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2. study design

This is a two-part study comprised of a Phase I Dose Escalation and Expansion portion and a Phase II
Efficacy at MTD portion. Dexamethasone was commonly used in myeloma treatment. After debating the effects of combining ABC294640 with dexamethasone in the study, it was decided to exclude the combination of dexamethasone for several considerations: 1) All the patients would have been treated with dexamethasone before and are likely resistant to dexamethasone when they relapse or become refractory. Thus, including dexamethasone offers little benefits while adding toxicities and side effects; 2) The effects of combining ABC294640 with dexamethasone are unknown and they could antagonize each other. In addition, dexamethasone could affect the mechanism of ABC294640; 3) Many agents such as Carfilzomib, Elotuzumab and pomalidomide were tested as a single agent without the combination of dexamethasone.  
2.1 Study description The study will be conducted in two parts, an initial Phase Ib dose-finding study with dose escalation of the study drug ABC294640. The projected ABC294640 doses for the escalation phase are: 250, 500, and 750 mg BID as determined in the single agent trial for ABC294640. The dose will be given under fasting conditions or after a light to moderate meal.
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2.2 phase 1b primary objectives

- To assess safety and determine the maximum tolerated dose (MTD) of single agent ABC294640 in patients with refractory or relapsed MM who have been previously treated with proteasome inhibitors and immunomodulatory agents.
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secondary objectives

- To assess the antitumor activity of single agent ABC294640 in patients with refractory or relapsed MM after 3 cycles of treatment.  
- To determine the pharmacokinetics of ABC294640 following administration of the single drug. - To describe the effects of ABC294640 on plasma levels of sphingosine 1-phosphate, IL-6 and other PT-PhI-II v11.08.18 Duke Cancer Institute Page 30 of 76 CONFIDENTIAL
cytokines in patients with refractory or relapsed MM.  
- To assess pharmacodynamic markers (SK2 mRNA level or activity, sphingolipid metabolites, cMyc, Mcl-1 and pS6) in bone marrow CD138+ myeloma cells that may predict tumor response to ABC294640. For patients who receive more than 3 cycles of treatment and have a repeated bone marrow biopsy, RNA sequencing and Assay for transposases accessible chromatin sequencing
(ATAC seq) will be performed to assess the effects of ABC294640 on global gene and epigenetic expression.  
- To perform correlative studies including serum cell-free PINK1/PARK2 (mitophagy markers), cell free DNA for next generation sequencing (for signal pathway analyses), serum bone destruction/formation markers (TRAP, Osteocalcin), and bone gene markers and Lyn/Src gene expression in both CD138+ and CD138- cells.  
- To evaluate immunologic function and immunologic panels (NK, NK T, T, B cells and myeloid derived suppressive cells (MDSCs) and the immune co-signalling molecules) in bone marrow environment.
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2.3 phase 1b design

After signing informed consent, patients will complete the evaluation process to determine eligibility. Once a patient is determined to be eligible for the study, he/she will be enrolled in the dose escalation Phase Ib study testing 3 ABC294640 doses (250 mg, 500 mg, and 750 mg BID). A cycle of treatment is defined as 28 days. One patient will be enrolled per week per dose. Subsequent patients on each cohort may not be enrolled less than one week after the previous patient. Patients in each dose cohort must complete Cycle 1 and undergo toxicity evaluation before the next dose level cohort is opened.  
We use the Bayesian model averaging continual reassessment method (BMA-CRM)98-100 for dose finding. In BMA-CRM, multiple CRM models are used, each equipped with a different skeleton and different skeletons represent different prior guesses of the toxicity profile of the drug. A discrete prior probability is assigned to each CRM model. The estimate of the toxicity probability at each dose level is the weighted average of the estimated probabilities at that dose level from the multiple CRM models, where the weight is the estimated probability of each model. BMA-CRM adaptively assigns a larger weight to a model of a better fit, and thus ensures the estimated probabilities to be always close to the best estimates among all the candidate models.  
Let be ABC294640 dose levels 250 mg BID, 500 mg BID and 750 mg BID, respectively. Let be the CRM probability model associated with the th skeleton , for .  
Under model , the toxicity probability at dose level is assumed to be where the 's are unknown parameters. Prior data suggest that the toxicity probability should fall in the intervals (0, 0.1), (0.25, 0.35), and (0.4, 0.6), for the 3 doses
, respectively. Therefore, we use 3 skeletons, with specified probabilities as
(0.03, 0.25, 0.4), (0.06, 0.3, 0.5), and (0.09, 0.35, 0.6.), for respectively. The prior distribution of is taken as , for . Assume equal prior probabilities for the 3 models.  
Suppose that up to the current stage of the trial, patients have experienced toxicity among patients treated at dose level , for . Given observed data, use the method described previously98-100 to obtain the BMA-CRM estimate of the toxicity probability at dose level , which is denoted by , for The target toxicity probability is set as . We treat a cohort of 3 patients at each dose level. Individual patients may continue to receive therapy at the same dose of ABC294640 provided they do not experience unacceptable toxicity or clinical disease progression. No intrapatient dose escalation is allowed. Patients will continue on therapy until the development of intolerable toxicity, withdrawal of patient consent or other event as outlined in patient discontinuation section 8.2. Patients may remain on study until there is unequivocal evidence of clinical progression or the development of intolerable toxicities. Patients will have an End of Treatment visit 4-6 weeks after last dose of study drug.
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2.4 definition of dose-limiting toxicities

Toxicities will be graded according to the NCI CTCAE version 4.0.3 criteria. Dose-limiting toxicities (DLTs) will be defined as any of the following events that are at least (possibly, probably, or definitely)
attributable to ABC294640 during dose escalation.
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non hematologic dlt is defined

Symptomatic adverse events such as nausea, vomiting and diarrhea will not be considered dose limiting if they can be reduced to less than grade 3 within 72 hours with standard supportive measures such as antiemetics and antidiarrheals.
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hematologic dlt is defined as

≥Grade 4 neutropenia or thrombocytopenia that lasts more than 7 days after the last dose of study drug; ≥Grade 3 thrombocytopenia in the presence of ≥grade 3 hemorrhage of any organ/site; Any grade 5 hematologic toxicity
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2.5 phase ii primary objectives

- Assess overall treatment response rate and OS in patients with relapsed or refractory MM treated with single-agent ABC294640.
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secondary objectives

- To assess the antitumor activity of ABC294640 in patients with refractory or relapsed MM after 3 cycles of treatment.  
- To determine if pharmacodynamic markers (SK2 mRNA or activity, sphingolipid metabolites, cMyc, Mcl-1 and pS6) in bone marrow CD138+ myeloma cells predict tumor response to ABC294640.  
- To perform correlative studies including serum cell-free PINK1/PARK2 (mitophagy markers),
cell free DNA for next generation sequencing (for signal pathway analyses), serum bone destruction/formation markers (TRAP, Osteocalcin), and bone gene markers and Lyn/Src gene expression in both CD138+ and CD138- cells.  
- To evaluate immunologic function and immunologic panels (NK, NK T, T, B cells and myeloid derived suppressive cells (MDSCs) and the immune co-signalling molecules) in bone marrow environment The Phase II portion of the study will commence once the MTD of ABC294640 has been identified, which will be the Phase II dose.
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3. study patients

Patients with relapsed or refractory multiple myeloma who have previously been treated proteasome PT-PhI-II v11.08.18 Duke Cancer Institute Page 32 of 76 CONFIDENTIAL
inhibitors or immunomodulatory agents are eligible for this trial, regardless of the patients' stem cell transplant status. Both patients who have had a transplant and patients who did not receive a transplant are eligible for the study. Potential study patients will be screened according to the Eligibility Criteria.  
Study-specific evaluations may be performed only after written informed consent has been obtained.
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3.1 eligibility criteria inclusion criteria

1. Patient must have a diagnosis of symptomatic multiple myeloma, who relapses or is refractory after previous treatment with a proteasome inhibitor (bortezomib or carfilzomib) and an immunomodulatory agent (thalidomide, lenalidomide or pomalidomide).  
2. Have measurable disease as defined by at least one of the following:
- Serum monoclonal (M) protein ≥0.5g/dl by protein electrophoresis
- >200 mg of M protein in the urine on 24-hour electrophoresis
- Serum immunoglobulin free light chain ≥10 mg/dL AND abnormal serum immunoglobulin kappa to lambda free light chain ratio
- Monoclonal bone marrow plasmacytosis ≥30%
3. Voluntary signed and dated institutional review board (IRB) approved informed consent form in accordance with regulatory and institutional guidelines.  
4. Time interval from last systemic chemotherapy (not including low dose dexamethasone) more than 2 weeks prior to initiation of ABC294640. Patients receiving high dose dexamethasone defined as 40mg dexamethasone a day for 4 days will need 2 weeks washout prior to initiation of ABC294640. 5. 18 years of age or older.  
6. ECOG performance status of 0-2. 7. Acceptable liver function:
- Bilirubin ≤ 1.5 times upper limit of normal (CTCAE Grade 1 baseline)
- AST (SGOT), ALT (SGPT)  5 x ULN (CTCAE Grade 2 baseline)
- Serum creatinine ≤1.5 XULN (CTCAE Grade 1 baseline)
8. Acceptable hematologic status (with or without transfusion support):
- Absolute neutrophil count ≥1000 cells/mm3,
- Platelet count ≥50,000 (plt/mm3),
- Hemoglobin≥9g/dL.  
NOTE: If the patient's bone marrow biopsy shows greater than or equal to 50% plasma cells, the platelet count should be >30,000 plt/mm3, Hemoglobin >8 g/dL and ANC >500 cells/mm3
(transfusion support or growth factor support is acceptable). 9. Urinalysis: No clinically significant abnormalities.  
10. PT and PTT ≤ 1.5 X ULN after correction of nutritional deficiencies that may contribute to prolonged PT/PTT. 11. As determined by the treating investigator, the patient must have well-controlled blood pressure, defined as systolic blood pressure <150mmHg and/or diastolic blood pressure <100 mmHg for the majority of measurements.  
12. A negative pregnancy test (if female of child bearing potential). For men and women of childproducing potential, willingness to use effective contraceptive methods during the study.
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exclusion criteria

1. Pregnant or nursing women. NOTE: Women of childbearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; or abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately.  
2. Patients who are currently participating in any other clinical trial of an investigational product.  
3. Major surgery within 30 days prior to start of treatment 4. Treatment with intravenous antibiotics, antivirals, or antifungals within 14 days prior to start of treatment.  
5. Known human immunodeficiency virus infection
6. Active hepatitis B or C infection with abnormal liver functions (i.e., LFTs > 2X upper normal limits)
7. Unstable angina or myocardial infarction within 4 months prior to start of treatment, NYHA Class III or IV heart failure, uncontrolled angina, history of severe coronary artery disease, severe uncontrolled ventricular arrhythmias, sick sinus syndrome, or electrocardiographic evidence of acute ischemia or Grade 3 conduction system abnormalities unless subject has a pacemaker 8. Uncontrolled hypertension or uncontrolled diabetes within 14 days prior to start of treatment 9. Nonhematologic malignancy within the past 3 years with the exception of a) adequately treated basal cell carcinoma, squamous cell skin cancer, or thyroid cancer; b) carcinoma in situ of the cervix or breast; c) prostate cancer of Gleason Grade 6 or less with stable prostate-specific antigen levels; or d) cancer considered cured by surgical resection or unlikely to impact survival during the duration of the study, such as localized transitional cell carcinoma of the bladder 10. Subjects with pleural effusions requiring thoracentesis or ascites requiring paracentesis within 14 days prior to initiation of ABC294640 11. Any other clinically significant medical or psychiatric disease or condition or social situation that, in the Investigator's opinion, may interfere with protocol adherence or a subject's ability to give informed consent
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4. enrollment and treatment 4.1

