Conditions: Glioblastoma Multiforme
Allocation: NON_RANDOMIZED | Intervention model: SEQUENTIAL
Enrollment: 35
Healthy volunteers: no

Brief summary:
The proposed phase I/II study of disulfiram (DSF) for patients with presumed glioblastoma multiforme (GBM) based on magnetic resonance imaging (MRI) or biopsy, including administration before surgery and during adjuvant chemoradiotherapy. Patients will be treated with 3 days of preoperative DSF/copper (Cu) prior to their surgery (or biopsy), which will be followed by collection of tumor samples during surgery for analysis of drug uptake. After the surgery, patients will receive standard radiation therapy (RT) and temozolomide (TMZ) with the addition of concurrent DSF/Cu.

Detailed description:

Arms:
arm 1: * Disulfiram (DSF) dose level 2=250mg.
* Preoperative DSF/Copper (CU) x 3 days (optional)
* Surgery performed per routine clinical care.
* After surgery, evaluation to confirm the final pathological diagnosis as GBM (if not the patient will not continue with the 2nd part of the study).
* Radiation therapy (RT) 4-6 weeks following surgery at 60 Gy in 30 daily fractions.
* Temozolomide (TMZ) from Day 1 of RT to the last day of RT at a daily oral dose for a maximum of 49 days as per standard clinical care.
* DSF daily and Cu three times daily during chemoradiotherapy as per preoperative dose.
* 4-6 weeks after completion of chemoradiotherapy, adjuvant TMZ may be administered for 6 cycles. TMZ on Days 1-5 of every 28-day cycle. Daily DSF of 500mg will be continued with adjuvant TMZ for up to 6 cycles. arm 2: * Disulfiram (DSF) dose level 3=375mg.
* Preoperative DSF/Copper (CU) x 3 days (optional)
* Surgery performed per routine clinical care.
* After surgery, evaluation to confirm the final pathological diagnosis as GBM (if not the patient will not continue with the 2nd part of the study).
* Radiation therapy (RT) 4-6 weeks following surgery at 60 Gy in 30 daily fractions.
* Temozolomide (TMZ) from Day 1 of RT to the last day of RT at a daily oral dose for a maximum of 49 days as per standard clinical care.
* DSF daily and Cu three times daily during chemoradiotherapy as per preoperative dose.
* 4-6 weeks after completion of chemoradiotherapy, adjuvant TMZ may be administered for 6 cycles. TMZ on Days 1-5 of every 28-day cycle. Daily DSF of 500mg will be continued with adjuvant TMZ for up to 6 cycles. arm 3: * Surgery performed per routine clinical care.
* Radiation therapy (RT) 4-6 weeks following surgery at 60 Gy in 30 daily fractions.
* Temozolomide (TMZ) from Day 1 of RT to the last day of RT at a daily oral dose for a maximum of 49 days as per standard clinical care.
* Disulfiram (DSF) daily (250 mg) and Copper (Cu) three times daily during chemoradiotherapy.
* 4-6 weeks after completion of chemoradiotherapy, adjuvant TMZ may be administered for 6 cycles. TMZ on Days 1-5 of every 28-day cycle. Daily DSF of 500mg will be continued with adjuvant TMZ for up to 6 cycles.
* If a patient develops recurrent tumor during follow-up and plans to undergo another resection, he/she may opt for an optional preoperative DSF study prior to salvage surgery.

Interventions: intervention 1: Disulfiram intervention 2: Copper Gluconate intervention 3: Surgery intervention 4: Radiation intervention 5: Temozolomide
Intervention descriptions: intervention 1: None intervention 2: None intervention 3: None intervention 4: None intervention 5: None

Protocol document:
Prot_SAP_000.pdf: 
Version 01/24/25, Amendment 6 
 
Page 1 of 72 
 
 
A phase I/II dose-escalation and dose-expansion study of disulfiram/copper with 
concurrent radiation therapy and temozolomide in patients with newly diagnosed 
glioblastoma   
 
 
Protocol#:  201604115 
Version Date: 01/24/25 
 
 
Principal Investigator: 
Jiayi Huang, M.D. 
Washington University School of Medicine 
Department of Radiation Oncology 
4921 Parkview Place // Box 8224 
St. Louis, MO 63110  
Telephone: 314-362-8516 // Fax: 314-747-9557 
Email: jiayi.huang@wustl.edu  
 
 
 
Sub-Investigators : 
 
Albert Kim, M.D., Ph.D.  
 
 
 
 
Eric Leuthardt, M.D. 
 
 
 
 
 
George Ansstas, M.D. 
 
 
 
 
 
Milan Chheda, M.D. 
 
 
Tanner Johanns, M.D., Ph.D. 
 
Gregory Zipfel, M.D. 
Joshua Dowling, M.D 
 
 
Joseph Ippolito, M.D., Ph.D. 
 
 
 
 
ClinicalTrials.gov #: NCT02715609 
 
CONFIDENTIAL 
The information contained in this document is regarded as confidential and, except to the extent necessary to 
obtain informed consent, may not be disclosed to another party unless law or regulations require such 
disclosure.  Persons to whom the information is disclosed must be informed that the information is 
confidential and may not be further disclosed by them 
 
 


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A phase I/II dose-escalation study of disulfiram/copper with concurrent radiation therapy 
and temozolomide in patients with newly diagnosed glioblastoma 
 
Protocol Revision History 
 
Initial Approval Version 
 
 
 
 
 
 
04/22/2016 
Amendment #1 Version 
 
 
 
 
 
 
10/04/2016 
Amendment #2 Version 
 
 
 
 
 
 
11/18/2016 
Amendment #3 Version 
 
 
 
 
 
 
06/23/2017 
Amendment #4 Version 
 
 
 
 
 
 
03/20/2019 
Amendment #5 Version 
 
 
 
 
 
 
05/26/2021 
Amendment # 6 Version 
 
 
 
 
 
 
01/24/2025 
 
 


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STATEMENT OF COMPLIANCE 
 
The trial will be carried out in accordance with International Conference on Harmonisation Good 
Clinical Practice (ICH GCP) and the following ethical guidelines and regulations:  
 
• United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 
CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812)  
 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled.  Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study.  In addition, all changes to the consent form will be IRB-approved; a 
determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form. 
 
 


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A phase I/II dose-escalation and dose-expansion study of disulfiram/copper with 
concurrent radiation therapy and temozolomide in patients with newly diagnosed 
glioblastoma 
 
SCHEMA of the Dose-escalation Phase 
 
Presumed GBM based on MRI or biopsy 
 
 
 
 
 
 
 
 
 
 
 
 
 
              
 
 
 
 
 
                                                         Surgery 
 
 
 
 
 
            GBM  
 
 
 
 
 
RT + TMZ (temozolomide)   
 
 
 
+ DSF (Per Dose Escalation Schedule)  
                                                + Cu 2 mg TID 
 
 
 
 
    
 
 
 
 
 
 
 
                                                             Adjuvant TMZ 
+ DSF 500 mg daily 
                                                            + Cu 2 mg TID 
                                                             
Dose Escalation Schedule 
Dose Level 
Dose of Disulfiram 
Level 1 
125 mg PO daily 
Level 2 
250 mg PO daily 
Optional: Preoperative DSF/Cu x 3 days  
(Per dose escalation schedule) 
Optional: 
Collection of 
blood/tumor for 
drug analysis 


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Level 3 
375 mg PO daily 
Level 4 
500 mg PO daily 
 
SCHEMA of the Dose-expansion Phase 
 
 
 
 
Glossary of Abbreviations 
 
3DCRT 
3-D conformal radiotherapy 
AE 
Adverse event 
ALDH 
Aldehyde dehydrogenase 
ALT (SGPT) 
Alanine transaminase (serum glutamate pyruvic transaminase) 
ANC 
Absolute neutrophil count 
ASCO 
American Society of Clinical Oncologists 
AST (SGOT) 
Aspartate transaminase (serum glutamic oxaloacetic transaminase) 
B-HCG 
Beta human chorionic gonadotropin  
BMP 
Basic metabolic panel 
CBC 
Complete blood count 
CFR 
Code of Federal Regulations 
CNS 
Central nervous system 
CR 
Complete response 
CRF 
Case report form 
CSC 
Cancer stem cell 
CT 
Computed tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
CTV 
Clinical tumor volume 
Cu 
DDTC 
Copper supplement 
Diethyldithiocarbamate 
DFS 
Disease-free survival 
DLTs 
Dose Limiting Toxicities 
DNA 
Deoxyribonucleic acid 


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DSF 
Disulfiram 
DSM 
Data and Safety Monitoring  
DSMC 
Data and Safety Monitoring Committee 
FDA 
Food and Drug Administration 
GBM 
Glioblastoma multiforme 
GSC 
GBM stem cell 
GTV 
Gross tumor volume 
HRPO 
Human Research Protection Office (IRB) 
IMRT 
INR 
Intensity modulated radiation therapy 
International normalized ratio 
IRB 
Institutional Review Board 
IV 
Intravenous (i.v.) 
KPS 
Karnofsky performance status 
LFT 
Liver function tests 
LITT 
Laser interstitial thermal therapy 
MedDRA 
Medical Dictionary for Regulatory Activity 
MGMT 
O6-methylguanine-DNA methyltransferase 
MRI 
Magnetic resonance imaging 
MTD 
Maximum tolerated dose 
NCI 
National Cancer Institute 
NED 
No evidence of disease 
NIH 
National Institutes of Health 
NYHA 
New  York Heart Association 
OHRP 
Office of Human Research Protections  
OS 
Overall survival 
PD 
Progressive disease 
PFS 
Progression-free survival 
PI 
Principal investigator 
PO 
Per os (by mouth) 
PR 
Partial response 
PsP 
Pseudoprogression 
PTV 
Planned tumor volume 
QA 
Quality assurance 
QASMC 
Quality Assurance and Safety Monitoring Committee 
QD 
Quaque die (daily) 
RANO 
Response Assessment in Neuro-Oncology criteria 
RT 
Radiation therapy 
RTOG 
Radiation Therapy Oncology Group 
SAE 
Serious adverse event 
SCC 
Siteman Cancer Center 
SD 
Stable disease 


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TITE-CRM 
Time-to-Event Continual Reassessment Method 
TMZ 
Temozolomide 
TTP 
Time to progression 
ULN 
UPN 
Upper limit of normal 
Unique patient number 
WBC 
White blood cell (count) 
WHO 
World Health Organization 
WUSM 
Washington University School of Medicine 
 
 
 
 


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Table of Contents 
SCHEMA of the Dose-escalation Phase ......................................................................................... 4 
SCHEMA of the Dose-expansion Phase ......................................................................................... 5 
1.0 
BACKGROUND AND RATIONALE ............................................................................. 10 
1.1 
Glioblastoma Multiforme.............................................................................................. 10 
1.2 
Disulfiram ..................................................................................................................... 11 
1.3 
Study Rationale ............................................................................................................. 19 
2.0 
OBJECTIVES AND ENDPOINTS .................................................................................. 21 
Dose-escalation Phase .............................................................. Error! Bookmark not defined. 
Dose-expansion Phase .............................................................. Error! Bookmark not defined. 
Dose-escalation phase ............................................................... Error! Bookmark not defined. 
3.0 
PATIENT SELECTION ................................................................................................... 21 
3.1 
Inclusion Criteria .......................................................................................................... 21 
3.2 
Exclusion Criteria ......................................................................................................... 24 
3.3 
Inclusion of Women and Minorities ............................................................................. 24 
4.0 
PATIENT REGISTRATION ............................................................................................ 25 
5.0 
TREATMENT PLAN ....................................................................................................... 25 
5.1 
Pretreatment Evaluation ................................................................................................ 25 
5.2 
Radiation Therapy ......................................................................................................... 26 
5.3 
Concurrent Temozolomide Treatment .......................................................................... 26 
5.4 
Disulfiram and Copper Administration during Chemoradiotherapy ............................ 26 
5.5 
Laboratory Studies and Tissue Collection during Chemoradiotherapy ........................ 27 
5.6 
Adjuvant Temozolomide and Disulfiram Treatment .................................................... 27 
5.7 
Optional Preoperative Disulfiram before Salvage Surgery .......................................... 27 
5.8 
Disulfiram Dose Escalation Criteria ............................................................................. 28 
5.9 
Definition of MTD, DLT, Dose Escalation Criteria, and Toxicity, Response, and DLT 
Evaluations ................................................................................................................................ 28 
5.10 
General Concomitant Medication and Supportive Care Guidelines ............................. 30 
5.11 
Women of Childbearing Potential ................................................................................ 31 
5.12 
Duration of Therapy ...................................................................................................... 31 
5.13 
Duration of Follow-up .................................................................................................. 32 
6.0 
DOSE MODIFICATIONS................................................................................................ 32 
6.1 
Temozolomide Dose Modifications during Radiation Therapy ................................... 32 
6.2 
DSF Dose Modifications............................................................................................... 33 
7.0 
REGULATORY AND REPORTING REQUIREMENTS .............................................. 34 
7.1 
Definitions..................................................................................................................... 34 
7.2 
Reporting to the Human Research Protection Office (HRPO) at Washington University
 
36 
7.3 
Reporting to the Quality Assurance and Safety Monitoring Committee (QASMC) at 
Washington University .............................................................................................................. 37 
7.4 
Timeframe for Reporting Required Events ................................................................... 37 
8.0 
PHARMACEUTICAL INFORMATION ......................................................................... 37 
8.1 
Disulfiram ..................................................................................................................... 37 
8.2 
Temozolomide (Temodar) ............................................................................................ 39 
9.0 
CORRELATIVE STUDIES ............................................................................................. 40 


