A Phase I Study of Methoxyamine and Temozolomide in Patients With Advanced Solid Tumors
Phase: PHASE1
Conditions: Unspecified Adult Solid Tumor, Protocol Specific
Sponsor: Case Comprehensive Cancer Center

Local Protocol #:  
CASE 1Y05 
 
TITLE:  A Phase I Study of Methoxyamine and Temozolomide in Patients with Advanced Solid Tumors 
 
Coordinating Center: Case Comprehensive Cancer Center 
 
Principal Investigator: 
Jennifer Eads, MD 
 
Department of Medicine 
 
University Hospitals of Cleveland 
 
Case Western Reserve University 
 
11100 Euclid Avenue 
 
Cleveland, OH   44106  
 
Tel: 216-844-6003 
 
Fax: 216-844-0500  
 
Email: jennifer.eads@uhhospitals.org 
 
Co-Investigators: 
Joseph Bokar, MD PhD 
 
Department of Medicine 
 
University Hospitals of Cleveland 
 
Case Western Reserve University 
 
11100 Euclid Avenue 
 
Cleveland, OH  44106 
 
Tel: 216-844-1582 
 
Email: jab5@case.edu 
 
 
Afshin Dowlati, M.D. 
 
Department of Medicine 
 
University Hospitals of Cleveland 
 
Case Western Reserve University 
 
11100 Euclid Avenue 
 
Cleveland, OH  44106 
 
Tel: 216-844-8573 
 
Email: axd44@cwru.edu 
 
 
Henry Koon, M.D. 
 
Department of Medicine 
 
University Hospitals of Cleveland 
 
Case Western Reserve University 
 
11100 Euclid Avenue 
 
Cleveland, OH  44106 
 
Tel:  216-368-1175 
 
Fax:  216-368-1166 
 
Email: henry.koon@uhhospitals.org 
 
 
 
Smitha Krishnamurthi, M.D. 
 
Department of Medicine 
 
University Hospitals of Cleveland 
 
Case Western Reserve University 
 
11100 Euclid Avenue 
 
Cleveland, OH  44106 
 
Tel:  216-844-5467 
 
Fax:  216-844-1721 
 
Email: ssk7@case.edu 
 
 
 

CASE 1Y05 v22 dated 03/18/15 
 
 
 
Neal Meropol, MD 
 
Department of Medicine 
 
University Hospitals of Cleveland 
 
Case Western Reserve University 
 
11100 Euclid Avenue 
 
Cleveland, OH  44106 
 
Tel: 216-844-5220 
 
Fax: 216-8445234 
 
Email: neal.meropol@uhhosptials.org  
 
 
 
 
John Pink, Ph.D. 
University Hospitals of Cleveland 
Case Western Reserve University 
 
 
 
11100 Euclid Avenue 
 
 
 
 
Cleveland, OH   44106  
 
 
 
Tel:  (216) 368-5420 
Email: jrp16@case.edu 
 
 
 
Lisa Rogers, DO 
University Hospitals of Cleveland 
Case Western Reserve University 
 
 
 
11100 Euclid Avenue 
 
 
 
 
Cleveland, OH   44106  
 
 
 
Tel:  (216) 844-3717 
Fax:  (216) 844-3192 
 
Email: lisa.rogers@uhhospitals.org 
 
 
 
Joel Saltzman, MD 
University Hospitals of Cleveland 
Case Western Reserve University 
 
 
 
11100 Euclid Avenue 
 
 
 
 
Cleveland, OH   44106  
 
 
 
Tel:  (440) 205-5755 
Fax:  (440) 205-5792 
 
Email: joel.saltzman@uhhospitals.org 
 
 
Neelesh Sharma, MD 
University Hospitals of Cleveland 
Case Western Reserve University 
 
 
 
11100 Euclid Avenue 
 
 
 
 
Cleveland, OH   44106  
 
 
 
Tel:  (216) 844-5182 
Fax:  (216) 844-0500 
 
Email: neelesh.sharma@uhhospitals.org 
 
 
Yan Xu, Ph.D. 
 
Translational Research and Pharmacology Core 
 
Case Comprehensive Cancer Center 
 
11001 Cedar Avenue, Suite 200 
 
Cleveland, OH 44106 
 
Tel.: (216) 832-0010 
 
Email: yan.xu@case.edu 
 

CASE 1Y05 v22 dated 03/18/15 
 
 
Statistician: 
Pingfu Fu Ph.D. 
 
Biostatistics Core Facility 
 
Case Western Reserve University 
 
 
Responsible Research 
Nurse: 
John Riendeau, RN 
 
Clinical Trials Unit 
 
Seidman Cancer Center 
 
University Hospitals of Cleveland 
 
11100 Euclid Avenue 
 
Cleveland, OH   44106 
 
Tel: (216) 844-8146 
 
Email:  john.riendeau@uhhospitals.org 
 
Responsible Data 
Manager: 
Rose Gerhart 
 
Case Comprehensive Cancer Center 
 
University Hospitals of Cleveland 
 
11100 Euclid Avenue 
 
Cleveland, OH   44106 
 
Supplied Agent(s): 
Methoxyamine (NSC 3801) 
 
IND #: 73,575 
 
 
Other Agent:                               
Temozolomide, commercially available 
 

 
 
SCHEMA 
 
Cycle 1 and subsequent cycles. 
 
Methoxyamine (MX) will be given as a single one hour infusion every 28 days. 
 
Temozolomide (TMZ) will be given orally for 5 days every 28 days on days 1-5. It will be 
administered within five minutes of initiation of methoxyamine 
 
Cycles are concluded every 28 days. 
  
Week1 
Day1 
2 
3 
4 
5 
MX 
↔ 
 
 
 
 
TMZ 
↓ 
↓ 
↓ 
↓ 
↓ 
 
Note: 
Treatment toxicities for cycle 1 will be considered for dose limiting toxicity (DLT) attribution. 
Dose modifications are allowed for cycle 2 and beyond. 
 
Cohort A (eligible patients with no CNS disease) 
DOSE-ESCALATION SCHEDULE 
Dose 
 
Dose Level  
TMZ 
(mg/m2/day) x 5days 
MX 
(mg/m2) 
Level  -1 
100 
15 
Level  1 
150 
15 
Level  2 
150 
30 
Level   3 
150 
60 
Level  4 
150 
90 
Level  5 
150 
120 
Level 6 
150 
150 
Level 7 
200 
150 
 
Cohort B (eligible patients with CNS disease) 
DOSE-ESCALATION SCHEDULE 
Dose 
 
Dose Level  
TMZ 
(mg/m2/day) x5days 
MX 
(mg/m2) 
Level  -1 
75 
15 
Level  1 
100 
15 
Level  2 
150 
15 
CASE 1Y05 v22 dated 03/18/15 
 4

 
Level   3 
150 
30 
Level  4 
150 
60 
Level 5 
150 
120 
Level 6 
150 
150 
Level 7 
200 
150 
 
For each cohort, 3 patients will be entered sequentially to each dose level.  
 
 
If none of the 3 patients at a dose level experience dose limiting toxicity (DLT) during 
the first cycle, new patients may be entered at the next dose level. 
 
 
If 1/3 patients experiences DLT during the first cycle, up to 3 more patients will be 
treated at the same dose level. If the 1st patient in the expanded cohort (4th at the given 
DL), experiences no DLT, then the remaining 2 patients can start treatment without a 
necessary delay. 
o As of protocol v22, if 1/3 patients experience any DLT that is not of a CNS 
nature in Cohort B dose level 6, we will continue dose escalation to dose level 7 
since we have already treated three subjects in Cohort A dose level 6 and seven 
subjects in Cohort A dose level 7, none of whom experienced non-CNS toxicities 
 
 
If 2 or more experience DLT during the first cycle, no further patients are started at that 
dose and the MTD is the highest dose level in which <2 (of 6) patients develop DLT. 
 
 
If the final dose level is deemed the MTD, 6 patients will be treated at this dose level, 
even if a DLT has not been observed. 
 
Select non-hematologic grade 3 or 4 or hematologic grade 4 drug-related toxicities (CTC version 
3.0) occurring in the first 28 days of study will be considered a DLT. 
CASE 1Y05 v22 dated 03/18/15 
 5

 
TABLE OF CONTENTS 
 
Page 
SCHEMA........................................................................................................................................4 
 
1. OBJECTIVES ..........................................................................................................................7 
 
2. BACKGROUND ......................................................................................................................7 
 
 
3. PATIENT SELECTION .......................................................................................................11 
 
4. TREATMENT PLAN............................................................................................................13 
 
5. DOSING DELAYS/DOSE MODIFICATIONS ..................................................................17 
 
6. AGENT FORMULATION AND PROCUREMENT .........................................................17 
 
 
7. CORRELATIVE/SPECIAL STUDIES ...............................................................................23  
 
8. STUDY CALENDAR ............................................................................................................26 
 
9. MEASUREMENT OF EFFECT ..........................................................................................27 
 
10. ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS…………………..32 
 
11. REGULATORY AND REPORTING REQUIREMENTS………………………………37 
 
12. STATISTICAL CONSIDERATIONS .................................................................................38 
 
REFERENCES.............................................................................................................................39 
 
APPENDICES 
 
APPENDIX A 
Performance Status Criteria ..............................................................................................40 
 
       APPENDIX B 
             Relevant Abstract..............................................................................................................41 
 
       APPENDIX C 
             Similation of one-hour infusion data to reach a Cmax of 41.40 ng/mL ...........................43 
 
       APPENDIX D 
             MMSE...............................................................................................................................45 
 
 
 
CASE 1Y05 v22 dated 03/18/15 
 6

 
1. OBJECTIVES 
 
1.1 To determine the maximum tolerated dose of methoxyamine given in conjunction        
with temozolomide in patients with and without CNS disease. 
 
1.2 To determine the dose limiting toxicities of the combination of methoxyamine and 
temozolomide in patients with and without CNS disease. 
                    
1.3 To determine the pharmacokinetics of these two agents when given alone or in 
combination, as well as the pharmacokinetic profile of methoxyamine after a single 
one-hour IV administration.  
 
1.4  To determine  relative DNA damage, as single or double strand breaks by comet 
assay in blood mononuclear cells which will serve as a surrogate for tumor response 
to the drug combination. 
 
  
2. BACKGROUND 
 
Base excision repair (BER) is a fundamental cellular process that reduces the cytotoxicity 
of alkylating agent chemotherapy. Heretofore, no therapeutic agents have targeted this 
DNA repair pathway.  
 
Methoxyamine (MX, NSC-3801) is a small organic amine that inhibits base excision 
repair (BER) by covalently binding to apurinic/apyrimidinic (AP) sites in DNA (1).  It 
has been demonstrated that MX alters the AP site structure by forming a covalent linkage 
with the aldehyde moiety to form an MX-bound AP site that is refractory to the catalytic 
activity of the apurinic/apyrimidinic endonuclease (APE), leading to the interruption of 
BER. Therefore, MX has been studied as a structural modulator of AP sites to enhance 
therapeutic effect of alkylating agents such as temozolomide (TMZ, NSC-362856).  
 
