An Open Label, Multicenter, Phase II Trial Testing Single Agent Decitabine in TP53 Mutated Relapsed/Refractory Acute Myeloid Leukemia
Phase: PHASE2
Conditions: Acute Myeloid Leukemia, Acute Myeloid Leukemia, Relapsed, Adult
Sponsor: Washington University School of Medicine

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An open label, multicenter, phase II trial testing single agent decitabine in TP53 mutated 
relapsed/refractory acute myeloid leukemia 
 
 
Washington University School of Medicine 
Division of Oncology 
660 South Euclid Avenue, Campus Box 8056 
St. Louis, MO  63110 
 
Protocol #: 201911185 
Version Date: 10/01/2020 
 
Coordinating Center: 
Washington University School of Medicine 
 
Principal Investigator:  
John Welch, M.D., Ph.D. 
Telephone Number: (314) 362-2626, 
Fax Number: (314) 362-9333 
Email: jwelch@wustl.edu 
 
Sub-Investigator 
 
Institution 
 
 
 
Modality 
 
 
Mary-Elizabeth Percival, M.D.  
 
University of Washington 
Hematologic 
Oncology 
Center 
Carlos Vigil, M.D.  
 
University of Iowa 
 
 
Hematologic Oncology 
Feng Gao, Ph.D.  
 
Washington University  
 
Biostatistics 
 
Study Drug(s): 
 
Decitabine (5-aza-2'-deoxycytidine) 
IND #: 
 
 
134433 EXEMPT 
ClinicalTrials.gov #:  
NCT03063203 
 
Sponsor: 
 
 
Washington University School of Medicine 
Support: 
 
 
Janssen Pharmaceuticals and NCI SPORE (2P50CA17963-06l) 
 
CONFIDENTIAL 
The information contained in this document is regarded as confidential and, except to the extent necessary to 
obtain informed consent, may not be disclosed to another party unless law or regulations require such 
disclosure.  Persons to whom the information is disclosed must be informed that the information is 
confidential and may not be further disclosed by them 
 
 
 

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An open label, multicenter, phase II trial testing single agent decitabine in TP53 mutated 
relapsed/refractory acute myeloid leukemia 
 
Protocol Revision History 
 
Initial Approval Version 
 
 
 
 
 
 
03/14/2017 
Amendment #1 Version 
 
 
 
 
 
 
05/24/2017 
Amendment #2 Version 
 
 
 
 
 
 
11/16/2017 
Amendment #3 Version 
 
 
 
 
 
 
01/04/2018 
Amendment #4 Version 
 
 
 
 
 
 
05/17/2018 
Amendment #5 Version 
 
 
 
 
 
 
08/31/2018 
Amendment #6 Version 
 
 
 
 
 
 
02/21/2019 
Amendment #7 Version 
 
 
 
 
 
 
05/28/2020 

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 An open label, multicenter, phase II trial testing single agent decitabine in TP53 mutated 
relapsed/refractory acute myeloid leukemia 
 
Principal Investigator Signature Page 
 
 
Principal Investigator 
(printed): 
      
Name of Institution:       
  
 PI Signature 
 
 
 
 
 
Date 
 
By my signature, I agree to personally supervise the conduct of this study 
and to ensure its conduct in compliance with the protocol, informed 
consent, IRB/HRPO procedures, the Declaration of Helsinki, ICH Good 
Clinical Practices guidelines, and the applicable parts of the United 
States Code of Federal Regulations or local regulations governing the 
conduct of clinical studies. 
 
 
 
 

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Glossary of Abbreviations  
 
AE 
Adverse event 
ALT (SGPT) 
Alanine transaminase (serum glutamate pyruvic transaminase) 
AML 
t-AML 
s-AML 
Acute myeloid leukemia 
Therapy-related Acute myeloid leukemia 
Secondary Acute myeloid leukemia 
ANC 
Absolute neutrophil count 
AST (SGOT) 
Aspartate transaminase (serum glutamic oxaloacetic transaminase) 
BMT 
BM 
Bone marrow transplant 
Bone marrow 
CBC 
Complete blood count 
CNS 
Central nervous system 
CR 
Complete response 
CRc 
Cytogenetic complete remission 
CRi 
Complete remission incomplete hematologic recovery 
CT 
Computed tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
DNA 
deoxyribonucleic acid 
DSM 
Data and Safety Monitoring  
DSMC 
Data Safety Monitoring Committee 
ECG (or EKG) 
Electrocardiogram 
EDTA 
ethylenediaminetetraacetic acid 
FDA 
Food and Drug Administration 
FISH 
fluorescent in situ hybridization 
GCP 
HB 
Good Clinical Practice 
Hemoglobin 
HHS 
HI 
Department of Health and Human Services 
Hematologic improvement 
HIV 
Human Immunodeficiency Virus 
HRPO 
Human Research Protection Office (IRB) 
IRB 
ITT 
Institutional Review Board 
Intention to Treat 
MDS 
mLFS 
Myelodysplastic syndrome 
Morphologic leukemia free state 
MM 
MPN 
Multiple myeloma 
Myeloproliferative neoplasm  
MRI 
Magnetic resonance imaging 
NCI 
National Cancer Institute 
NIH 
National Institutes of Health 
OHRP 
Office of Human Research Protections  
ORR 
Overall response rate 

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OS 
Overall survival 
PBMC 
PB 
Peripheral blood mononuclear cell 
Peripheral blood 
PD 
Progressive disease 
PI 
Principal investigator 
PR 
Partial remission 
QASMC 
Quality Assurance and Safety Monitoring Committee 
RFS 
Relapse free survival 
SAE 
SAP 
Serious adverse event 
Statistical Analysis Plan 
SCC 
Siteman Cancer Center 
SCT 
Stem cell transplant 
SD 
Stable disease 
TSH 
Thyroid stimulating hormone 
TTLR 
Time to leukemia relapse 
UPN 
WBC 
Unique patient number 
White blood cell count 
 
 

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Table of Contents 
SCHEMA ....................................................................................................................................... 8 
1.0 
BACKGROUND AND RATIONALE ............................................................................. 10 
1.1 
Introduction ................................................................................................................. 10 
1.2 
Study Rationale ........................................................................................................... 10 
1.3 
Investigational Agent .................................................................................................. 13 
2.0 
OBJECTIVES.................................................................................................................... 16 
2.1 
Primary Endpoint ....................................................................................................... 16 
2.2 
Secondary Endpoints .................................................................................................. 16 
2.3 
Exploratory Molecular Endpoints............................................................................. 17 
3.0 
PATIENT SELECTION ................................................................................................... 17 
3.1 
Inclusion Criteria ........................................................................................................ 17 
3.2 
Exclusion Criteria ....................................................................................................... 18 
3.3 
Inclusion of Women and Minorities .......................................................................... 19 
4.0 
REGISTRATION PROCEDURES ................................................................................. 19 
4.1 
Confirmation of Patient Eligibility ............................................................................ 19 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database ................. 20 
4.3 
Assignment of UPN ..................................................................................................... 20 
5.0 
INVESTIGATION PLAN ................................................................................................ 20 
5.1 
Summary ...................................................................................................................... 20 
5.2 
Premedication Administration .................................................................................. 24 
5.3 
Agent Administration ................................................................................................. 25 
5.4 
Relapsed or Progressive Disease ................................................................................ 25 
5.5 
Transplantation ........................................................................................................... 25 
5.6 
Women of Childbearing Potential ............................................................................. 25 
5.7 
Concomitant Therapy and Supportive Care Guidelines ......................................... 26 
5.8 
Duration of Therapy ................................................................................................... 27 
5.9 
Duration of Follow-up ................................................................................................ 27 
6.0 
DOSE DELAYS/DOSE MODIFICATIONS .................................................................. 28 
6.1 
Delay for Cytopenia or Infection ............................................................................... 28 
6.2 
Delay for Organ Dysfunction ..................................................................................... 28 
6.3 
Modification in Dose or Schedule .............................................................................. 28 
7.0 
REGULATORY AND REPORTING REQUIREMENTS ........................................... 28 
7.1 
Reporting to the Human Research Protection Office (HRPO) at Washington 
University ................................................................................................................................. 29 
7.2 
Reporting to the Quality Assurance and Safety Monitoring Committee (QASMC) 
at Washington University ....................................................................................................... 29 
7.3 
Secondary Sites Reporting Requirements ................................................................ 30 
7.4 
Reporting to Secondary Sites ..................................................................................... 30 
7.5 
Reporting to Janssen................................................................................................... 30 
7.6 
Reporting to the FDA ................................................................................................. 36 
7.7 
Exceptions to Expedited Reporting ........................................................................... 37 
8.0 
PHARMACEUTICAL INFORMATION ....................................................................... 37 
8.1 
Study Drug Preparation ............................................................................................. 37 
9.0 
CORRELATIVE STUDIES ............................................................................................. 38 
9.1 
Correlative Studies Background ............................................................................... 38 

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9.2 
Correlative studies sample ......................................................................................... 40 
10.0 STUDY CALENDAR ........................................................................................................ 42 
11.0 DATA SUBMISSION SCHEDULE ................................................................................ 43 
11.1 
Adverse Event Collection in the Case Report Form ................................................ 44 
12.0 MEASUREMENT OF EFFECT...................................................................................... 44 
12.1 
Response assessment ................................................................................................... 44 
13.0 DATA AND SAFETY MONITORING........................................................................... 46 
14.0 AUDITING ........................................................................................................................ 47 
15.0 STATISTICAL CONSIDERATIONS ............................................................................ 48 
15.1 
Study design and Sample size .................................................................................... 48 
15.2 
Analysis Populations ................................................................................................... 48 
15.3 
Multicenter studies...................................................................................................... 48 
15.4 
Statistical Analysis ...................................................................................................... 48 
16.0 MULTICENTER REGULATORY REQUIREMENTS ............................................... 51 
17.0 REFERENCES .................................................................................................................. 53 
APPENDIX A: Definitions for Adverse Event Reporting....................................................... 55 
APPENDIX B: Definition of TP53 Mutant AML .................................................................... 58 
APPENDIX C: Reporting Timelines ......................................................................................... 59 
APPENDIX D: Washington University Serious Adverse Event Reporting Cover Sheet .... 63 
 
 

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An open label, multicenter, phase II trial testing single agent decitabine in TP53 mutated 
relapsed/refractory acute myeloid leukemia 
 
SCHEMA 
 
 
A bone marrow biopsy may be performed at any time after Cycle 2 if there is clinical concern for progression. 
 
Patients with progressive disease after 2 cycles of decitabine (10 days each) may be removed from study. 
 
After Cycle 2, decitabine dose will be reduced FOR ALL PATIENTS from 20 mg/m2/day x 10 days to 20 mg/m2/day 
x 5 days. After Cycle 1, patients with blast counts <5% may reduce decitabine dose from 20 mg/m2/day x 10 days to 
20 mg/m2/day x 5 days. Each cycle is 28 days. 
 
Notes for transplant eligible patients 
Anytime after 3 cycles, transplant eligible patients in CR, CRc, CRi, or mLFS* should proceed to stem cell 
transplant according to institutional protocols. 
After 3 cycles, transplant eligible patients in PR* may be removed from study and proceed to salvage according to 
institutional protocols. 
 
Notes for transplant ineligible patients  
Transplant ineligible patients will continue on study with decitabine (x 5 days) until relapse or progression, with 
the exception of patients with SD* after 4 cycles who may continue on therapy or be removed from study per treating 
physician preference. 
 
Antimicrobial prophylaxis during therapy is strongly recommended due to anticipated neutropenia. Common agents 
include acyclovir, ciprofloxacin, and fluconazole. Alternative agents may be used at the discretion of the treating 
physician. 
 
Correlative samples:  
BM and PB should be collected on Cycle 1 Day 0 (C1D0), Cycle 1 Day 10 (C1D10)**, Cycle 1 Day 28 (C1D28), 
Cycle 2 Day 28 (C2D28)*** and Cycle 3 Day 28 (C3D28). A skin biopsy should be done on C1D0 (buccal swab may 
be substituted for skin if patient declines skin biopsy). A buccal swab should be done on C2D28. BM and PB should 
be collected at the time of progression (if possible). 
 
*For definition of responses see Section 12 
20 mg/m2/day  x 
10 days
Cycle 1
Cycle 2
Samples to 
collect:
BM
PB
Skin/Buccal
TP53 mutated relapsed/refractory acute myeloid leukemia
20 mg/m2/day  x 
10 days
20 mg/m2/day  
x 5 days
Cycle 3
Continue until transplant or 
progressive disease
End of study
(per treating Physician)
Samples to 
collect:
BM
PB
Cycle 4+

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** Bone marrow aspirate and biopsies on cycle 1 day 10 will only be performed in patients enrolled at Washington 
University. 
*** At the discretion of the treating physician. 
 
 

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1.0 
BACKGROUND AND RATIONALE 
 
1.1 
Introduction  
 
Acute myeloid leukemia (AML) is an aggressive, relapsing blood cancer characterized by 
ineffective hematopoiesis and malignant expansion of clonal myeloid cells and a broad 
variety of genetically distinct sub-types1. 
 
Through next generation sequencing techniques, we have identified patterns of somatic 
mutations commonly associated with AML and found that these mutations organize into 
founding clones and subclones2.  
 
Treatment options for AML remain limited, and personalized strategies are needed1. The 
5-year overall survival among patients with AML age 25-64 is 40%3. Both clinical and 
genomic prognostic markers have been identified, including age, performance status, type 
of AML (de novo, AML with antecedent hematopoietic malignancy, or therapy-related 
AML), response to induction treatment and, most importantly, genetics4-7. 
 
Cytogenetic abnormalities have been one of the most important prognostic markers for risk 
stratification2. Specifically, patients with complex karyotype or monosomy karyotype are 
associated with adverse risk, and often carry mutations in TP538. In this population, 
standard cytotoxic chemotherapy and allogeneic stem cell transplantation result in 5-year 
survival of less than 10% and a median survival of only few months, and many patients 
even fail to achieve complete remission after induction chemotherapy5-7. 
 
We recently observed that AML and myelodysplastic syndrome (MDS) patients with TP53 
mutations have high response rates to decitabine8. In this study we will determine whether 
decitabine leads to an increase in overall survival in patients with TP53 mutated AML, who 
have detectable disease after initial induction chemotherapy. These patients represent the 
group with the poorest prognosis, and alternative therapy is desperately needed.   
 
