Clinical trial NCT02340156
Conditions: RECURRENT GLIOBLASTOMA
Sponsor: SynerGene Therapeutics, Inc.
Start date: 2014-12-01; Completion date: 2018-11-01
Enrollment: 1 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This Phase II clinical trial is an open label, single arm, multicenter study of the combination of intravenously administered SGT-53 and oral temozolomide in patients with confirmed glioblastoma who have proven tumor recurrence or progression. The objective of this trial is to assess 6 month progression free survival (PFS), overall survival (OS), anti-tumor activity, safety and possibly to evaluate, nanoparticle delivery to tumor site, and the induction of apoptosis in the tumor..

Detailed description:
The p53 is a vital human tumor suppressor gene. Loss of p53 suppressor function is present in the majority of human cancers. The p53 protein has a diverse range of functions including regulation of cell cycle checkpoints, cell death (apoptosis), senescence, DNA repair, maintenance of genomic integrity, and control of angiogenesis. Abnormalities of the p53 gene may impact the efficacy of standard anticancer treatments such as radiation and chemotherapy. P53 mutation and pathway dysfunction are associated with poor clinical outcomes and the presence of the p53 mutation correlates with resistance to chemotherapy and radiation. The development of somatic gene therapy has created the potential to restore wild type function of p53. SGT-53 is a complex of cationic liposome encapsulating a normal human wild type p53 DNA sequence in a plasmid backbone. This complex has been shown to efficiently and specifically deliver the p53 cDNA to the tumor cells and to cross the blood-brain barrier. Introduction of the p53 cDNA sequence is expected to restore wtp53 function in the apoptotic pathway. P53 restoration has been shown most effective in enhancing cytotoxicity in combination with an agent which results in DNA damage or initiates apoptosis. The primary mechanism of resistance to current standard chemotherapeutic agent Temozolomide (TMZ) is overexpression of O6-methylguanine-DNA-methyl transferase (MGMT), which repairs the TMZ-induced DNA lesion by removing the o6-guanine adducts. Thus, a means to down modulate MGMT activity would enhance the therapeutic effect of TMZ. A number of reports have indicated that increasing wtp53 expression can down-regulate expression of DNA repair genes such as MGMT and increases the sensitivity of tumor cells to alkylating agents. This is a Phase II clinical trial of the tumor-targeted SGT-53 nanocomplex in combination with chemotherapeutic agent, temozolomide which is the standard of care for Glioblastoma Multiforme (GBM) brain tumors. We propose to test the combination of SGT-53 and standard temozolomide to determine efficacy and safety in patients with confirmed glioblastoma who have proven tumor recurrence or progression.

Arms: arm 1: SGT-53, at 3.6 mg DNA/infusion, will be administered twice weekly in a 28 day cycle starting on Day 1 (cycle 1), Day 29 (cycle 2) and Day 57 (cycle 3). Temozolomide (TMZ) will be administered by mouth daily on days 9-13 of each cycle. Patients who are responding to treatment may receive three additional cycles of SGT-53/TMZ therapy or continue on TMZ alone at investigator's discretion. Surgical resection of recurrent or progressive tumor for tumor analysis is an optional procedure. In these individuals SGT-53, at 3.6 mg DNA/infusion, will be administered twice (on days -1 and -3) in the week prior to surgery. Surgical resection is Day 0. 14-21 days post operatively and having recovered from the effects of surgery, the patients will then start cyclical TMZ with SGT-53 as described above.
Interventions: intervention 1: SGT-53 intervention 2: Temozolomide
Intervention descriptions: intervention 1: SGT-53, at 3.6 mg DNA per infusion, will be administered twice per week for 3 weeks (on Day 1, 4, 8, 11, 15 and 18 of each cycle) for 3 cycles. If SGT-53-related toxicity occurs, the dose of SGT-53 will be de-escalated to 2.4 or 1.2 mg DNA/infusion when appropriate. intervention 2: TMZ will be administered orally on days 9-13 of each cycle. In cycle 1, the dose of TMZ will be 150 mg/m². If the TMZ-related toxicities are tolerated in cycle 1, the dose of TMZ will be escalated to 200 mg/m² for cycle 2 and beyond. If TMZ-related toxicity occurs, the dose if TMZ will be de-escalated to 125 mg/m² (dose level -1), 100 mg/m² (dose level -2) or 75 mg/m² (dose level -3) when appropriate.

Protocol documents:
Prot_SAP_000.pdf: 
 
 
7/4/16 10:06 AM 
 
PHASE II STUDY OF COMBINED TEMOZOLOMIDE AND TARGETED P53 
GENE THERAPY (SGT-53) FOR TREATMENT OF PATIENTS WITH 
RECURRENT GLIOBLASTOMA 
 
PROTOCOL NUMBER: 
SGT53-02-2 
 
 
 
SPONSORED BY: 
SynerGene Therapeutics, Inc. 
9812 Falls Rd, #114 
Potomac, MD 20854 
(301) 706-1509 
Email: clinicaltrial@synergeneus.com 
 
VERSION HISTORY: 
Version 1 
December 2, 2013 
 
Amendment 1 (Version 3) 
July 1, 2104 
 
Amendment 2 (Version 3) 
August 11, 2014 
 
Amendment 2 (Version 4) 
August 24, 2014 
 
Amendment 2 (Version 5) 
September 26, 2014 
 
Amendment 2 (Version 6) 
October 20, 2014 
 
Amendment 2 (Version 7) 
October 27, 2014 
 
Amendment 3 
September 14, 2015 
 
Amendment 4 
March 17, 2016 
 
Amendment 5 
       April 28, 2016 
 
Amendment 6 
July 5, 2016 
 
This study will be performed in compliance with Good Clinical Practices (GCP) and applicable regulatory 
requirements, including the archiving of essential documents.  Information contained in this protocol is 


 
 
confidential in nature, and must not be used, divulged, published or otherwise disclosed to others except  
to the extent necessary to obtain approval of the Institutional Review Board or Independent Ethics 
Committee, or as required by law. Persons to whom this information is disclosed must be informed that 
this information is confidential and may not be further disclosed without the express permission of 
SynerGene. 


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SIGNATURES OF AGREEMENT FOR PROTOCOL 
 
I, the undersigned, have read this protocol and confirm that to the best of my knowledge it 
accurately describes the planned conduct of the study. 
 
 
 
 
 
 
 
John de Groot, M.D. 
Date 
Principal Investigator 
UT MD Anderson Cancer Center 
Dept. of Neuro-Oncology, Unit 431 
1515 Holcombe Blvd., Houston, TX 77030 
Phone: 713-745-3072 
Email: jdegroot@mdanderson.org 
 
 
 
 
 
 
 
David Cachia, M.D. 
Date 
Co- Investigator 
UT, MD Anderson Cancer Center 
Email: dcachia@mdanderson.org 
 
 
 
 
 
 
 
Mark Gilbert, M.D. 
Date 
Co- Investigator 
UT, MD Anderson Cancer Center 
Email:   mrgilbert@mdanderson.org 
 
 
 
 
 
 
 
Ivo Tremont, M.D. 
Date 
Co- Investigator 
UT, MD Anderson Cancer Center 
Email: itremont@mdanderson.org 


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Charles Conrad, M.D. 
Date 
Co- Investigator 
UT, MD Anderson Cancer Center 
Email: cconrad@mdanderson.org 
 
 
 
 
 
 
 
W.K. Alfred Yung, M.D. 
Date 
Co- Investigator 
UT, MD Anderson Cancer Center 
Email: 
 
 
 
 
 
 
 
Marta Penas-Prado, M.D. 
Date 
Co- Investigator 
UT, MD Anderson Cancer Center 
Email: mpenaspr@mdanderson.org 
 
 
 
 
 
 
 
Monica Loghin, M.D. 
Date 
Co- Investigator 
UT, MD Anderson Cancer Center 
Email: mloghin@mdanderson.org 


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Name 
Date 
 
 
 
 
 
 
 
 
 
 
 
 
Name 
Date 


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1. INVESTIGATOR APPROVAL STATEMENT 
I have read this protocol and agree to conduct this clinical trial as outlined herein.  I will ensure 
 
that all subinvestigators and other study staff members have read and understand all aspects of 
this protocol.  I agree to cooperate fully with SynerGene and any appointed CRO during the 
study.  I will adhere to the Declaration of Helsinki and its amendments, the International 
Conference on Harmonisation (ICH) principles of Good Clinical Practice (GCP; including 
archiving of essential study documents), and all US FDA regulations (for US sites) or European 
Directives (for European sites) and other applicable regulations and guidelines of the country in 
which the study is conducted. 


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2. TABLE OF CONTENTS 
1. INVESTIGATOR APPROVAL STATEMENT .......................................................5 
2. TABLE OF CONTENTS ............................................................................................6 
3. PROTOCOL SYNOPSIS ..........................................................................................10 
4. INTRODUCTION......................................................................................................13 
4.1 Background ...................................................................................................... 13 
4.2 
Preclinical Data with SGT-53 ....................................................................... 16 
4.3 Pre-clinical data of SGT-53 with Temozolomide (TMZ) in Brain Tumors.. 19 
4.3.1 
In vitro studies .......................................................................................19 
4.3.2 In vivo studies ........................................................................................20 
4.3.2.1 
Systemic Treatment with SGT-53 Sensitizes an Orthotopic 
(Intracranial) Mouse Model of Human Brain Cancer (U87) to TMZ 
..................................................................................................20 
4.3.2.2 
Tumor Regression in an Intracranial (IC) Mouse Model of Brain 
Cancer (U87) Induced by Systemic Treatment with the Combination 
of SGT-53 plus TMZ  ..............................................................21 
4.3.2.3 
Increased Survival of Mice Bearing Intracranial U87 GBM Tumors 
After Systemic Treatment with the Combination of SGT-53 Plus TMZ 
..................................................................................................23 
4.3.2.4 
Enhanced Apoptosis in Intracranial U87 Brain Tumors by the 
Combination of SGT-53 and TMZ ..........................................25 
4.3.2.5. 
Increased Survival of Mice Bearing Intracranial U87 GBM Tumors 
After Systemic Treatment with a 21 Day Cycle of TMZ 
Administered in Combination of SGT-53 ................................26 
4.3.2.6. 
Treatment of TMZ Resistant Intracranial T98 G GBM Tumors with 
SGT-53 Downmodulates MGMT Expression In Vivo .............27 
4.4. 
Clinical Data with SGT-53 ............................................................................ 31 
4.4.1. Phase 1 trial of SGT-53 monotherapy in patients with advanced solid tumors 
..............................................................................................................31 
4.4.1.1. 
Presence of Transgene (Exogenous p53) in Patients’ Tumors..32 
4.4.2. Phase 1b trial of SGT-53 in combination with docetaxel .....................32 
4.5. 
Study Design Rationale ................................................................................. 34 
4.5.1 Medical background .................................................................................34 
4.5.2. Patient Population ....................................................................................35 
4.6 
Study Design ................................................................................................. 35 
4.6.1. Dose Selection .........................................................................................36 
4.6.2. Treatment Duration .................................................................................37 


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4.6.3. Endpoints: ...............................................................................................37 
4.6.3.1 Primary Endpoints..........................................................................37 
4.6.3.2. 
Secondary Endpoints .................................................................38 
4.6.4. Statistical hypothesis and sample size .....................................................38 
4.6.5. Study Objectives: .....................................................................................39 
5. INVESTIGATIONAL PLAN....................................................................................39 
6. STUDY POPULATION: ...........................................................................................41 
6.1. Inclusion Criteria .............................................................................................. 41 
6.2. Exclusion Criteria ............................................................................................. 43 
6.2.1. Concomitant Medications ........................................................................45 
6.2.2. Concomitant Procedures: .........................................................................45 
7. STUDY DRUGS .........................................................................................................45 
7.1. Temozolomide (Temodar®) (NDC 0085-1366) ............................................... 46 
7.2. SGT-53 .............................................................................................................. 49 
8. STUDY ENDPOINTS ................................................................................................56 
8.1. Safety Endpoint Definitions .............................................................................. 56 
8.2. Efficacy Endpoints ............................................................................................ 56 
9. TREATMENT PLAN ................................................................................................57 
9.1. Dosing Plan: ...................................................................................................... 58 
9.2. Premedication ................................................................................................... 59 
9.3. SGT-53 Infusion ............................................................................................... 59 
9.3.1. Medications and Observations During and After Infusions of SGT-53..59 
9.3.2. SGT-53 Infusion Reactions ...................................................................60 
9.3.3. Observation for First SGT-53 Infusion .................................................60 
9.3.4. Outpatient Clinic for Subsequent SGT-53 Infusions ............................61 
9.4. 
Study drug discontinuation and study withdrawal: ....................................... 62 
9.4.1. Patient follow up after study discontinuation ..........................................63 
9.5. 
Replacement policy ....................................................................................... 63 
9.7. 
Dose Modification Plans: .............................................................................. 64 
9.7.1. SGT-53 and/or Temozolomide ................................................................64 
9.7.2. Temozolomide .........................................................................................66 
10. STUDY ASSESSMENTS ..........................................................................................68 
10.1. Pretreatment Evaluation .................................................................................. 68 
10.1.1. Laboratory Certification and Normal Values ........................................69 
10.2. Evaluation During Study ................................................................................. 69 
10.2.1. Patients with Optional Surgical Resection for Tumor Analysis ............69 
10.2.2. Patients Not undergoing Surgical Resection .........................................70 
10.2.3. All Patients ............................................................................................71 


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10.2.4. End of Treatment Evaluations (Day 85 or at the end of Cycle 6 if the 
patient received cycles 4-6) .....................................................72 
10.3. Follow-up ...................................................................................................... 72 
10.3.1. Long Term Follow-up ...........................................................................73 
10.4. Efficacy Assessments .................................................................................... 73 
10.4.1. Progression-Free Survival .....................................................................73 
10.4.2. Tumor response rate ..............................................................................74 
10.4.3. Time to progression ...............................................................................75 
10.4.4. Overall survival .....................................................................................75 
10.5.  Safety Endpoint Definitions .......................................................................... 75 
11. ADVERSE EVENTS .................................................................................................75 
11.1. Definition of Adverse Events .......................................................................... 76 
11.1.1. Definition of Serious Adverse Events ...................................................77 
11.2. Relationship of Adverse Event to Investigational Product ............................. 78 
11.2.1. Relationship to study drugs ...................................................................78 
11.3. Severity of adverse events............................................................................... 79 
11.4. Reporting of adverse events ............................................................................ 80 
11.5. Follow-up of adverse events ........................................................................... 80 
11.6. Adverse events of special interest ................................................................... 80 
11.7. Definition of Dose Limiting Toxicity (DLT) .................................................. 81 
11.8. Definition of Start Date, Stop Date and Duration ........................................... 81 
11.9. Action(s) Taken ............................................................................................. 81 
11.10. Definition of Outcome at the Time of Last Observation .............................. 81 
11.11. Treatment period ........................................................................................... 82 
11.12. Documentation of Adverse Events ............................................................... 82 
11.13. Follow-up of Patients With an Adverse Event .............................................. 83 
11.14. SAEs after the 30-day follow-up period ....................................................... 83 
11.15. Pregnancy ..................................................................................................... 83 
11.15.1. Teratogenicity ......................................................................................83 
11.15.2. Reporting of pregnancy .......................................................................84 
11.15.3. Follow-up of pregnancy ......................................................................85 
11.16. Notification of Sponsor of Serious Adverse Events ..................................... 85 
11.17. Reporting Adverse Events to the Competent Authorities ............................. 86 
12. REGULATORY CONSIDERATIONS ...................................................................87 
12.1. Ethics ............................................................................................................. 87 
12.2. FDA Regulations ........................................................................................... 87 
12.3.  Good Clinical Practice Guidelines ................................................................ 87 
12.4.  Finance and Insurance ................................................................................... 87 
13. DATA QUALITY ASSURANCE .............................................................................87 
13.1. Monitoring Procedures .................................................................................... 88 


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13.2. Data Management (Collection) ....................................................................... 88 
14. DATA SAFETY MONITORING BOARD .............................................................88 
15. GENERAL CONSIDERATIONS ............................................................................89 
15.1. Discontinuation of the Study........................................................................... 89 
15.2. Regular Study Termination ............................................................................. 89 
15.3. Premature Study Termination ......................................................................... 89 
15.4. Changes to the Protocol .................................................................................. 90 
15.5. Protocol Deviations for Emergency or Adverse Event ................................... 90 
15.6. Source Documents .......................................................................................... 90 
15.7. Use of Information and Publication ................................................................ 90 
16. FINAL CLINICAL STUDY REPORT ....................................................................91 
17. REFERENCES ...........................................................................................................91 
18. APPENDIX .................................................................................................................95 
18.3.  Karnofsky Performance Status Scale .......................................................... 108 


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3. PROTOCOL SYNOPSIS 
 
Title 
PHASE II STUDY OF COMBINED TEMOZOLOMIDE AND 
TARGETED P53 GENE THERAPY (SGT-53) FOR TREATMENT 
OF PATIENTS WITH RECURRENT GLIOBLASTOMA 
Study Number 
SGT53-02-2 
Clinical Study 
Phase 
Phase II 
Clinical Sites 
MD Anderson Cancer Center, Texas, USA 
China Medical University Hospital, Taichung, Taiwan 
Study Objectives 
Primary: 
• To evaluate the 6 month PFS in patients treated with SGT-53 
in combination with Temozolomide. 
Secondary: 
• To assess safety of the combination of SGT-53 and 
Temozolomide. 
• To evaluate progression free survival (PFS), and overall 
survival (OS) in patients in patients with recurrent or 
progressive GBM tumors treated with SGT-53 in 
combination with Temozolomide. 
• To determine the anti-tumor activity of the combination of 
SGT-53 and Temozolomide based upon the RANO criteria 
in patients with recurrent or progressive GBM tumors. 
• To assess nanoparticle delivery to tumor site by analysis of 
the presence of exogenous wt p53 in the tumor (optional 
procedure). 
• To assess induction of apoptosis by SGT-53 in the tumor by 
flow cytometry or histology (optional procedure). 
Study Design 
This is a single arm study wherein SGT-53, at a dose of 3.6 mg 
DNA per infusion, will be administered. SGT-53 will be 
administered twice weekly [every 3rd or 4th day] in a 28 day cycle 
(total of 6 infusions)] starting on Day 1 (cycle 1), Day 29 (cycle2) 
and Day 57 (cycle 3).  In those patients who undergo the optional 
surgical resection, the 1st cycle of SGT-53 and TMZ will start 14-21 
days post operatively after having recovered from the effects of 


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surgery. Temozolomide will be administered by mouth daily on  
days 9-13 of each cycle at 150mg/m2 (cycle 1), and 200mg/m2 as 
tolerated for cycle 2 and beyond provided the patient meets the 
criteria for non-hematological toxicity, ANC and platelet counts.. 
Patients who are responding to treatment (at least stable disease by 
RANO) may receive three additional cycles of SGT-
53/Temozolomide therapy at investigator’s discretion. Alternatively, 
they may continue on Temozolomide alone at investigator’s 
discretion. 
Optional Surgical Resection for Tumor Analysis: 
Surgical resection of recurrent or progressive tumor for tumor 
analysis is an optional procedure.  In these individuals SGT-53, at a 
dose of 3.6 mg DNA per infusion, will be administered twice (on 
days -1 and -3) in the week prior to surgery. Surgical resection is 
Day 0. 14-21 days post operatively and having recovered from the 
effects of surgery, the patients will then start cyclical TMZ with 
Study Subject 
Population 
The study population is subjects with confirmed glioblastoma or 
gliosarcoma who have proven tumor recurrence or progression. 
Study participants must have measurable disease on imaging studies 
and Eastern Oncology Cooperative Group (ECOG) performance 
status 0-2 (Karnofsky performance status [KPS] > 60). Tumors 
amenable to surgical resection is not a requirement. 
Study Procedures 
After screening, SGT-53 study drug will be administered by iv 
infusion twice weekly , beginning on Day 1 of a 28 day cycle as 
described above with Temozolomide administered orally daily on 
days 9-13 of each cycle at 150mg/m2 (cycle 1), and 200mg/m2 as 
tolerated from cycle 2 onwards provided the patient meets the 
criteria for non-hematological toxicity, ANC and platelet counts.  
. In those patients who have undergone the optional surgical 
resection, the 1st cycle of SGT-53 and TMZ will commence 14-
21 days post operatively and after having recovered from the 
effects of surgery. Following first infusion of study agent on 
Day1, participants will be evaluated weekly for a total of at least 
12 weeks. At these weekly study visits, participants will have a 
physical examination, routine chemistry, and complete blood 
count. 


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• After screening, SGT-53 will be administered by iv infusion 
twice during the week prior to surgical resection of the tumor. 
14-21 days post operatively and having recovered from the 
effects of surgery, SGT-53 study drug will be administered by iv 
infusion twice weekly beginning on Day 1 of a 28 day cycle as 
described above. 
• A sample of the tumor obtained at resection will be employed to 
assess levels of exogenous wild type (wt) p53 cDNA to validate 
targeting. 
Primary Study 
Outcome Measures 
• 
To evaluate the 6 month PFS in patients treated with SGT- 
53 in combination with Temozolomide. 
Secondary Study 
Outcomes 
• To assess safety of the combination of SGT-53 and 
Temozolomide by analysis of adverse experiences, clinical 
laboratory tests and physical examinations. 
• To evaluate PFS and OS in patients in patients with recurrent 
or progressive GBM tumors treated with SGT-53 in 
combination with Temozolomide. 
• To determine the anti-tumor activity of the combination of 
SGT-53 and Temozolomide based upon the RANO criteria 
in patients with recurrent or progressive GBM tumors. 
• To assess induction of apoptosis by SGT-53 in the tumor by 
flow cytometry or histology (optional procedure). 
• To assess nanoparticle tumor delivery by analysis of the 
presence of exogenous wt p53 in the tumor (optional 
procedure). 
Sample Size 
• Approximately 26 subjects will be enrolled. 
Study Duration 
• Approximately 12-24 months. 
Statistical Analysis 
• Safety data will be analyzed using summary descriptive statistics 
for the total study population.   The primary outcome of this 
phase II study is clinical response using PFS6 as the indicator. 


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4. INTRODUCTION 
 
4.1 
Background 
 
Primary brain tumors, and particularly gliomas, are one of the most difficult cancers to treat. It 
is expected that in the U.S. more than 22,000 will be diagnosed in 2012 (1), about 50% of 
which will be glioblastoma multiforme (GBM). GBM is one of the most lethal types of brain 
cancer, with a median survival of about 12 months (2). In addition to primary tumors, 
metastatic brain cancer from a variety of primary sources [predominately lung (60%), 
breast (20%) and melanoma (10%)], is diagnosed in over 150,000 patients a year (3). 
Thus, there is a critical need for improved therapies for brain cancers, which is confirmed by 
the fact that the NCI has made brain cancers one of its top 5 funding priorities. Such improved 
therapies would have significant commercial potential. 
 
The current standard of therapy for GBM is surgical resection, followed by radiotherapy and 
chemotherapy with Temozolomide (TMZ). TMZ, a second-generation alkylating (methylating) 
agent causing cytotoxic DNA lesions, is also approved for treatment of anaplastic astrocytoma 
(AA) and is in clinical trials for treatment of brain metastases from other non-CNS solid tumors. 
The mechanism of action and pharmacological properties have been recently reviewed (2, 4). 
TMZ is relatively well tolerated (5), however myelosuppression, neutropenia and 
thrombocytopenia are among its side effects and therapeutic dosages are limited by these. 
Extended TMZ dosing regimens were also found to provoke lymphocytopenia and opportunistic 
infections (4). The extensive tissue distribution that results from the non-tumor specific uptake 
of the orally administered TMZ is a major causality for these side effects. Thus, tumor-targeting 
delivery of TMZ could help reduce these adverse events. 
 
 
 
Temozolomide 
 
4-Methyl-5-oxo-2,3,4,6,8-pentazabicyclo[4.3.0]nona-2,7,9-triene-9-carboxamide, 
(Temozolomide) a prodrug, is a monofunctional alkylating agent that readily crosses the blood- 
brain barrier (6). It is chemically related to dacarbazine and is the 3-methyl derivative of the 
experimental anticancer drug, mitozolomide. Unlike dacarbazine, temozolomide does not require 
hepatic metabolism to the intermediate species methyltriazen-1-yl imidazole-4-carboxamide 
(MTIC) but spontaneously hydrolyzes to MTIC above pH7. MTIC degrades to a highly reactive 
cation that methylates guanines in DNA at the O6 position, causing base pair mismatch. 
Unsuccessful cycles of mismatch repair eventually lead to breaks and permanent nicks in the 
daughter strand preventing mitotic division and the cell undergoes apoptosis. 
TMZ has shown survival benefit in a subset of GBM patients, however this median increase 
is only 2.5 months compared to radiation alone (7). Recent studies have also indicated that 60- 
75% of GBM patients and 50% of AA patients do not benefit from TMZ (7). The failure of 
chemotherapy can be attributed to a number of factors including, short half-life in circulation, 
efflux of drugs from the tumor by p-glycoprotein, resistance of the tumors to the drug and failure 
to cross the blood-brain barrier.  The primary mechanism of resistance to TMZ is overexpression 
of O6-methylguanine-DNA-methyl transferase (MGMT), which repairs the TMZ-induced DNA 
lesion by removing the O6-guanine adducts (2).  Thus, a means to down modulate MGMT 
activity would enhance the therapeutic effect of TMZ.  A number of reports have indicated that 


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increasing wtp53 expression could down-regulate expression of DNA repair genes such as 
MGMT and increases the sensitivity of tumor cells to alkylating agents (8-10). 
 
SGT-53 
 
SynerGene Therapeutics, Inc. has developed a unique investigational product, SGT-53, that is a 
complex of cationic liposome encapsulating a normal human wtp53 DNA sequence in a plasmid 
backbone. The liposome is decorated on its surface with an anti-transferrin receptor (TfR) single 
chain antibody fragment (scFv) that is designed to target cancer cells through binding of the 
TfRscFv to the transferrin receptor.  This complex has been shown to efficiently and specifically 
deliver the p53 cDNA to the tumor cells via receptor-mediated endocytosis of the cationic 
liposomal complex (11, 12).  Introduction of the p53 cDNA sequence is expected to restore 
wtp53 function in the apoptotic pathway. P53 restoration has been shown most effective in 
enhancing cytotoxicity in combination with an agent which results in DNA damage or initiates 
apoptosis (13, 14). 
 
Use of Wild-type (wt) p53 as an Anti-cancer Therapeutic Agent 
 
The therapeutic agent in SGT-53 is a DNA sequence encoding normal human p53. The p53  
gene is a vital tumor suppressor gene in humans. Abnormalities in the p53 tumor suppressor gene 
have been reported in over 60% of human cancer, including brain cancer (15, 16).  The p53 
protein has a diverse range of functions including regulation of cell cycle checkpoints, cell death 
(apoptosis), senescence, DNA repair, maintenance of genomic integrity, and control of 
angiogenesis.  Abnormalities of the p53 gene may impact the efficacy of standard anticancer 
treatments such as radiation and chemotherapy. The development of somatic gene therapy has 
created the potential to restore wild type function of p53. 
 
Currently, approximately 37 gene therapy clinical trials employing p53 have been initiated or 
conducted in the USA (>75 world wide) and this number is likely to increase over the coming 
years.  Introduction of wtp53 by various viral gene therapy delivery systems, in particular 
retroviral and adenoviral vectors, has been reported to suppress the growth of various types of 
malignancies in both in vitro and in xenografts in mouse models. The types of malignancies 
studied include leukemia, prostate, head and neck, colon, cervical, glioblastomas, breast, liver, 
ovarian, kidney and lung tumor (17-19). 
 
