TET2 Mutations in Myelodysplastic Syndromes and Acute Myeloid Leukemia With Azacitidine + Ascorbic Acid

Primary Endpoint To estimate the overall response rate (ORR) of the combination of standard
dose azacitidine and oral dose of ascorbic acid in patients with MDS, AML, and MDS /
Myeloproliferative Neoplasm (MPN) overlap with heterozygous TET2 mutations

Secondary Endpoints

1. The safety profile of the combination in the targeted patient population

2. Response duration

3. Overall survival of the treated population (compared to matched historical cohort of
patients treated with single agent Azacitidine)

4. The identification of biomarkers that predict response to the combination

Study Design This is an open-label, phase II study that will be conducted at Cleveland
Clinic, Taussig Cancer Institute.

Azacitidine will be administered intravenously or subcutaneously at a fixed dose of
75mg/m2/day for 7 consecutive days, (allowing for weekends, and holidays) of each 28-day
cycle. Ascorbic acid will be administered orally daily at 1 g/day three days prior to start
azacitidine and then continues daily for a total of 28 days of each 28 day cycle.

Inclusion Criteria:

- Patients must have a confirmed heterozygous TET2 mutations identified by next
generation targeted deep sequencing.

- Patients must have MDS, or MDS/MPN overlap defined by 2016 World Health Organization
(WHO) criteria. Both newly diagnosed or previously treated MDS or MDS/MPN patients are
eligible as long as the patient has never received prior treatment with azacitidine or
decitabine.

- Patients with Leukemic/blast phase transformation MPN.

- Patient with AML according to 2016 WHO criteria.

- Newly diagnosed patients who are ineligible or declined to receive intensive
chemotherapy after discussion of risks and benefits of that approach or patients
with primary refractory/relapsed AML.

- Patients with active central nervous system (CNS) leukemia eligible at the
discretion of treating physician.

- Relapse/Refractory is defined as at least 1 course of treatment for AML excluding
any patients treated with azacitidine or decitabine.

- Patients should be off any prior treatment or line of therapy for 2 weeks
prior to start study with the exception of hydrea (Hydroxyurea).

- Prior therapy with hydroxyurea, biological or targeted therapy (e.g. flt3 inhibitors,
other kinase inhibitors) or hematopoietic growth factors is allowed.

- Eastern Cooperative Oncology Group (ECOG) performance status ≤ 3.

- Patients must have normal organ and marrow function as defined at the discretion of
the treating physician and PI.

- Women of childbearing potential must have a negative serum or urine pregnancy test
within 10-14 days prior to enrollment.

- Patients must have the ability to understand and the willingness to sign a written
informed consent document.

- Patient must be willing to comply with all aspects of the protocol including
completing the drug diary.

- Patient must discontinue any and all use of multivitamin and/or vitamin c medication
24 hours before first dose of Ascorbic Acid.

Exclusion Criteria:

- Any prior treatment with azacitidine or decitabine.

- Patients diagnosed with acute promyelocytic leukemia (APL), AML-M3.

- Patients receiving other active treatment for their myeloid malignancy including
investigational agents with the exception of hydrea for white blood cell control.

- Nursing or pregnant women.

- History of allergic reactions to either azacitidine or ascorbic acid.

- Patients with uncontrolled intercurrent illness including, but not limited to ongoing
or active infection, symptomatic congestive heart failure, unstable angina pectoris,
cardiac arrhythmia, or psychiatric illness/social situations that would limit
compliance with study requirements.

- Patients with higher risk of bleeding (deemed by the treating physician) or on
anticoagulation.

- Patients who are unwilling or unable to comply with all study requirements.