1.2 
Study Rationale 
 
 
Among patients with complex or monosomy karyotypes, nearly 60% carry TP53 
mutations; whereas nearly all patients with TP53 mutations have complex or monosomy 
karyotypes, and these karyotypes almost always involve deletion of chromosome 5q, 
chromosome 7, chromosome 12, or chromosome 17p2,4,7,9. Patients with TP53 mutations 
tend to be older (median age 61 vs 54 years), have worse response to conventional 
chemotherapy (complete remission rate: 28% vs 50%), shorter event free survival (3-year 
EFS: 1% vs 13%), and overall survival (3-year OS: 3% vs 28%)7,9.  
 
We correlated response to decitabine with mutation status in 99 patients with AML or 
MDS. We observed response (complete remission (CR), complete remission with 
incomplete blood count recovery (CRi), or marrow complete remission (mCR) in 21/21 
patients with TP53 mutations. (p < 0.0001). No other gene mutation was associated with 

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response in the 99 patients sequenced8 (Figure 1A).  
 
Consistent with this, we observed mutation clearance in all 16 cases with TP53 mutations 
evaluated at serial time points, and that TP53 mutations were cleared more quickly and 
consistently than other variants8 (Figure 2). 
 
 
 
Decitabine alone does not lead to a cure in the majority of responding patients. Mutation 
clearance is nearly always incomplete, and we could detect low levels of mutations (0.2 - 
5%) in 20 of 20 patients analyzed during remission with enhanced exome sequencing. 
Furthermore, in all 9 patients analyzed at relapse, the relapse occurred via subclonal 
evolution (expansion of a subclone that carries the founding clone mutations and additional 
mutations, suggesting that the founding clone mutations persisted during morphologic 
remission)8.  
 
Several clinical variables correlated with survival in this cohort: age, performance status 
(2 vs 0-1), and whether the patient underwent stem cell transplantation (Figure 3A). Thus, 
additional consolidation (e.g. hematopoietic cell transplantation) appears necessary to 
 
 
Figure 1. Correlation of mutation status and response in 99 patients with AML or MDS treated with 
decitabine. 

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achieve prolonged remissions. Importantly, in this cohort of patients who undergo 
decitabine induction, the presence of TP53 mutations no longer adversely affected survival 
following transplantation8.  
 
These data suggest that decitabine may have unique efficacy in patients with TP53 
mutations. In this study, we seek to determine whether decitabine therapy can improve 
outcomes, specifically overall survival, of this selected subset of AML patients with the 
poorest prognosis based on refractoriness to induction treatment and high-risk genetic 
mutations. 
 
 
 
Figure 2. Consistent clearance of TP53 mutations.  A. The variant allele frequency of TP53 mutations was 
consistently reduced during decitabine treatment. Twenty-one TP53 mutations were evaluated at multiple time 
points in 16 patients, (e.g. cycle 2 day 28, C2D28). Variant allele frequency indicates the proportion of variant 
reads vs. the total number of reads at that nucleotide, and is proportional to the tumor burden. B and C. Mutation 
clearance of SRSF2 and DNMT3A mutations. D. Summary of rate of mutation clearance. Note that during 
decitabine therapy, TP53 mutations were consistently, and rapidly, cleared when compared with mutations in 
other genes. P value calculated with ANOVA using Tukey’s post-test correction. 
 
 
 
 
Figure 3. Overall survival subgroup analysis. A. Overall survival was increased in patients treated with 10 day 
decitabine who underwent stem cell transplantation vs. those who did not. B. Among patients who underwent 
stem cell transplantation, survival was not impacted by the presence or absence of TP53 mutations. P value 
calculated as Log-rank. 
  

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1.3 
Investigational Agent 
 
Decitabine (5-aza-2’-deoxycitidine) is a DNA hypomethylating agent. Decitabine is an 
antimetabolite that can replace cytosine in DNA but, unlike cytosine, it cannot be 
methylated. The exact mechanism of decitabine activity has not been determined and may 
involve multiple pathways10-11. Decitabine is thought primarily to act by altering DNA 
methylation, a major mechanism for gene expression. Methylation of cytosine in the CpG 
dinucleotide by DNA methyltransferase leads to transcriptional silencing of genes during 
normal development and has emerged as a significant mechanism for the loss of tumor 
suppressor gene expression in human cancer, including AML12. Decitabine regulates DNA 
methylation (specifically targets the methyltransferase, DNMT1)13, effectively 
demethylating and reactivating different tumor suppressor genes. Other possible 
mechanisms for decitabine activity include cytotoxicity due to incorporation into DNA 
during S phase and formation of covalent adducts with DNA methyltransferase11-12. The 
irreversible inhibition and degradation of DNA methyltransferase 1 results in methylation-
independent induction of gene expression and it is associated with differentiation10. In 
addition to its differentiation inducing activity at low doses, decitabine has a direct 
cytotoxic effect at higher doses (1-2 µM)11-12.  
 
Decitabine has been investigated in hematologic malignancies using a range of doses and 
schedules.  Two dosing regimens are approved in the US compendium. A dose of 15 mg/m2 
every 8 hours for 3 days, based on a Phase III study in adults with MDS that demonstrated 
improved outcomes in the treatment arm compared to the supportive care arm14. And the 
dose of 20 mg/m2 daily for 5 days in 28-day cycles is also approved. 
 
In general, decitabine is well tolerated. Unlike conventional cytotoxic chemotherapy, 
decitabine can be administered in the outpatient setting. Cytopenias commonly result from 
AML/MDS inhibition of normal hematopoiesis, and often do not resolve until a complete 
response is achieved. Thus, neutropenic sepsis and thrombocytopenic bleeding remain 
significant problems regardless of therapy, especially during the first 4-8 weeks. In our 
experience treating elderly AML patients, neutropenia occurred in 24%, sepsis in 9%, and 
bacteremia in 7%.  Similar results have been observed in MDS patients14-16. As a result, 
death is not uncommon in the first 8 weeks of therapy, occurring in 15-17% of patients, 
and most commonly resulting from infection and cytopenias related to disease and therapy. 
While unsettling, these numbers are better than many historical patients treated with 
cytotoxic chemotherapy, and suggest a need for continued improvements in therapy. 
 
A. 
Pharmacokinetics and Metabolism of Decitabine 
 
In human subjects, after IV administration, decitabine displayed a distribution phase 
with a half-life of 7 minutes and a terminal phase elimination half-life of 10-35 
minutes as measured by bioassay17-20. The short plasma half-life is due to rapid 
inactivation of decitabine by deamination by liver cytidine deaminase17.  Total body 
clearance (Clp) in humans was high with a mean value of 126 mL/min/kg19. 
 
 
 

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Among five adult patients with advanced solid tumors administered seven courses 
of 100 mg/m2 of decitabine by 1-hour infusions21, maximum plasma concentration 
ranged from 1 to 4 µM. Disappearance from plasma was biphasic with a rapid initial 
decline to less than 0.1 µM during the first hour post infusion and a slower decline 
over the next two hours to 6 nM, the level of detectability. Plasma half-life 
(mean±SE) was estimated to be approximately 7±1 minutes in the initial phase (t½α) 
and 35±5 minutes in the second phase (t½β). The area under the plasma 
concentration-time curve was 408±88 ng.hour/mL for these patients, with a peak 
plasma concentration of 2.01±0.44 µM (0.44±0.1 µg/mL), while mean volume of 
distribution (Vdss) and CLp was 4.59±1.42 L/kg and 126±21 mL/min/kg, 
respectively. The time course of DAC concentrations was similar in 1 of 2 patients 
administered 75 mg/m2, while DAC was usually undetectable in the plasma of 
patients administered 25 to 60 mg/m2. 
 
Using a longer infusion time (up to 40 hours), Rivard et al.18 reported a plasma 
concentration of 0.1 to 0.4 µg/mL. With infusion times of 40-60 hours, at an infusion 
rate of 1 mg/kg/h, plasma concentrations of 0.43-0.76 µg/mL were achieved. The 
steady-state plasma concentration at an infusion rate of 1 mg/kg/h was estimated to 
be 0.2-0.5 µg/mL. The half-life after discontinuing the infusion was 12-20 min17. 
 
Urinary excretion of unchanged decitabine was low, ranging from less than 0.01% to 
0.9% of the total dose, and there was no relationship between excretion and dose or 
plasma drug levels. High clearance values and a total urinary excretion of <1% of the 
administered dose suggest that decitabine is eliminated rapidly and largely by 
metabolic processes, including extrahepatic metabolism22. 
 
The steady state plasma concentrations (Css) ranged from 0.31 to 0.39 µg/mL (1.27 
to 1.60 µM) during the infusion of 100 mg/m² decitabine over a 6-hour period. The 
range of concentrations during a 600 mg/m2 infusion over an 8-hour period was 0.41-
16 µg/mL(1.68 to 4.76 µM)22. These plasma concentrations are in the same range 
as the in vitro concentrations that activated the expression of tumor suppressor gene 
p16 in three human non-small-cell lung cancer (NSCLC) cell lines21.  
 
Steady state decitabine levels of 0.1 to 0.2 µM were achieved in solid tumor patients 
dosed with 30 mg/m²/day and 40 mg/m²/day by continuous intravenous infusion 
over 72 hours22. 
 
Summary of published steady state serum levels are below and are in proportion to 
infusion rate (R2 = 0.98, p < 0.0001)23.  
 
 

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Rate 
Serum 
Concentration 
mg/m2/hr 
ng/ml 
nM 
5 
55 
241 
7.5 
80 
351 
15 
180 
789 
21 
182.4 
800 
22.5 
350 
1535 
42 
456 
2000 
84 
1140 
5000 
 
In our experience treating primary patient blasts in vitro, concentrations of 100 – 
500 nM are required to maximize methylcytosine reduction without causing 
cellular toxicity. Because decitabine incorporation into DNA is S-phase dependent, 
exposure of cells during cell division is necessary for efficacy. 
  
 
 
 
B. 
Experience with extended dosing schedules 
 
Decitabine does not act quickly and the median time to response is 3 months. 
Several doses have been tested and reported in the literature with doses ranging 
from 5 mg/m2/day for 5-10 days to doses of 135 mg/m2/day for 3 days23.  
 
From our experience8 and from another report24 there is data to support that lower 
doses over longer periods of time results in significant improvement in response 
rate and have lower toxicity. 
 
The mechanism underlying this observation is unclear, however there are some 
reports that suggest that at lower doses (e.g. 20 mg/m2), decitabine might promote 
cell differentiation through effective methylcytosine reduction and gene expression 
derepression, as opposed to induction of apoptosis via DNA damage that is seen at 

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higher doses (e.g. 100 mg/m2) and it is more typical of conventional 
chemotherapeutic agents25.  
 
Lower dose schedule (20 mg/m2/day) on days 1-5 became the standard strategy 
based on a series of studies.14,15,16 However, subsequent studies using longer dose 
schedules (days 1-10) found that this led to improved response rates.8,24 
 
Therefore, we will use a dose of 20 mg/m2/day as a 1-hour intravenous infusion on 
consecutive Days 1-10 in 28-day cycles, dose reductions for subsequent cycles will 
be allowed as described in Sections 5.1 and 6.3.  
 
 
2.0 
OBJECTIVES 
 
2.1 
Primary Endpoint 
 
To determine the 1-year OS in patients with TP53 mutations treated with at least one dose 
of decitabine compared to historic controls (OS = 25%)5,26. 
 
2.2 
Secondary Endpoints 
 
1. To determine the proportion of responding TP53 mutated patients (CR, CRi) compared 
to historical controls (10%-15%)26 
 
2. To determine the time to stem cell transplant among subjects who are suitable 
candidates for transplant and have an identified donor.  
 
3. To correlate response and survival with clinical parameters: 
- 
morphologically evident disease (>5% blasts by cytomorphology) versus 
molecularly detected disease at the time of enrollment (disease detected with flow 
cytometry, cytogenetic, or mutational analysis if  ≤ 5% blasts by cytomorphology);  
- 
de novo AML versus secondary AML versus treatment-related AML, 
- 
presence versus absence of cytogenetic abnormalities in addition to TP53 
mutations. 
 
4. To determine the median time to leukemia relapse (TTLR) in non-transplant patients 
treated with decitabine compared to historical control (6-8 months)27. 
 
5. To determine the 2-year event free survival after transplant in patients treated with 
decitabine compared to historical control (18-22%)28. 
 
6. To determine the median and average number of hospital days during Cycles 1 and 2. 
 
 
 

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2.3 
Exploratory Molecular Endpoints 
 
1. To determine the proportion of patients who achieve mutation clearance to <0.1%, after 
3 cycles of decitabine. 
 
2. To determine whether PB or BM has the greater sensitivity for detecting residual 
mutation burden using a sensitive sequencing technology such as Haloplex. 
 
3. To determine TP53 clonal burden reduction after consolidation with stem cell 
transplantation using a sensitive sequencing technology such as Haloplex. 
 
4. To determine whether decitabine induces consistent methylation signatures using 
whole genome bisulfite sequencing. 
 
5. To determine whether decitabine induces consistent expression signatures using RNA 
sequencing, and whether these correlate with methylation signatures. 
 
 
3.0 
PATIENT SELECTION 
 
3.1 
Inclusion Criteria 
 
1. TP53 mutant AML. The presence of a TP53 mutation should be determined by 
Genoptix (or institutional preferred equivalent assay). Detection of a TP53 mutation at 
the time of initial diagnosis is sufficient for enrollment at the time of relapsed/refractory 
disease. Detection of a TP53 mutation in either the peripheral blood or bone marrow is 
adequate for enrollment. (Refer to Appendix B for definition of TP53 mutant AML.) 
Alternatively, patients who have not had TP53 mutation analysis performed, but who 
have > 20% TP53 positive cells by immunohistochemistry detected on a bone marrow 
aspirate may also be enrolled,29 provided that mutation analysis is requested at the time 
of enrollment. 
 
2. Relapsed/refractory AML following 7+3 (or similar cytarabine containing induction 
chemotherapy for AML) disease detected by one of the following methods: 
• Bone marrow blasts > 5%, or  
• Hematologics flow cytometry assay (threshold > 0.5%) (alternative equivalent 
assay may be substituted), or 
• Persistent cytogenetic abnormality (e.g. del5, del17p, etc) by FISH or 
conventional karyotyping, or 
• 
Persistent TP53 mutation (at least 5 variant reads with at least 50x coverage) 
determined by Genoptix (or institutional preferred equivalent assay).  
 
 
 

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Patients with > 10% blasts on a Day +14 bone marrow biopsy following 7+3 may either 
be enrolled or may be treated with a course of standard re-induction (e.g. 5+2 or similar) 
and then re-evaluated for response. Eligible patients will meet any of the above criteria 
on a subsequent biopsy. 
 