TMZ is a therapeutic alkylating agent that is efficacious in the treatment of gliomas, 
melanomas, carcinoid tumors and Hodgkin’s lymphoma. However, drug resistance 
remains a critical problem, often resulting in treatment failure in clinical use.   A major 
obstacle to effective treatment with TMZ in cancer is the presence of elaborate 
mechanisms of DNA repair. For instance, TMZ forms O6-methylguanine (O6mG), 7-
methylguanine (N7mG), and 3-methyladenine (N3mA) DNA adducts that are repaired by 
at least two mechanisms.  The O6mG DNA adduct, a cytotoxic and genotoxic lesion, is 
repaired by O6-methylguanine DNA-methyltransferase (MGMT). MGMT activity is a 
major mechanism of resistance to alkylating agents.  In contrast, cell death caused by 
O6mG adducts is promoted by the mismatch repair (MMR) system, such that, deficiency 
in MMR is associated with pronounced resistance to alkylating agents.  N7mG and 
N3mA DNA adducts are removed by the base excision repair (BER) pathway.  BER, is 
an important drug resistant factor because it recognizes a variety of substrates and has the 
ability to rapidly and efficiently repair these DNA lesions.  BER is the major pathway 
that protects cells against the potentially harmful effects of spontaneously and chemically 
occurring DNA damage, including  (i) inappropriate bases; (ii) abasic sites that are 
CASE 1Y05 v22 dated 03/18/15 
 7

 
formed by enzyme-catalyzed, spontaneous or chemical-induced base release; and (iii) 
DNA single strand breaks produced during the processing of damaged DNA.  Efficient 
BER minimizes the impact of these lesions in normal and tumor cells.  Thus, when BER 
is disrupted, these abundant N-methylated DNA adducts and intermediates generated in 
the repair process become highly cytotoxic.  Most importantly, BER disruption is able to 
bypass other resistance factors such as MMR defects and high MGMT activity.   
 
 
In several preclinical studies, we have demonstrated improved therapeutic efficacy of 
alkylating agents by blocking BER with MX (2,3).  We have demonstrated in in vivo 
studies that MX potentiates the antitumor effect of TMZ in human tumor xenografts in 
nude mice.  Mice carrying SW480 colon cancer tumors (AGT expressing, MMR wt and 
p53 mutant) treated with MX (2 mg/kg) plus TMZ (120 mg/kg) had cessation of tumor 
growth lasting 50±13 days and very slow regrowth, yielding tumor growth delays of 
70±14 days (p < 0.002) compared with untreated tumors.  In contrast, TMZ (120 mg/kg) 
combined with O6benzylguanine (BG, a new therapeutic agent being tested in clinical 
trials), gave rise to a tumor growth delay (T2x-C2x) of 25±2.4 days but was accompanied 
by significant weight loss (maximum body weight loss from 26 to 20 g, 23%) and very 
low leukocyte counts (90% decreased) 5 days after the last treatment.  Thus, compared to 
BG+TMZ, treatment with MX+TMZ was associated with less body weight loss and less 
myelosuppression (3).  Therefore, MX inhibition of DNA BER is a promising strategy to 
sensitize tumor cells to therapeutic alkylating agents. 
 
In this first in human phase I clinical trial, methoxyamine was administered as a 5-day 
continuous intravenous infusion based on animal data. Dosing started at a MX dose of 15 
mg/m2/day for 5 days and plasma samples were collected and analyzed for MX using 
validated methods. Pharmacokinetic parameters were derived using a single compartment 
iv infusion model and plasma methoxyamine concentrations from 5 patients across 15 
dosing cycles using WINNONLIN PK model 2 software. 
 
Pharmacokinetic studies obtained from the 5 patients who enrolled in the study 
demonstrated an unexpected prolonged half-life of methoxyamine (4).  In humans, the 
half life (t½) of MX was estimated to be 45.3 hours (range: 32.1 - 68.8 hours) which 
represents a 10-fold increase when compared to the MX half life observed in dogs (t½ = 
4.5 hours) and a 143-fold increase when compared to the MX half life observed in rats 
(t½ = 19 min). The volume of distribution (Vss) was estimated to be 1,437 L and the 
clearance (CL) was estimated to be 22.47 L/h. The Cmax (across all patients) was 41.4 
ng/mL. Individual pharmacokinetic exposures and derived PK parameters are presented 
for each cycle for each patient in table 1, demonstrating very little intra- and interpatient 
variability. 
 
Table 1. Individual pharmacokinetic exposures and derived PK parameters  
Patient 
Cycle 
Cmax 
(ng/mL) 
AUC 
(hr*ng/mL) 
Vss 
(L) 
t1/2 
(hr) 
1 
1 
40.57 
5,296 
1,125 
33.05 
 
2 
40.68 
5,572 
1,290 
39.85 
 
3 
38.06 
5,132 
1,324 
37.69 
 
4 
39.93 
5,544 
1,355 
41.66 
CASE 1Y05 v22 dated 03/18/15 
 8

 
2 
1 
34.33 
4,878 
1,851 
48.71 
 
2 
60.11 
10,015 
1,313 
68.76 
3 
1 
41.24 
5,826 
1,251 
43.93 
 
2 
40.95 
6,049 
1,422 
49.70 
 
3 
35.98 
4,996 
1,443 
41.64 
4 
1 
41.58 
5,499 
1,147 
34.97 
 
2 
36.90 
4,787 
1,211 
32.13 
 
3 
45.93 
6,646 
1,277 
47.06 
5 
1 
38.33 
5,876 
2,006 
54.47 
 
2 
42.16 
6,122 
1,679 
47.49 
 
3 
44.19 
7,169 
1,865 
61.79 
 
 
Figure 1. Methoxyamine concentration profiles, presented separately for each patient. 
 
Patient 1
Time (hr)
-100
0
100
200
300
400
500
[Methoxyamine] (ng/mL)
0.1
1
10
100
Cycle 1
Cycle 2
Cycle 3
Cycle 4
Patient 2
Time (hr)
-100
0
100
200
300
400
500
[Methoxyamine] (ng/mL)
0.1
1
10
100
Cycle 1
Cycle 2
 
 
 
Patient 3
Time (hr)
-100
0
100
200
300
400
500
[Methoxyamine] (ng/mL)
0.1
1
10
100
Cycle 1 
Cycle 2
Cycle 3
Patient 4
Time (hr)
-100
0
100
200
300
400
500
[Methoxyamine] (ng/mL)
0.1
1
10
100
Cycle 1
Cycle 2
Cycle 3
Patient 5
Time (hr)
-100
0
100
200
300
400
500
[Methoxyamine] (ng/mL)
0.1
1
10
100
Cycle 1
Cycle 2
Cycle 3
 
[Note] Time points may vary from patient to patient and cycle to cycle 
 
CASE 1Y05 v22 dated 03/18/15 
 9

 
The long half-life of methoxyamine in human plasma indicates that iv administration 
over a shorter time period than 5 days should achieve plasma concentrations needed for 
activity during the five day period of concurrent temozolomide dosing.  A 60 minute 
infusion is desirable to facilitate patient convenience and accrual to the trial.  The 
estimated dose of methoxyamine given over 60 minutes required to produce a Cmax 
equal to the observed Cmax of 41.40 ng/mL obtained with 5 day continuous IV 
administration was therefore calculated as follows, and simulation data are included in 
appendix C: 
 
Amount of Methoxyamine (A) needed to produce an observed Cmax of 41.40 ug/L by bolus injection: 
 
A = Cmax x Vss = 41.40 μg/L x 1,437.27 L = 59,502.98 μg =59.50 mg 
 
Additional methoxyamine (Ainf) required to compensate for methoxyamine eliminated during a 60 
minute infusion period: 
 
Ainf = A(1-e-kt) = 59.50 mg (1-e-(0.0153/h)(1 h) ) = 0.90 mg 
 
(k = 0.693/T1/2 = 0.693/45.26 h = 0.0153/h) 
 
Therefore, the total methoxyamine dose (Atotal) given over 60 minutes by intravenous infusion needed to 
maintain a Cmax of 41.4 ng/mL over 60 minutes was estimated as: 
 
Atotal = A + Ainf = 59.50 mg + 0.90 mg = 60.40 mg 
 
The estimated total dose of methoxyamine given over a 60 minute i.v. infusion needed to 
produce a Cmax of 41.40 ng/mL (60.40 mg) corresponds to 30 mg/m2 (assuming an 
average BSA of 2 m2).  Decreasing this calculated dose by 50% to 15mg/m2 provides a 
rational and safe starting methoxyamine dose to administer intravenously over 60 
minutes. 
 
In sum, a single dose of MX administered by 60 minute iv infusion in patients enrolled at 
dose level 1 (15 mg/m2), represents a conservative initial dose level based on human PK 
parameters obtained from five patients who received methoxyamine at doses of 15 
mg/m2/day IV over five days for a total of fifteen cycles.4  This dose was calculated so 
that expected peak concentration following a single 60 minute IV infusion at dose level 1 
will be approximately half the observed maximum concentration observed following 5 
day intravenous MX infusion. 
 
Temozolomide is now standard treatment for patients with high-grade gliomas5 and is 
often used in patients with metastatic brain tumors as a radiosensitizer or as a single agent 
therapy. Temozolomide has excellent brain penetration.  However, more than half of all 
GBM patients have MGMT-induced resistance to this agent.6 The FDA noted that there 
was neurotoxicity as DLT from combining temozolomide with methoxyamine in animal 
toxicology studies and they advised us to exclude patients with brain metastasis or glioma 
from the initial Phase I study.  We now propose to expand the scope of this study while 
maintaining the original aims by adding a “dose behind” cohort of patients with brain 
metastasis or glioma.   This cohort will be treated with a 1 hr infusion MX dose that is 
one dose level below that of patients currently enrolling with advanced malignancies but 
CASE 1Y05 v22 dated 03/18/15 
 10

 
without brain disease.  Patients will receive the dose-level appropriate temozolomide 
dose.  However, since many of these patients will have received prior temozolomide, the 
initial dose level -1 will be 100 mg/m2 of TMZ orally on days 1-5 of a 28-day cycle and 
15 mg/m2 of MX i.v. over one hour on day 1. Once patients without brain disease have 
accrued to dose level 2 of MX, we will begin to enroll patients with brain metastasis or 
gliomas at dose level 1. 
 
 
3. PATIENT SELECTION 
 
Given the animal toxicity data and CNS involvement of a proportion of eligible patients, 
two cohorts of eligible patients will be enrolled in the trial: 
 
 Cohort A will include patients with no CNS disease  
 Cohort B will include patients with CNS disease (including recurrent or 
progressive malignant gliomas and/or brain metastatic disease). Brain metastases 
do not have to be new to participate in this study.   
 
Inclusion of two separate cohorts was chosen, because this design will allow us to 
address toxicity concerns generated by the animal studies in a cohort of patients with no 
CNS disease (cohort A) where development of potential treatment-related CNS toxicity 
will not be confounded by pre-existing or disease-progression-related symptoms. 
Inclusion of patients with CNS disease in cohort B will allow us to evaluate the 
combination in the group of patients where TMZ is currently extensively evaluated and 
used. 
 
3.1  
Eligibility Criteria  
 
3.1.1 Patients must have a histologically confirmed solid tumor that is 
considered incurable and is not amenable to conventional surgical, 
radiation therapy or chemotherapy treatment programs.  
 
3.1.2 Prior chemotherapy and/or radiation are allowed.  At least 3 weeks 
must have elapsed since prior large-field radiation therapy; patients 
must have been off previous anti-cancer therapy for at least 3 weeks (6 
weeks for mitomycin-C and nitrosoureas); and recovered from all 
treatment related toxicity to < grade 1 according to NCI CTCAE 
version 3.0 (with the exception of alopecia and radiation-induced taste 
changes).  Prior temozolomide treatment is not restricted. 
 