Gene Therapy Delivery 
 
One of the major obstacles to gene therapy is the development of an effective gene delivery 
system specific to cancer cells.  Drawbacks of viral delivery systems include immunogenicity, 
integration problems, the potential for self-replication and/or creation of new classes of 
infectious pathogens as well as lack of specificity for cancer cells.  Gene therapy systems using 
cationic liposomes share the lack of specificity of viral vectors and have relatively low 
transfection efficiency.  However, SynerGene Therapeutics, Inc. has devised a strategy to use 
cationic liposomes that target tumor cells with a high transfection efficiency. 


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Most tumor cells, including pancreatic, prostate, ovarian, oral, colon, and breast cancer, express 
both increased folate and transferrin receptors and have increased receptor recycling (11, 12). 
SynerGene Therapeutics, Inc. has demonstrated that addition of either the folate or transferrin 
ligand to the cationic liposome facilitates the entry of the liposome-DNA complex into the tumor 
cells via receptor-mediated endocytosis.  Preferential delivery of genes into tumors using either 
the folate or transferrin ligands has been shown in both in vitro and in vivo mouse models (20- 
22). 
 
In addition to the use of ligands that bind to receptors on tumor cells, specific monoclonal 
antibodies (mAb) also can be attached to the liposome surface enabling them to target specific 
tumor surface antigens (including but not limited to receptors). These “immunoliposomes” can 
also deliver therapeutic drugs or genes to a specific target cell population (23). These 
immunoliposomes were found to be internalized efficiently by receptor-mediated endocytosis via 
the coated pit pathway and also possibly by membrane fusion.  Immunoliposomes are being 
developed for a variety of therapeutic uses.  Currently, they are primarily being used in drug 
therapy, delivering drugs, pro-drugs and enzymes capable of activating pro-drugs. 
 
There are drawbacks and limitations to the use of the mAb-based agents.  Full-sized mAbs 
exhibit a prolonged circulation time that can produce unacceptable myelotoxicities following 
bone marrow exposure, particularly when the mAb is coupled with radioisotopes. Adverse toxic 
reactions also can occur due to interactions between Fc receptors on normal tissues and the mAb 
carrying radioisotopes or toxins.  Moreover, the large size of the intact mAb (approximately 
155kDa) can limit their ability to diffuse from the capillaries into the solid tumor and thus their 
potential therapeutic effect in treating cancer. 
 
SGT-53 
 
The therapeutic component of SGT-53 is the DNA sequence for the normal human p53, situated 
within a plasmid backbone.  When taken up by tumor cells, this DNA sequence is expressed as 
the wild-type p53 protein, and is functional as a tumor suppressor regulating tumor cell growth, 
cell death (apoptosis) and regulation of angiogenesis. 
 
The delivery component of SGT-53 is a cationic liposome that encapsulates the plasmid-wtp53 
DNA.  Liposomes can be made from a wide variety of lipids, which have very different 
properties and characteristics. Many liposomes, including the commercially available liposome: 
chemotherapeutic agents Doxil, DaunoXome and AmBisome, contain cholesterol, which has 
been shown to be a stimulator of complement. Administration of these lipid-drug complexes can 
induce a “pseudoallergic” infusion reaction in some patients, presumably due to the presence of 
cholesterol in the liposome.  The liposome component of SGT-53 is comprised of two different 
types of lipids (DOTAP and DOPE), and does not contain cholesterol. 
 
The component of SGT-53 that allows targeting to tumor tissues after systemic administration is 
a single chain antibody fragment to the human transferrin receptor (TfRscFv) which decorates 
the surface of the liposome.  Progress in biotechnology has allowed the derivation of specific 
recognition domains from monoclonal antibodies (mAb).  The recombination of the variable 
regions of heavy and light chains and their integration into a single polypeptide provides the 


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possibility of employing single-chain antibody derivatives (designated scFv) for targeting 
purposes.  A scFv based on an anti-TfR mAb, contains the complete antibody binding site for the 
epitope of the transferrin receptor (TfR) recognized by this mAb as a single polypeptide chain of 
approximate molecular weight 28,000.  The TfRscFv is formed by connecting the component 
VH and VL variable domains from the respective heavy and light chains with an appropriately 
designed linker peptide.  The binding site of an scFv can replicate both the affinity and 
specificity of its parent antibody combining site.  For a number of reasons TfRscFv has 
advantages in human use over the Tf molecule itself or an entire mAb in targeting liposomes to 
cancer cells with elevated TfR levels : 
 
1. The size of the scFv (~28kDa) is much smaller than that of the Tf molecule (~80kDa) or 
the parental mAb (~155kDa), thus the scFv-liposome-DNA complex may exhibit better 
penetration into small capillaries characteristic of solid tumors. 
2. The smaller scFv also has practical advantages related to its production as a recombinant 
protein (large scale production of the TfRscFv will be required for clinical use). 
3. The scFv is a recombinant molecule (not a blood product like Tf) and therefore presents 
no issues related to potential contamination by blood borne pathogens. 
4. Without the Fc region of the mAb, the problem of non-antigen-specific binding through 
Fc receptors is eliminated. 
 
We have already shown that such an anti-TfR single chain antibody molecule can target an 
intravenously administered cationic liposome-DNA (wtp53) complex preferentially to tumors 
(24, 25), and, in combination with chemotherapeutic agent docetaxel, results in increased 
survival in a mouse model of human metastatic breast cancer (26). In preclinical studies, the 
TfRscFv targeting moiety has shown significant enhancement of selective delivery to tumor cells 
(both primary and metastatic).  In addition, the makeup of the complex with respect to choice 
and ratios of cationic and neutral lipids, ratio of ligand to liposome and liposome to DNA also 
enhances the uptake of the SGT-53 by the target tumor tissues. 
 
4.2 
Preclinical Data with SGT-53 
 
SGT-53 is a novel liposome encapsulating the wtp53 gene and complexed with an anti- 
transferrin receptor single chain antibody fragment (TfRscFv) as the targeting entity.  Pre- 
clinical studies with systemic (intravenous) delivery of the SGT-53 complex have demonstrated 
significant activity, resulting in tumor growth inhibition and even long-term regression, in a 
variety of solid tumor preclinical models, both as a single agent and in combination with 
chemotherapy and radiation [21, 22]. Further, these studies have demonstrated preferential tumor 
targeting capabilities of the TfRscFv liposome containing the wtp53 gene for both primary 
tumors and metastases. Tumor specific targeting has been observed in a variety of solid tumors 
including head and neck, prostate, breast, melanoma, pancreatic and brain tumor cells.  For this 
phase II clinical study, the study population will be subjects with confirmed glioblastoma or 
gliosarcoma who have radiographically proven tumor recurrence or progression.  Patients must 
also have evidence of tumor recurrence or progression but do not need to be surgical candidates. 
For those patients who have measureable disease on imaging studies amenable to surgical 
resection, they may also consider to participate in the optional surgical resection for tumor 
analysis. 


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Preclinical and clinical investigations of the safety of liposome-DNA complexes have reported 
that cationic lipid-DNA complexes are potent activators of the innate immune system, resulting 
in an inflammatory response in animals and in humans likely due to the DNA sequences. 
Investigations in mice have reported mononuclear cell infiltrates in the lung and activation of T 
cells and NK (natural killer) cells (27, 28).  In at least 2 phase 1 clinical studies, subjects reported 
fever and/or muscle/joint pain.  In the one phase 1 study that looked for them, no antibodies to 
the liposome or the DNA were detected.  All of the responses were transient and resolved within 
a few days. 
 
There are at least two reports of clinical trials where participants receiving IV liposome-DNA 
complexes experienced acute hypersensitivity reactions, including low-grade fever, chills, and 
nausea/vomiting, where premedication successfully alleviated these symptoms (29-31). 
 
In addition, Protiva Biotherapeutics reported at the 2005 American Society of Gene Therapy 
Annual Meeting that in a Phase I Clinical Trial of an IV administered PEG-liposome-DNA 
complex, premedication with antiemetics, antipyrogenics and a steroid successfully prevented 
the onset of severe infusion reactions.  Thus, the growing body of evidence suggests that for 
patient safety, premedication should be administered to offset the inflammatory response 
triggered by IV administration of liposome-DNA complexes. 
 
The NCI contractor, Batelle Memorial Institute, Columbus, Ohio, performed the initial toxicity 
studies in rats of the liposome to be used in this clinical study. No toxicity (on clinical 
observation, body weight, clinical and gross pathology) was evident even after multiple high 
dose injections. The animals received a maximum dose of 27 uM three times per day on days 1, 
4, and 7 and once a day on days 10, 13, 16, and 19.  In addition, in six separate in vivo preclinical 
studies evaluating the efficacy of SGT-53, a total of 55 female athymic nude mice received 9 - 
16 i.v. injections of SGT-53.  In one study, the animal received 10 ug DNA while in the 
remainder of the studies, animals received 10 – 20 ug DNA.  During infusions, no deaths or 
sustained weight loss due to toxicity were observed. 
 
A formal GLP preclinical study evaluating the toxicity of SGT-53 in male and female Balb/c 
mice (total of 152 mice) was performed by the Department of Veterinary Sciences at the 
University of Texas, M.D. Anderson Cancer Center.  This study evaluated 12 μg SGT-53 dose in 
mice equivalent to approximately 3.0 mg per injection in humans (60 kg) administered for five or 
ten injections.  None of the animals receiving SGT-53 died or exhibited observable side effects 
even after ten injections.  In addition, two follow-up studies were conducted (total of 140 mice). 
The first study evaluated 12 μg and 30 μg SGT-53 per injection; the latter dose is equivalent to a 
dose of 7.5 mg per infusion in a 60 kg human. The maximum dose to be evaluated in the 
proposed phase 1 study is 7.2 mg SGT-53 per injection.  The second study compared the safety 
of 30 μg lyophilized /reconstituted and liquid (freshly prepared) SGT-53 administered twice 
weekly over five weeks.  Both studies also included a control group of mice that were injected 
with 10% sucrose.  No animals died of demonstrable test article related causes in these studies. 
Five mice died during the two follow-up studies, however none of the deaths could be attributed 
to effects of the study agent. 


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In the preclinical toxicity studies, marked elevation of the liver transaminases, AST and ALT, as 
well as marked elevation in glucose levels were noted in both the SGT-53 treated and control 
(10% sucrose) mice. Some effect was observed in all groups (control and SGT-53 treated) on 
levels of creatinine, phosphorus, urea nitrogen, white blood cells, lymphocytes, monocytes, red 
blood cells, platelets, segmented neutrophils, hemoglobin, hematocrit, total bilirubin and total 
protein.  These effects were variable and not consistent between studies. 
 
Increases in spleen size and follicular hyperplasia and expansion of hematopoietic cell 
populations in the spleen and lymph nodes were noted in mice receiving SGT-53.  These changes 
were diminished or resolved in animals who had not received SGT-53 for two to six weeks. 
 
In the preclinical studies, accumulation of mononuclear cells was noted on histopathological 
examination of the liver and lung with both 12 μg and 30 μg SGT-53 and with both formulations 
(freshly prepared and lyophilized/reconstituted).  In the pulmonary tissue, scattered, mild 
multifocal infiltrates of mononuclear cells were noted in the perivascular, interstitial and 
subpleural pulmonary tissue.  At six weeks following discontinuation of SGT-53, fewer changes 
on histopathology examination of both the liver and pulmonary tissue were noted indicating 
ongoing resolution. 
 
In general, these histopathological findings are consistent with the literature that describes 
transient accumulation of liposomes in the lung and liver and to a lesser extent in the spleen in 
animal biodistribution studies.  Overall, results from the pre-clinical studies to date indicate that 
the incidence of potential toxic side effects with administration of SGT-53 at doses comparable 
to the maximal dose proposed to be evaluated in humans is very low. 


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Cell Survival (% of Control) 
Cell Survival (% of Control) 
 
4.3 
Pre-clinical data of SGT-53 with Temozolomide (TMZ) in Brain Tumors 
The below in vitro and in vivo data has been published (see Reference 33) 
 
4.3.1 In vitro studies 
 
To assess the ability of scL delivered wtp53 (SGT-53) to sensitize brain tumor cells to 
first-line chemotherapeutic agent TMZ, human brain tumor derived U87 and U251 cells were 
 
Figure 1 
Figure 2 
 
120 
 
100 
 
U87 
120 
 
100 
 
U251 
 
80 
80 
 
60 
60 
 
40 
TMZ 
TMZ + SGT-vec 
20 
TMZ + SGT-53 
 
40 
TMZ 
TMZ + SGT-vec 
20 
TMZ + SGT-53 
 
0 
1 
5 
10 
20 
40 
Concentration of TMZ (uM) 
 
0 
1 
5 
10 
20 
40 
Concentration of TMZ (uM) 
treated with TMZ alone, or the combination of TMZ plus SGT-53. As a control, cells were also 
treated with the combination of TMZ and the scL nanodelivery system carrying the same vector 
used to construct the pSCMVp53 plasmid, but without the p53 insert (SGT-vec). The cells were 
plated at 2 × 103 per well in a 96-well plate and treated 24 hours later with SGT-53 or SGT-vec. 
24 hours post-transfection, the TMZ was added in increasing concentrations.  The XTT assay 
was performed 72 h after the addition of the TMZ to the wells and the IC50 values (the 
concentration yielding 50% growth inhibition) determined.  As these two cell lines are known to 
be sensitive to TMZ, it was not unexpected that there was some response to TMZ alone. 
However, as shown in Figures 1 and 2 when compared to TMZ alone, there is a significant 
increase in sensitization to TMZ in both cell lines when the cells are transfected with wtp53 
delivered by the scL nanodelivery system. Minimal to no sensitization (U87 and U251, 
respectively) was observed with the complex carrying the empty vector, demonstrating that the 
effect is due to the p53 and not the delivery system. 
However, as only a subset of brain tumor patients respond to TMZ it was more critical to 
assess the ability of SGT-53 to sensitize TMZ resistant tumors to this chemotherapeutic agent. 
Thus, to assess the ability of scL delivered wtp53 to sensitize TMZ resistant brain tumor cells to 
this first-line chemotherapeutic agent, human brain tumor derived LN-18 and T98G cells were 
treated with TMZ alone, or the combination of TMZ plus SGT-53. As a control, cells were also 
treated with the combination of TMZ 


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Cell Survival (% of Control) 
Cell Survival (% of Control) 
 
Figure 3 
Figure 4 
 
120 
 
100 
 
120 
LN-18 
T98G 
100 
 
80 
80 
 
60 
 
40 
 
TMZ 
20 
TMZ +SGT-vec 
TMZ +SGT-53 
0 
100 
1000 
60 
 
40 
 
20 
 
0 
100 
 
 
 
TMZ 
TMZ + SGT-vec 
TMZ + SGT-p53 
 
250 
 
 
 
 
 
 
 
 
500 
 
 
 
 
 
 
 
 
1000 
Concentration of TMZ (uM) 
Concentration of TMZ (uM) 
and SGT-vec.  The cells were plated at 2 × 103 per well in a 96-well plate and treated 24 hours 
later with SGT-53 or SGT-vec. 24 hours post-transfection, TMZ was added in increasing 
concentrations.  The XTT assay was performed 24 or 72h after the addition of TMZ (T98G and 
LN-18, respectively) to the wells and the IC50 values determined.  As shown in Figure 3, after 
transfection with SGT-53 the TMZ resistant LN-18 cells are now responding to even very low 
doses of TMZ.  More than 50 % of the cells are killed at a dose of TMZ as low as ~50uM 
compared to TMZ alone where no significant cell death is observed until a dose of ~1000uM. 
Although the T98G cells were not as responsive to TMZ after SGT-53 treatment as LN- 
18, these highly TMZ resistant cells are also sensitized to the killing effects of this drug by SGT- 
53 (Figure 4).  The cells treated with SGT-53 prior to exposure to TMZ have an IC50 of 700uM 
while those receiving TMZ only do not reach IC50 even at a concentration of 1000uM. 
Extrapolating this curve, the IC50 for TMZ alone would be at least 2000uM.  As above, there is 
minimal or no effect on the response of the cells to TMZ after transfection with the control SGT- 
vec indicating that the response in these resistant cell lines is due to the presence of wtp53. 
 
 
 
 
4.3.2 
In vivo studies 
 
As in the in vitro studies above, the in vivo experiments described below employed both TMZ 
responsive and TMZ resistant models of IC brain tumors.  In Sections 4.3.2.1 to 4.3.2.5. tumors 
were induced by the IC inoculation of TMZ responsive cell line U87MG.  In Sections 4.3.2.6. to 
4.3.2.8. the TMZ resistant cell line T98G was used to induce IC tumors in the animals. 
 
 
 
4.3.2.1 Systemic Treatment with SGT-53 Sensitizes an Orthotopic (Intracranial) Mouse 
Model of Human Brain Cancer (U87) to TMZ 
The ultimate test of clinical potential is the demonstration of efficacy in an intracranial 
mouse model of brain cancer.  To this end we initially performed a small proof-of-principle in 
vivo efficacy study to examine the ability of i.v. administered SGT-p53 to sensitize orthotopic 
brain tumors to TMZ.  U87MG-Luc xenograft brain tumors were induced in nude mice by 
intracranially inoculating 5x105 U87MG-luc cells. This cell line, obtained from Caliper Life 
Sciences, has been modified to stably express the Luciferase gene.  10 days post-inoculation, 


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tumor-bearing animals were i.v. tail vein injected with TMZ alone (5.0 mg/kg) or TMZ in 
combination with SGT-53 (30 ug DNA/mouse). As a control, one group received only the 
empty, unliganded liposome (vehicle). All i.v. injections were administered 2X/week for 2.5 
weeks (total 5 injections).  To assess tumor response, bioluminescence imaging (BLI) was 
performed using IVIS® Imaging System’s Xenogen. The bioluminescence intensity of the brain 
tumors, a measure of tumor size/growth, was compared between groups using Xenogen Living 
Image® software. The results are shown in Fig 5 and Table 1. 
There was a significant difference in tumor response between the three groups. The intense 
bioluminescence signal in the mice that received only the Liposome (vehicle) indicates that the 
brain tumors grew significantly and were not affected by Liposome.  U87 cells are known to be 
sensitive to TMZ.  Thus, it is not unexpected that there was some response in these animals to 
TMZ, as shown by the decreased signal compared to the control mice. However, there was a 
significantly more pronounced tumor growth inhibition in the mice that received the combination 
 
Figure 5 
of SGT-53 and TMZ.  In these animals 
only a small area of very weak 
bioluminescence was evident post-treatment.  This 
difference was quantified based upon the measured 
intensity as shown in Table 1.  The combination of SGT- 
53 (SGT-53) and TMZ resulted in a 27 Fold decrease in 
signal intensity compared to the vehicle control. 
Moreover, this intensity was more than 7 Fold lower 
than that with TMZ alone. 
Thus, i.v. treatment with SGT-53 can significantly 
sensitize orthotopic brain tumors to first-line 
chemotherapeutic agent TMZ.  These results, along with 
the fact that the scL nanocomplex can cross the BBB, and that SGT-53 sensitized in vitro TMZ 
resistant cell lines (see Figures 3amd 4 above) supports potential of this combinatorial approach 
as a more effective clinical treatment modality for TMZ resistant GBM and other hard to treat 
tumors in the brain, and potentially at other sites in the body. 
 
4.3.2.2 Tumor Regression in an Intracranial (IC) Mouse Model of Brain Cancer (U87) 
Induced by Systemic Treatment with the Combination of SGT-53 plus TMZ 
 
 


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Tumor Volume (cm3) 
Bioluminescence (p/s/cm2/sr) 
 
A second larger experiment was performed to examine tumor growth inhibition induced 
by the sensitization of IC brain tumors to TMZ by systemic administration of SGT-53.  U87MG- 
Luc xenograft brain tumors were induced in nude mice by intracranially inoculating 5x105 
U87MG-luc cells. This cell line, obtained from Caliper Life 
Sciences, has been modified to stably express the Luciferase 
gene.  10 days post-inoculation, tumor-bearing animals were 
i.v. tail vein injected with TMZ alone (5.0 mg/kg/injection, 
equivalent to 15 mg/m2), SGT-53 alone (30 ug 
DNA/mouse/injection) or TMZ in combination with SGT-53. 
As a control, one group received PBS 
Figure 6 
(vehicle). The TMZ and SGT-53 were i.v. 
administered on alternating days as shown in the above 
schematic. All i.v. injections were administered 2X/week to a 
total of 10 injections.  To assess tumor response, 
bioluminescence imaging (BLI) was performed using IVIS® 
Imaging System’s Xenogen.  Figure 6 is a comparison of in 
vivo anti-tumor efficacy of the various groups using 
representative animals repeatedly imaged over time. 
Bioluminescence signals which correlate to tumor size are shown in a color map. Red color: the 
stronger signal, Violet color: the weaker signal.  The bioluminescence intensity of the brain 
tumors in all of the mice, a measure of tumor size/growth, was compared between groups using 
Xenogen Living Image® software and is plotted over time in Figure 7. The arrowed bar indicates 
the duration of treatment (Last treatment = Day 
24). While TMZ alone and SGT-53 alone had 
some minimal effect on IC tumor growth during 
treatment, the tumors in both groups rapidly 
increased in size after the end of treatment.  In 
contrast, the tumors in the group of mice that 
received the combination of SGT-53 and TMZ 
displayed not only tumor growth inhibition, but 
tumor regression during treatment. More 
significantly, this regression continued for more 
 
1e+8 
 
 
1e+7 
 
 
1e+6 
 
 
1e+5 
 
 
1e+4 
 
Figure 7 
vehicle 
SGT-53 
TMZ 
TMZ + SGT-53 
than 20 days after treatment had ended. 
 
To confirm the bioluminescence 
 
 
 
A 
B 
 
 
0.20 
 
 
0.15 
 
 
0.10 
 
 
0.05 
0 
15 
30 
45 
Days 
 
findings, the mice were also imaged 
by MRI, 
without 
contrast 
agent, 
before 
and after 
3 weeks 
of 
 
0.00  
Vehicle 
 
SGT-53   TMZ 
 
TMZ + 
SGT-53 
Figure 8 


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Survival 
 
treatment.  The tumor regression observed in the combination treatment group by 
bioluminescence was also observed here.  In Figure 8 the red lines indicate the glioblastoma 
tumors.  It is evident that instead of increasing in size post treatment as is evident in the single 
agent treatment groups, any residual tumor is barely detectable in the animals that received both 
SGT-53 and TMZ. 
The volume of the tumors detected by MRI in Figure 8A was calculated after 3 weeks of 
treatment and is shown in Figure 8B.  This graphic representation clearly demonstrates the 
increased efficacy of the combination of SGT-53 and TMZ in this animal model. Confirming the 
data obtained in the initial proof-of-principle study, this experiment demonstrates that the scL- 
delivered wtp53 can sensitize GBM tumors to TMZ leading to significant tumor response 
(regression) not just tumor growth inhibition. 
 
4.3.2.3 Increased Survival of Mice Bearing Intracranial U87 GBM Tumors After Systemic 
Treatment with the Combination of SGT-53 Plus TMZ 
As the above experiments demonstrated significant tumor responses, including 
regression, post-treatment we wanted to assess the effect of this combination treatment on 
survival.  U87MG-Luc xenograft brain tumors were induced in nude mice as described above. 
10 days post-inoculation, tumor-bearing animals were i.v. tail vein injected with TMZ alone, 
SGT-53 alone (30 ug DNA/mouse/injection) or the combination of SGT-53 and TMZ. The 
doses of TMZ and SGT-53 employed here were identical to those used in the experiment 
described above (4.3.2.2.): 15 mg/m2/mouse/injection and 30 ug DNA/mouse/injection, 
respectively.  As a control, one group received PBS (vehicle). All i.v. injections were 
administered 2X/week to a total of 10 injections. The TMZ and SGT-53 were i.v. administered 
on alternating days as shown in the schematic below.  The animals were monitored 2-3 times/wk 
 
 
 
and euthanized when moribund.  The results, analyzed by Kaplan–Meier method, are shown in 
Figure 9.  The arrowed lines indicate the duration 
1.00 
 
Untreated (5x105 U87) (n=8) 
SGT-53 (n=6) 
of treatment. Although SGT-53 alone and TMZ 
alone was able to prolong survival for a period of 
0.75 
TMZ (15 mg/m2, 2/wk, 5 wks) 
(n=7) 
time in this TMZ responsive cell line, all of the 
 
 
0.50 
 
 
0.25 
 
 
0.00 
 
 
 
 
 
 
SGT-53 
TMZ 
TMZ (15 mg/m2, 2/wk, 5 wks) 
+ SGT-53 (n=7) 
 
 
 
Figure 9 
mice succumbed to their tumor by ~day 60.  The 
Median Survival with SGT-53 alone was 30 days, 
a 15% increase in survival relative to the untreated 
mice.  The Median Survival in the mice treated 
with TMZ only was somewhat longer at 45 days 
which was a 73% increase in survival relative to 
0 
30 
60 
90 
120 
Days 
the untreated mice.  However, the survival time 
was extended considerably with the combination 
of SGT-53 and TMZ.  In these animals 20% of the mice survived beyond 100 days.  Thus, the % 


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Untreated 
SGT-53 
TMZ 
TMZ + SGT-53 
Fig. 10 
The results, analyzed by Kaplan–Meier method, are shown 
in Figure 10 and Table 2.  The arrowed bar indicates the 
duration of treatment.  As expected since the dose of SGT- 
53 was not changed, the mice that received SGT-53 alone 
all died or were euthanized by 60 days post-inoculation, a 
finding similar to the results shown in Figure 9.  Although 
this higher dose of TMZ alone was able to prolong survival 
for an extended period of time in this experiment compared 
to the previous one with the lower dose of TMZ, all of the 
0 
30 
60 
90 
Day 
120 
s 
150 
180 
210 mice here also succumbed to their tumor by ~day 155, with 
a Median Survival of 112 days.  More significantly, when 
Survival 
 
survival prolongation for mice receiving this combination regimen 115% that of the untreated 
mice. Thus, the combination of SGT-53 and TMZ at the doses used not only results tumor 
growth inhibition/regression, but in a significant increase in long term survival, the goal of any 
cancer treatment. 
A second survival experiment was performed which followed this same treatment 
schedule but with a higher dose of TMZ to see if the survival benefit could be further increased. 
U87 IC tumors were induced as above.  10 days post-inoculation, tumor-bearing animals were 
i.v. tail vein injected with TMZ alone, SGT-53 alone (30 ug DNA /mouse/injection) or the 
combination of SGT-53 and TMZ. While the dose of SGT-53 remained unchanged, the dose of 
TMZ was increased to 75 mg/m2/injection. As control, one group received PBS (vehicle). All 
i.v. injections were administered 2X/week to a total of 10 injections.  The TMZ and SGT-53 
were i.v. administered on alternating days as shown in the schematic below.  The animals were 
monitored 2-3 times/week and euthanized when moribund. 
 
