A Phase II Trial of Gemcitabine Plus High-Dose Ascorbate in Locally Advanced Unresectable or Metastatic Soft Tissue and Bone Sarcomas in Adults
Phase: PHASE2
Conditions: Sarcoma, Soft Tissue Sarcoma, Unresectable Soft Tissue Sarcoma, Metastatic Bone Tumor, Bone Sarcoma
Sponsor: Mohammed Milhem, MBBS

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Protocol V7 – 3/13/2019 
 
A Phase II Trial of Gemcitabine plus High-Dose Ascorbate in Locally Advanced 
Unresectable or Metastatic Soft Tissue and Bone Sarcomas in Adults 
 
 
Coordinating Center: 
 
 
Holden Comprehensive Cancer Center and Stead Family 
Children’s Hospital– University of Iowa. 
 
*Principal Investigator: 
      Varun Monga, MBBS  
Clinical Assistant Professor 
Division of Hematology, Oncology, & Blood and 
Marrow Transplantation 
Department of Internal Medicine 
University of Iowa Hospitals and Clinics 
C-32 G GH 
(319) 384-9497 
Fax: (319) 353-8383 
varun-monga@uiowa.edu 
 
Co-Investigators: 
 
Mohammed Milhem, MBBS   
 
Bryan Allen, MD, PhD  
 
Clinical Professor 
 
        
            Clinical Assistant Professor 
 
 
Division of Hematology, Oncology &  
Department of Radiology-Oncology 
Blood and Marrow Transplantation 
 
University of Iowa Hospitals and Clinics 
Department of Internal Medicine 
 
01620 PFP 
University of Iowa Hospitals and Clinics 
(319) 356-3693 
C32 G GH 
 
 
 
 
bryan-allen@uiowa.edu 
 
(319) 356-2324 
mohammed-milhem@uiowa.edu 
 
 
 
 
 
 
 
 
William Terry, MD, MPH 
 
 
 
David Gordon, MD, PhD 
Clinical Assistant Professor 
 
 
 
Assistant Professor 
Division of Hematology, Oncology & 
 
Division of Hematology, Oncology & 
Bone Marrow Transplantation 
 
 
 
Bone Marrow Transplantation 
Department of Pediatrics  
 
 
 
Department of Pediatrics 
University of Iowa Hospitals and Clinics  
University of Iowa Hospitals and Clinics 
BT1328 
 
 
 
3080-G ML 
(319) 356-7048 
 
 
 
(319) 384-5108 
william-terry@uiowa.edu 
 
 
david-j-gordon@uiowa.edu 
 
Protocol Version 7 
3/13/2019 
 
 

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Protocol V7 – 3/13/2019 
 
 
The Principal Investigator and all physicians responsible for patient care must have a current 
FDA Form 1572, Supplemental Investigator Data Form (SIDF), Financial Disclosure Form 
(FDF), and CV on file with the NCI.  Failure to register all appropriate individuals could delay 
protocol approval.  If you are unsure of an investigator's status, please contact the 
Pharmaceutical Management Branch, CTEP at (301) 496-5725 or by e-mail at 
PMBRegPend@ctep.nci.nih.gov.  Please indicate, on the title page, if an Associate Investigator 
is NOT responsible for patient care and therefore does not require a current 1572, SIDF, FDF, 
and CV on file. 
 
 
 
Statistician: 
 
Study Coordinator: 
Sarah Bell, MS  
 
 
 
Michelle Arnold, RN 
Holden Comprehensive Cancer Center   
Holden Comprehensive Cancer Center 
N319 CPHB 
 
 
 
11510 PFP 
(319) 217-0376 
 
 
 
(319) 356-2778 
sarah-mott@uiowa.edu 
 
 
  
michelle-arnold@uiowa.edu  
 
 
 
Study Agent:  High dose ascorbic acid   
Other Agent(s):  Standard chemotherapy with Gemcitabine  
 
Investigational Agent  
IND# 
IND Sponsor  
Ascorbic acid 
137968 
Mohammed Milhem, MD 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1. INTRODUCTION  
 
Disease Background 
1.1
Soft tissue sarcomas (STS) are a heterogeneous group of benign and malignant tumors of 
various supportive tissues arising from the mesoderm. There are 80 known subtypes 
classified by the tissue of origin. Soft tissue sarcomas account for 1% of all human 
malignancies. In contrast to major advances in the biological understanding of these 
heterogeneous subtypes, forward progress in the systemic treatment of sarcoma has been 
painstakingly slow. The prognosis of patients with metastatic or recurrent disease is poor 
and most of them will die from tumor progression. In 2016 an estimated 12,310 new soft 
tissue sarcoma cases will be diagnosed in United States with approximately 4,990 
deaths1. Taking into account differences in histology subtype, anatomic location of 
disease and age at disease onset, the overall median survival for patients with metastatic 
STS is approximately 8 to 12 months2.   
 
1.1.1 Ascorbate as an anti-tumor agent 
 
Ascorbate (ascorbic acid, vitamin C, AscH) is one of the early unorthodox therapies for 
cancer, based on two unsupported hypotheses. McCormick postulated that ascorbate 
protects against cancer by increasing collagen synthesis,3,4 while Cameron hypothesized 
that ascorbate could have anti-cancer action by inhibiting hyaluronidase and thereby 
prevent cancer spread.5 These hypotheses were subsequently promoted by Cameron and 
Pauling.6,7 Cameron and Campbell initially published case reports of 50 patients; some 
seemed to have benefited from high dose ascorbate.8 Cameron and Pauling then 
published results of 100 patients with terminal cancer that were given intravenous 
ascorbate.9 The ascorbate-treated patients were compared to 1000 retrospective controls 
with similar disease. Patients who received ascorbate survived on average 300 days 
longer than controls.7,9 A prospective study was then conducted that randomized patients 
to ascorbate treatment or palliative therapy. Treated patients had a median survival of 343 
days vs. 180 days for controls.10 Smaller studies have also reported benefits of 
ascorbate.11,12 
 
To test “definitively” whether ascorbate was effective, Moertel conducted two 
randomized placebo-controlled studies randomized to oral ascorbate; neither study 
showed benefit.13,14 Subsequently, ascorbate therapy was considered ineffective. 
However, it was not recognized until approximately 15 years later that oral and 
intravenous ascorbate have strikingly different pharmacokinetics.15,16 This difference in 
the administration route is key. Cameron gave patients ascorbate intravenously as well as 
orally, while Moertel’s patients received only oral ascorbate. Thus, the issue of ascorbate 
in cancer treatment needs to be re-examined.  
 
The evidence for use of ascorbate in cancer treatment falls into two categories: clinical 
data on dose concentration relationships and laboratory data describing potential cell 
toxicity with high concentrations of ascorbate in vitro. Clinical data show that when 
ascorbate is given orally, fasting plasma concentrations are tightly controlled at < 100 
µM.17 As doses exceed 200 mg, absorption decreases, urine excretion increases and 
ascorbate bioavailability is reduced.15,17 In contrast, when 1.25 grams of ascorbate are 

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Protocol V7 – 3/13/2019 
 
administered intravenously, concentrations as high as 1 mM are achieved. Some 
clinicians have infused more than 10 grams of ascorbate in cancer patients and achieved 
plasma concentrations of 1 to 5 mM.18 Thus, it is clear that intravenous administration of 
ascorbate can yield very high plasma levels, while oral treatment does not.  
 
Pharmacologic ascorbate concentrations have been shown to selectively kill many cancer 
cell types. Chen et al. measured cell death in 10 cancer and 4 normal cell types using 1-
hour exposures to pharmacological ascorbate.19 Normal cells were unaffected by 20 mM 
ascorbate whereas 5 cancer cell lines had EC50 values of < 4 mM, a concentration 
achievable by intravenous administration. In addition, cell death was independent of 
metal chelators, but dependent on formation of H2O2.20 H2O2 generation was dependent 
on ascorbate concentration, incubation time; [H2O2] displayed a linear increase with 
[AscH] and it increased as a quadratic function of ascorbate radical, ascorbate being an 
electron donor to O2 to form superoxide and, eventually, H2O2.  
 
When ascorbate is infused intravenously the resulting pharmacologic concentration will 
distribute rapidly into the extracellular water space.21 In vivo, Chen and colleagues 
demonstrated that intravenous injection of ascorbate (0.25-0.5 mg/g body weight) increased 
baseline concentrations of ascorbate in the blood and extracellular fluid to > 8 mM as well 
as increased formation of H2O2.22 More recent studies have demonstrated that 
intraperitoneal doses of 4 g/kg ascorbate resulted in blood concentrations of 40 mM; tumor 
extracellular fluid increased to peaks of 20 mM for up to 3 hours.17 Our data demonstrate 
that 
pharmacologic 
doses 
of 
ascorbate are cytotoxic to sarcoma 
cell lines and that it enhances 
chemotherapy sensitivity in vitro 
(Figure 
1). 
Additionally, 
intraperitoneal administration of 
high 
dose 
ascorbate 
in 
combination with gemcitabine and 
ascorbate 
inhibits 
orthotopic 
sarcoma growth and decreases 
tumor size in mice without causing 
an associated toxicity (Figure 2). 
Combined, these studies provide a 
foundation 
for 
pursuing 
pharmacologic ascorbate as a 
prooxidant agent in cancer therapy 
and specifically in sarcoma. 
 
Ascorbate-mediated cell death has 
been shown to be due to H2O2 
generation, via ascorbate radical 
formation, with ascorbate as the 
electron donor.19,20,22 When 
ascorbate is infused intravenously the resulting pharmacologic concentration distributes 
 
Figure 1: Ascorbate Demonstrates Dose-
Dependent Cytotoxicity in Two Sarcoma Cell 
Lines.  Clonogenic Cell survival of HT-1080 
(Fibrosarcoma) 
and 
SW-872 
(synovial 
cell 
sarcoma) cell lines following 1 hour exposure to 
increasing concentrations of ascorbate.  As 
ascorbate concentration increased, clonogenic cell 
survival decreased.   
*

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Protocol V7 – 3/13/2019 
 
 
Figure 2: Pharmacological Ascorbate Sensitizes Sarcoma Cell Lines to Gemcitabine. 
Pharmacological levels of ascorbate enhance sarcoma cell lines, HT-1080 (Fibrosarcoma) 
and SW-872 (Synovial cell sarcoma) sensitivity to gemcitabine chemotherapy. Cell 
survival was determined using the clonogenic cell survival assay. Cell lines were treated 
with ascorbate and gemcitabine for 1h. Clonogenic cell survival was decreased in both cell 
lines when treated with gemcitabine and ascorbate. *p < 0.05 vs. gemcitabine alone. 
rapidly in the extracellular water space.22 Thus, pharmacologic ascorbate concentrations 
in media, as a surrogate for extracellular fluid, should generate ascorbate radical and 
H2O2. In contrast, the same pharmacologic ascorbate concentrations in whole blood 
generate little detectable ascorbate radical and no detectable H2O2.14 This can be 
accounted for by efficient and redundant H2O2 catabolic pathways in whole blood relative 
to those in media or extracellular fluid. Thus, ascorbic acid administered intravenously in 
pharmacologic concentrations may serve as a pro-drug for H2O2 delivery to the 
extracellular milieu, but without H2O2 accumulation in blood.  
 

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Figure 3: Pharmacological Ascorbate Cytotoxicity is Dependent upon H2O2. Sarcoma 
cell lines, HT-1080 (Fibrosarcoma) and SW-872 (Synovial cell sarcoma) were treated with 
combinations of pharmacological doses of ascorbate and catalase.  Catalase reversed the 
toxic effects of ascorbate in sarcoma cell lines demonstrating that ascorbate toxicity is 
dependent upon H2O2.  *p < 0.05 vs. control and catalse alone. 
 
