Phase I Study of tTF-NGR in Patients With Recurrent or Refractory Malignant Tumors and Lymphomas Beyond All Standard Treatments
Phase: PHASE1
Conditions: Malignant Solid Tumors, Lymphomas
Sponsor: University Hospital Muenster

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Title: PHASE I STUDY OF tTF-NGR IN PATIENTS WITH RECURRENT OR 
REFRACTORY MALIGNANT TUMORS AND LYMPHOMAS BEYOND ALL 
STANDARD TREATMENTS 
Short title:  tTF-NGR Phase I Study 
EudraCT-No.:  2016-003042-85 
Sponsor:  
University Hospital Muenster, Germany 
Representative: Dr. Ch. Hoppenheit, Commercial Director 
Albert-Schweitzer-Campus 1, Gebäude D5 
D-48149 Münster, Germany 
Telephone: +49 251 83 55802 
Fax: +49 251 83 55803 
 
Sponsors Study Code:  UKM12_0018 
Investigator:  
PD Dr. Christoph Schliemann 
Department of Medicine A (Hematology, Hemostaseology, Oncology) 
University Hospital Muenster, Germany 
Albert-Schweitzer-Campus 1 
D-48149 Muenster, Germany 
Telephone: +49 251 83 47587 
Fax: +49 251 83 47588 
E-mail: Christoph.Schliemann@ukmuenster.de  
 
 
Deputy of the Investigator (Stellvertretender Prüfer): 
Prof. Dr. Rolf Mesters 
University Hospital Muenster, Germany 
Department of Medicine A (Hematology, Hemostaseology, Oncology) 
Albert-Schweitzer-Campus 1 
D-48149 Muenster, Germany 
Telephone: +49 251 83 47594 
Fax: +49 251 83 48745 
E-mail: Rolf.Mesters@ukmuenster.de 
 
Protocol version 10: 2016 07 28 
Study Contact: PD Dr. Christoph Schliemann 
E-mail: Christoph.Schliemann@ukmuenster.de  
Hotline: +49 251 8347587 
 
 
Confidential 
The information in this study protocol is strictly confidential. It may be used for the conduct of 
the study. It must not be available to persons or institutions who are not concerned with the 
study. Usage for other purposes requires written approval by the investigator.  
 
 
NCT02902237

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Head of the Production Unit (GMP) 
Dr. rer. nat. Christian Schwöppe 
University Hospital Muenster, Germany 
Department of Medicine A (Hematology, Hemostaseology, Oncology) 
Albert-Schweitzer-Campus 1 
D-48149 Muenster, Germany 
Telephone: +49 251 83 56225 
Fax: +49 251 83 56709 
E-mail:  christian.schwoeppe@uni-muenster.de  
 
Statistician 
Dr. rer. nat. Joachim Gerß, Dipl.-Stat. 
Institute of Biostatistics and Clinical Research 
Director: Prof. Dr. Andreas Faldum 
University of Muenster 
Schmeddingstr. 56 
D-48149 Muenster, Germany 
Telephone: +49 251 83 50660 
Fax: +49 251 83 55277 
E-mail: joachim.gerss@ukmuenster.de  
Study Radiologist 
Prof. Dr. Walter Heindel 
University Hospital Muenster, Germany 
Department of Radiology 
Albert-Schweitzer-Campus 1 
D-48149 Muenster, Germany 
Telephone: +49 251 83 45139 
Fax:  +49 251 83 47312 
E-mail:  heindel@uni-muenster.de 
Monitoring  
Stefanie Dickmänken 
Zentrum für Klinische Studien Münster 
Universitätsklinikum Münster 
Von-Esmarch-Str. 62 
D-48149 Muenster, Germany 
Tel.: +49 251 83 57256 
Fax: +49 251 83 57026 
E-mail: Stefanie.Dickmaenken@ukmuenster.de  
SAE Management  
Dr. Trude Butterfaß-Bahloul 
Zentrum für Klinische Studien Münster 
Universitätsklinikum Münster 
Von-Esmarch-Str. 62 
D-48149 Muenster, Germany 
Tel.: +49 251 83 57109 
Fax: +49 251 83 57112 
E-mail: butterft@ukmuenster.de; mssd@ukmuenster.de  
Data Management  
Sonja Baier 
Zentrum für Klinische Studien Münster 
Universitätsklinikum Münster 
Von-Esmarch-Str. 62 
D-48149 Muenster, Germany 
Tel.: +49 251 83 57496 
Fax: +49 251 83 57026 

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E-mail: sonja.baier@ukmuenster.de  
Signatures 
 
Sponsor: 
University Hospital Muenster 
represented by  
 
Dr. Christoph Hoppenheit 
(Commercial Director) 
 
 
 
 
 
____________________________ 
Place, date 
 
 
____________________________ 
Signature 
 
 
 
Statistician: 
Institute of Biostatistics and Clinical 
Research 
Dr. Joachim Gerß  
 
 
 
 
 
 
 
____________________________ 
Place, date 
 
 
____________________________ 
Signature 
 
 
 
Investigator: 
Department of Medicine A (Hematology, 
Hemostaseology, Oncology) 
 
PD Dr. Christoph Schliemann  
 
 
 
 
 
 
 
 
____________________________ 
Place, date 
 
 
____________________________ 
Signature 
 

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Table of contents 
1. 
General Information                                                                                              
1 
2. 
Protocol synopsis   
5 
3. 
Protocol overview 
9 
4. 
Background and rationale 
13 
5. 
Study design 
13 
6. 
Eligibility criteria and patient registration 
14 
7. 
Treatment plan 
16 
8. 
Dosing delays and dose de-escalation in individual patients 
18 
9. 
Dose-Limiting toxicity (DLT) and maximum tolerated dose (MTD) 
18 
10. Dose escalation and de-escalation according to tocixity and dose  
recommended for phase II trials (RDPII) 
20 
11. Study objectives and end-points 
23 
12. Patient evaluation and follow-up 
24 
13. Reporting requirements 
26 
14. Anticipated risks for the subjects  
32 
15. Assessment of disease status 
35 
16. Statistical considerations 
35 
17. Study duration, premature termination of the study 
36 
18. Informed consent 
37 
19. Study administration 
39 
20. Patient insurance 
43 
21. Financing of the study 
43 
22. Adherence to the protocol 
43 
23. Data protection 
44 
24. Reporting and publication policy 
44 
  
 
  
Appendix: Rekonstitution des Fertigarzneimittels tTF-NGR  
 
  
 
 
 
 
 
 
 

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2. Protocol Synopsis 
Title: 
PHASE I STUDY OF tTF-NGR IN PATIENTS WITH 
RECURRENT OR REFRACTORY MALIGNANT TUMORS OR 
LYMPHOMAS BEYOND ALL STANDARD TREATMENTS 
Short Title: 
tTF-NGR Phase I Study 
Sponsor’s Study Code: 
UKM12_0018 
 
EudraCT-No.: 
2016-003042-85 
Sponsor: 
Universitätsklinikum Münster  
Investigator:  
PD Dr. Christoph Schliemann 
Department of Medicine A (Hematology, Hemostaseology, 
Oncology), UKM 
Albert-Schweitzer-Campus 1 
D-48149 Muenster, Germany 
Telephone: +49 251 8347587 
Fax: +49 251 8347588 
E-mail: Christoph.Schliemann@ukmuenster.de 
Indication: 
All solid tumors and lymphomas beyond standard therapy 
Study Design: 
Phase I Study 
Investigational Medicinal 
Product: 
tTF-NGR 
Therapy: 
Phase I, open label, single arm, non-randomized prospective, 
monocenter study. tTF-NGR will be given as 1-hour infusion via 
central venous access once daily for 5 days with a subsequent 
rest period of 2 weeks and following cycles with dose escalation 
of 0.5 mg/m2 upon judgement of tolerability and therapeutic 
activity. Starting dose will be 1 mg/m2/day. Patients within the 
dose-escalation part will be treated in sequence and not in 
parallel. Individual patients can undergo a maximum of 8 dose-
escalations. Dose-escalation is stopped before the maximum 
number of 8 escalation steps if tumor response, tumor 
progression or a Dose-Limiting Toxicity (DLT) is observed. In 
the case of stable disease (SD) and with good tolerability these 
patients can obtain further cycles without dose-escalation until 
tumor progression or Dose-Limiting Toxicity (DLT) and the next 
patient can start with dose-escalation cycles on the highest 
tolerable dose for the previous patient. 
Objectives: 
Primary Objective: 
To evaluate the maximum tolerated dose (MTD) and the Dose-
Limiting Toxicity (DLT) of intravenously (iv) infused daily 
applications of tTF-NGR for 5 days every 3 weeks in patients 
with relapsed or refractory cancer, who had obtained all 

