A Phase 2 Study of Belinostat and SGI-110 (Guadecitabine) or ASTX727 for the Treatment of Unresectable and Metastatic Conventional Chondrosarcoma
Phase: PHASE2
Conditions: Locally Advanced Unresectable Primary Central Chondrosarcoma, Metastatic Primary Central Chondrosarcoma, Unresectable Primary Central Chondrosarcoma
Sponsor: National Cancer Institute (NCI)

NCI Protocol #10330 
Version Date: , March 25, 2025 
 
 
To:  
CTEP Protocol and Information Office 
From:  
Matthew Ingham, M.D. 
Date:  
March 25, 2025 
Re: 
Response to Disapproval of Amendment #8 of Protocol #10330: “A Phase 2 Study 
of Belinostat and SGI-110 (Guadecitabine) or ASTX727 for the Treatment of 
Unresectable and Metastatic Conventional Chondrosarcoma”  
 
SUMMARY OF CHANGES – Protocol 
 
I. Comments Requiring a Response– Administrative & Editorial Issues: 
# 
Section 
Comments 
1. 
ICD 
Risks 
Please add ASTX727 risk list (CAEPR version 2.2, December 19, 2024), as 
attached. 
PI Response: Risks updated in applicable consent.  ASTX727 risks not described 
in SGI-110 consent. 
 
II. Recommendations: 
# 
Section 
Comments 
2. 
8.1.4.1 
Agent Ordering and Agent Accountability 
Update the second paragraph to: 
Submit agent requests through the PMB AURORA application.  Access to 
AURORA requires the establishment of credentials necessary to access secure 
NCI Clinical Oncology Research Enterprise (CORE) systems, maintenance of an 
“active” account status, a “current” password, and active person registration status.  
For questions about drug orders, transfers, returns, or accountability, call or email 
PMB any time or use the dialog function in AURORA to communicate with PMB 
staff.  Refer to the PMB’s website for specific policies and guidelines related to 
agent management.   
PI Response: Updated 
3. 
8.1.4.2 
Agent Inventory Records 
In the first paragraph, replace “careful record” with “complete accountability”. 
Add the following as a second paragraph: 
Product Quality Complaint (PQC): A product quality complaint is defined as any 
suspicion of a product defect related to a potential quality issue during 
manufacturing, packaging, release testing, stability monitoring, dose preparation, 

NCI Protocol #10330 
Version Date: , March 25, 2025 
 
 
# 
Section 
Comments 
storage or distribution of the product, or delivery system.  Not all PQCs involve a 
study subject.  Lot or batch numbers are of high significance and need to be 
provided where and when possible. PQC must be reported to the PMB as soon as 
the PQC is identified. Report PQC to PMB at PMBAfterHours@mail.nih.gov or 
by using the dialog function in AURORA to communicate with PMB staff. 
PI Response: Updated and Added 
4. 
8.1.5 
Investigator Brochure 
Update the entire paragraph to: 
The current versions of the IBs for the agents will be accessible to site 
investigators and research staff through the PMB AURORA application.  
Access to AURORA requires the establishment of credentials necessary 
to access secure NCI Clinical Oncology Research Enterprise (CORE) 
systems, maintenance of an “active” account status, a “current” password 
and active person registration status.  Questions about IB access may be 
directed to the PMB IB Coordinator via email. 
PI Response: Updated 
5. 
8.1.6 
Useful Links and Contacts 
Change “PMB Online Agent Order Processing (OAOP) application:” to “PMB 
Agent Inventory Management System (AURORA) application: 
https://ctepcore.nci.nih.gov/aurora/login”.  
PI Response: Updated 
6. 
8.1.4 
Insert the following as a new subsection: 
Material Safety Data Sheets 
The current versions of the material safety data sheets (MSDS or SDS) for PMB-
distributed agents will be accessible to site investigators and research staff through 
the PMB AURORA application. Questions about MSDS access may be directed to 
the PMB at PMBAfterHours@mail.nih.gov or by using the dialog function in 
AURORA to communicate with PMB staff. 
PI Response: Added as section 8.1.4.2 
7. 
8.1.4 
Insert the following as a new subsection: 
Agent Shortages  
Specific guidance on how to address agent shortages for patients already enrolled 
on a clinical study as well as how to manage potential enrollment of new patients 
is provided at https://ctep.cancer.gov/branches/pmb/drug_shortages.htm.   
Treatment plan modifications being made to avoid immediate hazard to patients is 

NCI Protocol #10330 
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# 
Section 
Comments 
permissible under the Department of Health and Human Services (HHS) 
regulations at 45 CFR 46.103(b)(4)(iii). In accordance with HHS regulations, local 
investigators must promptly inform the IRB of record of this unanticipated 
problem and the management plan for the trial. 
PI Response: Added as section 8.1.4.3 
 
III. Protocol changes in response to the Request for Rapid Protocol Amendment dated 
02/25/25: 
 
# 
Section 
Comments 
1. 
Header 
Updated version date 
2. 
Title page 
• Updated version date and added Amendment #8 to list of versions 
• Updated local protocol number 
• Updated ClinicalTrials.gov Identifier 
3. 
10.3.3 
Expedited 
Reporting 
Guidelines 
Specific Protocol Revisions to Address Risk Mitigation Plan 
• 
The updated AE Reporting Table 
4. 
10.1.1.2 
CAEPR for 
ASTX727 
Revision of the Protocol CAEPR 
•     The SPEER grades have been updated. 
• 
Added New Risk:   
• 
Also Reported on ASTX727 Trials But With Insufficient Evidence 
for Attribution: Confusion; Dehydration; Hypokalemia; Intracranial 
hemorrhage    
• 
 Increase in Risk Attribution:  
• 
Changed to Less Likely from Also Reported on ASTX727 Trials But 
With Insufficient Evidence for Attribution: Aspartate 
aminotransferase increased 
• 
Decrease in Risk Attribution:  
• 
Changed to Less Likely from Likely: Fatigue 
• 
Changed to Also Reported on ASTX727 Trials But With Insufficient 
Evidence for Attribution from Less Likely: Dizziness; Headache 
• 
Deleted Risk:  
• 
Also Reported on ASTX727 Trials But With Insufficient Evidence 
for Attribution: Blood bilirubin increased; Colitis; Weight loss 
• 
Modified Specific Protocol Exceptions to Expedited Reporting 
(SPEER) reporting requirements: 
• 
Added: Upper respiratory infection; Urinary tract infection 
• 
Provided Further Clarification: 
• 
Infection is now reported as Lung infection/pneumonia, sepsis, 
tooth infection, upper respiratory infection, and urinary tract 
infection.  

NCI Protocol #10330 
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# 
Section 
Comments 
• 
Footnote #2 previously reported as, “Infection includes all 75 sites 
of infection under the INFECTIONS AND INFESTATIONS SOC” 
was deleted. 
• 
Footnote #2 is now reported as “The SPEER grade for febrile 
neutropenia should only be applied to cases of neutropenic fever  
• 
associated with hematologic malignancies and NOT for solid 
tumors.”  
• 
Additional changes due to migrating from CAEPR version 2.0 to 2.2 
• 
Replacing Cedazuridine with E7727 

NCI Protocol #10330 
Version Date: , March 25, 2025 
 
1 
 
NCI Protocol #: 
10330 
 
Local Protocol #: 
202008172 
 
ClinicalTrials.gov Identifier:  NCT04340843 
 
TITLE:  A Phase 2 Study of Belinostat and SGI-110 (Guadecitabine) or ASTX727 for the 
Treatment of Unresectable and Metastatic Conventional Chondrosarcoma 
 
Corresponding Organization: LAO-CT018 / Yale University Cancer Center LAO 
 
Principal Investigator: 
Mia Weiss, MD 
 
Medical Oncology, Barnes and Jewish Hospital 
 
660 S. Euclid Avenue 
 
St. Louis, MO 631110 
 
m.c.weiss@wustl.edu 
 
Translational PI: 
Gary Schwartz, M.D. 
Columbia University Medical Center 
177 Fort Washington Avenue, Suite 6GN-435 
New York, NY 10032 
Telephone: 212-305-2055 
Fax: 212-305-3035 
gks2123@cumc.columbia.edu 
 
Participating Organizations 
LAO-11030 / University Health Network Princess Margaret Cancer Center LAO 
LAO-CA043 / City of Hope Comprehensive Cancer Center LAO 
LAO-CT018 / Yale University Cancer Center LAO 
LAO-MA036 / Dana-Farber - Harvard Cancer Center LAO 
LAO-MD017 / JHU Sidney Kimmel Comprehensive Cancer Center LAO 
LAO-OH007 / Ohio State University Comprehensive Cancer Center LAO 
LAO-PA015 / University of Pittsburgh Cancer Institute LAO 
LAO-TX035 / University of Texas MD Anderson Cancer Center LAO 
LAO-NCI / National Cancer Institute LAO 
CATCHUP / Creating Access to Targeted Cancer Therapy for Underserved Populations 
 
 
 
 
 
 
 
 

NCI Protocol #10330 
Version Date: , March 25, 2025 
 
2 
 
 
 
Statistician: 
 
 
Shing Lee, Ph.D. 
 
 
722 West 168th Street 
 
 
Room 645 
 
 
Telephone:  212-342-1266 
 
 
Fax:  212-305-6891 
 
 
sml2114@cumc.columbia.edu 
 
Study Coordinator: 
 
Responsible Research Nurse: 
 
Zoe Singer 
 
Shahnaz Singh-Kandah, NP 
 
CPDM Office 
 
CPDM Office  
 
161 Fort Washington Avenue 
 
161 Fort Washington Avenue 
 
Mezzanine Level 
 
Mezzanine Level 
 
New York, NY 10032 
 
New York, NY 10032 
 
Telephone: 212-342-3178 
 
Telephone: 212-342-3178 
 
zs2423@cumc.columbia.edu 
 
svs2126@cumc.columbia.edu 
 
 
Responsible Data Manager:  
 
Zaniah Boykin 
 
CPDM Office 
 
161 Fort Washington Avenue 
 
Mezzanine Level 
 
New York, NY 10032 
 
Telephone: 212-342-3178 
 
zb2238@cumc.columbia.edu 
 
NCI-Supplied Agents:  Belinostat (PXD-101) (NSC # 726630), SGI-110 (Guadecitabine) (NSC 
# 780463), ASTX727 (NSC# 820631) 
 
IND #:  
 
IND Sponsor:  DCTD, NCI  
 
Protocol Type / Version # / Version Date: 
Original / December 12, 2019 
 
 
 
 
Revision 1 / February 27, 2020 
 
 
 
 
Revision 2a / May 1, 2020 
 
 
 
 
Revision 3 / May 26, 2020 
 
 
 
 
Amendment 1 / July 24, 2020 
 
 
 
 
Amendment 2 / September 8, 2020 
 
 
 
 
      Amendment 5 / June 15, 2021 
 
 
 
 
      Amendment 6 / June 15, 2022 
 
 
 
 
      Amendment 7 / February 14, 2023 
 
 
 
 
      Amendment 8 / March 7, 2025 
                                                  Amendment 9 / March 25, 2025 

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SCHEMA 
 
 

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TABLE OF CONTENTS 
 
SCHEMA .........................................................................................................................................3 
1. 
OBJECTIVES ......................................................................................................................7 
1.1 
Primary Objectives ...................................................................................................7 
1.2 
Secondary Objectives ...............................................................................................7 
1.3 
Correlative Objectives .............................................................................................7 
2. 
BACKGROUND .................................................................................................................8 
2.1 
Study Disease ...........................................................................................................8 
2.2 
CTEP IND Agents ...................................................................................................9 
2.3 
Rationale ................................................................................................................14 
2.4 
Correlative Studies Background ............................................................................23 
3. 
PATIENT SELECTION ....................................................................................................24 
3.1 
Eligibility Criteria ..................................................................................................24 
3.2 
Exclusion Criteria ..................................................................................................26 
3.3 
Inclusion of Women and Minorities ......................................................................27 
4. 
REGISTRATION PROCEDURES ...................................................................................28 
4.1 
Investigator and Research Associate Registration with CTEP ..............................28 
4.2 
Site Registration .....................................................................................................29 
4.3 
Patient Registration ................................................................................................31 
4.4 
General Guidelines .................................................................................................33 
5. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................33 
5.1 
Summary Table for Specimen Collection ..............................................................33 
5.2 
Summary Tables for Interventional Radiologist for Research Biopsies ................33 
5.3 
Specimen Procurement Kits and Scheduling .........................................................34 
5.4 
Specimen Tracking System Instructions ................................................................35 
5.5 
Specimen Collection ..............................................................................................38 
5.6 
Shipping Specimens from Clinical Site to the EET Biobank ................................39 
5.7 
Biomarker Plan ......................................................................................................42 
5.8 
Integrated Correlative Studies ................................................................................44 
5.9 
Exploratory/Ancillary Correlative Studies ............................................................45 
6. 
TREATMENT PLAN ........................................................................................................46 
6.1 
Agent Administration .............................................................................................46 
6.2 
General Concomitant Medication and Supportive Care Guidelines ......................51 
6.3 
Duration of Therapy ...............................................................................................54 
6.4 
Duration of Follow-Up ..........................................................................................54 
7. 
DOSING DELAYS/DOSE MODIFICATIONS................................................................55 
7.1 
General Principles ..................................................................................................55 
7.2 
Dose Levels of Study Agents .................................................................................55 

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7.3 
Criteria for Initiation of a New Cycle ....................................................................56 
7.4 
Dose Modifications for Hematologic Toxicity ......................................................56 
7.5 
Dose Modifications for Non-Hematologic Toxicity ..............................................57 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................58 
8.1 
CTEP IND Agents .................................................................................................58 
9. 
STATISTICAL CONSIDERATIONS...............................................................................66 
9.1 
Study Design/Endpoints.........................................................................................67 
9.2 
Dose-Limiting Toxicity .........................................................................................68 
9.3 
Safety Lead-In ........................................................................................................68 
9.4 
Continuous Toxicity Monitoring Rule ...................................................................69 
9.5 
Sample Size/Accrual Rate ......................................................................................70 
9.6 
Analysis of Secondary Endpoints ..........................................................................71 
9.7 
Analysis of Correlative Endpoints .........................................................................71 
9.8 
Reporting and Exclusions ......................................................................................72 
10. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................73 
10.1 
Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) .................73 
10.2 
Adverse Event Characteristics ...............................................................................80 
10.3 
Expedited Adverse Event Reporting ......................................................................81 
10.4 
Routine Adverse Event Reporting .........................................................................84 
10.5 
Pregnancy ...............................................................................................................84 
10.6 
Secondary Malignancy ...........................................................................................84 
10.7 
Second Malignancy ................................................................................................84 
11. 
STUDY CALENDAR .......................................................................................................85 
12. 
MEASUREMENT OF EFFECT........................................................................................87 
12.1 
Antitumor Effect – Solid Tumors ..........................................................................87 
13. 
STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS .............................................................................................................93 
13.1 
Study Oversight .....................................................................................................93 
13.2 
Data Reporting .......................................................................................................93 
13.3 
Data Quality Portal ................................................................................................96 
13.4 
CTEP Multicenter Guidelines ................................................................................96 
13.5 
Collaborative Agreements Language .....................................................................96 
13.6 
Genomic Data Sharing Plan ...................................................................................98 
13.7 
Incidental/Secondary Findings Disclosure Procedure ...........................................98 
14. 
REFERENCES ..................................................................................................................99 
APPENDIX A 
PERFORMANCE STATUS CRITERIA ................................................107 
APPENDIX B 
FORMULA TO ESTIMATE RENAL FUNCTION USING 
SERUM CREATININE ...................................................................................................108 

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APPENDIX C 
PRE-BIOPSY ASSESSMENT ................................................................109 
APPENDIX D 
PATIENT CLINICAL TRIAL WALLET CARD: 
BELINOSTAT and SGI-110 (Guadecitabine).................................................................110 
APPENDIX E 
PATIENT CLINICAL TRIAL WALLET CARD: 
BELINOSTAT and ASTX727 .........................................................................................111 
APPENDIX F  
PATIENT MEDICATION DIARY – ASTX727 ....................................112 
 
 

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1. OBJECTIVES 
 
1.1 
Primary Objectives 
 
1.1.1 To conduct a phase 2 clinical trial to evaluate whether combination treatment with 
belinostat and ASTX727 shows preliminary evidence of clinical activity in unresectable 
or metastatic conventional chondrosarcoma (CS) using an objective response rate 
endpoint. 
 
1.2 
Secondary Objectives 
 
1.2.1 To evaluate the toxicity profile associated with belinostat and ASTX727.  
 
1.2.2 To evaluate the progression free survival (PFS) associated with belinostat and ASTX727. 
 
1.2.3 To evaluate the toxicity profile, objective response rate and progression free survival 
among the initial six patients treated with belinostat and SGI-110 (guadecitabine) prior to 
Amendment 5 in which ASTX727 was substituted for SGI-110 (guadecitabine).  
 
1.3 
Correlative Objectives 
 
1.3.1 To determine the IDH1/2 mutational status of subject’s tumors and to evaluate for a 
relationship between presence of IDH1/2 mutation and clinical benefit from study 
treatment. 
 
1.3.2 To conduct RNAseq analysis using baseline and on-treatment tissue biopsies to study the 
effects of study treatment on CS gene expression patterns and identify candidate genes 
which may underlie treatment efficacy. 
 
1.3.3 To evaluate for changes in global DNA methylation levels using baseline and on-
treatment biopsies and correlate changes in global methylation with clinical benefit from 
study treatment. 
 
1.3.4 To use multiplex immunohistochemistry to interrogate the immune microenvironment in 
baseline and on-treatment tissue biopsies to define changes in infiltrating immune cell 
subsets and PD-L1/MHC expression by immune and tumor cells associated with study 
treatment. 
 
 

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2. 
BACKGROUND 
 
2.1 
Study Disease 
 
CS is a malignant bone tumor characterized by the production of cartilaginous matrix by 
neoplastic cells.  CS accounts for 20-27% of primary malignant bone cancers and is the second 
most common primary bone tumor after osteosarcoma (Dorfman and Czerniak, 1995).  CS most 
often occurs in the pelvis but can arise in the femur, humerus, ribs and at other sites.  Distinct 
clinical and histologic subtypes have been described which have variable molecular 
characteristics, biologic behavior, and responsiveness to treatment (Polychronidou et al., 2017).  
Conventional chondrosarcomas account for 90% of CS and are subdivided into primary (central) 
chondrosarcomas which form within the medullary cavity and much less common secondary 
(peripheral) chondrosarcomas which arise from the cartilage cap of pre-existing benign 
osteochondromas.  The remaining 10% of CS are composed of the dedifferentiated, clear cell, 
and mesenchymal subtypes.  Histologic grade is predictive of local recurrence and metastatic 
spread.  Conventional CS are often low or intermediate grade and pursue an indolent course with 
low metastatic potential; however, a subset are high grade with a poor prognosis (Bovee et al., 
2005).  Lower grade tumors often recur with higher histological grade and metastatic potential 
(Gelderblom et al., 2008). 
 
Surgical resection is the mainstay of CS treatment.  CS are inherently resistant to chemotherapy 
and radiotherapy.  Possible explanations for this resistance include low mitotic fraction, limited 
drug penetration due to poor vascularity and dense extracellular matrix, activation of multidrug 
resistance pumps, and increased expression of antiapoptotic factors (Polychronidou et al., 2017).  
Currently, no FDA approved therapies exist for conventional CS.  There is an unmet need for 
new treatment options for refractory, inoperable and metastatic CS.  Studies evaluating cytotoxic 
agents and immunotherapy in CS have shown limited efficacy.  In a retrospective study of 180 
patients with advanced CS treated with various chemotherapeutic agents, the overall response 
rate was 15% (Italiano et al., 2013).  73% of patients were treated with anthracycline-based 
regimens and 55% received combination cytotoxic therapy.  Response rates for mesenchymal CS 
(31%) and dedifferentiated CS (21%) were significantly higher than for conventional CS (12%) 
(Italiano et al., 2013).  A phase 2 trial of gemcitabine with docetaxel in 25 patients with CS 
demonstrated a similarly low objective response rate of 8% (Fox et al., 2012).  Immunotherapy, 
which has shown promise in multiple cancers, was evaluated in dedifferentiated CS where PD-
L1 expression is observed (Kostine et al., 2016).  A phase 2 trial of pembrolizumab, an anti-PD-
1 antibody, included 5 patients with dedifferentiated CS, and one patient achieved an objective 
response while three showed progressive disease (Tawbi et al., 2017).  Conventional CS does not 
commonly express PD-1 and the efficacy of existing immunotherapy-based approaches is likely 
limited. 
 
Mutations in the IDH1 or IDH2 genes are observed in 50-60% of conventional CS and are 
implicated in reprogramming the metabolic activity of CS cancer cells, similar to findings in 
AML, glioblastoma, and cholangiocarcinoma (Amary et al., 2011).  Normally, isocitrate 
dehydrogenase (IDH) catalyzes the oxidative decarboxylation of isocitrate to produce α-
ketoglutarate (αKG), carbon dioxide, and NADPH in the Krebs cycle.  Mutations in the IDH 
genes lead to conversion of αKG to the oncometabolite D-2-hydroxyglutarate (D-2HG).  D-2HG 

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accumulation competitively inhibits αKG-dependent enzymes, which are involved in modulating 
chromatin structure, DNA methylation, cellular signaling, response to hypoxia, and collagen 
maturation.  The dysregulation of these processes results in widespread epigenetic modifications 
and directly contributes to tumorigenesis (Molenaar et al., 2018).  Specifically, D-2HG inhibits 
the ten-eleven translocation (TET) family of demethylase enzymes, which leads to DNA 
hypermethylation causing transcriptional silencing of tumor suppressor genes.  In vitro, 
inhibitors of DNA methyltransferases (DNMTi) reverse global hypermethylation, thereby 
restoring expression of differentiation genes and promoting cell differentiation in CS 
(Borodovsky et al., 2013; Gagné et al., 2017).  The Jumonji C-domain lysine demethylases are 
another family of αKG-dependent dioxygenases that are inhibited by D-2HG.  Inhibition causes 
increased lysine methylation of histone tails, altering chromatin structure and gene expression 
and blocking cell differentiation.  Based on these findings and the high prevalence of 
IDH1/IDH2 mutation among patients with CS, epigenetic dysregulation and impairment of 
differentiation play an important role in CS pathogenesis and represent an attractive target for 
novel therapeutic approaches.  Impairment of differentiation through epigenetic dysregulation of 
various cell cycle and other genes appears relevant in IDH wild-type CS as well (Liu et al., 
2018). 
 
2.2 
CTEP IND Agents 
 
2.2.1 Belinostat (PXD-101) 
 
2.2.1.1 
Mechanism of Action 
 
Belinostat, FDA-approved in 2014 for relapsed/refractory peripheral T-cell lymphoma (PTCL), 
is a hydroxamate derivative that inhibits both class I and II HDACs (pan-HDACi) (Molife et al., 
2011).  HDAC inhibitors (HDACi) exert multiple biological effects in cancer cells, including 
induction of differentiation/apoptosis, cell cycle/mitotic arrest, and autophagic cell death.  
Malignant cells possess higher levels of HDACs than normal tissues, and normal cells are 
relatively resistant to DNA damage and cell death induced by HDACi (Ungerstedt et al., 2005; 
Lee et al., 2010).  As noted above, HDACi can modify gene expression secondary to acetylation 
of histones and by altering the acetylation status of transcription factors and other proteins 
involved in transcription.  One of the most important HDACi-induced genes is the cyclin-
dependent kinase inhibitor CDKN1A (p21WAF1/CIP1) (Richon et al., 2000).  HDACi-induced 
increases in the level of this protein (Rosato et al., 2003), as well as that of p16 (CDKN2 or 
INK4) and p27, decreased expression of cyclins A and D, and dephosphorylation of 
retinoblastoma (Rb) protein, all contribute to HDACi-induced cell cycle arrest.  HDACi also 
induce telomerase activity (Bhalla, 2005).  HDACi acetylate histone H3K9 in pericentromeric 
chromatin, thus interfering with assembly of the kinetochore.  This leads to mitotic arrest at 
prometaphase, followed by aberrant mitosis with chromosome segregation defects and ultimately 
apoptosis (Quintas-Cardama et al., 2011).  Furthermore, HDACi lethality has been related to 
disruption of various cell cycle checkpoints (Warrener et al., 2003) as well as induction of 
mitotic slippage (Stevens et al., 2008). 
 
