Protocol Update #04 03/07/2014 ALLIANCE FOR CLINICAL TRIALS IN ONCOLOGY _________________________________________ PROTOCOL UPDATE TO ALLIANCE A091102 _________________________________________ PHASE II STUDY OF MLN8237 IN ADVANCED/METASTATIC SARCOMA Clinicaltrials.gov Identifier: NCT01653028 Investigational Agent: MLN8237 (NSC # 747888; IND 116565) supplied by the NCI Update: Status Change: Eligibility changes Activation Therapy / Dose Modifications / Study Calendar changes Closure X Informed Consent changes Suspension / temporary closure Scientific / Statistical Considerations changes Reactivation Data Submission / Forms changes X Editorial / Administrative changes X Other: MLN8237 CAEPR Update The changes included in this update to Alliance A091102 have been made in response to the NCI Request for Amendment for MLN8237 from Dr. Richard Piekarz, dated January 6, 2014. Please note an action letter will not follow and there is no new risk information. IRB review of this update is required within 90 days. Expedited review is allowed. Please follow your local IRB guidelines. Patients currently enrolled on Alliance A091102 need not be re-consented. PROTOCOL UPDATES: References to the “Adverse Event Expedited Reporting System (AdEERS)” have been changed to “CTEP Adverse Event Reporting System (CTEP-AERS)” throughout the protocol. Cover Page: • The “Activation Date” and “Includes Update” have been moved to the newly added “Document History Table” under the “Protocol Resources table”. 1 • In keeping with the new CTEP policy the following sentence has been removed under the title “An Alliance trial conducted by CALGB*, NCCTG, and ACOSOG”. In addition, the “* Lead Group” has been removed from the bottom left corner. • The clinicaltrials.gov identifier has been added. • The telephone contact information for the Study Chair has changed from “212-639-5218” to “646-8884164”. • The data manager has been moved from the protocol resources page. • In the bottom left corner, the following has been added “Participating NCTN Groups: Alliance”. Protocol Resources: • Under the bolded title “Expedited Adverse Event Reporting,” the website has been updated to reflect the change from AdEERS to CTEP-AERS. • Within the “Protocol-related questions may be directed as follows” table, in the last column, the contact has been updated to “Alliance Regulatory: [email protected]”. Section 4.2 (OPEN Registration Procedures): The PMB number has been updated to “240-276-6575”, this change has been made throughout the protocol. Section 6.0 (Dosing Delays/Dose Modifications): • The ANC and Platelet Count criterion has been revised to reflect the number “9” as a superscript and the number “1” after the slash has been revised to the letter “l”. In addition the value “109/l” has been placed within parenthesis. • The following sentence has been added after the last sentence in this section: “Amylase, lipase, phosphorus or magnesium and not required to be routinely checked.” Section 7.1.1.1 (CAEPR for MLN8237): An updated CAEPR for MLN8237 (Version 2.2, November 27, 2013) has replaced the previous version. Section 7.2 (Expedited Adverse Event Reporting): The second paragraph has been removed, as it is not applicable: “In the rare event when Internet connectivity is disrupted, a 24 hour notification is to be made to the NCI by telephone at 301-879-7497. An electronic report MUST be submitted upon re-establishment of Internet connection.” Section 9.2 (Methods): The first sentence of the paragraph has been revised to, “Patients treated at MSKCC may have two optional biopsies: one pretreatment and the second 1-4 weeks after the start of treatment.” Section 9.3.1 ([F-18]FLT Administration): The first sentence has been revised to read, “An FLT-PET scan may be performed at baseline and 1-4 weeks after starting treatment for up to 20 patients treated with MLN8237 at MSKCC only in connection with [F-18]FLT CIP IND #71,260.” Appendix B (Pill Diary for Alliance A091102 The first sentence has been revised from, “Please remember to take your pills without food (except for water and prescribed medications at least 1 hour before and 2 hours after eating)” to “Please remember to 2 take your pills without food (except for water and prescribed medications at least 1 hour before and 2 hours after)”. MODEL CONSENT UPDATES What side effects or risks can I except from being in the study?: • The following has been placed above the Risk list for MLN8237: “If you choose to take part in this study, there is a risk that: • You may lose time at work or home and spend more time in the hospital or doctor’s office than usual • You may be asked sensitive or private questions which you normally do not discuss The MLN 8237 used in this study may affect how different parts of your body work such as your liver, kidneys, heart, and blood. The study doctor will be testing your blood and will let you know if changes occur that may affect your health. There is also a risk that you could have side effects from the study drug(s)/study approach. Here are important points about side effects: • The study doctors do not know who will or will not have side effects. • Some side effects may go away soon, some may last a long time, or some may never go away. • Some side effects may interfere with your ability to have children. • Some side effects may be serious and may even result in death. Here are important points about how you and the study doctor can make side effects less of a problem: • Tell the study doctor if you notice or feel anything different so they can see if you are having a side effect. • The study doctor may be able to treat some side effects. • The study doctor may adjust the study drugs to try to reduce side effects. The tables below show the most common and the most serious side effects that researchers know about. There might be other side effects that researchers do not yet know about. If important new side effects are found, the study doctor will discuss these with you.” Risks and side effects related to MLN8237 include those which are: • The risk list for MLN8237 has been updated to reflect the NCI’s new condensed risk profile format. The former “Likely” category has been replaced with “Common, Some May Be Serious,” the former “Less Likely” category has been replaced with “Occasional, Some May Be Serious,” and the former “Rare but Serious” has been replaced with “Rare, and Serious.” • The following changes have been made within “Common, Some May Be Serious” to be consistent with CTEP’s new condensed risk format for MLN8237: • The new condensed term “Anemia which may require blood transfusion” replaces the previous term “Lack of enough red blood cells (anemia)”. • The new condensed term “Diarrhea, nausea, vomiting” replaces the following old terms “Diarrhea, Nausea or the urge to vomit, Vomiting”. • The new term “Sores in mouth which may cause difficulty swallowing” replaces the following old term “Irritation or sores in the lining of the mouth”. 3 • • • • The new condensed term “Tiredness” replaces the following term “Fatigue or tiredness”. The new condensed term “Bruising, bleeding” has been added to be consistent with the CTEP condensed risk list. • The term “Infection, especially when white blood cell count is low” has been revised and moved from the “Occasional, some may be serious” category. • The following terms have been removed to be consistent with the new CTEP condensed risk list: Decreased number of a type of white blood cell (lymphocyte) Decreased number of a type of white blood cell (neutrophil/granulocyte) Decreased number of a type of blood cell that helps to clot blood (platelet) Decrease in the total number of white blood cells (leukocytes) Sleepiness, feeling drowsy, ready to fall asleep The following changes have been made within “Occasional, Some May be Serious” to be consistent with CTEP’s new condensed risk format for MLN8237: • The new term “Pain” replaces the following terms “Belly pain, Mouth pain, Back Pain” • The new term “Fever” replaces the following term “Fever associated with dangerously low levels of a type of white blood cell (neutrophils), Fever” • The new term “Swelling of arms, legs” replaces the following term “Swelling of the arms and/or legs” • The new term “Dehydration” replaces the following term “Dehydration (when your body does not have as much water and fluid as it should)” • The new term “Dizziness, headache” replaces the following terms “Dizziness (or sensation of lightheadedness, unsteadiness, or giddiness, Headache or head pain” • The new term “Cough, shortness of breath” replaces the following terms “Shortness of breath, Cough” • The following terms have been removed to be consistent with the new CTEP condensed risk list: Increased blood level of a liver enzyme (ALT/SGPT) Increased blood level of a liver or bone enzyme (alkaline phosphatase) Increased blood level of a liver enzyme (AST/SGOT) Increased blood level of a liver pigment (bilirubin) often a sign of liver problems Increased blood level of creatinine (a substance normally eliminated by the kidneys into the urine) Low blood pressure The following changes have been made within “Rare, And Serious” to be consistent with CTEP’s new condensed risk format for MLN8237: • The new term “Blisters on skin” replaces the following term “Skin condition with fluidfilled blisters” • The new term “Redness, pain or peeling of palms and soles” replaces the following term “Swelling and redness of the skin on the palms of the hands and soles of the feet” A replacement protocol and Model Consent documents has been issued ____________________________________________________________ ATTACH TO THE FRONT OF EVERY COPY OF THIS PROTOCOL ____________________________________________________________ 4 ALLIANCE A091102 ALLIANCE FOR CLINICAL TRIALS IN ONCOLOGY ALLIANCE A091102 PHASE II STUDY OF MLN8237 IN ADVANCED/METASTATIC SARCOMA Clinicaltrials.gov Identifier: NCT01653028 Investigational Agent: MLN8237 (NSC # 747888; IND 116565) supplied by the NCI Study Chair Mark A. Dickson MD Memorial Sloan-Kettering Cancer Center 1275 York Ave New York, NY 10065 Tel: 646-888-4164 Fax: 646-888-3231 [email protected] Experimental Therapeutics Committee Co-Chairs Charles Erlichman MD Tel: 507-266-3200 Fax: 507-538-6290 [email protected] Gary Schwartz, MD Tel: 212-639-8324 Fax: 212-717-3085 [email protected] Community Oncologist Roscoe F. Morton, M.D.,FACP Tel: 515-282-2921 Fax: 515-282-1035 [email protected] Primary Statistician Michelle R. Mahoney, M.S Tel: 507-266-4456 Fax: 507-266-2477 [email protected] Protocol Coordinator Guadalupe Aquino Tel: 773-702-0956 Fax: 312-345-0117 [email protected] Data Manager Carla Hilton Tel: 507-284-1370 Fax: 507-284-1902 [email protected] Participating NCTN Groups: Alliance and French Sarcoma Cosortium 1 Version Date 02/20/2014 Update #04 ALLIANCE A091102 Alliance Central Protocol Operations Office 230 West Monroe Street, Suite 2050 Chicago, IL 60606 Tel: 773-702-9171 Fax: 312-345-0117 www.alliance-website.org Alliance Statistical Data Center Mayo Clinic 200 First St. SW Rochester MN 55905 Expedited Adverse Event Reporting https://eapps-ctep.nci.nih.gov/ctepaers/ Medidata Rave iMedidata portal https://login.imedidata.com OPEN (Oncology Patient Enrollment Network) https://open.ctsu.org Protocol Resources: A091102 Nursing Contact Ms. Mercedes Condy R.N. ANP 300 East 66th Street-10th Floor New York City, NY 10065 Tel: 646-888-4158 Fax: 646-888-4250 [email protected] Alliance Pathology Coordinating Office The Ohio State University Innovation Centre 2001 Polaris Parkway Columbus, OH 43240 Tel: 614-293-7073 Fax: 614-293-7967 [email protected] Protocol-related questions may be directed as follows: Questions Questions regarding patient eligibility, treatment, and dose modification: Questions related to data submission, RAVE or patient follow-up: Questions regarding the protocol document: Questions related to IRB issues and model consent revisions: Questions regarding CTEP-AERS reporting: Contact (via email) Study Chair, Nursing Contact, Protocol Coordinator, or Data Manager Data Manager Protocol Coordinator Regulatory Affairs Manager: [email protected] Alliance Regulatory: [email protected] Document History Activation Date Update #01 Update #02 Version Date 02/20/2014 Effective Date: 08/22/2012 12/08/2012 12/08/2012 Update #03 Update #04 2 05/29/2013 03/07/2014 Update #04 ALLIANCE A091102 CANCER TRIALS SUPPORT UNIT (CTSU) ADDRESS AND CONTACT INFORMATION To submit site registration For patient enrollments: Submit study data directly to the Lead documents: Cooperative Group unless otherwise specified in the protocol: CTSU Regulatory Office Please refer to the patient All participating sites will submit study data 1818 Market Street, Suite enrollment section for via Medidata Rave System. 1100 instructions on using the Philadelphia, PA 19103 OPEN system. Do not submit study data or forms to CTSU Phone – 1-866-651-CTSU Data Operations. Do not copy the CTSU on Fax – 215-569-0206 data submissions The study protocol and all related forms and documents must be downloaded from the protocolspecific Web page of the CTSU Member Web site located at https://www.ctsu.org. Sites must use the current form version and adhere to the instructions and submission schedule outlined in the protocol. CTSU sites should follow procedures outlined in the protocol for Site registration, Patient Enrollment, Adverse Event Reporting, Data Submission (including ancillary studies), and Drug Procurement. For patient eligibility or treatment-related questions contact the Study PI of the Coordinating Group For questions unrelated to patient eligibility, treatment, or data submission contact the CTSU Help Desk by phone or e-mail: CTSU General Information Line – 1-888-823-5923, or [email protected]. All calls and correspondence will be triaged to the appropriate CTSU representative. For detailed information on the regulatory and monitoring procedures for CTSU sites please review the CTSU Regulatory and Monitoring Procedures policy located on the CTSU members’ website https://www.ctsu.org The CTSU Web site is located at https://www.ctsu.org French Sarcoma Consortium French Sarcoma Consortium Site: Institut Bergonié, Bordeaux Centre Léon Bérard, Lyon Institut Gustave Roussy, Villejuif, Centre Oscar Lambret, Lille Institut Curie, Paris Hôpital La Timone, Marseille Centre René Gauducheau, Saint Herblain Centre Georges François Leclerc, Dijon Institut Claudius Régaud, Toulouse Version Date 02/20/2014 3 Principal Investigator Dr Antoine Italiano Pr Jean Yves Blay A Le Cesne Dr F Watelle Dr Piperno-Neuman Dr Duffaud Dr E Bompas Dr N Isambert Dr C Chevreau Update #04 ALLIANCE A091102 PHASE II STUDY OF MLN8237 IN ADVANCED/METASTATIC SARCOMA SCHEMA MLN8237 50 mg PO BID d1-7, q21d Patient will be assigned to a cohort depending on the histologic sub-type of sarcoma, as described in section 3.1.1. Restage every 6 weeks*** CR, PR, SD: * Continue until Progression* or toxicity PD or Unacceptable toxicity: ** Stop therapy Off treatment * Patients who are in CR, PR or SD will continue on therapy until PD, or unacceptable adverse events occur (see section 5.2.1.1). ** Upon PD, patients will begin the Survival and Disease Status Follow-Up phase of the study (see section 5.2.1.1) *** Scans are repeated every 6 weeks, regardless of dose delays, ±8 days, starting timing from the first day of therapy. After 24 weeks (approximately 8 cycles), patients should be re-evaluated for response every 12 weeks (approximately every 4 cycles, ±8 days). Version Date 02/20/2014 4 Update #04 ALLIANCE A091102 TABLE OF CONTENT 1.0 OBJECTIVES ................................................................................................................... 7 1.1. Primary Objectives ............................................................................................................. 7 1.2. Secondary Objectives ......................................................................................................... 7 1.3 Correlative Objectives/ Translational Objectives ............................................................... 7 2.0 BACKGROUND ............................................................................................................... 7 2.1 Soft tissue sarcoma ............................................................................................................. 7 2.2 CTEP and CIP IND Agents ................................................................................................ 7 2.3 Rationale ........................................................................................................................... 16 3.0 PATIENT SELECTION ................................................................................................ 20 3.1 Eligibility Criteria ............................................................................................................. 20 3.2 Exclusion Criteria ............................................................................................................. 21 3.3 Inclusion of Women and Minorities ................................................................................. 22 4.0 REGISTRATION ........................................................................................................... 22 4.1 Registration Requirements ................................................................................................ 22 4.2 OPEN Registration Procedures ......................................................................................... 23 5.0 TREATMENT ................................................................................................................. 24 5.1 Agent Administration ....................................................................................................... 24 5.2 End of Treatment/Intervention.......................................................................................... 24 5.3 General Concomitant Medication and Supportive Care Guidelines ................................. 25 5.4 Definitions of Ineligible and canceled patients, and major protocol violations ................ 25 5.5 Extraordinary Medical Circumstances:............................................................................. 25 5.6 Criteria for Removal from Protocol Therapy.................................................................... 26 5.7 Clinical Benefit in the Setting of Apparent Radiological Progression ............................. 26 6.0 DOSING DELAYS/DOSE MODIFICATIONS ........................................................... 26 6.1 Dose adjustments: general principles................................................................................ 26 6.2 Dose Modifications for Hematologic Toxicity ................................................................. 27 6.3 Dose Modifications for Non-Hematologic Toxicity ........................................................ 27 6.4 Other non-hematologic Toxcity ........................................................................................ 27 7.0 Adverse Events: List and Reporting Requirements .................................................... 28 7.1 Comprehensive Adverse Events and Potential Risks Lists (CAEPRs)............................. 28 7.2 Expedited Adverse Event Reporting................................................................................. 31 7.3 Additional Instructions or Exclusions to CTEP-AERS ........................................................... 34 8.0 PHARMACEUTICAL and IMAGING AGENT INFORMATION .......................... 34 8.1 CTEP and CIP IND Agent ................................................................................................ 34 8.2 FLT-PET ........................................................................................................................... 38 9.0 CORRELATIVE STUDIES FOR MSKCC PATIENTS ............................................ 