Conditions: Recurrent Glioma
Keywords: glioma
Allocation: NON_RANDOMIZED | Intervention model: SEQUENTIAL
Enrollment: 22
Healthy volunteers: no

Brief summary:
The primary objective of step 1 is the rate of adverse events of minocycline and bevacizumab during reirradiation and of step 2 is the response rate to bevacizumab, reirradiation, and minocycline. The secondary objectives are the response rate, Progression Free Survival (PFS)-3, PFS-6, and effects on quality of life and cognition from repeat radiation and bevacizumab.

Detailed description:
After providing informed consent, patients will undergo screening for eligibility to participate in the study. Screening will start within 21 days prior to dosing.

Subjects will have an MRI within 21 days of starting radiation. QOL and cognition measures will be performed within 21 days of starting radiation. Radiation will be given with parameters determined on an individual basis by the radiation oncologist. Bevacizumab will be continued at 10mg/kg IV every 2 weeks. Minocycline will be given twice a day starting at 100mg PO bid. MRI, QOL, and cognitive tests will be obtained 1, 3 and 6 months after the end of radiation.

Arms:
arm 1: Patients receiving minocycline 100 mg bid, bevacizumab, and radiation therapy. arm 2: Patients receiving minocycline 200 mg bid, bevacizumab, and radiation therapy. arm 3: Patients receiving minocycline 400 mg bid, bevacizumab, and radiation therapy.

Interventions: intervention 1: Bevacizumab intervention 2: Minocycline intervention 3: Radiation
Intervention descriptions: intervention 1: Bevacizumab will be administered in accordance with the FDA-approved dose for gliomas, 10mg/kg IV every 2 weeks. Bevacizumab will be continued every two weeks as long as tolerated. One cycle of bevacizumab will be 28 days, with treatments on day1 and day 15. intervention 2: Minocycline will be given by mouth twice a day at the assigned dose level. Minocycline will be started on the day prior to radiation and continued until progression or intolerance. intervention 3: Radiation planning will be individualized by the radiation oncologist based on the location of the current radiation field relative to prior radiation doses. The length and fractionation will be determined individually by the radiation oncologist.

Protocol document:
Prot_SAP_000.pdf: 
Full Study Protocol and Statistical Analysis Plan 
 
 
 
Study Title:  A Phase 1b/2 Study of Repeat rAdiation, Minocycline, and 
Bevacizumab in patients with recurrent gliOma (RAMBO) 
 
Protocol Version 10: 12/03/2015 
 
 
 
NCT #: NCT01580969 
Unique Protocol ID: HCI55264 
U of U IRB#: IRB_00055264 
 
 
 
Principal Investigator:  Adam Cohen, MD, MS 
Huntsman Cancer Institute 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
 
A Phase 1b/2 Study of Repeat rAdiation, Minocycline, and Bevacizumab 
in patients with recurrent gliOma (RAMBO) 
Trial ID: HCI55264/ IRB# 55264 
 
 
Principal Investigator 
 
Adam Cohen, MD 
 
 
 
 
 
Huntsman Cancer Institute 
 
 
 
 
 
2000 Circle of Hope 
 
 
 
 
 
Salt Lake City, UT 84112 
801-587-4024 
adam.cohen@hci.utah.edu 
 
Sub-investigator(s) 
Howard Colman, MD, PhD 
Huntsman Cancer Institute 
 
 
2000 Circle of Hope 
 
 
Salt Lake City, UT 84112 
801-585-0617 
howard.colman@hci.utah.edu 
 
Dennis Shrieve, MD 
Huntsman Cancer Institute 
Radiation Oncology 
2000 Circle of Hope 
 
 
 
 
 
Salt Lake City, UT 84112 
801-581-2396 
dennis.shrieve@hci.utah.edu 
 
Sean Strope, PA 
 
Huntsman Cancer Institute 
2000 Circle of Hope  
Salt Lake City, UT 84112 
801-587-4024 
Sean.Strope@hci.utah.edu 
 
Karen Salzman, MD 
Huntsman Cancer Institute 
University of Utah School of Medicine 
Department of Radiology 
2000 Circle of Hope 
 
 
 
 
 
Salt Lake City, UT 84112 
801-581-4624 
karen.salzman@hsc.utah.edu 
 
Page 1 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
John Hoffman, MD 
Professor of Radiology and Neurology 
Director of Nuclear Medicine 
University of Utah School of Medicine 
Director: Molecular Imaging Program 
Huntsman Cancer Institute 
University of Utah School of Medicine 
1950 Circle of Hope Suite 6810 
Salt Lake City, UT 84112-5560 
Telephone: (801) 587-4064 
Fax: (801) 587-4008 
Email: john.hoffman@hci.utah.edu 
 
Randy Jensen, MD, PhD 
Huntsman Cancer Institute 
University of Utah School of Medicine 
Department of Neurosurgery 
2000 Circle of Hope 
 
 
 
 
 
Salt Lake City, UT 84112 
801-585-0617 
randy.jensen@hsc.utah.edu 
 
Matthew Poppe, MD 
1950 Circle of Hope 
Salt Lake City, UT 84112 
Matthew.poppe@hci.utah.edu 
 
David Gaffney, MD, PhD 
2000 Circle of Hope 
Salt Lake City, UT 84112 
David.gaffney@hci.utah.edu 
 
Gita Suneja, MD 
2000 Circle of Hope 
Salt Lake City, UT 84112 
Gita.suneja@hci.utah.edu 
 
Angela Gerrard, NP 
2000 Circle of Hope 
Salt Lake City, UT 84112 
Angela.gerrard@hci.utah.edu 
 
 
 
 
 
Page 2 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
 
Investigational agents 
 
Bevacizumab and Minocycline 
 
 
IND Number   
 
 
Exempt 
 
 
 
 
 
Historical Protocol Versions 
Version 1: 6-20-12 
Version 2: 7-23-2012 
Version 3: 8-24-2012 
Version 4: 9-12-2012 
Version 5:12-17-2012 
Version 6: 2-26-2013 
Version 7: 04-04-2013 
Version 8: 08-08-2013 
Version 9: 09-04-2014 
Version 10: 12-03-2015 
 
 
 
 
Page 3 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
TABLE OF CONTENTS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                Page 
LIST OF ABBREVIATIONS…………………………………………………………………..6 
PROTOCOL SIGNATURE PAGE……………………………….............................................8 
STUDY SUMMARY ………………………………………………………………………….....9 
1.0 
OBJECTIVES ..................................................................................................................13 
1.1 
Primary Objectives.................................................................................................13 
1.2 
Secondary Objectives.............................................................................................13 
2.0 
BACKGROUND ..............................................................................................................13 
2.1 
Bevacizumab ..........................................................................................................16 
2.1.1 
Description ............................................................................................16 
2.1.1 
Bevacizumab Safety ..............................................................................16 
2.2 
Minocycline ...........................................................................................................18 
2.2.1 
Description ............................................................................................18 
2.2.2 
Clinical Pharmacology ..........................................................................18 
2.2.3 
Adverse Reactions .................................................................................19 
3.0 
RATIONALE ...................................................................................................................20 
4.0 
STUDY DESIGN ..............................................................................................................21 
4.1 
Description .............................................................................................................21 
4.2 
Dose Limiting Toxicity ..........................................................................................21 
4.3 
Number of Patients ................................................................................................22 
4.4 
Number of Study Centers.......................................................................................22 
4.5 
Duration of Patient Participation ...........................................................................22 
4.6 
Duration of Study ...................................................................................................22 
5.0 
ELIGIBILITY CRITERIA .............................................................................................23 
5.1 
Inclusion Criteria ...................................................................................................23 
5.2 
Exclusion Criteria ..................................................................................................24 
5.3 
Screen Failures .......................................................................................................25 
5.4 
Prior Treatment ......................................................................................................25 
6.0 
CONCOMITANT TREATMENT .................................................................................26 
7.0 
TREATMENT PLAN ......................................................................................................26 
7.1 
Bevacizumab ..........................................................................................................26 
7.1.1 
How Supplied, Stored, Packaged and Labeled .....................................26 
7.1.2 
Preparation and Administration ............................................................26 
Page 4 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
7.1.3 
Accountability and Compliance ............................................................27 
7.2 
Minocycline ...........................................................................................................27 
7.2.1 
How Supplied, Stored, Packaged and Labeled .....................................27 
7.2.2 
Preparation and Administration ............................................................28 
7.2.3 
Accountability and Compliance ............................................................28 
8.0 
TOXICITIES AND DOSE MODIFICATION ..............................................................28 
8.1 
Bevacizumab ..........................................................................................................28 
8.2 
Minocycline ...........................................................................................................31 
8.3 
Discontinuation of Treatment and Withdrawal of Patients....................................32 
9.0 
STUDY CALENDAR ......................................................................................................33 
10.0 
STUDY PROCEDURES .................................................................................................34 
10.1 
Screening Evaluation .............................................................................................34 
10.2 
Baseline Evaluation ...............................................................................................34 
10.3 
Day 1 of subsequent cycles (± 7 Days) ..................................................................34 
10.4 
Day 15 of subsequent cycles (± 7 Days) ................................................................34 
10.5 
Weekly during radiation ........................................................................................35 
10.6 
Four weeks post-radiation ......................................................................................35 
10.7 
Twelve weeks post-radiation .................................................................................35 
10.8 
Twenty-six weeks post-radiation ...........................................................................36 
10.9 
Continuously during trial .......................................................................................36 
11.0 
CRITERIA FOR EVALUATION AND ENDPOINT ..................................................36 
11.1 
Efficacy Evaluation ................................................................................................36 
11.2 
Safety Evaluation ...................................................................................................38 
11.2.1 
Physical Examination ............................................................................38 
11.2.2 
Vital Signs .............................................................................................38 
11.2.3 
Safety Laboratory Determinations ........................................................38 
11.3 
Stopping Rules .......................................................................................................38 
12.0 
STATISTICAL ANALYSIS ...........................................................................................38 
12.1 
General Statistical Considerations .........................................................................38 
12.2 
Sample Size and Power ..........................................................................................39 
12.2.1 
Primary Objective: Rate of adverse events during and up to 4 weeks 
after radiation ........................................................................................39 
12.2.2 
Secondary Objectives ............................................................................39 
12.3 
Analysis Populations ..............................................................................................42 
12.4 
Efficacy Analysis ...................................................................................................42 
12.5 
Safety Analysis ......................................................................................................42 
Page 5 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
13.0 
REGISTRATION GUIDELINES ..................................................................................42 
14.0 
DATA SUBMISSION SCHEDULE ...............................................................................43 
15.0 
ETHICAL AND REGULATORY CONSIDERATIONS ............................................43 
15.1 
Informed consent ...................................................................................................43 
15.2 
Institutional Review ...............................................................................................43 
15.3 
Data and Safety Monitoring Plan ...........................................................................43 
15.4 
Adverse Events / Serious Adverse Events .............................................................44 
15.4.1 
Adverse Events (AE).............................................................................44 
15.4.2 
Serious Adverse Event (SAE) ...............................................................45 
15.5 
SAE Reporting Requirements ................................................................................46 
15.6 
Protocol Amendments ............................................................................................47 
15.7 
Protocol Deviations ................................................................................................47 
15.8 
FDA Annual Reporting ..........................................................................................47 
15.9 
Clinical Trials Data Bank.......................................................................................48 
16.0 
REFERENCES .................................................................................................................48 
ATTACHMENT 1:  RANO RESPONSE CRITERIA .............................................................51 
ATTACHMENT 2: COGSTATE INSTRUCTIONS ...............................................................53 
ATTACHMENT 3: MDASI-BT .................................................................................................57 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 6 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
LIST OF ABBREVIATIONS 
Abbreviation or Term1 
Definition/Explanation 
AE 
Adverse event 
ALT 
Alanine aminotransferase 
AST 
Aspartate aminotransferase 
β-HCG 
Beta-human chorionic gonadotropin 
BID 
Twice daily 
BP 
Blood pressure 
BUN 
Blood urea nitrogen 
CBC 
Complete blood count 
CNS 
Central nervous system 
CR 
Complete response 
CRF 
Case report form 
CSF-1 
Colony stimulating factor-1 [also known as macrophage stimulating factor (M-CSF)] 
CSF-1R 
Colony stimulating factor receptor (also known as Fms) 
CT 
Computed tomography 
CTCAE 
Common Toxicity Criteria for Adverse Events 
ECOG 
Eastern Cooperative Oncology Group 
eCRF 
Electronic case report form 
DLT 
Dose Limiting Toxicity 
ECG 
Electrocardiogram 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GFR 
Glomerular filtration rate 
HIV 
Human immunodeficiency virus 
HR 
Heart rate 
hr 
Hour or hours 
IC50 
Half maximal inhibitory concentration 
i.e. 
Id est (that is) 
IEC 
Independent ethics committee 
INR 
International normalized ratio 
Page 7 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
Abbreviation or Term1 
Definition/Explanation 
IRB 
Institutional review board 
IU 
International unit 
IV 
Intravenous, intravenously 
LDH 
Lactate dehydrogenase 
MedRA 
Medical Dictionary for Drug Regulatory Activities 
MRI 
Magnetic resonance imaging 
MTD 
Maximum tolerated dose  
PD 
Pharmacodynamic(s) 
PFS 
Progression Free Survival 
PK 
Pharmacokinetic(s) 
PO 
Per os (administered by mouth) 
PR 
Partial response 
PT 
Prothrombin time 
PTT 
Partial thromboplastin time 
SAE 
Serious adverse event 
T1/2 
Terminal elimination half-life 
T3 
Triiodothyronine 
T4 
Thyroxine 
Tmax 
Time of maximum observed concentration 
TSH 
Thyroid-stimulating hormone 
ULN 
Upper limit of normal 
WBC 
White blood cell 
1  All of these abbreviations may or may not be used in protocol.  
 
 
 
 
 
 
 
 
Page 8 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
 
PROTOCOL SIGNATURE 
 
 
I confirm that I have read this protocol, and I will conduct the study as outlined herein and 
according to the ethical principles stated in the latest version of the Declaration of Helsinki, the 
applicable ICH guidelines for good clinical practice, and the applicable laws and regulations of 
the federal government.  I will promptly submit the protocol to the IRB for review and 
approval. I understand that any modification made during the course of the study must first be 
approved by the IRB prior to implementation except when such modification is made to remove 
an immediate hazard to the subject. 
 
I will provide copies of the protocol and all pertinent information to all individuals responsible to 
me who assist in the conduct of this study.  I will discuss this material with them to ensure that 
they are fully informed regarding the study treatment, the conduct of the study, and the 
obligations of confidentiality. 
 
Note: This document is signed electronically through submission and approval by the Principal 
Investigator in the University of Utah IRB Electronic Research Integrity and Compliance 
Administration (ERICA) system. 
 
