Oral Temozolomide Research Articles

Clinicopathological, immunohistochemical and therapeutic approaches on survival in patients with epithelioid glioblastoma: Institutional experience in the management of 58 patients

Epithelioid glioblastoma (Ep-GBM) is a rare variant of glioblastoma characterized by a high recurrence rate and poor prognosis. Currently, there is no established standard treatment for Ep-GBM. Therefore, we identified 58 Ep-GBM cases to investigate these characteristics and identify the possible prognostic factors of survival. There were 30 male and 28 female patients with a median age of 39 years. Headaches and dizziness were the most common clinical symptom. The tumor is most frequently located in the temporal lobe (36.2%). The positivity rate for BRAF-V600E is 56.9% (33/58), for MGMT is 56.9% (33/58), and for INI-1 is 75% (30/40). Tumor recurrence was observed in 39 patients. The median progression-free survival (PFS) of all patients was 12.7 months, while the median overall survival (OS) was 29.1 months. Additionally, the median survival time after recurrence was 14.3 months. Both univariate and multivariate COX regression analyses revealed that individuals who received more than six cycles of adjuvant oral temozolomide experienced a longer median PFS compared to those who received fewer cycles. Characteristics associated with poorer PFS included tumor dissemination prior to initial surgery. Additionally, both analyses identified tumor dissemination, radiotherapy and adjuvant oral temozolomide as predictors of OS. Notably, for patients with recurrent Ep-GBM, reoperation was shown to significantly increase survival time after recurrence. In conclusion, the standard Stupp regimen is also applicable to patients with Ep-GBM, extending adjuvant oral temozolomide could further improve survival for Ep-GBM patients, reoperation may also prolong survival for recurrent Ep-GBM.

Irinotecan and temozolomide in combination with dasatinib and rapamycin versus irinotecan and temozolomide for patients with relapsed or refractory neuroblastoma (RIST-rNB-2011): a multicentre, open-label, randomised, controlled, phase 2 trial

Neuroblastoma is the most common extracranial solid tumour in children. Relapsed or refractory neuroblastoma is associated with a poor outcome. We assessed the combination of irinotecan-temozolomide and dasatinib-rapamycin (RIST) in patients with relapsed or refractory neuroblastoma. The multicentre, open-label, randomised, controlled, phase 2, RIST-rNB-2011 trial recruited from 40 paediatric oncology centres in Germany and Austria. Patients aged 1-25 years with high-risk relapsed (defined as recurrence of all stage IV and MYCN amplification stages, after response to treatment) or refractory (progressive disease during primary treatment) neuroblastoma, with Lansky and Karnofsky performance status at least 50%, were assigned (1:1) to RIST (RIST group) or irinotecan-temozolomide (control group) by block randomisation, stratified by MYCN status. We compared RIST (oral rapamycin [loading 3 mg/m2 on day 1, maintenance 1 mg/m2 on days 2-4] and oral dasatinib [2 mg/kg per day] for 4 days with 3 days off, followed by intravenous irinotecan [50 mg/m2 per day] and oral temozolomide [150 mg/m2 per day] for 5 days with 2 days off; one course each of rapamycin-dasatinib and irinotecan-temozolomide for four cycles over 8 weeks, then two courses of rapamycin-dasatinib followed by one course of irinotecan-temozolomide for 12 weeks) with irinotecan-temozolomide alone (with identical dosing as experimental group). The primary endpoint of progression-free survival was analysed in all eligible patients who received at least one course of therapy. The safety population consisted of all patients who received at least one course of therapy and had at least one post-baseline safety assessment. This trial is registered at ClinicalTrials.gov, NCT01467986, and is closed to accrual. Between Aug 26, 2013, and Sept 21, 2020, 129 patients were randomly assigned to the RIST group (n=63) or control group (n=66). Median age was 5·4 years (IQR 3·7-8·1). 124 patients (78 [63%] male and 46 [37%] female) were included in the efficacy analysis. At a median follow-up of 72 months (IQR 31-88), the median progression-free survival was 11 months (95% CI 7-17) in the RIST group and 5 months (2-8) in the control group (hazard ratio 0·62, one-sided 90% CI 0·81; p=0·019). Median progression-free survival in patients with amplified MYCN (n=48) was 6 months (95% CI 4-24) in the RIST group versus 2 months (2-5) in the control group (HR 0·45 [95% CI 0·24-0·84], p=0·012); median progression-free survival in patients without amplified MYCN (n=76) was 14 months (95% CI 9-7) in the RIST group versus 8 months (4-15) in the control group (HR 0·84 [95% CI 0·51-1·38], p=0·49). The most common grade 3 or worse adverse events were neutropenia (54 [81%] of 67 patients given RIST vs 49 [82%] of 60 patients given control), thrombocytopenia (45 [67%] vs 41 [68%]), and anaemia (39 [58%] vs 38 [63%]). Nine serious treatment-related adverse events were reported (five patients given control and four patients given RIST). There were no treatment-related deaths in the control group and one in the RIST group (multiorgan failure). RIST-rNB-2011 demonstrated that targeting of MYCN-amplified relapsed or refractory neuroblastoma with a pathway-directed metronomic combination of a multkinase inhibitor and an mTOR inhibitor can improve progression-free survival and overall survival. This exclusive efficacy in MYCN-amplified, relapsed neuroblastoma warrants further investigation in the first-line setting. Deutsche Krebshilfe.

