untitled h1
10 statistical considerations 10.1 phase

We will employ the Bayesian Optimal Interval (BOIN) design [46] to find the MTD. The BOIN design is a novel Bayesian dose-finding method that optimizes patient ethics by minimizing the chance of exposing patients to sub-therapeutic and overly toxic doses. The BOIN design yields an average performance comparable to that of the continual reassessment method (CRM) in terms of selecting the MTD, but has a lower risk of assigning patients to sub-therapeutic or overly toxic doses (i.e., better patient ethics). There are two dosing schedule treatment arms in the Phase I study: the combination treatment with Zotiraciclib (TG02) and dd TMZ; and the combination treatment of Zotiraciclib (TG02) with mn TMZ. Dose finding will be conducted independently in these two arms. For each arm, the target toxicity rate is 0.35 and the maximum sample size for dose finding is 24 patients. We will enroll and treat patients in cohorts of size 3. We consider four dose levels and the starting dose is level 0 (i.e., TMZ 125mg/m2 + 200mg/day Zotiraciclib (TG02)).  
| Level                              | Arm                                               |       |
|------------------------------------|---------------------------------------------------|-------|
| TMZ (mg/m2 x 7 days on/7 days off) | TG 02 (mg/day on 1, 12,15,26  per 28 days cycle)* |       |
| -1                                 | 125                                               | 150   |
| 0 (starting dose)                  | 125                                               | 200   |
| I                                  | 125                                               | 250   |
| II                                 | 125                                               | 300** |
| Level                              | Arm                                               |       |
| TMZ (mg/m2 daily)                  | TG 02 (mg/day on 1, 12,15,26 per 28 days cycle)*  |       |
| -1                                 | 50                                                | 150   |
| 0 (starting dose)                  | 50                                                | 200   |
| I                                  | 50                                                | 250   |
| II                                 | 50                                                | 300** |  
* The first dose of Zotiraciclib (TG02) will be given 3 days prior to Day1 of cycle 1. The subsequent doses for cycle 1 will be given on days 1, 12, 15, and 26. Zotiraciclib (TG02) will be given on days 1, 12, 15, and 26 every 28-day cycle in all the cycles starting cycle 2. ** One patient in MN arm developed severe toxicities which lead to ICU admission after one dose of Zotiraciclib (TG02) at 300mg. The etiology was not completely clear. However, due to the patient's safety concern, does level II of Zotiraciclib (TG02) was determined to be eliminated in both study arms by the investigator and pharmaceutical manufacture. The BOIN trial design is described as follows: 1. Patients in the first cohort are treated at dose level 0. 2. To assign a dose to the next cohort of patients, we conduct dose escalation/de-escalation according to the rule displayed in Table 13.  
| The number of patients treated at the current dose   |    |    |    |    |    |    |
|------------------------------------------------------|----|----|----|----|----|----|
| Action                                               | 3  | 6  | 9  | 12 | 15 | 18 |
| Escalate if # of patients who experienced DLT <=     | 0  | 1  | 2  | 3  | 4  | 4  |
| De-escalate if # of patients  who experienced DLT >= | 2  | 3  | 4  | 6  | 7  | 8  |
| Eliminate if # of patients  who experienced DLTs >=  | 3  | 5  | 6  | 7  | 9  | 10 |  
When using Table 13, please note the following:
(a) "Eliminate" means that we eliminate the current and higher doses from the trial to prevent treating any future patients at these doses because they are overly toxic. (b) When we eliminate a dose, we automatically de-escalate the dose to the next lower level.  
When the lowest dose is eliminated, we stop the trial for safety. In this case, no dose should be selected as the MTD. (c) If none of the actions (i.e., escalation, de-escalation or elimination) is triggered, we treat the new patients at the current dose. (d) If the current dose is the lowest dose and the rule indicates dose de-escalation, we will treat the new patients at the lowest dose unless the number of DLTs reaches the elimination boundary, at which point we will terminate the trial for safety. (e) If the current dose is the highest dose and the rule indicates dose escalation, we will treat the new patients at the highest dose.  
(f) If the number of patients treated at the current (or any) dose reaches 12, we will stop the trial early and select the MTD as described below.  
3. Repeat step 2 until the maximum sample size of 24 is reached or the trial is stopped. After the trial is completed, we select the MTD based on isotonic regression as specified previously. [46] Specifically, we select as the MTD the dose for which the isotonic estimate of the toxicity rate is closest to the target toxicity rate. If there are ties, we select the higher dose level when the isotonic estimate is lower than the target toxicity rate; and we select the lower dose level when the isotonic estimate is greater than the target toxicity rate. After identifying the MTD for each of the TMZ dosing schedules in combination with Zotiraciclib (TG02) (i.e., 125mg/m2 TMZ on days 1-7 and 15-21 per cycle, and 50 mg/m2 TMZ daily), cohort expansion will be conducted independently at each of the MTDs until the total number of patients treated at each of the MTDs reaches 18 patients (including the patients who have been treated in the dose-finding part). The dosing schedule with a higher PFS at 4 months (PFS4) will be selected and used in phase II. If the difference between the PFS4 values from the two full cohorts treated at each of the MTDs is less than 10% of the average of the two PFS4 values, then the dosing schedule with fewer AEs will be selected as the "winner." During the cohort expansion phase, the elimination rule displayed in the last row of Table 13 will be used to monitor toxicity. Given the cohort expansion of 18 patients at the MTD, there is 72.6% chance to correctly pick the better schedule when the PFS4 for two schedules are 50% and 60% (i.e., 10% difference in PFS4), respectively; and there is 81.9% chance to correctly pick the better schedule when the PFS4 for two schedules are 50% and 65% (i.e., 15% difference in PFS4) Table 14 shows the operating characteristics of the BOIN design for this trial with 4 scenarios defined by different DLT rates for 4 doses. These operating characteristics are based on 1,000 simulations of the trial using R package "BOIN", which is available from CRAN. The operating characteristics show that the design selects the true MTD with high probabilities and allocates more patients to the dose levels with the DLT rate closest to the target of 0.35.  
| Dose level    | Number   | % early   |      |      |      |      |
|---------------|----------|-----------|------|------|------|------|
| of pts        | stopping |           |      |      |      |      |
| -1            | 0        | 1         | 2    |      |      |      |
| True DLT rate | 0.05     | 0.15      | 0.35 | 0.47 |      |      |
| Selection %   | 0.3      | 25.3      | 54.3 | 20.1 | 19.7 | 0.0  |
| # pts treated | 0.4      | 7.5       | 8.5  | 3.4  |      |      |
| True DLT rate | 0.12     | 0.35      | 0.44 | 0.55 |      |      |
| Selection %   | 16.2     | 59.3      | 21.2 | 3.3  | 18.5 | 0.0  |
| # pts treated | 4.0      | 9.7       | 3.9  | 1.0  |      |      |
| True DLT rate | 0.35     | 0.50      | 0.55 | 0.62 |      |      |
| Selection %   | 57.0     | 28.3      | 4.3  | 0.2  | 17.1 | 10.2 |
| # pts treated | 8.2      | 7.4       | 1.4  | 0.1  |      |      |
| True DLT rate | 0.05     | 0.10      | 0.16 | 0.35 |      |      |
| Selection %   | 0.1      | 4.4       | 24.2 | 71.3 | 20.7 | 0.0  |
| # pts treated | 0.2      | 4.6       | 7.2  | 8.7  |      |      |  
In phase I, for each arm, the maximum sample size of 24 patients will be used for dose finding. As there are 4 doses, on average at least 6 patients will be treated at the MTD. After the MTD is selected, cohort expansion will be conducted at the MTD until the total number of patients treated at the MTD reaches 18 patients (including the patients who have been treated in the dosefinding part). Thus, no more than 12 additional patients will be enrolled during the cohort expansion phase. Therefore, the maximum number of patients for phase I, including dose finding and cohort expansion, is 24+12=36 patients per treatment arm, and 72 in total for two treatment arms. During the interim analysis of the Phase I study, we identified TG02 of 250 mg as the MTD in both Arm 1 and Arm 2. Cohort expansion was conducted independently at each of the MTD into treatment arms, and the PSF4 was found to be 38% in Arm 1 and 25% in Arm 2. Therefore, based on the preplanned analysis, the DD TMZ dosing schedule is considered a "winner" to be used in Phase II study. However, a better PFS was found in patients who received TG02 at dose level 0, compared to those received TG02 at dose level 1, which is MTD, in Arm 1, the winner arm, suggesting the lower dose with the scheduled TMZ may be sufficient if not more beneficial for patients with recurrent high grade astrocytoma. However, we cannot make the conclusion based on the small sample number in Arm 1 at dose level 0. Therefore, we would like to continue enrolling to the maximum, allow the additional 12 patients enrolled to be treated with TG02 at dose level 0 combined with dd TMZ. We do not plan to change the study design. The primary endpoint is still toxicity. The objective is to add a small cohort expansion to better characterize the dose-toxicity relationship and obtain some preliminary efficacy readout to determine RP2D. If PFS4 month difference between MTD and (MTD-1) is less than 5%, select the lower dose, I.e., MTD-1, as the RP2D; otherwise select the MTD as RP2D. There should not be safety concerns because additional patients will be treated with TG02 at a dose that is lower than the MTD that was identified previously. The purpose for enrolling more patients is to further define a dosage not only safe but optimal for the patients before we move to Phase II study. Only AE and PFS4 will be recorded in these subjects.
untitled h1
10.2 phase ii component