 
Page 9 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
STUDY SUMMARY 
 
Title 
A Phase 1b/2 Study of Repeat rAdiation, Minocycline, and Bevacizumab 
in patients with recurrent gliOma (RAMBO) 
Protocol 
Number 
IRB # 55264 
IND 
Exempt 
Phase 
Phase 1b/2 
Study 
Objective(s) 
The primary objective is the safety of minocycline and bevacizumab during 
and 4 weeks after reirradiation.  The secondary objectives are, the response 
rate, PFS3, PFS6, and effects on quality of life and cognition from repeat 
radiation, minocycline and bevacizumab.  
Study Design 
This will be an open label dose finding trial to assess the safety and efficacy 
of repeat radiation with bevacizumab and minocycline in patients with 
recurrent glioma.  The maximum tolerated dose will be established using 3 
patients per cohort and there will be an expansion cohort (step 2) at the 
MTD.  A total of 26 patients will be treated over 3 years.  Dose limiting 
toxicities will be monitored during radiation and for 1 month afterward.  
Response rate and PFS will be based on MRI using RANO criteria.  Quality 
of life and cognition will be assessed before treatment and 1, 3, and 6 months 
after radiation. 
Study Duration Patient recruitment period is approximately 30 months.   
Number of 
Patients/Sites 
Enrollment will be 26 patients at HCI, with approximately 6-9 patients in 
step 1 and 12 patients in step 2. 
Study 
Procedures 
After providing informed consent, patients will undergo screening for 
eligibility to participate in the study. Screening will start within 21 days prior 
to dosing.  
Subjects will have an MRI within 21 days of starting radiation.  QOL and 
cognition measures will be performed within 21 days of starting radiation.  
Radiation will be given with parameters determined on an individual basis 
by the radiation oncologist.  Bevacizumab will be continued at 10mg/kg IV 
every 2 weeks.  Minocycline will be given twice a day starting at 100mg PO 
BID.  MRI, QOL, and cognitive tests will be obtained 1, 3 and 6 months 
after the end of radiation. 
Key Patient 
Selection 
Inclusion 
1. 
Male or female patients  ≥18 years old with a life expectancy of at 
Page 10 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
Criteria 
least 8 weeks 
2. 
Radiographically proven recurrent (≥ first relapse), intracranial 
glioma  
3. 
Previous treatment with external beam radiation  
4. 
Radiographic progression on current or prior bevacizumab treatment 
by RANO criteria 
5. 
Women of child-bearing potential must have a negative pregnancy 
test within 7 days of initiation of dosing and must agree to use an 
acceptable method of birth control while on study drug and for 3 
months after the last dose. Women of non-childbearing potential may 
be included if they are either surgically sterile or have been 
postmenopausal for ≥1 year. Men who are able to father a child must 
also agree to use an acceptable method of birth control while on 
study drug, and for 3 months after the last dose. 
6. 
Karnofsky performance status of ≥50 
7. 
Adequate hematologic, hepatic, and renal function (absolute 
neutrophil count ≥1.0 x 109/L, Hgb >9 g/dL, platelet count ≥50 x 
109/L, AST/ALT ≤2.5x ULN, creatinine ≤1.5x ULN)  
8. Prothrombin time/international normalized ratio (PT INR) < 1.4 for 
patients not on warfarin confirmed by testing within 14 days prior to 
study registration 
9. Patients on full-dose anticoagulants (e.g., warfarin or LMW heparin) 
must have no active bleeding or pathological condition that carries a 
high risk of bleeding, and must be on a stable dose of oral 
anticoagulant for 14 days or on a stable dose of low molecular weight 
heparin for 14 days 
10. Willing and able to provide written informed consent prior to any 
study related procedures and to comply with all study requirements 
 
Exclusion 
1. 
Use of an investigational drug within 14 days or within 5 half-lives of 
the investigational drug, whichever is shorter 
2. 
Less than 6 months since the end of previous radiation 
3. 
History of Grade 2 (CTCAE v4) or greater acute intracranial 
hemorrhage 
4. A concurrent active cancer that requires non-surgical therapy (e.g. 
chemotherapy, radiation, adjuvant therapy).  
5. Patients with serious illnesses, uncontrolled infection, medical 
conditions, or other medical history including abnormal laboratory 
results, which in the investigator’s opinion would be likely to 
interfere with a patient’s participation in the study, or with the 
interpretation of the results 
Page 11 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
6. Women of child-bearing potential who are pregnant or breast feeding 
7. Unstable angina and/or congestive heart failure in the last 6 months, 
transmural myocardial infarction within the last 6 months, New York 
Heart Association grade II or higher congestive heart failure requiring 
hospitalization within 12 months prior to registration, evidence of 
recent (within 14 days of registration) myocardial infarction by EKG 
(only required if clinically indicated), serious or inadequately 
controlled cardiac arrhythmia, significant vascular and peripheral 
vascular disease, evidence of bleeding diathesis or coagulopathy 
8. History of stroke, cerebral vascular accident (CVA) or transient 
ischemic attack within 6 months 
9. Serious or non-healing wound, ulcer, or bone fracture or history of 
abdominal fistula, gastrointestinal perforation, intra-abdominal 
abscess major surgical procedure, open biopsy, or significant 
traumatic injury within 28 days prior to registration, with the 
exception of the craniotomy for tumor resection 
10. Chronic obstructive pulmonary disease exacerbation or other 
respiratory illness requiring hospitalization or precluding study 
therapy at the time of registration 
11. Active connective tissue disorders, such as lupus or scleroderma, that 
in the opinion of the treating physician may put the patient at high 
risk for radiation toxicity 
12. Uncontrolled symptomatic hypertension that cannot be controlled 
with anti-hypertensive agents. 
Dosage and 
Regimen 
Radiation will be administered per the judgment of the radiation oncologist. 
Bevacizumab will be given 10mg/kg every 2 weeks. Minocycline will be 
given twice a day starting at 100mg PO BID with dose modification in each 
cohort based on adverse event rate in previous cohorts.   
Safety and 
Tolerability 
Assessments 
Physical examinations, vital signs, and adverse events, will be used to assess 
safety and tolerability.  
Primary 
Endpoint 
Adverse event rate 
Important 
Secondary 
Endpoints 
PFS3, PFS6, response rate, change in MDASI-BT at 1, 3, and 6 months, and 
change in COGSTATE at 1, 3, and 6 months 
Statistical 
Considerations 
Descriptive statistics will be used to estimate endpoint rates.   
 
Page 12 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
1.0 
OBJECTIVES 
1.1 Primary Objectives  
1.1.1 To assess the safety of the combination of bevacizumab, minocycline and repeat 
radiation 
1.2 Secondary Objectives  
1.2.1  To assess thePFS3, PFS6, and response rate of bevacizumab, minocycline and 
repeat radiation as well as the course over time of QOL and cognition. 
 
2.0 
BACKGROUND 
Gliomas are the most frequent brain tumor, accounting for approximately 12% to 15% of all 
brain tumors (CBTRUS). The peak incidence occurs between the ages of 45 and 70 years. 
Patients with recurrent glioma are incurable.  Up front treatment options include surgery, 
radiation, and temozolomide chemotherapy (Stupp et al.). According to the National Cancer 
Institute, patients with brain tumors that are either infrequently curable or unresectable should be 
considered candidates for clinical trials that evaluate new drugs and biological response 
modifiers following radiation therapy. 
Bevacizumab is FDA approved for glioblastoma that progresses after temozolomide therapy and 
is NCCN recommended for all gliomas after progression on temozolomide (Brem et al.).  There 
is no FDA approved therapy for gliomas following progression on bevacizumab.  The median 
progression free and overall survival after progression on bevacizumab is 1 and 3 months, 
respectively (Kreisl et al.).  Because of the risk of rebound edema and retrospective data 
suggesting a survival advantage, many neuro-oncologists continue bevacizumab after 
progression. (D. A. Reardon) 
Although historically repeat radiation for gliomas was considered prohibitively toxic, modern 
radiation techniques allow for repeat radiation in many cases. (Kim et al. ; Combs et al. ; 
Vordermark et al. ; Fogh et al.)  Most studies of re-irradiation have not reported response rates or 
progression free survival.  Moreover, most if not all patients in these series did not receive 
bevacizumab prior to re-irradiation, making them more favorable than current patients.  Coombs 
et al reported on re-irradiation of 172 patients with recurrent gliomas, 54 of whom had 
glioblastoma. (Combs et al.)  The median PFS of the glioblastoma patients was 5 months, with a 
PFS6 of 28%.  Fugh reported on 105 patients with high grade gliomas who received repeat 
radiation with hypofractionation, of whom 53 were glioblastoma.  Although 60% of patients had 
stable disease at 3 months, only 10% had a partial response by Macdonald criteria. 
Two studies have directly addressed the question of reirradiation with concomitant bevacizumab. 
Niyazi treated thirty patients with repeat radiation, twenty of whom also received bevacizumab 
(Niyazi et al.).  There was one grade 3 deep venous thrombosis and one grade 4 wound 
dehiscence. The response rate was not recorded.  The PFS6 was 72% for radiation with 
bevacizumab and 24% for radiation alone.  Gutin treated 25 bevacizumab-naïve patients with 
Page 13 of 58 
 


Pr ot o c ol n a me: Re pe at R a di ati o n, Mi n oc ycli ne a n d Be v aciz u m a b i n P atie nt s wit h Rec urre nt Gli o m a  
Versi o n D ate : 1 2/ 0 3/ 2 0 1 5  
Pri nci p al I n vesti g at or:  A d a m C o he n, M D  
 
re peat ra diati o n a n d be vaciz u ma b (G uti n et al. ).  T here w ere t hree gra de 3 t o xicities, a n 
i ntrat u m oral blee d, w o u n d de hisce nce, a n d b o w el perf orati o n.   T he res p o nse rate w as 5 0 % a n d 
P F S 6 was a b o ut 6 4 %.  N eit her of t he pre vi o us st u dies i ncl u de d patie nts w h o ha d pr o gress e d o n 
be vaciz u ma b, w h o mi g ht ha ve a differ e nt a d verse e ve nt rate or res p o ns e rat e. M ore o ver, n o 
st u dies ha ve d oc u me nte d q ualit y of life or c o g niti o n f oll o wi n g re peat ra diati o n. 
Resista nce t o be vaciz u ma b a n d t o ra diati o n is i nc o m pletel y u n derst o o d.  I n d ucti o n of alter nat e 
pr o m oters of a n gi o ge n esis, i ncrease d i n v asi o n via i n d ucti o n of matri x metall o pr otei nases a n d c-
M E T, h y p o xia i n d uce d r ecr uit me nt of b o ne m arr o w- deri ve d cells, a n d c o o pti o n of n or mal 
vessels ha ve all bee n h y p ot hesize d t o pla y a r ol e i n be vaciz u ma b resista nce. ( Ber gers a n d 
Ha na ha n ; L u ci o -Eter o vi c et al. )  Ra di oresista nce has bee n h y p ot hesize d t o be d ue t o a 
c o m bi nati o n of G B M ste m cells, w hic h ma y be pr otecte d b y m T O R, s ur vi vi n, ga m ma secreatase, 
H y p o xia- i n d uce d N F- K B si g nali n g, or C O X- 2, E G F R- me diate d d o u bl e stra n d D N A re pair, 
S O C S - ge ne l oss, a n d micr o glia i n d ucti o n. (C ha kra varti et al. ; Lal et al. ; Jia n g et al. ; Ric h ; 
Z h o u et al. ; M urat et al. ; Hata n paa et al. ; Li n et al. ; A na n d haraj et al. ; H ellstr o m et al. ; 
Z h ua n g et al. ) A ntia n gi o ge ni c a ge nts, i ncl u di n g b e vaciz u ma b, ca n i ncrease t he effecti ve ness of 
ra diati o n i n vi v o.(Lee et al. ; Ge n g et al. ) 
 
Ge ne e x pressi o n st u dies ha ve i de ntifie d m ulti ple s u bt y pes of gli o blast o ma i ncl u di n g a 
mese nc h y mal ( M E S) s u bt y pe ass ociate d wit h i ncrease d a n gi o ge nesis a n d p o or s ur vi val ( P hilli ps 
et al., C ol ma n et al.). Pr o m oter a nal ysis of t he M E S s u bt y p e a n d i n gli o blast o ma ste m cells 
( G S Cs) has i de ntifie d se veral tra ns cri pti o n fact ors i ncl u di n g S T A T 3, C E B P B, a n d T A Z 
ass ociate d wit h t he M E S s u bt y pe ( C arr o et al; B hat et al). Rece nt st u dies ha ve i de ntifie d 
acti vati o n of N F k B as a ke y si g nali n g fact or pr o m oti n g t he M E S s u bt y pe t hr o u g h u pre g ulati o n of 
t he M E S tra nscri pti o n fact ors ( Vailla nt et al; B hat et al) i n G S Cs a n d h u ma n t u m ors. 
F urt her m ore, a cti vati o n of N F k B i n G S Cs b y T N F treat me nt res ulte d i n a M E S s hift, i ncrease d 
i nvasi o n, a n d ra diati o n resista nce. Bl oc k a de of N F k B acti vati o n b y I k B- a w as s ufficie nt t o 
pre ve nt t hese T N F i n d uce d eff ects.  I n v esti gati o n of p ote ntial s o urce of N F κ B acti vati o n i n G B M 
s u g geste d a r ole of micr o glia. I n d ee d, a d diti o n of s u per nata nt fr o m activate d micr o glia w as 
s ufficie nt t o acti vate N Fκ B a n d M E S tra nsiti o n i n G S Cs t hat c o ul d be bl oc ke d b y I κ B-  
( Vailla nt et al.). T o test t he r ole of micr o glia a n d N F κB acti vati o n o n treat me nt resista nce i n 
vi v o, treat me nt wit h mi n oc ycli ne, a n i n hi bit or of micr o glia acti vati o n, le d t o a re d ucti o n of t u m or 
gr a de a n d d o w n-r e g ulati o n of M E S mar ker s i n i ntracra nial G S C x e n o graft m o dels ( Vailla nt et 
al.). Ta ke n t o get her, t hes e data i n dicate a n i m p ort a nt r ole f or micr o glia acti vati o n of N F κ B i n t he 
i n d ucti o n a n d mai nte na n ce of t he M E S p he n ot y pe a n d ra diati o n resista nce i n G B M a n d G S Cs. 
T hese data als o s u g gest t hat bl oc ka de of N F κ B a n d/ or i n hi biti o n of micr o glia acti vati o n ma y be 
attracti ve t her a pe utic a p pr oac hes f or d o w nre g ulati n g M E S tra nsiti o n a n d o verc o mi n g treat me n t 
resista nce i n G B M.  
 
 
Mi n oc ycli ne is a tetrac ycli ne - deri vati ve t hat is F D A a p pr o ve d as a n a nti bi otic.  It als o h as a nti-
i nfla m mat or y pr o perties t hat are n ot s hare d b y all me m bers of t he tetrac ycli ne fa mil y.  
Mi n oc ycli ne h as p ote ntial as a n a nti- gli o ma  a ge nt a n d as a ra diati o n se nsitizer f or gli o ma.  
Mi n oc ycli ne i n hi bits matri x metall o pr otei nase e x pressi o n b y micr o glia, t h us re d uci n g gli o ma 
i n vasi o n a n d e x pa nsi o n. (Mar k o vic et al. ) Mi n o c ycli ne als o i n d uces gli o ma cell deat h via 
P a ge 1 4  of 5 8  
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
autophagy and apoptosis.(Liu et al.)  Animals treated with local administration of minocycline to 
tumor xenografts have improved survival.  (Weingart et al.) 
 
Minocycline also decreases inflammation following hypoxic or cytotoxic injury to the 
brain.(Nutile-McMenemy et al.) As such, it is currently being studied for neurodegenerative 
disorders.  Microglia has been implicated in resistance to radiation.  As described above, 
intracranial GSC xenograft studies in Dr. Colman’s lab and labs of his collaborators have shown 
that minocycline reverses resistance to radiation in these molecularly faithful models of GBM 
tumors. 
 
Because of its lipophilicity, minocycline is 100% bioavailable and does penetrate the brain. 
Minocycline is established to penetrate the CNS in humans and is the recommended 
antimicrobial for various meningoencephalitides (Tsai et al. ; Agustin et al. ; Fang et al.) In one 
study, after a single 200mg dose of minocycline, the CSF to serum ratio in one subject is 0.54. 
(Carney et al.)  In another study of a single subject, after several days of treatment at 100mg 
twice a day, the CSF to serum ratio was 0.10-0.2.  (Macdonald et al.)  In dogs, the concentration 
of minocycline in the brain is between on-half and three times that in the serum. (Kelly and 
Kanegis ; Barza et al.) In rats, after 5-7 days of oral treatment, the brain concentration of 
minocycline is approximately equal to plasma concentrations.  (Smith et al.)  In horses, after 2 
days of oral treatment, the CSF concentration of minocycline is approximately 50% of plasma 
concentration.  (Schnabel et al.)   
 
