Pilot Study of IGF-Methotrexate Conjugate in the Treatment of Myelodysplastic Syndrome, CMML and Oligoblastic AML
Phase: PHASE1
Conditions: Myelodysplastic Syndromes, Leukemia, Myelomonocytic, Chronic, Anemia, Refractory, With Excess of Blasts
Sponsor: IGF Oncology, LLC

 
 
 
 
 
 
 
 
 
 
 
 
IGF-MTX Conjugate in the Treatment of Myelodysplastic Syndrome 
 
NCT03175978 
 
Dated: December 6, 2018 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 2 of 57 
 
 
 
 
 
AML-03: Pilot Study of IGF-Methotrexate Conjugate in the Treatment of Myelodysplastic 
Syndrome, CMML and Oligoblastic AML. 
 
Principal Investigator at Mayo Clinic: 
Mrinal S. Patnaik, M.B.B.S 
Mayo Clinic 
Division of Hematology 
 
Principal Investigator at Regions Hospital 
Yan Ji, M.D. 
 
IND Sponsor: 
IGF Oncology, LLC 
 
Sub-Principal Investigator: 
 
Aref Al-Kali, MD, Mayo Clinic 
 
 
Biostatistician: Gil D. Fine, PhD 
 
 
Version Date: 
December 6, 2018 
 
 
 
 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 3 of 57 
 
Table of Contents 
Synopsis ..................................................................................................................................... 5 
Study Schema............................................................................................................................. 6 
Abbreviations .............................................................................................................................. 7 
1. 
Introduction and Rationale ................................................................................................... 9 
1.1. 
Introduction .............................................................................................................. 9 
1.1.1. The IGF-1R Pathway .............................................................................................. 9 
1.1.2. The IGF-1R and Cancer ......................................................................................... 9 
1.1.2.1. The IGF-1R and Hematologic Malignancies .......................................................11 
1.1.3. Using the IGF-1R Pathway to Reduce Tumor Growth ............................................11 
1.2. 
IGF-Methotrexate .....................................................................................................11 
1.2.1. Preclinical Experience with IGF-Methotrexate ........................................................12 
1.2.2. Clinical Experience with IGF-Methotrexate ............................................................15 
1.3. 
Study Rationale .......................................................................................................16 
2. 
Objectives ......................................................................................................................... 17 
2.1. 
Primary Objective ....................................................................................................17 
2.2. 
Secondary Objectives .............................................................................................17 
2.3. 
Correlative Objectives .............................................................................................17 
3. 
Endpoints .......................................................................................................................... 18 
3.1. 
Primary Endpoint .....................................................................................................18 
3.2. 
Secondary Endpoints ..............................................................................................18 
3.3. 
Correlative Endpoints .............................................................................................18 
4. 
Overall Design and Study Plan .......................................................................................... 19 
5. 
Selection of Patients .......................................................................................................... 20 
5.1. 
Inclusion Criteria .....................................................................................................20 
5.2. 
Exclusion Criteria ....................................................................................................21 
6. 
Registration/Enrollment ..................................................................................................... 23 
6.1. 
Registration/Enrollment with the Clinical Trials Office .........................................22 
6.2. 
Registered/Enrolled Patients Who Do Not Begin Study Treatment .....................23 
6.3. 
Re-screening Patients .............................................................................................23 
7. 
Treatment Plan .................................................................................................................. 23 
7.1. 
Study Drug Administration .....................................................................................23 
7.1.1. 765IGF-Methotrexate Administration .....................................................................23 
7.2. 
Dose Modifications ..................................................................................................25 
7.2.1. Start of a New Cycle ..............................................................................................26 
7.3. 
Permitted Concomitant Medications and Procedures ..........................................26 
7.4. 
The Effects of Other Drugs on Methotrexate .........................................................26 
7.5. 
Concomitant Medications and Non-Drug Therapies .............................................27 
7.6. 
Prohibited Concomitant Medications .....................................................................27 
7.7. 
Management of Clinical Events and Supportive Care Guidelines ........................28 
7.8. 
Nausea and Vomiting ..............................................................................................28 
7.9. 
Diarrhea ....................................................................................................................29 
7.10. Duration of Therapy .................................................................................................29 
7.11. Follow-up .................................................................................................................29 
8. 
Study Parameters.............................................................................................................. 30 
8.1. 
Standard of Care Procedures .................................................................................30 

Protocol, v3, dated December 6, 2018                  Page 4 of 57 
 
8.2. 
Research Related Procedures ................................................................................32 
9. 
Correlative Studies ............................................................................................................ 33 
9.1. 
Pharmacokinetics ....................................................................................................33 
9.1.1. Pharmacokinetic Sample Collection .......................................................................33 
9.1.2. Pharmacokinetic Sample Processing .....................................................................33 
9.1.3. Pharmacokinetic Parameter Determination ............................................................33 
9.1.4. Statistical Analysis for Pharmacokinetics ...............................................................34 
9.2. 
Pharmacodynamic Assessment .............................................................................34 
9.3. 
Evaluation of 765IGF-MTX for its QT prolongation potential ................................34 
9.4. 
Plasma IGF Level and 765IGF-MTX Toxicity/Response ........................................34 
9.5. 
Plasma and whole blood IGF-1R Level and 765IGF-MTX Toxicity/Response ......34 
9.6. 
Formation of anti-765IG-MTX antibodies. ..............................................................34 
9.7. 
Neutralizing antibodies and 765IGF-MTX Toxicity/Response ..............................34 
9.8. 
IGF-1R expression level in tumor (tissue or bone marrow) via IHC, or blood or 
bone marrow aspirate via flow cytometry .........................................................................35 
10. Drug Formulation and Procurement .................................................................................. 35 
10.1. 765IGF-MTX ..............................................................................................................35 
10.1.1. 
Other names ......................................................................................................35 
10.1.2. 
Classification ......................................................................................................35 
10.1.3. 
How supplied .....................................................................................................35 
10.1.4. 
Availability ..........................................................................................................35 
10.1.5. 
Description .........................................................................................................35 
10.1.6. 
Storage, Handing, and Accountability ................................................................36 
10.1.7. 
Administration ....................................................................................................36 
10.1.8. 
Risks ..................................................................................................................36 
10.1.9. 
Warnings and Precautions .................................................................................36 
11. Adverse Event Documentation and Reporting ................................................................... 37 
11.1. Definitions ................................................................................................................38 
11.2. Adverse Event Documentation ...............................................................................39 
11.3. Required Reporting: IRB, FDA, IGF-Oncology, LLC and Accelovance ................41 
11.4. Procedures for Reporting SAEs to IGF Oncology, LLC ........................................43 
11.5. Procedures for Reporting During Pregnancy and Birth Events ...........................43 
12. Study Data Collection and Monitoring ................................................................................ 43 
12.1. Data Management ....................................................................................................43 
12.2. Case Report Forms..................................................................................................43 
12.3. Data and Safety Monitoring Plan (DSMP) ..............................................................43 
12.4. Monitoring ................................................................................................................44 
12.5. Record Retention .....................................................................................................44 
13. Statistical Considerations .................................................................................................. 44 
13.3 
Analysis plan for primary objective: ......................................................................46 
13.4 
Analysis plan for secondary objectives: ................................................................46 
13.4.1 
Objective Response Rate, Progression-Free Survival, and Overall Survival ......46 
13.4.2 
Describe clinical response (CR) as defined by hematologic-specific response       
criteria  ...............................................................................................................46 
13.5 
Analysis plan for correlative objectives: ...............................................................46 
13.5.1 
Describe changes in pharmacokinetic parameters .............................................46 
13.5.2 
Describe changes in pharmacodynamics parameters ........................................46 
13.5.3 
Evaluation of 765IGF-MTX for potential of QT prolongation ...............................46 
13.5.4 
Plasma IGF level and 765IGF-MTX Toxicity/Response......................................47 

Protocol, v3, dated December 6, 2018                  Page 5 of 57 
 
13.5.5 
Antibody formation against 765IGF-MTX ...........................................................47 
13.5.7 
Neutralizing antibodies and 765IGF-MTX toxicity/response ...............................47 
13.5.8 
IGF-1R expression level in tumor biopsies via IHC ............................................47 
14. Conduct of the Study ......................................................................................................... 47 
14.1. Good Clinical Practice .............................................................................................47 
14.2. Ethical Considerations ............................................................................................47 
15. References ........................................................................................................................ 49 
Appendix I – Response Criteria for Acute Leukemia ................................................................. 52 
Appendix II – Response Criteria for MDS46 ............................................................................... 54 
Appendix III – ECOG Performance Status ................................................................................ 55 
Appendix IV – New York Heart Association Classification ......................................................... 55 
Appendix V – Prohibited Concomitant Medications ................................................................... 55 
Appendix VI – Medications to use with caution ......................................................................... 56 
 
 
 
PI Contact Information: 
Mrinal S. Patnaik, M.B.B.S. 
Mayo Clinic 
Division of Hematology 
Dept. of Internal Medicine 
200 First St. SW 
Rochester, MN 55905 
tel. 507-284-3417 
fax 507-266-4972 
Patnaik.Mrinal@mayo.edu 
  
 
IND Sponsor Contact Information: 
Hugh McTavish, Ph.D., 
 
IGF Oncology, 
7460 Pinehurst Road, 
Pine Springs, MN 55115 
651-207-8270 
hmctavish@igfoncology.com 
 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 6 of 57 
 
Synopsis 
Primary Objective: 
The primary objective of this study is to determine the safety and tolerability of utilizing the 
insulin-like growth factor-1-methotrexate conjugate, 765IGF-MTX for the treatment of advanced, 
previously treated myelodysplastic syndrome (MDS), chronic myelomonocytic leukemia (CMML) 
and oligoblastic acute myelogenous leukemia (oligoblastic AML or O-AML), including 
determining the maximum tolerated dose (MTD).   
 
Secondary Objective: 
The secondary objective of this study is to determine the clinical benefit of 765IGF-MTX as 
measured by partial and complete remission rates, relapse-free survival, and overall survival in 
patients with advanced, previously treated MDS, CMML, or O-AML.  
 
Patient Population: 
• 
Diagnosis of MDS, CMML or O-AML that is refractory to or intolerant of standard therapy 
and is no longer likely to respond to such therapy 
• 
Patient must have recovered from the acute toxic effects (≤ grade 1 CTCAE v.4.0) of 
previous anti-cancer treatment prior to study enrollment 
• 
Age 18 years or older 
• 
ECOG performance status 0, 1, or 2 (appendix III) 
 
Study Design: 
This pilot study will evaluate use of IGF-Methotrexate conjugate (765IGF-MTX) in patients with 
advanced, previously treated MDS, CMML and O-AML.  765IGF-MTX at a dose of 0.20 to 2.5 
µequivalents per kg is administered as an IV infusion over 1.5 hours on days 1, 8 and 15 of a 28 
day cycle.  Treatment continues until disease progression, as assessed after 2 cycles, 
unacceptable toxicity, or patient refusal. Assessment of response will be confirmed by bone 
marrow studies performed at the end of cycles 2, 4, and 6 (each +/- 3 days). 
 
Once a final maximum tolerated dose level (MTD) is determined, the pharmacokinetics (PK) of 
765IGF-MTX will be assessed on days 1 and 2 and days 15 and 16 of cycle 1 at the MTD in 
three patients. 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 7 of 57 
 
 
Study Schema 
 
 
Dose Finding Component: 1 cycle = 28 days 
 
Cycle 1 
Cycle 2 
Cycle 3 and beyond2 
day 
1 
8 
15 
 
1 
8 
15 
 
1 
8 
15 
 
765IGF-
MTX* 
   X 
X       X 
    X 
   X 
  X  
          X 
X1     X1 
Clinic visit 
X 
X 
X 
 
X 
X 
X  
 
X 
X1 
 X1 
 
* at assigned dose level (see table below) 
1Day 8 and day 15 visits at physician’s discretion cycle 3 and beyond 
2Treatment continues until disease progression, unacceptable toxicity, patient refusal or other reason as found in 
section 7.11 
 
Phase I Dose Levels  
Dose 
Level 
765IGF-MTX Dose 
Number of 
Patients* 
1 
0.20 µequivalents per kg 
1-9 
2 
0.40 µequivalents per kg  
1-9 
3 
0.80 µequivalents per kg  
1-9 
4 
1.6 µequivalents per kg  
1-9 
5 
2.5 µequivalents per kg  
1-9 
 
*dose escalation cohorts between 1-9 patients; total of 9 patients in MTD cohort.  At the 
discretion of the principal investigator, intra-patient dose escalation between cycles is also 
allowed but only after 2 cycles at the assigned dose level and confirmation of safety in at 
least 3 patients treated at the higher dose level.  
 
 
 
 
 
S
c
r
e
e
n
i
n
g 
Repeat the 28 day cycle with bone marrow 
studies initially q2 cycles, until cycle 6, 
response, progression, unacceptable toxicity, 
or withdrawal from study.  After cycle 6, bone 
marrow studies at physician discretion. 
765IGF-MTX at 0.20 to 2.5 
ueq/kg given days 1, 8, 15 q 28 
Pharmacodynamic samples on day 1 of cycle 1, days 1 and 15 of cycle 2, and day 15 of cycles 4 
and 6 before 765IGF-MTX administration. 
At the MTD: Pharmacokinetic samples starting on day 1 (including time points on day 2), and day 
15 (including time points on day 16) of cycle 1 
Week 1  
Week 2  
Week 3  
Week 4 
Week X 

Protocol, v3, dated December 6, 2018                  Page 8 of 57 
 
 
 
Abbreviations 
Abbreviation 
Definition 
AE 
adverse event 
ALT 
alanine aminotransferase 
AML 
acute myelogenous leukemia 
ANC 
absolute neutrophil count 
AST 
 
aspartate aminotransferase 
BM 
 
bone marrow 
CIR 
Cumulative Incidence of Relapse rate 
cm 
centimeter 
CR 
complete remission 
CRi 
Compete remission with incomplete hematologic recovery (same 
 
as "marrow CR") 
CMML 
Chronic myelomonocytic leukemia 
CTCAE 
(NCI) Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
dL 
deciliter 
DFS 
time to relapse 
DLT 
dose-limiting toxicity 
ECOG 
Eastern Cooperative Oncology Group 
EGFR 
epidermal growth factor receptor 
EFS 
Event-Free Response 
FDA 
Food and Drug Administration 
h 
hour 
HL 
Hodgkin Lymphoma 
IC50 
50% Inhibitory Concentration, the concentration needed to inhibit  
 
cell growth by 50% 
IGF-1 
insulin-like growth factor-1 
IGF-1R 
insulin-like growth factor-1 receptor 
IHC 
immunohistochemistry 
IND 
Investigational New Drug 
IRB 
institutional review board 
kg 
kilogram 
lb 
pound 
mg 
milligram 
min 
minute 
mL 
milliliter 
mm3 
cubic millimeters 
MDS 
myelodysplastic syndrome 
MTD 
maximum tolerated dose 
MTX 
methotrexate 
NCI 
National Cancer Institute 
O-AML 
Oligoblastic acute myelogenous leukemia 
ORR 
Overall response rate (= CR rate + CRi rate + PR rate) 
OS 
Overall Survival rate 
PK 
Pharmacokinetics studies 
PD 
Pharmacodynamics studies 
PFS 
Progression free survival (Time to disease progression or death 
 
from MDS, O-AML, or CMML) 

Protocol, v3, dated December 6, 2018                  Page 9 of 57 
 
PO 
per os (by mouth) 
PR 
Partial Remission 
RFS 
Relapse-Free Survival 
SAE 
serious adverse event 
US 
United States 
VEGF 
vascular endothelial growth factor 
wt 
weight 
 
 

Protocol, v3, dated December 6, 2018                  Page 10 of 57 
 
 
1. Introduction 
1.1. Introduction 
1.1.1. The IGF-1R Pathway 
The insulin-like growth factor type 1 receptor (IGF-1R) is a transmembrane 
heterotetramer tyrosine kinase whose intracellular kinase domain is 84% homologous to 
that of the insulin receptor (IR).1 These receptors activate several of the same signaling 
intermediates. IGF-1R is widely expressed in human tissues and is involved in numerous 
cellular processes. Binding of its ligands, insulin-like growth factor-1 (IGF-1) and IGF-2 
induces biological actions after conformational changes of the receptor, followed by 
activation of a cascade of intrinsic tyrosine kinase activity. Activated IGF-1R induces 
recruitment of adaptor proteins belonging to the insulin receptor substrate family (IRS 
1/2) or SHC. 
 
