A Phase II, Open-Label Study to Evaluate the Safety, Tolerability, and Efficacy of Disulfiram and Copper Gluconate When Added to Standard Temozolomide Treatment in Patients With Newly Diagnosed Resected Unmethylated Glioblastoma Multiforme
Phase: PHASE2
Conditions: Glioblastoma, Glioblastoma Multiforme
Sponsor: Wake Forest University Health Sciences

 
 
 
 
 A Phase II, Single Center, Open-Label, Single Arm Study to Evaluate 
the Safety, Tolerability, and Efficacy of Disulfiram and Copper 
Gluconate When Added to Standard Temozolomide Treatment in 
Patients with Newly Diagnosed Resected Unmethylated Glioblastoma 
Multiforme 
NCT: 03363659 
January 17th, 2019 

ANII 100-1 Clinical Study Protocol:  DSF-Cu for Unmethylated Glioblastoma 
  
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ANII 100-1 
 
A Phase II, Single Center, Open-Label, Single Arm Study to 
Evaluate the Safety, Tolerability, and Efficacy of Disulfiram and 
Copper Gluconate When Added to Standard Temozolomide 
Treatment in Patients with Newly Diagnosed Resected 
Unmethylated Glioblastoma Multiforme 
 
 
 
 
Version Date: 01/17/2019 
 
 
 
 
 
 
 
 
 
 
Confidentiality Statement 
The document contains confidential information and is the property of George Bobustuc, MD, 
Santhi Konduri, PhD, Richard Rovin, MD and Amin Kassam, MD. This protocol is part of the 
ANII / Neuroscience Department of Aurora Saint Luke’s Medical Center GBM protocol 
portfolio. The protocol information may be provided only to co or sub-investigators, appropriate 
trial personnel, members of the Institutional Review Board, and personnel of the authorities to 
whom it is submitted.  This protocol may not be photocopied or discussed with third parties 
without prior written authorization from George Bobustuc, M.D. 
 
 

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Table of Contents  
1.1 
Glioblastoma .................................................................................................................... 5 
1.2 
Glioblastoma in the Elderly.............................................................................................. 5 
1.3 
Incompletely Resected Glioblastoma ............................................................................... 6 
1.4 
Unmethylated Glioblastoma ............................................................................................. 6 
1.5 
Sensitizing Glioblastoma to Temozolomide .................................................................... 6 
1.6 
Preclinical Data of Disulfiram for Temozolomide Sensitization ..................................... 7 
1.7 
Clinical Trial of Repurposing Disulfiram for glioblastoma ........................................... 11 
1.8 
Drug Metabolism and Pharmacokinetics ....................................................................... 11 
1.9 
Toxicology and Safety ................................................................................................... 12 
1.10 Disulfiram and Copper Administration .......................................................................... 14 
1.11 Study Rationale .............................................................................................................. 14 
2.0 .......................................................................................................................... STUDY OBJECTIVES
....................................................................................................................................................... 15 
2.1 
Primary Objective .......................................................................................................... 15 
2.2 
Secondary Objectives ..................................................................................................... 15 
3.0 ........................................................................................................................ PATIENT SELECTION
....................................................................................................................................................... 15 
3.1 
Inclusion Criteria ............................................................................................................ 15 
3.2 
Exclusion Criteria ........................................................................................................... 16 
3.3 
Inclusion of Women and Minorities............................................................................... 17 
4.0 ............................................................................................................................ TREATMENT PLAN
....................................................................................................................................................... 17 
4.1 
Pretreatment Evaluation ................................................................................................. 17 
4.2 
Disulfiram and Copper Dosing ...................................................................................... 17 
4.3 
Study Evaluations ........................................................................................................... 18 
4.4 
General Concomitant Medication and Supportive Care Guidelines .............................. 19 
4.5 
Duration of Therapy ....................................................................................................... 21 
4.6 
Duration of Follow-up .................................................................................................... 22 
5.0 ................................................................................................................ RESPONSE ASSESSMENT
....................................................................................................................................................... 22 
5.1 
Evaluation of Best Overall Response ............................................................................. 24 
5.2 
Duration of Response ..................................................................................................... 25 
5.3 
Neurological Exam and Performance Status .................................................................. 25 
5.4 
Progression-Free Survival .............................................................................................. 25 
6.0 .................................................................................................................... DOSE MODIFICATIONS
....................................................................................................................................................... 25 
6.1 
Temozolomide Dose Modifications ............................................................................... 25 
6.2 
Disulfiram Dose Modifications ...................................................................................... 26 
7.0 ............................................................... REGULATORY AND REPORTING REQUIREMENTS
....................................................................................................................................................... 26 
7.1 
Adverse Events (AEs) .................................................................................................... 26 
7.2 
Unanticipated Problems ................................................................................................. 27 
7.3 
Noncompliance............................................................................................................... 27 

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7.4 
Serious Noncompliance.................................................................................................. 27 
7.5 
Protocol Exceptions........................................................................................................ 27 
7.6 
Reporting to the Institutional IRB .................................................................................. 28 
7.7 
Reporting to the FDA ..................................................................................................... 28 
7.8 
Timeframe for Reporting Required Events .................................................................... 29 
8.0 ........................................................................................... PHARMACEUTICAL INFORMATION
....................................................................................................................................................... 29 
8.1 
Disulfiram....................................................................................................................... 29 
9.0 ............................................................................................................................ STUDY CALENDAR
....................................................................................................................................................... 32 
10.0 ............................................................................................... STATISTICAL CONSIDERATIONS
....................................................................................................................................................... 33 
10.1 Definition of Primary Endpoints and Analytical Plan ................................................... 33 
10.2 Definition of Secondary Endpoints and Analytical Plans .............................................. 33 
11.0 ...................................................................................................................................... REFERENCES
....................................................................................................................................................... 34 
APPENDIX A: ECOG Performance Status Scale ........................................................................ 37 
APPENDIX B: Comparison of EGOC Peformance Status to Karnofsky Performance Status .... 39 
APPENDIX C: Disulfiram and Copper Medication Diary ........................................................... 42 
APPENDIX D: Concurrent Temozolomide Medication Diary………………………………….42 
APPENDIX E: Adjuvant Temozolomide Medication Diary ……………………………………44 
  
 
 
 
 

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Glossary of Abbreviations 
 
 
ALDH 
Aldehyde Dehydrogenase 
ALT 
Alanine aminotransferase 
AST 
Aspartate aminotransferase  
BVZ 
Bevacizumab 
CCNU 
Lomustine 
CR 
Complete Response 
Cu 
Copper Gluconate 
DDTC 
Diethyldithiocarbamate 
DSF 
Disulfiram 
ECOG 
ECOG Performance Status 
FDA 
Food and Drug Administration 
FLAIR 
Fluid-attenuated inversion recovery  
GBM 
Glioblastoma 
GSC 
Glioma-like stem cells 
Me-DDTC 
Methyl ester of diethyldithiocarbamate 
MGMT 
O6-methylguanine-DNA-methyltransferase 
MRI 
Magnetic resonance imaging 
OBG 
O6-benzylguanine 
ORR 
Objective response rate 
OS 
Overall survival 
PFS 
Progression-free survival 
PFS6 
Progression-free survival at six months 
PR 
Partial response 
RANO 
Response Assessment in Neuro-
Oncology Criteria 
RT 
Radiation therapy 
TMZ 
Temozolomide 
ULN 
Upper limit of normal 
WHO 
World Health Organization 
 
 
 
 
 
 
 
 
 
 
 

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1.0 
BACKGROUND AND RATIONALE 
 
1.1 
Glioblastoma 
 
Glioblastoma is the most common malignant primary brain tumor and one of the most 
devastating cancers (Johnson and O'Neill 2012). Between 2004 and 2007, there were 
37,690 patients newly diagnosed with glioblastoma, with an estimated incidence rate of 
3 cases per 100,000 people in the United States (Ostrom, et al. 2014). The current 
standard of care for glioblastoma includes maximal safe resection followed by 
radiotherapy (RT) and temozolomide. However, despite optimal multi-modality 
therapy, median progression-free survival (PFS) is less than 7 months, and median 
overall survival (OS) is less than 15 months (Stupp, et al. 2005). Effective treatment 
for recurrent glioblastoma is even more dismal. A meta-analysis of 8 phase II studies 
of different cytotoxic drugs or cytostatic agents on recurrent glioblastoma showed 
objective response rate (ORR, including both complete response and partial response) 
of 6%, median progression-free survival (PFS) of 9 weeks, and PFS at 6 months 
(PFS6) of 15%. Based on remarkable radiological response from two single-arm, non-
comparative phase II studies, bevacizumab (BVZ), an anti-angiogenesis antibody, was 
approved by the Food and Drug Administration (FDA) for the treatment of recurrent 
glioblastoma (Friedman, et al. 2009; Kreisl, et al. 2009). However, the duration of 
response is relatively short with median PFS of 3-4 months and OS of 7-9 month 
(Piccioni, et al. 2014). A recent randomized study (EORTC 26101) showed that the 
addition of BVZ to lomustine (CCNU) improved PFS but failed to improve OS as 
compared to CCNU alone (Wilk, et al. 2015). Previously, two large randomized studies 
also showed that the addition of BVZ to standard RT and temozolomide failed to 
improve OS (Chinot, et al. 2014; Gilbert, et al. 2014).  
 
New treatments for both newly diagnosed and recurrent glioblastoma are greatly 
needed.  
 
1.2 
Glioblastoma in the Elderly 
 
The median age of patients at the time of diagnosis of glioblastoma is 64, with 
approximately 6000 new patients over the age of 65 diagnosed each year in the United 
States with glioblastoma. The prognosis for these patients is worse than for younger 
patients, both as a consequence of the biologic characteristics of these tumors and 
comorbidities that may compromise surgery, radiation, or chemotherapy.  A 
retrospective study of Medicare claims data paired with the Surveillance, 
Epidemiology, and End Results (SEER) database indicated a median overall survival 
(OS) of 4 months for patients with glioblastoma aged >65 years, inclusive of all 
treatment modalities. A recent study, reported at ASCO 2016, in patients 70 years of 
age or older eligible for chemotherapy + radiation therapy, indicated a median survival 
of 9.2 months and progression-free survival of 5.3 months for patients receiving 
temozolomide + radiation as compared to 7.6 month median survival and progression-
free survival of 3.9 months in the radiation alone arm.  

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1.3 
Incompletely Resected Glioblastoma 
 
Glioblastoma is a highly invasive tumor and, as a consequence, surgical cure of a 
glioblastoma is not achievable. Gross total resection, defined as resection of contrast-
enhancing tumor, can be achieved in approximately 40% of patients and has clear benefit. 
The majority of glioblastoma patients, however, undergo incomplete resection and some 
of them receive biopsy only, which is due to diffuse tumor extension, involvement of 
functionally vital areas, and patient-related risk factors such as increased age and co-
morbidities.  
 
