doi: 10.1111/cas.12443. OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 88 of 101 02 February 2022 9 APPENDICES OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 89 of 101 02 February 2022 APPENDIX 1: RECIST 1.1 CRITERIA Eisenhauer EA , Therasse P, Bogaerts J , Schwart z LH , Sargent D , Ford R , Dancey J , Arbuck S , Gwyther S , Mooney M , Rubinstein L , Shankar L , Dodd L , Kaplan R , Lacombe D , Verweij J . New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009; 45(2):228 -47. doi: 10.1016/j.ejca.2008.10.026. This Append ix has been excerpted from the full RECIST 1.1 criteria. For information pertaining to RECIST 1.1 criteria not contained in the study protocol or in this Appendix, please refer to the full publication ( 17). 1 ASSESSMENT OF OVERALL TUMOR BURDEN AND MEASURABLE DISEASE To assess objective response or future progression, it is necessary to estimate t he overall tumor burden at baseline and use this as a comparator for subsequent measurements. Measurable disease is defined by the presence of at least one measurable lesion. 1.1 Measurability of tumor At baseline, tumor lesions/lymph nodes will be catego rized measurable or non -measurable as follows. All baseline evaluations should be performed as close as possible to the treatment start and never more than 4 weeks before the beginning of the treatment. Measurable lesions must be accurately measured in at least one dimension (longest diameter inthe plane of the measurement to be recorded) with a minimum size of: ➢ 10 mm by CT scan - (CT scan slice thickness no greater than 5 mm) ➢ 10 mm caliper measurement by clinical exam (lesions which cannot be accurately measured with calipers should be recorded as non -measurable) ➢ 20 mm by chest x -ray ➢ Malignant lymph nodes: To be considered pathologically enlarged and measurable, a lymphnode must be  15 mm in short axis when assessed by CT scan (CT scan slice thickness recommended to be no greater than 5 mm). At baseline and in follow -up, only the short axiswill be measured and followed. All measurements should be recorded in metric notation, using calipers if clinically assessed. Special considerations regarding lesion measurability Bone lesions: ➢ Bone scan, PET scan or plain films are not consider ed adequate imaging techniques to measure bone lesions. However, these techniques can be used to confirm the presence or disappearance of bone lesions. ➢ Lytic bone lesions or mixed lytic -blastic lesions, with identifiable soft tissue components, that can be evaluated by cross sectional imaging techniques such as CT or MRI can be OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 90 of 101 02 February 2022 considered as measurable lesions if the soft tissue component meets the definition ofmeasurability described above. ➢ Blastic bone lesions are non -measurable. Cystic lesions: ➢ Lesions that meet the criteria for radiographically defined simple cysts should not be considered as malignant lesions (neither measurable nor non -measurable) since they are, by definition, simple cysts. ➢ Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, if they meet the definition of measurability described above. However, if non - cystic lesions are present in the same patient, these are preferred for selection as target lesions. Lesions with prior local treatment: Tum or lesions situated in a previously irradiated area, or in an area subjected to other loco - regional therapy, are usually not considered measurable unless there has been demonstrated progression in the lesion. Non-measurable lesions are all other lesions, including small lesions (longest diameter < 10 mm or pathological lymph nodes with  10 to < 15 mm short axis), as well as non - measurable lesions. Lesions considered non -measurable include: leptomeningeal disease, ascites, pleural or pericardial effusion, inflammatory breast disease, lymphangitic involvement of skin or lung, abdominal masses/abdominal organomegaly identified by physical exam that is not measurable by reproducible imaging techniques. 