HDACi activate both the intrinsic and extrinsic pathways of apoptosis.  They increase levels of 
both Fas/Fas ligand and DR5/TRAIL (Insinga et al., 2005, Nebbioso et al., 2005) and down-

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regulate c-FLIP (Aron et al., 2003) in leukemic cells, but not in normal cells.  HDACi increase 
levels of the pro-apoptotic Bcl-2 family proteins Bax, Bak, Bim (Chen et al., 2009), and Bmf; 
down-regulate the anti-apoptotic proteins Bcl-2, Bcl-xL, Mcl-1, XIAP (Rosato et al., 2006), and 
survivin; induce conformational change of Bax, and enhance the cleavage and subsequent 
activation of Bid (Bhalla, 2005; Quintas-Cardama et al., 2011; Ruefli et al., 2001). 
 
HDACi induce DNA damage through increased generation of reactive oxygen species (ROS) 
(Rosato et al., 2003, Ruefli et al., 2001) and by impairing mechanisms of DNA repair (Bose et 
al., 2014).  HDAC3 is essential for the maintenance of chromatin structure and genome stability 
(Bhaskara et al., 2010).  HDACi decrease levels of the non-homologous end-joining (NHEJ) 
proteins Ku80 and Rad50 and acetylate Ku70 (Subramanian et al., 2005), thereby decreasing its 
DNA binding.  HDACi-mediated apoptosis is, in part, dependent on ROS generation, with 
subsequent DNA and mitochondrial damage and activation of the intrinsic apoptotic pathway 
(Bose et al., 2014).  In addition, HDACi inhibit homologous recombination (HR) DNA repair 
(Kachhap et al., 2010).  Recently, hypoacetylation of histone H3 lysine 56 has been shown to be 
necessary for efficient NHEJ (Miller et al., 2010), raising the possibility that HDACi may also 
disable this repair mechanism.  Disabling certain cytoprotective pathways (e.g., NF-κB) 
promotes HDACi-mediated DNA damage and cell death in human leukemia cells (Dai et al., 
2005).  
 
Induction of autophagy is another important mechanism of cell death in response to HDACi 
(Robert et al., 2011; Shubassi et al., 2012).  Finally, HDACi, particularly HDAC6 inhibitors 
(Bali et al., 2005), abrogate chaperone protein (Hsp90) function via hyperacetylation (Bhalla, 
2005; Lane and Chabner, 2009; Quintas-Cardama et al., 2011).  This leads to down-regulation, 
via polyubiquitinylation and proteasomal degradation, of misfolded Hsp90 client proteins such as 
Bcr-Abl (Nimmanapalli et al., 2003), FLT3, Akt, Raf (Bali et al., 2005) and checkpoint kinase 1 
(Chk1) (Arlander et al., 2003; Brazelle et al., 2010).  HDACi may also affect tumor cell survival 
by blocking tumor angiogenesis, and by inhibiting intracellular stress-response pathways (Lane 
and Chabner, 2009). 
 
2.2.1.2 
Summary of Clinical Experience 
 
Although belinostat has mostly been administered intravenously (IV) in clinical trials, an oral 
formulation has also been tested (Steele et al., 2011).  IV belinostat displays linear 
pharmacokinetics (PKs) with respect to the maximum concentration (Cmax) and the area under 
the “concentration time” curve (AUC) (Steele et al., 2008), without significant accumulation 
(Yeo et al., 2012).  The intermediate elimination half-life is 0.3 to 1.3 hrs and independent of 
dose (Steele et al., 2008).  Belinostat PKs are unaltered by concurrent administration with 
carboplatin and paclitaxel (Lassen et al., 2010).  Glucuronidation by UGT1A1 is by far the major 
route of belinostat elimination in humans (Wang et al., 2013).  The drug has 5 major metabolites, 
which are not expected to have anticancer effects, and the parent drug and metabolites can be 
quantified in human plasma by means of a validated liquid chromatography-tandem mass 
spectrometry assay (Kiesel et al., 2013).  In vitro studies indicate that belinostat is a 
weak/moderate inhibitor of cytochrome P450 family 2 subfamily C member 8 (CYP2C8) and a 
moderate to strong inhibitor of CYP2C9.  
 

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In a phase 1 study in patients with advanced solid tumors, the maximum tolerated dose (MTD) of 
belinostat was 1000 mg/m2 IV daily, administered over 30 minutes on Days 1-5 of a 21-day 
cycle (Steele et al., 2008).  Dose-limiting toxicities (DLTs) included grade 3 fatigue, diarrhea, 
and atrial fibrillation, as well as grade 2 nausea/vomiting resulting in inability to complete a full 
5-day cycle.  A phase 1 study in patients with advanced hematologic neoplasms reported the 
same MTD (Gimsing et al., 2008).  The most common treatment-related adverse events (AEs) 
(all grades) were nausea (50%), vomiting (31%), fatigue (31%), and flushing (31%).  There was 
one case of grade 3 lymphopenia and two cases of grade 4 renal failure in the context of tumor 
lysis syndrome (TLS).  The only related grade 3 events in more than one patient were fatigue and 
neurologic symptoms, and no cardiac events were noted.  Oral belinostat was studied in 15 
patients who were included in the phase 1 trial of IV belinostat in second or subsequent treatment 
cycles (Steele et al., 2011).  High doses, up to 1000 mg/m2 orally twice daily for 5 consecutive 
days, were found tolerable in this small study.  In a phase 1 trial of oral belinostat in patients 
with lymphoma, the drug was found to be safe (no DLTs) at daily doses of 750-1250 mg on 
Days 1-14 every 3 weeks (Zain et al., 2009).  In a phase 2 clinical trial, belinostat was 
administered IV at 1000 mg/m2 daily on Days 1-5 every 21 days in patients with 
relapsed/refractory AML or newly diagnosed patients with AML over the age of 60 (Kirschbaum 
et al., 2015).  Belinostat was well tolerated; however, only 4 patients displayed stable disease 
(SD) for at least five cycles.  A similar trial of belinostat at the same dose and schedule showed 
similar activity in myelodysplastic syndrome (MDS), with only one confirmed response (Cashen 
et al., 2012). 
 
Belinostat has been found to be well tolerated in combination with carboplatin and paclitaxel in 
patients with solid tumors; in a phase 1 study, the maximal administered dose of belinostat was 
1000 mg/m2/d IV on Days 1-5 every 21 days, with carboplatin (AUC 5) and/or paclitaxel (175 
mg/m2) administered on Day 3 after belinostat (Lassen et al., 2010).  Belinostat has also been 
evaluated in combination with 5-FU; cisplatin, doxorubicin, and cyclophosphamide (PAC, in 
advanced or recurrent thymic malignancies); cisplatin and etoposide; and 13-cis retinoic acid in 
phase 1 studies in patients with advanced solid tumors (Northfelt et al., 2007; Thomas et al., 
2012; Balasubramaniam et al., 2013; Luu et al., 2013).  In combination with a 96-hr infusion of 
5-FU, 500 mg/m2/d on Days 2-5, belinostat was well tolerated at doses up to 1000 mg/m2 IV 
daily on Days 1-5 of a 21-day cycle (Northfelt et al., 2007).  In combination with PAC 
(50/50/500 mg/m2 IV every 3 weeks), the recommended phase 2 dose (RP2D) of belinostat was 
1000 mg/m2 over a 48-hr continuous IV infusion (Thomas et al., 2012).  The RP2D of belinostat 
in combination with cisplatin 60 mg/m2 on Day 1 and etoposide 80 mg/m2/d on Days 1-3 of a 3-
week cycle was 500 mg/m2/24 h when administered by 48-hr continuous IV infusion 
(Balasubramaniam et al., 2013).  In contrast, when combined with the non-cytotoxic 13-cis 
retinoic acid, 100 mg/m2 daily on Days 1-14, the MTD of belinostat was not reached even at 
2000 mg/m2 daily on Days 1-5 every 21 days (Luu et al., 2013).  The combination of belinostat, 
1000 mg/m2/d IV and azacitidine, 75 mg/m2/d subcutaneously on Days 1-5 every 28 days has 
been found to be feasible and active in patients with advanced myeloid malignancies (Odenike et 
al., 2011).  Furthermore, this dose of belinostat, administered on Days 1-5 and 8-12 of a 3-week 
cycle in conjunction with bortezomib (1.3 mg/m2 on Days 1, 4, 8, and 11) was also found to be 
tolerable and active (1 complete response [CR], 2 partial responses [PRs], and 8 who have SD of 
22 evaluable patients) in a phase 1 trial in patients with relapsed/refractory acute leukemia or 
MDS (Holkova et al., 2012).  In this trial, the CR was attained in a heavily pretreated patient 

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with MLL-rearranged AML, while another patient with AML arising from JAK2-mutated 
myelofibrosis maintained SD for 2.5 years (Holkova et al., 2012). 
 
2.2.2 SGI-110 (Guadecitabine) 
 
2.2.2.1 
Mechanism of Action 
 
SGI-110 (guadecitabine; 2'-deoxy-5-azacytidylyl-(3'→5')-2'-deoxyguanosine sodium salt) is a 
next-generation hypomethylating agent (HMA) which inhibits DNA methyltransferase (DNMT) 
to reverse epigenetic aberrant DNA methylation characteristic of many cancer cells (SGI-110 
Investigator’s Brochure, 2019; Issa et al., 2015).  First-generation epigenetically targeted HMAs 
include azacitidine and decitabine, which are both approved in the U.S. for all myelodysplastic 
syndrome (MDS) subtypes and in Europe for acute myeloid leukemia (AML) (both) and MDS 
(azacitidine only). 
 
SGI-110 (guadecitabine) is a dinucleotide of decitabine (its active metabolite) and 
deoxyguanosine linked with a 3'→5' phosphodiester bond and was rationally designed to be 
more stable than decitabine to provide enhanced PK and pharmacodynamic properties.  In 
addition to SGI-110’s designed resistance to cytidine deaminase, the main enzyme responsible 
for degradation of decitabine, the gradual cleavage of the 3'→5' phosphodiester bond by 
phosphodiesterase Type 1 and other enzymes results in continuous release of decitabine, 
prolonging its short half-life of less than 30 minutes and exposure window (Issa et al., 2015).  
The prolonged exposure window and reduced peak plasma concentrations of decitabine formed 
after dosing with subcutaneous (SC) SGI-110 (guadecitabine) may result in better access to 
target tissues and is the proposed basis for potential increased efficacy (i.e., more efficient S-
phase dependent incorporation into DNA of cancer cells to cause DNA hypomethylation and 
subsequent cellular differentiation or apoptosis) and potential reduced off-target toxicity 
compared with IV decitabine (SGI-110 Investigator’s Brochure, 2019).   
 
2.2.2.2 
Summary of Clinical Experience 
 
As of June 30, 2019, a total of 1,388 subjects (AML, MDS, HCC, and ovarian cancer), 1,235 of 
which had AML or MDS, were treated with SGI-110 (guadecitabine) (SGI-110 Investigator’s 
Brochure, 2019).  Of the 1,235 subjects with AML/MDS treated with SGI-110 (guadecitabine) in 
Astex/Otsuka-sponsored studies, 966 subjects (78%) had serious adverse events (SAEs).  The 
most common SAEs were febrile neutropenia (32%), pneumonia (26%), and sepsis (13%).  
Across all studies, SAEs that occurred in ≥2% of subjects included febrile neutropenia, 
pneumonia, sepsis, bacteremia, cellulitis, pyrexia, septic shock, anemia, thrombocytopenia, and 
urinary tract infection.  Related SAEs occurred in 327 subjects (26.5%).  Related SAEs that 
occurred in ≥0.5% of subjects included febrile neutropenia, pneumonia, sepsis, cellulitis, 
thrombocytopenia, anemia, bacteremia, infection, febrile bone marrow aplasia, neutropenia, 
pyrexia, septic shock, and stomatitis. 
 
A total of 33 subjects (2.7%) died from related SAEs (more than half [24 subjects] died from 
infections, including 9 from pneumonia and 6 from sepsis; 4 died from general disorders 
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dysfunction syndrome; 2 died from febrile neutropenia; and the rest died from various other 
events). 
 
Common related AEs (incidence ≥10%) observed with SGI-110 (guadecitabine) treatment 
include thrombocytopenia, neutropenia, anemia, febrile neutropenia, nausea, injection site 
reaction, fatigue, injection site pain, diarrhea, decreased appetite, and constipation. 
 
2.2.3 ASTX727 
 
2.2.3.1 
Mechanism of Action 
 
ASTX727 is an orally bioavailable hypomethylating agent which consists of two components: 
cedazuridine and decitabine. Decitabine is a cytidine-nucleoside analogue which incorporates 
into DNA during S-phase and inhibits the function of DNMT1 resulting in reduced methylation 
of CpG residues and DNA hypomethylation. The earlier generation DNMT inhibitor decitabine 
is administered intravenously. Decitabine is poorly bioavailable after oral administration due to 
rapid inactivation by cytidine deaminase (CDA) in the gut and liver. Tetrahydrouridine, a CDA 
inhibitor, has been shown to increase the oral bioavailability of decitabine. Cedazuridine (E7727, 
Astex Pharmaceuticals) is a novel, orally bioavailable CDA inhibitor which increases the 
exposure of decitabine up to 14-fold, and may therefore be used in combination with oral 
decitabine to allow that agent to achieve clinically active levels.  
 
2.2.3.2 
Summary of Clinical Experience 
 
The oral cedazuridine and decitabine combination was initially studied in a multicenter, open-
label, phase 1 dose escalation study using a 3+3 dose escalation design (Savona et. al. 2020). The 
objective of this study was to establish an oral combination of decitabine and cedazuridine that 
would achieve similar pharmacokinetic parameters as 20 mg/m2 of decitabine administered 
intravenously. Eligible patients were age 18 or older with a diagnosis of MDS or AML and 
ECOG PS 0-2. Cedazuridine was dose-escalated first, and once maximum inhibition of CDA 
was achieved, the dose of decitabine was then escalated. Fixed doses of oral cedazuridine and 
decitabine were used without adjustment for body surface area. Dose escalation proceeded 
provided mean decitabine exposure from the oral cedazuridine decitabine combination was less 
than 90% of IV decitabine and no dose limiting toxicity was observed. The primary objective 
was to determine a fixed-dose oral combination of cedazuridine and decitabine that would 
closely approximate the pharmacokinetic and toxicity profile of intravenous decitabine 20 
mg/m2.  
 
In this study, 44 patients were enrolled in five dose-escalation cohorts. The combination of 
cedazuridine 100 mg with decitabine 30 mg was found to approximate the pharmacokinetic 
parameters of decitabine 20 mg/m2 (5-day AUC exposure 81% of IV decitabine) whereas 
decitabine 40 mg exceeded these parameters modestly (5-day AUC exposure 128% of IV 
decitabine). The elimination phase for oral cedazuridine and decitabine followed a similar 
trajectory to that of decitabine monotherapy. Drug-related adverse events seen with oral 
cedazuridine 100 mg plus decitabine 30 mg were thrombocytopenia (32%), fatigue (16%), 
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discontinued treatment for drug-related adverse events. The overall toxicity profile and clinical 
efficacy appeared similar to decitabine 20 mg/m2 IV.  
 
Subsequently, a phase 2 study, multi-center, open-label, crossover study was conducted using 
data from the phase 1 dose escalation to compare the pharmacokinetics, pharmacodynamics, 
safety and efficacy of oral cedazuridine and decitabine with IV decitabine (Garcia-Manero et. al. 
2020). Here, most patients received a fixed-dose combination tablet (ASTX727) consisting of 
cedazuridine 100 mg and decitabine 35 mg. Intravenous decitabine was administered at 20 
mg/m2. Patients were randomized 1:1 to receive one of two possible treatment sequences during 
the first two 28-day cycles: ASTX727 daily for 5 days in cycle 1 followed by IV decitabine daily 
for 5 days in cycle 2, or the reverse. After the first 2 cycles of treatment, all patients continued 
treatment with ASTX727 alone. The study included patients 18 years or older with intermediate 
or high risk MDS and CMML. The primary endpoints were pharmacokinetic exposure, DNA 
demethylation and overall response rate. This study found that ASTX727 and decitabine have 
similar AUC profiles and both achieved peak plasma concentration at one hour post-dose. Both 
agents had comparable effects on LINE-1 demethylation. The efficacy and toxicity profiles of 
ASTX727 were very similar to historical controls for intravenous decitabine. On the basis of 
these studies, the FDA approved ASTX727 for use in MDS. 
 
2.3 
Rationale 
 
DNMT inhibitors have been well characterized in the treatment of hematologic malignancies 
including myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML).  Currently, 
MDS represents the only FDA-approved indication for the hypomethylating agents 5-azacitidine 
and decitabine; however, these drugs are often used off-label in older adults with AML unfit for 
chemotherapy (Silverman et al., 2002; Kantarjian et al., 2006).  SGI-110 (guadecitabine) is a 
second-generation hypomethylating agent with more favorable PK properties which has shown 
efficacy in phase 1/2 studies in older treatment-naïve patients with AML, relapsed-refractory 
AML, higher-risk MDS, and CMML (Montalban-Bravo et al., 2016; Kantarjian et al., 2017). 
 
Histone deacetylases are important epigenetic regulators that function through deacetylation of 
histone and non-histone proteins leading to gene silencing, regulation of cell cycle progression 
and proliferation (Bernhart et al., 2017).  Although the role of HDACs in cancer pathogenesis is 
not fully understood owing to their pleiotropic effects, these agents have shown clinical benefit 
when applied to various malignancies.  Four HDAC inhibitors have received regulatory 
approval, including vorinostat and romidepsin for cutaneous T cell lymphoma, belinostat and 
romidepsin for peripheral T cell lymphoma, and panobinostat for multiple myeloma (Mann et al., 
2007; San-Miguel et al., 2014; O'Connor et al., 2015).  The anti-tumor effect of HDAC 
inhibitors may be enhanced through combination use with a hypomethylating agent as shown in 
preclinical studies in multiple malignancies.  A phase 1/2 trial of oral 5-azacitidine with 
romidepsin in patients with relapsed or refractory peripheral T cell lymphoma demonstrated an 
overall response rate of 80% and was well tolerated (O’Connor et al., 2017). 
 
In summary, CS represents a rare disease for which there is no effective or approved treatment.  
Patients are often treated with ineffective and toxic chemotherapy.  Although insights into CS 
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studies support this hypothesis and the potential efficacy of an epigenetic-based treatment 
strategy.  The HDAC inhibitor vorinostat was shown to induce p21, result in G1 cell cycle arrest, 
and effectively impair cell proliferation in preclinical CS models (Yamamoto et al., 2008; 
Bernhart et al., 2017).  Similarly, treatment with the HDAC inhibitor desipeptide modulated 
expression of extracellular matrix genes and resulted in differentiation and chondrocytic 
maturation of CS cells with suppression of tumor growth in vitro and in vivo (Sakimura et al., 
2007).  A particularly novel approach using HDAC-loaded bone cement for local cytotoxic 
activity demonstrated activity in CS models without toxicity on non-neoplastic cells (Tonak et 
al., 2014).  In addition, numerous studies have demonstrated activity for the DNMT inhibitor 5-
azacitidine in CS models, through reversal of the hypermethylated state induced by IDH1/2 
mutation, suppression of Wnt/B-catenin signaling, induction of the cancer testis antigens NY-
ESO-1 and PRAME, and various other mechanisms (Fitzgerald et al., 2011; Pollack et al., 2012; 
Sheng et al., 2018).  Among solid tumors, CS is an attractive target for an epigenetic treatment 
approach.  
 
2.3.1 Preclinical Data 
 
Preclinical studies were conducted in several conventional CS cell lines, including CH2879 
(grade III; IDH wild type), JJ102 (grade II; IDH1 mutant), CS1 (grade III; IDH2 mutant), and 
SW1353 (grade II; IDH2 mutant).  Monotherapy treatment with either 5-azacitidine (DNMT 
inhibitor) or vorinostat (SAHA, an HDAC inhibitor) demonstrated minimal anti-proliferative 
effect with IC50 for cell viability >1 mcM across all CS cell lines tested in 5-day proliferation 
assays (Figure 1A).  In contrast, combination treatment with 250 nM 5-azacitidine and 500 nM 
vorinostat significantly reduced cell viability as compared to no drug control and either 
monotherapy.  In combination, 5-azacitidine and vorinostat reduced cell viability by 
approximately 70% as compared to untreated controls and was significantly more effective than 
either monotherapy in all CS cell lines tested, regardless of IDH mutational status (Figure 1B). 
 
 
Figure 1: (A) 5-AZA (5-azacitidine) and SAHA (vorinostat) have limited anti-proliferative effect as 
monotherapy in CS cell lines.  CS cell lines were treated with 5-AZA or SAHA monotherapy at doses from 0-1,000 

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nmol/L daily for 5 days and cell viability was assessed.  A colorimetric cell proliferation assay using 96-well plates 
(Dojindo Molecular Technologies) was used to quantify the amount of formazan dye generated by the activity of 
dehydrogenases in the cells which is directly proportional to the number of living cells.  The optical density at 450 nm 
was measured using Spectra Max 340 PC (Molecular Devices Corp) to determine cell viability.  (B) 5-AZA + SAHA 
combination treatment demonstrates significantly greater anti-proliferative effect than either monotherapy.  
CS cell lines were treated with no drug (ND), 5-AZA 250 nM daily, SAHA 500 nM daily of the combination (A+S) for 5 
days and cell viability was assessed as described above. 
 
Western blots were performed to investigate the mechanisms of drug treatment.  In western blots 
from cells lysed after 48-hour treatment, combination 5-azacitidine and vorinostat induced 
apoptosis as evidenced by PARP cleavage, which was not observed with either monotherapy 
(except for the CS1 cell line when treated with vorinostat alone) (Figure 2A).  In all cell lines, 
the combination treatment induced greater DNA damage (H2AX), and in the CH2879, JJ012, 
and CS1 cell lines, the pro-apoptotic protein BIM was induced to a greater extent by combination 
treatment (Figure 2A). 
 
 
Figure 2:  5-azactidine (5-AZA) and vorinostat (SAHA) combination treatment induces apoptosis (cleaved 
PARP), acetylated histone H3, BIM, and E-cadherin in CS cell lines, regardless of IDH mutation status.  Cell 
lines were treated with no drug (-/-), 5-AZA (250 nm), SAHA (500 nm), or the combination (+/+) for 48 hours.  Cells 
were lysed and western blot analyses were performed using validated antibodies and GAPDH (Cell Signaling 
Technologies) as loading control. 
 
Feinberg has proposed the concept of epigenetic modulators, modifiers and mediators as a 
framework for understanding epigenetic dysregulation in cancer (Feinberg et al., 2016).  
Epigenetic modifiers are “genes whose products modify the epigenome directly through DNA 
methylation, post-translational modification of chromatin or alteration of the structure of 
chromatin” while epigenetic mediators are “genes whose products are the targets of epigenetic 
modifiers and which drive a tumor or progenitor cell towards a more stem-like state and prevent 
differentiation”.  Epigenetic modifiers include DNMTs and HDACs.  Dysregulation of 
epigenetic modifiers is evident through changes in DNA methylation, histone modification 
(including acetylation), and chromatin organization, which affect the gene expression of 
epigenetic mediators.  As one example of epigenetic modification, inactive genes show 
methylation at lysine 27 (H3K27me3), and permanently silenced genes carry methylation at 
lysine 9 (H3K9me3).  Gain of H3K27 and H3K9 methylation has been associated with cancer 
through inactivation of tumor suppressors and impairment of differentiation. 
 
In 50-60% of conventional CS cases, IDH1 or IDH2 mutations induce global DNA 
hypermethylation through production of the oncometabolite D-2HG which inhibits endogenous 
demethylases such as TET2.  In the IDH1 mutant JJ012 cell line, 5-azacitidine and vorinostat 
each reduced global DNA methylation by approximately 40% as compared to non-treated 
controls, while combination treatment reduced global DNA methylation to a significantly greater 
extent than either monotherapy, suggesting more effective reversal of the aberrantly 

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hypermethylated state (Figure 3A).  Furthermore, in western blot experiments, untreated CS cell 
lines expressed repressive methylation of H3K9 regardless of IDH mutational status.  H3K9me3 
levels were unaffected by monotherapy treatment with either 5-azacitidine or vorinostat.  In 
contrast, the combination treatment markedly suppressed H3K9 methylation in all cell lines 
tested (Figure 3B). 
 
 
Figure 3:  (A) Combination of 5-AZA and SAHA treatment effectively reverses the global DNA 
hypermethylation induced by IDH mutation in the JJ012 CS cell line.  Cell lines were treated with no drug (-/-), 5-
AZA (250 nm), SAHA (500 nM), or the combination (+/+) for 48 hours and methylation level using ELISA Easy kit 
(colorimetric).  (B) Combination of 5-AZA and SAHA treatment more effectively reduces repressive histone 
methylation at lysine 9 (H3K9me) while total histone H3 levels are unchanged.  Cell lines were treated with no 
drug (-/-), 5-AZA (250 nm), SAHA (500 nM), or the combination (+/+) for 48 hours and lysine 9 acetylated and total 
histone H3 levels were assessed by western blot using validated antibodies. 
 