1.4 
Unmethylated Glioblastoma 
 
Gene methylation is a DNA-based control mechanism that regulates gene expression.  In 
cancer, gene promoter regions can have increased or decreased levels of methylation. 
This epigenetic modification to DNA blocks gene function, resulting in the protein 
encoded for by the gene not being produced or being produced at a diminished level. 
 
O6-methylguanine-DNA methyltransferase (MGMT), is a DNA repair enzyme that plays 
a critical role in response to therapy.  The loss of or silencing of MGMT expression 
makes glioblastoma cells more sensitive to alkylating drugs such as temozolomide and 
BCNU.  Several studies have shown that approximately 40% to 45% of glioblastoma 
tumors exhibit MGMT gene methylation with this methylation making the tumor more 
likely to respond to temozolomide whose damaging effects are reversed by DNA repair 
enzymes, such as MGMT.  Methylation of MGMT results in diminished levels or loss of 
MGMT expression.  In glioblastoma, MGMT gene methylation status is predictive of an 
improved response to temozolomide, with improved survival and progression-free 
survival, when compared to patients with unmethylated MGMT. 
 
Glioblastoma patients with unmethylated MGMT respond poorly to temozolomide, with 
a very minor improvement in median survival and progression-free survival.  
 
1.5 
Sensitizing Glioblastoma to Temozolomide 
 
Currently, temozolomide represents the only systemic therapy that has been shown to 
improve OS for glioblastoma (Stupp, et al. 2005). A phase II study attempted to re-
sensitize recurrent temozolomide-resistant glioblastoma (those who would recur while 
receiving temozolomide or within 2 months of the last treatment of temozolomide) 
using an O6-methylguanine-DNA methyltransferase (MGMT) inhibitor called O6-
benzylguanine (OBG) (Quinn, et al. 2009). Since MGMT is an enzyme that repairs 
DNA damage by alkylating agents such as temozolomide, a MGMT inhibitor is 
thought to be a rational agent to re-sensitize glioblastoma to temozolomide. 
Unfortunately, combination of O6-benzylguanine and temozolomide did not show any 
evidence of significant re-sensitization: ORR of 3% (95% CI: 0-15%), PFS6 of 9% 
(95% CI: 2-21%), and median PFS of 7.5 weeks (95% CI: 4.2-7.9 weeks) (Quinn, et al. 
2009). 

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1.6 
Preclinical Data of Disulfiram for Temozolomide Sensitization 
 
Disulfiram (DSF) is a FDA-approved oral medication that has been used for treating 
alcoholism since 1951. It inhibits aldehyde dehydrogenase (ALDH), which leads to 
accumulation of acetaldehyde in the blood after ingestion of alcohol. It has well-known 
safety profile for up to 3000 mg per day in the absence of alcohol consumption and has 
been shown to readily cross the blood-brain barrier (Faiman, et al. 1978; Suh, et al. 
2006). Multiple preclinical in vitro studies have demonstrated promising activity against 
glioblastoma cells (Hothi, et al. 2012; Liu, et al. 2012; Lun, et al. 2016; Triscott, et al. 
2012). Specifically, two independent high-throughput drug screening studies have 
identified DSF with potent and selective activity against large panels of patient-derived 
glioma stem-like cells (GSCs, a subset of glioblastoma tumor cells that have been shown 
to be more resistant to RT and chemotherapy) (Hothi, et al. 2012; Lun, et al. 2016).  
 
1.6.1 In Vitro Data of Disulfiram for Temozolomide Sensitization 
 
In addition to promising cytotoxicity against glioblastoma cells, DSF has also appeared to 
synergize with temozolomide.  Triscott et al. showed that DSF is active against 
temozolomide-resistant glioblastoma cell lines and provided synergistic activity when 
combined with temozolomide. As seen in Figure 1, DSF remarkably sensitized 
glioblastoma cells that were relatively resistant to temozolomide treatment (Triscott, et al. 
2012).  
 
 
 
Using low passage patient-derived glioblastoma cells, Dr. Francis Ali-Osman at Duke 
University observed that copper (Cu) could significantly enhance the cytotoxicity of DSF 
(Figure 2A-B) and confirmed that the DSF-Cu combination could dramatically increase 
the sensitivity of glioblastoma cells to temozolomide (Figure 2C-D). 
 

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Lun et al. recently demonstrated that DSF-Cu not only could increase the sensitivity 
temozolomide-naïve GSCs to temozolomide (Figure 3A) but also recurrent 
temozolomide-resistant GSCs (Figure 3B). In Figure 3B, BT73R and BT206R 
represented two temozolomide-resistant GSC models that were derived from recurrent 
orthotopic glioblastoma tumors after serial temozolomide exposure, which simulated the 
evolutionary development of recurrent temozolomide-resistant glioblastomas in clinical 
practice. Of great interest, DSF-Cu was able to produce synergistic effect in combination 
with temozolomide on these temozolomide-resistant cells (Figure 3B), suggesting that 
DSF-Cu can re-sensitize temozolomide-resistant GSCs to temozolomide again (Figure 
3B). Lun et al.  also confirmed that Cu is crucial for the anti-tumor effect of DSF (Figure 
3A-B) (Lun, et al. 2016). 
 

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1.6.2 In Vivo Data of Disulfiram for Temozolomide Sensitization 
 
Lun et al. further verified the synergistic effect of DSF-Cu using orthotopic glioblastoma 
models that were produced from the GSCs. As seen in Figure 4A and 4B, DSF-Cu alone 
had limited effect on mice implanted with temozolomide-sensitive GSCs. However, when 
given with temozolomide, the combination significantly improved survival of mice with 
orthotopic tumors as compared to temozolomide alone. Furthermore, as seen in Figure 
4C, the combination of DSF-Cu and temozolomide also significantly improved survival 
of mice implanted with temozolomide-resistant BT73R cells as compared to 
temozolomide alone or DSF-Cu alone (either treatment alone was ineffective) (Lun, et al. 
2016). Altogether, these experiments provided proof of concept that DSF-Cu can (re)-
sensitize temozolomide-resistant glioblastoma tumors to temozolomide and the 
combination of both would be required to observe the maximal anti-tumor effect.  

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1.6.3 Mechanism of DSF’s Anticancer Activity 
 
The mechanism of DSF’s anti-cancer property is not definitively understood.  Multiple 
studies have suggested that it may be due to the inhibition of chymotrypsin-like 
proteasome activity (Chen, et al. 2006; Cvek, et al. 2008; Hothi, et al. 2012). Others have 
showed that DSF-Cu complex can induce intracellular reactive oxygen species to trigger 
intrinsic apoptosis of glioblastoma cells through activation of c-Jun amino-terminal 
kinases (JNK) and p38 pathways (Liu, et al. 2012). Paranjpe et al. showed that DSF 
increased the sensitivity of glioblastoma cells to temozolomide through inhibition of 
MGMT and demonstrated that DSF preferentially inhibited tumor MGMT in 
glioblastoma xenografts as compared to MGMT in the normal tissue (Paranjpe, et 
al. 2014). Lun et al. demonstrated that proteasome inhibition was not responsible for all 
the cytotoxicity of DSF-Cu. Complete proteasome inhibition using proteasome inhibitor 
bortezomib did not produce the same level of cell death as DSF-Cu, while very low 
concentration of DSF-Cu with minimal proteasome inhibition was able to produce 
significant cytotoxicity.  

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Lun et al. also showed that DSF-Cu inhibited DNA repair pathways and thus enhanced 
the effects of DNA alkylating agents and radiation to increase DNA damage (Lun, et al. 
2016). These data suggest that the mechanism of DSF against glioblastoma may be multi-
factorial and may be more likely to overcome temozolomide-resistance than a pure 
MGMT inhibitor such as O6-benzylguanine.   
 
1.7 
Clinical Trial of Repurposing Disulfiram for Glioblastoma 
 
A phase I, dose-escalation pharmacodynamics study of DSF in combination with 
adjuvant temozolomide for newly diagnosed glioblastoma after standard RT and 
concurrent temozolomide determined that the maximum tolerated dose (MTD) of DSF 
with adjuvant temozolomide is 500 mg per day. Dose-limiting toxicities of delirium and 
ataxia occurred at dose of 1000 mg per day within the first month of administration. The 
combination of 500 mg of DSF with adjuvant temozolomide had an acceptable safety 
profile but was associated with reversible neurological toxicities of delirium, ataxia, and 
neuropathy after prolonged use. The median PFS with RT plus concurrent temozolomide 
followed by 500 mg of DSF and adjuvant temozolomide was 8.1 months (Huang, et al. 
2016). In comparison, previous randomized studies showed only a median PFS of 5.5 to 
7.3 months with adjuvant temozolomide alone after chemoradiotherapy (Gilbert, et al. 
2014; Gilbert, et al. 2013; Stupp, et al. 2005). However, in the Huang et al study, the 
relative contributions of RT and temozolomide could not be distinguished; therefore, the 
single-agent efficacy of DSF was not clearly defined (Huang et al, 2016). Logical next 
steps would be to test DSF and Cu against recurrent temozolomide-resistant glioblastoma 
and against unmethylated glioblastoma to elucidate their single-agent efficacy and their 
potential for temozolomide sensitization.  
 
1.8 
Drug Metabolism and Pharmacokinetics 
 
After oral ingestion, DSF is partially reduced to diethyldithiocarbamate (DDTC) in the 
acidic stomach, which in turn forms a complex with Cu to form Cu(DDTC)2. Both the 
parent DSF and Cu (DDTC)2 are absorbed through the gastrointestinal tract. Generally, 
more than 80% of an oral dose is absorbed. Enteric formulation and oil may enhance 
absorption. After absorption, DSF is again reduced to DDTC and then Cu (DDTC)2. 
Downstream 
metabolites 
also 
include 
diethylamine, 
carbon 
disulfide, 
diethyldithiomethylcarbamate (Me-DDTC), and glucuronic acid of DDTC. Me-DDTC is 
biotransformed into active inhibitors of ALDH (Johansson 1992). Experiments with 
radiolabeled DSF have shown distribution in the blood, liver, kidney, heart, adrenal 
gland, thyroid, pancreas, testes, spleen, marrow, muscles, and, most importantly, brain 
(Faiman, et al. 1978).  
 
Previous pharmacokinetic studies were done on alcoholic patients after either single dose 
or repeated doses for 12 consecutive days. Apparent half-lives of DSF, DDTC, and Me-
DDTC were 7.3, 15.5, and 22.1 hours, respectively. Average time to reach maximal 
plasma concentration was 8-10 hours for DSF and its metabolites. The mean peak plasma 
concentrations of DSF and Me-DDTC were 1.3 nM and 4.7 nM, respectively.  

