This is “Advance Publication Article”

Study Protocol Kurume Medical Journal, 66, 115-120, 2019

A Single-Arm Open-Label Clinical Trial on the Efficacy and Safety

of Sirolimus for Epileptic Seizures Associated with Focal
Cortical Dysplasia Type II: A Study Protocol
AKIKO KADA ＊, JUN TOHYAMA **, HIDEAKI SHIRAISHI †, YUKITOSHI TAKAHASHI ‡,
EIJI NAKAGAWA §, TOMOYUKI AKIYAMA §§, AKIKO M SAITO ＊,
YUSHI INOUE # AND MITSUHIRO KATO ##

* Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya 460-0001,
** Department of Child Neurology, National Hospital Organization Nishi-Niigata Chuo National Hospital, Niigata 950-2085,
†
Department of Pediatrics, Hokkaido University Hospital, Sapporo 060-8648,
‡
Department of Pediatrics, National Epilepsy Center, National Hospital Organization Shizuoka Institute of Epilepsy and
Neurological Disorders, Shizuoka 420-8688,
§
Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira 187-8551,
§§
Department of Child Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical
Sciences, Okayama 700-8558,
#
National Epilepsy Center, National Hospital Organization Shizuoka Institute of Epilepsy and Neurological Disorders,
Shizuoka 420-8688,
##
Department of Pediatrics, Showa University School of Medicine, Shinagawa-ku 142-8555, Japan

Received 6 February 2019, accepted 15 April 2019

J-STAGE advance publication 15 June 2021

Edited by TAKAYUKI TANIWAKI

Summary: Epileptic seizures are core symptoms in focal cortical dysplasia (FCD), a disease that often develops in
infancy. Such seizures are refractory to conventional antiepileptic drugs (AED) and temporarily disappear in
response to AED in only 17% of patients. Currently, surgical resection is an important option for the treatment of
epileptic seizures in FCD. In 2015, Korean and Japanese groups independently reported that FCD is caused by
somatic mosaic mutation of the MTOR gene in the brain tissue. Based on these results we decided to test a novel
treatment using sirolimus, an mTOR inhibitor, for epileptic seizures in patients with FCD type II. A single arm
open-label clinical trial for FCD type II patients is being conducted in order to evaluate the efficacy and safety of
sirolimus. The dose of sirolimus is fixed for the first 4 weeks and dose adjustment is achieved to maintain a blood
level of 5 to 15 ng/mL during 8 to 24 weeks after initiation of administration, and it is kept within this level during
a maintenance therapy period of 12 weeks. Primary endpoint is a reduction in the rate of incidence of focal seizures
(including focal to bilateral tonic-clonic seizures) per 28 days during the maintenance therapy period from the
observation period. To evaluate the frequency of epileptic seizures, registry data will be used as an external control
group. We hope that the results of this trial will lead to future innovative treatments for FCD type II patients.

Key words Epileptic seizures, focal cortical dysplasia, focal seizures, registry, sirolimus

1971 by Taylor et al. as “focal dysplasia of the cerebral

INTRODUCTION
cortex in epilepsy” [1] and, was later established as an
Focal cortical dysplasia (FCD) was first reported in entity showing a specific pathological image in surgi-
Corresponding Author: Mitsuhiro Kato, MD, PhD, Department of Pediatrics, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo
142-8555, Japan. Tel: +81-3-3784-8565, Fax: 81-3-3784-8362, E-mail: ktmthr@gmail.com