A randomized phase II trial will be used to compare the combination of Zotiraciclib (TG02) plus TMZ (selected from phase I) with TMZ alone in patients with recurrent grade III or IV malignant glioma. The TMZ alone arm will use the same dosing schedule as it is in the combination arm. The primary endpoint is progression free survival. We will enroll at least 10 patients and at most 40 patients for each arm at a rate of 4 patients per month. Patients will be equally randomized into two arms. Patients' KPS, MGMT promoter methylation status of the tumors and the presence of measurable disease at study entry will be used as stratification factors. We will follow all patients for at least 12 months, and monitor futility and toxicity as described below. We will use the methods described by Thall et al., to monitor progression-free survival (PFS), and we will stop enrolling patients early if, based on the available data, we have reason to believe that the median PFS of the Zotiraciclib (TG02) plus TMZ arm is less than that of the TMZ arm.[50] Formally, we will stop enrolling patients early if Pr (median PFSTG02+TMZ ≥ median PFSTMZ | data from the trial) < 0.78, The futility monitoring will be conducted after enrolling 20, 40 and 60 patients (for two arms combined). Below are the operating characteristics of the above futility monitoring rule, assuming that the median PFS of the TMZ alone arm is 3 months.  
| Median PFS for Zotiraciclib (TG02) +TMZ (months)   |       |       |       |       |       |
|----------------------------------------------------|-------|-------|-------|-------|-------|
| 1                                                  | 2     | 3     | 4     | 5     |       |
| Early stop probability                             | 0.999 | 0.812 | 0.374 | 0.170 | 0.097 |
| Average sample size                                | 23.7  | 42.1  | 62.6  | 70.9  | 74.7  |  
Similar Bayesian methods will also be used to monitor the rate of DLT. We will monitor the two arms independently. Specifically, we will stop enrolling patients if the Pr(DLT > 35% | data) > 0.9. That is, we will stop enrolling patients if the data indicate that there is more than 90% chance that the true DLT rate is higher than 35%. This decision rule gives the following stopping rule, assuming a Beta (0.1, 0.4) prior distribution for DLT rate, Stop enrolling pts if [\# of pts with DLT] / [\# of pts evaluated] ≥ 4/5, 6/10, 10/20, and 15/30. Below are the operating characteristics of the toxicity monitoring rule.  
Table 16: Operating Characteristics of the Toxicity Monitoring Rule  
| True toxicity rate   |     |     |     |     |
|----------------------|-----|-----|-----|-----|
| 0.2                  | 0.3 | 0.4 | 0.5 | 0.6 |  
| Early stop probability   | 0.014   | 0.096   | 0.345   | 0.716   | 0.939   |
|--------------------------|---------|---------|---------|---------|---------|
| Average sample size      | 39.6    | 37.3    | 31.0    | 21.3    | 13.5    |  
At progression, patients on the control arm will be offered treatment with Zotiraciclib (TG02) in combination with continued treatment with TMZ. If an effective salvage regimen, this may impact the secondary OS endpoint, but will not affect the primary endpoint of the study. The maximum number is 80 patients.
untitled h1
statistical analysis plan

We will use descriptive statistics to summarize the demographic and clinical characteristics of patients. We will tabulate adverse events by grade by dose level and overall. For the cohort expansion and phase II component, we will estimate the proportion of patients with response with 95% exact binomial confidence intervals, and use descriptive statistics to summarize response duration. We will estimate PFS/OS with the Kaplan-Meier product limit estimator. Log-rank test will be used to compare the PFS/OS between Zotiraciclib (TG02)+TMZ and TMZ. Changes of symptom burden (i.e., MDASI-BT) through study time points will be assessed by paired t-tests and linear mixed model. In the mixed model, subject-specific random intercept will be used to account for within-subject correlation, and measurement time will be included as a covariate. A sample size of 40 patients has 80% power to detect an effect size of 0.454 between time points using a two-tailed test with an alpha of 0.05. The two-sample t-test and linear mixed model will be used to evaluate differences in symptom burden using the MDASI-BT between Zotiraciclib (TG02) plus TMZ and TMZ. Cox proportional hazard model will be used to evaluate the relationship between MDASI-BT and disease progression. Logistic regression will be used to evaluate the relationship between MDASI-BT and tolerance to treatment. Treatment effects will be evaluated by advanced MRI imaging study. Perfusion and diffusion - based MRI parameters, including but not restricted to blood volume, blood flow mean and median Apparent Diffusion Coefficient (ADC) value will be analysed. Results will be summarized. The mean and median value at different time points will be tabulated. Changes in such parameters will be analysed for statistical significance and correlate with the disease status.
untitled h1
10.2.1 patient reported outcomes

Received MDASI-BT form will be checked versus the timing schedule and considered as valid if they fall within ten days of the scheduled assessment window. Compliance rates will be calculated as the number of received valid forms over the number of expected forms. Differences between groups in compliance will be tested by use of Fisher's exact test at every time point. We will use descriptive statistics to describe how patients rate symptom severity and interference with function at each time point. Error bar graphs for each of the symptoms will be constructed at each time point. The proportion of patients rating their symptoms to be 5 or greater (on a 0-10 scale) will also be reported. We will construct individual patient profiles for each of the selected symptoms to describe the individual patients' patterns of change over time. We will calculate the mean symptom severity, and mean symptom interference at the time of clinical evaluation. Estimates of differences in the mean symptom severity and mean symptom interference between responders and non-responders will be estimated in the intent to treat population. All patients with at least one valid questionnaire will be included in the analyses. Questionnaires completed at study registration will be considered baseline. All questionnaire data received after randomization will be used in the primary analyses.  
Differences of at least 2 points will be classified as the minimum clinically meaningful change in the symptom severity and symptom interference measures. For example, an increase of 2 points or more would mean a moderate improvement, whereas a decrease of 2 points or more would be interpreted as moderate worsening. For individual symptoms, a rise in a symptom score means deterioration, whereas a reduced score means improvement of the specific symptom.
untitled h1
11 collaborative agreements 11.1 agreement

The study agent, Zotiraciclib (TG02) is provided by Adastra Pharmaceuticals, Inc. under a Clinical Trials Agreement (CTA \#01007-16). Results or study data may be communicated to CTA partner, Adastra Pharmaceuticals, Inc. according to the terms of the NIH- Advanced Accelerator Applications SA CTA. There is an executed Material Transfer Agreement (MTA\#40216-15) with Adastra Pharmaceuticals.
untitled h1
12 human subjects protections 12.1

This study was designed to include women and minorities but was not designed to measure differences of intervention effects. Males and females will be recruited with no preference to gender. No exclusion to this study will be based on race. Minorities will actively be recruited to participate.
untitled h1
12.2 participation of children

Because no dosing or adverse event data are currently available on the use of TMZ in combination with Zotiraciclib (TG02) in subjects <18 years of age, children are excluded from this study.
untitled h1
12.3 participation of subjects unable

Adults unable to give consent are excluded from enrolling in the protocol. However, re-consent may be necessary and there is a possibility, though unlikely, that subjects could become decisionally impaired. For this reason and because there is a prospect of direct benefit from research participation (a potential for reduction in their tumor volume, which may or may not have favorable impact on symptoms and/or survival), all subjects will be offered the opportunity to fill in their wishes for research and care, and assign a substitute decision maker on the NIH Advance Directive for Health Care and Medical Research Participation" form so that another person can make decisions about their medical care in the event that they become incapacitated or cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH Ability to Consent Assessment Team (ACAT) for evaluation as needed for the following: an independent assessment of whether an individual has the capacity to provide consent; assistance in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the capacity to appoint a surrogate. For those subjects that become incapacitated and do not have pre-determined substitute decision maker, the procedures described in NIH HRPP SOP 14E for appointing a surrogate decision maker for adult subjects who are (a) decisionally impaired, and (b) who do not have a legal guardian or durable power of attorney, will be followed.
untitled h1
12.4 evaluation of benefits and

