Clinical trial NCT03268382
Conditions: High-grade Serous Ovarian Cancer
Keywords: Ovarian Cancer Ovarian Carcinoma High Grade Serous Ovarian Cancer Recurrent Cancer Resistant Cancer
Sponsor: Aprea Therapeutics
Start date: 2017-07-31; Completion date: 2019-07-10
Enrollment: 36 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this study is to make a preliminary assessment of the efficacy of a combined APR-246 and PLD chemotherapy regimen in patients with platinum-resistant recurrent high grade serous ovarian cancer (HGSOC) with mutated TP53. In addition, the study aims to assess the safety profile of the combined APR-246 and PLD chemotherapy regimen, to evaluate potential biomarkers, and to assess the biological activity in tumor and surrogate tissues. The trial will enroll at least 25 evaluable patients.

Detailed description:

Arms: arm 1: None
Interventions: intervention 1: APR-246 intervention 2: Pegylated Liposomal Doxorubicin Hydrochloride (PLD)
Intervention descriptions: intervention 1: Intravenous infusion intervention 2: Intravenous infusion

Protocol documents:
Prot_SAP_000.pdf: 
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PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade Serous 
Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal Doxorubicin 
Chemotherapy With APR-246
Protocol No.:
APR-486
EudraCT No.:
2017-000265-67
IND No.:
124841
Coordinating Investigator:
Charlie Gourley
Edinburgh Cancer Research Centre
The University of Edinburgh
Crewe Road South
Edinburgh EH4 2XR
UK
Tel: +44 (0)131 6518608
Sponsor:
Aprea Therapeutics AB   
Nobels väg 3
SE-171 65 Solna
Sweden
Tel: +46 (0)8 50884504
Medical Monitor:
Theradex® (Europe) Ltd.
2nd Floor, the Pinnacle
Station Way
Crawley
West Sussex RH10 1JH
UK
Tel: +44 (0)1293 510319
Current version:
3.0
Replaces (previous versions):
2.0, 28 August 2017
Date:
12 September 2017
CONFIDENTIAL
This document contains strictly confidential information and cannot be disclosed or used, unless 
authorized in writing by Theradex and Aprea Therapeutics AB


19 September 2017


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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INVESTIGATOR’S STATEMENT
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade Serous Ovarian 
Cancer, a Phase II Study of Systemic Pegylated Liposomal Doxorubicin Chemotherapy With 
APR-246
This page will be institute specific and should list the investigator that will sign-off the separate protocol 
agreement.
1.
I agree to conduct this study as outlined in the protocol.
2.
I understand that this study will not be initiated without approval of the appropriate Independent 
Ethics Committee (IEC), and that all administrative requirements of the governing body of the 
Institution will be complied with fully.
3.
Informed written consent will be obtained from all participating patients in accordance with 
institutional guidelines, FDA requirements as specified in Title 21 CFR, Part 50, the European 
Union Directive 2001/20/EC and its associated Detailed Guidances, European Union GCP 
Directive 2005/28/EC, the ICH Guideline for Good Clinical Practice, Section 4.8, and the terms 
of the Declaration of Helsinki (2013).
4.
I will enroll patients who meet the protocol criteria for entry.
5.
I understand that my signature on each completed Electronic Case Report Form indicates that I 
have carefully reviewed each page and accept full responsibility for the contents thereof.
6.
I understand that the information presented in this study protocol is confidential, and I hereby 
assure that no information based on the conduct of the study will be released without prior 
consent from the Sponsor unless this requirement is superseded by the Food and Drug 
Administration, a Competent Authority of the European Union or another Regulatory Authority.
Investigator Signature
Name:
Title:
Signature
Date
Institution name and address:


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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TABLE OF CONTENTS
Page No.
PROTOCOL APPROVAL PAGE.......................................................................................... 2
INVESTIGATOR’S STATEMENT....................................................................................... 3
TABLE OF CONTENTS......................................................................................................... 4
CLINICAL STUDY SYNOPSIS............................................................................................. 9
LIST OF ABBREVIATIONS................................................................................................ 14
1.0 
GENERAL INFORMATION................................................................................. 16
1.1 Protocol Number and Title of the Study .................................................................. 16
1.2 Sponsor..................................................................................................................... 16
1.3 Clinical Research Organization................................................................................ 16
1.4 Coordinating Investigator......................................................................................... 16
1.5 Safety Review Committee........................................................................................ 17
2.0 
INTRODUCTION AND RATIONALE FOR THE STUDY ............................... 18
2.1 Background Information .......................................................................................... 18
 General Information..................................................................................... 18
2.1.1
The p53 Protein and APR-246..................................................................... 18
2.1.2
2.2 Disease Background................................................................................................. 19
2.3 Choice of Patient Population.................................................................................... 20
2.4 Investigational Medicinal Product ........................................................................... 20
2.5 Preclinical Studies.................................................................................................... 21
 Primary Pharmacology of APR-246............................................................ 21
2.5.1
Safety Pharmacology of APR-246............................................................... 22
2.5.2
Pharmacokinetics ......................................................................................... 22
2.5.3
Toxicology................................................................................................... 23
2.5.4
2.6 Previous Clinical Studies ......................................................................................... 23
2.7 Rationale for Study in Platinum-Resistant HGSOC Population.............................. 23
 Preliminary APR-407 Results and Rationale for Selected APR-246 Dose and 
2.7.1
Infusion Time........................................................................................................... 24
2.8 Characteristics of a Well-Conducted Trial............................................................... 26
3.0 
TRIAL OBJECTIVES AND ENDPOINTS........................................................... 27
3.1 Main Objectives and Endpoints ............................................................................... 27
 Primary Objective........................................................................................ 27
3.1.1
Secondary Objectives................................................................................... 27
3.1.2
Primary Endpoints ....................................................................................... 27
3.1.3
Secondary Endpoints ................................................................................... 27
3.1.4


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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3.2
Sub-Study Objectives and Endpoints....................................................................... 28
4.0
STUDY DESIGN...................................................................................................... 29
4.1
Overview of Study Design....................................................................................... 29
4.2 Registration of Patients ............................................................................................ 29
4.3 Shipment of p53 samples ......................................................................................... 30
4.4
Drug Products........................................................................................................... 30
Investigational Medicinal Product, APR-246.............................................. 30
4.4.1
Reference Product PLD ............................................................................... 30
4.4.2
4.5 Duration of Therapy................................................................................................. 30
4.6 End of Study............................................................................................................. 30
4.7
Study Discontinuation by the Sponsor..................................................................... 30
4.8
Treatment Plan for Patients after the Study ............................................................. 31
5.0 
SELECTION AND WITHDRAWAL OF PATIENTS......................................... 32
5.1 Inclusion Criteria...................................................................................................... 32
5.2 Exclusion Criteria..................................................................................................... 33
5.3 Withdrawal of Patients and Study Termination ....................................................... 34
5.4 Compliance with Study Procedures ......................................................................... 35
6.0 
TREATMENT OF PATIENTS .............................................................................. 36
6.1 Drug Supply and Handling Procedures.................................................................... 36
 Investigational Medicinal Product, APR-246.............................................. 36
6.1.1
Pegylated Liposomal Doxorubicin Hydrochloride ...................................... 36
6.1.2
6.2 IMP Accountability/Disposition of Clinical Trial Supplies..................................... 36
6.3 Main Study Treatment Administration .................................................................... 37
6.4 Sub-Study Treatment Administration ...................................................................... 38
 Sub-Study Doses and Infusion Times.......................................................... 38
6.4.1
6.5 Dose Modifications for APR-246 due to Adverse Events During Infusion............. 40
 Main Study APR-246 Dose Reductions ...................................................... 40
6.5.1
Sub-Study APR-246 Dose Reductions ........................................................ 41
6.5.2
6.5.2.1
APR-246 Infusion and Systemic PLD Chemotherapy Delays..............41 
 Dose Modifications for PLD........................................................................ 42
6.5.3
Cardiac Safety Monitoring in Relation to Treatment With PLD................. 42
6.5.4
Action to be Taken in the Event of QT/QTc Prolongation.......................... 42
6.5.5
Treatment of APR-246-Related Adverse Events of the CNS...................... 42
6.5.6
6.6 Concomitant Treatment and Prohibited Medication................................................ 43
6.7 Contraception ........................................................................................................... 44
7.0 
STUDY PROCEDURES.......................................................................................... 45
7.1 Schedule of Study Procedures.................................................................................. 45
7.2 Detailed Study Evaluations ...................................................................................... 48
 Registration/Informed Consent Form .......................................................... 48
7.2.1
Pretreatment ................................................................................................. 48
7.2.2


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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Registration.................................................................................................. 49
7.2.3
All Cycles, Days 1-28.................................................................................. 49
7.2.4
End of Treatment Visit................................................................................. 50
7.2.5
Follow-up Visits........................................................................................... 51
7.2.6
After Progression ......................................................................................... 51
7.2.7
7.3
Adverse Events......................................................................................................... 51
Definition of Adverse Events....................................................................... 51
7.3.1
Definitions of Serious Adverse Events........................................................ 52
7.3.2
SAE Exceptions ........................................................................................... 52
7.3.3
Recording of Adverse Events ...................................................................... 52
7.3.4
7.3.4.1
Time Period for Collection of Adverse Events .....................................52
7.3.4.2
Follow-up of Unresolved Adverse Events ............................................53
7.3.4.3
Variables................................................................................................53 
7.3.4.4
Causality Collection ..............................................................................54 
7.3.4.5
Adverse Events Based on Signs and Symptoms ...................................54 
7.3.4.6
Adverse Events Based on Examinations and Tests...............................54 
7.3.4.7
Hy’s Law...............................................................................................55 
7.3.4.8
Disease Symptomatic Management and Disease Progression ..............55 
7.3.4.9
New Cancers .........................................................................................55 
7.3.4.10 Handling of Deaths................................................................................55 
 Reporting of Serious Adverse Events.......................................................... 56
7.3.5
7.4 Pregnancy................................................................................................................. 56
 Maternal Exposure....................................................................................... 56
7.4.1
8.0 
EFFICACY ASSESSMENTS ................................................................................. 58
8.1 Definitions................................................................................................................ 58
 Measurable Disease ..................................................................................... 58
8.1.1
Non-measurable Disease.............................................................................. 58
8.1.2
8.1.2.1
Bone Lesions.........................................................................................58 
8.1.2.2
Cystic Lesions .......................................................................................59 
8.1.2.3
Lesions With Prior Local Treatment.....................................................59 
 Target Lesions.............................................................................................. 59
8.1.3
Lymph Node Assessment ............................................................................ 59
8.1.4
Non-target Lesions....................................................................................... 60
8.1.5
8.2 Guidelines for Evaluation of Measurable Disease ................................................... 60
8.3 Response Criteria ..................................................................................................... 61
 Evaluation of Target Lesions....................................................................... 61
8.3.1
8.3.1.1
Assessment of Target Lymph Nodes ....................................................61 
8.3.1.2
Target Lesions That Become “Too Small to Measure” ........................61 
8.3.1.3
Lesions That Split or Coalesce on Treatment .......................................62 
 Evaluation of Non-target Lesions ................................................................ 62
8.3.2
8.3.2.1
New Lesions..........................................................................................62 


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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8.3.2.2
Evaluation of Best Overall Response by RECIST................................62
Confirmatory Measurement/Duration of Response..................................... 64
8.3.3
8.3.3.1
Confirmation According to RECIST.....................................................64
8.3.3.2
Duration of Overall Response...............................................................64 
8.3.3.3
Overall Response Rate ..........................................................................65 
8.3.3.4
Duration of Stable Disease....................................................................65
Progression-free Survival............................................................................. 65
8.3.4
8.4 Pharmacokinetics ..................................................................................................... 65
 APR-246 ...................................................................................................... 65
8.4.1
8.5 Pharmacodynamics................................................................................................... 67
 Tumor Biopsies............................................................................................ 67
8.5.1
8.6
Exploratory Biomarker Research............................................................................. 67
8.7 Biological Sample Handling .................................................................................... 68
8.8 Chain of Custody of Biological Samples ................................................................. 68
8.9 Withdrawal of Informed Consent for Donated Biological Samples ........................ 69
9.0 
STATISTICS............................................................................................................ 70
9.1 Sample Size.............................................................................................................. 70
9.2 General ..................................................................................................................... 70
9.3 Analysis Populations................................................................................................... 70
9.4 Statistical Methods...................................................................................................... 71
9.4.1 Efficacy Data .................................................................................................. 71
9.4.2 Safety Data...................................................................................................... 71
9.4.3 Pharmacokinetic data...................................................................................... 72
10.0 
QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES ........ 73
10.1 Monitoring of the Study and Regulatory Compliance ............................................. 73
10.2 Curricula Vitae of Investigators ............................................................................... 73
10.3 Protocol Modifications............................................................................................. 73
10.4 Publication Policy .................................................................................................... 73
11.0
ETHICAL CONSIDERATIONS............................................................................ 74
11.1 Informed Consent..................................................................................................... 74
11.2 Independent Ethics Committee/Regulatory ............................................................. 74
11.3 Patient Privacy.......................................................................................................... 74
12.0 
DATA HANDLING AND RECORD KEEPING.................................................. 76
12.1 Data to be Recorded Directly in the Case Report Form........................................... 76
12.2 Recording of Data .................................................................................................... 76
12.3 Study Records .......................................................................................................... 76
13.0 
REFERENCES......................................................................................................... 77


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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TABLES
Table 1. Dose Modifications of APR-246 in Main Study.................................................................. 40
Table 2. Dose Modifications of APR-246 in Sub-Study.................................................................... 41
Table 3. Examples of Rescue Medications for Use With APR-246 .................................................. 43
Table 4. Schedule of Study Evaluations............................................................................................. 46
Table 5. Time Point Response: Patients With Target (+/- Non-target) Disease ................................ 63
Table 6. Time Point Response: Patients With Non-target Disease Only........................................... 63
Table 7. Best Overall Response When Confirmation of CR and PR is Required.............................. 64
Table 8. PK Blood Sampling Time Points for APR-246 During Cycle 1 (Patients Selected for ECG 
Holter) ................................................................................................................................................ 66
Table 9. Sparse PK Blood Sampling Time Points for APR-246........................................................ 66
FIGURES
Figure 1. Structure of APR-246 ......................................................................................................... 20
Figure 2: Simulated typical individual concentration time profiles, stratified by total infusion time.
............................................................................................................................................................ 25
Figure 3. Treatment Administration................................................................................................... 37
Figure 4. Treatment Administration in Sub-Study............................................................................. 38
Figure 5. Sub-Study Flowchart .......................................................................................................... 39
APPENDICES
Appendix I: ECOG Performance Status............................................................................................. 79
Appendix II: New York Heart Association Heart Failure Classification........................................... 80
Appendix III: Population Pharmacokinetic Analysis of APR-246 Based on Data From Two Phase 1 
Studies, Evaluation of the Impact of Fixed Versus Body Weight-Based Dosing and Exploration of 
the Probability of Exceeding Concentration Thresholds After Different Dosing Regimens............. 81
Appendix IV: Further Guidance on the Definition of a Serious Adverse Event and Interpreting the 
Causality Question ............................................................................................................................. 82
Appendix V: Actions Required in Cases of Increases in Liver Biochemistry and Evaluation of Hy’s 
Law..................................................................................................................................................... 84


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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CLINICAL STUDY SYNOPSIS
Name of Sponsor:
Aprea Therapeutics AB
Nobels väg 3
SE-171 65 Solna
Sweden
Study Phase:
Phase II 
Name of Finished Product: APR-246, concentrate for solution for infusion
Name of Active Ingredient: 2-(hydroxymethyl)-2-(methoxymethyl)-1-azabicyclo [2,2,2] octan-3-one
Title of the Study: PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade Serous Ovarian 
Cancer, a Phase II Study of Systemic Pegylated Liposomal Doxorubicin Chemotherapy With APR-246
Investigators and Study Centers: Please see Study Operations Manual
Publication (Reference): To be confirmed
Clinical Phases: Phase II 
Study Design and Number of Patients:
This study is an open-label, multicenter phase II study to evaluate the preliminary efficacy of APR-246 with 
systemic pegylated liposomal doxorubicin (PLD) chemotherapy in TP53-mutated high grade serous ovarian 
cancer (HGSOC) in patients with recurrent disease occurring between 4 weeks and 6 months after a preceding 
platinum-based treatment (platinum-resistant patients).
Different APR-246 infusion times will be explored.  The Main Study will assess the standard 6 hour APR-246 
infusion whilst the Sub-Study will explore shorter infusions (3 or 4 hour).
At least 25 evaluable patients will receive the standard 6 hour APR-246 infusion. Up to 25 additional patients
may be enrolled in a Sub-Study exploring shorter APR-246 infusion durations (3 or 4 hours). The Sub-Study will 
start enrollment after at least 6 patients have received the standard 6 hour infusion in the Main Study. The Sub-
Study will be conducted in parallel with the Main Study.
A safety review committee (SRC) will evaluate the first 6 patients who receive the standard 6 hour infusion and 
the first 6 patients in the Sub-Study, to determine whether further patients can be lled and receive the same APR-
246 infusion duration, at the same dose.
Objectives, Endpoints and Study Treatment:
Main Study Objectives: 
Primary Objectives:
To assess the preliminary efficacy of APR-246 with PLD chemotherapy in patients with platinum-
resistant HGSOC with mutated TP53
Secondary Objectives:
To evaluate the pharmacokinetics (PK) of APR-246 when administered with PLD chemotherapy
To evaluate cardiac safety of APR-246 when administered with PLD chemotherapy 
To assess the safety and tolerability of APR-246 with PLD chemotherapy in patients with platinum-
resistant HGSOC with mutated TP53


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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To assess:
o
Duration of response (complete or partial response) 
o
Progression-free survival (PFS) by assessment of cancer antigen 125 (CA-125)
o
PFS by RECIST 1.1
To evaluate potential biomarkers and tumor activity based on CA-125
To assess the biological activity in tumor and surrogate tissues
Main Study Endpoints:
Primary Endpoints:
Overall response rate according to RECIST 1.1
Secondary Endpoints:
PFS rate, defined as the time from registration to the time of disease progression or relapse (according to 
RECIST 1.1 only) or death, or the date of last tumor assessment without any such event (censored 
observation)
PK profile of APR-246 and concentration in plasma
Cardiac profile of APR-246 and concentration of PLD
The safety profile (adverse events [AEs], laboratory assessments, physical findings and biomarkers) of 
APR-246 and PLD chemotherapy
Duration of response (complete or partial response) 
Progression-free survival (PFS) by assessment of CA-125
Evaluation of potential biomarkers
Biological activity in tumor and surrogate tissues
Objectives, Endpoints and Study Treatment:
Sub-study Objectives: Same as Main Study Objectives, except safety and tolerability, in addition to preliminary 
efficacy, are Primary Objectives.
Sub-Study Primary Endpoints: The safety profile (adverse events [AEs], laboratory assessments, physical 
findings and biomarkers) of APR-246 with a shorter infusion and PLD chemotherapy; overall response rate 
according to RECIST 1.1.
Diagnosis and Main Criteria for Inclusion: 
Inclusion Criteria:
1.
Archived sections from the original formalin fixed paraffin embedded sample reviewed by a 
gynecological pathologist confirming HGSOC, high grade serous peritoneal cancer or primary fallopian 
tube cancer and positive immunohistochemistry staining for p53 assessed according to the local 
methodology (as detailed in the laboratory manual). Cases that do not show p53 staining will not be 
included. 
2.
Disease progression between 4 weeks and 6 months after the last platinum-based treatment was 
administered. 
3.
At least a single (RECIST 1.1) measurable lesion. 
4.
Adequate organ function prior to registration:
a)
Bone marrow reserve
x109/L


