Phase 1b/2 Neoadjuvant High Dose Ascorbate With Concurrent Preoperative Radiation in Patients With Locally Advanced Soft Tissue Sarcomas of Extremity, Trunk and Retroperitoneum
Phase: PHASE1
Conditions: Soft Tissue Sarcoma
Sponsor: Mohammed Milhem

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Phase 1b/2 Neoadjuvant High Dose Ascorbate with Concurrent 
Preoperative Radiation in Patients with Locally Advanced Soft 
Tissue Sarcomas of Extremity, Trunk and Retroperitoneum  
Coordinating Center: 
Holden Comprehensive Cancer Center – University of Iowa 
*Principal Investigator: 
Varun Monga, MBBS 
Clinical Assistant Professor 
Division of Hematology & Oncology 
Department of Internal Medicine 
University of Iowa Hospitals and Clinics 
C32 G GH 
(319) 384-9497 
varun-monga@uiowa.edu 
 
Co-Investigators: 
 
Mohammed Milhem, MBBS 
Clinical Professor 
Division of Hematology/Oncology 
Department of Internal Medicine C-32 GH 
(319) 356-2324 
mohammed-milhem@uiowa.edu 
Bryan Allen, MD, PhD 
Associate Professor 
Department of Radiation Oncology 
01620 PFP 
(319) 356-3696 
bryan-allen@uiowa.edu  
Benjamin Miller, MD, MS 
Clinical Associate Professor 
Department of Orthopedics 
Carryn Anderson, MD 
Clinical Associate Professor 
Department of Radiation Oncology 
Munir Tanas, MD 
Assistant Professor 
Department of Pathology 
 
 
 

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Statistician: 
Sarah L. Bell, M.S. 
The Holden Comprehensive Cancer Center 
The University of Iowa 
N319 CPHB 
sarah-mott@uiowa.edu  
 
Study Agent: 
Pharmacological ascorbate  
Other Agent(s): 
Standard external beam radiation 
 
Investigational Agent  
IND# 
IND Sponsor  
Ascorbic acid 
137968 
Mohammed Milhem 
 
 
 
 
 
Protocol Version 8 
Protocol Version Date: 17 November  2021 
 
 

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SCHEMA 
Study Timeline Schema: 
 
 
 
 
 
 
 
 
 
 
 
 
Phase 1b Schema: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
XRT 
Ascorbate IV three 
times weekly 
Screening 
End of Week 5 
End of Week 9, 10, or 11 
Follow up every 12 weeks through 24 months 
Trial dose of IV 
ascorbate & G6PD test 
Complete XRT 
MRI of tumor then Surgery 
Day 1 Week 1 
SCREENING
ENROLLMENT
END OF TREATMENT
SAFETY FOLLOW-UP
END OF STUDY
 
IV Ascorbate 75gm three 
times weekly   
+ 
Radiotherapy starting 
from week 1 
+ 
Surgery 4-6 weeks after 
XRT 
 
 

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SAFETY FOLLOW-UP
Table 1.  
Phase 1b Dose De-escalation Schedule 
 
Number of patients with 
DLT at a given dose level 
Decision Rule 
0 out of 3 
Enter 3 patients at the next higher dose level 
1 out of 3 
Enter up to 3 additional patients at the same dose level.  
• If 0 of these 3 patients experience DLT, proceed to the next 
dose level. 
• If 1 or more of these 3 patients experience DLT, then dose 
escalation is stopped and this dose is declared the 
maximally administered dose. Three (3) additional patients 
will be entered at the next lowest dose level if only 3 
patients were treated previously at that dose.  
≥2 out of 3 
Dose escalation will be stopped. This dose level will be 
declared the maximally administered dose. Three (3) 
additional patients will be entered at the next lowest dose level 
if only 3 patients were treated previously at that dose.  
 
 
Ascorbate Dose Levels: 
Dose 0 = Ascorbate 75 gm IV three times weekly concurrently with radiation   
Dose -1 = Ascorbate 62.5 gm IV three times weekly concurrently with radiation  
• Initial dose for all = Ascorbate 75gm IV  
Phase 2 Schema: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Phase II 
 
IV Ascorbate at 
recommended dose three 
times weekly 
+ 
Radiotherapy starting 
from week 1 
+ 
Surgery 4-6 weeks after 
XRT 
END OF TREATMENT
SURVIVAL F-UP
END OF STUDY
SCREENING
ENROLEMENT

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TABLE OF CONTENTS 
1. 
BACKGROUND .................................................................................................................7 
1.1 
Disease Background.................................................................................................7 
1.2 
Ascorbate as an anti-tumor agent .............................................................................7 
1.3 
Clinical Trial Data....................................................................................................9 
1.4 
Radiation Therapy in Sarcoma...............................................................................10 
2. 
REGISTRATION PROCEDURES ...................................................................................10 
3. 
OBJECTIVES ....................................................................................................................10 
3.1 
Primary Objectives.................................................................................................11 
3.2 
Secondary Objectives.............................................................................................12 
4. 
PATIENT SELECTION ....................................................................................................12 
4.1 
Inclusion Criteria ...................................................................................................12 
4.2 
Exclusion Criteria ..................................................................................................14 
5. 
TREATMENT PLAN AND STUDY SCHEMA ..............................................................15 
5.1 
Study Design ..........................................................................................................15 
5.2 
Phase Ib ..................................................................................................................15 
5.3 
Phase 2 ...................................................................................................................16 
5.4 
Study Timeline Schema: ........................................................................................16 
5.5 
Post-consent Screening Procedures .......................................................................17 
5.6 
Concomitant Ascorbate (High-dose Ascorbic Acid) Infusions .............................17 
5.7 
Radiation therapy ...................................................................................................18 
5.8 
General Concomitant Medication and Supportive Care Guidelines ......................21 
5.9 
Criteria for removal from study .............................................................................23 
5.10 
Duration of Follow Up ...........................................................................................23 
6. 
DOSING DELAYS/DOSE MODIFICATIONS/ DOSE LIMITING TOXICITIES .........23 
6.1 
Radiation Therapy ..................................................................................................23 
6.2 
Ascorbate Therapy .................................................................................................23 
6.3 
Dose Limiting Toxicities .......................................................................................24 
7. 
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS .............................24 
7.1 
Determination of Reporting Requirements ............................................................25 
7.2 
Institutional Review Board reporting requirements ...............................................25 
7.3 
FDA reporting requirements [M.Milhem, sponsor] ...............................................25 
7.4 
Routine Adverse Event Reporting Requirements to DSMC ..................................25 
7.5 
Serious Adverse Event Reporting to DSMC .........................................................26 
8. 
PHARMACEUTICAL INFORMATION – Ascorbic Acid Injection, ASCOR L 500® ..26 
8.1 
Availability ............................................................................................................26 
8.2 
Compatibility .........................................................................................................26 
8.3 
Storage and Stability ..............................................................................................26 
8.4 
Toxicities................................................................................................................27 

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9. 
Correlative and special studies...........................................................................................27 
9.1 
ROS Research blood ..............................................................................................27 
9.2 
Labile Iron Measurements using MRI Imaging (optional) ....................................27 
9.3 
Diffusion Weighted Imaging (optional).................................................................28 
9.4 
Ascorbate levels .....................................................................................................28 
9.5 
Tumor tissue...........................................................................................................28 
10. 
Study Calendar ...................................................................................................................30 
10.1 
Study Procedures ...................................................................................................30 
10.2 
Screening Procedures .............................................................................................32 
10.3 
Post-treatment Evaluations ....................................................................................32 
11. 
MEASUREMENT OF EFFECT........................................................................................32 
11.1 
Pathologic Response ..............................................................................................32 
11.2 
Time to Disease progression (TTP) .......................................................................32 
11.3 
Other Response Parameters ...................................................................................32 
12. 
STATISTICAL CONSIDERATIONS...............................................................................34 
12.1 
Phase Ib ..................................................................................................................34 
12.2 
Phase II...................................................................................................................34 
12.3 
Sample Size/Accrual Rate ......................................................................................34 
13. 
References ..........................................................................................................................35 
 
 
 

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1. BACKGROUND 
1.1 
Disease Background 
Adult soft tissue sarcomas (STS) constitute a wide heterogeneous group of very rare tumors, both 
in terms of histology and biological and clinical behavior. In contrast to major advances in the 
biological understanding of these heterogeneous subtypes, forward progress in the systemic 
treatment of sarcoma has been painstakingly slow. The prognosis of patients with metastatic or 
recurrent disease is poor and most of them will die from tumor progression. Taking into account 
differences in histology subtype, anatomic location of disease and age at disease onset, the overall 
median survival for patients with metastatic STS is approximately one year and only about 10% 
of these patients are alive at five years1.  
Control of localized disease is, therefore, of prime importance as evidenced by the National 
Comprehensive Cancer Network’s (NCCN) current treatment guidelines2. Pisters et al 
demonstrated that histologic grade, depth of location, and positive surgical margins are key 
determinants of STS recurrence.3 However, patients typically present late with local tumor 
extensions into critical adjacent structures, making complete surgical resection with uninvolved 
margins difficult. Preoperative radiotherapy has been shown to significantly improve local disease 
control, functional outcomes and survival in patients with locally advanced STS.4-6 
1.2 
Ascorbate as an anti-tumor agent 
Ascorbate (ascorbic acid, vitamin C, AscH) is one of the early unorthodox therapies for cancer, 
based on two unsupported hypotheses. McCormick postulated that ascorbate protects against 
cancer by increasing collagen synthesis,7,8 while Cameron hypothesized that ascorbate could have 
anti-cancer action by inhibiting hyaluronidase and thereby prevent cancer spread.9 These 
hypotheses were subsequently promoted by Cameron and Pauling.10,11 Cameron and Campbell 
initially published case reports of 50 patients; some seemed to have benefited from high dose 
ascorbate.12 Cameron and Pauling then published results of 100 patients with terminal cancer that 
were given intravenous ascorbate.13 The ascorbate-treated patients were compared to 1000 
retrospective controls with similar disease. Patients who received ascorbate survived on average 
300 days longer than controls.11,13 A prospective study was then conducted that randomized 
patients to ascorbate treatment or palliative therapy. Treated patients had a median survival of 343 
days vs. 180 days for controls.14 Smaller studies have also reported benefits of ascorbate.15,16 
To test “definitively” whether ascorbate was effective, Moertel conducted two randomized 
placebo-controlled studies randomized to oral ascorbate; neither study showed benefit.17,18 
Subsequently, ascorbate therapy was considered ineffective. However, it was not recognized until 
approximately 15 years later that oral and intravenous ascorbate have strikingly different 
pharmacokinetics.19,20 This difference in the administration route is key. Cameron gave patients 
ascorbate intravenously as well as orally, while Moertel’s patients received only oral ascorbate. 
Thus, the issue of ascorbate in cancer treatment needed to be re-examined.  
The evidence for use of ascorbate in cancer treatment falls into two categories: clinical data on 
dose concentration relationships and laboratory data describing potential cell toxicity with high 
concentrations of ascorbate in vitro. Clinical data show that when ascorbate is given orally, fasting 
plasma concentrations are tightly controlled at < 100 µM.21 As doses exceed 200 mg, absorption 
decreases, urine excretion increases and ascorbate bioavailability is reduced.19,21 In contrast, when 
1.25 grams of ascorbate are administered intravenously, concentrations as high as 1 mM are 