Stimulation of two downstream signaling pathways mediate the tumorigenic effects of 
the IGF cascade in the majority of cancers:  
 
1) the ras -raf-mitogen-activated protein kinase (MAPK)/extra-cellular related kinases 
(Erk-1/2) pathway, associated with differentiation, growth and proliferation, and  
 
2) the phosphatidylinositol 3-kinase (PI3K)/AKT/mTOR pathway, associated with 
inhibition of apoptosis.2 
 
In addition, IGF-1R activation stimulates glucose transport and utilization, amino acid 
transport and protein synthesis, RNA and DNA synthesis. Angiogenesis regulation is 
also mediated downstream from the IGF cascade, in concert with vascular endothelial 
growth factor (VEGF) and epidermal growth factor receptor (EGFR).2,3 
 
IGF-1, the main circulating IGF-1R ligand, is primarily produced by the liver. Serum IGF 
binding proteins (IGFBP1-6) regulate IGF 1/2 bioavailability. IGF 1/2 are also produced 
in other organs where autocrine or paracrine mechanisms of actions are important, and 
some tumors produce IGF-1/2 in an autocrine or paracrine manner.4 
 
1.1.2. IGF-1R is overexpressed in Cancer 
IGF-1R is overexpressed in many types of cancer, including breast, prostate, lung, 
colorectal, and hematologic malignancies5-20. IGF-1R expression appears to be a critical 
determinant of resistance to apoptosis, and its down-regulation leads to massive 
apoptosis.21,22  Its role in preventing apoptosis may underlie the observation that 
high/normal serum levels of IGF-1 correlate with an increased risk for developing various 
cancers, including cancers of the breast8,9,13,16,20, prostate8,15, and colon11,14,18. Finally 
IGF-1R activation promotes invasion and metastasis. In vitro and in vivo IGF-1R 
inhibition leads to anti-proliferative effects and often appears synergistic with 
chemotherapy.23,24  Lastly, IGF binding protein-3 (IGF-BP3) a circulating soluble protein 
that binds IGF-1 and prevents its binding to the IGF-1R, may have a role as tumor 
suppressor. TGF-β3-induced inhibition of growth of a human breast cancer cell line was 
mediated by IGF-BP3, and IGF-BP3 has been identified as a target gene regulated by 
p53.25  
 
Consistent with its overexpression in tumor cells, evidence also shows that IGF-1R is 
important to cancer cell physiology.  Multiple myeloma cell lines overexpressing IR and 
IGF-1R are more responsive to growth stimulation with insulin and IGF-1, as compared 
to pre-B cell lines49.  Strong evidence also links IGF-1R overexpression in breast tumors 

Protocol, v3, dated December 6, 2018                  Page 11 of 57 
 
with radiation resistance and tumor recurrence50. Overexpression of IGF-1R has also 
been shown to inhibit differentiation of rhabdomyosarcoma cells in tissue culture, 
whereas antisense RNA against IGF-1R promoted differentiation51.  In melanoma cell 
lines, there is evidence that IGF-1R expression is critical to sustaining cell growth and 
resisting apoptosis52.  IGF-1R expression has also been linked to chemotherapy 
resistance: cancer cells expressing IGF-1R and activated by IGF-1 have shown 
enhanced survival against etoposide53. 
 
 
1.1.2.1. 
IGF-1R is overexpressed in MDS and Acute Myelogenous Leukemia  
 
IGF-1R has been shown to be significantly overexpressed in malignant bone marrow 
nucleated cells in patients with either acute myelogenous leukemia (AML) or 
myelodysplastic syndrome (MDS), as compared to healthy controls.26 IGF-1R 
overexpression was greater in AML than MDS.26 A separate study showed, by 
immunohistochemical staining that MDS clonal cells markedly overexpressed IGF-1R 
relative to normal nucleated bone marrow cells in the same individuals (78% vs. 14%, p 
< .0001).27 Importantly IGF-1R was overexpressed in 25 of 26 MDS patients, and, in the 
26th patient, both MDS and normal cells expressed high levels of IGF-1R.27 Another 
report indicated that MDS cells could be sorted by flow cytometry based on  IGF-1R 
receptor expression.28 The expression of IGF-IR in CD34+ cells of 55 MDS patients was 
significantly higher than that of cells from normal controls (54.0 vs. 4.5%).28 In the 
healthy controls, of the 4.5% of cells that were IGF-1R positive, 70% expressed the 
erythroid lineage marker CD235a, indicating that IGF-1R is mostly expressed during 
erythropoiesis in healthy bone marrow. 
 
Literature indicates AML cells have been shown to be sensitive to the anti-metabolite 
methotrexate in vitro. The IC50 for methotrexate was 10 nM for the AML cell line HL-
60,29 suggesting that AML and MDS should be responsive to IGF-MTX clinically. 
 
The sponsor, IGF Oncology, has also shown in its laboratories that IGF-MTX inhibits 
division of 3 of 3 AML cell lines tested: HL-60, HL-60/S4, and Kasumi-1.  All three had 
IC50s of 458-668 nEq/L.  IGF-MTX was also synergistic with Azacytidine. In the 
presence of a concentration of Azacytidine about 1/3 of its IC50, the IC50 of IGF-MTX 
decreased from 668 to 398 nEq/L in Kasumi-1 cell line and decreased from 466 to 409 
nEq/L in HL-60.  These results provide further reason to believe IGF-MTX may be 
effective clinically against the myeloid malignancies MDS, O-AML, and CMML.     
 
1.1.3. Using the IGF-1R Pathway to Reduce Tumor Growth 
IGF binding proteins (IGFBPs) are soluble blood proteins that bind IGF-1. Over 90% of 
total IGF-1 in circulation is normally bound to IGFBPs, and when bound to the IGFBPs it 
is not available to bind to the IGF-1R membrane receptor. However, variants of IGF-1 
have been identified that have a reduced affinity for IGFBP-1 but still bind strongly to 
IGF-1R.30,31 One such variant is long-R3-IGF-1, which has a mutation at position 3 of the 
IGF-1 sequence (glutamic acid to arginine) and a short amino terminal extension.30,31 In 
theory, the long-R3-IGF-1 variant may more efficiently target the IGF-1R receptor in vivo 
because of a lack of interference (binding) by normally reactive IGFBPs. Antibodies 
against IGF-1R, and tyrosine kinase inhibitors that are relatively specific for IGF-1R have 
been developed as anticancer agents, and some of these agents have already been 
tested in clinical trials for solid tumors and shown promising results32-39. However, 
McTavish et al. took a different approach, hypothesizing that one could use the IGF 
system to deliver an anticancer drug relatively specifically to cancer cells that express 

Protocol, v3, dated December 6, 2018                  Page 12 of 57 
 
IGF-1R40. They developed a novel covalent conjugate that contains the antifolate (and 
anticancer) drug, methotrexate (MTX), coupled to the long-R3-IGF-1 variant (IGF-MTX 
conjugate), with the purpose of specifically destroying tumor cells that overexpress the 
membrane IGF-1 receptor. In in vivo studies of mice, they demonstrated that the novel 
IGF-MTX conjugate was more effective, at significantly lower doses than free MTX, at 
controlling tumor growth. These data provide proof-of-principle that IGF-chemotherapy 
conjugates can enhance the therapeutic effects of chemotherapy by specifically 
increasing anticancer drug localization in tumor cells and tumor-related tissues that 
overexpress IGF membrane receptors. Accordingly, we propose to examine the 
therapeutic use of MTX bound to an IGF-1 variant similar in structure to that of the long 
R3 IGF-1 protein in this pilot clinical trial. 
 
 
 
1.2.  Design of IGF-Methotrexate as a drug conjugate targeting IGF-1R  
The conjugate we propose to study is 765IGF-Methotrexate (765IGF-MTX). 765IGF-MTX is 
a novel anticancer agent containing 765IGF, a variant of human IGF-I similar to long-R3-
IGF-1, covalently coupled to the antifolate drug, methotrexate (MTX). 765IGF is 88 amino 
acids long, and has an 18 amino acid leader sequence that includes 5 lysine residues, 
followed by the 70 amino acid sequence of human IGF-1, with an arginine residue replacing 
the native glutamic acid residue at position 21 (position 3 of native IGF-1). The amino acid 
sequence of 765IGF is as follows:  
 
MVKGKHHHHH HNGKGKSKGP RTLCGAELVD ALQFVCGDRG FYFNKPTGYG 
50  
SSSRRAPQTG IVDECCFRSC DLRRLEMYCA PLKPAKSA 
88 
 
The underlined residues 19-88 constitute the complete mature sequence of human IGF-1, 
(residues 1-70) with a mutant R (arginine) residue in bold, replacing the native glutamic acid 
residue in that position. Residues 1-18 are nonnative residues and provide a polyhistidine 
purification tag and five lysine residues for coupling of methotrexate.   
 
Each methotrexate is coupled to 765IGF through one of the two free carboxyl groups of 
MTX to one of the nine amino groups of 765IGF (8 lysine residues and a free amino 
terminus). The coupling forms an amide bond between each methotrexate and a lysine side 
chain or alpha amino group of 765IGF. There may be secondary reactions to other locations 
on the protein. 
 
The drug has been found to have on average approximately eight methotrexate moieties per 
765IGF protein molecule. 
 
As discussed above, a similar conjugate containing long-R3-IGF-1 covalently coupled to 
MTX was previously made and tested against cancer in vitro and in vivo.40 Because IGF-1R 
and ligand are internalized upon ligand binding, MTX was expected to be internalized by 
target cells expressing the IGF-1R membrane receptor. The conjugate of MTX with long-R3-
IGF-1 was expected to have efficacy at lower doses than a conjugate with wild-type IGF-1, 
as the long-R3-IGF-1 variant has a reduced binding affinity for circulating IGFBPs, which 
normally keep the wild-type ligand in circulation and prevent it from binding to the IGF-1R 
membrane receptor.  765IGF has these same traits of binding to the IGF-1R but poor 
binding to circulating IGFBPs. 
 
The long-R3-IGF-1-MTX conjugate was significantly more effective than free methotrexate 
against human prostate tumor xenografts in mice, even at 6.25-fold lower dose.40 The IGF-

Protocol, v3, dated December 6, 2018                  Page 13 of 57 
 
MTX conjugate used in this pilot study is expected to behave similarly due to its high affinity 
for IGF-1R and low affinity for IGFBPs. 30,31,41 
 
The 765IGF-MTX dosage used here is based on our completed phase I dose-escalation 
study using this molecule (765IGF-MTX). 
 
 
1.2.1. Preclinical Experience with IGF-Methotrexate 
 
In Vitro and in Vivo Efficacy Studies: 
IGF-MTX binds specifically to the IGF-1R receptor. 
The KD (dissociation constant) for binding of 765IGF-MTX to the IGF-1R receptor is 
approximately 20 nM.  This is measured by competition binding to MCF7 cells with 
radiolabeled IGF-1. The KD of 765IGF, unconjugated to methotrexate, is approximately 
5nM. (IGF Oncology's results.  See also ref. 40.) 
 
IGF-MTX is cytotoxic against solid tumor cell lines in vitro 
765IGF-MTX inhibits proliferation of MCF7 (human breast cancer cell line) with an IC50 
of about 400-600 nEq/L (nM methotrexate groups) and LNCaP (human prostate cancer 
cell line) with a similar value.  (IGF Oncology's results.  See also ref. 40.) 
 
IGF-MTX inhibits tumor growth in vivo at more than 6-fold lower molar dose than free 
methotrexate. 
 
 
Fig. 1. Inhibition of LNCaP tumor growth in nu/nu mice. Mice were treated once by IV 
injection with the indicated dosages of free MTX or IGF-MTX conjugate once on day 5. 
The doses of the IGF-MTX conjugate are expressed in terms of moles of MTX molecules 
per gram. For clarity, error bars are shown only for the 8 nmol/g IGF-MTX group and the 
50 nmol/g MTX group. Data represent means ± SE. The 50 nmol/g MTX group had 8 
mice. All other groups had 4 mice per group. The difference between the 8 nmol/g IGF-
MTX and 50 nmol/g MTX groups was significant (P = 0.04).40 
 

Protocol, v3, dated December 6, 2018                  Page 14 of 57 
 
Similarly, IGF-MTX was more effective than free MTX even at 4-fold lower molar dose in 
treating MCF7 xenografts 40. 
 
IGF-MTX is cytotoxic in vitro against myeloid cancer cell lines and is synergistic with 
azacytidine 
Three AML cell lines were tested in our laboratory for sensitivity to IGF-MTX.  The three 
cell lines were HL-60, HL-60/S4, and Kasumi-1.  All three were sensitive to IGF-MTX 
with IC50s of 458-668 nEq/L (nM of methotrexate groups in the IGF-MTX conjugate).  
This is about the same as the IC50 against MCF7 breast cancer cell line and LNCaP 
prostate cancer cell line, both of which are sensitive to IGF-MTX in mouse xenografts.  
 
The effect of IGF-MTX was also additive or synergistic with Azacytidine on at least the 
Kasumi-1 and HL-60 cell lines (it was not tested the combination on HL-60/S4).  In the 
presence of a concentration of Azacytidine about 1/3 of its IC50, the IC50 of IGF-MTX 
decreased from 668 to 398 nEq/L in Kasumi-1 cell line and decreased from 466 to 409 
nEq/L in HL-60.   
 
In Vivo Toxicology Studies 
MTD is based on both non-rodent and rodent studies.  Formal GLP toxicity in vivo 
studies were completed in rats and Beagle dogs, in which the 765IGF-MTX conjugate 
was administered intravenously by a single 30 minutes infusion on study Days 1 and 8 
as shown in Table 1 for the dogs: 
 
Table 1. 
Group / Dose 
Target 
Concentration 
µeq/ml 
(µmol MTX 
groups/mL) 
Preparation1 
Amount of 4 
µeq/ml (4 mM 
MTX groups) 
765IGF-MTX 
Stock 
Solution (mL) 
D5W-Added 
(mL) 
Total Volume 
(mL) 
1. 765IGF-MTX 
0.2 µeq/kg 
(0.2 ul MTX groups 
/kg) 
0.04 
1.25 
123.75 
125 
2. 765IGF-MTX 
2.0 µeqlkg 
(2.0 µmol MTX 
groups/kg) 
0.4 
10 
90 
100 
3. 765IGF-MTX 
0.5 µeq/kg 
(0.5 µmol MTX 
groups/kg) 
0.1 
3.125 
121.875 
125 
4. 765IGF-MTX 
6.0 µeq/kg 
(6.0 µmol MTX 
groups/kg) 
1.2 
37.5 
87.5 
125 
 

Protocol, v3, dated December 6, 2018                  Page 15 of 57 
 
Analysis of all generated data, including clinical observations, serial blood glucose 
determinations, and clinical pathology revealed no drug/treatment-related significant 
toxicity in dogs treated by intravenous infusion with 765IGF-MTX conjugate in 5% 
dextrose at 0.2 and 0.5 µeq/kg. In the 0.2 µeq/kg group there was only transient dyspnea 
and passivity noted, while in the animals treated at 0.5 µeq/kg a single episode of vomiting 
and diarrhea were noted, and there was also mild reddening and swelling of the skin on 
the head of the female dog. Treatment of dogs in these two groups was well tolerated, and 
any reaction to the treatment was transient and resolved by itself. 
 
In animals dosed at 2 µeq/kg the reactions to the treatment included mild to moderate 
anaphylactoid and hives-type reactions, transient anorexia and weight loss, and 
hypoglycemia. Reactions to the treatment in the dogs dosed at 6 µeq/kg were similar to 
the reactions at 2 µmol/kg, but they were more severe and lasted longer. Thus, an MTD of 
765IGF-MTX conjugate in Beagle dogs in this study may be considered to be 6 µeq/kg, by 
a single infusion over 30 minutes. 
 
Recovery from anaphylactoid reactions and hypoglycemia in the female dog dosed at 2 
µmol/kg and in both animals dosed at 6 µmol/kg, was assisted by treatments with 
diphenhydramine and dextrose. 
 
Hypoglycemia in the higher dose groups was an exaggerated pharmacological effect of 
IGF, which was mitigated by the use of 5% dextrose as a vehicle for delivery of 765IGF-
MTX conjugate. The pathogenesis of the anaphylactoid reactions was not clear, but may 
have been caused by either methotrexate, IGF or the combination thereof. Vomiting, 
diarrhea, anorexia and weight loss are known reactions to methotrexate. 
 
The highest non-severely toxic dose in beagles was 0.5 µeq/kg. Using the conversion from 
doses in dogs in uEq/kg to equivalent human dose in µEq/kg, the equivalent human dose 
to 0.5 µEq/kg in dogs is 0.27 µEq/kg in humans42,43.  
 
IGF-MTX does not cause significant cytopenia 
Cytopenia is a particular concern for MDS, CMML, and O-AML since it is a principal 
sequela of these diseases.  In both rat and dog repeat dose GLP toxicology testing IGF-
MTX caused almost no cytopenia, even at the highest doses tested.  In both rat and dog 
toxicology studies IGF-MTX caused a slight dose-dependent reduction in erythrocyte 
mass, but even at the highest doses tested erythrocyte mass was within normal ranges.  
In rats but not dogs neutrophils were also slightly decreased by IGF-MTX but remained 
within normal ranges even at the highest doses.  No other hematological parameters were 
affected by IGF-MTX.   
 
In the completed Phase I dose-escalation study in human solid tumor patients, a dose of 
0.8 µEq/kg was found to be tolerated without any serious adverse events.   Since MDS 
patients have greater cytopenia than solid tumor patients, and for safety of MDS patients, 
we are conducting a new dose escalation in this study beginning at a dose level of 0.2 
µEq/kg administered on days 1, 8, and 15.  See the schema on page 6 for the dose 
escalation schema.  
 
 
 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 16 of 57 
 
1.2.2. Clinical Experience with IGF-Methotrexate 
 
Phase I Study of IGF-Methotrexate Conjugate in the Treatment of Advanced Tumors 
Expressing IGF-1R 
The primary objective of this study was to determine the maximum tolerated dose (MTD) 
of 765IGF-MTX by evaluation of toxicity during treatment of advanced, previously treated 
malignancies that express IGF-1R. One inclusion criterion was that a subject’s tumor 
(tissue, bone marrow, or blood) must express IGF-1R, defined as ≥10% of tumor cells 
expressing IGF-1R by immunohistochemistry (IHC). 
 
Nineteen subjects were enrolled in this dose escalation study. 765IGF-MTX was 
administered as an IV infusion over 1 hour on days 1, 8 and 15 of a 28 day cycle.  
Treatment continued until disease progression, unacceptable toxicity, or patient refusal. 
Assessment of response was confirmed with imaging studies performed at the end of 
cycle 2 +/- 7 days, and every 2 cycles thereafter. The table below shows, for each dose 
level tested, the subjects that were tested, the type of malignancies they had, number of 
cycles they completed, whether they experienced a DLT, and, if applicable, their reason 
for study discontinuation. One patient with Hodgkin Lymphoma at dose level 3 was 
treated with 22 doses with apparently stable disease by CT scan, but treatment was 
discontinued when a lymph node biopsy showed no evidence of cancer. 
 