The screening examination will take place between Day -30 and 0. An informed consent must be signed by the patient before any study-specific screening procedure takes place. Subject data to be collected at the Screening Examination includes:
- Complete medical history
- Concomitant medication assessment
- Baseline Review of Systems and AE documentation - Physical examination
- Vital signs (temperature, blood pressure, pulse rate, and respiratory rate)
- ECOG Performance Status
- Pregnancy test (for nonsterile women of childbearing potential within 2 days of Treatment Day 1)
- 12-lead electrocardiogram - Serum chemistry
- Coagulation parameters
- CBC with differential
- Urinalysis
- Bone marrow biopsy and aspirates (should be performed within 2 weeks of treatment day 1)
- SPEP, IFE, UPEP, serum free light chain, LDH, beta-2 microglobulin
- Bone skeletal survey. Subjects likely to meet eligibility criteria will be offered participation in the study after the investigator verifies that there is a current available slot (phase 1). Subjects will sign informed consent prior to any protocol associated procedure. Screening procedures will 1) ensure that subject meets all the eligibility criteria, 2) obtain disease assessment to allow efficacy measurements, 3) assess baseline toxicity, and 4)
provide initial biological samples for pharmacodynamic and correlative studies.
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4.2 phase ib dose escalation

The projected ABC294640 doses for the escalation phase are: 250, 500, and 750 mg BID as determined in the single agent trial for ABC294640. Drug doses are defined in Table 4-1. The dose will be given under fasting conditions or after a light to moderate meal. One patient will be enrolled per week per dose. Subsequent patients on each cohort may not be enrolled less than one week after the previous patient. Patients in each dose cohort must complete Cycle 1 and undergo toxicity evaluation before the next dose level cohort is opened.  
| Dose level   | ABC294640 Dose   | Capsules (AM / PM)   |
|--------------|------------------|----------------------|
| (mg AM / PM) |                  |                      |
| 0            | 250 / 250        | 1 / 1                |
| 1            | 500 / 500        | 2 / 2                |
| 2            | 750 / 750        | 3 / 3                |  
Let the target probability of toxicity be The following dose-finding algorithm will be employed.  
- Treat the first cohort of patients at the 250 mg BID dose level.  
- Suppose that the current dose level is . Denote the estimated probabilities of toxicity based on the accumulated data to be for the 3 dose levels , respectively. Find the dose level such that Then o if , de-escalate to dose level ;  
o if , escalate to dose level ; o otherwise, stay at dose level for the next cohort of patients.
- Once the maximum sample size is reached, the dose with the toxicity probability closest to is declared as the MTD.  
If the lowest dose is still too toxic, as indicated by the fact that the posterior probability that the toxicity rate for the lowest dose is greater than 0.33 is >0.9, the trial will be terminated early for safety.  
Individual patients may continue to receive therapy at the same dose of ABC294640 provided they do not experience unacceptable toxicity or disease progression. No intrapatient dose escalation is allowed. Patients experiencing Grade 3 or 4 hematologic toxicity will have the study drug withheld according to the Dose Modification Plan outlined in Table 4-2. If Grade 3 or 4 toxicity continues after 4 weeks, the patient will be removed from the study. The patient will have an End of Treatment visit 4-6 weeks after last dose of study drug.  
| Table 4-2 Dose Modification Plan NCI CTC 4.0.3 ABC294640 Dose   | Need for discontinuation from study                                                                                                                                                                                                                                                                                                                                         |
|-----------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Criteria                                                        | Modification Instructions                                                                                                                                                                                                                                                                                                                                                   |
| Hematologic toxicity (ANC                                       | Hold study drug. Assess patient weekly. If                                                                                                                                                                                                                                                                                                                                  |
| and/or platelet) ≥Grade 3                                       | the toxicity resolves to ≤ baseline by the beginning of subsequent week, restart study drug and reduce dose by 1 dose level (Table 4-1). Omitted doses are not made up. If the toxicity does not resolve to ≤ baseline after 4 weeks, the patient will be removed from the study.                                                                                           |
| Other non- hematologic                                          | Hold study drug. Assess patient weekly. If                                                                                                                                                                                                                                                                                                                                  |
| toxicity ≥3                                                     | the toxicity resolves to ≤ baseline by the beginning of subsequent week, restart study drug and reduce dose by 1 dose level (Table 4-1). Omitted doses are not made up. Subsequent cycle can be delayed for up to 2 weeks until toxicity is resolved to ≤ baseline. If toxicity does not resolve to ≤ baseline after the extended 2  weeks, discontinue patient from study. |
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4.3 phase ii

Once the MTD for ABC294640 is found, there will be expansion of the MTD cohort so that a total of 59 individuals will be treated at the MTD of ABC294640. The 3 phase Ib subjects taking the MTD will continue into Phase II portion of the study and will be included in the Phase II analysis. Thus, 56 additional patients will be enrolled in the Phase II portion of the study.  
For the phase II portion of the study, we have incorporated safety stopping rules into our design to ensure patient safety (Table below). The first column of the table gives the number of patients treated in each stage. The second column gives the minimum number of patients with unacceptable serious adverse event (SAE) required to stop the trial early for safety. The third column lists the proportion of subjects with related SAEs. Specifically, we will stop the trial early if there is significant toxicity defined as an unacceptable serious adverse event rate of grade 3 or 4 toxicities deemed possibly, probably or definitely related to study drug. We consider an acceptable level to be 15% (null hypothesis) and an unacceptable PT-PhI-II v11.08.18 Duke Cancer Institute Page 36 of 76 CONFIDENTIAL
rate to be 30% (alternative hypothesis). We will craft a stopping rule for early stopping for strong evidence that the SAE rate is 30% vs. 15%. Given our sample size of 59 and based on 1000 simulations, this stopping rule yields a 83% chance of early termination if the true SAE rate is 0.30 and only a 4%
chance of early stopping if the true SAE rate is 0.15.  
| Number of patients with grade 3 or 4  related SAEs   |                             |      |
|------------------------------------------------------|-----------------------------|------|
| Total number of patients treated                     | Point estimate of  SAE rate |      |
| 12                                                   | 8                           | 0.67 |
| 24                                                   | 10                          | 0.42 |
| 36                                                   | 11                          | 0.31 |
| 48                                                   | 12                          | 0.25 |
| 59                                                   | 13                          | 0.22 |  
4.4 Safety confirmation **and follow-up**
Individual patients may continue to receive therapy at the same dose provided they do not experience unacceptable toxicity or disease progression. No intrapatient dose escalation is allowed.  
Treatment will continue until documentation of clinically progressive disease, unacceptable side effects, or patient withdraws consent. The patient will have an End of Treatment visit 4-6 weeks after last dose of study drug. Patients will then be followed for survival every 3 months for 2 years following treatment discontinuation and then follow-up per standard practice.
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4.5 disease assessment

Disease assessment will occur at the beginning of each cycle. Full myeloma restaging and treatment response assessment will be performed at the end of Cycles 3 and 6 (+/- 7 days) and will consist of serum protein electrophoresis, serum and urine immunofixation, 24h urine protein electrophoresis, serum free light chains, beta-2 microglobulin, bone marrow aspiration and biopsy, complete blood counts and metabolic panel. Disease response will be categorized according to appendix E.
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5. pk and pd studies