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9.1 
Collection of Specimens ............................................................................................... 41 
10.0 
STUDY CALENDAR ...................................................................................................... 42 
11.0 
DATA SUBMISSION SCHEDULE ................................................................................ 44 
12.0 
MEASUREMENT OF EFFECT....................................................................................... 44 
12.1 
Antitumor Effect – Solid Tumors ................................................................................. 44 
12.2 
Disease Parameters ....................................................................................................... 46 
12.3 
Methods for Evaluation of Measurable Disease ........................................................... 47 
13.0 
DATA AND SAFETY MONITORING ........................................................................... 50 
14.0 
STATISTICAL CONSIDERATIONS.............................................................................. 51 
14.1 
Definition of Primary Endpoint .................................................................................... 51 
14.2 
Definition of Secondary and Exploratory Endpoints .................................................... 51 
14.3 
Analytic Plan for Primary Endpoint ............................................................................. 51 
14.4 
Analytic Plan for Secondary and Exploratory Endpoints ............................................. 55 
15.0 
REFERENCES ................................................................................................................. 56 
APPENDIX A: Karnofsky Performance Status Scale .................................................................. 63 
APPENDIX B: NYHA Classification of Cardiac Disease ........................................................... 64 
APPENDIX C: Concurrent Temozolomide Medication Diary .................................................... 65 
APPENDIX D: Concurrent Disulfiram and Copper Medication Diary ........................................ 67 
APPENDIX E: Optional Pre-Surgery Disulfiram and Copper Medication Diary ........................ 69 
APPENDIX F:  Adjuvant Temozolomide Medication Diary ....................................................... 70 
APPENDIX G:  Adjuvant Disulfiram Medication Diary ............................................................. 71 
APPENDIX H:  Adjuvant Copper Gluconate Diary..................................................................... 72 
 
 


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1.0 
BACKGROUND AND RATIONALE 
 
1.1 
Glioblastoma Multiforme 
 
Glioblastoma multiforme (GBM, World Health Organization/WHO grade IV) is the most 
common malignant primary brain tumor and one of the most devastating cancers [1]. 
Between 2004 and 2007, there were 37,690 patients newly diagnosed with GBM, with an 
estimated incidence rate of 3 cases per 100,000 people in the United States [2]. The current 
standard of care for GBM includes maximal safe resection followed by radiotherapy (RT) 
and temozolomide (TMZ). The incorporation of TMZ in the treatment of these patients 
represented the first breakthrough against this fatal cancer in decades and was shown to 
significantly improve outcome in a randomized study. However, despite such multi-
modality therapy, the median survival is approximately 14 months, with a five-year 
survival of less than 10% [3]. The combined RT and TMZ regimen was associated with 
relatively low rates of grade 3-4 toxicities: 4% neutropenia, 3% thrombocytopenia, 3% 
infection, 7% fatigue, 1% rash, <1% nausea/vomiting. Completion of therapy was also very 
high: 5% were unable to complete 90% of RT (4% due to disease progression, 1% due to 
incompliance), 13% did not complete concurrent TMZ (5% due to toxicity, 4% due to 
disease progression, and 4% due to other causes) [4]. 
 
Many institutions have attempted to increase the dose of RT to improve tumor control using 
various methods, including radiosurgery and brachytherapy, but each method has failed to 
improve outcome [5-7]. A recent retrospective study from our research group at 
Washington University showed that moderate RT dose-escalation with concurrent TMZ 
did not appear to improve outcome as compared to standard dose RT and TMZ [8]. Thus, 
novel therapeutic approaches are desperately needed for this devastating disease. 
 
Recent evidence suggests that a cellular hierarchy exists in GBM [9,10]. A small fraction 
of GBM cells have the ability to regenerate the entire tumor and share many similar 
characteristics as neural stem cells, such as self-renewal, extensive proliferation, and 
differentiation [11-14]. Those cells have been referred to as cancer stem cells (CSCs) or 
tumor-initiating cells. Experiments have shown that CSCs are more resistant to RT and 
chemotherapy than the rest of the tumor cell population [15,16]. Therefore, CSCs may 
represent an important reason why GBM may initially respond but invariably recur after 
chemoradiotherapy. Importantly, recent laboratory study has suggested that CSC hierarchy 
may be reversible and that non-CSCs can convert into CSCs [17], which would imply that 
the optimal therapeutic approach to GBM would be to combine conventional therapy that 
eradicates non-CSCs with CSC-directed therapy. Other preclinical studies have also 
suggested that disulfiram (DSF), a FDA-approved, non-cancer therapeutic drug, may target 
the CSC-like subpopulation of GBM. Its mechanism is still unclear but may be due to 
aldehyde dehydrogenase (ALDH) inhibition, O6-methylguanine-DNA methyltransferase 
(MGMT) inhibition, NF-kB inhibition, proteasome inhibition, DNA repair inhibition, or 
increased intracellular reactive oxygen species (ROS) generation (Brar, et al. 2004; Klein, 
et al. 1994).   
 


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1.2 
Disulfiram 
 
1.2.1 Current Usage of Disulfiram and Proteasome Inhibition 
 
Disulfiram (Antabuse, Teva Pharmaceuticals, North Wales, PA) is an FDA-
approved medication that has been used for treating alcoholism since 1951. It 
inhibits ALDH, which leads to accumulation of acetaldehyde in the blood after 
ingestion of alcohol. The resulting acetaldehyde causes unpleasant symptoms such 
as sweating, flushing, nausea, and vomiting. The association of these aversive 
reactions with drinking thus discourages further consumption of alcohol. More 
recently, disulfiram (DSF) has also been used to treat cocaine addiction [18]. Upon 
absorption, 
DSF 
is 
immediately 
reduced 
to 
its 
active 
metabolite, 
diethyldithiocarbamate (DDTC). DDTC is a potent copper (Cu) chelator and can 
readily penetrate the blood brain barrier [19]. Increasing data has emerged that the 
Cu-DDTC complex appears to be a proteasome inhibitor [20,21].    
 
A proteasome is a large multi-subunit complex in eukaryotes which controls the 
degradation of intracellular proteins [22]. As an important regulator of many 
cellular processes such as cell-cycle and apoptosis, proteasomes have emerged as a 
promising target for anticancer therapy [23]. Proteasomes contain at least three 
known catalytic activities: chymotrysin-like, trypsin-like, and caspase-like. 
Specifically, the inhibition of the proteasomal chymotrypsin-like activity has been 
shown to be associated with apoptosis of tumor cells [24,25]. One of the first 
proteasome inhibitors, bortezomib (Velcade, Millennium Pharmaceuticals, 
Cambridge, MA), is approved for the treatment of multiple myeloma. Bortezomib 
has also shown significant cytotoxic effect on GBM cells in vitro [26] but has 
limited penetration across the blood brain barrier [27,28]. It has been shown to be 
ineffective for recurrent GBM [29]. Although the results of the phase II study of 
bortezomib combined with vorinostat are disappointing, disease response may be 
complicated by bortezomib’s poor intracranial penetration and its focus on heavily 
pretreated tumors.  
    
 
1.2.2 In Vitro Studies of DSF on GBM Cells 
    
 
DSF has shown selective anti-tumor activity against breast cancer, melanoma, and 
prostate cancer in vitro with minimal cytotoxicity against their normal tissue 
counterpart [20,30,31]. Recently, a few studies have also demonstrated promising 
activity against GBM models. Hothi et al. have performed a high-throughput 
screening study of 2000 compounds and identified DSF as a potent inhibitor of 
patient-derived GBM stem cells (GSCs), with its greatest effect at a concentration 
above 0.75 µM. Similar to the previous reports for other tumor models, DSF 
showed remarkable selectivity against GSCs as compared to normal neural stem 
cells (IC50 of 31 nM versus 283 nM, respectively). The study further identified that 
the effect is dependent on a complex formation with Cu and its inhibition of 
chymotrypsin-like proteasomal activity [32].  
 


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Liu et al. have also confirmed the Cu-dependent cytotoxicity of DSF against GBM 
cell lines and provided evidence that DSF preferentially targets the GSC 
subpopulation. They observed that the IC50 ranged from 119.7 to 464.9 nM for 
different GBM cell lines. Furthermore, after only 3 hour exposure to 0.5 µM of 
DSF with 1 µM of Cu, the neurosphere-forming ability of different GBM cell lines 
was completely abolished, which is a key characteristic of the GBM stem-like cells. 
They also showed that DSF-Cu complex could induce intracellular reactive oxygen 
species (ROS) to trigger intrinsic apoptosis of GBM cells through activation of JNK 
and p38 pathways [33].  
 
In a third study, Triscott et al. showed that DSF is active against TMZ-resistant 
GBM cell lines and provided synergistic activity when combined with TMZ. They 
reported that the IC90 for the TMZ resistant cells was 100 nM. At such 
concentration, the neurosphere-forming ability of the GBM cells was abolished 
completely, but the normal astrocytes were not affected. Altogether, those in vitro 
studies support that DSF has selective activity against the GSC-like subpopulations 
and may also increase the efficacy of TMZ [34].  
 
1.2.3 In Vivo Studies of DSF 
 
Paranjpe et al. showed that DSF increased sensitivity of GBM cells to TMZ through 
inhibition 
of 
O6-methylguanine-DNA 
methyltransferase 
(MGMT) 
and 
demonstrated that DSF preferentially inhibited tumor MGMT in GBM xenografts 
as compared to MGMT in the liver. MGMT is a DNA repair protein that removes 
the mutagenic O6-akyl groups from guanines, which would negate the effect of 
TMZ on tumor cells. The inhibition of MGMT provided a mechanism explanation 
for the synergistic effect with TMZ [35]. Lun et al. have also recently reported that 
a combination of DSF, Cu gluconate, and TMZ could significantly improve 
survival of mice with orthotopic GBM tumors. They have also shown that DSF 
inhibited the 26S proteasome in a Cu-dependent manner and induced activation of 
both heat shock and unfolded protein responses [36].  Altogether, the in vivo studies 
have confirmed the findings of the in vitro experiments and support clinical trial to 
test the synergistic benefit of combining DSF and copper with RT and TMZ for 
treating GBM.  
 
DSF has also been tested on breast and prostate cancer xenografts. Chen et al. 
injected 50 mg/kg of DSF intraperitoneally daily for 29 days to mice implanted 
with breast cancer xenografts. They found that DSF reduced tumor growth by 74% 
as compared to the control group. They also confirmed that the proteasome 
chymotrypsin-like activity was inhibited by 87% in the tumor tissues treated with 
DSF as compared to the control. Along with the proteasome inhibition, there was 
also increased apoptosis within the treated tumor, including increased caspase-3 
activity and cleaved PARP [20]. When given to mice implanted with prostate 
cancer xenografts, daily treatment of 200 mg/kg/day DSF in olive oil for three 
weeks also reduced tumor growth by 40% as compared to olive oil alone [31].  
 
 


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These preclinical studies further support the promising role of DSF as a novel 
approach to treat cancer.   
 
1.2.4    Safety and Toxicology 
 
DSF has been used clinically for more than 50 years, so its safety profile is well 
known. The current FDA-recommended dose of DSF is 250-500 mg daily for 
alcohol abstinence. The primary pharmacological action of DSF is its irreversible 
inhibition of ALDH, leading to an accumulation of acetaldehyde with ingestion of 
alcohol. The acetaldehyde then produces unpleasant DSF-ethanol reaction, 
characterized by flushing, palpitation, headache, nausea, and vomiting [18]. In the 
early clinical practice, a much higher dose of 1000-3000 mg per day was used [37].  
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 [38]. 
At such high dosages, there were also case reports of psychosis in the absence of 
alcohol ingestion [39,40]. A previous phase I study combining a single dose of oral 
DSF and cisplatin every 3 weeks observed dose-limiting confusion at 3000 mg/m2 
(approximately 4800 mg) [41]. High doses of DSF may inhibit cerebrospinal 
dopamine B-hydroxylase [42], and people with very low activity of dopamine 
hydroxylase may be prone to transient psychosis with such inhibition [43].    
 
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. At 
those extreme doses, demyelination of brain and spinal cord was observed on 
histopathology [44]. Interestingly, long-term administration of high doses of DSF 
to rats did not induce any laboratory or histological signs of liver damage [45]. 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.   
 
1.2.5 Pharmacology and Drug Metabolism 
 
After oral ingestion, DSF is partially reduced to 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, and enteric formulation and oil may enhance 
improved absorption. After absorption, DSF is again reduced to DDTC and then 
Cu(DDTC)2. Downstream metabolites also include diethylamine, carbon 
disulphide, diethyldithiomethylcarbamate (Me-DDTC), and glucuronic acid of 
DDTC. Me-DDTC is biotransformed into active inhibitors of ALDH [19]. 
Experiments with radiolabeled DSF have shown distribution in the blood, liver, 


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Page 14 of 72 
kidney, heart, adrenal gland, thyroid, pancreas, testes, spleen, marrow, muscles, 
and, most importantly, brain [46].  
 