Dose 
Level 
Dose 
(µEq/kg) 
Subject 
# 
Malignancy 
DLT 
(Y/N) 
# doses  
Reason 
for 
discontinuation 
1 
0.05 
1 
Colon Ca 
N 
6 
Progression 
2 
0.10 
2 
Met 
adamantinoma 
N 
6 
Progression 
3 
0.20 
3 
Colorectal, met 
N 
6 
Progression 
3 
0.20 
4 
Endometrial Ca 
Y 
1 
not evaluable 
3 
0.20 
5 
Endometrial Ca 
N 
18 
stable disease 
3 
0.20 
6 
Pancreatic Ca 
N 
2 
not evaluable 
3 
0.20 
7 
Thymic Ca 
N 
6 
Progression 
3 
0.20 
8 
Hodgkin 
Lymphoma 
Y 
6 
Progression 
3 
0.20 
9 
Hodgkin 
Lymphoma 
N 
22* 
stable disease 
4 
0.40 
10 
Colon Ca 
N 
5 
Progression 
4 
0.40 
11 
Thymoma 
N 
6 
Progression 
4 
0.40 
12 
Colon Ca 
N 
9 
stable disease 
5 
0.80 
13 
mCRC 
N 
3 
not evaluable 
5 
0.80 
14 
Pancreatic Ca 
N 
6 
Progression 
5 
0.80 
15 
Colon Ca 
N 
3 
not evaluable 
5 
0.80 
16 
Endometrial Ca 
N 
4 
not evaluable 
5 
0.80 
17 
Colon Ca 
N 
6 
Progression 
5 
0.80 
18 
Breast Ca 
N 
6 
Progression 
5 
0.80 
19 
Basal 
cell 
Ca 
with lung mets. 
N 
6 
partial response. 
 
* At time of this report is tumor-free by lymph node biopsy. 
 
 
Adverse Events 

Protocol, v3, dated December 6, 2018                  Page 17 of 57 
 
Adverse events experienced during the prior solid tumor Phase I on solid tumor patients 
that were graded as possibly or probably related to the study drug are shown in the Table 
below. 
 
Adverse events possibly related to study drug 
  
Event 
Grade 
Hypotension 
3 
Fever 
2 
Seizure 
2 
Sinus tachycardia 
2 
Dyspnea 
2 
Abdominal pain or cramps 
2 
Nausea, Vomiting 
1 
Hypoglycemia 
1 
Dizziness 
1 
 
None of the adverse events were seen in all subjects or all drug administrations in a single 
subject.  The most common adverse events were hypoglycemia, which is an expected 
consequence of the study drug, chills, and fever.  When these occurred, they usually 
resolved within 2 hours after the end of the infusion.  One subject had grade 2 fever 
beginning with the infusion and lasting overnight.  One subject had grade 3 hypotension 
beginning during the infusion and lasting overnight.  Nausea and vomiting were common, 
but occurred during the infusion, not with a several hour delay as is typical with 
chemotherapy.  In all cases they resolved within 1 hour after the end of the infusion.  
Abdominal pain or cramping was common but appeared limited to patients with colon 
carcinoma, so it may have been associated with the study drug binding to and targeting their 
tumor tissue.  The one seizure that was seen occurred during the infusion in a subject 
during cycle 5, day 1 (the patient's 16th dose of drug) at dose level 0.4 uEq/kg, and resolved 
in 2 minutes.  This patient also experienced the grade 3 hypotension event at the same time 
and was hospitalized overnight for it. 
 
Other adverse events that have been observed with 765IGF-MTX administration in the 
present clinical trial have been syncope, tachycardia, fever and chills.  These have been 
observed during the infusion or within 3 hours after infusion. 
   
1.3. Study Rationale 
Cytotoxic drug conjugates consist of a tumor targeting agent covalently linked to a cytotoxic 
drug. The conjugated drug is designed to be nontoxic extracellularly, but, after 
internalization of the conjugate by target cancer cells and subsequent release of the free 
drug, it can disrupt intracellular enzymes and kill the cancer cell. A recent preclinical study 
using such an approach produced promising results.40 The investigators in that study 
developed a novel covalent conjugate that contains methotrexate (MTX) coupled to the 
long-R3-IGF-1 variant (IGF-MTX conjugate), with the purpose of specifically targeting and 
destroying tumor cells that overexpress the membrane IGF-1 receptor. Via in vivo studies 
with mice, they demonstrated that the novel IGF-MTX conjugate was more effective at 
significantly lower doses than free MTX at controlling tumor growth. These data provide 
proof-of-principle that IGF-chemotherapy conjugates can enhance the therapeutic effects of 
chemotherapy by specifically increasing anticancer drug localization in tumor cells and 

Protocol, v3, dated December 6, 2018                  Page 18 of 57 
 
tumor-related tissues that overexpress IGF-1 membrane receptors. Accordingly, here we 
propose to examine use of MTX covalently bound to an IGF-1 variant similar in structure to 
long R3 IGF-1 in this Phase I clinical trial. 
 
Based on the data described in section 1.1.2.126-29 we plan to proceed with this pilot study 
focusing on a select population of patients with specific hematologic malignances, i.e., MDS, 
CMML, and O-AML, that are refractory to or intolerant of standard treatment. The IGF-MTX 
drug appears well suited to treat these malignancies for three reasons.  (1) The malignant 
cells of MDS, CMML, and O-AML have been shown to overexpress IGF-1R, the receptor to 
which IGF-1R binds26-29.  (2) Our data show malignant myeloid cell lines are sensitive to 
IGF-MTX.  (3) These diseases are characterized by cytopenia, and IGF-MTX appears to 
cause no cytopenia in humans at the doses that will be used based on experience in the 
completed solid tumor Phase I clinical study and almost no cytopenia in rats and dogs in 
toxicology testing, even at the highest doses tested.  In rat and dog toxicology studies, IGF-
MTX caused only a slight reduction in erythrocyte mass, but even at the highest doses 
tested erythrocyte mass was within normal ranges.  In rats but not dogs neutrophils were 
also slightly decreased by IGF-MTX but remained within normal ranges even at the highest 
doses.   
 
Although the primary and secondary goals of this trial are to evaluate the safety and clinical 
benefit of 765IGF-MTX, this study is also important because other correlative studies will 
provide critical information. In addition to characterizing pharmacokinetics, 
pharmacodynamics markers will be collected before and during treatment, including serum 
IGF-1 and plasma and whole blood IGF-1R levels. Given that 765IGF-MTX cell killing is 
dependent on ligand-mediated binding and internalization, we plan to assess changes in PD 
markers during and pre- and post-treatment. Patients’ diagnostic tissue (available from the 
original BM biopsy obtained at time of diagnosis) will be stained to determine if detectable 
IGF-1R is present on the leukemia or MDS cells and the level of IGF-1R expression.   Based 
on publications that report that all or nearly all MDS and AML patients overexpress IGF-1R 
on their malignant cells, demonstrated expression of IGF-1R on the patients' diagnostic 
tissue will not be an inclusion criterion26-29. 
 
2. Objectives 
 
2.1. Primary Objective 
The primary objective is to determine the safety and tolerability of 765IGF-MTX when used 
for the treatment of advanced, previously treated MDS, CMML or O-AML, including 
determining the MTD of IGF-MTX. 
 
2.2. Secondary Objectives 
2.2.1 Evaluate clinical benefit of 765IGF-MTX by evaluating the overall response rate 
(ORR) complete and partial remission (CR and PR) rates, complete remission with 
incomplete hematologic recovery (CRi) rate, relapse-free survival (RFS), cumulative 
incidence of relapse (CIR), time to relapse, and overall survival (OS) in patients with 
advanced, previously treated O-AML, CMML or MDS.   
 
2.3. Correlative Objectives 
2.3.1. Characterize pharmacokinetics (PK) of 765IGF-MTX, 765IGF, methotrexate, and 
7-OH methotrexate 
 
2.3.2. Assess potential for QT prolongation 
 

Protocol, v3, dated December 6, 2018                  Page 19 of 57 
 
2.3.3. Assess Pharmacodynamic (PD) effects of 765IGF-MTX on soluble IGF-1 and 
IGF-1R levels 
  
2.3.4. Assess formation of antibodies against 765IGF-MTX 
 
2.3.5. Assess formation of neutralizing antibodies 
 
2.3.6. Assess level of diseased cell IGF-1R expression 
 
3. Endpoints 
3.1. Primary Endpoint 
The primary endpoint is safety and tolerability of 765IGF-MTX. This will be assessed by 
evaluation of adverse effects (AEs) as defined by CTCAE v.4.0. 
 
3.2. Secondary Endpoints 
3.2.1.  Evaluate clinical benefit of 765IGF-MTX by assessment of ORR, RFS, CIR, OS. 
 
3.2.2.  Complete remission (CR), Complete remission with incomplete hematologic 
recovery (CRi) (equivalent to "marrow CR" in Appendix II), PR as defined by the 
following response criteria for hematologic malignancies (see Appendix I Tables 5 and 6, 
and Appendix II): 
3.2.2.1. 
Acute leukemia: 2015 SWOG Manual Chapter 11A44 (Appendix I); 
European LeukemiaNet criteria45 and 2003 IWG criteria46 
3.2.2.2. 
MDS: 2006 IWG criteria 47 (Appendix II)  
 
 
3.3. Correlative Endpoints 
3.3.1 Pharmacokinetic (PK) parameters as defined by AUC from start of infusion to 
time of last quantifiable plasma concentration, AUC from start of infusion to infinity, 
maximum observed plasma concentration, time of maximum plasma concentration, 
terminal elimination constant of both free MTX and IGF-MTX for 765IGF-MTX, 765IGF, 
methotrexate, and 7-OH methotrexate. 
 
3.3.2 Evaluation of potential of 765IGF-MTX for QT prolongation 
 
3.3.3 Pharmacodynamic parameters (PD) as defined here by serum IGF-1 and plasma 
and whole blood IGF-1R concentration, and standard of care systemic PD variables (cell 
count, differential)  
 
3.3.4 Plasma 765IGF Level and 765IGF-MTX toxicity/response 
 
3.3.5 Plasma and whole blood IGF-1R level and 765IGF-MTX Toxicity/Response 
 
3.3.6 Assess formation of antibodies against 765IGF-MTX 
 
3.3.7 Assess formation of neutralizing antibodies 
 
3.3.8 IGF-1R expression level in diseased tissue in bone marrow, as measured by 
IHC, and flow cytometry, and in blood cells as measured by flow cytometry. 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 20 of 57 
 
 
 
4. Overall Design and Study Plan 
 
This pilot study will evaluate the safety and clinical benefit of 765IGF-MTX in patients with 
advanced, previously treated MDS, CMML or O-AML.  765IGF-MTX is administered as an IV 
infusion over 1.5 hours on days 1, 8 and 15 of a 28 day cycle. Treatment continues until disease 
progression, unacceptable toxicity, or patient refusal. Assessment of response will be confirmed 
with bone marrow studies performed at the end of cycle 2, and every 8 weeks +/- 7 days (2 
cycles) thereafter up to the end of cycle 6, and at physician's discretion thereafter. 
 
• 
Dose Finding Component: Up to 5 dose levels will be tested (refer to schema on page 6). 
The maximum tolerated dose (MTD) will be determined using the modified toxicity 
probability interval design with dose limiting toxicity (DLT) estimated at 0.33.   
 
Our modification involves using cohorts of size 1 for the initial doses, which allows rapid 
escalation through the initial dose levels, and expanding to cohorts of size 3 once any grade 
2 or higher toxicity is observed that is considered related to study drug (with the exception of 
alopecia, nausea, or diarrhea).  Additional patient cohorts will not be enrolled until 1 of 1 
(with no grade 2 toxicity), 3 of 3, 5 of 6, or 7 of 9 patients at the current dose level complete 
all planned treatment for cycle 1 (defined as 3 doses of 765IGF-MTX without DLT and are 
able to start cycle 2 with no more than a 2 week delay. At the discretion of the principal 
investigator, intra-patient dose escalation between cycles is also allowed but only after 2 
cycles at one dose level and confirmation of safety in at least 3 patients treated at the higher 
dose level. 
 
If none of the dose levels are acceptable at study completion, an optimal dose level will not 
be identified and the drug does not warrant further investigation.     
 
• 
Maximum Tolerated Dose (MTD) Cohort with pharmacokinetics (PKs) and 
pharmacodynamics (PD): The MTD will be defined as the highest dose associated with DLT 
in less than 33% of patients treated.  Once the MTD is determined, enrollment will continue 
until 9 patients total are accrued at the MTD. For this group, pharmacokinetics will be 
performed on at least 3 patients before and for up to 48 hours after drug administration on 
days 1 and 15 of cycle 1. Pharmacodynamic samples will be assessed on day 1 of cycle 1, 
and days 1 and 15 of cycle 2 before the infusion of 756IGF-MTX, and one sample will also 
be drawn within the fourth week of each treatment cycle. 
 
If none of the dose levels are acceptable at study completion, an optimal dose level will not be 
identified and the drug does not warrant further investigation.     
 
Dose limiting toxicity (DLT) for a patient is defined as one of the following events occurring 
during cycle 1:   
 
• 
Grade 4 or greater treatment related hematologic toxicity for > 7 days during the first 
cycle (28 days) of therapy 
• 
Grade 3 or greater treatment related clinical non-hematological toxicity (excluding ≥ 
grade 3 nausea, vomiting, or diarrhea without maximal medical intervention and/or 
prophylaxis) during the first cycle (28 days) of therapy 
• 
Febrile neutropenia during the first cycle (28 days) of therapy 
 

Protocol, v3, dated December 6, 2018                  Page 21 of 57 
 
• 
Platelets less than 10 x 109/L with clinically significant bleeding during the first cycle (28 
days) of therapy 
. 
 
Additional patient cohorts will not be enrolled until 1 of 1 (with no grade 2 toxicity), 3 of 3, 5 of 6, 
or 7 of 9 patients at the current dose level complete all planned treatment for cycle 1 (defined as 
3 doses of 765IGF-MTX without DLT and are able to start cycle 2 with no more than a 2 week 
delay.  
 
The MTD will be defined as a dose level at which fewer than 33% of patients treated experience 
a DLT. 
 
A minimum of 9 patients are to be treated at the MTD to assure safety and 765IGF-MTX based 
pharmacokinetics will be performed on at least 3 patients in total. 
 
Pharmacokinetics will be performed before and for up to 24 hours after drug administration on 
days 1 (for 24 hrs) and 15 (for 24 hrs) of cycle 1. Pharmacodynamic samples will be assessed 
pre-dosing on day 1 of cycle 1, pre-dosing on days 1 and 15 of cycle 2, and pre-dosing on day 
15 of cycles 4 and 6. 
 
 
5. Selection of Patients 
Study entry is open to adults ≥ 18 years regardless of gender or ethnic background. While there 
will be every effort to seek out and include women and minorities, the patient population is 
expected to be no different than that of other studies performed at the Mayo Clinic. 
 
 
5.1.  Inclusion Criteria 
5.1.1 Diagnosis of O-AML that is refractory to or intolerant to standard therapy and is 
no longer likely to respond to such therapy (at least one line of therapy); or  
Diagnosis of MDS/CMML that is refractory to or intolerant to standard therapy 
and is no longer likely to respond to such therapy (at least one line of therapy) 
5.1.2 Confirmed histologic diagnosis on bone marrow biopsy and aspirate within 28 
days of trial entry prior to starting cycle 1.  
5.1.3 Platelets > 10 x 109/L 
5.1.4 Age ≥ 18 years 
5.1.5 ECOG performance status of 0, 1 or 2 (appendix III). 
5.1.6 Prior systemic chemotherapy, immunotherapy, or biological therapy, radiation 
therapy and/or surgery are allowed; prior use of systemic methotrexate > 1 
month prior to study entry is allowed. Intrathecal methotrexate is allowed prior to 
and during treatment per investigator discretion. 
 
Time since prior therapy and the first dose of study drug: 
   
• 
At least 2 weeks since prior radiation, non cytotoxic small molecule drugs, 
prior major surgery (defined as a surgery involving a risk to the life of the 
patient; specifically: an operation upon an organ within the cranium, chest, 
abdomen, or pelvic cavity), prior systemic FDA-approved therapy 
 
5.1.7 Patient must have recovered from the acute toxic effects (≤ grade 1 CTCAE 
v.4.0) of previous anti-cancer treatment prior to study enrollment; the only 
exception is that grade 2 neuropathy is permitted 

Protocol, v3, dated December 6, 2018                  Page 22 of 57 
 
 
5.1.8 Adequate organ function within 14 days of study registration defined as: 
System 
Laboratory Values 
 
Hematologic 
 
Platelets 
> 10 x 109/L  
Hepatic 
Bilirubin total 
≤ 1.5 x ULN 
Alkaline Phosphatase, AST and 
ALT 
≤3 X ULN (< 5 x ULN is 
acceptable if liver has tumor 
involvement) 
Renal 
 
Serum Creatinine, or 
Creatinine Clearance, or        
GFR, or   
24 hour urine creatinine clearance 
≤ 1.5 x ULN 
> 60 mL/min 
> 60 mL/min 
 
> 50 mL/min 
 
5.1.9 Negative serum pregnancy test in females. Male and female patients with 
reproductive potential must use an approved contraceptive method if appropriate 
(for example, abstinence, oral contraceptives, implantable hormonal 
contraceptives, or double barrier methods) during, and for 3 months after the last 
dose of 765IGF-MTX. 
 
5.1.10 Voluntary written informed consent before performance of any study-related 
procedure not part of normal medical care, with the understanding that consent 
may be withdrawn by the patient at any time without prejudice to future medical 
care. 
 
