Full Trial Title: Adults with Acute Myeloid Leukaemia or High-Risk Myelodysplastic Syndrome (AML19) Approved by: Professor Nigel Russell Signature:

Transcription

1 Full Trial Title: Adults with Acute Myeloid Leukaemia or High-Risk Myelodysplastic Syndrome (AML19) ISRCTN: ISRCTN EudraCT: Approved by: Professor Nigel Russell Signature: Date: January 2017 Version: 6.0 Version 6.0 January 2017

2 This protocol is intended to describe a trial conducted by the AML Working Group of the National Cancer Research Institute (NCRI) Haematological Oncology Study Group in Acute Myeloid Leukaemia and high risk Myelodysplastic Syndrome in adults under the sponsorship of Cardiff University. It provides information about procedures for the entry, treatment and followup of patients. It is not intended that this protocol should be used as an aide-memoire or guide for the treatment of other patients. Every care has been taken in its drafting, but corrections or amendments may be necessary. Before entering patients into the trial, centres are required to complete a registration process with HCTU and to confirm acceptance of the terms of sponsorship required by Cardiff University. Centres must also conform to local Research Governance procedures. During the course of this 6-year trial, not all randomisation options will be open at all times and some additional options may be included by protocol amendment. Through the use of a risk based approach AML19 will evaluate several relevant therapeutic questions as summarised below. The trial is open to all patients aged 18 to 60 years, and also to patients aged 60 years or over for whom intensive therapy is considered appropriate. Approximately 3000 patients will be recruited. Summary of randomisations: For patients who do not have the Acute Promyelocytic Leukaemia (APL) subtype and are not known to have adverse cytogenetics ((using Grimwade 2010 classification 21 ), classification list can be found in Appendix L) an induction randomisation will compare two courses of FLAG-IDA with DA chemotherapy each in combination with one of two doses of the immunoconjugate Mylotarg in course 1. (Patients for whom Mylotarg is contraindicated will be randomised between DA and FLAG-Ida). One randomisation to one of four arms. After course 1 of treatment, patients will be segregated based on their molecular-genetic characteristics, and a validated risk score Patients who are at high risk of relapse based on the AML Risk Score, who are deemed refractory (>15% blasts present and <50% proportional reduction in blasts) or have a high Risk Genotype: FLT3 ITD mut/ NPM1 wt will be eligible for an allogeneic stem cell transplant if a donor is available, and to enter a study of a novel combination. These patients will be randomised between FLAG-Ida (standard arm) vs CPX-351 with the aim of allowing patients to proceed to allogeneic transplant. Patients can also be randomised between FLAG-Ida and CPX-351 at trial entry if known adverse Cytogenetics (using Grimwade 2010 classification 21 ). In high-risk patients, allogeneic SCT of either myeloablative or reduced intensity from sibling or alternative donors is recommended. One randomisation to one of two arms. Version 6.0 January 2017

3 o After course 2 of treatment, please note: Patients who are not in remission post course 2 or who are NPM1 mutated and MRD positive in the peripheral blood post course 2 are eligible to enter the high risk arm and proceed to allogeneic transplant. In consolidation: o Patients who have received FLAG-Ida and are not CBF leukaemia or high risk will be randomised to receive two or one or no further treatment courses of HDAC. One randomisation to one of three arms. o Patients receiving DA induction chemotherapy will receive two courses of HDAC consolidation. At relapse patients are eligible for the high risk options. Patients who exhibit a suitable molecular marker will be invited to enter a randomisation between minimal residual disease monitoring or not. One randomisation to one of two arms. For patients with APL, patients can be registered to receive the Italian AIDA anthracycline plus ATRA based chemotherapy approach. During the course of this 6-year trial, not all randomisation options will be open at all times and some additional options may be included by protocol amendment At diagnosis, material will be sent to reference labs for molecular and immunophenotypic characterisation and the identification of markers of minimal residual disease (MRD) detection. This will allow a continuation of the monitor versus no monitor randomisation. There are about 700 cases of AML aged years per annum in the British Isles alone. About 650 patients entered AML17 annually, so with a continuation of accrual at this, or a higher level, clear evidence on the relative benefits of the therapeutic options being tested in AML19 will be obtained in just a few years. This information will contribute to the continuing improvement of the treatment available to many future patients with AML. Clinicians are required to read the whole protocol before commencing treatment Version 6.0 January 2017

4 Administrative Summary: Study Title: AML19 Protocol Number: SPON Indication(s): Acute myeloid leukaemia (AML) Acute promyelocytic leukaemia (APL) High-risk Myelodysplastic syndrome (MDS) Development Phase: III Sponsor: Cardiff University Sponsor s Responsible Medical Officer: Professor Nigel Russell Date: January 2017 Version: 6.0 EUDRACT Number: REC number (UK): 14/WA/1056 Governance Statement: This study will be conducted according to the protocol and in compliance with the principles of the Declaration of Helsinki (1996), the principles of Good Clinical Practice (GCP) as described in International Conference on Harmonisation guidelines. The protocol has been approved in the UK by Wales REC 3 (REC) and the Medicines and Healthcare Products Regulatory Agency (MHRA). Approval in collaborating countries is provided by the relevant Ethics body and competent authority in that country. Version 6.0 January 2017

5 CONTENTS FLOW CHART... 1 TRIAL MANAGEMENT GROUP REGULATORY INFORMATION OBJECTIVES AML19 STUDY RATIONALE STUDY OBJECTIVES THERAPEUTIC QUESTIONS FOR PATIENTS WITH NON-APL AML AND HIGH RISK MYELODYSPLASTIC SYNDROME THERAPEUTIC QUESTIONS FOR PATIENTS WITH APL ENDPOINTS FOR PATIENTS WHO HAVE NON-APL AML ENDPOINTS FOR PATIENTS WHO HAVE APL SUBSIDIARY OBJECTIVES STUDY DESIGN TYPE/DESIGN OF TRIAL EXPECTED DURATION OF TRIAL DEFINITION OF INVESTIGATIONAL PRODUCTS FOLLOW UP INFORMATION ANY PLANNED VARIATION IN TRIAL SUCH AS DOSE ESCALATION OR A CHANGE IN SCHEDULE STUDY ENROLMENT ELIGIBILITY CRITERIA INCLUSION CRITERIA EXCLUSION CRITERIA - AML INCLUSION CRITERIA - APL EXCLUSION CRITERIA - APL PATIENT PROGRESS THROUGH TRIAL (NON-APL) Indications for Transplant in AML Rationale for randomisations ACUTE PROMYELOCYTIC LEUKAEMIA (APL) SUBJECT WITHDRAWAL TREATMENT ASSIGNMENT PROCEDURES (RANDOMISATION PROCEDURE) PREMATURE TERMINATION OR SUSPENSION OF THE TRIAL JUSTIFICATION OF TREATMENT OPTIONS AML (EXCLUDING APL) Experience from AML15 and dose rationale for Mylotarg Molecular Targeting Core Binding Factor Leukaemias Version 6.0 January 2017

6 High Risk Score Patients CPX-351: Dose rationale STEM CELL TRANSPLANTATION ACUTE PROMYELOCYTIC LEUKAEMIA (APL) MOLECULAR SCREENING AND MRD MONITORING Assessment of the value of MRD detection REFERENCES PROCEDURES FOR ENTRY INTO THE TRIAL CENTRE REGISTRATION PATIENT RECRUITMENT RANDOMISATION FIRST RANDOMISATION FOR NON-APL PATIENTS For patients not known to have adverse cytogenetics For patients known to have adverse risk cytogenetics Information required at first randomisation SUBSEQUENT RANDOMISATIONS PROVISION OF BIOLOGICAL MATERIAL DIAGNOSTIC MATERIAL CYTOGENETICS AND MOLECULAR GENETICS FLT3 MUTATION STATUS IMMUNOPHENOTYPIC DETECTION OF MINIMAL RESIDUAL DISEASE... ERROR! BOOKMARK NOT DEFINED. 7.5 FOLLOW-UP MATERIAL SAMPLE BANKING MOLECULAR SCREENING AND IMMUNOPHENOTYPIC DETECTION OF RESIDUAL DISEASE MARKER At diagnosis: MINIMAL RESIDUAL DISEASE MONITORING Frequency of Molecular Monitoring Molecular Monitoring in APL and non-apl Disease DATA RECORDING DATA SUBMISSION QUALITY OF LIFE Qol and Resource Usage in the Monitor vs No Monitor randomisation QoL in APL patients HEALTH ECONOMICS ACUTE PROMYELOCYTIC LEUKAEMIA TREATMENT OF APL PATIENTS AIDA Treatment Version 6.0 January 2017

7 INDUCTION CONSOLIDATION Treatment Modification Pseudotumor Cerebri Hepatotoxicity Treatment of relapse, molecular relapse or persistent MRD positivity NON-APL PATIENTS AML INDUCTION CHEMOTHERAPY: COURSES 1 AND DA schedule FLAG-Ida schedule Mylotarg ADDITIONAL TREATMENTS FLT3 Inhibition Core-binding factor (CBF) leukaemia HIGH RISK SCORE PATIENTS FLAG-Ida MACE MIDAC CPX Arrangements for transplantation AML CONSOLIDATION Timing of consolidation randomisation Required information High-dose Cytarabine TREATMENT FOR PATIENTS WHO ARE REFRACTORY, POST RELAPSE OR HAVE A VALIDATED MOLECULAR RELAPSE SAFETY EVALUATIONS ASSESSMENT OF RESPONSE AND MOLECULAR SCREENING DEFINITIONS OF COMPLETE REMISSION, PARTIAL REMISSION AND RESISTANT DISEASE FREQUENCY OF MOLECULAR MONITORING SUPPORTIVE CARE& CNS TREATMENT SUPPORTIVE CARE SUPPORTIVE CARE FOR APL PATIENTS CNS TREATMENT STEM CELL TRANSPLANTATION CONVENTIONAL ALLOGENEIC TRANSPLANTATION REDUCED INTENSITY ALLOGRAFT Version 6.0 January 2017

8 14 RELAPSE STATISTICAL CONSIDERATIONS PATIENT NUMBERS DATA ANALYSIS TRIAL GOVERNANCE AND ADVERSE EVENT REPORTING ADVERSE EVENT REPORTING DEFINITIONS CAUSALITY Causality Expectedness COLLECTION OF DATA TIME OF REPORT REPORTING TO THE REGULATORY AUTHORITIES ENHANCED PHARMACO-VIGILANCE APPENDIX A: WHO HISTOLOGICAL CLASSIFICATION OF ACUTE MYELOID LEUKAEMIAS APPENDIX B: PREPARATION, ADMINISTRATION AND TOXICITY OF DRUGS APPENDIX C: PROCEDURES FOR STEM CELL TRANSPLANTATION APPENDIX D: DERIVATION OF RISK INDEX FOR YOUNGER ADULTS APPENDIX E: SUPPORTIVE CARE RECOMMENDATIONS FOR APL APPENDIX F: RESOURCE USE QUESTIONNAIRE APPENDIX G: QUALITY OF LIFE QUESTIONNAIRE(S) APPENDIX H: IMP PROVISION SCHEDULE APPENDIX I: FLOW CHARTS WITH RELEVANT PATIENT INFORMATION SHEET/CONSENT FORM NUMBERS APPENDIX J: BIRTH CONTROL METHODS WHICH MAY BE CONSIDERED AS HIGHLY EFFECTIVE APPENDIX K SCHEDULE OF ASSESSMENTS APPENDIX L: 2010 GRIMWADE CYTOGENETIC CLASSIFICATION Version 6.0 January 2017

9 Flow Chart Page 1 of 111 Version 6.0 January 2017

10 Page 2 of 111 Version 6.0 January 2017

11 List of Abbreviations ADE: cytarabine (Ara-C), daunorubicin and etoposide AIDA: ATRA + Idarubicin ALFA: Acute Leukaemia French Association AML: acute myeloid leukaemia ANC: absolute neutrophil count APL: acute promyelocytic leukaemia ALT: alanine aminotransferase AST: aspartate aminotransferase ATRA: all trans-retinoic acid CBF: core binding factor CML: chronic myeloid leukaemia CNS: central nervous system CR: complete remission CSF: cerebro-spinal fluid CTA: Clinical Trials Authorisation DA: daunorubicin +_ cytarabine (Ara-C) DMC: data monitoring committee ECG: electrocardiogram ECMC: experimental cancer medicine centre EORTC: European Organisation for Research and Treatment of Cancer EUDRACT: European Clinical Trials Database FLAG-Ida: fludarabine _+ cytarabine (Ara-C) + G-CSF + idarubicin GCP: Good Clinical Practice GO: gemtuzumab ozogamicin (mylotarg) GVHD: graft versus host disease HADS: hospital anxiety and depression scale HCTU: Haematology Clinical Trials Unit HDAC: high-dose cytarabine (Ara-C) HIV: Human Immunodeficiency Virus ICH-GCP: International Conference on Harmonisation IMP: investigational medicinal product LAIP: leukaemia-associated aberrant immunophenotype LVEF: left ventricular ejection fraction MACE: Amsacrine, cytarabine (Ara-C), etoposide MDS: myelodysplastic syndrome MHRA: Medicine and Healthcare Products Regulatory Agency MiDAC: mitoxantrone, daunorubicin, cytarabine (Ara-C) MRC: Medical Research Council, UK MRD: minimal residual disease Page 1 of 111 Version 6.0 January 2017

12 MTD: maximum tolerated dose MUGA: multiple gated acquisition scan NCRI: National Cancer Research Institute, UK NHS: National Health Service, UK NRES: National Research Ethics Service, UK NYHA: New York Heart Association OS: Overall Survival PML-RARA: promyelocytic leukaemia (PML), retinoic acid receptor alpha (RARA) QoL: Quality of Life REC: Research Ethics Committee RSI: Refence Safety Information RIC: reduced intensity conditioning SAE: Serious Adverse Event SCT: stem cell transplantation SUSAR: Suspected unexpected serious adverse reaction TKI: tyrosine kinase inhibitor TMG: Trial Management Group TSC: Trial Steering Committee ULN: upper level of normal VAD: vascular access device WBC: whole blood count WHO: World Health Organisation WOCBP: Women of child-bearing potential Page 2 of 111 Version 6.0 January 2017

13 TRIAL MANAGEMENT GROUP CHIEF INVESTIGATOR Professor N H Russell Haematology Department Nottingham University Hospital (City Campus) Hucknell Road Nottingham NG5 1PB Tel: Fax: nigel.russell@nottingham.ac.uk CO-CHIEF INVESTIGATOR Dr Mike Dennis Haematology and Transplant Unit Christie Hospital NHS Trust Wilmslow Road MANCHESTER M20 4BX Tel: Fax: Mike.dennis@christie.nhs.uk STATISTICS Professor Robert Hills Centre for Trials Research College of Biomedical & Life Sciences Cardiff University 6 th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS Tel: Fax: HillsRK@cardiff.ac.uk CLINICAL COORDINATORS: Professor Richard Clark The University Department of Haematology Duncan Building Royal Liverpool Hospital Prescot Street P.O. Box 147 Liverpool L69 3BX Tel: Fax: Clarkre@Liverpool.ac.uk Prof David Bowen Department of Haematology Leeds General Infirmary Gt. George Street Leeds LS1 3EX Tel: Fax: David.Bowen@leedsth.nhs.uk Prof M F McMullin Consultant Haematologist Cancer Research Centre Queen's University Belfast City Hospital Lisburn Road BELFAST BT9 7AB Tel: Ext: 2242 Fax: m.mcmullin@qub.ac.uk Page 3 of 111 Version 6.0 January 2017

14 Prof J Cavenagh Department of Haematology, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, Tel: Fax: j.d.cavenagh@qmul.ac.uk Prof C Craddock (transplant) Centre for Clinical Haematology Queen Elizabeth Hospital Edgbaston Birmingham B15 2TH Tel: Fax : Charles.craddock@uhb.nhs.uk INTERNATIONAL CO-ORDINATORS: Dr Lars Kjeldsen (Denmark) Department of Haematology L-4042, National University Hospital Rigshospitalet DK-2100 Copenhagen Ø Phone: lars.kjeldsen@rh.regionh.dk Dr Ruth Spearing (New Zealand), Department of Haematology, Auckland City Hospital, Park Road, Grafton, Auckland 1023, NZ Phone: Ruth.Spearing@cdhb.health.nz MOLECULAR DIAGNOSTICS Ms Amanda Gilkes Department of Haematology School of Medicine Cardiff University Heath Park Cardiff CF14 4XN Tel: Fax: gilkes@cf.ac.uk MINIMAL RESIDUAL DISEASE MONITORING Dr Richard Dillon Division of Medical and Molecular Genetics 8th Floor, Guy's Tower Guy's Hospital London, SE1 9RT Tel: richard.dillon@kcl.ac.uk SAMPLE BANKING: Marie Gilmour Department of Haematology School of Medicine Cardiff University Heath Park Cardiff CF14 4XN Tel: Fax: GilmourM@cardiff.ac.uk TRIAL MANAGEMENT CYTOGENETIC REVIEW Sophie Betteridge Haematology Clinical Trials Unit (HCTU), School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN Tel: Fax: betteridgese@cardiff.ac.uk Sarah Charles and Alma Abby Haematology Clinical Trials Unit (HCTU), School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN Tel: Fax: Charless4@cardiff.ac.uk and abbyja@cardiff.ac.uk Dr Anthony Moorman Leukaemia Research Cytogenetics Group, Northern Institute for Cancer Research,Newcastle University, Level 5, Sir James Spence Institute, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP Page 4 of 111 Version 6.0 January 2017

15 PHARMACOVIGILANCE Dr S Knapper Department of Haematology School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN Tel: Fax: KnapperS@cardiff.ac.uk Dr P Mehta (CPX-351) Bristol Haematology and Oncology Centre Horfield Rd Bristol BS2 8ED Tel: Fax: Priyanka.mehta@uhbristol.nhs.uk RANDOMISATION, ADMINISTRATION, AND FOLLOW-UP HAEMATOLOGY CLINICAL TRIALS UNIT (HCTU) DEPARTMENT OF HAEMATOLOGY, SCHOOL OF MEDICINE CARDIFF UNIVERSITY HEATH PARK CARDIFF, CF14 4XN TEL: FAX: Website for data recording and randomisations: Telephone randomisation availability: hours, Monday to Friday (except bank holidays) Page 5 of 111 Version 6.0 January 2017

16 1 Regulatory Information The AML19 Trial has been approved by the National Research Ethics Service (NRES) and must also conform to local Research Governance procedures at each centre before patients are entered into the trial at that site. Centres are required to complete a registration process with HCTU before recruitment is started and to confirm acceptance of the terms of sponsorship required by Cardiff University. The right of a patient to refuse to participate in the trial, without giving reasons, must be respected. After the patient has entered the trial, the clinician is free to give alternative treatment to that specified in the protocol at any stage if he/she feels it to be in the patient's best interest, and the reason for doing so should be recorded. Similarly, the patient is free to withdraw at any time from protocol treatment without giving reasons and without prejudicing any further treatment. All patients who come off protocol therapy, for whatever reason, will still need to remain within the study for the purposes of followup and data analysis. All patients will be followed up annually for life. AML19 will be conducted in accordance with the principles of Good Clinical Practice as described in International Conference on Harmonisation guidelines, including the archiving of essential documents (CPMP/ICH/135/95). HCTU will manage the AML19 trial and will follow unit SOPs in regard to handling of substantial amendments, urgent safety measures, archiving and all other generic clinical trial activities. Monitoring of sites will be conducted as per the trial monitoring plan, as defined by the Sponsor. Central monitoring processes will be in place, and participating sites will be informed of the requirements for any site monitoring during trial training and throughout the trial, as necessary. Page 6 of 111 Version 6.0 January 2017

