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8.3.3. hemorrhage

One patient developed dose-limiting toxicity of grade 4 hemorrhage presenting as melena from a gastric ulcer within 5 days of the initial TRC105 infusion in the phase 1 monotherapy study at 0.1 mg/kg. He discontinued TRC105 treatment, was transfused 2 units of packed red blood cells and the bleeding resolved with nonsurgical management by the time of upper endoscopy. Serious blood loss was not observed following protocol amendment to exclude patients with a history of peptic ulcer disease (unless healing was documented). Subsequent bleeding associated with TRC105 has been limited to low grades including superficial gingival bleeding, epistaxis, and intermittent post-coital vaginal bleeding in a patient with uterine cancer recurrent at the vaginal cuff. Gingival bleeding and epistaxis are related to the development of mucocutaneous telangiectasia that occur on TRC105 therapy. Patients with epistaxis may benefit from saline nasal gel. All patients treated with TRC105 should be monitored for signs of hemorrhage and the risks and benefits of drug treatment reevaluated in any patient with hemorrhage. Cerebrovascular hemorrhage (grade 3) resulting in hemiparesis occurred in one patient with hepatocellular cancer who was thrombocytopenic (platelet count of 60,000/uL) in a study of TRC105 with sorafenib. Patients in TRC105 protocols are required to have platelet counts of 100,000/uL, with the exception of the hepatocellular cancer protocol, where patients with platelet counts as low as 60,000/uL (without transfusion support in the past 30 days) are permitted due to the underlying cirrhotic liver disease that results in secondary thrombocytopenia.  
Mucocutaneous telangiectasia is observed routinely in patients treated with TRC105 as early as 2 weeks after starting treatment. Telangiectasia is universally seen in patients with hereditary hemorrhagic telangiectasia (HHT), a disease of CD105 haplotype insufficiency. Patients with HHT are at risk of hemorrhage from abnormal blood vessels that could be exacerbated by treatment with TRC105, and are excluded from TRC105 trials. Additionally, Grade 5 intracranial hemorrhage occurred in one glioblastoma patient with markedly abnormal blood clotting parameters in a study of TRC105 with bevacizumab.
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8.3.4. other potential risks

Low grade fatigue is a commonly reported adverse event attributable to TRC105 although its cause is unclear and appears not to be caused by thyroid dysfunction. Headaches (grade 1 to 3) have been observed following TRC105 treatment, generally within hours following completion of the initial infusion. Headaches are throbbing in nature, have not been associated with radiographic abnormalities, and have responded to treatment with non-steroidal anti-inflammatory agents and to 103  
triptans. Headaches were particularly prominent in patients treated with TRC105 in combination with bevacizumab. Headaches were more common and most severe when TRC105 and bevacizumab were initially dosed on the same day and were ameliorated when the first dose of TRC105 was dosed one week following bevacizumab and was given over two days. Nasal congestion and periorbital edema have been observed with TRC105 dosing, particularly when dosed in combination with bevacizumab. The edema has been transient in nature and treated with corticosteroids. Antihistamines are useful for nasal congestion. Flushing and rash (typically maculo-papular and erythematous) occasionally develop following infusion of TRC105. Low grade anorexia, nausea, and vomiting are seen infrequently. Isolated serious adverse reactions include grade 2 pancreatitis in a hepatocellular carcinoma patient in treated with TRC105 in combination with sorafenib and grade 3 infected skin lipoma/cyst observed in a phase 2 study of TRC105 as a single agent in patients with metastatic bladder cancer. Both resolved without sequellae. While thrombosis has not been frequent on TRC105 treatment, patients who develop arterial thrombosis or grade 3 or 4 venous thrombosis should discontinue TRC105 therapy. Those with uncomplicated grade 1 or 2 venous thrombosis and with normal platelet count and platelet function, who appear to be benefiting from TRC105 therapy, may be anticoagulated and continue on TRC105 therapy at the discretion of the investigator. Patients with coagulation parameters above standard therapeutic levels (e.g., INR > 3) are at increased risk of hemorrhage and should therefore not receive TRC105. Transient Grade 3 hepatic encephalopathy occurred in one patient with cirrhosis and hepatocellular carcinoma who received TRC105 in combination with sorafenib. A patient with glioblastoma developed temporary confusion and slurred speech following treatment with TRC105 and bevacizumab that required hospitalization for observation. Another patient with glioblastoma, who underwent resection and had a history of an abnormal collection of cerebral spinal fluid, developed a grade 2 cerebral spinal fluid leak. Grade 3 myocardial infarction (non-Q wave infarct associated with hypertension following an infusion reaction) was observed in a patient with hepatocellular cancer following treatment with TRC105 that resolved without sequelae. In addition, a Grade 5 myocardial infarction occurred in a patient with coronary artery disease who received TRC105 in combination with sorafenib. Patients with evidence of active coronary artery disease are excluded from participation in this trial (see exclusion criteria). Adult respiratory distress syndrome that required temporary intubation occurred in one patient who received TRC105 with pazopanib, from which the patient recovered. Of note, interstitial lung disease has been added as an adverse drug reaction and warning/precaution to the core safety information for pazopanib. Infections have been observed rarely. Grade 3 infected lipoma/cyst was observed in a Phase 2 study of TRC105 as a single agent in patients with metastatic bladder cancer. Grade 3 orbital cellulitis and grade 3 brain abscess were observed in patients treated with TRC105 and bevacizumab and 104  
considered possibly related to TRC105. Grade 1 and 2 gingivitis including infection and ulceration has also been observed. Overall, infections have been observed in fewer than 5% of patients and have largely been considered unrelated to treatment with TRC105.
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9. data collection and study

The study must be conducted as described in this approved protocol. Should amendments to the protocol be required, the amendments will be originated and documented by the Principal Investigator at UAB. The written amendment will be sent to the IRB at the investigator's site for approval. All revisions to the protocol will be provided to Novartis and TRACON by UAB. The Investigator should not implement any deviation or change to the protocol without prior review and documented approval/favorable opinion from the IRB of an Amendment, except where necessary to eliminate an immediate hazard(s) to study patients. Documentation of approval signed by the chairperson or designee of the IRB(s) must be sent to the UAB Clinical Protocols and Data manager Shared Facility Regulatory Office (Alfreda Lewis fax 205-). If the revision is an Administrative Letter, Investigator must inform their IRB(s)/IEC(s). Principal investigator will hold the IND for the trial. All patients must be registered with the Clinical Trials Network and Monitoring Office of the UAB Comprehensive Cancer Center (Pam Dixon, O.C.N.) before enrollment in study. Prior to initiation of therapy eligibility criteria must be confirmed. At the time of registration, a study identification number will be generated. All subsequent case report forms will use this study identification number.
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9.1 data collection

The study will have electronic CRF in OnCore for each subject (UAB CCC). Entries made in the CRF must be verifiable against source documents; any discrepancies should be explained and documented. The investigator will be responsible for reviewing all data and CRF entries and will sign and date the designated pages in each subject's CRF, verifying that the information is true and correct. The investigator is responsible for the review and approval of all responses. Patients will be registered in the Clinical trial Network and Monitoring office of the UAB Comprehensive Cancer Center. 9.2 **Data Management**
Data management will be performed from CRFs. All CRF data will be entered into a validated database. All data entry, verification, and validation will be performed in accordance with the current standard operating procedures of the Clinical Trials and Data Management Shared Facility of the UAB CCC. The database will be authorized for lock once all defined procedures are completed.
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9.3 study management 9.3.1 institutional

Before study initiation, the Investigator must have written and dated approval/favorable opinion from the IRB for the protocol, consent form, patient recruitment materials/process (e.g., advertisements), and any other written information to be provided to patients. The Investigator should provide the IRB with reports, updates, and other information (e.g., Safety Updates, Amendments, Administrative 105  
Letters) according to regulatory requirements or Institution procedures. Copies of the initial IRB approval as well as annual re-approvals must be submitted to UAB. UAB will provide copies of IRB approval to Novartis and TRACON. It is expected that the IRB will have the proper representation and function in accordance with federally mandated regulations. In obtaining and documenting informed consent, the investigator should comply with the applicable regulatory requirement(s), and should adhere to Good Clinical Practice (GCP) and to ethical principles that have their origin in the Declaration of Helsinki. Before recruitment and enrollment onto this study, the patient will be given a full explanation of the study and will be given the opportunity to review the consent form. Each consent form must include all the relevant elements currently required by the FDA Regulations and local or state regulations. Once this essential information has been provided to the patient and the investigator is assured that the patient understands the implications of participating in the study, the patient will be asked to give consent to participate in the study by signing an IRB-approved consent form.  
Prior to a patient's participation in the trial, the written informed consent form should be signed and personally dated by the patient or the patient's legally acceptable representative, and by the person who conducted the informed consent discussion. Documentation of IRB approval must be on file before any patient can be registered. Registration begins with signed informed consent.
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9.3.2 data confidentiality

Information about study subjects will be kept confidential and managed under applicable laws and regulations. Those regulations require a signed subject authorization informing the subject of the following: - What protected health information (PHI) will be collected from subjects in this study - Who will have access to that information and why - Who will use or disclose that information
- The rights of a research subject to revoke their authorization for use of their PHI.  
In the event that a subject revokes authorization to collect or use PHI, the investigator, by regulation, retains the ability to use all information collected prior to the revocation of subject authorization. For subjects that have revoked authorization to collect or use PHI, attempts should be made to obtain permission to collect follow-up safety information (e.g. has the subject experienced any new or worsened AEs) at the end of their scheduled study period. The data collection system for this study uses built-in security features to encrypt all data for transmission in both directions, preventing unauthorized access to confidential participant information. Access to the system will be controlled by a sequence of individually assigned user identification codes and passwords, made available only to authorized personnel who have completed prerequisite training.
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9.3.3 study monitoring

Data will be captured on electronic CRFs, and supporting documents will be faxed to the UAB Clinical Trials Network and Monitoring Office. Personnel from the Clinical Trials Network and Monitoring office of the University of Alabama at Birmingham will monitor the trial in real time and will periodically visit the investigative site to ensure proper conduct of the trial and proper collection 106 of the data.  
 The principal investigator will check the completeness of patient records, the accuracy of entries on the CRFs, the adherence to the protocol to Good Clinical Practice, the progress of enrollment, and to ensure that study treatment is being stored, dispensed, and accounted for according to specifications. Key study personnel must be available to assist the principal investigator in these periodic checks. The investigator must maintain source documents for each patient in the study, consisting of case and visit notes (hospital or clinic medical records) containing demographic and medical information, laboratory data, and the results of any other tests or assessments. All information recorded on CRFs must be traceable to source documents in the patient's file. The investigator must also keep the original signed informed consent form (a signed copy is given to the patient). Trial will be followed by the Clinical Trials Monitoring Committee and audited by the UAB CCC according to the institutional guidelines.
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9.3.4 record retention

Study documentation includes all Case Report Forms, data correction forms or queries, source documents, Sponsor-Investigator correspondence, monitoring logs/letters, and regulatory documents (e.g., protocol and amendments, IRB correspondence and approved signed patient consent forms). Source documents include all recordings of observations or notations of clinical activities and all reports and records necessary for the evaluation and conduction of the clinical research study. Government agency regulations and directives require that all study documentation pertaining to the conduct of a clinical trial must be retained by the study investigator. In the case of a study with a drug pursuing regulatory approval and marketing, these documents shall be retained for at least two years after the last approval of marketing application in an International Conference on Harmonization (ICH) region. In all other cases, study documents should be kept on file until three years after the completion and final study report of this investigational study. If the Investigator withdraws from the study (e.g., relocation, retirement), the records shall be transferred to a mutually agreed upon designee (e.g., another Investigator, IRB). Notice of such transfer will be given in writing to NOVARTIS and TRACON Pharmaceuticals. Records of the patient's participation in this study will be kept confidential so far as permitted by law. However, the patient's doctor and his/her staff, representatives of NOVARTIS and TRACON Pharmaceuticals, representatives of the U.S. Food and Drug Administration, and the IRB will be able to inspect patient records and have access to confidential information which identifies the patient by name. Any publication of data will not identify the patient by name. Should the patient's medical record need to be reviewed by a foreign regulatory agency, a member of the IRB staff will observe the review so that the record is not removed, copied, or identifiable information recorded in any manner.
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9.3.5 obligations of investigators

The Principal Investigator is responsible for the conduct of the clinical trial at the site in accordance with Title 21 of the Code of Federal Regulations and/or the Declaration of Helsinki. The Principal Investigator is responsible for personally overseeing the treatment of all study patients. The Principal Investigator must ensure that all study site personnel, including sub-investigators and other study  
staff members, adhere to the study protocol and all FDA/GCP/NCI regulations and guidelines regarding clinical trials both during and after study completion. The Principal Investigator at each institution or site will be responsible for ensuring that all the required data will be collected and entered onto the Case Report Forms. Periodically, monitoring visits will be conducted and the Principal Investigator will provide access to his/her original records to permit verification of proper data entry. At the completion of the study, all case report forms will be reviewed by the Principal Investigator and will require his/her final signature to verify the accuracy of the data.
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10. statistical considerations

This is a phase I/II study with the primary objective to characterize the tolerability and feasibility of a novel combination of agents. The Primary Endpoint is defined as the determination of MTD and RP2D and rates of treatment-related toxicities. The secondary efficacy endpoints are rates of pCR or down-staging. The principal investigator will hold the IND for the trial (Appendix F).
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10.1 sample size and power

A. The dose escalation part of the study will follow a conventional 3+3 dose escalation design according to the schema above. We anticipate that up to 18 patients will be enrolled in this part anticipating that dose level 1 or 2 will be the RP2D. The number of patients to be enrolled ranges from 3 (if ≥2/3 DLTs in cohort 1) to 18 (if enrollment of 6 patients in all cohorts).  
B. The sample size of 20 in Phase II part study is NOT determined by the statistical power but the feasibility and relative precision of estimate, e.g. standards error of the estimation is ≤10%. We will estimate the pCR of the combination to generate hypotheses for further clinical investigations. In order to minimize exposure of patients to ineffective therapy, Gehan's two-stage design will be used51 which allows for the rapid rejection of an ineffective treatment at the end of the first stage, and provides an estimation of the success rate with a given precision, at the end of the second stage.  
The study will enroll 10 patients first, and if no patient has pCR or downstaging, it is unlikely
(p=0.1074) that 0/10 responses would occur if the true response rate were >20%. If responses were 0/10, the phase II portion will be closed. If at least one patient has pCR or downstaging, an additional 10 patients will be treated (total of 20). With an accrual of 20 patients to phase II portion of the study, estimated two-sided 95% confidence intervals (CI) would be 1.2%-31.7%, 5.7% -43.6% and 11.8%-54.3% if pCR is 10%, 20% or 30% respectively. The confidence intervals are calculated using the exact method Clopper-Pearson intervals54.  
Table 10-1 shows the probability of early termination and observing one response or at least one response at the first stage (N1=10).  
Table 10.1: Probability of early termination and observing one response or at least one response at the first stage (N1**=10)**  
| True ORR            | Probability of having   | Probability of having   | Probability of having at  least one response (x≥1)   |
|---------------------|-------------------------|-------------------------|------------------------------------------------------|
| zero response (x=0) | one response (x=1)      | 108 | P a g e           |                                                      |  
|      | UAB 1514 / Version 7-25-19   |        |        |
|------|------------------------------|--------|--------|
| 0.1  | 0.3486                       | 0.3874 | 0.6513 |
| 0.2  | 0.1074                       | 0.2684 | 0.8926 |
| 0.30 | 0.0282                       | 0.1211 | 0.9718 |
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10.2 statistical analysis

The primary analysis is of safety and will include any patients who receive at least one dose of the investigational regimen. The rate of adverse events will be estimated at the end of the study along with two-sided 95% exact CIs (Clopper-Pearson intervals). At the completion of the study, the secondary endpoint of pCR or downstaging rate will be estimated along with two-sided 95% CIs with the exact method of Clopper-Pearson intervals. Secondary endpoint analysis will be descriptive. Mean, median, geometric mean, range and coefficient of variation will be used to describe continuous demographic variables. Frequency and proportion will be used to describe categorical variables. We will use descriptive statistics (mean, median, geometric mean, coefficient of variation, and 95% confidence intervals) and graphical displays (mean concentration-time graphs, scatter plots, box plots or spaghetti plots) to evaluate the pharmacokinetic parameters of the TRC105 and everolimus. We will use descriptive statistics (mean, median, geometric mean, coefficient of variation, and 95% confidence intervals) and graphical displays (scatter plots, box plots, plots of PD parameters against PK data) to analyze the changes in markers of proliferation and angiogenesis with the investigational treatment. Exploratory analysis will be conducted on the correlations between clinical outcomes and pharmacodynamic biomarkers or translation profiles. Translational profiles will be analyzed between responders and non-responders and the differences between responders and non-responders will be presented in scatter plots along with corresponding 95% CI. Quartile normalization and logarithmic transformation will be conducted before analysis. Logistic regression analysis will be used to predict response with translational profiles or biomarkers with or without adjustment for covariates, e.g. age. Multivariate Cox proportional hazards model will be used to identify a set of biomarkers for prediction of response. Odds ratios with 95% CIs will be calculated for each significant biomarker in terms of predicting response. However, it is recognized that sample size may be too small for such analyses and these analyses are conducted only to generate hypotheses that will require further validation.
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10.3 stratification factors

No *a priori* stratification of patients will be undertaken in this study. Subgroup analyses will be conducted *a posteriori* according to grade (grade II vs. III), stage (stage IIA and IIB vs. IIIA and IIIB) lymph node involvement (N0 vs. N1-2), age (as a continuous variable). It is recognized that sample size may be too small for such analyses and these analyses are exploratory to generate hypotheses and will require further validation.
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11. protocol adherence

Investigators ascertain they will apply due diligence to avoid protocol deviations. No authorized  
 deviations are permitted. If an investigator feels a protocol deviation would improve the conduct of the study this must be considered a protocol amendment, and unless such an amendment is agreed upon by the principal investigator and approved by the IRB it cannot be implemented. All significant protocol deviations will be recorded and reported in the CSR.
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11.1 amendments to the protocol

Any change or addition to the protocol can only be made in a written protocol amendment that must be approved by the IRB. Only amendments that are required for patient safety may be implemented prior to IRB approval. Notwithstanding the need for approval of formal protocol amendments, the investigator is expected to take any immediate action required for the safety of any patient included in this study, even if this action represents a deviation from the protocol. In such cases, the principal investigator should be notified of this action and the IRB should be informed no later than 10 working days. Novartis requests to review any significant changes, excluding administrative protocol amendments
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references

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table of contents protocol synopsis
appendix a performance status criteria