44 9.1 Background ....................................................................................................................... 44 9.2 Methods ................................................................................................................................... 44 9.3 A091102-IM1 ................................................................................................................... 46 10.0 STUDY CALENDAR ..................................................................................................... 48 11.0 MEASUREMENT OF EFFECT ................................................................................... 49 11.1 Schedule of Evaluations.................................................................................................... 49 11.2 Definitions of Measurable................................................................................................. 49 11.3 Guidelines for Evaluation of Measurable Disease ............................................................ 49 11.4 Measurement of Effect...................................................................................................... 51 11.5 Formal Definitions of Variables ....................................................................................... 54 12.0 DATA REPORTING ...................................................................................................... 54 12.1 Data Reporting .................................................................................................................. 54 Version Date 02/20/2014 5 Update #04 ALLIANCE A091102 13.0 STATISTICAL CONSIDERATIONS .......................................................................... 54 13.1 Study Design/Endpoints ................................................................................................... 54 13.2 Sample Size/Accrual Rate................................................................................................. 55 13.3 Grouping Factors .............................................................................................................. 56 13.4 Analysis of Secondary Endpoints & Correlative End Points ............................................ 57 13.5 Reporting and Exclusions ................................................................................................. 57 14.0 REFERENCES .............................................................................................................................. 59 APPENDIX A ........................................................................................................................................ 63 APPENDIX B ........................................................................................................................................ 64 Version Date 02/20/2014 6 Update #04 ALLIANCE A091102 1.0 OBJECTIVES 1.1. Primary Objectives The primary objective is to determine the response rate (CR + PR) assessed for patients within each cohort: • • • • • Cohort 1: liposarcoma Cohort 2: leiomyosarcoma (non-uterine) Cohort 3: undifferentiated sarcoma (including pleiomorphic undifferentiated sarcoma, formerly known as malignant fibrous histiocytoma, and myxofibrosarcoma) Cohort 4: malignant peripheral nerve sheath tumor Cohort 5: other sarcomas 1.2. Secondary Objectives The Secondary objective is: • To estimate the PFS and OS for patients treated with MLN8237 in each cohort • To assess the adverse events associated with patients treated with MLN8237 in each cohort 1.3 Correlative Objectives/ Translational Objectives The correlative objectives are: • To correlate potential clinical benefit with markers of aurora kinase inhibition in pre- and post-treatment tumor biopsies • To correlate clinical outcome with change in FLT-PET uptake at baseline versus after one week of treatment (ie, Week 2 of Cycle 1) 2.0 BACKGROUND 2.1 Soft tissue sarcoma Soft tissue sarcomas (STS) are heterogeneous malignant tumors of mesenchymal origin. Approximately 13,000 cases of soft tissue and bone are diagnosed annually in the US. Surgery, often with adjuvant radiation therapy for larger tumors, is the mainstay of treatment. Despite primary combined modality therapy, between 30-80% of patients develop recurrent and/or metastatic disease. The standard of care for metastatic disease for many years has been doxorubicin or a doxorubicin combination. Response rates, however, are low [1]. Another chemotherapy option for metastatic disease is gemcitabine with docetaxel, however activity is limited [2]. Recent phase II studies of the targeted agents imatinib, sunitinib, and sorafenib have also been disappointing. Thus, there is a dearth of active agents and an unmet medical need. 2.2 CTEP and CIP IND Agents 2.2.1 MLN8237 Background The aurora kinase family of serine/threonine kinases consists of three members, designated aurora kinases A, B, and C [3]. Aurora kinases A and B are expressed in many different cell types, whereas the expression of aurora kinase C is Version Date 02/20/2014 7 Update #04 ALLIANCE A091102 restricted to testicular tissue. Aurora kinase A is located at the centrosome and required for centrosome maturation and division as well as the formation of the mitotic spindle. In a number of different experimental systems, aurora kinase A inhibition leads to mitotic delays and severe chromosome congression, and segregation defects followed by cell death [4-7]. By the G2 phase of the cell cycle through anaphase, it can be detected in the pericentriolar material, and spreads to mitotic spindle poles and midzone microtubules during mitosis [8] . In addition to its primary effects on the cell cycle, aurora kinase A appears to have a role in oncogenic signaling, including the activity of myc [9]. Aurora kinase A overexpression results in centrosome amplification, chromosome instability, and oncogenic transformation in mammalian cells [3]. Overexpression or amplification of the aurora kinase A gene has been identified in several malignancies including breast [10, 11], colon [12], lung [13], and head and neck cancers [14]. In some tumor types, aurora kinase A overexpression was associated with poorly differentiated tumors [13] and a poor prognosis [10, 14]. In addition, overexpression was found in aggressive lymphomas [15], ovarian cancer, specifically primary ovarian tumors and high-grade serous carcinoma [16-18], head and neck squamous cell carcinoma [14, 19], gastrointestinal adenocarcinomas [20], colorectal cancer [21], myelodyplastic syndromes and acute myeloid leukemia (AML) [22], and Barrett’s carcinogenesis [23]. Several polymorphisms in the aurora kinase A gene have been identified. Specifically, the polymorphic substitution of isoleucine for phenylalanine at residue 31 (F31I) has been correlated with an increased risk of developing breast cancer [24]. Preclinical Evaluations of MLN8237 MLN8237 is an adenosine triphosphate (ATP)-competitive and reversible inhibitor of aurora kinase A with an inhibition constant (Ki) of 0.43 nM [25]. MLN8237 inhibited aurora kinase A activity in HCT-116 human colon cancer cells with a half-maximal inhibitory concentration (IC50) of 6.7 nM and was approximately 200-fold more selective for aurora kinase A than aurora kinase B (IC50=1534 nM). In addition, MLN8237 was at least 250-fold more selective for aurora kinase A when compared to other kinases tested in vitro. In Vitro Activity Antiproliferative effect of MLN8237 has been noted in cell lines derived from a variety of malignancies (Table 1) including colon, lung, breast, prostate, ovary, pancreas, and lymphoid [25]. Version Date 02/20/2014 8 Update #04 ALLIANCE A091102 Table 1. Growth Inhibition Induced by MLN8237 in Cultured Tumor Cells Cell Line HCT-116 SW480 DLD-1 H460 MD-MB-231 PC3 SKOV3 HPAC LY-3 Origin MLN8237 GI50 (nM) Colon Tumor 34 ± 10 (8)a Colon Tumor 431 ± 159 (8) Colon Tumor 469 (1) Lung Tumor 17 (1) Breast Tumor 190 (1) Prostate Tumor 54 (1) Ovarian Tumor 111 (1) Pancreatic Tumor 130 (1) Lymphoma 43 (1) GI50 = concentration required to achieve 50% cell growth inhibition. a Numbers represent average GI50 ± standard deviation derived from the bromodeoxyuridine (BrdU) cell proliferation ELISA. Numbers in parentheses represent the number of experiments completed. MLN8237 was tested against the Pediatric Preclinical Testing Program (PPTP) in vitro panel at concentrations ranging from 1.0 nM to 10 μM [26]. The cell lines included AML, anaplastic large cell lymphoma (ALCL), acute lymphoblastic leukemia (ALL) B-precursor and T-cell, non-Hodgkin’s lymphoma (NHL), neuroblastoma (NB), and Ewing’s as well as rhabdoid and rhabdomyosarcoma. MLN8237 had a median IC50 of 61 nM. Specifically, the ALL cell lines were more sensitive and the rhabdomyosarcoma cell lines were less sensitive than the remaining PPTP cell lines. In a further confirmation of these results, MLN8237 demonstrated significant activity in vivo against solid tumor models (6 of them neuroblastoma) at the MTD of 20.8 mg/kg; however, only 2 of 6 neuroblastoma models had objective responses at 0.25 of the MTD [27]. In three ALL models, MLN8237 induced objective responses at its MTD and at 0.5 of the MTD, and in two out of three models at 0.25 of the MTD. PK studies at the MTD demonstrated a time to peak plasma concentration (Tmax) of 0.5 hours, maximum plasma concentration (Cmax) of 42.5 μM, area under the curve from zero to 24 hours (AUC0–24 hr) of 78.4 μM·h, and 12-hour trough level of 1.8 μM. Mitotic indices increased 6–12 hours after MLN8237 administration. In addition, objective responses were more frequent in tumors with decreased AURKA copy number (5/8) compared to those with increased gene copy number (2/14). MLN8237 inhibited the in vitro growth and survival of human chronic myeloid leukemia (CML) cell lines as well as primary CML cells from patients (Kelly et al., 2010). Activity was noted in imatinib-sensitive and -resistant CML cells as well as cells expressing unmutated and mutated BCR-ABL. MLN8237 induced apoptosis in AML cell lines and leukemia cells from patients with either newly diagnosed or relapsed AML [28]. Treatment with MLN8237 and cytarabine resulted in greater apoptosis and tumor regression than treatment with either agent alone. In addition, MLN8237 strongly inhibited the viability and proliferation of both primary multiple myeloma (MM) cells and MM cell lines in the presence of stroma cells, interleukin (IL)-6, and insulin growth factor-1 (IGF1) [29]. In Vivo Activity Version Date 02/20/2014 9 Update #04 ALLIANCE A091102 In several experimental solid and hematologic human xenograft models in mice, MLN8237 demonstrated tumor growth inhibition (TGI) >90% when administered orally on a daily basis for approximately 21 days [30]. Less frequent dosing (e.g., 5 days of treatment followed by 5 days of rest) was also efficacious, demonstrating that continuous dosing may not be necessary for antitumor activity [31]. MLN8237 was tested against the PPTP in vivo panels at a dose of 20 mg/kg administered orally BID for 5 days (Maris et al., 2010). Solid tumor xenografts were treated for 6 weeks and ALL xenografts for 3 weeks. MLN8237 induced differences in event-free survival (EFS) distributions in 32/40 (80%) solid tumor models and all (6/6) ALL models compared to controls. All six evaluable ALL xenografts achieved complete responses (CR; n=4) or maintained CR status (n=2); maintained CRs were observed in three of seven NB xenografts. There did not appear to be a correlation between aurora kinase A copy number or expression with kinase activity level in the xenografts suggesting that other cofactors of aurora kinase A may have a role in the response to MLN8237. Other xenograft models included MM [29] and diffuse large B-cell lymphoma (DLBCL) [32, 33]. Combination studies were also conducted in xenograft models. In DLBCL xenografts, MLN8237 administered 3 or 10 mg/kg QD for 21 days with rituximab (10 mg/kg; every 7 days [Q7D]) demonstrated additive activity or better, and resulted in complete regression of disease in some animals with the mean survival endpoint significantly longer than either agent alone [33]. In addition, MLN8237 in combination with docetaxel was studied in multiple human tumor xenografts, including breast, non-small cell lung cancer (NSCLC), and prostate models [30]. MLN8237 demonstrated either additive or synergistic antitumor activity in all combination studies, and long-term benefit was observed, as shown by increased tumor growth delay after terminating treatment. Antitumor activity was also observed when MLN8237 treatment was administered on an intermittent dosing schedule, including the 3 days on/4 days off combined with weekly taxane schedule [34]. This latter MLN8237 schedule of administration supports clinical evaluation of alternative schedules, including regimens designed to administer MLN8237 in combinations with other agents. In the clinic, protocol C14008 has been initiated in which MLN8237 is administered on Days 1, 2, 3, 8, 9, 10, 15, 16, and 17, and combined with paclitaxel administered weekly on Days 1, 8, and 15; the combination regimen is repeated in 28-day cycles (NCT01091428). Pharmacokinetics Rats and dogs were administered MLN8237 for 6 cycles with each cycle consisting of daily dosing for 21 consecutive days separated by a 7-day nondosing period [30]. For animals treated at 2 mg/kg, the Cmax and AUC0-24hr was 0.88 μM and 6.67 hr▪μM, respectively, for males, and 2.00 μM and 13.90 hr▪μM, respectively, for females on day 160. The Cmax and AUC0-24hr for the dose of 0.75 mg/kg on Day 160 in dogs was 1.34 μM and 14.4 hr▪μM, respectively. Toxicology The dose limiting toxicities (DLTs) were evaluated in both rats and dogs after repeat daily oral dosing for 2 cycles (each cycle consisted of 7 consecutive days separated by a 14-day dose rest) [30]. The DLT in rats was reversible Version Date 02/20/2014 10 Update #04 ALLIANCE A091102 myelosuppression (which resulted in secondary infections). The DLT in dogs was reversible gastrointestinal (GI) mucosal damage and myelosuppression. Principal findings included GI signs (stomatitis/mucositis/oral pain, nausea, vomiting, anorexia, abdominal pain, dyspepsia, diarrhea, and dehydration), decreased reticulocyte counts, and panleukopenia. Pharmacodynamics/Biomarkers MLN8237 decreases phosphorylation of aurora kinase A at the T288 amino acid residue and increases phosphorylation of histone H3 at Ser10 [29, 35]. In an asynchronous population of cells, mitotic delay manifested as an increase in the mitotic index (MI), which was used as a pharmacodynamic marker for MLN8237 in vivo [36]. The MI in HCT116 xenografts increased substantially in response to treatment. Maximally elevated MI levels in HCT116 tumors were observed at plasma concentrations ≥1 μM. The TGI was proportional to the average steadystate plasma concentration of MLN8237 and found to be saturated at higher steady-state plasma concentrations. The TGI at 12 days of continuous exposure was found to be proportional to the MI at 8 hours. Biomarker studies demonstrated that maintaining a plasma exposure in the vicinity of 1 μM led to maximal elevation of histone H3 phosphorylation and TGI [37] . Below 1 μM, both the histone H3 phosphorylation and TGI were dose-dependent. Notably, oral doses of MLN8237 that led to profound TGI maintained the critical 1 μM plasma exposure for 8–12 hours a day. Increased nuclear and cell body size, as well as staining for β-galactosidase (a molecular marker of cell senescence), revealed that aurora kinase A inhibitors (MLN8054 in this study) induced cellular senescence aside from apoptosis under some circumstances [38]. FDG (deoxy-2-[18F]-fluoro-D-glucose)-PET (positron emission technology) imaging demonstrated an acute change that appropriately predicted for the extent of chronic tumor volume response in CWR22RV1 SC xenografts [39]. Furthermore, FLT (fluorothymidine)-PET imaging in HCT-116 SC xenografts demonstrated an acute decrease preceding a significant change in tumor volume (unpublished data, Millennium Pharmaceuticals, Inc.). Further preclinical work to expand on the FLT-PET data is warranted and could support clinical evaluation of FLT-PET as a biomarker for pharmacodynamics or patient selection. Clinical Development of MLN8237 As of January 2011, there are ten completed or ongoing clinical studies of MLN8237 as listed in Table 2 below [30]. Another phase 1/2 study is planned to evaluate the combination of MLN8237 with rituximab and vincristine. Version Date 02/20/2014 11 Update #04 ALLIANCE A091102 Study Number C14001 C14002 C14003 C14004 C14005 C14006 C14007 C14008 with paclitaxel C14009 with docetaxel C14010 Table 2. Clinical Studies Sponsored by Millennium Pharmaceuticals, Inc. Phase Patient Population Dose and Schedule (All Adults) 1 Advanced solid tumors (U.S.) 21-, 14-, and 7-day schedules evaluated. Maximum tolerated dose ( MTD) was 50 mg BID for 7-days in a 21-day cycle. 1 Advanced malignancies (Spain) 21-, 14-, and 7-day schedules; MTD was 50 mg BID for 7 days in a 21-day cycle. 1 Relapsed or refractory advanced 14- and 7-day schedules; MTD was hematologic malignancies. 45 mg QD x 14 days in a 28-day cycle. Amended to evaluate MTD using Enteric Coated Tablet (ECT) Using ECT, MTD was 50 mg BID for formulation in 7-day schedule. 7 days in a 21-day cycle. 2 Aggressive non-Hodgkin’s lymphoma 50 mg BID for 7 days in a 21-day cycle. 2 Acute myelogenous leukemia; high50 mg BID for 7 days in a 21-day grade myelodysplastic syndrome cycle. 2 Platinum-refractory or -resistant Starting dose: 50 mg BID for 7 days fallopian tube, epithelial ovarian, or in a 21-day cycle. primary peritoneal carcinoma 1/2 Phase 1: nonhematological Enteric coated tablet. malignancies. Phase 1 doses studied: 10–60 mg BID. Phase 2: non-small cell lung (NSCLC), small cell lung (SCLC), breast, head and MTD and the Phase 2 dose 50 mg neck, or gastroesophageal malignancies. BID; for 7 days in a 21-day cycle. 1/2 Phase 1: ovarian or breast cancers. Phase 1 doses started with 10 mg BID Phase 2: relapsed ovarian cancer. on Days 1-3, 8-11, and 15-17, and Combination with weekly paclitaxel. paclitaxel on Days 1, 8, and 15 in a 28-day cycle. 1/2 Phase 1: solid tumors including castrate- Phase 1 doses started with 10 mg BID resistant prostate cancer. for 7 days; docetaxel on Day 1 in a 21-day cycle. Combination with Q3week docetaxel. 