Patient Derived Organoid-guided Personalized Treatment Versus Treatment of Physician's Choice in Patients With Relapsed and Refractory Breast Cancer：a Multicenter, Randomized, Controlled Phase III Trial
Phase: PHASE3
Conditions: Breast Cancer, Refractory Breast Carcinoma
Sponsor: Sun Yat-sen University

1
Patient Derived Organoid-guided Personalized Treatment
Versus Treatment of Physician's Choice in Patients With
Relapsed and Refractory Breast Cancer：a Multicenter,
Randomized, Controlled Phase III Trial
Research Unit: Sun Yat-sen University Cancer Center
Principal Investigator: Shi Yanxia
Contact: 020-87343874
Version number: 1.0
Version date: 12 December 2023

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1. Background of the study
Breast cancer is the leading cause of morbidity and mortality among women in
the world. 2.26 million new cases of breast cancer were diagnosed globally in 2020,
surpassing lung cancer (2.21 million cases) for the first time to become the world's
top cancer [1]. China is a big country for breast cancer , there were about 306,000
new cases of breast cancer in 2016, accounting for about 16.72% of all new cancers
[2]. In 2020, new cases of breast cancer increased to approximately 420,000,
resulting in nearly 120,000 deaths. Although the overall cure rate of breast cancer
has greatly improved over the past three decades with the improvement of
comprehensive treatments, a considerable proportion of patients still experience
recurrence and metastasis. Taking my country as an example, approximately 71,700
women died of breast cancer in 2016, accounting for approximately 25% of all breast
cancers [2]. Therefore, the prevention and treatment of breast cancer still has a long
way to go.
As research on tumour-like organs intensifies, we have new hope for breast
cancer treatment [3, 4]. Tumour organoids are three-dimensional cell culture models
that mimic the growth environment of a tumour in vivo, providing a model that is
closer to the reality of tumour research. Compared with traditional cell culture
models, tumour organoids can better simulate tumour heterogeneity, drug response
and metastatic behaviour [5] . Currently, tumour organoid models of lung cancer [6],
hepatocellular carcinoma [7], pancreatic cancer [8], bladder Cancer [9] gastric Cancer
[10] and endometrial cancer[11] have been successfully established, and breast
cancer organoids have also become a useful preclinical model. The main applications
of tumour organoids in breast cancer treatment include predicting drug response,
screening
anticancer
drugs,
investigating
tumour
resistance,
and
optimising
individualised treatment regimens [12]. Firstly, by using tumour-like organs, we can
predict a patient's response to a specific drug [13, 14]. This predictive ability is
essential for physicians to select the most appropriate drug for a patient [13, 14].
This predictive ability is crucial for doctors to choose the most appropriate treatment

3
regimen, which can help achieve better treatment outcomes at an early stage.
Secondly, tumour organoids have also been used to screen new anti-cancer drugs.
While traditional drug screening methods usually require a lot of time and resources,
tumour organoids are able to screen drugs in a shorter period of time, improving the
efficiency of drug development [15] . In addition, tumour organoids are also
important for the study of tumour drug resistance. By simulating the process of
tumour drug resistance, we can better understand the resistance mechanism and
thus develop more effective anti-cancer drugs. Finally, tumour organoids can also be
used to optimise individualised treatment plans. Each patient's tumour is unique,
and tumour organoids can help us understand the characteristics of each patient's
tumour and thus develop a more personalised treatment plan. Tumour organoids will
play an increasingly important role in the future treatment of breast cancer.
This study will make use of tumour-derived organoids to tailor the most
appropriate drug dosage and treatment regimen for each patient, thereby avoiding
the use of unnecessary drugs on patients and reducing the waste of healthcare
resources, which in turn will allow for a more effective treatment of breast cancer,
thus improving the survival rate and quality of life of patients.
1.2 Basis for study design
Treatment of advanced breast cancer has long been challenging. Genomic
profiling provides treatment options for some patients, but there are also many cases
where genomic profiling fails to specify effective interventions or where patients
develop tolerance to drugs associated with genomic alterations. This makes it critical
to find more effective treatments and predictive tools. PDO is an easy-to-operate tool
that serves as a three-dimensional cell culture that simulates the physiological and
pathological characteristics of a specific organ or tissue, providing a new way to solve
this problem. In breast cancer research, organoids can simulate the heterogeneity of
tumor tissue and provide a more realistic model for research. Research into breast
cancer organoids for personalized treatment is still in the developmental stages. By
cultivating a patient's breast cancer cell lines and observing their response to

4
different drugs, the most effective treatments can be found. In addition, organoids
can also be used to test new anti-tumor drugs, providing a useful tool for new drug
development. Previous studies have shown that PDO has strong biological fidelity to
its original tumor and that precision treatment based on PDO drug screening can
bring survival benefits to breast cancer patients.
Clinical practice shows that for patients with advanced multi-line treatment, not
every patient can participate in clinical research or find suitable treatment based on
genetic testing results. These patients still need to explore more feasible and
effective treatment options. Based on this, we The research team successfully
established a breast cancer organoid platform in the early stage, customized a
personalized drug library containing breast cancer anti-tumor drugs, and conducted
drug screening on most organoids. According to the results of our drug screening, it
can be seen that some drugs not only The anti-tumor effect is limited and can
promote tumor growth. Patients can follow our experimental results to choose drugs
that are more likely to be effective and avoid drugs that may promote tumor
progression, thereby improving the treatment effect and prolonging survival. This
provides personalized treatment for breast cancer. Provides new ideas and methods.
2 Purpose of the study
2.1 Purpose of the study
2.1.1 Main purpose
-Observation of the efficacy of an organoid-guided personalised treatment plan
for oncology patients in comparison with a physician's choice of plan for the
treatment of patients with recurrent refractory breast cancer.
2.1.2 Secondary objectives
-To observe the safety and tolerability of patient-derived organoid-guided
personalized treatment regimens versus physician-selected regimens in patients with
relapsed and refractory breast cancer.

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3 Experimental design
3.1 Summary of the experimental design
3.1.1 Subject population/treatment group allocation
This multicenter, open-label, randomized phase III trial is investigating
organoid-guided treatment (OGPT) versus treatment of physician's choice (TPC) in
previously treated breast cancer. effectiveness and safety. Randomization will be
stratified by molecular subtype, presence of visceral metastases, and number of prior
chemotherapy treatments for advanced or metastatic disease. Subjects in the OGPT
group will receive the treatment predicted to be most effective by PDO susceptibility
screening, and subjects in the TPC group will receive the treatment selected by the
attending physician. The main population included in the study is patients with
refractory breast cancer who have received multiple lines of treatment in the past
and have at least one measurable target lesion according to RECIST1.1 standards.
After meeting the enrollment conditions, randomization will be performed, and
patients will be randomly assigned to the experimental group or the control group in
a 1:1 ratio. Randomization will be conducted centrally by the GCP institution of this
research center. After the subjects sign the informed consent form, the researcher
will assign them an identification code based on the order of enrollment. The code
consists of 3 digits, representing the subject serial number. The researcher Fill in the
identification code into the "Subject Identification Code Table" and save it. This trial
is an open study without blinding.
Treatment: Subjects randomly assigned to OGPT need to provide sufficient
tissue for organoid culture. After successful organoid culture, drug screening will be
performed, and they will be treated with drugs predicted to be sensitive by PDO drug
susceptibility screening.
Subjects in the TPC arm will receive treatment with one of the following
regimens selected by the physician following NCCN guidelines: capecitabine,
gemcitabine, vinorelbine, and eribulin. If it is HER2-positive, anti-HER2 therapy can
be combined with it, except for ADC drugs.
3.1.2 Efficacy variables
3.1.2.1 Main efficacy parameters
Progression-free survival (PFS)

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3.1.2.2 Secondary efficacy parameters

Objective Rate of Effectiveness (ORR)

Duration of remission (DOR)

Overall survival (OS)

Duration of Continuous Remission (DCR)
3.1.3 Security variables
- Adverse events and serious adverse events
- Symptoms and signs
- Laboratory tests
-
Sudden
adverse
events
in
treatment
leading
to
dosage
adjustments,
interruptions in administration, delays, non-administration, and/or discontinuation of
study medication
3.1.4 Assessment of quality of life
Quality of life was assessed using the EQ-5D (Euro QoL five-dimensions
questionnaire) and the EORTC QLQ-C30 (European Organisation for Research and
Treatment of Cancer Quality of Life Questionnaire C30) scales were used to assess
patients' quality of life.
3.2 Duration of the experiment
The trial is intended to have 24 months of enrolment and 24 months of follow-up,
and is expected to last 48 months from the enrolment of the first subject to the
analysis of the data. Except in the event of progression, or death, subjects are
expected to complete the visit schedule specified in the protocol.
3.2 Study endpoints
3.2.1 Criteria for evaluating efficacy
Evaluation was performed according to the criteria for the evaluation of the
efficacy of solid tumours (RECIST) version 1.1, as detailed in Appendix 1.
3.2.2 Primary endpoints

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-Progression-free survival (PFS)
3.2.3 Secondary endpoints

Objective Rate of Effectiveness (ORR)

Duration of remission (DOR)

Overall survival (OS)

Duration of Continuous Remission (DCR)

Safety and tolerability (type, frequency, severity, relationship of adverse
events to study treatment, physical examination, vital signs, laboratory tests,
co-administration/treatment, and dose adjustment)

Quality of life assessment of patients
3.2.4 Exploratory molecular marker studies
Tumour samples (primary and/or metastatic), blood specimens are collected and
preserved for future exploratory studies of factors that have the potential to influence
or predict efficacy (including efficacy and safety) of the treatment, with the following
key measurements (but not limited to):
Other biomarkers, whole exome sequencing (WES), ctDNA testing, etc.
3.3 Evaluation of therapeutic efficacy
3.3.1 Timing of efficacy evaluations
Efficacy evaluations will be performed prior to administration of the study drug,
every 2 courses during chemotherapy, and at completion or withdrawal for all
patients.
3.3.2 Means of efficacy evaluation
The evaluation of the efficacy of the treatment before the administration of
drugs and after each chemotherapy, maintenance treatment, visceral lesion sites
require evaluation by CT, MRI or PET-CT, and surface lesions require evaluation by
physical examination by the physician and truthfully recorded in the original medical
record as objective evidence. Suspected invasive sites can be screened with chest

8
radiographs or ultrasound, but when a lesion is clearly present, it must be evaluated
with CT or MRI.
4 Trial population
4.1 Test centers
Sun Yat-sen University Cancer Center
Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University
Foshan First People's Hospital
4.2 Number of cases
This trial is expected to enrol 302 subjects with recurrent refractory breast cancer
patients within 24 months.
4.3 Inclusion criteria
(1) Voluntarily participate and sign the informed consent form
(2) Aged over 18 years old, regardless of gender;
(3) Locally advanced or metastatic breast cancer confirmed by histopathology;
(4) Received ≥2 previous lines of anti-tumor treatment and developed resistance to
standard treatment;
(5) Life expectancy ≥3 months;
(6) ECOG performance status 0 to 2;
(7) Have measurable or/and evaluable lesions (non-radiotherapy target areas) (lesion
evaluation is based on Recist1.1 standards);
(8) No serious organ (main organ: heart, lung, liver, kidney) functional abnormalities
(refer to respective standards);
(9) Routine blood test: white blood cells (WBC) ≥3 × 109/L; absolute neutrophil
count (ANC) ≥1.5 × 109/L; platelets (PLT) ≥100 × 109/L; hemoglobin
(Hgb) ≥8g /dL;
(10)Blood biochemical indicators: AST (SGOT), ALT (SGPT) ≤
2.5 ×
upper
limit of normal value (ULN) (in the case of no liver invasion) or ≤5 × upper