 
Ascorbate Preliminary Data 
1.2
1.2.1 Pre-clinical (in vitro).  
Figure 1 demonstrates that sarcoma cell lines, HT1080 and SW-872, are sensitive to 
increasing doses of pharmacological ascorbate. Cells were treated with increasing doses 
of ascorbate for 1 hour followed by clonogenic cell survival analysis.  Figure 2 shows 
that pharmacological doses of ascorbate enhance the sensitivity of sarcoma cell lines, 
HT1080 and SW-872, to gemcitabine. Cells were treated with ascorbate and gemcitabine 
for one hour. Cell survival was determined by clonogenic cell survival assay. These 
results support the hypothesis that ascorbate enhance standard of care induced cell killing 
of sarcoma cells. Figure 3 shows that ascorbate toxicity in sarcoma cell lines is 
dependent upon the presence of hydrogen peroxide (H2O2).  Cells were treated with 
combinations of catalase and ascorbate.  Catalase, which converts H2O2 into water and 
oxygen, reversed the toxicity of pharmacological doses of ascorbate. Figure 4 shows 
dose response curves for three Ewing’s sarcoma cell lines and a fibroblast cell line treated 
with different concentrations of ascorbate alone for 3 days. The dose response curves 
suggest that ascorbate impairs the growth of Ewing’s sarcoma cells.     
 
 
  
 
 

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Protocol V7 – 3/13/2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 4: Ascorbate impairs the growth of Ewing sarcoma cells. Dose-response curves for 
three Ewing sarcoma cell lines (A673, EW8 and TC71) and a non-transformed fibroblast cell 
line (BJ-fibroblast) treated with different concentrations of ascorbate for three days. Cell 
viability was assessed using the CellTiter-Glo Luminescent Assay.  
 

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Protocol V7 – 3/13/2019 
 
 
Figure 5: Pharmacological Ascorbate Enhances Gemcitabine Therapy in a Mouse 
Model. Sarcoma cell line cells, HT-1080 (Fibrosarcoma), were injected ino the flanks of 
athymic nude mice generating a xenograft.  Mice were treated with combinations of saline 
(control), ascorbate (4g/kg IP), and gemcitabine. Mice treated with the combination of 
gemcitabine and ascorbate (Gem + Asc) had significantly slower tumor growth rates (A) 
and lived significantly longer with a higher cure rate (B) than mice treated with 
gemcitabine alone.   
 
 
1.2.2 Pre-clinical (in vivo) 
To determine if treatment of established sarcoma tumors in a xenograft model with 
ascorbate would inhibit growth, HT-1080 tumor cells (2 x 106) were delivered 
subcutaneously into the flank region of nude mice and allowed to grow until they reached 
3 mm in greatest dimension (~ 10 days), at which time they were randomly assigned to a 
treatment group. This was defined as day 1 of the experiment. The animals were 
randomized to receive either: sham treatment (control), ascorbate (4 g/kg) i.p. given to 
mice every day for two weeks, gemcitabine (100mg/kg) i.p. given once weekly, and 
ascorbate with gemcitabine. Data from Dr. Mark Levine’s laboratory have demonstrated 
that 4 g/kg i.p. ascorbate resulted in blood concentration from baseline of 40 µM to peaks 
of 40 mM while tumor extracellular fluid increased to peaks of 20 mM for up to 3 hours 
[personal communication].15 The primary outcomes of interest were tumor growth over 
time and the potential toxicity of combining gemcitabine, radiation and pharmacological 
ascorbate. Tumor size (mm3) was periodically measured via calipers throughout the 
experiments, resulting in repeated measurements across time for each mouse. Linear 
mixed effects regression models were used to estimate and compare the group-specific 
tumor growth curves. The observed tumor volumes and overall survival for all mice are 
plotted over time in Figure 5 demonstrating that pharmacological ascorbate enhanced 
gemcitabine toxicity slowed tumor growth and prolonging survival in an animal model.   
 
1.2.3 Clinical Trial Data 
In a Phase I trial of intravenous ascorbic acid in patients with advanced malignancy the 
high-dose intravenous ascorbic acid was well tolerated when administered to patients. 
Adverse events and toxicity were minimal at all dose levels. Ascorbic acid concentrations 
reached up to 25 mmol/L in patients who received ascorbic acid of 1.5 g/kg. Of the 24 
patients in the study, only 4 recorded minor adverse events including headache, dizziness 

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Protocol V7 – 3/13/2019 
 
and diarrhea.23  In another phase I trial using pharmacological ascorbate concurrently with 
gemcitabine in patients with locally advanced and metastatic pancreatic cancer conducted 
at University of Iowa Hospitals and Clinics, 9 patients received treatment. Individual doses 
between 50 to 125 g per infusion were given for maintenance of 350 mg/dL level in 
plasma. 75-g dose yielded peak plasma levels ranging between 320 and 630 mg/dL. No 
dose limiting toxicities or serious adverse events were reported.24     
 
 
 
Rationale for the Study 
1.3
 
1.3.1 Gemcitabine and Sarcomas 
Gemcitabine (2',2'-difluorodeoxycytidine, also abbreviated dFdC) is a fluorinated 
analogue of the nucleoside deoxycytidine (dCTP). It is inactive in its parent form and 
requires successive intracellular phosphorylation of the parent drug to yield active di- and 
triphosphate metabolites25. The diphosphate form inhibits ribonucleotide reductase; the 
triphosphate form incorporates into DNA and competes with dCTP as a fraudulent base 
(dFdCTP). The inhibition of ribonucleotide reductase may allow for a self-potentiating 
mechanism to increase nucleotide incorporation in cells26. Once the gemcitabine 
triphosphate metabolite is incorporated into DNA, one additional nucleoside is 
incorporated, after which DNA chain synthesis is terminated. This "masked chain 
termination" leaves the fraudulent base resistant to excision repair by DNA repair 
enzymes, and may overcome an important mechanism of drug resistance27.  
 
Based on M.D. Anderson Cancer Center studies, the recommended phase II dosing for 
solid tumors was 790 mg/m2 per week, weekly for 3 weeks, every 28 days. To render 
gemcitabine more effective, that study suggested that a longer exposure to drug may be 
associated with a greater antitumor effect, by maximizing the amount of gemcitabine that 
can accumulate intracellularly in a given time period. The proposition that prolonged-
infusion gemcitabine (10 mg/m2 per minute) results in higher clinical response rates than 
with bolus infusions was addressed in a randomized phase II trial in pancreatic cancer28. 
Patients were all treated on days 1, 8, and 15, every 28 days. Response rates and median 
survival were superior for the 43 patients who received gemcitabine in a fixed-dose-rate 
infusion (1,500 mg/m2 at 10 mg/m2 per minute), compared with the 49 patients who 
received gemcitabine as a 30-minute bolus infusion (2,200 mg/m2 i.v. over 30 minutes); 
the median survival times were 8 months and 5 months, respectively, p = .013. Of note, 
despite the lower dose and lower concentration of gemcitabine triphosphate at 30 
minutes, the median maximum concentration for gemcitabine triphosphate in peripheral 
blood mononuclear cells was greater than that for the bolus infusion (398 versus 188 µM; 
n = 16 patients assayed; p = .046 for the 150-minute time point)29. Thus, it was logical to 
examine a fixed-dose rate of gemcitabine in patients with sarcomas. The 
pharmacodynamics of gemcitabine in patients with sarcoma was consistent with those 
found in the pancreatic cancer study30. There have been a number of phase II studies in 

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Protocol V7 – 3/13/2019 
 
sarcomas of soft tissue and bone that use gemcitabine as a single agent30-33.  
 
 
 
1.3.2 Combination of ascorbate with chemotherapy  
Metastatic soft tissue and bone sarcoma is associated with poor overall survival. We 
propose to investigate an entirely new approach, using pharmacological ascorbate, 
combined with chemotherapy to treat metastatic sarcoma. Intravenous ascorbate (i.e., 
ascorbic acid, vitamin C), but not oral ascorbate, produces high plasma 
concentrations, which are in the range that can be cytotoxic to tumor cells. Though 
ascorbate has been utilized in cancer therapy, few studies have investigated 
intravenous delivery of ascorbate. Preliminary studies from our group have 
demonstrated that ascorbate induces cytotoxicity in fibrosarcoma cells. Phase I 
clinical trial showed the combination of high dose ascorbate with gemcitabine therapy 
in metastatic and node-positive pancreatic cancer improved the toxicity profile 
associated with this chemotherapy regimen. Proceeding to a phase II clinical trial to 
study efficacy of high dose ascorbic acid in combination with gemcitabine 
chemotherapy in metastatic soft tissue and bone sarcoma patients is a logical next 
step in evaluation. 
 
 
 

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Protocol V7 – 3/13/2019 
 
2. OBJECTIVES 
 
Primary Objective:  Determine initial tumor response per RECIST 1.1 criteria. 
2.1
        
 
 
Secondary Objective 
2.2
2.2.1 Determine the median time to progression for patients with unresectable or metastatic 
soft tissue and bone sarcoma treated with high dose ascorbate when administered intravenously 
concurrently with gemcitabine 
2.2.2 Determine the progression free survival and overall survival of patients with unresectable 
or metastatic soft tissue and bone sarcoma treated with high dose ascorbate when administered 
intravenously concurrently with gemcitabine 
2.2.3  To evaluate the safety and tolerability of this regimen 
 
 
 
3. OVERALL STUDY DESIGN AND SCHEMA 
 
Phase II 
The primary objective of the Phase II portion of this study is to evaluate preliminary evidence of 
anti-tumor activity of intravenous ascorbate in combination with gemcitabine. The primary 
endpoint of interest is objective response rate defined as the percentage of patients with complete 
response (CR) or partial response (PR) per RECIST 1.1. Gemcitabine monotherapy has been 
estimated to confer a 10% response rate in the treatment of metastatic osteogenic bone and 17% 
in soft tissue sarcomas among pediatric patients33,34 and 10% among adults35,36.  
The secondary objectives of this study are to further evaluate the safety and tolerability of this 
regimen, estimate progression-free survival (PFS) and overall survival (OS).  
 
 

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Protocol V7 – 3/13/2019 
 
 
 
 
Legend 
-- Gemcitabine 900 mg/m2 given at a fixed dose rate of 10 mg/m2/min on D1, D8 and D15 to be 
given over 90 min every 28 days 
-- IV Ascorbate 75gm will be given on days 1, 2, 8,9,15 & 16 
-- Patient will be assessed every 2 cycles for progression. Treatment will continue for at least 6 
cycles if no disease progression. Treatment can continue with either concomitant ascorbate or 
gemcitabine or single agent gemcitabine beyond 6 cycles as per investigator    
--Treatment will be terminated with progression of disease 
 
 
 
 
4.  STUDY SUBJECTS 
 
Subject Selection 
4.1
All patients will be obtained from the University of Iowa cancer center patient 
population. Patients must have baseline evaluations performed prior to the first dose of 
study drug and must meet all inclusion and exclusion criteria. Results of all baseline 
evaluations, which assure that all inclusion and exclusion criteria have been satisfied, 
must be reviewed by the Principal Investigator or sub investigator prior to enrollment of 
that patient. In addition, the patient must be thoroughly informed about all aspects of the 
study, including the study visit schedule and required evaluations and all regulatory 
requirements for informed consent. The written informed consent must be obtained from 

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Protocol V7 – 3/13/2019 
 
the patient prior to enrollment. The following criteria apply to all patients enrolled onto 
the study unless otherwise specified. 
 