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However, there was marked inter-subject variability in the plasma concentrations 
(Faiman, et al. 1984; Jensen, et al. 1982). Doses as low as 100 mg of DSF could produce 
detectable plasma concentrations of Me-DDTC and complete blockade of ALDH activity 
in erythrocytes (Johansson, et al. 1991). As seen in Figure 1, three daily doses of DSF 
will allow for DSF and its metabolites to reach steady state. 
 
Figure 1: Predicted pharmacokinetic profile of DSF and its metabolites (DDTC & Me-DDTC) 
 
 
The metabolites of DSF are mainly excreted via kidneys, feces, and the lungs. Up to 20% 
of an oral dose may not be absorbed and thus excreted in the feces. About 65% is 
eliminated through the kidneys, mostly as the glucuronide of DDTC and inorganic 
sulfates. The metabolite carbon disulfide is mostly eliminated via the lungs (Johansson 
1992).  
 
In the blood, both DSF and Me-DDTC are mostly bound to albumin, with average 
binding percentages of 96 and 80% over the ranges 200-800 and 345-2756 nM, 
respectively. The average number of binding sites was approximately one for both 
substances, suggesting a single binding site for both. The average association constants 
were 7.1 x 104 and 6.1 x 103 M-1, respectively. Therefore, patients with impaired protein 
synthesis and decreased albumin levels may have considerably different plasma 
concentration of DSF and its metabolites. Both DSF and Me-DDTC are also very 
lipophilic, with Log P (octanol-water partition coefficient) of 2.81 and 1.85, respectively 
(Johansson 1990), which support their ability to cross the blood brain barrier.  
 
1.9 
Toxicology and Safety 
 
DSF has been used clinically to treat alcoholism for more than 60 years, so its safety 
profile is well known.  Early toxicology studies done in mice, rats, dogs, and rabbits have 
shown that DSF has very low toxicity, with LD50 between 1.8-10g/kg when administered 
orally.  

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At those extreme doses, demyelination of brain and spinal cord was observed on 
histopathology (Child and Crump 1952). Interestingly, long-term administration of high 
doses of DSF to rats did not induce any laboratory or histological signs of liver damage 
(Milandri, et al. 1980). High doses of DSF (up to 6 g daily) are relatively nontoxic in 
humans. Symptoms of overdose include vomiting, headache, apathy, ataxia, motor 
restlessness, irritability, hallucinations, psychosis, loss of consciousness and convulsions. 
Death occurs by respiratory arrest, preceded by ascending paralysis, and pathological 
lesions are seen in the liver, spleen, kidney and CNS, with congestion in the adrenal 
gland and edema in the heart muscle.   
 
The current FDA-recommended dose of DSF is 250-500 mg daily for alcohol abstinence. 
In early clinical practice, a much higher dose of 1000-3000 mg per day was used (Fuller 
and Gordis 2004).  At high dosages, the DSF-ethanol reaction may be severe and even 
fatal, but such high dosage in the absence of alcohol is well tolerated. In the early 1950s, 
4 patients (out of an estimated 11,000 patients prescribed high doses of DSF) died of 
sudden respiratory or cardiovascular causes likely related to the DSF-ethanol reaction 
(Jacobsen 1952). At such high dosages, there were also case reports of psychosis in the 
absence of alcohol ingestion (Guild and Epstein 1951; Martensen-Larsen 1951). A phase 
I study administered a single dose of oral DSF prior to cisplatin every 3 weeks and 
encountered dose-limiting reversible confusion at 3000 mg/m2 (approximately 4800 mg) 
(Stewart, et al. 1987). High doses of DSF may inhibit cerebrospinal dopamine B-
hydroxylase (Nilsson, et al. 1987), and people with very low activity of dopamine 
hydroxylase may be prone to transient psychosis with such inhibition (Major, et al. 1979). 
In another phase I study of non-metastatic recurrent prostate cancer patients treated with 
250-500 mg of DSF alone, grade 3 toxicities included double vision, hearing loss, LFT 
abnormality, diarrhea, constipation, and ataxia (Schweizer, et al. 2013).  
 
In a previous phase I study of 500-1000 mg DSF in combination with adjuvant 
temozolomide in newly diagnosed glioblastoma patients after chemoradiotherapy, grade 
2-3 toxicities that were attributed to DSF included delirium, ataxia, dizziness, 
neuropathy, and fatigue (Table 1). Higher dose of 1000 mg DSF per day could not be 
tolerated due to relatively fast onset of delirium and ataxia within the first month of 
therapy. Therefore, it was determined that 500 mg per day of DSF is the MTD in 
combination with adjuvant temozolomide. However, even at the MTD of 500 mg per day, 
2 of 7 patients eventually stopped DSF due to possibly DSF-related toxicity. One patient 
developed grade 3 delirium after 55 days of DSF; another patient developed grade 3 
motor neuropathy (lower extremity weakness and foot drop). Both toxicities resolved 
after discontinuing DSF (Huang, et al. 2016).  
 

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Table 1: Possible DSF-related toxicity during Adjuvant temozolomide 
Toxicities* 
DSF 500 mg (n=7) 
DSF 1000 mg (n=5) 
Grade 2 Grade 3 
Grade 2 
Grade 3 
Ataxia 
1 (14%) 
0 
2 (40%) 
1 (20%)† 
Delirium 
0 
1 (14%)† 2 (40%) 
2 (40%)§ 
Dizziness 
1 (14%) 
0 
1 (20%) 
0 
Fatigue 
3 (43%) 
0 
1 (20%) 
0 
Peripheral motor neuropathy 
0 
1 (14%)† 1 (20%) 
0 
Peripheral sensory neuropathy 2 (29%) 
0 
1 (20%) 
0 
*Grade 2-3 adverse events according to the National Cancer Institute Common Terminology Criteria for 
Adverse Events (NCI CTCAE) v. 4.0 (2009) that were possibly or probably related to DSF and that were 
not present at baseline. 
†Not dose-limiting toxicity as occurred after the first month of DSF.  
§Dose-limiting toxicity as occurred within the first month of DSF. 
 
 
1.10 
Disulfiram and Copper Administration 
 
Although the MTD of DSF in combination with adjuvant temozolomide was established 
at 500 mg once per day, continuous administration of this dose over time was associated 
with reversible delirium or neuropathy that prompted discontinuation of therapy in some 
patients. Furthermore, the pharmacodynamics study showed that 500 mg DSF per day 
(without concurrent Cu) produced limited proteasome inhibition on peripheral blood 
cells, one of the presumed mechanisms against glioblastoma cells (Huang et al 2016). 
Given that Cu has been shown to be essential for DSF’s anti-cancer effects, co-
administration of Cu with DSF may be necessary to maximize its efficacy (Hothi, et al. 
2012; Lun, et al. 2016). A previous phase I study for patients with advanced liver 
metastasis showed that 6 mg of elemental Cu in the form of copper gluconate is well 
tolerated when given with 250 mg of DSF daily. In this study, Cu was given in the 
morning half hour before breakfast, and DSF was given with the evening meals to avoid 
gastro-intestinal irritation from complexation of DSF and Cu in the stomach (Grossmann, 
et al. 2011).  
 
A recent double-blinded, randomized phase II study compared chemotherapy with and 
without DSF for metastatic non-small cell lung cancer. Patients who received concurrent 
DSF had significantly better PFS and OS than those who received chemotherapy alone 
(5.9 vs. 4.9 months, and 10.0 vs. 7.1 months, respectively) (Nechushtan, et al. 2015). In 
that study, DSF was given at 40 mg TID. In contrast to the Huang phase I study, 
Nechushtan et al. did not report any significant neurological toxicity except fatigue. This 
study suggests that lower DSF daily dosing may be more effective than higher dose. 
Given the results of this study and our ANII patient derived primary culture data which 
suggests that lower DSF dose may be more effective this study will limited DSF total 
daily dose to 250 mg split into two 125 mg doses given on a BID schedule. 
 
1.11 
Study Rationale 
 
Patients with unmethylated glioblastoma respond poorly to current standard treatment 
and have a poor prognosis.  

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Although standard post resection radiation therapy may provide a survival benefit of 
approximately two months, delayed radiation at or after 8 weeks has been shown to not 
increase overall survival. This study proposes standard of care treatment with 6 – 61/2 
weeks of radiation with concurrent temozolomide at 75mgs / m2 along with DSF – Cu 
followed by adjuvant temozolomide at 150mgs / m2 for 6 -12 cycles in patients with 
previously untreated, (aside from surgical resection), unmethylated glioblastoma. 
 
Preclinical studies have identified DSF-Cu as having promising activity in glioblastoma 
cells and can potentially sensitize temozolomide-resistant cells to temozolomide.  
A recent phase I study has demonstrated the feasibility and safety of combining DSF with 
adjuvant 
temozolomide 
in 
newly 
diagnosed 
glioblastoma 
patients 
after 
chemoradiotherapy (Huang, et al. 2016). This clinical trial will evaluate whether the 
addition of DSF-Cu to temozolomide in patients expected to be temozolomide-resistant 
can induce anti-tumor responses and validate the potential of DSF-Cu to sensitize 
glioblastoma to temozolomide.  
 
2.0 
STUDY OBJECTIVES 
 
2.1 
Primary Objective 
 
1. To determine evidence of an antitumor effect in patients with unmethylated 
glioblastoma treated concurrently with DSF-Cu and concurrent radiation and 
temozolomide. To determine 6 month PFS and 12 month OS of patients with 
unmethylated glioblastoma treated with DSF-Cu in combination with concurrent 
radiation and temozolomide. 
 
2.2 
Secondary Objectives 
 
2. To evaluate the safety and tolerability of DSF-Cu administered BID when given 
concurrently with temozolomide. 
3. To determine the impact of DSF + Cu on the quality of life (QOL) for patients with 
newly diagnosed GBM undergoing standard concurrent radiation and temozolomide 
treatment followed by adjuvant temzolomide. 
 
3.0 
PATIENT SELECTION 
 
Approximately 14-40 patients will be enrolled – depending on the preliminary subset 
analysis data (when accrual of 14 patients is reached) the study may conclude when 14-
20 patient mark is reached. 
 
