Phase II Study Of Oral PHA-848125AC In Patients With Malignant Thymoma Previously Treated With Multiple Lines Of Chemotherapy
Phase: PHASE2
Conditions: Malignant Thymoma
Sponsor: Tiziana Life Sciences LTD

Milciclib Maleate (PHA-848125AC) 
CDKO-125a-007-P5 
Protocol for Study CDKO-125a-007 Version No. 6 
09 March 2017 
 
 
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PHASE II STUDY OF ORAL PHA-848125AC IN PATIENTS 
WITH MALIGNANT THYMOMA PREVIOUSLY TREATED 
WITH MULTIPLE LINES OF CHEMOTHERAPY 
Sponsor: 
Tiziana Life Sciences, PLC 
Therapeutic Area: 
Oncology 
Substance Identifier: 
Milciclib maleate (PHA-848125AC) 
 
Protocol Number: 
CDKO-125a-007 
EudraCT Number: 
Not applicable 
IND Number: 
73,819 
Status: 
Final 
Protocol Version Number : 
6 
Included Amendment information as per: 
 
Amendment No. 
5 
Date 
09 March 2017  
Country(ies) 
All 
Site(s) 
All 
Amendment No. 
1 
2 
3 
4 
Date 
13 September 2011 
13 December 2011 
30 July 2012 
24 January 2013 
Country(ies) 
All 
Site(s) 
All 
 
This document contains confidential information belonging to the Sponsor. Except as may be 
otherwise agreed to in writing, by accepting or reviewing these materials, you agree to hold such 
information in confidence and not to disclose it to others (except where required by applicable 
law), nor to use it for unauthorized purposes. In the event of actual or suspected breach of this 
obligation, the Sponsor and CLIOSS should be promptly notified. 
 

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SIGNATURES 
 
 
 
 
Yaron Ilan, MD - Chief Medical Officer 
Date 
Tiziana Life Sciences, PLC 
& 
Director of the Department of Medicine 
Hebrew University Hadassah Medical Center 
91120 Jerusalem, Israel  
 
 
 
 
 
 
Patrizia Crivori, Chem. Pharm. D, PhD 
Date 
Head of Statistics  
CLInical Organization for Strategies and Solutions (CLIOSS) S.r.l. 
Viale Pasteur, 10 
Nerviano, Milan, Italy 
 
 
 
 
 
<First name Last name, Academic Title> , Principal Investigator 
Date 
<Department> , <Division (or corresponding)>  
<Company (legal name)> , <Place, Country>  
 
 
 
 

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TABLE OF CONTENTS 
1. SUMMARY ...........................................................................................................................8 
2. ABBREVIATIONS AND DEFINITIONS OF TERMS ......................................................20 
3. BACKGROUND INFORMATION AND STUDY RATIONALE .....................................23 
3.1. Thymic Carcinoma .........................................................................................................23 
3.2. PHA-848125AC .............................................................................................................25 
3.2.1. Description ...............................................................................................................25 
3.2.2. Pharmacology ..........................................................................................................25 
3.2.3. Safety Pharmacology ...............................................................................................27 
3.2.4. Nonclinical Pharmacokinetics .................................................................................27 
3.2.5. Toxicology ...............................................................................................................29 
3.2.6. Drug-Drug Interactions ............................................................................................30 
3.2.7. Phase I clinical trials ................................................................................................31 
3.2.8. Pharmacokinetics in Humans ...................................................................................33 
3.3. Rationale for the use of PHA-848125AC in Thymic Carcinoma ..................................37 
4. TRIAL OBJECTIVES AND ENDPOINTS .........................................................................37 
4.1. Objectives ......................................................................................................................37 
4.1.1. Primary Objective ....................................................................................................37 
4.1.2. Secondary Objectives ..............................................................................................38 
4.1.3. Exploratory Objective ..............................................................................................38 
4.2. Endpoints .......................................................................................................................38 
4.2.1. Primary Endpoint .....................................................................................................38 
4.2.2. Secondary Endpoints ...............................................................................................38 
4.2.3. Exploratory Endpoint ...............................................................................................39 
5. TRIAL DESIGN AND DESIGN RATIONALE .................................................................39 
6. SUBJECT SELECTION ......................................................................................................40 
6.1. Subject Inclusion Criteria ..............................................................................................40 
6.2. Subject Exclusion Criteria .............................................................................................42 
7. SCHEDULE OF EVENTS ...................................................................................................44 
8. ENROLLMENT PROCEDURES ........................................................................................47 

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9. TREATMENT ......................................................................................................................47 
9.1. Trial Products .................................................................................................................47 
9.1.1. Description ...............................................................................................................47 
9.1.2. Drug Preparation/Administration/Dispensing .........................................................48 
9.1.3. Patient Education & Information .............................................................................49 
9.2. Procedure for Handling Drug Spills ..............................................................................50 
9.3. Storage and Stability ......................................................................................................50 
9.3.1. Source of Drug .........................................................................................................50 
9.3.2. Drug Accountability ................................................................................................50 
9.4. Treatment Administration ..............................................................................................51 
9.4.1. Treatment Dose and Schedule .................................................................................51 
9.4.2. Duration of Treatment..............................................................................................51 
9.4.3. Dose Modifications ..................................................................................................52 
9.4.4. Retreatment and Dose Delay ...................................................................................55 
9.4.5. Overdose Instructions ..............................................................................................55 
9.4.6. Unblinding ...............................................................................................................55 
9.4.7. Assessment and Management of Potential CNS Toxicity .......................................55 
9.4.8. Assessment of Potential Ocular Toxicity .................................................................56 
9.4.9. Assessment of Potential Thrombotic Microangiopathy/Hemolytic Uremic 
Syndrome ...........................................................................................................................57 
9.4.10. Concomitant Medications and Other Therapy .......................................................58 
9.4.10.1. Antiemetics ......................................................................................................58 
9.4.10.2. Antidiarrheals ..................................................................................................58 
9.4.10.3. Antiacids ..........................................................................................................59 
9.4.10.4. Hematopoietic Growth Factors ........................................................................59 
9.4.10.5. Anticoagulants .................................................................................................59 
9.4.10.6. Inhibitors or Inducers of CYP3A4...................................................................59 
9.4.10.7. Steroids ............................................................................................................59 
9.4.10.8. Other Permitted Concomitant Medications .....................................................59 
9.4.10.9. Concomitant Radiotherapy ..............................................................................60 
9.4.10.10. Other Anticancer or Experimental Therapy ..................................................60 

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9.5. Management of Patients after Cut-Off Date ..................................................................60 
10. SUBJECT WITHDRAWAL FROM STUDY PARTICIPATION ....................................60 
11. ASSESSMENTS ................................................................................................................61 
11.1. Timing of Assessments ................................................................................................61 
11.2. Efficacy Assessments ...................................................................................................61 
11.2.1. Tumor Imaging ......................................................................................................61 
11.2.1.1. Measurability of Tumor Lesions .....................................................................62 
11.2.1.2. Recording Tumor Measurements ....................................................................63 
11.2.1.3. Target Lesions Tumor Response .....................................................................64 
11.2.1.4. Non Target Lesions Tumor Response .............................................................65 
11.2.1.5. Confirmation of Tumor Response ...................................................................66 
11.2.1.6. Determination of Overall Response by RECIST (version 1.1) .......................66 
11.3. Outcomes Research Assessments ................................................................................67 
11.4. Safety Assessments ......................................................................................................67 
11.4.1. Adverse Event Assessment ....................................................................................67 
11.4.1.1. Definition of Adverse Events ..........................................................................67 
11.4.1.2. Eliciting Adverse Event Information ...............................................................69 
11.4.1.3. Adverse Event Reporting Period .....................................................................69 
11.4.1.4. Reporting Requirements ..................................................................................70 
11.4.1.5. Recording Adverse Events in the Case Report Forms ....................................71 
11.4.1.6. Grading of Adverse Event Severity .................................................................72 
11.4.1.7. Exposure In Utero ............................................................................................73 
11.4.2. Laboratory Safety Assessments .............................................................................74 
11.4.3. Other Safety Assessments ......................................................................................75 
11.5. Other Assessments .......................................................................................................77 
11.5.1. Confirmation of histological diagnosis ..................................................................77 
11.5.2. Pharmacokinetics ...................................................................................................77 
11.5.3. Laboratory Exploratory Studies on Tumor Specimens ..........................................77 
11.5.3.1. Collection of Tumor Specimen(s) ...................................................................77 
11.5.3.2. Evaluation of Tumor Molecular Features ........................................................77 

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12. STATISTICAL METHODS ..............................................................................................77 
12.1. Sample Size Calculation ..............................................................................................77 
12.2. Definition of Analyzed Study Populations ..................................................................78 
12.3. Analyses .......................................................................................................................79 
12.3.1. Study Conduct and Subject Disposition ................................................................79 
12.3.2. Baseline Characteristics .........................................................................................79 
12.3.3. Treatment Administration/Compliance .................................................................79 
12.3.4. Efficacy Analyses ..................................................................................................80 
12.3.5. Outcomes Research Analyses ................................................................................81 
12.3.6. Safety Analyses ......................................................................................................81 
12.3.7. Analyses of Other Endpoints .................................................................................82 
12.3.7.1. Molecular Markers in Tumor Biopsies ............................................................82 
12.3.7.2. Pharmacokinetics .............................................................................................82 
12.3.7.3. Concomitant Medications and Post-Treatment Anti-tumor Therapies ...........82 
12.4. Interim Analysis Plan ...................................................................................................82 
12.5. Data Monitoring Committee ........................................................................................82 
13. END OF STUDY ...............................................................................................................82 
14. QUALITY CONTROL AND QUALITY ASSURANCE .................................................83 
15. DATA HANDLING AND RECORD KEEPING ..............................................................83 
15.1. Case Report Forms .......................................................................................................83 
15.2. Record Retention .........................................................................................................84 
16. ETHICS ..............................................................................................................................84 
16.1. Institutional Review Board (IRB)/Independent Ethics Committee (IEC) ...................84 
16.2. Ethical Conduct of the Trial .........................................................................................84 
16.3. Subject Information and Consent ................................................................................84 
17. SPONSOR DISCONTINUATION CRITERIA .................................................................85 
18. DISSEMINATION AND PUBLICATION OF RESULTS ...............................................85 
19. REFERENCES ...................................................................................................................86 
 

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TABLES 
Table 1. PHA-848125AC pharmacokinetic data from CDKO-125a-001 study ....................35 
Table 2. PHA-848125AC pharmacokinetic data from CDKO-125a-002 study ....................36 
Table 3. PHA-848125AC pharmacokinetic data from CDKO-125a-003 study ....................36 
Table 4. Criteria for PHA-848125AC Dose Modifications...................................................53 
Table 5. Drug-induced Tremors and Corresponding Neurologic Signs ................................56 
Table 6. Response Criteria ....................................................................................................66 
Table 7. Reporting requirements for adverse events .............................................................71 
Table 8. Grading of Adverse Event Severity for Events not reported in the CTCAE Version 
3.0 .............................................................................................................................72 
 
APPENDICES 
Appendix 1. Recommended Informed Consent Form ..........................................................90 
Appendix 2. The Distribution of Active Bone Marrow in the Adult ..................................100 
 

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1. SUMMARY 
Name of Company: Tiziana Life Sciences, PLC  
Name of Finished Product: PHA-848125AC (Milciclib maleate) 
Title of Study: PHASE II STUDY OF ORAL PHA-848125AC IN PATIENTS WITH MALIGNANT 
THYMOMA PREVIOUSLY TREATED WITH MULTIPLE LINES OF CHEMOTHERAPY 
Protocol Number: CDKO-125a-007 
Therapeutic Area: Oncology 
Background Information 
Thymic malignancies are rare tumors with an overall incidence in US (1973-1998) of 0.15 per 100000 
person/year; clinical behavior ranges from relatively indolent thymomas to highly aggressive among thymic 
carcinomas [1-2]. Patients with locally advanced or disseminated thymic malignancies are usually 
symptomatic, presenting with chest pain, shortness of breath, paralysis of the phrenic nerve, pleural effusion 
and superior vena cava syndrome. Immune disorders have also been associated with thymoma, the most 
common being myasthenia gravis [3]. In recent years, a few studies on molecular changes in thymomas and 
thymic carcinomas have been published. In particular, the expression of KIT and epidermal growth factor 
receptor (EGFR), targets, respectively, of imatinib and EGFR inhibitors (ie, erlotinib, gefitinib), have been 
tested by immunohistochemistry in a limited number of thymic malignancies: KIT was positive in 73% of 
thymic carcinomas and 5% of thymomas, in contrast, EGFR expression was more often present in thymomas 
(83%) than in thymic carcinomas (50%) [4]. Another study investigated HER2/neu amplification and 
expression of the apoptosis-related markers p53, BCL-2, BAX, BCL-XL, and p21 [5]; p53 and Bcl-2 were 
definitely more expressed in thymic carcinomas than thymomas and correlated with more advanced stages 
and unresectability, whereas no HER2/neu amplification was observed. Other markers, such as expression of 
thymidylate synthase and dihydropyrimidine dehydrogenase, which predict sensitivity to 5-fluorouracil-
based chemotherapy, were not correlated with clinicopathological characteristics in a series of thymic 
malignancies [6].  
The loss of control of cell cycle checkpoints seems a common occurrence in thymomas, supporting the idea 
that functional cooperation between different cell cycle inhibitor proteins regulates cell growth control and 
tumor suppression. Univariate analyses on the expression of p21 and p27 in specimens from 25 encapsulated 
thymomas (using immunohistochemistry) suggest that negative expressions of p21 and p27 (natural 
inhibitors of CDKs) significantly correlates with poor prognosis for disease-free survival [7]. In addition, 
some members of the neurotrophin receptors family seem to play a significant role in this disease: in a study 
investigating the expression of neurotrophin receptors in thymic epithelial tumors on a quite large series of 
patients (N=99) [8], the pattern of TRKA expression was analyzed according to WHO classification for the 
histologic subtypes (A, AB, B1, B2, B3, C). All patients, except one, had immunostaining for TRKA 
expression in the tumors gradually increasing from type A to C. Conversely, none of the tumors showed 
TRKB or TRKC immunoreactivity. In addition, from type A to type C, there was a decreasing percentage of 
tumors with p75 immunostaining. These observations suggest a further elucidation on the specific role of 
TRKA and p75 in this disease: the  Medical Oncology Branch/CCR laboratory at NCI has analyzed 60 
paraffin-embedded biopsies from patients diagnosed with thymoma and thymic carcinoma, founding 
amplification of TRKA in 45% of analyzed samples and 72% of thymic carcinomas [Giaccone G., personal 
communication]; these findings were confirmed by RT-PCR and FISH. The same laboratory demonstrated by 
immunohistochemistry the presence of IGF-1R in resected tumors from patients with thymic malignancies, 
with a higher degree of expression noted in thymic carcinoma [Giaccone G., Cancer, in press]. 
Besides the above mentioned WHO histological classification of thymoma, the Masaoka staging system is 
commonly employed to evaluate invasiveness and to determine the therapy, since the optimal treatment for 
this disease depends on its clinical stage [1]. Locally advanced or metastatic thymomas are often treated with 
combined treatment modalities, including surgery, radiation and chemotherapy. There are no drugs officially 

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Name of Company: Tiziana Life Sciences, PLC  
Name of Finished Product: PHA-848125AC (Milciclib maleate) 
approved for the treatment of thymoma and thymic carcinoma. However, several antineoplastic agents are 
used; cisplatin/doxorubicin-based combination chemotherapy [PAC regimen (cisplatin, doxorubicin, 
cyclophosphamide) or ADOC regimen (doxorubicin, cisplatin, vincristine, cyclophosphamide)] seem to 
produce the best overall response rate and survival. Other combined and /or single agent chemotherapy with 
cisplatin, etoposide, ifosfamide, epirubicin, maytansine, octreotide and steroids are used as well [9-11]. 
Examining treatments for patients with advanced disease who had received one or more prior lines of 
therapy, published data generally indicates a limited activity. Single agent studies with gefitinib, imatinib or a 
combination study erlotinib+bevacizumab did not produce satisfactory results [12,13,14], although only two 
cases of possible clinical benefit were observed with imatinib and sorafenib, due to the rare incidence of KIT 
mutations in those patients’ tumors [15,16]. An optimal treatment strategy has yet to be determined and other 
drugs are warranted to improve the outcome of patients with advanced invasive tumors [10]. The unmet 
medical need for new agents for the treatment of thymic malignancies is therefore high, as demonstrated by 
the number of studies with experimental agents currently in progress.  
Given the rarity of thymic carcinoma, prospective phase II studies of chemotherapy specifically targeting this 
patient population are rare. Combined therapies such as ADOC or VIP (cisplatin, ifosfamide, etoposide) 
achieved, as a first line treatment for the advanced disease, a median survival time around 19-20 months 
[17,18]. In previously untreated, unresectable thymic carcinoma, first-line combination of carboplatin and 
paclitaxel achieved an overall response rate of 36% with a median survival time of 22.7 months and a median 
progression-free survival of 7.9 months [19].   
In a single agent study with pemetrexed, on 23 previously treated evaluable patients with unresectable stage 
IV A and B disease, there were 4 objective responses (2 CRs and 2 PRs) (17% RR). Responses were 
obtained only in stage IVA thymoma patients, with a median duration of time to progression of 45.4 weeks; 
in thymic carcinoma patients the median duration of time to progression was much shorter (5.1 weeks) [20]. 
In other two recent series of previously treated patients with thymic malignancies, objective responses were 
reported in patients with B2 and B2/3 tumors with a gemcitabine/ capecitabine combination, but no type C 
thymic carcinoma patients were enrolled [21], and responses were also obtained in thymoma patients with 
histone deacetylase inhibitor (HDAC) belinostat [22], but no responses were seen in 16 patients with thymic 
carcinoma [Giaccone G., personal communication].  
In a phase II study currently ongoing at NCI evaluating the insulin-like growth factor 1-receptor (IGF-1R) 
monoclonal antibody IMC-A12 13 patients have been enrolled (5 thymomas and 8 thymic carcinoma) and 1 
objective responses has been seen in a thymoma patient so far [Giaccone G., personal communication]. 
The above studies illustrate the need for the development of newer agents for second-line therapy and 
beyond to improve the outcome of patients with advanced thymic tumors, especially thymic carcinoma. 
As shown above, in the current clinical scenario, a single agent therapy is able to induce in thymic carcinoma 
patients previously treated with chemotherapy a median PFS of approximately 5.1 weeks [20], roughly 
corresponding to an estimated  PFS rate at 3 months of about 17%. Therefore, doubling this PFS-rate at three 
months could be regarded as clinically interesting for a new investigational agent.     
PHA-848125, N,1,4,4-tetramethyl-8-{[4-(4-methylpiperazin-1-yl)phenyl]amino}-4,5-dihydro-1H- 
pyrazolo[4,3-h]quinazoline-3-carboxamide, is a potent inhibitor of the kinase activity of the CDK2/Cyclin A 
complex, some closely related CDKs (i.e. CDK1, CDK4, and CDK5) and TRKA; the block in G1 phase of 
the cell cycle observed in tumor cells exposed to PHA-848125 supports the postulated mechanism of action 
as determined by this biochemical activity: in fact, PHA-848125 is able to modulate both the phosphorylation 
of the Retinoblastoma protein (pRB), a substrate of CDK/Cyclin complex, as well as to reduce the 
phosphorylation status of TRKA and of the proteins of the TRKA signaling pathway [23]. Some specific 
preclinical experiments to evaluate the activity of PHA-848125 on thymoma cell lines are currently ongoing 
at the Medical Oncology Branch/CCR laboratory at NCI, with results expected around the third quarter of 
2010. 
PHA-848125, formulated for oral administration as maleate salt (PHA-125848AC), is being tested, with 

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Name of Company: Tiziana Life Sciences, PLC  
Name of Finished Product: PHA-848125AC (Milciclib maleate) 
different schedules of administration, in two recently completed phase I trials in advanced/metastatic solid 
tumor patients, in a phase I/II study in patients with recurrent malignant glioma, in a phase I combination 
study with gemcitabine in advanced/metastatic solid tumor patients and in a phase II study in patients with 
malignant pleural mesothelioma. 
In the first-time in man study CDKO-125a-001, in which PHA-848125AC was administered for 7 
consecutive days every 2 weeks to solid tumor patients, the flat dose identified as recommended phase II 
dose (RP2D) was 150 mg/day; this dose was associated with mild/moderate reversible adverse events, 
represented by maximum grade 2 nausea and/or vomiting and/or diarrhea and maximum grade 2 reversible 
tremors. 
As for efficacy, notably, two out of three patients with thymic malignancies, treated in the study CDKO-
125a-001 at the dose 150 mg/day, showed a partial response reached respectively after 10 and 6 months of 
treatment (the third patient was taken off study after two cycles for disease progression). It is of note that 
these responses were reported in patients with the most unfavorable thymoma subtypes (one type C thymic 
carcinoma and one B3 thymoma). 
Study rationale 
Chemotherapy was shown to have significant antitumor activity against unresectable metastatic thymomas 
and thymic carcinomas, but an optimal treatment strategy has not been determined and other drugs are 
needed to improve the outcome of patients with recurrent invasive tumors [10]. 
In recent years, a few studies on molecular changes in thymomas and thymic carcinomas point to alterations 
that may be of use in selecting patients for targeted therapies. Unfortunately for some of them, such as KIT 
and EGFR inhibitors, the reported results seem to be discouraging [12-14]. In addition, despite a lack of 
correlation of thymidilate synthase expression with thymoma clinicopathological characteristics, pemetrexed 
obtained interesting responses in stage IVA thymomas, but not in thymic carcinomas [20]. 
The pyrazoloquinazoline PHA-848125 is a compound counteracting the effects of some of the other so far 
identified, but not yet exploited, molecular alterations found in thymoma and thymic carcinoma, e.g. 
underexpressed p21 and p27 and overexpressed TRKA [7,8]. These targets have not yet been investigated in 
therapeutic intent clinical trials. In fact, p21 and p27 encode natural potent cyclin-dependent kinase inhibitors 
and their ablation in the cancer cell results in an activation of cyclin E/CDK2 or cyclin D/CDK4 complexes 
and thus uncontrolled cell cycle progression and cell proliferation [24-32], while TRKA activation promotes 
tumor growth [33], probably thorough MAPK pathway activation. PHA-848125 potently inhibits both the 
CDK/Cyclin complexes and TRKA, proposing in this way to be a “selective dual inhibitor” and appearing 
particularly attractive in this disease. The preliminary results in early clinical trials (2 out of 3 patients with 
type B3 and C thymic malignancies showing objective partial response) support this hypothesis and provide 
the rationale for this phase II study. 
An exploratory analysis on the relationship of p53 (natural regulator of p21), p21, p27, cyclin D1, p75, 
TRKA expression and TRKA gene copy number in tumor biopsies obtained before study entry with 
treatment efficacy variables will be performed if sufficient data and samples are collected. Additional 
biomarkers under validation may also be evaluated. 
Trial Objectives 
Primary objective:  
Assessment of the antitumor activity of PHA-848125AC in patients with recurrent or metastatic, unresectable 
B3 thymoma or thymic carcinoma who have received more than one line of prior systemic therapy for 
advanced / metastatic disease. Antitumor activity will be evaluated on the basis of the progression-free 
survival status at 3 months. 
Secondary objectives: 
Assessment of additional measures of tumor control to further characterize the efficacy profile of PHA-

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Name of Company: Tiziana Life Sciences, PLC  
Name of Finished Product: PHA-848125AC (Milciclib maleate) 
848125AC in recurrent or metastatic, unresectable B3 thymoma or thymic carcinoma patients who have 
received more than one line of prior systemic therapy for advanced / metastatic disease. 
Evaluation of the safety profile of repeated administrations of PHA-848125AC in patients with recurrent or 
metastatic, unresectable B3 thymoma or thymic carcinoma who have received more than one line of prior 
systemic therapy for advanced / metastatic disease. 
Exploratory objective: 
Relationship of p53, p21, p27, cyclin D1, p75, TRKA expression and TRKA copy number in tumor biopsies 
obtained before study entry with treatment efficacy. Additional biomarkers under validation may also be 
evaluated 
Trial endpoints 
Primary endpoint: 
Progression-free survival rate at 3 months (PFS-3 rate). The PFS-3 rate, will be calculated as the proportion 
of evaluable patients known to be alive and progression-free at ≥ 3 months since study treatment start out of 
the total number of evaluable patients. 
Secondary endpoints: 
- Objective Response Rate (CR + PR) according to RECIST guideline (version 1.1). 
- Disease Control Rate (Objective Response Rate + > 6 weeks SD rate). 
- Progression-free survival, calculated as the time from the date of treatment start to the date of first 
documentation of objective progression or of death due to any cause, whichever comes first. 
- Duration of Response, measured from the time measurement criteria are first met for CR/PR (whichever is 
first recorded) until the first date that recurrent or progressive disease is objectively documented (taking as 
reference for progressive disease the smallest measurements recorded on study). 
- Overall Survival (OS), i.e. the time from the date of treatment start to the date of death from any cause. 
- Overall safety profile, evaluated on the basis of laboratory and clinical safety parameters (i.e. hematology 
and blood chemistry, urinalysis, vital signs, ophthalmologic examinations and adverse events emerging 
during the trial).  The National Cancer Institute Common Terminology Criteria for Adverse Events (NCI 
CTCAE) Version 3.0 will be used for the severity grading of adverse events and hematological and blood 
chemistry abnormalities. 
Exploratory endpoint: 
Characterization of p53, p21, p27, cyclin D1, p75, and TRKA basal expression by IHC and TRKA copy 
number by FISH in tumor tissue involved in the PHA-848125AC mechanism of action will be performed in 
tumor tissue of consenting patients. Additional biomarkers under validation may also be evaluated. 
Assessments will be done on paraffin embedded material, obtained from patients before study entry. 
Study Design 
In consideration of the exploratory nature of the study, a single-arm, open-label, multicenter phase II clinical 
trial design is adopted, including an early stopping rule in case of identification of a clearly unacceptable 
progression free proportion by 3 months of treatment.  
Histological diagnosis of thymic carcinoma, when made by another institution, has to be confirmed by 
pathologists of the investigational site to whom the patient is addressed. 
Sample Size Determination and Statistical Methods: 
Unless an early stopping rule is invoked, the study will enroll 30 patients who have received more than one 
line of prior systemic therapy for advanced / metastatic disease. Accounting for a 10%-15% proportion of 

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non evaluable patients, an accrual ceiling up to 35 patients will be set for completing the trial.  
The primary endpoint of the study is the progression-free survival status at 3 months and the primary efficacy 
analysis will be performed on the proportion of successes (i.e. patients alive and progression-free at 3 months 
since treatment start) out of the total number of evaluable patients (PFS-3 rate).  
Under the assumption of an uninteresting PFS-3 rate of 25% (corresponding to a median PFS of 1.5 months) 
against an interesting one of 50% (corresponding to a median PFS of 3 months), =0.05 and =0.10, 30 
evaluable patients are required for a single stage trial.  If at the end of the trial 12 or more out of 30 evaluable 
patients are alive and progression-free at 3 months since the treatment start date, the null hypothesis will be 
rejected. The probability of this occurring is 5.1% if the true probability of avoiding progression by 3 months 
is 25% while the probability of this occurring is 90.0% if the true probability of avoiding progression by 3 
months is 50%. 
To ensure that the study is not continued in the event that the agent is not providing adequate prevention of 
progression, a Fleming multiple-testing procedure [42] will be utilized for the computation of acceptance and 
rejection critical boundaries at the interim look. If 3 or fewer patients out of the first 15 are progression-free 
at 3 months, accrual will stop for futility as soon as this can be determined. If 4 or more patients out of 15 are 
progression free, the trial will be continued until 30 evaluable patients are available.  
A two-tailed 90% CI on 12 out of 30 (40.0%) evaluable patients alive and in progression-free status at 3 
months ranges from 25.0% to 56.6%, whereas the two-tailed 90% CI of 4 out of 15 (26.7%) ranges between 
9.7% to 51.%  thus showing substantial consistency with the set of hypotheses. 
Supportive analyses of the primary endpoint will include the estimation of the PFS-3 rate together with its 
exact, two-tail, 95% confidence interval and the estimation of the PFS curve by the Kaplan-Meier method 
[43] in both the evaluable and the treated patient population.  The other efficacy endpoints including the 
confirmed objective response rate, the disease control rate, the duration of response, and the overall survival 
will be descriptively analyzed in both the evaluable and the treated patient populations.  Kaplan-Meier 
estimates will be generated and plotted for the overall survival endpoint.  
Patients’ baseline characteristics, treatment exposure and safety data will be analyzed in the treated patient 
population and, if clinically interesting, in other subsets such as the evaluable patient population.  
Descriptive statistical analyses and individual data listings will be used to report all collected data including 
patient disposition, protocol deviations, baseline characteristics, treatment exposure, efficacy, and safety data. 
Patient Populations:  
 
Screened Patients:  This population will include all subjects who are screened about their eligibility for 
the trial, regardless of whether or not they will be enrolled in the study.  This population will be 
evaluated in the analysis of patients’ disposition. 
 