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standard treatment known for their disease entity prior to entry 
on study.  
Secondary Objectives: 
1. To determine the perfusion and vascular volume fraction of 
measurable tumor lesions versus normal reference tissue 
before and after tTF-NGR application by MRI as a biological 
surrogate parameter for biological activity of the IMP in the 
patients treated within the verification cohorts. 
2.  To obtain pharmacokinetic data of tTF-NGR. 
Endpoints: 
Primary Safety Endpoint:  
Maximum Tolerated Dose (MTD). MTD is the dose below the 
dose leading to reproducible episodes of Dose Limiting Toxicity 
(DLT) in at least 2/6 patients. DLT will be characterized by 
clinical, blood and serum monitoring at specified time points 
before and during study period. 
Secondary Efficacy Endpoints: 
1. Occurrence and frequency of inhibition of tumor blood 
flow as measured by contrast-enhanced Magnetic 
Resonance Imaging (MRI) in the patients treated in the 
verification cohorts.  
2. Occurrence and frequency of tumor response defined 
as Complete Response (CR), Partial Response (PR), or 
Stabile Disease (SD) as defined by RECIST criteria. 
Descriptive statistics will be used. 
Planned Number of Study 
Centers: 
1 
Number of Patients/ 
Sample size: 
A minimum of 7 patients depending on occurrence of DLT. 
Inclusion Criteria: 
➢ age > 18 years 
➢ histologically proven or cytologically confirmed solid 
malignant tumor or malignant lymphoma 
➢ recurrent or refractory disease after standard therapy 
and with no known curative or survival-prolonging 

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treatment options according to the judgement of the 
investigators 
➢ life expectancy of at least 6 weeks according to the 
judgement of the investigators 
➢ Karnofsky performance status >50 
➢ measurable disease with at least one marker-lesion 
measurable in 2 dimensions by Vascular Volume-
Fraction-MRI 
➢ adequate bone marrow function with absolute neutrophil 
count > 1000/microliter and platelet count > 50/nl. 
➢ normal global coagulation parameters (Quick, PTT, TZ, 
fibrinogen), no prophylactic anticoagulation 
➢ adequate liver function (total bilirubin < 3x the upper 
normal limit (ULN), SGPT/SGOT < 3x ULN) 
➢ adequate renal function (serum creatinine < 3x ULN) 
➢ no history of coronary heart disease, stroke, transitory 
ischemic attacks, pulmonary embolism, or deep vein 
thrombosis 
➢ time elapsed from previous therapy (including other 
IMPs) > 3 weeks with recovery from side effects 
➢ exclusion of central nervous system (CNS) disease and 
CNS vascular abnormalities by MRI 
➢ ability to understand and provide written informed 
consent 
➢ written informed consent given 
➢ for female patients with child-bearing potential exclusion 
of pregnancy by adequate testing within 48 hours prior 
to entry on study 
➢ females of childbearing potential as well as fertile males 
must agree to use a highly effective form of 
contraception (Pearl Index < 1) during the study and for 
120 days following the last dose of the IMP 
Exclusion Criteria: 
➢ clinically significant unrelated illness which in the 
judgement of the investigators could compromise the 
patient’s ability to tolerate the IMP or be likely to interfere 
with the study procedures or results 

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➢ known hypersensitivity reactions to prior application of 
E. coli-derived material 
➢ women with breast-feeding activity 
➢ concomitant use of any other investigational agent 
(agent for which there is currently no approved 
indication from regulatory authorities) 
➢ clinical application of any other drug with known 
antitumor activity 
➢ prophylactic anticoagulation within the last 3 days 
 
 
Visits: 
Statistical Methods: 
Descriptive statistics are performed to characterize MTD (= 
dose level below DLT occurring in 2/6 patients) 
Financial Support: 
Deutsche Krebshilfe, grant 111004 
Schedule 
Planned start date of the study (FPFV): 01.11.2016 
Planned end date of recruitment (LPFV): 01.11.2017 
Planned end date of the study (LPLV): 01.05.2018 
 
Planned recruitment duration:  1 year 
Duration of single patient participation: according to 
tolerability and antitumor activity 
Planned overall duration of the study: 1.5 years 
 
 
 
 
 
*, times are selected by the decision of the investigator, patients in the verification groups are 
to be evaluated at least in one cycle of therapy 

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3.  Protocol overview 
3.1 Title of Study 
PHASE I STUDY OF tTF-NGR IN PATIENTS WITH RECURRENT OR 
REFRACTORY MALIGNANT TUMORS OR LYMPHOMAS BEYOND ALL 
STANDARD TREATMENTS 
 
3.2  Protocol summary 
Every year worldwide more than 8 million humans die from malignant diseases. The 
incidence of malignant diseases is increasing. Surgery, radiotherapy and systemic 
treatment with chemotherapy and immunotherapy have measurable therapeutic 
effects, but about half of the patients with cancer develop metastasis and have no 
curative outlook. There is an unmet need for new anticancer treatment strategies using 
innovative mechanisms of action. 
Antiangiogenesis therapy is a relatively new treatment approach for metastatic cancer. 
It interferes with the development of new vessel formation (neo-angiogenesis), which 
is essential for the spread of cancer. First agents, such as antibodies targeting vascular 
endothelial growth factor (VEGF) and small molecule receptor tyrosine kinase 
inhibitors have been shown to increase overall survival of patients with various tumor 
histologies for some months. Some agents are approved for medical use in cancer 
patients. Vascular targeting agents or vascular disrupting agents interfere and destroy 
already existing tumor vessels. Although interesting results from experimental and 
early clinical studies exist, no such agent is approved for clinical use. 
This document describes a clinical phase I study with an investigational medical 
product (IMP) inducing thrombosis of blood vessels in solid tumors by a fusion protein 
consisting of the extracellular domain of tissue factor (truncated tissue factor, tTF) and 
the peptide GNGRAHA, targeting aminopeptidase N (CD13) and the integrin v3 
(CD51/CD61) on tumor vascular endothelium. The designed fusion protein tTF-NGR 
retains its thrombogenic activity and demonstrated in vivo antitumor activity through 
partial or complete thrombotic occlusion of tumor vessels in human tumor xenograft 
models. Clinical first-in-man application of low dosages (up to 4 mg/m2) of this targeted 
coagulation factor revealed good tolerability and decrease of tumor perfusion as 
measured by magnetic resonance imaging (MRI).  

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In this phase I clinical trial cancer patients suffering from solid tumors or lymphomas, 
recurring after and/or refractory against standard treatment are treated intravenously 
(iv) with increasing doses of tTF-NGR. The objectives of this trial are to evaluate the 
maximum tolerated dose (MTD) and the dose-limiting toxicity (DLT) of intravenously 
(iv) infused daily applications of tTF-NGR for 5 days every 3 weeks in patients with 
cancer, who had obtained all standard treatment known for their disease entity prior to 
entry on study. Further objectives are to determine the perfusion and vascular volume 
fraction of measurable tumor lesions versus normal reference tissue before and after 
tTF-NGR application by MRI as a biological surrogate parameter for biological activity 
of the IMP and to obtain pharmacokinetic data. 
 
3.3 Trial Objectives 
Primary Objectives 
To evaluate the maximum tolerated dose (MTD) and the dose-limiting toxicity (DLT) of 
intravenously (iv) infused daily applications of tTF-NGR for 5 days every 3 weeks in 
patients with cancer (solid tumors and lymphomas), who had obtained all standard 
treatment known for their disease entity prior to entry on study.  
Secondary Objectives 
1. To determine the perfusion and vascular volume fraction of measurable tumor 
lesions versus normal reference tissue before and after tTF-NGR application by MRI 
as a biological surrogate parameter for biological activity of the IMP. Imaging will be 
preferentially done in the patients within the verification cohorts in at least one of the 
treatment cycles as determined by the investigator. 
2.  To obtain pharmacokinetic data of tTF-NGR. 
3.4  Investigational Medicinal Product 
The IMP is a fusion peptide of N-terminally histidine-tagged human truncated tissue 
factor (amino acids 1-218) and a C-terminal GNGRAHA binding peptide cloned into 
the expression vector pET-30(+)a (Novagen), generated by Escherichia coli (BL21 
DE3) and purified by high performance liquid chromatography (HPLC). Details are 
summarized in the accompanying Investigational Medicinal Product Dossier (IMPD). 

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3.5  Trial design 
Mono-center, non-randomised, open-label, multiple-dose level phase I trial. The study 
will be performed in the University Hospital Muenster (UKM). Patients will be treated 
with tTF-NGR by 1-hour iv infusions via central venous access daily for 5 days every 
3 weeks. Starting dose will be 1 mg/m2/day (for justification of this starting dose see 
IMPD). Dose escalation will be performed within a single patient in 0.5 mg/m2/day steps 
upon good toleration of the previous cycle. Patients within the dose-escalation part will 
be treated in sequence and not in parallel. Individual patients can undergo a maximum 
of 8 dose-escalations. The maximum number of 8 dose escalations is reached only if 
stable disease (SD) is ongoing upon 8 cycles of therapy. Dose-escalation is stopped 
before the maximum number of 8 escalation steps if tumor response, tumor 
progression or a Dose-Limiting Toxicity (DLT) is observed. In the case of SD and with 
good tolerability these patients can obtain further cycles without dose-escalation until 
tumor progression or Dose-Limiting Toxicity (DLT) and the next patient can start with 
dose-escalation cycles on the highest tolerable dose for the previous patient. A patient 
will undergo no further treatment in case of progressive disease or DLT, unless the 
DLT is resolved in a responding patient.  
Treatment will be followed by MRI tumor perfusion studies before treatment onset, on 
day 1 (4-6 hours after 1st application), and on day 5. Omission of MRT monitoring 
during single cycles is allowed as decided by the Investigator with the aim to 
concentrate MRT monitoring on the higher dose levels, in particular in the patients of 
the verification cohorts (see below).  
Pharmacokinetic monitoring will be performed as outlined below. 
3.6  Risk-Benefit Assessment   
Every year worldwide more than 8 million humans die from malignant diseases. The 
incidence of malignant diseases is increasing. Surgery, radiotherapy and systemic 
treatment with chemotherapy and immunotherapy have measurable therapeutic 
effects, but about half of the patients with cancer develop metastasis and have no 
curative outlook. There is an unmet need for new anticancer treatment strategies using 
innovative mechanisms of action. Patients accrued for this trial are suffering from 
relapsed or refractory solid tumors or lymphomas after standard therapy with no option 