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achieved. Some clinicians have infused more than 10 grams of ascorbate in cancer patients and 
achieved plasma concentrations of 1 to 5 mM.22 Thus, it is clear that intravenous administration of 
ascorbate can yield very high plasma levels, while oral treatment does not.  
Pharmacologic ascorbate concentrations have been shown to selectively kill many cancer cell 
types. Chen et al. measured cell death in 10 cancer and 4 normal cell types using 1-hour exposures 
to pharmacological ascorbate.23 Normal cells were unaffected by 20 mM ascorbate whereas 5 
cancer cell lines had EC50 values of < 4 mM, a concentration achievable by intravenous 
administration. In addition, cell death was independent of metal chelators, but dependent on 
formation of H2O2.24 H2O2 generation was dependent on ascorbate concentration, incubation 
time; [H2O2] displayed a linear increase with [AscH] and it increased as a quadratic function of 
ascorbate radical, ascorbate being an electron donor to O2 to form superoxide and, eventually, 
H2O2.  
When ascorbate is infused intravenously the resulting pharmacologic concentration will distribute 
rapidly into the extracellular water space.25 In vivo, Chen and colleagues demonstrated that 
intravenous injection of ascorbate (0.25-0.5 mg/g body weight) increased baseline concentrations 
of ascorbate in the blood and extracellular fluid to > 8 mM as well as increased formation of 
H2O2.26 More recent studies have demonstrated that intraperitoneal doses of 4 g/kg ascorbate 
resulted in blood concentrations of 40 mM; tumor extracellular fluid increased to peaks of 20 mM 
for up to 3 hours.21 Our data demonstrate that pharmacologic doses of ascorbate are cytotoxic to 
sarcoma cell lines and that it enhances radiation therapy sensitivity in vitro (Figure 1). 
Additionally, we also showed that intraperitoneal administration of high dose ascorbate in 
combination with radiation inhibits orthotopic sarcoma growth and decreases tumor size in mice 
without causing an associated toxicity in vivo (Figure 2). Combined, these studies provide a 
foundation for pursuing pharmacologic ascorbate as a prooxidant agent in cancer therapy and 
specifically in sarcoma.27 
 
 
 
 
 
 
 
 
 
 
 
Figure 1 Demonstrates that sarcoma cell 
lines, fibrosarcoma (HT1080) and synovial 
sarcoma (SW-872), are sensitive to 
increasing doses of pharmacological 
ascorbate. Cells were treated with 
increasing doses of ascorbate for 1 hour 
followed by clonogenic cell survival 
analysis. 

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Ascorbate-mediated cell death has been shown to be due to H2O2 generation, via ascorbate radical 
formation, with ascorbate as the electron donor.23,24,26 When ascorbate is infused intravenously the 
resulting pharmacologic concentration distributes rapidly in the extracellular water space.26 Thus, 
pharmacologic ascorbate concentrations in media, as a surrogate for extracellular fluid, should 
generate ascorbate radical and H2O2. In contrast, the same pharmacologic ascorbate 
concentrations in whole blood generate little detectable ascorbate radical and no detectable 
H2O2.18 This can be accounted for by efficient and redundant H2O2 catabolic pathways in whole 
blood relative to those in media or extracellular fluid. Thus, ascorbic acid administered 
intravenously in pharmacologic concentrations may serve as a pro-drug for H2O2 delivery to the 
extracellular milieu, but without H2O2 accumulation in blood.  
1.3 
Clinical Trial Data 
In a Phase I trial of intravenous ascorbic acid in patients with advanced malignancy the high-dose 
intravenous ascorbic acid was well tolerated when administered to patients. Adverse events and 
toxicity were minimal at all dose levels. Ascorbic acid concentrations reached up to 25 mmol/L in 
patients who received ascorbic acid of 1.5 g/kg. Of the 24 patients in the study, only 4 recorded 
minor adverse events including headache, dizziness and diarrhea.28  In another phase I trial using 
pharmacological ascorbate concurrently with gemcitabine in patients with locally advanced and 
Figure 2 Pharmacological ascorbate 
selectively sensitizes fibrosarcoma tumors 
to radiation in an orthotopic murine 
xenograft model. An orthotopic 
fibrosarcoma model was utilized by 
injecting 1×106 HT-1080 cells into the 
dermis of the right rear flank of athymic 
nude female mice. Once tumors were 
established, therapy was initiated with 
daily ascorbate (4 g kg−1 or sodium 
chloride control; IP) in combination with 
12 Gy IR in 2 fractions (days 2 and 4) (A) 
Tumor volume measurements (points +/- 
error) fitted with a logistical regression 
(line) for mice treated with daily ascorbate 
in combination with radiation (B) Overall 
survival in mice treated with ascorbate in 
combination with radiation. Mice were 
sacrificed when any tumor dimension 
reached 1.5 cm. NED=no evidence of 
macroscopic disease at end of experiment. 
(C) Mouse weight in mice treated with 
ascorbate in combination with radiation. 
For each treatment group, n = 8 mice. 

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metastatic pancreatic cancer conducted at University of Iowa Hospitals and Clinics, 9 patients 
received treatment. Individual doses between 50 to 125 g per infusion were given for maintenance 
of 350 mg/dL level in plasma. 75-g dose yielded peak plasma levels ranging between 320 and 630 
mg/dL. No dose limiting toxicities or serious adverse events were reported.29  
A phase I study of adding ascorbate to standard therapy in glioblastomas and NSCLC was initiated 
in 2013.30 Subjects were assigned to high-dose ascorbate dose cohorts for the concomitant portion 
of therapy. Dose cohorts ranged from 15g to 87.5g. During the adjuvant phase, subjects underwent 
interpatient dose escalation to achieve a targeted plasma ascorbate level of 350 mg/dL. Subjects 
received high-dose ascorbate during the adjuvant phase for up to 6 cycles. To date, 5 subjects have 
been enrolled in the recommended phase 2 dose of 87.5g. Treatment was well-tolerated with minimal 
adverse events. No subject experienced a grade 3 or greater hematologic or non-hematologic 
toxicity. The only adverse events associated with ascorbate were grade 1 dry mouth, grade 1 chills, 
and grade 2 hypertension. Dry mouth is transient and ends shortly after infusion. Grade 1 chills are 
infusion related, most likely due to the volume of fluid infused. Grade 2 hypertension occurs in some 
subjects during infusion, again most likely due to the volume of fluid infused.30    
1.4 
Radiation Therapy in Sarcoma 
The benefits of combination therapy with radiation and surgery in significantly improving local 
control in STS patients are well documented. Preoperative radiotherapy has been shown to 
significantly improve local disease control, functional outcomes and survival in patients with 
locally advanced STS4-6. Recent review of literature indicates that about 10% of patients will have 
≥ 95% tumor necrosis, and about 25% will achieve ≥ 80% tumor necrosis following preoperative 
radiation therapy alone.31,32  Further review indicates that only those patients who achieve ≥ 95% 
tumor necrosis with preoperative radiation have improved local and distant control as well as 
overall survival.32 Despite its reported benefits, radiotherapy is associated with a high rate of 
complications and significant functional morbidity. O’Sullivan et al compared preoperative versus 
postoperative external beam radiation (EBRT) for resectable extremity STS.  Long term follow up 
revealed no statistical difference in local control and cause specific survival, however, preoperative 
radiotherapy was associated with a significantly higher rate of acute wound complications (35% 
vs. 17%, p = 0.01) and a lower rate of late Grade 2– 4 fibrosis (32% vs. 48%, p = 0.07).33,34 Multiple 
retrospective reviews have similarly found high rates of acute wound complications in sarcoma 
patients ranging from 25% to 44%.35-38 These reported high rates of acute and late toxicities 
support the need for additional research to improve the safety profile of neoadjuvant radiotherapy. 
In addition, there is need to improve efficacy of the radiation treatments to achieve higher rates of 
tumor necrosis, and, to ensure resection of the tumor with clear margins for successful organ 
preserving treatment of sarcoma. 
2. REGISTRATION PROCEDURES 
NA; Single Institution study.  
3. OBJECTIVES 
 

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OBJECTIVES 
ENDPOINTS 
Primary 
 
Phase 1b: To determine the 
safety and tolerability of 
neoadjuvant ascorbate in 
combination with preoperative 
EBRT as assessed by incidence 
of dose-limiting toxicities (DLT) 
in subjects with locally advanced 
high grade soft tissue sarcomas 
of extremity, trunk and 
retroperitoneum.  
 
Phase 2: To estimate the 
efficacy of neoadjuvant 
ascorbate and radiotherapy as 
assessed by the pathological 
complete response rates (pCR) 
in subjects with locally advanced 
high grade soft tissue sarcomas. 
For this study, pCR will be 
defined as ≥ 95% tumor necrosis 
following concurrent radiation 
therapy and ascorbate. 
 
Incidence of Dose Limiting Toxicities. 
 
 
 
 
 
 
 
 
 
 
pCR rate- the proportion of subjects with pathologic 
tumor necrosis > 95%. 
Secondary 
 
Time to disease progression 
(local or distant recurrence) 
 
 
Overall response rate (ORR) pre 
op as measured by RECIST 1.1 
or a later tool for monitoring 
disease progression.  
 
 
Overall survival rate (OS) at 2  
Years 
 
 
To grade radiation related skin 
toxicity overlying the tumor 
 Time from first day of study treatment to first 
documented disease progression. 
 
 
The proportion of subjects with a complete or partial 
response. 
 
 
 
 
Time from first day of study treatment to death due to 
any cause.  Survival will be estimated at 2 years. 
 