Enrolled Patients:  This population will include all subjects who are enrolled in the trial, regardless of 
whether subjects receive the study drug or not.  This population will be evaluated in the analysis of 
patients’ disposition. 
 
Treated Patients: The treated patient population consists of all enrolled patients who actually receive at 
least one study drug administration. This population will be evaluated in the analysis of patient 
disposition, baseline characteristics, efficacy, safety and treatment exposure. 
 
Patients Evaluable for Efficacy Analysis:  This is the patient population for the primary efficacy analysis 
of PFS-3 rate and consists of all eligible and treated patients who fulfill the following additional 

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conditions:  
 
They have received at least 80% of drug in the first two cycles overall. 
 
They have baseline and 1 on-treatment tumor/oncologic assessment(s) or die before tumor 
re-assessment. 
If deemed of clinical interest, patient disposition, baseline characteristics, efficacy, safety and 
treatment exposure will be analyzed also in this population. 
Exploratory studies 
Exploratory analyses on the relationship of p53, p21, p27, cyclin D1, p75, TRKA expression, and TRKA 
gene copy number in tumor biopsies obtained before study entry with treatment efficacy variables will be 
performed if sufficient data and samples are collected. Additional biomarkers under validation may also be 
evaluated. 
Subject Selection 
Subject Inclusion Criteria 
Subjects must meet all of the following inclusion criteria to be eligible for enrollment into the study:  
1. Signed and dated IRB/IEC-approved Informed Consent. 
2. Histologically or cytologically proven diagnosis of unresectable B3 thymoma or thymic carcinoma 
recurrent or progressing after more than one prior systemic therapy for advanced / metastatic disease. 
Note: Any adjuvant or neoadjuvant systemic therapy followed by the recurrence of the disease within 12 
months after the start of the adjuvant treatment will be considered as one therapy for advanced / 
metastatic disease. 
3. Presence of measurable disease defined as at least one lesion that can be accurately measured by CT scan 
in at least one dimension, as  10 mm for non nodal lesions (longest diameter to be recorded) and  15 
mm for lymph nodal lesions (short axis to be recorded). (CT scan is the desirable method for lesion 
measurement. Other measurement techniques [eg MRI] are acceptable [but not for lung lesions] 
provided that the size of the measurable lesion is twice the slice thickness of the MRI). 
Tumor lesions situated in a previously irradiated area, or in an area subjected to other loco-regional 
therapy, are usually not considered measurable unless there has been demonstrated progression in the 
lesion. 
4. Age  18 years. 
5. ECOG performance status 0-1. 
6. Estimated life expectancy of at least 3 months. 
7. Negative pregnancy test (if female in reproductive years). 
8. Agreement upon the use of effective contraceptive methods (hormonal or barrier method of birth control, 
or abstinence) prior to study entry and for the duration of study participation, if men and women of 
child-producing potential. 
9. Adequate liver function: 
- Total Serum Bilirubin  1.5 x upper limit of normal (ULN) 
- Transaminases (AST/ALT)  2.5 ULN (if liver metastases are present, then  5 ULN is allowed) 
- ALP  2.5 ULN (if liver and/or bone metastases are present, then  5 ULN is allowed). 

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10. Adequate renal function: 
- Serum Creatinine  ULN 
or 
- Creatinine Clearance calculated by Cockcroft and Gault’s formula > 60 mL/min. 
11. Adequate hematologic status: 
- ANC  1,500 cells/mm3  
- Platelet Count  100,000 cells/mm3 
- Hemoglobin  9.0 g/dL.  
12. At the time of start of treatment, at least 2 weeks or 5 medication half-lives (whichever is longer) must 
have elapsed since completion of prior systemic therapy and at least 2 weeks since completion of prior 
minor surgery and radiotherapy (provided that no more than 25% of bone marrow reserve has been 
irradiated). 
13. With the exception of alopecia, resolution of all acute toxic effects of any prior chemotherapy, surgery 
or radiotherapy to NCI CTC (Version 3.0) grade  1 and to the baseline laboratory values as defined in 
Inclusion Criteria Number 9, 10, 11. 
14. Able and willing to comply with scheduled visits, therapy plans, and laboratory tests required in this 
protocol. 
15. Capability to swallow capsules intact (without chewing, crushing, or opening). 
Subject Exclusion Criteria 
The presence of any of the following will exclude a subject from study enrollment: 
1. Any of the following in the past 6 months: myocardial infarction, uncontrolled cardiac arrhythmia, 
unstable angina, coronary/peripheral artery bypass graft, symptomatic congestive heart failure, 
cerebrovascular accident or transient ischemic attack, pulmonary embolism, deep vein thrombosis. 
2. Grade >1 retinopathy as determined by an ophthalmologist. 
3. Known brain metastases. 
4. Major surgery, other than diagnostic surgery, within 4 weeks prior to treatment. 
5. Active, uncontrolled bacterial, viral, or fungal infections. 
6. Known infection with HIV, active hepatitis B or hepatitis C. 
7. Pregnant or breast feeding women. 
8. Previous (within the last 5 years) or current malignancies at other sites, except for adequately treated 
basal cell or squamous cell skin cancer or in situ carcinoma of the cervix uteri. 
9. Current enrollment in or participation in another therapeutic clinical trial within 4 weeks preceding 
treatment start. 
10. Diabetes mellitus uncontrolled. 
11. Gastrointestinal disease (e.g. Crohn’s disease, ulcerative colitis, or short gut syndrome) that would 
impact on drug absorption. 
12. Patients under treatment with anticoagulants or with coagulation disorders or with signs of hemorrhage 
at baseline. 

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13. Patients with previous history or current presence of neurological disorders (with the exception of 
myasthenia gravis), including epilepsy (although controlled by anticonvulsant therapy), Parkinson’s 
disease and extra-pyramidal syndromes.  
14. Other severe acute or chronic medical or psychiatric condition or laboratory abnormality that may 
increase the risk associated with study participation or may interfere with the interpretation of study 
results and, in the judgment of the Investigator, would make the patient inappropriate for entry into this 
study or could compromise protocol objectives in the opinion of the Investigator and/or the Sponsor. 
Treatment and Test Articles  
On the basis of the results of the first single agent Phase I study in solid tumor patients (CDKO-125a-001 
study), PHA-848125AC will be administered at the flat dose of 150 mg/day once daily for 7 consecutive 
days in each treatment cycle. A treatment cycle will comprise 7 days of PHA-848125AC administration 
(Days 1 to 7) followed by 7 days of rest (Days 8 to 14) for a total of a 14 days period (2-week cycle). 
PHA-848125AC is formulated as 10 mg, 50 mg and 100 mg hard gelatin capsules to be swallowed intact 
(without chewing, crushing or opening). The drug product is to be stored under refrigerated conditions (5  
3°C; 36-46 °F) and in the original packaging, out of the reach of children. 
PHA-848125AC is administered as home-based treatment. After an overnight fasting, with free access to 
water, patients will take the study drug with a large glass of plain water without ice. A light breakfast can be 
served 1.5-2 hours after study drug intake. 

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Schedule of Events 
The following table summarizes information on the timing of study assessments. 
SCHEDULE OF EVENTS 
Protocol Activities 
and Forms to Be Completed 
Pre 
Treatment 
Treatment 
Post Treatment 
Cycles 
Last 
Cycle 
 21 
Days 
 7 
Days 
Week 1 
Day 1 (*) 
Week 2 
between Days 
11-14 
AE 
FU 
(§) 
Follow up 
Informed Consent 1 
X 
 
 
 
 
 
 
Medical/ Oncologic History & Physical 
Examination 2 
X 
 
 
X 
 
 
 
Vital Signs 3 
 
X 
X 
 
 
 
 
ECG 4 
X 
 
As medically indicated 
X 
 
 
Chest X-Ray 5 
X 
 
 
 
X 
 
 
Ophthalmologic exam. 6 
X 
 
 
X
6  
X 
 
 
Laboratory Assessments 
Serum/ Urine Pregnancy Test 7 
 
X 
 
 
 
 
 
Urinalysis 8 
 
X 
X (*) 
(Cycle 1 only) 
X (even cycles)  
X 
 
 
Hematology 9 
 
X 
X (*) 
X 
 
 
 
Blood Chemistry 10 
 
X 
X (*) 
X 
 
 
 
Coagulation 11 
 
X 
X (*) 
(Cycle 1 only) 
X (even cycles)  
X 
 
 
Tumor Assessments 
Tumor Imaging: chest/abdomen/pelvic CT 
scan or MRI 12 
X 
 
q6wks (see footnote for 
assessment at month 3) 
X 
 
q6wks 
Survival 13 
 
 
 
 
 
 
q6wks 
(+ q6mos) 
Other Clinical Assessments 
Adverse Event Assessment  (including 
neurological status evaluation)  14 
 
X 
X 
 
X 
 
Concomitant Medications 15 
 
X 
X 
 
 
 
Special Studies 
Biomarker Status Assessment 16 
X 
Pharmacokinetic Blood Sampling 17 
 
 
As needed 
 
 
Histological confirmation 18 
X 
Study Treatment 
Enrollment 19 
 
X 
 
 
 
 
 
PHA-848125AC Administration 20 
 
 
Once daily for 
7 cons. days 
(D1 to D7) 
 
 
 
 

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Footnotes for Schedule of Events 
1. Informed Consent: Every patient must sign the informed consent to participate in this trial before starting any trial 
related procedures. After signature, a Patient Screening Number is assigned centrally by CLIOSS 
2. Medical/Oncology History & Physical Examination: Includes oncologic history, history of other disease processes 
(active, controlled or resolved) and concomitant illnesses (all of them at pretreatment only).  Physical examination will be 
done at pretreatment, and, on treatment, at the end of each cycle during the first three months of treatment (6 cycles) (see 
Section 11.4.3 Other safety assessments). For patients remaining on treatment for a period of time more than 6 cycles, 
the physical examination will be done in concomitance with the visit to the site (once every 3 cycles, 1.5 months).  
Oncologic and non-oncologic medical histories, including prior antitumor treatments/procedures, are to be reported in the 
relevant case report form (CRF). 
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
3. Vital signs: Blood pressure/pulse (supine): at baseline and on Day 1 of each treatment cycle, before treatment 
administration. Height (in cm or inches): at baseline only.  Weight (in kilograms or pounds): at baseline and on Day 1 of 
each treatment cycle. ECOG performance status: at baseline and on Day 1 of each treatment cycle. Temperature (in °C or 
in °F): at baseline and on Day 1 of each treatment cycle. For patients remaining on treatment for a period of time more 
than 6 cycles, vital signs (including blood pressure/pulse, weight and temperature) will be done in concomitance with the 
visit to the site (once every 3 cycles, 1.5 months). Following approval of Amendment 5, management  of patients 
should be as per Section 9.5 
4. ECG: 12-lead study. To be done at baseline, at the end of the last cycle and to be repeated during treatment as 
medically indicated. 
5. Chest X-Ray: Mandatory at screening visit and at the end of last cycle as safety assessment.  
6. Ophthalmologic Examination: to be conducted at baseline, at the end of even cycles (between days 11 and 14) 
during the first three months of treatment (6 cycles), at 4.5 months (ninth treatment cycle, between days 11 and 14) and 
then after every three months and at the end of last cycle. Includes visual acuity test and fundoscopic examination by an 
ophthalmologist. Additional assessments will be performed if clinically indicated. Ophthalmologic evaluations will be 
possibly done by the same ophthalmologist for a given patient. 
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
7. Pregnancy Test: For women of reproductive potential.  Must be done within 7 days prior to initial study treatment. 
8. Urinalysis: pH, dipstick for glucose, protein and blood. To be done at baseline and at the end of last cycle. During 
treatment, should be performed at the end of even cycles (between days 11 and 14). For patients remaining on treatment 
for a period of time more than 6 cycles, the urinalysis tests may be done locally when the visit to the site is not planned  
(one visit planned to the site every three cycles, 1.5 months) and must be sent to the site for safety evaluation and 
reported on CRF. 
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
9. Hematology (local laboratory): Hemoglobin, erythrocytes (RBC), white blood cell (WBC) with differential count 
(neutrophils, lymphocytes, monocytes, eosinophils, basophils, differential other cells), platelets (PLTs). To be done at 
baseline and between Day 11-14 of each cycle. In case of toxicity preventing re-treatment, hematology should be re-
assessed on Day 1 of the next cycle before starting treatment. For patients remaining on treatment for a period of time 
more than 6 cycles, the hematological tests may be done locally when the visit to the site is not planned  (one visit 
planned to the site every three cycles, 1.5 months) and must be sent to the site for safety evaluation and reported on 
CRF. 
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
10. Blood Chemistry (local laboratory): sodium, potassium, chloride, magnesium, blood urea nitrogen (BUN) or urea, 
creatinine, albumin, AST/SGOT, ALT/SGPT, Alkaline Phosphatase (ALP), total bilirubin, creatinine clearance (calculated 
by Cockroft and Gault’s formula), amylase and lipase.  
To be done at baseline and between Day 11-14 of each cycle. In case of toxicity preventing re-treatment, blood chemistry 
should be re-assessed on Day 1 of the next cycle before starting treatment. For patients remaining on treatment for a 
period of time more than 6 cycles, the biochemical tests  may be done locally when the visit to the site is not planned  
(one visit planned to the site every three cycles, 1.5 months) and must be sent to the site for safety evaluation and 
reported on CRF. 
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
11. Coagulation: INR (International Normalized Ratio), activated partial thromboplastin time (APTT in seconds). To be 
done at baseline, at the end of last cycle and, during treatment, at the end of even cycles (between Days 11 and 14). 
For patients remaining on treatment for a period of time more than 6 cycles, the coagulation tests may be done locally 
when the visit to the site is not planned (one visit planned to the site every three cycles, 1.5 months) and must be sent to 
the site for safety evaluation and reported on CRF. 
Following approval of Amendment 5, management  of patients should be as per Section 9.5 

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12. Tumor imaging: chest/abdomen/pelvic CT scan/ MRI : At baseline, to be done within 21 days before Day 1; during 
the treatment period (irrespectively from cycles duration), the first one to be done 6 weeks (between days 42 and 48) after 
first drug administration, the second one to be done 3 months (between days 92 and 98) after first drug 
administration, following ones to be repeated every 6 weeks (between days 42 and 48) after the previous one, and at 
end of last cycle (if not done in the previous 4 weeks). During Follow Up, to be performed every 6 weeks, until PD or until 
a new antitumor therapy starts. The same method of assessment and the same technique should be used to characterize 
and follow the same lesion at baseline and during treatment. CT scan is the desirable method for lesion measurement. 
MRI is acceptable (but not for lung lesions) provided that the size of the measurable lesion is twice the slice thickness of 
the MRI. After cut-off date of 31 May 2017, the patients should perform CT scan according to routine clinical 
practice and/or at investigator’s discretion 
13. Survival: To be assessed during Follow Up every 6 weeks until PD or until a new antitumor therapy starts; every 6 
months thereafter, up to 2 years from the end of treatment. 
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
14. Adverse Event Assessment (including neurological status evaluation): Events should be assessed and 
documented at each scheduled clinic visit since patient signs the Informed Consent: before treatment administration at 
baseline (baseline signs and symptoms), at the end of each treatment cycle, and 28 days after the last dose of study drug 
administration. For patients remaining on treatment for a period of time more than 6 cycles, the events will be assessed by 
phone call if the visit to the site is not planned (one visit planned to the site every three cycles, 1.5 months). The phone 
call information will be collected in a specific form signed and dated by the Investigator and included in the CRF. 
Patients must be followed for adverse events also until every ongoing drug-related toxicities and serious adverse events 
have resolved or the investigator assesses them as “chronic” or “stable”. However, if the patient begins a new anticancer 
therapy before 28 days after the last dose of study drug administration, the adverse event reporting period will end at the 
time the new treatment is started. AEs will be recorded in the relevant CRF pages. 
After cut-off date of 31 May 2017, AE/SAE data will be no longer collected into the CRF, but assessments 
information should continue to be collected into the patient’s medical notes.  
After protocol Amendment 5 approval, only SAEs will continue to be reported to CLIOSS Pharmacovigilance for 
patients still receiving treatment, up to 28 days after milciclib discontinuation, according to Section 9.5. 
15. Concomitant Medications: all concomitant medications should be reported in the relevant CRF, including supportive 
care drugs, and drugs used for treating adverse events or chronic diseases. For patients remaining on treatment for a 
period of time more than 6 cycles, the concomitant medications will be assessed by phone call if the visit to the site is not 
planned (one visit planned to the site every three cycles, 1.5 months). The phone call information will be collected in a 
specific form signed and dated by the Investigator and included in the CRF. Following approval of Amendment 5, 
management  of patients should be as per Section 9.5 
16. Biomarker Status Assessment: retrieval of paraffin embedded tumor biopsy (blocks or slides), obtained from consenting 
patients before study entry, and characterization of p53, p21, p27, cyclin D1, p75, TRKA expression and TRKA copy 
number. Additional biomarkers under validation may also be evaluated 
17. Pharmacokinetics: blood samples may be collected if, in the opinion of the Investigator and of the Sponsor, an 
evaluation of PK parameters is needed for safety reasons. 
18. Histological confirmation: histological diagnosis of thymic carcinoma, when made by another institution, has to be 
confirmed by pathologists of the investigational site to whom the patient is addressed. 
19. Enrollment: The Investigator is requested to sign a Request For Enrollment form. His/her signature is the guarantee 
that all the eligibility criteria are met. Patient Number is assigned by the Sponsor. Treatment must be administered within 
7 days from patient enrollment. 
20. PHA-848125AC administration: The study drug will be administered at 150 mg (flat dose) once daily for 7 
consecutive days of each treatment cycle (from day 1 to Day 7). After an overnight fasting with free access to water, 
patients will take the study drug with a large glass of plain water without ice. A light breakfast can be served 1.5-2 hours 
later. PHA-848125AC capsules have to be stored under refrigerated conditions (5  3 °C; 36-46 °F) and out of reach of 
children 
(*) Cycle 1, Day 1 assessments: hematology, blood chemistry, urinalysis and coagulation do not need to be repeated 
before treatment on Cycle 1, Day 1 if they were performed during screening within 1 week before first study drug 
administration. 
Cycle > 1, Day 1 assessments: hematology and blood chemistry do not need to be repeated before treatment on 
Cycles> 1, Day 1 if no toxicity preventing re-treatment resulted from laboratory assessments done within the previous 4 
days. 
(§) AE FU: end of adverse events reporting period (to be done 28 days after last study drug administration) and follow up 
of unresolved drug related/serious AEs. 
After cut-off date of 31 May 2017, AE/SAE data and related follow up will be no longer collected into the CRF, but 
assessments information should continue to be collected into the patient’s medical notes.  
After approval of Amendment 5 to the protocol, only SAEs should be reported to CLIOSS Pharmacovigilance for 
patients still receiving study treatment, up to 28 days after discontinuation of milciclib, according to Section 9.5. 

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2. ABBREVIATIONS AND DEFINITIONS OF TERMS 
ADL 
Activities of Daily Living 
AE 
Adverse Event 
ALP 
Alkaline Phosphatase 
ALT/SGPT 
Alanine aminotransferase 
ANC 
Absolute neutrophils count 
APTT 
Activated partial thromboplastin time 
AST/SGOT 
Aspartate aminotransferase 
AUC 
Area under the plasma concentration-time curve from time zero to infinity 
BAX 
BCL2-associated X protein 
BCL-2 
B-cell CLL/lymphoma 2 gene (BCL2) 
BCL-XL 
BCL2-like 1 (BCL2L1) 
BID 
Two times daily 
BUN 
Blood Urea Nitrogen 
CDKs 
Cyclin-dependent kinases 
CGH 
Comparative genomic hybridization 
CL 
Total plasma clearance 
Cmax 
Maximum plasma concentration 
CNS 
Central nervous system 
CR 
Complete Response 
CRF 
Case Report Form 
DMBA 
9,10-dimethyl-1,2-benzanthracene 
DPYD 
Dihydropyrimidine dehydrogenase 
ECOG  
Eastern Cooperative Oncology Group  
GCP 
Good clinical practice 
EGFR 
Epidermal growth factor receptor 
FISH 
Fluorescent in situ Hybridization 
FU 
Follow-up 
GI 
Gastrointestinal 
HER2/neu 
v-erb-b2 erythroblastic leukemia viral oncogene homolog 2, neuro/glioblastoma derived 
oncogene homolog (ERBB2) 
HLP 
Hemolymphopoietic 
IC50 
Concentration resulting in 50% inhibition 
IEC 
Independent Ethics Committee 

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IHC 
Immunohistochemistry 
IMP 
Investigational Medicinal Product 
IRB 
Institutional Review Board 
IV 
Intravenous 
Ki 
Inhibition constant 
KIT 
V-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog 
LC-MS/MS 
HPLC coupled with tandem mass spectrometry 
MedDRA 
Medical Dictionary for Regulatory Activities 
MTD 
Maximum Tolerated Dose 
NCI CTCAE 
National Cancer Institute Common Terminology Criteria for Adverse Events 
NMS 
Nerviano Medical Sciences  
NOAEL 
No-observed-adverse-effect-level 
NOEL 
No-observed-effect-level 
NSCLC 
Non Small Cell Lung Cancer 
OS 
Overall Survival 
P21 
Cyclin-dependent kinase inhibitor 1A (CDKN1A) 
P27 
Cyclin-dependent kinase inhibitor 1B (CDKN1B) 
P53 
Tumor protein p53 (TP53) 
P75 
Nerve growth factor receptor (NGFR) 
PD 
Progressive Disease 
PFS 
Progression-Free Survival 
PFS-3  
Progression-Free Survival at 3 months 
PHA-848125AC 
PHA-848125 maleate salt 
PR 
Partial Response 
pRb 
Retinoblastoma 1 (RB1) 
PS 
Performance Status 
PT 
Prothrombin time 
PXR 
Pregnane-X-Receptor 
RP2D 
Recommended Phase II Dose 
SAE 
Serious adverse event 
SD 
Stable Disease 
SGOT/AST 
Serum Glutamic-Oxaloacetic Transaminase 
SGPT/ALT 
Serum Glutamic Pyruvic Transaminase 
SMRP 
Soluble mesothelin-related proteins 

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t1/2 
Terminal half-life 
TGI 
Tumor Growth Inhibition 
tmax 
Time of occurrence of Cmax 
TRAMP 
Transgenic Adenocarcinoma Mouse Prostate 
TRKA 
Thropomyosin Receptor Kinase A (NTRK1) 
TYMS 
Thymidylate synthase 
ULN 
Upper Limit of Normal 
Vss 
Volume of distribution at steady-state 
WBC 
White Blood Cells 
wks 
Weeks 
WHO 
World Health Organization 
 

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3. BACKGROUND INFORMATION AND STUDY RATIONALE 
3.1. Thymic Carcinoma 
Thymic malignancies are rare tumors with an overall incidence in US (1973-1998) of 0.15 
per 100000 person/year; clinical behavior ranges from relatively indolent thymomas to 
highly aggressive among thymic carcinomas [1-2].  
Patients with locally advanced or disseminated thymic malignancies are usually 
symptomatic, presenting with chest pain, shortness of breath, paralysis of the phrenic nerve, 
pleural effusion and superior vena cava syndrome. Immune disorders have also been 
associated with thymoma, the most common being myasthenia gravis [3]. 
In recent years, a few studies on molecular changes in thymomas and thymic carcinomas 
have been published. In particular, the expression of KIT and epidermal growth factor 
receptor (EGFR), targets, respectively, of imatinib and EGFR inhibitors (ie, erlotinib, 
gefitinib), have been tested by immunohistochemistry in a limited number of thymic 
malignancies: KIT was positive in 73% of thymic carcinomas and 5% of other thymomas, in 
contrast, EGFR expression was more often present in other thymomas (83%) than in thymic 
carcinomas (50%) [4]. Another study investigated HER2/neu amplification and expression 
of the apoptosis-related markers p53, BCL-2, BAX, BCL-XL, and p21 [5]; p53 and Bcl-2 
were definitely more expressed in thymic carcinomas than thymomas and correlated with 
more advanced stages and unresectability, whereas no HER2/neu amplification was 
observed. Other markers, such as expression of thymidylate synthase and dihydropyrimidine 
dehydrogenase, which predict sensitivity to 5-fluorouracil-based chemotherapy, were not 
correlated with clinicopathological characteristics in a series of thymomas [6].  
The loss of control of cell cycle checkpoints seems a common occurrence in thymomas, 
supporting the idea that functional cooperation between different cell cycle inhibitor proteins 
regulates cell growth control and tumor suppression. Univariate analyses on the expression 
of p21 and p27 in specimens from 25 encapsulated thymomas (using immunohistochemistry) 
suggest that negative expressions of p21 and p27 (natural inhibitors of CDKs) significantly 
correlates with poor prognosis for disease-free survival [7]. In addition, some members of 
the neurotrophin receptors family seem to play a significant role in this disease: in a study 
investigating the expression of neurotrophin receptors in thymic epithelial tumors on a quite 
large series of patients (N=99) [8], the pattern of TRKA expression was analyzed according 
to WHO classification for the histologic subtypes (A, AB, B1, B2, B3, C). All patients, 
except one, had immunostaining for TRKA expression in the tumors gradually increasing 
from type A to C. Conversely, none of the tumors showed TRKB or TRKC 
immunoreactivity. In addition, from type A to type C, there was a decreasing percentage of 
tumors with p75 immunostaining. These observations suggest a further elucidation on the 
specific role of TRKA and p75 in this disease: the  Medical Oncology Branch/CCR 
laboratory at NCI has analyzed 60 paraffin-embedded biopsies from patients diagnosed with 
thymoma and thymic carcinoma, founding amplification of TRKA in 45% of  analyzed 
samples and 72% of thymic carcinomas [Giaccone G., personal communication]; these 

