Efficacy and Safety of NaviFUS System add-on Bevacizumab (BEV) in Recurrent GBM Patients

Study Overview
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Brief Summary
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This is a prospective, single-arm, two stages, open-label, pilot study to investigate the efficacy and safety of FUS add-on bevacizumab (BEV) in rGBM patients. The BEV is the best physician's choice of standard of care for rGBM after prior radiotherapy and temozolomide chemotherapy in the LinKou Chang Gung Memorial Hospital. Eligible patients will be enrolled through the process of informed consent.

Detailed Description
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This trial will be divided into two stages. The study design and procedures will be as follows: Stage 1: Eligible patients will first be administered with BEV 10 mg/kg intravenous (IV) infusion. After 30-60 minutes, patients will receive microbubbles (MB) (SonoVue®) 0.1 mL/kg and optimal ultrasound exposure doses (based on the acoustic emission feedback FUS power control algorithm) generated from the NaviFUS System single exposure unit for up to two minutes every 2 weeks to transiently open the BBB. After 4 weeks of treatment with BEV and single unit FUS-MB treatment, if the patient experienced BBB opening using FUS treatment and BEV IV infusion without any serious adverse effects (such as brain significant bleeding), then the patient may proceed to stage 2. Stage 2: Patients who complete stage 1 will enter stage 2 to receive the BEV with MB-mediated multiple units of FUS treatment for up to five minutes (but the maximum exposure time per single unit is two minutes) every 2 weeks for up to 30 weeks or until evidence of progressive disease, unacceptable toxicity, non-compliance with study follow-up, or withdrawal of consent. After completion of study treatment, patients will be followed up for 28 days.

Official Title
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An Open Label, Prospective, Pilot Study to Evaluate the Efficacy and Safety of Best Physician's Choice of Standard of Care Combined With NaviFUS System in Patients With Recurrent Glioblastoma Multiforme

Conditions
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Glioma, Glioblastoma Multiforme, Glioblastoma, Brain Tumor, Neoplasms, Neoplasms, Nerve Tissue

Intervention / Treatment
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* Device: NaviFUS System
* Drug: Bevacizumab


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult male/female patients ≥ 20 years of age Patients with histologically confirmed glioblastoma, recurrent after prior radiotherapy and temozolomide chemotherapy. Patient may have been operated for recurrence. If operated: with measurable residual tumor Minimum interval since completion of radiation treatment is 12 weeks Patients if already on the steroids then should be on a stable dose of steroids for at least 7 days prior to study treatment Body mass index (BMI) ≥17 kg / m2 Minimum interval since last drug therapy: 1 week for non-cytotoxic agents (e.g., interferon, tamoxifen), daily chemotherapy (e.g., metronomic temozolomide, cytoxan) or targeted therapies administered daily (e.g., gleevec, tarceva) 4 weeks since last cytotoxic therapy 6 weeks since the completion of a nitrosourea-containing chemotherapy regimen (e.g., carmustine (BCNU)) Patients with life expectancy ≥ 3 months The Karnofsky performance status (KPS) in the patient must be > 60 Eastern Cooperative Oncology Group (ECOG) Score ≤ 2 Adequate hepatic, renal, coagulation, and hematopoietic function Hemoglobin ≥ 8 g/dL Platelets ≥ 100,000/mm3 Neutrophils ≥ 1,500/mm3 Serum creatinine ≤ 1.5 x upper limit of normal (ULN) Urine protein creatinine (UPC) ratio < 1 or urine dipstick for proteinuria ≤ 2+ Alanine transaminase (ALT) < 3 ULN Aspartate transaminase (AST) < 3 x ULN Prothrombin time ≤ 1.2 x ULN International Normalized Ratio (INR) < 1.5 Bilirubin < 2 x ULN Patients with the region of interest (ROI) for FUS exposure are located close to the cortex with at least 20 mm distance beneath the skull bone and the ROI is not in the deep center brain with crucial brain functions, such as in the region of brain stem, or motor or speech regions Patients with the potential for pregnancy and their partner must agree to use adequate contraception or be surgically sterile, or abstain from heterosexual activity starting with the first dose of treatment through at least 6 months after the last dose of BEV to avoid conception. Female patients of child-bearing potential must have a negative pregnancy test. Male patients must agree to use an adequate method of contraception starting with the first dose of treatment through 6 months after the last dose of BEV. Able to give informed consent for the participation in the trial Exclusion Criteria: Patients who have had previous treatment with an inhibitor of vascular endothelial growth factor (VEGF) or VEGFR (including bevacizumab) New York Heart Association (NYHA) Grade II or greater congestive heart failure requiring hospitalization within 12 months prior to screening Severe hypertension at screening (diastolic blood pressure > 100 mmHg on medication) Uncontrolled intercurrent illness including, but not limited to symptomatic congestive heart failure, unstable angina pectoris, severe cerebral or myocardial infarction, cardiac shunt, heart attack within the previous 12 months, stroke (except for transient ischemic attack; TIA) within the previous 6 months, or psychiatric illness/social situations that would limit compliance with study requirements Unstable pulmonary disease or Chronic Obstructive Pulmonary Disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at the time of screening Implanted pacemaker, defibrillator or deep brain stimulator, other implanted electronic devices in the brain or documented clinically significant arrhythmias Major surgery such as intra-thoracic, intra-abdominal or intra-pelvic (with the exception of craniotomy), open biopsy or significant traumatic injury ≤ 4 weeks prior to screening, or patients who have had minor procedures, percutaneous biopsies or placement of vascular access device ≤ 1 week prior to screening, or who have not recovered from side effects of such procedure or injury Known HIV positive patients, however, that HIV testing is not required for entry into this study Acute bacterial or fungal infection requiring intravenous antibiotics at the time of screening Receiving anticoagulant (e.g. warfarin) or antiplatelet (e.g. aspirin) therapy within one week prior to beginning treatment Pregnant or breast-feeding women Known sensitivity/allergy to PET tracers, Magnetic Resonance Imaging (MRI) contrast agents, Computer Tomography (CT) contrast agents, SonoVue®, bevacizumab, or any of their components Abnormal baseline findings considered by the investigator to indicate conditions that might affect study endpoints Patients who have hemorrhage or cyst within the ROI The receipt of an investigational drug within a period of 4 weeks prior to the first FUS exposure Use of any recreational drugs or history of drug addiction Any other condition that, in the investigator's judgment, might increase the risk to the patients or decrease the chance of obtaining satisfactory data needed to achieve the objectives of the study

Ages Eligible for Study
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Minimum Age: 20 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Bevacizumab plus NaviFUS System<br>Device: NaviFUS System BBB Disruption by FUS in recurrent GBM Microbubbles (MB) (SonoVue®) 0.1 mL/kg and optimal ultrasound exposure doses (based on the acoustic emission feedback FUS power control algorithm) generated from the NaviFUS System every 2 weeks to transiently open the BBB. Drug: Bevacizumab 10 mg/kg every 2 weeks for up to 36 weeks or until evidence of progressive disease, unacceptable toxicity, non-compliance with study follow-up, or withdrawal of consent. | Device: NaviFUS System<br>* Open the BBB using focused ultrasound and contrast agent SonoVue®<br>Drug: Bevacizumab<br>* An anti-angiogenic agent to block tumor growth<br>* Other names: Avastin;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Adverse Event | Number and severity of adverse event | 38 weeks | 
| Progression-free survival at 6 months (PFS-6) | Estimated rate of patients treated during 6 months without experiencing disease | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Tumor shrinkage | The tumor shrinkage rate (TSR) by measuring the longest diameter and perpendicular diameter of the main mass on MRI scans | 38 weeks | 
| Objective response rate (ORR) | Proportion of subjects in the analysis population who have complete response (CR) or partial response (PR) using Radiologic Assessment in Neuro-Oncology criteria (RANO) criteria | 38 weeks | 
| PET uptake | The uptake of PET (as standard uptake value - SUV and tumor-to-background ratio - TBR) in tumor and in normal contralateral gray matter before start of BEV+FUS treatment will be determined. | 38 weeks | 
| Overall survival (OS) | OS is defined as the time in months from study treatment to death or last follow-up if alive from any cause | 38 weeks | 
| Degree of the BBB opening | The FUS with microbubbles can temporally open the BBB. The spatial permeability of the BBB-opened region will be assessed using dynamic contrast-enhanced MRI (DCE-MRI). | 38 weeks | 
| Corticosteroid consumption | Increase or decrease in corticosteroid use compared to baseline. The mean corticosteroid dosage prior to study treatment will be considered as the patient's baseline. | 38 weeks | 
| Quality of life (QoL) assessment with the EORTC QLQ-C30 | The validated European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ-C30) will be used. The EORTC QLQ-C30 is a 30-item questionnaire. All of the response scale to questions are rated on a 4-point Likert scale from 1 = not at all, 2 = a little, 3 = quite a bit, to 4 = very much, and are linearly transformed to a 0-100 scale, with higher scores indicating more severe symptoms. | 38 weeks | 
| Quality of life (QoL) assessment with the EORTC QLQ-BN20 | The EORTC QLQ-BN20 is a QoL assessment specific to brain neoplasms. The questionnaire includes 20 items. All of the response scale to questions are rated on a 4-point Likert scale from 1 = not at all, 2 = a little, 3 = quite a bit, to 4 = very much, and are linearly transformed to a 0-100 scale, with higher scores indicating more severe symptoms. | 38 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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NaviFUS System, Blood-Brain Barrier, Focused Ultrasound, GBM, Bevacizumab