 
Incidence of radiation related skin toxicity by grade 

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OBJECTIVES 
ENDPOINTS 
 
To measure labile iron using T2* 
imaging sequence on MRI pre 
and post ascorbate treatments 
and compare with serum iron 
measurements 
 
To evaluate diffusion weighted 
imaging sequences on MRI in 
pre and post treatment tumors 
 
Changes in labile iron and serum iron from pre to 
post-treatments 
 
 
 
 
Changes in diffusion weighted imaging sequence 
from pre-to post-treatment 
 
3.1 
Primary Objectives 
Phase 1b: To determine the safety and tolerability of neoadjuvant ascorbate in combination with 
preoperative EBRT as assessed by incidence of dose-limiting toxicities (DLT) in subjects with 
locally advanced high grade soft tissue sarcomas of extremity, trunk and retroperitoneum.  
Phase 2: To estimate the efficacy of neoadjuvant ascorbate and radiotherapy as assessed by the 
pathological complete response rates (pCR) in subjects with locally advanced high grade soft tissue 
sarcomas. For this study, pCR will be defined as ≥ 95% tumor necrosis following concurrent 
radiation therapy and ascorbate. 
3.2 
Secondary Objectives 
- Time to disease progression (local or distant recurrence) 
- Overall response rate (ORR) pre op as measured by RECIST 1.1 or a later tool for 
monitoring disease progression.  
- Overall survival rate (OS) at 2 years 
- To grade radiation related skin toxicity overlying the tumor as compared to historical 
controls  
- To measure labile iron using T2* imaging sequence on MRI pre and post ascorbate 
treatments and compare with serum iron measurements 
- To evaluate diffusion weighted imaging sequences on MRI in pre and post treatment 
tumors and correlate it with necrosis and survival  
4. PATIENT SELECTION 
4.1 
Inclusion Criteria  
4.1.5 Subject or subject’s legally acceptable representative has provided informed consent. 
4.1.6 Histologically confirmed diagnosis of locally advanced soft tissue sarcoma of extremity, 
trunk or retroperitoneum that is unresectable with clear wide margins, for which 
preoperative radiotherapy is considered appropriate. 
• Including metastatic (stage IV) disease for which radiotherapy and surgical resection 
of the primary tumor are indicated. 
4.1.7 Patients with locally recurrent sarcoma after surgery alone are eligible for enrollment if 

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other inclusion criteria are met. 
4.1.8 Patient does not have histologic subtypes: GIST, Desmoid, Ewing sarcoma, bone 
sarcomas and Kaposi sarcoma 
4.1.9 Age ≥18 years.  
4.1.10 Patients with history of non-melanomatous skin cancer, in situ carcinoma, or low-risk 
prostate cancer can be enrolled. 
4.1.11 ECOG performance status ≤1. 
4.1.12 Tolerate one test dose (15g) of ascorbate.  
4.1.13 Patient must have measurable disease: 
• Tumor size at least ≥ 5 cm in the longest diameter as measured by CT scan or MRI 
for which radiation is feasible and indicated. 
 
 

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4.2 
Exclusion Criteria 
4.2.1 Inadequate organ function within 21 days of Day 1 of study as defined by:  
• Hemoglobin < 9.0 g/dL 
• Absolute neutrophil count (ANC) </= 1500 per mm3  
• Platelet count </= 100,000 per mm3 
• Total bilirubin >/= 1.5 × ULN. Subjects with direct bilirubin < ULN with total 
bilirubin levels > 1.5 X ULN will not be excluded.  
• Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) > 2.5 × ULN 
• Alkaline phosphatase > 2.5 × ULN 
• PT (or INR) and PTT (or aPTT) >/= 1.5 × ULN 
• Creatinine > 2.0 × ULN 
4.2.2 G6PD (glucose-6-phosphate dehydrogenase) deficiency 
4.2.3 Prior history of two episodes of symptomatic oxalate kidney stones within last year. 
4.2.4 Prior radiation therapy in excess of 20 Gy to the site of the current diagnosis of sarcoma. 
No overlap with prior radiation fields in excess of 20 Gy is allowed. 
4.2.5 Prior history of receiving pharmacological ascorbate.  
4.2.6 Patients actively receiving insulin therapy AND needing daily fingerstick for glucose 
monitoring.  
4.2.7 Concurrent, clinically significant, active malignancies within two years of study 
enrollment. 
4.2.8 Female subjects who are pregnant or breast-feeding, or planning to become pregnant 
during study treatment and through 3 months after the last dose of study treatment. 
4.2.9 Female subjects of childbearing potential or male subjects who are unwilling to use 2 
highly effective methods of contraception during study treatment and through 3 months 
after the last dose of study treatment.  
4.2.10 Currently receiving treatment in another invasive investigational device or drug study, or 
less than 30 days since ending treatment on another investigational device or drug study(s). 
4.2.11 Patients who are on the following drugs and cannot have a drug substitution:  flecainide, 
methadone, amphetamines, quinidine, and chlorpropamide. High dose ascorbic acid may 
affect urine acidification and, as a result, may affect clearance rates of these drugs. 
4.2.12 Known CNS disease, except for treated brain metastasis: Treated brain metastases are 
defined as having no evidence of progression or hemorrhage after treatment and no ongoing 
requirement for dexamethasone, as ascertained by clinical examination and brain imaging 
(MRI or CT) during the screening period.  Anticonvulsants (stable dose) are allowed.  
Treatment for brain metastases may include whole brain radiotherapy (WBRT), radiosurgery 
(RS; Gamma Knife, LINAC, or equivalent) or a combination as deemed appropriate by the 
treating physician.  Patients with CNS metastases treated by neurosurgical resection or brain 
biopsy performed within 3 months prior to Day 1 will be excluded 
4.2.13 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to ascorbate  

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4.2.14 Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or 
psychiatric illness/social situations that would limit compliance with study requirements. 
4.2.15 Known HIV-positive and hepatitis B & C individuals. High-dose ascorbate acid is a 
known CYP450 3A4 inducer, which results in lower serum levels of antiretroviral drugs  
4.2.16 Patients who are on warfarin and cannot have a drug substitution or who decline the drug 
substitution.   
5. TREATMENT PLAN AND STUDY SCHEMA 
5.1 
Study Design 
This is a single-arm open-label phase Ib/II clinical study assessing the efficacy of concurrent high 
dose ascorbate in combination with radiotherapy in patients with locally advanced, resectable, high 
grade sarcomas, as measured by pathological response rates. Patients will be treated with three 
times weekly IV ascorbate concurrently with radiation therapy. Surgery will be performed 4-6 
weeks from the end of radiation therapy to allow for resolution of acute toxicities per current 
standard of care. 
5.2 
Phase Ib 
The phase Ib portion of this study is to ensure the safety and tolerability of high dose ascorbate in 
combination with EBRT as assessed by incidence of dose-limiting toxicities (DLT). Although this 
combination has been shown to be safe and well tolerated in GBM, this combination has not been 
studied in sarcoma patients.  EBRT will be given at the standard dose for resectable soft tissue 
sarcomas according to the NCCN sarcoma guidelines.2 Patients will receive 50 Gy over 25 fractions 
for extremity and trunk sarcomas or 45 – 50.4 Gy in 28 fractions for retroperitoneal sarcomas, during 
which time they will be receiving three times a week IV high dose ascorbate. IV ascorbate infusions 
will be continued until the end of radiation therapy. Surgery will be performed 4-6 weeks from the 
end of radiation to allow for adequate tissue healing and resolution of acute toxicities. 
Ascorbate will be dosed at an initial dose of 75gm IV three times a week concurrently with 
radiation therapy provided patient tolerated the test dose of ascorbate during screening without any 
reactions. Initially 3 patients will be entered at the Dose 0 for ascorbate and be monitored at this 
three times a week dose until surgery when safety issues will be addressed. Otherwise, ascorbate 
dose will be deescalated and dose -1 will be explored as outlined. For this protocol DLT will be 
defined as an attributed adverse event (definite, probable or possible) that meets the criteria 
(Section 6.3). 
Table 1.  
Phase 1b Dose De-escalation Schedule 
Number of Patients with DLT  
at a Given Ascorbate Dose 
Decision Rule 
> 2 
Dose level will be declared toxic. 
If this is the lowest dose level, stop the study due to 
excessive toxicity; otherwise enter three additional 
patients at the next lowest dose level. 
< 1 out of 3 
Enter three more patients at this dose level. 
< 1 out of 6 
This is the recommended dose for the subsequent Phase2. 

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Ascorbate Dose Levels 
Dose 0 
Ascorbate 75 gm IV three times weekly concurrently with radiation   
Dose -1 
Ascorbate 62.5 gm IV three times weekly concurrently with radiation 
 
• Initial dose for all = Ascorbate 75gm IV  
5.3 
Phase 2 
The phase 2 part of the study will provide an estimate of the relative treatment effect of 
pharmacological ascorbate in combination with preoperative EBRT in subjects with locally 
advanced, resectable, extremity or retroperitoneal high grade sarcomas, as measured by 
pathological response rates.    
As above, patients will receive the first dose of pharmacological ascorbate intravenously on day 1 
of week 1 provided no reactions are seen to the test dose. This will be followed by 3 times a week 
dosing (= 15 doses total) at Dose 0 until completion of EBRT. Standard doses of radiation for 
resectable soft tissue sarcomas according to the NCCN sarcoma guidelines will be administered.2 
Patients will receive preoperative radiation at a dose of 50 Gy over 25 fractions  for extremity and 
trunk sarcoma or 45 to 50.4 Gy in 28 fractions for retroperitoneal sarcomas starting on week 1 day 
1. Subjects should be followed either by clinic visit or phone contact every 12 weeks (+/- 4 weeks) 
for approximately 24 months after the end of the treatment phase, at which time the initial survival 
data and disease recurrence will be assessed. Details as per study calendar (Section 10). 
5.4 
Study Timeline Schema:  
 
 
 
 
 
 
 
 
 
 
 
Phase 1b schema: 
 
 
 
 
 
 
 
 
 
 
 
XRT 
Three times aweek IV 
ascorbate 
Screening 
End of Week 5 
End of Week 9, 10 or 11 
Follow up every 12 weeks through 24 months 
Test dose of IV ascorbate 
& G6PD test 
Complete XRT 
MRI of tumor then Surgery 
Day 1 Week 1 
SCREENING
ENROLLMENT
END OF TREATMENT
SAFETY FOLLOW-UP
END OF STUDY
 
IV Ascorbate 75gm three 
times weekly for 5 weeks  
+ 
Radiotherapy starting 
from week 1 
+ 
Surgery 4-6 weeks after 
XRT 
 
 

Version 8 17Novemberl2021 
17 
SAFETY FOLLOW-UP
Phase 2 schema: 
 
 
 
 
 
 
 
 
 
 
 
 
5.5 
Post-consent Screening Procedures 
If subjects fail the G6PD or test doses of ascorbate, they are considered a screen failure. 
• G6PD test (off-site test, so draw immediately). If subject has a prior G6PD test, this can 
be used as G6PD levels do not fluctuate (i.e., there is no window for this test). 
• One test dose of 15g of ascorbate.  A physician must review the patient's medication list 
against the list of medications prohibited on this trial prior to the test dose of ascorbate. 
5.6 
Concomitant Ascorbate (High-dose Ascorbic Acid) Infusions 
5.6.1 Participant dose. All patients will receive a standard ascorbate dose of 75 gm given over 
120 minutes 
5.6.2 Administration. Based on subject tolerance; infusion rate should not exceed 500 mL/hour 
without consulting with physician. Recommended infusions times are as follows (Table 1) 
but may be adjusted for subject comfort. Changes in infusion rates should be recorded. 
5.6.3 Initiation. Start the week prior to chemoradiation with one 15-g infusion. This is the test 
dose. 75 gm dosing begins week 1 of radiation therapy. If the participant fails the 15g test 
dose it is not considered dose limiting toxicity. 
5.6.4 Schedule. Scheduled three times weekly during chemoradiation;.  
5.6.5 Duration. Subjects will continue with therapy until the end of standard radiation therapy 
or if any criteria of removal are met (Section 5.7) 
5.6.6 Dose modifications. Provided in Section 6.2 
Table 1. Recommended Infusion Times for Pharmacological Ascorbate †   
Ascorbate dose  
(500 mg / mL) 
Total volume* 
Osmolarity 
(mOsm/L)§ 
Infusion Time 
 