17 2 OBJECTIVES 2.1 AML19 Study rationale In general the survival for Acute Myeloid Leukaemia in younger patients has improved in the last 25 years, with 85% of entrants to MRC/ NCRI Trials entering remission and 50% of entrants now surviving long-term. Approximately 80% of patients in the UK with AML aged < 60 years enter these trials. In a continuous sequence of trials since 1988, over patients have been recruited and 23,000 randomisations have been carried out to address 26 questions in this relatively rare disease. Another feature of this experience has been the advantage of using factorial designs to maximise the information gained. Our studies in this age group have resulted in significant improvement in survival over the years and represent the state of the art worldwide. The heterogeneity of this disease and the impact of prognostic factors result on a wide variation in outcomes ranging from 15% to 85% based primarily on molecular and genetic characteristics of the leukaemia. It seems likely that improving the cure rate beyond 50% will depend on exploiting the emerging molecular knowledge within the disease subgroups and the development of small molecules which can synergise with conventional chemotherapeutic agents. In AML19 we will ask a number of specific questions: 1. Is the use of a fractionated Mylotarg (GO) (2 doses of 3 mg/m 2 used in the ALFA) superior to a single Mylotarg dose (3mg/m 2 used in AML15 and 17) when combined with either DA or FLAG-Ida induction chemotherapy? 2. Does FLAG-Ida /GO induction (best of AML15) improve survival compared to DA (60mg/ m 2 x 3) /GO induction? 3. Does the addition of 1 or 2 courses of HDAC consolidation to 2 courses of FLAG-Ida induction improve survival? 4. In high risk patients or those patients with known poor risk cytogenetics at diagnosis is CPX-351 used at the dose schedule established in the Phase 2 study superior to FLAG-Ida? Page 7 of 111 Version 6.0 January 2017

18 2.2 Study Objectives The AML19 trial has two distinct parts: 1. For patients with acute myeloid leukaemia (AML), (other than acute promyelocytic leukaemia) and High Risk Myelodysplasia, as defined by the WHO Classification (2001) (Appendix A). 2. For patients with acute promyelocytic leukaemia (APL) The objectives for each of these components are summarised below. 2.3 Therapeutic questions for patients with non-apl AML and High Risk Myelodysplastic Syndrome For patients with acute myeloid leukaemia (AML) the aims of the AML19 trial are: To compare four induction chemotherapy schedules (namely DA + Mylotarg (3mg/m 2 dosing based on surface area of patient) or DA + Mylotarg (3mg/m 2 x2, maximum 5mg per day) versus FLAG-Ida + Mylotarg (3mg/m 2 ) or FLAG-Ida + Mylotarg (3mg/m 2 x2, maximum 5mg per day)) in patients who are not known at entry to have adverse cytogenetics. For patients receiving FLAG-Ida to compare one or two courses of HDAC consolidation versus no further treatment In high risk patients, and those known to have adverse cytogenetics at entry and those with high risk NPM1+ AML, to compare novel treatment, CPX-351 vs FLAG-Ida In high risk patients and those with high risk NPM1+ AML who have received 2 courses of FLAG-Ida induction, to evaluate in a non-randomised fashion the combination of Fludarabine + CPX-351 In high risk patients, to evaluate, the value of allogeneic stem cell transplantation (SCT), from sibling or alternative donors To assess the clinical value of minimal residual disease monitoring for patients overall survival 2.4 Therapeutic questions for patients with APL For patients with APL the aims of the AML19 trial are: To evaluate the Idarubicin based, AIDA Schedule. 2.5 Endpoints for Patients who have non-apl AML The main endpoints for each comparison will be: Page 8 of 111 Version 6.0 January 2017

19 Overall survival (OS). Complete remission (CR) achievement and reasons for failure (for induction questions). Duration of remission, relapse rates and deaths in first CR. Toxicity, both haematological and non-haematological. Quality of life for patients in the disease monitoring randomisation. Supportive care requirements (and other aspects of health economics). 2.6 Endpoints for Patients who have APL Remission and survival Kinetics of MRD Quality of Life 2.7 Subsidiary objectives Blood and bone marrow will be required at diagnosis, during remission and at relapse to evaluate the therapeutic relevance of morphological, cytogenetic, molecular-genetic and immunophenotypic assessments, with particular respect to: The relevance of the molecular and immunophenotypic detection of minimal residual disease To correlate biomarker measurements with clinical outcome To correlate molecular genotype with clinical outcome To store excess diagnostic material for future research Page 9 of 111 Version 6.0 January 2017

20 3 STUDY DESIGN 3.1 Type/design of trial AML19 is a randomised, controlled, open label Phase III trial factorial design for patients with AML and High Risk Myelodysplastic Syndrome (MDS), similar to previous NCRI AML trials. 3.2 Expected duration of trial The end of trial will be defined as the last protocol visit of any patient enrolled. Last patient last visit in this context may occur significantly before the above timepoint, and may curtail the capture of ongoing safety information and trial data. For the purposes of this definition, hospital visits in relation to transplant treatment are not defined as protocol visits. The trial is expected to recruit for 5 years, although some interventions will complete recruitment before this time, and may be replaced. Patients will continue on annual follow up for life. 3.3 Definition of investigational products The Investigational Medicinal Products (IMPs) are defined by the Sponsor as: Mylotarg CPX-351 Non-IMPs (nimps) are defined as the standard treatment options, as shown below: Daunorubicin Cytarabine (Cytarabine), including in high-dose regimens Components of FLAG-Ida (fludarabine, Cytarabine, Idarubicin, G-CSF) Components of MACE/MIDAC (mitoxantrone, amsacrine, etoposide) Idarubicin (AIDA regimen, APL only) All-trans retinoic acid (ATRA; APL only) Fludarabine Cyclophosphamide MESNA 3.4 Follow up information Survival and remission status of each patient will be requested from the randomising clinician on an annual basis until death. Upon a report of death, a cause and date of death must be provided by the randomising site. Page 10 of 111 Version 6.0 January 2017

21 It is accepted that patients may have their treatment transferred to another participating site. However, it is necessary for the randomising site to retain full information on any randomised patients therefore, HCTU will contact the randomising site for current survival status. 3.5 Any planned variation in trial such as dose escalation or a change in schedule Any changes to trial design or treatment schedules will be made via protocol amendment and communicated to participating sites accordingly. Significant changes may require updated training at participating sites. 3.6 Study enrolment A total of 3000 patients is planned to be recruited over the course of the trial from participating centres. The sample sizes for the different comparisons within the trial are given in Section Eligibility Criteria Eligibility will be confirmed as part of the necessary randomisation process at each timepoint. Participating centres should take every care to ensure the required information is accurate and to hand. In the event of pregnancy at any point during the trial the IMPs should be immediately stopped and the Chief Investigator should be contacted for further advice. Note: Sexually mature males must agree to use an adequate and medically accepted method of contraception throughout the study if their sexual partners are women of child bearing potential (WOCBP). Similarly women must agree to adequate contraceptive measures. This applies to APL and AML patients (See Appendix J). In both males and females these measures must be in place for at least 30 days after the last administration of all IMPs. 3.8 Inclusion Criteria Patients are eligible for the AML19 trial if: They have one of the forms of acute myeloid leukaemia as defined by the WHO Classification (Appendix A) this can be any type of de novo or secondary AML or high risk Myelodysplastic Syndrome (defined as >10% bone marrow blasts) Patients with acute promyelocytic leukaemia (APL) are eligible and should be entered into the randomisations specifically for APL (see Section 9). They have WHO performance status 0-2 They are considered suitable for intensive chemotherapy. Page 11 of 111 Version 6.0 January 2017

22 They should normally be 18 years up to the age of 60, but patients over this age are eligible if intensive therapy is considered a suitable option. The Serum creatinine should be 1.5 ULN (upper limit of normal) A negative pregnancy test within 2 weeks prior to trial entry in WOCBP to be repeated throughout the trial prior to each course of protocol treatment Sexually mature males must agree to use an adequate and medically accepted method of contraception throughout the study if their sexual partners are women of child bearing potential (WOCBP). Similarly women must agree to highly effective contraceptive measures (See Appendix J). This applies to APL and AML patients. In both males and females these measures must be in place for at least 30 days after the last administration of all IMPs. They have given written informed consent Patients eligible for the Mylotarg randomisation must have Serum Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST) 2.5 ULN and bilirubin 2. ULN (Note: Patients who do not comply with the liver inclusion criteria are eligible to enter the trial but will be excluded from the Mylotarg randomisation) 3.9 Exclusion Criteria - AML Patients are not eligible for the AML arms of the AML19 trial if: They have previously received cytotoxic chemotherapy for AML. [Hydroxycarbamide, or similar low-dose therapy, to control the white count prior to initiation of intensive therapy is not an exclusion.] They have received demethylation therapy for AML or high risk MDS defined as marrow blasts >10%. Patients treated for lower risk MDS who progress to have AML are eligible. They are in blast transformation of chronic myeloid leukaemia (CML). They have a concurrent active malignancy requiring treatment. They are pregnant or lactating. The physician and patient consider that intensive therapy is not an appropriate treatment option. Known infection with Human Immunodeficiency Virus (HIV). Patients with AST or ALT more than 2.5 times the local upper limit of normal or Bilirubin more than twice upper limit of normal, are not eligible for the Mylotarg randomisations Inclusion Criteria - APL Patients are eligible for the APL arm of the AML19 trial if: They have provided signed written informed consent (PIS 3) Page 12 of 111 Version 6.0 January 2017

23 They have a morphological diagnosis of APL (if cytogenetic or molecular diagnosis is not confirmed patients will transfer to the non-apl treatments) They should be over 18 years. They have WHO performance status 0-2 Their Serum total bilirubin is < 2.0 mg/dl ( 51 µmol/l) Their Serum creatinine is <3.0 mg/dl (<260 µmol/l) 3.11 Exclusion Criteria - APL Patients are not eligible for the APL arm of the AML19 trial if: They are aged < 18 They have an active malignancy requiring treatment at time of study entry There is a lack of subsequent diagnostic confirmation of PML-RARA fusion at molecular level Known infection with Human Immunodeficiency Virus (HIV). Significant arrhythmias, ECG abnormalities or neuropathy are apparent Severe uncontrolled pulmonary or cardiac disease is apparent. They are pregnant or lactating 3.12 Patient Progress through Trial (non-apl) There are five randomised comparisons within the trial: At diagnosis: (i) DA with Mylotarg 3mg/m 2 or 3mg/m 2 x2 versus FLAG-Ida with Mylotarg 3mg/m 2 or 3mg/m 2 x2 (maximum of 5mg per day if randomised to 2 doses of Mylotarg) (ii) FLAG-Ida vs CPX-351 for patients known at entry to have adverse risk karyotype End of Course 1: (iv) FLAG-Ida versus CPX-351 for high risk cases After Course 2: (for standard risk patients allocated FLAG-Ida who are not part of the high risk randomisation (ii, iii)) (v) Consolidation: 0 vs 1 vs 2 courses for high dose Cytarabine. Page 13 of 111 Version 6.0 January 2017

24 For patients with a suitable molecular marker: (vi) Patients will be invited to enter a randomisation between minimal residual disease monitoring and no monitoring. Page 14 of 111 Version 6.0 January 2017

25 Indications for Transplant in AML19.All patients defined as high risk in the trial should be referred for allogeneic transplant from a suitably matched sibling or alternative donor. Patients can be defined as high risk either at diagnosis, if entering the adverse cytogenetics randomisation, or post course 1 or post course 2 At Diagnosis Any patient with known adverse risk cytogenetics entering the high risk arm at randomisation. Post Course 1 Reasons 1: High Risk Genotype: FLT3 ITD mut / NPM1 wt 2. Primary Refractory Disease defined (>15% blasts present and <50% proportional reduction in blasts e.g. 40% to 21%). 3. High Risk by AML Risk Score (see protocol) Post course 2 Reasons 1. Patient refractory to 2 courses of treatment (i.e. not in CR/CRi) 2. NPM1 mutated patients have evidence of NPM1 mutant transcripts in the peripheral blood post course 2 (patients who are NPM1 MRD negative in the peripheral blood post course 2 are not recommended for transplant) Standard Risk AML (by risk score) RIC transplant from a sibling donor is also to be considered for standard risk AML patients over 40, who are not CBF AML and not NPM1 mutated AML who are MRD negative (irrespective of the presence of a FLT3 ITD) in the PB post course 2 Finally, any relapsed patient is eligible for the high risk randomisation and transplantation Page 15 of 111 Version 6.0 January 2017

26 Rationale for randomisations Full details of the rationale for these comparisons, progress through the trial and treatment can be found in the relevant sections of the protocol, but are summarised below (and in the flow diagrams at the front and back of the protocol): 1. At diagnosis: for patients not known to have adverse cytogenetics, randomise between DA and FLAG-Ida each with one of two doses of Mylotarg as induction chemotherapy. The four induction treatment arms will therefore be: 1. Two courses of DA with Mylotarg 3mg/m 2 on day 1 of course 1 2. Two courses of DA with Mylotarg 3mg/m 2 (max 5mg per day) on day 1 and day 4 of course 1 3. Two courses of FLAG-Ida with Mylotarg 3mg/m 2 on day 1 of course 1 4. Two courses of FLAG-Ida with Mylotarg 3mg/m 2 (max 5mg per day) on day 1 and day 4 of course 1 If patients are not suitable for Mylotarg, or Mylotarg is not available, the randomisation will be between DA and FLAG-Ida without Mylotarg. For patients known to have adverse cytogenetics at entry, randomise to one of two arms: 1. Two courses of FLAG-Ida followed by MACE/MidAC consolidation or 2. Up to four courses of CPX-351 By the end of the first course of induction chemotherapy, the FLT3 mutation, NPM1 mutation, cytogenetics (Core Binding Factor), and Risk Index status of each non-apl patient will be available. i) Patients who are high risk will enter the comparison of CPX-351 versus FLAG-Ida (Section 10.5) Page 16 of 111 Version 6.0 January 2017

27 ii) All patients except the High Risk Index patients will receive the same second induction treatment course but will not receive Mylotarg with course Following the second and subsequent courses of treatment, patients who have been randomised to MRD monitoring should have a bone marrow assessment (see Section 7.6). Patients who are high risk NPM1+ve AML defined by MRD positivity in the peripheral blood can enter the high risk arm of the trial, and will continue to be monitored following subsequent treatment including BMT. 4. On recovery from course two, patients receiving FLAG-Ida will be randomised to one versus two courses of HDAC consolidation versus no further treatment. Patients with CBF AML are excluded from this randomisation and will receive 2 courses of High Dose Cytarabine. 5. Patients who are not in CR following the second course of treatment i.e. have refractory disease, are also eligible to enter the high risk randomisation. Those who have received 2 courses of FLAG-Ida can receive the combination of Fludarabine + CPX Patients who relapse are eligible for the high risk randomisation. Those who relapse within 6 months following 2 courses of FLAG-Ida are eligible to receive the Fludarabine + CPX-351 combination. Page 17 of 111 Version 6.0 January 2017

28 3.13 Acute Promyelocytic Leukaemia (APL) Patients can be registered to the trial and should receive: AIDA (4 courses of Ida based chemotherapy). After 55 to 60 days assess molecular remission status (see Section 9). After Course 2, reassess remission status for minimal residual disease monitoring - If in morphological CR, continue with AML19 protocol. If not in morphological or molecular CR, the patient should be discussed with the Chief Investigator. Bone marrow should be sent for MRD monitoring. After courses 3 and 4 and at subsequent specified intervals, bone marrow should be sent for molecular monitoring (see section 7.6) 3.14 Subject Withdrawal Patients remain free not to complete study treatment at any time without giving reasons and without prejudicing any further treatment. All patients who come off protocol therapy, for whatever reason, will remain within the study for the purposes of follow-up and data analysis. Such patients will continue to be followed up annually for life. If a patient withdraws consent originally given; this means that they no longer wish to be involved in the trial. In this case the patient will not be followed up. For these patients a Study Withdrawal Form should be completed. Individual stopping criteria may include but are not restricted to the following: Pregnancy-In the event of pregnancy all IMPs must be stopped and pregnancy discussed with the Chief Investigator The Principal Investigator or Chief Investigator feels trial treatment is not in the patients best interest (this may include ongoing non-compliance with trial treatment) Randomisation Errors- Incorrect Inclusion/exclusion information may be entered at randomisation resulting in patient s withdrawal from trial. Patient relocates to a location where further trial treatment is not possible Patient is lost to Follow Up Urgent Safety Measure Page 18 of 111 Version 6.0 January 2017

29 Participants who wish to withdraw from trial medication (IMP) should be asked by their clinical team to confirm whether they are still willing to continue to provide data and samples to the trial Treatment assignment procedures (randomisation procedure) The trial is a randomised phase III trial. Randomisation will be performed using a computerimplemented minimisation algorithm by the Haematology Clinical Trials Unit. Centres may enter the patient onto the trial directly using the interactive Web-based system, or conduct the randomisation by telephone (see Section 6.3 for details). The statistical power calculations differ with each randomisation, so recruitment to some randomisations may be completed before others. This will mean that a randomised component of the trial may close or be changed before completion of the trial as a whole. Similarly, because individual components might require alteration in the light of trial monitoring or other experience this will be a feature of the trial. It is possible that for these or other reasons not all of the randomisations will be available at all times. When such circumstances arise investigators will be informed Premature Termination or Suspension of the Trial It is possible that the trial or any part of the trial may be closed or suspended at any time. There may be a number of potential reasons for this. For example, it may be because the original recruitment target has been achieved and the patients are in follow-up; there may be a recommendation from the DMEC, or a drug used in the study may have become unavailable. If this happens the trial team at each site will be informed and will receive an explanation which can, where relevant, be communicated to patients. Page 19 of 111 Version 6.0 January 2017