Minocycline can inhibit TNF secretion and NF-κB activation at concentrations less than 5µM, 
which is the serum concentratiom achieved after a single dose of 200mg.  (Bernardino et al. ; 
Huang et al.) Microglia proliferation and activation may be suppressed at minocycline 
concentrations as low as 20 nM.  (Tikka et al. ; Tikka et al.) At the usual dose of 100mg twice a 
day, the serum concentration averages about 4µM after several days.  (Macdonald et al.)  Two 
people treated at 400mg per day had serum levels of 6-12 µM.  Therefore, although 100mg twice 
a day may be achieve high enough doses in the brain to induce a mesenchymal to proneural shift, 
higher doses may be necessary.   
 
The long term tolerability of minocycline has been studied in patients with ALS, in whom the 
mean long-term tolerated dose of minocycline was 387mg per day.  (Gordon et al.)  Adverse 
effects were mainly gastrointestinal upset and nonsignificant increases in transaminases.  It is 
likely that glioblastoma patients would have higher tolerance for these effects than ALS patients, 
and antiemetics and bowel motility agents used as supportive care for temozolomide may 
ameliorate the gastrointestinal effects.  Minocycline doses of 5mg/kg/day for 5 days in 
combination with radiation have been well tolerated in animals without significant skin toxicity.  
(Sotomayor et al. ; Teicher et al.)  This is not surprising because minocycline is considered much 
less phototoxic than other tetracyclines and does not share their release of ionized oxygen in 
response to UV light.  (Hasan and Khan)  Daily intravenous doses of 10mg/kg/day for 3 days 
were tolerated by stroke patients in the MINOS dose finding study (Fagan et al.)   In a long-term 
study in people with Parkinson’s disease, 77% of people were able to take 200mg twice a day for 
18 months without quitting.   Therefore, we propose to start at the usual antimicrobial dose of 
100mg PO BID and increase up to a maximum dose of 800mg PO BID.  Because the long term 
Page 15 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
safety of minocycline is well established, we will limit the phase 1 component of this study to 
acute toxicity that occurs during or immediately after chemoradiation. 
 
Therefore, we hypothesize that addition of minocycline and bevacizumab to reirradiation for 
GBM after progression on bevacizumab will increase efficacy without adding significant 
toxicity.  Because minocycline has not been tested with radiation in humans and other drugs in 
the same class (such as tetracycline) can have photosensitizing effects, we will first establish the 
safety of this combination and then extend the study to assess for evidence of efficacy.   As a 
single agent, the mean long-term tolerated dose of minocycline is 387mg per day.  (Gordon et 
al.)  Adverse effects were mainly gastrointestinal upset and nonsignificant increases in 
transaminases.  Minocycline doses of 5mg/kg in combination with radiation have been well 
tolerated in animals.  (Sotomayor et al. ; Teicher et al.) 
 
2.1 Bevacizumab 
2.1.1 
Description 
 Bevacizumab is a recombinant humanized anti-VEGF monoclonal antibody, consisting 
of 93% human and 7% murine amino acid sequences. The agent is composed of human 
IgG framework and murine antigen-binding complementarity-determining regions.  
Bevacizumab blocks the binding of vascular endothelial growth factor (VEGF) to its 
receptors resulting in inhibition of angiogenesis. 
 
2.1.1 
Bevacizumab Safety 
Adverse Events >10%:  
 
Cardiovascular: Hypertension (23% to 67%; grades 3/4: 5% to 18%), thromboembolic 
event (≤21%; grades 3/4: 15%; venous thrombus/embolus: 8%; grades 3/4: 5% to 7%; 
arterial thrombosis 6%; grades 3/4: 3%), hypotension (7% to 15%)  
 
Central nervous system: Pain (31% to 62%), headache (24% to 37%; grades 3/4: 2% to 
4%), dizziness (19% to 26%), fatigue (≤45%; grades 3/4: 4% to 19%), sensory 
neuropathy (grades 3/4: 1% to 17%; in combination with paclitaxel: 24%) 
 
Dermatologic: Alopecia (6% to 32%), dry skin (7% to 20%), exfoliative dermatitis (3% 
to 19%), skin discoloration (2% to 16%) 
 
Endocrine & metabolic: Hypokalemia (12% to 16%) 
 
Gastrointestinal: Abdominal pain (50% to 61%; grades 3/4: 8%), vomiting (47% to 
52%; grades 3/4: 6% to 11%), anorexia (35% to 43%), constipation (29% to 40%), 
diarrhea (grades 3/4: 1% to 34%), stomatitis (25% to 32%), gastrointestinal hemorrhage 
(19% to 24%), dyspepsia (17% to 24%), taste disorder (14% to 21%), flatulence (11% 
to 19%), weight loss (9% to 20%), nausea (grades 3/4: 4% to 12%)  
 
Hematologic: Hemorrhage (≤40%; grades 3/4: 1% to 5%), leukopenia (grades 3/4: 
37%), neutropenia (grade 4: 6% to 27%)  
 
Neuromuscular & skeletal: Weakness (57% to 74%), myalgia (8% to 19%), back pain 
(≤12%)  
 
Ocular: Tearing increased (6% to 18%) 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
Renal: Proteinuria (4% to 36%; grades 3/4: ≤7%; median onset: 5.6 months; median 
time to resolution: 6.1 months)  
 
Respiratory: Upper respiratory infection (40% to 47%), epistaxis (16% to 35%), 
dyspnea (25% to 26%), rhinitis 
 
Miscellaneous: Infection (≤55%; serious: 9% to 14%; pneumonia, catheter, or wound 
infections) 
 
1% to 10%: 
 
Cardiovascular: DVT (6% to 9%; grades 3/4: 9%), HF (grades 3/4: 1% to 4%), syncope 
(grades 3/4: 3%), intra-abdominal venous thrombosis (grades 3/4: 3%), cardio-
/cerebrovascular arterial thrombotic event (2% to 4%), left ventricular dysfunction 
(grades 3/4: 1%) 
 
Central nervous system: Confusion (1% to 6%), abnormal gait (1% to 5%); CNS 
hemorrhage (1% to 5%; grades 3/4: 1%), reversible posterior leukoencephalopathy 
syndrome ([RPLS] ≤1%) 
 
Dermatologic: Nail disorder (2% to 8%), skin ulcer (≤6%), rash desquamation (grades 
3/4: 3%), wound dehiscence (1% to 6%), acne (≤1%)  
 
Endocrine & metabolic: Dehydration (grades 3/4: 3% to 10%), hyponatremia (grades 
3/4: 4%)  
 
Gastrointestinal: Xerostomia (4% to 7%), colitis (1% to 6%), ileus (grades 3/4: 4% to 
5%), gingival bleeding (2% to 4%), fistula (1%), gastrointestinal perforation (≤4%), 
gastroesophageal reflux (≤2%), gingivitis (≤2%), mouth ulceration (≤2%), tooth 
abscess (≤2%), intra-abdominal abscess (1%), gastritis (≤1%), gingival pain (≤1%) 
 
Genitourinary: Polyuria/urgency (3% to 6%), vaginal hemorrhage (4%) 
 
Hematologic: Neutropenic fever/infection (5%; grades 3 and/or 4: 4% to 5%), 
thrombocytopenia (5%) 
 
Hepatic: Bilirubinemia (1% to 6%) 
 
Neuromuscular & skeletal: Bone pain (grades 3/4: 4%), neuropathy (other than sensory: 
grades 3/4: 1% to 5%) 
 
Ocular: Blurred vision (≤2%) 
 
Otic: Tinnitus (≤2%), deafness (≤1%) 
 
Respiratory: Voice alteration (5% to 9%), pneumonitis/pulmonary infiltrates (grades 
3/4: 5%), hemoptysis (nonsquamous histology 2%), pulmonary embolism (≤1%) 
 
Miscellaneous: Infusion reactions (<3%) 
 
<1% (Limited to important or life-threatening): Anaphylaxis, anastomotic ulceration, 
angina, bladder perforation, cerebral infarction; fistula (biliary, bladder, bronchopleural, 
duodenal, enterocutaneous, esophageal, gastrointestinal, rectal, renal, 
tracheoesophageal [TE] and vaginal); gastrointestinal ulcer, hemorrhagic stroke, 
hypersensitivity, hypertensive crises, hypertensive encephalopathy, intestinal necrosis, 
intestinal obstruction, mesenteric venous occlusion, microangiopathic hemolytic 
anemia (when used in combination with sunitinib), MI, nasal septum perforation, 
nephrotic syndrome, pancytopenia, polyserositis, pulmonary hemorrhage, pulmonary 
hypertension, renal failure, renal thrombotic microangiopathy, sepsis, subarachnoid 
hemorrhage, toxic anterior segment syndrome (TASS), transient ischemic attack, 
ureteral stricture wound healing complications 
Page 17 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
Reported from unlabeled use: Eye disorders: Endophthalmitis, hemorrhage 
(conjunctival, retinal or vitreous), intraocular inflammation (iritis, vitritis), intraocular 
pressure increased, ocular hyperemia, ocular pain/discomfort, retinal detachment, visual 
disturbance, vitreous floaters 
 
2.2 Minocycline  
2.2.1 
Description 
Minocycline hydrochloride, is a semisynthetic derivative of tetracycline, 4,7-
Bis(dimethylamino)1,4,4a,5,5a,6,11,12a-octahydro-3,10,12,12a-tetrahydroxy-1,11-
dioxo-2-naphthacenecarboxamide monohydrochloride. 
Its structural formula is: 
 
C23H27N3O7•HCl M.W. 493.95 
 
2.2.2 
Clinical Pharmacology 
Following a single dose of two minocycline hydrochloride 100 mg capsules 
administered to 18 normal fasting adult volunteers, maximum serum concentrations 
were attained in 1 to 4 hours (average 2.1 hours) and ranged from 2.1 to 5.1 mcg/mL 
(average 3.5 mcg/mL).The serum half-life in the normal volunteers ranged from 11.1 to 
22.1 hours (average 15.5 hours). 
When minocycline hydrochloride capsules were given concomitantly with a high-fat 
meal, which included dairy products, the extent of absorption of minocycline 
hydrochloride capsules was unchanged compared to dosing under fasting conditions. 
The mean Tmax was delayed by one hour when administered with food, compared to 
dosing under fasting conditions. Minocycline hydrochloride capsules may be 
administered with or without food. 
In previous studies with other minocycline dosage forms, the minocycline serum half-
life ranged from 11 to 16 hours in 7 patients with hepatic dysfunction, and from 18 to 
69 hours in 5 patients with renal dysfunction. The urinary and fecal recovery of 
minocycline when administered to 12 normal volunteers was one-half to one-third that 
of other tetracyclines. 
Page 18 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
2.2.3 
Adverse Reactions 
Due to oral minocycline’s virtually complete absorption, side effects to the lower 
bowel, particularly diarrhea, have been infrequent. The following adverse reactions 
have been observed in patients receiving tetracyclines. 
Body as a whole: Fever, and discoloration of secretions. 
Gastrointestinal: Anorexia, nausea, vomiting, diarrhea, dyspepsia, stomatitis, glossitis, 
dysphagia, enamel hypoplasia, enterocolitis, pseudomembranous colitis, pancreatitis, 
inflammatory lesions (with monilial overgrowth) in the oral and anogenital regions. 
Instances of esophagitis and esophageal ulcerations have been reported in patients 
taking the tetracycline-class antibiotics in capsule and tablet form. Most of these 
patients took the medication immediately before going to bed (See DOSAGE AND 
ADMINISTRATION). 
Genitourinary: Vulvovaginitis. 
Hepatic toxicity: Hyperbilirubinemia, hepatic cholestasis, increases in liver enzymes, 
fatal hepatic failure, and jaundice. Hepatitis, including autoimmune hepatitis, and liver 
failure have been reported (See PRECAUTIONS). 
Skin: Alopecia, erythema nodosum, hyperpigmentation of nails, pruritus, toxic 
epidermal necrolysis, and vasculitis. Maculopapular and erythematous rashes. 
Exfoliative dermatitis has been reported. Fixed drug eruptions have been reported. 
Lesions occurring on the glans penis have caused balanitis. Erythema multiforme and 
Stevens-Johnson syndrome have been reported. Photosensitivity is discussed above 
(See WARNINGS). Pigmentation of the skin and mucous membranes has been 
reported. 
Respiratory: Cough, dyspnea, bronchospasm, exacerbation of asthma, and pneumonitis. 
Renal toxicity: Interstitial nephritis. Elevations in BUN have been reported and are 
apparently dose related (See WARNINGS). Reversible acute renal failure has been 
reported. 
Musculoskeletal: Arthralgia, arthritis, bone discoloration, myalgia, joint stiffness, and 
joint swelling. 
Hypersensitivity reactions: Urticaria, angioneurotic edema, polyarthralgia, anaphylaxis/ 
anaphylactoid reaction (including shock and fatalities), anaphylactoid purpura, 
myocarditis, pericarditis, exacerbation of systemic lupus erythematosus and pulmonary 
infiltrates with eosinophilia have been reported. A transient lupus-like syndrome and 
serum sickness-like reactions also have been reported. 
Blood: Agranulocytosis, hemolytic anemia, thrombocytopenia, leukopenia, 
neutropenia, pancytopenia, and eosinophilia have been reported. 
Page 19 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
Central Nervous System: Convulsions, dizziness, hypesthesia, paresthesia, sedation, 
and vertigo. Bulging fontanels in infants and benign intracranial hypertension 
(pseudotumor cerebri) in adults have been reported (see PRECAUTIONS - General). 
Headache has also been reported. 
Other: Thyroid cancer has been reported in the postmarketing setting in association 
with minocycline products. When minocycline therapy is given over prolonged periods, 
monitoring for signs of thyroid cancer should be considered. When given over 
prolonged periods, tetracyclines have been reported to produce brown-black 
microscopic discoloration of the thyroid gland. Cases of abnormal thyroid function 
have been reported. 
Tooth discoloration in children less than 8 years of age (see WARNINGS) and also, in 
adults has been reported. 
Oral cavity discoloration (including tongue, lip, and gum) has been reported. 
Tinnitus and decreased hearing have been reported in patients on minocycline 
hydrochloride. 
The following syndromes have been reported. In some cases involving these 
syndromes, death has been reported. As with other serious adverse reactions, if any of 
these syndromes are recognized, the drug should be discontinued immediately: 
Hypersensitivity syndrome consisting of cutaneous reaction (such as rash or exfoliative 
dermatitis), eosinophilia, and one or more of the following: hepatitis, pneumonitis, 
nephritis, myocarditis, and pericarditis. Fever and lymphadenopathy may be present. 
Lupus-like syndrome consisting of positive antinuclear antibody; arthralgia, arthritis, 
joint stiffness, or joint swelling; and one or more of the following: fever, myalgia, 
hepatitis, rash, and vasculitis. 
Serum sickness-like syndrome consisting of fever; urticaria or rash; and arthralgia, 
arthritis, joint stiffness, or joint swelling. Eosinophilia may be present. 
 
3.0 
RATIONALE 
As described above, there is a strong rationale for the use of bevacizumab and minocycline with 
repeat irradiation.  However, no study has adequately documented the safety and efficacy of 
repeat radiation with bevacizumab and minocycline in people with recurrent glioma who 
progress on bevacizumab.   
Page 20 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
4.0 
STUDY DESIGN 
4.1 Description 
This is an open-label, multi-agent design.  Bevacizumab will be administered in accordance with 
the FDA-approved dose for gliomas, 10mg/kg IV every 2 weeks.  Bevacizumab will be 
continued every two weeks as long as tolerated.    One cycle of bevacizumab will be 28 days, 
with treatments on day1 and day 15.  Blood pressure, CBC, CMP, and urine protein level, either 
by UA or urine protein/creatinine ratio will be checked at the beginning of each cycle. 
Radiation planning will be individualized by the radiation oncologist based on the location of the 
current radiation field relative to prior radiation doses.  The length and fractionation will be 
determined individually by the radiation oncologist.   
Minocycline will be given by mouth twice a day starting at about half of the monotherapy 
maximal tolerated dose, 100 mg PO BID. Minocycline will be started on the day prior to 
radiation and continued until progression or intolerance.  During the combined radiation, 
minocycline, and bevacizumab treatment, patients will be seen weekly with a CBC, CMP, and 
adverse event monitoring. 
4.2 Dose Limiting Toxicity 
Dose level 
Dose 
-1 
75mg PO BID 
0 
100mg PO BID 
1 
200mg PO BID 
1A (in case of DLT at dose level 1) 
150mg PO BID 
2 
400mg PO BID 
 
The toxicities described below will be considered DLT’s if they are felt to be possibly, probably 
or definitely related to the minocycline.  Patients experiencing a DLT will have minocycline 
stopped until the toxicity resolves to grade 1 or less, at which point the patient may resume 
minocycline at the next lowest dose level if agreed by the patient, the treating physician, and the 
PI. 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
Dose limiting toxicity will be determined in step 1 only during and 4 weeks after radiation.  The 
initial cohort of 3 patients will receive dose level 0 (100mg PO BID).  If 2 or 3 patients 
experience a related grade 3 or higher toxicity or related intolerable grade 2 toxicity (particularly, 
bullous dermatosis, photosensitivity, scalp pain not able to be controlled by oral pain 
medication), other than anemia, cholesterol, lymphopenia, or weight gain, which will only be 
considered dose limiting if grade 5, within 1 month of ending radiation, then the next cohort will 
receive dose level -1.  If 0 or 1 patients experience a related grade 3 or higher toxicity or related 
intolerable grade 2, other than anemia, cholesterol, lymphopenia, or weight gain, within 1 month 
of ending radiation, then the dose will be escalated to the next cohort.  If 2 or 3 patients 
experience related grade 3 or higher toxicity or related intolerable grade 2, other than anemia, 
cholesterol, lymphopenia, or weight gain, within 1 month of ending radiation at dose level -1, 
then the trial will be stopped.  The highest dose at which 1 or 0 patients experience related grade 
3 or higher toxicity will be declared the maximum tolerated dose (if dose level -1 or 0) or 
maximum achieved dose (if dose level 1, 1A or 2) and will be used for step 2. 
Enrollment in the dose expansion portion (step 2) will not begin until adverse events have been 
reviewed by the DSMC and the MTD/maximum achieved dose has been approved by the 
DSMC. 
4.3 Number of Patients 
Twenty-six patients will be enrolled in this study. 
4.4 Number of Study Centers 
The study will be performed at one investigational site.  
4.5 Duration of Patient Participation 
Bevacizumab will be offered to each patient as long as both the patient and investigator agree 
that it continues to be well tolerated and to offer potential clinical benefit.  Minocycline will be 
given from the day before the first day of radiation until progression or intolerance.  Assessment 
of dose limiting toxicities for stage 1 will end 4 weeks after the end of radiation. Assessment of 
adverse events will continue until the patient has been removed from study treatment. 
4.6 Duration of Study 
Approximately 1 patient is expected to enroll every 2 months, for a total of 6 per year.  Radiation 
treatment usually lasts 3-4 weeks for each patient, so patients will be followed for dose limiting 
toxicities for a total of 7-8 weeks and for clinical and QOL measures for 6 months.  Total 
recruitment time for the study will be 3 years. 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
5.0 
ELIGIBILITY CRITERIA 
All patients must participate in the consent process. During the consent process, the person 
obtaining consent must inform the patient of all elements of informed consent. No protocol-
specific procedures, including screening procedures, are to be performed until the patient has 
signed and dated an institutional review board (IRB)/independent ethics committee (IEC)-
approved informed consent form. The study begins with the signing and dating of the informed 
consent form. Patients must also meet the inclusion and exclusion criteria to be enrolled in the 
study.  
This eligibility checklist is used to determine patient eligibility and filed with signature in the 
patient research chart.  
  
Patient No. ______________________ 
 
Patient’s Initials: (L,F,M) _________________ 
 
5.1 Inclusion Criteria 
Yes/No  (Response of “no” = patient ineligible) 
 
_____ 5.1.1 
Male or female patients ≥18 years old with a life expectancy of at least 8 
weeks 
 
_____ 5.1.2  Radiographically proven recurrent (≥ first relapse), intracranial glioma  
 
_____ 5.1.3  Previous treatment with external beam radiation  
 
_____ 5.1.4  Radiographic progression on bevacizumab by RANO criteria 
 
_____ 5.1.5  Women of child-bearing potential must have a negative pregnancy test 
within 7 days of initiation of dosing and must agree to use an acceptable 
method of birth control while on study drug and for 3 months after the last 
dose. Women of non-childbearing potential may be included if they are 
either surgically sterile or have been postmenopausal for ≥1 year. Men 
who are able to father a child must also agree to use an acceptable method 
of birth control while on study drug, and for 3 months after the last dose. 
 
_____ 5.1.6  Karnofsky performance status of ≥50 
 
_____ 5.1.7  Adequate hematologic, hepatic, and renal function (absolute neutrophil 
count ≥1.0 x 109/L, Hgb >9 g/dL, platelet count ≥50 x 109/L, AST/ALT 
≤2.5x ULN, creatinine ≤1.5x ULN)  
Page 23 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
_____ 5.1.8  Prothrombin time/international normalized ratio (PT INR) < 1.4 for 
patients not on warfarin confirmed by testing within 14 days prior to study 
registration. 
 
_____ 5.1.9  Patients on full-dose anticoagulants (e.g., warfarin or LMW heparin) must 
have no active bleeding or pathological condition that carries a high risk of 
bleeding, and must be on a stable dose of oral anticoagulant for 14 days or 
on a stable dose of low molecular weight heparin for 14 days 
 
_____ 5.1.10  Willing and able to provide written informed consent prior to any study 
related procedures and to comply with all study requirements 
 
5.2 Exclusion Criteria 
Yes/No (Response of “yes” = patient ineligible) 
 
_____ 5.2.1  Use of an investigational drug within 14 days or within 5 half-lives of the 
investigational drug, whichever is shorter 
 
_____ 5.2.2  Less than 6 months since the end of previous radiation 
 
_____ 5.2.3 
History of Grade 2 (CTCAE v4) or greater acute intracranial hemorrhage 
 
_____ 5.2.4  A concurrent active cancer that requires non-surgical therapy (e.g. 
chemotherapy, radiation, adjuvant therapy).  
 
_____ 5.2.5  Patients with serious illnesses, uncontrolled infection, medical conditions, 
or other medical history including abnormal laboratory results, which in 
the investigator’s opinion would be likely to interfere with a patient’s 
participation in the study, or with the interpretation of the results 
 
_____ 5.2.6  Women of child-bearing potential who are pregnant or breast feeding 
 
_____ 5.2.7  Unstable angina and/or congestive heart failure in the last 6 months, 
transmural myocardial infarction within the last 6 months, New York 
Heart Association grade II or higher congestive heart failure requiring 
hospitalization within 12 months prior to registration, evidence of recent 
(within 14 days of registration) myocardial infarction by EKG (only 
required if clinically indicated) serious or inadequately controlled cardiac 
arrhythmia, significant vascular and peripheral vascular disease, evidence 
of bleeding diathesis or coagulopathy. 
Page 24 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
_____ 5.2.8  History of stroke, cerebral vascular accident (CVA) or transient ischemic 
attack within 6 months 
 
_____ 5.2.9  Serious or non-healing wound, ulcer, or bone fracture or history of 
abdominal fistula, gastrointestinal perforation, intra-abdominal abscess 
major surgical procedure, open biopsy, or significant traumatic injury 
within 28 days prior to registration, with the exception of the craniotomy 
for tumor resection. 
 
_____ 5.2.10  Chronic obstructive pulmonary disease exacerbation or other respiratory 
illness requiring hospitalization or precluding study therapy at the time of 
registration  
 
_____ 5.2.11  Active connective tissue disorders, such as lupus or scleroderma, that in 
the opinion of the treating physician may put the patient at high risk for 
radiation toxicity 
 
_____5.2.12  Uncontrolled symptomatic hypertension that cannot be controlled with 
anti-hypertensive agents 
 
I certify that this patient meets all inclusion and exclusion criteria for enrollment onto this 
study.  
 
______________________________ 
 
_________ 
_______ 
PI Signature   
 
 
 
Date 
 
Time 
 
5.3 Screen Failures 
Patients who sign an informed consent form, are not assigned to a treatment, and do not receive 
test article are defined as screen failures. For all screen failures, the investigator is to maintain a 
screening log that documents the screening number, patient initials, and reason(s) for screen 
failure.  
5.4 Prior Treatment 
Reasonable efforts will be made to determine all relevant treatment received by the patient 
within 28 days before administration of the test article. All previous treatments for glioma should 
be recorded. 
Page 25 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
6.0 
CONCOMITANT TREATMENT 
Concomitant treatment is permitted if the medication is not expected to interfere with the 
evaluation of safety or efficacy of the study drug. During the study, if the use of any concomitant 
treatment becomes necessary (e.g., for treatment of an adverse event), the treatment must be 
recorded on the CRF, including the reason for treatment, generic name of the drug, dosage, route, 
and date of administration. 
7.0 
TREATMENT PLAN 
Bevacizumab will be administered in accordance with the FDA-approved dose for gliomas, 
10mg/kg IV every 2 weeks.  Use screening or day 1 weight throughout the study unless there is a 
10% weight change. Actual body weight will be used for all dose calculations of bevacizumab. 
Radiation will be given based on the judgment of the prescribing radiation oncologist.  
Minocycline will be given by mouth twice a day starting at about half of the monotherapy 
maximal tolerated dose, 100 mg. 
7.1 Bevacizumab 
7.1.1 
How Supplied, Stored, Packaged and Labeled  
Bevacizumab is supplied as a clear to slightly opalescent, sterile liquid ready for 
parenteral administration. For Bevacizumab, each 100mg (25mg/mL – 4mL fill) and 
400 mg (25 mg/mL – 16 mL) glass vial contains bevacizumab with phosphate, 
trehalose, polysorbate 20, and Sterile Water for Injection, USP.  
 
On receipt, bevacizumab should be stored in the refrigerator (2o to 8oC) and should 
remain refrigerated until just prior to use. Do not freeze. Do not shake. Shelf-life 
studies of bevacizumab are continuing. Investigators will be notified when lots have 
expired. The sterile single use vials contain no antibacterial preservatives; therefore, 
vials should be discarded eight hours after initial entry. 
 
Bevacizumab will be supplied by the Huntsman Cancer Institute Pharmacy. 
 
7.1.2 
Preparation and Administration 
Vials contain no preservative and are intended for single use only. The calculated dose 
should be placed in a 100 mL of 0.9% Sodium Chloride for Injection. Once diluted in 
0.9% Sodium Chloride for Injection, the bevacizumab solution must be administered 
within 8 hours.  
 
Bevacizumab is administered intravenously as a continuous infusion. The initial dose 
should be administered over a minimum of 90 minutes. If no adverse reactions occur 
after the initial dose, the second dose should be administered over a minimum of 60 
minutes. If no adverse reactions occur after the second dose, all subsequent doses 
should be administered over a minimum of 30 minutes. If infusion-related adverse 
Page 26 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
reactions occur, all subsequent infusions should be administered over the shortest 
period that was well tolerated. To ensure complete delivery of bevacizumab, the IV 
infusion line must be flushed with 0.9% Sodium Chloride for Injection. Please note that 
this flush is not included in the infusion times. The following are two recommended 
methods for flushing the bevacizumab IV infusion line: When the bevacizumab 
infusion is complete, add an additional 50mL of 0.9% Sodium Chloride for Injection to 
the bevacizumab infusion bag. Continue the infusion until a volume equal to that of the 
volume contained in the tubing has been administered. Replace the empty bevacizumab 
infusion bag with a 50mL bag of 0.9% Sodium Chloride for Injection and infuse a 
volume equal to the volume contained in the tubing. 
 
7.1.3 
Accountability and Compliance 
Doses and infusions will be documented in the patient’s medical record. 
 
7.2 Minocycline 
7.2.1 
How Supplied, Stored, Packaged and Labeled  
Each minocycline hydrochloride capsule, USP for oral administration contains the 
equivalent of 50 mg, 75 mg or 100 mg of minocycline. In addition each capsule 
contains the following inactive ingredients: corn starch and magnesium stearate. 
The 50 mg, 75 mg and 100 mg capsule shells contain: gelatin and titanium dioxide. 
The 75 mg and 100 mg capsule shells also contain black iron oxide. 
The imprinting ink contains: black iron oxide, potassium hydroxide, propylene glycol, 
and shellac 
Minocycline Hydrochloride Capsules USP, 50 mg are Pink/Pink size ‘3’ hard gelatin 
capsule filled with yellow granular powder and imprinted with ‘C’ on Pink cap and ‘76’ 
on Pink body with black ink. 
Minocycline Hydrochloride Capsules USP, 75 mg are White/Grey size ‘3’ hard gelatin 
capsule filled with yellow granular powder and imprinted with ‘C’ on White cap and 
‘77’ on Grey body with black ink. 
Minocycline Hydrochloride Capsules USP, 100 mg are Maroon/Pink size ‘2’ hard 
gelatin capsule filled with yellow granular powder and imprinted with ‘C’ on Maroon 
cap and ‘78’ on Pink body with black ink. 
Minocycline should be stored at 20° to 25°C (68° to 77°F); excursions permitted to 15° 
to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Protect from light, 
moisture and excessive heat. Dispense in a tight, light-resistant container as defined in 
the USP. 
Page 27 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
Minocycline will be supplied by the Huntsman Cancer Institute Investigational 
Pharmacy. 
 
7.2.2 
Preparation and Administration 
Minocycline hydrochloride capsules may be taken with or without food. 
Ingestion of adequate amounts of fluids along with capsule and tablet forms of drugs in 
the tetracycline-class is recommended to reduce the risk of esophageal irritation and 
ulceration. The capsules should be swallowed whole. 
 
 
7.2.3 
Accountability and Compliance 
Administrations and doses will be noted in the patient’s medical record. 
 
8.0 
TOXICITIES AND DOSE MODIFICATION 
This study will utilize the CTCAE (NCI Common Terminology Criteria for Adverse Events) Version 4.0 
for adverse event and serious adverse event reporting.  A copy of the CTCAE Version 4.0 can be 
downloaded:  
(http://safetyprofiler-ctep.nci.nih.gov/CTC/CTC.aspx). 
 
8.1 Bevacizumab 
Reduction/interruption of dosing for adverse events may take place at any time. Below are 
guidelines for dosage modification for bevacizumab–related toxicities as well as guidelines for 
their management.  
 
Table 1: 
Dose Modifications 
Event  
CTCAE.v4.0 Grade  
Action To Be Taken 
Allergic reactions 
or 
Acute infusional 
reactions/ cytokine 
release syndrome 
Grade 1-2 
If infusion-related or allergic 
reactions occur, premedications 
should be given with the next dose 
and infusion time may not be 
reduced for the subsequent 
infusion.  
 
Page 28 of 58 
 


Pr ot o c ol n a me: Re pe at R a di ati o n, Mi n oc ycli ne a n d Be v aciz u m a b i n P atie nt s wit h Rec urre nt Gli o m a  
Versi o n D ate : 1 2/ 0 3/ 2 0 1 5  
Pri nci p al I n vesti g at or:  A d a m C o he n, M D  
 
Gra de 3  
 B e vaciz u ma b  i nf usi o n s h o ul d be 
st o p pe d a n d n ot restarte d o n 
t he sa me da y. At t he p h ysicia ns’ 
discreti o n, be vaciz u ma b ma y be 
per ma ne ntl y disc o nti n ue d or re -
i nstit ute d wit h pre me dicati o ns a n d at 
a rate of 9 0 + 1 5 mi n. If 
be v aciz u m a b is re -i nstit ute d, t he 
p atie nt s h o ul d be cl osel y 
m o nit ore d f or a d ur ati o n  
c o m p ar a ble t o or l o n ger t h a n t he 
d ur ati o n of t he pre vi o us re acti o ns . 
Gra de 4  
Disc o nti n ue be vaciz u ma b  
Arteri al T hr o m b osis  
- Car diac isc he mia/  
i nfracti o n 
- C N S isc he mia ( TI A,  
C V A)  
- a n y peri p heral or  
visceral arterial  
isc he mia/t hr o m b osis 
Gra de 2 ( if ne w or  
w orse ne d si nce 
be vaciz u ma b t hera p y)  
Disc o nti n ue be vaciz u ma b  
Gra de 3 -4  
Ve n o us T hr o m b osis  
Gra de 3  
O R  
as y m pt o matic gra de 4  
� H ol d be vaciz u ma b treat me nt. If 
t he pla n ne d d urati o n of f ull-d ose 
a ntic oa g ulati o n is < 2 wee ks, 
be vaciz u ma b s h o ul d be hel d u ntil  
t he f ull- dose a ntic oa g ulati o n p eri o d 
is o ver. 
� If t he pla n ne d d urati o n of f ull-
d ose a ntic oa g ulati o n is > 2 we e ks, 
be vaciz u ma b ma y be res u me d  
d uri n g t he peri o d of f ull -d ose 
a ntic oa g ulati o n I F all of t he criteria 
bel o w are met:  
- T he s u bj ect m ust ha ve a n i n -ra n ge 
I N R ( us uall y 2-3) o n a sta ble d ose of 
warfari n or be o n a sta ble d ose of 
he pari n pri or t o restarti n g 
be vaciz u ma b  
- T he s u bj ect m ust n ot ha ve 
pat h ol o gical c o n diti o ns t hat carr y 
hi g h ris k of blee di n g (e g, t u m or 
i n v ol vi n g maj or vessels or ot her 
c o n diti o ns)  
- T he s u bj ect m ust n ot ha ve ha d 
he m orr ha gic e ve nts w hile o n st u d y  
� If t hr o m b oe m b oli w orse n/re c ur 
u p o n res u m pti o n of st u d y t her a p y, 
disc o nti n ue be vaciz u ma b  
Gra de 4 (s y m pt o matic)  
Disc o nti n ue be vaciz u ma b  
H y perte nsi o n *  
[ Treat wit h a nti h y perte nsi ve me dicati o n as nee de d. T he g oal of B P c o ntr ol 
s h o ul d be c o nsiste nt wit h ge neral me dical practice] 
Gra de 1  
C o nsi der i ncrease d B P m o nit ori n g  
Gra de 2 -3  as y m pt o matic  
B e gi n or c o nti n ue a nti -h y perte nsi ve 
t hera p y a n d c o nti n ue be vaciz u ma b  
P a ge 2 9  of 5 8  
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
-Grade 2-3 Symptomatic  
 
• Hold bevacizumab  until symptoms 
resolve and hypertension is grade 2 
or less 
• Begin or continue anti-
hypertensive therapy 
Grade 4 
Discontinue bevacizumab 
Congestive Heart Failure 
Grade 3 or 4 
Discontinue bevacizumab 
Proteinuria 
UPC ratio < 3500mg/g 
Continue bevacizumab 
 
UPC ratio > 3500mg/g 
Hold bevacizumab until UPC 
<3500mg/g 
 
Grade 4 or nephrotic syndrome 
Discontinue bevacizumab 
Hemorrhage (CNS or pulmonary) 
Grade 2-4 
Discontinue bevacizumab 
Hemorrhage (non-CNS; non-
pulmonary) 
Grade 3 
• Patients receiving full-dose 
anticoagulation should 
discontinue bevacizumab  
• For patients not on full-dose 
anticoagulation, hold 
Bevacizumab until ALL of the 
following criteria are met: 
- the bleeding has resolved and Hb is 
stable 
- there is no bleeding diathesis that 
would increase the risk of therapy 
- there is no anatomic or pathologic 
condition that could increase the risk 
of hemorrhage recurrence. 
• Patients who experience recurrence 
of grade 3 hemorrhage should 
discontinue study therapy 
 
Grade 4 
Discontinue bevacizumab 
RPLS (reversible posterior 
leukoencephalopathy 
syndrome or PRES (posterior 
reversible 
encephalopathy syndrome) 
 
• Hold bevacizumab in patients 
with symptoms/signs suggestive of 
RPLS; subsequent management 
should include MRI scans and 
control of HTN 
• Discontinue bevacizumab upon 
diagnosis of RPLS 
Wound dehiscence requiring 
medical or surgical intervention 
 
Discontinue bevacizumab 
GI perforation, GI leak or fistula  
 
Discontinue bevacizumab  
Bowel obstruction  
Grade 2 requiring medical 
intervention 
Hold bevacizumab until complete 
resolution, with a minimum of 4 
weeks after surgery. 
Grade 3-4 
• Hold bevacizumab until complete 
resolution 
• If surgery is required, patient may 
restart bevacizumab after full 
recovery from surgery, and at 
investigator’s discretion 
Other unspecified 
bevacizumab-related AEs (except 
Grade 3 
Hold bevacizumab until symptoms 
resolve to < grade 1 
Page 30 of 58 
 


Pr ot o c ol n a me: Re pe at R a di ati o n, Mi n oc ycli ne a n d Be v aciz u m a b i n P atie nt s wit h Rec urre nt Gli o m a  
Versi o n D ate : 1 2/ 0 3/ 2 0 1 5  
Pri nci p al I n vesti g at or:  A d a m C o he n, M D  
 
c o ntr olle d  
na usea/ v o miti n g).  
Gra de 4  
Disc o nti n ue be vaciz u ma b  
• U p o n c o ns ult ati o n wit h t he 
pri nci p al i n vesti g at or, res u m pti o n 
of be vaciz u ma b ma y be c o nsi dere d 
if a patie nt is be nefiti n g fr o m 
t hera p y a n d t he gra de 4 t o xicit y is 
tra nsie nt, has rec o vere d t o < gra de 1 
a n d u nli kel y t o rec ur wit h 
retreat me nt 
* C urre nt C T C A E defi niti o ns use d b y C T E P:  
 
� Gra de 1: as y m pt o matic, tra nsie nt ( < 2 4 h o urs) i ncrease b y > 2 0 m m H g ( diast olic) or t o > 1 5 0/ 1 0 0 if  
pre vi o usl y W N L; i nter ve nti o n n ot i n dicate d  
� Gra de 2: rec urre nt or persiste nt ( >  2 4 h o urs) or s y m pt o matic i ncrease b y > 2 0 m m H g ( di ast olic) or t o > 1 5 0/ 1 0 0 if 
pre vi o usl y W N L; m o n ot hera p y ma y be i n dicate d  
� Gra de 3: re q uiri n g m ore t ha n o ne dr u g or m ore i nte nsi ve t hera p y t ha n pre vi o usl y  
� Gra de 4: life t hreate ni n g (e g, h y perte nsi ve cri sis)  
 
 
D ose i nterr u pti o ns f or Gr a de 2 n o n- he m at ol o gic t o xicit y f or u p t o 2 w ee k s ca n be i m ple me nte d 
at t he discreti o n of t he tr eati n g p h ysici a n t o ma na ge i nt olera ble or cli nicall y si g nifica nt t o xicit y . 
N o d ose re d u cti o n is re q uire d w he n r es u mi n g treat me nt. 
8. 2  Mi n oc ycli ne  
D ose le vel  
D ose  
-1  
7 5 m g P O BI D  
0  
1 0 0 m g P O BI D  
1  
2 0 0 m g P O BI D  
2  
4 0 0 m g P O BI D  
 
D uri n g t h e e x pa nsi o n p hase (ste p 2) or aft er t he first p ost -ra diati o n m o nt h d uri n g ste p 1, if a 
patie nt e x perie nces a n e w gra de 2 t o xicit y attri b uta ble t o mi n oc ycli ne ot h er t ha n t h ose s pecifi e d 
ne xt , mi n oc ycli ne m ust be i nterr u pte d u ntil rec o ver y t o < gra d e 1 a n d t he n rei ntr o d uce d at o n e 
l o wer d ose le v el.  T he f oll o wi n g t o xicities will  re q uire h ol di n g t he mi n oc ycli ne o nl y if gra de 3 or 
hi g her t o xicit y is e x perie nce d: a ne mia, c h olester ol.  T he f oll o wi n g t o xicities will n ot re q uire 
h ol di n g t he mi n oc ycli ne: l y m p h o pe nia, w ei g ht gai n.    If a patie nt re q uires a t o xicit y relate d d ose 
dela y of > 2 8 da ys, t he n t he patie nt m ust be disc o nti n ue d fr o m t he st u d y. Mi n oc ycli ne will be 
st o p pe d f or a r elate d gr a d e 3 or hi g her t o xicit y , e x ce pt as s pecifie d a b o v e, u ntil t he t o xicit y 
res ol ves t o gra d e 1 or less, at w hic h p oi nt t he patie nt ma y res u me mi n oc ycli ne at t he ne xt l o west 
d ose le vel if a gr ee d b y t h e patie nt, t he treati n g p h ysicia n, a n d t he PI.  D ose re d ucti o ns are 
P a ge 3 1  of 5 8  
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
allowed until 100 mg PO BID (dose level 0), after which the patient must be removed from the 
study.    
8.3 Discontinuation of Treatment and Withdrawal of Patients  
The reasons a patient may discontinue or be withdrawn from the study include, but are not 
limited to, adverse event, disease progression, patient request, investigator decision, protocol 
violation, patient noncompliance, and study termination. Follow-up information every 3 months 
after the last day of radiation should be obtained if possible for patients who discontinue the 
study for reasons other than disease progression and are not started on another therapy for their 
recurrent glioma, in order to capture PFS3 data.  
Patients withdrawn from the study for reasons other than toxicity or disease progression (e.g. 
protocol violation or noncompliance) may be replaced at the discretion of the investigator.  To be 
considered evaluable, patients must experience a drug-related dose-limiting toxicity or receive at 
least 28 days of minocycline and 2 infusions of bevacizumab. During the dose-escalation portion 
of the study (step 1), unevaluable patients will be replaced.  Treatment may be discontinued for 
an adverse event or at the discretion of the investigator. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 32 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
9.0 
STUDY CALENDAR 
 
STUDY DAY► 
Screening 
(within 21 
days of 
registration) 
Radiation 
Treatment 
Period 
D1 (+/- 7 
days) of each 
monthly 
bevacizumab 
cycle 
D15 (+/- 7 
days) of each 
monthly 
bevacizumab 
cycle 
28 (+/-14) 
days after the 
end of 
radiation  
84 (+/-14) 
days after the 
end of 
radiation  
182 (+/-28) 
days after the 
end of 
radiation  
EVENT▼ 
 
 
 
 
 
 
 
Informed 
Consent 
X 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
Height 
X 
 
 
 
 
 
 
Weight 
X 
 
X 
 
X 
X 
X 
Vital Signs 
X 
X5 
X 
X 
X 
X 
X 
Physical Exam 1 
X 
X5 
 
 
X 
X 
X 
Chem, Hem 
X 
X5 
X 
 
X 
X 
X 
UA/UPC 
 
 
X 
 
 
 
 
PT/INR 
X 
 
 
 
 
 
 
Pregnancy Test 2 
X 
 
 
 
 
 
 
Karnofsky 
Performance 
Status 
Assessment 
X 
 
 
 
X 
X 
X 
QOL by MDASI-
BT 
X 
 
 
 
X 
X 
X 
COGSTATE 
X 
 
 
 
X 
X 
X 
MRI Brain Scan3 
X 
 
 
 
X 
X 
X 
Concomitant 
Medications 
X 
 
 
 
X 
X 
X 
Adverse Events 4 
 
X5 
X 
X 
X 
X 
X 
Minocycline 
Administration 
 
X6 
X 
X 
X 
X 
X 
Radiation 
 
X 
 
 
 
 
 
Bevacizumab 
infusions 
 
X 
X 
X 
 
 
 
EXPLANATION OF SUPERSCRIPTS: 
1. 
Complete physical exam (including neurological exam) at Screening, and neurological exam plus symptom-directed 
physical exam subsequently. 
2. 
For women of child-bearing potential only; must be within 7 days of initiation of minocycline 
3. 
Obtained within 21 days of registration and then 4, 12 and 26 weeks after radiation. For each patient, standard sequences 
will be obtained and research sequences may be obtained.  Additional MRperfusion/spectroscopy scans may also be 
obtained.  
4. 
Assessment of adverse events (dose limiting toxicities) for determination of MTD will end 4 weeks after the end of 
radiation; adverse events will continue to be monitored until all study treatment has been discontinued. 
5. 
During the combined radiation, minocycline and bevacizumab treatment, patients will be seen weekly with a CBC, CMP, 
symptom directed physical exam, neurological exam, vital signs and adverse event monitoring. 
6. 
Minocycline administration should be started the day prior to radiation; a window of 7 days prior is allowed. 
Page 33 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
10.0 
STUDY PROCEDURES 
10.1 Screening Evaluation 
Within 21 days before registration, all patients will have a Screening evaluation that includes the 
following: 
1. Sign and date an IRB-approved informed consent form before any study-specific 
screening procedures are performed  
2. Medical history 
3. Height, weight, vital signs (sitting blood pressure, pulse rate, respiratory rate, and 
temperature), and physical examination 
4. Clinical laboratory evaluation [CBC with differential, CMP, PT/INR, serum pregnancy 
test (women of child-bearing potential)] 
5. Karnofsky performance status assessment  
6. MRI brain scan within 21 days of registration 
7. Recording of concomitant medications 
Patients who do not meet all inclusion and exclusion criteria will be noted as screen failures. 
10.2  Baseline Evaluation 
Between screening/consent and the first dose of radiation, QOL will be assessed by the MDASI-
BT and cognition by the COGSTATE 
10.3 Day 1 of subsequent cycles (± 7 Days) 
On D1 of each cycle, patients will undergo the following procedures: 
1. Weight, vital signs 
2. CBC, CMP, and UA (urine protein to creatinine ratio if protein present on UA) 
3. AE monitoring 
4. Bevacizumab infusion 
10.4 Day 15 of subsequent cycles (± 7 Days) 
On D15 of each cycle, patients will undergo the following procedures: 
1. Vital signs 
Page 34 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
2. Bevacizumab infusion 
3. AE monitoring 
10.5 Weekly during radiation 
Once per week during radiation, patients will undergo the following procedures: 
 
1. Vital signs 
2. CBC 
3. CMP 
4. AE monitoring 
5. Symptom-directed physical examination plus neurological exam 
 
10.6 Four weeks post-radiation 
Twenty-eight (+/-7) days after the end of radiation, patients will return to the clinic and undergo 
the following procedures: 
1. Weight, vital signs, and symptom-directed physical examination plus neurological exam  
2.  CBC 
3. CMP 
4. Karnofsky performance status assessment 
5. MRI brain scan 
6. Recording of concomitant medications 
7. AE monitoring 
8. MDASI-BT 
9. COGSTATE 
10.7 Twelve weeks post-radiation 
84 (+/- 14) days after the end of radiation, subjects are expected to return to the clinic and 
undergo the following procedures: 
1. Weight, vital signs, and symptom-directed physical examination plus neurological exam 
Page 35 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
2. CBC 
3. CMP 
4. Karnofsky performance status assessment 
5. Recording of concomitant medications 
6. MRI brain scan 
7. MDASI-BT 
8. COGSTATE 
9. AE monitoring 
10.8 Twenty-six weeks post-radiation 
182(+/-28) days after the end of radiation, subjects are expected to return to the clinic and 
undergo the following procedures: 
1. Weight, vital signs, and symptom-directed plus neurological physical examination. 
2. CBC 
3. CMP 
4. Karnofsky performance status assessment 
5. Recording of concomitant medications 
6. MRI brain scan 
7. MDASI-BT 
8. COGSTATE 
9. AE monitoring 
10.9 
Continuously during trial 
Minocycline oral administration (adverse event monitoring will continue until patient is removed 
from study treatment). 
 
11.0 
CRITERIA FOR EVALUATION AND ENDPOINT 
11.1 Efficacy Evaluation 
Response rate and PFS will be based on MRI using RANO criteria (see attachment 1).  PFS will 
be based on all evaluable patients in step 1 and step 2.  RR will be based on all evaluable patients 
in step 1 and step 2 who have measurable disease by RANO criteria. 
Page 36 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
Cognitive function will be assessed using Cogstate software, which is also being used in an 
RTOG trial open for low grade gliomas at HCI.  Cogstate consists of 4 brief cognitive tests.  
The 4 tests involve pseudo-randomization of content to provide multiple alternate forms of the 
tests. There are nearly unlimited alternate test forms available for 3 of the tests, and the fourth 
contains 20 matched alternate forms. All tests are preceded by practice items. The total time of 
administration is about 22 minutes. Patients will have 60 minutes to complete the CogState test.  
If a patient has not completed the CogState test within 60 minutes, the patient may stop the 
testing at that time.  Due to the CogState testing software, patients must complete all tests at each 
required time point in order to receive the test results, partially completed tests cannot be saved 
and therefore the data at that timepoint will not be used. 
Subjects who cannot operate a computer or who cannot perform the practice test will not be 
required to complete the cognitive function evaluation.   
 
11.2.2.1 One Card Learning Test (OCLT) (visuoperceptual learning and memory) 
Standard playing cards appear in the center of the computer’s screen one at a time, and the 
subject presses one mouse button if the card was presented previously and the other mouse 
button if it was not. Eighty-eight items are presented, in 8 trials of 11 cards. Learning and 
memory are operationally defined as the ability to discriminate between previously presented 
and novel (ie, distractors) information. Recognition paradigms are especially useful for 
assessing encoding and storage of newly learned information (Delis 2000).  The test takes about 
3 minutes. 
 
11.2.2.2 Detection Test (DET) (sensory registration, vigilance, and reaction time) 
A playing card appears in the center of the screen and turns face-up every 1 to 2 seconds. 
The subject presses one mouse button as quickly as possible after the card turns face-up. 
There are 35 items.  The test takes about 3 minutes. 
 
11.2.2.3 Identification Test (IDN) (basic information processing/decision speed) 
A playing card appears in the center of the screen and turns face-up every 1 to 2 second; 
The subject pushes one mouse button if the card is red and the other mouse button if it is black. 
There are 30 items.  The test takes about 8 minutes. 
 
11.2.2.4 Groton Maze Learning Test (GMLT) (spatial learning and executive functioning, 
including working memory, error monitoring, and ability to integrate feedback to modify 
problem solving) 
Subjects must learn a hidden pathway within a grid of tiles. Each time they click on a tile 
(using the mouse), they receive correct/incorrect feedback to help guide them through the 
pathway. Subjects must apply a set of simple rules to minimize errors. There are 28 steps and 11 
turns to complete the maze. There are 5 trials of the same hidden pathway.  The test takes about 
8 minutes. 
 
The instructions for the tests are given in attachment 2.   
 
MDASI-BT will be given as a written questionnaire; it is given in attachment 3. 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
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Principal Investigator:  Adam Cohen, MD 
 
 
11.2 Safety Evaluation 
Routine safety and tolerability will be evaluated from the results of reported signs and 
symptoms, scheduled physical examinations, vital sign measurements, and clinical laboratory 
test results.  
More frequent safety evaluations may be performed if clinically indicated or at the discretion of 
the investigator. All AEs will be recorded from the time the patient receives the first dose of 
radiation up to 28 days after the last dose of radiation to assess the MTD.  If the patient continues 
on minocycline, AE’s will be assessed until discontinuation of treatment. 
11.2.1 Physical Examination 
Complete and symptom-directed physical examinations will be performed by a licensed 
physician (or physician’s assistant or nurse practitioner). 
11.2.2 Vital Signs 
Vital signs (blood pressure, respiratory rate, pulse rate and temperature) will be 
obtained in the sitting position. Patients should be sitting for 3-5 minutes prior to 
obtaining vital signs. 
11.2.3 Safety Laboratory Determinations 
Laboratory evaluations will be performed as noted in the flow chart.  
11.3 Stopping Rules 
 
Refer to section 4.2 for definition and evaluation of Dose Limiting Toxicities and stopping rules.  
 
 
12.0 
STATISTICAL ANALYSIS 
12.1 General Statistical Considerations 
This is a Phase 1/2, single institution, open-label study with the primary objective to estimate the 
adverse event rate during reirradiation with concomitant bevacizumab and minocycline.  
Important secondary objectives are to estimate the PFS3, PFS6, response rate and cognitive 
effects with this regimen. 
Since this is an open-label, single regimen clinical trial, descriptive statistics will be employed to 
analyze the data. Summary statistics for continuous variables will include the mean, standard 
deviation, median, and range (minimum/maximum). Categorical variables will be presented as 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
frequency counts and percentages, and time-to-event variables will be summarized by Kaplan-
Meier plots, medians and range. 
The data will be tabulated and analyzed with respect to patient enrollment and disposition, 
demographic and baseline characteristics, prior and concomitant medications, efficacy, and 
safety measures.  
Data listings will be created to support each table and to present all data collected.  
For efficacy analyses, a 1-sided alpha of 0.2 without adjustment for multiple comparisons will be 
used 
12.2 Sample Size and Power 
12.2.1 Primary Objective: Rate of adverse events during and up to 4 weeks after 
radiation 
12.2.1.1 
Data needed 
1. 
Adverse events at each cycle during radiation 
2. 
Adverse events at 28 days post-radiation 
 
Source documentation will capture adverse events through the end of all study 
treatment.  Only those adverse events occurring through 28 days post-radiation 
will be recorded on the Case Report Forms. 
 
12.2.1.2 
Statistical analysis 
Adverse event rates will be categorized as non-severe (CTCAE grade 1-2) or 
severe (CTCAE grade 3-4).  The rate of non-severe and severe adverse events 
will be reported.  In step 1, 3 patients per cohort will be used to define the 
maximum tolerated dose/maximum achieved dose to carry forward into step 2.  
All patients treated at the step 2 dose will be used in all analyses. 
 
Fifteen patients at the final dose will give 80% power to detect any adverse 
event affecting at least 10.2% of patients.  Margins of error, with alpha = 0.05, 
for estimates of any event affecting more than 1 patient in the trial will be less 
than 27%. 
 
12.2.2 Secondary Objectives 
12.2.2.1 
PFS3 
12.2.2.1.1 
Data needed 
1. 
Size of target lesion on MRI at baseline 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
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Principal Investigator:  Adam Cohen, MD 
 
2. 
Size of target lesion on MRI 12 weeks after the end of radiation 
12.2.2.1.2 
Statistical analysis 
With bevacizumab continuation alone, the PFS3 would be expected to 
be <10%.  Indeed, the median overall survival after progression on 
bevacizumab is 3 months.   In prior studies in the bevacizumab-
refractory population, treatments with PFS3 of 10-20% and PFS6 of 0-
10% were considered not effective. (Reardon et al.)  On the other hand, 
chemotherapy with PFS3 of ~40% and PFS6 of 16% was considered 
worthy of further study.  (Reardon et al.) Assuming a 10% 
dropout/unevaluable rate, fifteen patients will give us 80 percent power 
to reject the null hypothesis of 10% if the true PFS3 is 30%. 
12.2.2.2 
PFS6 
12.2.2.2.1 
Data needed 
1. 
Size of target lesion on MRI at baseline 
2. 
Size of target lesion on MRI 26 weeks after the end of radiation 
12.2.2.2.2 
Statistical analysis 
With bevacizumab continuation alone, the PFS6 would be expected to 
be <10%.  In prior studies in the bevacizumab-refractory population, 
treatments with PFS3 of 10-20% and PFS6 of 0-10% were considered 
not effective. (Reardon et al.)  On the other hand, chemotherapy with 
PFS3 of ~40% and PFS6 of 16% was considered worthy of further 
study.  (Reardon et al.) Assuming a 10% dropout/unevaluable rate, 
fifteen patients will give us 80 percent power to reject the null 
hypothesis of 5% if the true PFS6 is 21%. 
12.2.2.3 
Response rate 
12.2.2.3.1 
Data needed 
1. 
Size of target lesion on MRI at baseline 
2. 
Size of target lesion on MRI 12 weeks after the end of radiation 
12.2.2.3.2 
Statistical analysis 
In Fugh et al, the response rate to radiation alone was 10%.  For drug 
studies in recurrent gliomas after bevacizumab, response rates over 10% 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
have been considered evidence of efficacy for proceeding to further 
trials.  Assuming a 10% dropout/unevaluable rate, fifteen patients will 
give us 80 percent power to reject the null hypothesis of 10% response if 
the true response rate is at least 30%. 
12.2.2.4 
Quality of life change over time 
12.2.2.4.1 
Data needed 
1. 
MDASI-BT at baseline, 4 weeks post-radiation, 12 weeks post-
radiation, and 26 weeks post-radiation 
12.2.2.4.2 
Statistical analysis 
MDASI-BT uses a 1-10 Likert scale for 22 symptoms.  In high grade 
brain tumor patients, changes in MDASI_BT scores of 2 or more are 
considered clinically significant.  The course of changes in MDASI-BT 
during and after progression has not been published.  We assume that 16 
patients are evaluable 4 weeks after radiation, 12 patients are alive and 
evaluable 12 weeks after radiation, and 8 patients are alive and evaluable 
26 weeks after radiation.  We will report the mean and standard 
deviation for each item, subscore, and total score at each time point. 
12.2.2.5 
Cognitive change over time 
12.2.2.5.1 
Data needed 
1. 
COGSTATE at baseline, 4 weeks post-radiation, 12 weeks post-
radiation, and 26 weeks post-radiation 
12.2.2.5.2 
Statistical analysis 
The primary endpoint of cognitive function is measured by a battery of 
tests: the Detection Test (DET), the Identification Test (IDN), the One 
Card Learning Test (OCLT), and the Groton Maze Learning Test 
(GMLT). The primary outcome measure of the DET and IDN tests is 
speed of performance using the mean of the log10 transformed response 
times for correct responses (lower score = better performance). 
Accuracy of performance is the primary outcome measure for the 
OCLT, using the arcsine transformation of the square root of the 
proportion of correct responses across 8 rounds (higher score = better 
performance). Number of errors is the primary outcome measure for 
GMLT.  Each of the battery’s tests will be evaluated using the 2-sample 
t-test with a 2-sided significance level of 0.05 to determine if there is a 
clinically meaningful difference in the average change of NCF score 
from baseline to the time of assessment. 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
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12.3 Analysis Populations 
The primary population for the safety analysis will consist of patients who receive at least one 
dose of minocycline and have any follow-up data.  The primary population for efficacy analyses 
will consist of all patients who receive at least one dose of minocycline. 
12.4 Efficacy Analysis 
Response to treatment will be evaluated using the Response Assessment in Neuro-Oncology 
(RANO) criteria (Wen 2010). The response criteria are summarized in Attachment 1. All patients 
who are eligible for efficacy analyses will be evaluable for PFS, calculated for each subject as 
the number of days from the first day of radiation to the date of the first documented disease 
progression or date of death, whichever occurs first. The Kaplan-Meier method will be used to 
estimate the median PFS. Those evaluable patients with measurable disease will be assessed for 
response. 
For each subject with a response to therapy, duration of response will be calculated. The duration 
of response is defined as number of days from the date of initial response to the date of first 
documented disease progression or death, whichever occurs first. The Kaplan-Meier method will 
be used to estimate median duration of response. In the event no disease progression or death is 
documented prior to study termination, analysis cutoff, or the start of confounding anticancer 
therapy, PFS and duration of response will be censored at the date of last evaluable tumor 
assessments.  
12.5 Safety Analysis 
Safety variables to be analyzed are AEs, laboratory test results (hematology and clinical 
chemistry), weight, and vital signs.  
Adverse event terms recorded on the eCRFs will be mapped to preferred terms using the Medical 
Dictionary for Drug Regulatory Activities (MedDRA®) version 10.1 or later. All AEs will be 
summarized according to the system organ class and preferred term within the organ class. 
Adverse events will be tallied for overall frequency (number and percentage of subjects), worst 
reported severity, and relationship to study drug for each preferred term per subject. Serious 
adverse events will be similarly summarized. Listings of deaths, SAEs, and AEs leading to early 
termination of study treatment or premature withdrawal from study will also be provided. 
Laboratory values will be categorized according to their CTCAE (version 4) toxicity grade and 
tabulated by worst on-study toxicity grade.  
13.0 
REGISTRATION GUIDELINES 
Patients must meet all of the eligibility requirements listed in Section 5 prior to 
registration.   
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
 
Study related screening procedures can only begin once the patient has signed a consent 
form.  Patients must not begin protocol treatment prior to registration. 
 
Treatment should start within five working days after registration. 
 
To register eligible patients on study, complete a Clinical Trials Office Patient Registration Form 
and submit to: CTORegistrations@hci.utah.edu.  
 
14.0 
DATA SUBMISSION SCHEDULE 
The Case Report Forms (CRFs) are a set of electronic forms for each patient that provides a 
record of the data generated according to the protocol.  CRF’s should be created prior to the 
study being initiated and updated (if applicable) when amendments to the protocol are IRB 
approved.  These forms will be completed on an on-going basis during the study.  Data will be 
entered into the CRFs via OnCore (clinical research management system) by assigned study staff 
at the Huntsman Cancer Institute, as indicated on the Delegation of Duties log. The medical 
records will be source of verification of the data.  During the study, the CRFs will be monitored 
for completeness, accuracy, legibility and attention to detail by a member of the Research 
Compliance Office.  The data will be reviewed no less than annually by the Data and Safety 
Monitoring Committee.  The Investigator will allow the Data and Safety Monitoring Committee 
or Research Compliance Office personnel access to the patient source documents, clinical 
supplies dispensing and storage area, and study documentation for the above-mentioned 
purpose.  The Investigator further agrees to assist the site visitors in their activities. 
 
15.0 
ETHICAL AND REGULATORY CONSIDERATIONS 
15.1 Informed consent  
Informed consent will be obtained from all research participants prior to performing any study 
procedures using the most recent IRB approved version.  
15.2 Institutional Review 
Study will be approved by the Institutional Review Board of University of Utah. 
15.3  Data and Safety Monitoring Plan 
A Data and Safety Monitoring Committee (DSMC) is established at Huntsman Cancer Institute 
(HCI) and approved by the NCI to assure the well-being of patients enrolled on Investigator 
Initiated Trials that do not have an outside monitoring review.  Roles and responsibilities of the 
DSMC are set forth in the NCI approved plan.  The activities of this committee include a 
quarterly review of adverse events including SAEs, important medical events, significant 
revisions or amendments to the protocol, and approval of cohort/dose escalations.  If the DSMC 
and/or the PI have concerns about unexpected safety issues, the study will be stopped and will 
not be resumed until the issues are resolved. The DSMC also reviews and approves audit reports 
generated by the Research Compliance Office.  
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
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Principal Investigator:  Adam Cohen, MD 
 
 
 
o This is a Phase I study. For each phase I study using an agent of potential risk a member 
of the DSMC will be assigned as the primary medical monitor.  The primary medical 
monitor will be notified immediately of all SAEs within 24 hours of knowledge of the 
event. A formal report should be submitted to the primary medical monitor within 10 
days. All serious adverse events (SAEs) occurring in patients treated at HCI or its 
affiliates will also be reviewed by the full DSMC quarterly. Approval from the primary 
medical monitor is required for all dose escalations.  The full committee will also review 
all grade 3 or greater toxicities for patients on treatment.  
 
 
15.4 Adverse Events / Serious Adverse Events 
This study will utilize the CTCAE (NCI Common Terminology Criteria for Adverse Events) 
Version 4.0 for AE and SAE reporting.  An electronic copy of the CTCAE Version 4.0 can be 
downloaded from:http://safetyprofiler-ctep.nci.nih.gov/CTC/CTC.aspx 
15.4.1 Adverse Events (AE) 
An adverse event is the appearance or worsening of any undesirable sign, symptom, or 
medical condition occurring after starting the study drug even if the event is not 
considered to be related to study drug. For the purposes of this study, the terms toxicity 
and adverse event are used interchangeably. Medical conditions/diseases present before 
starting study drug are only considered adverse events if they worsen after starting 
study drug. Abnormal laboratory values or test results constitute adverse events only if 
they induce clinical signs or symptoms, are considered clinically significant, or require 
therapy. 
 
A patient’s AE can occur from the time the patient receives the first dose of 
minocycline up to the last dose of study treatment.  SAEs will continue to be monitored 
and captured for a 30 day period after the last dose of study treatment. 
Information about all adverse events, whether volunteered by the subject, discovered by 
investigator questioning, or detected through physical examination, laboratory test or 
other means, will be collected and recorded and followed as appropriate. 
 
The occurrence of adverse events should be sought by non-directive questioning of the 
patient at each visit or phone contact during the study. Adverse events also may be 
detected when they are volunteered by the patient during or between visits or through 
physical examination, laboratory test, or other assessments. As far as possible, each 
adverse event should be evaluated to determine: 
1. 
the severity grade based on CTCAE v.4 (grade 1-5) 
2. 
its relationship to the study drug(s) (definite, probable, possible, unlikely, not 
related) For multi-drug regimens, relationship will be assessed for all treatments. 
3. 
its duration (start and end dates or if continuing at final exam) 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
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Principal Investigator:  Adam Cohen, MD 
 
4. 
action taken (no action taken; study drug dosage adjusted/temporarily interrupted; 
study drug permanently discontinued due to this adverse event; concomitant 
medication taken; non-drug therapy given; hospitalization/prolonged 
hospitalization) 
5. 
whether it constitutes an SAE 
 
All adverse events will be treated appropriately. Such treatment may include changes in 
study drug treatment as listed in the dose modification section of this protocol (see 
section 8 for guidance). Once an adverse event is detected, it should be followed until 
its resolution, and assessment should be made at each visit (or more frequently, if 
necessary) of any changes in severity, the suspected relationship to the study drug, the 
interventions required to treat it, and the outcome. 
 
Information about common side effects already known about the commercial drug is 
described in the Drug Information (section 2) and the FDA-approved product labels. 
This information will be included in the patient informed consent and will be discussed 
with the patient during the study as needed. 
 
All adverse events will be immediately recorded in the patient research chart.  
15.4.2 Serious Adverse Event (SAE) 
Information about all serious adverse events will be collected and recorded. A serious 
adverse event is an undesirable sign, symptom or medical condition which: 
• is fatal or life-threatening 
• results in persistent or significant disability/incapacity 
• is medically significant, i.e., defined as an event that jeopardizes the patient or may 
require medical or surgical intervention to prevent one of the outcomes listed above 
• causes congenital anomaly or birth defect 
• requires inpatient hospitalization or prolongation of existing hospitalization, unless 
hospitalization is for: 
o routine treatment or monitoring of the studied indication, not associated with 
any deterioration in condition (procedures such as central line placements, 
paracentesis, pain control) 
o elective or pre-planned treatment for a pre-existing condition that is unrelated to 
the indication under study and has not worsened since the start of study drug 
o treatment on an emergency outpatient basis for an event not fulfilling any of the 
definitions of a SAE given above and not resulting in hospital admission 
o social reasons and respite care in the absence of any deterioration in the 
patient’s general condition 
 
Any death from any cause while a patient is receiving treatment on this protocol or up 
to 30 days after the last dose of protocol treatment, or any death which occurs more 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
than 30 days after protocol treatment has ended but which is felt to be treatment related, 
must be reported. 
 
Toxicities which fall within the definitions listed above must be reported as an SAE 
regardless if they are felt to be treatment related or not.  Toxicities unrelated to 
treatment that do NOT fall within the definitions above, must simply be documented as 
AEs in the patient research chart.   
 
15.5 SAE Reporting Requirements 
 
SAEs must be reported to the DSMC, the FDA, and the IRB according to the 
requirements described below: 
 
DSMC Notifications: 
• Email or provide verbal notification of event within 24 hours of knowledge to 
compliance@hci.utah.edu. 
• Email 
completed 
MedWatch 
3500A 
form 
within 
10 
days 
to 
compliance@hci.utah.edu. 
• An HCI Research Compliance Officer will process and submit the SAE 
notification/MedWatch form to the proper DSMC member as necessary for each 
individual study.  
• The RCO will summarize and present all reported SAEs according to the DSMP at 
the quarterly DSMC meeting. 
 
FDA Notifications: 
• Adverse events occurring during the course of a clinical study that meet the 
following criteria will be promptly reported to the FDA: 
• Serious 
• Unexpected 
• Definitely, Probably or Possibly Related to the investigational drug 
• Fatal or life-threatening events that meet the criteria above will be reported within 7 
calendar days after first knowledge of the event by the investigator; followed by as 
complete a report as possible within 8 additional calendar days. 
• All other events that meet the criteria above will be reported within 15 calendar 
days after first knowledge of the event by the investigator. 
• The CRC will complete a MedWatch 3500A form on the reportable SAE, gather 
other relevant supporting information and forward this to the RCO within 10 days 
of first knowledge of the event (5 days for fatal or life-threatening events). 
• An RCO Compliance Officer will review the SAE information for completeness, 
accuracy and applicability to the regulatory reporting requirements. 
• The Compliance Officer will ensure the complete, accurate and timely reporting of 
the event to the FDA. 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
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• If the investigator of the IIT holds an investigational new drug application (IND), 
the Regulatory Coordinator will submit the report as an amendment to the 
application. 
• For studies with an IND, all other adverse events and safety information not 
requiring expedited reporting that occur or are collected during the course of the 
study will be summarized and reported to the FDA through the IND Annual Report. 
 
• IRB Notification:Events meeting the the University of Utah IRB reporting 
requirements (http://www.research.utah.edu/irb/) will be submitted through the 
IRB’s electronic reporting system within 10 working days. 
• The CRC will provide all necessary safety information to the Research Compliance 
Office for submission of the event.  
 
*Medwatch 3500A form can be found at 
https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm 
 
15.6 Protocol Amendments 
Any amendments or administrative changes in the research protocol during the period, for which 
the IRB approval has already been given, will not be initiated without submission of an 
amendment for IRB review and approval.    
 
These requirements for approval will in no way prevent any immediate action from being 
taken by the investigator in the interests of preserving the safety of all patients included in 
the trial.  
15.7 Protocol Deviations 
A protocol deviation (or violation) is any departure from the defined procedures and treatment 
plans as outlined in the protocol version submitted and previously approved by the IRB. Protocol 
deviations have the potential to place participants at risk and can also undermine the scientific 
integrity of the study thus jeopardizing the justification for the research.  Protocol deviations are 
unplanned and unintentional events.  
 
Because some protocol deviations pose no conceivable threat to participant safety or scientific 
integrity, reporting is left to the discretion of the PI within the context of the guidelines below. 
The IRB requires the prompt reporting of protocol deviations which are: 
• 
Exceptions to eligibility criteria. 
• 
Intended to eliminate apparent immediate hazard to a research participant or  
• 
Harmful (caused harm to participants or others, or place them at increased risk of harm - 
including physical, psychological, economic, or social harm), or  
• 
Possible serious or continued noncompliance  
15.8 FDA Annual Reporting  
This study is IND exempt therefore there are no annual reporting requirements to the FDA.   
 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
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15.9 Clinical Trials Data Bank  
The study will be registered on http://clinicaltrials.gov and the NCI CTRP (Clinical Trials 
Reporting Program) by the Clinical Trials Office. 
 
16.0 
REFERENCES 
 
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Principal Investigator:  Adam Cohen, MD 
 
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Neurosci 46(4): 710-719. 
Huang, W. C., Y. Qiao, et al. (2010). "Direct protection of cultured neurons from ischemia-like 
injury by minocycline." Anat Cell Biol 43(4): 325-331. 
Jiang, Z., N. Pore, et al. (2007). "Phosphatase and tensin homologue deficiency in glioblastoma 
confers resistance to radiation and temozolomide that is reversed by the protease inhibitor 
nelfinavir." Cancer Res 67(9): 4467-4473. 
Kelly, R. G. and L. A. Kanegis (1967). "Metabolism and tissue distribution of radioisotopically 
labelled minocycline." Toxicol Appl Pharmacol 11(1): 171-183. 
Kim, H. K., A. F. Thornton, et al. (1997). "Results of re-irradiation of primary intracranial 
neoplasms with three-dimensional conformal therapy." Am J Clin Oncol 20(4): 358-363. 
Kreisl, T. N., L. Kim, et al. (2009). "Phase II trial of single-agent bevacizumab followed by 
bevacizumab plus irinotecan at tumor progression in recurrent glioblastoma." J Clin 
Oncol 27(5): 740-745. 
Lal, B., S. Xia, et al. (2005). "Targeting the c-Met pathway potentiates glioblastoma responses to 
gamma-radiation." Clin Cancer Res 11(12): 4479-4486. 
Lee, C. G., M. Heijn, et al. (2000). "Anti-Vascular endothelial growth factor treatment augments 
tumor radiation response under normoxic or hypoxic conditions." Cancer Res 60(19): 
5565-5570. 
Lin, J., X. M. Zhang, et al. (2010). "gamma-secretase inhibitor-I enhances radiosensitivity of 
glioblastoma cell lines by depleting CD133+ tumor cells." Arch Med Res 41(7): 519-529. 
Liu, W. T., C. H. Lin, et al. (2011). "Minocycline inhibits the growth of glioma by inducing 
autophagy." Autophagy 7(2): 166-175. 
Lucio-Eterovic, A. K., Y. Piao, et al. (2009). "Mediators of glioblastoma resistance and invasion 
during antivascular endothelial growth factor therapy." Clin Cancer Res 15(14): 4589-
4599. 
Macdonald, H., R. G. Kelly, et al. (1973). "Pharmacokinetic studies on minocycline in man." 
Clin Pharmacol Ther 14(5): 852-861. 
Markovic, D. S., K. Vinnakota, et al. (2011). "Minocycline reduces glioma expansion and 
invasion by attenuating microglial MT1-MMP expression." Brain Behav Immun 25(4): 
624-628. 
Murat, A., E. Migliavacca, et al. (2008). "Stem cell-related "self-renewal" signature and high 
epidermal growth factor receptor expression associated with resistance to concomitant 
chemoradiotherapy in glioblastoma." J Clin Oncol 26(18): 3015-3024. 
Niyazi, M., U. Ganswindt, et al. (2010). "Irradiation and Bevacizumab in High-Grade Glioma 
Retreatment Settings." Int J Radiat Oncol Biol Phys. 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
Nutile-McMenemy, N., A. Elfenbein, et al. (2007). "Minocycline decreases in vitro microglial 
motility, beta1-integrin, and Kv1.3 channel expression." J Neurochem 103(5): 2035-
2046. 
Reardon, D. A., A. Desjardins, et al. (2011). "Phase II study of metronomic chemotherapy with 
bevacizumab for recurrent glioblastoma after progression on bevacizumab therapy." J 
Neurooncol 103(2): 371-379. 
Reardon, D. A., A. Desjardins, et al. (2011). "Phase 2 study of carboplatin, irinotecan, and 
bevacizumab for recurrent glioblastoma after progression on bevacizumab therapy." 
Cancer 117(23): 5351-5358. 
Rich, J. N. (2007). "Cancer stem cells in radiation resistance." Cancer Res 67(19): 8980-8984. 
Schnabel, L. V., M. G. Papich, et al. (2011). "Pharmacokinetics and distribution of minocycline 
in mature horses after oral administration of multiple doses and comparison with 
minimum inhibitory concentrations." Equine Vet J. 
Smith, D. L., B. Woodman, et al. (2003). "Minocycline and doxycycline are not beneficial in a 
model of Huntington's disease." Ann Neurol 54(2): 186-196. 
Sotomayor, E. A., B. A. Teicher, et al. (1992). "Minocycline in combination with chemotherapy 
or radiation therapy in vitro and in vivo." Cancer Chemother Pharmacol 30(5): 377-384. 
Stupp, R., W. P. Mason, et al. (2005). "Radiotherapy plus concomitant and adjuvant 
temozolomide for glioblastoma." N Engl J Med 352(10): 987-996. 
Teicher, B. A., S. A. Holden, et al. (1995). "Potentiation of cytotoxic therapies by TNP-470 and 
minocycline in mice bearing EMT-6 mammary carcinoma." Breast Cancer Res Treat 
36(2): 227-236. 
Tikka, T., B. L. Fiebich, et al. (2001). "Minocycline, a tetracycline derivative, is neuroprotective 
against excitotoxicity by inhibiting activation and proliferation of microglia." J Neurosci 
21(8): 2580-2588. 
Tikka, T. M., N. E. Vartiainen, et al. (2002). "Minocycline prevents neurotoxicity induced by 
cerebrospinal fluid from patients with motor neurone disease." Brain 125(Pt 4): 722-731. 
Tsai, Y. H., R. S. Hirth, et al. (1980). "A murine model for listerial meningitis and 
meningoencephalomyelitis: therapeutic evaluation of drugs in mice." Chemotherapy 
26(3): 196-206. 
Vordermark, D., O. Kolbl, et al. (2005). "Hypofractionated stereotactic re-irradiation: treatment 
option in recurrent malignant glioma." BMC Cancer 5: 55. 
Weingart, J. D., E. P. Sipos, et al. (1995). "The role of minocycline in the treatment of 
intracranial 9L glioma." J Neurosurg 82(4): 635-640. 
Wen, P. Y., D. R. Macdonald, et al. (2010). "Updated response assessment criteria for high-grade 
gliomas: response assessment in neuro-oncology working group." J Clin Oncol 28(11): 
1963-1972. 
Zhou, H., R. Miki, et al. (2007). "Reciprocal regulation of SOCS 1 and SOCS3 enhances 
resistance to ionizing radiation in glioblastoma multiforme." Clin Cancer Res 13(8): 
2344-2353. 
Zhuang, W., B. Li, et al. (2011). "Induction of autophagy promotes differentiation of glioma-
initiating cells and their radiosensitivity." Int J Cancer 129(11): 2720-2731. 
 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
ATTACHMENT 1:  RANO RESPONSE CRITERIA 
Patients will be assessed by the RANO (radiographic assessment in neurooncology) 
criteria.(Wen et al.). The response will be determined as outlined in the RANO criteria below. 
Measurable Disease 
a. Bidimensionally contrast-enhancing lesions with clearly defined margins by CT or MRI 
scan, with two perpendicular diameters of at least 10 mm, visible on two or more axial 
slices that are preferably, at most, 5 mm apart with 0-mm skip. 
b. Measurement of tumor around a cyst or surgical cavity represents a particularly difficult 
challenge. In general, such lesions should be considered nonmeasurable unless there is a 
nodular component measuring ≥ 10 mm in diameter. The cystic or surgical cavity should 
not be measured in determining response.  
Complete Response (requires all of the following): 
a. 
Complete disappearance of all enhancing measurable and non-measurable disease 
sustained for at least 4 weeks. In the absence of a confirming scan 4 weeks later, this scan 
will be considered only stable disease. 
b. 
No new lesions. 
c. 
All measurable and non-measurable lesions must be assessed using the same techniques 
as baseline. 
d. 
Patients must be on no steroids. 
e. 
Stable or improved non-enhancing (T2/FLAIR) lesions. 
f. 
Stable or improved clinically. 
Note: Patients with non-measurable disease cannot have a complete response. The best response 
possible is stable disease. 
Partial Response (requires all of the following): 
a. 
Greater than or equal to 50% decrease compared to baseline in the sum of products of 
perpendicular diameters (bi-dimensional measurements) of all measurable enhancing 
lesions sustained for at least 4 weeks. In the absence of a confirming scan 4 weeks later, 
this scan will be considered only stable disease. 
b. 
No progression of non-measurable disease. 
c. 
No new lesions. 
d. 
All measurable and nonmeasurable lesions must be assessed using the same techniques as 
baseline. 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
e. 
The steroid dose at the time of the scan evaluation should be no greater than the dose at 
time of baseline scan. 
f. 
Stable or improved non-enhancing (T2/FLAIR) lesions on same or lower dose of 
corticosteroids compared to baseline scan. 
g. 
Stable or improved clinically. 
Note: Patients with non-measurable disease cannot have a partial response. The best response 
possible is stable disease. 
Stable Disease (requires all of the following): 
a. 
Does not qualify for CR, PR, or progression. 
b. 
The designation of stable disease requires a minimum of 4-week duration. 
c. 
All measurable and non-measurable sites must be assessed using the same techniques as 
baseline. 
d. 
Stable non-enhancing (T2/FLAIR) lesions on same or lower dose of corticosteroids 
compared to baseline scan. In the event that the corticosteroid dose has been increased, 
the last scan considered to show stable disease will be the scan obtained when the 
corticosteroid dose was equivalent to the baseline dose. 
e. 
Stable clinically. 
Progressive Disease (defined by any of the following): 
a. 
>25% increase in sum of the products of perpendicular diameters (bi-dimensional 
measurements) of enhancing lesions (over baseline if no decrease) on stable or increasing 
doses of corticosteroids. and/or 
b. 
Significant increase in T2/FLAIR non-enhancing lesion on stable or increasing doses of 
corticosteroids compared to baseline scan or best response following initiation of therapy, 
not due to co-morbid events (radiation therapy, demyelination, ischemic injury, infection, 
seizures, postoperative changes, or other treatment effects). 
c. 
Any new lesion. 
d. 
Clear clinical deterioration not attributable to other causes apart from the tumor (e.g., 
seizures, medication side effects, complications of therapy, cerebrovascular events, 
infection, etc.). The definition of clinical deterioration is left to the discretion of the 
treating physician, but it is recommended that a decrease in 20% of KPS or from any 
baseline to 50% or less be considered, unless attributable to comorbid events. 
e. 
Failure to return for evaluation due to death or deteriorating condition. 
Assessment of Response (Efficacy) 
Timing of the Evaluation of Response: Assessment of response will begin with the previous 
MRI. All scans are to be compared to the smallest measurement scan to date.  
Page 52 of 58 
 