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results have been confirm by RT-PCR and FISH. The same laboratory demonstrated by 
immunohistochemistry the presence of IGF-1R in resected tumors from patients with thymic 
malignancies, with a higher degree of expression noted in thymic carcinoma [Giaccone G., 
Cancer, in press]. 
Besides the above mentioned WHO histological classification of thymoma, the Masaoka 
staging system is commonly employed to evaluate invasiveness and to determine the 
therapy, since the optimal treatment for this disease depends on its clinical stage [1]. Locally 
advanced or metastatic thymomas are often treated with combined treatment modalities, 
including surgery, radiation and chemotherapy. There are no drugs officially approved for 
the treatment of thymoma and thymic carcinoma. However, several antineoplastic agents are 
used. Cisplatin/doxorubicin-based combination chemotherapy [PAC regimen (cisplatin, 
doxorubicin, cyclophosphamide) or ADOC regimen (doxorubicin, cisplatin, vincristine, 
cyclophosphamide)] seem to produce the best overall response rate and survival. Other 
combined and /or single agent chemotherapy with cisplatin, etoposide, ifosfamide, 
epirubicin, maytansine, octreotide and steroids are used as well [9-11]. Examining 
treatments for patients with advanced disease who had received one or more prior lines of 
therapy, published data generally indicates a limited activity, in fact single agent studies with 
gefitinib, imatinib or a combination study erlotinib+bevacizumab did not produce 
satisfactory results [12-14], although only two cases of activity of possible clinical benefit 
were observed with imatinib and sorafenib, due to the rare incidence of KIT mutations in 
those patients’ tumors [15,16]. An optimal treatment strategy has yet to be determined and 
other drugs are warranted to improve the outcome of patients with advanced invasive tumors 
[10]. The unmet medical need for new agents for the treatment of thymic malignancies is 
therefore high, as demonstrated by the number of studies with experimental agents currently 
in progress.  
Given the rarity of the thymic carcinoma subtype, prospective phase II studies of 
chemotherapy specifically targeting this patient population are rare. Combined therapies 
such as ADOC or VIP (cisplatin, ifosfamide, etoposide) achieved, as a first line treatment for 
the advanced disease, a median survival time around 19-20 months [17, 18]. In previously 
untreated, unresectable thymic carcinoma, first-line combination of carboplatin and 
paclitaxel achieved an overall response rate of 36% with a median survival time of 22.7 
months and a median progression-free survival of 7.9 months [19].   
In a single agent study with pemetrexed, on 23 previously treated evaluable patients with 
unresectable stage IV A and B disease, there were 4 objective responses (2 CRs and 2 PRs) 
(17% RR). Responses were obtained only in stage IVA thymoma patients, with a median 
duration of time to progression of 45.4 weeks; in thymic carcinoma patients the median 
duration of time to progression was much shorter (5.1 weeks) [20]. In other two recent series 
of previously treated patients with thymic malignancies, objective responses were reported 
in patients with B2 and B2/3 tumors with a gemcitabine/ capecitabine combination, but no 
type C thymic carcinoma patients were enrolled [21], and responses were also obtained in 
thymoma patients with histone deacetylase inhibitor (HDAC) belinostat [22], but no 

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responses were seen in 16 patients with thymic carcinoma [Giaccone G., personal 
communication]. 
In a phase II study currently ongoing at NCI evaluating the insulin-like growth factor 1-
receptor (IGF-1R) monoclonal antibody IMC-A12 13 patients have been enrolled (5 
thymomas and 8 thymic carcinoma) and 1 objective responses has been seen in a patient 
with thymoma so far [Giaccone G., personal communication]. 
The above studies illustrate the need for the development of newer agents for second-line 
therapy and beyond to improve the outcome of patients with advanced thymic tumors, 
especially thymic carcinoma. As shown above, in the current clinical scenario, a single agent 
therapy is able to induce in thymic carcinoma patients previously treated with chemotherapy 
a median PFS of approximately 5.1 weeks [20], roughly corresponding to an estimated  PFS 
rate at 3 months of about 17%. Therefore, doubling this PFS-rate at three months could be 
regarded as clinically interesting for a new investigational agent.   
3.2. PHA-848125AC 
3.2.1. Description 
PHA-848125, N,1,4,4-tetramethyl-8-{[4-(4-methylpiperazin-1-yl)phenyl]amino}-4,5-
dihydro-1H- pyrazolo[4,3-h]quinazoline-3-carboxamide, is a potent inhibitor of the kinase 
activity of the CDK2/Cyclin A complex (Ki = 32 nM), showing activity also towards closely 
related CDKs (ie, CDK1, CDK4, and CDK5) and TRKA. 
The compound is formulated for oral administration as maleate salt (PHA-848125AC). 
Throughout this document, “PHA-848125” indicates the active compound as free base, 
which was used under various salt forms in preclinical studies. 
Details regarding the results of the pre-clinical and clinical studies are contained in the PHA-
848125AC Investigator Brochure, Version 7, 2011 [23]. 
3.2.2. Pharmacology 
CDKs are serine/threonine kinases that, in concert with their activators (cyclins) and 
negative regulators, play a crucial role in the cell cycle progression [24,25]. CDK/Cyclin 
complexes regulate the phosphorylation and inhibitory binding of the pRb to members of the 
E2F transcription factors family, that are essential for the transcriptional regulation of a 
number of genes whose products control cell cycle progression. These include genes 
essential for the progression from the G1 into the S phase of the cell cycle and genes that are 
involved in the regulation of DNA replication. 
Deregulation of CDKs activity, alterations of expression and/or genetic mutations of cyclins, 
CDKs, Cyclin Dependent Kinase Inibitors (CDKIs) and other components of the pRb 
pathway have been reported in more than 90% of human neoplasms [26]. For example, 
CDK2 activators, such as Cyclin E2 and A2 are found overexpressed in 50% of breast and 

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lung cancer, and decreased levels of their natural inhibitors (ie, p21, p27) predict a poor 
prognosis in breast, prostate, colon, gastric, lung and esophageal cancer. Indeed, alterations 
in the Rb pathway lead to release of E2F transcription factors, high commitment to cell cycle 
progression and, ultimately, in uncontrolled proliferation. These findings strongly support a 
pharmacological inhibition of CDKs as an attractive strategy in the treatment of human 
cancers [27-32]. 
In fact, according to the postulated mechanism of action, as determined in biochemical 
assays, in in vitro experiments PHA-848125 was able to cause a block in G1 phase of the 
cell cycle in tumor cells: it decreased the phosphorylation level of the Retinoblastoma 
protein (pRB), by inhibiting the CDK/Cyclin complexes, thus preserving the E2F 
transcription factors in an inactive state. 
Additionally, PHA-848125 reduced the phosphorylation status of TRKA and of the proteins 
of the TRKA signaling pathway in cells expressing this receptor tyrosine kinase. 
The antiproliferative effect of PHA-848125 was tested on a panel of 120 tumoral cell lines 
established from different solid tumors (ovary, breast, pancreas, lung, cervix, prostate, skin, 
brain, bone), leukemias and lymphomas. The IC50 values were in the range of 0.1-1 M for 
61 cell lines and in the range of 1-3 M for 42 cell lines, indicating a broad spectrum of 
activity of the compound. Only 17 cell lines were poorly responsive to PHA-848125 with an 
IC50 value > 3 M. Some specific preclinical experiments to evaluate the activity of PHA-
848125 on thymoma cell lines are currently ongoing at the Medical Oncology Branch/CCR 
laboratory at NCI, with results expected around the third quarter of 2010. 
Significant anti-tumor activity was observed in all tested preclinical animal models with 
different oral treatment schedules of PHA-848125. In various human xenograft models, as 
well as in two transgenic models (TRAMP prostate and K-RasG12DLA2 lung 
adenocarcinoma), consistent tumor growth inhibition (up to 91%), was reported with a 
repeat daily treatment at tolerated doses (40 mg/kg bid). In the rat DMBA (9,10-dimethyl-
1,2-benzanthracene)-induced mammary carcinoma model, comparable results (stasis and 
partial remission in 58 and 25% of the primary tumors, respectively) were obtained with 
repeat daily treatment at tolerated doses (up to 15 mg/kg bid). In the same model, 
intermittent treatment with a rest period was equally effective. 
A statistically significant increase in survival time was obtained in two disseminated human 
leukemia models (AML and ALL) and in a human glioma model implanted intracranially. 
In combination studies PHA-848125 exhibited synergistic or more than additive activity 
when administered with docetaxel, topotecan or temozolomide, and additive effect when 
combined with bevacizumab, irinotecan, 5-FU and gemcitabine. Also combination of PHA-
848125 with radiotherapy as well as a triple treatment adding PHA-848125 to radiotherapy 
and temozolomide resulted in a clear therapeutic gain. Combinations were well tolerated.  

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Inhibition of pRb phosphorylation status, reduced expression of Cyclin A and Ki67 and 
modulation of the expression of genes regulated by E2F1 and NPAT pathway were 
measured in a dose-dependent manner both in skin and tumors of mice treated with PHA-
848125. The in vivo findings confirmed the mechanism of action of the compound and set 
the stage for testing its pharmacodynamic effects in tissues samples (normal skin and/or 
tumors) of cancer patients. 
3.2.3. Safety Pharmacology 
Safety pharmacology studies were performed to investigate the effects of PHA-848125 on 
central nervous (CNS), respiratory and cardiovascular systems (all doses mentioned are 
expressed as free base). 
Central Nervous System: no effects on general behavior (Irwin’s test) and body temperature 
were observed in rats up to the highest single dose of 160 mg/kg and no alterations in the 
EEG were detected in adult rats given PHA-848125 for 5 consecutive days at 16 or 32 
mg/kg/day. 
Respiratory System: in a respiratory function study in rats, a dose-related shortening of the 
inspiratory time and an increase in peak inspiratory flow were observed from the dose of 80 
mg/kg with recovery within 4 hours. The dose of 40 mg/kg was considered the NOEL. 
Cardiovascular System: cardiovascular safety pharmacology assessments included in vitro 
evaluation for potential effects on cardiac ion channels (Ikr) and in vivo evaluations for 
effects on cardiovascular parameters and body temperature in conscious beagle dogs. A 
dose-related in vitro inhibition of the Ikr channel occurred from the concentration of 0.1 M 
with a calculated IC50 of 1.32 M (the IC50 for the antiproliferative activity in the A2780 cell 
line was 0.2 M). In a telemetry study in dogs, a temporary moderate decrease in heart rate 
was observed from 0.5 to 3 h after treatment at the dose of 32 mg/kg. QT/QTc interval was 
not affected at any of the tested doses. No effect was seen at 16 mg/kg; this dose was 
considered the NOEL for cardiovascular function. No changes in ECG parameters (including 
QT and QTc) were observed in single and repeat-dose toxicity studies in dogs and monkeys. 
3.2.4. Nonclinical Pharmacokinetics 
Pharmacokinetics of PHA-848125 was investigated in the mouse, rat, dog and monkey after 
single IV and oral administration. Since the compound is intended for oral route 
administration, its pharmacokinetics was further studied after repeated oral administrations. 
Following IV administration, PHA-848125 was characterized by moderate clearance in 
mice, rats and monkeys and high clearance in dogs. The clearance was mainly non renal as 
suggested by the very limited renal excretion of the unchanged drug. The volume of 
distribution was higher than the total body water in all the preclinical species, suggesting an 
extensive tissue distribution of the compound.  

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The results of the rat tissue distribution study conducted with [14C]-PHA848125 indicated 
that apart from the GI tract, the highest levels of radioactivity were measured in the liver, 
spleen, skin, kidneys, adrenal glands and lachrymal glands. The blood to plasma ratio was 
between 0.8-1.12 indicating a moderate distribution of the radioactivity into the red blood 
cells. In rats and monkeys PHA-848125 distributed in the brain. Moreover, the study carried 
out in the rat using [14C]-PHA848125, indicated that the distribution of the radioactivity was 
homogeneous in the different brain areas and cerebellum.  
The in vitro plasma protein binding ranged from 78 to 90%, depending on the species. 
The bioavailability of PHA-848125 after oral administration was equal or higher than 30 % 
in all the preclinical species. PHA-848125 plasma levels increased largely in direct 
proportion with the dose. No relevant gender differences were observed in the preclinical 
species. 
In dogs, the extent and rate of absorption of PHA-848125 was unaffected when the 
compound was administered in hard gelatin capsules or in 5% dextrose solution. No food 
effect was observed. 
The elimination profile of total radioactivity following a single oral administration of [14C]-
PHA-848125AC in rats suggested that the main route of elimination was via faeces, 
accounting for about 70 % of the dose within 96 hours post dose. The urinary excretion of 
the radioactivity represented 16% of the dose. In all preclinical species, after IV and oral 
treatment, the amount of parent compound excreted unchanged in urine was less than 6% of 
the administered dose. In the rat treated by oral route, the excretion of PHA-848125 in bile 
accounted for about 15% of the administered dose. Overall, the excretion data suggested that 
the compound was mainly eliminated via metabolic transformations.  
Metabolism studies (in vitro and in vivo) showed that the major route of metabolism of 
PHA-848125 was the N-oxidation of the N-methyl piperazine moiety to give the metabolite 
M1 (NMS-867734). More than one enzymatic pathway is involved in the metabolism of this 
compound, decreasing the risk for unwanted clinical relevant drug-drug interactions. From a 
qualitative point of view no species differences were observed in the metabolism of PHA-
848125 and no unique metabolite was detected in human microsomes. Given these results, 
both monkeys and dogs represented suitable nonrodent species for the conduct of repeat-
dose toxicological studies. The plasma profile of NMS-867734 was investigated in rats and 
monkeys showing a metabolite/parent AUC ratio of 0.2-0.4 and 0.05, respectively. 
PHA-848125 did not activate human and mouse PXR, suggesting that the compound is 
unlikely to increase the CYP3A mediated enzyme activities by increasing its gene 
transcription. PHA-848125 showed some competitive inhibition on CYP3A4 (Ki = 2.4 M 
and 18.7 M using triazolam and testosterone as substrate, respectively) at concentrations 
much higher than those needed for the pharmacological activity (Ki = 32 nM for 
CDK2/Cyclin A complex). 

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3.2.5. Toxicology 
PHA-848125 was characterized in single and repeat-dose toxicity studies in rats, dogs and 
monkeys. PHA-848125 was also characterized by in vitro genotoxicity and dermal and 
ocular irritation studies. 
Single-dose toxicity studies were carried out administering PHA-848125 by oral route in 
rats, dogs and monkeys. Effects related to the mechanism of action of the compound were 
seen in the hemolymphopoietic (HLP) system, the gastrointestinal (GI) tract and the male 
reproductive organs in all species. Regression was observed at the end of the 2-week 
recovery period for all the changes except for the testes, as expected considering the time of 
maturation of the seminiferous epithelium. Additional toxicities, apparently not related to the 
mechanism of action of the compound, were the vascular effects (congestion and 
hemorrhages in several organs) and the CNS toxicity observed in dogs.  
In rats, no mortality was observed up to the highest administered single dose of 160 mg/kg. 
The dose of 40 mg/kg (mean AUC = 69 M·h) was the NOAEL in rats after single oral 
administration.  
In dogs, one female given the highest dose of 69.1 mg/kg was sacrificed 9 h after treatment 
due to the severe clinical signs of CNS toxicity (tremors, incoordination, convulsions). In 
this animal, the AUC(0-8h) measured before death was 31.69 M·h. In addition, this dog 
showed hemorrhages in several organs and multifocal edema in the brain. The dose of 34.5 
mg/kg (mean AUC = 17 M·h) was the MTD in dogs after single oral administration.  
In monkeys, no mortality or significant signs of toxicity were observed after the 
administration of single oral doses up to 69.1 mg/kg (mean AUC = 31 M·h). 
Repeat-dose toxicity studies were conducted with PHA-848125 administered by oral route 
daily for 4/7 days, 4 weeks or 3 months period. Noteworthy effects of PHA-848125 in the 
repeat-dose toxicity studies included changes in the HLP system, GI tract and male 
reproductive organs in all species. Effects on female reproductive organs were also seen in 
rats and dogs. The effects on the HLP system were dose-related and were observed at all 
doses tested. In dogs, GI toxicity was seen at all doses with dose-relationship independently 
of the treatment schedule. All the above changes recovered after drug withdrawal, with the 
exception of the effects on the male reproductive system, which were still present at the end 
of the recovery period. 
Additional toxicities, that are considered not related to the mechanism of action of the 
compound, were CNS, ocular and renal toxicities. In addition, hemorrhages in different 
organs were observed in dogs and monkeys 
Clinical signs of CNS toxicity, characterized by tremors, increased reactivity, incoordination 
and convulsions were noted at high doses given as single administration in dogs or repeated 
administrations in rats and monkeys. This effect, observed at daily AUC  30 M·h, 

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recovered after drug withdrawal and was not supported by any morphological change in the 
brain. 
Ocular toxicity was observed in rats after prolonged administration ( 1 month) of PHA-
848125. Bilateral retinal atrophy occurred from the dose of 16 mg/kg/day in females (daily 
AUC = 27 M·h) and at 24 mg/kg/day in males (daily AUC = 38 M·h) in the 4-week 
study. The same finding was seen in rats given the dose of 16 mg/kg/day for 3 cycles of 3 
weeks + 1 week rest or 5 cycles of 2 weeks + 1 week rest (mean daily AUC from 25.5 to 
34.5 M·h). This effect did not regress after the 2- or 4-week recovery periods. The dose of 
8 mg/kg/day, given for 4 consecutive weeks or cyclically for 3 months, corresponding to 
mean daily AUC values of  9.8 and 11.7 M·h, respectively, was the NOEL for ocular 
changes. No retinal changes were seen in rats following administration of PHA-848125 for 7 
consecutive days up to the highest dose (51.8 mg/kg/day) or a daily AUC of about 50 M·h. 
Other effects, observed at lethal doses, involved the kidneys (cortical tubular nephropathy) 
in dogs at the dose of 8 mg/kg/day administered as two 2-week cycles (daily AUC 15 M·h) 
and at 12 mg/kg/day as two 1-week cycles (daily AUC  15 M·h). Some changes were also 
seen in monkeys at the toxic dose of 15.97 mg/kg/day given for 7 days (daily AUC 71 M·h 
in the only surviving animal). Renal changes did not completely regress at the end of the 
recovery period. 
Congestions and hemorrhages in different organs occurred following repeated 
administrations of PHA-848125 at high toxic lethal doses in dogs (34.5 mg/kg/day for 4 
days; daily AUC  27 M·h) and in monkeys (15.97 mg/kg/day for 4 and 7 consecutive 
days; daily AUC > 30 M·h). 
PHA-848125 was not genotoxic in the Ames test and did not induce any structural or 
numerical chromosome aberrations in human peripheral blood lymphocytes in vitro. 
In the dermal and ocular irritation tests, PHA-848125 was not irritating to the skin of rabbits, 
while it induced severe irritant reactions when applied to the eye of rabbits for 1 h. A 
complete recovery occurred within 10-16 days. 
3.2.6. Drug-Drug Interactions 
As detailed in Section 3.2.4, more than one enzymatic pathway is involved in the 
metabolism of PHA-848125AC, decreasing the risk for unwanted clinical relevant drug-drug 
interactions. Also, PHA-848125 did not activate human and mouse PXR, suggesting that the 
compound is unlikely to increase the CYP3A mediated enzyme activities by increasing its 
gene transcription. 
Significant drug-drug-interactions are therefore not expected.   

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3.2.7. Phase I clinical trials 
Details regarding the results of the clinical studies are contained in the PHA-848125AC 
Investigator Brochure, Version 7, 2011 [23]. 
PHA-848125AC is in phase I-II clinical development as an oral anti cancer treatment for 
patients with advanced malignancies.  
The phase I clinical program of PHA-848125AC as a single agent is ongoing with three 
studies testing four different schedules (daily x 7 every 2 weeks; 4 days on / 3 days off x 3 
weeks every 4 weeks; daily x 21 days every 4 weeks; daily x 14 days every 3 weeks), being 
conducted in US and Europe. Both a flat dose approach and a BSA-based approach have 
been investigated. A phase I study in combination with gemcitabine is also ongoing in 
Europe. As for phase II, three indications are currently under evaluation in Europe and in the 
US with the compound administered as a single agent in second-line treatment for 
glioblastoma, mesothelioma and thymic carcinoma.  
As of 30 September 2009, overall, a total of 106 patients (376 cycles) have been treated with 
PHA-848125AC as a single agent and 15 patients (61 cycles) were treated with PHA-
848125AC in combination with gemcitabine.  
The clinical experience gained so far indicated, overall, a similar pattern of toxicity across 
studies. The safety profile of the compound is characterized by a dose-limiting neurological 
toxicity and, to a lesser extent, by gastrointestinal toxicity. Nausea and/or vomiting and /or 
diarrhea were mostly of grade 1- 2 in severity and were manageable with appropriate 
therapy, including hydration. Haematological toxicity, mainly represented by neutrophils 
and platelets decrease, was also reported in some patients. Prolonged transaminitis was 
occasionally observed (but effects on liver enzymes appeared more pronounced with the 
daily x14 days every 3 weeks schedule than with the 7 days on / 7 days off schedule).  
The neurological toxicity consisted mainly in tremors and ataxia. In patients treated under 
the first schedule (7 days on /7 days off, flat dose) in study CDKO-125a-001 (where the 
highest doses of PHA-848125AC were administered), mild, short-lasting tremors were 
observed starting from the dose of 100 mg/day, increasing in frequency and in severity at 
200 mg/day and 300 mg/day. Grade 3 ataxia was repeatedly observed starting from the dose 
of 200 mg/day, where a mean Day 7 AUC0 – 24 of 29.2 M·h was reported, but occurred also 
in one patient (grade 2) after 7 cycles of treatment at 150 mg/day (in this patient, treatment 
was continued at a reduced dose of 100 mg/day, with no further episodes of the event). 
Tremors and ataxia progressively increased in frequency and severity with the dose, 
becoming dose-limiting at doses > 150 mg/day. These events were anyway reversible in all 
cases in up to 7-8 days, upon drug discontinuation.  
With the 7 days on /7 days off schedule, the MTD was attained at the dose of 200 mg/day.  
The Phase II recommended dose (RP2D) with this schedule of administration was identified 
in 150 mg/day. At the RP2D, where a mean Day 7 AUC0 – 24 of 25.3 M·h was measured, 
fatigue, tremors and GI tract toxicity (especially nausea and diarrhea) were the most 
common events. These effects were generally mild to moderate (of maximum grade 2 in the 

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majority of cases, with grade 3 events - diarrhea and dehydration - in two instances only), 
easily manageable and reversible. Ataxia (grade 2) was observed only in one patient after 7 
cycles of treatment. No grade 4 adverse events were reported. Hematologic toxicity was 
mild/moderate and sporadically recorded. The effects on liver function were mild and non 
clinically relevant. The effects on renal function were non important. Overall, all effects 
were easily manageable and reversible. 
In the same CDKO-125a-001 study, for the patients treated under the second schedule (4 
days on / 3 days off x 3 weeks every 4 weeks, flat dose) ataxia was never reported, but grade 
1 tremors were common findings at doses below 200 mg/day, reaching grade 2-3 in severity 
and qualifying for DLTs at 200 and 180 mg/day. With the 4 days on / 3 days off x 3 weeks 
every 4 weeks schedule, the MTD was attained at the dose of 180 mg/day and the dose of 
150 mg/day (mean Day 18 AUC0 – 24 of 19.5 M·h) resulted to be the dose recommended for 
phase II investigations also with this schedule, confirming an overall good tolerability, with 
maximum grade 1-2 events in the majority of cases. 
As for ocular toxicity, at the RP2D of 150 mg/day with the 7 days on / 7 days off schedule, 
no ERG abnormalities were detected (4/6 patients evaluable, median cumulative dose of 
4050 mg [range 2250-5250 mg]). More significantly, during the course of the CDKO-125a-
001 study, on a total of 37 patients (both schedules), no significant signs or symptoms of 
ocular toxicity attributed to the study drug were reported, even for patients treated for a long 
period of time (up to 2 years). 
With the 14 days every 3 weeks schedule (studied in the CDKO-125a-002 malignant glioma 
protocol), the effects on liver function appeared to be dose-dependent, starting from the 
second dose level of 36 mg/m2/day, with bilirubin and transaminase elevations of grade 2-3, 
becoming dose-limiting at 72 mg/m2/day. The other effects, i.e. neurological effects, 
diarrhea, nausea and vomiting and hematological toxicity, were in line with the already 
known toxicity pattern of the compound. No important effects on renal function were noted.  
The RP2D of 54 mg/m2/day was mainly characterized by mild /moderate hematologic 
toxicity in 6/8 patients (maximum grade 2), by reversible tremors in 2/8 patients (maximum 
grade 2), and by transaminase elevations in 5/8 patients (maximum grade 3), which, 
although transient, might be prolonged up to 5 weeks after treatment. Bilirubin elevation was 
also reported in 5/8 patients (maximum grade 2). Nausea and vomiting were mild and 
present only in 2/8 patients. Mild creatinine elevation was evident in 3/8 patients and 
(moderate) diarrhea was occasionally reported. Overall, the tolerability of the 54 mg/m2/day 
dose is acceptable and manageable, paying particular attention to the effects on liver. 
This same schedule (14 days every 3 weeks) studied on solid tumors patients (CDKO-125a-
003 study), did not evidence any major difference in tolerability compared to the CDKO-
125a-002 study.  
Regarding ocular toxicity, some differences were noted between the prolonged schedules 
(for 14 or 21 consecutive days) compared to the 7 days on / 7 days off schedule. In fact, with 
the 21 and the 14 days schedules, an ERG worsening although clinically asymptomatic, was 

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reported in two patients (at the MTD in both cases). No ERG worsening nor visual acuity 
and funduscopic alterations were reported at the RP2D (of note, one patient remained on 
treatment with the 14 consecutive days schedule for 12 cycles [9 months] without any sign 
or symptom of ocular toxicity). 
The combo study CDKO-125a-004 indicated that the combination PHA-848125AC and 
gemcitabine is feasible, with no significant overlapping toxicities between the two 
compounds. The dose level of 80 mg/m2/day of PHA-848125AC + 1000 mg/m2 gemcitabine 
can be regarded as the recommended phase II dose (RP2D) for further investigations in solid 
tumors. 
In the first US Phase I study, under the first schedule of treatment, a stable disease (SD) 
lasting > 11 months was observed in a patient with colorectal cancer treated at 150 mg/day 
and another SD lasting > 4 months was reported in a patient with NSCLC who received 9 
cycles at 200 mg/day (then reduced to 100 mg/day). In this same study, under the second 
schedule of treatment, two thymic carcinoma patients presented a confirmed PR by RECIST: 
one patient showed a PR at cycle 10, confirmed at cycle 11, in pleural and lung lesions, 
lasting until cycle 13. A second patient showed a PR at cycle 6 confirmed at cycle 7. In 
addition, a patient with pancreatic cancer remained on treatment with SD lasting > 7 months.  
Indications of antitumor activity were present also in other clinical studies: one glioblastoma 
patient is continuing on study PD-free for 7+ cycles of treatment and, in the second, 
European phase I study in solid tumors, one patient with parotid gland carcinoma remained 
on treatment with SD for 12 cycles (9 months). Of note, on skin biopsies collected in 
consenting patients before and after treatment in this same study, biomarker analysis by both 
IHC (Cyclin A and Ki67) and PCR (expression of 70 genes), indicated a biomarker 
modulation consistent with the given doses.   
3.2.8. Pharmacokinetics in Humans 
The pharmacokinetics of PHA-848125AC and its major metabolite, NMS-867734 (M1), has 
been investigated in the three ongoing phase I clinical trials CDKO-125a-001, CDKO-125a-
002, CDKO-125a-003. Results for PHA-848125AC are summarized in Table 1, Table 2 and 
Table 3, respectively. 
In particular, in the CDKO-125a-001 study, first schedule, which is the same schedule 
adopted in the present study, the pharmacokinetic profile of PHA-848125AC was 
characterized by: 
 achievement of maximal plasma concentration at 2 - 4 hours post dosing, after single and 
repeated administration 
 terminal half-life in the range of 30 and 40 hours 
 good dose proportionality in systemic exposure, in the range of 50-300 mg/day 
 similar exposure to the compound after subsequent cycles of treatment 

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 inter-patient variability limited 
 AUC of the major metabolite lower than that of the parent compound, accounting for 
30-50%. Its half-life is comparable to or slightly longer than that of the parent 
compound. 
Of note, at the RP2D of 150 mg/day, selected in the present study: 
 on day 1 in cycle 1, maximal plasma concentration was 0.660.24 M (n=6), attained on 
average at 2.5 h post-dosing. The corresponding daily AUC was 8.862.64 Mh (n=6). 
 after seven days of treatment in cycle 1, maximal plasma concentration was 1.470.51 
M (n=6), attained on average at 2.5 h post-dosing and corresponding to a daily AUC of 
25.318.56 Mh (n=6). 
 the day 7/day 1 AUC(0-24h) ratio was around 3, in line with what was expected 
considering the schedule and the half-life of the compound that at this dose level was on 
average 33.3 hours. 
Overall, at similar doses administered with different schedules, comparable PHA-848125AC 
PK profile was observed across studies. 
For more details on PHA-848125AC, please refer to Investigator Brochure for 
PHA-848125AC, Version 7, 2011 [23]. 