30 4 JUSTIFICATION OF TREATMENT OPTIONS 4.1 AML (excluding APL) Experience from AML15 and dose rationale for Mylotarg AML15 was a highly successful trial with a high overall CR rate of 84%, and survival which is significantly improved compared with the previous MRC AML12 trial and which compares very favourably with any international protocol. Thus, the therapy used in AML15 forms the backbone of the AML19 trial. The theme for AML 19 is best available chemotherapy with or without molecular intervention, and, for patients who are at high risk of relapse, novel treatment will be assessed. The AML15 trial demonstrated a significant benefit of giving Mylotarg when combined with DA, ADE or FLAG-Ida chemotherapy in at least 70% of patients with AML; this has been reinforced by the results of the AML16 trial, and a recent meta-analysis of all similar trials in adults. Included in this experience is that of the French ALFA group who demonstrated significantly improved survival in patients aged given fractionated doses of Mylotarg (1-4). The question of the best way to deploy Mylotarg is therefore of importance, and we propose to compare the ALFA schedule, where up to 5mg of Mylotarg is given, daily, on days 1 and 4 of chemotherapy, with the MRC schedule of 3mg/m 2 on day 1 of chemotherapy. The choice of induction treatments was informed by the experience from AML15 (5). In AML15 the overall complete remission rate after 2 induction courses was similar between DA and ADE (78% vs 82%). In the comparison of ADE and FLAG-Ida there was also no significant difference in the rate of CR (81% vs 84%) or overall response (85% vs 86%). The proportion achieving CR or CRi with one course was 63% for DA, 67% for ADE (78% of those who remitted) but was significantly better for FLAG-Ida at 77% (p<0.0001) and 92% of those who remitted did so post course 1. The rates of induction death and 30 and 60 day mortality were not different. Furthermore it has now emerged that FLAG-Ida significantly reduced subsequent relapse and improved relapse free survival overall and in all subgroups although there was no overall survival benefit at 5 years (48% vs 42%, HR 0.92 ( ), p=0.2). However FLAG-Ida was significantly more myelosuppressive requiring more supportive care. Of importance to the design of AML19, in AML15, 54 patients received only FLAG-Ida induction (2 courses) and had no further consolidation therapy primarily because of delayed haematopoietic recovery after course 2. However, in a landmark analysis of patients who survived 60 days from CR (to allow for immortal time bias as one group has to survive long enough to receive 4 courses), survival from CR was not significantly different from patients who received all 4 courses of ADE or DA induction and consolidation (57% vs 54%. P=0.5, Figure) Page 20 of 111 Version 6.0 January 2017

31 thus raising the question whether consolidation chemotherapy is necessary after 2 courses of FLAG-Ida. However, in the 230 FLAG-Ida patients who were fully compliant with 4 courses, the 5-year survival was significantly superior to the 979 ADE/DA patients who were fully compliant (70% vs 54%, p< ). The statistically significant benefit for FLAG-Ida remains in analyses adjusted for age WBC, cytogenetics and secondary disease (p=0.002). As selection factors may affect the above retrospective findings, we propose a randomisation post course 2 for patients receiving FLAG-Ida who have adequate haematologic recovery (have regenerated to 1.0 x 10 9 /l neutrophils and 80 x 10 9 /l platelets). These patients will be randomised to receive no further chemotherapy or 1 or 2 further courses of consolidation with high dose Cytarabine (HDAC) to determine if consolidation chemotherapy improves survival following 2 cycles of FLAG-Ida induction. Because this observation was not seen in the non- FLAG-Ida arms of AML17, patients randomised to DA at induction will not enter this randomisation and will receive 2 courses of HDAC consolidation. The choice of HDAC consolidation is based on AML15 where of the 2701 patients who successfully completed two courses of induction, 1445 were randomised between MRC consolidation with MACE/MiDAC and 2 courses of HDAC. There was no significant difference between the arms in cumulative incidence of relapse (CIR) deaths in remission/rfs or overall survival at 5 years in good or standard risk AML but HDAC was less toxic requiring less supportive care. Favourable and intermediate risk patients who received FLAG-Ida as induction (2 courses) and high dose Cytarabine (2 courses) as consolidation had an 8 year survival of 72% (favourable 95%: intermediate 63%). Given these excellent results patients with good risk CBF AML (characterised by the presence of t(8;21) or inv(16)) will be excluded from the consolidation randomisation question and will receive 2 courses of HDAC consolidation. Page 21 of 111 Version 6.0 January 2017

32 4.1.2 Molecular Targeting Selected centres within the AML19 trial will be supporting the Astellas Gilteritinib studies. Patients are eligible for this study if they are FLT3-ITD +ve and have completed all their allocated AML19 chemotherapy or are high risk and have undergone transplantation Core Binding Factor Leukaemias This subgroup is characterised by having either the t(8;21) or inv(16) balanced translocations which result in the production of a fusion transcript namely the AML1-ETO and CBF-MYHII respectively. These molecular targets are potentially useful as targets for monitoring minimal residual disease (MRD). Outcomes in core binding factor AML have improved over the past 25 years from a 5 year survival of 59% in 1988 to 84% post In 2002, the AML15 trials introduced an induction randomisation including FLAG-Ida, a 1:1 randomisation to add gemtuzumab ozogamicin (GO) to induction, and a 1:1 randomisation to high dose Cytarabine consolidation (2 courses). We previously reported that GO significantly improved OS in AML and have recently confirmed that high dose Cytarabine was more or less equivalent to, but less myelotoxic than MACE/MiDAC in the AML15 trial. Recently we investigated which factors have contributed to the improvements in survival, by performing a prognostic factor analysis including date of diagnosis, and the introduction of GO and high-dose Cytarabine as covariates (11). A total of 896 patients with cytogenetically confirmed core binding factor leukaemia from the MRC AML10, 12, 15 trials and the NCRI AML17 trial were included in the analysis. Date of diagnosis ranged from 1988 to Patients were aged between 16 and 60 years of age. A prognostic model was built using Cox regression with forward selection, at an entry probability of p<0.05, with candidate variables year of diagnosis, age, white blood cell count (WBC, both as WBC and log (WBC)), performance status, sex, secondary disease, type of abnormality (t(8;21) or inv(16)), and the use of FLAG-Ida and/or GO in induction, and high dose Cytarabine in consolidation. In multivariate analysis of survival, the following variables were significant, in order of entry to the model: use of GO in induction (HR 0.40 ( ) p<.0001); performance status (HR 1.20 ( ) p=0.001); age (HR per decade 1.18 ( ) p=0.001); log WBC (HR per unit increase 1.38 ( ) p=0.002). In particular, year of diagnosis was not significant in multivariate analysis (p=0.2) indicating that improvements over time are due to the introduction of GO, rather than a steady improvement in outcome over many years. The improvement due to GO was consistent across both types of CBF AML In analysis of relapse free survival log WBC (HR 1.86 ( ) p<.0001), FLAG-Ida (HR 0.38 ( ) p<.0001) and high dose Cytarabine (HR 0.76 ( ) p=0.02) were the only significant prognostic factors; however, for survival from remission, GO was the most significant factor (HR 0.50 ( ) p<.0001). Since 2009, all patients' treatment has included GO in induction and high dose Page 22 of 111 Version 6.0 January 2017

33 Cytarabine consolidation (2 courses) which in 176 patients overall has yielded 5-year survival of 89%. In AML19 all CBF patients will receive GO in induction with 2 courses of HDAC consolidation High Risk Score Patients Approximately 30% of all non-apl patients will be identified by the Risk Score after recovery from course 1. These patients merit evaluation of novel treatment approaches and/or should be offered stem cell transplantation from sibling or alternative donors. Since high risk patients do not derive benefit from Mylotarg in course 1, it may be possible to identify such patients based on rapid targeted FISH analysis at diagnosis. If identified in this way, these patients can enter the high risk randomisation directly. Patients identified as High Risk will be able to enter a randomisation between FLAG-Ida followed by MACE/MiDAC and CPX-351. In AML17 we utilised our validated risk score to identify patients at high risk of relapse and who benefit from allogeneic transplant in CR1. This is calculated as *age (in years) *sex (1=male, 0=female) *diagnosis (1=de novo, 2=secondary) *cytogenetics (1=favourable, 2=intermediate, 3=adverse) *status post C1 (1=CR, 2=PR, 3=NR) * WBC (x10 9 /L).The risk score will be continued in AML19 and will be used to identify patients who should proceed to allograft. The score will be supplemented by patients who have a FLT3 ITD+ve / NPM1wt genotype, and are not CBF AML - we have recently shown that these patients benefit from allogeneic transplant. Finally the score will be supplemented by patients who have primary refractory disease defined (>15% blasts present and <50% proportional reduction in blasts e.g. 40% to 21%). This modified HR score will now identify approximately 36% of patients for whom allograft from a sibling or alternative donor is recommended. In AML19 the control arm is FLAG-Ida followed by MRC consolidation with MACE/MiDAC for those patients unable to proceed to allograft. The choice of FLAG-Ida/ MACE / MiDAC as our standard arm for high risk patients is based upon results from AML15 which showed that MACE/MiDAC consolidation in high risk patients was associated with a reduced relapse risk (see Forest plot) compared to HDAC. For both arms a total of 3 courses maybe given. Page 23 of 111 Version 6.0 January 2017

34 CPX-351: Dose rationale CPX-351 is a liposomal formulation of a fixed combination of the antineoplastic drugs cytarabine and daunorubicin. The two drugs are in a 5:1 molar ratio within the liposome, a ratio shown in vitro to maximize antitumour efficacy across multiple leukemic and solid tumour cell lines and in animal model studies to be consistently more efficacious than conventional free drug treatment. The two drugs are present inside the liposome in a 5:1 molar ratio. The liposome membrane is composed of distearoylphosphatidylcholine, distearoylphosphatidylglycerol and cholesterol in a 7:2:1 molar ratio. These liposomes have a nominal diameter of approximately 100nm and are suspended in sucrose. The hypothesis and rationale for CPX-351 development is that delivery of the 5:1 molar ratio of cytarabine and daunorubicin will enhance efficacy compared to treatment with the same drugs in the 7+3 regimen. Preclinical and clinical data presented are consistent with the following proposed mechanism for enhanced efficacy (12,13) : The CPX-351 liposome is stable, circulates for >7 days after infusion, with minimal leakage of drug Based on preclinical data intact liposomes accumulate and persist in the bone marrow In the bone marrow CPX-351 is taken up preferentially within the cytoplasm of leukemic cells Intra-cytoplasmic release of cytarabine and daunorubicin from liposomes within leukemic cells leads to efficient and rapid killing. Following the dose finding study (15), a study dose of 100units/m 2 which contains 44mg/m 2 of daunorubicin was established as the daily dose to be given on days 1,3 and 5 as a 90 minute intravenous infusion. A randomised phase 2 study (204) (n=126) was carried out in newly diagnosed older patients (60-75 years) versus the traditional 3+7 schedule. At 1 year there Page 24 of 111 Version 6.0 January 2017

35 was a trend for better disease free and overall survival in the CPX arm, which was achieved with acceptable safety as seen by a superior 60 day mortality (4.7% vs 14.6%), in spite of more greater myelosuppression resulting in increased febrile neutropenia (63.5% vs 51.2%). In exploratory subgroup analysis it appeared that the benefit was suggested in patients with secondary disease. In a randomised phase 2 study (CLTR ) (n=120) in relapsed patients aged years, it was again found that patients with unfavourable disease were the likely beneficiaries with a 12 month survival advantage (30% vs 10%). Pharmacokinetic studies indicate that there are still plasma levels of Cytarabine and Daunorubicin a week after administration. These data suggest that this formulation might be capable of improving the outcome of patients who are defined as adverse risk, despite the fact that the definition of adverse risk in AML19 is not precisely the same as in the CPX-351 trials so far completed. CPX-351 will be given intravenously at 100u/m 2 on days 1, 3 and 5 by approximately 90 minute infusion. The interest in examining fludarabine with CPX-351 stems from the observation that fludarabine added to high-dose cytarabine increases the activity of deoxycitidine kinase within leukaemia cells, resulting in increased intracellular levels of CytarabineTP, the active metabolite of cytarabine (13) and from observations in animal models that leukaemia blasts exhibit active uptake of CPX-351 liposomes resulting in delivery of high intracellular levels of cytarabine and daunorubicin at the 5:1 molar ratio (14). We expect that fludarabine might also augment CytarabineTP levels within leukaemia blasts following CPX-351 treatment, potentiating its antileukaemia efficacy as well. CPX-351 by itself has very acceptable safety when compared to 7+3 regimen, marked by reduced 60-day mortality (4.7% vs. 14.6%) and relatively mild nonhaematological toxicities. This series of observations suggest that it may be possible to combine CPX-351 with fludarabine to produce a potentially safer and more efficacious CPX- 351-based version of FLAG-Ida. Consequently, we believe that it will be important to first compare CPX-351 against FLAG-Ida, the current standard of care for high risk patients in AML- 19 and then, following confirmation of acceptable safety and baseline activity for CPX Fludarabine to compare that regimen against FLAG-Ida to determine the level of safety and degree of efficacy potentiation contributed by combining fludarabine with CPX-351. Page 25 of 111 Version 6.0 January 2017

36 4.2 Stem Cell Transplantation Previous MRC trials have helped define the role of allogeneic transplant. In a large dataset the new AML17 risk score was used in a retrospective analysis, to re-examine the role of transplantation. In patients with a standard risk score there was no survival benefit from transplantation, however in the newly defined high risk score patients there was a significant survival difference (33% vs 18%,p=0.01). This leads to the conclusion that the risk score can identify a population of patients which benefits from transplantation, and comprises a larger population than defined as high risk by previous criteria. However in AML15 only 30% of such patients received a transplant and the relapse after transplant is still an important reason for patients failing. The aim of the AML17 trial, continued into AML19, in this group was to develop novel treatments which better enable a patient to get to transplant, by reducing early relapse, and similarly to reduce the risk of post-transplant relapse. Thus in AML17 a higher proportion of patients defined as high risk were transplanted. Furthermore it is clear that delivering the transplant is important where the survival was 44% compared with 28% if no transplant was given. The AML15 trial also permitted standard risk patients who had a matched sibling donor to go forward to transplantation including a reduced intensity allograft, and for high risk patients a matched unrelated donor was permitted. The comparative results of transplantation in the AML15 trial have recently been reviewed. This experience endorses the policy of myeloablative transplant from a matched sibling or volunteer donor for patients under 40 years, also those who have a FLT3+/NPM1- genotype benefit from a myeloablative transplant. AML15 also evaluated the role of RIC transplant in standard risk AML in patients over 40 years (Russell et al 2015). A survival advantage was seen for RIC but only when sibling donors were used. In AML19 RIC is recommended from a sibling donor for standard risk AML patients excluding those who are CBF AML and those who are NPM1 mutant AML but MRD negative (irrespective of the presence of a FLT3ITD) in the peripheral blood post course 2. The value of transplantation will continue to be assessed by a comparison of patients who were and were not transplanted using the methods described in the statistical plan. Page 26 of 111 Version 6.0 January 2017

37 Patients from AML19 may be eligible for the FIGARO trial which is a prospective, phase II, national, 2 arm, multicentre, RCT in patients with acute myeloid leukaemia (AML) or myelodysplasia (MDS) comparing the current UK transplant regimens (fludarabine/melphalan/alemtuzumab (FMA) or fludarabine/busulphan/alemtuzumab (FBA)) with an experimental conditioning regimen (FLAMSA-BU). 4.3 Acute Promyelocytic Leukaemia (APL) Acute Promyelocytic Leukaemia is characterised by the t(15;17) and presence of the PML-RARα fusion protein. In AML17 we compared the Idarubicin-based AIDA Schedule with the chemo-free combination of ATRA and Arsenic Trioxide (ATO) given intravenously. Arsenic Trioxide (ATO) is currently only approved for patients who relapse, where it is highly effective, and unlike ATRA, is able to render such patients molecularly negative (16).Over 230 patients (including high risk APL) were entered into this randomisation. The study has run alongside a similar but smaller trial from the Italian/German GIMEMA/SAL groups which has reported excellent outcomes with the chemofree ATRA/ATO approach in patients with low risk APL (97% EFS at 2 years) (17). In AML17 which unlike the GIMEMA study included high risk patients with a WCC>10 x 10 9 /L a similar result was seen. In AML19 we currently will register patients to receive AIDA treatment (standard of care) but it is hoped to bring in an ATO question into the trial soon. Patients who relapse post AIDA should be treated with ATO plus ATRA 4.4 Molecular screening and MRD monitoring At diagnosis all patients will have molecular screening. The particular target lesions concern the definition of favourable genetic abnormalities, i.e. AML1-ETO, CBF-MYHII and PML-RAR corresponding to t(8;21)(q22;q22), inv(16)(p13;q22) and t(15;17)(q22;q12-21) respectively. Page 27 of 111 Version 6.0 January 2017

38 Previous analyses suggest that approximately 15% of cases with these lesions that were not detected by conventional cytogenetics can be detected molecularly. In several cases this was due to technical failure, but may also be explained by more complex rearrangements. Although the number of cases is small they seem to respond in a similar way to cases defined by cytogenetics, and therefore can be used to define the favourable risk group. Studies have identified 20-27% of younger AML cases as associated with a mutation of the FLT3 gene, which is an independent prognostic factor. All samples will be sent to the reference labs and will be analysed: To establish the mutation status, FLT3 (and NPM1), to enable patients to enter the appropriate randomisation and to inform the risk score. Samples will be routinely screened for other mutations e.g. but not restricted to NPM1 CEBPα and RAS which in some studies have been shown to have prognostic value and will be necessary in evaluating the planned interventions. The FLT3/NPM1 genotype will be assessed to identify those standard risk patients who benefit from a myeloablative stem cell transplant. These may also contribute to a revised risk score for future treatment choices Assessment of the value of MRD detection The AML19 trial will continue to evaluate minimal residual disease monitoring in AML. An aim of the AML17 trial was to determine the clinical value of knowing the MRD status, when detected by any validated method. The chosen method of doing this, once a validated method has been identified, is to randomise patients to be monitored or not to be monitored. The monitor versus not monitor randomisation will continue into the AML19 trial. Within the AML19 protocol, patients who are monitored, and who are thought by the individual investigator in consultation with the CI to be at high risk because they have been found to have MRD detected, can enter the high risk component of the trial. The AML17 trial has identified a group of patients with NPM1 mutations who are at high risk of early treatment failure, We have established that persistence of NPM1 mutant transcripts in blood following the second course of chemotherapy predicted an increased risk of relapse (77% vs 28% at 3 years, p<0.0001) and poorer overall survival (25% vs 77%, p<0.0001). MRD status was the most significant prognostic factor in multivariable analysis (HR 4.51 ( ) p<0.0001), providing superior discrimination to mutational profile including FLT3-ITD and DNMT3A status (20) (see below). This comprises about 20% of patients with NPM1+ve AML entered into AML17. These patients are to be regarded as high risk in AML19 and eligible to enter the high risk arm of the trial and are eligible for transplantation. As a consequence all Page 28 of 111 Version 6.0 January 2017

39 patients with NPM1 mutations will be monitored for NPM1 transcripts in blood and bone marrow following courses 1 and 2. Patients who are NPM1 mutant in the PB post course 2 can enter the high risk arm and will continue to be monitored following further chemotherapy and BMT for 2 years. Those who are MRD -ve in the PB continue with their allocated chemotherapy and are not recommended for transplant in CR1 but are eligible to enter the monitor versus no monitor randomisation. Page 29 of 111 Version 6.0 January 2017