1.2.6 Clinical Experience 
   
Clinical experience with DSF for the treatment of alcoholism has been extensive 
over the last 50 years. At the dose of 250-500 mg per day as recommended by the 
FDA, DSF is safe and well-tolerated [18,37]. A few clinical studies have been 
reported in the literature on its use in cancer patients. A phase II study randomized 
64 non-metastatic breast cancer patients after mastectomy to chemotherapy either 
with DDTC (the main metabolite of DSF) or placebo. The group that received 
DDTC had significantly better disease-free survival (DFS) and overall survival 
(OS) as compared to the placebo group [47]. A phase I study treated non-metastatic 
recurrent prostate cancer patients with 250-500 mg of DSF (9 patients with 250 mg 
and 10 patients with 500 mg). Only 5 of the 19 patients completed at least 6 months 
of DSF, and the biochemical response appeared to be minimal. There were 3 
patients with grade 3 toxicity for each dose level, including double vision, hearing 
loss, LFT abnormality, diarrhea, constipation, and ataxia. Due to lack of clear signal 
for treatment response and the toxicities reported, the authors did not recommend 
additional testing of DSF in the recurrent prostate cancer population [48]. A recent 
double-blinded, randomized phase II study compared chemotherapy with and 
without DSF for metastatic non-small cell lung cancer [49]. DSF was given at 40 
mg three times daily (TID). Patients who received concurrent DSF had significantly 
better PFS and OS than who received chemotherapy alone (5.9 vs. 4.9 months, and 
10.0 vs. 7.1 months, respectively). The authors recommended a larger phase III 
studies to test DSF with chemotherapy for metastatic non-small cell lung cancer.  
 
We have recently conducted a phase I pharmacodynamic study combining 500-
1000 mg of DSF with adjuvant temozolomide for newly diagnosed GBM patients 
after RT and concurrent TMZ, which has determined 500 mg of DSF per day as the 
maximum tolerated dose (MTD) in combination with adjuvant TMZ. Dose-limiting 
toxicity, which was defined as within the first 28 days of DSF administration, 
occurred at 1000 mg of disulfiram per day and included delirium and ataxia. At the 
MTD of 500 mg per day, 2 of 7 patients eventually stopped DSF after the first 
month 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. Grade 2-3 toxicities that were possibly or probably related to DSF are 
described in table below. All the toxicities were self-limiting or resolved within 30 
days of cessation of DSF. A description of this clinical trial is available on 
http://clinicaltrials.gov/show/NCT01907165. 
 
 


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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 Nation Cancer Institute Common Terminology Criteria 
for Adverse Events (NCI-CTCAE) version 4.0 that were possibly or probably related to disulfiram 
(DSF) and that were not present at baseline. 
†Not dose-limiting toxicity (DLT) as occurred after the first month of DSF.  
§Dose-limiting toxicity (DLT) as occurred within the first month of DSF. 
 
1.2.7 Pharmacokinetics 
 
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. However, there was marked intersubject variability in the plasma 
concentrations [50,51]. Doses as low as 100 mg of DSF could produce detectable 
plasma concentrations of Me-DDTC and complete blockade of ALDH activity in 
erythrocytes [52]. As seen in Figure 1, three daily doses of DSF will allow for DSF 
and its metabolites to reach steady state.  
 
 


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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 disulphide is mostly eliminated via the 
lungs [19].  
 
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 1 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 [53], which support their ability to cross the BBB. 
However, specific measurement of DSF and its metabolites in gliomas have not 
been conducted to date.   
 
1.2.8 Measurement of Intratumoral Drug Concentration using Resected 
Tumors 
 
Although no studies have analyzed uptake of DSF and its metabolites in gliomas, a 
few prospective studies have investigated intracranial drug penetration by 
administering chemotherapy before planned resection of brain tumors. In a study 
measuring cisplatin level, high-grade gliomas appeared to have higher drug 


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concentration than low-grade gliomas but lower when compared to brain 
metastases, suggesting break-down of the blood-brain barrier plays an important 
factor in intratumoral drug concentration [54]. Previous studies have shown a 
sample size of 5 is typically sufficient to detect difference in drug concentration 
between dose levels [55]. Given the tumor specimen invariably contain blood, high 
plasma concentration may lead to over-estimation of the tissue drug concentration 
[56]. Thus, an accurate estimation of intratumoral drug concentration would require 
measurement of concurrent plasma level and would ideally be measured when the 
plasma level has peaked.      
 
1.2.9 Co-administration of Copper (Cu) 
 
Previous in vitro studies have consistently shown the effect of DSF is dependent on 
Cu, at a concentration of approximately 1 uM. Based on 130 autopsy cases of non-
poisoned people, the Cu concentration of brain, blood, and stomach were 
approximately 49.0 uM (median) [range: 10.6-118.3], 13.1 uM [9.0-20.6], 15.7 uM 
[3.8-76.7], respectively [57]. Furthermore, cancer cells including gliomas cells 
appear to contain highly elevated levels of Cu as compared to surrounding normal 
tissues [58-60]. However, typical Western diets provide only 1 mg of Cu daily, less 
than the lower limit of 1.5 to 3.0 mg which is estimated as a safe and adequate daily 
dietary intake (ESADDI) of copper [61,62]. Therefore, dietary Cu supplementation 
may be required for DSF to be maximally effective as an antineoplastic drug. The 
upper level of recommended daily elemental Cu is 8 mg a day (Institute for 
Medicine 2002), administered as Cu gluconate, a substance generally regarded as 
safe (GRAS) (Code of Federal Regulation 2004). Large amounts of ingested Cu 
could result in hepatic failure and hemolysis similar to that seen with Wilson's 
disease, the rare genetic syndrome from hyperabsorption of Cu. 
 
Prior reports have shown that 10 mg of elemental Cu can be administered for 2-3 
months without any apparent side-effect nor any significant increase of serum 
copper level [63,64]. A previous phase I study for patients with advanced liver 
metastasis has shown 6 mg of elemental Cu in the form of Cu gluconate is well 
tolerated when given with 250 mg of DSF daily. In this study, Cu gluconate was 
given in the morning half hour before breakfast, and DSF was given with the 
evening meals [65]. 
 
1.2.10 Potential Risks and Benefits 
 
The safety risks of DSF are well established based on over 60 years of clinical use 
[18,37,66]. From 1968 to 1991, 154 adverse drug reactions were reported to the 
Danish Committee on Adverse Drug Reactions: hepatic (34%), neurological (21%), 
cutaneous (15%), psychiatric (4%), and other (26%). However, some patients may 
have received much higher doses than the currently approved dosage and may have 
consumed alcohol while taking DSF. Rate of adverse event is estimated to be one 
per 200-2000 patients per year [67]. The more common and mild side effects 
include: drowsiness, usually of short duration (can be managed by taking 


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medication in the evening); headache; nausea and vomiting; metallic or garlic-like 
aftertaste; allergic dermatitis; impotence; DSF-ethanol reaction after ingestion of 
alcohol (flushing, headache, nausea, sweating, palpitation, dyspnea, tachycardia, 
hypotension, and rarely cardiovascular collapse). These symptoms are generally 
transient and typically resolve within first two weeks. DSF-ethanol reaction can be 
avoided by abstinence from drinking alcohol, and case reports of fatal DSF-ethanol 
reaction in the past occurred with much higher doses of DSF. Other rare but more 
severe toxicities include: hepatotoxicity or hepatitis, typically reversible if DSF is 
discontinued early (should be followed with liver function tests); peripheral 
neuropathy; optic neuritis; extrapyramidal symptoms; psychosis. Patients with 
hepatic dysfunction, active pregnancy, and idiopathic seizure disorder should not 
be given DSF.  
 
As discussed in Section 1.2.6, our previous phase 1 study of DSF in combination 
with adjuvant TMZ established 500 mg of DSF per day as the MTD. At this dose, 
most patients tolerated DSF with adjuvant TMZ well, but 2 of 7 patients developed 
dose-limiting confusion and motor neuropathy after prolonged administration. 
Possible or probable DSF-related toxicities were all neurological and were mostly 
self-limiting or reversible.  The investigators and patients should pay particular 
attention of any early signs of the neurological symptoms seen in the previous phase 
I study including delirium, ataxia, and neuropathy, but careful workup to rule out 
tumor progression or other causes should also be considered before attributing those 
symptoms to DSF. 
  
Given its long track record of safety when used alone, especially below 1000 mg, 
DSF should pose minimal risk when given to presumed GBM patients before their 
surgical resection. Although patients without histological confirmation would 
qualify for this study, a misdiagnosis of GBM based on MRI finding is relatively 
uncommon. Furthermore, since it is not a cytotoxic chemotherapy, a short-course 
administration of pre-operative DSF for 3 days to a patient with a different 
diagnosis should not adversely affect his/her subsequent treatment. As for 
overlapping toxicity with TMZ or RT, DSF appears to have preferential inhibition 
of tumor MGMT versus liver MGMT in vitro, and our previous phase I study 
demonstrated safety when combining it with TMZ. Since DSF may be 
radiosensitizing due to its possible effect on DNA repair based on in vitro studies, 
its tolerability with RT is currently unknown. To monitor for severe toxicity, 
patients will be followed frequently during RT with weekly clinical evaluation and 
CBC. Liver function test will be checked before starting DSF, and every month 
while taking DSF.   
 
 


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1.2.11 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 TMZ)  
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  
Less Likely: 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 TMZ)  
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 
 
1.3 
Study Rationale 
 
Preclinical in vitro studies have identified DSF as a promising and selective drug against 
GBM cells. In vivo experiments have showed synergistic effect of DSF with RT and TMZ 
against orthotopic GBM models. Given its well-established safety profile, excellent 
penetration across the blood brain barrier, relatively low cost, and ease of administration 
with an oral formulation, the potential of DSF to enhance the efficacy of RT and TMZ for 
GBM warrants clinical trial investigation. We have previously demonstrated the feasibility 


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and safety of combining DSF with adjuvant TMZ after RT and concurrent TMZ. Adding 
DSF to RT and concurrent TMZ in the initial treatment GBM is a rational next step to test 
the potential of DSF to improve clinical outcome of GBM patients. Since Cu has been 
shown in the preclinical studies to be crucial for the activity of DSF, patients will also take 
Cu TID with meals to maximize the biological activity of DSF. Therefore, the purpose of 
this study is to identify the optimal dose of DSF to combine with RT and TMZ.   
 
The proposed study will be a single arm, phase I/II study of DSF/Cu in combination with 
adjuvant standard RT and TMZ for patients with newly diagnosed GBM. There will be an 
optional phase 0 pharmacokinetic study where patients will take 3 days of DSF/Cu prior to 
their surgery to allow for collection of blood and tumor samples during surgery for analysis 
of drug uptake.  
 
As for the rationale for the proposed expansion cohort, this is based on the promising 
finding of the dose-escalation phase of the study. After enrollment of the 18 patients for 
the dose-escalation phase, 8 patients were treated with DSF of 250 mg/day (dose level 2) 
and 10 patients with 375 mg/day (dose level 3). Three dose-limiting toxicities (DLTs) were 
observed: 1 with 250 mg/day (grade 2 urinary incontinence and ataxia), and 2 with 375 
mg/day (both grade 3 elevated liver enzymes). The TITE-CRM model estimated the DLT 
probability of DSF to be 10% (95% CI: 3-29%) at 250 mg/day, and 21% (95% CI: 7-42%) 
at 375 mg/day. Thus, we have declared that the MTD of DSF in combination with 
RT/TMZ/Cu for GBM is 375 mg/day, and the recommended phase II dose is 250 mg/day. 
Furthermore, tumor mutations were evaluated with next-generation sequencing for all 
patients to explore possible biomarkers for response. Notably, GBM patients with IDH (n 
= 6), BRAF (n = 2), and NF1 (n = 1) mutations exhibited much better PFS and OS than 
those without these mutations (n = 9): 1-year PFS of 100% vs 22%, respectively, p = 0.001; 
1-year OS of 100% vs 42%, respectively, p = 0.006. Given that the historical PFS and OS 
of newly diagnosed GBM patients treated with RT and TMZ is approximately 27% and 
60% at one year [4], respectively, the preliminary data of this molecular subset of GBM 
are thought-provoking and raise the possibility that these mutations make GBM tumors 
more sensitive to DSF/Cu in combination with chemoradiotherapy. Interestingly, all three 
mutations, which affect approximately 15-20% of GBM tumors, make tumor cells more 
dependent on glutamate for cellular metabolism [68-70]. As DSF metabolite can affect 
glutamate uptake, this may be the biological mechanism for the improved outcomes for 
GBM with these mutations. Thus, we have proposed to add an expansion cohort to this 
phase I/II study to treat additional GBM patients with IDH, BRAF, or NF1 mutations to 
increase the statistical power of our preliminary finding. 
 
 
 
 


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2.0 
OBJECTIVES AND ENDPOINTS 
 
Objectives 
Endpoints 
Primary 
Dose-escalation Phase: To determine the 
maximum tolerated dose (MTD) or the 
recommended phase 2 dose (RP2D) of 
disulfiram (DSF) when administered with 
concurrent radiation therapy (RT) and 
temozolomide (TMZ) in patients with newly 
diagnosed glioblastoma (GBM). 
 
Dose-expansion Phase: To evaluate the OS 
of the molecularly-defined cohort of newly 
diagnosed GBM with IDH, BRAF, or NF1 
mutations when treated with the combination 
of DSF/Cu plus concurrent RT and TMZ. 
Dose-escalation Phase: The maximum tolerated 
dose (MTD) of DSF with concurrent RT+TMZ 
will be defined as the dose associated with a 20% 
probability of dose-limiting toxicity (DLT). 
Toxicity will be coded using CTCAE version 4.0, 
and DLT will be defined as toxicity that occurs 
within 18 weeks from the first day of RT and is 
possibly, probably or definitely related to DSF/Cu 
(or 12 weeks from the completion of RT if there is 
a delay/interruption of RT). 
 