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Table 1. PHA-848125AC pharmacokinetic data from CDKO-125a-001 study 
CDKO-125a-001 first schedule (7 days on, 7 days off q2wks) 
Day 
 
Dose 
(mg/day) 
No. of 
Pts 
Cmax 
(M) 
AUC0-t(24h) 
(M h) 
tmax (h) 
t1/2,z 
(h) 
1 
50 
3 
0.20.06 
2.560.52 
3.351.17 
N/A 
7 
50 
3 
0.40.15 
6.842.21 
3.331.15 
32.812.2 
1 
100 
6 
0.440.07 
6.192.26 
3.52.51 
N/A 
7 
100 
6 
1.20.47 
19.910.5 
2.761.89 
38.29.28 
1 
150 
6 
0.660.24 
8.862.64 
2.51.22 
N/A 
7 
150 
6 
1.470.51 
25.38.54 
2.51.22 
33.37.08 
1 
200 
6 
0.560.11 
8.411.68 
41.26 
N/A 
7 
200 
6 
1.680.17 
29.24.5 
4.331.51 
31.84.68 
1 
300 
1 
1.15 
22.3 
2 
N/A 
7 
300 
1 
5.12 
83.6 
4 
31.3 
CDKO-125a-001 second schedule (4 days on, 3 days off x 3wks q4wks) 
Day 
 
Dose 
(mg/day) 
No. of 
Pts 
Cmax 
(M) 
AUC0-t(24h) 
(M h) 
tmax (h) 
t1/2,z 
(h) 
1 
150 
3 
0.42±0.1 
6.67±1.72 
4±0 
N/A 
18 
150 
3 
1.08±0.07 
19.5±4.27 
3.13±1.96 
41±3.01 
1 
180 
1 
0.55 
6.67±1.72 
2 
N/A 
18 
180 
1 
1.22 (Day 4) 
6.67±1.72 
4 
-- 
1 
200 
4 
0.79±0.5 
9.58±7.34 
2±0 
N/A 
18 
200 
3 
2.33±0.58 
33.3±2.56 
1.71±0.44 
25.9±8.38 
N/A: not applicable 
 

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Table 2. PHA-848125AC pharmacokinetic data from CDKO-125a-002 study 
CDKO-125a-002 (14 days on, 7 days off q3wks) 
Day 
 
Dose 
(mg/m2/day) 
No. of 
Pts 
Cmax 
(M) 
AUC0-t(24h) 
(M h) 
tmax (h) 
t1/2,z 
(h) 
1 
18 
5 
0.103±0.042 
1.7±0.487 
4.8±1.09 
N/A 
14 
18 
4 
0.248±0.064 
4.08±1.23 
2.5±1 
40.1±6.68 
1 
36 
4 
0.218  0.031 
3.4  0.941 
3  1.15 
N/A 
14 
36 
3 
0.681  0.204 
11.4  3.77 
2  0 
33  5.87 
1 
54 
8 
0.320  0.085 
4.40  1.07 
2.4  1.06 
N/A 
14 
54 
7 
0.860  0.270 
15.4  6.54 
3.43  1.51 
36.1  5.5.3 
1 
72 
3 
0.453  0.127 
5.94  1.52 
2.7  1.16 
N/A 
14 
72 
2 
1.5  0.304 
21.7  2.47 
1.5  0.71 
40.2  5.69 
N/A: not applicable 
 
Table 3. PHA-848125AC pharmacokinetic data from CDKO-125a-003 study 
CDKO-125a-003 first schedule (21 days on, 7 days off q4wks) 
Day 
 
Dose 
(mg/m2/day) 
No. of 
Pts 
Cmax 
(M) 
AUC0-t(24h) 
(M h) 
tmax (h) 
t1/2,z 
(h) 
1 
16 
7 
0.220.28 
2.542.92 
2.861.57 
N/A 
21 
16 
6 
0.250.08 
4.071.29 
2.961.15 
33.610 
1 
24 
6 
0.20.09 
2.480.92 
1.781.26 
N/A 
21 
24 
5 
0.420.2 
6.242.44 
2.432.05 
37.15.77 
CDKO-125a-003 second schedule (14 days on, 7 days off q3wks) 
Day 
 
Dose 
(mg/m2/day) 
No. of 
Pts 
Cmax 
(M) 
AUC0-t(24h) 
(M h) 
tmax (h) 
t1/2,z 
(h) 
1 
24 
3 
0.180.05 
2.320.54 
2.31.5 
N/A 
14 
24 
3 
0.450.22 
7.13.94 
1.70.6 
41.24.26 
1 
48 
4 
0.30  0.08 
4.55  1.14 
3.7  2.0 
N/A 
14 
48 
4 
0.73  0.33 
12.9  6.46 
3.0  1.15 
32.0  4.63 
1 
72 
4 
0.54  0.11 
6.77 1.50 
2.0  0 
N/A 
14 
72 
3 
1.19  0.43 
14.8  6.14 
2.0  0 
25.5  6.29 
N/A: not applicable 

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3.3. Rationale for the use of PHA-848125AC in Thymic Carcinoma 
Chemotherapy was shown to have significant antitumor activity against unresectable 
metastatic thymomas and thymic carcinomas, but an optimal treatment strategy has not been 
determined and other drugs are needed to improve the outcome of patients with recurrent 
invasive tumors [10]. 
In recent years, a few studies on molecular changes in thymomas point to alterations that 
may be of use in selecting patients for targeted therapies [4-8]. Unfortunately for some of 
them, such as KIT and EGFR inhibitors, the reported results seem to be discouraging [12-
14]. In addition, despite a lack of correlation of thymidilate synthase expression with 
thymoma clinicopathological characteristics, pemetrexed obtained interesting responses in 
stage IVA thymomas, but not in thymic carcinomas [20]. 
The pyrazoloquinazoline PHA-848125 is a compound counteracting the effects of some of 
the other so far identified, but not yet exploited, molecular alterations found in thymoma and 
thymic carcinoma, e.g. underexpressed p21 and p27 and overexpressed TRKA [7,8]. These 
targets are not yet been investigated in therapeutic intent clinical trials. 
In fact, p21 and p27 encode natural potent cyclin-dependent kinase inhibitors and their 
ablation in the cancer cell results in an activation of cyclin E/CDK2 or cyclin D/CDK4 
complexes and thus in uncontrolled cell cycle progression and cell proliferation [24-32], 
while TRKA activation promotes tumor growth [33], probably through MAPK pathway 
activation. PHA-848125 potently inhibits both the CDK/Cyclin complexes and TRKA, 
proposing in this way to be a “selective dual inhibitor” and appearing particularly attractive 
in this disease. 
The preliminary results in early clinical trials (2 out of 3 patients with type B3 and C thymic 
malignancies showing objective partial response) support this hypothesis and provides the 
rationale for this phase II study. 
An exploratory analysis on the relationship of p53 (natural regulator of p21), p21, p27, 
cyclin D1, p75, TRKA expression and TRKA gene copy number in tumor biopsies obtained 
before study entry with treatment efficacy variables will be possibly performed in all 
patients. 
4. TRIAL OBJECTIVES AND ENDPOINTS 
4.1. Objectives 
4.1.1. Primary Objective 
 Assessment of the antitumor activity of PHA-848125AC in patients with recurrent or 
metastatic, unresectable B3 thymoma or thymic carcinoma who have received more than 

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one line of prior systemic therapy for advanced / metastatic disease. Antitumor activity 
will be evaluated on the basis of the progression-free survival status at 3 months. 
4.1.2. Secondary Objectives 
 Assessment of additional measures of tumor control to further characterize the efficacy 
profile of PHA-848125AC in recurrent or metastatic, unresectable B3 thymoma or 
thymic carcinoma patients who have received more than one line of prior systemic 
therapy for advanced / metastatic disease. 
 Evaluation of the safety profile of repeated administrations of PHA-848125AC in 
patients with recurrent or metastatic, unresectable B3 thymoma or thymic carcinoma 
who have received more than one line of prior systemic therapy for advanced / metastatic 
disease. 
4.1.3. Exploratory Objective 
 Relationship of p53, p21, p27, cyclin D1, p75, TRKA expression and TRKA copy 
number in tumor biopsies obtained before study entry with treatment efficacy. Additional 
biomarkers under validation may also be evaluated. 
4.2. Endpoints  
4.2.1. Primary Endpoint 
 Progression-free survival rate at 3 months (PFS-3 rate). The PFS-3 rate, will be 
calculated as the proportion of evaluable patients (see Section 12.2) known to be alive 
and progression-free at ≥ 3 months since study treatment start out of the total number of 
evaluable patients. 
4.2.2. Secondary Endpoints 
 Objective Response Rate (CR + PR) according to RECIST guideline (version 1.1). 
 Disease Control Rate (Objective Response Rate +  6 weeks SD rate). 
 Progression-free survival, calculated as the time from the date of treatment start to the 
date of first documentation of objective progression or of death due to any cause, 
whichever comes first.  
 Duration of Response, measured from the time measurement criteria are first met for 
CR/PR (whichever is first recorded) until the first date that recurrent or progressive 
disease is objectively documented (taking as reference for progressive disease the 
smallest measurements recorded on study). 
 Overall Survival (OS), i.e. the time from the date of treatment start to the date of death 
from any cause. 

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 Overall safety profile, evaluated on the basis of laboratory and clinical safety parameters 
(i.e. hematology and blood chemistry, urinalysis, vital signs, ophthalmologic 
examinations and adverse events emerging during the trial).  The National Cancer 
Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) Version 3.0 
will be used for the severity grading of adverse events and of hematological and blood 
chemistry abnormalities. 
4.2.3. Exploratory Endpoint 
 Characterization of p53, p21, p27, cyclin D1, p75 and TRKA basal expression by IHC 
and TRKA copy number by FISH in tumor tissue involved in the PHA-848125AC 
mechanism of action will be performed in tumor tissue of consenting patients. Additional 
biomarkers under validation may also be evaluated. Assessments will be done on 
paraffin embedded material, obtained from patients before study entry.  
5. TRIAL DESIGN AND DESIGN RATIONALE 
In consideration of the exploratory nature of the study, a single-arm, open-label, multicenter 
phase II clinical trial design including an early stopping rule is adopted for this study of 
PHA-848125AC, administered to patients with recurrent metastatic unresectable B3 
thymoma or thymic carcinoma who have received more than one line of prior systemic 
therapy for advanced / metastatic disease.  
The intent of the study is to assess the antitumor activity of PHA-848125AC and ultimately 
to improve the outcome of the patients. To this purpose, the progression free survival rate at 
3 months is considered to be an appropriate primary endpoint.  
Patients will receive repeated cycles of PHA-848125AC administered orally once daily at 
the flat dose of 150 mg/day, according to a 7 days on / 7 days off schedule in 2-week cycles. 
A treatment cycle will therefore comprise 7 days of PHA-848125AC administration (Days 1 
to 7) followed by 7 days of rest (Days 8 to 14) for a total of a 14 days period (2-week cycle). 
The 150 mg/day dose has been selected based on the results of the first single agent Phase I 
study in solid tumor patients (CDKO-125a-001), where PHA-848125AC was administered 
with the same schedule, at escalating dose levels, ranging from 50 to 300 mg/day: the dose 
of 150 mg/day was assessed as the dose recommended for Phase II investigations (RP2D); 
this dose was associated with mild/moderate reversible adverse events, mostly represented 
by maximum grade 2 nausea and/or vomiting and/or diarrhea and maximum grade 2 
neurological effects. 
Patients may continue on study treatment until disease progression, patient refusal or 
withdrawal of patient consent, or the occurrence of unacceptable toxicity and will be 
followed up for survival up to the end of the study and in any case for no more than 2 years 
from the end of treatment. 
 

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All patients will be evaluated clinically and with laboratory tests once at the end of each 
cycle (every 2 weeks and more frequently if medically indicated). 
The schedule of the visits to the site will be once at the end of each cycle during the first 3 
months of treatment (6 cycles). Patients remaining on treatment for longer than 3 months 
will be followed at the site once every 3 cycles (once every 1.5 month). The interval 
evaluation will be as follows: 
- the patient will perform the laboratory tests locally 
- the investigator or his delegate will contact the patient to ascertain whether a toxicity 
occurred. With this information the investigator decides whether the patient may continue 
the treatment or should visit the site for evaluation. The Investigator must document in 
writing the results of the phone call in a specific form and data are to be reported in the CRF. 
In the event the patient was not taking all the drug that he has received and he/she is off 
treatment, it is mandatory that he/she will be back to the site for performing the assessments 
required at the last cycle and for drug's return. 
A cut-off date is planned on 31 May 2017 in order to proceed with clinical database closure 
and preparation of the clinical study report. 
The management of patients after the cut-off date of 31 May 2017 should be conducted as 
per Section 9.5. 
The study will enroll 30 patients who have received at least two prior therapies. Accounting 
for a 10%-15% proportion of non evaluable patients, an accrual ceiling up to 35 patients will 
be set for completing the trial. In case of identification of a clearly unacceptable progression 
free proportion by 3 months of treatment, an early stopping rule will be invoked. 
For statistical considerations, see Section 12. 
6. SUBJECT SELECTION 
This clinical trial can fulfill its objectives only if appropriate subjects are enrolled.  The 
following eligibility criteria are designed to select subjects for whom protocol treatment is 
considered appropriate.  All relevant medical and non-medical conditions should be taken 
into consideration when deciding whether this protocol is suitable for a particular subject.  
Eligibility criteria may not be waived by the investigator and are subject to review in the 
case of a Good Clinical Practices (GCP) or a regulatory authority audit.  Any questions 
regarding a subject’s eligibility should be discussed with NMS Study Management prior to 
enrollment. 
6.1. Subject Inclusion Criteria 
Subjects must meet all of the following inclusion criteria to be eligible for enrollment into 
the study:  

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1. Signed and dated IRB/IEC-approved Informed Consent. 
2. Histologically or cytologically proven diagnosis of unresectable B3 thymoma or thymic 
carcinoma recurrent or progressing after more than one prior systemic therapy for 
advanced / metastatic disease. 
Note: Any adjuvant and neoadjuvant systemic therapy followed by the recurrence of the 
disease within 12 months after the start of the adjuvant treatment will be considered as 
one therapy for advanced / metastatic disease. 
3. Presence of measurable disease defined as at least one lesion that can be accurately 
measured by CT scan in at least one dimension, as  10 mm for non nodal lesions 
(longest diameter to be recorded) and  15 mm for lymph nodal lesions (short axis to be 
recorded). (CT scan is the desirable method for lesion measurement. Other measurement 
techniques [eg MRI] are acceptable [but not for lung lesions] provided that the size of 
the measurable lesion is twice the slice thickness of the MRI). 
Tumor lesions situated in a previously irradiated area, or in an area subjected to other 
loco-regional therapy, are usually not considered measurable unless there has been 
demonstrated progression in the lesion. 
4. Age  18 years. 
5. ECOG performance status 0-1. 
6. Estimated life expectancy of at least 3 months. 
7. Negative pregnancy test (if female in reproductive years). 
8. Agreement upon the use of effective contraceptive methods (hormonal or barrier method 
of birth control, or abstinence) prior to study entry and for the duration of study 
participation, if men and women of child producing potential. 
9. Adequate liver function: 
 Total Serum Bilirubin            1.5 x upper limit of normal (ULN) 
 Transaminases (AST/ALT)    2.5 ULN (if liver metastases are present, then  5  
 
 
 
 
 ULN is allowed) 
 ALP 
 
 
           2.5 ULN (if liver and/or bone metastases are present, 
 
 
 
 
  then  5 ULN is allowed). 
10. Adequate renal function: 
 Serum Creatinine 
           ULN 
or 
 
Creatinine Clearance calculated by Cockcroft and Gault’s formula > 60 mL/min. 
11. Adequate hematologic status: 
 ANC   
 
           1,500 cells/mm3  

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 Platelet Count  
           100,000 cells/mm3 
 Hemoglobin     
           9.0 g/dL.  
12. At the time of start of treatment, at least 2 weeks or 5 medication half-lives (whichever is 
longer) must have elapsed since completion of prior systemic therapy and at least 2 
weeks since completion of prior minor surgery and radiotherapy (provided that no more 
than 25% of bone marrow reserve has been irradiated). 
13. With the exception of alopecia, resolution of all acute toxic effects of any prior 
chemotherapy, surgery or radiotherapy to NCI CTC (Version 3.0) grade  1 and to the 
baseline laboratory values as defined in Inclusion Criteria Number 9, 10, 11. 
14. Able and willing to comply with scheduled visits, therapy plans, and laboratory tests 
required in this protocol. 
15. Capability to swallow capsules intact (without chewing, crushing, or opening). 
6.2. Subject Exclusion Criteria 
The presence of any of the following will exclude a subject from study enrollment: 
1. Any of the following in the past 6 months: myocardial infarction, uncontrolled cardiac 
arrhythmia, unstable angina, coronary/peripheral artery bypass graft, symptomatic 
congestive heart failure, cerebrovascular accident or transient ischemic attack, 
pulmonary embolism, deep vein thrombosis. 
2. Grade >1 retinopathy as determined by an ophthalmologist. 
3. Known brain metastases. 
4. Major surgery, other than diagnostic surgery, within 4 weeks prior to treatment. 
5. Active, uncontrolled bacterial, viral, or fungal infections. 
6. Known infection with HIV, active hepatitis B or hepatitis C. 
7. Pregnant or breast feeding women. 
8. Previous (within the last 5 years) or current malignancies at other sites, except for 
adequately treated basal cell or squamous cell skin cancer or in situ carcinoma of the 
cervix uteri. 
9. Current enrollment in or participation in another therapeutic clinical trial within 4 weeks 
preceding treatment start. 
10. Diabetes mellitus uncontrolled. 
11. Gastrointestinal disease (e.g. Crohn’s disease, ulcerative colitis, or short gut syndrome) 
that would impact on drug absorption. 
12. Patients under treatment with anticoagulants or with coagulation disorders or with signs 
of hemorrhage at baseline. 

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13. Patients with previous history or current presence of neurological disorders (with the 
exception of myasthenia gravis), including epilepsy (although controlled by 
anticonvulsant therapy), Parkinson’s disease and extra-pyramidal syndromes. 
14. Other severe acute or chronic medical or psychiatric condition or laboratory abnormality 
that may increase the risk associated with study participation or may interfere with the 
interpretation of study results and, in the judgment of the Investigator, would make the 
patient inappropriate for entry into this study or could compromise protocol objectives in 
the opinion of the Investigator and/or the Sponsor. 

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7. SCHEDULE OF EVENTS 
The following table summarizes information on the timing of study assessments. 
SCHEDULE OF EVENTS 
Protocol Activities 
and Forms to Be Completed 
Pre 
Treatment 
Treatment 
Post Treatment 
Cycles 
Last 
Cycle 
 21 
Days 
 7 
Days 
Week 1 
Day 1 (*) 
Week 2 
between Days 
11-14 
AE 
FU 
(§) 
Follow up 
Informed Consent 1 
X 
 
 
 
 
 
 
Medical/ Oncologic History & 
Physical Examination 2 
X 
 
 
X 
 
 
 
Vital Signs 3 
 
X 
X 
 
 
 
 
ECG 4 
X 
 
As medically indicated 
X 
 
 
Chest X-Ray 5 
X 
 
 
 
X 
 
 
Ophthalmologic exam. 6 
X 
 
 
X
6  
X 
 
 
Laboratory Assessments 
Serum/ Urine Pregnancy Test 7 
 
X 
 
 
 
 
 
Urinalysis 8 
 
X 
X (*) 
(Cycle 1 only) 
X (even cycles)  
X 
 
 
Hematology 9 
 
X 
X (*) 
X 
 
 
 
Blood Chemistry 10 
 
X 
X (*) 
X 
 
 
 
Coagulation 11 
 
X 
X (*) 
(Cycle 1 only) 
X (even cycles)  
X 
 
 
Tumor Assessments 
Tumor Imaging: 
chest/abdomen/pelvic CT scan or 
MRI 12 
X 
 
q6wks  
(see footnote for assessment at 
month 3) 
X 
 
q6wks 
Survival 13 
 
 
 
 
 
 
q6wks 
(+ q6mos) 
Other Clinical Assessments 
Adverse Event Assessment  
(including neurological status 
evaluation)  14 
 
X 
X 
 
X 
 
Concomitant Medications 15 
 
X 
X 
 
 
 
Special Studies 
Biomarker Status Assessment 16 
X 
Pharmacokinetic Blood Sampling 17 
 
 
As needed 
 
 
Histological confirmation 18 
X 
Study Treatment 
Enrollment 19 
 
X 
 
 
 
 
 
PHA-848125AC Administration 20 
 
 
Once daily for 7 
cons. days 
(D1 to D7) 
 
 
 
 

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Footnotes for Schedule of Events 
1. Informed Consent: Every patient must sign the informed consent to participate in this trial before starting any trial related 
procedures. After signature, a Patient Screening Number is assigned centrally by CLIOSS 
2. Medical/Oncology History & Physical Examination: Includes oncologic history, history of other disease processes 
(active, controlled or resolved) and concomitant illnesses (all of them at pretreatment only).  Physical examination will be done 
at pretreatment, and, on treatment, at the end of each cycle during the first three months of treatment (6 cycles) (see Section 
11.4.3 Other safety assessments). For patients remaining on treatment for a period of time more than 6 cycles, the physical 
examination will be done in concomitance with the visit to the site (once every 3 cycles, 1.5 months).  Oncologic and non-
oncologic medical histories, including prior antitumor treatments/procedures, are to be reported in the relevant case report 
form (CRF). 
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
3. Vital signs: Blood pressure/pulse (supine): at baseline and on Day 1 of each treatment cycle, before treatment 
administration. Height (in cm or inches): at baseline only.  Weight (in kilograms or pounds): at baseline and on Day 1 of each 
treatment cycle. ECOG performance status: at baseline and on Day 1 of each treatment cycle. Temperature (in °C or in °F): at 
baseline and on Day 1 of each treatment cycle.  
For patients remaining on treatment for a period of time more than 6 cycles, vital signs (including blood pressure/pulse, weight 
and temperature) will be done in concomitance with the visit to the site (once every 3 cycles, 1.5 months).  
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
4. ECG: 12-lead study. To be done at baseline, at the end of the last cycle and to be repeated during treatment as medically 
indicated. 
5. Chest X-Ray: Mandatory at screening visit and at the end of last cycle as safety assessment.  
6. Ophthalmologic Examination: to be conducted at baseline, at the end of even cycles (between days 11 and 14) during 
the first three months of treatment (6 cycles), at 4.5 months (ninth treatment cycle, between days 11 and 14) and then after 
every three months and at the end of last cycle. Includes visual acuity test and fundoscopic examination by an 
ophthalmologist. Additional assessments will be performed if clinically indicated. Ophthalmologic evaluations will be possibly 
done by the same ophthalmologist for a given patient.  
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
7. Pregnancy Test: For women of reproductive potential.  Must be done within 7 days prior to initial study treatment. 
8. Urinalysis: pH, dipstick for glucose, protein and blood. To be done at baseline and at the end of last cycle. During 
treatment, should be performed at the end of even cycles (between days 11 and 14). For patients remaining on treatment for a 
period of time more than 6 cycles, the urinalysis tests may be done locally when the visit to the site is not planned  (one visit 
planned to the site every three cycles, 1.5 months) and must be sent to the site for safety evaluation and reported on CRF.  
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
9. Hematology (local laboratory): Hemoglobin, erythrocytes (RBC), white blood cell (WBC) with differential count (neutrophils, 
lymphocytes, monocytes, eosinophils, basophils, differential other cells), platelets (PLTs). To be done at baseline and 
between Day 11-14 of each cycle. In case of toxicity preventing re-treatment, hematology should be re-assessed on Day 1 of 
the next cycle before starting treatment. For patients remaining on treatment for a period of time more than 6 cycles, the 
hematological tests may be done locally when the visit to the site is not planned  (one visit planned to the site every three 
cycles, 1.5 months) and must be sent to the site for safety evaluation and reported on CRF.  
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
10. Blood Chemistry (local laboratory): sodium, potassium, chloride, magnesium, blood urea nitrogen (BUN) or urea, 
creatinine, albumin, AST/SGOT, ALT/SGPT, Alkaline Phosphatase (ALP), total bilirubin, creatinine clearance (calculated by 
Cockroft and Gault’s formula), amylase and lipase.  
To be done at baseline and between Day 11-14 of each cycle. In case of toxicity preventing re-treatment, blood chemistry 
should be re-assessed on Day 1 of the next cycle before starting treatment. For patients remaining on treatment for a period 
of time more than 6 cycles, the biochemical tests  may be done locally when the visit to the site is not planned  (one visit 
planned to the site every three cycles, 1.5 months) and must be sent to the site for safety evaluation and reported on CRF.  
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
11. Coagulation: INR (International Normalized Ratio), activated partial thromboplastin time (APTT in seconds). To be done 
at baseline, at the end of last cycle and, during treatment, at the end of even cycles (between Days 11 and 14). 
For patients remaining on treatment for a period of time more than 6 cycles, the coagulation tests may be done locally when 
the visit to the site is not planned (one visit planned to the site every three cycles, 1.5 months) and must be sent to the site for 
safety evaluation and reported on CRF.  
Following approval of Amendment 5, management  of patients should be as per Section 9.5 

