Clinical trial NCT03884556
Conditions: Solid Tumor Lymphoma
Keywords: Cancer Metastatic Solid Tumors Advanced Solid Tumors Relapsed/Refractory Lymphoma Prostrate Cancer Pancreatic Cancer Monotherapy Combination Therapy CD39 Adenosine Pathway Immunotherapy Immuno-oncology PD-1 Checkpoint Inhibitor Nab-paclitaxel Gemcitabine Pembrolizumab Docetaxel Bladder Cancer Lung Cancer
Sponsor: Trishula Therapeutics, Inc.
Start date: 2019-04-10; Completion date: 2023-09-29
Enrollment: 56 participants; Allocation: RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
This is a phase 1/1b study of TTX-030, an antibody that inhibits CD39 enzymatic activity, leading to accumulation of pro-inflammatory adenosine triphosphate (ATP) and reduction of immunosuppressive adenosine, which may change the tumor microenvironment and promote anti-tumor immune response.

This trial will study the safety, tolerability, pharmacokinetics, and anti-tumor activity of TTX-030 as a single agent and in combination with an approved anti-PD-1 immunotherapy and standard chemotherapies.

Detailed description:

Arms: arm 1: TTX-030 arm 2: TTX-030 plus pembrolizumab arm 3: TTX-030 plus gemcitabine plus nab-paclitaxel
Interventions: intervention 1: TTX-030 intervention 2: Pembrolizumab intervention 3: Gemcitabine intervention 4: nab paclitaxel
Intervention descriptions: intervention 1: Variable dose and schedule intervention 2: Dose and schedule per standard of care intervention 3: Dose and schedule per standard of care intervention 4: Dose and schedule per standard of care

Protocol documents:
Prot_000.pdf: 
TTX-030-001 Version 8 (December 15, 2020) 
CONFIDENTIAL 
 
 
1 
Title Page 
Protocol Title:  
Phase 1/1b Study of the Safety of TTX-030 as a Single Agent and 
in Combination with Pembrolizumab or Chemotherapy in Patients 
with Lymphoma or Solid Tumor Malignancies 
Protocol Number:   
TTX-030-001 
Amendment Number:  
Version 8.0, December 15, 2020 
Compound:   
 
TTX-030 
Study Phase:   
 
1/1b  
Sponsor Name:  
 
Trishula Therapeutics, Inc. 
Legal Registered Address:   4000 Shoreline Court, Suite 200 
South San Francisco, CA 94080 
Regulatory Agency   
IND Number 138313 
Identifier Number(s): 
Approval Date:  
 
October 1, 2018  
 
Version 1.0 
 
 
 
October 24, 2018  
 
Version 1.1 
 
 
 
December 28, 2018 
 
Version 2.0 
 
 
 
September 12, 2019  
Version 3.0 
 
 
 
October 21, 2019 
 
Version 4.0 
 
 
 
November 22, 2019  
Version 5.0 
 
 
 
January 2, 2020 
 
Version 6.0 
 
 
 
October 12, 2020 
 
Version 7.0 
 
 
 
December 15, 2020 
 
Version 8.0 
 
CONFIDENTIAL 
This document and all copies thereof are the property of Trishula Therapeutics, Inc. This 
document contains valuable trade secrets and proprietary information and may not be 
disclosed to others without prior written authorization from Trishula Therapeutics, Inc. 
and may only be used for purposes intended by the document. 
 




TTX-030-001 Version 8 (December 15, 2020) 
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3 
PROTOCOL ACCEPTANCE FORM 
 
PROTOCOL TITLE: 
Phase 1/1b Study of the Safety of TTX-030 as a Single Agent and in Combination with 
Pembrolizumab or Chemotherapy in Patients with Lymphoma or Solid Tumor 
Malignancies 
 
PROTOCOL NUMBER: 
 
 
TTX-030-001 
 
STUDY TREATMENT: 
 
 
TTX-030 
 
IND NUMBER: 
 
 
 
138313 
 
SPONSOR:  
 
 
 
Trishula Therapeutics, Inc. 
 
 
 
 
 
 
4000 Shoreline Court, Suite 200 
 
 
 
 
 
 
South San Francisco, CA 94080 
 
 
DATE FINAL: 
 
 
 
December 15, 2020 
Version 8.0 
 
By my signature below, I hereby state that I have read and agree to abide by the instructions, 
conditions, and restrictions of the protocol, in accordance with Good Clinical Practice guidelines, 
the Declaration of Helsinki, and all applicable laws and regulations.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Name of investigator (print)  
 
 
 
Name of investigator (signature) 
 
 
 
 
 
 
Date 
 


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4 
Protocol Amendment Summary of Changes Table 
DOCUMENT HISTORY 
Document 
Date 
Version 8.0 Amendment 8 (Trishula) 
15 Dec 2020 
Version 7.0 Amendment 7 (Trishula) 
12 Oct 2020 
Version 6.0 Amendment 6 
2 Jan 2020 
Version 5.0 Amendment 5 
22 Nov 2019 
Version 4.0 Amendment 4 
21 Oct 2019 
Version 3.0 Amendment 3 
12 Sep 2019 
Version 2.0 Amendment 2 
28 Dec 2018 
Version 1.1 Amendment 1 
24 Oct 2018 
Version 1.0 Original Protocol  
01 Oct 2018 
Amendment 8 (15 December 2020) 
Overall Rationale for the Amendment: 
Section #  
Description of Change 
Brief Rationale 
Entire document 
Minor spelling, grammar, punctuation, 
capitalization, abbreviations, and other 
formatting edits were made throughout 
the document 
Consistency 
Section 1.3 
Schedule of Activities – update 
footnotes 
Clarity 
Section 1.1 
Section 3.0 
Section 4.1.1.2 
Section 5.1 
Section 9.2 
Remove the number of prior lines 
requirement for RCC population 
Population consideration 
Section 5.2 
Section 5.3 
Inclusion Criterion #22 
Exclusion Criterion #27 
-Update washout requirement from 28 
to 14 days 
Treatment consideration for 
advanced cancer population  
 
Section 6.1.13 
Table 11 
-Update TTX-030 administration 
guidance to follow the Pharmacy 
Manual 
Clarity 
The rationale for prior amendments is included in Section 11.1.  
 
 


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5 
Table of Contents 
1. 
Protocol Summary ........................................................................................................14 
1.1. 
Synopsis ..........................................................................................................................14 
1.2. 
Schema ............................................................................................................................19 
1.3. 
Schedule of Activities .....................................................................................................20 
2. 
Introduction ...................................................................................................................34 
2.1. 
Study Rationale ...............................................................................................................35 
2.2. 
Background .....................................................................................................................37 
2.2.1. 
Nonclinical Data .............................................................................................................37 
2.2.2. 
Clinical Data ...................................................................................................................48 
2.2.3. 
Rationale for TTX-030 Dose and Schedule ....................................................................49 
2.3. 
Benefit/Risk Assessment ................................................................................................50 
3. 
Objectives and Endpoints ............................................................................................51 
4. 
Study Design ..................................................................................................................53 
4.1. 
Overall Design ................................................................................................................53 
4.1.1. 
Overview .........................................................................................................................53 
4.1.2. 
Cohort Review Committee .............................................................................................55 
4.2. 
Justification for Dose in FIH study .................................................................................56 
4.2.1. 
Rationale for TTX-030 Starting Dose and Dosing Schedule..........................................56 
4.2.2. 
Selection of Agents in Combination with TTX-030 .......................................................56 
4.3. 
Treatment Assignment ....................................................................................................57 
4.4. 
Dose Levels.....................................................................................................................57 
4.5. 
Dose Escalation and Safety Lead-In Arms .....................................................................58 
4.6. 
Dose Escalation Using Modified Continual Reassessment 
Method ............................................................................................................................58 
4.7. 
Dose Escalation Using 3 + 3 Design ..............................................................................59 
4.8. 
Dose-Toxicity Modeling .................................................................................................59 
4.9. 
Early Stopping ................................................................................................................59 
4.10. 
Initiation of Safety Lead-In Combination Therapies (Arms 2 & 
4) .....................................................................................................................................59 
4.11. 
Maximum Tolerated Dose and Recommended Phase 2 Dose ........................................60 
4.12. 
Definition of Dose-limiting Toxicity ..............................................................................60 
4.13. 
Dosing Delays .................................................................................................................61 
4.14. 
Safety Criteria for Adjustment or Stopping Doses .........................................................62 
4.15. 
Pharmacokinetic Criteria for Adjustment or Stopping Doses ........................................62 
4.16. 
Intra-subject Dose Escalation .........................................................................................62 
4.17. 
Expansion Arms ..............................................................................................................63 
4.18. 
Retreatment Criteria ........................................................................................................63 
4.19. 
Follow-Up Safety and Survival Contact .........................................................................63 
4.20. 
Study Completion ...........................................................................................................64 
5. 
Study Population ...........................................................................................................65 
5.1. 
Target Population and Arm-Specific Eligibility Criteria ................................................65 
5.2. 
Common Inclusion Criteria ............................................................................................66 


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5.3. 
Common Exclusion Criteria ...........................................................................................67 
5.4. 
Screen Failures ................................................................................................................68 
5.5. 
Subject Adherence to Protocol Schedule ........................................................................68 
6. 
Investigational Product ................................................................................................69 
6.1. 
Investigational Product Description and Administration ................................................69 
6.1.1. 
Investigational Product Description ................................................................................69 
6.1.2. 
Other Study Treatments ..................................................................................................69 
6.1.3. 
Investigational Product Administration ..........................................................................69 
6.2. 
Preparation/Handling/Storage/Accountability ................................................................70 
6.2.1. 
Study Treatment Packaging and Labeling ......................................................................70 
6.2.2. 
Study Treatment Storage.................................................................................................70 
6.2.3. 
Study Treatment Preparation ..........................................................................................71 
6.2.4. 
Study Treatment Accountability .....................................................................................71 
6.2.5. 
Study Treatment Handling and Disposal ........................................................................71 
6.3. 
Measures to Minimize Bias: Randomization and Blinding ............................................71 
6.4. 
Treatment Compliance ....................................................................................................71 
6.5. 
Concomitant Therapy .....................................................................................................72 
6.5.1. 
Concomitant Medications Allowed During the Study ....................................................72 
6.5.2. 
Concomitant Medications Prohibited During the Study .................................................72 
7. 
Discontinuation of Study Treatment and Subject 
Discontinuation .............................................................................................................73 
7.1. 
Discontinuation of Study Treatment ...............................................................................73 
7.2. 
Subject Discontinuation/Withdrawal from the Study .....................................................73 
7.3. 
Lost to Follow-up............................................................................................................74 
8. 
Study Assessments and Procedures.............................................................................75 
8.1. 
Study Visits .....................................................................................................................75 
8.1.1. 
Study Visits for Arms 1 and 2 Safety Lead-in and Expansion .......................................75 
8.1.2. 
Study Visits for Arm 4 (TTX-030 Q2W, 28-Day Cycle) ...............................................76 
8.2. 
Efficacy Assessments .....................................................................................................77 
8.2.1. 
Tumor Assessment/Tumor Response Assessment..........................................................77 
8.3. 
Safety Assessments .........................................................................................................78 
8.3.1. 
Demographic/Medical History........................................................................................78 
8.3.2. 
Physical Examinations (Including Symptom-focused 
Examination) ...................................................................................................................78 
8.3.3. 
Vital Signs .......................................................................................................................78 
8.3.4. 
Electrocardiograms .........................................................................................................78 
8.3.5. 
Laboratory Assessments .................................................................................................78 
8.3.6. 
Adverse Events and Serious Adverse Events .................................................................80 
8.4. 
Pharmacokinetics ............................................................................................................95 
8.4.1. 
Pharmacokinetic Blood Sample Collection ....................................................................95 
8.4.2. 
Pharmacokinetic Sample Analysis ..................................................................................95 
8.5. 
Pharmacodynamics .........................................................................................................96 
8.5.1. 
Pharmacodynamic Blood Samples .................................................................................96 
8.5.2. 
Pharmacodynamic Tissue Samples .................................................................................96 


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8.6. 
Immunogenicity Assessments.........................................................................................97 
8.6.1. 
Anti-drug Antibody Assessments ...................................................................................97 
8.6.2. 
Blood Sample Collection ................................................................................................97 
8.6.3. 
Analysis of ADA Formation ...........................................................................................98 
9. 
Statistical Considerations .............................................................................................99 
9.1. 
Statistical Hypotheses .....................................................................................................99 
9.2. 
Statistical Considerations for Arm 1 and 2 Expansion Cohorts ...................................100 
9.3. 
Populations for Analyses ..............................................................................................102 
9.4. 
Interim Analyses ...........................................................................................................102 
10. 
Regulatory, Ethical, and Study Oversight Considerations .....................................103 
10.1. 
Criteria for Study Termination .....................................................................................103 
10.2. 
Protocol Adherence and Amendment ...........................................................................103 
10.3. 
Investigator Compliance ...............................................................................................103 
10.4. 
Institutional Review Board or Independent Ethics Committee ....................................104 
10.5. 
Financial Disclosure .....................................................................................................104 
10.6. 
Informed Consent .........................................................................................................104 
10.7. 
Data Protection .............................................................................................................105 
10.8. 
Committee Structure .....................................................................................................105 
10.9. 
Dissemination of Clinical Study Data ..........................................................................105 
10.10. 
Data Quality Assurance ................................................................................................106 
10.11. 
Inspection of Records ...................................................................................................106 
10.12. 
Retention of Records ....................................................................................................106 
10.13. 
Study and Site Start and Closure ..................................................................................107 
10.14. 
Publication Policy .........................................................................................................107 
11. 
Appendices ...................................................................................................................109 
11.1. 
Appendix 1: Protocol Amendment History ..................................................................110 
11.2. 
Appendix 2: Eastern Cooperative Oncology Group Performance 
Status .............................................................................................................................115 
11.3. 
Appendix 3: RECIST and iRECIST .............................................................................116 
11.4. 
Appendix 4: Response Criteria for Metastatic Prostate Cancer 
(Based on Prostate Cancer Clinical Trials Working Group 3 
Criteria) .........................................................................................................................117 
11.5. 
Appendix 5: Response Criteria for Lymphoma ............................................................119 
11.6. 
Appendix 6: Adaptive Design Report for the Phase I Dose 
Escalation Study of TTX-030 in Patients with Lymphoma or 
Solid Tumor Malignancies............................................................................................125 
12. 
References ....................................................................................................................145 
 
 
 


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8 
 
List of Tables 
Table 1: 
Arms 1 and 2: Schedule of Assessments (Screening Through Treatment Period 
Cycle 1 and Cycle 2) – Q3W Dosing Schedule (21-Day Cycle) .................................................. 20 
Table 2: 
Arms 1 and 2: Schedule of Assessments (Treatment Extension Cycles Through 
Post-Treatment) – Q3W Dosing Schedule (21-Day Cycle) .......................................................... 24 
Table 3: 
Arm 4: Schedule of Assessments (Screening Through Treatment Period 1 
(Cycle 1) – Q2W Dosing Schedule (28-Day Cycle) ..................................................................... 26 
Table 4: 
Arm 4: Schedule of Assessments (Treatment Extension Cycles Through Post-
Treatment) – Q2W Dosing Schedule (28-Day Cycle) .................................................................. 29 
Table 5: 
PK Sampling Intervals During Treatment (21-day treatment schedule Q3W) . 32 
Table 6: 
PK Sampling Intervals During Treatment (28-day treatment cycle, Q2W) ...... 33 
Table 7: 
Procedures and Parameters for the 28-Day GLP Toxicology Study of the 
Administration of TTX-030 to Male and Female Cynomolgus Monkeys .................................... 38 
Table 8: 
Dose-Escalation and Safety Lead-In Arms ....................................................... 58 
Table 9: 
Criteria for Adjusting or Stopping Doses of TTX-030 ..................................... 62 
Table 10:  
Investigational Product ...................................................................................... 69 
Table 11: 
Treatment Regimen Description ....................................................................... 70 
Table 12: 
Clinical Laboratory Tests .................................................................................. 79 
Table 13: 
Serum Pharmacokinetic Parameters to be Computed ....................................... 96 
Table 14: 
Efficacy Endpoints .......................................................................................... 100 
Table 15: 
Power for Study Design for Several Possible True Underlying Delta ORR 
Values 
101 
Table 16: 
Analysis Populations ....................................................................................... 102 
 


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9 
List of Figures 
Figure 1:  
Study Schema .................................................................................................... 19 
Figure 2: 
Short-Term Inhibition of CD39 by TTX-030 on Human and Cynomolgus 
Monocytes 
40 
Figure 3: 
TTX-030 Reduces CD39-Mediated Adenosine Production and Preserves ATP 
in SK-MEL-28 Cells ..................................................................................................................... 41 
Figure 4: 
TTX-030 Reverses Suppression of IFN-γ Response in a CMV Recall Assay .. 42 
Figure 5: 
TTX-030 Increases the Proliferation of Stimulated CD8+ and CD4+ T Cells in 
the Presence of ATP...................................................................................................................... 43 
Figure 6: 
TTX-030 Induces IL-2 Release by Stimulated PBMCs in Dose-Dependent 
Manner 
44 
Figure 7: 
Anti-Mouse CD39 Antibody B66 Inhibits MC38 Tumor Growth as Single 
Agent and in Combination with Anti-PD-1 .................................................................................. 45 
Figure 8:  
Combinatorial Anti-Tumor Efficacy of Anti-PD-1 and Anti-Mouse CD39 
Antibody B66 in an Immunotherapy-Resistant SM1WT1 Tumor Cell Line ............................... 46 
Figure 9:  
Anti-CD39 Antibody Inhibits Lung Metastasis Formation in Models of 
Disseminated Disease ................................................................................................................... 47 
Figure 10:  
Receptor Occupancy Analysis for 10 mg/kg Group in Cynomolgus Monkeys 48 
Figure 11: 
Algorithmic Approach to Risk Assessment of Tumor Lysis Syndrome ........... 87 
Figure 12: 
Transmission of Electronic Data ..................................................................... 105 
 
 


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10 
List of Abbreviations 
5-PS 
5-point scale 
A2AR 
adenosine A2A receptor 
ACTH 
adrenocorticotropic hormone 
ADA 
anti-drug antibodies 
ADP 
adenosine diphosphate 
AE 
adverse event 
ALT 
alanine aminotransferase 
ALP 
AMP 
alkaline phosphatase  
adenosine monophosphate 
ANOVA 
analysis of variance 
aPTT 
activated partial thromboplastin time 
AST 
aspartate aminotransferase 
ATP 
adenosine triphosphate 
AUC 
area under the serum concentration curve 
AUC0-t 
area under the serum concentration curve (AUC) from time zero to the last time of the last 
quantifiable concentration 
AUC0-∞ 
area under the serum concentration curve (AUC) from time zero extrapolated to infinity 
B-LCL 
Epstein Barr virus-transformed lymphoblastoid B cell line 
BOR 
best overall response 
BP 
blood pressure 
BUN 
C 
blood urea nitrogen 
Cycle 
CA19-9 
carbohydrate antigen 
CBC 
complete blood count 
CD 
cluster of differentiation 
CD39-/- 
cluster of differentiation 39 deficient 
CEA 
carcinoma embryonic antigen 
cIg 
isotype control 
CL 
apparent total body clearance of the drug from serum 
Cmax 
maximum serum observed concentration 
Cmin  
minimum serum observed concentration 
CMV 
cytomegalovirus 
CNS 
central nervous system  
CRS 
cytokine release syndrome 
CT 
computed tomography 
D 
day 
DCR 
disease control rate  
DLT 
dose-limiting toxicity 
DOR 
duration of response 
DVT 
deep vein thrombosis 


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eATP 
extracellular ATP 
EC50 
half-maximal effective concentration 
ECG 
electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group  
eCRF 
electronic case report form 
EHNA 
erythro-9-(2-hydroxy-3-nonyl)adenine 
ELISA 
enzyme-linked immunosorbent assay 
ENTPDase 
ectonucleoside triphosphate diphosphohydrolase 
EOI 
end of infusion 
EOT 
end of treatment 
FDG 
fluorodeoxyglucose 
FIH 
first-in-human 
FSH 
follicle-stimulating hormone  
GCP 
Good Clinical Practice 
GGT 
GH 
gamma-glutamyl transferase 
growth hormone  
GLP 
Good Laboratory Practice 
Hgb 
hemoglobin 
HgbA1c 
hemoglobin A1c  
HED 
human equivalent dose 
HR 
heart rate 
IB 
Investigator Brochure 
IC50 
half-maximal inhibition concentration 
ICF 
informed consent form 
IEC 
Independent Ethics Committee 
IFN 
interferon 
Ig 
immunoglobulin 
IL 
interleukin 
IND 
Investigational New Drug 
INR 
international normalized ratio 
IR 
immune response 
irAE 
immune-related adverse event 
IRB 
Institutional Review Board 
iRECIST 
immune-related Response Evaluation Criteria in Solid Tumors 
IV 
intravenous(ly) 
LD 
longest diameter 
LDi 
longest transverse diameter of a lesion 
LFT 
liver function tests 
LH 
luteinizing hormone  
LYRIC 
LYmphoma Response to Immunomodulatory Therapy Criteria 
mAb 
monoclonal antibody 


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mCRM 
modified continual reassessment method  
mCRPC 
metastatic castration-resistant prostate cancer 
MFI 
mean fluorescence intensity 
MRI 
magnetic resonance imaging 
MRSD 
maximum recommended starting dose 
MTD 
maximum tolerated dose 
N/A 
not applicable 
NCI CTCAE 
National Cancer Institute Common Terminology Criteria 
NP 
NHP 
Nab-paclitaxel (Abraxane®) 
non-human primate 
NOAEL 
no-observed-adverse-effect level  
O2 
oxygen 
ORR 
objective response rate  
OS 
overall survival 
PAD 
pharmacologically active dose 
PBMC 
peripheral blood mononuclear cell 
PCWG3 
Prostate Cancer Clinical Trials Working Group 3 
PD 
progressive disease 
PD-1 
programmed cell death protein-1 
PD-L1 
programmed cell death protein ligand-1 
PET 
positron-emission tomography 
PFS 
progression-free survival 
PLT 
platelets 
PK 
pharmacokinetic(s) 
PPD 
cross product of the LDi and perpendicular diameter 
PSA 
prostate-specific antigen 
PT 
prothrombin time 
PTT 
partial thromboplastin time 
Q 
every 
RCC 
renal cell carcinoma 
RECIST 
Response Evaluation Criteria in Solid Tumors 
RP2D 
recommended Phase 2 dose  
SAE 
serious adverse event 
SDi 
shortest axis perpendicular to the LDi 
SPD 
sum of the product of the perpendicular diameters for multiple lesions 
t1/2 
terminal elimination half-life 
TEAE 
treatment-emergent adverse event 
TIL 
tumor infiltrating leukocytes 
Tizona 
Tizona Therapeutics, Inc. 
TK 
toxicokinetics  
TKI 
tyrosine kinase inhibitor 


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TLS 
tumor lysis syndrome 
Tmax 
time at which Cmax is reached 
TME 
tumor microenvironment 
Treg 
regulatory T cells 
Trishula 
Trishula Therapeutics, Inc. 
TSH  
thyroid stimulating hormone 
TTP 
time to progression  
TTR 
time to tumor response  
Tx 
treatment 
ULN 
upper limit of normal 
Vss 
volume of distribution at steady state  
W 
week(s) 
WT 
wild type 
 
 
 


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14 
1. 
Protocol Summary 
1.1. 
Synopsis 
Protocol Title:  
Phase 1/1b Study of the Safety of TTX-030 as a Single Agent and in Combination with 
Pembrolizumab or Chemotherapy in Patients with Lymphoma or Solid Tumor Malignancies  
Rationale: 
There are compelling preclinical data to support the hypothesis that cluster of differentiation 
(CD)39-mediated reduction of adenosine triphosphate (ATP) and accumulation of adenosine 
both play a central role in establishing and maintaining the immunosuppressive 
microenvironment within solid tumors. CD39 expression is associated with worse outcomes in 
several cancer types. The enzymatic inhibition of CD39 maintains high levels of 
pro-inflammatory extracellular ATP (eATP), leading to immune activation and significant 
anti-tumor immune responses. The CD39 pathway contributes to T-cell exhaustion and limits the 
immunogenicity of chemotherapy, which provides the rationale for combining CD39 inhibition 
with checkpoint blockade and conventional cytotoxic therapies. 
Targeting CD39 is a rational strategy for the treatment of subjects with cancer, and blockade of 
CD39 may result in less potential for autoimmune side effects compared with rates seen with 
other immunotherapy agents. Although regulatory T cells (Treg) from CD39-deficient (CD39-/-) 
knockout mice have impaired suppressive activity, the mice do not show autoimmunity (Sun et 
al. 2010). TTX-030, as a single agent or in combination, is expected to have a manageable safety 
profile, thereby providing additional therapeutic options for subjects whose malignancies are 
otherwise refractory to or relapsed on current standard of care therapies. 
The indications selected were defined based on expression of CD39 on tumor infiltrating 
leukocytes (TIL), expression of CD39 on tumor cells, and tumor types that are amenable to be 
combined with chemotherapy or anti-programmed cell death protein-1 (PD-1) therapy. 




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Objectives 
Endpoints 
• To evaluate the pharmacokinetics 
(PK) of TTX-030 
• Serum PK parameters for TTX-030 
following single and multiple doses 
including the maximum serum 
observed concentration (Cmax),  time at 
which Cmax is reached (Tmax), 
minimum serum observed 
concentration (Cmin), volume of 
distribution at steady state (VSS), 
apparent total body clearance of the 
drug from serum (CL), terminal 
elimination half-life (t1/2), area under 
the serum concentration curve (AUC) 
to last quantifiable concentration 
(AUC0-t), and AUC from time zero 
extrapolated to infinity (AUC0−∞) for 
TTX-030 
• To assess the effects of TTX-030 on 
pharmacodynamic biomarkers relating 
to mechanism of action and immune 
responses 
• Immunogenicity (detection of 
anti-drug antibodies [ADA]) 
• Expression of CD39 
• Exploratory pharmacodynamic 
biomarkers 
 
Overall Design 
Study Design:  
This is a Phase 1/1b, open-label, and multicenter study of TTX-030 in adult subjects with 
lymphoma or solid tumor malignancies. The study will evaluate the safety and tolerability of: 
• TTX-030 as a single agent, and 
• TTX-030 in combination with pembrolizumab, a PD-1 inhibitor, and 
• TTX-030 in combination with specified chemotherapy regimens 
Number of Subjects: 
Up to 43 subjects may be enrolled across 1 dose escalation and 2 safety lead-in arms. 
TTX-030 will first be evaluated in the monotherapy dose escalation (Arm 1). Once the RP2D of 
TTX-030 has been determined in the monotherapy dose-escalation arm, the combination-therapy 
safety lead-in arms (Arms 2 and 4) can be initiated. For the safety lead-in arms, the TTX-030 
starting dose will be the RP2D identified during monotherapy dose escalation; de-escalation to 


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17 
one dose level below the RP2D is permitted. Upon completion of the monotherapy dose-
escalation and combination-therapy safety lead-in arms, each of those arms may have the option 
to enroll additional subjects per expansion cohort at the RP2D. 
As of Jan 2020, a RP2D was determined to be 40 mg/kg loading dose 7 days prior to Cycle 1 
Day 1, followed by either 30 mg/kg Q3W or 20 mg/kg Q2W. 
Arm 1 (single agent), n = up to 21 
• TTX-030 single-agent dose escalation (several doses and schedules may be 
evaluated) 
Arm 1 (expansion), n = 25 
• TTX-030 single-agent; loading dose 7 days prior to Cycle 1 Day 1, followed by 30 
mg/kg Q3W 
Arm 2 (anti-PD-1 combination), n = up to 6 
• Pembrolizumab 200 mg every (Q) 3 weeks (W) in combination with TTX-030 Q3W 
safety lead-in 
Arm 4 (chemotherapy combination), n = up to 6 
• Gemcitabine 1000 mg/m2 + nab-paclitaxel 125 mg/m2 Days 1, 8, and 15 every 
28 days + TTX-030 Q2W safety lead-in (Note: dose modification allowed for 
gemcitabine 1000 mg/m2 + nab-paclitaxel 125 mg/m2 (e.g., modify to Days 1 and 8 
or Days 1 and 15 every 28 days + TTX-030 Q2W) 
Expansion cohorts, n = 25 each in Arms 1 and 2 and n = up to 20 in Arm 4. The number of 
subjects evaluated in the combination-therapy safety lead-in Arm 4 may count toward the total 
number of subjects in an expansion cohort.  
Note: The sponsor may choose not to open one of the safety lead-in arms and/or expansion 
cohorts. 
Reference Therapy and Mode of Administration:  
• TTX-030 IV infusion Q3W for Arm 1 Dose Escalation (21-day cycle) 
• TTX-030 IV infusion Q3W for Arms 1 and 2 Safety Lead-in and Expansion (21-day 
cycle + a 7-day loading dose prior to C1D1) 
• TTX-030 IV infusion Q2W for Arm 4 (28-day cycle + a 7-day loading dose prior to 
C1D1) 
The investigational formulation of TTX-030 will be supplied as a sterile, single-use, 
preservative-free liquid containing 200 mg of antibody. The dosage form of TTX-030 is a liquid 
formulation containing 30 mg/mL of TTX-030 in 10 mM sodium citrate, 280 mM sucrose, 
0.02% polysorbate 20, and 1.0 mM methionine, with a pH of 6.5. The liquid TTX-030 will be 


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filled into a Type 1 glass serum vial with an elastomeric stopper and aluminum over seal with a 
plastic flip top. The fill volume will be 6.7 mL in a 10-cc glass vial stored at temperatures of 2°C 
to 8°C. TTX-030 will be administered IV Q3W or Q2W according to the study treatment arm 
schedule. 
Duration of Treatment:  
If well tolerated, treatment with TTX-030 may continue until disease progression, drug toxicity, 
or death. For combination arms, if a subject discontinues the pembrolizumab or chemotherapy 
regimens, treatment with TTX-030 may continue if it is well tolerated and if both the investigator 
and sponsor approve. 
Criteria for Evaluation:  
Safety: Clinical adverse events (AEs) will be graded according to the National Cancer Institute 
Common Terminology Criteria (NCI CTCAE) Version 5.0. AEs are to be monitored and 
collected for the duration of study treatment until 90 days after the last dose. A DLT is defined as 
any clinically significant AE that occurs during Treatment Cycle 1, is considered related to 
TTX-030 as a single agent or the combination of TTX-030 and other agent(s), and meets the 
criteria outlined in the protocol. In the dose escalation arm, for the Q3W dose schedule, the cycle 
length is 3 weeks and the DLT period will be the first cycle (21 days).  
In the safety lead-in Arm 2, the DLT evaluation period is 21-day (TTX-030 regimen given every 
3 weeks [Q3W]) plus a 7-day of loading dose. In the safety lead-in Arm 4, for the Q2W dose 
schedule, the cycle length is 4 weeks and the DLT period will be 28-day (TTX-030 regimen 
given every 2 weeks [Q2W]) plus a 7-day of loading dose. 
Pharmacokinetics: PK analyses will be conducted using samples drawn based on the provided 
schedule of assessments. TTX-030 concentrations will be measured by validated 
electrochemiluminescence-based method and used to calculate PK parameters including t1/2, 
Cmax, Tmax, Cmin, CL, Vss, AUC0-t, and AUC0-∞. 
Pharmacodynamics: Pharmacodynamic analyses will be performed using blood and tissue 
samples taken at designated time points. Parameters to be assessed include target and mechanism 
of action-related biomarkers, ADA formation, and pro-inflammatory cytokine release. 
Additionally, several exploratory analyses are planned, including immunoprofiling, target 
receptor coverage, and serum metabolomics. Detailed instructions for pharmacodynamic blood 
sample collection, processing, and shipping will be provided to the study sites in a separate 
laboratory manual. 
Early Signals of Activity: Anti-tumor activity, including BOR, ORR, DOR, TTR, DCR, TTP, 
PFS, and OS, will be assessed based on iRECIST, LYmphoma Response to Immunomodulatory 
Therapy Criteria (LYRIC), or Prostate Cancer Clinical Trials Working Group 3 (PCWG3) 
response criteria when applicable. 
Statistical Methods:  
A primary objective of the trial is to determine the MTD and/or RP2D for each arm. Dose 
escalation (Arm 1) will be conducted according to a modified continual reassessment method 
(mCRM) for doses up to 10 mg/kg and according to a 3 + 3 design for doses > 10 mg/kg, with 
the aim of estimating the dose-toxicity relationship and determining the MTD. The MTD will be 


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defined as the dose that has a model-estimated DLT rate closest to 30% and has less than 55% 
probability of a DLT rate exceeding 30%.  
Dose-toxicity modeling will be used to estimate the log-odds of DLT across dose levels and will 
be conducted using a 2-parameter logistic regression model. A detailed adaptive design and 
simulation report is included in Section 11.6.  
The RP2D will be determined based on the totality of data, including the estimated MTD, plus 
other endpoints such as observed efficacy, PK, and other AEs.  
Descriptive summary statistics will be presented. Longitudinal data will be presented by 
appropriate time intervals, such as monthly or quarterly, depending on the nature of the data.  
1.2. 
Schema 
The study schema is depicted in Figure 1.  
Figure 1:  
Study Schema 
Abbreviations: Gem = gemcitabine, NP = nab-paclitaxel, Q = every, RCC = renal cell carcinoma; 
RP2D = recommended Phase 2 dose, Q3W = every 3 weeks, Q2W = every 2 weeks 
Note:    Arm 3 is removed as a similar population is being evaluated in another protocol (TTX-030-002). 