 
 Inclusion Criteria 
4.2
1. Male or female patients aged ≥ 18 years old 
2. ECOG Performance Status of ≤ 2 
3. Ability to provide written informed consent obtained prior to participation in the 
study and any related procedures being performed 
• Patients must meet the following laboratory criteria:  
• Hematology: 
• Neutrophil count of  >1500/mm3  
• Platelet count of  > 100,000/mm3L 
• Hemoglobin ≥ 9 g/dL (transfusion to meet eligibility allowed) 
• Biochemistry: 
• AST/SGOT and ALT/SGPT ≤ 2.5 x upper limit of normal (ULN) or ≤ 5.0 x 
ULN if the transaminase elevation is due to disease involvement  
• Alkaline phosphatase < 5 x ULN 
• Serum bilirubin ≤ 1.5 x ULN 
• Serum creatinine ≤ 1.5 x ULN or 24-hour creatinine clearance ≥ 50 ml/min 
• Total serum calcium ≥ LLN or if calcium is below LLN then corrected 
calcium for serum albumin should be >/= LLN 
• Serum potassium ≥ LLN  
• Serum sodium ≥ LLN  
• Serum albumin ≥ 3g/dl 
4. Tolerate a 15g ascorbate infusion (screening dose) 
5. Baseline MUGA or ECHO done only in subjects with prior doxorubicin exposure.  
The test must demonstrate LVEF ≥ the lower limit of the institutional normal.  
6. Women of childbearing potential (WOCBP) must have a negative serum pregnancy 
test within 7 days of the first administration of study treatment and must be willing to 
use two methods of contraception one of them being a barrier method during the 
study and for 3 months after last study drug administration 
7. Any patient with the diagnosis of locally advanced, unresectable or metastatic soft 
tissue or bone sarcoma (except GIST and Kaposi’s) from any site. A minimum of 1 
prior chemotherapy regimen, including adjuvant or neo-adjuvant therapy for the 
treatment of sarcoma. Patients eligible for an anthracycline should have received a 
prior anthracycline containing regimen. Patients who decline or are not eligible for 
anthracycline treatment may be considered for this protocol as a first line treatment. 
Patients with a diagnosis of liposarcoma should also have received eribulin if they 
received anthracycline-based therapy prior to eribulin.  Patients with a diagnosis of 
myxoid liposarcoma should have received trabectedin. Patients with angiosarcoma 

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Protocol V7 – 3/13/2019 
 
should have received either taxol or docetaxel.  Patients must have measurable 
disease defined as at least 1 lesion ≥ 1cm in the greatest dimension. 
8. Patients with metastatic bone sarcomas who have failed all available therapies that 
have demonstrated clinical benefit. Available therapies include but not limited to 
methotrexate, adriamycin and cisplatin for osteosarcoma and vincristine, adriamycin 
and Cytoxan, ifosfamide, etoposide (VAC/IE)for Ewing’s sarcoma.  
9. Previous exposure to Gemcitabine will only be allowed if there is no residual toxicity 
from previous treatments. Toxicity must be graded as 0 or 1 prior to study. 
10. Patients must have had disease progression on or following their most recent 
treatment regimen or on presentation for the first time with locally advanced 
unresectable or metastatic disease. 
 
 
Exclusion Criteria  
4.3
1. G6PD (glucose-6-phosphate dehydrogenase) deficiency 
2. New York Heart Association (NYHA) Grade II or greater congestive heart failure 
(see Appendix E) 
3. History of myocardial infarction or unstable angina within 6 months prior to Day 1 
4. History of stroke or transient ischemic attack within 6 months prior to Day 1  
5. Known CNS disease, except for treated brain metastasis: Treated brain metastases are 
defined as having no evidence of progression or hemorrhage after treatment and no 
ongoing requirement for dexamethasone, as ascertained by clinical examination and 
brain imaging (MRI or CT) during the screening period.  Anticonvulsants 
(stable dose) are allowed.  Treatment for brain metastases may include whole brain 
radiotherapy (WBRT), radiosurgery (RS; Gamma Knife, LINAC, or equivalent) or a 
combination as deemed appropriate by the treating physician.  Patients with CNS 
metastases treated by neurosurgical resection or brain biopsy performed within 3 
months prior to Day 1 will be excluded 
6. Actively receiving insulin or requiring fingerstick glucose monitoring at time of 
ascorbate infusion (unless an exception is granted by the IND sponsor, medical 
monitor, and the PI). 
7. Significant  vascular disease (e.g., aortic aneurysm, requiring surgical repair or recent 
peripheral arterial thrombosis) within 6 months prior to Day 1 
8. Evidence of bleeding diathesis or significant coagulopathy (in the absence of 
therapeutic anticoagulation) 
9. Pregnancy (positive pregnancy test) or lactation. Use of effective means of 
contraception (men and women) in subjects of child-bearing potential 
10. Patients who are on the following drugs and cannot have a drug substitution: 
flecainide, methadone, amphetamines, quinidine, and chlorpropamide. High dose 
ascorbic acid may affect urine acidification and, as a result, may affect clearance rates 
of these drugs. 
11. Other concurrent severe and/or uncontrolled medical conditions 
12. Patients who have received chemotherapy or any investigational drug < 2 weeks prior 
to starting study drug or who have not recovered from side effects of such therapy.   

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Protocol V7 – 3/13/2019 
 
13. Major surgical procedure, open biopsy, or significant traumatic injury within 28 days 
prior to Day 1 or anticipation of need for major surgical procedure during the course 
of the study. 
14. Concomitant use of any other anti-cancer therapy or radiation therapy. Palliative 
radiation therapy to non-target lesions is permitted.  
15. Male patients whose sexual partners are WOCBP not using a double method of 
contraception during the study and 3 months after the end of treatment.  One of these 
methods must be a condom.  
16. Patients with a history of another primary malignancy within 2 years other than 
curatively treated CIS of the cervix,  or basal or squamous cell carcinoma of the skin 
17. Patients with known positivity for human immunodeficiency virus (HIV); baseline 
testing for HIV is not required. High-dose ascorbate acid is a known CYP450 3A4 
inducer, which results in lower serum levels of antiretroviral drugs.37 
18. Patients with any significant history of non-compliance to medical regimens or with 
inability to grant a reliable informed consent 
19. Patients with GIST tumors and Kaposi’s Sarcoma are excluded  
20. Patients with history of more than one symptomatic oxalate stone in the last 6 months 
or visible stone in the kidney or ureter on screening CT scan.  
 
5. TREATMENT PLAN (SEE SECTION 3 FOR OVERALL STUDY DESIGN AND 
SCHEMA) 
Once informed consent is obtained: 
• 
Enter subject into the OnCore database of the Holden Comprehensive Cancer Center 
 
for DSMC notification. 
• 
Scan a copy of signed eligibility criteria into OnCore. 
 
• 
 
• 
Scan the G12 into the subject’s medical record. 
 
 
Post-consent Screening Procedures 
5.1
If subjects fail the G6PD or test doses of ascorbate, they are considered a screen failure. 
 
5.1.1 G6PD test (off-site test, so draw immediately). If subject has a prior G6PD test, this can 
be used as G6PD levels do not fluctuate (i.e., there is no window for this test). 
 
5.1.2 Ascorbate initiation (one test dose of ascorbate): Can be given any time through the day 
prior to chemotherapy with one 15-g infusion over 30 minutes. Failure of the 15g test dose is 
defined as any toxicity ≥ CTCAE grade 3 or a significant medical event (in the opinion of the 
principal investigators). 
 
5.1.3 Concomitant Ascorbate (High-dose Ascorbic Acid) Infusions   
 

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Protocol V7 – 3/13/2019 
 
5.1.3.1 
Participant dose. After completing a 15g test dose for screening, subjects will 
receive a 75g dose. Dose modifications are not made for weight or body surface area. 
5.1.3.2 
Administration. Based on subject tolerance; infusion rate should not exceed 500 
mL/hour without consulting with physician. Recommended infusions times are 
provided (Table 1) but may be adjusted for subject comfort. Changes in infusion rates 
should be recorded. 
5.1.3.3 
Order of therapy: Ascorbate is infused prior to gemcitabine 
5.1.3.4 
Schedule. Schedule two times weekly, must be on separate calendar days. (within 7 
sequential days; does not have to be a calendar week) 
5.1.3.5 
Cycle. Concomitant with gemcitabine, 28 day cycle. 
5.1.3.6 
Duration. Subjects will continue with therapy until one of the criterions for removal 
is met (Section 5.5).  Patients with complete response, partial response or stable 
disease will continue for two more cycles of gemcitabine, ascorbate and another CT 
will be done to assess response after every 2 cycles until 6 cycles.  For treatment 
beyond 6 cycles, see section 5.3. 
  
 
Table 1. Recommended Infusion Times for Pharmacological Ascorbate †   
          Ascorbate dose  
           (500 mg / mL) 
Total volume* 
Osmolarity 
(mOsm/L)§ 
Infusion Time 
 
15g (30 mL) 
 
250 mL 
 
681 
 
30 minutes 
 
75g (150 mL) 
 
1000 mL 
 
851.7 
 
120 minutes 
† 
Provided by Drug Information Center at the University of Iowa, July 2011 
*  
Sterile water for injection only. Do not use D5W 
§  
Theoretical calculations provided by Drug Information Center; targeted osmolarity range 
is 500 – 900 mOsm/L 
5.1.4 Chemotherapy (Gemcitabine)  
Gemcitabine is administered following standard fixed dose infusion practice adopted at UIHC. 
See package insert for more details. 
5.1.4.1 Initiation. Within 21 days of signing the consent form 
5.1.4.2 Premedications. UIHC standard of care premedication procedures should be followed 
for chemotherapy administration. Thirty minutes before administering gemcitabine: 
• 
dexamethasone 12 mg orally 
• 
antiemetic  Prochlorperazine 10 mg oral  
5.1.4.3 Dose. 900 mg/m2 (actual body weight) over 90 mins continuous infusion.  
5.1.4.4 Antiemetics. Use Zofran (ondansetron) with caution as this medication may interact with 
high-dose ascorbic acid, resulting in sub-efficacious levels of Zofran. 
5.1.4.5 Order of therapy. Ascorbate is infused prior to Gemcitabine 
5.1.4.6 Duration of therapy – Up to 6 cycles.  Subjects will continue with therapy until one of 
the criterions for removal is met (Section 5.5).  Subjects with complete response, partial response 
or stable disease will continue for two more cycles of gemcitabine, ascorbate and another CT 
will be done to assess response after every 2 cycles until 6 cycles.  For treatment beyond 6 
cycles, see section 5.3.  
5.1.4.6 Dose modifications. Provided in Section 7.2.5 
 
 

Page | 17 
Protocol V7 – 3/13/2019 
 
 
General Concomitant Medication and Supportive Care Guidelines 
5.2
5.2.1 Prophylactic antibiotics for neutropenia: To be considered by the treating physician 
for neutropenia. Ciprofloxacin 500 orally, twice daily, is encouraged if ANC < 500/mm3  
5.2.2 Imaging Contrast. Iodine based imaging contrast should not be administered on the 
same day with ascorbate infusion. If administered within the same day, monitor liver function 
tests and contact the medical monitor for the IND.  
5.2.3 CYP450 3A4 interactions. Review drugs for the potential for interactions. Medically 
monitor subjects receiving a potentially interactive drug.  
5.2.4 Hyperuricemia (gout). Initial dose of colchicine should be 0.6 mg with a subsequent 
dose of 0.3 mg an hour later if the first dose is well-tolerated. Liver function tests (AST / ALT) 
should be monitored. 
5.2.5 Hypertension. Subjects should have blood pressure monitored at the start of each cycle. 
For subjects with documented hypertension, treating physicians should consider subsequent 
monitoring. Hypertensive medication should be initiated or increased for optimal blood pressure 
control according to standard public health guidelines.  
5.2.6 Fluid intake. Subjects will be encouraged to maintain adequate hydration to decrease the 
risk of nephrolithiasis. Those unable to maintain oral hydration should be considered for 
supplemental IV hydration per institutional care guidelines.  
5.2.7 G-CSF products. The use of G-CSF products is allowed on the study per the treating 
physician’s discretion. 
 