9
limit of normal value (ULN) (in the case of liver invasion) Bottom); total
bilirubin (TBIL) ≤ULN; serum creatinine clearance calculated according to the
CG formula > 30 mL/min
(11)Coagulation function: prothrombin time (PT), international normalized ratio (INR)
≤1.5 × ULN (unless warfarin is being used for anticoagulation);
(12)Able to comply with the research visit plan and other program requirements;
(13)All patients of childbearing age must agree to take effective contraceptive
measures during the study and within 6 months of stopping treatment. Female
patients of childbearing age must have a negative urine pregnancy test before
treatment.
Subjects must meet all of the following additional criteria to be included in the
OGPT group:
1) No absolute contraindications to tissue-invasive procedures required to obtain
organoid cultures。
2) Sufficient tissue can be provided for organoid culture: biopsy samples
(length
>1cm,
3
strips),
surgical
resection
samples
(total
volume
>1cm3,
weight >0.2g), thoracentesis, abdominal puncture, pericardiocentesis and other
malignant effusion samples (pleural effusion >500mL, ascites >500m) and confirmed
to contain malignant tumor cells.
4.4 Exclusion criteria:
(1) The medical history and comorbidities are as follows:
a.
The patient is participating in other interventional clinical studies or the
end of treatment in the previous clinical study is less than 4 weeks;（2）
Those who have been treated less than 4 weeks since the last anti-tumor
treatment (radiotherapy, chemotherapy, targeted therapy, immunotherapy
or local-regional treatment); the adverse reactions related to anti-tumor
treatment (except alopecia) after previous systemic anti-tumor treatment

10
have not returned to NCI- Patients with CTC AE ≤grade 1;
b.
Other active malignant tumors that require simultaneous treatment;
c.
Known history of organ transplantation and allogeneic hematopoietic
stem cell transplantation;
d.
For subjects who have undergone major surgery or severe trauma, the
effects of the surgery or trauma have been eliminated for less than 14
days before enrollment;
e.
Patients with active pulmonary tuberculosis need to be excluded.
Patients suspected of having active pulmonary tuberculosis should have
chest X-rays, sputum, and clinical symptoms and signs to rule out the
disease. Patients with a history of active pulmonary tuberculosis
infection within the previous year must be excluded, even if they have
been treated; patients with a history of active pulmonary tuberculosis
infection more than 1 year ago must also be excluded, unless it is proven
that the course and type of anti-tuberculosis treatment previously used
are satisfactory. appropriate;
f.
Severe acute or chronic infection requiring systemic treatment
g.
Suffering from heart failure (New York Heart Association Class III or IV)
and despite receiving appropriate medical treatment, poorly controlled
coronary artery disease or arrhythmia, or a history of myocardial
infarction within 6 months before screening patient.
(2) Pregnant or lactating women.
(3) No anti-tumor treatment is planned.
(4)
Known to have a positive history of human immunodeficiency virus (HIV) test
or known to have acquired immunodeficiency syndrome (AIDS);
(5) Untreated active hepatitis (hepatitis B: HBsAg positive and HBV DNA ≥
500IU/mL; hepatitis C: HCV RNA positive and abnormal liver function);
combined with hepatitis B and hepatitis C co-infection;
(6) Hypersensitivity to any study drug;
​

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4.5 Culling Criteria:
1) Those who are found to be incompatible with the case selection criteria after
selecting subjects;
2) Those who have taken the drug less than 2 times continuously after being
selected, and the objective efficacy cannot be evaluated (but adverse reactions can be
evaluated);
3) Patients who violate the requirements of the trial protocol.
4.6 Exit criteria
Patients can withdraw from a clinical trial at any time and for any reason. If the
researcher believes that it is not appropriate to continue taking the medication, the
researcher may also ask the patient to withdraw based on the interests of the patient.
If one of the following conditions occurs to a subject during the trial, the
investigator should arrange for the subject to interrupt treatment and withdraw from
the trial:
1) The subjects have poor compliance and cannot take the medicine on time and
in the right amount;
2) The use of other anti-tumor treatments affects the judgment of results;
3) Adverse reactions occur and the researcher determines that it is not
appropriate to continue this clinical study;
4) The subject withdraws voluntarily if he or she is unwilling to continue this
clinical study.
Before withdrawing from the trial, the latest follow-up and assessment of various
efficacy and adverse reaction indicators must be completed, and the reasons and dates
of withdrawal of the withdrawing patients must be recorded in detail.
5 Research flow chart
Item
Pre-enrolment
baseline
assessment
(within 2 weeks
prior to
Organ-Guided Therapy
(OGPT) or Therapy of
Physician's Choice (TPC) per
procedure
Examination at
the end of 2, 4
and 6 courses of
combined
treatment

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enrolment)
Imaging (CT/MRI/PET-CT
chest, abdomen, pelvis)
X
X
Pathological
examination/consultation
X
Entry Audit
X
Signed informed consent
X
Population statistics
X
Detailed history and
complete physical
examination
X
X
X
Clinical biochemistry, urine
and faecal laboratory tests
X
X
X
routine blood test
X
X
X
blood tumour marker
X
X
X
Urine pregnancy test
X
electrocardiography
X
X
X
tumour specimen
X
blood specimen
X
X
ECOG score
X
X
X
undesirable incident
X
X
Accompanying treatment
records
X
X
Quality of life assessment,
PRO assessment
X
X
Confirmation of tumour
progression and survival
status
X
X
6 Research steps
6.1 Screening
The investigator gave informed consent to subjects who were eligible for
enrolment and the next study step could only be performed if the subject signed the

13
latest version of the informed consent form. The investigator, in conjunction with the
inclusion/exclusion
criteria
of
the
protocol,
assessed
the
subjects'
tumour
characteristics based on the imaging data (tumour histopathology, CT/MRI chest,
abdomen and pelvis plain + enhancement, endoscopy, ultrasound as a complementary
means to CT, PET/CT scanning not routinely performed at the centre), which included
tumour site, number, size, extent of invasion of the large blood vessels, The
assessment includes tumour location, number, size, extent of macrovascular invasion,
cancer embolism, extent of surrounding tissue invasion, etc., and should be recorded
in the medical record, and the imaging data should be collected and stored as a source
file. If the imaging examination cannot be obtained or is not accepted by the
investigator within two weeks before enrolment, the subject will be recommended to
undergo another CT in our hospital, and the investigator will re-evaluate the
judgement based on this examination and record it.
6.2 Baseline
Before enrollment, the following aspects need to be reviewed to ensure
compliance with inclusion/exclusion criteria and to obtain baseline data:
• Chest + Abdomen + Pelvic CT (plain + enhanced)
• Blood tumor markers
• Tumor histopathology or cytology
• If the subject develops relevant abnormal clinical symptoms or signs, and the
researcher suspects that they are caused by distant metastasis of the tumor, relevant
imaging examinations and/or laboratory examinations may be performed:
○Suspect brain and nervous system metastasis, perform MRI examination
○If bone invasion is suspected, perform ECT examination
•
Blood
routine,
urine
routine,
stool
routine
+
occult
blood
test,
electrocardiogram
•
Liver function (aspartate aminotransferase, alanine aminotransferase,
γ
-glutamyl transpeptidase, total bilirubin, albumin, prealbumin), renal function

14
(creatinine), electrolytes, blood glucose, blood amylase
• Coagulation function (prothrombin time)
• Urine pregnancy test (female subjects of childbearing age)
• Vital signs, height, weight, physical examination
• ECOG score
• Collect the subject’s past diabetes, treatment history, and allergy history and
record them in the medical record
Based on the imaging report, combined with other laboratory tests and symptoms
and signs, the researcher determines whether the subject has disease progression and
records it in the medical record.
6.3 Enrolment
The researcher will determine whether the subject meets the enrollment
conditions based on the inclusion/exclusion criteria and comprehensive baseline
examination results, imaging and pathology results. If so, the researcher will obtain
the results based on the patient's informed consent and number the subject (trial code ).
For successfully enrolled subjects, researchers need to obtain a copy of their ID card
for archiving.
6.4 Treatment
6.4.1 Treatment implementation
Subjects randomly assigned to OGPT will undergo PDO drug susceptibility
screening to predict effective treatment. Patients need to provide sufficient tissue for
organoid culture. After successful organoid culture, drug screening will be performed.
Subsequently, sensitive drugs will be screened based on the drug. Get treatment.
Subjects in the TPC arm will receive treatment with one of the following
regimens
selected
by
the
attending
physician
following
NCCN
guidelines:
capecitabine,
gemcitabine,
vinorelbine,
and
eribulin.
If
it
is
HER2-positive,
anti-HER2 therapy can be combined with it, except for ADC drugs.

15
According to the current standard treatment, patients should receive antiemetic
drugs when receiving chemotherapy. It is recommended to use a standard antiemetic
regimen.
Optional
antiemetic
drugs
include
5-HT3
receptor
antagonists,
dexamethasone or combined NK-1 receptor antagonists. agent (fosaprepitant,
aprepitant, etc.), determined by the investigator.
In exceptional circumstances (e.g., dosing is withheld due to the need to manage
AEs or infusion-related reactions), subsequent administration of study drug may be
delayed to the second day of each cycle.
Test drugs and preparations
1. Specific medications for patients in the test group are based on PDO drug
sensitivity results. The current customised personalised drug screen library of the
subject group is as follows, and the corresponding drugs may be subsequently
adjusted according to the availability of marketed drugs:
Epirubicin
hydrochloride
Sunitinib
Malate
Erlotinib
Pemetrexe
d
Gemcitabi
ne
Lenvati
nib
5-Fluorou
racil
Doxorubic
in
hydrochlo
ride
Docetaxel
Ifosfamide
Temozolomid
e
Gefitinib
Olaparib
Cyclophos
phamide
hydrate
Capecitabi
ne
Dasatini
b
Axitinib
Nilotinib
Crizotinib
Imatinib
Mesylate
Vinblastine
sulfate
Abemacicli
b
Ixazomib
Cabazitaxe
l
Pazopanib
Neratini
b
Enzaluta
mide
Irinotecan
Bleomycin
Sulfate
Paclitaxel
Etoposide
Lapatinib
Sorafenib
tosylate
Methotrex
ate
Everolimu
s
Palbocic
lib
Decitabin
e
Cabozanti
nib
Tegafur
Alpelisib
Alectinib
Ribociclib
Vinorelbin
e
ditartrate
Idasanutli
n
Erdafitinib
Ipatase
rtib
Glumetini
b
Topotecan
Larotrecti
nib
Regorafenib
Hydrochlorid
e
Pralsetinib
Afatinib
Bendamu
stine
Savolitinib
Sotorasib