 
 
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1.3. 
Schedule of Activities 
The study-specific assessments and procedures are outlined in Table 1/Table 2, and Table 3/Table 4. 
Table 1: 
Arms 1 and 2: Schedule of Assessments (Screening Through Treatment Period Cycle 1 and Cycle 2) – Q3W 
Dosing Schedule (21-Day Cycle) 
Assessment 
Pretreatment 
Loading 
Dose  
Study Treatment Period = 2 cycles 
(1 cycle = 21 days) 
Screeninga 
(up to 28 
days prior 
to loading 
dose) 
Baseline 
(up to 3 
days prior 
to loading 
dose) 
Day -7a 
Cycle 1 
Cycle 2 
Day 1 
Day 2 
Day 3 
Day 8 
Day 15 
Day 22  
(+ 2 days) 
Day 29 
(± 2 days) 
Pre-C1D1 
C1D1 
C1D2 
C1D3 
C1D8 
C1D15 
C2D1 
C2D8 
Informed consent 
X 
 
Inclusion/Exclusion 
X 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical history & prior anti-
cancer treatments 
X 
 
 
 
 
 
 
 
 
 
Physical examination 
X 
X 
X 
X 
Symptom-directed 
examination   
 
X 
X 
X 
X 
X 
Vital signs (temperature, O2, 
HR, BP, weight, height) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
12-lead ECG 
X 
 
HgbA1c 
X 
 
 
 
 
 
 
 
 
 
ECOG performance status 
X 
 
X 
X 
Tumor assessment  
(CT or PET-CT)b 
X 
 
 
 
 
 
 
 
 
 
Serum tumor-associated 
markers as applicable (eg, 
CEA, CA19-9, PSA) 
X 
 
 
 
 
 
 
 
 
 


 
 
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Assessment 
Pretreatment 
Loading 
Dose  
Study Treatment Period = 2 cycles 
(1 cycle = 21 days) 
Screeninga 
(up to 28 
days prior 
to loading 
dose) 
Baseline 
(up to 3 
days prior 
to loading 
dose) 
Day -7a 
Cycle 1 
Cycle 2 
Day 1 
Day 2 
Day 3 
Day 8 
Day 15 
Day 22  
(+ 2 days) 
Day 29 
(± 2 days) 
Pre-C1D1 
C1D1 
C1D2 
C1D3 
C1D8 
C1D15 
C2D1 
C2D8 
Thyroid function testsc 
 
X 
X 
 
 
 
 
 
 
 
Clinical laboratory tests (CBC, 
LFTs, chemistry); LDH at 
Screening only  
X 
X 
X 
X 
X 
X 
X 
X 
Measurements of ACTH, 
FSH, LH, GH, amylase, lipase 
 
X 
 
 
 
 
 
 
 
 
Coagulation profiled (PT/INR, 
PTT, fibrinogen) 
X 
X 
X 
X 
X 
X 
Pregnancy teste 
X 
X 
X 
 
 
 
 
 
X 
 
Arm 1: TTX-030 only 
infusion  
 
 
X 
X 
 
 
 
 
X 
 
Arm 2: TTX-030 and 
pembrolizumab infusion 
 
 
TTX-030 
only 
X 
 
 
 
 
X 
 
PK blood samplesf 
X 
pre & post 
multiple 
X 
X 
X 
X 
pre & post 
ADA blood samples 
 
X 
 
X 
X 
 
 
 
X 
 
Pharmacodynamic and 
correlative blood samplesg 
X 
 
X 
X 
X 
X 
X 
Tumor biopsyh  
(optional for dose escalation, 
mandatory for safety lead-
in/cohort expansion) 
X 
 
X (-7 
days) 
Concomitant medicationsi 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 


 
 
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Assessment 
Pretreatment 
Loading 
Dose  
Study Treatment Period = 2 cycles 
(1 cycle = 21 days) 
Screeninga 
(up to 28 
days prior 
to loading 
dose) 
Baseline 
(up to 3 
days prior 
to loading 
dose) 
Day -7a 
Cycle 1 
Cycle 2 
Day 1 
Day 2 
Day 3 
Day 8 
Day 15 
Day 22  
(+ 2 days) 
Day 29 
(± 2 days) 
Pre-C1D1 
C1D1 
C1D2 
C1D3 
C1D8 
C1D15 
C2D1 
C2D8 
AEsj  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Abbreviations: ACTH = adrenocorticotropic hormone, ADA = anti-drug antibodies, AE = adverse event, BP = blood pressure, C = cycle, CA19-9 = carbohydrate antigen, 
CBC = complete blood count, CEA = carcinoma embryonic antigen, CT = computed tomography, D = day, ECG = electrocardiogram, ECOG = Eastern Cooperative Oncology 
Group, FSH = follicle-stimulating hormone, GH = growth hormone, HgbA1c = hemoglobin A1c, HR = heart rate, INR = international normalized ratio, LDH = Lactate 
Dehydrogenase, LFT = liver function test, LH = luteinizing hormone, O2 = oxygen, PD-L1 = programmed cell death protein ligand-1, PET = positron-emission tomography, 
PK = pharmacokinetic, PSA = prostate-specific antigen, PT = prothrombin time, PTT = partial thromboplastin time, Q = every, RP2D = recommended Phase 2 dose, TSH = 
thyroid stimulating hormone, W = weeks. 
 


 
 
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a 
Screening assessments and enrollment should occur prior to loading dose/first dose of TTX-030. Assessments done up to 3 days prior to each dosing visit do not need to be 
repeated.  
b 
Subjects with solid tumors will require CT scans of the chest, abdomen, and pelvis unless contraindicated. Subjects with prostate cancer will also require bone scan. Brain scans 
and bone scans will be performed at screening if disease is suspected and on study as appropriate to follow disease. Subjects with lymphoma will require CT or PET-CT; 
however, the method for each subject’s tumor assessments should remain consistent. 
c 
Thyroid function tests are to be performed at baseline, at the loading dose/first dose, and then every 3 months: TSH, T3, free T4, and thyroid antibody.  
d 
See Section 8.3.5. Fibrinogen is only required for eligibility. 
e 
Pregnancy test is for women of childbearing potential only. 
f 
Timing of PK draws: See Table 5. If using the same infusion filter line for PK draw, flushing is required. 
g 
Pharmacodynamic blood draws should occur at the same time as PK blood draws and tumor biopsy when applicable.  When multiple PKs are collected, collect PD with the 
pre-dose PK. 
h 
Subjects enrolled in the safety lead-in and expansion arms will be required to have a site of disease that is safely accessible for biopsy (paired) upon enrollment. If a subject has 
had a biopsy within 90 days with no intervening treatment prior to the loading dose/first dose of TTX-030, that tissue can be used for this study and the subject does not need to 
repeat a baseline biopsy. Invasive procedures that require general anesthesia should not be performed to obtain a biopsy specimen. If a surgical procedure is performed for a 
clinical indication, a sample may be used for research purposes. During the course of treatment, a decision may be made to perform the on-treatment biopsy earlier than C2D1 
(-7 days) if there will be no available tumor for biopsy due to a rapid clinical response. Similarly, tumor biopsy may be delayed if there is evidence of a delayed response. 
Accessible lesions are defined as those that can be biopsied (at screening) and are amenable to repeat biopsy at C2D1 (-7 days), unless clinically contraindicated. It is optimal to 
have the screening and on-treatment biopsy obtained from the same lesion if possible. 
i 
Concomitant medications are to be collected from screening through 30 days after the last dose of study treatment. 
j 
Adverse events (e.g., including COVID-19 symptoms) and AESIs are to be collected from the time subject provides written informed consent through 90 days after the last 
dose of TTX-030 or until initiation of a new systemic anticancer therapy, whichever occurs first. Positive COVID-19 test result will be collected as a medical event and 
submitted as SAE. 
 
 


 
 
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Table 2: 
Arms 1 and 2: Schedule of Assessments (Treatment Extension Cycles Through Post-Treatment) – Q3W Dosing 
Schedule (21-Day Cycle) 
Assessments 
21-Day Study Treatment Extension Period  
(Dosing Q3W) 
 
Post-Treatment 
Cycle 3 
Cycles 4+ 
EOT Visit 
Follow-Up Safety 
Contact 
Follow-up Survival 
Contact 
Day 43 (± 2 days) 
Day 64 (± 2 days) and 
Q21D thereafter 
30 (± 9) Days 
After Last Dosea 
60 and 90 (± 7) days 
After Last Dose 
180 (± 15) Days After  
Last Dose 
C3D1 
C4D1 
Physical examination 
X 
X 
X 
 
Symptom-directed examination   
 
Vital signs (temperature, O2, HR, 
BP, weight, height) 
X 
X 
X 
 
12-lead ECG 
 
 
 
 
 
ECOG performance status 
X 
X 
X 
 
Clinical laboratory tests (CBC, 
LFTs, chemistry) 
X 
X 
X 
 
 
Coagulation profile  
(PT/INR, PTT) 
X 
X 
X 
 
Pregnancy testb 
X 
X 
X 
 
Tumor assessment  
(CT or PET-CT)  
 
Q9W (- 7D) 
starting on C4D1 
 
Serum tumor-associated markers 
as applicable (eg, CEA, CA19-9, 
PSA) 
 
Q9W (- 4D) 
starting on C4D1 
 
 
 
Arm 1: TTX-030 infusion  
X 
X 
 
Arm 2: TTX-030 and 
pembrolizumab infusion 
X 
X 
 
 
 
PK blood samplesc 
multiple 
pre 
X 
 


 
 
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Assessments 
21-Day Study Treatment Extension Period  
(Dosing Q3W) 
 
Post-Treatment 
Cycle 3 
Cycles 4+ 
EOT Visit 
Follow-Up Safety 
Contact 
Follow-up Survival 
Contact 
Day 43 (± 2 days) 
Day 64 (± 2 days) and 
Q21D thereafter 
30 (± 9) Days 
After Last Dosea 
60 and 90 (± 7) days 
After Last Dose 
180 (± 15) Days After  
Last Dose 
C3D1 
C4D1 
Pharmacodynamic, ADA, and 
correlative blood samplesd  
X 
X 
X 
 
Tumor biopsy (optional for dose 
escalation, mandatory for safety 
lead-in/cohort expansion) 
 
 
 
Concomitant medicationse 
X 
X 
X 
 
 
AEsf 
X 
X 
X 
X 
 
Post-treatment anti-cancer 
therapy 
X 
X 
X 
Follow-up contact 
 
 
X 
X 
X 
Abbreviations: ADA = anti-drug antibodies, AE = adverse event, BP = blood pressure, C = cycle, CA19-9 = carbohydrate antigen, CBC = complete blood count, CEA = carcinoma 
embryonic antigen, CT = computed tomography, D = day, ECG = electrocardiogram, ECOG = Eastern Cooperative Oncology Group, EOT = End of Treatment, HR = heart 
rate, INR = international normalized ratio, LFT = liver function test, O2 = oxygen, PET = positron-emission tomography, PK = pharmacokinetic, PSA = prostate-specific 
antigen, PT = prothrombin time, PTT = partial thromboplastin time, Q = every, W = weeks. 
 
a 
EOT laboratory assessment do not need to be repeated if laboratory assessments were collected in the study within the past 5 days.  
b 
Pregnancy test is for women of childbearing potential only. 
c 
Timing of PK draws: See Table 5. If using the same infusion filter line for PK draw, flushing is required. 
d 
Pharmacodynamic blood draws should occur at the same time as PK blood draws and tumor biopsy when applicable. When multiple PKs are collected, collect PD with the pre-
dose PK. 
e 
Concomitant medications are to be collected from screening through 30 days after the last dose of study treatment. 
f 
Adverse events (e.g., including COVID-19 symptoms) and AESIs are to be collected from the time subject provides written informed consent through 90 days after the last 
dose of TTX-030 or until initiation of a new systemic anticancer therapy, whichever occurs first. Positive COVID-19 test result will be collected as a medical event and 
submitted as SAE. 
 
 


 
 
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Table 3: 
Arm 4: Schedule of Assessments (Screening Through Treatment Period 1 (Cycle 1) – Q2W Dosing Schedule (28-
Day Cycle) 
Assessment 
Pretreatment 
Loading 
Dosea   
28-Day Study Treatment Period (Dosing Every 14 Days) 
Cycle 1 
Screeninga 
(up to 28 
days prior 
to loading 
dose) 
Baseline 
(up to 3 
days prior 
to loading 
dose) 
Day -7 
Day 1 
Day 2 
Day 3 
Day 8 
Day 15 
Day 22 
Pre-C1D1 
C1D1 
C1D2 
C1D3 
C1D8 
C1D15 
C1D22 
Informed consent 
X 
 
Inclusion/Exclusion 
X 
 
Demographics 
X 
 
Medical history & prior anti-cancer treatments 
X 
 
 
 
 
 
 
 
 
Physical examination 
X 
X 
X 
 
 
 
 
X 
 
Symptom-directed examination 
 
X 
X 
X 
X 
Vital signs  
(temperature, O2, HR, BP, weight, height) 
X 
X 
X 
X 
X 
 
X 
X 
X 
12-lead ECG 
X 
 
 
 
 
 
 
 
 
HgbA1c 
X 
 
 
 
 
 
 
 
 
ECOG performance status 
X 
 
X 
Thyroid function testsb 
 
X 
X 
 
 
 
 
 
 
Clinical laboratory tests  
(CBC, LFTs, chemistry); LDH at Screening only 
X 
X 
X 
X 
X 
X 
X 
X 
Measurements of ACTH, FSH, LH, GH, 
amylase, lipase 
 
X 
 
 
 
 
 
 
 
Coagulation profile (PT/INR, PTT, fibrinogenc) 
X 
X 
X 
X 
X 
X 
Pregnancy test d 
X 
X 
X 
X 
Tumor assessment (CT or PET-CT)e 
X 
 
Serum tumor-associated markers as applicable 
(eg, CEA, CA19-9, PSA, CA 125) 
X 
 
 
 
 
 
 
 
 


 
 
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Assessment 
Pretreatment 
Loading 
Dosea   
28-Day Study Treatment Period (Dosing Every 14 Days) 
Cycle 1 
Screeninga 
(up to 28 
days prior 
to loading 
dose) 
Baseline 
(up to 3 
days prior 
to loading 
dose) 
Day -7 
Day 1 
Day 2 
Day 3 
Day 8 
Day 15 
Day 22 
Pre-C1D1 
C1D1 
C1D2 
C1D3 
C1D8 
C1D15 
C1D22 
Arm 4: TTX-030 and gemcitabine + 
nab-paclitaxel infusionf 
 
 
TTX-030 
only 
X 
 
 
Gem/nab 
only 
X 
 
PK blood samplesg 
X 
pre & post 
multiple 
X 
X 
X 
pre & 
post 
X 
Pharmacodynamic, ADA, and correlative blood 
samplesh 
X 
X 
X 
X 
 
X 
X 
Tumor biopsy (optional for dose escalation, 
mandatory for safety lead-in/cohort expansion)i 
X 
 
Concomitant medicationsj 
X 
X 
X 
X 
X 
X 
X 
X 
X 
AEsk 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Abbreviations: ACTH = adrenocorticotropic hormone, ADA = anti-drug antibodies, AE = adverse event, BP = blood pressure, C = cycle, CA19-9 = carbohydrate antigen, 
CBC = complete blood count, CEA = carcinoma embryonic antigen, CT = computed tomography, D = day, ECG = electrocardiogram, ECOG = Eastern Cooperative Oncology 
Group, EOT = End of Treatment, FSH = follicle-stimulating hormone, GH = growth hormone, HgbA1c = hemoglobin A1c, HR = heart rate, INR = international normalized 
ratio, LDH = Lactate Dehydrogenase, LH = luteinizing hormone, LFT = liver function test, O2 = oxygen, PD-L1 = programmed cell death protein ligand-1, PET = positron-
emission tomography, PK = pharmacokinetic, PT = prothrombin time, PTT = partial thromboplastin time, Q = every, RP2D = recommended Phase 2 dose, TSH = thyroid 
stimulating hormone, W = weeks. 
 
a 
Screening assessments and enrollment should occur prior to loading dose/first dose of TTX-030. Assessments done up to 3 days prior to each dosing visit do not need to be 
repeated. 
b 
Thyroid function tests are to be performed at baseline, at the loading dose, and then every 3 months: TSH, T3, free T4, and thyroid antibody. 
c 
See Section 8.3.5. Fibrinogen is only required for eligibility. 
d 
Pregnancy test is for women of childbearing potential only. 
e 
Subjects with solid tumors will require CT scans of the chest, abdomen, and pelvis unless contraindicated. Subjects with prostate cancer will also require bone scan. Brain scans 
and bone scans will be performed at screening if disease is suspected and on study as appropriate to follow disease. Subjects with lymphoma will require CT or PET-CT; 
however, the method for each subject’s tumor assessments should remain consistent. 


 
 
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f 
Gemcitabine + nab-paclitaxel are administered on Days 1, 8, and 15 every 28 days. After the loading dose, TTX-030 will be administered every 14 days. (Note: dose 
modification allowed for gemcitabine 1000 mg/m2 + nab-paclitaxel 125 mg/m2 (e.g, Days 1 and 8 or Days 1 and 15 every 28 days) + TTX-030 every 14 days). 
g 
Timing of PK draws: See Table 6. If using the same infusion filter line for PK draw, flushing is required. 
h 
Pharmacodynamic blood draws should occur at the same time as PK blood draws and tumor biopsy when applicable. When multiple PKs are collected, collect PD with the pre-
dose PK. 
i 
Subjects enrolled in the safety lead-in and expansion arms will be required to have a site of disease that is safely accessible for biopsy (paired) upon enrollment. If a subject has 
had a biopsy within 90 days with no intervening lines of therapy prior to the loading dose/first dose of TTX-030, that tissue can be used for this study and the subject does not 
need to repeat a baseline biopsy. Accessible lesions are defined as those that can be biopsied (at screening) and are amenable to repeat biopsy on C2D1 (-7 days), unless 
clinically contraindicated. It is optimal to have the screening and on-treatment biopsy obtained from the same lesion if possible. Invasive procedures that require general 
anesthesia should not be performed to obtain a biopsy specimen. If a surgical procedure is performed for a clinical indication, a sample may be used for research purposes. 
During the course of treatment, a decision may be made to perform the on-treatment biopsy earlier than C2D1 (-7 days)  if there is evidence to suggest a possibility that there 
will be no available tumor for biopsy due to a rapid clinical response. Similarly, tumor biopsy may be delayed if there is evidence of a delayed response. 
j 
Concomitant medications are to be collected from screening through 30 days after the last dose of study treatment. 
k 
Adverse events (e.g., including COVID-19 symptoms) and AESIs are to be collected from the time subject provides written informed consent through 90 days after the last 
dose of TTX-030 or until initiation of a new systemic anticancer therapy, whichever occurs first. Positive COVID-19 test result will be collected as a medical event and 
submitted as SAE. 
 
 


 
 
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Table 4: 
Arm 4: Schedule of Assessments (Treatment Extension Cycles Through Post-Treatment) – Q2W Dosing 
Schedule (28-Day Cycle) 
Assessment 
28-Day Treatment Extension Period (Dosing Q2W) 
Post-Treatment 
Cycle 2 
Cycle 3+ 
EOT Visit 
30 (± 7) 
Days 
After Last 
Dose 
Follow-
Up Safety 
Contact 
60 and 90 
(± 7) Days 
After Last 
Dose 
Follow-up 
Survival Contact 
180 (± 15) Days 
After Last Dose 
Day 29 
(+ 2 days) 
Day 36 
(± 2 days) 
Day 43 
(± 2 days) 
Day 57 
(± 2 days) 
and Every 
Cycle X Day 
1 Thereafter 
Day 64 
(± 2 days) 
and Every 
Cycle X Day 
8 Thereafter 
Day 71 (± 2 
days) and 
Every Cycle X 
Day 15 
Thereafter 
C2D1 
C2D8 
C2D15 
C3D1 
C3D8 
C3D15 
Physical examination 
X 
X 
X 
X 
X 
X 
X 
 
 
Symptom-directed 
examination 
 
 
Vital signs  
(temperature, O2, HR, BP, 
weight, height) 
X 
X 
X 
X 
X 
X 
X 
 
 
12-lead ECG 
 
 
ECOG performance status 
X 
X 
X 
X 
X 
X 
X 
 
Clinical laboratory tests 
(CBC, LFTs, chemistry) 
X 
X 
X 
X 
X 
X 
X 
 
Coagulation profile 
(PT/INR, PTT) 
X 
X 
X 
X 
X 
X 
X 
 
Pregnancy test a 
X 
X 
X 
X 
X 
 
Tumor assessment  
(CT or PET-CT)b 
 
Q8W 
(-7D) 
starting on 
C3D1 
 
Serum tumor-associated 
markers as applicable (eg, 
CEA, CA19-9) 
 
 
 
X 
(Q8W) 
 
 
  
 
 
 


 
 
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Assessment 
28-Day Treatment Extension Period (Dosing Q2W) 
Post-Treatment 
Cycle 2 
Cycle 3+ 
EOT Visit 
30 (± 7) 
Days 
After Last 
Dose 
Follow-
Up Safety 
Contact 
60 and 90 
(± 7) Days 
After Last 
Dose 
Follow-up 
Survival Contact 
180 (± 15) Days 
After Last Dose 
Day 29 
(+ 2 days) 
Day 36 
(± 2 days) 
Day 43 
(± 2 days) 
Day 57 
(± 2 days) 
and Every 
Cycle X Day 
1 Thereafter 
Day 64 
(± 2 days) 
and Every 
Cycle X Day 
8 Thereafter 
Day 71 (± 2 
days) and 
Every Cycle X 
Day 15 
Thereafter 
C2D1 
C2D8 
C2D15 
C3D1 
C3D8 
C3D15 
Arm 4: TTX-030 and 
gemcitabine + nab-
paclitaxel infusionc 
X 
Gem/nab 
only 
X 
X 
Gem/nab 
only 
X 
 
 
 
PK blood samples d 
multiple 
pre 
pre 
pre 
X 
 
ADA blood samples 
X 
 
 
X 
 
X 
X 
 
 
Pharmacodynamic and 
correlative blood samplese 
X 
 
X 
X 
X 
 
Tumor biopsy  
(optional for dose 
escalation, mandatory for 
safety lead-in/cohort 
expansion)f 
X 
(-7 days) 
 
 
 
 
 
 
 
 
Concomitant medicationsg 
X 
 
X 
X 
X 
X 
X 
 
 
AEsh 
X 
 
X 
X 
X 
X 
X 
X 
 
Post-treatment anti-cancer 
therapy 
 
 
 
 
 
 
X 
X 
X 
Follow-up contact 
 
 
 
 
 
 
X 
X 
X 
Abbreviations: ADA = anti-drug antibodies, AE = adverse event, BP = blood pressure, C = cycle, CA19-9 = carbohydrate antigen, CBC = complete blood count, CEA = carcinoma 
embryonic antigen, CT = computed tomography, D = day, ECG = electrocardiogram, ECOG = Eastern Cooperative Oncology Group, EOT = End of Treatment, HR = heart 
rate, INR = international normalized ratio, LFT = liver function test, O2 = oxygen, PET = positron-emission tomography, PK = pharmacokinetic, PSA = prostate-specific 
antigen, PT = prothrombin time, PTT = partial thromboplastin time, Q = every, W = weeks. 
 


 
 
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a 
Pregnancy test is for women of childbearing potential only. 
b 
Subjects with solid tumors will require CT scans of the chest, abdomen, and pelvis unless contraindicated. Subjects with prostate cancer will also require bone scan. Brain scans 
and bone scans will be performed at screening if disease is suspected and on study as appropriate to follow disease. Subjects with lymphoma will require CT or PET-CT; 
however, the method for each subject’s tumor assessments should remain consistent. 
c 
Gemcitabine + nab-paclitaxel are administered on Days 1, 8, and 15 every 28 days. After the loading dose, TTX-030 will be administered every 14 days. Cycle 4 and beyond 
also requires a dosing visit at Days 1, 8, and 15 for gemcitabine/nab-paclitaxel and Day 15 for TTX-030. (Note: dose modification allowed for gemcitabine 1000 mg/m2 + nab-
paclitaxel 125 mg/m2 (e.g., Days 1 and 8 or Days 1 and 15 every 28 days) + TTX-030 every 14 days). 
d 
Timing of PK draws: See Table 6. If using the same infusion filter line for PK draw, flushing is required. 
e 
Pharmacodynamic blood draws should occur at the same time as PK blood draws and tumor biopsy when applicable. When multiple PKs are collected, collect PD with the pre-
dose PK. 
f     Subjects enrolled in the safety lead-in and expansion arms will be required to have a site of disease that is safely accessible for biopsy (paired) upon enrollment. If a subject has 
had a biopsy within 90 days with no intervening lines of therapy prior to loading dose/first dose of TTX-030, that tissue can be used for this study and the subject does not need 
to repeat a baseline biopsy. Accessible lesions are defined as those that can be biopsied (at screening) and are amenable to repeat biopsy on C2D1 (-7 days), unless clinically 
contraindicated. It is optimal to have the screening and on-treatment biopsy obtained from the same lesion if possible. Invasive procedures that require general anesthesia 
should not be performed to obtain a biopsy specimen. If a surgical procedure is performed for a clinical indication, a sample may be used for research purposes. During the 
course of treatment, a decision may be made to perform the on-treatment biopsy earlier than C2D1 (-7 days) if there is evidence to suggest a possibility that there will be no 
available tumor for biopsy due to a rapid clinical response. Similarly, tumor biopsy may be delayed if there is evidence of a delayed response. 
g 
Concomitant medications are to be collected from screening through 30 days after the last dose of study treatment. 
h 
Adverse events (e.g., including COVID-19 symptoms) and AESIs are to be collected from the time subject provides written informed consent through 90 days after the last 
dose of TTX-030 or until initiation of a new systemic anticancer therapy, whichever occurs first. Positive COVID-19 test result will be collected as a medical event and 
submitted as SAE. 
 
 


 
 
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Table 5: 
PK Sampling Intervals During Treatment (21-day treatment schedule Q3W) 
Visit Identifier 
Pre-C1D1 
Loading Dose 
Cycle 1 
Cycle 2 
Cycle 3 
Cycles 4+ 
EOT 
Study Day 
-7 
1 
2 
3 
8 
15 
22 (+ 2) 
43 (± 2) 
64 (± 2) and 
Q21D 
thereafter 
30 days 
after last 
Tx 
Hours Before/After Dose 
0a 
EOIb 
0a 
EOIb 
4 
8 
24 
48 
168 
336 
0a 
EOIb 
0a 
EOIb 
4 
8 
0a 
0 
PK blood serum samplingc 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Abbreviations: C = cycle, D = day(s), EOI = end of infusion, EOT = End of Treatment, PK = pharmacokinetics, Q = every, Tx = treatment, W = weeks. 
a 
Predose sample collection 
b 
Sample to be collected at the EOI; specifically, collect the PK sample 15 ± 5 minutes after infusion of TTX-030 has completed.  
c 
Blood will be collected for determining the concentration of TTX-030: Loading Dose (pre-C1D1): predose (if not already drawn with baseline assessments) and at EOI 
(15 ± 5 minutes after end of TTX-030 infusion); Dose 2 (C1D1): predose, EOI (15 ± 5 minutes after end of TTX-030 infusion), and 4, 8, 24, and 48 hours (± 30 minutes) from 
start of TTX-030 infusion and on Day 8 and Day 15; Dose 3 (C2D1): predose and at EOI (15 ± 5 minutes after end of TTX-030 infusion); Dose 4 (C3D1): predose and at EOI 
(15 ± 5 minutes after end of TTX-030 infusion), and 4 and 8 hours (± 30 minutes) from start of TTX-030 infusion; Dose 5 and beyond (Cycles 4+): predose. Detailed 
instructions for sample collection, processing, and shipment will be provided in a separate laboratory manual. 
 
 
 
 


 
 
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Table 6: 
PK Sampling Intervals During Treatment (28-day treatment cycle, Q2W) 
Visit Identifier 
Pre-C1D1  
Loading Dose 
Cycle 1 
Cycle 2 
Cycles 3+ 
EOT 
Study Day 
-7 
1 
2 
3 
8 
15 
22 
29 (+ 2) 
43 (± 2) 
57 (± 2) and 
Q28D 
thereafter 
30 days 
after last 
Tx 
Hours Before/After Dose 
0a 
EOIb 
0a 
EOIb 
4 
8 
24 
48 
168 
0a 
EOIb 
0 
0a 
EOIb 
4 
8 
0a 
0a 
0 
PK blood serum samplingc 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Abbreviations: C = cycle, D = day(s), EOI = end of infusion, EOT = End of Treatment, PK = pharmacokinetics, Q = every, Tx = treatment, W = weeks. 
a 
Predose sample collection 
b 
Sample to be collected at the EOI; specifically, collect the PK sample 15 ± 5 minutes after infusion of TTX-030 has completed. 
c 
Blood will be collected for determining the concentration of TTX-030: Loading Dose (pre-C1D1): predose (if not already drawn with baseline assessments), and at EOI 
(15 ± 5 minutes after end of TTX-030 infusion); Dose 2 (C1D1): predose, EOI (15 ± 5 minutes after end of TTX-030 infusion), and 4, 8, 24, and 48 hours (± 30 minutes) from 
start of TTX-030 infusion and on Day 8; Dose 3 (C1D15): predose and at EOI (15 ± 5 minutes after end of TTX-030 infusion) and on Day 22; Dose 4 (C2D1): predose, EOI 
(15 ± 5 minutes after end of TTX-030 infusion), and 4 and 8 hours (± 30 minutes) from start of TTX-030 infusion; Dose 5 (C2D15) and beyond (Cycles 3+): predose. Detailed 
instructions for sample collection, processing, and shipment will be provided in a separate laboratory manual. 
 
 


 
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2. 
Introduction 
Adenosine Pathway 
Purinergic signaling plays a key role in regulation of immune response in the tumor 
microenvironment (TME). eATP released during cell death and/or apoptosis serves as an 
immune cell activator through interaction with and downstream signaling of P2 purinergic 
receptors (Yip et al. 2009; Schenk et al. 2008; Bours et al. 2006). Pro-inflammatory adenosine 
triphosphate (ATP) can be converted to adenosine via an enzymatically controlled 
phosphohydrolytic cascade, leading to the accumulation of adenosine in the TME. Adenosine 
exerts its suppressive function by binding to A2A receptors (A2AR) on multiple immune cells 
such as phagocytes, dendritic cells, natural killer cells, T cells, and B cells and inhibiting their 
pro-inflammatory properties (Eppell et al. 1989; Haskó et al. 1996; Haskó et al. 2000; Zhang et 
al. 2004; Lappas et al. 2005; Minguet et al. 2005; Deaglio et al. 2007; Ohta et al. 2009). 
CD39 
CD39, the cell surface-located prototypic member of the ectonucleoside triphosphate 
diphosphohydrolase (ENTPDase) family, is an integral membrane protein that is responsible for 
phosphohydrolysis of eATP to yield adenosine diphosphate (ADP) and adenosine 
monophosphate (AMP) (Kaczmarek et al. 1996; Dwyer et al. 2007). AMP is further converted to 
adenosine via another ecto-enzyme, CD73 (ecto-5, ecto-nucleotidase). CD39 and CD73 have a 
major impact on the dynamic balance of pro-inflammatory eATP and ADP nucleotides compared 
with the immunosuppressive adenosine nucleosides (Takenaka et al. 2016). Moreover, evidence 
supports CD39 and CD73 ectonucleotidases having an involvement in the regulation of other 
aspects of T-cell biology, such as naïve cell homeostatic survival, memory cell survival, and 
differentiation (Bono et al. 2015). CD39 is constitutively expressed on immune cell populations, 
such as B cells, natural killer cells, dendritic cells, Langerhans cells, monocytes, macrophages, 
mesangial cells, neutrophils, and Treg as well as normal endothelial cells and platelets 
(Koziak et al. 1999). 
In the TME, CD39 expression is most prominent on Treg and myeloid derived suppressor cells 
(Whiteside 2015). Additionally, exhausted CD8+ T cells upregulate CD39 in the context of the 
tumor, which is accompanied by reduced functional capacity (Canale et al. 2018). CD39 has 
been recognized as an activation marker and is increasingly appreciated as a regulatory marker 
(Zhao et al. 2017). 
Increasing or inhibiting CD39 can interfere with the abnormal pathophysiological process of 
disorders, especially inflammation and tumor (Zhao et al. 2017). 
CD39 and Tumor Activity 
One mechanism by which immunotherapies modulate an individual’s immune system is through 
the blocking of suppressive pathways, thus making the adenosine pathway a promising 
therapeutic target in this area of clinical research. Reportedly, both CD39 and CD73 are elevated 
in blood neoplasias such as leukemia and lymphoma, as well as in multiple solid tumor settings 
(Bastid et al. 2013). In solid tumors, ATP is abundantly released in the extracellular space, 
achieving concentrations more than a thousand times higher than in healthy tissues. This is 


 
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primarily due to cell death in the tumor core, metabolic or hypoxic stress, and pro-inflammatory 
signals that stimulate active export of ATP (Pellegatti et al. 2008; Di Virgilio et al. 2016). In 
addition, immunogenic cell death mediated by chemotherapy is in part mediated by increasing 
extracellular ATP. Tumors are proficient at converting ATP into adenosine via CD39 and CD73 
on malignant cells, regulatory immune cells, and the vasculature. These ectonucleotidases 
modulate purinergic signaling by scavenging mainly pro-inflammatory ATP and generating 
immunosuppressive adenosine (Allard et al. 2017). 
CD39, the main rate-limiting enzyme of this cascade, has an important role in tumor progression. 
Blockade of CD39 enzymatic activity may then stimulate anti-tumor immunity across a wide 
range of tumors by preventing the production of immunosuppressive adenosine and by 
promoting the accumulation of ATP in the TME. CD39 can be viewed as an immunological 
switch that shifts ATP-driven pro-inflammatory immune cell activity toward an 
anti-inflammatory state mediated by adenosine and is, therefore, a unique therapeutic target for 
oncology indications (Antonioli et al. 2014; Cai et al. 2016). 
TTX-030 
TTX-030 is a novel, fully human anti-CD39 antibody that inhibits CD39 ATPase enzymatic 
function allosterically with sub-nanomolar affinity and potency. The constant domain of 
TTX-030 is a hinge stabilized (S228P) human immunoglobulin (Ig)G4 containing the S228P 
mutation, which reduces antigen-binding fragment arm exchange by stabilizing the disulfides in 
the core-hinge of the IgG4 molecule, which has low/no effector function. 
TTX-030 is specific to CD39 and does not bind to other ENTPDase family member proteins. 
This antibody does bind to and inhibit cynomolgus monkey CD39 but is not cross-reactive with 
murine CD39. Trishula Therapeutics, Inc. (Tizona Therapeutics, Inc.’s spin-out company) 
(hereafter referred to as Trishula) has conducted studies demonstrating that TTX-030 binds to 
CD39+ cancer cell lines and primary human and cynomolgus monkey monocytes and T cells 
with high affinity. TTX-030 specifically and potently inhibits CD39-driven processing of ATP 
by tumor and immune cells and by CD39+ tumor tissues, as demonstrated by a tumor tissue slice 
immunohistochemistry assay. In addition to preserving pro-inflammatory ATP by inhibiting 
CD39 ATPase activity, TTX-030 inhibits downstream adenosine production in SK-MEL-28 
melanoma cell line. Functionally, TTX-030 reverses adenosine-driven suppression of 
proliferation of activated CD4+ and CD8+ human T cells in a dose-dependent manner. Inhibition 
of CD39 by TTX-030 in CD3/CD28 stimulated peripheral blood mononuclear cells (PBMCs) in 
the presence of exogenous ATP increased proliferation of both CD4+ and CD8+ T cells from 
multiple donors. TTX-030 incubation with stimulated PBMCs led to increased secretion of pro-
inflammatory cytokines interferon (IFN)-γ, interleukin (IL)-2, and tumor necrosis factor-α. 
Additionally, TTX-030 reversed adenosine-driven suppression of T-cell IFN-γ responses in 
cytomegalovirus (CMV) peptide recall assay (see also Section 2.2.1.3.3). 
2.1. 
Study Rationale 
The goal of this first-in-human (FIH) Phase 1/1b study is to evaluate the safety, tolerability, and 
preliminary anti-tumor activity of intravenous (IV) TTX-030 as monotherapy or in combination 
regimens in adults with unresectable or metastatic solid tumor malignancy, including 


