Clinical Investigation of Sonodynamic Therapy in Conjunction With Chemoradiotherapy for Glioblastoma Management
Phase: PHASE2
Conditions: Glioblastoma (GBM)
Sponsor: Yingjuan Zheng

Sonodynamic Therapy Combined with Chemoradiotherapy 
for Glioblastoma: Clinical Study  
1. Study Protocol Summary 
Glioblastoma (GBM) is characterized by its high aggressiveness and 
short survival. Despite ongoing exploration of various treatments, effective 
therapeutic strategies remain elusive. Therefore, we are introducing 
Sonodynamic Therapy (SDT) to potentially offer new hope for glioma 
patients. SDT is a novel therapeutic technique derived from Photodynamic 
Therapy (PDT). Preclinical models have demonstrated promising 
therapeutic effects with SDT. 
Studies in rat glioblastoma models have shown that SDT can 
effectively inhibit tumor growth and metastasis, and extend survival more 
significantly compared to standard temozolomide treatment. Furthermore, 
research both domestically and internationally exploring SDT in 
combination with immunotherapy and nanocarriers has also yielded 
encouraging results. The Harbin Medical University research team 
pioneered the use of SDT in treating patients with atherosclerosis, 
confirming its efficacy and safety in clinical settings. Multiple studies 
indicate synergistic effects between SDT and various tumor treatment 
regimens. 
Preliminary results from our Phase I clinical trial have confirmed the 
safety and efficacy of SDT in treating recurrent glioblastoma. Consequently, 
we plan to conduct a single-center, two-arm, randomized, open-label, Phase 
II clinical trial to evaluate SDT for newly diagnosed glioblastoma. We plan 

to enroll 220 patients with newly diagnosed GBM, randomly assigned to 
either the Experimental Group or the Control Group. 
Experimental Group: Patients will receive SDT plus investigator-
chosen 
treatment 
regimens 
(e.g., 
radiotherapy, 
temozolomide, 
bevacizumab, etc.). 
Control Group: Patients will receive only the investigator-chosen 
treatment regimens. 
Patients will be followed for 24 months, with monthly brain MRI 
scans. Treatment efficacy will be assessed according to the Response 
Assessment in Neuro-Oncology (RANO) criteria. The primary endpoint is 
Progression-Free Survival (PFS). The projected study duration is 
10/01/2024 to 10/01/2028. 
2. Research Background  
  Gliomas are the most common primary brain tumors, accounting for 81% 
of central nervous system malignancies. Glioblastoma (GBM), the highest-
grade glioma, has a dismal prognosis, with a 5-year survival rate of only 2.5-
5% and a median survival time (mOS) of 12-15 months. Post-recurrence, the 
mOS falls to 6.3-7.5 months[1]. Despite advancements in surgery, 
radiotherapy, chemotherapy, and targeted therapies, the overall survival for 
GBM patients has not significantly improved. 
GBM's infiltrative growth pattern, with indistinct margins, makes 
complete surgical resection difficult, leading to high recurrence rates and 
extremely poor outcomes. The postoperative standard Stupp protocol extends 

mOS to 14.6 months[2]. However, even with maximal safe resection followed 
by chemoradiation, the 5-year survival rate remains below 10%. 
The NCCN guidelines recommend surgery as the primary intervention 
for high-grade gliomas, followed by adjuvant involved-field radiotherapy 
with concurrent and adjuvant temozolomide. Standard treatment includes a 
combination of concurrent chemoradiation and adjuvant chemotherapy. 
Tumor Treating Fields (TTFields), a relatively novel anti-cancer therapy 
using low-intensity energy fields to disrupt cancer cell division, showed only 
a 2-month extension in survival in its Phase III trial and is expensive. 
Clinical trials are essential for medical research. After potential new anti-
cancer approaches are developed and tested in laboratories, investigations in 
humans are necessary. If drugs, devices, or treatments prove safe and effective 
in clinical trials, they may receive regulatory approval (e.g., FDA). 
The Chinese guidelines for childhood gliomas[4] state that for low-grade 
gliomas, surgery is first-line treatment. However, resection is often unfeasible 
for tumors involving deep midline supratentorial regions, optic 
pathways/hypothalamus, or brainstem. Extent of resection is a crucial factor 
for prolonging both progression-free survival (PFS) and overall survival (OS). 
Chemotherapy should commence promptly postoperatively, utilizing 
maximally tolerated doses with appropriate durations while monitoring 
toxicity. 
Chemotherapy 
regimens 
should 
be 
selected 
based 
on 
histopathological and molecular pathology findings. Patients should also be 
offered access to relevant and feasible clinical trials. 