|                                                                                                                                                                                            | UAB 1514 / Version 7-25-19                                    |                                                                                                               |                                                                        |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------|
| ECOG Performance Status Scale                                                                                                                                                              | Karnofsky Performance Scale                                   |                                                                                                               |                                                                        |
| Grade                                                                                                                                                                                      | Descriptions                                                  | Percent                                                                                                       | Description                                                            |
| 100                                                                                                                                                                                        | Normal, no complaints, no evidence  of disease.               |                                                                                                               |                                                                        |
| Normal activity. Fully active, able                                                                                                                                                        |                                                               |                                                                                                               |                                                                        |
| 0                                                                                                                                                                                          | to carry on all pre-disease  performance without restriction. | 90                                                                                                            | Able to carry on normal activity;  minor signs or symptoms of disease. |
| Symptoms, but ambulatory.  Restricted in physically strenuous  activity, but ambulatory and able  to carry out work of a light or  sedentary nature (e.g., light  housework, office work). | 80                                                            | Normal activity with effort; some  signs or symptoms of disease.                                              |                                                                        |
| 1                                                                                                                                                                                          | 70                                                            | Cares for self, unable to carry on  normal activity or to do active work. Requires occasional assistance, but |                                                                        |
| 60                                                                                                                                                                                         | is able to care for most of his/her needs.                    |                                                                                                               |                                                                        |
| In bed <50% of the time.  Ambulatory and capable of all  self-care, but unable to carry out  any work activities. Up and about  more than 50% of waking hours.                             |                                                               |                                                                                                               |                                                                        |
| 2                                                                                                                                                                                          | 50                                                            | Requires considerable assistance and  frequent medical care.                                                  |                                                                        |
| In bed >50% of the time. Capable  of only limited self-care, confined  to bed or chair more than 50% of  waking hours.                                                                     | 40                                                            | Disabled, requires special care and  assistance.                                                              |                                                                        |
| 3                                                                                                                                                                                          | 30                                                            | Severely disabled, hospitalization  indicated. Death not imminent.                                            |                                                                        |
| 100% bedridden. Completely  disabled. Cannot carry on any  self-care. Totally confined to bed  or chair.                                                                                   | 20                                                            | Very sick, hospitalization indicated.  Death not imminent.                                                    |                                                                        |
| 4                                                                                                                                                                                          | 10                                                            | Moribund, fatal processes  progressing rapidly. Dead.                                                         |                                                                        |
| 5                                                                                                                                                                                          | Dead.                                                         | 0                                                                                                             |                                                                        |  
| CYP3A4 inhibitors                                                                                                                                                                                          | CYP3A4 inducers   |            |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------|------------|
| Alosetron                                                                                                                                                                                                  | Aprepitant        |            |
| Atorvastatin                                                                                                                                                                                               | boceprevir        |            |
| Bosentan                                                                                                                                                                                                   | buprenorphine     |            |
| Buspirone                                                                                                                                                                                                  | carbamazepine     |            |
| clarithromycin                                                                                                                                                                                             | conivaptan        |            |
| Coumadin                                                                                                                                                                                                   | cyclosporine      |            |
| Diazepam                                                                                                                                                                                                   | Valdecoxib        |            |
| dihydroergotamine mesylate                                                                                                                                                                                 |                   |            |
| diltiazem                                                                                                                                                                                                  | docetaxel         |            |
| dofetilide                                                                                                                                                                                                 | efavirenz         |            |
| eplerenone                                                                                                                                                                                                 | estazolam         |            |
| fentanyl                                                                                                                                                                                                   | fosamprenavir     |            |
| galantamine                                                                                                                                                                                                | gefitinib         |            |
| grapefruit juice                                                                                                                                                                                           | imatinib          |            |
| indinavir                                                                                                                                                                                                  | itraconazole      |            |
| ketoconazole                                                                                                                                                                                               |                   |            |
| lopinavir/ritonavir                                                                                                                                                                                        |                   |            |
| lovastatin                                                                                                                                                                                                 | methadone         |            |
| mibefradil,                                                                                                                                                                                                | mifepristone      |            |
| nefazodone,                                                                                                                                                                                                | nelfinavir        |            |
| paclitaxel                                                                                                                                                                                                 | pimozide          |            |
| propafenone                                                                                                                                                                                                | posaconazole      |            |
| quinidine                                                                                                                                                                                                  | ranolazine        |            |
| rifampin                                                                                                                                                                                                   | rifabutin         |            |
| ritonavir                                                                                                                                                                                                  | saquinavir        |            |
| simvastatin                                                                                                                                                                                                | sirolimus         |            |
| solifenacin                                                                                                                                                                                                | succinate         |            |
| tacrolimus                                                                                                                                                                                                 | telaprevir,       |            |
| telithromycin                                                                                                                                                                                              | tinidazole        |            |
| valdecoxib                                                                                                                                                                                                 | valdenafil        |            |
| vinorelbine voriconazole zonisamide                                                                                                                                                                        | Alosetron         | Aprepitant |
| Bexarotene                                                                                                                                                                                                 | uprenorphine      |            |
| Buspirone                                                                                                                                                                                                  | cyclosporine      |            |
| diltiazel docetaxel efavirenze erlotinib estazolam exemestane                                                                                                                                              |                   |            |
| fosamprenavir galantamine gefitinib imatinib irinotecan itraconazole                                                                                                                                       |                   |            |
| lopinavir/ritonavir methadone mifepristone modafinil nisoldipine paclitaxel pimozide quinidine sirolimus solifenacin succinate sunitinib tacrolimus tramadol tinidazole valdecoxib voriconazole zonisamide |                   |            |  
APPENDIX B
Drugs with potential interactions with everolimus
table of contents protocol synopsis
appendix c

American College of Radiology (ACR) Practice **Guidelines for Imaging Studies of the Breast**  
  
The ACR Practice Guideline for the Performance of Screening and Diagnostic Mammography, http://www.acr.org/~/media/3484ca30845348359bad4684779d492d.pdf The ACR Practice Guideline for the Performance of a Breast Ultrasound Examination, http://www.acr.org/~/media/52D58307E93E45898B09D4C4D407DD76.pdf The ACR Practice Guideline for the Performance of Contrast-Enhanced MRI of the Breast, http://www.acr.org/~/media/2A0EB28EB59041E2825179AFB72EF624.pdf
appendix d
appendix c

NCI **Common Terminology Criteria for Adverse Events (NCI CTCAE) version 4.03**
http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_ 8.5x11.pdf
appendix f
appendix c

SOP for Investigator INDs Held by Physician Members of the UAB CCC  
  
(Available upon request; Pam Dixon 205- 975-5387)  
APPENDIX G
Blood and Biopsy Procedures UAB 1514 - **Blood Draw and Biopsy Schedule**  
  
Paraffin blocks to UAB
Frozen biopsies to UAB
Blood for Serum Collection (PK, PD, APA)
appendix f
a. uab - paraffin blocks