40 5 REFERENCES 1. Burnett AK, Hills RK, Milligan D, Kjeldsen L, Kell J, Russell NH, et al. Identification of patients with acute myeloblastic leukaemia who benefit from the addition of gemtuzumab ozogamicin: results of the MRC AML15 trial. J Clin Oncol ;29(4): Burnett AK, Hills RK, Hunter AE, et al. The addition of gemtuzumab ozogamicin to induction chemotherapy improves survival in older patients with acute myeloid leukaemia. J Clin Oncol 2012 J Clin Oncol Nov 10;30(32): Castaigne S, Pautas C, Terré C, Raffoux E, Bordessoule D, Bastie JN, et al. Acute Leukaemia French Association. Effect of gemtuzumab ozogamicin on survival of adult patients with de-novo acute myeloid leukaemia (ALFA-0701): a randomised, open-label, phase 3 study. Lancet. 2012; 379(9825): Hills RK, Petersdorf S, Estey EH, Othus M,. Appelbaum FR, Castaigne S, Dombret H, Chevret S, Delaunay J, Ifrah N, Cahn J-Y, Recher C, and Burnett AK. The Addition Of Gemtuzumab Ozogamicin (GO) To Induction Chemotherapy Reduces Relapse and Improves Survival In Patients Without Adverse Risk Karyotype: Results Of An Individual Patient Meta-Analysis Of The Five Randomised Trials. Blood :356 (AML15,16). 5. Burnett AK, Russell NH, Hills RK, et al. Optimization of chemotherapy for younger patients with Acute Myeloid Leukaemia: Results of the Medical Research Council AML15 Trial. Journal of Clinical Oncology 2013, 31(27), Gozgit JM, Wong MJ, Wardwell S, Tyner JW, Loriaux MM, Mohemmad QK, et al. Potent activity of ponatinib (AP24534) in models of FLT3-driven acute myeloid leukaemia (AML) and other hematologic malignancies. Mol Cancer Ther. 2011;10: Shah NP, Talpaz M, Deininger MW et al Ponatinib in patients with refractory acute myeloid leukaemia: findings from a phase 1 study.br J Haematol Aug;162(4): Whitesell L, Lindguist SL. HSP90 and the chaperoning of cancer. Nat Rev Cancer (10): Weinstein IB. Addiction to onco-genes the Achilles heel of cancer. Science. 2002; Shimamura T, Borgman CL, Chen L et al. The novel Hsp90 inhibitor STA-9090 has potential anticancer activity in vitro and in vivo models of lung cancer. Proc Am Assoc Cancer Res (50). A4679 (abstract) 11. Burnett AK,. Hills RK, Russell NH, Milligan D, Hunter AE, Clark RE, Bowen D, and McMullin MF. Reasons For Survival Improvement In Core Binding Factor AML: A 25 Year Analysis Of The UK MRC/NCRI AML Trials. Blood : Kim, P., G. Gerhard, T. O. Harasym, et al., Improved selectivity against acute myeloid leukaemia (AML) blasts over normal hematopoietic progenitors for cytarabine:daunorubicin delivered as CPX-351 liposome injection. Blood 114: GandhiV, Estey E, Keating MJ, Plunkett W. Fludarabine potentiates metabolism of cytarabine in patients with acute myelogenous leukaemia during therapy. J Clin Oncol 1993:11: Lim, W.S., P. G. Tardi, N. Dos Santos, et al., 2010a. Leukaemia-sensitive uptake and cytotoxicity of CPX- 351, a synergistic fixed-ratio cytarabine:daunorubicin formulation, in bone marrow xenografts. Leuk. Res. 34: Feldman EJ, Lancet JE, Kolitz JE, et al: First-In-Man Study of CPX-351: A Liposomal Carrier Containing Cytarabine and Daunorubicin in a Fixed 5:1 Molar Ratio for the Treatment of Relapsed and Refractory Acute Myeloid Leukaemia. J Clin Oncol 29:979-85, Estey E, Garcia-Manero G, Ferrajoli A, et al. Use of all-trans retinoic acid plus arsenic trioxide as an alternative to chemotherapy in untreated acute promyelocytic leukaemia. Blood. 2006;107: Page 30 of 111 Version 6.0 January 2017

41 17. Lo-Coco F, Avvisati G, Vignetti Met al. Retinoic acid and arsenic trioxide for acute promyelocytic leukaemia N Engl J Med Jul 11;369(2): Kumana CR, Au WY, Lee NSL, et al. Systemic availability of arsenic from oral arsenic-trioxide used to treat patients with hematological malignancies. Eur J Clin Pharmacol. 2002;58: Siu C-W, Au W-Y, Yung C, et al. Effects of oral arsenic trioxide therapy on QT intervals in patients with acute promyelocytic leukaemia: implications for long-term cardiac safety. Blood. 2006;108: Ivey A, Hills RK Simpson MA et al on behalf of the National Cancer Research Institute (NCRI) AML Working Group. Assessment of Minimal Residual Disease in Standard-Risk AML. N Engl J Med 2016; 374: February 4, Grimwade D, Hills RK, Moorman AV, et al; National Cancer Research Institute Adult Leukaemia Working Group. Refinement of cytogenetic classification in acute myeloid leukemia: determination of prognostic significance of rare recurring chromosomal abnormalities among 5876 younger adult patients treated in the United Kingdom Medical Research Council trials. Blood Jul 22;116(3): Page 31 of 111 Version 6.0 January 2017

42 6 PROCEDURES FOR ENTRY INTO THE TRIAL 6.1 Centre Registration Centres will be provided with trial information by way of an invitation to participate in the trial. In order to be registered as a trial centre, an individual at each participating institution is required to act as the Principal Investigator for the Institution. The following must be completed and returned to the Sponsor prior to the centre being open to recruitment: R&D approval Site added to Clinical Trials Authorisation Signed Site Agreement (including signed PI statement) Trial specific initiation, involving key personnel For administrative purposes, Investigators will also be asked to supply: Details of location of their immunophenotyping, cytogenetic, molecular, genetic and pharmacy services addresses of all personnel at site that will conduct trial procedures In addition a limited amount of biochemical data will be collected and, as part of the Centre Registration process, relevant institutional normal ranges (bilirubin, ALT) will be registered. Training will be provided to key personnel at participating sites prior to randomisations in the trial being made available. 6.2 Patient Recruitment Patients may be recruited only once a centre is fully registered (Section 6.1). All patients should be given Patient Information Sheet 1 to inform them of the overall structure of the trial. Where APL is suspected Patient Information Sheet 3 should also be given. For non-apl patients, a patient who has agreed to enter the trial (by Patient Information Sheet 1) should also receive Patient Information Sheet Randomisation Investigators are invited to regard this protocol as an evolving investigation into AML treatment. The statistical power calculations differ with each randomisation, so recruitment to some randomisations may be completed before others. This will mean that a randomised component of the trial may close or be changed before completion of the trial as a whole. Similarly, because individual components might require alteration in the light of trial monitoring or other experience this will be a feature of the trial. It is possible that for these or other reasons Page 32 of 111 Version 6.0 January 2017

43 not all of the randomisations will be available at all times. When such circumstances arise investigators will be informed in order that potential participants may be fully informed during the consent process. There are four randomisation points in the trial for which contact must be made with the Haematology Clinical Trials Unit (HCTU). Patients fulfilling the criteria for entry into the trial (see Section 4) should be entered into the first randomisation either by entering the patient using the secure website ( or by telephoning the HCTU in Cardiff (tel: / ). Telephone randomisation is available Monday to Friday, ; internet randomisation is available seven days a week, 24 hours a day. 6.4 First randomisation for Non-APL Patients The randomisation to be undertaken depends on whether the patient is known to have adverse risk cytogenetics For patients not known to have adverse cytogenetics Note: For this randomisation Patient Information Sheet 2 and Consent Form 2 should be used. During the course of the trial certain randomisation options may not be available permanently or on a temporary basis. Investigators will be informed in advance so that only relevant information is given to the patient during the consent procedure. Induction chemotherapy allocation will be given once the required patient details have been supplied. Patients will be allocated to one of the five induction chemotherapy treatment arms. If patients are ineligible for Mylotarg they will be randomised between DA and FLAG-Ida without Mylotarg. 1. Two courses of DA with Mylotarg 3mg/m 2 on day 1 of course 1 2. Two courses of DA with Mylotarg 3mg/m 2 (max 5mg per day) on days 1& 4 of course 1 3. Two courses of FLAG-Ida with Mylotarg 3mg/m 2 on day1 of course 1 4. Two courses of FLAG-Ida with Mylotarg 3mg/m 2 (max 5mg per day) on days 1 & 4 of course 1 If for any reason Mylotarg is not available patients should be randomised to DA or FLAG-Ida Page 33 of 111 Version 6.0 January 2017

44 6.4.2 For patients known to have adverse risk cytogenetics Note: For this randomisation Patient Information Sheet 2A and Consent Form 2A should be used. Induction chemotherapy allocation will be given once the required patient details have been supplied. Patients will be allocated to one of two chemotherapy treatment arms. 1. Two courses of FLAG-Ida followed by MACE/MidAC consolidation 2. Up to four courses of CPX Information required at first randomisation Centre and name of consultant in charge of management Patient's name (family name and given name) Sex Date of birth WHO performance status: o o o o o 0=normal activity 1=restricted activity 2=in bed <50% waking hours 3=in bed >50% waking hours 4=completely disabled. Type of disease: de novo AML / secondary AML Whether APL (FAB type M3) or not Baseline White Blood Count Whether the patient has known adverse risk cytogenetics Confirmation that the patient is eligible for Mylotarg Confirmation that diagnostic samples of bone marrow and/or blood will be sent to the reference lab for mutation analysis. 6.5 Subsequent randomisations Eligibility for subsequent randomisations will be assessed using data from the response to course 1 (to assign risk group), number of courses given and status of patient as relapsed/refractory (for high risk randomisation), cytogenetics, and FLT-3 mutation status. The information is required to be entered into the online system before the randomisation point is reached. At subsequent randomisations, patients will be identified using their trial number, and eligibility confirmed for the various randomisations. Please ensure the correct consent form is completed as specified below. Page 34 of 111 Version 6.0 January 2017

45 7 PROVISION OF BIOLOGICAL MATERIAL 7.1 Diagnostic material One objective of the trial is to investigate the therapeutic relevance of new techniques for detecting minimal residual disease and the quality of remission. Diagnostic material is essential for these studies. It is of particular importance to define the cytogenetic abnormalities, and where possible the molecular characteristics, of each patient as this may be relevant to the treatment strategy. 7.2 Cytogenetics and Molecular Genetics Cytogenetics should be carried out locally and the cytogentic report form completed on the AML19 online system. Each cytogeneticist will be given a secure login: it is important that the cytogenetic data is entered promptly as the cytogenetic results influence the risk score assignment of patients post course FLT3 Mutation Status Molecular definition is intended for all patients, initially for characterisation of FLT3 mutation, for identification of cases with cryptic gene rearrangements that reassign patients to the favourable risk group, and for the identification of cases suitable for minimal residual disease monitoring. To enable this to be achieved in the timescale required samples should be sent to Marie Gilmour (Cardiff) using the dispatch methods currently in place for existing AML trials. Additionally, they will be told of patients in whom molecular screening alters the risk group assignment and/or reveals a molecular marker suitable for randomisation into the monitor v no monitor randomisation. FLT3 and NPM1 mutation analysis will be analysed in real time. Diagnostic material will also be stored for molecular profiling and future research studies, for which patient informed consent must be obtained (use Patient Information Sheet and Consent Form 9). Molecular screening will be carried out in the reference molecular labs. It is essential that a sample is sent to the Cardiff laboratory for the identification of patients with a FLT3 mutation. The laboratory will pass samples on to the laboratories designated for MRD monitoring. It is intended that investigators will have the results of FLT3 assays by the end of the first course of chemotherapy (further details available from HCTU). Laboratory for FLT3 and NPM1 Mutation Analysis and Molecular Screening: Page 35 of 111 Version 6.0 January 2017

46 Department of Haematology, University Hospital of Wales, Cardiff, Marie Gilmour Samples at diagnosis for molecular analysis: 5 ml of bone marrow and 30ml of blood in EDTA. (To be sent to Cardiff Lab) Samples at diagnosis for cytogenetic analysis ((local labs) (please follow local procedures if they differ from below)): 4 ml of bone marrow in tissue culture medium with preservative-free heparin 30 ml of heparinised blood Ideally, both marrow and blood should be sent, but if only one is available that should be sent. 7.4 Follow-up Material Investigators will be informed of patients who are of particular interest for minimal residual disease monitoring. 7.5 Sample Banking Molecular Screening and Immunophenotypic detection of Residual disease Marker At diagnosis: Diagnostic material from all cases of suspected AML entering the trial should be sent by guaranteed next day delivery to the AML tissue bank at Cardiff (lead Marie Gilmour) Labs, from where it will immediately be analysed for FLT3 status and subsequent molecular screening and also stored for future research. (Note that consent to store samples for future research requires completion of Patient Information Sheet 9 and Consent Form 9). The banking lab does not require to be senta copy of the consent documentation but is working on the assumption that the sending of the sample constitutes consent. It is the responsibility of the investigator to ensure that when the sample is sent that consent has been obtained. If this is not the case the lab must be informed to enable the sample to be destroyed. Similarly if a patients withdraws consent to continue in the trial, the stored samples will be destroyed. Molecular screening for the more common mutations is intended on all patients. For this the samples will initially be sent to the Cardiff lab for characterisation. If a suitable marker is found, patients will be eligible for the molecular monitoring versus no monitoring randomisation, when monitored patients will be serially followed by the Guy s Lab (see section 7.7). Page 36 of 111 Version 6.0 January 2017

47 The Cardiff lab will undertake the FLT3 mutation assessment to enable entry into the FLT3 inhibitor randomisation and NPM1 assessment to enable the detection of patients with high risk NPM1 mutated AML Laboratory Contacts: Molecular screening: Marie Gilmour Department of Haematology Cardiff University School of Medicine Heath Park Cardiff CF14 4XN Tel: Fax: Minimal Residual Disease Monitoring A major question to be continued in the AML19 trial is the clinical value of disease monitoring using molecular approaches Frequency of Molecular Monitoring On entering the trial, it should be explained to patients that, if it emerges that the leukaemia cells have an appropriate molecular lesion, they will be invited to participate in the molecular disease monitoring. Once patients have been identified, investigators will be alerted by the molecular monitoring group by from the Trials Office. Since in patients with APL the strategy of treatment reduction is being tested, molecular monitoring is an inherent part of the treatment. The intention is routinely to monitor patients (blood and bone marrow) after each course of chemotherapy, followed by sequential 3-monthly paired samples until 36 months postconsolidation. The frequency and duration of monitoring may change during the trial as new information or new markers become available. It has become clear that persistent or recurrent positivity using established real-time quantitative polymerase chain reaction (RT-qPCR) assays powerfully predicts relapse, but a key question is whether MRD-directed therapy can improve patient outcome. In the event of positive or equivocal results, or receipt of suboptimal samples, advice may be received to repeat the test within the interval planned. In patients subject to transplantation, paired blood and bone marrow samples are requested immediately prior to transplant, then at ~d+30, ~d+100 and then 3-monthly to allow assessment of the value of MRD monitoring with respect to surveillance using conventional chimerism assays. The issue of sequential testing is incorporated in the Patient Information Sheet 8 and Consent Sheets 8. Page 37 of 111 Version 6.0 January 2017

48 7.6.2 Molecular Monitoring in APL and non-apl Disease Minimal residual disease monitoring is well established in APL and was an integral part of the treatment of patients in the AML17 trial. This was important to ensure that the chemo-free option of ATRA and Arsenic Trioxide was not detrimental. So for patients entering the APL component of the trial monitoring is required as is set out in consent form 3. Patients should be advised, as is stated in the information and consent form, that this is the case and it will involve marrow samples (2-3ml first pull into EDTA) being taken after each consolidation course and then at 3-monthly intervals for 36 months, and that for technical or confirmatory reasons extra tests may be recommended. Samples are not required post course 1. Samples should be sent to Dr Richard Dillon at the address below: Specialist Diagnostic Haemato-oncology Unit, Dept. of Pathology 4 th Floor Thomas Guy House, Guys Hospital, London SE1 9RT Tel: Fax: richard.dillon@kcl.ac.uk The AML19 trial will continue to evaluate minimal residual disease monitoring in non-apl AML. An aim of the AML17 trial was to determine the clinical value of knowing the MRD status, when detected by any validated method. The chosen method of doing this, once a validated method has been identified, is to randomise patients to be monitored or not to be monitored. The monitor versus not monitor randomisation will continue into the AML19 trial with the exception that NPM1 mutant AML patients will only be able to enter the randomisation if they are negative for NPM1 mutant transcripts in blood following chemotherapy course 2 or MRD negative in the peripheral blood and bone marrow, with good sensitivity post course 1. Sites will be informed by if their patient has an NPM1 mutation. Within the AML19 protocol patients who are monitored, and who are thought by the individual investigator (in consultation with the CI) to be at high risk because they have been found to have had MRD detected, can enter the high risk component of the trial. Although detection of MRD can detect patients at high risk of relapse, it is not clear that there is any advantage in therapeutic intervention at this point compared with at the time of frank relapse if/when it occurs. 8 DATA RECORDING Page 38 of 111 Version 6.0 January 2017

49 8.1 Data submission It is intended to develop data recording for this trial as a web-based system. This is a secure encrypted system accessed by an institutional password, and complies with Data Protection Act standards. The system can be accessed on: A user password will be supplied to investigators upon completion of all processes required prior to opening. Web-based data collection forms should be completed as follows: Notification of Entry Return when all the diagnostic data requested are available (but not later than 1 month after entry) Cytogenetic result To be completed by the cytogeneticist as soon as karyotype is known and before the completion of course 1 of therapy to allow risk stratification. This result will be completed online by the site s nominated cytogenetics laboratory. Clinicians will be asked at randomisation whether the patient is known to have adverse risk cytogenetics Response to Course 1 Complete online as soon as the response to course 1 (CR/Cri/PR/RD/Death/Not evaluable) is known to enable stratification by risk group (in any event before course 2) Response to Course 2 Complete online as soon as the response to course 2 (CR/Cri/PR/RD/Death/Not evaluable) is known to enable downstream randomisations to be enabled Induction Chemotherapy Return when blood counts have recovered after the second induction course, or at prior death (but not later than 2 months after completion of Course 2) Consolidation Chemotherapy Return when blood counts have recovered after the final course of consolidation chemotherapy, or at prior death (but not later than 2 months after the final course) Transplant (only for patients receiving a transplant) Page 39 of 111 Version 6.0 January 2017

50 Return when blood counts have recovered post-transplant, or at prior death (but not later than 3 months after transplant) One Year Follow-up Return at one year after the end of treatment in 1st CR (i.e. last consolidation chemotherapy or transplant), or at death if the patient dies within 1 year of finishing therapy Notification of Relapse form Complete online within 30 days of patient having a first validated molecular or haematological relapse to open up high risk relapse randomisation. Relapse (Molecular and Haematological) Return at the completion of reinduction (and consolidation) therapy or at death (but not later than 4 months after relapse). Withdrawal of Consent Form This should be completed when a patients requests to withdraw from the trial. Withdrawal from the trial is not the same as stopping protocol treatment; patients in this latter group will continue on follow up within the trial. Monitor/no monitor reason for non-randomisation Return for each patient with marker identified who does not enter the monitor vs no monitor randomisation Quality of Life/Resource use Patient-completed questionnaires to be returned according to the schedules set out in Section 8.2. Long-term Follow up All randomised patients will be followed up for life or until they withdraw consent to be part of the trial, irrespective of whether they complete all trial treatments. This information will normally be collected at the annual follow up. Please note: it is the responsibility of the site to ensure that these forms are completed and returned. Page 40 of 111 Version 6.0 January 2017