Abbreviations: FAS, full analysis set; FCD, focal cortical dysplasia; RES-R, registration of rare refractory epilepsy.
116 KADA ET AL.
cally resected lesions in intractable epilepsy. FCD is
not a “localized cortical dysplasia” but a unique entity
with a clinical picture that can be pathologically con-
firmed and diagnosed.
Epileptic seizures are core symptoms of FCD and
often develop in infancy. In about 60% of patients, sei-
zures occur before 4 years of age, and in about 90% of
patients by 12 years of age [2]. In patients where the
histological changes are mild (type IA), onset in adults
aged >60 years has also been reported. First observed
seizures are mainly tonic or generalized tonic-clonic
seizures and focal seizures associated with the lesion
site can be observed. In the case of early onset, sei-
zure-type changes according to age [2]. As symptoms
progress, other neurological symptoms, including im-
paired cognitive function and hemiplegia, appear.
The histopathological findings of FCD are charac-
terized by an abnormal structure of the cortical layer
and appearance of aberrant cells including i) giant
neurons, ii) immature neurons, iii) dysmorphic neu-
rons, and iv) balloon cells. In the classification of
Palmini et al. in 2004 [3], FCD type I shows an abnor-
mality only in the cortical layer structure (IA) or in the
cortical layer structure with giant neurons or immature
neurons (IB) in which presurgical diagnosis by neuro-
imaging techniques such as magnetic resonance imag-
ing, is currently difficult. FCD type II is also called
Taylor-type FCD and is classified into two types that
recognized either dysmorphic neurons (IIA) or dys-
morphic neurons and balloon cells (IIB), in addition to
abnormal structures of the cortical layers. The new
classification scheme in 2011 included, along with mi-
nor changes in type I, an additional type, FCD type III,
showing hippocampal sclerosis, brain tumor, or de-
structive lesions besides cortical dysplasia [4].
Seizures are intractable and temporarily disappear
in response to medical treatment in only 17% of pa-
tients. Currently, the primary treatment option for epi-
leptic seizures in FCD is surgical resection [2]. Sei-
zures disappear after surgery in 50-65% of the patients,
but remain or recur after surgery for the rest, and if
FCD localizes in a functionally-critical area such as
the primary motor cortex, surgery cannot be performed
due to the development of sequelae such as motor pa-
ralysis [5-7].
Although the cause of FCD remains unknown,
similar pathological features including giant neuron
and balloon cell are observed in both FCD type II and
tuberous sclerosis complex (TSC) or hemimegalen-
cephaly, suggesting common pathological mecha-
nisms [8]. Moreover, FCD or hemimegalencephaly
can be identified in patients with TSC, which is caused
Kurume Medical Journal Vol. 66, No. 2 2019
by the mutation of TSC1 or TSC2 gene related to the
mTOR signaling pathway. In patients with hemimega-
lencephaly, somatic mosaic mutations of the genes re-
lated to the mTOR pathway (PIK3CA, AKT3, and
mTOR) were also reported [9, 10]. In 2015, Korean
and Japanese groups independently reported that FCD
type II is caused by somatic mosaic mutations of the
MTOR gene in the brain tissue [11,12].
The mTOR gene contains a target protein of rapa-
mycin (sirolimus), which is an immunosuppressant
and is known to suppress the activation of mTOR by
binding to it [13]. Sirolimus suppresses activated
mTOR function caused by mTOR mutation, and rapa-
mycin and its rapalogs are applied as therapeutic
agents in patients with TSC [14,15,16]. Sirolimus or
its derivative, everolimus, reduce tumor size in sube-
pedymal giant cell astrocytoma and angiomyolipoma
in TSC, particularly in children [17,18]. Interestingly,
everolimus decreases the number of concomitant epi-
leptic seizures in TSC [19,20,21].
Therefore, we decided to evaluate the efficacy,
safety, and pharmacokinetics of the mTOR inhibitor,
sirolimus, by conducting a clinical trial in patients
with FCD type II epileptic seizures. Due to the small
number of subjects, we decided to evaluate the fre-
quency of epileptic seizures using existing registry
data for the external control group.
METHODS
Study design
This study (FCDS-01 trial) is a multicenter single-
arm open-label clinical trial with an external control
group from the registry. The study has been registered
in the University Hospital Medical Information Net-
work Clinical Trial Registry (UMIN000033504) on
July 25, 2018.
Participants
Inclusion criteria
1. Pathological diagnosis of FCD type II by neuroim-
aging findings in brain magnetic resonance imaging
within 156 weeks prior to enrollment or brain pa-
thology examination before enrollment
2. Age of 6-65 years at the time of informed consent.
We set the lower age limit at 6 years old, consider-
ing that the average weight of a 6-year-old child is
about 20 kg, which is enough to ensure that the
starting dose of 1mg/day can be administered safe-
ly, and assuming that the age at which tablets can be
taken is about 6 years old.