Dose-expansion Phase: For the expansion cohort 
of GBM with IDH, BRAF, and NF1 mutations, 
the overall survival (OS) of this molecularly-
defined cohort will be measured from the first 
day of RT. 
Secondary  
1. To describe the toxicities of DSF when 
given concurrently with RT and TMZ.  
2. To evaluate the PFS of the molecularly-
defined cohort of newly diagnosed GBM 
with IDH, BRAF, or NF1 mutations 
when treated with the combination of 
DSF/Cu plus concurrent RT and TMZ 
3. To determine the active DSF metabolite 
concentration in plasma and tumor 
tissues. 
1. The adverse events will be graded by NCI 
CTCAE version 4.0.  
2. Progression-free survival (PFS) will be 
determined from the first day of RT to the 
time of tumor progression or death, whichever 
occurs first. Tumor progression will be 
determined using the RANO criteria. 
3. Intratumor and plasma concentration of DSF 
metabolite (ditiocarb-copper complex) will be 
determined using mass spectrometer method. 
Tertiary/Exploratory 
1. To estimate rate of pseudo-progression 
after chemoradiotherapy 
2. To explore the pharmacodynamics effect 
of DFS on glutamate metabolism in 
plasma and tumor tissues 
1. Pseudo-progression is defined as a transient 
increase of tumor after chemoradiotherapy 
that subsequently stabilizes without a change 
of therapy 
2. Pharmacodynamics studies on glutamate 
metabolism will include measurement of 
glutamine, glutamate, aspartate, glucose, and 
lactate levels in blood and tumor tissues 
using mass spectrometry method.  
 
 
3.0 
PATIENT SELECTION 
 
3.1 
Inclusion Criteria 


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1. Diagnosis of GBM or its histological variants (WHO grade IV). Patients who are 
participating in the optional pre-operative pharmacokinetic study may have presumed 
GBM based on clinical/radiological findings. However, patient must have 
histologically confirmed GBM before continuing to receive DSF with concurrent 
RT/TMZ. 
 
2. Expansion Cohort: must have a diagnosis of GBM (or its histological variants) with 
IDH, BRAF or NF1 mutations. Confirmation of these mutations may be either by  
immunohistochemistry or next-generation sequencing. 
 
3. At least 18 years of age. 
 
4. Karnofsky performance status (KPS) of at least 60% (see Appendix A). 
 
5. For patients who will participate in the optional DSF pharmacokinetic study, they 
should be eligible for surgical resection for which at least 0.2 cubic cm or 
approximately 200 mg of tumor will be removed in additional to tumor specimen 
required for pathology evaluation.  Patients enrolled after undergoing surgical resection 
or biopsy with histologically confirmed GBM are not required to meet this point of 
inclusion. 
 
6. Eligible for and planning to receive standard fractionated RT with concurrent TMZ. 
 
7. Willing to remain abstinent from consuming alcohol while on DSF. 
 
8. Willing to defer definitive surgery for one week while taking DSF and Cu. Patients 
who declined the optional pre-operative pharmacokinetic study or enrolled after 
undergoing surgical resection or biopsy with histologically confirmed GBM are not 
required to meet this point of inclusion. 
 
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 ≤ 2x institutional upper limit of normal (ULN) 
e. AST and ALT < 3 x ULN 
f. Serum creatinine < 1.5 x ULN or creatinine clearance > 50 mL/min (by Cockcroft-
Gault) 
 
10. Females of childbearing potential (defined as a female who is non-menopausal or 
surgically sterilized) must be willing to use an acceptable method of birth control (i.e., 
hormonal contraceptive, intra-uterine device, diaphragm with spermicide, condom with 
spermicide, or abstinence) for the duration of the study.  Should a woman become 
pregnant or suspect she is pregnant while participating in this study, she must inform 
her treating physician immediately. 


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11. Able to take oral medication. 
 
12. Able to understand and willing to sign an IRB-approved written informed consent 
document (legally authorized representative permitted). 
 
 
 


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3.2 
Exclusion Criteria 
 
1. Receipt of any other investigational agents within 14 days prior to study treatment. 
 
2. Enrolled on another clinical trial testing a novel therapy or drug. 
 
3. History of allergic reaction to DSF or Cu. 
 
4. Treatment with the following medications are contraindicated with DSF when taken 
within 7 days prior to the first dose of DSF + Cu: metronidazole, isoniazid, dronabinol, 
carbocisteine, lopinavir, paraldehyde, ritonavir, sertraline, tindazole, tizanidine, 
atazanavir. (Note: the following medications are not contraindicated but should be 
cautioned if taking concurrently with DSF: warfarin, phenytoin, theophylline, 
chlorzoxazone, chlordiazepoxide, diazepam. If the patient is taking warfarin, INR 
should be monitored closely. If the patient has to remain on phenytoin, its serum 
concentration and response should be monitored closely.) 
 
5. Active or severe hepatic, cardiovascular, or cerebrovascular disease, including 
myocardial infarction within 6 months prior to enrollment, New York Heart 
Association (NYHA) Class III or IV heart failure (Appendix B), uncontrolled angina, 
severe uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute 
ischemia or active conduction system abnormalities. 
 
6. History of idiopathic seizure disorder, psychosis, or schizophrenia. 
 
7. History of Wilson’s disease or family member with Wilson’s disease. 
 
8. History of hemochromatosis or family member with hemochromatosis. 
 
9. Pregnant and breastfeeding women will be excluded because of the known teratogenic 
effect of RT and the unknown effect of TMZ and DSF on fetal development.  Women 
of childbearing potential must have a negative pregnancy test within 14 days of 
initiation of treatment. 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this trial. 
 
 
 
 


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4.0 
PATIENT REGISTRATION 
 
Patients must not start any protocol intervention prior to registration through the Siteman 
Cancer Center. 
 
The following steps must be taken before registering patients to this study: 
 
1. 
Confirmation of patient eligibility  
2. 
Registration of the patient in the Siteman Cancer Center OnCore database 
3. 
Assignment of unique patient number (UPN) 
 
 
4.1 
Confirmation of Patient Eligibility 
 
1. Confirm patient eligibility by collecting the information listed below: Registering 
MD’s name 
2. Patient’s race, sex, and DOB 
3. Three letters (or two letters and a dash) for the patient’s initials 
4. Copy of signed consent form  
5. Completed eligibility checklist, signed and dated by a member of the study team 
6. Copy of appropriate source documentation confirming patient eligibility 
 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database 
 
 
All patients must be registered through the Siteman Cancer Center OnCore database. 
 
4.3 
Assignment of UPN 
 
Each patient will be identified with a unique patient number (UPN) for this study.  All data 
will be recorded with this identification number on the appropriate CRFs. 
 
 
5.0 
TREATMENT PLAN 
 
5.1 
Pretreatment Evaluation 
 
Prior to enrollment, patient must have a complete history, physical examination, evaluation 
of performance status (KPS), baseline laboratory studies (CBC, BMP, and LFTs), and 
MRI. For the expansion cohort, patients must have confirmed diagnosis of GBM with IDH, 
BRAF, or NF1 mutations. Diagnosis will be confirmed through the pathology report as a 
part of standard of care. Although for the dose-escalation phase, there was an optional pre-
operative disulfiram study before the initial surgery, this will no longer be applicable for 
the expansion cohort and has been removed.   
 
 
 


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5.2 
Radiation Therapy 
 
RT should start approximately 4-6 weeks after surgery (up to 8 weeks is permissible). 
Standard fractionated RT to 60 Gy in 30 daily fractions will be administered in this study. 
Gross tumor volume (GTV) is defined as T1 contrast enhancing abnormality and surgical 
cavity. Clinical tumor volume 1 (CTV1) is defined as GTV with a margin of 1.5 cm. 
Clinical tumor volume 2 (CTV2) is defined as GTV with a margin of 0.5-0.7 cm.  CTVs 
may be modified to respect natural barriers such as bone or tentorium. CTV1 and CTV2 
should be expanded uniformly by 0.3-0.5 cm into planning target volume 1 and 2 (PTV1 
and PTV2), respectively to account for setup uncertainty. PTV1 should be treated to 46 Gy 
in 23 fractions of 2 Gy each, and PTV2 should be boosted to an additional 14 Gy in 7 
fractions of 2 Gy each for a cumulative total dose of 60 Gy in 30 fractions of 2 Gy each. 
3D conformal RT (3DCRT) and intensity modulated RT (IMRT) are all permitted for RT 
delivery. 
 
5.3 
Concurrent Temozolomide Treatment 
 
Concurrent TMZ will be administered continuously (Monday through Sunday) from Day 
1 of RT to the last day of RT at a daily oral dose of 75 mg/m2 for a maximum of 49 days 
as per standard clinical care. TMZ should be taken before RT. The drug should typically 
be administered orally at least 1 hour before breakfast every morning. TMZ should not be 
taken within one hour of DSF and Cu administration. Patients will be instructed to bring 
all unused drug and the completed medication diary (Appendix C) to each study visit for 
assessment of compliance. 
 
5.4 
Disulfiram and Copper Administration during Chemoradiotherapy 
 
DSF and Cu will be administered during chemoradiotherapy as per dose escalation 
instructions in Section 5.10.  For patients enrolling in the expansion cohort, the dose of 
DSF will be 250 mg/day.  During chemoradiotherapy, DSF should be taken in the morning 
with approximately 8 ounces of water approximately 1 hour after breakfast, and 2 mg of 
Cu gluconate should be taken TID with meals but not concurrently with DSF. The rationale 
of giving Cu in 3 doses is to maintain relatively constant plasma copper throughout the day 
while DSF is absorbed and metabolized. Concurrent DSF during chemoradiotherapy is 
administered in the morning to provide the maximum radiosensitizing effect. DSF and Cu 
should not be taken within one hour of TMZ administration.  If the 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 D) to each study visit for assessment of 
compliance.  
 
 
 
 
 
 


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Medication Schedule 
TMZ 
At least 1 hour before breakfast and 
before RT, but not within 1 hour of DSF 
+ Cu 
DSF 
1 hour after breakfast  
Cu 
With breakfast, lunch, and dinner 
 
5.5 
Laboratory Studies and Tissue Collection during Chemoradiotherapy 
 
Routine laboratory studies (CBC, BMP, and LFTs) will be obtained before the start of 
chemoradiotherapy and weekly (for CBC) and monthly (for BMP and LFTs) during 
chemoradiotherapy 
or 
more 
frequently 
as 
clinically 
indicated. 
If, 
during 
chemoradiotherapy treatment, the patient develops disease progression and undergoes 
surgical resection of the glioblastoma, a portion of the tissue removed during surgery and 
along with blood will be archived for future research purposes (please refer to Section 9.0). 
 
5.6 
Adjuvant Temozolomide and Disulfiram Treatment 
 
Approximately 4-6 weeks after completion of RT with concurrent TMZ, adjuvant TMZ 
may be administered for 6 cycles. Dosage of each cycle is 150-200 mg/m2 PO per day on 
Days 1-5 of every 28-day cycle. DSF will be administered at 500 mg PO daily continuously 
in combination with adjuvant TMZ for up to 6 cycles as established by our previous phase 
I study. The timing for DSF and Cu are same as in Section 5.7. Additional adjuvant TMZ 
beyond 6 cycles may be given at the discretion of the treating medical oncologist but not 
with DSF. Per standard clinical care, adjuvant TMZ is typically given in the evening before 
bedtime rather than in the morning. The timing of adjuvant TMZ will be established at the 
discretion of the treating medical oncologist.  Tumor-treating fields or Optune device 
(Novocure) as per routine clinical care during adjuvant TMZ is permitted at the discretion 
of the treating physician. 
 
During adjuvant TMZ, the patient should be assessed every 2 months as per routine clinical 
care; however, more frequent visits may be performed as per the treating physician. During 
adjuvant DSF with concurrent TMZ, if a patient develops disease progression and 
undergoes surgical resection of the GBM, a portion of the tissue removed during surgery 
and along with blood will be archived for future research purposes (please refer to Section 
9.0). 
 
5.7 
Optional Preoperative Disulfiram before Salvage Surgery 
After completion of adjuvant DSF, patients should be followed every 2-3 months as per 
routine clinical care. If a patient develops recurrent tumor during follow-up and plans to 
undergo another resection, he/she may opt for an optional preoperative DSF study prior to 
salvage surgery. Patients who would like to participate in this optional portion of the study 
will be treated with a 5-day (+/- 2 days) lead-in with oral DSF and Cu. DSF should be taken 
as 250 mg per day approximately 1 hour after dinner in the evening, and Cu should be 
taken as 2mg TID with each meals. Patient should not take DSF or Cu on the day of the 
surgery and should complete the drug diary (Appendix E). 


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5.8 
Disulfiram Dose Escalation Criteria 
 
The first patient will be treated at Dose Level 2 with 250 mg of DSF daily, and doses for 
subsequent patients will be provided at the time of registration based on the toxicity 
experience of the previous patients on study using the TITE-CRM method, as detailed in 
Section 13.3.  
 
Dose Escalation Schedule 
Dose Level 
Dose of Disulfiram 
Level 1 
125 mg PO daily 
Level 2 
250 mg PO daily 
Level 3 
375 mg PO daily 
Level 4 
500 mg PO daily 
 
For patients enrolling in the expansion cohort, the dose of DSF during RT will be 250 
mg/day. 
 
5.9 
Definition of MTD, DLT, Dose Escalation Criteria, and Toxicity, Response, 
and DLT Evaluations 
 
5.9.1 Definition of Maximum Tolerated Dose (MTD) 
 
The maximum tolerated dose (MTD) of DSF is defined as the dose level at which 
20% of the cohort experience DLT within 18 weeks from start of RT (or 12 weeks 
from the end of RT if there is a delay in RT).  MTD is assessed from the first dose 
of DSF in combination with TMZ and RT; patients will not be assessed for DLT 
during the pre-surgery period when they are receiving the lead-in doses of DSF. 
 
5.9.2 Dose Limiting Toxicities (DLTs) 
 
A DLT is defined as a clinically significant adverse event or abnormal laboratory 
value assessed as unrelated to disease progression, intercurrent illness, or 
concomitant medications/TMZ/adjuvant DSF which occurs within 18 weeks 
following the first dose of DSF with RT+TMZ (corresponding to approximately 6 
weeks during RT and 12 weeks after RT) and meets any of the following criteria 
(all toxicity will be graded using CTCAE version 4.0): 
 
• Any delay in RT treatment > 14 days that is possibly, probably, or definitely 
related to DSF will be considered a DLT. 
• Any adverse event that requires dose reduction or discontinuation of DSF 
during RT that is possibly, probably, or definitely related to DSF will be 
considered a DLT. 
• Grade 4 neutropenia or thrombocytopenia. 


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Note: These dose limiting hematological toxicities are most likely due to TMZ 
and may be attributed to TMZ. However, as a conservative assessment of the 
ability to combine DSF with RT and TMZ, these toxicities will be counted as a 
DLT as they would prompt discontinuation of TMZ.  
• Serum creatinine > 2.0 x ULN  
• Total bilirubin > 2.0 x ULN; AST or ALT > 3.0 x ULN  
• Other grade 3 or grade 4 non-hematologic toxicity that is possibly, probably, or 
definitely related to DSF, with the following specific exceptions: 
• Grade 3 fatigue 
• Grade 3 arthralgias/myalgias 
• Grade 3 or 4 nausea, vomiting, or anorexia that does not require 
discontinuing RT or TMZ 
• Diarrhea that can be adequately managed with outpatient medication such 
as loperamide and does not require hospitalization 
 
Headaches are frequent in the brain tumor population and are usually due to diffuse 
increased intracranial pressure or compression of pain-sensitive intracranial 
structures (example: dura). The oncologists participating in this study are 
experienced clinicians accustomed to evaluation of brain tumor patients with 
headaches. Each patient with a headache is approached individually with a 
systematic assessment as to the etiology of the pain. Appropriate tests may include 
vital signs, CT or MRI scans, or other investigations. If, in the opinion of the 
treating oncologist, the headache is due to DSF, then the toxicity will be graded as 
above, and if ≥ grade 3, it will be defined as a DLT. 
 
Seizures are also a common complication associated with brain tumors. As noted 
in the preceding paragraph each patient will be approached individually and 
assessment for the cause of the seizure will be performed. If, in the opinion of the 
treating oncologist, the seizure is due to DSF, then the toxicity will be graded, and 
if ≥ 3, it will be defined as a DLT. 
 
5.9.3 Toxicity, Response, and DLT Evaluations 
 
All patients who receive at least one dose of DSF are evaluable for toxicity. 
However, patients have to receive the combination of DSF with RT+TMZ to be 
evaluable for DLT. Of note, DLT evaluation starts when patient starts DSF with 
RT and does not apply during the preoperative DSF administration. Patients who 
do not have at least one dose of DSF with RT+TMZ will not be evaluable for DLT 
and will be replaced. 
 
 
 


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Page 30 of 72 
5.10 
General Concomitant Medication and Supportive Care Guidelines 
 
The following medications and procedures are prohibited during the study: 
• Any antineoplastic therapy other than RT, temozolomide, and DSF, except for the 
tumor-treating fields or Optune device when used in conjunction with adjuvant 
temozolomide and DSF 
• Any investigational therapy other than DSF  
 
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.   
 
5.10.1 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 
through the cytochrome P450 system, the use of benzodiazepines for antiemetic 
prophylaxis should be reserved for patients who cannot be satisfactorily managed 
otherwise.   
 
5.10.2 Diarrhea 
 
Antidiarrheal medications will not be used prophylactically; however, patients will 
be instructed to take loperamide, 4 mg total, 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. 
 
5.10.3 Central Nervous System Effects 
 
In our previous experience with 500-1000 mg of DSF per day with adjuvant TMZ, 
significant neurological toxicities, including delirium/psychosis, ataxia, visual 
changes, peripheral neuropathy, were observed, especially at the 1000 mg dose. 
Early signs of those symptoms should be carefully monitored. Once other causes 
such as tumor progression are ruled out, dose reduction of DSF during adjuvant 
TMZ should be considered if the toxicity is grade 2 or greater. 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 


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assessment to rule out other causes. Appropriate tests may include vital signs; CT 
or MRI scans or other investigations.  
 
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.  
 
5.10.4 Management of Disulfiram-Alcohol Reaction 
 
Severe DSF reactions caused by the patient's ingestion of alcohol should lead to 
emergency evaluation and supportive measures to restore blood pressure. Other 
recommendations include: oxygen, carbogen (95% oxygen and 5% carbon 
dioxide), vitamin C intravenously in massive doses (1 g), and ephedrine sulfate. 
Antihistamines have also been used intravenously. Potassium levels should be 
monitored, particularly in patients on digitalis, since hypokalemia has been 
reported. 
 
5.11 
Women of Childbearing Potential 
 
Women of childbearing potential (defined as women with regular menses, women with 
amenorrhea, women with irregular cycles, women using a contraceptive method that 
precludes withdrawal bleeding, or women who have had a tubal ligation) are required to 
have a negative serum pregnancy test within 14 days prior to the first dose of the study 
treatment.   
 
Female and male patients (along with their female partners) are required to use a method 
of acceptable contraception, including one barrier method, during participation in the study 
and for 4 months following the last dose of study treatment.  
 
If a patient is suspected to be pregnant, study treatment should be immediately 
discontinued.  In addition a positive urine test must be confirmed by a serum pregnancy 
test.  If it is confirmed that the patient is not pregnant, the patient may resume treatment. 
 
If a female patient or female partner of a male patient becomes pregnant during therapy or 
within 4 months after the last dose of study treatment, the investigator must be notified in 
order to facilitate outcome follow-up. 
 
5.12 
Duration of Therapy 
 
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 documented 
in the case report forms. 
 
 
 


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In the absence of treatment delays due to adverse events, DSF treatment may continue until 
completion of 6 cycles of adjuvant TMZ or in the event of following: 
 
• 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 
• General or specific changes in the patient’s condition render the patient 
unacceptable for further treatment in the judgment of the investigator 
• Suspected pregnancy 
• Serious noncompliance with the study protocol 
• Lost to follow-up 
• Patient withdraws consent 
• Investigator removes the patient from study 
• The Siteman Cancer Center decides to close the study 
 
5.13 
Duration of Follow-up 
 
Patients are evaluated for adverse events for 30 days after the last dose of DSF 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 adjuvant TMZ + DSF will be per routine clinical care.  Two years after the 
patient comes off study, the chart will be reviewed to collect data on progression and 
survival. 
 
6.0 
DOSE MODIFICATIONS 
 
6.1 
Temozolomide Dose Modifications during Radiation Therapy  
 
No dose reduction will be made, but delay or discontinuation of TMZ administration will 
be decided weekly according to hematologic and non-hematologic adverse events, as 
specified below.  Additionally, TMZ can be held at the discretion of the treating physician.  
If the administration of TMZ has to be interrupted, RT will proceed normally. Missed doses 
of TMZ will not be made up at the end of RT. The total number of days and total dose of 
temozolomide will be recorded on the patient’s medication diary (Appendix C). 
 
If one or more of the following are observed: 
• ANC < 1.5 x 109/ L (Grade 2) 
• Platelet count < 75 x 109/L (Grade 2) 
• Grade 3 non-hematologic AE (except alopecia, nausea and vomiting while on 
maximal antiemetic therapy, and fatigue) 
 
 
 


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Then treatment with concurrent TMZ will be withheld until all of the following conditions 
are met: 
• ANC ≥ 1.5 x 109/L 
• Platelet count ≥ 75 x 109/L 
• Grade ≤ 1 non-hematologic AE (except alopecia, nausea and vomiting, and fatigue) 
In case of hematologic AE as defined above, a complete blood count (CBC) should be 
performed at least weekly. In case of non-hematologic AE, the patient should be assessed 
at least weekly with relevant laboratory test(s). As soon as all of the above conditions are 
met, the administration of temozolomide will resume at the same dose as used initially. 
 
If one or more of the following are observed: 
• ANC < 0.5 x 109/L (Grade 4) 
• Platelet count < 25 x 109/L (Grade 4) 
• Grade 4 non-hematologic AE (except alopecia, nausea and vomiting unless the 
patient has failed maximal antiemetic therapy, and fatigue) 
Then treatment with concurrent temozolomide should be discontinued. 
 
AE 
Value 
Action 
Grade 3 neutropenia 
≥ 0.5 and < 1.0 x 109/L 
Hold TMZ until  
--ANC ≥ 1.5 x 109/L 
--Platelet ≥ 75 x 109/L 
--Grade ≤ 1 non-
hematologic AE 
Grade 2-3 thrombocytopenia 
≥ 25 and < 75 x 109/L 
Grade 3 non-hematologic 
(except alopecia, 
nausea/vomiting unless on 
maximal antiemetic therapy) 
NA 
Grade 4 neutropenia 
< 0.5 x 109/L 
Stop TMZ 
Grade 4 thrombocytopenia 
< 25 x 109/L 
Grade 4 non-hematologica 
(except alopecia, 
nausea/vomiting) 
NA 
 
If RT has to be temporarily interrupted for technical or medical reasons unrelated to TMZ, 
then treatment with daily TMZ should continue. If RT has to be permanently discontinued 
then TMZ should stop until it is re-initiated at the adjuvant phase of treatment. 
 
6.2 
DSF Dose Modifications 
 
During radiotherapy, if a patient experiences any adverse event that requires dose reduction 
in the opinion of the investigator and that is considered by the investigator to be possibly, 
probably, or definitely related to DSF, DSF/Cu should be discontinued and the event will 
be considered a DLT. If RT has to be temporarily interrupted for technical or medical 
reasons unrelated to TMZ or DSF/Cu, then treatment with daily TMZ and DSF/Cu should 
continue.  If RT has to be permanently discontinued then TMZ and DSF/Cu should stop 
until re-initiated at the adjuvant phase of treatment.  If TMZ is held due to toxicity unrelated 
to DSF/Cu, DSF/Cu should continue as tolerated. 
 


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During adjuvant TMZ, the dose of DSF may be reduced from 500 mg per day to 250 mg per 
day due to toxicity or intolerance at the discretion of the treating physician. Expansion 
patients who discontinued DSF during RT and concurrent TMZ due to toxicity may be 
considered to resume DSF with adjuvant TMZ but at 250 mg/day as long as the toxicity has 
resolved prior to the start of cycle 1 of adjuvant TMZ and after discussion between the 
treating physician and the PI.  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 consideration of dose reduction if thought to be related to DSF. No second dose 
reduction (below 250 mg/day) is allowed—if a second dose reduction is required, DSF and 
Cu will be permanently discontinued. Of note, hematologic toxicity is uncommon for DSF 
and is likely related to TMZ. 
 
6.2.1 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 including TMZ.  
 
6.2.2 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 should not be re-challenged.    
 
 
7.0 
REGULATORY AND REPORTING REQUIREMENTS 
 
The entities providing oversight of safety and compliance with the protocol require reporting as 
outline below. 
 
The Washington University Human Research Protection Office (HRPO) requires that all events 
meeting the definition of unanticipated problem or serious noncompliance be reported as outlined 
in Section 7.2. 
 
7.1 
Definitions 
 
7.1.1 Adverse Events (AEs) 
 


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Definition: any unfavorable medical occurrence in a human subject including any 
abnormal sign, symptom, or disease. 
 
Grading: the descriptions and grading scales found in the revised NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for 
all toxicity reporting.  A copy of the CTCAE version 4.0 can be downloaded from 
the CTEP website. 
 
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.html 
 
7.1.2 Serious Adverse Event (SAE) 
 
Definition:  any adverse drug experience occurring at any dose that results in any 
of the following outcomes: 
o Death 
o A life-threatening adverse drug experience 
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 
 
7.1.3 Unexpected Adverse Experience 
 
Definition: 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). 
 
7.1.4 Life-Threatening Adverse Experience  
 
Definition: 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. 
 
7.1.5 Unanticipated Problems 
 
Definition: 
 
• unexpected (in terms of nature, severity, or frequency) given (a) the research 


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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 
• suggests 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. 
 
7.1.6 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. 
 
7.1.7 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. 
 
7.1.8 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. 
 
Pre-approval of all protocol exceptions must be obtained prior to the event.   
 
7.2 
Reporting to the Human Research Protection Office (HRPO) at Washington 
University 
 
The PI is required to promptly notify the IRB of the following events: 
 
• Any unanticipated problems involving risks to participants or others which occur 
at WU, any BJH or SLCH institution, or that impacts 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. 
 


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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. 
 
7.3 
Reporting to the Quality Assurance and Safety Monitoring Committee 
(QASMC) at Washington University 
 
The PI is required to notify the QASMC of any unanticipated problem occurring at WU or 
any BJH or SLCH institution that has been reported to and acknowledged by HRPO as 
reportable.  (Unanticipated problems reported to HRPO and withdrawn during the review 
process need not be reported to QASMC.) 
 
QASMC must be notified within 10 days of receipt of IRB acknowledgment via email to 
a QASMC auditor. 
 
7.4 
Timeframe for Reporting Required Events  
 
Adverse events will be tracked until the last dose of DSF. However, DLTs will only be 
evaluated for 18 weeks from the first day of DSF with RT+TMZ or at least 12 weeks 
following the completion of RT in the event there is a delay/interruption of RT.  All 
clinically or laboratory adverse events that are > grade 1 (excluding lymphopenia) will be 
collected. 
 
 
8.0 
PHARMACEUTICAL INFORMATION 
 
8.1 
Disulfiram 
 
8.1.1 DSF 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. GBM cells and its stem-like 
subpopulation (also referred to as CSC) may be more susceptible to the effect of 


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proteasomal inhibition than normal brain cells.  DSF is very lipophilic and readily 
crosses the blood-brain barrier. 
 
 
 


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8.1.3 Supplier 
 
DSF (trade name Antabuse) is commercially available and will be provided to 
participants by the study.   
 
8.1.4 Dosage Form 
 
DSF is supplied as white, round tablets of 250 mg. Each tablet also contains 
colloidal silicon dioxide, anhydrous lactose, magnesium stearate, microcrystalline 
cellulose, sodium starch glycolate, and stearic acid. The tablet may be cut in half to 
obtain 125 mg dose. 
 
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 DSF Administration 
 
DSF is taken by mouth daily. It should be taken with meal to improve absorption. 
It should not be taken within one hour of temozolomide. Patient 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. 
 
8.2 
Temozolomide (Temodar) 
 
8.2.1 Temozolomide Description 
 
Chemical 
name: 
3,4-dihydro-3-methyl-4-oxoimidazo[5,1-d]-as-tetrazine-8-
carboxamide. 
Structural formula: 
 
 
8.2.2 Clinical Pharmacology 
 
Temozolomide is not directly active but undergoes rapid nonenzymatic conversion 
at physiologic pH to the reactive compound 5-(3-methyltraizen-1-yl)-imaidazole-
4-carboxamide (MTIC).  The cytotoxicity of MTIC is thought to be primarily due 
to alkylation of DNA.  Alkylation (methylation) occurs mainly at the O6 and N7 
positions of guanine. 
 


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8.2.3 Pharmacokinetics and Drug Metabolism 
 
Temozolomide is rapidly and completely absorbed after oral administration with a 
peak plasma concentration (Cmax) achieved in a median Tmax of 1 hour.  Food 
reduces the rate and extent of temozolomide absorption. 
 
Temozolomide is spontaneously hydrolyzed at physiologic pH to the active species, 
MTIC and to temozolomide acid metabolite.  MTIC is further hydrolyzed to 5-
amino-imidazole-4-carboxamide (AIC), which is known to be an intermediate in 
purine and nucleic acid biosynthesis, and to methylhydrazine, which is believed to 
be the active alkylating species.  Cytochrome P540 enzymes play only a minor role 
in the metabolism of temozolomide and MTIC. 
 
About 38% of the administered temozolomide total radioactive dose is recovered 
over 7 days: 37.7% in urine and 0.8% in feces.  Temozolomide is rapidly 
eliminated, with a mean elimination half-life of 1.8 hours. 
 
8.2.4 Supplier 
 
Temozolomide is commercially available. 
 
8.2.5 Dosage Form and Preparation 
 
Temozolomide capsules are supplied in child-resistant sachets containing the 
following capsule strengths: 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, and 250 mg. 
 
8.2.6 Storage and Stability 
 
Store temozolomide capsules at 35°C (77°F); excursions permitted to 15-30°C (59-
86°F). 
 
8.2.7 Administration 
 
Please refer to Sections 5.6 and 5.9. 
 
8.2.8 Special Handling Instructions 
 
The use of gloves is recommended. 
 
 
9.0 
CORRELATIVE STUDIES 
 
The correlative studies to measure drug concentration will be performed in all enrolled patients 
that have agreed to take part in collection of blood and tumor samples. Drug concentration of DSF 
metabolites (such as ditiocarb-copper complex) from the serum and tumor samples will be 
measured by mass spectrometry by our collaborator Dr. Martin Mistrik at Palacky University 


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Page 41 of 72 
Olomouc in Czech Republic as previously described [71]. Of note, the tumor, plasma, cell pellet 
or lysate may be stored at -80 ºC for up to 2 years before batch analysis. 
 
9.1 
Collection of Specimens 
 
If a patient is participating in the optional tumor collection at time of recurrence, a tumor 
specimen of at least 0.2 cubic cm or approximately 200 mg will be collected. At the time 
of salvage surgery, approximately 20 mL of peripheral blood (10 mL into each of 2 green 
top tube containing sodium heparin) will also be collected. Tumor and blood samples will 
be submitted at ambient temperature to Tissue Procurement Core (TPC) for processing and 
storage.  
 
 
 
 
 
 
 
 


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10.0 
STUDY CALENDAR 
 
 
10.1 Dose-escalation phase: 
Baseline evaluations are to be conducted up to 14 days prior to start of pre-operative DSF.  Labs 
and MRIs must be done no more than 30 days prior to the start of the protocol therapy. 
1. Weekly during RT + TMZ 
2. Women of childbearing potential only 
3. Daily during RT 
4. Days 1-5 of every 28-day cycle 
5. Adjuvant TMZ will start 4-6 weeks after the end of RT and will be given for 6 28-day cycles 
6. 500 mg daily with adjuvant TMZ 
7. 2 mg TID with meals while taking DSF 
8. Reviewed weekly by the treating radiation oncologist or the institutional PI during concurrent RT + TMZ, and reviewed every 8 weeks 
during adjuvant TMZ. 
9. Only if patient is still receiving DSF 
10. DSF/Cu are taken for 3 days prior to surgery, and preoperative DSF should be taken in the evening approximately 1 hour before or 1 
hour after dinner. The dose of DSF is as per dose-escalation criteria.  
11. DSF is taken in the morning approximately1 hour before or 1 hour after breakfast. The dose of DSF is as per dose-escalation criteria  
12. Must be resection with at least 200 mg of tissue available beyond what is required for pathology. This is only required for patients that 
have opted into the preoperative DSF + Cu phase of treatment. 
13. For patients consented for the optional preoperative DSF, eligibility must be reconfirmed after surgery and before the start of RT.  For 
patients consented after surgery, they need to meet eligibility prior to RT. 
14. RT and TMZ will start 4-6 weeks after resection (up to 8 weeks is permissible) 
15. 30 fractions of RT given over 6 weeks 
16. The patient will be followed for 30 days after the last dose of disulfiram for adverse events; 2 years after coming off study, a review 
of the patient’s medical records will be conducted to collect data on progression and survival 
17. If the tumor recurs during the 6-month treatment period and the patient has surgery, we will request a portion of the tissue removed 
during surgery for future correlative studies 
 
B/l 
3 days 
pre-
surg18 
Surg12 
Pre-
RT13 
Wks 
1-614 
Adjuvant TMZ5 Cycles 
F/U16 
1 
2 
3 
4 
5 
6 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
Physical exam 
X 
 
 
X 
X1 
X 
X 
X 
X 
X 
X 
 
KPS 
X 
 
 
X 
 
 
 
 
 
 
 
 
CBC 
X 
 
X 
X 
X1 
X 
X 
X 
X 
X 
X 
 
BMP 
X 
 
X 
X 
X20 
X 
X 
X 
X 
X 
X 
 
LFTs 
X 
 
X 
X 
X20 
X 
X 
X 
X 
X 
X 
 
β-hCG2 
X 
 
 
X 
 
 
 
 
 
 
 
 
MRI w/ and w/o contrast 
X 
 
 
X19 
 
 
X 
 
X 
 
X 
 
Path. conf. of GBM diagnosis 
 
 
 
X 
 
 
 
 
 
 
 
 
RT 
 
 
 
 
X15 
 
 
 
 
 
 
 
Temozolomide 
 
 
 
 
X3 
X4 
X4 
X4 
X4 
X4 
X4 
 
DSF 
 
X10 
 
 
X11 
X6 
X6 
X6 
X6 
X6 
X6 
 
Cu7 
 
X10 
 
 
X 
X 
X 
X 
X 
X 
X 
 
Review of medication diary 
 
 
X 
 
X8 
 
 
 
 
 
 
 
Adverse events 
 
X 
 
X 
X8 
X8 
X8 
X9 
X9 
X9 
X9 
X17 
Collection of tumor17 
 
 
X 
 
 
 
 
 
 
 
 
 
Collection of blood 
 
 
X 
 
 
 
 
 
 
 
 
 


Version 01/24/25, Amendment 6 
 
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18. OPTIONAL; patients whose disease recurs and who will undergo another resection may opt to take p 5 days (+/- 2 days) of preoperative 
DSF (250 mg per day in the morning) and Cu (2mg PO TID with meals) until the day before the planned surgery. Patient should not take 
DSF/Cu on the day of surgery. 
19. Simulation MRI can be used as pre-RT MRI if conducted with and without contrast 
20. Monthly during RT + TMZ. 
 
10.2 Dose-expansion phase: 
Baseline evaluations, labs and MRIs must be done no more than 30 days prior to the start of the 
protocol therapy. 
1. RT and TMZ will start 4-6 weeks after resection (up to 8 weeks is permissible) 
2. Adjuvant TMZ will start 4-6 weeks after the end of RT and will be given for 6 28-day cycles 
3. The patient will be followed for 30 days after the last dose of disulfiram for adverse events; 2 years after coming off study, a review 
of the patient’s medical records will be conducted to collect data on progression and survival 
4. If a patient develops recurrence and is eligible for salvage surgery, he/she will be eligible for optional tissue collection at time of 
salvage surgery. If he/she is not on DSF/Cu any more, he/she may opt to take 5 days (+/- 2 days) of preoperative DSF and Cu before 
the planned surgery.  
5. Weekly during RT + TMZ 
6. Monthly during RT + TMZ. 
7. Women of childbearing potential only 
8. Simulation MRI can be used as pre-RT MRI if conducted with and without contrast 
9. 60 Gy in 30 fractions 
10. 75 mg/m2 daily during RT 
11. Days 1-5 of every 28-day cycle 
12. DSF is taken in the morning approximately1 hour after breakfast. The dose of DSF in the expansion cohort is 250 mg once daily 
during RT.  
13. DSF dose during adjuvant TMZ will be 500 mg once daily 
14. 2 mg TID with meals while taking DSF 
 
B/l 
Wks 
1-61 
Adjuvant TMZ5 Cycles 
F/U3 
Optional: 
Tissue 
collection at 
recurrence4 
1 
2 
3 
4 
5 
6 
Informed consent 
X 
 
 
 
 
 
 
 
 
X 
Physical exam 
X 
X5 
X 
X 
X 
X 
X 
X 
 
 
KPS 
X 
 
 
 
 
 
 
 
 
 
CBC 
X 
X5 
X 
X 
X 
X 
X 
X 
 
 
BMP 
X 
X6 
X 
X 
X 
X 
X 
X 
 
 
LFTs 
X 
X6 
X 
X 
X 
X 
X 
X 
 
 
β-hCG7 
X 
 
 
 
 
 
 
 
 
 
MRI w/ and w/o contrast 
X8 
 
 
X 
 
X 
 
X 
 
 
Path. diagnosis of GBM with 
IDH, BRAF, or NF1 
mutations 
X 
 
 
 
 
 
 
 
 
 
RT 
 
X9 
 
 
 
 
 
 
 
 
Temozolomide 
 
X10 
X11 
X11 
X11 
X11 
X11 
X11 
 
 
DSF 
 
X12 
X13 
X13 
X13 
X13 
X13 
X13 
 
X16 
Cu14 
 
X 
X 
X 
X 
X 
X 
X 
 
X16 
Review of medication diary 
 
X15 
 
 
 
 
 
 
 
X 
Adverse events 
 
X15 
X15 
X15 
X15 
X15 
X15 
X15 
X 
X 
Collection of tumor 
 
 
 
 
 
 
 
 
 
X17 
Collection of blood 
 
 
 
 
 
 
 
 
 
X17 


Version 01/24/25, Amendment 6 
 
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15. Reviewed weekly by the treating radiation oncologist or the institutional PI during concurrent RT + TMZ, and reviewed every 8 weeks 
during adjuvant TMZ. 
16. If patient is still receiving DSF/Cu on study, they should continue until the day before the planned surgery. If they are off DSF/Cu at 
time of recurrence, they may opt to take 5 days (+/- 2 days) of preoperative DSF (250 mg per day in the evening) and Cu (2mg PO 
TID with meals) until the day before the planned surgery. Patient should not take DSF/Cu on the day of surgery. 
17. A portion of resected tumor tissue and blood will be collected for future correlative studies. 
 
 
11.0 
DATA SUBMISSION SCHEDULE 
 
Case report forms with appropriate source documentation will be completed according to the 
schedule listed in this section. 
 
Case Report Form 
Submission Schedule 
Original Consent Form 
Prior to registration 
On-Study Form 
Prior to starting treatment 
Surgery Form 
Time of surgery 
Treatment Form 
At completion of RT 
End of every cycle during adjuvant TMZ 
Correlatives Form 
Time of surgery 
Time of progression 
Toxicity Form 
Continuous 
Treatment Summary Form 
Completion of treatment 
Follow Up Form 
2 years after last dose of disulfiram 
MedWatch Form 
See Section 7.0 for reporting requirements 
 
 
 
12.0 
MEASUREMENT OF EFFECT 
 
12.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, patients should be re-evaluated for response every 9 +/- 1 
weeks.  In addition to a baseline scan, confirmatory scans should also be obtained 9 weeks 
(not less than 4) weeks following initial documentation of objective response. 
 
Response and progression will be evaluated in this study using the updated response 
assessment criteria for high-grade gliomas: Response Assessment in Neuro-Oncology 
(RANO) working group guideline [78]. 
 
 
 


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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 postradiotherapy 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 nonenhancing 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, 
demyelination, ischemic injury, infection, seizures, postoperative 
changes, or other treatment effects).  
 
Criteria for Response Assessment Incorporating MRI and Clinical Factors (Adapted from JCO 
2010) 
Response 
Criteria 
Complete response 
• 
Requires all of the following: complete disappearance of all enhancing 
measurable and nonmeasurable disease sustained for at least 4 weeks. 
• 
No new lesions; stable or improved nonenhancing (T2/FLAIR) lesions. 
• 
Patients must be off corticosteroids (or on physiologic replacement doses only) 
and stable or improved clinically. Note: Patients with nonmeasurable 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 nonmeasurable disease. 


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Response 
Criteria 
• 
Stable or improved nonenhancing (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 nonmeasurable 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 nonenhancing (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 nonenhancing 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. 
• 
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 nonmeasurable disease.  
• 
NOTE. All measurable and nonmeasurable 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.  
 
12.2 
Disease Parameters 
 
Measurable disease:  Bi-dimensionally measurable lesions with clearly defined margins 
by MRI scan.  All tumor measurements must be recorded in millimeters (or decimal 
fractions of centimeters).   
 
Non-measurable or evaluable disease:  Uni-dimensionally measurable lesions or lesions 
with margins not clearly defined such as areas of T2/FLAIR signal abnormality or poorly 
defined enhancing abnormality.  
 


Version 01/24/25, Amendment 6 
 
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Note: For cystic lesions, the only measurable part is any enhancement area around the cyst 
that is clearly defined and bi-dimensionally measurable. The cyst itself should not be 
considered measurable or non-measureable disease. 
 
Target lesions: All measurable lesions that are residual of the lesion treated with MLA 
should be identified as target lesions and recorded and measured.  Target lesions should be 
selected on the basis of their size (lesions with the longest diameter), but in addition should 
be those that lend themselves to reproducible repeated measurements.  It may be the case 
that, on occasion, the largest lesion does not lend itself to reproducible measurement in 
which circumstance the next largest lesion, which can be measured reproducibly should be 
selected.  When there are too many measurable lesions, choose the largest 3 lesions as 
target lesions to follow.  The other measurable lesions should be considered evaluable for 
the purpose of objective status determination. 
 
Non-target lesions:  All non-measurable lesions should be identified as non-target lesions 
and should also be recorded at baseline.  Measurements of these lesions are not required, 
but the presence, absence, or in rare cases unequivocal progression of each should be noted 
throughout follow-up.  
 
12.3 
Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler.  All 
baseline evaluations should be performed as closely as possible to the beginning of 
treatment and never more than 2 weeks before the beginning of the treatment. 
 
Clinical lesions:  Clinical lesions will only be considered measurable on brain MRI when 
they are ≥ 5 mm diameter as assessed using a ruler. 
 
Histology:  This technique can be used to differentiate between partial responses (PR) and 
complete responses (CR) in rare cases when biopsy or surgical resection of a measureable 
lesion is clinically indicated.  
 
Perfusion/CBV: This advanced brain MRI technique can be used as an adjunct test to 
determine treatment response or disease status.  However, it should not be used as the 
primary or sole method to determine response or disease status.  
 
Brain FDG-PET coupled with head CT or brain MRI: This advanced metabolic 
imaging technique can be used as an adjunct test to determine response or disease status. 
However it should be used as the primary or sole method of determining response or 
disease status. 
 
12.3.1 Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions. 
 
Partial Response (PR):  ≥ 50% decrease compared with baseline in the sum of 


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products of perpendicular diameters of all target lesions sustained for at least 4 
weeks. 
 
Progressive Disease (PD):  At least a 25% increase in the sum of products of 
perpendicular diameters of at least 1 target lesion, taking as reference the smallest 
sum of products of perpendicular diameters on study (this includes the baseline sum 
if that is the smallest on study).  The absolute increase in any dimension must be at 
least 5mm when calculating the products of perpendicular diameters. 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum of products of 
perpendicular diameters while on study. 
 
12.3.2 Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions.  
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s). 
 
Progressive Disease (PD): Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions 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). Unequivocal progression should not normally trump target lesion status.  
It must be representative of overall disease status change, not a single lesion 
increase.     
 
Although a clear progression of “non-target” lesions only is exceptional, the 
opinion of the treating physician should prevail in such circumstances, and the 
progression status should be confirmed at a later time by the review panel (or 
Principal Investigator). 
 
12.3.3 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. 
 
 


Version 01/24/25, Amendment 6 
 
Page 49 of 72 
 
Summary of the RANO Response Criteria (Adapted from JCO 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. 
 
12.3.4 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from 
the time measurement criteria are met for CR or 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.  
 
12.3.5 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression 
or death, whichever occurs first. 
 
 


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13.0 
DATA AND SAFETY MONITORING 
 
In compliance with the Washington University Institutional Data and Safety Monitoring Plan, the 
Principal Investigator will provide a Data and Safety Monitoring (DSM) report to the Washington 
University Quality Assurance and Safety Monitoring Committee (QASMC) semi-annually 
beginning six months after accrual has opened (if at least five patients have been enrolled) or one 
year after accrual has opened (if fewer than five patients have been enrolled at the six-month mark). 
 
During the phase I dose escalation, the Principal Investigator will review all patient data at least 
monthly (or before each dose-escalation if occurring sooner than monthly), and provide a semi-
annual report to the Quality Assurance and Safety Monitoring Committee (QASMC).  During the 
phase II, the Principal Investigator will review all patient data at least every six months, and 
provide a semi-annual report to the QASMC. This report will include: 
• HRPO protocol number, protocol title, Principal Investigator name, data coordinator name, 
regulatory coordinator name, and statistician 
• Date of initial HRPO approval, date of most recent consent HRPO approval/revision, date 
of HRPO expiration, date of most recent QA audit, study status, and phase of study 
• History of study including summary of substantive amendments; summary of accrual 
suspensions including start/stop dates and reason; and summary of protocol exceptions, 
error, or breach of confidentiality including start/stop dates and reason 
• Study-wide target accrual and study-wide actual accrual  
• Protocol activation date  
• Average rate of accrual observed in year 1, year 2, and subsequent years  
• Expected accrual end date and accrual by cohort 
• Objectives of protocol with supporting data and list the number of participants who have 
met each objective 
• Measures of efficacy 
• Early stopping rules with supporting data and list the number of participants who have met 
the early stopping rules 
• Summary of toxicities separated by cohorts with the number of dose-limiting toxicities 
indicated 
• Abstract submissions/publications 
• Summary of any recent literature that may affect the safety or ethics of the study  
 
 
 
The study principal investigator and Research Patient Coordinator will monitor for serious 
toxicities on an ongoing basis. Once the principal investigator or Research Patient Coordinator 
becomes aware of an adverse event, the AE will be reported to the HRPO and QASM Committee 
according to institutional guidelines. 
 
 
 
 
 
 


Version 01/24/25, Amendment 6 
 
Page 51 of 72 
14.0 
STATISTICAL CONSIDERATIONS 
 
14.1 
Definition of Primary Endpoint 
 
The maximum tolerated dose (MTD) of DSF with concurrent RT+TMZ will be defined as 
the dose associated with a 20% probability of dose-limiting toxicity (DLT). Toxicity will 
be coded using CTCAE version 4.0, and DLT will be defined as toxicity that occurs within 
18 weeks from the first day of RT and is possibly, probably or definitely related to DSF/Cu 
(or 12 weeks from the completion of RT if there is a delay/interruption of RT). 
 
For the expansion cohort of GBM with IDH, BRAF, and NF1 mutations, the overall 
survival (OS) of this molecularly-defined cohort will be measured from the first day of RT. 
 
14.2 
Definition of Secondary and Exploratory Endpoints 
 
1. The adverse events will be graded by NCI CTCAE version 4.0.  
2. Progression-free survival (PFS) will be determined from the first day of RT to the time 
of tumor progression or death, whichever occurs first. Tumor progression will be 
determined using the RANO criteria. 
3. Intratumor and plasma concentration of DSF metabolite (ditiocarb-copper complex) 
will be determined using mass spectrometer method. 
4. Pharmacodynamics studies on glutamate metabolism will include measurement of 
glutamine, glutamate, aspartate, glucose, and lactate levels in blood and tumor tissues 
using mass spectrometry method.  
5. Pseudo-progression is defined as a transient increase of tumor after chemoradiotherapy 
that subsequently stabilizes without a change of therapy.    
 
14.3 
Analytic Plan for Primary Endpoint 
 
14.3.1 Background of Time-to-Event Continual Reassessment Method (TITE-
CRM) and Trial Rules 
 
The standard phase I 3+3 design is poorly suited for trials of RT, for which 
toxicities may occur up to several months after treatment. In this case, the 3+3 
design, or any design that requires all patients to have completed observation for 
toxicity, is subject to openings and closings as patients present after a dose level 
potentially has filled, but before sufficient time has elapsed to be certain that 
treatment has not produced DLT.  
 
As such, dose escalation for this trial will be guided by the Time-to-Event Continual 
Reassessment Method (TITE-CRM).  TITE-CRM seeks to determine the target 
dose, defined as the dose most closely identified with the target rate, which is the 
largest acceptable probability of toxicity, determined a priori by the investigators 
based on the relative costs and benefits of the treatment (typically between 5% and 
25%). As the trial progresses and patients do or do not experience toxicities at 
different doses, the estimates of probability of toxicity are recalculated using a 


Version 01/24/25, Amendment 6 
 
Page 52 of 72 
Bayesian expectation, and subsequent patients are assigned to doses under the 
principle to always treat at the target dose.  In a Monte Carlo simulation of 60,000 
phase I trials comparing 3+3 design to TITE-CRM in studies with delayed toxicity, 
the TITE-CRM trials were significantly shorter when toxicity observation times are 
long, treated more patients at or above the MTD, identified the MTD more 
accurately, but did not expose patients to significant additional risk [79]. 
Additionally, given that TITE-CRM concentrates most of the accrual around the 
MTD, early estimates of efficacy are possible for a phase I trial. 
 
The Time-to-Event Continual Reassessment Method (TITE-CRM) proposed by 
Cheung and Chappell is an adaptive Phase I design [80]. In a TITE-CRM clinical 
trial, patients enroll as they become available to be studied. Each participant is 
assigned to a dose level from a set of dose levels pre-defined by investigators and 
is monitored for DLTs over time. The design is adaptive in that the dose level 
assigned to a newly enrolled patient depends on the dose level assignments and 
DLT outcomes of the patients already in the study.  A patient's observation period 
ends at the occurrence of a DLT, or if a DLT does not occur, after a fixed time T of 
follow-up. The trial ends when a fixed number of patients, n, have been observed. 
Once the final patient has been observed, the MTD can be estimated using the 
available data. The TITE-CRM differs from the traditional CRM in that the 
estimation process is weighted to account for the proportion of the observation 
period that each currently enrolled patient has been observed.  By not requiring 
complete observation before the enrollment of the next patient, new participants 
can be assigned a dose and begin evaluation as they become available, subsequently 
shortening the overall duration of the study. 
 
The Biostatistics Unit at the University of Michigan Comprehensive Cancer Center 
has developed a program titecrm.sas for SAS 9 (SAS Institute, Inc.; Cary, NC) that 
makes all of the calculations necessary to determine dose allocation of a trial in 
real-time.  They have also developed simulation programs that allow the user to 
determine the efficacy of the trial based on a priori estimates of the probabilities of 
toxicity and necessary sample sizes.   
 
In order to properly utilize this type of trial, a few assumptions and many rules must 
be determined before the start of the trial.  The main assumption that must be 
determined is how many different dose levels will be included in the trial and a 
priori estimates of the probability of a DLT at each of those dose levels.  For this 
trial, we have 4 dose levels (d1,…, d4) ranging from 125mg PO daily to 500 mg PO 
daily, with initial toxicity probability estimates (p1,…, p4) ranging from 0.05 to 
0.30, respectively.  The following table shows the dose design with associated 
estimated probabilities of toxicity. 
 
 


Version 01/24/25, Amendment 6 
 
Page 53 of 72 
 
Dose Escalation Schedule 
 
Dose Level 
 
Dose of DSF 
Initial Toxicity 
Estimate 
Level 1 
125 mg PO daily 
0.05 
Level 2 
250 mg PO daily 
0.10 
Level 3 
375 mg PO daily 
0.20 
Level 4 
500 mg PO daily 
0.30 
 
14.3.2 TITE-CRM Design for the Dose-escalation Phase 
 
The starting dose can have a large impact on the properties of the design. After the 
trial is completed, most information about the MTD will be obtained if many 
patients are treated at or near the MTD, thus the sooner the choice of dose can 
converge on the MTD the more effective the trial will be. However, with concerns 
about safety we will start at the one dose level lower than the expected MTD. 
Therefore, our starting dose for this trial will be 250 mg PO daily.   
 