PK sampling will occur during Cycle 1 on Day 1. During these study time-points, administration of ABC294640 should only occur at the investigative site.  
Blood samples for PK will be drawn on Day 1 of Cycle 1 immediately before dosing and at 1, 2, 4, and 8 hours after dosing.  
On Day-1 of Cycle-1, a blood sample will be drawn from each subject for PD and PK analysis prior to drug administration. Then, all subjects will receive their morning dose. PK sampling will continue over an 8 hour period. Patients should take the afternoon dose approximately 12 hours after the morning dose. In the event a patient vomits within 60 minutes after ingesting the investigational agent on Day 1 of Cycle 1, the PK blood draw schedule will be suspended. The investigational agent will not be administered again. Prior to receiving the investigational agent the following morning, the patient is to be treated with adequate anti-nausea therapy (reference Appendix B for contraindicated medications) prior to study drug administration.  
5.2 **Pharmacodynamic and correlative assays**
For our secondary objectives, we will perform pharmacodynamic assays to measure the effects of ABC294640 on S1P in the plasma and in the bone marrow as well as on the c-Myc and Mcl-1 expression on myeloma cells. The key end-points for our pharmacodynamics and mechanistic studies are:
- Plasma PD analysis for sphingosine 1-phosphate (performed using samples collected during the PK sampling and at the beginning of each cycle prior to ABC294640 drug administration). Plasma IL-6 level performed at the beginning of each cycle for the first 6 cycles. Up to 41 different cytokines will be measured using multiplex cytokine assay. - Sphingolipid concentrations (ceramides, sphingosine and sphingosine 1-phosphate (assessed on the bone marrow aspirate supernatants at the beginning of treatment, at the last day of cycle \#3 and at the last day of cycle \#6). For patients who receive more than 3 cycles of treatment and have a repeated bone marrow biopsy, RNA sequencing and Assay for transposases accessible chromatin sequencing (ATAC seq) will be performed to assess the effects of ABC294640 on global gene and epigenetic expression. - Expression of sphingolipid signaling genes, SK2 mRNA or activity, c-Myc, Mcl-1 and pS6 (measured in bone marrow CD138+ myeloma cells isolated at the beginning of treatment, at the last day of cycle \#3 and at the last day of cycle \#6) (if sufficient number of bone marrow CD138+ cells can be obtained)
- To perform correlative studies including serum cell-free PINK1/PARK2 (mitophagy markers), cell free DNA for next generation sequencing (for signal pathway analyses), serum bone destruction/formation markers (TRAP, Osteocalcin), and bone gene markers and Lyn/Src gene expression in both CD138+ and CD138- cells. - To evaluate immunologic function and immunologic panels (NK, NK T, T, B cells and myeloid derived suppressive cells (MDSCs) and the immune co-signalling molecules) in bone marrow environment  
| Table 5-1 - Pharmacodynamic (PD) and correlative assays: Assay Material Time points   | Lab performing the assay                                                          |                                  |
|---------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------|----------------------------------|
| PK study                                                                              | Peripheral                                                                        | Day 1 of cycle 1                 |
| blood plasma                                                                          | immediately before dosing  and at 1, 2, 4 and 8 hours  after dosing               | Sent-out test (Alliance  Pharma) |
| S1P levels                                                                            | Peripheral                                                                        | In the PK draws and at the       |
| blood plasma                                                                          | beginning of each cycle  prior to ABC294640 drug  administration (up to  cycle#6) | Sent-out test (Alliance  Pharma) |
| PT-PhI-II v11.08.18                                                                   | Duke Cancer Institute                                                             | Page 38 of 76                    |
| CONFIDENTIAL                                                                          |                                                                                   |                                  |  
Pharmacodynamic assays intend to verify if the hypothesized effects of the study drugs are indeed occurring in vivo.  
| IL-6 level                                                                                                                  | Peripheral                                                                                                                             | At the beginning of each                                                                           |                                                                          |
|-----------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------|
| blood plasma                                                                                                                | cycle prior to ABC294640  drug administration (up to  cycle#6)                                                                         | Dr. Yubin Kang's lab at  Duke                                                                      |                                                                          |
| Cytokines (up to 41                                                                                                         | Peripheral                                                                                                                             |                                                                                                    |                                                                          |
| different cytokines)                                                                                                        | blood plasma  (using existing  samples)                                                                                                | In the PK draws (0, 4, 8  hours on cycle 1 day 1 and  beginning of each cycle)                     | Dr. Yubin Kang's Lab and  Duke core facility                             |
| Cell free PINK1/PARk2  expression, Serum bone  formation/destruction  markers                                               | Peripheral                                                                                                                             | At the beginning of each                                                                           |                                                                          |
| blood plasma                                                                                                                | cycle prior to ABC294640  drug administration (up to  cycle#6)                                                                         | Dr. Yubin Kang's lab at  Duke                                                                      |                                                                          |
| Cell free DNA for next                                                                                                      | Peripheral                                                                                                                             | At the beginning of each                                                                           |                                                                          |
| generation sequencing                                                                                                       | blood plasma                                                                                                                           | cycle prior to ABC294640  drug administration (up to  cycle#6)                                     | Performed at the discretion  of PI and only if the funds  are available. |
| Ceramide, sphingosine,                                                                                                      | Bone marrow                                                                                                                            | At the beginning of                                                                                |                                                                          |
| and S1P levels                                                                                                              | supernatant                                                                                                                            | treatment, at the last day of  cycle #3 and at the last day  of cycle #6                           | Sent-out test (Medical  University of South  Carolina)                   |
| SK mRNA or activity (if  sufficient number of  bone marrow CD138+  cells can be obtained)                                   | Bone marrow                                                                                                                            | At the beginning of                                                                                |                                                                          |
| CD138+ cells                                                                                                                | treatment, at the last day of  cycle #3 and at the last day  of cycle #6                                                               | For mRNA, Dr. Kang's lab. For SK activity, Dr. Charles  Smith's lab at Apogee  Biotechnology Corp. |                                                                          |
| RNA seq and ATAC seq  for determination of the  ABC294640 on global  gene and epigenetic  expression                        | Bone marrow                                                                                                                            | We had one patient in phase                                                                        |                                                                          |
| CD138+ cells                                                                                                                | I who had received >3  cycles of treatment and had  a repeated bone marrow  biopsy. RNAseq and  ATACseq will be only for  this patient | Dr. Yubin Kang's lab and  Duke Genomic Core facility                                               |                                                                          |
| Protein level of c-Myc,  Mcl-1 and pS6 (Western  blot) (if sufficient  number of bone marrow CD138+ cells can be  obtained) | Bone marrow                                                                                                                            | At the beginning of                                                                                |                                                                          |
| CD138+ cells                                                                                                                | treatment, at the last day of  cycle #3 and at the last day  of cycle #6                                                               | Dr. Yubin Kang's lab at  Duke                                                                      |                                                                          |
| Gene expression  (Lyn/Src,  Osteoclast/osteoblast  genes, mitophagy  markers)                                               | Bone marrow  CD138+ cells  and CD138- cells                                                                                            | At the beginning of  treatment, at the last day of  cycle #3 and at the last day  of cycle #6      | Dr. Yubin Kang's lab at  Duke                                            |
| Immunologic function  and immunologic panel  (immune cells and cosignaling molecules)                                                                                                                             | Bone marrow                                                                                                                            | At the beginning of                                                                                |                                                                          |
| aspirate                                                                                                                    | treatment, at the last day of  cycle #3 and at the last day  of cycle #6                                                               | Dr. Yubin Kang's lab at  Duke                                                                      |                                                                          |  
5.3 **Time points of sample collection**
Please see the Table 5-1 (pharmacodynamics and correlative assays) for the time points at which samples will be collected. To compare with healthy control plasma samples, we will acquire up to 20 deidentified plasma samples from healthy donors, collected prior to 12/04/2018 under the biorepository protocol Pro00006268, *A Research Specimen Repository and Database to Evaluate Hematologic* Malignancies. 5.4 **Sample collection and shipment**
For peripheral blood samples, at each time point, a total of 8ml of blood will be collected (2x 4ml collected in K3EDTA tubes). Blood samples will be centrifuged as soon as possible at 500 x g for 15 min and the plasma will be transferred to cryovials (in 0.5 ml aliquots) and frozen at -800 C. These samples will be periodically transferred (shipped on dry ice by FedEx) to Alliance Pharma for analysis. For bone marrow samples, a total of 10 ml of marrow aspirate will be collected in K3 EDTA tube(s). For samples collected at Duke during the daytime, the samples will be transported immediately to Dr.  
Kang's lab. For samples collected at nighttime, the samples can be stored at 40C refrigerator and transportation to Dr. Kang's lab the following day. The address for Dr. Kang's laboratory: Room 4040, GSRB1, Duke University, phone: 919 668-4532.
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5.5 assays

-- Sphingolipid metabolite measurement (ceramides, sphingosine and sphingosine-1-phosphate):
Bone marrow aspirates will be centrifuged at 500 × g for 15 min and the supernatants will be collected.  
The samples will then be measured for sphingolipid metabolites related to the ceramide/S1P axis, including ceramides, sphingosine, and S1P. The sphingolipid metabolites will be measured using HPLCMS/MS as described by Dr. Bielawski et al101. The concentration of each sphingolipid metabolite will be normalized against total cellular phosphate and represented as pM/nM of cellular phosphate.
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-- sk activity assay

The SK activity in cell lysates prepared as described below, will be measured using HPLC-based SK
activity assay as described61. In brief, the cell lysates will be incubated with NBD-Sph in the isozymeselective assay buffers detailed below with 1 mg/ml fatty acid-free bovine serum albumin, 100 μM ATP,
and 400 μM MgCl2. The product, i.e., NBD-S1P, is separated from NBD-Sph by HPLC with fluorescence detection. The ratio of NBD-S1P/(NBD-Sph + NBD-S1P) is used as a measure of SK
activity. SK-isozyme selective assay buffers each contain 20 mM Tris, pH7.4, 5 mM EDTA, 5 mM
EGTA, 3 mM β-mercaptoethanol, 5% glycerol, 1× protease inhibitors (Sigma-Aldrich) and 1×
phosphatase inhibitors (Roche Diagnostics, Indianapolis, IN). For the SK1 assay buffer, 0.25% (final) Triton X-100 is added; and for the SK2 buffer, 1 M (final) KCl is added. Assays are run at room temperature, and then a 1.5 volume of methanol is added to terminate the kinase reaction. After 10 min, the samples are centrifuged at 20,000g to pellet the precipitated protein, and the supernatants are analyzed by HPLC. The assay will be performed at Apogee Biotechnology Corporation.  
-- Western blot for measurement of c-Myc, Mcl-1 and pS6 Bone marrow CD138+cells will be isolated from the bone marrow aspirates of these patients using Histopaque-1077 (Sigma) gradient separation followed by human CD138 enrichment kit (EasySep™,
StemCell Technologies). The purity of the human CD138+cells is normally > 95%. The protein expression of c-Myc, Mcl-1 and pS6 will be measured by Western blot as we described81. MM cells are harvested, washed with PBS, and re-suspended in lysis buffer containing 50 mM Tris-HCl pH 7.4, 150 mM NaCl, 1mM EDTA, 1% Triton x100, 1% Sodium deoxycholate, and 0.1% SDS. The cells are further lysed by brief sonication. The lysates are centrifuged at high speed for 10min to remove the cell debris. Total protein is quantified using Dc protein estimation kit (Bio Rad) with BSA for standard PT-PhI-II v11.08.18 Duke Cancer Institute Page 40 of 76 CONFIDENTIAL
curve. Approximately 20μg protein is loaded and run on SDS PAGE. The proteins are transferred onto nitrocellulose membrane. The membrane is blocked with 5% milk in *Tris-Buffered Saline* containing 0.05% of Tween 20 (TBST) and primary antibodies are applied with 1% BSA in TBST for overnight at 4 0C with gentle rocking. The membrane is then probed with HRP-conjugated secondary antibody and developed using Pierce ECL substrate.
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-- correlative biomarker studies

For the measurement of cell free serum/plasma PINK1/PARK2 (mitophagy markers), cell free DNAs will be isolated from the plasma/serum using cell free DNA isolation columns. PINK1/PARK2 expression will be quantitated by PCR. For the measurement of serum/plasma bone formation/destruction markers, TRAP, Osteocalcin, osterix and others will be measured by ELISA or western blot analysis. For signaling pathway analyses, cell free DNA will be isolated from plasma samples and subject to the next generation sequencing and pathway enrichment analyses. For the measurement of Lyn/Src, osteoclast function and macrophage, CD138+ and CD138- cells will be isolated from the bone marrow aspirate and gene expression will be measured by quantitative RT-PCR.  
For the measurement of immunologic function and immunologic panel, bone marrow aspirates (CD138+ and CD138- cells) will be cultured with antibodies and cell proliferation will be measured. Additionally, the bone marrow aspirate will be measured for NK cells, NK T cells, T (CD3, CD4, CD8), B cells, MDSCs and co-signaling molecules (PD-1, PD-L1, CTLA-4, TIGIT, TIM3 etc). For simultaneous measurement of up to 41 different cytokines, multiplex cytokine assay will be performed using existing samples at the Duke Immunology core facility. We had one patient in our phase I study who had received >3 cycles of ABC294640 treatment and had a repeated bone marrow biopsy. To determine the effects of ABC294640 treatment on gene and epigenetic expression, we will perform RNA seq and Assay for transposases accessible chromatin with high-throughput sequencing (ATAC seq) using the existing bone marrow samples on this patient.  
-- Healthy control plasma samples. To compare with healthy control plasma samples, we will use the plasma samples collected under the 00006268 biorepository protocol.
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6. study drug abc294640

ABC294640 is an orally available inhibitor of the enzyme sphingosine kinase-2.
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6.1 formulation

ABC294640 Capsules contain 250 mg of the milled active pharmaceutical ingredient (API) ABC294640 along with the excipients microcrystalline cellulose, USP/NF (Avicel® PH102, FMC) (FMC biopolymer) and colloidal silicon dioxide, NF (Cab-O-Sil® M5P). ABC294640 is a white to off-white powder and for clinical use it is encapsulated in white opaque hard gelatin capsules.
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6.2 dosage and administration

The study drug will be administered approximately every 12 hours, under fasting conditions or after a light to moderate meal for 28 days according to the dose escalation and de-escalation guidelines outlined in Section 4. A dose modification plan is also provided in Section 4.  
Storage conditions: Store atroomtemperature, 15-30C(59-86F)in a secure, locked area, properly labeled and segregated from other materials. This storage area should only be accessible to authorized individuals.
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6.4 labeling

The test article will be labeled with the sponsor name and address, description of contents and storage conditions, and will contain the statement "Caution: New Drug—Limited by Federal (or United States) law to investigational use."
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6.5 test article and accountability

The Investigator must maintain adequate records showing the receipt, dispensing, return, or other disposition of the test article including the date, quantity, batch or code number and identification of subjects (patient number and initials) who receive the test article. The Investigator will not supply the test article to any person except those named as sub-investigators and submitted to the local regulatory authority, designated staff and patients in this study. The Investigator will not dispense the test article from any sites other than those submitted to the local regulatory authority. The test article will not be relabeled or reassigned for use by other patients Drug accountability procedures to be followed by study staff and patients are outlined in Section 7. Upon completion of the study, unused supplies of the ABC294640 test article will be returned to the sponsor or destroyed as directed.
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7. method of determining treatment