3.1.3 Age >18 years.   
 
3.1.4 ECOG performance status <2 (Karnofsky >50%, see Appendix A). 
 
3.1.5 Life expectancy > 12 weeks. 
 
CASE 1Y05 v22 dated 03/18/15 
 11

 
3.1.6 Patients must have normal organ and marrow function as defined 
below: 
 absolute neutrophil count  
> 1,500/l 
 platelets  
 
 
 
 
 
> 100,000/l 
 hemoglobin  
 
 
 
 
> 10.0 g/dl 
 total bilirubin 
 
 
 
 
< 1.5 mg/dl 
 AST(SGOT) 
 
 
 
 
< 2.5 X institutional upper limit of 
normal 
 creatinine 
 
 
 
 
 
< 1.5 mg/dl 
 
and/or 
 creatinine clearance  
 
 
> 60 mL/min/1.73 m2  
 
3.1.7 Patients with known primary or metastatic CNS disease, are eligible 
for participation in cohort B, but not in cohort A. 
 
3.1.8   Women of child-bearing potential and men must agree to use adequate 
contraception (hormonal or barrier method of birth control; abstinence) 
prior to study entry and for the duration of study participation.  Should 
a woman become pregnant or suspect she is pregnant while 
participating in this study, she should inform her treating physician 
immediately. 
 
3.1.9   Ability to understand and the willingness to sign a written informed 
consent document. 
 
3.2  
Exclusion Criteria 
 
3.2.1 Patients may not be receiving any other investigational agents or have 
received other investigational agents for at least 3 weeks. 
 
3.2.2 Uncontrolled intercurrent illness including, but not limited to, ongoing 
or active infection, symptomatic congestive heart failure, unstable 
angina pectoris, cardiac arrhythmia, or psychiatric illness/social 
situations that would limit compliance with study requirements. 
 
3.2.3 Pregnant and lactating women are excluded from this study because 
the methoxyamine and temozolomide combination is likely to be 
teratogenic.    
 
 
 
3.2.5 
NYHA classification III or IV heart disease 
 
3.2.6 Patients with known primary or metastatic CNS disease (cohort B) are 
not eligible if they have a mini mental status exam score < 15 (per 
Appendix D) or evidence of leptomeningeal disease. 
 
 
 
 
 
 
3.2.7 Patients with pre-existing neurologic toxicity > grade 1 (as per 
CASE 1Y05 v22 dated 03/18/15 
 12

 
CTCAE, version 3.0) are not eligible for participation in cohort A.  
 
 
 
 
 
Patients screened for participation in cohort B with pre-existing 
neurologic toxicity > grade 2 (as per CTCAE, version 3.0) are not 
eligible, unless pre-existing neuroloxic toxicity is documented in detail 
and patient’s participation in the trial has been approved by the neuro-
oncology team at participating institutions.    
 
3.3  
Inclusion of Women and Minorities 
 
 
 
Both men and women of all ethnic groups are eligible for this trial.   
 
 
4. TREATMENT PLAN 
 
To enter eligible patients on study, investigators will register patients by contacting the 
study coordinator for this trial.  The following information will be requested:  a 
registration card, copy of the informed consent, and copy of the signed eligibility criteria 
from the study protocol.  These must be submitted prior to a patient starting treatment and 
placed in the chart.     
 
4.1  
Agent Administration 
 
For all cycles, TMZ will be given orally for 5 days every 28 days.  MX will be given as a 
single one-hour IV infusion every 28 days. Temozolomide will be administered within 5 
minutes following the initation of methoxyamine. 
   
Patients will be treated and monitored in the inpatient setting (Clinical Research Unit) 
during MX administration (on cycle 1 day 1). A physician will be onsite within the 
hospital in case an adverse event occurs. 
  
Cohort A (eligible patients with no CNS disease) 
DOSE-ESCALATION SCHEDULE  
Dose 
 
Dose Level  
TMZ 
(mg/m2/day) x5days 
MX 
(mg/m2) 
Level -1 
100 
15 
Level  1 
150 
15 
Level  2 
150 
30 
Level  3 
150 
60 
Level  4 
150 
90 
Level  5 
150 
120 
Level 6 
150 
150 
CASE 1Y05 v22 dated 03/18/15 
 13

 
Level  7 
200 
150 
 
Cohort B (eligible patients with CNS disease) 
DOSE-ESCALATION SCHEDULE 
Dose 
 
Dose Level  
TMZ 
(mg/m2/day) x5days 
MX 
(mg/m2) 
Level  -1 
75 
15 
Level  1 
100 
15 
Level  2 
150 
15 
Level   3 
150 
30 
Level  4 
150 
60 
Level 5 
150 
120 
Level 6 
150 
150 
Level 7 
200 
150 
 
For each cohort, 3 patients will be entered sequentially to each dose level.  
 If none of the 3 patients at a dose level experience dose limiting toxicity (DLT) 
during the first cycle, new patients may be entered at the next higher dose level.  
 If 1/3 patients experience a DLT during the first cycle, up to 3 more patients will 
be treated at the same dose level. If the 1st patient in the expanded cohort (4th at 
the given DL), experiences no DLT, then the remaining 2 patients can start 
treatment without a necessary delay.  
o As of protocol v22, if 1/3 patients experience any DLT that is not of a 
CNS nature in Cohort B dose level 6, we will continue dose escalation to 
dose level 7 since we have already treated three subjects in Cohort A dose 
level 6 and seven subjects in Cohort A dose level 7, none of whom 
experienced non-CNS toxicities 
 If 2 or more experience DLT during the first cycle, no further patients are started 
at that dose and the MTD is the highest dose level in which <2 (of 6) patients 
develop DLT. 
 If the final dose level is deemed the MTD, 6 patients will be treated at this dose 
level even if a DLT has not been observed. 
 
Select non-hematologic grade 3 or 4 or hematologic grade 4 drug-related toxicities (CTC 
version 3.0) occurring within the first 28 days of the study will be considered a DLT. 
 
Cohort A, Dose level 1:  Two DLTs were observed in Dose Level 1 of Cohort A:  grade 
3 psychosis and grade 3 allergic reaction.  Upon further review of the hypersensitivity 
reaction, it is believed that this was an idiosyncratic event, and further expansion of this 
CASE 1Y05 v22 dated 03/18/15 
 14

 
dose level is warranted.  Dose level 1 of Cohort A will be expanded to 10 evaluable 
patients.  Further dose escalation will occur only if less than 4 out of the 10 patients 
experience a DLT.  Enrollment to subsequent dose levels will follow the rules outlined 
above. 
 
4.2 
Definition of Dose-Limiting Toxicity (DLT) and Criteria for Dose 
Escalation 
DLT in a given patient is defined as any grade III non-hematologic (thought to 
be MX related) or IV non-hematological toxicity or any grade IV anemia, 
neutropenia or thrombocytopenia lasting greater than 7 days, that is felt to be 
related to MX or the MX + TMZ drug combination occurring during the first 
cycle of treatment.  
 
MTD (maximum tolerated dose) will be defined based on the toxicities 
observed during the first cycle of treatment  
 
Definition of MTD: The MTD is defined as the highest dose tested in which 
none or only one patient experienced DLT attributable to the study drug 
combination, when at least six patients were treated at that dose and are 
evaluable for toxicity. The MTD is one dose level below the highest dose 
tested in which 2 or more patients experienced DLT attributable to the study 
drug. At least 6 patients will be treated at the MTD. 
 
Management and dose modifications associated with the above adverse events 
are outlined in Section 5. 
 
Special consideration is given to the evaluation of neurologic toxicity given 
the animal toxicity data and CNS involvement of a proportion of eligible 
patients. 
 
Specifically: 
- 
all patients will be evaluated by a staff Neurologist prior to initiation of 
treatment 
- 
patients will undergo frequent (every 4-8 hours) neurologic checks by a 
CRU RN during the 1-day inpatient CRU stay on the first day of 
treatment. 
- 
Patients will be evaluated by the covering Oncology clinician during the 
1-day inpatient CRU stay on cycle 1. 
 
A neurology consult will be obtained for any observed treatment-related 
neurologic toxicity ≥ grade 2. For patients enrolled in cohort B (patients with 
CNS disease) with pre-existing neurologic toxicity cleared for participation by 
the neuro-oncology team, a neuro-oncology or neurology consult will be 
obtained for any observed treatment-related worsening in neurologic 
toxicities. 
 
CASE 1Y05 v22 dated 03/18/15 
 15

 
Dose escalation will proceed within each cohort according to the following 
scheme.  DLT is defined above.     
 
Number of Patients with DLT at a 
Given Dose Level 
Escalation Decision Rule 
0 out of 3 
Enter 3 patients at the next dose level. 
>2 
Dose escalation will be stopped.  This dose level will be 
declared the maximally administered dose (highest dose 
administered).  Three (3) additional patients will be 
entered at the next lowest dose level if only 3 patients were 
treated previously at that dose. 
1 out of 3 
Enter at least 3 more patients at this dose level.  
 If 0 of these 3 patients experience DLT, proceed to the 
next dose level. 
 If 1 or more of this group suffer DLT, then dose 
escalation is stopped, and this dose is declared the 
maximally administered dose.  Three (3) additional 
patients will be entered at the next lowest dose level if 
only 3 patients were treated previously at that dose. 
o 
As of protocol v22, if 1/3 patients experience any 
DLT that is not of a CNS nature in Cohort B dose 
level 6, we will continue dose escalation to dose 
level 7 since we have already treated three 
subjects in Cohort A dose level 6 and seven 
subjects in Cohort A dose level 7, none of whom 
experienced non-CNS toxicities 
<1 out of 6 at highest dose level below 
the maximally administered dose 
This is generally the recommended phase 2 dose. At least 6 
patients must be entered at the recommended phase 2 dose. 
 
Cohort A, Dose level 1:  Dose level 1 of Cohort A will be expanded to 10 evaluable 
patients.  Further dose escalation will occur only if less than 4 out of the 10 patients 
experience a DLT.  Enrollment to subsequent dose levels will follow the rules outlined in 
Sec. 4.1. 
 
4.3  
Supportive Care Guidelines 
 
Compazine or ondansetron in the usual doses may be used to manage 
constitutional symptoms of nausea and vomiting. Steroids may be added 
based on the treating physicians discretion. Blood products may be 
administered at the treating physician’s discretion. Growth factors will not be 
administered during cycle 1, but can be administered in subsequent cycles 
based on treating physician’s judgment. 
 
4.4  
Duration of Therapy 
 
In the absence of treatment delays due to adverse events, treatment may 
CASE 1Y05 v22 dated 03/18/15 
 16

 
continue until one of the following criteria applies: 
 
 
Disease progression, 
 
Intercurrent illness that prevents further administration of 
treatment, 
 
Unacceptable adverse event(s), 
 
Patient decides to withdraw from the study, or 
 
General or specific changes in the patient's condition that render 
the patient unacceptable for further treatment in the judgment of 
the investigator. 
 
 
5. DOSING DELAYS/DOSE MODIFICATIONS 
 
On the day of starting each cycle, neutrophil and platelet hematologic parameters 
must have returned to eligibility values.  Furthermore, grade 3 non-hematologic 
toxicity that is felt to be drug related must return to a grade 2 or better. If these 
criteria are not met, therapy will be held by 1 week increments for a maximum of 
2 weeks. If treatment cannot be given during that time frame the patient will be 
removed from study. 
 
Any grade 4 hematologic toxicity will result in a dose reduction to the lower dose 
level for methoxyamine/temozolomide. If this occurs at dose level 1, the dose of 
temozolomide will be decreased to dose level -1 (75 mg/m2/d for 5 days if in the 
CNS cohort; 100mg/m2 for 5 days if in the non-CNS cohort). 
 
