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Amendment  
| Protocol Number:                                            | 14C0150-E                                                                                                                                                                                | Reference Number:   | 367158       |                      |
|-------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------|--------------|----------------------|
| Principal Investigator: Alice Chen                          | NCI                                                                                                                                                                                      | DCTD                | 301.435.0517 | chenali@mail.nih.gov |
| (NIH Employee Name, Institute/Branch, Telephone and e-mail) |                                                                                                                                                                                          |                     |              |                      |
| Protocol Title:                                             | Phase I Study of Ganetespib and Ziv-Aflibercept in Patients with Advanced Gastrointestinal Carcinomas, Non-Squamous Non-Small Cell  Lung Carcinomas, Urothelial Carcinomas, and Sarcomas |                     |              |                      |  
SIGNATURES
Principal Investigator (*): Alice Chen - applied signature on 03/01/2017 8:57 AM EST Accountable Investigator: PI is the Accountable Investigator Branch Chief/CC Department Head (**): Jim Doroshow - applied signature on 02/27/2017 5:11 PM EST Medical Advisory Investigator (if applicable): N/A
Lead Associate Investigator signature:
N/A Referral Contact signatures: N/A Associate Investigators signatures: N/A For Institute/Center Scientific Review Committee: N/A Other IC Clinical Director signatures: N/A
APPROVALS
IRB Chair: Michael Hamilton - applied signature on 03/20/2017 1:25 PM EDT Clinical Director: N/A
CONCURRENCE
OPS Protocol Specialist:  
Lemuel Clayborn AM E 03/30/2017  
Signature Print Name Date  
* Signature signifies that investigators on this protocol have been informed that the collection and use of personally identifiable information at the NIH are maintained in a system of record governed under provisions of the Privacy Act of 1974. The information provided is mandatory for employees of the NIH to perform their assigned duties as related to the administration and reporting of intramural research protocols and used solely for those purposes. Questions may be addressed to the Protrak System Owner. ** I have reviewed this research project and considered the NIH Policy for Inclusion of Women and Minorities in Clinical Research. Taking into account the overall impact that the project could have on the research field involved, I feel the current plans adequately includes both sex/ gender, minorities, children, and special populations, as appropriate. The current enrollment is in line with the planned enrollment report for inclusion of individuals on the basis of their sex/gender, race, and ethnicity and is appropriate and of scientific and technical merit.  
IRB Meeting Date: N/A
Protocol Version Date:02/13/2017  
| DEC Clearance Date:   | N/A   |
|-----------------------|-------|  
TITLE: Phase I Study of Ganetespib and Ziv-aflibercept in Patients With Advanced Gastrointestinal Carcinomas, Non-Squamous Non-Small Cell Lung Carcinomas, Urothelial Carcinomas, and Sarcomas  
| Abbreviated Title:                                                                | Ph I Ganetespib Ziv-aflibercept                                                                                     |                       |
|-----------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------|-----------------------|
| Coordinating Center:                                                              | Developmental Therapeutics Clinic (NCIDTC) National Cancer Institute 10 Center Drive  Bethesda, MD 20892            |                       |
| Principal Investigator:                                                           | A.P. Chen, MDA-E 31 Center Drive  Bldg 31 Room 3A44  Bethesda, MD 20892                                             |                       |
|                                                                                   | Phone: (301) 496-4291; Fax: (301) 496-0826                                                                          |                       |
|                                                                                   | chenali@mail.nih.gov                                                                                                |                       |
| NCI Associate                                                                     | Peter Choyke, MDA-E                                                                                                 | MIP/CCR               |
| Barbara Conley, MDA-E                                                             |                                                                                                                     |                       |
| Investigators:                                                                    | DCTD                                                                                                                |                       |
| James H. Doroshow, MDA-E                                                          | DCTD                                                                                                                |                       |
| Paula Jacobs, PhDE                                                                | CIP/DCTC                                                                                                            |                       |
| Karen Kurdziel, MDA-E                                                             | MIP/CCR                                                                                                             |                       |
| Maria L. Lindenberg, MDA-E                                                        | MIP/CCR                                                                                                             |                       |
| Richard Piekarz, MD, PhDA-E                                                       | DCTD                                                                                                                |                       |
| Howard Streicher, MDA-E Elad Sharon, MDA-E Geraldine O'Sullivan Coyne, MD, PhDA-E | CTEP/DCTD CTEP/DCTD DCTD                                                                                            |                       |
| Non-NCI Associate                                                                 | Lamin Juwara, CRNPA,B,E                                                                                             | Leidos Biomed., FNLCR |
| Investigators:                                                                    | Robert Kinders, PhDE                                                                                                | Leidos Biomed., FNLCR |
| Statistician                                                                      | Larry Rubinstein, PhD, BRB, DCTDE 9609 Medical Center Dr. Rm 5W106  Phone: (240) 276-6026  rubinsteinl@mail.nih.gov |                       |
| Responsible  Research Nurse:                                                      | Jennifer Zlott, RNA,B,E Building 10, Rm 13N214  Phone: (301) 594-5664  Fax: (301) 480-7281  zlottjh@mail.nih.gov    |                       |  
| CTEP Drug Monitor:   | Pamela Harris, MD                                                                                                                 |
|----------------------|-----------------------------------------------------------------------------------------------------------------------------------|
| Study Sponsor:       | CTEP                                                                                                                              |
| NCI Supplied Agent:  | Ganetespib (NSC 777169)  Ziv-aflibercept (NSC 724770)  89Zr-Labeled, EGFR-targeting Antibody Panitumumab   (supplied by CIP/DCTD) |
| IND Number:          | 123037                                                                                                                            |
| Version Date:        | February 13, 2017                                                                                                                 |  
Roles: Aobtains information by intervening or interacting with living individuals for research purposes; Bobtains identifiable private information about living individuals; Cobtains the voluntary informed consent of individuals to be subjects; Dmakes decisions about subject eligibility; Estudies, interprets, or analyzes identifiable private information or data/specimens for research purposes
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precis background

- Ganetespib is a non-geldamycin synthetic inhibitor of Hsp90 that has demonstrated activity against multiple cancer cell lines and tumor xenografts. Inhibiting the Hsp90 chaperone complex results in the recruitment of ubiquitin ligases, polyubiquination, and proteosomal degradation of Hsp90 client proteins, including transcription factors and proteins involved in angiogenesis (VEGF, VEGFR, HIF-1, STAT-3); growth factor independence (RAF, EGFR, Her2, IGFR); resistance to anti-growth signals (CDK4); tissue invasion and metastases (MET, MMP2); and avoidance of apoptosis (AKT, RIP, Survivin, Bcl-2).  
- HIF-1α activation has been implicated in mediating resistance to anti-angiogenic therapy; recent evidence implicates a greater role for Hsp90 in direct modulation of VEGF signaling
- Combining Hsp90 inhibition with ganetespib and anti-angiogenic therapy with ziv-aflibercept, a soluble fusion protein with high binding affinity for VEGF-A, VEGF-B, and PIGF, presents a novel rational strategy for improving on and overcoming resistance to anti-angiogenic therapy
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primary objective

- To establish the safety, tolerability, and maximum tolerated dose (MTD) of the combination of ganetespib and ziv-aflibercept in patients with refractory gastrointestinal carcinomas, nonsquamous non-small cell lung carcinomas, urothelial carcinomas, and sarcomas
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secondary objectives

- To assess modulation of HIF1α as a pharmacodynamic marker of therapy with the combination of ganetespib and ziv-aflibercept
- To assess modulation of EGFR expression using 89Zr-labeled, EGFR-targeting antibody panitumumab PET/CT imaging of tumor lesions prior to and following treatment with study drugs Eligibility:
- Adult patients with histologically confirmed metastatic gastrointestinal carcinomas, non-squamous non-small cell lung carcinomas, urothelial carcinomas, and sarcomas with disease progression after at least one line of standard therapy
- Participants in the expansion phase must demonstrate EGFR expression on archival tumor samples and have disease amenable to biopsy with willingness to undergo pre- and post-treatment biopsies
- No major surgery within 4 weeks prior to study enrollment, no radiation or chemotherapy within 3 weeks prior to enrollment; patients must have recovered from toxicities of prior therapies to at least eligibility levels prior to enrollment.
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study design

- Ganetespib will be administered IV weekly on days 1, 8, and 15 of a 28-day cycle. Ziv-aflibercept will be administered IV on days 1 and 15 of a 28-day cycle.  
- The escalation portion of the trial will follow a standard 3+3 design, whereby patients are doseescalated in cohorts of 3 until dose-limiting toxicity is observed.  
- Once the MTD is established, 10 additional patients will be enrolled to the expansion phase at the MTD, and tumor biopsies will be obtained to assess pharmacodynamic endpoints. During cycle 1 of the expansion phase, ganetespib will be administered IV weekly, on days 8 and 15 with omission of day 1 treatment to accommodate a baseline biopsy pre-ganetespib but after administration of ziv-aflibercept. For all subsequent cycles, ganetespib will be administered days 1, 8, and 15. Ziv-aflibercept will still be administered IV on days 1 and 15 of a 28-day cycle.  
- PET/CT imaging with 89Zr-labeled panitumumab will be performed to evaluate tumor distribution prior to and following treatment with study agents.  
| C1D1                            | D8   | D15   | D22   | C2D1   | D8   | D15   | D22   |
|---------------------------------|------|-------|-------|--------|------|-------|-------|
| *                               |      |       |       |        |      |       |       |
| G A                             |      |       |       |        |      |       |       |
| *Tumor   Biopsy  #CTCs ‡ PET/CT |      |       |       |        |      |       |       |  
SCHEMA
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g = ganetespib a =

* Tumor biopsies (optional during the escalation phase, mandatory during the expansion phase) will be performed on C1D7 prior to administration of ganetespib on C1D8 and again on C2D7 prior to administration of ganetespib on C2D8. If tumor biopsies are pursued, the first dose of ganetespib on C1D1 will be omitted. \#Circulating tumor cells (optional) will be collected during the expansion phase only at baseline (pre-treatment), on C1D8 (+/- 1 day) prior to the administration of ganetespib, on C1D15 4 hours (+/- 1 hour) after completion of drug administration, on C2D8 (+/- 1 day) prior to the administration of ganetespib, on C2D15 4 hours (+/- 1 hour) after completion of drug administration, on day 1 of all subsequent cycles before drug administration, and at disease progression.  
‡ 89Zr-panitumumab PET/CT imaging will be performed in all patients during the expansion phase (optional during the escalation phase), prior to initiation of treatment. If there is evidence of measurable uptake on baseline scans, patients will receive a second scan on C1D16 day to assess for evidence of EGFR target modulation. If patients are unable to have a second scan on C1D16 + 1 day due to scheduling conflicts, scans may be done on C2D16 + 1 day.  
| TABLE OF CONTENTS                                                                                                                                              |                                                                                                                                                |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------|
| PRÉCIS .                                                                                                                                                       |                                                                                                                                                |
| SCHEMA.......................................................................................................................................................4 |                                                                                                                                                |
| 1                                                                                                                                                              | OBJECTIVES .                                                                                                                                   |
| 2                                                                                                                                                              | BACKGROUND .                                                                                                                                   |
| 2.1                                                                                                                                                            | Role of Hsp 90 chaperone in Angiogenesis and Cancer .................................................7                                         |
| 2.2                                                                                                                                                            | Ganetespib                                                                                                                                     |
| 2.3                                                                                                                                                            | Ziv-aflibercept                                                                                                                                |
| PATIENT SELECTION                                                                                                                                              |                                                                                                                                                |
| 3                                                                                                                                                              | Eligibility Criteria ...................................................................................................................20     |
| 3.1                                                                                                                                                            |                                                                                                                                                |
| 3.2                                                                                                                                                            | Exclusion Criteria .                                                                                                                           |
| 3.3                                                                                                                                                            | Inclusion of Women and Minorities .................................................................................23                          |
| 3.4                                                                                                                                                            | Screening Evaluation ................................................................................................................23        |
| 4                                                                                                                                                              | REGISTRATION PROCEDURES ....................................................................................................................24 |
| 4.1                                                                                                                                                            | Registration Process                                                                                                                           |
| S                                                                                                                                                              | TREATMENT PLAN .                                                                                                                               |
| 5.1                                                                                                                                                            | Agent Administration                                                                                                                           |
| 5.2                                                                                                                                                            | Definition of Dose-Limiting Toxicity                                                                                                           |
| 5.3                                                                                                                                                            | General Concomitant Medication and Supportive Care Guidelines ........................28                                                       |
| 5.4                                                                                                                                                            | D Duration of Therapy                                                                                                                          |
| 5.5                                                                                                                                                            | Duration of Follow Up                                                                                                                          |
| 5.6                                                                                                                                                            | Criteria for Removal from Study ...................................................................................30                          |
| 6                                                                                                                                                              | DOSING DELAYS/DOSE MODIFICATIONS ...................................................................30                                         |
| 6.1                                                                                                                                                            | Dose Modifications                                                                                                                             |
| 7                                                                                                                                                              | ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................34                                                                |
| 7.1                                                                                                                                                            | Comprehensive Adverse Events and Potential Risks List (CAEPR) for                                                                              |
| Ganetespib (NSC 777169)                                                                                                                                        |                                                                                                                                                |
| 7.2                                                                                                                                                            | Comprehensive Adverse Events and Potential Risks list (CAEPR) for Ziv-                                                                         |
| aflibercept (VEGF-Trap, NSC 724770)                                                                                                                            |                                                                                                                                                |
| 7.3                                                                                                                                                            | Adverse Event Characteristics ....................................................................................40                           |
| 7.4                                                                                                                                                            | Expedited Adverse Event Reporting                                                                                                              |
| 7.5                                                                                                                                                            | NCI-IRB Reporting                                                                                                                              |
| 7.6                                                                                                                                                            | Secondary Malignancy                                                                                                                           |
| 7.7                                                                                                                                                            | Second Malignancy                                                                                                                              |
| 8                                                                                                                                                              | PHARMACEUTICAL INFORMATION                                                                                                                     |
| 8.1                                                                                                                                                            | Ganetespib (NSC 777169)                                                                                                                        |
| 8.2                                                                                                                                                            | Ziv-aflibercept (NSC 724770)                                                                                                                   |
| 8.3                                                                                                                                                            | 89Zr-labeled Panitumumab                                                                                                                       |
| 8.4                                                                                                                                                            | Agent Ordering .                                                                                                                               |
| 8.5                                                                                                                                                            | Agent Accountability                                                                                                                           |
| 9                                                                                                                                                              | CORRELATIVE/SPECIAL STUDIES ......................................................................................................54           |  
| 9.1                                                                                                                                                                                                                                                                                                         | Pharmacodynamic Assays 55                                                                                                                                                                                                                                                               |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 10                                                                                                                                                                                                                                                                                                          | STUDY CALENDAR 62                                                                                                                                                                                                                                                                       |
| 11                                                                                                                                                                                                                                                                                                          | MEASUREMENT OF EFFECT 64 11.1 Antitumor Effect - Solid Tumors 64 11.2 Guidelines for Evaluation of Measurable Disease 66 11.3 Response Criteria 69 11.4 Duration of Response 71                                                                                                         |
| 12                                                                                                                                                                                                                                                                                                          | DATA REPORTING / REGULATORY REQUIREMENTS 71 12.1 Data Reporting 71 12.2 CTEP Multicenter Guideline 72 12.3 Collaborative Agreements Language 72                                                                                                                                         |
| 13                                                                                                                                                                                                                                                                                                          | STATISTICAL CONSIDERATIONS 73 13.1 Study Design/Endpoints 73 13.2 Sample Size/Accrual Rate 74 13.3 Analysis of Secondary Endpoints 74                                                                                                                                                   |
| 14                                                                                                                                                                                                                                                                                                          | HUMAN SUBJECTS PROTECTIONS 74 14.1 Justification for Subject Selection 74 14.2 Evaluation of Benefits and Risks/Discomforts 75 14.3 Consent and Assent Process and Documentation 75 14.4 Procedure for Protecting Against or Minimizing Any Potential Risks 76 14.5 Patient Advocate 76 |
| REFERENCES 77 APPENDIX A: PERFORMANCE STATUS CRITERIA 80 APPENDIX B: POTENTIAL DRUG INTERACTIONS 81 APPENDIX C: DRUGS WITH RISK OF TORSADES DE POINTES 83 APPENDIX D: 89Zr-LABELED PANITUMUMAB ORDER FORM 86 APPENDIX E - PATIENT STUDY CALENDAR 88 APPENDIX F: EXPANSION PHASE PD COLLECTION WORKSHEETS 91 |                                                                                                                                                                                                                                                                                         |
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1 objectives primary objective