 
Duration of Therapy Beyond 6 Cycles 
5.3
In the absence of treatment delays due to adverse event(s), treatment may continue until criteria 
for removal is met (Section 5.4.2and 5.5). If there are delays due to adverse events, continuation 
of the protocol and continued treatment will be determined by the treating medical oncologist 
and IND sponsor.  Subjects whose disease has not progressed while receiving gemcitabine and 
ascorbate and who are tolerating therapy well may continue concomitant treatment with 
gemcitabine and ascorbate on trial beyond 6 cycles. The disease assessment will occur every 2 
cycles. The investigator may choose to continue single agent gemcitabine off trial. Subject will 
be followed for survival for up to 2 years. Single agent ascorbate beyond 6 cycles will not be 
allowed. The ascorbate level and the reactive oxygen species research blood draw levels need not 
be drawn beyond 6 cycles of concomitant therapy.     
 
 
Duration of Follow Up 
5.4
5.4.1 Early termination. Subjects who withdraw or were removed from study prior to 
completing all 6 cycles of concomitant therapy will be followed a minimum of 21 days 
from the final ascorbate infusion. Further follow-up is per investigator discretion. 
5.4.2 Completed therapy. Subjects who complete all six cycles of concomitant therapy will be 
actively followed for 2 years from the end of study-directed therapy.  Follow-up assessments are 
listed in Section 6.3 
5.4.3 The first follow-up appointment will be 21 days ( +/- 10  days) after the last infusion of 
study drug. Follow-up appointments should be scheduled every three months thereafter (±2) 
calendar week). The final study appointment will be the subject’s 2 year follow-up appointment 
(± 1 month). Subjects will be passively followed through chart review for progressive free 
survival and overall survival. 
 

Page | 18 
Protocol V7 – 3/13/2019 
 
 
 Interruption or Discontinuation of Treatment 
5.5
For patients who are unable to tolerate the protocol-specified dosing schedule, dose adjustments 
are permitted in order to keep the patient on study drug. If administration of any drug must be 
interrupted because of unacceptable toxicity, drug dosing will be interrupted or modified 
according to rules described in Section 7.2.5. Toxicity will be assessed using the NIH-NCI 
Common Terminology Criteria for Adverse Events, version 4.0 (CTCAE v4.0).  All interruption 
or changes to study drug administration must be recorded.  
It will be documented whether or not each patient completed the clinical study. If for any patient 
either study treatment or observations were discontinued, the reason will be recorded.  
Reasons that a patient may discontinue treatment are considered to constitute one of the 
following: 
1. Subject’s condition no longer requires study treatment (e.g. satisfactory therapeutic response) 
2. Disease progression 
3. Adverse event(s) 
4. Abnormal laboratory value(s) 
5. Abnormal test procedure result(s) 
6. Protocol violation  
7. Subject withdrew consent  
8. Lost to follow-up 
9. New cancer therapy 
10. Death  
11. Grade ≥ 2 pulmonary or CNS hemorrhage; any Grade 4 hemorrhage 
12. Unwillingness or inability of subject to comply with study requirements 
13. Determination by the investigator that it is no longer safe for the subject to continue therapy 
 
 
 Toxicities and Delays 
5.6
Patients whose treatment is interrupted or permanently discontinued due to an adverse event or 
abnormal laboratory value must be followed until resolution or stabilization of the event, 
whichever comes first.  
If a patient requires a dose delay of > 21 days from the intended day of the next scheduled dose, 
then the patient must be discontinued from the study. If however the patient was clearly 
benefiting from this therapy, the patient may be able to continue treatment with a dose reduction 
at the Investigator discretion, after resolution of the adverse event. All patients will be followed 
for adverse events and serious adverse events for at least 4 weeks following the last dose of any 
drug. Collection of new AEs will end if a new treatment regimen is initiated prior to the EOT 
visit.  Patients will be followed every 3 months for disease status, new or ongoing therapies and 
survival status until death.  This information can be obtained through a clinic visit, phone call or 
email.   
 
 

Page | 19 
Protocol V7 – 3/13/2019 
 
6. VISIT SCHEDULE AND ASSESSMENTS         
 
Visit Schedule 
6.1
Required Data 
 
Screening 
(28 day 
window up 
to day 1 of 
treatment) 
 
Day 1 
of each 
cycle11 
 
 
Day 2 
of 
each 
cycle 
 
Day 8 
of 
each 
cycle 
 
Day 9 
of 
each 
cycle  
Day 
15 of 
each 
cycle 
Day 
16 of 
each 
cycle 
 
End of 
treatment 
21 days from 
last 
treatment(+/- 
7days) 
Follow 
up 
(every 
3 
months 
+/-
2wks)x 
2 years 
Progress Note 
X 
X 
 
X12 
 
 
 
X 
X 
Examination 
X 
X 
 
 
 
 
 
X 
X 
Vital signs1 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Ht2 and Wt 
X 
X 
 
X 
 
 
 
X 
 
BSA 
 
X 
 
 
 
 
 
 
 
Performance 
status 
X 
X 
 
 
 
 
 
X 
X 
Drug Toxicity 
Assessment 
X 
X 
 
X 
 
X 
 
X 
 
CBC, 
differential 
 
X  
X 
 
X 
 
X 
 
X 
X13 
G6PD3 
X 
 
 
 
 
 
 
 
 
Chemistries4 
X  
X 
 
X 
 
X 
 
X 
X13 
Glucose 
X 
X 
 
 
 
 
 
 
 
Serum 
pregnancy5 
X 
 
 
 
 
 
 
 
 
UA 
X  
 
 
 
 
 
 
 
 
LDH 
X  
 
 
 
 
 
 
X 
 
Ascorbate 
level6 
 
X 
X 
 
 
 
 
 
 
Blood for 
ROS7 
X 
 
X 
 
 
 
 
 
X13 
Gemcitabine 
 
X15 
 
X15 
 
X15 
 
 
 
Ascorbate 
infusion 
Test dose 
X 
X 
X 
X 
X 
X 
 
 
CT Chest, 
Abdomen, 
Pelvis8 or MRI 
of lesion9  
X 
Every 
2 
cycles 
 
 
 
 
 
X 
X14 
EKG; MUGA/ 
Echo10 
X 
 
 
 
 
 
 
 
 

Page | 20 
Protocol V7 – 3/13/2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. T,P,R,B/P. Blood pressure should be obtained before and after (≤ 15 min EOI) ascorbate infusion   
2. Ht will only be taken once 
3. G6PD may be obtained at any time prior to test dose as the value does not fluctuate 
4. Chemistries listed in section 6.5.5 in protocol 
5. Serum pregnancy test will be done in all females of child bearing potential; see section 6.5.6 
6. Draw blood specimens ~4cc green top tube Day 1 pre- and Day 2 post- infusion (at 5min and 60 min post) drawn once 
per odd cycles.  Should be stopped after 6 cycles of therapy. 
7. Draw 1 EDTA pink-top tube (5-6 mL) prior to 15 g test dose, D2 post-infusion and put on ice for transport. Should be 
stopped after 6 cycles of therapy except for one collection at first follow up visit. 
8. CT of the chest, abdomen and pelvis with contrast will be done at screening (obtained ≤ 30d from D1) obtain every 2 
cycles (approximately 21 – 28 days after D1). DO NOT schedule on days with ascorbate infusions. Ascorbate and contrast 
are contra-indicated. 
9. If limb primary, subject will need MRI of the lesion; if abdominal/pelvic lesion, a CT scan will suffice. 
10.  MUGA or Echo only obtained if subject has had prior exposure to doxorubicin. 
11. Screening labs are valid up to 7 days prior to day 1 of the treatment cycle 
12. Cycle 1 only 
13. Only collected at follow up #1 
14. CT scan as clinically indicated. 
15. +/- 1 day allowed for gemcitabine infusion  
   
Pre-infusion is defined as any time during the same calendar day prior to infusion. 
BSA calculated at day 1 of each cycle and dose changed for 10% weight change 
 
 
 
 
 
 
 Efficacy Assessments 
6.2
6.2.1 Tumor Response  
Tumor response will be defined using the RECIST 1.1 guidelines as below 
• Complete response is the disappearance of all target lesions;  
• Partial response is a 30% decrease in the sum of the longest dimension (LD) of target 
lesions, relative to baseline measurement;  
• Progressive disease is an increase of 20% or more in the sum of the LD of target lesions;  
• Stable disease is a decrease in tumor size of less than 30% or increase of less than 20%. 
6.2.2 Progression Free Survival 
Time from start of therapy (day 1, cycle 1) to documented disease progression or 
death due to any cause. Progression will be defined using the RECIST 1.1 

Page | 21 
Protocol V7 – 3/13/2019 
 
guidelines.38  
6.2.3 Overall Survival 
Time from start of therapy (day 1, cycle 1) to death.  
6.2.4 Toxicity 
Categorize and quantify adverse events from start of therapy (day 1, cycle 1) to end of 
study 
 
 
Follow up assessments 
6.3
The following assessments should be done at follow-up visits after completion of 
protocol-directed therapy. The first scheduled follow up is 21 days after the last ascorbate 
infusion (+/- 7 days). 
6.3.1 (follow-up #1, only) Blood sample for ROS testing. Draw 5-6 cc in a pink-top tube and  
 
 
put on ice for transport. 
6.3.2 (follow-up #1, only) CBC w/differential 
6.3.3 (follow-up #1, only) Comprehensive metabolic panel. 
6.3.4 If labs were ordered for another clinic visit, and within window, these can be used at the  
 
 
discretion of the medical monitor, sponsor, and investigator. 
6.3.5 Lab information, including CBC w/differential and plasma chemistries, ordered for  
 
 
standard of care or other reasons may be pulled from subsequent follow-up visits or  
 
 
physician’s visits, for the purposes of monitoring treatment effects and lingering adverse  
 
 
events . 
6.3.6 Medical record information will be reviewed for the purposes of monitoring treatment  
 
 
effects and lingering adverse events. 
6.3.7 Follow up CT scans as clinically indicated for standard of care  
 
 
 
End of Treatment Assessments 
6.4
The following assessments should be performed when a criteria for removal is met 
(Section 5.5). An End-of-Treatment (EOT) visit should be scheduled within 21days (+/-7 
days)from last study drug infusion. An existing clinical visit may be used for the EOT 
visit. 
6.4.1 Minimum follow-up. Every effort will be made to follow patients who come off 
treatment for toxicity per the schedule of events. If the subject does not return to clinic, phone 
call contact is acceptable. If phone call contact cannot be made, and the subject does not return a 
phone call, documentation should be made of at least 3 attempts. 
 
