Conditions: Recurrent Glioblastoma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 23
Healthy volunteers: no

Brief summary:
This study of DSF-Cu in combination with TMZ for recurrent GBM will evaluate the antitumor effect in patients who have recurrent GBM. Patients will take DSF-Cu daily during their routine standard of care with TMZ therapy for approximately 6 months. Patients will be evaluated for response every 8 weeks. Patients will be followed up 2 years after the last dose of DSF-Cu.

Detailed description:

Arms:
arm 1: Disulfiram/copper (oral capsules) dosed 80 mg/1.5 mg three times a day for approximately 6 months.

Interventions: intervention 1: Disulfiram/Copper intervention 2: Temozolomide (TMZ)
Intervention descriptions: intervention 1: Disulfiram/copper gluconate is taken three times a day. intervention 2: TMZ is given per standard of care

Protocol document:
Prot_SAP_001.pdf: 
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A Phase II Study of Disulfiram and Copper to Re-sensitize Temozolomide-Resistant 
Glioblastoma to Temozolomide 
 
Protocol#:  Pending 
Version Date: 05/28/16 
 
Principal Investigator:  
Jiayi Huang, M.D. 
Washington University School of Medicine 
Department of Radiation Oncology 
4921 Parkview Place // Box 8224 
St. Louis, MO 63110 
 
Telephone: 314-362-8516 // Fax: 314-747-9557 
Email: jhuang@radonc.wustl.edu 
 
 
 
 
 
 
 
 
 
 
Sub-Investigators 
 
Institution 
 
 
Department 
Jian Campian M.D., Ph.D.  
Washington University 
 
Medical Oncology (Med Onc Co-chair) 
Albert Kim, M.D., Ph.D.  
Washington University 
 
Neurosurgery (Neurosurgery Co-Chair) 
George Ansstas, M.D. 
 
Washington University 
 
Medical Oncology 
Amit Gujar, Ph.D. 
 
Washington University 
 
Neurosurgery 
Christina Tsien, M.D. 
 
Washington University 
 
Radiation Oncology 
Craig Lockhart 
 
 
Washington University 
 
Medical Oncology 
Todd DeWees, Ph.D. 
 
Washington University 
 
Biostatistics/Radiation Oncology 
 
 
 
 
 
 
 
 
IND #: 
 
 
Pending 
ClinicalTrials.gov #:  
Pending 
 
CONFIDENTIAL 
The information contained in this document is regarded as confidential and, except to the extent necessary to obtain 
informed consent, may not be disclosed to another party unless law or regulations require such disclosure.  Persons to 
whom the information is disclosed must be informed that the information is confidential and may not be further disclosed 
by them 
 
 


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Table of Contents (Stephanie, this needs to be fixed) 
1.1 
Recurrent Glioblastoma.................................................................................................... 7 
1.2 
Re-sensitizing Glioblastoma to Temozolomide ............................................................... 7 
1.3 
Preclinical Data of Disulfiram for Temozolomide Sensitization ..................................... 8 
1.4 
Clinical Trial of Repurposing Disulfiram for GBM....................................................... 12 
1.5 
Drug Metabolism and Pharmacokinetics ....................................................................... 12 
1.6 
Toxicology and Safety ................................................................................................... 13 
1.7 
Disulfiram Dosing and Copper Administration ............................................................. 15 
1.8 
Study Rationale .............................................................................................................. 15 
2.0 
OBJECTIVES .................................................................................................................... 16 
2.1 
Primary Objective .......................................................................................................... 16 
2.2 
Secondary Objectives ..................................................................................................... 16 
3.0 
PATIENT SELECTION .................................................................................................... 16 
3.1 
Inclusion Criteria ............................................................................................................ 16 
3.2 
Exclusion Criteria ........................................................................................................... 17 
3.3 
Inclusion of Women and Minorities............................................................................... 18 
4.0 
TREATMENT PLAN ........................................................................................................ 18 
4.1 
Pretreatment Evaluation ................................................................................................. 18 
4.2 
Disulfiram and Copper Dosing ...................................................................................... 18 
4.3 
Temozolomide Dosing ................................................................................................... 18 
4.4 
Study Evaluations ........................................................................................................... 19 
4.5 
General Concomitant Medication and Supportive Care Guidelines .............................. 20 
4.6 
Women of Childbearing Potential .................................................................................. 21 
4.7 
Duration of Therapy ....................................................................................................... 21 
4.8 
Duration of Follow-up .................................................................................................... 22 
5.0 
RESPONSE ASSESSMENT ............................................................................................. 22 
5.1 
Evaluation of Best Overall Response ............................................................................. 24 
5.2 
Duration of Response ..................................................................................................... 25 
5.3 
Neurological Exam and Performance Status .................................................................. 25 
5.4 
Progression-Free Survival .............................................................................................. 26 
6.0 
DOSE MODIFICATIONS ................................................................................................ 26 
6.1 
Temozolomide Dose Modifications ............................................................................... 26 
6.2 
Disulfiram Dose Modifications ...................................................................................... 26 
7.0 
REGULATORY AND REPORTING REQUIREMENTS ............................................... 26 
7.1 
Adverse Events (AEs) .................................................................................................... 26 
7.2 
Unanticipated Problems ................................................................................................. 27 
7.3 
Noncompliance............................................................................................................... 27 
7.4 
Serious Noncompliance.................................................................................................. 27 
7.5 
Protocol Exceptions........................................................................................................ 27 