E-cadherin is a tumor suppressor gene which regulates cell migration, motility, and invasiveness.  
In many cancers, E-cadherin is epigenetically modified and represents an epigenetic mediator as 
described by Feinberg.  In untreated CS cell lines evaluated by western blot, E-cadherin was not 
appreciably expressed regardless of IDH mutational status (Figure 2B).  Monotherapy treatment 
with either 5-azacitidine or vorinostat was insufficient to re-express E-cadherin, although 5-
azacitidine did have minimal effect in some CS cell lines (Figure 2B).  In contrast, combination 
treatment with 5-azacitidine and vorinostat effectively induced E-cadherin expression in all CS 
cell lines (Figure 2B).  The significance of E-cadherin expression for the anti-proliferative effect 
of combination 5-azacitidine and vorinostat treatment was explored in the JJ012 and CS1 cell 
lines using siRNA techniques (Figure 4).  Following siRNA knockdown of E-cadherin gene 
expression, the additional activity of combination treatment over monotherapy was abrogated 
(Figure 4).  These findings suggest epigenetic re-expression of E-cadherin is partially 
responsible for the anti-proliferative effect of combination treatment.  In additional studies, the 
combination treatment was shown to reduce levels of the transcription factors SNAIL1, SNAIL2 
and ZEB1, which are known to regulate E-cadherin expression through epigenetic mechanisms 
involving H3K9 and H3K27 methylation (Cui et al., 2018). 
 

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Figure 4:  siRNA knockdown of E-cadherin gene expression partially abrogates the anti-proliferative effect of 
combination 5-azacitidine (5-AZA) and vorinostat (SAHA) treatment.  Approximately 3-5 × 105 cells were plated 
and transfected with 100 nmol/L of indicated siRNAs (GE Dharmacon).  48 hours after transfection, cells were 
trypsinized, counted using a Nexcelom cell counter, and plated in 96-well plates (1,400 cells/well) in triplicate for cell 
viability assays or 60-mm plates (3-5 × 105 cells/plate) for western blotting analysis.  Cells were also collected, lysed, 
and analyzed by western blot to check for knockdown of protein expression (shown below graphs).  For western 
blotting, cells in 60-mm plates were treated for 24 hours, whereas, for cell viability assays, cells in 96-well plates were 
treated for 72 hours with no drug control (ND), 5-AZA (250 nm), SAHA (500 nM), or 5-AZA + SAHA.  Cell viability was 
measured as described in Figure 2.  Combined data from at least two independent experiments is shown. 
 
Epigenetic modifications influence the tumor microenvironment by regulating expression of 
cytokines and checkpoint molecule expression on immune, stromal, and neoplastic cells.  The 
suppression of interferon-responsive genes may assist tumors in evading the host immune 
response.  At baseline, the CS1 and JJ012 CS cell lines expressed low levels of the interferon 
responsive genes IRF7, OASL, ISG15 and DDX58 (Figure 5).  Treatment with either 5-
azacitidine or vorinostat monotherapy had no effect on expression of these genes aside from 
modest induction of IRF7 in the JJ012 cell line (Figure 5).  In contrast, combination treatment 
induced dramatic expression of IRF7 in both CS1 and JJ012, with up to 900-fold and 30,000-fold 
increase in expression over untreated controls, respectively (Figure 5).  In the CS1 line, 
expression of OASL, ISG15, and DDX58 was also markedly increased with combination 
treatment (Figure 5).  The relevance of IRF7 gene expression for the anti-proliferative effect of 
combination treatment was further evaluated using siRNA techniques (Figure 6).  In the JJ012 
cell line, siRNA knockdown of IRF7 gene expression partially abrogated the efficacy of 
combination treatment in proliferation assays (Figure 6).  Similar effects were seen for the 
MDA5 gene, which is involved in the innate immune response, in the CS1 cell line. (Figure 6). 
 

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Figure 5:  Combination of 5-azacitidine (5-AZA) + SAHA (vorinostat) treatment induces expression of the 
interferon-responsive gene IRF7 in the CS cell lines CS1 and JJ012.  Cell lines were treated with no drug (-/-), 5-
AZA (250 nM), SAHA (500 nM), or the combination (+/+) for 48 hours.  Gene expression was measured using 
quantitative polymerase chain reaction (qPCR) and expression was reported relative to untreated control cell lines. 
 
 
 
Figure 6:  siRNA knockdown of IRF7 gene expression in the JJ012 cell line (left), and MDA5 gene expression 
in the CS1 cell line (right), partially abrogates the anti-proliferative effect of combination 5-azacitidine (5-AZA) 
and vorinostat (SAHA) treatment.  Approximately 3-5 × 105 cells were plated and transfected with 100 nmol/L of 
indicated siRNAs (GE Dharmacon).  48 hours after transfections, cells were trypsinized, counted using a Nexcelom 
cell counter, plated in 96-well plates (1,400 cells/well) in triplicate, and treated for 72 hours with no drug control (ND), 
5-AZA (250 nM), SAHA (500 nM), or 5-AZA + SAHA.  Cell viability was measured as described in Figure 2.  
Combined data from at least two independent experiments is shown. 
 
The use of combination DNMT and HDAC inhibitors for the treatment of CS was further 
assessed in vivo using a JJ012 mouse xenograft model.  In this experiment, four groups of mice 
were treated for 4 weeks:  group 1:  vehicle IP daily for 5 days/wk; group 2:  5-azacitidine 2 
mg/kg IP daily for 4 days/wk; group 3:  vorinostat 50 mg/kg IP 4 days/wk; group 4:  5-
azacitidine 2 mg/kg IP + vorinostat 50 mg/kg IP concurrently for 4 days/wk.  Five mice were 
treated per group.  In these experiments, 5-azacitidine or vorinostat monotherapy suppressed 
tumor growth modestly as compared to vehicle control, and when animals were sacrificed at 90 
days, vorinostat appeared somewhat more active as monotherapy when compared with 5-
azacitidine (Figure 7A). In contrast, at day 90, mice treated with combination 5-azacitidine and 
vorinostat treatment had experienced minimal tumor growth from baseline over the course of the 
experiment, and tumors were over 80% smaller by volume than vehicle control (Figure 7A).  
The combination treatment was significantly more effective than either monotherapy (Figure 
7A).  In western blots of cell lysates from the treated animals, combination treatment showed 
greater induction of E-cadherin, Ac.H3, and H2AX as compared to vehicle control or 
monotherapy treatment, and combination treatment showed some evidence of apoptosis, all 
consistent with the in vitro experiments described in Figure 7B. 

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Figure 7:  Combination treatment with 5-azacitidine (5-AZA) and vorinostat (SAHA) induces significantly 
greater suppression of tumor growth than either monotherapy in vivo.  (A) Tumor growth of JJ012 mouse 
xenografts treated with the indicated drugs is shown (5 animals per group).  (B) For western blots, 30 micrograms of 
RIPA lysates obtained using a sample grinding kit (GE Healthcare) from xenograft tissues at the end of 90-day 
treatments were loaded on SDS/PAGE and immunoblotted using the indicated antibodies with GAPDH as loading 
control. 
 
Additional experiments were conducted using other combinations of DNMT and HDAC 
inhibitors to demonstrate class effect, including the second-generation DNMT inhibitor SGI-110 
(guadecitabine) and the HDAC inhibitors romidepsin and belinostat.  In summary, these studies 
showed equivalent efficacy for combinations of 5-azacitidine and romidepsin as compared to 
combinations of SGI-110 (guadecitabine) and romidepsin across all CS cell lines tested (Figure 
8).  In all cases, combination treatments were more effective than monotherapy with the 
respective DNMT and HDAC inhibitor (Figure 8).  In these experiments, concurrent 6-day 
treatments, or sequential treatments (2 days hypomethylating agent followed by 4 days 
concurrent treatment) showed comparable efficacy except in the CH2879 cell line, where 
sequential treatment appeared modestly more active (Figure 8).  In western blot studies from 
related cell lysates, combination treatment resulted in greater induction of PD-L1 and Ac.H3, and 
more evident apoptosis as demonstrated by PARP cleavage (Figure 9).  Furthermore, 
combinations of 5-azacitidine and romidepsin appeared similar to guadecitabine and romidepsin 
western blot experiments (Figure 9). 
 
 
 
 
 

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Figure 8:  (A) SGI-110 and romidepsin exhibits comparable efficacy as 5-azacitidine (AZA) and romidepsin 
when given in combination as either concurrent or sequential treatment in CS cell lines.  Romidepsin was 
given at 1 nanomolar, 5-azacitidine at 250 nM, and SGI-110 at 250 nM in all experiments.  In concurrent treatments, 
both drugs were given together for 6 days.  In sequential treatments, the hypomethylating agent was given alone for 2 
days, followed by 4 days of concurrent treatment.  Cell viability was assessed.  A colorimetric cell proliferation assay 
using 96-well plates (Dojindo Molecular Technologies) was used to quantify the amount of formazan dye generated 
by the activity of dehydrogenases in the cells which is directly proportional to the number of living cells.  The optical 
density at 450 nm was measured using Spectra Max 340 PC (Molecular Devices Corp) to determine cell viability. 
 
 
Finally, additional studies were conducted with the CTEP IND agents belinostat and SGI-110 
(guadecitabine).  In cell viability assays, belinostat or SGI-110 (guadecitabine) appeared 
somewhat more active as monotherapy when compared with the other HDAC or DNMT 
inhibitors when used as monotherapy, as presented above (Figure 10).  Nonetheless, the 
belinostat and SGI-110 (guadecitabine) combination remained significantly more active as 
compared to either monotherapy in all CS cell lines tested (Figure 10).  In the IDH mutant cell 
lines, cell viability was reduced by approximately 90% as compared to no drug control (Figure 
10).  In western blots from cells lysed after 48-hour treatment, the combination treatment was 
more effective at inducing PD-L1, E-cadherin, and acetylated histone H3 than no drug treatment 
or either monotherapy.  Evidence of PARP cleavage was seen both with the combination 
treatment and belinostat alone (Figure 11). 
 
Figure 9:  Combination treatment with 5-azacitidine (AZA) + romidepsin or SGI-110 + 
romidepsin effectively induce apoptosis, PD-L1, and acetylated histone H3.  Cell 
lines were treated with no drug, 1 nM romidepsin, 250 nM SGI-110, 250 nM 5-AZA, 
combination 1 nM romidepsin + 250 nM SGI-110, or combination 1 nM romidepsin + 250 
nM 5-AZA for 3 days.  Cells were lysed and western blot analyses were performed using 
validated antibodies and GAPDH (Cell Signaling Technologies) as loading control. 

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Figure 10:  Belinostat and SGI-110 combination treatment is also effective in CS cell lines, regardless of IDH 
mutational status.  CS cell lines were treated with no drug (ND), belinostat 300 nM daily, SGI-110 250 nM daily, or 
the combination, for 6 days and cell viability was assessed as described in Figure 2. 
 
 
In summary, our preclinical work suggests combination treatment with a DNMT and HDAC 
inhibitor has marked efficacy for the treatment of CS in vitro and in vivo and regardless of IDH 
mutational status.  Combining a DNMT inhibitor with an HDAC inhibitor demonstrates 
significantly greater efficacy than either agent used alone, which was particularly apparent in 
vivo, where the combination treatment resulted in near complete suppression of xenograft tumor 
growth.  Efficacy was demonstrated with various combinations of DNMT and HDAC inhibitors.  
The mechanisms accounting for the observed efficacy are likely complex and multifactorial.  
However, our experiments suggest that reversal of the global hypermethylated state and 
differentiation block seen in CS is central to the treatment’s efficacy, including re-expression of 
E-cadherin and IRF7, among others.   
 
On the basis of these findings, we proposed a phase 2 clinical trial with the DNMT inhibitor 
SGI-110 (guadecitabine) and the HDAC inhibitor belinostat in patients with unresectable or 
metastatic conventional chondrosarcoma. 
 
Figure 11:  Belinostat and SGI-110 combination treatment 
induces apoptosis, PD-L1, E-cadherin, and acetylated histone 
H3 (AC.H3) in CS cell lines.  Cell lines were treated with no drug (-/-
), belinostat (300 nM), SGI-110 (250 nM), or the combination, for 48 
hours.  Cells were lysed and western blot analyses were performed 
using validated antibodies and tubulin (Cell Signaling Technologies) 
as loading control. 

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During the conduct of this study, further clinical development of the hypomethylating agent SGI-
110 (guadecitabine) was discontinued by the drug manufacturer and further enrollment on the 
belinostat and SGI-110 treatment regimen will stop. ASTX727 is a novel, orally bioavailable 
hypomethylating agent which contains the same active agent (decitabine) and an analogous 
mechanism of action. Additional information on ASTX727 is provided in Section 2.2.3. 
Effective with Amendment 5, patients entering the study will be treated with belinostat and 
ASTX727, as described in Section 6.  
 
 
2.4 
Correlative Studies Background 
 
2.4.1 Integrated Studies 
 
2.4.1.1 
Whole Exome Sequencing 
 
CS is a rare disease.  Currently, aside from recurrent mutations in IDH1/2, little is known 
regarding the genomic landscape of these tumors.  A better understanding of genomic alterations 
in CS may inform the development of new therapeutic approaches for this disease.  Only one 
major genomic profiling study has been performed in CS (Tarpey et al., 2013).  In this study of 
49 patients, IDH1/2 mutations were found in 59% of cases.  Recurrent alterations in the collagen 
regulator gene COL2A1 were present in 37%, including both IDH mutant and wild-type cases.  
Mutations were also found in TP53 (20%), the Rb pathway (33%), and Hedgehog signaling 
(18%).  In IDH wild-type cases, recurrent alterations in other epigenetic regulators were 
apparent, such as KDM6A, SETD2, TET, and DNMT3A, suggesting alternative mechanisms of 
epigenetic dysregulation may contribute to pathogenesis of IDH1/2 wild-type tumors.  We 
hypothesize that recurrent IDH1/2 mutations will be found in CS, consistent with observations 
from prior studies, and that alterations in other genes may be responsible for epigenetic 
dysregulation in IDH1/2 wild-type tumors. 
 
2.4.1.2 
RNAseq 
 
The efficacy of treatment with belinostat and SGI-110 (guadecitabine) or ASTX727 in an 
epigenetically-dysregulated malignancy such as CS is hypothesized to depend upon favorable 
changes in gene expression and reversal of aberrant hypermethylation of tumor suppressors 
imparted by effects of IDH1/2 mutation and other biologic mechanisms.  In our preclinical 
studies, combination treatment reduced global DNA methylation levels in CS cell lines.  
Furthermore, changes in expression of BIM, E-cadherin, PD-L1, MHC, and interferon-related 
genes such as IRF7 occurred with this treatment.  siRNA studies showed that induction of E-
cadherin and IRF7 expression was partially responsible for the anti-proliferative effect of 
combination treatment.  In other preclinical studies, epigenetic repression of p16, E-cadherin, 3-
OST (a heparin sulfate proteoglycan), and RUNX3 (cell cycle) appeared important for CS 
tumorigenesis.  We hypothesize that belinostat and SGI-110 (guadecitabine) or ASTX727 will 
result in favorable changes in gene expression resulting in induction of differentiation and re-
expression of tumor suppressors and endogenous retroviral elements with associated favorable 
effects on the tumor immune microenvironment. 
 

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2.4.2 Exploratory Studies 
 
2.4.2.1 
Tumor Immune Microenvironment 
 
The effectiveness of many anti-cancer therapeutics depends upon activity of the immune system.  
Many cancers alter normal cellular processes to evade immune surveillance, and increasing 
evidence suggests that immune evasion is accomplished in part through epigenetic modification 
of genes involved in antigen presentation, expression of immunosuppressive cell surface 
molecules, suppression of candidate neoantigens, and other mechanisms.  There is increasing 
evidence to support combining epigenetic-based therapies, including HDAC and DNMT 
inhibitors, with immune checkpoint inhibitors, and clinical trials with these combinations are 
ongoing (Weisenberger et al., 2006).  However, studies evaluating the effects of epigenetic 
treatments on the immune microenvironment using tissue from prospective clinical trials with 
HDAC and DNMT inhibitors is limited.  We will analyze changes in densities of infiltrating 
immune cell subsets between pre-treatment and on-treatment specimens to evaluate changes 
induced by study treatment.  We hypothesize that belinostat and SGI-110 (guadecitabine) or 
ASTX727 treatment will induce expression of MHC and PD-L1 by tumor cells and will increase 
infiltration of cytotoxic T-cells into chondrosarcoma tumors. 
 
2.4.2.2 
Global DNA Methylation Assay 
 
Changes in global methylation represent one pharmacodynamic marker of epigenetic treatment 
activity in tumor tissue.  In several clinical studies of HDAC and DNMT inhibitors in solid 
tumors, greater reduction in global methylation or higher levels of global methylation or 
methylation of specific genes at baseline correlated with clinical outcomes.  In our preclinical 
studies, HDAC inhibitor and hypomethylating agent combinations effectively reduced global 
DNA methylation to a greater extent than either monotherapy in chondrosarcoma cell lines.  We 
hypothesize that belinostat and SGI-110 (guadecitabine) or ASTX727 treatment will reduce 
global DNA methylation levels in CS tumors, which could serve as a relevant biomarker for the 
treatment’s anti-cancer effects. 
 
3. 
PATIENT SELECTION 
 
3.1 
Eligibility Criteria  
 
3.1.1 Patients must have biopsy-proven conventional CS which is: 
- 
either metastatic or locally advanced and unresectable, and 
- 
measurable at study entry according to RECIST version 1.1 criteria, and 
- 
amenable to biopsy with imaging guidance at no or acceptable risk to the patient as 
defined by institutional guidelines for research-related biopsies or the treating 
investigator’s assessment. 
 
In addition, the following criteria must be met: 
- 
patients must have at least one lesion measurable by RECIST version 1.1 criteria 
which has not been previously irradiated.  
- 
patients who have histologic evidence of grade 1 chondrosarcoma only must either be 

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symptomatic from their disease in the opinion of the treating investigator or 
demonstrate radiographic evidence of disease progression in the 3 months prior to 
initiation of study treatment.  
 
Note: Pathology review and confirmation of diagnosis will occur at the site enrolling the 
patient on this study. 
 
3.1.2 Patients may have been treated with any number of prior systemic therapies.  Because 
there are no FDA-approved treatments for this disease, patients who have received no 
prior systemic therapy are also eligible.  However, disease must be deemed surgically 
unresectable. 
 
3.1.3 Age ≥18 years.  Chondrosarcoma is rarely encountered in children and adolescents. 
 
3.1.4 ECOG performance status ≤2 (Karnofsky ≥60%, see Appendix A). 
 
3.1.5 Patients must have adequate organ and marrow function as defined below: 
 
− 
absolute neutrophil count 
 
≥1,000/mm3  
− 
hemoglobin 
 
8 g/dL 
− 
platelet count 
 
≥75,000/mm3 
− 
total bilirubin 
 
≤1.5 × institutional upper limit of normal (ULN) 
− 
AST(SGOT)/ALT(SGPT) 
 
≤2 × institutional ULN 
− 
creatinine  
 
≤1.5 × institutional ULN 
OR 
− 
glomerular filtration rate (GFR*) 
≥45 mL/min/1.73 m2 
*Refer to Appendix B for calculation of GFR 
 
3.1.6 Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral 
therapy with undetectable viral load within 6 months are eligible for this trial. 
 
3.1.7 For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral 
load must be undetectable on suppressive therapy, if indicated. 
 
3.1.8 Patients with a history of hepatitis C virus (HCV) infection must have been treated and 
cured.  For patients with HCV infection who are currently on treatment, they are eligible 
if they have an undetectable HCV viral load. 
 
3.1.9 Patients with treated brain metastases are eligible if follow-up brain imaging after 
central nervous system (CNS)-directed therapy shows no evidence of progression, if 
patients have been clinically asymptomatic, and if patients have not received systemic 
corticosteroids for at least 28 days.  Patients with brain metastases not meeting these 
criteria are not eligible. 
 
3.1.10 Patients must be disease-free of prior invasive malignancies for >5 years, with the 
exception of curatively-treated basal cell or squamous cell carcinoma of the skin or 

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carcinoma in situ of the cervix. 
 
NOTE:  If there is a history of prior malignancy, patients must not be receiving other 
specific treatment for that cancer. 
 
3.1.11 Patients with known history or current symptoms of cardiac disease, or history of 
treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac 
function using the New York Heart Association Functional Classification.  To be eligible 
for this trial, patients should be class 2B or better. 
 
3.1.12 The effects of belinostat and SGI-110 (guadecitabine) or ASTX727 on the developing 
human fetus are unknown.  For this reason, and because the DNA methyltransferase 
inhibitor decitabine, the active metabolite of SGI-110 (guadecitabine) and a component 
of ASTX727, is known to be teratogenic, and because belinostat may cause teratogenicity 
and/or embryo-fetal lethality by virtue of targeting actively dividing cells, women of 
child-bearing potential and men must agree to use adequate contraception (hormonal or 
barrier method of birth control; abstinence) prior to study entry and for the duration of 
study participation and for at least 6 months after the last dose of study drugs.  Should a 
woman become pregnant or suspect she is pregnant while she or her partner is 
participating in this study, she should inform her treating physician immediately.  Men 
treated or enrolled on this protocol must also agree to use adequate contraception prior to 
the study, for the duration of study participation, and 3 months after completion of 
belinostat and SGI-110 (guadecitabine) or ASTX727 administration. 
 
3.1.13 Patients must be able to understand and willing to sign a written informed consent 
document.  Participants with impaired decision-making capacity (IDMC) who have a 
legally-authorized representative (LAR) and/or family member available will also be 
eligible. 
 
3.2 
Exclusion Criteria 
 
3.2.1 Patients with dedifferentiated, mesenchymal, or clear cell chondrosarcoma are not 
eligible. 
 
3.2.2 Patients who have not recovered from AEs (i.e., have residual toxicities > Grade 1) due to 
prior anti-cancer therapy are not allowed, with the exceptions of alopecia and 
endocrinopathies from prior immunotherapy-based treatments that are well-controlled 
with hormone replacement. 
 
In addition, the following time periods must elapse between the last dose of prior anti-
cancer treatment and initiation of study treatment on this protocol: 
- 
Cytotoxic chemotherapy or biologic, including immunotherapy: 28 days 
- 
Small molecule targeted drug: 21 days or 5 half-lives, whichever is shorter. If 5 
half-lives is shorter than 21 days, then 21 days applies. 
- 
Radiation: 28 days, except for palliative radiation, for which 14 days applies.  
 

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3.2.3 Patients who are receiving any other investigational agents. 
 
3.2.4 Patients with known history of allergic reactions or sensitivity attributed to compounds of 
similar chemical or biologic composition to SGI-110 (guadecitabine), its active 
metabolite decitabine, or ASTX727, or belinostat. 
 
3.2.5 Chronic use of any medications or substances that are strong inhibitors of UGT1A1 is not 
allowed.  Patients must switch to alternative medications 7-14 days before treatment with 
belinostat.  Because the lists of these agents are constantly changing, it is important to 
regularly consult a frequently-updated medical reference.  As part of the 
enrollment/informed consent procedures, the patient will be counseled on the risk of 
interactions with other agents, and what to do if new medications need to be prescribed or 
if the patient is considering a new over-the-counter medicine or herbal product. 
 
3.2.6 Patients with any known UGT1A1 polymorphism, heterozygous or homozygous, 
associated with reduced function (UGT1A1*6, UGT1A1*28, or UGT1A1*60). 
 
3.2.7 Patients with uncontrolled intercurrent illness. 
 
3.2.8 Patients with psychiatric illness/social situations that would limit compliance with study 
requirements. 
 
3.2.9 Pregnant women are excluded from this study because SGI-110 (guadecitabine) is a 
derivative of decitabine, and ASTX727 contains the agent decitabine, which has the 
potential for teratogenic or abortifacient effects, and because belinostat may cause 
teratogenicity and/or embryo-fetal lethality by virtue of targeting actively dividing cells.  
Because there is an unknown but potential risk for AEs in nursing infants secondary to 
treatment of the mother with SGI-110 (guadecitabine), ASTX727 and belinostat, 
breastfeeding should be discontinued. 
 
3.2.10 Prolongation of the heart-rate corrected QT (QTc) interval ≥450 ms (i.e., grade 1 or 
higher) on the screening electrocardiogram (ECG) prior to initiation of study treatment. 
 
If baseline QTc on screening ECG is ≥450 ms (i.e., grade 1 or higher): 
o Check potassium and magnesium serum levels, and 
o Correct any identified hypokalemia and/or hypomagnesemia and repeat ECG to 
confirm a QTc interval <450 ms. 
 