 
6. AGENT FORMULATION AND PROCUREMENT 
 
6.1 
Temodar (Temozolomide) 
 
6.1.1 Availability: Temodar is commercially available.  
 
6.1.2 Chemical Name - The chemical name of temozolomide is 3,4-dihydro-3-methyl-
4-oxoimidazo[5,1-d]-as-tetrazine-8-carboxamide.  
 
6.1.3 Molecular Formula - C6H6N6O2 
 
6.1.4 Mechanism of Action - Temozolomide is not directly active but undergoes rapid 
non-enzymatic conversion at physiologic pH to the reactive compound MTIC. The 
cytotoxicity of MTIC is thought to be primarily due to alkylation of DNA. Alkylation 
(methylation) occurs mainly at the O6 and N7 positions of guanine.  
 
6.1.5 Pharmacokinetics - Temozolomide is rapidly and completely absorbed after oral 
administration; peak plasma concentrations occur in 1 hour. Food reduces the rate and 
extent of temozolomide absorption. Mean peak plasma concentration and AUC decreased 
by 32 % and 9 %, respectively, and Tmax increased 2- fold (from 1.1 to 2.25 hours) when 
CASE 1Y05 v22 dated 03/18/15 
 17

 
temozolomide was administered after a modified high fat breakfast. Temozolomide is 
rapidly eliminated with a mean elimination half- life of 1.8 hours and exhibits linear 
kinetics over the therapeutic dosing range. Temozolomide has a mean apparent volume of 
distribution of 0.4 L/kg (% CV= 13%). It is weakly bound to human plasma proteins; the 
mean percent bound of drug- related total radioactivity is 15%.  
 
6.1.6 How Supplied - TEMODAR (temozolomide) Capsules are supplied in amber 
glass bottles with child-resistant polypropylene caps containing the following capsule 
strengths:  
 
TEMODAR (temozolomide) Capsules 5 mg: opaque white bodies with green caps.  The 
capsule body is imprinted with two stripes, the dosage strength, and the Schering-Plough 
logo.   The cap is imprinted with “TEMODAR”. 
 
5 and 14 capsule bottles.  
5 count - NDC# 0085-3004-02  
14 count - NDC# 0085-3004-01  
 
TEMODAR (temozolomide) Capsules 20 mg: opaque white bodies with yellow caps.  
The capsule body is imprinted with two stripes, the dosage strength, and the Schering-
Plough logo.   The cap is imprinted with “TEMODAR”. 
 
5 and 14 capsule bottles.  
5 count - NDC# 0085-1519-02 
14 count - NDC# 0085-1519-01  
 
TEMODAR (temozolomide) Capsules 100 mg: opaque white bodies with pink caps.  The 
capsule body is imprinted with two stripes, the dosage strength, and the Schering-Plough 
logo.   The cap is imprinted with “TEMODAR”. 
 
5 and 14 capsule bottles. 
5 count - NDC# 0085-1366-02 
14 count - NDC# 0085-1366-01  
 
TEMODAR (temozolomide) Capsules 140 mg: opaque white bodies with blue caps.  The 
capsule body is imprinted with two stripes, the dosage strength, and the Schering-Plough 
logo.   The cap is imprinted with “TEMODAR”. 
 
5 and 14 capsule bottles. 
5 count - NDC# 0085-1425-01 
14 count - NDC# 0085-1425-02  
 
TEMODAR (temozolomide) Capsules 180 mg: opaque white bodies with orange caps.  
The capsule body is imprinted with two stripes, the dosage strength, and the Schering-
Plough logo.   The cap is imprinted with “TEMODAR”. 
 
5 and 14 capsule bottles. 
5 count - NDC# 0085-1430-01 
CASE 1Y05 v22 dated 03/18/15 
 18

 
14 count - NDC# 0085-1430-02  
 
TEMODAR (temozolomide) Capsules 250 mg:  opaque white bodies with white caps.  
The capsule body is imprinted with two stripes, the dosage strength, and the Schering-
Plough logo.   The cap is imprinted with “TEMODAR”. 
 
5 capsule bottles. 
5 count - NDC# 0085-1417-01  
 
Store at 25° (77° F); excursions to 15°-30° C (59°-86° F).  
[See USP Controlled Room Temperature]  
 
6.1.7 Route of Administration – Oral 
 
6.1.8 Toxicity - The incidence of adverse events in the 158 patients in the Anaplastic 
Astrocytoma study for whom data are available. In the absence of a control group, it is 
not clear in many cases whether these events should be attributed to temozolomide or the 
patients' underlying conditions, but nausea, vomiting, fatigue and hematologic effects 
appear to be clearly drug-related. The most frequently occurring side effects were nausea, 
vomiting, headache and fatigue. The adverse events were usually NCI Common Toxicity 
Criteria (CTC) Grade 1 or 2 (mild to moderate in severity) and were self-limiting, with 
nausea and vomiting readily controlled with antiemetics. The incidence of severe nausea 
and vomiting (CTC grade 3 or 4) was 10% and 6%, respectively. Myelosuppression 
(thrombocytopenia and neutropenia) was the dose-limiting adverse event. It usually 
occurred within the first few cycles of therapy and was not cumulative. 
 
Myelosuppression occurred late in the treatment cycle and returned to normal, on 
average, within 14 days of nadir counts. The median nadirs occurred at 26 days for 
platelets [range 21-40 days] and 28 days for neutrophils [range 1-44 days]. Only 14% 
(22/158) of patients had a neutrophil nadir and 20% (32/158) of patients had a platelet 
nadir which may have delayed the start of the next cycle. (See WARNINGS). Less than 
10% of patients required hospitalization, blood transfusion or discontinuation of therapy 
due to myelosuppression.  
 
In clinical trial experience with 110-111 women and 169-174 men (depending on 
measurements), there were higher rates of Grade 4 neutropenia (ANC < 500 cells/µL) 
thrombocytopenia (< 20,000 cells/µL) in women than men in the first cycle of therapy: 
(12% versus 5% and 9% versus 3%, respectively).  
 
In the entire Safety database for which hematologic data exist (N= 932), 7% (4/61) and 
9.5% (6/63) of patients over age 70 experienced Grade 4 neutropenia or 
thrombocytopenia in the first cycle, respectively. For patients less than or equal to age 70, 
7% (62/871) and 5.5% (48/879) experienced Grade 4 neutropenia or thrombocytopenia in 
the first cycle, respectively. 
 
Data released by the European Organization for Research and Treatment of Cancer 
(EORTC) in January 2014 shows that amongst 44 patients receiving temozolomide 
CASE 1Y05 v22 dated 03/18/15 
 19

 
worldwide, hepatic injury, including fatal hepatic failure was identified in patients 
receiving temozolomide. These events are rare but for patients with liver function 
abnormalities, the risk/benefit of receiving temozolomide should be considered prior to 
initiation of this agent. 
 
6.2.  METHOXYAMINE HYDROCHLORIDE: 
 
6.2.2.1.Chemistry and Manufacturing Introduction:   
 
Methoxyamine hydrochloride: a small organic amine is soluble in water.   
Synonymous: O-methylhydroxyamine hydrochloride 
Specifications: 
 
 
 
Molecular Formula 
CH5NO.HCl 
Molecular Weight 
83.5 
Physical description 
White crystal 
Melting point 
149-153 C 
Moisture 
1.0% Max 
Purity (GC) 
98.2%  
 
There are not any chemical or manufacturing differences between the drug product 
proposed for clinical use and the drug product used in the animal toxicology trials.  
 
6.2.2.2. Drug Substance: 
 
 
NSC 3801 is Methoxyamine hydrochloride. Following is a description of 
the drug substance 
 
 
 
Non-Proprietary Names: 
n.a. 
 
 
 
Chemical Names: 
 
Methoxyamine hydrochloride, 
 
O-methylhydroxyamine 
hydrochloride 
 
 
 
 
Other Names:  
 
TRC102 
 
 
 
 
CAS Number:  
 
593-56-4 
 
 
 
 
 
NCI Code: 
 
 
NSC 3801 
 
 
 
 
Chemical Structure:  
CH3-O-NH2•HCl 
                 
6.2.2.3. Manufacturer of the Drug Substance: 
 
 
 
Manufactured for: Tracon Pharamceuticals 
4510 Executive Drive, Suite 330 
San Diego, CA 92121 
CASE 1Y05 v22 dated 03/18/15 
 20

 
Phone: 858/550-0780 
Fax: 858/550-0786 
            
6.2.2.4. Drug Product: 
 
1. Components and Composition 
 
Methoxyamine HCl Injection (also referred to as TRC102 Injection) 
 
The drug product is a sterile solution of methoxyamine hydrochloride in Water 
For Injection filled into 10 mL single-use vials.  Each vial contains 10 mL of a 15 
mg/mL solution for a total of 150 mg of methoxyamine hydrochloride per vial.  
Vials of Methoxyamine HCl Injection are labeled with the following. 
Methoxyamine HCl Injection (TRC102 Injection) 
 10 mL per vial at 15 mg/mL 
 
______________ 
    _____________             xxx-xx-xxxx 
 
Protocol Number         Patient Number          
 Lot No. 
For IV/Single use only 
Instructions for Use: Give as directed per protocol 
Caution: New Drug-Limited by Federal (or United States) law to investigational use 
Store at 25ºC; excursions permitted to 15-30 ºC  
TRACON Pharmaceuticals, Inc., San Diego, CA 92121 USA 
 
2. Methoxyamine HCl Injection Storage and Shipping 
 
Methoxyamine HCl Injection should be stored upright at controlled room 
temperature (25ºC; excursions permitted to 15-30 ºC). 
 
3.  TRC102 Injection Preparation 
Methoxyamine HCl Injection will be prepared in the pharmacy and diluted 
with normal saline in a 250 mL bag.  Following dilution in normal saline, 
Methoxyamine HCl Injection will be administered at room temperature within 
24 hours of preparation if refrigerated or 8 hours of preparation if maintained 
at room temperature.  Depending on the dose and patient weight, multiple 
vials may be required for a single dose.   
The following formulae should be used to calculate the volume of 
Methoxyamine HCl Injection to be added to normal saline: 
 Patient weight (kg) × dose level (mg/kg) divided by Methoxyamine 
HCl Injection (mg/mL) = volume of Methoxyamine HCl Injection 
(mL) to be administered. 
The volume of Methoxyamine HCl Injection to be administered can be 
rounded up or down to the nearest 0.1 mL.  If an increment of 0.05 mL is 
calculated, the volume should be rounded up.  The calculated volume of 
Methoxyamine HCl Injection is to be diluted in normal saline.  A 250 mL 
normal saline bag is recommended for this purpose.  Appropriate judgment 
CASE 1Y05 v22 dated 03/18/15 
 21

 
should be exercised in withdrawing an adequate amount of saline (if any) 
necessary to permit injection of the appropriate volume of diluted antibody 
into the appropriate sized normal saline bag.   
 
4.The absorption, distribution, metabolism, and excretions of methyoxyamine. 
 
Methoxyamine is a small organic amine; it is very soluble in aqueous solution and 
plasma.  A [14C]-MX protein-binding study in mouse plasma at 37C indicated 
insignificant protein binding.  100% of radiolabelled MX was recovered from the 
samples after Centrifree processing, indicating a lack of reactivity with plasma 
proteins. 
 
6.2.3. Toxicology information:  
 
Methoxyamine (MX) is a novel biochemical inhibitor of the base excision repair (BER) 
pathway.  It has potential as a chemotherapeutic agent through its ability to synergize 
with compounds whose DNA damage is normally repaired by BER, such as the 
alkylating agent, temozolomide (TMZ).  In vitro studies and xenograft models have 
confirmed synergistic cytotoxicity in tumor cells treated with both MX and TMZ. 
 