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7.6 
Reporting to the Human Research Protection Office (HRPO) and the Quality Assurance 
and Safety Monitoring Committee (QASMC) at Washington University ................................ 28 
7.7 
Reporting to the FDA ..................................................................................................... 28 
7.8 
Timeframe for Reporting Required Events .................................................................... 29 
8.0 
PHARMACEUTICAL INFORMATION .......................................................................... 29 
8.1 
Disulfiram....................................................................................................................... 29 
9.0 
STUDY CALENDAR ....................................................................................................... 32 
10.0 DATA SUBMISSION SCHEDULE ................................................................................. 32 
11.0 STATISTICAL CONSIDERATIONS............................................................................... 33 
11.1 Definition of Primary Endpoint and Analytical Plan ..................................................... 33 
11.2 Definition of Secondary Endpoints and Analytical Plans .............................................. 33 
12.0 REFERENCES .................................................................................................................. 34 
APPENDIX A: Karnofsky Performance Status Scale .................................................................. 38 
APPENDIX B: NYHA Classification of Cardiac Disease ............ Error! Bookmark not defined. 
APPENDIX C: Concurrent Disulfiram and Copper Medication Diary ........................................ 39 
APPENDIX D: Concurrent Temozolomide Medication Diary .................................................... 40 
 
Glossary of Abbreviations 
Stephanie, can you insert this section: 
FDA 
GBM 
RT 
TMZ 
ORR 
WHO 
BVZ 
CCNU 
OS 
MGMT 
OBG 
PFS 
ORR 
PFS6 
DSF 
Cu 
ALDH 
GSC 
DDTC 
Me-DDTC 
MRI 
RANO 
AST 
ALT 


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ULN 
FLAIR 
CR 
PR 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SCHEMA 
 
 
 
 
 
Abbreviations: GBM = glioblastoma multiforme, TMZ = temozolomide, DSF = disulfiram, Cu = copper gluconate, 
PO = by mouth, TID = three time a day. 


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1.0 
BACKGROUND AND RATIONALE 
 
1.1 
Recurrent Glioblastoma 
 
Glioblastoma (GBM, World Health Organization/WHO grade IV) is the most common 
malignant primary brain tumor and one of the most devastating cancers (Johnson and 
O'Neill 2012). Between 2004 and 2007, there were 37,690 patients newly diagnosed with 
GBM, with an estimated incidence rate of 3 cases per 100,000 people in the United States 
(Ostrom, et al. 2014). The current standard of care for GBM includes maximal safe 
resection followed by radiotherapy (RT) and temozolomide (TMZ). However, despite 
optimal multi-modality therapy, median progression-free survival (PFS) is less than 7 
months, and median overall survival (OS) is less than 15 months (Stupp, et al. 2005). 
Effective treatment for recurrent GBM is even more dismal. A meta-analysis of 8 phase 
II studies of different cytotoxic drugs or cytostatic agents on recurrent GBM showed 
objective response rate (ORR, including both complete response and partial response) of 
6%, median progression-free survival (PFS) of 9 weeks, and PFS at 6 months (PFS6) of 
15%. Based on remarkable radiological response from two single-arm, non-comparative 
phase II studies, bevacizumab (BVZ), an anti-angiogenesis antibody, was approved by 
the Food and Drug Administration (FDA) for the treatment of recurrent GBM (Friedman, 
et al. 2009; Kreisl, et al. 2009). However, the duration of response is relatively short with 
median PFS of 3-4 months and OS of 7-9 month (Piccioni, et al. 2014). A recent 
randomized study (EORTC 26101) showed that the addition of BVZ to lomustine 
(CCNU) improved PFS but failed to improve OS as compared to CCNU alone (Wilk, et 
al. 2015). Previously, two large randomized studies also showed that the addition of BVZ 
to standard RT and TMZ failed to improve OS (Chinot, et al. 2014; Gilbert, et al. 2014). 
Altogether, these data confirm that the radiological response from BVZ does not 
accurately reflect its anti-tumor effect and challenges the current prevalent approach of 
testing BVZ-based combination therapies in clinical studies for recurrent GBM. 
Therefore, a novel agent is desperately needed for recurrent GBM and should be ideally 
tested without BVZ in future trials. 
 