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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x 109/L
g/dL
b)
Hepatic
Total bilirubin level < 1.5 x ULN without hepatic metastasis, and < 4 x ULN with hepatic 
metastasis
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) < 2.5 x ULN  without 
hepatic metastasis, and < 4 x ULN with hepatic metastasis
c)
Renal
Calculated creatinine clearance > 30 mL/min calculated per local practice
d)
Electrolytes 
Potassium within institutional normal ranges.
5.
Toxicities from previous cancer therapies (excluding alopecia) must have recovered to grade 1 (defined by 
National Cancer Institute [NCI] Common Terminology Criteria for Adverse Events [CTCAE] version 
4.0). Chronic stable grade 2 peripheral neuropathy secondary to neurotoxicity from prior therapies may be 
considered on a case by case basis by the Principal Investigator.
6.
If of childbearing potential, negative pretreatment serum pregnancy test.
7.
If of childbearing potential, willing to use an effective form of contraception (see below) during 
chemotherapy treatment and for at least 6 months thereafter. Such methods include the following (if using 
hormonal contraception, this method must be supplemented with a barrier method, preferably male 
condom):
combined (estrogen and progestogen containing) hormonal contraception associated with inhibition of 
ovulation:
o
oral
o
intravaginal
o
transdermal
progestogen-only hormonal contraception associated with inhibition of ovulation:
o
oral
o
injectable
o
implantable 
intrauterine device (IUD) 
intrauterine hormone-releasing system (IUS) 
bilateral tubal occlusion 
vasectomized partner 
true sexual abstinence when this is in line with the preferred and usual lifestyle of the subject. Periodic 
abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods), declaration of 
abstinence for the duration of a trial, and withdrawal are not acceptable methods of contraception.
8.
Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2 (Appendix I).
9.
10. Signed informed consent.
Exclusion Criteria:
1.
Prior exposure to cumulative doses of doxorubicin >400 mg/m2 or epirubicin >720 mg/m2.
2.
Confirmed cardiac history of any of the following: 
a)
A myocardial infarct within 6 months prior to registration,


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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b)
New York Heart Association Class II or worse heart failure (Appendix II)
c)
A history of familial long QT syndrome
d)
Clinically significant pericardial disease
e)
Electrocardiographic evidence of acute ischemia 
f)
Symptomatic atrial or ventricular arrhythmias not controlled by medications
g)
readings using Fridericia’s  correction (QTcF = QT/RR0.33) 
h)
Bradycardia (< 40 bpm)
i)
Left ventricular ejection fraction (LVEF) < the institution lower limit of normal as assessed by 
echocardiogram.
3.
Major abdominal surgery or peritonitis within 6 weeks prior to study treatment.
4.
Unresolved bowel obstruction, subocclusive disease or the presence of brain metastases.
5.
Hypersensitivity to PLD or to any of the excipients.
6.
Unable to undergo imaging by either computed tomography (CT) scan or magnetic resonance imaging 
(MRI).
7.
Evidence of any other medical conditions (such as psychiatric illness, infectious diseases, neurological 
conditions, physical examination or laboratory findings) that may interfere with the planned treatment, 
affect patient compliance or place the patient at high risk from treatment related complications.
8.
Breast feeding. 
9.
Concurrent malignancy requiring therapy (excluding non-invasive carcinoma or carcinoma in situ).
10. Known HIV positive status, active hepatitis B or C status.
11. Is taking any concurrent (or within 4 weeks prior to registration) anti-cancer therapy, immunotherapy, 
radiotherapy, biological, or ancillary anti-cancer therapy, or any therapy that is considered to be 
investigational (i.e., used for non-approved indications(s) and in the context of a research investigation). 
Supportive care measures are allowed. Palliative limited radiation therapy for pain reduction is allowed.
Test Product, Dose and Mode of Administration: 
Main Study:
Patients will receive a fixed dose of 4.5 g APR-246 (1.5 g of the dose during first 45 minutes followed by 3 g of 
the dose during 5 hours 15 minutes) on Days 1 to 4 with PLD 40 mg/m2 on Day 4. The PLD administration to be 
given on Day 4 only should commence 2 hours after the start of the APR-246 infusion. Similarly for the following 
28-day cycles, APR-246 will be administered on Days 1 to 4 with the PLD infusion on Day 4 starting 2 hours 
after the start of the APR-246 infusion. In all cycles, APR-246 will be administered as a 6-hour infusion.
Test Product, Dose and Mode of Administration: 
Study Day
-1 1
2
3
4
5
6
7
8
27 28 29 30 31 32 33 34
PLD
APR-246 6-hr IV 
infusion per day
PLD
APR-246 6-hr IV 
infusion per day


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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Sub-Study:
Starting within 28 days of registration, patients will receive a fixed dose of 4.5 g APR-246 in a 2-step infusion, 
starting with a loading dose given during first 45 minutes followed by slower infusion of the remainder of the 
dose, during 2 hours 15 minutes on Days 1 to 4, with PLD 40 mg/m2 on Day 4. The PLD administration to be 
given on Day 4 only should commence 2 hours after the start of the APR-246 infusion.
Other infusion durations and doses that may be explored in the Sub-Study are 4 hour 4.5 g, or 4 hour 3.7 g. 
Duration of Treatment: 
Patients will receive 28-day cycles of PLD chemotherapy with APR-246. Patients may continue to receive 
APR-246 with PLD for as long as in the Investigator’s opinion they are benefiting from treatment and in the 
absence of disease progression and unacceptable toxicity. After the tenth 28-day cycle, data from assessments 
conducted within each treatment cycle will no longer be collected, but patients may continue to receive treatment 
after confirmation from the sponsor.
Reference Therapy, Dose and Mode of Administration:  
Not applicable
Criteria for Evaluation:  
Efficacy: 
Patients with measurable disease will be assessed using RECIST 1.1 criteria.
Safety: 
AEs will be collected throughout the study, from informed consent until 30 days after the last administration of 
study treatment. AEs will be graded according to NCI CTCAE version 4.0.  Serious adverse events (SAEs) will be 
reported according to Directive 2001/20/EC and 2005/28/EC and the International Conference on Harmonisation 
(ICH) Good Clinical Practice (GCP) guidelines.
Main Study Sample Size Calculation:
This study uses a two-stage design to test the null hypothesis is that the true response rate of APR-246 in 
versus
platinum-resistant, TP53-mutated HGSOC.  In the first stage, 16 patients will be asses
response is seen in these 16 patients the study will be curtailed for futility. Otherwise the study will continue and a 
further 9 patients will be entered
25 
patients, the null hypothesis will be rejected in favor of the alternative. This design provides 90.3% power and a 
1-sided alpha of 9.5%.
Sub-Study Sample Size:
At one of the shorter infusion levels (3 hr 4.5 g, 4 hr 4.5 g, or 4 hr 3.7 g) if there are 0 or 1 out of  6 patients with 
DLTs across the first patients, then an additional 8 patients will be treated for an initial total of N=14.   If 0 or 1 
out of 14 responses are seen, then recruitment will cease.  If 2 or more out of 14 responses are seen, a further 11 
patients will be recruited for a total of N=25.  Observance of 5/25 responses will result in rejection of the null 
hypothesis.   The design carries 89% power and a 1-sided type I error of 9.1% to test the null hypothesis that the


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
Confidential - Entire Page
Copyright© 2011 by Theradex®, Princeton, NJ
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LIST OF ABBREVIATIONS
AE
Adverse Event
ALP
Alkaline Phosphatase
ALT
Alanine Aminotransferase
AML
Acute Myeloid Leukemia
ANC
Absolute Neutrophil Count
APTT
Activated Partial Thromboplastin Time
AST
Aspartate Aminotransferase
AUC
Area Under the Curve
CA
Competent Authority
CA-125
Cancer Antigen 125
CD
Candidate Drug
CLL
Chronic Lymphocytic Leukemia
Cmax
Maximal Plasma Concentration
CNS
Central Nervous System
CR
Complete Response
CT
Computed Tomography
CTCAE
Common Terminology Criteria for Adverse Events
DLT
Dose-Limiting Toxicity
DNA
Deoxyribonucleic acid
ECG
Electrocardiogram
ECHO
Echocardiogram
ECOG
Eastern Cooperative Oncology Group
eCRF
Electronic Case Report Form
EOC
Epithelial Ovarian Carcinoma
ESMO
European Society for Medical Oncology
FDA
US Food and Drug Administration
FFPE
Formalin Fixed Paraffin Embedded
GCP
Good Clinical Practice
GMP 
Good Manufacturing Practice
HGSOC
High Grade Serous Ovarian Cancer
IB
Investigator’s Brochure
ICH
International Conference on Harmonisation
IEC
Independent Ethics Committee
IHC
Immunohistochemistry
IMP
Investigational Medicinal Product
INR
International Normalized Ratio
IUD
Intrauterine Device
IUS
Intrauterine Hormone-releasing System
IV
Intravenous
IWRS
Interactive Web Response System


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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LBM
Lean Body Mass
LD
Longest Diameter
LDH
Lactate Dehydrogenase
LVEF
Left Ventricular Ejection Fraction
MedDRA
Medical Dictionary for Regulatory Activities
MHRA
UK Medicine and Healthcare Products Regulatory Agency
MQ
Methylene Quinuclidinone
MRI
Magnetic Resonance Imaging
NCI
National Cancer Institute
NOAEL
No Observed Adverse Effect Level
PARP
Poly (adenosine diphosphate [ADP]) Ribose Polymerase
PD
Progressive Disease
PFI
Platinum-free Interval
PFS
Progression-free Survival
PiSARRO-R
p53 Suppressor Activation in Recurrent High Grade Serous Ovarian Cancer-Resistant
PK
Pharmacokinetics
PLD
Pegylated Liposomal Doxorubicin 
PR
Partial Response
PRIMA
p53 Reactivation and Induction of Massive Apoptosis
RECIST
Response Evaluation Criteria In Solid Tumors
SAE
Serious Adverse Event
SD
Stable Disease
SRC
Safety Review Committee
tid
Three Times Daily
ULN
Upper Limit of Normal
US
United States
WBC
White Blood Cell Count


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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1.0
GENERAL INFORMATION
1.1
Protocol Number and Title of the Study 
APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade Serous Ovarian Cancer, 
a Phase II Study of Systemic Pegylated Liposomal Doxorubicin Chemotherapy With APR-246
1.2
Sponsor
This study is being sponsored by Aprea Therapeutics AB.
Aprea Therapeutics AB
Nobels väg 3
SE-171 65 Solna 
Sweden
Tel.:+46(0)8 50884504
Fax: +46(0)8 52487022
1.3
Clinical Research Organization
Theradex® (Europe) Ltd
2nd Floor, the Pinnacle
Station Way, Crawley
West Sussex RH10 1JH
UK
Tel.: +44(0)1293 510319
Fax: +44(0)1293 510322
1.4
Coordinating Investigator 
Charlie Gourley
Edinburgh Cancer Research Centre
The University of Edinburgh
Crewe Road South
Edinburgh EH4 2XR
UK
Tel:  +44 (0)131 6518608
Fax: +44 (0)131 7773520


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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1.5
Safety Review Committee 
After the first six patients have been enrolled in the Main Study, and after the first six patients are 
enrolled in the Sub-Study, a Safety Review Committee (SRC) will evaluate the safety, tolerability 
and all other data concerning the action of APR-246 to determine should the study proceed to 
complete enrollment, or should an alternative dose and/or schedule be explored. The SRC will 
consist of: 
Medical Monitor (Theradex®), who will chair the committee, or delegate
Principal Investigator or delegate from each investigational site
Medical Monitor (Aprea Therapeutics AB) or delegate
The Study Pharmacokineticist, Project Managers and other technical experts may also be invited as 
appropriate. If required, a SRC Remit document will define the exact membership and who should 
be present for decisions to be made.
The decisions and decision-making of the SRC on dose and duration of APR-246 infusion will be 
documented and provided to the investigators prior to dosing any new patients.


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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2.0
INTRODUCTION AND RATIONALE FOR THE STUDY
The purpose of this phase II study is to evaluate the preliminary safety and efficacy of different
APR-246 infusion durations with systemic pegylated liposomal doxorubicin (PLD) chemotherapy in 
TP53-mutated high grade serous ovarian cancer (HGSOC) in patients with recurrent disease 
occurring between 4 weeks and 6 months after a preceding platinum-based treatment (platinum-
resistant patients). The study will also determine PK variables for APR-246. Patients will receive 
APR-246 with PLD chemotherapy.
2.1
Background Information
General Information
2.1.1
Aprea Therapeutics AB was founded in 2003 by the inventors Klas Wiman, Galina Selivanova, 
Vladimir Bykov, Staffan Strömblad, Wenjie Bao and Natalia Issaeva together with Karolinska 
Innovations AB. The company is aiming to develop targeted, specific drugs for the treatment of 
cancer by restoration of p53 function. 
The company has identified molecules that via p53-dependent pathways induce apoptosis in cancer 
cells with mutant or wild type p53. Aprea Therapeutics AB has since its inception confirmed the 
data in house and has screened for novel substances. The compound APR-246 has been selected as 
the company’s first candidate drug (CD).
The p53 Protein and APR-246
2.1.2
p53 was discovered in 1979 as a cellular protein that forms a complex with the viral large T protein 
in SV40-infected cells. Later studies showed that p53 was a tumor suppressor which could inhibit 
cell growth and trigger cell death by apoptosis. TP53, the p53 gene is mutated in almost half of all 
human tumors. The p53 status of a tumor may have a strong impact on sensitivity to commonly used 
anticancer drugs and radiotherapy [1].  Thus, p53 is an important clinical marker and also a novel 
therapeutic target. In contrast to other tumor suppressor genes, TP53 is typically inactivated by 
single missense mutations, which is accompanied by loss of the remaining wild type allele. As a 
rule, mutant p53 proteins are deficient for specific DNA binding suggesting that DNA binding and 
transcriptional regulation of target genes are critical functions for p53-mediated tumor suppression
[2].
The fact that TP53 is mutated in around 50% of human tumors, that mutant p53 protein usually 
accumulates at high levels, and that mutant p53-expressing tumors respond poorly to conventional 
therapy makes mutant p53 an attractive target for novel cancer therapy [3].  In hematological 
malignancies, between 5 and 20% of the patients carry a TP53 mutation in their malignant cell 
clone. However, for the current indication more than 95% of patients with HGSOC carry TP53 
mutations [4].


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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Recent studies have demonstrated that restoration of p53 in p53-deficient murine tumors triggers 
rapid and efficient elimination of the tumor through cell cycle arrest, senescence and/or apoptosis
[5]. This supports the idea that pharmacological reactivation of p53 should allow efficient 
elimination of tumors with minimal effects on normal cells.
The small molecule PRIMA-1 (p53 reactivation and induction of massive apoptosis-1; later denoted 
APR-017) was identified in a cellular screen for compounds that preferentially induce apoptosis in 
human tumor cells expressing exogenous mutant p53. Optimization of APR-017 resulted in the 
structural analogue APR-246, the IMP for this study. Treatment with APR-246 has been shown to 
restore sequence specific DNA binding, wild type conformation and transcriptional transactivation 
to mutant p53 protein. Furthermore, APR-246 has been shown to synergize with the DNA damaging 
anticancer agents, including platinum compounds and doxorubicin (see Investigator’s Brochure 
[IB]).
2.2
Disease Background
Ovarian cancer is the sixth most commonly diagnosed cancer among women in the world, at over 
60,000 cases per year, and causes more deaths per year than any other cancer of the female 
reproductive system [6]. Ovarian cancer has been of considerable interest to clinical cancer 
investigators due to the fact that it is among the most chemosensitive of all solid tumors [7]. The 
commonest histological subtype is HGSOC, which is the focus of this study.
First line management of HGSOC involves optimal debulking surgery and platinum/taxane 
combination chemotherapy. Although this often produces a radiological complete response, the 
majority of patients will subsequently relapse and eventually develop platinum resistance to which 
the patient will ultimately succumb. The 5-year survival rate remains poor at less than 40%. Thus, 
there is a need for improved treatment of relapsed ovarian cancer. 
Patients are generally retreated at relapse with platinum-based combinations unless the cancer 
relapses within 6 months of previous platinum-based chemotherapy (previously referred to as 
‘platinum resistant’). Patients who relapse within this timescale have poor prognosis and are often 
resistant to multiple chemotherapeutic agents [8]. Single-agent therapies used to treat this subset of 
patients include weekly paclitaxel, PLD and topotecan. The response rate is in the 10–15% range 
and overall survival is approximately 12 months [9].
HGSOC accounts for approximately 70% of epithelial ovarian carcinoma in Europe and North 
America [10].  Mutant TP53 is a hallmark of HGSOC, resulting in deregulation of cell cycle 
checkpoints and uncontrolled tumor cell proliferation and thus represents a key driver event. 
Pathogenic TP53 mutations have been quoted as occurring in up to 96% of patients with HGSOC
[4].
APR-246  has been shown to induce apoptosis and cell death in cancer cells with mutant or 
otherwise non-functional p53, and in addition to display strong synergistic anticancer effects in 
combination with several conventional chemotherapeutic drugs including platinum drugs and
doxorubicin [11, 12].


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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2.3
Choice of Patient Population
The study population will include patients with TP53-mutated HGSOC whose cancer recurs more 
than 4 weeks and less than 6 months after their last administration of platinum-based chemotherapy
and who, in the Investigator’s opinion, are still suitable for chemotherapy. Relapse should be 
verified radiologically.
On the basis of preliminary efficacy data from study APR-407 (Section 2.7.1), which recruited 
patients relapsing between 6 and 24 months after preceding platinum-based chemotherapy, there is a
strong scientific rationale to explore whether similar initial clinical responses could be observed in 
patients who progress 1-6 months after a preceding platinum regime.
2.4
Investigational Medicinal Product
The investigational medicinal product (IMP), APR-246 concentrate for solution for infusion 150 
mg/mL, contains APR-246, 2-(hydroxymethyl)-2-(methoxymethyl)-1-azabicyclo [2,2,2] octan-3-
one, is also called PRIMA-1Met in the literature, where PRIMA is an acronym for p53 reactivation 
and induction of massive apoptosis (see IB).
The APR-246 compound has a molecular weight of 199.24 g/mol, is a racemic mixture and is 
isolated as a white powder. The structure of APR-246 can be seen in Figure 1 below. 
Figure 1. Structure of APR-246
OH
N
O
OMe
The IMP should be stored at 2-8 C. The IMP is a concentrated solution which should be diluted 
with sterile 0.9% sodium chloride solution for infusion before administration. The solution for 
infusion should be prepared with the prescribed dosage for each patient in accordance with the 
protocol and separate technical instruction. After preparation of the ready-to-use solution for 
infusion, the pH of the solution will range from slightly above 4 up to approximately 4.8, depending 
on dosage. The infusion will be slightly hypertonic. The prepared APR-246 study product is to be 
stored at not more than 25 C. The infusion to the patient should be finalized within 24 hours from 
the time of preparation.
APR-246 is a prodrug that is converted to the active compound MQ, responsible for the anticancer 
effects of APR-246. APR-246 in physiological conditions is converted to MQ, which has been 


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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shown to bind to cysteines in mutant unfolded p53, stabilising the protein in a functional wild type 
conformation.
2.5
Preclinical Studies
Please refer to the IB for full details.
Primary Pharmacology of APR-246
2.5.1
APR-246 has demonstrated efficacy in various preclinical in vitro, ex vivo, and in vivo cancer 
models, as single substance as well as in combination with several conventional chemotherapeutics. 
In many of these models APR-246 has shown good potency and efficacy and unique 
pharmacological profile in comparison with conventional chemotherapeutic drugs.
APR-246 reduced cell viability in a dose-dependent manner being more potent in SaOS-2-His273 
cells, expressing mutant p53 than in TP53 null cells (lacking p53 expression). It also reduced cell 
viability in a large number of other cancer cell lines with different TP53 status. In ex vivo
experiments with primary cancer cells from patients with AML and ovarian cancer, APR-246 
reduced cell viability and, in contrast to conventional drugs, was effective also in TP53 mutant 
cancer cells.
A large number of solid cancer cell lines with various cisplatin sensitivity and TP53 status, were 
investigated in combination studies with APR-246 and cisplatin. In the various resistant cell lines 
tested, platinum compounds and doxorubicin showed resistance, while the sensitivity for APR-246
was considerably less affected. Strong synergistic (CI<0.5) effects with APR-246 were observed in 
all cell lines with homozygous hotspot TP53 mutations. These cell lines showed high levels of 
mutant p53 protein. Synergistic (CI<0.8) or strong synergistic (CI<0.5) effects were observed in 
cancer cell lines with frequently occurring TP53 mutations accumulating moderate levels of mutant
p53. Variable rather than strong synergistic combination effects were observed in the cell lines with 
wild-type p53 and in those in which full length p53 protein is not detectable.
These results are consistent with the proposed dual mechanisms of action of APR-246, and show 
that APR-246 can exert its anticancer effects both in cells carrying wild type p53 and cells carrying 
mutant p53. Hence, both p53 dependent and independent apoptotic effects contribute to its efficacy.
Strong synergistic effects were also observed with APR-246 and cisplatin in the cisplatin-resistant 
ovarian carcinoma cell line OVCAR-3, carrying the TP53 hotspot mutation R248Q. APR-246
resensitized the OVCAR-3 cancer cells to cisplatin as well as to the anthracycline doxorubicin; the 
IC50 value of cisplatin was decreased 5-fold. 
Strong synergistic effects of APR-246 the DNA-damaging compound doxorubicin was also seen in 
the doxorubicin-resistant A2780ADR ovarian cancer cell line. 