12.4.1 The primary risk to patients participating in this research study is from toxicity of the Zotiraciclib (TG02) and TMZ as described in the protocol.
untitled h1
12.4.2 alternative approaches or treatments

Patients will be consented verbally and in writing regarding the risks and benefits of this trial, the treatment requirements, and alternative approaches to entering on this trial.
untitled h1
12.4.3 procedure for protecting against

All care will be taken to minimize side effects, but they can be unpredictable in nature and severity. This study may involve risks to patients, which are currently unforeseeable. All patients will have blood tests, examinations and scans as described in the study calendar (Section 3.8). Patients will also be required to have a local physician to provide long-term care and to monitor for complications. If patients suffer any physical injury as a result of the participation in this study, immediate medical treatment is available at the Clinical Center, National Cancer Institute, Bethesda, Maryland. Although no compensation is available, any injury will be evaluated and treated in keeping with the benefits or care to which patients are entitled under applicable regulations.
untitled h1
12.4.4 provisions for monitoring data

As information is gathered from this trial, clinical results will be shared with patients as they become available. Laboratory and clinical data will be frequently gathered and any new significant finding(s) found during the course of the research, which may affect a patient's willingness to participate further, will be explained. Confidentiality of information concerning participants will be maintained, including in all publications and presentations resulting from this study. Names of participants and/or material identifying participants will not be released without permission, except as such release is required by law. Records at the National Cancer Institute are maintained according to current legal requirements, and are made available for review, as required by the Food and Drug Administration or other authorized users, only under the guidelines established by the Federal Privacy Act.
untitled h1
12.5 risks/benefits analysis 12.5.1 benefits

The potential benefit to a patient on this study is a reduction in the bulk of their tumor and improvement in cancer lesions, which may or may not have favorable impact on symptoms and/or survival.
untitled h1
12.5.2 risks

Risks include the possible occurrence of any of a range of side effects which are listed in the Consent Document or this protocol document. Frequent monitoring for adverse effects will help to minimize the risks associated with administration of the study agents.
untitled h1
12.5.3 mr imaging with gadolinium

The MRIs to be done in this study will involve contrast. The risks associated with MRIs and contrast are discussed in the consent form. Although MR imaging with gadolinium has been used as part of the standard care for patients with high grade gliomas, long term toxicities of gadolinium as a consequence of gadolinium accumulation in the body has been reported. All investigators will ascertain the MR imaging history of all prospective study participants to determine the extent of prior exposure to gadolinium contrast. Radiology will be consulted if there is a history of repeated gadolinium exposure.
untitled h1
12.5.4 risks/benefits analysis

Given the potential benefits and the efforts to minimize risk with the administration of this combination, this protocol involves greater than minimal risk, but presents the potential for direct benefit to individual subjects, including those able to consent as well as those that may lose the capacity to do so over the course of the trial.
untitled h1
12.6 consent and assent process

The informed consent document will be provided to the participant for review prior to consenting. A designated study investigator will carefully explain the procedures and tests involved in this study, and the associated risks, discomforts and benefits. In order to minimize potential coercion, as much time as is needed to review the document will be given, including an opportunity to discuss it with friends, family members and/or other advisors, and to ask questions of any designated study investigator. A signed informed consent document will be obtained prior to entry onto the study. 12.6.1 The initial consent process as well as re-consent, when required, may take place in person or remotely (e.g., via telephone or other NIH approved remote platforms) per discretion of the designated study investigator and with the agreement of the participant/consent designee(s). Whether in person or remote, the privacy of the subject will be maintained. Consenting investigators (and participant/consent designee, when in person) will be located in a private area (e.g., clinic consult room). When consent is conducted remotely, the participant/consent designee will be informed of the private nature of the discussion and will be encouraged to relocate to a more private setting if needed. Request for Waiver of Consent for Screening Activities Prior to the subject signing the consent for this study pre-screening activities listed in section 2.2.1 may be performed. We request a waiver of consent for these activities as they involve only minimal risk to the subjects. A waiver will not adversely affect the rights and welfare of the subjects given that the activities are only intended to determine suitability for screening for participation in research protocols. These activities could not practicably be carried out without the wavier as central recruiting services, utilized in the NIH Clinical Center, perform pre-screening activities for multiple studies and obtaining consent for each one is beyond their resources. The subjects will be provided with additional pertinent information after participation as they will be informed whether or not they are eligible to sign a consent for additional screening.
untitled h1
13.1.1 source

Temozolomide will be purchased from commercial sources to the NIH CC Pharmacy.
untitled h1
13.1.2 formulation and preparation

Temozolomide Capsules are available in 5-mg, 20-mg, 100-mg, 140-mg, 180-mg, and 250- mg strengths. The capsules contain a white capsule body with a color cap, and the colors vary based on the dosage strength. Each strength of TEMODAR must be dispensed in a separate vial or in its original package (one strength per one container). Follow the instructions below: Based on the dose prescribed, determine the number of each strength of TEMODAR capsules that are needed. Label each container with the appropriate number of capsules to be taken each day. Dispense to the patient, making sure each container lists the strength (mg) per capsule and that he or she understands to take the appropriate number of capsules of TEMODAR from each package or vial to equal the total daily dose prescribed by the physician. TEMODAR is store at 25°C, excursions permitted to 15-30°C.
untitled h1
13.1.3 contraindications

There are no dietary restrictions for patients taking TEMODAR. TEMODAR may affect testicular function, so male patients should exercise adequate birth control measures. TEMODAR may cause birth defects. Female patients should avoid becoming pregnant while receiving this drug. Women who are nursing prior to receiving TEMODAR should discontinue nursing. It is not known whether TEMODAR is excreted into breast milk. Because many drugs are excreted in human milk, and because of the potential for serious adverse reactions in nursing infants and tumorigenicity shown for temozolomide in animal studies, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of TEMODAR to the mother.
untitled h1
13.1.4 administration procedures

Patients should take each day's dose with a full glass of water at the same time each day. Taking the medication on an empty stomach or at bedtime may help ease nausea. If patients are also taking anti-nausea or other medications to relieve the side effects associated with TEMODAR,
they should be advised to take these medications 30 minutes before they take TEMODAR. Temozolomide causes the rapid appearance of malignant tumors in rats. Patients SHOULD NOT open or split the capsules. If capsules are accidentally opened or damaged, rigorous precautions should be taken with the capsule contents to avoid inhalation or contact with the skin or mucous membranes. The medication should be kept away from children and pets. The TEMODAR capsules should be swallowed whole and NEVER CHEWED.
untitled h1
13.1.5 side effects