3. Bone marrow and organ function as defined below: 
• Peripheral white blood cell count < 50,000/mcl (patients may receive hydroxyurea 
as necessary for cytoreduction), 
• Total bilirubin < 1.5 x upper limit of normal, 
• AST and ALT < 2.5 x upper limit of normal, 
• Serum creatinine < 2.0 x upper limit of normal, and, 
 
4. At least 18 years of age. 
5. Women of childbearing potential and men must agree to use adequate contraception 
(hormonal or barrier method of birth control, abstinence) prior to study entry and for 
the duration of study participation.  Should a woman become pregnant or suspect she 
is pregnant while participating in this study, she must inform her treating physician 
immediately 
 
6. Ability to understand and willingness to sign an IRB approved written informed 
consent document (or that of legally authorized representative, if applicable 
 
7.  Performance status ≤ 3 
 
3.2 
Exclusion Criteria 
 
1. Prior treatment with either decitabine or azacitidine, or an investigational agent. 
 
2. Acute promyelocytic leukemia with PML-RARA or t(15;17). 
 
3. History of HIV, Hepatitis B, or Hepatitis C infection. 
 
4. Concurrent illness including, but not limited to, ongoing uncontrolled infection, 
symptomatic NYHA class 3 or 4 congestive heart failure, unstable angina pectoris, or 
cardiac arrhythmia. 
 
5. Radiation therapy within 14 days of enrollment. 
 
6. Chemotherapy administration in the 7 days preceding enrollment with the exception of 
hydroxyurea, which can be continued until through Cycle 2. A washout period for oral 
tyrosine kinase inhibitors (e.g. Jakafi, etc) is not required, although tyrosine kinase 
inhibitors therapy must be discontinued prior to enrollment. 
 

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7. Malignancies (other than AML) requiring active therapy or diagnosed within the last 
year, with the exception of non-melanoma skin cancer which can be treated or in situ 
malignancies (such as cervical, breast, prostate, etc.). 
 
8. Currently receiving any other investigational agents. 
 
9. Known CNS leukemia or testicular involvement of leukemia.   
 
10. A history of allergic reactions attributed to compounds of similar chemical or biologic 
composition to decitabine or other agents used in the study. 
 
11. Pregnant and/or breastfeeding.  Women of childbearing potential must have a negative 
urine pregnancy test within 7 days of study entry. 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this trial.   
 
 
4.0 
REGISTRATION PROCEDURES 
 
Patients must not start any treatment on protocol prior to registration through the Siteman 
Cancer Center. Pre-study assessments, such as blood testing, bone marrow biopsy or others 
as listed under baseline evaluation (Section 5.1.2) are allowed.  
 
The following steps must be taken before registering patients to this study: 
 
1. Confirmation of patient eligibility by Washington University 
2. Registration of patient in the Siteman Cancer Center database 
3. Assignment of unique patient number (UPN) 
 
Once the patient has been entered in the Siteman Cancer Center OnCore database, the WUSM 
coordinator will forward verification of enrollment and the UPN via email. 
 
4.1 
Confirmation of Patient Eligibility 
 
Confirm patient eligibility by collecting the information listed below and scanning and 
emailing it to the research coordinator listed in the Siteman Cancer Center Clinical Trials 
Core Protocol Procedures for Secondary Sites packet at least one business day prior to 
registering patient: 
1. Your name and contact information (telephone number, fax number, and email 
address) 
2. Your site PI’s name, the registering MD’s name, and your institution name 
3. Patient’s race, sex, and DOB 
4. Three letters (or two letters and a dash) for the patient’s initials 
5. Currently approved protocol version date 

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6. Copy of signed consent form (patient name may be blacked out) 
7. Planned date of enrollment 
8. Completed eligibility checklist, signed and dated by a member of the study team 
9. Copy of appropriate source documentation confirming patient eligibility 
 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database 
 
Registrations may be submitted Monday through Friday between 8am and 5pm CT. Urgent 
late afternoon or early morning enrollments should be planned in advance and coordinated 
with the Washington University research coordinator.  The research coordinator or his/her 
delegate will confirm registration by email within one business day. Verification of 
eligibility and registration should be kept in the patient chart. 
 
All patients at all sites must be registered through the Siteman Cancer Center OnCore 
database at Washington University. 
 
4.3 
Assignment of UPN 
 
Each patient will be identified with a unique patient number (UPN) for this study.  Patients 
will also be identified by first, middle, and last initials.  If the patient has no middle initial, 
a dash will be used on the case report forms (CRFs).  All data will be recorded with this 
identification number on the appropriate CRFs. 
 
 
5.0 
INVESTIGATION PLAN 
 
5.1 
Summary 
 
See Section 10 for synoptic table.  
 
Patients will receive decitabine 20 mg/m2/day as a 1-hour infusion on consecutive days 1-
10 of each 28-day cycle.  Decitabine dose will be calculated on baseline weight (obtained 
within a week of the start of cycle 1). Decitabine dose should be recalculated for weight 
changes above or below 10% from baseline weight 
 
Patients with clinical evidence of progressive disease or relapse (see Section 12 for 
definitions) should undergo a bone marrow biopsy to evaluate for progression.  
 
After 2 cycles, patients with progressive disease or relapse (a clear progression with at least 
>20% bone marrow blasts and an increase of at least 50% from prior biopsy) should be 
removed from protocol and proceed to salvage treatment according to center preference.  
 
Transplant eligible patients with PR after 3 cycles, may be removed from protocol and 
proceed to salvage treatment or transplant according to center preference. 
 

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Transplant eligible patients with a suitable donor who achieve mLFS, CR, CRc, or CRi, 
may proceed to transplant after at 3 cycles (Section 5.5).  
 
Transplant ineligible patients with CR, CRc or CRi, PR will continue on maintenance doses 
(see below and Section 6.3) until progression or death, whichever occur first.  
 
Transplant ineligible patient with SD after cycle 4 may be removed from protocol and 
proceed to alternative treatment or continue on protocol according to treating physician’s 
preference.  
 
After Cycle 1, patients with blast counts < 5% may reduce decitabine dose from 20 
mg/m2/day x 10 days to 20 mg/m2/day x 5 days. 
 
For all other patients, after Cycle 2, decitabine administration dose will be decreased to 20 
mg/m2/day for 5 consecutive days (Days 1-5) every 28 days (unless otherwise specified) 
to limit myelosuppressive toxicity.  
 
Peripheral blood sampling and bone marrow biopsies with aspirate will be performed pre-
study, on Cycle 1 Day 10 ± 2, Cycle 1 Day 28 ± 4, on Cycle 2 Day 28 ± 4, on Cycle 3 Day 
28 ± 4, and at progression or relapse. Patients will provide a skin biopsy sample pre-study; 
a buccal swab can be performed for patients who decline skin biopsy. A buccal swab will 
be collected on Cycle 2 Day 28 ± 4.  
 
Following Cycle 3, bone marrow biopsies should be performed at the discretion of the 
treating physician to assess for response and for relapse or progression.  
 
If at any bone marrow collection the aspirate is a “dry tap”, two additional tubes of blood 
(10 mL each) will be collected and banked. 
 
A. 
Pre-study Procedures 
 
Pre-study procedures must take place no more than 28 days prior to the first dose 
of decitabine except where noted below. 
 
• Bone marrow aspirate and biopsy. Standard bone marrow procurement 
procedures will be followed for collection of the tissue. Assessments 
performed on bone marrow will include correlative studies, morphologic 
assessment, flow cytometry, cytogenetics, and FISH.  
• Bone marrow or peripheral blood for flow cytometry. 
• Collection and banking of bone marrow aspirate and peripheral blood. 
• Skin biopsy sample: Patients who decline to undergo a skin biopsy can 
provide a buccal swab as alternative. There is no required time frame for this 
sample; it may have been collected months or even years prior to the first 
dose of decitabine. If WBC at enrollment is > 30,000/µl, the skin biopsy 
should be collected at C1D28. 
 

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B. 
Baseline Evaluation 
 
Baseline evaluations must take place no more than 7 days prior to the first dose of 
decitabine.  
 
• Medical history 
• Physical exam including height, and weight. 
• CBC with differential and platelets 
• Serum chemistries, including, albumin, creatinine, total bilirubin, AST, 
ALT, LDH 
• Urine βHCG pregnancy test in women of childbearing age 
 
C. 
Day 1 of Each Cycle 
 
• Physical exam, including weight  
• CBC with differential and platelets 
• Serum chemistries, including albumin, creatinine, total bilirubin, AST, 
ALT, LDH 
 
D. 
All Cycles Days 1-10 
 
Decitabine administration, 20 mg/m2/day will be given as a 1-hour continuous 
intravenous infusion.  Decitabine dose will be calculated on baseline weight 
(obtained within a week of the start of Cycle 1). Decitabine dose only should be 
recalculated for weight changes at the beginning of each cycle that are above or 
below 10% from baseline weight.  
 
Decitabine may be reduced to Days 1-5 after Cycle 2 or Days 1-3 after Cycle 4. See 
Section 6 for details. 
 
E. 
Cycle 1 Day 10 ± 2 
 
Bone marrow aspirate and biopsy. Standard bone marrow procurement procedures 
will be followed for collection of the tissue. Assessments performed on bone 
marrow will include correlative studies and morphologic assessment. Bone marrow 
aspirate and biopsies at this time point will only be performed in patients enrolled 
at Washington University.  
 
F. 
Weekly 
 
CBC with differential and platelets. After the first cycle, this may be changed to 
every other week at the discretion of the treating physician. 
 
 
 

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G. 
At the Discretion of the Treating Physician 
 
Serum chemistries, such as bicarbonate, calcium, glucose, total protein, albumin, 
BUN, potassium, chloride, sodium, creatinine, total bilirubin, AST, ALT, alkaline 
phosphatase, LDH.  
 
Transfusions should be performed at the discretion of the treating physician and are 
permitted at any time during the protocol. 
 
H. 
Cycles 1, 2, and 3 Day 28 ± 4  
 
• Bone marrow aspirate and biopsy. Standard bone marrow procurement 
procedures will be followed for collection of the tissue. Assessments 
performed on bone marrow will include: correlative studies, morphologic 
assessment, cytogenetics, and FISH. 
• CBC with differential and platelets 
 
I. 
End-of-Study Procedures  
 
• Physical exam. 
• CBC with differential and platelets.  
• Serum chemistries albumin, creatinine, total bilirubin, AST, ALT, and 
LDH.  
• Bone marrow aspirate and biopsy. Standard bone marrow procurement 
procedures will be followed for collection of the tissue. Assessments 
performed on bone marrow will include morphologic assessment, 
cytogenetics, and FISH.  
 
J. 
Post-study Follow-up 
 
Patients are to be followed according to standard patient care procedures for 30 
days following the date of the last decitabine dose to monitor for toxicity, survival, 
and response. Thereafter, the investigator or designee will record information on 
subsequent therapy, disease progression, and/or death every 6 months for 2 years 
after last dose of study drug or until the patient is lost to follow-up or dies. 
 
5.2 
Premedication Administration 
 
Patients may be premedicated with lorazepam, prochlorperazine, palonosetron, 
granisetron, or ondansetron at the treating physician’s discretion before decitabine 
infusion. 
 
 
 

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5.3 
Agent Administration 
 
Cycle 1: All patients will receive decitabine 20 mg/m2 IV infusion per day over one hour 
on Days 1-10 of a 28-day cycle. 
 
Cycle 2: Patients with bone marrow blast counts < 5% may receive decitabine 20 mg/m2 
IV infusion per day over one hour on Days 1-5 of a 28-day cycle. All other patients will 
receive decitabine 20 mg/m2 IV infusion per day over one hour on Days 1-10 of a 28-day 
cycle. 
 
Cycle 3 and subsequent cycles: All patients will receive 20 mg/m2 IV infusion per day over 
one hour on Days 1-5 of the 28-day cycle  
 
Patients will continue on therapy until time of transplantation or progression as detailed in 
Sections 5.1 and 6.3. Delays in therapy are permitted due to infection and other 
complications. 
 
5.4 
Relapsed or Progressive Disease 
 
Patients who relapse or who have progressive disease (PD) after 2 cycles of decitabine, 
may proceed to alternative salvage regimen or to stem cell transplant according to treating 
physician and to center preference. (Please refer to Section 12 for the definition of PD.) 
 
5.5 
Transplantation  
 
Patients in mLFS, CR, CRc, or CRi who are considered fit for stem cell transplantation and 
who have an appropriate donor will undergo stem cell transplantation per treating physician 
recommendations. Haploidentical and allogenic transplantation may be utilized. 
Myeloablative and non-myeloablative protocols may be utilized per institutional protocols.  
Patients will be considered on study through day of transplant and will be followed for 
overall survival. 
 
5.6 
Women of Childbearing Potential 
 
Women of childbearing potential (defined as women with regular menses, women with 
amenorrhea, women with irregular cycles, women using a contraceptive method that 
precludes withdrawal bleeding, and women who have had a tubal ligation) are required to 
have a negative serum/urine pregnancy test within 7 days prior to the first dose of the study 
agent.   
 
Female and male patients (along with their female partners) are required to use two forms 
of acceptable contraception, including one barrier method, during participation in the study 
and for 6 months following the last dose of the study agent.  
 
 
 

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If a patient is suspected to be pregnant, the study agent should be immediately 
discontinued.  In addition, a positive urine test must be confirmed by a serum pregnancy 
test.  If it is confirmed that the patient is not pregnant, the patient may resume dosing. 
 
If a female patient or female partner of a male patient becomes pregnant during therapy or 
within 6 months after the last dose of the study agent, the investigator must be notified in 
order to facilitate outcome follow-up. 
 
5.7 
Concomitant Therapy and Supportive Care Guidelines 
 
A. 
Chemotherapy 
 
Patients may be receiving hydroxyurea at enrollment and may continue on 
hydroxyurea through Cycle 2 of decitabine. An indication for hydroxyurea 
following 2 cycles of decitabine is evidence that the patient is not responding and 
decitabine should be discontinued. Other than decitabine, patients cannot receive 
chemotherapy during this trial.  
 
B. 
Growth Factors 
 
Erythroid growth factors should not be routinely administered to patients during the 
study. 
 
Thrombopoietin receptor agonists should not be routinely administered to patients 
during the study. 
 
Filgrastim (G-CSF) or sargramostim (GM-CSF) may be administered to patients 
with septic shock or febrile neutropenia at the discretion of the treating physician. 
 
C. 
Transfusions 
 
RBC transfusions and platelet transfusions will be administered at the discretion of 
the treating physician.  
 