1.2 Method of assessment The same method of assessment an d the same technique should be used to characterize each identified and reported lesion at baseline and during follow -up. Imaging based evaluation should always be performed rather than clinical examination unless the lesion(s) being followed cannot be ima ged but are assessable by clinical examination. CT, MRI: CT is the best currently available and reproducible method to measure lesions selected for response assessment. Measurability of lesions on CT scan is based on the assumption that CT slice thickness is 5 mm or less. When CT scans have slice thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. Chest x -ray: Chest CT is preferred over chest x -ray, particularly when progression is an important endpoint, since CT is more sensitive than x -ray, particularly in identifying new lesions. However, lesions on chest x -ray may be considered measurable if they are clearly defined and surrounded by aerated lung. Clinical lesions : Clinical lesions will only be considered measurable when they are superficial and  10 mm diameter as assessed using calipers. For the case of skin lesions, documentation by color photography including a ruler to estimate the size of the lesion is suggested. As noted OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 91 of 101 02 February 2022 abov e, when lesions can be evaluated by both clinical exam and imaging, imaging evaluation should be undertaken since it is more objective and may be reviewed at the end of the study. Ultrasound : Ultrasound is not useful in assessment of lesion size and shoul d not be used as a method of measurement. If new lesions are identified by ultrasound in the course of the study, confirmation by CT or MRI is advised. Endoscopy, laparoscopy : The utilization of these techniques for objective tumor evaluation is not advis ed. Tumor markers: Tumor markers alone cannot be used to assess objective tumor response. 2 BASELINE DOCUMENTATION OF ‘TARGET’ AND ‘NON -TARGET’ LESIONS Target lesions: When more than one measurable lesion is present at baseline all lesions up to a maxim um of five lesions total (and a maximum of two lesions per organ) representative of all involved organs should be identified as target lesions and will be recorded and measured at baseline. Target lesions should be selected on the basis of their size (lesi ons with the longest diameter), be representative of all involved organs, and should lend themselves to reproducible repeated measurements. Lymph nodes merit special mention since they are normal anatomical structures which may be visible by imaging even i f not involved by tumor. Pathological nodes which are defined as measurable and may be identified as target lesions must meet the criterion of a short axis of  15 mm by CT scan. Only the short axis of these nodes will contribute to the baseline sum. All other pathological nodes (those with short axis  10 mm but < 15 mm) should be considered non-target lesions. Nodes that have a short axis < 10 mm are considered non -pathological and should not be recorded or followed. A sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target lesions will be calculated and reported as the baseline sum diameters. The baseline sum diameters will be used as reference to further characterize any objective tumor regression in the measur able dimension of the disease. Non-target lesions: All other lesions (or sites of disease) including pathological lymph nodes should be identified as non -target lesions and should also be recorded at baseline. Measurements are not required and these lesio ns should be followed as ‘present’, ‘absent’, or ‘unequivocal progression’. In addition, it is possible to record multiple non -target lesions involving the same organ as a single item on the case record form (eg, ‘multiple enlarged pelvic lymph nodes’ or ‘multiple liver metastases’). OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 92 of 101 02 February 2022 3 TUMOR RESPONSE EVALUATION AND RESPONSE CRITERIA 3.1 Evaluation of target lesions Complete Response (CR): Disappearance of all target lesions. Any pathological lymph nodes (whether target or non -target) must have reduction in short axis to < 10 mm. Partial Response (PR ): At least a 30% decrease in the sum of diameters of target lesions, taking as reference the baseline sum diameters. Progressive Disease (PD) : At least a 20% increase in the sum of diameters of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study). In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. Note: the appearance of one or more new lesions is also considered progression. Stable Disease (SD ): Neither sufficient shrinkage from the baseline stu dy to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum diameters while on study. Special notes on the assessment of target lesions ➢ Lymph nodes: Lymph nodes identified as target lesions should always have the ac tual short axis measurement recorded and should be measured in the same anatomical plane as the baseline examination, even if the nodes regress to below 10 mm on study. This means that when lymph nodes are included as target lesions, the ‘sum’ of lesions m ay not be zero even if complete response criteria are met, since a normal lymph node is defined as having a short axis of < 10 mm. ➢ Target lesions that become ‘too small to measure’: All lesions (nodal and non -nodal) recorded at baseline should have their a ctual measurements recorded at each subsequent evaluation, even when very small (e.g., 2 mm). If the radiologist is able to provide an actual measure, that should be recorded, even if it is below 5 mm. However, when such a lesion becomes difficult to assi gn an exact measure to then: (i) if it is the opinion of the radiologist that the lesion has likely disappeared, the measurement should be recorded as 0 mm. (ii) if the lesion is believed to be present and is faintly seen but too small to measure, a defau lt value of 5 mm should be assigned (note: in case of a lymph node believed to be present and faintly seen but too small to measure, a default value of 5 mm should be assigned in this circumstance as well). This default value is derived from the 5 mm CT sl ice thickness (but should not be changed with varying CT slice thickness). Lesions that split or coalesce on treatment: When non -nodal lesions ‘fragment’, the longest diameters of the fragmented portions should be added together to calculate the target le sion sum. Similarly, as lesions coalesce, a plane between them may be maintained that would aid in obtaining maximal diameter measurements of each individual lesion. If the lesions have OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 93 of 101 02 February 2022 coalesced such that they are no longer separable, the vector of the lo ngest diameter in this instance should be the maximal longest diameter for the ‘coalesced lesion’. 3.2 Evaluation of non -target lesions While some non -target lesions may actually be measurable, they need not be measured and instead should be assessed only qualitatively at the time points specified in the protocol. Complete Response (CR): Disappearance of all non -target lesions and normalization of tumor marker level. All lymph nodes must be non -pathological in size (< 10 mm short axis). Non-CR/Non -PD: Pers istence of one or more non -target lesion(s) and/or maintenance of tumor marker level above the normal limits. Progressive Disease (PD) : Unequivocal progression of existing non -target lesions. (Note: the appearance of one or more new lesions is also considered progression). ➢ The concept of progression of non -target disease requires additional explanation as follows: ➢ When the patient also has measurable disease : To achieve ‘unequivocal progression’ on the basis of the non -target disease, there must be an overall level of substantial worsening in non -target disease such that, even in presence of SD or PR in target disease, the overall tumor burden has increased sufficiently to merit discontinuation of therapy. A modest ‘increase’ in the size of one or mo re non -target lesions is usually not sufficient to qualify for unequivocal progression status . ➢ When the patient has only non -measurable disease : To achieve ‘unequivocal progression’ on the basis of the non -target disease, there must be an overall level of substantial worsening such that the overall tumor burden has increased sufficiently to merit discontinuation of therapy. A modest ‘increase’ in the size of one or more non -target lesions is usually not sufficient to qualify for unequivocal progression stat us. Because worsening in non -target disease cannot be easily quantified (by definition: if all lesions are non -measurable) a useful test that can be applied when assessing patients for unequivocal progression is to consider if the increase in overall disea se burden based on the change in non -measurable disease is comparable in magnitude to the increase that would be required to declare PD for measurable disease: ie, an increase in tumor burden representing an additional 73% increase in ‘volume’ (which is eq uivalent to a 20% increase diameter in a measurable lesion). Examples include an increase in a pleural effusion from ‘trace’ to ‘large’, an increase in lymphangitic disease from localized to widespread, or may be described in protocols as ‘sufficient to require a change in therapy’. If ‘unequivocal progression’ is seen, the patient should be considered to have had overall PD at that point. 