Safety and Efficacy Study of Sirolimus in Complicated Vascular Anomalies

Patients with vascular anomalies (VA) have a spectrum of diseases that can be broadly
classified into vascular tumors and malformations. Complicated vascular anomalies can cause
disfigurement, chronic pain, and organ dysfunction with significant morbidity and mortality.
Despite the severity of potential complications, we lack uniform guidelines for the
treatment and response to treatment of children and young adults with these diseases. There
are pre-clinical and clinical data supporting the essential regulatory function of the
PI3K/Akt/mTOR pathway in vascular growth and organization, and suggest a therapeutic target
for patients with complicated vascular anomalies. The overall goal of this trial is to
objectively determine the effectiveness and safety of the mTOR inhibitor Rapamycin* in the
treatment of children and young adults diagnosed with complicated vascular anomalies. We
propose a Phase 2 trial with the diagnostic, therapeutic and response criteria
experimentally determined in this study used as a framework for future Phase 3 clinical
trials.

Inclusion Criteria:

Inclusion will be strictly limited to children and young adults with vascular anomalies
with complications that require systemic therapy for control.

Diagnosis: All patients must have one of the following vascular anomalies as determined by
clinical, radiographic and histologic criteria (when possible):

- Kaposiform Hemangioendotheliomas with Kasabach-Merritt Phenomenon

- Kaposiform Hemangioendotheliomas without Kasabach-Merritt Phenomenon

- Tufted Angioma with Kasabach-Merritt Phenomenon

- Tufted Angioma without Kasabach-Merritt Phenomenon

- Capillary Lymphatico-Venous Malformation (CLVM)

- Venous Lymphatic Malformation (VLM)

- Microcystic Lymphatic Malformation (MLM)

- Multifocal Lymphangiomatosis and Thrombocytopenia (MLT)/Cutaneovisceral Angiomatosis
and Thrombocytopenia (CAT)

- Capillary Lymphatic Arterial Venous Malformations (CLAVM)

- PTEN Overgrowth syndrome with vascular anomaly

- Lymphangiectasia Syndromes

If archived tissue is available, histological diagnosis will be confirmed by the pathology
lab at the enrolling site.

Complications: Patients must have vascular anomalies that have potential to cause
significant morbidity. In addition to the above diagnosis, one or more of the following
criteria needs to be met:

- Coagulopathy

- Chronic pain

- Recurrent cellulitis (>3 episodes/year)

- Ulceration

- Visceral and/or bone involvement

- Cardiac dysfunction

Age: Patients must be 0 - 31 years of age at the time of study entry. Enrollment includes
patients of both genders and all ethnic groups.

Organ function requirements:

Adequate liver function defined as:

- Total bilirubin (sum of conjugated and unconjugated) ≤1.5 x ULN for age, and

- SGPT (ALT) <5 x ULN for age, and

- Serum albumin > or = 2 g/dL.

Fasting LDL and cholesterol:

- Fasting LDL cholesterol of <160 mg/dL

- Patients taking a cholesterol lowering agent must be on a single medication and on a
stable dose for at least 4 weeks

Adequate Bone Marrow Function defined as:

- Peripheral absolute neutrophil count (ANC) > or = 1000/microL

- Hemoglobin > or = 8.0 gm/dL (may receive RBC transfusions)

- Platelet count > or = 50,000/microL (transfusion independent defined as not receiving
a platelet transfusion within a 7 day period prior to enrollment)

Note: There is NO platelet requirement for patients with Kasabach-Merritt Phenomenon

Adequate Renal Function Defined as:

• A serum creatinine based on age as follows:

- ≤ 5 years of age maximum serum creatinine (mg/dL) of 0.8

- 6 < age ≤ 10 years of age maximum serum creatinine (mg/dL) of 1.0

- 11 < age ≤ 15 years of age maximum serum creatinine (mg/dL) of 1.2

- > 15 years of age maximum serum creatinine (mg/dL) of 1.5

AND cystatin C equal to or less than the upper limit of normal for the patient. If
cystatin C does not initially meet this criterion, it may be repeated or a more sensitive
screening by nuclear GFR must be ≥ 70 ml/min.

• Urine protein to creatinine ratio (UPC) < 0.3 g/l

Performance Status: Karnofsky > or = 50 (>10 years of age) and Lansky > or = 50 for
patients < or = 10 years of age

Prior therapy requirements:

1. Patients who have undergone surgical resection or interventional radiology procedures
for disease control are eligible if they meet all inclusion criteria after
surgery/procedure

2. Surgery: At least 2 weeks since undergoing any major surgery

3. Steroids: Patients with endocrine deficiencies are allowed to receive physiologic or
stress doses of steroids if necessary. Other patients, such as vascular tumor
patients, need to be on a weaning dose of steroids (steroid use defined as
intravenous or oral steroids required for more than one day).

4. Myelosuppressive chemotherapy: Must not have received within 4 weeks of entry onto
this study.

5. Hematopoietic GFs: At least 7 days since the completion of therapy with a GF that
supports platelet, red or white cell number or function.

6. Biologic (anti-neoplastic agent): At least 14 days since the completion of therapy
with a biologic agent. For agents that have known AEs occurring beyond 14 days after
administration, this period must be extended beyond the time during which AEs are
known to occur. These patients must be discussed with the Study Chair on a
case-by-case basis.

7. Patients diagnosed with Kaposiform Hemangioendotheliomas or Tufted Angiomas will not
require a washout period prior to enrollment, but will be required to discontinue the
use of prohibited concomitant medications upon enrollment in the study following the
guidelines of the protocol.

8. Investigational Drugs: Patients must not have received any non-FDA approved drug
within 4 weeks.

9. XRT: > or = 6 months from involved field radiation to vascular tumor.

10. CYP3A4 inhibitors: Patients may not be currently receiving strong inhibitors of
CYP3A4, and may not have received these medications within 1 week of entry. (See
Appendix II). These include:

- Macrolide Antibiotics: clarithromycin, telithromycin, erythromycin,
troleandomycin.

- Gastrointestinal prokinetic agents: cisapride, metoclopramide.

- Antifungals: itraconazole, ketoconazole, fluconazole (doses > 200 mg/day),
voriconazole, clotrimazole

- Calcium channel blockers: verapamil, diltiazem, nicardipine

- Other drugs: rifampin, bromocriptine, cimetidine (Tagamet®), danazol,
cyclosporine oral solution, lansoprazole (Prevacid®).

- Grapefruit juice.

11. CYP3A4 inducers: Patients must also avoid strong inducers of CYP3A4, and may not
have received these medications within 1 week of entry. These include:

- Anticonvulsants: carbamazepine, phenobarbital, phenytoin

- Antibiotics: rifabutin, rifapentine.

- Herbal preparations: St. John's Wort (Hypericum perforatum, hypericine).

12. Enzyme inducing anticonvulsants: Patients may not be taking enzyme-inducing
anticonvulsants, and may not have received these medications within 1 week of entry,
as these patients may experience different drug disposition. These medications
include:

- Carbamazepine (Tegretol®)

- Felbamate (Felbtol®)

- Phenobarbitol

- Phenytoin (Dilantinl®)

- Primidone (Mysoline®)

- Oxcarbazepine (Trileptal®)

Exclusion Criteria:

- Dental braces or prosthesis only if it interferes with radiologic analysis of
vascular anomaly.

- Concurrent severe and/or uncontrolled medical disease which could compromise
participation in the study (e.g. uncontrolled diabetes, uncontrolled hypertension,
severe infection, severe malnutrition, chronic liver or renal disease, active upper
GI tract ulceration).

- Chronic treatment with systemic steroids or another immunosuppressive agent. Patients
with endocrine deficiencies are allowed to receive physiologic or stress doses of
steroids if necessary. Patients with the diagnosis of a vascular tumor (KHE, TA) can
be on a weaning dose of steroids.

- Patients who require medications that inhibit/induce CYP3A4 enzyme activity to
control concurrent medical conditions.

- Known history of HIV seropositivity or known immunodeficiency. Testing is not
required unless a condition is suspected.

- Impairment of gastrointestinal function or gastrointestinal disease that may
significantly alter the absorption of sirolimus (e.g. ulcerative disease,
uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome or small bowel
resection). A gastric tube or nasogastric tube is allowed.

- Women who are pregnant or breast feeding.

- Males or females of reproductive potential may not participate unless they have
agreed to use an effective contraceptive method during the period they are receiving
the study drug and for 3 months thereafter. Abstinence is an acceptable method of
birth control. Women of childbearing potential will be given a pregnancy test within
7 days prior to administration of sirolimus and must have a negative urine or serum
pregnancy test.

- Patients who have received prior treatment with an mTOR inhibitor.

- Patients unwilling or unable to comply with the protocol, or who in the opinion of
the investigator may not be able to comply with the safety monitoring requirements of
the study.

- Patients who currently have an uncontrolled infection, defined as receiving
intravenous antibiotics.