3.1 
Inclusion Criteria 
 
1. Age 18 or older 
2. Diagnosis of histologically confirmed glioblastoma (WHO grade IV). Subjects with 
an original histologic diagnosis of low grade glioma or anaplastic glioma (WHO 

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grade II or III) are eligible if a subsequent histological diagnosis of glioblastoma is 
made 
3. Patients whose tumor is determined to be unmethylated 
4. Patients with incomplete resection as determined by residual, measurable gadolinium 
or contrast-enhancing lesion or lesions 
5. Recent resection of glioblastoma. Patients who have only had a tumor biopsy and 
who are considered unresectable are eligible (but based on the study accrual this 
subset of patients with unreseactable tumor may be considered for separate analysis) 
6. ECOG PS of ≤ 2 (see appendix A) 
7. Willing to remain abstinent from consuming alcohol while on DSF 
8. No prior radiation or chemotherapy 
9. Meets the following laboratory criteria: 
a. Absolute neutrophil count ≥ 1,500/mcL 
b. Platelets ≥ 100,000/mcL 
c. Hemoglobin > 10.0 g/dL (transfusion and/or ESA allowed) 
d. Total bilirubin and alkaline phosphatase ≤ 2x institutional upper limit of normal 
(ULN) 
e. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) < 3 x 
ULN 
f. Blood urea nitrogen (BUN) and creatinine < 1.5 x ULN 
10. Able to take oral medication 
11. Able to understand and willing to sign an institutional review board (IRB)-approved 
written informed consent document (legally authorized representative permitted) 
12. MRI with and without contrast prior to enrollment. 
 
3.2 
Exclusion Criteria 
 
1. Radiographic evidence of leptomeningeal dissemination, extensive intraparenchymal 
dissemination, infratentorial tumor, or metastatic disease to sites remote from the 
supratentorial brain 
2. Enrolled in another clinical trial testing a novel therapy or drug 
3. Received prior radiation therapy or chemotherapy for glioblastoma 
4. History of allergic reaction/hypersensitivity to DSF (without alcohol) or copper. 
5. Treatment with the following medications that may interfere with metabolism of 
DSF: warfarin (unless otherwise chosen by the study PI who will actively adjust 
Coumadin dose to consistently maintain a safe, therapeutic INR < 3), theophylline, 
amitriptyline, isoniazid, metronidazole, phenytoin, phenobarbital, chlorzoxazone, 
halothane, imipramine, chlordiazepoxide, diazepam. (Note: lorazepam and oxazepam 
are not affected by the P450 system and are not contraindicated with DSF). 
6. Active severe hepatic or renal disease  
7. Grade 2 or higher peripheral neuropathy or ataxia per NCI CTCAE version 4.0 (2009) 
8. History of idiopathic seizure disorder schizophrenia, or psychosis unrelated to 
glioblastoma, corticosteroid, or anti-epileptic medications 
9. History of Wilson’s or Gilbert’s disease 
10. Current excessive use of alcohol. 
 

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3.3 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this 
trial. 
 
4.0 
TREATMENT PLAN 
 
This study is a single arm, open-label, phase II study of DSF-Cu in combination with 
concurrent temozolomide and radiation therapy followed by DSF – Cu and adjuvant 
temozolimide for patients with unmethylated tumors. 
 
4.1 
Pretreatment Evaluation 
 
Prior to enrollment, patient must have a complete history, physical examination including 
neurological exam, evaluation of performance status using the ECOG, assessment of 
corticosteroid usage (mg per day), baseline laboratory studies (CBC, CMP, and Cu) and 
pregnancy test (if applicable), and brain MRI.  A baseline MRI must be performed prior 
to registration.  
 
4.2 
Disulfiram and Copper Dosing 
 
DSF will be given at 125 mg (half of a 250 mg capsule) two times daily with meals. Cu 
gluconate will be taken with each dose of DSF at a dose of 2 mg (one capsule/tablet). A 
previous phase I study determined that the MTD is 500 mg per day in combination with 
temozolomide (Huang et al, 2016). However, in this protocol, DSF-Cu will be 
administered BID. The DSF total daily dose will be 250 mg per day, as lower dose may 
be associated with a higher MGMT inhibitory effect, which is approximately half of the 
daily dose of disulfiram (500 mg) given safely and chronically to patients treated for 
alcoholism. If administration of DSF and Cu together causes gastrointestinal discomfort, 
then Cu will be administered 30 minutes after the DSF dose. If a patient misses a dose, 
s/he should be instructed not to make up that dose but should instead resume dosing with 
the next scheduled dose. Patients will be instructed to bring all unused drug and the 
completed medication diary (Appendix B) to each study visit for assessment of 
compliance.  
 
Temozolomide will be administered following the standard Stupp protocol at a dose of 75 
mg/m2 for 42 days with concurrent radiation therapy followed by a two to three week 
rest. In patients with stable or responding disease, temozolomide dose will resume at 
maintenance dose of 150 mg/m2 once daily on Days 1-5 of every 28-day cycle.  
Patients demonstrating continued benefit from the adjuvant temozolomide after 6 cycles 
can continue treatment to a maximum of 12 cycles. 
 
Patients may be treated with IV temozolomide if they are unable to take the oral 
formulation of the drug or if they do not have insurance coverage for oral formulation. If 
patients are treated with the IV formulation they will receive the temozolomide Monday 

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– Friday during concurrent treatment with radiation and then on days 1 -5 every 28 days 
in the adjuvant phase. 
 
The recommended dose for Temozolomide as an intravenous infusion over 90 minutes is 
the same as the dose for the oral capsule formulation. Bioequivalence has been 
established only when Temozolomide for infusion was given over 90 minutes. 
Standard Photon irradiation using 3DCRT or IMRT: 46 Gy in 23 fractions followed by a 
sequential boost for an additional 7 fractions to 60 Gy 
 
Concurrent temozolomide should be taken within an hour of radiation treatment. During 
weekends without radiotherapy (Saturday and Sunday), the drug will be taken in the 
morning.  
 
Adjuvant temozolomide should be taken at bedtime on an empty stomach and should not 
be taken within one hour of DSF-Cu administration. Patients will be instructed to fast at 
least 2 hours before and 1 hour after temozolomide administration. Water is allowed 
during the fast period. If vomiting occurs during the course of treatment, no re-dosing of 
the patient is allowed before the next scheduled dose. 
 
Patients will be instructed to bring their completed medication diary (Appendix C) to the 
study visit for assessment of compliance. 
 
If patients receive the IV formulation of Temozolomide, compliance will be assessed by 
review of the medical record daily administration. 
 
4.3 
Study Evaluations 
 
Consistent with standard of care, patients will be seen approximately every 4 weeks. At 
each visit, a ECOG evaluation and corticosteroid usage (mg per day) will be recorded. 
Brain MRI will be obtained every 8 weeks to assess for radiological response. Quality of 
Life (QOL) will be assessed using the Edmonton Symptom Assessment System – 
Revised (ESAS-r) questionnaire. Subjects will be monitored for copper levels on Day 1 
(+/- 7 days) of Cycle 1 and Cycle 4 of adjuvant temozolomide. 
 
Patients are evaluated for adverse events for 30 days from the last treatment of DSF-Cu, 
or until death, whichever occurs first. Patients removed from study for unacceptable 
adverse events will be followed until resolution or stabilization of the adverse event. 
Patients will also be removed from the study for non-compliance.  
 
 

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Table 2: Potential Adverse Events Related to DSF 
MedDRA Term 
Frequency: 
Likely:  greater than 10% 
Less Likely: 1-10% 
Rare: 1% or less 
Neoplasms  
Rare: Tumor necrosis  
Blood and lymphatic 
system disorders  
Rare: Neutropenia, anemia, leukopenia, 
thrombocytopenia, lymphopenia (likely due to 
temozolomide)  
Immune system 
disorders  
Rare: Hypersensitivity  
Metabolism and 
nutrition disorders  
Likely: Alcohol intolerance, metallic or garlic-like 
aftertaste  
Psychiatric disorders  
Less Likely: psychosis, delirium (need to rule out 
tumor progression) 
Nervous system 
disorders  
Likely: Drowsiness, headache, confusion 
Less Likely: ataxia, gait disturbance, peripheral 
neuropathy 
Rare: Extrapyramidal symptoms 
Eye disorders  
Rare: Optic neuritis  
Cardiac disorders  
Less Likely: Tachycardia, hypotension (need to rule 
out DSF-alcohol reaction)  
Respiratory, thoracic, 
and mediastinal 
disorders  
Less Likely: Dyspnea (need to rule out DSF-alcohol 
reaction) 
Gastrointestinal 
disorders  
Likely: Nausea, vomiting, diarrhea 
Less Likely: constipation (likely due to temozolomide)  
Hepatobiliary disorders  Rare: Hepatitis 
Skin and subcutaneous 
tissue disorders  
Less Likely: Allergic dermatitis 
  
Musculoskeletal 
Rare: Arthralgia, myalgia  
Renal and urinary 
disorders  
Rare: Dysuria, hematuria 
Reproductive system 
Less likely: impotence 
General disorders 
Likely: Fatigue 
 
4.4 
General 
Concomitant 
Medication/Treatment 
and 
Supportive 
Care 
Guidelines 
 
Treatment with Optune® may be initiated by Day 1 of Cycle 1, but can begin at any time 
prior to this as long as it is not started until after completion of radiation therapy. If 
patient did not declare intent for Optune® to start on Day 1 of Cycle 1, treatment with 
Optune® may be initiated on Day 1 of  Cycle 6, otherwise it may not be initiated until all 
protocol therapy is completed. 

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The following medications and procedures are prohibited during the study: 
 Any antineoplastic therapy (other than those already used for the treatment of 
autoimmune disorders) other than temozolomide and DSF  
 Any investigational therapy other than DSF  or Cu  
 
All other medical conditions or manifestations of the patient’s malignancy should be 
treated at the discretion of the investigator in accordance with local community standards 
of medical care. 
 
Patients should not drive, operate dangerous tools or machinery, or engage in any other 
potentially hazardous activity that requires full alertness and coordination if they 
experience sedation while enrolled in this study. 
 
Patients are to be instructed to abstain from alcohol while enrolled in this study.   
 
4.4.1 Nausea and Vomiting 
 
Prophylactic antiemetic therapy may be used in this study at the discretion of 
treating physician. Because of the potential of benzodiazepines to interact with 
DSF, the use of benzodiazepines for antiemetic prophylaxis should be reserved 
for patients who cannot be satisfactorily managed otherwise.   
 
4.4.2 Diarrhea 
 
Antidiarrheal medications will not be used prophylactically; however, patients 
will be instructed to take loperamide, 4 mg, at the occurrence of the first loose 
stool and then 2 mg every 2 hours until they are diarrhea-free for at least 12 hours.  
During the night, patients may take 4 mg of loperamide every 4 hours.  Fluid 
intake should be maintained to avoid dehydration. 
 
4.4.3 Central Nervous System Effects 
 
Doses of 500-1000 mg of DSF per day with adjuvant temozolomide produced 
neurological toxicities in some patients, including delirium/psychosis, ataxia, and 
peripheral neuropathy, especially at the 1000 mg dose. Patients should be 
carefully monitored for early signs of these symptoms. Once other causes such as 
tumor progression are ruled out, dose reduction of DSF to 125 mg (half of 250 mg 
tablet) once a day should be considered if the toxicity is grade 2 or greater (refer 
to Section 6.2). If symptoms are not improving with dose reduction, DSF should 
be discontinued. Patients whose symptoms are not considered immediately life-
threatening should be carefully monitored. Each patient may be approached 
individually with a systematic assessment to rule out other causes. Appropriate 
tests may include vital signs measurement, computerized tomography, MRI scans, 
or other appropriate medical assessment.  
 

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If the patient’s level of consciousness is considered to be life-threatening, the 
patient should be hospitalized and necessary measures should be instituted to 
secure the airway, ventilation, and intravenous access. 
 
4.4.4 Management of Disulfiram-Alcohol Reaction 
 
In severe reactions caused by the patient's excessive ingestion of alcohol, 
supportive measures to restore blood pressure and treat shock should be instituted. 
Potassium levels should be monitored, particularly in patients on digitalis, since 
hypokalemia has been reported. 
 
4.5 
Duration of Therapy 
 
Patients demonstrating continued benefit from the adjuvant temozolomide after 6 
cycles can continue treatment to a maximum of 12 cycles. 
 
If at any time the constraints of this protocol are considered to be detrimental to 
the patient’s health and/or the patient no longer wishes to continue protocol 
therapy, the protocol therapy should be discontinued and the reason(s) for 
discontinuation will be documented. 
 
In the absence of treatment delays due to adverse events, DSF-Cu treatment may 
continue until: 
 
Documented and confirmed disease progression 
 
Death 
 
Adverse event(s) that, in the judgment of the investigator, may cause 
severe or permanent harm or which rule out continuation of study drug 
 
Patient develops unacceptable toxicity deemed possibly,  probably, or 
definitely related to drug that does not resolved to grade 1 or to the 
patient’s baseline status 
 
Patient requires more than 1 dose reductions 
 
General or specific changes in the patient’s condition render the patient 
unacceptable for further treatment in the judgment of the investigator 
 
Serious noncompliance with the study protocol 
 
Lost to follow-up 
 
Patient withdraws consent 
 
Investigator removes the patient from study 
 
The investigator, or the investigator’s institution decides to close the study 
 
In the case of tumor progression, both temozolomide and DSF-Cu should be 
discontinued, and patient should be considered for second-line therapy. If temozolomide 
is temporarily withheld due to toxicity, DSF-Cu should be continued until temozolomide 
may be resumed again. If temozolomide is discontinued, DSF-Cu may be continued as 
per the discretion of the treating physician. If DSF-Cu is discontinued due to toxicity, 
temozolomide may be continued as per the discretion of the treating physician.  
 

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4.6 
Duration of Follow-up 
 
Patients are evaluated for adverse events for 30 days after the last dose of DSF-Cu or 
until death, whichever occurs first. Patients removed from study for unacceptable adverse 
events will be followed until resolution or stabilization of the adverse event. Follow-up 
after the conclusion of the study participation will be per routine clinical care.  Two years 
after the patient goes off study, the patient’s chart will be reviewed to collect data on 
progression and survival. 
 
 
5.0 
RESPONSE ASSESSMENT 
 
For the purposes of this study, patients should be evaluated for response approximately every 8 weeks.  
 
 
Response and progression will be evaluated in this study using the updated RANO response 
assessment criteria for high-grade gliomas (Wen, et al. 2010).  
 
Criteria for Determining First Progression Depending on Time from Initial Chemoradiotherapy 
 
First Progression 
Definition 
Progressive disease < 12 
weeks after completion of 
chemoradiotherapy 
Progression can only be defined using diagnostic imaging if there is new 
enhancement outside of the radiation field (beyond the high-dose region or 
80% isodose line) or if there is unequivocal evidence of viable tumor on 
histopathologic sampling (eg, solid tumor areas [ie, > 70% tumor cell nuclei 
in areas], high or progressive increase in MIB-1 proliferation index 
compared with prior biopsy, or evidence for histologic progression or 
increased anaplasia in tumor). Note: Given the difficulty of differentiating 
true progression from pseudoprogression, clinical decline alone, in the 
absence of radiographic or histologic confirmation of progression, will not 
be sufficient for definition of progressive disease in the first 12 weeks after 
completion of concurrent chemoradiotherapy.  
Progressive disease ≥ 12 
weeks after 
chemoradiotherapy 
completion 
1. New contrast-enhancing lesion outside of radiation field on 
decreasing, stable, or increasing doses of corticosteroids. 
2. Increase by ≥ 25% in the sum of the products of perpendicular 
diameters between the first post-radiotherapy scan, or a subsequent 
scan with smaller tumor size, and the scan at 12 weeks or later on 
stable or increasing doses of corticosteroids.  
3. Clinical deterioration not attributable to concurrent medication or 
comorbid conditions is sufficient to declare progression on current 
treatment but not for entry onto a clinical trial for recurrence.  
4. For patients receiving antiangiogenic therapy, significant increase in 
T2/FLAIR non-enhancing lesion may also be considered progressive 
disease. The increased T2/FLAIR must have occurred with the 
patient on stable or increasing doses of corticosteroids compared 
with baseline scan or best response after initiation of therapy and not 
be a result of comorbid events (eg, effects of radiation therapy, 

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First Progression 
Definition 
demyelination, ischemic injury, infection, seizures, postoperative 
changes, or other treatment effects).  
 
Criteria for Response Assessment Incorporating MRI and Clinical Factors (Adapted from (Wen, 
et al. 2010). 
 
Response 
Criteria 
Complete response 
 
Requires all of the following: complete disappearance of all enhancing 
measurable and non-measurable disease sustained for at least 4 weeks. 
 
No new lesions; stable or improved non-enhancing (T2/FLAIR) lesions. 
 
Patients must be off corticosteroids (or on physiologic replacement doses only) 
and stable or improved clinically. Note: Patients with non-measurable disease 
only cannot have a complete response; the best response possible is stable 
disease.  
Partial response 
Requires all of the following:  
 
≥ 50% decrease compared with baseline in the sum of products of perpendicular 
diameters of all measurable enhancing lesions sustained for at least 4 weeks. 
 
No progression of non-measurable disease. 
 
Stable or improved non-enhancing (T2/FLAIR) lesions on same or lower dose 
of corticosteroids compared with baseline scan; the corticosteroid dose at the 
time of the scan evaluation should be no greater than the dose at time of baseline 
scan. 
 
Stable or improved clinically. Note: Patients with non-measurable disease only 
cannot have a partial response; the best response possible is stable disease.  
Stable disease 
Requires all of the following:  
 
Does not qualify for complete response, partial response, or progression. 
 
Stable non-enhancing (T2/FLAIR) lesions on same or lower dose of 
corticosteroids compared with baseline scan. In the event that the corticosteroid 
dose was increased for new symptoms and signs without confirmation of disease 
progression on neuroimaging, and subsequent follow-up imaging shows that this 
increase in corticosteroids was required because of disease progression, the last 
scan considered to show stable disease will be the scan obtained when the 
corticosteroid dose was equivalent to the baseline dose.  
Progression 
Defined by any of the following:  
 
≥ 25% increase in sum of the products of perpendicular diameters of enhancing 
lesions compared with the smallest tumor measurement obtained either at 
baseline (if no decrease) or best response, on stable or increasing doses of 
corticosteroids*. The absolute increase in any dimension must be at least 5mm 
when calculating the products. 
 
Significant increase in T2/FLAIR non-enhancing lesion on stable or increasing 
doses of corticosteroids compared with baseline scan or best response after 
initiation of therapy* not caused by comorbid events (e.g. radiation therapy, 
demyelination, ischemic injury, infection, seizures, postoperative changes, or 
other treatment effects). 
 
Any new measureable lesion. 

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Response 
Criteria 
 
Clear clinical deterioration not attributable to other causes apart from the tumor 
(e.g. seizures, medication adverse effects, complications of therapy, 
cerebrovascular events, infection, and so on) or changes in corticosteroid dose. 
 
Failure to return for evaluation as a result of death or deteriorating condition; or 
clear progression of non-measurable disease.  
 
NOTE. All measurable and non-measurable lesions must be assessed using the same techniques as at 
baseline. 
 
Abbreviations: MRI, magnetic resonance imaging; FLAIR, fluid-attenuated inversion recovery. 
 
Stable doses of corticosteroids include patients not on corticosteroids.  
 
5.1 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started).   
 
The patient's best response assignment will depend on the achievement of both 
measurement and confirmation criteria. 
 
Summary of the RANO Response Criteria (Adapted from (Wen, et al. 2010). 
Criterion 
CR 
PR 
SD 
PD 
T1 gadolinium 
enhancing disease 
None 
≥ 50% ↓ 
< 50% ↓ but < 25% 
↑ 
≥ 25% ↑* 
T2/FLAIR 
Stable or 
↓ 
Stable or 
↓ 
Stable or ↓ 
↑* 
New lesion 
None 
None 
None 
Present* 
Corticosteroids 
None 
Stable or 
↓ 
Stable or ↓ 
NA† 
Clinical status 
Stable or 
↑ 
Stable or 
↑ 
Stable or ↑ 
↓* 
Requirement for 
response 
All 
All 
All 
Any* 
Abbreviations: RANO, Response Assessment in Neuro-Oncology; CR, complete response; PR, partial 
response; SD, stable disease; PD, progressive disease; FLAIR, fluid-attenuated inversion recovery; NA, not 
applicable.  
* Progression occurs when this criterion is present.  
† Increase in corticosteroids alone will not be taken into account in determining progression in the absence 
of persistent clinical deterioration.  
NOTE: Patients may continue on treatment and remain under close observation and evaluation at 4-8 
week intervals if there is uncertainty regarding whether pseudoprogression may be present as determined 
by the investigators. If subsequent radiographic or clinical assessments suggest that the patient is in fact 
experiencing progression, then the date of progression should be the time point at which this issue was 
first raised.  Similarly, stable disease may be assigned in cases of presumed “pseudoprogression” 
associated with decreased steroid use. 
 

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5.2 
Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the 
time measurement criteria are met for complete response (CR) or partial response (PR) 
(whichever is first recorded) until the first date that recurrent or progressive disease is 
objectively documented (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met 
for CR until the first date that progressive disease is objectively documented. 
 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment 
until the criteria for progression are met, taking as reference the smallest measurements 
recorded since the treatment started, including the baseline measurements.  
 
 
5.3 
Neurological Exam and Performance Status  
 
Patients will be graded using the ECOG scale and their neurological function evaluated 
as improved, stable or deteriorated in addition to objective measurement of tumor size. 
These parameters will be used to determine the overall response assessment. 
 
5.4 
Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression or 
death, whichever occurs first. 
 
 
6.0 
DOSE MODIFICATIONS 
 
6.1 
Radiation therapy Dose Modicications 
 
Radiation therapy modification is at the discretion of the treating physician as per routine 
clinical care. 
 
Concomitant temozolomide, if radiotherapy is interrupted  
If radiotherapy has to be temporarily interrupted for technical or medical reasons 
unrelated to the  temozolomide administration, then treatment with daily temozolomide 
should continue. If radiotherapy has to be permanently interrupted then treatment with 
daily temozolomide should stop. Temozolomide can resume with the initiation of the 
adjuvant phase of treatment. 
 
6.2 
Temozolomide Dose Modifications 
 
Temozolomide dosage modification is at the discretion of treating physician as per routine 
clinical care.  

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On day 1 of each cycle (+/- 7 days), ANC ≥ 1.5 x 109/L, platelet count ≥ 100 x 109/L and all 
treatment-related grade 3 or 4 non-hematologic AEs (except nausea and vomiting unless the 
patient has failed maximal antiemetic therapy and fatigue) must have resolved (to grade ≤ 1). 
 
6.3 
Disulfiram Dose Modifications 
 
If a patient experiences any grade 2 or higher non-hematologic toxicity considered by the 
investigator to be possibly, probably, or definitely related to DSF, the dose of DSF may 
be decreased by 50% (i.e., from 125 mg BID to 125 mg qd – and when taken with 
temozolomide to be administered within 6-8 hours prior to temozolomide dose) once. 
Special attention should be paid to neurological symptoms such as delirium/psychosis, 
gait disturbance/ataxia, and peripheral neuropathy. A grade 2 toxicity of the above 
neurological symptoms should prompt a consideration for further work-up and dose 
reduction.  
No second dose reduction is allowed—if a second dose reduction is required, DSF and 
Cu will be discontinued and the patient will be taken off study. Of note, hematologic 
toxicity is uncommon for DSF and is likely related to temozolomide. 
 
6.3.1 Administration of DSF to Patients with Abnormal Hepatic Function 
 
DSF-Cu should only be administered if hepatic function is within the parameters 
established in the eligibility criteria. Hepatic toxicity from DSF-Cu is uncommon 
but may occur. Therefore, hepatic dysfunction that occurs while the patient is on 
study should prompt an evaluation to determine the cause, including the 
possibility of hepatotoxicity from concurrent medications.  
 
6.3.2 Hypersensitivity Reactions  
 
Hypersensitivity reactions rarely occur. If they do occur, minor symptoms such as 
flushing, skin reactions, dyspnea, lower back pain, hypotension, or tachycardia 
may require no intervention; however, severe reactions, such as hypotension 
requiring treatment, dyspnea requiring bronchodilators, angioedema, or 
generalized urticaria require immediate discontinuation of study drug 
administration and aggressive symptomatic therapy. Patients who experience a 
severe hypersensitivity reaction to DSF should discontinue DSF immediately and 
not be re-challenged.    
 
7.0 
REGULATORY AND REPORTING REQUIREMENTS 
 
7.1 
Adverse Events (AEs) 
 
Definition: any unfavorable medical occurrence including any abnormal sign, symptom, 
or disease. 
 

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Grading: the descriptions and grading scales found in the revised NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 4.0 (2009) will be utilized for 
all toxicity reporting.  A copy of the CTCAE version 4.0 can be downloaded from the 
CTEP website: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
Attribution (relatedness), Expectedness, and Seriousness: the definitions for the terms 
listed that should be used are those provided by the Department of Health and Human 
Services’ Office for Human Research Protections (OHRP).  A copy of this guidance can 
be found on OHRP’s website:   http://www.hhs.gov/ohrp/policy/advevntguid.htm 
 
7.2 
Unanticipated Problems 
 
Definition: 
 
 unexpected (in terms of nature, severity, or frequency) given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document; and (b) the 
characteristics of the subject population being studied; 
 related or possibly related to participation in the research (in this guidance 
document, possibly related means there is a reasonable possibility that the 
incident, experience, or outcome may have been caused by the procedures 
involved in the research); and 
 any factual suggestion that the research places subjects or others at a greater risk 
of harm (including physical, psychological, economic, or social harm) than was 
previously known or recognized. 
 
7.3 
Noncompliance 
 
Definition: failure to follow any applicable regulation or institutional policies that govern 
human subjects’ research or failure to follow the determinations of the 
IRB.  Noncompliance may occur due to lack of knowledge or due to deliberate choice to 
ignore regulations, institutional policies, or determinations of the IRB. 
 
7.4 
Serious Noncompliance 
 
Definition: noncompliance that materially increases risks, that results in substantial harm 
to subjects or others, or that materially compromises the rights or welfare of participants. 
 
7.5 
Protocol Exceptions 
 
Definition: A planned deviation from the approved protocol that are under the research 
team’s control. Exceptions apply only to a single participant or a singular situation. 
 
Protocol exceptions are not expected or encouraged, and should be discussed first with 
the Study Sponsor. 

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7.6 
Reporting to the Institutional IRB 
 
The PI is required to promptly notify the IRB of the following events: 
 
 Any unanticipated problems involving risks to participants or others or that 
impact participants or the conduct of the study. 
 Noncompliance with federal regulations or the requirements or determinations of 
the IRB. 
 Receipt of new information that may impact the willingness of participants to 
participate or continue participation in the research study. 
 
These events must be reported to the IRB within 10 working days of the occurrence of 
the event or notification to the PI of the event.  The death of a research participant that 
qualifies as a reportable event should be reported within 1 working day of the occurrence 
of the event or notification to the PI of the event. 
 
7.7 
Reporting to the FDA 
 
The conduct of the study will comply with all FDA safety reporting requirements.  It is 
the responsibility of the investigator and Aurora ANII Clinical Research team to report 
any unanticipated problem to the FDA as follows: 
 
 Report any unexpected fatal or life-threatening adverse experiences associated 
with use of the drug (i.e., there is a reasonable possibility that the experience may 
have been caused by the drug) by telephone or fax no later than 7 calendar days 
after initial receipt of the information.  A life-threatening adverse experience is 
defined as any adverse drug experience that places the subject (in the view of the 
investigator) at immediate risk of death from the reaction as it occurred, i.e., it 
does not include a reaction that, had it occurred in a more severe form, might have 
caused death. 
 Report any serious, unexpected adverse experiences, as well as results from 
animal studies that suggest significant clinical risk within 15 calendar days after 
initial receipt of this information.  A serious adverse drug experience is defined as 
any adverse drug experience occurring at any dose that results in any of the 
following outcomes: 
o Death 
o Is life-threatening 
o Inpatient hospitalization or prolongation of existing hospitalization 
o A persistent or significant disability/incapacity (i.e., a substantial 
disruption of a person’s ability to conduct normal life functions) 
o A congenital anomaly/birth defect 
o Any other experience which, based upon appropriate medical judgment, 
may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed above 

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An unexpected adverse drug experience is defined as any adverse drug 
experience, the specificity or severity of which is not consistent with the current 
investigator brochure (or risk information, if an IB is not required or available). 
 
All MedWatch (Form FDA 3500A) forms will be sent by ANII Clinical Research Team 
to the FDA at the following address or by fax: 
 
Food and Drug Administration 
Center for Drug Evaluation and Research 
Division of Oncology Drug Products 
5901-B Ammendale Rd. 
Beltsville, MD 20705-1266 
FAX: 1-800-FDA-0178 
 
7.8 
Timeframe for Reporting Required Events  
 
Reportable adverse events will be tracked for 30 days after the last dose of DSF-Cu.  
 
8.0 
PHARMACEUTICAL INFORMATION 
 
8.1 
Disulfiram 
 
8.1.1 Disulfiram Description 
 
DSF is an alcohol antagonist drug approved by the FDA for the treatment of 
alcoholism. Its powder is white, odorless, and almost tasteless. It is soluble in 
water to the extent of about 20mg in 100mL, and in alcohol to the extent of about 
3.8 g in 100 mL. 
 
Molecular formula: C10H20N2S4 
Chemical name: bis(diethylthiocarbamoyl) disulfide.  
Molecular weight: 296.54. 
 
8.1.2 Clinical Pharmacology 
 
DSF is mostly known as an irreversible inhibitor of aldehyde dehydrogenase, 
which affects alcohol metabolism and causes accumulation of acetaldehyde. 
However, increasing preclinical studies have shown that DSF is also a proteasome 
inhibitor, specifically the chymotrypsin-like activity.  
Glioblastoma cells and its stem-like subpopulation (also referred to as CSC) may 
be more susceptible to the effect of proteasome inhibition than normal brain cells. 
DSF is an effective MGMT inhibitor. DSF is very lipophilic and readily crosses 
the blood-brain barrier.  
 
 
 

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8.1.3 Supplier 
 
ANII Clinical Research Team together with the Aurora Saint Luke’s Pharmacy 
Committee will decide upon a US unique manufacturer / supplier of DSF. Aurora 
Pharmacy Committee will ensure that for the purposes of the study that Aurora Saint 
Luke’s dispensing pharmacy will ensure cutting DSF 250 mg tabs into halves. 
 
8.1.4 Dosage Form 
 
DSF will be supplied in roughly 125 mg per dose (one half of 250 mg tab).  
 
8.1.5 Storage and Stability 
 
DSF is dispensed in a tight, light-resistant container. It should be stored at 
controlled room temperature (20° to 25°C or 68° to 77°F) in its original container 
to protect from bright light.  
 
8.1.6 Disulfiram Administration 
 
DSF is taken by mouth two times daily. It should be taken with meals to improve 
absorption. It should not be taken within one hour of temozolomide. Patients 
should not have consumed any alcohol at least 12 hours prior to the first dose. In 
the rare event of a severe hypersensitivity reaction, discontinue DSF immediately. 
 
8.1.7 Supplier 
 
DSF will be dispensed via the Aurora Saint Luke’s Pharmacies and provided by 
US manufacturer of choice which will be designated following review by the 
ANII Research Team and by the Aurora Pharmacy Committee  
 
8.1.8 Copper Gluconate Description 
 
Cu gluconate is a dietary food supplement generally recognized as safe (GRAS) under 
§21CFR184.1260. Cu is an important nutrient in the human body and plays an essential 
role by participating in numerous metabolic reactions in the body (Lecyk 1980; Stern et 
al. 2007).  Exposure to Cu usually occurs from consumption of food and drinking 
water.   Several studies have concluded that chronic dietary intakes of Cu less than 10 
mg/day pose no significant health risk 
 
8.1.9 Dosage Form 
 
Copper gluconate is supplied as 2 mg capsules/tablets.  
 
 
 
 

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8.1.10 Storage and Stability 
 
Copper gluconate is dispensed in a tight, light-resistant container. It should be 
stored at controlled room temperature (20° to 25°C or 68° to 77°F) in its original 
container to protect from bright light.  
 
8.1.11 Copper Gluconate Administration 
 
Copper gluconate is taken by mouth two times daily. It should be taken with 
meals and at the same time with DSF.  
 
8.1.12 Supplier 
 
A sufficient supply of Copper Gluconate will be  purchased by Aurora Research 
Institute and will be provided to subjects participating in this study at no cost to 
the subject. 
 
 

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9.0 
STUDY CALENDAR 
 
Screening/baseline evaluations are to be conducted within 4 weeks (+/- 7 days) prior to start of 
protocol therapy.  Scans will be performed prior to the start of the protocol therapy.  Each 
treatment cycle is 28 days. 
 
 
Screening / Baseline 
Weekly during 
radiation treatment 
Start of Fourth Week 
of radiation therapy 
Day 1 of Each Cycle 
(+/- 7 days)  
End of Every Even-
Numbered Cycle 
Day 1 of Cycle 1  
(+/- 7 days) 
Day 1 of Cycle 4  
(+/- 7 days) 
End of Treatment 
Follow-Up1 
Informed consent 
X 
 
 
 
 
 
 
 
 
H&P incl. neurologic exam, ECOG 
X 
 
 
X 
 
 
 
X 
 
Evaluation of corticosteroid usage 
X 
 
X 
X 
 
 
 
 
 
CBC 
X 
X 
 
X 
 
 
 
 
 
CMP 
X 
 
 
X 
 
 
 
 
 
Copper, blood 
X 
 
 
 
 
X 
X 
 
 
Pregnancy testing (if applicable) 
X 
 
 
 
 
 
 
 
 
Edmonton Symptom Assessment 
System – Revised (ESAS-r) QOL 
Questionnaire 
X 
 
X 
X 
 
 
 
X 
 
Brain MRI prior to enrollment 
X 
 
 
 
X2 
 
 
X 
 
Temozolomide 
 
 
 
Concurrent 
radiation with 
temozolomide 
on days 1-42 at 
75 mg/m2. 3 
Responding 
patients will 
subsequently 
receive  
adjuvant TMZ 
150 mg/m2 
Days 1-5 of 
each following 
28 day cycle3 
 
 
 
 
Disulfiram 
 
 
 
Days 1-28 of 
each cycle4 
 
 
 
 
Copper gluconate 
 
 
 
Days 1-28 of 
each cycle4 
 
 
 
 
AE assessment 
 
 
X 
X 
X 
X 
X 
X 
X 

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Version:  January 17, 2019 
 
page 33 of 42 
1. Follow-up will be as clinically indicated.  A chart review will be done at 2 years after the last dose of DSF 
to look for progression and survival. 
2. A confirmatory MRI should be considered in 8 weeks after documentation of complete response (CR) or 
partial response (PR) if consistent with the institutional standard of care 
3. To be taken at bedtime on an empty stomach.  Must not be taken within an hour of DSF. 
4. To be taken  two times a day with meals. 
5. AEs will be tracked for 30 days after the last dose of DSF. 
 
10.0 
STATISTICAL CONSIDERATIONS 
 
10.1 
Definition of Primary Endpoints and Analytical Plan 
 
The co-primary endpoints will be ORR and PFS6. ORR will be defined as the percentage 
of patients with CR or PR according to the RANO criteria as described in Section 6.0. 
PFS6 will be defined as proportion of patients that are free from progressive disease (PD) 
as per RANO criteria or death at 6 months from the date of the first dose of DSF-Cu. 
PFS6 and median PFS will be estimated using the Kaplan-Meier product-limit method. 
For unmethylated glioblastoma receiving temozolomide without DSF-Cu, an ORR of less 
than 10% and PFS6 of less than 20% (Quinn, et al. 2009).  
 
To justify future use of or drug development of DSF-Cu for glioblastoma, we 
hypothesized that the addition of DSF-Cu to temozolomide would improve ORR to 20% 
or increase PFS6 to 30%. The sample size is calculated based on the above hypotheses 
with one-sided exact test at an approximate α level of 0.10 and 80% statistical power.  At 
these type I and II error rates, 14 -20 patients will detect a proportion of patients who 
have ORR significantly higher than 5% or PFS6 significantly higher than 10%. Of note, 
previous phase II study testing addition of O6-benzylguanine (a MGMT inhibitor) to 
temozolomide for temozolomide-resistant glioblastoma used similar hypothesis and 
observed a disappointing ORR of 3% and PFS6 of 9% (Quinn, et al. 2009). This negative 
phase II study has detailed information on ORR, PFS, and OS as well as associated 
estimated 95% CIs and will serve as a historical comparison for this study.  
 
10.2 
Definition of Secondary Endpoints and Analytical Plans 
 
The secondary endpoints will be toxicity, and OS. 
 
1. Toxicities that are possibly/probably/definitively related to DSF will be graded by 
NCI CTCAE version 4.0 (2009) and will be tabulated by type and grade. 
2. OS will be measured from the date of the first dose of DSF+Cu to the date of 
death or, otherwise, the last follow-up date on which the patient was reported 
alive. Median OS and OS12 (proportion of patients that are alive at 12 months) 
will be estimated using the Kaplan-Meier product-limit method. 
 
 
 

ANII 100-1 Clinical Study Protocol:  DSF-Cu for Unmethylated Glioblastoma 
  
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11.0 
REFERENCES 
 
Chen, D., et al. 
 
2006 Disulfiram, a clinically used anti-alcoholism drug and copper-binding agent, 
induces apoptotic cell death in breast cancer cultures and xenografts via inhibition of the 
proteasome activity. Cancer Res 66(21):10425-33. 
Child, G. P., and M. Crump 
 
1952 The toxicity of tetraethylthiuram disulphide (antabuse) to mouse, rat, rabbit and 
dog. Acta Pharmacol Toxicol (Copenh) 8(3):305-14. 
Chinot, O. L., et al. 
 
2014 Bevacizumab plus radiotherapy-temozolomide for newly diagnosed glioblastoma. 
N Engl J Med 370(8):709-22. 
Cvek, B., et al. 
 
2008 Ni(II), Cu(II), and Zn(II) diethyldithiocarbamate complexes show various 
activities against the proteasome in breast cancer cells. J Med Chem 51(20):6256-8. 
Faiman, M. D., D. E. Dodd, and R. E. Hanzlik 
 
1978 Distribution of S35 disulfiram and metabolites in mice, and metabolism of S35 
disulfiram in the dog. Res Commun Chem Pathol Pharmacol 21(3):543-67. 
Faiman, M. D., J. C. Jensen, and R. B. Lacoursiere 
 
1984 Elimination kinetics of disulfiram in alcoholics after single and repeated doses. 
Clin Pharmacol Ther 36(4):520-6. 
Friedman, H. S., et al. 
 
2009 Bevacizumab alone and in combination with irinotecan in recurrent glioblastoma. 
J Clin Oncol 27(28):4733-40. 
Fuller, R. K., and E. Gordis 
 
2004 Does disulfiram have a role in alcoholism treatment today? Addiction 99(1):21-4. 
Gilbert, M. R., et al. 
 
2014 A randomized trial of bevacizumab for newly diagnosed glioblastoma. N Engl J 
Med 370(8):699-708. 
Gilbert, M. R., et al. 
 
2013 Dose-dense temozolomide for newly diagnosed glioblastoma: a randomized phase 
III clinical trial. J Clin Oncol 31(32):4085-91. 
Grossmann, K.F. , et al. 
 
2011 A phase I clinical study investigating disulfiram and copper gluconate in patients 
with advanced treatment-refractory solid tumors involving the liver. Cancer Res 71(Suppl 
8):[Abstract] nr 1308. 
Guild, J., and N. B. Epstein 
 
1951 Psychosis during the treatment of alcoholism with tetraethylthiuram disulfide. Q J 
Stud Alcohol 12(3):360-6. 
Hothi, P., et al. 
 
2012 High-throughput chemical screens identify disulfiram as an inhibitor of human 
glioblastoma stem cells. Oncotarget 3(10):1124-36. 
Huang, J., et al. 
 
2016 A phase I study to repurpose disulfiram in combination with temozolomide to 
treat newly diagnosed glioblastoma after chemoradiotherapy. J Neurooncol. 

ANII 100-1 Clinical Study Protocol:  DSF-Cu for Unmethylated Glioblastoma 
  
Version:  January 17, 2019 
 
page 35 of 42 
 
 
Jacobsen, E. 
 
1952 Deaths of alcoholic patients treated with disulfiram (tetraethylthiuram disulfide) 
in Denmark. Q J Stud Alcohol 13(1):16-26. 
Jensen, J. C., M. D. Faiman, and A. Hurwitz 
 
1982 Elimination characteristics of disulfiram over time in five alcoholic volunteers: a 
preliminary study. Am J Psychiatry 139(12):1596-8. 
Johansson, B. 
 
1990 Plasma protein binding of disulfiram and its metabolite diethylthiocarbamic acid 
methyl ester. J Pharm Pharmacol 42(11):806-7. 
 
1992 A review of the pharmacokinetics and pharmacodynamics of disulfiram and its 
metabolites. Acta Psychiatr Scand Suppl 369:15-26. 
Johansson, B., et al. 
 
1991 Dose-effect relationship of disulfiram in human volunteers. II: A study of the 
relation between the disulfiram-alcohol reaction and plasma concentrations of 
acetaldehyde, diethyldithiocarbamic acid methyl ester, and erythrocyte aldehyde 
dehydrogenase activity. Pharmacol Toxicol 68(3):166-70. 
Johnson, D. R., and B. P. O'Neill 
 
2012 Glioblastoma survival in the United States before and during the temozolomide 
era. J Neurooncol 107(2):359-64. 
Kreisl, T. N., et al. 
 
2009 Phase II trial of single-agent bevacizumab followed by bevacizumab plus 
irinotecan at tumor progression in recurrent glioblastoma. J Clin Oncol 27(5):740-5. 
Liu, P., et al. 
 
2012 Cytotoxic effect of disulfiram/copper on human glioblastoma cell lines and 
ALDH-positive cancer-stem-like cells. Br J Cancer 107(9):1488-97. 
Lun, X., et al. 
 
2016 Disulfiram when combined with copper enhances the therapeutic effects of 
temozolomide for the treatment of Glioblastoma. Clin Cancer Res. 
Major, L. F., et al. 
 
