12 (Agent Ordering/Requests). 3RVW3URWRFRO)ROORZ8S 3DWLHQWVRQSRVWSURWRFROVLQJOHDJHQWODSDWLQLEZLOOKDYHIROORZXSYLVLWVHYHU\PRQWKVIRU VXUYLYDODVVHVVPHQWDQGUDGLRJUDSKLFHYDOXDWLRQRIGLVHDVHSHU05,RU&7VFDQ
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5.1.2 rationale

The purpose of analyzing the tissue samples is to confirm the diagnosis of ependymoma, as well as to determine the status of key molecular markers. As described below, such markers will be examined in an effort to further characterize other factors that may be predictive of response and prognosis using the treatment regimens that are undergoing evaluation in this clinical trial. Furthermore, in the case where frozen tumor tissue is also available, more extensive genetic testing will be performed so that correlative profiles of gene expression to response and outcome can be made in this carefully studied, uniformly treated group of patients. 5.1.3 Specimen Collection: Tissue specimens should be taken from pre-study diagnostic open biopsy or surgical resection.  
5.1.3.1 To be eligible for this study, the patient must have an ependymoma. Features of a grade II or III ependymoma according to WHO guidelines must be present.
5.1.3.2 The following materials will be required for tissue evaluation:  
5.1.3.2.1 Representative tissue blocks that contain diagnostic tumor. As a guide, at least 1 cubic centimeter of tissue composed primarily of tumor is desired. If tissue block is not available, 15 unstained slides from a representative tumor block is required.  
5.1.3.2.2 If a representative tissue block is submitted, an accompanying H&E is encouraged for rapid diagnosis but not required. If an H&E is included, Dr. Aldape will use this for the review. If not included, Dr. Aldape will cut a section from the paraffin block, stain this with H&E, and use that slide for the review.  
5.1.3.2.3 A Pathology Report documenting that the submitted material contains tumor; the report must include the protocol number, patient case number, and the patient's initials. The patient's name and/or other identifying information should be removed from the report. The surgical pathology numbers and information must NOT be removed from the report.  
5.1.3.2.4 Tissue evaluation will be required for every case before study registration Step 2.  
Send pathology material by overnight mail directly to:
Ken Aldape, MD MacFeeters- Hamilton Centre for Neuro-Oncology, 101 College St, Room 14-701 Princess Margaret Cancer Centre, Toronto Medical Discovery Tower (TMDT), Toronto, ON M5G 1L7 Canada kaldape@gmail.com  
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6.1.1 confidentiality

All documents, investigative reports, or information relating to the patient are strictly confidential. Any patient specific reports (i.e., Pathology Reports, MRI Reports, Operative Reports, etc.) submitted to the NCI must have the patient's full name & social security number "blacked out" and the assigned patient ID number, protocol accession number, and protocol number written in. Patient initials may be included or retained for cross verification of identification.
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6.1.2 certificate of confidentiality

As part of study efforts to provide confidentiality of subject information, this study has obtained a Certificate of Confidentiality, which helps to protect personally identifiable research information. The Certificate of Confidentiality allows investigators on this trial to refuse to disclose identifying information related to the research participants, should such disclosure have adverse consequences for subjects or damage their financial standing, employability, insurability or reputation. The informed consent includes the appropriate coverage and restrictions of the Certificate of Confidentiality.
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6.1.3 safety data

All patients receiving study agents will be evaluated for safety. The safety parameters include all laboratory tests and hematological abnormalities, CNS observations, physical examination findings, and spontaneous reports of adverse events reported to the investigator by patients. All toxicities encountered during the study will be evaluated according to the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 and recorded prior to each course of therapy. Life-threatening toxicities that are unexpected and assessed to be possibly related to the study agent/s should be reported immediately to the study Coordinator and Institutional Review Board (IRB). Information about all adverse events, whether volunteered by the subject, discovered by investigator questioning, or detected through physical examination, laboratory test or other means, will be collected and recorded on the Adverse Event Case Report Form and followed as appropriate. An adverse event is any undesirable sign, symptom or medical condition occurring after starting study drug (or therapy) even if the event is not considered to be related to study drug. Medical conditions/diseases present before starting study treatment are only considered adverse events if they worsen after starting study treatment (any procedures specified in the protocol). Adverse events occurring before starting study treatment but after signing the informed consent form are recorded on the Baseline Evaluations Adverse Events Case Report Form. Abnormal laboratory values or test results constitute adverse events only if they induce clinical signs or symptoms or require therapy, and are also recorded on the Adverse Events Case Report Form.
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7.2.2 Suspected adverse reaction
Suspected adverse reaction means any adverse event for which there is a reasonable possibility that the drug caused the adverse event. For the purposes of IND safety reporting, 'reasonable possibility' means there is evidence to suggest a causal relationship between the drug and the adverse event. A suspected adverse reaction implies a lesser degree of certainty about causality than adverse reaction, which means any adverse event caused by a drug.
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7.2.3 unexpected adverse reaction

An adverse event or suspected adverse reaction is considered "unexpected" if it is not listed in the investigator brochure or is not listed at the specificity or severity that has been observed; or, if an investigator brochure is not required or available, is not consistent with the risk information described in the general investigational plan or elsewhere in the current application. "Unexpected" also refers to adverse events or suspected adverse reactions that are mentioned in the investigator brochure as occurring with a class of drugs or as anticipated from the pharmacological properties of the drug, but are not specifically mentioned as occurring with the particular drug under investigation.
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7.2.4 serious

An Unanticipated Problem or Protocol Deviation is serious if it meets the definition of a Serious Adverse Event or if it compromises the safety, welfare or rights of subjects or others. 7.2.5 Serious Adverse Event An adverse event or suspected adverse reaction is considered serious if in the view of the investigator or the sponsor, it results in any of the following:
- Death,  
- A life-threatening adverse drug experience - Inpatient hospitalization or prolongation of existing hospitalization - Persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions
- A congenital anomaly/birth defect. - Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.  
7.2.6 Disability
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SULRULLWLVDVVXPHGWKDWWKHPHGLDQ3)6WLPH4(IROORZVDQLQYHUVHJDPPDGLVWULEXWLRQZLWK VKDSHSDUDPHWHU DQGVFDOHSDUDPHWHU 7KLVSULRUGLVWULEXWLRQKDVPHGLDQRI PRQWKV7KHKLVWRULFDOPHGLDQ3)6WLPHLVUHSUHVHQWHGE\46,QDGGLWLRQ46LVDVVXPHGWR IROORZDQLQYHUVHJDPPDGLVWULEXWLRQZLWKVKDSHSDUDPHWHU DQGVFDOHSDUDPHWHU 7KLVSULRUDOVRKDVPHGLDQRIPRQWKV The trial will be stopped early if, based on the current data, Pr ( QE > QS +3.5| data) < 0.065. That is, the trial will be stopped early if, it is very unlikely that the median time to progression with the experimental therapy (temozolomide and lapatinib) is less than the historical median time to progression for the standard treatment as described in the literature. The rule will be applied every 2 months, with the probability criterion recomputed based on the most recent data available at that time. Based on an anticipated accrual rate of 2.5 patients per month, the trial is expected to complete accrual in 40 months. To obtain operating characteristics of the early stopping rule, the trial was simulated under three scenarios, which we have summarized in the Table below. The design's operating characteristics are as follows. Each entry in the table is the mean from 2000 simulated trials:  
| Median      |           |                |                   |
|-------------|-----------|----------------|-------------------|
| Case        | Time to   | Pr(Stop Early) | # Patients        |
| Progression | (25%,75%) |                |                   |
| Scenario 1  | 2.0       | 1              | 16.435 ( 13, 19 ) |
| Scenario 2  | 7.0       | 0.896          | 36.694 ( 27, 50 ) |
| Scenario 3  | 10.5      | 0.173          | 47.354 ( 50, 50 ) |
| Scenario 4  | 14.0      | 0.034          | 49.054 ( 50, 50 ) |  
We also summarize the median lower and median upper credible intervals for this trial on an assumption of that the data follows an exponential distribution (with median survivals summarized in the Table below). To calculate the expected lower and expected upper credible intervals we simulated progression free survival data (1000 simulations) from exponentially distributed data and assuming observations without events were censored at 48 months (40 months of accrual and 8 months of additional follow-up). For each simulation we recorded the lower (1st decile) and upper (9th decile) credible sets from the posterior distribution of the median PFS parameter. At the end of the simulation we then calculated and recorded below the median 1st decile and median 9th deciles from the vector of recorded deciles obtained from our simulation.  
| True Median Survival Median 1st decile and Median 9th decile Credible Limits 10.5 Months (8.72, 12.50) 14 Months (11.52, 16.66)   |
|-----------------------------------------------------------------------------------------------------------------------------------|
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secondary efficacy analysis