For childhood high-grade gliomas (HGG), maximal safe surgical 
resection remains the cornerstone of treatment. The utility of adjuvant 
cytotoxic chemotherapy combined with radiotherapy remains unclear. There 
is no standard chemotherapy regimen, and participation in relevant clinical 
trials is strongly recommended. 
Sonodynamic Therapy (SDT) is a novel technique evolving from 
Photodynamic Therapy (PDT). PDT selectively destroys local tumors while 
sparing normal tissue. Its safety, minimal side effects, and repeatability have 
established it in clinical guidelines for skin, esophageal, biliary tract, and 
bladder cancers, among others[6]. Significant literature demonstrates that 
intraoperative PDT improves glioma outcomes. However, PDT's reliance on 
invasive surgery and the poor tissue penetration depth of light (<1 cm in soft 
tissue) limit its application, particularly for deep-seated tumors[7]. 
 
SDT addresses PDT's limitations by utilizing Low-Intensity, Low-
Frequency Focused Ultrasound (LILFU), which provides superior tissue 
penetration (~10 cm depth). LILFU can non-invasively focus acoustic energy 
deep within tissues to activate sonosensitizing drugs, thereby inducing 
localized anti-tumor effects[8-10]. SDT thus combines PDT-like tumor 
selectivity and efficacy with significant depth penetration capability for 
precise treatment of deeper lesions. It offers targeted tumor destruction with 
minimal damage to normal tissues and has shown demonstrated efficacy with 
low toxicity. 
 

SDT is a rapidly developing, highly promising treatment attracting 
significant research and clinical attention globally. Numerous preclinical 
studies confirm its efficacy against glioblastoma[11-15]. Research indicates 
SDT induces glioblastoma cell necrosis and potentiates the anti-tumor effect 
of temozolomide[16]. Studies using C6 glioblastoma models in mice showed 
SDT significantly inhibits tumor growth rate[17]. 
 
Critically, our Phase I clinical trial results demonstrated the safety and 
efficacy of SDT for recurrent glioblastoma, with significant tumor shrinkage 
observed in some patients. However, the Phase I trial was limited by 
significant patient heterogeneity, small sample size, and underpowered 
statistical analysis. Therefore, a larger Phase II trial is urgently needed to 
robustly validate both the safety and efficacy of SDT for glioblastoma. 
 
In summary, glioblastoma's complex pathogenesis, characterized by 
deep location, infiltrative growth, incomplete surgical resection tolerance, and 
resistance to maximal radiotherapy doses, poses significant therapeutic 
challenges. The absence of truly effective treatments and extremely poor 
prognosis causes immense suffering for patients and families. Identifying safe, 
efficacious, and accessible therapeutic modalities to maximally extend 
survival and improve quality of life remains a critical unmet clinical need. 
 
SDT, emerging from PDT, represents an effective, safe, and non-invasive 
therapeutic technology. Its promising preclinical results in glioma models and 

the encouraging safety/efficacy signals from our Phase I trial justify further 
investigation. To address the limitations of our preliminary Phase I findings 
(heterogeneity, small sample size), we propose this single-center, randomized, 
open-label Phase II clinical trial. This study will further substantiate the 
efficacy and safety profile of SDT in glioblastoma treatment. 
 