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According to the results of drug sensitivity, all the drugs applied in the test group
will be used according to the instructions or guidelines, the specific dosage and time
intervals refer to the instructions of the corresponding drugs, some patients may be
involved in the use of super-indications, this part of the application of the drug will be
communicated to the patient, under the condition that the patient is fully informed,
clear risks and benefits of the application of the drug, and the specific dosage will
refer to the corresponding instructions.
2.Table 1 Dose selection and time of administration for each patient in the control
group
Research drug
Dosages
Frequency of administration
Route
of
administration
Gemcitabine
1000mg/m2
Day 1, Day 8 of each 21-day
cycle
intravenous
Capecitabine
1000mg/m2
Days 1-14 of each 21-day cycle
Oral
Vinorelbine
25 mg/m2 (IV);
60mg/m
²
(oral)
Day 1, Day 8 of each 21-day
cycle
Oral/intravenous
Eribulin
1.4 mg/m2
Day 1, Day 8 of each 21-day
cycle
intravenous
Labelling and packaging
Drugs in the OGPT and TPC groups were selected as marketed drugs, with labels and
packaging identical to the commodity specifications, and labels bearing the following
markings: [drug name], [drug number], [serial number], [product lot number], and
[expiry date].
storage conditions

17
The investigator has the responsibility for the clinical trial drug count. Trial
drugs are to be stored according to relevant standards and meet temperature control
requirements.
Cycle Time Setting
Chemotherapy in this trial is administered at intervals recommended by the
drug's specification or the drug's clinical trial until disease progression or intolerable
toxicity is discontinued. Pre- and post-dose investigations are required to assess safety
events before and after each course of treatment, and imaging studies are repeated
every 2 courses of treatment during the course of treatment.
6.4.3 Pre-treatment manoeuvres
The following actions need to be completed within one week prior to dosing:
- CT chest, abdomen, pelvis (plain + enhanced)
- blood tumour marker
- Routine blood, urine, faecal + occult blood test, electrocardiograms
-
Liver
function
(alanine
aminotransferase,
alanine
aminotransferase,
gamma-glutamyl transpeptidase, total bilirubin, albumin, prealbumin), renal function
(creatinine), electrolytes, blood glucose, blood amylase
- Coagulation (prothrombin time)
- Urine pregnancy test (female subjects of childbearing age)
- Vital signs, height, weight, physical examination
- ECOG score
- History of previous diabetes mellitus, treatment and allergy history of the
subject is taken and recorded in the medical record
6.4.4 Therapeutic administration
Subjects
were
administered
drugs
according
to
established
cycles. The
investigator decides whether or not to administer the chemotherapeutic agent and the

18
dose adjustment to be administered based on the subject's prior treatment and
pre-dose laboratory test results. When a subject develops intolerable chemotherapy
toxicity, the investigator may reduce or discontinue the chemotherapy (refer to Dose
Adjustment Regulations), provided that the investigator documents the reason for the
reduction or discontinuation in the medical record.
Common toxicities of chemotherapeutic agents include nausea, vomiting,
abdominal pain, diarrhoea, haematopenia (WBC, RBC, PLT, ANC, etc.), and
abnormalities in liver and kidney function. If leakage occurs during the administration
of chemotherapeutic agents, it may result in skin damage or even necrosis. Any
adverse events occurring during the study, whether or not related to the study drug,
should be treated with appropriate monitoring and recorded truthfully in the medical
record.
6.4.5 Post-treatment examinations
Relevant laboratory tests need to be completed at the end of the study drug (may
overlap with the next pre-treatment test):
- Routine blood, routine urine, routine faeces + occult blood test, ECG
-
Liver
function
(alanine
aminotransferase,
alanine
aminotransferase,
gamma-glutamyl transpeptidase, total bilirubin, albumin, prealbumin), renal function
(creatinine), electrolytes, blood glucose, blood amylase
- Coagulation (prothrombin time)
- blood tumour marker
6.5 Follow-up visits
When subjects are treated with study drug (end of regimen or early
discontinuation for any reason, except death), CT is repeated every 2 courses (6
weeks) during the dosing period; CT is repeated every 3 months after discontinuation
of the drug until disease recurrence, progression, or metastasis occurs, after which
time it is changed to a telephone visit for survival follow-up of the patient, which will

19
be performed every 3 months until the patient's death or until the trial is analysed for a
second study (whichever occurs sooner). whichever occurs earlier). Tumour
progression and death events were to be recorded, as well as concomitant relevant
treatments. All anticancer treatments received by the subject prior to death are
recorded in the follow-up record.
6.6 Completion of the test
The
trial
was
considered
completed
when
the
subject
experienced
a
progression/death event before the second study analysis condition was met. The trial
was also considered completed if no recurrence/metastasis/death occurred by the time
the second analysis condition was met. The time frame for completion of the trial was
defined as follows:
- If progression has occurred but the investigational drug was not immediately
stopped, the last administration of the investigational drug is the date of completion of
the trial.
- If the test was terminated because the second analysis was reached, the date of
completion of the test is entered as the date of the end of the test, i.e. when the second
analysis was reached.
- In case of death, the date of completion of the trial is the time of death of the
subject
6.7 Suspension test visits
The following assessments should be completed at the same time as withdrawal,
if possible, once there has been an event that terminates the trial. If the subject is
terminating the trial because of an adverse event, the subject needs to be followed to
the greatest extent possible until the investigator determines that the adverse event has
recovered, stabilized, or is unchangeable.
The following procedures need to be performed during the termination trial visit:
- Investigators must inform subjects of the need to withdraw from the trial and

20
the reasons for withdrawal
- Detailed record of the reason for the subject's early withdrawal from the trial,
date of withdrawal from the trial, in the Scientific Medical Record and Case Report
Form (CRF).
- A security assessment is required, including:
○Physical examination
○Weight and vital signs
○Blood test, urine test, faecal test + occult blood test, ECG
○Blood tumour markers
○Liver and kidney function, prothrombin time
○ECOG score
○Accompanying medication and adverse event reports
- Regular follow-up of subjects by the investigator or authorised person
How to record the time of termination of the test:
- If pregnancy occurs, the date of the urine pregnancy test with a positive result is
used to terminate the test.
- If the trial is terminated due to a combination of treatments that is contrary to
the protocol, the date of commencement of the combination of treatments will be used
to terminate the trial.
- In the event of an adverse event that results in or prevents compliance, the date
of the last imaging/lab evaluation in the study for that subject will be used as the time
of termination of the trial
- If a subject is lost to follow-up, the trial is terminated on the date of the last
follow-up visit with clear survival information.
- If the subject or his/her legal representative requests or is specifically requested
by the investigator to withdraw from the study, the termination of the trial shall occur
on the date of such request by the subject or his/her legal representative or the
investigator.

21
6.8 Programme departures
The investigator should conduct the study in accordance with the protocol and
the appropriate laws and regulations. Written approval from the Principal Investigator
is required before performing protocol deviations.
The investigator or authorized personnel should document and explain this
protocol deviation. If a subject is ineligible for enrolment or has received the wrong
dose of trial treatment and has used the study drug at least once, it is necessary to
collect the relevant data and notify the ethics committee of the deviation in
accordance with the relevant procedures for safety reasons.
6.9 Laboratory tests
Specimens of blood, urine, and faeces are collected several times during the test,
before each cycle of dosing. The following specific parameters need to be measured:
- WBC/ANC/RBC/PLT/Hb
-
Glutamate
aminotransferase/glutamate
aminotransferase/gamma-glutamyl
transpeptidase/total bilirubin/albumin/prealbumin/electrolytes/creatinine
- prothrombin time
- blood tumour marker
- blood tumour marker
- Urine routine/facal routine + occult blood test
- Blood glucose/blood amylase
- Urine pregnancy test
All laboratory tests were performed in our laboratory department and followed
the relevant hospital protocols and the use of the hospital's reference values for
screening tests as a reference for screening indicators. The investigator must review
the results and sign for confirmation. For clinically significant laboratory results, they
must be reported as medical history or adverse events.
6.10 Imaging

22
Review imaging is required before every 2 cycles of treatment and every 3
months after the end of medication. Included:
- CT Chest + Abdomen + Pelvis (Plain + Enhanced)
7 Treatment and restraint
7.1 Treatment
7.1.1 Rules and duration of treatment
Subjects must be dosed according to the protocol before progression occurs until
completion of the dosing regimen, and at the end of the regimen receive follow-up as
required until the end of the second study analysis.
After progression has occurred in a subject, it is up to the investigator to decide
whether or not to continue the trial dosing treatment based on the subject's condition,
and if the trial dosing is continued. It may be discontinued at any time prior to the end
of the trial as determined by the investigator. At the end of the course of treatment, the
subject is not required to continue the study drug as prescribed.
7.1.2 Dose adjustment
Dose withholding was defined as a therapeutic regimen interruption (i.e., drug
administration delayed beyond the visit window). A dose hold is defined as an
infusion interruption. Every effort should be made to administer the study drug
according to the planned dose and schedule. In the event of serious toxicity, dose
administration may be delayed and/or reduced according to the guidelines below.
Reasons for dose adjustments or delays, supportive measures taken, and outcomes
will be documented in the patient's medical record.
The dose adjustment guidelines in this section are not a substitute for clinical
judgement. Dosage may be withheld or adjusted at the discretion of the investigator
for other reasons (e.g., adverse events, weight loss, laboratory findings). Interruption
of dosing is permitted if it is due to a medical/surgical event or for logistical reasons
unrelated to study treatment (e.g., unrelated medical event, patient leave, and/or

23
holiday). However, it is recommended that patients should continue study treatment
within 3 weeks of the planned interruption.
For AEs that have been present at baseline, dose adjustments will be based on the
change in toxicity grade, as determined by the investigator. For example, if a patient
has experienced Grade 1 frailty at baseline and elevates to Grade 2 during treatment,
this would be considered a relative Grade 1 change and the dose adjustment would be
aimed at a reduction to Grade 1 toxicity.
When several
toxicities of varying
severity
occur simultaneously, dose
adjustments should be based on the highest level observed.
If the investigator believes that the toxicity is due to only one portion of the
study treatment and the dose for that portion has been withheld or adjusted according
to the following guidelines, the other portion may continue to be administered if there
are no contraindications.
In the event of a chemotherapy-related toxicity, chemotherapy will be withheld
until the toxicity reaches baseline levels or ≤grade 1 (whichever is more severe) prior
to the next chemotherapy administration, with the exception of alopecia, grade 2
fatigue, or other adverse events that, in the opinion of the investigator, will not affect
the assessment of the safety of the study drug. If AE does not subside within 10 days,
no further chemotherapy will be administered for this cycle. If the AE subsides within
21 days, chemotherapy will be administered on the first day of the next treatment
cycle as originally scheduled.
If severe neutropenia (ANC <0.5x 109/L for 1 week or more) occurs during
treatment, the dose of the subsequent course of therapy should be reduced by 20%. If
severe neutropenia occurs again as described above, the subsequent treatment dose
should be adjusted downward by 20-25%. The chemotherapy regimen should be
permanently discontinued if the chemotherapeutic agent has been withheld for more
than 2 cycles (6 weeks) from the expected date of treatment, or if a 2-dose reduction
is not tolerated (as shown in Table 3).
Table 1 Chemotherapy dose adjustments for cytotoxicity of chemotherapeutic agents in the