The secondary endpoint of this trial is anti-tumor activity as determined by the overall response (CR or PR) rate. MacDonald criteria will be used to determine the overall response. Patients must have completed at least 4 weeks of treatment to be considered evaluable for overall response, unless treatment is stopped for neurologic progression. Patients with neurologic progression will be scored as non-responders regardless of duration of treatment. Safety Analysis All patients will be considered evaluable for safety after the first dose of therapy. AEs and clinically significant laboratory abnormalities with associated incidence rates and severities will be tabulated.
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deaths and serious adverse events

Serious adverse events and deaths will be listed. Data from the adverse event page that specify the event is serious will be used to generate the listing. Summaries of serious unique adverse events will include:  
- all serious treatment emergent adverse events,
- all serious treatment emergent adverse events by sex,
- all serious treatment emergent adverse events by race,
- all serious treatment emergent adverse events by the worst grade,
- all related serious treatment emergent adverse events by the worst grade.
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neurological symptoms and signs

Neurological symptoms and signs collected on the neurological examination CRFs will be summarized at the baseline and by scheduled visit.
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laboratory tests

Changes from baseline in laboratory measurements will be summarized by study visit. The worst post-baseline laboratory measurements up to (1) 30 days after the permanent discontinuation of the study medication or (2) the initiation of subsequent anti-ependymoma therapy will be summarized. Marked laboratory toxicity (baseline grade 0 to post-baseline grade 3 or 4, or baseline grade 1 to post-baseline grade 4) will also be summarized.
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vital signs weight and karnofsky

Descriptive statistics will be used to summarize vital signs, weight, and Karnofsky performance status. For continuous outcomes the mean, standard deviation, median, 25% percentile, 75% percentile, minimum, and maximum will be reported for change from baseline at each scheduled visit. For discrete (i.e., Karnofsky performance status) outcomes, descriptive analyses will be based on the distribution of this outcome and will be reported as percentages and patient counts by category.
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mdasi-bt

The sample size for this trial was based on the primary end point of the study. Received MDASI-BT and MDASI-SP forms will be checked versus the timing schedule and considered as valid if they fall within one week of the scheduled assessment. Compliance rates will be calculated as the number of received valid forms over the number of expected forms. Differences between groups in compliance will be tested by use of Fisher's exact test at every time point. We will use descriptive statistics to describe how patients rate symptom severity and interference with function at each time point. Error bar graphs for each of the symptoms will be constructed at each time point. The proportion of patients rating their symptoms to be 7 or JUHDWHURQDVFDOHZLOODOVREHUHSRUWHG:HZLOOFRQVWUXFWLQGLYLGXDOSDWLHQWSURILOHVIRU HDFKRIWKHVHOHFWHGV\PSWRPVWRGHVFULEHWKHLQGLYLGXDOSDWLHQWV¶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10.1.1 formulation

10.1.2 Other Names: - methazolastone; Temozolomide is supplied in white opaque, preservative-free, two-piece, hard gelatin capsules of the following p.o. dosage strengths: 5 mg, 20 mg, 100 mg, 180 mg and 250 mg. Each capsule contains drug substance in combination with lactose, anhydrous NF, colloidal silicon dioxide NF, sodium starch glycolate NF, tartaric acid NF, and stearic acid NF. The capsule shells contain gelatin NF, titanium dioxide USP, and sodium lautyl sulfate NF.  
10.1.3 Mode of Action: Alkylating agent of imidazotetrazinone class.
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10.1.4 storage and stability

The capsules are packaged in 30 cc, 28 mm, 48 Type I amber glass bottles (30 capsules/bottle) and should be stored at 25°C but temperatures between 15 and 30 degrees centigrade are permissible. Capsules are stable for at least 30 months when stored in amber glass bottles at this temperature.
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10.1.5 supply commercially available 10.1.6

Temozolomide is rapidly and completely absorbed after oral administration; peak plasma concentrations occur in 1 hour. Food reduces the rate and extent of temozolomide absorption. Mean peak plasma concentration and AUC decreased by 32% and 9%, respectively, and Tmax increased 2-fold (from 1.1 to 2.25 hours) when temozolomide was administered after a modified high-fat breakfast. Temozolomide is rapidly eliminated with a mean elimination halflife of 1.8 hours and exhibits linear kinetics over the therapeutic dosing range. Temozolomide has a mean apparent volume of distribution of 0.4 L/kg (%CV=13%). It is weakly bound to human plasma proteins; the mean percent bound of drug-related total radioactivity is 15%.
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10.1.7 metabolism and elimination