 
1.00 
 
 
0.75 
 
 
0.50 
 
 
0.25 
 
 
0.00 
 
 
the mice were treated with both SGT-53 and TMZ, their life-span was significantly extended.  In 
these animals 60% of the mice were still surviving at day 210 which is more than 6 after the end 
of treatment.  Therefore, the % survival prolongation for mice receiving this combination 
regimen was >740 % greater than that of the untreated mice, 500% that of SGT-53 alone and 
almost twice that of TMZ alone.  Thus, when administered in combination with the SGT-534 
nanocomplex, increasing the dose of TMZ would significantly increase survival. 
Table 2 
 
Treatment 
n 
Median 
Survival 
(Days) 
Survival 
Prolongation 
(%) * 
Log Rank 
p-value 
Untreated 
4 
25 
- 
- 
SGT-53 
5 
35 
40 
0.0117 
TMZ 
5 
112 
348 
0.0088 
TMZ + 
5 
>210 
>740 
0.58 


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Apoptotoic Cells (%) 
Tumor Weight (mg) 
Sub-G1 (%) 
 
 
SGT-53 
 
 
4.3.2.4 Enhanced Apoptosis in Intracranial U87 Brain Tumors by the Combination of 
SGT-53 and TMZ 
Tumor suppressor p53 is known to play a role in the apoptotic (programmed cell 
 
 
150 
 
 
 
100 
 
 
 
50 
 
 
0 
vehicle  
SGT-53  
TMZ  
TMZ + 
 
 
 
100 
 
80 
 
60 
 
40 
 
20 
 
Figure 11a 
 
Annexin V+PI- 
(early apoptosis) 
Annexin V+PI+ 
(necrosis/late apoptosis) 
SGT-53 
Figure 11b 
 
40 
 
 
30 
 
 
20 
 
 
10 
 
0 
vehicle 
 
SGT-53 
 
TMZ 
 
TMZ + 
 
0 
vehicle 
 
 
SGT-53 
 
 
TMZ 
 
 
TMZ + 
 
death) 
Figure 11c 
SGT-53 
 
Figure 11d 
SGT-53 
pathway.  To begin to evaluate the 
mechanism 
responsible for this increase in tumor cell response and increase in animal survival, the level of 
Apoptosis induced in U87MG-luc2 brain tumors after various treatments was determined using 
Annexin V-FITC and Flow Cytometry. U87MG-luc2 brain tumors were induced as described 
above.  10 days post inoculation of the cells, the mice were treated with either TMZ alone 
(15mg/m2 /mouse/injection, 2 injections per week), SGT-53 alone (30 ug DNA per injection per 
mouse, 2 injections per week) or the combination of SGT-53 and TMZ.  Each animal received a 
total of 3 injections after which the animals were euthanized, and the tumors weighed.  A single 
cell population was subsequently isolated from the tumors and subjected to the Annexin V assay. 
As shown in Figure 11a, there is a major difference in the weight of the tumors from the mice 
that received the combination of SGT-53 and TMZ even after just three injections when 
compared to those that receive single agent treatment.  Although SGT-53 and TMZ alone both 
somewhat inhibited tumor growth compared to the untreated controls (a 50-60 % decrease in 
tumor weight), this response was significantly greater after the combination treatment.  In these 
mice there was an almost 90% decrease in the weight of the tumor compared to the untreated 
controls.  In addition, this response was least 1.5 fold greater than that observed with either 
single agent treatment.   More importantly, these findings regarding tumor weight correlated with 


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Survival 
 
apoptosis in the tumors.  There was a significant increase in the percent of the tumors cells in 
apoptosis after treatment with the combination of SGT-53 and TMZ compared to either 
treatment alone when assessed by flow cytometry (Figure 11b), by staining with Annexin V 
(Figure 11c) and by assessment of the percent of cell in the sub G1 phase of the cell cycle 
(Figure 11d).  Thus, these results indicate that systemic administration and uptake of SGT-53 
increases the response of IC tumors to chemotherapeutic agent TMZ through enhancement of the 
apoptotic pathway. 
 
4.3.2.5. Increased Survival of Mice Bearing Intracranial U87 GBM Tumors After Systemic 
Treatment with a 21 Day Cycle of TMZ Administered in Combination of SGT-53 
Due to the potential toxicities associated with TMZ we began to explore the possibilities 
of using lower doses of TMZ in combination with SGT-53 by extending the time frame of TMZ 
administration.  As it has been reported that human clinical trials have been performed wherein 
TMZ is administered daily for 21 days, we chose this time frame for testing here. 
 
 
 
 
 
 
 
U87MG-Luc 
xenograft brain 
tumors were 
induced in nude 
mice as described above.  7 days post-inoculation, tumor-bearing animals were i.v. tail vein 
injected with TMZ alone, SGT-53 alone (30 ug DNA/mouse/injection) or the combination of 
SGT-53 and TMZ. TMZ was 
administered at a dose of 7.5 
1.0 
 
 
0.8 
 
 
0.6 
 
 
0.4 
 
 
0.2 
 
 
0.0 
 
 
 
 
 
 
 
 
 
 
SGT-
53 
TMZ 
  
 Untreated (n=3) 
SGT-53 (n=10) 
TMZ (n=10) 
TMZ + SGT-53 (n=10) 
 
 
 
 
 
 
Log-Rank 
p < 0.001 
mg/m2/mouse/injection. As a control, 
one group received PBS (vehicle). SGT- 
53 i.v. injections were administered 
2X/week to a total of 10 injections. TMZ 
was i.v. administered daily for 21 days on 
Days 1 through 21 as shown in the above 
schematic. The animals were monitored 
2-3 times/week and euthanized when 
moribund. The results, analyzed by 
Kaplan–Meier method, are shown in 
0 
20 
40 
60 
80 
100 
140 
Figure 12.  The duration of treatment is 
Figure 12 
Days 
indicated by the arrowed lines. As 
expected since the dose of SGT-53 was the same as employed in previous 
experiments, the mice that received SGT-53 alone all died or were euthanized by day 32 post- 
inoculation, a finding similar to the results shown in Figures 9 and 10.  Based upon the survival 
data it appears that this 21 day administration of a lower dose of TMZ alone was able to prolong 
survival in this experiment.  However, all of the mice treated with TMZ only succumbed  to their 
tumor by ~day 60, with a Median Survival of 45 days, compared to a Median Survival of only 18 
days for the untreated animals. More significantly, here once again, when the mice were treated 


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with the combination of SGT-53 and TMZ, their life-span was considerably extended.  In these 
animals the Median survival was ~70 days, 290% longer than that of the untreated mice and 80% 
longer than those that received TMZ only. Moreover, 20% of the mice were still surviving 
beyond 140 days, which is more than 100 days after the end of treatment.  The difference 
between the groups of mice that received only TMZ and those that received the combination 
treatment was found to be statistically significant (Log-Rank p<0.001). Thus, this treatment of 
21 day low dose TMZ, when administered in combination with SGT-53, has the potential to be 
an effective clinical regimen with the possibility of reduced TMZ side effects. 
 
 
 
4.3.2.6.Treatment of TMZ Resistant Intracranial T98 G GBM Tumors with SGT-53 
Downmodulates MGMT Expression In Vivo 
The primary mechanism of resistance to TMZ is overexpression of O6-methylguanine- 
DNA-methyl transferase (MGMT), 
which repairs TMZ- 
Figure 13 
induced DNA lesions 
by removing the O6-guanine adducts. 
Thus, a means to downmodulate 
MGMT activity would enhance the 
therapeutic effect of TMZ. A number 
of reports have indicated that 
increasing wtp53 expression could 
downregulate expression of MGMT 
and increase the sensitivity of tumor 
cells to alkylating agents such as TMZ. We investigated if uptake of SGT-53 had an effect on the 
level of MGMT expression in vivo. An experiment to analyze the duration of scL-mediated p53 
expression and MGMT downmodulation was performed in mice bearing TMZ-resistant T98G 
human glioblastoma intracranial xenograft tumors. IC T98G tumors were induced in athymic 
nude mice by intracranially inoculation of T98G human glioblastoma cell line (5.0x105 cells per 
animal). Ten days after the inoculation, animals were imaged by MRI. Immediately after 
imaging, a single IV injection of SGT-53 (30 ug DNA/injection) was administered to each 
animal. At 6, 16, 24, 48, and 72 hours following the injection, the mice were euthanized, tumors 
harvested, and protein extracted. The control group did not receive SGT-53 treatment. Forty 
micrograms of total protein was electrophoretically fractionated using a Nu-PAGE Precast 4-12 
% gradient gel, transferred to nitrocellulose membrane, and probed for expression of p53, 
MGMT, cleaved PARP (a marker of apoptosis), and GAPDH by Western blot analysis. The 
signal was detected by ECL reagent.  As shown in Figure 13, at 6 and 16 hours after the single 
SGT-53 i.v. injection, an increase in the level of p53 protein is evident as compared to the 
untreated animal indicating the presence of the exogenous p53. The transient expression of p53 
peaks at 48 hours post-injection, then this signal decreases back to a level close to that of the 
untreated control by 72 hours. 
Importantly, the opposite was true for the expression of MGMT. There was a significant 
decrease in the expression of MGMT observed at 24 hours, which lasted as long as 72 hours after 
the injection. The timing for the observed decrease in MGMT signal is consistent with the 
mechanism of action of p53 in sensitizing cells to TMZ by interfering with DNA repair 
mechanisms. Expression of cleaved PARP, an indicator of apoptosis, was detected as early as 6 
hours and showed maximum expression 72 hours after the injection. Consistent expression of 
 
GAPDH protein demonstrated equal protein loading. Thus, there is a correlation between 
expression of the exogenous p53 (delivered through administration of SGT-53) and the down 


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modulation of MGMT in these TMZ resistant tumors. 
 


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4.4. 
Clinical Data with SGT-53 
 
4.4.1. Phase 1 trial of SGT-53 monotherapy in patients with advanced solid tumors 
 
A total of 11 humans have been infused with the TfRscFv-liposome-DNA complex, i.e. SGT-53, 
at doses of 0.6, 1.2, 2.4 or 3.6 mg DNA/infusion administered IV over 1 to 2 hours twice weekly 
for 5 weeks. There was no intra-patient dose escalation. These 11 patients were both male and 
female and ranged in age from 37 to 75 years of age.  They suffered from a range of cancer 
types, including metastatic adenocarcinoma of the colon, metastatic medullary carcinoma of the 
thyroid, metastatic colorectal cancer, adenoid cystic carcinoma, metastatic thymoma, metastatic 
nasopharyngeal carcinoma, metastatic cervical cancer, metastatic and progressive vaginal cancer 
and leiomyosarcoma. 
 
70% of the patients displayed stable disease after a single cycle of SGT-53. Significant tumor 
necrosis was evident in two of these subjects, one who received the lowest dose of 0.6 mg 
DNA/infusion and one who received the 2.4 mg DNA/infusion dose.  A report of the findings 
from this trial have recently been published (32). 
 
An MTD was not reached. The study was ended as biologically relevant doses were reached The 
Adverse events experienced by these 11 subjects were 95% were Grade 1 and 2 and only 5% 
were either Grade 3 or Grade 4. These toxicities are outlined in the table in section 7.2b, and 
they included: 
 
• 
Grade 1: fatigue, fever, hypotension, neutropenia, thrombocytopenia, leucopenia, headache, 
chills, tachycardia, pleural effusion, cough, dizziness, anorexia. 
 
• 
Grade 2: fatigue, dehydration, diarrhea, hypotension, fever, anemia, leucopenia, elevated 
AST/ALT, headache, neutropenia. 
 
• 
Grade 3: A single patient experienced fatigue correlating with massive tumor necrosis 
 
 
• Grade 4: Three events were reported, all of which were classified as Unrelated or Unlikely to 
be related to SGT-53. 
 
There were four Serious Adverse Events reported during the trial.  Of these, three were classified 
as Unrelated or Unlikely to be related to the SGT-53 study drug. One was classified as only 
possibly related.  Overall SGT-53 was found to have a good safety profile at potentially 
therapeutic doses. 
 
No MTD was reached in the Phase I trial which included doses up to 3.6mg DNA/infusion which 
is the dose at which the presence of exogenous normal (wt) p53 DNA has been demonstrated in 
tumor tissue. 
 
Of note, 8 out of 11 patients experienced grade 1 to 2 hypotension. 


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However, due to the evidence that i.v. liposome-DNA complexes do induce an inflammatory 
response and the observation of induction of fever in the first subject to be infused with SGT-53, 
each trial participant was premedicated before every infusion with acetominophen, a 
combination of histamine H1 and H2 blockers (e.g. Benadryl and Pepcid), and dexamethasone as 
described below in Section 9.3.1. 
 
 
 
 
 
Figure 16 
Figure 17 
 
4.4.1.1.Presence of Transgene (Exogenous p53) in Patients’ Tumors 
A critical requirement for gene therapy to be successful is the demonstration that the 
transgene delivered by SGT-53 (exogenous wtp53 DNA) was present in the tumors of treated 
subjects. Moreover, the transgene should not be detected in the normal tissue.  Thus to assess 
tumor specific delivery of SGT-53, we performed DNA PCR to determine if we could detect the 
exogenous p53 gene delivered by the SGT-53 complex in the tumors. We amplified a 700bp 
fragment using one primer in the vector and one primer in the p53 insert.  Using this approach, 
we could specifically amplify only the exogenous p53 transgene. Tumor biopsies were obtained 
from subjects after the end of treatment with the lowest dose (0.6mg/infusion) (T1) and with the 
3.6mg/infusion dose (T2).  As shown above in Figure 16, the amplified 700bp fragment of the 
exogenous p53 gene was clearly present in both tumors.  More importantly, the transgene was 
present in a dose dependent manner as would be expected with tumor-targeted delivery.  With a 
third subject who had also received the 3.6mg/infusion dose (T3), in addition to the tumor 
biopsy, a biopsy sample was obtained from normal skin.  Figure 17 demonstrates that while there 
is strong PCR signal in the tumor tissue, indicating a significant presence of the exogenous p53 
in the tumor of this individual, no p53 could be detected in the normal skin sample.  These 
results indicate the tumor-targeting ability systemically administered SGT-53 in patients. 
 
 
 
 
4.4.2. Phase 1b trial of SGT-53 in combination with docetaxel 
Currently, there is a Phase Ib study ongoing at the Mary Crowley Cancer Research Center, 
Dallas Texas to test the safety of SGT-53 in combination with docetaxel.  This Phase Ib is an 
open-label, range finding trial with a set dose of SGT-53 at 2.4mg DNA/infusion and escalating 
doses of docetaxel as shown in the Schedule for Phase Ib below.  Eight subjects have received 
treatment to date.  These subjects were male (3) and female (5) ranging in age from 33 to 77 


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years of age and had been diagnosed primarily with metastatic grade 3 or 4 pancreatic, 
endometrial, ovarian, anal, angiosarcoma, NSCLC or esophageal cancers.  Only the subject with 
angiosarcoma was categorized as grade Ia. Three of the subjects demonstrated significant tumor 
shrinkage by RECIST, one of which demonstrated a 47% , one a 51% and the third a 79% 
decrease in tumor size.  This subject is receiving a second round of treatment.  An additional 
subject demonstrated significant tumor shrinkage based upon photographic evidence. 
 
SCHEDULE FOR PHASE 1b 
Weeks 
Days1 
 
1 
2 
3 
4 
5 
 
1 
SGT532 
Doc3 
SGT53 
 
2 
SGT53 
3 
SGT53 
4 
SGT53 
Doc4 
SGT53 
 
5 
SGT53 
 
6 
SGT53 
7 
SGT53 
Doc5 
SGT53 
 
 
 
 
 
Cycle 1 
 
 
 
 
Cycle 2 
 
 
Cycle 3 
 
1In case of holiday or other logistic issue, schedule will allow for weeks 1, 4, and 7 treatments to 
be delivered on days 1, 4 and 5 or on days 2, 4 and 5. Weeks 2, 3, 5 and 6 treatments may, for the 
same circumstances be administered on day 2. 
2SGT53 = SGT-53 2.4mg per infusion 
3Doc = Starting dose-Docetaxel 40 mg/m2 
4Doc = For cohort 1, cycle 2 intra-patient dose escalation of docetaxel to 60 mg/m2 if no DLT 
occurred in cycle 1. 
5Doc = Same dose at cycle 2 if no DLT; if DLT, may repeat cycle 1 dose (40 mg/m2) as per PI. 
 
The number and dose of infusions of SGT-53 and Docetaxel is shown in the Table below: 
 
Infusions Phase Ib 
 
Patient ID 
# of Infusions 
of SGT-53 
DoseSGT-53 
/Infusion 
# of 
Infusions of 
Docetaxel 
Dose 
Docetaxel/Infusion 
02-018 a 
1 
2.4 mg 
1 
40 mg/m2 
02-019b 
7 
2.4 mg 
2 
40/60 mg/m2 
02-020 
9 
2.4 mg 
3 
40/60/60 mg/m2 
02-023 
10 
2.4 mg 
3 
40/60/60 mg/m2 
02-024c 
2 
2.4 mg 
1 
75 mg/m2 
02-025 
10 
2.4 mg 
3 
75/75/75 mg/m2 
02-026 
10 
2.4 mg 
3 
75/60/60 mg/m2 
a  Early termination due to Disease Progression 


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Grade 1 & 2 AE’s 
Relation to Study Drug 
02-018 
Fever, Chills, Emesis 
None 
None 
02-019 
Intermittent fatigue, 
None 
None 
02-020 
Intermittent diarrhea, 
Intermittent anemia 
Chills, Headache 
None 
02-023 
None 
None 
Hypotension, 
Fever 
02-024 
Hypotension 
Elevated ALT 
Elevated AST 
Hypocalcemia 
02-025 
None 
None 
None 
02-026 
Intermittent hypotension 
Intermittent dehydration 
None 
None 
 
b Subject withdrew voluntarily from study 
c  Early Termination due to only possibly related syncopal episode 
 
 
 
Drug related grade 1, 2 AEs occurring in ≥ 5% of patients are shown below.  These primarily 
consisted of transient fever, chills and hypotension 
 
Adverse Events 
 
 
 
 
Pt ID 
Possible 
Probable 
Definite 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Combination therapy in Phase 1b has been relatively well tolerated to date. Five SAEs have been 
recorded, two of which were in one subject. All were categorized as unrelated to the administration 
of SGT-53. Two were related to disease progression, one was related to docetaxel administration 
and two were related to possible small bowel obstruction. 
 
 
 
4.5.   Study Design Rationale 
 
4.5.1 Medical background 
 
To date, there is no consensus on the standard of care for relapsed/recurrent glioblastoma. Prior 
to 2009, patients were offered older approved chemotherapies such as carmustine or lomustine, 
TMZ at different regimens, or even no further therapeutic intervention. In 2009, Avastin® 
(bevacizumab), the humanized monoclonal antibody to human VEGF, was approved by FDA as 
a single agent for adult patients with progressive disease following prior therapy on the basis of 
objective response rate, but has not (to date) demonstrated an effect on survival. Different 
regimens are commonly employed by clinicians in an effort to prolong life and/or provide other 
clinical benefits for patients with recurrent GBM but there is also no consensus in this clinical 


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setting. The prognosis for patients with relapsed/progressive disease remains very poor (median 
survival about 6 months). 
 
A Phase 1 trial of SGT-53 monotherapy has been completed in patients with advanced solid 
tumors as described above. Tolerance of the agent was acceptable with no SAEs related to SGT- 
53 reported. No MTD was established.  Ten doses of SGT-53 were administered over 5 weeks. 
The combination therapy of SGT-53 (10 doses) and docetaxel in the ongoing Phase 1b has been 
relatively well tolerated to date and responses have been observed. The dose for this Phase II 
trial will be 3.6 mg DNA per infusion.  This is the highest dose administered in the Phase Ia trial. 
 
This trial is a single arm study wherein SGT-53, at a dose of 3.6 mg DNA per infusion, will be 
administered by iv infusion.  Patients will receive SGT-53 and Temozolomide in 28 day cycles. 
Patients who are responding to treatment (at least stable disease by RANO) may receive three 
additional cycle of SGT-53/Temozolomide therapy at investigator’s discretion. The primary 
objective is to evaluate the 6 month PFS in patients treated with SGT-53 in combination with 
Temozolomide. 
 
Surgical resection for tumor analysis before the commencement of SGT-53/Temozolomide 
treatment is an optional procedure. For these patients, SGT-53 will be administered twice during 
the week prior to surgical resection of the tumor. 14-21 days post-surgical resection, patients will 
receive SGT-53 and Temozolomide in 28 day cycles. These patients who respond to treatment 
(at least stable disease by RANO) may receive three additional cycle of SGT-53/Temozolomide 
therapy at investigator’s discretion. The primary objective of this surgical resection is to assess 
nanoparticle tumor delivery by analysis of the presence of exogenous wt p53 in the tumor. 
 
All patients enrolled in the study will be evaluated for PFS, PFS-6 and OS. 
 
4.5.2. Patient Population 
 
The target study population is subjects with confirmed glioblastoma or gliosarcoma who have 
proven tumor recurrence or progression. 
 
This study will enroll males or females aged 18 years or older with recurrent GBM or GS who 
may benefit from receiving SGT in combination with a cyclical TMZ. Eligible patients must 
have histological confirmation of GBM or GS and a diagnosis of recurrent disease with an 
interval of at least 3 months after radiotherapy plus TMZ. For patients who have had surgery, 
there must be an interval of at least 14-21 days post operatively and having recovered from the 
effects of surgery for the recurrent disease before initiation of cyclical treatment. 
 
4.6 
Study Design 
 
Based on efficacy and overall safety demonstrated in preclinical studies and the first-in-man 
Phase Ia and Phase Ib study in combination with docetaxel, SynerGene Therapeutics, Inc. 
proposes to perform a Phase II clinical study of the combination SGT-53 and temozolomide in 
subjects with confirmed glioblastoma who have proven tumor recurrence or progression. The 
goals of the proposed clinical study are to determine the anti-tumor activity of the combination 


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of SGT-53 and temozolomide by RANO and by evaluating the 6 month PFS; PFS and, OS and 
by evaluating the safety of the combination of SGT-53 and temozolomide. 
 
The goals of the optional surgical resection are to demonstrate the nanoparticle delivery of 
systemically administered SGT-53 to tumor in GBM patients and to assess induction of 
apoptosis by SGT-53 in the tumor. Participation in the optional surgical resection will be at the 
discretion of the subject and investigator. 
 
Based on the pre-clinical intra-tumoral half-life, in Phase Ia SGT-53 was given as a twice- 
weekly intravenous infusion over 1.5 – 2 hours, depending on dose level. The time of infusion 
can be extended in the event of infusion reactions (see Section 9.3.2); however infusion of the 
study agent must be completed as soon as possible, but no longer than eight hours after dilution 
in dextrose. 
 
Below is the schedule of treatment: 
 
 
This is a single arm study wherein SGT-53, at a dose of 3.6 mg DNA per infusion, will be 
administered. Patients will receive SGT-53 every 3rd or 4th day in 28 day cycles (total of 6 
infusions) starting on Day 1 (cycle 1), Day 29 (cycle2) and Day 57 (cycle 3). Temozolomide 
will be administered by mouth daily on days 9-13 of each cycle at 150mg/m2 (cycle 1), and 
200mg/m2 as tolerated for cycle 2 and beyond provided the patient meets the criteria for non-
hematological toxicity, ANC and platelet counts (as given in 9.7.2). In those patients who had a 
surgical resection, the 1st cycle of SGT-53 and TMZ will start 14-21 days post operatively and 
having recovered from the effects of surgery. 
 
Patients who are responding to treatment (at least stable disease by RANO) may receive three 
additional cycle of SGT-53/Temozolomide therapy at investigator’s discretion. Alternatively, 
they may continue on Temozolomide alone at investigator’s discretion. 
 
If optional surgical resection will be performed, SGT-53 will be administered on day -3 and day 
-1 prior to surgery. Surgical resection of recurrent or progressive tumor is Day 0. 14-21 days post 
operatively and having recovered from the effects of surgery the patients will then start cyclical 
TMZ with SGT as described above. A maximum of 6 patients will be have this optional testing. 
Once the presence of exogenous wtp53 from SGT-53 is demonstrated in the resected tumor of 3 
patients, the option for surgical resection for tumor analysis will no longer be offered. 
 
 
 
 
4.6.1. Dose Selection: 
 
In the Phase 1a study of SGT-53 as a single agent the nanocomplex was administered twice 
weekly for five consecutive weeks.  No patient received more than 10 infusions in a single cycle. 
Two cycles of 10 infusions were administered to one patient. 
 
In various clinical trials Temozolomide has been administered daily for 5 days in one 28 day 
period.  To optimize effectiveness of the potential chemosensitization of SGT53, SGT53 


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treatment will be given three times prior to the start of temozolomide treatment. Pre-clinical 
studies have shown that the wtp53 tumor suppressor gene delivered by the SGT-53 nanoparticle 
functions to sensitize tumors to the chemotherapeutic agent, making them more responsive to the 
drug.  Thus, it is critical that p53 be expressed when temozolomide is administered in order to 
have the benefit of the SGT-53. Using the proposed schedules, SGT-53 is being expressed at the 
start of temozolomide treatment. For patients who undergo optional surgical resection for tumor 
analysis, two doses of SGT-53 will be administered in the week prior to surgical resection of the 
tumor to demonstrate the presence of exogenous wtp53 in the tumor to validate SGT-53 crossing 
the BBB and targeting the tumor. 
 
 
 
 
4.6.2. Treatment Duration: 
 
Patients will receive a total of 3 cycles of TMZ in combination with SGT. Patients who are 
responding to treatment (at least stable disease by RANO) may receive three additional cycles of 
SGT-53/Temozolomide therapy at investigator’s discretion. Alternatively, they may continue on 
Temozolomide alone at investigator’s discretion. 
 
Withdrawal from the study will be allowed at any point due to unacceptable toxicity or 
withdrawal for other reasons (eg patient withdrawal of consent, or protocol violation etc), 
evidence of disease progression as defined in Section 9.5. All patients who received treatment 
with SGT-53 must be followed-up for 30 days after discontinuation of study drug. The 30-day 
follow-up visit should include a physical examination, vital signs, concomitant medications, 
assessment of AEs/SAEs and Urine analysis. Blood samples will be taken for: Hematology 
(CBC with differential, platelet count), Chemistries (BUN, Cr, Na+, K+, CO2, Cl, Mg++, Ca++, 
phosphorus, albumin, alkaline phosphatase, ALT, AST, total bilirubin, total protein, glucose, 
LDH), PT/PTT and D-dimer. 
 
Patients who permanently discontinue study drug(s) for reasons other than complete response, 
progression, or death should also have visits approximately every 2 months for the first year that 
should include a MRI, physical examination, vital signs, and recording of concomitant 
medications for glioblastoma. 
 
Patients who are withdrawn from study treatment due to a complete response will have the 30- 
day follow-up visit. Further follow-up visits every 2 months will include a physical/neurological 
exam, concomitant medications, vital signs and a MRI. 
 
A telephone contact to check on vital status and any additional treatment for glioblastoma will 
occur yearly. 
 
4.6.3. Endpoints: 
 
4.6.3.1 Primary Endpoints 
 
PFS-6 using the RANO criteria (see Section 18.2) will be used as primary endpoints. 


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4.6.3.2.Secondary Endpoints 
 
• 
Safety of the combination of SGT-53 and Temozolomide. 
 
• 
PFS, OS 
 
• 
Anti-tumor activity of the combination of SGT-53 and Temozolomide based upon the 
RANO criteria. 
 
• 
The induction of apoptosis by SGT-53 in the tumor (optional procedure). 
 
• 
Nanoparticle delivery (optional procedure) 
 
 
 
4.6.4. Statistical hypothesis and sample size: 
 
A total of 26 patients will be enrolled. A maximum of 6 patients will be enrolled to participate in 
the optional surgical resection for tumor analysis. 
 
Patients who have received at least one dose of study drug will be considered evaluable for 
safety and toxicity endpoints.  Patients who require a dose interruption or reduction during the 
initial cycle will remain evaluable for toxicities if the reduction or interruption is due to a DLT. 
Patients who do not complete one cycle of treatment but do not have a DLT may be replaced as 
described in more detail in Section 9.6. 
 
The primary endpoint for the trial is PFS6. Progression-free survival will be defined as the time 
from study enrollment until the time of first occurrence of disease progression, relapse, or death 
due to disease. 
 
The analysis of the biological correlate data in patients with surgical resection for tumor analysis 
has the overall goal of providing an increased understanding of the ability of SGT-53 to cross the 
Blood-brain Barrier and be delivered into tumor cells in the brain. As such, the objective of the 
tumor analysis is qualitative rather than quantitative.  It should be noted that in the Phase I dose 
escalation trial of SGT-53, the presence of the exogenous wtp53 delivered by SGT-53 was found 
to be present in the tumors in a DNA dose dependent manner.  Moreover, even the lowest dose 
of SGT-53 (0.6mg DNA/infusion) was not only found to be present in the tumors of the patients, 
but to have some anti-tumor effect. A DNA dose 6-fold higher (3.6mg DNA/infusion) is being 
used in this trial. 
 
