RAD001 and Neurocognition in PTEN Hamartoma Tumor Syndrome

This is a signal seeking Phase I/II 6-month, randomized, double-blind placebo-controlled
trial of everolimus in individuals, ages 5 to 45 years with a PTEN mutation, with safety and
neurocognition as the primary endpoints.

Participant's or a legal guardian will need to sign an informed consent prior to enrollment
in the study. To determine eligibility participants will undergo a series of screening tests
and safety measures. If determined to be eligible for the blinded phase of the study,
participants will be randomly assigned to take either the study drug or a placebo (pill with
no medicine).

The blinded phase of the study involves about eight visits, five of which will occur at the
study site, and three of which will be conducted over the phone. These visits will take place
over a six month period. Study visits will vary in length. Baseline, three month and six
month visits may last up to 8 hours, if optional measures are done, while all other visits
will be less than 2 hours. The study visits include blood draws, general health exams, and
neuropsychological assessments. The study will also include optional eye-tracking, EEG and
auditory evoked potential (AEP) measures, and the collection of microbiome/mycobiome and
biomarker blood sample. There is no fee to participate in this study. The study drug will be
provided at no charge during the study.

After the 6 month treatment phase, individuals who were randomly assigned to take placebo
will be offered inclusion in a 6 month open label phase where the study drug will be provided
at no charge. The open label phase assessments will be similar to those done in the blinded
phase, but patients/families will only need to return to the study site three times during
this phase.

Participants will receive a developmental assessments report after completing the study.
After all study data has been analyzed, patients and families will also be informed of the
overall results. Treatment on this study may or may not improve an individual's learning
skills (neurocognition) or behavior. We hope that future patients and families will benefit
from what is learned by this study.

Specific Aims /Objectives Primary objective

-To evaluate the safety of everolimus compared with placebo in patients with PTEN mutations
focusing on NCI CTCAE Grade 3 and 4 adverse events, serious adverse events, and Grade 3 and 4
laboratory toxicities.

Secondary objectives

-To evaluate the efficacy of everolimus on neurocognition and behavior in inividuals with
PTEN mutations compared to placebo as measured by standardized, direct and indirect
neurocognitive tools and behavioral measures.

Inclusion Criteria:

1. Male and female outpatients between 5 and 45 years of age (inclusive);

2. Pathogenic PTEN mutation confirmed by clinical genetic testing;

3. IQ ≥ 50 (either verbal, nonverbal, or full scale IQ) (IQ necessary to be able to
complete the required neurocognitive and developmental assessments)

4. Performance below the age-adjusted population mean on at least one standardized
measure such as attention (CPT-3, mean reaction time), working memory (SB5), or fine
motor skills (Purdue Pegboard Test; either dominant hand, non-dominant hand, or both
hands);

5. Adequate bone marrow function as shown by:

1. platelets ≥ 80,000/mm3

2. absolute neutrophil count ≥ 1,000/mm3

3. hemoglobin ≥ 9 g/dL

6. Adequate liver function as shown by:

1. Total serum bilirubin < 1.5 x ULN

2. AST and ALT levels < 2.5 x ULN

3. INR ≤ 2

7. Adequate renal function: serum creatinine < 1.5 x ULN,

8. Signed informed consent obtained prior to any screening procedures;

9. Individuals on psychotropic and anti-epileptic medications should maintain a stable
dose for at least 2 months prior to the screening visit;

10. Negative serum pregnancy test for females at screening and no plans to become pregnant
or conceive a child while participating in the study. The effects of mTOR inhibitors
on the developing fetus at the doses used in this study are unknown. For this reason,
women of child-bearing potential and men must agree to use adequate contraception
prior to study entry and for the duration of the study. Estrogen-containing oral
contraceptives are not recommended in women enrolled in this study. Abstinence or two
effective non-estrogen or barrier methods of contraception (such as condoms +
spermicidal foam) must be used;

11. No anticipated changes in the frequency and intensity of existing interventions such
as behavioral and developmental treatments, in home services, and speech therapy;

12. No planned changes in school placement;

13. For individuals under 18 or who are otherwise incapable, there must be an available
caregiver who can reliably bring subject to clinic visits and provide trustworthy data

14. Able to communicate fluently in English

Double-Blind Exclusion Criteria

1. Patients currently receiving anticancer therapies or who have received anticancer
therapies within 4 weeks of the start of Everolimus (including chemotherapy, radiation
therapy, antibody based therapy, etc.);

2. Known intolerance or hypersensitivity to Everolimus or other rapamycin analogs (e.g.
sirolimus, temsirolimus);

3. Known impairment of gastrointestinal (GI) function or GI disease that may
significantly alter the absorption of oral Everolimus;

4. Uncontrolled diabetes mellitus as defined by HbA1c >8% despite adequate therapy.
Patients with a known history of impaired fasting glucose or diabetes mellitus (DM)
may be included, however blood glucose and antidiabetic treatment must be monitored
closely throughout the trial and adjusted as necessary;

5. Patient with uncontrolled hyperlipidemia: fasting serum cholesterol > 300 mg/dL OR
>7.75 mmol/L AND fasting triglycerides > 2.5 x ULN.

6. Patients who have any severe and/or uncontrolled medical or psychiatric conditions
(see section 4.6 for additional details)

7. Chronic treatment with corticosteroids or other immunosuppressive agents. Topical or
inhaled corticosteroids are allowed;

8. Known history of or seropositivity for Hepatitis B, Hepatitis C, or HIV;

9. Patients who have received live attenuated vaccines within 1 week of start of
Everolimus and during the study. Patient should also avoid close contact with others
who have received live attenuated vaccines. Examples of live attenuated vaccines
include intranasal influenza, measles, mumps, rubella, oral polio, BCG, yellow fever,
varicella and TY21a typhoid vaccines;

10. Patients who have a history of another primary malignancy, with the exceptions of:

1. non-melanoma skin cancer,

2. and carcinoma in situ of the cervix, uteri, or breast from which the patient has
been disease free for ≥3 years;

11. Planned changes to concomitant medications;

12. Prior or concomitant therapy with known or possible anti-mTOR activity, including
rapamycin (sirolimus);

13. Concomitant therapy with strong inhibitor (e.g., cyclosporine and ketoconazole) or
inducer of CYP3A;

14. Active infection at time of enrollment;

15. Patients with a history of non-compliance to medical regimens or who are considered
potentially unreliable or will not be able to complete the entire study;

16. Patients who are currently part of or have participated in any clinical investigation
with an investigational drug within 1 month prior to dosing;

17. Pregnant or nursing (lactating) women;

18. Women of child-bearing potential (WOCBP), defined as all women physiologically capable
of becoming pregnant, must use highly effective methods of contraception during the
study and 8 weeks after. Highly effective contraception methods include:

a. A combination of any two of the following:

i. Use of oral, injected or implanted hormonal non-estrogen containing methods of
contraception or;

ii. Placement of an intrauterine device (IUD) or intrauterine system (IUS);

iii. Barrier methods of contraception: condom or occlusive cap (diaphragm or
cervical/vault caps) with spermicidal foam/gel/film/cream/ vaginal suppository;

b. Total abstinence or;

c. Male/female sterilization. Women are considered post-menopausal and not of
child-bearing potential if they have had 12 months of natural (spontaneous) amenorrhea
with an appropriate clinical profile (e.g. age appropriate, history of vasomotor
symptoms) or have had surgical bilateral oophorectomy (with or without hysterectomy)
or tubal ligation at least six weeks prior to randomization. In the case of
oophorectomy alone, only when the reproductive status of the woman has been confirmed
by follow up hormone level assessment is she considered not of child-bearing
potential.

19. Male patients whose sexual partner(s) are WOCBP who are not willing to use adequate
contraception, during the study and for 8 weeks after the end of treatment

20. Major surgery, radiation therapy, or stereotactic radio-surgery within previous 4
weeks at time of screening

21. Neurosurgery within prior 6 months at time of screening.