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12. Tumor imaging: chest/abdomen/pelvic CT scan/ MRI : At baseline, to be done within 21 days before Day 1; during the 
treatment period (irrespectively from cycles duration), the first one to be done 6 weeks (between days 42 and 48) after first 
drug administration, the second one to be done 3 months (between days 92 and 98) after first drug administration, 
following ones to be repeated every 6 weeks (between days 42 and 48) after the previous one, and at end of last cycle (if not 
done in the previous 4 weeks). During Follow Up, to be performed every 6 weeks, until PD or until a new antitumor therapy 
starts. The same method of assessment and the same technique should be used to characterize and follow the same lesion 
at baseline and during treatment. CT scan is the desirable method for lesion measurement. MRI is acceptable (but not for lung 
lesions) provided that the size of the measurable lesion is twice the slice thickness of the MRI. After cut-off date of 31 May 
2017, the patients should perform CT scan according to routine clinical practice and/or at investigator’s discretion. 
13. Survival: To be assessed during Follow Up every 6 weeks until PD or until a new antitumor therapy starts; every 6 months 
thereafter, up to 2 years from the end of treatment.  
Following approval of Amendment 5, management  of patients should be as per Section 9.5 
14. Adverse Event Assessment (including neurological status evaluation): Events should be assessed and documented 
at each scheduled clinic visit since patient signs the Informed Consent: before treatment administration at baseline (baseline 
signs and symptoms), at the end of each treatment cycle, and 28 days after the last dose of study drug administration. For 
patients remaining on treatment for a period of time more than 6 cycles, the events will be assessed by phone call if the visit 
to the site is not planned (one visit planned to the site every three cycles, 1.5 months). The phone call information will be 
collected in a specific form signed and dated by the Investigator and included in the CRF. 
Patients must be followed for adverse events also until every ongoing drug-related toxicities and serious adverse events have 
resolved or the investigator assesses them as “chronic” or “stable”. However, if the patient begins a new anticancer therapy 
before 28 days after the last dose of study drug administration, the adverse event reporting period will end at the time the new 
treatment is started. AEs will be recorded in the relevant CRF pages.  
After cut-off date of 31 May 2017, AE/SAE data will be no longer collected into the CRF, but assessments information 
should continue to be collected into the patient’s medical notes.  
After protocol Amendment 5 approval, only SAEs will continue to be reported to CLIOSS Pharmacovigilance for 
patients still receiving treatment, up to 28 days after milciclib discontinuation, according to Section 9.5. 
15. Concomitant Medications: all concomitant medications should be reported in the relevant CRF, including supportive 
care drugs, and drugs used for treating adverse events or chronic diseases. For patients remaining on treatment for a period 
of time more than 6 cycles, the concomitant medications will be assessed by phone call if the visit to the site is not planned 
(one visit planned to the site every three cycles, 1.5 months). The phone call information will be collected in a specific form 
signed and dated by the Investigator and included in the CRF. Following approval of Amendment 5, management  of 
patients should be as per Section 9.5 
16. Biomarker Status Assessment: retrieval of paraffin embedded tumor biopsy (blocks or slides), obtained from consenting 
patients before study entry, and characterization of p53, p21, p27, cyclin D1, p75, TRKA expression and TRKA copy number. 
Additional biomarkers under validation may also be evaluated. 
17. Pharmacokinetics: blood samples may be collected if, in the opinion of the Investigator and of the Sponsor, an 
evaluation of PK parameters is needed for safety reasons. 
18. Histological confirmation: histological diagnosis of thymic carcinoma, when made by another institution, has to be 
confirmed by pathologists of the investigational site to whom the patient is addressed. 
19. Enrollment: The Investigator is requested to sign a Request For Enrollment form. His/her signature is the guarantee that 
all the eligibility criteria are met. Patient Number is assigned by the Sponsor. Treatment must be administered within 7 days 
from patient enrollment. 
20. PHA-848125AC administration: The study drug will be administered at 150 mg (flat dose) once daily for 7 consecutive 
days of each treatment cycle (from day 1 to Day 7). After an overnight fasting with free access to water, patients will take the 
study drug with a large glass of plain water without ice. A light breakfast can be served 1.5-2 hours later. PHA-848125AC 
capsules have to be stored under refrigerated conditions (5  3 °C; 36-46 °F) and out of reach of children 
(*) Cycle 1, Day 1 assessments: hematology, blood chemistry, urinalysis and coagulation do not need to be repeated before 
treatment on Cycle 1, Day 1 if they were performed during screening within 1 week before first study drug administration. 
Cycle > 1, Day 1 assessments: hematology and blood chemistry do not need to be repeated before treatment on Cycles> 1, 
Day 1 if no toxicity preventing re-treatment resulted from laboratory assessments done within the previous 4 days. 
(§) AE FU: end of adverse events reporting period (to be done 28 days after last study drug administration) and follow up of 
unresolved drug related/serious AEs.  
After cut-off date of 31 May 2017, AE/SAE data and related follow up will be no longer collected into the CRF, but 
assessments information should continue to be collected into the patient’s medical notes.  
After approval of Amendment 5 to the protocol, only SAEs should be reported to CLIOSS Pharmacovigilance for 
patients still receiving study treatment, up to 28 days after discontinuation of milciclib, according to Section 9.5. 

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8. ENROLLMENT PROCEDURES 
The informed consent should be signed and dated before starting any trial specific 
procedures. After signature of informed consent, the patient will be registered with a 
patient’s screening number centrally assigned by CLIOSS, on behalf of Tiziana (details 
reported in the Study Manual). Upon completion of screening evaluation, the patient, if 
eligible, will be enrolled and assigned a patient number to be carried out during the trial. 
In order to obtain screening number and then patient number for each patient, the 
Investigator will fill in a registration/enrollment form and fax it to the CLIOSS study 
management (details reported in the Study Manual).  Investigator’s signature on the 
registration/enrollment form is the guarantee that all the eligibility criteria are met. A reply 
by fax will be sent within 1 working day. The time between enrollment and initiation of 
treatment should not be longer than 7 days. 
9. TREATMENT  
Only qualified personnel familiar with procedures that minimize undue exposure to 
themselves and to the environment should undertake the preparation, handling, and safe 
disposal of chemotherapeutic agents.  
9.1. Trial Products  
9.1.1. Description 
PHA-848125AC is formulated as hard gelatin capsules containing 10 mg, 50 mg and 100 
mg, respectively, of active ingredient. 
The three different strengths are distinguishable each other by the different colors and sizes: 
10 mg capsules are size 4 hard gelatin capsules, opaque Swedish orange cap and opaque 
caramel body; 50 mg capsules are size 2 hard gelatin capsules, opaque Swedish orange cap 
and body; 100 mg capsules are size 1 hard gelatin capsules, opaque white cap and body. All 
the described capsules contain a pale yellow to yellow powder. 
PHA-848125AC 10 mg, 50 mg and 100 mg capsules are packaged in white High Density 
Polyethylene (HDPE) bottles with twist off plastic caps. 
New capsule formulations have been developed in order to have a formulation suitable for 
an automatic filling process, whereas the original formulations are filled with a 
semiautomatic capsule filling machine. 
For more details on the new formulations, see PHA-848125AC Investigator Brochure, 
Version 7, 2011 [23]. 

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9.1.2. Drug Preparation/Administration/Dispensing 
PHA-848125AC will be administered as home-based treatment. The Investigator (or 
delegate) will dispense to the patient the doses of PHA-848125AC covering one cycle at a 
time during the first three months of treatment (6 cycles) and covering three cycles at a time 
after three months of treatment (for patients who continue treatment after 6 cycles).  The 
daily doses will be made out of a number of capsules, according to the dose (in mg/day) at 
which the patient has been assigned for a given cycle. 
The study medication has to be stored under refrigerated conditions (5  3 °C; 36-46 °F), in 
the original packaging, out of the reach and sight of children. 
Original IMP Packaging 
As each capsule of PHA-848125AC is individually packaged in a bottle (the primary 
packaging), the daily dose of PHA-848125AC will consist of a number of bottles packed 
together in an outer packaging (bag) and the 7 bags will be stored in a weekly container 
(box). At each cycle, patients will take the assigned daily dose for 7 consecutive days (from 
Day 1 to Day 7) and will be instructed not to take the study drug for the subsequent 7 days 
(i.e. Days 8-14), so to ensure a 7-day resting period. 
A secondary packaging (box) will be used to store stocks of bottles in the pharmacy of the 
participating institutions only. 
Primary, secondary and outer packaging, and weekly container will be labeled with the 
relevant information. 
New IMP Packaging 
A new IMP packaging, currently under preparation, will be introduced and will consist of 
one PHA-848125AC capsule of each strength individually packaged in a labeled bottle (the 
primary packaging) and each bottle inserted in one labeled small single carton (the 
secondary packaging).  
The Sponsor has considered to simplify the original IMP packaging above described, so that 
no repacking activities for patient doses preparation should occur at clinical trial sites. The 
original IMP packaging will be used in the clinical trial until the new IMP packaging will be 
available.  
The different IMP strengths (50 mg and 100 mg) will be easily distinguished by using 
different colors for labels stuck on primary and secondary packaging. 
As each capsule of PHA-848125AC is individually packaged in a bottle/single carton, the 
daily dose of PHA-848125AC will consist of a number of bottles/cartons (e.g. for a full dose 
of 150 mg/day: 1 bottle containing one 50 mg capsule in a single small carton and 1 bottle 

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containing one 100 mg capsule in a single small carton). At each cycle, patients will take the 
assigned daily dose for 7 consecutive days (from Day 1 to Day 7) and will be instructed not 
to take the study drug for the subsequent 7 days (i.e. Days 8-14), so to ensure a 7-day resting 
period. 
9.1.3. Patient Education & Information 
All patients will receive their doses of PHA-848125AC together with a patient’s diary, 
which includes also the instructions relevant to study drug administration. The site personnel 
handing the study medication to patients must ensure that they fully understand that the 
treatment period (cycle) comprises 14 days, consisting of 7 days of daily administration 
(from Day 1 to Day 7), followed by a 7-day resting period, from Day 8 to Day 14. Extension 
of treatment period to Days >7 is not allowed, even in case of missed doses. 
Additionally, the patients should be informed: 
 to take the study drug every day as prescribed by their doctor. Some patients may find 
particularly hard to remember the idea of repeated short courses of treatment with 'gaps' 
between them. 
 to take the study drug at the same time each day (1.5-2 hours before breakfast with a 
glass of plain water without ice; water is allowed during fasting period). 
 if the patient forgets to take the study drug at the usual time, to take it between meals at 
any time during the same day and record the events on the patient’s diary. 
 if the patient misses one day, to take the normal amount the next day, if scheduled. Not 
to double the daily prescribed dose of the study drug and to track the number of capsules 
missed and the reason for it in the patient’s diary. 
 if vomiting occurs during or after having taken the daily dose, not to take extra capsules 
that day and to take the normal amount the next day, if scheduled. Not to double the 
daily prescribed dose of the study drug and record the events in the patient’s diary. 
 to adhere to the principles of safe handling and storage of the study medication. 
Breaking/crushing or opening the capsules must be avoided. In such cases, record of the 
broken capsules should be kept in the patient’s diary. In case of opening of the capsules, 
to avoid contact or inhalation. In case of skin contact, to wash the affected area with 
plenty of water or soap and water. In case of eye-contact, to rinse thoroughly with plenty 
of water and seek medical advice as soon as possible. 
 to return all packaging (bottles, bags and carton boxes for the original IMP packaging 
and bottles and single cartons for the new IMP packaging) as well as not-taken capsules 
(if applicable) and the patient diary to the site personnel. 
As much as possible of this information should first be given at the pre-treatment visit and 
reinforced on subsequent visits. 

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9.2. Procedure for Handling Drug Spills 
Precautions for drug handling of cytotoxic agents should be followed for PHA-848125AC. 
In case of opening of the capsules, avoid contact or inhalation. In case of skin contact, the 
affected area should be washed with plenty of water or soap and water. Any contaminated 
clothing should be removed. In case of eye-contact, rinse thoroughly with plenty of water. 
Seek medical advice as soon as possible. 
9.3. Storage and Stability 
PHA-848125AC is to be stored under refrigerated conditions (5  3 °C; 36-46 °F) and in the 
original packaging, out of the reach and sight of children. 
To ensure optimal environmental and patient exposure protection, the packaging has been 
designed as a single use one. 
On the basis of the available supportive stability results, a provisional shelf-life of  30 
months is assigned to the 50 mg capsules and 24 months to the 100 mg capsules when stored 
at 5  3 °C (36-46 °F) in the original packaging. 
Concurrent stability studies on the clinical batches of the current formulation will be carried 
out in order to evaluate the chemical and physical parameters, and the expiry date will be 
extended accordingly with the stability results.  Any unexpected finding will be promptly 
communicated to the investigators and to the Health Authorities. 
9.3.1. Source of Drug 
NerPharMa (NMS Group), on behalf of the Sponsor Tiziana Life Sciences PLC will supply 
PHA-848125AC (milciclib maleate) free of charge. Additional supply may be obtained by 
contacting CLIOSS (see Study Manual for contact information). 
9.3.2. Drug Accountability 
PHA-848125AC must not be used outside the context of this protocol.  Under no 
circumstances should the Investigator or site personnel supply study product to other 
Investigators or clinics, or allow the supplies to be used other than as directed by this 
protocol without prior authorization from the Sponsor. 
Adequate records on receipt, use, return, loss, or other disposition of medication must be 
maintained. A specific drug accountability form supplied by the Sponsor or computer 
records used by the pharmacy at the investigational site, can be used to provide drug 
accountability information. In either case, information describing study drug supplies and 
their disposition, subject by subject, must be provided, signed by the Investigator (or the 
pharmacist or other person who dispensed the drug) and collected by the study monitor. 

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Requisite data includes relevant dates, quantities, batches or code numbers, and subject 
identification for subjects who received study drug. 
At the end of the study and upon authorization of the Sponsor, the study drug may be 
destroyed at the site as dictated by the appropriate standard procedures of the participating 
institutions.  Destruction must be documented.  Alternatively, all unused product will be 
collected by the local monitor and returned to NerPharMa. 
If disposed locally, all used bottles and containers of study product should be discarded 
according to the standard institutional policy. 
Study drug handling and accountability after the cut-off date of 31 May 2017 should 
continue as described above. 
9.4. Treatment Administration 
9.4.1. Treatment Dose and Schedule 
PHA-848125AC will be administered orally at the dose of 150 mg/day (flat dose) once daily 
for 7 consecutive days of each treatment cycle. A treatment cycle will comprise 7 days of 
PHA-848125AC administration (Day 1 to 7) followed by 7 days of rest for a total of 14 days 
(2 weeks) period. 
After an overnight fasting, with free access to water, patients will take the study drug with a 
large glass of plain water without ice. A light breakfast can be served 1.5-2 hours after study 
drug intake. 
9.4.2. Duration of Treatment  
Each patient will remain on treatment until disease progression, patient refusal, consent 
withdrawal, or the occurrence of unacceptable toxicity or of any other criteria for withdrawal 
as detailed in Section 10. 
At the end of the treatment period, all patients will be followed for survival every 6 months 
up to 2 years after the end of treatment. Anyhow, if a patient stops the treatment before any 
documentation of PD, the follow up will be initially performed at 6-week intervals and will 
include a complete oncological assessment up to documentation of PD or the start of another 
antitumor therapy, then it will be continued for survival only every 6 months. 
Patients still on treatment after the cut-off date of 31 May 2017, will be managed according 
to Section 9.5  

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9.4.3. Dose Modifications 
Dose modifications may occur as a consequence of drug-related toxicities, during a cycle or 
at the start of a new cycle. In the event of multiple toxicities, dose modifications should be 
applied based upon the most severe toxicity observed and attributable to PHA-848125AC. 
As far as dose reductions are concerned, a dose reduction to the dose level of 100 mg/day 
(i.e. –33%) is recommended in case of poor tolerability of the full dose of 150 mg/day. 
The dose of 100 mg/day (mean Day 7 AUC 19.9 M·h) was successfully used for 20 cycles 
in keeping disease control in a patient with colorectal cancer, initially treated at 150 mg/day 
for 7 cycles in the CDKO-125a-001 study. 
Doses reduced for drug-related toxicity should not be re-escalated. Any exception is to be 
discussed between the Investigator and the Sponsor. 
Table 4 describes the recommended dose modifications during the treatment cycles and at 
the start of any new cycle. 
Note: the dose adjustments in the third column are intended as referred to the dose of Day 
1 of the previous cycle. 

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Table 4. Criteria for PHA-848125AC Dose Modifications 
Toxicity (Graded as per NCI CTCAE Criteria, 
Version 3.0) 
During Treatment Cycle 
Dose Adjustment for Next 
Treatment Cycle (after recovery 
from toxicities to grade 1, or to 
baseline values) ¶ 
Hematologic  
 
 
Grade 0 or Grade 1 
Maintain dose level 
Maintain dose level 
Grade 2 Neutropenia (ANC < 1500-1000/mm
3) 
and/or Grade 2 Thrombocytopenia (platelet 
count <75000-50000/mm3) 
If occurs during treatment, maintain 
daily dose level 
Monitor until resolved to grade 1 
Maintain dose level 
Grade 3 Neutropenia (ANC <1000-500/mm
3) 
If occurs during treatment, 
decrease daily dose by one dose 
level  
Monitor until resolved to grade 1 
Maintain dose level 
Grade 3 Thrombocytopenia (platelet count 
<50000-25000/mm3), uncomplicated or lasting 
less than 5 days 
If occurs during treatment, 
decrease daily dose by one dose 
level 
Monitor until resolved to grade 1 
Maintain dose level 
Grade 4 Neutropenia (ANC < 1000/mm
3) 
lasting < 7 days 
If occurs during treatment, 
decrease the daily dose  by one 
dose level 
Monitor until resolved to grade  1  
Maintain dose level 
Grade 4 Neutropenia (ANC < 1000/mm
3)  
lasting 7 days or more 
 
 
Febrile neutropenia 
(ANC <1,000/mm3 and fever of unknown origin 
38.5C) 
 
 
Neutropenic infection: grade  3 (i.e. infection 
documented clinically or microbiologically with 
grade 3 or grade 4 neutropenia) 
If occurs during treatment, interrupt 
the treatment 
Monitor until resolved to grade 1 
 1 dose level 
Grade  3 Thrombocytopenia (platelet count 
<50000/mm
3) uncomplicated lasting 5 days or 
more, or associated with bleeding and/or 
requiring transfusion  
 
 
Any other grade 4 hematological toxicity 
 
 
Nausea and/or Vomiting  
 
 
Grade 1 or 2 in absence of antiemetics 
If occurs during treatment, maintain 
daily dose level and add 
antiemetics, if needed. 
If occurs during rest period, add 
antiemetics, if needed 
Maintain dose level with 
antiemetics §, if needed 
Grade 3 in absence of antiemetics 
If occurs during treatment, 
decrease the daily dose by one 
dose level, add antiemetics. 
If occurs during rest period, add 
antiemetics 
Monitor until resolved to grade 1 
Maintain dose level with 
antiemetics § 
Grade 3 in presence of antiemetics § 
If occurs during treatment, interrupt 
treatment 
Monitor until resolved to grade 1 
 1 dose level  

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Toxicity (Graded as per NCI CTCAE Criteria, 
Version 3.0) 
During Treatment Cycle 
Dose Adjustment for Next 
Treatment Cycle (after recovery 
from toxicities to grade 1, or to 
baseline values) ¶ 
 
Diarrhea 
 
 
Grade 1 or 2 (in absence or presence of 
management of the event §) 
If occurs during treatment, maintain 
daily dose level, add/adjust 
antidiarrheal treatment, if needed. 
If occurs during rest period, 
add/adjust antidiarrheal treatment, 
if needed 
Maintain dose level 
Grade 3 despite optimal management of the 
event § 
If occurs during treatment, interrupt  
treatment 
Monitor until resolved to grade 1 
 1 dose level 
Neurologic 
 
 
Grade 0, 1 or no worsening compared to 
baseline 
Maintain dose level 
Maintain dose level 
Grade 2 tremors 
If occurs during treatment, interrupt  
treatment 
 1 dose level or discontinue 
study treatment (Investigator to 
discuss with the Sponsor) 
Grade > 2 tremors or any other Grade  2 
neurological toxicity 
Discontinue study treatment  
(Investigator to discuss with the 
Sponsor) 
Discontinue study treatment 
(Investigator to discuss with the 
Sponsor) 
Ocular/Visual 
 
 
Grade 0  
Maintain dose level 
Maintain dose level 
Increase of 1 or more grades retinopathy by 
ophthalmologic examination compared to 
baseline  
Discontinue study treatment 
Discontinue study treatment 
Other non hematological toxicity (except alopecia) 
Grade 0, 1 
Maintain dose level 
Maintain dose level 
Grade 2 
If occurs during treatment, maintain  
or decrease the daily dose by 1 
dose level, if clinically indicated 
Monitor until resolved to grade 1 
Maintain dose level 
Grade  3 
If occurs during treatment, interrupt 
treatment 
Monitor until resolved to grade 1 
 1 dose level  
Failure to recover 
 
 
Failure to recover to grade  1 toxicity (except 
alopecia) or to baseline values, if grade 2 is 
allowed at study entry, after delaying the 
initiation of next cycle by > 2 weeks 
Monitor until resolved to grade 1 
 1 dose level  (Investigator to 
discuss with the Sponsor) 
¶ : the dose adjustments in the third column are intended as referred to the dose of Day 1 of the previous cycle. 
§  For prophylaxis and management of the events, see Concomitant Medications and Other Therapy, Section  9.4.9. 
Abbreviations: ANC = absolute neutrophil count; CTCAE = Common Terminology Criteria for Adverse Events, NCI = 
National Cancer Institute 
 

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9.4.4. Retreatment and Dose Delay 
A new cycle of treatment may begin when the ANC is  1500/mm3, the platelet count is 
 100,000/mm3, and the non-hematologic toxicities are  grade 1, except for alopecia (for 
which a grade > 1 is allowed) and for ocular toxicity (for which a worsening retinopathy of 1 
or more grades compared to baseline implies study treatment discontinuation) or are 
recovered to baseline values, if grade 2 is allowed at study entry. If these conditions have not 
been met, treatment should be delayed for 1 or 2 weeks to allow for recovery. If after a 
maximum of a 2-week delay all toxicities (except for alopecia and for toxicities for which 
grade 2 is allowed at study entry) are  grade 1, then proceed with treatment as outlined in 
the Dose Modification Table 4. An increased delay > 2 weeks is to be discussed between the 
Investigators and the Sponsor on a case by case basis. 
9.4.5. Overdose Instructions 
There are no known antidotes for milciclib maleate (PHA-848125AC).  In the case of an 
overdose of PHA-848125AC, neurological toxicity (tremors and ataxia) and gastrointestinal 
toxicity are among the expected effects. The Sponsor study management should be contacted 
to discuss the details of any overdose. 
9.4.6. Unblinding  
Not applicable in this study. 
9.4.7. Assessment and Management of Potential CNS Toxicity 
Signs of CNS toxicity, including tremors, hyperactivity and ultimately convulsions have 
been observed during the toxicology evaluations of PHA-848125AC administered at high 
single or high repeated doses attaining daily systemic exposures  30M.h. In all species, 
this pattern of toxicity was reversible and not accompanied by morphological/pathological 
findings. 
In humans, reversible tremors and ataxia have been reported in the CDKO-125a-001 study 
(see Section 3.2.7). Resolution of both events in approximately 7-8 days was reported, upon 
study treatment discontinuation. 
Tremors which can be induced by other drugs include enhanced physiologic tremor, rest 
tremor, and action tremor. Signs and symptoms of drug-induced tremors depend on the drug 
used and on a patient's predisposition to its side effects. Cessation of the causative agent may 
improve drug-induced tremor symptoms. Table 5 lists drugs that may induce tremor, along 
with the types of tremors and neurologic signs they produce. 