Reverse transcription PCR to determine transgene expression is not applicable for these studies 
because it would not be able to unequivocally establish that the p53 protein detected was from 
the exogenous transgene. In contrast, since we have designed primers that included part of the 
plasmid vector backbone, only the exogenous DNA is amplified. This DNA PCR approach was 
used to detect the presence of the transgene in the tumors in the Phase I trial (See Figures 16 and 
17 in Section 4.4.1.1) and will be used for these studies. The presence of at least 30 copies of 
exogenous p53 in the tumors sample will be considered positive evidence of drug penetration. 


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All of the patients in the trial will receive the same dosing of the combination of SGT-53 and 
TMZ (6 doses of SGT-53 and 5 doses of TMZ every 4 weeks for three 4 week cycles) and thus 
patients with or without surgical resection for tumor analysis will be used for the Simon two 
stage calculation.  Even for the patients who undergo the optional surgical resection for tumor 
analysis PFS6 is the primary endpoint.  No TMZ will be administered during the time these 
patients receive the two doses of SGT-53 prior to the resection.  Exogenous p53 expression is 
transient. The patients who receive surgery will not begin treatment for 2-3 weeks post-surgery. 
Previous studies have demonstrated that there is no indication of the exogenous wtp53, even by 
DNA PCR, after this length of time. Thus, there will be no additional residual DNA present from 
the two pre-surgery doses of SGT-53 by the time the combination therapy being evaluated is 
initiated. 
 
According to the Simon Minimax design, our study, with its sample size of n = 26, has a 10% 
probability of rejecting (a) the hypothesis of a PFS6 15% (P0) (the historical PFS6 rate) and a 
70% probability of accepting (1-b) the hypothesis of a PFS-6 of 30% (P1). If two, or fewer of the 
first 18 patients were progression free at 6 months, PFS-6 would be considered <15% and the 
study terminated. Otherwise, the study would be completed, the accrual target being 26 patients. 
If six or fewer of the 26 patients were progression-free at 6 months, then no further investigation 
of the treatment regimen would be considered warranted.  PFS6 and secondary endpoints 
progression free survival and overall survival will be evaluated using the Kaplan-Meier product- 
limit survival curve methodology. 
 
 
 
4.6.5. Study Objectives: 
 
Primary: 
• To evaluate the 6 month PFS in patients treated with SGT-53 in combination with 
Temozolomide. 
 
Secondary: 
• To assess safety of the combination of SGT-53 and Temozolomide. 
• To evaluate progression free survival (PFS) and OS in patients in patients with recurrent 
or progressive glioblastoma or gliosarcoma treated with SGT-53 in combination with 
Temozolomide. 
• To determine the anti-tumor activity of the combination of SGT-53 and Temozolomide 
based upon the RANO criteria in patients with recurrent or progressive GBM tumors. 
• To assess nanoparticle delivery to tumor site by analysis of the presence of exogenous wt 
p53 in the tumor (optional procedure). 
• To assess induction of apoptosis by SGT-53 in the tumor by flow cytometry or histology 
(optional procedure). 
 
5. 
INVESTIGATIONAL PLAN 
 
This is a prospective open label single arm Phase II study to assess the efficacy of nanoparticle 
delivery to tumor site of exogenous wt p53.  This trial will also evaluate the safety, tolerability, 


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toxicity and efficacy of SGT-53 (given in combination with temozolomide) on PFS and OS in 
adult patients with recurrent Glioblastoma or gliosarcoma. 
 
The study population (26 patients) will be registered through and treated at: MD Anderson 
Cancer Center, Texas, USA and China Medical University Hospital, Taichung, Taiwan, based on 
Inclusion/Exclusion Criteria (see Sections 6.1. and 6.2.) 
 
Although an MTD for SGT-53 was not reached in the previous Phase Ia trial, the highest dose 
tested was 3.6mg of DNA. This is the dose of SGT-53 that will be employed in this trial.  Below 
is the schedule of treatment: 
 
Cycles 1-3 (1 Cycle is 28 days) 
• Day 1: SGT infusion 
• Day 4: SGT infusion 
• Day 8: SGT infusion 
• Days 9-13-: TMZ (150mg/m2 (cycle 1) increasing to 200mg/m2 (from cycle 2 onwards) 
as tolerated, provided the patient meets the criteria for non-hematological toxicity, ANC 
and platelet counts (see 9.7.2) 
• Day 11: SGT infusion 
• Day 15: SGT infusion 
• Day 18: SGT infusion 
• Days 19-28: No treatment 
 
Cycles 4-6: Patients who are responding to treatment (at least stable disease by RANO) may 
receive three additional cycles of SGT-53/Temozolomide therapy at investigator’s discretion. 
Alternatively, they may continue on Temozolomide alone at investigator’s discretion. 
 
 
 
When the Patient has Undergone Optional Surgical Resection For Tumor Analysis (4-6 
patients only): 
 
• SGT infusion on days -3 and -1 
• Surgery on Day 0 
• 14-21 days post operatively and having recovered from the effects of surgery the patients 
then start 28 day cycles of treatment as described above:  SGT-53 will be administered 
every 3rd or 4th day in a 28 day cycle (total of 6 infusions)] starting on Day 1 (cycle 1), 
Day 29 (cycle2) and Day 57 (cycle 3).  Day 1(cycle 1) will be the day of the first 
infusion of SGT-53 post-surgery. Temozolomide will be administered by mouth daily on 
days 9-13 of each cycle at 150mg/m2 (cycle 1), and 200mg/m2 as tolerated for cycle 2 
and beyond provided the patient meets the criteria for non-hematological toxicity, ANC 
and platelet counts (see 9.7.2).. 
• Patients who are responding to treatment (at least stable disease by RANO) may receive 
three additional cycles of SGT-53/Temozolomide therapy at investigator’s discretion. 
Alternatively, they may continue on Temozolomide alone at investigator’s discretion. 
 
 
 
Post Treatment safety follow up: 


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All patients who received treatment with SGT-53 must be followed-up for 30 days after 
discontinuation of study drug. The 30-day follow-up visit should include a physical examination, 
vital signs, concomitant medications and assessment of AEs/SAEs and Urine analysis. Blood 
samples will be taken for: Hematology (CBC with differential, platelet count), Chemistries 
(BUN, Cr, Na+, K+, CO2, Cl, Mg++, Ca++, phosphorus, albumin, alkaline phosphatase, ALT, 
AST, total bilirubin, total protein, glucose, LDH), PT/PTT, and D-dimer. Patients who 
permanently discontinue study drug(s) for reasons other than complete response, progression, or 
death should also have visits approximately every 2 months for the first year that should include 
a MRI, physical examination, vital signs, and recording of concomitant medications for 
glioblastoma. 
 
Patients who are withdrawn from study treatment due to a complete response will have the 30- 
day follow-up visit as described above. Further follow-up visits every 2 months will include only 
a physical/neurological exam, concomitant medications, vital signs and a MRI. 
 
A telephone contact to check on vital status and any additional treatment for glioblastoma will 
occur yearly. 
 
6. STUDY POPULATION: 
 
The study population is subjects at least 18 years of age with histologically confirmed 
glioblastoma or gliosarcoma who have proven tumor recurrence or progression. 
 
6.1. Inclusion Criteria: 
 
Eligible patients must meet all of the following inclusion criteria: 
 
1. Signed informed consent prior to any study-mandated procedure. 
 
2. Histologically confirmed glioblastoma or gliosarcoma in first, second or third relapse. A 
pathology report constitutes adequate documentation of histology for study inclusion. 
Subjects with an initial diagnosis of a lower grade glioma are eligible if a subsequent biopsy 
is determined to be glioblastoma. The amount of prior systemic therapy for this population is, 
nevertheless, restricted to three regimens. 
 
3. Radiographic demonstration of disease progression following prior therapy (RANO criteria) 
 
4. Measurable disease on MRI performed within 14 days prior to registration. Baseline MRIs 
for subjects who underwent salvage surgery after first or second relapse must be obtained ≥ 4 
weeks after the procedure. 
 
5. Male or female patients ≥ 18 years of age. 
 
6. Recurrent disease with an: 
 
 interval of ≥ 3 months following radiotherapy + temozolomide; 


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 interval of ≥ 14 days between end of surgery and start of protocol therapy for patients 
who have undergone surgery for recurrent disease. 
 
7. Patients who tolerated previous administration with temozolomide, i.e.,during adjuvant 
Temozolomide, no dose reductions below the starting dose were required due to treatment- 
related toxicities 
 
8. Recovery from the effects of prior therapy, including the following: 
 
• 
Four weeks from cytotoxic agents (3 weeks from procarbazine, 2 weeks from 
vincristine) 
 
• 
6 weeks from nitrosoureas (CCNU, BCNU) 
 
• 
Four weeks from any investigational agent 
 
• 
One week from non-cytotoxic agents 
 
• 
12 weeks from radiotherapy to minimize the potential for MRI changes related to 
radiation necrosis that might be misdiagnosed as progression of disease, or 4 weeks if a 
new lesion, relative to the pre-radiation MRI, develops that is outside the primary 
radiation field 
 
9. Karnofsky performance status ≥ 60% (see Section 18.3. for details). 
 
10. Complete blood count (CBC)/differential at screening (within 7 days of study initiation), 
with adequate bone marrow function as defined by: absolute neutrophil count (ANC) ≥ 
1,500/µL; platelets ≥ 100,000/µL; hemoglobin ≥ 10 g/dL. 
 
11. If patient is receiving steroids, must be on stable or decreasing steroid dose within 5 days 
prior to treatment initiation with SGT-53. 
 
12. Patients must be willing to forego other cytotoxic and non-cytotoxic drug or radiation 
therapy against the tumor while enrolled in the study. 
 
13. Women of childbearing potential must have a negative serum beta-HCG pregnancy test 
documented within 3 days prior to study initiation. 
 
14. Women of childbearing potential must agree to use two reliable methods of contraception 
from screening and up to 30 days after discontinuation of study treatment (refer to Section 
11.15 for further details). 
 
•Reliable methods of contraception include intrauterine devices (IUD) or intrauterine 
systems (IUS), tubal sterilization, and barrier methods (male condom, diaphragm, or 
cervical cap). A female partner’s vasectomy still requires 1 additional method of 
contraception. Abstinence, the rhythm method, or contraception by the other partner 
alone, will not be considered as a reliable methods of contraception. 


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15. Males not naturally or surgically sterile, who have a female partner of childbearing potential, 
must agree to use two reliable methods of contraception from screening and up to 30 days 
after discontinuation of study treatment (refer to Section 11.15. for further details). 
 
16. Acceptable liver function (obtained within 7 days prior to registration): 
 
• Bilirubin ≤  1.5 times upper limit of normal (CTCAE Grade 1 baseline); Total bilirubin 
≤3xULN with direct bilirubin within normal range in patients with well documented 
Gilbert’s syndrome 
• AST (SGOT), ALT (SGPT) ≤ 2.5 x ULN  (CTCAE Grade 1 baseline) 
• Serum creatinine ≤ 1.5 X ULN (CTCAE Grade 1 baseline) 
 
17. Acceptable blood sugar control (based on labs obtained within 7 days prior to registration): 
Fasting glucose value < 160 mg/dL (CTCAE Grade 1 baseline) 
 
18. Urinalysis (obtained within 7 days prior to registration): No clinically significant 
abnormalities. 
 
19. PT and PTT ≤ 1.5 X ULN after correction of nutritional deficiencies that may contribute to 
prolonged PT/PTT (obtained within 7 days prior to registration). 
 
20. Have recovered from any previous therapy side effects or toxicities (to < grade 1, except 
alopecia) prior to initiating protocol study infusions. 
 
21. Organ function characterized by ≤ Grade 1 scores defined by CTCAE v4.03 unless, at the 
discretion of the investigator, the condition is not deemed to cause unacceptable risk to the 
patient.  If deemed not to cause unacceptable risk to the patient, organ function of grade 2 is 
acceptable. 
 
6.2. Exclusion Criteria 
 
Eligible patients must not meet any of the following exclusion criteria: 
 
1. 
Histology other than astrocytoma grade IV (GBM or gliosarcoma). 
 
2. 
Tumor foci detected below the tentorium or beyond the cranial vault. 
 
3. 
Glioblastoma or gliosarcoma disease with leptomeningeal spread. 
 
4. 
Patients with a history of any other cancer, unless in complete remission, and off all therapy 
for that disease for a minimum of 5 years (except history of basal or squamous cell skin 
cancers that are completely excised/cured at time of enrollment). 
 
5. 
Patients with serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) > 
2.5 X the upper limit of normal (ULN) and bilirubin >1.5 ULN, (unless there is a medical 
justification for the elevation of bilirubin and ALT, AST). 
 
6. 
Moderate to severe hepatic impairment, i.e., Child-Pugh Class B/C. 


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7. 
Positive results from HIV serology testing, if any available. 
 
8. 
Supine systolic blood pressure < 100 mmHg or supine diastolic blood pressure < 50 mmHg 
at screening and baseline, or documented medical history of orthostatic hypotension. 
 
9. 
Renal insufficiency (estimated creatinine clearance < 50 mL/min) or serum creatinine >1.5 
X ULN at screening. 
 
10. Females who are pregnant or lactating or plan to become pregnant during the course of this 
study. 
 
11. Substance or alcohol abuse or dependence, within 12 months prior to screening. 
 
12. Prior chemotherapy for recurrent GBM with nitrosourea compounds including Gliadel® 
(carmustine) wafers or bevacizumab. 
 
13. Prior focal radiotherapy (stereotactic radiotherapy or Gamma Knife) within 3 months of 
screening. 
 
14. Planned treatment, or treatment with any investigational drug within 4 weeks prior to 
screening. 
 
15. Severe, active co-morbidity, including: Cardiac disease – congestive heart failure class 
III/IV NYHA; unstable angina or new onset angina (began within the last 3 months) or  
acute or chronic myocardial infarction within the past 6 months; cardiac ventricular 
arrhythmias requiring anti-arrhythmic therapy; cerebrovascular accident within 6 months 
prior to enrollment; acute bacterial or fungal infection requiring intravenous antibiotics at 
the time of screening; chronic hepatitis B or C infection; chronic obstructive pulmonary 
disease exacerbation or other respiratory illness requiring hospitalization or precluding study 
therapy at the time of screening; hematological and bone marrow diseases. Severe 
malabsorption (defined as > 15% unintentional loss of body weight in the last 6 months 
prior to study enrollment), Major medical illnesses or psychiatric impairments that, in the 
investigator’s opinion, will prevent administration or completion of protocol therapy. 
 
16. Patients who are currently taking Coumadin or Coumadin derivatives other than to maintain 
patency of venous access lines. 
 
17. Requiring renal dialysis 
 
18. Receiving hematopoietic growth factors 
 
19. Have significant baseline neuropathies (> grade 2 based upon CTCAE v 4.03) 
 
20. Had prior exposure to gene vector delivery products within 6 months 
 
21. Any condition that prevents compliance with the protocol or adherence to therapy. 
 
22. Active, uncontrolled bacterial, viral, or fungal infections, requiring systemic therapy. 


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23. Treated with antibiotics for infection within one week prior to study entry. 
 
24. Fever (> 38.1oC) 
 
25. Have diastolic blood pressure of > 90 mm Hg resting at baseline despite medication. 
(Acceptable if on hypertensive medication and diastolic blood pressure is < 90 mm Hg.). 
 
26. Serious nonmalignant disease (e.g., hydronephrosis, liver failure, or other conditions) that 
could compromise protocol objectives in the opinion of the Investigator and/or the Sponsor. 
 
27. Enrollment in a concomitant clinical study 
 
28. Have a history of hypersensitivity reaction (such as urticaria, allergic reaction including 
anaphylaxis, toxic epidermal necrolysis, and Stevens-Johnson syndrome) to any of the 
components of Temozolomide 
 
29. Have a history of hypersensitivity to dacarbazine (DTIC) 
 
6.2.1. Concomitant Medications: 
 
Allowed concomitant medications 
 
Concomitant medications permitted during all study periods include: 
 
• 
Anti-epileptics 
 
• 
Oral corticosteroids, provided that the dose is stable for at least 5 days prior to each 
contrast-enhanced brain MRI performed to assess tumor progression. Any change in the dose 
of corticosteroids must be recorded in the Case Report Form (CRF). 
 
• 
Other concomitant medications: therapies considered necessary for the well-being of the 
patient may be given at the discretion of the treating physicians for both prophylaxis and 
treatment (e.g., anti-emetic). 
 
All concomitant medications must be recorded in the CRF. 
Prohibited concomitant medications 
Concomitant medications prohibited during all study periods include: 
 
• 
Concurrent treatment with bevacizumab or nitrosourea, including Gliadel® wafers. 
 
• 
Cytotoxic chemotherapy other than TMZ. 
 
• 
Any investigational drug other than the study drugs. 
 
6.2.2. Concomitant Procedures: 
 
If whilst on protocol, a patient needs surgery for tumor progression or brain surgery for other 
causes e.g. hydrocephalus, bleeding, the patient can be continued on the study at the discretion of 
the investigator. 


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7. STUDY DRUGS: 


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7.1. Temozolomide (Temodar®) (NDC 0085-1366) 
 
a. 
DESCRIPTION 
 
4-Methyl-5-oxo-2,3,4,6,8-pentazabicyclo[4.3.0]nona-2,7,9-triene-9-carboxamide 
(Temozolomide) is a white-to-off-white crystalline powder with a molecular weight of 194.1508 
 
Mechanism of Action:  Temozolomide is an imidazotetrazine derivative Temozolomide is not 
directly active but undergoes rapid nonenzymatic conversion at physiologic pH to the reactive 
compound 5-(3-methyltriazen-1-yl)-imidazole-4-carboxamide (MTIC).  The cytotoxicity of 
MTIC is thought to be primarily due to alkylation of DNA. Alkylation (methylation) occurs 
mainly at the O6 and N7 positions of guanine. 
 
b. 
TOXICOLOGY 
 
Human Toxicology: 
 
In patients with newly diagnosed Glioblastoma Multiforme, during the concomitant phase 
(temozolomide+radiotherapy), adverse reactions including thrombocytopenia, nausea, vomiting, 
anorexia, and constipation were more frequent in the temozolomide+RT arm. The incidence of 
other adverse reactions was comparable in the two arms. The most common adverse reactions 
across the cumulative temozolomide experience were alopecia, nausea, vomiting, anorexia, 
headache, and constipation. Forty-nine percent (49%) of patients treated with temozolomide 
reported one or more severe or life-threatening reactions, most commonly fatigue (13%), 
convulsions (6%), headache (5%), and thrombocytopenia (5%).  Overall, the pattern of reactions 
during the maintenance phase was consistent with the known safety profile of temozolomide. 
 
Myelosuppression (neutropenia and thrombocytopenia), which is a known dose-limiting toxicity 
for most cytotoxic agents, including temozolomide, was observed. When laboratory 
abnormalities and adverse reactions were combined, Grade 3 or Grade 4 neutrophil abnormalities 
including neutropenic reactions were observed in 8% of the patients, and Grade 3 or Grade 4 
platelet abnormalities, including thrombocytopenic reactions, were observed in 14% of the 
patients treated with temozolomide. 
 
In patients with refractory anaplastic astrocytoma,the most frequently occurring adverse 
reactions were nausea, vomiting, headache, and fatigue. The adverse reactions were usually NCI 
Common Toxicity Criteria (CTC) Grade 1 or 2 (mild to moderate in severity) and were self- 
limiting, with nausea and vomiting readily controlled with antiemetics. The incidence of severe 
nausea and vomiting (CTC Grade 3 or 4) was 10% and 6%, respectively. Myelosuppression 
(thrombocytopenia and neutropenia) was the dose limiting adverse reaction. It usually occurred 
within the first few cycles of therapy and was not cumulative. Myelosuppression occurred late in 
the treatment cycle and returned to normal, on average, within 14 days of nadir counts. The 
median nadirs occurred at 26 days for platelets (range: 21-40 days) and 28 days for neutrophils 
(range: 1-44 days). Only 14% (22/158) of patients had a neutrophil nadir and 20% (32/158) of 
patients had a platelet nadir, which may have delayed the start of the next cycle. Less than 10% 


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of patients required hospitalization, blood transfusion, or discontinuation of therapy due to 
myelosuppression. 
 
In clinical trial experience with 110 to 111 women and 169 to 174 men (depending on 
measurements), there were higher rates of Grade 4 neutropenia (ANC <500 cells/µL) and 
thrombocytopenia (<20,000 cells/µL) in women than men in the first cycle of therapy (12% vs. 
5% and 9% vs. 3%, respectively). 
 
In the entire safety database for which hematologic data exist (N=932), 7% (4/61) and 9.5% 
(6/63) of patients over age 70 experienced Grade 4 neutropenia or thrombocytopenia in the first 
cycle, respectively. For patients less than or equal to age 70, 7% (62/871) and 5.5% (48/879) 
experienced Grade 4 neutropenia or thrombocytopenia in the first cycle, respectively. 
Pancytopenia, leukopenia, and anemia have also been reported. 
 
Contraindication: 
Temozolomide is contraindicated in patients who have a history of hypersensitivity reaction 
(such as urticaria, allergic reaction including anaphylaxis, toxic epidermal necrolysis, and 
Stevens-Johnson syndrome) to any of its components. TEMODAR is also contraindicated in 
patients who have a history of hypersensitivity to DTIC, since both drugs are metabolized to 5- 
(3-methyltriazen-1-yl)-imidazole-4-carboxamide (MTIC). 
 
Pregnancy and Lactation: Temozolomide can cause fetal harm when administered to a pregnant 
woman.  Male and female patients who take temozolomide should use effective birth control. 
Female patients and female partners of male patients should avoid becoming pregnant while 
taking temozolomide. Administration of temozolomide to rats and rabbits during organogenesis 
at 0.38 and 0.75 times the maximum recommended human dose (75 and 150 mg/m2), 
respectively, caused numerous fetal malformations of the external organs, soft tissues, and 
skeleton in both species. There is no data on temozolomide administration during human 
pregnancy, and it is not currently known if metabolites are excreted in human milk. However, 
many drugs are excreted in human milk, and there is a potential for adverse effects in nursing 
infants.  Therefore, the use of temozolomide should be avoided in pregnant or nursing women 
because of the potential hazard to the fetus or infant. 
 
c. 
PHARMACOLOGY 
 
Kinetics:  Absorption: Temozolomide is rapidly and completely absorbed after oral 
administration with a peak plasma concentration (Cmax) achieved in a median Tmax of 1 hour. 
Food reduces the rate and extent of temozolomide absorption. Mean peak plasma concentration 
and AUC decreased by 32% and 9%, respectively, and median Tmax increased by 2-fold (from 
1-2.25 hours) when temozolomide was administered after a modified high-fat breakfast. A 
pharmacokinetic study comparing oral and intravenous temozolomide in 19 patients with 
primary CNS malignancies showed that 150 mg/m2 TEMODAR for injection administered over 
90 minutes is bioequivalent to 150 mg/m2   TEMODAR oral capsules with respect to both Cmax 
and AUC of temozolomide and MTIC. Following a single 90-minute intravenous infusion of 
150 mg/m2, the geometric mean Cmax values for temozolomide and MTIC were 7.3 mcg/mL 
and 276 ng/mL, respectively. Following a single oral dose of 150 mg/m2, the geometric mean 


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Cmax values for temozolomide and MTIC were 7.5 mcg/mL and 282 ng/mL, respectively. 
Following a single 90-minute intravenous infusion of 150 mg/m2, the geometric mean AUC 
values for temozolomide and MTIC were 24.6 mcg·hr/mL and  891 ng·hr/mL, respectively. 
Following a single oral dose of 150 mg/m2, the geometric mean AUC values for temozolomide 
and MTIC were 23.4 mcg·hr/mL and 864 ng·hr/mL, respectively. 
 
Distribution: Temozolomide has a mean apparent volume of distribution of 0.4 L/kg 
(%CV=13%). It is weakly bound to human plasma proteins; the mean percent bound of drug- 
related total radioactivity is 15%. Metabolism and Elimination: Temozolomide is spontaneously 
hydrolyzed at physiologic pH to the active species, MTIC and to temozolomide acid metabolite. 
MTIC is further hydrolyzed to 5-amino-imidazole-4-carboxamide (AIC), which is known to be 
an intermediate in purine and nucleic acid biosynthesis, and to methylhydrazine, which is 
believed to be the active alkylating species. Cytochrome P450 enzymes play only a minor role in 
the metabolism of temozolomide and MTIC. Relative to the AUC of temozolomide, the exposure 
to MTIC and AIC is 2.4% and 23%, respectively. 
 
Excretion: About 38% of the administered temozolomide total radioactive dose is recovered over 
7 days: 37.7% in urine and 0.8% in feces. The majority of the recovery of radioactivity in urine 
is unchanged temozolomide (5.6%), AIC (12%), temozolomide acid metabolite (2.3%), and 
unidentified polar metabolite(s) (17%). Overall clearance of temozolomide is about 5.5 L/hr/m2. 
Temozolomide is rapidly eliminated, with a mean elimination half-life of 1.8 hours, and exhibits 
linear kinetics over the therapeutic dosing range of 75 to 250 mg/m2/day. 
 
Formulation: 100mg capsules of temozolomide are supplied as a white capsule with a pink cap . 
The capsules contain temozolomide and inactive ingredients lactose anhydrous, colloidal silicon 
dioxide, sodium starch glycolate, tartaric acid, and stearic acid in the form of a white powder. 
The body of the capsules are made of gelatin and are opaque white. The cap is also made of 
gelatin, and the colors vary based on the dosage strength. 
 
Storage and Stability: Store temozolomide Capsules at 25°C (77°F); excursions permitted to 15°-
30°C (59°-86°F) . 
 
Administration:  Oral 
 
Handling Precautions:  Care should be exercised in the handling and preparation of TEMODAR. 
Vials and capsules should not be opened. If vials or capsules are accidentally opened or 
damaged, rigorous precautions should be taken with the contents to avoid inhalation or contact 
with the skin or mucous membranes.  The use of gloves and safety glasses is recommended to 
avoid exposure in case of breakage of the vial or capsules.  Procedures for proper handling and 
disposal of anticancer drugs should be considered. (1) 
 
d. 
SUPPLIER 
 
Temozolomide is commercially available as Temodar for the treatment of adult patients with 
newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as 


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maintenance treatment. Temodar is manufactured by Merck&Co., Inc., Whitehouse Station, 
New Jersey, USA. Generic drug may also be used with prior approval from sponsor. 
 