5.2. Exclusion Criteria 
5.2.1. ECOG PS >2. 
5.2.2. Patients with active extramedullary disease. 
5.2.3. Active CNS involvement. 
5.2.4. Pleural effusions or ascites. 
5.2.5.  Grade 3 peripheral neuropathy within 14 days before enrollment.  
5.2.6. Active uncontrolled infection or severe systemic infection (enrollment is possible     
after control of infection). 
5.2.7. Myocardial infarction within ONE months prior to enrollment or has New York 
Heart Association (NYHA – appendix IV) Class III or IV heart failure, uncontrolled 
angina, severe uncontrolled ventricular arrhythmias, or electrocardiographic 
evidence of acute ischemia or active conduction system abnormalities. Prior to 
study entry, any ECG abnormality at screening has to be documented by the 
investigator as not medically relevant. 
5.2.8. Pregnant or breastfeeding – methotrexate is Pregnancy Category X - has been 
reported to cause fetal death and/or congenital abnormalities. Confirmation that 
the subject is not pregnant must be established by a negative serum -human 
chorionic gonadotropin (-hCG) pregnancy test result obtained during screening. 
Pregnancy testing is not required for post-menopausal or surgically sterilized 
women.  
5.2.9. Uncontrolled diabetes mellitus defined as a Hemoglobin A1C≥ 10% in patients 
with a prior history of diabetes, prior to study enrollment. 

Protocol, v3, dated December 6, 2018                  Page 23 of 57 
 
5.2.10. Serious concomitant systemic disorders (e.g., active uncontrolled infection or 
uncontrolled diabetes) or psychiatric disorders that, in the opinion of the 
investigator, would compromise the safety of the patient or compromise the 
patient’s ability to complete the study. 
5.2.11. Other severe acute or chronic medical or psychiatric conditions, or laboratory 
abnormality that may increase the risk associated with study participation or 
investigational product administration or may interfere with the interpretation of 
study results and, in the judgment of the investigator, would make the patient 
inappropriate for enrollment in this study. 
5.2.12. Any history of epilepsy or a seizure disorder or any known prior seizures.  
5.2.13. Abnormalities on 12-lead electrocardiogram (ECG) considered by the 
investigator to be clinically significant. 
5.2.14. Known immediate or delayed hypersensitivity reaction or idiosyncrasy to drugs 
chemically related to IGF or methotrexate.  
 
 
6. Registration/Enrollment 
 
Registration/enrollment will occur after the patient has signed the informed consent document 
and eligibility is confirmed, but before any treatment has been administered. To be eligible for 
registration/enrollment into this study, the patient must meet each criterion listed on the eligibility 
checklist and supported by the clinical documentation in the patient’s medical record. A copy of 
the eligibility checklist is maintained by the Clinical Trials Office (CTO) and can be found for 
each individual subject within the subject shadow chart. Patients must be registered/enrolled on 
the study within 30 days of signing the informed consent document. If the patient cannot be 
registered/enrolled within this timeframe, the patient may later be reconsidered for participation 
as outlined in section 6.3 below. 
 
6.1. Registration/Enrollment with the Clinical Trials Office 
Upon obtaining informed consent, completion of the screening evaluation, and verifying 
eligibility, the site study coordinator or designee will enroll the patient into EDC Easy®, the 
CTO Clinical Trials Management System (CTMS). The eligibility checklist must be 
completed by the study coordinator and verified/confirmed by the Principal Investigator or 
her designee (i.e., a sub-Investigator). 
 
6.2. Registered/Enrolled Patients Who Do Not Begin Study Treatment 
If a patient signs the informed consent document, is subsequently registered/enrolled to the 
study but is then not able to begin the planned study treatment for any reason, the patient 
will be removed from study and treated at the physician’s discretion. The patient will be 
considered a screen/baseline failure and be replaced. Further data will not be collected if the 
patient has not begun study treatment at the time of removal from trial. The reason for 
removal from study will be clearly indicated in EDC Easy®. 
 
If a patient begins treatment and is then removed from treatment for any reason, the patient 
must be followed per section 7.11. 
 
6.3. Re-screening Patients 
A patient who was once classified as a screening/baseline failure for any reason can later 
be reconsidered for participation, if deemed clinically beneficial for the patient by the treating 
physician and Principal Investigator. In such case, the patient must again go through the 
consent process and must be rescreened. The patient must meet each criterion listed on the 
eligibility checklist based on the clinical documentation in the patient’s medical record. After 

Protocol, v3, dated December 6, 2018                  Page 24 of 57 
 
the patient has reaffirmed his/her desire to participate, the rescreening process must take 
place within 14 days of Cycle 1, Day 1 (C1D1) as mandated by the treatment start 
guidelines. Patients who were previously treated with the study drug but were removed from 
treatment for any reason cannot be reconsidered for participation at a later date. Patients 
must be re-registered/re-enrolled on the study within 30 days of re-signing the informed 
consent document. 
 
7. Treatment Plan 
7.1. Study Drug Administration 
After Cycle #1 a new treatment cycle will be initiated when all of the following conditions are 
met: 
 
• 
Non-hematologic treatment related toxicities have improved to grade 1 or 
resolved (CTCAE v.4.0) 
• 
Platelets > 10 x 109/L  
 
Refer to section 7.3 for guidelines for dose modifications based on treatment-related delays and 
toxicities of the previous cycle. 
 
7.1.1. 765IGF-Methotrexate Administration 
765IGF-MTX will be given at the assigned dose as a 1.5 hour IV infusion in 250 ml of 5% 
dextrose on days 1, 8, and 15 of a four-week treatment cycle. Every 4 week period will 
be considered one treatment cycle. Subsequent cycles must meet the criteria found in 
section 7.3.1 and may begin 1 day earlier to accommodate scheduling issues, or up to 4 
weeks later if a patient needs this time to recover to meet criteria for start of a new cycle 
as specified in section 7.2.1.  At the investigator's discretion, the study drug may be 
administered in 10% dextrose rather than 5% dextrose if it is believed necessary to 
prevent or control hypoglycemia. 
 
Pre-medication 
None is required, but can be utilized per clinician discretion.  The program of predication 
below has been used in the prior solid tumor phase I with some of the later enrolled 
patients to prevent nausea and an allergic reaction.  Nausea during infusion was seen in 
a few patients and a possible allergic reaction to the drug was seen in one patient. 
 
Zofran 8mg PO  
Benadryl 50mg PO  
Tylenol 650mg PO  
Hydrocortisone 100mg IV push 
D5 .45 normal saline 100cc/hr to start with premeds 
 
 
Monitoring 
Vital signs including blood pressure, pulse, temperature, respirations, and pulse 
oximetry, and blood glucose will be measured immediately before the infusion and 
immediately after completion of the infusion in all patients during all cycles. IGF-MTX 
causes hypoglycemia at higher dose levels, so it is important to monitor blood glucose 
levels.  During the first 28-day cycle, patients will be monitored for blood glucose on 
infusion days for a total of 3.5 hours. Vital signs listed above will be monitored per the 
following table: 
 

Protocol, v3, dated December 6, 2018                  Page 25 of 57 
 
Monitoring interval 
Immediately before infusion  
All vitals 
To Hour 1.5 (during infusion) 
Glucose only, every 15 min 
Hour 1.5 
All vitals 
Hours 1.5-3.5 
Glucose only, every 30 min 
 
The patients will be provided with a home blood glucose monitoring device and 
instructed to measure and record blood glucose at 7 hours (± 2 hours) and 24 hours (± 6 
hours) after the start of the infusion.  The same device will be used to monitor blood 
glucose at the clinic during the 3.5 hour monitoring. 
 
On all subsequent cycles that patients are on treatment (i.e., cycle 2 and beyond), those 
patients that did not experience a severe adverse event during the infusion and 3.5-hr 
post-infusion period in cycle 1 will be monitored for a total of 2.5 hours on infusion days 
(i.e., during the 1.5 hour infusion and one hour after termination of the infusion). Vital 
signs listed above will be monitored per the following table:  
 
Monitoring interval 
Immediately before infusion 
All vitals 
To Hour 1.5 (during infusion) 
Glucose only, every 15 min 
Hour 1.5 
All vitals 
Hours 1.5-2.5 
Glucose only, every 30 min 
 
The patients will be instructed to measure and record blood glucose at 7 hours (± 2 
hours) and 24 hours (± 6 hours) after the start of the infusion for each dose. 
 
Patients will be closely monitored for toxicities. Strict I/O will be measured during patient 
stay both in the ambulatory and inpatient setting (per unit protocol). 
 
 
Supportive Measures: See also section 7.7 
Hypoglycemia will be treated with oral glucose or if necessary IV glucose to maintain 
blood glucose levels above 50 mg/dl.  Acetaminophen for fevers, meperidine for chills, 
anti-emetics for nausea and vomiting, normal saline or furosemide to maintain fluid 
balance/blood pressure/pulmonary function, electrolyte replacement, albumin to maintain 
serum albumin at 3 g/dL or greater.  Anaphylactoid reactions will be treated with 100 mg 
methylprednisolone IV, diphenhydramine 25 mg IV, or 0.3 cc epinephrine (1:1000) IV 
and transfer to an ICU setting for monitoring. Refer to section 7.2.1. regarding 
management of Allergic Reaction/Hypersensitivity reactions.  
 
Precautions 
Patients should not drive, operate dangerous tools or machinery, or engage in any other 
potentially hazardous activity that requires full alertness and coordination if they 
experience sedation while enrolled in this study. 
 
Methotrexate has been reported to cause fetal death and/or congenital anomalies. If a 
woman becomes pregnant or suspects that she is pregnant while participating in this 
study, she must inform the investigator immediately and must permanently discontinue 
study drug. Effective barrier contraception must be practiced during the entire study 
treatment period and through three months after the last dose of study drug by females 

Protocol, v3, dated December 6, 2018                  Page 26 of 57 
 
of childbearing potential and male patients (even if surgically sterilized (i.e., status post 
vasectomy) or the patient must completely abstain from heterosexual intercourse. 
Refer to section 11.5 for reporting pregnancy in a female patient or the partner of a male 
patient. 
 
 
7.2. Dose Modifications 
7.2.1. Start of a New Cycle 
Toxicity and adverse will be classified according to NCI's Common Terminology Criteria 
for Adverse Events Version 4.0 (CTCAE). A copy of the CTCAE can be downloaded 
from the CTEP home page: 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40). 
Assessment of clinical benefit will be performed by investigators at the end of cycle 1 
and confirmed with bone marrow studies as per MDS, CMML or O-AML specific 
response criteria (Appendices I and II) done at the end of cycles #2, 4, and 6 (i.e., at 8, 
16, and 24 weeks, each +/- 7 days) and at the discretion of the physician thereafter. 
 
A new treatment cycle will only be initiated when all of the following conditions are met: 
• 
non- hematologic treatment related toxicities have improved to ≤ Grade 1 
(CTCAE v.4.0) or to the patient’s baseline values (except alopecia) 
• 
Platelets per 7.1 (platelets > 10 x 109/L) 
 
If blood counts are below this threshold at the 4 week point, blood work is to be repeated 
weekly until counts are at an acceptable level. Treatment will be restarted with 
appropriate dose modifications provided CTCAE hematologic grade ≥4 is not prolonged 
for more than 6 weeks in the absence of persistent disease. If treatment is unable to 
restart within 4 weeks of the planned treatment date, the patient will be permanently 
discontinued from study therapy. 
 
CTCAE Grade 1 Allergic Reaction/Hypersensitivity: (Transient flushing or rash, drug fever 
< 38°C): Supervise without further treatment for allergic reaction/hypersensitivity. 
 
CTCAE Grade 2 Allergic Reaction/Hypersensitivity: (Rash, flushing, dyspnea, urticaria, 
drug fever greater than or equal to 38°C) and/or asymptomatic bronchospasm: Interrupt the 
infusion. If symptoms abate, attempt re-infusion at a slower rate. If the symptoms recur, 
CTCAE v.4.0 Adverse Effects Terms & 
Descriptions (see below for allergic 
reaction/hypersensitivity)  
765IGF-MTX Dose Modifications (for 
treatment-related toxicities deemed 
clinically significant) 
Any persistent (>4 weeks) grade 2 
treatment-related non-hematologic toxicity 
Drop to next lower dose level or 
discontinue treatment. 
Grade 4 or greater treatment-related 
hematological toxicity for >7 days. 
Drop to next lower dose level or 
discontinue treatment. 
Grade 3 or greater treatment-related 
clinical non-hematological toxicity, 
excluding grade 3 nausea, vomiting, or 
diarrhea without maximal medical 
intervention and/or prophylaxis. 
Drop to next lower dose level or 
discontinue treatment. 
Febrile neutropenia. 
Drop to next lower dose level or 
discontinue treatment. 
Platelets less than 10 x 109/L 
Wait to improve and then drop to next 
lower dose level or discontinue treatment. 

Protocol, v3, dated December 6, 2018                  Page 27 of 57 
 
discontinue infusion and follow for recurrent allergic reaction/hypersensitivity in the next 
paragraph. 
 
Recurrent CTCAE Grade 2 or CTCAE Grade 3 or 4 Allergic Reaction/Hypersensitivity: 
Stop the infusion. Administer additional doses of H1 and H2 blockers intravenously. 
Administer IV steroids and consider epinephrine and bronchodilators as clinically indicated.  
 
CTCAE Grade 3 or 4 Allergic Reaction/Hypersensitivity: Stop the infusion. Administer 
additional doses of H1 and H2 blockers intravenously. Administer IV steroids and consider 
epinephrine and bronchodilators as clinically indicated. Will be permanently discontinued 
from study treatment. 
 
Prior to re-challenge of Grade 2 allergic reaction/HSR and with all subsequent cycles: 
The following prophylactic premedications are recommended for future infusions: give both 
an H1 and H2 blocker intravenously plus dexamethasone 20 mg (orally or intravenously) 
within 30 to 60 minutes before 765IGF-MTX infusion. Dexamethasone could be used at the 
investigator’s discretion in subsequent cycles for recurrent (i.e. occurring despite slowing 
infusion as discussed above) Grade 2 reactions but would not be mandated. 
 
An appropriate resuscitation plan should be in place and a physician readily available during 
the period of drug administration. If treatment delay necessitates a period longer than 4 
weeks, treatment is stopped and the subject is discontinued from the study. 
 
7.3. Permitted Concomitant Medications and Procedures 
Myeloid growth factors to treat patients with neutropenia or cytopenia are permitted.   
 
Antiemetic agents may be administered at the discretion of the investigator but are not 
commonly required as a prophylactic agent. All other manifestations of the patient’s 
malignancy should be treated at the discretion of the investigator. 
 
Medications with potential CNS effects are not prohibited in this study, but it is 
recommended that their use be minimized to avoid confusion in the interpretation of CNS 
effects should they occur during the course of treatment with 765IGF-MTX. 
 
In appropriate settings, such as combinations with agents known to produce frequent 
thrombocytopenia, restricted uses of anticoagulants should be considered. 
 
All other medical conditions should be treated at the discretion of the investigator in 
accordance with local community standards of medical care. 
 
7.4. The Effects of Other Drugs on Methotrexate 
Nonsteroidal anti-inflammatory drugs should not be administered prior to or concomitantly 
with the high doses of methotrexate, such as used in the treatment of osteosarcoma. 
Concomitant administration of some NSAIDs with high dose methotrexate therapy has been 
reported to elevate and prolong serum methotrexate levels, resulting in deaths from severe 
hematologic and gastrointestinal toxicity. 
 
Caution should be used when salicylates are administered concomitantly with lower doses 
of methotrexate. These drugs have been reported to reduce the tubular secretion of 
methotrexate in an animal model and may enhance its toxicity. 
 

Protocol, v3, dated December 6, 2018                  Page 28 of 57 
 
Methotrexate is partially bound to serum albumin, and toxicity may be increased because of 
displacement by certain drugs, such as salicylates, phenylbutazone, phenytoin, and 
sulfonamides including BACTRIM. Renal tubular transport is also diminished by probenecid; 
use of methotrexate with this drug should be carefully monitored. 
 
Methotrexate increases the plasma levels of mercaptopurine. The combination of 
methotrexate and mercaptopurine may therefore require dose adjustment. 
 
Oral antibiotics such as tetracycline, chloramphenicol, and nonabsorbable broad spectrum 
antibiotics, may decrease intestinal absorption of methotrexate or interfere with the 
enterohepatic circulation by inhibiting bowel flora and suppressing metabolism of the drug 
by bacteria. 
 
Penicillins may reduce the renal clearance of methotrexate; increased serum concentrations 
of methotrexate with concomitant hematologic and gastrointestinal toxicity have been 
observed with high and low dose methotrexate. Use of methotrexate with penicillins should 
be carefully monitored. 
 
The potential for increased hepatotoxicity when methotrexate is administered with other 
hepatotoxic agents has not been evaluated. However, hepatotoxicity has been reported in 
such cases. Therefore, patients receiving concomitant therapy with methotrexate and other 
potential hepatotoxins (e.g., azathioprine, retinoids, sulfasalazine) should be closely 
monitored for possible increased risk of hepatotoxicity. 
 
Methotrexate may decrease the clearance of theophylline; theophylline levels should be 
monitored when used concurrently with methotrexate. 
 
Vitamin preparations containing folic acid or its derivatives may decrease responses to 
systemically administered methotrexate.  
 
Folate deficiency states may increase methotrexate toxicity. Trimethoprim/sulfamethoxazole 
has been reported rarely to increase bone marrow suppression in patients receiving 
methotrexate, probably by decreased tubular secretion and/or an additive antifolate effect. 
 
7.5. Concomitant Medications and Non-Drug Therapies 
All patients will be asked to provide a complete list of prescription and over-the-counter 
medications that have been taken within the 4 weeks prior to screening. The investigator 
must be informed as soon as possible about any new medication(s) taken from the time of 
screening until the completion of the post-treatment follow-up visit.  
 