1 Advanced solid tumors Pill and oral solution; bioavailability and food effects. Pharmacokinetics Preliminary PK results were reported from two phase 1 studies in over 100 patients with advanced solid tumors receiving the powder in capsule (PIC) formulation or the newer ECT formulation [40, 41]. Using the PIC formulation, MLN8237 was administered orally QD or BID for 7, 14, or 21 days with a 14-day rest between cycles. MLN8237 was absorbed rapidly with a median Tmax of 2 hours. Mean terminal half-life (t1/2) was ~23 hours. Steady-state exposures were achieved by 7 days and were dose-proportional over 5–200 mg/day. The overall mean peak/trough ratios were 5.2 and 2.5 for QD and BID dosing, respectively (Investigator's Brochure, 2010). The overall mean accumulation ratios were 1.8 and 2.9 for QD and BID dosing, respectively. Version Date 02/20/2014 12 Update #04 ALLIANCE A091102 Using the ECT formulation (protocol C14007), MLN8237 was absorbed well with an overall median Tmax of 3 hours and dose-related increase in exposure over 10–50 mg BID. Mean t1/2 was ~20 hours following multiple dosing. Pharmacodynamics/Biomarkers Pharmacodynamic evaluations were performed in patient skin and tumor biopsies with PK evaluation of potential associations to the levels of MLN8237 exposures. These analyses have demonstrated that pharmacodynamics effects are dose- and/or exposure-dependent [40]. In phase 1 studies in patients with advanced solid tumors, at steady-state exposures, skin mitotic and apoptotic indices and tumor MI increased, while tumor mitotic cell chromosome alignment and spindle bipolarity decreased, all consistent with inhibition of aurora kinase A. In evaluable patients with paired tumor biopsies (n=8), exposure-related changes were observed by Day 7, including decreases in chromosome alignment and spindle bipolarity. In adults with advanced solid tumors, the recommended phase 2 dose (RP2D) was equivalent with the PIC and ECT formulations, e.g., 50 mg BID ×7 days in 21-day cycles. This dosing produced steady-state average plasma concentrations exceeding the target 1 μM concentration, estimated preclinically to be associated with pharmacodynamic effects. Safety In adult patients enrolled in phase 1-2 studies, the most frequent grade 3 or greater toxicities related to MLN8237 included blood and lymphatic system disorders such as neutropenia, leukopenia, and thrombocytopenia; gastrointestinal disorders including mucositis and diarrhea; and skin disorders (alopecia). These latter toxicities likely represent anti-proliferative effects in normal tissues which generally appear after completion of the dosing period in the first treatment cycles, and they are managed and monitored during the treatment-free period to allow recovery (except for alopecia) prior to the start of a new treatment cycle. Reflecting the benzodiazepine chemical structure of MLN8237, central nervous system (CNS) effects (such as somnolence, dizziness, confusion, gait disturbance, memory impairment) or other benzodiazepine-like effects were observed, and sometimes reported during initial drug administration. MLN8237 is structurally related to the benzodiazepines (e.g., diazepam, lorazepam, etc.) and has activity against the GABA receptor. The frequency and/or severity of benzodiazepineassociated CNS toxicities may be reduced in adult patients enrolled to recent protocols, which administered MLN8237 with divided doses (e.g., BID), a schedule designed to reduce peak plasma levels while maintaining overall AUC. However, some patients continued to report intermittent CNS events, including some serious adverse events (SAEs) after administration of the BID schedule. Overall, CNS effects were generally reversible and manageable by dose delay or reduction, and some patients have been managed by reduced dosing of other sedative medications, or coadministration of CNS stimulants such as methylphenidate. If a patient experiences sedation or any benzodiazepine-like effect after MLN8237 administration, it is recommended that the patient should not drive, operate dangerous tools or machinery, or engage in any other potentially hazardous activity that requires full alertness and coordination. Differential diagnosis of observed CNS effects should also be considered, such as co-morbidities associated with the patient’s oncologic diagnosis, concomitant medications, infection, metabolic abnormalities, etc. Version Date 02/20/2014 13 Update #04 ALLIANCE A091102 The initial phase 1-2 studies employed a PIC formulation of MLN8237. Recent studies have employed an ECT formulation, which will be administered in newer studies. In the phase 1 part of C14007, MLN8237 ECT was administered BID for 7 days followed by a 14-day treatment-free period (21-day cycle) [41]. Doses were escalated in a 3+3 design based on dose-limiting toxicities in cycle 1 until the maximum tolerated dose (MTD). AEs were graded according to NCI-CTCAE v4.0. Neutropenia was the most common grade ≥3 AE, and was generally reversible. Table 3 below lists treatment-emergent across all dose levels evaluated in the study, including any grade reported in ≥20% or grade ≥3 in ≥10% of patients. At the maximum administered dose of 60 mg BID, 3 patients experienced grade 4 neutropenia, and this dose level was determined to be above the MTD. The MTD was determined to be 50 mg BID for 7 days in a 21-day cycle. Table 3. Adverse Events Profile of MLN8237 Administered to Adult Patients with Nonhematologic Malignancies Adverse Event No. (%) of Patients (N=17) Any Grade Grade ≥3 Fatigue 12 (42) 3 (13) Alopecia 10 (43) -Anorexia 10 (43) -Diarrhea 10 (43) 3 (13) Neutropenia 10 (43) 9 (39) Leukopenia 8 (35) 6 (26) Vomiting 8 (35) 4 (17) Nausea 7 (39) 5 (22) Stomatitis 7 (30) -Abdominal pain 6 (26) 3 (13) Hypersomnia (Somnolence) 5 (22) Thrombocytopenia 5 (22) -Febrile neutropenia 3 (13) 3 (13) White blood cell decreased 3 (13) 3 (13) Anemia 2 (12) 3 (13) The appearance of toxicities on days 8–15, some of which were dose limiting at higher dose levels, favored a 7-day administration schedule followed by a 2-week treatment-free period to allow recovery with safety monitoring prior to start of a new cycle. In addition, an alternative multi-day schedule is supported by results in preclinical xenograft models [34], in which MLN8237 is administered BID for 3 consecutive days in 3 out of 4 weeeks, e.g., 3 days on/4 days off, given alone or in combination with another agent given weekly, e.g., Days 1, 8, and 15 in a 28-day cycle to allow overlapping exposures. After administration of multi-day schedules, the dominant toxicities observed to date included reversible hematologic and GI events (mucositis, diarrhea), likely reflecting the anti-proliferative mechanism of action. Safety data from the C14001 study were reported at the American Society of Clinical Oncology (ASCO) 2010 meeting [42]. In that study, sixty-five patients with solid tumors received the PIC formulation of 5–150 mg MLN8237, orally QD for 7 days or 25–70 mg QD for 14 or 21 days. DLTs included grades 3–4 neutropenia with fever (n=4), thrombocytopenia (n=3), somnolence (n=2), and mucositis (n=1), and were seen at doses ≥40 mg BID x 14 days, ≥110 mg/day x 7 days, and 50 mg BID x 7 Version Date 02/20/2014 14 Update #04 ALLIANCE A091102 days. The reversibility of alopecia has not been established; however, other prevalent toxicities (myelotoxicities and GI disorders) are largely manageable by dose reduction, interruption of the planned dosing schedule, or supportive care. The AE profile is listed in Table 4 below [42]. At 75 mg BID for 7 days in a 21-day cycle, one patient experienced neutropenia lasting more than 7 days, and another patient experienced stomatitis/oral mucositis with neutropenia requiring dose reduction in cycle 2 [30]. Grade 4 thrombocytopenia, grade 4 neutropenic fever, and grade 3 somnolence were observed in patients treated with 60 mg BID. Table 4. Adverse Events Profile of MLN8237 Administered to Patients with Solid Tumors Most Frequent No. (%) of Patients (N=65) Drug-Related AEs Any Grade Grade ≥3 Nausea 33 (51) 1 (2) Fatigue 28 (43) 3 (5) Diarrhea 24 (40) 6 (9) Somnolence 25 (38) 2 (3) Alopecia 24 (37) -Neutropenia 24 (37) 16 (25) Anemia 21 (32) 5 (8) Vomiting 20 (31) 1 (2) Anorexia 19 (29) -Stomatitis 14 (22) 1 (2) Thrombocytopenia 10 (15) 5 (8) Febrile neutropenia 6 (9) 6 (9) 8 patients (12%) discontinued due to AEs across all dose levels. Other common AEs (grades 1-4) include: (1) reversible myelosuppression including leukopenia, lymphopenia, and neutropenia; (2) GI toxicity including abdominal pain, dehydration, and dyspepsia; (3) confusion and disorientation, sedation, and associated memory loss and gait disturbances; (4) fever; (5) infection; (6) alopecia; (7) asthenia/fatigue; (8) fever, (9) infection, (10) abnormal liver function tests (including alanine transaminase [ALT], aspartate aminotransferase [AST], bilirubin, alkaline phosphatase, and gamma-glutamyl transpeptidase [GGT]); (11) rash, which may include bullous dermatitis or palmar-plantar erythrodysaesethesia syndrome (hand and foot syndrome); and (12) dehydration [30]. However, because of limited human experience with MLN8237, it is possible that other toxicities that have not been observed/predicted in rats and dogs, and from ongoing studies in humans, will occur. SAEs included effects related to MLN8237 and those attributable to disease progression in the advanced malignancy patient population. In a phase 2 trial, patients with advanced AML or intermediate-2/high-risk myelodysplastic syndrome (MDS) received 50 mg of MLN8237 for 7 days followed by a 14-day rest in 21-day cycles (Goldberg et al., 2010). Treatment-related grade 3/4 AEs were seen in 24 (42%) patients and included febrile neutropenia (11%), anemia (9%), thrombocytopenia (9%), neutropenia (7%), and fatigue (7%). Treatmentemergent somnolence was identified in 14 (25%) patients; grade 3/4 somnolence was reported in 2 (4%) patients. Efficacy Partial (PR) or CRs have been observed in multiple hematologic malignancies and solid tumors. In a phase 1 study of patients with solid tumors, durable response was Version Date 02/20/2014 15 Update #04 ALLIANCE A091102 seen in a patient with platinum-refractory ovarian cancer who continued to tolerate the treatment over 2 years (>30 cycles) [42]. Eight patients continued ≥6 cycles with stable disease (3 head and neck, 2 lung, and 3 others). With single agent MLN8237 treatment, objective responses were also observed in a phase 2 study that enrolled patients with relapsed ovarian, fallopian tube, or primary peritoneal carcinoma [43]. Objective antitumor activity has been observed in patients with relapsed lymphoma and myeloma. In a phase 2 study that enrolled 48 patients with mixed types of aggressive B- or T- cell lymphomas, responses (PR and CR) were reported in patients with multiple lymphoma histologies (peripheral T-cell lymphoma [PTCL], DLBCL, mantle cell, transformed follicular, and Burkitt’s lymphoma) and some responses have been durable over 1 year with continued treatment cycles [44]. Six (13%) responses were observed (all AML patients) in 45 evaluable patients who received 50 mg of MLN8237 for 7 days followed by a 14-day rest in 21-day cycles [45]. One CR was documented in a 79-year-old female with AML and no prior therapy, while 5 patients had a PR. Seventeen (49%) AML and 2 MDS (20%) patients achieved stable disease. Pediatric Studies In children with refractory solid tumors, MLN8237 was administered orally as the PIC formulation QD or BID for 7 days, every 21 days [46]. Using the rolling-six design, four dose levels (45, 60, 80, and 100 mg/m2/day) were evaluated on the QD regimen and two dose levels (60 and 80 mg/m2/day) on the BID regimen. On the QD regimen, 1/6 patients developed DLT (grade 3 mucositis) at 45 mg/m2 and 1/6 developed DLT (grade 4 mood alteration) at 80 mg/m2. At 100 mg/m2, 3/4 patients developed DLT (neutropenia/thrombocytopenia), thus exceeding the MTD. On the BID regimen, 2/6 patients developed dose-limiting myelosuppression at 80 mg/m2; one of these patients also experienced grade 3 mucositis. One out of five patients experienced DLT (grade 3 alkaline phosphatase) at 60 mg/m2. Of note, 5/11 patients experienced hand-foot-skin syndrome (grades 1–3) versus 1/21 (grade 2) on the QD schedule. Although the BID regimen appeared to be well tolerated in adults, children experienced more myelosuppression and hand-foot-skin syndrome with BID versus QD dosing. Therefore, the recommended pediatric phase 2 dose and schedule of MLN8237 is 80 mg/m2/day administered QD for 7 days, followed by a 2-week treatment-free period. 2.3 Rationale Several lines of evidence suggest that an inhibitor of Aurora Kinase A (AURKA) represents a promising new treatment for soft tissue sarcoma. Our group has studied AURKA expression and inhibition in multiple STS subtypes. We have shown that AURKA is commonly overexpressed in STS, and that inhibition of AURKA by shRNA or by a specific AURKA inhibitor inhibits proliferation of STS cells. These observations provide a strong rationale for a clinical trial of an AURKA inhibitor in multiple STS subtypes. Beginning with liposarcoma, we applied a microarray-based gene-expression profiling approach to identify molecular signatures that distinguish liposarcoma subtypes (welldifferentiated/de-differentiated; myxoid/round cell; and pleomorphic). Differentially expressed genes for each liposarcoma subtype compared to normal fat were used to identify histologyspecific signaling pathways and candidate genes important to liposarcoma pathogenesis and progression. We postulated that these differentially expressed genes may serve as potential therapeutic targets. Among the most strongly overexpressed genes in liposarcoma is AURKA, which is both overexpressed and amplified. Specifically, we have found a 3-fold increase in Version Date 02/20/2014 16 Update #04 ALLIANCE A091102 AURKA in dedifferentiated liposarcoma (p<0.0002) and 10-fold increase in pleomorphic liposarcoma (p<0.00005), when each is compared to normal fat. In vitro, shRNA knockdown of AURKA inhibits proliferation of dedifferentiated liposarcoma cell lines. Preclinical development of AURKA inhibitors for treatment of liposarcoma: We next sought to determine whether liposarcoma cell lines could be growth inhibited with a specific AURKA inhibitor. Using a small molecule AURKA inhibitor (AURKAi), we first confirmed target specificity in an in vitro kinase assay using purified AURKA and biotinylated Polo like kinase 1 (PLK1) peptide, known substrates of AURKA. As shown in figure 1 (i) phosphorylation of PLK1 peptide (Ser137) was inhibited when the kinase assay was done in the presence AURKAi (500 nM). T-288, an auto-phosphorylation site of AURKA, was also inhibited (Figure 1 (ii)) upon incubation with AURKAi. As a negative control, the experiment was repeated using Aurora B kinase and histone H3 as substrate. No inhibition of phosphorylation of AURKB or histone H3 was observed upon incubation with AURKAi (Figure 1 (iii)), indicating the specificity of AURKAi for AURKA and not AURKB. Figure 1. AURKAi inhibits the phosphoryl-ation of AURKA substrate PLK1 (i) and AURKA auto-phosphorylation (ii) but not the Aurora B substrate H3 (iii). Figure 2. Growth inhibition of three liposarcoma cell lines treated for 6 days with 5 and 10 µM of AURKAi. Growth inhibition was determined with the CCK-8 cell counting kit and is represented as proliferation as a percentage of untreated controls. With AURKA specificity established, we next treated a panel of liposarcoma cell lines with either 5 or 10 µM of AURKAi. As shown in Figure 2, all the cell lines were inhibited by the drug. Interestingly, this was also observed in LS141 cells, which we have reported shows increased AURKA protein expression relative to normal fat, but in which the gene is not amplified [47]. We reported similar results with shRNA such that all the cell lines could be Version Date 02/20/2014 17 Update #04 ALLIANCE A091102 inhibited by shRNA, including LS141. Thus, amplification of AURKA is not an absolute requirement for growth inhibition by an AURKA inhibitor. Figure 3. Growth inhibition of two malignant peripheral nerve sheath tumor (MPNST) cell lines treated for 6 days with 5 and 10 µM of AURKAi. We next extended this observation to other subtypes of sarcoma. We treated two malignant peripheral nerve sheath tumor (MPNST) cell lines (MPNST and ST88) with AURKAi. As shown in figure 3, these cells are also exquisitely sensitive to AURKA inhibition, suggesting that sensitivity to AURKA inhibitors may be a property of several subtypes of STS. Indeed, we have tested other sarcoma cell lines, including Ewing sarcoma, synovial sarcoma, and rhabdomyosarcoma, and have observed similar results (data not shown). Collectively, this data supports the clinical testing of AURKA inhibitors in multiple STS subtypes. We have also begun to examine the effect of AURKAi on the cell cycle. Figure 4 shows the flow cytometry results of liposarcoma cells treated with 5 µM of AURKAi. Drug treatment induces a G2/M peak with a time dependent increase in the mitotic population (figure 4). Western blot confirms AURKA protein expression in the cell lines. Interestingly, AURKA expression increases with drug therapy, as a result of cells accumulating in the M phase of the cell cycle. Version Date 02/20/2014 18 Update #04 ALLIANCE A091102 Figure 4. Flow cytometry of DDLS and LS141 cells treated with 5 µM of AURKAi for 24 hours indicates the induction of a G2/M peak with an increase in the mitotic population as reflected by an increase in MPM-2 labeling (upper right boxes). Western blot shows AURKA expression increases with drug therapy as cells accumulate in M phase. Our colleagues in France have also studied the role of AURKA in STS. Through gene expression profiling, they identified AURKA as a key component of the CINSARC (complexity index in sarcomas) signature, a group of genes related to mitosis and chromosome management [48]. This data supports the oncogenic role of AURKA in STS, particularly those subtypes with complex genetic changes such as leiomyosarcoma and undifferentiated sarcoma (also called malignant fibrous histiocytoma or MFH). Thus, multiple lines of preclinical evidence support the selective targeting of AURKA in STS subtypes. MLN8237 is a novel, oral, ATP-competitive, selective small-molecule inhibitor of AURKA currently in clinical development. It was designed as a second generation AURKA inhibitor so as to reduce the benzodiazepine-like central nervous system effects observed with the parent compound MLN8054. MLN8054 has broad anti-tumor activity both in tumor cell lines and in xenografts.(Manfredi et al., 2008) In preclinical studies MLN8237 is more potent than MLN8054. Clinical development of AURKA inhibitors: A phase I trial examining the safety and efficacy of MLN8237 has been completed [40, 42].Grade 3 and 4 neutropenia with stomatitis Version Date 02/20/2014 19 Update #04 ALLIANCE A091102 was dose-limiting and the recommended phase II dose was 50 mg BID. Pre and post treatment skin biopsies showed an increase in the number of mitotic cells, by measuring MPM2 and phospho-ser10 Histone H3 as mitotic markers, at doses ≥ 50 mg BID, suggesting effective target inhibition. A partial response was observed in a patient with pleomorphic liposarcoma who had failed prior chemotherapy. This patient remained on study for over one year without evidence of disease progression. This clinical result is especially remarkable considering the natural history of the disease. Historical data show that the prognosis for advanced sarcoma patients who have failed at least one prior therapy is poor, with 90% experiencing disease progression within 6 months (i.e., the 6-month progression-free survival is 10%) [49]. Thus, we consider the prolonged progression-free survival in this patient a meaningful result. 3.0 PATIENT SELECTION 3.1 Eligibility Criteria 3.1.1 Patients must have histologically or cytologically confirmed sarcoma that is metastatic and/or locally advanced or locally recurrent and unresectable. Confirmation of pathologic diagnosis will be performed at the registering site. Patients will be enrolled on one of five cohorts of the study: • Cohort 1: liposarcoma • Cohort 2: leiomyosarcoma (non-uterine) • Cohort 3: undifferentiated sarcoma (including malignant fibrous histiocytoma and myxofibrosarcoma) • Cohort 4: malignant peripheral nerve sheath tumor • Cohort 5: other sarcomas 3.1.2 Patients must have measurable disease per RECIST 1.1 Note: defined as at least one lesion that can be accurately measured in at least one dimension (longest diameter to be recorded for non-nodal lesions and short axis for nodal lesions) as ≥ 2 cm with conventional techniques or as ≥ 1 cm with spiral CT scan, MRI, or calipers by clinical exam. See Section 11 for the evaluation of measurable disease. 3.1.3 Any number of prior therapies is permitted. Note: The last dose of systemic therapy (including tyrosine kinase inhibitors) must have been given ≥ 4 weeks prior to initiation of therapy. Patients receiving BCNU or mitomycin C must have received their last dose of such therapy at least 6 weeks prior to initiation of therapy. 3.1.4 Age ≥ 18 years. 3.1.5 ECOG PS ≤ 2 (Please refer to appendix A) 3.1.6 Patients must have normal organ and marrow function as defined below: Version Date 02/20/2014 -leukocytes ≥3,000/mcL -absolute neutrophil count ≥1,500/mcL -platelet count ≥100,000/mcL 20 Update #04 ALLIANCE A091102 ≤1.5X institutional upper limit of normal -total bilirubin -SGOT(AST) and SGPT(ALT) <3X institutional upper limit of normal if no liver metastases or <5X institutional upper limit of normal if liver metastases present ≤ 1.5 X ULN -creatinine OR -creatinine clearance ≥60 mL/min/1.73 m2 for patients with creatinine levels above institutional normal. 3.1.7 Women of childbearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation. Note: The effects of MLN8237 on the developing human fetus are teratogenic. 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 adequate contraception prior to the study, for the duration of study participation, and 4 months after completion of MLN8237 administration. 3.1.8 Ability to understand and the willingness to sign a written informed consent document. 3.1.9 According to current guidelines, patients must be able to take oral medication and to maintain a fast as required for approximately one hour before and two hours after MLN8237 administration. 3.2 Exclusion Criteria 3.2.1 Patients who have had chemotherapy or radiotherapy within 4 weeks (6 weeks for nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered from adverse events due to agents administered more than 4 weeks earlier. Patients who have had radiation therapy to more than 25% of the bone marrow. Whole pelvic radiation is considered to be over 25%. 3.2.2 Patients who are receiving any other investigational agents. 3.2.3 Patients with known brain metastases. Note: These patients should be excluded from this clinical trial because of their poor prognosis and because they often develop progressive neurologic dysfunction that would confound the evaluation of neurologic and other adverse events. 3.2.4 History of allergic reactions attributed to compounds of similar chemical or biologic composition to MLN8237, including but not limited to established allergic reaction to benzodiazepines. 3.2.5 Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, NYHA Class II-IV heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements. Version Date 02/20/2014 21 Update #04 ALLIANCE A091102 3.2.6 Pregnant women. Note: Women of child bearing potential must have a negative serum or urine pregnancy test within 7 days prior to registration. This is because MLN8237 is an aurora kinase A inhibitor with the potential for teratogenic or abortifacient effects. • Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with MLN8237, breastfeeding should be discontinued if the mother is treated with MLN8237. These potential risks may also apply to other agents used in this study. 3.2.7 Leiomyosarcoma of the uterus 3.2.8 Patients known to be HIV-positive on antiretroviral therapy. Note: These patients are ineligible because of the potential for pharmacokinetic interactions with MLN8237. 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 antiretroviral therapy when indicated. 3.2.9 Prior allogeneic bone marrow or organ transplantation. 3.2.10 Known history of uncontrolled sleep apnea syndrome and other conditions that could result in excessive daytime sleepiness, such as severe chronic obstructive pulmonary disease; requirement for supplemental oxygen; or any conditions that could result in excessive toxicity associated with the benzodiazepine-like effects of MLN8237. 3.2.11 Requirement for constant administration of proton pump inhibitor, H2 antagonist, or pancreatic enzymes. Note: Intermittent uses of antacids or H2 antagonists are allowed as described in Section 8.1.1. 3.2.12 Inability to swallow oral medication or to maintain a required fast for approximately one hour before and two hours after MLN8237 administration or any condition that would modify small bowel absorption of oral medications, including malabsorption, or resection of pancreas or upper bowel. 3.2.13 Treatment with clinically significant enzyme inducers, such as the enzymeinducing antiepileptic drugs phenytoin, carbamazepine, oxcarbazepine, primidone or phenobarbital, or rifampin, rifabutin, rifapentine, or St. John's wort within 14 days prior to the first dose of MLN8237 and during the study. 3.3 Inclusion of Women and Minorities Both men and women of all races and ethnic groups are eligible for this trial. 4.0 REGISTRATION 4.1 Registration Requirements Informed Consent: the patient must be aware of the neoplastic nature of his/her disease and willingly consent after being informed of the procedure to be followed, the experimental nature of the therapy, alternatives, potential benefits, side- effects, risks, and discomforts. Human subjects protection committee approval of this protocol and a consent form are required. Registration must occur prior to the initiation of therapy. Version Date 02/20/2014 22 Update #04 ALLIANCE A091102 Registration to the optional correlative studies will be performed at the time registration occurs to the treatment study. Registration to both the treatment study and the companion study will not be completed if eligibility requirements are not met for both trials. 4.2 OPEN Registration Procedures This study is supported by the NCI Cancer Trials Support Unit (CTSU). Prior to the recruitment of a patient for this study, investigators must be registered members of a Cooperative Group. Each investigator must have an NCI investigator number and must maintain an “active” investigator registration status through the annual submission of a complete investigator registration packet (FDA Form 1572 with original signature, current CV, Supplemental Investigator Data Form with signature, and Financial Disclosure Form with original signature) to the Pharmaceutical Management Branch, CTEP, DCTD, NCI. These forms are available on the CTSU Web site (enter credentials at https://www.ctsu.org; then click on the Register tab) or by calling the PMB at 240-276-6575 Monday through Friday between 8:30 a.m. and 4:30 p.m. Eastern time. Each investigator or group of investigators at a clinical site must obtain IRB approval for this protocol and submit IRB approval and supporting documentation to the CTSU Regulatory Office before they can enroll patients. Study centers can check the status of their registration packets by querying the Regulatory Support System (RSS) site registration status page of the CTSU member web site by entering credentials at https://www.ctsu.org. Requirements for Alliance 091102 site registration: • CTSU IRB Certification • CTSU IRB/Regulatory Approval Transmittal Sheet Please note: Patient enrollment will be facilitated using the CTSU Slot Reservation System in conjunction with the Oncology Patient Enrollment Network (OPEN). Prior to discussing protocol entry with prospective patients, site staff must use the CTSU OPEN Slot Reservation System to ensure that a slot for the study is available to the patient. Once a slot reservation confirmation is obtained, site staff may then proceed to enroll patients to this study. Please note that a slot reservation will only be held for up to seven calendar days. Patient registration can occur only after pre-treatment evaluation is complete, eligibility criteria have been met, and the study site is listed as ‘approved’ in the CTSU RSS. Patients must have signed and dated all applicable consents and authorization forms. All site staff (Lead Group and CTSU Sites) will use OPEN to enroll patients to this study. OPEN can be accessed at https://open.ctsu.org or from the OPEN tab on the CTSU members’ side of the website at https://www.ctsu.org. Prior to accessing OPEN site staff should verify the following: All eligibility criteria has been met within the protocol stated timeframes. Site staff should use the registration forms provided on the group or CTSU web site as a tool to verify eligibility. All patients have signed an appropriate consent form and HIPAA authorization form (if applicable). Access requirements for OPEN: Site staff will need to be registered with CTEP and have a valid and active CTEP-IAM account. This is the same account (user id and password) used for the CTSU members' web site. Version Date 02/20/2014 23 Update #04 ALLIANCE A091102 To perform registrations, the site user must have been assigned the 'Registrar' role on the relevant Group or CTSU roster. To perform registrations on protocols for which you are a member of the Lead Group, you must have an equivalent 'Registrar' role on the Lead Group roster. Role assignments are handled through the Groups in which you are a member To perform registrations to trials accessed via the CTSU mechanism (i.e., non-Lead Group registrations) you must have the role of Registrar on the CTSU roster. Site and/or Data Administrators can manage CTSU roster roles via the new Site Roles maintenance feature under RSS on the CTSU members' web site. This will allow them to assign staff the "Registrar" role. Note: The OPEN system will provide the site with a printable confirmation of registration and treatment information. Please print this confirmation for your records. Further instructional information is provided on the OPEN tab of the CTSU members’ side of the CTSU website at https://www.ctsu.org or at https://open.ctsu.org. For any additional questions contact the CTSU Help Desk at 1-888-823-5923 or [email protected]. Please note : PMB will not provide MLN8237 to the international sites. 5.0 TREATMENT 5.1 Agent Administration 5.1.1 MLN8237 MLN8237 50 mg orally twice daily on day 1-7, every 21 days until the patient meets any of the criteria in Section 5.2, 5.4 or 5.5. Treatment will be administered on an outpatient basis. No investigational or commercial agents or therapies other than those described below may be administered with the intent to treat the patient's malignancy. The study drug MLN8237 will be administered on an empty stomach with the patient remaining NPO (nothing by mouth), except for water and prescribed medications, for approximately one hour before and two hours after each dose. Patients will be instructed to take each oral dose of MLN8237 with 8 ounces (1 cup, 240 mL) of water. The patient will be requested to maintain a medication diary of each dose of medication. The medication diary will be returned to clinic staff at the end of each course. See Appendix B for an example of the medication diary. 5.2 End of Treatment/Intervention 5.2.1 5.2.1.1 Duration of Treatment Clinical Follow-Up Phase: Patients who are in CR, PR or SD will continue on therapy until PD, or unacceptable adverse events occur. There is no limit to the number of cycles of therapy patient may receive on study, assuming availability of agents and no change in the status regarding commercialization of MLN8237 with respect to sarcoma. Upon PD, patients will begin the Survival and Disease Status Follow-Up phase of the study. Patients discontinuing for reasons other than PD will return in 4 weeks (+/- 7 days) for an assessment of adverse events associated with the last cycle of treatment. Version Date 02/20/2014 24 Update #04 ALLIANCE A091102 Thereafter, they will begin the Survival and Disease Status Follow-Up phase of the study. Subsequent off-study treatment is at the discretion of their attending physician. 5.2.1.2 Survival and Disease Status Follow-Up Phase: During the Survival and Disease Status Follow-Up Phase, patients are monitored for off-treatment PD, long-term adverse events, new primaries, and survival. Here, patients should be followed per standard of care. Submit the appropriate form(s) per forms packet, every 6 months until a period of 18 months following registration. 5.3 General Concomitant Medication and Supportive Care Guidelines See Section 6.1 for guidelines in managing drug toxicity. 5.4 Definitions of Ineligible and canceled patients, and major protocol violations 5.4.1 A patient is deemed ineligible if after registration, it is determined that at the time of registration, the patient did not satisfy each and every eligibility criteria for study entry. The patient may continue treatment off-protocol at the discretion of the physician as long as there are no safety concerns, and the patient was properly registered. The patient will go directly to the Survival and Disease Status Follow-Up phase of the study (or off study, if applicable). • If the patient received treatment, all data up until the point of confirmation of ineligibility must be submitted. • If the patient never received treatment, on-study material must be submitted. 5.4.2 A patient’s registration is deemed a major violation if protocol requirements regarding treatment in cycle 1 of the initial therapy are severely violated that evaluability for primary end point is questionable. The patient may continue therapy at the discretion of the treating physician as long as there are no safety concerns and the patient was properly registered. If the patient continues on treatment, all scans, tests, and data submission will continue per protocol. If the patient does not continue therapy, all data until the patient stops therapy will be submitted, and the patient will go to the Survival and Disease Status Follow-Up phase of the study, or off-study if applicable. 5.4.3 A patient’s registration is deemed a cancel if s/he is removed from the study for any reason before any study treatment is given. On-study material and the End of Active Treatment/Cancel Notification Form must be submitted. No further data submission is necessary. 5.5 Extraordinary Medical Circumstances: If, at any time the constraints of this protocol are detrimental to the patient's health and/or the patient no longer wishes to continue protocol therapy, protocol therapy shall be discontinued. In this event: • Notify the Study Chair. • Document the reason(s) for discontinuation of therapy on Case Report Forms. • Follow the patient for survival or secondary malignancy for a minimum of 18 months following registration. Version Date 02/20/2014 25 Update #04 ALLIANCE A091102 5.6 Criteria for Removal from Protocol Therapy Patients will be removed from protocol therapy when any of the criteria listed in Section 5.2, 5.3, or 5.4 apply. The reason for removal from protocol therapy and the date the patient was removed must be documented in the Case Report Form. 5.7 Clinical Benefit in the Setting of Apparent Radiological Progression In exceptional cases there may be evidence of clinical benefit in the setting of progression by imaging studies. For example, with the use of imatinib in metastatic GIST, apparent progression was noted in liver metastases after exposure to imatinib. In retrospect, this radiological finding represented necrosis of occult lesions in the liver, not overt progression of disease. If a patient has evidence of clinical benefit in the setting of progression on imaging studies, the participating site investigator may petition to continue the patient on study. The patient will continue therapy pending a review of the imaging by the PI and discussion with CTEP as to whether to continue or not. The patient will come off study therapy if it is decided that the changes represent tumor progression instead of response, using a date of the measurement of the tumor as the date of progression. A patient allowed to continue on study therapy will maintain the follow up as defined in the study, and the Study Chair will remain involved in the decision making for continuation of the patient on study, incorporating the advice of CTEP staff. 6.0 DOSING DELAYS/DOSE MODIFICATIONS Therapy may be administered provided that the patient meets the following criteria at the beginning of each cycle: ANC > 1 x (109/l) Platelet Count > 50 x (109/l) Non-hematologic toxicity recovered to ≤ grade 1 (or tolerable grade 2); the following laboratory evaluations are excluded, which must recover to within one grade toxicity of their baseline: elevated lipase and/or amylase without pancreatitis, and lymphopenia. Patients who experience grade ≥ 3 hypophosphatemia or hypomagnesemia must recover to ≤ grade 2 before resuming treatment. No evidence of progressive disease Amylase, lipase, phosphorus or magnesium and not required to be routinely checked. 6.1 Dose adjustments: general principles • • • • Grading of AEs for dose modification is based on NCI-CTCAE (Version 4.0), unless otherwise indicated The maximum delay of starting a cycle of treatment for any reason is 2 weeks. If treatment is withheld for more than 2 continuous weeks due to a treatment-related toxicity that does not resolve, the patient will be withdrawn from the protocol treatment. AEs that can be managed with supportive care (anti-emetics, anti-diarrheals, GCSF, etc.) may not require dose reduction. The maximum number of dose reductions is 2. Version Date 02/20/2014 26 Update #04 ALLIANCE A091102 Dose Level -2 -1 0 MLN8237 Dose 30 mg PO BID d1-7, q21d 40 mg PO BID d1-7, q21d 50 mg PO BID d1-7, q21d 6.2 Dose Modifications for Hematologic Toxicity • For grade 3 or 4 neutrophil count decresed on day 1 of a cycle, delay MLN8237 until ANC improves to ≤ grade 2, then resume treatment with one dose level reducation for all subsequent cycles. • For febrile neutropenia, grade 4 neutropenia lasting longer than 7 days, or infection, at any time during a cycle, decrease MLN8237 by one dose level for all subsequent cycles. • For grade 3 or 4 platelet count on day 1 of a cycle, delay MLN8237 until platelets improve to ≤ grade 2, then resume treatment with one dose level reduction for all subsequent cycles. • For platelet count decrease complicated by bleeding at any time during a cycle decrease MLN8237 by one dose level for all subsequent cycles. • Myeloid growth factors may be used according to ASCO guidelines. 6.3 Dose Modifications for Non-Hematologic Toxicity 6.3.1 Dose Modifications for GI Toxicity Nausea and Vomiting • For grade 2 nausea or vomiting that the patient finds intolerable, delay (day 1) or interrupt MLN8237 until symptoms improve to ≤ grade 1, then resume treatment at the previous dose. • For grade 3 nausea or vomiting, or for grade 4 vomiting, delay (day 1) or interrupt MLN8237 until symptoms improve to ≤ tolerable grade 2, then resume treatment with one dose level reduction for all subsequent cycles. • Manage nausea and vomiting according to institutional procedures. Diarrhea • For grade 2 diarrhea that the patient finds intolerable, or grade 3 or 4 diarrhea, delay (day 1) or interrupt MLN8237 until diarrhea improves to ≤ tolerable grade 2, then resume treatment with one dose level reduction for all subsequent cycles. • Manage diarrhea with loperamide ( 4mg at onset, then 2mg with each loose bowel movement, until diarrhea free for 12 hours) or according to instutional guidelines. 6.4 Other non-hematologic Toxcity • For other grade 2 non-hematologic toxicity that the patient finds intolerable and that is considered at least possibly related to MLN8237, delay (day 1) or interrupt MLN8237 until toxicity improves to ≤ grade 1, then resume treatment at the previous dose. Version Date 02/20/2014 27 Update #04 ALLIANCE A091102 • For other grade 3 or 4 non-hematologic toxicity considered at least possibly related to MLN8237, delay ( day 1) or interrupt MLN8237 until toxicity improves to ≤ tolerable grade 2, then resume treatment with one dose level reduction for all subsequent cycles. 7.0 ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS 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. Adverse Events are required to be reported once the patient has been registered to treatment. 7.1 Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) 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 of AEs, the Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized text. The 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.info.nih.gov/protocolDevelopment/default.htm - adverse_events_adeers for further clarification. The CAEPR may not provide frequency data; if not, refer to the Investigator’s Brochure for this information. 