24
TPC group
Undesirable incident
Treatment
Neutropenia
Level 3
(0.5-0.99 x 109 /L)
Chemotherapy withheld until recovery to ≤grade 1 (≥1.5 x
109 /L); restarted at full dose
Level 4
(<0.5 x 109 /L)
(lasting 1 week or more)
1. Chemotherapy withheld until recovery to ≤grade 1; all
subsequent doses reduced by 1 dose level
2. If a second dose reduction occurs after a dose reduction,
all subsequent doses are reduced by an additional dose
level.
3. If a third occurrence occurs, discontinue chemotherapy.
Thrombocytopenia
Level 2
1. Chemotherapy withheld until return to normal; restarted
at full dose
≥3
1. Chemotherapy withheld until recovery to ≤grade 1; all
subsequent doses reduced by 1 dose level
2. If a second dose reduction occurs after a dose reduction,
all subsequent doses are reduced by an additional dose
level.
3. If a third occurrence occurs, discontinue chemotherapy.
Renal insufficiency
≥3
1. Chemotherapy withheld until recovery to ≤grade 2; all
subsequent doses reduced by 1 dose level
2. If a second dose reduction occurs after a dose reduction,
all subsequent doses are reduced by an additional dose

25
level.
3. If a third occurrence occurs, discontinue chemotherapy.
NOTE: The investigator may decide to use supportive measures/treatment and/or
secondary prevention rather than dose reduction in the next cycle if it is in the best
interest of the patient and consistent with clinical practice. Dose adjustment
recommendations are provided for informational purposes only.
8.1.3 Treatment allocation and blinding
8.1.3.1 Identification codes
After subjects sign the informed consent form, the investigator will assign them
an identification code based on the order of enrolment, which consists of a 3-digit
number representing the subject's serial number, and the investigator will fill in the
identification code in the Subject Identification Code Form and save it. This trial is an
open study and is not blinded.
8.1.3.2 Enrolment randomization
Patients will be randomized in a 1:1 ratio to either the trial or control group.
Randomization will be centrally randomized by the GCP facility at the centre of this
study, using a validated random number generation system to generate the
randomization list, with the clinical trial support team supervising the retention of the
randomization code. All personnel directly involved in the execution and analysis of
the trial will not have access to the randomization table until the database is locked.
8.1.4 Compliance control
This trial requires that subjects are able to return to the hospital as scheduled to
complete all dosing cycles and related examinations in accordance with the protocol.

26
The number of cycles of medication, the actual amount and duration of the test drug
received per cycle, and the reason for deviation from the treatment plan should be
recorded in the original medical record and CRF to determine the compliance of the
subjects. The investigator needs to maintain close contact and communication with
the subject, try to explain any questions the subject may have about any of the
medical procedures and medical events during the study, and also inform that low
compliance may result in being asked to withdraw from the trial in order to improve
the subject's adherence.
8.2 Test constraints
8.2.1 Permitted concomitant medications and treatments
- May receive conventional standard supportive care
- Can be treated for any underlying disease (including diabetes)
8.2.2 Prohibited concomitant medicines and treatments
- Use of other clinical study drugs is not permitted during the study
- Chemotherapeutic agents other than those specified in this protocol are not
permitted during the study period
- No other systemic anti-tumour therapy, including chemotherapy, radiotherapy,
radiofrequency ablation, molecular targeted therapy, is permitted prior to progression
8.2.3 Necessary Concomitant Medications and Treatments
- In the event of infection, the appropriate sensitive antibiotics must be
administered.
- For information on other drugs that may interact with the test drug and affect its
metabolism, pharmacokinetics, or excretion, refer to the relevant drug handbook.
- Any co-administration of medication or treatment during the study should be
accurately documented in the medical record and the CRF
8.2.4 Subject restraint
- Must return to the hospital on time to complete all programme-required
examinations and laboratory tests

27
- Cannot leave the hospital during inpatient treatment
- The need to report any discomfort to the researcher in a timely manner
- Women of childbearing age are required to use appropriate contraception
throughout the treatment phase of the trial and for 6 months after the trial has ended
9 Therapeutic assessment
9.1 Assessment of the screening period
The enrolment assessment must be completed no later than 14 days prior to study
drug administration. After obtaining informed consent, the investigator will perform
the appropriate clinical assessments on the subject (see 6.1 and 6.2).
9.2 Assessment of the treatment period
The appropriate clinical assessment of the subject (see 6.4.4 and 6.4.6) is
required prior to the start of each treatment cycle and within 3 days of its completion
in order to make a correct assessment of efficacy (see below).
9.3 Assessment of efficacy
9.3.1 Efficacy variables
- See 3.4.3
9.3.2 Description of procedures
- See 3.2.2
9.4 End of study treatment (EOT) assessment
An EOT evaluation should be performed on all patients ending study treatment,
and the following procedures will be completed:
- Physical examination, weight, vital signs, ECOG score
- Combined medication and combined treatment assessment
- Serum EBV DNA copy number
- Blood count, liver and kidney function, blood glucose
- Imaging is determined by follow-up time
- Peripheral neuropathy assessment

28
- Adverse event assessment (see 10.3)
9.5 Follow-up of disease recurrence and metastasis
See 6.5, 6.6, 6.7
9.6 Follow-up of overall survival
See 6.5, 6.6, 6.7
10 Security variables
10.1 Description of variables and protocols
- Symptoms and signs
- Laboratory tests
- Adverse Events (AE) and Serious Adverse Events (SAE)
Any abnormal symptoms, signs (including clinically significant laboratory
findings), or medical diagnoses recorded by medical personnel from the time of
subject enrolment until treatment with the trial drug must be documented in the
medical record and CRF.
After enrolment, the investigator is required to perform appropriate laboratory
tests according to the protocol and record the results in the medical record and CRF,
and clinically significant abnormal results should be recorded as adverse events.
10.2 Symptoms and signs
10.2.1 Medical history and concomitant medication
A complete medical history of the subject needs to be recorded. All concomitant
medications between Day 1 of Cycle 1 and 30 days after the last use of the test drug
need to be documented, including changes in dosage, changes in reasons for use, etc.
10.2.2 Physical examination and weight
A complete physical examination should include an assessment of the following

29
components, but is not limited to an assessment of the vital organs of the body:
- Head, ears, eyes, nose, throat
- Lungs and respiratory system
- Cardiovascular system
- Gastrointestinal system
- central nervous system, CNS
- skins
- lymphatic system
- Muscular and skeletal system
- Endocrine and metabolic system
All inconsistencies with the baseline examination need to be documented in the
medical record and CRF.
10.2.3 Electrocardiogram
Electrocardiograms were required before and after each treatment cycle,
including a baseline electrocardiogram assessment that was also required prior to the
first treatment cycle. Any clinically significant change from baseline was to be
reported as an adverse event and recorded in the subject's medical record and CRF.
10.2.4 Imaging
Imaging assessments, including CT scans, are to be performed as required by the
protocol, including a baseline CT examination prior to the first treatment cycle. Any
clinically significant change from baseline needs to be reported as an adverse event
and documented in the subject's medical record and CRF. If additional imaging
evaluations are performed as part of the subject's routine work-up, they will also need
to be evaluated and determined to be adverse events.
10.3 Adverse events
10.3.1
Definitions

30
Any undesired medical event related or unrelated to treatment that occurs after
the use of a drug by a subject in a clinical trial is an adverse event. It can be any
unfavourable and undesired abnormal result of signs, symptoms, laboratory tests, etc.,
irrespective of whether it is related to the drug or not. All adverse events should be
recorded on the CRF form. The intensity of the adverse event is graded according to
the grading method recommended by the NCI Common Toxicity Criteria Grading
System.
Clinical supervisors must systematically collect and verify information on
adverse events during visits to the study centre when examining the patient's clinical
history (raw data reconciliation). Adverse events that are not resolved at the time of
assessment need to be followed up until they are resolved. For adverse events that
cannot be resolved within the clinically possible observation period (e.g., blindness,
neurotoxicity, loss of limbs, etc.), the investigator will classify them as permanently
unresolved, and the time of resolution of the event will be left blank in the CRF table.
10.3.2
Adverse event correlation
The investigator should make an assessment of the possible association between
the adverse event and the study drug and the combined drug, rated with reference to
the following 5-level classification criteria:
(1)
Definitely relevant: the reaction appears in a reasonable chronological order
after administration of the drug, the reaction is consistent with the type of reaction
known to occur with the suspected drug; it improves after discontinuation of the drug,
and the reaction occurs again with repeated administration of the drug.
(2)
Possibly relevant: the reaction appears in a reasonable chronological sequence
after administration of the drug and the reaction is consistent with the type of reaction
known to occur with the suspected drug; the patient's clinical status or other
therapeutic modalities are also likely to produce the reaction.
(3)
Possibly unrelated: the reaction appears less consistent with a reasonable
chronology of events following administration of the drug, the reaction is less

31
consistent with the type of reaction known to occur with the suspected drug; the
patient's clinical status or other therapeutic modalities are likely to produce the
reaction.
(4) Unrelated: the reaction does not appear in a reasonable chronological order after
administration of the drug, the reaction has a type of reaction consistent with that
known for non-test drugs; the patient's clinical status or other treatment modalities
may have produced the reaction, the reaction is eliminated by improvement of the
disease state or cessation of the other treatment modalities, and the reaction occurs by
repetition of the other treatment modalities.
(5)
Unable to assess: the reaction appears in no clear relation to the chronological
sequence after administration of the drug, is similar to the type of reaction known to
occur with the drug, and other drugs used at the same time may cause the same
reaction.
Items (1), (2) and (5) above were recorded as adverse reactions to the study drug.
Incidence of adverse reactions = number of cases of adverse reactions/total number of
cases × 100%.
10.3.3
Serious adverse events
A serious adverse event was defined as an undesired adverse event occurring at
any dose of the drug and meeting any of the following criteria: 1) resulting in death; 2)
life-threatening as a result of the test drug; 3) resulting in hospitalisation or prolonged
hospitalisation; 4) permanent or significant loss of function/disability; and 5)
teratogenicity or carcinogenicity.
Some events that require hospitalisation or prolonged hospitalisation may not be
reported as serious adverse events, including 1) hospitalisation for non-adverse events
for social reasons; 2) hospitalisation for elective surgery, investigations or other
treatments that were booked prior to entry into the study; and 3) tumour progression
and related events.