15g (30 mL) 
 
250 mL 
 
681 
 
30 minutes 
 
75g (150 mL) 
 
1000 mL 
 
851.7 
 
120 minutes 
 
62.5 g (125 mL) 
 
1000 mL 
 
709 
 
120 mins 
† Provided by Drug Information Center at the University of Iowa, July 2011 
*  Sterile water for injection only. Do not use D5W 
§  Theoretical calculations provided by Drug Information Center; targeted osmolarity range is 500 – 900 mOsm/L 
 
Phase II 
IV Ascorbate at 
recommended dose three 
times weekly 
+ 
Radiotherapy starting 
from week 1 
+ 
Surgery 4-6 weeks after 
XRT 
END OF TREATMENT
SURVIVAL F-UP
END OF STUDY
SCREENING
ENROLEMENT 

Version 8 17Novemberl2021 
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5.7 
Radiation therapy  
External beam radiation therapy will be given at the standard dose for resectable soft tissue 
sarcomas according to the NCCN sarcoma guidelines.2 Patients with extremity and trunk STS will 
receive 50 Gy over 25 fractions  and those with retroperitoneal STS will receive 45 to 50.4 Gy in 
28 fractions, during which time they will be receiving three times weekly IV ascorbate until the 
end of radiation therapy. Surgery will be performed 4-6 weeks from the end of radiation to allow 
for adequate tissue healing and resolution of acute toxicities. 
Radiation therapy for this protocol is as per currently used standard pre-operative radiation therapy at 
the University of Iowa even for non-protocol patients. Selected guidelines from previously conducted 
Radiation Therapy Oncology Groups (RTOG) studies are briefly summarized for this protocol. 
5.7.1 Preoperative Radiation therapy (3D-CRT or IMRT). Either 3D conformal 
radiotherapy or intensity modulated radiation therapy may be utilized for adequate tumor 
coverage and to meet the dose constraints for critical normal structures. 
5.7.2 Radiation treatment planning scans and immobilization. CT scans with patient in a 
stable and comfortable position will be used for planning. MRI scans are optional and may 
be used for co-registration with CT for tumor localization as needed. VacLoc or other 
immobilization devices can be used for immobilization. 
5.7.3 Target volumes and treatment field (Extremity Sarcoma): 
Gross Target Volume (GTV): Outline of the tumor as seen on CT or CT/MRI fusion.  
Clinical Target Volume (CTV): CTV = GTV plus 4 cm margins in the proximal and distal 
directions. However, the margin can be reduced if it extends beyond the compartment, the 
field can be shortened to include the end of a compartment. The radial margin from the 
lesion should be 1 cm. It can be reduced in areas confined by the fascial barrier or bone or 
skin surface as per standard of care and treating radiation oncologist’s discretion. 
Planning Target Volume (PTV): Include CTV and error of setup and organ motion. 
Typically PTV includes CTV plus 0.5 - 1 cm in all dimensions. Final PTV is usually GTV 
+ 5 cm longitudinal and 2 cm radial, except where restricted by the compartment end, 
fascia, bone or skin surface as per standard of care and treating radiation oncologist’s 
discretion. 
Use of bolus on the skin surfaces is optional as needed. Where applicable biopsy scars 
should be bolused with appropriate thickness specific to the energy of the photon beam. 
5.7.4 Target volumes and treatment field (Retroperitoneal/Trunk Sarcoma): 
Gross Target Volume (GTV): Outline of the tumor as seen on CT or CT/MRI fusion. 
Clinical Target Volume (CTV): 4D-CT imaging should be performed for tumors above 
the iliac brim to assess for possible tumor motion associated with respiration.  The CTV is 
generated by expanding the different respiratory phases GTV (ITV) by 1.5 cm 
symmetrically.  The margin can be reduced if it extends beyond the retroperitoneal 
compartment into bone, kidney, or liver.  If tumor extends through inguinal canal, an 
additional 3cm can be added distally as per standard of care and treating radiation 
oncologist’s discretion. 
 
 

Version 8 17Novemberl2021 
19 
Planning Target Volume (PTV): Include CTV and error of setup and organ motion. PTV 
expansions are typically CTV plus 0.5 - 1 cm in all dimensions.  Final PTV is typically 
ITV + 2 cm symmetrically as confined to the retroperitoneal compartment as per standard 
of care and treating radiation oncologist’s discretion.   
5.7.5 Dose Specifications: 
A dose of 50 Gy in 25 daily fractions for extremity STS and 45 to 50.4 Gy in 28 fractions 
for retroperitoneal STS will be prescribed to the planning target volume (PTV) using linear 
accelerator and megavoltage photon beams with energies of 6MV or greater.  
For retroperitoneal/intra-abdominal sarcomas, a dose-painted simultaneous integrated 
boost (SIB) to total dose of 57.5 Gy in 25 fractions is allowed in select cases. A 
postoperative EBRT boost is discouraged. 
Prescribed dose should cover > 90% of the PTV. More than 95% of the PTV should receive 
> 95% of the prescribed dose. No more than 20% of the PTV will receive ≥ 110% 
prescription dose. 
5.7.6 Precautions and Dose Constraints for critical structures: 
Radiation dose to normal tissues should be kept within the accepted normal tissue 
tolerances. Every effort should be made to: 
a) Avoid treating the full circumference of an extremity;  
b) Avoid treating anus, urogenital tract, perineum and genitalia; if the tumor is close to 
these structures, typically less than 50% volume of the anus and vulva should receive 
30 Gy; less than 50% volume of the testis should receive 3 Gy, if the patient prefers to 
reserve fertility;  
c) Avoid treating the lung, through use of appropriate shielding and treatment planning; 
less than 20% of the lungs should receive 20 Gy (V20); 
d) Avoid dose maximums in areas where surgical scars will be placed; this may require 
reviewing treatment plans with the surgeon; 
e) If possible, avoid treating skin over areas commonly traumatized to full dose (e.g., the 
elbow, knee, shin, femoral neck). 
f) If possible, less than 50% of any joints (including shoulder, elbow and knee) should 
receive 50 Gy.  
g) Less than 50% of kidney volumes should receive 18 Gy.  
h) No more than 50% of normal weight-bearing bone within the radiation field should 
receive 50 Gy except when the tumor invades the bone or when there is circumferential 
involvement of the tumor more than a quarter of the bone or when the bone will be 
resected in a subsequent surgical resection after radiation. 
For any other normal tissue structures, no radiation dose more than the established TD5/5 
limit should be given.  
5.7.7 Image Guidance and Verification Devices 
Portal films or conebeam CT images should be used for target localization and alignment. 
Daily cone beam CT will be preferred and dose from daily cone beam should be included 

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in the final dosimetry. 
 
 

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21 
5.7.8 Simultaneous Integrated Boost 
A simultaneous integrated boost to a total dose of 57.5 Gy in 25 fractions is allowed for 
patients in whom the surgeon feels a margin negative resection will be difficult to 
achieve. The boost volume is defined as the high-risk retroperitoneal margin jointly 
identified by the surgeon and treating radiation oncologist. In this scenario, no further 
postoperative boost is allowed. 
 
5.7.9 Postoperative Radiotherapy Boost  
An External Beam or Brachytherapy boost can be given at the discretion of the radiation 
oncologist. If deemed necessary, the boost volume would include the positive tumor 
margin (residual tumor) plus a margin of 1 cm. Boost treatment should be delivered within 
2 weeks following surgery or after adequate wound healing has occurred. 
The target volume for postoperative radiotherapy will be the residual tumor bed as defined 
by the surgical and pathological findings.  
5.7.10 External Beam Radiotherapy 
Postoperative external beam boost dose is 16 Gy in 8 fractions (once a day) for microscopic 
disease and 20 Gy in 10 fractions for gross residual disease providing normal tissue is 
spared (likely requires a biologic or synthetic tissue spacer).  
5.7.11 Anticipated Radiation Therapy Adverse Events  
Acute: Wound complications of any grade are expected to develop in about one third of 
patients. Other common radiation adverse events include: fatigue, regional alopecia, 
diarrhea, skin erythema and desquamation within the treatment fields, and reduction in 
blood counts. 
Long-term: Common long-term treatment adverse events include: lymphedema of the 
extremity receiving radiation and surgery, subcutaneous fibrosis, and joint stiffness. Much 
less common radiation adverse events include bowel injury, osteoradionecrosis, and bony 
fracture in the radiation field. There also is a risk of secondary malignancy occurring in the 
irradiated field.  
5.8 
General Concomitant Medication and Supportive Care Guidelines 
Patients should receive full supportive care, including transfusions of blood and blood products, 
antibiotics, etc., when appropriate. The reason(s) for treatment, dosage, and the dates of treatment 
should be recorded.  
Throughout the study, investigators may prescribe any concomitant medications or treatments 
deemed necessary to provide adequate supportive care. All prescription and nonprescription 
concomitant medication administered up to 28 days prior to enrollment, on an ongoing basis at 
enrollment, as well as changes in such concomitant medication, and any new concomitant 
medication taken while the subject is on study, should be recorded up to 30 days after the last dose 
of ascorbate. 
5.8.1 Antiemetics. Use Zofran (ondansetron) with caution as this medication may be less 
effective when used with ascorbate. Prefer alternative agents such as prochlorperazine 
5.8.2 Fluid intake. Subjects will be encouraged to maintain adequate hydration to decrease the 
risk of nephrolithiasis. Those unable to maintain oral hydration should be considered for 

Version 8 17Novemberl2021 
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supplemental IV hydration per institutional care guidelines.  
5.8.3 For diabetics, be aware high-dose ascorbate can provide false results for finger-stick 
glucose readings. This effect is dose dependent but can last up to 6h post-infusion. 
Serum/plasma tests are not affected.39 
 
 

Version 8 17Novemberl2021 
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5.9 
Criteria for removal from study  
Treatment with pharmacological ascorbate may be discontinued if any one of the following criteria 
is met: 
• Intercurrent illness that prevents further administration of treatment, 
• Unacceptable adverse event(s), 
• Patient decides to withdraw from the study, or 
• General or specific changes in the patient's condition render the patient unacceptable for 
further treatment in the judgment of the investigator 
• Progressive disease as determined by the investigator 
• A female subject becomes pregnant or fails to use 2 highly effective methods of 
contraception (for those subjects who are able to conceive).  
• A female subject breast feeds while on study treatment. 
• A male subject fails to use a highly effective method of contraception  
5.10 
Duration of Follow Up 
Post-operatively subjects should be followed either by clinic visit or phone contact every 12 ± 4 
weeks for approximately 2 years from the end of enrollment, to assess for survival, and disease 
recurrence. Surveillance imaging and clinical assessment to assess for disease recurrence will be 
as per NCCN guidelines. 
6. DOSING DELAYS/DOSE MODIFICATIONS/ DOSE LIMITING TOXICITIES 
6.1 
Radiation Therapy 
6.1.1 Dose modification - Radiation therapy dose will not be modified. 
6.1.2 Treatment delay - Will only occur for reasons of safety due to intercurrent illness or 
medical conditions that in the judgment of the radiation oncologist forbid delivery of 
radiation therapy. 
6.1.3 Interruptions or delays of greater than three days should be discussed with the study’s 
principal investigator and documented 
6.2 
Ascorbate Therapy  
6.2.1 Dose reductions – As per Table 1 (below) if there is a DLT (Section 5.6) 
Table 1.  
Phase 1b Dose De-escalation Schedule 
Number of Patients with DLT  
at a Given Ascorbate Dose 
Decision Rule 
> 2 
Dose level will be declared toxic. 
If this is the lowest dose level, stop the study due to 
excessive toxicity; otherwise enter three additional 
patients at the next lowest dose level. 
< 1 out of 3 
Enter three more patients at this dose level. 
< 1 out of 6 
This is the recommended dose for the subsequent Phase2. 