The most common adverse reactions (≥10% incidence) are: alopecia, fatigue, nausea, vomiting, headache, constipation, anorexia, convulsions, rash, hemiparesis, diarrhea, asthenia, fever, dizziness, coordination abnormal, viral infection, amnesia, and insomnia. The most common Grade 3 to 4 hematologic laboratory abnormalities (≥10% incidence) that have developed during treatment with temozolomide are: lymphopenia, thrombocytopenia, neutropenia, and leukopenia. The adverse reaction from clinical trials that are conducted in different patient population are summarized as following: Newly Diagnosed Glioblastoma: During the concomitant phase (TEMODAR+radiotherapy), adverse reactions including thrombocytopenia, nausea, vomiting, anorexia, and constipation were more frequent in the TEMODAR+RT arm. The incidence of other adverse reactions was comparable in the two arms. The most common adverse reactions across the cumulative TEMODAR experience were alopecia, nausea, vomiting, anorexia, headache, and constipation. Forty-nine percent (49%) of patients treated with TEMODAR reported one or more severe or life-threatening reactions, most commonly fatigue (13%), convulsions (6%), headache (5%), and thrombocytopenia (5%). Overall, the pattern of reactions during the maintenance phase was consistent with the known safety profile of TEMODAR. Myelosuppression (neutropenia and thrombocytopenia), which is a known dose-limiting toxicity for most cytotoxic agents, including TEMODAR, was observed. When laboratory abnormalities and adverse reactions were combined, Grade 3 or Grade 4 neutrophil abnormalities including neutropenic reactions were observed in 8% of the patients, and Grade 3 or Grade 4 platelet abnormalities, including thrombocytopenic reactions, were observed in 14% of the patients treated with TEMODAR.  
Refractory Anaplastic Astrocytoma: The incidence of adverse reactions in the 158 patients in the anaplastic astrocytoma study for whom data are available. In the absence of a control group, it is not clear in many cases whether these reactions should be attributed to temozolomide or the patients' underlying conditions, but nausea, vomiting, fatigue, and hematologic effects appear to be clearly drug-related. The most frequently occurring adverse reactions were nausea, vomiting, headache, and fatigue. The adverse reactions were usually NCI Common Toxicity Criteria (CTC) Grade 1 or 2 (mild to moderate in severity) and were self-limiting, with nausea and vomiting readily controlled with anti-emetics. The incidence of severe nausea and vomiting (CTC Grade 3 or 4) was 10% and 6%, respectively. Myelosuppression (thrombocytopenia and neutropenia) was the dose-limiting adverse reaction. It usually occurred within the first few cycles of therapy and was not cumulative. Myelosuppression occurred late in the treatment cycle and returned to normal, on average, within 14 days of nadir counts. The median nadirs occurred at 26 days for platelets (range: 21-40 days) and 28 days for neutrophils (range: 1-44 days). Only 14% (22/158) of patients had a neutrophil nadir and 20% (32/158) of patients had a platelet nadir, which may have delayed the start of the next cycle. Less than 10% of patients required hospitalization, blood transfusion, or discontinuation of therapy due to myelosuppression. In clinical trial experience with 110 to 111 women and 169 to 174 men (depending on measurements), there were higher rates of Grade 4 neutropenia (ANC less than 500 cells/μL) and thrombocytopenia (less than 20,000 cells/μL) in women than men in the first cycle of therapy (12% vs. 5% and 9% vs. 3%, respectively). In the entire safety database for which hematologic data exist (N=932), 7% (4/61) and 9.5% (6/63) of patients over age 70 experienced Grade 4 neutropenia or thrombocytopenia in the first cycle, respectively. For patients less than or equal to age 70, 7% (62/871) and 5.5% (48/879) experienced Grade 4 neutropenia or thrombocytopenia in the first cycle, respectively. Pancytopenia, leukopenia, and anemia have also been reported.
untitled h1
13.2 zotiraciclib (tg02) 13.2.1 description

The chemical name for Zotiraciclib (TG02) citrate is (16E)-14-Methyl-20-oxa-5,7,14,26-tetraazatetracyclol[19.3.1.1(2,6).1(8,12)]heptacosa-1(25),2(26),3,5,8(27),9,11,16,21,23-decaene − citric acid. The molecular formula of Zotiraciclib (TG02) citrate is C23H24N4O C6H8O7 and it has a molecular weight of 564.58 (TG02 citrate salt) and 372.46 (TG02 base). The structure is as follows:  
  
| TG02 Citrate                                                                                                                                                                             |                                                                        |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------|
| Trade name                                                                                                                                                                               | Zotiraciclib citrate                                                   |
| Manufacturer                                                                                                                                                                             | Adastra Pharmaceuticals, Inc.                                          |
| Strength (mg)                                                                                                                                                                            | 50, 150                                                                |
| Take appropriate number of capsules with 8oz. water while fasting (i.e., at least 1  hour before or 2 hours after a meal). Capsules should not be crushed or broken for  administration. |                                                                        |
| Route                                                                                                                                                                                    | Oral                                                                   |
| Dosage form                                                                                                                                                                              | Capsule                                                                |
| Storage                                                                                                                                                                                  | Store at 25°C (77°F); excursions permitted 15°C to 30°C (59°F to 86°F) |
| Dosing  instructions                                                                                                                                                                     |                                                                        |
untitled h1
13.2.2 source

Zotiraciclib (TG02) is an investigational agent. The IND holder is the NCI Center for Cancer Research. Adastra Pharmaceutical, Inc. will provide Zotiraciclib (TG02) citrate capsules for this protocol.
untitled h1
13.2.3 toxicity

All toxicities observed in patients are from the data provided in the Investigators Brochure Version 6. All data are derived from clinical studies that are summarized in the table 6 in Section 1.
untitled h1
11.2.3.1 single agent zotiraciclib (tg02)

Fifty-five acute leukemia patients were evaluated for the safety and efficacy of single agent Zotiraciclib (TG02). 96% (53/55) patients experienced Treatment Emergent Adverse Events (TEAE). Most frequently reported TEAEs (43/55 patients 78%) occurred in the System Organ Class of Gastrointestinal Disorders. They were also frequently reported in the following System Oran Classes: General Disorders and Administration Site Conditions (23/55 patients, 42%), Metabolism and Nutrition Disorders (22/55 patients, 40%), Nervous system Disorders (17/55patients, 31%), Respiratory, Thoracic and Mediastinal Disorders (14/55 patients, 25%), and Skin and Subcutaneous Tissue Disorders (12/55 patients, 22%). The most frequently reported TEAEs were as follows: nausea (32/55 patients, 58%), vomiting (21/55 patients 38%), fatigue (15/55 patients, 27%) and diarrhea, decreased appetite and abdominal pain (13/55 patients each, 24%). Thirty-nine patients (39/55 patients, 71%) had ≥1 treatment-related TEAEs. Five patients (9%) experienced grade 5/fatal TEAE and all five were assed as unrelated to the study drug by the investigator. Three patients (5%) had grade 4/life threatening TEAE, including hyperglycemia, cardio-respiratory arrest and enterococcal sepsis. All events were assed as unrelated to the study drug. The most commonly reported grade 3TEAEs were fatigue (11%) and nausea (7%). When TEAEs were analyzed by their maximum severity, regardless of causality, five acute leukemia patients (5/55 [9%]) who were administered single agent Zotiraciclib (TG02) experienced a Grade 5/fatal TEAE (Schedule A, 3/27 patients [11%]; Schedule B, 2/22 [9%]; Schedule D, 0/6 [0%]). The Preferred Terms for the Grade 5 TEAEs were pneumonia (2 patients), sepsis, intracranial hemorrhage, and cardio-respiratory arrest. All five events were assessed as unrelated to study drug by the investigator. Three acute leukemia patients (3/55 [5%]) administered single agent Zotiraciclib (TG02) experienced a Grade 4/life-threatening TEAE (Schedule A, 1/27 patients [4%]; Schedule B, 2/22 patients [9%]; Schedule D, 0/6 patients [0%]). The Preferred Terms for the Grade 4 TEAEs were hyperglycemia, cardio-respiratory arrest and enterococcal sepsis. All events were assessed as unrelated to study drug by the investigator. The most frequently reported Grade 3 TEAEs were fatigue (6/55 patients [11%]) and nausea (4/55 patients [7%]) occurring on Schedules A and B. No Grade 3 or higher fatigue, nausea, vomiting or diarrhea occurred on Schedule D. Serious Adverse Events: Fifteen acute leukemia patients (15/55 [27%]) administered single agent Zotiraciclib (TG02) experienced ≥1 SAE (Schedule A, 5/27 patients [19%]; Schedule B, 8/22 patients [36%]; Schedule D 2/6 patients [33%]). No individual body system had an incidence of SAEs of ≥10%. No significant differences were noted between schedules. Four patients (4/55 patients [7%]) experienced ≥ 1 serious suspected adverse reaction considered related to study drug by the investigator (Schedule A, 1/27 patients [4%]; Schedule B, 3/22 patients [14%];
Schedule D, (0/6 patients [0%]).  
Patient 03-002 (Schedule A, 10 mg) experienced two occurrences of related nausea resulting in hospitalization and three occurrences of related vomiting resulting in hospitalization (2 of the occurrences occurred concomitantly with the related nausea). Study drug was interrupted. The patient recovered without sequelae from all events.  
Patient 03-018 (Schedule B, 50 mg) experienced related vomiting that resulted in hospitalization. Study drug was interrupted due to this event.  
Patient 01-053 (Schedule B, 150 mg) experienced two occurrences of related fatigue which required hospitalization. The first occurrence of fatigue occurred during Cycle 1 and was considered a DLT. Study drug was withheld and resumed at the start of Cycle 2 at 100 mg. The second occurrence of fatigue was in Cycle 2. Study drug was held and resumed at the start of Cycle 3 at 100 mg on Days 1-3 and 8-10, a reduced schedule. The patient came off study at the end of Cycle 4 for progressive disease. This patient also experienced the non-related SAE of respiratory syncytial virus infection. The patient recovered without sequelae from all events.  
Patient 03-057 (Schedule B, 150 mg) experienced the related SAE of severe failure to thrive, which required hospitalization. Study drug was interrupted and subsequently discontinued the study due to this event. The patient recovered without sequelae from the SAE.  
Study Drug Discontinuations Due to TEAEs: Seven acute leukemia patients (7/55 [13%]) administered single agent Zotiraciclib (TG02) discontinued study drug due to a TEAE (Schedule A, 3/27 [11%]; Schedule B, 3/22 patients [14%]; Schedule D 1/6 patients [17%]). No individual body system had an incidence of SAEs of ≥10%. No significant differences were noted between schedules. The Preferred Terms for these TEAEs were vomiting, pneumonia, maculopapular rash, dyspepsia, nausea, fatigue and balance disorder (in one patient) and stomatitis.  
Deaths: Five patients (5/55 [9%]) experienced a Grade 5/ fatal TEAE (Schedule A, 3/27 patients
[11.1%]; Schedule B, 2/22 patients [4.5%]; Schedule D, (0/6 patients [0%]).  
Patient 01-026 (Schedule A, 50 mg Zotiraciclib (TG02)) died of pneumonia. The patient had discontinued study drug and the event occurred during the follow-up period. The event was assessed as not related to study drug by the investigator.  
Patient 01-044 (Schedule A, 70 mg Zotiraciclib (TG02)) died of pneumonia. The event was assessed as not related to study drug by the investigator.  
Patient 03-015 (Schedule A, 30 mg Zotiraciclib (TG02)) died due to sepsis and refractory AML. The patient had discontinued study drug and the event occurred during the followup period. The event was assessed as not related to study drug.  
Patient 01-059 (Schedule B, 150 mg Zotiraciclib (TG02)) died due to intracranial hemorrhage. The patient had discontinued study drug and the event occurred during the follow-up period. The event was assessed as not related to study drug by the investigator.  
Patient 03-049 (Schedule B, 100 mg Zotiraciclib (TG02) died due to cardiopulmonary arrest. The event was assessed as not related to study drug by the investigator.
untitled h1
11.2.3.2 single agent zotiraciclib (tg02)

Eighteen multiple myeloma patients administered single agent Zotiraciclib (TG02) were evaluated for safety. All patients had discontinued from the study as of the data cut-off date. The reasons for discontinuation were withdrawal of consent (7/18 patients [39%]), progressive disease (7/18 patients [39%]), other (2/18 patients [11%]), adverse event (1/18 patients [6%]) and investigator decision (1/18 patients [6%]). Most frequently reported TEAEs (17/18 patients 94%) occurred in the System Organ Class of Gastrointestinal Disorders. The most frequently reported TEAEs were as follows: diarrhea (10/18 patients, 56%), nausea and fatigue (9/18 patients, 50%), vomiting and constipation (7/18 patients each, 39%), hypophosphatemia (6/18 patients, 33%), decreased appetite and hypokalemia (5/18 patients each, 28%). The incidence of the TEAEs constipation, hypophosphatemia, decreased appetite and hypokalemia did not differ significantly between the dosing schedules. Diarrhea, fatigue, nausea and vomiting occurred more frequently on Schedule G than Schedule C. Higher doses were administered in Schedule G (100 and 150 mg) than in Schedule C (50 and 70 mg). Fatigue and vomiting occurred more frequently on Schedule G than Schedule H. A less dose-intense schedule was administered in Schedule H (BIW for 3 weeks) than in Schedule G (TIW for 3 weeks) although the number of patients in Schedule H is small. - Diarrhea: Schedule C, 2 pts [33%]; Schedule G, 6 pts [78%]; Schedule H, 2 pts [67%] - Fatigue: Schedule C, 1 pts [17%]; Schedule G, 7 pts [77%]; Schedule H, 1 pt [33%] - Nausea: Schedule C, 1 pts [17%]; Schedule G, 6 pts [67%]; Schedule H, 2 pts [67%] - Vomiting: Schedule C, 0 pts [0%]; Schedule G, 6 pts [67%]; Schedule H, 1 pt [33%] Fifteen patients (15/18 patients, 83%) had ≥1 treatment-related TEAEs. One patients (17%) experienced grade 5/fatal TEAE and the event was assed as unrelated to the study drug by the investigator. Five patients (28%) had grade 4/life threatening TEAE, including GI hemorrhage, thrombocytopenia, neutrophil count decreased, platelet count reduced and hyperuricemia. All events were assed as unrelated to the study drug. The most commonly reported grade 3TEAEs were hypophosphatemia (28%). Serious Adverse Events: Five multiple myeloma patients (5/18 patients [28%]) administered single agent Zotiraciclib (TG02) experienced ≥1 SAE (Schedule C, 4/6 patients [67%];
Schedule G, 0/9 patients [0%]; Schedule H, 1/3 patients [33%]). Each of the SAEs (GI hemorrhage and respiratory failure [in the same patient], fatigue, pneumonia, bone pain and pneumonia streptococcal) were experienced by 1 patient each. One patient (1/18 [6%]) experienced a serious suspected adverse reaction considered related to study drug by the investigator. Patient 02-058 (Schedule C, 70 mg) experienced Grade 3 related fatigue resulting in hospitalization. This event was considered a DLT. Study drug was interrupted and then discontinued due to this event. The patient recovered without sequelae from the event. Study Drug Discontinuations Due to TEAEs: Two multiple myeloma patients (2/18 [11%]) administered single agent Zotiraciclib (TG02) discontinued study drug due to a TEAE (Schedule C, 2/6 patients [33%], Schedules G and H (0/12 patients [0%]). One patient discontinued study drug due to fatigue that was assessed by the investigator as related to study drug and a DLT. The patient recovered without sequelae from the event. The second patient discontinued study drug due to musculoskeletal bone pain that was assessed by the investigator as not related to study drug. The patient recovered with sequela from the event.  
Deaths: One multiple myeloma patient (1/18 [16.7%]) administered single agent Zotiraciclib
(TG02) experienced Grade 5 fatal respiratory failure. Patient 05-045 (Schedule C, 50 mg) died of respiratory failure. The event was assessed as not related to study drug by the investigator and related to the patient's underlying disease state (i.e., progressive disease). 11.2.3.3 Single Agent Zotiraciclib (TG02) in Chronic Lymphocytic Leukemia (CLL) patients Only eight CLL patients administered single agent Zotiraciclib (TG02) were evaluated for the drug safety. Seven of them (88%) experienced ≥1 TEAEs.  
Most frequently reported TEAEs (17/18 patients 94%) occurred in the System Organ Class of Gastrointestinal Disorders. The most frequently reported TEAEs were as follows: nausea (6/8 patients, 75%), diarrhea (4/8 patients, 50%), vomiting, constipation, cough and dyspnea (3/8 patients each, 38%). Four patients developed treatment –related TEAEs with nausea being the most frequently reported treatment –related TEAEs. No dose-related trends were noted due to the small number of patients. No CLL patients experienced a Grade 5/ fatal TEAE. Three CLL patients (3/8 patients [38%]) administered single agent Zotiraciclib (TG02) experienced Grade 4/ Life-Threatening TEAEs. Preferred Terms for the Grade 4 TEAEs were sepsis and thrombocytopenia (1 patient), sepsis, pneumonia staphylococcal and staphylococcal bacteremia (1 patient), thrombocytopenia, neutropenia and hypotension. The events of sepsis and thrombocytopenia occurring in the same patient were assessed as related to study drug by the investigator. The other Grade 4 TEAEs were assessed as unrelated to study drug by the investigator. No Grade 3 TEAE was experienced by more than one patient (1/8 [13%]). Serious Adverse Events: Three CLL patients (3/8 [38%]) administered single agent Zotiraciclib
(TG02) experienced ≥ 1 SAE. The body systems in which the SAEs occurred were Infections and Infestations (2/8 patients [25%]), Blood and Lymphatic System Disorders (1/8 patients [13%]) and Psychiatric Disorders (1/8 patients [13%]). Only the SAE of sepsis was experienced by more than one patient (2/8 patients [25%]). Two CLL patients (2/8 [25%]) experienced a serious suspected adverse reaction considered by the investigator to be related to study drug.  
Patient 200-005 (Schedule A, 70 mg) experienced related confusion state resulting in hospitalization. This event was Grade 2 and did not meet the criteria for a DLT. Study drug was interrupted. The patient recovered without sequelae from the event.  
Patient 400-010 (Schedule A, 100 mg) experienced related sepsis, thrombocytopenia and febrile neutropenia. Sepsis was considered a DLT. Study drug was interrupted and restarted at 70 mg, a reduced dose.
Study Drug Discontinuations Due to TEAEs: One CLL patient (1/8 [13%]) administered single agent Zotiraciclib (TG02) discontinued study drug due to a TEAE. Patient 100-003 discontinued study drug due to pneumonia staphylococcal, staphylococcal abscess and staphylococcal bacteremia. The patient recovered without sequelae from the events. Deaths: No CLL subjects administered single agent Zotiraciclib (TG02) died on study.
untitled h1
13.2.4 formulation and preparation

Zotiraciclib (TG02) citrate capsules will be provided as formulated dry powder blend containing Zotiraciclib (TG02) citrate in hard gelatin capsules. Capsule strengths are expressed as Zotiraciclib
(TG02). The formulation compositions and brief descriptions of the capsule products are shown in the following table. The capsule strengths (50 and 150mg) are distinguished by size and color, and the actual dose of Zotiraciclib (TG02) has been corrected for citrate salt (e.g., 50mg Zotiraciclib (TG02) is 76mg Zotiraciclib (TG02) citrate).  
| Strength (mg)                         |                |            |
|---------------------------------------|----------------|------------|
| 50mg                                  | 150mg          |            |
| (TG02-50)                             | (TG02-150)     |            |
| Capsule size                          | 2              | 0          |
| Capsule color                         | Swedish orange | Light blue |
| Ingredients (mg/capsule) TG02 citrate | 76.0           | 228.0      |
| Silicified microcrystalline           | 109.9          | 88.2       |
| cellulose, NF Hypromellose 2910, USP  | 10.5           | 18.0       |
| Crospovidone, NF                      | 10.5           | 18.0       |
| Magnesium stearate, NF                | 1.1            | 1.8        |  
13.2.5 Stability and Storage Zotiraciclib (TG02) citrate capsules should be stored at room temperature 25°C (77°F), with excursions permitted at 15°C to 30°C (59°F to 86°F). 13.2.6 Administration procedures Patients are instructed to swallow the appropriate number of capsules whole with 8oz. of water while fasting (i.e., at least 1 hour before or 2 hours after a meal). Capsules should not be crushed or broken for administration. 13.2.7 Incompatibilities Please refer to section **13.1**. A copy of the drug brochure will be provided to the Pharmacy Department.
untitled h1
14 references

1. Ostrom, Q.T., et al., CBTRUS Statistical Report: Primary Brain and Central Nervous System Tumors Diagnosed in the United States in 2008-2012. Neuro Oncol, 2015. 17 Suppl 4: p. iv1-iv62.  
2. Stupp, R., et al., *Radiotherapy plus concomitant and adjuvant temozolomide for* glioblastoma. N Engl J Med, 2005. 352(10): p. 987-96.  
3. Wong, E.T., et al., Outcomes and prognostic factors in recurrent glioma patients enrolled onto phase II clinical trials. J Clin Oncol, 1999. 17(8): p. 2572-8.  
4. Yung, W.K., et al., *Multicenter phase II trial of temozolomide in patients with anaplastic* astrocytoma or anaplastic oligoastrocytoma at first relapse. Temodal Brain Tumor Group. J Clin Oncol, 1999. 17(9): p. 2762-71.  
5. Louis, D.N., *Molecular pathology of malignant gliomas.* Annu Rev Pathol, 2006. 1: p.  
97-117.  
6. Li, J., et al., *PTEN, a putative protein tyrosine phosphatase gene mutated in human* brain, breast, and prostate cancer. Science, 1997. 275(5308): p. 1943-7.  
7. Fujisawa, H., et al., Acquisition of the glioblastoma phenotype during astrocytoma progression is associated with loss of heterozygosity on 10q25-qter. Am J Pathol, 1999. 155(2): p. 387-94.  
8. Goh, K.C., et al., TG02, a novel oral multi-kinase inhibitor of CDKs, JAK2 and FLT3 with potent anti-leukemic properties. Leukemia, 2012. 26(2): p. 236-43.  
9. Loyer, P., et al., *Role of CDK/cyclin complexes in transcription and RNA splicing.* Cell Signal, 2005. 17(9): p. 1033-51.  
10. Romano, G. and A. Giordano, *Role of the cyclin-dependent kinase 9-related pathway in* mammalian gene expression and human diseases. Cell Cycle, 2008. 7(23): p. 3664-8.  
11. Atkinson, J.M., et al., An integrated in vitro and in vivo high-throughput screen identifies treatment leads for ependymoma. Cancer Cell, 2011. 20(3): p. 384-99.  
12. Nechaev, S. and K. Adelman, *Pol II waiting in the starting gates: Regulating the* transition from transcription initiation into productive elongation. Biochim Biophys Acta, 2011. **1809**(1): p. 34-45.  
13. Lam, L.T., et al., *Genomic-scale measurement of mRNA turnover and the mechanisms of* action of the anti-cancer drug flavopiridol. Genome Biol, 2001. 2(10): p. RESEARCH0041.  
14. Carter, B.Z., et al., *Small-molecule XIAP inhibitors derepress downstream effector* caspases and induce apoptosis of acute myeloid leukemia cells. Blood, 2005. 105(10): p. 4043-50.  
15. Quinn, B.A., et al., *Targeting Mcl-1 for the therapy of cancer.* Expert Opin Investig Drugs, 2011. 20(10): p. 1397-411.  
16. Day, B.W., et al., *ELK4 neutralization sensitizes glioblastoma to apoptosis through* downregulation of the anti-apoptotic protein Mcl-1. Neuro Oncol, 2011. 13(11): p. 120212.
17. Wagenknecht, B., et al., Expression and biological activity of X-linked inhibitor of apoptosis (XIAP) in human malignant glioma. Cell Death Differ, 1999. 6(4): p. 370-6.  
18. Rahl, P.B., et al., *c-Myc regulates transcriptional pause release.* Cell, 2010. 141(3): p.  
432-45.  
19. Barboric, M., et al., NF-kappaB binds P-TEFb to stimulate transcriptional elongation by RNA polymerase II. Mol Cell, 2001. 8(2): p. 327-37.  
20. Bhat, K.P., et al., *Mesenchymal differentiation mediated by NF-kappaB promotes* radiation resistance in glioblastoma. Cancer Cell, 2013. 24(3): p. 331-46.  
21. Herms, J.W., et al., *c-myc oncogene family expression in glioblastoma and survival.* Surg Neurol, 1999. 51(5): p. 536-42.  
22. Malumbres, M. and M. Barbacid, *Cell cycle, CDKs and cancer: a changing paradigm.*
Nat Rev Cancer, 2009. 9(3): p. 153-66.  
23. Simone, C. and A. Giordano, *New insight in cdk9 function: from Tat to MyoD.* Front Biosci, 2001. 6: p. D1073-82.  
24. Huang, C.H., et al., *CDK9-mediated transcription elongation is required for MYC*
addiction in hepatocellular carcinoma. Genes Dev, 2014. 28(16): p. 1800-14.  
25. Alvarez-Fernandez, S., et al., Potent antimyeloma activity of a novel ERK5/CDK
inhibitor. Clin Cancer Res, 2013. 19(10): p. 2677-87.  
26. Gunther, W., et al., Temozolomide induces apoptosis and senescence in glioma cells cultured as multicellular spheroids. Br J Cancer, 2003. 88(3): p. 463-9.  
27. Gratas, C., et al., *Bak and Mcl-1 are essential for Temozolomide induced cell death in* human glioma. Oncotarget, 2014. 5(9): p. 2428-35.  
28. Shiraishi, S., et al., Influence of p53 mutations on prognosis of patients with glioblastoma. Cancer, 2002. 95(2): p. 249-57.
29. Oren, M. and V. Rotter, *Mutant p53 gain-of-function in cancer.* Cold Spring Harb Perspect Biol, 2010. 2(2): p. a001107.  
30. Trent, J., et al., *Evidence for rearrangement, amplification, and expression of c-myc in a* human glioblastoma. Proc Natl Acad Sci U S A, 1986. 83(2): p. 470-3.  
31. Cancer Genome Atlas Research, N., *Comprehensive genomic characterization defines* human glioblastoma genes and core pathways. Nature, 2008. 455(7216): p. 1061-8.
32. Tohma, Y., et al., *PTEN (MMAC1) mutations are frequent in primary glioblastomas (de* novo) but not in secondary glioblastomas. J Neuropathol Exp Neurol, 1998. 57(7): p. 684-9.  
33. Austin, M. and S.J. Cook, Increased expression of Mcl-1 is required for protection against serum starvation in phosphatase and tensin homologue on chromosome 10 null
mouse embryonic fibroblasts, but repression of Bim is favored in human glioblastomas. J Biol Chem, 2005. 280(39): p. 33280-8.  
34. Radu, A., et al., PTEN induces cell cycle arrest by decreasing the level and nuclear localization of cyclin D1. Mol Cell Biol, 2003. 23(17): p. 6139-49.  
35. Siegel, D.S., et al., A phase 2 study of single-agent carfilzomib (PX-171-003-A1) in patients with relapsed and refractory multiple myeloma. Blood, 2012. 120(14): p. 281725.  
36. Bower, M., et al., *Multicentre CRC phase II trial of temozolomide in recurrent or* progressive high-grade glioma. Cancer Chemother Pharmacol, 1997. 40(6): p. 484-8.  
37. Bocangel, D.B., et al., *Multifaceted resistance of gliomas to temozolomide.* Clin Cancer Res, 2002. 8(8): p. 2725-34.  
38. Hirose, Y., M.S. Berger, and R.O. Pieper, *p53 effects both the duration of G2/M arrest* and the fate of temozolomide-treated human glioblastoma cells. Cancer Res, 2001. 61(5): p. 1957-63.  
39. Tolcher, A.W., et al., *Marked inactivation of O6-alkylguanine-DNA alkyltransferase* activity with protracted temozolomide schedules. Br J Cancer, 2003. 88(7): p. 1004-11.  
40. Wick, A., et al., Efficacy and tolerability of temozolomide in an alternating weekly regimen in patients with recurrent glioma. J Clin Oncol, 2007. 25(22): p. 3357-61.  
41. Han, S.J., et al., *Phase II trial of 7 days on/7 days off temozolmide for recurrent highgrade glioma.* Neuro Oncol, 2014. 16(9): p. 1255-62.  
42. Perry, J.R., et al., *Phase II trial of continuous dose-intense temozolomide in recurrent* malignant glioma: RESCUE study. J Clin Oncol, 2010. 28(12): p. 2051-7.  
43. Armstrong, T.S., et al., Reliability and validity of the M. D. Anderson Symptom Inventory-Spine Tumor Module. J Neurosurg Spine, 2010. 12(4): p. 421-30.  
44. Armstrong, T.S., et al., *Validation of the M.D. Anderson Symptom Inventory Brain Tumor* Module (MDASI-BT). J Neurooncol, 2006. 80(1): p. 27-35.  
45. Liu, S.a.Y., Ying, *Bayesian optimal interval designs for phase I clinical trials.* Journal of the Royal Statistical Society: Series C (Applied Statistics), 2015. 64(3).  
46. Liu, S. and Y. Yuan, *Bayesian optimal interval designs for phase I clinical trials.* Journal of the Royal Statistical Society: Series C (Applied Statistics), 2015. 64(3): p. 507-523.  
47. Wen, P.Y. and P.W. Marks, *Medical management of patients with brain tumors.* Curr Opin Oncol, 2002. 14(3): p. 299-307.  
48. Semrad, T.J., et al., *Epidemiology of venous thromboembolism in 9489 patients with* malignant glioma. J Neurosurg, 2007. 106(4): p. 601-8.  
49. Wen, P.Y., et al., Updated response assessment criteria for high-grade gliomas: response assessment in neuro-oncology working group. J Clin Oncol, 2010. 28(11): p. 1963-72.  
50. Thall, P.F., L.H. Wooten, and N.M. Tannir, Monitoring event times in early phase clinical trials: some practical issues. Clin Trials, 2005. 2(6): p. 467-78.
untitled h1
15 appendices 15.1 appendix performance