Patients will be provided a drug diary at the beginning of each cycle, i.e. when additional drug is dispensed to the patient. Patients will be instructed to complete the drug diary and record their daily administration of ABC294640 during the morning and evening timeframes. Any missed or modified doses should be documented along with the reason for the modification. Patients will be instructed to return their container(s) of ABC294640 at each clinic visit so that the delegated research team can conduct a pill count to assess patient compliance. The research team has the ability to withdraw a patient from the study if that patient demonstrates repeated protocol noncompliance. Noncompliance is defined as intentionally not taking ABC294640 for 1 week in the absence of side effects attributed to ABC294640.
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7.1 safety plan 7.1.1. general

A number of measures will be taken to ensure the safety of patients participating in this trial. These measures will be addressed through exclusion criteria and routine monitoring as follows. In addition, an early stopping monitoring plan is outlined in Section 8.6.2.  
Patients enrolled in this study will be evaluated clinically and with standard laboratory tests before and at regular intervals during their participation in this study. Safety evaluations will consist of medical interviews, recording of adverse events, physical examinations, blood pressure, and laboratory measurements (performed by local laboratories). Patients will be evaluated for adverse events (all grades), serious adverse events, and adverse events requiring study drug interruption or discontinuation at each study visit for the duration of their participation in the study. Patients discontinued from the treatment phase of the study for any reason will be evaluated ~30 days (within 30–42 days) after last dose of study drug. Patients who have an ongoing treatment-related Grade > 3 or serious adverse event at the time of discontinuation from study treatment will continue to be followed as per Section 7.2.  
Women of childbearing potential must have a negative pregnancy test prior to starting therapy and must use adequate contraceptive methods during and for 12 weeks after discontinuing study therapy. If a patient becomes pregnant despite precautions, she should be apprised of the potential risk of fetal morbidity or loss.
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7.1.2. concomitant and excluded therapies

All supportive care measures consistent with optimal patient care will be given throughout the study.  
Use of anti-neoplastic or anti-tumor agents not part of the study therapy, including chemotherapy, radiation therapy*, immunotherapy, and hormonal anticancer therapy, is not permitted while participating in this study. Use of concurrent investigational agents is not permitted. Use of full dose warfarin is not permitted.  
*Localized radiation is allowed. Patients should receive full supportive care, including anti-emetic drugs, hematopoietic growth factors, transfusions of blood and blood products, fluid and electrolyte replacement, and antibiotics when appropriate. Patients are not permitted to have received cancer chemotherapy, including any other investigational therapy, within two weeks prior to study entry.  
Allopurinol (in subjects at risk for TLS due to high tumor burden) is optional and will be prescribed at the Investigator's discretion. These subjects may receive allopurinol 300 mg PO daily. Vitamins and supplements should be recorded on the concomitant medication page. All transfusions and/or blood product related procedures must be recorded on the appropriate form. Patients cannot receive concomitant therapy with drugs that are sensitive substrates of CYP450 1A2, 3A4, 2C9, 2C19 or 2D6, or strong inhibitors or inducers of all major CYP450 isozymes (including grapefruit juice). A list of commonly used drugs that are that are sensitive substrates of CYP450 1A2, 3A4, 2C9, 2C19 or 2D6, or strong inhibitors or inducers of all major CYP450 isozymes (with the half-life of each drug identified) is included as Appendix B. Patients who receive any of these medications on a regular basis should be instructed not to take them during their participation in this study. Where possible, alternative medications should be prescribed or recommended. If a patient is receiving a drug that is a sensitive substrate of CYP450 1A2, 3A4, 2C9, 2C19 or 2D6, or strong inhibitor or inducer of a major CYP450 isozyme that cannot be stopped or replaced by another medication for the duration of the clinical study that patient should not be enrolled. Additionally, due to the protein binding affinity of ABC 294640, patients should not receive concomitant therapy with Coumadin or Coumadin derivatives.
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7.2 post-treatment evaluations

The visit at which a response assessment shows disease progression or the decision was made to discontinue treatment for other reasons, such as toxicity, will be considered the End of Treatment visit. Patients completing their treatment should return for Post-30 day visit per Study Calendar Section 4.4.  
Patients who have an ongoing Grade ≥ 3 or serious adverse event that is at least possibly related to treatment will be contacted by the investigator or designee approximately every week until the event is resolved or determined to be irreversible.  
Patients will be followed for survival by clinic visit, review of medical record, and/or telephone call every 3 months from treatment discontinuation date, until 2 years post treatment discontinuation.
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7.3 patient discontinuation

Patients may discontinue study treatment at any time. Any patient who discontinues treatment will be asked to return to the study center to undergo treatment discontinuation assessments as outlined within Study Calendar Section 4.4 End of *Treatment visit*. The primary reason for discontinuation should be recorded.  
Subjects who meet the following criteria should be discontinued from study treatment:
- Grade 4 hypertension or Grade 3 hypertension not controlled with medication
- Nephrotic syndrome
- Grade ≥ 2 pulmonary or CNS hemorrhage; any Grade 4 hemorrhage
- Any grade arterial thromboembolic event that that cannot be treated with non-coumadin therapy, such as IVC filter, or LMW heparin
- Grade 4 congestive heart failure - Gastrointestinal perforation
- Tracheoesophageal fistula (any grade) or Grade 4 fistula
- Grade ≥ 3 bowel obstruction that has not fully recovered despite medical or surgical intervention
- Wound dehiscence requiring major medical or surgical intervention
- Documented disease progression per Appendix E
- Clinically significant deterioration of the patient's condition
- Patient noncompliance defined as intentionally not taking ABC294640 for 1 week in the absence of side effects attributed to ABC294640.  
- Adverse events requiring treatment discontinuation
- Investigator determination that it is not in the patient's best interest to continue participation
- Pregnancy
- Withdrawal of consent by patient
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8. statistical considerations 8.1 primary

Phase 1b: The primary objective of the phase 1b component of the clinical trial is to determine the maximum tolerated dose (MTD) and evaluate the safety of single agent ABC294640 in patients with relapsed or refractory multiple myeloma who have previously been treated with a proteasome inhibitor and an immunomodulatory agent.  
Phase 2: The primary objective of the phase 2 portion of the clinical trial is to evaluate the effects of single agent ABC294640 on treatment response and overall survival (OS) in patients with relapsed or refractory multiple myeloma who have previously been treated with a proteasome inhibitor and an immunomodulatory agent.
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8.2 primary endpoints 8.2.1. maximum

The primary endpoint of the phase 1b portion of the trial is the maximum tolerated dose (MTD), determined using Bayesian model average continual reassessment method (BMA-CRM) for dose finding.
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8.2.2. treatment response

One of the primary endpoints for the phase 2 portion of the trial is treatment response after Cycle 3 of treatment as defined by the International Myeloma Working Group criteria.  
8.2.3. Overall *survival* The other primary endpoint for the phase 2 portion of the trial is OS defined as the time interval from trial enrollment to death due to any cause. Survival times will be censored for patients lost to follow-up or still alive at the trial's termination.
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8.3 secondary endpoints

8.3.1. Safety *Endpoints* Safety assessments will consist of monitoring and reporting adverse events (AEs) and serious adverse events (SAEs) that are considered related to study drug, all events of death, and any study specific issue of concern.  
Dose-limiting **toxicity:** For the phase 1b portion of the trial, toxicities will be graded according to the NCI CTCAE version 4.0.3 criteria. DLTs will be defined as any events that are at least (possibly, probably, or definitely) attributable to ABC294640 during dose escalation.
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non hematologic dlt is defined

Symptomatic adverse events such as nausea, vomiting and diarrhea will not be considered dose limiting if they can be reduced to less than grade 3 within 72 hours with standard supportive measures such as antiemetics and antidiarrheals.
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hematologic dlt is defined as

≥Grade 4 neutropenia or thrombocytopenia that lasts more than 7 days after the last dose of study drug; ≥Grade 3 thrombocytopenia in the presence of ≥grade 3 hemorrhage of any organ/site; Any grade 5 hematologic toxicity
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8.3.2 pk pd and correlative

- Plasma PD analysis for sphingosine 1-phosphate (performed using the PK samples and at the beginning of each cycle prior to ABC294640 drug administration). Plasma IL-6 performed at the beginning of each cycles for the first 6 cycles. Up to 41 different cytokines will be performed using multiplex cytokine assay. - Sphingolipid concentrations (ceramides, sphingosine and sphingosine 1-phosphate (assessed on the bone marrow aspirate supernatants at the beginning of treatment, at the last day of cycle \#3 and at the last day of cycle \#6) - Expression of sphingolipid signaling genes, SK2 mRNA or activity, c-Myc, Mcl-1 and pS6 PT-PhI-II v11.08.18 Duke Cancer Institute Page 45 of 76 CONFIDENTIAL
(measured in bone marrow CD138+ myeloma cells isolated at the beginning of treatment, at the last day of cycle \#3 and at the last day of cycle \#6) (if sufficient number of bone marrow CD138+ cells can be obtained). For patients who receive more than 3 cycles of treatment and have a repeated bone marrow biopsy, RNA sequencing and Assay for transposases accessible chromatin sequencing (ATAC seq) will be performed to assess the effects of ABC294640 on global gene and epigenetic expression.  
- Correlative studies including: serum cell-free PINK1/PARK2 (mitophagy markers), cell free DNA for next generation sequencing (for signal pathway analyses), serum bone destruction/formation markers
(TRAP, Osteocalcin), and bone gene markers and Lyn/Src gene expression in both CD138+ and CD138cells. - Immunologic function and immunologic panels (NK, NK T, T, B cells and myeloid derived suppressive cells (MDSCs) and the immune co-signalling molecules) in bone marrow environment.
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8.4 determination of sample size

The phase 1b trial will explore three dose cohorts of ABC294640. Bayesian model average continual reassessment method (BMA-CRM) will be used for dose finding to determine the MTD. One patient will be enrolled per week per dose. Subsequent patients on each cohort may not be enrolled less than one week after the previous patient. Patients in each dose cohort must complete cycle 1 and undergo toxicity evaluation before the next dose level cohort is opened. Up to 18 patients will be used for phase 1b study. The patients at the MTD will contribute to the total sample size for the phase 2 portion of the trial.
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8.4.2. phase 2

Multiple myeloma patients who relapse or become refractory after receiving previous treatment with a proteasome inhibitor and an immunomodulatory agent usually achieve an response rate of less than 10% and survive less than a year with weekly dexamethasone salvage therapy. Currently several investigational drugs have improved the overall response rate (ORR) to about 20-35% and prolonged the OS to 1.5 years to 2 years. We consider an ORR of 20% and a 6 month improvement in OS for patients treated with single ABC294640 to be sufficiently promising to warrant further drug development.  
We therefore design the phase 2 trial to test a null ORR of 10% versus an alternative of 20% and a null median OS of 12 months versus an alternative of 18 months - equivalent to a hazard ratio (HR) of 0.67 –
assuming exponential survival, with approximately 36 months total accrual time (including 12 months of accrual for the phase 1b patients treated at the MTD), and 24 months of follow-up following accrual of the final patient.  
The exponential survival assumption is strong. Assuming exponential survival, a test of the null hypothesis that median OS = 12 months versus the alternative that median OS = 18 months is equivalent to a test of a null hazard rate of 0.058 versus an alternative hazard rate of 0.039 (HR = 0.67). We will test this hypothesis based on a likelihood ratio test of the exponential hazard rate parameter. Fifty nine subjects yields 80% power to detect a HR of 0.67 based on the stated assumptions and one-sided α = 0.025. Power was estimated using the Southwest Oncology Group's one sample survival power and sample size calculator (http://www.swogstat.org/stat/public/one_survival.htm). This number of patients will yield 73% (or 80%) power to detect an increase of ORR from 10% to 20% (or 21%) with a one-sided chi-square test (α = 0.025).
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8.5 analysis plans 8.5.1. phase