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for further standard treatment leading to cure or prolongation of overall survival as 
judged by the investigator. 
The IMP, tTF-NGR, was developed as a new bifunctional protein carrying an essential 
pro-coagulatory molecule – tissue factor (TF) – via a C-terminal peptide (GNGRAHA) 
into tumor vessels to induce selective tumor vascular infarction. To this end the non-
specific membrane anchor of TF was replaced by the CD13-binding NGR motif. CD13 
is an aminopeptidase selectively occurring on stimulated and growing endothelial cells 
(EC), as on tumor endothelial cells, with only limited expression on normal tissue 
(http://www.proteinatlas.org/ENSG00000166825-ANPEP/tissue). With this molecule 
we target and accumulate TF in tumor vasculature and induce tumor vascular infarction 
leading to tumor cell death. tTF-NGR showed robust in vitro and in vivo activity. tTF-
NGR retains complete procoagulatory activity, specifically binds to CD13 on growing 
EC, it leads to tumor vessel infarction and occlusion with resulting tumor growth 
inhibition and regression in experimental models. Therapeutic activity of tTF-NGR was 
independent of tumor histology (e.g. melanoma, lung, breast, sarcoma). Repeated 
rounds of treatment showed no resistance development. Xenograft experiments in the 
mouse showed a safe therapeutic window.  
The IMP tTF-NGR will be given to few patients with intraindividual dose escalation in 
sequence until DLT is observed. Subsequently, 5 further patients will be treated 
sequentially within a verification cohort for DLT. In case a deadly DLT occurs, the 
verification cohort will be sequentially dosed at the next-lower dose level for safety 
reasons. Exact dose-escalation is described below. MTD is defined as the dose below 
observation of 2/6 patients with DLT. MTD dose level will then be verifyed by treating 
5 further patients on this dose level below the one on which DLT was observed. This 
will allow to reduce the risk of DLT to few individual patients and simultaneously avoid 
treating any patient at dose level so low, that antitumor activity can not occur.  
All patients (minimum 7 patients) treated within this protocol can hypothetically reach 
tumor control by the IMP with a minimum of only 2 patients at risk for DLT. Thus, the 
potential benefit for the individual patients treated within this study outweighs the risks.   
4. Background and Rationale 

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The scientific background and rationale for performing this phase I trial and the 
complete set of information on the IMP tTF-NGR are outlined in detail in the 
Investigational Medicinal Product Dossier (IMPD) on tTF-NGR. 
5.  Study Design 
This is an open-label, single-center phase I study of tTF-NGR in patients with relapsed 
and/or refractory solid tumors and lymphomas.  
Patients will be treated with tTF-NGR by 1-hour iv infusions via central venous access 
daily for 5 days every 3 weeks. Starting dose will be 1 mg/m2/day. Intraindividual dose 
escalation will be performed within one single patient in 0.5 mg/m2/day steps upon 
good toleration of the previous cycle. Patients within the dose-escalation part will be 
treated in sequence and not in parallel. Individual patients can undergo a maximum of 
8 dose-escalations. The maximum number of 8 dose escalations is reached only if 
stable disease (SD) is ongoing upon 8 cycles of therapy. Dose-escalation is stopped 
before the maximum number of 8 escalation steps if tumor response, tumor 
progression or a Dose-Limiting Toxicity (DLT) is observed. In the case of SD and with 
good tolerability these patients can obtain further cycles without dose-escalation until 
tumor progression or Dose-Limiting Toxicity (DLT) and the next patient can start with 
dose-escalation cycles on the highest tolerable dose for the previous patient. A patient 
will undergo no further treatment if any of the criteria under 7.4 is reached.  
Treatment will be followed by MRI tumor perfusion studies at cycles as decided by the 
Investigator as a surrogate marker for target-hit. MRI tumor perfusion studies will be 
performed before treatment onset, on day 1 (4-6 hours after application), and on day 
5. MRI will be done not in every cycle of every patient, but in every patient of the 
verification cohorts in at least one cycle. 
Toxicity monitoring will be performed according to the most recent version of the CTC 
criteria.  
MTD is the dose below the dose leading to reproducible episodes of Dose Limiting 
Toxicity (DLT). DLT will be characterized by clinical, blood and serum monitoring at 
specified time points before and during study period. 

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Antitumor activity and response will be determined according to RECIST criteria with 
extent of disease evaluation before and after treatment period and in 3-monthly 
intervals thereafter, or as defined by clinical needs. Waterfall-analysis for response 
quantification in % of the marker lesions before treatment onset and at best response 
will be done centrally by the study radiologist. 
Pharmacokinetic monitoring will be done as outlined below. 
6. Eligibility criteria and patient registration 
6.1  Inclusion Criteria 
Inclusion criteria for entry on trial are 
➢ age > 18 years 
➢ histologically proven or cytologically confirmed solid malignant tumor or 
malignant lymphoma 
➢ recurrent or refractory disease after standard therapy and with no known 
curative or survival-prolonging treatment options according to the judgement of 
the investigators 
➢ life expectancy of at least 6 weeks according to the judgement of the 
investigators 
➢ Karnofsky performance status > 50 
➢ measurable disease with at least one marker-lesion measurable in 2 
dimensions by Vascular Volume-Fraction-MRI 
➢ adequate bone marrow function with absolute neutrophil count                              > 
1000/microliter and platelet count > 50/nl. 
➢ normal global coagulation parameters (Quick, PTT, TZ, fibrinogen), no 
prophylactic anticoagulation 
➢ adequate liver function (total bilirubin < 3x the upper normal limit (ULN), 
SGPT/SGOT < 3x ULN) 
➢ adequate renal function (serum creatinine < 3x ULN) 
➢ no history of coronary heart disease, stroke, transitory ischemic attacks, 
pulmonary embolism, or deep vein thrombosis 
➢ time elapsed from previous therapy (including other IMPs) > 3 weeks with 
recovery from side effects 

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➢ exclusion of central nervous system (CNS) disease and CNS vascular 
abnormalities by MRI 
➢ ability to understand and provide written informed consent 
➢ written informed consent given 
➢ for female patients with child-bearing potential exclusion of pregnancy by 
adequate testing within 48 hours prior to entry on study 
➢ females of childbearing potential as well as fertile males must agree to use a 
highly effective form of contraception (Pearl Index < 1) during the study and for 
120 days following the last dose of the IMP 
6.2 Exclusion criteria 
➢ clinically significant unrelated illness which in the judgement of the investigators 
could compromise the patient’s ability to tolerate the IMP or be likely to interfere 
with the study procedures or results 
➢ known hypersensitivity reactions to prior application of E. coli-derived material 
➢ women with breast-feeding activity 
➢ concomitant use of any other investigational agent (agent for which there is 
currently no approved indication from regulatory authorities) 
➢ clinical application of any other drug with known antitumor activity 
➢ prophylactic anticoagulation within the last 3 days 
 
NOTE: Since this is a phase I study for end-stage cancer patients, patients who would 
be excluded from the protocol strictly for laboratory abnormalities only can be included 
at the Investigator’s discretion. This will be documented as an exception to the criteria 
and will be signed and filed in the CRF and the Trial Master File. 
 
Patient’s eligibility for entry to the study will be assessed by the Investigator or their 
delegated representative physician. Distribution of gender in the study population will 
be random and gender will be no factor influencing accrual. tTF-NGR is not expected 
to differ in its effects in male and female patients. 
 
Patients identified as eligible for entry into the study will be registered centrally through 
the study bureau of the Department of Medicine A (Hematology, Hemostaseology and 
Oncology) of the UKM.   

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7.  Treatment Plan 
7.1  Administration of tTF-NGR 
Patients will receive their assigned dose of tTF-NGR as an i.v. infusion via central 
venous access (PORT-systems allowed) with an infusion duration of 1 hour at a 
constant rate. The IMP is stored at -80oC and will be thawed, solved in saline and 
filtered (Millipore filter unit, 0.2 µm) short before application (see Appendix: Phase I: 
Rekonstitution tTF-NGR). 
Potential side effects and toxicities anticipated can be classified as those related 
to infusional reactions, venous thrombosis, arterial vascular occlusion and embolism, 
disseminated intravascular coagulation (DIC), tumor bleeding, antibody formation, liver 
toxicity, and transient thrombocytopenia (see IMPD).  Thus, treatment has to be 
performed obligatory in-house for the complete application time of 5 days with all 
appropriate drugs for hypertensive reactions, for fibrinolysis and anticoagulation ready 
to use and with appropriate transfusions of platelets and red blood cells available and 
prepared for. Constant back-up and information of the Intensive Care Unit (ICU) of the 
UKM is mandatory. 
7.2  General concomitant medication and supportive care 
Concomitant therapy and supportive care will be provided as deemed necessary by 
the Investigators and according to the institutional guidelines. 
7.3.  Other anti-cancer medication 
Administration of any other anti-cancer medication including chemotherapy and 
biologic therapy and other IMPs is not permitted during study period. Palliative 
radiotherapy of single tumor-lesions e.g. causing tumor-related pain is allowed, 
however, these lesions have to be excluded from response judgement. 
 