D. 
Prophylactic Antimicrobial Agents  
 
Antimicrobial agents will be administered at the discretion of the treating physician. 
Common antimicrobial prophylaxis includes acyclovir, ciprofloxacin, and 
fluconazole. Alternative antibacterial and antifungal agents (e.g. voriconazole or 
posaconazole) may be used at the discretion of the treating physician. 
 
Administration of live or attenuated vaccination is not permitted. 
 
 
 

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E. 
Radiotherapy 
 
Patients cannot receive radiotherapy within 14 days prior to study enrollment or 
while on study. 
 
 
F. 
Plasmapheresis or other anti-cancer therapy 
 
The use of plasmapheresis, other anti-cancer therapies, or other investigational 
agents is not permitted. 
 
5.8 
Duration of Therapy 
 
If at any time the constraints of this protocol are considered to be detrimental to the 
patient’s health and/or the patient no longer wishes to continue protocol therapy, the 
protocol therapy should be discontinued and the reason(s) for discontinuation documented 
in the case report forms. 
 
In the absence of treatment delays due to adverse events, treatment may continue until the 
start of conditioning therapy for transplant or, in transplant ineligible patients, treatment 
may continue indefinitely or until one of the following criteria applies: 
 
• Documented and confirmed disease progression 
• Death 
• Adverse event(s) that, in the judgment of the investigator, may cause severe or 
permanent harm or which rule out continuation of study drug 
• General or specific changes in the patient’s condition render the patient unable to 
receive further treatment in the judgment of the investigator 
• Suspected pregnancy 
• Serious non-compliance with the study protocol 
• Lost to follow-up 
• Patient withdraws consent 
• Investigator removes the patient from study 
• The Siteman Cancer Center decides to close the study 
 
Patients who prematurely discontinue treatment for any reason will be followed as 
indicated in the study calendar. 
 
5.9 
Duration of Follow-up 
 
Patients will be followed with regular office visits for at least 2 years since enrollment or 
until death, whichever occurs first.   
 
 
 
 

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6.0 
DOSE DELAYS/DOSE MODIFICATIONS 
 
A criterion for discontinuation of the study is a delay of > 12 weeks between any two cycles.  
Dose delays and modifications are allowed as specified below. 
 
6.1 
Delay for Cytopenia or Infection 
 
As cytopenias are a defining feature of AML, their presence alone does not warrant dose 
modifications or delays. Patients will receive two cycles of therapy without adjustment for 
any cytopenia. Following Cycle 2, dose delays for cytopenias will be made at the discretion 
of the investigator in patients who have had significant infection complications.  
 
In patients with febrile neutropenia (temperature ≥ 38.5° with ANC < 1,000/µl) or systemic 
infections, treatment will be held at discretion of treating physician.  
 
In patients who experience significant infection complications during Cycle 1, Cycle 2 may 
be reintroduced with a 50% dose reduction (10 mg/m2/day for 10 consecutive days), or at 
full dose at the discretion of the investigator. 
 
6.2 
Delay for Organ Dysfunction 
 
If renal dysfunction (creatinine ≥ 3 X IULN) or hepatic dysfunction (bilirubin ≥ 2.5 mg/dl 
or ALT/AST ≥ 3 X IULN) occurs, therapy may not resume until the abnormalities have 
resolved to below the limits stated above. If renal or hepatic dysfunction occurs during a 
treatment course, the next dose of decitabine should be held, and serum chemistries should 
be checked twice per week.  Decitabine can be resumed at full dose when creatinine, 
bilirubin, ALT and AST are below the limits listed above.  
 
For grade 3-4 non-hematologic toxicities related to decitabine, decitabine treatment should 
be delayed until recovery to baseline or to grade ≤ 1. Decitabine may be reintroduced with 
a 50% dose reduction (10 mg/m2/day), or at full dose at the discretion of the investigator. 
 
6.3 
Modification in Dose or Schedule  
 
To limit myelosuppressive toxicity, Cycles 3 and beyond will consist of 20 mg/m2/day for 
5 consecutive days (Days 1-5). 
 
 
7.0 
REGULATORY AND REPORTING REQUIREMENTS 
 
The entities providing oversight of safety and compliance with the protocol require reporting as 
outlined below. 
 
Please refer to Appendix A for definitions and Appendix C for a grid of reporting timelines.  
Adverse events will be tracked from the time of consent until 30 days after the last dose of 
chemotherapy. Adverse events will be tracked from the time of consent until 30 days after the last 

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dose of chemotherapy.  All adverse events must be recorded on the toxicity tracking case report 
form (CRF) with the exception of baseline adverse events, which shall be recorded on the medical 
history CRF. 
 
Refer to the data submission schedule in Section 11 for instructions on the collection of AEs in the 
EDC. 
 
Reporting requirements for Washington University study team may be found in Section 1.1.  
Reporting requirements for secondary site study teams participating in Washington University-
coordinated research may be found in Section 1.2. 
 
The safety and side effects of decitabine have been well characterized in numerous clinical trials 
involving patients with AML and MDS. In specific, cytopenias are commonplace in patients with 
AML and in patients treated with decitabine. These frequently result in infection complications, 
bleeding complications, and transfusion requirements. 
 
Janssen requires that all events be reported as outlined in Section 7.5. 
 
7.1 
Reporting to the Human Research Protection Office (HRPO) at Washington 
University 
 
Reporting will be conducted in accordance with Washington University IRB Policies. 
 
Pre-approval of all protocol exceptions must be obtained prior to implementing the change.   
 
7.2 
Reporting to the Quality Assurance and Safety Monitoring Committee 
(QASMC) at Washington University 
 
The Washington University Sponsor-Investigator (or designee) is required to notify the 
QASMC of any unanticipated problems involving risks to participants or others occurring 
at WU or any BJH or SLCH institution that has been reported to and acknowledged by 
HRPO.  (Unanticipated problems reported to HRPO and withdrawn during the review 
process need not be reported to QASMC.) 
 
QASMC must be notified within 10 days of receipt of IRB acknowledgment via email to 
qasmc@wustl.edu.  Submission to QASMC must include the myIRB form and any 
supporting documentation sent in with the form. 
 
For events that occur at secondary sites, the Washington University Sponsor Investigator  
(or designee) is required to notify the QASMC within 10 days of Washington University 
notification via email to qasmc@wustl.edu.  Submission to QASMC must include either 
the myIRB form and supporting documentation or (if not submitted to myIRB) the date of 
occurrence, description of the event, whether the event is described in the currently IRB 
approved materials, the event outcome, determination of relatedness, whether currently 
enrolled participants will be notified, and whether the informed consent document and/or 
any study procedures will be modified as a result of this event. 

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7.3 
Secondary Sites Reporting Requirements 
 
The research team at each secondary site is required to promptly notify the Washington 
University Sponsor-Investigator and designee of all serious adverse events (refer to 
Appendix A, Section D)  within 1 working day of the occurrence of the event or 
notification of the secondary site’s PI of the event.  This notification may take place via 
email if there is not yet enough information for a formal written report using an FDA Form 
3500a (MedWatch form) and Washington University’s Cover Sheet (Appendix C).  A 
formal written report must be sent to the Washington University Sponsor-Investigator and 
designee within 4 calendar days (for fatal or life threatening suspected adverse 
reactions) or 11 calendar days (for serious unexpected, suspected adverse reaction) of 
the occurrence of the event or notification of the secondary site’s PI of the event.  The death 
of a research participant that qualifies as a reportable event should be reported within 1 
working day of the occurrence of the event or notification of the secondary site’s PI of the 
event. 
 
The research team at a secondary site is responsible for following its site’s guidelines for 
reporting applicable events to its site’s IRB according to its own institutional guidelines. 
The research team at Washington University is responsible for reporting all applicable 
events to the FDA, and Janssen. 
 
7.4 
Reporting to Secondary Sites 
 
The Washington University Sponsor-Investigator (or designee) will notify the research 
team at each secondary site of all unanticipated problems involving risks to participants or 
others that have occurred at other sites within 10 working days of the occurrence of the 
event or notification of the Sponsor-Investigator (or designee) of the event.  This includes 
events that take place both at Washington University and at other secondary sites, if 
applicable.  Refer to Section 16.0 (Multicenter Management) for more information. 
 
7.5 
Reporting to Janssen  
 
A. 
Overview 
 
As the sponsor of the Study, the principal investigator shall be solely responsible 
for complying, within the required timelines, any safety reporting obligation to 
competent Health Authorities, IRB/ECs and any participating (co or sub) 
investigators, as defined in applicable laws and regulations.  For the purposes of 
this section, safety data includes adverse events, product quality complaints 
(PQCs), and special situations including pregnancies. 
 
The principal investigator will provide safety information to Janssen Scientific 
Affairs, LLC on adverse events, special situations including pregnancies and 
product quality complaints as defined within this section. 
 

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B. 
Management of Safety Data 
 
This Study has been designated as an interventional study.  As such, all adverse 
events, special situations including pregnancies and product quality complaints will 
be reported  as described in this Exhibit from the time a subject has signed and 
dated an Informed Consent Form (ICF) until  30 days after the last documented use 
of a product under study within the study.  All subsequent AEs and SAEs will be 
collected after this period if the Principal Investigator considers the AE/SAE to be 
causally-related to the use of the study drug. 
 
For the purposes of this study, the J&J medicinal product is DACOGEN™ (decitabine).  
 
C. 
Hospitalization 
 
For reports of hospitalization, it is the sign, symptom or diagnosis which led to the 
hospitalization that is the serious event for which details must be provided. 
 
Any event requiring hospitalization or prolongation of hospitalization that occurs 
during the study must be reported as a serious adverse event, except hospitalizations 
for the following: 
 Hospitalizations not intended to treat an acute illness or adverse event (e.g., 
social reasons such as pending placement in long-term care facility) 
 Surgery or procedure planned before entry into the study. [Note: 
Hospitalizations that were planned before the start of data collection and 
where the underlying condition for which the hospitalization was planned 
has not worsened will not be considered serious adverse events. Any 
adverse event that results in a prolongation of the originally planned 
hospitalization is to be reported as a new serious adverse event.] 
 For convenience, the investigator may choose to hospitalize the subject for 
the duration of the treatment period. 
 
D. 
Maintenance of Safety Information and Procedure for 
Reporting  
 
All safety data should be maintained in a clinical database in a retrievable format. 
The principal investigator shall provide all adverse events, both serious and non-
serious, in report format. However, in certain circumstances more frequent 
provision of safety data may be necessary, e.g. to fulfill a regulatory request, and 
as such the data shall be made available within a reasonable timeframe at Janssen 
Scientific Affairs, LLC request. 
 
E. 
Procedures for Reporting Safety Data and Product Quality 
Complaints (PQCs) for Janssen Medicinal Products to Janssen Scientific 
Affairs, LLC 
 

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All adverse events and special situations, whether serious or non-serious, related or 
not related, following exposure to a J&J medicinal product are to be documented 
by the investigator and recorded in the CRF and in the subject’s source records. 
Investigators must record in the CRF their opinion concerning the relationship of 
the adverse event to a J&J medicinal product.  
All (serious and non-serious) adverse events reported for a J&J medicinal product 
should be followed-up in accordance with clinical practice. 
 
F. 
SAEs, Adverse Events of Special Interest and Special Reporting 
Situations 
 
All serious adverse events that have not resolved by the end of the study, or that 
have not resolved upon discontinuation of the subject's participation in the study, 
must be followed until any of the following occurs: 
o The event resolves 
o The event stabilizes 
o The event returns to baseline, if a baseline value/status is available 
o The event can be attributed to agents other than the study drug or to factors 
unrelated to study conduct 
o It becomes unlikely that any additional information can be obtained (subject 
or health care practitioner refusal to provide additional information, lost to 
follow-up after demonstration of due diligence with follow-up efforts) 
 
The principal investigator will transmit all SAEs, Adverse Events of Special 
Interest, and special situations following exposure to a J&J product under study in 
a form provided by Janssen Scientific Affairs, LLC in accordance with Section 
7.5.L Transmission Methods, in English within 24-hours of becoming aware of 
the event(s). 
 
In the event the study is blinded, the principal investigator will submit an unblinded 
SAE or pregnancy exposure report to Janssen Scientific Affairs, LLC. 
 
All follow-up information for serious adverse events that are not resolved at the end 
of the study or by the time of patient withdrawal must be reported directly by the 
principal investigator, within 24 hours becoming aware, to Janssen Scientific 
Affairs, LLC using the Janssen Scientific Affairs, LLC Serious Adverse Event 
Report  
 
All available clinical information relevant to the evaluation of a related SAE, 
Adverse Events of Special Interest, serious ADR or special situation is required. 
 
• The principal investigator is responsible for ensuring that these cases are 
complete and if not are promptly followed-up. A safety report is not 
considered complete until all clinical details needed to interpret the case are 
received. Reporting of follow-up information should follow the same 
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• Copies of any and all relevant correspondences with regulatory authorities 
and ethics committees regarding any and all serious adverse events, 
irrespective of association with the J&J Product under study, are to be 
provided to Janssen Scientific Affairs, LLC using a transmission method in 
Section 7.5.L within 24 hours of such report or correspondence being 
sent to applicable health authorities. 
 
Special Reporting Situations 
Safety events of interest for a J&J medicinal product that require expediting 
reporting and/or safety evaluation include, but are not limited to: 
o Drug exposure during pregnancy (maternal and paternal) 
o Overdose of a J&J medicinal product  
o Exposure to a J&J medicinal product from breastfeeding  
o Suspected abuse/misuse of a J&J medicinal product 
o Inadvertent or accidental exposure to a J&J medicinal product  
o Any failure of expected pharmacological action (i.e., lack of effect) of 
a J&J medicinal product 
o Medication error involving a J&J medicinal product (with or without 
patient exposure to the J&J medicinal product, e.g., name confusion) 
o Suspected transmission of any infectious agent via administration of a 
medicinal product 
o Unexpected therapeutic or clinical benefit from use of a Janssen 
medicinal product 
 
These safety events may not meet the definition of an adverse event; however, from 
a Janssen Scientific Affairs, LLC perspective, they are treated in the same manner 
as adverse events. Special situations should be recorded on the Adverse Event page 
of the CRF. 
 
Any special situation that meets the criteria of a serious adverse event should be 
recorded on a Serious Adverse Event Report Form and be reported to Janssen 
Scientific Affairs, LLC within 24 hours of becoming aware of the event. 
 
G. 
Non-Serious AEs 
 
All non-serious adverse events should be reported to Janssen Scientific Affairs, 
LLC according to the timeframe outlined in the Research Funding Agreement 
section entitled Reporting of Data. 
 
