From the Divisions of Nephrology and
`Hypertension (J.J.B.), Pulmonary Medi-
`cine (L.R.Y.), Neurology (G.C., J.M.L.,
`D.N.F.), Radiology (V.J.S., T.L., A.S.B.),
`and Biostatistics (J.B., S.S.), Cincinnati
`Children’s Hospital Medical Center; and
`the Division of Pulmonary and Critical
`Care, University of Cincinnati College of
`Medicine (F.X.M., L.R.Y., J.M.E.) — both
`in Cincinnati. Address reprint requests to
`Dr. Bissler at Cincinnati Children’s Hos-
`pital Medical Center, MLC 7022, 3333 Bur-
`net Ave., Cincinnati, OH 45229-3039, or
`at john.bissler@cchmc.org.
`
`Drs. McCormack, Young, and Franz con-
`tributed equally to the article.
`
`N Engl J Med 2008;358:140-51.
`Copyright © 2008 Massachusetts Medical Society.
`
`T h e ne w e ngl a nd jou r na l o f m e dicine
`
`original article
`
`Sirolimus for Angiomyolipoma in Tuberous
`Sclerosis Complex or Lymphangioleiomyomatosis
`John J. Bissler, M.D., Francis X. McCormack, M.D., Lisa R. Young, M.D.,
`Jean M. Elwing, M.D., Gail Chuck, L.M.T., Jennifer M. Leonard, R.N.,
`Vincent J. Schmithorst, Ph.D., Tal Laor, M.D., Alan S. Brody, M.D.,
`Judy Bean, Ph.D., Shelia Salisbury, M.S., and David N. Franz, M.D.
`
`ABS TR ACT
`
`Background
`Angiomyolipomas in patients with the tuberous sclerosis complex or sporadic
`lymphangioleiomyomatosis are associated with mutations in tuberous sclerosis
`genes resulting in constitutive activation of the mammalian target of rapamycin
`(mTOR). The drug sirolimus suppresses mTOR signaling.
`
`Methods
`We conducted a 24-month, nonrandomized, open-label trial to determine whether
`sirolimus reduces the angiomyolipoma volume in patients with the tuberous scle-
`rosis complex or sporadic lymphangioleiomyomatosis. Sirolimus was administered
`for the first 12 months only. Serial magnetic resonance imaging of angiomyolipo-
`mas and brain lesions, computed tomography of lung cysts, and pulmonary-func-
`tion tests were performed.
`
`Results
`Of the 25 patients enrolled, 20 completed the 12-month evaluation, and 18 com-
`pleted the 24-month evaluation. The mean (±SD) angiomyolipoma volume at 12
`months was 53.2±26.6% of the baseline value (P<0.001) and at 24 months was
`85.9±28.5% of the baseline value (P = 0.005). At 24 months, five patients had a per-
`sistent reduction in the angiomyolipoma volume of 30% or more. During the period
`of sirolimus therapy, among patients with lymphangioleiomyomatosis, the mean
`forced expiratory volume in 1 second (FEV1) increased by 118±330 ml (P = 0.06), the
`forced vital capacity (FVC) increased by 390±570 ml (P<0.001), and the residual
`volume decreased by 439±493 ml (P = 0.02), as compared with baseline values. One
`year after sirolimus was discontinued, the FEV1 was 62±411 ml above the baseline
`value, the FVC was 346±712 ml above the baseline value, and the residual volume
`was 333±570 ml below the baseline value; cerebral lesions were unchanged. Five
`patients had six serious adverse events while receiving sirolimus, including diar-
`rhea, pyelonephritis, stomatitis, and respiratory infections.
`
`Conclusions
`Angiomyolipomas regressed somewhat during sirolimus therapy but tended to in-
`crease in volume after the therapy was stopped. Some patients with lymphangio-
`leiomyomatosis had improvement in spirometric measurements and gas trapping
`that persisted after treatment. Suppression of mTOR signaling might constitute an
`ameliorative treatment in patients with the tuberous sclerosis complex or sporadic
`lymphangioleiomyomatosis. (ClinicalTrials.gov number, NCT00457808.)
`
`140
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`n engl j med 358;2 www.nejm.org
`
`january 10, 2008
`
`The New England Journal of Medicine
`
`Downloaded from nejm.org on January 8, 2017. For personal use only. No other uses without permission.
`
` Copyright © 2008 Massachusetts Medical Society. All rights reserved.