3.3 
Inclusion of Women and Minorities 
 
NIH policy requires that women and members of minority groups and their subpopulations be 
included in all NIH-supported biomedical and behavioral research projects involving NIH-
defined clinical research unless a clear and compelling rationale and justification establishes to 
the satisfaction of the funding Institute & Center (IC) Director that inclusion is inappropriate 
with respect to the health of the subjects or the purpose of the research.  Exclusion under other 

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29 
 
An active CTEP-IAM user account and appropriate RCR registration is required to access all 
CTEP and Cancer Trials Support Unit (CTSU) websites and applications.  In addition, IVRs and 
NPIVRs must list all clinical practice sites and Institutional Review Boards (IRBs) covering their 
practice sites on the FDA Form 1572 in RCR to allow the following: 
 
• Addition to a site roster, 
• Assign the treating, credit, consenting, or drug shipment (IVR only) tasks in OPEN, and 
• Act as the site-protocol Principal Investigator (PI) on the IRB approval. 
• Assign the Clinical Investigator (CI) role on the Delegation of Tasks Log (DTL). 
 
In addition, all investigators act as the Site-Protocol PI, consenting/treating/drug shipment, or as 
the CI on the DTL must be rostered at the enrolling site with a participating organization. 
 
Additional information is located on the CTEP website at 
https://ctep.cancer.gov/investigatorResources/default.htm.  For questions, please contact the 
RCR Help Desk by email at RCRHelpDesk@nih.gov. 
 
4.2 
Site Registration 
 
Sites participating with the NCI Central Institutional Review Board (NCI CIRB) must submit the 
Study Specific Worksheet for Local Context (SSW) to the CIRB using IRBManager to indicate 
their intent to open the study locally.  The NCI CIRB’s approval of the SSW is automatically 
communicated to the CTSU Regulatory Office, but sites are required to contact the CTSU 
Regulatory Office at CTSURegPref@ctsu.coccg.org to establish site preferences for applying 
NCI CIRB approvals across their Signatory Network.  Site preferences can be set at the network 
or protocol level.  Questions about establishing site preferences can be addressed to the CTSU 
Regulatory Office by emailing the email address above or calling 1-888-651-CTSU (2878). 
 
Sites using their local IRB or REB must submit their approval to the CTSU Regulatory Office 
using the Regulatory Submission Portal located in the Regulatory section of the CTSU website.  
Acceptable documentation of local IRB/REB approval includes: 
• Local IRB documentation, 
• IRB-signed CTSU IRB Certification Form, and/or 
• Protocol of Human Subjects Assurance Identification/IRB Certification/Declaration of 
Exemption Form. 
 
In addition, the Site-Protocol PI (i.e., the investigator on the IRB/REB approval) must meet the 
following five criteria to complete processing of the IRB/REB approval record: 
• Holds an Active CTEP status, 
• Rostered at the site on the IRB/REB approval and on at least one participating roster, 
• If using NCI CIRB, rostered on the NCI CIRB Signatory record, 
• Includes the IRB number of the IRB providing approval in the Form FDA 1572 in the 
RCR profile, and 
• Holds the appropriate CTEP registration type for the protocol.  
 

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Additional Requirements 
 
Additional requirements to obtain an approved site registration status include: 
• 
An active Federal-wide Assurance (FWA) number, 
• 
An active roster affiliation with the Lead Protocol Organization (LPO) or a Participating 
Organization, and 
• 
Compliance with all protocol-specific requirements (PSRs). 
 
4.2.1 Downloading Regulatory Documents 
 
Download the site registration forms from the protocol-specific page located on the CTSU 
members’ website.  Permission to view and download this protocol and its supporting documents 
is restricted based on person and site roster assignment.  To participate, the institution and its 
associated investigators and staff must be associated with the LPO or a Participating 
Organization on the protocol.  
 
• Log on to the CTSU members’ website (https://www.ctsu.org) using your CTEP-IAM 
username and password, 
• Click on Protocols in the upper left of your screen 
o Enter the protocol number in the search field at the top of the protocol tree, or 
o Click on the By Lead Organization folder to expand, then select LAO-CT018, and 
protocol number 10330, 
• Click on Documents, select Site Registration, and download and complete the forms 
provided.  (Note:  For sites under the CIRB initiative, IRB data will load automatically to 
the CTSU as described above.)  
 
4.2.2 Protocol Specific Requirements For Protocol #10330 Site Registration 
 
Upon site registration approval in RSS, the enrolling site may access OPEN to complete 
enrollments.  The enrolling site will select their credentialed provider treating the subject in the 
OPEN credentialing screen and may need to answer additional questions related to treatment in 
the eligibility checklist.   
 
•  Specimen Tracking System Training Requirement: 
o All data entry users (Clinical Research Associate role) at each participating site will 
need to complete the Theradex-led training. 
o Theradex will provide a certificate of completion, which will need to be submitted to 
the CTSU through the Regulatory Submission Portal. 
o The training is a one-time only requirement per individual.  If an individual has 
previously completed the training for another ETCTN study, the training does not 
need to be completed again nor does the certificate of completion need to be 
resubmitted to the CTSU.  However, new versions of the Specimen Tracking System 
may require new training. 
o This training will need to be completed before the first patient enrollment at a given 
site. 
o Please contact STS Support at Theradex for the training 

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(STS.Support@theradex.com, Theradex phone: 609-799-7580). 
 
4.2.3 Submitting Regulatory Documents 
 
Submit required forms and documents to the CTSU Regulatory Office via the Regulatory 
Submission Portal on the CTSU website.  
 
To access the Regulatory Submission Portal, log on to the CTSU members’ website → 
Regulatory → Regulatory Submission. 
 
Institutions with patients waiting that are unable to use the Regulatory Submission Portal should 
alert the CTSU Regulatory Office immediately at 1-866-651-2878 in order to receive further 
instruction and support. 
 
Delegation of Tasks Log (DTL) 
 
Each site must complete a protocol-specific DTL using the DTL application in the Delegation 
Log section on the CTSU members’ website.  The Clinical Investigator (CI) is required to review 
and electronically sign the DTL prior to the site receiving an Approved site registration status and 
enrolling patients to the study.  To maintain an approved site registration status the CI must re-
sign the DTL at least annually and when a new version of the DTL is released; and activate new 
task assignments requiring CI sign-off.  Any individual at the enrolling site on a participating 
roster may initiate the site DTL.  Once the DTL is submitted for CI approval, only the designated 
DTL Administrators or the CI may update the DTL.  Instructions on completing the DTL are 
available in the Help Topics button in the DTL application and include a Master Task List, which 
describes DTL task assignments, CI signature, and CTEP registration requirements. 
 
4.2.4 Checking Site Registration Status 
 
You can verify your site’s registration status on the members’ side of the CTSU website.  
 
• 
Log on to the CTSU members’ website 
• 
Click on Regulatory at the top of your screen 
• 
Click on Site Registration  
• 
Enter your 5-character CTEP Institution Code and click on Go 
 
Note:  The status shown only reflects institutional compliance with site registration requirements 
as outlined above.  It does not reflect compliance with protocol requirements for individuals 
participating on the protocol or the enrolling investigator’s status with the NCI or their affiliated 
networks. 
 
4.3 
Patient Registration 
 
4.3.1 OPEN / IWRS 
 
The Oncology Patient Enrollment Network (OPEN) is a web-based registration system available 

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on a 24/7 basis.  OPEN is integrated with CTSU regulatory and roster data and with the Lead 
Protocol Organization (LPOs) registration/randomization systems or Theradex Interactive Web 
Response System (IWRS) for retrieval of patient registration/randomization assignment.  OPEN 
will populate the patient enrollment data in NCI’s clinical data management system, Medidata 
Rave. 
 
Requirements for OPEN access:   
 
• A valid CTEP-IAM account. 
• To perform enrollments or request slot reservations:  Be on an LPO roster, ETCTN 
Corresponding roster, or Participating Organization roster with the role of Registrar.  
Registrars must hold a minimum of an AP registration type. 
• If a DTL is required for the study, the registrar(s) must hold the OPEN Registrar task on the 
DTL for the site. 
• Have an approved site registration for a protocol prior to patient enrollment. 
 
To assign an Investigator (IVR) or Non-Physician Investigator (NPIVR) as the treating, 
crediting, consenting, drug shipment (IVR only), or receiving investigator for a patient transfer in 
OPEN, the IVR or NPIVR must list the IRB number used on the site’s IRB approval on their 
Form FDA 1572 in RCR.  If a DTL is required for the study, the IVR or NPIVR must be 
assigned the appropriate OPEN-related tasks on the DTL. 
 
Prior to accessing OPEN, site staff should verify the following: 
 
1. 
Patient has met all eligibility criteria within the protocol stated timeframes, and  
2. 
All patients have signed an appropriate consent form and HIPAA authorization form (if 
applicable). 
 
Note:  The OPEN system will provide the site with a printable confirmation of registration and 
treatment information.  Please print this confirmation for your records.  
 
Access OPEN at https://open.ctsu.org or from the OPEN link on the CTSU members’ website.  
Further instructional information is in the OPEN section of the CTSU website at 
https://www.ctsu.org or https://open.ctsu.org.  For any additional questions, contact the CTSU 
Help Desk at 1-888-823-5923 or ctsucontact@westat.com. 
 
4.3.2 Special Instructions for Patient Enrollment 
 
This Study will use the ETCTN Specimen Tracking System (STS).  
 
• 
All biospecimens collected for this trial must be submitted using the ETCTN Specimen 
Tracking System (STS) unless otherwise noted.   
• 
The system is accessed through special Rave user roles:  “CRA Specimen Tracking” for 
data entry at the treating institutions and “Biorepository” for users receiving the 
specimens for processing and storage at reference labs and the Biorepository.   
• 
Please refer to the Medidata Account Activation and Study Invitation Acceptance link on 

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Core 
Priority 
Use in the Trial 
Biomarker Name(s) 
Tumor Content 
Required 
Post-Biopsy 
Processing 
1 
Integrated 
WES/RNAseq in 
Tumor Tissue 
>50% 
formalin 
2 
Exploratory 
Global Methylation 
Assay 
>50% 
formalin 
3 
Exploratory 
Tumor Immune 
Microenvironment 
>50% 
formalin 
 
Biopsy #:  2 
Trial Time Point:  Cycle 2, Day 3, 4, or 5 (2-8 hours post treatment) 
IR Biopsy Definition:  Research – No Clinical Impact (All cores from a single biopsy 
procedure impact research goals, but do not directly impact patient care or benefit the patient.) 
Core 
Priority 
Use in the 
Trial 
Biomarker 
Name(s) 
Tumor Content 
Required 
Post-Biopsy Processing 
1 
Integrated 
WES/RNAseq in 
Tumor Tissue 
>50% 
formalin 
2 
Exploratory Global Methylation 
Assay 
>50% 
formalin 
3 
Exploratory Tumor Immune 
Microenvironment 
>50% 
formalin 
 
Note:  Pre-biopsy assessments will be reported and tracked through a trial-specific CRF within 
the CTEP Medidata Rave system (see Appendix C).  
 
5.3 
Specimen Procurement Kits and Scheduling 
 
5.3.1 Specimen Procurement Kits  
 
Kits for the collection and shipment of specimens to the ETCTN Biorepository can be ordered 
online via the Kit Management system: 
(https://ricapps.nationwidechildrens.org/KitManagement).  
 
Users at the clinical sites will need to set up an account in the Kit Management system and select 
a specific clinical trial protocol to request a kit.  Please note that protocol may include more than 
one type of kit.  Each user may order two kit types per protocol per day (daily max = 6 kits).  
Kits are shipped ground, so please allow 5-7 days for receipt.  A complete list of kit contents for 
each kit type is located on the Kit Management system website. 
 
Note:  Kits or supplies are only provided for specimens shipped to the Biorepository. 
Institutional supplies must be used for all other specimen collection and processing.  
 
5.3.2 Scheduling of Specimen Collections  
 
5.3.2.1 
Scheduling of Specimen Collections for the ETCTN Biorepository 
 

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Please adhere to the following guidelines when scheduling procedures to collect tissue:  
• Tumor tissue specimens collected during biopsy procedures and fixed in formalin must 
be shipped on the same day of collection. 
• Tissue in formalin can be collected Monday through Wednesday and shipped overnight 
for arrival on Tuesday through Thursday at the ETCTN Biorepository at Nationwide 
Children’s Hospital. 
• Fresh blood specimens may be collected and shipped Monday through Friday.  
 
5.4 
Specimen Tracking System Instructions 
 
5.4.1 Specimen Tracking System Overview and Enrollment Instructions 
 
For the ETCTN STS, the following information will be requested: 
• Protocol Number 
• Investigator Identification  
o Institution and affiliate name 
o Investigator’s name 
• Eligibility Verification:  Patients must meet all the eligibility requirements listed in 
Section 3. 
• Additional Requirements: 
o Patients must provide a signed and dated, written informed consent form. 
 
Upon enrolling a patient, IWRS will communicate with OPEN, assigning two separate and 
unique identification numbers to the patient, a Universal patient ID (UPID) and a Treatment 
patient ID.  The UPID is associated with the patient and used each and every time the patient 
engages with the portion of this protocol that uses the ETCTN Specimen Tracking System.  The 
UPID contains no information or link to the treatment protocol.  IWRS will maintain an 
association between the UPID for ETCTN biobanking and molecular characterization and any 
treatment protocols the patient participates in, thereby allowing analysis of the molecular 
characterization results with the clinical data.   
 
Immediately following enrollment, the institutional anatomical pathology report for the diagnosis 
under which the patient is being enrolled must be uploaded into Rave.  The report must include 
the surgical pathology ID (SPID), collection date, block number, and the IWRS-assigned UPID 
and patient study ID for this trial.  For newly acquired biopsies, the radiology and operative 
report(s) must also be uploaded into Rave.  Important:  Remove any personally identifying 
information, including, but not limited to, the patient’s name, initials, medical record 
number, and patient contact information from the institutional pathology report prior to 
submission. 
 
Additionally, please note that the STS software creates pop-up windows when reports are 
generated, so you will need to enable pop-ups within your web browser while using the software.   
 
For questions regarding the Specimen Tracking System, please contact STS Support at 
STS.Support@theradex.com. 
 

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A shipping manifest must be included with all sample submissions. 
 
5.4.2 Specimen Labeling 
 
5.4.2.1 Blood Specimen Labels 
 
Include the following on blood specimens: 
• Patient Study ID 
• Universal Patient ID (UPID) 
• Specimen ID (automatically generated by Rave) 
• Time point 
• Specimen type (e.g., blood, serum) 
 
5.4.2.2 Tissue Specimen Labels 
 
Include the following on all tissue specimens or containers (e.g., formalin jar):  
• Patient Study ID 
• Universal Patient ID (UPID) 
• Specimen ID (automatically generated by Rave) 
• Time point 
• Specimen type (e.g., Formalin Fixed Tissue) 
• Tissue type (P for primary, M for metastatic or N for normal) 
• Surgical pathology ID (SPID) number, if applicable 
 
5.4.2.3 Example of Specimen Label 
 
The following image is an example of a tissue specimen label printed on a standard Avery label 
that is 1” high and 2.625” wide. 
 
  
 
The QR code in the above example is for the Specimen ID shown on the second line.   
NOTE:  The QR code label is currently under development at Theradex as of 31-Aug-2018; 
therefore, labels generated by the STS for this study may not include a QR code. 
 
The second line item from the end includes four data points joined together: 
1. Tissue only: Primary (P), Metastatic (M), Normal (N) tissue indicated at the 
beginning of the specimen ID; this field is blank if not relevant (e.g., for blood) 

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2. Block ID or blank if not relevant 
3. SPID (Surgical Pathology ID) or blank if none 
4. The last alpha-numeric code is protocol specific and is only included if the protocol 
requires an additional special code classification 
 
The last line on the example label is for the handwritten date and optional time. 
 
5.4.3 Overview of Process at Treating Site 
 
5.4.3.1 OPEN Registration 
 
All registrations will be performed using the Oncology Patient Enrollment Network (OPEN) 
system.  OPEN communicates automatically with the Interactive Web Response System (IWRS) 
which handles identifier assignments, any study randomization, and any prescribed slot 
assignments.  If specimen analysis is required to determine eligibility, the protocol will be set up 
with multi-step registration. 
 
Registration without eligibility specimen analysis:  
 
1. Site enters registration data into OPEN during one or more steps. 
2. IWRS receives data from OPEN, generates the Patient Study ID and the Universal Patient 
ID, both of which are sent back to OPEN. 
3. IWRS sends all applicable registration data directly to Rave at the end of the final 
registration step. 
Any data entry errors made during enrollment should be corrected in Rave. 
 
5.4.3.2 Rave Specimen Tracking Process Steps 
 
Step 1:  Complete the Histology and Disease form (but do not upload reports until a specimen 
label can be applied to them) and the Baseline forms regarding Prior Therapies.  Enter the 
initial clinical specimen data:  
• Specimen Tracking Enrollment CRF:  Enter Time Point, Specimen Category, 
Specimen Type, Block number (if applicable), Tissue type, Surgical Path ID (if 
applicable), and number of labels needed (include extra labels to apply to reports to be 
uploaded).  CRF generates unique Specimen ID.  
 
Step 2:  Print labels using report in EDC and collect specimen. 
• Label specimen containers and write collection date and pre-treatment/on-treatment 
status on each label.  After collection, store labeled specimens as described in Section 
5.4.2. 
• Apply an extra specimen label to each report before scanning.  Return to the Histology 
and Disease form to upload any initial Pathology, Radiology, Molecular Reports (up to 
4), Surgical (or Operative) reports and Pathology Verification form (when applicable).  
Return to Specimen Tracking Enrollment CRF to upload any molecular report (one per 
specimen) and/or specimen specific pathology or related report (one per specimen).  
Uploaded reports should have protected health information (PHI) data, like name, 

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mailing address, medical record number or social security number (SSN), redacted.  Do 
not redact SPID, block number or relevant dates (such as collection date), and include the 
UPID and patient study ID on each document.  
 
Step 3:  Complete specimen data entry. 
• Specimen Transmittal Form:  Enter collection date and pre-treatment/on-treatment 
status and other required specimen details. 
 
Step 4:  When ready to ship, enter shipment information. 
• Shipping Status CRF:  Enter tracking number, your contact information, recipient, 
number of containers and ship date once for the first specimen in a shipment. 
• Copy Shipping CRF:  Select additional specimens to add to an existing shipment 
referenced by the tracking number. 
 
Step 5:  Print shipping list report and prepare to ship.  
• Print two copies of the shipping list, one to provide in the box, the other for your own 
records. 
• Print pathology or other required reports to include in the box.  Be sure the printed copy 
includes the specimen label. 
 
Step 6:  Send email notification.  
• For only one of the specimens in the shipment, click “Send Email Alert” checkbox on the 
Shipping Status CRF to email recipient. 
 
Step 7:  Ship the specimen(s). 
 
5.5 
Specimen Collection  
 
5.5.1 Formalin-Fixed Tumor Biopsies  
 
1. Label formalin-filled containers according to instructions in Section 5.4.2.  
2. Obtain 3-4 16-gauge or 18-gauge core needle biopsy specimens, and place one core in 
each cassette.  
3. Snap the cassette lids closed and place cassettes into a formalin-filled pre-labeled 
container as soon as possible after collection to prevent air drying.  Up to two cassettes 
may be placed in one formalin jar. 
4. Secure the container lids and package containers into the shipping kit according to 
instructions in Section 5.6.  Keep tissue in formalin jars at room temperature until 
shipment to the EET Biobank.  
 
5.5.2 Collection of Blood in EDTA Tubes for Ambient Whole Blood Shipment 
 
1. Label EDTA tubes according to the instructions in Section 5.4.2. 
2. Collect the specified amount of blood (10 mL) in EDTA tube(s) and gently invert tube to 
mix. 
3. Ship on day of collection (whenever possible) according to instructions in Section 5.6. 

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4. If blood cannot be shipped on the day of collection (e.g., a late scheduled collection), 
then refrigerate until shipment.  
 
5.6 
Shipping Specimens from Clinical Site to the EET Biobank  
 
5.6.1 General Shipping Information 
 
Core biopsies that are fixed in formalin and fresh blood should be shipped as one shipment at 
ambient temperature, whenever possible.  The shipping container sent with kit contents should 
be used to ship specimens to the EET Biobank.  In winter months, please include extra 
insulation, such as bubble wrap, inside the shipping container. 
 
For formalin-fixed biopsies, if the corresponding anatomical pathology report is not available at 
the time of shipment, then the surgical and/or radiology reports from the tissue removal 
procedure and the diagnostic anatomic pathology report must be included in the package, or the 
specimen will not be processed.  Once completed, upload the corresponding pathology report to 
the ETCTN specimen tracking system and send a copy to the EET Biobank. 
 
5.6.2 Specimen Shipping Instructions 
 
Tissue in formalin must be shipped on the day of collection.  Collect and ship on Monday 
through Wednesday. 
 
Fresh blood may be shipped on Monday through Friday.  Please select “Saturday Delivery” 
when shipping fresh blood on a Friday.  
 
5.6.2.1 
Shipping Ambient Blood in Your Own Container 
 
If blood and tissue are ready to ship on the same day, then the blood may be packaged and 
shipped in the single chamber kit with the tissue.  If blood is shipped separately then it must be 
shipped using institutional supplies.  Packaging guidelines for sending blood in a separate box 
are provided below. 
 
1. Before packaging specimens, verity that each specimen is labeled according to 
instructions in Section 5.4.1 
2. Place the blood collection tube(s) into a zip-lock bag.   
3. Place zip-lock bag into a biohazard envelope with absorbent material.  Expel as much air 
as possible and seal the envelope securely.  
4. Place the biohazard envelope into a Tyvek envelope.  Expel as much air as possible and 
seal securely. 
5. Place the specimen(s) and a copy of the shipping manifest into a sturdy shipping 
container. In winter months, please use an insulated container and include extra 
insulation, such as bubble wrap, inside the shipping container to prevent specimens from 
freezing.  
6. Close the container and tape shut. 
7. Attach a shipping label to the top of the shipping container.  

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8. Attach an Exempt Human Specimen sticker to the side of the container. 
9. Ship specimens via overnight courier to the address below.  FedEx Priority Overnight is 
strongly recommended to prevent delays in package receipt.  
 
5.6.2.2 
Shipping Ambient Tissue and Blood in a Single-Chamber Kit  
 
If blood and tissue are ready to ship on the same day, then the blood may be packaged and 
shipped in the single chamber kit with the tissue.  If blood is shipped separately then it must be 
shipped using institutional supplies.  Packaging guidelines for sending both specimens in the kit 
box are provided below. 
 
1. Before packaging specimens, verify that each specimen is labeled according to the 
instructions above and that the lids of all primary receptacles containing liquid are tightly 
sealed.  The lids of formalin jars should be wrapped in parafilm.  Absorbent material 
must be placed around each primary container that holds liquid.   
2. Place the specimens in zip-lock bags.  Use a separate bag for each specimen type. 
3. Place specimens into the secondary pressure vessel surrounded by bubble wrap.  Place 
the lid on the secondary pressure vessel and set it inside the kit chamber.  
4. Place a copy of the shipping manifest and corresponding reports such as pathology, 
surgical, or radiology reports into the insulated shipping container.  
5. Set the lid on top of the container.  Close the outer flaps and tape shut. 
6. Attach a shipping label to the top of the shipping container.  
7. Attach an Exempt Human Specimen sticker to the side of the container. 
8. Ship specimens via overnight courier to the address below.  FedEx Priority Overnight is 
strongly recommended to prevent delays in package receipt.  
 
5.6.3 Shipping Address 
 
Ship to the address below.  Ship formalin-fixed and fresh blood specimens the same day of 
specimen collection.  Do not ship specimens the day before a holiday. 
 
EET Biobank 
The Research Institute at Nationwide Children's Hospital 
700 Children's Drive, WA1340 
Columbus, Ohio 43205 
PH: (614) 722-2865 
FAX: (614) 722-2897 
Email: BPCBank@nationwidechildrens.org 
 
FedEx Priority Overnight service is very strongly preferred.   
 
NOTE:  The EET Biobank FedEx Account will not be provided to submitting institutions. 
 
5.6.4 Contact Information for Assistance 
 
For all queries, please use the contact information below: 

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EET Biobank 
Toll-free Phone:  (800) 347-2486 
E-mail:  BPCBank@nationwidechildrens.org 

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5.8 
Integrated Correlative Studies 
 
5.8.1 Whole Exome Sequencing in Tumor Tissue 
 
5.8.1.1 
Specimen Receipt and Processing at the EET Biobank 
 
Tumor tissue received in formalin will be paraffin-embedded.  All FFPE blocks will be 
sectioned to generate an initial hematoxylin and eosin (H&E)-stained slide and, for 
nucleic acid extractions, additional RNase-free slides.  If needed, slides will be 
macrodissected to enrich tumor content before scraping for nucleic acid co-extraction. 
 
DNA and RNA will be co-extracted from tumor tissue.  The nucleic acids will be 
analyzed to determine concentration and quality.  Aliquots of DNA will be shipped to the 
central sequencing laboratory for analysis. 
 