3. Diagnosis of focal seizure (focal aware seizure with
 FCDS- 01
motor signs that can be objectively diagnosed, focal
impaired awareness seizure, or focal to bilateral
tonic-clonic seizure) based on the 2017 seizure
classification of the International League Against
Epilepsy [22]
4. Treatment with ＞＿2 antiepileptic drugs for at least 52
weeks after diagnosis of epilepsy
5. Treatment with 1-4 antiepileptic drugs
6. Constant dose and regimen of antiepileptic drug
from the 8th week before enrollment or constant
stimulation condition from the 8th week before en-
rollment in case of vagus nerve stimulation therapy
7. Two or more focal seizures (including bilateral ton-
ic-clonic seizures) during the baseline observation
period of 28 days
8. Written informed consent by the patient/parent or
legal representatives
Exclusion criteria
1. Participation in other trials within 12 weeks before
the time of consent
2. Use of sirolimus or everolimus within 52 weeks be-
fore enrollment
3. Inability to accurately record the number and time
of epileptic seizures by themselves/representatives
4. Suspected progressive lesions in computed tomog-
raphy or magnetic resonance imaging
5. Brain surgery for epilepsy within 28 weeks prior to
enrollment
6. Use of felbamate or vigabatrin within 28 weeks be-
fore enrollment
7. Ketogenic diet therapy
8. Previous suicide attempts
9. History or complications of substance abuse includ-
ing alcohol abuse
10. Pregnancy, lactation, or inability to perform con-
traception during the study period (including part-
ners)
11. Any of the following in the clinical examination
during baseline observation period:
- At least 2.5 times the reference value of AST or ALT
level
- WBC count <3,000/uL, Ht <30%, platelet count
<80,000/uL, or neutrophil count <1,000/uL
- Ccr level <50 mL/min
- HBs antigen positive, HBs antibody positive except
after vaccination with hepatitis B vaccine, or HBc an-
tibody -positive or active hepatitis C excluding inac-
tive cases with normal liver function
- Poor control of dyslipidemia with serum triglyceride
level ＞＿500 mg/dL or LDL cholesterol level ＞ ＿190 mg/
dL despite treatment for dyslipidemia
Kurume Medical Journal Vol. 66, No. 2 2019
117
- Renal dysfunction (estimated glomerular filtration
rate of less than 30 ml/min/1.73 m2)
12. Complication of arrhythmia requiring treatment
13. Complication of heart/renal failure that may affect
hemodynamics
14. Immunodeficiency complications
15. Fever of 38 ℃ or more, or active infectious lesions
16. Interstitial pneumonia
17. Surgery (surgery requiring invasion into a body
＿3 needles including biopsy)
cavity or suture of ＞
within 12 weeks before enrollment
18. Judged as inappropriate for participating in this
study by the principal investigator/subinvestiga-
tors
Intervention and schedule
The investigational drug (sirolimus, 1 mg/tablet)
is orally administered once a day with 1 mg/day for
body weight <40 kg and 2 mg/day for ＞ ＿40 kg. The
administration period consists of a dose adjustment
period and subsequent maintenance therapy period
(Fig. 1). The subjects will visit the hospitals at 2,4,
and 8 weeks during the dose adjustment period and
continue to visit the hospital every 4 weeks until 24
weeks, as necessary. The dose is not changed in the
first 4 weeks, the blood sirolimus concentration is
measured, and from the time when the trough concen-
tration reaches 5-15 ng/mL, the dose is adjusted in the
maintenance therapy period.
The subjects will visit the hospitals at 4,8, and 12
weeks during the maintenance therapy period and
continue to visit the hospital for 12 weeks.
Obtaining informed consent
Baseline observational period (4 weeks)
Enrollment
Initial administration of sirolimus
Dose adjustment period (8–24 weeks)
Maintenance therapy period (12 weeks)
Fig. 1. Schedule of the study
118 KADA ET AL.
External control group
Registration of rare refractory epilepsy (RES-R)
began in 2014, and currently >2100 patients have
been registered in 30 disease groups. Among them,
>100 patients with FCD are registered. However,
since details of the frequency of seizures are not ob-
tained in the existing registry data, we will conduct a
prospective cohort study on epileptic seizures of FCD
type II in the registry of RES-R (RES-FCD, UMIN-
CTR No. UMIN000033606) and collect details of sei-
zures, in order to compare them with the frequency of
seizures in the clinical trials on patients with epileptic
seizure of FCD type II. In this cohort study, the study
population was set to be comparable to that of the clin-
ical trial by adopting the same patient selection crite-
ria. The frequency of seizures and other endpoints
were set similar to those of the clinical trial. Addition-
ally, we are using the same platform of electronic data
capturing, but with a different server, as that in the
clinical trial, cohort study of RES-FCD, and registra-
tion of RES-R, in which an efficient operation is per-
formed.
Endpoints
Primary endpoint
The primary endpoint is a reduction in the rate of
incidence of focal seizures (including bilateral tonic-