51 8.2 Quality of Life Qol and Resource Usage in the Monitor vs No Monitor randomisation Studies using molecular or immunophenotypic techniques have been shown in a number of retrospective studies to be capable of predicting relapse. In AML19, we will continue the monitor versus no monitor randomisation started in AML17. The aim is to establish clinical value of monitoring by randomising patients to be monitored or not to be monitored. In these circumstances patients will be asked to consent to be randomised to be monitored or not to be monitored. The monitored patients will be required to agree to samples being taken according to the prescribed monitoring schedule, which will be established for each marker in phases 1 and 2. If and when a patient becomes MRD positive by any informative method (patients may well be being monitored using more than one marker), the investigator will be given this information, and will be asked to confirm that they have received this information. The protocol leaves the question of therapeutic intervention to the discretion of the investigator e.g. entering the treatment options provided for high risk score patients. Investigators will receive standardised lab reports, and information on action taken will be collected. If a patient is randomised to the no monitor arm no additional samples should be sent or taken: this randomisation is not appropriate for centres which perform their own local monitoring. It is recognised that repeated testing of this nature could cause patients extra anxiety, but it could also provide reassurance. In order to assess this, all patients in this randomisation (monitored or not monitored) will also be asked to participate in a Quality of Life assessment at 6 weeks, 18 weeks, 24 weeks, 30 weeks, 9 months, 12 months, 15 months and 18 months following the start of course 3 of chemotherapy. It is imperative that this data is collected at the correct time points, and the Quality of Life questionnaire will need to be completed if the patient relapses or is to receive a transplant. From the start of course 3, patients will be asked to complete a short resource use questionnaire together with the research team at each centre to assess the use of other resources since their last clinic visit. A patient diary will be available for patients to use as an aide memoire. Page 41 of 111 Version 6.0 January 2017

52 It is of the utmost importance that the monitor vs no monitor assessment is carefully explained to patients and consent should be obtained using Patient Information Sheet 8 and Consent Form QoL in APL patients Additionally, all patients in the APL component of the trial will have a Quality of Life assessment at baseline and 3, 6, 12, and 24 months from diagnosis. This will take the form of the EORTC QLQC-30 questionnaire plus the Leukaemia Specific Module which has been used in previous AML trials, and the Hospital Anxiety and Depression Scale (HADS). This will be sent to the investigator at the appropriate times, who should arrange for the patient to receive it. The patient should complete the questionnaire and return it (Freepost) to HCTU. A copy of the questionnaire is attached in Appendix G. 8.3 Health Economics Basic information on resource usage will be collected in the AML19 data forms on all patients. This will include time to neutrophil and platelet recovery, days in hospital, blood product usage, and days on antibiotics. This will be collected by the data collection system (internet or record books). Patients in the monitor vs no monitor randomisation will be invited to provide additional information to be collected on a resource usage form by the investigator. Once a patient has been randomised, it is very important to have full details of the subsequent course of events, even if allocated therapy has been abandoned. Although clinical decisions remain with the physician, follow-up data must continue to be collected on such patients and trial forms must be filled in, as far as possible, giving details of the therapy actually received and its outcome. Page 42 of 111 Version 6.0 January 2017

53 9 ACUTE PROMYELOCYTIC LEUKAEMIA 9.1 Treatment of APL patients Patients will enter this part of the protocol at diagnosis with de novo or secondary acute promyelocytic leukaemia (APL) recognised morphologically as FAB-M3/M3v. Treatment with ATRA and supportive care for coagulopathy should be started as soon as the diagnosis is suspected, without awaiting results of cytogenetic/fish/pcr analyses (see BCSH AML guideline). Diagnostic bone marrow (4ml in heparinised culture medium) and peripheral blood (30mls in EDTA) from all patients with suspected APL should be sent to Guy s laboratory, London Tissue Bank (for contact details see page ii). Arrangements can be made for rapid confirmation of presence of PML-RARA fusion by PML immunofluorescence. Confirmation of the molecular lesion is important because cases lacking the PML-RARA fusion will be under treated. Patients who enter the APL part of this trial will monitored for minimal residual disease (MRD) with the aim of identifying patients failing first line therapy who require additional therapy in first CR AIDA Treatment INDUCTION All-transretinoic acid, 45 mg/m²/day will be administered orally in two equally divided doses and rounded to the nearest 10 mg increment, starting on day 1. ATRA treatment will be continued until haematologic CR and for a maximum of 60 days Idarubicin, 12 mg/m² on days 2, 4, 6 and 8 by short (20 minute) intravenous infusion. Idarubicin doses should be brought forward by one day to days 1, 3, 5 and 7 in patients presenting with WBC>10 x 10 9 /l, with first dose given within a few hours of starting ATRA. If marrow appearances are equivocal at around d30, then ATRA is continued. If haematological CR is not achieved by 60 days after the start of induction the patient will go offstudy CONSOLIDATION After the achievement of haematological CR, patients will receive three successive courses of consolidation chemotherapy and ATRA. Each course will be initiated at haematological recovery from the previous course defined as: ANC >1.5x10 9 /L and platelets >80 x10 9 /L. In case of Page 43 of 111 Version 6.0 January 2017

54 toxicity requiring a delay of more than 3 months from the initiation of the previous course, consolidation treatment will be discontinued. First consolidation cycle Idarubicin, 5 mg/m 2 /d by short (20 minute) intravenous infusion on days 1, 2, 3, 4 ATRA, 45 mg/m 2 /d, will be administered orally in two divided doses and rounded to the nearest 10 mg increment, starting from day 1 to day 15 (30 doses total). Second consolidation cycle Mitoxantrone, 10 mg/m 2 /d as 30 minute intravenous infusion on days 1, 2, 3, 4, and 5. ATRA, 45 mg/m 2 /d will be administered orally in two divided doses and rounded to the nearest 10 mg increment, starting from day 1 to day 15. Third consolidation cycle Idarubicin, 12 mg/m 2 /d as short (20 minute) intravenous infusion only on day 1. ATRA, 45 mg/m 2 /d will be administered orally in two divided doses and rounded to the nearest 10 mg increment, starting from day 1 to day 15. Marrow samples will be collected around day 60 (i.e. following course 1 in patients requiring prolonged ATRA to achieve CR, or following course 2 in those with earlier documentation of CR) and on regeneration following each consolidation course for testing by real-time quantitative PCR (RQ-PCR) by the reference laboratory for assessment of molecular remission. Patients who do not achieve molecular remission by the end of the 3 rd consolidation cycle will be considered as molecular resistant and will go off study. Marrow samples collected at earlier time points are used to measure disease response and provide early indication of patients at risk of failing first line therapy Treatment Modification During induction treatment, ATRA may be temporarily discontinued in the presence of one of the following complications: differentiation syndrome, pseudotumor cerebri, hepatotoxicity. Page 44 of 111 Version 6.0 January 2017

55 Pseudotumor Cerebri This is defined as presence of: severe headaches with nausea, vomiting, and visual disorders. In this case, generally developing in patients under 20 years of age, it is often necessary to discontinue ATRA treatment temporarily and to administer opiates Hepatotoxicity This is defined as: an increase in serum bilirubin, AST/ALT, or alkaline phosphatase >5 times the normal upper level. This requires a temporary suspension of the ATRA. If hepatotoxicity persists following discontinuation of ATRA, Idarubicin doses should not be changed on the AIDA arm. As soon as the symptoms and the patient s clinical condition improves, treatment with ATRA will be resumed at 50% of the previous dose during the first 4 days after the disappearance of retinoic acid syndrome, amelioration of pseudotumor cerebri or when serum bilirubin, AST/ALT or alkaline phosphates are reduced to <4 times the normal upper level. Thereafter, in absence of worsening of the previous toxicity, ATRA should be resumed at full dosage. In case of reappearance of signs and symptoms of ATRA toxicity, the drug must be discontinued indefinitely during induction therapy Treatment of relapse, molecular relapse or persistent MRD positivity Initial treatment of APL may fail, in which case patients will either relapse or be at high risk of relapse. In this study patients who relapse, or who are deemed to be at high risk of relapse based on molecular data, and who have previously been treated on AIDA therapy, should be treated with Arsenic Trioxide combined with ATRA. Gemtuzumab Ozogamicin (Mylotarg) and potential stem cell transplant options discussed with the Chief Investigators. Note: At relapse, CNS should be checked for occult disease by FISH. Page 45 of 111 Version 6.0 January 2017

56 10 NON-APL PATIENTS FLT3 and NPM1 mutation status should be available by the end of the first course of chemotherapy. After recovery from course 1 and assessment of response, the risk score can be provided for individual patients who are not Core Binding Factor Leukaemias and not NPM1 mutant. Those with high risk disease post course 1 or post course 2 should enter the high risk randomisation treatment options (see Section 10.4 and 10.6). All except the high risk or refractory patients should receive the second chemotherapy course as allocated. Some patients receiving 2 courses of FLAG-Ida may have slow haematologic recovery following the second course and every effort should be made to enter these patients into the second randomisation even if this is delayed. The marrow should be re-assessed at days after the end of Courses 1 and 2 for the assessment of response After course 1, if the patient is in CR and the counts have regenerated to 1.0 x 10 9 /L neutrophils and 80 x 10 9 /L platelets, course 2 treatment can commence. After Course 2, when patients in complete remission have regenerated to 1.0 x 10 9 /L neutrophils and 80 x 10 9 /L platelets and are not high risk, they are ready for the consolidation randomisation (see Section 10.5) and commencement of consolidation treatment, i.e. Course 3. For patients who are not in complete remission after Course 2 treatment will be deemed to have failed. Patients failing 2 courses of DA may be entered into the high risk randomisation options or withdrawn from the trial and treated at the investigator s discretion. Patients failing 2 courses of FLAG-Ida can enter the high risk part of the trial but will be allocated Fludarabine plus CPX All patients off protocol will still continue to be followed up within AML19. Patients who relapse can also enter the high risk randomisation. For patients who have received 2 courses of FLAG-Ida and relapsed within 6 months of achieving remission, the treatment will be Fludarabine plus CPX-351; all other patients will enter the FLAG-Ida vs CPX- 351 randomisation AML INDUCTION CHEMOTHERAPY: Courses 1 and 2 For patients who are not known to have adverse risk cytogenetics, each induction schedule comprises two courses of allocated chemotherapy. Remission status will be determined after each course. After Course 1, the additional or alternative treatments will be decided as patients are characterised as having Core Binding Factor leukaemia, the presence of a FLT3 mutation, the presence of an NPM1 mutation, high risk disease, or none of these. The additional interventions Page 46 of 111 Version 6.0 January 2017

57 are described in section 10.3 of the protocol. If a patient who is not high risk after Course 1 and is not in complete remission after course 2, they may enter the high risk randomisation (section 10.4). Except where in the protocol it is specifically stated to the contrary in general it is recommended to deliver chemotherapy dosing according to full surface area based on actual body weight, but if in doubt please discuss with one of the Clinical co-ordinators. Patients with adverse risk cytogenetics confirmed at diagnosis will enter the high risk randomisation, with the same treatments except that the first course of treatment is to be repeated (giving a total of 4 courses of treatment). For this randomisation, Patient Information Sheet 2A and Consent Form 2A should be used DA schedule Course 1: DA 3+10 Daunorubicin 60 mg/m 2 daily by slow (1 hour) i.v. infusion on days 1, 3 and 5 (3 doses). Cytarabine 100 mg/m 2 12-hourly by i.v. push on days 1-10 inclusive (20 doses). Course 2: DA 3+8 Daunorubicin 50 mg/m 2 daily by slow (1 hour) i.v. infusion on days 1, 3 and 5 (3 doses). Cytarabine 100 mg/m 2 12-hourly by i.v. push on days 1-8 inclusive (16 doses) FLAG-Ida schedule Course1: Fludarabine 30 mg/m 2 daily by 30-minute i.v. infusion on days 2-6 inclusive (5 doses). Cytarabine 2 g/m 2 daily over 4 hours, starting 4 hours after Fludarabine on days 2-6 inclusive (5 doses) G-CSF [Lenograstim 263g or equivalent (300mcg) 263g (1 vial)] s.c. daily days 1-7 inclusive (7 doses) Idarubicin 8 mg/m 2 i.v. daily on days 4, 5 and 6 (3 doses). Page 47 of 111 Version 6.0 January 2017

58 For patients receiving FLAG-Ida course 1 who have a WCC 30 x 10 9 /L it is advised to omit G-CSF until the WCC has fallen to <30. Course2: Fludarabine 30 mg/m 2 daily by 30-minute i.v. infusion on days 2-6 inclusive (5 doses). Cytarabine 2 g/m 2 daily over 4 hours starting 4 hours after Fludarabine on days 2-6 inclusive (5 doses). G-CSF [Lenograstim 263g or equivalent (300mcg) (1 vial)] s.c. daily days 1-7 inclusive (7 doses) Idarubicin 8 mg/m 2 i.v. daily on days 4, 5 and 6 (3 doses). Note: The dose of Cytarabine in FLAG-Ida should be reduced to 1g/m 2 on days 2-6 for patients 60+years of age in both course 1 and Mylotarg Patients allocated to receive Mylotarg must not have a white count greater than 30 x 10 9 /L at the time of Mylotarg administration because of the risk of tumour lysis. Such patients should either have the WBC reduced with Hydroxycarbamide before commencing trial chemotherapy or have the administration of Mylotarg delayed until day 4 of the chemotherapy. If the first dose is delayed to day 4 and the patient has been randomised to receive 2 doses then the second dose should be given on day 7. Patients with AST or ALT more than 2.5 times the local upper limit of normal or Bilirubin more than twice upper limit of normal, are not eligible for the Mylotarg randomisations. Mylotarg will be given at a dose of 3 mg/m 2 on day 1 of Course 1 (no maximum dose) or at a dose of 3mg/m 2 (up to a maximum of 5mg per day) on days 1 and 4. Details of the premedication, and other procedures for Mylotarg administration, are set out in Appendix B. Please note that Mylotarg is given on day 1 of chemotherapy, in the FLAG-Ida schedule this is actually day 2 as G-CSF is given alone on day Additional Treatments After course 1, sufficient information will be available to assign a risk score to individual patients. This is based on age, de novo or secondary disease, cytogenetics, white blood count, sex and response to course 1. This will be allocated by providing the required information to Page 48 of 111 Version 6.0 January 2017

59 HCTU or via the web-based system. Patients with NPM1+ AML will be allocated their risk score post course 2 (unless the patient is NPM1 mutant negative in the peripheral blood and bone marrow post course 1 when they are not high risk and are eligible to enter the monitoring randomisation) when the results of PB MRD status is known. The additional information required, in addition to what was provided in Form A is cytogenetic result and marrow response after course 1. Patients with Core Binding Factor Leukaemias will be identified and sufficient information will be available to calculate the individual patient s risk score (section 4.1.6). The investigator will be informed if the patient is high risk, and that the patient should therefore enter the high risk treatment options (Section 10.4). Additional consent is required for any additional randomisations that are undertaken, as well as to consent to storage of excess samples, as summarised in Section FLT3 Inhibition Immediately after the completion of chemotherapy patients become eligible for additional or alternative treatment. Within 10 days of entering the trial the reference labs will have defined the FLT3 mutation status. If a mutation is found the site Principal Investigator (PI) and research nurses will be informed Core-binding factor (CBF) leukaemia Patients who have Core Binding Factor leukaemias (t(8;21) and inv(16)) will continue with the chemotherapy as allocated for course 2 whether DA or FLAG-Ida. These patients are excluded from the consolidation randomisation - all will receive 2 course of HDAC consolidation. These patients can also enter the monitor v no monitor randomisation High risk score patients Patients who are defined as high risk will enter the high risk treatment randomisation with the expectation that they should proceed to transplantation. Patients are defined as high risk if they fulfil one of the following criteria: They are known to have adverse cytogenetics at entry They have a high risk score They have a FLT3 ITD+ve, NPM1 ve genotype They have NPM1+ve AML and have persistence of NPM1 mutant transcripts in peripheral blood following chemotherapy course 2 Page 49 of 111 Version 6.0 January 2017

60 They have refractory disease after course 1, defined as a less than 50% reduction in bone marrow blasts, and resistant disease (>15% blasts) They are not in remission following two courses of induction. (Note that patients who have received two courses of FLAG-Ida at this point are not eligible for the randomisation, but will instead be allocated Fludarabine + CPX-351 The standard arm in this patient group is FLAG-Ida followed by MACE then MiDAC consolidation in those patients not proceeding to transplant. This randomisation is open to those designated high risk after receiving first induction therapy irrespective of initial allocation. Patients will be randomised to treatment in a 1:2 manner, so the chance of receiving the standard arm (FLAG-Ida) is 1 in 3, and of receiving the novel arm CPX-351 is 2 in 3. For entry into this randomisation Patient Information Sheet 6 and Consent Form 6 should be used. The treatments are: FLAG-Ida followed by MACE / MiDAC [standard arm] Up to three courses of CPX-351 For patients known to have adverse karyotype at entry, there will be an additional course of FLAG-Ida (two courses) or CPX-351 (up to 4 courses) (Patient Information Sheet 2A and Consent Form 2A) FLAG-Ida Fludarabine 30 mg/m 2 daily by 30-minute i.v. infusion on days 2-6 inclusive (5 doses) Cytarabine* 2 g/m 2 daily over 4 hours, starting 4 hours after Fludarabine on days 2-6 inclusive (5 doses) G-CSF [Lenograstim 263g or equivalent (300mcg) (1 vial)] s.c. daily days 1-7 inclusive (7 doses) Idarubicin 8 mg/m 2 i.v. daily on days 4, 5 and 6 (3 doses). *Note: The dose of Cytarabine in FLAG-Ida should be reduced to 1gm/m2 on days 2-6 for patients 60+years of age MACE Amsacrine* 100 mg/m 2 daily by 1 hour i.v. infusion (in 5% dextrose) on days 1-5 inclusive (5 doses) Page 50 of 111 Version 6.0 January 2017

61 Cytarabine 200 mg/m 2 daily by continuous i.v. infusion on days 1-5 inclusive Etoposide** 100 mg/m 2 daily by 1 hour i.v. infusion on days 1-5 inclusive (5 doses) *Note: Amsacrine must not be infused in 0.9% sodium chloride: precipitation or flocculation occurs. This will necessitate a 2-hour interruption of the Cytarabine infusion. **Where venous access is limited to a single lumen line a 2 hour interruption to the Cytarabine infusion may be required to enable the Amsacrine and Etoposide administration MIDAC Mitoxantrone 10 mg/m 2 daily by slow (1 hour) i.v. infusion on days 1-5 inclusive (5 doses) Cytarabine 1g/m 2 12-hourly by 2-hour i.v. infusion on days 1-3 inclusive (6 doses) CPX-351 CPX units/m 2 is administered by intravenous infusion over 90 minutes on days 1, 3 and 5 inclusive for course 1 of CPX-351. (this is equivalent to 132 mg/m 2 of daunorubicin) For the second course CPX-351 will be administered by intravenous infusion over 90 minutes at a dose of 100 units/m2 on days 1 and 3 only (two doses) For 3 rd and subsequent courses CPX-351 will be administered by intravenous infusion over 90 minutes at a dose of 65 unit/m 2 on days 1 and 3 only (two doses) Arrangements for transplantation The indications for transplantation in AML19 are detailed in Section 4.2 However it is recognised that it takes time for the arrangements for transplant to be made, and that there will be a number of patients for whom a donor cannot be identified. Therefore patients should continue with the allocated treatment courses until the transplant can be delivered. It is recommended that patients for whom a reduced intensity allograft is intended should receive a minimum of two high risk treatment courses. Page 51 of 111 Version 6.0 January 2017