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Table 5. Drug-induced Tremors and Corresponding Neurologic Signs 
Drug/Drug Class 
Tremor Type 
Neurologic Signs 
Neuroleptics 
Rest, postural 
Extrapyramidal 
Metoclopramide 
Rest, postural 
Extrapyramidal 
Lithium 
Rest, postural, action 
Extrapyramidal 
Theophylline 
Postural 
None 
Bronchodilators 
Postural, action 
None 
Valproate 
Postural 
Rarely parkinsonism 
Amiodarone 
Postural 
Rarely parkinsonism 
 
During visits, patients treated with PHA-848125AC will undergo regular clinical 
examination, which includes the assessment of clinical tremors and associated signs and 
symptoms. Patients should be examined during rest, when assuming various positions and 
when moving.  Tremors will be graded according to NCI CTCAE version 3.0 grading 
system as follows: 
Tremor Grades, NCI CTCAE Version 3.0 
0. Absent 
1. Mild and brief or intermittent but not interfering with function 
2. Moderate tremor interfering with function, but not interfering with ADL 
3. Severe tremor interfering with ADL 
4. Disabling 
 
PHA-848125AC dose modifications for neurologic adverse events attributable to the study 
drug are detailed in Table 4. 
Pharmacological management of neurological adverse events, such as tremors and/or 
convulsions, should refer to institutional and/or published interventional protocols [35,36]. 
9.4.8. Assessment of Potential Ocular Toxicity 
Ocular toxicity has been reported in rats treated for prolonged period of time (daily 
treatments for 3 consecutive weeks + 1 week of rest x 3 cycles or daily treatments for 4 
consecutive weeks) at doses associated with daily AUCs close to 25 M·h, as well as in rats 
given daily treatments for 2 consecutive weeks +1 week of rest for 5 cycles at doses 
associated to AUC of about 32 M·h. 
No ocular toxicity was observed in rats with a 7-day repeat treatment schedule up to doses 
associated to a daily AUC of about 50M·h or up to doses associated to a daily AUC of 
about 10 Mh in the 4-week schedule and up to doses associated to daily AUC of about 12 
M·h. in the 3-week schedule. 
Despite clinical manifestations of ocular toxicity were not observed in the clinical studies so 
far, a potential ocular toxicity cannot be excluded. During visits, patients treated with PHA-
848125AC will undergo regular clinical examinations, i.e. ophthalmologic examination 

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(visual acuity test and funduscopic examination), at the end of even cycles during the first 
three months of treatment (6 cycles), at 4.5 months (ninth treatment cycle, between days 11 
and 14) and then after every three months and at the end of last cycle (see Schedule of 
Events in Section 7 and also Section 11.4.3). 
Retinopathy will be graded according to NCI CTCAE version 3.0 grading system as follows: 
Retinopathy Grades, NCI CTCAE Version 3.0 
0. 
Absent 
1. 
Asymptomatic 
2. 
Symptomatic with moderate decrease in visual acuity (20/40 or better) 
3. 
Symptomatic with marked decrease in visual acuity (worse than 20/40) 
4. 
Blindness (20/200 or worse) 
 
Grade 1 retinopathy is allowed at study entry since it is an asymptomatic event occurring in 
relation to common medical conditions such as hypertension [37,38]. It is recognized that 
several patients in their 50s and 60s with underlying hypertension may present asymptomatic 
retinopathy. Such a status is to be regarded as a condition which does not prevent patients’ 
enrollment in the study, being not clinically significant. 
Ophtalmologic evaluations will be possibly done by the same ophthalmologist for a given 
patient. 
The increase of 1 or more grades retinopathy by ophthalmologic examination will require 
immediate study drug discontinuation. 
Management of ocular adverse events should refer to institutional interventional protocols. 
9.4.9. Assessment of Potential Thrombotic Microangiopathy/Hemolytic Uremic 
Syndrome 
Two patients, both treated in the CDKO-125a-004 combination study with gemcitabine (‘A 
Phase I Dose-Escalation Study of Oral PHA-848125AC Administered in Combination with 
Gemcitabine in Adult Patients with Advanced/Metastatic Solid Tumors'), developed 
Thrombotic Microangiopathy/Hemolytic Uremic Syndrome (TMA/HUS). 
The two cases were considered to be probably related to gemcitabine and unlikely related to 
PHA-848125AC by the participating Investigator, and occurred in patients with very 
prolonged and high exposure to both drugs (after 14 and 21 months on treatment, 
respectively); both patients recovered in the opinion of the Investigator, and only one of 
them required plasmapheresis. No other cases of TMA/HUS were reported in any of the 
other studies completed or ongoing with PHA-848125AC (all single agent studies). Anyway, 
taking into consideration the small number of patients treated so far at this stage of 
development of PHA-848125AC (about 200 patients), a contribution of the study drug on 
the two observed TMA/HUS events cannot be completely ruled out. As a consequence, the 
following events are to be strictly monitored: 

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 Progressive increase of anemia up to CTC Grade  3 no otherwise explained 
 Progressive platelets decrease up to CTC Grade  2 
 Increase of creatinine (shift to CTC Grade 2) or calculated creatinine clearance 
diminished by  25% vs baseline 
 Presence of hematuria or proteinuria 
 Appearance of high blood pressure in a patient with unknown history or with high blood 
pressure previously well controlled with medications  
 Appearance of oedema concomitant to proteinuria 
Whenever  2 of the above listed alterations appear concomitantly for the first time, or at 
any time if the Investigator judges it appropriate, study drug administration is to be 
temporarily held, until further evaluations are done. The latter ones consisting of the search 
of schistocytes in the peripheral blood smear, the count of reticulocytes in the peripheral 
blood, coagulation test, total LDH and 24-hour proteinuria [39]. Routine Hematology, Blood 
Chemistry and Urinalysis tests foreseen by study protocol, should also be repeated at the 
time when this evaluation is performed. 
If based on the above examinations MTA/HUS can be ruled out, study drug administration 
can be resumed, adopting the dose modifications outlined in Table 4 for drug-related 
toxicities, as applicable. 
In case of suspicion or evidence of MTA/HUS, study drug has to be discontinued. 
9.4.10. Concomitant Medications and Other Therapy 
All concomitant medications must be entered into the CRF. After the cut-off date of 31 May 
2017 and protocol Amendment 5 is approved at the investigational site, data will be no 
longer collected into the CRF, and information on concomitant medications should continue 
to be recorded into the patient’s medical notes only.  
Directives for supportive care are outlined below. 
9.4.10.1. Antiemetics 
Prophylactic therapy with antiemetics is allowed starting from the first onset of emesis. 
Pharmacological management of nausea and/or vomiting may refer to institutional and/or 
published guidelines for treatment [39,41]. 
9.4.10.2. Antidiarrheals 
Treatment with loperamide might be started at the occurrence of grade 1 diarrhea (increase 
of < 4 stools per day over baseline; mild increase in ostomy output compared to baseline). 
Loperamide should be taken in the following manner: 4 mg at the first onset of diarrhea, 

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then 2 mg every 2 hours. This therapy should continue for 12 hours after the last liquid stool.  
Patients may take loperamide 4 mg every 4 hours during the night. In no instance should 
loperamide be administered for more than 48 consecutive hours because of the risk of 
paralytic ileus. 
Other antidiarrhetic agents and/or antibiotics used by the Institutions are allowed. 
Patients should be instructed to refer to the center in case of diarrhea lasting > 24 hours 
despite optimal supportive care or diarrhea with fever. 
9.4.10.3. Antiacids 
Patients with chronic/ intensive use of H2-receptor antagonists, proton pump inhibitors, 
antacids, should take these drugs at a time point far from PHA-848125AC intake (at least 3-
4 hours) during the day, or the night before treatment, to avoid any potential effect on 
PHA-848125AC absorption. 
9.4.10.4. Hematopoietic Growth Factors 
Hematopoietic growth factors may be used as medically indicated in patients with relevant 
neutropenic complications, such as tissue infection, sepsis, etc., at the Investigator’s 
discretion. Red blood cell and/or platelets transfusion should be considered at the 
Investigator’s discretion in patients with significant anemia and/or thrombocytopenia. 
9.4.10.5. Anticoagulants 
Concomitant anticoagulant treatment is not recommended.  
9.4.10.6. Inhibitors or Inducers of CYP3A4 
Significant drug-drug interactions with inhibitors or inducers of CYP3A4 are not expected 
(see Section 3.2.4). Therefore, there are no specific contraindications to the use of inhibitors 
or inducers of CYP3A4. 
9.4.10.7. Steroids 
Concurrent use of steroids for treatment of a pre-existing autoimmune disorder or as 
antiemetic therapy is allowed. 
9.4.10.8. Other Permitted Concomitant Medications 
Therapies considered necessary for the patient’s well being may be given at the discretion of 
the Investigator, i.e. chronic treatments for concomitant medical conditions, as well as 
agents required for life-threatening medical problems, analgesics etc. Patients should be 
advised to contact the treating physician before starting any new drug. 

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9.4.10.9. Concomitant Radiotherapy 
Palliative radiotherapy to specific sites is permitted if considered medically necessary by the 
treating physician. However, the irradiated area should be as small as possible, and involve 
≤20% of the bone marrow reserve [Appendix 2]. During the period of irradiation and for 2 
weeks after, chemotherapy should be withheld. If irradiation-related toxicities (other than 
xerostomia) have not normalized to pre-irradiation levels after these 2 weeks of rest, the 
patient should be removed from the study. Radiotherapy should be avoided for at least 5 
days after the last dose of PHA-848125AC. 
9.4.10.10. Other Anticancer or Experimental Therapy 
No other approved or investigational anticancer treatment will be permitted during the study 
period including chemotherapy, biological response modifiers, hormones or immunotherapy. 
No other investigational drug may be used during therapy on this protocol. Simultaneous 
participation in other clinical treatment study protocols is not allowed. 
9.5. Management of Patients after Cut-Off Date 
Patients still receiving milciclib maleate at the cut-off date of 31 May 2017 can continue 
with their treatment, and will continue with their protocolled scheduled visits to the site until 
they meet any discontinuation criteria as per Section 10.  
However, after protocol Amendment 5 is approved at the investigational site, data will be no 
longer collected into the CRF, and assessments information should continue to be recorded 
into the patient’s medical notes only. After protocol Amendment 5 approval, the patients 
should attend visit according to routine clinical practice and/or at investigator’s discretion, 
until they meet any discontinuation criteria as per Section 10. 
After cut-off date of 31 May 2017, SAEs will continue to be reported as per protocol for 
patients still receiving study treatment, up to 28 days after discontinuation of milciclib. 
Drug supply will be granted by the Sponsor free of charge, and accountability should 
continue to be performed until the patient stops study treatment completely. 
The end of the study is defined as the date of the last visit of the last patient, occurring when 
all patients have discontinued study treatment.  
 
10. SUBJECT WITHDRAWAL FROM STUDY PARTICIPATION 
Patients may continue with therapy unless any of the following occurs: 
 Disease progression at any time 
 Unacceptable toxicity dictating cessation of treatment 

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 Changing in medical status of the patient (including pregnancy) such that the 
Investigator believes that patient safety will be compromised or that it would be in the 
best interest of the patient to stop treatment  
 Withdrawal of consent (includes any reason why the patient decides to discontinue 
completely his/her study participation and does not wish that the Sponsor follows 
him/her to collect information regarding disease status. In this case no further evaluation 
should be performed and no attempts should be made to collect additional data) 
 Patient’s refusal to continue the study treatment (includes any patient who does not want 
to be treated anymore in the frame of this study but accepts that the Sponsor continues to 
follow him/her in order to collect information regarding disease status). Applicable only 
for patients treated pre-Amendment 5. 
 Non-compliance by the patient with protocol requirements. Applicable only for patients 
treated pre-Amendment 5. 
 Patient lost to follow up. If a patient does not return for a scheduled visit, every effort 
should be made to contact the patient. In any circumstance, every effort should be made 
to document patient outcome. Applicable only for patients treated pre-Amendment 5. 
 
11. ASSESSMENTS  
11.1. Timing of Assessments 
Section 7 summarizes information on the timing of study assessments.  
11.2. Efficacy Assessments 
The determination of antitumor efficacy will be based on objective tumor assessments made 
according to the RECIST guideline (version 1.1) [34]. 
11.2.1. Tumor Imaging 
Tumor imaging by chest/abdomen/pelvic CT scan or MRI: the baseline tumor 
assessment has to be performed within 3 weeks prior to the treatment start; during the 
treatment period (irrespectively of cycles duration) the first assessments will be performed 
6 weeks (between days 42 and 48) after first drug administration, the second one 3 months 
(between days 92 and 98) after first drug administration, the following ones every 6 
weeks (between days 42 and 48) after the previous one (or whenever a clinical deterioration 
will be observed) and at end of last cycle (if not done in the previous 4 weeks). 
In addition, in patients withdrawn from study treatment for causes other than disease 
progression, tumor response will have to be reassessed at the time of study drug 
discontinuation, unless a tumor assessment was performed within the previous 4 weeks; 

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regular tumor imaging assessments are then to be performed every 6 weeks during follow-
up, until PD or until a new antitumor therapy starts. If off study treatment of patients 
withdrawn for causes other than disease progression occurs before 3 months since treatment 
start, the oncologic assessment should be scheduled at the time of endpoint assessment 
(between days 92 and 98 after first drug administration), unless a new antitumor therapy has 
started. 
The same method and technique (CT scan or MRI) should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation, 
over clinical examination, is the required technique when both could be used to assess the 
antitumor effect of the treatment. 
CT scan is the desirable method for lesion measurement. CT scans should have a maximum 
slices thickness of 5 mm and a minimum size for a measurable lesion is twice that: 10 mm 
(even if slice thickness is <5 mm). If scanners with slice thickness > 5 mm are used, to 
qualify for a measurable lesion, the minimum lesion size must have a longest diameter twice 
the actual slice thickness. MRI is acceptable (but not for lung lesions), provided that the size 
of the measurable lesion is twice the slice thickness of the MRI. 
All patients’ files and scans must be available for source verification. 
11.2.1.1. Measurability of Tumor Lesions 
At baseline, tumor lesions will be categorized by the Investigator as measurable or non-
measurable by the RECIST guideline (version 1.1) criteria as described below. 
Measurable:  
Tumour lesions: Must be accurately measured in at least one dimension (longest diameter in 
the plane of measurement is to be recorded) with a minimum size of:  
• 10 mm by CT scan (CT scan slice thickness no greater than 5 mm). In case of MRI, the 
size of the measurable lesion must be twice the slice thickness of the MRI and a minimum of 
10 mm. 
• 10 mm caliper measurement by clinical exam (lesions which cannot be accurately 
measured with calipers should be recorded as non-measurable). 
• 20 mm by chest X-ray. 
Malignant lymph nodes: To be considered pathologically enlarged and measurable, a lymph 
node must be 15 mm in short axis when assessed by CT scan (CT scan slice thickness 
recommended to be no greater than 5 mm). At baseline and in follow-up, only the short axis 
will be measured and followed.  
Non-Measurable: 
All other lesions, including small lesions (longest diameter <10 mm or pathological lymph 
nodes with 10 to <15 mm short axis) as well as truly non-measurable lesions. Lesions 
considered truly non-measurable include: leptomeningeal disease, ascites, pleural or 
pericardial effusion, inflammatory breast disease, lymphangitic involvement of skin or lung, 

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abdominal masses/abdominal organomegaly identified by physical exam that is not 
measurable by reproducible imaging techniques. 
Special considerations regarding lesion measurability: 
Bone lesions, cystic lesions, and lesions previously treated with local therapy require 
particular comment: 
Bone lesions: 
• Bone scan, PET scan or plain films are not considered adequate imaging techniques to 
measure bone lesions. However, these techniques can be used to confirm the presence or 
disappearance of bone lesions. 
• Lytic bone lesions or mixed lytic-blastic lesions, with identifiable soft tissue components, 
that can be evaluated by cross sectional imaging techniques such as CT or MRI can be 
considered as measurable lesions if the soft tissue component meets the definition of 
measurability described above. 
• Blastic bone lesions are non-measurable. 
Cystic lesions: 
• Lesions that meet the criteria for radiographically defined simple cysts should not be 
considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 
• “Cystic lesions” thought to represent cystic metastases can be considered as measurable 
lesions, if they meet the definition of measurability described above. However, if non-cystic 
lesions are present in the same patient, these are preferred for selection as target lesions. 
Lesions with prior local treatment: 
• Tumor lesions situated in a previously irradiated area, or in an area subjected to other loco-
regional therapy, are usually not considered measurable unless there has been demonstrated 
progression in the lesion.  
When effusions are known to be a potential adverse effect of treatment, the 
cytological/histological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or SD is 
mandatory to differentiate between response or SD and PD. 
11.2.1.2. Recording Tumor Measurements 
Target lesions. When more than one measurable lesion is present at baseline, all lesions up 
to a maximum of five lesions total (and a maximum of two lesions per organ) representative 
of all involved organs should be identified as target lesions and will be recorded and 
measured at baseline (this means in instances where patients have only one or two organ 
sites involved a maximum of two and four lesions respectively will be recorded). Target 
lesions should be selected on the basis of their size (lesions with the longest diameter), be 
representative of all involved organs, but in addition should be those that lend themselves to 
reproducible repeated measurements. It may be the case that, on occasion, the largest lesion 
does not lend itself to reproducible measurement in which circumstance the next largest 
lesion which can be measured reproducibly should be selected.  

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Pathological nodes which are defined as measurable and may be identified as target lesions 
must meet the criterion of a short axis of 15 mm by CT scan. Only the short axis of these 
nodes will contribute to the baseline sum. The short axis of the node is the diameter 
normally used by radiologists to judge if a node is involved by solid tumor. Nodal size is 
normally reported as two dimensions in the plane in which the image is obtained (for CT 
scan this is almost always the axial plane; for MRI the plane of acquisition may be axial, 
sagittal or coronal). The smaller of these measures is the short axis. For example, an 
abdominal node which is reported as being 20 mm × 30 mm has a short axis of 20 mm and 
qualifies as a malignant, measurable node. In this example, 20 mm should be recorded as the 
node measurement.  
A sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all 
target lesions will be calculated and reported as the baseline sum diameters. If lymph nodes 
are to be included in the sum, then as noted above, only the short axis is added into the sum. 
The baseline sum diameters will be used as reference to further characterize any objective 
tumor regression in the measurable dimension of the disease. 
Non-target lesions. All other lesions (or sites of disease) should be identified as non-target 
lesions and should also be recorded at baseline, including pathological lymph nodes with 
short axis 10 mm but <15 mm (nodes that have a short axis <10 mm are considered non-
pathological and should not be recorded or followed). 
Measurements are not required and these lesions should be followed as “present”, “absent”, 
or in rare cases “unequivocal progression”. In addition, it is possible to record multiple non-
target lesions involving the same organ as a single item on the case record form (e.g. 
“multiple enlarged pelvic lymph nodes” or “multiple liver metastases”). 
11.2.1.3. Target Lesions Tumor Response 
Complete response (CR) is defined as disappearance of all target lesions and reduction in 
short axis to <10 mm of any pathological lymph nodes (whether target or non-target). 
Partial response (PR) is defined as at least 30% decrease in the sum of the diameters of the 
target lesions, taking as a reference the baseline sum diameters. 
Progressive disease (PD) is defined as at least 20% increase in the sum of diameters of target 
lesions, taking as reference the smallest sum on study (this includes the baseline sum if that 
is the smallest on study). In addition to the relative increase of 20%, the sum must also 
demonstrate an absolute increase of at least 5 mm. (Note: the appearance of one or more new 
lesions is also considered progression). 
Stable Disease (SD) is defined as neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum diameters while on study. 
Special notes on the assessment of target lesions 
Lymph nodes: lymph nodes identified as target lesions should always have the actual short 

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axis measurement recorded (measured in the same anatomical plane as the baseline 
examination), even if the nodes regress to below 10 mm on study. This means that when 
lymph nodes are included as target lesions, the ‘sum’ of lesions may not be zero even if 
complete response criteria are met, since a normal lymph node is defined as having a short 
axis of <10 mm. For PR, SD and PD, the actual short axis measurement of the nodes is to be 
included in the sum of target lesions. 
Target lesions that become “too small to measure”: while on study, all lesions (nodal and 
non-nodal) recorded at baseline should have their actual measurements recorded at each 
subsequent evaluation, even when very small (e.g. 2 mm). However, sometimes lesions or 
lymph nodes which are recorded as target lesions at baseline become so faint on CT scan 
that the radiologist may not feel comfortable assigning an exact measure and may report 
them as being ‘too small to measure’. When this occurs it is important that a value be 
recorded on the case report form. If it is the opinion of the radiologist that the lesion has 
likely disappeared, the measurement should be recorded as 0 mm. If the lesion is believed to 
be present and is faintly seen but too small to measure, a default value of 5 mm should be 
assigned. (Note: It is less likely that this rule will be used for lymph nodes since they usually 
have a definable size when normal and are frequently surrounded by fat such as in the 
retroperitoneum; however, if a lymph node is believed to be present and is faintly seen but 
too small to measure, a default value of 5 mm should be assigned in this circumstance as 
well). This default value is derived from the 5 mm CT slice thickness (but should not be 
changed with varying CT slice thickness). The measurement of these lesions is potentially 
non-reproducible, therefore providing this default value will prevent false responses or 
progressions based upon measurement error. To reiterate, however, if the radiologist is able 
to provide an actual measure, that should be recorded, even if it is below 5 mm. 
Lesions that split or coalesce on treatment: when non-nodal lesions “fragment”, the longest 
diameters of the fragmented portions should be added together to calculate the target lesion 
sum. Similarly, as lesions coalesce, a plane between them may be maintained that would aid 
in obtaining maximal diameter measurements of each individual lesion. If the lesions have 
truly coalesced such that they are no longer separable, the vector of the longest diameter in 
this instance should be the maximal longest diameter for the “coalesced lesion”. 
11.2.1.4. Non Target Lesions Tumor Response 
While some non-target lesions may actually be measurable, they need not be measured and 
instead should be assessed only qualitatively at the time points specified in the protocol. 
Complete response (CR) is defined as the disappearance of all non-target lesions and 
normalization of tumor marker level. All lymph nodes must be non-pathological in size (<10 
mm short axis). 
Non-CR/Non-PD is defined as a persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal limits. 

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Progressive disease (PD) is defined as unequivocal progression of existing non-target 
lesions. (Note: the appearance of one or more new lesions is also considered progression). 
Special notes on assessment of progression of non-target disease 
To achieve “unequivocal progression” on the basis of the non-target disease, there must be 
an overall level of substantial worsening in non-target disease such that, even in presence of 
SD or PR in target disease, the overall tumor burden has increased sufficiently to merit 
discontinuation of therapy. A modest increase in the size of one or more non-target lesions is 
usually not sufficient to qualify for unequivocal progression status. The designation of 
overall progression solely on the basis of change in non-target disease in the face of SD or 
PR of target disease will therefore be extremely rare. 
11.2.1.5. Confirmation of Tumor Response 
To be assigned a status of PR or CR, changes in tumor measurements in patients with 
responding tumors must be assessed by the same tumor imaging technique used at baseline 
and on treatment (eg CT scan or MRI).   
In case of SD, measurements must have met the SD criteria at least once after study entry at 
the minimum interval of 6 weeks. 
11.2.1.6. Determination of Overall Response by RECIST (version 1.1) 
When both target and non-target lesions are present, individual assessments will be recorded 
separately.  The overall assessment of response will involve all parameters as depicted in 
Table 6. 
Table 6. Response Criteria 
Target Lesions 1 
Non-Target Lesions 2 
New Lesions 3 
Overall Response 
CR 
CR 
No 
CR 
CR 
Non-CR/Non-PD 
No 
PR 
CR 
Not evaluated 
No 
PR 
PR 
Non-PD or not all 
evaluated 
No 
PR 
SD 
Non-PD or not all 
evaluated 
No 
SD 
Not all evaluated 
Non-PD 
No 
NE 
PD 
Any response 
Yes or No 
PD 
Any response 
PD 
Yes or No 
PD 
Any response 
Any response 
Yes 
PD 
1 Measurable lesions only  
2 May include measurable lesions not followed as target lesions or non-measurable lesions 
3 Measurable or non-measurable lesions 
Abbreviations:  CR = complete response, PD = progressive disease, PR = partial response, SD = stable disease, NE = 
inevaluable 
 

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The best overall response is the best response recorded from the start of the study treatment 
until the end of treatment taking into account any requirement for confirmation (achievement 
of both measurement and confirmation criteria, depending on the nature of the study and the 
protocol requirement).  The patient’s best overall response assignment will depend on the 
findings of both target and non-target disease and will also take into consideration the 
appearance of new lesions. In the case of SD, follow-up measurements must have met the 
SD criteria at least once after study entry at a minimum interval of 6 weeks. 
Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be reported as 
“symptomatic deterioration” (see Study Manual specific data collection instructions).  
Of note, every effort should be made to document the objective progression even after 
discontinuation of treatment. Symptomatic deterioration is not a descriptor of an objective 
response: it is a reason for stopping study therapy. The objective response status of such 
patients is to be determined by evaluation of target and non-target disease. 
In some circumstances, it may be difficult to distinguish residual disease from normal tissue.  
When the evaluation of a CR depends upon this determination, it is recommended that the 
residual lesion be investigated by fine needle aspirate or biopsy before assigning a status of 
CR. 
For equivocal findings of progression (e.g. very small and uncertain new lesions; cystic 
changes or necrosis in existing lesions), treatment may continue until the next scheduled 
assessment. If at the next scheduled assessment, progression is confirmed, the date of 
progression should be the earlier date when progression was suspected. 
11.3. Outcomes Research Assessments 
Not applicable in this study. 
11.4. Safety Assessments   
11.4.1. Adverse Event Assessment  
11.4.1.1. Definition of Adverse Events 
11.4.1.1.1. Adverse Event 
According to ICH definition an AE is defined as any untoward medical occurrence in a 
patient or a clinical trial subject administered a medicinal product and which does not 
necessarily have to have a causal relationship with the use of the product. An adverse event 
can therefore be any unfavorable and unintended sign (e.g. an abnormal laboratory finding), 
symptom, or diagnosis temporally associated with the use of a medicinal product, whether or 
not considered related to the medicinal product.  

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Any untoward medical occurrence, which occurs outside the period of subject follow-up 
defined in the protocol (28 days after the last treatment administration for the present study, 
see Section 11.4.1.3), is not considered an AE. Symptoms or medically significant 
laboratory or instrumental (e.g. electrocardiograph) abnormalities of a pre-existing condition 
should not be considered an AE. However, occurrences of new symptoms, laboratory or 
instrumental abnormalities, as well as worsening of pre-existing ones, are considered AEs. 
In this trial, the following should not be reported as adverse event: 
 The general wording “Progression of the disease”.  
Note: the specific symptoms of the disease worsening have to be considered as adverse 
events.  
 Uncomplicated and asymptomatic abnormal laboratory findings.  
Note: abnormal laboratory findings have to be considered as adverse events when they 
cause treatment discontinuation or when require clinical intervention (e.g., 
hospitalization for further investigation or management of the laboratory abnormality).   
11.4.1.1.2. Serious Adverse Events 
A serious adverse event is an adverse event that falls into one or more of the following 
categories:  
 Results in death 
 Is life-threatening, i.e., is an event which, in the view of the Investigator, places the 
subject at immediate risk of death from the event as it occurred (it does not include 
an event which hypothetically might have caused death if it was more severe) 
 Requires inpatient hospitalization or prolongation of existing hospitalization  
 Results in persistent or significant disability/incapacity, where disability is defined as 
a substantial disruption of a person’s ability to conduct normal life functions, either 
reported or defined as per clinical judgment 
 Is a congenital anomaly/birth defect (if exposure to product just before conception or 
during pregnancy resulted in an adverse outcome in the child) 
 Is any other important medical event, i.e., may not result in death, be life-threatening, 
or require hospitalization, but based upon appropriate medical judgment, it may 
jeopardize the subject and may require medical or surgical intervention to prevent 
one of the outcomes listed in the points above.  Examples of such events include 
allergic bronchospasm requiring intensive treatment in an emergency room or at 
home, and blood dyscrasias or convulsions that do not result in inpatient 
hospitalization. 