1.2 
Re-sensitizing Glioblastoma to Temozolomide 
 
Currently, TMZ represents the only systemic therapy that has been shown to improve 
OS for GBM (Stupp, et al. 2005). If GBM recurs after at least a 2 month interval from 
discontinuing TMZ, re-challenging with TMZ has demonstrated promising results 
(Perry, et al. 2010). Another phase II study attempted to re-sensitize recurrent TMZ-
resistant GBM (those who would recur while receiving TMZ or within 2 months of the 
last treatment of TMZ) using an O6-methylguanine-DNA methyltransferase (MGMT) 
inhibitor called O6-benzylguanine (OBG) (Quinn, et al. 2009). Since MGMT is an 
enzyme that repairs DNA damage by alkylating agents such as TMZ, a MGMT inhibitor 
is thought to be a rational agent to re-sensitize GBM to TMZ. Unfortunately, 
combination of OBG and TMZ did not show any evidence of significant re-sensitization: 
ORR of 3% (95% CI: 0-15%), PFS6 of 9% (95% CI: 2-21%), and median PFS of 7.5 
weeks (95% CI: 4.2-7.9 weeks) (Quinn, et al. 2009). 


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1.3 
Preclinical Data of Disulfiram for Temozolomide Sensitization 
 
Disulfiram (DSF) is a FDA-approved oral medication that has been used for treating 
alcoholism since 1951. It inhibits aldehyde dehydrogenase (ALDH), which leads to 
accumulation of acetaldehyde in the blood after ingestion of alcohol. It has well-known 
safety profile for up to 3000 mg per day in the absence of alcohol consumption and has 
been shown to readily cross the blood-brain barrier (Faiman, et al. 1978; Suh, et al. 2006). 
Multiple preclinical in vitro studies have demonstrated promising activity against GBM 
cells (Hothi, et al. 2012; Liu, et al. 2012; Lun, et al. 2016; Triscott, et al. 2012). Specifically, 
two independent high-throughput drug screening studies have identified DSF with potent 
and selective activity against large panels of patient-derived glioma stem-like cells (GSCs, 
a subset of GBM tumor cells that have been shown to be more resistant to RT and 
chemotherapy) (Hothi, et al. 2012; Lun, et al. 2016).  
 
1.3.1 In Vitro Data of Disulfiram for Temozolomide Sensitization 
 
In addition to promising cytotoxicity against GBM cells, DSF has also appeared to 
synergize with TMZ.  Triscott et al. showed that DSF is active against TMZ-resistant GBM 
cell lines and provided synergistic activity when combined with TMZ. As seen in Figure 
1, DSF remarkably sensitized GBM cells that were relatively resistant to TMZ treatment 
(Triscott, et al. 2012).  
 
 
 
Using low passage patient-derived GBM cells, Dr. Francis Ali-Osman at Duke University 
observed that copper (Cu) could significantly enhance the cytotoxicity of DSF (Figure 2A-
B) and confirmed that the DSF-Cu combination could dramatically increase the sensitivity 
of GBM cells to TMZ (Figure 2C-D) (personal communications).  
 


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


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


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


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increase DNA damage (Lun, et al. 2016). These data suggest that the mechanism of DSF 
against GBM may be multi-factorial and may be more likely to overcome TMZ-resistance 
than a pure MGMT inhibitor such as OBG.   
 
1.4 
Clinical Trial of Repurposing Disulfiram for GBM 
 
Washington University has previously completed a phase I, dose-escalation 
pharmacodynamic study of DSF in combination with adjuvant TMZ for newly diagnosed 
GBM after standard RT and concurrent TMZ. The study has determined that the maximum 
tolerated dose (MTD) of DSF with adjuvant TMZ is 500 mg per day. Dose-limiting 
toxicities of delirium and ataxia occurred at dose of 1000 mg per day within the first month 
of administration. The combination of 500 mg of DSF with adjuvant TMZ had an 
acceptable safety profile but was associated with reversible neurological toxicities of 
delirium, ataxia, and neuropathy after prolonged use. The median PFS with RT plus 
concurrent TMZ followed by 500 mg of DSF and adjuvant TMZ was promising at 8.1 
months (Huang, et al. 2016). In comparison, previous randomized studies showed 
onlymedian PFS of 5.5 to 7.3 months with adjuvant TMZ alone after chemoradiotherapy 
(Gilbert, et al. 2014; Gilbert, et al. 2013; Stupp, et al. 2005). However, as the relative 
contributions of RT and TMZ cannot be distinguished from Washington University’s 
previous phase I study, single-agent efficacy of DSF cannot be clearly defined. A logical 
next step would be to test DSF and Cu against recurrent TMZ-resistant GBM to elucidate 
their single-agent efficacy and their potential for TMZ re-sensitization.  
 