1979 Dopamine-beta-hydroxylase in the cerebrospinal fluid: relationship to disulfiram-
induced psychosis. Biol Psychiatry 14(2):337-44. 
Martensen-Larsen, O. 
 
1951 Psychotic phenomena provoked by tetraethylthiuram disulfide. Q J Stud Alcohol 
12(2):206-16. 
Milandri, M., et al. 
 
1980 Effect of long-term disulfiram administration on rat liver. Pharmacology 
21(1):76-80. 
Nilsson, G. E., O. Tottmar, and G. Wahlstrom 
 
1987 Effects of aldehyde dehydrogenase inhibitors on hexobarbital sensitivity and 
neuroamine metabolism in rat brain. Brain Res 409(2):265-74. 
Ostrom, Q. T., et al. 
 
2014 CBTRUS statistical report: primary brain and central nervous system tumors 
diagnosed in the United States in 2007-2011. Neuro Oncol 16 Suppl 4:iv1-63. 
 

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page 36 of 42 
 
 
Paranjpe, A., et al. 
 
2014 Disulfiram is a direct and potent inhibitor of human O6-methylguanine-DNA 
methyltransferase (MGMT) in brain tumor cells and mouse brain and markedly increases 
the alkylating DNA damage. Carcinogenesis 35(3):692-702. 
Perry, J. R., et al. 
 
2010 Phase II trial of continuous dose-intense temozolomide in recurrent malignant 
glioma: RESCUE study. J Clin Oncol 28(12):2051-7. 
Piccioni, D. E., et al. 
 
2014 Deferred use of bevacizumab for recurrent glioblastoma is not associated with 
diminished efficacy. Neuro Oncol 16(6):815-22. 
Quinn, J. A., et al. 
 
2009 Phase II trial of temozolomide plus O6-benzylguanine in adults with recurrent, 
temozolomide-resistant malignant glioma. J Clin Oncol 27(8):1262-7. 
Schweizer, M. T., et al. 
 
2013 Pharmacodynamic study of disulfiram in men with non-metastatic recurrent 
prostate cancer. Prostate Cancer Prostatic Dis 16(4):357-61. 
Stewart, D. J., S. Verma, and J. A. Maroun 
 
1987 Phase I study of the combination of disulfiram with cisplatin. Am J Clin Oncol 
10(6):517-9. 
Stupp, R., et al. 
 
2005 Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N 
Engl J Med 352(10):987-96. 
Suh, J. J., et al. 
 
2006 The status of disulfiram: a half of a century later. J Clin Psychopharmacol 
26(3):290-302. 
Triscott, J., et al. 
 
2012 Disulfiram, a drug widely used to control alcoholism, suppresses the self-renewal 
of glioblastoma and over-rides resistance to temozolomide. Oncotarget 3(10):1112-23. 
Wen, P. Y., et al. 
 
2010 Updated response assessment criteria for high-grade gliomas: response 
assessment in neuro-oncology working group. J Clin Oncol 28(11):1963-72. 
Wilk, W., et al. 
 
2015 Phase III trial exploring the combination of bevacizumab and lomustine in 
patients with first recurrence of a glioblastoma: the EORTC 26101 trial. Neuro Oncol 
17(suppl 5):v1 [abstract: LB-05]. 
 
 
 
 

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APPENDIX A:  
 
 
 
GRADE 
ECOG PERFORMANCE STATUS 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out work of 
a light or sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all selfcare but unable to carry out any work activities; up 
and about more than 50% of waking hours 
3 
Capable of only limited selfcare; confined to bed or chair more than 50% of waking 
hours 
4 
Completely disabled; cannot carry on any selfcare; totally confined to bed or chair 
5 
Dead 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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page 38 of 42 
 
APPENDIX B – Comparison of the ECOG Performance Status to the Karnofsky Performance 
Status 
 
ECOG PERFORMANCE STATUS 
KARNOFSKY PERFORMANCE 
STATUS 
0—Fully active, able to carry on all pre-disease 
performance without restriction 
100—Normal, no complaints; no 
evidence of disease 
90—Able to carry on normal 
activity; minor signs or symptoms of 
disease 
1—Restricted in physically strenuous activity but 
ambulatory and able to carry out work of a light or 
sedentary nature, e.g., light house work, office work 
80—Normal activity with effort, 
some signs or symptoms of disease 
70—Cares for self but unable to 
carry on normal activity or to do 
active work 
2—Ambulatory and capable of all selfcare but unable to 
carry out any work activities; up and about more than 50% 
of waking hours 
60—Requires occasional assistance 
but is able to care for most of 
personal needs 
50—Requires considerable assistance 
and frequent medical care 
3—Capable of only limited selfcare; confined to bed or 
chair more than 50% of waking hours 
40—Disabled; requires special care 
and assistance 
30—Severely disabled; 
hospitalization is indicated although 
death not imminent 
4—Completely disabled; cannot carry on any selfcare; 
totally confined to bed or chair 
20—Very ill; hospitalization and 
active supportive care necessary 
10—Moribund 
5—Dead 
0—Dead 
 
 

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APPENDIX C: Disulfiram and Copper Medication Diary 
 
Today’s Date:    
 
 
 
 
Agent:   Disulfiram/Copper 
Month: ____ 
 
Patient Name:    
 
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete one form for each month.  Take __ mg ( ___capsule) of disulfiram two times a day with meals with 
breakfast and dinner). Please also take 2 mg of copper gluconate supplement two times a day with each meal. 
Do not take disulfiram or copper within one hour of your dose of temozolomide. 
2. Record the date, and how many times you took disulfiram and copper on that date. 
3. If you have any questions or notice any side effects, please record them in the comments section.  Record the 
time if you should vomit. 
4. Please return the forms to your physician or your study coordinator when you go to your next appointment.  
Please bring your unused study medications and/or empty bottles with you to each clinic visit so that a pill count 
can be done. 
5. Avoid consuming alcohol before and throughout the entire study.   
 
Day 
Date 
Check each time you take 
your disulfiram dose 
Check each time you take 
your copper dose 
Comments 
 
 
Breakfast 
Lunch 
Dinner 
Breakfast 
Lunch 
Dinner 
 
1 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
3 
 
 
 
 
 
 
 
 
4 
 
 
 
 
 
 
 
 
5 
 
 
 
 
 
 
 
 
6 
 
 
 
 
 
 
 
 
7 
 
 
 
 
 
 
 
 
8 
 
 
 
 
 
 
 
 
9 
 
 
 
 
 
 
 
 
10 
 
 
 
 
 
 
 
 
11 
 
 
 
 
 
 
 
 
12 
 
 
 
 
 
 
 
 
13 
 
 
 
 
 
 
 
 
14 
 
 
 
 
 
 
 
 
15 
 
 
 
 
 
 
 
 
16 
 
 
 
 
 
 
 
 
17 
 
 
 
 
 
 
 
 
18 
 
 
 
 
 
 
 
 
19 
 
 
 
 
 
 
 
 
20 
 
 
 
 
 
 
 
 
21 
 
 
 
 
 
 
 
 
22 
 
 
 
 
 
 
 
 
23 
 
 
 
 
 
 
 
 
24 
 
 
 
 
 
 
 
 
25 
 
 
 
 
 
 
 
 
26 
 
 
 
 
 
 
 
 
27 
 
 
 
 
 
 
 
 
28 
 
 
 
 
 
 
 
 
 
 
 

ANII 100-1 Clinical Study Protocol:  DSF-Cu for Unmethylated Glioblastoma 
  
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APPENDIX D: Concurrent Temozolomide Medication Diary 
 
Today’s Date:    
 
 
 
 
Agent:   Temozolomide  
Month: ____ 
 
Patient Name:    
 
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
 
1. Complete this form.  Take _____mg ( ___capsules) of temozolomide daily as instructed by 
your oncologist. Temozolomide should be taken within one hour of your radiation appointment 
each day on an empty stomach and should not be taken within one hour of your disulfiram or 
copper supplement. During weekends without radiation treatments (Saturday and Sunday), 
temodar will be taken in the morning.  
2. Record the date, the number of capsules taken, and when you took them. 
3. If you forget to take temozolomide before midnight, then do not take a dose that day. Restart it the next day. 
4. If you have any questions or notice any side effects, please record them in the comments section.  Record 
the time if you should vomit. 
5. Please return the forms to your physician or your study coordinator when you go to your next appointment.  
Please bring your unused study medications and/or empty bottles with you to each clinic visit so that a pill 
count can be done. 
6. Avoid consuming alcohol before and throughout the entire study.   
 
Day 
Date 
What time was 
dose taken? 
# of tablets 
taken 
Comments 
1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
6 
 
 
 
 
7 
 
 
 
 
8 
 
 
 
 
9 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
13 
 
 
 
 
14 
 
 
 
 
15 
 
 
 
 
16 
 
 
 
 
17 
 
 
 
 
18 
 
 
 
 
19 
 
 
 
 
20 
 
 
 
 
21 
 
 
 
 
22 
 
 
 
 
23 
 
 
 
 
24 
 
 
 
 
25 
 
 
 
 
26 
 
 
 
 
27 
 
 
 
 
28 
 
 
 
 
29 
 
 
 
 

ANII 100-1 Clinical Study Protocol:  DSF-Cu for Unmethylated Glioblastoma 
  
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page 41 of 42 
30 
 
 
 
 
31 
 
 
 
 
32 
 
 
 
 
33 
 
 
 
 
34 
 
 
 
 
35 
 
 
 
 
36 
 
 
 
 
37 
 
 
 
 
38 
 
 
 
 
39 
 
 
 
 
40 
 
 
 
 
41 
 
 
 
 
42 
 
 
 
 
 
 
 

ANII 100-1 Clinical Study Protocol:  DSF-Cu for Unmethylated Glioblastoma 
  
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page 42 of 42 
 
APPENDIX E: Adjuvant Temozolomide Medication Diary 
 
Today’s Date:    
 
 
 
 
Agent:   Temozolomide  
Month: ____ 
 
Patient Name:    
 
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete this form.  Take _____mg ( ___capsules) of temozolomide daily as instructed by your oncologist. 
Temozolomide should be taken at bedtime on an empty stomach and should not be taken within one 
hour of your disulfiram or copper supplement. 
2. Record the date, the number of capsules taken, and when you took them. 
3. If you forget to take temozolomide before midnight, then do not take a dose that day.  Restart it the next day. 
4. If you have any questions or notice any side effects, please record them in the comments section.  Record the 
time if you should vomit. 
5. Please return the forms to your physician or your study coordinator when you go to your next appointment.  
Please bring your unused study medications and/or empty bottles with you to each clinic visit so that a pill count 
can be done. 
6. Avoid consuming alcohol before and throughout the entire study.   
 
Day 
Date 
What time was 
dose taken? 
# of tablets 
taken 
Comments 
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