`
`West-Ward Exhibit 1109
`Bissler 2008
`Page 001
`
`

`

`Sirolimus for Angiomyolipoma in Tuberous Sclerosis or Lymphangioleiomyomatosis
`
`The tuberous sclerosis complex, a
`
`tumor-suppressor syndrome caused by mu-
`tations in the tuberin gene (TSC2) or the
`hamartin gene (TSC1), is characterized by hamar-
`tomas in organs including the brain, kidney, lung,
`skin, and heart.1 Angiomyolipomas — tumors
`rich in fat, muscle, and blood vessels that can
`hemorrhage or infiltrate the kidney, leading to
`renal failure — develop in approximately 80% of
`patients.2 Lymphangioleiomyomatosis, the major
`pulmonary manifestation in women with the tu-
`berous sclerosis complex, is a progressive lung
`disease characterized by infiltration of smooth-
`muscle cells and formation of parenchymal cysts.3
`Sporadic lymphangioleiomyomatosis can develop
`in women without the tuberous sclerosis complex,
`owing to somatic mutations in tuberous sclero-
`sis genes.4 The cells comprising the lymphangio-
`leiomyomatosis lesions and angiomyolipomas
`appear to arise from a common source.5
`The hamartin–tuberin complex regulates the
`activity of the target of rapamycin complex 1,
`which lies downstream of cellular pathways con-
`trolling cell growth and proliferation. Abnormal
`signaling through the target of rapamycin com-
`plex 1 is involved in a number of tumor-suppres-
`sor syndromes6-8 and cancers.9 Sirolimus, an im-
`munosuppressive agent approved by the Food and
`Drug Administration, forms a complex with FK
`binding protein 12 and inactivates the target of
`rapamycin complex 1, abrogating the signaling.
`Sirolimus corrects size defects in tuberin-defi-
`cient Drosophila melanogaster cells and induces the
`apoptosis of renal cystadenomas and hepatic
`hemangiomas in rodent models of the tuberous
`sclerosis complex.10,11 In our phase 1–2, proof-of-
`concept study, we aimed to determine whether
`sirolimus has an effect on the volume of angio-
`myolipomas in patients with the tuberous sclero-
`sis complex, sporadic lymphangioleiomyomatosis,
`or both.
`
`Methods
`
`Selection and Enrollment of Patients
`The consecutive enrollment of male and female
`patients, 18 to 65 years of age, began in May 2003
`and continued until November 2004, when the
`target of 25 patients was reached. The voluntary
`provision of written informed consent, a con-
`firmed diagnosis of the tuberous sclerosis com-
`
`plex12 or sporadic lymphangioleiomyomatosis,13,14
`the use of contraception (for female patients), and
`the presence of at least one angiomyolipoma 1 cm
`or more in the largest dimension were required
`for participation. Exclusion criteria were the use
`of continuous supplemental oxygen; concurrent
`infection; surgery within 8 weeks before the start
`of sirolimus therapy; current or planned preg-
`nancy; lactation; substantial hematologic, renal,
`hepatic, or metabolic abnormalities; and the use
`of an investigational drug within 30 days before
`entrance into the study. All female patients who
`could conceive were administered a pregnancy
`test before enrollment and at each visit.
`
`Study Design
`The study was conducted at the General Clinical
`Research Center of the Cincinnati Children’s Hos-
`pital Medical Center. Patients were recruited from
`the Tuberous Sclerosis Clinic and the patient reg-
`istry of the LAM Foundation. The institutional
`review board approved the study protocol, and a
`data and safety monitoring board reviewed trial
`progress semiannually.
`In our open-label, phase 1–2 trial, all patients
`received sirolimus for 1 year and were then fol-
`lowed for an additional year after the therapy was
`stopped. The primary end point was angiomyoli-
`poma volume at 1 year, and secondary end points
`included angiomyolipoma volume at 2 years and
`spirometric measurements, lung volumes, diffus-
`ing capacity, results of the 6-minute walk test, and
`the percentage of the cyst volume at 1 and 2 years.
`Patients were seen at baseline; at week 2, 3, or 4;
`and at months 2, 4, 6, 9, 12, 18, and 24. The
`angiomyolipomas were imaged at all visits except
`the visit at week 2, 3, or 4 and the visit at month
`9. Sirolimus dosing was based on serum target
`levels that would prevent rejection in patients who
`had renal transplants. The initial sirolimus dose
`was 0.25 mg per square meter of body-surface
`area. Sirolimus levels were measured at 2 weeks,
`and the dosage was adjusted to achieve a blood
`sirolimus level between 1 and 5 ng per milliliter.
`If the target angiomyolipoma lesions had not de-
`creased by 10% of the baseline value in the lon-
`gest coronal-plane dimension at the 2-month
`visit, the dose was increased to achieve a blood
`sirolimus level of 5 to 10 ng per milliliter. At the
`4-month visit, if the threshold of a 10% reduc-
`tion from the baseline value had not been reached,
`
`n engl j med 358;2 www.nejm.org
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`141
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`
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`T h e ne w e ngl a nd jou r na l o f m e dicine
`
`the dose was increased to achieve a blood siroli-
`mus level of 10 to 15 ng per milliliter. The dose
`chosen at the 4-month visit was continued through
`12 months.