clonic seizures) per 28 days during the maintenance
therapy period from the observation period, which is
defined as (A - B)/A × 100. A is the incidence of focal
seizures per 28 days during the baseline observation
period, and B represents the incidence of focal sei-
zures per 28 days during the maintenance therapy pe-
riod. Here, the incidence of focal seizures per 28 days
is obtained by dividing the seizure incidence in that
period by the number of days in the period and multi-
plying it by 28.
Secondary endpoints
- Change in incidence of generalized seizures per 28
days during the maintenance therapy period from the
observation period
- Change in incidence of epileptic spasms per 28 days
during the maintenance therapy period from the obser-
vation period
- Change in incidence of status epilepticus per 28 days
during the maintenance period from the observation
period
- Response rate (proportion of patients in which the
incidence of seizures during the maintenance therapy
period decreased by ＞＿50% from the observation peri-
od)
Kurume Medical Journal Vol. 66, No. 2 2019
- Proportion of resolution of focal seizures during the
maintenance therapy period
- Decrease in the incidence and response rate of focal
seizures at 4,8, and 12 weeks in the maintenance ther-
apy period from the observation period
- Adverse events
Sample size
The sample size is 15 for the feasibility of the
study. Even if the number of subjects exceeds 15, we
will continue to enroll patients until the end of the reg-
istration period of this trial.
Statistical analysis
Patients enrolled in the trial and administered the
investigational drug are classified as belonging to the
full analysis set (FAS). However, patients who have a
serious protocol violation after registration, those
found to be ineligible after registration, or those with-
out any seizure data after administration of the study
drug are excluded from the FAS. Among the FAS, pa-
tients who do not have a serious protocol violation,
fulfill the provision of the clinical trial practice plan,
and can be evaluated for efficacy in accordance with
the protocol are categorized as Per Protocol Set. The
FAS is the main statistical analysis set for efficacy.
The median and quartile of the reduction rate of
incidence of focal seizures are calculated. The one-
sample Wilcoxon test is used to evaluate the null hy-
pothesis against median 0. Moreover, the incidence of
focal seizures is log transformed, and the ratio of the
maintenance therapy period to baseline and 90% con-
fidence interval are calculated. Regarding the change
in incidence, the incidence in the baseline observation
period and maintenance therapy period is divided into
categories, and a cross-table is created. The response
rate and proportion of resolution of focal seizures and
their 90% confidence interval are estimated.
We will estimate the difference in frequency of
seizures between patients administered with sirolimus
and those not administered with sirolimus after exam-
ining the differences in characteristics between the pa-
tients in the external control group and those in this
trial.
DISCUSSION
The disease concept of FCD has been newly estab-
lished. In Japan, FCD was recognized as a designated
intractable disease in July 2015. Effective therapeutic
drugs are urgently required. We decided to evaluate
 FCDS- 01
the efficacy, safety, and pharmacokinetics of sirolimus
by conducting a clinical trial on patients with epileptic
seizure of FCD type II. In the rare disease field, there
are various challenges in study design and analysis,
and the use of registry data as real-world data has been
recommended [23-25]. In order to make a reasonable
consideration of the external validity of this trial re-
sult, we planned to evaluate the primary endpoint, “a
reduction rate of incidence of focal seizures,” using
data from a cohort study in the existing registry for the
external control group, in which the study population
and endpoints were set similar to those of the clinical
trial. We can perform this operation efficiently using
the same electronic data capturing platform. We hope
that this study will lead to the development of thera-
peutic drugs for FCD type II.
DECLARATION
COMPETING INTERESTS: Authors declare no conflicts of
interest.
FUNDING: This study is supported by grants from the Project
Promoting Clinical Trials for Development of New Drugs
(18lk0201069h0002) from the Japan Agency for Medical
Research and Development via the Japan Medical Association
Center for Clinical Trials, a grant from the Ministry of Health,
Labour and Welfare (grant number: H29-nanchi-ippan-010),
and Grants-in-aid for Scientific Research–KAKENHI (C)
(grant number: 15K00067). Nobelpharma Co., Ltd. provided
the investigational drug and the investigators’ brochure.
ETHICS APPROVAL AND CONSENT TO
PARTICIPATE: This study was approved by the institutional
review boards of each participating institution.
Written informed consent was obtained from every partici-
pant in the study.
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