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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Safety Pharmacology of APR-246
2.5.2
APR-246 has been investigated for core safety pharmacology endpoints. The compound induced 
clinical signs indicating adverse reactions on CNS and the respiratory function, after bolus injection 
to mice or as short-term infusion in dogs. These effects were observed in direct connection with the 
dosing and were transient, with a rapid and full recovery after the end of the infusion or after the 
interruption of a non-tolerated dose at a stage of moderate CNS-related clinical signs. Irwin and 
rotarod tests in mice indicate that the CNS toxicity is due to the active moiety MQ and not to any of 
the two enantiomers of the prodrug APR-246.
The severity of clinical signs was directly correlated to the plasma levels. Independently of dose, 
infusion rate or infusion time the plasma threshold for inducing CNS adverse reactions was at least 
100 µg/mL. The infusion rate of 100 mg/kg/h induced no signs related to CNS or respiratory 
function at 200 mg/kg in two independent studies in dogs. Daily infusion for 9 h in 3 cycles of 7 
days at the rate of 100 mg/kg/h giving a total daily dose of 900 mg/kg/day induced no significant 
adverse reactions related to CNS or respiratory function. There were no cardiovascular effects at any 
dose level in a telemetric study and the hERG study was negative up to 100 µM. At the No 
Observed Adverse Effect Level (NOAEL) of 200 mg/kg given as a 30-minute infusion in the 
cardiovascular study the peak plasma level was 154 and 130 µg/mL in male and female dogs, 
respectively.
It was concluded that cardiovascular and respiratory effects induced by APR-246 were 
concentration dependent. No significant toxicity was observed when infusion was prolonged up to 9 
h at the rate of 100 mg/kg/h (900 mg/kg/day) reaching plasma concentrations around 120 µg/mL.
Pharmacokinetics
2.5.3
The pharmacokinetics of APR-246 have been studied using validated bioanalytical methods. The 
data demonstrate that APR-246 has a low protein binding across species. The terminal plasma half-
life was about 3 hours in mice and 2 to 5 hours in dogs. There were no gender differences regarding 
exposure or half-life. The exposure was reduced by approximately 50% in mice following a 4-week 
treatment compared with Day 1, whereas no clear time dependency on dose proportionality was 
observed in dogs in the corresponding 4-week study. Also in the cyclic study, the systemic exposure 
showed dose proportionality without gender deviations. However, exposure data in the cyclic study 
in dogs demonstrated generally lower exposure on Day 7 compared with Day 1 after each cycle. A
whole body quantitative autoradiography study in rat using carbon-14 labeled APR-246 showed that 
the radioactivity was rapidly distributed into the whole body, and was excreted both into the 
gastrointestinal tract and urine.


Aprea Therapeutics AB
Protocol No. APR-486
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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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Toxicology
2.5.4
APR-246 has been investigated for toxicology in agreement with existing regulatory guidelines for 
initiation of early clinical trials in patients with malignancies.
The data clearly demonstrate that APR-246 induces CNS toxicity in a dose- and rate-dependent
manner. The severity of clinical signs was found to be directly correlated to the plasma 
concentration. With an infusion rate of 400 mg/kg/h during 40 minutes, plasma levels around 400 
µg/mL were reached without mortality. Based on this carefully monitored additional dog study, the 
CNS toxicity window, from detected mild signs to severe signs, was found to be approximately 140 
to 400 µg/mL. Independently of dose, infusion rate or infusion time the plasma threshold for 
inducing CNS adverse reactions was at least 100 µg/mL. The CNS effects showed reversibility, for 
example after interruption of infusion after 40 minutes at the non-tolerated rate of 400 mg/kg/h, all 
animals recovered and had normal movements from 30 minutes after the infusion, whereas slight 
tremor and hypoactivity lasted longer with full recovery after 3 h.
It can be concluded that APR-246 induced clinical signs of adverse reactions when the compound 
was given at high dose levels as bolus injection or short-term infusion. The NOAEL of APR-246 in 
the 4-week repeat dose toxicity study in dogs given as a 2-hour infusion was 200 mg/kg/day. The 
mean systemic exposure at this dose level was 63.7 µg/mL (Cmax) and 129 µg·h/mL (AUC). The 
mean plasma level at the NOAEL of 200 mg/kg in the follow-up dog study was 114 µg/mL (Cmax). 
With prolonged infusion time at the infusion rate of 100 mg/kg/h, APR-246 was well tolerated at 
much higher daily dose concentrations given over 7-days in cycles. study.No significant toxicity and 
no target organ toxicity were observed at 900 mg/kg/day in the cyclic study. The mean Cmax varied 
between 61 to 185 µg/mL (males) and 65 to 190 µg/mL (females) during the study. The mean AUC 
on day 1 of the 3rd cycle was 1510 µg·h/mL (males) and was 797 µg·h/mL (females).
2.6
Previous Clinical Studies
The first clinical trial (APR-246-01) was conducted with APR-246 in patients with refractory 
hematological malignancies and prostate cancer. For further information please refer to the IB.
2.7
Rationale for Study in Platinum-Resistant HGSOC Population
HGSOC accounts for approximately 70% of epithelial ovarian carcinoma (EOC) in Europe and 
North America [10].
There are a number of active treatment options available for women with platinum-resistant EOC,
including weekly paclitaxel, PLD [14] and topotecan, but the ideal treatment is not known 
(European Society for Medical Oncology [ESMO] EOC guidelines [15]). A Cochrane systematic 
review of trials (n = 1323) with platinum-resistant EOC concluded that topotecan, paclitaxel and 
PLD have similar efficacy, but different patterns of side effects [16]. The SmPC dose for PLD in 
breast and ovarian cancer is 50 mg/m2 administered once every 4 weeks. A dose of 40 mg/m2/4 


Aprea Therapeutics AB
Protocol No. APR-486
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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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weeks will be used in this study, as this is the dose that is almost ubiquitously used in clinical 
practice and is the dose recommended by an international panel of experts [17].
APR-246 may offer an opportunity to improve current treatment of platinum-resistant HGSOC 
patients. The rationale for this derives from preclinical evidence that MQ (i.e., the active moiety of 
APR-246) induces apoptosis and cell death in cancer cells with mutant TP53 or otherwise non-
functional p53.
Preliminary APR-407 Results and Rationale for Selected APR-246 Dose and Infusion 
2.7.1
Time
The APR-407 study was designed to determine a safe dose level of APR-246 when administered in 
combination with carboplatin/PLD chemotherapy and to assess whether patients with platinum-
sensitive p53-mutated HGSOC benefit from this treatment. 
Platinum sensitive patients were 
selected based upon relapse between 6 and 24 months after preceding platinum-based 
chemotherapy.  APR-246 was administered intravenously (IV) in combination with carboplatin 
AUC5 and PLD 30 mg/m2 every 28 days at three dose levels based on mg/kg body weight:
35 mg/kg, 50 mg/kg and 67.5 mg/kg, to 27 women with HGSOC, previously treated with 
platinum-based antineoplastic agents.  Each treatment cycle was repeated every 28 days to a 
maximum of six treatment cycles.  
The first phase of study APR-407 was the dose confirmation component of the study; the primary 
study objectives were an assessment of safety and tolerability and an evaluation of the 
pharmacokinetics of APR-246, and the primary endpoints were dose-limiting toxicity and a safety 
assessment of the APR-246 and carboplatin/PLD combination together with limited 
pharmacokinetic profiles.
APR-246 67.5 mg/kg given as a 6-hour infusion was considered an appropriate dose for Phase II.
At the data cut-off point of 08 April 2017, over 60% of patients experienced nausea, dizziness and 
fatigue associated with the study treatment; these events were primarily mild to moderate (grade 1 
and 2) severity.  Treatment-related grade 3 or grade 4 neutropenia and vomiting were reported in 
37.1% and 14.3% of patients, respectively.  Other treatment-related grade 3 or greater TEAEs were 
reported in <10% patients.  This pattern of toxicity, except for the bone marrow suppression, was 
similar to that reported following treatment with APR-246 alone in study APR-246-01.
There is no evidence of a pharmacokinetic interaction between APR-246 and carboplatin or PLD 
and no evidence of consistent QTc prolongation at any of the explored dose levels.
Though not a study objective of APR-407, preliminary efficacy findings were similar to APR-246-
01, with 19 of 24 patients being progression free at 120 days, which is encouraging compared to 
what might have been expected from the carboplatin/PLD combination in this patient population. A 
randomized phase II component of APR-407 comparing carboplatin/PLD plus APR-246 to
carboplatin/PLD is underway in patients with platinum sensitive relapsed HGSOC.


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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A population pharmacokinetic analysis using data from the first two clinical studies has recently 
been conducted and the results show that the effects of body weight or lean body mass on the 
pharmacokinetics of APR-246 are limited and that dosing of APR-246 by a fixed dosing regimen 
can be supported (Appendix III).
The effect on exposure of shorter infusion time has also been investigated in an extended population 
pharmacokinetic analysis. This showed that shorter infusion durations will invariably lead to higher 
Cmax values and that a regimen achieving the lowest possible Cmax requires a more balanced split 
of the dose over the two infusion steps compared with the 6-hour infusion; for 3- and 4-hour 
infusion of 4500 mg, the ideal dose combinations are 2500 mg/2000 mg and 2200 mg/2300 mg for 
first/second infusion steps, respectively. These optimized 3- and 4-hour infusion regimens result in a 
Cmax that lies in between the two previously investigated dosing regimens, with the 3-hour infusion 
closer to the tolerated 2-hour constant infusion in the first-in-human study and the 4-hour infusion 
closer to the established 6-hour 2-step infusion (Figure 2). Further, a reduced dose 4-hour regimen 
(3700 mg split 1600mg/2100mg) yielding the same Cmax as the full dose given over 6 hours was 
constructed.
Figure 2: Simulated typical individual concentration time profiles, stratified by total infusion time.
The red lines in the three left most graphs show the simulated concentrations after a 45-minute infusion of 
2500 mg, 2200 mg and 1500 mg followed by a 2.25-, 3.25-, and 5.25-hour infusion of 2000 mg, 2300 mg and 
3000 mg for the 3-, 4-, and 6-hour total infusion time, respectively. The blue lines show the simulated 
concentrations obtained after a constant rate infusion of 60 mg/kg for 2 hours and 4500 mg for 3, 4 and 6 
hours, respectively. The red line in the right most graph corresponds to the current 6-hour regimen.
The APR-246 dose that will be used in the present study will be a fixed dose of 4.5 g. Since
APR-246 dose finding studies have not been performed in combination with PLD alone (without 
carboplatin), the planned dose level of APR-246 in the present study will be subject to SRC review
during the study.


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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2.8
Characteristics of a Well-Conducted Trial
The following characteristics of an adequate and well-conducted trial will be implemented:
1.
The Investigators will be well qualified by scientific training and experience.
2.
Detailed electronic case report forms (eCRFs) will be completed for every patient.
3.
Requirements for institutional ethics review as set forth by the appropriate Independent 
Ethics Committee (IEC), Title 21 Code of Federal Regulations (CFR) Part 56, the European 
Union Directive 2001/20/EC and its associated Detailed Guidances, European Union Good 
Clinical Practice (GCP)
Directive 2005/28/EC, the International Conference on 
Harmonisation (ICH) Guideline for Good Clinical Practice, Sections 3 and 4, and the terms 
of the Declaration of Helsinki (2013), will be followed.
4.
Requirements for informed consent in accordance with institutional guidelines, US Food and 
Drug Administration (FDA) requirements as specified in Title 21 CFR, Part 50, the 
European Union Directive 2001/20/EC and its associated Detailed Guidances, European 
Union GCP Directive 2005/28/EC, the ICH Guideline for Good Clinical Practice, Section 
4.8, and the terms of the Declaration of Helsinki (2013), will be followed.
5.
Safety data will be recorded and evaluated.
6.
Routine monitoring visits will be conducted by the Sponsor’s representative (Theradex ) to 
ensure data accuracy.
7.
APR-246 accountability will be strictly maintained.
8.
This trial will be conducted according to Good Clinical Practice (GCP), the protocol and 
applicable regulatory requirements.


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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3.0
TRIAL OBJECTIVES AND ENDPOINTS
3.1
Main Objectives and Endpoints
Primary Objective
3.1.1
To assess the preliminary efficacy of APR-246 with PLD chemotherapy in patients with 
platinum-resistant HGSOC with mutated TP53
Secondary Objectives
3.1.2
To evaluate the pharmacokinetics (PK) of APR-246 when administered with PLD 
chemotherapy
To evaluate cardiac safety of APR-246 when administered with PLD chemotherapy 
To assess the safety and tolerability of APR-246 with PLD chemotherapy in patients with 
platinum-resistant HGSOC with mutated TP53
To assess:
o
Duration of response (complete or partial response) 
o
Progression-free survival (PFS) by assessment of cancer antigen 125 (CA-125)
o
PFS by RECIST 1.1
To evaluate potential biomarkers and tumor activity based on CA-125
To assess the biological activity in tumor and surrogate tissues.
Primary Endpoints
3.1.3
Overall response rate according to RECIST 1.1
Secondary Endpoints
3.1.4
Secondary endpoints include the following:
PFS rate, defined as the time from registration to the time of disease progression or relapse 
(according to RECIST 1.1 only) or death, or the date of last tumor assessment without any 
such event (censored observation)
PK profile APR-246 and concentration in plasma


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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Cardiac profile of APR-246 and concentration of PLD
The safety profile (adverse events [AEs], laboratory assessments, physical findings and 
biomarkers) of APR 246 and PLD chemotherapy
Duration of response (complete or partial response) 
Progression-free survival (PFS) by assessment of CA-125
Evaluation of potential biomarkers
Biological activity in tumor and surrogate tissues.
3.2
Sub-Study Objectives and Endpoints
Sub-study Objectives: Same as Main Study Objectives, except safety and tolerability, in addition to 
preliminary efficacy, are Primary Objectives.
Sub-study Primary Endpoint for safety and tolerability: The safety profile (adverse events [AEs], 
laboratory assessments, physical findings and biomarkers) of APR 246 with a shorter infusion and 
PLD chemotherapy.


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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4.0
STUDY DESIGN
4.1
Overview of Study Design
This study is an open-label, multicenter phase II study to assess whether patients with platinum-
resistant TP53-mutated HGSOC will benefit from treatment with APR-246 and PLD chemotherapy. 
At least 25 evaluable patients will be included in this study. Patients may continue to receive 
treatment for as long as they are benefiting from it.
Different APR-246 infusion times will be explored.  The Main Study will assess the standard 6 hour 
APR-246 infusion whilst the Sub-Study will explore shorter infusions (3 or 4 hour).
All patients will have pre-screening IHC to determine p53 status and therefore eligibility. Archived
sections from the original tumor sample will be reviewed by a gynecological pathologist to confirm 
the diagnosis of HGSOC and positive IHC staining for p53. Patients without positive p53 staining 
will not be included.
Patients will receive standard 6 hour APR-246 infusion (fixed dose of 4.5 g APR-246) and PLD 
chemotherapy.
After evaluation of the first six patients with the standard 6 hour infusion, a 
subgroup of up to 25 additional patients will be given the APR-246 dose over a shorter infusion time
in order to evaluate this dosing schedule according to the same criteria as in the main study. The
sub-study will be conducted in parallel with the main study.
At follow-up visits after the end of treatment, radiological tumor assessments should be performed
every 8 weeks until protocol-defined progression occurs. For patients with stable disease, follow-up
will take place until disease progression or until death.
All scans for each individual patient should have the same modality (CT or MRI) but CT is 
preferred.
A safety review committee (SRC) will evaluate the first 6 patients who receive the standard 6 hour 
infusion and the first 6 patients in the sub-study, to determine whether further patients can be 
enrolled and receive the same APR-246 infusion duration, at the same dose.
4.2
Registration of Patients
Upon completion of all screening evaluations, the center will register the patient using the
Interactive Web Response System (IWRS). After successful completion of patient registration, a
registration number will be issued.
Once the patient is registered through the IWRS, the patient is considered enrolled in the study. 
Specific instructions for the central enrollment and registration procedures are provided to the center
in the study manual.
Registered patients will be assigned a unique patient identifier number. If a patient is withdrawn and
replaced (as described in Section 5.3), the patient identifier number will not be reused.


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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4.3
Shipment of p53 samples
All archived pathology samples will be sent for centralized p53 analysis after registration and 
following local analysis. Labeling and shipment procedures will be provided in a separate laboratory 
manual.
4.4
Drug Products
Investigational Medicinal Product, APR-246
4.4.1
The study substance APR-246 (2-(hydroxymethyl)-2-(methoxymethyl)-1-azabicyclo [2,2,2] octan-
3-one) is isolated as a white powder. APR-246 is prepared from quinuclidin-3-one in one reaction 
step using formaldehyde in methanol and in the presence of potassium carbonate (see IB). The IMP, 
APR-246 concentrate for solution for infusion, will be manufactured by Cobra BioPharma, Matfors,
Sweden.
Reference Product PLD
4.4.2
PLD will be supplied by the hospital’s pharmacy and will be administered in 28-day cycles.
4.5
Duration of Therapy
Patients will receive 28-day cycles of PLD chemotherapy with APR-246. Patients may continue to 
receive APR-246 with PLD for as long as in the Investigator’s opinion they are benefiting from 
treatment and in the absence of disease progression and unacceptable toxicity. After the tenth 28-day 
cycle, data from assessments conducted within each treatment cycle will no longer be collected, but 
patients may continue to receive treatment after confirmation from the sponsor.
4.6
End of Study
The end of the study is defined as the date of the last visit of the last patient taking part in the study.
4.7
Study Discontinuation by the Sponsor
For reasonable cause, either the Investigator or the Sponsor may terminate this study prematurely. 
Written notification of the termination is required. Conditions that warrant termination by the 
Sponsor include, but are not limited to:
The discovery of an unexpected, significant, or unacceptable risk to the patients enrolled in the 
study.
Failure of the Investigator to enter patients at an acceptable rate.
Insufficient adherence to protocol requirements (non-compliance).