 
 
 Safety Assessments 
6.5
Safety assessments will consist of monitoring and recording all adverse events and serious 
adverse events, the regular monitoring of hematology, blood chemistry and urine values, vital 
signs, ECOG performance status, and the regular physical examinations.  
Adverse events will be assessed according to the Common Toxicity Criteria for Adverse Events 
(CTCAE) version 4.03.  CTCAE v4.0 can be accessed on the NIH/NCI website at 
http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf 

Page | 22 
Protocol V7 – 3/13/2019 
 
 
6.5.1 Adverse events 
Information about all adverse events, whether volunteered by the subject, discovered by 
investigator questioning, or detected through physical examination, laboratory test or other 
means, will be collected and recorded and followed as appropriate. Adverse events will be 
collected for 30 days post last dose of drug, or until new therapy is initiated, whichever occurs 
first  
 
An adverse event is the appearance or worsening of any undesirable sign, symptom, or medical 
condition occurring after starting the study drug even if the event is not considered to be related 
to study drug. Medical conditions/diseases present before starting study drug are only considered 
adverse events if they worsen after starting study drug.  All patients will be followed for adverse 
events and serious adverse events for at least 4 weeks following the last dose of study drug.. (For 
Adverse Event Reporting: see Section 9.0 Safety Monitoring) 
  
The occurrence of adverse events should be sought by non-directive questioning of the patient at 
each visit during the study. Adverse events also may be detected when they are volunteered by 
the patient during or between visits or through physical examination, laboratory tests (deemed 
clinically significant or treated), or other assessments. As far as possible, each adverse event 
should be evaluated to determine: 
1. the severity grade (mild, moderate, severe) or (grade 1-4) 
2. its relationship to the study drug(s) (suspected/not suspected) 
3. its duration (start and end dates or if continuing at final exam) 
4. action taken (no action taken; study drug dosage adjusted/temporarily interrupted; study drug 
permanently discontinued due to this adverse event; concomitant medication taken; non-drug 
therapy given; hospitalization/prolonged hospitalization) 
5. whether it constitutes a serious adverse event (SAE) 
All adverse events should be treated appropriately. Such treatment may include changes in study 
drug treatment including possible interruption or discontinuation, starting or stopping 
concomitant treatments, changes in the frequency or nature of assessments, hospitalization, or 
any other medically required intervention. Once an adverse event is detected, it should be 
followed until its resolution (or stabilized), and assessment should be made at each visit (or more 
frequently, if necessary) of any changes in severity, the suspected relationship to the study drug, 
the interventions required to treat it, and the outcome. 
Information about common side effects already known about the investigational drug can be 
found in the [Investigators’ Brochure] or will be communicated between IB updates in the form 
of Investigator Notifications. This information will be included in the patient informed consent 
and should be discussed with the patient during the study as needed. 
 
6.5.2  Serious Adverse Events 
Information about all serious adverse events will be collected and recorded. To ensure patient 
safety each serious adverse event must also be reported to data and safety monitoring committee 
(DSMC) within 24 hours of learning of its occurrence, see section 9.3 for details of reporting. A 
serious adverse event is an undesirable sign, symptom or medical condition which: 

Page | 23 
Protocol V7 – 3/13/2019 
 
• is fatal or life-threatening 
• results in persistent or significant disability/incapacity 
• constitutes a congenital anomaly/birth defect 
• requires inpatient hospitalization or prolongation of existing hospitalization, unless 
hospitalization is for: 
• routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition (specify what this includes) 
• elective or pre-planned treatment for a pre-existing condition that is unrelated to the 
indication under study and has not worsened since the start of study drug 
• treatment on an emergency outpatient basis for an event not fulfilling any of the 
definitions of a SAE given above and not resulting in hospital admission 
• social reasons and respite care in the absence of any deterioration in the patient’s general 
condition is medically significant, i.e., defined as an event that jeopardizes the patient or 
may require medical or surgical intervention to prevent one of the outcomes listed above. 
 
6.5.3 Vital Signs 
Vital sign assessment consists of height (first visit), pulse, blood pressure, respiration rate, 
temperature and weight. . Blood pressure should be obtained before and after (≤ 15 min EOI) 
ascorbate infusion. If the infusion runs for longer than 1 hour, blood pressure assessment should 
be done in the interm as clinically indicated. 
Pre-infusion is defined as any time during the same calendar day prior to infusion. 
Post infusion is ≤ 15 minutes from end of infusion 
 
6.5.4 Physical Examination 
Physical examination will be performed which must comprise a total body examination (general 
appearance, skin, neck, including thyroid, eyes, ears, nose, throat, lungs, heart, abdomen, back, 
lymph nodes, extremities and basic nervous system). 
Significant findings made after the start of study drug which meet the definition of an Adverse 
Event must be recorded. 
 
6.5.5 Laboratory Evaluations 
Laboratory evaluation should be done at baseline (within ≤ 7 days prior to dosing prior to the 
first administration of ascorbate test dose), during the course of the study and at the time of the 
study treatment completion visit. Results must be reviewed prior to administering any agent. 
More frequent examinations may be performed if medically indicated; results should be 
recorded. 
 
Hematology 
Hematology must include hemoglobin, hematocrit, platelets, total white blood cell count (WBC) 
and differential.  

Page | 24 
Protocol V7 – 3/13/2019 
 
Blood Chemistry 
Biochemistry includes the following parameters: BUN, creatinine, calcium, sodium, potassium, 
chloride, CO2 (HCO3), total bilirubin, alkaline phosphatase,  AST/SGOT, ALT/SGPT, GGT.  If 
total bilirubin is greater than the upper limit of normal, direct and indirect bilirubin should be 
performed. Albumin level needed at baseline only  
 
G6PD levels  
Glucose – 6 phosphate dehydrogenase levels will be checked at screening visit. Pt will be 
excluded from the study if he is found to be deficient.    
Urinalysis 
Standard urinalysis assessment (pH, protein, glucose, blood, ketones, and leukocytes) can be 
performed. This must be supplemented with laboratory quantification of any potentially relevant 
abnormalities 
 
6.5.6 Serum Pregnancy Test 
All females of childbearing potential should complete a serum pregnancy test within 7 days prior 
to the administration of the protocol i.e. prior to cycle 1 day 1. Postmenopausal women must 
have been amenorrheic for ≥ 12 months in order to be considered “of non-childbearing 
potential”.  The subjects in this study are being treated for stage IV sarcoma, and are unlikely to 
become pregnant.  The PI will discuss, before the study, the importance of contraceptives with 
woman of child bearing age.  If he considers a subject at risk for become pregnant, he will order 
a pregnancy test during any clinic visit the need presents itself. 
 
6.5.7 Performance Status 
 
Performance status will be assessed 
 
ECOG PERFORMANCE STATUS* 
Grade ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or 
sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about 
more than 50% of waking hours 
3 
Capable of only limited self-care, confined to bed or chair more than 50% of waking hours 
4 
Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair 
5 
Dead 
 
 
* As published in Am. J. Clin. Oncol.: 
Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And 

Page | 25 
Protocol V7 – 3/13/2019 
 
Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982.  
 
 
7.  STUDY MEDICATIONS 
 
Ascorbic Acid Injection, USP; Ascorbate; NDC 67457-118-50 
7.1
7.1.1 Availability. Ascorbic Acid Injection, USP (Bioniche Pharma USA LLC) is a 
commercially available injection available in sterile single-use 50 mL vials containing 25 g of 
ascorbic acid (500 mg/mL). 
7.1.2 Compatibility. Ascorbate is considered a CYP4503A4 inducer.32 Therefore close 
monitoring of subjects who may be concomitantly receiving CYP3A4 substrates with narrow 
therapeutic indexes for toxicities is required. A table of CYP3A4 substrates, inhibitors, and 
inducers is provided in the Appendix. Ascorbate may decrease plasma/blood concentrations of 
substrates (Appendix B, tables 1, 2, and 3). Ascorbate may increase CYP3A4 induction 
(Appendix B, Table 4). Imaging contrast should not be given on the same day as an ascorbate 
infusion. 
7.1.3 Storage and Stability. Unopened vials of Ascorbic Acid for Injection USP are stable 
until the expiration date indicated on the package when stored between 2° – 8°C (36°–46°F). 
Protect from light and store in the carton until time of use. 
7.1.4 Toxicities.  
Diarrhea, nausea and/or vomiting, kidney stones, dry mouth/thirst, headache, abdominal pain, 
fatigue, facial flushing, sweating, weakness, injection site irritation, and faint/dizzy (after rapid 
infusion) have been reported in the literature. When administered on the same day as imaging 
contrast, liver function tests may be elevated. Recommendation is to not schedule imaging with 
contrast on the same day as an ascorbate infusion. 
7.1.5 Ascorbate Dose modifications/delays.  
There are no dose adjustments for toxicities. If an unexpected adverse event is observed, the 
treating physicians may withhold ascorbic acid for up to 1 calendar weeks to determine if the 
effect diminishes or resolves entirely. Considering the nature and severity of the event, if 
reasonable ascorbic acid should then be continued to determine if the event again presents. This 
will function as a test for causality. Due to holidays or inclement weather, doses may be delayed 
by up to one week with physician and PI approval. Reason for treatment delay should be noted in 
the study chart. Missed doses should not be made up. If holding Gemcitabine, then Ascorbate as 
single agent can be given as per discretion of investigator. 
 
 
Gemcitabine 
7.2
Gemzar® (gemcitabine HCl) is a nucleoside analogue that exhibits antitumor activity. 
Gemcitabine HCl is 2´-deoxy-2´,2´-difluorocytidine monohydrochloride (β -isomer). The 
structural formula is as follows: The empirical formula for gemcitabine HCl is 
C9H11F2N3O4•HCl. It has a molecular weight of 299.66. 
7.2.1 Availability  
Gemcitabine HCl is a white to off-white solid. It is soluble in water, slightly soluble in methanol, 
and practically insoluble in ethanol and polar organic solvents. 
The clinical formulation is supplied in a sterile form for intravenous use only. Vials of Gemzar 
contain either 200 mg or 1 g of gemcitabine HCl (expressed as free base) formulated with 
mannitol (200 mg or 1 g, respectively) and sodium acetate (12.5 mg or 62.5 mg, respectively) as 
a sterile lyophilized powder. Hydrochloric acid and/or sodium hydroxide may have been added 
for pH adjustment. 

Page | 26 
Protocol V7 – 3/13/2019 
 
7.2.2 Compatibility. Compatibility with other drugs has not been studied. No incompatibilities 
have been observed with infusion bottles or polyvinyl chloride bags and administration sets 
7.2.3 Storage and stability  
Store at controlled room temperature 20° to 25°C (68° to 77°F). The USP has defined controlled 
room temperature as "A temperature maintained thermostatically that encompasses the usual and 
customary working environment of 20° to 25°C (68° to 77°F); that results in a mean kinetic 
temperature calculated to be not more than 25°C; and that allows for excursions between 15° and 
30°C (59° and 86°F) that are experienced in pharmacies, hospitals, and warehouses." 
7.2.4 Toxicities  
Gemzar® can suppress bone marrow function as manifested by leukopenia, thrombocytopenia, 
and anemia and myelosuppression is usually the dose-limiting toxicity. Pulmonary toxicity has 
been reported. Hemolytic Uremic Syndrome (HUS) and/or renal failure have been reported 
following one or more doses. Renal failure leading to death or requiring dialysis, despite 
discontinuation of therapy, has been reported. The majority of the cases of renal failure leading 
to death were due to HUS. Serious hepatotoxicity, including liver failure and death, has been 
reported in patients receiving Gemzar® alone or in combination with other potentially 
hepatotoxic drugs 
 
7.2.5 Dose Modifications for Gemcitabine 
7.2.5.1 Hematologic toxicity  
Dosage adjustment is based upon the degree of hematologic toxicity experienced by the patient 
on the day of dosing as well as those in the prior cycles (see 7.2.5.2). Patients must have an ANC 
of >1000 and a platelet count of >100,000 on Day 1 of each cycle to begin treatment with 
gemcitabine. On Day 8 and 15 of the chemotherapy cycle the below guidelines will be used.  
Absolute granulocyte 
count 
(x 106/L) 
  
Platelet count 
(x 106/L) 
% of full dose 
≥ 1000 
And 
≥ 100,000 
100 (dose level 0) 
500-999 
Or 
50,000-99,999 
75 (dose level -1) 
< 500 
Or 
< 50,000 
Hold 
Missed doses of gemcitabine are not made up.  
 
Dose levels of gemcitabine as below: 
 
Dose level 0  
900 mg/m2 over 90 min 
Dose level -1 
675 mg/m2 over 67.5 min 
Dose level -2 
500/m2 over 50 mins  
 
Neutropenic fever.  
If a subject experiences grade 3 or 4 neutropenia associated with a febrile event (temperature > 
38.3°C) at any time, the gemcitabine dose will be held until ANC > or = 1000/mm3. When 
restarted, gemcitabine will be reduced 1 dose level. This dose reduction applies to the remainder 
of treatment.   Use of growth factor support is permitted as per discretion of the treating 
physician.  
 

Page | 27 
Protocol V7 – 3/13/2019 
 
7.2.5.2 Thrombocytopenia, bleeding.  
If a subject experiences a clinically significant bleeding episode and/or platelet nadir of < 
25,000/mm3 at any time during therapy, further gemcitabine doses will be held until platelets > 
25,000 and bleeding resolves (see table above). When restarted, gemcitabine will be reduced one 
dose level. This dose reduction applies to the remainder of combination therapy. [significant 
bleeding episode is defined as one requiring a transfusion or other medical intervention to stop 
the bleeding 
 
7.2.6 Non hematologic toxicity  
Nausea and vomiting should be treated aggressively with standard antiemetics. If still 
uncontrolled, follow the table below. This applies to all non-hematologic toxicities.  Dose 
reductions for non- hematologic toxicities with Gemcitabine will be permanent with the following 
exceptions. The investigator will be allowed to dose modify at their discretion for minor AEs or AEs that 
may be corrected by other measures. Examples of minor non-hematological toxicities include alopecia, 
nausea, vomiting, fever without grade IV neutropenia, or metabolic imbalances that may be corrected by 
provision of supportive care (e.g. hypokalemia and provision of potassium). For minor AEs in which the 
patient recovers, the investigator will be allowed to re-escalate. 
 
7.2.6.1 Gemcitabine Dose Modifications for Hepatic Toxicity. The following dose 
adjustments should be made for patients experiencing hepatic toxicity at any time during 
treatment. Hepatic toxicity should be graded using Common Terminology Criteria for Adverse 
Events v4.0 (CTCAE). 
• 
When held for liver toxicity, gemcitabine will be resumed at one dose reduction when the 
toxicity resolves to grade 2 or less. This will be maintained for the remainder of combination 
therapy. 
Toxicity grade 
Gemcitabine 
Ascorbate  
0–2 (& grade 3 nausea/ 
vomiting)  
Continue dose 
Continue treatment 
3 
Decrease one dose 
level 
Continue per discretion of 
investigators 
4 
Hold until toxicity resolves to ≤ grade 2 (≤ grade 3 for nausea 
& vomiting). Decrease 1 dose level for gemcitabine when 
resuming concurrent ascorbate. This dose reduction applies to 
the remainder of concurrent treatment.  
Hepatic toxicity 
(AST or ALT or Bilirubin or ALP) 
Gemcitabine dose level 
Grade 0 – 2 
No change 
Grade 3 
Decrease one dose level* 
Grade 4 
Hold** 
* Patients who have a repeated episode of Grade 3 hepatic toxicity after dose reduction of 
gemcitabine therapy should discontinue gemcitabine. 
** Patients with grade 4 hepatic toxicity should be evaluated for disease progression. If disease 
progression is found, discontinue protocol therapy (gemcitabine and ascorbate). If no disease is 
found resume gemcitabine at one dose level lower than the previous dose when toxicity resolves 
to grade 0 - 2. If toxicity does not resolve to grade 0 - 2 within 4 weeks, discontinue protocol 
therapy. 

Page | 28 
Protocol V7 – 3/13/2019 
 
7.2.6.2 Gemcitabine Dose Modifications for Edema. Edema, not associated with any evidence 
of cardiac, hepatic or renal failure, has been reported in patients receiving gemcitabine. Edema 
should be graded using Common Terminology Criteria for Adverse Events v4.0 (CTCAE). 
When held for edema toxicity, gemcitabine will be resumed at one dose reduction when the 
toxicity resolves to grade 2 or less. This will be maintained for the remainder of combination 
therapy. 
 
 
 
 
 
8. SAFETY MONITORING   
This study will also be monitored by internal oversight specialists at the University of Iowa. The 
Data and Safety Monitoring Plan of the Holden Comprehensive Cancer Center provides 
standard operating procedures to monitor all clinical cancer trials at the UIHC. All investigator-
initiated trials are automatically monitored by the Data and Safety Monitoring Committee 
(DSMC). A detailed data and safety monitoring plan for this study is provided (Appendix C). 
This study has been assigned as a risk level 4 as a physician sponsored IND phase study.  
 
Determination of Reporting Requirements 
8.1
An adverse event (AE) is defined in the CTEP, NCI Guidelines [2005] as “any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom or disease temporally 
associated with the use of a medical treatment or procedure (attribution of unrelated, unlikely, 
possible, probably or definite).” 
 
Adverse event recording. The clinical research team is responsible for identifying, 
8.2
collecting, and recording clinical data, including adverse events, through 30 days after the 
last dose of study drug (ascorbate).  
 
Adverse event grading. Adverse events will be graded according to NCI’s Common 
8.3
Toxicity Criteria (CTCAE v4). Grading may be done by any licensed medical personnel 
(e.g., research nurse, treating physician, etc.) with final determination made by the 
principal investigator. 
 
Adverse event attribution. Initial attribution of ascorbate to a grade 3 or greater event 
8.4
may be assigned by any licensed medical personnel (e.g., research nurse, treating 
physician, etc.). The principal investigator will make the final determination regarding 
the attribution of the study drug to the adverse event and also decide course of action for 
the study participant. CTCAE grade 2 and lesser events do not require attribution unless 
the event is unexpected (i.e., not related to chemotherapy, tumor, or previously diagnosed 
underlying condition). 
 
Routine Adverse Event Reporting Requirements 
8.5
Adverse events attributed to the study drug will be reported to the Data Safety Monitoring 
Committee (DSMC) via the Clinical Research Safety Officer (CRSO) following established 
standard operating procedure of the DSMC.  
Grade of Edema 
Gemcitabine dose level 
1 or 2 
No change 
3 
Decrease one dose level 

Page | 29 
Protocol V7 – 3/13/2019 
 
 
Expedited Adverse Event Reporting 
8.6
Investigators MUST immediately report to the DSMC any serious adverse events (SAE), 
whether or not they are considered related to the investigational agent(s)/intervention (21 CFR 
312.64). Reporting requirements are in Appendix C. 
 
 
 

Page | 30 
Protocol V7 – 3/13/2019 
 
 
9. CORRELATIVE/SPECIAL STUDIES 
Parameters of oxidative stress. Research blood for ROS and ascorbate testing will be 
obtained at each cycle according to the table below: 
• 
 
 The last ROS blood sample will be obtained at the first follow-up visit (protocol section 6.5 
Follow-up Assessments) prior to any therapy that would be administered that day. 
ROS research samples are. 5-6 mL in an EDTA tube (pink top) and placed immediately on 
ice. The basic science RA must be contacted immediately after the blood draw is obtained. 
Samples should be spun to yield plasma using standard procedures as soon as possible. 
Plasma should then be transferred to a cryovial and frozen immediately at -80°C. It is 
imperative that plasma is not thawed until analysis in the Eicosanoid Core Laboratory as F2-
IsoPs can be generated in plasma ex vivo, even at temperatures of -20°C. A minimum of 1 
mL plasma is required for analysis. This research analysis will not be added to the subject’s 
medical record.  
Time point 
ROS 
(pink*)   
pre 
dose 
ROS 
(pink*) 
post 
dose 
Ascorbate 
level 
(green 
top) pre 
dose odd 
cycles 
Ascorbate 
level 
(green 
top) post 
dose 5 
min & 60 
min odd 
cycles 
Test Dose 
x 
  
  
  
C1D1 
  
  
x 
  
C1D2 
  
x 
  
x 
C2D1 
  
  
  
  
C2D2 
  
x 
  
  
C3D1 
  
  
x 
  
C3D2 
  
x 
  
x 
C4D1 
  
  
  
  
C4D2 
  
x 
  
  
C5D1 
  
  
x 
  
C5D2 
  
x 
  
x 
C6D1 
  
  
  
  

Page | 31 
Protocol V7 – 3/13/2019 
 
C6D2 
  
x 
  
  
Follow up #1 
x 
  
  
  
*Pink tubes go on ice  
Ascorbate level:  Draw 4cc green top (sodium heparin) tube. Keep ambient. 
ROS sample: Draw in a 5-6 cc pink top (EDTA) tube. Put on ice for transport. 
For sample pick up email: RadOncLabSamples@healthcare.uiowa.edu   
 
 
10. STATISTICAL CONSIDERATIONS 
 
 
Endpoints 
10.1
• 
Tumor response 
• 
Progression free survival (PFS) 
• 
Overall survival (OS) 
• Safety profile 
 
 
Sample Size & Accrual  
10.2
A response rate of 10% or less is considered to be clinically uninteresting, whereas a 
response rate of at least 30% may warrant further investigation. Sample size requirements 
are based on an optimal Simon two-stage design with 80% power and a significance level 
of 5%. Ten (10) patients will be enrolled in the first stage, and the study will be 
terminated if 1 or fewer respond. Otherwise an additional 19 patients will be enrolled in 
the second stage. If 6 or more of the 29 total patients respond, the treatment will be 
deemed worthy of further investigation.  
 
A total of 29 evaluable patients will be enrolled in this study. The anticipated accrual rate 
is 2 patients per month who would meet inclusion criteria.  
 
 
Statistical Analysis & Reporting 
10.3
The number and severity of all adverse events will be summarized by simple descriptive 
statistics. Objective response rate (CR+PR) point estimates and 95% exact confidence 
intervals will be reported. For PFS (time from first day of study treatment to first 
documented disease progression or death due to any cause) and OS (time from first day 
of study treatment to death due to any cause), survival curves using the Kaplan-Meier 
method will be constructed. Estimates along with 95% confidence intervals will be 
reported.  
 
 
 
 
 
APPENDIX A:  New York Heart Association (NYHA) GUIDELINES 

Page | 32 
Protocol V7 – 3/13/2019 
 
The Stages of Heart Failure – NYHA Classification 
In order to determine the best course of therapy, physicians often assess the stage of heart failure 
according to the New York Heart Association (NYHA) functional classification system. This 
system relates symptoms to everyday activities and the patient's quality of life. 
 