 
 

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H. 
Pregnancy  
 
Initial reports of pregnancy must be reported to Janssen Scientific Affairs, LLC by 
the principal investigator within 24 hours of becoming aware of the event using 
the Serious Adverse Event Form. Abnormal pregnancy outcomes (e.g. spontaneous 
abortion, fetal death, stillbirth, congenital anomaly, ectopic pregnancy) are 
considered serious adverse events and must be reported using the Serious Adverse 
Event Form.  
 
Any subject who becomes pregnant during the study must be promptly withdrawn 
from the study and discontinue further study treatment. 
 
Because the effect of the J&J medicinal product on sperm is unknown, pregnancies 
in partners of male subjects exposed to a J&J medicinal product will be reported by 
the principal investigator within 24 hours of their knowledge of the event using the 
Serious Adverse Event Form.  Depending on local legislation, this may require 
prior consent of the partner. 
 
Follow-up information regarding the outcome of the pregnancy and any postnatal 
sequelae in the infant will be required. 
 
I. 
PQC Reporting 
 
A PQC may have an impact on the safety and efficacy of the product. Timely, 
accurate, and complete reporting and analysis of PQC information from studies are 
crucial for the protection of patients, investigators, and Janssen Scientific Affairs, 
LLC, and are mandated by regulatory agencies worldwide. Janssen Scientific 
Affairs, LLC has established procedures in conformity with regulatory 
requirements worldwide to ensure appropriate reporting of PQC information. Lot 
and/or Batch #s shall be collected for any reports of failure of expected 
pharmacological action (i.e., lack of effect). The product should be quarantined 
immediately and if possible, take a picture. 
 
All initial PQCs involving a J&J medicinal product under study must be reported 
to Janssen Scientific Affairs, LLC by the principal investigator within 24 hours 
after being made aware of the event. The J&J contact will provide additional 
information/form to be completed. 
 
If the defect for a J&J medicinal product under study is combined with either a 
serious adverse event or non-serious adverse event, the principal investigator must 
report the PQC to Janssen Scientific Affairs, LLC according to the serious adverse 
event reporting timelines.  A sample of the suspected product should be maintained 
for further investigation if requested by Janssen Scientific Affairs, LLC. 
 
 
 

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J. 
Reporting Procedures for Reporting Safety Data and Product 
Quality Complaints (PQCs) for Non-J&J Medicinal Products  
 
For SAEs, special reporting situations and PQCs following exposure to a non-J&J 
medicinal product under study, the principal investigator should notify the 
appropriate regulatory/competent authority or the manufacturer of that medicinal 
product (in the absence of appropriate local legislation) as soon as possible. 
 
K. 
Individual Case Safety Report (ICSR) 
 
A valid ICSR must contain the four minimum criteria required to meet regulatory 
reporting requirements. 
• an identifiable subject (but not disclosing personal information such as the 
subject’s name, initials or address) 
• an identifiable reporter (investigational site) 
• a J&J medicinal product 
• an adverse event, outcome, or certain special situations 
 
The minimum information required is: 
• suspected J&J medicinal product (doses, indication) 
• date of therapy (start and end date, if available) 
• batch or lot number, if available  
• subject details (subject ID and country)  
• Gender  
• age at AE  
• onset 
• reporter ID 
• adverse event detail (AE verbatim in English) 
• onset date 
• relatedness  
• causality  
• action taken  
• outcome, (if available)  
• J&J protocol ID 
 
L. 
Transmission Methods 
 
The following methods are acceptable for transmission of safety information to 
Janssen Scientific Affairs, LLC: 
• Electronically via Janssen SECURE Email service (preferred) to IIS-BIO-
VIRO-GCO@its.jnj.com 
• For business continuity purposes, if SECURE Email is non-functional: to 
1-866-451-0371 
 

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• Facsimile (fax), receipt of which is evidenced in a successful fax 
transmission report 
• Telephone (if fax is non-functional). 
 
Please use the contact information and process information provided by Janssen 
Scientific Affairs, LLC.  
 
7.6 
Reporting to the FDA 
 
The conduct of the study will comply with all FDA safety reporting requirements.  
PLEASE NOTE THAT REPORTING REQUIREMENTS FOR THE FDA DIFFER 
FROM REPORTING REQUIREMENTS FOR HRPO/QASMC.  It is the 
responsibility of the Washington University principal investigator to report to the FDA as 
follows: 
 
• Report any unexpected fatal or life-threatening suspected adverse reaction (refer to 
Appendix A for definitions) no later than 7 calendar days after initial receipt of the 
information.   
• Report a suspected adverse reaction that is both serious and unexpected (SUSAR, refer 
to Appendix A) no later than 15 calendar days after it is determined that the information 
qualifies for reporting.  Report an adverse event (refer to Appendix A) as a suspected 
adverse reaction only if there is evidence to suggest a causal relationship between the drug 
and the adverse event, such as: 
o 
A single occurrence of an event that is uncommon and known to be 
strongly associated with drug exposure 
o 
One or more occurrences of an event that is not commonly associated with 
drug exposure but is otherwise uncommon in the population exposed to the drug 
o 
An aggregate analysis of specific events observed in a clinical trial that 
indicates those events occur more frequently in the drug treatment group than in a 
concurrent or historical control group 
• Report any findings from epidemiological studies, pooled analysis of multiple studies, 
or clinical studies that suggest a significant risk in humans exposed to the drug no later 
than 15 calendar days after it is determined that the information qualifies for reporting. 
• Report any findings from animal or in vitro testing that suggest significant risk in 
humans exposed to the drug no later than 15 calendar days after it is determined that the 
information qualifies for reporting.  
• Report any clinically important increase in the rate of a serious suspected adverse 
reaction of that listed in the protocol or IB within 15 calendar days after it is determined 
that the information qualifies for reporting. 
 
Submit each report as an IND safety report in a narrative format or on FDA Form 
3500A or in an electronic format that FDA can process, review, and archive.  Study 
teams must notify the Siteman Cancer Center Protocol Development team of each 
potentially reportable event within 1 business day after initial receipt of the 
information, and must bring the signed 1571 and FDA Form 3500A to the Siteman 

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Cancer Center Protocol Development team no later than 1 business day prior to the 
due date for reporting to the FDA. 
 
Each notification to FDA must bear prominent identification of its contents (“IND 
Safety Report”) and must be transmitted to the review division in the Center for 
Drug Evaluation and Research (CDER) or in the Center for Biologics Evaluation 
and Research (CBER) that has responsibility for review of the IND.  Relevant 
follow-up information to an IND safety report must be submitted as soon as the 
information is available and must be identified as such (“Follow-up IND Safety 
Report”). 
 
7.7 
Exceptions to Expedited Reporting 
 
Events that do not require expedited reporting as described in include: 
• 
planned hospitalizations 
• 
respite care 
• 
events related to disease progression 
 
Events that do not require expedited reporting must still be captured in the EDC. 
 
 
8.0 
PHARMACEUTICAL INFORMATION 
 
8.1 
Study Drug Preparation  
 
OSHA Guidelines for handling cytotoxic drugs outlined in the American Journal of 
Hospital Pharmacy must be followed. 
 
Decitabine (5-aza-2’-deoxycytidine) is supplied as a lyophilized powder for injection, 50 
mg in 20-ml vials. When reconstituted with 10 ml of sterile water for injection, each ml 
will contain 5 mg of decitabine and 6.8 mg of KH2PO4. The reconstituted solution should 
be diluted to 0.1-1.0 mg/mL with pre-chilled 0.9% sodium chloride intravenous infusion, 
which has been cooled to 2-8oC. Reconstitution of the powder results in a rapidly 
decomposing solution. Unless used within 15 minutes of reconstitution, the diluted solution 
must be prepared using cold (2—8 degrees C) infusion fluids and stored at 2—8 degrees C 
(36—46 degrees F) for a maximum of 7 hours. 
 
Decitabine will be administered per dosing schedule every 28 ± 4 days.  
 
The site according to institutional drug disposal procedures should discard any partially 
used vials.  
 
Decitabine may be administered either as an inpatient or as an outpatient.  
 
Recommended safety measures for handling and preparation includes masks, protective 
clothing, gloves (double glove with nitrile gloves) and vertical laminar airflow safety 

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cabinets.  
 
A. 
Supplier 
 
Decitabine is available commercially. 
 
 
9.0 
CORRELATIVE STUDIES 
 
9.1 
Correlative Studies Background 
 
A. 
Methylation Changes 
 
Decitabine causes hypomethylation of DNA by inhibiting DNA methyltransferase 
(Section 1.3). DNA methylation is an important epigenetic event in modulating 
development, cellular differentiation, and proliferation30-32. DNA methylation, 
primarily occurring at C5 of the cytosine ring within cytosine–guanine (CpG) 
dinucleotides, is frequently found clustered at gene regulatory sites such as 
promoter regions and results in transcriptional silencing of the affiliated gene. 
Depending on the promoter regions affected, DNA hypermethylation could lead to 
tumor suppressor gene silencing and ultimately tumorigenesis. 
 
B. 
Genome-wide decitabine induced DNA methylation signatures 
 
To determine whether decitabine treatment results in hypomethylation at consistent 
CpGs in AML blasts, we will perform whole genome bisulfite sequencing and 
assess for DNA methylation patterns in pre-treatment (Day 0), at Day 10 (C1D10), 
at Day 28 (C1D28), and in samples collected at relapse. 
  
C. 
Decitabine induced gene expression signatures 
 
To determine if changes in methylation induced by decitabine treatment correlate 
with gene expression changes, we will perform RNA sequencing on RNA extracted 
from bone marrow cells pre treatment  (Day 0), on Day 10 (C1D10), and on Day 
28 (C1D28) post decitabine. 
 
D. 
DNA Changes 
 
Conventional chemotherapies in AML cause early termination of DNA synthesis 
(cytarabine) or topoisomerase inhibition (daunorubicin) that ultimately converge 
onto TP53 that, together with CDKN2A sense irreparable DNA damage and 
ultimately trigger cell cycle arrest and cell death33. Therefore, it is not surprising 
that AML with defective TP53 are resistant to conventional chemotherapeutic 
agents. The effectiveness of decitabine that we observed in the cohort of patient 
with TP53 mutation suggests that decitabine acts through a different, TP53 
independent, mechanism. Interestingly, Tp53 null mice develop normally34, thus 

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suggesting that cell cycle exit via differentiation is intact in these mice. As 
mentioned in Section 1, treatment with decitabine does not lead to clone 
eradication. Morphologic blast clearance precedes mutation clearance, with the 
malignant clone often remaining detectable at low levels over time (Figure 4).  
 
This is consistent with a model in which the proliferating cells of the malignant 
clone enter terminal differentiation after exposure to the drug, with the remaining 
quiescent stem cells carrying the mutation remaining dormant and eventually 
contributing to relapse when challenged to cycle.  
 
 
 
Figure 4: Kinetics of blast clearance versus clonal burden: bone marrow blast reduction detected by 
morphology at C1D28 does not correlate with founding clone reduction at the same time-point.  
 
Furthermore, difference in DNA methylation may not result in changes in gene 
expression34. For example, AMLs with mutations in DNMT3A that result in 
significant hypomethylation in specific DNA regions, do not display differences in 
whole transcriptome compared to AML bearing wild type DNMT3A36. This could 
be partially explained by the fact that DNA modifications (i.e. methylation status 
of gene promoters) are not the only determinant of gene transcription. Histones 
modifications, such as histones methylation, can alter chromatin structure through 
changes in the chemical moieties on the nucleosome surface and subsequently 
affect recruitment of the transcription factor machinery to specific DNA regions, 
silencing or activating gene transcription independently from promoter 
methylation. 
 
E. 
Decitabine induced myeloid differentiation 
 
To determine whether decitabine induces multilineage differentiation, or myeloid 
biased differentiation, we will identify cases where discordant morphologic blast 
clearance occurs without mutation clearance (Figure 4). We will flow sort 
differentiated peripheral blood monocytes, neutrophils, T cells, B cells, and NK 
cells and evaluate each population for the presence of AML-associated mutations. 
We compare results of samples sorted from Day 0, C1D28, C2D28, and C3D28, as 
appropriate. 

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F. 
Correlation of the rate and depth of mutation clearance with 
survival 
 
We will assess tumor burden by allele frequency of patient-specific mutations in 
bone marrow or peripheral blood samples collected pre study, C1D28, C2D28 and 
C3D28 as well as at regular intervals after transplant. The velocity and depth of 
tumor response will be correlated to: 
 
• Achievement of clinical CR, 
• Time to best response, 
• Mutational status, 
• Time to disease progression 
 
9.2 
Correlative studies sample 
 
Samples should be identified with the patient UPN, the source (e.g. BM: bone marrow, PB: 
peripheral blood, S: skin; U: buccal), the cycle (e.g. D0: day 0; C1D10: cycle 1 day 10; 
C1D28; cycle 1 day 28, etc), the month/day/year of collection. Individual tubes or vials 
may be labeled with a specimen number. Specimen records should be included with each 
collection. 
 
Peripheral blood and bone marrow samples collected by collaborating institutions should 
be frozen as viable cells at 5-106 cells per ml.  For convenience, samples can be stored 
locally in liquid nitrogen and may be shipped in batches to Washington University for 
further processing, at the address below: 
Washington University 
Division of Oncology 
SWT621 
4940 Parkview Place 
St. Louis, MO  63110 
 
Samples to be collected: 
Bone Marrow 
• Baseline 
• C1D10 (± 2)** 
• C1D28 (± 4) 
• C2D28 (± 4)*** 
• C3D28 (± 4) 
• Progression or relapse 
 
After the necessary samples are obtained for optimal medical care of the patient (if 
applicable), additional aspiration will be performed to obtain a sample for research 
purposes.  The anticoagulated specimen (10 mL) will be placed in sterile EDTA vacutainer 
tubes, and then the cellular elements of the collected marrow will be separated and 

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cryopreserved.  If at any bone marrow collection the aspirate is a “dry tap”, two additional 
tubes of blood (10 mL each) will be collected and banked. 
 
** Bone marrow aspirate and biopsies will only be performed in patients enrolled at Washington University. 
*** At the discretion of the treating physician 
 
Peripheral Blood 
• Baseline 
• C1D10 (± 2) 
• C1D28 (± 4) 
• C2D28 (± 4) 
• C3D28 (± 4) 
• Progression or relapse 
 
Peripheral blood will be obtained by venipuncture or cannulation of an indwelling venous 
access device.  Ten mL will be placed in sterile EDTA anticoagulated vacutainer tubes 
which will be processed to cryopreserved cells w/RBC Lyse (up to 15 aliquots at 1x10⁷ 
cells/aliquot).   
 
Skin Biopsy 
•  If WBC at time of enrollment is < 30,000/µl, skin biopsy should be collected 
during enrollment bone marrow biopsy. 
• If WBC at time of enrollment is >30,000/µl, skin biopsy should be collected at the 
time of C1D28 bone marrow biopsy or thereafter. 
 
A single 6 mm punch biopsy of normal skin will be performed using standard techniques 
and local anesthesia.  The skin samples will be placed in a sterile specimen cup and snap 
frozen following collection. 
 
Buccal Swab 
• Baseline (if skin biopsy is declined) 
• C2D28 (±4) 
• Buccal cells should be spun down and snap frozen as a single pellet at the time of 
collection. 
 
 

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10.0 
STUDY CALENDAR 
 
 
Screening 
B/l 
C1D
1 
C1D1
0 
C1D2
8 
C2D
1 
C2 
D28 
C3D
1 
C3 
D28 
All cycles 
thereafter 
Time of 
progression 
F/U 
D1 
D28 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
X 
 
 
X 
 
X 
 
X 
 
 
 
Physical exam, ht, wt  
X 
X4 
X 
 
 
X 
 
X 
 
X 
 
X 
 
CBC + diff 
X 
X4 
X ------------ X9 
X9 
X 
X9 
X 
X9 
 
X 
 
Serum chemistry5 
X 
X4 
X 
 
 
X 
 
X 
 
X 
 
X 
 
Pregnancy test1 
X 
X4 
 
 
 
 
 
 
 
 
 
 
 
HIV, hepatitis tests 
X16 
 
 
 
 
 
 
 
 
 
 
 
 
BM bx + aspirate17 
 
 
 
X13 
X14 
 
X10,14 
 
X11,14 
 
X12 
X 
 
Flow cytometry2 
 
 
 
 
 
 
 
 
 
 
 
 
 
PB for research 
 
 
 
X13 
X14 
 
X14 
 
X15 
 
 
X 
 
Skin biopsy 
 
 
 
 
 
 
 
 
 
 
 
 
 
Buccal swab 
 
 
 
 
 
 
X 
 
 
 
 
 
 
Decitabine 
 
 
X ---- X6 
 
X6 
 
X7 
 
X7 
 
 
 
AE assessment 
 
 
 
 
 
 
 
 
 
 
 
 
 
Progression/survival  
 
 
 
 
 
 
 
 
 
 
 
 
X15 
1. 
Women of childbearing potential only 
2. 
On bone marrow or peripheral blood 
3. 
For BMBX, no more than 28 days prior to the 1st dose of decitabine. For the skin biopsy, if WBC at enrollment is > 30,000/µl, the skin biopsy should be collected during C1D28, or thereafter. 
4. 
No more than 7 days prior to the 1st dose of decitabine 
5. 
Including albumin, creatinine, total bilirubin, AST, ALT, LDH 
6. 
Days 1-10 
7. 
May be reduced to Days 1-5 for Cycles 3 and 4 
8. 
Buccal swab may be performed at baseline in patients who decline skin biopsy  
9. 
Drawn weekly during Cycle 1; may be reduced to Days 1 and 15 of each cycle after Cycle 1 
10. Patients who relapse or who have progressive disease (PD) after 2 cycles of decitabine may proceed to alternative salvage regimen or to stem cell transplant per treating physician and center preference. 
11. Transplant eligible patients who achieve CR, CRc, CRi, or mLFS after 3 cycles with a suitable donor will proceed to conditioning regimen and transplant; transplant eligible patients who are in PR after 3 cycles will be 
removed from protocol and proceed to salvage treatment according to center preference; transplant ineligible patients with all responses (CR, CRc or CRi, PR, SD) will continue on maintenance doses until progression 
or death 
12. At the discretion of the treating physician 
13. +/- 2 days, only patients enrolled at Washington University 
14. Typically 28 +/- 4 days. At the discretion of the treating physician this biopsy may be delayed until the next cycle is initiated. The biopsy at the end of cycle 2 will be collected at the discretion of the treating physician. 
15. For 2 years 
16. Prior negative screening at any time is sufficient. If no prior screening is available, the patient should be tested during screening. 
17. If at any bone marrow collection the aspirate is a “dry tap”, two additional tubes of blood (10 mL each) will be collected and banked.

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11.0 
DATA SUBMISSION SCHEDULE 
 
Case report forms with appropriate source documentation will be completed according to the 
schedule listed in this section. 
Case Report Form 
Submission Schedule 
Original Consent Form 
Prior to registration 
Patient Registration Form 
Medical and Surgical History Form 
Treatment History Form 
On Study Form 
Correlative Skin Biopsy Form 
 
Prior to starting treatment 
Decitabine Form 
End of each cycle 
CBC Form 
Baseline 
Day 1 
Day 10 
Day 28 
Time of progression 
Correlative Bone Marrow Form 
Correlative Blood Form 
Baseline 
C1D10 
End of Cycle 1 
End of Cycle 2 
End of Cycle 3 
Time of progression or relapse 
Correlative Buccal Swab Form 
Baseline 
End of Cycle 2 
Disease Assessment Form 
Baseline 
End of Cycle 1 
End of Cycle 2 
End of Cycle 3 
Time of progression 
Off Treatment Form 
 
Due at the completion of the EOT visit, at the time of 
death, and/or at the time that the patient is lost to 
follow-up 
Follow Up Form 
30 days post date of last decitabine dose. 
Every 6 months for 2 years after the last dose of study 
drug. 
Hospitalization Form 
Time of hospitalization 
Death Form 
Time of death 
Record of Adverse Events 
At the time of any AE 
 
Any queries generated by Washington University must be responded to within 28 days of receipt 
by the participating site.  The Washington University research team will conduct a regular review 
of data status at all secondary sites, with appropriate corrective action to be requested as needed. 

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11.1 
Adverse Event Collection in the Case Report Form 
 
All adverse events that occur beginning with start of treatment (minus exceptions defined 
in Section 7.0) must be captured in the Toxicity Form.  Baseline AEs should be captured 
on the Medical History Form. 
 
Participant death due to disease progression should be reported on the Toxicity Form as 
grade 5 disease progression.  If death is due to an AE (e.g. cardiac disorders: cardiac 
arrest), report as a grade 5 event under that AE.  Participant death must also be recorded 
on the Death Form. 
 
 
12.0 
MEASUREMENT OF EFFECT 
 
12.1 
Response assessment  
 
Bone marrow biopsy will be obtained on Cycle 1 Day 28 ± 4, Cycle 2 Day 28 ± 4, and 
Cycle 3 Day 28 ± 4.  The cycle 2 Day 28 collection may be performed at the discretion of 
the treating physcian. 
 
All patients will be assessed for response according to the 2017 ELN AML 
Recommendations37: 
 
Complete remission (CR) – Defined as bone marrow blasts <5%; absence of circulating 
blasts and blasts with Auer rods; absence of extramedullary disease; absolute neutrophil 
count ≥1.0 x 109/L (1,000/μL); platelet count ≥100 x 109/L (100,000/μL). 
Complete remission with incomplete hematologic recovery (CRi): All CR criteria except 
for residual neutropenia - <1.0 x 109/L (1,000/μL) or thrombocytopenia -<100 x 109/L 
(100,000/μL) 
Cytogenetic complete remission (CRc) – Defined as morphologic complete remission plus 
a reversion to a normal karyotype. For this study, reversion of a normal karyotype is 
defined as no clonal abnormalities detected in a minimum of 20 mitotic cells. 
 
Morphologic leukemia free state (mLFS): Defined as bone marrow blasts <5%; absence of 
blasts with Auer rods; absence of extramedullary disease; no hematologic recovery 
required. Marrow should not merely be “aplastic”; at least 200 cells should be enumerated 
or cellularity should be at least 10% 
 
Partial remission (PR) – Defined as all hematologic criteria of CR; decrease of bone 
marrow blast percentage to 5% to 25%; and decrease of pretreatment bone marrow blast 
percentage by at least 50%.  
 
Stable Disease (SD) – Defined as not meeting the definitions of CR, CRi, PR, PD, or 
recurrence/morphologic relapse.   
 
 

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Progressive disease (PD) – Defined as a clear increase in bone marrow blast count, 
typically a greater than 50% increase compared with baseline, or new extramedullary 
disease. Patients with a > 50% increase in peripheral blast count with an increase of the 
total peripheral white blood cell count to > 10,000/µl should undergo evaluation by bone 
marrow biopsy to access for progressive disease. Patients enrolled with a bone marrow 
blast count < 20% will have > 20% blasts and a > 50% increase compared with baseline. 
 
Recurrence/morphologic relapse - Defined as relapse following complete remission is 
defined as reappearance of blasts in the blood or the finding of ≥ 5% blasts in the bone 
marrow, not attributable to any other cause. New dysplastic changes is considered relapse. 
If there are no blasts in the peripheral blood and 5-20% blasts in the bone marrow, bone 
marrow biopsy should be repeated in > 1 week to confirm relapse. 
  
A. 
Duration of Response and Stable Disease, Treatment Failure, 
Overall Survival and Event-free Survival 
 
Duration of overall response:  The duration of overall response is measured from 
the time measurement criteria are met for CR or PR (whichever is first recorded) 
until the first date that recurrent or progressive disease is objectively documented 
 
The duration of overall CR is measured from the time measurement criteria are first 
met for CR until the first date that progressive disease is objectively documented.  
 
Duration of stable disease:  Stable disease is measured from the start of the 
treatment until the criteria for progression are met, taking as reference the smallest 
measurements recorded since the treatment started, including the baseline 
measurements.  
 
Treatment failure is defined as death or failure to achieve a complete or partial 
remission following 4 cycles of therapy. 
 
Overall survival is defined as the date of first dose of study drug to the date of death 
from any cause.  Patients still alive at the time of the final analysis will be right-
censored. 
 
Event-free survival is defined as the interval from the date of first dose of study 
drug to date of treatment failure, recurrence, death due to any cause, or loss to 
follow up. 
 
B. 
Duration of Remission and Relapse-free Survival for Patients 
Having Complete Remission 
 
Duration of complete remission is defined as the interval from the date that 
complete remission is documented to the date of recurrence, death due to any cause, 
or loss to follow-up.  
 

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Relapse-free survival is defined only for those patients achieving a CR or CRi. It is 
defined as the interval from the date of first documentation of a leukemia-free state 
to the date of recurrence, death due to any cause, or loss to follow up.   
 
 
13.0 
DATA AND SAFETY MONITORING 
 
In compliance with the Washington University Institutional Data and Safety Monitoring Plan, an 
independent Data and Safety Monitoring Board (DSMB) will be specifically convened for this 
trial to review toxicity data.  .  A DSMB will consist of no fewer than 3 members including 2 
clinical investigators and a biostatistician.  DSMB members must be employed by Washington 
University, Barnes-Jewish  Hospital, or St. Louis Children’s Hospital.  Like investigators, DSMB 
members are subject to the Washington University School of Medicine policies regarding 
standards of conduct. Individuals invited to serve on the DSMB will disclose any potential 
conflicts of interest to the trial principal investigator and/or appropriate university officials, in 
accordance with institution policies. Potential conflicts that develop during a trial or a member’s 
tenure on a DSMC must also be disclosed.  
 
Until such a time as the first secondary site enrolls its first patient, a semi-annual DSM report to 
be prepared by the study team will be submitted to the Quality Assurance and Safety Monitoring 
Committee (QASMC) semi-annually beginning six months after study activation at Washington 
University (if at least one patient has been enrolled) or one year after study activation (if no patients 
have been enrolled at the six-month mark). 
 
The DSM report for the DSMB will be prepared by the study team with assistance from the 
statistician, will be reviewed by the DSMB, and will be submitted to the Quality Assurance and 
Safety Monitoring Committee (QASMC).  The DSMB must meet at least every six months 
beginning six months after study activation at Washington University or beginning six months 
after enrollment of the first patient at a secondary site, no more than one month prior to the due 
date of the DSM report to QASMC.  This report will include: 
 
• HRPO protocol number, protocol title, Principal Investigator name, data coordinator 
name, regulatory coordinator name, and statistician 
• Date of initial HRPO approval, date of most recent consent HRPO approval/revision, 
date of HRPO expiration, date of most recent QA audit, study status, and phase of study 
• History of study including summary of substantive amendments; summary of accrual 
suspensions including start/stop dates and reason; and summary of protocol exceptions, 
error, or breach of confidentiality including start/stop dates and reason 
• Study-wide target accrual and study-wide actual accrual including numbers from 
participating sites 
• Protocol activation date at each participating site 
• Average rate of accrual observed in year 1, year 2, and subsequent years at each 
participating site 
• Expected accrual end date and accrual by site 
• Objectives of protocol with supporting data and list the number of participants who 
have met each objective 

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• Measures of efficacy 
• Early stopping rules with supporting data and list the number of participants who have 
met the early stopping rules 
• Summary of toxicities at all participating sites 
• Abstract submissions/publications 
• Summary of any recent literature that may affect the safety or ethics of the study 
 
Further DSMC responsibilities are described in the DSMC charter. 
 
Until such a time as the first secondary site activates this protocol, a semi-annual DSM report to 
be prepared by the study team will be submitted to the QASM Committee beginning 6 months 
after study activation at Washington University. 
 
The study principal investigator and coordinator will monitor for serious toxicities on an ongoing 
basis. Once the principal investigator or coordinator becomes aware of an adverse event, the AE 
will be reported to the HRPO and QASMC according to institutional guidelines (please refer to 
Section 7.0). 
 
Refer to the Washington University Quality Assurance and Data Safety Monitoring Committee 
Policies and Procedures for full details on the responsibilities of the DSMC at 
https://siteman.wustl.edu/wp-content/uploads/2015/10/QASMC-Policies-and-Procedures-
03.31.2015.pdf  
 
 
14.0 
AUDITING 
 
As coordinating center of this trial, Washington University (via the Quality Assurance and Safety 
Monitoring Committee (QASMC) will monitor each participating site to ensure that all protocol 
requirements are being met; that applicable federal regulations are being followed; and that best 
practices for patient safety and data collection are being followed per protocol.  Participating sites 
will be asked to send copies of all audit materials, including source documentation.  The audit 
notification will be sent to the Washington University Research Patient Coordinator, who will 
obtain the audit materials from the participating institution. 
 
Notification of an upcoming audit will be sent to the research team one month ahead of the audit. 
Once accrual numbers are confirmed, and approximately 30 days prior to the audit, a list of the 
cases selected for review (up to 10 for each site) will be sent to the research team. However, if 
during the audit the need arises to review cases not initially selected, the research team will be 
asked to provide the additional charts within two working days. 
 