The phase 1b trial will explore three dose cohorts of ABC294640 following the Bayesian model averaging continual reassessment design: 250 mg BID (dose 0), 500 mg BID (dose 1), and 750 mg BID (dose 2). The starting dose of 250 mg BID is known to be safely tolerated as a single agent in patients with solid tumors. A dose-limiting toxicity (DLT) is defined per section 2.4. The MTD is the dose at which the estimated toxicity probability based on all 18 patients is closest to the targeted probability 0.33 among all doses. If the lowest dose (250 mg BID) is found to be too toxic, as indicated by the fact that the posterior probability that the toxicity rate for the lowest dose is greater than 0.33 is >0.9, then the trial will close and the drug declared unsafe.
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8.5.2. safety analysis

The primary safety analysis will be conducted using descriptive statistics of the incidence of adverse events (AEs), including DLTs and discontinuations due to AEs. Adverse events will be coded by body system, and summary tables with incidence rates of AEs will be generated. Descriptive statistics of AEs will be reported by dose and for subsets of patients with DLTs, patients who discontinue due to AEs, and patients with related AEs. Severity, duration, investigator attributed relationship to treatment, and outcomes of AEs will be reported. The DLT rate will be estimated with its 95% CI.
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8.5.3. phase 2

Survival times will be displayed graphically using a Kaplan-Meier curve. Median survival will be estimated, and the corresponding 95% CI constructed using Greenwood's variance estimate (Hosmer and Lemeshow, 1999). Assuming exponential survival, a test of the null hypothesis that median OS = 12 months versus the alternative that median OS = 18 months is equivalent to a test of a null hazard rate of 0.058 versus an alternative hazard rate of 0.039 (HR = 0.67). We will test this hypothesis based on a likelihood ratio test of the exponential hazard rate parameter. The overall response rate will tested with a chi-square test, under a null hypothesis that the ORR is 10% and an alternative hypothesis that the ORR is greater than 10%.
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8.5.4. analysis of secondary endpoints

Treatment response will be determined using international multiple myeloma working group response criteria after 3 cycles and 6 cycles of treatment (Appendix E). Frequencies and rates of complete response (CR), partial response (PR), stable disease, and progressive disease will be reported.
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8.6 interim analyses 8.6.1. efficacy

An interim analysis is planned after the enrollment of 33 efficacy evaluable patients in the Phase II portion of the study. Response data collected after the completion of 3 cycles of treatment will be reviewed. If there are 4 or more responses (PR, VGPR, CR, sCR) to this therapy at this time point, an additional 26 efficacy evaluable patients will be enrolled. Otherwise, the trial is stopped early for futility.  
If the ORR is 10%, the probability of early stop is 0.58, but if the ORR is 20%, the probability that the trial is stopped early is 0.08.  
We have incorporated safety stopping rules into our design to ensure patient safety (Table below) during our phase II portion of the study. The first column of the table gives the number of patients treated in each stage. The second column gives the minimum number of patients with unacceptable serious adverse event (SAE) required to stop the trial early for safety. The third column lists the proportion of subjects with related SAEs. Specifically, we will stop the trial early if there is significant toxicity defined as an unacceptable serious adverse event rate of grade 3 or 4 toxicities deemed possibly, probably or definitely related to study drug. We consider an acceptable level to be 15% (null hypothesis) and an unacceptable rate to be 30% (alternative hypothesis). We will craft a stopping rule for early stopping for strong evidence that the SAE rate is 30% vs. 15%. Given our sample size of 59 and based on 1000 simulations, this stopping rule yields a 83% chance of early termination if the true SAE rate is 0.30 and only a 4% chance of early stopping if the true SAE rate is 0.15.  
| Number of patients with grade 3 or 4  related SAEs   |                             |      |
|------------------------------------------------------|-----------------------------|------|
| Total number of patients treated                     | Point estimate of  SAE rate |      |
| 12                                                   | 8                           | 0.67 |
| 24                                                   | 10                          | 0.42 |
| 36                                                   | 11                          | 0.31 |
| 48                                                   | 12                          | 0.25 |
| 59                                                   | 13                          | 0.22 |
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8.7 analysis populations 8.7.1 intent

The efficacy analysis will be performed using the intent to treat (ITT) population that is composed of all patients enrolled and who has received at least one dose of study medication. For the analysis of tumor response, patients lost to follow-up prior to the 12-week evaluation will be considered failures.
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8.7.2 safety population

The safety population is defined as all patients who receive at least one dose of study drug.
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9. safety monitoring and reporting

The PI is responsible for the identification and documentation of adverse events and serious adverse events, as defined below. At each study visit, the PI or designee must assess, through non-suggestive inquiries of the subject or evaluation of study assessments, whether an AE or SAE has occurred.  
The investigator is responsible for ensuring that all AEs and SAEs that are observed or reported during the study is collected and reported to the FDA, appropriate IRB(s), DCN, and the sponsor in accordance with CFR 312.32 (IND Safety Reports).  
9.1 ADVERSE EVENTS
An adverse event (AE) is any untoward medical occurrence in a subject receiving study drug and which does not necessarily have a causal relationship with this treatment. For this protocol, the definition of AE also includes worsening of any pre-existing medical condition, except MM. An AE can therefore be any unfavorable and unintended or worsening sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of study drug, whether or not related to use of the study drug. Abnormal laboratory findings without clinical significance (based on the PI's judgment)
should not be recorded as AEs. But laboratory value changes that require therapy or adjustment in prior therapy are considered adverse events.  
From the time the subject initiates study treatment through the End of Treatment visit, all AEs must be recorded in the subject medical record and adverse events case report form. AEs will be followed until resolution, the condition stabilizes, the event is otherwise explained, or the subject is lost to follow-up. AEs will be assessed according to the CTCAE version 4.0.3 (Appendix A). If CTCAE grading does not exist for an AE, the severity of the AE will be graded as mild (1), moderate (2), severe (3), lifethreatening (4), or fatal (5).  
Attribution of AEs will be indicated as follows:
- Definite: The AE is clearly related to the study drug - Probably: The AE is likely related to the study drug - Possible: The AE may be related to the study drug - Unrelated: The AE is clearly NOT related to the study drug 9.2 SERIOUS ADVERSE EVENTS
An AE is considered "serious" if in the opinion of the investigator it meets one or more of the following criteria:
- Results in death - Is Life-threatening
- Constitutes a congenital anomaly or birth defect
- Is a medically significant condition (defined as an event that compromises subject safety or may require medical or surgical intervention to prevent one of the three outcomes above).  
- Requires inpatient hospitalization or prolongation of existing hospitalization
- Results in persistent or significant incapacity or substantial disruption to conduct normal life functions.
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9.3 adverse event assessment

The study period during which all AEs and SAEs must be reported begins after initiation of study treatment and ends 30 days following the last administration of study treatment. After this period, investigators should only report SAEs that are attributed to prior study treatment.  
All AEs and SAEs whether volunteered by the subject, discovered by study personnel during questioning, or detected through physical examination, laboratory test, or other means will be reported appropriately. Each reported AE or SAE will be described by its duration (i.e., start and end dates), regulatory seriousness criteria if applicable, severity, suspected relationship to the study, outcome, and actions taken.  
A consistent methodology for eliciting AEs at all subject evaluation time points should be adopted. Examples of non-directive questions include:
"How have you felt since your last clinical visit?" "Have you had any new or changed health problems since you were last here?"
Pre-existing diseases or conditions will not be considered AEs unless there is an increase in the PT-PhI-II v11.08.18 Duke Cancer Institute Page 49 of 76 CONFIDENTIAL
frequency or severity, or a change in the quality, of the disease or condition. Progression of cancer also will not be considered an AE.
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9.4 adverse event causality

To ensure consistency of AE and SAE causality assessments, investigators should apply the following general guideline:  
| Definitely       | An adverse event occurring in a plausible time relationship to drug                                                                                                                                                                                                                                               |
|------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| related          | administration, and which cannot be explained by concurrent disease or other drugs or chemicals. The response to withdrawal of the drug should be clinically plausible. The event must be definite pharmacologically or phenomenologically, using a satisfactory rechallenge procedure if necessary and feasible. |
| Probably         | An adverse event with a reasonable time sequence to administration,                                                                                                                                                                                                                                               |
| related          | and which cannot be explained by concurrent disease or other drugs or chemicals, and which follows a clinically reasonable response on  withdrawal. Rechallenge information is not required to fulfill this definition. (Note: there are important exceptions when an adverse event does not disappear upon discontinuation of the drug, yet drugrelatedness clearly exists, (e.g. bone marrow suppression, fixed-drug eruptions, and tardive dyskinesias)                                                                                                                                                                                                                                                                                                                   |
| Possibly related | An adverse event with a reasonable time sequence to administration of the drug, but which could also be explained by concurrent disease or other drugs or chemicals. Information on drug withdrawal may be lacking or unclear.                                                                                    |
| Not related      | An adverse event with a temporal relationship to drug administration which makes a causal relationship improbable, and in which other drugs, chemicals or underlying diseases provide plausible explanations.                                                                                                     |
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9.5 adverse reaction expectedness

Adverse reactions are those adverse events considered possibly, probably or definitely related to study medication. Expected adverse **reaction**s are those adverse events that are listed or characterized in the Package Insert or current Investigator Brochure. Unexpected adverse **reactions** are those not listed in the Package Insert (P.I.) or current Investigator Brochure (I.B.) or not identified. This includes adverse events for which the specificity or severity is not consistent with the description in the P.I. or I.B. For example, under this definition, hepatic necrosis would be unexpected if the P.I. or I.B. only referred to elevated hepatic enzymes or hepatitis. )
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9.6 additional adverse event considerations

a. Diagnosis vs. Signs and **Symptoms**
If known at the time of reporting, a diagnosis should be reported rather than individual signs and symptoms (e.g., record only liver failure or hepatitis rather than jaundice, asterixis, and elevated transaminases). However, if a constellation of signs and/or symptoms cannot be medically characterized as a single diagnosis or syndrome at the time of reporting, it is acceptable to report the information that is currently available. If a diagnosis is subsequently established, it should be reported as follow-up information.
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b. deaths

All deaths that occur during the protocol-specified AE reporting period, regardless of attribution, will be reported to the appropriate parties. When recording a death, the event or condition that caused or contributed to the fatal outcome should be reported as the single medical concept. If the cause of death is unknown and cannot be ascertained at the time of reporting, report "Unexplained Death".
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c. preexisting medical conditions

A preexisting medical condition is one that is present at the start of the study. Such conditions should be reported as medical and surgical history. A preexisting medical condition should be re-assessed throughout the trial and reported as an AE or SAE only if the frequency, severity, or character of the condition worsens during the study. When reporting such events, it is important to convey the concept that the preexisting condition has changed by including applicable descriptors (e.g., "more frequent headaches").
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d. hospitalizations for medical or

Any AE that results in hospitalization or prolonged hospitalization should be documented and reported as an SAE. If a subject is hospitalized to undergo a medical or surgical procedure as a result of an AE, the event responsible for the procedure, not the procedure itself, should be reported as the SAE. For example, if a subject is hospitalized to undergo coronary bypass surgery, record the heart condition that necessitated the bypass as the SAE.
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e. pregnancy