Temozolomide is spontaneously hydrolyzed at physiologic pH to the active species, 3-methyl- (triazen-1-yl)imidazole-4-carboxamide (MTIC) and to temozolomide acid metabolite. MTIC is further hydrolyzed to 5-amino-imidazole-4-carboxamide (AIC), which is known to be an intermediate in purine and nucleic acid biosynthesis and to methylhydrazine, which is believed to be the active alkylating species. Cytochrome P450 enzymes play only a minor role in the metabolism of temozolomide and MTIC. Relative to the AUC of temozolomide, the exposure to MTIC and ACI is 2.4% and 23%, respectively. About 38% of the administered temozolomide total radioactive dose is recovered over 7 days; 37.7% in urine and 0.8% in feces. The majority of the recovery of radioactivity in urine is as unchanged temozolomide (5.6%), AIC (12%), temozolomide acid metabolite (2.3%), and unidentified polar metabolites(s) (17%). Overall clearance of temozolomide is about 5.5 L/hr/m2.  
10.1.8 Special Populations 10.1.8.1 Creatinine Clearance: Population pharmacokinetic analysis indicates that creatinine clearance over the range of 36-130 mL/min/m2 has no effect on the clearance of temozolomide after oral administration. The pharmacokinetics of temozolomide have not been studied in patients with severely impaired renal function (CLcr < 36 mL/min/m2). Caution should be exercised when temozolomide is administered to patients with severe renal impairment. Temozolomide has not been studied in patients on dialysis.  
10.1.8.2 Hepatically Impaired Patients: In a pharmacokinetic study, the pharmacokinetics of temozolomide in patients with mild to moderate hepatic impairment (Child's-Pugh Class I-II) were similar to those observed in patients with normal hepatic function. Caution should be exercised when temozolomide is administered to patients with severe hepatic impairment.
10.1.8.3 Gender: Population pharmacokinetic analysis indicates that women have an approximately 5% lower clearance (adjusted for body surface area) for temozolomide than men. Women have higher incidences of grade 4 neutropenia and thrombocytopenia in the first cycle of therapy than men.  
10.1.8.4 Population pharmacokinetic analysis indicates that age (range 19-78 years) has no influence on the pharmacokinetics of temozolomide. In the anaplastic astrocytoma study population, patients 70 years of age or older had a higher incidence of grade 4 neutropenia and grade 4 thrombocytopenia in the first cycle of therapy than patients under 70 years of age. In the entire safety database, however, there did not appear to be a higher incidence in patients 70 years of age or older.  
10.1.8.5 Drug-Drug Interactions: In a multiple dose study, administration of temozolomide with ranitidine did not change the Cmax or AUC values for temozolomide or MTIC. Population analysis indicates that administration of valproic acid decreases the clearance of temozolomide by about 5%. The clinical implication of this effect is not known. Population analysis failed to demonstrate any influence of co-administered dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2receptor antagonists, or phenobarbital on the clearance of orally administered temozolomide.  
10.1.9 Known Potential Adverse Events Hematologic: Thrombocytopenia, leukopenia, myelodysplastic syndrome Gastrointestinal: Nausea, vomiting, anorexia Hepatic: Elevated liver enzymes (reversible) Skin: Rash Neurologic: Convulsions, weakness on one side of the body, abnormal coordination, paralysis Other: Constipation, diarrhea, stomatitis, fatigue, decreased performance status, headache Likely (occurring in more than 20% of patients)  
| - fatigue  - headache - seizures   |
|------------------------------------|  
| - alopecia - nausea - vomiting   |
|----------------------------------|  
Common (occurring in 3-20% of patients)  
| - constipation - anorexia   |
|-----------------------------|  
| - dizziness - abnormal muscle  movements/ coordination  - abnormal gait - hemiplegia or partial  paralysis - upper and/or lower  extremity edema - weakness (such as  weakness on one side of the  body)  - tickling/tingling sensation - pain (such as in the  abdomen, joints, back,  and/or muscles) - breast pain in females - confusion  - memory problems - anxiety   | - depression  - difficulty sleeping - drowsiness  - skin rash  - pruritus  - dry skin  - mucositis  - dysphagia  - dysgeusia or taste changes - diarrhea  - excess steroid in the body  (possible bruising and/or  increase in size of the face  and/or neck)  - viral infection   | - weight gain - loss of urinary control  - urinary tract infection  - frequent urination  - abnormal vision  - blurry vision  - diplopia or double  vision  - fever - head cold - cough  - sore throat  - sinusitis  - dyspnea  - allergic reaction   |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
Temozolomide may commonly cause low blood cell counts (white blood cells, red blood cells, and platelets). This means that while you take the drug, there is more of a chance of getting an infection, including pneumonia. You may become anemic and/or have problems with bleeding, bruising, fatigue, and/or shortness of breath. You may need a blood transfusion. Rare but serious (occurring in fewer than 3% of patients)  
| -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | hallucinations         |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------|
| -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | nervous system disease |
| (possible pain and/or weakness)  - neuropathies (nerve  damage- possible numbness,  tingling, and pain)  - hyperglycemia (possible  diabetes) - hypokalemia (possible  weakness) - severe allergic reaction leukemia) - allergic skin reaction - severe skin damage with  loss of a large portion of  skin  - weight loss - fever due to low white  blood   cell counts - bruising  - hemorrhage  - Steven-Johnson  Syndrome  damage) - pneumonitis (lung  inflammation) - flu-like symptoms - injection site  reactions (skin redness,  irritation, pain, itching,  swelling, and/or warmth) - opportunistic  infection - herpes infection  causing painful skin rash  (shingles) |                        |  
| - BUN blood level increase - creatinine blood elevated - lymphopenia  - thrombocytopenia  - neutropenia   |
|-----------------------------------------------------------------------------------------------------------|  
The following side effects have been reported in research studies with temozolomide. It is unclear if these side effects were caused by temozolomide, but they may be:  
10.1.10Temozolomide is potentially mutagenic and should be handled with appropriate precautions by both staff and patients. Capsules should not be opened. If capsules are accidentally opened or damaged, rigorous precautions should be taken with the capsule contents to avoid inhalation or contact with the skin or mucous membranes. Procedures for proper handling and disposal of anticancer drugs should be considered.  
| - death - hypoxia  - weight loss - epistaxis - sepsis   | - cholecystitis - pancreatitis - GI perforation  - dehydration   |
|---------------------------------------------------------|------------------------------------------------------------------|  
10.1.11Contraindications: Temozolomide is contraindicated in patients who have a history of a hypersensitivity reaction to any of its components or to DTIC.
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10.1.12pregnancy category d

Temozolomide may cause fetal harm when administered to a pregnant woman. There are no adequate and well-controlled studies in pregnant women. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Women of childbearing potential should be advised to avoid becoming pregnant during therapy with temozolomide. Treatment of a man with temozolomide may increase the risk of birth defects if he causes a woman to become pregnant while he is taking temozolomide. Men treated with temozolomide may have difficulty causing a woman to become pregnant after their treatment is completed. Men receiving temozolomide should be directed to use effective contraception while they are EHLQJWUHDWHG7KHUHLVLQVXIILFLHQW GDWDWR NQRZZKDWWKH ULVN RI VXEVHTXHQW SUREOHPVZLWK IHUWLOLW\ ZLOO EH  6LPLODUO\ ZRPHQ ZKR DUH WUHDWHG ZLWK WHPR]RORPLGH PD\ KDYH GLIILFXOW\ EHFRPLQJSUHJQDQWLQWKHIXWXUHDQGPD\DWEHDWLQFUHDVHGULVNRIKDYLQJFKLOGUHQZLWKELUWK GHIHFWV7KHUHLVLQVXIILFLHQWHYLGHQFHWRGHWHUPLQHZKDWWKHULVNRIWKHVHFRPSOLFDWLRQVZLOO EH
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This information will be forwarded to GSK by the NCI upon protocol activation for each site. After this is done lapatinib may be requested directly from GlaxoSmithKline by the Principal Investigator (or their authorized designees) at each participating institution. NCI policy requires that the agent be shipped directly to the institution where the patient is to be treated. NCI does not permit the transfer of agents between institutions. Requests for drug supply should be sent to Mary Jo Penna at: Mary Jo Penna North America Medical Affairs, GSK Oncology 1250 S. College Rd., UP4440 Collegeville, PA 19426-0989 E-mail: mary-jo.q.penna@gsk.com Telephone: 610-917-5109 10.2.13 Agent Accountability The Investigator, or a responsible party designated by the investigator, must maintain a careful record of the inventory and disposition of all agents received.  
10.2.14 Investigational Drug Disposition Policy
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investigational agent destruction or returns

Investigators/Designees should make every effort to minimize the amount of agent ordered and returned or destroyed unused, (e.g. limit inventories to an 8 week supply or less). Investigators/Designees must return or destroy unused supplied agent as directed by the protocol when:
- The agent is no longer required because the study is completed.  
- Agent is outdated. Investigators/designees should only return or destroy outdated agents with a firm expiration date or if they have received written notification that an agent has expired and should be returned or destroyed.  
- The agent is damaged or unfit for use. Investigators/designees should contact the supplier prior to returning or destroying investigational agents because of stability concerns, (e.g. loss of refrigeration or exposure to elevated temperatures). Do NOT
return broken vials. Broken vials should be destroyed at the clinical site. Follow the appropriate agent accountability guidelines.  
The destruction of the study agent should be carried out in accordance with the local institutions policies and procedures. The destruction of the agent must be documented on the DARF. 10.2.15 Drug Interactions In vitro studies with human liver microsomes indicate that CYP3A4 and CYP3A5, and to a lesser extent CYP2C19, may be the enzymes primarily responsible for Lapatinib metabolism. Therefore, compounds known to modulate CYP3A4 activity may therefore affect metabolism of Lapatinib. Inhibitors of CYP3A4 may decrease the metabolism and increase Lapatinib levels, while inducers of CYP3A4 may increase the metabolism and decrease Lapatinib levels.  
Ketoconazole, a CYP3A4 inhibitor, has been shown to elevate Lapatinib plasma concentrations 3.5-fold. Carbamazepine, a CYP3A4 inducer, has been shown to reduce Lapatinib plasma concentrations by 72%. Therefore, co-administration of Lapatinib with known inhibitors or inducers of CYP3A4 should be avoided. If there is no medically acceptable alternative coadministration should proceed with caution. There may be a potential interaction between Lapatinib and warfarin. Patients have experienced elevated INRs and bleeding with warfarin and quinazolines. Patients on warfarin and Lapatinib should have more frequent INR/PT determinations after starting Lapatinib (e.g. weekly for the first month and weekly for a minimum of 2 weeks following discontinuation of Lapatinib. Alternatively, to avoid this interaction, it is strongly advised to switch patients to low molecular weight heparin, e.g. 5000 units of deltaparin subQ daily, or Lovenox 40mg sub Q daily. In addition, Lapatinib may inhibit CYP3A4 and increase concentrations of drugs metabolized by CYP3A4. Glucocorticoids: should be used at lowest effective dose of dexamethasone. Note that dexamethasone equivalent dose > 1.5 mg/day, may alter metabolism of Lapatinib (see chart below for conversion). Glucocorticoid Conversion Table  
Glucocorticoid Equivalent Dose (mg) Cortisone 25 Hydrocortisone 20 Prednisone 5 Methylprednisolone 4 Dexamethasone 0.75  
In human in vitro systems, Lapatinib showed minimal induction potential of CYP3A activity and was shown to have varying inhibitory potential towards CYPs 3A4, 1A2, 2C9, 2C19, and 2D6 at concentrations above those observed clinically in human plasma. Gastric pH Modifiers may modify the absorption of lapatinib. Therefore, the administration of H2 inhibitors, proton pump inhibitors should be noted on the CRF. Antacids should not be given within 1 hour before and after dosing with Lapatinib. One should attempt to maximize the time interval between Lapatinib and proton pump inhibitors (aim for a 12hr interval if possible) Schedule Lapatinib at least one hr prior to the PPI or H2 blocker. It may help to take Lapatinib with a coke or pepsi drink. See Appendix 18.6 for a partial list of medications that induce or inhibit CYP3A4. 10.2.16Lapatinib Prohibited Medication List 10.2.16.1 Inhibitors of CYP3A4 The following drugs are prohibited beginning at least seven (7) days prior to registration Step 2 and for the duration of the study:  
- Antibiotics: clarithromycin, erythromycin, troleandomycin, telithromycin, ciprofloxacin, norfloxacin
- Antifungals: itraconazole, ketoconazole, voriconazole, fluconazole (doses up to 150 mg/day are permitted)
- Antidepressants: nefazodone, fluvoxamine
- Calcium channel blockers: verapamil, diltiazem
- GI: cimetidine, aprepitant
- Miscellaneous: Grapefruit or its juice, amiodarone*; Bitter Orange
- *Amiodarone use should have been discontinued at least 6 months prior to the administration of the first dose of study medication and for the duration of the study.
10.2.16.2 Inducers of CYP3A4 The following drugs are prohibited beginning at least fourteen (14) days prior to registration Step 2 and for the duration of the study.  
- Anticonvulsants: phenytoin, carbamezepine, Barbiturates (e.g. Phenobarbital),
oxcarbazepine
- Antibiotics: all rifampin class agents (e.g. rifampin (rifampicin), rifabutin, rifapentene)
- Miscellaneous: St. John's Wort, modafinil 10.2.16.3 Gastric pH Modifiers (not to be administered within 1 hour before and after Lapatinib dosing)
- H2 blockers (ranitidine, nizatidine, famotidine), proton pump inhibitors(omeprazole, esomeprazole, rabeprazole, pantoprazole, lansoprazole), antacids
10.2.17Pre-clinical Toxicology A range of toxicology studies has been conducted to support the oral administration of Lapatinib to humans. Repeat oral dose toxicity studies have been completed in rats and dogs for up to 6 and 9 months, respectively. The effects of Lapatinib on fertility in the rat and embryofetal development in the rat and rabbit have been investigated. A range of genetic toxicity studies has been performed in vitro and in vivo. The significant findings from the toxicology studies are summarized below. Following single oral administration, Lapatinib was well-tolerated by both CD-1 mice and Wistar Han rats at doses up to 2000 mg/kg. Treatment-related findings consisted of reversible changes in body weight and body weight gain as well as reversible GI effects. A 13-week oral dose ranging pilot carcinogenicity study in mice showed that treatment with Lapatinib at doses up to 200 mg/kg/day was generally well tolerated. Microscopic changes attributable to treatment with Lapatinib were noted in the liver and preputial gland of males and large intestines (cecum and colon) of males and females. Administration of Lapatinib to rats and dogs for up to 6 months or 9 months resulted primarily in exaggerated pharmacologic effects and organ toxicities generally associated with degenerative and/or inflammatory epithelial changes (GI tract and accessory digestive organs, skin, mammary gland, liver and prostate). Other treatment-related effects included clinical signs, decreased body weight and food consumption, organ weight changes and alterations in clinical pathology parameters. Following the recovery period, treatment-related changes were either significantly improved or completely reversed. There were no effects on male or female rat gonadal function, mating, fertility or pregnancy nor were there any increases in the number or incidence of any malformations when rats or rabbits were given Lapatinib during the period of major organogenesis. At maternally toxic doses (≥60 mg/kg/day in rats and rabbits), Lapatinib treatment was associated with growth retardation and developmental variations. In genetic toxicity studies, Lapatinib was demonstrated to be non-mutagenic and nonclastogenic. Lapatinib was well tolerated in dogs at doses of <40 mg/kg/day (treated for 39 weeks). The No Observed Adverse Effect Level (NOAEL) in dogs was 10 mg/kg/day for both males and females. Inflammatory gastrointestinal toxicities were noted on repeated dosing along with changes in the epithelium of tissues that were considered related to EGFR inhibition. Fertility studies in male and female rats demonstrated no Lapatinib-related effects at any dose tested. No fetal malformations occurred when Lapatinib was given to pregnant, female rats or rabbits during the period of major organogenesis (Investigator's Brochure, 2003). At maternally toxic doses (60 mg/kg/day in rats and rabbits), Lapatinib treatment was associated with growth retardation and developmental variations. Groups of 4 male and 4 female beagle dogs treated orally with Lapatinib at 10, 40, or 160 mg/kg/day for up to 93 days resulted in mild leukocytosis (females only), mild decreases in albumin, total protein, and calcium, and mild increases in globulin, cholesterol, ALT, alkaline phosphatase, total bilirubin and total bile acids. Improvement occurred in all parameters during the 29-day recovery period (Investigator's Brochure, 2003). An additional study evaluated Lapatinib administered orally daily to groups of 4 male and female Beagle dogs at 0, 10, 40, or 100 mg/kg/day for 39 weeks. The effects noted on the skin of males given 100-mg/kg/day and females given >40 mg/kg/day included ulceration with epidermal hyperplasia or epidermal hyperplasia with inflammation and follicular atrophy (Investigator's Brochure, 2003). Lung alveolar histiocytosis and/or interstitial inflammation were seen in the 14-day and 3-month rat study and in the 3-month dog study. This was seen at doses ≥180 mg/kg/day in rats and at 160 mg/kg/day in dogs. No lung changes were seen when Lapatinib was given chronically for 6 or 9 months at lower doses (Investigator's Brochure, 2003). Cardiac changes were seen at a low incidence (3 males and 1 female) only at the high dose in the rat 3-month study. The lesions in the heart were identical to those observed with a spontaneous age-related cardiomyopathy primarily seen in male Wistar rats. In spite of a 7 fold greater exposure in female rats, the incidence was consistent with the natural history of this spontaneous lesion. There were no cardiac changes in the rat 6-month study or in all dog studies indicating that Lapatinib is not directly cardiotoxic (Investigator's Brochure, 2003). 10.2.18 Clinical Studies and Toxicities As of November 2003, four trials in healthy volunteers had been completed, and five Phase 1 studies and four Phase 2 studies in cancer patients were ongoing. A phase 1 study of Lapatinib at doses of 175 to 1800 mg/day in heavily pre-treated patients (n=39) with solid tumors reported that the drug was well-tolerated and showed preliminary evidence of antitumor activity. In this study, 3 patients in each of the 175 and 375 mg/day cohorts; 4 in the 675, 900, and 1600 mg/day cohorts; 6 in the 1200 mg/day and 9 in the 1800 mg/d were enrolled. Six additional patients were administered 900 mg bid to compare safety of bid versus qday schedules. Grade 1-2 rash, diarrhea, nausea, vomiting, constipation, fatigue, and anorexia were the most frequent adverse events in all qday dose cohorts. Grade 3 toxicity was not observed in any of the qday dose cohorts. Grade 3 diarrhea was observed in 2 of 6 patients at 900 mg bid, requiring dose reductions. Eight patients (non-small cell lung cancer (NSCLC), carcinoma of unknown primary site, head and neck, colon, breast carcinomas) remained on study with stable disease (SD) of 4+ months duration. Two NSCLC patients resistant to gefitinib (ZD1839, Iressa™) had minor responses (MRs) (3+ months, 12 months). Patients continuing on therapy for more than 4 months had received Lapatinib at doses > 1200 mg/day. Lapatinib was well tolerated when administered on a qday schedule, with preliminary evidence of anti-tumor activity in this heavily pre-treated population (Burris, Hurwitz et al. 2005). A Phase 1B trial evaluating tolerability and effects on biomarkers in tumor biopsies in heavily pre-treated patients with metastatic disease expressing EGFR or erbB2 reported that Lapatinib was well tolerated at all dose levels tested (500-1600 mg/day)(Burris, Hurwitz et al. 2005). Of 33 evaluable patients, 3 partial responses (PR) (10%) and 12 SD (36%) were reported. An evaluation of tumor biopsies obtained prior to, and after 2-3 weeks of treatment with Lapatinib revealed that induction of apoptosis in tumor tissue and inhibition of intratumor expression of activated Erk1/2, Akt and cyclin D protein appeared to correlate with PR and SD (Burris, Hurwitz et al. 2005). Disease progression was associated with persistent, high levels of expression of these biomarkers. Treatment with Lapatinib was not effective when insulin growth factor receptor (IGFR) was highly expressed (Bacus, Gudkov et al. 2000). Tumor types in which objective response or stable disease were seen included: breast (7), colorectal (2), ovarian (2), lung (1), granular cell (1), and head and neck (1) carcinomas as well as adenocarcinoma of unknown primary (1). Objective responses were observed in ErbB2-expressing breast cancer patients who had progressed after receiving prior trastuzumab (Herceptin™)-based regimens. The most common adverse events included grade 1-2 rash (25%), diarrhea (27%), and nausea/vomiting (21%). 10.2.19 Reported Adverse Events and Potential Risks Common Adverse Effects:  
- Constitutional Symptoms: fatigue (lethargy, malaise, asthenia), insomnia
- Dermatology/Skin: rash (acne/acneiform), rash (desquamation) - Gastrointestinal: diarrhea, anorexia, nausea, vomiting
Less Common Adverse Effects:  
- Constitutional Symptoms: weight loss
- Dermatology/Skin: flushing,
- Gastrointestinal: distension/bloating (abdominal), heartburn/dyspepsia, mucositis/stomatitis (clinical exam) - oral cavity, constipation, early satiety
- Pain: head/headache
- Syndromes: flu-like syndrome
- Cardiac arrhythmia: atrial fibrillation
- Pulmonary/Upper respiratory: pneumonitis/pulmonary infiltrates Uncommon Adverse Effects:
- Blood/Bone Marrow: hemoglobin, platelets*
- Constitutional Symptoms: fever, weight loss
- Cardiac General: left ventricular systolic dysfunction, hypotension - Dermatology/Skin: pruritus
- Gastrointestinal: dehydration, taste alteration, flatulence
- Neurology: neurology - other*
- Ocular/Visual: blurred vision
- Pain: abdomen NOS
- Sudden Death
- HepatoBiliary: Liver dysfunction/failure (clinical)
* These events were only reported in studies of Lapatinib in normal volunteers, a few of whom received a placebo. Also reported on Lapatinib trials but with the relationship to Lapatinib still undetermined: 10.2.20Recommended management for most common toxicities: Rash: Skin rash (usually grade 1-2) has been observed during the first several days of treatment with EGFR inhibitors and has been observed to diminish in severity after 4 weeks of treatment in many patients. In some patients, this rash appeared to be treatable with standard acne therapies, including topical and oral antibiotics used to treat acne. Anecdotal reports of improvement have occurred with several agents. In patients with severe rash, treatment may need to be discontinued or the dose reduced. Anecdotal reports of improvement have occurred with any of the following: minocycline, topical tetracycline, topical clindamycin, topical silver sulfadiazine, diphenhydramine, oral prednisone (short course).  
- Lymphatics: edema: limb
- Metabolic/Laboratory: bilirubin*, AST*, ALT*
- leukocytes (total WBC)
Diarrhea: Diarrhea has been seen with Lapatinib and with other EGFR inhibitors. In general EGFR inhibitor-induced diarrhea has been transient, usually not of sufficient severity to hinder administration of the agents, and responsive to loperamide. The recommended dose of loperamide is 4 mg at first onset, followed by 2 mg q 2-4 hr until diarrhea free for 12 hr. Nausea: Routine premedication for nausea is not necessary, but symptomatic patients should be treated with standard anti-nausea/antiemetic therapy as necessary. If the patient vomits after taking the tablets, the dose is replaced only if the tablets can actually be seen and counted.
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10.2.21 safety issues