1.5 
Drug Metabolism and Pharmacokinetics 
 
After oral ingestion, DSF is partially reduced to diethyldithiocarbamate (DDTC) in the 
acidic stomach, which in turn forms a complex with Cu to form Cu(DDTC)2. Both the 
parent DSF and Cu(DDTC)2 are absorbed through the gastrointestinal tract. Generally, 
more than 80% of an oral dose is absorbed. Enteric formulation and oil may enhance 
absorption. After absorption, DSF is again reduced to DDTC and then Cu(DDTC)2. 
Downstream 
metabolites 
also 
include 
diethylamine, 
carbon 
disulfide, 
diethyldithiomethylcarbamate (Me-DDTC), and glucuronic acid of DDTC. Me-DDTC is 
biotransformed into active inhibitors of ALDH (Johansson 1992). Experiments with 
radiolabeled DSF have shown distribution in the blood, liver, kidney, heart, adrenal gland, 
thyroid, pancreas, testes, spleen, marrow, muscles, and, most importantly, brain (Faiman, 
et al. 1978).  
 
Previous pharmacokinetic studies were done on alcoholic patients after either single dose 
or repeated doses for 12 consecutive days. Apparent half-lives of DSF, DDTC, and Me-
DDTC were 7.3, 15.5, and 22.1 hours, respectively. Average time to reach maximal plasma 
concentration was 8-10 hours for DSF and its metabolites. The mean peak plasma 
concentrations of DSF and Me-DDTC were 1.3 nM and 4.7 nM, respectively. However, 
there was marked inter-subject variability in the plasma concentrations (Faiman, et al. 
1984; Jensen, et al. 1982). Doses as low as 100 mg of DSF could produce detectable plasma 
concentrations of Me-DDTC and complete blockade of ALDH activity in erythrocytes 


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(Johansson, et al. 1991). As seen in Figure 1, three daily doses of DSF will allow for DSF 
and its metabolites to reach steady state. 
 
Figure 1: Predicted pharmacokinetic profile of DSF and its metabolites (DDTC & Me-DDTC) 
 
 
The metabolites of DSF are mainly excreted via kidneys, feces, and the lungs. Up to 20% 
of an oral dose may not be absorbed and thus excreted in the feces. About 65% is eliminated 
through the kidneys, mostly as the glucuronide of DDTC and inorganic sulfates. The 
metabolite carbon disulfide is mostly eliminated via the lungs (Johansson 1992).  
 
In the blood, both DSF and Me-DDTC are mostly bound to albumin, with average binding 
percentages of 96 and 80% over the ranges 200-800 and 345-2756 nM, respectively. The 
average number of binding sites was approximately one for both substances, suggesting a 
single binding site for both. The average association constants were 7.1 x 104 and 6.1 x 103 
M-1, respectively. Therefore, patients with impaired protein synthesis and decreased 
albumin levels may have considerably different plasma concentration of DSF and its 
metabolites. Both DSF and Me-DDTC are also very lipophilic, with Log P (octanol-water 
partition coefficient) of 2.81 and 1.85, respectively (Johansson 1990), which support their 
ability to cross the blood brain barrier.  
 
1.6 
Toxicology and Safety 
 
DSF has been used clinically for more than 50 years, so its safety profile is well known.  
Early toxicology studies done in mice, rats, dogs, and rabbits have shown that DSF has 
very low toxicity, with LD50 between 1.8-10g/kg when administered orally. At those 
extreme doses, demyelination of brain and spinal cord was observed on histopathology 
(Child and Crump 1952). Interestingly, long-term administration of high doses of DSF to 
rats did not induce any laboratory or histological signs of liver damage (Milandri, et al. 
1980). High doses of DSF (up to 6 g daily) are relatively nontoxic in humans. Symptoms 
of overdose include vomiting, headache, apathy, ataxia, motor restlessness, irritability, 


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hallucinations, psychosis, loss of consciousness and convulsions. Death occurs by 
respiratory arrest, preceded by ascending paralysis, and pathological lesions are seen in the 
liver, spleen, kidney and CNS, with congestion in the adrenal gland and edema in the heart 
muscle.   
 
The current FDA-recommended dose of DSF is 250-500 mg daily for alcohol abstinence. 
In early clinical practice, a much higher dose of 1000-3000 mg per day was used (Fuller 
and Gordis 2004).  At high dosages, the DSF-ethanol reaction may be severe and even 
fatal, but such high dosage in the absence of alcohol is well tolerated. In the early 1950s, 4 
patients (out of an estimated 11,000 patients prescribed high doses of DSF) died of sudden 
respiratory or cardiovascular causes likely related to the DSF-ethanol reaction (Jacobsen 
1952). At such high dosages, there were also case reports of psychosis in the absence of 
alcohol ingestion (Guild and Epstein 1951; Martensen-Larsen 1951). A phase I study 
administered a single dose of oral DSF prior to cisplatin every 3 weeks and encountered 
dose-limiting reversible confusion at 3000 mg/m2 (approximately 4800 mg) (Stewart, et al. 
1987). High doses of DSF may inhibit cerebrospinal dopamine B-hydroxylase (Nilsson, et 
al. 1987), and people with very low activity of dopamine hydroxylase may be prone to 
transient psychosis with such inhibition (Major, et al. 1979). In another phase I study of 
non-metastatic recurrent prostate cancer patients treated with 250-500 mg of DSF alone, 
grade 3 toxicities included double vision, hearing loss, LFT abnormality, diarrhea, 
constipation, and ataxia (Schweizer, et al. 2013).  
 