Class 
Patient Symptoms 
Class I (Mild) 
No limitation of physical activity. Ordinary physical activity does not 
cause undue fatigue, palpitation, or dyspnea (shortness of breath). 
Class II (Mild) 
Slight limitation of physical activity. Comfortable at rest, but 
ordinary physical activity results in fatigue, palpitation, or dyspnea. 
Class III 
(Moderate) 
Marked limitation of physical activity. Comfortable at rest, but less 
than ordinary activity causes fatigue, palpitation, or dyspnea. 
Class IV (Severe) 
Unable to carry out any physical activity without discomfort. 
Symptoms of cardiac insufficiency at rest. If any physical activity is 
undertaken, discomfort is increased. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PROTOCOL APPENDIX B: CYP3A4 INTERACTION TABLE 
 

Page | 33 
Protocol V7 – 3/13/2019 
 
CYP3A4 INTERACTION TABLE  
(Ascorbate may decrease the plasma/blood concentrations of substrates) 
Drugs with strikeout text are antiretroviral drugs that are not allowed for use on this study. 
* 3A4 substrate & inhibitor; # 3A4 substrate & inducer 
abiraterone 
acetaminophen 
ado-trastuzumab  
alfentanil 
alfuzosin 
aliskiren 
alitretinoin 
almotriptan 
alprazolam 
ambrisentan 
amiodarone* 
amitriptyline 
amlodipine 
amprenavir 
apixaban 
aprepitant* 
aripiprazole 
armodafinil# 
artemether 
asenapine 
astemizole 
atazanavir* 
atorvastatin 
avanafil 
axitinib 
beclomethasone 
bedaquiline 
benzphetamine 
bexarotene  
bisoprolol 
boceprevir 
bortezomib 
bosentan# 
bosutinib 
brentuximab 
bromazepam 
bromocriptine 
budesonide 
buprenorphine 
buspirone 
busulfan 
cabazitaxel 
cabozantinib 
caffeine 
canagliflozin 
carbamazepine# 
cevimeline 
chlordiazepoxide 
chloroquine 
chlorpheniramine 
ciclesonide  
cilostazol 
cinacalcet 
cisapride  
citalopram 
clarithromycin* 
clindamycin 
clobazam 
clomipramine 
clonazepam 
clopidogrel 
clorazepate 
clozapine 
cobicistat* 
cocaine 
codeine 
colchicine 
conivaptan* 
crizotinib 
cyclobenzaprine 
cyclophosphamide 
cyclosporine* 
dantrolene 
dapsone 
darifenacin 
darunavir 
dasatinib 
delavirdine* 
desogestrel  
dantrolene 
dexamethasone# 
dexlansoprazole 
dextromethorphan 
diazepam 
diclofenac 
dienogest 
dihydroergotamine 
diltiazem* 
disopyramide 
docetaxel 
dofetilide 
dolasetron 
domperidone 
donepezil 
doxorubicin 
dronedarone 
droperidol 
dutasteride 
efavirenz*# 
eletriptan 
elvitegravir 
enzalutamide 
eplerenone 
ergoloids 
ergonovine 
ergotamine 
erlotinib 
erythromycin* 
escitalopram 
esomeprazole 
estazolam 
estradiol 
estradiol valerate 
estrogens 
eszopiclone 
ethinyl estradiol 
ethosuximide 
etonogestrel 
etoposide 
etravirine 
everolimus 
exemestane 
felbamate 
felodipine 
fentanyl 
fesoterodine 
fexofenadine 
finasteride 
fingolimod 
flunisolide 
flurazepam 
flutamide 
fluticasone 
fosamprenavir* 
fosaprepitant 
fulvestrant 
galantamine 
gefitinib 
granisetron 
guanfacine 
haloperidol* 
hydrocodone 
hydrocortisone 
ifosfamide 
iloperidone 
imatinib* 
imipramine 
indacaterol 
indinavir* 
irinotecan 
isosorbide dinitrate 
isosorbide 
mononitrate 
isradipine 
itraconazole* 
ivacaftor 
ixabepilone 
ketamine 
ketoconazole* 
lansoprazole  
lapatinib 

Page | 34 
Protocol V7 – 3/13/2019 
 
CYP3A4 INTERACTION TABLE  
(Ascorbate may decrease the plasma/blood concentrations of substrates) 
Drugs with strikeout text are antiretroviral drugs that are not allowed for use on this study. 
* 3A4 substrate & inhibitor; # 3A4 substrate & inducer 
lercanidipine 
letrozole 
levonorgestrel 
lidocaine* 
linagliptin 
lomitapide 
loperamide  
lopinavir 
loratadine 
losartan 
lovastatin 
lumefantrine 
lurasidone 
maraviroc 
marijuana 
medroxyprogesterone 
mefloquine 
meloxicam 
mestranol 
methadone 
methylergonovine 
methylprednisolone 
miconazole* 
midazolam 
mifepristone 
mirabegron 
mirtazapine 
modafinil 
mometasone 
montelukast 
nateglinide 
nefazodone* 
nelfinavir* 
nevirapine# 
nicardipine* 
nifedipine 
nilotinib 
nimodipine 
nisoldipine 
nitrendipine 
norethindrone 
norgestrel 
nortriptyline 
omeprazole 
ondansetron 
ospemifene 
oxybutynin 
oxycodone 
paclitaxel 
paliperidone 
palonosetron 
pantoprazole 
paricalcitol 
paroxetine 
pazopanib 
perampanel 
perphenazine 
pimozide 
pioglitazone 
pomalidomide 
ponatinib 
prasugrel 
prednisolone 
prednisone  
primaquine 
progesterone/ 
progestins 
propafenone 
propranolol 
quazepam 
quetiapine 
quinidine*  
quinine 
rabeprazole 
ramelteon 
ranolazine 
regorafenib 
repaglinide 
rifabutin# 
rilpivirine 
risperidone 
ritonavir* 
rivaroxaban 
roflumilast 
romidepsin 
ruxolitinib 
salmeterol 
saquinavir* 
saxagliptin 
selegiline 
sertraline 
sibutramine 
sildenafil 
silodosin 
simvastatin 
sirolimus 
sitagliptin 
solifenacin 
sorafenib 
sufentanil 
sunitinib 
tacrolimus 
tadalafil 
tamoxifen 
tamsulosin 
telaprevir 
telithromycin* 
temsirolimus 
teniposide 
terfenadine 
testosterone  
tetracycline* 
theophylline 
tiagabine 
ticagrelor 
ticlopidine 
tinidazole 
tipranavir 
tofacitinib 
tolterodine 
tolvaptan 
topotecan 
toremifene 
tramadol 
trazodone 
triazolam 
trimethoprim 
trimetrexate 
trimipramine 
ulipristal 
vandetanib 
vardenafil 
vemurafenib  
venlafaxine 
verapamil* 
vilazodone 
vinblastine 
vincristine 
vinorelbine 
vismodegib 
voriconazole 
warfarin 
zaleplon 
zileuton 
ziprasidone 
zolpidem 
zonisamide 
zopiclone 
 
 
PROTOCOL APPENDIX C:  Data and Safety Monitoring Plan 
 

Page | 35 
Protocol V7 – 3/13/2019 
 
Type of Clinical Trial: 
        Investigator-initiated (UI/HCCC) 
 Investigator-initiated, participating site 
 Pilot study 
 Phase I 
 Phase I/II 
        Phase II 
 Phase III 
 Compassionate-use/Expanded Access  
       Interventional Treatment 
 Interventional Non-Treatment 
 Non-Interventional 
 
 
Study risk-level:  
 Level 1—low risk of morbidity or death, * <1% of death or any adverse event  
 Level 2—risk of death* <1% or any adverse event 1% – 5%  
 Level 3—risk of death* 1% – 5% or grade 4 – 5 SAE 1% – 5%  
            Level 4—risk of death* >5% or grade 4 – 5 SAE >5%  
 Drugs being used on a “compassionate” basis  
* Risk of death” refers specifically to 100-day treatment-related mortality 
___________________________ 
 
Reporting and Monitoring Requirements:  
All institutional investigator initiated trials (IITs), regardless of assigned risk level are subject to 
routine DSMC monitoring activities which may include but are not limited to review of signed 
consent documents, eligibility and adverse event reporting.  
 
All institutional IITs have the following reporting requirements as part of their DSMP: 
• Provide an annual progress report to the DSMC and PRMC 
• Register subjects in HCCC’s Clinical Trial Management System, OnCore 
• Document Adverse Events  
• Document protocol deviations  
 
 
 
 
Selected monitoring strategy based on risk-level: 

Page | 36 
Protocol V7 – 3/13/2019 
 
 
Risk Level 4 
Interventional treatment trials involving investigational agents or devices with a risk of death* 
(>5% or grade 4 – 5 SAE >5%), e.g. all investigator initiated INDs, most Phase I/II trials, gene 
therapy, gene manipulation or viral vector systems high-risk clinical procedures if performed 
solely for research purposes.  The use of a new chemical or drug for which there is limited or no 
available safety data in humans. 
 
Study Safety Review 
An independent study monitor and/or the DSMC Chair (or designee), will review study data 
(provided by the PI/available in OnCore) and communicate with the PI at least biannually.  A 
copy of this communication will be forwarded to the DSMC and PRMC Chairs.   
 
Additional Reporting Requirements:  
- A scanned copy of the completed eligibility checklist, with screening information and PI 
signature, will be attached in OnCore for ongoing review by DSMC staff.  
- Serious adverse events will be entered directly into an OnCore SAE report by the research 
team.  OnCore will send an automatic notification to the DSMC Chair/acting Chair and staff 
for review.  
- The DSMC utilizes a risk-based monitoring approach.  The trial's research records will be 
monitored at minimum twice per year.  Monitoring may be done more frequently depending 
on the protocol, risks to subjects, reported serious/adverse events, patient population and 
accrual rate.   Records for a minimum of 25% of subjects will be monitored for the entire 
study.    
Monitoring will involve the following: 
• review eligibility of patients accrued to the study, 
• check for the presence of a signed informed consent, 
• determine compliance with protocol’s study plan, 
• determine whether SAEs are being appropriately reported to internal and external 
regulatory agencies,  
• compare accuracy of data in the research record with the primary source documents, 
• review investigational drug processing and documentation, 
• assess cumulative AE/SAE reports for trends and compare to study stopping rules. 
 
 
 
 
 
 
Routine Adverse Event Reporting 
 

Page | 37 
Protocol V7 – 3/13/2019 
 
For non-serious Adverse Events, documentation must begin from the first day of study treatment 
and typically continue through the 30 day follow-up period after the last dose of study drug 
(ascorbate). 
 
Collected information should be recorded in the electronic/Case Report Forms (eCRF/CRF) for 
that subject. A description of the event, its severity or toxicity grade (according to NCI’s 
Common Toxicity Criteria (CTCAE)), onset and resolved dates (if applicable), and the 
relationship to the study drug should be included. Documentation should occur in real time. The 
principal investigator has final responsibility for determining the attribution of the event as it is 
related to the study drug. 
 
 
Serious Adverse Event Reporting 
 
For any experience or condition that meets the definition of a serious adverse event (SAE), 
recording of the event must begin after signing of the informed consent and continue through the 
30 day follow-up period after treatment is discontinued.  
Investigators must report to the DSMC any serious adverse events (SAE), whether or not they 
are considered related to the investigational agent(s)/intervention (21 CFR 312.64). SAEs must 
be reported via an OnCore SAE Report within 24 hours of learning of the event.  
 
 
An adverse event is considered serious if it results in ANY of the following outcomes:   
 
1. Death 
2. A life-threatening adverse event  
3. An adverse event that results in inpatient hospitalization OR prolongation of existing 
hospitalization for ≥ 24 hours  
4. A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions  
5. A congenital anomaly/birth defect.  
6. Important Medical Events (IME) that may not result in death, be life threatening, or 
require hospitalization may be considered serious when, based upon medical judgment, 
they may jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. (FDA, 21 CFR 
312.32; ICH E2A and ICH E6). 
 