Due to the limited amount of experience in human subjects, there is only preliminary information available about the relationship of adverse events and administration of Lapatinib. The following adverse events are included in the development core safety information for Lapatinib: diarrhea, which may lead to dehydration, nausea, fatigue, rash (including dermatitis acneiform), vomiting and anorexia. At present, there are no known absolute contraindications with Lapatinib, with the exception of individuals who are hypersensitive to this compound. Congestive heart failure has been reported in the clinic with trastuzumab (Herceptin™), a monoclonal antibody directed against the ErbB2 receptor. This cardiomyopathy has been seen at a higher incidence in patients that previously received anthracyclines and is characterized by dilatation and thinning of the ventricular walls with decreased left ventricular ejection fraction. As of 21 January 2004, a total of 10 patients in Phase I and II studies of Lapatinib have experienced a decrease in LVEF, 9 of which showed decreases ≥ 20% from baseline LVEF. In Phase I trials, 2 patients reported asymptomatic Grade 2 decreases in LVEF, and neither event met the criteria of an SAE. For one patient (study EGF10003), the etiology of the LVEF decrease remains indeterminate, and a drug-related effect cannot be excluded. The LVEF decrease in the other patient (study EGF10004) was not assessed as drug related, the patient having a prior history of cardiac disease. Both patients withdrew from treatment because of progressive disease. A total of eight serious adverse event reports of decreased LVEF were received for patients participating in Phase II studies. After the first two serious adverse events and possibly related cases, GSK instituted a 'per protocol' serious criterion of LVEF decreases ≥20% from baseline and below the institutions' lower limit of normal. For all eight cases the investigators considered there was a reasonable possibility that the LVEF decreases were associated with Lapatinib. Two patients presented with symptoms (breathlessness and signs of cardiac failure) and were found as part of their examination to have LVEF reduction. Both patients had co-morbidities, which could have contributed to the symptoms (pericardial and pleural effusions in one; diabetes, coronary artery disease, hypertension and hypercholesterolaemia in the other). The remaining six Phase II reports were asymptomatic and discovered during the routine protocol specified cardiac monitoring. These events were reported as serious per the protocol specific requirement. Treatment with Lapatinib was stopped in all eight Phase II patients and the LVEF decrease resolved with the exception of one patient who died of disease progression before a follow-up assessment was completed. Because of the known effects of trastuzumab on cardiac function and the observed transient reductions of LVEF seen among patients receiving Lapatinib, only patients with normal LVEF are eligible for study and patients will undergo monitoring of LVEF while on this study. Interstitial pneumonitis/lung disease has been reported with the structurally similar anilinoquinazoline, gefitinib (ZD1839, Iressa™), which inhibits EGFR tyrosine kinase. The incidence and death rate has been reported to be 0.44% and 0.12% respectively world wide and 12% and 0.4-0.5% respectively in Japan. At the time of the SAE data cut off, 30 January 2004, no cases of idiopathic interstitial pneumonitis (IP) has been reported in phase I monotherapy. However, one patient in study EGF10004 was diagnosed with interstitial pneumonia which the investigator attributed this event to disease under study and not related to Lapatinib. Two reports of possible interstitial pneumonitis in studies of Lapatinib have been received, both occurring in the phase I combination study with the FOLFIRI regimen (EGF10011). One report was considered possibly related to treatment with Lapatinib and one is unknown. Both patients reported in this study were asymptomatic, had pulmonary metastases, and were diagnosed with interstitial pneumonitis after undergoing routine CT scanning for disease assessment. Both cases resolved. One report of possible interstitial pneumonitis has been reported from Phase II study EGF20002. The event reported was an SAE of pulmonary pneumonitis and was ongoing at the time of the reporting. Treatment was interrupted and the investigator considered the event unrelated to Lapatinib and related to disease under study, pericardial effusion and treatment failure. Lapatinib should be withheld pending investigation and diagnosis in patients with symptoms and signs of suggestive pneumonitis. Patients diagnosed with pneumonitis possibly related to Lapatinib should be removed from study. Fetal malformations were not observed when Lapatinib was administered to pregnant female rats or rabbits during the period of major organogenesis. At maternally toxic doses, Lapatinib treatment was associated with growth retardation and developmental variations. There has been no evidence of genotoxicity or clastogenicity in mutagenic studies. In healthy volunteers (EGF10013) receiving the CYP3A4 inhibitor ketoconazole at 200 mg twice daily for 7 days, plasma concentrations (AUC) of Lapatinib were increased approximately 3.5-fold, and half-life increased 1.7-fold. In healthy volunteers (EGF10018) receiving the CYP3A4 inducer carbamazepine (CBZ) at 100 mg twice daily for 3 days and 200 mg twice daily for 17 days, plasma concentrations (AUC) of Lapatinib were decreased approximately 72%. These results are consistent with the strong dependence of Lapatinib elimination on CYP3A metabolism. Co-administration of Lapatinib with known inhibitors or inducers of CYP3A4 should proceed with caution. The most common toxic effects of Lapatinib are diarrhea, which may lead to dehydration, nausea, fatigue, rash (including dermatitis acneiform), vomiting and anorexia. Co-administration of Lapatinib with known inhibitors of CYP3A4, and/or compounds metabolized by CYP3A4, should proceed with caution. In vitro studies have shown that Lapatinib is metabolized predominantly by CYP3A4 and CYP3A5, and to a lesser extent by CYP2C19. Lapatinib has also been shown to have inhibitory potential towards CYP3A4 Investigator's Brochure, 2003). At this time, the effect of known inhibitors of CYP3A4 on Lapatinib metabolism or the effect of Lapatinib on drugs metabolized by CYP3A4 is unknown. As part of ongoing pharmacovigilance by GlaxoSmithKline, a review of all hepatobiliary events reported across the entire lapatinib clinical development programme has been performed. Two hundred sixteen reports of hepatic events were retrieved from the GSK safety database as of 31 December 2007 regardless of source (clinical trials, spontaneous/marketed use data). In 39 of the 216 cases, a causal association to lapatinib could not be ruled out: 38.5% (15/39) of these subjects received lapatinib monotherapy, 53.8% (21/39) of subjects received lapatinib in combination with other chemotherapies, such as capecitabine, and 3 cases were still blinded. A total of 13 deaths were identified which contained hepatobiliary events. In 3 of these cases, an association with lapatinib could not be excluded. The remaining 10 cases were confounded by the patients underlying condition (progressive disease and/or progression of pre-existing liver metastases). Based on an additional sub-analysis, of 18 clinical studies of lapatinib in breast cancer, using Hy's Law (defined as AST or ALT >3 x ULN, and total bilirubin >2 x ULN, with no initial findings of cholestasis i.e.: ALP <2 x ULN) as a predictor for potential drug induced liver injury, the liver injury associated with lapatinib seems to be the result of a prolonged exposure to the drug. All the subjects whose events potentially met Hy's Law received study medication for three months or longer. The majority of these cases appeared reversible. Most patients experienced a decline in liver enzymes with drug cessation. Based on the results of this review, GSK concluded a causal relationship between hepatobiliary disorders (specifically transaminase elevations) and lapatinib cannot be excluded. As a consequence, hepatotoxicity was added to the core safety information (CSI) for lapatinib. In addition, for ongoing clinical trials, the monitoring interval for hepatic function has been increased to every 4-6 weeks during treatment, and stopping rules have been added for severe hepatic events. Lapatinib dosing should be discontinued if changes in liver function are severe and patients should not be retreated. 10.2.22Pharmacokinetics Pharmacokinetic studies in healthy subjects receiving daily doses of Lapatinib (10-250 mg) found that the agent was well tolerated and resulted in moderate accumulation in systemic exposure (Bence, Anderson et al. 2005). Peak concentrations (Cmax) occurred 3-4 hours following drug administration. Drug accumulation of at least 50% was reported over an 8-day dosing period based on trough concentrations. AUC values increased with increasing dose in a nearly proportional manner. The average half life (t1/2) was 8 hours. The pharmacokinetics of Lapatinib are similar in healthy volunteers and patients, demonstrating oral absorption that is incomplete, highly variable, and sometimes delayed. After dosing, plasma concentrations rise to a peak at approximately 4 h and thereafter decline with measured half-lives averaging up to 14 h. However, accumulation with daily dosing achieves steady state in 6-7 days, which suggests a true elimination half-life on the order of 24 h. Administration of the same daily dose in a BD schedule results in 2-fold greater systemic exposure than a OD schedule. Despite this inconsistency, systemic exposure generally increases with increasing dose. Absorption is increased by ingestion with food. Elimination of Lapatinib is predominantly through metabolism by CYP3A4/5 with negligible renal excretion. Significant changes in systemic exposure to Lapatinib result from co-administration of drugs that are potent inhibitors or inducers of CYP3A. 10.2.23Human Toxicity
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comprehensive adverse events and potential

The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single, list of reported and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by body system. In addition to the comprehensive list, a subset, the Agent Specific Adverse Event List (ASAEL), appears in a separate column and is identified with *bold* and *italicized* text. This subset of AEs (ASAEL) contains events that are considered 'expected' for expedited reporting purposes only. Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' http://ctep.cancer.gov/reporting/adeers.html for further clarification. *Frequency is provided based on 975 patients*. Below is the CAEPR for lapatinib (GW572016).  
| Version 2.2, March 5, 20081                                               |                                                          |                           |
|---------------------------------------------------------------------------|----------------------------------------------------------|---------------------------|
| Adverse Events with Possible                                              |                                                          |                           |
| Relationship to Lapatinib (GW572016)  (CTCAE v3.0 Term)  [n=975 patients] | 'Agent Specific Adverse  Event List' (ASAEL)             |                           |
| Likely (>20%)                                                             | Less Likely (<=20%)                                      | Rare but Serious  (<3%)   |
| CARDIAC ARRHYTHMIA                                                        | Prolonged QTc                                            | Prolonged QTc interval    |
| interval                                                                  |                                                          |                           |
| CARDIAC GENERAL                                                           | Left ventricular                                         | Left ventricular systolic |
| systolic dysfunction                                                      | dysfunction                                              |                           |
| CONSTITUTIONAL SYMPTOMS Fatigue (asthenia,                                | Fatigue (asthenia, lethargy,                             |                           |
| lethargy, malaise)                                                        | malaise)                                                 |                           |
| Weight loss                                                               |                                                          |                           |
| DERMATOLOGY/SKIN Flushing                                                 | Flushing                                                 |                           |
| Pruritus/itching                                                          | Pruritus/itching                                         |                           |
| Rash/desquamation                                                         | Rash/desquamation                                        |                           |
| Rash: acne/acneiform                                                      | Rash: acne/acneiform                                     |                           |
| GASTROINTESTINAL                                                          | Anorexia                                                 | Anorexia                  |
| Dehydration                                                               | Dehydration                                              |                           |
| Diarrhea                                                                  | Diarrhea                                                 |                           |
| Distension/bloating,                                                      | Distension/bloating,                                     |                           |
| abdominal                                                                 | abdominal                                                |                           |
| Flatulence                                                                | Flatulence                                               |                           |
| Heartburn/dyspepsia                                                       | Heartburn/dyspepsia                                      |                           |
| Mucositis/stomatitis                                                      | Mucositis/stomatitis (clinical                           |                           |
| (clinical exam) - Select                                                  | exam) - Select                                           |                           |
| Mucositis/stomatitis  (functional/symptomatic) -  Select                  | Mucositis/stomatitis  (functional/symptomatic) -  Select |                           |
| Nausea                                                                    | Nausea                                                   |                           |
| Taste alteration (dysgeusia)                                              | Taste alteration (dysgeusia)                             |                           |  
| Vomiting                                                                                     | Vomiting                                             |                                       |
|----------------------------------------------------------------------------------------------|------------------------------------------------------|---------------------------------------|
| HEPATOBILIARY/PANCREAS                                                                       | Liver  dysfunction/failure  (clinical)               | Liver dysfunction/failure  (clinical) |
| METABOLIC/LABORATORY ALT, SGPT (serum  glutamic pyruvic  transaminase)                       | ALT, SGPT (serum glutamic  pyruvic transaminase)     |                                       |
| AST, SGOT (serum  glutamic oxaloacetic  transaminase)                                        | AST, SGOT (serum glutamic  oxaloacetic transaminase) |                                       |
| Bilirubin                                                                                    | Bilirubin                                            |                                       |
| (hyperbilirubinemia)                                                                         | (hyperbilirubinemia)                                 |                                       |
| PAIN                                                                                         | Pain - Abdomen NOS                                   | Pain - abdomen NOS                    |
| Pain - Head/headache                                                                         | Pain - head/headache                                 |                                       |
| PULMONARY/UPPER RESPIRATORY                                                                  | Pneumonitis/pulmo nary infiltrates                   |                                       |
| SYNDROMES                                                                                    | Flu-like syndrome                                    | Flu-like syndrome                     |
| 1This table will be updated as the toxicity profile of the agent is revised. Updates will be |                                                      |                                       |  
Also reported on lapatinib (GW572016) trials but with the relationship to lapatinib (GW572016) still undetermined: ALLERGY/IMMUNOLOGY - allergic reaction BLOOD/BONE MARROW - hemoglobin; leukopenia; lymphopenia; platelets; neutrophils/granulocytes CARDIAC ARRHYTHMIA - atrial fibrillation CARDIAC GENERAL - cardiac failure; cardiomyopathy; hypotension CONSTITUTIONAL SYMPTOMS - fever; insomnia DEATH - sudden death DERMATOLOGY/SKIN - dry skin; hand-foot skin reaction; nail changes; urticaria GASTROINTESTINAL - constipation; gastro-esophageal reflux disease (gastritis); intestinal obstruction HEMORRHAGE/BLEEDING - CNS hemorrhage; GI hemorrhage; nose hemorrhage (epistaxis); LYMPHATICS - limb edema METABOLIC/LABORATORY - alkaline phosphatase; hyperglycemia; hypoglycemia; hypokalemia; hyponatremia; hypophosphatemia NEUROLOGY - coma; dizziness OCULAR/VISUAL - blurred vision PAIN - back pain; joint pain; pain NOS; muscle pain
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pulmonary/upper respiratory - cough dyspnea

VASCULAR - hypovolemia; pulmonary embolism Note: The following additional adverse events have been reported from all lapatinib studies (Periodic Safety Report to Investigators) as suspected and unexpected serious adverse reactions; acute respiratory failure, lung abscess, hemoptysis, laryngeal edema,dysphagia, odynophagia, hypertension,cardiac neoplasm, pericarditis, myocardial infarction, shock, GI
infection, colitis, hematochezia, hematemesis, dehydration, renal failure, renal impairment, dysuria, facial swelling, hepatic failure, leukocytoclastic vasculitis, syncope, shingles, cellulitis, hypothyroidism, thyroiditis, alkaline phosphatase level increase, gammaglutamyltransferase level increase, hypercreatinemia, myocarditis, abnormal behavior, confusional state, coronary artery disease, atrial fibrillation, urinary tract infection, polyneuropathy, cerebrovascular ischemia, oral cavity hemorrhage, aplasia, anal fissure, deep vein thrombosis-limb, disseminated intravascular coagulation, hand-foot syndrome, viral infection, cardiac infection, respiratory tract infection, peripheral neuropathy, and chronic hepatitis. Note: Lapatinib (GW572016) in combination with other agents could cause an exacerbation of any adverse event currently known to be caused by the other agent, or the combination may result in events never previously associated with either agent. Note: There is a chemical that is present in lapatinib in small quantities. This chemical by itself may cause changes to genes (DNA--the genetic material of cells) that may lead to an increased chance of developing new cancer or tumors.
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| o                                             | o   | o   |     |    |
| i. Your pain at is WORS 17                    | o   |     |     |    |
| 2. Vour futines (tiredness) of                | o   | o   | o   | o  |
| IL WORE                                       |     |     |     |    |
| 3 Your nausea at its WORS 7                   | o   | o   | o   | o  |
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' Views ' ?                                               | o   | o   | o   | o  |
| 5 You'                                        | o   | o   | o   | o  |
| Ycur shortness of breath all                  | o   | o   | o   | a  |
| Your problem will remembering
things and workstra                                               | o   | o   | o   | o  |
| Yen - problem with lack of a pedical
at its WORS - ?                                               | o   | o   | o   | o  |
| Your fool relationsy (sloopy) and its WORST ? | o   | o   | o   | o  |
| 10. Year having a dry in ouch                 | o   | o   | o   | o  |
| 11 Year from sading                           | o   | o   | o   | o  |
| 12 Year voining si s. WORST 2                 | o   | o   | a   | o  |
| 15. Year mumbrook or tingling :::             | o   | o   | o   | o  |
| 14 Year woaknown (Yearn) will all             | o   | o   | o   | o  |
| 15 Y:xx <!! c > Ty understanding > .          | o   | o   | o   | o  |
| 10 You clif cully speaking (included)         | o   | o   | o   | o  |  
12.7 MD ANDERSON SYMPTOM INVENTORY FOR BRAIN TUMORS (MDASI-BT)  
  
  
Purt I. How severe are your symptoms?
People with cancer frequently have symptoms that are caused by their disease or by their treatment. We ask to rate to how severe the following symptoms have been in the last 24 hours. Please fill in the circle below from 0 (symptom has not been present) to 10 (the symptom was as bad as you can imagine it could be) for each item.  
Copyright 2009 The University of Texa M.D. Anderson Cancer Center Page  1  of  2  All rights reserved.  
| ax decision of the linear control.   |    |    |    |    |    |
|--------------------------------------|----|----|----|----|----|
| ring: rin                            |    |    |    |    |    |
| 5                                    | s  | is | g  | .  |    |
| o                                    | o  | o  | o  | o  | o  |
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| o                                    | o  | o  | o  | o  | o  |
| o                                    | o  | o  | o  | o  | o  |  
  
  
  
  
| Acc # :                               | As Bad As You can   |    |    |    |     |    |    |    |    |    |    |
|---------------------------------------|---------------------|----|----|----|-----|----|----|----|----|----|----|
| Nct                                   |                     |    |    |    |     |    |    |    |    |    |    |
| PI .                                  | Irrisoirie          |    |    |    |     |    |    |    |    |    |    |
| u                                     | 1                   |    | a  | 4  | tor | s  |    | "  |    | 10 |    |
| 7. Your seizures and WORST 7          | o                   | o  | o  | o  | o   | o  | o  | o  | o  | o  | o  |
| 8. Year difficulty concentrating >    |                     |    |    |    |     |    |    |    |    |    |    |
| s website                             | o                   | o  | o  | o  | o   | o  | o  | o  | o  | o  | o  |
| 9. Year vision and WORST2             | o                   | o  | o  | o  | o   | o  | o  | o  | o  | o  | o  |
| 23. You change in appearance cl       | o                   | o  | o  | o  | o   | o  | o  | o  | o  | o  | o  |
| rs Weksit?                            |                     |    |    |    |     |    |    |    |    |    |    |
| 2 . Your change in bowel pattern      | o                   | o  | o  | o  | o   | o  | o  | o  | o  | o  | o  |
| idianneal or constration institution. |                     |    |    |    |     |    |    |    |    |    |    |
| MERSI                                 |                     |    |    |    |     |    |    |    |    |    |    |
| 2.7 cur i mitab il ity al il~         | o                   | o  | o  | o  | o   | o  | o  | o  | o  | o  | o  |
| A                                     |                     |    |    |    |     |    |    |    |    |    |    |  
Part II. How have your symptoms interfered with your life?  
Symptoms frequently interefere with how we feel and function. How much have your symptoms interfered with the following items in the last 24 hours:  
| Cid not.
Interere                                                                   |  Inte fared
Completels   |    |    |    |    |    |    |    |    |    |    |
|-------------------------------------------------------------------|---|----|----|----|----|----|----|----|----|----|----|
| u                                                                 | 1 | s  | 3  | 4  | s  | is | i  | s  | :  | n  |    |
| 23. General activity ?                                            | o | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 2. Mood ?                                                         | o | O  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 25. Work (including work around                                   | o | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| the house) ?                                                      |   |    |    |    |    |    |    |    |    |    |    |
| 25. Relations with other                                          | o | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| people?                                                           |   |    |    |    |    |    |    |    |    |    |    |
| 2. " Valking?                                                     | a | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 28. Enjoyment of life ?                                           | o | o  | o  | o  | ,  | o  | o  | o  | o  | o  | o  |
| Copyright 2009 The University of Texa M.D. Anderson Cancer Center |   |    |    |    |    |    |    |    |    |    |    |
| All rights reserved.                                              |   |    |    |    |    |    |    |    |    |    |    |
| Page 2 of 2                                                       |   |    |    |    |    |    |    |    |    |    |    |  
Page 2 of 2 12.8 MD A NDERSON S YMPTOM I NVENTORY FOR S PINE T UMORS (MDASI-SP).  
  