Version 8 17Novemberl2021 
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Ascorbate Dose Levels 
Dose 0 
Ascorbate 75 gm IV three times weekly concurrently with radiation   
Dose -1 
Ascorbate 62.5 gm IV three times weekly concurrently with radiation 
 
• Initial dose for all = Ascorbate 75gm IV  
6.2.2 Test/retest. If an unexpected adverse event is observed, the treating physicians may 
withhold ascorbic acid for up to 2 calendar weeks to determine if the effect diminishes or 
resolves entirely. Considering the nature and severity of the event, if reasonable ascorbic 
acid should then be continued to determine if the event again presents. This will function 
as a test for causality.  
6.2.3 Dose delays. Due to holidays or inclement weather, doses may be delayed by up to one 
week with physician and PI approval. Reason for treatment delay should be noted in the 
study chart.  
6.3 
Dose Limiting Toxicities 
Definitions of dose-limiting toxicity: 
Toxicity will be evaluated according to CTCAE version 5.0. DLT will be defined as any of the 
following ascorbate related toxicity or related to the combination of pharmacologic ascorbate and 
radiation therapy during treatment and up to 28 days after the first pharmacologic ascorbate 
infusion:  
• Infection grade 4 
• SAE per 21CFR312.21 with an attribution of possible, probable, or definite to ascorbate 
• Grade 3 diarrhea or nausea/vomiting despite maximal support 
• Any grade 3/4 or greater hematologic or non-hematologic toxicity not explainable by 
another cause in the opinion of the principal investigator, with the exceptions of:  
o Expected radiation related skin toxicity of any grade. 
o Brief (< 1 week) grade 3 fatigue. 
If unexpected DLT occurs, ascorbate administration should be delayed until the DLT has resolved 
to at least CTCAE version 5.0 grade 1 or baseline and future dose be reduced to dose level -1 as 
per table 1. If dosing is delayed by more than 4 weeks due to the occurrence of unexpected adverse 
event or if a patient already dose reduced to level -1 (62.5 gm/dose) experiences another DLT that 
is considered related to ascorbate, then the subject should be taken off study. 
7. ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS  
This study will also be monitored by internal oversight specialists at the University of Iowa. The 
Data and Safety Monitoring Plan of the Holden Comprehensive Cancer Center provides standard 
operating procedures to monitor all clinical cancer trials at the UIHC. All investigator-initiated 
trials are automatically monitored by the Data and Safety Monitoring Committee (DSMC). A 
detailed data and safety monitoring plan for this study is provided (Appendix). This study has been 
assigned as a risk level 4 as it utilizes an investigator sponsored IND.  
 
 

Version 8 17Novemberl2021 
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7.1 
Determination of Reporting Requirements 
The clinical research team is responsible for collecting and recording the research data. As these 
results are collected, all toxicities and adverse events will be identified and reported to the principal 
investigator (PI). The principal investigator (PI) will determine final relationship of the event to 
the investigational product (ascorbate): 
• 
Grade 1 and 2 events do not require attributions assigned. 
• 
Grade 3 and higher adverse events require attribution assigned to ascorbate.  
Toxicity will be graded according to NCI’s Common Toxicity Criteria (CTCAE v5 ). The principal 
investigator will have final responsibility for determining the attribution of toxicity as it is related 
to the investigational product.  
7.2 
Institutional Review Board reporting requirements 
Adverse events that meet criteria of both serious and attributed (possible, probable, or definite) to 
the study agent. Thus: 
• Serious adverse events only 
• Attributable to ascorbate (i.e., drug related) 
• Report to the IRB via HawkIRB within 10 business days of event 
7.3 
FDA reporting requirements [M.Milhem, sponsor] 
Adverse events meeting the criteria of serious, unexpected, and attributed (possible, probable, or 
definite) to ascorbate must be reported by the sponsor or the sponsor’s appointed designee to the 
FDA: 
• Serious adverse events only [21 CFR 312.32] 
• Attributable to ascorbate with a causal relationship (possible, probable, or definite)  
• Unexpected, as defined by the FDA: “…not listed in the investigator brochure or is not 
listed at the specificity or severity that has been observed; or, if an investigator or, if an 
investigator brochure is not required or available, is not consistent with the risk 
information described in the general investigational plan or elsewhere in the current 
application, as amended.” 
To help the sponsor meet these reporting requirements, all serious adverse events that are 
unexpected and attributed to study drug must be reported to the sponsor within 1 business day. 
This coincides with SAE reporting requirements for the DSMC. 
7.4 
Routine Adverse Event Reporting Requirements to DSMC 
An adverse event (AE) is defined in the CTEP, NCI Guidelines [2005] as “any unfavorable and 
unintended sign (including a clinically significant abnormal laboratory finding), symptom or 
disease temporally associated with the use of a medical treatment or procedure (attribution of 
unrelated, unlikely, possible, probably or definite).” 
Routine adverse events are captured in OnCore, the clinical trials management system, for review 
and assessment by the P.I., sponsor, medical monitor, and DSMC.  
 
 

Version 8 17Novemberl2021 
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7.5 
Serious Adverse Event Reporting to DSMC 
For any experience or condition meeting the definition of a serious adverse event (SAE; 
21CFR312.32), from the first day of study treatment and typically continue through the 30 day 
follow-up period after treatment is discontinued.  
Investigators must report to the DSMC any SAE, regardless of attribution to study drug. SAEs 
must be reported via an OnCore SAE Report within 1 business day of learning of the event.  
An adverse event is considered serious if it results in ANY of the following outcomes:   
• 
Death 
• 
A life-threatening adverse event  
• 
An adverse event that results in inpatient hospitalization OR prolongation of 
existing hospitalization for ≥ 24 hours  
• 
A persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions  
• 
A congenital anomaly/birth defect.  
• 
Important Medical Events (IME) that may not result in death, be life threatening, 
or require hospitalization may be considered serious when, based upon medical 
judgment, they may jeopardize the patient or subject and may require medical or 
surgical intervention to prevent one of the outcomes listed in this definition. (21 
CFR 312.32; ICH E2A and ICH E6). 
8. PHARMACEUTICAL INFORMATION – ASCORBIC ACID INJECTION, ASCOR L 
500® 
8.1 
Availability 
IND 137968 allows ascorbate to be obtained through McGuff Pharmaceuticals (Santa Ana, 
CA). Their product Ascor L 500® is now a commercially available injection available in 
sterile single-use 50 mL vials containing 25 g of ascorbic acid (500 mg/mL).  
8.2 
Compatibility 
Ascorbate is considered a CYP4503A4 inhibitor.40 Therefore close monitoring of subjects 
who may be concomitantly receiving CYP3A4 substrates with narrow therapeutic indexes 
for toxicities is required. A table of CYP3A4 substrates, inhibitors, and inducers is 
provided in the Appendix. Ascorbate may decrease plasma/blood concentrations of 
substrates (Appendix B, tables 1, 2, and 3). Ascorbate may increase CYP3A4 induction 
(Appendix B, Table 4).  
8.3 
Storage and Stability 
Unopened vials of are stable until the expiration date indicated on the package when stored 
between 2° – 8°C (36°–46°F). Protect from light and store in the carton until time of use. 

Version 8 17Novemberl2021 
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8.4 
Toxicities 
9. DIARRHEA, NAUSEA AND/OR VOMITING, KIDNEY STONES, DRY 
MOUTH/THIRST, HEADACHE, ABDOMINAL PAIN, FATIGUE, FACIAL 
FLUSHING, SWEATING, WEAKNESS, INJECTION SITE IRRITATION, AND 
FAINT/DIZZY (AFTER RAPID INFUSION), AND HYPERTENSION THAT MAY 
REQUIRE MEDICATION HAVE BEEN REPORTED. CORRELATIVE AND 
SPECIAL STUDIES  
9.1 
ROS Research blood 
Research blood for future use will be drawn at: 
• Baseline prior to test dose of ascorbate  
• Prior to XRT dose 1  
• Week 3 of radiation therapy prior to XRT dose  
• After last fraction of radiation therapy (≤60 minutes of completing that fraction) 
• End of study visit which will be ~ 1 month of completing ascorbate therapy 
 
The specimen should be placed on ice immediately after the draw and carried to Spitz lab. 
Time point 
Ascorbate level  
(4 cc green top)  
ROS (6cc pink)      Immuno  (6cc  pink)  
Test Dose 
pre 
pre 
pre 
W1D1 
30 min post Ascorbate 
pre XRT dose  
NA 
W3D1 
30 min post Ascorbate 
pre XRT dose  
NA 
W5 
30 min post last 
Ascorbate dose 
≤ 60 min post last  
fraction of XRT  
30 min post last Ascorbate 
dose (or can be drawn with 
ROS after last fraction of 
XRT) 
30 Day post last 
Ascorbate 
NA 
yes 
yes 
 
9.2 
Labile Iron Measurements using MRI Imaging (optional) 
Pharmacological ascorbate’s mechanism of action is hypothesized to involve changes in labile iron 
pools within the tumor. The presence of labile iron and/or iron containing metalloproteins is 
necessary to oxidize ascorbate and eventually lead to the generation of hydrogen peroxide, thereby 
increasing tumor cell oxidative stress. In vitro laboratory studies demonstrate treating GBM and 
non-small cell lung cancer (NSCLC) cells with high doses of ascorbate increases labile iron 
pools.30 Additionally, chelating (e.g., removing) iron from tissue culture media reduces 
pharmacological ascorbate toxicity to tumor cells. 
MRI imaging will be done only for extremity sarcoma subjects prior to ascorbate treatment as a 
pre-scan control (at diagnosis) and will be done at  60 minutes +/- 30 minutes)and 4 hours post 
ascorbate treatment (in radiation oncology suite during week 3) as it has been seen that ascorbate 
levels tend to peak between 1 and 2 hours after injection.30 Imaging studies will be conducted on 