The successful clinical translation of SDT holds significant potential 
societal impact by alleviating patient suffering, enhancing quality of life, and 
extending overall survival. 
3. Study Objectives 
• To further substantiate the efficacy and safety of Sonodynamic Therapy 
(SDT) in the treatment of glioblastoma. 
• To identify and characterize any clinical issues associated with SDT 
treatment for glioblastoma. 
4. Study Design 
This study is a single-center, randomized, open-label, Phase II clinical 
trial evaluating the efficacy and safety of SDT in the treatment of glioblastoma. 
The trial plans to enroll 220 subjects with newly diagnosed glioblastoma or 
with residual disease post-surgery. 
Subjects will be stratified based on baseline characteristics such as tumor 
location and size. 
Subjects will be randomized in a 1:1 ratio to either the Experimental 
Group or the Control Group. 
• Experimental Group: Subjects will receive SDT in addition to the 
investigator-chosen treatment regimen (e.g., radiotherapy, 
temozolomide, bevacizumab, etc.). 

• Control Group: Subjects will receive only the investigator-chosen 
treatment regimen. 
5. Study Population 
5.1 Inclusion Criteria 
1. Provision of signed and dated written Informed Consent Form (ICF). 
2. Age < 75 years. 
3. Newly diagnosed glioblastoma patients with pathological 
confirmation post-surgery. 
4. Absence of severe hematopoietic, cardiac, pulmonary, hepatic, renal 
dysfunction, or immunodeficiency. Laboratory values within the 
following limits within the pre-enrollment period: 
• Hematology: White blood cell count ≥ 4.0 x 10⁹/L; Absolute 
neutrophil count ≥ 1.5 x 10⁹/L; Platelets ≥ 100 x 10⁹/L; 
Hemoglobin ≥ 90 g/L. 
• Renal Function: Serum creatinine ≤ 1.2 mg/dL or Calculated 
creatinine clearance (CrCl) ≥ 60 mL/min. 
• Hepatic Function: Total bilirubin ≤ 1.5 x ULN (≤ 3.0 x ULN if 
liver metastases present); Aspartate aminotransferase (AST) and 
Alanine aminotransferase (ALT) ≤ 2.0 x ULN (≤ 5.0 x ULN if 
liver metastases present). 
• Coagulation: International Normalized Ratio (INR) ≤ 2.0; 
Prothrombin Time (PT), Activated Partial Thromboplastin Time 
(aPTT), and Thrombin Time (TT) within normal limits. 
5. Expected survival ≥ 3 months. 
6. Resolution of toxicities from prior anticancer therapy to Grade ≤ 1 
(Common Terminology Criteria for Adverse Events [CTCAE] v5.0), or 
complete recovery from prior surgery (Investigator judgment). 
7. Contraception Requirements: Women of childbearing potential 
(WOCBP) and all male subjects must agree to use highly effective 

contraception (e.g., condom, contraceptive sponge, gel, diaphragm, 
intrauterine device, oral or injectable contraceptives, subdermal implant) 
during the trial and for 12 months after the last dose of the sonosensitizer. 
WOCBP must have a negative pregnancy test within ≤7 days prior to the 
first SDT administration. 
5.2 Exclusion Criteria 
1. Patients with recurrent glioblastoma, brainstem tumors, or prior 
postoperative chemoradiotherapy. 
2. History of hypersensitivity to the 
sonosensitizer (Hematoporphyrin/Xipofin). 
3. Uncontrolled conditions: Active infection, poorly controlled seizures, 
elevated intracranial pressure, hypertension, or hyperglycemia. 
4. Active infection with Human Immunodeficiency Virus (HIV), active 
Hepatitis B Virus infection (HBsAg positive and HBV DNA positive), or 
active Hepatitis C Virus infection (HCV antibody positive). 
5. History of other malignancy within 5 years, except adequately treated 
carcinoma in situ of the cervix, cutaneous squamous cell carcinoma, or 
localized basal cell carcinoma of the skin. 
6. Any other condition that, in the Investigator’s judgment, would 
preclude safe participation in the study or interfere with study 
assessments. 
5.3 Criteria for Exclusion from Efficacy/Safety Analysis  
1. Subjects who fail to meet major protocol requirements such that valid 
assessment of efficacy and/or safety endpoints is precluded. 
5.4 Withdrawal/Termination Criteria 
1. Subject Withdrawal: Subject decides to withdraw consent and 
discontinues participation. 