If a female subject becomes pregnant while receiving investigational therapy or within 12 weeks after the last dose of study drug, a report should be completed and expeditiously submitted to the sponsor, and CATO Pharmacovigilance. Follow-up to obtain the outcome of the pregnancy should also occur.  
Similarly, any congenital anomaly/birth defect in a child born to a female subject exposed should be reported as an SAE.  
f. Post-Study Adverse *Events* The investigator should expeditiously report any SAE occurring after a subject has completed or discontinued study participation if attributed to prior investigational agent exposure. If the investigator should become aware of the development of cancer or a congenital anomaly in a subsequently conceived offspring of a female subject who participated in the study, this should be reported as an SAE.
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9.7 procedures for eliciting recording

Investigators must report all SAEs within 24 **hours of first becoming aware** of the event.  
The completed SAE report form should be faxed or emailed to the following recipients:
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the duke study team

ATTN: Ivy Belskie, RN cc: Dr. *Yubin Kang* FAX: (919) 668-1091 Email: Ivy.Belskie@duke.edu; Yubin.Kang@duke.edu
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and

All SAEs must be reported promptly to **CATO Pharmacovigilance** within 24 hours of first becoming aware of the event by sending to the pharmacovigilance email box:
RedHill-PhV@cato.com Terry F Plasse, MD, Medical Director, RedHill Biopharma Ltd. is available for discussion should an investigator or other study staff members require consultation. Phone: +1-917-913-7315 OR +972-50-588-7376 Email: Terry@Redhillbio.com At the time of first notification of an SAE, the following information, if available, should be provided by the site to Duke and the pharmacovigilance email:
- Study protocol number
- Site Number
- Subject's study number
- Patient's date of birth
- Patient's gender
- Date of first dose of study treatment - Date of last dose of test article, if applicable
- Unit dose and schedule of test article - Adverse event term
- Time and date of occurrence of the event
- A brief description of the event, outcome to date and any actions taken
- The seriousness criteria (on) that were met - Concomitant medication at onset of the event
- Relevant past history information
- Relevant laboratory test findings
- Investigator's opinion of the relationship to test article (refer to Section 11.6.4.7)
- Investigator's signature Any missing or additional relevant information concerning the SAE should be provided in a follow-up SAE
report.  
The Investigator is required to comply with applicable regulations regarding the notification to the IRB. Acknowledgement of IRB review should be forwarded to the Duke study team.
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follow-up information

After the initial SAE report, the investigator is required to follow and provide further information in regards to the subject's condition. All SAEs should be followed until resolution, the condition stabilizes, the event is otherwise explained, or the subject is lost to follow-up. A follow-up SAE report form should be submitted within 24 hours of first awareness.
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9.8 quality control and quality

This clinical research study will be monitored internally by the PI and externally by the sponsor or designee. The PI and study staff will continuously monitor and tabulate adverse events at each study visit. Appropriate reporting to the Duke University Medical Center IRB will be made. If an unexpected frequency of Grade III or IV events occur, depending on their nature, action appropriate to the nature and frequency of these adverse events will be taken. This may require a protocol amendment, dose deescalation, or potentially closure of the study. The PI of this study will also continuously monitor the conduct, data, and safety of this study to ensure that:  
- Interim analyses occur as scheduled;
- Stopping rules for toxicity and/or response are met;
- Risk/benefit ratio is not altered to the detriment of the subjects;
- Appropriate internal monitoring of AEs and outcomes is done; - Over-accrual does not occur; - Under-accrual is addressed with appropriate amendments or actions; - Data are being appropriately collected in a reasonably timely manner.
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9.8.1 sponsor or designee oversight

RedHill Biopharma Ltd. (or its designee) will be responsible for activities such as monitoring, Study Trial Master File (TMF) maintenance, data querying and data transfers, pharmacovigilance, statistical analysis and clinical study report writing. The sponsor (or its designee) will also be responsible for FDA Reporting that includes: Expedited Serious Adverse Events Review and Annual IND reports.
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9.9 audits

The Duke School of Medicine Office of Audit, Risk and Compliance (OARC) may conduct confidential audits to evaluate compliance with the protocol and the principles of GCP. The PI agrees to allow the OARC auditor(s) direct access to all relevant documents and to allocate his/her time and the time of the study team to the OARC auditor(s) in order to discuss findings and any relevant issues. OARC audits are designed to protect the rights and well-being of human research subjects. OARC audits may be routine or directed (for cause). Routine audits are selected based upon risk metrics generally geared towards high subject enrollment, studies with limited oversight or monitoring, Investigator PT-PhI-II v11.08.18 Duke Cancer Institute Page 53 of 76 CONFIDENTIAL
initiated Investigational Drugs or Devices, federally-funded studies, high degree of risk (based upon adverse events, type of study, or vulnerable populations), Phase I studies, or studies that involve Medicare populations. Directed audits occur at the directive of the IRB or an authorized Institutional Official.  
OARC audits examine research studies/clinical trials methodology, processes and systems to assess whether the research is conducted according to the protocol approved by the DUHS IRB. The primary purpose of the audit/review is to verify that the standards for safety of human subjects in clinical trials and the quality of data produced by the clinical trial research are met. The audit/review will serve as a quality assurance measure, internal to the institution. Additional goals of such audits are to detect both random and systemic errors occurring during the conduct of clinical research and to emphasize "best practices" in the research/clinical trials environment.
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9.10 data management and processing

The electronic CRF will be the primary data collection document for the study. The CRFs will be updated in a timely manner following acquisition of new source data. Only approved study staff (i.e. Data managers, Data Coordinators), are permitted to make entries, changes, or corrections in the CRF. Any paper CRFs created for the study will have errors crossed out with a single line, and this line will not obscure the original entry. Changes or corrections will be dated, initialed, and explained (if necessary). The PI or authorized key personnel will maintain a record of the changes and corrections.  
In the electronic CRF, an audit trail will be maintained automatically by the electronic CRF management system. Designated personnel will complete user training, as required or appropriate per regulations.  
9.10.2 *Data Management Procedures and Data Verification* The sponsor or its designee will be responsible for clinical data management.  
The database will be reviewed and discussed prior to database closure, and will be closed only after resolution of all remaining queries. An audit trail will be kept of all subsequent changes to the data.
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9.10.3 study closure

Following completion of the study, the PI will be responsible for ensuring the following activities:
- Data clarification and/or resolution
- Accounting, reconciliation, and destruction/return of used and unused study drugs
- Review of site study records for completeness
- Shipment of all remaining laboratory samples to the designated laboratories
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10. administrative and ethical considerations

This protocol was designed and will be conducted and reported in accordance with the International Conference on Harmonization (ICH) Harmonized Tripartite Guidelines for Good Clinical Practice, the Declaration of Helsinki, and applicable federal, state, and local regulations.
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10.2 duhs institutional review board

The protocol, informed consent form, advertising material, and additional protocol-related documents must be submitted to the DUHS Institutional Review Board (IRB) and DCI Cancer Protocol Committee (CPC) for review. The study may be initiated only after the Principal Investigator has received written and dated approval from the CPC and IRB. The Principal Investigator must submit and obtain approval from the IRB for all subsequent protocol amendments and changes to the informed consent form. The CPC should be informed about any protocol amendments that potentially affect research design or data analysis (i.e. amendments affecting subject population, inclusion/exclusion criteria, agent administration, statistical analysis, etc.). The Principal Investigator must obtain protocol re-approval from the IRB within 1 year of the most recent IRB approval. The Principal Investigator must also obtain protocol re-approval from the CPC within 1 year of the most recent IRB approval, for as long as the protocol remains open to subject enrollment.
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10.3 informed consent

The informed consent form must be written in a manner that is understandable to the subject population. Prior to its use, the informed consent form must be approved by the IRB. The Principal Investigator or authorized key personnel will discuss with the potential subject the purpose of the research, methods, potential risks and benefits, subject concerns, and other study-related matters.  
This discussion will occur in a location that ensures subject privacy and in a manner that minimizes the possibility of coercion. Appropriate accommodations will be made available for potential subjects who cannot read or understand English or are visually impaired. Potential subjects will have the opportunity to contact the Principal investigator or authorized key personnel with questions, and will be given as much time as needed to make an informed decision about participation in the study. Before conducting any study-specific procedures, the Principal Investigator must obtain written informed consent from the subject or a legally acceptable representative. The original informed consent form will be stored with the subject's study records, and a copy of the informed consent form will be provided to the subject. The Principal Investigator is responsible for asking the subject whether the subject wishes to notify his/her primary care physician about participation in the study. If the subject agrees to such notification, the Principal Investigator will inform the subject's primary care physician about the subject's participation in the clinical study.
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10.4 study documentation

Study documentation includes but is not limited to source documents, case report forms (CRFs), monitoring logs, appointment schedules, study team correspondence with sponsors or regulatory bodies/committees, and regulatory documents that can be found in the DCI-mandated "Regulatory PT-PhI-II v11.08.18 Duke Cancer Institute Page 55 of 76 CONFIDENTIAL
Binder", which includes but is not limited to signed protocol and amendments, approved and signed informed consent forms, FDA Form 1572, CAP and CLIA laboratory certifications, and clinical supplies receipts and distribution records.  
Source documents are original records that contain source data, which is all information in original records of clinical findings, observations, or other activities in a clinical trial necessary for the reconstruction and evaluation of the trial. Source documents include but are not limited to hospital records, clinical and office charts, laboratory notes, memoranda, subjects' diaries or evaluation checklists, pharmacy dispensing records, recorded data from automated instruments, copies or transcriptions certified after verification as being accurate copies, microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject files, and records kept at the pharmacy, at the laboratories and at medico-technical departments involved in the clinical trial. When possible, the original record should be retained as the source document. However, a photocopy is acceptable provided that it is a clear, legible, and an exact duplication of the original document.  
A case report form (CRF) (including both electronic and paper CRFs) will be the primary data collection document for the study. The CRFs will be updated within two weeks of acquisition of new source data. Only approved study staff (i.e. Data Managers, Data Coordinators), are permitted to make entries, changes, or corrections in the CRF. For paper CRFs, errors will be crossed out with a single line, and this line will not obscure the original entry. Changes or corrections will be dated, initialed, and explained (if necessary). The Principal Investigator or authorized key personnel will maintain a record of the changes and corrections. For electronic CRFs, an audit trail will be maintained by the electronic CRF management system.
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10.5 privacy confidentiality and data

The Principal Investigator will ensure that subject privacy and confidentiality of the subject's data will be maintained. Research Data Security Plans (RDSPs) will be approved by the appropriate institutional Site Based Research group.  
To protect privacy, every reasonable effort will be made to prevent undue access to subjects during the course of the study. Prospective participants will be consented in an exam room where it is just the research staff, the patient and his family, if desired. For all future visits, interactions with research staff (study doctor and study coordinators) regarding research activities will take place in a private exam room. All research related interactions with the participant will be conducted by qualified research staff who are directly involved in the conduct of the research study. To protect confidentiality, subject files in paper format will be stored in secure cabinets under lock and key accessible only by the research staff. Subjects will be identified only by a unique study number and subject initials. Electronic records of subject data will be maintained using dedicated databases which are located on secure file servers. Access to electronic databases will be limited to Dr. Kang's staff, DCN staff, RedHill staff and designated affiliates. Upon completion of the study, research records will be archived and handled per DUHS HRPP policy.  
Subject names or identifiers will not be used in reports, presentations at scientific meetings, or publications in scientific journals.
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10.6 data and safety monitoring

Data and Safety Monitoring will be performed in accordance with the Duke Quality Assurance Plan.
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10.7 protocol amendments

All protocol amendments must be initiated by the Principal Investigator and approved by the IRB prior to implementation. IRB approval is not required for protocol changes that occur to protect the safety of a subject from an immediate hazard. However, the Principal Investigator must inform the IRB and all other applicable regulatory agencies of such action immediately.  
Though not yet required, the CPC should be informed about any protocol amendments that potentially affect research design or data analysis (i.e. amendments affecting subject population, inclusion/exclusion criteria, agent administration, etc.).
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10.8 records retention