7.6. Prohibited Concomitant Medications and Concomitant Medications to be used 
with caution. 
The only prohibited concomitant medications are mercaptopurine, and concomitant other 
anti-cancer therapy (cytotoxic, biologic, or radiation).   
Concomitant use of salicylates, sulfonamides, BACTRIM (trimethoprim/sulfomethoxazole) 
and phenylbutozone is not prohibited, but should be used with caution because of their 
interactions with high dose methotrexate (doses greater than or equal to 500mg/m2 of 
methotrexate are considered high), although the methotrexate doses used in this study are 
not high (the highest dose of 765IGF-MTX used in this study of 2.5 microEq/kg is about 
equal to 45 mg of methotrexate per meter2). 
 

Protocol, v3, dated December 6, 2018                  Page 29 of 57 
 
Patients should not receive other anti-cancer therapy (cytotoxic, biologic, or radiation) while 
on treatment in this study.  
 
7.7. Management of Clinical Events and Supportive Care Guidelines 
Optimal patient care is to be provided to all patients. 
 
Patients should receive full supportive care during the study, including transfusion of blood 
and blood products, treatment with antibiotics, analgesics, or erythropoietin, when 
appropriate. 
 
Although acetaminophen at doses of 2 grams/day is permitted, it should be used with 
caution in patients with impaired liver function. 
 
Patients with significant third spacing (anasarca, symptomatic pleural effusions, 
symptomatic ascites) should be monitored closely.  
 
Infusion of IGF-methotrexate for 1.5 hours and follow up observation for an additional 1-2 
hours (see section 7.1.1. for further details on duration of follow up observation) will be 
performed in monitored room with available sealed cart with Diazepam 2 mg vials for 
immediate intravenous infusion in case of seizures. The following protocol will be in place in 
case of this drug toxicity: 
 
• Call physician on service. 
• Start BLS SPECIFIC CARE: 
- 
Administer oxygen (high flow if neurological deficits or altered mental status) 
- 
Place the patient in recovery position, and prevent accidental harm. 
- 
Anticipate brief combativeness or agitation in post-ictal phase. 
• Start ALS SPECIFIC CARE:  
Anticonvulsant Therapy 
- 
Diazepam (Valium): IV: 2-10 mg, every 5-10 minutes as needed 
(max of 20 mg), if status epilepticus start phenytoin load 20 mg/kg. 
 
Once the situation is resolved, the duration of further monitoring will be at the discretion of 
the study physician.  
 
7.8. Nausea and Vomiting 
Prophylactic antiemetic therapy will not be used in this study unless it becomes clear that 
765IGF-MTX causes acute nausea and vomiting. If prophylactic antiemetic therapy is 
needed, 5-HT3 receptor antagonists (without corticosteroids) should be tried first. Because 
of the potential of benzodiazepines to cause sedation, the use of benzodiazepines for 
antiemetic prophylaxis should be reserved for patients who cannot be satisfactorily 
managed otherwise. 
 
Although this study will not initially employ prophylactic antiemetics, there is no prohibition 
against antiemetic use in the management of a patient who develops nausea or vomiting, or 
both. 
 
7.9. Diarrhea 
Antidiarrheal medications will not be used prophylactically; however, patients will be 
instructed to take loperamide, 4 mg, at the occurrence of the first loose stool and then 2 mg 

Protocol, v3, dated December 6, 2018                  Page 30 of 57 
 
every 2 hours until they are diarrhea-free for at least 12 hours. During the night, patients 
may take 4 mg of loperamide every 4 hours. Fluid intake should be maintained to avoid 
dehydration. 
 
7.10. 
Duration of Therapy 
Patients will receive protocol therapy unless: 
• 
Extraordinary Medical Circumstances: If at any time the constraints of this protocol 
are detrimental to the patient’s health, protocol treatment should be discontinued.  
• 
Patient withdraws consent. 
• 
There is evidence of progressive disease or unacceptable toxicity. 
• 
The treating physician thinks a change of therapy would be in the best interest of the 
patient. 
• 
More than a 4 week delay between cycles 
 
7.11. 
Follow-up 
Administration of study medication will be continued after cycle 2 until disease progression, 
unacceptable toxicity, or patient withdrawal. A final study visit will occur 30 days (+/-1 week) 
after the last dose of 765IGF-MTX. This visit will end study participation unless there is 
ongoing toxicity at least possibly related to study treatment.  In this case, the patient will be 
followed as medically appropriate until resolution or stabilization of the adverse event. 
 
 

Protocol, v3, dated December 6, 2018                  Page 31 of 57 
 
8. Study Parameters 
8.1. Standard of Care Procedures 
 
Baseline, 
within 28 
days of 
enrollment 
Each treatment cyclea 
Every 8 
weeks 
( 1 
week) 
30 days ( 1 week) 
after final dose of 
765IGF-MTX1 
 
Day 12 
(1 day) 
Day 8 
(1 day) 
Day15 
(1 day) 
 
 
Signed consent 
(Registration/ 
Enrollment must occur 
within 30 days. 
X 
 
 
 
 
 
Medical history 
X 
X 
 
 
 
X 
Review of prior 
therapy 
X 
 
 
 
 
 
Bone marrow biopsy 
and aspirate 
confirming disease 
and blast count3 
X 
 
 
 
x3 
 
Physical exam  
X 
X 
 
 
 
X 
Vital signs 
X 
X 
X 
X 
 
X 
Height, weight 
X 
X 
 
 
 
X 
Concomitant meds 
review 
X 
X 
X 
X 
 
X 
Performance status 
X 
X 
 
 
 
X 
Symptom and toxicity 
X 
X 
X 
X 
 
x3 
CBC w/ diff 
X 
X 
X 
X 
 
X 
CMP (with: calcium, 
glucose,  sodium, 
potassium, CO2, 
chloride, BUN, 
creatinine, albumin, 
ALT, AST, bilirubin, 
alkaline phosphatase, 
total protein)  
X 
X 
X 
X 
 
X 
Uric acid (cycle 1 only) 
X 
X 
 
X 
 
 
LDH 
X 
X 
 
 
 
 
HbA1C for diabetic 
patients 
X 
 
 
 
 
X 
Serum pregnancy test 
for females of child-
bearing potential 
X 
 
 
 
 
 
ECG4 
X 
X 
 
 
 
X 
765IGF-MTX 
administration 
 
X 
X 
X 
 
 
 
a Subsequent cycles beyond cycle 1 must meet the criteria found in section 7.3 and may begin 1 day 
earlier or up to 2 days later to accommodate scheduling issues.   
1 For patients who leave treatment with a response, repeat appropriate disease assessment every 6-12 
weeks until progression or start of a new treatment. 
2 For cycle 1 only, tests and procedures do not need to be repeated if done within 3 days of day 1. 
3 Bone marrow biopsy should be at end of end of cycle 2, and every 2 cycles thereafter to cycle 6. 
Patients who achieve response (CR) could have repeat bone marrow biopsies per MD discretion. 
4 ECG performed at screening, at cycle 1 and at the end of study visit 30 days after the final dose. 

Protocol, v3, dated December 6, 2018                  Page 32 of 57 
 
 
 
 
8.2. Research Related Procedures 
 
 
 
1   Done only in the PK patients in the MTD. Pre-765IGF-MTX infusion (at the time of am labs if 
am labs are within one hour of 765IGF-MTX infusion), 5 min before the infusion ends (+/- 5 
minutes), and at the following time points after completion of the infusion: 30 min (+/- 5 
minutes), 60 min (+/- 15 minutes), 2 h (+/- 15 minutes), 4 h (+/- 15 minutes), 6 h (+/- 15 
minutes), 8 h (+/- 15 minutes and 24 h (+/- 2 hours)). The 8 hour time point will be collected 
on day 1 but not on day 15. 
2   Done only in PK patients in the MTD. Pre-765IGF-MTX infusion (+/- 5 minutes), and 30 min 
(+/- 5 minutes) after starting the infusion, at the following time points after completion of the 
infusion: 60 min (+/- 15 minutes) and 3 hours (+/- 15 minutes). In all patients, ECG is done at 
baseline, on day 1, cycle 1 (before the infusion), and 30 days (± 1 week) after the final dose 
(see section 8.1).  
3    Blood draw prior to infusion 
4   Bone marrow biopsy and aspirate will be collected at baseline and every 8 weeks (±1 week) 
up to week 24, i.e., after cycles 2, 4, and 6, before the first dose of the next cycle.  If no bone 
marrow aspirate viably frozen for flow cytometry is available from a patient in the 28-day 
baseline period before cycle 1, day 1, the patient may still enroll and no new bone marrow 
biopsy will be required for a baseline sample.    
5   Whole blood collection in EDTA tubes.   
 
 
Baseline 
(within 28 
days of 
Cycle 1, 
D1 
C1D1 
C1 
D15  
C2 
D1  
C2 
D15 
Every 8 
weeks (±1 
week) up to 
week 24 
Cycles 4 and 
6, D15 
PKs per section 9.1 
 
x1 
x1 
 
 
 
 
ECG (QT study) done 
during PK blood 
collection per section 
9.3.  PK patients only.2 
 
x2 
x2 
 
 
 
 
Serum IGF-1 level. All 
subjects. 
 
x3 
 
x3 
x3 
 
 
Plasma and whole 
blood IGF-1R level. All 
subjects. 
 
x3 
 
x3 
x3 
 
x3 
Anti-765IGF antibody 
assay. All subjects. 
 
x3 
 
x3 
x3 
 
x3 
Neutralizing antibodies. 
All subjects. 
 
x3 
 
x3 
x3 
 
x3 
IGF-1R expression in 
bone marrow biopsy 
and aspirate by IHC 
and flow cytometry. All 
subjects. 
x4 
 
 
 
 
x4 
 
IGF-1R expression in 
blood cells by flow 
cytometry.  All subjects. 
x5 
 
 
 
 
x5 
 

Protocol, v3, dated December 6, 2018                  Page 33 of 57 
 
9. Correlative Studies 
Information on the collection of blood samples for the correlative studies (collection tubes to be 
used, volume of blood drawn, collection processing, aliquot procedure and storage, and 
particular assay to be used) can be found in a laboratory manual to be supplied. 
 
9.1. Pharmacokinetics  
9.1.1. Pharmacokinetic Sample Collection 
The pharmacokinetics of 765IGF-MTX will be examined following the doses 
administered on days 1 and 15 of cycle 1. On these days the 765IGF-Methotrexate will 
be infused in the morning as described in section 7.1.1.  The research team will record 
the start and stop times of the infusion and volume of the 765IGF-MTX solution infused. 
Whole blood (6 mL) will be collected from an inserted butterfly needle on the opposite 
arm or from a peripheral site if the patient has a central venous catheter immediately 
prior to the 765IGF-MTX infusion, 5 min before the infusion ends, and at the following 
time points after completion of the infusion:  30 min, 60 min, 2 h, 4 h, 6 h, 8 h, and 24 h, 
(windows as above [Research-Related Procedures table, footnote 1). The 10 h time 
point will be collected on day 1 but not day 15. IGF-MTX and MTX unbound to IGF 
toxicokinetic analysis will be performed. These time points are based on 
pharmacokinetics in dogs.  Please see the laboratory manual for PK sample collection 
procedures. 
 
9.1.2. Pharmacokinetic Sample Processing 
Blood samples (6 mL) will be collected in 6-mL EDTA (purple top) tubes. The tube 
should be gently inverted a few times for complete mixing with the anticoagulant. The 
exact time of sample collection should be recorded on the tube label and 
Pharmacokinetics Data Form provided. The tube should be kept on wet ice until 
centrifugation. Within 120 minutes of blood collection, centrifuge each blood sample at 
approximately 3,000 X g for 5-10 minutes at 4°C. Aliquots, approximately 0.5 mL each, 
will be pipetted into 4 separate plastic centrifuge tubes and frozen at -80oC until analysis. 
Please see the laboratory manual for PK sample collection procedures. 
 
765IGF-MTX, 765IGF, methotrexate and 7-OH-methotrexate plasma concentrations will 
be determined using validated assays under GLP conditions at the Toxicology Research 
Laboratory, University of Illinois at Chicago. 
 
9.1.3. Pharmacokinetic Parameter Determination 
The pharmacokinetics of the 765IGF-Methotrexate, 765IGF, methotrexate and 7-OH 
methotrexate will be analyzed by compartmental and noncompartment approaches.  
Non-compartmental analysis of the plasma concentration-time data for each of the 
compounds of interest will be performed using WinNonlin 6.3 (Pharsight, St Louis, MO). 
Pharmacokinetic parameters to be estimated include: 1). area under the drug plasma 
concentration-time curve from the start of the infusion to the time of the last quantifiable 
plasma concentration (AUC0-t), 2) AUC from the start of the infusion to infinity (AUC0-∞), 
3). maximum observed plasma concentration (Cmax), 4). time of maximum plasma 
concentration (Tmax) and 5). terminal elimination constant (λz).  
 
Plasma concentration versus time data for the compounds of interest will be fit 
individually and simultaneously to appropriate models using nonlinear mixed effects 
modeling as implemented in NONMEM (version7.3). Data will be modeled with individual 
and population approaches. One, two, and three-compartment models incorporating 
parent and metabolite disposition will be evaluated. First order conditional estimation, 

Protocol, v3, dated December 6, 2018                  Page 34 of 57 
 
Monte Carlo expectation maximization and Monte Carlo Bayesian methods will be 
explored for estimating the maximum likelihood. 
 
If anti-765IGF antibodies are detected in some or all patients, the effect of the presence 
of these antibodies on the pharmacokinetic parameters will be investigated. This will be 
done, for instance, by comparing pharmacokinetic parameters in the first dose, when no 
anti-drug antibodies could be present, with the parameters in later doses after anti-
765IGF antibodies have been shown to have developed, and by comparing the 
parameters in patients who have anti-765IGF antibodies with those that do not. 
  
 
9.1.4. Statistical Analysis for Pharmacokinetics   
The parameters for 765IGF-MTX, 765IGF, methotrexate, and 7-OH methotrexate will be 
expressed by descriptive statistics (geometric mean, median, standard deviation and 
coefficient of variation). The primary pharmacokinetic parameters investigated for each 
compound will be AUC0-t, AUC0-∞, Cmax and λz.  Descriptive statistics will be calculated for 
the demographic data. Graphs and correlations will be used to examine the distribution 
of values and bivariate relationships. 
 
9.2. Pharmacodynamic Assessment 
Pharmacodynamic samples will be assessed on D1 of cycle 1, D1 and D15 of cycle 2, and 
D15 of cycles 4 and 6. 
 
Systemic responses are defined as serum concentration of IGF-1 and plasma and whole 
blood concentrations of IGF-1R, which will be measured for all subjects and used to assess 
whether 765IGF-MTX has affected the production of these biological markers. Measures of 
toxicity (e.g., changes WBC counts, differential cell populations, platelets, etc.) are also 
considered systemic PD variables. 
 
Pharmacodynamic data will be fit to an appropriate model, using maximum likelihood 
estimation. To determine whether any relationship exists between systemic activity of drug 
and biomarkers, the individual baseline corrected maximum biomarker concentrations will be 
plotted against individual 765IGF-MTX pharmacokinetic values, and Pearson’s correlation 
coefficients will be calculated. 
 
9.3. Evaluation of potential of 765IGF-MTX for QT prolongation  
QT evaluation will be performed in the PK subjects only during PK collection times by 
ECG immediately prior to the 765IGF-MTX infusion, 30 minutes after starting the infusion, 
and at the following time points after completion of the infusion: 60 minutes and 3 hours.  In 
all subjects, QT evaluation will be performed by ECG at baseline (within 14 days of 
enrollment), at cycle 1 day 1 (before the infusion) and at 30 days (±1 week) after the final 
dose of 765IGF-MTX. 
 
9.4. Serum IGF-1 Level and 765IGF-MTX Toxicity/Response 
Blood serum samples from before the infusion on D1 of cycle 1, and before the infusion on 
D1 and D15 of cycle 2 will be collected from each patient to determine if pre- and during 
treatment serum soluble IGF-1 level is associated with 765IGF-MTX toxicity and/or 
response. Quantification of IGF-1 in serum will be performed by Q2 Solutions, using 
Chemiluminescence methodology. A descriptive analysis will be done between clinical 
response and marker levels. Please see the laboratory manual for biomarker collection 
procedures. 
 

Protocol, v3, dated December 6, 2018                  Page 35 of 57 
 
9.5. Plasma and whole blood IGF-1R Level and 765IGF-MTX Toxicity/Response 
Plasma and whole blood samples from before the infusion on D1 of cycle 1, and before the 
infusion on D1 and D15 of cycle 2 and on D15 of cycles 4 and 6 will be collected from each 
patient to determine if pre- and within-treatment serum and blood IGF-1R level is associated 
with 765IGF-MTX toxicity and/or response. Quantification of IGF-1R in plasma will be 
performed by IGF Oncology using western blotting.  A descriptive analysis will be done 
between clinical response and marker levels. Please see the laboratory manual for 
biomarker collection procedures. 
 
9.6. Formation of anti-765IG-MTX antibodies. 
Serum samples from before the infusion on D1 of cycle 1, and before the infusion on D1 and 
D15 of cycle 2 will be collected from each patient and analyzed for anti-drug antibodies by 
an assay the sponsor has used for detecting anti-765IG-MTX antibodies in preclinical tests 
in dogs and rats.  The assay is a sandwich ELISA involving plating serum in 96-well plates, 
adding drug to the wells of the plates to bind to any anti-drug antibodies that may be present 
in the serum, and then detecting bound 765IGF-MTX drug with an anti-IGF-HRP conjugate 
antibody from R&D Systems, Quantikine human IGF-1 ELISA kit. 
 
That sandwich assay detects antibodies against 765IGF-MTX.   
 
