Biological Medicine for Diffuse Intrinsic Pontine Glioma (DIPG) Eradication 2.0

Study Overview
=================
Brief Summary
-----------------
The BIOMEDE 2.0 study is the second stage of the BIOMEDE multi-arm, multistage rolling programme (adaptive platform protocol). It is a multicenter, randomized open-label phase-3 controlled trial evaluating efficacy of ONC201 in comparison with everolimus (primary objective based on internal comparison) and subsequently to historical controls. Two treatment groups will be compared. A switch between treatment groups is allowed after confirmation of the disease progression (real-time central review blinded to the treatment arm allocation). Study treatment will be continued until disease progression, unacceptable toxicity or consent withdrawal. The final conclusion of the trial will be successful for ONC201, if ONC201 is found significantly superior to everolimus in terms of centrally-reviewed PFS (Progression-free survival) from randomization (internal comparison) either overall, considering ND-DMG and DIPG-patients together, or in the subgroup of ND-DMG patients alone. In other cases, Everolimus will remain the standard arm unless it appears associated with an excess of toxicity compared to ONC201 which could then be discussed as a new standard.

Official Title
-----------------
Biological Medicine for Diffuse Intrinsic Pontine Glioma (DIPG) Eradication

Conditions
-----------------
Diffuse Intrinsic Pontine Glioma, Diffuse Midline Glioma, H3 K27M-Mutant

Intervention / Treatment
-----------------
* Drug: Everolimus
* Drug: ONC201
* Radiation: Radiotherapy