7.4  Duration of therapy and Study Period 
Treatment with tTF-NGR may continue until one of the following criteria applies: 
➢ disease progression 

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➢ intercurrent illness that prevents further administration of treatment according 
to the judgement of the Investigators 
➢ Occurrence of Dose Limiting Toxicity (DLT), i.e., unacceptable adverse 
event(s), including Grade > 3 (CTCAE) toxicity for any organ with the exception 
of the hematopoietic system or Grade 4 for the hematopoietic system attributed 
to the IMP 
➢ patient decides to withdraw from the study 
➢ general or specific changes in the patient´s condition rendering the patient unfit 
for further treatment in the judgement of the Investigators 
➢ patient is lost to follow-up 
➢ death 
Duration of Study Period with follow-up is defined as being 
➢ from day of signature of Informed Consent to 
➢ day 5 after the start of the last dose level plus 3 months of observation 
  
Patients will be removed from study treatment when any of the criteria listed under 
section 7.4 applies or the Study Period is completed.  
In patients with objective response and good toleration on a specific dose-level 
reached, or with stable disease upon 8 cycles of therapy, individual dose-escalation 
will be stopped and patients will be further treated for up to 3 months with the specific 
dose under which response occurred, or in case of stable disease with the dose at the 
8th cycle. If this patient is treated with dose-escalation steps, he/she will be replaced 
by the next patient to continue the dose-escalation. This is to not add further risk to an 
individual, when individual benefit is visible. Upon this time Study Period in these 
individual patients will end. These patients will be eligible for further compassionate-
use treatment with the IMP on the dose-level after completion of the Study Period as 
long as they benefit from treatment in accordance with §34 of the Declaration of 
Helsinki (2013 Fortaleza, Brazil). Serious adverse events (see paragraph 13 of this 
protocol) occurring during compassionate use treatment will be reported as within the 
defined Study Period to guarantee patient safety within this trial. 

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8.  Dosing delays and dose de-escalations in individual patients 
De-escalation in individual patients in dosing is not allowed during the Study Period to 
not interfere with the description of Dose Limiting Toxicity (DLT) and MTD.  
Delays in dosing of the next application for up to 6 days in individual patients are 
allowed in case anticipated adverse events connected with the composition of the  drug 
or the mechanism of action of tTF-NGR occur, which need to be addressed before 
treatment can continue. This is in particular foreseen in the following situations: 
1. Consumption of platelets due to tumor vascular coagulation with platelet count drops 
to grade 3 of CTCAE version 4.0 (page 112; 25.000 – 50.000 platelets per microliter) 
to allow recovery of counts to >50.000 per microliter, 
2. Infusional reactions due to the protein application in case tTF-NGR was applied 
without premedication (see below) to allow resolution to CTCAE grade <2 and a 
following application with premedication. 
However, in patients with objective response and good toleration of the drug, who are 
further treated in the compassionate-use program with the IMP after completion of the 
Study Period, dosing delays and/or modifications are allowed and handled according 
to the judgement of the Investigators. 
 
9.  Dose Limiting Toxicity (DLT) and Maximum Tolerated Dose (MTD)  
Dose Limiting Toxicity (DLT): DLT is defined as occurrence of toxicity of Grade 3 or 
more according to the revised NCI Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 (http://ctep.cancer.gov) for non-hematological toxicity or Grade 4 
or more for hematological toxicity. DLT must be considered by the investigator as being 
causally related to the IMP. In case the investigator comes to no decision, the data 
safety monitoring board is to be involved. Intensity of toxicity will be graded according 
to CTCAE using a five-point scale: 
 
 

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CTC 
Grade  
Equivalent To:  
 
 
Definition_________________________ 
 
Grade 1           Mild   
 
 
 
Mild; asymptomatic or mild 
symptoms; clinical or diagnostic 
observations only; intervention not 
indicated. 
 
Grade 2           Moderate  
 
 
 
Moderate; minimal, local or 
noninvasive intervention indicated; 
limiting age-appropriate 
instrumental Activities of Daily Living 
(ADL). 
 
Grade 3           Severe  
 
 
 
Severe or medically significant but 
not immediately life-threatening; 
hospitalization or prolongation of 
hospitalization indicated; disabling; 
limiting self care ADL. 
 
Grade 4           Lifethreatening/Disabling                  Life-threatening consequences; 
urgent intervention indicated 
 
Grade 5  
Death   
 
 
 
Death related to AE. 
When DLT is observed in the 1st patient, up to 5 more patients will be treated on the 
same dose level, or in case of deadly DLT in the dose level below (verification group 
for DLT; maximum of 6 patients on this level). Upon observation of no additional DLT 
after treating 6 patients on this dose level dose escalation can be resumed in one 
patient. The remaining 5 patients can be treated without dose-escalation until tumor 
progression or DLT. Upon observation of one more episode of any DLT within the 
verification group, patient accrual to this verification group is stopped with this second 
patient with DLT and de-escalation by a 0.5 mg/m2/day step is performed in 5 further 
patients until ≤1 DLT occurs in 5 further patients treated on a specific dose-level, i.e. 
with ≤1/6 patients in total with DLT on this dose level (scheme see below). 
Maximum Tolerated Dose (MTD): MTD is the dose below the lowest dose level on 
which reproducible episodes of any DLT are observed. Reproducible episodes of DLT 
have also to be stated if DLT occurs in different organ systems of individual patients. 
 

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10. Dose escalation and de-escalation according to toxicity and dose 
recommended for phase II trials (RDPII)  
The patients will be treated daily with tTF-NGR by 1-hour iv infusions for 5 days with 
MRI studies before, 4-6 hours after the 1st application, and on day 5 after treatment 
as decided by the Investigator. 
Starting dose will be 1 mg/m2/day. Intraindividual dose-escalation will be performed in 
1 patient in 0.5 mg/m2/day steps (to a maximum of 8 cycles) upon a rest period of 16 
days for the next treatment cycle of 5 days. The maximum number of 8 dose 
escalations is reached only if stable disease (SD) is ongoing upon 8 cycles of therapy. 
Dose-escalation is stopped before the maximum number of 8 escalation steps if tumor 
response, tumor progression or a Dose-Limiting Toxicity (DLT) is observed. If tumor 
response is observed or if a patient is diagnosed with progressive disease (PD) after 
> 2 cycles or clinically as judged by the investigator even before 2 cycles, this patient 
will go off study and will be replaced by a further patient in whom individual dose 
escalation will be resumed, starting with the highest dose level reached without DLT in 
the previous patient. When any DLT is observed in this patient, intraindividual dose 
escalation is stopped and the patient is taken off study. In case of stable disease or 
response and resolution of the DLT this patient can be further treated on the highest 
tolerable dose level without DLT until any of the criteria under 7.4 is reached. This 
treatment will then be given on an individual compassionate-use basis (off study) 
according to § 34 of the Helsinki declaration (2013, Fortaleza; Post-Trial Provision). 
If this first observed DLT is nonfatal, up to 5 more patients will then be treated on the 
same dose level having caused DLT (verification group). Patients of the verification 
group will be treated in sequence of each other, thus a patient has to tolerate the first 
cycle (5 days) and the rest period of 16 days without DLT before the next patient can 
be added to this verification group.  
Upon observation of no additional DLT in the verification group in a minimum of 2 
cycles for each patient, dose escalation can be resumed in one patient out of these 
until DLT (continue as above). The remaining patients in the verification group will be 
further treated at this dose-level until any of the criteria under 7.4 is reached.  

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Upon observation of one more episode of any DLT within the first 2 cycles given to the 
patients in the verification group, patient accrual to this verification group is stopped 
with this second patient with DLT and de-escalation by a 0.5 mg/m2/day step is 
performed in further up to 5 patients. If on the next lower dose level there are ≥2 DLT 
in 5 further patients (i.e., ≥2 DLT in 6 patients in total on this dose level), de-escalation 
will continue. In case, patients of the verification group experience DLT in a later cycle 
(3rd and following), this will be counted as DLT with all consequences, although the 
procedure of the study was not influenced before such an event occurred. 
 
Dose de-escalation will continue until ≤1 DLT occurs in 5 further patients treated on a 
specific dose-level, i.e. there are ≤1/6 patients with DLT in total on this dose level. This 
dose level is declared the MTD and will be recommended for further studies, such as 
phase II trials (RDPII). 