The next thing to be considered is the dose escalation rules.  For this trial, we will 
only allow a single dose level escalation per new patient enrolled on the trial.  
Therefore, if the previous patient was treated at dose level, dk, then a new patient 
can only be treated at dose levels dk+1 or lower.  In order to determine at which level 
to treat the new patient, we will use a non-weighted, cumulative time of exposure 
approach.  The total length of follow-up for DLT for any patient is 18 weeks.  In 
order to efficiently and effectively determine the MTD, we allow for a dose change 
when the cumulative time of exposure is 18 weeks.  Also, since previously 
published data shows that toxic events occur evenly throughout the time of the 
study we will not implement a weighting function.  The dose for the next patient is 
selected so that the estimated probability at that dose is close to the target level. A 
feature of the dose escalation part of the TITE-CRM program is the flexibility in 
specifying the margin for the dose selection. This allows the selection of the dose 
level for the next patient that may have an estimated probability of toxicity larger 
than the target level but less than the target level plus the margin. It finds the dose 
closest to the target probability even if it has a higher estimated probability. For this 
trial we set the admissible margin to be 5%, therefore, the MTD will be chosen as 
the dose that yields a posterior toxicity estimate closest to 20% while being between 
15% and 25%.  The admissible margin is also used to help determine stopping rules 
for the trial.  In order to account for the possibility of poor initial outcomes we will 
employ a run-in of 6 patients, meaning that the minimum number of treated patients 
will be 6.  If after these 6 patients, or any other time during the trial, the lowest dose 
level has a posterior probability higher than 25% then the trial will stop.   
 
14.3.3 Simulation and Sample Size Calculations 
 
The TITE-CRM manual details methods for utilizing trial simulation in order to 
obtain estimated posterior probabilities on toxicity estimates.  We utilize the 


Version 01/24/25, Amendment 6 
 
Page 54 of 72 
simulation program to determine the efficacy of our trial and obtain estimates for 
needed sample size.  While there is no exact power calculation for this type of trial, 
the effectiveness of the trial’s sample size can be determined by looking at the 
stability of the posterior probability under different prior probabilities.  We ran 
1000 simulations under various increasing and decreasing prior probability 
estimates utilizing the previously described rules and assumptions for this trial and 
found that we will be able to determine the MTD with 18 patients. Simulations 
showed that approximately 98% of the time the trial will come to completion after 
18 patients and the MTD will fall between the 2nd and 3rd dose level more than 95% 
of the time.  Therefore, the sample size of this adaptive phase I/II study will be 18 
patients.  
 
14.3.4 Workflow 
 
The first patient will be enrolled on the trial and treated at the 250 mg PO daily 
dose level, which is one dose level below the hypothesized MTD.  That patient will 
be entered into the titecrm.sas program and follow-up will begin from start of 
treatment (RT+TMZ+DSF+Cu).  Although the entire study duration is 34 weeks or 
at the completion of adjuvant DSF, for the purposes of DLT evaluation, the patient 
will be followed from start of treatment until the patient completes 18 weeks of 
follow-up, has a DLT, or is lost to follow-up.  If any of these endpoints occur, the 
statistician will be notified and the date corresponding to the event will be entered 
into the program.  While there is a maximum follow-up of 18 weeks for observation 
of possible DLTs, sometimes patients have a delay in their treatment resulting in 
the need for a prolonged observation period (at least 12 weeks after completion of 
RT if there is delay/interruption of RT). This delay will be accounted for as needed 
for this study to ensure completed 18 week follow-up.  When a new patient is 
enrolled on the trial the statistician will be notified of the date of enrollment.  At 
this time the statistician will update the follow-up for all patients currently on the 
trial and determine the dose that will be administered for the new patient.  We will 
utilize the cumulative time of exposure method which will allow the contribution 
of patients with no DLT at this time to be partially weighted consistent with their 
time observed.  At this point, the program provides a summary of the number of 
patients treated at each dose so far, along with the number of DLTs that have 
occurred. The posterior probability and 95% credible intervals of dose limiting 
toxicity for each dose level is calculated.  At this point, the model determines the 
dose level that has an estimated toxicity rate closet to 20% within the 5% admissible 
margin.  The newly enrolled patient will be enrolled in the corresponding dose level 
if that dose level is within one dose jump from the dose level the most current 
patient is enrolled on.  If the suggested dose level is more than one dose level from 
the current dose level, the next patient will be enrolled on the dose level that is 
closest to the current level in the direction of the dose level determined from the 
estimated posterior probability.  This continues until the trial has accrued all 18 
patients or, if after 6 patients are enrolled, the estimated posterior probability for 
the lowest dose level is higher than 25%.  
 


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14.3.5 Sample Size for the Dose-expansion Phase 
To further explore the effect of the addition of DSF/Cu to standard 
chemoradiotherpay for the subset of GBM with IDH/BRFA/NF1 mutations, we 
propose to add an expansion cohort to further confirm that the addition of DSF/Cu 
to chemoradiotherapy may be a promising strategy to treat GBM with these 
mutations. Given historical data for a cohort of GBM is not readily available, some 
assumptions are used to derive a historical control benchmark. GBM with BRAF or 
NF1 mutations are not known to have different prognosis than typical IDH-
wildtype GBM [81,82], with historical OS of approximately 30% at 2 years and 
10% at 5 years [3,83,84]. Both BRAF and NF1 mutations affect the RAS/MAPK 
pathway and can also occur in the same patient, thus we will combine both 
mutations into one molecular cohort. However, IDH-mutant GBM is known to have 
better OS than IDH-wildtype GBM, with 2 year OS of approximately 50% and 5 
year OS of approximately 20% [85], so we will define the second molecular cohort 
by the presence of IDH mutation.  Therefore, a cohort with equal proportion of 
IDH-mutant GBM and BRAF/NF1-mutant GBM should theoretically have 2 year 
OS of 40% and 5-year OS of 15%. Based on such assumptions, a sample size of 24 
patients (including 12 with IDH mutations and 12 with BRAF/NF1 mutations) 
would provide 80% power with one-sided alpha of 0.10 to detect an improvement 
of 2-year OS from historical 40% to 60% (or a hazard ratio of 0.55). Since we have 
already enrolled 9 patients with these mutations (6 with IDH mutation, 2 with BRAF 
mutation, and 1 with NF1 mutation), only additional 15 patients will be needed: 6 
with IDH mutation, 9 patients with BRAF and/or NF1 mutations.  For the dose-
expansion phase, patients are considered evaluable if a patient has received at least 
4 weeks of DSF with RT, at either the MTD (375mg/day) or the RP2D 
(250mg/day). Inevaluable patients will be replaced. 
 
14.4 
Analytic Plan for Secondary and Exploratory Endpoints 
 
Adverse events will be tabulated by type and grade. 
 
Descriptive statistics will be used to summarize and compare concentration of ditiocarb-
copper complex and glutamate metabolites in plasma and tumor tissue, including median 
and range. 
 
The cox proportional hazard models will be used to assess for associations between 
intratumor drug concentration with tumor control and survival.  
 
The Kaplan-Meier product-limit method will be used to estimate tumor control and 
survival probabilities. 
 
 
 
 
 


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15.0 
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APPENDIX A: Karnofsky Performance Status Scale 
 
100 
Normal to no complaints; no 
evidence of disease 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease 
80 
Normal activity with effort; some 
signs or symptoms of disease 
70 
Cares for self; unable to carry on 
normal activity or do active work 
60 
Requires occasional assistance but is 
able to care for most personal needs 
50 
Requires considerable assistance 
and frequent medical care 
40 
Disabled; requires special care and 
assistance 
30 
Severely disabled; hospital admission 
is indicated although death not 
imminent 
20 
Very sick; hospital admission 
necessary; active supportive 
treatment necessary 
10 
Moribund; fatal processes 
progressing rapidly 
0 
Dead 
 
 
 


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APPENDIX B: NYHA Classification of Cardiac Disease 
 
Class 
Functional Capacity 
Objective Assessment 
I 
Patients with cardiac disease but without resulting limitations of physical 
activity.  Ordinary physical activity does not cause undue fatigue, 
palpitation, dyspnea, or anginal pain. 
No objective evidence of 
cardiovascular disease. 
II 
Patients with cardiac disease resulting in slight limitation of physical 
activity.  They are comfortable at rest.  Ordinary physical activity results in 
fatigue, palpitation, dyspnea, or anginal pain. 
Objective evidence of 
minimal cardiovascular 
disease. 
III 
Patients with cardiac disease resulting in marked limitation of physical 
activity.  They are comfortable at rest.  Less than ordinary activity causes 
fatigue, palpitation, dyspnea, or anginal pain. 
Objective evidence of 
moderately severe 
cardiovascular disease. 
IV 
Patients with cardiac disease resulting in inability to carry on any physical 
activity without discomfort.  Symptoms of heart failure or the anginal 
syndrome may be present even at rest.  If any physical activity is undertaken, 
discomfort is increased. 
Objective evidence of 
severe cardiovascular 
disease. 
Source:  The Criteria Committee of New York Heart Association.  Nomenclature and Criteria for Diagnosis of 
Diseases of the Heart and Great Vessels.  9th Ed. Boston, MA:  Little, Brown & Co; 1994:253-256. 
 
 
 


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APPENDIX C: Concurrent Temozolomide Medication Diary 
 
Today’s Date:    
 
 
 
 
Agent:   Temozolomide  
Month: with RT 
 
Patient Name:    
 
 
 
 
 
 
Study ID#:   
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete this form during radiation therapy.  Take _____mg ( ___capsules) of temozolomide daily approximately 
1 hr before breakfast. Temozolomide 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 6:00PM, 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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Version 01/24/25, Amendment 6 
 
Page 67 of 72 
APPENDIX D: Concurrent Disulfiram and Copper Medication Diary 
 
Today’s Date:    
 
 
 
 
Agent:   Disulfiram/Copper 
Month: With RT 
 
Patient Name:    
 
 
 
 
 
 
Study ID#:   
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete one form for each month.  Take _____mg ( ___tablets) of disulfiram daily at approximately the same 
time each day (you should take with 8 ounces of water approximately 1 hour after BREAKFAST in the MORNING). 
Please also take 2 mg of copper gluconate supplement three time a day with each meal. Do not take disulfiram 
or copper within one hour of your dose of temozolomide. 
2. Record the date, what time you took disulfiram on that date and how many times you took copper supplement 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 
What time was 
disulfiram 
taken? 
How many times 
was the copper 
supplement 
taken? 
Comments 
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Version 01/24/25, Amendment 6 
 
Page 69 of 72 
APPENDIX E: Optional Pre-Surgery Disulfiram and Copper Medication Diary 
 
Today’s Date:    
 
 
 
 
Agent:   Disulfiram/copper 
Month: Pre-surgery 
 
Patient Name:    
 
 
 
 
 
 
Study ID#:   
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete this form for the pre-surgery doses of disulfiram (3-7 doses).  Take 250mg (1 tablet) of disulfiram daily 
at approximately the same time each day (you should take with 8 ounces of water approximately 1 hour after 
DINNER in the EVENING). Please also take 2 mg of copper gluconate supplement three times a day with each 
meal. You should not take disulfiram nor copper on the day of surgery. 
2. Record the date, what time you took disulfiram on that date, and how many times you took copper supplement 
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 on the day of surgery. 
5. Avoid consuming alcohol before and throughout the entire study.   
 
Day 
Date 
What time was 
Disulfiram 
taken? 
How many 
times was 
the copper 
supplement 
taken  
Comments 
1 
 
 
 
 
2 
 
 
 
 
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Version 01/24/25, Amendment 6 
 
Page 70 of 72 
APPENDIX F:  Adjuvant Temozolomide Medication Diary 
Today’s Date:    
 
 
 
 
Agent:   Temozolomide  
Month: ______ 
 
Patient Name:    
 
 
 
 
 
 
Study ID#:   
 
 
 
INSTRUCTIONS TO THE PATIENT: 
7. Complete one form for each month.  Take _____mg ( ___capsules) of temozolomide daily at approximately the 
same time each day as instructed by your oncologist.  It is recommended that you take it at night before bedtime. 
8. Record the date, the number of capsules taken, and when you took them. 
9. If you forget to take temozolomide before midnight, then do not take a dose that day.  Restart it the next day. 
10. If you have any questions or notice any side effects, please record them in the comments section.  Record the 
time if you should vomit. 
11. 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.  Please also inform your study coordinator of any new medications before starting. 
12. Avoid consuming alcohol before and throughout the entire study.   
Day 
Date 
What time was 
dose taken? 
# of tablets 
taken 
Comments 
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Version 01/24/25, Amendment 6 
 
Page 71 of 72 
APPENDIX G:  Adjuvant Disulfiram Medication Diary 
 
Today’s Date:    
 
 
 
 
Agent:   Disulfiram 
Month: _____________ 
 
Patient Name:    
 
 
 
 
 
 
Study ID#:   
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete one form for each month.  Take ____ mg (___ tablets) of disulfiram daily at approximately the same 
time each day (1 hour after breakfast).  Do not take within one hour of your dose of temozolomide. 
2. Record the date, the number of capsules taken, and when you took them. 
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.  Please also inform your study coordinator of any new medications before starting. 
5. 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 
 
 
 
 
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Version 01/24/25, Amendment 6 
 
Page 72 of 72 
APPENDIX H:  Adjuvant Copper Gluconate Diary 
 
Today’s Date:    
 
 
 
Agent:   Copper Gluconate 
Month: _____________ 
 
Patient Name:    
 
 
 
 
 
 
Study ID#:   
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete one form for each month.  Take 2 mg of copper daily 3 times a day (with a meal is recommended). 
2. Record the date, the number of pills taken, and when you took them. 
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.  Please also inform your study coordinator of any new medications before starting. 
5. Avoid consuming alcohol before and throughout the entire study.   
Day 
Date 
What time was dose taken? 
# of tablets 
taken 
Comments 
#1 
#2 
#3 
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