 
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relapsed-refractory lymphoma. There are compelling preclinical data to support the hypothesis 
that CD39-mediated reduction of adenosine triphosphate (ATP) and accumulation of adenosine 
both play a central role in establishing and maintaining the immunosuppressive 
microenvironment within solid tumors. CD39 expression is associated with worse outcomes in 
several cancer types. The enzymatic inhibition of CD39 maintains high levels of pro-
inflammatory extracellular ATP (eATP), leading to immune activation and significant anti-tumor 
immune responses. The CD39 pathway contributes to T-cell exhaustion and limits the 
immunogenicity of chemotherapy, which provides the rationale for combining CD39 inhibition 
with checkpoint blockade and conventional cytotoxic therapies. Targeting CD39 is a rational 
strategy for the treatment of patients with cancer. TTX-030, as a single agent or in combination, 
is expected to have a manageable safety profile, thereby providing additional therapeutic options 
for subjects whose malignancies are otherwise refractory to or relapsed on current standard of 
care therapies. The indications selected were defined based on the following criteria: expression 
of CD39 on TIL, expression of CD39 on tumor cells, and tumor types that are amenable to be 
combined with chemotherapy or anti-PD-1 therapy. 
While impressive and durable responses are observed in subsets of patients treated with 
anti-PD-1 agents, response rates are rarely > 50%, and for most patients, a response is short 
lasting. Thus, a synergistic strategy may be beneficial for patients. Co-expression of PD-1 and 
CD39 is highly prevalent on TILs and marks exhausted effector T-cell subsets in multiple tumor 
types (Canale et al. 2018; Trishula data on file Study No. 18-006-TRL). The rationale for 
combining with an anti-PD-1 antibody is that CD39 inhibition and subsequent ATP 
accumulation and adenosine reduction in the TME may make the tumor more susceptible to 
anti-PD-1 therapy. This combination strategy is supported by the in vivo data generated in using 
an anti-murine CD39 antibody B66 in multiple syngeneic tumor models (Section 2.2.1.4). 
Combining anti-CD39 therapy with an anti-PD-1 antibody in an MC38 syngeneic colorectal 
tumor model resulted in a significant decrease in tumor growth compared with the control or 
either monotherapy. Anti-PD-1 treatment of SM1WT1, which is generally refractory to 
immunotherapies, including anti-PD-1, shows marked tumor growth inhibition when anti-PD-1 
treatment is combined with an antibody capable of inhibiting enzymatic function of CD39, 
suggesting that the latter treatment sensitizes an otherwise refractory tumor to checkpoint 
blockade. These findings are consistent with previously reported data in CD39-/- animals that 
suggested that anti-PD-1 treatment of MCA205 resulted in a more pronounced tumor growth 
inhibition and increased number of complete responders in CD39-/- mice compared with the same 
treatment in wild-type mice (Lapierre et al. 2016). 
Similarly, treatment with oxaliplatin either alone or in combination with an anti-PD-1 antibody 
resulted in regression of MCA205 tumors in CD39-/- mice but not in wild-type mice 
(Boyd-Tressler et al. 2014). A study by Michaud et al. 2012 compared the effects of treatment 
with the anthracycline mitoxantrone on tumor growth of MCA205 tumor cells versus MCA205 
expressing mouse CD39. Tumor cells were pretreated with mitoxantrone prior to injection into 
wild-type mice – only MCA205 tumor cells expressing mouse CD39 grew (Michaud et al. 2012). 
Chemotherapy drugs such as oxaliplatin, cisplatin, and mitoxantrone have been shown to induce 
the release of ATP from dying tumor cells (Boyd-Tressler et al. 2014); CD39 then processes 
ATP in concert with CD73 resulting in the generation of immune-suppressive adenosine. 
Inhibition of CD39 prevents phosphohydrolytic processing and maintains high levels of 


 
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pro-inflammatory ATP in the TME and can lead to immune activation. These data support the 
potential synergy of the combination of chemotherapy and TTX-030. 
2.2. 
Background 
2.2.1. 
Nonclinical Data 
2.2.1.1. 
Non-human Primate Pharmacokinetic Study with TTX-030 
Multiple non-Good Laboratory Practice (GLP) pharmacokinetic (PK) studies were conducted 
with TTX-030, including a single-dose study at 10 mg/kg IV and multiple-dose studies at 
30 mg/kg and 100 mg/kg. Titers of TTX-030 were measured using an antigen-down 
enzyme-linked immunosorbent assay (ELISA) method and used for PK parameter calculations. 
Linear PK was observed for doses starting at 10 mg/kg, 30 mg/kg, and 100 mg/kg. In addition to 
PK parameters, blood samples were collected for assessment of treatment-related clinical 
observations and clinical pathology parameters (hematology, clinical chemistry, and 
coagulation). There were no treatment-related effects noted for clinical observations or for the 
hematology and clinical chemistry parameters collected in any of the cynomolgus monkeys in 
either the single- or multiple-dose cohorts. 
 
 
 
 
 
 
 
2.2.1.2. 
Non-human Primate Good Laboratory Practice Toxicology 
Since TTX-030 has equivalent binding and functional potency on both human and cynomolgus 
monkey CD39, testing TTX-030 in healthy male and female cynomolgus monkeys allowed for 
the characterization of effects of TTX-030 on immune cells, endothelial cells, and other tissues. 
A multiple-dose 28-day GLP toxicology study with 28-day recovery period was performed in 
cynomolgus monkeys, and no TTX-030-related findings were observed. The animals were IV 
dosed with 0, 30, or 100 mg/kg of TTX-030 once per week for 4 weeks (5 doses total). The main 
study groups consisted of 3 males and 3 females with an additional 2 males and 2 females 
included as part of the control and high-dose recovery groups.  
Three animals per sex from each group were sacrificed at the end of the dosing period. The 
2 remaining animals of each sex from each group were allowed to recover for 4 additional weeks 
and then were sacrificed. The 4-week recovery period provides approximately 5 to 6 half-lives 
for TTX-030 elimination, based on the preliminary PK measured in the pilot tolerability study. 
The recovery cohorts served to determine whether any toxicities observed at the end of the 
30-day dosing period are reversible. 


 
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Data collected from this toxicology study are summarized in Table 7. Gross observations on 
animal health (body weight, food consumption, and behavior) were collected and a battery of 
serological analyses from blood samples (hematology, blood chemistry, toxicokinetics, ADA, 
and cytokine analysis) were performed throughout the course of the study. In addition, a set of 
safety pharmacology assessments were conducted, including evaluation of heart rate and blood 
pressure, body temperature measurements, quality and rate of respiration, ophthalmology 
examinations, and neurological/central nervous system behavior evaluations. At sacrifice, a 
comprehensive examination of all animals (necropsy, urinalysis, and histopathology) was 
performed. The groups were compared using a parametric dose-response curve or 
non-parametric analysis of variance (ANOVA) method, as appropriate. 
 
 
 
 
 
 
 
 
Table 7: 
Procedures and Parameters for the 28-Day GLP Toxicology Study of the 
Administration of TTX-030 to Male and Female Cynomolgus Monkeys 
Procedure/Parameters 
Time Points 
Mortality/morbidity 
observations 
All animals: Twice daily, beginning Day -7 and continuing through the 
End of Study 
Cage-side observations 
All animals: Twice daily, beginning Day -14 and continuing through the 
End of Study 
Postdose observations 
All animals: For 1 continuous hour following dose 
Body weight 
All animals: Twice pre-study (Weeks -2 and -1) and weekly thereafter 
starting on Day 7 
Food consumption 
(qualitative) 
All animals: Daily beginning Day -14 and continuing through the End of 
Study 
Clinical pathology 
(hematology) 
All animals: Predose on Days 1, 15, and 29 
Clinical pathology (serum 
chemistry, and coagulation 
[PT/INR, aPTT]) 
All animals: Predose and postdose on Days 1, 15, and 29  
Recovery animals: Day 56 
TK 
All animals: Day 1 predose and 0.5, 4, 12, 24, 96, and 168 hours 
postdose; Day 15: predose; Day 29: predose and 0.5, 4, 12, 24, 96, and 
168 hours postdose 
ADA 
All animals: Day -2 and predose on Days 15 and 29  
Recovery animals: At the end of recovery period on Day 56 
Cytokines 
All animals: Predose, and multiple time points in 24 hours following first 
and last dose 


 
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Procedure/Parameters 
Time Points 
Electrocardiograms 
All animals: Once pretreatment (Week -2), on Day 1 (1 to 4, 12, and 24 
hours postdose), and at Week 4 (1 to 4, 12, and 24 hours postdose) 
Recovery animals: At the end of the recovery period prior to necropsy 
Blood pressure measurements All animals: Once during acclimation and at multiple time points within 
24 hours after first and last dose  
Respiratory examinations  
All animals: By visual assessment pretreatment (Week -1), predose, and 
2, 6, and 24 hours postdose on Days 1, 8, 15, and 22 
Recovery animals: At the end of the recovery period prior to necropsy 
Neurological / CNS behavior 
examinations  
All animals: Once pretreatment (Week -1), on Day 1 (1 to 4 hours 
postdose), and on Day 22 (predose and 1 to 4 hours postdose) 
Recovery animals: At the end of the recovery period prior to necropsy  
Body temperature  
All animals: Using infrared monitor, pretreatment (Week -1), and 
predose and 2, 6, and 24 hours postdose on Days 1, 8, 15, and 22  
Recovery animals: At the end of the recovery period prior to necropsy  
Ophthalmology examinations  All animals: Assessed pretreatment and during Week 4  
Recovery animals: Additionally, at the end of the recovery period prior 
to necropsy  
Examinations were performed by a board-certified veterinarian 
ophthalmologist  
Urinalysis  
All animals: At necropsy  
Necropsy  
Full necropsy of 12 main study animals on Day 30 and 8 recovery 
animals on Day 56  
Organ weights  
Standard organs measured  
Histopathology  
Full histopathologic evaluation on all animals  
Abbreviations: ADA = anti-drug antibodies, aPTT = activated partial thromboplastin time, CNS = central nervous 
system, INR = international normalized ratio, PT = prothrombin time, TK = toxicokinetics. 
Trishula data on file Study No. 18-002-TOX. 
2.2.1.3. 
Modeling and In Vitro Studies 
2.2.1.3.1. Enzymatic Inhibition of CD39 by TTX-030 
TTX-030 was evaluated for its ability to inhibit enzymatic activity of endogenous CD39 
expressed on human and cynomolgus monkey primary cells and multiple tumor cell lines. CD39 
expressing cells were pretreated with TTX-030 before administering ATP; phosphate release 
resulting from enzymatic phosphohydrolysis was subsequently measured. TTX-030 inhibited 
CD39 activity in multiple cell types with sub-nanomolar half-maximal inhibition concentration 
(IC50) values, ranging from 51.4% inhibition in primary human artery endothelial cells to 85.3% 
in the SK-MEL-28 cell line. TTX-030 also inhibited activity of CD39 in human monocytes and 
in cynomolgus monkey monocytes with similar IC50 values (Figure 2). 


 
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Figure 2: 
Short-Term Inhibition of CD39 by TTX-030 on Human and Cynomolgus 
Monocytes 
 
Abbreviation: IC50 = half-maximal inhibition concentration. 
Trishula data on file Study No. 17-001-IVT: TTX-030 inhibits CD39 enzymatic activity on human and cynomolgus 
monkey monocytes. Inhibition curves of ATPase activity by TTX-030 on human (A) and cynomolgus monkey 
(B) monocytes (average and standard deviation are shown, n = 2). Enzymatic inhibition on human monocytes 
was calculated at 72.0 ± 1.1% with an IC50 of 0.02 nM. For cynomolgus monocytes, enzymatic inhibition was 
98.7 ± 8.8%, with IC50 of 0.01 nM. 
2.2.1.3.2. TTX-030 Reduces Adenosine and Preserves ATP in SK-MEL-28 Cancer Cell Line 
To assess functional effect of CD39 inhibition by TTX-030, the antibody was evaluated for its 
ability to inhibit CD39-mediated adenosine production on tumor cell lines. The melanoma cell 
line SK-MEL-28 (CD39 and CD73 positive) was pretreated with TTX-030 and adenosine 
production following ATP addition was measured by liquid chromatography-tandem mass 
spectrometry. TTX-030 (100 nM) inhibited 73.0 ± 7% of CD39-mediated adenosine production 
by SK-MEL-28 cells compared with cells treated with ATP only. TTX-030 also preserved ATP 
levels in the supernatant of SK-MEL-28 cells by preventing ATP processing by CD39 (Figure 
3). ATP was not hydrolyzed by SK-MEL-28 cells that had CD39 expression ablated by 
Clustered Regularly Interspaced Short Palindromic Repeats (designated as CD39KO). 
Additionally, adenosine levels were lower in supernatants of CD39KO cells, indicating that 
CD39 is critical for ATP processing to adenosine by SK-MEL-28. These data demonstrate that 
inhibition of CD39 enzymatic activity by TTX-030 is sufficient to impact downstream 
immunosuppressive adenosine production while simultaneously preserving pro-inflammatory 
ATP. 


 
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Figure 3: 
TTX-030 Reduces CD39-Mediated Adenosine Production and Preserves ATP 
in SK-MEL-28 Cells 
 
Abbreviations: ATP = adenosine triphosphate, EHNA =41rythrono-9-(2-hydroxy-3-nonyl)adenine. 
Trishula data on file Study No. 17-012-IVT: Average and standard deviation of adenosine production from 
SK-MEL-28 (n = 3) and average and standard deviation of ATP accumulation in SK-MEL-28 (n = 6). Dotted 
line denotes the adenosine production and ATP accumulation from CD39KO SK-MEL-28 cells. Adenosine was 
measured by liquid chromatography-tandem mass spectrometry. ATP was measured by EnzyLight Kit. The 
nonspecific small molecule inhibitors ARL67156 and POM-1 were used as positive controls. EHNA is an 
adenosine deaminase inhibitor. 
2.2.1.3.3. TTX-030 Induces IFN-γ in CMV Recall Assay 
Human PBMCs express both CD39 and CD73 and stimulation of T-cell proliferation in the 
presence of ATP results in generation of immunosuppressive adenosine. Adenosine can lead to 
decrease in pro-inflammatory cytokine release by activated T cells. The effect of TTX-030 on 
T-cell response was measured using human PBMCs that were stimulated with a mixture of 
immunogenic CMV peptides. Following an initial recall stimulation period of 5 days using 
PBMCs, T cells were purified and rested overnight, prior to treatment with TTX-030. T cells 
were then re-stimulated with CMV peptides in the presence of autologous CD39+ Epstein Barr 
virus-transformed lymphoblastoid B cell lines (B-LCLs) and ATP (Figure 4). Addition of ATP in 
this system led to suppression of IFN-γ responses by CD4+ and CD8+ T cells, which was nearly 
completely reversed by TTX-030 treatment (25 μg/mL). 


 
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Figure 4: 
TTX-030 Reverses Suppression of IFN-γ Response in a CMV Recall Assay 
 
Abbreviations: ATP = adenosine triphosphate, B-LCL = Epstein Barr virus-transformed lymphoblastoid B cell line, 
CMV = cytomegalovirus, IFN = interferon, PBMC = peripheral blood mononuclear cell. 
Trishula data on file Study No. 17-011-IVT: TTX-030 reverses adenosine-driven suppression of IFN-γ response in 
T-cell CMV recall assay. Human PBMCs were stimulated with CMV peptides and rested prior to re-stimulation 
with the same peptides in the presence of ATP, autologous B-LCL, and TTX-030. Levels of IFN-γ produced by 
CD4+ and CD8+ T cells were analyzed by intracellular cytokine staining (* P < 0.05 by t test). 
2.2.1.3.4. TTX-030 Induces T Cell Proliferation and Cytokine Response 
The impact of TTX-030 treatment on CD39-mediated adenosine production in PBMCs was 
measured using functional readouts of CD4+ and CD8+ T-cell proliferation and cytokine 
expression. Addition of ATP to activated PBMCs decreased proliferation, which was reversed 
through addition of TTX-030 in a dose-dependent manner compared with isotype control and 
untreated T cells (Figure 5). Similar results were obtained with TTX-030 without the addition of 
exogenous ATP (data are not presented). 


 
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Figure 5: 
TTX-030 Increases the Proliferation of Stimulated CD8+ and CD4+ T Cells 
in the Presence of ATP 
 
Abbreviations: ATP = adenosine triphosphate, PBMC = peripheral blood mononuclear cell. 
Trishula data on file Study No. 17-014-IVT: PBMCs isolated from human donor were fluorescently labeled, 
stimulated with anti-CD3/anti-CD28 antibody cocktail, and incubated with TTX-030 and ATP for 96 hours. 
Proliferation of CD4+ and CD8+ T cells was assessed by flow cytometry gating on the specific T-cell 
populations. Dotted line depicts baseline level of proliferation without the addition of exogenous ATP or 
antibody. 
The effects of TTX-030 treatment on pro-inflammatory cytokines secretion by 
anti-CD3/anti-CD28 activated PBMC was measured using a multi-cytokine 
electrochemiluminescent assay. TTX-030 increased IL-2 secretion by stimulated PBMCs 
compared with isotype control in a dose-dependent manner with a half-maximal effective 
concentration (EC50) of 129.10 ± 43.99 nM (19.37 μg/mL) when 50 μM ATP was added to the 
culture and an EC50 of 155.20 ± 24.47 nM (23.30 μg/mL) without the addition of exogenous 
ATP (Figure 6). 


 
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Figure 6: 
TTX-030 Induces IL-2 Release by Stimulated PBMCs in Dose-Dependent 
Manner 
 
Abbreviations: ATP = adenosine triphosphate, IL-2 = interleukin-2, PBMC = peripheral blood mononuclear cell. 
Trishula data on file Study No. 17-014-IVT: TTX-030 induces dose-dependent IL-2 production by 
anti-CD3/anti-CD28 stimulated PBMC. Assay performed with addition of 50 μM ATP (left) and without 
exogenous ATP (right) is shown. TTX-030 indicated by black squares while gray squares indicate isotype 
control. Data are representative of 3 independent PBMC donors. 
2.2.1.4. 
In Vivo Studies: Mouse 
The impact of CD39 on tumor growth and anti-tumor immunity has previously been studied 
using CD39-/- knockout mice. Published data suggest that growth of syngeneic tumors, including 
MC38 and B16F10 (Sun et al. 2010; Feng et al. 2011), is reduced in these mice. These effects are 
more pronounced when combined with therapeutic intervention via anti-programmed cell death 
ligand-1 (PD-L1) (Lapierre et al. 2016) or chemotherapeutic agents (Michaud et al. 2012; 
Lapierre et al. 2016). In both cases, combinatorial efficacy was observed in tumor-bearing 
CD39-/- mice but not in matched wild-type C57BL/6 animals. 
To test the effect of therapeutic inhibition of CD39 enzymatic activity on tumor growth and to 
complement findings from the CD39-/- mouse studies, Trishula has generated antibody clone 
B66, an antibody specific for murine CD39 with the ability to inhibit CD39-mediated ATP 
hydrolysis (Trishula data on file Study No. 18-001-IVT). This antibody was used to characterize 
the role of pharmacological inhibition of CD39 activity on tumor growth. B66 was used both as a 
single agent and in combination with anti-PD-1 in the syngeneic MC38 mouse tumor model 
(Figure 7). In single-agent studies, treatment with B66 significantly decreased tumor growth of a 
subcutaneous murine colorectal tumor cell line in a dose-dependent fashion (Figure 7A). 
Therefore, inhibition of CD39 enzymatic activity in the MC38 syngeneic mouse tumor model by 
B66 monoclonal antibody (mAb) is sufficient to decrease tumor growth as a single agent. These 
data agree with the previous findings from MC38 tumors grown in the CD39-/- mice. 
Given the single-agent efficacy observed with B66, a suboptimal dosing strategy with a delayed 
treatment schedule (100 μg/dose on Days 12, 15, 18, and 21) was employed to maximize the 
window for seeing therapeutic combination effects (Figure 7B). Employing this treatment 


 
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regimen, efficacy was reduced but was still significant versus isotype control for B66 
monotherapy. Additionally, the anti-tumor effect was similar to that seen for anti-PD-1 treatment 
alone. In combination, anti-PD-1 and B66 resulted in a highly significant increase in anti-tumor 
efficacy compared with either monotherapy or isotype control. 
Figure 7: 
Anti-Mouse CD39 Antibody B66 Inhibits MC38 Tumor Growth as Single 
Agent and in Combination with Anti-PD-1 
 
Abbreviations: ANOVA = analysis of variance, cIg = isotype control, PD-1 = programmed cell death protein-1. 
Trishula data on file Study No.17-015-IVO: MC38 cells were injected subcutaneously on Day 0.  
A) B66 was administered intraperitoneally at 20, 100, or 200 μg, and cIg was administered at 20  μg/dose on 
Days 7, 10, 13, and 16.  
B) B66 was administered intraperitoneally 100 μg/dose and anti-PD-1 at 250 μg/dose on Days 12, 15, 18, and 21 
(*** P < 0.001, **** P < 0.0001 by 2-way ANOVA). Arrows indicate dosing days. 
Similar responses were observed in an immunotherapy-resistant melanoma tumor model 
SM1WT1 (Figure 8). Treatment with B66 demonstrated a slight, but statistically significant 
effect on subcutaneous SM1WT1 tumor growth alone, while anti-PD-1 treatment demonstrated 
no single-agent efficacy. In combination, B66 and anti-PD1 led to significant tumor growth 
reduction compared with either agent alone. Therefore, combination treatment of anti-PD1 and 
B66 in both anti-PD1-sensitive MC38 and anti-PD1-resistant SM1WT1 tumors resulted in an 
additive and potentially synergistic impact on tumor growth. These findings suggest that 
PD-1/PD-L1 and CD39/adenosine represent non-overlapping immune resistance mechanisms. 


 
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Figure 8:  
Combinatorial Anti-Tumor Efficacy of Anti-PD-1 and Anti-Mouse CD39 
Antibody B66 in an Immunotherapy-Resistant SM1WT1 Tumor Cell Line 
 
Abbreviations: ANOVA = analysis of variance, cIg = isotype control, PD-1 = programmed cell death protein. 
Trishula data on file Study No.17-015-IVO: SM1WT1 cells were injected subcutaneously on Day 0. B66 and cIg 
were administered intraperitoneally at 200 μg/dose and anti-PD1 was administered at 250 μg/dose on Days 6, 9, 
12, and 14. (* P < 0.05, **** P < 0.0001 by 2-way ANOVA). Arrows indicate dosing days. 
To assess the impact of inhibition of CD39 enzymatic function on models of disseminated 
disease, the anti-mouse CD39 inhibitory antibody B66 was tested in lung metastasis seeding 
models of 2 melanoma-derived tumors, LWT1 and B16F10. Treatment with B66 significantly 
inhibited lung metastasis of LWT1 in wild-type mice in a dose-dependent fashion – the 50 μg 
dose of B66 was sufficient to mediate significant reduction in lung metastatic burden; maximal 
inhibition of metastasis formation was observed at the 200 μg dose of antibody in this model 
(Figure 9A). Therapeutic inhibition of CD39 activity by B66 antibody in wild-type mice had a 
more pronounced effect on metastasis compared with metastasis observed in CD39-/- mice. This 
effect of B66 was not limited to LWT1 as similar results were observed in B16F10 metastasis 
model (Figure 9B). Anti-CD39 inhibitory antibody treatment in wild-type mice in the B16F10 
model was more efficacious in reducing metastasis compared with CD39-/- animals. However, 
there was no benefit observed between B66 treatment and the control treatment groups in the 
CD39-/- background, suggesting that the observed reduction of lung metastatic burden is 
dependent on CD39 inhibition. 
Inhibition of CD39 enzymatic activity in mouse metastasis models of cancer is sufficient to 
reduce number of lung metastasis in vivo. Reduction in number of lung metastasis by B66 
antibody in both LWT1 and B16F10 models resulted in a more pronounced effect compared with 
decreases in metastasis observed in CD39-/-. 


 
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Figure 9:  
Anti-CD39 Antibody Inhibits Lung Metastasis Formation in Models of 
Disseminated Disease 
 
Abbreviations: ANOVA = analysis of variance, cIg = isotype control, IV = intravenously, WT = wild type. 
Trishula data on file Study No. 17-016-IVO: Anti-tumor efficacy of B66 in disseminated models of disease.  
A) LWT1 cells were injected IV on Day 0. Mice were injected intraperitoneally with B66 or cIg at indicated 
doses (all doses are in μg) on Day 0 and on Day 3. Lungs were collected on Day 14 and perfused with India ink 
and analyzed for number of metastasis.  
B) B16F10 cells were injected IV on Day 0. Mice were injected intraperitoneally with B66 or cIg at 200 μg/dose 
on Days 0 and 3. Lungs were collected on Day 14 and perfused with India ink and analyzed for number of 
metastasis. (*P < 0.05, *** P < 0.001, **** P < 0.0001 by one-way ANOVA). 
2.2.1.5. 
In Vivo Studies: Cynomolgus Monkey 
TTX-030 has been tested in vivo in cynomolgus monkeys in single-dose (10 mg/kg) and 
multiple-dose non-GLP and GLP (30 and 100 mg/kg) studies. No adverse effects have been 
observed; all clinical chemistry, hematology, and coagulation results were within the normal 
range for cynomolgus monkeys. 
CD39 receptor occupancy by TTX-030 in cynomolgus monkeys was analyzed as part of a 
non-GLP study. Target coverage was assessed by flow cytometry using fluorescently labeled 
TTX-030 on whole blood samples and gated on monocyte population. Free CD39 receptor was 
calculated relative to baseline (mean fluorescence intensity [MFI] of an unblocked sample at 


 
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predose). The percent of free receptor at each time point was calculated using the following 
formula: 
% of Free 
Receptor = 
(MFI of Unblocked Sample MFI of Pre-Blocked Sample) 
÷ 
(MFI of Unblocked Sample at Predose—- MFI of Pre-Blocked Sample) 
 
Receptor occupancy exceeding 90% was achieved following TTX-030 dosing at 10 mg/kg. 
Occupancy was 91.1% 24 hours postdose and remained high (83% ± 3%) through Day 14 
(Figure 10) with Cmax for that group calculated as 19.8 μg/mL. 
Figure 10:  
Receptor Occupancy Analysis for 10 mg/kg Group in Cynomolgus Monkeys 
 
Trishula data on file Study No. 17-019-PK: TTX-030 covers CD39 cynomolgus monkey peripheral blood 
monocytes for > 2 weeks at 10 mg/kg. Cynomolgus monkey whole blood was incubated in fluorescently labeled 
TTX-030 for 30 minutes and analyzed by flow cytometry. 
2.2.2. 
Clinical Data 
As of the data cutoff date of 10 January 2020, 21 subjects in Study TTX-030-001 have received 
TTX-030 monotherapy every 3 weeks (Q3W) at the following escalating doses: 0.5 mg/kg 
(n = 1), 1.5 mg/kg (n = 2), 3.0 mg/kg (n = 2), 6.0 mg/kg (n = 4), 10 mg/kg (n = 3), 20 mg/kg (n = 
3), or 40 mg/kg (n = 6). 
As of 10 January 2020, 17 of 21 subjects in Study TTX-030-001 experienced treatment-emergent 
adverse events (TEAEs). A majority of the TEAEs were of Grade 1 or 2 severity. TEAEs of 
≥ Grade 3 severity were reported in 6 subjects: Grade 3 lipase increase (1.5 mg/kg cohort), Grade 
3 hyperbilirubinemia (3.0 mg/kg cohort), Grade 3 gamma-glutamyltransferase (GGT) increase 
(10 mg/kg cohort), Grade 3 bilateral lower extremity muscle weakness (10 mg/kg cohort), Grade 
3 dyspnea, ascites, increased alkaline phosphate, esophageal hemorrhage, upper gastrointestinal 
(GI) bleed, and decreased lymphocyte count (40 mg/kg cohort), and Grade 5 sepsis (6.0 mg/kg 
cohort). There were no Grade 4 events. Treatment-related TEAEs were reported in 9 subjects and 
included arthralgia in 2 subjects and malaise, myalgia, worsening back pain, intermittent rib 
pain, dizziness, worsening diarrhea, foot maculo-papular rash, bruising left hand, vaginal 
discharge, nausea, headache, creatine phosphokinase (CPK) increased, and fatigue in 1 subject 


 
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each; all of these events were of Grade 1 or 2 severity. Five subjects experienced a total of 
6 serious adverse events (SAEs): Grade 2 bee sting reaction (1.5 mg/kg cohort), Grade 3 
hyperbilirubinemia (3.0 mg/kg cohort), Grade 3 bilateral lower extremity muscle weakness (10 
mg/kg cohort), Grade 3 dyspnea and esophageal hemorrhage (40 mg/kg cohort), and Grade 5 
sepsis (6.0 mg/kg cohort). None of the SAEs were considered to be treatment-related by the 
Investigator. No dose-limiting toxicities (DLTs) were observed, and the maximum tolerated dose 
has not been determined. 
As of 08 January 2020, PK data are available for 21 subjects treated at TTX-030 doses through 
40 mg/kg. Overall, the 2-compartment model was consistent with the individual subject data. 
Clearance appears to be independent of dose at doses  6 mg/kg suggesting linear or dose-
proportional PK. For doses from 6 to 40 mg/kg, there was reasonable consistency among doses 
and subjects with respect to the PK parameters. The elimination half-life over that dose range 
averaged 18.9 days.  
Refer to the TTX-030 Investigator Brochure (IB) for more information. 
2.2.3. 
Rationale for TTX-030 Dose and Schedule 
Based on the current PK, receptor occupancy data and safety from the ongoing first-in-human 
Phase 1 study (TTX-030-001) that is evaluating TTX-030 as monotherapy and in combination 
with other agents in subjects with advanced solid tumor malignancies or lymphoma, a RP2D was 
determined to be 40 mg/kg loading dose 7 days prior to Cycle 1 Day 1 and then either 30 mg/kg 
Q3W or 20 mg/kg Q2W. 
As of the clinical data cut-off date of 10 January 2020, doses of TTX-030 monotherapy up to 40 
mg/kg Q3W have been evaluated in Study TTX-030-001 and demonstrated to be well tolerated. 
No DLTs have been reported (Section 2.2.2). 
PK demonstrated that a dose of 40 mg/kg Q3W achieved a minimal functional trough level based 
on activity of TTX-030 in preclinical human functional assays (i.e., enhancement of IL-2 from 
PBMCs and inflammasome activation). Clearance appears to be independent of dose at doses  6 
mg/kg, suggesting linear or dose-proportional PK. The half-life was 18.9 days. After the 
completion of the dose escalation portion of the study, the totality of the PK data was used for 
PK modeling for the RP2D. Based on the simulations, it was determined that a loading dose of 
40 mg/kg one week prior to Cycle 1, Day 1 dosing of 30 mg/kg Q3W or 20 mg/kg Q2W will 
provide a minimal functional trough level in greater than 80% of patients before Cycle 1, Day 1 
and in cycles thereafter.  
In the 0.5, 1.5, 3.0, 6.0, 10.0 and 20.0 mg/kg Q3W dose groups, receptor occupancy data 
demonstrated that doses greater than or equal to 6 mg/kg achieved and maintained higher levels 
of peripheral blood receptor occupancy through 21 days post-Cycle 1 on CD39+ monocytes, B 
cells, and regulatory T cells. At doses less than or equal to 3 mg/kg, receptor occupancy levels 
were lower and decreased 7-14 days post-Cycle 1.  
Refer to the TTX-030 Investigator’s Brochure for more information. 


 
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2.3. 
Benefit/Risk Assessment 
Blockade of CD39 may result in less potential for autoimmune side effects compared with rates 
seen with other immunotherapy agents. Although Treg from CD39-/- knockout mice have 
impaired suppressive activity, the mice do not show autoimmunity (Sun et al. 2010). 
TTX-030 has a different mechanism of action from each of the regimens in the combination 
arms (Arms 2 and 4, presented in Table 8), and toxicities are anticipated to be manageable and 
nonoverlapping. Conversely, it is also possible that TTX-030 could potentiate some of the 
existing toxicities of the combination regimens. 
The clinical risks and benefits of TTX-030 are unknown at this time; however, several 
investigational agents targeting A2AR and CD73 in the adenosine pathway have reportedly 
entered Phase 1 trials and may offer insights on potential risks and benefits of targeting the 
adenosine pathway. Clinical data from an ongoing Phase 1 trial with CPI-444 (NCT02655822), 
an oral small molecule inhibitor of the A2A receptor, suggest that inhibiting adenosine-mediated 
suppression can be achieved with a favorable safety profile (Hotson et al. 2017). Similarly, no 
SAEs were reported in a Phase 1b/II study in Parkinson’s Disease with the same compound 
(Pinna 2014). A similar safety profile was observed with NIR178 (previously known as 
PBF-509), also a small molecule inhibitor of A2AR, which has been evaluated in both healthy 
volunteers (NCT01691924 and NCT02111330) and subjects with advanced non-small-cell lung 
cancer (NCT02403193). NIR178 was reportedly well-tolerated. Adverse events (AEs) were 
manageable, and there were no Grade 4 drug-related AEs; immune-related AEs (irAEs) may 
indicate immune stimulation (Chiappori et al. 2018). 
Antibodies targeting CD73 have also recently entered clinical development. Data from 
NZV930/SFF3737 (NCT03549000) and CPI-006 (NCT03454451) have not been reported. The 
anti-CD73 antibody MEDI9447 (oleclumab) was evaluated for safety, efficacy, and PK alone or 
in combination with the anti-PD-L1 antibody (IMFINZI®, 2018) in advanced pancreatic cancer 
or colorectal cancer (NCT02503774). No treatment-related deaths or DLTs were reported, and 
no SAEs were reported in any of the oleclumab monotherapy dose-escalation cohorts. Overall, 
treatment with oleclumab alone or with durvalumab demonstrated a manageable safety profile as 
measured by low incidence of treatment-related discontinuation and SAEs 
(Overman et al. 2018). 
Overall, clinical experience with other investigational agents targeting A2AR and CD73 in the 
adenosine pathway were shown to be well tolerated. Publicly disclosed safety data have been 
summarized in more detail in the IB. 