The serum samples will also be analyzed for the presence of neutralizing antibodies.  In this 
assay, serum will be mixed with 765IGF-MTX in an in vitro assay for killing of human MCF7 
breast cancer cells to determine whether the addition of patient serum affects the minimum 
inhibitory concentration of 765IGF-MTX in inhibiting growth of MCF7 cells.  This assay will 
be performed on the same serum samples collected before treatment on Cycle 2, days 1 
and 15 and on day 15 of cycles 4 and 6. Please see the laboratory manual for biomarker 
collection procedures. 
 
Risk assessment. The risk to patients from assaying for anti-765IGF-MTX antibodies is 
minimal and arises only from an additional blood draw before the infusion on D1 of cycle 1, 
and D1 and D15 of cycle 2. A small amount of blood (7.5 mL/draw) will be taken, which will 
have no effects on patient health. The risk to patients from possibly developing anti-765IGF-
MTX antibodies is also small and would be lessened by our knowledge as to whether they 
are developing these antibodies. First, none of the dogs and none of the rats developed 
anti-drug antibodies in preclinical testing, so it appears unlikely that patients will develop 
anti-765IGF-MTX antibodies. The risk to patients from developing the antibodies, if it occurs, 
would be that the antibodies would be expected to possibly reduce the effectiveness of the 
drug, and would raise a risk of an anaphylactic reaction to administration of the drug.  
Anaphylactic reactions occur with some biologic medicines, such as Rituximab, and can 
usually be managed with antihistamines, such as diphenhydramine. Formation of antibodies 
against 765IGF-MTX may also potentially cause similar side effects of antibodies against 
IGFR1 receptor, such as the possibility of development of hyperglycemia. Monitoring blood 
sugar levels will be routinely performed in this study. 
 
 
9.7. Neutralizing antibodies and 765IGF-MTX Toxicity/Response 
Serum samples from before the infusion on D1 of cycle 1 and before the infusion on D1 and 
D15 of cycle 2, and on D15 of cycles 4 and 6 will be analyzed for the presence of 
neutralizing antibodies. In this assay, serum will be mixed with 765IGF-MTX in an in vitro 
assay for killing of human MCF7 breast cancer cells to determine whether the addition of 
patient serum affects the minimum inhibitory concentration of 765IGF-MTX in inhibiting 

Protocol, v3, dated December 6, 2018                  Page 36 of 57 
 
growth of MCF7 cells. Please see the laboratory manual for biomarker collection 
procedures. 
 
A descriptive analysis will be done correlating neutralizing antibody presence or levels with 
clinical response to, and toxicity of, 765IGF-MTX. 
 
9.8. IGF-1R expression level in diseased cells of bone marrow aspirate via IHC and 
flow cytometry 
When bone marrow aspirates are collected from patients, a portion will be clotted, fixed, and 
paraffin embedded; and a second portion will be shipped fresh the same day to Charles 
River Laboratories (Reno, NV) for flow cytometry assay of IGF-1R and CD34.  A pathology 
report will be prepared for the fixed sample.  The fixed samples will be held at Mayo Clinic 
and shipped together at the end of the study with their pathology reports to Quest 
Diagnostics for IGF-1R expression level testing by IHC with their test code 19429X.   
 
The fresh second portion of the bone marrow aspirate will be kept at room temperature and 
shipped on the day of collection in an insulated container at room temperature to Charles 
River, Inc. (Reno, NV), for testing of IGF-1R and CD34 expression by flow cytometry.  This 
assay will be similar to that of He et al.28    
  
9.9. IGF-1R expression level in diseased cells of whole blood via flow cytometry 
Whole blood will be collected in EDTA tubes (6 ml) and shipped overnight the same day in 
an insulated container at room temperature to Charles River, Inc., for testing of IGF-1R and 
CD34 expression by flow cytometry. This assay will be similar to that of He et al.28 This 
collection and testing will be at baseline and every 8 weeks after treatment is begun.  
 
 
10. Drug Formulation and Procurement 
10.1. 
  765IGF-MTX 
10.1.1. Other names 
765IGF-methotrexate, IGF-methotrexate, IGF-methotrexate conjugate, IGF-MTX 
 
10.1.2. Classification 
Insulin-Like Growth Factor and an enzyme inhibitor of dihydrofolic acid reductase 
(methotrexate) 
 
10.1.3. How supplied 
765IGF-MTX is supplied as a 5 ml sterile solution at 4.0 µeq per ml 765IGF-MTX 
concentration in aqueous 10 mM HCl in a 10 ml glass vial.   
 
10.1.4. Availability 
765IGF-MTX will be provided by IGF Oncology with approval of the FDA for 
investigational purposes. (IND # 116840). 
 
10.1.5. Description 
765IGF-MTX is formulated as a sterile solution at 4.0 µeq/ml (4.0 µmol 
methotrexate groups per ml) in 10 mM HCl in a 10 ml vial. The appropriate volume 
of the drug is then added to 250 ml of either 5% of 10% dextrose (per discretion of 
Principal Investigator) on the day of administration. 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 37 of 57 
 
10.1.6. Storage, Handing, and Accountability 
The final product of 765IGF-MTX is stored refrigerated at 4°C. Studies at elevated 
temperatures suggest the drug is stable for at least 2 years when stored in this 
manner. 
 
10.1.7. Administration 
Vials with the dissolved drug are stored refrigerated. Each vial should be mixed 
with a gentle swirling motion. As with all protein based products, avoid vigorous 
shaking. The solution must be yellow and translucent. The solution must not be 
used unless it is translucent and without visible particulate matter. 
 
The aliquot is calculated in µeq/kg dose x patient weight in kg. (All patient doses 
are calculated in µeq/kg body weight). On the day of administration, the 
appropriate volume is withdrawn from one or more vials and then diluted into 250 
ml of either 5% of 10% dextrose (per discretion of Principal Investigator) for 
infusion.  It is infused over a period of 90 minutes. 
 
10.1.8. Risks 
The primary side effect predicted in adults receiving 765IGF-MTX is low blood 
sugar immediately after receiving the drug. This will be treated by intravenous 
administration of either 5% of 10% dextrose (per discretion of Principal 
Investigator) or by oral administration of sugar.   
 
The following toxicities are predicted in adults receiving methotrexate: 
Immediate side effects include allergic reactions associated with low blood 
pressure, shortness of breath, hypotension, , back pain and hives.  These will be 
treated with medications, fluids and oxygen. If symptoms persist, the patient may 
have to be hospitalized for further treatment. 
 
Other adverse events that have been observed with 765IGF-MTX administration 
have been nausea, syncope, tachycardia, fever and chills, seizure, and abdominal 
cramps.  These have been observed during the infusion or within 3 hours after 
infusion. 
 
Delayed toxicities of methotrexate which occur within hours to days include skin 
rashes, diarrhea, fever, anorexia, nausea, vomiting, mouth sores, fatigue, malaise, 
myalgias, arthralgias, chills, high blood sugar level.  These will be treated with 
medications as needed. Work up for infections will be conducted as needed. 
 
Possible late toxicities include abnormal liver function tests. These effects occur 
several days to a week after treatment. See section 10.1.9 Warnings and 
Precautions. 
 
Rare toxic effects of methotrexate include encephalopathy, sensory changes, 
kidney problems, and lung problems. See section 10.1.9  Warnings and 
Precautions.   
 
10.1.9. Warnings and Precautions 
Methotrexate has been reported to cause fetal death and/or congenital anomalies. 
Therefore, it is not recommended for women of childbearing potential unless there 
is clear medical evidence that the benefits can be expected to outweigh the 
considered risks. If a woman becomes pregnant or suspects that she is pregnant 

Protocol, v3, dated December 6, 2018                  Page 38 of 57 
 
while participating in this study, she must inform the investigator immediately and 
must permanently discontinue study drug. 
 
Methotrexate elimination is reduced in patients with impaired renal function, 
ascites, or pleural effusions. Such patients require especially careful monitoring for 
toxicity, and may require dose reduction or, in some cases, discontinuation of 
methotrexate administration. 
 
Unexpectedly severe (sometimes fatal) bone marrow suppression, aplastic 
anemia, and gastrointestinal toxicity have been reported with concomitant 
administration of methotrexate (usually in high dosage) along with some 
nonsteroidal anti-inflammatory drugs (NSAIDs). 
 
Methotrexate causes hepatotoxicity, fibrosis and cirrhosis, but generally only after 
prolonged use. Acutely, liver enzyme elevations are frequently seen. These are 
usually transient and asymptomatic and also do not appear predictive of 
subsequent hepatic disease. Liver biopsy after sustained use often shows 
histologic changes, and fibrosis and cirrhosis have been reported. 
 
Methotrexate-induced lung disease, including acute or chronic interstitial 
pneumonitis, is a potentially dangerous lesion, which may occur acutely at any 
time during therapy and has been reported at low doses. It is not always fully 
reversible and fatalities have been reported. Pulmonary symptoms (especially a 
dry, nonproductive cough) may require interruption of treatment and careful 
investigation. 
 
Diarrhea and ulcerative stomatitis require interruption of therapy: otherwise, 
hemorrhagic enteritis and death from intestinal perforation may occur. 
 
Like other cytotoxic drugs, methotrexate may induce "tumor lysis syndrome" in 
patients with rapidly growing leukemias. Appropriate supportive and pharmacologic 
measures may prevent or alleviate this complication. 
 
Severe, occasionally fatal, skin reactions have been reported following single or 
multiple doses of methotrexate. Reactions have occurred within days of oral, 
intramuscular, intravenous, or intrathecal methotrexate administration. Recovery 
has been reported with discontinuation of therapy. 
 
Potentially fatal opportunistic infections, especially Pneumocystis carinii 
pneumonia, may occur with methotrexate therapy. 
 
11.  
Adverse Event Documentation and Reporting 
Toxicity and adverse events will be classified according to NCI’s Common Terminology Criteria 
for Adverse Events V 4.0. (CTCAE) and reported on the schedule below. A copy of the CTCAE 
can be downloaded from the CTEP home page 
(http://ctep.cancer.gov/prtocolDevelopment/electronic_applications/ctc.htm#ctc_40) 
 
Note: throughout this section the generic term “drug” refers to 765IGF-MTX. 
 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 39 of 57 
 
11.1. 
Definitions 
The following definitions are based on the Code of Federal Regulations Title 21 Part 
312.32 (21CFR312.32(a)). 
 
Adverse Event:  Any untoward medical occurrence associated with the use of a drug in 
humans, whether or not considered drug related.  
 
Suspected Adverse Reaction:  Any adverse event for which there is a reasonable 
possibility that the drug caused the adverse event.  
 
Life-Threatening Adverse Event or Life-Threatening Suspected Adverse Reaction: 
An adverse event or suspected adverse reaction is considered “life-threatening” if, in the 
view of either the investigator or sponsor, its occurrence places the patient or subject at 
immediate risk of death. 
 
Serious Adverse Event or Serious Suspected Adverse Reaction:  An adverse event 
or suspected adverse reaction is considered “serious” if, in the view of either the 
investigator or sponsor, it results in any of the following outcomes:  
• 
Death 
• 
A life-threatening adverse event 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
• 
A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
A congenital anomaly/birth defect.  
 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical 
judgment, they may jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition.  
 
Preplanned hospitalization: A hospitalization planned before signing the ICF is not 
considered an SAE, but rather a therapeutic intervention. However, if during the 
preplanned hospitalization an event occurs, which prolongs the hospitalization or 
meets any other SAE criteria, the event will be considered an SAE. Surgeries or 
interventions that were under consideration, but not performed before signing the 
ICF, will not be considered serious if they are performed after signing the ICF for a 
condition that has not changed from its baseline level. Elective hospitalizations for 
social reasons, solely for the treatment of prior conditions or due to long travel 
distances are also not SAEs. 
 
If either the IND sponsor or the investigator believes the event is life-threatening or 
serious, the event must be evaluated by the sponsor for expedited reporting (21CRF 
312.32(a)).  
 
Unexpected adverse event or unexpected suspected adverse reaction: An adverse 
event or suspected adverse reaction is considered “unexpected” if it is not listed in the 
investigator brochure or is not listed at the specificity or severity that has been observed; 
or, if an investigator brochure is not required or available, is not consistent with the risk 
information described in the general investigational plan or elsewhere in the current 
application, as amended.  Thus, adverse events that occur as part of the disease process 

Protocol, v3, dated December 6, 2018                  Page 40 of 57 
 
or underlying medical conditions are considered unexpected; however, they will not be 
reportable per section 11.3. 
 
Unanticipated (unexpected) problems/events defined as those that are not already 
described as potential risks in the consent form, are not listed in the Investigator’s 
Brochure, and are not caused by an underlying disease. 
 
Note:  The major discord between the FDA and IRB definitions is whether or not the 
underlying disease is included when considering expectedness. 
 
UPIRSO: Federal regulations [45CFR46.103(b)(5) and 21CFR56.108(b)(1)] require the 
IRB to ensure that researchers promptly report “any unanticipated problems involving risk 
to subjects or others” (UPIRSOs).  The Mayo Clinic IRB defines a UPIRSO as any 
problem or event which in the opinion of the local researcher was unanticipated, reflects 
new or increased risk to the subjects and at least possibly related to the research 
procedures.  
 
In addition, the Mayo Clinic IRB has defined the following problems/events as reportable 
using the Prompt Report form found on the IRB website: 
• 
Any accidental or unintentional change to the IRB-approved protocol that increases 
risk or has the potential to recur 
• 
Any deviation from the protocol taken without prior IRB review to eliminate apparent 
immediate hazard to a research subject  
• 
Any publication in the literature, safety monitoring report (including Data and Safety 
Monitoring Reports), interim result or other finding that indicates an unexpected 
change to the risk/benefit ratio of the research  
• 
Any breach in confidentiality that may involve risk to the subject or others  
• 
Any complaint of a subject that cannot be resolved by the research staff 
• 
Any other possibly related event which in the opinion of the investigator constitutes an 
unanticipated risk  
 
Expedited (Rapid) Reporting: Certain events may require rapid notification to entities 
providing patient safety oversight (e.g. IRB, FDA) as detailed in section 11.3.  For the IRB 
this is 5 working days.  For studies under an IND, it is 7 or 15 calendar days. 
 
11.2. 
Adverse Event Documentation 
Adverse events occurring from the first dose of 765IGF-MTX up to and including 30 days 
after administration of the last dose must be documented.  Adverse events attributed to a 
study-related procedure which occur prior to the initiation of study treatment must be 
documented as well. 
 
For the purposes of this study, adverse event documentation requirements will be determined 
based on grade, expectedness and relationship to study therapy as follows: 
 
 
 
Grade 1 
Grade 2 
Grade 3 
Grade 
4 
and 5 
Expected or 
Unexpected 
Expected 
Un-
expected 
Expected 
Un-
expected 
Expected or 
Unexpected 
Unrelated 
Unlikely 
Not 
required 
Not 
required 
Not 
required 
Not 
required 
Required 
Required 

Protocol, v3, dated December 6, 2018                  Page 41 of 57 
 
Possible 
Probable 
Definite 
Not 
required 
Required 
Required 
Required 
Required 
Required 
 
All patients will be monitored with appropriate event documentation in EDC Easy® through the 
final study visit per section 7 as it is expected that most treatment related adverse events will 
occur during this period. 
 
However, all toxicities (grades 1, 2, 3, 4, 5) must be reported within internal study forms, and 
include the following descriptors: 
• 
Toxicity 
• 
Grade 
• 
Date 
• 
Expected or Unexpected 
• 
Attribution (unrelated, unlikely, possible, probably, definite) 
 
For grade 2 or higher toxicities, principal investigator and/or treating physician will be notified 
the same day as study visit. 
 
11.3  Required Reporting, IRB, FDA, IGF Oncology, LLC 
 
Agency 
Criteria for 
reporting 
Timeframe 
Form to 
Use 
Submission address/ fax 
numbers 
Copy AE to: 
Study Site 
IRB 
UPIRSO: 
Events which 
are  
unanticipated, 
involved risk to 
subjects or 
others, and was 
at least possibly 
related to study 
procedures/ 
treatment 
5  Working 
Days 
EDC Easy®  
(Paper 
report can 
be 
generated 
from 
system)/ 
Mayo Clinic 
IRB Prompt 
Report 
Form 
Study Site IRB 
Study Site 
Regulatory 
Coordinator 
Other 
Problems or 
Events meeting 
the definition of 
UPIRSO in 
section 11.1 
5-15 
Working 
Days per 
IRB 
requirements 
 Mayo 
Clinic 
Rochester 
IRB/Prompt 
Report 
Form  
FDA  
 
 
 
 
 
Unexpected 
and fatal or life 
threatening 
suspected 
adverse 
reaction 
As soon as 
possible but 
no later than 
7 Calendar 
Days 
Medwatch/  
EDC Easy®  
(Paper 
report can 
be 
generated 
Fax SAE to IND/IDE 
Regulatory Health Project 
Manager, Techiya (Thea) 
Toaff, R.N., B.S.N., Division 
of Oncology Products 1  
at 1-301-796-9845.  

Protocol, v3, dated December 6, 2018                  Page 42 of 57 
 
 
In each IND safety report, the sponsor must identify all IND safety reports previously submitted 
to the FDA concerning a similar suspected adverse reaction and must analyze the significance 
of the suspected adverse reaction in light of the previous, similar reports. 
 