`
`performed at baseline; if the results were posi-
`tive, during subsequent visits, spirometric variables
`were measured after the administration of a bron-
`chodilator.
`
`Imaging
`Cross-sectional brain and abdominal evaluations
`were performed by means of magnetic resonance
`imaging (MRI) with the use of a clinical 1.5-Tesla
`system (General Electric Medical Systems). Coro-
`nal and axial fast spin–echo T2-weighted sequenc-
`es were performed with and without fat suppres-
`sion. At baseline, up to five lesions per patient
`were identified for volume measurement through-
`out the study. The volumes for all lesions from a
`given time point were averaged for use in analy-
`ses. Computed tomography (CT) of the lungs was
`performed during full inspiration and during full
`expiration, with the use of thin-section images.
`Brain MRI was performed with the use of an
`8-channel phased-array head coil.
`Tumor volume is typically estimated with the
`use of orthogonal measurements, which assume
`that the masses are ellipsoid.15 However, angio-
`myolipomas often have complex shapes, resulting
`from asymmetrical growth or the coalescence of
`multiple lesions.2 MRI and CT are easily adapted
`for volumetric analysis.16,17 Because volumetric
`techniques are superior to diameter-based ap-
`proaches for measuring the size of tumors with
`complex shapes,18 we used a standardized vali-
`dated software program,19 similar to software
`used for other renal-volume determinations,20 for
`volumetric analyses of angiomyolipomas and cys-
`tic lung lesions. One investigator measured angio-
`myolipoma volumes. For validation, another inves-
`tigator independently measured the lesion volumes
`by measuring the three orthogonal diameters.
`
`Pulmonary Function and 6-Minute Walk
`Testing
`Testing was performed according to guidelines
`of the American Thoracic Society.21,22 Patients
`with lymphangioleiomyomatosis underwent com-
`plete pulmonary-function testing — including
`the measurement of spirometric variables, lung
`volumes, diffusing capacity, and the 6-minute
`walk distance — at baseline, 6 or 9 months, 12
`months, and 24 months; simple spirometric
`measurements were obtained at other study visits.
`Assessment of reversible airflow obstruction was
`
`Laboratory Studies
`To assess safety, at each visit we measured the
`levels of electrolytes, blood urea nitrogen, creati-
`nine, glucose, hepatic enzymes, bilirubin, serum
`lipids, and sirolimus, and performed a complete
`blood count and urinalysis.
`
`Statistical Analysis
`We estimated that 25 patients would be needed
`for our study to have a statistical power of 95%
`to detect the difference between a 0% reduction
`in the mean angiomyolipoma volume from the
`baseline value (the null hypothesis) and a 30% re-
`duction (the alternative hypothesis). A one-sided
`test was used, since angiomyolipomas do not
`spontaneously regress. An independent interim
`analysis was undertaken by the Cincinnati Chil-
`dren’s Hospital Biostatistical Core, after 10 pa-
`tients had completed 1 year of sirolimus therapy,
`to determine whether there was evidence of a re-
`duction in lesion volume and of adequate safety.
`Analyses were performed with the use of the
`Proc Mixed procedure with the Kenward–Roger
`correction (SAS software, version 9.1). To avoid
`bias due to missing data, least-square means
`(±SD) are reported. These are model-based es-
`timates calculated from parameter estimates.
`Separate analyses were performed for the angio-
`myolipoma volumes alone, those expressed as
`percentages of the baseline value, and the percent-
`ages of the predicted values for the pulmonary-
`function outcomes, which are comparisons of the
`patients’ pulmonary-function values with norma-
`tive values derived from population studies.
`For variables for which there was a significant
`difference between the means at baseline and
`follow-up, we also compared the least-square
`means at these time points. To estimate the
`slopes and determine whether the least-square
`means had changed significantly by 12 months,
`a random-coefficient model involving a spline
`function was applied. All tests reflected in Ta-
`bles 1 and 2 were conducted a priori. P values
`of less than 0.05 were considered to indicate
`statistical significance. Reported P values were
`not adjusted for multiple testing.
`
`142
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`n engl j med 358;2 www.nejm.org
`
`january 10, 2008
`
`The New England Journal of Medicine
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`Downloaded from nejm.org on January 8, 2017. For personal use only. No other uses without permission.
`
` Copyright © 2008 Massachusetts Medical Society. All rights reserved.
`
`West-Ward Exhibit 1109
`Bissler 2008
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`

`Sirolimus for Angiomyolipoma in Tuberous Sclerosis or Lymphangioleiomyomatosis
`
`28 Patients with TSC or sporadic
`LAM were screened
`
`3 Were not enrolled
`2 Were ineligible
`1 Declined to participate
`
`25 Were enrolled
`7 Had TSC only
`12 Had TSC and LAM
`6 Had sporadic LAM
`
`16 Had pulmonary-outcome data
`11 With TSC and LAM
`5 With sporadic LAM
`
`5 Withdrew
`2 Withdrew consent
`2 Had an adverse event
`1 Was noncompliant
`
`Sirolimus
`therapy
`
`20 Had angiomyolipoma evalu-
`ation at 12 mo
`6 With TSC only
`8 With TSC and LAM
`6 With sporadic LAM
`
`11 Had pulmonary-outcome data
`6 With TSC and LAM
`5 With sporadic LAM
`
`2 Withdrew to use sirolimus
`off-label
`
`No sirolimus
`therapy
`
`18 Had angiomyolipoma evalu-
`ation at 24 mo
`6 With TSC only
`7 With TSC and LAM
`5 With sporadic LAM
`
`10 Had pulmonary-outcome data
`5 With TSC and LAM
`5 With sporadic LAM
`
`Figure 1. Overview of Screening, Enrollment, and Follow-up of the Patients with the Tuberous Sclerosis Complex
`(TSC) or Sporadic Lymphangioleiomyomatosis (LAM).
`Angiomyolipoma volumes and pulmonary-function tests in patients with LAM were assessed during the period of
`sirolimus treatment, from baseline to 12 months, and during a post-treatment observation period, from 12 to 24
`AUTHOR:
`Bissler
`1st
`RETAKE
`ICM
`months. At baseline, 18 patients had LAM, but pulmonary data were uninterpretable in 2 patients because of chylo-
`2nd
`FIGURE:
`1 of 4
`REG F
`thorax or pneumothorax. At the 12-month time point, one patient declined to undergo pulmonary-function tests,
`3rd
`CASE
`Revised
`and four patients had withdrawn from the study. One patient withdrew during the second year.
`4-C
`Line
`SIZE
`EMail
`ARTIST:
`ts
`H/T
`H/T
`33p9
`Combo
`
`Enon
`
`R esults
`
`Characteristics of the Patients
`JOB:
`35802
`The 25 study patients consisted of 5 men and
`2 women with the tuberous sclerosis complex only
`and 18 women with lymphangioleiomyomatosis,
`12 of whom had the tuberous sclerosis complex
`with lymphangioleiomyomatosis and 6 of whom
`had sporadic lymphangioleiomyomatosis only. Five
`patients with the tuberous sclerosis complex (four
`who also had lymphangioleiomyomatosis) left the
`study during the first year: two withdrew consent,
`one had pyelonephritis and recurrent diarrhea,
`
`AUTHOR,PLEASENOTE:
`one had a unilateral renal hemorrhage, and one
`Figurehasbeenredrawnandtypehasbeenreset.
`Pleasecheckcarefully.
`did not comply with the protocol (Fig. 1).
`In one patient with sporadic lymphangioleio-
`ISSUE:
`01-10-07
`myomatosis, the target serum sirolimus range of
`1 to 5 ng per milliliter was maintained, but in all
`other patients the dose was increased to the high-
`est range (10 to 15 ng per milliliter) on the basis
`of imaging results at 2 months and 4 months.
`Twenty patients underwent the 12-month eval-
`uation. Two patients withdrew from the study
`after the 12-month visit to continue sirolimus
`therapy off-label because of self-perceived bene-
`fit, leaving 18 patients at the 24-month assess-
`
`n engl j med 358;2 www.nejm.org
`
`january 10, 2008
`
`143
`
`The New England Journal of Medicine
`
`Downloaded from nejm.org on January 8, 2017. For personal use only. No other uses without permission.
`
` Copyright © 2008 Massachusetts Medical Society. All rights reserved.
`
`West-Ward Exhibit 1109
`Bissler 2008
`Page 004
`
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`

`T h e ne w e ngl a nd jou r na l o f m e dicine
`
`Table 1. Response of Angiomyolipoma Volume to Sirolimus Therapy.*
`
`Value
`Least-square mean (95% CI)
`— ml
`Range — ml
`
`Least-square mean (95% CI)
`— % of baseline value
`P value for change from base-
`line value
`
`Baseline (N = 20)
`71.6±105.3 (24.9 to 118.2)
`
`12 Mo (N = 20)
`36.5±105.3 (−10.2 to 83.2)
`
`24 Mo (N = 18)
`18 Mo (N = 19)
`64.8±106.1 (18.1 to 111.6) 74.9±108.0 (27.8 to 121.9)
`
`1.0 to 389.0
`
`0.7 to 169.9
`
`0.7 to 357.2
`
`1.1 to 462.4
`
`53.2±26.6 (46.3 to 60.2)
`
`76.8±27.5 (69.7 to 83.9)
`
`85.9±28.5 (78.7 to 93.2)
`
`P<0.001
`
`P<0.001
`
`P = 0.005
`
`* Plus–minus values are least-square means ±SD. The least-square means were calculated with the use of the Proc Mixed procedure (SAS
` software, version 9.1). Some patients had withdrawn from the study by the 18-month and 24-month follow-up visits. The two hepatic
` angiomyolipomas studied had the same pattern of response as that shown here for the renal angiomyolipomas.