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to mechanism of action and immune 
responses 
• Exploratory pharmacodynamic 
biomarkers 


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4. 
Study Design 
4.1. 
Overall Design 
4.1.1. 
Overview 
This is a Phase 1/1b, FIH, open-label, and multicenter study to investigate the safety, tolerability, 
PK, pharmacodynamic, and preliminary clinical activity of TTX-030 in adult subjects with 
advanced solid tumor malignancies or lymphoma. The study will evaluate the safety and 
tolerability of: 
• TTX-030 as a single agent, and 
• TTX-030 in combination with pembrolizumab, a PD-1 inhibitor, and 
• TTX-030 in combination with specified chemotherapy regimens. 
The study consists of 2 stages: dose escalation/safety lead-in and dose expansion Figure 1. Dose 
escalation/safety lead-in comprises Part A (1 dose-escalation arm of TTX-030 monotherapy 
[Arm 1]) and Part B (2 safety lead-in arms of combination therapy [TTX-030 with other agents; 
Arms 2 and 4]). Arm 3 is removed from study design as similar population is being evaluated in 
another Trishula protocol, TTX-030-002. 
Up to 43 subjects may be enrolled across the dose-escalation and safety lead-in arms. Cohort 
expansions of n=25 subjects each in Arms 1 and 2 and n=up to 20 in Arm 4. The number of 
subjects evaluated in the combination-therapy safety lead-in Arm 4 may count toward the total 
number of subjects in an expansion cohort. Note: The sponsor may choose not to open one of the 
safety lead-in arms and/or expansion cohorts.  
The study includes pretreatment (screening and baseline), study treatment, treatment extension, 
and post-treatment (end-of-treatment and follow-up) periods. 
4.1.1.1. 
Dose Escalation and Safety Lead-in 
Dose escalation (Arm 1) will be conducted according to a mCRM for doses up to 10 mg/kg (see 
Section 4.4 for details) and according to a traditional 3 + 3 design for doses > 10 mg/kg (see 
Section 4.7 for details) to estimate the dose-toxicity relationship and determine the MTD 
(defined as the dose that has a model-estimated DLT rate closest to 30% and also has less than 
55% probability that the DLT rate exceeds 30%). The study will be overseen by a Cohort 
Review Committee. 
A DLT is defined as any clinically significant AE that occurs during Treatment Cycle 1, is 
considered related to TTX-030 as a single agent or the combination of TTX-030 and other 
agent(s), and meets the criteria outlined in Section 4.12. In Arm 1 dose escalation, for the Q3W 
dose schedule, the DLT period will be the first cycle (21 days).  
In the safety lead-in Arm 2, the DLT evaluation period is 21-day (TTX-030 regimen given every 
3 weeks [Q3W]) plus a 7-day of loading dose. In the safety lead-in Arm 4, for the Q2W dose 
schedule, the cycle length is 4 weeks and the DLT period will be 28-day (TTX-030 regimen 
given every 2 weeks [Q2W]) plus a 7-day of loading dose. 


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Safety and tolerability will be assessed by physical examination (including symptom-directed 
examinations), vital signs, and clinical laboratory tests and evaluated as the incidence, severity, 
duration, seriousness, type, and relationship of AEs that occur during the treatment and 
follow-up periods. Subjects will be followed for determination of AE incidence through  
through 90 days after the last dose of TTX-030 or until initiation of a new systemic anticancer 
therapy, whichever occurs first. Clinical AEs will be graded according to the NCI CTCAE 
Version 5.0. 
TTX-030 will first be evaluated in monotherapy dose escalation (Arm 1). Once the RP2D of 
TTX-030 has been determined in the monotherapy dose-escalation arm, the combination-therapy 
safety lead-in arms (Arms 2 and 4) can be initiated. For the safety lead-in arms, the TTX-030 
starting dose will be the RP2D identified during monotherapy dose escalation; de-escalation to 
1 dose level below the RP2D is permitted. Upon completion of the dose-escalation and safety 
lead-in arms, each of those arms may have the option to enroll up to 20 to 25 additional subjects 
per expansion cohort. The number of subjects evaluated in the combination-therapy safety 
lead-in Arm 4 may count toward the total number of subjects in an expansion cohort. 
Dose escalation and safety lead-in arms are presented in Table 8, and dosing regimens are 
presented in Table 11. Subjects in Arms 1 and 2, are to be dosed Q3W on a 21-day schedule 
(Table 1/Table 2). Subjects in Arm 4 may be dosed Q2W on a 28-day schedule (Table 3/Table 
4).  
As of Jan 2020, a RP2D was determined to be 40 mg/kg loading dose 7 days prior to Cycle 1 
Day 1, followed by either 30 mg/kg Q3W or 20 mg/kg Q2W. 
Enrollment will continue in the monotherapy dose-escalation arm (Arm 1) until the MTD is 
determined or the highest dose level has been reached and deemed safe by the Cohort Review 
Committee. The Cohort Review Committee may select interim dose levels as recommended by 
the mCRM for doses up to 10 mg/kg and by the 3 + 3 design for doses > 10 mg/kg and deemed 
appropriate. 
4.1.1.2. 
Expansion Phase 
Once a dose level in the dose-escalation arm has been declared safe, that particular dose level 
may be expanded to further explore the PK/pharmacodynamics of TTX-030 in the tumor cohorts 
listed below (see Section 5 for disease-specific eligibility criteria for each cohort). A total of up 
to 90 subjects (20 to 25 subjects per cohort) may be enrolled for PK/pharmacodynamic 
exploration. 
The expansion phase includes 3 arms, as described below. Multiple expansion cohorts may 
enroll in parallel. 
Arm 1 and 2 Expansion Cohorts 
In Arm 1 and 2 Expansion Cohorts, 50 subjects (25 subjects in each arm) with advanced or 
metastatic renal cell carcinoma with a clear-cell component and previously treated with anti-PD-
(L)1 therapy and tyrosine kinase inhibitor (TKI) therapy, will be randomized 1:1 to TTX-030 or 
TTX-030 and pembrolizumab. These agents will be administered at the doses and schedules 
identified in the safety lead-in. 


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• Arm 1 Expansion: TTX-030 (n = 25) 
• Arm 2 Expansion: TTX-030 and pembrolizumab (n = 25) 
Expansion Arm 4 
In Expansion Arm 4, up to 20 subjects will receive TTX-030 40 mg/kg 7-day prior to C1D1, 
followed by 20 mg/kg Q2W in combination with gemcitabine + nab-paclitaxel  at a dosing 
schedule equivalent to that evaluated in the safety lead-in.  
• Expansion Arm 4: Histologically or cytologically confirmed diagnosis of locally advanced, 
unresectable, or metastatic pancreatic adenocarcinoma, naïve to any prior treatment for 
metastatic disease. Prior adjuvant therapy (including chemotherapy and/or radiotherapy) is 
permitted if neoadjuvant or adjuvant therapy was completed at least 6 months prior to study 
enrollment. 
4.1.2. 
Cohort Review Committee 
The Cohort Review Committee is composed of study investigators, the sponsor’s medical 
monitor (or qualified delegate), and a statistician. Treatment cohorts will be dosed in escalating 
order as determined by the mCRM (for doses up to 10 mg/kg) or 3 + 3 design (for doses 
> 10 mg/kg) and with approval from the Cohort Review Committee, only after the safety of each 
dose level has been established, or until the MTD has been determined. Subsequent cohorts will 
not be dosed until safety data from the Study Treatment Period are obtained from subjects in the 
current cohort. 
A review of the safety data for each cohort will be conducted by the Cohort Review Committee. 
The Cohort Review Committee will be fully aware of clinical and laboratory data, the mCRM 
recommendation (where applicable), and will determine whether dose escalation to the next 
cohort is appropriate. Safety will be evaluated based on AEs, clinical laboratory test results, and 
other relevant clinical findings observed during the Study Treatment Period, as well as data from 
the Treatment Extension Period for prior cohorts. PK and pharmacodynamic data that are 
available will also be reviewed but are not required to make a dose-escalation decision. 
No dose escalation will take place until the Cohort Review Committee has reviewed the safety 
data and approved escalation. Cohort Review Committee evaluations will determine whether a 
DLT has occurred. Cohort Review Committee evaluations are also required to open combination 
treatment in Arms 2 through 4. The mCRM for doses up to 10 mg/kg and 3 + 3 design for doses 
> 10 mg/kg will be applied to each treatment arm independently; however, the Cohort Review 
Committee will be made aware of all safety data across all arms and cohorts. The Cohort Review 
Committee may choose to apply safety knowledge gained from one arm to more conservatively 
manage other arms. 
Any toxicity occurring within an earlier dose level after formal Cohort Review Committee 
review will be reviewed by the Cohort Review Committee along with safety data from the 
current dose level and used to make decisions regarding further dose escalation. 


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4.2. 
Justification for Dose in FIH study 
4.2.1. 
Rationale for TTX-030 Starting Dose and Dosing Schedule 
To inform selection of the starting dose for a FIH study, Trishula will primarily employ the 
no-observed-adverse-effect level (NOAEL) method from the Good Laboratory Practice (GLP) 
toxicology studies in non-human primates (NHPs) (FDA, 2005). Additionally, the 
pharmacologically active dose (PAD) method was used to independently calculate a starting dose 
value, with both methodologies arriving at similar dose levels.   
No adverse effects were observed in the non-GLP and GLP NHP multi-dose studies performed 
with TTX-030. As such, Trishula proposes to calculate the maximum recommended starting dose 
(MRSD) for TTX-030 based on a 10-fold safety factor over the NOAEL. A multiple-dose GLP 
NHP study found no observed toxicities at a maximum dose level of 100 mg/kg, administered 
weekly for a total of 5 doses. The human equivalent dose (HED) based on the body size mg/kg 
scaling factor is calculated at 32.36 mg/kg. Coupled with a 10-fold safety factor, the resulting 
MRSD for TTX-030 is 3.23 mg/kg. 
A PAD level was calculated based on in vitro functional data to derive the FIH starting dose. In 
vitro human PBMC bioactivity assays (IL-2 release from stimulated PBMC in the presence of 
TTX-030) predict that a minimum exposure concentration of 10 µg/mL of TTX-030 is required 
to maintain efficacy (Section 2.2.1.3.4). In this assay, the half maximal dose of TTX-030 needed 
for increased cytokine release was calculated at 19.37 µg/mL when 50 µM ATP was added to the 
culture and 23.3 µg/mL without the addition of exogenous ATP; cytokine release dropped off 
when TTX-030 concentration was below 10 µg/mL (see Figure 6). By combining these in vitro 
results with exposure levels in NHP studies and allometric scaling from cynomolgus monkey to 
human, a 1.8 mg/kg Q3W HED dose was calculated as the PAD, which is almost 2-fold lower 
than MRSD. 
A dose of 0.5 mg/kg given Q2W or Q3W is 2 to 3 dose levels below the predicted PAD dose and 
below the 10-fold safety margin based on NOAEL. The FIH starting dose of 0.5 mg/kg Q3W 
initiated in the single-agent arm.  
4.2.2. 
Selection of Agents in Combination with TTX-030 
TTX-030 is postulated to potentiate the effectiveness of each of these combination-therapy 
regimens. 
The backbone regimens chosen for each combination arm are approved and/or standard of care 
for several indications, and the regimens all have a well-characterized safety profile. TTX-030 
has a different mechanism of action from each of the regimens in the combination arms, and 
toxicities are anticipated to be manageable and nonoverlapping. 
Treatment with pembrolizumab 200 mg every 21 days has been approved for multiple oncology 
indications, including melanoma, non-small-cell lung cancer, small-cell lung cancer, head and 
neck squamous cancer, classical Hodgkin lymphoma, primary mediastinal large B-cell 
lymphoma, urothelial carcinoma, MSI-H/MMR deficient malignancies, gastric cancer, 
esophageal cancer, cervical cancer, hepatocellular carcinoma, Merkel cell carcinoma, RCC, and 
endometrial carcinoma (KEYTRUDA®, 2019). 


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Treatment with docetaxel 75 mg/m2 every 21 days is widely used in lung, breast, prostate, 
bladder, and other cancers (TAXOTERE®, 2015).  
Treatment with gemcitabine 1000 mg/m2 + nab-paclitaxel 125 mg/m2 is widely used in treatment 
of metastatic pancreatic cancer (GEMZAR®, 2017 and ABRAXANE®, 2018). 
4.3. 
Treatment Assignment 
This is an open-label study with multiple arms. At times, multiple arms may be enrolling in 
parallel. Investigators are responsible for contacting the sponsor, or delegate, for treatment 
assignment before treating subjects with TTX-030. The sponsor will have records of the number 
of subjects treated within a specific cohort and will determine which treatment cohort to assign 
the newly enrolled subjects. 
Subject’s treatment assignment/randomization may be done in EDC or alternative randomization 
system upon enrollment confirmation by the sponsor or designee. Subjects in Arm 1 and 2 
Expansion Cohorts will be randomized (as described in Section 4.1.1.2). A separate instruction 
manual will be provided to each site. A subject is considered entered into the study once the 
investigator (or designee) confirms eligibility and notifies the sponsor that the subject is enrolled 
in the study.  
4.4. 
Dose Levels 
The doses for this trial will include a set of primary doses (0.5, 1.5, 3, 6, 10, 20, and 40 mg/kg) 
as well as several intermediate doses. As mentioned above, dose escalation (Arm 1) will be 
conducted according to a mCRM for doses up to 10 mg/kg and according to a 3 + 3 design for 
doses > 10 mg/kg. Not all dose levels may be explored as dose levels may be skipped during 
escalation based on mCRM recommendation. A detailed adaptive design and simulation report is 
included in Section 11.6. 
TTX-030 will first be evaluated as a single agent (Arm 1). Subjects will be enrolled into the 
study sequentially beginning with a single-subject cohort at 0.5 mg/kg. Beginning with 
1.5 mg/kg, subjects will be enrolled in dosing cohorts of 2 subjects each. If no Grade 2 toxicities 
(related to TTX-030) and no DLTs are observed, the trial may enroll 2 subjects each to the 
primary dose levels (1.5, 3, 6, 10, 20, and 40 mg/kg). Upon the first instance of a DLT or a 
Grade 2 or above toxicity that is related to TTX-030, that cohort and subsequent cohorts 
receiving higher doses will enroll at least 3 subjects each. Each dosing cohort must complete its 
DLT observation period (see Section 4.12 for discussion of DLT) of 1 cycle before enrollment of 
the next dosing cohort. 
Based on clinical data as of 10 Jan 2020, a loading dose of 40 mg/kg one week prior to Cycle 1, 
Day 1 followed by dosing of 30 mg/kg Q3W or 20 mg/kg Q2W has been established.  See 
Section 2.2.3 for RP2D dose selection details. 
Subjects who discontinue from the study for reasons other than a DLT (eg, noncompliance, 
subject request, or disease progression), and are not evaluable for at least a single complete cycle 
of TTX-030 as single agent or in combination, will be replaced. Subjects who discontinue after 
Cycle 1 will not be replaced. For the cohort expansion, subjects will not be replaced. 


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4.5. 
Dose Escalation and Safety Lead-In Arms 
Up to 43 subjects across 1 dose escalation and 2 safety lead-in arms are planned. The 3 arms are 
summarized in Table 8. 
Refer to Section 5 for details on subject eligibility. 
Table 8: 
Dose-Escalation and Safety Lead-In Arms 
Arm 
Monotherapy or 
Combination 
Therapy 
Examples 
of Eligible 
Indications 
Treatment 
Number of 
Subjects 
Dose-Escalation Arm 
1 
Monotherapy 
All tumors 
TTX-030 
Up to 21 
Safety Lead-In Arm 
2 
Anti-PD-1 
Combination 
Indicated 
tumors 
TTX-030 with pembrolizumab 
Up to 6 
4 
Chemotherapy 
Combination 
Pancreas 
TTX-030 with gemcitabine + 
nab-paclitaxel 
Up to 6 
Abbreviation: PD-1 = programmed cell death protein-1 
4.6. 
Dose Escalation Using Modified Continual Reassessment Method 
Dose escalation will be conducted according to the mCRM, with the aim of estimating the 
dose-toxicity relationship and determining the MTD. The MTD will be defined as the dose that 
has a model-estimated DLT rate closest to 30% and has less than 55% probability of a DLT rate 
higher than 30%. 
The starting dose for TTX-030 will be 0.5 mg/kg. Ascending IV doses of TTX-030 as a single 
agent will be administered to subjects on the first day of each 21-day treatment cycle. See 
Section 4.4 for dose levels. 
Subjects in Arm 1 will be enrolled sequentially beginning with a single subject at 0.5 mg/kg and 
followed by dosing cohorts of 2 subjects each. Upon the first instance of a DLT or a Grade 2 or 
above toxicity that is related to TTX-030, that cohort and subsequent cohorts receiving higher 
doses will be expanded to a minimum of 3 subjects each. 
Each dosing cohort must be completed through the DLT observation window before escalation 
can be allowed within its arm. After 1.5 mg/kg, untried dose levels may be skipped if they are 
deemed safe by the dose-toxicity model and are no more than a 100% increase (a doubling) from 
the current dose. If the dose-toxicity model (described in Section 4.8) deems the current dose to 
be unsafe and de-escalation is required, the dose will be decreased to the highest safe dose level. 
Thus, if no DLTs are observed in Arm 1, the trial would enroll 1 subject to 0.5 mg/kg followed 
by 2 subjects each to 1.5 mg/kg, 3 mg/kg, 6 mg/kg, 10 mg/kg, 20 mg/kg, and then proceed to the 
highest dose, 40 mg/kg. 
If the dose-toxicity model deems all doses up to 40 mg/kg to be safe, the Cohort Review 
Committee will have the option to dose escalate above 40 mg/kg, or a comparable flat dose, in 


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appropriate increments (no more than a 100% increase) if it is felt a higher dose would be safe 
and potentially beneficial to study subjects. 
4.7. 
Dose Escalation Using 3 + 3 Design 
Escalation of doses > 10 mg/kg will progress according to a traditional 3 + 3 design. This design 
proceeds with cohorts of 3 subjects; the first cohort is treated at the starting dose, and subsequent 
cohorts are treated at increasing dose levels. 
• If none of the 3 subjects in a cohort experiences a DLT, dose escalation may proceed 
to the next higher dose level (ie, another 3 subjects will be treated at the next higher 
dose level). 
• If 1 of the first 3 subjects in a cohort experiences a DLT, 3 more subjects will be 
treated at the same dose level. 
• Dose escalation continues until ≥ 2 subjects in a cohort of 3 to 6 subjects experience 
a DLT (ie, ≥ 33% of subjects with a DLT at that dose level). The MTD is defined as 
the dose level just below this toxic dose level. 
The recommended RP2D of TTX-030 was selected based on the overall safety/tolerability and 
available PK/pharmacodynamic data. The RP2D may or may not be the same as the MTD 
identified during dose escalation. For example, if the MTD is not reached despite increasing drug 
dose, or if exposure at the MTD is much higher than the level believed to be required for 
efficacy, or if subsequent cycles of treatment provide additional insight regarding the safety 
profile, then the RP2D may be a different dose. 
4.8. 
Dose-Toxicity Modeling 
Dose-toxicity modeling will be used to estimate the log-odds of a DLT across the dose levels and 
to guide dose recommendation. The model is a 2-parameter logistic regression model. Full 
details of the statistical model are provided in Section 11.6. 
4.9. 
Early Stopping 
The trial may be stopped early if all doses are considered unsafe (that is, if all doses have more 
than 55% probability that the DLT rate exceeds 30%). Conversely, the study may be stopped 
early for having sufficiently characterized the MTD if at least 6 subjects have been enrolled to 
the current highest safe dose level, have completed the DLT observation period, and additional 
dose escalation is not recommended. After the highest safe dose level is identified, the Cohort 
Review Committee will have the option to explore a comparable flat dose. 
4.10. 
Initiation of Safety Lead-In Combination Therapies (Arms 2 & 4) 
Enrollment into combination Arms 2 and 4 will be initiated once the RP2D of TTX-030 has been 
determined in monotherapy dose escalation in Arm 1. For each of Arms 2 and 4, the TTX-030 
starting dose will be the RP2D identified in Arm 1. 


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In Arm 2, eligible pembrolizumab-naive subjects and other eligible subjects with pembrolizumab 
experience may be entered into the study. Subjects who tolerated prior PD-(L)1-containing 
regimens, and now want to try a new PD-(L)1 regimen again, can enter. 
Treatment in Arm 4 is planned to be TTX-030 in combination with separate chemotherapy 
regimens used for selected malignancies. The chemotherapy regimens suggested for combination 
with TTX-030 will be considered standard of care for the planned subject populations in the 
respective arms. Pembrolizumab will not be included in Arm 4. 
In Arm 4, TTX-030 is planned to be administered with gemcitabine + nab-paclitaxel. 
In each safety lead-in cohort, all subjects will be treated and closely monitored for the occurrence 
of DLTs. If ≥ 2 of up to 6 subjects experience a DLT during the DLT period, the Cohort Review 
Committee will discuss whether dose de-escalation to a lower dose of TTX-030 will be evaluated 
as appropriate and if further addition of subjects is needed to re-assess the RP2D. 
4.11. 
Maximum Tolerated Dose and Recommended Phase 2 Dose 
Dose escalation (Arm 1) will be conducted according to a mCRM for doses up to 10 mg/kg and 
according to a 3 + 3 design for doses > 10 mg/kg, with the aim of estimating the dose-toxicity 
relationship and determining the MTD. The MTD will be defined as the dose that has a 
model-estimated DLT rate closest to 30% and has less than 55% probability of a DLT rate higher 
than 30%. Escalation will continue until the MTD has been determined for TTX-030 as a single 
agent or the highest dose level has been reached and deemed safe by the Cohort Review 
Committee using either the 3 + 3 design or mCRM. 
The RP2D may be defined as any dose level that is either explored using the mCRM or 3 + 3 
design or determined using PK modeling equal to or below the determined MTD. The RP2D 
determination may also depend on PK, pharmacodynamic, efficacy, and other safety data as well 
as the MTD.  
4.12. 
Definition of Dose-limiting Toxicity 
A DLT is defined as any clinically significant AE that occurs during Treatment Cycle 1 that the 
investigator or sponsor considers as possibly or likely related to TTX-030 as a single agent, or 
the combination of TTX-030 and other agent(s), and meets the following criteria: NCI CTCAE 
Version 5.0 Grade 5 event, Grade 4 hematological or ≥ Grade 3 non-hematological toxicities, or 
≥ Grade 3 irAEs. Laboratory abnormalities that are asymptomatic and deemed not clinically 
significant will not be regarded as a DLT, unless specified below. 
DLTs include the following: 
• Grade ≥ 3 neutropenia lasting ≥ 5 days 
• Any febrile neutropenia 
• Grade ≥ 3 thrombocytopenia with clinically significant hemorrhage 
• Grade 4 thrombocytopenia 
• Grade ≥ 3 non-hematologic adverse events, except the following 


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- 
Grade ≥ 3 nausea, vomiting, or diarrhea lasting < 72 hours in the absence of 
maximal medical therapy. 
- 
Grade ≥ 3 abnormal laboratory values that are not clinically significant and 
corrected within 72 hours 
- 
Grade ≥ 3 fatigue lasting < 5 days 
- 
Grade 3 aspartate aminotransferase (AST) or alanine aminotransferase (ALT) 
elevations lasting < 7 days 
- 
Grade 3 non-hepatic-related increases in alkaline phosphatase will not be 
considered a DLT 
• AST or ALT > 3 x upper limit of normal (ULN) (> 2 x baseline AND > 3 x ULN in 
subjects with baseline elevation) AND total bilirubin > 2 x ULN (> 2 x baseline AND 
> 2 x ULN in subjects with baseline elevation) or clinical jaundice, without initial 
findings of cholestasis AND no other immediately apparent identifiable possible 
causes of elevated liver enzymes and hyperbilirubinemia 
Safety data will be evaluated by the Cohort Review Committee (described in Section 4.1.2). 
Delayed DLTs will be evaluated on a case-by-case basis. If 2 or more delayed DLTs are noted 
within a dose-escalation/safety lead-in arms, further accrual will be held pending safety analysis 
of the AEs and will be restarted only with Cohort Review Committee review and approval. For 
the Q3W dose escalation dosing schedule, the cycle length is 3 weeks and the DLT period will 
be the first cycle (21 days). For the safety lead-in Q2W dosing schedule, the cycle length is 4 
weeks and the DLT period will be the first cycle (28 days) plus a 7-day of loading dose. 
For the safety lead-in Q3W dosing schedule, the cycle length is 3 weeks and the DLT period will 
be the first cycle (21 days) plus a 7-day of loading dose. 
The DLT must either return to the baseline level at which the subject was enrolled or to a 
Grade 1 or less prior to subsequent administration of TTX-030 or a TTX-030 combination. 
If an AE does not meet the DLT criteria but is deemed clinically significant and one that can 
require a change in the dosing interval, then the investigator is asked to contact the medical 
monitor to develop a subject management plan. With mutual agreement, such a case may lead to 
the dosing interval being prolonged for an additional 21 days without the AE being deemed a 
DLT. If the AE leads to the dosing interval being extended beyond the additional 21 days, then 
the event will be deemed a DLT. 
4.13. 
Dosing Delays 
During the dose-escalation/safety lead-in period, prolonging infusion times and treatment delays 
are allowed in response to treatment toxicity. Delays of more than one month necessitate medical 
monitor discussion and approval for continuation of therapy. 
Any necessary interim visits will be captured as unscheduled visits on the electronic case report 
form (eCRF). 


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If toxicity is attributed by the investigator as likely related to TTX-030, the administration of 
TTX-030 should be managed per Table 9. The dose adjustment criteria apply whether TTX-030 
is administered as a single agent or in combination therapy. Please refer to Section 8.3.6.5 for 
details on adverse events of special interest, including immune-related adverse event (irAE) 
management. 
4.14. 
Safety Criteria for Adjustment or Stopping Doses 
If toxicity is attributed by the investigator as likely related to TTX-030, the administration of 
TTX-030 should be managed per Table 9. The dose adjustment criteria apply whether TTX-030 
is administered as a single agent or in combination therapy. Please refer to Section 8.3.6.5 for 
details on toxicity management, including irAE management. 
If toxicity is attributed by the investigator as likely related to chemotherapy in the combination 
arms, and unlikely related to TTX-030, the subject should be medically managed per standard of 
care, and the dose and schedule of chemotherapy should be managed per institutional guidelines. 
Administration of TTX-030 may continue as long as the investigator feels TTX-030 is unlikely 
contributing to toxicity. If the subject continues to experience significant toxicities despite 
medical management and after dose/schedule adjustment of chemotherapy, then TTX-030 must 
be managed per Table 9. 
If an irAE is observed in Arm 2, the AE should be attributed to the combination of 
pembrolizumab and TTX-030, and not pembrolizumab alone. Management of pembrolizumab 
dosing should follow institutional guidelines. Management of TTX-030 should follow Table 9. 
Table 9: 
Criteria for Adjusting or Stopping Doses of TTX-030 
Management/Next Dose for TTX-030 
≤ Grade 1 
No change in dose; medical management per standard of care. 
Grade 2 
If Grade 2 AE despite medical management, hold TTX-030 until ≤ Grade 1. 
Resume at same dose level. 
Grade 3 
If Grade 3 AE despite medical management, hold TTX-030. Discontinuation 
or dose modification to be determined by investigator and Cohort Review 
Committee on a case-by-case basis. 
Grade 4 
Discontinue TTX-030. 
4.15. 
Pharmacokinetic Criteria for Adjustment or Stopping Doses 
Toxicity-based dose escalation/safety lead-in decisions may depend on PK parameters like Cmax, 
Cmin, and AUC that correlate with desired target stimulation or suppression. For example, Cmax 
may correlate with toxicity and t1/2 may predict recovery from toxicity. Available PK data will be 
reviewed by the Cohort Review Committee but is not required for dose escalation/safety lead-in 
decisions. 
4.16. 
Intra-subject Dose Escalation 
Subjects in their Treatment Extension Period may be eligible to receive study treatment at a 
higher dose level that has been deemed safe. If there are multiple successful dose escalations 


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throughout the study, subjects who started with lower doses may be eligible for multiple 
intra-subject dose escalations up to 40 mg/kg. Each case of intra-subject dose escalation must be 
approved by the Cohort Review Committee (Section 4.1.2) and may not exceed the current 
highest dose level deemed safe. The first subject treated on the study at 0.5 mg/kg is the 
exception; in the absence of toxicity during their first cycle, the subject may initiate doses of 
1.5 mg/kg Q3W without prior approval from the Cohort Review Committee. 
Safety data from intra-subject dose escalation will not be assessed by the mCRM or 3 + 3 
method but will be reviewed and assessed by the Cohort Review Committee. 
4.17. 
Expansion Arms 
Upon completion of dose escalation (Arm 1) and safety lead-in (Arms 2 and 4), each arm may 
have the option to enroll additional subjects per expansion cohort at the RP2D. Arm 1 and Arm 2 
Expansion Cohorts will enroll an additional 50 total subjects (25 per randomized treatment arm), 
and Expansion Arm 4 will enroll up to 20 subjects. The number of subjects evaluated in the 
safety lead-in of Arm 4 may count toward the total number of subjects in an expansion arm. The 
sponsor will determine the eligible patient population for each expansion cohort after discussion 
with the Cohort Review Committee. Each dose-escalation and safety lead-in arm may lead to 
more than one expansion cohort if different patient populations will be studied. 
Monitoring of all safety and toxicity data are performed by the investigator and the Cohort 
Review Committee. The Cohort Review Committee may choose to apply safety knowledge 
gained from any arm or cohort to more conservatively manage other arms or cohorts. 
4.18. 
Retreatment Criteria 
After safely completing the Study Treatment Period, each subject may continue to receive dosing 
during the Treatment Extension Period until discontinuation for any reason. Upon 
discontinuation, the subject has a Post-treatment Period that includes an End of Treatment (EOT) 
Visit, and post-treatment evaluations, including both follow-up safety and survival contact 
(Table 2 and Table 4). 
Arm 1 dose escalation has a 21-day cycle. 
Arm 1 Expansion and Arm 2 have a 21-day cycle plus a 7-day of loading dose. 
Arm 4 has a 28-day cycle plus a 7-day of loading dose. 
4.19. 
Follow-Up Safety and Survival Contact 
Subjects will be followed for a minimum of 30 days from the last dose of TTX-030 (EOT Visit). 
Scheduled follow-up safety contact will be scheduled for 60 and 90 days after the last dose and a 
follow-up survival contact will be scheduled for 180 days after the last dose. 
Subjects removed from study for unacceptable AE(s) will be followed until resolution or 
stabilization of the AE. 


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4.20. 
Study Completion 
A subject is considered to have completed the study if he or she has completed the 
protocol-defined activities for the EOT Visit shown in the Schedule of Activities (Table 2 and 
Table 4). 


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5. 
Study Population 
5.1. 
Target Population and Arm-Specific Eligibility Criteria 
Arm 1 (Escalation): Single-Agent TTX-030 Q3W 
1. Histologically confirmed diagnosis of unresectable or metastatic solid tumor malignancy, 
or relapsed/refractory lymphoma, for which all standard therapies have been previously 
given. 
2. Meets all Common Inclusion and Exclusion Criteria below. 
Arm 2 (Safety Lead-In): Pembrolizumab 200 mg Q3W + TTX-030 Q3W 
3. Histologically confirmed diagnosis of unresectable or metastatic solid tumor malignancy, 
or relapsed/refractory lymphoma. 
4. Subjects must fulfill one of the following criteria: 
a) Eligible to receive single-agent pembrolizumab as standard of care. 
b) Received prior anti-PD-(L)1 containing regimen and had refractory or relapsed 
disease, for which all standard therapies have been previously given. 
5. Subjects who experienced immune-related or other AEs on prior anti-PD-(L)1 therapy 
that required discontinuation or modification are not eligible for this study. 
6. Meets all Common Inclusion and Exclusion Criteria listed below. 
Arm 1 and 2 Expansion Cohorts 
Randomized 1:1 to TTX-030 Q3W or TTX-030 Q3W + Pembrolizumab 200 mg Q3W 
7. Histologically or cytologically confirmed diagnosis of advanced (not amenable to 
curative surgery or radiation therapy) or metastatic (AJCC stage IV) RCC with a 
clear-cell component. 
8. Failed any anti-PD-(L)1 and TKI agents. Subjects refractory/relapsed to an anti-PD-(L)1-
containing regimen must have confirmed radiographic disease progression no earlier than 
4 weeks after initial disease progression.  
Arm 4 (Safety Lead-In and Expansion): Gemcitabine 1000 mg/m2 + nab-paclitaxel 
125 mg/m2 Days 1, 8, and 15 every 28 days + TTX-030 Q2W 
9. Histologically or cytologically confirmed diagnosis of locally advanced, unresectable, or 
metastatic pancreatic adenocarcinoma. 
10. Naïve to any prior treatment for metastatic disease. Prior adjuvant therapy (including 
chemotherapy and/or radiotherapy) is permitted if neoadjuvant or adjuvant therapy was 
completed at least 6 months prior to study enrollment.  
11. Eligible to receive gemcitabine + nab-paclitaxel as standard of care. 
12. Meets all Common Inclusion and Exclusion Criteria listed below. 