2. Investigator Decision: The Investigator determines that withdrawal is 
necessary for the subject's best interests (e.g., safety concerns, major 
protocol deviation, intercurrent illness). 
6. Trial Procedures 
• Sonosensitizer: Hematoporphyrin Injection (Xipofin®) 
• Device: Transcranial Ultrasound Therapy Apparatus 
Treatment Schema: 
1. Pre-treatment Evaluation: Upon admission, subjects will undergo pre-
treatment laboratory tests and assessments. A head MRI will be 
performed if not done within the previous month. 
2. Randomization & Stratification: After completing baseline 
evaluations, subjects will be stratified and randomized 1:1 to the 
Experimental or Control Group based on clinical and pathological 
characteristics. 
3. Treatment Allocation: 
• Experimental Group: SDT + Investigator-Chosen Regimen 
(Radiotherapy, TMZ, Bevacizumab, etc.) 
• Control Group: Investigator-Chosen Regimen only. 
4. Investigator-Chosen Treatment Regimen (Example - Standard 
Stupp-like Regimen +/- Bevacizumab): 
• Radiotherapy (RT): Total dose 50-54 Gy in daily fractions of 1.8-
2.0 Gy, delivered 5 times per week over 6 weeks (approximately 
25 fractions). 
• Temozolomide (TMZ): 
o Concurrent with RT: 75 mg/m² orally daily throughout RT 
course. 
o Adjuvant: Starting post-RT, cycles consist of 150 mg/m²/day 
orally for 5 days, followed by 23 days without treatment 

(28-day cycles). Dose may be escalated to 200 mg/m²/day 
for cycles 2-6 if tolerated. 
• Bevacizumab (if included): 7.5-10 mg/kg intravenous infusion 
every 3 weeks for 4 to 6 cycles. 
5. SDT Procedure: 
a. Sonosensitizer Administration: 
* Hematoporphyrin (Xipofin) administered intravenously at 5 mg/kg 
body weight. 
* Adults: Hematoporphyrin administered via percutaneous trans-arterial 
catheterization for locoregional drug perfusion. 
* Place subject in a room with controlled illumination post-
administration. 
b. SDT Treatment Initiation & Setup: 
* Commence SDT approximately 40 hours post-sonosensitizer 
administration. 
* Before SDT, use MRI guidance for precise ultrasound transducer 
placement and tumor targeting. Shave hair in the transducer 
application area(s). c. SDT Parameters: 
* Ultrasound Intensity: 1.0 - 1.25 W/cm² 
* Ultrasound Frequency: 800 kHz - 1 MHz 
* Treatment Duration: 15 minutes per session. 
d. Post-SDT Precautions: Subjects must observe strict light avoidance 
precautions for one month following sonosensitizer administration. e. 
SDT Schedule: Treat subjects twice daily at 24 hours, 48 hours, and 72 
hours after sonosensitizer administration. 
Management of Adverse Events and Treatment Modification: 
Monitor and manage potential adverse reactions including, but not limited to: 
• Systemic Symptoms: Photosensitivity reactions, fatigue, asthenia, fever, 
pain. 
• Skin/Mucosa Symptoms: Rash, ulceration, hemorrhage. 
• Gastrointestinal Symptoms: Diarrhea, nausea, vomiting, anorexia, 
melena. 
• Respiratory Symptoms: Cough, wheezing, hemoptysis, dyspnea. 

• Neurological and Cardiovascular Symptoms: As reported. 
Serious Adverse Reactions (e.g., anaphylaxis, shock): 
• Immediately discontinue sonosensitizer infusion. 
• Initiate prompt anti-allergic and anti-shock management protocols. 
7. Study Endpoints 
7.1 Efficacy Evaluation Endpoints 
• Primary Endpoint: Progression-Free Survival (PFS) 
• Secondary Endpoints: 
1. Overall Survival (OS) 
2. Disease Control Rate (DCR) 
3. Treatment-Emergent Adverse Event (TRAE) Rate 
7.2 Safety Evaluation Endpoints 
• Incidence, severity, and duration of any adverse event (AE). 
• Incidence, severity, and duration of drug-related adverse events. 
8. Data Collection 
8.1 Data Source 
• This study plans to collect data from 50 patients with newly diagnosed 
glioblastoma or with residual disease post-surgery. 
8.2 Data Collection Content 
• Demographics/Baseline Characteristics: Gender, age, height, weight, 
ethnicity, smoking history, alcohol history, allergy history, medical history, 
surgical history. 
• Clinical Diagnosis & Staging: Pre-/post-treatment complete blood count 
(CBC), liver/kidney function tests, tumor location, tumor size, TNM stage 
(if applicable), clinical stage, Eastern Cooperative Oncology Group 

(ECOG) Performance Status or Karnofsky Performance Status (KPS), 
EGFR expression status. Severity of adverse events graded per the World 
Health Organization (WHO) Common Toxicity Criteria for Adverse 
Events (see Appendix 1). 
• Prior Anti-tumor Therapy Information: 
1. Surgery: Procedure name, details. 
2. Radiotherapy: Technique, total radiation dose, treated volume, 
fraction dose, number of fractions. 
3. Chemotherapy: Drug(s), dosage/regimen, number of cycles. 
4. Other relevant anti-tumor therapies. 
• Concomitant Medications/Therapies: Name of therapy/medication, 
drug(s), dosage/regimen, start/end dates, reason for administration. 
• Imaging Data: Magnetic Resonance Imaging (MRI). Baseline tumor 
assessment MRI must be performed within 2 weeks before treatment 
initiation. Post-treatment, MRI scans will be performed every 4 weeks (±7 
days) for response assessment until disease progression, patient 
intolerance, or withdrawal occurs. 
• Clinical Follow-up Information: 
1. Safety: Descriptive statistics of all treatment-related adverse 
events, including nature of event, duration, severity, and 
relationship to SDT. Calculation of AE and Serious Adverse Event 
(SAE) incidence rates. 
2. Efficacy - Short-term: Collection of imaging data for response 
assessment. Evaluation after one cycle of SDT for tumor response: 
Complete Response (CR), Partial Response (PR), Stable Disease 
(SD), Progressive Disease (PD). Calculation of Objective Response 
Rate (ORR) and Disease Control Rate (DCR) based on the best 
overall response within the first 12 months post-treatment. 
3. Efficacy - Long-term: Collection of survival data for enrolled 
patients. Documentation of date and cause of death. Assessment of 
survival status at 1 year, 2 years, and 3 years post-treatment. 

Calculation of 1-year OS rate, 1-year PFS rate, and safety outcomes. 
Recording of median PFS (mPFS) and median OS (mOS). 
9. Statistical Analysis 
1. Safety Analysis: Descriptive analysis will be performed for the incidence 
of all AEs and SAEs. 
2. Efficacy Analysis: 
• PFS and OS curves will be generated using the Kaplan-Meier 
method. 
• Differences in survival outcomes between groups will be assessed 
using the Log-rank test. 
• Multivariate analysis using the Cox proportional hazards 
model will be performed to evaluate the effect of prognostic factors. 
Hazard ratios (HRs) and their corresponding 95% confidence 
intervals (CIs) will be reported. 
• Unless otherwise specified, all statistical tests will be two-sided, 
conducted at the α = 0.05 level of significance. Two-sided 95% 
confidence intervals will be calculated. 
 
 
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                                                            Investigator: Yingjuan Zheng 
Version Date: October 1, 2024