62 10.4 AML consolidation After Course 2, when patients in complete remission have regenerated to 1.0 x 10 9 /l neutrophils and 80 x 10 9 /l platelets, they are ready for the consolidation randomisation and commencement of consolidation treatment, i.e. Course 3. For patients who are not in complete remission after Course 2, treatment will be deemed to have failed (Section 10.7) Patients failing 2 courses of DA may be entered into the high risk randomisation options or withdrawn from the trial and treated at the investigator s discretion Patients failing 2 courses of FLAG-Ida can enter the high risk part of the trial but will be allocated Fludarabine + CPX-351 in a non-randomised fashion. The consolidation randomisation is available to patients who have achieved complete remission following 2 courses of FLAG-Ida chemotherapy and are not candidates for the high risk score randomisation Patients receiving DA chemotherapy are not eligible for this randomisation and should receive 2 courses of HDAC consolidation. The randomisation will apply to the FLAG-Ida patients only and will be no further treatment or one (course 3) or two (courses 3 and 4) courses of consolidation treatment. For this randomisation Patient Information Sheet 7 and Consent Form 7 should be used. The treatment to be used is HDAC. Patients who have been identified as having a marker for molecular monitoring and are found to have disease related transcripts in the peripheral blood or bone marrow post course 2 will not be eligible for the consolidation randomisation and should receive 2 courses of consolidation treatment Timing of consolidation randomisation Statistically, it is preferable for the randomisation to take place as close as possible to the start of consolidation course 1 (Course 3). This will reduce non-compliance, which would have an adverse impact on the power of the trial. Although randomisation should be carried out as close to Course 3 as possible, it is recommended that the options available are discussed with the patient at an earlier stage, e.g. during induction therapy, in order to ensure that the patient has plenty of time to consider the options and arrive at an informed decision. This should reduce the risk of non-compliance with allocated treatment Required information Before carrying out the consolidation randomisation please ensure that the patient s risk group is established and the patient is: In complete remission Page 52 of 111 Version 6.0 January 2017

63 Not a Core Binding Factor AML Has received 2 courses of FLAG-Ida Willing to be randomised between 1 or 2 courses of consolidation chemotherapy with HDAC or no further treatment Once blood counts have recovered after the final course of treatment, the "Consolidation" form (Form C) on the web-based data collection system should be completed High-dose Cytarabine Courses 3 and 4 (if allocated) should ideally be given once counts have recovered to 1.0 x 10 9 /L neutrophils and 80 x 10 9 /L platelets following their previous course of therapy. Delay in count recovery regularly occurs, and problem cases should be discussed with the clinical coordinators. Course 3: Cytarabine 3g/m 2 12-hourly by 4 hour i.v. infusion on days 1, 3 and 5 (6 doses). Course 4: Cytarabine 3g/m 2 12-hourly by 4 hour i.v. infusion on days 1, 3 and 5 (6 doses). Note 1: Prednisolone (0.5% Predsol) eye drops should be used during each course of highdose Cytarabine, and during the course of MiDAC which also contains high-dose Cytarabine, and be continued for 5 days after the course finishes. Note 2: If the patient is 60+ years the dose of Cytarabine should be reduced to 1.5 g/m 2 from 3 g/m 2. Note 3:Consolidation schedule post FLAG-Ida comprises one or two courses of chemotherapy or no further treatment. Patients who do not wish to be randomised for the consolidation options should be allocated to receive both courses of High Dose Cytarabine Treatment for patients who are refractory, post relapse or have a validated molecular relapse Patients who are refractory, defined as either >15% blasts post course 1 (Resistant Disease) with a less than 50% proportional reduction in bone marrow blast percentage, or who are not in complete remission following course 2 of treatment, can enter the High Risk randomisation. This Page 53 of 111 Version 6.0 January 2017

64 option is also available for patients who relapse, or who have a validated molecular relapse as part of monitoring within the trial. For these patients, the same randomisation and consent forms as for the high risk randomisation (Section 10.4) apply with the following exception. Patients who are refractory to 2 courses of FLAG-Ida treatment, or who relapse following 2 courses of FLAG-Ida within 6 months of achieving remission will not be eligible for the randomisation. However, they can register to receive Fludarabine + CPX-351 in a nonrandomised pilot study. For this Patient Information Sheet 6B and Consent Form 6B should be used. The treatment schedule for Course 1 will be: CPX units/m 2 is administered by intravenous infusion over 90 minutes on days 1, 3, 5 Fludarabine 30mg/m 2 to be given on days 1-5 as a 30 minute IV infusion starting 2 hours following the CPX-351 infusion on days 1,3,5. The treatment may be given for up to 3 courses. For the second course CPX-351 will be administered by intravenous infusion over 90 minutes at a dose of 100 units/m 2 on days 1 and 3 only (two doses) and the Fludarabine 30mg/m 2 to be given on days 1 to 3 inclusive as a 30 minute infusion starting 2 hours following the CPX-351 infusion on days 1 and 3. For the third and subsequent courses CPX-351 will be administered by intravenous infusion over 90 minutes at a dose of 65 units/m 2 on days 1 and 3 (two doses) and the Fludarabine 30mg/m 2 to be given on days 1 to 3 inclusive as a 30 minute infusion starting 2 hours following the CPX-351 infusion on days 1 and 3. The same recommendations regarding stem cell transplantation apply as for the other high risk patients Safety Evaluations Some novel therapies will be subject to enhanced pharmacovigilance from the Trials Office. Currently enhanced pharmacovigilance is only being carried out for all patients during their first course of CPX-351. HCTU staff will communicate with investigators, or relevant personnel at Page 54 of 111 Version 6.0 January 2017

65 site, by telephone or on a weekly basis for four weeks following the start of treatment to monitor events. The site will be informed of the information required beforehand. Page 55 of 111 Version 6.0 January 2017

66 11 ASSESSMENT OF RESPONSE AND MOLECULAR SCREENING A bone marrow aspirate to assess remission status should be carried out at days after the end of Course 1. If the bone marrow is of adequate cellularity for the assessment of haematopoiesis, the patient's remission status should be ascertained. If the marrow is hypoplastic and assessment of status is not possible, a repeat marrow should be performed after a further 7-10 days and remission status be assessed. In order to achieve a subsidiary aim of the trial (i.e. assessing the relevance of residual cytogenetic or molecular existence of disease in morphological CR) investigators should also request cytogenetic analysis on this sample and, if known to be relevant, molecular analysis Definitions of Complete Remission, Partial Remission and Resistant Disease Complete Remission (CR): The bone marrow is regenerating normal haemopoietic cells and contains <5% blast cells by morphology in an aspirate sample with at least 200 nucleated cells. Additionally there is an absolute neutrophil count of more than 1000/µL and platelet count of at least 100/µL Complete Remission with incomplete recovery (CRi): Fulfilling all criteria for CR except for residual neutropenia (<1000/µL) or thrombocytopenia (<100,000/µL) Partial Remission (PR): The bone marrow is regenerating normal haemopoietic cells and blast count has reduced by at least half, to a value between 5 and 15% leukaemic cells. Resistant Disease (RD): The bone marrow shows persistent AML, and patient survives at least 7 days beyond end of course. Once blood counts have recovered after the second course of induction therapy, the completed "Induction Chemotherapy" form (Section B) should be entered onto the web-based data collection system Frequency of molecular monitoring On entering the trial, it should be explained to patients that, if it emerges that the leukaemia cells have an appropriate molecular lesion, they will be invited to participate in the molecular disease monitoring. In APL, molecular monitoring is an inherent part of the treatment. Once patients have been identified as having a marker for molecular monitoring, investigators will be alerted by , the intention is routinely to monitor patients in the monitor arm with samples (blood and bone marrow) after each course of chemotherapy and then 3-monthly for 2 years following consolidation courses unless otherwise specified. If the patient relapses during Page 56 of 111 Version 6.0 January 2017

67 monitoring then it is recommended that monitoring continues for a further 2 years following relapse. All patients with NPM1 mutant AML will be monitored following course 1 and course 2 and will only be eligible to enter the molecular monitoring randomisation if negative for NPM1 mutant transcripts in the peripheral blood following chemotherapy course 2. Patients who are NPM1 negative in the peripheral blood post course 1 will be eligible for early entry into the Monitor versus no Monitor randomisation but only if they are also negative for NPM1 transcripts in the bone marrow with good sensitivity at this stage. All patients with high risk NPM1 disease (as defined with a positive MRD result in PB post course 2) should continue to be monitored following subsequent therapy. The frequency of monitoring may change during the trial as new information, or as new markers become available. Since it has become clear that persistent or recurrent RT-PCR positivity powerfully predicts relapse, it is important to ensure that the test is completely reliable for that patient. This may result in advice to repeat the test within the interval planned. The issue of sequential testing is incorporated in the Patient Information Sheet 8 and Consent Form SUPPORTIVE CARE& CNS TREATMENT Page 57 of 111 Version 6.0 January 2017

68 12.1 Supportive Care The remission induction and consolidation phases of therapy are intensive and will be associated with a risk of infection and haemorrhage. The care of patients will make stringent demands on supportive care. Some information regarding aspects of supportive care will be collected in the patient record books, since this will be one factor to be taken into account in assessing the schedules. Participants should have local supportive care protocols. It is considered that policies related to the following aspects should be decided in advance to ensure that treatment-related complications are minimised. Venous access via Hickman-type catheter Control of nausea and vomiting Mouth care Steroid eye drops for Cytarabine Prophylactic gut decontamination (if considered appropriate) Antifungal prophylaxis in accordance with ECIL guidelines Response to a significant pyrexia i.e. two readings of 38 C two hours apart, or a single reading 39 C Antibiotic treatment of febrile episodes including antibiotic choice(s) and monitoring, duration of therapy, and the treatment of non-response G-CSF therapy [Lenograstim 263µg or equivalent (300mcg) (1 vial) s.c. daily may be given in case of prolonged neutropenia particularly following FLAG-Ida chemotherapy Irradiated blood products should be given to patients who receive Fludarabine or Stem Cell Transplant. There is a low risk of Veno-occlusive disease (VOD) of the liver with Mylotarg but if this does occur the recommended treatment is with intravenous Defibrotide according to BCSH guidelines. If there is a reaction to the first dose of Mylotarg patients scheduled to receive a second dose should receive prophylactic hydrocortisone in addition to the measures detailed in Appendix B 12.2 Supportive Care for APL patients APL treatment has some particular requirements with respect to supportive care which are described in the BCSH Guideline ( an extract of which is shown in Appendix E. Page 58 of 111 Version 6.0 January 2017

69 12.3 CNS Treatment The routine administration of treatment to the central nervous system is not recommended for patients where this is no evidence of CNS disease at diagnosis. Routine CNS investigation at diagnosis for patients without CNS symptoms is not recommended, but this should be considered for APL patients who relapse. Patients who present with CNS disease may be entered into the trial and be randomised at the same points as patients without obvious CNS involvement. If a patient presents with physical signs suggesting CNS disease, an intrathecal injection of Cytarabine (50 mg) should be given when the diagnostic lumbar puncture is performed. If blast cells are identified in the CSF sample, a series of intrathecal injections with Cytarabine should be given on 3 days each week until CSF samples are clear. This may need to be modified if the platelet count is very low or coagulation is abnormal. Thereafter, treatment should be repeated at intervals of approximately 2 weeks until consolidation treatment has been completed. Page 59 of 111 Version 6.0 January 2017

70 13 STEM CELL TRANSPLANTATION As soon as a potential donor is identified the transplant centre should be informed. The transplant should be carried out 6-8 weeks after the final course of chemotherapy. The type of transplant and the transplant protocol will be determined by the transplant centre s usual policy. As a guide based on prior evidence: Patients <40 years should receive a conventional allogeneic transplant with Cyclophosphamide and Total Body Irradiation (8 x 180cGy fractions or with Busulphan and Cyclophosphamide] or Busulphan and Fludarabine (See Appendix E). Patients 40 years should receive a reduced intensity allograft Conventional Allogeneic Transplantation If the patient meets the criteria of the transplant centre, he/she will receive the transplant as soon as practical. It is expected that they will have received one or two of the allocated treatment courses in the pick a winner evaluation. The most widely used myeloablative schedule is Cyclophosphamide and Total Body Irradiation. The source of stem cells can be bone marrow or peripheral blood. If peripheral blood is used, a dose of at least 4 x 10 6 CD34 cells/kg should be given. Graft versus host prophylaxis will be determined by the transplant centre, but the most widely used is Methotrexate and Cyclosporine. It is required that patients who receive a transplant will provide written consent in line with the transplant centre policy Reduced Intensity Allograft Patients who will receive a reduced intensity allograft must first receive two courses of the high risk arm and the mini-allograft as Course 4. The precise protocol to be used in the AML19 trial will be that chosen by the transplant centre, but may be subject to change in light of emerging evidence in the field. Since patient and donor will require time to be counselled about the transplant option which may be delivered as early as course 3, investigators are encouraged to identify donor availability as soon as possible after diagnosis. Collection of Autologous stem cells is not an inherent part of the AML19 trial but nor is it proscribed. On completion of the transplant, the Transplant form should be completed and returned to HCTU either via the web-based system or in hard copy. Page 60 of 111 Version 6.0 January 2017

71 14 RELAPSE Patients entered into AML19 who are refractory (i.e. have not achieved complete remission after the second course of induction chemotherapy or who post course 1 have >15% blasts present and <50% proportional reduction in blasts or subsequently relapse (validated molecular or haematological) can be entered into the high risk treatment options (they will be eligible to be randomised to the high risk treatment options i.e. to receive either FLAG-Ida or CPX-351), with a view to progressing to stem cell transplant. This is also applicable to AML17 patients who relapse for the first time. Entry into the High risk randomisation must be completed within 30 days of confirmation of relapse. There is two exceptions to this: Patients who relapse within 6 months after receiving FLAG-Ida in first induction will be allocated to receive Fludarabine + CPX-351. Patients who are not in complete remission following 2 courses of FLAG-Ida will be allocated to receive Fludarabine + CPX-351. Where possible, bone marrow or peripheral blood, taken to diagnose relapse, should be sent to the Cardiff laboratory and your sites designated flow cytometry laboratory for evaluation of molecular progression of the disease. During the course of the trial newer molecularly targeted treatments are likely to become available and could be provided to patients who have entered the AML19 trial. Investigators will be informed of developments in this area by way of the regular newsletters and should discuss relevant cases with the Chief Investigator. Page 61 of 111 Version 6.0 January 2017

72 15 STATISTICAL CONSIDERATIONS 15.1 Patient Numbers Trial recruitment will run for 5 years. Historically, AML15 and AML17 both accrued around 650 patients per annum, so that over 5 years, we expect at least 300 APL patients and 2700 non- APL patients to enter AML19. There is no comparison for APL patients at present, but information will be collected to identify risk factors for treatment failure and to inform future use of sequential monitoring. The 2700 non-apl patients will be randomised 1:1 between DA and FLAG-Ida, giving almost 90% power to see an improvement in survival from the current 50% to around 56% at p<0.05 after 1326 events using the logrank test. For the comparison of single dose versus fractionated GO, a total of 1200 patients will be recruited in the first instance: there will be 80% power to detect an 8% difference in survival from 50% to 58% (HR 0.79, 546 events). The consolidation randomisation for the FLAG-Ida patients should accrue up to 700 patients (those patients who are allocated FLAG-Ida and not high risk) randomised equally between 0, 1 and 2 courses of consolidation with HDAC. Historical data showed a nearly 20% difference in survival (47% vs 66%) between 0 and 2 courses of consolidation: here there will be 80% power to detect a difference between 0 and 2 courses of 13% (from 52% to 65%, HR 0.6 with 93 deaths per group) with additional power from the use of the 1 course data to detect trend for increasing benefit with more treatment. Analyses will be performed after a total of 280 events in the randomisation have been observed. Just under 30% of patients starting their second course will be poor risk. These patients will be randomised between FLAG-Ida vs CPX-351 in a 1:2 randomisation carrying forward from AML17. Five-year survival of this group of patients is currently 30%, so recruiting 315 patients will give 80% power to detect a clinically meaningful 15% improvement in survival from 30% to 45%, requiring 189 deaths. This allows the option of introducing a further high risk option at a later point as approximately 800 high risk patients will be identified during the course of the trial. At present only around 40% of poor risk patients entering CR receive a transplant; with 360 patients randomised there will be approximately 80% power to detect an improvement from 40% to 55% in the numbers being transplanted. The monitor vs no monitor randomisation carries forward from AML17. Patients will continue to be randomised in a 2:1 Fashion between monitoring and no monitoring. A total of 600 patients Page 62 of 111 Version 6.0 January 2017

73 between AML17 and AML19 is sufficient to give 90% power to detect an improvement in survival from 40% to 52.5% with 198 deaths overall. For patients who become high risk after receiving FLAG-Ida treatment, and who are not eligible for the FLAG-Ida vs CPX-351 randomisation, a non-randomised pilot will evaluate the safety and efficacy of the combination of Fludarabine plus CPX-351. A total of 15 patients will be recruited, to allow for 10 evaluable patients who complete one course of treatment. The toxicity and efficacy data on this cohort will be examined by the data monitoring committee at this stage to determine whether the combination is suitable for evaluation in a randomised fashion Data analysis Interim analyses of the main endpoints will be supplied periodically, in strict confidence, to the AML Trials Data Monitoring and Ethics Committee (DMEC). In the light of these interim analyses, the DMEC will advise the chairman of the AML Trials Trial Steering Committee and Chief Investigator if, in their view, one or more of the randomised comparisons in the trial have provided proof beyond reasonable doubt * that for all, or for some, types of patient one treatment is clearly indicated or clearly contraindicated. The main analyses will be based on the intention to treat - i.e. all patients believed to be eligible at the time of randomisation will be included in the analysis, irrespective of protocol compliance, early death, etc. Comparisons of randomised treatments will be made using the log-rank test for time to event outcomes; and the Mantel-Haenszel test for dichotomous outcomes. Resource usage data will be compared using Wilcoxon rank-sum tests or t-tests as appropriate. The primary outcome is survival for all randomisations. The randomisations will be stratified by age, performance status, and type of disease (de novo/secondary AML). Consolidation randomisations will also be stratified by initial allocation and by risk group. All stratification variables used at randomisation will be used in analyses: in addition any analyses of treatment effectiveness will be stratified by cytogenetic risk group, and any relevant molecular markers (including, but not limited to FLT3-ITD, FLT-3 TKD and NPM1 status). All stratified analyses will assume that there may be some quantitative differences in the size of any treatment effects in these different strata, but that there is unlikely to be any qualitative difference (i.e. harm in one group, benefit in another). Interactions will be tested using standard techniques developed by * Appropriate criteria of proof beyond reasonable doubt cannot be specified precisely, but a difference of at least three standard deviations in an interim analysis of a major endpoint may be needed to justify halting, or modifying, a randomisation prematurely. If this criterion were to be adopted, it would have the practical advantage that the exact number of interim analyses would be of little importance, and so no precise schedule is proposed. Page 63 of 111 Version 6.0 January 2017

74 the Early Breast Cancer Trialists Collaborative Group; simultaneous adjustment for more than one stratification variable will be by means of logistic or Cox regression analysis. 16 TRIAL GOVERNANCE AND ADVERSE EVENT REPORTING Investigators have obligations as described in GCP guidelines. The AML19 Trial is sponsored by Cardiff University and managed by HCTU and with defined responsibilities delegated to the Principal Investigator on each site. The trial is authorised in the UK by a Clinical Trials Authorisation (CTA) issued by the MHRA, and by the relevant competent authorities in other participating countries. The trial protocol has been approved by the National Research Ethics Service (NRES). The trial, including its safety data, will be monitored by an independent Data Monitoring Committee Adverse Event Reporting Principal Investigators at each participating institution have an obligation to report relevant Serious Adverse Events that occur in this trial to HCTU, in a timely manner. Reports should be faxed to HCTU at the number below: CTR SAE FAX Number: It is recognised that adverse events that may be life-threatening are a normal consequence of acute myeloid leukaemia or its effective treatment, and many clinical changes in the patient s condition are expected. Within the AML19 Trial, any event that occurs within 28 days of the patient s protocol treatment, and meets the criteria laid out in Section 16.2 of the protocol, should be reported as an SAE. Beyond this period, any event which is felt to be causally linked to the medication received on the trial, and meets the criteria laid out in the protocol, should also be reported Definitions For the purpose of this trial a Serious Adverse Event (SAE) is defined as: Development of a non-haematological toxicity of grade 3 as defined in the NCI Common Toxicity Criteria, which does not resolve to grade 2 or less within 7 days. Development of any grade 4 non-haematological toxicity (excluding alopecia). Grade 4 toxicity includes any life threatening event. Development of neutropenia (<1.0 x 10 9 /l) or thrombocytopenia (<50 x 10 9 /l) for longer than 42 days after the end of chemotherapy in the absence of significant disease in the bone marrow (>5% blasts) Any event which is unrelated to the expected consequences of AML or its treatment which results in hospital admission or prolongation. Page 64 of 111 Version 6.0 January 2017

75 Any event which results in persistent or significant disability or incapacity. Any event which results in a congenital abnormality or birth defect. Death in the absence of persistent or progressive disease. The following do not require to be reported as SAEs: Patients may present with some pre-existing toxicities which meet the criteria set out above, but it is only the development of these toxicities after entering the trial which should be reported. Neutropenic fever is an expected severe adverse event which may occur as a result of the disease or the treatment. This or its consequences do not have to be reported unless fulfilling the criteria set out above. Deaths from persistent or progressive disease Causality Causality Investigators will be required to record their opinion as to whether the SAE as defined above was related to the study medication. It is accepted that a causality assessment is not always available at the time of the initial report however, this opinion should be provided as soon as possible to ensure regulatory reporting timelines are met Expectedness On behalf of the sponsor, a limited number of safety reviewers will assess the expectedness of reported events. When assessing expectedness, reviewers should refer to the following (sections of) IMP-specific documentation: IMP Mylotarg CPX-351 Document used as Reference Safety Information Current Summary of Product Characteristics (held by Pfizer Japan Inc.) Current investigator brochure (held by Celator Pharmaceuticals) Relevant Section Section 4 (Clinically Significant Adverse Reactions) Section 7 HCTU will consider the above assessments and report events as per the required reporting requirements Collection of Data Preliminary discussion of the event may take place with a Clinical Co-ordinator or Chief Investigator. SAEs should be recorded on the Serious Adverse Event form which is available from the Trials Office, and sent to HCTU (see page i). Details of adverse events (including SAEs) should be recorded in the patient s notes at the Study Site. Relevant concomitant Page 65 of 111 Version 6.0 January 2017

76 medications, including details of the dose and duration for the period of 14 days before, and until conclusion of, the event should be recorded in the patient s record. For SUSARs, the Chief Investigator (or delegated Safety Reviewer) will require to review the clinical documented record of the event and relevant concomitant medication history for each event. For SAEs the reviewer may wish to review information as for a SUSAR, but will not routinely do so. Important note: All SAEs must be followed up until outcome Time of Report All SAEs should be reported to HCTU within 24 hours of the investigator being made aware of the event. The responsibility of the site to report adverse events is clearly defined in the Clinical trial site agreement Reporting to the Regulatory Authorities The Chief Investigator or his nominee will review and record all SAEs. HCTU will be responsible for reporting the events to the MHRA (or equivalent competent authorities), MREC (or equivalent Ethical authority) and Data Monitoring and Ethics Committee according to the appropriate timelines. The Chief Investigator (or his nominee) will also report, where relevant, to the provider of the IMP (Investigational Medicinal Product) and produce periodic reports for all investigators to forward to their R&D Office Enhanced Pharmacovigilance Some unlicensed agents will be used in this trial. This will require additional pharmacovigilance arrangements which will be carried out by HCTU. HCTU staff will communicate with investigators, or relevant personnel at site, by telephone or on a regular basis (minimum weekly) to monitor events, and may include periodic site visits. The site will be informed of the information required beforehand. Page 66 of 111 Version 6.0 January 2017

77 APPENDIX A: WHO Histological Classification of Acute Myeloid Leukaemias ICD Code Acute myeloid leukaemia with recurrent genetic abnormalities Acute myeloid leukaemia with t(8;21)(q22;q22); (AML1(CBFα)/ETO) 9896/3 Acute myeloid leukaemia with abnormal bone marrow eosinophils 9871/3 Inv(16)(p13q22) or t(16;16)(p13;q22); (CBFß/MYHII) Acute Promyelocytic leukaemia (AML with t(15;17)(q22;q12-21), 9866/3 (PML/RARα) and variants. Acute myeloid leukaemia with 11q23 (MLL) abnormalities 9897/3 Acute myeloid leukaemia with multilineage dysplasia 9895/3 Acute myeloid leukaemia and myelodysplastic syndromes, 9920/3 therapy-related Acute myeloid leukaemia not otherwise categorised Acute myeloid leukaemia minimally differentiated 9872/3 Acute myeloid leukaemia without maturation 9873/3 Acute myeloid leukaemia with maturation 9874/3 Acute myelomonocytic leukaemia 9867/3 Acute monoblastic and monocytic leukaemia 9891/3 Acute erythroid leukaemias 9840/3 Acute megakaryoblastic leukaemia 9910/3 Acute basophilic leukaemia 9870/3 Acute panmyelosis with myelofibrosis 9931/3 Myeloid sarcoma 9930/3 Acute leukaemia of ambiguous lineage 9805/3 Undifferentiated acute leukaemia 9801/3 Bilineal acute leukaemia 9805/3 Biphenotypic acute leukaemia 9805/3 Page 67 of 111 Version 6.0 January 2017

78 APPENDIX B: Preparation, Administration and Toxicity of Drugs The below is for information purposes however for non IMPs if standard practice differs from below please follow local procedures for preparation/stability or to refer to SmPC for products used as standard at site. DAUNORUBICIN (Hospitals regular supplier) Daunorubicin is presented as a red powder in glass vials containing 20 mg with mannitol as a stabilising agent. The drug is reconstituted in sodium chloride 0.9% or water for injection. Following reconstitution, further dilution with sodium chloride 0.9% to a concentration of 1mg/ml is recommended. The resultant solution is given by a one hour infusion into a swiftly flowing drip. For hepatic dysfunction with a bilirubin µmol/l reduce by 25%: bilirubin >50 µmol/l reduce by 50%. In patients with renal impairment dose reduction should take place: Serum Creatinine , reduce dose by 25%: Creatinine >265 reduce by 50%. Side effects include nausea, alopecia, chronic and acute cardiac failure and dysrhythmias. Subcutaneous extravasation may cause severe tissue necrosis. CYTARABINE (Ara-C) (Hospital s regular supplier) Cytarabine is available as a clear, colourless solution for injection. Cytarabine 20 mg/ml Injection is a ready to use solution and is suitable for intravenous, subcutaneous and intrathecal use. Cytarabine 20 mg/ml Injection can be diluted with Sterilised Water for Injections BP, Glucose Intravenous Infusion BP or Sodium Chloride Intravenous Infusion BP. Prepared infusions, in the recommended diluents should be used immediately. Alternatively, the diluted infusion fluids may be stored at 2-8 C, protected from light, but portions remaining unused after 24 hours must be discarded. It may be supplied in packs containing: 5, 25 or 50 x 100 mg/5 ml vials 5, 25 or 50 x 500 mg/25 ml vials 5, 25 or 50 x 1 g/50 ml vials From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2-8 C, unless dilution has taken place in controlled and validated aseptic conditions. Page 68 of 111 Version 6.0 January 2017

79 It is recommended that before administration by intravenous bolus injection the hypertonic 100 mg/ml solution is further diluted in water for injection, sodium chloride 0.9%, or glucose 5% solution, to produce a solution of 20 mg/ml concentration. In patients with impaired hepatic function (bilirubin >34 µmol/l) the dose should be reduced by 50%. No reductions are necessary for renal impairment. Side effects at the doses prescribed for remission induction include nausea, diarrhoea, oral ulceration and hepatic dysfunction. A Cytosar syndrome has also been described. It is characterised by fever, myalgia, bone pain, occasional chest pains, maculopapular rash, conjunctivitis and malaise. It usually occurs 6 12 hours following administration, and is more common with higher doses. Etoposide (VP16-213) (Hospitals regular supplier) Etoposide is available as a solution in ampoules containing 100 mg in 5 ml. The appropriate dose should be diluted in sodium chloride 0.9% for infusion. The company recommend that the infusion solution concentration does not exceed 0.25 mg/ml of etoposide. If local procedures differ to these then this is allowed. Give over at least 30 minutes as hypotension may be produced by excessively rapid infusion. Fludarabine (Hospitals regular supplier) Fludara contains 50mg fludarabine phosphate per vial. It should be given by slow intravenous infusion after dilution in 2ml water for injection. For hepatic dysfunction no dose change is required. For renal impairment a Cr Cl of ml/min requires a dose reduction of 50%; Greater impairment excludes the administration. The most frequent adverse event is myelosuppression. Patients less commonly suffer nausea, vomiting or alopecia. Fludarabine is a prolonged inhibitor of T-cells and has been associated with the development of transfusional GVHD and pneumocystis pneumonia. Rarely fludarabine has caused CNS side-effects with agitation, confusion and visual disturbance. Irradiated blood products should be given to patients who receive Fludarabine or Stem Cell Transplant. Idarubicin (Hospitals regular supplier) Idarubicin is available as a sterile pyrogen-free, orange-red freeze-dried powder, in vials containing 5 or 10 mg of idarubicin hydrochloride with 50 or 100 mg of lactose respectively. For administration the vial contents should be dissolved in water for injection to give a solution of 1mg/ml. The resultant solution should be administered intravenously into the side arm of a freely running intravenous infusion of 0.9% sodium chloride over 5 to 10 minutes. Page 69 of 111 Version 6.0 January 2017

80 In cases with hepatic dysfunction dose reduction is required: bilirubin 40 85umol/L reduce the dose by 50%.Greater rises contraindicate the administration. For renal impairment with a serum creatinine umol/L reduce the dose to 50%.Administration at higher creatinine levels is a clinical decision. Side-effects: The major side effect is myelosuppression. Cardiac toxicity may occur, manifested by cardiac failure, arrhythmias or cardiomyopathies, either during therapy or several weeks later. The cumulative dose associated with cardiotoxicity is not known, but it is believed that a total dose of mg/m 2, which is considerably higher than that used in AML15, is not problematic. Idarubicin may cause a red discoloration of the urine for 1-2 days after administration. Reversible alopecia will occur, and some nausea or vomiting and oral mucositis should be expected. Elevation of liver enzymes and bilirubin may occur in a minority of patients. Idarubicin should not be given to patients with severe renal or liver impairment. G-CSF- Human Granulocyte Colony-Stimulating Factor: (Granocyte TM -rhug-csf, lenograstim - Chugai Pharma UK Limited) similar products may be used Granocyte is available as lyophilised power, each single use vial containing either 105g of lenograstim (13.4 MIU rhug-csf) or 263g of lenograstim (33.6 MIU rhug-csf) or equivalent (300mcg). A pre-filled syringe of Water for Injections (1 ml) for each vial of Granocyte is provided for reconstitution before administration. Granocyte can now be stored at room temperature, up to 30C. Dose: In allogeneic PBPC mobilisation: 10 g/kg/day for 4-6 days Post BMT: 1 vial/day sc or as per local protocol Chemotherapy induced neutropenia: 1 vial/day sc as required In FLAG/Ida regimen: 1 vial/day sc days 1-7 Bone pain and injection site reaction have been associated with Granocyte treatment in some patients. Amsacrine (Hospitals regular supplier) Amsacrine is presented as two sterile liquids which are combined immediately prior to use. The drug ampoule contains 1.5 ml of amsacrine, a bright orange-red liquid at a concentration of 50 mg/ml. The diluent vial contains 13.5 ml of M L-lactic acid. When 1.5 ml (75mg) of Page 70 of 111 Version 6.0 January 2017

81 concentrated amsacrine is added to 13.5 ml of lactic acid diluent the resulting solution contains 5 mg/ml of amsacrine (i.e. 75mg in 15ml). It is recommended that preparation of the drug should be carried out using a GLASS SYRINGE where appropriate due to possible extraction of components of rubber or certain plastic material. The solution should be added to 500 ml of 5% dextrose and infused over a period of minutes. Amsacrine is incompatible with sodium chloride 0.9%. In patients with impaired hepatic function (bilirubin > 34µmol/L) the dose should be reduced to 60%. If renal function is reduced (Cr Cl < 60ml/min) the dose should be reduced by 25%. Side-effects: Some nausea and mucositis occur fairly frequently. Cardiac toxicity has been described as with anthracyclines; the risk of arrhythmias is increased by hypokalaemia. Hepatotoxicity is uncommon but is associated with a rise in serum bilirubin and alkaline phosphatase. Phlebitis may be a problem with peripheral venous access points and local necrosis is described. The risk of phlebitis can be decreased by a slow rate of infusion. The degree of alopecia is variable but sometimes severe. Mitoxantrone (Hospitals regular supplier) Mitoxantrone is presented as a dark blue aqueous solution in vials of 20 mg, 25 mg and 30 mg (2 mg/ml) with saline and a buffer of sodium acetate and acetic acid. The required dose should be diluted to at least 50ml in 0.9% saline or 5% dextrose. It should be injected as a 30 minute intravenous infusion. In hepatic dysfunction with a bilirubin > 60µmol/L maximum dose should be 8mg/m 2. Side effects include tissue necrosis following extravasation outside a vein. It is probably slightly less cardiotoxic than daunorubicin but care should be taken to avoid low serum potassium levels. Anorexia, diarrhoea, stomatitis, fatigue and mild alopecia have also been described. Cyclophosphamide (Hospitals regular supplier) Endoxana is available as a powder in vials containing 100 mg, 200 mg, 500 mg or 1000 mg of anhydrous cyclophosphamide and sufficient sodium chloride to render the reconstituted solution isotonic. The vial should be reconstituted with a suitable volume of Water for Injection to produce a 20mg/ml solution. This solution can then be administered by slow intravenous bolus injection or further diluted for infusion. The dose should be reduced in renal impairment: for GFR 10-50ml/min reduce dose by 25%; for GFR <10 the dose should be reduced by 50%. Page 71 of 111 Version 6.0 January 2017

82 Side-effects: Haemorrhagic cystitis, mucositis, nausea and vomiting, and hypoglycaemia and hyperglycaemia may occur. ATRA (Vesanoid TM - Roche Products or hospitals regular supplier) The most common adverse effect of ATRA has been headaches of mild to moderate severity. Younger (paediatric) patients appear to be more sensitive to this particular effect. Bone pain, occasionally requiring analgesic treatment, has also been observed. Biochemical abnormality of liver function has occasionally been reported, specifically raised transaminases, alkaline phosphatase and bilirubin, but these are reversible on stopping the drug. The most serious adverse event has been a syndrome characterised by fever, respiratory distress and episodic hypotension, usually in association with leucocytosis (now known as "ATRA Syndrome"). The onset of this syndrome has usually been in the first 1-2 weeks of drug treatment. Should this occur the ATRA should be stopped and steroids commenced. Some cases are reported to respond well to high-dose corticosteroid therapy (dexamethasone 10 mg i.v. 12 hourly for 3 or more days). Prolonged ATRA treatment may cause dryness of the skin. ATRA is also believed to be highly teratogenic. Page 72 of 111 Version 6.0 January 2017

83 MYLOTARG TM (Gemtuzumab Ozogamicin for Injection) Mylotarg is supplied as an amber glass vial containing 5mg of MYLOTARG lyophilised powder. This vial should be refrigerated (2 8ºC). Any temperature deviations should be reported to HCTU immediately, and the affected stock placed in quarantine. : Handling and Disposal Please follow your local policies and procedures for the handling and disposal of cytotoxic drugs. Vials are for single use, discard any unused reconstituted product or partially used vials. Preparation The drug product is light-sensitive and must be protected from direct and indirect sunlight and unshielded fluorescent light during the preparation and administration of the infusion. All preparation should take place in a biological safety hood or similar with the fluorescent light off. 1. Reconstitute the contents of each vial with 5ml water for injection. 2. Gently swirl each vial to dissolve the drug taking care not to bubble the contents to make 1mg/ml solution. Each vial should be inspected to ensure complete dissolution and for particulates. 3. Withdraw the desired volume from each vial and inject into a 100ml IV bag of 0.9% Sodium Chloride for injection. Do not dilute with any other solution. 4. The diluted drug solution should be inspected visually for particulate matter and discolouration. 5. Place the 100ml IV bag into a UV protectant bag. 6. The diluted drug solution may be stored for up to 16 hours at room temperature and must be protected from light at all times. Administration 1. To reduce infusion reaction, premedication with antihistaminic drugs and antipyretic analgesic drugs can be given one hour before infusion of Mylotarg (It is acceptable to pre-medicate with only antihistaminic drugs). 2. Administered as a 2 hour intravenous infusion (DO NOT administer as an intravenous push or bolus). Mylotarg will be given at a dose of 3mg/m 2 on day 1 of course 1 for patients in arm A (1 dose of Mylotarg) and on days 1 and 4 at a dose of 3mg/m 2 capped at a maximum of 5mg for patients with BSA above 1.67m 2 (1 vial) of course 1 for patients in arm B (2 doses of Mylotarg). 3. The diluted drug must be given through a peripheral or central vein using an IV line equipped with an in-line filter of the low protein-binding 1.2 micron or smaller membrane filter (polyether sulfone etc).* 4. Do not co-administer other drugs through the same infusion line. 5. Vital signs should be monitored during infusion and for four hours following infusion. Page 73 of 111 Version 6.0 January 2017