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All Expansion Cohorts 
13. At least one tumor site (primary or metastasis) that is amenable to biopsy, and subject 
must be willing to consent for both pretreatment (screening) and on-treatment biopsy. 
14. Meets eligibility criteria for subject population(s) specified by sponsor. 
15. Meets all Common Inclusion and Exclusion Criteria listed below. 
5.2. 
Common Inclusion Criteria 
16. Age 18 years or older and is willing and able to provide informed consent. 
17. Fresh and/or archival tumor tissue is optional for dose-escalation; fresh and/or archival 
tumor biopsies at screening and on-treatment are mandatory for safety lead-in arms and 
expansion cohorts. 
18. Evidence of measurable disease by CT, CT-positron-emission tomography (PET-CT) for 
dose escalation only, or MRI. (NOTE: Subjects with prostate cancer may instead have 
evaluable disease using bone scan per PCWG3 criteria and are not required to have 
Response Evaluation Criteria in Solid Tumors [RECIST] measurable disease.) 
19. Life expectancy > 12 weeks. 
20. Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 1 (see 
Appendix 2). 
21. Demonstrated adequate organ function, including: 
a. Oxygen saturation ≥ 92% on room air. 
b. Absolute neutrophil count ≥ 1.5 k/μL, platelets (PLT) ≥ 75 k/μL (PLT ≥ 100 k/μL 
required for chemotherapy arms), and hemoglobin (Hgb) ≥ 8 g/dL (Hgb ≥ 9 g/dL 
for chemotherapy arms). NOTE: Prior red blood cell transfusion is allowed. 
c. Serum creatinine ≤ 1.5 x ULN or creatinine clearance ≥ 40 mL/min. 
d. AST/ALT ≤ 3 x ULN (or ≤ 5 x ULN with liver metastases). 
e. Total bilirubin ≤ 1.5 x ULN (or ≤ 3 x ULN with Gilbert’s syndrome). 
f. Prothrombin time (PT)/international normalized ratio (INR) and activated partial 
thromboplastin time (aPTT) ≤ 1.2 x ULN; fibrinogen ≥ 150 mg/dL. 
22. At least 14 days since last dose of chemotherapy or biological therapy, or tyrosine kinase 
inhibitor or high-dose (eg, > 10 mg prednisone or equivalent) steroid therapy prior to first 
dose of study treatment. 
23. Resolution of adverse effects from any prior chemotherapy, immunotherapy, or prior 
systemic anti-cancer therapy, radiotherapy, or surgery to Grade 1 or baseline (except 
Grade 2 alopecia and Grade 2 sensory neuropathy). 
24. Women of childbearing potential and all men must agree to use highly effective methods 
of birth control through 120 days after the last dose of study treatment. 
NOTE: Highly effective contraception methods include: 


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- 
Total abstinence 
- 
Female sterilization (tubal ligation, bilateral oophorectomy, and/or 
hysterectomy) 
- 
Male sterilization, at least 6 months prior to screening 
- 
Intrauterine device 
- 
Oral, injected, or implanted hormonal contraception AND barrier methods of 
contraception 
25. Willing to comply with and able to tolerate study procedures. 
5.3. 
Common Exclusion Criteria  
26. History of allergy or hypersensitivity to study treatment components. Subjects with a 
history of severe hypersensitivity reaction to any mAb should also be excluded. 
27. Use of investigational agent within 14 days prior to the first dose of study treatment and 
throughout the study. 
28. Prior surgery or radiotherapy within 14 days of study treatment. 
29. Receiving high-dose (eg, > 10 mg prednisone or equivalent) systemic steroid therapy or 
any other form of immunosuppressive therapy within 14 days prior to the first dose of 
study treatment. NOTE: inhaled, intranasal, intraocular, topical, and intraarticular steroids 
are allowed. Transient steroid administration as anti-emetic or chemotherapy 
preconditioning (eg, for paclitaxel) is allowed per institutional guidelines. 
30. Receiving therapeutic anticoagulation. NOTE: Low molecular weight heparin, Factor Xa 
inhibitors, and low-dose aspirin are allowed for deep vein thrombosis (DVT) prophylaxis. 
31. History of autoimmune disease requiring systemic treatment or transplant that requires 
systemic steroids or immunosuppressive agents. NOTE: History of vitiligo, autoimmune 
thyroiditis, or mild psoriasis is allowed. 
32. Subjects who are on steroids for any irAE that has not resolved, Grade 3 or higher irAE, 
and ocular or neurologic toxicity of any grade.  
33. Known history of human immunodeficiency virus or other chronic immunodeficiency. 
34. Uncontrolled intercurrent illness including, but not limited to: 
a. Uncontrolled diabetes with hemoglobin A1c (HgbA1c) ≥ 8.0% 
b. Ongoing or active bacterial, viral, or fungal infection requiring systemic treatment 
c. Clinically significant congestive heart failure defined by New York Heart 
Association Class 3 or Class 4 
d. Unstable angina, arrhythmia, or myocardial infarction within 6 months prior to 
screening 
35. Known brain metastases or central nervous system (CNS) involvement. NOTE: Subjects 
with asymptomatic and stable brain metastases following prior treatment may be eligible. 
36. Other active malignancy requiring ongoing treatment. 


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37. Women who are pregnant or breastfeeding. 
38. For Arm 1 and 2 Expansion Cohorts only (Renal Cell Cancer): 
a.  Subjects with Lactate Dehydrogenase (LDH) ≥ 1.5x ULN  
5.4. 
Screen Failures 
Screen failures are defined as subjects who consent to participate in the clinical study but are not 
subsequently entered/enrolled in the study. A minimal set of screen failure information is 
required to ensure transparent reporting of screen failure subjects to meet the Consolidated 
Standards of Reporting Trials publishing requirements and to respond to queries from regulatory 
authorities. Minimal information includes date of screening, informed consent, reason for screen 
failure (eg, eligibility criteria), and any SAEs. 
Individuals who do not meet the criteria for participation in this study (screen failure) may be 
rescreened. 
5.5. 
Subject Adherence to Protocol Schedule 
General study instructions to be discussed or provided by the study staff: 
• Subjects must use highly effective birth control. 
o Women of childbearing potential and all men should be counseled and must 
agree to use highly effective birth control during treatment through 120 days 
after the last dose of study treatment. 
• Subjects may not receive other investigational or approved anti-cancer therapy while 
participating in this trial. 
• Subjects must come to the clinic on days defined in Table 1/Table 2, and Table 
3/Table 4 for study test procedures and post-study follow-up contact information. 
• From the first dose of TTX-030 until all procedures are completed on Cycle 2 Day 1, 
subjects should be instructed not to change their concomitant medications to the 
extent possible. 
• On dosing days, subjects should be discharged from the clinic with directions on 
self-administration of medications as needed to ameliorate potential delayed reactions 
(which should be described) to study treatment infusion. 
• Subjects should report any concerns of pregnancy immediately. 


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6. 
Investigational Product 
6.1. 
Investigational Product Description and Administration 
6.1.1. 
Investigational Product Description 
The investigational formulation of TTX-030 will be supplied as a sterile, single-use, 
preservative-free liquid containing 200 mg of antibody (Table 10). The dosage form of TTX-030 
is a clear, colorless liquid formulation containing 30 mg/mL of TTX-030 in 10 mM sodium 
citrate, 280 mM sucrose, 0.02% polysorbate 20, and 1.0 mM methionine, with a pH of 6.5. The 
liquid TTX-030 will be filled into a Type 1 glass serum vial with an elastomeric stopper and 
aluminum over seal with a plastic flip top. The fill volume will be 6.7 mL in a 10-cc glass vial 
stored at temperatures of 2°C to 8°C. TTX-030 will be administered IV Q3W, Q2W, or Q4W 
depending on the study arm. 
Table 10:  
Investigational Product 
Product name: 
TTX-030 
Dosage form: 
injection, solution in a vial 
Unit dose: 
200 mg/15 mL (30 mg/mL) 
Route of administration: 
intravenous infusion 
Physical description: 
clear liquid in a serum vial with an elastomeric stopper 
Manufacturer: 
ProBioGen AG 
6.1.2. 
Other Study Treatments 
TTX-030 will be administered in combination with standard of care regimens for selected 
malignancies (Table 8). Sites will obtain approved agents listed in Table 11 for combination 
therapy with TTX-030. Pembrolizumab will be provided by Trishula.  
6.1.3. 
Investigational Product Administration 
TTX-030 can be administered in an outpatient setting. The infusion should be administered 
under the supervision of a physician. Doses will be administered through an IV line controlled by 
a volumetric pump. TTX-030 should not be co-administered with other medications through the 
same IV line during the TTX-030 infusion. TTX-030 doses of ≤ 20 mg/kg should be infused 
over 30 to 60 minutes, and TTX-030 doses of > 20 mg/kg may be infused over 60 minutes (see 
Pharmacy Manual for details), unless otherwise revised by the study’s Cohort Review 
Committee. Subjects should be monitored for any infusion-related AEs for 8 hours after the first 
dose and for 1 hour after subsequent doses. If an infusion-related reaction (IRR) of Grade 3 or 
above occurs, the medical monitor should be contacted prior to any further subject dosing. It is 
recommended to have vital signs check every 1-hour for 4 hours and then every 2-hour based on 
clinical conditions. Vital signs monitoring at subsequent dosing visits may occur as per 
Investigator’s discretion. 
Monitoring of the subject should include blood pressure, pulse, temperature, respirations, and 
pulse oximetry. Additionally, subjects should be monitored for infusion-related reactions such as 


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rash, acute allergic reaction, bronchospasm, respiratory distress, and acute vascular leak 
syndrome. 
Treatment will be administered as presented in Table 11. Subjects in any combination treatment 
arm may receive premedication according to institutional practice. 
Table 11: 
Treatment Regimen Description 
Arm 
Treatment 
Dose 
Route 
Schedule 
1a 
TTX-030 
Loading dose 
40 mg/kg 
IVb 
Day -7 
1 
TTX-030 
30 mg/kg 
IVb  
Q3W 
2a 
TTX-030 
Loading dose 
40 mg/kg 
IVb 
Day -7 
2 
TTX-030 
30 mg/kg 
IVb  
 
Q3W 
2 
Pembrolizumab 
200 mg 
IVb,  
60 minutes after TTX-030 
Q3W 
4a 
TTX-030 
Loading dose 
40 mg/kg 
IVb 
Day -7 
4 
TTX-030 
20 mg/kg 
IVb,  
prior to nab-paclitaxel 
Q2W 
Days 1 and 15 of 
each 28-day cycle 
4 
Nab-paclitaxel 
125 mg/m2 
IV over 30-40 minutes,  
60 minutes after TTX-030 and prior 
to gemcitabine 
Days 1, 8, and 15 of 
each 28-day cycle 
4 
Gemcitabine 
1000 mg/m2 
IV over 30-40 minutes, 
immediately after nab-paclitaxel  
Days 1, 8, and 15 of 
each 28-day cycle 
Abbreviations: IV = intravenous, Q = every, RP2D = recommended Phase 2 dose, W = week(s). 
a 
A loading dose of TTX-030 40 mg/kg is to administer on Day -7 prior to Cycle 1 Day 1. 
b 
Refer to the Pharmacy Manual for dosing instruction. Infusion duration is dependent on subject’s weight 
and IV bag size and may be longer than 60 minutes. 
6.2. 
Preparation/Handling/Storage/Accountability 
The study treatment will be administered by the study personnel; the day and time of study 
treatment administration will be recorded by the study personnel. 
6.2.1. 
Study Treatment Packaging and Labeling 
The study treatment will be packaged and labeled according to current Good Manufacturing 
Practice. Details of the packaging and labeling of clinical supplies may be found in the pharmacy 
manual. 
6.2.2. 
Study Treatment Storage 
Cartons will be used for secondary packaging. Each carton will be labeled per regulations with 
the product name, product lot number, recommended storage condition, manufacturer, and the 
Federal Caution Statement “Caution: New Drug – Limited by Federal (US) Law to 
Investigational Use Only.” The sponsor’s name and address will also be included. 


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TTX-030 vials must be stored at a temperature of 2°C to 8°C and should be protected from light 
and freezing. If stored in a glass-front refrigerator, vials should be stored in the carton. 
Recommended safety measures for preparation and handling of TTX-030 include laboratory 
coats and gloves. After TTX-030 has been prepared for administration, the total storage time 
(combination of refrigeration and room temperature) is not to exceed 4 hours. 
The product storage manager should ensure that the study treatment is stored in accordance with 
the environmental conditions (temperature, light, and humidity) as determined by the sponsor. If 
concerns regarding the quality or appearance of the study treatment arise, do not dispense the 
study treatment and contact the sponsor immediately. 
6.2.3. 
Study Treatment Preparation 
Steps for preparing the study treatment are provided in the pharmacy manual. 
6.2.4. 
Study Treatment Accountability 
The study treatment is to be used only as directed by this protocol. Clinical supplies are not to be 
dispensed to any individual who is not enrolled in the study. An accurate and timely record of the 
receipt of all clinical supplies and dispensing of study treatment to the subject will be 
maintained. This may include (a) documentation of receipt of clinical supplies, (b) study 
treatment dispensing/return reconciliation log, (c) study treatment accountability log, and (d) all 
shipping service receipts. 
6.2.5. 
Study Treatment Handling and Disposal 
If study treatments (those supplied by the sponsor or sourced by the investigator) are to be 
destroyed on site, it is the investigator’s responsibility to ensure that arrangements have been 
made for the disposal; procedures for proper disposal have been established according to 
applicable regulations, guidelines, and institutional procedures; and appropriate records of the 
disposal have been documented. The unused study treatment may be destroyed only after being 
inspected and reconciled by the responsible study monitor. 
6.3. 
Measures to Minimize Bias: Randomization and Blinding 
Only subjects in Arm 1 and Arm 2 Expansion Cohorts will be randomized (as described in 
Section 4.1.1.2) and treatment assignment will occur as described in Section 4.3.  
This is an open-label study. 
6.4. 
Treatment Compliance 
The study treatment will be administered by the study personnel; the day and time of study 
treatment administration will be recorded by the study personnel. 


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6.5. 
Concomitant Therapy 
6.5.1. 
Concomitant Medications Allowed During the Study 
On dosing days, subjects should be discharged from the clinic with directions on 
self-administration of medications as needed to ameliorate potential delayed reactions to study 
treatment infusion, such as fever, chills, and myalgia. Medications may include antipyretics and 
antihistamines. All concomitant medications, including self-administered medications, are to be 
recorded. Concomitant medications are to be collected from screening through 30 days after the 
last dose of study treatment. 
Inhaled, intranasal, intraocular, topical, and intraarticular steroids are allowed. Transient steroid 
administration as anti-emetic or chemotherapy preconditioning (eg, for paclitaxel) is allowed per 
institutional guidelines. Supportive care may be given as indicated after a subject experiences 
nausea, vomiting, fever, or diarrhea while on study treatment. Use of supportive care agents must 
be recorded. Prednisone doses ≤ 10 mg (physiological doses) are permitted.  
Supportive treatments that are indicated for treatment of AEs should be given as medically 
required. Standard supportive medications may be used such as hematopoietic growth factors to 
treat neutropenia or thrombocytopenia in accordance with American Society for Clinical 
Oncology guidelines. 
Concomitant medications may be necessary in the event of an acute infusion-related reaction, 
cytokine release syndrome, or another AE as detailed in Section 8.3.6.5.4. 
Low molecular weight heparin, Factor Xa inhibitors, and low-dose aspirin are allowed for DVT 
prophylaxis. 
6.5.2. 
Concomitant Medications Prohibited During the Study 
Concomitant treatments or procedures with any of the following are not allowed while the 
subject is receiving study treatment, unless approved by the sponsor, or as otherwise described in 
the protocol: 
• Any alternative drug treatments or procedures directed toward the treatment of solid 
tumors, including immunotherapy, chemotherapy, and radiation therapy. NOTE: 
Palliative radiation may be allowed during trial on a case-by-case basis – please 
discuss with the medical monitor. 
• Any investigational product, including investigational symptomatic treatment or 
procedures for solid tumors and investigational treatment or procedures for 
non-cancer indications. 
Any concomitant treatment or procedure required for the subject’s welfare may be given by the 
investigator. However, it is the responsibility of the investigator to ensure that details regarding 
the treatment or procedure are to be recorded. 


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7. 
Discontinuation of Study Treatment and Subject Discontinuation 
7.1. 
Discontinuation of Study Treatment 
Treatment with TTX-030 may continue until precluded by toxicity, progression, or death. 
For combination arms, if a subject discontinues the pembrolizumab or chemotherapy regimens, 
treatment with TTX-030 may continue if it remains well tolerated and if approved by the 
investigator and sponsor. 
For all arms, in the absence of treatment delays due to AE(s), treatment may continue until 1 of 
the following criteria applies: 
• Disease progression (includes radiological or clinical progression). 
• Intercurrent illness that prevents further administration of treatment 
• Unacceptable AE 
• Subject decides to withdraw from the study 
• General or specific changes in the subject's condition that render the subject 
unacceptable for further treatment in the judgment of the investigator 
• Subject non-compliance 
• Pregnancy 
o All women of childbearing potential should be instructed to contact the 
investigator immediately if they suspect they might be pregnant (eg, missed 
or late menstrual period) at any time during study participation 
(see Section 8.3.6.4 for reporting requirements) 
• Termination of the study by sponsor 
• The drug manufacturer can no longer provide the study treatment 
The reason(s) for protocol therapy discontinuation, the reason(s) for study removal, and the 
corresponding dates must be documented in the eCRF. 
7.2. 
Subject Discontinuation/Withdrawal from the Study 
Any subject can withdraw from the trial at any time. 
Reasons why a subject may discontinue or be withdrawn from the study include lack of efficacy, 
AE, DLT, death, withdrawal by subject, physician decision, study terminated by sponsor, 
protocol deviation, pregnancy, lost to follow-up, or other reasons not otherwise specified within 
this list. 
When a subject discontinues or is withdrawn from the study after receiving ≥ 1 dose of study 
treatment, the investigator will, when possible, perform the procedures indicated for the EOT 
Visit (Table 2 and Table 4). 
The Sponsor may terminate enrollment into Arm 1 of the Expansion Cohort (i.e. TTX-030 
monotherapy, see Section 4.1.1.2) should there be evidence of a lack of efficacy. The totality of 


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available data will be used to make this determination, however, should zero responders be seen 
out of the first 16 subjects the 90% one-sided confidence interval (using exact methods) excludes 
a responder rate of 13.4% or more. 
Subjects who have been consented or randomized into Arm 1 before the termination will 
continue to receive study treatment as per protocol.  
7.3. 
Lost to Follow-up 
A subject will be considered lost to follow-up if he or she repeatedly fails to return for scheduled 
visits and is unable to be contacted by the study site. 
The following actions must be taken if a subject fails to return to the clinic for a required study 
visit: 
• 
The site must attempt to contact the subject and reschedule the missed visit as soon as 
possible and counsel the subject on the importance of maintaining the assigned visit 
schedule and ascertain whether or not the subject wishes to and/or should continue in 
the study. 
• 
Before a subject is deemed lost to follow-up, the investigator or designee must make 
every effort to regain contact with the subject (where possible, 3 telephone calls and, if 
necessary, a certified letter to the subject’s last known mailing address or local 
equivalent methods). These contact attempts should be documented in the subject’s 
medical record. 
• 
Should the subject continue to be unreachable, he/she will be considered to have 
withdrawn from the study.  


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8. 
Study Assessments and Procedures 
All screening and baseline assessments must be performed prior to loading dose/first dose of 
TTX-030. 
Assessments done up to 3 days prior to the loading dose do not need to be repeated. Assessment 
results must be deemed acceptable before the subject is cleared to receive the first dose of study 
treatment. 
Unless otherwise indicated, laboratory test collections are to be performed before the start of 
study treatment infusion on infusion days.  
COVID-19 guidance from applicable local regulatory authorities will be followed as 
necessary during the study in order to ensure subject safety. Variance from the study 
assessments schedule may be permitted at the Sponsor’s discretion in consultation with the 
Investigator and will be documented accordingly. 
After safely completing the Study Treatment Period, each subject may continue to receive dosing 
during the Treatment Extension Period until discontinuation for any reason. Upon 
discontinuation, the subject has a Post-treatment Period that includes an EOT Visit, and 
post-treatment evaluations including both follow-up safety and survival contact (Table 1/Table 2, 
and Table 3/Table 4). 
• Arm 1 (dose escalation) has a 21-day cycle (Q3W). 
• Arms 1 and 2 expansion have a 21-day cycle (Q3W) plus a 7-day of loading dose. 
• Arm 4 has a 28-day cycle (Q2W) plus a 7-day of loading dose.  
8.1. 
Study Visits 
8.1.1. 
Study Visits for Arms 1 and 2 Safety Lead-in and Expansion 
• Arm 1 treatment is TTX-030 as a single agent. 
• Arm 2 treatment is TTX-030 and pembrolizumab. 
Overview of Study Periods for Arms 1 and 2 (21-Day Cycle) 
Pretreatment Period 
Pretreatment consists of screening (up to 28 days prior to loading dose/first dose) and baseline 
(up to 3 days prior to loading dose/first dose). 
Study Treatment and Treatment Extension Period 
• A loading dose of TTX-030 40 mg/kg is to administer on Day -7 prior to Cycle 1 Day 1. 
• After the loading dose, TTX-030 30 mg/kg will be administered every 21 days, on Day 1 
of each cycle.  
• Cycle 1 includes assessments on Day 1, Cycle 1 Day 1 (C1D1) (dosing), Day 2, C1D2; 
Day 3, C1D3; Day 8, C1D8; and Day 15, C1D15. 


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• Cycle 2 includes assessments on Day 22 + 2 days, C2D1 (dosing) and Day 29 ± 2 days, 
C2D8. 
• Treatment Extension Period begins with Cycle 3, with treatment on Day 43 ± 2 days, 
C3D1 (dosing), followed by Cycles 4+, Day 64 ± 2 days, C4D1 (dosing), and every 
21 days thereafter, with dosing on Day 1 of each subsequent cycle. 
Post-treatment Period 
• The Post-treatment Period includes the EOT Visit at 30 ± 7 days after the last dose, 
follow-up safety contact at 60 and 90 ± 7 days and a follow-up survival contact at 
180 ± 15 days after last dose. 
8.1.2. 
Study Visits for Arm 4 (TTX-030 Q2W, 28-Day Cycle) 
Arm 4 treatment is TTX-030 and nab-paclitaxel + gemcitabine. 
Overview of Study Periods for Arm 4 (28-Day Cycle) 
Pretreatment Period 
Pretreatment consists of screening (up to 28 days prior to loading dose/first dose) and baseline 
(up to 3 days prior to loading dose/first dose). 
Study Treatment and Treatment Extension Period 
• A loading dose of TTX-030 40 mg/kg is to administer on Day -7 prior to Cycle 1 Day 
1. 
• After the loading dose, TTX-030 20 mg/kg will be administered every 14 days, on 
Day 1 and Day 15 of each cycle.  
• Cycle 1 includes assessments on Day 1, C1D1 (dosing); Day 2, C1D2; Day 3, C1D3; 
Day 8, C1D8 (Gem/NP dosing only); Day 15, C1D15 (dosing); and Day 22, C1D22. 
• Treatment Extension begins with Cycle 2, with treatment on Day 29 + 2 days, C2D1 
(dosing), Day 36 ± 2 days, C2D8 (Gem/NP dosing only) and Day 43 ± 2 days, 
C2D15 (dosing), and every 14 days thereafter, with TTX-030 dosing on Day 1 and 
Day 15 of each subsequent cycle. 
• Treatment Extension continues with Cycle 3, with treatment on Day 57 ± 2 days, 
C3D1 (dosing), Day 64 ± 2 days, C3D8 (Gem/NP dosing only) and Day 71 ± 2 days 
C3D15 (dosing), followed by Cycles 4+, with treatment on Days 1, 8 (Gem/NP 
dosing only) and 15 thereafter. 
Post-treatment Period 
• The Post-treatment Period includes the EOT Visit at 30 ± 7 days after the last dose, 
follow-up safety contact at 60 and 90 ± 7 days, and a follow-up survival contact at 
180 ± 15 days after last dose. 


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8.2. 
Efficacy Assessments 
8.2.1. 
Tumor Assessment/Tumor Response Assessment 
Tumor response assessments will be performed as scheduled in Table 1/Table 2, and Table 
3/Table 4.  
Radiological assessments for subjects with solid tumors include CT scans of the chest, abdomen, 
and pelvis unless contraindicated. Subjects with prostate cancer will also require bone scans. 
Subjects with lymphoma may be assessed with CT or PET-CT; however, the method for each 
subject’s radiology assessments should remain consistent.  
8.2.1.1. 
Criteria for Response Assessment for Solid Tumors 
To evaluate early signs of activity, iRECIST will be used for solid tumors. Response criteria to 
be determined by the investigator are found in Appendix 3 (Section 11.3).  
Additional response criteria for subjects with prostate cancer are found in Appendix 4 
(Section 11.4).  
Lymphoma will be assessed per LYRIC (see Section 8.2.1.2).   
For immunotherapeutics, response assessment may be confounded by a delayed onset of clinical 
effect of these agents allowing for early tumor growth or even the appearance of new lesions 
known as pseudo-progression. Efforts have been made to modify standard response criteria to 
account for the impact of immunotherapeutics on anti-tumor activity with the utilization of 
iRECIST for solid tumor and LYRIC for lymphoma to evaluate tumor response.  
In an attempt to apply response criteria and optimize response assessments with the use of 
immunotherapeutics, the RECIST Version 1.1 criteria have been modified to include an 
immune-related progressive disease response category in iRECIST. The addition of the immune 
response (IR) category to the more standard RECIST for solid tumors may provide information 
to the immune response as well as distinguish delayed responses and capturing pseudo 
progression (flare reaction). A comparison of RECIST and iRECIST response criteria for solid 
tumor is provided in Section 11.3 (Appendix 3). 
8.2.1.2. 
Criteria for Response Assessment for Lymphoma 
Subjects with lymphoma should have their response assessments conducted per LYRIC. 
Response criteria to be determined by the investigator are found in Section 11.5 (Appendix 5). 
The current Lugano criteria have been used for more traditional therapies in lymphoma. The 
proposed provisional modification, LYRIC, for immunomodulatory agents has introduced the 
term “IR”. The term “IR” does not make a direct reference to the underlying mechanism, 
acknowledging that both a delayed response and an immune-mediated flare (“pseudo 
progression”) can occur in the early treatment period and may be challenging to differentiate 
from progression by physical examination or imaging alone. The term provides the flexibility to 
allow subjects to continue treatment past IR in some circumstances with a mandatory subsequent 
evaluation within 12 weeks to confirm or refute true progressive disease. 


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A comparison of response based on PET-CT and CT evaluations is provided in Section 11.5 
(Appendix 5). Exceptions to Lugano for the LYRIC response assessments accounting for a 
development of a flare reaction (“pseudo-progression”) and a true progressive disease are 
provided in Section 11.5 (Appendix 5). 
For details on the response criteria and evaluations for lymphomas, see Cheson et al. 2014 and 
Cheson et al. 2016. 
8.3. 
Safety Assessments 
8.3.1. 
Demographic/Medical History 
Subject demographics and baseline characteristics (including age, sex, race, ethnicity, weight and 
height, disease information, and medical conditions) are to be summarized at screening. 
8.3.2. 
Physical Examinations (Including Symptom-focused Examination) 
A physical examination requires assessment of all major body systems to evaluate any new 
clinically significant abnormalities within the following: general appearance, skin, 
head/eyes/ears/nose/throat, neck, heart, lungs, abdomen, extremities, back/spinal, and lymph 
nodes. This includes worsening of baseline conditions. 
For a symptom-focused examination, only the relevant or affected body system(s) must be 
examined and a full physical examination is not required. 
8.3.3. 
Vital Signs 
Sitting blood pressure, pulse rate, respiratory rate, and oral temperature will be measured after 
the subject has been resting for at least 5 minutes. Arterial oxygen saturation will be measured by 
pulse oximetry. 
8.3.4. 
Electrocardiograms 
Electrocardiograms (ECGs) will be obtained via 12-lead ECGs at screening with the subject in 
semi-recumbent position after 5 minutes of rest. The investigator may perform additional 
unscheduled ECGs to manage or evaluate a suspected AE as clinically necessary. Unscheduled 
ECGs will be documented. 
8.3.5. 
Laboratory Assessments 
Blood samples will be collected for clinical laboratory testing, including complete blood count 
(CBC), chemistry, coagulation, and other tests. Clinical laboratory tests are summarized in Table 
12. 
Additional or repeated clinical laboratory testing may be performed while on treatment as 
clinically indicated by the investigator. Laboratory assessments may be performed up to 3 days 
prior to the dosing visit specified in Table 1/Table 2, and Table 3/Table 4. Visits conducted 
outside the windows are to be discussed with the medical monitor (or designee). On treatment 
days, samples for clinical laboratory testing should be drawn prior to the infusion. 


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Table 12: 
Clinical Laboratory Tests 
Hematology Tests 
Coagulation Tests 
RBC count 
PT/INR 
Hgb 
PTT 
Hematocrit 
Fibrinogen (within 14 days of dosing) 
WBC count 
Other 
Neutrophils 
Serum pregnancy 
Lymphocytes 
HgbA1c (at screening only) 
Monocytes 
Creatinine clearance (at screening) 
Basophils 
Thyroid function tests: TSH, T3, free T4, thyroid 
antibody (at baseline, at the loading dose/first 
dose, and every 3 months thereafter) 
Eosinophils 
ACTH (at baseline only) 
PLT 
FSH (at baseline only) 
Chemistry Tests 
LH (at baseline only) 
 Sodium 
GH (at baseline only) 
Potassium 
Amylase (at baseline only) 
Chloride 
Lipase (at baseline only) 
Bicarbonate 
 LDH (at screening only) – for RCC 
Glucose 
Creatinine 
ALT 
AST 
ALP 
GGT 
Lactate dehydrogenase 
Total bilirubin 
Total protein 
Albumin 
BUN 
Calcium 
Phosphorous 
Magnesium 
Creatine kinase 
Uric acid 
Abbreviations: ACTH = adrenocorticotropic hormone, ALT = alanine aminotransferase, ALP = alkaline 
phosphatase, AST = aspartate aminotransferase, BUN = blood urea nitrogen, FSH = follicle-stimulating 
hormone, GGT = gamma-glutamyl transferase, GH = growth hormone, Hgb = hemoglobin, 
HgbA1c = hemoglobin A1c, INR = international normalized ratio, LH = luteinizing hormone, PLT = platelets, 
PT = prothrombin time, PTT = partial thromboplastin time, RBC = red blood cell, TSH = thyroid stimulating 
hormone, WBC = white blood cell, Lactate dehydrogenase (LDH). 


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8.3.5.1. 
Hematology 
Hematology assessments are included in the clinical laboratory assessments in Table 1/Table 2, 
and Table 3/Table 4. 
8.3.5.2. 
Blood Chemistry 
Chemistry is included in the clinical laboratory assessments in the Table 1/Table 2, and Table 
3/Table 4. 
8.3.5.3. 
Urinalysis 
Urinalysis is not required for this study but allowed for pregnancy testing. 
8.3.5.4. 
Virus Serology 
Virus serology is not required. 
8.3.5.5. 
Drug Screen 
Drug screen is not required. 
8.3.5.6. 
Pregnancy Screen 
For women of childbearing potential, pregnancy test (serum or urine, per institutional practice) 
will be administered at screening, baseline, and on C2D1 and the first day of each subsequent 
cycle. 
8.3.6. 
Adverse Events and Serious Adverse Events 
Any subject who receives at least 1 dose of study treatment will be included in the evaluation for 
safety. Safety will be assessed by physical examinations, vital signs, and laboratory assessments. 
Safety will also be evaluated using the proportion of subjects requiring modifications of the 
infusion schedule. 
Safety and tolerability will be evaluated by the incidence, severity, seriousness, type, and 
causality of AEs that occur during the treatment and follow-up periods. 
The incidence of AEs and SAEs will be evaluated for each dose level and for all subjects 
combined. Subjects are to be followed for AEs that begin or worsen after start of study treatment 
through EOT or 90 days (± 7 days) after the last dose of study treatment, whichever is later. 
“Lack of efficacy” or “failure of expected pharmacological action” per se will not be reported as 
an AE or SAE; nor will progressive disease. Such instances will be captured in the efficacy 
assessments. However, the signs, symptoms, and/or clinical sequelae resulting from lack of 
efficacy will be reported as AE or SAE if they fulfill the definition of an AE or SAE. 
Clinical AEs will be graded according to the NCI CTCAE Version 5.0. Adverse events are to be 
monitored and collected for the duration of study treatment until 90 days after the last dose. 


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8.3.6.1. 
Definition of Adverse Events 
8.3.6.1.1. Adverse Event  
An AE is any untoward medical occurrence associated with the use of a drug in humans, whether 
or not considered drug related. 
An AE (also referred to as an adverse experience) can be any unfavorable and unintended sign 
(eg, an abnormal laboratory finding), symptom, or disease temporally associated with the use of 
a treatment and does not imply any judgment about causality. An AE can arise with any use of 
the treatment (eg, off-label use, use in combination with another treatment) and with any route of 
administration, formulation, or dose, including an overdose. 
All AEs that occur after any subject has been enrolled, before treatment, during treatment, or 
within 90 days following the cessation of treatment, whether or not the events are related to the 
study, must be recorded on the eCRF provided by the sponsor. 
8.3.6.1.2. Suspected Adverse Reaction 
Suspected adverse reactions are a subset of all AEs for which there is reasonable possibility that 
the treatment caused the AE. Reasonable possibility means that there is evidence to suggest a 
causal relationship between the treatment and the AE. A suspected adverse reaction implies a 
lesser degree of certainty about causality than adverse reaction, which means any AE caused by a 
treatment. 
The principal investigator is responsible for determining whether there is a reasonable possibility 
that the treatment caused the AE and will capture the causality assessment in the eCRF. 
8.3.6.1.3. Adverse Reaction 
An adverse reaction is any AE caused by a treatment. Adverse reactions are a subset of all 
suspected adverse reactions where there is reason to conclude the treatment caused the event. 
8.3.6.1.4. Unexpected 
An AE or suspected adverse reaction is considered “unexpected” if it is not listed in the IB or is 
not listed at the specificity or severity that has been observed. The sponsor is responsible for 
determining whether an event meets the definition of “unexpected,” based on adverse reactions 
listed in the sponsor’s IB. 
8.3.6.1.5. Serious Adverse Event  
An SAE is an AE occurring during any study period (baseline, treatment, washout, or follow-up), 
and at any dose of the study treatment, comparator, or placebo, that fulfils 1 or more of the 
following: 
• It results in death 
• It is immediately life-threatening 
• It requires in-patient hospitalization or prolongation of existing hospitalization 
• It results in persistent or significant disability or incapacity 
• It results in a congenital abnormality or birth defect 


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• It is an important medical event that may jeopardize the subject or may require medical 
intervention to prevent 1 of the outcomes listed above 
All SAEs that occur after any subject has been enrolled, before treatment, during treatment, or 
within 90 days following the cessation of treatment, whether or not they are related to the study, 
must be recorded on eCRF provided by the sponsor. 
8.3.6.1.6. Further AE and SAE Definitions 
Wherever possible, a specific disease or syndrome rather than individual associated signs and 
symptoms should be identified. However, if an observed or reported sign or symptom is not 
considered a component of a specific disease or syndrome by the investigator, it should be 
recorded as a separate AE. Laboratory data are to be collected as stipulated in this protocol. 
Clinical syndromes associated with laboratory abnormalities are to be recorded as appropriate 
(eg, diabetes mellitus rather than hyperglycemia). 
Scheduled hospitalizations or elective surgical procedures will not be considered as AEs or 
SAEs. Complications associated with scheduled procedures are considered AEs or SAEs. 
An abnormal test finding will be classified as an AE if one or more of the following criteria are 
met: 
• The test finding is accompanied by clinical symptoms. 
• The test finding necessitates additional diagnostic evaluation(s) or medical/surgical 
intervention; including significant additional concomitant treatment or other therapy. 
NOTE: Simply repeating a test finding, in the absence of any of the other listed criteria, 
does not constitute an AE. 
• The test finding leads to a change in study treatment dosing or discontinuation of subject 
participation in the clinical research study. 
• The test finding is considered an AE by the investigator. 
8.3.6.1.7. Other Adverse Event  
Other AEs will be identified by the sponsor and, if applicable, also by the Clinical Study Team 
Physician during the evaluation of safety data for the clinical study report. Significant AEs of 
particular clinical importance, other than SAEs and those AEs leading to discontinuation of the 
subject from the study, will be classified as other AEs. For each other AE, a narrative may be 
written and included in the clinical study report. 
8.3.6.2. 
Relationship to Study Treatment 
An investigator who is qualified in medicine must make the determination of relationship to the 
investigational product for each AE (unrelated, possibly related, or probably related). The 
investigator should decide whether, in his or her medical judgment, there is a reasonable 
possibility that the event may have been caused by the study treatment. If no valid reason exists 
for suggesting a relationship, then the AE should be classified as “unrelated.” If there is any valid 
reason, even if undetermined, for suspecting a possible cause-and-effect relationship between the 
study treatment and the occurrence of the AE, then the AE should be considered “related.” 