In a previous phase I study of 500-1000 mg DSF in combination with adjuvant TMZ in 
newly diagnosed GBM patients after chemoradiotherapy, grade 2-3 toxicities that were 
attributed to DSF included delirium, ataxia, dizziness, neuropathy, and fatigue (Table 1). 
Higher dose of 1000 mg DSF per day could not be tolerated due to relatively fast onset of 
delirium and ataxia within the first month of therapy. Therefore, it was determined that 500 
mg per day of DSF is the MTD in combination with adjuvant TMZ. However, even at the 
MTD of 500 mg per day, 2 of 7 patients eventually stopped DSF due to possibly DSF-
related toxicity. One patient developed grade 3 delirium after 55 days of DSF; another 
patient developed grade 3 motor neuropathy (lower extremity weakness and foot drop). 
Both toxicities resolved after discontinuing DSF (Huang, et al. 2016).  
 
 
 
Table 1: Possible DSF-related toxicity during Adjuvant TMZ 
Toxicities* 
DSF 500 mg (n=7) 
DSF 1000 mg (n=5) 
Grade 2 Grade 3 
Grade 2 
Grade 3 
Ataxia 
1 (14%) 
0 
2 (40%) 
1 (20%)† 
Delirium 
0 
1 (14%)† 2 (40%) 
2 (40%)§ 
Dizziness 
1 (14%) 
0 
1 (20%) 
0 
Fatigue 
3 (43%) 
0 
1 (20%) 
0 
Peripheral motor neuropathy 
0 
1 (14%)† 1 (20%) 
0 
Peripheral sensory neuropathy 2 (29%) 
0 
1 (20%) 
0 
*Grade 2-3 adverse events according to the Nation Cancer Institute Common Terminology Criteria for 
Adverse Events (NCI-CTCAE) version 4.0 that were possibly or probably related to disulfiram (DSF) and 
that were not present at baseline. 
†Not dose-limiting toxicity (DLT) as occurred after the first month of DSF.  
§Dose-limiting toxicity (DLT) as occurred within the first month of DSF. 
 


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1.7 
Disulfiram Dosing and Copper Administration 
 
Although Washington University’s previous phase I study of DSF in combination with 
adjuvant TMZ established the MTD at 500 mg once per day, continuous administration of 
this dosage over time was associated with reversible delirium or neuropathy that prompted 
discontinuation of therapy in some patients. Furthermore, the pharmacodynamic study 
showed that 500 mg DSF per day (without concurrent Cu) produced limited proteasome 
inhibition on peripheral blood cells, one of the presumed mechanisms against GBM cells. 
Given that Cu has been shown to be essential for DSF’s anti-cancer effects, co-
administration of Cu with DSF may be necessary to maximize its efficacy (Hothi, et al. 
2012; Lun, et al. 2016). A previous phase I study for patients with advanced liver metastasis 
showed that 6 mg of elemental Cu in the form of copper gluconate is well tolerated when 
given with 250 mg of DSF daily. In this study, Cu was given in the morning half hour 
before breakfast, and DSF was given with the evening meals to avoid gastro-intestinal 
irritation from complexation of DSF and Cu in the stomach (Grossmann, et al. 2011). 
Currently, at Washington University, a phase I expansion cohort study is being conducted 
in which patients take 500 mg of DSF every morning along with 2mg of Cu three times a 
day (TID). The combination of DSF and Cu has been well tolerated to date. 
 
A recent double-blinded, randomized phase II study compared chemotherapy with and 
without DSF for metastatic non-small cell lung cancer (Nechushtan, et al. 2015). Patients 
who received concurrent DSF had significantly better PFS and OS than those who received 
chemotherapy alone (5.9 vs. 4.9 months, and 10.0 vs. 7.1 months, respectively). In that 
study, DSF was given at 40 mg TID. In contrast to Washington University’s phase I study, 
Nechushtan et al. did not report any significant neurological toxicity except fatigue. Given 
the half-life of DSF is approximately 7 hours, TID administration may be superior to 
improve its bioavailability and tolerability. By dividing DSF into three doses, it may also 
be more tolerable to take Cu at the same time to optimize its anti-GBM effect. Given the 
above considerations, this phase II study will administer DSF at 80 mg TID together with 
1.5 mg of Cu TID. 
 