84 *The recommended in-line filter for Mylotarg administration is a 1.2 micron polyether sulfone (PES) filter, e.g. Intrapur Lipid (Braun product number ). If that filter is not available the following filters may be used: 0.22 micron PES, 0.20 micron cellulose acetate, 0.8 to 1.2 micron cellulose acetate/cellulose nitrate (mixed ester), or 1.2 micron acrylic copolymer. Cautions 1. Hepatic Insufficiency Patients with hepatic impairment will not be included in the Mylotarg randomisations. 2. Renal Insufficiency Patients with renal impairment will not be included in the Mylotarg randomisations. 3. Patients allocated to receive Mylotarg must not have a white blood cell count greater than 30x10 9 /L because of the risk of tumour lysis. Such patients should have their WBC reduced with Hydroxycarbamide before commencing trial chemotherapy. 4. Azole fungal prophylaxis should also be avoided until 5 days after Mylotarg administration Page 74 of 111 Version 6.0 January 2017

85 Instructions for Use, Handling and for Disposal: Institution s procedures for handling and disposal of cytotoxic drugs should be applied. Cautions Hepatic Insufficiency: Patients with hepatic impairment will not be included in the Mylotarg randomisations. Renal Insufficiency: Patients with renal impairment will not be included in the Mylotarg randomisations. Note 1 The recommended in-line filter for Mylotarg administration is a 1.2-micron polyether sulfone (PES) filter, e.g. intrapurlipid (Braun product number ). If that filter is not available, the following filters may be used 0.22 micron PES, 0.20 micron cellulose acetate, 0.8 to 1.2 micron cellulose acetate/cellulose nitrate (mixed ester), or 1.2 micron acrylic copolymer. Adverse Events The most important serious adverse event may be hepatotoxicity or myelosuppression. These should be reported to the Chief Investigator as described in Section 16. Other events which have been reported in at least 10% of recipients of single agent Mylotarg include fever, nausea, chills, vomiting, headache, dyspneoa, hypotension, hypertension, and hyperglycaemia. It is not necessary to report these events. CPX-351(Celator Pharmaceutical Inc.) Drug Preparation The appropriate number of vials of CPX-351 (cytarabine:daunorubicin) Liposome Injection should be removed from the refrigerator prior to reconstitution. Reconstitute with 19 ml of sterile water for injection using a 20 ml syringe. Do not heat CPX-351 (cytarabine:daunorubicin) Liposome Injection. After reconstitution, invert vials gently 3-4 times and let rest for 15 minutes and repeat vial inversion prior to withdrawing drug for dilution. The concentration of the reconstituted dispersion is 5 units. CPX-351 (cytarabine:daunorubicin) Liposome Injection should be diluted in approximately 500 ml of sodium chloride injection or dextrose injection. The IV bags and infusion sets must be non-dehp. Aseptic technique must be strictly observed throughout the handling of CPX-351 (cytarabine:daunorubicin) Liposome Injection since no bacteriostatic agent or preservative is present. The infusion of CPX-351 Page 75 of 111 Version 6.0 January 2017

86 (cytarabine:daunorubicin) Liposome Injection must be started within 4 hours of dilution. Vials are for single use. Unused material should be recorded as such and discarded according to institutional policies. Procedures for proper handling and disposal of anticancer drugs should be implemented. Drug Administration The infusion of CPX-351 (cytarabine:daunorubicin) Liposome Injection will be performed through a central venous catheter, using an infusion pump to ensure that the drug is infused over the specified time period. Non-DEHP containing administration sets should be used. Do not use an in-line filter. CPX-351 should never be given by the intramuscular or subcutaneous route. Administer CPX-351 over approximately 90 minutes via an infusion pump. Flush the line to ensure administration of the full dose. Page 76 of 111 Version 6.0 January 2017

87 APPENDIX C: Procedures for Stem Cell Transplantation Pre-transplant investigations Centres will wish to perform their own pre-transplant investigations but the following are strongly recommended because they may reveal possible contraindications for proceeding with therapy. 1. Bone marrow aspiration to confirm remission (ABSOLUTELY ESSENTIAL) 2. Chest x-ray 3. ECG 4. MUGA scan or Echocardiogram 5. Lung function studies Pre-graft ablative therapy with TBI and cyclophosphamide The patient should receive allopurinol 300 mg/day for at least two days before the cyclophosphamide. One of the most distressing and dose-limiting side-effects of cyclophosphamide is haemorrhagic cystitis. This may be prevented by MESNA, a compound that inactivates toxic metabolites of cyclophosphamide in the bladder. Patients should also receive intensive hydration during the giving of cyclophosphamide and TBI. Cyclophosphamide Dosage Cyclophosphamide is administered at a dose of 60 mg/kg for each of 2 successive days (use lean body weight for obese patients). It is dissolved in 250 ml of 5% glucose and administered over 60 min. Following the cyclophosphamide a clear 24 hours should elapse before TBI commences. The stem cells are infused within 24 hours of completing TBI whether the TBI was given by single or multiple fractions. MESNA During cyclophosphamide administration MESNA is given in 4 divided doses by i.v. push at time 0 (time of commencement of cyclophosphamide), time +3 hours, and +6 and +9 hours. Each dose of MESNA is 40% of the total dose of cyclophosphamide, i.e. the total MESNA dose is 160% of the total cyclophosphamide dose. Each individual dose of MESNA must be prescribed separately and the time of administration clearly noted. The hydration regimen (up to 3l/m 2 /day), unless used with MESNA, is itself insufficient to prevent cystitis. Diuresis Adequate urine flow must be maintained before and following cyclophosphamide administration to prevent urate nephropathy and haemorrhagic cystitis. All patients should receive i.v. fluids at Page 77 of 111 Version 6.0 January 2017

88 twice the maintenance rate beginning at 6-12 hours before the cyclophosphamide dose. This will ensure adequate hydration. Total body irradiation TBI procedures cannot be completely standardized throughout the UK because of constraints of machine characteristics and availability. It is recognised that many schedules in use at present are effective and safe, but the adoption of a limited number for this study is recommended to make it possible to evaluate the significance of fractionation and lung shielding for control of leukaemia and normal; tissue toxicity. This study should not obscure in any way the primary aims of the trial Single fraction TBI No lung shielding 1050 cgy if the dose rate is less than 5 cgy per minute. 950 cgy if the dose rate is 5-10 cgy per minute. 750 cgy if the dose rate is more than 10 cgy per minute. Fractionated TBI 1440 cgy in 8 fractions over 4 days, 180 cgy per fraction. Treatment will be given using a linear accelerator or cobalt unit operating at the SSD/FSD which gives an adequate, or the largest available, field size. The whole body dose should be defined as the maximum dose to the lung measured by thermoluminescent dosimetry or diodes over 20 minutes for single fraction treatments and for one whole fraction for fractionated treatments. Patient separations will be taken at, and calculation of dose made for, the following sites: Lung Abdomen (at umbilicus) Pelvis Additional measurements can be made at the discretion of the participating clinician. No lung shielding will be used and the prescribed dose will be that to the lung. Compensators may be used to give homogenous whole body dose if required: doses will then be measured under compensators. Depth dose data, built up depth and beam flatness must be determined by phantom measurement at the extended treatment distance. A central review of machine operating data and calculated doses will be undertaken. Page 78 of 111 Version 6.0 January 2017

89 Note: For patients with initial CNS involvement, additional cranial irradiation (3 x 200 cgy over 3 to 5 days) will be given before TBI using lateral fields encompassing the whole brain down to C2 and including the orbit with shielding of the lens. Additional radiotherapy will not be given to sites of initial bulk disease unless there is persistent extra-medullary disease in one site only which is not thought to be a contra-indication to transplantation. A dose of 1000 cgy in 5 fractions will then be given before TBI. If you are unable to use TBI ablation please contact one of the transplant coordinators about possible alternatives. Sedation and anti-nausea Combinations of metoclopramide (20 mg i.v.), lorazepam (1-3 mg i.v.), ondansetron (8 mg i.v.) or other 5HT antagonists and dexamethasone (10 mg i.v.) may be used. Prevention of infection Specific prophylactic measures are not laid down and procedures may vary slightly from centre to centre. Infection prophylaxis is of great importance because of the difficulties in diagnosing and treating infection in immunocompromised patients. Infusion of stem cells The stem cells should be infused intravenously through a normal giving set. This may be at any time up to 24 hours following the TBI. Toxicity of the infusion includes volume overload, pulmonary emboli and allergic reactions. Other supportive care Red cell or platelet transfusions will be necessary in the period following the graft. It is recommended that platelets be given if the peripheral platelet count is less than 10 x 10 9 /L. All blood products, including platelets, must be irradiated to at least 2500 cgy post-transplant. CMV negative recipients should receive CMV negative blood products whenever possible. GVHD Prophylaxis and treatment of graft versus host disease following allo-sct should follow the practice of the individual transplant centre. Page 79 of 111 Version 6.0 January 2017

90 APPENDIX D: Derivation of risk index for younger adults This appendix gives brief details of the derivation of the risk index for younger adults used in AML17 and AML19. The work has been published (Burnett et al, Blood 2006;108;11:10a (Abstract 18)). It can be viewed as a companion index to the previously developed Wheatley index for elderly patients with AML (Wheatley et al. Blood 2005;106;11:199a (Abstract 674)). AML is a heterogeneous disease, and prognosis, particularly in younger patients, varies considerably. Traditionally risk group stratification in MRC AML trials has been based on cytogenetics and response to the first course of chemotherapy, but this approach does not take into account variables such as age, white cell count, and performance status that are known to be prognostic. As a result, data from the MRC AML10 and AML12 trials (recruiting some 5,400 patients between 1988 and 2002) were used to construct an index for survival following complete remission. Because of the design of AML17, where patients with APL are given separate treatment, these patients were excluded from the analyses. Additionally, all children were excluded. The analysis concentrated on clinical parameters which were likely to be available following the end of the first course of chemotherapy. (For example, in view of the fact that FLT3 ITD status is only known for a minority of AML10,12 patients, and that FLT3 ITD +ve patients will in any event enter a CEP-701 randomisation, ITD status and other laboratory markers were not included as candidates for the model). Using Cox regression, a forward selection model was derived for overall survival from remission, with the following candidate variables: Age WBC Performance status Sex de Novo/Secondary Cytogenetics (Using Grimwade classification favourable/intermediate/adverse) Platelets BM blasts Response after course 1 (CR/PR/NR) Height Weight Page 80 of 111 Version 6.0 January 2017

91 Count The level of significance to enter the model was set at p=0.05. In order of entry to the model, the variables which make up the index are: Variable Estimate 2 p-value Cytogenetics < Age < Status post < C1 WBC Male sex Secondary The index is therefore: *age (in years) *sex (1=male, 0=female) *diagnosis (1=de novo, 2 secondary) *cytogenetics (1=favourable, 2=intermediate, 3 adverse) *status post C1 (1=CR, 2=PR, 3=NR) * WBC (x10 9 /l) and the distribution of patients in AML10,12 by index is: icrnoapl Taking into account the apparent bimodality of the curve, patients with an index of 2 or below were deemed good risk, and the data were arbitrarily divided at the 75 th centile between standard and poor risk. Survival from CR in AML10,12 according to the risk groups was as follows: Page 81 of 111 Version 6.0 January 2017

92 The index was validated on data from AML15: One important feature of the new risk classification is that the number of poor risk patients has increased. Compared to the old MRC risk classification, the new approach identifies a number of patients who have poor prognosis for reasons other than their cytogenetics: MRC Good MRC Standard MRC Poor Total New good New standard New poor Total Page 82 of 111 Version 6.0 January 2017

93 APPENDIX E: Supportive care recommendations for APL (Extract from the BCSH Guideline on the Management of acute myeloid leukaemia in adults) All-trans retinoic acid (ATRA) should be started as soon as the diagnosis is suspected (grade A; evidence level Ib). Leucopheresis should be avoided in high count patients (grade B; evidence level III). During induction, platelet count should be maintained at > /l, together with fresh frozen plasma (FFP) and cryoprecipitated to normalize the activated partial thromboplastin time (APTT) and fibrinogen levels (grade B; evidence level IIb). Differentiation syndrome should be treated promptly with dexamethasone 10 mg twice daily i.v., until the symptoms resolve (grade C; evidence level IV). Diagnostic work-up should include documentation of underlying PML-RARA fusion (grade B; evidence level IIa). Patients should undergo molecular monitoring after treatment to guide further therapy (grade B; evidence level IIa). Coagulopathy: A major cause of treatment failure is induction death as a result of haemorrhage, which reflects to varying degree DIC excessive fibrinolysis and proteolysis. Patients with higher presenting WBC (i.e. > /l) are at highest risk of haemorrhagic death. Patients with very high presenting leucocyte counts should not undergo leucopheresis, which commonly precipitates fatal exacerbation of the coagulopathy. High rates of induction death have also been observed when low-dose chemotherapy was used to attempt to reduce WBC in the first instance (Vahdat et al, 1994). Haemorrhagic deaths may be reduced by rigorous monitoring of the coagulation profile and administration of appropriate replacement therapy until morphological CR has been attained. APTT, prothrombin time, thrombin time, fibrinogen level and platelet count should be checked at least twice daily during the early stages of treatment. Coagulation times should be kept within the normal range using FFP as replacement. Fibrinogen levels may be low due to DIC and cryoprecipitate should be given as replacement aiming for a level of approximately 2 g/l. Elevated levels of fibrinogen should be avoided because of the increased risk of thrombosis associated with APL, which may be further exacerbated by ATRA. The platelet count should ideally be maintained above /l until morphological remission has been confirmed. Clinical studies have not established proven benefit for use of heparin or anti-fibrinolytic agents as a means of decreasing induction death rates in APL and their routine use is not recommended. Indeed, anti-fibrinolytic agents when combined with ATRA could potentially increase the inherent risk of thrombotic complications. Nevertheless, anti-fibrinolytic agents could be contemplated in situations of life-threatening haemorrhage in the presence of normal coagulation assays. Page 83 of 111 Version 6.0 January 2017

94 Differentiation syndrome: This potentially life-threatening complication of ATRA therapy is characterized by fluid retention and features of capillary leak and is most likely related to surface adhesion molecule modulation and cytokine release following induction of differentiation of APL cells. Symptoms and signs include cough, dyspnoea, fever, weight gain, oedema, pleural and pericardial effusions and pulmonary infiltrates differentiation syndrome occurs in up to a third of patients receiving ATRA as single-agent induction therapy and was fatal in approximately 30% in early studies. The syndrome typically develops approximately 10 d after initiation of ATRA, but can appear as early as 2 d and is commonly, but not invariably, associated with a rising peripheral WBC count. Patients on ATRA should be observed very carefully for symptoms, signs or falling oxygen saturation levels indicative of impending differentiation syndrome. If there are clinical suspicions of this complication, ATRA should be temporarily discontinued and steroids administered promptly (dexamethasone 10 mg i.v. b.i.d. until disappearance of symptoms and signs, and for a minimum of 3 d), which may prevent progression to the full blown syndrome. ATRA can then be cautiously re-introduced. Evidence to date suggests that steroids act by modulating the surface adhesion characteristics of APL blasts, preventing ATRA-induced aggregation that accompanies differentiation. Its occurrence during induction is not a contraindication to use of ATRA later in the patient's treatment course (including management of any relapse). Patients with a relatively high presenting WBC (> /l) have in some studies been reported to be at higher risk of differentiation syndrome during induction and some trial groups advocate use of prophylactic steroids as a component of induction therapy, whether this confers any benefit remains to be clear. Page 84 of 111 Version 6.0 January 2017

95 APPENDIX F: Resource Use questionnaire Trial Number.... Date.... Patient initials AML MRD Monitoring Trial RESOURCE USE QUESTIONNAIRE Dear Participant, We would like to know whether you have had any contacts with NHS and other services as listed below. If so, please tell us the number of times you have had contacts with them since your last visit to the hospital, i.e. since. <Trial Nurse to fill in this date>. Please check the diary sheet we gave you to help you remember all of your contacts. Please put number of times and dates in the appropriate boxes. If no contact was made, put 0. Where AML related appears, please indicate whether this contact was related to AML, treatment or side effects. If you find any of the questions are irrelevant or difficult please make a note of this on the last page. Note to trial nurse: please guide patients to fill this form if necessary and on completion, check this form for completeness. Please answer all the questions yourself by ticking the box that best applies to you. Please enter the date on which you completed this questionnaire:././. Page 85 of 111 Version 6.0 January 2017

96 Have you visited the GP? If yes please provide more information:- Visit Date Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Reason AML related? Has the GP visited you at home? If yes please provide more information:- Visit Date Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Reason AML related? Page 86 of 111 Version 6.0 January 2017

97 Have you seen the nurse at your surgery? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Has your nurse visited you at home? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Page 87 of 111 Version 6.0 January 2017

98 Have you spent at least one night in the hospital? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Have you visited the hospital out-patient department? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Page 88 of 111 Version 6.0 January 2017

99 Have you visited the hospital/haematology day care facility? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Have you visited the Accident and Emergency (A&E) department? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Page 89 of 111 Version 6.0 January 2017

100 Have you spent at least a night in another healthcare facility? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Have you received home help? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Page 90 of 111 Version 6.0 January 2017

101 Have you received services of a social worker? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Have you received services of an occupational therapist? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Page 91 of 111 Version 6.0 January 2017

102 Have you received services of a physiotherapist? If yes please provide more information:- Visit 1 Visit 2 Visit 3 Visit 4 Visit5 Visit Date Reason AML related? Thank you for your help. We are going to ask you similar questions next time you are here. Therefore, it would be helpful if you could take the attached sheet (Diary) home and note down any NHS and social care you use between now and then. If you bring it back with you next time, it would help both of us to go through this process much more quickly. Page 92 of 111 Version 6.0 January 2017

103 APPENDIX G: Quality of Life Questionnaire(s) Page 93 of 111 Version 6.0 January 2017

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115 APPENDIX H: IMP Provision Schedule IMP SUPPLIER DISTRIBUTOR Mylotarg Pfizer 3,000 per patient St Mary s Pharmaceutical Unit (SMPU) CPX351 Celator Pharmaceutical Inc (supplied free of charge) SMPU Initial supply of IMP, following randomisation, will be arranged by Haematology Clinical Trials Unit. Subsequent treatment courses for individual patients will be requested from the Haematology Clinical Trials Unit in Cardiff by the participating site using the current request forms provided. Any queries regarding supply, storage, handling or destruction of IMP should be directed to the Trial Manager (see page 2). Deliveries are usually made within 2 working days of collection from the distribution facility. Deliveries from SMPU are via a temperature controlled supply chain, so no temperature logs are included with the deliveries. QP release certification is included with each delivery. Page 105 of 111 Version 6.0 January 2017

116 Appendix I: Flow charts with relevant Patient Information Sheet/Consent Form Numbers Page 106 of 111 Version 6.0 January 2017