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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Lack of evaluable and/or complete data.
Decision to modify the developmental plan of the drug.
A decision on the part of the Sponsor to suspend or discontinue development of the drug.
4.8
Treatment Plan for Patients after the Study
It is expected that patients will go on to receive treatment according to usual hospital practice.


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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5.0
SELECTION AND WITHDRAWAL OF PATIENTS
5.1
Inclusion Criteria
To be eligible to participate in this study, patients must meet all of the following inclusion criteria:
1.
Archived sections from the original formalin fixed paraffin embedded sample reviewed by a 
gynecological pathologist confirming HGSOC, high grade serous peritoneal cancer or 
primary fallopian tube cancer and positive immunohistochemistry staining for p53 assessed 
according to the local methodology (as detailed in the laboratory manual). Cases that do not 
show p53 staining will not be included. 
2.
Disease progression between 4 weeks and 6 months after the last platinum-based treatment 
was administered. 
3.
At least a single (RECIST 1.1) measurable lesion. 
4.
Adequate organ function prior to registration:
a) Bone marrow reserve
o
Absolute neutrophil count
9/L
o
9/L
o
b) Hepatic
o
Total bilirubin level < 1.5 x upper limit of normal (ULN) without hepatic metastasis,
and < 4 x ULN with hepatic metastasis
o
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) < 2.5 x ULN
without hepatic metastasis, and < 4 x ULN with hepatic metastasis
c) Renal
o
Calculated creatinine clearance > 30 mL/min calculated per local practice
d) Electrolytes 
o
Potassium within institutional normal ranges.
5.
Toxicities from previous cancer therapies (excluding alopecia) must have recovered to grade 
1 (defined by National Cancer Institute [NCI] Common Terminology Criteria for Adverse 
Events [CTCAE] version 4.0). Chronic stable grade 2 peripheral neuropathy secondary to 
neurotoxicity from prior therapies may be considered on a case by case basis by the Principal 
Investigator.
6.
If of childbearing potential, negative pretreatment serum pregnancy test.
7.
If of childbearing potential, willing to use an effective form of contraception (see below) 


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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during chemotherapy treatment and for at least 6 months thereafter. Such methods include the 
following (if using hormonal contraception, this method must be supplemented with a barrier 
method, preferably male condom):
combined (estrogen and progestogen containing) hormonal contraception associated with 
inhibition of ovulation:
o
oral
o
intravaginal
o
transdermal
progestogen-only hormonal contraception associated with inhibition of ovulation:
o
oral
o
injectable
o
implantable 
intrauterine device (IUD) 
intrauterine hormone-releasing system (IUS) 
bilateral tubal occlusion 
vasectomized partner 
true sexual abstinence when this is in line with the preferred and usual lifestyle of the 
subject. Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation 
methods), declaration of abstinence for the duration of a trial, and withdrawal are not 
acceptable methods of contraception.
8.
Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2 (Appendix I). 
9.
10. Signed informed consent.
5.2
Exclusion Criteria
1.
Prior exposure to cumulative doses of doxorubicin >400 mg/m2 or epirubicin >720 mg/m2.
2.
Confirmed cardiac history of any of the following: 
a) A myocardial infarct within 6 months prior to registration,
b) New York Heart Association Class II or worse heart failure (Appendix II)
c) A history of familial long QT syndrome
d) Clinically significant pericardial disease


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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e) Electrocardiographic evidence of acute ischemia 
f)
Symptomatic atrial or ventricular arrhythmias not controlled by medications
g)
three ECG readings using Fridericia’s  correction (QTcF = QT/RR0.33) 
h) Bradycardia (< 40 bpm)
i)
Left ventricular ejection fraction (LVEF) < the institution lower limit of normal as 
assessed by echocardiogram (ECHO).
3.
Major abdominal surgery or peritonitis within 6 weeks prior to study treatment.
4.
Unresolved bowel obstruction, subocclusive disease or the presence of brain metastases.
5.
Hypersensitivity to PLD or to any of the excipients.
6.
Unable to undergo imaging by either computed tomography (CT) scan or magnetic resonance 
imaging (MRI).
7.
Evidence of any other medical conditions (such as psychiatric illness, infectious diseases, 
neurological conditions, physical examination or laboratory findings) that may interfere with 
the planned treatment, affect patient compliance or place the patient at high risk from 
treatment related complications.
8.
Breast feeding. 
9.
Concurrent malignancy requiring therapy (excluding non-invasive carcinoma or carcinoma in 
situ).
10. Known HIV positive status, active hepatitis B or C status.
11. Is taking any concurrent (or within 4 weeks prior to registration) anti-cancer therapy, 
immunotherapy, radiotherapy, ancillary anti-cancer therapy, or any therapy that is considered 
to be investigational (i.e., used for non-approved indications(s) and in the context of a 
research investigation). Supportive care measures are allowed. Palliative limited radiation 
therapy for pain reduction is allowed.
5.3
Withdrawal of Patients and Study Termination
In accordance with the Declaration of Helsinki, each patient is free to withdraw from the study at 
any time without penalty or loss of benefits or other adequate treatments to which he/she is 
otherwise entitled. 
Investigators also have the right to withdraw patients from the study in the event of illness, AEs, or 
other reasons concerning the health or well-being of the patient, or in the case of lack of co-
operation. After withdrawal of a patient, the investigator is responsible for ensuring adequate 
treatment and follow-up, although every effort should be made to complete all assessments at an 
end-of-treatment visit as listed in Section 7.2.5.


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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Should a patient decide to withdraw after administration of the IMP, or should the investigators 
decide to withdraw the patient, all efforts will be made to complete and report the observations up to 
the time of withdrawal as thoroughly as possible. A complete final evaluation at the time of the 
patient’s withdrawal should be made and an explanation given of why the patient is withdrawing or 
being withdrawn from the study. 
The reason, time and date for withdrawal must be noted in the eCRF. If the reason for withdrawal is 
a clinical AE, monitoring will continue until the outcome is evident. The specific event must be 
recorded in the eCRF.
Patients who are withdrawn before completion of the first cycle of APR-246 and PLD as prescribed 
will be replaced.
The study treatment with APR-246 will be discontinued if any of the following situations occur (in 
the case of study termination by the Sponsor, patients will be allowed to continue to receive the 
standard of care):
1.
Progressive disease per RECIST 1.1 criteria. 
2.
The development of toxicity which precludes further study treatment. 
3.
Patient refusal.
4.
Lost to follow-up/noncompliance.
5.
Significant illness that can affect the patient’s ability to comply with study procedures.
6.
At the discretion of the Investigator.
7.
Pregnancy.
8.
Study termination by Sponsor.
5.4
Compliance with Study Procedures
Patients will receive the study treatment as outlined in Section 6.0. The details of the study treatment 
will be documented in the eCRF and IMP accountability forms as applicable.
All study treatment related procedures will be performed in the hospital or clinic by qualified health 
care personnel. All instances of noncompliance and all resulting protocol deviations will be recorded 
by the monitors during the routine monitoring visits in the Monitoring Report.


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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6.0
TREATMENT OF PATIENTS
6.1
Drug Supply and Handling Procedures
Investigational Medicinal Product, APR-246
6.1.1
The IMP will be manufactured according to Good Manufacturing Practice (GMP), and labeled 
according to GCP, GMP and the national requirements for each site.  The labels will comply with 
the legal requirements of the country. They will include storage conditions for the drug but no 
information about the study.
The IMP will be distributed in vials to the pharmacies of each participating study center. The 
APR-246 substance will be diluted in 0.9% sodium chloride solution at the appropriate 
concentration for infusion for each patient.
At the pharmacies, the IMP vials are to be stored at 2-8ºC. At the pharmacies and at the study 
centers, the prepared APR-246 study product (diluted in sodium chloride solution) is to be stored at 
not more than 25ºC. The infusion should be completed within 24 hours from the time of preparation 
(see Study Manual). 
Detailed instructions on vial concentration, preparation and dispensing can be found in the 
pharmacy file.
Pegylated Liposomal Doxorubicin Hydrochloride
6.1.2
PLD will be provided from the pharmacy stock. The PLD bag used for administration will be 
labeled according to the local routines and regulatory requirements. The hospital will be responsible 
for ordering PLD. The manufacturer and batch numbers will be documented.  
Please refer to the summary of product characteristics for further information on PLD.
6.2
IMP Accountability/Disposition of Clinical Trial Supplies
IMP accountability records will be maintained for all clinical trial supplies.
IMP accountability records will be kept at the pharmacy and at the study centers. The pharmacy 
must maintain accurate records demonstrating date and amount of IMP received, to whom and by 
who administered, and accounts of any IMP accidentally or deliberately destroyed.
The investigator is responsible for keeping records to ensure that:
Deliveries of IMPs are correctly received and recorded by a designated person.
Study medications are handled and stored safely and properly.
Study medications are dispensed only to study patients in accordance with the protocol.
All unused medication and empty containers are stored until they have been checked by the 


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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study monitor.
It is possible to reconcile records of all used and unused stocks as confirmed by the
investigator’s signature.
The IMP is the property of Aprea Therapeutics AB and must not be passed on to third parties. Any 
discrepancies between returned and expected returned IMP should be explained.
6.3
Main Study Treatment Administration
Starting within 28 days of registration, patients will receive a fixed dose of 4.5 g APR-246 (1.5 g of 
the dose during first 45 minutes followed by 3 g of the dose during 5 hours 15 minutes) on Days 1 to 
4 with PLD 40 mg/m2 on Day 4 (Figure 3). The PLD administration to be given on Day 4 only 
should commence 2 hours after the start of the APR-246 infusion.
Similarly for the following 28-day cycles, APR-246 will be administered on Days 1 to 4 with the 
PLD infusion on Day 4 starting 2 hours after the start of the APR-246 infusion.
Figure 3. Treatment Administration 
Note: The entire dose should be given even if the infusion needs to be extended beyond a total time of 6 hours (e.g. 
due to slightly larger start volume in prefilled infusion bags).
APR-246 Treatment Duration
Treatment will be repeated every 28 days in the absence of disease progression or unacceptable 
toxicity. Supportive therapy, including growth factors, can be given as per institutional standard of 
care.
Pegylated Liposomal Doxorubicin Dosing
The dose of PLD will be calculated based on the body surface of the patients at 40 mg/m2 as per 
standard practice at that hospital.
Study Day
-1 1
2
3
4
5 6
7 8
27 28 29 30 31 32 33 34
PLD
APR-246 6-hr IV 
infusion per day
PLD
APR-246 6-hr IV 
infusion per day


Aprea Therapeutics AB
Protocol No. APR-486
PiSARRO-R: p53 Suppressor Activation in Platinum-Resistant High Grade 
Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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6.4
Sub-Study Treatment Administration
Starting within 28 days of registration, patients will receive a fixed dose of 4.5 g APR-246 in a 
2-step infusion, starting with a loading dose given during first 45 minutes followed by slower 
infusion of the remainder of the dose, during 2 hours 15 minutes on Days 1 to 4, with PLD 40 
mg/m2 on Day 4 (Figure 4). The PLD administration to be given on Day 4 only should commence 
2 hours after the start of the APR-246 infusion.
Similarly for the following 28-day cycles, APR-246 will be administered on Days 1 to 4 with the 
PLD infusion on Day 4 starting 2 hours after the start of the APR-246 infusion.
Figure 4. Treatment Administration in Sub-Study
Note: The entire dose should be given even if the infusion needs to be extended beyond a total time of 3 hours (e.g. 
due to slightly larger start volume in prefilled infusion bags).
APR-246 Treatment Duration
Treatment will be repeated every 28 days in the absence of disease progression or unacceptable 
toxicity. Supportive therapy, including growth factors, can be given as per institutional standard of 
care.
Pegylated Liposomal Doxorubicin Dosing
The dose of PLD will be calculated based on the body surface of the patients at 40 mg/m2 as per 
standard practice at that hospital.
Sub-Study Doses and Infusion Times
6.4.1
Follow the flowchart for the Sub-Study (Figure 5), starting with 3 hr 4.5 g dose.  Switch to 4 hr 4.5 g
infusion or 4 hr 3.7 g infusion, as indicated, based on the occurrence of dose-limiting toxicities 
(DLTs).
Study Day
-1 1
2
3
4
5
6
7
8
27 28 29 30 31 32 33 34
PLD
APR-246 3-hr IV 
infusion per day
PLD
APR-246 3-hr IV 
infusion per day


Aprea Therapeutics AB
Protocol No. APR-486
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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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DLTs include:
Grade 4 thrombocytopenia lasting greater than 7 days
Grade 4 neutropenia lasting greater than 7 days
Other grade 4 hematological toxicities which last at least 5 days
Grade 3 or 4 febrile neutropenia
Grade 3 or greater non-hematological toxicities; these include grade 3 or greater diarrhea, 
nausea or vomiting despite adequate treatment which last greater than 3 days
Patients who are unable to be dosed for more than 5 weeks from the planned start date of the 
next cycle due to toxicity
Please refer to Section 6.5 for dose modification procedures.
Figure 5. Sub-Study Flowchart


Aprea Therapeutics AB
Protocol No. APR-486
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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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6.5
Dose Modifications for APR-246 due to Adverse Events During Infusion
If a 
-246 infusion, the infusion 
should immediately be stopped. The type, severity and duration of the adverse event should be 
carefully assessed as well as the relationship to APR-246.
If the adverse event is considered to be unrelated to APR-246, the infusion may be resumed within 2 
hours.
If the adverse event is considered to be related to APR-246, as long as all symptoms resolve to 
CTCAE Grade 1 or less within 2 hours, the infusion may be resumed. 
In case of re-challenge, the infusion should resume at the same infusion rate (the same dose per time 
unit) as the initial infusion. If no symptoms occur during re-challenge, the infusion can continue 
until the whole dose is given and the treatment can continue according to the protocol. 
If the same symptoms do occur or increase in severity during re-challenge the infusion should be 
stopped. 
If the event lasts longer than 2 hours, then the remainder of the APR-246 infusion for that day 
should be discarded. If the patient has recovered sufficiently by the next day, the remainder of the 
planned course should be administered. 
Main Study APR-246 Dose Reductions 
6.5.1
After an adverse event considered as related, a single level dose reduction of APR-246 is allowed. 
Dose reductions are defined in Table 1. If there is a further need for a patient to have another dose 
reduction, this should be discussed with the Sponsor prior to any treatment decisions. The type, 
severity and duration of the symptoms, adverse event and infusion timings (start and stop) should be 
carefully documented in the patient’s medical charts as per trial procedures.
Table 1. Dose Modifications of APR-246 in Main Study
Dose Modification
APR-246 Dose
Current Dose Level 
(DL)
APR-246 4.5 g
1.5 g (for first 45 minutes ) + 3 g (for 5 hours 15minutes)
First dose reduction 
DL-1
APR-246 4.0 g
1.33 g (for first 45 minutes) + 2.67 (for 5 hours 15 minutes)
Second dose DL-2*
APR-246 3.5 g
1.16 g (for first 45 minutes) + 2.34 g (for 5 hours 15 minutes)
The rationale behind this dose reduction scheme is the steep relation between Cmax and dose, e.g. the suggested 11.1%
and 22.2% reductions in dose results in 19.4% and 33.4% lowering of the average Cmax, respectively. See
alsoAppendix III.
* Discuss with Sponsor and or medical monitor before implementing this reduction.


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Sub-Study APR-246 Dose Reductions
6.5.2
After an adverse event considered as related, the infusion time may be extended to a total of 4 hours 
to achieve a reduced maximum blood concentration of APR-246. If a related adverse event occurs 
with the 4 hour infusion, APR-246 dose will be de-escalated. Dose reductions are defined in
Table 2. If there is a further need for a patient to have another dose reduction, this should be 
discussed with the Sponsor prior to any treatment decisions. The type, severity and duration of the 
symptoms, adverse event and infusion timings (start and stop) should be carefully documented in the 
patient’s medical charts as per trial procedures.
Table 2. Dose Modifications of APR-246 in Sub-Study
Dose Modification
APR-246 Dose and Regimen
Starting Regimen, 
3-hour infusion
APR-246 4.5 g
2.3 g (for first 45 minutes) + 2.2 g (for 2 hours 15minutes)
4-hour infusion
APR-246 4.5 g
2.0 g (for first 45 minutes) + 2.5 (for 3 hours 15 minutes)
4-hour infusion of 
reduced amount*
APR-246 3.7 g
1.6 g (for first 45 minutes) + 2.1 g (for 3 hours 15 minutes)
* Discuss with Sponsor and or medical monitor before implementing this reduction.
6.5.2.1
APR-246 Infusion and Systemic PLD Chemotherapy Delays
The Day 1 to 4 APR-246 administration, together with the Day 4 PLD chemotherapy, is to be 
regarded as one treatment cycle and must not be administered separately. 
On Day 1, prior to APR-246 administration, the hematological status of the patient should be 
assessed. If the patient has any hematological AE that would prevent systemic chemotherapy 
administration on Day 4, the APR-246 infusion and systemic chemotherapy should be delayed until 
recovery. 
If a patient has any AE on Day 2, 3 or 4 prior to the APR-246 infusion which, in the opinion of the 
Investigator, would prevent systemic chemotherapy administration, the remainder of the planned 
APR-246 administration should be stopped. Once the patient has recovered sufficiently to receive 
chemotherapy, the whole treatment cycle (consisting of Days 1-4 APR-246 and Day 4 
chemotherapy) should be restarted as previously planned. 
If APR-246 and/or systemic chemotherapy are delayed, the reasons for delay should be recorded in 
the eCRF.


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Dose Modifications for PLD 
6.5.3
For typical hematological and non-hematological AEs seen with PLD the dose modifications should 
be according to the current summary of product characteristics. However, if any AEs occur that are 
not typical or that are considered unusual, the Sponsor should be consulted prior to re-treating the 
patient.
If due to AEs the patient is unable to continue chemotherapy with PLD, the patient may continue 
monotherapy APR-246 if the following criteria are met:
Latest radiological scans show evidence of response.
Patient is evaluated as not having symptoms suggestive of progressive disease.
The Investigator assessment is that APR-246 monotherapy is of continued benefit to the 
patient.
APR-246 administration has been approved by the Sponsor.
Cardiac Safety Monitoring in Relation to Treatment With PLD
6.5.4
Whenever cardiomyopathy is suspected, i.e., the LVEF has substantially decreased relative to 
pretreatment values and/or LVEF is lower than a prognostically relevant value (e.g., < 45%), the 
benefit of continued therapy must be carefully evaluated against the risk of developing irreversible 
cardiac damage. Cardiology consultation is recommended. Local practice should be followed.
Previous clinical trial experience with PLD for the treatment of ovarian cancer has been summarized 
and may be a useful reference [18].
Action to be Taken in the Event of QT/QTc Prolongation
6.5.5
Although the risk of QT/QTc prolongation is considered to be very low, in the event of prolongation 
of the QT/QTc interval > 500 msec or an increase of > 60 msec over baseline, study treatment 
should be discontinued and appropriate close (continuous) ECG monitoring in a hospital setting 
should be initiated until the opinion of a cardiologist is obtained.
Treatment of APR-246-Related Adverse Events of the CNS 
6.5.6
If a patient reports any clinical AE of any grade during the administration period of APR-246 that 
could be considered to originate from the CNS (e.g., dizziness, vertigo or nausea), then the 
following medications may be used (Table 3). Medications of a similar nature to reflect local 
practice may be used.