The Principal Investigator will maintain study-related records for the longer of a period of:
- at least two years after the date on which a New Drug Application is approved by the FDA
- at least two years after formal withdrawal of the IND associated with this protocol
- at least six years after study completion
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11. sponsor and multi-site investigator

Dr. Yubin Kang will be responsible for selecting qualified investigators, providing them with the information they need to conduct an investigation properly, ensuring proper monitoring of the investigation, ensuring that the investigation is conducted in accordance with the general investigational plan and protocol, and ensuring that FDA and all participating investigators are promptly informed of significant new adverse effects or risks with respect to the drug.
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11.1 study initiation

Centers participating in the Phase II portion of the study cannot begin enrollment until an initiation letter has been issued from the DCN. Each center is required to participate in an initiation conference call. Before the start of this study and the shipment of ABC294640 to a participating center, the following documents must be on file at Duke Cancer Center. Participating centers will be responsible for forwarding the initiation documents to DCN. Initiation documents can be submitted via electronic mail to the regulatory coordinator at Duke. Please ensure that the site and study identifier are clearly identified. These documents are required to be submitted by each participating center:  
1. U.S. Food and Drug Administration (FDA) Form 1572, signed by the Principal Investigator at the participating center.  
2. The names of any sub-investigators at the participating center must appear on this form. Investigators must also complete all regulatory documentation as required by local regulations. This includes any required human subjects training required by the site's local IRB.  
3. Current curricula vitae and documentation of professional licensure of the Principal Investigator and co-Investigators listed on the 1572.  
4. Resumes and human subject protections documentation (e.g. NIH, CITI) for all research personnel
(e.g. study coordinators, data managers and other research personnel).  
5. A signed and dated protocol signature page.  
6. Written documentation of IRB approval of protocol (identified by title, protocol version and date of approval) for each site.  
7. IRB approved study informed consent and HIPAA consent form, if applicable. HIPAA consent language can be included within the study informed consent. Please note that all informed consent forms should be reviewed and approved by the Duke Cancer Network office prior to submission to the site's designated IRB.
8. A signed Confidentiality Agreement. 9. A signed Clinical Trial Agreement for each site.  
10. Laboratory certifications (CAP, CLIAs) and laboratory reference value ranges for each laboratory listed on the site's 1572.  
11. Any Duke Cancer Network site specific forms as required.
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11.2 study completion

The following data and materials are required by DCN before a study can be considered complete or terminated:
1. Copies of protocol amendments and IRB approval/notification, if appropriate. 2. Copies of the IRB final report, documentation of submission to the IRB.  
3. A summary of the study prepared by the Principal Investigator (Study report, manuscript and/or abstract).  
4. All regulatory documents (e.g., updated curriculum vitae for each Principal Investigator, updated U.S. FDA Form 1572 for each site).
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11.3 institutional review board approval

This protocol, the informed consent document, and relevant supporting information must be submitted to the IRB for review and must be approved before the study is initiated. In addition, any advertising materials, if applicable, must be approved by the IRB. The study will be conducted in accordance with U.S. FDA, applicable national and local health authority, and IRB requirements.  
The Principal Investigator at each site is responsible for keeping his/her IRB apprised of the progress of the study and of any changes made to the protocol as deemed appropriate, but in any case the IRB must be updated at least once a year. The Principal Investigator must also keep the IRB informed of any significant adverse events.  
Investigators are required to promptly notify their respective IRB of all adverse drug reactions that are both serious and unexpected. This generally refers to serious adverse events that are not already identified in the Investigator Brochure and that are considered possibly or probably related to the study drug by the investigator. Some IRBs may have other specific adverse event requirements to which investigators are expected to adhere. If a center's IRB does not require the review of all external adverse events, a written policy or statement outlining the IRB's reporting requirements must be provided to
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11.4 quality assurance

The PI, sponsor or its designee will be responsible for quality assurance. Steps to assure the accuracy and reliability of data include the review of protocol procedures with the Investigator and associated personnel prior to the study, and periodic monitoring visits by the sponsor and/or its representative, and ongoing data quality reviews of received case report forms. Data will be reviewed for accuracy and completeness and any discrepancies will be resolved with the Investigator or designees as appropriate.
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11.5 data collection

Data collected will be entered into electronic CRFs managed by the sponsor or designee. The eCRF
system is a 21CFR part 11 compliant system. The sponsor and its representatives will be provided access to the data collected, and for monitoring purpose, to source information, in accordance with institutional policy.
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12. general considerations

12.1 **Discontinuation of the Study**
The Sponsor reserves the right to discontinue this study for safety or administrative reasons at any time.  
12.3 **Premature Study Termination**
The study may be terminated prematurely for any reason and at any time by the sponsor, an IRB/IEC, or a Regulatory Authority. A decision to prematurely terminate the study is binding to all investigators of all study sites. If the study is terminated prematurely, all investigators have to inform their patients and take care of appropriate follow-up and further treatment of the patients to ensure protection of the patients' interests.  
12.4 **Changes to the Protocol**
This protocol cannot be altered or changed except through a formal protocol amendment, which requires the written approval of the Sponsor. The protocol amendment must be signed by the Investigator and approved by the IRB or IEC before implementation. Protocol amendments will be filed with the appropriate regulatory agency(s) having jurisdiction over the conduct of the study.
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12.5 protocol deviations for emergency

An Investigator shall notify the Principal Investigator and the reviewing IRB of any deviation from the investigational plan to protect the life or physical well-being of a patient in an emergency. Such notice shall be given as soon as possible, but in no event later than five working days after the emergency occurred. Except in such an emergency, prior approval by the Principal Investigator is required for PT-PhI-II v11.08.18 Duke Cancer Institute Page 59 of 76 CONFIDENTIAL
12.2 **Routine Study Termination**
The end of this study is defined as the date of the last visit of the last patient (last patient out or last patient last visit) participating in the study. Within 90 days of the end of the clinical study, the sponsor or designee will notify the IRB and regulatory authorities regarding routine termination of the study as required.  
changes or deviations from a plan, and if these changes or deviations affect the scientific soundness of the plan or the rights, safety, or welfare of patients, notification of the FDA and IRB in accordance with government regulations is also required.  
12.6 **Source Documents**
All information recorded in the CRF must be supported by corresponding source documentation. Examples of acceptable source documentation include, but are not limited to, hospital records, clinic and office charts laboratory notes, and recorded data from automated instruments, memoranda, and pharmacy dispensing records. For the proposed study, electronic records will be the primary source documentation, along with written reports for laboratory assays.  
During the study, select CRF data may be used as original data collection tools as long as a description of this documentation process is maintained in the Investigator's study files. Before the study starts, a list identifying any data to be recorded directly on the CRFs (i.e., no prior written or electronic record of data) and considered to be source data will be provided.  
Clinical laboratory data required by the protocol will be electronically transferred from the central laboratory to the sponsor or its designee. A paper copy of the laboratory results will be provided to the study site and should be retained with each patient's source data.
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appendix b list of cyp3a4

From http://www.georgetown.edu/departments/pharmacology/davetab.html  
| The following are known inhibitors of CYP3A4: Delaviridine   | Indinavir               |
|--------------------------------------------------------------|-------------------------|
| Nelfinavir                                                   | Ritonavir               |
| Saquinavir                                                   | Amiodarone              |
| Cimetidine                                                   | Ciprofloxacin           |
| Clarithromycin                                               | Diethyl-dithiocarbamate |
| Diltiazem                                                    | Erythromycin            |
| Fluconazole                                                  | Fluvoxamine             |
| Gestodene ++                                                 | Grapefruit juice        |
| Itraconazole                                                 | Ketoconazole            |
| Mifepristone                                                 | Nefazodone              |
| Norfloxacin                                                  | Norfluoxetine           |
| Mibefradil                                                   | Troleandomycin          |
| Atazanavir                                                   | Indinavir               |
| Telithromycin                                                | Voriconazole            |
| The following are known inducers of CYP3A4: Rifampicine      | Phenytoin               |
| Rifabutin                                                    | Rifapentine             |
| Carbamazepine                                                | Phenobarbital           |
| St. John's Wort                                              |                         |
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appendix c ecog performance status

| Grade   | Description                                                                                                                                                 |
|---------|-------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 0       | Fully active, able to carry on all pre-disease performance without restriction                                                                              |
| 1       | Restricted in physically strenuous activity but ambulatory and able to  carry out work of a light or sedentary nature, e.g., light housework or office work |
| 2       | Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about >50% of waking hours                                      |
| 3       | Capable of only limited self-care, confined to a bed or chair >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 d new york heart

| Class I   | People whose physical activity is not limited. Ordinary physical activity does not cause undue fatigue, heart palpitations, trouble breathing, or chest pain.                                          |
|-----------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Class II  | People who have some limitation on physical activity. They are comfortable at rest, but ordinary physical activity causes fatigue, heart palpitations, trouble breathing, or chest pain.               |
| Class III | People who have a marked limitation on physical activity. They are comfortable at rest, but less-than-ordinary physical activity causes fatigue, heart palpitations, trouble breathing, or chest pain. |
| Class IV  | People who are unable to carry on any physical activity without discomfort. Symptoms may be present even at rest. If any physical activity is undertaken, discomfort is increased                      |  
| Response category                 | Criteria                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
|-----------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Stringent complete response (sCR) | CR as defined below plus  - Normal FLC ratio  - Absence of clonal cells in bone marrow by  immunohistochemistry or immunofluorescence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |
| Complete response (CR)            | - Negative immunofixation of the serum and urine and - • < 5% plasma cells in bone marrow and - Disappearance of any soft tissue plasmacytomas.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |
| Very good partial response (VGPR) | - Serum and urine M-protein detectable by immunofixation  but not on electrophoresis or  - 90% or greater reduction in serum M-protein plus urine Mprotein level <100 mg per 24 hour.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |
| Partial response (PR)             | ≥ 50% reduction of serum M-protein and reduction in 24- hour urinary M-protein by ≥ 90% or to < 200 mg per 24 hour. - If the serum and urine M-protein are unmeasurable, a ≥ 50%  decrease in the difference between involved and uninvolved  FLC levels is required In place of the M-protein criteria - If serum and urine M-protein are unmeasurable, and serum  free light assay is also unmeasurable, ≥ 50% reduction in  bone marrow plasma cells is required in place of M-protein,  provided baseline bone marrow plasma cell percentage was ≥  30%  - In addition to the above listed criteria, if a plasmacytoma is  present at baseline, ≥ 50% reduction in the size of soft tissue  plasmacytomas is also required |
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appendix e response and relapse