1.8 
Study Rationale 
 
Recurrent TMZ-resistant GBM currently lacks any effective treatment. Preclinical studies 
have identified DSF-Cu as having promising activity in GBM cells and can potentially re-
sensitize TMZ-resistant cells to TMZ again. DSF has a well-established safety profile, 
excellent penetration across the blood brain barrier, relatively low cost, and ease of 
administration with an oral formulation. If its activity against GBM is validated, its 
therapeutic and economic impact will be enormous. A recent phase I study has 
demonstrated the feasibility and safety of combining DSF with adjuvant TMZ in newly 
diagnosed GBM patients after chemoradiotherapy (Huang, et al. 2016). A clinical trial of 
continuing TMZ with the addition of DSF-Cu for TMZ-resistant GBM would provide 
valuable single-agent efficacy data regarding DSF and would prospectively validate its 
potential to re-sensitize GBM to TMZ. The results of this study will provide important 
insights on whether further clinical trials for DSF for GBM are warranted or not.  


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2.0 
OBJECTIVES 
 
2.1 
Primary Objective 
 
To determine if treating patients who have TMZ-resistant GBM with DSF-Cu concurrently 
with TMZ would re-sensitize their disease to TMZ. 
 
2.2 
Secondary Objectives 
 
1. To evaluate the safety and tolerability of DSF-Cu administered TID when given 
concurrently with TMZ. 
2. To determine OS of TMZ-resistant GBM patients treated with DSF-Cu in combination 
with TMZ. 
 
 
 
3.0 
PATIENT SELECTION 
 
3.1 
Inclusion Criteria 
 
1. At least 18 years of age. 
 
2. Diagnosis of histologically confirmed GBM (WHO grade IV). Subjects with an 
original histologic diagnosis of low grade glioma or anaplastic glioma (WHO grade II 
or III) are eligible if a subsequent histological diagnosis of GBM is made. 
3. The subject must have completed RT with concurrent TMZ at least 3 months prior to 
the planned start of treatment on this study UNLESS there is pathological verification 
of recurrent GBM and at least 4 weeks have elapsed since the end of RT with concurrent 
TMZ. 
4. Experienced first unequivocal progression of GBM by magnetic resonance imaging 
(MRI) [as assessed via Radiologic Assessment in Neuro-Oncology (RANO) criteria] 
within 3 months from the last dose of TMZ.  
5. Recent resection of recurrent or progressive tumor will be allowed as long as at least 2 
weeks have elapsed from the date of surgery and the subject has recovered from the 
effects of surgery. Evaluable or measurable disease following resection of recurrent 
tumor is mandated for eligibility into the study. 
6. Karnofsky performance status (KPS) of at least 70% (see Appendix A). 
7. Willing to remain abstinent from consuming alcohol while on DSF. 
8. Recovered from the toxic effects of prior therapy to < grade 2 toxicity per NCI CTCAE 
version 4 prior to study registration (except lymphopenia). The minimum duration 
required between prior therapy and initiation of study drug treatment is as follows: 
a. 12 weeks from completion of radiation therapy UNLESS there is histological 
confirmation of tumor recurrence in which case at least 4 weeks from completion 
of RT will suffice 


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b. 4 weeks from prior cytotoxic therapy 
c. 4 weeks from prior experimental drug 
d. 6 weeks from nitrosoureas 
e. 3 weeks from procarbazine 
f. 1 week for non-cytotoxic agents, such as interferon, tamoxifen, and cis-retinoic acid 
9. Meets the following laboratory criteria: 
a. Absolute neutrophil count ≥ 1,000/mcL 
b. Platelets ≥ 75,000/mcL 
c. Hemoglobin > 10.0 g/dL (transfusion and/or ESA allowed) 
d. Total bilirubin and alkaline phosphatase ≤ 2x institutional upper limit of normal 
(ULN) 
e. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) < 3 x ULN 
f. Blood urea nitrogen (BUN) and creatinine < 1.5 x ULN 
10. Able to take oral medication. 
11. Females of childbearing potential (defined as a female who is not menopausal or 
surgically sterilized) must be willing to use an acceptable method of birth control (i.e., 
hormonal contraceptive, intra-uterine device, diaphragm with spermicide, condom with 
spermicide, or abstinence) for the duration of the study.  Should a woman become 
pregnant or suspect she is pregnant while participating in this study, she must inform 
her treating physician immediately. 
12. Able to understand and willing to sign an institutional review board (IRB)-approved 
written informed consent document (legally authorized representative permitted). 
 
3.2 
Exclusion Criteria 
 
1. Radiographic evidence of leptomeningeal dissemination, gliomatosis cerebri, 
infratentorial tumor, or metastatic disease to sites remote from the supratentorial brain. 
2. Enrolled in another clinical trial testing a novel therapy or drug. 
3. Received more than one course of radiation therapy or more than a total dose of 75 Gy. 
Subjects may have received radiosurgery as part of the initial therapy (i.e., in addition 
to one course of radiation therapy); however, the dose used for the radiosurgery counts 
against the total dose limit listed above. 
4. History of allergic reaction to DSF or Cu. 
5. Treatment with the following medications that may interfere with metabolism of DSF: 
warfarin, 
theophylline, 
amitriptyline, 
isoniazid, 
metronidazole, 
phenytoin, 
Phenobarbital, chlorzoxazone, halothane, imipramine, chlordiazepoxide, diazepam. 
(Note: lorazepam and oxazepam are not affected by the P450 system and are not 
contraindicated with DSF). 
6. Active infection including known Acquired Immunodeficiency Syndrome (AIDS) or 
Hepatitis C or with a fever ≥ 38.5°C within 3 days prior to the study enrollment. 
7. Active or severe hepatic disease.  
8. Grade 2 or higher peripheral neuropathy or ataxia per NCI CTCAE version 4. 
9. History of idiopathic seizure disorder schizophrenia, or psychosis unrelated to 
glioblastoma, corticosteroid, or anti-epileptic medications. 
10. History of Wilson’s disease. 
11. History of hemochromatosis. 
Commented [SM1]: Why? 


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12. Pregnant and breastfeeding women will be excluded because of the unknown effect of 
DSF on fetal development (and because of use of temozolomide).  
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this trial. 
 
 
 
4.0 
TREATMENT PLAN 
 
This multi-center study is a single arm, open-label, phase II study of DSF-Cu in combination with 
TMZ for recurrent TMZ-resistant GBM patients after their first relapse from TMZ. 
 
4.1 
Pretreatment Evaluation 
 
Prior to enrollment, patient must have a complete history, physical examination including 
neurological exam, evaluation of performance status using the KPS, assessment of 
corticosteroid usage (mg per day), baseline laboratory studies (CBC, BMP, and LFTs), and 
brain MRI.  A baseline MRI scan must be performed within 21 days prior to registration. 
Women of childbearing potential must have a negative pregnancy test within 14 days of 
initiation of treatment. 
 
 
4.2 
Disulfiram and Copper Dosing 
 
Two study drugs will be provided: disulfiram in 40 mg capsules and copper gluconate in 
1.5 mg capsules. DSF will be given at 80 mg (two capsules) three times daily with meals. 
Copper gluconate will be taken with each dose of DSF at a dose of 1.5 mg (one capsule) to 
improve the potential effect of DSF on GBM tumors. Although Washington University’s 
previous phase 1 study has demonstrated MTD of DSF to be 500 mg per day in combination 
with TMZ, the current protocol uses a TID administration with concurrent Cu, which may 
improve absorption and bioavailability. Thus, the DSF dose will be a total of 240 mg per 
day. If administration of DSF and Cu together causes gastrointestinal discomfort, then Cu 
will be administered 30 minutes before the DSF dose. If a patient misses a dose, s/he should 
be instructed not to make up that dose but should instead resume dosing with the next 
scheduled dose. Patients will be instructed to bring all unused drug and the completed 
medication diary (Appendix B) to each study visit for assessment of compliance. 
 
4.3 
Temozolomide Dosing 
 
TMZ should be continued according to the standard adjuvant dose that the patient has been 
receiving. TMZ will not be provided by the study sponsor. Dosage is typically 150-200 
mg/m2 PO per day on Days 1-5 of every 28-day cycle. If the patient was receiving adjuvant 
TMZ with an experimental agent, only TMZ should be continued. TMZ should be taken at 
bedtime on an empty stomach and should not be taken within one hour of DSF 
Commented [SM2]: Is this really necessary? It may mandate 
additional costly MRI’s. 


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administration. Patients will be instructed to bring their completed medication diary 
(Appendix C) to the study visit for assessment of compliance. 
 
4.4 
Study Evaluations 
 
Consistent with institutional standard of care, patients will be seen approximately every 4 
weeks and typically within 10 days before the start of the next cycle. At each visit, a KPS 
evaluation and corticosteroid usage (mg per day) will be recorded. Brain MRI will be 
obtained every 8 weeks to assess for radiological response. 
 
Patients are evaluated for adverse events for 30 days from the last treatment of DSF-Cu, or 
until death, whichever occurs first. Patients removed from study for unacceptable adverse 
events will be followed until resolution or stabilization of the adverse event.  
 