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If an observed DLT is fatal, the above dose escalation scheme is modified. Denote this 
dose dfatal. In the unlikely event that further patients are treated with this dose, 
treatment in these patients will be stopped at this dose level and the investigator 
decides how to go on with the treatment in these patients. The next patients will not be 
treated with the dose dfatal, but on the next lower dose level dfatal - 0.5 mg/m2/day. If on 
the dose level dfatal - 0.5 mg/m2/day no DLT or not more than 1 DLT is observed that is 
non-fatal, further patients are treated on the dose level dfatal until any further DLT is 
observed or 6 patients are included on this dose level in total. Possible later dose 
escalation to a level at which one death occurred has to be discussed with the data 
safety board. 
Only in the very unlikely event, that DLT occurs at the starting dose or the dose 0.5 
mg/m2/day higher, further dose de-escalation below the starting dose level can be 
performed as described to establish MTD. 
The above procedure is constructed so that MTD is defined similarly to a standard 3+3 
design. I.e., any dose with observed DLT in ≤1/6 patients is defined to be the MTD, if 
on the next higher dose level the observed number of patients with DLT is ≥2/6. The 
following summary visualizes this procedure: 
Start 1 pt at 1 mg/m2/day with individual dose escalation at 0.5 mg/m2/day for 5 days 
every 3 weeks until any DLT (= dose “d1”) or to a max of 8 cycles 
 ➢Verification group (VG) of ≤5 further pts at d1 without indiv. dose esc. 
 
(➢Verification group (VG) of ≤5 further pts at d1-0.5mg/m2/day without indiv. 
 
 
     dose esc. in case a death occurs as DLT) 
    ➢No further DLT in VG ➢resume dose escalation: start 1 pt of VG 
at d1 + 0.5 mg/m2/day (d), then as above 
                               ➢1 further DLT  in VG ➢ dose de-escalation d1 - 0.5 mg/m2/d,  
5 further pts (d-1(-2)) 
 
 
 
          ➢ ≤1 further  DLT: d-1 = MTD 
          ➢>1 further DLT ➢dose de-escalation, continue as    
 
above 
 
Again, if a patient has been taken off the study due to a DLT or progressive disease, 
the patient may further be treated as follows. If the patient has stable disease or 
response and the DLT has been resolved, outside the study the patient may be treated 

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with the study medication on the highest tolerable dose level without DLT (§ 34 
Declaration of Helsinki, Fortaleza 2013). In case of progressive disease or if the DLT 
has not been resolved, different treatment options are offered. 
11.  Study objectives and end-points 
Primary Objectives 
To evaluate the maximum tolerated dose (MTD) and the dose-limiting toxicity (DLT) of 
intravenously (i.v.) infused daily applications of tTF-NGR in patients with cancer (solid 
tumors and lymphomas), who had obtained all standard treatment known for their 
disease entity prior to entry on study.  
Secondary Objectives 
1. To determine the perfusion and vascular volume fraction of measurable tumor 
lesions versus normal reference tissue before and after tTF-NGR application by MRI 
as a imaging surrogate parameter for biological activity of the IMP. 
2.  To obtain pharmacokinetic data of tTF-NGR. 
Primary Safety end-point 
Maximum Tolerated Dose (MTD). MTD is the dose below the dose leading to 
reproducible episodes of Dose Limiting Toxicity (DLT) in at least 2/6 patients. DLT will 
be characterized by clinical, blood and serum monitoring at specified time points before 
and during study period. 
Secondary Safety end-points 
1. Occurrence and frequency of inhibition of tumor blood flow as measured by 
contrast-enhanced Magnetic Resonance Imaging (MRI).  
2. Occurrence and frequency of tumor response defined as Complete Response 
(CR), Partial Response (PR), or Stabile Disease (SD) as defined by RECIST 
criteria. 
Descriptive statistics will be used. 
 

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12.  Patient evaluation and follow-up  
Patients will be evaluated as outlined in the study calendar below. The time-points 
given are in relation to IMP application. Additional visits will occur as clinically 
indicated.  
 
Study Calendar for each 5-day cycle 
 
*, times are selected by the decision of the investigator, patients in the verification groups are 
to be evaluated at least in one cycle of therapy 
 
12.1 History, physical examination and summary of laboratory investigations 
A full history and physical examination will be done pre-IMP infusion, and thereafter 
as indicated in the study calendar. Examination also comprises statement on the 
performance score (Karnofsky index) of the patient and an ECG. Lab tests comprise 
a full blood count, urea, creatinine, electrolytes, glucose, protein, lipids, bilirubin, ALT 
(SGOT), AST (SGPT), AP, LDH, PCHE, ferritin, haptoglobin, CPK, troponin, lactate, 
standard urinalysis and coagulation assays. Coagulation assays comprise Quick, PTT, 
TZ, fibrinogen, fibrin-split-products, alpha 2 AP, AT III, D-dimers.  Human anti-human 
antibodies (HAHA) will be tested for as indicated. 
 
12.2 Clinical/blood assessment of toxicity 

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Clinical and blood assessment of toxicity will be done in intervals given in the study 
calendars during study period according to NCI CTCAE as stated above in section 9 
of this protocol.  
12.3 Pharmacokinetics 
For pharmacokinetic studies the IMUBIND® assay will be used according to the 
protocol given by the manufacturer. Blood samples will be collected at the time points 
indicated in the calendars and stored frozen until testing. Since there is data from the 
first testings in patients treated that the half-life of tTF-NGR (t1/2) is in the range of few 
hours, the time point given as “1h” in the calendars will be indeed multiple samplings 
in 30 min intervals for the first 5 hours. 
 
12.4 Adverse events and unexpected toxicities 
All adverse events will be assessed by the Investigator for their seriousness, 
expectedness and relationship to the study protocol. If appropriate, the IMPD will be 
referenced. Anticipated toxicities are listed in the IMPD. If the tTF-NGR is suspected 
of causing unexpected serious adverse reactions, SUSAR reporting will be instigated 
as in section 13 below and the Investigator and sponsor informed immediately. It is the 
Sponsor’s responsibility to report any SUSARs to the Bundesoberbehörde Paul-
Ehrlich-Institute complying with the mandated timelines  (7 days for fatal and life-
threatening events and within 15 days for all others). Additional information will be 
provided as relevant within the 8 day designated time-frame. The Sponsor will also be 
responsible for reporting to the Regulatory Authorities, Ethics Committees and 
Principal Investigators as per current legislation.  
12.4.1  Data and safety monitoring board (DSMB) and Trial Steering Committee 
(TSC)  
The Data and Safety Monitoring Board (DSMB) comprises 3 clinicians with appropriate 
expertise, all of whom are independent of the sponsor and have no involvement in the 
development of the protocol. The DSMB will consist of Univ.-Prof. Dr. Ulrich Dührsen 
(Director, Department of Hematology, University Hospital Essen), Prof. em. Dr. 
Normann Willich (Geschäftsführer, Deutsche Ges. für Radioonkologie), and Prof. Dr. 
Carsten Bokemeyer (Director Department of Medicine – Hematology and Oncology, 
University Hospital Hamburg). Procedures governing the convening and execution of 

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the responsibilities of the DMC will be specified separately in a written DMC Charter. 
The DSMB will review data on recruitment, safety and data collection and will advise 
the Trial Steering Committee (TSC) on whether it is appropriate for the trial to continue. 
The TSC will consist of Prof. Dr. Wolfgang E. Berdel (Director Department of Medicine 
A, UKM), Prof. Dr. Rolf Mesters (Co-Investigator), and Prof. Dr. Andreas Faldum (Trial 
statistician). 
 
13.  Reporting requirements 
All patients will be registered on the study enrollment log and data on study end-
points will be kept on Case Report Forms (CRFs) for each subject. 
13.1 Definitions of Adverse Events 
Adverse Events are defined according to the Directive 2001/20/EC, the European 
Detailed Guidance CT 3, corresponding to the relevant definitions in the German GCP 
Ordinance.  
Adverse Event (AE) 
This is defined as any untoward medical occurrence in the patient administered an 
investigational medicinal product that does not necessarily have a causal relationship 
with this treatment. An AE is therefore described as any unfavorable and unintended 
sign (including abnormal laboratory results), symptom or disease temporally (timely) 
associated with the use of an investigational medicinal product, whether or not related 
to the product. 
Clarification:  
• 
A pathological finding, improved or unchanged in comparison to its status before 
first administration of the investigational medicinal product, does not constitute an 
adverse event. 
• 
Symptoms of the disease under study should not be classified as AEs as long as 
they are within the normal day-to-day fluctuation or expected progression of the 
disease, and as long as they are not serious.  

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• 
Laboratory test value abnormalities will be reported in the CRF. Abnormal values 
should not be reported on the AE page of the CRF unless they are associated with 
a clinically relevant condition. 
 
 
Adverse Reaction (AR) 
An adverse reaction is defined as any untoward and unintended response in a subject 
to an investigational medicinal product, related to any dose administered. A causal 
relationship between the investigational medicinal product and the adverse event is at 
least a reasonably possibility, which means that there are facts or arguments to 
suggest a causal relationship. 
The definition covers also medication errors and uses outside what is foreseen in the 
protocol, including misuse and abuse of the product. 
 
Serious Adverse Event (SAE) 
A serious adverse event is defined as any untoward medical occurrence in the patient 
administered a pharmaceutical product, which does not necessarily have a causal 
relationship with this treatment, and that at any dose: 
➢ results in death 
➢ is life threatening (at immediate risk of death at the time of the event) 
➢ results in persistent or significant disability/incapacity 
➢ requires in-patient hospitalization or prolongs existing hospitalization* 
➢ results in a congenital abnormality or birth defect 
➢ is medically significant (i.e. any event which the investigator considers 
significant but which is not covered by the above.) 
*: Hospitalization means overnight admission. Hospitalization without underlying 
adverse event (AE) is not an SAE. Examples are:  
• Hospitalization for protocol procedures e.g. chemotherapy, biopsy or 
monitoring of the study 
• Elective hospitalization for a pre-existing condition (i.e. a condition other than 

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the indication for the chemotherapy) that has not worsened  
• Admission to a rehabilitation centre or hospice.  
 
Unexpected Adverse Reaction  
“Unexpected” means that the nature, severity or outcome of the adverse reaction is 
not consistent with the applicable product information for the investigational medicinal 
product, which is the current version of the IMPD. 
• The term “severe” is often used to describe the intensity (severity) of a specific 
event. This is not the same as “serious,” which is based on patient/event outcome 
or action criteria. 
• Reports which add significant information on the specificity, increase of occurrence, 
or severity of a known, already documented serious adverse reaction constitute 
unexpected events. 
 
Suspected Unexpected Serious Adverse Reaction (SUSAR)  
A suspected unexpected serious adverse reaction (SUSAR) is a serious adverse 
reaction that has been judged to be unexpected. 
 
Severity  
Severity for each adverse event, including any lab abnormality, will be determined by 
using the National Cancer Institute Common Toxicity Criteria (NCI CTCAE, version 
4.0) as a guideline, wherever possible. The criteria are available online at 
http://ctep.cancer.gov/reporting/ctc.html. In those cases where the NCI CTC criteria do 
not apply, severity should be defined according to the general CTCAE definitions of 
grades (see chapter 9). 
 
Causality 
Relationship to study drug administration will be determined as follows: 
• Reasonable possibility 
There are facts or arguments to suggest a causal relationship. 

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• No reasonable possibility 
Time relationship is improbable and another explanation is more likely (e.g. disease 
or other drugs provide plausible explanation). 
 
13.2 Procedures for Adverse Event reporting 
 
All Adverse Events 
Toxicity will be monitored from the first study-related procedure (tTF-NGR application) 
until 8 days post last administration of tTF-NGR. All adverse events including serious 
adverse events that occur during this period will be recorded in the CRF.  
Investigators must record in the CRF (Case Record Form) and the patient notes their 
opinion concerning details of nature, onset, duration/end, severity, seriousness, 
relationship to the IMP tTF-NGR and action taken concerning the IMP. Medical 
terminology should always be used to describe any event. Investigators should avoid 
vague terms such as “sick”. If possible, a diagnosis rather than a list of signs, 
symptoms and laboratory abnormalities should be given.  
All SAEs will also be reported to the Sponsor using the Serious Adverse Event Form. 
Serious adverse events (SAE) reporting  
The investigator has to report any SAE occurring from the first study-related procedure 
(tTF-NGR application) until 8 days post last administration of tTF-NGR, including any 
compassionate use treatment after end of a patient’s study period. If the investigator 
suspects a reasonable causal relationship to the investigational medicinal product in 
an SAE occurring even later, this event should also be reported to the Safety Desk.  
SAE reporting has to be done within 24 hours of knowledge by faxing the SAE form to 
the sponsor’s Safety Desk. Personal data have to be replaced by the trial patient 
number before forwarding any information.  
 
 
 
 

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Safety Desk Contact 
Zentrum für Klinische Studien (ZKS) Münster 
Von-Esmarch-Straße 62 
48129 Münster 
Germany 
Fax:     0251 83 57112 
Phone: 0251 83 57109 
E-Mail: mssd@ukmuenster.de 
 
Where possible, a diagnosis rather than a list of symptoms should be given. The 
investigator is responsible for assessing seriousness, severity (CTCAE v4.0) and 
causality of the SAE. The SAE form should be completed with as much information as 
possible. The investigator should not wait for full details before making the initial report.  
Minimal information to be included in any initial report:  
1. Trial patient number 
2. Detailed description of the event  
3. Details about administration of the IMP  
4. Causality assessment of SAE to the IMP 
5. Reporting person 
 
The immediate reports should be followed promptly by detailed, written reports. In case 
of death, an autopsy report should be provided, if any. For reported deaths, the 
investigator should also supply the competent authority and the Ethics Committee with 
any information, if additionally requested by them.  
 
All Serious Adverse Events will be followed up until resolution or definite outcome. The 
investigator will be asked to provide interim and follow-up reports, as necessary, if the 
SAE has not resolved at the time of initial report. The investigator should answer all 
queries from the Safety Desk as soon as possible.  
Monitoring pregnancies for potential Serious Adverse Events  
Pregnancy is not serious by itself. However, if a subject has a positive pregnancy test 
during trial participation, this is reportable on an SAE form in order to identify and 
follow-up on outcome of pregnancy and on any congenital abnormalities. The report 

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should be made as soon as the investigator gains knowledge of the event. Follow-up 
of a pregnancy will be done using specific additional questionnaires supplied by the 
Safety Desk if required. Information will be collected as far as covered by consent 
(information about the partner or about a child needs to be covered by consent of the 
patient’s partner, too). 
 
13.3 Sponsor’s obligations 
The Safety Desk will document each SAE, check it and query additionally required 
information.  
Fulfilling sponsor’s responsibilities, the Investigator will review each SAE again for 
seriousness and relatedness. Furthermore he will assess whether a serious adverse 
reaction is expected or unexpected (SUSAR) according to the current version of the 
IMPD, and whether any SAE might influence the benefit-risk-ratio or might require 
changes in the conduct of the trial. 
It is the duty of the sponsor’s Safety Desk to inform the Ethics Committee, the 
Competent Authority and participating investigators of all SUSARs in accordance with 
legal requirements (immediately, fatal or life-threatening SUSARs by the latest within 
7 calender days, other SUSARs by the latest within 15 calender days of first 
knowledge. For fatal or life-threatening SUSARs, additional information will be 
provided as relevant within a further 8 days.). SUSAR follow-up reports will be 
submitted, if appropriate. 
The Safety Desk will observe SUSAR cross reporting obligations with other trials of the 
same sponsor investigating the same active substance, if any. 
The Investigator is responsible for the ongoing safety evaluation of the trial. The Safety 
Desk and the Investigator will inform each other immediately about any relevant safety 
information coming to their knowledge. In case of safety relevant issues (besides 
SUSARs) which require expedited reporting, the Safety Desk will support the 
Investigator in submitting an appropriate report in due time. This includes issues which 
might materially alter the current benefit-risk assessment of an investigational 
medicinal product or that would be sufficient to consider changes in the investigational 
medicinal product’s administration or in the overall conduct of the trial as well as urgent 
safety measures to protect the subjects against any immediate hazard. 

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Annual safety reports will be prepared and submitted in accordance with legal 
requirements (Development Safety Update Report, DSUR). The Investigator is 
responsible for providing the updated benefit-risk assessment of the trial for the report 
(passages requiring medical assessment). The Safety Desk is responsible for 
preparing the other parts of the report, finalizing it and submitting it to the Competent 
Authority and the Ethics Committee in due time. The report will be prepared annually 
from the date of the initial clinical trial authorisation and submitted within 60 days of 
data lock point (day before anniversary of initial authorisation). Additional reports will 
be prepared on request by the Competent Authority or the Ethics Committee. 
Details of all AEs will be reported to the Competent Authority on request. 
 
14.  Anticipated Risks for the Subjects 
According to the first-in-man experience doses of tTF-NGR up to 4 mg/m2 are tolerated 
without side effects when infused over a central venous access for 1 hour with weekly 
intervals. Single patients have been treated up to 5 times with weekly intervals. 
Anticipated side effects and toxicities are classified as those related to infusional 
reactions, venous thrombosis, arterial vascular occlusion and embolism, disseminated 
intravascular coagulation (DIC), tumor bleeding, antibody formation, liver toxicity, and 
a transient thrombocytopenia.  A detailed justification of the starting dose for tTF-NGR 
in this trial is given in the IMPD. 
14.1 Infusional reactions 
Allergic reactions including rash, fever, rigors and bronchospasm are possible after 
infusion of proteins. This did not happen during the treatment of the first patients. 
However, in case these side effects occur, patients will be premedicated with 
chlorpheniramine, paracetamol and corticosteroids to prevent such reactions. 
 
14.2 Venous thrombosis 
The occurrence of venous thrombosis has not been observed in the patients treated 
with tTF-NGR. Additionally, such an event is unlikely, since there are rare binding sites 
for the NGR-binding moiety in venous endothelial cells of adult vessels. However, after 
repeated injections of the IMP into the tail veins of mice, acral necrosis occurred and 
high local concentrations might theoretically induce venous thrombosis. Thus, tTF-

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NGR has to be infused over a time period of 1 hour via a central venous access. 
Patients have to be treated in-house with all appropriate drugs for fibrinolysis and 
anticoagulation ready to use. 
14.3  Arterial vascular occlusion and embolism 
The occurrence of arterial vascular occlusion and/embolism has not been observed in 
the patients treated with tTF-NGR. It also did not occur in mice treated within the 
therapeutic dose range. However, in the safety pharmacology studies with mice to 
establish limiting toxicity and maximum tolerated dose, we have observed pulmonary 
embolism and indirect signs of infarction in brain histology of mice deceasing upon 
treatment (see IMPD). Thus, patients have to be treated in-house with close back-up 
of an intensive care unit (ICU), their vital parameters (including ECG-monitoring, 
capillary O2-saturation) and clinical symptoms have to be checked upon continuously 
during the infusion and for at least 5 hours afterwards by the investigator or a trained 
physician and in intervals later as specified by the protocol. Repeated checks on 
appropriate blood and serum parameters such as troponin and creatinine 
phosphokinase isoenzymes are outlined above. Appropriate drugs, including those for 
fibrinolysis and anticoagulation have to be ready for use. 
14.4  DIC 
DIC was not observed in the patients treated with tTF-NGR thus far. However, DIC can 
occur theoretically upon dose escalation. Thus patients have to be treated in-house as 
outlined above and have to be tested repeatedly for blood and serum parameters such 
as platelet count, D-dimer, fibrinogen, fibrin split products, plasmatic coagulation 
parameters as outlined above. 
14.5 Tumor bleeding 
During the preclinical studies we have observed thrombosed tumor vessels with blood 
pooling, disruption of vessels and intratumoral bleeding (see IMPD). This effect is 
part of the mechanism of action of tTF-NGR, which enriches and binds in tumor 
vessels and causes local thrombosis. During all animal studies we have observed 
sporadic deaths of treated mice with no clear dose-dependency. However, we had 
the impression this was occurring more often with animals carrying large tumors of 
>0.5 cm3. Thus, tumor bleeding may occur. It may preferentially occur in patients with 

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large tumor masses. Thus, patients have to be treated in-house with appropriate 
transfusions of platelets and red blood cells available and prepared for. 
14.6 Antibody formation 
Human anti-human antibody (HAHA) formation is a theoretical concern although highly 
unlikely. 1. The amino acid sequence of the tTF-moiety is the unchanged human 
sequence and thus should be of low or absent immunogenicity. 2. The short NGR-
binding moiety used has been reported as being of very low or absent immunogenicity 
(Di Matteo P et al. Immunogenic and structural properties of the Asn-Gly-Arg (NGR) 
tumor neovasculature-homing motif. Mol. Immunol. 43: 1508-1518, 2006). 3. The His-
tag consists of less than 50 amino acids. However, antibody formation could occur 
after repeated application and possibly interfere with the therapeutic activity of tTF-
NGR. Thus, patients with longer treatment duration will be monitored for HAHA 
formation. 
14.7  Pregnancy, Breast Feeding and Fathering of a Child 
There are no data on embryonal or fetal toxicity of tTF-NGR. Since endothelial cells in 
blood vessels of a growing fetus might express the targets CD13 and 
lphav eta3, 
treatment of pregnant women has to be avoided. Premenopausal women are only 
allowed to participate in trials with the IMP under strict birth control and upon a negative 
result of a pregnancy test. Female patients are considered to have no child bearing 
potential if they are permanently sterile or post-menopausal. Permanent sterilization 
methods include hysterectomy, bilateral salpingectomy and bilateral oophorectomy. A 
postmenopausal state is defined as no menses for 12 months without alternative 
medical cause. 
 
Female patients of childbearing potential (and male patients with a partner of child 
bearing potential) must agree to use a highly effective contraceptive method (Pearl 
index <1) throughout the study period and during the 2 months thereafter. 
14.8 Liver toxicity 
Since we have observed increase in bilirubin levels to values higher than the upper 
limit normal in the dog toxicology (see IMPD) liver toxicity including bilirubin values has 
to be monitored carefully throughout the study. 

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14.9 Transient thrombocytopenia 
We have observed transient platelet drops under therapy with tTF-NGR in single 
patients before, which are possibly due to consumption of platelets within the tumor 
vascular infarction. Thus, this phenomenon might belong to the mechanism of action 
of the IMP. It is therefore necessary to treat the patients within this phase I study as 
"in-house" patients, to make fast transfusions of platelets realistic. 
 
15.  Assessment of disease status 
Assessment of disease status is made at the time points given in the study calendars. 
Disease response criteria are according to the RECIST guidelines. The study 
radiologist will give special attention to tumor necrosis in lesions not shrinking in their 
outer diamenter and report these in addition. As a surrogate parameter for target hit, 
MRI will be performed. Vascular volume fraction will be measured to quantify reduction 
of blood flow in the tumor induced by tTF-NGR. These data will be reported in addition. 
 
16.  Statistical Considerations 
All statistical evaluations within the study will be performed by Prof. Dr. J. Gerß. 
 
 
16.1. Estimation of the number of patients needed to complete this trial. 
The number of patients needed for completion of this trial is determined by the 
occurrence of dose limiting toxicity (DLT). 
A first patient will be treated daily with tTF-NGR by 1-hour iv infusions for 5 days. 
Starting dose will be 1 mg/m2/day, intraindividual dose-escalation will be performed in 
0.5 mg/m2/day steps upon a rest period of 16 days for the next treatment cycle of 5 
days in this patient. If diagnosed with progressive disease (PD) after 2 cycles or 
clinically as judged by the investigator even before, this patient will go off study and 
will be replaced by a further patient in whom individual dose escalation will be resumed. 
Upon occurrence of DLT up to 5 further patients will be treated at this specific dose in 
a verification cohort. Further procedure such as de-escalation and definition of MTD 
and dose level recommended for further clinical trials will be performed as described 
above. Thus, a minimum number of patients to reach objectives of this study are 
envisaged as being 7 patients. This number of patients represent 1 patient for first 

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dose-escalation with DLT at the highest dose, starting the verification cohort and 
reproduction of DLT in the first patient (of up to 5 patients) of the verification cohort, 
de-escalation with -0.5 mg/m2/day in 5 further patients with ≤1 additional DLT.                          
 
 
Possible higher numbers of patients in situations such as with no additional DLT in 
the verification group and further dose-escalation is possible, but cannot be 
determined before the study with confidence. 
17. Study duration, Premature Termination of the Study  
Planned start date of the study (FPFV, first patient first visit):  
01.11.2016  
  
Planned end date of recruitment (LPFV, last patient first visit):  
01.11.2017 
 
Planned end date of the study: 
 
 
 
 
 
01.05.2018 
 
Planned duration of single patient participation: according to occurrence of DLT and 
antitumor activity 
 
Planned duration of recruitment:   
 
 
01.11.2016 - 01.11.2017 
 
Planned overall duration of the study:   
 
01.11.2016 - 01.05.2018 
 
Planned duration of follow up of individual patients within study: 
   3 months 
 
Definition of the End of the Study 
To allow reasonable time for evaluation and report, the end of study is plannned to be 
at "last patient last visit" (LPLV). 
 

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Premature Study Termination 
Premature Termination of Study Participation of a Single Patient 
A patient is free to withdraw consent and discontinue participation in the study at any 
time, without prejudice to further treatment according to standard clinical practice. In 
this case the patient will be asked to permit the conduct of the study termination visit. 
In certain circumstances the investigator may exclude a patient from further study 
participation irrespective of the patient’s will. Reasons may be: 
• treatment failure 
• insufficient compliance 
• further participation might jeopardize the patient’s health or well-being 
• the patient was administered medication which is not permitted 
• termination of the entire study. 
If, after treatment initiation, a patient’s participation is realized not to agree with the 
inclusion and exclusion criteria, the Investigator will decide on further participation. 
In case of premature termination, the reason will be recorded on the CRF. 
 
Premature Termination of the Entire Study 
The sponsor may terminate the entire study for relevant medical or administrative 
reasons. Reasons for termination will be documented in detail. Particular reasons for 
termination of the study may be: 
• insufficient recruitment 
• serious problems with the quality of the study data which cannot be solved 
• discovery of an unexpected, serious and unacceptable risk to patients enrolled 
in the study 
• new scientific evidence suggesting that study continuation is not justified. 
 
 
18.  Informed Consent 
As the study is performed in Muenster, Germany and is a monocentric study, the 
informed consent form will be provided in German as in Appendix 2. 
Prior to inclusion into the study, the investigator informs each patient about nature, 
significance, implications, and risks of the study as well as about the patient’s right to 
withdraw from study participation at any time without any resulting detriment. Further, 

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the patients are informed that an insurance has been taken out to cover risks 
originating from the study. According to the insurance conditions, they are advised to 
immediately inform the investigator if they were treated for an emergency and not to 
undergo any other medical treatment without prior consultation with the investigator.  
 
Additionally, patients are handed out the patient information sheet incl. the informed 
consent form which are provided for this study. Patient consent in study participation 
must be given in writing. Before informed consent is requested, patients are left 
sufficient time for consideration. They are provided the opportunity for clarification of 
any study issues. 
According to German drug law (“Arzneimittelgesetz”) §40(2a) patients are informed 
that their disease related data are stored in a pseudonymized way and used for 
scientific evaluations. For study participation they must agree therein in writing. 
The informed consent form is dated and signed by the patient and by the investigator. 
The originally signed informed consent form is archived in the investigator site file. A 
copy of the signed informed consent form (or a second original) is handed over to the 
patient together with a copy of the patient information sheet and a copy of the general 
conditions of the patient insurance. 
If the patient is unable to write, in exceptional cases, instead of the written consent 
required, oral consent in the presence of at least one witness, who was also included 
when the patient was being informed may be given. The witness may not be anyone 
working at the study site nor a member of the investigating team. The orally given 
consent has to be documented in writing, dated and signed by the witness. 
In case of any study issue which requires a change of the patient information sheet, 
patients already included into the study must, if relevant to them, be informed about 
these issues orally and in writing and their written consent in further study participation 
must be obtained. 
Note: Before undergoing any study specific procedure the patient must have 
provided written informed consent!  
 

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19.  Study Administration 
This study will be conducted in compliance with the protocol, the International 
Conference on Harmonisation of Good Clinical Practice (ICH GCP) guidelines and the 
Declaration of Helsinki (Fortaleza, 2013), the requirements of the current German drug 
law (“Arzneimittelgesetz”), the current legal provisions regarding data protection, and the 
principals of Good Clinical Practice.   
The present study will not be started before the competent ethics committee has given 
a favorable opinion and an approval by the competent federal authority has been 
obtained.  
 
In case of substantial amendments, a new application will be submitted to the ethics 
committee and/or the competent federal authority. Changes will not be implemented 
unless the competent ethics committee has given a favorable opinion and/or the 
competent authority has granted an approval. 
 
Issues, which always require a favorable opinion of the ethics committee are for 
example: 
• inclusion of additional study sites, 
• change of the investigator or his deputy, 
• changes in any documents addressed to study participants or in any study 
information addressed to potential study participants. 
 
According to German drug law §67, the investigator is required to notify the local 
surveillance authority about the beginning, the end and a premature termination of the 
study, about any substantial amendments and if the study is on hold. These 
notifications will be performed by an appointee of the sponsor (GCP-V, §12(3)).  
Additionally, the investigator is required to notify the competent federal authority of the 
beginning of the study. 
19.1 Sponsor  
This study is sponsored by the University Hospital Muenster (UKM). The study will be 
monitored by the Centre for Clinical Trials Münster of the UKM, the Zentrum für 
Klinische Studien (ZKS) Münster and performed according to the standard operating 
procedures of the ZKS Münster.  

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19.2 Monitoring 
In order to ensure a high degree of data quality, the study site will be monitored during 
the recruitment and follow-up period (frequency depending on the site’s recruitment).  
The objectives of the monitoring procedures are to ensure that the study safety and 
rights of the study subjects as a study participant are respected and that accurate, valid 
and complete data are collected, and that the study is conducted in accordance with 
the study protocol, the principles of GCP and local legislation. 
The investigator agrees that the monitor will visit the study site in appropriate intervals. 
During these visits the monitor will check the quality of the data recording and ensure 
that the study site adheres to the timeframe as set in the study protocol. The 
investigators agree to provide any relevant information and documentation whenever 
the monitor requires this information. This includes access to all original study 
documents and source data. 
 
It is the responsibility of the investigator to keep the participant’s chart as complete as 
possible (e.g. history, concomitant diseases, inclusion in the clinical study, visit dates, 
results of laboratory tests, distribution of the study medication, and adverse events). 
Source data are checked and compared with entries in the eCRF. The participant has 
given consent with this procedure by signing the patient information and written 
informed consent form. Additional tasks of the monitor are: 
• to check, whether the study site fulfils requirements of the clinical study (e.g. 
participant population, technical equipment), 
• instruction of the investigators and personnel for the clinical study, 
• to check the ISF for completeness and actuality, 
• documentation of the status of the participant, 
• matching of original data, 
• to check SAE reports according to regulations. 
The monitor has the responsibility to treat all information confidentially and to 
safeguard the integrity and personal privacy of the study participants. 
The exact extent of the monitoring procedures is described in a separate monitoring 
manual. 

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19.3 Audits und Inspections 
For the purpose of ensuring compliance with the study protocol, the principles of GCP 
and local legislation, the sponsor may initiate an audit at any study site during the study 
and after completion. All study-related documentation must be made available to the 
designated auditor(s).  
In addition, representatives of the regulatory authorities may choose to inspect a study 
site at any time prior to, during, or after completion of the clinical study. In this case, all 
pertinent study data should be made available as requested to the regulatory authority 
for verification, or inspection purposes. The investigator has to be available during 
these visits. 
 
19.4 Documentation, Data Management, Archiving 
Patient Identification List 
All subject data will be collected in a pseudonymized form. Every trial subject can be 
identified by a unique subject identification code consisting of a three digit center code, 
a hyphen and three digit numbers. A confidential subject identification list which links 
the patients’ names with the subject identification code will be stored in the investigator 
site file. 
 
Source Data / Source documents 
Source data are, within the meaning of the ICH E6 Guideline, all information in original 
records and certified copies of original records of clinical findings, observations, or 
other activities in a clinical trial necessary for the reconstruction and evaluation of the 
trial. Source data will be documented in various source documents (e.g. hospital 
records, doctor's report, subjects' diaries or evaluation checklists, x-rays) and then 
entered into the electronic Case Report Form (eCRF).  
 
The following study specific data will only be recorded electronically in separate files 
and is not going to be entered in the eCRF: 
• pharmacokinetics 
 
 
Recording of Data / Case Report Form (CRF) 

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Data will be recorded electronically using an EDC (Electronic Data Capture) system. 
Only persons authorised to enter data into the eCRF will have access to the EDC 
system. All users will be trained to use the EDC system and will comply with the 
instructions in the study-specific user manual. They will have continuous access to the 
data and reports of subjects at their own study site. The investigator is responsible for 
ensuring that the study data will be documented correctly, completely and in a timely 
manner. A study team physician takes on responsibility for the collected data by 
signing electronically. The electronic signature according to FDA 21 CFR Part 11 is the 
legally binding equivalent of the study team physician's handwritten signature. 
 
 
Data Management 
For data management, the validated data management system MACRO v4 (Elsevier 
InferMed) will be used. All entered data will be stored on servers of the 
Universitätsklinikum Münster. The servers are located in a secure data center and 
behind a firewall in the network of the Universitätsklinikum Münster. A backup of the 
data will be saved on a daily basis and all data changes will be recorded in an audit 
trail. 
 
All data will be checked for plausibility during initial data entry. Missing or non-plausible 
data are highlighted by the system right at input at the clinical study site and may be 
corrected immediately. Thereafter, according to the data validation plan, further data 
checks will be performed with regard to completeness and plausibility by the data 
management of the ZKS Münster. In case of non-plausible or missing data, queries 
will be sent to the study site. The queries must be resolved by authorized members of 
the investigator`s staff in the respective study site in a timely manner. 
 
After completion of data entry and data processing, the database will be locked and 
the data will be exported for statistical analysis. The investigator will receive a CD-
ROM of the eCRF data for archiving at the clinical study site. 
Archiving 

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After the end of the trial, the originals of all trial-specific documents (Trial Master File) 
including the CRFs must be stored by the sponsor according to national regulations (§ 
13(10) GCP-Verordnung) for at least 10 years. Furthermore, the investigator stores the 
ISF (Investigator Site File) including copies of the CRFs for the time period given 
above.  
Trial data or documents may not be destroyed without prior written agreement between 
the sponsor and the investigator(s) or his/her designee. 
Investigator Site File 
Each study site keeps an ISF provided by the investigator/sponsor. During monitoring, 
the ISF will be checked regularly for completeness and actuality. After the clinical trial 
is finished or stopped, the ISF has to be stored for at least 10 years. 
20. Patient Insurance  
As required by German drug law, patients will be insured against risks originating from 
the study. 
Insurance:  HDI-Gerling Industrie Versicherung AG 
Riethorst 2 
30659 Hannover. 
 
21. Financing 
The study is financed by Deutsche Krebshilfe, grant 111004 to Univ.-Prof. Dr. 
Wolfgang E. Berdel.  
 
22. Adherence to the Protocol 
The investigator must adhere to the protocol as detailed in this document. Substantial 
changes to the protocol will require a written favorable opinion from the competent 
ethics committee and written approval by the competent authority prior to 
implementation. This does not apply when the modification is needed to eliminate an 
immediate hazard to patients. Any deviations from the protocol must be fully 

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documented in the source documentation and recorded and explained in the CRF (if 
applicable). 
 
23. Data Protection 
This study will be performed in compliance with the applicable data protection laws. 
Study personnel will handle all patient data in a strictly confidential way. 
To prevent the identification of a person to whom study data belong, study data will be 
pseudonymized by means of the patient identification number. If patient documents 
(e.g., examination results) are transferred to an institution outside the study site, copies 
will be used on which the patient’s name and initials are obscured and the patient 
identification number is indicated. 
 
24. Reporting and Publication Policy 
 
Final Report 
After completion of the biometric evaluation, the Investigator prepares a study report. 
The report includes all trial results, irrespective of whether favorable or not. It is signed 
by him and the person who is responsible for the evaluation. 
Within 12 months after the end of the study, the Investigator submits a summary of the 
final report to the ethics committee and to the competent federal authority. The 
summary is prepared in the format provided for report synopses by the ICH Guideline 
E3 “Guidance on Structure and Content of Clinical Study Reports”. After review by the 
competent federal authority the report is published on the web site of DIMDI (German 
drug law, §42 b). 
According to European Commission Guideline 2012/C 302/03 the study results should 
be posted within 12 months to the EU Database on Clinical Trials (EudraCT).  
Safety Reports 
The rules for the annual safety reports are specified above. 
 

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Publication Policy 
The study will be registered in a clinical trials database, which is accessible to the 
public. 
 
Publication details, authorship and journal selection will be decided by the Investigator 
and Prof. Berdel. 
 
 
APPENDIX