3.3 New lesions The appearance of new malignant lesions denotes disease progression. The finding of a new lesion shoul d be unequivocal: ie, not attributable to differences in scanning technique, change in imaging modality or findings thought to represent something other than tumor (for example, some ‘new’ bone lesions may be simply healing or flare of pre -existing lesions ). This is particularly important when the patient’s baseline lesions show partial or complete response. For OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 94 of 101 02 February 2022 example, necrosis of a liver lesion may be reported on a CT scan report as a ‘new’ cystic lesion,which it is not. A lesion identified on a follow -up study in an anatomical location that was not scanned at baseline is considered a new lesion and will indicate disease progression. An example of this is the patient who has visceral disease at baseline and while on study has a CT or MRI brain ordered whi ch reveals metastases. The patient’s brain metastases are considered to be constitute PD even if he/she did not have brain imaging at baseline.If a new lesion is equivocal, for example because of its small size, continued therapy and follow -up evaluation w ill clarify if it represents new disease. If repeat scans confirm that there is a new lesion, then progression should be declared using the date of the initial scan. 3.4 Tumor markers Tumor markers alone cannot be used to assess objective tumor responses. If markers are initiallyabove the upper normal limit, however, they must normalize in order for a patient to be considered as having attained a complete response. 4 EVALUATION OF BEST OVERALL RESPONSE 4.1 Time point response A response assessment should occur at each time point specified in the protocol. For patients who have measurable disease at baseline Appendix Table 6 provides a summary of the overall response status calculation at each time point. Table 6: Summary of the Overall Response Status Calculation [Time point response - patients with target ± non -target disease] Target lesions Non-target lesions New lesions Overall response CR CR No CR CR Non-CR/non -PD No PR CR Not evaluated No PR PR Non-PD or not all evaluated No PR SD Non-PD or not all evaluated No SD Not all evaluated Non-PD No NE PD Any Yes or No PD Any PD Yes or No PD Any Any Yes PD 4.2 Missing assessments and inevaluable designation When no imaging/measurement is done at all at a particular time point, the patient is not evaluable (NE) at that time point. If only a subset of lesion measurements are made at an OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 95 of 101 02 February 2022 assessment, usually the case is also considered NE at that time point, unless a convincing argument can be made that the contribution of the individual missing lesion(s) would not change the assigned time point response. This would be most likely to happen in the case of PD. 4.3 Best overall response: all timepoints Best response determination in trials where confirmation of complete or partial response IS required: Complete or partial responses may be claimed only if the criteria for each are met at a subsequent time point as specified in the protocol. In this circumstance, the best overall response can be interpreted as in Appendix Table 7. Table 7: Best overall response when confirmation of CR and PR required Overall Response First Timepoint Overall Response Subsequent Timepoint Best Overall response CR CR CR CR PR SD, PD or PRa CR SD SD provided minimum criteria for SD duration met, otherwise, PD CR PD SD provided minimum criteria for SD duration met, otherwise, PD CR NE SD provided minimum criteria for SD duration met, otherwise NE PR CR PR PR PR PR PR SD SD PR PD SD provided minimum criteria for SD duration met, otherwise, PD PR NE SD provided minimum criteria for SD duration met, otherwise NE NE NE NE CR = complete response, PR = partial response, SD = stable disease, PD = progressive disease, and NE = inevaluable. a If a CR is truly met at first time point, then any disease seen at a subsequent time point, even disease meeting PR criteria relative to baseline, makes the disease PD at that point (since disease must have reappeared after CR). Best response would depend on whether minimum duration for SD was met. However, sometimes ‘CR’ may be claimed when subsequent scans suggest small lesions were likely still present and in fact the patient had PR, not CR at the first time point. Under these circumstances, the origina l CR should be changed to PR and the best response is PR. OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 96 of 101 02 February 2022 4.4 Special notes on response assessment When nodal disease is included in the sum of target lesions and the nodes decrease to ‘normal’size (< 10 mm), they may still have a measurement reported on scans. This measurement should be recorded even though the nodes are normal in order not to overstate progression should it be based on increase in size of the nodes. As noted earlier, this means that patients with CR may not have a total sum o f ‘zero’ on the case report form (CRF). Patients with a global deterioration of health status requiring discontinuation of