DNA will be extracted from whole blood in EDTA. An aliquot of blood (germline) DNA 
will be shipped with the tumor DNA. 
 
5.8.1.2 
Site Performing Correlative Study 
 
This assay will be performed at the Molecular Characterization (MoCha) Laboratory, 
Frederick National Laboratory for Cancer Research (FNLCR).  
 
5.8.1.3 
Shipment of Specimens 
 
Specimens will be shipped from the EET Biobank to: 
 
MoCha, Frederick National Laboratory for Cancer Research (FNLCR) 
1050 Boyles St. 
Bldg. 459, Rm. 125 
Frederick, MD 21702 
Attn: Alyssa Chapman or Ruth Thornton 
 
5.8.1.4 
Contact Information/Notification of Speicmen Shipment 
 
Thomas Forbes, mochasamplereceiving@nih.gov  
 
5.8.2 RNAseq 
 
5.8.2.1 
Specimen Receipt and Processing at the ETCTN Biorepository 
 
Tumor tissue received in formalin will be paraffin-embedded.  All FFPE blocks will be 
sectioned to generate an initial hematoxylin and eosin (H&E)-stained slide and, for 
nucleic acid extractions, additional RNase-free slides.  If needed, slides will be 
macrodissected to enrich tumor content before scraping for nucleic acid co-extraction. 
 

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DNA and RNA will be co-extracted from tumor tissue.  The nucleic acids will be 
analyzed to determine concentration and quality.  Aliquots of RNA will be shipped to the 
central sequencing laboratory for analysis. 
 
5.8.2.2 
Site Performing Correlative Study 
 
This assay will be performed at the Molecular Characterization (MoCha) Laboratory, 
Frederick National Laboratory for Cancer Research (FNLCR).  
 
5.8.2.3 
Shipment of Specimens 
 
Specimens will be shipped from the EET Biobank to: 
 
MoCha, Frederick National Laboratory for Cancer Research (FNLCR) 
1050 Boyles St. 
Bldg. 459, Rm. 125 
Frederick, MD 21702 
Attn: Alyssa Chapman or Ruth Thornton 
 
5.8.2.4 
Contact Information/Notification of Specimen Shipment 
 
Thomas Forbes, mochasamplereceiving@nih.gov  
 
5.9 
Exploratory/Ancillary Correlative Studies 
 
5.9.1 Tumor Immune Microenvironment 
 
5.9.1.1 
Specimen Receipt and Processing at the EET Biobank 
 
Tumor tissue received in formalin will be paraffin-embedded.  All FFPE blocks will be 
sectioned to generate an initial hematoxylin and eosin (H&E)-stained slide. 
 
Ten (10) unstained, uncharged, 4-micron, air-dried slides are created from both the 
baseline (pre-treatment) and on-treatment biopsies, labeled appropriately, and sent under 
ambient conditions by overnight courier to the Immune Monitoring Core at Columbia 
University. 
 
Shipping Address 
 
Immune Monitoring Core Facility 
Physicians and Surgeons Building, Room 9-428 
630 West 168th Street 
New York, NY 10032 
 
Contact Information for Assistance 
 

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Name:  Matthew Ingham, M.D. 
Phone:  202-285-4944 
Email:  mi2337@cumc.columbia.edu 
 
5.9.1.2 
Site Performing Correlative Study 
 
This assay will be performed at the Columbia University Medical Center Immune 
Monitoring Core. 
 
5.9.2 Global DNA Methylation Assay 
 
5.9.2.1 
Specimen Receipt and Processing at the EET Biobank 
 
Tumor tissue received in formalin will be paraffin-embedded.  All FFPE blocks will be 
sectioned to generate an initial hematoxylin and eosin (H&E)-stained slide. 
 
Ten (10) unstained, uncharged, 4-micron, air-dried slides are created from both the 
baseline (pre-treatment) and on-treatment biopsies, labeled appropriately, and sent under 
ambient conditions by overnight courier to the laboratory of Dr. Chao Lu at Columbia 
University. 
 
Shipping Address 
 
Chao Lu Laboratory 
Irving Cancer Research Center 
1130 St. Nicholas Avenue (ICRC Room 312) 
New York, NY 10032 
 
Contact Information for Assistance 
 
Name:  Chao Lu, PhD 
Phone:  212-851-5243 
Email:  cl3684@cumc.columbia.edu 
 
5.9.2.2 
Site Performing Correlative Study 
 
This assay will be performed at the laboratory of Dr. Chao Lu at Columbia University 
Medical Center. 
 
6. 
TREATMENT PLAN 
 
6.1 
Agent Administration 
 
Patients Receiving Belinostat and SGI-110 (guadecitabine) 
 
Note: Effective with Amendment 5, no further subjects will be enrolled to the belinostat 

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and SGI-110 (guadecitabine) regimen. Patients enrolling on the study will be treated with 
belinostat and ASTX727 (see Section 6.2).  
 
Patients enrolled prior to Amendment 5 who have been receiving belinostat and SGI-110 
(guadecitabine) will continue to receive that treatment regimen. SGI-110 will no longer be 
available from the company as of 31-AUG-2021. Further treatment options will be 
discussed with subjects enrolled to the belinostat/SGI-110 regimen who remain on 
treatment as of 31-AUG-2021. Patients may be allowed to change treatment to ASTX727 
and belinostat in August 2021 if the overall assessment of risks versus benefits support that 
change, primarily related to any observations of adverse safety and tolerability of 
ASTX727 and belinostat at that time. 
 
Treatment will be administered on an outpatient basis.  Patients will be evaluated in the 
outpatient clinic by the treating investigator and research team on day 1 of each cycle.  Patients 
need not be evaluated by the investigator on the other treatment days in a cycle unless clinically 
warranted.  The study agents will be administered by qualified nursing staff consistent with 
institutional guidelines for administration of subcutaneous and intravenous oncology agents of 
these classes. 
 
SGI-110 (guadecitabine) is given first by subcutaneous injection.  At least 10 minutes, but no 
longer than 60 minutes, after the SGI-110 (guadecitabine) injection is completed, the belinostat 
infusion may begin. 
 
There is no clinical evidence to support the sequencing of one agent prior to the other in terms of 
efficacy or toxicity.  SGI-110 (guadecitabine) will be given first considering this agent is 
administered subcutaneously and may take longer to absorb than belinostat.  This approach is 
also consistent with published combination studies with SGI-110 (guadecitabine) in solid tumors.  
In addition, in our preclinical studies exploring a sequential approach to treatment, efficacy 
appeared greater when SGI-110 (guadecitabine) was given prior to concurrent treatment as 
compared to giving belinostat before concurrent treatment, providing further support for this 
approach (Figure 8). 
 
Reported AEs and potential risks are described in Section 10.  Appropriate dose modifications 
are described in Section 7. No investigational or commercial agents or therapies other than those 
described below may be administered with the intent to treat the patient's malignancy. 
 
The proposed study is an open-label, single-arm, Simon 2-stage phase 2 clinical trial with a 
safety lead-in and a continuous toxicity monitoring rule.  All patients will receive SGI-110 
(guadecitabine) 45 mg/m2 SC in combination with belinostat 1,000 mg/m2 IV over 30 minutes on 
Days 1-5 in 28-day cycles.  Treatment will continue until a criterion for removal from the study 
is met (see Section 6.3 Duration of Therapy). 
 
The belinostat and SGI-110 (guadecitabine) combination has not been previously studied and 
there is no defined RP2D.  The FDA-approved dose of belinostat in relapsed or refractory 
peripheral T-cell lymphoma is 1,000 mg/m2 IV on Days 1-5 of a 21-day cycle.  SGI-110 
(guadecitabine) is not FDA-approved.  This agent was initially evaluated in a phase 1 dose 

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escalation study in patients with AML or MDS where the drug was administered on Days 1-5 of 
a 28-day cycle (Issa et al., 2015).  DLT related to myelosuppression was observed at 125 mg/m2; 
therefore, the MTD was established at 90 mg/m2.  Because pharmacodynamic studies 
demonstrated maximal biologic (demethylating) effect at 60 mg/m2, the RP2D was 60 mg/m2 SC 
on Days 1-5 of a 28-day cycle.  
 
Although SGI-110 (guadecitabine) and belinostat have not been formally studied together, 
numerous published studies have evaluated various combinations of hypomethylating agents and 
histone deacetylase inhibitors and have found these combinations to be well tolerated.  For 
example, in a phase 1 dose escalation study of azacitidine and belinostat in AML, no DLTs were 
observed at any dose level, and the RP2D was belinostat 1,000 mg/m2 with azacitidine 75 mg/m2 
on Days 1-5 of a 28-day cycle (Odenike et al., 2015).  Thus, both agents were combined at their 
FDA-approved monotherapy doses.  The most common toxicities were grade 1/2 nausea, 
vomiting, anorexia, and fatigue.  Even in this heavily pretreated AML population, grade 3/4 
hematologic events were uncommon.  Similarly, in another phase 1 study in AML/MDS, 
decitabine and vorinostat were safe and tolerable in combination at their monotherapy doses 
(Kirschbaum et al., 2014).  Other studies evaluating azacitidine and panobinostat in myeloid 
malignancies and azacitidine and entinostat in both colorectal cancer and in breast cancer further 
support favorable tolerability of these combinations (Azad et al., 2017; Connolly et al., 2017).  
 
SGI-110 (guadecitabine) has been studied as monotherapy and in combination with several other 
agents in solid tumors.  In hepatocellular carcinoma, the RP2D as monotherapy was 45 mg/m2 on 
Days 1-5 of a 28-day cycle.  In colorectal cancer, SGI-110 (guadecitabine) was well tolerated at 
45 mg/m2 in combination with irinotecan with growth factor in a heavily pretreated population 
(Lee et al., 2018).  In melanoma, SGI-110 (guadecitabine) was well tolerated at 60 mg/m2 in 
combination with checkpoint blockade (Di Giacomo et al., 2019).  Although a phase 1 study 
evaluating SGI-110 (guadecitabine) in combination with carboplatin in ovarian cancer arrived at 
a lower dose of SGI-110 (30 mg/m2), this study included a heavily pre-treated population in 
which the median number of prior treatment lines was 7 and a myelosuppressive dose of 
carboplatin (AUC 5) was used (Matei et al., 2018).  
 
Considering there are no FDA-approved treatments for chondrosarcoma (that is, patients will not 
be heavily pretreated with chemotherapy) and noting that combination studies with 
hypomethylating agents and HDAC inhibitors have shown favorable tolerability as discussed 
above, a starting dose of 45 mg/m2 appears warranted.  To closely monitor for unexpected 
adverse events, both a safety lead-in and continuous toxicity monitoring rule are applied as 
further described in Section 9. 
 
Regimen Description 
Agent 
Dose 
Route 
Schedule 
Cycle 
Length 
SGI-110 
(guadecitabine) 
45 mg/m2 
Slow SC injection 
Days 1-5 
28 days 
(4 weeks) 
Belinostat 
1,000 mg/m2 
IV over 30 (±5) min* 
Days 1-5 
*May extend belinostat infusion to 3 hours if infusion-related reactions occur. 

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• SGI-110 (guadecitabine) is administered first, followed by belinostat.  Separate SGI-
110 (guadecitabine) and belinostat administration by at least 10 minutes but no more 
than 60 minutes. 
• Patients must receive a prophylactic 5-HT3 receptor antagonist prior to belinostat 
during the first two cycles of treatment – see Section 6.2.3.1. 
• Patients must receive prophylactic use of growth factor– see Section 6.2.1.1. 
 
Patients Receiving Belinostat and ASTX727 
 
Beginning with Amendment 5, subsequent patients enrolled on this study will receive treatment 
with belinostat and ASTX727. These patients will not receive SGI-110 (guadecitabine).  
 
ASTX727 is an orally available DNMT inhibitor which consists of oral cedazuridine, a cytidine 
deaminase inhibitor, in combination with oral decitabine. ASTX727 is an oral tablet with a fixed 
dose combination of cedazuridine 100 mg and decitabine 35 mg. See Section 2.2.3 for additional 
information on ASTX727. Because ASTX727 has not been studied in combination with an 
HDAC inhibitor, we will repeat the safety lead-in portion of this study among the first 6 patients 
to receive belinostat and ASTX727. The safety lead-in and the effects of this change on study 
design and statistical considerations are further described in Section 9.  
 
Treatment will be administered on an outpatient basis.  Patients will be evaluated in the 
outpatient clinic by the treating investigator and research team on day 1 of each cycle.  Patients 
need not be evaluated by the investigator on the other treatment days in a cycle unless clinically 
warranted.  The study agents will be administered by qualified nursing staff consistent with 
institutional guidelines for administration of oral and intravenous oncology agents of these 
classes. 
 
ASTX727 will be given first orally.  At least 30 minutes, but no longer than 60 minutes, after 
ASTX727 is administered, the belinostat infusion may begin. Treatment will continue until a 
criterion for removal from the study is met (see Section 6.3 Duration of Therapy). 
 
Regimen Description 
Agent 
Dose 
Route 
Schedule 
Cycle 
Length 
ASTX727 
1 tablet, which consists 
of cedazuridine 100 mg / 
decitabine 35 mg 
Orally 
Days 1-5 
28 days 
(4 weeks) 
Belinostat 
1,000 mg/m2 
IV over 30 (±5) min* 
Days 1-5 
*May extend belinostat infusion to 3 hours if infusion-related reactions occur. 
 
• ASTX727 is administered first, followed by belinostat.  Separate ASTX727 and 
belinostat administration by at least 30 minutes but no more than 60 minutes. Patients 
will be instructed to bring ASTX727 to clinic and take the medication in clinic to ensure 
the timeframe is observed.  

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• Patients must receive a prophylactic 5-HT3 receptor antagonist prior to belinostat 
during the first two cycles of treatment – see Section 6.2.3.1. 
• Patients must receive prophylactic use of growth factor– see Section 6.2.2.1. 
 
6.1.1 CTEP IND Agents 
 
6.1.1.1 
SGI-110 (Guadecitabine) 
 
SGI-110 (guadecitabine) will be administered via slow SC injection, preferably in the abdominal 
area, upper thigh, or arm.  The injection site should be rotated for the five injections in each 
cycle.  Due to the viscosity of the SGI-110 (guadecitabine) solution, a 25-gauge, 5/8 inch needle 
is recommended for administration.  SGI-110 (guadecitabine) should be administered in the 
clinic by a health professional.  The total amount (in mg) of SGI-110 (guadecitabine) to be 
administered is determined by body surface area (BSA).  In calculating BSA, use actual heights 
and weights.  Do not adjust to "ideal" body weight.  Utilize the dose calculated for the baseline 
BSA throughout the protocol unless weight changes by ±10% or more as assessed on Day 1 of 
each cycle, in which case it should be adjusted.  For all dose calculations, sites can round the 
volume to the nearest tenth or follow institutional standards. 
 
There may not be additional supply of SGI-110 (guadecitabine) after 31-AUG-2021 if the 
current batch of SGI-110 and its diluents expiry dates cannot be extended. Further 
treatment options will be discussed with subjects enrolled to the belinostat/SGI-110 
regimen who remain on treatment with that regimen as of 31-AUG-2021. Patients may be 
allowed to change treatment to ASTX727 and belinostat in August 2021 if the overall 
assessment of risks versus benefits support that change, primarily related to any 
observations of adverse safety and tolerability of ASTX727 and belinostat at that time. 
 
6.1.1.2 
ASTX727 
 
ASTX727 is an oral fixed-dose combination tablet and consists of cedazuridine 100 mg and 
decitabine 35 mg in one tablet. ASTX727 dosing is not based on weight or body surface area. All 
patients will receive the same dose of one tablet.  
 
Patients should take the ASTX727 tablet at approximately the same time each day on an empty 
stomach. Do not eat, or drink milk or alcohol 2 hours before or 2 hours after taking ASTX727. 
Clear liquids, such as water, black coffee, or tea are allowed. Take whole tablets with 8 oz (240 
mL) of water; do not crush, cut or chew the tablet.  
 
Missed doses within 12 hours of the scheduled time can be made up. The patient needs to take 
the missed dose as soon as possible and resume the next day on schedule. If the patient fails to 
make up the dose within 12 hours, the dose should be resumed at the scheduled time the next 
day.  
 
6.1.1.3 
Belinostat (PXD-101) 
 
Belinostat will be administered IV over 30 minutes (± 5 minutes) by central or peripheral access 

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through an in-line 0.22-micron filter.  The total amount (in mg) of belinostat to be administered 
is determined by BSA.  In calculating BSA, use actual heights and weights.  Do not adjust to 
"ideal" body weight.  Utilize the dose calculated for the baseline BSA throughout the protocol 
unless weight changes by ±10% or more as assessed on Day 1 of each cycle, in which case it 
should be adjusted.  For all dose calculations, sites can round the volume to the nearest tenth or 
follow institutional standards. 
 
Belinostat infusions may be prolonged up to 3 hours, if deemed necessary, to ameliorate acute 
infusion-related reactions (nausea, flushing, rhinitis, vomiting, etc.) that may occur during, or 
immediately following infusion.  Once diluted in 250 mL of 0.9% sodium chloride, belinostat 
may be stored at ambient room temperature (15°-25°C) for up to 36 hours, including the infusion 
time. 
 
6.2 
General Concomitant Medication and Supportive Care Guidelines 
 
Because there is a potential for interaction of SGI-110 (guadecitabine), ASTX727 and belinostat 
with other concomitantly administered drugs, the case report form must capture the concurrent 
use of all other drugs, over-the-counter medications, or alternative therapies.  The Principal 
Investigator should be alerted if the patient is taking any agent known to affect or with the 
potential for drug interactions.  The study team should check a frequently-updated medical 
reference for a list of drugs to minimize use of or avoid entirely.  Appendix D (Patient Clinical 
Trial Wallet Card) should be provided to patients if available. 
 
6.2.1 SGI-110 (Guadecitabine) 
 
6.2.1.1 
Concomitant medications and supportive guidelines 
 
SGI-110 (guadecitabine) is associated with myelosuppression.  Patients must receive G-CSF 
prophylactically, with filgrastim (Neupogen®), pegfilgrastim (Neulasta®), or biosimilar.  
The recommended dose of filgrastim is 5 mcg/kg SC per day, rounding off the dose to the 
nearest vial size, for 5-10 days.  Start filgrastim the next day (and no later than 3 days) after 
completion of study treatment on day 5 of a given cycle.  The recommended dose of 
pegfilgrastim is 6 mg SC once per cycle.  Pegfilgrastim is given approximately 24 hours after 
completing Day 5 of study treatment (if treatment finishes on a Friday, pegfilgrastim may be 
given the following Monday).  Biosimilars are acceptable.  The duration of treatment with 
growth factor is per the treating investigator’s discretion. 
 
Patients should receive all supportive care appropriate for their medical condition, including, but 
not limited to, antibiotics, transfusions, and other agents deemed necessary for symptom 
management, unless specifically prohibited elsewhere in the protocol. 
 
If patients develop injection site pain related to SGI-110 (guadecitabine) administration, 
pretreatment of topical or systemic analgesics can be considered. 
 
6.2.1.2 
Interactions with CYP proteins 
In vitro studies in human hepatocytes suggest SGI-110 (guadecitabine) is unlikely to inhibit or 

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induce human cytochrome P450 (CYP) enzymes and is not a substrate for CYPs, indicating that 
CYP-mediated drug-drug interactions with SGI-110 (guadecitabine) are not anticipated.  Neither 
SGI-110 (guadecitabine) nor the active metabolite decitabine inhibit major human drug 
transporters. 
 
In human transporter studies, SGI-110 (guadecitabine) was noted to have some potential to be a 
substrate for concentrative nucleoside transporter (CNT) 1 and CNT2, and decitabine was a 
substrate for CNT1 and equilibrative nucleoside transporter (ENT) 1 (Study No. OPT-2012-062 
and OPT-2013-070).  SGI-110 (guadecitabine) minimally inhibited multidrug and toxin 
extrusion (MATE) 1 and decitabine minimally inhibited MATE1 and MATE2-K (Study No. 
OPT-2014-071). No drug-drug interactions with SGI-110 (guadecitabine) are expected.  Overall, 
the nonclinical PK/toxicokinetic (TK) profile of SGI-110 (guadecitabine) has been well 
characterized to support its use as a therapeutic agent.  However, patients receiving concomitant 
cytotoxic drugs are at greater risk of significant myelosuppression from SGI-110 
(guadecitabine).  Dose reductions and delays may be necessary to continue therapy. 
 
6.2.1.3 
Drug-drug interactions 
Drug-drug interaction studies have not been conducted with SGI-110 (guadecitabine) or 
decitabine. 
 
6.2.2 ASTX727 
 
6.2.2.1 
Concomitant medications and supportive guidelines 
 
ASTX727 is associated with myelosuppression.  Patients must receive G-CSF 
prophylactically, with filgrastim (Neupogen®), pegfilgrastim (Neulasta®), or biosimilar.  
The recommended dose of filgrastim is 5 mcg/kg SC per day, rounding off the dose to the 
nearest vial size, for 5-10 days.  Start filgrastim the next day (and no later than 3 days) after 
completion of study treatment on day 5 of a given cycle.  The recommended dose of 
pegfilgrastim is 6 mg SC once per cycle.  Pegfilgrastim is given approximately 24 hours after 
completing Day 5 of study treatment (if treatment finishes on a Friday, pegfilgrastim may be 
given the following Monday).  Biosimilars are acceptable.  The duration of treatment with 
growth factor is per the treating investigator’s discretion. 
 
Patients should receive all supportive care appropriate for their medical condition, including, but 
not limited to, antibiotics, transfusions, and other agents deemed necessary for symptom 
management, unless specifically prohibited elsewhere in the protocol. 
 
6.2.2.2 
Drug-drug interactions 
 
Drug-drug interaction studies have not been conducted with cedazuridine or decitabine. 
Nonclinical studies indicate that neither cedazuridine nor decitabine is likely to inhibit or induce 
major human cytochrome P450 enzymes. Thus, CYP450-mediated drug-drug interactions are not 
anticipated for cedazuridine or decitabine. Cedazuridine is not an inhibitor or a substrate of 
major human drug transporters. Cedazuridine is an inhibitor of CDA and as such, drugs known 

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to be metabolized by CDA should be avoided during treatment with ASTX727. Concomitant 
proton pump inhibitor medication usage was shown not to have a significant impact on 
decitabine, cedazuridine, and cedazuridine-epimer parameters and subsequent exposures, based 
on population PK analysis. 
 
6.2.3 Belinostat 
 
6.2.3.1 
Concomitant medications and supportive guidelines 
 
Belinostat is associated with nausea.  Patients must receive prophylactic treatment with a 5-
HT3 receptor antagonist for the first two cycles of treatment.  Ondansetron (oral 
disintegrating tablet 8 mg PO or equivalent) may be administered once prior to each dose of 
belinostat.  Alternatively, granisetron extended-release injection 10 mg SC may be administered 
once on day one prior to the first administration of belinostat in each treatment cycle.  If nausea 
or vomiting occurs despite the use of a 5-HT3 receptor antagonist, consider the addition of 
dexamethasone 8-10 mg PO or IV prior to each dose of belinostat.  Continuation of the 5-HT3 
receptor antagonist after the first two cycles is at the treating investigator’s discretion. 
 
As discussed in Section 6.2.1.1 and 6.2.2.1, patients will be administered prophylactic growth 
factor. 
 
Patients should receive all supportive care appropriate for their medical condition, including, but 
not limited to, antibiotics, transfusions, and other agents deemed necessary for symptom 
management, unless specifically prohibited elsewhere in the protocol. 
 
6.2.3.2 
Drug-drug interactions 
 
Belinostat is primarily metabolized by hepatic UGT1A1, and to a lesser extent by CYP2A6, 
CYP2C9, and CYP3A4 enzymes.  Patients with known UGT1A1 genetic polymorphisms, such as 
UGT1A1*28, may have reduced UGTA1A activity and may be at risk for increased belinostat 
exposure.  Subjects with known UGT1A1 genetic polymorphisms are not eligible for this 
study. 
 
Chronic use of any medications or substances that are strong inhibitors of UGT1A1 is not allowed.  
Patients must switch to alternative medications 7-14 days before treatment with belinostat.  Because 
the lists of these agents are constantly changing, it is important to regularly consult a frequently-
updated medical reference.  As part of the enrollment/informed consent procedures, the patient will 
be counseled on the risk of interactions with other agents, and what to do if new medications need to 
be prescribed or if the patient is considering a new over-the-counter medicine or herbal product. 
 
In vitro studies have shown belinostat and its metabolites are weak to moderate inhibitors of 
CYP2C8 and moderate to strong inhibitors of CYP2C9, although studies did not demonstrate 
effects when co-administered with warfarin.  Avoid CYP2C8 and CYP2C9 substrates during 
belinostat treatment. 
 
