A Study to Compare Vincristine to Sirolimus for Treatment of High Risk Vascular Tumors

• Sponsor: Boston Children's Hospital (Other)
• Overall Status: Terminated
• CT.gov ID: NCT02110069
• Collaborator: Pfizer (Industry)
• Enrollment: 4
• Locations: 7
• Arms: 2
• Actual Duration (Months): 40.4
• Patients Per Site: 0.6
• Patients Per Site Per Month: 0

Study Details

Study Description

Brief Summary

In this research study we want to learn more about which treatment works better for patients diagnosed with a vascular tumor called Kaposiform Hemangioendothelioma (KHE) or other high risk vascular tumors such as Tufted Angioma (TA). In these tumors, the blood cells that help your blood clot called platelets become trapped in the tumor causing swelling, pain, and bruising. Vascular tumors can be life threatening. There are few medical treatments that will work to shrink the vascular tumor. Some doctors will use steroids and vincristine to try and shrink vascular tumors.

In this research study, the study doctor will compare two different drugs to see which one will work better to help shrink your vascular tumor. One of the drugs is vincristine. Vincristine is approved by the Food and Drug Administration (FDA) to treat people with cancer. Vincristine is used to stop the abnormal cells from growing such as cells that make up blood vessels.

The other drug to be used in this study is sirolimus. Sirolimus is currently approved by the Food and Drug Administration (FDA) to prevent transplanted organ rejection. Sirolimus is not approved by the FDA for treatment of vascular abnormalities and is considered experimental. Sirolimus belongs to a class of drugs call 'mTOR inhibitors'. mTOR (mammilian target of rapamycin) helps cells to grow and may also help blood vessels to grow in a more normal fashion. Sirolimus is currently being tested in patients with vascular tumors and cancer. In vascular tumors, we hope sirolimus will stop the blood vessel growth.

Funding Source: FDA - OOPD (Office of Orphan Products Development)

Condition or Disease	Intervention/Treatment	Phase
Kaposiform Hemangioendothelioma (KHE); Kasabach-Merritt Syndrome; Tufted Angioma	Drug: Vincristine; Drug: Sirolimus	Phase 2

Detailed Description

Kaposiform hemangioendotheliomas (KHE) are extremely rare life threatening tumors which can be associated with Kasabach-Merritt Phenomenon consisting of profound thrombocytopenia and hypofibrinogenemia causing a significant risk of bleeding and an associated mortality rate as high as 20% to 30%. Despite the severity of potential complications, we lack uniform guidelines for the treatment and response to treatment of children and young adults with these tumors. KHE patients have been treated with a multitude of aggressive drug regimens without prospective evaluation of response or safety. Presently, vincristine is considered the standard of practice. We have treated a subset of these patients on study SIR-DA-0901 (FDA Grant# 5RO1FD003712-01). This study is a phase II trial assessing the efficacy and safety of sirolimus for the treatment of complicated vascular anomalies. Although the numbers are small, the response has been extremely promising with excellent tolerability. There is pre-clinical and clinical data supporting the essential regulatory function of the PI3 kinase/AKT/mTOR pathway in vascular growth and organization which suggests a therapeutic target for patients with complicated vascular anomalies. The overall goal of this trial is to objectively assess the efficacy of sirolimus compared to vincristine for the treatment of patients with high risk KHE.

Hypothesis: Sirolimus treatment for children and young adults with Kaposiform hemangioendotheliomas will be more effective than vincristine, assessed by time to response in an induction period and provide equivalent safety parameters.

Study Rationale We propose a multi-center, phase II trial with participation from 8 sites. The study will consist of two phases. The first of these is an initial induction phase in which vincristine and steroids will be compared to sirolimus and steroids. Response in the induction phase will be assessed as time to hematologic response. At the end of induction phase, cross over can occur if there is failure to respond. Part 2 is a maintenance phase which will be 1 year in length. Continued safety and efficacy data will be collected during maintenance and there will be cross over at any time for patients who lose their response following induction. Failure will be defined as worsening of hematological parameters on two separate laboratory evaluations at any time during maintenance or if they meet the definition of progressive disease following response assessments. Formal response in maintenance will be evaluated by imaging studies, functional assessment, and quality of life as per study SIR-DA-0901. Present therapies are very limited and new therapies are desperately needed for this devastating disease. Based on our preliminary data, there is a very good rationale for sirolimus therapy in KHE patients and so a phase II trial is urgently needed to determine if this therapy is to become the new standard of care for KHE patients.

Our secondary aims will be addressing biomarker analysis. There are limited studies describing the biology of these tumors. Per study SIR-DA-0901 there is some preliminary data indicating the importance of VEGF-C and other upregulated markers in the mTor pathway. This needs to be further investigated especially in KHE patients. Furthermore there are no clear objective measurements to determine response data.

Study Design

• Study Type: Interventional
• Actual Enrollment: 4 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: A Randomized Phase 2 Study of Vincristine Versus Sirolimus to Treat High Risk Kaposiform Hemangioendothelioma (KHE).
• Actual Study Start Date: Jun 14, 2017
• Actual Primary Completion Date: Oct 2, 2019
• Actual Study Completion Date: Oct 27, 2020

Arms and Interventions

Arm	Intervention/Treatment
Active Comparator: Vincristine Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months.	Drug: Vincristine; Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance); Other Names: Oncovin Vincasar® PFS Vincrex
Experimental: Sirolimus Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml.	Drug: Sirolimus; Continuous dosing to maintain trough level of 10-15ng/ml.; Other Names: Rapamune

Outcome Measures

Primary Outcome Measures

1. Change in Hematologic Parameters [2 months]

   Hematologic parameters are defined as a platelet count greater than 100,000/uL (or a 2 times increase in platelet count compared to baseline) and a fibrinogen level greater than 150mg/dl.

2. Number of Serious and Non-Serious Adverse Events [2 months; 12 months]

   Serious and non-serious adverse events will be recorded for all participants and graded using CTCAE v4.0 (Common Toxicity Criteria for Adverse Effects). Adverse event rates will be calculated for both sirolimus and vincristine.

Secondary Outcome Measures

1. Evaluation of Disease Response - Maintenance [6 months; 12 months]

   Disease evaluation will be measured using a combination of quality of life assessments, clinical parameters, and radiologic images.

2. Number of Serious and Non Serious Adverse Events - Maintenance [6 months; 12 months]

   Serious adverse events and adverse events will be graded according to CTCAE v4.0. Adverse event rates will be calculated for both sirolimus and vincristine.

3. Change in the Serum Levels of KHE Biomarkers [Baseline, 2 months, 6 months, and 12 months]

   The following KHE biomarkers will be evaluated vascular endothelial growth factor A, C, and D (VEGF-A, C, D_, IL-8 (interleukin), Pleiotrophin, IGF-1 (insulin-like growth factor), endothelin-1, thrombospondin and angiopoietin 1 and 2.

4. Identify Genetic Variants in Drug Metabolism Enzymes. [Baseline]

   Single nucleotide polymorphism array analysis to obtain genetic information on variants in drug metabolism enzymes that affect sirolimus and vincristine metabolism.

Eligibility Criteria

Criteria

• Ages Eligible for Study: N/A to 31 Years
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Diagnosis: All patients must have one of the following vascular anomalies as determined by clinical, radiologic and histologic criteria (when possible). Biopsy strongly recommended (but not required) with suggested immunostains: CD34, PROX-1 or D240, Glut-1 and MIB-1.

1. Kaposiform Hemangioendotheliomas

2. Tufted angioma

High Risk Stratification: In addition to the above diagnosis, all of the following criteria need to be met:

1. Kasabach Merritt Syndrome defined at a platelet counts less than 50,000 K/µl and/or fibrinogen level < 100 mg/dl at the time of diagnosis.

• 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:

1. Adequate liver function defined as:

2. Total bilirubin ≤ 1.5 x ULN for age, and

3. SGPT (ALT) ≤ 5 x ULN for age, and

4. Serum albumin >/= 2 g/dL.

5. Fasting LDL cholesterol of <160 mg/dL

6. Fasting triglyceride <400 mg/dl

7. Adequate Bone Marrow Function defined as:

8. Peripheral absolute neutrophil count (ANC) >/= 1000/uL

9. Hemoglobin >/= 8.0 g/dL (may receive RBC transfusions)

10. No Platelet requirement

11. Adequate Renal Function Defined as:

12. A serum creatinine based on age as follows:

Age (Years) Maximum Serum Creatinine (mg/dL)

• 5 0.8 6 to ≤10 1.0 11 to ≤15 1.2 >15 1.5

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

• Performance Status: Karnofsky >/= 50 (≥16 years of age) and Lansky >/= 50 for patients <16 years of age.

• Prior therapy

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. Radiation: > 6 months from involved field radiation

4. Prior vincristine therapy is permitted. Patients may also have received up to 2 doses of vincristine prior to randomization.

Exclusion Criteria:

• Concurrent severe and/or uncontrolled medical disease that 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).

• Patients who require medications that are strong inhibitors/inducers CYP3A4 enzyme activity, including anticonvulsants, (Appendix II) to control concurrent medical conditions are not eligible. Patients who discontinue use of prohibited medications with a one week washout prior to start of study treatment are eligible.

• 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.

• Females 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. Females of childbearing potential will be given a pregnancy test within 7 days prior to administration of study treatment 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.

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Lucille Packard Children's Hospital Stanford	Palo Alto	California	United States	94304
2	Emory Children's Healthcare of Atlanta	Atlanta	Georgia	United States	30322
3	Johns Hopkins	Baltimore	Maryland	United States	21287
4	Boston Children's Hospital	Boston	Massachusetts	United States	02115
5	Cincinnati Children's Hospital Medical Center	Cincinnati	Ohio	United States	45229
6	Texas Children's Hospital	Houston	Texas	United States	77094
7	Medical College of Wisconsin	Milwaukee	Wisconsin	United States	53226

Sponsors and Collaborators

• Boston Children's Hospital
• Pfizer

Investigators

• Principal Investigator: Denise Adams, MD, Boston Children's Hospital

Study Documents (Full-Text)

• Study Protocol and Statistical Analysis Plan - Jan 31, 2018

More Information

Additional Information:

• Cincinnati Children's Hospital Medical Center Hemangioma and Vascular Malformation Center
• National Organization of Vascular Anomalies

Publications

None provided.

• Responsible Party: Denise Martin Adams, Associate Professor, Boston Children's Hospital
• ClinicalTrials.gov Identifier: NCT02110069
• Other Study ID Numbers: SIR-DA-1202; 1R01FD004363-01A1; 2013-2339
• First Posted: Apr 10, 2014
• Last Update Posted: May 24, 2021
• Last Verified: May 1, 2021

• Individual Participant Data (IPD) Sharing Statement: No
• Plan to Share IPD: No
• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No
• Keywords provided by Denise Martin Adams, Associate Professor, Boston Children's Hospital: KHE; Vascular anomaly; Kasabach-Merritt Syndrome; Tufted angioma; hemangioendothelioma
• Additional relevant MeSH terms: Sarcoma, Kaposi; Hemangioendothelioma; Hemangioma; Kasabach-Merritt Syndrome; Sirolimus; Vincristine

Study Results

Participant Flow

Arm/Group Title	Vincristine	Sirolimus
Arm/Group Description	Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months. Vincristine: Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance)	Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml. Sirolimus: Continuous dosing to maintain trough level of 10-15ng/ml.
Period Title: Overall Study
STARTED	2	2
COMPLETED	0	2
NOT COMPLETED	2	0

Baseline Characteristics

Arm/Group Title	Vincristine	Sirolimus	Total
Arm/Group Description	Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months. Vincristine: Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance)	Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml. Sirolimus: Continuous dosing to maintain trough level of 10-15ng/ml.	Total of all reporting groups
Overall Participants	2	2	4
Age (Count of Participants)
<=18 years	2 100%	2 100%	4 100%
Between 18 and 65 years	0 0%	0 0%	0 0%
>=65 years	0 0%	0 0%	0 0%
Age (years) [Mean (Full Range) ]
Sex: Female, Male (Count of Participants)
Female	0 0%	0 0%	0 0%
Male	2 100%	2 100%	4 100%
Ethnicity (NIH/OMB) (Count of Participants)
Hispanic or Latino	0 0%	0 0%	0 0%
Not Hispanic or Latino	2 100%	2 100%	4 100%
Unknown or Not Reported	0 0%	0 0%	0 0%
Race (NIH/OMB) (Count of Participants)
American Indian or Alaska Native	0 0%	0 0%	0 0%
Asian	1 50%	1 50%	2 50%
Native Hawaiian or Other Pacific Islander	0 0%	0 0%	0 0%
Black or African American	1 50%	0 0%	1 25%
White	0 0%	1 50%	1 25%
More than one race	0 0%	0 0%	0 0%
Unknown or Not Reported	0 0%	0 0%	0 0%
Region of Enrollment (participants) [Number]
United States	2 100%	2 100%	4 100%

Outcome Measures

1. Primary Outcome

Title	Change in Hematologic Parameters
Description	Hematologic parameters are defined as a platelet count greater than 100,000/uL (or a 2 times increase in platelet count compared to baseline) and a fibrinogen level greater than 150mg/dl.
Time Frame	2 months

Outcome Measure Data

Analysis Population Description

no analysis was performed due to study being closed for low enrollment

Arm/Group Title	Vincristine	Sirolimus
Arm/Group Description	Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months. Vincristine: Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance)	Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml. Sirolimus: Continuous dosing to maintain trough level of 10-15ng/ml.
Measure Participants	0	0

2. Primary Outcome

Title	Number of Serious and Non-Serious Adverse Events
Description	Serious and non-serious adverse events will be recorded for all participants and graded using CTCAE v4.0 (Common Toxicity Criteria for Adverse Effects). Adverse event rates will be calculated for both sirolimus and vincristine.
Time Frame	2 months; 12 months

Outcome Measure Data

Analysis Population Description

study was closed early due to slow enrollment

Arm/Group Title	Vincristine	Sirolimus
Arm/Group Description	Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months. Vincristine: Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance)	Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml. Sirolimus: Continuous dosing to maintain trough level of 10-15ng/ml.
Measure Participants	0	0

3. Secondary Outcome

Title	Evaluation of Disease Response - Maintenance
Description	Disease evaluation will be measured using a combination of quality of life assessments, clinical parameters, and radiologic images.
Time Frame	6 months; 12 months

Outcome Measure Data

Analysis Population Description

no analysis was performed

Arm/Group Title	Vincristine	Sirolimus
Arm/Group Description	Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months. Vincristine: Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance)	Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml. Sirolimus: Continuous dosing to maintain trough level of 10-15ng/ml.
Measure Participants	0	0

4. Secondary Outcome

Title	Number of Serious and Non Serious Adverse Events - Maintenance
Description	Serious adverse events and adverse events will be graded according to CTCAE v4.0. Adverse event rates will be calculated for both sirolimus and vincristine.
Time Frame	6 months; 12 months

Outcome Measure Data

Analysis Population Description

no data analyzed as study was closed early

Arm/Group Title	Vincristine	Sirolimus
Arm/Group Description	Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months. Vincristine: Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance)	Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml. Sirolimus: Continuous dosing to maintain trough level of 10-15ng/ml.
Measure Participants	0	0

5. Secondary Outcome

Title	Change in the Serum Levels of KHE Biomarkers
Description	The following KHE biomarkers will be evaluated vascular endothelial growth factor A, C, and D (VEGF-A, C, D_, IL-8 (interleukin), Pleiotrophin, IGF-1 (insulin-like growth factor), endothelin-1, thrombospondin and angiopoietin 1 and 2.
Time Frame	Baseline, 2 months, 6 months, and 12 months

Outcome Measure Data

Analysis Population Description

no analysis performed as study was closed early

Arm/Group Title	Vincristine	Sirolimus
Arm/Group Description	Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months. Vincristine: Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance)	Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml. Sirolimus: Continuous dosing to maintain trough level of 10-15ng/ml.
Measure Participants	0	0

6. Secondary Outcome

Title	Identify Genetic Variants in Drug Metabolism Enzymes.
Description	Single nucleotide polymorphism array analysis to obtain genetic information on variants in drug metabolism enzymes that affect sirolimus and vincristine metabolism.
Time Frame	Baseline

Outcome Measure Data

Analysis Population Description

study closed early due to slow enrollment

Arm/Group Title	Vincristine	Sirolimus
Arm/Group Description	Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months. Vincristine: Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance)	Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml. Sirolimus: Continuous dosing to maintain trough level of 10-15ng/ml.
Measure Participants	0	0

Adverse Events

Time Frame	14 months for 2 subjects 12 months for 1 subject 6 months for 1 subject
Arm/Group Title	Vincristine		Sirolimus
Arm/Group Description	Induction phase: participants assigned to vincristine will receive vincristine weekly at a dose of 0.05mg/kg/dose IV (for participants less than 10kg) or a dose of 1.5 mg/m2/dose (for participants greater than 10kg) for 2 months. Maintenance: if participants continue to receive vincristine weekly for 2 months, every 2 weeks for 5 months and every 3 weeks for 5 months. Vincristine: Vincristine dose dependent upon weight. Weekly for 2 months (Induction); Weekly 2 months; every 2 weeks for next 5 months; every 3 weeks for 5 months (Maintenance)		Sirolimus will be administered at a dose of 0.8mg/m2/dose twice a day on a continuous dosing schedule throughout the trial for participants randomized to Sirolimus or for participants who fail vincristine may cross-over to the sirolimus arm. Sirolimus trough levels will be maintained between 10-15 ng/ml. Sirolimus: Continuous dosing to maintain trough level of 10-15ng/ml.
All Cause Mortality
	Vincristine		Sirolimus
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/2 (0%)		0/2 (0%)
Serious Adverse Events
	Vincristine		Sirolimus
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	1/2 (50%)		1/2 (50%)
Infections and infestations
Lung infection	1/2 (50%)	1	0/2 (0%)	0
Lung infection	1/2 (50%)	1	0/2 (0%)	0
Sepsis	0/2 (0%)	0	1/2 (50%)	1
Other (Not Including Serious) Adverse Events
	Vincristine		Sirolimus
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	1/2 (50%)		2/2 (100%)
Blood and lymphatic system disorders
anemia	0/2 (0%)	0	2/2 (100%)	2
Neutrophil count decreased	0/2 (0%)	0	2/2 (100%)	2
Infections and infestations
Fever	1/2 (50%)	1	1/2 (50%)	1

Limitations/Caveats

[Not Specified]

More Information

Certain Agreements

All Principal Investigators ARE employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.