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A non-serious adverse event is any adverse event that does not meet the criteria listed above 
for a serious adverse event or the outcome (i.e., subject treatment, life-threatening condition, 
hospitalization, recovery) cannot be determined with the information provided. 
Each adverse event has to be classified by the Investigator as serious or non-serious. This 
classification of seriousness of the event determines the reporting procedures to be followed.  
In this trial the following do not have to be classified as Serious Adverse Events: 
 Admission to hospital required by the protocol. 
 Events definitely related to disease progression. 
All deaths occurring during the reporting period have to be reported as SAEs, even if 
due to disease progression. 
11.4.1.2. Eliciting Adverse Event Information 
The Investigator has to report all directly observed adverse events and all adverse events 
spontaneously reported by the trial subject using concise medical terminology.  In addition, 
each trial subject will be questioned about adverse events at each clinic visit following the 
signature of the informed consent. The question asked will be “Since your last clinical visit 
have you had any health problems?” 
11.4.1.3. Adverse Event Reporting Period 
Adverse event reporting period: 
The adverse event reporting period for this trial begins upon signing of informed consent 
form and ends 28 days after the last treatment administration. 
Events should be assessed and documented at each scheduled clinic visit since patient signs 
the Informed Consent, before treatment administration at baseline (baseline signs and 
symptoms), at the end of each treatment cycle, and 28 days after the last dose of study drug 
administration. For patients remaining on treatment for a period of time more than 6 cycles 
the events will be assessed by phone call if the visit to the site is not planned (one visit 
planned to the site every three cycles, 1.5 months). The phone call information will be 
collected in a specific form signed and dated by the Investigator and included in the CRF. 
 
However, if the patient begins a new anticancer therapy before 28 days after the last dose of 
study treatment administration, the adverse event reporting period will end at the time the 
new treatment is started. 
All adverse events that occur in trial subjects during the adverse event reporting period must 
be reported to CLIOSS (delegated by the Sponsor), whether or not the event is considered 
related to the study treatment.  

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Adverse event follow up after the end of the reporting period: 
The following events should be followed after the end of the reporting period (i.e., 28 days 
after the last treatment administration): 
1. All serious adverse events with outcome “not recovered” or “unknown” at the end of the 
reporting period. 
2. Those non-serious events whose relationship with investigational study treatment has 
been classified as “Unlikely”, “Possible”, “Probable” and “Definite” with outcome ‘ not 
recovered’ at the end of the reporting period. 
Such events should be followed until they resolve, the patient begins a new anticancer 
therapy or the Investigator determines, whenever possible, that they have become “chronic” 
or “stable”. Resolution of such events is to be documented on the appropriate report form. 
In addition, if, after the end of the reporting period, suspected serious adverse reactions or 
deaths are reported to the Investigator and he/she believes that they are related to the 
investigational product, it is the Investigator’s responsibility to report this suspected serious 
adverse reactions to CLIOSS Pharmacovigilance. Such suspected serious adverse reactions 
will be reported using a Serious Adverse Event Report Form or any other way chosen by the 
Investigator. 
After the cut-off date of 31 May 2017 and approval of Amendment 5 to the protocol , SAEs 
will continue to be reported to CLIOSS Pharmacovigilance for patients still receiving  
treatment, up to 28 days after discontinuation of milciclib, according to Section 9.5. 
11.4.1.4. Reporting Requirements 
Each adverse event has to be classified by the Investigator as SERIOUS or NON SERIOUS.  
The seriousness of the event determines the reporting procedures to be followed. If a serious 
adverse event occurs, the CLIOSS Pharmacovigilance (delegated by the Sponsor) has to be 
notified, by Fax (+39 0331 581681) or by e-mail (drugsafety@clioss.com) using the 
designated form, within 24 hours of awareness of the event by the Investigator. The initial 
report should be followed by submission of more detailed adverse event information within 
5 calendar days after the Investigator first became aware of the serious adverse event. 
Reporting requirements for adverse events are summarized in the following table. 

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Table 7. Reporting requirements for adverse events 
Gravity 
Reporting Time 
Type of Report 
SERIOUS 
Within 24 hours 
Initial report on designated serious adverse event 
form (SAER-F) 
Within 5 calendar days 
Follow-up/Final report on designated serious 
adverse event form (SAER-F) 
NONSERIOUS 
Per case report form submission 
procedure 
Study case report forms 
 
Serious adverse events should also be recorded on appropriate section of the case report 
form. 
In the rare event that the Investigator does not become aware of the occurrence of a serious 
adverse event immediately (for example, if an outpatient trial subject initially seeks 
treatment elsewhere), the Investigator should report the event within 24 hours after learning 
of it and document his/her first awareness of the adverse event. 
Non serious adverse events have to be recorded on the study case report forms. 
11.4.1.5. Recording Adverse Events in the Case Report Forms 
Information on adverse events must be evaluated by a physician and recorded in a source 
document such as the hospital file.  Adverse events are to be recorded on the case report 
forms as above specified.  The Investigator will also be asked to assess the relationship 
between the adverse event and the investigational medication. 
 Preexisting Conditions 
In this trial, a pre-existing condition (i.e., a disorder present before an adverse event occurs 
and recorded on the pretreatment medical history/physical examination form) should not be 
reported as an adverse event unless the condition worsens or episodes increase in frequency 
during the adverse event reporting period. 
 Baseline Signs and Symptoms 
All Signs and Symptoms (either tumor-related or not tumor-related) collected at baseline 
should not be reported anymore during the study except in case they worsen in severity or in 
frequency. 
 Procedures 
Diagnostic and therapeutic non-invasive and invasive procedures, such as surgery, should 
not be reported as adverse events.  However, the medical condition for which the procedure 
was performed should be reported if it meets the definition of adverse event.  For example, 
an acute appendicitis that begins during the adverse event reporting period should be 
reported as the adverse event and the resulting appendectomy should be recorded in the 
source documents. After cut-off date of 31 May 2017, AE/SAE data will be no longer 

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collected into the CRF, but assessments information should continue to be collected into the 
patient’s medical notes. 
11.4.1.6. Grading of Adverse Event Severity 
The severity of adverse events will be graded using the Common Terminology Criteria for 
Adverse Events (CTCAE, Version 3.0) of the US National Cancer Institute. See the website: 
http://ctep.info.nih.gov/reporting/ctc.html. For each event, the highest severity grade attained 
should be reported. 
Schedule of adverse events safety assessment is reported in Section 7, Schedule of Events. 
For events not reported in the CTCAE Version 3.0, the Investigator will use the grade or 
adjectives reported in Table 8: 
Table 8. Grading of Adverse Event Severity for Events not reported in the CTCAE 
Version 3.0 
Grade 
Adjective 
Description 
Grade 1 
Mild 
Does not interfere with patient’s usual function 
Grade 2 
Moderate 
Interferes to some extent with patient’s usual function 
Grade 3 
Severe 
Interferes significantly with patient’s usual function 
Grade 4 
Life-threatening 
Results in threatening to life or in an incapacitating disability 
Grade 5 
Death 
Results in death 
 
Note the distinction between the term “serious” and “severe”, which are not synonymous. 
The term “severe” is used to describe the intensity of a specific event (i.e. severe headache) 
while the term “serious” is based on patient/event outcome or action criteria. Seriousness 
(not severity) serves as a guide for defining regulatory reporting obligations. For example 
vomiting grade 1 for which a hospitalization occurred is a serious event even if the event is 
not severe. 
11.4.1.6.1. Relationship to the Investigational product 
The causality between each adverse event and the investigational product should be 
classified according to the following terms: 
Unrelated: the event is a pre-dose event or is definitely due to causes separate from the 
administration of the investigational product, i.e.: documented pre-existing condition, 
concomitant medication, the subject’s clinical state or the event is judged as not related and 
does not fall under any of the above points. 
Unlikely: an event for which the exclusion of drug causality seems most plausible, whilst 
other drugs or underlying disease provide plausible explanation. 
Possible: a clinical event, including laboratory test abnormality, with a reasonable temporal 
sequence from administration of the investigational product and with a known response 

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pattern to the investigational product, but the event could have been caused by subject’s 
clinical state, other therapy administered or diagnostic/interventional procedure. Information 
on drug withdrawal may be lacking or unclear. 
Probable: a clinical event, including laboratory test abnormality, with a reasonable temporal 
sequence from administration of the investigational product and with a known response 
pattern to the investigational product, but the event cannot be reasonably explained by the 
known characteristics of the subject’s clinical state, other therapy administered or 
diagnostic/interventional procedure and for which there is evidence of partial or complete 
disappearance of the event after withdrawal of the product (positive dechallenge). 
Definite: a clinical event that follows a reasonable temporal sequence from administration of 
the drug or in which the drug level has been established in body fluids or tissues; that 
follows a known response pattern to the suspected drug; and that is confirmed by 
improvement on withdrawal (positive dechallenge) or reducing the dose, and reappearance 
of the event after reintroduction of the drug (positive rechallenge). 
11.4.1.7. Exposure In Utero 
The Investigator will be asked to submit an Exposure in Utero Form in the cases reported 
below: 
 a trial patient becomes or is found to be pregnant while receiving an investigational 
medication/product or within 90 days of its discontinuation 
 a partner of a male patient becomes or is found to be pregnant, while the patient is 
receiving an investigational medication/product or within 90 days of discontinuing 
the investigational medication/product. 
This must be done irrespective of whether an adverse event has occurred and within 24 
hours of awareness of the pregnancy. The information submitted should include the 
estimated date of delivery (see below for information related to induced termination of 
pregnancy). However if the patient begins a new anticancer therapy before 90 days after the 
last dose of study treatment administration, the exposure in utero reporting period will end at 
the time the new treatment is started.  
The Investigator will follow the patient until completion of the pregnancy or until pregnancy 
termination (i.e., induced abortion) and then notify the CLIOSS Pharmacovigilance of the 
outcome within 5 days or as specified below. The Investigator will provide this information 
as a follow up to the initial Exposure in Utero form. The reason(s) for an induced abortion 
must be specified.  
If the outcome of the pregnancy meets the criteria for immediate classification as a serious 
adverse event (i.e., spontaneous abortion, stillbirth, neonatal death, or congenital anomaly 
[including that in an aborted fetus]), the Investigator should follow the procedures for 

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reporting serious adverse events, i.e., report the event to Nerviano Medical Sciences (as 
described in Section 11.4.1.4, Reporting Requirements).  
In the case of a live birth, the “normality” of the newborn can be assessed at the time of birth 
(i.e., no minimum follow-up period of a presumably normal infant must pass before an 
Exposure in Utero Form can be completed). The “normality” of an aborted fetus can be 
assessed by gross visual inspection unless pre-abortion laboratory findings are suggestive of 
a congenital anomaly.  
Additional information about pregnancy outcomes that are classified as serious adverse 
events follows:  
 “Spontaneous abortion” includes miscarriage and missed abortion. 
 All neonatal deaths that occur within 1 month of birth should be reported, without regard 
to causality, as serious adverse events. In addition, any infant death after 1 month that 
the investigator assesses as possibly related to the in utero exposure to the investigational 
medication should also be reported. 
11.4.2. Laboratory Safety Assessments 
Laboratory safety assessments will include repeated evaluation of hematology and 
biochemistry parameters, urinalyses and pregnancy test that after the cut-off date of 31 May 
2017 will be done according to routine clinical practice and/or at investigator’s discretion. 
The results of these exams should be recorded only in the patient’s medical notes.  
Hematology tests include: hemoglobin, erythrocytes (RBC), white blood cell (WBC) with 
differential count (neutrophils, lymphocytes, monocytes, eosinophils, basophils, differential 
other cells), platelets (PLTs). 
They will be performed during baseline and repeated during treatment between the Days 11 
and 14 of all cycles. If toxicity preventing re-treatment results from the Day 11-14 
assessment, hematology should be repeated as needed to monitor for recovery. 
Hematology tests will be done also on Day 1 of cycles, before study drug administration, 
only in case toxicity preventing re-treatment resulted from the assessment done within the 
previous 4 days at the end of the prior cycle.  
For patients remaining on treatment for a period of time more than 6 cycles the 
hematological tests may be done locally when the visit to the site is not planned  (one visit 
planned to the site every three cycles, 1.5 months) and must be sent to the site for safety 
evaluation and reported on CRF. 
Blood chemistry tests include: sodium, potassium, chloride, magnesium, blood urea nitrogen 
(BUN) or urea, creatinine, albumin, AST/SGOT, ALT/SGPT, Alkaline Phosphatase (ALP), 
total bilirubin, creatinine clearance (calculated by the Cockroft and Gault’s formula), 
amylase and lipase. 
They will be performed during baseline and repeated during treatment between the Days 11 

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and 14 of all cycles. If toxicity preventing re-treatment results from the Day 11-14 
assessment, blood chemistry should be repeated as needed to monitor for recovery. 
Blood chemistry tests will be done also on Day 1 of cycles, before study drug 
administration, only in case toxicity preventing re-treatment resulted from the assessment 
done within the previous 4 days at the end of the prior cycle. 
For patients remaining on treatment for a period of time more than 6 cycles the biochemical 
tests may be done locally when the visit to the site is not planned  (one visit planned to the 
site every three cycles, 1.5 months) and must be sent to the site for safety evaluation and 
reported on CRF. 
Coagulation tests include: INR (International Normalized Ratio) and activated partial 
thromboplastin time (APTT, in seconds). To be done at baseline, at the end of last cycle and, 
during treatment, at the end of even cycles (between Days 11 and 14). 
For patients remaining on treatment for a period of time more than 6 cycles the coagulation 
tests may be done locally when the visit to the site is not planned  (one visit planned to the 
site every three cycles, 1.5 months) and must be sent to the site for safety evaluation and 
reported on CRF. 
Urinalysis includes: pH, dipstick for glucose, protein and blood.  It will be performed at 
baseline and at the end of last cycle. During treatment, should be performed at the end of 
even cycles (between Days 11 and 14). 
For patients remaining on treatment for a period of time more than 6 cycles the urinalysis 
tests may be done locally when the visit to the site is not planned  (one visit planned to the 
site every three cycles, 1.5 months) and must be sent to the site for safety evaluation and 
reported on CRF. 
Serum/urine pregnancy test is indicated only for women of reproductive potential and is to 
be carried out within 7 days prior to the first treatment administration. 
The timing and specific requirements for each laboratory safety evaluation are given in 
Section 7, Schedule of Events. 
Specific analyses to be performed in presence of events indicative of, or suggestive of, 
MTA/HUS (see Section 9.4.9): search of schistocytes in the peripheral blood smear, count of 
reticulocytes in the peripheral blood, coagulation test, total LDH and 24-hour proteinuria. 
Routine Hematology, Blood Chemistry and Urinalysis tests, foreseen by the study protocol, 
should also be repeated at the time when this evaluation is performed. 
11.4.3. Other Safety Assessments 
The following safety assessments will also be performed, according to timing reported in 
Section 7, Schedule of Events: 

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Physical examination will be done at pretreatment and on treatment at the end of each cycle 
during the first three months of treatment (6 cycles). Any abnormality at pretreatment should 
be reported in the Baseline Signs and Symptoms CRF page and on treatment in the AE CRF 
page. For patients still on treatment at the cut-off date of 31 May 2017, assessments data 
should be recorded only in the patient’s medical notes. Vital Signs: Blood pressure/pulse 
(supine) is to be monitored at baseline and on Day 1 of each treatment cycle, before 
treatment administration; height (in cm or inches) will be measured at baseline only; weight 
(in kg or pounds) will be assessed at baseline and on Day 1 of each treatment cycle; ECOG 
performance status will be monitored at baseline and on Day 1 of each treatment cycle; 
temperature (in °C or °F) will be measured at baseline and on Day 1 of each treatment cycle. 
A time window of 1 day before treatment start is allowed at each cycle. 
For patients remaining on treatment for a period of time more than 6 cycles, vital signs 
(including blood pressure/pulse, weight and temperature) will be done in concomitance with 
the visit to the site (once every 3 cycles, 1.5 months). 
ECG (12-lead) will be carried out at the pretreatment visit and at the end of last cycle. To be 
repeated during treatment as medically indicated. 
Chest X-ray will be carried out, for safety assessment, at the pretreatment visit and at the end 
of last cycle. 
Ophthalmologic examination will include visual acuity test and fundoscopic examination 
and will be carried out at the pretreatment visit, at the end of even cycles (between Days 11 
and 14) during the first three months of treatment (6 cycles), at 4.5 months (ninth treatment 
cycle, between days 11 and 14) and then after every three months and at the end of last cycle 
by an ophthalmologist. Additional assessments will be performed if clinically indicated.  
Ophthalmologic evaluations will be done by the same ophthalmologist for a given patient. 
For patients still on treatment at the cut-off date of 31 May 2017, data should be recorded 
only in the patient’s medical notes. 
Neurological status evaluation: at each scheduled clinical visit (at baseline, at the end of 
each treatment cycle, and 28 days after the last dose of study drug administration) patients 
will undergo regular clinical examination, including the assessment of clinical tremors and 
associated signs and symptoms. During the visits at the site, patients should be examined 
during rest, when assuming various positions and when moving (see also Section 9.4.7, 
Assessment and Management of Potential CNS Toxicity). Any sign and symptom of 
neurological toxicity should be recorded in the Adverse Events CRF pages of the relevant 
cycle. For patients still on treatment at the cut-off date of 31 May 2017, no AEs will be 
collected in the CRF, and all evaluations should be recorded only in the patient’s medical 
notes. 

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11.5. Other Assessments 
11.5.1. Confirmation of histological diagnosis 
Histological diagnosis of thymic carcinoma, when made by another institution, has to be 
confirmed by pathologists of the investigational site to whom the patient is addressed, based 
on paraffin embedded tumor tissue slides retrieved from patients. 
11.5.2. Pharmacokinetics 
No blood sampling is expected during the study for pharmacokinetics analysis. Blood 
samples may be collected if, in the opinion of the Investigator and of the Sponsor, an 
evaluation of the systemic exposure of PHA-848125AC is needed for safety reasons. In such 
case the IRB will be notified. 
The eventual blood samples collected for safety reason will be sent to the Sponsor for 
analysis in Accelera Srl and stored in a secure place to ensure protection of patient 
confidentiality. 
If applicable, the actual time of sample collection has to be recorded in the Case Report 
Form. 
11.5.3. Laboratory Exploratory Studies on Tumor Specimens 
11.5.3.1. Collection of Tumor Specimen(s) 
A Paraffin-embedded tumor biopsy, or at least 10 derived slides, obtained from all patients 
before study entry will be procured from the institutions where the procedures were 
performed. 
11.5.3.2. Evaluation of Tumor Molecular Features 
Molecular analysis of p53, p21, p27, cyclin D1, p75, TRKA expression by IHC and TRKA 
gene copy number by FISH on paraffin-embedded tissues of consenting patients obtained 
before study entry, will be performed in designated facilities in NMS and/or NIH/NCI. 
Additional biomarkers under validation may also be performed. 
12. STATISTICAL METHODS 
12.1. Sample Size Calculation 
In consideration of the exploratory nature of the study, and the lack of certainty regarding 
the expected PFS-3 rate, a single-arm, open-label, multicenter phase II clinical trial design 
including an early stopping rule will be used. 

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Unless an early stopping rule is invoked, the study will enroll 30 patients who have received 
at least two prior therapies. Accounting for a 10%-15% proportion of non evaluable patients, 
an accrual ceiling up to 35 patients will be set for completing the trial.  
The primary endpoint of the study is the progression-free survival status at 3 months and the 
primary efficacy analysis will be performed on the proportion of successes (i.e. patients alive 
and progression-free at 3 months since treatment start) out of the total number of evaluable 
patients (PFS-3 rate). 
Under the assumption of an uninteresting PFS-3 rate of 25% (corresponding to a median 
PFS of 1.5 months) against an interesting one of 50% (corresponding to a median PFS of 3 
months), =0.05 and =0.10, 30 evaluable patients are required for a single stage trial.  If at 
the end of the trial 12 or more out of 30 evaluable patients are alive and progression-free at 3 
months since the treatment start date, the null hypothesis will be rejected. The probability of 
this occurring is 5.1% if the true probability of avoiding progression by 3 months is 25% 
while the probability of this occurring is 90.0% if the true probability of avoiding 
progression by 3 months is 50%. 
To ensure that the study is not continued in the event that the agent is not providing adequate 
prevention of progression, a Fleming multiple-testing procedure [42] will be utilized for the 
computation of acceptance and rejection critical boundaries at the interim look. If 3 or fewer 
patients out of the first 15 are progression-free at 3 months, accrual will stop for futility as 
soon as this can be determined. If 4 or more patients out of 15 are progression free, the trial 
will be continued until 30 evaluable patients are available.  
A two-tailed 90% CI on 12 out of 30 (40.0%) evaluable patients alive and in progression-
free status at 3 months ranges from 25.0% to 56.6%, whereas the two-tailed 90% CI of 4 out 
of 15 (26.7%) ranges between 9.7% to 51.%  thus showing substantial consistency with the 
set of hypotheses. 
12.2. Definition of Analyzed Study Populations 
For the purpose of the analysis, the following patient populations are defined and the 
endpoints, to be analyzed in these populations, are specified: 
 Screened Patients:  This population will include all subjects who are screened about 
their eligibility for the trial, regardless of whether or not they will be enrolled in the 
study.  This population will be evaluated in the analysis of patients’ disposition. 
 Enrolled Patients:  This population will include all subjects who are enrolled in the trial, 
regardless of whether subjects receive the study drug or not.  This population will be 
evaluated in the analysis of patients’ disposition. 
 Treated Patients: The treated patient population consists of all enrolled patients who 
actually receive at least one study drug administration. This population will be evaluated 

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in the analysis of patient disposition, baseline characteristics, efficacy, safety and 
treatment exposure. 
 Patients Evaluable for Efficacy Analysis:  This is the patient population for the primary 
efficacy analysis of PFS-3 rate and consists of all eligible and treated patients who fulfill 
the following additional conditions:  
 They receive at least 80% of drug in the first two cycles overall. 
 They have baseline and 1 on-treatment tumor/oncologic assessment(s) or die before 
tumor re-assessment. 
If deemed of clinical interest, patient disposition, baseline characteristics, efficacy, safety 
and treatment exposure will be analyzed also in this population. 
12.3. Analyses 
12.3.1. Study Conduct and Subject Disposition 
Patients’ disposition will be presented in frequency distribution tables and individual data 
listings.  All screened patients will be included in this evaluation. Violations of eligibility 
criteria at study entry as recorded in the relevant sections of the CRF will be documented. 
Reasons for stopping treatment will be summarized as frequency distribution in the treated 
patient population and, if clinically interesting, in other patient subsets (e.g. evaluable 
patients). 
12.3.2. Baseline Characteristics 
Descriptive statistics of the baseline characteristics will be generated in the treated patient 
population and, if clinically interesting, in other patient subsets (e.g. evaluable patients). 
Frequency distributions will be presented for the categorical / categorized variables.  
Summary statistics including mean, standard deviation, median, minimum, maximum and 
the number of assessed patients will be calculated, as appropriate, for the quantitative 
variables.  Individual data will be presented in listings. 
12.3.3. Treatment Administration/Compliance 
The treatment exposure and the compliance with study treatment will be descriptively 
analyzed in the treated patient population and, if clinically interesting, in other patient 
subsets (e.g. evaluable patients). Descriptive statistics (e.g. min, max, mean, standard 
deviation, and median value) will be calculated on a per-patient basis for the following 
variables: the number of cycles administered, the overall duration of treatment, the actual 
and total doses administered, and the absolute and relative dose intensity. Frequency 
distributions of patients and/or cycles will be used to describe dose modifications, delays 
and omissions, as well as the reasons for deviation from the planned therapy. These data will 
be presented as reported in the relevant CRF sections. 

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12.3.4. Efficacy Analyses 
Primary Efficacy Endpoint 
For the primary efficacy analysis, the primary endpoint, i.e. the PFS-3 rate (see Section 
4.2.1), will be calculated as the proportion of evaluable patients (see Section 12.2) known to 
be alive and progression-free at ≥ 3 months since study treatment start out of the total 
number of evaluable patients. 
A decision rule will be applied in the primary efficacy analysis as described in Section 12.1: 
i.e., at least 4 of the first 15 evaluable patients alive and progression free at  3 months are 
required not to stop the trial. 
A rate of at least 12 out of 30 evaluable patients alive and progression free at  3 months at 
end of the trial will be regarded as an indication of interesting antitumor activity of PHA-
848125AC.   
Supportive analyses of the primary endpoint will include the estimation of the PFS-3 rate 
together with its exact, two-tail, 95% confidence interval and the estimation of the PFS 
curve by the Kaplan-Meier method [43] in both the evaluable and the treated patient 
population. 
Other Efficacy Endpoints 
The secondary efficacy endpoints outlined in section 4.2.2 and including the confirmed 
objective response rate, the disease control rate, the duration of response and the overall 
survival will be analyzed in both the evaluable and the treated patient population as follows: 
Objective tumor response rate: Point and 95% confidence interval estimates will be 
calculated for the objective tumor response rate (confirmed CRs or PRs).  The analysis will 
be performed in the evaluable and in the treated patient populations.  The estimates of the 
rates of unconfirmed tumor objective responses will also be provided and considered as 
supportive. 
Disease control rate: Point and 95% confidence interval estimates will be calculated for the 
disease control rate (confirmed CRs / PRs and SD  6 weeks).  The analysis will be 
performed in the evaluable and in the treated patient populations.   
Time-to-event endpoints:  For the other secondary endpoints, duration of response (in 
patients achieving a confirmed objective tumor response by RECIST version 1.1 criteria) 
and overall survival (OS), individual calculated times will be presented in patients’ data 
listings together with the identification of censored vs. failure status. Kaplan-Meier curves 
will be estimated for OS in both the evaluable and the treated patient populations.   
All collected efficacy data will be presented in individual patients’ data listings. 