Participation Criteria
=================
Eligibility Criteria
-----------------
Eligibility criteria for the inclusion (registration) in BIOMEDE 2.0 study: Diagnosis Criteria: Diagnosis of DIPG (clinical and radiological). As biopsy is not standard for these tumors, an informed consent is required for the necessary histological verification. [Biopsy-part of BIOMEDE 2.0 trial]. OR Histological diagnosis of DIPG (i.e. H3K28M or EZHIP positive Diffuse Midline Glioma located in the pons) in case the biopsy was performed before study entry. The diagnosis will be defined by 1/ diffuse glioma, 2/ H3K28M mutation or loss of H3K28 trimethylation together with EZHIP overexpression. In this situation, patient will sign the consent after the diagnosis to allow central review and biomarkers assessment thereafter. OR Non-DIPG diffuse midline gliomas, H3K28M mutant (ND-DMG) or with H3K28 trimethylation loss together with EZHIP overexpression, will be eligible for the trial after biopsy or surgery. As biopsy and surgery is considered as standard practice for these locations, informed consent for the biopsy will not be necessary. Patient will sign the consent after the diagnosis to allow central review and biomarkers assessment thereafter. Eligible for a biopsy, or biopsy material available for the biomarker assessment. Age > 6 months, with no upper age limit. Children between 6 months and 3 years will be discussed on a case by case basis for inclusion in the study for the feasibility of the stereotactic biopsy. Eligible for cerebral or craniospinal radiotherapy. Tumor at diagnosis: no prior chemotherapy for the present cancer; no prior cerebral radiation therapy even for another neoplasm. Surgery is allowed when performed for diagnostic or therapeutic purpose. Metastatic diseases or spinal tumors allowed; in this case, patients would receive craniospinal or spinal radiotherapy and medical treatment (everolimus or ONC201) will be postponed and only started after the end of radiotherapy. Patients must be affiliated to a social security system or beneficiary of the same according to local requirements. Written informed consent from parents/legal representative, patient, and age-appropriate assent before any study-specific procedures are conducted according to local, regional or national guidelines. Non eligibility criteria for the inclusion (registration) in BIOMEDE 2.0 study: Spontaneous massive intratumor bleeding. Patients with post-operative bleeding will be allowed to enter the study provided the hemorrhage is controled. Same rule applies for the other post-operative complications (infection, CSF leakage, absence of wound closure, subdural collection…). Any other concomitant anti-cancer treatment not foreseen by this protocol is not allowed, except corticosteroids and Bevacizumab which are allowed at any dosage during the protocol. Bevacizumab is not allowed before surgery. Their used will be taken into account when judging the possibility of progression/pseudoprogression. Any other cancer during the last 5 years. Uncontrolled intercurrent illness or active infection. Any other co-morbid condition that in the investigator's opinion would impair study participation. Unable for medical follow-up (geographic, social or mental reasons). Patient previously treated with irradiation on the brainstem for another neoplasm. Participation in another clinical study with an investigational product while on study treatment. Patient under guardianship or deprived of his liberty by a judicial or administrative decision or incapable of giving its consent. Eligibility criteria for the randomization in BIOMEDE 2.0 study: Patient enrolled in the BIOMEDE 2.0 study. Life expectancy > 12 weeks after the start of study treatment. Confirmed histological diagnosis of diffuse intrinsic pontine glioma (as per the WHO criteria) or ND-DMG confirmed by central pathology review, with: mutation in the histone H3.1, H3.2, H3.3 genes or loss of H3K28me3 and EZHIP overexpression by immunohistochemistry. Patients with a suspected DIPG but no histological confirmation (biopsy not informative) are eligible for the randomized trial if and only if the radiology is typical of a DIPG (mandatory central radiological review) as well as the short clinical history (less than three months of pre-existing symptoms). Confirmation of the diagnosis of non-DIPG diffuse midline gliomas by central review is needed before the randomization of cases of ND-DMG. Karnofsky performance status scale or Lansky Play Scale > 50%. The PS should not take the neurologic deficit per se into account. NB: Children and adults with a worse performance status due to glioma-related motor paresis can be included. Effective and appropriate contraception for patients (male and female) of reproductive potential during their entire participation in the study and during 6 months after the end of treatment. Negative pregnancy test (serum beta-HCG or urinary test) evaluated within one week prior randomization in sexually active females of reproductive potential. Absolute neutrophil count > 1.5 x 109/l, Platelets > 100 x 109/l. Total bilirubin < 1.5 x ULN, AST and ALT< 2.5 x ULN. Serum creatinine < 1.5 X ULN for age. If serum creatinine > 1.5 x ULN, creatinine clearance must be > 70 ml/min/1.73 m² (as per local practice). Normal coagulation tests within the local reference ranges. Ability to swallow capsules. Patients unable to swallow capsules will be treated in the everolimus arm without randomization (except if contra-indication to everolimus and in this case, patients will not be included in the treatment part of the trial). Written informed consent from parents/legal representative, patient, and age-appropriate assent before randomization according to local, regional or national guidelines. Non Eligibility criteria for the randomization in BIOMEDE 2.0 study: Current organ toxicity > grade 2 according to the NCI-CTCAE version 5.0 especially cardiovascular or renal disease (including but not limited to: congenital long QT syndrome, nephrotic syndrome, glomerulopathy, uncontrolled high blood pressure despite adequate treatment). ONC201 administration should be avoided for patients with: Prolongation of QT/QTcF interval (QTc interval > 480 milliseconds) using Frederica's QT correction formula on two ECGs separated by at least 48 hours. A history of Torsades de pointes or heart failure, hypokalemia, or family history of prolonged QT Syndrome. Required concomitant use of medication(s) known to prolong the QT/QTc interval. Pregnant or breastfeeding women. Patients with chronic HBV disease compatible with the trial are not excluded from the study. These patients randomized to everolimus treatment will have regular viral load monitoring throughout the study. Patients unable to swallow the capsules will be treated with everolimus without randomization (except in case of a contra-indication to everolimus). Patients with a BSA (calculated by Mosteller Formula) below 0.56 cannot receive ONC201, they will be treated in the everolimus arm without randomization (except if contra-indication to everolimus). Patients diagnosed without mTOR pathway activation will not be randomized and will be treated with the ONC201 arm (except if contra-indication to ONC201). mTOR pathway activation will be analysed by IHC showing PTEN loss of expression in the tumor cells. In case of doubt, pS6 and/or pAKT expression will be used to confirm mTOR pathway activation. Patients taking strong P450 inhibitors or inducers or PgP inhibitors are not excluded from the study but drug concentration of everolimus should be monitored carefully to avoid toxicity. Preferably alternative medications should be considered. Patient with known congenital galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption will not be randomized and will be treated with the ONC201 arm. Patients with known hypersensitivity to any component of Everolimus (active substance, other rapamycin be treated with the ONC201 arm. Patients with known hypersensitivity to any component of ONC201 (drug product or excipients) will not be randomized and will be treated with the Everolimus arm.

Ages Eligible for Study
-----------------
Minimum Age: 6 Months

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: everolimus<br>Tablets of 2.5 mg or 10mg. The prescribed dose is 5 mg/m²/day, orally, once daily. Dose will be capped at 10mg once daily. Treatment will be continued until unacceptable toxicity, tumor progression, and/or withdrawal of patient, parents or legal representative consent. At the time of centrally confirmed relapse or progression, patients will be allowed to switch to the other arm in case no better option is available after considering the results of the molecular profiling. In case of switch (everolimus to ONC201 or vice-versa) after confirmed disease progression (real-time central review blinded to the treatment allocation), the treatment will also be continued until unacceptable toxicity, tumor progression, and/or withdrawal of patient, parents or legal representative consent. | Drug: Everolimus<br>* Tablets of 2.5 mg or 10mg. The prescribed dose is 5 mg/m²/day, orally, once daily. Dose will be capped at 10mg once daily.<br>* Other names: VOTUBIA;Radiation: Radiotherapy<br>* All patients will be treated with 30 conventional single daily fraction of 1.8 Gy to a total of 54 Gy over a planned period of 6 weeks. The clinical target volume will include all the areas of abnormality on T2/FLAIR sequences with a 1-cm margin. Radiotherapy will have to start ideally within three weeks (MAXIMUM four weeks) after the biopsy or last surgery. Radiotherapy should be planned as soon as the biopsy date is known (between 10 and 21/28 days after the planned date of biopsy). Treatments will start on the first day of irradiation (+3 days max). Reirradiation is permitted according to local practice. In case of metastatic disease or intramedullary tumors, patients can be included in the study. In this situation, radiotherapy will have to start within three weeks (4 weeks maximum) after the biopsy while targeted treatment will start at the end of the irradiation.<br>|
| Experimental: ONC201<br>Capsules of 125mg. 375mg/m2 per dose, day 1 and day 2 of each week. Dose will be capped at 625mg per dose. Treatment will be continued until unacceptable toxicity, tumor progression, and/or withdrawal of patient, parents or legal representative consent. At the time of centrally confirmed relapse or progression, patients will be allowed to switch to the other arm in case no better option is available after considering the results of the molecular profiling. In case of switch (everolimus to ONC201 or vice-versa) after confirmed disease progression (real-time central review blinded to the treatment allocation), the treatment will also be continued until unacceptable toxicity, tumor progression, and/or withdrawal of patient, parents or legal representative consent. | Drug: ONC201<br>* Capsules of 125mg. 375mg/m2 per dose, day 1 and day 2 of each week. Dose will be capped at 625mg per dose.<br>Radiation: Radiotherapy<br>* All patients will be treated with 30 conventional single daily fraction of 1.8 Gy to a total of 54 Gy over a planned period of 6 weeks. The clinical target volume will include all the areas of abnormality on T2/FLAIR sequences with a 1-cm margin. Radiotherapy will have to start ideally within three weeks (MAXIMUM four weeks) after the biopsy or last surgery. Radiotherapy should be planned as soon as the biopsy date is known (between 10 and 21/28 days after the planned date of biopsy). Treatments will start on the first day of irradiation (+3 days max). Reirradiation is permitted according to local practice. In case of metastatic disease or intramedullary tumors, patients can be included in the study. In this situation, radiotherapy will have to start within three weeks (4 weeks maximum) after the biopsy while targeted treatment will start at the end of the irradiation.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression-free survival | Defined as the time between date of randomization and unequivocal clinical or radiological progression confirmed by central review, or death whatever the cause. | Until 2 years after inclusion of the last patient | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall survival (for all the comparisons to historical controls) | Defined from the date of radiological diagnosis to the date of death from any cause. | Until 5 years after randomization of the last patient | 
| Overall survival (for the internal comparison between randomized groups) | Defined from the date of randomization to the date of death from any cause. | Until 5 years after randomization of the last patient | 
| Progression-free survival after first progression | It will also be computed from the date of progression to the date of subsequent progression or death from any cause, in order to describe the outcome after progression. | Until 5 years after randomization of the last patient | 
| Complication rate of the diagnostic biopsy-based procedure |  | Until 5 years after randomization of the last patient | 
| Severity of the complications (including prolongation of the hospital stay) of the diagnostic biopsy-based procedure |  | Until 5 years after randomization of the last patient | 
| Duration of the complications (including delay for starting treatment) of the diagnostic biopsy-base procedure |  | Until 5 years after randomization of the last patient | 
| Safety profile of the drugs | Using the NCI-CTC v5.0 criteria, during radiotherapy and during the entire duration of the administration of the drug, considering all adverse events except adverse events unequivocally related to the disease (pseudo)-progression. | Until 5 years after randomization of the last patient | 
| Relative benefit/risk ratio of ONC201 compared to everolimus | It will be assessed using the Q-TWiST approach (Quality-adjusted time without symptoms of disease or adverse event) evaluated from survival times (overall survival and progression-free survival) and adverse events data (date of occurrence of grade 3+ adverse event). | Until 5 years after randomization of the last patient | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Children, Adolescents, Adults, Newly diagnosed