Version 8 17Novemberl2021 
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a GE 1.5T/3T MRI scanner using appropriate anatomical coils.  Images will be acquired using a 
T2* fast gradient-echo, multi-echo pulse sequence with short echo time (~6 ms) and repetition 
time ~25 ms which has shown to be beneficial in previous studies involving iron overload 
measurements in the liver and heart.41,42  Image analysis will initially be done using a region of 
interest approach in which the tumor region will be contoured and then analyzed using a mono-
exponential decay of the T2* relaxation time.  This image analysis has been shown by Positano, 
et. al 42 to be clinically acceptable and more clinically relevant. Serum iron, transferrin saturation, 
total iron binding capacity and ferritin levels will be obtained to evaluate if they correlate with 
responses and T2* imaging findings.     
This series will be done at three time points – baseline (as part of simulation in radiation oncology 
suite or as part of diagnostic MRI if it is being done), week 3 and end of study (as part of diagnosis). 
The imaging in week 3, done in the radiation oncology suite, is centered around that day’s 
ascorbate infusion. Contrast is not allowed for these sequences and will not be ordered. The 
following MRI should be ordered to be completed on the same day: 
9.2.1 Contrast.  No contrast is to be used (oral or IV) 
9.2.2 Scheduling. The infusional T2* is scheduled in week 3. The other time points are at RT 
simulation and end of treatment study (diagnostic) 
9.2.3 Pre-infusion (week 3). A pre-infusion T2* MR series will be obtained. This will contain 
both the T2* and also axial imaging for reference.  
9.2.4 Post-infusion (week 3). 30 to 90 minutes within the end-of-infusion, a second T2* / axial 
series will be obtained. This should be obtained prior to the day’s radiation therapy. 
9.2.5 4h post-infusion (week 3). The last T2* / axial series will be done approximately 4h 
after the end-of-infusion (± 60 minutes). 
9.3 
Diffusion Weighted Imaging (optional) 
Addition of functional diffusion-weighted MRI (DW-MRI) to standard anatomic and postcontrast 
MRI greatly facilitates interpretation of response to therapy43,44. After radiation therapy, new 
enhancement alone can be seen which may be a result of vascular disruption rather than histologic 
response. Hence should be interpreted carefully. Although currently not a standard clinical trial 
endpoint, DW-MRI appears to be a promising as a quick, noninvasive tool showing excellent 
reproducibility for apparent diffusion coefficient measurements, which reflect tumor cellularity 
and microarchitecture in STS. However, the relationship of these MRI parameter changes with 
clinical outcomes has not yet been validated. Hence we intend to evaluate this MRI sequence which 
is currently acquired routinely for imaging brain tumors and stroke. This sequence will be added 
to the planning MRI acquired in radiation oncology prior to starting radiation therapy treatment 
and will be compared to the DWI sequence acquired pre-operatively. 
9.4 
Ascorbate levels 
Serum ascorbate levels will be drawn at screening, 30 mins post at week 1 day 1, as well as 30 
mins  post  week 3 Day 1 and 30 min post  last infusion in week 5. This is being done to ensure a 
target serum level of 20 mM is reached during treatment. 
9.5 
Tumor tissue  
A part of the resected tumor (1 x 1 inch) specimen together with the surrounding normal tissue 
will be testing for immune markers such as CD4, CD8, T regulatory cells. MDSCs and 

Version 8 17Novemberl2021 
29 
macrophages. Flash frozen tissue will be subjected to T2 * imaging testing to determine labile iron 
concentrations in comparison to the surrounding normal tissue. Molecular testing including next 
generation testing may be performed on the paraffin embedded tissue specimens. Optional pre- 
treatment tumor biopsies will be taken from approximately 5 subjects total and immune markers 
will be compared between pre and post treatment tissue in the immunology lab. 
 
 

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10. STUDY CALENDAR  
10.1 
Study Procedures 
 
Screenb 
Treatmenta 
Off 
treatment 
and end 
of studyc 
Follow 
Upd 
Week 1 
Week 2 
Week 3 
Week 4 
Week 5 
(+ 1wkj) 
H & P 
X 
X 
 
X 
 
X 
 
 
Tumor biopsy (optional) 
Xb 
 
 
 
 
 
 
 
Performance status 
X 
 
 
 
 
 
X 
X 
Clinical MRI/ Staging CT     
X 
 
 
 
 
 
X 
Xe 
Pregnancy testk (urine) 
X 
 
 
 
 
 
 
 
G6PD 
X 
 
 
 
 
 
 
 
EKG 
X 
 
 
 
 
 
 
 
CBC w/diff  
X 
 
 
X 
 
X 
 
 
PT/INR, PTT & uric acid 
X 
 
 
 
 
 
 
 
Height 
X 
 
 
 
 
 
 
 
Weight, BSA 
X 
 
 
 
 
 
X 
 
Vitals (BP, pulse)m 
X 
X 
x 
X 
x 
X 
X 
 
Comprehensive metabolic panel 
(CMP)  
X 
X 
 
X 
 
X 
X 
 
Ascorbate infusion 
Xi 
XXX 
XXX 
XXX 
XXX 
XXX 
 
 
Blood for ascorbate levelsf 
X 
X 
 
X 
 
X 
 
 
ROS Research bloodg   
X 
X 
 
X 
 
X 
X 
 
Immunology research labg 
X 
 
 
 
 
X 
X 
 
Iron Panel including ferritinh 
X 
 
 
 
 
 
X 
 
T2* /QSM and DWI MR imaging 
sequences (optional) 
X 
 
 
X 
 
 
X 
 
Adverse Events &Con Meds 
 
 
X 
X 
X 
X 
X 
 
a 
study day 1 is defined as radiation therapy day 1 (i.e., fraction 1). 
b 
screening labs, history, and physical must be obtained ≤ 28d from d1. G6PD may be obtained at any time prior to 
test dose.  MRI/CT obtained ≤ 28d from d1 (RT sim is acceptable). Pregnancy test per institutional guidelines. 
Optional tumor biopsy can be done anytime before week 1 dosing.  
c 
includes both off-treatment evaluation  and study completion.  Study completion requires a final study dictated 
visit 4 to 6 weeks after the last dose of ascorbate. Follow at least monthly until resolution of all ascorbate related 
adverse events. 
d 
approx every 3 months (every 12 weeks [+/- 4 weeks]) for overall survival through passive chart review, phone 
call or scheduled follow-up visit for 2 years   
e 
Imaging as per standard of care for site specific sarcomas 
f  
4cc green-top Na-Heparin tube. Draw pre-infusion at 15g dose, then 30 min post-infusion: week 1 day 1 , week 
3 and last infusion of week 5 
g 
6cc pink-top EDTA tube. Draw pre infusion The specimen should be placed on ice immediately after draw and 
carried to the lab   
h 
At time of screening and end of study 
i 
Test dose of 15 g intravenously once G6PD levels confirmed to be adequate.  A physician must review the 
patient's medication list against the list of medications prohibited on this trial prior to the test dose of ascorbate.   
j 
In case of radiation treatment delays due to holidays  
k 
±7 days prior to day 1  

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m Blood pressure should be obtained before and after (≤ 15 min EOI) ascorbate infusion   
 
 

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10.2 
Screening Procedures 
Procedures to be completed within 28 days prior to first treatment (day 1) (unless otherwise noted). 
• Informed consent 
• Review of eligibility criteria- 
• Recording of medical history and concomitant medications 
• Physical exam (including weight) 
• ECG 
• Vital signs (blood pressure, temperature, pulse and respirations) 
• Radiographic imaging (chest, abdomen, and pelvis and all other sites of disease)  
• Imaging of primary tumor site 
Laboratory Assessments 
Procedures to be completed within 28 days prior to enrollment 
• CBC w/diff  
• CMP and uric acid 
•  PT/INR, PTT., Urine pregnancy test for females of childbearing potential within 7 days 
of W1D1 
10.3 
Post-treatment Evaluations 
Following surgical resection of primary tumor, patients will be followed as per NCCN guidelines 
for approximately 2 years for survival data and disease recurrence. 
11. MEASUREMENT OF EFFECT 
11.1 
Pathologic Response  
4 to 6 weeks after the end of neoadjuvant therapy, patients will undergo resection of the treated 
tumor. The SOC pretreatment biopsy and all the resected tumor samples will be reviewed by the 
same pathologist.  
The percentage of post treatment tumor necrosis must be documented. The primary end point for 
this study is pathologic complete response (pCR), and is defined as ≥ 95% tumor necrosis 
following concurrent radiation therapy and ascorbate  
Treatment effect on the resected overlying skin tissue will be graded and recorded (to be done by 
the pathologist). This will be compared with historical controls.   
Additional immunohistochemical studies will be performed as determined by the pathologist. 
11.2 
Time to Disease progression (TTP) 
TTP is defined as the time from Enrollment until objective tumor progression including local and 
distant recurrences. 
11.3 
Other Response Parameters 
The following response assessment guidelines may be amended during the course of the study if 
changes are made to the current RECIST Guidelines or if a new disease assessment tool becomes 
available.  

Version 8 17Novemberl2021 
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Response Measurement Criteria:  
Measurements of the tumor in its largest dimension should be obtained at baseline and at the end 
of the treatment phase, prior to surgical resection.  
Response criteria should be by RECIST v 1.1. 
• Complete response is the disappearance of all target lesions. 
• Partial response is a 30% decrease in the sum of the longest dimensions of the target 
lesions, relative to baseline. 
• Progressive disease is an increase of 20% or more in the sum of the longest dimension of 
target lesions 
• Stable disease is a decrease in the tumor size of < 30% or an increase of < 20%. 
• Antitumor response by pathologic assessment will be performed on the resected tumors. 
Pathologic assessment will be performed per institutional guidelines.  
• The percent of tumor necrosis and the percent of tumor-infiltrating lymphocytes will be 
documented. 
• Complete pathological response will be considered ≥ 95% pathologic tumor necrosis. 
Radiologic response will be evaluated in this study using the new international criteria proposed 
by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1) 
[Eur J Ca 45:228-247, 2009].  Changes in the largest diameter (unidimensional measurement) of 
the tumor lesions and the shortest diameter in the case of malignant lymph nodes are used in the 
RECIST criteria. 
 
 
 

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12. STATISTICAL CONSIDERATIONS 
12.1 
Phase Ib 
The primary objective of the Phase Ib portion of this study is to confirm the current standard dose 
of intravenous ascorbate, 75 gm, utilized in patients diagnosed with pancreatic cancer also 
receiving concurrent chemo radiation is safe within this population of sarcoma patients being 
treated concurrently with pre-operative radiation. Up to six (6) patients will be recruited to the 
standard dose, 75 grams administered intravenously 3 times a week during radiation therapy (5 
weeks). If at most 1 out of 6 patients experience a DLT, the standard dose will be considered safe. 
If 2 or more patients experience a DLT, the next cohort of patients will be assigned to dose level -
1. The recommended phase II dose (RP2D) will be defined as the highest dose level for which at 
most 1 out of 6 patients experience a DLT.   
12.2 
Phase II 
The primary objective of the Phase II portion of this study is to evaluate the proportion of patients 
with pathologic tumor necrosis ≥95%. Previous literature indicates approximately 10% of patients 
will achieve ≥95% tumor necrosis with pre-operative radiation therapy alone. A sample size of 25 
patients achieves 81% power to detect a difference of 20% (from 10% to 30%) using a one-sided 
binomial exact test. The target significance level is 0.05 and the achieved level is 0.03. If 6 or more 
patients achieve ≥95% tumor necrosis, the treatment will be deemed worthy of further 
investigation. For secondary objectives, time to disease progression and overall survival will be 
estimated using the Kaplan-Meier method. Estimated survival probabilities will be plotted and 
medians reported, along with 95% confidence intervals. To identify differences in wound 
complication and Grade 3-4 dermatitis rates relative to historical controls, binomial point estimates 
and 95% exact confidence intervals will be reported. Mixed effects regression models will be used 
to estimate changes in labile iron and diffusion imaging sequences on MRI pre and post treatment.   
12.3 
Sample Size/Accrual Rate 
The Phase I portion of this study is expected to require 6 evaluable patients (min 6, max 12). 
Patients treated in Phase Ib at the RP2D will also be included in the Phase II portion. Additional 
evaluable patients will be accrued for a total of 25 patients treated at the RP2D. The anticipated 
accrual rate is 2 patients per month who would meet inclusion criteria.  
 