| 15.1   | APPENDIX: PERFORMANCE STATUS CRITERIA Karnofsky Performance Scale Percent Description 100 Normal, no complaints, no evidence of disease. 90 Able to carry on normal activity; minor signs or symptoms of  disease. 80 Normal activity with effort; some signs or symptoms of disease. 70 Cares for self, unable to carry on normal activity or to do active  work. 60 Requires occasional assistance, but is able to care for most of his/her  needs. 50 Requires considerable assistance and frequent medical care. 40 Disabled, requires special care and assistance. 30 Severely disabled, hospitalization indicated. Death not imminent. 20 Very sick, hospitalization indicated. Death not imminent. 10 Moribund, fatal processes progressing rapidly. 0 Dead.   |
|--------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
untitled h1
15.2 appendix pregnancy & contraception

A female of childbearing potential (FCBP) is a sexually mature female who: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months). Pregnancy tests must occur within 14 days prior to initiation of study. FCBP must have a pregnancy test before each new cycle; at discontinuation of Zotiraciclib (TG02) and at Day 28 post the last dose of Zotiraciclib (TG02).  
Required Pregnancy test: Serum -HCG
Adequate method of contraception: one highly effective method or more than one of the additional methods. Highly effective methods:
Intrauterine device (IUD) Hormonal (birth control pills, injections, implants)
Tubal ligation Partner's vasectomy Abstinence Additional effective methods:
Latex condom Diaphragm Cervical Cap
untitled h1
15.3 appendix cyp1a2 and cyp3a4

Lists including medications and substances known or with the potential to interact with the CYP1A2 and CYP3A4 isoenzymes Known inhibitors of CYP1A2:
o Acyclovir o fluvoxamine Known inhibitors of CYP3A4:
o Atazanavir o Clarithromycin o indinavir o itraconazole o ketoconazole o nefazodone o nelfinavir o ritonavir o saquinavir o telithromycin Known inducers of CYP1A2:
o omeprazole o insulin o cigarette smoking, Known inducers of CYP3A4:
o rifampin and o carbamazepine Sensitive CYP1A2 substrates with narrow therapeutic indices:
o theophylline and o tizanidine, Sensitive CYP2D6 substrates with narrow therapeutic indices:
o thioridazine o tamoxifen Version Date: 06/01/2020  
15.4   APPENDIX: STUDY FLOW CHART
untitled h1
15.5 appendix r ano

| CR                                                                                           | PR          | SD          | PD          |          |
|----------------------------------------------------------------------------------------------|-------------|-------------|-------------|----------|
| <50% -                                                                                       |             |             |             |          |
| T1-Gd+                                                                                       | None        | ≥50%        | ≥≥          |          |
| <25%↑                                                                                        |             |             |             |          |
| T2/FLAIR                                                                                     | Stable or ✦ | Stable or ✦ | Stable or ✦ | ↑*       |
| New Lesion                                                                                   | None        | None        | None        | Present* |
| Corticosteroids                                                                              | None        | Stable or ✦ | Stable or ✦ | na       |
| Clinical Status                                                                              | Stable or ↑ | Stable or ↑ | Stable or ↑ | ✦        |
| Requirement for                                                                              | All         | All         | All         | Any*     |
| Response                                                                                     |             |             |             |          |
| CR = Complete Response, PR = Partial Response, SD = Stable Disease, PD = Progressive Disease |             |             |             |          |  
* Progression occurs when any of these criteria are met present.  
NA: An increase in steroid dose alone will not cause a determination of progression in the absence of clinical deterioration or radiographically documented lesion growth.  
15.6 APPENDIX: DOSING SCHEDULE FOR BOTH TREATMENTS ARMS FOR PHASE I **STUDY**
untitled h1
15.7 appendix pill diary