Avoid concomitant medications that may cause Torsade de Pointes.  

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6.3 
Duration of Therapy 
 
In the absence of treatment delays due to AEs, treatment may continue until one of the following 
criteria applies: 
 
• 
Disease progression as defined by RECIST 1.1 criteria 
 
• 
Intercurrent illness that prevents further administration of treatment 
 
• 
Unacceptable AEs 
 
• 
Patient decides to withdraw from the study 
 
• 
General or specific changes in the patient's condition render the patient unacceptable for 
further treatment in the judgment of the investigator 
 
• 
Clinical progression 
 
• 
Patient non-compliance 
 
• 
Pregnancy 
 
o All women of child-bearing potential should be instructed to contact the investigator 
immediately if they suspect they might be pregnant (e.g., missed or late menstrual 
period) at any time during study participation. 
 
o The investigator must immediately notify CTEP in the event of a confirmed 
pregnancy in a patient participating in the study. 
 
• 
Termination of the study by sponsor 
 
• 
The drug manufacturer can no longer provide the study agent 
 
The reason(s) for protocol therapy discontinuation, the reason(s) for study removal, and the 
corresponding dates must be documented in the Case Report Form (CRF). 
 
6.4 
Duration of Follow-Up 
 
Patients will be followed for up to 24 months after removal from study or until death, whichever 
occurs first.  During the follow-up period, patients will be evaluated in the clinic or contacted by 
telephone approximately once every 3 months to ascertain information related to disease status 
and subsequent anti-cancer treatment.  Patients removed from study for unacceptable AEs will be 
followed until resolution or stabilization of the AE. 
 

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There may not be additional supply of SGI-110 (Guadecitabine) after 31-AUG-2021 if the 
current batch of SGI-110 and its diluents expiry dates cannot be extended. Further 
treatment options will be discussed with subjects enrolled to the belinostat/SGI-110 
regimen who remain on treatment with that regimen as of 31-AUG-2021. Patients may be 
allowed to change treatment to ASTX727 and belinostat in August 2021 if the overall 
assessment of risks versus benefits support that change, primarily related to any 
observations of adverse safety and tolerability of ASTX727 and belinostat at that time. 
 
Chemical Name: 
Sodium[(2R,3S,5R)-5-(2-amino-6-oxo-1,6-dihydro-9H-purin-9-yl)-3-hydroxyoxolan-2-yl]methyl 
(2R,3S,5R)-5-(4-amino-2-oxo-1,3,5-triazin-1(2H)-yl)-2-(hydroxymethyl)oxolan-3-yl phosphate  
 
Other Names: Guadecitabine 
 
Classification: DNA methylation inhibitor 
 
Molecular Formula: C18H23N9NaO10P 
 
 
M.W.: 579.39 Da 
 
Approximate Solubility:  It is water soluble at about 30 mg/mL over a pH range of 6.0 to 7.0. It 
is unstable in aqueous solutions and is relatively more stable at neutral pH.  SGI-110 is soluble in 
common organic solvent systems such as methanol, dimethylamine (DMA), and dimethyl 
sulfoxide (DMSO). 
 
Mode of Action: SGI-110 is a potent inhibitor of DNA methylation. SGI-110 is a dinucleotide 
of decitabine and deoxyguanosine linked with a phosphodiester bond. Decitabine is the active 
metabolite. Guadecitabine is a new chemical entity that was designed to enhance 
pharmacokinetic (PK) properties compared with decitabine, with potential to improve 
pharmacodynamics (PD), clinical efficacy, and safety. 
 
How Supplied:  SGI-110 drug product as a two-vial system is supplied by Astex Pharmaceutical 
and distributed by the Pharmaceutical Management Branch, CTEP/DCTD/NCI as follows: 
• 
SGI-110 for Injection: 100 mg dry powder lyophile containing free acid equivalent in a 
single-use vial;  
• 
Diluents for Reconstitution:  1.2 mL single-use vial containing non-aqueous diluent of 
propylene glycol, glycerin, and ethanol. 
All vials are packaged in clear glass vials with stoppers made of latex-free rubber stopper and 
capped with an aluminum flip-off seal. 
 
Preparation:   
• 
Allow SGI-110 vial(s) and diluent vial(s) to reach room temperature approximately 60 
minutes.   
• 
Next, loosen the lyophilized powder of SGI-110 by gently tapping and rotating the vial 
on a hard surface.   
• 
Use a 1 mL syringe and withdraw 0.9 mL of diluent and add it to the SGI-110 vial 
resulting in a final concentration of 100 mg/mL.  Manually shake or mechanically vortex 
the diluted vial(s). 

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• 
Manually shake: Intermittently shake the reconstituted vial vigorously (approximately 5 
minutes).  In general, the shaking process will take 5 to 10 minutes.  Rotate the vial and 
inspect the vial contents to ensure that all lyophilized SGI-110 powder has dissolved.  
After dissolution, allow the vial to rest until all bubbles have dissipated (approximately 
10 minutes). 
• 
Mechanically shake (vortex): Before vortexing, rotate or shake the vial to ensure that the 
drug powder is thoroughly wetted with diluent.  Then, vortex for 5-10 minutes at a speed 
setting of 5.  Remove the vial from the holder and invert it 2-3 times.  Place the vial on 
the vortex and mix for another 10 minutes. Ensure that all SGI-110 powder is completely 
dissolved. Repeat the process if partially dissolved.  Once all drug is dissolved, allow the 
solution rest until all bubbles dissipate (approximately 10 minutes). 
• 
The final solution of the diluted vial should be clear and colorless to pale yellow. 
• 
Withdraw the diluted solution into a syringe. If two or more syringes are needed to 
deliver the total prescribed dose, all dispensed syringes should have equivalent volumes 
for consistency and ease of administration. 
• 
If the local institutional standards require the use of a safety device, such as a PhaSealTM, 
then the extractable volume is reduced to around 60 mg (0.6 mL).  
 
Note:  If SGI-110 powder has not dissolved 60 minutes after completion of manually shaking or 
vortex, do not use the vial(s).  
 
Storage:  
• 
Store SGI-110 lyophilized powder refrigerated between 2° and 8° C (36° and 46° F)   
• 
Store 1.2 mL diluent between 2° and 8° C (36° and 46° F) 
 
If a storage temperature excursion is identified, promptly return SGI-110 vials and the diluents to 
the recommended storage temperatures above and quarantine the supplies.  Provide a detailed 
report of the excursion (including documentation of temperature monitoring and duration of the 
excursion) to PMBAfterHours@mail.nih.gov for determination of suitability. 
 
Stability:  Stability studies of SGI-110 intact vials are ongoing.   
 
• 
Upon reconstitution, the diluted drug solution is good for 8 days (either in syringe or vial) 
when refrigerated between 20 and 80 C (360 and 460 F) or up to 24 hours at room 
temperature. 
 
Route(s) of Administration: subcutaneous injection 
 
Method of Administration: Administer by slow subcutaneous injection.  If injection site pain 
occurs, give slow injection (over 60 seconds) and apply ice packs to the injection site both before 
and after injection for 5 – 10 minutes each; however, using icepack for the first dosing is not 
recommended (as it may not be needed). Pretreatment of topical or systemic analgesics can be 
considered. 
 
Potential Drug Interactions: Drug-drug interaction studies have not been conducted with SGI-
110 or decitabine.  In vitro studies suggested that SGI-110 is unlikely to inhibit or induce major 

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P450 enzymes and is not a CYPs substrate.  Furthermore, SGI-110 nor the active metabolite 
decitabine inhibit major human drug transporters. 
 
Special Handling: SGI-110 is a cytotoxic agent.  Use PPE when preparing SGI-110.  If SGI-110 
comes in direct contact with the skin, wash immediately with copious amount of water and soap 
(soap degrades the chemical rapidly).  If SGI-110 comes in direct contact with the mucous 
membranes, flush the affected area thoroughly with water. 
 
Drug spills can be inactivated by either using a 2 N sodium hydroxide solution or water and 
kericide CR Biocide B which consists of a blend of stabilized chlorine dioxide and a quaternary 
ammonium compound. 
 
Availability:  SGI-110 (guadecitabine) is an investigational agent supplied to investigators by 
the Division of Cancer Treatment and Diagnosis (DCTD), NCI. 
 
SGI-110 (guadecitabine) is provided to the NCI under a Collaborative Agreement between Astex 
Pharmaceuticals, and the DCTD, NCI (see Section 13.5). 
 
8.1.2 ASTX727 (NSC# 820631) 
 
Chemical Name (Cedazuridine): (4R)-1-[(2R,4R,5R)-3,3-difluoro-4-hydroxy-5- 
(hydroxymethyl)oxolan-2-yl]-4-hydroxy-1,3-diazinan-2-one  
 
Chemical Name (Decitabine): 4-amino-1-[(2R,4S,5R)-4-hydroxy-5-(hydroxymethyl)oxolan-2-
yl]-1,3,5-triazin-2-(1H)-one 
 
Other Names:  Cedazuridine and decitabine; INQOVI® 
 
Classification: Cytidine deaminase inhibitor and DNA hypomethylating agent 
 
CAS Registry Number (Cedazuridine):  1141397-80-9  
 
CAS Registry Number (Decitabine): 2353-33-5  
 
Molecular Formula (Cedazuridine): C9H14F2N2O5  
 
M.W.: 268.21 Daltons  
 
Molecular Formula (Decitabine): C8H12N4O4  
 
M.W.: 228.21 Daltons  
 
Approximate Solubility of Cedazuridine: Soluble in dimethylsulfoxide, sparingly soluble in 
water and 50 mM phosphate, slightly soluble in methanol, and insoluble in acetone, and 
acetonitrile. Not hygroscopic.  
 
Approximate Solubility of Decitabine:  Freely soluble in dimethyl sulfoxide, slightly soluble in 
water, very slightly soluble in methanol. Hygroscopic.  
 
Mode of Action: Decitabine is a cytidine nucleoside analog that inhibits DNA methylation,  

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thereby causing hypomethylation of DNA and cellular differentiation and/or apoptosis. 
Cytidine deaminase (CDA) is an enzyme that catalyzes the degradation of cytidine, 
including the cytidine analog decitabine. High levels of CDA in the gastrointestinal tract  
and liver degrade decitabine and limit its oral bioavailability. Cedazuridine is a CDA 
 inhibitor. Administration of cedazuridine with decitabine increases systemic exposure of  
decitabine. 
 
How Supplied: Astex Pharmaceuticals Inc. supplies and PMB distributes, ASTX727 as a red, 
film-coated, oval, immediate-release, fixed dose combination (FDC) tablet containing the 
cedazuridine (100 mg) and decitabine (35 mg).   
 
Inactive ingredients consist of lactose, hypromellose, croscarmellose sodium, colloidal silicon 
dioxide, magnesium stearate, and Opadry II 85F15458 Red. The Opadry is a tablet coating 
formula that contains titanium dioxide, polyvinyl alcohol, polyethylene glycol, talc, and iron 
oxide red. Tablets are plain faced on both sides. Future clinical supply may contain a debossed 
marking of “H35” on each tablet. 
 
ASTX727 is packaged as 5 tablets per bottle. The bottles are white opaque high-density 
polyethylene (HDPE) with a child resistant closure containing 1 or 2 desiccant canisters for 
moisture absorption.  Bottles have an induction seal. 
 
Storage: Store intact/unopen bottles at 20°C to 25°C (68°F to 77°F); excursions permitted to 
15°C to 30°C (59°F to 86°F). 
 
If a storage temperature excursion is identified outside of the permitted excursion 15°C to 
30°C (59°F to 86°F), promptly return ASTX727 to 20°C to 25°C (68°F to 77°F) and 
quarantine the supplies. Provide a detailed report of the excursion (including 
documentation of temperature monitoring and duration of the excursion) to 
PMBAfterHours@mail.nih.gov for determination of suitability. 
 
Stability:  Stability studies are ongoing.  
 
Route and Method of Administration: Oral. Take ASTX727 tablet approximately at the same 
time on an empty stomach. Do not eat, drink milk or alcohol 2 hours before and 2 hours after 
taking ASTX727.  Clear liquids such as water, black coffee, or tea are allowed. Take whole 
tablets with 8 oz. (240 mL) of water; do not crush, cut, or chew the tablet.   
 
Missed dose within 12 hours of the scheduled time can be made up.  Patient needs to take as 
soon as possible and resume the next day on schedule. If the patient fails to make up the dose 
within 12 hours, the dose should be resumed at the scheduled time the next day. 
 
Potential Drug Interactions: Decitabine had no clinically meaningful effect on the 
pharmacokinetics of cedazuridine. Cedazuridine increased the exposure of decitabine.  
 
Cedazuridine is an inhibitor of cytidine deaminase (CDA) and as such, drugs known to be 
metabolized by CDA should be avoided during treatment with ASTX727.  

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CYP450:  Cedazuridine is not a substrate of cytochrome P450 (CYP) enzymes. Cedazuridine 
does not induce CYP1A, CYP2B6, CYP2C9, or CYP3A or inhibit CYP1A, CYP2B6, CYP2C8, 
CYP2C9, CYP2C19, CYP2D6, CYP2E1, or CYP3A. 
 
Protein Transporters: Cedazuridine is not a substrate of P-glycoprotein (P-gp), MATE1, 
MATE2-K, OAT1, OAT3, OATP1B1, OATP1B3, OATP2B1, OCT1, or OCT2, and does not 
inhibit P-gp, BCRP, MATE1, MATE2-K, OAT1, OAT3, OATP1B1, OATP1B3, or OCT2. 
 
Concomitant use of proton pump inhibitor does not have significant impact on decitabine or 
cedazuridine exposure. 
 
Protein binding:  Plasma protein binding of decitabine is negligible (<1%) and for cedazuridine 
is low (~34% to 38%), therefore interactions due to displacement of more highly protein bound 
drugs from plasma proteins are not expected. 
 
Patient Care:  ASTX727 can cause fetal harm when administered to pregnant women.  For that 
reason, women of childbearing potential must use highly effective contraception during treatment 
with ASTX727 and for at least 6 months after the last dose. Men with female partners of 
childbearing potential should be advised to practice highly effective contraceptive measures of 
birth control and not to father a child while receiving treatment with decitabine and for 3 months 
after the last dose.  Breastfeeding is not allowed during the study and for 2 weeks after the last 
dose. 
 
8.1.3 Belinostat (PXD-101) (NSC # 726630) 
 
Chemical Name: 
(E)-N-hydroxy-3-(3-(N-phenylsulfamoyl)phenyl)acrylamide  
 
Other Names: 
 
PXD101; Beleodaq® 
 
Classification:  
Histone deacetylase (HDAC) inhibitor 
 
CAS Registry Number: 
414864-00-9; 866323-14-0  
 
Molecular Formula: C15H14N2O4S 
 
M.W.: 318.35 
 
Approximate Solubility:  
Water 0.14 mg/mL; ethanol >200 mg/mL;  
polyethylene glycol 400 ~ 1.5 mg/mL; 1,2-propanediol ~ 0.2 mg/mL 
 
Mode of Action:    
Histone deacetylases (HDACs) are a family of enzymes that regulate 
chromatin remodeling and gene transcription via the dynamic process of acetylation and 
deacetylation of core histones. Belinostat is a novel and potent HDAC inhibitor of the 
hydroxamate class. It alters acetylation levels of histone and non-histone proteins, thus 
influencing chromatin accessibility and ultimately gene transcription.  
 
How Supplied:  
Acrotech Biopharma supplies and the Pharmaceutical Management 

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Branch, CTEP, DCTD, NCI distributes belinostat in single-use 30 mL clear glass vials with 
coated stoppers and aluminum crimp seals with “flip-off” caps containing 500 mg belinostat For 
Injection. The sterile yellow lyophilized product also contains 1000 mg arginine, Ph. Eur/USP.   
 
Preparation:  
Reconstitute the lyophilized product with 9 mL Sterile Water for Injection 
to yield a final belinostat concentration of 50 mg/mL. Before intravenous administration, further 
dilute in 250 mL 0.9 % Sodium Chloride Injection. 
 
Storage:  Store intact vials of belinostat at controlled room temperature (20-25°C; 68- 77°F); 
brief excursions permitted (15-30°C; 59-86 °F). Leave intact vials of belinostat in the secondary 
packaging until use. 
 
If a storage temperature excursion is identified, promptly return belinostat to controlled room 
temperature and quarantine the supplies.  Provide a detailed report of the excursion (including 
documentation of temperature monitoring and duration of the excursion) to 
PMBAfterHours@mail.nih.gov for determination of suitability.   
 
Stability: Shelf life stability studies of intact vials of belinostat are on-going; once the 
lyophilized product is reconstituted, the vialed solution is stable for up to 12 hours at ambient 
temperature (15-25°C).  
 
Once further diluted in 250 mL of 0.9% sodium chloride, belinostat may be stored at ambient 
temperature (15-25°C) for up to 36 hours, including the infusion time. 
 
Route and Method of Administration:  
Infuse belinostat intravenously over 30 minutes 
through a 0.22 micron in-line filter. 
 
Potential Drug Interactions:  
Belinostat is primarily metabolized by hepatic UGT1A1, and to 
a lesser extent by CYP2A6, CYP2C9 and CYP3A4 enzymes. Concomitant use of strong 
inhibitors of UGT1A1 is not allowed. Use caution when co-administering agents which may 
compete for UGT1A1 metabolism, such as irinotecan. Patients with known UGT1A1 genetic 
polymorphisms, such as UGT1A1*28, can have reduced UGTA1A activity and may be at risk 
for increased belinostat exposure. If subjects with UGT1A1 genetic polymorphisms are not 
excluded from study participation, reduced doses are warranted.  
 
 
In vitro studies have shown belinostat and its metabolites are weak to moderate 
inhibitors of CYP2C8 and moderate to strong inhibitors of CYP2C9; although, studies did not 
demonstrate effects when co-administered with warfarin. Avoid CYP2C8 and CYP2C9 
substrates during belinostat treatment unless deemed medically necessary.  
 
 
Avoid concomitant medications that may cause Torsade de Pointes. 
 
Availability:  Belinostat (PXD101) is an investigational agent supplied to investigators by the 
Division of Cancer Treatment and Diagnosis (DCTD), NCI. 
 
Belinostat (PXD101) is provided to the NCI under a Collaborative Agreement between Acrotech 

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Biopharma and the DCTD, NCI (see Section 13.5). 
 
8.1.4 Agent Ordering and Agent Accountability 
 
8.1.4.1 
NCI-supplied agents may be requested by eligible participating Investigators (or their 
authorized designee) at each participating institution.  The CTEP-assigned protocol 
number must be used for ordering all CTEP-supplied investigational agents.  The 
eligible participating investigators at each participating institution must be registered 
with CTEP, DCTD through an annual submission of FDA Form 1572 (Statement of 
Investigator), NCI Biosketch, Agent Shipment Form, and Financial Disclosure Form 
(FDF).  If there are several participating investigators at one institution, CTEP-
supplied investigational agents for the study should be ordered under the name of one 
lead participating investigator at that institution. 
 
Confirmation of patient enrollment is required for initial supply. 
 
Submit agent requests through the PMB AURORA application.  Access to AURORA 
requires the establishment of credentials necessary to access secure NCI Clinical 
Oncology Research Enterprise (CORE) systems, maintenance of an “active” account 
status, a “current” password, and active person registration status.  For questions 
about drug orders, transfers, returns, or accountability, call or email PMB any time or 
use the dialog function in AURORA to communicate with PMB staff.  Refer to the 
PMB’s website for specific policies and guidelines related to agent management. 
   
 
8.1.4.2 
Material Safety Data Sheets 
The current versions of the material safety data sheets (MSDS or SDS) for PMB-
distributed agents will be accessible to site investigators and research staff through 
the PMB AURORA application. Questions about MSDS access may be directed to 
the PMB at PMBAfterHours@mail.nih.gov or by using the dialog function in 
AURORA to communicate with PMB staff. 
 
8.1.4.3 
Agent Shortages 
Specific guidance on how to address agent shortages for patients already enrolled on 
a clinical study as well as how to manage potential enrollment of new patients is 
provided at https://ctep.cancer.gov/branches/pmb/drug_shortages.htm.   
Treatment plan modifications being made to avoid immediate hazard to patients is 
permissible under the Department of Health and Human Services (HHS) regulations 
at 45 CFR 46.103(b)(4)(iii). In accordance with HHS regulations, local investigators 
must promptly inform the IRB of record of this unanticipated problem and the 
management plan for the trial. 
 
8.1.4.4 
Agent Inventory Records – The investigator, or a responsible party designated by the 
investigator, must maintain a complete accountability of the receipt, dispensing and 

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final disposition of all agents received from the PMB using the appropriate NCI 
Investigational Agent (Drug) Accountability Record (DARF) available on the CTEP 
forms page.  Store and maintain separate NCI Investigational Agent Accountability 
Records for each agent, strength, formulation and ordering investigator on this 
protocol. 
 
Product Quality Complaint (PQC): A product quality complaint is defined as any 
suspicion of a product defect related to a potential quality issue during manufacturing, 
packaging, release testing, stability monitoring, dose preparation, storage or 
distribution of the product, or delivery system.  Not all PQCs involve a study subject.  
Lot or batch numbers are of high significance and need to be provided where and 
when possible. PQC must be reported to the PMB as soon as the PQC is identified. 
Report PQC to PMB at PMBAfterHours@mail.nih.gov or by using the dialog 
function in AURORA to communicate with PMB staff. 
 
 
8.1.5 Investigator Brochure Availability 
 
The current versions of the IBs for the agents will be accessible to site investigators and research 
staff through the PMB AURORA application.  Access to AURORA requires the establishment of 
credentials necessary to access secure NCI Clinical Oncology Research Enterprise (CORE) 
systems, maintenance of an “active” account status, a “current” password and active person 
registration status.  Questions about IB access may be directed to the PMB IB Coordinator via 
email. 
 
 
 
8.1.6 Useful Links and Contacts 
• CTEP Forms, Templates, Documents:  http://ctep.cancer.gov/forms/ 
• NCI CTEP Investigator Registration:  RCRHelpDesk@nih.gov 
• PMB policies and guidelines: 
http://ctep.cancer.gov/branches/pmb/agent_management.htm  
 
• 
PMB Agent Inventory Management System (AURORA) application: 
https://ctepcore.nci.nih.gov/aurora/login 
• CTEP Identity and Access Management (IAM) account: https://ctepcore.nci.nih.gov/iam/  
• CTEP IAM account help:  ctepreghelp@ctep.nci.nih.gov  
• IB Coordinator:  IBCoordinator@mail.nih.gov  
• PMB email:  PMBAfterHours@mail.nih.gov 
• PMB phone and hours of service: (240) 276-6575 Monday through Friday between 8:30 
am and 4:30 pm (ET) 
 
9. 
STATISTICAL CONSIDERATIONS 
 
The proposed study is an open-label, single-arm, Simon 2-stage phase 2 clinical trial.  Neither 

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the combination of belinostat and SGI-110 (guadecitabine) nor the combination of belinostat and 
ASTX727 have been formally evaluated in a phase 1 dose-finding study and therefore a safety 
lead-in and continuous safety monitoring rule will be applied to monitor for excessive or 
unexpected toxicity as described in this section. 
 
There is no approved or accepted standard therapy for CS.  Chemotherapy is generally 
ineffective, and no drug has shown clinical efficacy to date.  Conventional CS patients are 
commonly enrolled on clinical trials in the first-line setting.  Although chemotherapy is 
sometimes employed, efficacy is marginal and toxicity is significant.  We expect that many 
sarcoma oncologists would find a chemotherapy control arm problematic, and this would create a 
barrier to accrual.  For these reasons, a single-arm (non-randomized) design is proposed in this 
rare disease. 
 
With Amendment 5, the study was modified to substitute ASTX727 for SGI-110 
(guadecitabine). These are similar agents with the same mechanism of action. At the time of this 
modification, 6 patients were enrolled and treated with belinostat and SGI-110 (guadecitabine). 
We will report safety and efficacy endpoints separately for these 6 patients. These 6 patients will 
be replaced for the purposes of the original study design. The Simon 2-stage design described 
below will be conducted among patients treated with belinostat and ASTX727. A new safety 
lead-in will be performed among the first 6 patients treated with belinostat and ASTX727. The 
continuous toxicity monitoring rule will also apply. The total sample size for the study will 
increase from 26 patients to 32 patients, accounting for the 6 patients that will be replaced.   
 