M.D. Anderson Symptom Inventory - Spine Tumor (MDASI-SP)
'Part I. How severe are your symptoms?'
People with cancer frequently have symptoms that ore caused by their disease or by their treatment. We ask to rate te how severe the following symptoms have been in the last 24 hours. Please fill in the circle below from 0 (symptom has not been present) to 10 (the symptom was as bad as you can imagine it could be) for each item.  
| 45                                 | ..       |    |    |    |    |    |    |    |    |    |    |
|------------------------------------|----------|----|----|----|----|----|----|----|----|----|----|
| P examples                         | rise ins |    |    |    |    |    |    |    |    |    |    |
| CORE Items                         | u        | 2  | s  | 4  | o  | g  | .  |    |    |    |    |
| n                                  |          | 3  |    |    |    |    |    |    |    |    |    |
| o                                  | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  |    |
| . Your pain all is WORST?          |          |    |    |    |    |    |    |    |    |    |    |
| 2. You catigue (tiredness) at      | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 3 Your nausea at its VVDRST ?      | o        | o  | o  | o  | o  | o  |    |    |    |    |    |
| o                                  | o        | o  | o  | o  |    |    |    |    |    |    |    |
| You disturbed sicep at to          | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 120 -2                             |          |    |    |    |    |    |    |    |    |    |    |
| 5. You leel release and istressed  | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| (upset) at 3, WORST?               |          |    |    |    |    |    |    |    |    |    |    |
| Ycur shortness of breath ab        | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| its WCRST?                         |          |    |    |    |    |    |    |    |    |    |    |
| Yeu: problem with remombering      | o        | o  | a  | o  | o  | o  | o  | o  | o  | o  | o  |
| things a leworst?                  |          |    |    |    |    |    |    |    |    |    |    |
| Your problem will lack of a pooter | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| at its WORST?                      |          |    |    |    |    |    |    |    |    |    |    |
| Your feel res drowsy (sloopy) :    | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| its WORST?                         |          |    |    |    |    |    |    |    |    |    |    |
| 10. Year having a dry in outh      | o        | o  | a  | o  | o  | o  | o  | o  | o  | o  | o  |
| alulx VXPRSS ?                     |          |    |    |    |    |    |    |    |    |    |    |
| 11. Year feeling sad at the        | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| NOISEI 2                           |          |    |    |    |    |    |    |    |    |    |    |
| 12 Year voiniting alli s WORST?    | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 15. Year numbness or tingling sil  | o        | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| ils (WORS)?                        |          |    |    |    |    |    |    |    |    |    |    |  
Copyright 2009 The University of Texa M.D. Anderson Cancer Center All rights reserved.  
  
  
| As Bad As You can                                          |     |      |    |    |    |    |    |    |    |    |    |
|------------------------------------------------------------|-----|------|----|----|----|----|----|----|----|----|----|
| Nct                                                        |     |      |    |    |    |    |    |    |    |    |    |
| SPINE Tumor Specific                                       | P1. | Irrr |    |    |    |    |    |    |    |    |    |
| Items                                                      | u   | 1    | s  | 2  | 4  | s  | s  | ,  | "  | :  |    |
| 4. You redisting spine pain et
e elecs WORST?                                                            | o   | o    | o  | o  | o  | o  | o  | o  | o  | a  | o  |
| 5. Your weakness in the arms                               | o   | o    | o  | o  | o  | 'O | o  | o  | o  | o  | o  |
| and/or legs at its WORST?                                  |     |      |    |    |    |    |    |    |    |    |    |
| /5. Your lass at contral of bayel                          |     |      |    |    |    |    |    |    |    |    |    |
| and or bladder x Ts WORST
and or legs a: ts WORST?                                                            | O   | o    | o  | o  |    | o  | o  | o  | o  | o  | o  |
| f. Your change in boyel                                    | o   | o    | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| pattem(diarrhea/constipation)                              |     |      |    |    |    |    |    |    |    |    |    |
| st its WCRST?                                              |     |      |    |    |    |    |    |    |    |    |    |
| 8. Your sexual function                                    | o   | o    | o  | o  |    |    | o  | o  | o  | o  |    |
| o                                                          |     |      |    |    |    |    |    |    |    |    |    |
| style WORST?                                               |     |      |    |    |    |    |    |    |    |    |    |
| Part II. How have your symptoms interfered with your life? |     |      |    |    |    |    |    |    |    |    |    |  
Part II. How have your symptoms interfered with your life?  
Symptoms frequently interefere with how we feel and function. How much have your symptoms interfered with the following items in the last 24 hours:  
| Did not
interfere                                                                   |  Inte fared
Completels   |    |    |    |    |    |    |    |    |    |    |
|-------------------------------------------------------------------|---|----|----|----|----|----|----|----|----|----|----|
| n                                                                 | 1 | s  | 2  | 4  | "  | s  | :  | s  | :  | n  |    |
| 19. General activity ?                                            | o | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 20. Mood ?                                                        | o | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 21. Work (including work around                                   | o | o  | o  | o  | o  | o  | o  | o  | o  | o  |    |
| e                                                                 |   |    |    |    |    |    |    |    |    |    |    |
| the house) ?                                                      |   |    |    |    |    |    |    |    |    |    |    |
| 2. Relations with other                                           | o | o  | o  | o  | o  | ,  | o  | o  | o  | o  | o  |
| people?                                                           |   |    |    |    |    |    |    |    |    |    |    |
| 23. Walking?                                                      | a | o  | o  | o  | o  | o  | o  | o  | o  | o  | a  |
| 24. Enjoyment of life ?                                           | o | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| Copyright 2009 The University of Texa M.D. Anderson Cancer Center |   |    |    |    |    |    |    |    |    |    |    |
| All rights reserved.                                              |   |    |    |    |    |    |    |    |    |    |    |
| Page 2 of 2                                                       |   |    |    |    |    |    |    |    |    |    |    |  
Page 2 of 2  
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Abbreviated Title: Ph II Recurrent Ependymoma Version Date: 07/21/17 82
*Is this problem related or possibly related to participation in the research? __YES __NO Please explain:
*Does the problem suggest the research places subjects or others at a greater risk of harm than was previously known or recognized? __YES __NO Please explain: Is this problem? (*select all that apply*)
[ ] An Unanticipated Problem* that is: [ ] Serious [ ] Not Serious [ ] A Protocol Deviation that is: [ ] Serious [ ] Not Serious [ ] Non-compliance *Note if the 3 criteria starred above are answered, "YES", then this event is also a UP. Is the problem also *(select one)* [ ] AE [ ] Non-AE Have similar problems occurred on this protocol at your site? __YES __NO If "Yes", how many? ____ Please describe: Describe what steps you have already taken as a result of this problem:
In addition to the NCI IRB, this problem is also being reported to: (*select all that apply*)
[ ] Local IRB [ ] Study Sponsor [ ] Manufacturer : ____________________ [ ] Institutional Biosafety Committee [ ] Data Safety Monitoring Board [ ] Other: ____________________________________ [ ] None of the above, not applicable INVESTIGATOR'S SIGNATURE: DATE: