Chinese Herbal Formulation PHY906 and Sorafenib Tosylate in Treating Patients With Advanced Liver Cancer

PRIMARY OBJECTIVES:

I. To characterize the safety and tolerability of KD018 (Chinese herbal formulation PHY906)
in combination with daily sorafenib (sorafenib tosylate) and to determine the maximum
tolerated dose (MTD) of the combination of KD018 plus sorafenib to bring forward into phase
2.

SECONDARY OBJECTIVES:

I. To describe the efficacy of the combination of KD018 plus sorafenib at the explored
dose-levels in terms of best overall response as defined by Response Evaluation Criteria in
Solid Tumors (RECIST) guidelines.

II. To assess the safety and tolerability of the combination of KD018 plus sorafenib as
measured by the rate and severity of adverse events (AEs).

III. To determine the steady state of sorafenib after KD018 exposure at pre-dose and 1 hour
and 2 hours post-dose at the explored combination dose-levels using concentrations at
pre-dose (Cmin) and at 1 hour (C1h) and 2 hours (C2h) post-dose.

TERTIARY OBJECTIVES:

I. To assess the effect of treatment on soluble markers of angiogenesis, fibroblast growth
factor (FGF), vascular endothelial growth factor (VEGF), placental growth factor (PLGF),
soluble vascular endothelial growth factor receptor 1 (sVEGFR1), sVEGFR2, apoptosis (i.e. M30
monoclonal antibody [M30] and M65) and on the insulin-like growth factor (IGF) axis including
molecules such as IGF-binding protein 2 (IGFII).

II. To correlate the above soluble biomarker measurements with clinical endpoints.

III. To examine the correlation between the soluble biomarkers.

IV. To examine the predictive relationship of immunohistochemical tumor biomarkers at
baseline, i.e. phosphorylated ribosomal protein S6 kinase (pS6), p-protein kinase B (pAKT),
p-mitogen-activated protein kinase 1 (ERK), p-mitogen-activated protein kinase kinase (pMEK),
hypoxia-inducible factor 2, alpha subunit (HIF2a), phosphatase and tensin homolog gene
(PTEN), signal transducer and activator of transcription 3 (acute-phase response factor)
(STAT3) and tumor protein p53 (p53), as well as of mutational status, i.e. p53,
phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha (PIK3CA) and PTEN,
with efficacy endpoints (time to progression [TTP]).

V. To determine if soluble apoptosis markers (M30/M65) correlate with proliferative markers
at baseline (proliferation-related Ki-67 antigen [Ki67] and p53) in archival tumor samples.

VI. To examine the relationship of immunohistochemical and/or soluble biomarkers with
subgroup classification namely, patients with hepatitis B virus (HBV), patients with
hepatitis C virus (HCV) and patients with other etiologies.

VII. To explore potential biomarker differences within patient subgroups, namely, patients
with HBV, patients with HCV and patients with other etiologies.

VIII. To determine the effect of KD018 on cytokine/chemokine levels including interleukin
(IL)-2, IL-4, IL-5, IL-6, IL-10, monocyte chemotactic protein 1 (MCP-1), tumor necrosis
factor (TNF)-alpha, interferon (IFN)-alpha, VEGF, FGF-basic (b), sargramostim (GM-CSF),
filgrastim (G-CSF).

IX. To explore potential relationships between efficacy and Cmin of sorafenib after
co-administration with KD018 and between occurrence of adverse events and C1h/C2h endpoints
(efficacy, safety, pharmacokinetics [PK]).

OUTLINE: This is a phase I, dose-escalation study of Chinese herbal formulation PHY906.

Patients receive Chinese herbal formulation PHY906 orally (PO) twice daily (BID) on days 1-4,
8-11, 15-18, 21-24 and sorafenib tosylate PO BID on days 1-28. Courses repeat every 28 days
in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months.

Inclusion Criteria:

- Ability to take oral drugs

- Diagnosis of advanced hepatocellular carcinoma (HCC) according to the American
Association for the Study of Liver Diseases (AASLD) guidelines

- HCC stage B or C according to the Barcelona Clinic Liver Cancer (BCLC)

- Previous or current use of sorafenib allowed

- Measurable disease according to RECIST, i.e. at least one measurable lesion; this
lesion should not have been previously treated with local therapy; a treated lesion
may be used where these lesions are the only lesions available for evaluation and have
shown definite progression since their last local treatment; local therapy must have
been completed at least four weeks prior to baseline evaluation

- Patients with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or
1

- Cirrhotic status of current Child-Pugh class A and B with no encephalopathy and no
ascites (ascites controlled by diuretics is also excluded in this study); Child-Pugh
status should be calculated based on clinical findings and laboratory results during
the screening period

- For patients with positive HBV-deoxyribonucleic acid (DNA) and/or positive of
hepatitis B surface antigen (HBsAg) results, they must be treated with anti-virals, as
prophylaxis at least 1-2 weeks prior to receiving study drug, cycle 1, day 1

- Absolute neutrophil count (ANC) >= 1.5 x 10^9/L

- Platelets >= 75000 x 10^6/L

- Hemoglobin (Hgb) >= 9 g/dL

- Alanine aminotransferase (ALT) =< 5 x upper limit of normal (ULN)

- Serum creatinine =< 1.5 x ULN

- Ability to understand and willingness to sign a written informed consent and to be
able to follow the visit schedule

- Life expectancy of approximately 6 months

- Women of child-bearing potential and men must agree to use adequate contraception
(hormonal or barrier method of birth control or abstinence) prior to study entry and
for three months following duration of study participation; should a woman become
pregnant, or suspect that she is pregnant while participating on the trial, she should
inform her treating physician immediately

- All subjects must have the ability to understand and the willingness to sign a written
informed consent

- Previous or current use of sorafenib and previous use of tamoxifen is allowed as
previous systemic therapy

Exclusion Criteria:

- Patients currently receiving any anti-cancer therapy, except sorafenib, or who have
received any local anti-cancer therapy =< 4 weeks prior to baseline computed
tomography (CT)/magnetic resonance imaging (MRI) scan, prior to cycle 1 treatment

- Active bleeding during the last 30 days prior to cycle 1 treatment including variceal
bleeding (esophageal varices should be treated according to standard practice e.g.
ligation/banding and procedure completed 30 days prior to cycle 1 treatment)

- Patients with a known hypersensitivity to KD018 or known hypersensitivity to sorafenib
or contraindications to sorafenib based on the local sorafenib label

- Known history of human immunodeficiency virus (HIV) seropositivity (HIV testing is not
mandatory)

- Any severe and/or uncontrolled medical conditions including:

- Unstable angina pectoris, symptomatic congestive heart failure, myocardial
infarction =< 6 months prior to cycle 1 treatment, serious uncontrolled cardiac
arrhythmia, uncontrolled hypertension

- Previous transient ischemic attack (TIA), cerebral vascular accident (CVA),
symptomatic posterior vitreous detachment (PVD) within last 6 months of cycle 1
treatment

- Congenital long QT syndrome

- Patients with active alcohol intake

- Acute and chronic, active infectious disorders and nonmalignant medical illnesses
that are uncontrolled or whose control may be jeopardized by the complications of
this study therapy, in the opinion of the investigator, except chronic HBV or HCV

- Impairment of gastrointestinal function or who have gastrointestinal disease that
may significantly alter the absorption of study drugs (e.g., ulcerative disease,
uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome)

- Patients receiving chronic treatment with corticosteroids (except for intermittent
topical or local injection or aldosterone) or another immunosuppressive agent

- Patients treated with drugs known to be strong inhibitors or inducers of isoenzyme
cytochrome P450, family 3, subfamily A (CYP3A) unless the drugs are medically
necessary and no substitutes are available

- Patients who have undergone major surgery =< 2 weeks prior to starting study drug or
who have not recovered from surgery

- Patients who have received an investigative drug or therapy within the last 30 days
prior to cycle 1 treatment

- Pregnant and/or breastfeeding women