9.1 
Study Design/Endpoints 
 
9.1.1 Primary Endpoint 
 
The primary endpoint for this phase 2 study is the objective response rate.  Noting that 
chemotherapy is associated with objective response rates of 8-12% in conventional 
chondrosarcoma (Fox et al., 2012; Italiano et al., 2013), and most clinical trials with targeted 
agents have shown response rates of 0%, we will consider an objective response rate of 8% as 
reflecting the activity of chemotherapy and an objective response rate of 28% suggesting 
promising activity warranting further study.  A Simon optimal 2 stage design is employed.  The 
design calls for 26 patients.  In stage one, 13 patients will be enrolled.  If 2 or more responses are 
observed, the study will proceed to full accrual.  If 5 or more responses are seen among the 26 
patients, the study treatment is considered promising for further study.  This design has 85% 
power with alpha of 0.054 to test for a response rate of 8% (null hypothesis) versus 28% 
(alternative hypothesis).  The probability of early stopping is 72%. 
 
With Amendment 5, the study was modified to substitute AST727 for SGI-110 (guadecitabine). 
At that time, 6 patients had been enrolled and initiated study treatment. We will report safety and 
efficacy separately for these 6 patients. We will report the objective response rate, progression-
free survival and safety and tolerability for this group of patients. These 6 patients will be 
replaced. The Simon optimal 2 stage design described above will be applied to patients receiving 
the belinostat and ASTX727 combination.  
 

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9.1.2 Secondary Endpoints 
 
Secondary endpoints are the presence of treatment related AEs, the occurrence of DLTs, and 
PFS.  Adverse events will be recorded at each clinical visit and will be categorized according to 
NCI CTCAE version 5.0.  The attribution of AEs to each of the study drugs will also be 
recorded.   
 
Secondary endpoints will be reported separately for the population of patients receiving 
belinostat and SGI-110 (guadecitabine) and the population of patients receiving belinostat and 
ASTX727.  
 
The study will use a continuous toxicity monitoring rule as described in Section 9.4.  DLTs are 
defined in Section 9.2 and to qualify as DLT must be attributed to the study drugs and not to 
disease, and occur (or first become evident) during the first four cycles of treatment for the 
purposes of continuous toxicity monitoring. 
 
PFS is defined as the time from first treatment with the study drug to the earliest of either disease 
progression or death from any cause.  Patients who are alive and progression free will be 
censored at the time of their last follow-up. 
 
9.2 
Dose-Limiting Toxicity 
 
The following definitions of dose-limiting toxicity (DLT) apply to both the safety lead-in 
(Section 9.3) and the continuous toxicity monitoring rule (Section 9.4).  DLTs are defined as the 
following toxicities which are attributed to the study drug(s) and not to disease, and which occur 
(or first become evident) during a prespecified timeframe.  For the purposes of the safety lead-in, 
this timeframe is the first two cycles of treatment.  For the purposes of the continuous toxicity 
monitoring rule, this timeframe is the first four cycles of treatment.  
 
1. Any grade 3 non-hematologic toxicity, except grade 3 fatigue, nausea, or vomiting 
which must persist >5 days despite maximal supportive care to be considered dose 
limiting. 
2. Any grade 4 hematologic toxicity lasting >14 days, except grade 4 lymphopenia, which 
is not considered a DLT. 
3. Grade 3 neutropenia with fever 
4. Grade 3 thrombocytopenia with clinically significant bleeding 
5. Any laboratory abnormality not otherwise addressed above which is associated with 
clinical sequelae and which fails to resolve to grade 1 within 5 days of occurrence, or 
any laboratory criteria meeting Hey’s law for liver toxicity. 
6. Any event leading to dose reduction or permanent discontinuation of any study drug 
during cycles 1-2 (applies to safety lead-in subjects only). 
9.3 
Safety Lead-In 
 
Recognizing that SGI-110 (guadecitabine) and belinostat have not been formally evaluated 
together, but that previously completed studies have shown DNA hypomethylating agents and 

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HDAC inhibitors are generally well tolerated in combination, we will perform a safety lead-in 
among six patients to confirm safety and tolerability of the proposed dose and schedule.  
 
The safety lead-in will apply to the first six patients treated for two cycles (8 weeks).  These 
patients will undergo safety assessments as specified in the study calendar.  The study will not 
proceed to further accrual until these six patients have completed two cycles or 8 weeks of study 
treatment; however, patients who end study treatment during this period for reasons other than 
toxicity, i.e., disease progression, will not be replaced.  At that time, the study investigators, 
CTEP, and the DSMB (if applicable) will review the safety data.  If two or more patients in the 
safety lead-in population experience DLTs as defined in Section 9.2, the study team, CTEP, and 
the DSMB (if applicable) will consider terminating the study, amending the study to evaluate a 
lower dose level, and/or further evaluating safety at the current dose level among a limited 
number of additional patients, and the amended protocol and rationale for modification will be 
submitted to the CIRB for review.  The study team, CTEP, and the DSMB (if applicable) may 
also take such action if safety concerns exist even in the absence of 2 or more DLTs occurring 
during the safety lead-in.  Formal documentation of the study team’s review of toxicity data from 
the safety lead-in will be provided prior to resuming accrual.  
 
With Amendment 5, the study was modified to substitute AST727 for SGI-110 (guadecitabine). 
The safety lead-in period will be repeated as described among the first 6 patients treated with 
ASTX727 and belinostat. However, the safety lead-in period for belinostat and ASTX727 will 
use a DLT monitoring period of 4 weeks (instead of 8 weeks). The continuous toxicity 
monitoring rule discussed below will continue to monitor for later-onset toxicity. Definitions of 
DLT remain the same.  
 
Investigators are expected to report any DLT events directly to the study statistician and 
the Data Coordinating Center within 24 hours of their knowledge of such an event. 
 
9.4 
Continuous Toxicity Monitoring Rule 
 
In addition to the safety lead-in, a continuous toxicity monitoring rule will be applied to this 
study to monitor for excessive or unexpected toxicity associated with study treatment (Ivanova et 
al., 2005).  Patients will be subjected to continuous toxicity monitoring during the first four 
cycles of study treatment.  Sequential boundaries will be used to monitor the DLT rate.  DLTs 
are defined in Section 9.2 above.  According to this model, shown in the table below, enrollment 
will be halted if the number of DLTs is equal to or exceeds bn out of n patients with completed 
DLT follow-up.  This is a Pocock-type stopping boundary which yields a probability of crossing 
the boundary (early stopping) of at most 30% stopping when then the rate of DLT is equal to the 
acceptable rate of 20% using a pre-defined sample size of 26 patients.  This boundary is 
equivalent to testing the null hypothesis, after each patient, that the event rate is equal to 0.20, 
using a one-sided level 0.14 test.   
 
With Amendment 5, the study was modified to substitute ASTX727 for SGI-110 
(guadecitabine). The continuous toxicity monitoring rule will apply as defined above to patients 
treated with belinostat and ASTX727. Toxicities experienced by the initial cohort of 6 patients 
treated with SGI-110 (guadecitabine) and belinostat will not be considered in the model as it 

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expression changes defined as significant based on absolute log2 fold changes >2 and adjusted p 
values <0.005 for each comparison with consideration of the false discovery rate.   
 
9.7.3 Changes in Global DNA Methylation 
 
A Wilcoxon signed-rank test with continuity correction will be used to calculate P values for 
comparing methylation level distribution at the different time points. 
 
9.7.4 Changes in Tumor Microenvironment 
 
For quantitative immune multiplexing, data is derived from inForm software, and changes in 
defined immune cell subsets and expression between baseline and on-treatment samples will be 
assessed using paired T-tests. 
 
9.8 
Reporting and Exclusions 
 
9.8.1 Evaluation of Toxicity 
 
All patients will be evaluable for toxicity from the time of their first treatment with SGI-110 
(guadecitabine) and/or belinostat. 
 
9.8.2 Evaluation of Response 
 
All patients included in the study must be assessed for response to treatment, even if there are 
major protocol treatment deviations or if they are ineligible.  Each patient will be assigned one of 
the following categories:  1) complete response, 2) partial response, 3) stable disease, 4) 
progressive disease, 5) early death from malignant disease, 6) early death from toxicity, 7) early 
death because of other cause, or 9) unknown (not assessable, insufficient data).  [Note:  By 
arbitrary convention, category 9 usually designates the “unknown” status of any type of data in a 
clinical database.] 
 
All of the patients who met the eligibility criteria (with the possible exception of those who 
received no study medication) should be included in the main analysis of the response rate.  
Patients in response categories 4-9 should be considered to have a treatment failure (disease 
progression).  Thus, an incorrect treatment schedule or drug administration does not result in 
exclusion from the analysis of the response rate.  Precise definitions for categories 4-9 will be 
protocol specific.  
 
All conclusions should be based on all eligible patients.  Subanalyses may then be performed on 
the basis of a subset of patients, excluding those for whom major protocol deviations have been 
identified (e.g., early death due to other reasons, early discontinuation of treatment, major 
protocol violations, etc.).  However, these subanalyses may not serve as the basis for drawing 
conclusions concerning treatment efficacy, and the reasons for excluding patients from the 
analysis should be clearly reported.  The 95% confidence intervals should also be provided.  
 

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10. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
AE monitoring and reporting is a routine part of every clinical trial.  The following list of AEs 
(Section 10.1) and the characteristics of an observed AE (Sections 10.2 and 10.3) will determine 
whether the event requires expedited reporting via the CTEP Adverse Event Reporting System 
(CTEP-AERS) in addition to routine reporting. 
 
10.1 
Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system. In addition to the comprehensive list, a subset, the 
Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and 
is identified with bold and italicized text. This subset of AEs (SPEER) is a list of events that are 
protocol specific exceptions to expedited reporting to NCI (except as noted below).  Refer to the 
'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for 
further clarification. 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to 
the AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple 
investigational agents and has an AE listed on different SPEERs, use the lower of the grades to 
determine if expedited reporting is required. 
 
10.1.1 CAEPRs for CTEP IND Agents 
 
10.1.1.1 
CAEPR for SGI-110 (Guadecitabine) 
 
Frequency is provided based on 757 patients.  Below is the CAEPR for SGI-110 
(Guadecitabine). 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR) 
for 
SGI-110 (Guadecitabine, NSC 780463) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI (except as noted below).  Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting 
Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic applications/docs/aeguidelines.pdf 
for further clarification. Frequency is provided based on 757 patients. Below is the CAEPR for SGI-110 
(Guadecitabine). 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the 
AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple investigational 
agents and has an AE listed on different SPEERs, use the lower of the grades to determine if 
expedited reporting is required. 
 
Version 2.1, May 8, 20191 

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Adverse events reported on SGI-110 (Guadecitabine) trials, but for which there is insufficient evidence 
to suggest that there was a reasonable possibility that SGI-110 (Guadecitabine) caused the adverse 
event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other 
(agranulocytosis); Blood and lymphatic system disorders - Other (coagulopathy); Blood and lymphatic system 
disorders - Other (febrile bone marrow aplasia); Blood and lymphatic system disorders - Other (histiocytosis 
hematophagic); Blood and lymphatic system disorders - Other (lymphadenopathy); Blood and lymphatic 
system disorders - Other (pancytopenia); Bone marrow hypocellular; Leukocytosis; Thrombotic 
thrombocytopenic purpura 
CARDIAC DISORDERS - Atrial fibrillation; Cardiac disorders - Other (atrial tachycardia); Cardiac disorders - 
Other (bradycardia); Chest pain - cardiac; Heart failure; Left ventricular systolic dysfunction; Palpitations; 
Sinus tachycardia 
CONGENITAL, FAMILIAL AND GENETIC DISORDERS - Congenital, familial and genetic disorders - Other 
(phimosis) 
EAR AND LABYRINTH DISORDERS - Ear pain; Vertigo  
ENDOCRINE DISORDERS - Adrenal insufficiency 
EYE DISORDERS - Blurred vision; Eye disorders - Other (eye/retinal/conjunctival hemorrhage) 
GASTROINTESTINAL DISORDERS - Abdominal distension; Abdominal pain; Belching; Cheilitis; Colitis; Dry 
mouth; Dyspepsia; Dysphagia; Enterocolitis; Esophagitis; Flatulence; Gastritis; Gastroesophageal reflux 
disease; Gastrointestinal disorders - Other (small intestinal hemorrhage); Gastrointestinal disorders - Other 
(tongue discoloration); Gastrointestinal pain; Gingival pain; Hemorrhoids; Ileus; Lip pain; Lower 
gastrointestinal hemorrhage; Oral hemorrhage; Oral pain; Periodontal disease; Rectal hemorrhage; Rectal 
pain; Small intestinal mucositis; Small intestinal obstruction; Toothache; Typhlitis; Upper gastrointestinal 
hemorrhage 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Edema limbs; Gait 
disturbance; General disorders and administration site conditions - Other (exercise tolerance decreased); 
General disorders and administration site conditions - Other (general physical health deterioration); General 
disorders and administration site conditions - Other (systemic inflammatory response syndrome [SIRS]); 
Infusion site extravasation; Localized edema; Malaise; Multi-organ failure; Non-cardiac chest pain 
HEPATOBILIARY DISORDERS - Cholecystitis 
IMMUNE SYSTEM DISORDERS - Allergic reaction 
INVESTIGATIONS - Activated partial thromboplastin time prolonged; Alanine aminotransferase increased; 
Alkaline phosphatase increased; Aspartate aminotransferase increased; Blood bilirubin increased; Creatinine 
increased; Ejection fraction decreased; Electrocardiogram QT corrected interval prolonged; GGT increased; 
INR increased; Investigations - Other (elevated c-reactive proteins [c-reactive protein increased]); 
Investigations - Other (klebsiella test positive); Investigations - Other (reticulocyte count decreased); 
Investigations - Other (thrombocytosis); Lymphocyte count increased; Weight loss 
METABOLISM AND NUTRITION DISORDERS - Acidosis; Alkalosis; Dehydration; Hypercalcemia; 
Hyperglycemia; Hyperkalemia; Hyperphosphatemia; Hyperuricemia; Hypoalbuminemia; Hypocalcemia; 
Hypoglycemia; Hypokalemia; Hypomagnesemia; Hyponatremia; Hypophosphatemia; Metabolism and 
nutrition disorders - Other (failure to thrive); Metabolism and nutrition disorders - Other (gout) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthralgia; Arthritis; Back pain; Bone 
pain; Flank pain; Generalized muscle weakness; Joint range of motion decreased; Muscle cramp; 
Musculoskeletal and connective tissue disorder - Other (joint contracture); Musculoskeletal and connective 
tissue disorder - Other (musculoskeletal stiffness); Musculoskeletal and connective tissue disorder - Other 
(pain in jaw); Myalgia; Neck pain; Pain in extremity 
NERVOUS SYSTEM DISORDERS - Ataxia; Dysgeusia; Lethargy; Paresthesia; Presyncope; Syncope 
PSYCHIATRIC DISORDERS - Anxiety; Delirium; Depression 
RENAL AND URINARY DISORDERS - Acute kidney injury; Hematuria; Urinary frequency; Urinary tract pain; 
Urinary urgency 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Penile pain; Vaginal hemorrhage 

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Adverse events reported on Belinostat (PXD-101) trials, but for which there is insufficient 
evidence to suggest that there was a reasonable possibility that Belinostat (PXD-101) caused the 
adverse event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Febrile neutropenia 
CARDIAC DISORDERS - Atrial fibrillation; Cardiac disorders - Other (bundle branch block left); Chest 
pain - cardiac; Heart failure; Left ventricular systolic dysfunction; Myocardial infarction; Palpitations; Sinus 
bradycardia; Sinus tachycardia; Supraventricular tachycardia; Ventricular fibrillation 
EYE DISORDERS - Eye disorders - Other (visual loss); Vision decreased 
GASTROINTESTINAL DISORDERS - Abdominal distension; Dyspepsia; Gastroesophageal reflux 
disease; Mucositis oral; Rectal hemorrhage; Small intestinal obstruction; Upper gastrointestinal 
hemorrhage 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Flu like symptoms; 
General disorders and administration site conditions - Other (general physical health deterioration); 
Malaise; Multi-organ failure; Non-cardiac chest pain; Pain 
HEPATOBILIARY DISORDERS - Hepatic failure; Hepatobiliary disorders - Other (hepatic cirrhosis) 
IMMUNE SYSTEM DISORDERS - Allergic reaction; Anaphylaxis; Cytokine release syndrome 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Infusion related reaction; Tracheal 
hemorrhage 
INVESTIGATIONS - Alkaline phosphatase increased; Blood bilirubin increased; CPK increased; Cardiac 
troponin I increased; Cholesterol high; Ejection fraction decreased; Electrocardiogram T wave abnormal; 
INR increased; Investigations - Other (prothrombin time shortened); Investigations - Other (total protein 
decrease); Lipase increased; Weight gain 
METABOLISM AND NUTRITION DISORDERS - Hypercalcemia; Hyperglycemia; Hypermagnesemia; 
Hypertriglyceridemia; Hypoalbuminemia; Hypocalcemia; Hypokalemia; Hyponatremia; Hypophosphatemia 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthralgia; Back pain; Bone pain; 
Chest wall pain; Generalized muscle weakness; Muscle cramp; Myalgia; Pain in extremity 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Tumor pain 
NERVOUS SYSTEM DISORDERS - Ataxia; Depressed level of consciousness; Dysesthesia; 
Encephalopathy; Lethargy; Nervous system disorders - Other (apraxia); Nervous system disorders - 
Other (burning sensation); Peripheral sensory neuropathy; Reversible posterior leukoencephalopathy 
syndrome; Seizure; Stroke; Syncope 
PSYCHIATRIC DISORDERS - Confusion; Depression; Insomnia; Psychosis 
RENAL AND URINARY DISORDERS - Acute kidney injury; Renal and urinary disorders - Other 
(azotemia); Urinary frequency 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Genital edema; Vaginal inflammation 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Cough; Hiccups; Hypoxia; Nasal 
congestion; Pneumonitis; Pulmonary hypertension 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Hyperhidrosis; Pruritus; Urticaria 
VASCULAR DISORDERS - Hematoma; Hypertension; Hypotension; Phlebitis; Thromboembolic event; 
Vasculitis 
 
 
Note: Belinostat (PXD-101) in combination with other agents could cause an exacerbation of any adverse 
event currently known to be caused by the other agent, or the combination may result in events never 
previously associated with either agent. 
 
10.2 
Adverse Event Characteristics  
 
• CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
5.0 will be utilized for AE reporting.  All appropriate treatment areas should have access 
to a copy of the CTCAE version 5.0.  A copy of the CTCAE version 5.0 can be 
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http://ctep.cancer.gov/protocolDevelopment/electronic applications/ctc.htm. 
 
 
• For expedited reporting purposes only:   
- 
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in the 
SPEER column, Section 10.1) should be reported through CTEP-AERS only if the 
grade is above the grade provided in the SPEER. 
 
• Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
10.3 
Expedited Adverse Event Reporting 
 
10.3.1 Rave-CTEP-AERS Integration 
 
The Cancer Therapy Evaluation Program Adverse Event Reporting System (CTEP-
AERS) integration enables evaluation of post-baseline AEs entered in Rave to determine 
whether they require expedited reporting, and facilitates entry in CTEP-AERS for those 
AEs requiring expedited reporting.    
 
All AEs that occur after baseline are collected in Medidata Rave using the Adverse Event 
form, which is available for entry at each treatment or reporting period, and used to 
collect AEs that start during the period or persist from the previous reporting period.  The 
Clinical Research Associate (CRA) will enter AEs that occur prior to the start of 
treatment on a baseline form that is not included in the Rave-CTEP-AERS integration.  
AEs that occur prior to enrollment must begin and end on the baseline Adverse Event 
form and should not be included on the standard Adverse Events form that is available at 
treatment unless there has been an increase in grade. 
 
Prior to sending AEs through the rules evaluation process, site staff should verify the 
following on the Adverse Event form in Rave: 
 
• The reporting period (course/cycle) is correct, and 
• AEs are recorded and complete (no missing fields) and the form is query-free 
(fields added to the form during study build do not need to be query-free for the 
integration call with CTEP-AERS to be a success). 
 
The CRA reports AEs in Rave at the time the Investigator learns of the event.  If the CRA 
modifies an AE, it must be re-submitted for rules evaluation. 
 
Upon completion of AE entry in Medidata Rave, the CRA submits the AE for rules 
evaluation by completing the Expedited Reporting Evaluation form.  Both NCI and 

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protocol-specific reporting rules evaluate the AEs submitted for expedited reporting.  A 
report is initiated in CTEP-AERS using information entered in Medidata Rave for AEs 
that meet reporting requirements.  The CRA completes the report by accessing CTEP-
AERS via a direct link on the Medidata Rave Expedited Reporting Evaluation form. 
 
In the rare occurrence that Internet connectivity is lost, a 24-hour notification is to be 
made to CTEP by telephone at 301-897-7497.  Once Internet connectivity is restored, the 
24-hour notification that was phoned in must be entered immediately into CTEP-AERS 
using the deep link from Medidata Rave. 
 
 
 
 
Additional information about the CTEP-AERS integration is available on the CTSU 
website: 
 
• Study specific documents:  Protocols > Documents > Education and Promotion, 
and   
• Expedited Safety Reporting Rules Evaluation user guide:  Resources > CTSU 
Operations Information > User Guides. 
 
NCI requirements for SAE reporting are available on the CTEP website:  
 
• NCI Guidelines for Investigators:  Adverse Event Reporting Requirements is 
available at 
https://ctep.cancer.gov/protocolDevelopment/electronic applications/docs/aeguid
elines.pdf. 
 
10.3.2 Distribution of Adverse Event Reports 
 
CTEP-AERS is programmed for automatic electronic distribution of reports to the following 
individuals:  Principal Investigator and Adverse Event Coordinator(s) (if applicable) of the 
Corresponding Organization or Lead Organization, the local treating physician, and the Reporter 
and Submitter.  CTEP-AERS provides a copy feature for other e-mail recipients.  
 
10.3.3 Expedited Reporting Guidelines 
 
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 
registration on all reports. 
 
Note:  A death on study requires both routine and expedited reporting, regardless of 
causality as long as the death occurred within 30 days after the last administration of the 
investigational agent.  Attribution to treatment or other cause must be provided. 
 
Death due to progressive disease should be reported as Grade 5 “Disease progression” in the 
system organ class (SOC) “General disorders and administration site conditions.”  Evidence that 

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10.4 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions.  AEs reported 
expeditiously through CTEP-AERS must also be reported in routine study data 
submissions. 
Adverse event data collection and reporting, which are required as part of every clinical trial, are 
done to ensure the safety of patients enrolled in the studies as well as those who will enroll in 
future studies using similar agents.  AEs are reported in a routine manner at scheduled times 
during the trial using Medidata Rave.  For this trial the Adverse Event CRF is used for routine 
AE reporting in Rave. 
 
10.5 
Pregnancy 
 
Although not an adverse event in and of itself, pregnancy as well as its outcome must be 
documented via CTEP-AERS.  In addition, the Pregnancy Information Form included within 
the NCI Guidelines for Adverse Event Reporting Requirements must be completed and 
submitted to CTEP.  Any pregnancy occurring in a patient or patient’s partner from the time of 
consent to 90 days after the last dose of study drug must be reported and then followed for 
outcome.  Newborn infants should be followed until 30 days old.  Please see the “NCI 
Guidelines for Investigators: Adverse Event Reporting Requirements for DCTD (CTEP and CIP) 
and DCP INDs and IDEs” (at http://ctep.cancer.gov/protocolDevelopment/adverse effects.htm) 
for more details on how to report pregnancy and its outcome to CTEP.  
 
10.6 
Secondary Malignancy 
 
A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., 
treatment with investigational agent/intervention, radiation or chemotherapy). A secondary 
malignancy is not considered a metastasis of the initial neoplasm. 
 
CTEP requires all secondary malignancies that occur following treatment with an agent under an 
NCI IND/IDE be reported expeditiously via CTEP-AERS.  Three options are available to 
describe the event:  
 
• 
Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia [AML])  
• 
Myelodysplastic syndrome (MDS)  
• 
Treatment-related secondary malignancy  
 
Any malignancy possibly related to cancer treatment (including AML/MDS) should also be 
reported via the routine reporting mechanisms outlined in each protocol.  
 
10.7 
Second Malignancy 
 
A second malignancy is one unrelated to the treatment of a prior malignancy (and is NOT a 
metastasis from the initial malignancy).  Second malignancies require ONLY routine AE 
reporting unless otherwise specified. 
 
 

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12. MEASUREMENT OF EFFECT 
 
12.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, patients should be re-evaluated for response every 8 weeks.  In 
addition to a baseline scan, confirmatory scans should also be obtained 8 (not less than 4) weeks 
following initial documentation of objective response. 
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1) [Eur J Ca 45:228-247, 2009].  Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph 
nodes are used in the RECIST criteria. 
 
12.1.1 Definitions 
 
Evaluable for toxicity.  All patients will be evaluable for toxicity from the time of their first 
treatment with SGI-110 (guadecitabine) and/or belinostat. 
 
Evaluable for objective response.  All patients will be evaluable for objective response from the 
time of their first treatment with SGI-110 (guadecitabine) and belinostat. 
 