7.2.SGT-53 
 
a. 
DESCRIPTION 
 
The study agent, SGT-53, consists of a DOTAP/DOPE liposome encapsulating a plasmid 
containing a cDNA encoding the normal human wild type p53 gene, with a TfRscFv targeting 
entity decorating the surface of the liposome A final concentration of 10% sucrose is included in 
the complex as an excipient.  Each of the components is prepared under cGMP conditions at the 
following facilities: 
 
TfRscFv – TfRscFv single chain antibody cell paste and inclusion bodies were 
manufactured at the Waisman Clinical BioManufacturing Facility, Madison, 
WI. 
TfRscFv single chain antibody was isolated from the inclusion bodies by 
Advanced Bioscience Laboratories, Inc., Kensington, MD 
 
• 
Liposome – Walter Reed Army Institute for Research, Silver Spring, MD, USA 
 
• 
DNA – Aldevron, Fargo, ND, USA 
 
Mechanism of Action:  The therapeutic agent in SGT-53 is a DNA sequence encoding normal 
human p53.  The p53 gene is a vital tumor suppressor gene in humans. Numerous human 
tumors, including brain cancers possess a loss or mutation of the wild type p53 (wtp53) gene.  In 
addition to playing a crucial role in cell cycle control, the p53 protein is a critical component in 
two of the pathways involved in regulating tumor cell growth: cell death (apoptosis) and the 
regulation of angiogenesis. Due to its role in the apoptotic pathway, restoration of functional p53 
in tumor cells permits the cells to enter apoptosis when treated with conventional 
chemotherapeutic agents.  This results in sensitization of the tumors to the killing effects of 
chemotherapy and more effective tumor cell death. 
 
b. 
TOXICOLOGY 
 
Human Toxicology: 
 
No MTD reached when used as a single agent in Phase Ia trial. No Grade 4 AEs related to SGT- 
53 occurred in the Phase Ia Trial.  The Table below list the Grades 1-3 AEs that were observed in 
the Phase Ia single agent train and the Phase Ib combination trial of SGT-53 and docetaxel to 
date. 


 
 
 
 
 
Phase Ia 
Grade 1, 2, & 3 AE’s 
Pt 
ID 
Relation to Study Drug 
Grade 1 
Grade 2 
Grade 3 
Possible 
Probable 
Definite 
Possible 
Probable 
Definite 
Possib 
le 
Probab 
le 
Defini 
te 
02- 
003 
None 
None 
None 
None 
Intermitten 
t Diarrhea, 
Intermitten 
t 
Dehydratio 
n, 
Hypotensi 
on 
None 
None 
None 
None 
02- 
006 
None 
Chills, 
Hypotensio 
n, 
Headache, 
Tachycardi 
a, Fever 
Fever 
Fatigue 
Fever 
None 
None 
None 
None 
02- 
007 
Fatigue, 
Fever, 
Neutropenia, 
Chills 
Fever, 
Tumor 
Necrosis in 
Mouth 
None 
Fatigue, 
Dehydratio 
n, 
Phlebetis 
IV site L 
Neutropeni 
a, Tumor 
Necrosis in 
Mouth 
None 
Fatigu 
e* 
None 
None 
02- 
008 
None 
Hypotensio 
n 
None 
None 
Hypotensi 
on 
None 
None 
None 
None 
02- 
010 
None 
None 
Hypotensio 
n 
Intermitten 
t Diarrhea 
None 
None 
None 
None 
None 


 
 
 
 
02- 
011 
Anorexia, 
Fatigue, 
Tachycardia, 
Dizziness, 
Oral Ulcer, 
Lightheadedne 
ss, Elevated 
D-Dimer 
Fever, 
Hypotensio 
n 
Fever, 
Hypotensio 
n, 
Anemia, 
Fatigue, 
Headache 
Fever, 
Leukopeni 
a, Elevated 
AST, 
Elevated 
ALT, 
Neutropeni 
a 
Fever 
None 
None 
None 
02- 
012 
Fatigue 
Hypotensio 
n 
None 
Anemia, 
Elevated 
LDH 
None 
None 
None 
None 
None 
02- 
013 
Anorexia, 
Nausea 
None 
None 
None 
Anemia 
Chills/Rigo 
r, Fever, 
Hypotensio 
n, 
Stomatitis 
None 
None 
None 
02- 
014 
Intermittent 
Diarrhea 
None 
Chills/Rigo 
r 
Diarrhea 
None 
None 
None 
None 
None 
02- 
015 
Nausea, 
Hypomagnese 
mia, Flushed, 
Wheezing, 
Intermittent 
Nausea, 
Transient 
Shortness of 
Breath 
None 
Chills/Rigo 
r, Nausea 
Diffuse 
Patchy 
Infiltrates, 
Wheezing, 
Fluid 
Overload, 
Tachycardi 
a, 
Dyspepsia, 
Neutropeni 
a, Chest 
Pain 
Fatigue 
Fever, 
Fatigue, 
Hypotensio 
n 
None 
None 
None 


 
 
 
 
02- 
016 
Fatigue, 
Weakness, 
Blurred 
Vision, 
Flushing, 
Headache, 
Mild Nausea, 
Dizziness, 
Insomnia, 
Lightheadedne 
ss, Chest 
Tightness, 
Dyspnea on 
Exertion, 
Choking 
Feeling, 
Weight Loss 
None 
None 
Diarrhea, 
Nausea, 
Depression 
, Malaise, 
Nervousne 
ss, 
Increased 
Shortness 
of Breath 
None 
None 
None 
None 
None 
 
* - Not a serious adverse event 


 
 
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Protocol Number: SGT53-02-2 
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Phase Ib  Grade 1, 2, & 3 AE’s 
Pt 
ID 
Relation to Study Drug 
Grade 1 
Grade 2 
Grade 3 
Possible 
Probable 
Definite 
Possible 
Probable 
Definite Possible 
Probable 
Definite 
02- 
018 
SGT-53 
Nausea, 
Vomiting, 
Fever 
Docetaxel 
Fever, 
Coating on 
the tongue 
SGT-53 
Chills 
Docetaxel 
Fever 
None 
SGT-53 
Hypotension, 
Fatigue 
Docetaxel 
Dehydration, 
Intractable nausea, 
Intractable 
vomiting Fatigue 
None 
None 
SGT-53 
Neutropenia 
Docetaxel 
Neutropenia 
None 
02- 
019 
SGT-53 
Intermittent 
fatigue 
Docetaxel 
Intermittent 
fatigue 
None 
None 
None 
None 
None 
None 
None 
None 
02- 
020 
SGT-53 
Diarrhea, 
Anorexia, 
Anemia, 
Weakness 
Docetaxel 
SGT-53 
Chills, 
Headache, 
None 
SGT-53 
Diarrhea, Anemia, 
Dehydration 
Docetaxel 
Anemia, 
Dehydration 
None 
None 
None 
None 
None 


 
 
SynerGene Therapeutics, Inc. 
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Page 54 of 108 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
 
 
 
Anorexia, 
Anemia, 
Weakness 
02- 
023 
Docetaxel 
Thrush, 
Thrombocyto 
-penia 
None 
SGT-53 
Fever, 
Hypo- 
tension 
Docetaxel 
Thrombocytopenia 
None 
None 
None 
None 
None 
02- 
024 
p53 
Elevated 
ALT, 
Hypocalcemi 
a, Elevated 
AST, 
None 
None 
p53 
Elevated AST, 
Hypotension 
None 
None 
p53 
Syncopal 
episode 
None 
None 
02- 
025 
None 
None 
None 
None 
None 
None 
None 
None 
None 
02- 
026 
None 
None 
None 
p53 
Intermittent 
hypotension, 
dehydration 
None 
None 
None 
None 
None 


 
 
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Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
 
Pregnancy and Lactation: No Data Available 
 
c. 
PHARMACOLOGY 
 
Kinetics:  No Data Available 
 
Formulation: 
 
Each of the components is prepared under cGMP conditions at the following facilities: 
 
• 
TfRscFv –  Walter Reed Army Institute for Research, Silver Spring, MD, USA 
• 
Liposome – Walter Reed Army Institute for Research (WRAIR), Silver Spring, 
MD, USA 
• 
DNA – Aldevron, Fargo, ND, USA 
 
The cGMP grade sucrose is obtained in crystalline form.  A sterile 70% aqueous solution 
for use in the complex was prepared under cGMP conditions at the WRAIR, Silver 
Spring MD as part of the process for production of the SGT-53 complex. 
 
The SGT-53 complex was prepared under cGMP conditions at WRAIR, Silver Spring 
MD. The components were mixed in a set order and at a specific ratio of TfRscFv: 
Liposome:DNA as per SOP supplied by SynerGene Therapeutics, Inc to WRAIR. The 
resulting SGT-53 complex (at a dose of 0.6mg DNA/vial) was vialed, lyophilized and 
stored at -20oC at WRAIR.  This batch was tested and qualified for human use.  These 
vials are shipped in batches of 50 - 100 vials to the Investigational Pharmacy of clinical 
trial site on dry ice and stored at the Investigational Pharmacy at the clinical trial site at 2-
8oC .  They are reconstituted in the same facility with WFI using the procedure provided 
by SynerGene Therapeutics, Inc. 
 
Storage and Stability: 
 
The doses are given as mg of wtp53 plasmid DNA.  The complex is prepared at a specific 
ratio of 1 ug of DNA to a specific amount of TfRscFv and a specific amount of liposome. 
Therefore, as the amount of DNA increases, the amount of TfRscFv and liposome in the 
complex increases proportionally.  The complex will then be mixed with 5% Dextrose for 
infusion.  The final volume of the complex/5% Dextrose per infusion will be ~200 ml and 
will be infused intravenously over 90-120 minutes. 
 
The complex diluted in 5% Dextrose (at ratios of 1:2 to 1:5) is stable for at least eight 
hours at 20oC once prepared.  Infusion of the complex should be initiated within one hour 
of preparation and the infusion completed within eight hours of dilution of study agent in 
dextrose. 
 
The investigator will be responsible for dispensing and accounting of all components of 
the complex provided by the sponsor. Records of document control numbers and dates 
received will be kept on a Drug Inventory Form provided by the sponsor.  Under no 


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Protocol Number: SGT53-02-2 
Amendment 6 July 5 , 2016 
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Page 56 of 108 
 
 
circumstances will the investigator supply study drug to other investigators, allow study 
drug to be used other than directed by this protocol, or destroy or dispose of study drug in 
any other manner without prior authorization from the sponsor. 
 
Any residual clinical trial materials must be returned to the clinical site’s investigational 
drug pharmacy for disposition.  All unopened or partially used vials of the SGT-53 
components will be returned to SynerGene Therapeutics, Inc. at the end of the study. 
 
Reconstitution: 
 
With sterile WFI as directed by Sponsor supplied SOP 
Administration:  Intravenous. 
Handling Precautions: 
 
None to date. 
 
d. 
SUPPLIER 
SGT-53 is not commercially available.  It is provided free of charge by the Sponsor 
SynerGene Therapeutics, Inc 
9812 Falls Road, Suite 114 
Potomac MD 20854 
Tel: 301-706-1509 
Email: clinicaltrial@synergeneus.com 
 
 
8. 
STUDY ENDPOINTS: 
 
 
 
8.1. Safety Endpoint Definitions 
Patients will be evaluated and adverse events (AEs) assessed according to the Study 
Calendar (Section 18.1) using Common Toxicity Criteria 4.0 (CTC 4.03, 2010). For 
definition of DLT see Section 9.7. 
 
 
 
8.2. Efficacy Endpoints 
 
To evaluate the PFS, 6 month PFS, OS in patients treated with SGT-53 in combination 
with Temozolomide.  These parameters will be evaluated using RANO Response Criteria 
(Response Assessment in Neuro-Oncology). All patients who have measureable disease 
according to RANO, received at least one dose of SGT-53, and have had disease re- 
evaluated will be included in the analyses of secondary endpoints. 
 
Optional surgical resection for tumor analysis: 


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Protocol Number: SGT53-02-2 
Amendment 6 July 5 , 2016 
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DNA PCR will be employed to determine the presence of the nanoparticle delivered 
exogenous wtp53 gene in the tumor sample obtained during surgical resection. A 
maximum of 6 patients will be have this optional testing. Detection of exogenous wtp53 
in the tumors from at least 3 patients will be considered a positive outcome. If the 
presence of the exogenous wtp53 is detected in at least 3 of the first 4 tumors assessed, 
the option for surgical resection for tumor analysis will no longer be offered. 
 
 
 
 
 
 
9. 
TREATMENT PLAN: 
 
Cycles 1-3 (1 Cycle is 28 days) 
 
• Day 1: SGT infusion 
• Day 4: SGT infusion 
• Day 8: SGT infusion 
• Days 9-13: TMZ (150mg/m2 increasing to 200mg/m2 as tolerated, provided the 
patient meets the criteria for non-hematological toxicity, ANC and platelet counts) 
• Day 11: SGT infusion 
• Day 15: SGT infusion 
• Day 18: SGT infusion 
• Days 19-28: No treatment 
 
In those patients who had a surgical resection, the 1st cycle of SGT-53 and TMZ will start 
14-21 days post operatively and having recovered from the effects of surgery. 
 
Cycles 4-6: Patients who are responding to treatment (at least stable disease by RANO) 
may receive three additional cycles of SGT-53/Temozolomide therapy at investigator’s 
discretion. Alternatively, they may continue on Temozolomide alone at investigator’s 
discretion. 
 
Optional surgical resection for tumor analysis (Maximum of 6 Patients): 
 
• SGT infusion on days -3 and -1 
• Surgery on Day 0 
• 14- 21 days post operatively and having recovered from the effects of surgery, the 
patients will then start cyclical TMZ with SGT-53 as described above: SGT-53 
will be administered every 3rd or 4th day in a 28 day cycle (total of 6 infusions)] 
starting on Day 1 (cycle 1), Day 29 (cycle2) and Day 57 (cycle 3).  The day of the 
first post-surgical infusion of SGT-53 will be Day 1 (cycle 1). Temozolomide will 
be administered by mouth daily on days 9-13 of each cycle at 150mg/m2 (cycle 
1), and 200mg/m2 as tolerated for cycle 2 and beyond provided the patient meets 
the criteria for non-hematological toxicity, ANC and platelet counts (see 9.7.2). 
• Patients who are responding to treatment (at least stable disease by RANO) may 
receive three additional cycle of SGT-53/Temozolomide therapy at investigator’s 
discretion. Alternatively, they may continue on Temozolomide alone at 
investigator’s discretion. 


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9.1. Dosing Plan: 
Administration of SGT-53 and Temozolomide therapy 
 
Agent 
Dose 
Route 
Temozolomide 
SGT-53 
150 mg/m2 (starting dose) 
3.6mg DNA per infusion 
Oral 
IV over 90-120 minutes 
 
9.1.1. Treatment Schedules 
 
 
 
 
 
 
 
 
 
With Optional Surgical Resection for Tumor Analysis 
 
 
 
 
 
In case of holiday or other logistic issue, schedule will allow for SGT-53 treatments to be 
delivered on Monday and Thursday, or Tuesday and Friday of each week.  If necessary, 
other schedules may be permitted with the approval of the Sponsor and PI. 


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9.2. Premedication 
 
Pre-medication will follow emerging principles for liposomal agents, consisting of 
allergic prophylaxis and close monitoring for bronchospasm (i.e., grade 3 
hypersensitivity reaction) and other signs of acute hypersensitivity (≥ grade 2 
hypersensitivity).  Specifically, for each infusion of SGT-53, patients will receive 
dexamethasone 8 mg i.v. 1 hour +/-5 minutes prior to dosing, and a combination of 
histamine H1 and H2 blockers (e.g. Benadryl 25 mg and Pepcid 20 mg, both i.v.) 30 
minutes +/- 15 minutes and indocin 25 mg, or an equivalent NSAID, p.o. approximately 
30 +/- 5 minutes prior to receiving SGT-53.  All patients will also receive acetaminophen 
650 mg p.o. just prior to SGT-53 administration as prophylaxis for pyretic reactions. 
Generic drugs may be used with prior approval from sponsor. 
 
Premedications for temozolomide will be at investigator discretion, according to 
institutional practices. Antiemetic(s) suitable for controlling mild to moderate nausea and 
vomiting should be given prior to chemotherapy. 
 
9.3. SGT-53 Infusion 
 
Once the study drug is prepared, the investigational pharmacy will immediately deliver 
the study drug to the outpatient clinic for administration to the study participant. A final 
volume of ~200 ml of SGT-53 in 5% Dextrose will be infused over 90-120 minutes 
intravenously via a newly inserted central venous line or following flushing of an intact 
central venous line.  Infusion must be completed as soon as possible, but no later than 
within eight hours of dilution of SGT-53 in dextrose. 
 
If infusion reactions occur, acetaminophen, diphenhydramine, steroids or other 
medications may be given for symptom control as needed. Although prolonged use of 
systemic corticosteroids to prevent allergic reactions is discouraged, intermittent use of 
corticosteroids is permitted. Use of corticosteroids (dose, name, start/off dates) should 
also be documented in CRFs 
 
9.3.1. Medications and Observations During and After Infusions of SGT-53 
 
Four hours after completion of each infusion of SGT-53, subjects will receive 
acetominophen, 650 mg p.o.  In addition, Demerol, 12.5 mg i.v.p.b. will be available for 
prn use (up to two doses) as needed for rigors.  All infusions will be given where 
epinephrine (1:1000) 0.3-0.5 mL s.q. or i.m. (or epinephrine (1:10,000) 3-5 mL i.v.). is 
IMMEDIATELY available, along with dexamethasone 20 mg i.v. for prn use for 
suspected acute hypersensitivity reactions, including hypotension or bronchospasm. 
Insulin will be available for use for subjects with elevation in blood glucose levels. 
 
Subjects will have vital sign (pulse, blood pressure and temperature) monitoring every 15 
+ 5 minutes during infusion and every 30 + 5 minutes for two hours after each infusion, 
and will be monitored closely for wheezing, change in blood pressure or signs of 
hypoperfusion such as cold, clammy skin, cyanosis or tachycardia.  If any of these signs 
occur, infusion will be stopped.  All patients will continue to have an i.v. fluid (at a rate 


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Protocol Number: SGT53-02-2 
Amendment 6 July 5 , 2016 
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Page 60 of 108 
 
 
of at least 100 mL/hr) during this two hour post-infusion observation period.  A 12-lead 
ECG will be performed weekly (2 hours post-infusion) during the first 2 weeks of cycle 
1,and at the End Of Treatment (EOT) visit.  If these patients receive additional rounds of 
SGT-53/Temozolomide a 12-lead ECG will only be performed as necessary and at the 
EOT visit. 
 
9.3.2. SGT-53 Infusion Reactions 
 
Infusion reactions are defined as any adverse event that occurs during the infusion of 
SGT-53 or during the two hours following completion of the infusion. Hypersensitivity 
reactions are those events defined by NCI criteria, e.g., bronchospasm, dyspnea, etc. 
 
If infusion reactions occur during the infusion of SGT-53, the infusion will be 
discontinued and appropriate medical care administered. SGT-53 is to be administered 
only by physicians or nurses with training and experience with the administration of 
chemotherapeutic agents.  All medications and interventions used to treat infusion 
reactions will be recorded and reviewed by the DSMB at the routine scheduled meetings 
(see Section 14). 
 
The SGT-53 infusion may resume at a slower infusion rate if the symptoms resolve 
within two hours.  If the infusion recurs at the same grade or higher, the infusion will be 
terminated and no further infusions of SGT-53 administered to that patient. 
 
If a hypotensive reaction (BP < 90 systolic) occurs during infusion of SGT-53, infusion 
should be discontinued and not resumed during that visit.  SGT-53 infusions may resume 
if the symptoms of hypotension have resolved by the time of the next scheduled infusion. 
Should this occur during SGT-53 infusions and not resolve within 24 hours the patient 
will not receive any further treatments (neither Temozolomide nor SGT-53) that week. 
The treatments will begin again the following Monday, repeating the interrupted week. 
 
Should a second acute hypotensive reaction (BP < 90 systolic) occur during infusion of 
SGT-53 the patient will be removed from protocol and be replaced. 
 
In the event that an infusion reaction consists of respiratory wheeze, including 
symptomatic bronchospasm or any grade 3 or 4 hypersensitivity reaction, the infusion is 
to be permanently discontinued and the patient replaced. 
 
If infusion reactions occur, acetaminophen, diphenhydramine, steroids or other 
medications may be given for symptom control as needed. Although prolonged use of 
systemic corticosteroids to prevent allergic reactions is discouraged, intermittent use of 
corticosteroids is permitted. Use of corticosteroids (dose, name, start/off dates) should 
also be documented in CRFs 
 
9.3.3. Observation for First SGT-53 Infusion 
 
For the first infusion of SGT-53, subjects will be monitored and observed for 23 hours 
from the time of admittance to the clinic. Subjects will receive the infusion in the 


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outpatient clinic and be monitored there until infusion is completed and for 2 to 8 hours 
after the completion of the infusion. After the initial period of 2-8 hours, the patient will 
be admitted and monitored as an inpatient for the remainder of the 23 hour observation 
period. Alternatively, patients can be admitted directly to the hospital prior to receiving 
the first infusion of SGT-53 and to be monitored and observed there for, at least, 24 hours 
from the time of admittance. 
 
Additionally a 12-lead ECG will be performed 2 hours and 23 hours after the first 
infusion of SGT-53. 
 
During the observation period, subjects will have continued i.v. access with maintenance 
of a 20 gauge catheter for rapid fluid management if necessary.  The IV access rate 
should be ≥ 100 mL/hour during the observation period. 
 
The patient will continue to receive i.v. fluid at ≥ 100 mL/hr during the observation 
period after the initial infusion and vital signs (blood pressure, pulse, temperature and 
respiration) will be obtained every 15 + 5 minutes during infusion, every 30 + 5 minutes 
for the first two hours after the infusion and every 1 hour ± 15 minutes during hours 3 to 
8 post-infusion, and thereafter every 2 hours ± 15 minutes for the remainder of the 
observation period. Patients will be monitored closely for wheezing, change in blood 
pressure or signs of hypoperfusion such as cold, clammy skin, cyanosis or tachycardia. 
 
Four hours after completion of the first infusion of SGT-53, subjects will receive 
acetaminophen, 650 mg p.o.  The patient will receive acetaminophen 650 mg po 
alternating with Indocin 25 mg, or an equivalent NSAID, po every 4 hours during the 
observation period. 
 
During the hospitalization, Demerol 12.5 mg i.v.p.b. must be available as needed for 
rigors. Epinephrine (1:1000 0.3-0.5 mL s.q. or i.m.) or epinephrine [(1:10,000) 3-5 mL 
i.v.] must also be IMMEDIATELY available, along with dexamethasone 20 mg i.v. for 
prn use for suspected acute hypersensitivity reactions, including hypotension or 
bronchospasm.  Insulin will be available for use for subjects with elevation in blood 
glucose levels. 
 
The next day the subjects will be discharged if medically stable. If at the end of the 
observation period, the subject has not resolved any SGT-53 related toxicities to ≤ grade 
1, the subject will be observed until the time at which the managing physician deems the 
patient medically stable for discharge. 
 
If patient is receiving a second course of treatment, the 23 or 24hour observation period 
and 12-lead ECG are not required. 
 
9.3.4. Outpatient Clinic for Subsequent SGT-53 Infusions 
 
For subsequent infusions, subjects will be infused with SGT-53 in the outpatient infusion 
unit of in one of the outpatient ambulatory treatment centers at the clinical trial sites. The 
treatment centers are staffed with medical personnel and equipment to treat emergency 
and non-emergency events and is highly experienced with phase I and II trials. Subjects 


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will be monitored for two hours, as in Section 9.3.1., and will be discharged only if 
medically stable. The subject can be monitored for up to 8 hours in the clinic prior to 
discharged if medically stable.  If necessary, the subject can be admitted for 23 hour 
observation as described for the first infusion (Section 9.3.3.). 
 
 
 
 
9.4. Study drug discontinuation and study withdrawal: 
 
Every reasonable effort should be made to maintain patient compliance and participation 
in the study.  However, all patients are free to withdraw from participation in this study at 
any time, for any reason, and without prejudice. 
 
A patient will be considered as withdrawn from the study if, and only if, he/she 
withdraws consent, or is lost to follow-up after unsuccessful attempts by the investigator 
to contact the patient. 
 
The Investigator may terminate a patient from the study for administrative reasons, or in 
the investigator’s opinion, to protect the patient’s best interest. Reasons may include the 
following: 
 
• Patient withdraws consent and refuses to continue procedures/observations. 
• If at any time, continued participation in the study is determined not to be in the 
best interest of the patient. 
• Development of a severe (grade 4) or intolerable adverse event that does not 
resolve within a 14 day time-frame. 
• Development of a significant intercurrent illness. 
• Deterioration in patient’s disease status such that chemotherapy is no longer 
indicated. 
• Termination of the study by the Sponsor.  Patient’s care will not be affected in the 
event of premature termination of this study. 
• At any time during study in patients with Progressive Disease as defined below, 
as determined by Investigator (see Section 18.2.) 
 
If a patient is withdrawn before completing the study, the reason for withdrawal will be 
entered on the appropriate CRF. Whenever possible and reasonable, the evaluations that 
were to be conducted at the completion of the study and radiographic tumor measurement 
should be performed at the time of premature discontinuation. 
 
For grade 2 events of increased bilirubin, AST, ALT, dyspnea, or DIC, the dose of SGT- 
53 can be held for up to two weeks.  If the grade 2 event resolves within two weeks, then 
infusion of SGT-53 can resume at the same dose per calendar at incident week + 1-2 
weeks (i.e., treatment would be made up and moved 1-2 weeks later). 
 
For non-hematological events other than increased bilirubin, AST, ALT, dyspnea, or 
DIC, participants who develop a > or = to grade 2 toxicity (except for alopecia, or fever, 
chills, hypotension that respond to treatment) or grade 3 fatigue will discontinue twice- 


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weekly infusions until the toxicity level reduces to at least grade 1.  Infusions will be held 
for one week intervals, and infusions that are withheld will be made-up (i.e. moved 1-2 
weeks later).  If the toxicity does not resolve within two weeks, study drug will be 
discontinued. 
 
In the event that a patient is removed from the study for reasons other than toxicity, they 
can be replaced at the same dose level. 
 
Patients who go off-treatment after receiving any infusions of SGT-53 will be considered 
eligible for evaluation of toxicity. Patients withdrawing consent prior to initiation of 
therapy will be replaced at the same dose level. 
 
 
 
 
9.4.1. Patient follow up after study discontinuation: 
 
All patients who received treatment with SGT-53 must be followed-up for 30 days after 
discontinuation of study drug. The 30-day follow-up visit should include a physical 
examination, vital signs, concomitant medications and assessment of AEs/SAEs and 
Urine analysis.  Blood samples will be taken for: Hematology (CBC with differential, 
platelet count), Chemistries (BUN, Cr, Na+, K+, CO2, Cl, Mg++, Ca++, phosphorus, 
albumin, alkaline phosphatase, ALT, AST, total bilirubin, total protein, glucose, LDH), 
PT/PTT, and D-dimer. Patients who permanently discontinue study drug(s) for reasons 
other than complete response, progression, or death should also have visits approximately 
every 2 months for the first year that should include a MRI, physical examination, vital 
signs, and recording of concomitant medications for glioblastoma. 
 
Patients who are withdrawn from study treatment due to a complete response will have 
the 30-day follow-up visit as described above. Further follow-up visits every 2 months 
will include only a physical/neurological exam, concomitant medications, vital signs and 
a MRI. 
 
A telephone contact to check on vital status and any additional treatment for glioblastoma 
will occur at yearly. 
 
9.5. Replacement policy 
 
Patient replacement will be decided by the Safety Monitoring Committee. 
 
9.6. Dose Modification 
 
Reduction/interruption of dosing for adverse events may take place at any time.  Below 
are guidelines for dose modification for drug-related toxicities as well as guidelines for 
their management. These parameters are only a guide and are not intended to supersede 
the clinical judgment of the treating physician.  All adjustments should be made in 
consultation with the Medical Monitor and the Sponsor. 


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All dose modifications should be based on the worst preceding toxicity. If study 
treatment is being held due to toxicity, scheduled visits and all assessments should 
continue to occur except the dosing of the study drug. 
 
 
 
9.7. Dose Modification Plans: 
 
9.7.1. SGT-53 and/or Temozolomide 
 
Table 9.7.1. reviews management of non-hematologic toxicities as they pertain to both 
study agents SGT-53 and/or Temozolomide. 
 