32
10.3.4 Reporting forms
Reporting of serious adverse events requires the use of the SAE report form.
10.3.5 Serious Adverse Event Reporting-Investigator Procedures
Reporting of serious adverse events requires the use of the SAE report form. In
the event of a serious adverse event (drug-related or not), the investigator should send
the completed initial report to the Ethics Committee of Guangzhou Sun Yat-sen
University Cancer Prevention and Control Centre, the head unit (Guangzhou Sun
Yat-sen University Cancer Prevention and Control Centre, Tel: 020-87343363), the
head unit (Guangzhou Sun Yat-sen University Cancer Prevention and Control Centre,
Tel: 020-87343363), and as soon as possible, send the final report (including the
serious Adverse event regression, etc., if the serious adverse event is death, it is not
necessary to send out the final report retroactively) completed and reported again to
the above departments.
10.4 Pregnancy events in clinical trials
Any subject participating in the trial should notify the organisers if a pregnancy
event occurs. Although pregnancy is not strictly an AE, all pregnancies need to be
followed up to completion for outcome determination. This information is highly
relevant to drug safety and public health. It is the responsibility of the investigator to
report all pregnancies in the trial using the Pregnancy Event Report Form.
If a pregnancy event occurs in the subject or spouse within 30 days of
administration or discontinuation of the test drug, the investigator is required to
contact a higher authority to discuss the management of the subject. Reporting of a
pregnancy event will include the expected date of delivery and a Pregnancy Event
Report Form will be submitted within 24 hours of the pregnancy event in accordance
with the procedures for reporting to the SAE. If termination of pregnancy is required,
an estimated time of termination is required.
If a pregnancy event occurs with the subject's spouse, rather than the subject

33
herself, the completion of the Pregnancy Event Report Form needs to include the
subject's screening number, initials, and date of birth. Details about the spouse need to
be recorded in the narrative section of the Pregnancy Event Report Form. The
subject/spouse should be followed until the end of the trial. If the pregnancy is
terminated before the expected date of delivery, the investigator needs to record this
as such. At the end of the pregnancy, the investigator will need to record the
adjudicated pregnancy outcome.
11 Rules for withdrawal and cessation of research
11.1 Patient Withdrawal
A patient may withdraw from a clinical trial at any time and for any reason and
without prejudice to the investigator's right to treat his/her disease. The investigator
has the right, in the interest of the subject, to ask the subject to withdraw for any
reason, including concomitant disease, adverse events, or treatment failure. The
Clinical Research Core Group reserves the right to ask a subject to withdraw for
protocol violations, administrative reasons, or other valid and ethical reasons.
Although subject withdrawal should be avoided whenever possible, it is
important to know that subject withdrawal does occur in clinical research. Regardless
of when a subject withdraws from a study and for any reason, a final study evaluation
of the subject must be completed and the reason for withdrawal must be noted. All
documentation regarding the subject must be as complete as possible. As long as the
patient has not withdrawn his/her consent, these withdrawn patients should be
followed up and their disease status recorded as if they had not withdrawn.
The researcher must follow up with those who drop out due to poor adherence to
obtain reasons for not attending follow-up appointments. When a patient withdraws,
the study will do its best to complete and report the observations as fully as possible.
As long as the patient has not withdrawn his consent, these patients will continue to
be followed up, if possible, and the disease will be recorded as if they had not
withdrawn.

34
Withdrawals due to concomitant illness or adverse events must be recorded in
detail on the observation form with all other appropriate and valuable information.
11.2 Early termination of studies
Reasons for early termination may include external events, recurrence of serious
adverse events, elevated treatment-related mortality, or insufficient enrolment in the
clinical trial. All investigators will be notified in writing when a clinical study is
terminated early. Any Investigator who wishes to discontinue participation in this
clinical study must immediately inform the Principal Investigator of his/her decision.
11.2.1
Follow-up of the study
11.2.2
Follow-up time
Subjects were followed up at the end of treatment or withdrawn from the study
for other reasons at three-monthly intervals, which was changed to six-monthly after
two years, until the end of the entire study.
11.2.3
Content of the follow-up visit
Subject follow-up included collection of subject's chief complaint, physical
examination, blood and urine routine, biochemical routine and tumour evaluation.
Record the above follow-up in the original medical record. Tumour evaluation should
be completed in the CRF form.
12 Statistical analyses
12.1 Statistical analyses of populations
- Full analysis population (FAS): includes all subjects who entered randomisation
and received the study drug (test or control drug) at least once.The FAS is the primary
dataset for the evaluation of the primary efficacy and secondary efficacy indicators.
- Protocol-eligible population (PPS): includes all subjects in the analysis set who
did not experience a major protocol deviation, completed the study in accordance with

35
the protocol or remained under observation until the second analysis endpoint of the
trial, did not receive any other comorbid treatments during the period that could
potentially affect the efficacy of the study medication, and remained in good
adherence. Delineation criteria were determined by the study and statistical parties
prior to data analysis.
- Safety analysed population (SS): includes all subjects who have received the
study drug once and have a post-dose safety record.
12.2 Statistical methods
Once the trial protocol was finalised, a statistical analysis plan was developed by
a professional statistician in consultation with the principal investigator. SPSS 26.0
statistical software was used. All statistical tests were performed using one-sided or
two-sided tests as needed, and a P value of less than 0.05 would be considered
statistically significant for testing differences. Quantitative indicators will be
described by calculating the mean, standard deviation, median, minimum, maximum,
lower quartile, upper quartile, and categorical indicators will be described by the
number of cases and percentage of each category. Comparison of the general
conditions of the two groups will be analysed according to the types of indicators,
with paired samples t-test or Wilcoxon rank-sum test for between-group comparisons
of quantitative data, chi-square test or Fisher's exact probability method for
categorical data, and Wilcoxon rank-sum test or CMH test for hierarchical
data.Survival such as PFS will be analysed with log rank test and COX regression.
Analyses were performed.
12.2.1 Enrolment and Completion
In principle, all patients who met the inclusion/exclusion criteria were enrolled,
and the number of enrollments and completions were summarized with a list of
shedding cases. Detailed list of different data set sizes, case distribution, comparison
of total shedding rates, and reasons for termination for each group. Patients'

36
demographic characteristics (age, height, vital signs, etc.), medical history, and
medication history were described, and age, height, and weight were compared
between the two groups to measure the comparability of data.
12.2.2 Compliance analysis
- Medication adherence analysis: Follow-up of patients to see if they are using
the trial medication on time and in the correct dosage, and are not using medications
and foods prohibited in the programme
- Co-medication analysis: the number of co-medications needs to be counted and
tabulated in detail to statistically analyse the potential impact of co-medication on the
efficacy of the trial medication.
12.2.3 Analysis of baseline data
According to the baseline indicators listed in 6.2, n-values, means, standard
deviations, medians, minimums, and maximums will be described for continuous data,
and frequencies and percentages for each group will be described for categorical data.
12.2.4 Analysis of efficacy
Analysed for FAS and PPS
12.2.4.1 Main efficacy analyses
Progression-free survival (PFS), PFS being the time from the start of
randomization to disease progression or death of the patient due to all causes, will be
analyzed using Kaplan-Meier curves depicting changes in the trial groups.
12.2.4.2 Secondary efficacy analysis
Duration of remission (DOR),Overall survival (OS) will be analyzed using a
Kaplan-Meier curve depicting the change in the trial group at the time of analysis, and
subjects who withdrew early from the trial prior to the study analysis will have a
cut-off time of the time of the last tumour imaging assessment or the time of the last
follow up visit, whichever is later. Objective Rate (ORR), the sum of partial and
complete remission rates. Disease Control Rate (DCR), defined as the sum of the CR
rate, the PR rate and the Stable Disease (SD) rate.SD is defined as neither sufficient

37
contraction to qualify as PR (referenced to the sum of diameters at baseline) nor
sufficient increase to qualify as PD (referenced to the sum of minimum diameters
during the study period).
12.2.5 Security analysis
This included monitoring and recording all AEs and SAEs (including number of
events versus subject incidence), routine blood and biochemical parameters, body
weight, vital signs, physical examination, and all therapies and concomitant
medications. Safety indicators include: body weight, vital signs, clinical laboratory
parameters, and AE. For laboratory parameters, actual values at each evaluation,
change from baseline, and classification of abnormality (below, normal, or above the
reference range) will be tabulated according to treatment subgroups, and change over
time; for body weight, vital signs will be tabulated according to treatment subgroups,
and change from baseline according to treatment subgroups, and change from actual
values at each evaluation, and change over time.
The ratio of the number of subjects who developed AE during treatment to the
number of subjects available for safety evaluation was calculated using the term
to indicate AE incidence.AE incidence will be summarised using the Research Data
Coding System (MedDRA) organ classification and standard terminology. AEs
occurring during treatment are defined as AEs occurring on or after the day of the first
dose through to the day of the last dose or before +30 days or the day of termination
of treatment.The severity of toxic reactions is graded according to the NCI-CTCAE
version 3.0. When analysed by subject, subjects with more than one occurrence of the
same event were counted only once and the worst CTCAE-graded event was selected.
All AEs were tabulated to describe in detail the type, grade, frequency of
occurrence, severity, and duration, as well as the relationship to the test drug,
management measures, and regression.
12.3 Sample size calculation
The study was a randomized controlled design and the primary study endpoints

38
included PFS, which is defined as the time from the start of randomisation to disease
progression or death of the patient due to various causes. Based on the available
clinical data, the following parameters were used to calculate the sample size:
1. Duration of enrolment = 24 months, duration of follow-up = 24 months
(overall 48 months), with reference to the results of previous studies and our centre's
clinical experience, PFS = 3.5 months in the control group, assuming that the PFS
improves to 5.3 months in the experimental group.
2. α = 0.05 (bilateral).
3. The effectiveness of the test is 80 per cent.
Based on the above parameter considerations, according to the logrank test for
PFS, and taking into account the 10% dropout rate during the course of the study, 302
subjects were required to be enrolled, 151 in the control group and 151 in the
experimental group.
13 Regulatory matters
13.1 Ethics and GCP compliance
All investigators must implement the study in compliance with the requirements
of the Good Clinical Practice (GCP) for the management of drug clinical studies,
ethics regulations, and study protocols as described in International Conference on
Harmonisation (ICH) guideline E6.
- Approved by the Institutional Review Board/Ethics Committee (IRB/EC): The
investigator shall be required to obtain approval from the Ethics Committee of the
study protocol, revisions to the study protocol, informed consent, the investigator's
manual, and any documents that may be required or requested prior to the initiation of
this study.
- Ethical considerations for the conduct of the study: The study protocol and
SOPs must follow the GCP requirements and the Declaration of Helsinki on Ethical
Guidelines for Medical Research on Human Subjects.
- Subject information and informed consent: The principal investigator or his/her

39
authorised person will be responsible for obtaining informed consent. The background
of the study and the benefits and risks of participation should be clearly explained.
Subjects will be provided with a signed and dated copy of the informed consent form
and the original will be retained by the investigator. Acknowledgement of informed
consent should be documented in the subject's medical record prior to any testing or
intervention (including screening and evaluation) under this study protocol.
- Subject data protection: Subjects should not be identified by name in any study
report. Study reports will be used for research purposes only. Every effort will be
made to ensure the confidentiality of subjects' personal medical data.
13.2 Responsibilities of the researcher
- Ensure that persons assisting in this study are fully aware of the protocol,
revisions, study treatments, and study-related duties and functions. The investigator
should have a list of assistant investigators and other qualified personnel who have
been assigned important study-related duties.
- Responsible for keeping records of all patients who have signed the informed
consent form and who are screened for entry into the study. For patients who fail
screening, the reason must be documented in the source document for that patient.
- During the monitoring visit, the investigator or his/her authorized personnel
must review the data, resolve queries, and allow direct access to patient records
(medical records, study-related charts, etc.) for primary source verification. The
investigator must complete the CRF in a timely and accurate manner.
13.3 Informed Consent
Before subjects are enrolled in the trial, the investigator must explain to them the
purpose of the trial, the methodology, the possible benefits, the potential risks, and the
possible discomforts. Subjects will be informed that participation in the trial is
voluntary, that
they
may
withdraw
at
any
time,
and
that
participation
or
non-participation in the trial will have no effect on the treatment of their disease.

40
Subjects' right to privacy will be protected.
Subjects or guardians should have sufficient time to read the informed consent form
and ask questions. Prior to enrolment, the subject or his/her guardian must sign the
informed consent form and the subject retains a copy of the informed consent form.
13.4 Good Clinical Practice (GCP)
This clinical study will be conducted in accordance with the Declaration of
Helsinki and the Chinese Good Clinical Practice (GCP). The study protocol must be
approved by the ethics committee of the unit responsible for the clinical study before
implementation. The investigator will ensure that this clinical study is conducted in
compliance with the laws, regulations, scientific and ethical standards of the People's
Republic of China regarding medical research. If this study protocol is found to be in
need of revision during the course of the study, the revised study protocol must be
submitted again to the Ethics Committee of the unit responsible for the study for
record/approval before implementation. If important new information concerning the
study drug is found, the informed consent form shall be revised in writing and sent to
the Ethics Committee of the responsible unit for approval, and the consent of the
subjects shall be obtained again.
13.5 Confidentiality of subjects' personal data
The information collected in this trial is limited to what is necessary for the study
of the effectiveness and safety of the drug. The collection and use of this data will be
in accordance with the relevant laws and regulations for the protection of privacy.
13.6 Programme revisions
The study protocol may be revised during the course of the study if there is a
genuine need to do so in order to guide the next steps of the study. Protocol revisions
must be made in accordance with GCP regulations, and draft revisions to the protocol
must be developed by the investigators and organisers in the light of the progress of

41
the study, and must be reviewed and approved by the Ethics Committee before they
are implemented. The revised protocol approved by the Ethics Committee must
become part of the revised protocol.
13.7 Institutional Review Board/Independent Ethics Committee Review and
Approval
Prior to commencement of the study, the study protocol, informed consent form,
and any other appropriate documents will be submitted to the IRB/EC with a cover
sheet or form listing the documents submitted, the date of release, and the research
centre(s) for which approval is required. If applicable, documents will also be
submitted to the regulatory agency as required by local law.
14 Data management and record-keeping
14.1 Data management
14.1.1 Data processing
Investigators are required to fill in the CRF with data from enrolled subjects;
patients who fail screening are not required to do so. The investigator should ensure
that the CRF is filled out accurately and completely, and that the original records are
also kept intact. CRF completion for each enrolled subject must be completed on time.
Completed CRFs will be reviewed and transferred to the data manager of this trial for
data entry and management.
14.1.2 Data entry
Data entry and management is the responsibility of the designated data
management unit. The data manager uses computer software to prepare data entry
procedures for data entry and management. In order to ensure the accuracy of the data,
proofreading should be carried out by others at the end of the entry.
14.1.3 Coding of medical information
The following tools will be used for coding medical information:

42
- MedDRA 11.0 (medical history and adverse events)
- WHO Drug 2008.03 (concomitant medication)
- NCI-CTCAE 5.0 (toxic reactions)
14.1.4 Data review
The established database is reviewed by the principal investigator, data manager,
and statistical analyser, and the database is locked after confirmation of the research
dataset and statistical analysis plan.
14.2 Record-keeping
In accordance with GCP guidelines, the principal investigator must preserve all
information related to the clinical trial, such as subject medical records, drug disposal
records, signed informed consent forms, and ethics committee approvals, for a period
of five years after the termination of the clinical trial.
14.3 Raw data/document permissions
Any observation and examination results in the clinical trial should be timely,
accurately, completely, standardised and truthfully recorded in the medical record and
correctly filled in the CRF by the investigator, and should not be changed arbitrarily.
If it is indeed due to filling in the error, any corrections made by the investigator
should keep the original record clearly legible, and be signed by the person who made
the corrections with his/her name and time. Raw data/documentation must be properly
stored in the research centre in accordance with ICH GCP and local regulations.
Higher authorities and drug regulatory authorities may monitor, audit, and
inspect the clinical trial implementation process and raw data/source documents.
Supervisors, auditors, and regulatory authorities have the right to verify all
trial-related raw data/source documents, but do not have the right to make corrections.
If a problem is found, the investigator must be informed to make corrections and sign.

43
15 Specimen collection and storage
15.1 Standard operating procedures for specimen collection
Subject specimens were collected according to the standard operating procedure
(SOP) for the collection of blood samples and tumour tissue specimens from our
tissue bank.
15.2 Storage of specimens
Subject specimens will be stored by the principal investigator. After patients have
signed informed consent for enrolment, their postoperative tumour tissue will be
routinely retained in paraffin and frozen specimens, and the tumour specimens
(paraffin) will be made into tissue microarrays after completion of enrolment of all
subjects. Blood samples will be centrifuged and serum and blood cells will be stored
separately.
16 Quality control and quality assurance
16.1 Data quality assurance
In order to ensure the completeness, accuracy and reliability of the data, the
following measures were taken in this study: selecting qualified and experienced
research units and researchers; using lectures and written materials, etc., to introduce
the contents of the study protocol in detail to the researchers before the start of the
study, and to work together to formulate solutions to any problems that may occur;
regular verification of the completeness and accuracy of the data by the supervisors; if
any doubt is found in the data , the researchers should be communicated with and
confirmed or corrected in a timely manner; blind verification of the data was carried
out during the statistical phase. If there is a bias, it is confirmed or corrected by the
researcher.
16.2 Monitoring
16.2.1
Purpose of monitoring

44
Ensure that clinical trials are conducted in strict accordance with protocols and
relevant regulations, guaranteeing data integrity, reliability and consistency of
multi-centre data, while coordinating the uniformity of trial progress.
16.2.2
Content of monitoring
Supervisors visit the clinical research unit regularly to monitor and report on the
conduct of the trial, and the supervisors have the right to verify the original
information of all patients related to the study. The monitoring mainly includes:
whether the subjects meet the enrolment criteria; whether the case report form (CRF)
is completed in a timely, accurate, complete and credible manner; whether the method
and dose of medication used by the subjects are in accordance with the protocol;
whether all the adverse events are recorded in the CRF form; and to ensure that all the
errors or omissions have been corrected, and signed and dated by the investigator.
Supervisors are also responsible for passing on information in various forms,
including information on the normal values of clinical tests, to ensure that there is a
scientifically consistent system of clinical testing between the participating units and
the team leader.
In the event of serious adverse events or deaths (including chemotherapy-related
deaths) related or unrelated to this study during the course of the clinical trial, the
managing
physician
or the host hospital will
immediately
take appropriate
management measures.
17 Audit
A representative of the sponsor may visit the research unit to audit all study
records for this trial, including original documents, and compare them to the CRF
form. The study unit will be informed of the appropriate preparations prior to the
audit. A similar inspection may be conducted by the Medicines Control Agency. In
this case, the investigator should notify the sponsor immediately.
18 Publication policy

45
The results of this study may be published in medical journals and magazines or
used for teaching purposes. In addition, this study and its results may be submitted for
inclusion in all appropriate health research agency registries, as well as posted on
health agency research registry websites (e.g., ClinicalTrials.gov), as required by local
health agency regulations. First authors were selected based on several considerations
including, but not limited to: study participation, contribution to protocol development,
and analysis and input in the study manuscript, associated abstracts, and presentations.
19 Clinical Trial Management Information
19.1 Organisational units
Affiliation: Sun Yat-sen University Cancer Prevention and Treatment Centre
Address: No. 651 Dongfeng East Road, Guangzhou, China
Tel: 020-87343088
Postcode: 510060
20.bibliography
[1] Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer
Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185
Countries. ca: a cancer journal for clinicians. 2021;71:209-49.
[2] Zheng R, Zhang S, Zeng H, Wang S, Sun K, Chen R, et al. Cancer incidence and mortality in China,
2016. Journal of the National Cancer Center. 2022;2:1-9.
[3] Chen P, Zhang X, Ding R, Yang L, Lyu X, Zeng J, et al. Patient-Derived Organoids Can Guide
Personalised-Therapies for Patients with Advanced Breast Cancer. advanced science (Weinheim,
Baden-Wurttemberg, Germany). 2021;8:e2101176.
[4] Sachs N, de Ligt J, Kopper O, Gogola E, Bounova G, Weeber F, et al. A Living Biobank of Breast
Cancer Organoids Captures Disease Heterogeneity. cell. 2018;172:373-86 e10.
[5] Bhatia S, Kramer M, Russo S, Naik P, Arun G, Brophy K, et al. Patient-Derived Triple-Negative
Breast Cancer Organoids Provide Robust Model Systems That Recapitulate Tumor Intrinsic
Characteristics. cancer research. 2022;82:1174-92.
[6] Kim M, Mun H, Sung CO, Cho EJ, Jeon HJ, Chun SM, et al. Patient-derived lung cancer organoids
as in vitro cancer models for therapeutic screening. nature communications. 2019;10:3991.
[7] Nuciforo S, Fofana I, Matter MS, Blumer T, Calabrese D, Boldanova T, et al. Organoid Models of
Human Liver Cancers Derived from Tumor Needle Biopsies. Cell reports. 2018;24:1363-76.
[8] Seino T, Kawasaki S, Shimokawa M, Tamagawa H, Toshimitsu K, Fujii M, et al. Human Pancreatic
Tumor Organoids Reveal Loss of Stem Cell Niche Factor Dependence during Disease Progression. cell
stem cell. 2018;22:454-67.e6.

46
[9] Minoli M, Cantore T, Hanhart D, Kiener M, Fedrizzi T, La Manna F, et al. Bladder cancer organoids
as a functional system to model different disease stages and therapy response. nature communications.
2023;14:2214.
[10] Yan HHN, Siu HC, Law S, Ho SL, Yue SSK, Tsui WY, et al. A Comprehensive Human Gastric
Cancer Organoid Biobank Captures Tumor Subtype Heterogeneity and Enables Therapeutic Screening.
cell stem cell. 2018;23:882-97.e11.
[11] Boretto M, Maenhoudt N, Luo X, Hennes A, Boeckx B, Bui B, et al. Patient-derived organoids
from endometrial disease capture clinical heterogeneity and are amenable to drug screening. nature cell
biology. 2019;21:1041-51.
[12] Shu D, Shen M, Li K, Han X, Li H, Tan Z, et al. Organoids from patient biopsy samples can
predict
the
response
of
BC
patients
to
neoadjuvant
chemotherapy.
Annals
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medicine.
2022;54:2581-97.
[13] Wensink GE, Elias SG, Mullenders J, Koopman M, Boj SF, Kranenburg OW, et al. Patient-derived
organoids as a predictive biomarker for treatment response in cancer patients. npj precision oncology.
2021;5:30.
[14] Su C, Olsen KA, Bond CE, Whitehall VLJ. The Efficacy of Using Patient-Derived Organoids to
Predict Treatment Response in Colorectal Cancer. cancers . 2023;15.
[15] Guillen KP, Fujita M, Butterfield AJ, Scherer SD, Bailey MH, Chu Z, et al. A human breast
cancer-derived xenograft and organoid platform for drug discovery and precision oncology. nature
cancer. 2022;3:232-50.
21 Researcher's statement
I wish to sign my name and agree to the following:
I have read the protocol and I agree with it and acknowledge all the necessary
details of the implementation of the research process as described in the protocol. I
will carry out and endeavour to complete the study as designed and specified in the
protocol and within the time-frame specified. Under my management/supervision, I
will give a copy of the protocol and related information to the researchers involved in
the trial. I will discuss these documents with them to ensure that they fully understand
the study protocol and study procedures. I will inform them that this information is
confidential and belongs to the research centre and that it will not be disclosed to third
parties. I understand that recruitment may be terminated or stopped at any time by the
Ethics Committee, a higher authority, or the Drug Administration for any reason, or if
I believe it is necessary to protect the best interests of the subjects. I agree to conduct
the study in full compliance with the requirements of the SFDA, the Ethics

47
Committee, and the ICH GCP.
Signature of researcher Date

48
22 Appendix
Appendix 1 Criteria for evaluating the efficacy of solid tumours version 1.1
(Response Evaluation Criteria in Solid Tumors RECIST Version 1.1)
1 Tumour measurability at baseline level
1.1 Definitions
At the baseline level, tumour lesions/lymph nodes will be classified as measurable and
non-measurable as defined below:
Measurable lesions
Tumour lesion: at least one accurately measurable diameter line (recorded as the maximum
diameter) with the following minimum lengths:

CT scan 10 mm (CT scan layer thickness not more than 5 mm)

Routine clinical examination instruments 10 mm (tumour lesions that cannot be accurately
measured with a calibrating instrument should be recorded as non-measurable)

Chest X-ray 20 mm

Malignant lymph nodes: pathologically enlarged and measurable, the short diameter of the
CT scan of a single lymph node must be ≥15 mm (CT scan layer thickness of no more than 5
mm is recommended). At baseline and follow-up, only short diameters are measured and
followed up.
Non-measurable lesions
All other lesions, including small lesions (longest diameter <10 mm or pathological lymph
nodes with short diameters ≥10 mm to <15 mm) and non-measurable lesions. Unmeasurable
lesions included: meningeal disease, ascites, pleural or pericardial effusion, inflammatory breast
cancer, carcinomatous lymphadenopathy of the skin/lungs, abdominal masses that could not be
diagnosed and followed up on imaging, and cystic lesions.
Special considerations on lesion measurement
Bone lesions, cystic lesions and lesions previously treated locally require special mention:
Bone lesions:

Bone scans, PET scans or plain films are not suitable for measuring bone lesions, but
can be used to confirm the presence or absence of bone lesions;

Osteolytic lesions or mixed osteolytic/osteogenic lesions with a defined soft tissue

49
component that meets the above definition of measurability may be treated as
measurable lesions if they can be evaluated with tomographic imaging techniques such
as CT or MRI;

Osteogenic lesions are non-measurable lesions.
Cystic lesions:
A lesion that meets the radiological imaging criteria for the definition of a simple cyst
should not be considered malignant because it is a simple cyst by definition and is
neither a measurable nor a non-measurable lesion;
If a cystic metastatic lesion is present and meets the above definition of measurability, it
can be treated as being a measurable lesion. However, if a non-cystic lesion is present
in the same patient, the non-cystic lesion should be preferred as the target lesion.
Locally treated lesions:
Lesions located at sites that have been treated with radiotherapy or with other local
regional treatments are generally treated as non-measurable lesions, unless the lesion
shows definite progression. The study protocol should describe in detail the
conditions under which these lesions are measurable.
1.2 Description of measurement methods
Lesion measurement
All tumour measurements should be recorded in metric metres at the time of clinical
evaluation. All baseline ratings of tumour lesion size should be completed as close to the start of
treatment as possible and must be completed within 28 days (4 weeks) prior to the start of
treatment.
Evaluation methodology
The same techniques and methods should be used for baseline evaluation of lesions and
subsequent measurements. All lesions must be evaluated using imaging, except for lesions that
cannot be evaluated with imaging but only with clinical examination.
Clinical lesions: Clinical lesions are only considered measurable if they are superficial and ≥
10 mm in diameter when measured (e.g. skin nodules, etc.). For patients with skin lesions, it is
recommended to archive colour photographs containing scale measurements of the size of the

50
lesion.
When lesions are evaluated using both imaging and clinical examination, imaging should be used
whenever possible because it is more objective and can be reviewed repeatedly at the end of the
study.
Chest X-ray: When tumour progression is an important study endpoint, chest CT should
be used in preference to X-ray because it is more sensitive than X-ray, especially for
new lesions. Chest X-ray testing is indicated only when the measured lesion is well
defined and the lungs are well ventilated.
CT, MRI: CT is currently the best available reproducible method for efficacy evaluation.
The definition of measurability in this guideline is based on a CT scan layer thickness
of ≤5 mm. If the CT layer thickness is greater than 5 mm, the minimum measurable
lesion should be twice the layer thickness.MRI is also acceptable in some cases (e.g.,
whole-body scan).
Ultrasound: Ultrasound should not be used as a measurement for lesion size. Ultrasound
is not reproducible at the end of the measurement due to its operational dependency
and does not guarantee homogeneity of technique and measurement between
measurements. If a new lesion is detected using ultrasound during the trial, it should
be confirmed using CT or MRI. MRI can be used instead if the radiation exposure of
CT is taken into account.
Endoscopy, laparoscopy: the use of these techniques is not recommended for objective
tumour evaluation, but this method can be used to confirm CR in the case of biopsy
specimens obtained, and also in trials where the study endpoint is recurrence or
surgical resection after CR.
Tumour markers: Tumour markers cannot be used alone to evaluate objective tumour
remission. However, if the marker level exceeds the upper limit of normal at baseline,
it must return to normal when used to evaluate complete remission. Because tumour
markers vary from disease to disease, this needs to be taken into account when
writing measurement criteria into the protocol. Specific criteria for CA-125 remission
(recurrent ovarian cancer) and PSA (recurrent prostate cancer) remission have been
published. The International Organisation for Gynaecological Cancer has developed

51
criteria for CA-125 progression, which will soon be added to the objective tumour
assessment criteria for first-line treatment regimens for ovarian cancer.
Cytological/histological techniques: These techniques can be used to identify PR and
CR in specific circumstances as defined by the protocol (e.g. residual benign tumour
tissue is often present in the lesions of germ cell tumours). When exudation may be a
potential side effect of a therapy (e.g. treatment with paclitaxel compounds or
angiogenesis inhibitors) and the measurable tumour meets the criteria for remission or
disease stabilisation, the appearance or exacerbation of tumour-associated exudation
during the course of treatment may be confirmed by cytological techniques to
differentiate remission (or disease stabilisation) from disease progression.
2 Assessment of tumour remission
2.1 Assessment of target lesions

Complete remission (CR): disappearance of all target lesions and the short diameter of
all pathological lymph nodes (both target and non-target) must be reduced to <10 mm.
- Partial remission (PR): The sum of the diameters of the target lesions is reduced by at least
30% from the baseline level.
- Progression of Disease (PD): A relative increase in the sum of the diameters of the target
lesions of at least 20% (or the baseline value if the baseline
measurement is the smallest), referenced to the minimum of the sum
of the diameters of all the target lesions measured throughout the
experimental study; in addition to this, an increase in the sum of the
diameters of at least 5 mm in absolute terms must be met (the presence
of one or more new lesions is also considered to be a progression of
the disease).
- Stable Disease (SD): The target lesion has not decreased to the extent of PR, nor has it
increased to the level of PD, and is somewhere in between, the
smallest value of the sum of the diameters can be used as a reference
for the study.
2.2 Considerations for target lesion assessment

52

Lymph nodes: Even if a lymph node identified as a target lesion is reduced to less than
10 mm, the value of the actual short diameter corresponding to the baseline (in line with
the anatomical plane at the time of the baseline measurement) should be recorded at
each measurement. This means that if a lymph node is a target lesion, even if the criteria
for complete remission are met, the lesion cannot be said to have disappeared
completely, because the short diameter of a normal lymph node is defined as <10 mm.
Target lymph node lesions need to be recorded exclusively at specific locations on the
CRF form or in other recording modalities: for CR, the short diameters of all lymph
nodes must be <10 mm; for PR, SD, and PD, the short diameters of target lymph nodes
will be included in the target node short diameter (<10 mm), and the actual
measurement will be included in the target node short diameter. The actual measurement
will be included in the sum of the target lesion diameters.

Target lesions too small to measure: In clinical studies, all lesions (nodular or
non-nodular) recorded at baseline should have the actual measurements re-recorded in
subsequent evaluations, even if they are very small (e.g. 2 mm). However, sometimes
the lesion may be too small to be reported as "too small to measure" because the image
on the CT scan is very blurred and it is difficult for the radiologist to define the exact
value. When this happens, it is important to record a value on the CRF chart. If the
radiologist thinks that the lesion may have disappeared, this should also be recorded as 0
mm, or 5 mm if the lesion is present but too faint to give a precise measurement. (Note:
This is unlikely to be the case with lymph nodes, which normally have measurable
dimensions or are often surrounded by adipose tissue, as is often the case in the
retroperitoneal space; however, if this is also the case, it is important to record a value
on the CRF chart. The default value of 5 mm is derived from the cut thickness of the CT
scan (this value does not change depending on the cut thickness value of the CT).
Providing this default value will reduce the risk of incorrect assessment, as the chance of
the same measurement being repeated is small. However, it is important to reiterate that
if the radiologist can give an exact value for the size of the lesion, the actual value must
be recorded even if the lesion diameter is less than 5 mm.

Separated or bound lesions: When a non-nodular lesion splits into fragments, the longest

53
diameters of the separated parts are added together to calculate the sum of the diameters
of the lesions. Similarly, in the case of united lesions, they can be distinguished by the
planes between the united parts, and their respective maximum diameters are then
calculated. However, if the union is inextricably linked, the longest diameter should be
taken as the longest diameter of the fused lesion as a whole.
2.3 Assessment of non-target lesions
This section defines the remission criteria for tumours with non-target lesions. Although
some non-target foci are actually measurable, they need not be measured, but only qualitatively
assessed at the time points specified in the programme.

Complete remission (CR): disappearance of all non-target lesions and return of tumour
markers to normal levels. All lymph nodes were non-pathological in size (short
diameter <10 mm).

Non-complete remission/non-disease progression: presence of one or more off-target
lesions and/or persistence of tumour marker levels above normal.

Disease progression: Definite progression of a pre-existing non-target lesion. Note: The
appearance of one or more new lesions is also considered as disease progression.
2.4 Special considerations for the assessment of progression of non-target lesions
An additional explanation of the definition of progression of a non-target lesion is as follows:
when a patient has a measurable non-target lesion, even if the target lesion is assessed as stable or
in partial remission, a clear definition of progression on the basis of the non-target lesion must be
satisfied that the overall deterioration of the non-target lesion has reached a level that necessitates
the discontinuation of therapy. A general increase in the size of one or more non-target lesions is
often insufficient to meet the criteria for progression, and therefore it is almost rare that overall
tumour progression can be defined on the basis of changes in non-target lesions alone when the
target lesion is stable or in partial remission.
When none of the patient's non-target lesions are measurable: in some phase III trials this
occurs when the inclusion criteria do not specify that measurable lesions must be present. The
overall assessment is still based on the criteria above, but because there are no measurable data on
the lesions in this case. Worsening of non-target lesions is not easily assessed (by definition: it is
necessary that all non-target lesions are truly unmeasurable), so when changes in non-target

54
lesions result in an increase in overall disease load equivalent to the presence of disease
progression in the target lesion, a clear definition of progression based on non-target lesions
requires the establishment of a validated assay for this assessment. This is described, for example,
as an increase in tumour load equivalent to an additional 73% increase in volume (equivalent to a
20% increase in measurable lesion diameter). For example, peritoneal leakage from "trace" to
"massive"; lymphadenopathy from "localised" to "widely disseminated"; or in the protocol, a clear
definition of progression. "or described in the protocol as "sufficient to warrant a change in
therapy". Examples include pleural exudate ranging from trace to massive, lymphatic involvement
spreading from the primary site to distant sites, or may be described in the protocol as
"necessitating a change in therapy". If definite progression is identified, the patient should be
considered to have progressed overall at that point in time. It is desirable to have objective criteria
that can be applied to the assessment of non-measurable lesions, noting that additional criteria
must be reliable.
2.5 New lesions
The appearance of new malignant lesions signals disease progression; therefore some
evaluation of new lesions is important. There are no specific criteria for detecting lesions on
imaging, however the detection of a new lesion should be unequivocal. For example, progression
cannot be attributed to a difference in imaging technique, a change in imaging morphology, or a
lesion other than the tumour (e.g., some so-called new bone lesions are simply a cure of the
original lesion, or a recurrence of the original lesion). This is important when a patient has a
partial or complete response to a baseline lesion, e.g., a case of necrosis in a liver lesion may be
designated as a new cystic lesion on the CT report when it is not.
Lesions that have been detected at follow-up but not at baseline examination will be
considered new and suggestive of disease progression.
For example a patient with a visceral lesion on baseline examination who is found to have
metastases when he undergoes a cranial examination with CT or MRI will have intracranial
metastatic lesions that will be considered as the basis for disease progression, even if he did not
undergo a cranial examination at the time of the baseline examination.
If a new lesion is ill-defined, e.g., due to its small morphology, further treatment and
follow-up evaluation is required to confirm that it is a new lesion. If repeated investigations

55
confirm that it is a new lesion, then the time of disease progression should be counted from the
time of its initial discovery.
Evaluation of lesions by FDG-PET generally requires additional testing for supplemental
confirmation, and a combination of FDG-PET and supplemental CT findings is reasonable for
evaluating progression (especially in new suspected disease). New lesions that can be clarified by
FDG-PET are performed according to the following procedure:
A negative baseline FDG-PET test result followed by a positive FDG-PET test at follow-up
indicates disease progression.
No baseline FDG-PET was performed and the follow-up FDG-PET was positive:
Disease progression was demonstrated if new lesion foci detected by positive FDG-PET
findings on follow-up were consistent with trans-CT findings.
If new lesions detected by positive findings on follow-up FDG-PET are not confirmed by CT
findings, additional CT is required to confirm them (if confirmed, the time to disease progression
is counted from the time when the abnormality was detected on the prior FDG-PET examination).
Disease is not progressive if positive findings on follow-up FDG-PET are consistent with a
pre-existing lesion by CT that has not progressed on imaging tests.
2.6 Assessment of missing and non-evaluable notes
If a lesion could not be imaged or measured at a specific time point, the patient was not
evaluable at that time point. If only a portion of a lesion can be evaluated in an evaluation, this is
generally considered to be an inability to evaluate at that time point unless there is evidence to
confirm that the missing lesion does not affect the evaluation of the efficacy response at the
specified time point.
2.7 Special tips for efficacy assessment
When a nodular lesion is included in the total target lesion assessment while that nodule is
large there is a lesion size scan reported. To avoid over-assessment based on what is reflected by
an increase in nodule size, measurements will be recorded even if the nodule is normal. As already
mentioned, this means that subjects whose efficacy is a complete remission will not be recorded as
0 on the CRF form either.
If efficacy confirmation is required during the course of the trial, repeated "non-measurable" time
points will complicate the assessment of optimal efficacy. The trial's analysis plan must indicate

56
that these missing data/assessments can be accounted for when determining efficacy. For example,
in most trials, a subject's PR-NE-PR response can be taken as confirmation of efficacy.
When reduced to a "normal" size (<10 mm), they will still be
Symptomatic progression should be reported when a subject experiences an overall
deterioration in health requiring discontinuation of the administered treatment, but there is no
objective evidence of it. Objective progression should be assessed as far as possible even after
termination of treatment. Symptomatic deterioration is not an assessed description of objective
response: it is the reason for discontinuing treatment. Objective response in subjects like that will
be assessed by the target and non-target lesion profiles shown in Tables 1 to 3.
Conditions defined as early progression, early death and non-assessable are study exceptions and
should be clearly described in each protocol (depending on the treatment interval and treatment
cycle).
In some cases, it is difficult to identify localised lesions from normal tissue. When the
assessment of complete remission is based on such a definition, we recommend biopsy prior to
performing an efficacy assessment of a localised lesion in complete remission. FDG-PET has been
used as a similar assessment criterion to biopsy for efficacy confirmation of complete remission
when abnormalities in localised lesion imaging findings in some subjects are thought to represent
lesion fibrosis or scar formation. In such cases, the use of FDG-PET should be described
prospectively in the protocol, supported by reports in the specialist medical literature for this
condition. However, it must be realised that the limitations of FDG-PET and biopsy (including
their high resolution and sensitivity) will lead to false-positive results in the assessment of
complete remission.
Table 1 Time-point responses: subjects with target lesions (including or excluding non-target
lesions)
target lesion
non- target lesions
new lesions
overall
CR
CR
No
CR
CR
No CR / non PD
No
PR
CR
Cannot
No
PR
PR
Not progressing or not fully
No
PR
SD
Not progressing or not fully
No
SD
cannot
be
fully
non-pro
No
NE
PD
Any case
Yes or no
PD

57
Any case
PD
Yes or no
PD
Any case
Any case
yes
PD
CR=complete
remission
PR= partial remission
SD=stable
disease
PD=disease
progression
Table 2 Time Point Response-Subjects with Non-Target Lesions Only
non- target lesions
new
overall remission
CR
No
CR
Non-CR or non-PD
No
Non-CR or non-PD
Cannot be fully assessed
No
Cannot evaluate
Unspecified PD
Yes or
PD
Any case
yes
PD
Note: For non-target lesions, "non-CR/non-PD" refers to efficacy that is superior to SD. As
SD is increasingly used as an endpoint indicator for evaluating efficacy, non-CR/non-PD
efficacy was developed to target situations where no lesion is specified to be measurable.
For unclear progression findings (e.g., very small indeterminate new lesions; cystic or
necrotic lesions in pre-existing lesions) treatment may continue until the next assessment. If
disease progression is confirmed at the next assessment, the date of progression should be the
date of the previous suspected progression.
Table 3 CR and PR efficacy required to confirm optimal total remission
First time point
overall
Subsequent
time points
Best overall response
CR
CR
CR
CR
PR
SD, PD or PR _
CR
SD
If SD lasts for a sufficient period of time , then SD, otherwise it should be PD
CR
PD
If SD lasts for a sufficient period of time , then SD, otherwise it should be PD
CR
NE
If SD lasts for a sufficient period of time , then SD, otherwise it should be NE
PR
CR
PR
PR
PR
PR
PR
SD
SD
PR
PD
If SD lasts for a sufficient period of time , then SD, otherwise it should be PD
PR
NE
If SD lasts for a sufficient period of time , then SD, otherwise it should be NE
NE
NE
NE
Note: CR is complete remission, PR is partial remission, SD is stable disease, PD is
progressive disease, and NE is not evaluable. Superscript "a": if CR actually occurs at the
first time point and any disease occurs at a subsequent time point, then even if the subject's
efficacy relative to baseline meets the criteria for PR, his/her efficacy will still be evaluated
as PD at a subsequent time point (because disease will reappear after CR). Optimal remission

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depends on whether SD occurs within the shortest treatment interval; however, sometimes
the first evaluation is a CR, but subsequent time point scans suggest that small lesions appear
to persist, so that the subject's outcome at the first time point should in fact be a PR rather
than a CR. In this case, the first CR judgement should be modified to a PR, and the best
response is a PR.
2.8. Efficacy evaluation / confirmation of remission period
Confirmation of efficacy
For non-randomized clinical studies with tumor response as the main endpoint, the efficacy
of PR and CR must be confirmed to ensure that the efficacy is not the result of evaluation errors.
In studies with disease stabilization or disease progression as the primary endpoint, confirmation
of efficacy is no longer required because it is of no value to the interpretation of trial results. In the
case of SD, within the shortest time interval after the start of the trial (generally not less than 6 to
8 weeks), at least one measurement meets the SD standard specified in the protocol.
Overall remission period
Overall response period is measured from the time when criteria for CR or PR (whichever is
measured first) are first measured to the time when disease relapse or progression is first
documented (using the smallest measurement recorded in the trial as the reference for disease
progression). Overall complete response time is measured from the time when CR criteria are first
met to the first true documented disease recurrence or progression.
Stable disease stage
is the time from the start of treatment to disease progression (in randomized trials, from the
time of randomization), with the smallest sum in the trial as the reference (if the baseline sum is
the smallest, it is used as the reference for PD calculations). The clinical relevance of stable
disease varies between studies and among different diseases. If the proportion of patients
remaining stable for a minimum period of time is used as the study endpoint in a particular trial,
the protocol should specifically state the minimum time interval between two measurements in the
definition of SD.
Note: The period of remission, stability, and PFS are affected by the frequency of follow-up
after baseline assessment. Defining standard follow-up frequency is outside the scope of this
guideline. The frequency of follow-up should take into account many factors, such as disease type
and stage, treatment cycle and standard specifications. However, if comparisons between trials are

59
required, limitations in the accuracy of these measurement endpoints should be considered.
2.9 PFS/TTP
Many trials in advanced tumors use PFS or TTP as the primary endpoint. If the protocol
requires that all patients have measurable disease, assessment of progress is relatively simple. An
increasing number of trials are allowing patients with and without measurable disease to enter the
trial. In this setting, the clinical findings of disease progression in patients with no measurable
disease must be clearly described in detail. Because progression dates are often ascertained, the
observation time points should be arranged the same for each trial group.

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Appendix 2: Eastern Cooperative Oncology Group physical status score (ECOG
score)
Level (points)
Description of physical condition
0
Asymptomatic, completely normal mobility, no difference from before onset of
illness
1
With symptoms, able to move around freely and engage in light physical
activities, including general housework or office work, but cannot engage in
heavier physical activities
2
If you have symptoms, you can move around freely and take care of yourself,
but you have lost the ability to work. You can get up and move around no less
than half of the time during the day.
3
Symptomatic, can only partially take care of himself, spends more than half of
the day in bed or in a wheelchair, but not bedridden
4
Total loss of function, unable to take care of oneself, bedridden
5
die