Evaluable Non-Target Disease Response.  Patients who have lesions present at baseline that are 
evaluable but do not meet the definitions of measurable disease, have received at least one cycle 
of therapy, and have had their disease re-evaluated will be considered evaluable for non-target 
disease.  The response assessment is based on the presence, absence, or unequivocal progression 
of the lesions.  
 
12.1.2 Disease Parameters 
 
Measurable disease.  Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as ≥20 mm (≥2 cm) by chest x-ray or as 
≥10 mm (≥1 cm) with CT scan, MRI, or calipers by clinical exam.  All tumor measurements 
must be recorded in millimeters (or decimal fractions of centimeters). 
 
Note:  Tumor lesions that are situated in a previously irradiated area might or might not be 
considered measurable. 
 
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a lymph 
node must be ≥15 mm (≥1.5 cm) in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm [0.5 cm]).  At baseline and in follow-up, 
only the short axis will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm [<1 cm] or pathological lymph nodes with ≥10 to <15 mm [≥1 to <1.5 cm] 
short axis), are considered non-measurable disease.  Bone lesions, leptomeningeal disease, 

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ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
and abdominal masses (not followed by CT or MRI), are considered as non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not 
be considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, 
if they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions. 
 
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded 
and measured at baseline.  Target lesions should be selected on the basis of their size (lesions 
with the longest diameter), be representative of all involved organs, but in addition should be 
those that lend themselves to reproducible repeated measurements.  It may be the case that, on 
occasion, the largest lesion does not lend itself to reproducible measurement in which 
circumstance the next largest lesion which can be measured reproducibly should be selected.  A 
sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target 
lesions will be calculated and reported as the baseline sum diameters.  If lymph nodes are to be 
included in the sum, then only the short axis is added into the sum.  The baseline sum diameters 
will be used as reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 
 
Non-target lesions.  All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Measurements of these lesions are not required, but the presence, absence, 
or in rare cases unequivocal progression of each should be noted throughout follow-up.  
 
12.1.3 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment. 
 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam. 
 
Clinical lesions.  Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and ≥10 mm (≥1 cm) diameter as assessed using 
calipers (e.g., skin nodules).  In the case of skin lesions, documentation by color photography, 
including a ruler to estimate the size of the lesion, is recommended.  
 
Chest x-ray.  Lesions on chest x-ray are acceptable as measurable lesions when they are clearly 

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defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI.  This guideline has defined measurability of lesions on CT scan 
based on the assumption that CT slice thickness is 5 mm (0.5 cm) or less.  If CT scans have slice 
thickness greater than 5 mm (0.5 cm), the minimum size for a measurable lesion should be twice 
the slice thickness.  MRI is also acceptable in certain situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which greatly 
impact image quality, lesion conspicuity, and measurement.  Furthermore, the availability of 
MRI is variable globally.  As with CT, if an MRI is performed, the technical specifications of the 
scanning sequences used should be optimized for the evaluation of the type and site of disease.  
Furthermore, as with CT, the modality used at follow-up should be the same as was used at 
baseline and the lesions should be measured/assessed on the same pulse sequence.  It is beyond 
the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all 
scanners, body parts, and diseases.  Ideally, the same type of scanner should be used and the 
image acquisition protocol should be followed as closely as possible to prior scans.  Body scans 
should be performed with breath-hold scanning techniques, if possible. 
 
PET-CT.  At present, the low dose or attenuation correction CT portion of a combined PET-CT 
is not always of optimal diagnostic CT quality for use with RECIST measurements.  However, if 
the site can document that the CT performed as part of a PET-CT is of identical diagnostic 
quality to a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be 
used for RECIST measurements and can be used interchangeably with conventional CT in 
accurately measuring cancer lesions over time.  Note, however, that the PET portion of the CT 
introduces additional data which may bias an investigator if it is not routinely or serially 
performed.   
 
Ultrasound.  Ultrasound is not useful in assessment of lesion size and should not be used as a 
method of measurement.  Ultrasound examinations cannot be reproduced in their entirety for 
independent review at a later date and, because they are operator dependent, it cannot be 
guaranteed that the same technique and measurements will be taken from one assessment to the 
next.  If new lesions are identified by ultrasound in the course of the study, confirmation by CT 
or MRI is advised.  If there is concern about radiation exposure at CT, MRI may be used instead 
of CT in selected instances. 
 
Endoscopy, Laparoscopy.  The utilization of these techniques for objective tumor evaluation is 
not advised.  However, such techniques may be useful to confirm complete pathological 
response when biopsies are obtained or to determine relapse in trials where recurrence following 
complete response (CR) or surgical resection is an endpoint. 
 
Tumor markers.  Tumor markers alone cannot be used to assess response.  If markers are initially 
above the upper normal limit, they must normalize for a patient to be considered in complete 
clinical response.  Specific guidelines for both CA-125 response (in recurrent ovarian cancer) 
and PSA response (in recurrent prostate cancer) have been published [JNCI 96:487-488, 2004; J 
Clin Oncol 17, 3461-3467, 1999; J Clin Oncol 26:1148-1159, 2008].  In addition, the 

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Gynecologic Cancer Intergroup has developed CA-125 progression criteria which are to be 
integrated with objective tumor assessment for use in first-line trials in ovarian cancer [JNCI 
92:1534-1535, 2000]. 
 
Cytology, Histology.  These techniques can be used to differentiate between partial responses 
(PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as 
germ cell tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens 
during treatment when the measurable tumor has met criteria for response or stable disease is 
mandatory to differentiate between response or stable disease (an effusion may be a side effect of 
the treatment) and progressive disease. 
 
FDG-PET.  While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible 'new' disease).  New lesions on the basis of 
FDG-PET imaging can be identified according to the following algorithm:  
 
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD 
based on a new lesion. 
b. No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive FDG-
PET at follow-up corresponds to a new site of disease confirmed by CT, this is PD.  If the 
positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, 
additional follow-up CT scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-
PET scan).  If the positive FDG-PET at follow-up corresponds to a pre-existing site of 
disease on CT that is not progressing on the basis of the anatomic images, this is not PD. 
c. FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy in 
cases where a residual radiographic abnormality is thought to represent fibrosis or 
scarring.  The use of FDG-PET in this circumstance should be prospectively described in 
the protocol and supported by disease-specific medical literature for the indication.  
However, it must be acknowledged that both approaches may lead to false positive CR 
due to limitations of FDG-PET and biopsy resolution/sensitivity. 
 
Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake greater 
than twice that of the surrounding tissue on the attenuation corrected image. 
 
12.1.4 Response Criteria 
 
12.1.4.1 
Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm (<1 cm). 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target lesions, 
taking as reference the baseline sum diameters. 

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Progressive Disease (PD):  At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the 
smallest on study).  In addition to the relative increase of 20%, the sum must also demonstrate an 
absolute increase of at least 5 mm (0.5 cm).  (Note:  the appearance of one or more new lesions is 
also considered progressions). 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum diameters while on study. 
 
12.1.4.2 
Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and normalization of tumor 
marker level.  All lymph nodes must be non-pathological in size (<10 mm [<1 cm] short axis). 
 
Note:  If tumor markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response. 
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits. 
 
Progressive Disease (PD):  Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions.  Unequivocal progression should not normally trump 
target lesion status.  It must be representative of overall disease status change, not a single lesion 
increase. 
 
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the 
treating physician should prevail in such circumstances, and the progression status should be 
confirmed at a later time by the review panel (or Principal Investigator). 
 
12.1.4.3 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started).  The patient's best response assignment will 
depend on the achievement of both measurement and confirmation criteria. 
 
 
 
 
 
 
 
 
 
 
 

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For Patients with Measurable Disease (i.e., Target Disease) 
 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response when 
Confirmation is Required* 
CR 
CR 
No 
CR 
≥4 wks. Confirmation** 
CR 
Non-CR/Non-
PD 
No 
PR 
≥4 wks. Confirmation** 
CR 
Not evaluated 
No 
PR 
PR 
Non-CR/Non-
PD/not 
evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/not 
evaluated 
No 
SD 
Documented at least once ≥4 
wks. from baseline** 
PD 
Any 
Yes or No 
PD 
no prior SD, PR or CR 
Any 
PD*** 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
 
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
**    Only for non-randomized trials with response as primary endpoint. 
***  In exceptional circumstances, unequivocal progression in non-target lesions may be 
accepted as disease progression. 
 
Note:  Patients with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
reported as “symptomatic deterioration.”  Every effort should be made to document the 
objective progression even after discontinuation of treatment. 
 
For Patients with Non-Measurable Disease (i.e., Non-Target Disease) 
 
Non-Target Lesions 
New Lesions 
Overall Response 
CR 
No 
CR 
Non-CR/non-PD 
No 
Non-CR/non-PD* 
Not all evaluated 
No 
not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 
 
‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign this 
category when no lesions can be measured is not advised 
 
12.1.5 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started). 

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The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that progressive disease is objectively documented. 
 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment until the 
criteria for progression are met, taking as reference the smallest measurements recorded since the 
treatment started, including the baseline measurements.  
 
12.1.6 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression or death, 
whichever occurs first. 
 
12.1.7 Response Review 
 
Not applicable. 
 
13. STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 10 
(Adverse Events: List and Reporting Requirements). 
 
13.1 
Study Oversight 
 
This protocol is monitored at several levels, as described in this section.  The Protocol Principal 
Investigator is responsible for monitoring the conduct and progress of the clinical trial, including 
the ongoing review of accrual, patient-specific clinical and laboratory data, and routine and 
serious adverse events; reporting of expedited adverse events; and accumulation of reported 
adverse events from other trials testing the same drug(s).  The Protocol Principal Investigator and 
statistician have access to the data at all times through the CTMS web-based reporting portal.   
Click or tap here to enter text. 
All Study Investigators at participating sites who register/enroll patients on a given protocol are 
responsible for timely submission of data via Medidata Rave and timely reporting of adverse 
events for that particular study.  This includes timely review of data collected on the electronic 
CRFs submitted via Medidata Rave. 
 
All studies are also reviewed in accordance with the enrolling institution’s data safety monitoring 
plan. 
 
13.2 
Data Reporting 
 
Medidata Rave is a clinical data management system being used for data collection for this 
trial/study.  Access to the trial in Rave is controlled through the CTEP-IAM system and role 
assignments.  To access Rave via iMedidata: 
 

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• 
Site staff will need to be registered with CTEP and have a valid and active CTEP-IAM 
account, and  
• 
Assigned one of the following Rave roles on the relevant Lead Protocol Organization 
(LPO) or Participating Organization roster at the enrolling site:  Rave CRA, Rave Read 
Only, Rave CRA (LabAdmin), Rave SLA, or Rave Investigator.  Refer to 
https://ctep.cancer.gov/investigatorResources/default.htm for registration types and 
documentation required. 
1. 
To hold Rave CRA or Rave CRA (Lab Admin) role, site staff must hold a 
minimum of an AP registration type, 
2. 
To hold Rave Investigator role, the individual must be registered as an NPIVR or 
IVR, and 
3. 
To hold Rave Read Only role, site staff must hold an Associates (A) registration 
type. 
 
If the study has a DTL, individuals requiring write access to Rave must also be assigned the 
appropriate Rave tasks on the DTL. 
 
Upon initial site registration approval for the study in Regulatory Support System (RSS), all 
persons with Rave roles assigned on the appropriate roster will be sent a study invitation e-mail 
from iMedidata.  To accept the invitation, site staff must log in to the Select Login 
(https://login.imedidata.com/selectlogin) using their CTEP-IAM username and password, and 
click on the accept link in the upper right-corner of the iMedidata page.  Site staff will not be 
able to access the study in Rave until all required Medidata and study specific trainings are 
completed.  Trainings will be in the form of electronic learnings (eLearnings), and can be 
accessed by clicking on the link in the upper right pane of the iMedidata screen.  If an eLearning 
is required and has not yet been taken, the link to the eLearning will appear under the study name 
in iMedidata instead of the Rave EDC link; once the successful completion of the eLearning has 
been recorded, access to the study in Rave will be granted, and a Rave EDC link will display 
under the study name.  
 
Site staff that have not previously activated their iMedidata/Rave account at the time of initial 
site registration approval for the study in RSS will also receive a separate invitation from 
iMedidata to activate their account.  Account activation instructions are located on the CTSU 
website in the Rave section under the Rave resource materials (Medidata Account Activation and 
Study Invitation Acceptance).  Additional information on iMedidata/Rave is available on the 
CTSU members’ website in the Data Management > Rave section at www.ctsu.org/RAVE/ or by 
contacting the CTSU Help Desk at 1-888-823-5923 or by e-mail at ctsucontact@westat.com.   
 
13.2.1 Method 
 
This study will be monitored by the Clinical Trials Monitoring Service (CTMS).  Data will be 
submitted to CTMS at least once every two weeks via Medidata Rave (or other modality if 
approved by CTEP).  Information on CTMS reporting is available at:  
http://www.theradex.com/clinicalTechnologies/?National-Cancer-Institute-NCI-11.  On-site 
audits will be conducted on an 18-36 month basis as part of routine cancer center site visits. 
More frequent audits may be conducted if warranted by accrual or due to concerns regarding 

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data quality or timely submission.  For CTMS monitored studies, after users have activated their 
accounts, please contact the Theradex Help Desk at (609) 619-7862 or by email at 
CTMSSupport@theradex.com for additional support with Rave and completion of CRFs. 
 
13.2.2 Responsibility for Data Submission 
 
For ETCTN trials, it is the responsibility of the PI(s) at the site to ensure that all investigators at 
the ETCTN Sites understand the procedures for data submission for each ETCTN protocol and 
that protocol specified data are submitted accurately and in a timely manner to the CTMS via the 
electronic data capture system, Medidata Rave.   
 
Data are to be submitted via Medidata Rave to CTMS on a real-time basis, but no less than once 
every 2 weeks.  The timeliness of data submissions and timeliness in resolving data queries will 
be tracked by CTMS.  Metrics for timeliness will be followed and assessed on a quarterly basis.  
For the purpose of Institutional Performance Monitoring, data will be considered delinquent if it 
is greater than 4 weeks past due. 
 
Data from Medidata Rave and CTEP-AERS is reviewed by the CTMS on an ongoing basis as 
data is received.  Queries will be issued by CTMS directly within Rave.  The queries will appear 
on the Task Summary Tab within Rave for the CRA at the ETCTN to resolve.  Monthly web-
based reports are posted for review by the Drug Monitors in the IDB, CTEP.  Onsite audits will 
be conducted by the CTMS to ensure compliance with regulatory requirements, GCP, and NCI 
policies and procedures with the overarching goal of ensuring the integrity of data generated 
from NCI-sponsored clinical trials, as described in the ETCTN Program Guidelines, which may 
be found on the CTEP 
(http://ctep.cancer.gov/protocolDevelopment/electronic applications/adverse events.htm)  and 
CTSU websites. 
 
CTMS will utilize a core set of eCRFs that are Cancer Data Standards Registry and Repository 
(caDSR) compliant (http://cbiit.nci.nih.gov/ncip/biomedical-informatics-
resources/interoperability-and-semantics/metadata-and-models).  Customized eCRFs will be 
included when appropriate to meet unique study requirements.  The PI is encouraged to review 
the eCRFs, working closely with CTMS to ensure prospectively that all required items are 
appropriately captured in the eCRFs prior to study activation.  CTMS will prepare the eCRFs 
with built-in edit checks to the extent possible to promote data integrity. 
 
CDUS data submissions for ETCTN trials activated after March 1, 2014, will be carried out by 
the CTMS contractor, Theradex.  CDUS submissions are performed by Theradex on a monthly 
basis.  The trial’s lead institution is responsible for timely submission to CTMS via Rave, as 
above. 
 
Further information on data submission procedures can be found in the ETCTN Program 
Guidelines 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm). 
 

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13.3 Data Quality Portal 
 
The Data Quality Portal (DQP) provides a central location for site staff to manage 
unanswered queries and form delinquencies, monitor data quality and timeliness, 
generate reports, and review metrics.  
 
The DQP is located on the CTSU members’ website under Data Management.  The Rave 
Home section displays a table providing summary counts of Total Delinquencies and 
Total Queries.  DQP Queries, DQP Delinquent Forms, and the DQP Reports modules are 
available to access details and reports of unanswered queries, delinquent forms, and 
timeliness reports.  Review the DQP modules on a regular basis to manage specified 
queries and delinquent forms. 
 
The DQP is accessible by site staff that are rostered to a site and have access to the CTSU 
website.  Staff that have Rave study access can access the Rave study data using a direct 
link on the DQP. 
 
To learn more about DQP use and access, click on the Help icon displayed on the Rave 
Home, DQP Queries, and DQP Delinquent Forms modules. 
 
Note:  Some Rave protocols may not have delinquent form details or reports specified on 
the DQP.  A protocol must have the Calendar functionality implemented in Rave by the 
Lead Protocol Organization (LPO) for delinquent form details and reports to be available 
on the DQP.  Site staff should contact the LPO Data Manager for their protocol regarding 
questions about Rave Calendaring functionality.  
 
13.4 
CTEP Multicenter Guidelines 
 
N/A 
 
13.5 
Collaborative Agreements Language 
 
The agents supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI under  
Collaborative Agreements (CRADA, CTA, CSA) between the Pharmaceutical Companies 
(hereinafter referred to as “Collaborators”) and the NCI Division of Cancer Treatment and 
Diagnosis.  Therefore, the following obligations/guidelines, in addition to the provisions in the 
“Intellectual Property Option to Collaborator”  
(http://ctep.cancer.gov/industryCollaborations2/intellectual property.htm) contained within the 
terms of award, apply to the use of the Agents in this study: 
 
1. Agents may not be used for any purpose outside the scope of this protocol, nor can Agents be 
transferred or licensed to any party not participating in the clinical study.  Collaborators’ data 
for Agents are confidential and proprietary to Collaborators and shall be maintained as such 
by the investigators.  The protocol documents for studies utilizing Agents contain 
confidential information and should not be shared or distributed without the permission of 
the NCI.  If a copy of this protocol is requested by a patient or patient’s family member 

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participating on the study, the individual should sign a confidentiality agreement.  A suitable 
model agreement can be downloaded from: http://ctep.cancer.gov. 
 
2. For a clinical protocol where there is an investigational Agent used in combination with 
another Agents, each the subject of different Collaborative Agreements, the access to and use 
of data by each Collaborator shall be as follows (data pertaining to such combination use 
shall hereinafter be referred to as "Multi-Party Data”): 
 
a. NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NCI, the design of the 
proposed combination protocol, and the existence of any obligations that would tend to 
restrict NCI's participation in the proposed combination protocol. 
 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator 
to develop, obtain regulatory approval or commercialize its own Agent. 
 
c. Any Collaborator having the right to use the Multi-Party Data from these trials must 
agree in writing prior to the commencement of the trials that it will use the Multi-Party 
Data solely for development, regulatory approval, and commercialization of its own 
Agent. 
 
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement 
will be made available to Collaborators, the NCI, and the FDA, as appropriate and unless 
additional disclosure is required by law or court order as described in the IP Option to 
Collaborator (http://ctep.cancer.gov/industryCollaborations2/intellectual property.htm).  
Additionally, all Clinical Data and Results and Raw Data will be collected, used and 
disclosed consistent with all applicable federal statutes and regulations for the protection of 
human subjects, including, if applicable, the Standards for Privacy of Individually 
Identifiable Health Information set forth in 45 C.F.R. Part 164. 
 
4. When a Collaborator wishes to initiate a data request, the request should first be sent to the 
NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them. 
 
5. Any data provided to Collaborators for Phase 3 studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a 
DMC for this clinical trial. 
 
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the 
Group office for Cooperative Group studies or by the principal investigator for non-
Cooperative Group studies for immediate delivery to Collaborators for advisory review and 
comment prior to submission for publication.  Collaborators will have 30 days from the date 
of receipt for review.  Collaborators shall have the right to request that publication be delayed 
for up to an additional 30 days in order to ensure that Collaborators’ confidential and 
proprietary data, in addition to Collaborators’ intellectual property rights, are protected.  

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Copies of abstracts must be provided to CTEP for forwarding to Collaborators for courtesy 
review as soon as possible and preferably at least three 3 days prior to submission, but in any 
case, prior to presentation at the meeting or publication in the proceedings.  Press releases 
and other media presentations must also be forwarded to CTEP prior to release.  Copies of 
any manuscript, abstract and/or press release/ media presentation should be sent to: 
 
Email:  ncicteppubs@mail.nih.gov 
 
The Regulatory Affairs Branch will then distribute them to Collaborators.  No publication, 
manuscript or other form of public disclosure shall contain any of Collaborators’ confidential/ 
proprietary information. 
 
13.6 
Genomic Data Sharing Plan 
 
Not applicable.  
 
13.7 
Incidental/Secondary Findings Disclosure Procedure 
 
In the event that a germline genomic mutation/alteration of potential clinical significance is 
noted, the Study Chair will discuss the findings with the treating investigator.  The treating 
investigator will be responsible for discussing such findings with the patient according to 
institutional procedures at the treating site.  A genetic counselor should be involved in the 
discussion whenever possible.  Germline genomic alterations will be confirmed at the treating 
site at the direction of the treating investigator.  Disclosure must be documented in the electronic 
medical record at the treating institution.  
 
 
 
 

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

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APPENDIX C 
PRE-BIOPSY ASSESSMENT 
 
A pre-biopsy lesion assessment can increase trial safety and efficiency.  By agreement between 
all investigators, an attempt at biopsy will be made if the clinical trial team determines that a 
biopsy poses minimal relative risk, provides potential clinical gain to the participant, and will 
likely yield sufficient tissue for analysis.   
 
Pre-biopsy assessments will be reported and tracked through a trial-specific CRF within the 
CTEP Medidata Rave system.  Additional information can be found in the Investigational 
Radiology SOP available at:   
https://ctep.cancer.gov/initiativesPrograms/docs/ETCTN IR Research Biopsy SOP.pdf.  
 
Individual Patient Pre-Biopsy Assessment.  IR co-investigators are encouraged to apply this 
pre-biopsy scoring and correlation system to assist in the determination of biopsy 
appropriateness. 
 
• IR co-investigators assign a subjective score of 1-3 based on likelihood of success due to 
lesion characteristics.  
 
1.  Biopsy should not be done  
A. Due to safety concerns 
B. Due to lack of suitable lesion for biopsy 
 
2.  Uncertainty about success  
A. Due to access path to lesion 
B. Due to lesion characteristics  
 
3.  Likely successful  
 
• Lesion characteristics to be considered 
• Size (small) (<2 cm) 
• Location/path to lesion 
• Morphologic features (necrosis, sub-solid, sclerosis, ill-defined/infiltrative) 
• PET (+/-), avidity  
• Organ/site (sclerotic bone is low yield; fine needle aspiration to be used) 
 
 

NCI Protocol #10330 
Version Date: , March 25, 2025 
 
112 
 
APPENDIX F  
PATIENT MEDICATION DIARY – ASTX727 
 
PATIENT’S MEDICATION DIARY  
     Today’s date _______________________________ 
Agent _________ASTX727______ 
     Patient Name
 (initials acceptable) Patient Study ID 
 
INSTRUCTIONS TO THE PATIENT: 
1. 
Complete one form every four weeks. 
2. 
You will take 1 tablet each day during the first 5 days of a 28-day cycle as shown below, unless instructed otherwise. 
You will bring the ASTX727 tablets to the clinic and take them at the clinic under the direction of a doctor or nurse.  
3.     Do not eat, drink milk or alcohol 2 hours before and 2 hours after taking ASTX727.  Clear liquids such as water, black 
coffee, or tea are allowed. Take whole tablets with 8 oz. (240 mL) of water; do not crush, cut, or chew the tablet.   
4. 
If you miss or forget about a dose, you can still take that day’s medication if you remember within 12 hours of the 
scheduled time you were supposed to take that dose. If you miss or forget about a dose and it is beyond 12 hours 
from the time you were supposed to take it, you should skip that dose, and resume at the scheduled time the next day. 
Always tell your nurse or doctor if you miss, forget about, or vomit up a dose..  
6. 
Record the date and time the tablet is taken below.    
7. 
If you have any comments or notice any side effects, please record them in the Comments column.   
8. 
Please return the forms to your doctor when you go for your next appointment. 
 
Day 
 
Date 
What time 
was dose taken? 
# of tablets taken 
Comments 
1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
 
6 
 
through 
 
28 
 
 
 
 
 
 
 
 
 
Do not take ASTX727 on days 6 through 28. 
 
 
 
 
 
 
 
 
Physician’s Office will complete this section: 
 
Date patient started protocol treatment: _____________                       Date patient was removed from study______________ 
 
Patient’s planned total daily dose________________________           Total number of pills taken this month (each size):_____________ 
 
Physician/Nurse/Data Manager’s Signature _____________________________________________________ 
     
Patient’s Signature:____________________________________________________________________ 
 
CTEP-assigned Protocol #    10330 
 
Local Protocol # ___________________