Pre-therapy paraffin blocks **and core research biopsies (all patients)** will be obtained and prepared. Time points include baseline, cycle 2 day 1 and at the time of surgery. Formalin-fixed paraffin embedded tissue blocks from the patient's primary tumor collected for diagnostic purposes will be requested for all patients enrolled in the study at the time of registration. For the research cores, the goal is for 2-4 core biopsy specimens obtained using standard institutional guidelines for a diagnostic core biopsy of a breast mass. However, biopsy samples will preferably be obtained using a 14-18 gauge core needle. At least one core will be used to prepare a paraffin block (paraffinembedded blocks or formalin fixed tissue) and at least one core will be immediately frozen (snap frozen individually for gene expression). Snap frozen research biopsies will be sent to UAB Tissue Procurement where biopsies will be stored for batching. The batched biopsies will then be forwarded to HudsonAlpha Institute for Biotechnology. These biopsies should be labeled with an indelible marker to include: 1. The clinical trial identification number (UAB 1514)
2. The subject's study number 3. The date of acquisition Fifteen slides will be prepared from the paraffin blocks or formalin fixed tissue by Dr. Grizzle at UAB for analysis by conventional IHC of ER, PR, Her-2, EGFR, Ki67, apoptotic markers, and biomarkers of DNA repair such as H2AX and BRCA localization.  
B. UAB - **Snap-Frozen research biopsies (all patients)** All cryovials (NALGENE® Cryoware™ 5000-0000) will be labeled with an indelible marker to include: 1. The study identification number (UAB 1514);
2. The subject's study number; 3. The date of acquisition Ed Acosta's Lab Lab Contact: Kevin J. Ryan University of Alabama at Birmingham CCC PK/PD Core Laboratory 1670 University Blvd, Volker Hall, Lab 175 Preparing **Tissue in Frozen Cryovials** Snap Freezing: Do not Cut the tissue and simply ship as is. Place each core of tissue into a labeled individual 2.0 ml NALGENE® Cryoware™ cryovials. The label should contain the UAB clinical trial number (UAB 1514) followed by the subject's study number, as well as the date the specimen was collected. Do not place the patient's name or medical record number on the label. The container will become very cold. Do not handle with unprotected hands. Safety goggles should be use throughout the procedure. Snap freeze samples in liquid nitrogen. If not available, you may use an alcohol/dry ice bath. Fill pan about 1-2 inches deep with methanol. The depth should be enough to cover the height of the vial. Slowly add crushed dry ice until the boiling stops. The bath is now ready for use. Drop the sealed vials directly into the liquid nitrogen (LN2) carefully. Leave the vials in the liquid nitrogen for at least one minute. Once frozen, transfer the samples using tongs or a large spoon to remove the vials from the liquid nitrogen and transfer to a –80 C freezer until shipped.
appendix f
c. serum (pk pd apa)

1. Blood samples for the assays will be taken at the times described in the protocol. Serum will be obtained in red top serum separator tubes and will be sent to Ed Acosta's Lab. Dr.  
Acosta's **lab should be notified of these samples. The laboratory address is:**
E**d Acosta's Lab**
Lab Contact: Kevin J. Ryan University of Alabama at Birmingham CCC PK/PD Core Laboratory 1670 University Blvd, Volker Hall, Lab 175 2. PK: A 5 mL blood sample will be collected pre-dose and 1, 2, 4, 6 and 24 **hours postdose on the days indicated within Table 7-1: Study Calendar. Samples will be separated**
and stored at approximately -70 °C. Ed Acosta's Lab Lab Contact: Kevin J. Ryan University of Alabama at Birmingham CCC PK/PD Core Laboratory 1670 University Blvd, Volker Hall, Lab 175 APA: Anti-Product Antibody (APA) will be collected will be collected before dosing on cycle 1 day 1, every 4 weeks thereafter, 4 and 12 weeks following the last dose of TRC105  
(Table 7-1: Study Calendar). Concentrations will be measured using validated ELISA methods. APA concentrations will be evaluated in the context of pharmacokinetic parameters and AE profiles. Samples will be separated and stored at approximately -
70 °C. Ed Acosta's Lab Lab Contact: Kevin J. Ryan University of Alabama at Birmingham CCC PK/PD Core Laboratory 1670 University Blvd, Volker Hall, Lab 175