(a) The toxicity of MX was studied in Fischer 344 rats.  MX was administrated as a 5-
day continuous IV infusion in sterile water.  Twelve dose groups, including vehicle 
control, 0.25, 0.5, 1.25, 2.5, 5, 10, 15, 20, 50, 200 and 500 mg/kg/day were studied using 
4-5 males/dose group.  Body weight was measured baseline, and on days 1-5, 8, and 12.  
Blood was drawn for clinical pathology baseline and on day 8 and 12.  Animals were 
sacrificed on day 12.  Histopathology was performed on animals that received vehicle 
control, 2.5, 20 and 50 mg/kg/day.    
 
 
Mortality:  all rats in the 500 mg/kg/day group were found dead or sacrificed moribund 
on day 1.  All animals in the 200 mg/kg/day group were found dead on day 2. 
 
Clinical Observations, Body Weights: animals given 500 mg/kg/day had bradycardia 
dyspnea, convulsions, prostration and/or were comatose within the first few hours of the 
beginning of dosing.  There were no statically significant changes in body weight in any 
group compared to the vehicle control group.   
 
 
Hematology and Clinical chemistry: these parameters are not available for animals given 
200 mg/kg/day.  Animals that received 500 mg/kg/day that were sacrificed moribund had 
elevated AST/ALT (4-6X).  A decrease in RBC (25-30%) was noted on day 12 in rats 
given 50 mg/kg/day. 
 
 
Histopathology: no drug-related lesions were seen in animals given 20 or 50 mg/kg/day.   
Conclusions: the maximum tolerated dose of MX given as a 5-day continuous iv infusion 
in rats is greater than 50 mg/kg/day (> 300 mg/m2/day) but less than 200 mg/kg/day (< 
1200 mg/m2/day).  
 
CASE 1Y05 v22 dated 03/18/15 
 22

 
(b) Multiple dose toxicity study of methoxyamine and temozolomide in rats and 
dogs.  The effect of escalating doses of MX on the pharmacology and toxicity of a 
constant dose of TMZ was assessed in rats and dogs on a 5-day schedule.  TMZ was 
given orally, and MX was administered as a continuous iv infusion. 
 
In rats: vehicle control, MX alone (100 mg/kg/day), TMZ alone (30 mg/kg/day), 
or 25, 50, 75, or 100 mg/kg/day MX in combination with 30 mg/kg/day TMZ were 
studied using 10 rats/sex/dose group.  Body weights were determined baseline, and on 
days 1-5, 8, 15, 22, and 33.  Blood was drawn for clinical pathology on days 8, 15, 22 and 
33.  Animals were sacrificed on day 8 or 33, and histopathology was performed.  
 
In dogs: vehicle control, MX alone (15 mg/kg/day), TMZ alone (2.5 mg/kg/day), 
5 or 15 mg/kg/day MX in combination with 2.5 mg/kg/day TMZ were studied using 2 
males and 2 females/dose group.  Due to adverse clinical signs seen in males given 15 
mg/kg/day TMZ, females in these dose groups received 10 mg/kg/day MXTMZ.  
Body weights were determined at baseline, and on days 1-5, 8, 12, 19, 26, and 33.  Body 
temperatures were measured baseline, immediately prior to and at 2 and 4 hours after 
each TMZ dose, and on day 6-8, 12, 15, 19, 26 and 33.  Food consumption was measured 
daily on days 1-5 and weekly thereafter.  Blood was drawn for clinical pathology on days 
8, 12, 15, 19, 26 and 33.  One animal/sex/group was sacrificed on day 8 or 33, and 
histopathology was performed. 
 
In summary, in both rats and dogs, MX alone (1200-3000 mg/m2/day in rats and 
300 mg/m2/day in dogs) caused dose-limiting neurotoxicity (convulsions, tremors, ataxia, 
and/or head tilt).  TMZ alone caused minimal anemia in dogs (50 mg/m2/day) and 
minimal to moderate neutropenia in rats (180 mg/m2/day).  In rats, TMZ-induced 
neutropenia increased with increasing doses of MX.  Lethality also increased in rats with 
increasing doses of MX in combination with TMZ.  The maximum tolerated dose (MTD) 
in rats is 25 mg/kg/day MX + 30 mg/kg/day TMZ. In dogs, the combination of MX + 
TMZ did not produce lethality.  The MTD is ~10-15 mg/kg/day MX + 2.5 mg/kg/day 
TMZ.  The recommended clinical starting dose of MX is 15 mg/m2/day when given as a 
5-day continuous iv infusion in combination with orally administered TMZ.  This dose is 
one-tenth the MTD in the most sensitive species (rat).  
 
Pharmacokinetic interaction studies were performed with TMZ and MX in F344 
rats and dogs (M.D. Anderson Cancer Center). TMZ concentrations in rat and dog plasma 
were analyzed after treatment with TMZ and MX.  Results showed that MX did not 
appear to alter the pharmacokinetics of TMZ in either rats or dogs. (Plasma samples were 
obtained for TMZ analysis 30 min post-TMZ on day 5 and 10 min before the end of the 
MX infusion on day 6 for MX analysis.)  
 
(c) In vitro studies.  In vitro bone marrow assays were conducted to determine the effect 
of MX on the myelotoxicity of TMZ.  Granulocyte-macrophage colony-forming units 
(CFU-GM) were obtained from two human and two murine donors.  The study provided 
evidence that TMZ is likely more potent to murine than human CFU-GM. Single agent 
CASE 1Y05 v22 dated 03/18/15 
 23

 
MX was well tolerated in both murine and human CFU-GM. Combination of TMZ with 
MX shows that MX mildly enhances TMZ toxicity to CFU-GM in both species. 
 
 
7. CORRELATIVE/SPECIAL STUDIES 
 
This protocol will utilize the Translational Research Core (TRC) of the Case 
Comprehensive Cancer Center for the collection, processing, storage, and distribution of 
patient samples before and after therapy. 
 
Translational Research Core 
ATTN  Erin Hohler 
University Hospitals of Cleveland 
11100 Euclid Avenue 
Seidman Cancer Center, Room 3608 
Cleveland, OH 44106 
Telephone: 216-286-3889/216-386-3890 
Fax: 216-286-5772 
Pager: 33471 
E-mail: emh14@case.edu 
 
The TRC will schedule patient sample collection in direct communication with the 
clinical trials research nurse. For UH patients a representative from the TRC will be 
present during patient sampling, wherein every sample will be given a patient identifier, 
and collected in the appropriate tubes or vials.  
 
1. Pharmacokinetic studies  
 
PK blood sampling schedule for Temozolomide (TMZ) and Methoxyamine (MX) during 
cycle 1 are shown in the table that follows.  Depending upon the PK data from initial 
patients, the timing of blood draws for correlative studies may be revised for future 
patients.   PK data during and following single one-hour MX infusion may be obtained in 
all subsequent cycles (cycles 2 and beyond) as necessary.   
 
Preclinical data have not provided any evidence of significant drug interactions between 
TMZ and MX. However, this needs to be confirmed. TMZ is not stable in plasma, so 
plasma sample isolation must be carried out without delay. Plasma from one tube of 
whole blood will be used for both TMZ and MX determinations. 
 
Collection Instructions for MX and TMX determinations: 
1. 
Draw 5 ml of blood into a lithium heparinized, chilled syringe.  
2. 
Immerse the tube in an icewater bath for 2 min.  
3. 
Centrifuge at 1500 x g and 4 deg. C. for 5 min.  
4. 
Transfer 1.0 ml of plasma into each of two Nunc brand cryostorage tubes.  
5. 
To one tube, to be used for TMZ determination, add 0.1 ml of cold 1 M HCl.  
6. 
Cap, mix, label, and store frozen at -60˚C. 
CASE 1Y05 v22 dated 03/18/15 
 24

 
a) 
Methoxyamine determination 
 
An LC-MS/MS method for quantitative determination of MX in human plasma was 
developed.  In this method, MX and its stable isotope methoxyl-d3-amine (MX-d3 as 
internal standard) were directly derivatized in human plasma with 4-(N,N-
diethylamino)benzaldehyde.  The derivatized MX and IS were extracted by methyl-tert-
butyl ether, and separated isocratically on a Xterra C18 column (2.1 x 100 mm) using an 
aqueous mobile phase containing 45% acetonitrile and 0.4% formic acid at a flow rate of 
0.200 ml/min.  Quantitation of MX was carried out by multiple-reaction-monitoring 
(MRM) mode of positive turbo-ion-spray tandem mass spectrometry. This method has 
been validated according to FDA guidelines for bioanalytical method.  The linear 
calibration range for MX was 1.25-500 ng/ml in human plasma with a correlation 
coefficient ≥ 0.9993.  The intra- and inter-assay precision (%CV) at three concentration 
levels (3.50, 45.0 and 450 ng/ml) ranged 0.9-1% and 0.8-3%, respectively. The stability 
studies showed that MX met the acceptable criteria under all tested conditions.   
b) 
Temozolomide determination 
 
Analyses will be performed in the Core Pharmacology laboratory, directed by Dr. 
Hoppel.  
 
2.  
DNA strand break determination by comet assay. 
 
The comet assay is based on the ability of denatured, cleaved DNA fragments to migrate 
out of fixed cells under the influence of an electric field.  Undamaged DNA migrates 
slower and remains within the confines of the nuclei when a current is applied. This assay 
is a simple assay but sensitively detects both single and double stranded DNA breaks, 
resulting from AP sites as well as other alkali labile DNA adducts in individual cells.  To 
perform this assay, the cell suspension (1x 105 /ml cold PBS) is mixed with 1% low 
melting point agarose at 42 C at a ratio of 1:10 (v/v) and immediately pipetted (75 l) 
onto a CometSlide. When the agarose has set, slides are electrophoresed in both alkali 
and neutral solution. DNA is stained using SYBR Green and the images of comets are 
visualized and captured using a microscope coupled with a digital camera. DNA damage 
is assessed based on evaluation of the DNA “comet” tail shape and migration distance 
that are analyzed using Komet version 6.0 software. In previous in vitro studies with 
human lymphocytes, we have shown that DNA strand breaks are correlated with the 
levels of AP sites in cells treated with TMZ. A 2 hr treatment with TMZ plus MX 
generated higher levels of DNA strand breaks (up to 2-fold greater), compared to TMZ 
alone. This demonstrates that the comet assay can be used to monitor drug effects on 
DNA damage in clinical studies. Analyses for DNA strand breaks by comet assay will be 
performed in the Translational Research Core Facility lab in the Wolstein Research 
Building.  
 
Collection Instructions: 
1. Immediately deliver tubes to the Translational Research Core Laboratory, 
Seidman Cancer Center, Room 3608, (phone number 216-286-3889) for 
processing and analysis by comet assay. 
CASE 1Y05 v22 dated 03/18/15 
 25

 
Cycle 1  
Week 1 
Day1 
2 
3 
4 
5 
6 
 
MX 
↔ 
 
 
 
 
 
 
TMZ 
↓ 
↓ 
↓ 
↓ 
↓ 
 
Pharmacokinetic 
Studies 
0 
30min 
1h 
2h 
4h 
8h 
 
24h 
 
48h 
 
72h 
96h 
 
120h  
 
 
 
 
Correlative Studies 
    Comet assay 
0 
2h 
4h 
24h 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
8. STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 2 weeks prior to start of protocol 
therapy.  Scans and x-rays must be done ≤ 4 weeks prior to the start of therapy.  In the 
event that the patient’s condition is deteriorating, laboratory evaluations should be 
repeated within 48 hours prior to initiation of the next cycle of therapy.  
 