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Table 3. Examples of Rescue Medications for Use With APR-246
Indication
Supportive Measure
CNS symptoms (treatment and prevention)
Prochlorperazine 10 mg orally tid a
Start Day -1 prior to APR-246 administration
Persistent CNS symptoms
Cyclizine 50 mg IM 
a Prochlorperazine 10 mg orally tid (three times daily). To continue until end of Day 4 of the cycle. When used 
prophylactically for future treatment, start the day prior to the Day 1 administration of APR-246.
If during the infusion the patient continues to remain symptomatic intramuscular administration of 
cyclizine 50 mg should be considered.
6.6
Concomitant Treatment and Prohibited Medication
Patients are allowed to receive supportive care therapies (including cytokine growth factors) 
concomitantly during the trial.  
No anti-cancer therapy other than that given in this clinical trial;  no immunotherapy; no hormonal 
cancer therapy; no radiation therapy (except palliative); and no experimental medications are 
permitted during the trial. No PARP inhibitors are permitted after a beneficial response to study 
therapy.
Radiation therapy to index lesions should be avoided where possible; when deemed essential for 
patient well-being, the sponsor must be informed as the patient will become non-evaluable for 
endpoints assessed by RECIST, i.e. response rate and PFS.
Concomitant use of paracetamol-based compounds is allowed. However, caution should be taken 
when co-administrating APR-246 with high doses of paracetamol (i.e., 4 g/24 h). Use of 
paracetamol must be terminated if any liver function tests increase above normal ranges.
Any disease progression that requires other specific antitumor therapy will be cause for 
discontinuation from the trial.
Anticoagulant Therapy: Patients who are taking warfarin may participate in this trial; however, it is 
recommended that prothrombin time (international normalized ratio [INR]) is monitored carefully at 
least once per week for the first month, then monthly if the INR is stable. Subcutaneous heparin is 
permitted.
Concurrent or procedural medications or therapy given to or taken by the patient will be recorded in 
the CRF along with the indication. All concomitant medication should be recorded for up to 30 days 
following the last protocol treatment. After this period, only relevant medication (e.g., medication in 
patients with treatment-related AEs) will be recorded in the CRF.
Both generic and trade names may be recorded. However, the generic name is generally preferred 
because of its specificity, whereas trade names are preferred for combination products.


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The potential interaction of APR-246 with other medicinal products has not been investigated.
6.7
Contraception
Female patients of childbearing potential (defined as < 2 years after last menstruation and not 
surgically sterile) must use a highly effective method of contraception resulting in a low failure rate 
(i.e., less than 1% per year) during chemotherapy treatment and for at least 6 months thereafter. 
These methods of contraception according to the note for guidance on non-clinical safety studies for 
the conduct of human trials for pharmaceuticals (CPMP/ICH/286/95, modification) include 
consistent and correct use of hormone containing implants and injectables, combined oral 
contraceptives, hormone containing IUDs, true sexual abstinence when this is in line with the 
preferred and usual lifestyle of the subject and partner with vasectomy. Periodic abstinence (e.g., 
calendar, ovulation, symptothermal, post-ovulation methods), declaration of abstinence for the 
duration of a trial and withdrawal are not acceptable methods of contraception.


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7.0
STUDY PROCEDURES
7.1
Schedule of Study Procedures
Study evaluations are summarized in Table 4 below and described in Sections 7.2 through 7.2.7.
The Principal Investigator is responsible for ensuring that all staff involved in the study are familiar 
with the content of this section.


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Table 4. Schedule of Study Evaluations 
Pretreatment1
Cycle 1 
Cycle 2 and Subsequent Cycles 
EoT 
FU12
Day
1
2
3
4
5
19
1
2
3
4
25-28
Eligibility Criteria 
X
Registration / Informed Consent
X
Medical History 
X
X*
Tumor Assessment
X
X6
X
X
Physical Exam / ECOG
X
X
X
X
Vital Signs
X
X
X
X
X
X**
X
X
X
X
Hematology
X
X*
X**
X**
X*
Coagulation
X
X*
X*
Blood Chemistry
X
X*
X**
X*
Creatinine Clearance
X
CA-125
X
X*
X*
X
X
Urinalysis
X
X*
X*
Serum Pregnancy Test (Females of 
Childbearing Potential)
X
LVEF2
X
X2
ECG in selected patients, at sites 
given Mortara 12-lead recorder
X
X
X3,4
X**4
X*4
X
ECG in selected patients, at sites 
given Holter4
12-lead
24h 
Holter
24h 
Holter
12-lead
ECG, non-selected patients
X
X
Tumor Biopsy5
X
X
Exploratory Biomarkers – Whole 
Blood
X7
Exploratory Biomarkers – Plasma 
X8
X8
X
X9


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Pretreatment1
Cycle 1 
Cycle 2 and Subsequent Cycles 
EoT 
FU12
Day
1
2
3
4
5
19
1
2
3
4
25-28
Administer APR-246
X
X
X
X
X
X
X
X
Administer PLD
X
X
Pharmacokinetics10
X
X4
X
X4
X
X
New anticancer treatment11
X
Adverse Events and Concomitant 
Medication13
X
X
Examinations marked * need not be repeated if already performed within +/-3 days prior to Day 1. 
Examinations marked ** may be performed within +/-2 days.
1.
Pretreatment evaluations to be performed within 28 days prior to Day 1. 
2.
LVEF assessed by echocardiography. At pretreatment and within 7 days prior to the start of Cycle 3 and Cycle 6 and every 3rd cycle thereafter.  In addition, evaluation of 
LVEF is mandatory before each additional administration of PLD that exceeds a lifetime cumulative anthracycline dose of 450 mg/m2.
3.
Optional rhythm strip performed using limb leads of 12-lead ECG machine, after the end of APR-246 infusion.
4.
These assessments will be discontinued once sufficient evaluable data has been collected.
5.
An optional tumor biopsy to be performed prior to Day 1 APR-246 infusion and on Cycle 1 Day 3, as per laboratory manual.
6.
CT scan/MRI at the end of Cycle 2 (within 4 days prior to the start of Cycle 3), and at the end of Cycle 4 (within 4 days prior to the start of Cycle 5) and every two cycles 
thereafter. In patients who have discontinued therapy without progression, scans will be performed every 8 weeks until progression has occurred.
7.
Blood sample taken within 72 hours of pretreatment biopsy.
8.
Blood sample taken before infusion of APR-246 in Cycles 1, 2 and 6.
9.
Blood samples should be taken at each follow-up visit before progression and at progression, as per laboratory manual.
10. Pharmacokinetics: please refer to Section 8.4.
11. New anticancer treatment to be collected in eCRF during follow up.
12. Follow-up visits should be performed at least every 8 weeks.
13. AEs will be collected throughout the study, from informed consent until 30 days after the last administration of study treatment.


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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
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7.2
Detailed Study Evaluations 
The following sections provide details of the study evaluations to be conducted pretreatment, during
study and in follow-up. Please refer to Table 4 for a complete schedule of assessments required.
Registration/Informed Consent Form
7.2.1
Prior to performing any procedures or assessments, the nature of the study and the potential risks 
associated with the trial will be explained to all subject candidates and written informed consent will 
be obtained. Subjects who choose to participate will have to consent to the biobanking program and 
will be asked to sign the mandatory section in the main study consent form related to biobank 
samples. Evaluations obtained as part of routine medical care and performed during the screening 
period may be used in place of the study-specific evaluations. Subjects will acknowledge and agree 
to the possible use of this information for the study by giving informed consent.
Pretreatment
7.2.2
All pretreatment evaluations are to be performed within 28 days prior to Day 1 unless otherwise 
noted. Please see Table 4 for treatment windows for individual evaluations.
Eligibility criteria: Including archived tumor sample review for positive IHC staining for 
p53.
Registration.
Medical history. Including documentation of all previous therapies for ovarian cancer.
Tumor assessment: CT scan/MRI to be performed within 4 weeks prior to Day 1. 
Physical examination: Height, weight, body surface area and description of external signs 
of cancer. To be performed by an authorized investigator or nurse.
ECOG performance status.
Vital signs: Heart rate, blood pressure, respiratory rate and temperature. 
Hematology: Hemoglobin, hematocrit, mean corpuscular volume, platelet count, white 
blood cell count (WBC) and WBC differentials.
Coagulation: INR and activated partial thromboplastin time (APTT). If patient is receiving 
warfarin, assessments should be done weekly. 
Blood chemistry: Sodium, potassium, calcium, magnesium, chloride, glucose, creatinine, 
total bilirubin, AST, ALT, urea, total protein, albumin and lactic dehydrogenase (LDH),
direct bilirubin and uric acid.  
Creatinine clearance: Calculated as per hospital practice.
CA-125.
Urinalysis: Dipstick for protein, glucose, bilirubin and blood (perform microscopy if more 
than one positive dipstick test).
Serum pregnancy test: For patients with reproductive potential.
LVEF: Assessed by echocardiography.
ECG: Standard 12-lead ECG, taken in triplicate (use Mortara ELI 150RX 12 lead ECG 


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Recorder if provided).
Tumor biopsy (optional): To be performed prior to Day 1 APR-246 infusion, as per 
laboratory manual.
Exploratory biomarkers: Whole blood sample taken within 72 hours of pretreatment 
biopsy. The sample will be collected in order to sequence target genes of germline DNA. 
Archive pathology samples and blood samples to be sent for centralized analysis after 
registration. Refer to Laboratory Manual for detailed instructions. 
AEs: From the date the Informed Consent form is signed. 
Concomitant medication.
Registration 
7.2.3
This is performed per Section 4.2. Patients should be treated within 28 days of registration.
All Cycles, Days 1-28
7.2.4
Day 1 examinations marked * do not need to be repeated if already performed within +/-3 days prior 
to Day 1. Examinations marked ** may be performed within +/- 2 days. 
Medical history: Day 1*
Physical examination: Day 1. Height, weight, body surface area and description of external 
signs of cancer. To be performed by an authorized investigator or nurse.
ECOG performance status: Day 1. 
Vital signs: Days 1, 2, 3 and 4.  Only on Cycle 1 perform also on day 19**. Heart rate, blood 
pressure, respiratory rate and temperature. 
Hematology: Cycle 1 performed on Days 1*, 4** and 19** (repeat to follow up on AEs as 
appropriate). Subsequent cycles perform only on Day 1*. Hemoglobin, hematocrit, mean 
corpuscular volume, platelet count, WBC and WBC differentials.
Coagulation: Day 1* INR and APTT. If patient is receiving warfarin, assessments should be 
done weekly. 
Blood chemistry: Cycle 1 perform on Days 1* and 4** (repeat to follow up on AEs as 
appropriate). Subsequent cycles perform only on Day 1*. Sodium, potassium, calcium, 
magnesium, chloride, glucose, creatinine, total bilirubin, AST, ALT, urea, total protein, 
albumin and LDH, direct bilirubin and uric acid.  
CA-125: Day 1*.
Urinalysis: Day 1*. Dipstick for protein, glucose, bilirubin and blood (perform microscopy 
if more than one positive dipstick test).
LVEF: Assessed by echocardiography within 7 days prior to Cycle 3 and Cycle 6 and every 
3rd cycle thereafter. LVEF is mandatory before each additional administration of PLD that 
exceeds a lifetime cumulative anthracycline dose of 450 mg/m2.
Tumor biopsy: Cycle 1 only (optional). Tumor biopsy performed optimally at the end of 
APR-246 infusion on Day 3 of the first cycle, however a biopsy obtained at the end of the 


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APR-246 infusion on Day 2 is acceptable. Refer to Laboratory Manual for detailed
instructions.
Exploratory biomarkers: Blood samples taken before infusion of APR-246 on Day 1 of 
Cycles 1, 2 and 6. The plasma samples will be collected in order to analyze circulating tumor
DNA. Refer to Laboratory Manual for detailed instructions.
APR-246 administration: Days 1, 2, 3 and 4.
PLD chemotherapy administration: Day 4. 
AEs: Even though premedicated, patients should be closely monitored for hypersensitivity 
reactions, especially during the first cycle.
Concomitant medications.
Tumor assessments: CT scan/MRI at the end of Cycle 2 (within 4 days prior to the start of 
Cycle 3), at the end of Cycle 4 (within 4 days prior to the start of Cycle 5) and at the end of 
every two cycles of treatment thereafter. In patients who have discontinued therapy without 
progressive disease CT/MRI scans should be performed every 8 weeks until radiological 
progression.
ECG in selected patients: Only at centers provided with Mortara ELI 150RX 12 lead ECG 
Recorder. 12-lead ECG, taken in triplicate:
o
Cycle 1 Day 1
o
Cycle 1, Day 4, optional, rhythm strip performed using limb leads of the 12-lead 
ECG machine, after the end of APR-246 infusion
o
Cycle 1 Day 19**
o
From Cycle 2 onwards performed on Day 1* each cycle
All recordings must be reviewed, dated and signed by the Investigator or an authorized 
subinvestigator. Refer to Laboratory Manual for detailed instructions.
12-lead continuous ECG Holter† in selected patients: Only at centers provided with H12+ 
Holter Recorder. Cycle 1 only. Recorded for 24 hours, start prior to APR-246 administration 
on Day 1 and Day 4. Refer to Laboratory Manual for detailed instructions.
Pharmacokinetics: At centers provided with H12+ Holter Recorder and Mortara ELI 
150RX 12 lead ECG Recorder. Sampling for APR-246 in Cycle 1 on Day 1, 2, 4 and 5
(see Table 8); then sparse sampling for APR-246 on Day 1 and Day 4 from Cycle 2 onwards 
(see Table 9).†
Pharmacokinetics: In all other patients: sparse sampling for APR-246 on Day 1 and Day 4 
of all cycles (see Table 9).
† These assessments will be discontinued once sufficient evaluable data has been collected.
End of Treatment Visit
7.2.5
The end of treatment visit should take place 30 days (+/- 2 days) after the last APR-246 dose.
Tumor assessment: CT scan/MRI. Tumor assessment should be performed at end of 


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treatment.
Physical examination: Height, weight, body surface area and description of external signs 
of cancer. To be performed by an authorized investigator or nurse.
ECOG performance status.
CA-125.
ECG: Standard 12-lead ECG, taken in triplicate (use Mortara ELI 150RX 12 lead ECG 
Recorder if provided).
Exploratory biomarkers: Blood sample to analyze circulating tumor DNA. Refer to 
Laboratory Manual for detailed instructions.
Follow-up Visits
7.2.6
Follow-up visits should be performed at least every 8 weeks after the End of Treatment visit.
Tumor assessment: CA-125 assessment and CT/MRI scans should be performed every 8 
weeks until disease progression.
Exploratory biomarkers: Blood samples taken at each visit before progression and at 
progression to analyze circulating tumor DNA. Refer to Laboratory Manual for detailed 
instructions.
After Progression
7.2.7
Survival after progression will be monitored every 6 months until death. This can be done remotely 
(e.g., via telephone, via general practitioner or via review of medical records).
7.3
Adverse Events
Definition of Adverse Events
7.3.1
An AE is the development of an undesirable medical condition or the deterioration of a pre-existing 
medical condition following or during exposure to a pharmaceutical product, whether or not 
considered causally related to the product. An undesirable medical condition can be symptoms (e.g., 
nausea, chest pain), signs (e.g., tachycardia, enlarged liver) or the abnormal results of an 
investigation (e.g., laboratory findings, ECG). In clinical studies, an AE can include an undesirable 
medical condition occurring at any time, including run-in or washout periods, even if no study 
treatment has been administered.
Any deterioration of the disease under study and associated symptoms or findings should not be 
regarded as an AE as far as the deterioration can be anticipated (see Section 7.3.4.8).
The term AE is used generally to include any AE whether serious or non-serious.


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Definitions of Serious Adverse Events
7.3.2
A serious adverse event (SAE) is an AE occurring during any study phase (i.e., run-in, treatment, 
washout, follow-up) that fulfills one or more of the following criteria:
Results in death
Is immediately life-threatening (i.e., the patient was at risk of death at the time of the event; 
it does not refer to an event which hypothetically might have caused death if it was more 
severe)
Requires in-patient hospitalization or prolongation of existing hospitalization
Results in persistent or significant disability/incapacity or substantial disruption of the ability 
to conduct normal life functions
Is or results in a congenital abnormality or birth defect
Is an important medical event (may not be immediately life-threatening or result in death or
hospitalization) that may jeopardize the patient or may require medical intervention to 
prevent one of the outcomes listed above.
For further guidance on the definition of a SAE, see Section 7.3.4.10 below and Appendix IV.
SAE Exceptions
7.3.3
The following scenarios that may lead to hospitalization should not be considered SAEs:
o
Routine treatment or monitoring of the disease under study, including hospitalization 
due to trial related procedures (e.g. APR-246 administration) not associated with any 
deterioration of the patient’s status;
o
Elective treatment (planned before signing Informed Consent) for a pre-existing 
condition that is unrelated to the disease under study and has not worsened since 
signing Informed Consent;
o
Treatment on an emergency outpatient basis for an event not fulfilling any of the 
definitions for an SAE;
o
Social reasons, respite care in the absence of a medical condition 
Recording of Adverse Events
7.3.4
7.3.4.1
Time Period for Collection of Adverse Events
AEs will be collected throughout the study, from informed consent until 30 days after the last 
administration of study treatment.   
SAEs occurring in this period should be reported to the Theradex® Safety Desk in the usual manner 
(see Section 7.3.5).


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7.3.4.2
Follow-up of Unresolved Adverse Events
All AEs should be followed until they are resolved or until the EOT visit, whichever comes first. All 
AEs that are still ongoing after the EOT visit, should be followed on a regular basis, according to 
the investigator’s clinical judgment, until the event has resolved or until the investigator assesses it 
as chronic and all queries have been resolved. After the EOT visit, AEs that are unrelated to 
APR-246 (serious or non-serious) or related but not serious, do not require further recording in the 
eCRF. For Related SAEs that resolve, the date the event resolved and the outcome of Resolved or 
Resolved with sequelae, as appropriate, should be recorded on the eCRF and the SAE Report Form. 
The Sponsor retains the right to request additional information for any patient with ongoing AE(s) at 
the end of the study, if judged necessary.
If an Investigator learns of any SAEs, including death, at any time following 30 days after the last 
administration of study treatment and he/she considers there is a reasonable possibility that the SAE 
is related to the study treatment, the Investigator should notify Theradex® Safety Desk.
7.3.4.3
Variables
The following variables will be collected for each AE: 
AE diagnosis/description
The date the AE started and stopped
CTCAE version 4.0 grade
Whether the AE is serious or not and the reason(s) it is serious
Investigator causality rating against the investigational product (yes or no) 
Action taken with regard to study treatment
Outcome.
For SAEs, other variables will be collected including treatment given for the event.
It is important to distinguish between serious and severe AEs.  Severity is a measure of intensity 
whereas seriousness is defined by the criteria in Section 7.3.2.  An AE of severe intensity need not 
necessarily be considered serious. For example, nausea that persists for several hours may be 
considered severe nausea, but not a SAE.  On the other hand, a stroke that results in only a limited 
degree of disability may be considered a mild stroke but would be a SAE.
The grading scales found in the current National Cancer Institute CTCAE version 4.0 will be 
utilized for all events with an assigned CTCAE grading.  For those events without assigned CTCAE 
grades, the recommendation in the CTCAE criteria that converts mild, moderate and severe events 
into CTCAE grades should be used. A copy of the current CTCAE version can be downloaded from 
the Cancer Therapy Evaluation Program web site (http://ctep.cancer.gov).