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12.3.5. Outcomes Research Analyses 
Not applicable in this study. 
12.3.6. Safety Analyses 
Safety data will be evaluated in the treated patient population and, if clinically interesting, in 
other patient subsets (e.g. evaluable patients). 
The adverse events (AEs) will be coded by the Medical Dictionary for Regulatory Activities 
(MedDRA) and their severity graded according to the NCI Common Terminology Criteria 
for Adverse Events (CTCAE) version 3.0.  The MedDRA preferred term and system organ 
class (SOC) will be used to identify and group events in data listings and descriptive 
analyses. All reported baseline signs and symptoms and on-treatment adverse events will be 
reported in the patients’ data listings. The analysis will address all the events that are 
recorded on treatment (i.e. from cycle 1, on). The raw incidence of each sign/symptom, of 
the subsets of events grouped by system organ class and, in general, the raw incidence of any 
AE, will be calculated. In this analysis, every patient will be accounted for on the basis of 
the worst CTCAE grade reported during the whole period, within the considered category 
(e.g. the analyzed sign/symptom or system organ class).  The following subsets of AEs will 
also be specifically considered: serious AEs, AEs with CTCAE grade 3-5, AEs with a 
relationship to study treatment classified by the Investigator as possible or probable or 
definite and AEs reported as leading to discontinuation from treatment. 
Raw incidence of death will be calculated.  Deaths will also be described in terms of 
relationship to the study treatment and according to the time from treatment stop. 
Laboratory test values will be graded according to the NCI CTCAE scale, v3.0, whenever 
possible. For each laboratory test included in the NCI CTCAE system, the incidence of 
abnormalities will be evaluated by considering the worst occurrence for each patient 
throughout the whole treatment period. The frequency distributions of cycles according to 
the worst CTCAE grade will also be calculated for selected parameters, as clinically 
indicated. Preliminary conversions of reported values from the originally reported units to a 
set of predefined units will be applied to facilitate the comparison.  For selected parameters 
descriptive analysis of shifts relative to baseline will be performed if deemed of clinical 
relevance. Coagulation tests will be evaluated with respect to the corresponding baseline 
values and to the recorded normal ranges. Urinary parameters will be documented in patient 
data listings. 
Ophthalmologic examinations will be summarized in terms of normal / abnormal findings.  
Shift tables comparing patients’ worst assessments after treatment initiation to the 
corresponding baseline assessments will be built. 
All collected safety data (including vital signs, ECG, ophthalmologic evaluations, laboratory 
tests and adverse events) will be presented in individual patients’ data listings. Identification 

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of clinically relevant values and calculation of changes from baseline will be provided in the 
listings for those parameters and conditions deemed of clinical relevance. 
12.3.7. Analyses of Other Endpoints 
12.3.7.1. Molecular Markers in Tumor Biopsies 
The collection of these data is foreseen in consenting patients. Descriptive statistics of p53, 
p21, p27, cyclin D1, p75 and TRKA expression and TRKA gene copy number alterations in 
the tumor samples will be presented. Additional biomarkers may also be presented. 
Exploratory analyses on the relationship between these markers and treatment efficacy 
variables (e.g. PFS-3, PFS, objective tumor response, OS) will be performed only if 
sufficient data are collected. 
12.3.7.2. Pharmacokinetics 
Plasma levels versus sampling times will be presented in tabular and graphic form, if 
applicable. 
12.3.7.3. Concomitant Medications and Post-Treatment Anti-tumor Therapies 
Individual patients’ data listings will be prepared to document the administration of 
concomitant medications. 
Patients starting antitumor therapies during follow-up will be identified in a patients’ data 
listing. 
12.4. Interim Analysis Plan 
To ensure that the study is not continued in the event that the agent is not providing adequate 
prevention of progression, the primary endpoint will be evaluated after 15 patients have been 
recruited and observed for three months, or if they failed earlier. 
The final report will be compiled once that 30 evaluable patients have been observed for 
three months or failed earlier, if the trial is not stopped earlier for futility. 
12.5. Data Monitoring Committee 
Not applicable. 
13. END OF STUDY 
After approval of Amendment 5, the end of the trial is defined as the last visit of the last 
patient, occurring when all patients have discontinued study therapy. 

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14. QUALITY CONTROL AND QUALITY ASSURANCE 
Monitoring visits to the trial site will be made periodically during the trial to ensure that 
GCPs and all aspects of the protocol are followed.  Source documents will be reviewed for 
verification of agreement with data on case report forms.  The investigator/institution 
guarantees direct access to source documents by the Sponsor and appropriate regulatory 
authorities. 
The trial site may also be subject to review by the institutional review board 
(IRB)/independent ethics committee (IEC) to quality assurance audits performed by the 
Sponsor, and/or to inspection by appropriate regulatory authorities to assure compliance 
with proper trial conduct. 
It is important that the investigator(s) and their relevant personnel are available during the 
monitoring visits and possible audits or inspections and that sufficient time is devoted to the 
process 
15. DATA HANDLING AND RECORD KEEPING 
15.1. Case Report Forms  
A case report form is required and should be completed for each included subject.  The 
completed original case report forms are the sole property of Tiziana Life Sciences, PLC and 
should not be made available in any form to third parties, except for authorized 
representatives of appropriate regulatory authorities, without written permission from 
Tiziana Life Sciences. 
It is the investigator's responsibility to ensure completion and to review and approve all case 
report forms.  Case report forms must be signed by the investigator or by an authorized staff 
member.  These signatures serve to attest that the information contained on the case report 
forms is true.  At all times, the investigator has final personal responsibility for the accuracy 
and authenticity of all clinical and laboratory data entered on the case report forms.  Subject 
source documents are the physician's subject records maintained at the study site.  In most 
cases, the source documents will be the hospital's or the physician's chart.  In cases where 
the source documents are the hospital or the physician's chart, the information collected on 
the case report forms must match those charts.  In some cases, a portion of the source 
documents for a given study/site may be the case report forms.  The investigator must agree 
which items will be recorded in the source documents and for which items the case report 
form will stand as the source document. 
For patients still on treatment at the cut-off date of 31 May 2017, data should be recorded 
only in the patient’s medical notes. 
 

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15.2. Record Retention 
To enable evaluations and/or audits from regulatory authorities or Tiziana Life Sciences, 
PLC, the investigator agrees to keep records, including the identity of all participating 
subjects (sufficient information to link records, case report forms and hospital records), all 
original signed informed consent forms, copies of all case report forms, source documents, 
and detailed records of treatment disposition.  The records should be retained by the 
investigator according to local regulations or as specified in the Clinical Trial Agreement, 
whichever is longer.   
If the investigator relocates, retires, or for any reason withdraws from the study, the Sponsor 
should be prospectively notified.  The study records must be transferred to an acceptable 
designee, such as another investigator, another institution, or to Tiziana Life Sciences, PLC.  
The investigator must obtain the Sponsor  written permission before disposing of any 
records.  
For patients still on treatment at the cut-off date of 31 May 2017, data should be recorded 
only in the patient’s medical notes. 
16. ETHICS 
16.1. Institutional Review Board (IRB)/Independent Ethics Committee (IEC) 
Approval of the trial protocol, protocol amendments, informed consent forms, and other 
relevant documents (eg, advertisements), if applicable, must be obtained from the IRB/IEC 
according to applicable regulatory requirements. 
The only circumstance in which an amendment may be initiated prior to IRB/IEC approval 
is where the change is necessary to eliminate apparent immediate hazards to the subjects.  In 
that event, the investigator must notify the IRB/IEC and the local Nerviano Medical 
Sciences site personnel as soon as the change has been implemented. 
16.2. Ethical Conduct of the Trial 
The trial will be performed in accordance with International Conference on Harmonization 
Good Clinical Practice guidelines, the Declaration of Helsinki (1996 Version), and 
applicable local regulatory requirements and laws. 
16.3. Subject Information and Consent 
It is the responsibility of the Investigator to give each subject (or the subject’s acceptable 
representative) full and adequate verbal and written information regarding the objective and 
procedures of the trial and the possible risks involved.  This information must be provided to 
the subject prior to undertaking any trial-related procedure.  The subjects must be informed 
about their right to withdraw from the trial at any time.  Written subject information, 
approved by the IRB/IEC, must be given to each subject before any trial-related procedure is 

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undertaken. The written subject information must not be changed without prior approval by 
NMS and the IRB/IEC. Furthermore, it is the responsibility of the Investigator to obtain 
signed and dated informed consent from all subjects, and a signature from the persons 
conducting the informed consent discussion, prior to undertaking any trial-related procedure. 
A recommended informed consent sample is provided in Appendix 1 of this protocol. 
17. SPONSOR DISCONTINUATION CRITERIA 
Tiziana Life Sciences, PLC reserves the right to discontinue the trial prior to inclusion of the 
intended number of subjects, but intends only to exercise this right for valid scientific or 
administrative reasons.  After such a decision, the Investigator must contact all participating 
subjects within a time period set by the Sponsor.  In any case, for patients on treatment, the 
Sponsor will guarantee the supply of PHA-848125AC until the patients will benefit from 
this product. As directed by the Sponsor, all study materials must be collected and all case 
report forms completed to the greatest extent possible. 
18. DISSEMINATION AND PUBLICATION OF RESULTS 
The conditions regulating dissemination of the information derived from this clinical study 
are described in the Clinical Trial Agreement. Presentations, abstracts, publications of the 
study results are to be submitted to The Sponsor for internal review procedure, at least 1 
month before submission. 

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19. REFERENCES 
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14. Bedano PM, Perkins S, Burns M, Kessler K, Nelson R, Schneider BP, Risley L, 
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Saegusa H. Chemotherapy for advanced thymic carcinoma: clinical response to 
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18. Magois E, Guigay J, Blancard PS, Margey J, Milleron B, Lher P, Jounieaux V. 
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24. Sherr CJ, Roberts JM. Living with or without cyclins and cyclin-dependent kinases. 
Genes Dev 2004;18(22):2699-2711. 

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25. Malumbres M, Barbacid M. To cycle or not to cycle: a critical decision in cancer. Nat 
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Arbuck S, Gwyther S, Mooney M, Rubinstein L, Shankar L, Dodd L, Kaplan R, 
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39. Desramé J, Duvic C, Béchade D et al. Is the frequency of hemolytic uremic syndrome 
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Stat Assoc 1958; 53:457-481. 

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Appendix 1. Recommended Informed Consent Form 

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Patient Information and Informed Consent 
__________________________________________________________________________ 
Phase II study of oral PHA-848125AC in patients with malignant thymoma previously 
treated with multiple lines of chemotherapy. 
Protocol No. CDKO-125a-007 
Institution/Hospital: 
Investigator: 
Sponsor: 
Tiziana Life Sciences, PLC 
__________________________________________________________________________ 
You are being asked if you want to take part in a research study using an experimental drug 
called PHA-848125AC. Whether you take part or not is entirely your decision.  You may 
decide to participate to the study or not to take part at all.  If you decide to participate to the 
study, you may end your participation at any time.  In any case, your decision will not affect 
your regular medical care or any benefit to which you are otherwise entitled.  If there is 
anything you do not understand about this study after reading this information, please ask 
your study doctor or study staff member. 
Why is this study being done? 
PHA-848125AC is a new drug selected for clinical evaluation because of its antitumor 
activity in experimental models. This drug acts by blocking specific proteins (called cyclin-
dependent kinases) involved in the control of cell division.  In the case of tumor cells such 
control is altered and leads to abnormal cell replication.  Experiments have shown that the 
addition of PHA-848125AC may block this uncontrolled proliferation.  Treatment with 
PHA-848125AC might possibly have a positive effect on your disease. 
This drug was evaluated in a number of clinical studies in the US and in Europe, with 
different schedules of administration. As of November 2011, PHA-848125AC has been 
administered to approximately 200 patients with various solid tumors. Currently, two studies 
are ongoing, including this one. 
The most relevant side effects encountered so far in the evaluation in humans were transient 
nausea and/or vomiting and /or diarrhea and neurological toxicity, mainly represented by 
transient tremors and ataxia (incoordination). Fatigue has been frequently reported. See also 
section “Risks” here below. 
Two objective tumor responses were obtained so far in the US study, in two out of three 
patients affected by thymic malignancies, one with B3 thymoma and one with thymic 
carcinoma. 

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This is a study with PHA-848125AC specifically dedicated to patients with B3 thymoma 
and thymic carcinoma. 
This study is called phase II clinical study. Patients will be all treated at the same dose of 
PHA-848125AC; this dose has been selected based on results of the first clinical study in 
solid tumors patients where patients treated at this dose had mild/moderate reversible 
adverse events, represented by nausea, vomiting, diarrhea and tremors.  
The dose of PHA-848125AC will never be increased and could be reduced based on the 
tolerability of the patient. 
The purpose of this study is to help researchers to: 
- evaluate if PHA-848125AC can be effective as a treatment for B3 thymoma and thymic 
carcinoma 
- get additional information on the side effects of PHA-848125AC.  
If you decide to take part in this clinical study, you will get PHA-848125AC every day for 7 
consecutive days and then you will not take the drug from day 8 to day 14. A period of 14 
days (2 weeks) is called a cycle.  You will take the study medicine by oral route.  The 
number of cycles you may receive will depend both on the observed side effects and the 
evolution of your disease. 
During your stay in the study you will be also followed regularly for the status of your 
disease. 
This study is conducted in US. A total of about 35 patients will participate. 
This is what will happen if you decide to be in this study 
Your doctor will talk to you about your disease, ask you questions about your health, and 
give you a physical exam.  Blood will be taken from one of your veins and you will be asked 
to give a urine sample for laboratory tests. Electrocardiogram and ocular examination will be 
carried out. The ocular examination includes a fundoscopic examination and a visual acuity 
test. The funduscopic examination will consist of projection of a light from an 
ophthalmoscope through the pupil to view the back (fundus) of the eyeball. The examination 
will take few minutes and will not be painful. The exam may be preceded by drops in the 
eye, to dilate pupils. Visual acuity test measures the smallest letters that you can read on a 
standardized chart at a standard distance. 
During the course of this study, blood samples will be periodically taken. These regular 
blood tests, as well as other examinations, will be performed to check that the study 
medicine is not adversely affecting your bone marrow, kidneys, liver and other organs. At 
each sampling, the volume of blood taken for these analyses will be about 5 mL. 
There is the possibility, for safety reasons, that a few additional 5 ml blood samples may be 

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required by the Investigator and the Sponsor to investigate the presence of PHA-848125AC 
in your body.  
Part of your tumor tissue (paraffin embedded block), previously taken at the time of 
diagnosis of your disease, will be used to confirm histological diagnosis by the NCI 
pathologists.       
You will also have other tests and activities to monitor your disease and the possible effects 
of the treatment as shown in the following table: 
Schedule of Visits/Tests 
Activity 
Before you 
begin  
the study 
During the 
study 
End of 
treatment 
After end of 
treatment 
period 
Discussion With Nurse/Study Doctor 
X 
X 
X 
X 
Medical/Oncology history/Physical exam 
X 
X 
X 
 
Confirmation of histological diagnosis  
 
X 
 
 
Vital signs 
X 
X 
X 
X 
Pregnancy Test 
X 
 
 
 
Blood Samples 
X 
X 
X 
 
Urine Samples 
X 
X 
X 
 
Chest X-Ray and ECG 
X 
 
X 
 
Ophthalmologic visit 
X 
X 
X 
 
Other exams to follow your disease (CT 
scan or MRI) 
X 
X 
X 
X 
Anything the study doctor believes is 
medically needed 
As needed 
 
Your doctor will ask you to record your daily drug intake in a diary. 
The effect of the study medicine on your disease will be assessed periodically by a CT scan 
or MRI. 
The administration of PHA-848125AC will continue as long as you can tolerate the 
experimental compound and if there are no indications that the disease is worsening. If 
unacceptable side-effects occur, the study medicine will be stopped and appropriate medical 
care will be provided. If your disease becomes worse during treatment, you will be told, the 
treatment will be stopped and alternate medical care will be provided. 

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Experimental Aspects of the Trial 
Analysis of the tumor baseline molecular markers 
Alteration of some genes is very common in human cancers, including B3 thymoma and 
thymic carcinoma. 
It would be of value to know if the cells of your tumor have this kind of alteration, to study 
the relationship between the affected genes and the study treatment efficacy. To do so, a 
sample of your tumor tissue collected in the past, if you had a surgery or a biopsy, is needed. 
Collection of your tumor tissue may also be requested by your doctor to understand the 
status of your disease before entering this study. 
Part of your tumor sample will be analyzed also in this study to determine the expression of 
the genes p53, p21, p27, cyclin D1, p75, TRKA and the copy number TRKA gene. 
Additional biomarkers under validation may also be evaluated. 
 
The possible correlation between any detected molecular markers and the effect of 
PHA-848125AC on the disease may be of help to support in the future the choice of the best 
treatment option for patients having thymic carcinoma. 
The possible correlation between any detected molecular markers and the effect of PHA-
848125AC on the disease may be of help to support in the future the choice of the best 
treatment option for patients having thymic carcinoma. 
________________________________________________________________________________________ 
Your Responsibilities 
If you decide to be in this study, you will have to: 
 Keep all scheduled appointments. 
 Tell your doctor about any other medicines that you take, even if it is medicine you buy 
without a prescription or it is an herbal remedy. 
 Tell your doctor about any medical problems you have. 
 Adopt effective contraceptive methods if you are sexually fertile while on the study and 
for 90 days after you leave the study. 
 Avoid, if you are female, becoming pregnant while on the study and for 90 days after 
you leave the study. 
 Avoid, if you are male, father a child while on the study and for 90 days after you leave 
the study. 
 Avoid breast-feeding while you are taking the study medicine. 

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If you do not follow the items listed above, you may be removed from the study. 
________________________________________________________________________________________ 
Other Treatments 
There may be other ways to treat your disease. Your doctor can tell you more about these 
other treatments and their side effects. 
Benefits 
The medicine that you are given might help you with your disease, but this cannot be 
guaranteed. However, even if you does not benefit personally from being in this study, 
having you take part in this study will help researchers find out if PHA-848125AC will help 
other people who are affected by B3 thymoma and thymic carcinoma.  
Of note, two objective tumor responses were obtained so far in a previous study performed 
in the US, in two patients affected by a B3 thymoma and a thymic carcinoma. 
If you are in this clinical study, you will get free medical examinations and laboratory tests 
that are not part of the routine care for your condition. You will not have to pay for the 
medicine. 
Risks 
The medicine you receive may cause side effects in human beings. Since PHA-848125AC is 
an experimental drug, these side effects in humans are not fully known. If you have any side 
effects, your doctor may stop or temporarily interrupt the treatment, or give you other drugs 
to make them less serious and to make you more comfortable. 
The most common side effects seen in animals after treatment with PHA-848125AC were: 
anemia, thrombocytopenia, neutropenia, lymphopenia, diarrhea, nausea and vomiting. These 
events were almost completely reversible. Ocular and central nervous system (CNS) toxicity 
were reported in animals at high doses or after prolonged administration, as well as 
congestions and/or hemorrhages (including hemorrhagic diarrhea, hemorrhages in the heart), 
gastrointestinal (GI) tract ulceration, bleeding and infection. 
The most relevant side effects encountered so far in the evaluation in humans were transient 
nausea and/or vomiting and /or diarrhea and neurological toxicity, mainly represented by 
transient tremors and ataxia (incoordination) and less frequent episodes of dizziness. The 
neurological symptoms gradually improved in all patients after temporary suspension of the 
study drug. Fatigue is a side effects reported in about half of patients. Hematological toxicity 
was sporadically reported, consisting especially in mild/moderate anemia (low hemoglobin) 
and neutropenia (low neutrophils). A prolonged elevation in liver enzymes was occasionally 
observed with the schedule adopted in the present study (7 days on / 7 days off), however, 
with a more prolonged treatment schedules (eg a schedule encompassing 14 consecutive 

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days every 3 weeks), alterations of liver function tests were more frequently reported. Some 
episodes of transient elevation of lipase (a pancreatic enzyme), without clinical symptoms, 
have been reported, as well as mild transient elevations of creatinine (a parameter indicative 
of renal function status). There could be the possibility that the daily dose of study drug is 
reduced after recovery of adverse effects in order to continue study treatment at a better 
tolerated dose. 
Ocular toxicity was never encountered so far, with the exception of a worsening of the 
electroretinography examination during treatment compared to baseline in one diabetic 
patient treated at 24 mg/m2/day for 21 consecutive days and in a second patient treated at 72 
mg/m2/day for 14 consecutive days (dose then reduced to 48 mg/m2/day in the two 
subsequent cycles). Both patients, however, did not show any ocular clinical symptoms. Two 
cases of TMA/HUS (Thrombotic Microangiopathy/Haemolytic Uraemic Syndrome) 
occurred in two different patients, both treated for more than a year, in a study administering 
PHA-848125AC together with Gemcitabine, a drug approved for the treatment of different 
tumor types, which is known to produce HUS. Both patients recovered. 
There may be some side effects that researchers do not yet know about. If researchers learn 
important new information that could change your decision to continue to take part in the 
study, your study doctor will tell you in a timely manner. PHA-848125AC might not work 
for you or might not work as well as other medicines you have received in the past. 
Your study doctor will be checking you closely to see if you are having any side effects. 
Your study doctor may give you medicines to help with side effects. Many side effects stop 
after the treatment is stopped. Your study doctor may also change the schedule or the 
amount of study treatment to reduce side effects. 
The risks of having blood taken from your vein include pain, bruising, or infection at the site 
where the blood was taken, and fainting. 
Stopping Early 
You may decide to leave the study at any time without any disadvantage to you. You are not 
obliged to provide reason for your withdrawal. 
Your doctor may also decide to remove you from the study if you fail to follow instructions, 
for medical reasons, or for other reasons.  There is also the possibility the study could be 
stopped by the Sponsor before your participation is complete.  If this would happen and if 
this is because of non-medical reasons, and you are benefiting by the study treatment, the 
supply of PHA-848125AC will be guaranteed.  From that moment on, the treatment will be 
under the responsibility of your doctor. 
If you leave the study for any reason, you will be asked to return to the study doctor to bring 
back any left study medicine and to complete the final study activities.  All study 

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information that is collected about you until the time you leave the study and refuse further 
evaluations will be kept and used by the Sponsor. 
________________________________________________________________________________________ 
Pregnancy 
You must avoid becoming pregnant while you are in this study.  If you become pregnant 
while you are in the study or within 90 days after completing your participation, you must 
tell your study doctor.  Your doctor must then report the outcome of your pregnancy to the 
Sponsor. 
Similarly, if you are male, you must avoid making a partner become pregnant while you are 
in the study. If you make a partner pregnant while you are in the study, or within 90 days 
after completing your participation, you must tell the study doctor. The study doctor must 
then report this and also the outcome of the pregnancy to the Sponsor. 
________________________________________________________________________________________ 
Compensation 
Every effort will be made to prevent research related injury.  If any injury is due to your 
participation in this study you will receive emergency care.  The Sponsor has insurance that 
covers any research-related injury you should suffer. The term “research-related injury” 
means physical injury caused by the product or procedures required by the trial which are 
different from the medical treatment you would have received if you had not participated in 
the trial. 
You will not be paid for participating in this trial. You will not need to pay for the study 
medicine and for any tests or procedures which are “research-related”. 
Confidentiality and Data Privacy 
Your doctor will record the study information described above on case report forms that will 
be sent to the study Sponsor.  In these case report forms, you will only be identified with a 
study subject number.  All records in which your name appears will be kept by your doctor 
and be kept confidential.  Your name will never appear on any Sponsor forms or in a report 
or publication. 
The study Sponsor will use the information recorded on the case report form to support new 
approvals for medical use of the PHA-848125AC and for any required regulatory reporting 
of side effects.  The information may be transferred and exported by the Sponsor to other 
entities within the Sponsor organization, to its business partners, and to regulatory 
authorities, on a global basis. 

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Authorized persons from the Sponsor, governmental regulatory agencies, and/or the ethics 
committees may need to look at the medical records kept by your doctor to verify the 
information on the case report forms. 
By signing this informed consent form you agree to allow this review of your records as well 
as to the processing and transfer of your personal information as described above. 
Storage and Analysis of Biological Samples 
Eventual blood samples collected for safety reason to investigate the presence of PHA-
848125AC in your body will be sent to the Sponsor for analysis in Accelera Srl and stored in 
a secure place to ensure protection of your confidentiality. 
Tumor samples to be analyzed for the characterization of baseline molecular marker will be 
analyzed at NMS and /or NIH/NCI and stored in a secure place to ensure protection of your 
confidentiality. 
__________________________________________________________________________ 
If You Have Questions 
For questions about your responsibilities or study activities, please contact: 
 
 
 
 
 
 
at 
 
 
 
 
 
 
For questions about your rights as a participant in this study, please contact 
 
 
 
 
 
 
at 
 
 
 
 
 
 
For questions about possible injury due to activities in this study, please contact 
 
 
 
 
 
 
at 
 
 
 
 
 
 

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Patient’s Statement 
 
 I voluntarily agree to participate in this study 
 I understand that the study Sponsor may stop the study at any time 
 I have read and understood this statement of informed consent and the risks described 
 I understand that I will receive a signed and dated copy of this consent form 
 I understand that I may withdraw my consent at any time 
 I also voluntary agree to have my tumor tissue analyzed for the molecular markers. 
 I have had a chance to ask questions and understand the answers given to all of my 
questions 
 
 
 
Signature of study patient:  
 
 
 
 
 
 Date:   
 
 
Printed name of study patient:  
 
 
 
 
 
 
**************************************** 
 
Signature of person conducting informed consent discussion:   
 
 
 
 
Printed name of person conducting informed consent discussion:   
 
 
 
Date:    
 
 
 

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Appendix 2.  The Distribution of Active Bone Marrow in the Adult 

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The distribution of bone marrow in the adult 
Site 
Marrow 
Weight (g) 
Fraction Red 
Marrow - Age 40 
Red Marrow 
Weight -Age 40 (g) 
% Total Red 
Marrow 
Head 
 
 
136.6 
13.1 
Cranium 
165.8 
0.75 
124.3 
 
Mandible 
16.4 
0.75 
12.3 
 
Upper Limb Girdle 
 
 
86.7 
8.3 
2 Humerus, head & neck 
26.5 
0.75 
20.0 
 
2 Scapulae 
67.4 
0.75 
50.5 
 
2 Clavicles 
21.6 
0.75 
16.2 
 
Sternum 
39.0 
0.6 
23.4 
2.3 
Ribs 
 
 
82.6 
7.9 
1 pair 
10.2 
All 0.4 
4.1 
 
2 
12.6 
 
5.0 
 
3 
16.0 
 
6.4 
 
4 
18.6 
 
7.4 
 
5 
23.8 
 
9.5 
 
6 
23.6 
 
9.4 
 
7 
25.0 
 
10.0 
 
8 
24.0 
 
9.6 
 
9 
21.2 
 
8.5 
 
10 
16.0 
 
6.4 
 
11 
11.2 
 
4.5 
 
12 
4.6 
 
1.8 
 
Vertebrae  (Cervical) 
 
 
35.8 
3.4 
1 
6.6 
All 0.75 
5.0 
 
2 
8.4 
 
6.3 
 
3 
5.4 
 
4.1 
 
4 
5.7 
 
4.3 
 
5 
5.8 
 
4.4 
 
6 
7.0 
 
5.3 
 
7 
8.5 
 
6.4 
 
Vertebrae (Thoracic) 
 
 
147.9 
14.1 
1 pair 
10.8 
All 0.75 
8.1 
 
2 
11.7 
 
8.8 
 
3 
11.4 
 
8.5 
 
4 
12.2 
 
9.1 
 
5 
13.4 
 
10.1 
 
6 
15.3 
 
11.5 
 
7 
16.1 
 
12.1 
 
8 
18.5 
 
13.9 
 
9 
19.7 
 
14.8 
 
10 
21.2 
 
15.9 
 
11 
21.7 
 
16.3 
 
12 
25.0 
 
18.8 
 

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The distribution of bone marrow in the adult 
Site 
Marrow 
Weight (g) 
Fraction Red 
Marrow - Age 40 
Red Marrow 
Weight -Age 40 (g) 
% Total Red 
Marrow 
Vertebrae (Lumbar) 
 
 
114.1 
10.9 
1 pair 
27.8 
All 0.75 
20.8 
 
2 
29.1 
 
21.8 
 
3 
31.8 
 
23.8 
 
4 
32.1 
 
24.1 
 
5 
31.4 
 
23.6 
 
Sacrum 
194.0 
0.75 
145.6 
13.9 
Lower limb girdle 
 
 
273.0 
26.1 
2 os coxae 
310.6 
0.75 
233.0 
 
2 femoral head & neck 
53.0 
0.75 
40.0 
 
Total 
1497.7 
 
1045.7 
100.0 
 
R.E. ELLIS - The Distribution of Active Bone Marrow in the Adult. Phy. Med. Biol. 5, 255 – 258, 1961