HGG-19. H3- AND IDH-WILDTYPE DIFFUSE PAEDIATRIC-TYPE HIGH-GRADE GLIOMA WITHMYCN-AMPLIFICATION: AN INDICATION CRITERION FOR LI-FRAUMENI SYNDROME TESTING

Abstract BACKGROUND: In the current World Health Organization (WHO) Classification of Tumors of the Central Nervous System (CNS) (5th edition), the introduction of a molecular layer to the integrated diagnosis not only helps to characterize and prognosticate paediatric CNS tumors but the molecular alteration may predict a potential therapeutic option with a targeted agent. Furthermore, certain gene alterations may be a presage of germline alterations or cancer predisposition syndromes, portending significant implications to the index patients and their families. We report a 5-year-old boy diagnosed with non-metastatic left hemispheric H3-wildtype and IDH-wildtype diffuse paediatric-type high-grade glioma with MYCN-amplification, who was subsequently found to have Li-Fraumeni syndrome. He presented with a 3-day history of facial asymmetry, unsteady gait and right sided weakness. There was no family history of malignancy. Initial MRI revealed a restricting and enhancing solid cystic lesion (5.9 x 4.3 x 5.8cm) in the left frontal-temporal-parietal region. Tumor debulking was performed. Histopathological examination by the local pathologist revealed features of high-grade glioma. Second pathology review with next generation sequencing confirmed H3-wildtype and IDH-wildtype diffuse paediatric-type high-grade glioma with MYCN-amplification and TP53 p.Y103* mutation. He was started on focal radiotherapy and oral temozolomide but succumbed to local and metastatic progressive disease. After genetic counselling, his DNA extracted from blood was sent for targeted exome sequencing and germline mutation of TP53 was demonstrated. Cascade screening of the family members were negative of TP53 mutation. Guerrini-Rousseau et al reported that 57% (n=7) of H3-wildtype and IDH-wildtype diffuse paediatric-type high-grade glioma with MYCN-amplification harboured germline TP53 pathogenic variants. This case further highlights the importance of screening of Li-Fraumeni syndrome in patient with H3-wildtype and IDH-wildtype diffuse paediatric-type high-grade glioma with MYCN-amplification even in the absence of a family history.

HGG-09. CONTRASTING CLINICAL COURSES OF THREE PEDIATRIC PATIENTS WITH PDGFRA AMPLIFIED RADIATION-INDUCED HIGH-GRADE GLIOMA

Abstract BACKGROUND Radiation-induced gliomas (RIG) can occur in 3% of patients receiving cranial radiation. Often, these gliomas are high-grade, treatment refractory, and share common molecular profiles like PDGFRA amplification, regardless of their previous malignant origin. Despite similar genetic alterations, the clinical course of these tumors is varied and not well-studied. Herein, we describe three patients with a PDGRFA-amplified RIG with a particular focus on their contrasting disease course. CASE DESCRIPTION: Our first patient is a now-deceased male diagnosed with medulloblastoma at 5 years of age, treated with surgical resection and craniospinal radiation followed by chemotherapy per COG ACNS0332. Ten years later, he was diagnosed with diffuse pediatric type high-grade-glioma (HGG) in the pons with PDGFA, KIT, MTAP amplification, and CDKN2A/B loss. His condition deteriorated quickly, and he succumbed to his disease in 8 weeks after family decided against further therapies. Our second patient is a now 20-year-old female, initially diagnosed with a craniopharyngioma at 6 years of age and treated with surgical resection and adjuvant radiation therapy. Eleven years later, she developed a diffuse pediatric type HGG in the pons with PDGFRA, MDM2, and MYCN amplification. She was treated with radiation therapy and has had stable disease on serial imaging for 3 years. Our third patient is a now-deceased male diagnosed with a right temporal melanotic neuroectodermal tumor at 5 years of age, treated with surgical resection and craniospinal radiation followed by chemotherapy per POG99701. Fifteen years later, he developed a diffuse pediatric-type HGG in the cerebellum/pons with PDGRFA amplification. He was treated with proton radiation and concurrent oral Temozolomide per COG ACNS0423. His disease progressed on treatment, and he died prior to initiation of a PDGFRA kinase inhibitor (avapritinib). CONCLUSIONS Further investigation into the underlying factors that drive the differing disease course in patients with RIG is needed.

Diffuse midline gliomas in children: Does changing strategies change results?

10045 Background: The prognosis of children with diffuse intrinsic pontine gliomas (DIPG)/diffuse midline glioma (DMG) is dismal. Radiotherapy (RT) is considered the standard of treatment. We previously published results of our center, where patients receiving temozolomide or other chemotherapy after radiotherapy (RT) had a better survival than those receiving RT alone (1). This study aims to evaluate a larger cohort of children with DMG in a single center. Methods: We retrospectively reviewed demographic, clinical characteristics and treatment outcome of children with DMG diagnosed and treated at Istanbul University, Oncology Institute between Feb1999-Feb 2023. We compared the groups that received only radiotherapy (Group 1, only RT, n=19), the ones that received RT with concomitant and adjuvant temozolomide po (Group 2-n= 38 TMZ 75 mg/m2/day for 6 weeks concomitant (c.) with RT, followed by TMZ (200 mg/m2/day) for 5 days every 28 days until progression or for 12 cycles), and the ones that received RT with c. TMZ, followed by other systemic agents (Group 3 n= 18 RT c.TMZ, followed by nimotuzumab containing regimens; Group 4 the rest 26 received other agents such as bevacizumab, CCNU, ONC201 and other). The ones that progressed on group 2, received nimotuzumab containing or other regimens. Results: 114 children (49 female, 65 male) with a mean age of 7± 4 years (6 months-16 years) were analyzed. The most frequent clinical findings were ataxia, strabismus and motor weakness. 108 had diffuse intrinsic pontine gliomas (DIPG). In total 106 patients received RT, 54-60 Gy to the tumor site. The overall survival (OS) in all patients at 2 years, 3 years and 5 years were 25.6%,15% and 11.5% respectively. The 2 years, 3 years and 5 years OS in group1 were 0.79%, 0% ,0% respectively; in group 2 they were 38.4%, 27.9%, 16%respectively ; in group 3 they were 17.6% , 0 % ,0% respectively, in Group 4 they were 10.3%, 0.34%, 0% respectively, The OS in Group 2 or3 or 4 were significantly higher than group 1 (only RT) (P =0.002, p=0.004, p<0.001,respectively). There was no major side effect due to TMZ, nor nimotuzumab. Seven patients were re-irradiated at progression. The number of patients undergoing biopsies and molecular testing increased to 50% of the patients after 2016 versus only in two patients previously. Conclusions: In our series, the overall survival was significantly superior in patients who received RT with concurrent and adjuvant temozolomide and/or adjuvant nimotuzumab containing regimens or other adjuvant systemic treatment in comparison to patients that received RT alone, suggesting that adding systemic treatment after RT (poTMZ or iv nimotuzumab containing regimens or other) may help extend survival. Oral temozolomide may be easier to use as first line treatment after radiotherapy especially in resource limited settings, switching to nimotuzumab containing or other chemotherapy and/or re-radiotherapy at progression. 1. Kebudi R, 2013.

Abstract LB155: Intra-cranial administration of MTL-004, a promising post-resection treatment for glioblastoma

Abstract Objectives Gliomas (GBM), are exceptionally hard to treat, aggressive and genetically heterogeneous tumors. This study reports the control of tumor recurrence and improved survival in male and female rats by combining a single intra-cranial dose of MTL-004 (5-(aziridine-1- yl)-4 hydroxylamino-2-nitrobenzamide), in a bioresorbable paste (a blend of poly DL-lactic acid-co-glycolic acid; (PLGA) and poly ethylene glycol; (PEG)) to surgical resection of primary glioma tumors. Comparison is made with oral temozolomide (TMZ), the current standard of care (SOC), following resection. Experimental procedures On day 0, 2 mm3 tumor fragments were implanted into the brains of healthy female and male Fischer rats. On day 5 rats the growing tumors were removed using microsurgery. Treatments started as follows: •Group 1 (Placebo) received a single intracranial dose of excipient powder in PGLA/PEG paste; •Group 2 (SOC) received 5 daily oral doses of TMZ at 50 mg/kg; •Group 3 (MTL-004) received a single intracranial dose of excipient powder containing 1 mg/kg MTL-004 in PGLA/PEG paste. Results Body Weight Between day 0 and 5, no groups had statistically significant body weight changes. Between days 5 to 9, mean body weight of rats receiving TMZ was significantly reduced. Tumor Volumes Tumor volumes from MRI were evaluated when at least 80% of rats were still alive in each group (day 14 post tumor resection/treatment initiation). Mean tumor volume was significantly higher in the placebo groups compared to MTL-004 and TMZ treatments. Survival Rats were studied for 58-days post tumor resection/treatment. At this time out of twelve rats per group, none or one survived on TMZ, two or no animals were still alive on placebo, and seven or ten rats treated with MTL-004 were still alive (male or female respectively). Post resection median survival time was between 20.5 to 27.5 days for rats treated with oral placebo or TMZ. Rats treated with MTL-004 had a significantly higher survival compared to both placebo and TMZ groups and remained in apparent good health for the 58 days of the study. Conclusions Consistent trends were observed in each group of male and female rats following tumor resection. •PGLA/PEG paste with MTL-004 or without (placebo) or were both well tolerated. •Treatment with MTL-004 in PGLA/PEG paste provided good tumor control, was better tolerated and led to significantly greater survival than oral TMZ or placebo. •Oral TMZ (SOC) provided control of tumor volume but was associated with significant, transient body weight losses and no significant survival gain compared to placebo. Our data highlight significant survival benefits associated with a single intracranial dose of MTL-004 with PLGA/PEG paste post-surgery. In conclusion, surgery followed by MTL-004 in PGLA/PEG paste is a well-tolerated and promising treatment for glioblastoma, suitable for clinical evaluation. Citation Format: Mike Hudson, Sylvie Maubant, Elisabeth Bertrand, Marie Lux, Jordan Longin, Elodie Marie Dit Chatel, Maxime Ramelet, Olivier Duchamp. Intra-cranial administration of MTL-004, a promising post-resection treatment for glioblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB155.

Spinal and cervical nodal metastases in apatient with glioblastoma.

This article presents the rare case of a54-year-old gentleman with primary glioblastoma developing multiple extracranial metastases 7months after diagnosis. Initially, the patient complained of progressive headaches, confusion, and weakness of the left arm. Magnetic resonance imaging of the brain showed aright temporoparietal tumor with substantial surrounding subcortical edema and midline shift to the left. Two consecutive craniotomies resulted in complete microsurgical resection of the lesion. Histology was consistent with aWorld Health Organization gradeIV, IDH-wildtype glioblastoma. Further treatment was standard chemoradiation including intensity-modulated radiotherapy with oral temozolomide chemotherapy. Seven months after diagnosis, the cranial lesion progressed, and the patient developed painful metastases in multiple bones and suspicious right-sided cervical lymph nodes. Immunohistochemistry and molecular signature supported the case of ametastatic glioblastoma. Further treatment was palliative radiotherapy of the spinal lesions along with symptomatic pain management. Extracranial metastasis of glioblastoma is arare complication of which only afew cases have been reported in the literature. Little is known about the precise mechanisms of tumor dissemination and the appropriate treatment.

Adjuvant Wilms’ tumour 1-specific dendritic cell immunotherapy complementing conventional therapy for paediatric patients with high-grade glioma and diffuse intrinsic pontine glioma: protocol of a monocentric phase I/II clinical trial in Belgium

IntroductionDiffuse intrinsic pontine glioma (DIPG) and paediatric high-grade glioma (pHGG) are aggressive glial tumours, for which conventional treatment modalities fall short. Dendritic cell (DC)-based immunotherapy is being investigated as a...

Effective re-induction regimen for children with recurrent medulloblastoma.

There is no standard treatment for the recurrence of medulloblastoma, the most common malignant childhood brain tumor, and prognosis remains dismal. In this study, we introduce a regimen that is well-tolerated and effective at inducing remission. The primary objectives of this study were to assess tolerability of the regimen and overall response rate (ORR). A retrospective chart review of patients with recurrent medulloblastoma, treated at two institutions with a re-induction regimen of intravenous irinotecan and cyclophosphamide with oral temozolomide and etoposide, was performed. Demographic, clinicopathologic, toxicity, and response data were collected and analyzed. Nine patients were identified. Median age was 5.75 years. Therapy was well-tolerated with no therapy-limiting toxicities and no toxic deaths. Successful stem cell collection was achieved in all 5 patients in whom it was attempted. ORR after 2 cycles was 78%. Three patients had a complete response, 4 patients had a partial response, 1 patient had stable disease, and 1 patient had progressive disease. Four patients are alive with no evidence of disease (NED), 2 patients are alive with disease, 2 patients have died of disease, and 1 patient died of toxicity related to additional therapy (NED at time of death). This regimen is well-tolerated and effective. Tumor response was noted in the majority of cases, allowing patients to proceed to additional treatment with no or minimal disease. Further study of this regimen in a clinical trial setting is an important next step.

Dispensing Oral Temozolomide in Children: Precision and Stability of a Novel and Ready to Use Liquid Formulation in Comparison with Capsule Derived Mixtures.

Temozolomide (TMZ) is part of the therapeutic armamentarium used in managing pediatric cancers; however, available oral forms (capsules) are not adapted for use in children. Our aim was to assess the dose accuracy and stability of TMZ using capsule contents mixed with food compared with a novel, ready-to-use liquid formulation specifically developed for children (Ped-TMZ, brand name KIZFIZO). Dose accuracy and TMZ stability testing were performed with TMZ capsule contents (90 mg) mixed with food vehicles (apple juice, apple sauce, cream, milk, and mashed potatoes) and compared to an equivalent dose of Ped-TMZ. Acceptance criteria were predefined for TMZ (95.0-105.0%) and its degradation product amino-imidazole-carboxamide (AIC; <1%) content. The delivered dose was significantly higher using Ped-TMZ (96.6 ± 1.2%) and within the predefined criteria for TMZ content, whereas it was systematically under the lower specifications of 95% using capsule-derived preparations with apple juice (91.0 ± 1.5%) and apple sauce (91.6 ± 1.4%), respectively (p < 0.0001). In chemical stability tests, the four food vehicles (apple sauce, cream, milk, mashed potatoes) had a significant effect on TMZ stability (p = 0.0042), and the AIC significantly increased with time in three of the four vehicles (p < 0.0001). Only 1/72 of preparations from capsules met the predefined acceptance criteria, whereas Ped-TMZ showed no TMZ loss, and the AIC remained within specifications. In conclusion, mixing TMZ capsule content with food may result in significant underexposure, possibly even greater in routine practice, as complete food intake by the child is unlikely.

The Mini-Teddi-R Treatment Demonstrated a High Rate of Remission in Patients with DLBCL Involving the CNS Who Had Previously Been Exposed to BTK Inhibitors

Background: Secondary CNS B-cell lymphomas (SCNSL) are aggressive lymphomas with a bleak prognosis. TEDDI-R has been successful in achieving lasting remission in relapsed/refractory primary DLBCL of the CNS (PCNSL), but the effectiveness of ibrutinib-responsive tumors in SCNSL remains unknown. This study presents initial findings from the use of mini-TEDDi-R in SCNSL. Methods: Efficacy and safety data of mini-TEDDi-R were retrospectively analyzed for patients with DLBCL involving the CNS. All patients experienced relapse in the CNS or/and peripheral region after initial therapy. Brain parenchyma involvement allowed for treatment with MTX, Ara-c, and/or BTK inhibitors. The dosage of the drugs used in the original regimen was reduced, leading to the adoption of the term “mini-TEDDi-R.” Each 21-day cycle involved the following treatments: intravenous rituximab at a dose of 375 mg/m 2/day on days 1-2, oral temozolomide at a dose of 150 mg/m 2/day on days 2-5, intravenous infusion of 30 mg/m 2/day etoposide on days 2-5, intravenous infusion of 25 mg/m 2 of pegylated liposomal doxorubicin on day 2, intravenous infusion of dexamethasone at a dose of 10 mg/m 2/BID on days 1-5, and oral zanubrutinib at a dose of 200mg/BID or oral orelabrutinib at a dose of 150mg/qd or oral ibrutinib at a dose of 560mg/qd from day 1 until neutrophil count &amp;lt;0.5*10^9/L or platelet count &amp;lt;30*10^9/L. Additionally, intrathecal administration of 70 mg of cytarabine occurred on days 1 and 5, All remissions observed on MRI were confirmed through FDG-PET and CSF analysis. Results: Between December 2019 and June 2023, 24 patients with a median age of 53 (range 28-69) received mini-TEDDi-R treatment. All patients had DLBCL, comprising 16 (66.7%) non-GCB, 6 (25%) GCB, and 2 (8.3%) transformed from FL. All patients experienced relapse in the CNS system after a median of 6 (range 1-17) prior therapies, and all (100%) patients received prior anthracycline treatment. A total of 21 patients (87.5%) had received multiple lines of therapy before mini-TEDDi-R. Among them, 19 patients (79.2%) had received HD-MTX based salvage therapy, 11 patients (45.8%) had received HD-Ara-c based salvage therapy, and 14 patients (58.3%) had been exposed to BTK inhibitors. Seven patients (29.2%) showed triple resistance to MTX, Ara-c, and BTK inhibitors. Six patients had previously undergone transplantation, and four patients had experienced failure of CD19 CART treatment. Thirteen patients (54.2%) had isolated CNS disease, while 11 patients (45.8%) had both CNS and peripheral disease. Thirteen patients (54.2%) underwent 1 cycle of mini-TEDDi-R, 8 patients (33.3%) completed 2 cycles, 2 patients (8.3%) finished 3 cycles, and 1 patient (4.2%) completed 4 cycles. The objective remission rate (ORR) was determined to be 70.8%, with a complete remission (CR) rate of 58.3%. Notably, patients (N=14) exposed to BTK inhibitors previously exhibited a similar CR rate compared to patients (N=10) who had not received prior BTK inhibitor treatment (50% vs. 70%, p = 0.348). Patients (N=19) who had undergone HD-MTX based salvage therapy achieved an ORR of 74% and a CR rate of 58%. No significant difference in response rate was observed between patients with peripheral and non-peripheral secondary CNS involvement. In patients who achieved complete remission, only one patient experienced a second CNS relapse. Four patients bridged to auto-HSCT, 2 patients bridged to CART treatment, and 4 patients underwent auto-HSCT combined with CART treatment for consolidation. The median overall survival and median PFS have not been reached within the 11.8-month follow-up period. Toxicity was evaluated over 39 cycles. Grade 3 and 4 neutropenia occurred in 51% and 16% of cycles, respectively, while febrile neutropenia was observed in 10% of cycles. The median duration of neutropenia was 6 days (range 4-10). Three cycles (8%) were complicated by infections graded as ≥G3, but no opportunistic infections (including Aspergillus) were observed. Grade 3 and 4 thrombocytopenia occurred in 26% and 14% of cycles, respectively. The median duration of neutropenia was 7 days (range 3-14). Conclusions: The mini-TEDDi-R regimen demonstrated a favorable remission rate in patients with DLBCL involving the CNS. The treatment was well-tolerated, and patients with tumors that were previously exposed to BTK inhibitors and HD-MTX treatment also showed positive responses to mini-TEDDi-R.

A Multicenter Randomized Bioequivalence Study of a Novel Ready-to-Use Temozolomide Oral Suspension vs. Temozolomide Capsules.

Temozolomide (TMZ) oral suspension (Ped-TMZ, KIZFIZO®) is being developed for the treatment of relapsed or refractory neuroblastoma, a rare cancer affecting infants and young children. The study assessed the safety and the bioequivalence of this novel pediatric formulation with existing TMZ oral capsules. In vitro dissolution profiles and the bioequivalence were evaluated following the European Medicines Agency "Guidelines on the investigation of Bioequivalence". The phase I, multicenter, randomized, open-label, crossover, single-dose bioequivalence study enrolled 36 adult patients with glioblastoma multiforme or lower-grade glioma. Each patient received 200 mg/m2 Ped-TMZ suspension and TMZ capsules (Temodal®) on 2 consecutive days, with the order being randomly assigned. Fourteen blood samples were collected up to 10 h post-dosing. Bioequivalence was assessed by comparing the 90% confidence interval for the ratio of the geometric means of maximum TMZ plasma concentration (Cmax) and the area under the curve (AUCt). Other endpoints included further pharmacokinetic parameters and safety. Both formulations exhibited a fast in vitro dissolution profile with more than 85% of TMZ dissolved within 15 min. For the bioequivalence study, thirty patients completed the trial as per the protocol. The ratio of Ped-TMZ/TMZ capsule geometric means (90% CI) for AUCt and Cmax were 97.18% (95.05-99.35%) and 107.62% (98.07-118.09%), respectively, i.e., within the 80-125% bioequivalence limits. No buccal toxicity was associated with Ped-TMZ liquid formulation. This study showed that Ped-TMZ oral suspension and TMZ oral capsule treatment are immediate release and bioequivalent medicines. There were also no unexpected safety signals or local toxicity (funded by ORPHELIA Pharma; ClinicalTrials.gov number, NCT04467346).

BIOM-28. PROGNOSTIC BIOMARKERS IN GLIOBLASTOMA PATIENTS TREATED WITH TEMOZOLOMIDE

Abstract OBJECTIVE Identifying blood biomarkers that predict favorable outcomes for patients with glioblastoma treated with temozolomide (TMZ). BACKGROUND Glioblastoma is the most aggressive primary brain tumor. The standard of care is maximum safe resection, then radiation plus oral TMZ, followed by six months of cyclic oral TMZ. Previous studies have revealed that TMZ-induced myelosuppression is associated with improved overall survival. METHODS Adults with glioblastoma who completed radiation therapy and received temozolomide for at least 6-months at Beth Israel Deaconess Medical Center between 2018-2021 were identified. Baseline and nadir white blood cell count, absolute neutrophil count, absolute lymphocyte count, red blood cells, and platelets were collected retrospectively. Additionally, IDH1 R132H, MGMT promoter methylation, progression free survival (PFS), and overall survival (OS) were also collected retrospectively. Data was combined with that of Vaios et al. and Ho et al. Kaplan-Meier analysis and multivariate testing were performed. RESULTS Leukopenia is associated with increased overall survival (p = 0.008) and progression free status (p = 0.02). Grade 3 thrombocytopenia is associated with decreased PFS (p = 0.0005) and OS (p = 0.0006). Grade 1 &amp; 2 lymphopenia is associated with increased progression free survival (p = 0.01 and p = 0.03). Lower baseline absolute lymphocyte count is associated with improved OS (p = 0.007). Higher baseline absolute neutrophil count is associated with worse OS (p = 0.002). CONCLUSION Cytopenia may serve as a prognostic biomarker for OS and PFS. Leukopenia may reflect adequate temozolomide dosing, anti-tumor activity, or changes in the tumor micro-environment. Peripheral biomarker monitoring may improve prognostic stratification and lead to personalized treatment with improved outcomes.

FRI337 Progressive Suprasellar Chordoid Glioma Presenting With Panhypopituitarism, Diabetes Insipidus And Encephalopathy

Abstract Disclosure: J.D. Gatillo: None. M.D. Maningat-Goco: None. F.K. Co: None. Chordoid glioma is a rare central nervous system neoplasm of uncertain origin, with most cases seen at anterior wall or roof of the third ventricle. It is described as a perplexing lesion as it tends to mimic benign lesions at the onset but eventually some develop with threatening complications. We present a case of a 39 year old Filipino, female, who initially presented with a 1- year history of memory lapses, behavioral changes, and blurring of vision. MRI showed 4.3 x 3 x 4.2 cm heterogeneously enhancing suprasellar mass and was initially worked-up as pituitary macroadenoma. The imaging also showed heterogeneously enhancing extra-axial lesion along the right anteromedial temporal convexity. She underwent pterional craniotomy and sub temporal craniectomy with excision biopsy of tumor. Histopathology confirmed the diagnosis of chordoid glioma WHO Grade 2. However, only a few days after the surgery, she began to experience emotional lability and more behavioral changes. She then received oral Temozolomide for 4 cycles and whole brain radiotherapy for 32 cycles. Approximately 10 months since diagnosis was made, patient eventually developed seizures and manifested progressive drowsiness and generalized weakness. Patient was diagnosed and clinically presented with Panhypopituitarism and Diabetes Insipidus. She was maintained on levothyroxine, prednisone and desmopressin. A repeat MRI was done which showed apparent progression in the size (4.6 x 3.7 x 4.1 cm) of the heterogeneously enhancing suprasellar mass with signs of tumor infiltration and extension in the left lateral ventricle. Further, patient was treated with Bevacizumab and Nimotuzumab. Repeat MRI showed regression in size of the known suprasellar mass and improvement of symptoms. Little is still known about chordoid gliomas especially in the Asian population - their initial presentation as well as the best diagnostic approach and treatment strategy for this elusive disease. There is no formally recognized treatment protocol for chordoid glioma, and postoperative mortality and morbidity is high. More case reports are needed in order to ascertain the best diagnostic and treatment strategy for patients with chordoid glioma and its endocrine complications. Presentation: Friday, June 16, 2023

HGG-28. INTERIM ANALYSIS OF THE GCC1949 PHASE 2 TRIAL USING INDOXIMOD-BASED CHEMO-IMMUNOTHERAPY FOR PATIENTS WITH PEDIATRIC BRAIN TUMORS

Abstract Brain tumors are the leading cause of cancer-related death in children. We report interim results of an ongoing multi-institutional phase 2 trial (NCT04049669) of the IDO pathway-inhibitor indoximod utilized in a chemo-immunotherapy regimen for patients 3-21 years of age with either recurrent malignant brain cancer or newly-diagnosed diffuse intrinsic pontine glioma (DIPG). Patients are treated with oral indoximod (38.4 mg/kg/day, divided BID) plus oral temozolomide (200 mg/m2/day for 5 days) in 28-day cycles. Patients for whom radiation therapy is planned as standard-of-care receive indoximod during the up-front radiation regimen. During treatment, palliative radiation, surgery, or dexamethasone are allowed as needed for clinical management. To date, 53 patients have been treated. Estimated median follow-up time was 23 months (range 0.2-35.5 months), and indoximod-based therapy was well tolerated. Estimated median overall survival (OS) was 15 months for the entire mixed population (n= 53, 95%-C.I. 11.5-23.2 months); 23.8 months for recurrent ependymoma (n=26); 13.5 months for recurrent medulloblastoma (n=12); 5.8 months for recurrent glioblastoma/diffuse midline glioma (GBM/DMG, n=9, excludes DIPG); and 9.6 months for newly-diagnosed DIPG (n=6). For the 39 response-evaluable patients to date (those with measurable disease and at least one follow-up MRI on-therapy), objective response in any single lesion by pediatric RANO criteria occurred in 20/39 patients (9/17 ependymoma, 9/11 medulloblastoma, 0/6 GBM/DMG, 2/5 DIPG). Lesion response was associated with significantly better overall survival (estimated median OS 23.2 months, n=20) compared to patients without lesion response (median OS 6.6 months, n=19) (p=0.0005). Single-cell RNA sequencing of serial peripheral blood samples allowed identification of expanded T cell clones, which was correlated with survival. Updated results from the first 53 patients will be presented. These data are replicating results of the preceding phase 1 study (NCT02502708) and provide preliminary evidence of anti-tumor activity in pediatric brain tumors.

Phase I/IIa study of concomitant radiotherapy with olaparib and temozolomide in unresectable high grade glioma patients: OLA-TMZ-RTE-01.

2046 Background: Although the Stupp protocol (radiotherapy + temozolomide (TMZ)) remains the mainstay of glioblastoma (GBM) first line treatment after extended surgery, the prognosis is still poor. PARP inhibitors, such as olaparib, may improve GBM outcomes by enhancing cytotoxic effects of ionizing radiation and TMZ. The non-dividing nature of normal brain cells allows a dedicated tumor radiosensitization. We implemented a phase I/IIa trial to assess safety and efficacy of olaparib combined with TMZ concomitant with intensity modulated radiotherapy (IMRT) as a first line treatment in unresectable GBM patients (pts). We herein present results of the phase I step. Methods: Based on the Stupp protocol, 2 treatment periods were considered. The radiotherapy period (RT) occurs after surgery: pts received IMRT (60 Gy/30 fractions/6 wks), oral TMZ (75 mg/m²) during IMRT, and olaparib orally given at the same dose until 4 wks after the end of IMRT. For the maintenance period (MT) from 4 wks after IMRT, pts received TMZ (150 mg/m², days (D) 1-5 every 28 days, for 6 cycles) plus olaparib at the MT dose level up to disease progression or unacceptable toxicity. The phase I included 2 sequential dose escalations (DE1, DE2) of olaparib to split both periods for DLT (Dose Limiting Toxicities) assessment. Olaparib dose levels (DL) were: 50 mg Q12H D 1-3 (DL1), 100 mg Q12H D1-3 (DL2) or D1-5 (DL3), 200 mg Q12H D1-3 (DL4) or D1-5 (DL5) or 200 mg Q12H continuously (DL6). Pts in DE1 received olaparib only during RT to determine the MTD1 (Maximum-Tolerated Dose), by assessing DLT on this period. Next, after olaparib administered at MTD1 during RT, pts in DE2 received olaparib during MT to determine MTD2 (≤MTD1) during the MT period, assessing DLT from the first 2 cycles. DE1 and DE2 were performed by a TITE-CRM (TIme-To-Event Continual Reassessment Method). Results: From 2017 to 2021, 30 pts were enrolled: 20 (67%) men, median age 59 yrs [range 25-70]. 16 and 11 pts were assessable for determining MTD1 and MTD2, respectively. In DE1, 2 pts received olaparib at DL1, 6 at DL2, 6 at DL3, 1 at DL4 and 1 at DL5. 4 pts observed DLT (3 at DL3, 1 at DL5): thrombocytopenia G3-4 (n=4) + neutropenia G4 (n=2). MTD1 was defined as DL2 with estimated probability of DLT of 22.1% [95%CI 8-40.5]. In DE2, 2 pts were treated at DL1, 9 at DL2. 1 pt observed DLT at DL2: thrombocytopenia G4. MTD2 was defined as DL2 with estimated probability of DLT of 13.3% [0.2-0.35]. No interruption of IMRT for toxicity was observed. Excepted DLT, permanent olaparib discontinuation for toxicity was observed in 1 pt during RT and 2 pts during MT. Toxicity induced temporary TMZ interruption in 4 pts, none with permanent discontinuation. No toxic death was observed. Conclusions: Olaparib 100 mg Q12H D1-3 in concomitant with the Stupp protocol has an acceptable safety profile in unresectable GBM pts: it warrants efficacy determination, in the ongoing phase IIa step. Clinical trial information: NCT03212742 .

Prognostic Markers in Glioblastoma Patients Treated with Temozolomide (P13-13.002)

<h3>Objective:</h3> To identify biomarkers that are able to predict favorable outcomes for patients with glioblastoma treated with temozolomide (TMZ) <h3>Background:</h3> Glioblastoma is the most aggressive primary brain tumor. The standard of care treatment is maximum safe resection, radiation plus oral temozolomide (TMZ) chemotherapy, followed by six months of cyclic oral TMZ. Treatment-related side effects are common while the 5-year overall survival is less than 10%. Previous studies have reported that TMZ-induced myelosuppression is associated with improved overall survival. <h3>Design/Methods:</h3> Adults with histology-confirmed glioblastoma treated at Beth Israel Deaconess Medical Center from (2017–2018) who had completed both radiation therapy and temozolomide for at least 6 months were identified. Lab values (WBC, ANC, ALC, RBC, PLT), molecular markers (IDH1 R132H, MGMT promoter methylation ), progression free survival (PFS), overall survival (OS) will be collected retrospectively. This data will be combined with published data of 86 cases [Vaios et al.]. <h3>Results:</h3> 60 new patients with glioblastoma were identified and data collected. 32 were included in this study and their data combined with previous data collected from 2012–2017 for a total of 173 patients. Preliminary results according to Kaplan-Meier analysis with a log-rank test confirms that leukopenia is associated with increased survival (p=0.008) and progression free status (p=0.02). <h3>Conclusions:</h3> Decreased white blood cell counts may serve as a peripheral blood biomarker for OS and PFS in glioblastoma patients treated with radiation therapy and TMZ. It is possible that leukopenia reflects adequate temozolomide dosing and anti-tumor activity or reflects changes in the tumor micro-environment. Standardized approaches to peripheral blood monitoring in glioblastoma patients undergoing chemotherapy is likely to improve prognostic stratification and overall survival. <b>Disclosure:</b> Dr. McMillan has nothing to disclose. Dr. Zhang has nothing to disclose. Dr. McGuinness has nothing to disclose. Dr. Trudeau has nothing to disclose. Dr. Uhlmann has nothing to disclose.

Malignant Melanoma of the Anorectal Region: A Case Study and Review of the Contemporary Treatment Options

Aims: Anorectal melanoma, an uncommon malignancy of mucosal origin accounts for 0.05 per cent of all colorectal malignancies and 1 per cent of tumours of the anal canal. The typical clinical presentation includes local pain, palpable mass, bleeding, change in bowel habits, and weight loss. The symptoms are somewhat nondescript and unremarkable and can be easily confused with other conditions native to the region. Hence, a careful and timely assessment is imperative in treating this condition.&#x0D; Presentation of Case: A case involving a 54-year-old male who presented with a 3-month history of rectal bleeding and pain. Further assessment revealed a malignant melanoma of the anal canal. After undergoing laparoscopic abdominoperineal resection, the patient was on 6 cycles of dacarbazine. He was subsequently found to have liver metastasis. He subsequently started oral Temozolomide for 2 cycles. He has been on close follow-up for the last 6 months and the disease has not progressed since.&#x0D; Discussion: The course of evaluation in suspected cases of anorectal melanoma is a rectal examination, biopsy and histopathologic examination. Immunohistochemistry aids in the confirmation of the diagnosis. Laparoscopic abdominoperineal resection demonstrates good response rates. Adjuvant chemotherapy in anorectal melanoma can be given in patients following surgical resection of the primary anorectal tumour and with a high risk of recurrence. Targeted therapies like c-kit inhibitors, BRAF inhibitors, anti- CTLA-4 antibodies and anti-PD-1 antibodies can also be used.&#x0D; Conclusion: Melanomas of the anorectal region present a diagnostic dilemma and carry poor prognoses. Despite an aggressive management approach, the disease maintains an average five-year survival rate of 20%.

INNV-05. CO-OCCURRENCES OF A HIGH-GRADE GLIOMA WITH CAVERNOUS MALFORMATIONS AND PATHOGENIC VARIANTS IN PDCD10 AND SMARCA4

Abstract INTRODUCTION The co-occurrence of multiple disease processes can make for more challenging diagnoses. Here we report an unusual case of a patient found to have an IDH1-mutant high-grade glioma along with multiple cerebral cavernous malformations and pathogenic germline variants in PDCD10 and SMARCA4. Case Description: A 17-year-old female presented with left arm paresthesia and weakness along with persistent headaches within the frontal and occipital regions that progressed in intensity to include nausea and emesis. A fast sequence magnetic resonance imaging (MRI) of her head was obtained that revealed the presence of multiple bilateral cystic lesions suspicious for cavernomas with the most notable lesion in the right parietal lobe. Ophthalmology consultation revealed grade III papilledema bilaterally. A full brain MRI with and without contrast was obtained and demonstrated a right anterior parietal lobe lesion with associated mass effect, as well as multiple bilateral supratentorial and left cerebellar cavernous malformations. The patient underwent tumor debulking of her dominant lesion. Pathology revealed an IDH1 mutant diffuse astrocytoma, WHO grade 3. Germline genetic testing was pursued which revealed a PDCD10 pathogenic variant consistent with familial cerebral cavernous malformation syndrome and a likely pathogenic variant in SMARCA4. Treatment of her high-grade-glioma included radiation therapy followed by maintenance oral temozolomide. DISCUSSION This case illustrates the unusual co-occurrences of a high-grade glioma with familial cavernous malformation syndrome and germline pathogenic variants in PDCD10 and SMARCA4. Our patient continues to do well clinically, but because of her now significant risk of developing ovarian cancer she has elected to undergo a prophylactic bilateral salpingo-oophorectomy. Recognition of abnormal genetic results is critical in the setting of multiple disease processes and can play a crucial role in the on-going care for a patient.

Efficacy and Safety of Lanreotide Autogel and Temozolomide Combination Therapy in Progressive Thoracic Neuroendocrine Tumors (Carcinoid): Results from the Phase 2 ATLANT Study

Introduction: Lanreotide autogel (LAN) and temozolomide (TMZ) are guidelines-recommended monotherapies for thoracic neuroendocrine tumors (carcinoids; T-NETs), but prospective data for both combined and monotherapies are lacking. ATLANT (NCT02698410) evaluated efficacy and safety of LAN/TMZ in progressive T-NETs. Methods: ATLANT was a 12-month, Italian, phase 2, single-arm, open-label, multicenter pilot study. Eligible patients had unresectable, locally advanced/metastatic, well-/moderately differentiated T-NETs with radiological progression. Patients received subcutaneous LAN 120 mg every 28 days and oral TMZ 250 mg/day for 5 consecutive days every 28-day cycle. Main endpoints are disease control rate (DCR) at 9 months (primary; investigator-assessed), median progression-free survival (PFS), biomarkers, and safety. Results: The number of patients was 40; 60% were male. Primary tumor site was lung (90%) and thymus (10%). Carcinoid type was typical (20.0%) and atypical (52.5%). DCR at 9 months was 35.0% (95% confidence interval (CI) 20.63–51.68; nonacceptability threshold ≤10%, p < 0.0001; not significantly above clinically relevant threshold ≥30%, p = 0.2968). DCR between 7.5 and 10.5 months (sensitivity analysis) was 45.0% (95% CI: 29.26–61.51) and clinically relevant (p = 0.0320 at ≥30% threshold). Median PFS was 37.1 (95% CI: 24.1–52.9) weeks. No association was observed between biomarker variations (chromogranin A, neuron-specific enolase, somatostatin receptor type-2, Ki-67, 6-O-methylguanine-DNA-methyl-transferase) and DCR or PFS. Most patients (97.5%) had treatment-emergent adverse events (TEAEs); 72.5% had treatment-related TEAEs. TEAEs were mainly grade 1/2. No unanticipated TEAEs were reported. Conclusions: This study showed that the LAN/TMZ combination has promising efficacy in progressive T-NETs, and was well tolerated. Larger studies are warranted to support the clinical benefits of LAN/TMZ in patients with T-NETs.