- To establish the safety, tolerability, and the maximum tolerated dose of the combination of ganetespib and ziv-aflibercept in patients with refractory gastrointestinal carcinomas, nonsquamous non-small cell lung carcinomas, urothelial carcinomas, and sarcomas
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secondary objectives

- To assess the modulation of HIF1α as a pharmacodynamic marker of therapy with the combination of ganetespib and ziv-aflibercept
- To assess modulation of EGFR expression using 89Zr-labeled, EGFR-targeting antibody panitumumab PET/CT imaging of tumor lesions prior to and following treatment with study drugs as an exploratory non-invasive evaluation of Hsp90 client protein modulation
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2 background 2.1 role of

Induction of angiogenesis is one of the hallmarks of carcinogenesis; malignant tumors are dependent upon angiogenesis for oxygen support, growth, and metastasis [1]. The central driving force behind angiogenesis is the interaction of pro-angiogenic signaling pathways with various endothelial cell signaling pathways. Additionally, more recent evidence also implicates a role for the co-optation of cells in the tumor microenvironment for additional tumor support and progression [2]. The development of anti-angiogenic agents has brought to light new resistance mechanisms invoked by both tumor cells as well as cells in the tumor microenvironment, leading to the idea that simultaneous targeting of multiple resistance pathways will enhance anti-tumor activity.  
Hsp90 is a molecular chaperone involved in the folding and stabilization of newly synthesized or misfolded proteins, and accordingly involved in many signaling pathways important for tumor cell survival, proliferation, and metastasis [3]. More than 100 individual Hsp90 client proteins have been identified. These include transcription factors and proteins involved in angiogenesis (VEGF, VEGFR, HIF1, STAT-3); growth factor independence (RAF, EGFR, HER-2, IGFR); resistance to anti-growth signals (CDK4); tissue invasion and metastases (MET, MMP2); and avoidance of apoptosis (AKT, RIP, Survivin, Bcl-2). Hsp90 inhibition results in ubiquination and proteosomal degradation of misfolded client proteins, providing an opportunity for effecting antitumor activity through inhibition of multiple oncogenic pathways.  
Extensive preclinical and clinical evidence supports the hypothesis that exposure to antiangiogenic therapy can, paradoxically, cause an adaptive-evasive response with induction of local invasiveness and distant metastases [4]; HIF1α has been implicated in mediating this response and inducing resistance to anti-VEGF therapy [5]. Preclinical models in sarcomas confirm synergism of anti-VEGF inhibition and HIF1α-inhibition [6]. Based on recent evidence implicating a greater role for Hsp90 in angiogenesis, with direct modulation of VEGF signaling, vessel formation [7], and stabilization of the HIF1α dimerization complex required for Raf/Mek/Erk-mediated endothelial cell proliferation [8], the combination of Hsp90 inhibition with ganetespib and an anti-angiogenic agent such as ziv-aflibercept, present a rational novel strategy for improving upon and overcoming resistance to the inhibition of angiogenesis. Ganetespib is a non-geldamycin Hsp90 inhibitor which exerts its action by binding to the ATP pocket in the N-terminus of Hsp90. Preclinical studies demonstrate potent Hsp90 inhibition in multiple tumor models including colon, lung, and breast [9-12]. Zivaflibercept is a soluble fusion protein comprised of the immunoglobulin domain of VEGFR1 and VEGFR2 fused to the Fc portion of human IgG1. It acts as a high-affinity soluble VEGFR decoy receptor, and has high affinity for VEGF-A, VEGF-B, and PIGF. VEGF is central to endothelial cell survival and promotion of angiogenesis; PIGF is a chemotactic factor of endothelial cells and has been implicated in the mobilization of bone marrow-derived progenitor cells and response to VEGF-induced angiogenic signaling [13].
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rationale for combination of ganetespib

Epidermal growth factor receptor is a member of the ErbB family of receptors, and its expression is found in an estimated 60-80% of colorectal cases [14]. Events downstream of the EGFR pathway have been implicated in colon carcinogenesis, and include Rasmediated activation of the PI3K/Akt/mTOR and Raf/Mek/Erk pathways. EGFR-mediated activation of the PI3K/Akt/mTOR pathway has also been implicated in upregulation of HIF1α and VEGF [15]. Additionally, both Akt and Raf are known client proteins modulated by Hsp90. In vitro evidence supports antiangiogenic modulation by ganetespib in colorectal cancer cells, where significant inhibition of HIF1α and STAT-3 in addition to PDGFA, FGF2, Ang-1, Ang-2, TGFβ1, and VEGF were observed in both KRAS wild-type and mutant cell lines. Downregulation of mRNA transcripts for the same angiogenic factors previously mentioned were also seen in ganetespib-treated tumor samples [16]. Antiangiogenic therapy with ziv-aflibercept is currently approved for use in patients with metastatic colorectal cancer [17].
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rationale for combination of ganetespib

Extensive preclinical evidence exists for antitumor activity of Hsp90 inhibition in nonsmall cell lung cancer (NSCLC) [18, 19]. Ganetespib has also previously been tested in combination with bevacizumab in preclinical models of NSCLC, with evidence of enhancement of in vitro and in vivo efficacy [16]. Based on results of the Phase 3 ECOG 4599 trial [20] and AVAiL trial [21], bevacizumab is currently approved for the initial systemic treatment of patients with metastatic NSCLC. A recent multicenter Phase 2 study of ganetespib in advanced non-small cell lung cancer has demonstrated significant single agent activity [22]. In this study, PFS rates at 16 weeks were 13.3% in patients with EGFR mutation, 5.9% in patients with KRAS mutation, and 19.7% in patients who had neither mutation. The combination of Hsp90 inhibition, with ganetespib, and anti-angiogenic inhibition, with ziv-aflibercept, allows for enhancement of antitumor efficacy.
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rationale for combination of ganetespib

EGFR and HER2/neu, both Hsp90 client proteins, are highly expressed in urothelial carcinoma cells and expression correlates with stage, grade, and survival [23, 24]. In case series studied, HER2/neu expression and amplification correlated with survival both alone and when co-expressed with other EGFR family members; median survival for those with HER2/neu-expressing tumors was 33 months compared with 50 months in HER2/neu-nonexpressing tumors [25]. Early preclinical data with the EGFR inhibitor cetuximab demonstrated a dose-dependent decrease in cell proliferation of the malignant urothelial cell line 253J [26]. Additionally, HIF1α overexpression has been implicated as a predictor of tumor recurrence and progression in urothelial carcinomas [27]. The combination of Hsp90 inhibition, with ganetespib and anti-angiogenic inhibition, with ziv-aflibercept, allows for the targeting of multiple poor-prognostic pathways, and amplification of antitumor activity.
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rationale for combination of ganetespib

Angiogenesis is crucial to the growth and dissemination of sarcomas. Microarray profiling of soft tissue sarcomas demonstrated 10-fold higher levels of VEGF compared to normal tissues controls [28]. More recent studies demonstrated a role for upregulation of HIF1α as a mechanism of resistance of soft tissue sarcomas to antiangiogenic therapies, and that inhibition of HIF1α can augment the destruction of tumor vasculature within sarcoma xenografts [29]. In addition to VEGF, overexpression of many receptor tyrosine kinases has also been implicated in the pathogenesis of soft tissue sarcomas, including HER2 and IGF-1R, both are client proteins of Hsp90 [30]. Recent proteonomic analyses of osteosarcomas also show overexpression of Hsp90 in all osteosarcomas, and 30 of 75 highgrade sarcomas analyzed [31].
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2.2 ganetespib mechanism of action

Ganetespib is a non-geldamycin inhibitor of Hsp90 chaperone activity, exerting activity through binding at the N-terminal adenosine triphosphate (ATP) pocket of Hsp90, and inhibiting its function. Hsp90 inhibition causes its client proteins to adopt aberrant conformations, which are then targeted for ubiquination and proteosomal degradation. Client protein degradation results in induction of cell cycle arrest and apoptosis, thereby inhibiting tumor growth [9]. Ganetespib has activity against a broad spectrum of cancer cell lines compared to first generation Hsp90 inhibitors [32] with an average IC50 value 20-fold lower than 17-AAG [9].
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preclinical studies in vitro studies

Reverse Phase protein arrays performed on lysates from four KRAS mutant NSCLC cell lines treated with for 24 hours show diminished expression of multiple receptor kinases
(including EGFR, MET, HER2), signaling intermediates (CRAF, Src, STAT3, MAPK,
GSK3), kinases involved in protein synthesis and growth (AKT/mTOR), resulting in the activation of apoptotic mediators and cell cycle arrest [33].  
| Cell Lines                                                                          |                |       |       |      |        |
|-------------------------------------------------------------------------------------|----------------|-------|-------|------|--------|
| Function                                                                            | Analyte        | H2009 | A549  | H358 | Calu-1 |
| S6 (pS235/S236)                                                                     | -9.1           | -6.3  | -27.2 | -7.5 |        |
| S6 (pS240/S244)                                                                     | -9.2           | -7.5  | -22.4 | -9.8 |        |
| AKT (pS473)                                                                         | -2.0           |       |       |      |        |
| -2.0                                                                                | -1.7           | -1.1  |       |      |        |
| 4E-BP1 (pS65)                                                                       | -1.3           | -1.7  | 4.2   | -1.7 |        |
| AKT/mTOR                                                                            | AKT            | -1.8  | -1.7  | -1.8 | -3.0   |
| mTOR (pS2448)                                                                       | -1.9           | -1.3  | -1.9  | -2.3 |        |
| PDK1 (pS241)                                                                        | -1.6           | -1.9  | -1.4  | -1.8 |        |
| p70S6K                                                                              | -1.5           | -1.6  | -1.3  | -1.9 |        |
| Tuberm                                                                              | -1.8           | -1.4  | -1.5  | -1.5 |        |
| C-RAF (pS338)                                                                       | -2.7           | -2.3  | -2.8  | -1.9 |        |
| C-RAF                                                                               | -2.1           | -2.8  | -2.3  | -2.4 |        |
| MAPK                                                                                | EphA2          | -1.6  | -1.6  | -2.1 | -1.7   |
| MAPK (pT202/Y204)                                                                   | -1.7           | -1.4  | -1.5  | -1.5 |        |
| MEK1 (pS217/S221)                                                                   | -1.1           | -1.1  | -1.5  | -2.4 |        |
| ATP/metabolism                                                                      | ACC (pS79)     | -2.0  | -1.8  | -2.7 | -4.4   |
| CHK1                                                                                | -1.4           | -1.4  | -1.7  | -1.6 |        |
| Cell Cycle                                                                          | Cyclin E1      | -1.4  | -1.6  | -1.5 | -1.4   |
| GSK3 (pS9)                                                                          | -1.6           | -1.9  | -2.6  | -2.8 |        |
| Src (pY416)                                                                         | -4.0           | -2.0  | -2.2  | -3.0 |        |
| GSK3-A/B (pS21S9)                                                                   | -1.6           | -1.6  | -1.7  | -1.8 |        |
| Other                                                                               | Src (pY527)    | -2.2  | -1.6  | -1.5 | -2.5   |
| STAT3 (pY705)                                                                       | -2.8           | -1.4  | -1.7  | -2.2 |        |
| GSK3-A/B                                                                            | -1.6           | -1.3  | -1.3  | -1.4 |        |
| EGFR (pY1068)                                                                       | -14.1          | -1.6  | -1.6  | -1.7 |        |
| HR2 (pY12480                                                                        | -1.7           |       |       |      |        |
| -5.5                                                                                | -1.9           | -1.6  |       |      |        |
| IGF-1R                                                                              | -1.8           | -1.5  | -2.0  | -1.7 |        |
| RTK                                                                                 | c-Met (pY1235) | -10.9 | 1.0   | 1.1  | -1.1   |
| HER2                                                                                | -3.2           | 1.6   | -1.9  | -1.9 |        |
| EGFR                                                                                | -1.2           | -1.3  | -1.1  | -1.3 |        |
| Annexm I                                                                            | 1.1            | 1.1   | 1.4   | 1.6  |        |
| Caspase 7 (cleaved)                                                                 | 1.4            | 1.4   | 1.2   | 1.3  |        |
| Apoptosis/Arrest                                                                    | 1.1            | 1.3   | 2.0   |      |        |
| p21                                                                                 | 1.4            |       |       |      |        |
| Cyclin B1                                                                           | 1.5            | 2.2   | 1.2   | 1.1  |        |
| BIM                                                                                 | 1.7            | 1.3   | 1.5   | 2.5  |        |
| Stress                                                                              | HSP70          | 2.4   | 2.4   | 2.6  | 2.4    |
| Table 1. Fold-changes in protein expression following Ganetespib Treatment (250 nM, |                |       |       |      |        |
| 24 hours) in KRAS- Mutant NSCLC Lines .                                             |                |       |       |      |        |
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in vivo studies

Pharmacodynamic analyses were performed in mice bearing H3122 xenografts, a nonsmall cell lung carcinoma model with constitutively active ELM4-ALK fusion kinase.  
Animals were treated with a single-bolus injection of ganetespib (50 mg/kg) and tumors were harvested at 24, 48, 72, and 96 hours. For comparison, animals were treated with a single injection of vehicle or crizotinib (50 mg/kg) and tumors were collected at 24 hours. Levels of Hsp90 client proteins were evaluated by immunoblotting, namely ERK, MET, EGFR, pSTAT3, and pAKT, and all showed evidence of degradation detectable at 24 hours, and lasting up to 72 hours (Figure 1).  
 Human NSCLC Xenograft Model SCID mice bearing H3122 tumors were treated with vehicle or a single bolus injection of ganetespib (50 mg/kg) at the indicated time points between 24 and 96 hours. Mice were also treated with a single bolus injection of crizotinib (50 mg/kg) for 24 hours.  
Tumors were resected and the levels of the indicated proteins determined by immunoblotting.  
Ganetespib was also shown to reduce the expression of HIF1α levels in NSCLC tumor xenografts, as far as 150 µM from the nearest blood vessel, suggesting ganetespib can penetrate deep into the hypoxic regions of tumor tissue [data not shown]. In addition, exposure to a single bolus of ganetespib also resulted in reduction of CD31 expression (endothelial cell marker) by 39%, coordinate with a reduction in cell proliferation and rise of apoptosis and hypoxia (Figure 2).  
  
Figure 2: In Vivo Effect of Ganetespib on Tumor Vasculature, Proliferation, and Apoptosis in the NCI H1975 Xenograft Model .  Mice were injected sc with 5 million NCI-H1975 tumor cells in 50% Matrigel.  On D11, animals were treated with vehicle or a single bolus injection of ganetespib (125 mg/kg).  Tumors were excised 24 hours after dosing and subject to quantitative image analysis for markers of proliferation (BrdU), apoptosis (TUNEL), vasculature (CD31),
hypoxia (pimonidazole), and perfusion (DiOC7).  
H3122 NSCLC tumor xenografts, with constitutively active ELM4-ALK fusion kinase, were also treated with ganetespib once weekly, with evidence of durable tumor regression, when compared with crizotinib (Figure 3).  
  
Figure 3: Anti-Tumor Activity of Ganetespib in the NCI H3122 Human NSCLC Xenograft Model .  Mice (7/group) were injected sc with 5x106NCI H3122 tumor cells in 50% Matrigel.  
IV drug treatments (arrowheads)
were performed starting on D24 and continued once/week for 5 weeks for ganetespib (150 mg/kg) and 5 times/week for crizotinib
(200 mg/kg).  %Tumor/Control values for D59 are indicated on the right.  No excessive body weight loss (>20%) was observed in any animal.  Error bars represent SEM.
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non-clinical pharmacokinetics

The pharmacokinetic (PK) profiles of ganetespib were evaluated in mice, rats, and monkeys following intravenous administration. Ganetespib displayed dose proportional PK in all species over the dose ranges tested. It is highly protein-bound and highly distributed throughout nearly all tissues, with limited distribution into the central nervous system. It is extensively metabolized in the liver to mainly glucuronide conjugates. The major route of excretion is in the feces. Ganetespib was highly cleared in mice and rats, and moderately cleared in monkeys. Mean terminal half-life (T1/2) values for ganetespib in the multiple dose studies were approximately 6 and 11 hours in rats and monkeys, respectively. Ganetespib does not appear to accumulate after multiple dosing. No marked sex differences were observed in the PK of ganetespib in either rats or monkeys.
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preclinical safety pharmacology studies and

Ganetespib was evaluated for safety pharmacology effects in a panel of receptor-binding assays in vitro and in a rabbit Langendorff heart preparation ex vivo. Rabbit hearts were perfused with vehicle (dimethylsulfoxide [DMSO] in Krebs solution) followed by escalating concentrations of ganetespib (10-8, 10-7, 10-6, 10-5, and 10-4 M) for 15 minutes each. Ganetespib minimally decreased the rate of atrioventricular (AV) conductance at 10-6 and 10-5 M. At 10-4 M, the PQ interval was not measurable because of arrhythmia. Also at 10-4 M, the QRS duration increased, a second degree AV block was produced, and occasional supraventricular premature depolarization occurred. Other cardiac parameters were not significantly altered by ganetespib. The Cmax at 1 mg/kg in cynomolgus monkeys correlates to a concentration of 10-8 M, when corrected for plasma protein binding, and is 100-fold lower than the minimum concentration of 10-6 M at which PQ interval increase was observed. At this concentration, there were no ganetespib-related changes in the mean arterial blood pressures or heart rates and no qualitative or quantitative ganetespib-related electrocardiogram changes. To evaluate ocular toxicities, adult male Sprague Dawley rats received bolus IV injection of vehicle or 20 mg/kg/day ganetespib for 2 days. Twenty-four hours after the last dose, ocular toxicity was assessed by TUNEL staining of retinal tissues to detect apoptotic cell death. In subsets of animals, plasma and retinal tissues were collected to determine drug exposure. Ganetespib, at an exposure (AUCt 36.1 µM*h) that exceeded the 216-mg/m3 human exposure (AUCt 22.5 µM*h), did not elicit retinal photoreceptor injury with no increase in TUNEL-positive cells. In 3-month studies, ganetespib was administered on Days 1 and 15 of four 21-day cycles. Rats tolerated a dose of 20 mg/kg/dose, the NOAEL. Transient decreases in weight gain occurred at 50 and 100 mg/kg/dose, and early deaths occurred at 100 mg/kg/dose. Cynomolgus monkeys on the same regimen tolerated doses up to 7 mg/kg/dose, the NOAEL.
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clinical pharmacokinetic studies

Pharmacokinetic profiles in a Phase 1 study in solid tumors demonstrated that the  
 concentration of ganetespib declined to approximately 10% of Cmax within one hour of infusion termination and 1% of Cmax within 8 to 10 hours. The mean time to reach Cmax was 0.79 hours. There was no apparent drug accumulation with once weekly dosing. The mean ± SD terminal T1/2 was approximately 7.54 ± 2.64 h and plasma drug clearance was 52.59 ± 17.80 L/h (28.55 + 9.33 L/h/m2). Clearance and volume of distribution were approximately constant across doses. AUC increased in proportion to dose (Figure 4) [34]:
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clinical experience

Ganetespib has been studied in 5 completed Synta-sponsored clinical trials and 3 completed Synta-sponsored studies in normal healthy volunteers. Ganetespib is currently being studied in 6 ongoing Synta-sponsored clinical trials and 17 investigator-sponsored clinical trials. In Phase 1 studies, ganetespib was well tolerated as a weekly infusion for 3 weeks of a 4 week cycle, with the maximum tolerated dose at 216 mg/m2 and recommended Phase 2 dose at 200 mg/m2. A recent Phase 2 study of ganetespib monotherapy in previously treated patients with non-small cell lung cancer (NSCLC) demonstrated 4 objective responses of 99 enrolled patients, stratified by mutant EGFR, mutant KRAS, or neither mutation [22]. These 4 patients were found to harbor anaplastic lymphoma kinase (ALK) gene rearrangement on retrospective analysis. PFS rates at 16 weeks were 13.3% for the mutant EGFR cohort, 5.9% for the mutant KRAS cohort, and overall 19.7% for the remaining cohort which included the 4 patients who achieved a partial response [22]. Ganetespib has also been tested in combination with docetaxel
(Synta-sponsored Study 9090-07) and was found to be tolerable at a dose of 150 mg/m2 on day 1 and 15, with docetaxel at 75 mg/m2 on day 1.
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potential drug interactions

Inhibition and induction potentials of ganetespib were investigated in human liver microsomes and human hepatocytes. Ganetespib is a substrate for P-gp but not BRCP. Ganetespib is an inhibitor of CYP2C19 and CYP3A4 (midazolam specific), but is not an inducer of CYP or UGT enzymes. In liver microsomal studies, inhibition of CYP1A2, CYP2B6, CYP2D6 and CYP3A4 (testosterone-specific) by ganetespib was less than 50%
at concentrations up to 10 µM (IC50 > 10 µM, maximum solubility conditions); ganetespib inhibited activities of CYP2C8, CYP2C9, CYP2C19 and CYP3A4 (midazolam-specific)
with IC50 values of 9.8, 8.3, 1.0, and 1.1 µM, respectively. Inhibition of CYP2C8, CYP2C9, and CYP2C19 were competitive with inhibition constant (Ki) values of 3.2, 4.1, and 0.28 µM, respectively, whereas inhibition of CYP3A4 (midazolam specific) was noncompetitive with a Ki value of 1.8 µM. Inhibition of CYP enzymes was reversible in all cases. In human hepatocytes, ganetespib did not induce CYP1A2, CYP2B6, or CYP3A4 at concentrations up to 10 µM. No increases in the levels of CYP1A2, CYP2B6, CYP3A4, UGTA1, and UGT1A6 were observed by Western Blot analyses after incubation of ganetespib in human hepatocytes. A panel of potential co-medications (atorvastatin, dexamethasone, fentanyl, furosemide, morphine, and warfarin) was evaluated for potential drug interactions with ganetespib via hepatic metabolism using human cryopreserved hepatocytes suspensions. Ganetespib in vitro clearance was not affected by any of the co-medications tested at clinically relevant concentrations. Ganetespib did not markedly affect the CYP3A4-mediated metabolism of atorvastatin, dexamethasone, fentanyl, or warfarin. Ganetespib at 20 µM inhibited UGT
mediated metabolism of potential co-medications, morphine (mainly UGT2B7), and furosemide (UGT1As), by approximately 30% in human hepatocytes at clinically relevant concentrations of these medications. Due to evidence of increase in QTc interval 24 hours after the dose of ganetespib in a pharmacology study of healthy volunteers (Investigator's Brochure), certain drugs known to be associated with QTc prolongation (Appendix C) should not be used by patients treated with ganetespib. The use of any medication that has the potential for QTc prolongation and has been linked to the occurrence of torsades de pointes is strictly prohibited. Ondansetron has been associated with QTc prolongation and the occurrence of torsades de pointes. Therefore it should not be used in patients being treated with ganetespib. The use of all other serotonin 5HT3 antagonists is acceptable (e.g., palonosetron, granisetron, or tropisetron).
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2.3 ziv-aflibercept mechanism of action

Angiogenesis is one of the hallmarks of carcinogenesis and malignant tumors are dependent upon angiogenesis for oxygen support, growth, and metastasis. VEGF, the key growth factor in angiogenesis, is comprised of 5 isoforms (VEGF-A, -B, -C, -D, -E, and placental growth factor [PlGF]). These growth factors exert their action through 3 tyrosine kinase receptors, VEGFR1, VEGFR2 and VEGF receptor 3 (VEGFR3). Ziv-aflibercept is a recombinant fusion protein consisting of human vascular endothelial growth factor (VEGF) receptor extracellular domains fused to the Fc portion of human immunoglobulin G1 (IgG1). Ziv-aflibercept contains portions of the extracellular domains of 2 different vascular endothelial growth factor receptors (VEGFRs): VEGFR1 (also known as Flt-1) and VEGFR2 (also known as KDR or Flk-1). It acts as a high-affinity soluble VEGFR decoy receptor, and has high affinity for VEGF-A, VEGF-B, and PIGF. The affinity constants (KD) for binding to 2 human isoforms of VEGF, VEGF165 and VEGF121, are 0.50 pmol/L and 0.36 pmol/L, respectively. The KD for human PlGF2 is 39 pmol/L. The binding of ziv-aflibercept to its ligands in vivo is expected to block tumor angiogenesis and vascular permeability.
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nonclinical toxicology studies

General toxicity studies were conducted in cynomolgus monkeys and based on weekly and every two week intravenous administration of ziv-aflibercept for up to 6 months, and consistent with inhibition of the VEGF pathway previously reported with other anti-VEGF agents. Target organs indentified in these studies included bone (interference with growth plate maturation of long bones and osteocartilaginous exostoses of vertebrae), kidney (frequently increased glomerular mesangial matrix, occasionally hyperplasia of parietal epithelium, and periglomerular fibrosis), adrenals (decreased vacuolation with inflammation), nasal cavity (atrophy/loss of the septum and/or turbinates), kidney (glomerulopathy with inflammation), ovary (decreased number of maturing follicles, granulosa cells, and/or theca cells). Other microscopic findings in the 6-month chronic toxicity study included vascular alterations in the choroid plexus and digestive tract, vascular degeneration and fibrosis in several tissues including the heart, and hepatic portal inflammation and periportal necrosis. Ziv-aflibercept was shown to alter fertility parameters in sexually mature male and female monkeys treated for 6 months. These effects were noted at plasma exposures of free zivaflibercept that were close to exposures in patients at the recommended pharmacological doses and were considered to impact fertility in both males and females. Inhibition of the female reproductive function by anti-VEGF drugs is related to the key role of VEGFmediated angiogenesis in follicular and luteal development. The effects of ziv-aflibercept on sexually mature male and female fertility were reversible. The safety pharmacology studies showed that ziv-aflibercept reduced vascular density in certain normal tissues in mice, increased blood pressure in rats and mice and delayed wound repair and healing in rabbits. Detectable effects these parameters were noted at doses that were lower than the optimal pharmacologic doses determined in tumor bearing mice. Maximal effects on wound healing and blood pressure were noted only at doses in the same range as pharmacologically active doses. The increase in blood pressure reported in rodents was reversible and was reported in patients treated with ziv-aflibercept. The reversibility of the effect on wound repair and healing was not evaluated. In full-thickness excisional and incisional skin wound models, ziv-aflibercept administration reduced fibrous response, neovascularization, epidermal hyperplasia/re-epithelialization, and tensile strength. Ziv-aflibercept had no effects on respiratory function in rats or on thrombus formation in rabbits.
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pharmacokinetic studies

Plasma concentration of free and VEGF-bound ziv-aflibercept were measured using specific enzyme-linked immunosorbent assays (ELISA). Free ziv-aflibercept concentrations exhibited linear pharmacokinetics in the dose range of 2-9 mg/kg. Following 4 mg/kg every two week administration schedule, the elimination half-life of free ziv-aflibercept was approximately 6 days (range 4-7 days). Steady state concentrations of free ziv-aflibercept were reached by the second dose. The accumulation ratio for free ziv-aflibercept was approximately 1.2 after an administration of 4 mg/kg every 2 weeks. Based on population pharmacokinetic analyses in patients with mild and moderate hepatic impairment, there was no effect of total bilirubin, aspartate aminotransferase, and alanine aminotransferase on the clearance of free ziv-aflibercept. There are currently no data available for patients with severe hepatic impairment (defined as total bilirubin >3 times upper limit of normal and any SGOT/AST). Based on population pharmacokinetic analyses of patients with mild, moderate, and severe renal impairment, there was no clinically observed effect of creatinine clearance on the clearance of free ziv-aflibercept.
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summary of clinical studies

To date, the clinical development of ziv-aflibercept encompasses a total of 41 clinical oncology trials (25 Sanofi trials and 16 NCI trials) in more than 3700 cancer patients mostly with advanced solid malignancies as well as 2 clinical trials in 76 healthy subjects (PDY6655 and PDY6656). Doses have been administered up to 800 μg/kg SC twice weekly, 7 mg/kg IV every 2 weeks (q2w), and 9 mg/kg IV every 3 weeks (q3w). Based on combination Phase I dose-escalation studies conducted to evaluate safety, PK, and antitumor activity in patients with solid malignancies, the recommended Phase II dose (RP2D) of ziv-aflibercept was established at 4 mg/kg administered intravenously every 2 weeks when combined with chemotherapy. In Phase III combination studies, ziv-aflibercept at a dose of 4 mg/kg administered intravenously every 2 weeks was combined with standard doses of the following cytotoxic agents: oxaliplatin/5-fluorouracil/leucovorin (FOLFOX4), [TCD6117]), irinotecan/leucovorin/5-fluorouracil (irinotecan/LV5FU2, [TCD6118]), and gemcitabine or gemcitabine and erlotinib (TCD6121), gemcitabine (EFC10547/VANILLA), and irinotecan/5-FU/leucovorin (FOLFIRI, [EFC10262/VELOUR]). Additional Phase III studies have also combined ziv-aflibercept at a dose of 6 mg/kg every 3 weeks in combination with standard doses of docetaxel (Taxotere®)/cisplatin/5-fluorouracil (TCF, [TCD6119]), docetaxel or docetaxel/cisplatin or pemetrexed (TCD6120), and docetaxel (EFC10261/VITAL). FDA Approval was obtained based on results of Study EFC10262/VELOUR, a multinational, randomized, double-blind study, comparing the efficacy of ziv-aflibercept administered at a dose of 4 mg/kg intravenously every 2 weeks versus placebo in patients with metastatic colorectal cancer treated with irinotecan /5-FU combination (FOLFIRI) after failure of an oxaliplatin based regimen. The efficacy conclusion from EFC10262/VELOUR was that ziv-aflibercept administered at a dose of 4 mg/kg over 1 hour, every 2 weeks, in combination with the FOLFIRI regimen demonstrated a statistically and clinically significant improvement in overall survival (OS), progression free survival (PFS) duration and a significantly higher overall response rate (ORR) compared to placebo/FOLFIRI. The addition of ziv-aflibercept to FOLFIRI gave no new toxicity signals but did enhance some toxicities of FOLFIRI, namely diarrhea, asthenia, decrease appetite, weight decrease, palmar plantar erythrodysesthesia syndrome, and hematological abnormalities (with the exception of anemia). Grade 3 or 4 events occurred with >2% higher incidence in the ziv-aflibercept/FOLFIRI arm compared to placebo/FOLFIRI arm, and included neutropenia, hypertension, diarrhea, asthenia, leucopenia, stomatitis and ulceration, infection, neutropenic complications and gastrointestinal (GI) and abdominal pain. The risk of treatment-emergent adverse events identified as possible anti-VEGF class specific adverse events were significantly increased and these were more frequently all grade hypertension and hemorrhage. Analyses of pre-specified subgroups during EFC10262/VELOUR, showed no statistically significant differences across subgroups (gender, race, age, of body weight, creatinine clearance, ECOG PS at baseline) with regard to incidences of hypertension, hemorrhage, venous thromboembolic events, arterial thromboembolic events, wound healing complications, renal failure events, acute drug reactions. The safety profile (either VEGF-blockade adverse events or chemotherapy induced toxicities) in patients with renal or liver function impairment did not significantly differ when compared to that observed in patients with normal renal or liver function at baseline. The safety profile of ziv-aflibercept in combination with FOLFIRI was also comparable between patients with or without prior bevacizumab. Since this current study (14-C-0150) opened, there have been two dose limiting toxicities in patients on DL1. The first patient, who had a history of peptic ulcer disease, had grade 3 recurrent epigastric pain despite optimal management. The second patient had abdominal pain with colon cancer; a CT scan showed progressive disease and bowel perforation. This patient died on cycle 1 day 22. Because bowel perforation has been seen with zivaflibercept, it may have contributed to the toxicity. In response to these events the protocol was amended to add lower dose levels.
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2.4 89zr-labeled egfr-targeting antibody panitumumab

Panitumumab is a fully human monoclonal antibody (mAb) that targets EGFR and is approved for use by the FDA for the treatment of EGFR-expressing metastatic colorectal cancer with disease progression [35]. Panitumumab competes with endogenous ligands such as epidermal growth factor and tumor growth factor α (TGF-α) to block stimulation of the EGF receptor.  
89Zr has emerged as a promising positron-emitting radionuclide [36-39] for diagnostic immune-PET imaging. The half-life (78.4 h) provides a good match with the biological half-life of an intact mAb. Based on findings from recent clinical trials in Europe, 89Zrlabeled mAbs are safe for human use [39]. It is also being used for imaging in NCI
Protocol \# 06-C-0164 with no adverse events. We anticipate that 89Zr-immuno-PET with panitumumab as targeting ligand will prove to be an ideal imaging modality to quantify EGFR expression as a biomarker to guide patient selection, therapy, and dosing in the future. No clinical decisions will be made based on the 89Zr-panitumumab imaging findings in this study. Use of 89Zr-panitumumab as an investigational agent is covered by a cross-reference letter from IND 116,229, held by DCTD/CIP.  
89Zr-panitumumab has been prepared with high radiochemical purity and specific activity at the Frederick National Laboratory for Cancer Research. The immunoconjugate was found to be stable with respect to loss of the radio-isotope in human serum. Immuno-PET
experiments indicated that 89Zr-panitumumab shows excellent potential as a PET tracer for specific noninvasive delineation of EGFR-positive tumors in vivo. Human cell lines with low, medium, and high levels of EGFR (BT-474, MDA-MB-231,  
 and MDA-MB-468, respectively) were implanted subcutaneously as xenografts in athymic nude mice (Figure 5)[40]. 89Zr-panitumumab was administered intravenously, and a CT
scan followed by a static PET scan was performed at 96 hours. EGFR protein expression correlated well with the PET tracer present in tumors.  
Figure 5. Tumor uptake of 89Zrpanitumumab in sc xenograft models with different levels of EGFR expression. 10.18 ±1.24 MBq of 89Zr-panitumumab were administered IV via tail-vein, and a 5 min CT scan followed by a 30min static PET scan were performed 96-h post-injection [40].  
Biodistribution studies of 89Zr-panitumumab were performed in male and female mouse cohorts, which were injected with ~100 µCi of agent via tail vein injection. A fraction of the animals were sacrificed daily up until 6-days post injection. The organs, blood, and carcass activity was measured and recorded as %ID/g. For the hollow organs (i.e., gut, urinary bladder) the total activity within the organ was recorded. Minimal radiotracer was excreted from the body over the entire 6-day period; the loss via urinary excretion was likewise minimal. Human dose estimates were made using appropriate correction factors (to account for the differences in percent total body weight of each solid organ) to calculate residence times for each organ. OLINDA/EXM 1.1 software was used to calculate human dose estimates (Table below). Based on these figures, we intend to administer a dose of not more than 1.0 mCi (mass dose <1 mg) to patients in this protocol.  
89Zr-labeled, EGFR-targeting antibody panitumumab human dosimetry estimates for the organs receiving the highest dose:  
| Target Organ             | 89Zr-panitumumab male/female  (rads/mCi)   |
|--------------------------|--------------------------------------------|
| Heart                    | 10.1/12.7                                  |
| Lungs                    | 3.14/3.77                                  |
| Liver                    | 2.74/3.47                                  |
| Red marrow               | 2.57/3.15                                  |
| Spleen                   | 2.61/2.87                                  |
| Effective Dose (rem/mCi) | 1.92/2.47                                  |  
We have early human experience with 89Zr-panitumumab imaging in the ongoing Phase II Study of BAY 43-9006 (Sorafenib) in Combination with Cetuximab (ErbituxTM) in EGFR Expressing Metastatic Colorectal Cancer (CRC) Protocol 06-C-0164. So far, two patients have undergone imaging with good tolerability and no adverse side effects.
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3 patient selection 3.1 eligibility

3.1.1 Patients must have histologically confirmed recurrent or metastatic gastrointestinal carcinomas, non-squamous non-small cell lung carcinomas, urothelial carcinomas, and sarcomas with disease progression after at least one line of standard therapy. Disease should have progressed following all treatments known to prolong survival, unless a given treatment is contraindicated.  
- Patients with colorectal carcinoma must have progressed through at least two lines of standard chemotherapy in the metastatic setting.  
- Patients with non-small cell lung cancer with known sensitizing EGFR mutation and/or ALK rearrangement should have received prior erlotinib and/or crizotinib, respectively.  
- Patients with urothelial carcinoma will have progressed on prior platinum-based therapy or for which platinum-based therapy is contraindicated.  
- Patients enrolled on the expansion phase of the protocol must demonstrate EGFR expression by immunohistochemistry on archival tumor samples prior to undergoing 89Zr-panitumumab PET/CT scans.
3.1.2 Age ≥18 years of age. 3.1.3 ECOG performance status < 2 (see Appendix A).  
3.1.4 Life expectancy > 3 months.  
3.1.5 Patients must have normal organ and marrow function as defined below:  
| − absolute neutrophil count   | ≥1,500/mcL                                                                         |
|-------------------------------|------------------------------------------------------------------------------------|
| − platelets                   | ≥100,000/mcL                                                                       |
| − total bilirubin             | ≤1.5 X institutional upper limit of normal                                         |
| − AST(SGOT)/ALT(SGPT)         | ≤3 X institutional upper limit of normal                                           |
| − creatinine                  | ≤1.2X institutional upper limit of normal                                          |
| OR                            |                                                                                    |
| − creatinine clearance        | ≥60 mL/min/1.73 m2 for patients with creatinine  levels above institutional normal |
| − urine protein/creatinine    | < 1 mg/mg                                                                          |
| − INR                         | < 1.5                                                                              |  
3.1.6 Cardiac function within institutional normal limits on echocardiogram.  
3.1.7 Patients must have blood pressure no greater than 140 mmHg (systolic blood pressure) and 90 mmHg (diastolic blood pressure) for eligibility. Initiation or adjustment of antihypertensive medications is permitted prior to study entry provided that the average of three blood pressure measurements at enrollment visit is less than 140/90 mmHg.  
3.1.8 The effects of ganetespib on the developing human fetus are unknown. For this reason and because anti-angiogenic agents similar to ziv-aflibercept are known to be teratogenic, women of child-bearing potential and men must agree to use two forms of contraception (hormonal or barrier method of birth control; abstinence; sterilization) prior to study entry, for the duration of study participation, and for 3 months after completing study treatment. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately. Men treated or enrolled on this protocol must also agree to use two forms of contraception prior to the study, for the duration of study participation, and for 3 months after completion of administration of both ganetespib and ziv-aflibercept.  
3.1.9 Ability to understand and the willingness to sign a written informed consent document.
3.1.10 During the escalation phase of the protocol, patients may have evaluable or measurable disease. During the expansion phase of the protocol, patients must have 1) measurable disease, 2) disease amenable to biopsy and 3) willingness to undergo pre- and post-treatment biopsies.
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3.2 exclusion criteria

3.2.1 Patients who have had chemotherapy or radiotherapy within 3 weeks (6 weeks for nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered from adverse events due to agents administered more than 3 weeks earlier.  
3.2.2 Patients who are receiving any other investigational agents. 3.2.3 Patients with known active brain metastases or carcinomatous meningitis are excluded from this clinical trial. Patients whose brain metastatic disease status has remained stable for ≥ 4 weeks following treatment of brain metastases are eligible to participate at the discretion of the principal investigator.  
3.2.4 Uncontrolled intercurrent illness including, but not limited to, ongoing or active untreated infection, or psychiatric illness/social situations that would limit compliance with study requirements.  
3.2.5 Patients with known serious cardiac illness or medical conditions, including but not limited to:
- Clinically unstable cardiac disease, including unstable atrial fibrillation, symptomatic bradycardia, unstable congestive heart failure, unstable angina or history of myocardial infarct within 6 months prior to enrollment, or indwelling temporary pacemaker
- Ventricular tachycardia or a supraventricular tachycardia that requires treatment with antiarrhythmic agents
- Second- or third-degree atrioventricular block unless treated with a permanent pacemaker
- Complete left bundle branch block
- History of long QT syndrome or a family member with this condition 3.2.6 No major surgery within 4 weeks prior to enrollment or history of gastrointestinal bleeding within 3 months prior to enrollment. No signs or symptoms of active bleeding or nonhealing ulcer will be permitted at study entry. Patients with central pulmonary tumors with evidence of bronchial invasion, or presenting with hemoptysis will be excluded.  
3.2.7 QTc > 470 msec on electrocardiogram (by Bazett's; average of triplicate recordings at the discretion of the PI) will exclude patients from entry on study. Medications that are known to cause QTc interval prolongation are prohibited for patients entering on trial. Patients for whom a given medication that may cause QTc interval prolongation cannot be discontinued, may be eligible at the discretion of the study PI, provided QTc interval criteria is met at enrollment. A comprehensive list of agents with the potential to cause QTc prolongation can be found in Appendix C and at http://crediblemeds.org.  
3.2.8 Pregnant women and women who are breastfeeding are excluded from this study because the effects of the study drugs on the developing fetus are unknown.
3.2.9 HIV-positive patients on combination antiretroviral therapy are ineligible because of the potential for pharmacokinetic interactions with ganetespib and zivaflibercept. In addition, these patients are at increased risk of lethal infections when treated with marrow-suppressive therapy. Appropriate studies will be undertaken in patients receiving combination antiretroviral therapy when indicated.
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3.2.10 substrates of cyp3a4 or

Preliminary results of a clinical drug-drug interaction study, examining the effect of ganetespib on the pharmacokinetics of the CYP2C19-sensitive probe omeprazole, show a modest (20%) increase in omeprazole exposure when coadministered with ganetespib. In vitro data implies expectation of greater interaction with CYP2C19 substrates than with CYP3A4 substrates. Caution is advised when sensitive narrow therapeutic range CYP3A4 or CYP2C19 substrates are concomitantly administered. Inhibitors of P-Glycoprotein Efflux Transporters Concomitant medications that are strong inhibitors of P-glycoprotein efflux transporters should be used with caution during the study; examples of these medications include ritonavir, cyclosporine, verapamil, erythromycin, ketoconazole, itraconazole, quinidine, and elacridar.  
3.2.11 Concurrent anticoagulation will be permitted providing the patient is receiving a stable dose of anticoagulants before study entry. Patients receiving anticoagulants will be eligible for this trial. Evidence of clinically significant bleeding diathesis or underlying coagulopathy (e.g., INR > 1.5 without vitamin K antagonist therapy) will not be permitted
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3.3 inclusion of women and

Both men and women of all races and ethnic groups are eligible for this trial.
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3.4 screening evaluation

3.4.1 Histologic confirmation of primary tumor tissue or of known recurrence will be required from each participant to confirm diagnosis. Additionally, EGFR expression by immunohistochemistry on archival tissue will be required for patients undergoing 89Zr-panitumumab scans.  
3.4.2 History and physical examination: Complete history and physical examination
(including height, weight, vital signs, and performance score) will be conducted within 72 hours prior to enrollment.  
3.4.3 Imaging Studies (Baseline): Every participant should have an evaluation of known sites of disease as part of the baseline evaluation. All patients will be required to undergo a CT scan of the chest/abdomen/pelvis to evaluate sites of disease within 28 days prior to enrollment. MRI evaluation of site of disease may be performed in lieu of CT evaluation at the discretion of the principal investigator if it is the opinion of the investigator that this modality would provide a more accurate assessment of disease than a CT would, for a given site.  
3.4.4 Electrocardiogram within 1 week prior to enrollment. Echocardiogram evaluation to assess cardiac function must be performed within 4 weeks of enrollment.  
3.4.5 Laboratory Evaluation: Baseline laboratory data are to be obtained within 72 hours prior to enrollment:
- Hematological Profile: CBC with differential.  
- Biochemical Profile: albumin, total bilirubin, BUN, calcium, creatinine, SGOT [AST], SGPT [ALT], amylase, lipase, magnesium, potassium, and sodium.  
- Coagulation Profile: PT, PTT, INR.  
- Serum pregnancy test for female participants of childbearing potential.
3.4.6. All study participants must have a baseline eye exam by a qualified ophthalmologist within 4 weeks prior to enrollment and as clinically indicated thereafter.
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4 registration procedures 4.1 registration

Authorized staff must register an eligible candidate with NCI Central Registration Office (CRO) within 24 hours of signing consent. A registration Eligibility Checklist from the Web site (http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) must be completed and sent via encrypted email to: NCI Central Registration Office (HOIS) (ncicentralregistration-l@mail.nih.gov). After confirmation of eligibility at Central Registration Office, CRO staff will call pharmacy to advise them of the acceptance of the patient on the protocol prior to the release of any investigational agents. Verification of Registration will be forwarded electronically via e-mail to the research team. A recorder is available during non-working hours.  
Off-Study Procedure: Authorized staff must notify the Central Registration Office (CRO)
when a patient is taken off-study. An off-study form from the Web site (http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) main page must be completed and sent via encrypted email to: NCI Central Registration Office (HOIS) (ncicentralregistration-l@mail.nih.gov).
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5 treatment plan

This is an open-label Phase I trial evaluating the combination of ganetespib, Hsp90 inhibitor, and ziv-aflibercept, VEGF-trap, in patients with refractory gastrointestinal carcinomas, nonsquamous non-small cell lung carcinomas, urothelial carcinomas, and sarcomas, whose disease has progressed following at least one line of standard therapy.  
Reported adverse events and potential risks for ganetespib and ziv-aflibercept are described in Section 7. Appropriate dose modifications for ganetespib and ziv-aflibercept are described in Section 6. History and physical examination can be done up to 3 days before the start of a new cycle. Patients will be examined at the Clinical Center on days 1, 8, and 15 of each cycle, prior to treatment. Each cycle is 28 days (± 1 day due to scheduling conflicts). Labs (CBC with differential; serum chemistries) will be performed on days 1, 8, and 15 of each cycle (+/- 1 day during the cycle and up to 3 days before start of a new cycle). Electrocardiogram will be done before each ganetespib administration and approximately 24 hours after drug administration during each week of treatment of the first cycle. For subsequent cycles, electrocardiogram will be done before each ganetespib administration with post-treatment electrocardiogram as clinically indicated. All study participants must have a baseline eye exam by a qualified ophthalmologist within 4 weeks prior to enrollment and as clinically indicated thereafter. CT scans will be performed at baseline, and repeat-imaging scans will be performed every 2 cycles. MRI evaluation of site of disease may be performed in lieu of CT evaluation at the discretion of the principal investigator if it is the opinion of the investigator that this modality would provide a more accurate assessment of disease than a CT would for a given site. The starting dose will start at dose level 1 per dosing schema below. Ganetespib will be dosed based on body surface area (mg/m2). Ziv-aflibercept will be dosed based on body weight
(mg/kg).
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5.1 agent administration 5.1.1 ganetespib

Ganetespib will be administered intravenously, over one hour, weekly, on days 1, 8, and 15 of each 28-day cycle. During the expansion phase, for cycle 1 only, ganetespib will be administered intravenously on days 8 and 15 of the 28-day cycle, with omission of day 1 treatment in order to accommodate tumor biopsies (*see dosing schema below).  
5.1.2 Ziv-aflibercept administration Ziv-aflibercept will be administered intravenously, over one hour, every 2 weeks, on days 1 and 15 of each 28-day cycle.  
| Dose Level         | Ganetespib (IV)   | Ziv-aflibercept (IV)   |
|--------------------|-------------------|------------------------|
| days 1, 8, and 15* | days 1 and 15     |                        |
| -2                 | 80 mg/m2          | 3 mg/kg                |
| -1                 | 100 mg/m2         | 3 mg/kg                |
| 1                  | 100 mg/m2         | 4 mg/kg                |
| 2                  | 150 mg/m2         | 4 mg/kg                |  
Reported adverse events and potential risks are described in Section 7. Appropriate dose modifications are described in Section 6. No investigational or commercial agents or therapies other than those described below may be administered with the intent to treat the patient's malignancy. Due to evidence of increase in QTc interval 24 hours after the dose of ganetespib in a pharmacology study of healthy volunteers (Investigator's Brochure), certain drugs known to be associated with QTc prolongation (Appendix C) should not be used by patients treated with ganetespib. The use of any medication that has the potential for QTc prolongation and has been linked to the occurrence of torsades de pointes is strictly prohibited. **Ondansetron has been associated with QTc prolongation and the** occurrence of torsades de pointes. Therefore it should not be used in patients being treated with ganetespib. The use of all other serotonin 5HT3 antagonists is acceptable (e.g., palonosetron, granisetron, tropisetron).
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5.2 definition of dose-limiting toxicity

Determination of dose-limiting toxicity will be based on toxicities observed in the first cycle of therapy. Dose escalation will proceed within each cohort according to the following scheme. Dose-limiting toxicity (DLT) is defined below:  
| Number of Patients with DLT  at a Given Dose Level   | Escalation Decision Rule                                                                                                                                                                                                                                               |
|------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 0 out of 3                                           | Enter 3 patients at the next dose level.                                                                                                                                                                                                                               |
| ≥2                                                   | Dose escalation will be stopped. This dose level will be declared  the maximally administered dose (highest dose administered).  Three (3) additional patients will be entered at the next lowest  dose level if only 3 patients were treated previously at that dose. |  
| 1 out of 3                                                                | Enter at least 3 more patients at this dose level. - If 0 of these 3 patients experience DLT, proceed to the next  dose level. - If 1 or more of this group suffer DLT, then dose escalation is  stopped, and this dose is declared the maximally administered  dose. Three (3) additional patients will be entered at the next  lowest dose level if only 3 patients were treated previously at  that dose.   |
|---------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| ≤1 out of 6 at highest dose level  below the maximally  administered dose | This is generally the recommended phase 2 dose. At least 6  patients must be entered at the recommended phase 2 dose.                                                                                                                                                                                                                                                                                          |  
Dose limiting toxicity (DLT) is defined as an adverse event that is related (possibly, probably, or definitely) to administration of study drugs and fulfills one of the following criteria.  
5.2.1 Grade ≥ 3 Non-Hematological Toxicity Grade ≥ 3 non-hematological toxicity felt to be related to study medications will be considered dose-limiting with the following clarifications:  
5.2.1.1 Diarrhea Grade 3 will only be considered dose-limiting if it is refractory to treatment as outlined in Section 5.3.2, Supportive Care Guideline, and unable to be corrected to Grade 2 or less within 24 hours. Bloody or Grade 4 diarrhea will be dose-limiting.  
5.2.1.2 Nausea and vomiting Grade 3 will only be considered dose-limiting if it is refractory to anti-emetic therapy and unable to be corrected to Grade 1 or less within 24 hours as outlined in Section 5.3.1.  
5.2.1.3 Rise in creatinine to Grade 3, not corrected to Grade 1 or less within 48 hours with IV fluids will be considered dose-limiting. All Grade 4 rises in creatinine will be dose limiting.  
5.2.1.4 Grade ≥ 3 metabolic toxicities unable to be corrected to Grade 1 or baseline within 48 hours (hypocalcemia or hypercalcemia, hypomagnesemia or hypermagnesemia, and hyponatremia) will be considered dose limiting. For hypokalemia or hyperkalemia, grade ≥ 2 toxicities unable to be corrected to grade 1 or less within 48 hours will be considered dose limiting. Grade 4 metabolic toxicities that are symptomatic will be considered dose limiting regardless of duration or ability to correct.  
5.2.1.5 Any Grade 4 QTc prolongation will be considered dose limiting and will require treatment discontinuation 5.2.2 Grade 4 thrombocytopenia or Grade 3 thrombocytopenia associated with bleeding.
5.2.3 Grade 4 neutropenia ≥ 5 days or febrile neutropenia. 5.2.4 Any degree or anemia, leukopenia in the absence of grade 4 neutropenia ≥ 5 days, or lymphopenia will not be considered dose limiting.  
5.2.5 Any degree of alopecia will not be considered dose limiting. 5.2.6 Grade 3 fatigue of greater than 1 week duration. 5.2.7 Failure to tolerate 100% of the dosing in the first cycle.
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5.3 general concomitant medication and

The predominant toxicity observed in clinical and non-clinical toxicology studies was diarrhea, nausea, vomiting, and abdominal pain. Anemia was more commonly seen with ziv-aflibercept. Weekly blood counts and chemistry panels will be obtained prior to treatment each week. If any weekly evaluation demonstrates grade ≥ 2 neutropenia or thrombocytopenia, treatment will proceed but a repeat hematology assessment will be obtained prior to the next treatment or within a week if the last treatment received was on Day 15 of the cycle. Platelet count must improve to Grade 1 or better and neutrophil count must improve to Grade 2 or better prior to dosing. All patients will be provided with the best available supportive care. All concurrent medications should be documented prior to initiation of treatment, and be periodically reviewed with the patient. Based on in vitro and in vivo data, ganetespib is primarily metabolized (glucuronidated) by UGT1A9 and to a lesser extent by UGT1A1, UGT1A3, and various P450 enzymes. It is also a substrate for P-glycoprotein, but is primarily eliminated through glucuronidation. In in vitro studies, ganetespib is a moderate inhibitor of CYP2C19 and CYP3A4. No dedicated drug-drug interaction studies have been conducted for ziv-aflibercept. Due to the potential for drug-drug interactions with study agents, the case report form must capture the concurrent use of all other drugs, over-the-counter medications, and alternative therapies. Concurrent use of strong P450 inducers or inhibitors will not be permitted. Concurrent use of moderate or strong UGT1A9 inhibitors (e.g., efavirenz and propofol) should be avoided. Concurrent use of inducers of UGTs (e.g., rifampin, phenobarbital, phenytoin, and St. John's Wort) may significantly increase ganetespib clearance, resulting in reduced plasma concentration and should be avoided. Concurrent use of weak P450 inducers, inhibitors, or substrates will be permitted at the discretion of the Principal Investigator. The QTc study in healthy volunteers has reported a modest increase in QT interval 24 hours post ganetespib dose. To date, clinical experience with ganetespib does not support evidence of a clinical safety risk for QTc interval prolongation and Torsade de Pointes or other uncontrolled arrhythmias. However, until the effect of ganetespib on QT interval is completely characterized, patients should avoid concomitant drugs that may cause QTc prolongation, see Appendix C.
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5.3.1 nausea/vomiting

Anti-emetics will not be administered routinely prior to either ganetespib or zivaflibercept (VEGF-Trap). However, if a patient develops nausea/vomiting, antiemetics such as but not limited to prochlorperazine, metoclopramide, 5-HT3 antagonists (**except for ondansetron**), or aprepitant may be given. In addition, if a patient develops nausea and/or vomiting that is Grade 2 or greater, antiemetics may be instituted prophylactically at the discretion of the investigator with subsequent treatments. Nausea and vomiting will be considered refractory if it does not resolve to ≤ Grade 1 within 24 hours.
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5.3.2 diarrhea

Prophylactic anti-motility agents will be permitted with treatment as diarrhea is a known toxicity of both agents and the established recommended dose of ganetespib was established based on prophylactic administration of anti-motility agents. Prophylactic treatment will start 1-2 hours before ganetespib administration. If diarrhea develops despite prophylactic treatment with anti-motility agents and does not have an identifiable cause other than study drug administration, addition of antimotility agents such as tincture of opium (deodorized 10%), Lomotil (diphenoxylate HCl 2.5 mg + atropine sulfate 0.025 mg/tablet) dosed according to package insert, or loperamide 4 mg po after the first unformed stool with 2 mg po with every 2 hours as long as unformed stools continue (4 mg every 4 hours while asleep) may be used. No more than 16 mg of loperamide should be taken during a 24-hour period). This regimen can be repeated for each diarrheal episode and will continue for 12 hours after the first formed stool. Diarrhea will be considered refractory if it does not resolve within 24 hours ≤ to Grade 2 with the above measures. If the patient develops blood or mucus in the stool, dehydration, or hemodynamic instability, or fever along with the diarrhea, anti-diarrheals will be discontinued and the patient will be treated with IV fluids and antibiotics as medically indicated.
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5.3.3 neutropenia

To reduce the risk of severe myelosuppression events, a complete blood count (CBC) should be performed prior to each weekly treatment. Febrile neutropenia is a life-threatening complication requiring hospitalization and urgent broad-spectrum antibiotics, as well as an aggressive search for the source and microbial cause of the episode. Growth factors to prevent neutropenia will not be administered prophylactically. If necessary, they may be administered according to accepted American Society of Clinical Oncology (ASCO) guidelines to allow re-treatment.
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5.3.4 anemia

Symptomatic anemia should be treated with red blood cell transfusion and is recommended if the hemoglobin falls below 8 g/dL. The initiation of erythropoietic therapy for the management of chemotherapy-induced anemia follows the American Society of Hematology/ASCO clinical practice guidelines (http://www.asco.org).
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5.3.5 thrombocytopenia

Thrombocytopenia will be treated conservatively. In the absence of bleeding, or a necessary invasive procedure, platelet transfusions should be given for a platelet count ≤10,000/mm3. If invasive procedure(s) is (are) planned, or the patient develops bleeding, platelet transfusions should be administered in accordance with the standard of practice, usually maintaining a platelet count above 50,000/mm3.
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5.4 duration of therapy

In the absence of treatment delays due to adverse events, treatment may continue until one of the following criteria applies:
- Disease progression - Intercurrent illness that prevents further administration of treatment
- Significant toxicity occurs despite 2 dose reductions as described in Section 6
- Pregnancy - Patient decides to withdraw from the study, or - General or specific changes in the patient's condition render the patient unacceptable for further treatment in the judgment of the investigator.
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5.5 duration of follow up

Patients will be followed for 30 days after the last dose is administered or until one of the following occurs: patient enrolls on another protocol, patient receives standard of care, or death, whichever comes first. The follow-up will consist of a phone call between Days 2730 after the last dose to evaluate adverse events that were ongoing and any new events that might be deemed related to the therapy. Toxicities felt to be possibly, probably, or definitely related to the study drugs that have not resolved or stabilized by Day 30 posttreatment will be followed until stabilization or resolution via phone calls as clinically indicated.
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5.6 criteria for removal from

Patients will be removed from study for one of the following reasons: completed 30-day follow up period or toxicities are unresolved but stabilized, patient enrolls on another protocol, or patient receives standard of care. The reason for study removal and the date the patient was removed must be documented in the medical record and communicated by fax to Central Registration per Section 4.
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6 dosing delays/dose modifications

Toxicities should have resolved to ≤ Grade 2 prior to starting the next cycle. Treatment may be delayed for a maximum of 2 weeks beyond the actual cycle length of 28 days for toxicities that develop and do not resolve as defined above. Beyond two weeks, the patient may remain in the study at the discretion of the PI. Treatment may be delayed for a maximum of ± 1 day during a cycle due to unavoidable scheduling conflicts. If treatment is held during a cycle, that week's treatment will be omitted for the cycle and treatment will proceed with the following week's treatment as scheduled (e.g., if Day 8 ganetespib treatment is held, the next treatment will be Day 15 treatment with both agents).
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6.1 dose modifications

Dose modifications are defined below:  
6.1.1 Grade 2 Drug-related toxicity: No changes will be made to the dose of either ganetespib or ziv-aflibercept for Grade 2 toxicities. Therapy will not be interrupted for Grade 2 hematologic toxicities.  
6.1.2 Grade 3-4 Drug-related non-hematologic toxicities attributed to both drugs: Doses of both ganetespib and ziv-aflibercept will be held until toxicities recover to ≤ Grade 2 or baseline prior to re-initiating treatment at the next lower dose level. Electrolyte abnormalities will not require dose reduction if resolution to Grade 2 or less is documented within 72 hours. Dose modifications (per dosing Schema B) for nausea, vomiting, and diarrhea will be made only if they are refractory to treatment (See Section 5.2).
6.1.3 Grade 3 Drug-related hematologic toxicities: Both ganetespib and ziv-aflibercept will be held until hematologic toxicities, except anemia, lymphopenia, or leucopenia in the absence of Grade 3 or higher neutropenia, have resolved to ≤ Grade 2 prior to re-initiating treatment at the same dose level.  
6.1.4 Grade 4 Drug-related Hematologic Toxicities: Both ganetespib and ziv-aflibercept
(VEGF-Trap) will be held until hematologic toxicities, except anemia, lymphopenia, or leucopenia in the absence of Grade 4 neutropenia, have resolved to ≤ Grade 2 prior to re-initiating treatment at the next lower dose level (per dosing Schema B).
6.1.5 Diarrhea attributed to both ganetespib and ziv-aflibercept: As diarrhea is an expected toxicity for both agents, and as the recommended dose of ganetespib was established in the setting of prophylactic loperamide, prophylactic anti-motility agents will be given 1 to 2 hours before ganetespib administration, and will be repeated every 4 hours for the first 12 hours. If diarrhea occurs despite prophylactic administration of anti-motility agents, supportive care guidelines will follow Section 5.3.2.  
6.1.6 Ocular toxicities attributed to ganetespib: Dose of ganetespib will be held until toxicities recover to < Grade 2 or baseline prior to re-initiating treatment at the next lower dose level per Schema A (above).  
6.1.7 QTc interval prolongation ≥ 500 msec (by Bazett's formula) attributed to ganetespib: Dose of ganetespib will be held until QTc interval is <500 msec or baseline prior to re-initiating treatment at the next lower dose level per Schema A (above). Dose of ziv-aflibercept will not be modified.
6.1.8 Proteinuria attributed to ziv-aflibercept: For proteinuria ≥ 1 grams/24 hours, dose of ziv-aflibercept will be held until proteinuria is < 1 grams/24 hours prior to reinitiating treatment at the same dose level. Dose reduction will occur for proteinuria ≥ 3 grams/ 24 hours or for recurrent proteinuria of ≥ 1 grams/24 hours per Schema C (above). Ziv-aflibercept will be discontinued for proteinuria with gross hematuria. Dose of ganetespib will not be modified for proteinuria.  
| CTCAE V4.0 Grade                              | Action to be taken:   |
|-----------------------------------------------|-----------------------|
| Grade 1 (SBP 120-139 mmHg or  DBP 80-89 mmHg) | Consider increased BP monitoring; Start anti-hypertensive medication if persistent.  For patients without prior antihypertensive therapy, at the  time of the hypertensive episode the initiation of calciumchannel blockers should be considered as a first-intent  treatment. A close monitoring of the BP should be initiated  for further adjustment in treatment, as needed.  For patients already under anti-hypertensive therapy, efforts  should be done to optimize the existing therapy before adding  other agents as required to control the BP.                       |  
| CTCAE V4.0 Grade                                           | Action to be taken:                                                                                                                                                                                        |
|------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade 2 asymptomatic (SBP 140-159 mmHg or  DBP 90-99 mmHg) | Start or add an additional anti-hypertensive agent and continue  ziv-aflibercept per recommendations below.  Close monitoring of BP for further adjustment, as needed.  No dose modification and no delay. |
| Grade 3 (SBP ≥ 160 mmHg or  DBP ≥ 100 mmHg)                | Hold ziv-aflibercept for a maximum of 2 weeks, until recovery  to < Grade 2.  - If BP is controlled within 2 weeks delay: -First episode: re-administer ziv-aflibercept at the same  dose  -Subsequent episode: re-administer ziv-aflibercept with  dose reduction as per Schema C (above).  - If BP is still uncontrolled despite appropriate antihypertensive treatment and after 2 weeks delay, zivaflibercept will be discontinued and patient will go off  study.                                                                                                                                                                                                            |
| Grade 4 (Hypertensive crisis or  Malignant hypertension)   | Discontinue ziv-aflibercept. Patient will go off study.                                                                                                                                                    |  
6.1.10 For any Grade 3-4 arterial thromboembolic event, Grade 3-4 hemorrhage, Grade 34 venous thromboembolic event, GI perforation, reversible posterior leukoencephalopathy syndrome attributed to ziv-aflibercept, ziv-aflibercept will be discontinued and the patient will go off study.  
6.1.11 Infusional reaction attributed to either ganetespib or ziv-aflibercept: Ganetespib contains a surfactant (polysorbate 80) which has been associated with hypersensitivity reactions with other medications administered by infusion. Zivaflibercept has also been associated with an antibody-associated infusional reaction.  
Symptoms have included pruritis, flushing, shortness of breath, chest tightness, dizziness, headache, increased systolic blood pressure and heart rate.  
| Severity of Symptoms Mild transient reaction                                                                                                                                | Give diphenhydramine HCl 25 mg to 50 mg IV,  continue treatment, close monitoring of vitals  q 5 min. for 15 min. after onset of symptoms.                          |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Mild to moderate persistent reaction                                                                                                                                        | Stop treatment; give dexamethasone 10 mg IV and diphenhydramine HCl 25 mg to 50 mg IV; may  resume treatment after recovery of symptoms; premedication indicated for subsequent drug  administration: pre-medication indicated prior to reinitiation: dexamethasone 12 mg PO and  diphenhydramine HCl 25 mg to 50 mg PO  approximately 4 to 6 hours prior to re-challenge                                                                                                                                                                     |
| Severe symptoms (e.g., hypotension  requiring pressor therapy or IV fluids,  angioedema, respiratory distress  requiring bronchodilator therapy, or  generalized urticaria) | Stop treatment; give dexamethasone 10 mg IV and diphenhydramine HCl 25 mg to 50 mg IV; add  bronchodilators as needed; patients may not receive  further treatment. |
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7 adverse events list and

Adverse event (AE) monitoring and reporting is a routine part of every clinical trial. The following list of AEs (Section 7.1) and the characteristics of an observed AE (Section 7.2) will determine whether the event requires expedited reporting (via CTEP-AERS) **in addition** to routine reporting.
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7.1 comprehensive adverse events and

The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of reported and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited reporting to NCI via CTEP-AERS (except as noted below). Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for further clarification. NOTE: Report AEs on the SPEER **ONLY IF** they exceed the grade noted in parentheses next to the AE in the SPEER. If this CAEPR is part of a combination protocol using multiple investigational agents and has an AE listed on different SPEERs, use the lower of the grades to determine if expedited reporting is required.  
| Version 2.0, January 27, 20141                                                                                                                                   |                     |                        |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------|------------------------|
| Adverse Events with Possible  Relationship to Ganetespib (CTCAE 4.0 Term) [n= 423]                                                                               | Specific Protocol   |                        |
| Exceptions to Expedited  Reporting (SPEER)                                                                                                                       |                     |                        |
| Likely (>20%)                                                                                                                                                    | Less Likely (<=20%) | Rare but Serious (<3%) |
| BLOOD AND LYMPHATIC SYSTEM DISORDERS Anemia CARDIAC DISORDERS Atrial fibrillation Cardiac arrest GASTROINTESTINAL DISORDERS Abdominal pain Constipation Diarrhea | Diarrhea (Gr 2)     |                        |
| Nausea                                                                                                                                                           | Nausea (Gr 2)       |                        |
| Vomiting                                                                                                                                                         | Vomiting (Gr 2)     |                        |
| GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS Fatigue                                                                                                     | Fatigue (Gr 2)      |                        |  
Below is the CAEPR for ganetespib. *Frequency is provided based on 423 patients.*  
| HEPATOBILIARY DISORDERS                                                                                       | Hepatic failure                                                                                                    |
|---------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------|
| INFECTIONS AND INFESTATIONS                                                                                   | Sepsis                                                                                                             |
| INVESTIGATIONS                                                                                                | Alanine aminotransferase increased Alkaline phosphatase increased Aspartate aminotransferase increased Weight loss |
| METABOLISM AND NUTRITION DISORDERS Anorexia                                                                   | Anorexia (Gr 2)                                                                                                    |
| Dehydration Hypokalemia Hyponatremia                                                                          |                                                                                                                    |
| NERVOUS SYSTEM DISORDERS Dizziness Headache PSYCHIATRIC DISORDERS Insomnia RENAL AND URINARY DISORDERS        | Acute kidney injury                                                                                                |
| RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS Dyspnea SKIN AND SUBCUTANEOUS TISSUE DISORDERS Rash acneiform |                                                                                                                    |  
1This table will be updated as the toxicity profile of the agent is revised. Updates will be distributed to all Principal Investigators at the time of revision. The current version can be obtained by contacting PIO@CTEP.NCI.NIH.GOV. Your name, the name of the investigator, the protocol and the agent should be included in the e-mail. Also reported on Ganetespib trials but with the relationship to Ganetespib still undetermined: BLOOD AND LYMPHATIC SYSTEM DISORDERS - Febrile neutropenia EYE DISORDERS - Blurred vision; Eye disorders - Other (transient visual impairment) GASTROINTESTINAL DISORDERS - Colonic fistula; Gastrointestinal disorders - Other (gastroenteritis) GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Edema limbs; Infusion related reaction INVESTIGATIONS - Blood bilirubin increased; Cardiac troponin I increased; Electrocardiogram QT corrected interval prolonged; GGT increased; Investigations - Other (blood lactate dehydrogenase increased); Lipase increased; Lymphocyte count decreased; Neutrophil count decreased; Platelet count decreased; Serum amylase increased; White blood cell decreased METABOLISM AND NUTRITION DISORDERS - Hyperkalemia; Hyperuricemia; Hypophosphatemia MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Back pain; Musculoskeletal and connective tissue disorder - Other (muscle spasms); Pain in extremity NERVOUS SYSTEM DISORDERS - Syncope PSYCHIATRIC DISORDERS - Confusion RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Cough VASCULAR DISORDERS - Hypertension Note: Ganetespib 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.
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7.2 comprehensive adverse events and

Frequency is provided based on 811 patients. Below is the CAEPR for Ziv-aflibercept (VEGFTrap, AVE 0005).  
| Version 2.6, November 24, 20151                                                    |                                                                                                                          |                        |
|------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------|------------------------|
| Adverse Events with Possible                                                       |                                                                                                                          |                        |
| Relationship to Ziv-aflibercept (VEGF-Trap, AVE 0005) (CTCAE 4.0 Term) [n= 811]    | Specific Protocol Exceptions to  Expedited Reporting (SPEER)                                                             |                        |
| Likely (>20%)                                                                      | Less Likely (<=20%)                                                                                                      | Rare but Serious (<3%) |
| BLOOD AND LYMPHATIC SYSTEM DISORDERS Anemia                                        | Anemia (Gr 2)                                                                                                            |                        |
| Febrile neutropenia Hemolytic uremic syndrome Thrombotic thrombocytopenic  purpura |                                                                                                                          |                        |
| CARDIAC DISORDERS                                                                  | Chest pain - cardiac Myocardial infarction Restrictive cardiomyopathy Cardiac disorders - Other  (intracardiac thrombus) |                        |
| GASTROINTESTINAL DISORDERS Abdominal pain                                          | Abdominal pain (Gr 2)                                                                                                    |                        |
| Anal mucositis Constipation                                                        | Constipation (Gr 2)                                                                                                      |                        |
| Diarrhea                                                                           | Diarrhea (Gr 2)                                                                                                          |                        |
| Gastrointestinal fistula2 Gastrointestinal perforation3                            |                                                                                                                          |                        |
| Mucositis oral                                                                     |                                                                                                                          |                        |
| Nausea                                                                             | Nausea (Gr 2)                                                                                                            |                        |
| Vomiting                                                                           | Vomiting (Gr 2)                                                                                                          |                        |
| GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS Edema limbs                   | Edema limbs (Gr 2)                                                                                                       |                        |
| Fatigue                                                                            | Fatigue (Gr 3)                                                                                                           |                        |
| Fever                                                                              | Fever (Gr 2)                                                                                                             |                        |  
| Adverse Events with Possible                                                                                                                                                                                                                                                                                           |                                                              |                        |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------|------------------------|
| Relationship to Ziv-aflibercept (VEGF-Trap, AVE 0005) (CTCAE 4.0 Term) [n= 811]                                                                                                                                                                                                                                        | Specific Protocol Exceptions to  Expedited Reporting (SPEER) |                        |
| Likely (>20%)                                                                                                                                                                                                                                                                                                          | Less Likely (<=20%)                                          | Rare but Serious (<3%) |
| Pain                                                                                                                                                                                                                                                                                                                   |                                                              |                        |
| IMMUNE SYSTEM DISORDERS Allergic reaction INFECTIONS AND INFESTATIONS Infection4 INJURY, POISONING AND PROCEDURAL COMPLICATIONS Wound complication Wound dehiscence INVESTIGATIONS Alanine aminotransferase  increased Alkaline phosphatase increased Aspartate aminotransferase  increased Lymphocyte count decreased | Lymphocyte count decreased (Gr 4)                            |                        |
| Neutrophil count decreased                                                                                                                                                                                                                                                                                             | Neutrophil count decreased (Gr 4)                            |                        |
| Platelet count decreased                                                                                                                                                                                                                                                                                               | Platelet count decreased (Gr 4)                              |                        |
| Weight loss White blood cell decreased                                                                                                                                                                                                                                                                                 | White blood cell decreased (Gr 2)                            |                        |
| METABOLISM AND NUTRITION DISORDERS Anorexia                                                                                                                                                                                                                                                                            | Anorexia (Gr 2)                                              |                        |
| Dehydration                                                                                                                                                                                                                                                                                                            |                                                              |                        |
| MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS Arthralgia                                                                                                                                                                                                                                                             | Arthralgia (Gr 2)                                            |                        |
| Back pain Myalgia                                                                                                                                                                                                                                                                                                      | Myalgia (Gr 2)                                               |                        |
| NERVOUS SYSTEM DISORDERS Dizziness Headache                                                                                                                                                                                                                                                                            | Headache (Gr 3)                                              |                        |
| Ischemia cerebrovascular                                                                                                                                                                                                                                                                                               | Ischemia cerebrovascular (Gr 2)                              |                        |
| Reversible posterior  leukoencephalopathy syndrome Transient ischemic attack                                                                                                                                                                                                                                           |                                                              |                        |
| RENAL AND URINARY DISORDERS                                                                                                                                                                                                                                                                                            | Acute kidney injury                                          |                        |
| Proteinuria                                                                                                                                                                                                                                                                                                            | Proteinuria (Gr 3)                                           |                        |
| Renal disorders - Other  (nephrotic syndrome)                                                                                                                                                                                                                                                                          |                                                              |                        |
| REPRODUCTIVE SYSTEM AND BREAST DISORDERS Genitourinary system fistula5 RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS Cough                                                                                                                                                                                           | Cough (Gr 2)                                                 |                        |
| Dyspnea                                                                                                                                                                                                                                                                                                                | Dyspnea (Gr 3)                                               |                        |
| Pharyngolaryngeal pain                                                                                                                                                                                                                                                                                                 |                                                              |                        |
| Voice alteration                                                                                                                                                                                                                                                                                                       | Voice alteration (Gr 2)                                      |                        |  
| Adverse Events with Possible                                                                                                                                           |                                                              |                        |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------|------------------------|
| Relationship to Ziv-aflibercept (VEGF-Trap, AVE 0005) (CTCAE 4.0 Term) [n= 811]                                                                                        | Specific Protocol Exceptions to  Expedited Reporting (SPEER) |                        |
| Likely (>20%)                                                                                                                                                          | Less Likely (<=20%)                                          | Rare but Serious (<3%) |
| Respiratory, thoracic, and  mediastinal disorders - Other  (rhinorrhea)                                                                                                |                                                              |                        |
| SKIN AND SUBCUTANEOUS TISSUE DISORDERS Alopecia Palmar-plantar erythrodysesthesia  syndrome Rash maculo-papular Skin hyperpigmentation VASCULAR DISORDERS Hypertension | Hypertension (Gr 3)                                          |                        |
| Thromboembolic event                                                                                                                                                   | Thromboembolic event (Gr 3)                                  |                        |
| Vascular disorders - Other                                                                                                                                             | Vascular disorders - Other (hemorrhage)6                     |                        |
| (hemorrhage)6                                                                                                                                                          | (Gr 2)                                                       |                        |  
1This table will be updated as the toxicity profile of the agent is revised. Updates will be distributed to all Principal Investigators at the time of revision. The current version can be obtained by contacting PIO@CTEP.NCI.NIH.GOV. Your name, the name of the investigator, the protocol and the agent should be included in the e-mail.  
2Gastrointestinal fistulas may include: Anal fistula, Colonic fistula, Duodenal fistula, Esophageal fistula, Gastric fistula, Gastrointestinal fistula, Rectal fistula, and other sites under the GASTROINTESTINAL DISORDERS SOC.  
3Gastrointestinal perforation imay include: Colonic perforation, Duodenal perforation, Esophageal perforation, Gastric perforation, Ileal perforation, Jejunal perforation, Rectal perforation, and Small intestinal perforation under the GASTROINTESTINAL DISORDERS SOC.  
4Infection may include any of the 75 infection sites under the INFECTIONS AND INFESTATIONS SOC.  
5Genitourinary fistulas may include: female genital tract fistula, uterine fistula, and vaginal fistula.  
6The majority of hemorrhage events were mild. Major events, defined as symptomatic bleeding in a critical area or organ (e.g., eye, GI hemorrhage, GU hemorrhage, respiratory hemorrhage), and nervous system [including fatal intracranial hemorrhage and cerebrovascular accident] have been reported.  
Adverse events reported on Ziv-aflibercept (VEGF-Trap, AVE 0005) trials but for which there is insufficient evidence to suggest that there was a reasonable possibility that Ziv-aflibercept (VEGF-Trap, AVE 0005) caused the event.  
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other (hemoglobin increased); Hemolysis CARDIAC DISORDERS - Acute coronary syndrome; Cardiac disorders - Other (left ventricular diastolic dysfunction); Heart failure; Left ventricular systolic dysfunction; Pericarditis; Supraventricular tachycardia
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ear and labyrinth disorders -