 
Pre-
study 
C1 
Wk 
1 
C1 
Wk 
2 
C1 
Wk 
3 
C1 
Wk 
4 
Cx  
Wk 
1 f 
Cx 
Wk 
2 
Cw 
Wk 
3 
Cx 
Wk 
4 
Off 
study 
Physical exam 
X 
X 
 
 
 
X 
 
 
 
X 
Neurologic exam 
X d 
 
 
 
 
 
 
 
 
 
MMSE 
X i 
 
 
 
 
 
 
 
 
 
Vital signs 
X 
X 
 
 
 
 
 
 
 
X 
Heights 
X 
 
 
 
 
 
 
 
 
 
Weight 
X 
X 
 
 
 
 
 
 
 
X 
Performance Status 
X 
X 
 
 
 
 
 
 
 
X 
CBC w/diff, plts 
X 
X 
X 
X 
X 
X j 
 
 
X j 
X 
Serum chemistry a 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Serum tumor specific 
tumor markers g 
X 
 
 
 
 
 
 
 
 
X 
EKG (as indicated) 
X 
X 
 
 
 
 
 
 
 
 
Adverse event 
evaluation 
 
X 
X 
X 
X 
X 
 
 
 
 
Tumor measurements h 
X 
Tumor measurements are repeated at week 8, then every 8 
weeks. Documentation (radiologic) must be provided for 
patients removed from study for progressive disease. 
X 
B-HCG 
X b 
 
 
 
 
 
 
 
 
 
Pharmacokinetics e, Lab 
Correlates 
 
X c 
 
 
 
 
 
 
 
 
 
CASE 1Y05 v22 dated 03/18/15 
 26

 
a: Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, 
phosphorus, potassium, total protein, SGOT [AST], SGPT [ALT], sodium. 
b: Serum pregnancy test (women of childbearing potential). 
c: See section 7.0. Pharmacokinetics will be done during week 1. 
d:   All patients will be evaluated by a staff Neurologist prior to initiation of treatment and then will undergo frequent 
(every 4-8 hours) neurologic checks by a CRU RN during the 1-day inpatient CRU stay on cycle 1, day1. 
e:   Pharmacokinetics will be obtained for the first cycle only. 
f:   Subsequent cycles and associated evaluations may be conducted within +/- 2 days of the previous cycle. 
g: Tumor specific tumor markers to be obtained per physician discretion (CEA, CA 19-9, CA 125, etc) if appropriate. 
h.  For cohort A, CT of the chest, abdomen and pelvis will be obtained. For cohort B, CT of the chest, abdomen and 
pelvis as well as MRI of the brain will be obtained if malignancy is a non-CNS primary. For primary brain tumors, 
CT of the chest, abdomen and pelvis not required. 
i.  MMSE to be done at screening for subjects in Cohort B only. These subjects must have a score of < 15. See 
appendix D. 
j. CBCs to be done Days 1 and 22 for Cycles 2 and beyond, for both Cohorts. 
 
 
9. MEASUREMENT OF EFFECT 
Although response is not the primary endpoint of this trial, patients with measurable 
disease will be assessed by standard criteria.  For the purposes of this study, patients 
should be reevaluated every 8 weeks.  For measurement of effect purposes, baseline 
imaging studies are the ones obtained pretreatment. If a patient has a complete 
response, partial response or stable disease, a confirmatory scans will be obtained at 
least 4 weeks following initial documentation of an objective response. Imaging 
evaluations will then return to an every 8 week schedule. All responses will be 
reviewed by the Cancer Center Data Safety and Toxicity Committee. 
 
9.1 
Definitions 
 
Response and progression will be evaluated in this study using the new 
international criteria proposed by the Response Evaluation Criteria in Solid 
Tumors (RECIST) Committee [JNCI 92(3):205-216, 2000].  Changes in only 
the largest diameter (unidimensional measurement) of the tumor lesions are 
used in the RECIST criteria.  Note:  Lesions are either measurable or non-
measurable using the criteria provided below. The term “evaluable” in 
reference to measurability will not be used because it does not provide 
additional meaning or accuracy. 
 
9.1.1 Measurable Disease 
Measurable lesions are defined as those that can be accurately measured 
in at least one dimension (longest diameter to be recorded) as >20 mm 
with conventional techniques (CT, MRI, x-ray) or as >10 mm with spiral 
CT scan.  All tumor measurements must be recorded in millimeters (or 
decimal fractions of centimeters). 
 
9.1.2 Non-measurable Disease 
All other lesions (or sites of disease), including small lesions (longest 
CASE 1Y05 v22 dated 03/18/15 
 27

 
diameter <20 mm with conventional techniques or <10 mm using spiral 
CT scan), are considered non-measurable disease.  Bone lesions, 
leptomeningeal 
disease, 
ascites, 
pleural/pericardial 
effusions, 
lymphangitis cutis/pulmonis, inflammatory breast disease, abdominal 
masses (not followed by CT or MRI), and cystic lesions are all non-
measurable. 
 
9.1.3 Target Lesions 
All measurable lesions up to a maximum of five lesions per organ and 10 
lesions in total, representative of all involved organs, should be identified 
as target lesions and recorded and measured at baseline.  Target lesions 
should be selected on the basis of their size (lesions with the longest 
diameter) and their suitability for accurate repeated measurements (either 
by imaging techniques or clinically).  A sum of the longest diameter (LD) 
for all target lesions will be calculated and reported as the baseline sum 
LD.  The baseline sum LD will be used as reference by which to 
characterize the objective tumor response. 
 
9.1.4 Non-target Lesions 
All other lesions (or sites of disease) should be identified as non-target 
lesions and should also be recorded at baseline.  Non-target lesions 
include measurable lesions that exceed the maximum numbers per organ 
or total of all involved organs as well as non-measurable lesions.  
Measurements of these lesions are not required but the presence or 
absence of each should be noted throughout follow-up.  
9.2  
Guidelines for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a 
ruler or calipers.  All baseline evaluations should be performed as closely as 
possible to the beginning of treatment and never more than 4 weeks before the 
beginning of the treatment. 
 
Note: Tumor lesions that are situated in a previously irradiated area might or  
might not be considered measurable.   
 
The same method of assessment and the same technique should be used to 
characterize each identified and reported lesion at baseline and during follow-
up. Imaging-based evaluation is preferred to evaluation by clinical 
examination when both methods have been used to assess the antitumor effect 
of a treatment. 
 
Clinical lesions.  Clinical lesions will only be considered measurable when 
they are superficial (e.g., skin nodules and palpable lymph nodes).  In the case 
of skin lesions, documentation by color photography, including a ruler to 
CASE 1Y05 v22 dated 03/18/15 
 28

 
estimate the size of the lesion, is recommended.  
 
Chest x-ray.  Lesions on chest x-ray are acceptable as measurable lesions 
when they are clearly defined and surrounded by aerated lung.  However, CT 
is preferable.  
 
Conventional CT and MRI.  These techniques should be performed with 
cuts of 10 mm or less in slice thickness contiguously.  Spiral CT should be 
performed using a 5 mm contiguous reconstruction algorithm.  This applies to 
tumors of the chest, abdomen, and pelvis.  Head and neck tumors and those of 
extremities usually require specific protocols. 
 
Ultrasound (US).  When the primary endpoint of the study is objective 
response evaluation, US should not be used to measure tumor lesions.  It is, 
however, a possible alternative to clinical measurements of superficial 
palpable lymph nodes, subcutaneous lesions, and thyroid nodules.  US might 
also be useful to confirm the complete disappearance of superficial lesions 
usually assessed by clinical examination. 
 
Endoscopy, Laparoscopy.  The utilization of these techniques for objective 
tumor evaluation has not yet been fully and widely validated.  Their uses in 
this specific context require sophisticated equipment and a high level of 
expertise that may only be available in some centers.  Therefore, the 
utilization of such techniques for objective tumor response should be 
restricted to validation purposes in reference centers.  However, such 
techniques can be useful to confirm complete pathological response when 
biopsies are obtained. 
 
Tumor markers.  Tumor markers alone cannot be used to assess response.  If 
markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response.  Specific additional 
criteria for standardized usage of prostate-specific antigen (PSA) and CA-125 
response in support of clinical trials are being developed. 
 
Cytology, Histology.  These techniques can be used to differentiate between 
partial responses (PR) and complete responses (CR) in rare cases (e.g., 
residual lesions in tumor types such as germ cell tumors, where known 
residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that 
appears or worsens during treatment when the measurable tumor has met 
criteria for response or stable disease is mandatory to differentiate between 
response or stable disease (an effusion may be a side effect of the treatment) 
and progressive disease. 
 
 
9.3  
Response Criteria 
 
CASE 1Y05 v22 dated 03/18/15 
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9.3.1 Evaluation of Target Lesions 
 
Complete Response (CR):Disappearance of all target lesions 
 
Partial Response (PR): 
At least a 30% decrease in the sum of 
the longest diameter (LD) of target 
lesions, taking as reference the baseline 
sum LD 
 
Progressive Disease (PD): 
At least a 20% increase in the sum of the 
LD of target lesions, taking as reference 
the smallest sum LD recorded since the 
treatment started or the appearance of 
one or more new lesions 
 
Stable Disease (SD):  
Neither sufficient shrinkage to qualify 
for PR nor sufficient increase to qualify 
for PD, taking as reference the smallest 
sum LD since the treatment started 
 
9.3.2 
Evaluation of Non-target Lesions 
 
 
Complete Response (CR): 
Disappearance of all non-target lesions 
and normalization of tumor marker level 
 
 
 
Incomplete Response/  
  
 
 
Stable Disease (SD):  
 
Persistence of one or more non-target 
lesion(s) or/and maintenance of tumor 
marker level above the normal limits 
 
 
Progressive Disease (PD): 
Appearance of one or more new lesions 
and/or 
unequivocal 
progression 
of 
existing non-target lesions 
 
Although a clear progression of “non-target” lesions only is 
exceptional, in such circumstances, the opinion of the treating 
physician should prevail, and the progression status should be 
confirmed at a later time by the review panel (or study chair). 
Note:  If tumor markers are initially above the upper normal limit, they 
must normalize for a patient to be considered in complete clinical 
response. 
 
 
 
 
9.3.3 Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start 
of the treatment until disease progression/recurrence (taking as 
CASE 1Y05 v22 dated 03/18/15 
 30

 
reference for progressive disease the smallest measurements recorded 
since the treatment started).  The patient's best response assignment 
will depend on the achievement of both measurement and 
confirmation criteria (see section 9.3.1 and 9.4.1). 
 
 
Target Lesions 
 
Non-target Lesions 
 
New Lesions 
 
Overall Response 
 
CR 
 
CR 
 
No 
 
CR 
 
CR 
 
Incomplete 
response/SD 
 
No 
 
PR 
 
PR 
 
Non-PD 
 
No 
 
PR 
 
SD 
 
Non-PD 
 
No 
 
SD 
 
PD 
 
Any 
 
Yes or No 
 
PD 
 
Any 
 
PD 
 
Yes or No 
 
PD 
 
Any 
 
Any 
 
Yes 
 
PD 
 
Note: 
 
 Patients with a global deterioration of health status requiring 
discontinuation of treatment without objective evidence of disease 
progression at that time should be classified as having 
“symptomatic deterioration.”  Every effort should be made to 
document the objective progression, even after discontinuation of 
treatment. 
 
 In some circumstances, it may be difficult to distinguish residual 
disease from normal tissue.  When the evaluation of complete 
response depends on this determination, it is recommended that the 
residual lesion be investigated (fine needle aspirate/biopsy) before 
confirming the complete response status. 
 
9.4  
Confirmatory Measurement/Duration of Response 
 
9.4.1 
Confirmation 
 
To be assigned a status of PR or CR, changes in tumor measurements 
must be confirmed by repeat assessments that should be performed at a 
minimum of 4 weeks after the criteria for response are first met.  In the 
case of SD, confirmatory scans must have met the SD criteria at least 
once at a minimum interval of 4 weeks (see section 9.3.3). 
 
9.4.2 Duration of Overall Response 
 
CASE 1Y05 v22 dated 03/18/15 
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The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first 
recorded) until the first date that recurrent or progressive disease is 
objectively documented (taking as reference for progressive disease 
the smallest measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement 
criteria are first met for CR until the first date that recurrent disease is 
objectively documented. 
 
9.4.3 
Duration of Stable Disease 
 
Stable disease is measured from the start of the treatment until the 
criteria for progression are met, taking as reference the smallest 
measurements recorded since the treatment started.  
 
 
9.5  
 
Evaluation of response in patients with CNS disease (cohort B) 
 
In addition to evaluation of response using RECIST criteria, additional 
analyses will be performed on patients with CNS disease enrolled in 
cohort B. More specifically, contrast-enhanced MRI or CT scans and 
neurological examinations will be used to determine the response to 
therapy.  
 
The following modified definitions of response will be used in the 
additional analyses: 
 
 Complete Response: Complete disappearrance of all tumor on 
MRI/CT scan, off all glucocorticoids with a stable or improving 
neurological examination for a minimum of 4 weeks. 
 
 Partial Response: Greater than or equal to 50% reduction in tumor 
size on MRI/CT scan, on a stable or decreasing dose of 
glucocorticoids, with a stable or improving neurological 
examination for a minimum of 4 weeks. 
 
 Progressive Disease: Progressive neurological abnormalities not 
explained by causes unrelated to tumor progression (e.g. 
anticonvulsant or corticosteroid toxicity, electrolyte abnormalities, 
hyperglycemia, etc.) or a greater than 25% increase in the size of 
the tumor by MRI/CT scan. If neurological status deteriorates, on a 
stable or 
 
 increasing dose of steroids, or if new lesions appear on serial 
MRI/CT, further study treatment will be discontinued. 
 
CASE 1Y05 v22 dated 03/18/15 
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 Stable Disease: A patient whose clinical status and MRI/CT scan 
do not meet the criteria for Complete Response, Partial Response 
or Progressive Disease. 
  
  
10.  
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS 
 
This protocol will adhere to the policies of the Case Comprehensive Cancer Center 
Data and Safety Monitoring Plan in accordance with NCI regulations. 
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  
The following list of AEs (Section 10.1) and the characteristics of an observed AE 
(Section 10.2) will determine whether the event requires expedited reporting in 
addition to routine reporting. 
 
10.1 
Comprehensive Adverse Events and Potential Risks Lists 
 
 
10.1.1 
CAEPR 
 
The Comprehensive Adverse Event and Potential Risks list (CAEPR) 
provides a single, complete list of reported and/or potential adverse events 
(AE) associated with an agent using a uniform presentation of events by body 
system.  
 
In addition to the comprehensive list, a subset, the Agent Specific Adverse 
Event List (ASAEL), appears in a separate column and is identified with bold 
and italicized text.  This subset of AEs (the ASAEL) contains events that are 
considered ‘expected’ for expedited reporting purposes only.  
 
10.1.1.1 Comprehensive Adverse Events and Potential Risks List (CAEPR) 
for Methoxyamine   
 
The Comprehensive Adverse Event and Potential Risks list (CAEPR) was developed to 
provide a single, complete list of reported and/or potential adverse events associated with 
an agent using a uniform presentation of events by body system. The table below 
identifies reported adverse events (AEs) that may be expected to occur with 
Methoxyamine and/or Temozolamide. The subset of AEs that is used to guide expedited 
reporting requirements [i.e., the Agent Specific Adverse Event List (ASAEL)], as 
presented in the right hand column, is identified with bold and italic text. This subset 
contains events that are considered expected and may not need to be reported via 
expedited AE reporting.  
 
 
Category 
(Body 
System) 
 
 
Adverse Events with Possible Relationship to 
Methoxyamine 
(CTCAE v3.0 Term) 
 
 
“Expected” Adverse Events 
(see above) 
 
Likely  
Less Likely 
Rare but Serious 
 
CASE 1Y05 v22 dated 03/18/15 
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(> 20%) 
(≤ 20%) 
(< 3%) 
ALLERGY/IMMUNOLOGY 
 
 
 
Allergic reaction 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
 
 
 
Febrile 
neutropenia 
 
CONSTITUTIONAL SYMPTOMS 
 
 
 
DERMATOLOGY/SKIN 
 
 
 
ENDOCRINE 
 
 
 
GASTROINTESTINAL 
 
 
 
HEMORRHAGE/BLEEDING 
 
 
 
HEPATOBILIARY/PANCREAS 
 
 
 
INFECTION 
 
 
 
METABOLIC/LABORATORY 
 
 
 
NEUROLOGY 
 
 
 
hallucinations 
 
PAIN 
 
 
 
PULMONARY/UPPER RESPIRATORY 
 
 
 
VASCULAR 
 
 
 
 
 
10.2 
Adverse Event Characteristics  
 
 
CTCAE term (AE description) and grade:  The descriptions and 
grading scales found in the revised NCI Common Terminology Criteria 
for Adverse Events (CTCAE) version 3.0 will be utilized for AE 
reporting.  All appropriate treatment areas should have access to a copy of 
the CTCAE version 3.0.  A copy of the CTCAE version 3.0 can be 
downloaded from the CTEP web site (http://ctep.cancer.gov). 
 
 
‘Expectedness’: AEs can be ‘Unexpected’ or ‘Expected’ (see Section X.1 
above) for expedited reporting purposes only.  ‘Expected’ AEs (the 
ASAEL) are bold and italicized in the CAEPR (Section X.1.1). 
 
 
Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
CASE 1Y05 v22 dated 03/18/15 
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10.3 
SERIOUS ADVERSE EVENT (SAE) REPORTING  
 
All adverse clinical experiences, whether observed by the investigator or reported by 
the patient, must be recorded, with details about the duration and intensity of each 
episode, the action taken with respect to the study agent(s), and the patient’s outcome.  
The investigator must evaluate each adverse experience for its relationship to the 
study agents and for its seriousness. 
 
The investigator must evaluate all abnormal laboratory results for their clinical 
significance.  If any abnormal laboratory result is considered clinically significant, the 
investigator must provide details about the action taken with respect to the 
combination of drugs and about the patient’s outcome. 
 
Adverse events will use the descriptions and grading scales found in the revised NCI 
Common Toxicity Criteria (CTC), version 3.0. 
  
Severity Ratings 
 
The investigator will evaluate the severity of each adverse experience using the 
following definitions: 
 
 Mild-noticeable to the patient, does not interfere with the patient’s daily 
activities, usually does not require additional therapy, dose reduction, or 
discontinuation of the study drug. 
 Moderate-interferes with the patient’s daily activities, possibly requires 
additional therapy, but does not require discontinuation of study drug. 
 Severe-severely limits the patient’s daily activities and may require 
discontinuation of the study drug. 
 
Serious, Life-threatening, or Unexpected Adverse Experience (21 CFR 314.80) 
 
 A “serious” adverse event (experience) or reaction is any untoward medical 
occurrence that at any dose: results in death, is life threatening, results in 
persistent, significant and/or permanent disability/incapacity, requires 
inpatient hospitalization or prolongation of existing hospitalization, or is a 
congenital anomaly/birth defect.  A “life-threatening” adverse experience 
places the patient at immediate risk of death in the judgment of the 
investigator. 
 The definition of serious adverse event (experience) also includes important 
medical event. Medical and scientific judgment should be exercised in 
deciding whether expedited reporting is appropriate in other situations, such 
as important medical events that may not be immediately life-threatening or 
result in death or hospitalization but may jeopardize the patient or may require 
intervention to prevent one of the other outcomes listed in the definition 
above. These should also usually be considered serious. Examples of such 
events are intensive treatment in an emergency room or at home for allergic 
CASE 1Y05 v22 dated 03/18/15 
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bronchospasm; blood dyscrasias or convulsions that do not result in 
hospitalization; or development of drug dependency or drug abuse. 
 An “unexpected” adverse experience is one not identified in nature, severity, 
or frequency in the Investigator’s Brochure or the product package insert for 
the study drug. 
 
Relationship to Study Drug 
 
 Probably Related-the experience occurs within a reasonable time period 
following drug administration or follows a known response for the drug and 
cannot be reasonably explained by known patient characteristics (including 
use of concomitant medications). The definition of “related” being that there 
is a reasonable possibility that the drug caused the adverse experience. 
 Unknown Relationship-the etiology of the experience is not known and the 
experience does not occur within a reasonable time period following drug 
administration and does not follow a known response pattern for the drug. 
 Definitely Not Related-the experience is not known to be caused by the study 
drug. 
 
Investigator Reporting Responsibilities 
 
The conduct of the study will comply with all FDA safety reporting requirements. 
 
All adverse experience reports must include the patient number, age, sex, weight, 
severity of reaction (mild, moderate, severe), relationship to study drug (probably 
related, unknown relationship, definitely not related), date and time of administration 
of test medications and all concomitant medications, and medical treatment provided.  
The investigator will record this information on FORM 3500 A (or Medwatch form) 
and will provide reports of adverse experiences on a regular basis during the study 
conduct.  The investigator is responsible for evaluating all adverse events to 
determine whether criteria for “serious” and “unexpected” as defined above are 
present. 
 
Adverse Drug Reaction Reporting 
 
Toxicity will be scored using CTCAE Version 3.0 for toxicity and adverse event 
reporting.  A copy of the CTCAE Version 3.0 can be downloaded from the CTEP 
homepage (http://ctep.info.nih.gov).  All appropriate treatment areas have access to a 
copy of the CTCAE Version 3.0.  All adverse clinical experiences, whether observed 
by the investigator or reported by the patient, must be recorded, with details about 
the duration and intensity of each episode, the action taken with respect to the test 
drug, and the patient's outcome.  The investigator must evaluate each adverse 
experience for its relationship to the test drug and for its seriousness. 
 
The investigator must appraise all abnormal laboratory results for their clinical 
significance.  If any abnormal laboratory result is considered clinically significant, 
CASE 1Y05 v22 dated 03/18/15 
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the investigator must provide details about the action taken with respect to the test 
drug and about the patient's outcome. 
 
Investigator Reporting to the FDA: 
 
Adverse drug reactions should be reported promptly to the Food and Drug 
Administration (FDA) in writing by each investigator/physician engaged in clinical 
research if the type of effect is Serious, Unlisted/unexpected event, and at least 
possibly associated to the drug and has not previously been reported in the 
Investigators brochure, or reference safety information document, or literature.  A 
clear description of the suspected reaction should be provided along with an 
assessment as to whether the event is drug or disease related.   
 
The investigator/physician must also call the FDA as soon as an adverse reaction 
occurs.  The phone number is (301) 594-5778.  A recorder is available after hours.  
Report these reactions to the FDA within ten (10) working days both verbal and 
written. 
 