treatment without objective evidence of disease progression at that time should be reported as‘symptomatic deterioration’. Every effo rt should be made to document objective progression even after discontinuation of treatment. Symptomatic deterioration is not a descriptor of an objective response: it is a reason for stopping study therapy. The objective response status of such patients is to be determined by evaluation of target and non -target disease as shown in Appendix Table 6 and Table 7. For equivocal findings of progression (eg, very small and uncertain new lesions; cystic changes or necrosis in existing lesions), treatment may continue until the next scheduled assessment. If at the next scheduled assessment, progression is confirmed, the date of progression should be the earlier date when progression was suspected. 5 ADDI TIONAL CONSIDERATIONS 5.1 Duration of response Duration of overall response: The duration of overall response is measured from the time measurement criteria are first met for CR/PR (whichever is first recorded) until the first date that recurrent or progre ssive disease is objectively documented (taking as reference for progressive disease the smallest measurements recorded on study). The duration of overall complete response is measured from the time measurement criteria are first met for CR until the first date that recurrent disease is objectively documented. Duration of stable disease: Stable disease is measured from the start of the treatment (in randomized trials, from date of randomization) until the criteria for progression are met, taking as reference the smallest sum on study (if the baseline sum is the smallest, this is the reference for calculation of PD). 5.2 Lesions that disappear and reappear If a lesion disappears and reappears at a subsequent time point it should continue to be measur ed. However, the patient’s response at the point in time when the lesion reappears will depend upon the status of his/her other lesions. For example, if the patient’s tumour had reached a CR status and the lesion reappeared, then the patient would be consi dered PD at the time of reappearance. In contrast, if the tumour status was a PR or SD and one lesion which had disappeared then reappears, its maximal diameter should be added to the sum of the remaining lesions for a calculated response: in other words, the reappearance of an apparently ‘disappeared’ single lesion amongst many which remain is not in itself enough to qualify for PD: that requires the sum of all lesions to meet the PD criteria. The rationale for such a categorization is based upon OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 97 of 101 02 February 2022 the reali zation that most lesions do not actually ‘disappear’ but are not visualized because they are beyond the resolving power of the imaging modality employed. 5.3 Use of FDG -PET While FDG -PET response assessments need additional study, it is sometimes reasonab le to incorporate the use of FDG -PET scanning to complement CT scanning in assessment of progression (particularly possible ‘new’ disease). New lesions on the basis of FDG -PET imaging can be identified according to the following algorithm: a. Negative FDG -PET at baseline, with a positive FDG -PET at follow -up is a sign of PD based on a new lesion. Confirmatory CT is recommended. b. No FDG -PET at baseline and a positive FDG -PET at follow -up: ➢ If the positive FDG -PET at follow -up corresponds to a new site of d isease confirmed by CT, this is PD. ➢ If the positive FDG -PET at follow -up is not confirmed as a new site of disease on CT, additional follow -up CT scans are needed to determine if there is progression occurring at that site (if so, the date of PD will be th e date of the initial abnormal FDG -PET scan). ➢ If the positive FDG -PET at follow -up corresponds to a pre -existing site of disease on CT that is not progressing on the basis of the anatomic images, this is not PD. OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 98 of 101 02 February 2022 APPENDIX 2: EORTC QOL QUESTIONNAIRES As consulted on July 16th, 2015 at http://groups.eortc.be/qol/sites/default/files/img/specimen_lc13_english.pdf and http://groups.eortc.be/qol/sites/default/files/img/slider/specimen qlq -c30 english.pdf specimen_lc13_englis h.pdf specimen_qlq-c30_e nglish.pdf OSE2101 Protocol OSE2101C301 Confidential Version n°6.0 Page 99 of 101 02 February 2022 APPENDIX 3: ECOG ECOG Performance Status Developed by the Eastern Cooperative Oncology Group, Robert L. Comis, MD, Group Chair (57) Oken MM , Creech RH , Tormey DC , Horton J , Davis TE , McFadden ET , Carbone PP . Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol.