Intraperitoneal Paclitaxel and Carboplatin With IV Avastin Therapy in Patients With Carcinomas of Mullerian Origin

The Study Drugs:

Carboplatin is designed to interfere with the growth of cancer cells by stopping cell
division, which may cause the cells to die.

Paclitaxel is designed to block the mechanisms of cell division in cancer cells, which may
cause them to die.

Avastin is designed to prevent or slow down the growth of cancer cells by blocking the
effects of VEGF, a blood-vessel stimulating agent that plays an important role in the growth
of both normal and abnormal blood vessels.

Intraperitoneal Port (IP) Placement:

If you are found eligible to take part in this study, you will need to have an IP port,
called an intraperitoneal catheter tube, placed into the abdomen. The catheter will be used
to give the paclitaxel and carboplatin directly into your abdomen. You may already have had
this catheter placed at a previous surgery. If not, you will have a minor surgical procedure
in the operating room to have it placed. You will be asked to sign a separate surgical
consent form describing this procedure, the risks involved, and the steps for taking care of
the catheter while it is in place.

Study Drug Administration:

You will receive up to 6 cycles of treatment with the study drugs. Each cycle is 21 days (3
weeks) long.

Cycle 1:

You will receive paclitaxel and carboplatin through a needle in your vein on Day 1.
Paclitaxel is given first followed by carboplatin. Both drugs are given over 1 hour. On Days
8 and 15 you will only receive paclitaxel by vein. This infusion is also given over 1 hour.

Cycle 2:

On Day 1, about 2 cups of normal saline will be infused into your abdomen through the IP
catheter. This infusion takes 30-60 minutes. You will then receive paclitaxel through the IP
port in your abdomen. When the paclitaxel infusion is complete, you will receive carboplatin
through the IP port. Each infusion takes about 1 hour. After the chemotherapy infusions are
complete, another 2-4 cups of normal saline will be infused through the port. This is done to
help move the chemotherapy to all areas of your abdomen. You will be asked to change position
frequently.

On Day 8, about 2 cups of normal saline will be infused into your abdomen through the IP
catheter. You will then receive paclitaxel through the IP port in your abdomen over 1 hour.
While you are receiving paclitaxel through your IP port, you will also receive Avastin by
vein. The first dose of Avastin will be given over 90 minutes. If you tolerate the first
infusion well, the second infusion (given in Cycle 3) may be given over 60 minutes. If the
60-minute infusion is well-tolerated, all infusions after that may be given over 30 minutes.
After the paclitaxel infusion is complete, you will receive another 2-4 cups of normal saline
through the port. You will be asked to change position frequently.

On Day 15, about 2 cups of normal saline will be infused into your abdomen through the IP
catheter. You will then receive paclitaxel through the IP port in your abdomen. After the
paclitaxel infusion is complete, you will receive another 2-4 cups of normal saline through
the port. You will be asked to change position frequently.

Cycles 3-6:

On Day 1, about 2 cups of normal saline will be infused into your abdomen through the IP
catheter. You will receive paclitaxel through the IP catheter over 1 hour. After completing
paclitaxel, you will receive carboplatin through the IP catheter over 1 hour. After these
infusions are complete you will receive another 2-4 cups of normal saline through the port.
You will be asked to change position frequently. While undergoing IP therapy with paclitaxel
and carboplatin, you will also receive the second infusion of Avastin by vein. The length of
this infusion will depend how well you tolerated the drug the first time it was given in
Cycle 2.

On Days 8 and 15, about 2 cups of normal saline will be infused into your abdomen through the
IP catheter. You will then receive paclitaxel through the IP port in your abdomen over 1
hour. After the paclitaxel infusion is complete, you will receive another 2-4 cups of normal
saline through the port. You will be asked to change position frequently.

Before you receive paclitaxel and carboplatin, you will receive the drug dexamethasone by
vein to help decrease the risk of study drug side effects. You may also receive other drugs
(such as cimetidine and diphenhydramine) by vein to help with side effects, such as nausea
and allergic reaction. The choice of which drugs to use is up to your doctor.

Study Visits:

On Day 1 of each cycle, the following tests and procedures will be performed:

- Your medical history will be recorded, including a list of any drugs you are taking.

- You will be asked how well you are able to perform your normal daily activities
(performance status evaluation).

- You will have physical exam, measurement of your vital signs, and a neurological exam.

- You will be asked about any side effects you are experiencing.

- Blood (about 3 teaspoons) will be drawn for routine tests (this will be repeated on Days
8 and 15 of each cycle as well).

Blood (about 1 teaspoon) will be drawn to check your CA125 level before treatment starts in
Cycle 1 and on Day 1 of Cycles 2, 4, and 6.

Before treatment starts in Cycle 1 and on Day 8 of Cycle 2 and Day 1 of Cycles 3-6, urine
will be collected for routine tests.

On Days 1, 8, and 15 of Cycles 1, 2, and 4, blood (1 teaspoon each time) will be drawn 12
different times each day for pharmacokinetic (PK) testing. PK testing measures the amount of
study drugs in the body at different time points. Blood (1 teaspoon each time) will also be
drawn 1 time on Days 2 and 3 of Cycles 1, 2, and 4.

On Day 8 of Cycle 2 and Day 1 of Cycles 3, 4, and 6 before paclitaxel starts, you will have
the levels of vascular endothelial growth factor (VEGF) in your abdominal fluid measured.
VEGF is a protein that causes fluid build-up (ascites) in the abdomen. About 2 cups of normal
saline will be infused through the IP port. You will be asked to change positions for about
15 minutes. Then about 3-4 tablespoons of the fluid will be removed from the port with a
syringe. This shows how Avastin is affecting your abdominal fluid. You will also have blood
(about 1 teaspoon) drawn to check the levels of VEGF in your blood.

Length of Study:

You may remain on this study for up to 6 cycles. You will be taken off study early if the
disease gets worse or intolerable side effects occur.

End-of-Study Visit:

Once you are off study, you will have an end-of-study visit. At this visit, the following
tests and procedures will be performed:

- You will have a physical exam.

- You will have a computed tomography (CT) scan.

- Blood (about 1 teaspoon) will be drawn to check your CA125 level.

Long-Term Follow-Up:

After your last study visit, you will be contacted about every 3 months from then on to check
on how you are doing. You will return to the clinic or researchers will call you on the phone
to ask you questions about how you are doing. Your doctor will tell you if any standard tests
and procedures need to be performed.

This is an investigational study. Avastin, carboplatin, and paclitaxel are FDA approved and
commercially available for the treatment of many types of cancer. At this time, the addition
of Avastin to paclitaxel and carboplatin is being used to treat ovarian cancer in research
only.

Inclusion Criteria:

1. Histologically confirmed epithelial carcinoma of mullerian origin. Specifically,
ovarian, primary peritoneal and tubal carcinoma will be allowed. All histologic
subtypes are eligible.

2. Stage III or IV disease. Stage IV disease by virtue of pleural effusions is allowed
but stage IV disease with visceral metastases e.g. lung, liver or abdominal wall is
NOT ELIGIBLE. Please discuss any eligibility concerns directly with the P.I., Dr.
Richard Penson.

3. Patient must have undergone surgical staging and debulking with optimal (less than
1cm) cytoreduction.

4. No significant intra-abdominal adhesions or other contraindication to IP port
placement.

5. Patients must give written informed consent.

6. Patient must be age 18 years or older.

7. Adequate bone marrow function with an ANC greater that 2,500 and Platelets greater
than 100,000 cubic millimeters.

8. No proteinuria or less than +1; if greater, 24-hour urine collection must be performed
to document less than or equal to 1gm/24 hours of protein.

9. ECOG performance status less than or equal to 1.

Exclusion Criteria:

1. Visible disease on post-operative imaging (recognizing the limitations of
postoperative CT scans due to postoperative changes there should be unequivocal CT
evidence of residual disease greater than 1cm)

2. ECOG performance status greater than or equal to 2

3. Previous chemotherapy for the disease under study

4. Suboptimal (greater than 1 cm residual disease) cytoreduction

5. Creatinine greater than 1.5 mg/dL

6. SGOT greater than 2 x ULN, bilirubin greater than 1.5 x ULN

7. Colostomy or ileostomy

8. Concurrent invasive malignancy. (Patients with concurrent superficial endometrial
carcinoma are eligible if their endometrial carcinoma is superficial or invades less
than 50% the thickness of the myometrium.)

9. Known hypersensitivity to E.coli derived products or to any component of Avastin

10. Active psychiatric or mental illness that makes informed consent or careful clinical
follow-up unlikely

11. History of myocardial infarction within 6 months

12. History of stroke or transient ischemia attack within 6 months

13. Inadequately controlled hypertension greater than 140/90 mm Hg on antihypertensive
medication(s)

14. Any prior history of hypertensive crisis or hypertensive encephalopathy

15. Clinically significant peripheral vascular disease

16. Significant vascular disease (e.g. aortic aneurysm, aortic dissection)

17. Unstable angina

18. New York Heart Association (NYHA) grade II or greater congestive heart failure

19. Evidence of coagulopathy or bleeding diathesis

20. Known central nervous system disease or brain metastases

21. Major surgical procedure, open biopsy, or significant traumatic injury within 28 days
prior to day 28 (first dose of Avastin), anticipation of need for major surgical
procedure during the course of the study

22. Minor surgical procedures such as fine needle aspirations or core biopsies or
laparoscopy for IP catheter placement within 7 days prior to cycle 2 day 8

23. Open wound, ulcer, or bone fracture

24. History of abdominal fistula, gastrointestinal perforation or intra-abdominal abscess;
current signs and symptoms of bowel obstruction; current dependency on IV hydration or
TPN

25. Pregnant (positive pregnancy test) or lactating