 
 

Version 8 17Novemberl2021 
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12. Cameron E, Campbell, A: The orthomolecular treatment of cancer. II Clinical trial of 
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13. Cameron E, Pauling L: Supplemental ascorbate in the supportive treatment of cancer: 
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14. Cameron E, Campbell, A:: Innovation vs. quality control: an ‘unpublishable’ clinical 
trial of supplemental ascorbate in incurable cancer Med Hypotheses 36:185-189, 1991 
 
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‘spontaneous’ regressions, in response to high dose ascorbic acid therapy. A report on 
subsequent progress. Oncology 48:495-497, 1991 
 
16. Murata A, Morishige, F, Yamaguchi, H: Prolongation of survival times of terminal 
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Suppl 23:103-113, 1982 
 
17. Creagan E, Moertel, CG, O’Fallon, JR, Schutt, AJ, O’Connell, MJ, Rubin, J, Frytak, S: 
Failure of high-dose vitamin C (ascorbic acid) therapy to benefit patients with advanced 
cancer: A controlled trial. N Engl J Med 301:687-690, 1979 
 
18. Moertel C, Flemin, TR, Creagan, ET, Rubin, J, O’Connell, MJ, Ames, MM: : High-
dose vitamin C versus placebo in the treatment of patients with advanced cancer who 
have had no prior chemotherapy. A randomized double-blind comparison. N Engl J 
Med 312:137-141, 1985 
 
19. Levine M, Conry-Cantilena, C, Wang, Y, Welch, RW, Washko, PW, Dhariwal, KR, 
Park, JB, Lazarev, A, Graumlich, JF, King, J, Cantilena, LR. : Vitamin C 
Pharmacokinetics in healthy volunteers: Evidence for a recommended dietary 
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20. Padayatty SJ, Levine, M: Reevaluation of vitamin C in cancer treatment: emerging 
evidence, open minds and serendipity. J. Amer. Coll. Nutr. 19:423-425, 2000 
 
21. Graumlich J, Ludden, TM, Conry-Cantilena, C, Cantilena, Jr LR, Wang, Y, Levine, M: 
Phamacokinetic model fo ascorbic acid in healthy male volunteers during depletion and 
repletion. Pharm Res 14:1133-1139, 1997 
 
22. Riordan N, Riordan, HD, Meng, X, Li, Y, Jackson, JA: Intravenous ascorbate as a 
tumor cytotoxic chemotherapeutic agent. Med Hypotheses 44:207-213, 1995 
 
23. Chen Q, Espey, MG, Krishna, MC, Mitchel,l JB, Corpe, CP, Buettner, GR, Shacter, E, 
Levine, M. : Pharmacologic ascorbic acid concentrations selectively kill cancer cells: 
Action as a pro-drug to deliver hydrogen peroxide to tissues. Proc Natl Acad Sci USA 
102:13604-13609, 2005 
 
24. Chen Q, Espey, MG, Sun, AY, Lee, JH, Krishna, MC, Shacter, E, Choyke, PL, Pooput, 
C, Kirk, KL, Buettner, GR, Levin, M.: Ascorbic acid in pharmacologic concentrations: 
a pro-drug for selective delivery of ascorbate radical and hydrogen peroxide to 
extracellular fluid in vivo Proc Natl Acad Sci USA 104:8749-8754, 2007 
 
25. Padayatty S, Sun, H, Wang, Y, Riordan, HD, Hewitt, SM, Katz, A, Wesley, RA, 
Levine, M. : Vitamin C pharmacokinetics: implications for oral and intravenous use. 
Annals of Internal Medicine 140:533-537, 2004 
 
26. Chen Q, Sun, AY, Espey, MG, Levine, M: Ascorbic acid as a pro-oxidant therapeutic 
agent in cancer. Free Radical Biology and Medicine 43:S52, 2007 
 
27. Schoenfeld JD, Sibenaller ZA, Mapuskar KA, et al: Redox active metals and H2O2 
mediate the increased efficacy of pharmacological ascorbate in combination with 
gemcitabine or radiation in pre-clinical sarcoma models. Redox Biol 14:417-422, 2018 
 
28. Hoffer LJ, Levine M, Assouline S, et al: Phase I clinical trial of i.v. ascorbic acid in 
advanced malignancy. Annals of oncology : official journal of the European Society for 

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Medical Oncology / ESMO 19:1969-74, 2008 
 
29. Welsh JL, Wagner BA, van't Erve TJ, et al: Pharmacological ascorbate with 
gemcitabine for the control of metastatic and node-positive pancreatic cancer 
(PACMAN): results from a phase I clinical trial. Cancer Chemother Pharmacol 71:765-
75, 2013 
 
30. Schoenfeld JD, Sibenaller ZA, Mapuskar KA, et al: O2- and H2O2-Mediated 
Disruption of Fe Metabolism Causes the Differential Susceptibility of NSCLC and 
GBM Cancer Cells to Pharmacological Ascorbate. Cancer Cell 31:487-500.e8, 2017 
 
31. Canter RJ, Martinez SR, Tamurian RM, et al: Radiographic and histologic response to 
neoadjuvant radiotherapy in patients with soft tissue sarcoma. Ann Surg Oncol 
17:2578-84, 2010 
 
32. Shah D, Borys D, Martinez SR, et al: Complete pathologic response to neoadjuvant 
radiotherapy is predictive of oncological outcome in patients with soft tissue sarcoma. 
Anticancer Res 32:3911-5, 2012 
 
33. O'Sullivan B, Davis AM, Turcotte R, et al: Preoperative versus postoperative 
radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. Lancet 359:2235-
41, 2002 
 
34. Davis AM, O'Sullivan B, Turcotte R, et al: Late radiation morbidity following 
randomization to preoperative versus postoperative radiotherapy in extremity soft tissue 
sarcoma. Radiother Oncol 75:48-53, 2005 
 
35. Cannon CP, Ballo MT, Zagars GK, et al: Complications of combined modality 
treatment of primary lower extremity soft-tissue sarcomas. Cancer 107:2455-61, 2006 
 
36. Cheng EY, Dusenbery KE, Winters MR, et al: Soft tissue sarcomas: preoperative 
versus postoperative radiotherapy. J Surg Oncol 61:90-9, 1996 
 
37. San Miguel I, San Julian M, Cambeiro M, et al: Determinants of toxicity, patterns of 
failure, and outcome among adult patients with soft tissue sarcomas of the extremity 
and superficial trunk treated with greater than conventional doses of perioperative high-
dose-rate brachytherapy and external beam radiotherapy. Int J Radiat Oncol Biol Phys 
81:e529-39, 2011 
 
38. Devisetty K, Kobayashi W, Suit HD, et al: Low-dose neoadjuvant external beam 
radiation therapy for soft tissue sarcoma. Int J Radiat Oncol Biol Phys 80:779-86, 2011 
 
39. Ma Y, Sullivan GG, Schrick E, et al: A convenient method for measuring blood 
ascorbate concentrations in patients receiving high-dose intravenous ascorbate. J Am 
Coll Nutr 32:187-93, 2013 
 
40. van Heeswijk RP, Cooper CL, Foster BC, et al: Effect of high-dose vitamin C on 
hepatic cytochrome P450 3A4 activity. Pharmacotherapy 25:1725-8, 2005 
 
41. Positano V, Pepe A, Santarelli MF, et al: Standardized T2* map of normal human heart 
in vivo to correct T2* segmental artefacts. NMR Biomed 20:578-90, 2007 
 
42. Positano V, Salani B, Pepe A, et al: Improved T2* assessment in liver iron overload by 
magnetic resonance imaging. Magn Reson Imaging 27:188-97, 2009 

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43. Dudeck O, Zeile M, Pink D, et al: Diffusion-weighted magnetic resonance imaging 
allows monitoring of anticancer treatment effects in patients with soft-tissue sarcomas. 
J Magn Reson Imaging 27:1109-13, 2008 
 
44. Messiou C, Bonvalot S, Gronchi A, et al: Evaluation of response after pre-operative 
radiotherapy in soft tissue sarcomas; the European Organisation for Research and 
Treatment of Cancer-Soft Tissue and Bone Sarcoma Group (EORTC-STBSG) and 
Imaging Group recommendations for radiological examination and reporting with an 
emphasis on magnetic resonance imaging. Eur J Cancer 56:37-44, 2016 
 
 
 
 

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PROTOCOL APPENDIX A: Performance status criteria 
 
 
 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no 
evidence of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of 
disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active 
work. 
2 
In bed <50% of the time. 
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities. Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance 
and frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated. Death not imminent. 
4 
100% bedridden. Completely 
disabled. Cannot carry on any 
self-care. Totally confined to bed 
or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
 

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

Version 8 17Novemberl2021 
41 
CYP3A4 INTERACTION TABLE  
(Ascorbate may decrease the plasma/blood concentrations of substrates) 
Drugs with strikeout text are antiretroviral drugs that are not allowed for use on this study. 
* 3A4 substrate & inhibitor; # 3A4 substrate & inducer 
isradipine 
itraconazole* 
ivacaftor 
ixabepilone 
ketamine 
ketoconazole* 
lansoprazole  
lapatinib 
lercanidipine 
letrozole 
levonorgestrel 
lidocaine* 
linagliptin 
lomitapide 
loperamide  
lopinavir 
loratadine 
losartan 
lovastatin 
lumefantrine 
lurasidone 
maraviroc 
marijuana 
medroxyprogesterone 
mefloquine 
meloxicam 
mestranol 
methadone 
methylergonovine 
methylprednisolone 
miconazole* 
midazolam 
mifepristone 
mirabegron 
mirtazapine 
modafinil 
mometasone 
montelukast 
nateglinide 
nefazodone* 
nelfinavir* 
nevirapine# 
nicardipine* 
nifedipine 
nilotinib 
nimodipine 
nisoldipine 
nitrendipine 
norethindrone 
norgestrel 
nortriptyline 
omeprazole 
ondansetron 
ospemifene 
oxybutynin 
oxycodone 
paclitaxel 
paliperidone 
palonosetron 
pantoprazole 
paricalcitol 
paroxetine 
pazopanib 
perampanel 
perphenazine 
pimozide 
pioglitazone 
pomalidomide 
ponatinib 
prasugrel 
prednisolone 
prednisone  
primaquine 
progesterone/ 
progestins 
propafenone 
propranolol 
quazepam 
quetiapine 
quinidine*  
quinine 
rabeprazole 
ramelteon 
ranolazine 
regorafenib 
repaglinide 
rifabutin# 
rilpivirine 
risperidone 
ritonavir* 
rivaroxaban 
roflumilast 
romidepsin 
ruxolitinib 
salmeterol 
saquinavir* 
saxagliptin 
selegiline 
sertraline 
sibutramine 
sildenafil 
silodosin 
simvastatin 
sirolimus 
sitagliptin 
solifenacin 
sorafenib 
sufentanil 
sunitinib 
tacrolimus 
tadalafil 
tamoxifen 
tamsulosin 
telaprevir 
telithromycin* 
temsirolimus 
teniposide 
terfenadine 
testosterone  
tetracycline* 
theophylline 
tiagabine 
ticagrelor 
ticlopidine 
tinidazole 
tipranavir 
tofacitinib 
tolterodine 
tolvaptan 
topotecan 
toremifene 
tramadol 
trazodone 
triazolam 
trimethoprim 
trimetrexate 
trimipramine 
ulipristal 
vandetanib 
vardenafil 
vemurafenib  
venlafaxine 
verapamil* 
vilazodone 
vinblastine 
vincristine 
vinorelbine 
vismodegib 
voriconazole 
warfarin 
zaleplon 
zileuton 
ziprasidone 
zolpidem 
zonisamide 
zopiclone 
 
 

Version 8 17Novemberl2021 
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References:  
1. Lexi-comp On-line. Cytochrome P450 Enzymes: Substrates, Inhibitors, and Inducers. (accessed 
1/16/15) 
2. Pharmacist’s Letter/Prescriber’s Letter. Cytochrome P450 Drug Interactions. October 2013. 
3. P450 Drug Interaction Table. Indiana University Department of Medicine Division of Clinical 
Pharmacology.  http://medicine.iupui.edu/clinpharm/ddis/main-table/ 
4. Hansten and Horn’s Drug Interactions Analysis and Management. Facts and Comparisons. 2014 
 
 
UIHC Drug Information Center: 1/15 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Version 8 17Novemberl2021 
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APPENDIX D: DATA AND SAFETY MONITORING PLAN 
Type of Clinical Trial: 
 Investigator-initiated (UI/HCCC) 
 Investigator-initiated, participating site 
 Pilot study 
 Phase I 
 Phase I/II 
 Phase II 
 Phase III 
 Compassionate-use/Expanded Access  
 Interventional Treatment 
 Interventional Non-Treatment 
 Non-Interventional 
 
Study risk-level:  
 Level 1—low risk of morbidity or death, * <1% of death or any adverse event  
 Level 2—risk of death* <1% or any adverse event 1% – 5%  
 Level 3—risk of death* 1% – 5% or grade 4 – 5 SAE 1% – 5%  
 Level 4—risk of death* >5% or grade 4 – 5 SAE >5%  
 Drugs being used on a “compassionate” basis  
* Risk of death” refers specifically to 100-day treatment-related mortality 
___________________________ 
Reporting and Monitoring Requirements:  
All institutional investigator initiated trials (IITs), regardless of assigned risk level are subject to 
routine DSMC monitoring activities which may include but are not limited to review of signed 
consent documents, eligibility and adverse event reporting.  
All institutional IITs have the following reporting requirements as part of their DSMP: 
• Register all subjects in HCCC’s Clinical Trial Management System, OnCore 
• Document Adverse Events  
• Document protocol deviations  
• Provide an annual progress report to the DSMC via OnCore data export 
Selected monitoring strategy based on risk-level: 
Risk Level 4 
Interventional treatment trials involving investigational agents or devices with a risk of death* 
(>5% or grade 4 – 5 SAE >5%), e.g. all investigator initiated INDs, most Phase I/II trials, gene 
therapy, gene manipulation or viral vector systems high-risk clinical procedures if performed 
solely for research purposes.  The use of a new chemical or drug for which there is limited or no 
available safety data in humans. 
 
 

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Study Safety Review 
An independent study monitor and/or the DSMC Chair (or designee), will review study data 
(provided by the PI/available in OnCore) and communicate with the PI at least biannually.  A copy 
of this communication will be forwarded to the DSMC and PRMC Chairs.   
Additional Reporting Requirements:  
- A scanned copy of the completed eligibility checklist, with screening information and PI 
signature, will be attached in OnCore for ongoing review by DSMC staff.  
- Serious adverse events will be entered directly into an OnCore SAE report by the research 
team.  OnCore will send an automatic notification to the DSMC Chair/acting Chair and staff 
for review.  
- The DSMC utilizes a risk-based monitoring approach.  The trial's research records will be 
monitored at minimum twice per year.  Monitoring may be done more frequently depending 
on the protocol, risks to subjects, reported serious/adverse events, patient population and 
accrual rate.   Records for a minimum of 25% of subjects will be monitored for the entire 
study.    
Monitoring will involve the following: 
• review eligibility of patients accrued to the study, 
• check for the presence of a signed informed consent, 
• determine compliance with protocol’s study plan, 
• determine whether SAEs are being appropriately reported to internal and external 
regulatory agencies,  
• compare accuracy of data in the research record with the primary source documents, 
• review investigational drug processing and documentation, 
• assess cumulative AE/SAE reports for trends and compare to study stopping rules. 
Routine Adverse Event Reporting 
For non-serious Adverse Events, documentation must begin from the time the subject signs the 
informed consent document and continue through the 30-day follow-up period after the last dose 
of study drug. 
Collected information should be recorded in the electronic/Case Report Forms (eCRF/CRF) for 
that subject. A description of the event, its severity or toxicity grade (according to NCI’s Common 
Toxicity Criteria (CTCAE)), onset and resolved dates (if applicable), and the relationship to the 
study drug should be included. Documentation should occur in real time. The principal investigator 
has final responsibility for determining the attribution of the event as it is related to the study drug. 
Serious Adverse Event Reporting 
For any experience or condition that meets the definition of a serious adverse event (SAE), 
recording of the event must begin after signing of the informed consent and continue through the 
30 day follow-up period after treatment is discontinued.  
Investigators must report to the DSMC any serious adverse events (SAE), whether or not they are 
considered related to the investigational agent(s)/intervention (21 CFR 312.64). SAEs must be 
reported via an OnCore SAE Report within 24 hours of learning of the event.  
 

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An adverse event is considered serious if it results in ANY of the following outcomes:   
1. Death 
2. A life-threatening adverse event  
3. An adverse event that results in inpatient hospitalization OR prolongation of existing 
hospitalization for ≥ 24 hours  
4. A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions  
5. A congenital anomaly/birth defect.  
6. Important Medical Events (IME) that may not result in death, be life threatening, or 
require hospitalization may be considered serious when, based upon medical judgment, 
they may jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. (FDA, 21 CFR 
312.32; ICH E2A and ICH E6). 
 
Study Stopping and Pausing Rules 
The study will pause enrollment and stop treatment for all participants if any of the 
following events occur pending submission to Regulatory Agencies and review by the  
DSMC and IRB who will determine if the study may resume: 
• 
Any event of treatment related death in a study subject 
 
FDA Reporting Requirements (for Sponsor-Investigators)  
It is the responsibility of the IND sponsor-investigator to comply with IND safety reporting as set 
forth in the Code of Federal Regulations, Section 312.32. This responsibility includes providing 
an annual IND report to the FDA.  
All IND safety reports must be submitted on Form 3500A  and be accompanied by Form 1571. 
The type of report (initial or follow-up) should be checked in the respective boxes on Forms 3500A 
and 1571. See Instructions for completing Form 3500A.  Please note all instance of UIHC, 
location, and faculty / staff should be redacted from supporting documentation and the 3500A. 
The submission must be identified as: 
• “IND safety report” for 15-day reports, or 
• “7-day IND safety report” for unexpected fatal or life-threatening suspected adverse 
reaction reports, or 
• “Follow-up IND safety report” for follow-up information. 
For detailed explanation of the above definitions, requirements, and procedures related to IND 
application safety reports and the responsibilities of IND applications sponsors with regard to such 
reporting, refer to Guidance for Industry and Investigators: Safety Reporting Requirements for 
INDs and BA/BE Studies (PDF - 227KB) 
In addition to completing appropriate patient demographic and suspect medication information, 
the report should include the following information within the Event Description (section 5) of the 
MedWatch 3500A form: 
• Treatment regimen (dosing frequency, combination therapy) 

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• Protocol description (and number, if assigned) 
• Description of event, severity, treatment, and outcome, if known (grading the event per 
CTCAE) 
• Supportive laboratory results and diagnostics 
• Sponsor-Investigator’s assessment of the relationship of the adverse event to each 
investigational product and suspect medication 
Data Monitoring and Management  
Subject Registration 
All studies that undergo PRMC review and/or utilize HCCC Clinical Research Services (CRS) 
resources are required to register subjects in OnCore. Each subject registration includes the 
following: 
• The subject’s IRB approved (version date) consent form and the date of their consent.  
• Date of eligibility and eligibility status (eligible, not eligible) 
• On study date and subject’s disease site (and histology if applicable) 
• On treatment date (if applicable)  
All subject registration information is expected to be entered into OnCore within 2 (two) business 
days after the subject’s study visit.  
Subject Data 
For HCCC investigator initiated trials, research staff are responsible for entering subject study data 
(data collection) into OnCore electronic case report forms (eCRFs). These eCRFs must be 
approved by the PI and statistician prior to study activation to ensure sufficient and necessary data 
acquisition. All information entered into eCRFs will be traceable to the source documents which 
are generally maintained in the subject’s file.  
eCRF data entry needs to be timely and should be entered into OnCore as soon as possible but no 
later than 14 (fourteen) business days after the subject’s visit, including adverse events, tumor 
measurements, administration of study medication, concomitant medications, labs, and vitals. 
Physical exam assessments must be entered no later than 14 (fourteen) business days following 
completion of the physician’s clinic note in the medical record.  
Timely data entry facilitates remote monitoring of data, allows the data to progress appropriately 
through the data cleaning process, and helps prevent a backlog of data queries. 
Forms Monitoring 
OnCore eCRF data are monitored on a routine basis (dependent on accrual) to ensure all data are 
entered completely, accurately, and within time requirements outlined above. The assigned DSMC 
monitor will coordinate and complete the data monitoring review. When the time comes to monitor 
a study (based on patient accrual and assigned risk level of trial) the monitor arranges for a 
selection of cases to be reviewed from among the subjects registered in OnCore.  As part of the 
forms monitoring process, the assigned monitor will issue queries via OnCore (linked to the eCRF) 
to resolve missing, incomplete, and/or incorrect information. A member of the research team is 
expected to respond to these monitoring queries within 14 (fourteen) business days.  
The monitoring process can often identify misunderstandings or deficiencies in the written, 
research protocol requirements earlier in the study process and thereby improve data quality and 

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reduce rework.  
Final Reports 
A summary of each subject’s data record is continually available to the PI, research staff, and 
DSMC from OnCore’s Biostat Console. The availability of this information is a valuable tool for 
the preparation of final reports and manuscripts as well as ongoing deficiency reports.