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If the relationship between the AE/SAE and the study treatment is determined to be “possible” or 
“probable,” the event will be considered to be related to the study treatment for the purposes of 
expedited regulatory reporting. 
8.3.6.3. 
Recording Adverse Events 
Adverse events spontaneously reported by the subject and/or in response to an open question 
from the study personnel or revealed by observation will be recorded during the study at the 
investigational site. Clinically significant changes in laboratory values, blood pressure, and pulse 
need not be reported as AEs. However, abnormal values that constitute an SAE or lead to 
discontinuation of administration of study treatment must be reported and recorded as an AE. 
Information about AEs will be collected from the signing of consent form until the end of the 
study. Serious adverse event information will be collected from signing of consent form until 
90 days following the last dose of study treatment. The AE term should be reported in standard 
medical terminology when possible. For each AE, the investigator will evaluate and report the 
onset (date and time), resolution (date and time), intensity, causality, action taken, serious 
outcome (if applicable), and whether or not it caused the subject to discontinue the study. 
Adverse event grading will be defined by the NCI CTCAE Version 5.0. In the event the NCI 
CTCAE Version 5.0 criterion does not apply, the general severity descriptions of mild, moderate, 
severe, life-threatening and death will be used as listed below by NCI CTCAE: 
Grade 1 Mild: asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated. 
Grade 2 Moderate: minimal, local, or noninvasive intervention indicated; limiting age-
appropriate instrumental activities of daily living.a 
Grade 3 Severe or medically significant but not immediately life-threatening: 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self-care 
activities of daily living.b 
Grade 4 Life-threatening consequences: urgent intervention indicated. 
Grade 5 Death related to AE. 
a 
Instrumental activities of daily living refer to preparing meals, shopping for groceries or clothes, using the 
telephone, managing money, etc. 
b 
Self-care activities of daily living refer to bathing, dressing, and undressing; feeding self; using the toilet; 
taking medications; and not bedridden. 
It is important to distinguish between serious and severe AEs. Severity is a measure of intensity, 
whereas seriousness is defined by the criteria under Section 8.3.6.1.5. An AE of severe intensity 
may not be considered serious. 


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8.3.6.3.1. Pregnancy 
Should a pregnancy occur, it must be reported to and recorded by the sponsor. Pregnancy in itself 
is not regarded as an AE unless there is a suspicion that a study treatment may have interfered 
with the effectiveness of a contraceptive medication. 
The outcome of all pregnancies (spontaneous miscarriage, elective termination, normal birth, or 
congenital abnormality) must be followed up and documented even if the subject was 
discontinued from the study. 
All reports of congenital abnormalities/birth defects are SAEs. Spontaneous miscarriages should 
also be reported and handled as SAEs. Elective abortions without complications should not be 
handled as AEs. 
8.3.6.4. 
Reporting Adverse Events 
All AEs (e.g., including COVID-19 symptoms) and SAEs will be collected from the time the 
subject signs informed consent through 90 days after the last dose of TTX-030 or until initiation 
of a new systemic anticancer therapy, whichever occurs first. Positive COVID-19 test result will 
be collected as a medical event and submitted as SAE.  
 
Any SAEs considered possibly or probably related to the study treatment and discovered by the 
investigator at any time after the study should be reported. All SAEs must be reported to the 
sponsor within 1 business day of the first awareness of the event. The investigator must 
complete, sign, and date the SAE pages; verify the accuracy of the information recorded on the 
SAE pages with the corresponding source documents; and send a copy to the contact information 
listed on the SAE forms.  
Additional follow-up information, if required or available, should all be faxed to the sponsor 
within 1 business day of receipt, and this should be completed on a follow-up SAE form and 
placed with the original SAE information and kept with the appropriate section of the eCRF 
and/or study file. 
The sponsor is responsible for notifying the relevant regulatory authorities of certain events. It is 
the investigator’s responsibility to notify the Institutional Review Board (IRB) or Independent 
Ethics Committee (IEC) of all SAEs that occur at his or her site. Investigators will also be 
notified of all unexpected, serious, treatment-related events (7/15 Day Safety Reports) that occur 
during the clinical trial. Each site is responsible for notifying its IRB or IEC of these additional 
SAEs. 
8.3.6.4.1. SAE Reporting 
The investigator is obligated to report immediately to the sponsor or designee each SAE that 
occurs during this study, within 24 hours from knowledge of the event, whether or not it is 
considered study treatment related. All requested supplementary documents (eg, discharge 
summary and autopsy report) and relevant data (eg, ECGs, laboratory tests, discharge 
summaries, and postmortem results) must be faxed to the number on the SAE form within 
24 hours after available to the sponsor or sponsor’s designee. If any questions or considerations 
regarding SAE arise, the sponsor’s medical monitor or designee should be consulted. 


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The information provided in a SAE report should be as complete as possible, but contain a 
minimum of the following: 
• A short description of the AE (diagnosis) and the reason why the AE was categorized as 
serious 
• Subject identification and treatment  
• Investigator’s name and phone number (if applicable) 
• Name of the suspect medicinal product and dates of administration 
• Assessment of causality 
If all information about the SAE is not yet known, the investigator will be required to report any 
additional information within 24 hours as it becomes available. 
All SAEs will be evaluated by the sponsor’s medical monitor or designee.  
The investigators must notify their governing IRB of any SAEs. 
8.3.6.4.1.1.Serious and Unexpected Suspected Adverse Reaction 
For any suspected adverse reaction that is both serious and unexpected (not documented in the 
IB or package insert), an Investigational New Drug (IND) safety report or revision to the IB may 
be issued to inform all investigators involved in any study with the same study treatment. 
8.3.6.4.2. Post-treatment Safety Follow-up 
In this study, all AEs occurring after the informed consent is signed will be captured on the 
eCRF. All subjects should be instructed to report AEs or SAEs occurring up to 30 (± 7) days 
after the last dose of study treatment. Unresolved study treatment-related AEs and SAEs at the 
time of treatment discontinuation, or new study treatment-related AEs and SAEs that occur 
during the 30-day postdose timeframe, will be followed until they have, in opinion of the 
investigator, resolved to baseline, have stabilized, or are deemed to be irreversible. 
8.3.6.5. 
Adverse Events of Special Interest  
8.3.6.5.1. Adverse Events from Commercial Study Agents 
For AEs related to any of the commercially available agents used in combination treatment in 
this study, please refer to the discussion in Section 4.2.2 and the individual package inserts 
referenced there. 
8.3.6.5.2. Infections 
Follow National Comprehensive Cancer Network guidelines for the prevention and treatment of 
cancer-related infections (Baden et al. 2012).  
8.3.6.5.3. Tumor Lysis Syndrome 
Tumor lysis syndrome (TLS) is defined by both laboratory criteria and by clinical features. It 
most commonly occurs after initiation of cytotoxic therapy in individuals with aggressive 
lymphomas and acute lymphoblastic leukemia but can occur spontaneously and with other tumor 
types that have high proliferate rate or large tumor burden.  


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For individuals who are at risk for TLS, please monitor and select prophylaxis methods based on 
institutional guidelines. Guidelines commonly include IV hydration, hypouricemic agents (eg 
allopurinol, rasburicase), frequent monitoring of urine output, and serial assays of electrolytes 
and serum uric acid. 
The following algorithmic approach to risk assessment and monitoring of tumor lysis syndrome 
should also be used as guidance (Figure 11): 


 
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Figure 11: 
Algorithmic Approach to Risk Assessment of Tumor Lysis Syndrome 


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8.3.6.5.4. Cytokine Release Syndrome 
Cytokine release syndrome (CRS) is a potentially severe immune reaction that may occur in 
response to immunotherapies. The largest risk factor is high tumor load. Symptoms may include 
high fevers, rigors, myalgia, headache, nausea, vomiting, malaise, hypotension, rash, dyspnea, 
hypoxia, and tachycardia. Elevations in serum aminotransferases and bilirubin can be seen, and, 
in some cases, disseminated intravascular coagulation, capillary leak syndrome, and 
hemophagocytic lymphohistiocytosis-like syndrome have been reported.  
Management of CRS depends on the severity and may include interruption of the infusion, 
discontinuation of therapy, symptomatic treatment, IV fluids, and ventilator and/or pressor 
support, as well as corticosteroids and anti-cytokine therapy (Lee et al. 2014). Vigilant 
supportive care is recommended including empiric treatment of concurrent bacterial infections 
and maintenance of adequate hydration and blood pressure for every subject regardless of CRS 
grade.  
The following treatment algorithm for management of CRS is recommended by Lee et al. 2014: 
 
In the event of an acute infusion-related reaction/CRS, the infusion of study treatment will be 
stopped, and the subject will be closely monitored until resolution of the reaction. Drugs that 
may be used to facilitate resolution and permit resumption of study treatment administration 


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include epinephrine and other vasopressors, acetaminophen, antihistamines 
(eg, diphenhydramine), opiates for pain (eg, short-term meperidine), supplemental oxygen, IV 
fluids, and corticosteroids. For acute infusion-related reactions less than Grade 3, resumption of 
study treatment administration at a slower infusion rate may be considered at the investigator’s 
discretion. 
Cytokine release syndrome may have a delayed onset following the completion of the infusion. 
Study subjects must be instructed to contact their study site immediately if they develop a fever. 
The lack of any clinical symptoms related to CRS in Trishula cynomolgus monkey PK studies 
may indicate a low potential for this effect. However, serum cytokine levels were monitored after 
the first and last administration of TTX-030 in the GLP cynomolgus monkey safety study.   
8.3.6.5.5. Immune-related Adverse Events 
(Content for this section has been adapted from UpToDate, Postow M;Wolchok J, 2018.) 
Checkpoint inhibition is associated with irAEs, including dermatologic, gastrointestinal, hepatic, 
endocrine, and other inflammatory events. These irAEs are typically transient but occasionally 
can be severe or life-threatening. In general, treatment of moderate or severe irAEs requires 
interruption of the checkpoint inhibitor and the use of corticosteroid immunosuppression. 
Treatment is based upon the severity of the observed toxicity.  
• For subjects with Grade 2 (moderate) immune-mediated toxicities, treatment with the 
checkpoint inhibitor should be withheld and should not be resumed until symptoms or 
toxicity is Grade 1 or less. Corticosteroids (prednisone 0.5 mg/kg/day or equivalent) 
should be started if symptoms do not resolve within a week. 
• For subjects experiencing Grade 3 or 4 (severe or life-threatening) immune-mediated 
toxicities, treatment with the checkpoint inhibitor should be permanently 
discontinued. High doses of corticosteroids (prednisone 1-2 mg/kg/day or equivalent) 
should be given. When symptoms subside to Grade 1 or less, steroids can be 
gradually tapered over at least 1 month. 
Subjects who will benefit from corticosteroids generally do so within days. If symptoms do not 
clearly improve, particularly after approximately 3 days with IV steroids, administering 
infliximab (5 mg/kg) rather than continuing with a prolonged course of high-dose IV 
corticosteroids is suggested. If symptoms persist after the first infliximab dose, a second dose of 
infliximab (5 mg/kg) can be repeated 2 weeks after the initial dose. 
Fatigue 
• Fatigue is among the most common side effect seen and is generally mild. Severe 
fatigue is rare as a side effect of checkpoint inhibitors. When fatigue is present, it is 
important to exclude thyroid, pituitary, and other endocrine disorders, such as primary 
adrenal insufficiency.  


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Infusion-related Reactions 
• Mild infusion-related side effects have been reported in up to 25% of individuals 
treated with anti-PD-1 or anti-PD-L1 agents. The reported incidence of severe or 
life-threatening infusion-related reactions has been less than 2%. Premedication with 
acetaminophen and an antihistamine may be considered as needed.  
Dermatologic and Mucosal Toxicity 
• Dermatologic toxicity is the most common irAE associated with checkpoint 
inhibitors. Approximately 30% to 50% of individuals will have dermatologic 
complications. Alopecia has been reported in approximately 1% to 2% of cases. For 
most individuals, dermatologic toxicity is the earliest irAE experienced, with onset an 
average of 3.6 weeks after treatment initiation. 
• Oral mucositis and/or complaints of dry mouth may also occur. Oral candidiasis 
remains an important consideration in the differential diagnosis, particularly if an 
individual has been on oral corticosteroids for management of other irAEs. In some 
individuals, oral corticosteroid rinses and lidocaine have been effective. 
• Most checkpoint inhibitor rashes can be treated with topical corticosteroid creams. If 
pruritus is a prominent symptom, oral antipruritics (eg, hydroxyzine or 
diphenhydramine) can be helpful. Severe rashes (Grade 3/4) should be managed with 
oral corticosteroids, and treatment with checkpoint blockade should be held as per 
established management algorithms. Any rash that does not promptly resolve with 
corticosteroid creams or shows signs of blistering should be evaluated promptly by a 
dermatologist and biopsy considered. 
Diarrhea/Colitis 
• Diarrhea is a common clinical complaint in individuals undergoing treatment with 
checkpoint-blocking antibodies and most commonly presents approximately 6 weeks 
into treatment. Subjects being treated with a checkpoint inhibitor should be counseled 
on the importance of maintaining oral hydration if diarrhea develops. If symptoms 
persist for more than 3 days or increase and no infectious causes are identified, 
prompt assessment and use of oral or IV corticosteroids are required. 
• Mild (Grade 1) symptoms (fewer than 4 stools per day over baseline) can be managed 
symptomatically. Some clinicians feel that the American Dietary Association colitis 
diet and anti-motility agents (loperamide or oral diphenoxylate atropine sulfate) can 
be helpful for mild symptoms. Oral or rectal budesonide may be helpful in the early 
treatment of mild noninfectious diarrhea symptoms that persist but do not escalate 
after 2 to 3 days of dietary modification and anti-motility agents. 


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• Colonoscopy may be helpful if Grade 2 symptoms (increase of 4 to 6 stools per day 
over baseline) or greater occur or in situations where the diagnosis is unclear. 
Treatment should be initiated if colitis is observed. 
• For individuals with severe or life-threatening enterocolitis (Grade 3 or 4, increase of 
7 or more stools per day over baseline or other complications), treatment with 
checkpoint inhibitor should be permanently discontinued. High doses of 
corticosteroids (prednisone 1-2 mg/kg/day or equivalent) should be given. 
• If individuals do not improve with IV corticosteroids after approximately 3 days on 
IV steroids, infliximab at a dose of 5 mg/kg Q2W is typically recommended. The 
dose and schedule of infliximab in this setting is based upon experience treating 
individuals with inflammatory bowel disease. In cases refractory to infliximab, 
mycophenolate may be needed.  
• In very rare cases, colitis can result in bowel perforation, potentially requiring 
colostomy. 
• Prophylactic treatment with the matrix-release corticosteroid budesonide is not 
recommended for the prevention of diarrhea/colitis. This approach was studied as a 
way to reduce the incidence and/or severity of diarrhea in a double-blind, 
placebo-controlled Phase 2 study and the rates of diarrhea were similar in both study 
arms. 
Hepatotoxicity 
• Elevations in serum levels of the hepatic enzymes, AST and ALT, may be observed. 
Most episodes involve asymptomatic laboratory abnormalities, but occasionally 
individuals have an associated fever. Rarely, elevations in total bilirubin are seen as 
well, usually in association with a prolonged period of AST and ALT increase. 
Among individuals that develop hepatic-related toxicities, the most common time of 
onset is 8 to 12 weeks after initiation of treatment, although early or delayed events 
may also be seen. 
• Hepatic function (transaminases and bilirubin) should be monitored prior to each dose 
of checkpoint inhibitor. When an individual has an elevated AST and/or ALT, 
exclusion of viral or other drug-induced causes of hepatitis is important. If no other 
etiology is obvious, then prompt treatment with corticosteroids following an 
established algorithm is the next step. Hepatitis may persist for quite some time and 
may require prolonged or repeated corticosteroid tapers (a minimum of 3 weeks of 
treatment is suggested) and/or additional immunosuppression. 
• Grade 2 hepatic toxicity: AST or ALT > 2.5 times the ULN but ≤ 5 times the ULN, or 
total bilirubin > 1.5 times the ULN but ≤ 3 times the ULN. Treatment with the 
checkpoint inhibitor should be withheld. 


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• Grade 3 or greater hepatic toxicity: AST or ALT > 5 times the ULN, or total bilirubin 
> 3 times the ULN. Treatment should be permanently discontinued. 
• In rare cases, elevations in AST and ALT are refractory to corticosteroid therapy, and 
mycophenolate mofetil (500 mg every 12 hours) may be administered concurrently 
with corticosteroids. The use of antithymocyte globulin therapy has also been 
described. 
• Infliximab should not be given to individuals with elevated AST/ALT since 
infliximab itself carries a risk of hepatotoxicity. 
Pneumonitis 
• Pneumonitis is an uncommon but potentially severe or fatal complication of treatment 
with checkpoint inhibitor immunotherapy. Drug-induced pneumonitis is a diagnosis 
of exclusion, and alternative diagnoses, including infection and malignancy, need to 
be excluded. 
• An empiric approach to treatment includes the following: 
o For asymptomatic, Grade 1 pneumonitis, clinicians generally withhold drug 
for 2 to 4 weeks with close follow-up. If symptoms arise or there is 
radiographic progression, corticosteroids are appropriate. 
o Subjects with Grade 2 or higher pneumonitis should have their drug withheld 
and be treated using corticosteroids with close follow-up. Additional 
immunosuppression may be used in individuals with worsening of 
pneumonitis, although the benefit of this approach is uncertain. 
Endocrinopathies  
• Inflammation of the pituitary, thyroid, or adrenal glands as a result of checkpoint 
blockade often presents with nonspecific symptoms such as nausea, headache, 
fatigue, and vision changes. The most common endocrinopathies are hypothyroidism, 
hyperthyroidism, and hypophysitis. 
• Thyroid function should be monitored prior to each dose of a checkpoint inhibitor. 
Hypothyroidism and hyperthyroidism should be managed per standard clinical 
guidelines and an endocrinologist should be consulted.  
• Typically, hypophysitis is manifested by clinical symptoms of fatigue and headache. 
The diagnosis is established by low levels of the hormones produced by the pituitary, 
including adrenocorticotropic hormone (ACTH), thyroid stimulating hormone (TSH), 
follicle-stimulating hormone (FSH), luteinizing hormone (LH), growth hormone 
(GH), and prolactin. When hypophysitis is suspected, a course of high-dose 
corticosteroids (1 mg/kg of prednisone daily) given during the acute phase may result 
in reversal of the inflammatory process in some cases and prevent the need for longer 
term hormone replacement. In most individuals, however, long-term supplementation 


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of the affected hormones is necessary due to secondary hypothyroidism (treated with 
levothyroxine) or secondary hypoadrenalism (treated with replacement doses of 
hydrocortisone, typically 20 mg each morning and 10 mg each evening). In some 
cases, individuals can be successfully weaned from replacement steroids over time.  
Adrenal Insufficiency 
• The most critical endocrinopathy is adrenal insufficiency, which can cause 
dehydration, hypotension, and electrolyte imbalances (hyperkalemia, hyponatremia) 
and constitutes an emergency. Adrenal insufficiency is rare and has been reported in 
0.7% of individuals treated in randomized clinical trials. When an adrenal crisis is 
suspected, IV corticosteroids and immediate hospitalization is warranted. 
Consultation with an endocrinologist, aggressive hydration, and evaluation for sepsis 
are also critical.  
Type 1 Diabetes Mellitus  
• Treatment with checkpoint inhibitors has been associated with acute onset of type 1 
diabetes mellitus in approximately 0.2% of cases. It is important to monitor glucose 
with each dose of immunotherapy. 
Renal 
• Acute renal injury is a rare complication of checkpoint inhibitor immunotherapy. 
Discontinuation of checkpoint inhibitor immunotherapy and treatment with 
corticosteroids are indicated for individuals with severe renal injury. The most 
common reported underlying pathology is acute tubulointerstitial necrosis, but acute 
interstitial nephritis, immune complex glomerulonephritis, and thrombotic 
microangiopathy have also been observed. Acute renal injury due to checkpoint 
inhibitor therapy has been managed by discontinuing immunotherapy and 
administering a course of corticosteroids, typically 1 mg/kg tapering over 1-2 months. 
Rechallenging with checkpoint inhibitor after resolution of the renal injury has been 
successful in some cases (Wanchoo et al. 2017). 
Exocrine Pancreas 
• Monitoring serum amylase and lipase in asymptomatic individuals is not 
recommended unless pancreatitis is suspected clinically. Corticosteroid treatment is 
not indicated in individuals with modest asymptomatic elevations in serum amylase 
and lipase, as long as there are no other signs or symptoms of pancreatic 
inflammation. 


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Neurologic  
• A wide range of neurologic syndromes have been associated with checkpoint 
blockade neurotoxicity, which is estimated to occur in approximately 1-3% of 
individuals. Serious neurologic irAEs should be treated with corticosteroids. 
Consultation with neurology is indicated to consider additional treatment such as 
plasmapheresis and IV Ig. 
Cardiotoxicity  
• Cardiotoxicity (eg, myocarditis) may develop in the absence of a history of 
significant cardiac risk factors and may be associated with a more general myositis as 
well as other irAEs. High-dose steroids have been used to treat cardiac complications, 
but symptoms may progress in some cases despite aggressive therapy. Immediate 
transfer to a coronary care unit or, if available, cardiac transplant unit should be 
considered for individuals with elevated troponin or conduction abnormalities. The 
early institution of cardiac transplant rejection doses of steroids (methylprednisolone 
1 g every day) and the addition of mycophenolate, infliximab, or antithymocyte 
globulin should be considered in individuals without an immediate response to 
high-dose steroids. Mechanical circulatory support may also be considered in severe 
cases when deemed clinically appropriate. 
Hematologic  
• Red cell aplasia, neutropenia, thrombocytopenia, acquired hemophilia A, and 
cryoglobulinemia have been described in individuals treated with checkpoint 
inhibitors. As with other irAEs, the standard approach is initial corticosteroid 
treatment with addition of other immune-suppressing agents if symptoms are 
steroid-refractory. 
Ophthalmologic 
• Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) blockade with ipilimumab 
has been associated with eye inflammation, which can be manifested by episcleritis, 
conjunctivitis, uveitis, or orbital inflammation. An ophthalmology consultation is 
recommended, and treatment with topical corticosteroids (eg, 1% prednisolone 
acetate suspension) may be helpful. Oral corticosteroids can be used for severe 
(Grade 3 or 4) for refractory cases.  
Rheumatologic and Musculoskeletal  
• A wide range of rheumatologic toxicities has been observed with checkpoint 
inhibition immunotherapy. These include inflammatory arthritis, salivary gland 


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dysfunction (sicca syndrome), and inflammatory myositis, among others. The 
incidence of these side effects has not been clearly determined. 
8.4. 
Pharmacokinetics 
PK assessments are for TTX-030, whether administered as a single agent or in combination with 
other agents. 
8.4.1. 
Pharmacokinetic Blood Sample Collection 
The serial sampling scheme for TTX-030 concentration assessments scheduled in Table 1/Table 
2, Table 3/Table 4, and Table 5/Table 6 will contribute to the characterization of the TTX-030 
PK profile. Blood will be collected in the vacutainers specified in the Laboratory Manual. Serum 
will be harvested from these collections and stored for subsequent analysis. Samples from each 
collection period will be shipped to the analytical laboratory selected by the sponsor and 
analyzed for concentrations of TTX-030 by validated methods. Instructions for processing and 
shipping samples will be provided in a separate Laboratory Manual. All sampling should be 
collected as close as possible to the sample collection times specified. The actual time and date 
of each blood sample will be recorded. If a subject has a dosing interruption or delay for any 
reason, PK sampling may be delayed or skipped after discussion with the sponsor. If the infusion 
was interrupted or a sample was not drawn, the reason will be documented on the eCRF. 
Post-infusion samples should be obtained from a site other than the infusion site (ie, contralateral 
arm) on infusion days. 
The number of samples taken, volume required for each analysis, and timing of the PK sampling 
may change during the course of the study as additional data emerge. 
8.4.2. 
Pharmacokinetic Sample Analysis 
Serum concentrations of TTX-030 will be determined by a validated 
electrochemiluminescence-based method at the time points listed in Table 1/Table 2, Table 
3/Table 4, and Table 5/Table 6.  
TTX-030 concentration data will be tabulated and summarized for each cycle at which PK are to 
be measured. Descriptive statistics will include means, medians, ranges, and standard deviations, 
as appropriate. Dose-exposure relationships will be characterized. Additional analyses may be 
conducted if they further address the PK objectives. 
PK parameters for TTX-030 will be estimated by fitting a 2-compartment IV infusion model to 
the serum concentration-time data using Phoenix 64 WinNonlin. The serum PK parameters are 
listed in Table 13. 


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Table 13: 
Serum Pharmacokinetic Parameters to be Computed 
Parameter 
Definition 
t1/2 
terminal elimination half-life 
Cmax 
maximum serum observed concentration 
Vss 
volume of distribution at steady state 
CL 
apparent total body clearance of the drug from serum 
AUC 
Area under the curve (AUC)  
Concentrations below the lower limit of quantitation will be treated as 0.00 for descriptive 
statistics and noncompartmental PK analysis. Values for missing PK samples will not be imputed 
unless supported by PK principles (eg, concentration[s]) prior to dosing or in the elimination 
phase following decline below the assay lower limit of quantitation and will be identified as 
“missing” in the data listings. 
8.5. 
Pharmacodynamics 
8.5.1. 
Pharmacodynamic Blood Samples 
Pharmacodynamic blood samples should occur at the same time as PK blood draws or tumor 
biopsy when applicable as shown in Table 1/Table 2, Table 3/Table 4, and Table 5/Table 6. 
Detailed instructions for pharmacodynamic blood sample collection, processing, and shipping 
will be provided to the study sites in a separate Laboratory Manual. 
Peripheral blood mononuclear cells, whole blood, and serum and/or plasma will be analyzed for 
pharmacodynamic readouts, including TTX-030 relevant target- and 
mechanism-of-action-related biomarkers. 
Pro-inflammatory cytokine release will be measured as a marker of immune activation. 
Additionally, several exploratory analyses are planned. Whole blood will be collected to enable 
immunoprofiling, measurements of lymphocyte activation status, and analysis of CD39 receptor 
occupancy by the test article. Additionally, recent reports (Giannakis et al. 2017) have suggested 
that elevated presence of adenosine and its metabolites in serum may correlate with intratumoral 
CD39 activity. Therefore, potential exploratory biomarkers may include the detection of 
adenosine and inosine using liquid chromatography-tandem mass spectrometry techniques or 
similar alternatives. 
8.5.2. 
Pharmacodynamic Tissue Samples  
Subjects may consent to undergo pretreatment biopsy or may provide archival tumor tissue 
(either a paraffin embedded tissue block or ≥ 10 unstained slides) obtained from a procedure that 
was performed any time prior to first dose.  
Fresh and/or archival tumor tissue is optional for dose escalation; fresh tumor biopsy at screening 
and on-treatment is mandatory for safety lead-in arms and expansion cohorts. If a subject is 
clinically contraindicated for tumor biopsy, discuss with Medical Monitor. If a subject has had a 
biopsy within 90 days with no intervening treatment prior to the loading dose/first dose of TTX-


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030, that tissue can be used for this study and the subject does not need to repeat a baseline 
biopsy. 
Follow-up tissue biopsies will occur on C2D1 (-7 days) [Table 1/Table 2 and Table 3/Table 4 
Invasive procedures that require general anesthesia should not be performed to obtain a biopsy 
specimen. If a surgical procedure is performed for a clinical indication, a sample may be used for 
research purposes. During the course of treatment, a decision may be made to perform the 
on-treatment biopsy earlier than Cycle 2 Day 1 (-7 days) if there is evidence to suggest a 
possibility that there will be no available tumor for biopsy due to a rapid clinical response. 
Similarly, tumor biopsy may be delayed if there is evidence of a delayed response.  
When PK and pharmacodynamic sampling are scheduled on days when tissue samples (tumor 
biopsy) are to be obtained, every effort will be made to schedule the assessments together.  
Archival/pretreatment and on-treatment tumor biopsies will be collected and embedded in 
paraffin. Expression of CD39 will be assessed by immunohistochemistry. Additional analysis 
may include immunohistochemistry staining for markers of TIL populations (eg, CD3, CD8, 
CD73, FoxP3, or CD68), functional markers (Ki67), or immune checkpoints (eg, PD-L1). 
Additionally, expression analysis of tumor tissue may be performed using Nanostring™ or 
Illumina RNA-seq. 
Other TTX-030-relevant targets and mechanism-of-action-related biomarkers may be examined 
using available assays. Tissue blocks or slides from fresh biopsies will be retained to research 
disease pathways. Any future use of samples following study completion will be in compliance 
with the Guidance on Informed Consent for In Vitro Diagnostic Device Studies Using Leftover 
Human Specimens that are Not Individually Identifiable Guidance for Sponsors, Institutional 
Review Boards, and Food and Drug Administration Staff (FDA, 2006). Tissue blocks from 
archival biopsies will be returned to the archival facility from which it was originally received. 
Other TTX-030-relevant targets and mechanism-of-action-related biomarkers may be examined 
using available assays.  
Detailed instructions for tissue sample preparation and shipping will be provided to the study 
sites as needed in a separate laboratory manual. 
8.6. 
Immunogenicity Assessments 
8.6.1. 
Anti-drug Antibody Assessments 
Formation of ADA against TTX-030 will be evaluated in serum samples collected from all 
subjects, whether administered as a single agent or in combination with other agents. 
8.6.2. 
Blood Sample Collection 
Serum samples will be collected for the purpose of ADA analysis from all subjects as scheduled 
in Table 1/Table 2, Table 3/Table 4, and Table 5/Table 6. Blood will be collected in the 
vacutainers specified in the laboratory manual and serum extracted as specified. Actual time and 
date of each blood draw are to be recorded. Samples from each scheduled collection period will 
be shipped to the analytical laboratory selected by the sponsor and analyzed for ADA reactivity 
to TTX-030. 


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Additionally, serum samples should also be collected at the final visit from subjects who 
discontinued study treatment or were withdrawn from the study. These samples will be tested by 
the sponsor or sponsor’s designee. 
8.6.3. 
Analysis of ADA Formation 
Immunogenicity results will be analyzed descriptively by summarizing the number and 
percentage of subjects who develop detectable anti-TTX-030 antibodies (population defined as 
per Table 16). The immunogenicity titer will be reported for samples confirmed positive for the 
presence of anti-TTX-030 antibodies. 


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9. 
Statistical Considerations 
9.1. 
Statistical Hypotheses 
Details of the statistical model are included in Section 11.6 (Appendix 6). 
A primary objective of the trial is to determine the MTD and/or RP2D for each arm. Dose 
escalation (Arm 1) will be conducted according to a mCRM for doses up to 10 mg/kg and 
according to a 3 + 3 design for doses > 10 mg/kg, with the aim of estimating the dose-toxicity 
relationship and determining the MTD. The MTD will be defined as the dose that has a 
model-estimated DLT rate closest to 30% and also has less than 55% probability of a DLT rate 
exceeding 30%. The log-odds of a DLT will be modeled across the dose levels with a 
2-parameter logistic regression model. 
The model will be fit to the available data following each dosing cohort to support escalation 
decisions. The observed DLT data will be summarized by dose (within each 
dose-escalation/safety lead-in arm) and reported along with the model fit. Summaries from the 
model will include the posterior means and 95% confidence intervals (CI) for each dose along 
with the posterior probability that the DLT rate exceeds 30%. 
The RP2D was determined based on the totality of data, including the estimated MTD, plus other 
endpoints such as observed efficacy, PK, and other AEs.  
Descriptive summary statistics will be presented. Longitudinal data will be presented by 
appropriate time intervals, such as monthly or quarterly depending on the nature of the data.  
The efficacy in subjects treated with TTX-030 as a single agent or in combination with specified 
regimens will be evaluated and analyzed using the endpoints listed in Table 14. 


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Table 14: 
Efficacy Endpoints 
Efficacy Endpoint 
Definition 
Best Overall Response (BOR) 
Best response recorded after the start of the study 
treatment/randomization 
Objective Response Rate (ORR) 
Confirmed partial response or confirmed complete response 
Duration of Response (DOR) 
Time from documentation of tumor response to disease 
progression 
Time to Progression (TTP) 
Time from the start of study treatment/randomization until 
objective tumor progression; TTP does not include deaths 
Time to Tumor Response (TTR) 
Time from the start of study treatment/randomization to the 
first documentation of an objective response 
Progression-Free Survival (PFS) 
Time from the start of study treatment/randomization until 
objective tumor progression or death 
Disease Control Rate (DCR) 
Percentage of subjects who have achieved complete 
response, partial response, or stable disease for at least 
6 weeks 
Overall Survival (OS) 
Time from the start of study treatment/randomization until 
death from any cause and is measured in the Efficacy 
Evaluable Population 
 
9.2. 
Statistical Considerations for Arm 1 and 2 Expansion Cohorts 
In Arm 1 and 2 Expansion Cohorts (n = 25 subjects each) subjects with advanced or metastatic 
RCC with a clear-cell component and previously treated with anti-PD-(L)1 therapy and TKI 
therapy, will be randomized 1:1 to TTX-030 or TTX-030 and pembrolizumab. These agents will 
be administered at the doses and schedules identified in the safety lead-in. 
• Arm 1: TTX-030 (n = 25) 
• Arm 2: TTX-030 and pembrolizumab (n = 25) 
The primary objective of this randomization procedure is to obtain unbiased estimates of safety 
and efficacy parameters of TTX-030 plus pembrolizumab compared with TTX-030. For 
example, a 25% improvement in ORR (ie, ORR Δ) in Arm 2 relative to Arm 1 (assuming a 15% 
ORR in Arm 1) will have an 80% CI of (9%, 41%) and a power of 76%. See Table 15. 
Demographic and baseline characteristics will be summarized by treatment arm for all 
randomized subjects. Descriptive summaries of continuous data will be presented by the group 
mean, standard deviation, median, minimum, and maximum. Descriptive summaries of discrete 
data will be presented by the category counts as frequencies and percentages. 
An estimate of the difference between the ORR in the two arms will be computed along with its 
90% CI and 80% CI. The Mantel-Haenszel test will be used to compare the ORR between the 
two treatment arms at the two-sided significance level of 5% and 10%. 


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PFS and OS will be analyzed when 65% of the 50 subjects have experienced a PFS event and an 
OS event, respectively. Data for a subject without disease progression or death as of the clinical 
data cutoff date will be censored at the time of the last tumor assessment (or at the date of 
randomization plus 1 day if no tumor assessment was performed after the baseline visit). Data 
from a subject who is lost to follow-up will be included in the analysis and censored on the last 
date of tumor assessment that the subject was known to be progression free or death. A stratified 
Cox proportional-hazards model will be used to estimate the hazard ratio and its 90% CI and 
80% CI. The two-sided stratified log-rank test will be used to compare PFS and OS between the 
two treatment arms. Kaplan-Meier methodology will be used to estimate the PFS curve and OS 
curve as well as the median PFS and OS for each treatment arm. 
Safety analyses will be conducted in all randomized subjects who received at least one dose of 
TTX-030 or pembrolizumab. Safety analyses will be performed by treatment arm and will be 
based on actual treatment received. Specifically, a subject will be included in Arm B in the safety 
analyses if the subject receives any amount of pembrolizumab, regardless of the initial treatment 
assignment at randomization. Safety endpoints will include incidence, nature, and severity of 
adverse events (using NCI CTCAE v5.0), including SAEs and AEs of special interest. 
Table 15: 
Power for Study Design for Several Possible True Underlying Delta 
ORR Values 
 
 
True Underlying ORRΔ 
13% 
17% 
21% 
25% 
Power to detect ORRΔa 
44% 
55% 
66% 
76% 
80% CI 
(-2%, 28%)  
(2%, 32%) 
(6%, 36%) 
(9%, 41%) 
Abbreviations:  CI = confidence interval, ORR = objective response rate. 
aTwo-sided  = 0.20. 
Notes: Arm A is assumed to have an ORR of 15%. Results are based on 25 subjects in each arm. 


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9.3. 
Populations for Analyses 
The following populations are defined for statistical analyses (Table 16). 
Table 16: 
Analysis Populations 
Population 
Population Definition 
Enrolled Population 
All subjects who sign an ICF. 
Safety Population 
All subjects who receive at least 1 dose or any partial dose of study 
treatment. 
Efficacy Evaluable Population 
All treated subjects with measurable disease at baseline and 1 of the 
following: 1) at least 1 on-treatment tumor assessment, 2) clinical 
progression, or 3) death. 
MTD Analysis Population 
All subjects dosed at the MTD (or the highest dose tested if the 
MTD is not determined) in the Safety Population who have the valid 
baseline tumor assessment showing measurable disease, and at least 
1 valid post-baseline tumor assessment. Any subject who has a 
major inclusion/exclusion deviation, major dosing deviation, or 
major protocol conduct deviation that impacts MTD assessment will 
be excluded from the MTD Analysis Population. A subject who 
withdraws from the study during Cycle 1 for reasons other than a 
DLT will be replaced and will be excluded from the MTD Analysis 
Population. 
PK Population 
All subjects who receive at least 1 dose of study treatment and have, 
in the opinion of the pharmacokineticist, sufficient data for PK 
analysis. 
Biomarker/Pharmacodynamic 
Population 
All subjects who receive at least 1 dose of study treatment and have 
available biomarker data. 
Immunogenicity Population 
All subjects who receive at least 1 dose of study treatment and have 
available ADA data. 
DLT Evaluable Population 
All subjects who receive 1 infusion during the treatment cycle, 
completed the DLT evaluation period, and are DLT evaluable. 
Abbreviations: ADA = anti-drug antibodies, DLT = dose-limiting toxicity, ICF = informed consent form, 
MTD = maximum tolerated dose, PK = pharmacokinetic. 
9.4. 
Interim Analyses 
No formal interim analysis is planned. 
An informal interim analysis will be performed when 16 subjects treated in Arm 1 of the 
Expansion Cohort (i.e. TTX-030 monotherapy, see Section 4.1.1.2) have had 2 response 
evaluations completed or experienced progression. The Sponsor may terminate enrollment into 
Arm 1 Expansion should there be evidence of a lack of efficacy. The totality of available data 
will be used to make this determination, however, should zero responders be seen out of the first 
16 subjects the 90% one-sided confidence interval (using exact methods) excludes a responder 
rate of 13.4% or more. 


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10. 
Regulatory, Ethical, and Study Oversight Considerations 
The study will be performed in accordance with ethical principles that have their origin in the 
Declaration of Helsinki and are consistent with International Conference on Harmonisation/Good 
Clinical Practice (GCP), applicable regulatory requirements and the sponsor’s policy on 
bioethics. 
10.1. 
Criteria for Study Termination 
The sponsor or designee may suspend or terminate the study or part of the study at any time for 
any reason.  
If the investigator suspends or terminates the study, the investigator will promptly inform the 
sponsor or designee and the IRB/IEC and provide them with a detailed written explanation. The 
investigator will destroy all unused (after final study treatment accountability has been 
performed) and partially used investigational product per site standard operating procedures. 
Upon study completion, the investigator will provide the sponsor or designee, IRB/IEC, and 
regulatory agency with final reports and summaries as required by regulations. For IND studies, 
or when the data will be used in support of an IND, the investigator must submit a written report 
to the sponsor or designee and the IRB/IEC within 3 months after the completion or termination 
of the study. 
Study enrollment may be paused at any time for safety reasons by the sponsor and/or Cohort 
Review Committee. In the event enrollment is suspended, the decision as to whether subjects 
who have already undergone dosing may be made on a case-by-case decision in consultation 
with the Cohort Review Committee. Subjects who have already been treated with TTX-030 will 
be followed throughout the study.  
Enrollment and treatment with the study treatment may be temporarily suspended for death that 
is not related to disease progression (timeframe) or underlying disease. Re-initiation of 
enrollment will be considered depending on the determination of the cause of death. 
10.2. 
Protocol Adherence and Amendment 
The treating physician or other involved health care professionals will apply due diligence to 
avoid protocol deviations. The protocol should be amended and updated as needed throughout 
the course of the study. Any change or addition to the protocol requires a written protocol 
amendment that must be approved by the sponsor, the treating physician, and the relevant 
IEC/IRB before implementation, unless the amendment is safety related. Safety-related 
amendments will be implemented immediately and documented with a Note to File. 
Amendments affecting only administrative aspects of the study do not require formal protocol 
amendments or IEC/IRB approval, but the IEC/IRB must be kept informed of such 
administrative changes. 
10.3. 
Investigator Compliance 
The protocol and the proposed informed consent form (ICF) must be reviewed and approved by 
a properly constituted IRB/IEC or equivalent board before the study start. A signed and dated 


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statement that the protocol and informed consent have been approved by the IEC/IRB must be 
given to the sponsor before study initiation. Prior to study start, the treating physician is required 
to sign a protocol signature page confirming agreement to conduct the study in accordance with 
these documents and all the instructions and procedures found in this protocol and to give access 
to all relevant date and records to the sponsor’s representatives or designees, IECs/IRBs, and 
regulatory authorities as required. If an inspection of the clinical site is requested by a regulator 
authority, the investigator must inform the sponsor immediately that this request has been made. 
10.4. 
Institutional Review Board or Independent Ethics Committee 
The final study protocol, including the final version of the ICF, must be approved or given a 
favorable opinion in writing by an IRB or IEC as appropriate. The investigator must submit 
written approval to the sponsor before he or she can enroll any subject into the study. 
The investigator is responsible for informing the IRB or IEC of any amendment to the protocol 
in accordance with local requirements. In addition, the IRB or IEC must approve all advertising 
used to recruit subjects for the study. The protocol must be re-approved by the IRB or IEC upon 
receipt of amendments and annually, as local regulations require. 
The investigator is also responsible for providing the IRB with reports of any reportable serious 
adverse drug reactions from any other study conducted with the study treatment. The sponsor 
will provide this information to the investigator. 
Progress reports and notifications of serious adverse drug reactions will be provided to the IRB 
or IEC according to local regulations and guidelines. 
10.5. 
Financial Disclosure 
Investigators and sub-investigators will provide the sponsor with sufficient, accurate financial 
information as requested to allow the sponsor to submit complete and accurate financial 
certification or disclosure statements to the appropriate regulatory authorities. Investigators are 
responsible for providing information on financial interests during the course of the study and for 
1 year after completion of the study. 
10.6. 
Informed Consent 
The investigator(s) at each center will ensure that the subject is given full and adequate oral and 
written information about the nature, purpose, and possible risk and benefit of the study. Subjects 
must also be notified that they are free to discontinue from the study at any time. The subject 
should be given the opportunity to ask questions and allowed time to consider the information 
provided. 
The subject’s signed and dated informed consent must be obtained before conducting any study 
procedures. 
The investigator(s) must maintain the original, signed ICF. A copy of the signed ICF must be 
given to the subject. 


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10.7. 
Data Protection 
The sponsor maintains confidentiality standards by assigning a unique study-specific number to 
each subject enrolled in the study. This means that subject names are not included in data sets 
that are transmitted to any sponsor location. 
Subject medical information obtained by this study is confidential and may be disclosed to third 
parties only as permitted by the ICF (or separate authorization for use and disclosure of personal 
health information) signed by the subject or as permitted or required by law. 
Medical information may be given to a subject’s personal physician or other appropriate medical 
personnel responsible for the subject’s welfare, for treatment purposes. 
Data generated by this study must be available for inspection upon request by representatives of 
national and local health authorities, the sponsor or its designee, and the IRB/IEC for each study 
site, as appropriate. 
10.8. 
Committee Structure 
The investigator must obtain IRB approval for the investigation. Initial IRB approval and all 
materials approved by the IRB for this study including the consent form and recruitment 
materials must be maintained by the investigator and made available for inspection.  
10.9. 
Dissemination of Clinical Study Data 
The standard flow of the clinical study data from collection to clinical study report is illustrated 
in Figure 12. 
Figure 12: 
Transmission of Electronic Data 
 
Abbreviations: eCRF = electronic case report form. 
Data will be transcribed from source into a validated 21 CFR Part 11 compliant, electronic data 
capture system using single data entry. External data will also be imported into the system. PK 
data will be merged into the database using SAS or Excel transfers. Data originators, as well as 
system administrators, will be trained, authorized, and each assigned an individual identifier 


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(username and password). Electronic tools (prompts), as well as data review and query, will be 
used to alert users to and correct for missing data, data inconsistencies, inadmissible values, 
entries out of range, and to request additional data as applicable. An audit trail will be maintained 
to record data entries and edits. Data originators will have access to their data during study 
conduct and will be provided a read-only copy of the final data, audit trail, and queries in a 
human readable file suitable for long term storage. 
The investigator and any vendors will permit study-related monitoring, audits, IRB review, and 
regulatory inspection(s) by providing direct access to source data/documents. Data entered into 
the eCRF will be available to the parties responsible for study data management (sponsor, 
contract research organization) as it is entered and can be exported into files compatible with 
SAS and Excel, among other data formats. 
Subject data necessary for analysis and reporting of this study will be transferred via a validated 
procedure into a validated database or data system (eg, SAS), to enable the data to be 
restructured into industry standards. Clinical data management will be performed in accordance 
with applicable sponsor or designee’s standards and data cleaning procedures. This is applicable 
for data recorded on eCRF as well as for data from other sources. Examples of other data would 
be the medical glossary coding (eg, AEs, medication) that will be performed with internationally 
recognized and accepted dictionaries. Additional details are recorded in the monitoring and data 
management documentation. 
10.10. Data Quality Assurance 
To ensure compliance with GCP and all applicable regulatory requirements, the sponsor may 
conduct a quality assurance audit. Please see Section 10.11 for more details regarding the audit 
process. 
10.11. Inspection of Records 
Authorized representatives of the sponsor, a regulatory authority, an IEC, or an IRB may visit the 
site to perform audits or inspections, including source data verification. The purpose of a sponsor 
audit or inspection is to systematically and independently examine all study-related activities and 
documents to determine whether these activities were conducted, and data were recorded, 
analyzed, and accurately reported according to the protocol, GCP guidelines of the International 
Conference on Harmonisation, and any applicable regulatory requirements. The investigator 
should contact the sponsor immediately if contacted by a regulatory agency about an inspection. 
The sponsor will be allowed to conduct site visits to the investigation facilities for the purpose of 
monitoring any aspect of the study. The investigator agrees to allow the monitor to inspect the 
study treatment storage area, study treatment stocks, treatment accountability records, subject 
charts and study source documents, and other records relative to study conduct. 
10.12. Retention of Records 
The investigator must maintain all documentation relating to the study for a period of 2 years 
after the last marketing application approval, or if not approved, for 2 years following the 
discontinuance of the test article for investigation. If it becomes necessary for the sponsor or the 


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regulatory authority to review any documentation relating to the study, the investigator must 
permit access to such records. 
10.13. Study and Site Start and Closure 
Before an investigational site can enter a subject into the study, a representative of the sponsor 
will visit the investigational study site to: 
• Determine the adequacy of the facilities 
• Discuss with the investigator(s) and other personnel their responsibilities with regard 
to protocol adherence and the responsibilities of the sponsor or its representatives. 
This will be documented in a Clinical Study Agreement between the sponsor and the 
investigator. 
During the study, a monitor from the sponsor or representative will have regular contacts with 
the investigational site, for the following: 
• Provide information and support to the investigator(s). 
• Confirm that facilities remain acceptable. 
• Confirm that the investigational team is adhering to the protocol, that data are being 
accurately recorded in the case report forms, and that study treatment accountability 
checks are being performed. 
• Perform source data verification. This includes a comparison of the data in the eCRF 
with the subject’s medical records at the hospital or practice and other records 
relevant to the study. This will require direct access to all original records for each 
subject (eg, clinic charts). 
• Record and report any protocol deviations not previously sent to the sponsor. 
• Confirm AEs and SAEs have been properly documented on eCRFs and confirm any 
SAEs have been forwarded to the sponsor and those SAEs that met criteria for 
reporting have been forwarded to the IRB. 
The monitor will be available between visits if the investigator(s) or other staff needs 
information or advice. 
10.14. Publication Policy 
The sponsor’s policy is to publish or otherwise communicate the results of its hypothesis testing 
clinical studies, regardless of outcome, for compound(s) being investigated that are later 
approved for marketing. Hypothesis-testing clinical studies are those studies intended to provide 
meaningful results by examining prestated questions using predefined statistically valid plans for 
data analysis, thereby providing firm evidence of safety and/or efficacy to support product 
claims. 
Exploratory studies, in contrast, serve to set direction for possible future studies. They have 
significant statistical limitations, provide only preliminary information about a disease, 


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condition, or product, and are not designed to provide final conclusions on product claims. The 
sponsor does not commit to publish or otherwise communicate the results of every exploratory 
study because this information is of an exploratory nature and often highly proprietary. However, 
if information from an exploratory study is of significant medical importance, the sponsor will 
publish or otherwise communicate the results. 
The sponsor’s decision to publish or otherwise publicly communicate the results of this study 
will be made in accordance with all applicable laws, regulations, and sponsor policies regarding 
publication and communication of clinical study results. 
 
 


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11. 
Appendices 


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11.1. 
Appendix 1: Protocol Amendment History 
 
Version 
Number 
Section Number 
or Title 
Description of Change 
Reason for Change 
7.0 
Entire document 
Minor spelling, grammar, punctuation, 
capitalization, abbreviations, and other 
formatting edits were made throughout the 
document 
Consistency 
7.0 
Entire document 
Tizona Therapeutics, Inc. to Trishula 
Therapeutics, Inc. 
Change company name to 
Trishula (Tizona’s spin-out 
company) 
7.0 
Sponsor 
Approval Page 
Update Medical Monitor 
Personnel change 
7.0 
Section 1.1 
Synopsis: Revised to align with protocol body 
Consistency 
7.0 
Section 1.2 
Modified study schema to reflect updated 
study design 
Consistency 
7.0 
Section 1.3 
Schedule of assessments:  
- update Tables 1-4  
- remove Tables 5-6 
- add missing D8 gem/nab dosing visits to 
Arm 4 
- add COVID-19 AE collection guidanace 
- removed optional sampling for PK and PD 
correlative blood sample at C1D3 
 
- for consistency with text in 
protocol 
- to align with RP2D dosing 
schedules 
-for clarity and consistency 
 
 
- additional safety monitoring 
7.0 
Section 2.2.2 
Section 2.2.3 
Section 2.3 
 Update clinical data and rationale for RP2D 
dose and schedule 
RP2D dose selection 
7.0 
Section 4.1 
Section 4.1.1.2 
Section 4.5 
Section 4.10 
Section 4.17 
Section 4.18 
-Remove Arm 3 
-Update “n” for expansion arms 
-Update study design as a 
similar population is being 
evaluated in another Trishula 
protocol (TTX-030-002) 
-Clarity 
7.0 
Section 4.1.1.1 
Section 4 
Update DLT evaluation period and RP2D 
dose and schedule 
To reflect RP2D dose and 
schedule 
7.0 
Section 4.4 
Remove dose schedule scenarios 
To reflect established RP2D 
dose and schedule 
7.0 
Section 4.13 
Update dose delays guidance 
Safety monitoring 
7.0 
Section 5.1 
Inclusion Criteria: 
-remove Arm 3 criteria 
Consistency due to removal of 
Arm 3 


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7.0 
Section 6.1.3 
Add vital signs checks for infusion-related-
reaction (IRR) management 
Safety monitoring 
7.0 
Section 6.5.2 
Remove mCRPC requirement 
Consistency due to removal of 
Arm 3 
7.0 
Section 7.2 
Section 9.4 
Add Arm 1 Expansion rule for termination 
Efficacy analysis 
7.0 
Table 11 
Section 8 
Section 8.1 
Remove Arm 3 and update dose and schedules 
To reflect established RP2D 
dose and schedule 
7.0 
Section 8 
Section 8.3.6.4 
Add COVID-19 guidance for AEs/SAEs 
management 
Safety monitoring 
7.0 
Section 8.4.2 
Update Table 13 for PK sample analysis 
Clarity 
7.0 
Section 8.5.2 
Section 1.3 
Update timing for archival tumor biopsy 
collection from 45 to 90 days 
Recruitment flexibility 
7.0 
Section 6.3 
Update ADA analysis 
Program consistency  
7.0 
Section 11.1 
Update protocol amendment history 
Consistency 
6.0 
Entire document 
Updated protocol to a new template 
Update 
6.0 
Entire document 
Minor spelling, grammar, punctuation, 
capitalization, and other formatting edits were 
made throughout the document 
Consistency 
6.0 
Section 1.1 
Synopsis: Revised to align with protocol body 
Consistency 
6.0 
Section 1.2 
Modified study schema to reflect updated 
study design 
Consistency 
6.0 
Section 1.3 
Schedule of assessments:  
- clarified CT/CT-PET scans 
- update Table 2 for tumor assessments and 
serum tumor-associated markers to be 
collected Q2M to Q9W (21-day cycle) 
- add clinical laboratory test to be collected at 
C1D3 
- removed optional sampling for PK and PD 
correlative blood sample at C1D3 
- add PD-L1 to serum tumor-associated 
markers at screening  
- Included dose modification for Arm 4 for 
gemcitabine/nab-paclitaxel 
 
- for consistency with text in 
protocol 
- to align with 21-day cycle 
visits 
 
 
- additional safety monitoring 
 
- optional samples removed 
 
- to assess for this serum 
tumor-associated marker 
- to allow dose modification in 
case of toxicities 
6.0 
Section 1.3 
Section 8.3.5 
Clarify that fibrinogen is only required for 
eligibility (within 14 days of dosing) 
To align with inclusion 
criterion  
6.0 
Section 2.1.3 
Updated indications of pembrolizumab 
New indications have been 
approved since the original 
version of the protocol 
6.0 
Section 3 
 
Updated objectives and endpoints for Arm 1 
and Arm 2 Expansion Cohorts 
To align with randomized 
expansion cohorts 
6.0 
Section 4.4 
Modified loading dose language to remove 
reference to Q2W and Q1W (loading dose on 
Day -14 or Day -7 only).  
Clarification 


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6.0 
Section 4.1.1.2 
Section 4.3 
Section 4.17 
Modified study design for Arm 1 and Arm 2 
expansion from single arm cohort expansion 
to randomized 1:1 to TTX-030 or TTX-030 
and pembrolizumab in subjects with advanced 
or metastatic RCC with a clear-cell 
component and previously treated with up to 3 
lines of prior therapies, including anti-PD-L1 
therapy and TKI therapy.  
To allow for clearer decision 
making than single arm 
expansion 
6.0 
Section 5.1 
Modified the disease-specific inclusion 
criteria for Arm 1 and Arm 2 Expansion 
Cohorts 
Defining of subject 
populations 
6.0 
Section 5.1 
Modified inclusion criteria for Arm 3 to 
clarify the type of prior therapy and to clarify 
that subjects had not previously received 
docetaxel 
Clarify population 
6.0 
Section 5.3 
Updated exclusion criteria to exclude:  
Subjects who are on steroids for any irAE that 
has not resolved, and Grade 3 or higher irAE, 
and ocular or neurologic toxicity of any grade.  
For subject safety 
6.0 
Section 6.1.2 
Clarified that pembrolizumab would be 
provided by Tizona 
Clarity 
6.0 
Section 6.3 
Updated randomization section to refer to 
treatment assignment and randomization for 
Arm 1 and Arm 2 Expansion Cohorts 
To align with randomized 
expansion cohorts 
6.0 
Section 6.5.1 
Clarified allowed prednisone dose 
Clarity 
6.0 
Section 6.13 
Updated treatment regimen description table 
to include optional loading dose 
Consistency 
6.0 
Section 7.3 
Added section entitled Lost to Follow Up 
To define and address lost to 
follow-up subjects 
6.0 
Section 8.2.1 
Clarified that CT scans are to be performed 
unless contraindicated 
Subject safety 
6.0 
Section 8.3.6 
Clarified that AEs/SAEs are to be 
monitored/followed until EOT or 90 days 
(rather than 30 days) after the last dose 
Consistency with safety 
follow-up contact at 60 and 90 
days after the last dose 
6.0 
Section 8.4.2 
Updated description of PK parameter 
estimation 
Clarity 
6.0 
Section 9.1 
Updated definitions of efficacy endpoints to 
from start of study treatment rather than from 
time of randomization 
Modified since the study is not 
randomized (except for Arm 1 
and 2 Expansion Cohorts) 
6.0 
Section 9.2 
Added statistical considerations for Arm 1 and 
Arm 2 Expansion Cohorts 
Added due to modified study 
design 
6.0 
Section 9.3 
Changed “Response Evaluable Population” to 
“Efficacy Evaluable Population” and “Per-
protocol Population” to “MTD Analysis 
Population”. In addition, revised the definition 
of the DLT Evaluable Population 
Clarity 
6.0 
Section 11.3 
Replaced the comparison of RECIST and 
iRECIST table with the version from Seymour 
et al. 2017 
Clarity 
5.0 
Section 2.2.2 
Summarized clinical safety data up to first 
3 subjects in the 40 mg/kg from Study 
TTX-030-001 
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5.0 
Synopsis, 
Section 1.3, 
Section 5.1, 
Section 5.4, 
Section 5.11, 
Section 6.6, 
Table 4, Sections 
9.1-9.3. 
Added text to allow for a TTX-030 loading 
dose to be explored 
Added Schedule of Assessments for loading 
dose visit (Tables 7-12) 
Added PK time points to reflect the loading 
dose intervals (Tables 13-15) 
Based on PK and reaching 
functional trough 
concentration 
4.0 
Synopsis 
Revised to align with protocol body 
Consistency 
4.0 
List of 
Abbreviations, 
Section 2.1.5, 
Section 4.2, 
Section 10.7.2 
Replaced plasma with serum for PK-related 
items 
PK parameters are/were 
measured in serum 
4.0 
Section 2.2 
Summarized clinical safety data up to 
20 mg/kg from Study TTX-030-001  
To support the 20 mg/kg dose 
4.0 
Section 2.1.2, 
Section 5.1, 
Section 5.2, 
Section 5.4, 
Section 5.5, 
Section 5.6, 
Section 5.10, 
Section 5.11, 
Section 5.12, 
Section 5.13, 
Section 5.15, 
Section 5.17, 
Section 6.2, 
Section 13 
Added 2 higher dose levels (20 and 40 mg/kg) 
for monotherapy dose escalation (Arm 1) and 
allowed for several doses and schedules to be 
tested (added Q2W and Q4W). 
Changed the combination-therapy dose-
escalation arms (Arms 2-4) to safety lead-in 
arms. These arms are to start at the RP2D to 
be identified in the monotherapy dose-
escalation arm (Arm 1). Modified the text 
throughout the protocol to reflect this change. 
Added a study design schema (Figure 10). 
Based on PK and safety higher 
doses and varying schedules 
are being explored 
4.0 
Section 6.1 
Modified the disease-specific inclusion 
criteria for Arm 3 and Arm 4. 
Defining of subject 
populations 
4.0 
Section 6.6, 
Section 6.7, 
Section 9, 
Section 10.5, 
Section 10.5.1, 
Section 10.5.2, 
Section 10.6.2, 
Section 10.6.3, 
Section 10.7.1, 
Section 10.7.2, 
Section 10.8.1, 
Section 10.8.2, 
Section 10.9, 
Section 10.10 
Added Schedule of Assessments for the Q4W 
schedule – Arm 1 (Table 11/Table 12) and 
included Arm 1 in the existing Schedule of 
Assessments for Q2W schedule 
(Table 9/Table 10). 
Added PK sampling interval tables for Q3W 
schedule (Table 13), Q2W schedule 
(Table 14), and Q4W schedule (Table 15). 
Added to support the varying 
schedules being explored 
3.0 
Protocol 
Approval Page 
Replaced Angela Shen with Joyson 
Karakunnel as medical monitor 
New Chief Medical Officer 
3.0 
Synopsis 
Revised to align with protocol body 
Consistency 
3.0 
Section 5.1, 
Section 5.2, 
Section 5.7, 
Section 5.11, 
Added text to indicate that a traditional 3 + 3 
dose-escalation design will be implemented 
for doses > 10 mg/kg 
Due to evaluation of higher 
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Section 5.16, 
Section 13 
2.0 
Section 5.11 
Clarification of DLT definition 
Request from FDA 
2.0 
Section 6.1, 6.2 
Clarification of eligibility criteria #1, 4, and 
25 
Request from FDA 
2.0 
Section 8.3, 8.4 
Guidance provided on management of TLS 
and CRS 
Request from FDA 
2.0 
Section 5.18 
Section 9 
Table 8, 10 
Added follow-up safety contact at 60 and 90 
days (± 7 days) after last dose of study drug  
Request from FDA 
2.0 
Table 7 
Corrected footnotes d and e  
Correction of typo  
1.1 
Section 2.1 
Updated data from non-human primate PK 
study 
Final report completed 
 
DOCUMENT HISTORY 
Document 
Date 
Version 8.0 Amendment 8 (Trishula) 
15 Dec 2020 
Version 7.0 Amendment 7 (Trishula) 
12 Oct 2020 
Version 6.0 Amendment 6 
2 Jan 2020 
Version 5.0 Amendment 5 
22 Nov 2019 
Version 4.0 Amendment 4 
21 Oct 2019 
Version 3.0 Amendment 3 
12 Sep 2019 
Version 2.0 Amendment 2 
28 Dec 2018 
Version 1.1 Amendment 1 
24 Oct 2018 
Original Protocol  
01 Oct 2018 
 
 


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11.2. 
Appendix 2: Eastern Cooperative Oncology Group Performance 
Status 
 
Grade  
Description 
0 
Fully active, able to carry on all pre-disease performance without restriction  
1 
Restricted in physically strenuous activity but ambulatory and able to carry out work of a 
light or sedentary nature, eg, light housework, office work  
2 
Ambulatory and capable of all self-care; but unable to carry out any work activities. Up 
and about more than 50% of waking hours  
3 
Capable of only limited self-care; confined to bed or chair more than 50% of waking hours  
4 
Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair  
5 
Dead 
Source: Oken et al. 1982. 
 
 
 


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11.3. 
Appendix 3: RECIST and iRECIST 
 
Comparison of RECIST and iRECIST 
 
RECIST 1.1 
iRECIST 
Definitions of 
measurable and 
nonmeasurable 
disease; numbers and 
site of target disease 
Measurable lesions are ≥ 10 mm in 
diameter (≥ 15 mm for nodal lesions); 
maximum of 5 lesions (2 per organ); all 
other disease is considered non-target 
(must be ≥ 10 mm in short axis for nodal 
disease) 
No change from RECIST 1.1; however, new 
lesions are assessed as per RECIST 1.1 but 
recorded separately on the case report form 
(but not included in the sum of lesions for 
target lesions identified at baseline) 
CR, PR, or SD 
Cannot have met criteria for progression 
before CR, PR, or SD 
Can have had iUPD (1 or more instances), 
but not iCPD, before iCR, iPR, or iSD 
Confirmation of CR 
or PR 
Only required for non-randomized trials 
As per RECIST 1.1 
Confirmation of SD 
Not required 
As per RECIST 1.1 
New lesions 
Result in progression; recorded but not 
measured 
Results in iUPD but iCPD are only assigned 
on the basis of this category if at next 
assessment additional new lesions appear or 
an increase in size of new lesions is seen 
(≥ 5 mm for sum of new lesion target or any 
increase in new lesion non-target); the 
appearance of new lesions when none have 
previously been recorded can also confirm 
iCPD 
Independent blinded 
review and central 
collection of scans 
Recommended in some circumstances 
(eg, in some trials with progression-
based endpoints planned for marketing 
approval) 
Collection of scans (but not independent 
review) recommended for all trials 
Confirmation of 
progression 
Not required (unless equivocal) 
Required 
Consideration of 
clinical status 
Not included in assessment 
Clinical stability is considered when 
deciding whether treatment is continued 
after iUPD 
Abbreviations:  CPD = confirmed progressive disease; CR = complete response; iRECIST = immune-related Response 
Evaluation Criteria in Solid Tumors; PR = partial response; RECIST = Response Evaluation Criteria in Solid Tumors; 
SD = stable disease; UPD = unconfirmed progressive disease. NOTE: “i” indicates immune responses assigned using iRECIST. 
Source: Seymour et al. 2017. 
 
 


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11.4. 
Appendix 4: Response Criteria for Metastatic Prostate Cancer 
(Based on Prostate Cancer Clinical Trials Working Group 3 
Criteria) 
 
Prostate-specific Antigen  
As long as subject safety is the primary concern, in the absence of other indicators of disease 
progression, therapy should not be discontinued solely on the basis of a rise in PSA.  
PSA progression is defined as the date that a 25% or greater increase and an absolute increase of 
2 ng/mL or more from the nadir are documented and confirmed by a second value obtained 3 or 
more weeks later. Where no decline from baseline is documented, PSA progression is defined as 
a 25% increase from the baseline value along with an increase in absolute value of 2 ng/mL or 
more after 12 weeks of treatment. 
Bone 
Record post-treatment changes as either “no new lesions” or “new lesions.” 
Progressing disease on bone scan is considered when at least 2 new lesions are observed. If these 
2 or more new lesions are identified at the first post-treatment bone scans, progression remains 
unconfirmed unless at least 2 additional new lesions appear at a subsequent time point at least 
6 or more weeks later (“2 + 2” rule). This is intended to account for bone scan flare response that 
is generally seen at earlier time points. If progression (defined as at least 2 new lesions on bone 
scan) is first identified at a time point beyond the first post-treatment bone scan (ie, beyond the 
typical flare response window), then these 2 (or more) lesions should be confirmed on a 
subsequent bone scan, performed at least 6 weeks later. When further progression is documented 
on the confirmatory scan, the date of progression recorded for the trial is the date of the first scan 
that shows the change.  


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Prostate Cancer Clinical Trials Working Group Outcome Measures 
Variable 
Prevent/Delay Endpoints 
PSA 
Decline from baseline: record time from start of therapy to first 
PSA increase that is ≥ 25% and ≥ 2 ng/mL above the nadir and that 
is confirmed by a second value 3 or more weeks later (ie, a 
confirmed rising trend)a 
No decline from baseline: PSA progression ≥ 25% from baseline 
and ≥ 2 ng/mL increase from baseline after 12 weeks 
Soft-tissue lesions 
Use iRECIST criteria  
Bone 
The appearance of approximately 2 new lesions, and, for the first 
reassessment only, a confirmatory scan performed 6 or more weeks 
later that shows at least 2 or more additional new lesions (“2 + 2” 
rule).  
 
If progression (2 or more new lesions) is identified at a time point 
beyond the first post-treatment scan, then these lesions must be 
confirmed on a subsequent scan. 
 
The date of progression is the date of the first scan that shows the 
change 
Abbreviations: iRECIST = immune-related Response Evaluation Criteria in Solid Tumors, 
PSA = prostate-specific antigen. 
a Particularly important when anticipated effect on PSA is delayed or for biologic therapies. 
Source: Scher et al. 2016 
 
 
 


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11.5. 
Appendix 5: Response Criteria for Lymphoma 
 
Comparison of Response Based on PET-CT and CT 
Response and Site 
PET-CT-Based Response 
CT-Based Response 
Complete 
Complete metabolic response 
Complete radiologic 
response (all of the 
following) 
Lymph nodes and 
extralymphatic sites 
Score 1, 2, or 3a with or without a 
residual mass on 5-PSb 
 
It is recognized that in Waldeyer’s 
ring or extranodal sites with high 
physiological uptake or with 
activation within spleen or marrow, 
eg, with chemotherapy or myeloid 
colony stimulating factors, uptake 
may be greater than normal 
mediastinum and/or liver. In this 
circumstance, complete metabolic 
response may be inferred if uptake at 
sites of initial involvement is no 
greater than surrounding normal 
tissue even if the tissue has high 
physiological uptake 
Target nodes/nodal masses 
must regress to ≤ 1.5 cm in 
LDi 
 
No extralymphatic sites of 
disease 
Non-measured lesion 
N/A 
Absent 
Organ enlargement 
N/A 
Regress to normal 
New lesions 
None 
None 
Bone marrow 
No evidence of FDG-avid disease in 
marrow 
Normal by morphology; if 
indeterminate, 
immunohistochemistry 
negative 


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Response and Site 
PET-CT-Based Response 
CT-Based Response 
Partial 
Partial metabolic response 
Partial remission (all of the 
following) 
Lymph nodes and 
extralymphatic sites 
Score 4 or 5b with reduced uptake 
compared with baseline and residual 
mass(es) of any size  
At interim these findings suggest 
responding disease 
 
At End of Treatment these findings 
indicate residual disease 
≥ 50% decrease in SPD of 
up to 6 target measurable 
nodes and extranodal sites 
When a lesion is too small to 
measure on CT, assign 5 mm 
× 5 mm as the default value 
When no longer visible, 
0 mm × 0 mm 
For a node > 5 mm × 5 mm, 
but smaller than normal, use 
actual measurement for 
calculation 
Non-measured lesions 
N/A 
Absent/normal, regressed, 
but no increase 
Organ enlargement 
N/A 
Spleen must have regressed 
by > 50% in length beyond 
normal 
New lesions 
None 
None 
Bone marrow 
Residual uptake higher than uptake 
in normal marrow but reduced 
compared with baseline (diffuse 
uptake compatible with reactive 
changes from chemotherapy 
allowed). If there are persistent focal 
changes in the marrow in the context 
of a nodal response, consideration 
should be given to further evaluation 
with MRI or biopsy, or an interval 
scan 
N/A 


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Response and Site 
PET-CT-Based Response 
CT-Based Response 
No response or stable 
disease (SD) 
No metabolic response 
Stable disease 
Target nodes/nodal 
masses, extranodal 
lesions 
No response: score 4 or 5 with no 
significant change in FDG uptake 
from baseline, at interim or End of 
Treatment 
Stable disease: < 50% 
decrease from baseline in 
SPD of up to 6 dominant, 
measurable nodes and 
extranodal sites; no criteria 
for PD are met 
Non-measured lesions 
N/A 
No increase consistent with 
progression 
Organ enlargement 
N/A 
No increase consistent with 
progression 
New lesions 
None 
None 
Bone marrow 
No change from baseline 
N/A 


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Response and Site 
PET-CT-Based Response 
CT-Based Response 
Progressive disease  
Progressive metabolic disease 
Progressive disease 
requires at least 1 of the 
following 
Individual target 
nodes/nodal masses, 
extranodal lesions 
Score 4, 5 with an increase in 
intensity of uptake from baseline 
and/or new FDG-avid foci consistent 
with lymphoma at interim or End of 
Treatment assessment 
PPD progression: 
An individual node must be 
abnormal with: 
• LDi >1.5 cm 
• Increase by ≥50% from 
PPD nadir 
An increase in LDi or SDi 
from nadir 
• 0.5 cm for lesions ≤ 2 cm 
• 1.0 cm for lesions > 2 cm 
In the setting of 
splenomegaly, the splenic 
length must increase by 
> 50% of the extent of its 
 
 
prior increase beyond 
baseline (eg, a 15 cm spleen 
must increase to > 16 cm). If 
no prior splenomegaly, must 
increase by at least 2 cm 
from baseline 
New or recurrent 
splenomegaly 
Non-measured lesions 
None 
New or clear progression of 
pre-existing non-measured 
lesions 


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Response and Site 
PET-CT-Based Response 
CT-Based Response 
New lesions 
New FDG-avid foci consistent with 
lymphoma rather than another 
etiology, eg, infection, inflammation. 
If uncertain regarding etiology of 
new lesions, biopsy or interval scan 
may be considered 
Regrowth of previously 
resolved lesions 
A new node > 1.5 cm in any 
axis 
A new extranodal site 
> 1.0 cm in any axis if less 
than 1.0 cm in any axis, its 
presence must be 
unequivocal and must be 
attributable to lymphoma 
Assessable disease of any 
size unequivocally 
attributable to lymphoma 
Bone marrow 
New or recurrent FDG avid foci 
New or recurrent 
involvement 
Abbreviations: 5-PS = 5-point scale, CT = computed tomography, FDG = fluorodeoxyglucose, LDi = longest 
transverse diameter of a lesion, MRI = magnetic resonance imaging, N/A = not applicable, PD = progressive 
disease, PET = positron emission tomography, PPD = cross product of the LDi and perpendicular diameter, 
SDi = shortest axis perpendicular to the LDi, SPD = sum of the product of the perpendicular diameters for 
multiple lesions. 
a Score 3 in many individuals indicates a good prognosis with standard treatment, especially if at the time of an 
interim scan. However, in trials involving PET where de-escalation is investigated, it may be preferable to 
consider score 3 as inadequate response (to avoid under-treatment).  
Measured dominant lesions: Up to 6 of the largest dominant nodes, nodal masses, and extranodal lesions selected 
to be clearly measurable in 2 diameters. Nodes should preferably be from disparate regions of the body and 
should include, where applicable, mediastinal and retroperitoneal areas. Non-nodal lesions include those in solid 
organs, eg, liver, spleen, kidneys, lungs, etc., gastrointestinal involvement, cutaneous lesions of those noted on 
palpation. Non-measured lesions: any disease not selected as measured, dominant disease and truly assessable 
disease should be considered not measured. These sites include any nodes, nodal masses, and extranodal sites not 
selected as dominant, measurable, or which do not meet the requirements for measurability but are still 
considered abnormal. In addition, they include truly assessable disease, which is any site of suspected disease 
that would be difficult to follow quantitatively with measurement, including pleural effusions, ascites, bone 
lesions, leptomeningeal disease, abdominal masses, and other lesions that cannot be confirmed and followed by 
imaging. In Waldeyer’s ring or in extranodal sites, eg, gastrointestinal tract, liver, and bone marrow, FDG uptake 
may be greater than mediastinum with complete metabolic response but should be no higher than surrounding 
normal physiological uptake, eg, with marrow activation due to chemotherapy or myeloid growth factors.  
b PET 5-PS: 1, no uptake above background; 2, uptake ≤ mediastinum; 3, uptake > mediastinum, but ≤ liver; 4, 
uptake moderately > liver; 5, uptake markedly higher than liver and/or new lesions; X, new areas of uptake 
unlikely to be related to lymphoma. 
 


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Features Distinguishing Between Lugano and LYRIC 
Criteria  
Complete 
Response 
Partial 
Response Progressive Disease 
LYRIC 
Same as 
Lugano  
Same as 
Lugano  
As with Lugano with the following exceptions: 
IR 
IR(1): > 50% increase in SPD in first 12 weeks  
IR(2): < 50% increase in SPD with 
New lesion(s), or 
> 50% increase in PPD of a lesion or set of lesions at any 
time during treatment 
IR(3): Increase in FDG uptake without a concomitant 
increase in lesion size meeting criteria for PD. 
Abbreviations: FDG = fluorodeoxyglucose, IR = immune response; LYRIC = LYmphoma Response to 
Immunomodulatory Therapy Criteria, PD = progressive disease; PPD = cross product of the longest transverse 
diameter of a lesion and perpendicular diameter; SPD = sum of the product of the diameters. 
Source: Cheson et al. 2016 
 
 


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11.6. 
Appendix 6: Adaptive Design Report for the Phase I Dose Escalation 
Study of TTX-030 in Patients with Lymphoma or Solid Tumor 
Malignancies 
 
Note: This appendix only applies to the monotherapy dose-escalation portion of the study.  
Submitted to Trishula 
By Berry Consultants 
 
 
1.0 
Introduction 
2.0 
Dose Escalation 
2.1 Overview 
2.2 DLT Observation Period 
2.3 Dose-Toxicity Model 
2.4 Dose Escalation Rules 
2.4.1 Entry into the Study 
2.4.2 Assignment of Dose Levels 
2.5 Interim Monitoring 
2.5.1 Safety Monitoring 
2.5.2 Success in Identifying the MTD 
3.0 
Example Trials 
4.0 
Single Agent Operating Characteristics 
4.1 Simulation Assumptions 
4.2 Simulation Scenarios 
4.2.1 All Doses Safe 
4.2.2 No Doses Safe 
4.2.3 True MTD = 2 mg/kg 
4.2.4 True MTD = 5 mg/kg 
4.2.5 True MTD = 8 mg/kg 
4.2.6 True MTD = 3 mg/kg 
4.2.7 True MTD = 6 mg/kg 
5.0 
Combination Operating Characteristics 
5.1 First Dosing Cohort Behavior 
5.2 Operating Characteristics 
 
1.0 Introduction 
This is a Phase I dose-escalation study of TTX-030 in patients with lymphoma or solid tumor 
malignancies. The primary objective of this trial is to characterize the dose-toxicity relationship 
and to estimate the maximum tolerated dose (MTD) that will help determine the RP2D for each 
arm. Dose escalation to determine the MTD will be conducted according to a modified continual 
reassessment method (mCRM). The single-agent investigation may enroll up to 21 subjects. 


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Safety lead-in combination investigations may enroll up to 12 subjects. The single-agent and the 
combination investigations will be conducted independently and identically with the exception of 
the starting dose.   
2.0 Dose Escalation 
2.1 Overview 
The primary objective of the dose escalation portion of the study is to estimate an MTD to help 
determine the RP2D. We target a dose-limiting toxicity (DLT) rate of 30% and define the MTD 
as the highest safe dose where the DLT rate is closest to 30%.   
There are a total of 11 possible dose levels between 0.5 mg/kg and 10 mg/kg. Dose levels are 
shown in Table 1. These include a set of primary dose levels (indicated by asterisks) as well as 
several intermediate dose levels. 
Table 1: Dose Levels  
Dose in mg/kg 
Dose Level 
Modeled as  
( vd) 
0.5* 
1 
1.5* 
2 
2 
3 
3* 
4 
4 
5 
5 
6 
6* 
7 
7 
8 
8 
9 
9 
10 
10* 
11 
 
Dose escalation will be conducted according to a mCRM. Dose escalation is also conducted 
according to a set of rules that govern entry into the study and assignment of dose level. These 
rules allow skipping untried dose levels provided they are estimated to be safe. The trial is 
continuously monitored for safety and for early stopping for successfully identifying the MTD. 
2.2 DLT Observation Period 


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The DLT observation period, for the purpose of dose-escalation, is one cycle. One cycle is 
3 weeks in length for the single agent. Once a subject has completed this first cycle DLT 
observation period, the subject will be considered to have complete DLT information for the 
purposes of making dose escalation decisions for the next subject enrolling into the trial.   
2.3 Dose-Toxicity Model 
For each dose we model the log-odds of a DLT, π, at each dose level with a 2-parameter model, 
log (
πd
1 −πd
) = α + β(vd). 
where vd is the modeled dose level as show in Table 1.   
We place the following prior distributions on the model parameters:  
[
α
ln (β)] ~N [[
μα
μβ] , [
σα
2
ρσασβ
ρσασβ
σβ
2
]] 
where 
μα = −4 and σα= 2.5 
μβ= −1.6 and σβ = 0.9 
ρ = 0. 
Figure 1 shows 100 draws from the prior dose-toxicity curve. The solid blue line corresponds to 
the mean probability of a DLT at each dose. The dotted blue lines correspond to 95% confidence 
interval (CI) for the probability of a DLT at each dose. The MTD based on the prior distribution 
is 9 mg/kg, but with large uncertainty.   


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Figure 1: Prior dose-toxicity curve. The solid blue line represents the mean probability of a DLT 
at each dose. The gray lines represent draws from the prior distribution. The dotted blue lines 
show the 95% confidence interval around the probability of DLT at each dose level. The dotted 
red line is at 30% for reference. 
The model will be updated as frequently as necessary. In particular, the model may be updated as 
each dosing cohort is treated and assessed for DLT. When the model is updated, the distributions 
of all parameters are updated using Markov chain Monte Carlo methods and the MTD is 
estimated based on the posterior probability of DLT at each dose.   
Additionally, we define a dose as safe if there is at least a 45% probability that the DLT rate is 
less than 30%,  
Pr(πvd < 30%) > 45%. 
If the DLT rate is estimated to be exactly 30%, the Pr(πd < 30%) will be approximately 50%. 
Therefore, only doses with a mean estimated DLT rate close to 30% will be considered safe by 
this definition. 
0.0
0.2
0.4
0.6
0.8
1.0
Dose
Pr Tox
0.5
1.5
2
3
4
5
6
7
8
9
10


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2.4 Dose Escalation Rules 
2.4.1 Entry into the Study 
Dose escalation for the single agent begins with a run-in of a single subject on the 0.5 mg/kg 
dose. Beginning with the next subject enrolled, this trial will enroll in dosing cohorts. Dosing 
cohorts will be 2 subjects until the first Grade 2 toxicity related to study treatment or a DLT is 
observed. After that, dosing cohorts will be 3 subjects. 
Dose escalation for the combinations may begin at a higher dose level depending on which dose 
levels have already been determined to be safe in the single-agent investigation. For the 
combination investigations, enrollment will begin with dosing cohorts. 
2.4.2 Assignment of Dose Levels 
The dose-toxicity model will be used to determine which doses are safe and to assign subjects to 
doses, ie, to assign subjects to the highest safe dose. However, assignment of dose levels is also 
governed by rules concerning the speed of dose escalation and rules that determine what untried 
dose levels may be skipped. 
When the dose is escalated, it may only escalate to the highest safe dose that is no more than a 
100% increase over the current dose level. The only exception to this is the escalation from the 
0.5 mg/kg dose to the 1.5 mg/kg dose. Therefore, the fastest dose escalation for the single agent 
that could occur would be 0.5 mg/kg to 1.5 mg/kg, then 3 mg/kg, 6 mg/kg, and then finally to 
10 mg/kg (skipping all intermediate dose levels). If the dose must be de-escalated, the dose will 
de-escalate to the highest safe dose regardless of how large a decrease in dose level. 
As long as no Grade 2 toxicity related to study drug or DLT has yet been observed, there must be 
complete DLT information on at least 2 subjects at the current dose level in order to escalate 
(with the exception of the single subject required at the 0.5 mg/kg dose for the single agent). 
Once the first Grade 2 toxicity related to study drug or DLT is observed in the trial, there must be 
complete DLT information on at least 3 subjects at the current dose level in order to escalate.  
2.5 Interim Monitoring 
Dose escalation will be continuously monitored for safety and for success in identifying the 
MTD. In this section, we describe the prespecified rules to stop the dose-escalation early. If the 
dose-escalation is not stopped early, dose escalation will stop when the maximum number of 
subjects has been enrolled. This is 25 subjects for the single agent and 12 subjects for each 
combination. At that time, the MTD will be the highest safe dose as estimated by the dose 
toxicity model.   
 
 


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2.5.1 Safety Monitoring 
If no doses are safe, dose escalation will stop and no MTD will be declared. Formally if all  
Pr(d < 30%) < 45% for all vd = 1,…11 
then the trial will stop early for safety. 
2.5.2 Success in Identifying the MTD 
Dose escalation may be stopped early when we are sufficiently confident the MTD has been 
identified. We define this as having 6 subjects with complete DLT information at the current 
estimate of the MTD.   
 
 
 


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3.0 Example Trials 
In this section we show a single simulated trial in order to illustrate the dose-toxicity modeling 
and dose escalation decisions of the mCRM.   
Figure 2 shows the allocation of the first 3 subjects in the trial. The trial begins with the single 
agent with a single subject run-in on the 0.5 mg/kg dose level. This subject experiences no 
toxicity and the dose is escalated. Dosing cohorts begin after this single subject run-in. The first 
dosing cohort of size 2 is enrolled at the 1.5 mg/kg dose. Neither of these subjects experiences a 
toxicity event. The highest safe dose is estimated to be 10 mg/kg; however, the largest increase 
allowed is a 100% increase.   
 
Figure 2: Example trial with 3 total subjects enrolled. The left panel shows subject allocation 
where each dot represents one subject. The right panel shows the dose-toxicity model estimates. 
The solid red line is the mean and the dotted red lines show the 95% confidence interval. The 
black horizontal reference line is at 30% for reference and the black vertical reference line 
indicates the highest safe dose. 
 


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Figure 3: Example trial with 5 total subjects enrolled. The left panel shows subject allocation 
where each dot represents one subject. The right panel shows the dose-toxicity model estimates. 
The solid red line is the mean and the dotted red lines show the 95% confidence interval. The 
black horizontal reference line is at 30% for reference and the black vertical reference line 
indicates the highest safe dose. 
The next dosing cohort is enrolled at 3 mg/kg (Figure 3). One of these subjects experiences a 
DLT. The highest safe dose level is now estimated to be 4 mg/kg. When either a Grade 2 toxicity 
related to study drug or a DLT is observed, the dosing cohort size must expand to 3 subjects. 
Because 3 mg/kg is still considered safe, a third subject is added to the 3 mg/kg dose (Figure 4). 


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Figure 4: Example trial with 6 total subjects enrolled. The left panel shows subject allocation 
where each dot represents one subject. The right panel shows the dose-toxicity model estimates. 
The solid red line is the mean and the dotted red lines show the 95% confidence interval. The 
black horizontal reference line is at 30% for reference and the black vertical reference line 
indicates the highest safe dose.   
This third subject does not experience a DLT, and the highest safe dose is now 5 mg/kg 
(Figure 4), one of the intermediate doses. The observed toxicity results in the model slowing 
down the escalation so that the next dose is a 67% increase from the current dose. A dosing 
cohort of 3 subjects is enrolled at the 5 mg/kg dose (Figure 5).   


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Figure 5: Example trial with 9 total subjects enrolled. The left panel shows subject allocation 
where each dot represents one subject. The right panel shows the dose-toxicity model estimates. 
The solid red line is the mean and the dotted red lines show the 95% confidence interval. The 
black horizontal reference line is at 30% for reference and the black vertical reference line 
indicates the highest safe dose.   
One of the subjects at 5 mg/kg experiences a DLT (Figure 5). The 5 mg/kg remains the highest 
safe dose, and a second dosing cohort of 3 subjects is added to the 5 mg/kg dose (Figure 6). 


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Figure 6: Example trial with 12 total subjects enrolled. The left panel shows subject allocation 
where each dot represents one subject. The right panel shows the dose-toxicity model estimates. 
The solid red line is the mean and the dotted red lines show the 95% confidence interval. The 
black horizontal reference line is at 30% for reference and the black vertical reference line 
indicates the highest safe dose. 
We have now observed 1 DLT out of 6 subjects on the 5 mg/kg dose (Figure 6). The highest safe 
dose is 7 mg/kg. A dosing cohort of 3 subjects is added to 7 mg/kg, and 2 of these subjects 
experience a DLT (Figure 7). 


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Figure 7: Example trial with 15 total subjects enrolled. The left panel shows subject allocation 
where each dot represents one subject. The right panel shows the dose-toxicity model estimates. 
The solid red line is the mean and the dotted red lines show the 95% confidence interval. The 
black horizontal reference line is at 30% for reference and the black vertical reference line 
indicates the highest safe dose. 
The dose is de-escalated, and the highest safe dose is 5 mg/kg (Figure 7). There are already 
6 subjects with complete DLT information at 5 mg/kg and this trial stops early for having 
identified the MTD.  
4.0 Single-Agent Operating Characteristics 
We evaluate the design by clinical trial simulation. We hypothesize several possible underlying 
truths of the dose-toxicity curve and determine how the trial will behave in those scenarios. For 
example, if all the doses were toxic, we would want the trial to recognize that all doses were 
unsafe and stop as soon as possible. If the smaller doses are safe and a higher dose is in truth the 
MTD, we would like the algorithm to identify a dose near the MTD as much as possible. The 
same design can ideally handle different scenarios. Note that this ideal is difficult to achieve in 
practice with any Phase 1 design due to the small sample sizes. 
4.1 Simulation Assumptions 
We consider 7 scenarios for the dose-toxicity relationship to characterize the mCRM for 
different possible underlying truths for the probability of DLT at each dose level. Each scenario 
assumes the probability of Grade 2 toxicities related to study drug are a constant increase from 


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the probability of DLT on the log-odds scale. For technical reasons, simulations always assume 
that the run-in subject assigned to the 0.5 mg/kg dose level experiences no Grade 2 toxicity or 
DLT. This subject is included in the simulations as a “pseudo-subject” and as such is not 
reflected in the mean sample size or mean number of DLT operating characteristics presented 
below.   
4.2 Simulation Scenarios 
Figure 8 shows the different simulation scenarios used to characterize the performance of the 
mCRM. We consider a scenario in which all doses are considered safe, a scenario in which no 
doses are considered safe, and then explore other dose-toxicity curves where the true MTD is in 
various locations across the dose range.   
 
Figure 8: Dose-toxicity scenarios. The red line indicates the probability of DLT, and the pink 
line indicates the probability of a Grade 2 or higher toxicity. The horizontal line is at 30% for 
reference. 
 
 
0.0
0.2
0.4
0.6
0.8
1.0
All Safe
Dose
Probability of Toxicity
0.5
2
3
4
5
6
7
8
9
10
Pr(DLT)
Pr(Grade2)
0.0
0.2
0.4
0.6
0.8
1.0
None Safe
Dose
Probability of Toxicity
0.5
2
3
4
5
6
7
8
9
10
0.0
0.2
0.4
0.6
0.8
1.0
2mg
Dose
Probability of Toxicity
0.5
2
3
4
5
6
7
8
9
10
0.0
0.2
0.4
0.6
0.8
1.0
5mg
Dose
Probability of Toxicity
0.5
2
3
4
5
6
7
8
9
10
0.0
0.2
0.4
0.6
0.8
1.0
8mg
Dose
Probability of Toxicity
0.5
2
3
4
5
6
7
8
9
10
0.0
0.2
0.4
0.6
0.8
1.0
3mg
Dose
Probability of Toxicity
0.5
2
3
4
5
6
7
8
9
10
0.0
0.2
0.4
0.6
0.8
1.0
6mg
Dose
Probability of Toxicity
0.5
2
3
4
5
6
7
8
9
10


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4.1.1 All Doses Safe 
In this scenario all doses are considered safe. The true MTD is 10 mg/kg with a DLT rate of 
18%. The 10 mg/kg dose is the dose most likely to be selected as the MTD. There is a 97% 
probability of selecting 10 mg/kg dose as the MTD. The total mean number of subjects in this 
scenario is 13.7. The mean samples sizes per dose reflect the skipping rules that allow untried 
doses to be skipped. On average, most subjects are allocated to the primary dose levels, with 
fewer subjects allocated to the intermediate dose levels. 
Scenario 1: All Doses Safe 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.00 
0.00 
0.00 
0.01 
0.01 
0.02 
0.03 
0.05 
0.08 
0.12 
0.18 
Mean N 
0 
2.0 
0.0 
2.0 
0.0 
0.1 
2.2 
0.0 
0.5 
0.3 
6.5 
Mean 
DLTs 
0.00 
0.00 
0.00 
0.01 
0.00 
0.00 
0.07 
0.00 
0.04 
0.04 
1.16 
Pr(MTD) 
0 
0 
0 
0 
0 
0 
0 
0.003 
0.02 
0.02 
0.97 
 
4.1.2 No Doses Safe 
In this scenario, none of the dose levels would be considered safe. The lowest dose level, 
0.5 mg/kg has a DLT rate of 49%. This lowest dose is selected as the MTD with 12% 
probability. There is a 69% probability of stopping for toxicity and selecting no dose as the 
MTD. The total mean number of subjects in this scenario is 9. The operating characteristics of 
this scenario may be slightly more aggressive than in truth due to the simulation assumption that 
the first run-in subject on the 0.5 mg/kg dose level does not experience a toxicity.   


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Scenario 2: No Doses Safe 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.49 
0.55 
0.60 
0.64 
0.67 
0.70 
0.72 
0.74 
0.76 
0.78 
0.79 
Mean N 
2.7 
4.0 
0.5 
1.6 
0.1 
0.1 
0.1 
0.0 
0.0 
0.0 
0.0 
Mean 
DLTs 
1.3 
2.2 
0.3 
1 
0.0 
0.1 
0.0 
0.0 
0.0 
0 
0.0 
Pr(MTD) 
0.12 
0.14 
0.01 
0.03 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
 
4.1.3 True MTD = 2 mg/kg 
In this scenario the true MTD is 2 mg/kg with a DLT rate of 26%. This dose is declared as the 
MTD with 31% probability. The 3 mg/kg dose is slightly more likely to be selected as the MTD. 
The 3 mg/kg dose has a true DLT rate of 41% is selected as the MTD with 41% probability. The 
probability of selecting a dose within 1 dose level of the true MTD is 22% + 31% + 41% = 94%. 
A mean of 5 subjects are enrolled at the 3 mg/kg dose and a mean of 2 DLTs are observed. The 
total mean number of subjects in this scenario is 14.5. 
Scenario 3: 2 mg/kg 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.08 
0.15 
0.26 
0.41 
0.59 
0.74 
0.85 
0.92 
0.96 
0.98 
0.99 
Mean N 
0.5 
3.9 
2.8 
4.8 
0.5 
1.3 
0.6 
0.0 
0.0 
0.0 
0.0 
Mean 
DLTs 
0.0 
0.6 
0.7 
2.0 
0.3 
0.9 
0.5 
0.0 
0.0 
0.0 
0.0 
Pr(MTD) 
0.02 
0.22 
0.31 
0.41 
0.01 
0.01 
0.00 
0.00 
0.00 
0.00 
0.00 
 
4.1.4 True MTD = 5 mg/kg 
The true MTD in this scenario is 5 mg/kg with a true DLT rate of 29%. This dose is the mostly 
likely to be selected as the MTD and is selected with 25% probability. There is 57% probability 
of selecting a dose within 1 dose level of the true MTD. The total mean number of subjects is 
17.6. 


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Scenario 4: 5 mg/kg 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.08 
0.11 
0.14 
0.18 
0.23 
0.29 
0.35 
0.43 
0.50 
0.57 
0.65 
Mean N 
0.1 
2.7 
0.5 
3.6 
1.0 
2.8 
2.9 
1.2 
1.3 
0.5 
1.0 
Mean 
DLTs 
0.0 
0.3 
0.1 
0.7 
0.2 
0.8 
1.0 
0.5 
0.7 
0.3 
0.6 
Pr(MTD) 
0.00 
0.02 
0.03 
0.16 
0.10 
0.25 
0.22 
0.09 
0.07 
0.02 
0.02 
 
4.1.5 True MTD = 8 mg/kg 
The true MTD in this scenario is 8 mg/kg with a true DLT rate of 26%. This dose is selected as 
the MTD with 22% probability. The 10 mg/kg dose, which has a true DLT rate of 41% is 
selected as the MTD with 46% probably. A mean of 4.2 subjects are enrolled at the 10 mg/kg 
dose and a mean of 1.7 DLTs are observed. The total mean sample size in this scenario is 17.6. 
Scenario 5: 8 mg/kg 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.02 
0.03 
0.04 
0.06 
0.08 
0.11 
0.15 
0.20 
0.26 
0.33 
0.41 
Mean N 
0.0 
2.2 
0.1 
2.5 
0.1 
0.8 
3.0 
1.1 
2.6 
1.1 
4.2 
Mean 
DLTs 
0.0 
0.1 
0.0 
0.2 
0.0 
0.1 
0.5 
0.2 
0.7 
0.4 
1.7 
Pr(MTD) 
0.00 
0.00 
0.00 
0.01 
0.00 
0.03 
0.09 
0.10 
0.22 
0.08 
0.46 
 
4.1.6 True MTD = 3 mg/kg 
The true MTD in this scenario is 3 mg/kg with a DLT rate of 24%. This dose is the most likely to 
be selected as the MTD and is selected with 56% probability. The total mean sample size in this 
scenario is 16. 
Scenario 6: 3 mg/kg 


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0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.03 
0.06 
0.13 
0.24 
0.40 
0.60 
0.76 
0.87 
0.94 
0.97 
0.99 
Mean N 
0.1 
2.6 
1.6 
5.4 
2.0 
2.5 
1.6 
0.0 
0.2 
0.0 
0.0 
Mean 
DLTs 
0.0 
0.2 
0.2 
1.3 
0.8 
1.5 
1.2 
0.0 
0.2 
0.0 
0.0 
Pr(MTD) 
0.00 
0.03 
0.15 
0.56 
0.18 
0.08 
0.01 
0.00 
0.00 
0.00 
0.00 
 
4.1.7 True MTD = 6 mg/kg 
The true MTD in this scenario is 6 mg/kg with a true DLT rate of 27%. This dose is the most 
likely to be selected as the MTD and is selected with 38% probability. The total mean sample 
size in this scenario is 18.6. 
Scenario 7: 6 mg/kg 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.02 
0.03 
0.05 
0.08 
0.12 
0.18 
0.27 
0.38 
0.50 
0.62 
0.73 
Mean N 
0.0 
2.2 
0.1 
2.7 
0.6 
2.4 
4.4 
1.8 
2.4 
0.5 
1.6 
Mean 
DLTs 
0 
0.1 
0.0 
0.2 
0.1 
0.4 
1.2 
0.7 
1.2 
0.3 
1.2 
Pr(MTD) 
0.00 
0.00 
0.00 
0.02 
0.05 
0.23 
0.38 
0.16 
0.13 
0.02 
0.02 
 
5.0 Combination Operating Characteristics 
In the section we describe the behavior of the mCRM for the combination in the case that the 
starting dose is higher. If the starting dose is a low dose, the behavior will be very similar to that 
described for the single agent. The highest starting dose for the combination is likely to be 
5 mg/kg dose. Therefore, in this section we describe the behavior of the mCRM assuming this 
higher starting dose. 
5.1 First Dosing Cohort Behavior 
At the 5 mg/kg starting dose, the dosing cohort will be size 2. If no DLTs are observed, the dose 
may escalate to the 10 mg/kg dose. If 1 DLT is observed, the dosing cohort will add 1 subject to 


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be size 3. If out of a dosing cohort of 3 subjects, only 1 DLT is observed the dose will escalate to 
7 mg/kg. If 2 DLTs are observed out of a dosing cohort of 3 subjects, the dose will de-escalate to 
1 mg/kg and if 3 DLTs are observed the dose will de-escalate to 0.5 mg/kg. 
5.2 Operating Characteristics 
We simulate the behavior of the design where the starting dose is 5 mg/kg assuming the same 
true dose-toxicity scenarios as described for the single agent. Generally, we see similar trends in 
behavior to the single-agent escalation in terms of correctly identifying the MTD. Several 
scenarios show that should 5 mg/kg be an unsafe dose, the mCRM is able to de-escalate to safe 
doses. 
Scenario 1: All Doses Safe 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.00 
0.00 
0.00 
0.01 
0.01 
0.02 
0.03 
0.05 
0.08 
0.12 
0.18 
Mean N 
0.0 
0.0 
0.0 
0.0 
0.0 
2.1 
0.2 
0.3 
0.1 
0.3 
6.4 
Mean 
DLTs 
0.00 
0.00 
0.00 
0.00 
0.00 
0.04 
0.01 
0.01 
0.01 
0.04 
1.18 
Pr(MTD) 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.01 
0.02 
0.05 
0.92 
 
Scenario 2: No Doses Safe 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.49 
0.55 
0.60 
0.64 
0.67 
0.70 
0.72 
0.74 
0.76 
0.78 
0.79 
Mean N 
1.2 
2.1 
0.3 
0.5 
0.1 
3.1 
0.6 
0.1 
0.0 
0.0 
0.2 
Mean 
DLTs 
0.54 
1.16 
0.19 
0.31 
0.06 
2.16 
0.46 
0.04 
0.01 
0.00 
0.12 
Pr(MTD) 
0.04 
0.09 
0.04 
0.03 
0.02 
0.01 
0.01 
0.00 
0.00 
0.00 
0.00 
 
Scenario 3: 2 mg/kg 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 


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True 
Pr(DLT) 
0.08 
0.15 
0.26 
0.41 
0.59 
0.74 
0.85 
0.92 
0.96 
0.98 
0.99 
Mean N 
1.3 
3.1 
1.2 
1.8 
0.2 
3.1 
0.4 
0.0 
0.0 
0.0 
0.1 
Mean 
DLTs 
0.10 
0.45 
0.32 
0.75 
0.09 
2.30 
0.37 
0.01 
0.00 
0.00 
0.09 
Pr(MTD) 
0.04 
0.26 
0.20 
0.29 
0.08 
0.01 
0.00 
0.00 
0.00 
0.00 
0.00 
 
Scenario 4: 5 mg/kg 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.08 
0.11 
0.14 
0.18 
0.23 
0.29 
0.35 
0.43 
0.50 
0.57 
0.65 
Mean N 
0.1 
0.7 
0.2 
1.0 
0.4 
3.6 
2.0 
1.0 
0.3 
0.2 
2.0 
Mean 
DLTs 
0.01 
0.06 
0.02 
0.20 
0.09 
1.03 
0.69 
0.44 
0.13 
0.12 
1.31 
Pr(MTD) 
0.01 
0.02 
0.03 
0.09 
0.19 
0.18 
0.20 
0.12 
0.08 
0.02 
0.06 
 
Scenario 5: 8 mg/kg 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.02 
0.03 
0.04 
0.06 
0.08 
0.11 
0.15 
0.20 
0.26 
0.33 
0.41 
Mean N 
0.0 
0.1 
0.0 
0.1 
0.0 
2.8 
1.1 
1.2 
0.6 
0.5 
4.4 
Mean 
DLTs 
0.00 
0.00 
0.00 
0.01 
0.00 
0.28 
0.16 
0.25 
0.14 
0.20 
1.84 
Pr(MTD) 
0.00 
0.00 
0.00 
0.01 
0.02 
0.05 
0.09 
0.14 
0.16 
0.11 
0.43 
 
Scenario 6: 3 mg/kg 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 


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True 
Pr(DLT) 
0.03 
0.06 
0.13 
0.24 
0.40 
0.60 
0.76 
0.87 
0.94 
0.97 
0.99 
Mean N 
0.6 
2.3 
1.1 
2.7 
0.6 
3.4 
0.8 
0.0 
0.0 
0.0 
0.3 
Mean 
DLTs 
0.02 
0.12 
0.13 
0.66 
0.22 
2.04 
0.65 
0.00 
0.00 
0.00 
0.29 
Pr(MTD) 
0.01 
0.07 
0.12 
0.40 
0.31 
0.07 
0.00 
0.00 
0.00 
0.00 
0.00 
 
Scenario 7: 6 mg/kg 
 
0.5 
1.5 
2 
3 
4 
5 
6 
7 
8 
9 
10 
True 
Pr(DLT) 
0.02 
0.03 
0.05 
0.08 
0.12 
0.18 
0.27 
0.38 
0.50 
0.62 
0.73 
Mean N 
0.0 
0.2 
0.0 
0.5 
0.3 
3.9 
2.0 
1.5 
0.3 
0.2 
2.6 
Mean 
DLTs 
0.00 
0.01 
0.00 
0.04 
0.03 
0.70 
0.54 
0.57 
0.16 
0.15 
1.86 
Pr(MTD) 
0.00 
0.00 
0.01 
0.02 
0.11 
0.22 
0.27 
0.21 
0.09 
0.03 
0.04 
 
 


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12. 
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