`
`ment of angiomyolipoma. Fourteen patients with
`lymphangioleiomyomatosis remained in the study
`for the second year, but chylothorax or pneumo-
`thorax at baseline precluded pulmonary-outcome
`assessments in two patients, and one patient who
`had the tuberous sclerosis complex with lymph-
`angioleiomyomatosis declined the 12-month pul-
`monary-function tests.
`Pulmonary end points after 1 year of receiv-
`ing sirolimus were available for 11 patients with
`lymphangioleiomyomatosis (6 with the tuberous
`sclerosis complex with lymphangioleiomyomato-
`sis and 5 with sporadic lymphangioleiomyoma-
`tosis). During the second year, 1 patient with
`lymphangioleiomyomatosis withdrew from the
`study to take the drug off-label; therefore, data
`for 10 patients with lymphangioleiomyomatosis
`were available for the 24-month analysis.
`
`Angiomyolipoma Burden
`The targeted renal angiomyolipoma lesions were
`bilateral in 12 of the 20 patients (60%) and unilat-
`eral in 6 of the 20 patients (30%). Hepatic angio-
`myolipoma lesions were targeted in the remaining
`two patients (10%). The mean (±SD) angiomyoli-
`poma volume at baseline was 71.6±105.3 ml (Ta-
`ble 1). After 12 months of therapy, the mean vol-
`ume decreased to 53.2±26.6% of the baseline
`volume (P<0.001). At 12 months, 16 of the 20 pa-
`tients for whom we had data for the first-year
`follow-up period (80%) had at least a 30% reduc-
`tion in angiomyolipoma volume (Fig. 2). At 6 and
`12 months after stopping sirolimus, the mean an-
`giomyolipoma volume had increased to 76.8±27.5%
`of the baseline volume (P<0.001) and 85.9±28.5%
`of the baseline volume (P = 0.005), respectively
`(Table 1 and Fig. 2). Angiomyolipomas in 5 of the
`18 patients (28%) remained at least 30% smaller
`
`1 year after therapy than they were at baseline.
`There was no correlation between statin use or
`lesion size at baseline and the response to siroli-
`mus (see the Supplementary Appendix, available
`with the full text of this article at www.nejm.org).
`The response of a renal angiomyolipoma after 12
`months of sirolimus therapy, visualized on MRI,
`is shown in Figure 3.
`The angiomyolipoma volumes were divided
`into three categories: small (<6.5 ml), medium
`(6.5–85.0 ml), and large (>85.0 ml). The size as-
`sessments obtained with the use of volumetric
`techniques and those obtained by means of mea-
`suring the orthogonal diameters were correlated
`for each category. The intraclass correlation co-
`efficients for the two methods ranged from 0.76
`to 0.86 (mean, 0.81; P<0.001) across the visits.
`The statistical significance of the measurements
`obtained through either method was similar.
`
`Pulmonary Studies
`Pulmonary structural and functional data for 11
`female patients with lymphangioleiomyomatosis
`are listed in Table 2. One patient was a current
`smoker, three were former smokers, and seven
`had never been smokers. At enrollment, spiro-
`metric measurements were normal in four pa-
`tients, revealed moderate airflow obstruction
`(forced expiratory volume in 1 second [FEV1], 50
`to 70% of the predicted value) in three patients,
`and indicated severe airflow obstruction (FEV1
`<50% of the predicted value) in four patients. Dur-
`ing sirolimus therapy, the mean FEV1 increased
`from the baseline mean by 120±230 ml at 6 months
`(P = 0.009) and by 118±330 ml at 12 months
`(P = 0.06), with 5 of the 11 patients gaining 100 ml
`or more in volume during therapy (Fig. 4A and
`4C). After 1 year of sirolimus therapy, the FEV1 in
`
`144
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`n engl j med 358;2 www.nejm.org
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`january 10, 2008
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`The New England Journal of Medicine
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` Copyright © 2008 Massachusetts Medical Society. All rights reserved.
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`Sirolimus for Angiomyolipoma in Tuberous Sclerosis or Lymphangioleiomyomatosis
`
`oxide, FEV1 forced expiratory volume in 1 second, and FVC forced vital capacity.
`patients; 1 patient had withdrawn during the second year. Changes from baseline were not significant unless otherwise indicated. DlCO denotes diffusing capacity of the lung for carbon mon-
`function tests were uninterpretable, and 1 patient who declined to undergo pulmonary-function tests at the 12-month visit. Data for the 24-month study visit were available for 10 of these 11
`patients with lymphangioleiomyomatosis who completed the 12-month study visit; excluded were 2 patients with chylothorax or pneumothorax at baseline, for whom data from pulmonary-
`
`‖ P = 0.04 for the change from the baseline value.