The address of the Food and Drug Administration is: 
 FDA 
 Division of Oncology  
 HFD-150 
 1451 Rockville Pike 
 Rockville, MD  20852-1448 
 
The phone number of the FDA is (301) 594-5778.  Please ask to speak with Maureen 
Pelosi in the Division of Oncology 
 
10.4 
DATA SAFETY AND MONITORING PLAN 
 
This protocol will adhere to the policies of the Case Comprehensive Cancer Center 
Data and Safety Monitoring Plan in accordance with NCI regulations. The Data and 
Safety Toxicity Committee will review all serious adverse events and toxicity reports 
as well as annual reviews. 
 
 
11.0 
REGULATORY AND DATA REPORTING REQUIREMENTS 
 
Data will also be collected using the Oncore database at the Case 
Comprehensive Cancer Center.  
 
Initial Enrollment Forms – at time of enrollment 
 
Patient History Form– within 2 weeks of enrollment 
 
Lab Form – Weekly during treatment 
CASE 1Y05 v22 dated 03/18/15 
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Course Assessment Form – For each treatment cycle 
 
Physical Assessment, Vital Signs and Toxicity Form – For each treatment 
cycle 
 
Response Form – At the time response is assessed/confirmed 
 
Off Treatment Form – When patient comes off treatment 
 
Survival Form –Patients to be followed annually for survival 
 
 
12. STATISTICAL CONSIDERATIONS 
 
For cohort A, a maximum of 36 patients can theoretically participate on this study, based 
on 6 dose levels with a maximum of 6 patients at each dose level. However, given the 
fact that a 10-fold increase in MX is being tested in 6 consecutive dose escalation levels it 
is highly unlike that the maximum number of patients will need to be enrolled at each 
level. 
 
For cohort B, a maximum of 42 patients can theoretically participate on this study, based 
on 7 dose levels with a maximum of 6 patients at each dose level. However, given the 
fact that a 1.5- fold increase in TMZ and a 10-fold increase in MX is being tested in 7 
dose escalation levels it is highly unlike that the maximum number of patients will need 
to be enrolled at each level. 
 
 
 
The baseline levels (at 0h) of AP sites and DNA strand breaks will be compared to the 
levels at various time points (i.e. 2h, 4h and 122h) after treatment by paired T-test or 
Wilcoxon rank sum test. The predictive value of PK parameters (e.g. AUC, Cmax), levels 
of AP sites and levels of DNA strand breaks on clinical response and grade 3/4 toxicity 
will be examined by logistic regression after adjusting the dose level; their predictive 
value on time to event outcomes, such as disease progression free survival, will be tested 
using (extended) Cox model after controlling other factors including dose level. 
 
CASE 1Y05 v22 dated 03/18/15 
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REFERENCES 
 
1. L Liu, P Taverna, CM Whitacre, S Chatterjee, and SL Gerson. Pharmacologic 
disruption of base excision repair sensitizes mismatch repair-deficient and –proficient 
colon cancer cells to methylating agents. Clin Cancer Res 5:2908-2917, 1999. 
2. L Liu, Y Nakatsuru, and SL Gerson. Base excision repair as a therapeutic target in 
colon cancer. Clin Cancer Res 8:2985-2991, 2002. 
3. L Liu, JR Donze, and SL Gerson. Methoxyamine enhances antitumor efficacy of 
BCNU in colon tumor xenografts. Proc Amer Assoc Cancer Res 43:794 (#3938), 2002. 
4. P Savvides, Yan Xu, Lili Liu, Stanton Gerson. Unexpected prolonged half life of the 
base-exsicion repair inhibitor Methoxyamine (MX) given with Temozolomide(TMZ) in 
the first in human phase 1 clinical trial. Proc Amer Assoc Cancer Res (submitted, full 
abstract included in appendix B ) 
5. Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJ, et al. 
Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma.N Engl J 
Med. 352: 987-96, 2005. 
6. Hegi ME, Diserens AC, Gorlia T, Hamou MF, de Tribolet N, Weller M, et al. MGMT 
gene silencing and benefit from temozolomide in glioblastoma. N Engl J Med. 352:997-
1003, 2005. 
 
CASE 1Y05 v22 dated 03/18/15 
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APPENDIX A 
 
 
Performance Status Criteria 
 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
100 
Normal, no complaints, no evidence 
of disease. 
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
1 
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
2 
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours. 
50 
Requires considerable assistance and 
frequent medical care. 
40 
Disabled, requires special care and 
assistance. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
CASE 1Y05 v22 dated 03/18/15 
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APPENDIX B 
 
Submitted Abstract: 
  
Unexpected prolonged half life of the base-excision repair inhibitor Methoxyamine 
(MX) given with Temozolomide (TMZ) in the first in human phase 1 clinical trial  
 
Author Block: Panos S. Savvides, Yan Xu, Lili Liu, Stanton Gerson. Ireland Cancer Ctr., 
Cleveland, OH, Ireland Cancer Center, Cleveland, OH 
 
Abstract: 
Background: MX is the first base excision repair (BER) inhibitor evaluated in humans. 
MX blocks the BER pathway by covalently binding to apurinic/pymidinic (AP) sites in 
DNA. In several preclinical studies, improved therapeutic efficacy has been demonstrated 
with various chemotherapeutic agents including alkylating agents, such as TMZ. Initial 
results and correlative studies of the first in humans administration of MX are presented. 
 
Methods: This ongoing phase I dose-escalation trial investigates the safety, 
pharmacokinetic (PK) and pharmacodynamic (PD) profile of MX given as an intravenous 
continuous infusion (CI) for 5 days in combination with TMZ given orally for 5 days on a 
28-day cycle. PD markers, including analysis of AP sites measured on DNA extracted 
from patients’ mononuclear cells (PBMCs) as well as DNA strand break determined by 
comet assay at multiple time points during the 5-day treatment with MX and TMZ, are 
included. 
 
Results: 5 patients with metastatic solid tumors have enrolled, 4 at dose-level (DL) 1 
(TMZ 100 mg/m2/day, x5days and MX 15 mg/m2/day, x5days CI) and 1 at DL 2 (TMZ 
150 mg/m2/day, x5days, MX at same dose as in DL 1). Primary tumors include colon 
cancer (n=2), head and neck cancer (n=1), radiation-associated sarcoma (n=1), thymic 
carcinoma (n=1). Treatment has been well tolerated. No treatment-related AEs leading to 
dose reduction, interruption or discontinuation were reported. No grade 3 or higher 
treatment related toxicities or AEs have occurred. Grades 1-2 toxicities observed include: 
nausea, vomiting, fatigue, fever, dyspnea on exertion, anemia, leukopenia, lymphopenia, 
hypophosphatemia, dyspnea on exertion, nystagmus. 
 
PK analyses on samples from the 5 patients included in the study revealed a distinct PK 
profile different from the one observed in rats and dogs, where half-life of MX was 
estimated to be 19 minutes and 4.5 hours respectively. In humans, MX half life is 
estimated to be 45.3 hours (range: 32 - 68.8 hours). 
 
An increase in formation of AP sites over time in cells was detected after patients 
received a single dose of TMZ (100 mg/m2), reaching the highest levels 2 or 4 h after 
TMZ in different patients. 
 
Administration of the combination of TMZ and MX resulted in at least 60% reduction in 
detectable AP sites, due to the binding of MX to AP sites to form MX-bound AP sites. 
CASE 1Y05 v22 dated 03/18/15 
 41

 
Comet assay in PBMCs following treatment with the combination of MX and TMZ 
detected a 1.5 to 3-fold increase of DNA strand breaks compared to single dose of TMZ. 
 
Conclusions: Initial data from the first in humans MX phase I clinical trial demonstrate 
that MX in combination with TMZ is well tolerated. MX has a distinct PK profile in 
humans, corresponding to a 10-fold increase in estimated half-life when compared to the 
half-life observed in dogs. PD demonstration of MX’s biologic activity on patients’ 
mononuclear cells has been demonstrated even at the first dose level.  
 
CASE 1Y05 v22 dated 03/18/15 
 42

 
APPENDIX C 
 
 
Simulation of One-Hour Infusion for a Cmax of 41.40 µg/L 
 
User_Defined_Settings 
PK Model 2  - [Untitled6] 
Simulating data 
 
1 compartment IV-Infusion, no lag time, 1st order elimination 
 
 
 
 C(T)=(D/TI)/V/K10*(EXP(-K10*TSTAR)-EXP(-K10*T)) 
 
Parameter 
Units 
Estimate 
VIF 
Sqrt[VIF]_P_% 
V 
L 
1437.27 
0.13 
0.81 
K10 
1/hr 
0.015315 
0.000000 
2.75 
Worksheet: Non-Transposed Final Parameters 
(20-Jan-2009) 
 
Constant 
Value (mg) 
Number of Doses 
1 
Dose #1 
59.961 
Start Time of Dose #1 
0 
End Time of Dose #1 
1 
Worksheet: Dosing 
(20-Jan-2009) 
 
Time_obs (hr) 
Time (hr) 
Predicted (ug/L) 
VIF 
0 
0.0000 
0.0000 
0.0000 
0.1 
0.1000 
4.1687 
0.0011 
0.2 
0.2000 
8.3310 
0.0045 
0.4 
0.4000 
16.6365 
0.0179 
0.6 
0.6000 
24.9166 
0.0399 
0.8 
0.8000 
33.1713 
0.0703 
1 
1.0000 
41.4008 
0.1091 
1.2 
1.2000 
41.2742 
0.1074 
1.4 
1.4000 
41.1480 
0.1057 
1.6 
1.6000 
41.0222 
0.1041 
1.8 
1.8000 
40.8967 
0.1026 
2 
2.0000 
40.7716 
0.1011 
5 
5.0000 
38.9408 
0.0826 
10 
10.0000 
36.0702 
0.0663 
15 
15.0000 
33.4113 
0.0630 
20 
20.0000 
30.9484 
0.0677 
24 
24.0000 
29.1094 
0.0750 
36 
36.0000 
24.2225 
0.1032 
45.26 
45.2600 
21.0199 
0.1229 
CASE 1Y05 v22 dated 03/18/15 
 43

 
60 
60.0000 
16.7723 
0.1417 
72 
72.0000 
13.9566 
0.1449 
96 
96.0000 
9.6639 
0.1287 
120 
120.0000 
6.6915 
0.0992 
144 
144.0000 
4.6334 
0.0699 
168 
168.0000 
3.2083 
0.0463 
200 
200.0000 
1.9653 
0.0250 
 
 
Parameter 
Units 
Estimate 
VIF 
Sqrt[VIF]_P_% 
AUC 
hr*ug/L 
2724.07573 
4547.78338 
2.48 
K10_HL 
hr 
45.259956 
1.546513 
2.75 
Cmax 
ug/L 
41.400843 
0.109058 
0.80 
CL 
L/hr 
22.011503 
0.000298 
2.48 
AUMC 
hr*hr*ug/L 
179234.144 
85014379.981 
5.14 
MRT 
hr 
65.296315 
3.218864 
2.75 
Vss 
L 
1437.270000 
0.134888 
0.81 
 
 
 
0
5
10
15
20
25
30
35
40
45
0
20
40
60
80
100
120
140
160
180
200
Time (hr)
 
X vs. Predicted Y 
(20-Jan-2009) 
 
 
CASE 1Y05 v22 dated 03/18/15 
 44

 
APPENDIX D 
 
 
CASE 1Y05 v22 dated 03/18/15 
 45

 
 
 
 
 
CASE 1Y05 v22 dated 03/18/15 
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CASE 1Y05 v22 dated 03/18/15 
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CASE 1Y05 v22 dated 03/18/15 
 48