Toxicity 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Hyperbilirubin- 
emia 
Continue both 
at same dose 
Hold both until 
grade 1 or less 
in 2 weeks 
Discontinue 
TMZ, hold 
SGT-53 until 
grade 1 or less 
(up to 2 
weeks)* 
Discontinue 
TMZ, hold 
SGT-53 
until grade 1 
or less (up to 
2 weeks)* 
AST &/or ALT 
Continue both 
at same dose 
Hold both until 
grade 1 or less 
in 2 weeks 
Discontinue 
TMZ, hold 
SGT-53 until 
grade 1 or less 
(up to 2 
weeks)* 
Discontinue 
TMZ, hold 
SGT-53 
until grade 1 
or less (up to 
2 weeks)* 
Dyspnea not 
associated with 
infusion 
Continue both 
at same dose 
Hold both until 
grade 1 or less 
in 2 weeks 
Discontinue 
TMZ, hold 
SGT-53 until 
grade 1 or less 
(up to 2 
weeks)* 
Discontinue 
TMZ, hold 
SGT-53 
until grade 1 
or less (up to 
2 weeks)* 
DIC 
Continue both 
at same dose 
Hold both until 
grade 1 or less 
in 2 weeks 
Discontinue 
TMZ, hold 
SGT-53 until 
grade 1 or less 
(up to 2 
weeks)* 
Discontinue 
TMZ, hold 
SGT-53 
until grade 1 
or less (up to 
2 weeks)* 
Fatigue 
Continue both 
at same dose 
Continue both 
at same dose 
Hold both until 
grade 1 or less 
in 2 weeks 
Discontinue 
both 
Infusion 
reaction 
May 
rechallenge 
after 1st event, 
if resolves in 2 
h** 
May 
rechallenge 
after 1st event, 
if resolves in 2 
h** 
Discontinue inciting agent** 
Hypotension 
during infusion 
See Section 
9.3.2. 
See Section 
9.3.2. 
See Section 9.3.2. 


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Other non- 
hemetoxicity*** 
Continue both 
at same dose 
Hold both until 
grade 1 or less 
in 2 weeks 
Hold both until 
grade 1 or less 
in 2 weeks 
Discontinue 
both 
 
*If toxicity reduces to grade 1 or less in 2 weeks, patient may continue SGT-53 until end 
of cycle at discretion of investigator. 
 
**Note that infusion reactions are discussed in detail in Section 9.3.2. 
 
***Other non-heme toxicity refers to any non-heme toxicity at least possibly related to 
SGT-53, or temozolomide with the exception of alopecia, inadequately treated nausea, 
vomiting, diarrhea, or fever, chills or hypotension which respond promptly to treatment 
and lasts less than 24 hours. 
 
For grade 2 events of increased bilirubin, AST, ALT, dyspnea, or DIC, the dose of SGT- 
53 and Temozolomide can be held for up to two weeks.  If the grade 2 event reduces at 
least to grade 1 within two weeks, then infusion of SGT-53 and Temozolomide can 
resume at the same dose per calendar at incident week + 1-2 weeks (i.e., treatment would 
be made up and moved 1-2 weeks later). 
 
For non-hematological events other than increased bilirubin, AST, ALT, dyspnea, or 
DIC, participants who develop a > or = grade 2 toxicity (except for alopecia, fever, chills 
or hypotension that respond to treatment) or grade 3 fatigue will discontinue twice- 
weekly infusions until the toxicity level reduces to at least grade 1.  Infusions will be held 
for one week intervals, and infusions that are withheld will be made-up (i.e. moved 1-2 
weeks later).  If the toxicity does not resolve within two weeks, study drug will be 
discontinued. 
 
A minimum of 2-week rest period will be required if there is grade III or greater non- 
hematologic toxicity related to SGT-53/Temozolomide that cannot be controlled with 
supportive medications/measures. After the minimum 2-week rest period and the toxicity 
has resolved to a grade II or better, the patient will resume taking the drug at a reduced 
dose level as shown in Table 9.7.2b below. 
 
Subjects who receive less than four of twelve of the intended drug infusions, due to 
experiencing these grade 2 events that have not resolved as described above, and that are 
determined by the PI to be at least probably related to SGT-53, will be considered to have 
experienced a DLT. 
 
Patients forced to discontinue temozolomide due to a temozolomide-related toxicity (e.g., 
grade 3, 4 hypersensitivity) will be removed from the study. 


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9.7.2. Temozolomide 
 
Table 9.7.2a. reviews management of hematologic toxicities associated with 
Temozolomide treatment. Note that there are no dose adjustments for anemia. 
 
Grade 1 
Grade 2 
Grade 3 or Grade 4 
Neutropenia 
< LLN to 
1500/mm3 
Proceed at 
current dose 
<1500 to 
1000/mm3 
Proceed at 
current dose 
Grade 3: <1000 to 500/mm3 
Grade 4: <500/mm3 
If resolves to grade ≤ 2 within 14 
days, rechallenge at same dose of 
SGT-53, and reduce dose of TMZ 
in increments after each event 
according to Table 9.7.2b below, 
i.e. in Cycle 1reduce to 100 
mg/m2 after the first event, in 
Cycle 2 reduce to 150 mg/m2 
after the first event, if recurs 
reduce to 100 mg/m2 etc 
If recurs at lowest dose of TMZ 
(100 mg/m2 or less), withdraw 
from study. If at any time it does 
not resolve within 14 days, 
withdraw from study. 
Thrombo- 
cytopenia 
<LLN to 
75,000/mm3 
Proceed at 
current dose 
<75,000 to 
50,000/mm3 
Proceed at 
current dose 
Grade 3: <50,000 to 25,000/mm3 
Grade 4: <25,000/mm3 
If resolves to grade ≤ 2 within 14 
days, rechallenge at same dose of 
SGT-53, and reduce dose of TMZ 
in increments after each event 
according to Table 9.7.2b below, 
i.e.in Cycle 1 reduce to 100 
mg/m2 after the first event, in 
Cycle 2 reduce to 150 mg/m2 after 
the first event, if recurs reduce to 
100 mg/m2 etc 
If recurs at lowest dose of TMZ 
(100 mg/m2 or less), withdraw 
from study. If at any time it does 
not resolve within 14 days, 
withdraw from study. 
 
Table 9.7.2.b Dose de-escalation for TMZ: 
Treatment 
Cycle 
Agent 
Schedule 
Level 
Level 
Level 
 
 
 
0 (Target 
Dose) 
-1 
-2 
Cycle 1 
TMZ 
Days 9-13 150  mg/m2 
100mg/m2 
Cycle 2 
onwards 
 
Days 9-13 200 mg/m2 
150  mg/m2 100 mg/m2 
 


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In the event of grade III or higher toxicity associated with TMZ after cycle 1, treatment 
will be interrupted and patient monitored for resolution of toxicity, with subsequent re- 
initiation of treatment. TMZ dosing will resume after complete resolution of toxicities to 
Grade II or less. 
 
The dose of Temozolomide will only be escalated to 200 mg/m2 if the patient meets the 
following criteria: If the CTC nonhematologic toxicity for Cycle 1 is < Grade 2 (except for 
alopecia, nausea, and vomiting, diarrhea, or fever, chills or hypotension which respond 
promptly to treatment and lasts less than 24 hours), absolute neutrophil count (ANC) is > 
1,500/mm3, and the platelet count is > 100,000/mm3. The dose remains at 200 mg/m2 per 
day for the first 5 days of each subsequent cycle except if toxicity occurs. If the dose was 
not escalated at Cycle 2, escalation should not be done in subsequent cycles. 
 
If more than a 2 week delay is required to meet hematologic parameters for treatment, the 
patient must be removed from study and replaced. 
 
9.7.3. Dose de-escalation for SGT-53: 
 
Permitted dose modifications for SGT-53 
 
Investigators should follow the guidelines described in Table 9.7.1. above and Table 
9.7.3. below for the modification of SGT-53 treatment unless there is an urgent need for 
action due to consideration of patient safety. 
 
If the patient requires a dose interruption of >42 days from the previous dose, then the 
patient must be discontinued from study treatment.  Within the 42-day dose delay, if the 
toxicity has resolved, there is no evidence of true progressive disease, and the patient has 
not started any other antineoplastic therapy, the patient may resume study treatment. For 
patients who undergo dose interruptions (delays), if the same toxicity returns after re- 
initiation of treatment, regardless of duration, the second re-initiation must resume at a 
lower dose (see Table 9.7.3. below). Only two dose reductions will be allowed.  If further 
reduction is needed, the patient must be discontinued from study treatment. Patients who 
discontinue the treatment due to an adverse event or an abnormal laboratory value must 
be followed until resolution or stabilization of the event. All dose changes or 
interruptions must be recorded in the dosage administration record CRF, as appropriate. 
 
Table 9.7.3.  Recommended Dose modifications and dose delays for suspected SGT- 
53 treatment related hematologic toxicities 
 
Recommended dose modifications 
Worst toxicity CTCAE grade at any time during treatment 
Hematologic: 
Neutropenia (ANC) 
Grade 1 (ANC<LLN-1500/mm3) 
Maintain dose 
Grade 2 (ANC<1500-1000/mm3) 
Maintain dose 


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Grade 3 or 4 (ANC< 1000-500/mm3 
or <500/mm3) 
Hold dose until resolved to  ≤ grade 1 
If resolved in ≤ 14 days, then maintain 
dose level 


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If resolved >14 days, then decrease dose 
of SGT-53 to 2.4 mg DNA/infusion. 
If occurs at 2.4mg DNA dose then 
decrease dose of SGT-53 to 1.2 mg 
DNA/infusion. 
If occurs at this second reduced dose of 
SGT-53 withdraw from study. 
Thrombocytopenia 
Grade 1 (PLT<LLN-75,000/mm3) 
Maintain dose 
Grade 2 (PLT<75,000-50,000/mm3) 
Maintain dose 
Grade 3or 4 (PLT<50,000- 
25,000/mm3 or <25,000/mm3) 
Hold dose until resolved to  ≤ grade 1 
If resolved in ≤ 14 days, then maintain 
dose level 
If resolved >14 days, then decrease dose 
of SGT-53 to 2.4 mg DNA/infusion. 
If occurs at 2.4mg DNA dose then 
decrease dose of SGT-53 to 1.2 mg 
DNA/infusion. 
If occurs at this second reduced dose of 
SGT-53 withdraw from study. 
 
 
 
 
10. 
STUDY ASSESSMENTS: 
 
10.1. Pretreatment Evaluation 
 
Pre-study assessments will be performed according to the Study Calendar (Section 18.1.) 
before study registration and include: 
 
Within 7 days of registration: 
 
• 
Radiographic tumor measurements 
• 
Complete medical history 
• 
Concomitant medication assessment 
• 
Baseline Review of Systems and AE documentation 
• 
Physical examination (all body systems) 
• 
Vital signs (temperature, blood pressure, pulse rate, and respiratory rate) 
• 
KPS Performance Status 


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• 
12-lead electrocardiogram 
• 
Limited Echocardiogram with the results reviewed by a cardiologist 
• 
Serum chemistry including: sodium, chloride, carbon dioxide, potassium, 
calcium, phosphorous, magnesium, BUN, creatinine, blood sugar (random), 
albumin, alkaline phosphatase, alanine aminotransferase, aspartate 
aminotransferase, bilirubin (total, direct), and total protein. 
• 
Coagulation parameters 
• 
CBC with differential and platelet counts 
• 
Urinalysis 
 
Within 3 days of initiation of treatment: 
 
• 
Pregnancy test (for nonsterile women of childbirth potential) 
 
10.1.1. Laboratory Certification and Normal Values 
 
Before initiation of the study, the laboratory certification for all local laboratories to be 
used in the study must be provided to the Sponsor.  Normal ranges of all laboratory 
parameters required during the study must be provided by the Investigator. 
 
 
 
 
10.2. Evaluation During Study 
 
The starting dose of SGT-53 will be 3.6 mg of DNA. If necessary, dose de-escalation for 
SGT-53 will proceed according to the dose de-escalation scheme in Table 9.7.3 above. 
Assessment of DLTs will be made based on the first cycle (4 weeks of treatment). At the 
end of the first cycle, if no DLT are observed, additional patients may be enrolled and 
treated simultaneously. If the first patient experiences a DLT in the first cycle (4 weeks), 
then only one additional patient will be enrolled and evaluated for DLT.  If the second 
patient does not experience DLT in the first cycle (4 weeks), then additional patients may 
be enrolled simultaneously. 
 
10.2.1. Patients with Optional Surgical Resection for Tumor Analysis: 
 
Beginning 5 days prior to scheduled surgical resection of their recurrent glioblastoma, 
patients will initiate 3.6mg DNA dosing/infusion with SGT. Dosing will continue 
through the day before surgery. 
 
• 
One portion of the surgical section will be saline rinsed and flash frozen for 
measurement of exogenous wt p53 in tumor tissue, one portion will be immediately 
formalin-fixed for evaluation of PD biomarkers of activity of SGT-53 including but 
not limited to Annexin V and TUNEL staining.  In addition, one portion of fresh 
tissue will be used for flow cytometry and/or immunohistochemistry analysis to 
determine the level of apoptosis in Cancer Stem Cells (CSC) and bulk tumor cells. 
Any remaining tumor tissue from an earlier procedure will be collected and stored in 
a research tissue bank at Georgetown University or the clinical site. 


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Following surgery, an MRI scan should be done no later than 72 hours from the time of 
surgery. 
 
Following recovery from surgical resection (POD ~14-21), patients will restart SGT-53 
and TMZ on the morning of Cycle 1 Day 1 (C1D1). Each cycle will consist of 28 days. 
Patients will return to the clinic for twice weekly (every 3rd or 4th day) infusions of SGT- 
53 for three weeks (see treatment schedule diagram in section 9.1.1). Temozolomide will 
be taken daily by mouth daily on days 9-13 of each cycle. During week 4 of each cycle 
the patient will not receive any treatments.   Patients will return to the clinic on Day 29 
(C2D1) and Day 57 (C3D1) for evaluation. If the drug has been well tolerated, continued 
dosing will be permitted even if they appear to be progressing. 
 
Patients will be monitored for response and disease progression with MRI brain scans 
every 2 cycles (8 weeks) and/or at the end of cycle 3, or earlier if progressive disease is 
suspected. 
 
All patients who participate in this study will continue treatment with SGT-53 and TMZ 
after surgery. The following conditions should be satisfied before initiation of treatment 
with SGT: 
 
1) They have recovered from the effects of surgery including adequate wound healing. 
 
2) A brain MRI should be done no later than 72 hours in the immediate post-operative 
period to best assess the extent of residual measurable disease post-operatively. 
 
3) The patient has followed the study requirements for birth control and pregnancy 
testing since the initial pre-operative doses of SGT and TMZ. 
 
4) Post-operatively, patients must have adequate bone marrow function (absolute 
neutrophil count > 1,500/μL and platelet count of >100,000/μL), normal coagulation 
profile (PT/PTT), adequate liver function (SGPT, SGOT, and alkaline phosphatase <2.5 
times upper limit of normal and bilirubin < 1.5 X upper limit of normal), adequate renal 
function (BUN or creatinine <1.5 times upper limit of institutional normal within 7 days 
prior to starting therapy. 
 
5) The patient continues to meet all the eligibility criteria of the study outlined above. 
 
10.2.2. Patients Not undergoing Surgical Resection: 
 
Patients who have had surgery for recurrent glioblastoma will follow the guidelines listed 
above for patients with optional surgical resection for tumor analysis. 
 
If no surgery has been performed, patients will start SGT-53 and TMZ on the morning of 
Cycle 1 Day 1 (C1D1). Each cycle will consist of 28 days. Patients will return to the 
clinic for twice weekly (every 3rd or 4th day) infusions of SGT-53 for three weeks (see 
treatment schedule diagram in section 9.1.1). Temozolomide will be taken daily by 
mouth daily on days 9-13 of each cycle. During week 4 of each cycle the patient will not 


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receive any treatments.   Patients will return to the clinic on Day 29 (C2D1) and Day 57 
(C3D1) for evaluation. If the drug has been well tolerated continued dosing will be 
permitted even if they appear to be progressing. 
 
Patients will be monitored for response and disease progression with MRI brain scans 
every 2 cycles (8 weeks) and/or at the end of cycle 3 or earlier if progressive disease is 
suspected. 
 
 
 
10.2.3. All Patients: 
Evaluations done at each clinic visit are detailed in Section 18.1. 
 
Patients will return to clinic at least weekly for assessments (until the last week of 
protocol therapy).  Refer to the Study Calendar, Appendix 18, for evaluations to be 
completed during each clinic visit. Each clinic visit will include: assessment of vital signs 
(blood pressure, pulse and temperature).  The following will be performed only on a 
weekly basis (usually on the first visit of each week) unless clinically significant values 
were obtained at the previous visit: physical exam; assessment of the ECOG/ Karnofsky 
Performance Status; assessment of concomitant medications; assessment of adverse 
events; completion of a serum chemistry panel; completion of a CBC with differential. 
At the beginning of every cycle a urinalysis panel will be completed. A 12-lead ECG and 
echocardiogram will be performed at baseline. Additional ECGs/ echocardiograms 
should be obtained on any patient who demonstrates signs or symptoms of myocardial 
degeneration. Additionally a 12-lead ECG will be performed 2 hours and 24 hours after 
the first infusion of SGT-53.  A 12-lead ECG will be performed weekly (2 hours post- 
infusion) during the first 2 weeks of cycle 1, and at the End Of Treatment (EOT) visit.  If 
these patients receive additional rounds of SGT-53/Temozolomide a 12-lead ECG will 
only be performed as necessary and at the EOT visit. 
 
The first two subjects enrolled in this trial under the current protocol will be monitored 
for PT/PTT, D-dimer and LDH at baseline/screening; in cycle 1 ~20 hours after the first 
infusion (during the 23 observation period), and weekly during cycle 1, and once in two 
weeks during cycles 2 and 3 and at the exit visit. If these patients receive additional 
rounds of SGT-53/Temozolomide PT/PTT, D-dimer and LDH will be monitored once in 
two weeks during cycle 1 and monthly in cycle 2 and beyond. 
 
Subsequent subjects will be monitored for PT/PTT, D-dimer and LDH at: 
(i) 
baseline/screening; 
(ii) 
in cycle 1 (a) ~20 hours after the first infusion (during the 23 observation 
period) 
(iii) 
at the exit visit. 
 
Patients who are responding to treatment (at least stable disease by RANO) may receive 
three additional cycle of SGT-53/temozolomide therapy at investigator’s discretion. 
Alternatively, they may continue on Temozolomide alone at investigator’s discretion. 


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10.2.4. End of Treatment Evaluations (Day 85, at the end of Cycle 6 if the patient 
received cycles 4-6, or for premature withdrawal/study drug discontinuation) 
 
Once a patient has completed study treatment, including premature withdrawal/study 
drug discontinuation, the patient should complete an End of Treatment Visit. During this 
visit the following assessments will be completed: 
 
• 
Radiographic tumor measurement 
• 
Complete medical history 
• 
Physical examination (all body systems) 
• 
Karnofsky Performance Status 
• 
Vital signs (temperature, blood pressure, pulse rate, and respiratory rate) 
• 
Concomitant medication assessment 
• 
Serum chemistry including: sodium, chloride, carbon dioxide, potassium, 
calcium, phosphorous, magnesium, BUN, creatinine, blood sugar (random), 
albumin, alkaline phosphatase, alanine aminotransferase, aspartate 
aminotransferase, bilirubin (total, direct), and total protein. 
• 
CBC with differential and platelet counts 
• 
12-lead electrocardiogram 
• 
Limited Echocardiogram, only if needed 
• 
Urinalysis 
• 
Assessment of adverse events 
 
10.3. Follow-up 
 
If the patient was removed from the Study for toxicity, the patient should be followed 
with weekly clinic visit and laboratory studies as appropriate, at clinical trial site or the 
patient’s local MD, until the AE has resolved to baseline or is documented as irreversible. 
 
All patients who received treatment with SGT-53 must be followed-up for 30 days after 
discontinuation of study drug. The 30-day follow-up visit should include a physical 
examination, vital signs, concomitant medications and assessment of AEs/SAEs and 
Urine analysis.  Blood samples will be taken for: Hematology (CBC with differential, 
platelet count), Chemistries (BUN, Cr, Na+, K+, CO2, Cl, Mg++, Ca++, phosphorus, 
albumin, alkaline phosphatase, ALT, AST, total bilirubin, total protein, glucose), 
PT/PTT, D-dimer, LDH. 
 
Patients who permanently discontinue study drug(s) for reasons other than complete 
response, progression, or death should also have visits approximately every 2 months for 
the first year that should include a MRI, physical examination, vital signs, and recording 
of concomitant medications for glioblastoma. 
 
Patients who are withdrawn from study treatment due to a complete response will have 
the 30-day follow-up visit as described above and in Sections 5 and 9.4.1. Further follow- 
up visits every 2 months will include only a physical/neurological exam, concomitant 
medications, vital signs and an MRI. 


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10.3.1. Long Term Follow-up 
 
The FDA currently recommends that safety data from participants participating in studies 
evaluating gene transfer vectors be collected for 15 years (post gene transfer). All 
participants receiving a dose of SGT-53 will continue to be followed after the completion 
of all study related procedures to meet the requirements of 15 years post gene transfer 
follow-up. 
 
All participants upon completion or exit from the study will be presented with written 
instructions on how to contact the investigator if they experience any serious adverse 
event that they consider possibly related to study agent or study participation. All 
participants will be instructed to notify the investigator of a change of address or contact 
information. 
 
Participants will be contacted on an annual basis by the Principal Investigator and 
requested to provide information concerning any cancer, neurological, autoimmune, or 
hematological disorder that occurred or worsened since last contact. The participants will 
also be requested to provide information concerning any unexpected medical problems 
including hospitalizations or use of medications. Information will be collected via 
questionnaire, either by mail or by telephone. The investigator will submit these follow- 
up data to the sponsor. 
 
The sponsor will submit all information collected during long-term follow-up in annual 
reports to the FDA. All participants participating in the study will receive an explanation 
of these procedures at the time of Informed Consent 
 
10.4. Efficacy Assessments 
 
10.4.1. Progression-Free Survival 
 
The percentage of patients who are alive and progression-free clinically and 
radiologically 6 and 12 months after starting treatment will be evaluated using the 
Kaplan-Meier method. Progression is defined by any of the following using the RANO 
criteria: 
 
a) >25% increase in sum of the products of perpendicular diameters of enhancing 
lesions compared with the smallest tumor measurement obtained either at baseline (if no 
decrease) or best response, on stable or increasing doses of corticosteroids*. 
 
b) Significant increase in T2/FLAIR non-enhancing lesion on stable or increasing doses 
of corticosteroids compared with baseline scan or best response after initiation of therapy 
*not caused by co-morbid events (e.g. radiation therapy, demyelination, ischemic injury, 
infection, seizures, postoperative changes, or other treatment effects) 
 
c) Any new lesion 


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d) Clear clinical deterioration not attributable to other causes apart from the tumor (e.g. 
seizures, medication adverse effects, complications of therapy, cerebrovascular events, 
infection, and so on) or changes in corticosteroid dose 
 
e) Failure to return for evaluation as a result of death or deteriorating condition 
 
f) Clear progression of non-measurable disease 
 
Note: All measurable and non-measurable lesions must be assessed using the same 
techniques as at baseline. 
 
*Stable doses of corticosteroids include patients not on corticosteroids. 
 
10.4.2. Tumor response rate: 
 
The percentage of patients with a complete or partial response 6 and 12 months after 
starting treatment will be evaluated using the RANO criteria: 
 
Complete response (CR). Requires all of the following 
 
a) complete disappearance of all enhancing measurable and non-measurable disease 
sustained for at least 4 weeks 
 
b) no new lesions 
 
c) stable or improved non-enhancing (T2/FLAIR) lesions 
 
d) patients must be off corticosteroids (or on physiologic replacement doses only) 
 
e) stable or improved clinically 
 
Note: Patients with non-measurable disease only cannot have a complete response; the 
best response possible is stable disease. 
 
Partial response (PR). Requires all of the following: 
 
a) >50% decrease compared with baseline in the sum of products of perpendicular 
diameters of all measurable enhancing lesions sustained for at least 4 weeks 
 
b) No progression of non-measurable disease 
 
c) No new lesions 
 
d) Stable or improved non-enhancing (T2/FLAIR) lesions on same or lower dose of 
corticosteroids compared with baseline scan 


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e) The corticosteroid dose at the time of the scan evaluation should be no greater than 
the dose at the time of baseline scan 
 
f) Improved or stable clinically 
 
Note: Patients with non-measurable disease only cannot have a partial response; the best 
response possible is stable disease. 
 
Stable disease (SD).  Requires all of the following: 
 
a) Does not qualify for complete response, partial response, or progression 
 
b) Stable non-enhancing (T2/FLAIR) lesions on same or lower dose of corticosteroids 
compared with baseline scan.  In the event that the corticosteroid dose was increased for 
new symptoms and signs without confirmation of disease progression on neuroimaging, 
and subsequent follow-up imaging shows that this increase in corticosteroids was 
required because of disease progression, the last scan considered to show stable disease 
will be the scan obtained when the corticosteroid dose was equivalent to the baseline 
dose. 
 
10.4.3. Time to progression 
 
The time to progression is defined as the time from treatment initiation until a contrast- 
enhanced MRI documents a progression of the disease or until neurological deterioration 
(if a brain MRI cannot be performed due to the patient’s debilitation). Clinical 
deterioration and worsening of symptoms, in the absence of a MRI must be considered by 
the investigator to be linked to disease progression and not any other cause(s). Patients 
without progression or neurological deterioration at EOS will be censored at their last 
date without progression or neurological deterioration. 
 
 
 
 
10.4.4. Overall survival 
 
Overall survival is defined as the time from treatment initiation to death or to time last 
seen alive. The overall survival rate will be estimated by the proportion of patients who 
are alive at EOS and 12 months after starting treatment using the Kaplan-Meier method. 
 
10.5. Safety Endpoint Definitions 
 
Patients will be evaluated and adverse events (AEs) assessed according to the Study 
Calendar (Section 18.1.) using Common Toxicity Criteria 4.03 (CTC 4.03, 2010). For 
definition of DLT see Section 9.7. 
 
 
 
 
11. ADVERSE EVENTS 


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Spontaneous reports of adverse events to the investigator by patients, and toxicities 
encountered during the study will be evaluated for severity according to the NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 4.03 (June 2010) 
[NCI 2010] and recorded at study visits. The investigator and site staff should have 
access to the CTCAE version 4.03 by hard copy or on the internet. 
 
Information about all adverse events, whether reported by the patient, discovered by the 
investigator upon questioning the patient, or detected from a physical examination, lab 
result or other means, will be collected and recorded in the CRF as an AE or on an SAE 
form (as applicable) and will be followed as appropriate. 
 
11.1. Definition of Adverse Events 
 
An adverse event (AE) is any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom or disease temporally associated with the use of a medical 
treatment or procedure that may or may not be considered related to the medical 
treatment or procedure. 
 
Medical conditions or diseases present prior to starting study treatment are only 
considered AEs if they worsen after starting study treatment. After the ICF is signed and 
prior to the start of study treatment, only serious adverse events are reported if related to 
a study mandated procedure. 
 
Adverse events include: 
 
• 
Exacerbation of a pre-existing disease. 
 
• 
Increase in frequency or intensity of a pre-existing episodic disease or medical 
condition. 
 
• 
Disease or medical condition detected or diagnosed after study drug 
administration even though it may have been present prior to the start of the study. 
 
• 
Continuous persistent disease or symptoms present at baseline that worsen 
following the start of the study. 
 
• 
Lack of efficacy in the acute treatment of a life-threatening disease. 
 
• 
Events considered by the investigator to be related to study-mandated procedures. 
 
• 
Abnormal assessments, e.g., change on physical examination, ECG findings, if 
they represent a clinically significant finding that was not present at baseline or 
worsened during the course of the study. 
 