FDA 
(continued) 
1) Serious and 
unexpected 
suspected 
adverse 
reaction or 
2)  increased 
occurrence of 
serious 
suspected 
adverse 
reactions over 
that listed in the 
protocol or 
investigator 
brochure or 
3) findings from 
other sources 
(other studies, 
animal or in 
vitro testing) 
As soon as 
possible but 
no later than 
15 Calendar 
Days 
from 
system) 
Email:techiya.toaff@fda.hhs.
gov 
 
Follow-up with written report 
submitted as an amendment 
to: 
 
MedWatch,  
5600 Fishers Lane, 
Rockville, MD 20852-9787 
 
All other events 
per CRF 312.33 
At time of 
IND annual 
report 
Summary 
format 
Submit as part of the IND 
annual report 
Note: Events due to the disease under treatment or an underlying medical condition will 
not require expedited reporting to the FDA for the purposes of this study 
IGF-
Oncology, 
LLC 
All serious 
adverse events, 
regardless of 
expectedness 
or relationship 
with any study 
drug per section 
11.4 
Within 24 
hours of 
knowledge 
SAE Initial 
and Follow-
up Report 
Forms 
provided to 
each site 
 
MedWatch/  
EDC Easy®  
(Paper report 
can be 
generated 
from system) 
IGF Clinical Operations Team 
(SAE and Pregnancy Reporting 
Contact Information): 
 
Hugh McTavish, Ph.D., IGF 
Oncology, President, CEO 
 hmctavish@igfoncology.com 
Phone: 651-492-0283 
 
Arkadiusz Dudek. M.D., IGF 
Oncology, Chief Medical Officer 
 adudek021@outlook.com 
Phone: 612-718-1960 
 
William E. Gannon Jr., M.D.  
Chief Medical Monitor 
 WGannon@capcitytek.com 
Phone: 703-447-2615 
 
Kathleen Littrell, IGF Oncology,  
Sr. Project Management  
Klittrell@igfoncology.com 
Phone: 919-606-8581 
 
Linda Sneed, IGF Oncology,  
Sr. Clinical Research Associate  
lpsneed@IGFOncology.com 
Phone: 423-747-8515 
 
Pregnancy in a 
female patient 
or the partner of 
a male patient 
per section 11.5 
Pregnancy 
Reporting 
Form  

Protocol, v3, dated December 6, 2018                  Page 43 of 57 
 
The Mayo CTO Regulatory Coordinator will provide the Cancer Center’s Data and Safety 
Monitoring Council (DSMC) with the SAE in an appropriate format depending on the individual 
SAE (as reported or in a summary format). 
 
11.4   Procedures for Reporting SAEs to IGF Oncology, LLC 
Adverse events (AEs) may be spontaneously reported by the patient and/or in response to 
an open question from study personnel or revealed by observation, physical examination, or 
other diagnostic procedures must be reported to the IGF Oncology Clinical Operations team. 
AEs which are serious must be reported to the IGF Oncology Clinical Operations team (see 
contact information in the chart above) from first dose of 765IGF-MTX up to and including 30 
days after administration of the last dose of 765IGF-MTX. When possible, signs and 
symptoms indicating a common underlying pathology should be noted as one comprehensive 
event. Any SAE that occurs at any time after completion of 765IGF-MTX treatment or after 
the designated follow-up period that the investigator and/or sub-investigator considers to be 
related to any study drug must be reported to the IGF Oncology Clinical Operations team. 
 
Planned hospital admissions or surgical procedures for an illness or disease that existed 
before the patient was enrolled in the trial are not to be considered AEs unless the condition 
deteriorated in an unexpected manner during the trial (e.g., surgery was performed earlier or 
later than planned). All SAEs should be monitored until they are resolved or are clearly 
determined to be due to a patient’s stable or chronic condition or intercurrent illness(es). 
 
This is an IGF Oncology sponsored study. The principal investigators conducting the study 
are Mrinal S. Patnaik, M.B.B.S., at Mayo Clinic and Dr. Yan Ji, at Health Partners Regions 
Cancer Care Center. 
 
Investigator must report all SAEs, regardless of expectedness or relationship with any study 
drug, to the IGF Oncology Clinical Operations team (contacts noted in above chart ) as soon 
as possible, but no later than 5 calendar days of the sponsor-investigator’s observation or 
awareness of the event.  In the event that this is a multisite study, the sponsor-investigator is 
responsible to ensure that the SAE reports are sent to the IGF Oncology Clinical Operations 
team (contacts noted on page 42) and reports will be sent to all sites participating in the 
study. Subinvestigators must report all SAEs to the sponsor-investigator so that the sponsor-
investigator can meet his/her foregoing reporting obligations to the IGF Oncology Clinical 
Operations team, unless otherwise agreed between the sponsor-investigator and 
subinvestigator(s). The IGF Oncology Clinical Operations team may request follow-up 
information to a reported SAE, which the sponsor-investigator will be responsible for 
providing to the IGF Oncology Clinical Operations team. 
 
The SAE report must include event term(s), serious criteria, and the investigator’s or sub-
investigator’s determination of both the intensity of the event(s) and the relationship of the 
event(s) to study drug administration. 
 
Intensity for each SAE, including any lab abnormality, will be determined by using the NCI 
CTCAE v.4.0. 
 
Relationship to all study drugs for each SAE will be determined by the investigator or sub-
investigator by responding yes or no to the question: Is there a reasonable possibility that the 
AE is associated with the study drug. 
 
Sponsor-investigator must also provide the IGF Oncology Clinical Operations team with a 
copy of all communications with applicable regulatory authorities related to the study or study 

Protocol, v3, dated December 6, 2018                  Page 44 of 57 
 
drug(s), including, but not limited to, telephone conversation logs, as soon as possible but no 
later than 5 calendar days of such communication. 
 
Data will be entered in the SAE section of EDC Easy®, from which a paper report can be 
generated at any time.  In addition, IGF Oncology will provide the investigators with both an Initial 
SAE Report Form, (to be completed at the time of the SAE) and an SAE Follow-up Report form 
(to be completed when all follow-up information has been gathered).  The SAE Report forms 
should be E-mailed to the IGF Oncology Clinical Operations team (contact E-mails are noted on 
the chart above (page 42).  
 
11.5       Procedures for Reporting During Pregnancy and Birth Events 
If a woman becomes pregnant or suspects that she is pregnant while participating in this 
study, she must inform the investigator immediately and must permanently discontinue study 
drug(s).  All pregnancies and suspected pregnancies must be reported to the IGF Oncology 
Clinical Operations team immediately using a Pregnancy Report Form (see Section 11.3 for 
contact information). The pregnancy must be followed for the final pregnancy outcome (i.e., 
delivery, still birth, miscarriage) and the IGF Oncology Operations team will request this 
information from the investigator. 
 
If a female partner of a male patient becomes pregnant during the male patient’s participation 
in this study, this must be reported to the IGF Oncology Clinical Operations team immediately 
using a Pregnancy Report Form (see Section 11.3 for contact information). Every effort 
should be made to follow the pregnancy for the final pregnancy outcome. 
 
 
12. Study Data Collection and Monitoring 
12.1. 
Data Management 
This study will report clinical data using the EDC Easy® Data Management System utilizing 
study specific case report forms. Key study personnel are trained on the use of case report 
forms and will comply with protocol specific instructions for data collection. 
 
Patient demographics, patient specific study treatment calendars, adverse events and other 
information required for IND annual reporting will be maintained with EDC Easy®. 
 
12.2. 
Case Report Forms 
Participant data will be collected using protocol specific case report forms (CRFs). The CRFs 
will be approved by the study’s Principal Investigator and the study biostatistician prior to 
release for use. The Study Coordinator or designee will be responsible for registering the 
patient into EDC Easy® at time of study entry, completing CRFs based on the patient specific 
calendar, and updating the patient record until patient death or end of required study 
participation.   
 
12.3. 
Data and Safety Monitoring Plan (DSMP) 
The study’s Data and Safety Monitoring Plan will be in compliance with Mayo Clinic Cancer 
Center's Data & Safety Monitoring Plan (DSMP). 
 
For the purposes of data and safety monitoring, this study is classified as high risk (under a 
locally held IND).  Therefore, the following requirements will be fulfilled: 
• 
The PI will complete and submit a quarterly Trial Progress Report to the Cancer 
Center Data and Safety Monitoring Committee (DSMC) with the understanding the 
Cancer Center Protocol Review Committee (CCPRC) may require more frequent 
reporting. 

Protocol, v3, dated December 6, 2018                  Page 45 of 57 
 
• 
The PI will comply with at least twice yearly monitoring of the project by the Cancer 
Center monitoring services. 
• 
The PI will oversee the submission of all reportable adverse events per the definition 
of reportable in section 11.3 to the Cancer Center’s SAE Coordinator, the Mayo 
Clinic IRB, and the FDA.   
 
In addition, at the time of the continuing review with the Mayo Clinic IRB, a copy of the report 
with any attachments will be submitted to the Protocol Review Committee (PRC). 
 
IND Annual Reports 
In accordance with regulation 21 CFR § 312.33, the sponsor will submit a progress report 
annually. The report will be submitted within 60 days of the anniversary date that the IND 
went into effect. Included as a part of the annual report for this IND will be initial reporting of 
all deaths due to disease at any time and all deaths (regardless of cause) occurring more 
than 2 years after 765IGF-MTX infusion. 
 
12.4. 
Monitoring 
The investigator will permit study-related monitoring, audits, and inspections by the study’s 
Investigator and/or any designees, the local IRB, government regulatory bodies, and Mayo 
Clinic compliance groups. The investigator will make available all study related documents 
(e.g. source documents, regulatory documents, data collection instruments, study data, etc.). 
The investigator will ensure the capability for inspections of applicable study-related facilities 
(e.g. pharmacy, diagnostic laboratory, etc.) will be available for trial related monitoring, 
audits, or regulatory inspections. 
 
12.5. 
Record Retention 
The investigator will retain study records including source data, copies of case report form, 
consent forms, HIPAA authorizations, and all study correspondence in a secured facility for at 
least 6 years after the study file is closed with the IRB and FDA. 
 
In addition, the CTO will keep a master log of all patients participating in the study with 
sufficient information to allow retrieval of the medical records for that patient. 
 
The CTO must be contacted before destroying any study related records. 
 
 
13. Statistical Considerations 
 
A brief overview of the statistical analysis plan is presented below. Complete details of the 
planned analysis will be documented in a full Statistical Analysis Plan, which will be finalized 
before locking the study database. 
 
13.1. 
Sample Size 
Given the design and primary objectives of this study, the sample size will be determined by the 
guidelines governing dose escalation/de-escalation and the identification of DLTs. As a result, 
the final sample size is not fixed and will not be determined by consideration of inferential 
analyses conducted via statistical hypothesis testing. 
 
13.2. 
Statistical Methods 
Statistical analyses will be performed using SAS software version 9.4 or higher. In general, data 
summaries will be compiled by 765IGF-MTX dose level and overall and will include the mean, 

Protocol, v3, dated December 6, 2018                  Page 46 of 57 
 
standard deviation, median, minimum and maximum values for continuous data; the median, 
25th and 75th percentiles, minimum and maximum values for time-to-event endpoints; and the 
number and percentage of patients in each category for categorical data. Pointwise 95% 
confidence intervals (CI) will also be estimated for the mean (continuous data), median (time-to-
event endpoints) or percentage of patients (categorical data). 
 
Baseline value of a characteristic is defined as the last measured value prior to the first dose of 
765IGF-MTX. 
 
Descriptive statistics such as Spearman or Pearson correlation coefficients will be estimated with 
95% CIs to assess the relationship between anti-765IGF antibody and anti-765IGF-MTX 
antibody levels with clinical response and toxicity. 
 
13.2.1. Efficacy Endpoints 
The numbers of overall complete remissions (patients with a best objective response of CR or 
CRi), and overall remissions (patients with a best objective response of CR, CRi or PR) will be 
summarized by observed rates and estimated 95% CIs. If there are sufficient numbers of patients 
achieving remissions for an analysis to be informative, logistic regression will be used to model 
the probability of achieving a remission as a function of the assigned 765IGF-MTX dose level 
for Cycle 1. Other factors may be added to the model to investigate their prognostic value in 
predicting remission. 
 
In general, missing values will not be replaced by imputed values. Patients who, for any reason, 
do not supply bone marrow for response assessment are counted among those not achieving a 
response. 
 
Kaplan-Meier time-to-event analyses will be conducted on overall survival and progression-free 
survival. Mortality (all causes) at certain landmark time points (e.g., 90 and 180 days) will also 
be estimated together with 95% CIs. Cox proportional hazards models will be fit to these time-
to-event endpoints with the assigned 765IGF-MTX dose level for Cycle 1 serving as the 
independent variable in the model. 
 
13.2.2. Pharmacokinetic Endpoints 
Dose linearity for the pharmacokinetic parameters AUC and Cmax will be tested using a standard 
power model such as, AUC = α + doseβ, which is equivalent to log(AUC) = log(α) + β∙log(dose). 
Linearity (also called dose proportionality) will be accepted if β is not significantly different 
from 1 at a nominal 10% level of significance. 
 
13.2.3. Safety Endpoints 
Incidence rates of treatment-emergent adverse events will be summarized within treatment group 
at the MedDRA preferred term and primary system organ class levels. Similar summaries will be 
made for subsets of AEs such as (1) those judged by the Investigator to be related to study 
treatment, and (2) serious adverse events (SAEs). Other routine safety assessments (e.g., clinical 
laboratory parameters, ECG parameters, and vital signs) will be summarized by standard 
deviation, median, minimum and maximum observed values and changes from baseline values. 
NCI-CTCAE severity grades for laboratory parameters and other endpoints measured on an 
ordinal categorical scale may be summarized using shift tables (a two-way frequency table 
pairing baseline value with the most extreme post-baseline result). 

Protocol, v3, dated December 6, 2018                  Page 47 of 57 
 
 
Additional exploratory analyses may be performed to assist the sponsor in planning future 
studies. 
 
13.3. Analysis plan for primary objective:   
The primary objective is to determine safety and tolerability of 765IGF-MTX by evaluation 
of toxicity for the treatment of advanced, previously treated hematologic malignancies. 
Preliminary information will be collected for treatment related toxicity and tolerance. 
Toxicity will be graded using the NCI’s Common Terminology Criteria for Adverse Events 
version 4 (CTCAE v.4.0). Treatment tolerance will be based on the number of dose-
limiting toxicities, treatment delays and dose reductions. Information will be presented in 
a tabular and descriptive manner. 
 
13.4   Analysis plan for secondary objectives: 
13.4.1 Objective Response Rate, Relapse-Free Survival, Overall Survival and 
Cumulative Incidence of Relapse; descriptive statistics will be used to describe clinical 
benefit measured by the above parameters. 
 
 
13.4.2 Describe clinical response (CR) as defined by hematologic-specific 
response criteria: Disease response will be assessed every 8 weeks +/- 7 days while 
on study treatment using appropriate hematologic-specific response criteria (Appendices 
I and II). Due to the small sample sizes and heterogeneous patient population, clinical 
responses will be reported by dose and disease (MDS, CMML, or O-AML) type. 
 
13.5 
Analysis plan for correlative objectives: 
13.5.1 
Describe changes in pharmacokinetic parameters: The pharmacokinetic 
parameters for 765IGF-MTX, 765IGF, methotrexate, and 7-OH methotrexate will be 
expressed by descriptive statistics (geometric mean, median, standard deviation and 
coefficient of variation). The primary pharmacokinetic parameters investigated for each 
compound will be AUC0-t, AUC0-∞, Cmax and λz. Descriptive statistics will be calculated for 
the demographic data. Graphs and correlations will be used to examine the distribution of 
values and bivariate relationships. 
 
13.5.2 
Describe changes in pharmacodynamics parameters: The 
pharmacodynamics parameters of IGF-1, IGF-1R, formation of antibodies against 765IGF-
MTX, and formation of neutralizing antibodies will be expressed by descriptive statistics 
(geometric mean, median, standard deviation and coefficient of clinical response). Percent 
change from pre- and post-treatment levels will be correlated with response using 
summary statistics and the two-sample t-test and nonparametric Wilcoxon rank-sum test if 
warranted. Graphs and correlations will be used to examine the distribution of values and 
bivariate relationships. 
 
13.5.3 
Evaluation of 765IGF-MTX for potential of QT prolongation: Compare 
baseline ECG profile to post-765IGF-MTX ECG profiles to determine if the drug prolongs 
QT interval. 
 
13.5.4 
Serum IGF level and 765IGF-MTX Toxicity/Response: Determine if pre- and 
within-treatment serum soluble IGF-1 level is associated with 765IGF-MTX toxicity and/or 
response. A descriptive analysis will be done between clinical response and marker levels. 
 

Protocol, v3, dated December 6, 2018                  Page 48 of 57 
 
13.5.5 
Plasma and blood IGF-1R level and 765IGF-MTX Toxicity/Response: 
Determine if pre- and within-treatment plasma and whole blood IGF-1R level is associated 
with 765IGF-MTX toxicity and/or response. A descriptive analysis will be done between 
clinical response and marker levels. 
 
13.5.6 
Antibody formation against 765IGF-MTX: Serum samples from before infusion 
on D1 of cycle 1, and before infusion on D1 and D15 of cycle 2 and day 15 of cycles 4 and 
6 will be collected and analyzed for anti-765IGF-MTX antibodies. A descriptive analysis 
will be done correlating anti-765IGF-MTX antibody presence or levels with clinical 
response and toxicity. 
 
13.5.7 
Neutralizing antibodies and 765IGF-MTX toxicity/response: Serum samples 
from before infusion on D1 of cycle 1 and before infusion on D1 and D15 of cycle 2 and 
D15 of cycles 4 and 6 will be collected for presence of neutralizing antibodies. A 
descriptive analysis will be done correlating presence or levels of neutralizing antibodies 
with clinical response and toxicity. 
 