Dose-dense arm Cycle 1 Patient Initials: __________________Patient ID\#: __________________Phase___Cycle \# 1:____________ This diary is for you to record that you took the drugs as instructed by your doctor. Please put a check mark or your initials after each dose. Please sign this diary at the end of the cycle. Bring the diary and all study drug bottles back to your next clinic visit.  
| diary and all study drug bottles back to your next clinic visit. TG02 AM Temozolomide   | PM                                               |                                 |      |          |     |      |      |      |          |
|-----------------------------------------------------------------------------------------|--------------------------------------------------|---------------------------------|------|----------|-----|------|------|------|----------|
| Zotiraciclib                                                                            | Frequency: Only on Day 1, Day 12, Day 15, Day 26 | Frequency: 7days ON, 7 days OFF |      |          |     |      |      |      |          |
| *Cycle 1 only: extra dose on                                                            | D -3                                             |                                 |      |          |     |      |      |      |          |
| DAY #                                                                                   | DATE                                             | TIME                            | DOSE | INITIALS | DAY | DATE | TIME | DOSE | INITIALS |
| #                                                                                       |                                                  |                                 |      |          |     |      |      |      |          |
| -3 *                                                                                    | off day off day                                  |                                 |      |          |     |      |      |      |          |
| 1                                                                                       | 1                                                |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 2                                                |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 3                                                |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 4                                                |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 5                                                |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 6                                                |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 7                                                |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 8                                                | off day                         |      |          |     |      |      |      |          |
| off day                                                                                 | 9                                                | off day                         |      |          |     |      |      |      |          |
| off day                                                                                 | 10                                               | off day                         |      |          |     |      |      |      |          |
| off day                                                                                 | 11                                               | off day                         |      |          |     |      |      |      |          |
| 12                                                                                      | 12                                               | off day                         |      |          |     |      |      |      |          |
| off day                                                                                 | 13                                               | off day                         |      |          |     |      |      |      |          |
| off day                                                                                 | 14                                               | off day                         |      |          |     |      |      |      |          |
| 15                                                                                      | 15                                               |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 16                                               |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 17                                               |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 18                                               |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 19                                               |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 20                                               |                                 |      |          |     |      |      |      |          |
| off day                                                                                 | 21                                               |                                 |      |          |     |      |      |      |          |  
| off day   | 22   | off day   |
|-----------|------|-----------|
| off day   | 23   | off day   |
| off day   | 24   | off day   |
| off day   | 25   | off day   |
| 26        | 26   | off day   |
| off day   | 27   | off day   |
| off day   | 28   | off day   |  
My signature signifies that the study drug(s) have been taken as indicated: Patient's Signature _________________________________Date: ____________________________
Dose Dense Arm Cycle 2 and beyond Patient Initials: __________________Patient ID\#: __________________Phase____/Cycle \#_____ ____________ This diary is for you to record that you took the drugs as instructed by your doctor. Please put a check mark or your initials after each dose. Please sign this diary at the end of the cycle. Bring the diary and all study drug bottles back to your next clinic visit.  
| diary and all study drug bottles back to your next clinic visit. TG02 AM Temozolomide   | PM                                               |                      |            |          |     |      |      |      |          |
|-----------------------------------------------------------------------------------------|--------------------------------------------------|----------------------|------------|----------|-----|------|------|------|----------|
| Zotiraciclib                                                                            | Frequency: Only on Day 1, Day 12, Day 15, Day 26 | Frequency: 7days ON, | 7 days OFF |          |     |      |      |      |          |
| *Cycle 1 only: extra dose on                                                            | D -3                                             |                      |            |          |     |      |      |      |          |
| DAY #                                                                                   | DATE                                             | TIME                 | DOSE       | INITIALS | DAY | DATE | TIME | DOSE | INITIALS |
| #                                                                                       |                                                  |                      |            |          |     |      |      |      |          |
| 1                                                                                       | 1                                                |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 2                                                |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 3                                                |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 4                                                |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 5                                                |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 6                                                |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 7                                                |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 8                                                | off day              |            |          |     |      |      |      |          |
| off day                                                                                 | 9                                                | off day              |            |          |     |      |      |      |          |
| off day                                                                                 | 10                                               | off day              |            |          |     |      |      |      |          |
| off day                                                                                 | 11                                               | off day              |            |          |     |      |      |      |          |
| 12                                                                                      | 12                                               | off day              |            |          |     |      |      |      |          |
| off day                                                                                 | 13                                               | off day              |            |          |     |      |      |      |          |
| off day                                                                                 | 14                                               | off day              |            |          |     |      |      |      |          |
| 15                                                                                      | 15                                               |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 16                                               |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 17                                               |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 18                                               |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 19                                               |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 20                                               |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 21                                               |                      |            |          |     |      |      |      |          |
| off day                                                                                 | 22                                               | off day              |            |          |     |      |      |      |          |
| off day                                                                                 | 23                                               | off day              |            |          |     |      |      |      |          |
| off day                                                                                 | 24                                               | off day              |            |          |     |      |      |      |          |
| off day                                                                                 | 25                                               | off day              |            |          |     |      |      |      |          |
| 26                                                                                      | 26                                               | off day              | 99         |          |     |      |      |      |          |  
| off day   | 27   | off day   |
|-----------|------|-----------|
| off day   | 28   | off day   |  
My signature signifies that the study drug(s) have been taken as indicated:
Patient's Signature _________________________________Date: _____________________________
Metronomic arm
untitled h1
cycle 1

Patient Initials: __________________Patient ID#: __________________Phase___/Cycle # 1 ____________ This diary is for you to record that you took the drugs as instructed by your doctor. Please put a check mark or your initials after each dose. Please sign this diary at the end of the cycle. Bring the diary and all study drug bottles back to your next clinic visit.  
TG02 AM **Temozolomide** PM  
Zotiraciclib  
Frequency: Only on Day 1, Day 12, Day 15, Day 26  
| study drug bottles back to your next clinic visit. TG02 AM   | Temozolomide                                     | PM               |      |          |       |      |      |      |          |
|--------------------------------------------------------------|--------------------------------------------------|------------------|------|----------|-------|------|------|------|----------|
| Zotiraciclib                                                 | Frequency: Only on Day 1, Day 12, Day 15, Day 26 | Frequency: Daily |      |          |       |      |      |      |          |
| *Cycle 1 only: extra dose on                                 | D -3                                             |                  |      |          |       |      |      |      |          |
| DAY #                                                        | DATE                                             | TIME             | DOSE | INITIALS | DAY # | DATE | TIME | DOSE | INITIALS |
| -3 *                                                         | off day off day                                  |                  |      |          |       |      |      |      |          |
| 1                                                            | 1                                                |                  |      |          |       |      |      |      |          |
| off day                                                      | 2                                                |                  |      |          |       |      |      |      |          |
| off day                                                      | 3                                                |                  |      |          |       |      |      |      |          |
| off day                                                      | 4                                                |                  |      |          |       |      |      |      |          |
| off day                                                      | 5                                                |                  |      |          |       |      |      |      |          |
| off day                                                      | 6                                                |                  |      |          |       |      |      |      |          |
| off day                                                      | 7                                                |                  |      |          |       |      |      |      |          |
| off day                                                      | 8                                                |                  |      |          |       |      |      |      |          |
| off day                                                      | 9                                                |                  |      |          |       |      |      |      |          |
| off day                                                      | 10                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 11                                               |                  |      |          |       |      |      |      |          |
| 12                                                           | 12                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 13                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 14                                               |                  |      |          |       |      |      |      |          |
| 15                                                           | 15                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 16                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 17                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 18                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 19                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 20                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 21                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 22                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 23                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 24                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 25                                               |                  |      |          |       |      |      |      |          |
| 26                                                           | 26                                               |                  |      |          |       |      |      |      |          |
| off day                                                      | 27                                               |                  |      |          |       |      |      |      |          |  
off day 28 My signature signifies that the study drug(s) have been taken as indicated: Patient's Signature _________________________________Date: _____________________________
Metronomic Arm Cycle 2 and beyond Patient Initials: __________________Patient ID\#: __________________Phase___/Cycle \#_____________________ This diary is for you to record that you took the drugs as instructed by your doctor. Please put a check mark or your initials after each dose. Please sign this diary at the end of the cycle. Bring the diary and all study drug bottles back to your next clinic visit.  
| diary and all study drug bottles back to your next clinic visit. TG02 AM Temozolomide   | PM                                               |                  |      |          |     |      |      |      |          |
|-----------------------------------------------------------------------------------------|--------------------------------------------------|------------------|------|----------|-----|------|------|------|----------|
| Zotiraciclib                                                                            | Frequency: Only on Day 1, Day 12, Day 15, Day 26 | Frequency: Daily |      |          |     |      |      |      |          |
| *Cycle 1 only: extra dose on                                                            | D -3                                             |                  |      |          |     |      |      |      |          |
| DAY #                                                                                   | DATE                                             | TIME             | DOSE | INITIALS | DAY | DATE | TIME | DOSE | INITIALS |
| #                                                                                       |                                                  |                  |      |          |     |      |      |      |          |
| 1                                                                                       | 1                                                |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 2                                                |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 3                                                |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 4                                                |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 5                                                |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 6                                                |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 7                                                |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 8                                                |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 9                                                |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 10                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 11                                               |                  |      |          |     |      |      |      |          |
| 12                                                                                      | 12                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 13                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 14                                               |                  |      |          |     |      |      |      |          |
| 15                                                                                      | 15                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 16                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 17                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 18                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 19                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 20                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 21                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 22                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 23                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 24                                               |                  |      |          |     |      |      |      |          |
| off day                                                                                 | 25                                               |                  |      |          |     |      |      |      |          |
| 26                                                                                      | 26                                               | 103              |      |          |     |      |      |      |          |  
| off day                                                                                                                                                               | 27   |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------|------|
| off day                                                                                                                                                               | 28   |
| My signature signifies that the study drug(s) have been taken as indicated:  Patient's Signature _________________________________Date: _____________________________ |      |