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7.3.4.4
Causality Collection
The Investigator will assess causal relationship between investigational product and each AE, and 
answer ‘yes’ or ‘no’ to the question: ‘Do you consider that there is a reasonable possibility that the 
event may have been caused by the study treatment?’
For SAEs, causal relationship will also be assessed for other medications and study procedure(s).  
Note that for SAEs that could be associated with any study procedure the causal relationship is 
implied as ‘yes’.
A guide to the interpretation of the causality question is found in Appendix IV.
7.3.4.5
Adverse Events Based on Signs and Symptoms
All AEs spontaneously reported by the patient or reported in response to the open-ended and non-
leading verbal questioning from the study personnel (e.g., “How are you feeling?”, “Have you had 
any health problems since the previous visit/you were last asked?”), or revealed by observation will 
be collected and recorded in the eCRF. Where possible a diagnosis should be recorded, rather than 
recording a list of signs and symptoms.  However, if a diagnosis is known and there are other signs 
or symptoms that are not generally part of the diagnosis, the diagnosis and each sign or symptom 
will be recorded separately.
7.3.4.6
Adverse Events Based on Examinations and Tests
The results from protocol-mandated laboratory tests, vital signs, ECGs and other safety assessments 
will be summarized in the clinical study report. Deterioration as compared to pretreatment in these 
parameters will therefore only be reported as AEs if they fulfill any of the criteria for a SAE, dose-
limiting toxicity (DLT) or are the reason for modifying the study treatment unless clearly due to 
progression of disease under study (see Section 7.3.4.8).
If deterioration in a laboratory value, vital sign, ECG or other safety assessment is associated with 
clinical events, the clinical event will be reported as an AE and the associated laboratory result or 
other finding will be considered as additional information. Wherever possible the reporting 
Investigator will use the clinical, rather than the laboratory term (e.g., anemia versus low 
hemoglobin value). In the absence of clinical events, clinically relevant deteriorations in non-
mandated parameters should be reported as AEs.
Deterioration of a laboratory value that is unequivocally due to disease progression should not be 
reported as an AE.
Any new or aggravated clinically relevant abnormal medical finding at a physical examination as 
compared with the pretreatment assessment will be reported as an AE.


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7.3.4.7
Hy’s Law
Cases where a patient shows elevations in liver biochemistry may require further evaluation and 
may need to be reported as SAEs if serious criteria are met. Please refer to Appendix V for further 
instruction on cases of increases in liver biochemistry and evaluation of Hy’s Law.
7.3.4.8
Disease Symptomatic Management and Disease Progression
Events that are unequivocally due to the patient’s underlying cancer, that occur after informed 
consent but before the patient is registered, should not be reported as an AE or an SAE.
Disease progression can be considered as a worsening of a patient’s condition attributable to the 
disease for which the investigational product is being studied.  It may be an increase in the severity 
of the disease under study and/or increases in the symptoms of the disease. The development of 
new, or progression of existing metastasis to the primary cancer under study should be considered as 
disease progression and not an AE.  Events that are unequivocally due to disease progression 
should not be reported as AEs during the study.
7.3.4.9
New Cancers
The development of a new cancer should be regarded as an AE and will generally meet at least one 
of the serious criteria. New cancers are those that are not the primary reason for the administration 
of the study treatment and have been identified after the patient’s inclusion in this study. They do 
not include metastases of the original cancer.
7.3.4.10 Handling of Deaths
All deaths that occur during the study, or within the follow-up period after the administration of the 
last dose of investigational product, should be reported as follows:
Death which is unequivocally due to disease progression should be communicated to the study 
monitor at the next monitoring visit and should be documented in the eCRF module, but should 
not be reported as a SAE during the study
Where death is not clearly due to disease progression of the disease under study, the AE causing 
the death should be reported to the Theradex® Safety Desk as an SAE within 24 hours. The 
report should contain a comment regarding the co-involvement of progression of disease, if 
appropriate, and should assign a single primary cause of death together with any contributory 
causes
Deaths with an unknown cause should always be reported as a SAE but every effort should be 
made to establish a cause of death. A post-mortem may be helpful in the assessment of the cause 
of death and, if performed, a copy of the post-mortem results (with translation of important parts 
into English) should be reported in an expedited fashion to the Theradex® Safety Desk within the 
usual timeframes.


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Reporting of Serious Adverse Events
7.3.5
All SAEs have to be reported to the Theradex® Safety Desk, whether or not considered causally 
related to the investigational product or to the study procedure(s). All SAEs will be recorded in the 
eCRF.
If any SAE occurs in the course of the study, then Investigators or other site personnel must inform 
the Theradex® Safety Desk immediately or no later than 24 hours of when he or she becomes 
aware of it.
For fatal or life-threatening AEs where important or relevant information is missing, active follow 
up is undertaken immediately. Investigators or other site personnel must inform the Theradex®
Safety Desk of any follow-up information on a previously reported SAE immediately, or no later 
than 24 hours of when he or she becomes aware of it.
All SAEs require that a Serious Adverse Event Report Form be completed and forwarded either via 
fax or as a PDF via e-mail to the Theradex® Safety Desk at the fax number or e-mail address listed 
below within 24 hours of becoming aware of the event. The fax and telephone numbers listed below 
may be used during both business and non-business hours. During non-business hours, a recorded 
message will provide the caller with the contact information for the on-call monitor.
Report SAEs to:
Theradex® (Europe) Ltd. Safety Desk
Telephone: +44 (0) 1293 510 319
Fax: +44 (0) 1293 510322
E-mail: 
SafetyDeskEurope@theradex.co.uk
SAEs will be reported according to Directive 2001/20/EC and 2005/28/EC and the International 
Conference on Harmonisation (ICH) Good Clinical Practice (GCP) guidelines.
7.4
Pregnancy
All pregnancies and their subsequent outcome (spontaneous miscarriage, elective termination, 
ectopic pregnancy, normal birth or congenital abnormality) should be reported to the Theradex®
Safety Desk using the appropriate forms.
Maternal Exposure
7.4.1
If a patient becomes pregnant during the course of the study, investigational product should be 
discontinued immediately.
Pregnancy itself is not regarded as an AE unless there is a suspicion that the investigational product 
under study may have interfered with the effectiveness of a contraceptive medication. Congenital 
abnormalities/birth defects and spontaneous miscarriages should be reported and handled as SAEs.  
Elective abortions without complications should not be handled as AEs. The outcome of a 
pregnancy should be followed up and documented even if the patient was withdrawn from the study.
If a pregnancy occurs during exposure to investigational product or in the 30 days after 


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discontinuing investigational product, then Investigators or other site personnel must inform the 
Theradex® Safety Desk immediately, or no later than 24 hours of when he or she becomes aware 
of it.
The same time lines apply when outcome information is available.


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8.0
EFFICACY ASSESSMENTS
8.1
Definitions
Response and progression will be evaluated in this study using the international criteria (version 1.1) 
proposed by the Response Evaluation Criteria in Solid Tumors (RECIST) Committee [19].
Changes in only the largest diameter (unidimensional measurement) of the tumor lesions are used in 
the RECIST 1.1 criteria. Note: Lesions are either measurable or non-measurable using the criteria 
provided below. The term “evaluable” in reference to measurability will not be used because it does 
not provide additional meaning or accuracy.
Measurable Disease
8.1.1
Measurable disease is defined by the presence of at least one measurable lesion. Measurable lesions 
are defined as those that can be accurately measured in at least one dimension (longest diameter 
[LD] in the plane of measurement to be recorded) with a minimum size of: 
10 mm by CT scan (CT scan slice thickness no greater than 5 mm)
10 mm caliper measurement by clinical exam (lesions which cannot be accurately measured with 
calipers should be recorded as non-measurable)
20 mm by chest X-ray.
Malignant lymph nodes:  To be considered pathologically enlarged and measurable, a lymph node 
must be 
15 mm in short axis when assessed by CT scan (CT scan slice thickness no greater than 
5 mm).
Non-measurable Disease
8.1.2
All other lesions (or sites of disease), including small lesions (longest diameter < 10 mm or 
pathological lymph nodes with 
10 to < 15 mm short axis) are considered non-measurable disease. 
Lesions 
considered 
truly 
non-measurable 
include: 
leptomeningeal 
disease, 
ascites, 
pleural/pericardial effusions, lymphangitis cutis/pulmonis, inflammatory breast disease, abdominal 
masses/abdominal organomegaly identified by physical exam and not followed by CT or MRI.
Bone lesions, cystic lesions and lesions previously treated with local therapy must be considered as 
follows:
8.1.2.1
Bone Lesions
Bone scan, PET scan or plain films are not considered adequate imaging techniques to measure 
bone lesions.  However, these techniques can be used to confirm the presence or disappearance 
of bone lesions.
Lytic bone lesions or mixed lytic-blastic lesions, with identifiable soft tissue components, that 
can be evaluated by cross sectional imaging techniques (i.e., CT scan or MRI) can be considered 


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as measurable lesions if the soft tissue component meets the definition of measurability 
described above.
Blastic bone lesions are non-measurable.
8.1.2.2
Cystic Lesions
Lesions that meet the criteria for radiographically defined simple cysts should not be considered 
malignant lesions (neither measurable nor non-measurable) since they are, by definition, simple 
cysts.
‘Cystic lesions’ thought to represent cystic metastases can be considered measurable lesions, if 
they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions.
8.1.2.3
Lesions With Prior Local Treatment
Tumor lesions situated in a previously irradiated area, or in an area subjected to other loco-
regional therapy, are usually not considered measurable unless there has been demonstrated 
progression in the lesion. 
Target Lesions
8.1.3
All measurable lesions up to a maximum of two lesions per organ and five lesions in total, 
representative of all involved organs, should be identified as target lesions and recorded and 
measured at pretreatment. Target lesions should be selected on the basis of their size (lesions with 
the longest diameter) and their suitability for accurate repeated measurements, either by imaging 
techniques or clinically). A sum of the diameters (longest for non-nodal lesions, short axis for nodal 
lesions) for all target lesions will be calculated and reported as the pretreatment sum diameter. The 
pretreatment sum diameters will be used as a reference by which to characterize the objective tumor 
response.
Lymph Node Assessment
8.1.4
For lymph nodes, measurements should be made of the short axis, which is defined as perpendicular 
to the LD of node assessed in the plane of measurement:
Target lesion if short axis 
15 mm
Non-target lesion if short axis is 10 but < 15 mm
Normal if short axis < 10 mm.
For pretreatment, add the actual short axis measurement to the sum of LD of non-nodal lesions.


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Non-target Lesions
8.1.5
All other lesions (or sites of disease) including pathological lymph nodes should be identified as 
non-target lesions and should also be recorded at pretreatment. Measurements of these lesions are 
not required and these lesions should be followed as “present,” “absent,” or in rare cases 
“unequivocal progression.”  In addition, it is possible to record multiple non-target lesions involving 
the same organ as a single item on the CRF (e.g., ‘multiple enlarged pelvic lymph nodes’ or 
‘multiple liver metastases’).
8.2
Guidelines for Evaluation of Measurable Disease
All measurements should be taken and recorded in metric notation using a ruler or calipers. All 
pretreatment evaluations should be performed as closely as possible to the beginning of treatment 
and never more than 4 weeks before the beginning of the treatment.
(Note: Tumor lesions that are situated in a previously irradiated area might or might not be 
considered measurable. If the Sponsor/Investigator thinks it appropriate to include them, the 
conditions under which such lesions should be considered must be defined in the protocol.) 
The same method of assessment and the same technique (CT and/or MRI) should be used to 
characterize each identified and reported lesion at pretreatment and during follow-up. Imaging-
based evaluation is preferred to evaluation by clinical examination when both methods have been 
used to assess the antitumor effect of a treatment.
Clinical lesions. Clinical lesions will only be considered measurable when they are superficial and 
10 mm diameter as assessed using calipers (e.g., skin nodules). In the case of skin lesions, 
documentation by color photography, including a ruler to estimate the size of the lesion, is 
recommended. When lesions can be evaluated by both clinical exam and imaging, imaging 
evaluation should be undertaken since it is more objective and may be reviewed at the end of the 
study.
Chest X-ray. Chest CT is preferred over chest X-ray, particularly when progression is an important 
endpoint. Lesions on chest x-ray may be considered measurable if they are clearly defined and 
surrounded by aerated lung.  
Conventional CT scan and MRI. This guideline has defined measurability of lesions on CT scan 
based on the assumption that CT slice thickness is 5 mm or less. When CT scans have slice 
thickness > 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. 
MRI is acceptable in certain situations (e.g., for body scans).
Ultrasound. Ultrasound should not be used to measure tumor lesions. Ultrasound examinations 
cannot be reproduced in their entirety for independent review at a later date because they are 
operator dependent.  If new lesions are identified by ultrasound, confirmation by CT or MRI is 
advised.  If there is concern about radiation exposure at CT, MRI may be used instead of CT.


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Endoscopy, Laparoscopy. The utilization of these techniques for objective tumor evaluation is not 
advised. However, such techniques can be useful to confirm complete pathological response when 
biopsies are obtained or to determine relapse in trials where recurrence following complete response 
or surgical resection is an endpoint.
Tumor markers. Tumor markers alone cannot be used to assess objective tumor response. If 
markers are initially above the upper normal limit, they must normalize for a patient to be 
considered in complete clinical response.  
Cytology, Histology. These techniques can be used to differentiate between partial responses (PR) 
and complete responses (CR) in rare cases (e.g., residual lesions in tumor types such as germ cell 
tumors, where known residual benign tumors can remain). 
8.3
Response Criteria
Evaluation of Target Lesions
8.3.1
Complete Response (CR):
Disappearance of all target lesions. Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to 
< 10 mm.
Partial Response (PR):
At least a 30% decrease in the sum of diameters of target lesions, 
taking as reference the pretreatment sum diameters.
Progressive Disease (PD):
At least a 20% increase in the sum of diameters of target lesions, 
taking as reference the smallest sum on study (this includes the 
pretreatment sum if that is the smallest). In addition to the relative 
increase of 20%, the sum must also demonstrate an absolute 
increase of at least 5 mm. (Note: the appearance of one or more 
new lesions is also considered progression.)
Stable Disease (SD):
Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum 
diameters while on study.
8.3.1.1
Assessment of Target Lymph Nodes
Lymph nodes identified as target lesions should always have the actual short axis measurement 
recorded (measured in the same anatomical plane as the pretreatment exam), even if the nodes 
regress to below 10 mm on study.  In order to qualify for CR, each node must achieve a short axis < 
10 mm.  For PR, SD and PD, the actual short axis measurement of the nodes is to be included in the 
sum of target lesions.
8.3.1.2
Target Lesions That Become “Too Small to Measure”
All lesions (nodal and non-nodal) recorded at pretreatment should have their actual measurements 


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recorded at each subsequent evaluation, even when very small (e.g., 2 mm). If it is the opinion of the 
radiologist that the lesion has disappeared, the measurement should be recorded as 0 mm. If the 
lesion is believed to be present and is faintly seen but too small to measure, a default value of 5 mm 
should be assigned.  
8.3.1.3
Lesions That Split or Coalesce on Treatment
When non-nodal lesions fragment, the longest diameters of the fragmented portions should be added 
together to calculate the target lesion sum.  Similarly, as lesions coalesce, a plane between them may 
be maintained that would aid in obtaining diameter measurements of each individual lesion. If the 
lesions have truly coalesced such that they are no longer separable, the vector of the longest 
diameter should be the maximal longest diameter for the ‘coalesced lesion.’
Evaluation of Non-target Lesions
8.3.2
Complete Response (CR):
Disappearance of all non-target lesions and normalization of tumor 
marker level. All lymph nodes must be non-pathological in size 
(< 10 mm short axis).
Non-CR/Non-PD:
Persistence of one or more non-target lesion(s) and/or maintenance 
of tumor marker level above the normal limits.
Progressive Disease (PD):
Unequivocal progression of existing non-target lesions. To achieve 
‘unequivocal progression’ on the basis of the non-target disease, 
there must be an overall level of substantial worsening in non-
target disease such that, even in the presence of SD or PR in target 
disease, the overall tumor burden has increased sufficiently to 
merit discontinuation. (Note: the appearance of one or more new 
lesions is also considered progression.)
8.3.2.1
New Lesions
The finding of a new lesion should be unequivocal (i.e., not attributed to differences in scanning 
technique, change in imaging modality, or findings thought to represent something other than tumor, 
such as a ‘new’ healing bone lesion). A lesion identified on a follow-up assessment in an anatomical 
location that was not scanned at pretreatment is considered a new lesion and will indicate disease 
progression. If a new lesion is equivocal, continued therapy and follow-up evaluation will clarify if 
it represents truly new disease. If repeat scans confirm this is definitely a new lesion, then 
progression should be declared using the date of the initial scan.
8.3.2.2
Evaluation of Best Overall Response by RECIST
The best overall response is the best response recorded from the start of the treatment until disease 
progression/recurrence (taking as reference for progressive disease the smallest measurements 


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recorded since the treatment started). The patient’s best overall response assignment will depend on 
findings of both target and non-target disease and will also take into consideration the appearance of 
new lesions. 
It is assumed that at each protocol-specified time point, a response assessment occurs. Table 5
provides a summary of the overall response status calculation at each time point for patients who 
have measurable disease at pretreatment. When patients have non-measurable disease, Table 6
should be used.
Table 5. Time Point Response: Patients With Target (+/- Non-target) Disease
Target Lesions
Non-target Lesions
New Lesions
Overall Response
CR
CR
No
CR
CR
Non-CR / non-PD
No
PR
CR
Not evaluated
No
PR
PR
Non-PD or not all evaluated
No
PR
SD
Non-PD or not all evaluated
No
SD
Not all evaluated
Non-PD
No
NE
PD
Any
Yes or No
PD
Any
PD
Yes or No
PD
Any
Any
Yes
PD
CR=complete response, PR=partial response, SD=stable disease, PD=progressive disease, NE=not 
evaluable
Table 6. Time Point Response: Patients With Non-target Disease Only
Non-target Lesions
New Lesions
Overall Response
CR
No
CR
Non-CR / non-PD
No
Non-CR / non-PD*
Not all evaluated
No
NE
Unequivocal PD
Yes or No
PD
Any
Yes
PD
CR=complete response; PD=progressive disease; NE=not evaluable
* Non-CR/non-PD is preferred over SD for non-target disease
Best response determination for studies where confirmation of CR or PR is required: Complete or 
partial responses may be claimed only if the criteria for each are confirmed by a repeat assessment at 
least 4 weeks later. In this circumstance, the best overall response can be interpreted as in Table 7.


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Table 7. Best Overall Response When Confirmation of CR and PR is Required
Overall Response
First Time Point
Overall Response
Subsequent Time Point
Best Overall Response
CR
CR
CR
CR
PR
SD, PD or PR*
CR
SD
SD provided minimum criteria for SD duration met, otherwise PD
CR
PD
SD provided minimum criteria for SD duration met, otherwise PD
CR
NE
SD provided minimum criteria for SD duration met, otherwise NE
PR
CR
PR
PR
PR
PR
PR
SD
SD
PR
PD
SD provided minimum criteria for SD duration met, otherwise PD
PR
NE
SD provided minimum criteria for SD duration met, otherwise NE
NE
NE
NE
CR=complete response; PR=partial response; SD=stable disease; PD=progressive disease; NE=not evaluable
* If CR is truly met at first time point, then any disease seen at a subsequent time point, even disease meeting PR criteria 
relative to pretreatment, makes the disease PD at that point (since disease must have reappeared after CR). Best response 
would depend on whether minimum duration for SD was met. However, sometimes ‘CR’ may be claimed when
subsequent scans suggest small lesions were likely still present and in the fact patient had PR, not CR, at the first time 
point. Under these circumstances, the original CR should be changed to PR and the best response is PR.
Confirmatory Measurement/Duration of Response
8.3.3
8.3.3.1
Confirmation According to RECIST
To be assigned a status of PR or CR, changes in tumor measurements must be confirmed by repeat 
assessments that should be performed no less than 4 weeks after the criteria for response are first 
met. In the case of SD, follow-up measurements must have met the SD criteria at least once after 
study entry at a minimum interval of not less than 6-8 weeks.
8.3.3.2
Duration of Overall Response
The duration of overall response is measured from the time measurement criteria are met for CR or 
PR (whichever is first recorded) until the first date that recurrent or progressive disease is 
objectively documented (as defined by the RECIST 1.1 criteria; taking as reference for progressive 
disease the smallest measurements recorded since the treatment started).
The duration of overall CR is measured from the time measurement criteria are first met for CR until 
the first date that recurrent disease is objectively documented.