`¶ P = 0.004 for the change from the baseline value.
`§ P = 0.01 for the change from the baseline value.
`‡ P = 0.02 for the change from the baseline value.
`† P<0.001 for the change from the baseline value.
`
`* Plus–minus values are least-square means ±SD. The least-square means were calculated with the use of the Proc Mixed procedure (SAS software, version 9.1). Data are listed for 11 of the 14
`
`23.91±60.23 (−18.53 to 66.35)−19.42±111.42 (−97.93 to 59.08)
`
`6-Minute walk distance (95% CI) — m485.30±82.87 (426.91 to 543.69)509.21±100.31 (438.53 to 579.89)465.88±160.65 (352.69 to 579.07)
`
`−3.46±8.15 (−7.26 to 0.34)
`
`−2.84±5.56 (−5.50 to −0.18)
`
`18.17±12.49 (10.01 to 26.34)
`
`18.79±12.32 (10.66 to 26.93)
`
`21.63±12.32 (13.50 to 29.77)
`
`Cyst volume (95% CI) — % of lung
`
`2.77±15.49 (−8.00 to 13.55)
`
`0.09±11.66 (−8.12 to 8.30)
`
`55.95±23.95 (39.18 to 72.73)
`
`53.27±14.62 (42.97 to 63.57)
`
`53.18±14.12 (43.24 to 63.12)
`
`Percent of predicted value (95% CI)
`
`volume
`
`−0.74±4.02 (−2.06 to 3.53)
`
`−0.08±2.67 (−1.80 to 1.96)
`
`13.82±7.35 (8.67 to 18.97)
`
`13.16±4.48 (10.01 to 16.32)
`
`104.78±28.42 (84.76 to 124.79)−27.00±27.06 (−46.07 to −7.94)§−22.86±31.45 (−44.74 to −0.98)‖
`
`100.64±25.17 (82.90 to 118.37)
`
`Least-square mean (95% CI) —
`DlCO
`Percent of predicted value (95% CI)127.64±46.52 (94.86 to 160.41)
`
`13.08±4.34 (10.02 to 16.14)
`
`ml/mm Hg/min
`
`−0.33±0.57 (−0.73 to 0.07)
`
`−0.44±0.49 (−0.79 to −0.09)‡
`
`1.97±0.55 (1.58 to 2.36)
`
`1.87±0.48 (1.53 to 2.20)
`
`2.30±0.84 (1.72 to 2.89)
`
`Least-square mean (95% CI) — liters
`
`−0.61±11.31 (−5.87 to 4.65)
`
`−0.64±7.68 (−4.34 to 3.06)
`
`98.48±15.65 (88.37 to 108.59)
`
`98.45±15.33 (88.39 to 108.52)
`
`Percent of predicted value (95% CI)99.09±15.33 (89.02 to 109.15)
`
`−0.02±0.59 (−0.30 to 0.26)
`
`−0.04±0.40 (−0.23 to 0.16)
`
`5.23±0.87 (4.66 to 5.81)
`
`5.22±0.86 (4.64 to 5.79)
`
`5.25±0.86 (4.68 to 5.82)
`
`Least-square mean (95% CI) — liters
`
`Total lung capacity
`
`9.83±17.81 (3.32 to 16.35)¶
`
`88.65±19.99 (75.60 to 101.70)10.36±14.19 (5.07 to 15.65)†
`
`89.18±19.72 (76.17 to 102.19)
`
`Percent of predicted value (95% CI)78.82±19.72 (65.81 to 91.83)
`
`0.35±0.71 (0.08 to 0.61)§
`
`0.39±0.57 (0.18 to 0.60)†
`
`3.34±0.86 (2.77 to 3.90)
`
`3.38±0.85 (2.81 to 3.95)
`
`2.99±0.85 (2.42 to 3.56)
`
`Least-square mean (95% CI) — liters
`
`Residual volume
`
`2.64±13.84 (−2.52 to 7.80)
`
`4.27±11.07 (0.11 to 8.44)
`
`60.37±22.73 (44.93 to 75.81)
`
`62.00±22.57 (46.58 to 77.42)
`
`57.2±22.57 (42.31 to 73.15)
`
`Percent of predicted value (95% CI)
`
`0.06±0.41 (−0.09 to 0.22)
`
`0.12±0.33 (−0.01 to 0.24)
`
`1.83±0.79 (1.29 to 2.38)
`
`1.89±0.79 (1.34 to 2.44)
`
`1.77±0.79 (1.23 to 2.32)
`
`Least-square mean (95% CI) — liters
`FEV1
`
`24 Mo (N = 10)
`
`12 Mo (N = 11)
`
`Change from Baseline
`
`24 Mo (N = 10)
`
`12 Mo (N = 11)
`
`Baseline (N = 11)
`
`Value
`
`Table 2. Pulmonary Structural and Functional Characteristics of Patients with Lymphangioleiomyomatosis.*
`
`FVC
`
`n engl j med 358;2 www.nejm.org
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`january 10, 2008
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`T h e ne w e ngl a nd jou r na l o f m e dicine
`
`ue (range, −190 to 1100 ml) (P<0.001) (Fig. 4B and
`4C). Eight of the 11 patients had an increase of at
`least 250 ml in FVC during the year of sirolimus
`therapy. The mean FVC remained 346±712 ml
`above the baseline mean at 24 months (P = 0.01),
`and the mean percent of the predicted FVC value
`was significantly improved at 12 months (P<0.001)
`and at 24 months (P = 0.004).