EYE DISORDERS - Blurred vision; Extraocular muscle paresis; Eye disorders - Other (blindness transient); Eye disorders - Other (diplopia); Vitreous hemorrhage GASTROINTESTINAL DISORDERS - Abdominal distension; Colitis; Dental caries; Dry mouth; Dyspepsia; Dysphagia; Esophageal pain; Flatulence; Gastritis; Gastrointestinal disorders - Other (early satiety); Gastrointestinal disorders - Other (enteric fistula); Gastrointestinal disorders - Other (eructation); Gastrointestinal disorders - Other (gastrointestinal necrosis); Gastrointestinal disorders - Other (hiatal hernia);Gastrointestinal disorders - Other (intestinal ischemia); Gastrointestinal disorders - Other
(pneumatosis intestinalis); Gastrointestinal disorders - Other (peritonitis); Gingival pain; Hemorrhoids; Ileus; Oral pain; Rectal mucositis; Rectal ulcer; Small intestinal mucositis; Small intestinal obstruction GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Edema face; Edema trunk; Facial pain; Infusion related reaction; Injection site reaction; Non-cardiac chest pain HEPATOBILIARY DISORDERS - Cholecystitis INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Biliary anastomotic leak; Gastric anastomotic leak; Vascular access complication INVESTIGATIONS - Activated partial thromboplastin time prolonged; Blood bilirubin increased; Creatinine increased; Ejection fraction decreased; GGT increased; Investigations - Other (elevated LDH) METABOLISM AND NUTRITION DISORDERS - Hypercalcemia; Hyperglycemia; Hyperkalemia; Hypoalbuminemia; Hypocalcemia; Hypoglycemia; Hypokalemia; Hypomagnesemia; Hyponatremia; Hypophosphatemia MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthritis; Avascular necrosis; Chest wall pain; Generalized muscle weakness; Head soft tissue necrosis; Joint range of motion decreased; Muscle weakness upper limb; Musculoskeletal and connective tissue disorder - Other (muscle spasms);
Musculoskeletal and connective tissue disorder - Other (musculoskeletal stiffness); Musculoskeletal and connective tissue disorder - Other (rotator cuff tear); Myositis; Neck pain; Osteonecrosis of jaw; Pain in extremity; Pelvic soft tissue necrosis NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Neoplasms benign, malignant and unspecified (incl cysts and polyps) - Other (tumor hemorrhage) NERVOUS SYSTEM DISORDERS - Amnesia; Ataxia; Cognitive disturbance; Dysgeusia; Encephalopathy; Extrapyramidal disorder; Leukoencephalopathy; Memory impairment; Paresthesia; Peripheral sensory neuropathy; Seizure; Syncope; Vagus nerve disorder PSYCHIATRIC DISORDERS - Anxiety; Confusion; Depression; Insomnia; Psychiatric disorders - Other
(mental status change); Psychosis REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Irregular menstruation RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Hypoxia; Laryngeal mucositis; Nasal congestion; Pharyngeal mucositis; Pleural effusion; Pneumonitis; Pneumothorax; Pulmonary fibrosis; Respiratory, thoracic and mediastinal disorders - Other (nasal dryness); Respiratory, thoracic and mediastinal disorders - Other (tracheal fistula); Respiratory, thoracic and mediastinal disorders - Other
(septal perforation); Tracheal mucositis SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Dry skin; Hyperhidrosis; Nail loss; Rash acneiform; Skin and subcutaneous tissue disorders - Other (hyperemia); Skin ulceration VASCULAR DISORDERS - Hematoma; Hypotension; Peripheral ischemia; Phlebitis Note: Ziv-aflibercept (VEGF-Trap) 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.
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safety monitoring for 89zr-panitumumab pet/ct

Panitumumab was well tolerated in previous clinical trial studies where doses were much higher. The most common adverse events related to panitumumab at doses of 6 mg/kg every 14 days were skin rash with variable presentation, hypomagnesemia, paronychia, fatigue, abdominal pain, nausea, and diarrhea. The most serious events that have been reported were fibrosis, severe dermatologic toxicity complicated by infectious sequelae and septic death, infusion reactions, abdominal pain, hypomagnesemia, nausea, vomiting, and constipation.  
No adverse events are expected for the 89Zr-panitumumab PET/CT imaging study. The dose of panitumumab anticipated for this study will be <1 mg for a single injection. The radiation exposure associated with this study is comparable to the dose for the other widely used clinical nuclear medicine procedures.  
Subjects will be monitored for adverse events during each 89Zr-panitumumab PET/CT imaging session and for one month post injection. Adverse events are defined as any signs of illness or symptoms that have appeared or worsened since the infusion of the 89Zr-panitumumab. The infusion and imaging procedure will be terminated in any patient who exhibits anaphylaxis, significant hypotension (systolic blood pressure less than 80 mmHg on 2 measurements obtained within 1-2 minutes of each other), dyspnea, or chest pain. At the beginning and end of the imaging session, subjects will be questioned regarding any appearance or change in signs and symptoms. The adverse events to be specifically monitored during the infusion include localized discomfort at the IV injection site, pain, respiratory difficulties, flushing, dizziness, itching/rash, and any other symptoms that could be secondary to anaphylactic reaction. If one participant develops any grade
≥ 2 AE reaction attributable to the imaging agent, the 89Zr-panitumumab study will be placed on hold and discussed with the study sponsor. Injection site monitoring will be performed prior to administration of the imaging agent and at various time points post-injection over a 24-hr period. Any abnormal findings during this period will be recorded as an AE on the research record. Abnormal injection site findings include, but are not limited to, radiopharmaceutical extravasation, bleeding, hematoma, redness, and infection. Any abnormal finding that is new or represents a worsening from baseline is an AE. Once AE notification is decided upon, the procedure for AE notification will be followed, as described below.
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7.3 adverse event characteristics

- **CTCAE term (AE description) and grade:** The descriptions and grading scales found in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 4.0. A copy of the CTCAE version 4.0 can be downloaded from the CTEP Web site http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
Attribution of the AE:
1. Definite - The AE *is clearly related* to the study treatment. 2. Probable - The AE *is likely related* to the study treatment. 3. Possible - The AE *may be related* to the study treatment. 4. Unlikely - The AE *is doubtfully related* to the study treatment. 5. Unrelated - The AE *is clearly NOT related* to the study treatment.
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7.4 expedited adverse event reporting

7.4.1 Expedited AE reporting for this study must use CTEP-AERS (CTEP Adverse Event Expedited Reporting System), accessed via the CTEP Web site (http://ctep.cancer.gov). The reporting procedures to be followed are presented in the "NCI Guidelines for Investigators: Adverse Event Reporting Requirements for DCTD (CTEP and CIP) and DCP INDs and IDEs" which can be downloaded from the CTEP Web site (http://ctep.cancer.gov). These requirements are briefly outlined in the tables below (Section 7.3.2). In the rare occurrence when Internet connectivity is lost, a 24-hour notification is to be made to CTEP by telephone at 301-897-7497. Once Internet connectivity is restored, the 24-hour notification phoned in must be entered electronically into CTEP-AERS by the original submitter at the site.  
7.4.2 Expedited Reporting Guidelines Use the NCI protocol number and the protocol-specific patient ID assigned during trial registration on all reports. Note: A death on study requires both routine and expedited reporting regardless of causality, unless as noted below. Attribution to treatment or other cause must be provided. Death due to progressive disease should be reported as Grade 5 "Neoplasms benign, malignant and unspecified (incl cysts and polyps) - Other (Progressive Disease)" under the system organ class (SOC) of the same name. Evidence that the death was a manifestation of underlying disease (e.g., radiological changes suggesting tumor growth or progression: clinical deterioration associated with a disease process) should be submitted.  
Phase 1 and Early Phase 2 Studies: Expedited Reporting Requirements for Adverse Events that Occur on Studies under an IND/IDE within 30 Days of the Last Administration of the Investigational Agent/Intervention 1, 2  
6) Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization may be considered serious when, based upon 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. (FDA, 21 CFR 312.32; ICH E2A and ICH E6).  
ALL **SERIOUS** adverse events that meet the above criteria MUST be immediately reported to the NCI via CTEPAERS within the timeframes detailed in the table below.  
| Hospitalization                            | Grade 1 and Grade 2 Timeframes   | Grade 3-5 Timeframes    |
|--------------------------------------------|----------------------------------|-------------------------|
| Resulting in Hospitalization  ≥ 24 hrs     | 10 Calendar Days                 | 24-Hour 5 Calendar Days |
| Not resulting in Hospitalization  ≥ 24 hrs | Not required                     |                         |  
NOTE: Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR.   
  
Effective Date: May 5, 2011
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7.4.3 protocol-specific expedited ae reporting

For this protocol only, certain AEs/grades are exceptions to the Expedited Reporting Guidelines and do not require expedited reporting (i.e., CTEP-AERS). These are any grade lymphopenia, any grade alopecia, Grade 2 electrolyte (sodium, potassium, phosphorous, magnesium) abnormalities, Grade 2 anemia, Grade 2 hypoalbuminemia, Grade 2 hyperglycemia, Grade 2 INR, Grade 2 PTT, and Grade 2 hyperuricemia will NOT be reported through CTEP-AERS but will be reported in the routine data submissions.
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7.4.4 pregnancy fetal death and

NOTE: When submitting CTEP-AERS reports for "Pregnancy", "Pregnancy loss",
or "Neonatal loss", the Pregnancy Information Form should also be completed for patients who became pregnant on study, and faxed along with any additional medical information to **301-230-0159.** The potential risk of exposure of the fetus to the investigational agent(s) or chemotherapy agent(s) should be documented in the "Description of Event" section of the CTEP-AERS report.
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7.4.4.1 pregnancy

- Because patients who become pregnant on study risk intrauterine exposure of the fetus to agents which may be teratogenic, DCTD/DCP is requesting that pregnancy should be reported in an expedited manner via CTEP-AERS as Grade 3 "Pregnancy, puerperium and perinatal conditions - *Other* (pregnancy)" under the *Pregnancy, puerperium and perinatal conditions* SOC.  
- The pregnancy outcome for patients on study should be reported via CTEPAERS at the time the outcome becomes known, accompanied by the same Pregnancy Report Form used for the initial report.
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7.4.4.2 fetal death

- Fetal death is defined in CTCAE as "A disorder characterized by death in utero; failure of the product of conception to show evidence of respiration, heartbeat, or definite movement of a voluntary muscle after expulsion from the uterus, without possibility of resuscitation."
- Any fetal death should be reported expeditiously, as Grade 4 "Pregnancy, puerperium and perinatal conditions - Other (pregnancy loss)" under the Pregnancy, puerperium and perinatal conditions SOC.  
- A fetal death should NOT be reported as "Fetal death," a Grade 5 event under the Pregnancy, puerperium and perinatal conditions SOC, as currently CTEP-AERS recognizes this event as a patient death.
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7.4.4.3 death neonatal

- Neonatal death, defined in CTCAE as "A disorder characterized by cessation of life occurring during the first 28 days of life" that is felt by the investigator to be at least possibly due to the investigational agent/intervention, should be reported expeditiously.  
- A neonatal death should be reported expeditiously as Grade 4 "General disorders and administration - Other (neonatal loss)" under the General disorders and administration SOC.  
- Neonatal death should NOT be reported as "Death neonatal" under the General disorders and administration SOC, a Grade 5 event. If reported as such, the CTEP-AERS interprets this as a death of the patient being treated.  
7.4.5 NCI-IRB Expedited Reporting of Adverse Events, Unanticipated Problems, and Deaths
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7.4.5.1 definitions adverse event

An adverse event is defined as any reaction, side effect, or untoward event that occurs during the course of the clinical trial associated with the use of a drug in humans, whether or not the event is considered related to the treatment or clinically significant. For this study, AEs will include events reported by the patient, as well as clinically significant abnormal findings on physical examination or laboratory evaluation. A new illness, symptom, sign or clinically significant laboratory abnormality or worsening of a pre-existing condition or abnormality is considered an AE. All AEs must be recorded on the AE case report form unless otherwise noted above in Section 7.3.3. All AEs, including clinically significant abnormal findings on laboratory evaluations, regardless of severity, will be followed until satisfactory resolution. AEs should be reported up to 30 days following the last dose of study drug. An abnormal laboratory value will be considered an AE if the laboratory abnormality is characterized by any of the following:  
- Results in discontinuation from the study
- Is associated with clinical signs or symptoms - Requires treatment or any other therapeutic intervention
- Is associated with death or another serious adverse event, including hospitalization
- Is judged by the Investigator to be of significant clinical impact
- If any abnormal laboratory result is considered clinically significant, the investigator will provide details about the action taken with respect to the test drug and about the patient's outcome.
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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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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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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.
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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.
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disability

A substantial disruption of a person's ability to conduct normal life functions.
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life-threatening adverse drug experience

Any adverse event or suspected adverse reaction that places the patient or subject, in the view of the investigator or sponsor, at immediate risk of death from the reaction as it occurred, i.e., it does not include a reaction that had it occurred in a more severe form, might have caused death.
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non-compliance (nih definition)

The failure to comply with applicable NIH Human Research Protections Program (HRPP) policies, IRB requirements, or regulatory requirements for the protection of human research subjects.
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unanticipated problem

Any incident, experience, or outcome that:
- Is unexpected in terms of nature, severity, or frequency in relation to
(a) the research risks that are described in the IRB-approved research protocol and informed consent document; Investigator's Brochure or other study documents, and (b) the characteristics of the subject population being studied; AND
- Is related or possibly related to participation in the research; AND
- Suggests that the research places subjects or others at a g*reater risk of harm*
(including physical, psychological, economic, or social harm) than was previously known or recognized.
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7.5 nci-irb and nci clinical

7.5.1 NCI-IRB Expedited Reporting of Unanticipated Problems and Deaths The Protocol PI will report in the NIH Problem Form to the NCI-IRB and NCI Clinical Director:
- All deaths, except deaths due to progressive disease
- All Protocol Deviations
- All Unanticipated Problems
- All non-compliance Reports must be received within 7 days of PI awareness via iRIS.  
7.5.2 NCI-IRB Requirements for PI Reporting at Continuing Review For reporting of adverse events at time of continuing review, the NCI-IRB requires a summary report of adverse events that have occurred on the protocol since the previous continuing review and in aggregate. The method of presentation should provide the NCI-IRB with the information necessary to clearly identify risks to participants and to make a risk:benefit determination. Please sort the events by the system organ class and by grade. The summary report is based on the following guidance: any unexpected severity and/or unexpected frequency of expected events needs to be reported and interpreted in relation to the risk:benefit of study participants in the narrative. Please use following table for reporting adverse events at time of CR:  
| System                                      | CTCAE   | Grade         | # of Events   | Total #     | Attribution   | Serious?   | Unexpected?   |
|---------------------------------------------|---------|---------------|---------------|-------------|---------------|------------|---------------|
| Organ Class                                 | Term    | since last CR | of Events     | to Research |               |            |               |
| The protocol PI will report to the NCI-IRB: |         |               |               |             |               |            |               |  
1. A summary of all protocol deviations in a tabular format to include the date the deviation occurred, a brief description of the deviation and any corrective action.  
2. A summary of any instances of non-compliance 3. A tabular summary of the following adverse events:
- All Grade 2 **unexpected** events that are possibly, probably or definitely related to the research;
- All Grade 3 and 4 events that are possibly, probably or definitely related to the research;
- All Grade 5 events regardless of attribution;
- All Serious Events regardless of attribution.
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7.5.3 nci-irb reporting of ind

Only IND Safety Reports that require a sponsor recommended change to the protocol or the consent form or in the opinion of the PI increase risks to study participants will need to be reported to the NCI IRB.
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7.6 secondary malignancy

A *secondary malignancy* is a cancer caused by treatment for a previous malignancy (e.g.,
treatment with investigational agent/intervention, radiation, or chemotherapy). A secondary malignancy is not considered a metastasis of the initial neoplasm. CTEP requires all secondary malignancies that occur following treatment with an agent under an NCI IND/IDE be reported via CTEP-AERS. Three options are available to describe the event:
- Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia [AML])
- Myelodysplastic syndrome (MDS)
- Treatment-related secondary malignancy Any malignancy possibly related to cancer treatment (including AML/MDS) should also be reported via the routine reporting mechanisms outlined in each protocol.
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7.7 second malignancy

A second malignancy is one unrelated to the treatment of a prior malignancy (and is **NOT** a metastasis from the initial malignancy). Second malignancies require **ONLY** routine reporting via CDUS unless otherwise specified.
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8 pharmaceutical information