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8.3.3.3
Overall Response Rate
Best overall response, being confirmed and maintained for at least 28 days as defined in Section 
8.3.2.2 and Table 7, will constitute the primary endpoint for response assessment and analysis.
8.3.3.4
Duration of Stable Disease
Stable disease is measured from the start of the treatment until the criteria for progression are met, 
taking as reference the smallest measurements recorded since the treatment started.
Progression-free Survival
8.3.4
PFS is defined as the time from randomization to the time of disease progression or relapse 
(according to RECIST 1.1) or death, or to the date of last tumor assessment without any such event 
(censored observation) and includes any of the following:
Occurrence (clinically or imaging signs) of any new lesion
Increase in measurable and/or non-measurable tumor as defined by the RECIST 1.1 criteria
8.4
Pharmacokinetics
Please refer to the laboratory manual for detail instructions on processing of the pharmacokinetic 
samples.
APR-246
8.4.1
A full PK profile will be taken during Cycle 1 from patients selected for ECG Holter testing
(Table 8), followed by sparse PK sampling from Cycle 2 onwards (Table 9).
For all other patients, sparse PK sampling will be done from Cycle 1 until the last Cycle (Table 9).
The objective of the sparse PK sampling scheme is to enable construction of individual PK 
parameters (AUC and Cmax) for correlation with efficacy and safety. The PK of APR-246 follow a 
bi-exponential decline and therefore a minimum of three samples are needed to construct the PK 
individual profiles.
The PK sampling scheme allows for some flexibility in the timing of the blood sampling and 
whenever possible time windows for sample collection are given. Nevertheless it is critical for the 
PK evaluation that the exact times of dose administration and PK sample collection are recorded on 
each occasion.


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Table 8. PK Blood Sampling Time Points for APR-246 During Cycle 1 (Patients Selected for ECG Holter)
Day 1
Before infusion
0-2 hrs prior to APR-246 infusion
During infusion
5-15 min prior to end of infusion 
After infusion
15 mins +/-3 min AFTER the end of infusion
1 hr +/-5 min AFTER the end of infusion
3 hrs +/-15 min AFTER the end of infusion
Day 2
Before infusion 
0-30 min prior to APR-246 infusion
Day 4
Before infusion
0-30 min prior to APR-246 infusion
During infusion
5-15 min prior to end of infusion
After infusion
15 min +/-3 min AFTER the end of infusion
1 hrs +/-5 min AFTER the end of infusion
3 hrs +/-15 min AFTER the end of infusion
Day 5
No infusion
12-24 hrs AFTER the end of Day 4 infusion
Table 9. Sparse PK Blood Sampling Time Points for APR-246
D1
C1*-final cycle
Before infusion
0-2 hrs prior to APR-246 infusion
At end of infusion
+/-5 min relative to the end of infusion
After infusion
30-60 min AFTER infusion
D4
C1*-final cycle
Before infusion
0-2 hrs prior to APR-246 infusion
At end of infusion
+/-5 min relative to the end of infusion
After infusion
30-60 min AFTER infusion
*From Cycle 2 (C2) in patients selected for ECG Holter testing.


Aprea Therapeutics AB
Protocol No. APR-486
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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
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8.5
Pharmacodynamics
Tumor Biopsies
8.5.1
Archived tumor tissue (formalin fixed paraffin embedded [FFPE] sections) from all patients will be 
reviewed by a gynecological pathologist to confirm the diagnosis of HGSOC, and positive IHC 
staining for p53. In addition, these samples will be used to determine p53 status by IHC by a central 
laboratory.
Additional analysis may include biomarkers and evaluation of tumor cell DNA. 
Where possible paired tumor biopsies should be collected: one prior to treatment and the other 
during treatment (optimally within the last 30 minutes of the APR-246 infusion on day 3 of the first 
cycle, however a biopsy obtained at the end of the APR-246 infusion on day 2 is acceptable).
Two tumor cores will be taken at each biopsy, one will be flash frozen and one will be formalin 
fixed.
The choice of the tumor lesion is at the Investigator’s discretion. The reasons for failure to obtain a 
biopsy must be recorded in the eCRF. If the pretreatment tumor biopsy is not obtained, no further 
tumor biopsies will be attempted.
Any lesion that is used for biopsy purposes should be recorded a non-target lesion only.
The following assessments may be performed by Aprea Therapeutics AB or a central laboratory 
appointed by Aprea Therapeutics AB (please refer to Laboratory Manual). 
Immunohistochemistry for tumor cellularity and p53 protein staining and other IHC markers 
(i.e., BRCA1, endoplasmic reticulum stress markers)
RNA/DNA extraction for microarray tumor gene expression profiling
Proteomics – lysates for reverse phase proteomics.
Specimens may be stored for future evaluation of APR-246 in target tissue.
The quality and quantity of the biopsy will determine which analyses are to be performed. The 
mutational analyses will be done in batches and the results will not be reported to the trial site 
during the treatment period.
8.6
Exploratory Biomarker Research
Plasma, whole blood and tumor samples will be collected from all patients and stored for 
retrospective exploratory analyses. These analyses may include (but are not necessarily limited to):
Predictive markers of efficacy, tolerability and clinical pharmacology
Biomarkers of acquired or innate resistance to APR-246


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Circulating free tumor DNA
The results of the exploratory biomarker research will be reported separately and will not be part of 
the Clinical Study Report.
Blood samples will be taken pre-treatment for collection of germ line DNA in order to allow 
comparison of germ-line and tumor cell DNA sequence. Refer to Laboratory Manual for detailed 
instructions.
The results of exploratory biomarker research may be pooled with data from other studies with 
APR-246 to generate hypotheses to be tested in future studies.
8.7
Biological Sample Handling
Details of sample collection, processing, shipping and storage will be described in the laboratory 
manual. Each sample for exploratory research will be identified with the study number and patient 
enrollment number. In this way exploratory biomarker and genetic data may be correlated with 
clinical data. Samples will be destroyed in the case of withdrawal of consent and regulatory audit 
enabled. Where genetic analysis will be undertaken the processes adopted for the coding and storage 
of samples will be more stringent in order to maintain patient confidentiality. As an added 
precaution, irrespective of the type of sample, the DNA sample will be assigned a unique number 
replacing the information on the sample tube. Thereafter, the DNA sample will be identifiable by the 
unique DNA number only. The DNA number will be used to identify the sample and corresponding 
data at the Aprea Therapeutics AB’s designated contract laboratory. No personal details identifying 
the individual will be available to any person (Aprea Therapeutics AB or contract laboratory staff) 
working with the DNA. The samples and data for genetic analysis in this study will be single coded. 
The link between the patient enrollment code and the DNA number will be maintained and stored in 
a secure environment, with restricted access. The link will be used to identify the relevant DNA 
samples for analysis, facilitate correlation of genotypic results with clinical data, allow regulatory 
audit and to trace samples for destruction in the case of withdrawal of consent when the patient has 
requested disposal/destruction of collected samples not yet analyzed.
8.8
Chain of Custody of Biological Samples
A full chain of custody is maintained for all samples throughout their lifecycle. The Principal 
Investigator at each center keeps full traceability of collected biological samples from the patients 
while in storage at the center until shipment or disposal (where appropriate) and keeps 
documentation of receipt of arrival. The Principal Investigator will also ensure that access to the
samples while in storage at the study center will be limited only to those people for whom access is 
required. The sample receiver keeps full traceability of the samples while in storage and during use 
until used or disposed of or until further shipment and keeps documentation of receipt of arrival.


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Aprea Therapeutics AB keeps oversight of the entire life cycle through internal procedures, 
monitoring of study sites and auditing of external laboratory providers. Samples retained for further 
use will be registered in the Aprea Therapeutics AB biobank system during the entire life cycle. 
Samples will be stored for up to 15 years.
8.9
Withdrawal of Informed Consent for Donated Biological Samples
If a patient withdraws consent to the use of voluntarily donated biological samples, then the samples 
will be disposed of/destroyed, and the action documented. If samples are already analyzed, Aprea 
Therapeutics AB is not obliged to destroy the results of this research. As collection of the genetic 
blood sample is a voluntary part of the study then the patient may continue in the study.


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9.0
STATISTICS
At least 25 evaluable patients will be enrolled in the Main Study. Up to 25 patients will be enrolled 
in the Sub-Study.
9.1
Sample Size 
The aim is to determine the preliminary efficacy of APR-246 with PLD. The endpoint of interest is 
the ORR as defined in Section 8.3.2.2.
A two stage design is used to test the null hypothesis that the true response rate of APR-246 in 
first stage,
study will be curtailed for futility. Otherwise the study will continue and a further 9 patients will be 
entered, for a total of 25 evaluable 
nses are observed in these 25 patients, the 
null hypothesis will be rejected in favor of the alternative. This design provides 90.3% power and a 
1-sided alpha of 9.5%.
Sub-Study Sample Size:
The aim is to determine the safety, tolerability and efficacy of a shorter infusion of APR-246 with 
PLD. The endpoint of interest is safety.
At one of the shorter infusion levels (3 hr 4.5 g, 4 hr 4.5 g, or 4 hr 3.7 g) if there are 0 or 1 out of 6 
patients with DLTs across the first 6 patients, then an additional 8 patients will be treated for an 
initial total of N=14. If 0 or 1 out of 14 responses are seen, then recruitment will cease. If 2 or more 
out of 14 responses are seen, a further 11 patients will be recruited for a total of N=25.  Observance 
of 5/25 responses will result in rejection of the null hypothesis. The design carries 89% power and a 
1-
alternative that the true response rate is 30%.
9.2
General
A statistical analysis plan (SAP) will be prepared prior to data lock to expand and provide further 
details on the analysis and presentation of data described below.   
Demographic data and disease-related characteristics will be summarized using descriptive statistics 
(count and percent, mean, median, standard deviation, minimum, maximum). All patient data, 
efficacy and safety, will be summarized similarly and fully listed.     
9.3 Analysis Populations
The following populations will apply:
Safety Evaluable Population: All patients who received study medication (APR-246 or PLD) will be 
considered evaluable for safety regardless of the duration of treatment. This population will be used 


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to summarize all safety parameters.
Efficacy Evaluable Population: All patients with pretreatment measurable disease by RECIST 1.1 
who have at least one radiographic assessment after pretreatment or discontinue study medication 
early due to disease progression and have a p53 mutation will be considered evaluable for efficacy. 
The efficacy-evaluable population will be the primary analysis population for efficacy. 
9.4 Statistical Methods
All demographic data and disease-related characteristics will be summarized using descriptive
statistics (count and percent, mean, median, standard deviation, minimum, maximum).
9.4.1 Efficacy Data
Overall Response Rate
Best overall response according to RECIST 1.1 will be presented along with the associated exact 
Clopper-Pearson 2-sided 95% and 1-sided lower 90% binomial confidence limits [20].
Progression-free Survival
PFS is defined as the time from registration to the time of disease progression or relapse (according 
to RECIST 1.1 only) or death.  Patients who do not experience a PFS event will be censored at their 
last clinic visit contact for the assessment of disease progression. 
PFS time will be summarized via a Kaplan-Meier curve with 95% confidence interval. Median PFS 
will be estimated from the Kaplan-Meier and presented long with 2-sided 95% confidence limits
using the method of Brookmeyer and Crowley (1982) [21]. The PFS rate at 3, 6 and 9 months’
follow-up will also be presented together with 2-sided 95% confidence limits using the method of 
Klein (2007) [22].
Evaluation of Biomarkers
The relationship between biomarkers and efficacy in terms of PFS and RECIST response will be 
explored using logistic regression methodology and accelerated failure time analysis.   
9.4.2 Safety Data
Adverse Event Data
Safety data will be summarized for the safety evaluable population. These data will include AEs and 
laboratory parameters. AE terms will be coded using the Medical Dictionary for Drug Regulatory 
Activities (MedDRA; version 16.0 or higher). AEs will be summarized by body system, preferred 
term, severity and relationship to treatment. SAEs, deaths and AEs leading to early discontinuation 
of study drug will be summarized. DLTs will be provided in a separate listing by dose. Laboratory 
parameters will be summarized by maximum NCI CTCAE severity grade and also by change from 
study entry to scheduled time points using descriptive statistics. Laboratory parameter listings will 


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include the normal ranges for each parameter. Each value will be classified as falling above, below
or within the normal range. 
Data summaries will include only treatment-emergent AEs (TEAEs), defined as events occurring on 
or after Day 1 Cycle 1 up to and including 30 days after last dose.
Pharmacokinetic versus ECG Parameters
The relationship between changes in ECG parameters and plasma concentration of APR-246 will be 
explored where possible using non-linear mixed effects modelling.
9.4.3 Pharmacokinetic data
APR-246 concentrations will be determined by a validated HPLC tandem mass spectrometry 
(LC/MS/MS) method. The sampling scheme is designed to allow evaluation by non-compartmental 
as well as population pharmacokinetic analysis. The decision on the method and whether or not the 
APR-246 pharmacokinetic evaluation and reporting will be done as standalone or pooled across 
several clinical studies with APR-246 will be taken at the time of analysis. PK parameters of 
APR-246 will include: Cl, Vss, Cmax, AUC0-24, AUC0- and t1/2.
Individual and mean profiles of concentrations of all analytes (APR-246) will be presented 
graphically. Protocol-specified blood sampling times will be used in the graphical presentation.
No formal statistical analysis beyond descriptive statistics is planned. For each PK parameter, 
individual and mean data and summary statistics (including number of subjects, arithmetic mean, 
geometric mean, SD, CV, median, Min and Max) will be presented.


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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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10.0 QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES
10.1 Monitoring of the Study and Regulatory Compliance
The project manager, or designee, will make an initiation site visit to each institution to review the 
protocol and its requirements with the Investigator(s), inspect the drug storage area, and fully inform 
the Investigator of his/her responsibilities and the procedures for assuring adequate and correct 
documentation. During the initiation site visit the CRFs will be reviewed. Other pertinent study 
materials will also be reviewed with the Investigator’s research staff. During the course of the study, 
the monitor will make regular site visits in order to review protocol compliance, examine CRFs and 
individual subject’s medical records and assure that the study is being conducted according to 
pertinent regulatory requirements. All CRF entries will be verified with source documentation. The 
review of medical records will be done in a manner to assure that patient confidentiality is 
maintained. 
10.2 Curricula Vitae of Investigators
All Principal Investigators and subinvestigators will be required to provide a current signed and 
dated curriculum vitae and evidence of GCP training to Theradex .
10.3 Protocol Modifications
No modification of the protocol should be implemented without the prior written approval of the 
Sponsor or the Sponsor’s representative (Theradex ). Any such changes which may affect a 
patient’s treatment or informed consent, especially those increasing potential risks, must receive 
prior approval by the IEC. The exception to this is where modifications are necessary to eliminate an 
immediate hazard to trial subjects, or when the change involves only logistical or administrative 
aspects of the trial (e.g., change in monitor, change in telephone number). Other administrative 
revisions which may impact the clinical portion of a study will be duly reported to the IEC by the 
Principal Investigator.
10.4 Publication Policy
This is a collaborative European Network for Translational Research in Ovarian Cancer (EUTROC)
study. The first publication will include all patients. Centers recruiting 3 evaluable patients will be 
entitled to nominate one coauthor. The highest recruiting center would be entitled to be the first 
author on the first publication. However, the Chief Investigator would be the senior author. 
Contribution to sample collection and analysis for the translational components of the study will be 
assessed on a case-by-case basis. The Investigator agrees to inform the Sponsor of any other 
publication or presentations on the study.  All manuscripts, abstracts or presentations (in outline 
form with copies of slides if available) will be submitted to the Sponsor and Theradex
at least 30 
days prior to the submission of the data for publication in order for the Sponsor to protect 
proprietary information.  The Sponsor will review the submitted material within a reasonable period 
of time and will not unreasonably withhold publication permission.


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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
Doxorubicin Chemotherapy With APR-246
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11.0 ETHICAL CONSIDERATIONS
11.1 Informed Consent
The Investigator will obtain written informed consent from each patient, or their authorized 
representative, participating in the study. The form must be signed, witnessed and dated prior to any 
study-specific procedures being performed. The informed consent form will contain all the Essential 
Elements of Informed Consent set forth in 21 CFR, Part 50, the European Union Directive 
2001/20/EC and its associated Detailed Guidances, European Union GCP Directive 2005/28/EC, the 
ICH Guideline for Good Clinical Practice, Section 4.8, and the terms of the Declaration of Helsinki 
(2013). Copies of the signed document should be given to the patient and filed in the Investigator’s 
study file, as well as the patient’s medical record if in conformance with the institution’s standard 
operating procedures. 
In cases where minors or incapacitated subjects are to be included, two sets of information sheets 
might be needed according to national regulations (not applicable for the PiSARRO-R). In addition 
to the information given to the patient’s parent or legal representative, the patient should be given 
information according to his/her capacity to understand. This information should include, where 
appropriate, a statement that the patient’s decision not to participate or to withdraw from a trial will 
be respected, even if consent is given by the parent/legal representative.
In all instances, the Principal Investigator or an appropriately qualified delegate should consent the 
patient to the study. The patient should be given adequate time to read the information provided and 
consider whether she wants to participate in the study.  
Only adult women who are mentally competent will be in enrolled and treated in this study. 
11.2 Independent Ethics Committee/Regulatory 
The study will not be initiated without approval of the appropriate IEC and compliance with all 
administrative requirements of the governing body of the institution as well as the national 
competent authority (CA) in each country.  This protocol, consent procedures and any amendments 
must be approved by the IEC/CA in compliance with current regulations of the FDA and the 
European Union as applicable and in accordance with ICH GCP. A letter of approval will be sent to 
the Sponsor prior to initiation of the study and when any subsequent modifications are made. The 
IEC/CA will be kept informed by the Investigator, Theradex
or the Sponsor, as required by 
national regulations, as to the progress of the study as well as to any serious and unexpected AEs. 
11.3 Patient Privacy 
In order to maintain patient confidentiality, all CRFs, study reports and communications relating to 
the study will identify patients by initials and assigned patient numbers; patients should not be 
identified by name.  In accordance with local, national or federal regulations, the Investigator will
allow the Sponsor or designee personnel access to all pertinent medical records in order to verify the 
data gathered on the CRFs and to audit the data collection process. Regulatory agencies such as the 


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FDA and the UK Medicine and Healthcare Products Regulatory Agency (MHRA) may also request 
access to all study records, including source documentation for inspection. Clinical information will 
not be released without the written permission of the patient as outlined in the patient consent form.