`The mean residual volume fell by 439±493 ml
`after 1 year of sirolimus therapy, as compared with
`the baseline value (P = 0.02). The six patients who
`had substantial air trapping at baseline (residual
`volume >120% of the predicted value) had a reduc-
`tion in the residual volume after 12 months of re-
`ceiving sirolimus (Fig. 4D). The improvement in
`the percent of the predicted residual volume re-
`mained significant at 24 months (P = 0.04), where-
`as the improvement for the absolute residual vol-
`ume did not (P = 0.09).
`The mean diffusing capacity of the lung for
`carbon monoxide (DlCO) was reduced in all but
`one patient at baseline (overall mean, 53.2±14.1%
`of the predicted value). Neither the DlCO nor the
`6-minute walk distance changed significantly dur-
`ing the study (Table 2).
`CT volumetric analysis of lung-cyst volume did
`not reveal a significant change (Table 2). For the
`year of sirolimus therapy, the correlation coeffi-
`cient between residual volume and FVC was −0.75
`(P = 0.01) and that between residual volume and
`cyst volume was 0.76 (P<0.001). There was no
`clear relationship between the reduction in angio-
`myolipoma volume and the pulmonary response
`to sirolimus in the study population. The chang-
`es in FEV1, FVC, and residual volume associated
`with sirolimus therapy were similar in the pa-
`tients who had the tuberous sclerosis complex
`with lymphangioleiomyomatosis and in those
`who had sporadic lymphangioleiomyomatosis,
`but there may have been too few patients in each
`subgroup to detect a significant difference.
`
`Neurologic Assessment
`All patients with the tuberous sclerosis complex
`had cortical tubers; 64% had subependymal nod-
`ules. None had hydrocephalus or giant-cell astro-
`cytomas. There were no changes in the size of
`the tubers, in the characteristics of the tubers on
`MRI, or in cerebral vasculature or perfusion.
`
`Adverse Events
`The most common adverse events included aph-
`thous ulcers, diarrhea, and upper respiratory in-
`
`120
`
`100
`
`80
`
`60
`
`40
`
`20
`
`(% of baseline value)
`
`Angiomyolipoma Volume
`
`Sirolimus therapy
`
`No sirolimus therapy
`
`0
`
`0
`
`6
`
`12
`Months
`
`18
`
`24
`
`Figure 2. Angiomyolipoma Volume in the Patients with the Tuberous
` Sclerosis Complex or Sporadic Lymphangioleiomyomatosis during the Study.
`AUTHOR:
`Bissler
`1st
`RETAKE
`ICM
`2nd
`FIGURE:
`2 of 4
`Angiomyolipomas were visualized with the use of abdominal magnetic reso-
`REG F
`3rd
`nance imaging, and volumetric analysis was performed at baseline and at 2,
`CASE
`Revised
`4-C
`Line
`4, 6, 12, 18, and 24 months. The angiomyolipoma volume at each visit is ex-
`SIZE
`EMail
`ARTIST:
`ts
`H/T
`H/T
`pressed as a percentage of the baseline size. The dashed line represents 70%
`4 col
`Enon
`Combo
`of the baseline value; data below the line indicate that the mean angiomyo-
`AUTHOR, PLEASE NOTE:
`lipoma volume was reduced by 30% or more.
`Figure has been redrawn and type has been reset.
`Please check carefully.
`
`JOB:
`
`35802
`
`ISSUE:
`
`01-10-07
`
`Baseline
`
`12Months
`
`Figure 3. Renal Angiomyolipomas in the Abdomen of a Patient with the Tu-
`berous Sclerosis Complex.
`Bissler
`AUTHOR:
`1st
`RETAKE
`ICM
`2nd
`Bilateral angiomyolipomas are shown at baseline and after 12 months of si-
` 3 of 4
`FIGURE:
`REG F
`3rd
`rolimus therapy. Three lesions in the left kidney are identified by arrows; at
`CASE
`Revised
`12 months, the top lesion had become reduced in size and the bottom two
`Line
`4-C
`SIZE
`EMail
`ARTIST:
`ts
`had become imperceptible. The images were obtained with the use of fast
`H/T
`H/T
`36p6
`Enon
`Combo
`spin–echo T2-weighted magnetic resonance imaging with fat suppression.