A list of the adverse events and potential risks associated with the investigational administered in this study can be found in Section 7.
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8.1 ganetespib (nsc 777169)

| Other Names:     | STA-9090                                                                                                                                                                                                                                                                                                                                         |
|------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Chemical Name:   | 5-[2,4-dihydroxy-5-(1-methylethyl)phenyl]-2,4-dihydro-4-(1-methyl1H-indol-5-yl)-3H-1,2,4-triazole-3-one                                                                                                                                                                                                                                                                                                                                                  |
| Classification:  | Hsp90 inhibitor                                                                                                                                                                                                                                                                                                                                  |
| CAS Registry No. | 888216-25-9                                                                                                                                                                                                                                                                                                                                      |
| Mode of Action:  | Ganetespib inhibits heat shock protein 90 (Hsp90) chaperone activity  by binding to its N-terminal adenosine triphosphate pocket resulting  in the proteosomal degradation of oncogenic client proteins. Client  protein degradation results in induction of cell cycle arrest and  apoptosis, thereby inhibiting tumor growth.                  |
| Mol. Formula:    | C20H20N4O3                                                                                                                                                                                                                                                                                                                                       |
| Mol. Weight:     | 364.40 g/mol                                                                                                                                                                                                                                                                                                                                     |
| Description:     | Ganetespib is a novel triazolone heterocyclic compound, provided as a  concentrate solution and is a clear, colorless-to-pale-yellow solution.                                                                                                                                                                                                   |
| How Supplied:    | Synta Pharmaceuticals supplies ganetespib and PMB, CTEP, DCTD  distributes as 300 mg vials, 25 mg/mL, (total volume is 12.84 mL  with 0.84 mL overfill). The solution is a clear, colorless-to-pale  yellow solution free of visible particles in a polyethylene glycol 300,  polysorbate 80 and dehydrated alcohol cosolvent-surfactant system. |
| Storage:         | The 300 mg vials should be stored at 20°C - 25°C (68°F - 77°F) with  excursions allowed between 15°C and 30°C (59°F and 86°F) (USP  Controlled Room Temperature), protected from light.                                                                                                                                                          |
| Stability:       | Stability of the intact vials is ongoing. If not used immediately, store the prepared IV solution at controlled  room temperature, protect from light. Do not refrigerate the IV  solution. The IV solution is to be administered over 1 hour and must  be completed within 4 hours of finishing the preparation.                                |
| Preparation:     | Use an empty non-PVC and non-DEHP IV bag to prepare ganetespib IV  solution to a final concentration between 0.1 and 1.1 mg/mL. For  consistency, 500 mL D5W should be the final volume of the prepared IV                                                                                                                                       |  
1. Add the calculated volume (mL) of D5W into the non-PVC, nonDEHP empty IV bag 2. Next, add the calculated amount (mL) of ganetespib. Note:
ganetespib solution is viscous. Use a 16G or 18G needle to withdraw the calculated amount of ganetespib.  
3. Gently invert the IV bag approximately 10 times to completely mix  
the IV solution  
| the IV solution                                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
|-------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 4. Visually inspect the final IV solution. The solution must be clear  and free of visible particles. Do not use it if the IV solution is not  clear. |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
| Route of                                                                                                                                              | Intravenous.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
| Administration: Method of                                                                                                                             | 1. Set up the infusion pump to deliver the 500 mL ganetespib infusion                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |
| Administration:                                                                                                                                       | solution over 60 minutes.  Note: Use of Vascular Access Devices: Based on preclinical data, use  of vascular access devices (VADs) (such as ports and peripherallyinserted central catheters [PICCS]) containing silicone catheters are  permitted. Use of VADs with catheters made of any material other  than silicone is not allowed. Following ganetespib administration through a VAD, care should be  taken to flush the line after each dose of study drug. Please follow  routine clinical practice for care of patients utilizing VADs. 2. At the end of the infusion, the IV tubing must be flushed with D5W  to ensure complete delivery of the required dose of ganetespib. The  infusion rate of the D5W flush should be at the same rate as the drug  infusion.  3. Dispose of used IV bags, tubing and used drug vials per institutional  guidelines.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
| Potential Drug                                                                                                                                        | In vitro and in vivo, ganetespib is primarily metabolized (glucuronidated)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
| Interaction:                                                                                                                                          | by UGT1A9 and to a lesser extent by UGT1A1, UGT1A3, and various  P450 enzymes. It is also a substrate for P-glycoprotein, but is primarily  eliminated through glucuronidation. In vitro, ganetespib is a moderate  inhibitor of CYP2C19 and CYP3A4, but has not demonstrated any  clinically significant drug interactions to date, including a study of its effect  on omeprazole (a sensitive CYP2C19 substrate) pharmacokinetics in  healthy human volunteers. Avoid concomitant administration with  moderate or strong UGT1A9 inhibitors, which include efavirenz and  propofol. The concomitant use of inducers of UGTs (e.g., rifampin,  phenobarbital, phenytoin, various herbal preparations including St. John  Wort) might significantly increase ganetespib clearance, resulting in  reduced plasma concentrations. |  
| The QTc study in healthy volunteers has reported a modest increase in QT  interval 24 hours post ganetespib dose. To date, clinical experience with  ganetespib does not support an evidence of a clinical safety risk for QTc  interval prolongation and Torsade de Pointes or other uncontrolled  arrhythmias. However, until the effect of ganetespib on QT interval is  completely characterized, patients should avoid concomitant drugs that  may cause QTc interval prolongation while receiving ganetespib, see  Appendix C.   |                                                                                                                                                                                                                                                                                                                                                                                |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Availability                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | Ganetespib is an investigational agent supplied to investigators by  DCTD, NCI. Ganetespib is provided to the NCI under a Collaborative  Agreement between the Pharmaceutical Collaborator and DCTD, NCI.                                                                                                                                                                      |
| 8.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | Ziv-aflibercept (NSC 724770)                                                                                                                                                                                                                                                                                                                                                   |
| Other Names:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | AVE0005; Zaltrap                                                                                                                                                                                                                                                                                                                                                               |
| Classification:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | Recombinant humanized fusion protein (Chinese hamster ovary  source)                                                                                                                                                                                                                                                                                                           |
| Mode of Action:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | The cytokine VEGF binds to and activates VEGFR1 and VEGFR2 on  the vascular endothelium, promoting new vessel formation. VEGF  Trap is a soluble recombinant decoy receptor that binds and inactivates  extravascular and hematologic VEGF. It reduces tumor vasculature  density, available nutrient supply, and tissue matrix components  escaping from leaky tumor vessels. |
| Molecular Weight:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      | 115 kDa                                                                                                                                                                                                                                                                                                                                                                        |
| Approximate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | At least 100 mg/mL water (with 5mM Na phosphate, 5 mM Na citrate,                                                                                                                                                                                                                                                                                                              |
| Solubility:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | 100 mM NaCl, 0.004-0.08% Polysorbate 20) at 5°C and 25°C.                                                                                                                                                                                                                                                                                                                      |
| Description:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | The fusion protein ziv-aflibercept (VEGF Trap) is comprised of  2 portions of human VEGF receptor extracellular domains, VEGFR1  and VEGFR2, fused to the Fc portion of human IgG1.                                                                                                                                                                                            |
| How Supplied:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          | Ziv-aflibercept (VEGF Trap) is supplied by Sanofi-Aventis  Pharmaceuticals and distributed by CTEP, DCTD, NCI. Zivaflibercept (VEGF Trap) is a sterile, nonpyrogenic, colorless to pale  yellow solution in vials of 200 mg (8 mL) at a concentration of 25  mg/mL. The solution contains the following excipients: sucrose,  sodium chloride, sodium citrate dehydrate, citric acid monohydrate,  polysorbate 20, sodium phosphate dibasic heptahydrate, sodium  phosphate monobasic monohydrate, and water for injection. The pH of  ziv-aflibercept (VEGF Trap) is 6.2. The product is packaged in a type  1, clear borosilicate glass vial closed with a flanged cap with tear-off  lid and inserted sealing disc, Flurotec® (PTFE) coated.                                                                                                                                                                                                                                                                                                                                                                                |
| Preparation:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | Prior to infusion, the VEGF Trap dosage form must be diluted directly                                                                                                                                                                                                                                                                                                          |  
| Clinical Center #14-C-0150   | into infusion bags of 0.9% sodium chloride solution or 5% dextrose.  The concentration of the diluted solution can range between 0.6 and 8  mg/mL. The pH of the diluted solution is about 6.2.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
|------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Storage:                     | Intact vials are stored at 2°C to 8°C (Refrigerated condition).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
| Stability:                   | Shelf-life stability studies of intact vials are ongoing. Ziv-aflibercept's  provisional shelf-life is up to 36 months at 2°C to 8°C. Caution: The sterile single use vials contain no antibacterial  preservatives. Discard remaining agent 8 hours after initial entry.  Ziv-aflibercept (VEGF Trap) diluted to a concentration of 0.6 to 8  mg/mL in 0.9% NaCl or 5% dextrose has demonstrated chemical and  physical stability for up to 24 hours under refrigerated conditions (2°C  to 8°C) or up to 8 hours at ambient temperature (approximately 25°C)  in infusion bags made of polyvinyl chloride (PVC) containing di(2- ethylhexyl)phthalate (DEHP) or polyolefin (PVC free DEHP free), or  polyethylene. |
| Route of                     | Intravenous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |
| Administration: Method of    | Administer ziv-aflibercept (VEGF Trap) intravenously over 1 hour into                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |
| Administration:              | a peripheral vein or central venous catheter using gravity, an infusion  pump, or syringe pump. The infusion should not exceed two hours at  room temperature (approximately 25°C).  Ziv-aflibercept (VEGF Trap) may be administered using infusion  tubing made of PVC containing DEHP, polyethylene lined PVC,  DEHP free PVC containing tris (2-ethylhexyl) trimellitate (TOTM),  polypropylene, or polyurethane, or polybutadiene.  The infusion set must contain a 0.2 micron polyethersulfone inline  filter. Polyvinylidene fluoride (PVDF) filters or Nylon filters should  not be used.                                                                                                                     |
| Availability                 | Ziv-aflibercept is an investigational agent supplied to investigators by  DCTD, NCI. Ziv-aflibercept is provided to the NCI under a  Collaborative Agreement between the Pharmaceutical Collaborator and  DCTD, NCI.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
| 8.3                          | 89Zr-labeled Panitumumab 89Zr]-DFO-panitumumab or 89Zr-panitumumab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
| Other Names:                 | [                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |
| Classification:              | Radiopharmaceutical for imaging                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
| IND#:                        | Cross reference support from IND 116229, held by DCTD/CIP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |
| Composition:                 | Fully human IgG2 monoclonal antibody                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |  
| Mechanism of    | Panitumumab competes with endogenous ligands such as                                                                                                |
|-----------------|-----------------------------------------------------------------------------------------------------------------------------------------------------|
| Action:         | epidermal growth factor and tumor growth factor α (TGF α) to  block stimulation of the EGF receptor. By blocking the ligandreceptor interaction, critical signaling cascades are prohibited from  occurring which would otherwise result in downstream activation  of signaling pathways involved in the progression of metastatic  disease. Some of these processes include: cell growth, survival,  motility, proliferation, and transformation.                                                                                                                                                     |
| How Supplied:   | 89Zr-panitumumab is a sterile, IV injectable solution with a  volume of ≤10 mL containing 0.9% saline and <5 mg gentistic  acid.                    |
| Storage:        | Vials are stored at 2°C to 8°C (36°C to 46°F) (refrigeration  conditions) until time of use. Protect from direct sunlight  exposure. Do not freeze. |
| Route of        | The agent is administered by intravenous injection, not to exceed                                                                                   |
| Administration: | 1.0 mCi, of 89Zr-panitumumab. Appropriate shielding to meet  Radiation Safety Guidelines will be used.                                              |  
Toxicity: Panitumumab was well tolerated in previous clinical trials studies where doses were much higher. The most common adverse events related to panitumumab, at doses of 6mg/kg every 14 days, were skin rash with variable presentation, hypomagnesemia, paronychia, fatigue, abdominal pain, nausea, and diarrhea. The most serious events that have been reported were fibrosis, severe dermatologic toxicity complicated by infectious sequelae and septic death, infusion reactions, abdominal pain, hypomagnesemia, nausea, vomiting, and constipation.  
NOTE: For PET imaging purpose we will be using panitumumab labeled with 89Zr. 89Zr-labeled, EGFR-targeting antibody panitumumab is expected to be administered as a microdose. A
microdose is defined as less than 1/100th of the dose calculated to yield a pharmacological effect of a test substance, or, for proteins, not more than 30 nanomoles. In this trial, we propose administering <1 mg of panitumumab, which is approximately 1/500th (0.2%) of the recommended therapeutic (pharmacologic) dose of 6 mg/kg, less than 7 nmol. Microdose studies are designed to evaluate the pharmacokinetics or imaging of specific targets and are not designed to induce pharmacological effects. Thus, the potential risk is very low and information adequate to support the initiation of such limited studies can be derived from limited pre-clinical safety studies.  
Safety monitoring for 89Zr-panitumumab PET/CT: Panitumumab was well tolerated in previous clinical trial studies where doses were much higher. The most common adverse events related to panitumumab at doses of 6 mg/kg every 14 days were skin rash with variable presentation, hypomagnesemia, paronychia, fatigue, abdominal pain, nausea, and diarrhea. The most serious events that have been reported were fibrosis, severe dermatologic toxicity complicated by infectious sequelae and septic death, infusion reactions, abdominal pain, hypomagnesemia, nausea, vomiting, and constipation.  
No adverse events are expected for the 89Zr-panitumumab PET/CT imaging study. The dose of panitumumab anticipated for this study will be <1 mg for a single injection. The radiation exposure associated with this study is comparable to the dose for the other widely used clinical nuclear medicine procedures.  
A 5-mL blood sample will be drawn for immunogenicity testing prior to initial 89Zr panitumumab administration and during Cycle1 Day 16. Samples will be delivered at room temperature to Building 10/IB54 for appropriate testing.  
Drug Interactions: There are no formal evaluations regarding drug-food, drug-lab, or drugdisease interaction that are currently available.  
Production of the Radiopharmaceutical: The 89Zr-panitumumab used in this study is prepared locally by the Leidos Biomedical Research Radiopharmacy, Frederick, MD. The precursors for the radiosynthesis include panitumumab, deferoxamine-NCS, and 89Zr-oxalate.  
The other reagents used in the synthesis are sodium carbonate, water, gentisic acid, HEPES, and USP saline for injection. The radiopharmaceutical product is a clear and colorless liquid that is stored at room temperature in a sterile serum vial. 89Zr-panitumumab has an expiration time of 48 hours after sterile filtration.
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8.4 agent ordering

NCI-supplied agents may be requested by the Principal Investigator (or their authorized designee) at each participating institution. Pharmaceutical Management Branch (PMB) policy requires that agent be shipped directly to the institution where the patient is to be treated. PMB does not permit the transfer of agents between institutions (unless prior approval from PMB is obtained). The CTEP-assigned protocol number must be used for ordering all CTEP-supplied investigational agents. The responsible investigator at each participating institution must be registered with CTEP, DCTD through an annual submission of FDA Form 1572 (Statement of Investigator), Curriculum Vitae, Supplemental Investigator Data Form (IDF), and Financial Disclosure Form (FDF). If there are several participating investigators at one institution, CTEP-supplied investigational agents for the study should be ordered under the name of one lead investigator at that institution. Active CTEP-registered investigators and investigator-designated shipping designees and ordering designees can submit agent requests through the PMB Online Agent Order Processing (OAOP) application (https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx). Access to OAOP requires the establishment of a CTEP Identity and Access Management (IAM) account (https://eapps-ctep.nci.nih.gov/iam/) and the maintenance of an "active" account status and a "current" password. For questions about drug orders, transfers, returns, or accountability, call (240) 276-6575 Monday through Friday between 8:30 am and 4:30 pm (ET) or email PMBAfterHours@mail.nih.gov anytime.  
Agent Ordering for 89Zr-panitumumab: 89Zr-panitumumab will be ordered from the Leidos Biomedical Radiopharmacy using the form supplied in Appendix D; orders should be placed 5 business days prior to the scheduled scan date and time. George Afari, PharmD, BCNP Clinical Radiopharmacist Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc. Frederick National Laboratory for Cancer Research Phone: 301 846 7391 Fax: 301 846 5935 E-mail: george.afari@nih.gov