13.5.8 
IGF-1R expression level in bone marrow biopsies via IHC and flow 
cytometry and IGF-1R expression level in blood cells by flow cytometry: IGF-1R 
expression at baseline will be performed on paraffin-embedded fixed bone marrow 
aspirates by Quest Diagnostics by IHC and IGF-1R expression at baseline will be 
performed on fresh viable bone marrow aspirates and fresh whole blood by Charles River, 
Inc. by flow cytometry. If sample sizes are small and heterogeneous, clinical responses 
will be reported by dose and disease (MDS, CMML, or O-AML) type 
 
14 Conduct of the Study 
14.1   Good Clinical Practice 
The study will be conducted in accordance with the appropriate regulatory requirement(s). 
Essential clinical documents will be maintained to demonstrate the validity of the study and 
the integrity of the data collected.  Master files should be established at the beginning of the 
study, maintained for the duration of the study and retained according to the appropriate 
regulations. 
 
14.2 Ethical Considerations 
The study will be conducted in accordance with ethical principles founded in the Declaration 
of Helsinki. The IRB will review all appropriate study documentation in order to safeguard the 
rights, safety and well-being of the patients. The study will only be conducted at sites where 
IRB approval has been obtained. The protocol, consent, written information given to the 
patients, safety updates, progress reports, and any revisions to these documents will be 
provided to the IRB by the Investigator. 
 
 

Protocol, v3, dated December 6, 2018                  Page 49 of 57 
 
15 References 
 
1. 
Ullrich A, Gray A, Tam AW, et al. Insulin-like growth factor I receptor primary 
structure: comparison with insulin receptor suggests structural determinants that define 
functional specificity. The EMBO journal 1986; 5:2503-12. 
2. 
Strammiello R, Benini S, Manara MC, et al. Impact of IGF-I/IGF-IR circuit on the 
angiogenetic properties of Ewing's sarcoma cells. Hormone and metabolic research = Hormon- 
und Stoffwechselforschung = Hormones et metabolisme 2003; 35:675-84. 
3. 
Tao Y, Pinzi V, Bourhis J, Deutsch E. Mechanisms of disease: signaling of the insulin-
like growth factor 1 receptor pathway--therapeutic perspectives in cancer. Nature clinical 
practice Oncology 2007; 4:591-602. 
4. 
Pollak M. Insulin and insulin-like growth factor signalling in neoplasia. Nature reviews 
Cancer 2008; 8:915-28. 
5. 
Bruning PF, Van Doorn J, Bonfrer JM, et al. Insulin-like growth-factor-binding protein 3 
is decreased in early-stage operable pre-menopausal breast cancer. International journal of cancer 
Journal international du cancer 1995; 62:266-70. 
6. 
Chan JM, Stampfer MJ, Giovannucci E, et al. Plasma insulin-like growth factor-I and 
prostate cancer risk: a prospective study. Science 1998; 279:563-6. 
7. 
Chang YS, Kong G, Sun S, et al. Clinical significance of insulin-like growth factor-
binding protein-3 expression in stage I non-small cell lung cancer. Clinical cancer research: an 
official journal of the American Association for Cancer Research 2002; 8:3796-802. 
8. 
Hankinson SE, Willett WC, Colditz GA, et al. Circulating concentrations of insulin-like 
growth factor-I and risk of breast cancer. Lancet 1998; 351:1393-6. 
9. 
Krajcik RA, Borofsky ND, Massardo S, Orentreich N. Insulin-like growth factor I (IGF-
I), IGF-binding proteins, and breast cancer. Cancer epidemiology, biomarkers & prevention: a 
publication of the American Association for Cancer Research, cosponsored by the American 
Society of Preventive Oncology 2002;11:1566-73. 
10. 
Kuhn DJ, Berkova Z, Jones RJ, et al. Targeting the insulin-like growth factor-1 receptor 
to overcome bortezomib resistance in preclinical models of multiple myeloma. Blood 
2012;120:3260-70. 
11. 
Ma J, Pollak MN, Giovannucci E, et al. Prospective study of colorectal cancer risk in 
men and plasma levels of insulin-like growth factor (IGF)-I and IGF-binding protein-3. Journal 
of the National Cancer Institute 1999; 91:620-5. 
12. 
Medyouf H, Gusscott S, Wang H, et al. High-level IGF1R expression is required for 
leukemia-initiating cell activity in T-ALL and is supported by Notch signaling. The Journal of 
experimental medicine 2011; 208:1809-22. 
13. 
Peyrat JP, Bonneterre J, Hecquet B, et al. Plasma insulin-like growth factor-1 (IGF-1) 
concentrations in human breast cancer. European journal of cancer 1993;29A:492-7. 
14. 
Sandhu MS, Dunger DB, Giovannucci EL. Insulin, insulin-like growth factor-I (IGF-I), 
IGF binding proteins, their biologic interactions, and colorectal cancer. Journal of the National 
Cancer Institute 2002; 94:972-80. 
15. 
Stattin P, Bylund A, Rinaldi S, et al. Plasma insulin-like growth factor-I, insulin-like 
growth factor-binding proteins, and prostate cancer risk: a prospective study. Journal of the 
National Cancer Institute 2000; 92:1910-7. 
16. 
Toniolo P, Bruning PF, Akhmedkhanov A, et al. Serum insulin-like growth factor-I and 
breast cancer. International journal of cancer Journal international du cancer 2000; 88:828-32. 

Protocol, v3, dated December 6, 2018                  Page 50 of 57 
 
17. 
Vishwamitra D, Shi P, Wilson D, et al. Expression and effects of inhibition of type I 
insulin-like growth factor receptor tyrosine kinase in mantle cell lymphoma. Haematologica 
2011; 96:871-80. 
18. 
Wei EK, Ma J, Pollak MN, et al. A prospective study of C-peptide, insulin-like growth 
factor-I, insulin-like growth factor binding protein-1, and the risk of colorectal cancer in women. 
Cancer epidemiology, biomarkers & prevention: a publication of the American Association for 
Cancer Research, cosponsored by the American Society of Preventive Oncology 2005;14:850-5. 
19. 
Yaktapour N, Ubelhart R, Schuler J, et al. Insulin-like growth factor-1 receptor (IGF1R) 
as a novel target in chronic lymphocytic leukemia. Blood 2013; 122:1621-33. 
20. 
Yu H, Jin F, Shu XO, et al. Insulin-like growth factors and breast cancer risk in Chinese 
women. Cancer epidemiology, biomarkers & prevention: a publication of the American 
Association for Cancer Research, cosponsored by the American Society of Preventive Oncology 
2002;11:705-12. 
21. 
Leroith D, Werner H, Beitnerjohnson D, Roberts CT. Molecular and Cellular Aspects of 
the Insulin-Like Growth-Factor-I Receptor. Endocr Rev 1995; 16:143-63. 
22. 
O Connor R, KauffmannZeh A, Liu YM, et al. Identification of domains of the insulin-
like growth factor I receptor that are required for protection from apoptosis. Molecular and 
cellular biology 1997; 17:427-35. 
23. 
Cohen BD, Baker DA, Soderstrom C, et al. Combination therapy enhances the inhibition 
of tumor growth with the fully human anti-type 1 insulin-like growth factor receptor monoclonal 
antibody CP-751,871. Clinical cancer research: an official journal of the American Association 
for Cancer Research 2005; 11:2063-73. 
24. 
Resnicoff M, Coppola D, Sell C, Rubin R, Ferrone S, Baserga R. Growth inhibition of 
human melanoma cells in nude mice by antisense strategies to the type 1 insulin-like growth 
factor receptor. Cancer research 1994; 54:4848-50. 
25. 
Oh Y, Muller HL, Ng L, Rosenfeld RG. Transforming growth factor-beta-induced cell 
growth inhibition in human breast cancer cells is mediated through insulin-like growth factor-
binding protein-3 action. The Journal of biological chemistry 1995; 270:13589-92. 
26. 
He Q, Xiao L, Lingyun W, et al. Expression of type 1 insulin-like growth factor receptor 
in marrow nucleated cells in malignant hematological disorders: correlation with apoptosis. 
Annals of hematology  2006; 85:95-101.  
27. 
He Q, Li X, Zhang Z, et al. Overexpression of IGF-IR in malignant clonal cells in bone 
marrow of myelodysplastic syndromes. Cancer Investigation 2010; 28:983-8.  
28. 
He Q, Chang CK, Xu F, Zhang QX, Shi WH, Li X. Purification of Bone Marrow Clonal 
Cells from Patients with Myelodysplastic Syndrome via IGF-IR. PLoS One 2015; 
10(10):e0140372. 
29. 
Chen CS, Ofner CM 3rd. The effect of molecular weight, drug load, and charge of 
gelatin-MTX conjugates on growth inhibition of HL-60 leukemia cells. Pharmaceutical research 
2009;26:338-45.  
30. 
Francis GL, Ross M, Ballard FJ, et al. Novel recombinant fusion protein analogues of 
insulin-like growth factor (IGF)-I indicate the relative importance of IGF-binding protein and 
receptor binding for enhanced biological potency. Journal of molecular endocrinology 1992; 
8:213-23. 
31. 
Tomas FM, Knowles SE, Chandler CS, Francis GL, Owens PC, Ballard FJ. Anabolic 
effects of insulin-like growth factor-I (IGF-I) and an IGF-I variant in normal female rats. The 
Journal of endocrinology 1993; 137:413-21. 

Protocol, v3, dated December 6, 2018                  Page 51 of 57 
 
32. 
Haluska P, Shaw HM, Batzel GN, et al. Phase I dose escalation study of the anti insulin-
like growth factor-I receptor monoclonal antibody CP-751,871 in patients with refractory solid 
tumors. Clinical cancer research: an official journal of the American Association for Cancer 
Research 2007; 13:5834-40. 
33. 
Karp DD, Pollak MN, Cohen RB, et al. Safety, pharmacokinetics, and 
pharmacodynamics of the insulin-like growth factor type 1 receptor inhibitor figitumumab (CP-
751,871) in combination with paclitaxel and carboplatin. Journal of thoracic oncology: official 
publication of the International Association for the Study of Lung Cancer 2009; 4:1397-403. 
34. 
Olmos D, Postel-Vinay S, Molife LR, et al. Safety, pharmacokinetics, and preliminary 
activity of the anti-IGF-1R antibody figitumumab (CP-751,871) in patients with sarcoma and 
Ewing's sarcoma: a phase 1 expansion cohort study. The lancet oncology 2010; 11:129-35. 
35. 
Rowinsky EK, Youssoufian H, Tonra JR, Solomon P, Burtrum D, Ludwig DL. IMC-
A12, a human IgG1 monoclonal antibody to the insulin-like growth factor I receptor. Clinical 
cancer research: an official journal of the American Association for Cancer Research 2007; 
13:5549s-55s. 
36. 
Sarantopoulis J, et al., A phase IB study of AMG479, a type 1 insulin-like growth factor 
receptor (IGF1R) antibody, in combination with panitumumab (P) or gemcitabine (G). J of 
Clinical Oncology, 2008. 26: p. Abstr 3583. 
37. 
Seraj J, et al. Evaluation of Safety and pharmacokinetics of a fully human IGF-1 receptor 
antibody, SCH 717454, in healthy volunteers. in AACR-NCI-EORTC International Conference 
on Molecular Targets and Cancer Therapeutics. 2007. 
38. 
Tolcher AW, et al. A phase 1 pharmacokinetic and pharmacodynamic study of AMG 
479, a fully human monoclonal antibody against insulin-like growth factor type 1 receptor (IGF-
1R), in advanced solid tumors. in JCO Suppl 25. 2007. 
39. 
Weickhardt A, Doebele R, Oton A, et al. A phase I/II study of erlotinib in combination 
with the anti-insulin-like growth factor-1 receptor monoclonal antibody IMC-A12 
(cixutumumab) in patients with advanced non-small cell lung cancer. Journal of thoracic 
oncology: official publication of the International Association for the Study of Lung Cancer 
2012; 7:419-26. 
40. 
McTavish H, Griffin RJ, Terai K, Dudek AZ. Novel insulin-like growth factor-
methotrexate covalent conjugate inhibits tumor growth in vivo at lower dosage than methotrexate 
alone. Translational research: the journal of laboratory and clinical medicine 2009; 153:275-82. 
41. 
Applebaum.  1989.  U.S. Patent No. 4, 242. 
42. Guidance for Industry: Estimating the Maximum Safe Starting Dose in Initial Clinical Trials 
for Therapeutics in Adult Healthy Volunteers 2005. at 
http://www.fda.gov/downloads/Drugs/Guidances/UCM078932.pdf.) 
43. 
Reagan-Shaw S, Nihal M, Ahmad N. Dose translation from animal to human studies 
revisited. FASEB journal: official publication of the Federation of American Societies for 
Experimental Biology 2008; 22:659-61. 
44. 
SWOG Leukemia Response Criteria Oct 2015 revised. 
45. 
Dohner H, Estey EH, Amadori S, et al. Diagnosis and management of acute myeloid 
leukemia in adults: recommendations from an international expert panel, on behalf of the 
European LeukemiaNet. Blood 2010; 115:453-74. 
46. 
Cheson BD, Bennett JM, Kopecky KJ, et al.; International Working Group for Diagnosis, 
Standardization of Response Criteria, Treatment Outcomes, and Reporting Standards for 
Therapeutic Trials in Acute Myeloid Leukemia. Revised recommendations of the International 
Working Group for Diagnosis, Standardization of Response Criteria, Treatment Outcomes, and 

Protocol, v3, dated December 6, 2018                  Page 52 of 57 
 
Reporting Standards for Therapeutic Trials in Acute Myeloid Leukemia. J Clin Oncol. 2003; 15; 
21:4642-9. 
47. 
Cheson BD, Greenberg PL, Bennett JM, et al. Clinical application and proposal for 
modification of the International Working Group (IWG) response criteria in myelodysplasia. 
Blood 2006; 108:419-25. 
48. 
O'Neill A, Shah N, Zitomersky N, et al. Insulin-like growth factor 1 receptor as a 
therapeutic target in ewing sarcoma: lack of consistent upregulation or recurrent mutation and a 
review of the clinical trial literature. Sarcoma 2013; 2013:450478. 
49. Freund GG, Kulas DT, Way BA, Mooney RA.  Functional insulin and insulin-like growth 
factor-1 receptors are preferentially expressed in multiple myeloma cell lines as compared to B-
lymphoblastoid cell lines. Cancer Res 1994; 54:3179-85. 
50. Surmacz, E. Function of the IGF-I receptor in breast cancer. J. Mammary Gland Biol. 
Neoplasia 2000; 5:95-105. 
51. Schilsky RL, Ordway FS.  Insulin effects on methotrexate polyglutamate synthesis and 
enzyme binding in cultured human breast cancer cells. Cancer Chemother Pharmacol 1985; 
15:272-277. 
52. Kanter-Lewensohn L, Dricu A, Wang M, Wejde J, Kiessling R, Larsson O. Expression of the 
insulin-like growth factor-1 receptor and its anti-apoptotic effect in malignant melanoma: a 
potential therapeutic target. Melanoma Res 1998; 8:389-397. 
53. Sell C, Baserga R, Rubin R. Insulin-like growth factor I (IGF-I) and the IGF-I receptor 
prevent etoposide-induced apoptosis. Cancer Res 1995; 55:303-306. 
54.  Mughal TI, Cross NC, Padron E, Tiu RV, et al.  An International MDS/MPN Working 
Group's perspective and recommendations on molecular pathogenesis, diagnosis and clinical 
characterization of myelodysplastic/myeloproliferative neoplasms. Haematologica. 
2015;100(9):1117-30.  
 
 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 53 of 57 
 
Appendix I – Response Criteria for Acute Leukemia 
 
Acute Myeloid Leukemia45  
 
 
 
 
 
 
 
 
 

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Protocol, v3, dated December 6, 2018                  Page 55 of 57 
 
Appendix II – Response Criteria for MDS47  
 
 
 
 
 
 
 
 

Protocol, v3, dated December 6, 2018                  Page 56 of 57 
 
 
 
 
Appendix III – ECOG Performance Status 
 
 
ECOG Score 
Performance Status 
0 
Asymptomatic 
1 
Symptomatic, fully ambulatory 
2 
Symptomatic, in bed < 50% of the day 
3 
Symptomatic, in bed > 50% of the day but not bedridden 
4 
Bedridden 
5 
Dead 
 
 
 
Appendix IV – New York Heart Association Classification 
 
Class 
Functional Capacity 
Objective 
Assessment 
I 
Patients with cardiac disease but without resulting 
limitations of physical activity.  Ordinary physical activity 
does not cause undue fatigue, palpitation, dyspnea, or 
anginal pain. 
No objective evidence 
of cardiovascular 
disease. 
II 
Patients with cardiac disease resulting in slight limitation of 
physical activity.  They are comfortable at rest.  Ordinary 
physical activity results in fatigue, palpitation, dyspnea, or 
anginal pain. 
Objective evidence of 
minimal cardiovascular 
disease. 
III 
Patients with cardiac disease resulting in marked limitation 
of physical activity.  They are comfortable at rest.  Less 
than ordinary activity causes fatigue, palpitation, dyspnea, 
or anginal pain. 
Objective evidence of 
moderately severe 
cardiovascular disease. 
IV 
Patients with cardiac disease resulting in inability to carry 
on any physical activity without discomfort.  Symptoms of 
heart failure or the anginal syndrome may be present even 
at rest.  If any physical activity is undertaken, discomfort is 
increased. 
Objective evidence of 
severe cardiovascular 
disease. 
 
 
Appendix V – Prohibited Concomitant Medications 
 
Mercaptopurine 
Concomitant other anti-cancer therapy (cytotoxic, biologic, or 
radiation) 
 
 

Protocol, v3, dated December 6, 2018                  Page 57 of 57 
 
Appendix VI – Medications to use with caution, see Sections 7.4 and 
7.6 
 
NSAIDs 
Phenytoin 
BACTRIM ( trimethoprim/sulfamethoxazole) 
Sulfonamides 
Phenylbutazone 
Salicylates 
Oral antibiotics 
Penicillins 
Azathioprine 
Retinoids 
Sulfasalazine 
other potential hepatotoxins 
Theophylline 
Folic acid vitamin supplement