 
 
 
FDA Reporting Requirements (for Sponsor-Investigators)  

Page | 38 
Protocol V7 – 3/13/2019 
 
It is the responsibility of the IND sponsor-investigator to comply with IND safety reporting as 
set forth in the Code of Federal Regulations, Section 312.32. This responsibility includes 
providing an annual IND report to the FDA.  
All IND safety reports must be submitted on Form 3500A  and be accompanied by Form 1571. 
The type of report (initial or follow-up) should be checked in the respective boxes on Forms 
3500A and 1571. See Instructions for completing Form 3500A.  Please note all instance of 
UIHC, location, and faculty / staff should be redacted from supporting documentation and the 
3500A. 
The submission must be identified as: 
• 
“IND safety report” for 15-day reports, or 
• 
“7-day IND safety report” for unexpected fatal or life-threatening suspected adverse 
reaction reports, or 
• 
“Follow-up IND safety report” for follow-up information. 
For detailed explanation of the above definitions, requirements, and procedures related to IND 
application safety reports and the responsibilities of IND applications sponsors with regard to 
such reporting, refer to Guidance for Industry and Investigators: Safety Reporting Requirements 
for INDs and BA/BE Studies (PDF - 227KB) 
In addition to completing appropriate patient demographic and suspect medication information, 
the report should include the following information within the Event Description (section 5) of 
the MedWatch 3500A form: 
 
• Treatment regimen (dosing frequency, combination therapy) 
• Protocol description (and number, if assigned) 
• Description of event, severity, treatment, and outcome, if known (grading the event per 
CTCAE) 
• Supportive laboratory results and diagnostics 
• Sponsor-Investigator’s assessment of the relationship of the adverse event to each 
investigational product and suspect medication 
 
Data Monitoring and Management  
All studies that undergo PRMC review and/or utilize HCCC Clinical Research Services (CRS) 
resources are required to register subjects in OnCore. Subject registration includes the following: 
• Consent date and the IRB approved consent used  
• Date of eligibility and eligibility status (eligible, not eligible) 
• On study date and subject’s disease site (and histology if applicable) 
• On treatment date (if applicable)  
Subject Data 
 

Page | 39 
Protocol V7 – 3/13/2019 
 
In addition to the subject registration and subject status data entered in OnCore for all HCCC 
trials, research staff also enters the subject study data into electronic case report forms (eCRFs) 
for HCCC investigator initiated studies. eCRFs are approved by the PI and statistician prior to 
study activation to ensure the most effective data acquisition. All information on eCRFs will be 
traceable to the source documents which are generally maintained in the subject’s file. eCRF 
data are expected to be entered into OnCore within 30 calendar days after a subject’s study visit.  
 
Forms Monitoring 
 
OnCore eCRF data are monitored on a routine basis (dependent on accrual) to ensure all 
mandatory fields are entered completely, accurately and within time requirements. The assigned 
DSMC monitor manages the logistics associated with the data monitoring review. Once the 
clinical trial is identified for monitoring, the monitor arranges for a selection of cases to review 
from among the subjects registered in OnCore.  As part of the forms monitoring process, the 
assigned monitor will issue queries within the eCRF to resolve missing, incomplete and/or 
incorrect information. A member of the research team is expected to respond to monitoring 
queries within 14 business days.  
 
This process can often identify a misunderstanding or deficiency in protocol requirements early 
in the study and can improve data quality.  
 
Final Reports 
 
A summary of each subject’s data record is continually available to the PI, research staff, and 
DSMC from OnCore’s Biostat Console. The availability of this information is a valuable tool for 
the preparation of final reports and manuscripts as well as ongoing deficiency reports. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
References: 
 

Page | 40 
Protocol V7 – 3/13/2019 
 
 
1. 
Siegel RL, Miller KD, Jemal A: Cancer statistics, 2016. CA Cancer J Clin 66:7-
30, 2016 
 
2. 
Riedel RF: Systemic therapy for advanced soft tissue sarcomas: highlighting 
novel therapies and treatment approaches. Cancer 118:1474-85, 2012 
 
3. 
McCormick W: Cancer: the preconditioning factor in pathogenesis. Arch Pediat 
71:313-322, 1954 
 
4. 
McCormick W: Cancer: a collagen disease, secondary to a nutritional deficiency? 
. Arch Pediat 76:166-171, 1959 
 
5. 
Cameron E, Rotman, D: Ascorbic acid, cell proliferation, and cancer. Lancet 
299:542, 1972 
 
6. 
Cameron E, Pauling, L: Ascorbic acid and the glycosaminoglycans. An 
orthomolecular approach to cancer and other diseases. Oncology 27:181-192, 1973 
 
7. 
Cameron E, Pauling, L: Supplemental ascorbate in the supportive treatment of 
cancer: Prolongation of survival times in terminal human cancer. Proc Natl Acad Sci USA 
73:3685-3689, 1976 
 
8. 
Cameron E, Campbell, A: The orthomolecular treatment of cancer. II Clinical trial 
of high-does ascorbic acid supplements in advanced human cancer. Chem Biol Interact 9:285-
315, 1974 
 
9. 
Cameron E, Pauling L: Supplemental ascorbate in the supportive treatment of 
cancer: reevaluation of prolongation of survival times in terminal human cancer. Proceedings of 
the National Academy of Sciences of the United States of America 75:4538-42, 1978 
 
10. 
Cameron E, Campbell, A:: Innovation vs. quality control: an ‘unpublishable’ 
clinical trial of supplemental ascorbate in incurable cancer Med Hypotheses 36:185-189, 1991 
 
11. 
Campbell A, Jack, T, Cameron, E: Reticulum cell sarcoma: two complete 
‘spontaneous’ regressions, in response to high dose ascorbic acid therapy. A report on 
subsequent progress. Oncology 48:495-497, 1991 
 
12. 
Murata A, Morishige, F, Yamaguchi, H: Prolongation of survival times of 
terminal cancer patient by administration of large doses of ascorbate. Int J. Vitam Nutr Res 
Suppl 23:103-113, 1982 
 
13. 
Creagan E, Moertel, CG, O’Fallon, JR, Schutt, AJ, O’Connell, MJ, Rubin, J, 
Frytak, S: Failure of high-dose vitamin C (ascorbic acid) therapy to benefit patients with 
advanced cancer: A controlled trial. N Engl J Med 301:687-690, 1979 
 
14. 
Moertel C, Flemin, TR, Creagan, ET, Rubin, J, O’Connell, MJ, Ames, MM: : 
High-dose vitamin C versus placebo in the treatment of patients with advanced cancer who have 
had no prior chemotherapy. A randomized double-blind comparison. N Engl J Med 312:137-141, 
1985 
 
15. 
Levine M, Conry-Cantilena, C, Wang, Y, Welch, RW, Washko, PW, Dhariwal, 
KR, Park, JB, Lazarev, A, Graumlich, JF, King, J, Cantilena, LR. : Vitamin C Pharmacokinetics 
in healthy volunteers: Evidence for a recommended dietary allowance. Proc Natl Acad Sci USA 
93:3704-3709, 1996 
 
16. 
Padayatty SJ, Levine, M: Reevaluation of vitamin C in cancer treatment: 
emerging evidence, open minds and serendipity. J. Amer. Coll. Nutr. 19:423-425, 2000 
 
17. 
Graumlich J, Ludden, TM, Conry-Cantilena, C, Cantilena, Jr LR, Wang, Y, 
Levine, M: Phamacokinetic model fo ascorbic acid in healthy male volunteers during depletion 
and repletion. Pharm Res 14:1133-1139, 1997 
 
18. 
Riordan N, Riordan, HD, Meng, X, Li, Y, Jackson, JA: Intravenous ascorbate as a 

Page | 41 
Protocol V7 – 3/13/2019 
 
tumor cytotoxic chemotherapeutic agent. Med Hypotheses 44:207-213, 1995 
 
19. 
Chen Q, Espey, MG, Krishna, MC, Mitchel,l JB, Corpe, CP, Buettner, GR, 
Shacter, E, Levine, M. : Pharmacologic ascorbic acid concentrations selectively kill cancer cells: 
Action as a pro-drug to deliver hydrogen peroxide to tissues. Proc Natl Acad Sci USA 
102:13604-13609, 2005 
 
20. 
Chen Q, Espey, MG, Sun, AY, Lee, JH, Krishna, MC, Shacter, E, Choyke, PL, 
Pooput, C, Kirk, KL, Buettner, GR, Levin, M.: Ascorbic acid in pharmacologic concentrations: a 
pro-drug for selective delivery of ascorbate radical and hydrogen peroxide to extracellular fluid 
in vivo Proc Natl Acad Sci USA 104:8749-8754, 2007 
 
21. 
Padayatty S, Sun, H, Wang, Y, Riordan, HD, Hewitt, SM, Katz, A, Wesley, RA, 
Levine, M. : Vitamin C pharmacokinetics: implications for oral and intravenous use. Annals of 
Internal Medicine 140:533-537, 2004 
 
22. 
Chen Q, Sun, AY, Espey, MG, Levine, M: Ascorbic acid as a pro-oxidant 
therapeutic agent in cancer. Free Radical Biology and Medicine 43:S52, 2007 
 
23. 
Hoffer LJ, Levine M, Assouline S, et al: Phase I clinical trial of i.v. ascorbic acid 
in advanced malignancy. Annals of oncology : official journal of the European Society for 
Medical Oncology / ESMO 19:1969-74, 2008 
 
24. 
Welsh JL, Wagner BA, van't Erve TJ, et al: Pharmacological ascorbate with 
gemcitabine for the control of metastatic and node-positive pancreatic cancer (PACMAN): 
results from a phase I clinical trial. Cancer Chemother Pharmacol 71:765-75, 2013 
 
25. 
Heinemann V, Hertel LW, Grindey GB, et al: Comparison of the cellular 
pharmacokinetics and toxicity of 2',2'-difluorodeoxycytidine and 1-beta-D-
arabinofuranosylcytosine. Cancer Res 48:4024-31, 1988 
 
26. 
Iwasaki H, Huang P, Keating MJ, et al: Differential incorporation of ara-C, 
gemcitabine, and fludarabine into replicating and repairing DNA in proliferating human 
leukemia cells. Blood 90:270-8, 1997 
 
27. 
Gandhi V, Legha J, Chen F, et al: Excision of 2',2'-difluorodeoxycytidine 
(gemcitabine) monophosphate residues from DNA. Cancer Res 56:4453-9, 1996 
 
28. 
Abbruzzese JL, Grunewald R, Weeks EA, et al: A phase I clinical, plasma, and 
cellular pharmacology study of gemcitabine. J Clin Oncol 9:491-8, 1991 
 
29. 
Tempero M, Plunkett W, Ruiz Van Haperen V, et al: Randomized phase II 
comparison of dose-intense gemcitabine: thirty-minute infusion and fixed dose rate infusion in 
patients with pancreatic adenocarcinoma. J Clin Oncol 21:3402-8, 2003 
 
30. 
Patel SR, Gandhi V, Jenkins J, et al: Phase II clinical investigation of gemcitabine 
in advanced soft tissue sarcomas and window evaluation of dose rate on gemcitabine 
triphosphate accumulation. J Clin Oncol 19:3483-9, 2001 
 
31. 
Merimsky O, Meller I, Kollender Y, et al: Palliative effect of gemcitabine in 
osteosarcoma resistant to standard chemotherapy. Eur J Cancer 34:1296-7, 1998 
 
32. 
Amodio A, Carpano S, Manfredi C, et al: [Gemcitabine in advanced stage soft 
tissue sarcoma: a phase II study]. Clin Ter 150:17-20, 1999 
 
33. 
Wagner-Bohn A, Paulussen M, Vieira Pinheiro JP, et al: Phase II study of 
gemcitabine in children with solid tumors of mesenchymal and embryonic origin. Anticancer 
Drugs 17:859-64, 2006 
 
34. 
Weitman S, Ochoa S, Sullivan J, et al: Pediatric phase II cancer chemotherapy 
trials: a Pediatric Oncology Group study. J Pediatr Hematol Oncol 19:187-91, 1997 
 
35. 
Maki RG, Wathen JK, Patel SR, et al: Randomized phase II study of gemcitabine 

Page | 42 
Protocol V7 – 3/13/2019 
 
and docetaxel compared with gemcitabine alone in patients with metastatic soft tissue sarcomas: 
results of sarcoma alliance for research through collaboration study 002 [corrected]. J Clin Oncol 
25:2755-63, 2007 
 
36. 
Bauer S, Seeber S, Schutte J: Gemcitabine in the treatment of soft tissue 
sarcomas. Onkologie 27:180-6, 2004 
 
37. 
van Heeswijk RP, Cooper CL, Foster BC, et al: Effect of high-dose vitamin C on 
hepatic cytochrome P450 3A4 activity. Pharmacotherapy 25:1725-8, 2005 
 
38. 
Eisenhauer EA, Therasse P, Bogaerts J, et al: New response evaluation criteria in 
solid tumours: revised RECIST guideline (version 1.1). European Journal of Cancer 45:228-47, 
2009