`AUTHOR,PLEASENOTE:
`Figurehasbeenredrawnandtypehasbeenreset.
`Pleasecheckcarefully.
`these patients was significantly improved (P = 0.002)
`35602
`01-10-07
`ISSUE:
`as compared with the expected decline in FEV1 for
`patients with lymphangioleiomyomatosis of 75 ml
`per year.23 Twelve months after stopping siroli-
`mus, the mean FEV1 was 62±411 ml greater than
`the mean baseline value.
`The forced vital capacity (FVC) at 12 months
`was increased by 390±570 ml over the baseline val-
`
`JOB:
`
`146
`
`n engl j med 358;2 www.nejm.org
`
`january 10, 2008
`
`The New England Journal of Medicine
`
`Downloaded from nejm.org on January 8, 2017. For personal use only. No other uses without permission.
`
` Copyright © 2008 Massachusetts Medical Society. All rights reserved.
`
`West-Ward Exhibit 1109
`Bissler 2008
`Page 007
`
`

`

`Sirolimus for Angiomyolipoma in Tuberous Sclerosis or Lymphangioleiomyomatosis
`
`12
`
`0
`
`6
`Sirolimus
`therapy
`
`No sirolimus
`therapy
`
`24
`
`Months
`
`35
`
`30
`
`25
`
`20
`
`15
`
`10
`
`5 0
`
`−5
`
`−10
`
`−15
`
`250
`
`200
`
`150
`
`100
`
`50
`
`FVC (% change from baseline value)
`
`Residual Volume (% of predicted value)
`
`B
`
`D
`
`12
`
`0
`
`6
`Sirolimus
`therapy
`
`No sirolimus
`therapy
`
`24
`
`Months
`
`P<0.001
`
`P=0.01
`
`FVC
`
`P=0.002
`
`P=0.009
`
`FEV1
`
`35
`
`30
`
`25
`
`20
`
`15
`
`10
`
`5 0
`
`−5
`
`−10
`
`−15
`
`500
`
`450
`
`400
`
`350
`
`300
`
`250
`
`200
`
`150
`
`100
`
`50
`
`0
`
` (% change from baseline value)
`
`FEV1
`
`Mean Change (ml)
`
`A
`
`C
`
`−50
`
`0
`
`12
`
`6
`Sirolimus
`therapy
`
`No sirolimus
`therapy
`
`24
`
`Months
`
`0
`
`0
`
`12
`
`9
`6
`Sirolimus
`therapy
`
`No sirolimus
`therapy
`
`24
`
`Months
`
`Figure 4. Pulmonary Function in Patients with Lymphangioleiomyomatosis.
`Panel A shows the forced expiratory volume in 1 second (FEV1) for each patient. Panel B shows the forced vital capacity
`(FVC) for each patient. Panel C shows the mean change (in milliliters) from the baseline values for FEV1 and for FVC.
`I bars indicate the standard errors. Panel D shows the residual volume for each patient.
`
`ICM
`REG F
`
`Bissler
`AUTHOR:
`FIGURE:
`4 of 4
`
`RETAKE
`
`1st
`2nd
`3rd
`
`CASE
`
`EMail
`
`Revised
`Line
`4-C
`SIZE
`ARTIST:
`ts
`H/T
`H/T
`33p9
`Enon
`Combo
`january 10, 2008
`n engl j med 358;2 www.nejm.org
`AUTHOR, PLEASE NOTE:
`Figure has been redrawn and type has been reset.
`Please check carefully.
`
`JOB:
`
`35802
`
`ISSUE:
`
`01-10-07
`
`147
`
`The New England Journal of Medicine
`
`Downloaded from nejm.org on January 8, 2017. For personal use only. No other uses without permission.
`
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`
`

`

`T h e ne w e ngl a nd jou r na l o f m e dicine
`
`Table 3. Adverse Events.*
`
`Category
`
`No. of
`Patients
`
`No. of
`Events
`
`Gastrointestinal
`Aphthous ulcer or mucositis
`Diarrhea
`Infection
`Upper respiratory infection, sinusitis,
`or bronchitis
`Pneumonia
`Pharyngitis
`Cellulitis
`Urinary tract infection or pyelonephritis
`Conjunctivitis
`Salivary gland infection
`Skin-related
`Folliculitis
`Acne
`Other
`Metabolic or laboratory
`Hyperlipidemia
`Hypokalemia
`Pain
`Headache
`Abdominal or flank pain
`Other
`Pulmonary or upper respiratory
`Dyspnea
`Hypoxia
`Wit