Pr ot o c ol n a me: Re pe at R a di ati o n, Mi n oc ycli ne a n d Be v aciz u m a b i n P atie nt s wit h Rec urre nt Gli o m a  
Versi o n D ate : 1 2/ 0 3/ 2 0 1 5  
Pri nci p al I n vesti g at or:  A d a m C o he n, M D  
 
 
A T T A C H M E N T 2: C O G S T A T E I N S T R U C TI O N S  
T E S T I N S T R U C TI O N S A N D A D MI NI S T R A TI O N P R O C E D U R E S  
A d diti o n al c o m me nts:  
1. T he c o m p uter use d f or t he c o g niti ve tests m ust be l ocate d i n a q ui et area relati vel y free of 
distracti o ns a n d wit h reas o na ble li g hti n g, c o mf orta ble seati n g, a n d a ta bl e of s ufficie nt size f or 
t he c o m p uter. N o f a mil y me m bers or fri e n ds of t h e patie nt, or site c ollea g u es, ma y b e prese nt 
d uri n g testi n g, e v e n if t he y re mai n q uiet or sit i n t he bac k of t h e r o o m. 
2. Testi n g m ust be c o m pl ete d i n 1 sessi o n. Test i nstr ucti o ns m ust be f oll o we d ver bati m (test 
i nstr ucti o n scri pts f or eac h of t he 4 tests are pr o vi de d i n t he ne ur oc o g niti ve t ests ma n ual) wit h 
e ver y patie nt at e ver y st u d y visit.  
3. Tests are a d mi nistere d i n t he f oll o wi n g or d er t o e ver y patie nt:  
C o g St ate tests i nstr ucti o ns scri pt  
�I m p ort a nt 
T ur n t he c o m p uter s cree n s o t hat it faces t he s u bj ect. E ns ure t hat t he s cree n is p ositi o ne d s o t hat 
it is directl y i n fr o nt of t h e s u bject ( n ot a n gle d t o t he si de) a n d at a c o mf orta ble dista nce fr o m t he 
s u bject. A dj ust t he scree n pitc h if necessar y. 
 
Detecti o n Test ( D E T)  
Bef ore t he D etecti o n T est be gi ns, a s cree n a p pears t ha t all o ws t he s u bject t o practice e nteri n g 
“ yes” a n d “ n o” res p o nses via t he m o use. T he left m o use b utt o n is al wa ys “ n o” a n d t he ri g ht 
m o use b utt o n is al wa ys “ yes, ” re gar dless of t h e ha n d use d. E ns ure t hat t he s u bject u n dersta n ds 
b y pr actici n g clic ki n g t he p r o per b utt o ns se veral ti mes. D o n ot per mit t he s u bject t o use t he 
ke y b o ar d t o e nter res p o nses. 
Click E nter t o be gi n t he Detecti o n test. 
T he i nstr ucti o ns a p pear o n t he scree n. T he s u bject s h o ul d re a d t he m sile ntly as y o u re a d t he m 
al o u d. 
S ay, H as t he c ar d t ur ne d over ? Y o u are n o w g oi n g t o d o a pr actice. Y o u will o nly nee d t o use 
t he “ Y es ” b utt o n f or t his t as k. I n t his t as k, a pl ayi n g c ar d will a p pe ar i n t he ce nter of t he 
scree n. Press t he “ Y es ” b utt o n w he n t he c ar d t ur ns f ace - u p as f ast as y o u c a n. If y o u m a ke a 
mist a ke y o u will he ar a n err or s o u n d. T his m e a ns y o u h ave res p o n de d t o o s o o n. Try t o m a ke 
y o ur res p o nse as acc ur ate a n d f ast as p ossi ble after a c ar d t ur ns f ace- u p. Are y o u re a dy t o 
st art ? 
Click E nter t o be gi n t he practice ite ms. Re mi n d t he s u bject to press t he “ Yes” b utt o n as s o o n as 
t he car d t ur ns 
face- u p. 
If t he s u bject a p p ears c o nf use d or r es p o n ds i nc orrectl y, re vie w t he test re q uire me nts, i ncl u di n g 
use of t he ri g ht m o use b utt o n (t he “ Yes” b utt o n) f or res p o nses. E ns ure t he s u bject u n dersta n ds 
t hat i n t his test, all car ds s h o w n are t he s a me J o ker car d. T h ere is n o nee d f or t he s u bject t o 
e x a mi ne details of t he car d cl osel y.  
W he n t he practice ite ms are c o m plet e, t he i nstr ucti o ns f or t he sc ore d or “real” p orti o n of t he test 
a p pear.  
S ay, H as t he c ar d t ur ne d over ? Y o u are n o w g oi n g t o d o t he re al test. Are y o u re a dy t o st art ? 
Click E nter t o be gi n t he sc ore d ite ms. 
P a ge 5 3  of 5 8  
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
When presentation of items is complete, the Detection test ends and the Identification Test 
begins automatically. 
Identification Test (IDN) 
The instructions appear on the screen. The subject should read them silently as you read them 
aloud. 
Say, Is the card red? You are now going to do a practice. You will need to use both the “Yes” 
and “No” buttons for this task. In this task, a playing card will appear in the center of the 
screen. As soon as it turns face-up you must decide: is the color of the card red? If it is red, 
press the “Yes” button. If it is not red, press the “No” button. If you make a mistake you will 
hear an error sound. Try to make your responses as accurate and fast as possible after a card 
turns face-up. Are you ready to start? 
Click Enter to begin the practice items. Remind the subject to press the “Yes” or “No” buttons as 
quickly and accurately as possible. 
If the subject appears confused or responds incorrectly, review the test requirements, including 
use of the left and right mouse button (left button = “No” and right button = “Yes” for responses. 
Ensure the subject understands that in this test, all cards shown are the same Joker card, the only 
difference being color (red or black). There is no need for the subject to examine details of the 
card closely. 
When the practice items are complete, the instructions for the scored or “real” portion of the test 
appear. 
Say, Is the card red? You are now going to do the real test. Are you ready to start? 
Click Enter to begin the scored items. 
When presentation of items is complete, the Identification test ends and the One Card Learning 
Test begins automatically. 
One Card Learning Test (OCLT) 
The instructions appear on the screen. The subject should read them silently as you read them 
aloud. 
Say, Have you seen this card before in this task? You are now going to do a practice. You will 
need to use both the “Yes” and “No” buttons for this task. 
In this task, a playing card will appear face-down in the center of the screen and then turn 
face-up. As soon as a card turns face-up decide if you have seen it before in this task. Only a 
few of the face-up cards will repeat during the task. If you have seen the card before in this 
task, press the “Yes” button. If you have not seen the card before in this task, press the “No” 
button. If you make a mistake you will hear an error sound. Try to make your responses as 
accurate and fast as possible after the card turns face-up. 
Click Enter to begin the practice items. 
Ensure that the subject understands that now the stimuli are standard playing cards (no jokers, no 
tricks such as slightly altered cards) and when deciding whether the card in view was shown 
before, color, number, and suit must all be considered before responding. If the subject appears 
confused or responds incorrectly, review the test requirements, including use of the left and right 
mouse button (left button = “No” and right button = “Yes” for responses. 
When the practice items are complete, the instructions for the scored or “real” portion of the test 
appear. 
Say, Have you seen this card before in this task? Cards seen in the practice are not used again. 
You are now going to do the real test. 
Click Enter to begin the scored items. 
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Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
If the subject appears confused, offer a single prompt. Say, Have you seen this card before in 
this task? 
When presentation of items is complete, OCLT ends and the Groton Maze Learning Test begins 
automatically. 
Groton Maze Learning Test (GMLT) 
Test administrators should expect to provide active assistance to subjects during the practice 
portions of this test, as it is somewhat complex. In brief, subjects must find a hidden pathway in 
a grid of tiles. The practice portion involves a small grid, presented three times, and each time 
the subject must try to find the same hidden pathway. 
The scored portion involves a larger grid, presented five times, and each time the subject must 
try to find the same hidden pathway within the larger grid. 
Say, Find the hidden pathway. This is a practice to help you learn the rules of this maze. To 
begin, you must tap the top left blue tile, and then find the hidden pathway by tapping on tiles 
one at a time until you get to the tile in the lower right corner. The first time you try to find the 
pathway, you need to guess each step. A green tick means you were correct, but a red cross 
means the move was wrong. After a wrong move, you need to go back to the last correct tile, 
and then try a move in a different direction. The rules of this task are: 
1. Only move to adjacent tiles (up, down, left, or right). 
2. Do not move diagonally. 
3. Do not move backwards along the pathway. 
4. Do not tap twice on the same tile. 
Tap as quickly and accurately as you can. 
Click Enter to begin the practice maze. 
If the subject appears confused or responds incorrectly, review the four rules, including, if 
needed, that the blue tile is the starting point and that after a red cross, go back to the last correct 
tile (green tick), click it, and try a move in a different direction. 
When the target is reached, a new grid appears (the pathway is the same, however). 
Say, You must now find the same hidden pathway. To begin, tap the top left blue tile, and then 
tap on the hidden pathway one tile at a time until you get to the target tile. The rules are the 
same as before. Tap as quickly and accurately as you can. 
If the subject appears confused or responds incorrectly, review the four rules, including, if 
needed, that the blue tile is the starting point and that after a red cross, go back to the last correct 
tile (green tick), click it, and try a move in a different direction. When the target is reached, a 
new grid appears (the pathway is the same, however). 
This process occurs for a total of three practice maze trials, after which the instructions appear 
once again. 
If the subject appears to be rushing and moving along the pathway so fast that gridlines are being 
clicked (in other words, insufficient care or time is taken to position the mouse pointer within a 
tile before clicking), remind the subject not to rush and to work carefully. If grout lines are 
clicked, the computer doesn’t know which tile is selected and so will score the click (move) as an 
error. 
When the instructions screen appears, say, Find the hidden pathway. You are now going to do 
the real test. To begin, you must tap the top left blue tile, and then find the hidden pathway by 
tapping on tiles one at a time until you get to the tile in the lower right corner. The first time 
you try to find the pathway, you need to guess each step. A green tick means you were correct, 
Page 55 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
but a red cross means the move was wrong. After a wrong move, you need to go back to the 
last correct tile, and then try a move in a different direction. The rules of this task are: 
1. Only move to adjacent tiles (up, down, left, or right). 
2. Do not move diagonally. 
3. Do not move backwards along the pathway. 
4. Do not tap twice on the same tile. 
Tap as quickly and accurately as you can. 
Click Enter to begin the maze. Do not review task rules during the scored portions of the test. If, 
during the real test, subjects ask you to review the instructions because they forgot them or don’t 
know what to do, or ask you to clarify something, say, “The rules won’t let me help you.” 
Encourage subjects to do their best. Encourage them to guess if they aren’t sure of the correct 
next move. 
When the target is reached, a new grid appears (the pathway is the same, however). This process 
occurs for a total of five scored maze trials. 
Say, You must now find the same hidden pathway. To begin, tap the top left blue tile, and then 
tap on the hidden pathway one tile at a time until you get to the target tile. The rules are the 
same as before. Tap as quickly and accurately as you can. 
Click Enter to begin. 
When GMLT is finished, the subject receives a cheer. 
The CogState tests are complete. 
© 2009 CogState Limited. (The above instructions script was edited slightly for clarity.) 
 
 
Page 56 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
ATTACHMENT 3: MDASI-BT 
 
 
 
Page 57 of 58 
 


Protocol name: Repeat Radiation, Minocycline and Bevacizumab in Patient s with Recurrent Glioma 
Version Date: 12/03/2015 
Principal Investigator:  Adam Cohen, MD 
 
  
 
Page 58 of 58