| Progressive Disease   | Progressive Disease requires any one or more of the following: Increase of ≥25% from baseline in - Serum M-component and/or (the absolute increase must be ≥0.5  g/dl) - Urine M-component and/or (the absolute increase must be ≥200  mg/24hour - Only in patients without measurable serum and urine M-protein  levels: the difference between involved and uninvolved FLC  levels. The absolute increase must be >10 mg/dl - Bone marrow plasma cell percentage: the absolute % must be  ≥1-% - Definite development of new bone lesions or soft tissue  plasmacytomas or definite increase in the size of existing bone  lesions or soft tissue plasmacytomas - Development of hypercalcemia (corrected serum calcium >  11.5 mg/dl or 2.65 mmol/l) that can be attributed solely to the  plasma cell proliferative disorder   |
|-----------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Clinical relapse      | Clinical relapse requires one or more of: Direct indicators of increasing disease and/or end organ dysfunction  (CRAB features). It is not used in calculation of time to progression or  progression-free survival but is listed here as something that can be  reported optionally or for use in clinical practice 1. Development of new soft tissue plasmacytomas or bone lesions 2. Definite increase in the size of existing plasmacytmas or bone  lesions. A definte increase is defined as a 50% (and at least  1cm) increase as measured serially by the sum of the products  of the corr-diameters of the measurable lesion. 3. Hypercalcemia (> 11.5 mg/dl) [2.65 mmol/l] 4. Decrease in hemoglobin of ≥ 2g/dl [1.25 mmol/l] 5. Rise in serum creatinine by 2 mg/dl or more [177 micro mol/l  or more]                   |  
| PHASE Ib AND II PORTION - CLINICAL AND LABORATORY EVALUATIONS a Cycle 2 Cycle 3 Cycle 4   | Subsequent      |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
|-------------------------------------------------------------------------------------------|-----------------|----|-----|----|-----|----|----|----|--------|------------|----|----|----|----|----|----|
| Cycle 1                                                                                   | End of          | Followup    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| W 1 W                                                                                     | p               |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| W 3 W                                                                                     | W  W  W 3 W 4 W | W  | W   | W  | W   | W  | W  | W  | cycles | Treatmentu |    |    |    |    |    |    |
| 2                                                                                         | 4               | 1  | 2   | 1  | 2   | 3  | 4  | 1  | 2      | 3          | 4  |    |    |    |    |    |
| Screening                                                                                 |                 |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| Activity                                                                                  | Phase b         |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| Informed Consent c                                                                        | X               |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| Serum Pregnancy Test d                                                                    | X               |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| Study Registration e                                                                      | X               |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| History and Physical Examt                                                                | Xs              | Xq | X   | X  | X   | X  | X  | X  | X      | X          | X  | X  | X  | X  |    |    |
| ECOG Performance Status                                                                   | Xs              | Xq | X   | X  | X   | X  | X  | X  | X      | X          | X  | X  | X  |    |    |    |
| Vital Signs                                                                               | X               | X  | X   | X  | X   | X  | X  | X  | X      | X          | X  | X  | X  |    |    |    |
| Assessment of Concomitant Medications                                                     | Xs              | X  | X   | X  | X   | X  | X  | X  | X      | X          | X  | X  | X  |    |    |    |
| Serum chemistry f                                                                         | Xr,s            | Xq | X   | X  | X   | X  | X  | X  | X      | X          | X  | X  | X  | X  |    |    |
| PT/INR and aPTT g                                                                         | Xs              | Xq | X   | X  | X   | X  | X  | X  | X      |            |    |    |    |    |    |    |
| Xs                                                                                        | Xq              | X  | X   | X  | X   | X  | X  | X  | X      | X          | X  | X  | X  |    |    |    |
| Complete blood count with differential h Screening HIV, HBV and HCV i                     | X               |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| 12 Lead ECG j                                                                             | X               |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| Echocardiogram k                                                                          | X               |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| Urinalysis                                                                                | Xs              | Xq | X   | X  | X   | X  | X  |    |        |            |    |    |    |    |    |    |
| Xs                                                                                        | Xq              | X  | X   | X  | X   | X  |    |    |        |            |    |    |    |    |    |    |
| SPEP (serum protein  electrophoresis) Serum free light chain                              | Xs              | Xq | X   | X  | X   | X  | X  |    |        |            |    |    |    |    |    |    |
| Urine monoclonal protein                                                                  | Xs              | Xq | X   | X  | X   | X  | X  |    |        |            |    |    |    |    |    |    |
| IFE (immunofixation                                                                       | Xs              | Xq | X   | X  | X   | X  | X  |    |        |            |    |    |    |    |    |    |
| electrophoresis) Immunoglobulin profile                                                   | Xs              | Xq | X   | X  | X   | X  | X  |    |        |            |    |    |    |    |    |    |
| Beta-2 microglobulin                                                                      | Xs              | Xq | X   | X  | X   | X  | X  |    |        |            |    |    |    |    |    |    |
| Metastatic bone survey l                                                                  | X               | X  |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| Administration of ABC296460                                                               | X               | X  | X   | X  | X X | X  | X  | X  | X      | X          | X  | X  | X  | X  | X  | X  |
| Adverse Events Assessment m                                                               | X               | X  | X   | X  | X   | X  | X  | X  | X      | X          | X  | X  |    |    |    |    |
| Review Patient Diary and Pill Count                                                       | X               | X  | X   | X  | X   | X  | X  | X  | X      | X          | X  | X  |    |    |    |    |
| Plasma PK n                                                                               | X               |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |
| Plasma PD v                                                                               | X               | X  | X   | X  | Xv  |    |    |    |        |            |    |    |    |    |    |    |
| Bone marrow biopsy o                                                                      | X               | X  | X o |    |     |    |    |    |        |            |    |    |    |    |    |    |
| Survival Follow-up                                                                        | X               |    |     |    |     |    |    |    |        |            |    |    |    |    |    |    |  
Footnotes: a) Cycle = 28 days. For cycle 1 to 4, ± 3 days for all visits except cycle 1 day 1. For cycle 5 and beyond, ± 7 days for all visits.  
b) Screening Evaluations must be completed within 30 calendar days prior to Treatment Day 1, except for bone marrow biopsy, which should be performed within 2 weeks prior to Treatment Day 1.  
c) Informed Consent must be signed within 30 days before Treatment Day 1, and will be updated and re-signed by Investigator and Subjects, as needed.  
d) Pregnancy test (for WOCBP) must be performed within 48 hours of first administration of study drug on Treatment Day 1.  
e) Investigator must confirm that patient will not have taken chemotherapy for at least 14 days prior to Treatment Day 1.  
f) Serum Chemistries will include: sodium, chloride, carbon dioxide, potassium, calcium, phosphorous, magnesium, BUN, creatinine, blood sugar (random), albumin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and bilirubin (total, direct).  
g) INR and aPTT will be performed at screening, every week during cycle 1 and then the first week of each following cycle.  
h) Complete blood count will include hemoglobin, hematocrit, total leukocyte count including differential, platelets.  
i) Patients undergo HIV and hepatitis screening (HBVsAg, anti-HBs, anti-HBc; anti-HCV
qualitative).  
j) ECGs will be obtained during screening.  
k) Performed at baseline and end of treatment, and if patient demonstrates signs or symptoms of myocardial degeneration.  
l) Metastatic bone survey: at the screening, then every year or at the end of treatment.  
m) Performed according to CTCAE version 4.  
n) Plasma for PK analysis ABC294640 alone will be collected Cycle 1, Day 1 immediately before dosing and at approximately 1, 2, 4, and 8, hours after dosing and will be sent to Dr. Kang's lab and/or Apogee Biotechnology Corporation for analysis.  
o) Bone marrow biopsy must be obtained prior to initiation of treatment with ABC294640 (within 2 weeks prior to the treatment), at the end of cycle 3 (± 7 days) and at the end of cycle 6 (± 7 days).  
For patients who discontinue therapy for any reason before completing 3 cycles, bone marrow biopsy will be obtained at the time of discontinuation or as soon as feasible thereafter. After cycle 6, the bone marrow biopsy will be performed at the discretion of the treating physician.  
p) If the patient was removed from treatment for toxicity, the patient should be followed with weekly clinic visit and laboratory studies as appropriate, at Duke Cancer Center or the patient's local MD,
until the AE has resolved to baseline.  
Phase II patients should be followed every 3 months for survival, for 2 years from the time of their End of Treatment visit.  
q) If Screening was performed within 1 week prior to C1D1, these procedures/labs do not need to be repeated. If urine monoclonal protein was performed within 14 days of C1D1, it will not need to be repeated.  
r) Includes LDH at screening.s) Screening procedures/labs which can be assessed prior to drug administration may be completed on C1D1, if necessary.  
t) Physical exam at screening, and day 1 of each cycle will be a focused exam including vital signs, HEENT, heart/lung/chest/abdomen/skin and neurological assessment. Physical exam at all other time points will be symptom-directed.  
u) EOT should occur within 4-6 weeks after the last dose of study drug.  
v) PD samples will be collected on C1D1 prior to study drug administration and at approximately 1, 2, 4, and 8, hours after dosing along with PK samples and prior to ABC294640 drug administration on D1 of each subsequent cycle through C6.  
PT-PhI-II v11.08.18 Duke Cancer Institute Page 66 of 76 CONFIDENTIAL
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appendix g drug diary

ABC294640 Drug Diary (Page 67 **of 3) Cycle**:____________**Subject ID:______** *Version 3, 03/22/2017* Take _____ pills in the morning and _____ pills in the evening approximately 12 hours apart. (Example: 9:00am and 9:00 pm)
Take the pills at least 1 hour before or 2 hours after eating. Bring the pill bottle with any leftover pills (or if empty) and diary with you to *each* clinic visit.  
If you have questions, call _______________________ at the phone number: ___________________. My doctor's name is:  
____________________.  
| ____________________.                                  | ABC294640                                          |            |        |            |
|--------------------------------------------------------|----------------------------------------------------|------------|--------|------------|
| # of                                                   | Comment                                            |            |        |            |
| Tablets                                                | (include details and reason                        |            |        |            |
| Taken                                                  | for missed doses, etc)                             |            |        |            |
| Exact Time  Tablets  Taken                             | # of                                               |            |        |            |
| Tablets  Taken                                         | Exact Time  Tablets  Taken                         |            |        |            |
| Week Day                                               | Date                                               |            |        |            |
| (DD-MMMYYYY)                                                        | ___ mg                                             | HH:MM (AM) | ___ mg | HH:MM (PM) |
| 1 2 3 4 5 6 7                                          |                                                    |            |        |            |
| 1                                                      | 8 9 10 11 12 13 14                                 |            |        |            |
| 2 *To be completed by Research RN:                     | wk1 date reviewed: _______ time:_____ Initials:___ |            |        |            |
| wk2 date reviewed: _______ time:_____ Initials:_______ |                                                    |            |        |            |  
Ph  
ABC294640 Drug Diary (Page 68 **of 3) Cycle**:___________**Subject ID:______** *Version 3, 03/22/2017* Take _____ pills in the morning and _____ pills in the evening approximately 12 hours apart. (Example: 9:00am and 9:00 pm)
Take the pills at least 1 hour before or 2 hours after eating. Bring the pill bottle with any leftover pills (or if empty) and diary with you to *each* clinic visit.  
If you have questions, call _______________________ at the phone number: ___________________. My doctor's name is:  
| ABC294640                      |                            |            |         |            |
|--------------------------------|----------------------------|------------|---------|------------|
| # of                           |                            |            |         |            |
| Tablets  Taken                 | Exact Time  Tablets  Taken | # of       |         |            |
| Tablets  Taken                 | Exact Time  Tablets  Taken | Comment    |         |            |
| (include details and           |                            |            |         |            |
| reason for missed doses,  etc) |                            |            |         |            |
| Week Day                       | Date                       |            |         |            |
| (DD-MMMYYYY)                                | ___ mg                     | HH:MM (AM) | ____ mg | HH:MM (PM) |
| 15 16 17 18 19 20 21           |                            |            |         |            |
| 3                              | 22 23 24 25 26 27 28       |            |         |            |
| 4 ____________________.        |                            |            |         |            |  
____________________. *To be completed by Research RN: wk3 date reviewed: _______ time:_____ Initials:___  
wk4 date reviewed: _______ time:_____ Initials:_______  
Ph  
If you need additional room to write your information or comments, please use the table below. Write any additional notes regarding your answers above.  
| Date   | Additional Notes   |
|--------|--------------------|
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