7.1.1 7.1.1.1 CAEPRs for CTEP IND Agent CAEPR for MLN8237 Comprehensive Adverse Events and Potential Risks list (CAEPR) for MLN 8237 (NSC 747888) 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/aeguidelin es.pdf for further clarification. Frequency is provided based on 640 patients. Below is the CAEPR for MLN 8237. 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 2.2, November 27, 20131 Adverse Events with Possible Relationship to MLN 8237 Version Date 02/20/2014 28 Specific Protocol Exceptions to Expedited Reporting Update #04 ALLIANCE A091102 (CTCAE 4.0 Term) [n= 640] Likely (>20%) (SPEER) Rare but Serious (<3%) Less Likely (<=20%) BLOOD AND LYMPHATIC SYSTEM DISORDERS Anemia (Gr 3) Febrile neutropenia (Gr 3) Anemia Febrile neutropenia GASTROINTESTINAL DISORDERS Abdominal pain (Gr 2) Constipation (Gr 2) Diarrhea (Gr 2) Mucositis oral (Gr 3) Nausea (Gr 2) Oral pain (Gr 2) Vomiting (Gr 2) Abdominal pain Constipation Diarrhea Mucositis oral Nausea Oral pain Vomiting GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS Edema limbs (Gr 2) Fatigue (Gr 2) Fever (Gr 2) Edema limbs Fatigue Fever INFECTIONS AND INFESTATIONS Infection2 Infection2 (Gr 2) Alanine aminotransferase increased Alkaline phosphatase increased Aspartate aminotransferase increased Blood bilirubin increased Creatinine increased Lymphocyte count decreased Alanine aminotransferase increased (Gr 2) Alkaline phosphatase increased (Gr 2) Aspartate aminotransferase increased (Gr 2) INVESTIGATIONS Blood bilirubin increased (Gr 2) Creatinine increased (Gr 2) Lymphocyte count decreased (Gr 4) Neutrophil count decreased (Gr 3) Neutrophil count decreased Platelet count decreased White blood cell decreased Platelet count decreased (Gr 3) White blood cell decreased (Gr 4) METABOLISM AND NUTRITION DISORDERS Anorexia (Gr 2) Dehydration (Gr 2) Anorexia Dehydration NERVOUS SYSTEM DISORDERS Dizziness Headache Somnolence Headache (Gr 2) Somnolence (Gr 2) RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS Cough Dyspnea Dyspnea (Gr 2) SKIN AND SUBCUTANEOUS TISSUE DISORDERS Alopecia (Gr 2) Alopecia Bullous dermatitis Palmar-plantar Version Date 02/20/2014 29 Update #04 ALLIANCE A091102 erythrodysesthesia syndrome 1 This 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 [email protected]. Your name, the name of the investigator, the protocol and the agent should be included in the e-mail. 2Infection includes all 75 sites of infection under the INFECTIONS AND INFESTATIONS SOC. Also reported on MLN 8237 trials but with the relationship to MLN 8237 still undetermined: BLOOD AND LYMPHATIC SYSTEM DISORDERS - Bone marrow hypocellular; Leukocytosis CARDIAC DISORDERS - Left ventricular systolic dysfunction; Restrictive cardiomyopathy; Sinus tachycardia EAR AND LABYRINTH DISORDERS - Hearing impaired EYE DISORDERS - Eye pain; Flashing lights; Floaters; Keratitis; Photophobia GASTROINTESTINAL DISORDERS - Anal mucositis; Colitis; Dry mouth; Dyspepsia; Dysphagia; Enterocolitis; Esophagitis; Flatulence; Hemorrhoids; Typhlitis GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Flu like symptoms; Gait disturbance; General disorders and administration site conditions - Other (systemic inflammatory response syndrome); Localized edema; Multi-organ failure; Pain HEPATOBILIARY DISORDERS - Hepatobiliary disorders - Other (venoocclusive liver disease) INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Fall INVESTIGATIONS - CD4 lymphocytes decreased; Ejection fraction decreased; GGT increased; Investigations - Other (pancytopenia); Weight loss METABOLISM AND NUTRITION DISORDERS - Hypercalcemia; Hypernatremia; Hypoalbuminemia; Hypocalcemia; Hypokalemia; Hyponatremia; Hypophosphatemia; Metabolism and nutrition disorders Other (failure to thrive) MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthralgia; Back pain; Generalized muscle weakness; Muscle weakness lower limb; Musculoskeletal and connective tissue disorder - Other (rhabdomyolysis); Pain in extremity NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) Myelodysplastic syndrome NERVOUS SYSTEM DISORDERS - Ataxia; Depressed level of consciousness; Dysgeusia; Lethargy; Memory impairment; Nervous system disorders - Other (bradyphrenia); Paresthesia; Sinus pain; Syncope PSYCHIATRIC DISORDERS - Agitation; Confusion; Euphoria; Insomnia RENAL AND URINARY DISORDERS - Acute kidney injury; Proteinuria RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Bronchopulmonary hemorrhage; Epistaxis; Nasal congestion; Pharyngolaryngeal pain SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Dry skin; Periorbital edema; Pruritus; Rash maculo-papular; Skin hyperpigmentation VASCULAR DISORDERS - Hypotension; Vascular disorders - Other (shock) Note: MLN 8237 in combination with other agents could cause an exacerbation of any adverse event currently known to be caused by the other agent, or the combination may result in events never previously associated with either agent. 7.1.1.2 Comprehensive Adverse Events and Potential Risks List (CAEPR) for 3'deoxy-3'-[F-18]fluorothymidine (NSC 743144) The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of reported and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by body system. In addition to the comprehensive list, a subset, the Agent Specific Adverse Event List (ASAEL), appears in a separate column and is identified with bold and italicized text. This Version Date 02/20/2014 30 Update #04 ALLIANCE A091102 subset of AEs (ASAEL) contains events that are considered 'expected' for expedited reporting purposes only. Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' http://ctep.info.nih.gov/protocolDevelopment/default.htm#adverse_events_adeers for further clarification. The CAEPR does not provide frequency data; refer to the Investigator's Brochure for this information. Below is the CAEPR for 3'-deoxy-3'[F-18]fluorothymidine. Version 1.0, July 1, 2010 1 Category (Body System) Adverse Events2 with Possible Relationship to 3'-deoxy-3'-[F18]fluorothymidine (CTCAE v4.0 Term) EXPECTED AEs FOR CTEP-AERS REPORTING Agent Specific Adverse Event List (ASAEL) No AEs reported in human studies2,3. 1 This 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 [email protected]. Your name, the name of the investigator, the protocol, and the agent should be included in the e-mail. 2 No adverse events have been attributed to Positron-Emission Tomography (PET) imaging/diagnostic administration of [3'-deoxy-3'-[F-18] fluorothymidine at the levels described in the Investigators Brochure. Therefore, no adverse events are expected as a result of the intravenous (IV) administration of 3'-deoxy-3'-[F-18] fluorothymidine for typical PET imaging applications. 3 As with many intravenously administered agents, 3'-deoxy-3'-[F-18] fluorothymidine could cause an allergic reaction that could potentially pose a threat to life (anaphylaxis). This has not been observed in limited human exposure to date. Reasonable precautions should be taken, consistent with normal radiologic and clinical facility practice. The patient should be monitored until the PET procedure is completed, and trained personnel and emergency equipment should be available per facility standards. For purposes of informed consent regarding reasonably foreseeable risks to subjects in trials utilizing 3’-deoxy-3’-[F-18]fluorothymidine, the following potential adverse events are considered extremely rare: Injection-related risks that may include infection, or accidental extravasation of the dose that may lead to discomfort, localized pain, or infection. Risks related to allergic reaction/anaphylaxis that may be life threatening. Note: As with all PET imaging agents, 3'-deoxy-3'-[F-18]fluorothymidine is a radiopharmaceutical that decays with positron emission. As such, it poses an intrinsic radiation exposure risk. However, when administered in accordance with the Investigator’s Brochure as a PET imaging agent, this risk is felt to be extremely small. The organ and total body doses associated with FLT PET imaging are comparable to or lower than those associated with other widely used clinical nuclear medicine procedures. Note: 3'-deoxy-3'-[F-18]fluorothymidine in combination with other agents could cause an exacerbation of any adverse event currently known to be caused by the other agent, or the combination may result in events never previously associated with either agent. 7.2 Expedited Adverse Event Reporting Investigators are required by Federal Regulations to report serious adverse events as defined below. Investigators are required to notify the Alliance Protocol Operations Office the Study Chair, and their Institutional Review Board if a patient has an adverse event requiring Version Date 02/20/2014 31 Update #04 ALLIANCE A091102 expedited reporting. All such events must be reported in an expedited manner using the NCI CTEP Adverse Event Reporting System (CTEP-AERS). The descriptions and grading scales found in the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for reporting. All 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 website (http//ctep.cancer.gov). The Alliance requires investigators to route all expedited adverse event reports through the Alliance Protocol Operations Office for Alliance –coordinated studies. Be sure to read this entire protocol section, as requirements are described in both the table and bullet points following the table. Note that the table and the Additional instructions or exclusions may conflict. The additional instructions or exclusions are protocol-specific, and in the case of a conflict, the additional instructions or exclusions supersede the table. Most exclusions cover “expected” events that the sponsor would not be required to report to the FDA in an expedited manner. Version Date 02/20/2014 32 Update #04 ALLIANCE A091102 Late Phase 2: Expedited Reporting Requirements for Adverse Events that Occur on Studies under an IND within 30 Days of the Last Administration Agent(s) 1, 2 FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312) NOTE: Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether or not they are considered related to the investigational agent(s)/intervention (21 CFR 312.64) An adverse event is considered serious if it results in ANY of the following outcomes: 1) Death 2) A life-threatening adverse event 3) An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 hours 4) A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions 5) A congenital anomaly/birth defect. 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 CTEP-AERS within the timeframes detailed in the table below. Grade 1 Grade 2 Grade 3 Grade 4 & 5 Hospitalization Timeframe Timeframes Timeframes Timeframes s Resulting in Hospitalization 10 Calendar Days ≥ 24 hrs 24-Hour 5 Calendar Days Not resulting in Hospitalization Not required 10 Calendar Days ≥ 24 hrs Expedited AE reporting timelines are defined as: o “24-Hour; 5 Calendar Days” - The AE must initially be reported via CTEP-AERS within 24 hours of learning of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report. o “10 Calendar Days” - A complete expedited report on the AE must be submitted within 10 calendar days of learning of the AE. 1Serious adverse events that occur more than 30 days after the last administration of the Agent(s) require reporting as follows: Expedited 24-hour notification followed by complete report within 5 calendar days for: • All Grade 4, and Grade 5 Aes that are at least possibly related to treatment Expedited 10 calendar day reports for: • Grade 2 adverse events resulting in hospitalization or prolongation of hospitalization, and that are at least possibly related to treatment. • Grade 3 adverse events 2 For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half lives, rounded UP to the nearest whole day, after the agent/intervention was last administered. Footnote “1” above applies after this reporting period. NOTE: Deaths clearly due to progressive disease should NOT be reported via CTEP-AERS but rather should be reported via routine reporting methods (e.g., CDUS and/or CTMS). Version Date 02/20/2014 33 Update #04 ALLIANCE A091102 7.3 Additional Instructions or Exclusions to CTEP-AERS Additional instructions or exclusions to CTEP-AERS expedited reporting requirements for A091102 • All adverse events reported via CTEP-AERS (i.e., serious adverse events) should also be forwarded to your local IRB. • Treatment expected adverse events include those listed in Section 2.2, in the Investigator’s Brochure for MLN8237, in the CAEPR for MLN8237 and in the CAEPR for (3'-deoxy-3'[F-18] fluorothymidine. Note that the ASAEL column of the CAEPR has been replaced with the Specific Protocol Exceptions to Expedited Reporting (SPEER) column. The SPEER includes “expected” severity grades in addition to event terms. Events listed in the SPEER only require expedited reporting if the severity grade is above the grade noted in the SPEER. • All new malignancies should be reported through CTEP-AERS whether or not they are thought to be related to either previous or current treatment. All new malignancies should be reported including solid tumors (including non-melanoma skin malignancies), hematologic malignancies, myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML), and in situ tumors. In CTCAE version 4.0, the new malignancies (both second and secondary) may be reported as one of the following (1) Leukemia secondary to oncology chemotherapy, (2) Myelodysplastic syndrome, (3) Treatment-related secondary malignancy, or (4) Neoplasm other, malignant (grade 3 or 4). Whenever possible, the CTEP-AERS reports for new malignancies should include, tumor pathology, history of prior tumors, prior treatment/current treatment including duration, any associated risk factors or evidence regarding how long the new malignancy may have been present, when and how the new malignancy was detected, molecular characterization or cytogenetics of the original tumor (if available) and of any new tumor, and new malignancy treatment and outcome, if available. • Patients who become pregnant on study risk intrauterine exposure of the fetus to agents, which may be teratogenic. For this reason, pregnancy occurring on study or within 6 months following the last dose of study therapy should be reported in an expedited manner via CTEP-AERS as “Pregnancy, puerperium and perinatal conditions - Other (Pregnancy) under the Pregnancy, puerperium and perinatal conditions SOC and reported as Grade 3. • Pregnancy should be followed up until the outcome of the pregnancy is known at intervals deemed appropriate by the investigator and the outcome reported via CTEP-AERS. . • All Adverse Events must be reported in routine study data submissions. AEs reported through CTEP-AERS must also be reported in routine study data submissions. • Deaths due to progressive disease do not require CTEP-AERS, but must be reported as part of study results via routine reporting. 8.0 PHARMACEUTICAL AND IMAGING AGENT INFORMATION A list of the adverse events and potential risks associated with the investigational agent administered in this study can be found in Section 7.1. 8.1 CTEP and CIP IND Agent 8.1.1 MLN8237 (NSC 747888) Chemical Name: sodium 4-{[9-chloro-7-(2-fluoro-6-methoxyphenyl)-5H-pyrimido[5,4d][25]benzazepin-2-yl]amino}-2-methoxybenzoate Version Date 02/20/2014 34 Update #04 ALLIANCE A091102 Other Names: MLN8237-004, ML00653668 Classification: Aurora A kinase inhibitor CAS Registry Number: 1208255-63-3 Molecular Formula: C27H19ClFN4NaO4.H2O M.W.: 558.92 (sodium salt) 518.92 (free acid) Approximate Solubility: MLN8237’s solubility in water (pH = 8.4) is 8.5 mg/mL. Mode of Action: MLN8237 inhibits aurora A kinase activity; the aurora A kinase gene is amplified, overexpressed, or both in many tumors, and results in transformation of normal cells. Description: In its solid state, MLN8237-004 drug substance is an off-white to yellow solid. How Supplied: Millennium supplies and the Pharmaceutical Management Branch, CTEP, DCTD, distributes MLN8237 as enteric coated 10 mg tablets (expressed as MLN8237 free acid). Excipients include a buffer (sodium bicarbonate), surfactant (sodium lauryl sulfate), enteric coating, binder (povidone), filler (microcrystalline cellulose), disintegrant (croscarmellose sodium), and lubricant (sodium stearyl fumarate). Each bottle contains 10 tablets. Storage: Store MLN8237 at controlled room temperature (20oC-25ºC). Excursions from 15°C to 30°C are permitted. Stability: Stability testing is ongoing. Route of Administration: Oral Method of Administration: Patients will take nothing by mouth (NPO) except for water and prescribed medications for approximately one hour before and two hours after each dose. Patients will be instructed to take each oral dose of MLN8237 with 8 ounces (1 cup, 240 mL) of water. All tablets are to be ingested whole; patients who have difficulty swallowing tablets should not be registered to the trial. Potential Drug Interactions: Agents that alter gastric pH may MLN8237absorption. The following concomitant medications are not permitted: change Proton pump inhibitors (PPI are not permitted). Patients must stop using the PPI for at least 4 days prior to the first dose of MLN8237. Histamine-2 (H2) receptor antagonists are not permitted from the day prior (Day -1) through to the end of the MLN8237 dosing period in a cycle. Antacid preparations are not permitted for 2 hours before or 2 hours after administration of MLN8237. The effect of drug-metabolizing enzyme inducers on the clinical PK of MLN8237 has not been characterized, so decreased systemic exposures of MLN8237 in patients receiving clinically significant enzyme inducers is possible. Co-administration of enzyme-inducing antiepileptic drugs, rifampin, rifabutin, rifapentine, or St. John’s wort is not permitted. Patient Care Implications: Concurrent bisphosphonate therapy is allowed if it was started before study entry and is maintained at recommended dosing intervals. If bisphosphonate therapy is initiated after study entry, bone lesions will not be considered evaluable for disease responses. Version Date 02/20/2014 35 Update #04 ALLIANCE A091102 If a patient experiences excessive sedation or other benzodiazepine-like effects, they should not drive, operate dangerous tools or machinery, or engage in any other potentially hazardous activity that requires full alertness and coordination. Differential diagnosis of observed CNS effects should also be considered, such as co-morbidities associated with the patient’s oncologic diagnosis, concomitant medications, infection, metabolic abnormalities, etc. If excessive sedation is believed to be related to MLN8237, treatment with MLN8237 should be delayed or the doses modified as described in Section 6. Patients must limit alcohol consumption to no more than 1 standard unit of alcohol [12 oz beer (350 mL), 1.5 oz (45 mL) of 80-proof alcohol, or one 6-oz (175 mL) glass of wine] per day during the study and for 30 days from the last dose of MLN8237. Minimize the use of agents with CNS effects. Because of their structural and pharmacological similarity to MLN8237, benzodiazepine use is discouraged but not prohibited. Availability MLN8237 is an investigational agent supplied to investigators by the Division of Cancer Treatment and Diagnosis (DCTD), NCI. MLN8237 is provided to the NCI under a Collaborative Agreement between the Pharmaceutical Collaborator and the DCTD, NCI 8.1.2 Agent Ordering and Agent Accountability 8.1.2.1 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 [email protected] anytime. 8.1.2.2 Agent Inventory Records – The investigator, or a responsible party designated by the investigator, must maintain a careful record of the inventory and disposition of all agents received from DCTD using the NCI Drug Accountability Record Form (DARF). (See the NCI Investigator’s Handbook for Procedures for Drug Accountability and Storage.) Please note : PMB will not supply MLN8237 to the French Sarcoma Consortium. Version Date 02/20/2014 36 Update #04 ALLIANCE A091102 8.1.3 Collaborative Agreements Language The agent(s) supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI under a Collaborative Agreement (CRADA, CTA, CSA) between the Pharmaceutical Company (ies) (hereinafter referred to as “Collaborator(s)”) and the NCI Division of Cancer Treatment and Diagnosis. Therefore, the following obligations/guidelines, in addition to the provisions in the “Intellectual Property Option to Collaborator” (http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm) contained within the terms of award, apply to the use of the Agent(s) in this study: 1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor can Agent(s) be transferred or licensed to any party not participating in the clinical study. Collaborator(s) data for Agent(s) are confidential and proprietary to Collaborator(s) and shall be maintained as such by the investigators. The protocol documents for studies utilizing Agents contain confidential information and should not be shared or distributed without the permission of the NCI. If a copy of this protocol is requested by a patient or patient’s family member participating on the study, the individual should sign a confidentiality agreement. A suitable model agreement can be downloaded from: http://ctep.cancer.gov. 2. For a clinical protocol where there is an investigational Agent used in combination with (an)other Agent(s), each the subject of different Collaborative Agreements, the access to and use of data by each Collaborator shall be as follows (data pertaining to such combination use shall hereinafter be referred to as "MultiParty Data”): a. NCI will provide all Collaborators with prior written notice regarding the existence and nature of any agreements governing their collaboration with NCI, the design of the proposed combination protocol, and the existence of any obligations that would tend to restrict NCI's participation in the proposed combination protocol. b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial by any other Collaborator solely to the extent necessary to allow said other Collaborator to develop, obtain regulatory approval or commercialize its own Agent. c. Any Collaborator having the right to use the Multi-Party Data from these trials must agree in writing prior to the commencement of the trials that it will use the Multi-Party Data solely for development, regulatory approval, and commercialization of its own Agent. 3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement will be made available to Collaborator(s), the NCI, and the FDA, as appropriate and unless additional disclosure is required by law or court order as described in the IP Option to Collaborator (http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm). Additionally, all Clinical Data and Results and Raw Data will be collected, used and disclosed consistent with all applicable federal statutes and regulations for the protection of human subjects, including, if applicable, the Standards for Privacy of Individually Identifiable Health Information set forth in 45 C.F.R. Part 164. 4. When a Collaborator wishes to initiate a data request, the request should first be sent to the NCI, who will then notify the appropriate investigators (Group Chair for Version Date 02/20/2014 37 Update #04 ALLIANCE A091102 Cooperative Group studies, or PI for other studies) of Collaborator's wish to contact them. 5. Any data provided to Collaborator(s) for Phase 3 studies must be in accordance with the guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a DMC for this clinical trial. 6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the Group office for Cooperative Group studies or by the principal investigator for non-Cooperative Group studies for immediate delivery to Collaborator(s) for advisory review and comment prior to submission for publication. Collaborator(s) will have 30 days from the date of receipt for review. Collaborator shall have the right to request that publication be delayed for up to an additional 30 days in order to ensure that Collaborator’s confidential and proprietary data, in addition to Collaborator(s)’s intellectual property rights, are protected. Copies of abstracts must be provided to CTEP for forwarding to Collaborator(s) for courtesy review as soon as possible and preferably at least three (3) days prior to submission, but in any case, prior to presentation at the meeting or publication in the proceedings. Press releases and other media presentations must also be forwarded to CTEP prior to release. Copies of any manuscript, abstract and/or press release/ media presentation should be sent to: Email: [email protected] The Regulatory Affairs Branch will then distribute them to Collaborator(s). No publication, manuscript or other form of public disclosure shall contain any of Collaborator’s confidential/ proprietary information. 8.2 FLT-PET For complete information, please refer to the current Investigator’s Brochure (3'-deoxy-3'-[F18] fluorothymidine: [F-18]FLT: An Investigational Positron Emission Tomography (PET) Radiopharmaceutical for Injection intended for use as an in vivo diagnostic for imaging active cellular proliferation of malignant tumors, Edition Number: 8, Edition Date: May 2011). 8.2.1 Pharmacology and Toxicology The pharmacology of FLT is based on its action as an inhibitor of DNA synthesis (Langen, 1969; 1972; 1972; Matthes, 1988). Intracellular metabolism of FLT produces nucleotides that inhibit endogenous DNA polymerases because they lack a 3'-hydroxyl substituent. This results in premature chain termination of DNA synthesis (Matthes 1987, Sundseth 1996). These biochemical properties can account for FLT's prominent hematological and liver toxicity in treatment studies. The proposed PET tracer studies using approximately 6 µg single dose [F-18]FLT are significantly lower than the oral 0.125 mg/kg or 2 mg/day multi dose used in the human studies (Flexner, 1994; Faraj, 1994; Sundseth, 1996; Katlama, 2004; Ghosn, 2007). The pharmacology of FLT closely parallels that of the widely used prescription HIV-antiviral drug azidothymidine (AZT) (Lundgren, 1991; Kong, 1992). Both FLT and AZT are 3'-deoxythymidine analogs that act as inhibitors of DNA synthesis and are cleared from the body in the same way. Although FLT is significantly more cytotoxic than AZT in test cell lines (Faraj, 1994) at comparable levels of exposure, this is not a factor when [F18]FLT exposure is limited to typical PET imaging microdose requirements. Cellular uptake of FLT and thymidine is greater than that of AZT. Transport of Version Date 02/20/2014 38 Update #04 ALLIANCE A091102 FLT and thymidine across cell membranes occurs by active transport and passive diffusion (Kong, 1992). 8.2.2 Toxicity of [F-18]FLT in Humans In a study performed at the University of Washington, Turcotte and colleagues (Turcotte, 2008) assessed the toxicity of [F-18]FLT in twenty patients with proven or suspected diagnosis of non-small cell lung cancer (Table 5). All patients gave written informed consent to the [F-18]FLT injection, and subsequent PET imaging and blood draws. Blood samples were collected for each patient at multiple times before and after [F-18]FLT-PET. These samples were assayed for comprehensive metabolic panel, total bilirubin, complete blood and platelet counts. In addition, a standard neurological examination by a qualified physician was performed for each patient before and immediately after [F-18]FLT-PET. All [F-18]FLT doses were calculated based on patient weight (2.59 MBq/kg = 0.07 mCi/kg) with a maximal dose of 185 MBq (5.0 mCi). Starting with the [F-18]FLT injection, dynamic PET images were acquired for 90 or 120 minutes. By placing a region-of-interest in the center of the left ventricular chamber, blood time- activity curves were generated for each patient from the dynamic PET data and then extrapolated to 720 minutes. This provided a measure of the area under the [F-18]FLT concentration curve for 12 hours (AUC12). A separate estimation of the AUC12 was also obtained from sequential blood samples collected during PET data acquisition. No side effects were reported by patients or observed. No change was observed in the neurological status of patients. A neurological examination was performed by an experienced neurologist prior to [F-18]FLT administration, the day after [F-18]FLT administration, and at four weeks post [F-18]FLT administration. Only albumin, red blood cell count, hemoglobin, and hematocrit show a statistically significant decrease over time (Table 5). These changes were attributed to IV hydration during PET imaging and to subsequent blood loss at surgery. The AUC12 values estimated from imaging data are not significantly different from those found from serial measures of [F-18]FLT blood concentrations (P = 0.66). No significant neurologic sequelae have been attributed to [F-18]FLT use in pet imaging to date. As a result, peripheral neuropathy, which had been listed as a possible risk based upon observations at significantly higher doses in early therapeutic HIV studies, is no longer considered a risk of [F-18]FLT use in a micro-dose imaging setting. Screening for peripheral neuropathy is not justified based upon the available evidence in multiple [F-18]FLT imaging trials. Table 5. Laboratory Values (mean ± SD) At Each Time Point Pre[F18]FLT Immediate < 5 hours 5 – 24 hours 1 – 7 days > 1 week P* Sodium (mEq/L ± SD) 139.4 ± 1.5 138.2 ± 2.1 138.3 ± 2.0 137.5 ± 1.8 138.1 ± 2.3 0.064 Potassium (mEq/L ±S D) 4.2 ± 0.4 4.1 ± 0.4 4.2 ± 0.3 104.2 ± 3.7 104 ± 3.8 102.3 ± 2.4 101.2 ± 3.1 0.055 4.2 ± 0.5 Chloride (mEq/L ± SD) 102.3 ± 3.3 Version Date 02/20/2014 39 4.2 ± 0.4 0.968 Update #04 ALLIANCE A091102 Glucose (mEq/L ± SD) 95.1 ± 14.8 96.6 ± 20.7 98.5 ± 23.1 105.4 ± 17.7 109.5 ± 14.6 0.175 Creatinine (mEq/L ± SD) 0.885 ± 0.198 0.882 ± 0.207 0.881 ± 0.180 0.910 ± 0.190 0.844 ± 0.217 0.949 BUN (mEq/L ± SD) 15.8 ± 5.0 15.1 ± 5.6 15.2 ± 6.3 14.3 ± 5.2 15.3 ± 5.7 0.959 SGOT (U/L ± SD) 20.8 ± 5.0 22.0 ± 5.1 22.0 ± 5.3 22.2 ± 11.4 21.8 ± 6.7 0.973 SGPT (U/L ± SD) 18.7 ± 6.7 18.5 ± 6.6 19.1 ± 6.5 17.6 ± 5.3 17.2 ± 6.5 0.978 Albumin (g/dL ± SD) 3.9 ± 0.5 3.5 ± 0.4 3.44 ± 0.3 3.1 ± 0.6 3.2 ± 0.8 0.003 Alk Phos (U/L ± SD) 73.8 ± 19.4 61.1 ± 14.7 58.3 ± 17.0 59.5 ± 22.7 Bilirubin (mg/dL ± SD) 0.647 ± 1.81 0.573 ± 0.246 0.581 ± 0.263 0.621 ± 0.286 0.752 ± 0.418 0.714 RBC (X109 /ml ± SD) 4.5 ± 0.4 4.3 ± 0.5 4.2 ± 0.5 3.8 ± 0.3 3.7 ± 0.4 <0.000 1 Hematocrit (% ± SD) 39.1 ± 4.4 38.4 ± 4.0 35.2 ± 3.4 35.0 ± 3.4 <0.000 1 WBC (X106/ml ±S D) 7.6 ± 2.1 7.7 ± 3.4 7.9 ± 3.3 9.5 ± 2.8 9.0 ± 3.2 0.262 Platelets (X106/ml ± SD) 259.1 ± 103.1 255.9 ± 103.0 230.1 ± 76.7 233.5 ± 69.5 0.674 40.9 ± 3.1 278.1 ± 96.9 0.081 *one-way ANOVA P values (from Turcotte et al, 2007) The single dose AUC12 values derived from blood clearance studies performed at the University of Washington ranged from 0.22 to 1.34 ng-h/mL with a mean of 0.80 ngh/mL. This range corresponds to 0.46% to 2.7% of the Flexner therapeutic clinical trial AUC12 of 50 ng-h/mL. In the Flexner trial the only dose-limiting toxicity was hematologic, either anemia or granulocytopenia, and the threshold for this response was greater than 50 ng-h/mL. The only adverse event at the 50 ng-h/mL level was a peripheral neuropathy in 2 of 15 patients that manifested at about 40 days. The peripheral neuropathy was detected by vibration sensation scores and was not a dose limiting toxicity. For FLT, the average arterial blood curve (% injected dose per mL of blood) from 16 University of Washington FLT two hour studies were extrapolated to 12 hours using the conservative estimation that there would be no more clearance of FLT from the plasma and that all the radioactivity in the blood was in the form of the unmetabolized FLT. It was then assumed that 100% of the dose (6.1 µg = 6100 ng) was in a plasma volume of 3,000 mL. The dose in nanograms was multiplied by the fraction of the injected dose per mL divided by the plasma volume to obtain ng/mL for each time point. The area under this curve was 0.5 ng-h/mL. Thus, the AUC12 of a single injected dose of FLT will be < 1% of the single dose and less than 0.01% of the cumulative 40 day dose Version Date 02/20/2014 40 Update #04 ALLIANCE A091102 of the lowest mass associated with any reported toxic effect in humans, 50 ng-h/mL and will not lead to clinically detectable toxic effects. An NCI-sponsored study (Spence, 2008) was conducted at University of Washington in Seattle beginning in 2005. Twelve patients with brain tumors were enrolled. Overall, 2 of the 12 subjects receiving FLT experienced an elevation in BP from baseline to two hours post infusion: Subjects 1 (119/56 – 133/66) and 4 (120/78 – 163/74). In Subject 4, abnormal BP was attributed to discomfort from the head immobilization device. There were no clinically relevant events reported. All subjects performed consistently on the pre- and post- neurological exams and there were no changes in status. The clinical chemistry data are shown in Table 6. Four of these analytes demonstrated statistically significant changes on one-way ANOVA: potassium, carbon dioxide, total protein, and albumin. Some of the other values were above or below normal, but no pattern was seen except that many were lower on the day of the study. These decreases are attributed to two main factors. Normal saline infusion, which expands blood volume, and arterial blood sampling for kinetic analysis are performed during the procedure, both of which will cause a general lowering of the concentration of blood components. The subsequent recovery of these values to baseline is consistent with this explanation and consistent with the results obtained by Turcotte (2008). The AUC12 values, estimated from assaying arterial blood samples, ranged from 0.004 to 0.035 ng-hr/ml, with a mean of 0.016 ng-hr/ml. These mass levels correspond to 0.008% to 0.07% of the least toxic single dose of 50 ng-hr/ml in the Flexner trial (a 40 day, 2 dose per day study). If comparison is made to the cumulative dose, the [F-18]FLT is at0.0001% to 0.0009% of the therapeutic dose. Version Date 02/20/2014 41 Update #04 ALLIANCE A091102 Table 6. Laboratory Values (mean ± SD) At Each Time Point Analyte Pre Mean ± SD Amylase Na+ K+ ClCO2 total Ion Gap Glucose BUN Creatinine Protein total Albumin Bilirubin total Ca++ AST (GOT) Alk Phos GPT GGT LDH Phosphate Prothrombin INR PTT WBC RBC Hgb Hct MCV MCH MCHC Platelets ANC Spec Gravity pH 75.4 ± 23.1 140.8 ± 2.6 4.27 ± 0.42 106.0 ± 3.7 27.6 ± 2.9 6.29 ± 1.60 121.8 ± 47.7 12.45 ± 4.06 1.00 ± 0.17 6.45 ± 0.38 4.15 ± 0.25 0.68 ± 0.16 9.35 ± 0.19 26.3 ± 5.9 86.0 ± 22.7 39.4 ± 15.8 44.7 ± 21.1 224.9 ± 104.9 3.15 ± 0.55 12.74 ± 1.39 1.02 ± 0.04 26.8 ± 3.1 6.13 ± 1.91 4.65 ± 0.42 14.5 ± 1.1 42.5 ± 3.1 91.5 ± 3.3 31.4 ± 1.6 34.3 ± 0.9 233.9 ± 54.2 4.08 ± 1.42 1.02 ± 0.01 6.05 ± 1.01 Immediately Pre-Mean ± SD 68.5 ± 27.6 138.4 ± 4.6 3.88* ± 0.20 106.0 ± 4.6 24.6* ± 2.3 7.83 ± 2.29 98.7 ± 33.4 10.58 ± 4.01 0.85 ± 0.17 5.66* ± 0.37 3.66* ± 0.18 0.79 ± 0.24 9.01 ± 0.29 22.5 ± 4.4 78.5 ± 26.4 30.2 ± 9.6 42.3 ± 22.4 151.8 ± 41.9 3.03 ± 0.55 13.59 ± 0.52 1.05 ± 0.05 29.4 ± 5.7 5.75 ± 1.40 4.37 ± 0.39 13.4 ± 0.9 39.9 ± 3.4 91.3 ± 3.5 30.8 ± 1.4 33.7 ± 0.8 226.2 ± 42.7 3.79 ± 1.15 1.01 ± 0.00 6.88 ± 0.80 Day 1 Mean ± SD 77.8 ± 33.9 139.3 ± 3.3 4.20 ± 0.28 104.5 ± 3.6 26.9 ± 2.1 7.70 ± 2.21 125.2 ± 73.5 11.00 ± 3.03 0.97 ± 0.24 6.14 ± 0.57 4.01 ± 0.51 0.79 ± 0.17 9.38 ± 0.39 23.7 ± 5.0 84.3 ± 27.9 32.7 ± 11.2 47.2 ± 23.3 174.9 ± 57.9 3.16 ± 0.59 13.12 ± 0.94 1.01 ± 0.09 30.9 ± 15.8 6.96 ± 3.98 4.50 ± 0.38 13.9 ± 1.1 41.1 ± 3.0 91.3 ± 3.2 31.0 ± 1.4 33.9 ± 0.6 220.9 ± 47.8 5.02 ± 3.34 1.02 ± 0.00 6.60 ± 0.97 Day 28 Mean ± SD 75.4 ± 33.7 141.1 ± 3.1 4.08 ± 0.30 106.5 ± 3.3 26.8 ± 2.5 7.67 ± 3.08 116.9 ± 71.6 13.73 ± 4.63 1.01 ± 0.27 6.33 ± 0.76 3.99 ± 0.50 0.65 ± 0.12 9.24 ± 0.54 26.8 ± 5.1 86.5 ± 30.3 33.0 ± 7.7 44.3 ± 26.0 248.6 ± 205.4 3.07 ± 0.41 12.82 ± 1.39 1.01 ± 0.06 26.3 ± 2.8 5.85 ± 2.10 4.48 ± 0.52 13.9 ± 1.6 41.2 ± 4.5 92.1 ± 3.3 31.2 ± 1.3 33.9 ± 0.8 220.0 ± 52.4 3.89 ± 1.42 1.02 ± 0.00 5.85 ± 1.08 * Statistically significant change (p < 0.05); one-way ANOVA The published studies on [F-18]FLT are discussed in Section VII of this Investigator’s Brochure. While none of these studies reported explicit safety information, the majority of these publications did indicate that Institutional Review Board (IRB) or Ethics Committee approval was obtained for the study, so the patients would have been observed for clinically evident adverse events, none of which were reported. Version Date 02/20/2014 42 Update #04 8.2.3 Dosimetry Table F18-FLT Patient Dosimetry Absorbed Doses 1 FLT PET-CT scan 0.9 rad 2 CT + 0.3 rad 3 CT + rad/8 mCi rad 0.61 1.81 0.47 1.67 0.10 1.30 0.25 1.45 0.50 1.70 0.49 1.69 1.05 2.25 0.13 1.33 0.37 1.57 0.31 1.51 1.34 2.54 0.30 1.50 0.50 1.70 0.68 1.88 0.71 1.91 0.13 1.33 0.42 1.62 0.42 1.62 0.39 1.59 0.31 1.51 0.37 1.57 F18-FLT1 Target Organ Adrenals Bone Surfaces Brain Breasts Gall Bladder Wall Heart Wall Kidneys Large Intestine - Lower Wall Large Intestine - Upper Wall Lens of Eye Liver Lungs Muscle / Other tissue Pancreas Red Marrow Skin Small Intestine Stomach Wall Testes Thyroid Total Body Urinary Bladder Wall 2-hr Voiding Interval Effective Dose Equivalent (rem) 1 2 3 8.2.4 rad/mCi 0.0766 0.0585 0.0125 0.0310 0.0625 0.0618 0.132 0.0168 0.0459 0.0389 0.1680 0.0374 0.0622 0.0851 0.0888 0.0164 0.0525 0.0522 0.0488 0.0385 0.0466 0.2927 0.10 2.34 0.83 3.54 2.03 Vesselle et al. J Nucl Med 44: 1482-1488, 2003. Wu et al. Eur J Nucl Med Mol Imaging 31:38-43, 2004 Dos estimates scaled to low-dose (90-mA) CT scan Wu et al. Eur J Nucl Med Mol Imaging 31:38-43, 2004 Dos estimates scaled to ultra-low-dose (30-mA) CT scan for optional dynamic PET scan at 1 bed position [F-18]FLT Administered Dose [F-18]FLT will be administered to subjects over 1 minute by intravenous bolus injection. Doses will be pre-calibrated to 8 mCi. 8.2.5 Quality Assurance, Quality Control and Storage In accordance with regulations, the radioisotope vendor conducts several quality control tests on the [F-18] FLT product prior to release for human administration. Once delivered to the participating institution, doses will be stored in the appropriate storage area in the nuclear medicine facility until they are administered to the patient on the same day. 43 12/08/2012 ALLIANCE A091102 8.2.6 Supplier of [F-18]FLT Drug Ordering: [F-18] FLT will be purchased from the NCI IND AUTHORIZED commercial vendor (e.g. PetNet, Cardinal, IBA) under the CIP IND # 71260 cross-referenced to CTEP IND # 113149. The vendor must be specifically authorized within the NCI IND. The investigator or appropriate investigator-designee will order subject doses of [F-18] FLT for this specific trial. The investigational radiopharmaceutical [F-18] FLT solution will be shipped to the site the same day the participant is to be injected. The investigational pharmacist or qualified nuclear medicine technologist at the participating institution will be the responsible party designated by the investigator. Drug Returns: If for any reason the study imaging is unable to be completed, sites will allow the radioactivity of the [F-18] FLT solution to decay and then discard it appropriately per site’s policies and procedures, making a record of the event as required. A copy of the policy should be available upon request. Drug Accountability: The investigator or the investigator-designee must maintain a detailed record of receipt, disposition, and destruction dates of [F-18]FLT solution. 9.0 CORRELATIVE STUDIES FOR MSKCC PATIENTS 9.1 Background In preclinical studies, AURKA amplification was not necessary for sensitive to AURKA inhibition, so we have not made AURKA gene amplification an entry criterion. However, we will undertake an exploratory analysis to determine whether patients with a gene amplification have an improved clinical benefit (CR, PR, SD). Similarly, we will determine in the posttreatment biopsies whether the AURKA pathway is being inhibited. These studies may include staining for the mitotic markers MPM2 and phospho- Histone H3 at Serine10 by IHC and western blot. We may also examine the tissues for induction of apoptosis by TUNEL and cleaved caspase 3, inhibition of cell proliferation by Ki67 staining, and changes in cellular morphology (increase in % of bipolar spindles). Staining intensity by IHC will be graded semiquantitatively, with a five-point scale: 0, no staining; 1+, weak; 2+, moderate; 3+, strong and 4+, intense. Pre and post-treatment protein levels will be compared by Wilcoxon signed-rank test (for paired samples). The association of response or clinical benefit with the presence or absence of markers of pathway inhibition in patient tumors will be tested using Fisher’s exact test. For changes in morphology, the number of mitotic cells at baseline will be counted from 5 randomly selected high powered fields and will be subtracted from those counted on the second biopsy. A positive result will represent an increase in the mitotic index in the posttreatment biopsy relative to the baseline. These analyses of the correlative endpoints would be exploratory and hypothesis-generating. 9.2 Methods Patients treated at MSKCC may have two optional biopsies: one pretreatment and the second 1-4 weeks after the start of treatment. Tissue will be divided with part sent to the Pathology Core for IHC and FISH and the remainder flash frozen for Western blots. Tissues will be tested at baseline Version Date 02/20/2014 44 Update #04 ALLIANCE A091102 for AURKA gene amplification by FISH. This test may be performed by Cytogenetics Core at Memorial Sloan-Kettering or in the laboratory of Cristina Antonescu, MD. FISH analysis will be performed by hybridization of bacterial artificial chromosome (BAC) probes, covering AURKA (RP11-65K20, 20q13.2-13.31) and two reference probes (RP11-380E19 & RP11-713N22, on 20q11.21) onto 4μm sections of formalin-fixed paraffin-embedded tissue from each tumor. BAC clones are chosen according to their genomic location as defined in the UCSC genome browser (http://genome.ucsc.edu). The BAC clones will be obtained from BACPAC sources of Children's Hospital of Oakland Research Institute (CHORI) (Oakland, CA) (http://bacpac.chori.org). BAC DNA will be isolated according to the manufacturer’s instructions, labeled with different fluorochromes in a nick translation reaction, denatured, and hybridized to pretreated slides. Slides will be then incubated, washed, and mounted with DAPI in an antifade solution, as previously described (Antonescu et al., 2010). The genomic location of each BAC set will be verified by hybridizing them to normal metaphase chromosomes. Two hundred interphase nuclei from each tumor will be examined using a Zeiss fluorescence microscope (Zeiss Axioplan, Oberkochen, Germany), controlled by Isis 5 software (Metasystems). Other tests may include IHC and Western blot staining for the mitotic markers MPM2 and phospho- Histone H3 at Serine10. Aurora Kinase A may be assessed by Western blot (Cell signaling # 3092, 1:500 dilution). We may also examine the tissues for induction of apoptosis by TUNEL and cleaved caspase 3, inhibition of cell proliferation by Ki67 staining, chromosomal complexity, and changes in cellular morphology (increase in % of bipolar spindles). Cryostat-cut frozen tissue sections are used unfixed or fixed for 10 minutes (methanol:acetone or 1% formalin). Formalin-fixed/paraffin-embedded sections are also used. The avidin-biotin immunoperoxidase technique is our method of choice and will be utilized for the experiments proposed. For specific epitopes on paraffin sections we utilize antigen retrieval methods (0.01% citric acid for 15 minutes under microwave treatment) prior to incubation with primary antibodies or antiserum overnight at 40C. Secondary antibodies are biotinylated horse anti-mouse or goat anti-rabbit antibodies, which are used at 1:500 dilutions (Vector Laboratories). Diaminobenzidine will be utilized as the final chromogen and hematoxylin as the nuclear counterstain. Collection of Specimens Tumors samples will be collected from patients with accessible material treated at Memorial Sloan Kettering Cancer Center. Submission of Specimens For each sample indicate the unique subject ID number, histology diagnosis, and the date of the specimen. Tumors will be sent to: Grazia Ambrosini, Ph.D. Memorial Sloan-Kettering Cancer Center G. Schwartz Laboratory, Z-1841 1275 York Ave New York, NY 10065 Tel: 646-888-2183 Fax: 646-422-0631 Email: [email protected] NOTE: Research Tissue Submission Form should accompany all samples sent to the MSKCC. Version Date 02/20/2014 45 Update #04 ALLIANCE A091102 9.3 A091102-IM1 9.3.1 [F-18]FLT Administration An FLT-PET scan may be performed at baseline and 1-4 weeks after starting treatment for up to 20 patients treated with MLN8237 at MSKCC only in connection with [F-18]FLT CIP IND # 71,260. These will be optional. [F-18]FLT will be provided by a vendor authorized within the NCI IND. [F18]FLT will be administered according to the guidance provided in the most current Investigators Brochure for this IND. 9.3.2 9.3.2.1 [F-18]FLT-PET Imaging Methods Patients will not have dietary restriction for FLT imaging. Up to 8 mCi FLT will be injected IV. Following low dose CT (for attenuation correction and anatomic localization), PET emission images will be obtained from mid skull to floor of pelvis for up to 5-minutes/bed position, starting approximately 60 minutes after FLT injection. Optionally, we may obtain a one field of view dynamic scan for up to 60 minutes over a lesion of interest (e.g. largest lesion seen on prior CT or FDG PET scans). We may obtain one approx. 3mL venous blood sample at approximately 60 minutes after FLT injection for metabolite analysis (needed for quantitative analysis). All studies will be obtained on dedicated PET/CT scanners (either DSTE or 690 scanners). Regardless which specific scanner is chosen, baseline and follow up scans must be obtained on the same scanner. 9.3.2.2 Image Analysis and Interpretation Details All FLT-PET images will be reviewed and examined by a board-certified nuclear medicine physician who is experienced in PET interpretation. CT, attenuationcorrected PET, and fusion PET-CT images will be available and reviewed simultaneously for each patient. Interpretation of the cancer site will be based on the intensity of the signal, focality of radiotracer uptake, and whether the lesion could be adequately discriminated from background activity in the surrounding tissues. 9.3.2.3 Imaging Related Procedures A venous catheter will be placed in a superficial hand or arm vein for administration of the radiopharmaceuticals. If a central venous catheter is present, it will also be used for radiopharmaceutical administration. 9.3.2.4 Background 18 F Fluorothymidine PET 3'-deoxy-3'-[(18)F] fluorothymidine 18F FLT is a new investigational PET radiotracer that can be used to assess tumor cell proliferation [50]. Imaging with FLT takes advantage of the fact that pyrimidine nucleosides and several of their analogues are phosphorylated to the respective monophosphate (MP) by thymidine kinase 1 (TK-1) and are incorporated into DNA. FLT is also substrate for thymidine kinase-1 (TK-1), which has been demonstrated both in vitro and in vivo [51-54]. TK-1 activity is upregulated in cells entering the S-phase, whereas the protein is nearly undetectable in growth arrested cells. TK-1 catalyzes the phosphorylation of FLT to FLTmonophosphate. Because it lacks a 3'-hydroxyl group, very little FLT is incorporated Version Date 02/20/2014 46 Update #04 ALLIANCE A091102 into DNA. Thus, FLT measures an early event in DNA synthesis, rather than DNA incorporation. Nevertheless, many reports have shown a positive correlation between FLT uptake and S-phase fraction of cells in vitro, and the fraction of proliferating cells in vivo (MIB-1; Ki-67) [52, 55-57]. Accordingly, FLT might be a useful imaging agent to monitor the early response to therapy in cancer patients. Preclinical and in vitro studies showed a close correlation between FLT uptake in tumor cell cultures or xenografts and growth arrest [58, 59]. In particular, changes in the FLT signal in consecutive imaging studies occur earlier than changes in the FDG signal (FDG PET is currently the only widely available imaging test for response assessment). As MLN8237 is a potent inhibitor of AURKA and induces a mitotic arrest, we would anticipate that FLT-PET could be used as an early predictive marker of response. Patients treated with MLN8237 will undergo FLT PET/CT at baseline and after the first week of therapy. Of note FLT PET/CT is used as an exploratory tool. Data will not be used to guide treatment decisions. However, retrospective analysis of these data will demonstrate whether FLT PET/CT can indeed be used as potential biomarker for response assessment and prediction in the clinic for patients treated with Aurora Kinase inhibitors. FLT findings will be correlated with FDG PET and traditional RECIST criteria. Version Date 02/20/2014 47 Update #04 ALLIANCE A091102 10.0 STUDY CALENDAR Pre- study evaluations are to be performed ≤ 7 days prior to registration. Scans and x-rays must be done ≤ 28 days prior to registration. Informed consent can be obtained ≤4 weeks prior to the start of treatment and must be re-signed if the patient falls outside of this treatment window (e.g. to schedule biopsies) Clinical Follow-Up Pre- Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Study 1 2 3 1 2 3 1 2 3 1 2 3 Cycle 1 → → 2 → → 3 → → 4 → → MLN8237 A A A A A→ VisitC 5+ f Informed consent X Demographics X Medical history X Concurrent meds X X X X X X Physical exam X X X X X X→ X Vital signs X X X X X X→ X Height X Weight X X X X X X→ X Performance status X X X X X X→ X CBC w/diff, plts X X X X X X→ X Serum chemistry X X X X X X→ X Adverse event evaluation X X X X X X X X Tumor measurements are repeated every 6 weeks. Documentation (radiologic) must be provided for patients removed from study for progressive disease. X→ X a Tumor measurements Radiologic evaluatione X B-HCG Xb X X Radiologic measurements should be performed every 6 weeks. X LVEF assessments will be conducted during the study as clinically indicated Correlative Study A091102-IM1 (MSKCC Patients Only) See Section 9.2 for collection and submissiond A: MLN8237: (see section 5.1.1) a: Comprehensive Metabolic Panel (Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, potassium, total protein, SGOT [AST], SGPT [ALT], sodium) b: Serum pregnancy test (women of childbearing potential). Pregnancy test must be done ≤ 7 days prior to registration c: To be performed ≤4 weeks after removal from active study treatment d: Only patients at Memorial Sloan-Kettering e: Scans are repeated every 6 weeks, regardless of dose delays, ±8 days, starting timing from the first day of therapy. After 24 weeks (approximately 8 cycles), patients should be re-evaluated for response every 12 weeks (approximately every 4 cycles, ±8 days). f: Treatment and assessments are to be completed per cycles 2-4. For scans refer to footnote e. Version Date 02/20/2014 48 Update #04 ALLIANCE A091102 11.0 MEASUREMENT OF EFFECT Response and progression will be evaluated in this study using the new international criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guidelines (version 1.1) [60]. Changes in the largest diameter (unidimensional measurement) of the tumor lesions and the short axis measurements in the case of lymph nodes are used in the RECIST guideline. 11.1 Schedule of Evaluations For the purposes of this study, patients should be reevaluated every 6 weeks, regardless of dose delays, ±8 days, starting timing from the first day of therapy. After 24 weeks (approximately 8 cycles), patients should be re-evaluated for response every 12 weeks (approximately every 4 cycles, ±8 days). In addition to a baseline scan, confirmatory scans should also be obtained 6 weeks following initial documentation of objective response. 11.2 Definitions of Measurable 11.2.1 Measurable Disease 11.2.1.1 A non-nodal lesion is considered measurable if its longest diameter can be accurately measured as ≥2.0 cm with chest x-ray, or as ≥1.0 cm with CT scan, CT component of a PET/CT, or MRI. 11.2.1.2 A superficial non-nodal lesion is measurable if its longest diameter is ≥ 1.0 cm in diameter as assessed using calipers (e.g. skin nodules) or imaging. In the case of skin lesions, documentation by color photography, including a ruler to estimate the size of the lesion, is recommended. 11.2.1.3 A malignant lymph node is considered measurable if its short axis is >1.5 cm when assessed by CT scan (CT scan slice thickness recommended to be no greater than 5 mm). 11.3 Guidelines for Evaluation of Measurable Disease 11.3.1 Measurement Methods: • All measurements should be recorded in metric notation (i.e., decimal fractions of centimeters) using a ruler or calipers. • The same method of assessment and the same technique must be used to characterize each identified and reported lesion at baseline and during followup. For patients having only lesions measuring at least 1 cm to less than 2 cm must use CT imaging for both pre- and post-treatment tumor assessments. • Imaging-based evaluation is preferred to evaluation by clinical examination when both methods have been used at the same evaluation to assess the antitumor effect of a treatment. 11.3.2 Acceptable Modalities for Measurable Disease: • Conventional CT and MRI: This guideline has defined measurability of lesions on CT scan based on the assumption that CT slice thickness is 5 mm Version Date 02/20/2014 49 Update #04 ALLIANCE A091102 or less. If CT scans have slice thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. • As with CT, if an MRI is performed, the technical specifications of the scanning sequences used should be optimized for the evaluation of the type and site of disease. The lesions should be measured on the same pulse sequence. Ideally, the same type of scanner should be used and the image acquisition protocol should be followed as closely as possible to prior scans. Body scans should be performed with breath-hold scanning techniques, if possible. • PET-CT: If the site can document that the CT performed as part of a PET-CT is of identical diagnostic quality to a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be used for RECIST measurements and can be used interchangeably with conventional CT in accurately measuring cancer lesions over time. • Chest X-ray: Lesions on chest x-ray are acceptable as measurable lesions when they are clearly defined and surrounded by aerated lung. However, CT scans are preferable. • Physical Examination: For superficial non-nodal lesions, physical examination is acceptable, but imaging is preferable, if both can be done. In the case of skin lesions, documentation by color photography, including a ruler to estimate the size of the lesion, is recommended. • FDG-PET: FDG-PET scanning is allowed to complement CT scanning in assessment of progressive disease [PD] and particularly possible 'new' disease. A ‘positive’ FDG-PET scanned lesion is defined as one which is FDG avid with an update greater than twice that of the surrounding tissue on the attenuation corrected image; otherwise, an FDG-PET scanned lesion is considered ‘negative.’ New lesions on the basis of FDG-PET imaging can be identified according to the following algorithm: 11.3.3 Version Date 02/20/2014 a. Negative FDG-PET at baseline with a positive FDG-PET at follow-up is a sign of PD based on a new lesion. b. No FDG-PET at baseline and a positive FDG-PET at follow-up: i. If the positive FDG-PET at follow-up corresponds to a new site of disease confirmed by CT, this is PD. ii. If the positive FDG-PET at follow-up is not confirmed as a new site of disease on CT at the same evaluation, additional followup CT scans (i.e., additional follow-up scans at least 4 weeks later) are needed to determine if there is truly progression occurring at that site. In this situation, the date of PD will be the date of the initial abnormal PDG-PET scan. iii If the positive FDG-PET at follow-up corresponds to a preexisting site of disease on CT that is not progressing on the basis of the anatomic images, it is not classified as PD. Measurement at Follow-up Evaluation: 50 Update #04 ALLIANCE A091102 • A subsequent scan must be obtained 6 weeks following initial documentation of an objective status of either complete response (CR) or partial response (PR). • In the case of stable disease (SD), follow-up measurements must have met the SD criteria at least once after study entry at a minimum interval of 6 weeks (see Section 11.4.4). • The cytological confirmation of the neoplastic origin of any effusion that appears or worsens during treatment when the measurable tumor has met criteria for response or stable disease is mandatory to differentiate between response or stable disease (an effusion may be a side effect of the treatment) and progressive disease. • Cytologic and histologic techniques can be used to differentiate between PR and CR in rare cases (e.g., residual lesions in tumor types such as germ cell tumors, where known residual benign tumors can remain.) 11.4 Measurement of Effect 11.4.1. Target Lesions & Target Lymph Nodes Measurable lesions (as defined in Section 11.2.1) up to a maximum of 5 lesions, representative of all involved organs, should be identified as “Target Lesions” and recorded and measured at baseline. These lesions can be non-nodal or nodal (as defined in 11.2.1), where no more than 2 lesions are from the same organ and no more than 2 malignant nodal lesions are selected. Note: If fewer than 5 (target lesions and target lymph nodes are identified (as there often will be), there is no reason to perform additional studies beyond those specified in the protocol to discover new lesions. Target lesions and target lymph nodes should be selected on the basis of their size, be representative of all involved sites of disease, but in addition should be those that lend themselves to reproducible repeated measurements. It may be the case that, on occasion, the largest lesion (or malignant lymph node) does not lend itself to reproducible measurements in which circumstance the next largest lesion (or malignant lymph node) which can be measured reproducibly should be selected. Baseline Sum of Dimensions (BSD): A sum of the longest diameter for all target lesions plus the sum of the short axis of all the target lymph nodes will be calculated and reported as the baseline sum of dimensions (BSD). The BSD will be used as reference to further characterize any objective tumor response in the measurable dimension of the disease. Post-Baseline Sum of the Dimensions (PBSD): A sum of the longest diameter for all target lesions plus the sum of the short axis of all the target lymph nodes will be calculated and reported as the post-baseline sum of dimensions (PBSD). If the radiologist is able to provide an actual measure for the target lesion (or target lymph node), that should be recorded, even if it is below 0.5 cm. If the target lesion (or target lymph node) is believed to be present and is faintly seen but too small to measure, a default value of 0.5 cm should be assigned. If it is the opinion of the radiologist that the target lesion or target lymph node has likely disappeared, the measurement should be recorded as 0 cm. Version Date 02/20/2014 51 Update #04 ALLIANCE A091102 The minimum sum of the dimensions (MSD) is the minimum of the BSD and the PBSD. 11.4.2 Non-Target Lesions & Non-Target Lymph Nodes Non-measurable sites of disease are classified as non-target lesions or non-target lymph nodes and should also be recorded at baseline. These lesions and lymph nodes should be followed in accord with 11.4.3.2. 11.4.3 Response Criteria All target lesions and target lymph nodes followed by CT/MRI/PET-CT/Chest Xray/physical examination must be measured on re-evaluation at evaluation times specified in Section 11.1. Specifically, a change in objective status to either a PR or CR cannot be done without re-measuring target lesions and target lymph nodes. Note: Non-target lesions and non-target lymph nodes should be evaluated at each assessment, especially in the case of first response or confirmation of response. In selected circumstances, certain non-target organs may be evaluated less frequently. For example, bone scans may need to be repeated only when complete response is identified in target disease or when progression in bone is suspected. 11.4.3.1 Evaluation of Target Lesions • Complete Response (CR): All of the following must be true: o Disappearance of all target lesions. o Each target lymph node must have reduction in short axis to <1.0 cm. • Partial Response (PR): At least a 30% decrease in PBSD (sum of the longest diameter for all target lesions plus the sum of the short axis of all the target lymph nodes at current evaluation) taking as reference the BSD (see Section 11.4.1). • Progression (PD): At least one of the following must be true: o At least one new malignant lesion, which also includes any lymph node that was normal at baseline (< 1.0 cm short axis) and increased to ≥ 1.0 cm short axis during follow-up. o At least a 20% increase in PBSD (sum of the longest diameter for all target lesions plus the sum of the short axis of all the target lymph nodes at current evaluation) taking as reference the MSD (Section 11.4.1). In addition, the PBSD must also demonstrate an absolute increase of at least 0.5 cm from the MSD. o See Section 11.3.2 for details in regards to the requirements for PD via FDG-PET imaging. • Stable Disease (SD): Neither sufficient shrinkage to qualify for PR, nor sufficient increase to qualify for PD taking as reference the MSD. 11.4.3.2 Evaluation of Non-Target Lesions & Non-target Lymph Nodes • Complete Response (CR): All of the following must be true: a Disappearance of all non-target lesions. Version Date 02/20/2014 52 Update #04 ALLIANCE A091102 b. Each non-target lymph node must have a reduction in short axis to <1.0 cm. • Non-CR/Non-PD: Persistence of one or more non-target lesions or non-target lymph nodes. • Progression (PD): At least one of the following must be true: a. At least one new malignant lesion, which also includes any lymph node that was normal at baseline (< 1.0 cm short axis) and increased to ≥ 1.0 cm short axis during follow-up. b. Unequivocal progression of existing non-target lesions and non-target lymph nodes. (NOTE: Unequivocal progression should not normally trump target lesion and target lymph node status. It must be representative of overall disease status change.) c. See Section 11.3.2 for details in regards to the requirements for PD via FDG-PET imaging. 11.4.4 Overall Objective Status The overall objective status for an evaluation is determined by combining the patient’s status on target lesions, target lymph nodes, non-target lesions, nontarget lymph nodes, and new disease as defined in the following tables: For Patients with Measurable Disease Target Lesions & Target Lymph Nodes CR CR PR CR/PR SD Not all Evaluated PD CR/PR/SD/PD/Not Evaluated CR/PR/SD/PD/Not Evaluated * all all Non-Target Lesions & Non-Target Lymph Nodes CR Non-CR/Non-PD CR Non-CR/Non-PD Not All Evaluated* CR Non-CR/Non-PD Not All Evaluated* CR Non-CR/Non-PD Not All Evaluated* Unequivocal PD CR Non-CR/Non-PD Not All Evaluated* Unequivocal PD New Sites of Disease No No No Overall Objective Status CR PR PR No No PR** SD No Not Evaluated (NE) Yes or No PD Yes or No PD CR Non-CR/Non-PD Not All Evaluated* Yes PD See Section 11.4.3.1 11.4.5 Symptomatic Deterioration: Patients with global deterioration of health status requiring discontinuation of treatment without objective evidence of disease progression at that time, and not either related to study treatment or other medical conditions, should be reported as PD due to “symptomatic deterioration.” Every Version Date 02/20/2014 53 Update #04 ALLIANCE A091102 effort should be made to document the objective progression even after discontinuation of treatment due to symptomatic deterioration. A patient is classified as having PD due to “symptomatic deterioration” if any of the following occur that are not either related to study treatment or other medical conditions: • • • Weight loss >10% of body weight. Worsening of tumor-related symptoms. Decline in performance status of >1 level on ECOG scale. 11.5 Formal Definitions of Variables Formal definitions of variables used for the statistical analysis appear in Section 13.0. 12.0 DATA REPORTING Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 (Adverse Events: List and Reporting Requirements). 12.1 Data Reporting 12.1.1 Method This study will be monitored by the Clinical Data Update System (CDUS) version 3.0. Cumulative CDUS data will be submitted quarterly to CTEP by electronic means. Reports are due January 31, April 30, July 31, and October 31. Instructions for submitting data using the CDUS can be found on the CTEP Web site (http://ctep.cancer.gov/protocolDevelopment/electronic_applications/cdus.htm) 12.1.2 Data Submission This study will use Medidata Rave® for remote data capture (RDC) of all study data. The Rave system can be accessed through the iMedidata portal at https://login.imedidata.com. For additional information regarding account setup or training, please visit the training section of the CALGB website. Common Terminology Criteria for Adverse Events: This study will utilize the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 for toxicity and adverse event reporting. 13.0 STATISTICAL CONSIDERATIONS 13.1 Study Design/Endpoints Overview: This study was originally developed and fully approved by CTEP to be coordinated through the Memorial Sloan Kettering Cancer Center. In 2012 and due to recent N01 funding and contract developments, the study was transferred to the Alliance. This study is evaluating the primary endpoint of confirmed response rate following treatment with MLN8237 in 5 cohorts which are defined by histologic subtype [ie, Cohort 1 -Liposarcoma, Cohort 2 – Leiomyosarcoma (non-uterine), Cohort 3 – Undifferentiated Sarcoma (including Pleiomorphic Undifferentiated Sarcoma which is formerly known as Malignant Fibrous Histiocytoma, and Myxofibrosarcoma), Cohort 4 – Malignant Peripheral Nerve Sheath Tumor, and Cohort 5 – Other Sarcomas]. Accrual and efficacy will be determined for each cohort and independently from the other cohorts. Version Date 02/20/2014 54 Update #04 ALLIANCE A091102 13.1.1 Primary Endpoint: The confirmed response (CR/PR) rate within each cohort of patients enrolled to this study. 13.1.2 Secondary Endpoints: 13.1.3 13.1.4 • To estimate progression-free survival and overall survival • To assess adverse events Correlative/Translational Endpoints: • To correlate potential clinical benefit with pre- and post-treatment tumor biopsies • To correlate clinical outcome with change in FLT-PET uptake at baseline versus after one week of treatment Study Design We will use a Simon two-stage design [61] to assess the primary endpoint within each patient cohort. See section 13.5.2 for the definition of patients to be included in evaluating this endpoint. We will consider a response rate of 0.05 as not promising, and a response rate of 0.25 as promising. The type I error rate is set at 0.1 and the type II error rate at 0.1. In each of the five cohorts, 9 patients will be accrued initially (ie, Stage 1). If there are no responses, further accrual to that cohort will be stopped and the treatment will be declared ineffective. If there is at least one response, then an additional 15 patients (ie, Stage 2) will be accrued for a total of 24 in that cohort. If at least 3 responses out of the 24 patients are observed, the new treatment would be considered worthy of further testing in this subtype. The probability of stopping the study earlier is 63% under the null hypothesis. The overall response rate (CR + PR) will be estimated and a 90% confidence interval provided. The sample size required to address the primary endpoint will range from 45 patients (ie, 9 patients x 5 cohorts) to 120 patients (24 patients x 5 cohorts, if each cohort proceeds to Stage 2 of the Simon two-stage study design). NOTE: Given the expected accrual rate, we will not suspend accrual after enrolling a sufficient number of patients to the 1st stage noted above and to allow patients to become evaluable. However, we will suspend accrual to a cohort if we observe an unexpectedly high accrual rate or excessive toxicity within a cohort. 13.2 Sample Size/Accrual Rate 13.2.1 Sample Size: The study design requires up to 120 patients. We will accrue an additional 10% (ie, 15) of patients to account for those who are deemed non-evaluable due to cancellation, ineligibility, major treatment violation, or not satisfying the definition of “evaluable” as provided above. Therefore, we anticipate enrolling a minimum of 50 (ie, 9 for stage 1 of each cohort, plus 1 for replacing those deemed non-evaluable) to a projected maximum of 135 (ie, 24 for stages 1 and 2 of each cohort, plus 3 for replacing those deemed non-evaluable). 13.2.2 Version Date 02/20/2014 Accrual Rate: 55 Update #04 ALLIANCE A091102 We are basing our accrual estimates on those provided by Memorial Sloan Kettering Cancer Center, recognizing that the Alliance (ie, CALGB and NCCTG) have neither conducted studies in this population and we have no estimates of expected accrual. Based on estimates from Memorial Sloan Kettering Cancer Center, it was expected that between their enrolling sites there will be 10 new patients a month accrued. We are also assuming that each cohort will enroll at the similar rates (ie, of the 10 patients – two patients will be enrolled for each cohort). The minimum duration of the study is 5 months if the study is stopped early for all 5 cohorts and the expected duration is approximately 14 months if the study fully accrues to completion for all 5 cohorts. This study will be available to all patients, regardless of gender, race, or ethnicity. The Alliance (ie, NCCTG and CALGB) has not conducted trials in this population and therefore do not have an estimate of accrual a rates for these specific patient groups. The table below represents the estimated accrual based on the rates provided by Memorial Sloan Kettering Cancer Center for each of the NCI/CTEP defined categories. Sex/Gender Ethnic Category Females Males Total Hispanic or Latino 8 + 8 = 16 Not Hispanic or Latino 60 + 59 = 119 Ethnic Category: Total of all subjects 68 + 67 = 135 Racial Category American Indian or Alaskan Native + = Asian 5 + 4 = 9 Black or African American 9 + 9 = 18 Native Hawaiian or other Pacific Islander + = White 54 + 54 = 108 Racial Category: Total of all subjects 68 + 67 = 135 Accrual Rate: 10 pts/month 13.2.3 Total Expected Accrual: 50 Min 135 Max Requirements for Clinicaltrials.gov Results Reporting on ClinicalTrials.gov: At study activation, this study will have been registered within the “ClincialTrails.gov” web site. The Primary and Secondary Endpoints (ie, “Outcome Measures”) along with other required information for this study will be reported on ClinicalTrials.gov. For purposes of timing of the Results Reporting, the initial estimated completion date for the Primary Endpoint of this study is 20 months after the study opens to accrual. The definition of “Primary Endpoint Completion Date” (PECD) for this study is the time the last patient registered has been followed for at least 6 months. 13.3 Grouping Factors Patient will be assigned to a cohort depending on the histologic sub-type of sarcoma, and identified administratively as the following. Version Date 02/20/2014 56 Update #04 ALLIANCE A091102 • Cohort 1: Liposarcoma • Cohort 2: Leiomyosarcoma (non-uterine) • Cohort 3: Undifferentiated Sarcoma (including Pleiomorphic Undifferentiated Sarcoma, formerly known as Malignant Fibrous Histiocytoma, and Myxofibrosarcoma) • Cohort 4: Malignant Peripheral Nerve Sheath Tumor • Cohort 5: Other Sarcomas 13.4 Analysis of Secondary Endpoints & Correlative End Points 13.4.1 Progression-free survival (PFS) & Overall Survival (OS): PFS will be calculated as the time between registration and disease progression or death. Patients lost to follow-up will be censored at the date of their most recent disease assessment. Overall Survival (OS) will be calculated as the time between registration and death. Again, patients lost to follow-up will be censored at their most recent date last known alive. The distributions of PFS and survival will be estimated using the methods of Kaplan and Meier [62] . The estimates of PFS and survival at specific time points will be calculated (eg, median, 1 year PFS, 6 month survival). No direct comparisons across cohorts will be performed as this study lacks sufficient power to draw meaningful statistical conclusions. All patients will be followed for a period of 18 months post-registration and for survival. 13.4.2 Adverse Events: Adverse events will be summaries using summary statistics and frequency tables for each separate cohort. Analyses will be descriptive in nature. 13.4.3 Correlative Endpoints Analyses of the correlative endpoints will be exploratory and hypothesisgenerating. For tumor biopsies, pre- and post-treatment protein levels will be compared by Wilcoxon signed-rank test (for paired samples). The association of response or clinical benefit with the presence or absence of markers of pathway inhibition in patient tumors will be tested using Fisher’s exact test. Changes in FLT-PET uptake at baseline versus after one week of treatment will be compared by Wilcoxon Rank Sum test between responders and non-responders defined by RECIST criteria. An exploratory analysis will be performed to identify clinical meaningful thresholds for classifying patients into FLT-PET responders (high change in FLT-PET uptake) versus FLT-PET non-responders (low change in FLT-PET uptake). The receiver operating characteristic (ROC) curve will be reported using RECIST response status as “gold” standard. Candidate thresholds in FLT-PET uptake change will be selected based on ROC curve. Each threshold will classify patients into high vs. low change in FLT-PET uptake subgroups. Fisher’s exact test will be used to assess the association between dichotomous change in FLT-PET uptake change and RECIST response status. We acknowledge the exploratory nature of this analysis. The findings are subject to further validation in an independent study. 13.5 Reporting and Exclusions 13.5.1 Version Date 02/20/2014 Evaluation of adverse events 57 Update #04 ALLIANCE A091102 All patients will be evaluable for adverse events from the time of their first treatment with MLN8237. Patients determined to be ineligible after having started treatment will be included in the assessment of toxicity for MLN8237. Summary statistics and frequencey tables will be used to describe the distributions of toxicity. 13.5.2 Evaluation of response Each patient will be assigned one of the following categories: 1) complete response, 2) partial response, 3) stable disease, 4) progressive disease, 5) early death from malignant disease, 6) early death from toxicity, 7) early death because of other cause, or 8) unknown (not assessable, insufficient data). [Note: By arbitrary convention, category 8 usually designates the “unknown” status of any type of data in a clinical database.] We are conducting our analyses using “Per Protocol” (vs Intention to Treat) principles. That is, our analyses will be performed on the basis of a subset of patients enrolled to this trial and will exclude patients deemed ineligible, cancelled, or in major treatment violation. Reasons for excluding patients from the analysis will be clearly reported. All eligible patients will be classified as evaluable for assessing the primary endpoint if they have at least one cycle of treatment and been assessed for response to treatment. Patients in response categories 4-8 should be considered to have a treatment failure (disease progression) and are deemed evaluable. Thus, an incorrect treatment schedule or drug administration does not result in exclusion from the analysis of the response rate. The 95% confidence intervals should also be provided and estimated using the method of Duffy and Santner [62] Version Date 02/20/2014 58 Update #04 ALLIANCE A091102 14.0 REFERENCES 1. Lorigan, P., et al., Phase III trial of two investigational schedules of ifosfamide compared with standard-dose doxorubicin in advanced or metastatic soft tissue sarcoma: a European Organisation for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group Study. J Clin Oncol, 2007. 25(21): p. 3144-50. 2. 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Kaplan E, M.P., Nonparametric estimation for incomplete observations. J Am Stat Assoc 53:457481, 1958. Version Date 02/20/2014 62 Update #04 ALLIANCE A091102 APPENDIX A Performance Status Criteria ECOG Performance Status Scale Karnofsky Performance Scale Grade Descriptions Percent 100 0 Normal activity. Fully active, able to carry on all pre-disease performance without restriction. 1 2 3 4 5 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). 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. In bed >50% of the time. Capable of only limited self-care, confined to bed or chair more than 50% of waking hours. 90 80 Normal activity with effort; some signs or symptoms of disease. 70 Cares for self, unable to carry on normal activity or to do active work. 60 50 40 30 100% bedridden. Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair. 20 Dead. 0 Version Date 02/20/2014 63 Description Normal, no complaints, no evidence of disease. Able to carry on normal activity; minor signs or symptoms of disease. 10 Requires occasional assistance, but is able to care for most of his/her needs. Requires considerable assistance and frequent medical care. Disabled, requires special care and assistance. Severely disabled, hospitalization indicated. Death not imminent. Very sick, hospitalization indicated. Death not imminent. Moribund, fatal processes progressing rapidly. Dead. Update #04 ALLIANCE A091102 APPENDIX B Pill Diary for Alliance A091102: A Phase 2 Study of MLN8237 in Advanced / Metastatic Sarcoma Number of Pills Given:___________ Pill Bottle(s) returned: Circle Yes or No Total Daily Dose:________________ Number of Pills returned:___________ (To be completed by RN) PLEASE FILL OUT AND BRING THIS SHEET AT YOUR NEXT VISIT. Please remember to take your pills without food (except for water and prescribed medications at least 1 hour before and 2 hours after). Pills should be taken at approximately the same time each day with 8 ounces of water (1 cup). You will be asked to maintain the below pill diary for each dose of medication. CYCLE #: _____ DAY MEDICATION Example MLN8237 Day 1 MLN8237 Day 2 MLN8237 Day 3 MLN8237 Day 4 MLN8237 Day 5 MLN8237 Day 6 MLN8237 Day 7 MLN8237 DATE 01/01/2010 TIME 9:00 9:00 NUMBER of 10mg tablets taken AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM AM/PM 5 5 Patient Signature: ____________________________________ Date: __________ Consenting Professional/Research RN Signature: ____________________ Date: ______________ Consenting Professional/Research RN Comments:___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Version Date 02/20/2014 64 Update #04
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