Items to be evaluated include: 
• 
Subject screening and enrollment 
• 
Reporting of adverse events 
• 
Maintenance of HIPAA compliance 
• 
Completeness of regulatory documentation 
• 
Completeness of participant documentation 

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• 
Acquisition of informed consent 
• 
IRB documentation 
• 
Issues of protocol adherence 
 
Additional details regarding the auditing policies and procedures can be found at 
https://siteman.wustl.edu/wp-content/uploads/2015/10/QASMC-Policies-and-Procedures-
03.31.2015.pdf  
 
 
15.0 
STATISTICAL CONSIDERATIONS 
 
15.1 
Study design and Sample size 
 
This will be an open-label single-arm phase II trial. The primary endpoint of this study is 
the 1-year overall survival (OS) which will be compared to historical data. TP53 mutations 
occur in 10-15% of patients with AML, and tend to occur in older adults3-6. Our power 
analysis suggests that we need at least 60 total patients enrolled. We anticipate that 500-
700 total AML patients will need to be available at enrolling institutions in order to reach 
the patient goal of 60. Time to complete accrual will be 24 months.  
 
15.2 
Analysis Populations 
 
Intent-to-Treat - Defined as all patients who receive at least one dose of decitabine.  
 
Efficacy-Evaluable - Defined as all patients who receive at least one cycle of treatment.   
 
Safety - Defined as all patients with at least one dose of decitabine. 
 
15.3 
Multicenter studies 
 
There are multiple centers in this study, however it is not anticipated that any center will 
accrue enough patients to warrant an analysis by center 
 
15.4 
Statistical Analysis 
 
A. 
Descriptive Analyses 
 
Patient Disposition: The number of patients discontinued, the reasons for 
discontinuation, and the number of cycles administered will be summarized. 
 
Demographics and Baseline Characteristics: Descriptive summary statistics will be 
provided for demographic and important baseline characteristics.  For continuous 
variables, the number of patients, mean, standard deviation, median, minimum and 
maximum will be provided.  For categorical variables, the number and percent of 
patients in each demographic/characteristic category will be summarized. 
 

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B. 
Primary Endpoint Analysis 
 
The primary end-point of this phase II study is the 1-year survival in primary 
relapsed/refractory AML patients treated with decitabine. 
Overall survival (OS) is defined as the time from enrollment to death due to any 
cause.  For a patient who is not known to be alive at the end of study follow up, 
observation of OS is censored on the date the patient was last known to be alive 
(i.e. date of last contact). 
 
C. 
Overall survival analysis  
 
Kaplan-Meier curves depicting OS in the study population compared to historical 
control will be generated. Additionally, the median OS and the probability of OS 
from 1 month to the end of the follow-up period will be reported at pre-specified 
intervals. The associated 2-sided 90% CIs will be calculated using the 
complementary log-log transformation method (Collett 1994).  
 
D. 
Interim Analysis  
 
The estimated duration of the study is approximately 3 years from enrollment of 
the first patient to the final analysis. An interim analysis for OS will be performed 
at 1.5-year (where approximately one-fourth of patients will have at least 1-year 
follow-up if assuming uniform accrual) and the conditional power will be 
calculated for futility analysis based on the accumulated data. Conditional power is 
defined as the projected power to reject the null hypothesis (that treatment of TP53-
mutated AML patients with relapsed/refractory disease is associated with 1-year 
survival  of 25%) at the end of the study given the data accrued up to the interim 
analysis. Therefore, a small value of conditional power indicates a highly likely, if 
not inevitable, conclusion of negative finding given the current data. If conditional 
power of 0.3 or less is obtained at the interim analysis, an early termination due to 
futility will be recommended. 
 
E. 
Secondary Clinical Endpoints Analyses 
 
The principal measurement of toxicity will be a measure of the total number 
hospitalized days during the first 60 days of therapy. 
 
CRc rate will be analyzed based on the ITT population. The remission rate and its 
2-sided 90% confidence interval (CI) will be summarized.  
 
Event-free survival: EFS will be analyzed using Kaplan-Meier methodology and 
Kaplan-Meier plots will be provided using the ITT analysis set. The median EFS 
and its 2-sided 90% CI using the complementary log-log transformation method 
(Collett 1994) will be calculated.  
 
Leukemia-free survival: LFS will be analyzed using Kaplan-Meier methodology 

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and Kaplan-Meier plots will be provided using the ITT analysis set. The median 
LFS and its 2-sided 90% CI using the complementary log-log transformation 
method (Collett 1994) will be calculated.  
 
Time to leukemia relapse: TTCR will be summarized using descriptive statistics. 
 
The time to stem cell transplant, the proportion of patients who are able to undergo 
transplantation, and the average number of hospital days during cycles 1 and 2, will 
also be documented. The association between response and clinical characteristics 
(morphologically evident disease -i.e., >5% blasts by cytomorphology- versus 
molecularly detected disease at the time of enrollment -i.e., disease detected with 
flow cytometry, cytogenetic, or mutational analysis with ≤ 5% blasts by 
cytomorphology-, de novo AML versus secondary AML versus treatment-related 
AML, presence versus absence of cytogenetic abnormalities in addition to TP53 
mutations, etc.) will be described using contingency tables and compared by Chi-
square test or Fisher’s exact test as appropriate. The association between survival 
(OS, EFS, LFS) and clinical characteristics will be described using Kaplan-Meier 
methods and compared by log-rank test. 
 
F. 
Secondary Molecular Endpoints Analyses 
 
Rate of patient specific mutation clearance after 28, and 56 days of therapy will 
be determined using an Illumina based platform. We will compare the rate of 
mutation clearance between the patients who achieve a CR/CRi after 4 cycles and 
those who do not. We anticipate that we will identify between 6 and 25 exonic 
SNVs per case (the range obtained with >200 AML samples sequenced to date with 
whole genome or exome sequencing), and that the expected 95% confidence 
interval of the mean variant allele frequency will be ±2.56% and ±1.25%, 
respectively, if we assume an anticipated standard deviation of 3.2% within the 
same clone. The change of tumor burden over time and its association with clinical 
response will be assessed using 2-way ANOVA for repeated measurement data, 
followed by the ad-hoc multiple comparisons for between-group differences (e.g., 
responders vs. non-responders) at given time points as well as the between-time 
differences within each group. The resultant critical P values will also be corrected 
using permutation analysis for multiple testing. 
 
The percent decrease in bone marrow methylcytosine will be calculated on day 
10±1. We will compare this reduction with previously published data and between 
the patients who achieve CR/CRi and those who do not. The correlation of peak 
plasma levels of decitabine with response will be assessed using 2-sample t-test or 
Mann-Whitney non-parametric rank-sum test as appropriate. The change of total 
bone marrow DNA methylcytosine from baseline and its association with both 
steady-state plasma drug levels and response will be assessed using 2-way ANOVA 
for repeated measurement data, followed by the ad-hoc multiple comparisons for 
between-group differences (e.g., responders vs. non-responders) and between-time 

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differences. Similar analyses will be performed for the correlation of expression 
profiles and SNP analysis with pharmacokinetic data.   
 
The proportion of patients who achieve mutation clearance to <0.1%, after 3 cycles 
of decitabine, will be calculated and its 2-sided 90% confidence interval (CI) will 
also be provided. Using a sensitive sequencing technology such as Haloplex, the 
sensitivity of PB or BM for detecting residual mutation burden, as well as the TP53 
clonal burden reduction after consolidation with stem cell transplantation will be 
summarized using contingency tables. 
 
G. 
Statistical Power Justification 
 
Primary endpoint. The primary endpoint of this study is the 1-year overall survival 
(OS) which will be compared to historical data (1-year OS=25%). Assuming 
survival times following an exponential distribution and an additional 1-year 
follow-up period after the accrual period, a total of 60 patients will be enrolled and 
this allows us 85% power at 1-sided alpha=0.05 to detect 15% difference (40% vs. 
25%) in 1-year OS.  
 
Secondary endpoints.  A power analysis was performed using two-sample t-test 
for between-group difference and paired t-test for the change over time. For tumor 
clearance, this will provide > 99% power to detect a 10% difference in the means 
at two separate time points for clones with 6 or more variants, and > 98% power to 
detect a 15% difference if there are 3 or more variants per clone with α = 0.05 
(power will decrease to 91% and 82%, respectively, in cases where the standard 
deviation is 4.7%, the maximum we have observed thus far). For pharmacologic 
correlations, we anticipate 85% power to determine a 25 ng/ml difference between 
the average Cmax of 45 evaluable responders and 55 evaluable non-responders with 
an anticipated average Cmax of 70 ng/ml and a standard deviation of 40 ng/ml 
within the entire cohort, and with α = 0.05. We believe a less significant difference 
would not be sufficient to warrant application in clinical decision making (i.e. 
whether to continue therapy for more than 1 cycle). We anticipate 99% power to 
determine a difference of 20% in the reduction of bone marrow methylcytosine 
between 45 evaluable responders and 55 evaluable non-responders with an 
expected standard deviation of 15% and α = 0.05. The difference in methylcytosine 
reduction previously observed was 30% between patients achieving CR/PR and 
those with only hematologic improvement. 
 
 
16.0 
MULTICENTER REGULATORY REQUIREMENTS 
 
Washington University requires that each participating site sends its informed consent document 
to be reviewed and approved by the Washington University Regulatory Coordinator (or designee) 
prior to IRB/IEC submission.    
 

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Site activation is defined as when the secondary site has received official written documentation 
from the coordinating center that the site has been approved to begin enrollment.  At a minimum, 
each participating institution must have the following documents on file at Washington University 
prior to study activation: 
• Documentation of IRB approval of the study in the form of a letter or other official 
document from the participating institution’s IRB.  This documentation must show which 
version of the protocol was approved by the IRB. 
• Documentation of IRB approval of an informed consent form. The consent must include 
a statement that data will be shared with Washington University, including the Quality 
Assurance and Safety Monitoring Committee (QASMC), the DSMC (if applicable), and 
the Washington University study team. 
• Documentation of FWA, signed FDA Form 1572 (if applicable), and the CVs of all 
participating investigators. 
• Protocol signature page signed and dated by the investigator at each participating site. 
 
The coordinating center Principal Investigator (or designee) is responsible for disseminating to the 
participating sites all study updates, amendments, reportable adverse events, etc.  Protocol/consent 
modifications and IB updates will be forwarded electronically to the secondary sites within 4 
weeks of obtaining Washington University IRB approval.  Activated secondary sites are expected 
to submit protocol/consent/IB modifications to their local IRBs within 4 weeks of receipt unless 
otherwise noted.  Upon the secondary sites obtaining local IRB approval, documentation of such 
shall be sent to the Washington University study team within 2 weeks of receipt of approval. 
 
Documentation of participating sites’ IRB approval of annual continuing reviews, protocol 
amendments or revisions, all SAE reports, and all protocol violations/deviations/exceptions must 
be kept on file at Washington University. 
 
The investigator or a designee from each institution must participate in a regular conference call 
to update and inform regarding the progress of the trial. 
 
 

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17.0 
REFERENCES 
 
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4. 
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Papaemmanuil, E., et al. Genomic Classification and Prognosis in Acute Myeloid 
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6. 
Patel, J.P., et al. Prognostic relevance of integrated genetic profiling in acute myeloid 
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7. 
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8. 
Welch, John S., et al. TP53 and decitabine in acute myeloid leukemia and 
myelodysplastic syndromes. New England Journal of Medicine 375.21 (2016): 2023-2036. 
9. 
Hou, H.A., et al. TP53 mutations in de novo acute myeloid leukemia patients: 
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10. 
Christman, J.K. 5-Azacytidine and 5-aza-2'-deoxycytidine as inhibitors of DNA 
methylation: mechanistic studies and their implications for cancer therapy. Oncogene 21, 5483-
5495 (2002). 
11. 
Lubbert, M. DNA methylation inhibitors in the treatment of leukemias, myelodysplastic 
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12. 
Issa, J.P., Baylin, S.B. & Herman, J.G. DNA methylation changes in hematologic 
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13. 
Link, P.A., Baer, M.R., James, S.R., Jones, D.A. & Karpf, A.R. p53-inducible 
ribonucleotide reductase (p53R2/RRM2B) is a DNA hypomethylation-independent decitabine 
gene target that correlates with clinical response in myelodysplastic syndrome/acute 
myelogenous leukemia. Cancer Res 68, 9358-9366 (2008). 
14. 
Kantarjian, H., et al. Decitabine improves patient outcomes in myelodysplastic 
syndromes: results of a phase III randomized study. Cancer 106, 1794-1803 (2006). 
15. 
Jabbour, E., Issa, J.P., Garcia-Manero, G. & Kantarjian, H. Evolution of decitabine 
development: accomplishments, ongoing investigations, and future strategies. Cancer 112, 2341-
2351 (2008). 
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Kantarjian, H., et al. Results of a randomized study of 3 schedules of low-dose decitabine 
in higher-risk myelodysplastic syndrome and chronic myelomonocytic leukemia. Blood 109, 52-
57 (2007). 
17. 
Chabot, G.G., Bouchard, J. & Momparler, R.L. Kinetics of deamination of 5-aza-2'-
deoxycytidine and cytosine arabinoside by human liver cytidine deaminase and its inhibition by 
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18. 
Rivard, G.E., et al. Phase I study on 5-aza-2'-deoxycytidine in children with acute 
leukemia. Leuk Res 5, 453-462 (1981). 
19. 
Lin, K.T., Momparler, R.L. & Rivard, G.E. Sample preparation for the determination of 
5-aza-2'-deoxycytidine in plasma by high-performance liquid chromatography. J Chromatogr 
345, 162-167 (1985). 
20. 
Momparler, R.L., Rivard, G.E. & Gyger, M. Clinical trial on 5-aza-2'-deoxycytidine in 
patients with acute leukemia. Pharmacol Ther 30, 277-286 (1985). 
21. 
Momparler, R.L., et al. Pilot phase I-II study on 5-aza-2'-deoxycytidine (Decitabine) in 
patients with metastatic lung cancer. Anticancer Drugs 8, 358-368 (1997). 
22. 
Aparicio, A., et al. Phase I trial of continuous infusion 5-aza-2'-deoxycytidine. Cancer 
Chemother Pharmacol 51, 231-239 (2003). 
23. 
Bryan, J., Kantarjian, H., Garcia-Manero, G. & Jabbour, E. Pharmacokinetic evaluation 
of decitabine for the treatment of leukemia. Expert Opin Drug Metab Toxicol 7, 661-672 (2011). 
24. 
Blum, W., et al. Clinical response and miR-29b predictive significance in older AML 
patients treated with a 10-day schedule of decitabine. Proc Natl Acad Sci U S A 107, 7473-7478 
(2010). 
25. 
Saunthararajah, Y. Key clinical observations after 5-azacytidine and decitabine treatment 
of myelodysplastic syndromes suggest practical solutions for better outcomes. Hematology Am 
Soc Hematol Educ Program 2013, 511-521 (2013). 
26. 
Mrozek, K. Cytogenetic, molecular genetic, and clinical characteristics of acute myeloid 
leukemia with a complex karyotype. Semin Oncol 35, 365-377 (2008). 
27. 
Kadia, T.M., et al. TP53 mutations in newly diagnosed acute myeloid leukemia: 
Clinicomolecular characteristics, response to therapy, and outcomes. Cancer (2016). 
28. 
Middeke, J.M., et al. Outcome of high-risk acute myeloid leukemia after allogeneic 
hematopoietic cell transplantation: negative impact of abnl(17p) and -5/5q. Blood 120, 2521-
2528 (2012). 
29.  
Fernandez-Pol S, Ma L, Ohgami RS, Arber DA. Immunohistochemistry for p53 is a 
useful tool to identify cases of acute myeloid leukemia with myelodysplasia-related changes that 
are TP53 mutated, have complex karyotype, and have poor prognosis. Mod Pathol. 2017;30:382-
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30. 
Robertson, K.D. & Wolffe, A.P. DNA methylation in health and disease. Nat Rev Genet 
1, 11-19 (2000). 
31. 
Li, E. Chromatin modification and epigenetic reprogramming in mammalian 
development. Nat Rev Genet 3, 662-673 (2002). 
32. 
Jones, P.A. & Baylin, S.B. The fundamental role of epigenetic events in cancer. Nat Rev 
Genet 3, 415-428 (2002). 
33. 
Saunthararajah, Y., et al. p53-Independent, normal stem cell sparing epigenetic 
differentiation therapy for myeloid and other malignancies. Semin Oncol 39, 97-108 (2012). 
34. 
Jacks, T., et al. Tumor spectrum analysis in p53-mutant mice. Curr Biol 4, 1-7 (1994). 
35. 
Tuma, R.S. Epigenetic therapies move into new territory, but how exactly do they work? 
J Natl Cancer Inst 101, 1300-1301 (2009). 
36. 
Ley, T.J., et al. DNMT3A mutations in acute myeloid leukemia. N Engl J Med 363, 
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APPENDIX A: Definitions for Adverse Event Reporting  
 
Definition: An adverse event is any untoward medical occurrence in a clinical study subject 
administered a medicinal (investigational or non-investigational) product. An adverse event does 
not necessarily have a causal relationship with the treatment. An adverse event can therefore be 
any unfavorable and unintended sign (including an abnormal finding), symptom, or disease 
temporally associated with the use of a medicinal (investigational or non- investigational) 
product, whether or not related to that medicinal (investigational or non-investigational) product. 
(Definition per International Conference on Harmonisation [ICH]). 
 
This includes any occurrence that is new in onset or aggravated in severity or frequency from the 
baseline condition, or abnormal results of diagnostic procedures, including laboratory test 
abnormalities. 
 
Grading: the descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for all toxicity reporting.  A copy 
of the CTCAE version 4.0 can be downloaded from the CTEP website. 
 
Attribution (relatedness), Expectedness, and Seriousness: the definitions for the terms listed 
that should be used are those provided by the Department of Health and Human Services’ Office 
for Human Research Protections (OHRP).  A copy of this guidance can be found on OHRP’s 
website: 
http://www.hhs.gov/ohrp/policy/advevntguid.html 
 
All serious adverse events (SAE) that occur within 30 days of the last dose of therapy will be coded 
using NCI CTCAE v. 4.0.  Grade 3-5 laboratory abnormalities will only be considered if they do 
not resolve within 7 days. The incidence of treatment-emergent adverse events (number and 
percent of patients reporting the adverse event at least once during the study) will be summarized.  
In addition, adverse events will be summarized by investigator attribution of relationship to study 
medication and by grade. 
 
A. 
Serious Adverse Event (SAE)  
 
Definition of SAE:  any adverse drug experience that results in any of the following 
outcomes and is unrelated to infection, bleeding, or a transfusion reaction: 
• Death 
• A life-threatening  
• Inpatient hospitalization or prolongation of existing hospitalization  
• A persistent or significant disability/incapacity (i.e., a substantial disruption of a 
person’s ability to conduct normal life functions) 
• A congenital anomaly/birth defect 
• A suspected transmission of any infectious agent via a medicinal product 
• Any other experience which, based upon appropriate medical judgment, may 
jeopardize the subject and may require medical or surgical intervention to prevent 
one of the outcomes listed above 
• It is medically important * 

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*Medical and scientific judgment should be exercised in deciding whether expedited 
reporting is also appropriate in other situations, such as important medical events that 
may not be immediately life threatening or result in death or hospitalization but may 
jeopardize the subject or may require intervention to prevent one of the other outcomes 
listed in the definition above. These should usually be considered serious. 
 
NOTE: DEATH FOR ANY REASON SHOULD BE REPORTED AS A SERIOUS 
ADVERSE EVENT. 
 
B. 
Adverse Events of Special Interest (AESI) 
 
Definition of Adverse Events of Special Interest  
Adverse events of special interest are events that Janssen Scientific Affairs, LLC is 
actively monitoring as a result of a previously identified signal (even if non-serious).  
No adverse events of special interest will be collected for this study.  
 
C. 
Unexpected Adverse Experience/Reference Safety Information 
 
Definition: an adverse event  is considered unlisted if the nature or severity is not 
consistent with the applicable reference safety information.  current investigator brochure 
(or risk information, if an IB is not required or available). For a medicinal product(s) with 
a marketing authorization, the expectedness of an adverse event will be determined by 
whether or not it is listed in the applicable Package Insert..  
 
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=deb4a13c-855b-4372-9778-
6e81da598df6 
D. 
Life-Threatening Adverse Experience  
 
Definition: any adverse drug experience that places the subject (in the view of the 
investigator) at immediate risk of death from the reaction as it occurred, i.e., it does not 
include a reaction that, had it occurred in a more severe form, might have caused death. 
Disease progression should not be recorded as an adverse event or serious adverse event 
term.  
 
E. 
Unanticipated Problems 
 
Definition: 
 
• unexpected (in terms of nature, severity, or frequency) given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document; and (b) the 
characteristics of the subject population being studied; 
• related or possibly related to participation in the research (“possibly related” means 
there is a reasonable possibility that the incident, experience, or outcome may have 
been caused by the procedures involved in the research); and 

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• suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized 
 
F. 
Product Quality Complaint (PQC) 
 
A product quality compliant is defined as any suspicion of a product defect related to a 
potential quality issue during manufacturing, packaging, release testing, stability 
monitoring, dose preparation, storage or distribution of the product, or delivery system.  
Not all PQCs involve a subject.  Lot and batch numbers are of high significance and need 
to be collected whenever available. 
 
Examples of PQC include but not limited to: 
• Functional Problem: e.g., altered delivery rate in a controlled release product 
• Physical Defect:  e.g. abnormal odor, broken or crushed tablets/capsules 
• Potential Dosing Device Malfunction: e.g., autoinjector button not working, needle 
detaching from syringe 
• Suspected Contamination 
• Suspected Counterfeit 
 
G. 
Noncompliance 
 
Definition: failure to follow any applicable regulation or institutional policies that govern 
human 
subjects 
research 
or 
failure 
to 
follow 
the 
determinations 
of 
the 
IRB.  Noncompliance may occur due to lack of knowledge or due to deliberate choice to 
ignore regulations, institutional policies, or determinations of the IRB. 
 
H. 
Serious Noncompliance 
 
Definition: noncompliance that materially increases risks, that results in substantial harm 
to subjects or others, or that materially compromises the rights or welfare of participants. 
 
I. 
Protocol Exceptions 
 
Definition: A planned deviation from the approved protocol that are under the research 
team’s control. Exceptions apply only to a single participant or a singular situation. 
 
Local IRB pre-approval of all protocol exceptions must be obtained prior to the event.  For 
secondary sites, the Washington University PI will issue approval of the exception, but it 
must also be submitted to the local IRB with documentation of approval forwarded to 
Washington University.  Washington University IRB approval is not required for protocol 
exceptions occurring at secondary sites. 
 
  
 
 

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APPENDIX B: Definition of TP53 Mutant AML 
 
A patient with TP53 mutant AML is defined as having a minimum variant allele frequency of 10% 
identified with at least 50 total reads and 5 variant reads. If a germline sample was sequenced, the 
variant reads must have a Fisher exact test p value < 0.01 when compared with the leukemia 
sample. If a germline sample was not available for sequence comparison, the TP53 variant must 
be described in Cosmic and not identified in dbGaP as a germline variant in > 0.1% of the 
population. 
 
 
 
 

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APPENDIX C: Reporting Timelines 
 
Expedited Reporting Timelines 
Event 
HRPO 
QASMC 
FDA 
IBC 
Janssen 
Serious AND 
unexpected suspected 
adverse reaction 
 
 
Report no later than 15 
calendar days after it is 
determined that the 
information qualifies for 
reporting 
N/A 
Report within 24-hours of 
becoming aware of the 
event(s). 
Unexpected fatal or 
life-threatening 
suspected adverse 
reaction 
 
 
Report no later than 7 
calendar days after initial 
receipt of the information 
 
Report within 24-hours of 
becoming aware of the 
event(s). 
Unanticipated 
problem involving risk 
to participants or 
others 
Report within 10 working days.  
If the event results in the death 
of a participant enrolled at 
WU/BJH/SLCH, report within 
1 working day. 
Report via email after 
IRB acknowledgment 
 
 
 
Major deviation 
Report within 10 working days.  
If the event results in the death 
of a participant enrolled at 
WU/BJH/SLCH, report within 
1 working day. 
 
 
 
 
A series of minor 
deviations that are 
being reported as a 
continuing 
noncompliance 
Report within 10 working days.    
 
 
 
Protocol exception 
Approval must be obtained 
prior to implementing the 
change 
 
 
 
 
Clinically important 
increase in the rate of 
a serious suspected 
adverse reaction of 
 
 
Report no later than 15 
calendar days after it is 
determined that the 
information qualifies for 
reporting 
 
 

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Expedited Reporting Timelines 
Event 
HRPO 
QASMC 
FDA 
IBC 
Janssen 
that list in the protocol 
or IB 
Complaints 
If the complaint reveals an 
unanticipated problem 
involving risks to participants 
or others OR noncompliance, 
report within 10 working days.  
If the event results in the death 
of a participant enrolled at 
WU/BJH/SLCH, report within 
1 working day.  Otherwise, 
report at the time of continuing 
review. 
 
 
 
 
Breach of 
confidentiality 
Within 10 working days. 
 
 
 
 
Incarceration 
If withdrawing the participant 
poses a safety issue, report 
within 10 working days.   
 
If withdrawing the participant 
does not represent a safety issue 
and the patient will be 
withdrawn, report at continuing 
review. 
 
 
 
 
SAEs, and Adverse 
Events of Special 
Interest and Special 
Reporting Situations 
(See Section 7.5.F) 
 
 
 
 
Report within 24-hours of 
becoming aware of the 
event(s). 
Pregnancy 
 
 
 
 
Report within 24-hours of 
becoming aware of the 
event(s). 
 
 

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Routine Reporting Timelines 
Event 
HRPO 
QASMC 
FDA 
Janssen 
Adverse event or SAE 
that does not require 
expedited reporting 
If they do not meet the definition of an 
unanticipated problem involving risks to 
participants or others, report summary 
information at the time of continuing review 
Adverse events will be 
reported in the toxicity 
table in the DSM report 
which is typically due 
every 6 months. 
The most current 
toxicity table from the 
DSM report is provided 
to the FDA with the 
IND’s annual report. 
 
Minor deviation 
Report summary information at the time of 
continuing review. 
 
 
 
Complaints 
If the complaint reveals an unanticipated problem 
involving risks to participants or others OR 
noncompliance, report within 10 working days.  If 
the event results in the death of a participant 
enrolled at WU/BJH/SLCH, report within 1 
working day.  Otherwise, report at the time of 
continuing review. 
 
 
 
Incarceration 
If withdrawing the participant poses a safety 
issue, report within 10 working days.   
 
If withdrawing the participant does not represent a 
safety issue and the patient will be withdrawn, 
report at continuing review. 
 
 
 
 
Expedited Reporting Timelines for Secondary Sites 
Event 
WU (Coordinating Center) 
Local IRB 
FDA 
Janssen 
Serious AND unexpected 
suspected adverse reaction 
Report no later than 11 calendar days 
after it is determined that the information 
qualifies for reporting. 
Report all applicable 
events to local IRB 
according to local 
institutional guidelines. 
The research team at 
Washington University is 
responsible for reporting all 
applicable events to the 
FDA as needed. 
The research team at 
Washington University is 
responsible for reporting all 
applicable events to Janssen 
as needed. 
Unexpected fatal or life-
threatening suspected 
adverse reaction 
Report no later than 4 calendar days after 
initial receipt of the information. 
Unanticipated problem 
involving risk to participants 
or others 
Report no later than 4 calendar days after 
initial receipt of the information. 

Version 10/01/2020, Amendment 8 
 
 62 of 63 
Expedited Reporting Timelines for Secondary Sites 
Event 
WU (Coordinating Center) 
Local IRB 
FDA 
Janssen 
Adverse event or SAE that 
does not require expedited 
reporting 
As per routine data entry expectations 
Protocol exception 
Approval must be obtained prior to 
implementing the change. 
 
 
 

Version 10/01/2020, Amendment 8 
 
 63 of 63 
APPENDIX D: Washington University Serious Adverse Event Reporting Cover Sheet 
 
SAE COVER SHEET- Secondary Site Assessment 
 
Washington University HRPO#:  
Sponsor-Investigator:  
Subject Initials:   
Subject ID:  
Treating MD:  
Treating Site:  
EVENT TERM:  
Event Start Date:  
EVENT GRADE: 
Date of site’s first notification: 
 
Treating MD Event Assessment:  
 
 
Is this event possibly, probably, or definitely related study treatment? 
 
 yes  
 
 no 
 
If yes, please list which drug (if more than one)______________________________ 
 
       
Explain ______________________________________________________________________ 
 
______________________________________________________________________________ 
 
 
 
_________________________           ___________________________      _________________  
Physician’s Name 
 
 
Physician’s Signature 
 
Date