• Laboratory test abnormalities if they represent a clinically significant finding, 
symptomatic or not, which was not present at baseline or worsened during the course 


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of the study or led to dose reduction, interruption or permanent discontinuation of 
study drug. 
 
Adverse events do not include: 
 
• 
Medical or surgical procedure, e.g., surgery, endoscopy, tooth extraction, 
transfusion. However, the event leading to the procedure is an AE, with one 
exception. Patients who participate in the optional surgical resection for tumor 
analysis are pre-treated with SGT-53 prior to surgery; therefore, this event is recorded 
as medical history and is not required to be reported as an AE. However medical 
complications related to this surgery must be reported as AE. For all other events, the 
event leading to the procedure is reported as an AE, and if the event is serious, the 
procedure must be described in the serious adverse event narrative. 
 
• 
Pre-existing disease or medical condition that does not worsen. 
 
• 
Situations in which an adverse change did not occur, e.g., hospitalizations for 
cosmetic elective surgery or for social and/or convenience reasons. 
 
 
• Planned Hospitalization during the 23 hour observation period after the first 
infusion 
 
• Overdose of SGT-53, TMZ or concomitant medication without any signs or 
symptoms. Any overdose of SGT-53 or TMZ must be noted in the patient’s Study 
Drug Log. In the event of an overdose with TMZ, a hematological evaluation should 
be performed. 
 
Patients will be evaluated for AEs for the first 28 days of therapy. Adverse events will be 
reported at all subsequent study visits (i.e. prior to each infusion of SGT-53 or at the end 
of each cycle of treatment). 
 
The Safety Monitoring Committee will convene every 3 months, or more frequently, if 
deemed necessary, to review safety data. 
 
A treatment-emergent AE is further defined in this protocol as any AE temporally 
associated with the use of study drug (from study drug initiation until 30 days after study 
drug discontinuation), whether or not considered related to the study drug. 
 
11.1.1. Definition of Serious Adverse Events 
 
An SAE is any untoward medical occurrence that at any dose has the following 
characteristics: 
 
• Results in death 
• Is life-threatening 
• Requires unscheduled inpatient hospitalization or prolongation of existing 
hospitalization 


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• Results in permanent (persistent) disability/incapacity 
• Is a congenital anomaly 
• Is an important medical event 
 
Medical and scientific judgment should be exercised in deciding whether it is appropriate 
to consider other situations serious, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize the 
patient or may require intervention to prevent one of the other outcomes listed in the 
definition above. 
 
Examples of such events are intensive treatment in an emergency room or at home for 
allergic bronchospasm, blood dyscrasias or convulsions that do not result in 
hospitalization, or development of drug dependency or drug abuse. 
 
An elective hospital admission to treat a condition present before exposure to the test 
drug, or a hospital admission for a diagnostic evaluation of an AE, does not qualify the 
condition or event as an SAE. 
 
A newly diagnosed pregnancy in a patient that has received a study drug is not 
considered an SAE unless it is suspected that the test article interacted with a 
contraceptive method and led to the pregnancy. A congenital anomaly in an infant born to 
a mother who was exposed to the study drug during pregnancy is an SAE. 
 
 
 
 
11.2. Relationship of Adverse Event to Investigational Product 
 
The assessment of the relationship of an adverse event to the administration of study drug 
is a clinical decision based on all available information at the time of the completion of 
the case report form. 
 
The relationship to study drug therapy should be assessed using the following definitions: 
 
Not Related: Evidence exists that the AE has an etiology other than the study drug (eg, 
pre-existing condition, underlying disease, intercurrent illness, or concomitant 
medication). 
 
Possibly/Probably Related:  A temporal relationship exists between the event onset and 
administration of the study drug.  It cannot be readily explained by the patient’s clinical 
state, intercurrent illness or concomitant therapies.  In case of cessation or reduction of 
the dose, the event abates or resolves and reappears upon rechallenge.  It should be 
emphasized that ineffective treatment should not be considered as causally related in the 
context of AE reporting. 
 
11.2.1. Relationship to study drugs 


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Each adverse event must be assessed by the investigator as to whether or not there is a 
reasonable possibility of causal relationship to the study drugs, and will be reported as 
either related or unrelated to SGT-53 and/or TMZ. Therefore, the causal relationship of 
each AE, based on the judgment of the Investigator with respect to SGT-53 and TMZ 
must be reported. 
 
Related to study drug(s) 
 
This category applies to any AE (whether serious or not) that appears to have a 
reasonable possibility of causal relationship to the use of SGT-53 and/or TMZ (i.e., a 
relationship cannot be ruled out). Guidelines to determine whether an event might be 
considered related include (but are not limited to) the following: 
 
• 
The event occurred in close temporal relationship to study drug administration. 
 
• 
The event abated (diminished) or disappeared when treatment with the study drug 
was down-titrated, interrupted, or discontinued. 
 
• 
The event reoccurred when treatment was reintroduced. 
 
• 
Environmental factors such as clinical state, and other treatments, or other reasons 
not related to SGT-53, Temozolomide, or both, such as intercurrent illness, could 
equally have caused the event. 
 
Unrelated to study drug(s) 
 
This category applies to any AE (whether serious or not) that does not appear to have a 
reasonable relationship to the use of SGT-53 and/or TMZ (see above guidelines). 
 
 
 
 
11.3. Severity of adverse events 
 
The severity of AEs will be classified according to the CTCAE version 4.03 (June 2010) 
[NCI 2010]. Grades 1 through 5 refer to the severity of the AE, which are based on 
general guidelines described below.  Not all grades are appropriate for each AE. 
Therefore, the CTCAE may list some AEs with less than five options for grade selection. 
 
Grade 1 
 
• 
Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated. 
 
 
 
Grade 2 


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• 
Moderate; minimal, local or noninvasive intervention indicated; limiting age 
appropriate instrumental activities of daily living (ADL) which refer to preparing 
meals, shopping for groceries or clothes, using the telephone, managing money etc. 
 
Grade 3 
 
• 
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self 
care ADL which refer to bathing, dressing and undressing, feeding self, using the 
toilet, taking medication, and not bedridden. 
 
Grade 4 
 
• 
Life-threatening consequences; urgent intervention indicated. 
 
Grade 5 
 
• 
Death related to AE 
 
11.4. Reporting of adverse events 
 
All AEs occurring after study drug initiation and up to 30 days after study drug 
discontinuation must be recorded in the CRF. 
 
Any AE reported with a toxicity level of grade 4 or grade 5 indicate a level of seriousness 
that must be reported as a serious adverse event (refer to Section 11.1.1. for definition of 
SAEs). The Investigator must consider if AEs reported with a toxicity level of grade 3 
meet at least one of the criteria for seriousness (refer to Section 11.1.1.) and should be 
reported as an SAE. 
 
11.5. Follow-up of adverse events 
 
Adverse events that are ongoing after study drug discontinuation for a given patient must 
be followed until 30 days after study drug discontinuation, or until resolution or 
stabilization, or until the event is otherwise explained. 
 
11.6. Adverse events of special interest 
 
Temozolomide is associated with a ≥ 10% incidence of grade 3 and grade 4 
hematological abnormalities [Temodar® Prescribing Information]. If ANC or platelet 
levels reach thresholds of <1,000/μL or  <50,000/μL respectively, the dose of TMZ may 
be lowered or interrupted (see Section 9.7.). Time to recovery from grade 3 and grade 4 
hematological events for these selected AEs will be evaluated. 
 
SGT-53 is associated with a ≥ 10% incidence of grade 1 and grade 2 fever and 
hypotension after the first infusion, as well as grade 1 and grade chills and mild nausea. 
Due to the known occurrence of fever/hypotension after the first infusion, a 23 hour 


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observation period for the first infusion is planned and described in the protocol (Section 
9.3.3.). 
 
11.7.Definition of Dose Limiting Toxicity (DLT) 
 
• 
See Section 9.4. 
 
11.8. Definition of Start Date, Stop Date and Duration 
 
The definitions of AE start/stop dates and duration will be as follows: 
 
Start Date: 
The date at which the AE is first noted 
Stop Date: 
The date at which the AE is known to be resolved. If it is not known 
to have stopped, then indicate “ongoing.” 
Duration: 
A time in days 
 
11.9. Action(s) Taken 
 
Action(s) taken may consist of the following: 
None: 
No actions taken 
Discontinued test article: 
Test article was permanently discontinued because of 
the AE 
Change test article: 
Test article was given at a lower dose, at a longer 
interval between doses, or was temporarily withheld 
because of the AE 
Treatment: 
Specified medication (to be listed on the concomitant 
medication chart) has been used as a countermeasure 
Others: 
Other actions, such as an operative procedure were 
required because of the AE 
 
11.10. Definition of Outcome at the Time of Last Observation 
 
The outcome at the time of last observation will be classified as: 
 
• 
Resolved 
 
• 
Resolved with Sequelae 
 
• 
Ongoing 
 
• 
Death 
 
• 
Unknown 
 
Death should only be entered as the outcome for an AE when the patient’s death is 
probably related to the AE (Note: the causal relationship of the AE to the test article is 


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not to be considered in making this decision). If more than 1 AE is possibly related to the 
patient's death, the outcome of death should be indicated for each such AE. 
 
11.11. Treatment period 
 
All SAEs, regardless of causal relationship, must be reported, including those related to 
study-mandated procedures. Those SAEs occurring during study drug administration, i.e., 
between study drug initiation and 30 days  after study drug discontinuation,  are 
defined as treatment-emergent SAEs. 
 
Treatment-emergent SAEs are reported on the Drug Safety SAE form and also on an AE 
CRF page. These events are entered into both the Drug Safety and Clinical Trial 
Databases. As grade 4 and grade 5 events are by definition within seriousness criteria, 
within the clinical database, events reported as grade 4 and grade 5 should have a 
corresponding SAE documented on the AE page and a corresponding SAE form 
completed (i.e., SAE documented in the Argus Drug Safety Database). The investigator 
must consider if adverse events reported with a toxicity level of grade 3 meet at least one 
of the criterion for seriousness [Section 11.1.1] and should be reported as an SAE. The 
toxicity grade of an event reported on the AE CRF page must be entered in the narrative 
section of the Drug Safety SAE form. 
 
11.12. Documentation of Adverse Events 
 
The Investigator will monitor and/or ask about or evaluate AEs using non leading 
questions at each visit or evaluation. The occurrence of all AEs will be documented in the 
CRF with the following information, where appropriate: 
 
• 
AE name or term 
 
• 
When the AE first occurred (start date) 
 
• 
When the AE stopped (stop date), (or an indication of “ongoing”) 
 
• 
How long the AE persisted (optional) 
 
• 
Severity of the AE 
 
• 
Seriousness 
 
• 
Actions taken 
 
• 
Outcome 
• 
Investigator opinion regarding the relationship of AE to the study drug(s) 
Adverse events should be documented from the time informed consent is obtained. The 
AEs must be documented as soon and as completely as possible on the “Adverse Event 


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Report Form” pages in the CRF. Follow-up information must be entered as soon as 
available. The causality assessment must be assigned by the Investigator. 
 
Corrections to most AE details may be made, but must be dated and signed according to 
ICH rules. (Exceptions: Changes in severity and/or seriousness; see below). If a 
suspected diagnosis has been ruled out, the Investigator or a delegated member of the 
research team may change the AE term, but should add a comment stating the original 
suspected diagnosis as well as reasons for change. 
 
A clinically relevant worsening of an AE (e.g. relevant change in severity, seriousness) 
must result in a new entry. The original entry remains unresolved and is given an end 
date reflecting the date of the worsening and a comment must be entered stating that the 
AE is continuing with a changed severity/seriousness (eg, “continues as event name with 
onset date and new severity/seriousness”). The onset date of the new entry is also the date 
of worsening. The onset date of a SAE is the time at which the event fulfills a criterion 
for seriousness. 
 
Adverse events that occur during the study should be treated using established standards 
of care in order to protect the life and health of the subject. If such treatment constitutes a 
violation of study entry criteria, as determined by the Investigator, the subject should be 
withdrawn from the study and the reason must be documented in the CRF. 
 
11.13. Follow-up of Patients With an Adverse Event 
 
The Investigator will follow patients with AEs, even if the patient was withdrawn from 
the study due to the AE, until the adverse event has resolved: 
 
• 
the patient has returned to baseline state of health, 
 
• 
the patient is lost to follow-up, 
 
• 
the event is otherwise explained, 
 
• 
the Investigator does not expect any further improvement or worsening of the 
adverse event. 
 
11.14. SAEs after the 30-day follow-up period 
 
New SAEs occurring at any time after the 30-day follow-up period after study drug 
discontinuation should be reported to SynerGene within 24 hours of the investigator’s 
knowledge of the event, if considered causally related to previous exposure to study 
medication by the investigator. These SAEs are only entered in the drug safety database, 
and hence will not affect study closure. 
 
11.15. Pregnancy 
 
11.15.1. Teratogenicity 


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Due to the unknown potential for teratogenicity of SGT-53 and the known effects of 
TMZ on impairment of fertility, as well as the carcinogenic and mutagenic potential of 
TMZ, females of childbearing potential and males must take appropriate precautions 
from screening until 30 days after discontinuation of SGT-53 and TMZ, to prevent 
pregnancy in female patients and female partners of male patients. Women of 
childbearing potential must agree to use two reliable methods of contraception from 
screening and up to 30 days after discontinuation of study treatment. 
 
• Women of childbearing potential with negative serum and urine pre-treatment 
pregnancy tests are allowed in the study if they consistently and correctly use two 
reliable methods of contraception at the same time. Reliable methods of contraception 
include intrauterine devices (IUD) or intrauterine systems (IUS), tubal sterilization, 
and barrier methods (male condom, diaphragm, or cervical cap). A female partner’s 
vasectomy still requires one additional method of contraception. Abstinence, the 
rhythm method, or contraception by the other partner alone, will not be considered as 
reliable methods of contraception. 
 
A woman is considered to be of childbearing potential unless she meets at least one of the 
following criteria: 
 
• 
previous bilateral salpingo-oophorectomy or hysterectomy 
 
• 
premature ovarian failure confirmed by a specialist gynaecologist 
 
• 
pre-pubescence, XY genotype, Turner syndrome, uterine agenesis 
 
• 
Age > 50 years and not treated with any kind of hormone replacement therapy for 
at least 2 years prior to screening, and with amenorrhea for at least 24 consecutive 
months prior to screening. An assessment of serum follicle stimulating hormone 
showing a level of > 40 IU/L at screening may be used to exclude childbearing 
potential, based on the discretion of the investigator. 
 
Males who are not naturally or surgically sterile who have a female partner of 
childbearing potential must agree to use two reliable methods of contraception from 
screening and up to 30 days after discontinuation of study treatment (e.g., one male 
contraceptive method and another reliable method used by a male’s female partner). 
 
If a female patient becomes pregnant, or if pregnancy is suspected, the study drugs must 
be immediately withheld until the result of a serum pregnancy test is available. If the 
pregnancy is confirmed, the patient must be discontinued from the study, and the sponsor 
notified within 24 hours. The investigator must counsel the female patient and discuss the 
risks of the pregnancy and the possible effects on the fetus. 
 
11.15.2. Reporting of pregnancy 


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Any pregnancy occurring during study drug administration with SGT-53macitentan or 
TMZ or up to 30 days after study drug discontinuation must be reported to the SynerGene 
within 24 hours of the investigator’s knowledge of the event. 
 
Pregnancies must be reported on the Actelion Pregnancy form, which is faxed to 
SynerGene, and as an AE in the eCRF if it occurred during the treatment period or 30- 
day follow-up period. 
 
11.15.3. Follow-up of pregnancy 
 
Any pregnancy must be followed to its conclusion and its outcome must be reported to 
SynerGene. 
 
Such follow-up information will only be entered in the Drug Safety database, and hence 
will not affect study closure. 
 
11.16. Notification of Sponsor of Serious Adverse Events 
 
The Investigator must report all SAEs promptly to SynerGene within 24 hours of first 
becoming aware of the event, sooner if possible. If an SAE occurs, the site should notify 
the designated SynerGene individual(s) by telephone.  The primary contact is: 
 
Chris Poki Leung, Ph.D., 
Clinical Research Coordinator 
SynerGene Therapeutics, Inc. 
9812 Falls Road, Suite 114 
Potomac MD 20854 
Tel: 301-706-1509 
Email: clinicaltrial@synergeneus.com 
The secondary phone number for this contact is 301-802-8639 
 
The Investigator must follow up the initial telephone notification within 48 hours of first 
becoming aware of the event by providing a written report by facsimile or electronic mail 
describing the SAE to SynerGene. This report will be accomplished by completing a 
Medwatch 3500A form which is available on the FDA website at http://www.fda.gov, 
and Sponsor supplied forms. 
 
At the time of first notification of an SAE, the following information should be provided 
by the site to the SynerGene contact person, if available: 
 
• 
Patient’s study number and initials 
• 
Patient’s date of birth 
• 
Patient’s gender 
• 
Date of first dose of test article 
• 
Date of last dose of test article, if applicable 
• 
Adverse event term 
• 
Time and date of occurrence of the event 


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• 
A brief description of the event, outcome to date and any actions taken 
• 
The seriousness criteria(on) that were met 
• 
Concomitant medication at onset of the event 
• 
Relevant past history information 
• 
Relevant laboratory test findings 
• 
Investigator’s opinion of the relationship to test article (refer to Section 11.6.4.7) 
 
Any missing or additional relevant information concerning the SAE should be provided 
in a written follow-up report as soon as possible, but no later than 14 days after the first 
report. Additional written follow-up reports will be sent as necessary. The last report 
will be the final report after the resolution of the SAE. 
 
The Investigator is required to comply with applicable regulations regarding the 
notification of his/her IRB or Ethics Committee. 
 
The research site should also report the serious adverse event (SAE) by completing the 
study SAE case report forms and submitting to the Sponsor (SGT). Reports should be 
faxed or e-mailed to SynerGene and the Data Safety Monitoring Committee for review. 
 
The following items should be included at the time of forwarding the SAE notification to 
SynerGene and to the IRB as per institutional guidelines. 
 
• 
(i) SAE cover sheet – within case report form packet 
 
• 
(ii) Completed Sponsor supplied forms and MedWatch Form FDA 3500A – available 
online at (www.fda.gov/medwatch/getforms.htm) 
 
• 
(iii) Any de-identified supporting clinical documents serving as source document of 
the SAE as deemed important by the site or as requested by the coordinating center. 
 
11.17. Reporting Adverse Events to the Competent Authorities 
 
The sponsor will be responsible for reporting AEs to the FDA as described in 21 CFR 
Section 312.32 (IND Safety Reports) and to other competent authorities according to 
local regulations. 
 
In addition, the Investigator is required by FDA regulations to notify the IRB promptly of 
all unexpected SAEs occurring at the Investigator’s study site. The Investigator is also 
required by FDA regulations to forward to the IRB all IND Safety Reports received from 
the sponsor. 
 
Counseling for Women of Reproductive Age 
 
All women of reproductive age who participate in the study should be counseled on the 
need to practice adequate birth control and on the importance of avoiding pregnancy 
during study participation. Women should be instructed to contact the Investigator or 
study staff immediately if pregnancy occurs or is suspected. 


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12. REGULATORY CONSIDERATIONS 
 
12.1.Ethics 
 
This study will be conducted in compliance with the Declaration of Helsinki and its 
amendments, the International Conference on Harmonisation (ICH) principles of Good 
Clinical Practice (GCP; including archiving of essential study documents), and all US 
FDA regulations (for US sites). 
 
A properly constituted, valid Institutional Review Board (IRB) must review and approve 
the protocol, the Investigator’s informed consent document, and related patient 
information and recruitment materials before the start of the study. 
 
It is the responsibility of the Investigator to ensure that written informed consent is 
obtained from the patient before any activity or procedure is undertaken that is not part of 
routine care. 
 
Refer to the following regulations if additional clarity is needed: 
12.2.FDA Regulations 
Refer to the following US Code of Federal Regulations (CFR): 
 
 
• FDA Regulations 21 CFR, Parts 50.20 – 50.27 
Subpart B – Informed Consent of Human Subjects 
• FDA Regulations 21 CFR, Parts 56.107 – 56.115 
Part 56 – Institutional Review Boards 
Subpart B – Organization and Personnel 
Subpart C – IRB Functions and Operations 
Subpart D – Records and Reports 
• FDA Regulations 21 CFR, Parts 312.50 – 312.70 
Subpart D – Responsibilities of Sponsors and Investigators 
 
12.3. Good Clinical Practice Guidelines 
 
ICH GCP guidelines can be found at the following URL: 
 
• http://www.fda.gov/RegulatoryInformation/Guidances/UCM122049 
 
12.4.Finance and Insurance 
 
Details on finance and insurance will be outlined in separate agreements between the 
Institutions, Investigator and CRO and/or between the Investigator and the Sponsor, as 
appropriate. 
 
13. DATA QUALITY ASSURANCE 


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Steps to assure the accuracy and reliability of data include the selection of qualified 
investigators and appropriate study sites, review of protocol procedures with the 
Investigator and associated personnel prior to the study, and periodic monitoring visits by 
SynerGene and/or its representative. Data will be reviewed for accuracy and 
completeness during and after on-site monitoring visits and any discrepancies will be 
resolved with the Investigator or designees as appropriate. 
 
13.1. Monitoring Procedures 
 
The study monitor(s) will conduct site visits to the study facilities to monitor the study or 
via remote access. The Investigator agrees to allow these monitors and other authorized 
SynerGene personnel access to the clinical supplies dispensing and storage area and to 
study documentation for the above-mentioned purpose and agrees to assist the monitors 
in their activities, if requested. Requests by regulatory agencies to inspect the study sites 
may be made. The Investigator agrees to allow inspectors from regulatory agencies to 
review records and to assist the inspectors in their duties, if requested. 
 
Source documents are the physician’s or hospital’s subject records maintained at the 
study site. In most cases, the source documents will be the physician’s or hospital’s 
subject chart. In some cases, the source documents may be electronic. In both cases, the 
information captured on the CRF must match the information in the chart or electronic 
source document. Periodically, the monitor or SynerGene representative will visit the 
study site for the purpose of directly comparing the data in the CRF with the source. The 
Investigator agrees to make source documents (hard copy or electronic) available for this 
purpose. 
 
It is the Investigator’s responsibility to ensure accurate completion of the CRFs. 
 
13.2. Data Management (Collection) 
 
Data entry into the research database will be audited by the Principal Investigator at 
100% of study participants. Summary reports will be prepared for monthly review by the 
P.I. and the research nurse. The study will be reviewed by the Department of Neuro- 
Oncology, every 6 months while it is open for accrual. Full datasets of patient results 
generated under the protocol will be provided to Sponsor promptly after completion of 
each cycle of treatment for each patient. 
 
 
 
14. DATA SAFETY MONITORING BOARD 
The study will be independently reviewed by a Data Safety Monitoring Board (DSMB). 
The DSMB will be comprised of three to four physicians not associated with the UT M.D. 
Anderson Cancer Center, and who are not investigators on the study.  The DSMB shall 
receive a monthly report from the investigators to review toxicities (potential toxicities 
include infusion reactions, hypersensitivity reactions, fever, flushing, anaphylaxis and 
elevation in hepatic enzymes). In addition, the DSMB will request follow up results of 
participants with particular emphasis placed on significant adverse events. The DSMB will 
keep reports of these meeting which will be forwarded to the Institutional Biosafety 
Committee (IBC) and Institutional Review Board (IRB) at the M.D. Anderson Cancer 
Center.  The DSMB reports will include toxicities and will be submitted to the IRB. The 


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DSMB has the authority to halt accrual or further dose escalations and may audit the source 
documents to confirm or clarify any details of the trial results. 
 
Furthermore the adequacy of the data and safety monitoring plan will be reviewed by the 
IBC and IRB on a quarterly basis. All Severe Adverse Events are required to be reported 
to the IRB. Based on the occurrence and severity of the Severe Adverse Events, the IRB 
retains the authority to close the study to further accrual pending more detailed reporting 
and/or modifications to further reduce risk to trial participants and maximize the safety of 
the participating subjects. 
 
DSMB recommendations should be based not only upon results from the study but also 
upon data available to the DSMB from other studies. It is the responsibility of the PI, John 
DeGroot, MD, to ensure that the DSMB is kept apprised of non-confidential results from 
related studies that become available. It is the responsibility of the DSMB to determine 
the extent to which this information is relevant to its decisions related to the specific study 
being monitored. 
 
A written copy of the DSMB recommendations will be given to the clinical study PI, John 
DeGroot, M.D., and chairs of the IBC and IRB. If the DSMB recommends a study change 
for subject safety or efficacy reasons, or that the study is to be closed early due to slow 
accrual, the study PI must act to implement the change as expeditiously as possible. In the 
unlikely event that the trial PI does not concur with the DSMB, then the UT M.D. Anderson 
Cancer Center IRB Chair must be informed of the reason for the disagreement. The trial 
PI, DSMB Chair, and UT M.D. Anderson Cancer Center IRB Chair will be responsible for 
reaching a mutually acceptable decision about the study. Confidentiality must be preserved 
during these discussions. However, in some cases, relevant data may be shared with other 
selected study investigators and staff to assist in reaching a mutually acceptable decision. 
 
If a recommendation is made to change the study for reasons other than subject safety or 
efficacy, or for slow accrual, the DSMB will provide a rationale in writing to the sponsor 
for its decision. 
 
 
 
 
15. GENERAL CONSIDERATIONS 
 
15.1. Discontinuation of the Study 
 
SynerGene reserves the right to discontinue this study for safety or administrative reasons 
at any time. 
 
15.2. Regular Study Termination 
 
The end of this study is defined as the date of the last visit of the last patient (last patient 
out or last patient last visit) participating in the study. Within 90 days of the end of the 
clinical study, SynerGene or designee will notify the IRB and regulatory authorities about 
the regular termination of the study as required. 
 
15.3. Premature Study Termination 


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The study may be terminated prematurely for any reason and at any time by SynerGene, 
an IRB/IEC, or a Regulatory Authority. A decision to prematurely terminate the study is 
binding to all investigators of all study sites. 
 
If the study is terminated prematurely, all investigators have to inform their patients and 
take care of appropriate follow-up and further treatment of the patients to ensure 
protection of the patients’ interests. 
 
15.4. Changes to the Protocol 
 
This protocol cannot be altered or changed except through a formal protocol amendment, 
which requires the written approval of the Sponsor. The protocol amendment must be 
signed by the Investigator and approved by the IRB or IEC before implementation. 
Protocol amendments will be filed with the appropriate regulatory agency(s) having 
jurisdiction over the conduct of the study. 
 
15.5. Protocol Deviations for Emergency or Adverse Event 
 
An Investigator shall notify the Sponsor-Investigator, the CTN and the reviewing IRB of 
any deviation from the investigational plan to protect the life or physical well being of a 
patient in an emergency.  Such notice shall be given as soon as possible, but in no event 
later than two working days after the emergency occurred. Except in such an emergency, 
prior approval by the Principal Investigator and Sponsor is required for changes or 
deviations from a plan, and if these changes or deviations affect the scientific soundness 
of the plan or the rights, safety, or welfare of patients, notification of the FDA and IRB in 
accordance with government regulations is also required. 
 
15.6. Source Documents 
 
All information recorded in the CRF (electronic or hard copy) must be supported by 
corresponding source documentation. Examples of acceptable source documentation 
include, but are not limited to, hospital records, clinic and office charts, laboratory notes, 
and recorded data from automated instruments, memoranda, and pharmacy dispensing 
records. All source documents will be secured and maintained by the study site. 
Monitoring access must be provided for proper quality assurance as outlined in Section 
11 Quality Assurance. 
 
15.7. Use of Information and Publication 
 
All information concerning SGT-53, SynerGene’s operations, patent applications, 
formulas, manufacturing processes, basic scientific data and formulation information 
supplied by SynerGene or the CRO to the Investigator and not previously published, is 
considered confidential and remains the sole property of SynerGene. Case Report Forms 
also remain the property of SynerGene. The Investigator agrees to use this information 
for purposes of study execution through finalization only. 
 