Aprea Therapeutics AB
Protocol No. APR-486
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Doxorubicin Chemotherapy With APR-246
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12.0 DATA HANDLING AND RECORD KEEPING
12.1 Data to be Recorded Directly in the Case Report Form
Not applicable.
12.2 Recording of Data
Data collected during the study will be recorded in the patient’s eCRF by the investigational site 
staff. The staff will keep records of the patient’s visit in the files considered as source documents for 
the site, e.g., hospital chart, research chart. The Investigator will be responsible for the recording of 
all data on the eCRF in a timely manner. Should any value be significantly different from normal, 
the Investigator will comment in the appropriate sections provided in the CRF. 
The Investigator will provide access to his/her original records to permit a representative from the 
Sponsor to verify the proper transcription of data.  
12.3 Study Records
European laws require that the Investigator maintain all study records (excluding the subject’s 
medical files, see below):
for at least 15 years after completion or discontinuation of the trial
or for at least 2 years after the granting of the last marketing authorization in the European 
Community (EC) and where there are no pending or contemplated marketing applications in 
the EC
or for at least 2 years after the formal discontinuation of clinical development of the 
investigational product.
Subjects’ medical files should be retained in accordance with applicable legislation and in 
accordance with the maximum period of time permitted by the hospital, institution or private 
practice.


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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
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13.0
REFERENCES
1.
Brown, J.M. and B.G. Wouters, Apoptosis, p53, and Tumor Cell Sensitivity to Anticancer 
Agents. Cancer Research, 1999. 59(7): p. 1391-1399.
2.
van Oijen, M.G.C.T. and P.J. Slootweg, Gain-of-Function Mutations in the Tumor 
Suppressor Gene p53. Clinical Cancer Research, 2000. 6(6): p. 2138-2145.
3.
Wiman, K.G., Strategies for therapeutic targeting of the p53 pathway in cancer. Cell Death 
Differ, 2006. 13(6): p. 921-6.
4.
Ahmed, A.A., et al., Driver mutations in TP53 are ubiquitous in high grade serous 
carcinoma of the ovary. The Journal of Pathology, 2010. 221(1): p. 49-56.
5.
Kastan, M.B., Wild-Type p53: Tumors Can't Stand It. Cell, 2007. 128(5): p. 837-840.
6.
Permuth-Wey, J. and T.A. Sellers, Epidemiology of ovarian cancer. Methods Mol Biol, 
2009. 472: p. 413-37.
7.
Hennessy, B.T., R.L. Coleman, and M. Markman, Ovarian cancer. The Lancet, 2009. 
374(9698): p. 1371-1382.
8.
Markman, M. and M.A. Bookman, Second-line treatment of ovarian cancer. Oncologist, 
2000. 5(1): p. 26-35.
9.
Naumann, R.W. and R.L. Coleman, Management strategies for recurrent platinum-resistant 
ovarian cancer. Drugs, 2011. 71(11): p. 1397-412.
10.
Seidman, J.D., et al., The Histologic Type and Stage Distribution of Ovarian Carcinomas of 
Surface Epithelial Origin. International Journal of Gynecologic Pathology, 2004. 23(1): p. 
41-44.
11.
Mohell, N., et al., APR-246 overcomes resistance to cisplatin and doxorubicin in ovarian 
cancer cells. Cell Death Dis, 2015. 6: p. e1794.
12.
Aprea AB, In vitro combination studies with APR-246 and platinum compounds, 
doxorubicin, and gemcitabine in ovarian cancer cell lines, in Report No.: 2013-002. 2013.
13.
Stuart, G.C.E., et al., 2010 Gynecologic Cancer InterGroup (GCIG) Consensus Statement on 
Clinical Trials in Ovarian Cancer: Report From the Fourth Ovarian Cancer Consensus 
Conference. International Journal of Gynecological Cancer, 2011. 21(4): p. 750-755.
14.
Mutch, D.G., et al., Randomized phase III trial of gemcitabine compared with pegylated 
liposomal doxorubicin in patients with platinum-resistant ovarian cancer. J Clin Oncol, 
2007. 25(19): p. 2811-8.
15.
Ledermann, J.A., et al., Newly diagnosed and relapsed epithelial ovarian carcinoma: ESMO 
Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol, 2013. 24
Suppl 6: p. vi24-32.
16.
Peng, L.H., X.Y. Chen, and T.X. Wu, Topotecan for ovarian cancer. Cochrane Database 
Syst Rev, 2008(2): p. CD005589.
17.
von Moos, R., et al., Pegylated liposomal doxorubicin-associated hand-foot syndrome: 
recommendations of an international panel of experts. Eur J Cancer, 2008. 44(6): p. 781-90.
18.
Pisano, C., et al., Clinical Trials with Pegylated Liposomal Doxorubicin in the Treatment of 
Ovarian Cancer. Journal of Drug Delivery, 2013. 2013: p. 12.
19.
Eisenhauer, E.A., et al., New response evaluation criteria in solid tumors: Revised RECIST 


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Serous Ovarian Cancer, a Phase II Study of Systemic Pegylated Liposomal 
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guideline (version 1.1). European journal of cancer (Oxford, England : 1990), 2009. 45(2): p. 
228-247.
20.
Clopper, C.J. and E.S. Pearson, The use of confidence or fiducial limits illustrated in the case 
of the binomial. Biometrika, 1934. 26(4): p. 404-413.
21.
Brookmeyer, R. and J. Crowley, A Confidence Interval for the Median Survival Time.
Biometrics, 1982. 38(1): p. 29-41.
22.
Klein, J.P., et al., Analyzing survival curves at a fixed point in time. Stat Med, 2007. 26(24): 
p. 4505-19.


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Appendix I: ECOG Performance Status
Grade
0
Fully active, able to carry on all pre-disease performance without restriction.
1
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light 
or sedentary nature, e.g., light house work, office work.
2
Ambulatory and capable of all self-care but unable to carry out any work activities. Up and 
about more than 50% of waking hours.
3
Capable of only limited self-care, confined to bed or chair more than 50% of waking hours.
4
Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
5
Dead.


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Appendix II: New York Heart Association Heart Failure Classification
Functional Capacity 
Objective Assessment 
Class I. Patients with cardiac disease but without 
resulting limitation of physical activity. Ordinary 
physical activity does not cause undue fatigue, 
palpitation, dyspnea, or anginal pain.
A. No objective evidence of cardiovascular 
disease.
Class II. Patients with cardiac disease resulting 
in slight limitation of physical activity. They are 
comfortable at rest. Ordinary physical activity 
results in fatigue, palpitation, dyspnea, or anginal 
pain.
B. Objective evidence of minimal cardiovascular 
disease.
Class III. Patients with cardiac disease resulting 
in marked limitation of physical activity. They 
are comfortable at rest. Less than ordinary 
activity causes fatigue, palpitations, dyspnea, or 
anginal pain.
C. Objective evidence of moderately severe 
cardiovascular disease.
Class IV. Patients with cardiac disease resulting 
in inability to carry on any physical activity 
without discomfort. Symptoms of heart failure or 
the anginal syndrome may be present even at rest. 
If any physical activity is undertaken, discomfort
is increased.
D. Objective evidence of severe cardiovascular 
disease
The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of 
Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256


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Appendix III: Population Pharmacokinetic Analysis of APR-246 Based on Data From Two 
Phase 1 Studies, Evaluation of the Impact of Fixed Versus Body Weight-Based Dosing and 
Exploration of the Probability of Exceeding Concentration Thresholds After Different Dosing 
Regimens
APR-246 dosing was based on mg/kg body weight in the phase I of clinical development, and 67.5 
mg/kg was identified as the maximum tolerated dose when given as 6-hour infusion. A previous 
population pharmacokinetic analysis using data from the first two clinical studies suggested that the 
influence of body weight on the pharmacokinetics of APR-246 is relatively small and that dosing by 
lean body mass (LBM) could lead to lower variability in the patient exposure. Subsequently, the 
67.5 mg/kg dose has been converted into 100 mg/kg based on LBM.
The apparent difference in the clearance of APR-246 between men and women (higher clearance in 
males vs females) was also accounted for with the inclusion of LBM effects into the model. Overall 
the differences between men and women are small, but slightly lower exposure in terms of AUC0-24
and Cmax can be expected in men given the same fixed dose as women. Further data from additional 
patients will be needed to evaluate the underlying physiological difference and to determine the 
clinical relevance of the observation.
In conclusion, giving a fixed dose of 4500 mg of APR-246 as a 6-hour infusion to women, gives the 
same average exposure in terms of AUC0-24 and Cmax compared to the established dose of 67.5 
mg/kg and the currently tested LBM based dose of 100 mg/kg. As the predicted PK variability is 
also very similar, it is justified to switch to fixed dosing of APR-246 as it will also improve the 
safety of the compound by removing the risk for miscalculations of the dose. In case of adverse 
events, stepwise dose reductions in 500 mg increments are advised to considerably reduce the 
maximum concentrations of APR-246 while maintaining a reasonable general exposure in terms of 
AUC0-24.


Aprea Therapeutics AB
Protocol No. APR-486
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Appendix IV: Further Guidance on the Definition of a Serious Adverse Event and 
Interpreting the Causality Question
Further Guidance on the Definition of a Serious Adverse Event
Life threatening
‘Life-threatening’ means that the patient was at immediate risk of death from the AE as it occurred 
or it is suspected that use or continued use of the product would result in the patient’s death. ‘Life-
threatening’ does not mean that had an AE occurred in a more severe form it might have caused 
death (e.g., hepatitis that resolved without hepatic failure).
Hospitalization
Out-patient treatment in an emergency room is not in itself a serious AE, although the reasons for it 
may be (e.g., bronchospasm, laryngeal edema). Hospital admissions and/or surgical operations 
planned before or during a study are not considered AEs if the illness or disease existed before the 
patient was enrolled in the study, provided that it did not deteriorate in an unexpected way during 
the study.
Important medical event or medical intervention
Medical and scientific judgment should be exercised in deciding whether a case is serious in 
situations where important medical events may not be immediately life-threatening or result in 
death, hospitalization, disability or incapacity but may jeopardize the patient or may require medical 
intervention to prevent one or more outcomes listed in the definition of serious. These should 
usually be considered as serious. Simply stopping the suspect IMP does not mean that it is an 
important medical event; medical judgment must be used.
Examples of such events are:
Angioedema not severe enough to require intubation but requiring i.v. hydrocortisone 
treatment
Hepatotoxicity caused by paracetamol (acetaminophen) overdose requiring treatment with 
N-acetylcysteine
Intensive treatment in an emergency room or at home for allergic bronchospasm
Blood dyscrasias (e.g., neutropenia or anemia requiring blood transfusion, etc.) or 
convulsions that do not result in hospitalization
Development of drug dependency or drug abuse.
A Guide to Interpreting the Causality Question
The following factors should be considered when deciding if there is a “reasonable possibility” that 
an AE may have been caused by the IMP.
1. Time course. Exposure to suspect IMP. Has the patient actually received the suspect IMP? 
Did the AE occur in a reasonable temporal relationship to the administration of the suspect 
IMP?


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2. Consistency with known drug profile. Was the AE consistent with the previous knowledge 
of the suspect IMP (pharmacology and toxicology) or drugs of the same pharmacological 
class? OR could the AE be anticipated from its pharmacological properties?
3. Dechallenge experience. Did the AE resolve or improve on stopping or reducing the dose of 
the suspect IMP?
4. No alternative cause. The AE cannot be reasonably explained by another etiology such as the 
underlying disease, other drugs, other host or environmental factors.
5. Rechallenge experience. Did the AE reoccur if the suspect IMP was reintroduced after 
having been stopped? Rechallenge is not normally recommended or supported.
6. Laboratory tests. A specific laboratory investigation (if performed) has confirmed the 
relationship?
A “reasonable possibility” could be considered to exist for an AE where one or more of these factors 
exist. In contrast, there would not be a “reasonable possibility” of causality if none of the above 
criteria apply or where there is evidence of exposure and a reasonable time course but any 
dechallenge (if performed) is negative or ambiguous or there is another more likely cause of the AE.
In difficult cases, other factors could be considered such as:
Is this a recognized feature of overdose of the IMP?
Is there a known mechanism?
Ambiguous cases should be considered as being a “reasonable possibility” of a causal relationship 
unless further evidence becomes available to refute this. Causal relationship in cases where the 
disease under study has deteriorated due to lack of effect should be classified as no reasonable 
possibility.


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Protocol No. APR-486
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Doxorubicin Chemotherapy With APR-246
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Appendix V: Actions Required in Cases of Increases in Liver Biochemistry and Evaluation of 
Hy’s Law
1.
Introduction
This Appendix describes the process to be followed in order to identify and appropriately report 
cases of Hy’s Law. It is not intended to be a comprehensive guide to the management of elevated 
liver biochemistries.  
During the course of the study the Investigator will remain vigilant for increases in liver 
biochemistry. The investigator is responsible for determining whether a patient meets potential Hy’s 
Law (PHL) criteria at any point during the study.
The Investigator participates, together with Aprea Therapeutics AB’s representatives, in review and 
assessment of cases meeting PHL criteria to agree whether Hy’s Law (HL) criteria are met. HL 
criteria are met if there is no alternative explanation for the elevations in liver biochemistry other 
than drug-induced liver injury (DILI) caused by the IMP. 
The Investigator is responsible for recording data pertaining to PHL/HL cases and for reporting AEs
and SAEs according to the outcome of the review and assessment in line with standard safety 
reporting processes.
2.
Definitions
Potential Hy’s Law (PHL)
AST or ALT
x ULN together with total bilirubin 
x ULN at any point during the study 
following the start of study medication irrespective of an increase in ALP.
Hy’s Law (HL)
x ULN, where no other reason, other than the IMP, 
can be found to explain the combination of increases, e.g., elevated ALP indicating cholestasis, viral 
hepatitis, another drug.  
For PHL and HL, the elevation in transaminases must precede or be coincident with (i.e., on the 
same day) the elevation in TBL, but there is no specified timeframe within which the elevations in 
transaminases and TBL must occur.
3.
Identification of Potential Hy’s Law Cases
In order to identify cases of PHL it is important to perform a comprehensive review of laboratory 
data for any patient who meets any of the following identification criteria in isolation or in 
combination:
x ULN
x ULN


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x ULN
The Investigator will without delay review each new laboratory report and if the identification 
criteria are met will:
Determine whether the patient meets PHL criteria (see Section 2 of this Appendix for 
definition) by reviewing laboratory reports from all previous visits.
Promptly enter the laboratory data into the laboratory CRF.
4.
Follow-up
4.1 Potential Hy’s Law Criteria Not Met
If the patient does not meet PHL criteria the Investigator will:
Perform follow-up on subsequent laboratory results according to the guidance provided in 
the clinical study protocol.
4.2 Potential Hy’s Law Criteria Met
If the patient does meet PHL criteria the Investigator will:
Determine whether PHL criteria were met at any study visit prior to starting study 
treatment (See Section 6 of this Appendix)
Notify the Theradex representative who will then inform Aprea Therapeutics AB
The Medical Monitor contacts the Investigator, to provide guidance, discuss and agree an approach 
for the study patients’ follow-up and the continuous review of data. Subsequent to this contact the 
Investigator will:
Monitor the patient until liver biochemistry parameters and appropriate clinical symptoms 
and signs return to normal or baseline levels, or as long as medically indicated 
Investigate the etiology of the event and perform diagnostic investigations as discussed 
with the Medical Monitor
Complete the relevant eCRF pages as information becomes available 
If at any time (in consultation with the Medical Monitor) the PHL case meets serious 
criteria, report it as an SAE using standard reporting procedures.
5.
Review and Assessment of Potential Hy’s Law Cases
The instructions in this Section should be followed for all cases where PHL criteria are met.
No later than 3 weeks after the biochemistry abnormality was initially detected, the Medical Monitor 
contacts the Investigator in order to review available data and agree on whether there is an 
alternative explanation for meeting PHL criteria other than DILI caused by the IMP.  The Medical 
Monitor and Aprea Therapeutics AB will also be involved in this review together with other subject 
matter experts as appropriate.  
According to the outcome of the review and assessment, the Investigator will follow the instructions 


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below.
If there is an agreed alternative explanation for the ALT or AST and TBL elevations, a 
determination of whether the alternative explanation is an AE will be made and subsequently 
whether the AE meets the criteria for a SAE:
If the alternative explanation is not an AE, record the alternative explanation on the 
appropriate CRF
If the alternative explanation is an AE/SAE, record the AE/SAE in the CRF accordingly 
and follow the SAE reporting processes as defined in Section 7.3.5 of this protocol.
If it is agreed that there is no explanation that would explain the ALT or AST and TBL elevations 
other than the IMP:
Report an SAE (report term ‘Hy’s Law’) according to Theradex standard processes 
The ‘Medically Important’ serious criterion should be used if no other serious criteria 
apply
As there is no alternative explanation for the HL case, a causality assessment of 
‘related’ should be assigned.
If, there is an unavoidable delay, of over 3 weeks, in obtaining the information necessary to assess 
whether or not the case meets the criteria for HL, then it is assumed that there is no alternative 
explanation until such time as an informed decision can be made:
Report an SAE (report term ‘Potential Hy’s Law’) applying serious criteria and causality 
assessment as per above
Continue follow-up and review according to agreed plan. Once the necessary 
supplementary information is obtained, repeat the review and assessment to determine 
whether HL criteria are met.  Update the SAE report according to the outcome of the 
review.
6.
Actions Required When Potential Hy’s Law Criteria are Met Before and After Starting 
Study Treatment 
This section is applicable to patients who meet PHL criteria on study treatment having previously 
met PHL criteria at a study visit prior to starting study treatment.
At the first on study treatment occurrence of PHL criteria being met the Investigator will:
Determine if there has been a significant change in the patient’s condition# compared with 
the last visit where PHL criteria were met#
If there is no significant change no action is required
If there is a significant change, notify the Theradex representative then follow the 
subsequent process described is Section 4.2 of this Appendix.


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# A ‘significant’ change in the patient’s condition refers to a clinically relevant change in any of the 
individual liver biochemistry parameters (ALT, AST or total bilirubin) in isolation or in 
combination, or a clinically relevant change in associated symptoms.  The determination of whether 
there has been a significant change will be at the discretion of the Investigator; this may be in 
consultation with the Medical Monitor if there is any uncertainty.
7.
Actions Required for Repeat Episodes of Potential Hy’s Law
This section is applicable when a patient meets PHL criteria on study treatment and has already met 
PHL criteria at a previous on study treatment visit.
The requirement to conduct follow-up, review and assessment of a repeat occurrence(s) of PHL is 
based on the nature of the alternative cause identified for the previous occurrence.  
The Investigator should determine the cause for the previous occurrence of PHL criteria being met 
and answer the following question:
Was the alternative cause for the previous occurrence of PHL criteria being met found to 
be the disease under study, e.g., chronic or progressing malignant disease, severe infection 
or liver disease, or did the patient meet PHL criteria prior to starting study treatment and 
at their first on study treatment visit as described in Section 6 of this Appendix?
If No: follow the process described in Section 4.2 of this Appendix.
If Yes:
Determine if there has been a significant change in the patient’s condition# compared with when 
PHL criteria were previously met.
If there is no significant change, no action is required
If there is a significant change, follow the process described in Section 4.2 of this 
Appendix.
# A ‘significant’ change in the patient’s condition refers to a clinically relevant change in any of the 
individual liver biochemistry parameters (ALT, AST or total bilirubin) in isolation or in 
combination, or a clinically relevant change in associated symptoms.  The determination of whether 
there has been a significant change will be at the discretion of the Investigator; this may be in 
consultation with the Medical Monitor if there is any uncertainty.
8.
References
FDA Guidance for Industry (issued July 2009) ‘Drug-induced liver injury: Premarketing clinical 
evaluation’:
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UC
M174090.pdf