The information developed in this study will be used by SynerGene in connection with 
the continued development of SGT-53 and thus may be disclosed as required to other 
clinical investigators or government regulatory agencies. 
 
Publication or other public presentation of SGT-53 data resulting from this study will be 
done in collaboration with the Sponsor and requires prior review and written approval of 
SynerGene. Abstracts, manuscripts and presentation materials should be provided to 
SynerGene for review ≥ 30 days prior to the relevant submission deadline. 


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16.  FINAL CLINICAL STUDY REPORT 
 
SynerGene will retain ownership of the data. 
 
The final clinical study report (CSR) will be written within 6 months of completion of the 
clinical part of the study as a collaboration between the PI at the M D Anderson Cancer 
Center and the Sponsor.  This report will include a summary of the study results based on 
a statistical evaluation and clinical assessment. 
 
17. REFERENCES 
 
1. American Cancer Society. Cancer Facts and Figures. http://www.cancer.org (2012). 
 
2. Mrugala MM, Adair J, Kiem HP. Temozolomide: Expanding Its Role in Brain Cancer. 
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3. Newton HB and Malkin MG. Neurologic Complications of Systemic Cancer and 
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4. Tentori L and Graziani G. Recent Approaches to Improve the Antitumor Efficacy of 
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5. Jiang G, Wei ZP, Pei DS, Xin Y, Liu YQ, Zheng JN. A Novel Approach to Overcome 
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7. Chamberlain MC. Temozolomide: Therapeutic Limitations in the treatment of Adult 
High-Grade Gliomas. Expert Review of Neurotherapeutics. 2010; 10(10):1537-1544. 
 
8. Newlands ES, Blackledge GR, Slack JA, Rustin GJ, Smith DB, Stuart NS, Quarterman 
CP, Hoffman R, Stevens MF, Brampton MH, Gibson AC. Phase-I Trial of 
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1992; 65(2):287-291. 
 
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Transcription of the Human O6-Methylguanine-DNA Methyltransferase Gene. Cancer 
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Expression of Wild-Type P53 Curtails the Transcription of the O6-Methylguanine-DNA 
Methyltransferase Gene in Human Tumor Cells and Enhances Their Sensitivity to 
Alkylating Agents. Clinical Cancer Research. 2001; 7:1398-1409. 


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Amendment 6 July 5 , 2016 
Confidential 
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Sørensen B, Montesano R, Harris CC. Database of p53 gene somatic mutations in human 
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Vogelstein B. Clonal Expansion of p53 mutant cells is associated with brain tumor 
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Amendment 6 July 5 , 2016 
Confidential 
Page 94 of 108 
 
 
22. Xu L, Frederik P, Pirollo KF, Tang WH, Rait A, Xiang LM, Huang W, Cruz I, Yin Y, 
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EH. Systemic p53 gene therapy of cancer with immunolipoplexes targeted by anti- 
transferrin receptor scFv. Molecular Medicine. 2001; 7(10):723-734. 
 
25. Xu L, Huang CC, Huang W, Tang WH, Rait A, Yin YZ, Cruz I, Xiang LM, Pirollo 
KF, Chang EH. Systemic tumor-targeted gene delivery by anti-transferrin receptor scFv- 
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clinical practice. Pharmacology & therapeutics. 2003; 99(1):55-77. 
 
27. Judge AD, Sood V, Shaw JR, Fang D, McClintock K, MacLachlan I. Sequence- 
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Liposomes as Delivery Vectors for Gene Therapy.  Pharmaceutical Research. 2002; 
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29. Madhusudan S, Tamir A, Bates N, Flanagan E, Gore ME, Barton DP, Harper P, Seckl 
M, Thomas H, Lemoine NR, Charnock M, Habib NA, Lechler R, Nicholls J, Pignatelli 
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intraperitoneal administration of E1A-lipid complex in patients with recurrent epithelial 
ovarian cancer overexpressing HER-2/neu oncogene. Clinical cancer research. 2004; 
10(9):2986-2996. 
 
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Steinberg J, Wanaski S, Kasid UN, Ratain MJ. Delivery of a liposomal c-raf-1 antisense 
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31. Papachristou E, Link KH, Schoenberg MH. Regional celiac artery infusion in the 
adjuvant treatment of pancreatic cancer. Anticancer research. 2003; 23(2A):831-834. 
 
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Nanoparticle in Advanced Solid Tumors. Molecular therapy. 2013; 21(5):1096-1103. 


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Protocol Number: SGT53-02-2 
Amendment 6 July 5 , 2016 
Confidential 
Page 95 of 108 
 
 
33. Kim SS, Rait A, Kim E, Pirollo KF, Nishida M, Farkas N, Dagata JA, Chang EH. A 
Nanoparticle Carrying the p53 Gene Targets Tumors Including Cancer Stem Cells, 
Sensitizes Glioblastoma to Chemotherapy and Improves Survival. ACS Nano. 2014; 
8(6):5494-5514. 


 
 
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Protocol Number: SGT53-02-2 
Amendment 5 July 5, 2016 
 
 
18. APPENDIX 


 
 
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Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
 
 
18.1 Schedule of Assessments 
 
18.1.1. Patient WITHOUT Surgical Resection for Tumor Analysis 
 
TYPE OF 
EVALUATION 
Baseline 
Screening 
Cycle 1 
D1 
D2 
D3 
D4 
D5 
D6 
D7 
D8 
D9 
D10 
D11 
D12 
D13 
D14 
D15 
D16 
D17 
D18 
D19 
D20 
D21 
D22 
D23-D28 
Informed Consent 
X 
Physical 
Examination¹ 
X 
X 
X 
X 
X 
Symptom-oriented 
Exam¹ 
X 
X 
X 
ECG² 
X 
X 
X 
X 
Limited ECHO 
X 
Vital Signs 
X 
X 
X 
X 
X 
X 
X 
X 
Performance Status 
X 
X 
X 
X 
X 
X 
X 
X 
Medical History³ 
X 
X 
X 
X 
X 
X 
X 
X 
Hematology⁴ ’ 9 
X 
X 
X 
X 
X 
PT/PTT, D-dimer, ⁵ 
X 
X 
X 
X 
X 
Chemistries⁶, 9 
X 
X 
X 
X 
X 
Urine Analysis 
X 
Serum Pregnancy 
Test 
X 
MRI Scan 7 
X 
SGT-53 
Administration8 
X 
X 
X 
X 
X 
X 
Temozolomide 
Administration 
X 
X 
X 
X 
X 
 
 
¹ Physical examination will be done on 1st visit of each week. A symptom-oriented examination will be done on the intervening study visits  only if necessary. 
² ECG will be performed at baseline; 2 hours and 24 hours after the 1st SGT-53 infusion; weekly (2 hours post-infusion) during the first 2 weeks of Cycle 1 and at the EOT visit when the patient goes 
off study. If these patients receive additional rounds of SGT-53/Temozolomide a 12-lead ECG will only be performed as necessary and the EOT visit when the patient goes off study. 
³ Medical History includes review of concomitant medications and adverse events. 


 
 
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Confidential 
Page 97 of 108 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
 
 
⁴ Hematology values include complete white count (CBC) with differential and platelet count. 
⁵ PT/PTT and D-dimer for the first two subjects: at baseline/screening; ~20 hours post-infusion (during the 23 hour observation period after the first SGT-53 infusion), and thereafter once a week 
during Cycle 1, once in two weeks during Cycles 2 and 3; and at the exit visit.  When blood chemistries are not being assessed on this same day LDH will also be determined. 
PT/ PTT and D-dimer for subsequent subjects: at baseline/screening; at Cycle 1, ~20 hours post-infusion 1 (during the 23 observation period); and at the exit visit.  When blood chemistries are 
not being assessed on this same day LDH will also be determined. 
⁶ Chemistries include: BUN, Cr, Na⁺, K⁺, CO₂, Cl, Mg⁺⁺, Ca⁺⁺, phosphorus, albumin, alkaline phosphatase, ALT, AST, total and direct bilirubin, total protein, glucose and LDH.. 
 
 
7 Tumor size will be assessed by MRI at baseline, every 2 cycles (8 weeks) and/or at the end of cycle 3 to determine if the patient is to continue on study. 
8 Prior to each infusion of SGT-53, subjects will receive the following premedication: dexamethasone (i.v.), a combination of histamine H1 and H2 blockers (i.v.), indocin (p.o.) and acetominophen 
(p.o.). 
9 Hematology and Full panel chemistries will be completed at each visit only if they were clinically significant at the previous visit. 


 
 
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Confidential 
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Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
 
 
 
 
 
 
 
 
TYPE OF 
EVALUATION 
Cycle 2 
D1 
D2 
D3 
D4 
D5 
D6 
D7 
D8 
D9 
D10 
D11 
D12 
D13 
D14 
D15 
D16 
D17 
D18 
D19 
D20 
D21 
D22 
D23-D28 
Informed 
Consent 
Physical 
Examination¹ 
X 
X 
X 
X 
Symptom- 
oriented Exam¹ 
X 
X 
X 
ECG² 
limited ECHO 
Vital Signs 
X 
X 
X 
X 
X 
X 
X 
Performance 
Status 
X 
X 
X 
X 
X 
X 
X 
Medical 
History³ 
X 
X 
X 
X 
X 
X 
X 
Hematology⁴ ’ 9 
X 
X 
X 
X 
PT/PTT, D- 
dimer, ⁵ 
X 
X 
Chemistries⁶,9 
X 
X 
X 
X 
Urine Analysis 
X 
Serum 
Pregnancy Test 
MRI Scan7 
X 
SGT-53 
Administration8 
X 
X 
X 
X 
X 
X 
Temozolomide 
Administration 
X 
X 
X 
X 
X 
 
 
¹ Physical examination will be done on 1st visit of each week. 


SynerGene Therapeutics, Inc. 
Protocol Number: SGT53-02-2 
Amendment  July 5, 2016 
Confidential 
Page 99 of 108 
 
 
 
 
² ECG will be performed at baseline; 2 hours and 24 hours after the 1st SGT-53 infusion; weekly (2 hours post-infusion) during the first 2 weeks of Cycle 1 and at the EOT visit when the patient 
goes off study. If these patients receive additional rounds of SGT-53/Temozolomide a 12-lead ECG will only be performed as necessary and the EOT visit when the patient goes off study.. 
³ Medical History includes review of concomitant medications and adverse events. 
⁴ Hematology values include complete white count (CBC) with differential and platelet count. 
⁵ PT/PTT and D-dimer for the first two subjects: at baseline/screening; ~20 hours post-infusion (during the 23 hour observation period  after the first SGT-53 infusion), and thereafter once a 
week during Cycle 1, once in two weeks during Cycles 2 and 3; and at the exit visit.  When blood chemistries are not being assessed on this same day LDH will also be determined. 
PT/ PTT and D-dimer for subsequent subjects: at baseline/screening; at Cycle 1, ~20 hours post-infusion 1 (during the 23 observation period); and at the exit visit.  When blood chemistries are 
not being assessed on this same day LDH will also be determined. 
⁶ Chemistries include: BUN, Cr, Na⁺, K⁺, CO₂, Cl, Mg⁺⁺, Ca⁺⁺, phosphorus, albumin, alkaline phosphatase, ALT, AST, total and direct bilirubin, total protein, glucose and LDH. 
 
 
7 Tumor size will be assessed by MRI at baseline, every 2 cycles (8 weeks) and/or at the end of cycle 3 to determine if the patient is to continue on study 
8 Prior to each infusion of SGT-53, subjects will receive the following premedication: dexamethasone (i.v.), a combination of histamine H1 and H2 blockers (i.v.), indocin (p.o.) and acetominophen 
(p.o.). 
9 Hematology and Full panel chemistries will be completed at each visit only if they were clinically significant at the previous visit. 


SynerGene Therapeutics, Inc. 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
Confidential 
Page 100 of 108 
 
 
 
 
 
 
 
 
 
 
 
 
TYPE OF 
EVALUATION 
Cycle 3 
D1 
D2 
D3 
D4 
D5 
D6 
D7 
D8 
D9 
D10 
D11 
D12 
D13 
D14 
D15 
D16 
D17 
D18 
D19 
D20 
D21 
D22 
D23-D28 
EOT 
30 Day 
Follow- 
up11 
Informed 
Consent 
Physical 
Examination¹ 
X 
X 
X 
X 
X 
X 
Symptom- 
oriented Exam¹ 
X 
X 
X 
ECG² 
X 
limited ECHO 7 
X 
Vital Signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Performance 
Status 
X 
X 
X 
X 
X 
X 
X 
X 
Medical 
History³ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Hematology⁴ ¹⁰ 
X 
X 
X 
X 
X 
X 
PT/PTT, D- 
dimer, ⁵ 
X 
X 
X 
X 
Chemistries⁶, 10 
X 
X 
X 
X 
X 
X 
Urine Analysis 
X 
X 
X 
Serum 
Pregnancy Test 
MRI Scan⁸ 
X 
SGT-53 
Administration⁹ 
X 
X 
X 
X 
X 
X 
Temozolomide 
Administration 
X 
X 
X 
X 
X 


SynerGene Therapeutics, Inc. 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
Confidential 
Page 101 of 108 
 
 
 
 
 
 
¹ Physical examination will be done on 1st visit of each week. A symptom-oriented examination will be done on the intervening study visits  only if necessary. 
² ECG will be performed at baseline; 2 hours and 24 hours after the 1st SGT-53 infusion; weekly (2 hours post-infusion) during the first 2 weeks of Cycle 1 and at the EOT visit when the 
patient goes off study. If these patients receive additional rounds of SGT-53/Temozolomide a 12-lead ECG will only be performed as necessary and the EOT visit when the patient goes 
off study.. 
³ Medical History includes review of concomitant medications and adverse events. 
⁴ Hematology values include complete white count (CBC) with differential and platelet count. 
⁵ PT/PTT and D-dimer for the first two subjects: at baseline/screening; ~20 hours post-infusion (during the 23 hour observation period  after the first SGT-53 infusion), and thereafter 
once a week during Cycle 1, once in two weeks during Cycles 2 and 3; and at the exit visit.  When blood chemistries are not being assessed on this same day LDH will also be determined. 
PT/ PTT and D-dimer for subsequent subjects: at baseline/screening; at Cycle 1, ~20 hours post-infusion 1 (during the 23 observation period); and at the exit visit.  When blood 
chemistries are not being assessed on this same day LDH will also be determined. 
⁶ Chemistries include: BUN, Cr, Na⁺, K⁺, CO₂, Cl, Mg⁺⁺, Ca⁺⁺, phosphorus, albumin, alkaline phosphatase, ALT, AST, total and direct bilirubin, total protein, glucose and LDH.. 
⁷ A limited ECHO will only be performed if needed.. 
⁸ Tumor size will be assessed by MRI at baseline,  every 2 cycles (8 weeks) and/or at the end of cycle 3 to determine if the patient is to continue on study 
⁹ Prior to each infusion of SGT-53, subjects will receive the following premedication: dexamethasone (i.v.), a combination of histamine H1 and H2 blockers (i.v.), indocin (p.o.) and 
acetominophen (p.o.). 
¹⁰ Hematology and Full panel chemistries will be completed at each visit only if they were clinically significant at the previous visit. 
11   The 30 day and long-term follow-ups will be performed as described in Section 10.3 


SynerGene Therapeutics, Inc. 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
Confidential 
Page 102 of 108 
 
 
 
 
18.1.2. Patients Who Undergo Surgical Resection for Tumor Analysis 
 
TYPE OF 
EVALUATION 
Baseline 
Screen 
Pre- Surgery 
Cycle 1 
D-3 
D-2 
D-1 
D1 
D2 
D3 
D4 
D5 
D6 
D7 
D8 
D9 
D10 
D11 
D12 
D13 
D14 
D15 
D16 
D17 
D 18 
D 19 
D 20 
D 21 
D 22 
D23- 
D28 
Informed 
Consent 
X 
Physical 
Examination¹ 
X 
X 
X 
X 
X 
X 
Symptom- 
oriented Exam¹ 
X 
X 
X 
X 
ECG² 
X 
X 
X 
X 
X 
Limited ECHO 
X 
Vital Signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Performance 
Status 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Medical 
History³ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Hematology⁴ 9 
X 
X 
X 
X 
X 
X 
PT/PTT, D- 
dimer⁵ 
X 
X 
X 
X 
X 
X 
Chemistries⁶, 9 
X 
X 
X 
X 
X 
Urine Analysis 
X 
X 
Serum 
Pregnancy Test 
X 
MRI Scan7 
X 
SGT-53 
Administration⁹ 
X 
X 
X 
X 
X 
X 
X 
X 
TMZ 
Administration 
X 
X 
X 
X 
X 
 
 
 
¹ Physical examination will be done on 1st visit of each week. A symptom-oriented examination will be done on the intervening study visits  only if necessary. . 
² ECG will be performed at baseline; 2 hours and 24 hours after the 1st SGT-53 infusion; weekly (2 hours post-infusion) during the first 2 weeks of Cycle 1 and at the EOT visit when the patient goes off 
study. If these patients receive additional rounds of SGT-53/Temozolomide a 12-lead ECG will only be performed as necessary and the EOT visit when the patient goes off study. 


SynerGene Therapeutics, Inc. 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
Confidential 
Page 103 of 108 
 
 
 
 
³ Medical History includes review of concomitant medications and adverse events. 
⁴ Hematology values include complete white count (CBC) with differential and platelet count. 
⁵ PT/PTT, and D-dimer for the first two subjects: at baseline/screening; ~20 hours post-infusion (during the 23 hour observation period  after the first SGT-53 infusion), and thereafter once a week 
during Cycle 1, once in two weeks during Cycles 2 and 3; and at the exit visit.  When blood chemistries are not being assessed on this same day LDH will also be determined. 
PT/ PTT, D-dimer and LDH for subsequent subjects: at baseline/screening; at Cycle 1, ~20 hours post-infusion 1 (during the 23 observation period after the first infusion); and at the exit visit. When 
blood chemistries are not being assessed on this same day, LDH will also be determined. 
⁶ Chemistries include: BUN, Cr, Na⁺, K⁺, CO₂, Cl, Mg⁺⁺, Ca⁺⁺, phosphorus, albumin, alkaline phosphatase, ALT, AST, total and direct bilirubin, total protein, glucose and LDH. 
 
 
7 Tumor size will be assessed by MRI at baseline, no later than 72 hours post-surgery, every 2 cycles (8 weeks) and/or at the end of cycle 3 to determine if the patient is to continue on study 
8 Prior to each infusion of SGT-53, subjects will receive the following premedication: dexamethasone (i.v.), a combination of histamine H1 and H2 blockers (i.v.), indocin (p.o.) and acetominophen 
(p.o.). 
9 Hematology and Full panel chemistries will be completed at each visit only if they were clinically significant at the previous visit. 


SynerGene Therapeutics, Inc. 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
Confidential 
Page 104 of 108 
 
 
 
 
TYPE OF 
EVALUATION 
Cycle 2 
D1 
D2 
D3 
D4 
D5 
D6 
D7 
D8 
D9 
D10 
D11 
D12 
D13 
D14 
D15 
D16 
D17 
D18 
D19 
D20 
D21 
D22 
D23-D28 
Informed 
Consent 
Physical 
Examination¹ 
X 
X 
X 
X 
Symptom- 
oriented Exam¹ 
X 
X 
X 
ECG² 
Limited ECHO 
Vital Signs 
X 
X 
X 
X 
X 
X 
X 
Performance 
Status 
X 
X 
X 
X 
X 
X 
X 
Medical 
History³ 
X 
X 
X 
X 
X 
X 
X 
Hematology⁴ 9 
X 
X 
X 
X 
PT/PTT, D- 
dimer, ⁵ 
X 
X 
Chemistries⁶, 9 
X 
X 
X 
X 
Urine Analysis 
X 
Serum 
Pregnancy Test 
MRI Scan7 
X 
SGT-53 
Administration8 
X 
X 
X 
X 
X 
X 
Temozolomide 
Administration 
X 
X 
X 
X 
X 
 
 
¹ Physical examination will be done on 1st visit of each week. A symptom-oriented examination will be done on the intervening study visits  only if necessary. 
² ECG will be performed at baseline; 2 hours and 24 hours after the 1st SGT-53 infusion; weekly (2 hours post-infusion) during the first 2 weeks of Cycle 1 and at the EOT visit when the patient 
goes off study. If these patients receive additional rounds of SGT-53/Temozolomide a 12-lead ECG will only be performed as necessary and the EOT visit when the patient goes off study. 
³ Medical History includes review of concomitant medications and adverse events. 
⁴ Hematology values include complete white count (CBC) with differential and platelet count. 
⁵ PT/PTT and D-dimer for the first two subjects: at baseline/screening; ~20 hours post-infusion (during the 23 hour observation period  after the first SGT-53 infusion), and thereafter once a 
week during Cycle 1, once in two weeks during Cycles 2 and 3; and at the exit visit.  When blood chemistries are not being assessed on this same day LDH will also be determined. 


SynerGene Therapeutics, Inc. 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
Confidential 
Page 105 of 108 
 
 
 
 
PT/ PTT and D-dimer for subsequent subjects: at baseline/screening; at Cycle 1, ~20 hours post-infusion 1 (during the 23 observation period); and at the exit visit.  When blood chemistries are 
not being assessed on this same day LDH will also be determined. 
⁶ Chemistries include: BUN, Cr, Na⁺, K⁺, CO₂, Cl, Mg⁺⁺, Ca⁺⁺, phosphorus, albumin, alkaline phosphatase, ALT, AST, total and direct bilirubin, total protein, glucose and LDH. 
 
 
7 Tumor size will be assessed by MRI at baseline, no later than 72 hours post-surgery, every 2 cycles (8 weeks) and/or at the end of cycle 3 to determine if the patient is to continue on study 
8 Prior to each infusion of SGT-53, subjects will receive the following premedication: dexamethasone (i.v.), a combination of histamine H1 and H2 blockers (i.v.), indocin (p.o.) and acetominophen 
(p.o.). 
9 Hematology and Full panel chemistries will be completed at each visit only if they were clinically significant at the previous visit. 


SynerGene Therapeutics, Inc. 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
Confidential 
Page 106 of 108 
 
 
 
 
 
 
 
TYPE OF 
EVALUATION 
Cycle 3 
D1 
D2 
D3 
D4 
D5 
D6 
D7 
D8 
D9 
D10 
D11 
D12 
D13 
D14 
D15 
D16 
D17 
D18 
D19 
D20 
D21 
D22 
D23-D28 
EOT 
30 Day 
Follow- 
up11 
Informed Consent 
Physical 
Examination¹ 
X 
X 
X 
X 
X 
X 
Symptom- 
oriented Exam¹ 
X 
X 
X 
ECG² 
X 
Limited ECHO7 
X 
Vital Signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Performance 
Status 
X 
X 
X 
X 
X 
X 
X 
X 
Medical History³ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Hematology⁴ ’ ¹⁰ 
X 
X 
X 
X 
X 
X 
PT/PTT, D-dimer, 
⁵ 
X 
X 
X 
X 
Chemistries⁶, 10 
X 
X 
X 
X 
X 
X 
Urine Analysis 
X 
X 
X 
Serum Pregnancy 
Test 
MRI Scan⁸ 
X 
SGT-53 
Administration⁹ 
X 
X 
X 
X 
X 
X 
Temozolomide 
Administration 
X 
X 
X 
X 
X 
 
 
¹ Physical examination will be done on 1st visit of each week. A symptom-oriented examination will be done on the intervening study visits  only if necessary.. 
² ECG will be performed at baseline; 2 hours and 24 hours after the 1st SGT-53 infusion; weekly (2 hours post-infusion) during the first 2 weeks of Cycle 1 and at the EOT 
visit when the patient goes off study.  If these patients receive additional rounds of SGT-53/Temozolomide a 12-lead ECG will only be performed as necessary and the EOT 
visit when the patient goes off study. 
³ Medical History includes review of concomitant medications and adverse events. 


SynerGene Therapeutics, Inc. 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
Confidential 
Page 107 of 108 
 
 
 
 
⁴ Hematology values include complete white count (CBC) with differential and platelet count. 
⁵ PT/PTT and D-dimer for the first two subjects: at baseline/screening; ~20 hours post-infusion (during the 23 hour observation period  after the first SGT-53 infusion), and 
thereafter once a week during Cycle 1, once in two weeks during Cycles 2 and 3; and at the exit visit.  When blood chemistries are not being assessed on this same day LDH 
will also be determined. 
PT/ PTT and D-dimer for subsequent subjects: at baseline/screening; at Cycle 1, ~20 hours post-infusion 1 (during the 23 observation period); and at the exit visit.  When 
blood chemistries are not being assessed on this same day LDH will also be determined. 
⁶ Chemistries include: BUN, Cr, Na⁺, K⁺, CO₂, Cl, Mg⁺⁺, Ca⁺⁺, phosphorus, albumin, alkaline phosphatase, ALT, AST, total and direct bilirubin, total protein, glucose and LDH. 
⁷ A limited ECHO will only be performed if needed.. 
⁸ Tumor size will be assessed by MRI at baseline, no later than 72 hours post-surgery, every 2 cycles (8 weeks) and/or at the end of cycle 3 to determine if the patient is to 
continue on study 
⁹ Prior to each infusion of SGT-53, subjects will receive the following premedication: dexamethasone (i.v.), a combination of histamine H1 and H2 blockers (i.v.), indocin 
(p.o.) and acetominophen (p.o.). 
¹⁰ Hematology and Full panel chemistries will be completed at each visit only if they were clinically significant at the previous visit. 
11   The 30 day and long-term follow-ups will be performed as described in Section 10.3 


 
 
SynerGene Therapeutics, Inc 
Confidential 
Page 108 of 108 
Protocol Number: SGT53-02-2 
Amendment 6 July 5, 2016 
 
 
 
 
18.2. Summary of the RANO Response Criteria 
 
Criterion 
CR 
P 
S 
PD 
T1 gadolinium enhancing disease 
None 
>50% ↓ 
≤50% ↓ but <25% ↑ 
≥25% ↑ * 
T2/FLAIR 
Stable or ↓ 
Stable or ↓ 
Stable or ↓ 
↑ 
New lesion 
None 
Non 
None 
Present* 
Corticosteroids 
None 
Stable or ↓ 
Stable or ↓ 
NA† 
Clinical status 
Stable or ↑ 
Stable or ↑ 
Stable or ↑ 
↓* 
Requirement for Response 
All 
All 
All 
Any* 
 
Abbreviations: RANO, Response Assessment in Neuro-Oncology; CR, complete 
response; PR, partial response; SD, stable disease; PD, progressive disease; FLAIR, 
fluid-attenuated inversion recovery; NA, not applicable. 
 
*Progression occurs when this criterion is present. 
 
†Increase in corticosteroids alone will not be taken into account in determining 
progression in the absence of persistent clinical deterioration 
 
 
 
 
18.3. Karnofsky Performance Status Scale 
 
Patient performance status will be graded according to the following scale: 
KPS 100 
Normal; no complaints; no evidence of disease 
 
KPS 90 
Able to carry on normal activity; minor signs or symptoms of disease 
KPS 80 
Normal activity with effort some sign or symptoms of disease 
KPS 70 
Care for self; unable to carry on normal activity or do active work 
 
KPS 60 
Requires occasional assistance, but able to care for most personal needs 
KPS 50 
Requires considerable assistance and frequent medical care 
KPS 40 
Disabled; requires special care and assistance 
 
KPS 30 
Severely disabled; hospitalization is indicated, although death not 
imminent 
 
KPS 20 
Very sick; hospitalization necessary; active support treatment is necessary 
KPS 10 
Moribund; fatal processes progressing rapidly 
KPS 0 
Dead