Table 2: Potential Adverse Events Related to DSF 
MedDRA Term 
Frequency: 
Likely:  greater than 10% 
Less Likely: 1-10% 
Rare: 1% or less 
Neoplasms  
Rare: Tumor necrosis  
Blood and lymphatic 
system disorders  
Rare: Neutropenia, anemia, leukopenia, 
thrombocytopenia, lymphopenia (likely due to TMZ)  
Immune system 
disorders  
Rare: Hypersensitivity  
Metabolism and 
nutrition disorders  
Likely: Alcohol intolerance, metallic or garlic-like 
aftertaste  
Psychiatric disorders  
Less Likely: psychosis, delirium (need to rule out 
tumor progression) 
Nervous system 
disorders  
Likely: Drowsiness, headache, confusion 
Less Likely: ataxia, gait disturbance, peripheral 
neuropathy 
Rare: Extrapyramidal symptoms 
Eye disorders  
Rare: Optic neuritis  
Cardiac disorders  
Less Likely: Tachycardia, hypotension (need to rule 
out DSF-alcohol reaction)  
Respiratory, thoracic, 
and mediastinal 
disorders  
Less Likely: Dyspnea (need to rule out DSF-alcohol 
reaction) 
Gastrointestinal 
disorders  
Likely: Nausea, vomiting, diarrhea 
Less Likely: constipation (likely due to temozolomide)  
Hepatobiliary disorders  Rare: Hepatitis 
Skin and subcutaneous 
tissue disorders  
Less Likely: Allergic dermatitis 
  
Musculoskeletal 
Rare: Arthralgia, myalgia  
Renal and urinary 
disorders  
Rare: Dysuria, hematuria 


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MedDRA Term 
Frequency: 
Likely:  greater than 10% 
Less Likely: 1-10% 
Rare: 1% or less 
Reproductive system 
Less likely: impotence 
General disorders 
Likely: Fatigue 
 
4.5 
General Concomitant Medication and Supportive Care Guidelines 
 
The following medications and procedures are prohibited during the study: 
 Any antineoplastic therapy other than TMZ and DSF  
 Any investigational therapy other than DSF  
 
All other medical conditions or manifestations of the patient’s malignancy should be 
treated at the discretion of the investigator in accordance with local community standards 
of medical care. 
 
Patients should not drive, operate dangerous tools or machinery, or engage in any other 
potentially hazardous activity that requires full alertness and coordination if they 
experience sedation while enrolled in this study. 
 
Patients are to be instructed to abstain from alcohol while enrolled in this study.   
 
4.5.1 Nausea and Vomiting 
 
Prophylactic antiemetic therapy may be used in this study at the discretion of 
treating physician. Because of the potential of benzodiazepines to interact with 
DSF, the use of benzodiazepines for antiemetic prophylaxis should be reserved for 
patients who cannot be satisfactorily managed otherwise.   
 
4.5.2 Diarrhea 
 
Antidiarrheal medications will not be used prophylactically; however, patients will 
be instructed to take loperamide, 4 mg, at the occurrence of the first loose stool and 
then 2 mg every 2 hours until they are diarrhea-free for at least 12 hours.  During 
the night, patients may take 4 mg of loperamide every 4 hours.  Fluid intake should 
be maintained to avoid dehydration. 
 
4.5.3 Central Nervous System Effects 
 
Doses of 500-1000 mg of DSF per day with adjuvant TMZ produced neurological 
toxicities in some patients, including delirium/psychosis, ataxia, and peripheral 
neuropathy, especially at the 1000 mg dose. Patients should be carefully monitored 
for early signs of these symptoms. Once other causes such as tumor progression are 
ruled out, dose reduction of DSF to 40 mg (one capsule) three times daily should 
be considered if the toxicity is grade 2 or greater (refer to Section 6.2). If symptoms 


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are not improving with dose reduction, DSF should be discontinued. Patients whose 
symptoms are not considered immediately life-threatening should be carefully 
monitored. Each patient may be approached individually with a systematic 
assessment to rule out other causes. Appropriate tests may include vital signs 
measurement, computerized tomography, MRI scans, or other appropriate medical 
assessment.  
 
If the patient’s level of consciousness is considered to be life-threatening, the 
patient should be hospitalized and necessary measures should be instituted to secure 
the airway, ventilation, and intravenous access. 
 
4.5.4 Management of Disulfiram-Alcohol Reaction 
 
In severe reactions caused by the patient's excessive ingestion of alcohol, 
supportive measures to restore blood pressure and treat shock should be instituted. 
Other recommendations include: oxygen, carbogen (95% oxygen and 5% carbon 
dioxide), vitamin C intravenously in massive doses (1 g), and ephedrine sulfate. 
Antihistamines have also been used intravenously. Potassium levels should be 
monitored, particularly in patients on digitalis, since hypokalemia has been 
reported. 
 
4.6 
Women of Childbearing Potential 
 
Women of childbearing potential (defined as women with regular menses, women with 
amenorrhea, women with irregular cycles, women using a contraceptive method that 
precludes withdrawal bleeding, or women who have had a tubal ligation) are required to 
have a negative serum pregnancy test within 14 days prior to the first dose of the study 
treatment.   
 
Female and male patients (along with their female partners) are required to use a method 
of acceptable contraception, including one barrier method, during participation in the study 
and for 4 months following the last dose of study treatment.  
 
If a patient is suspected to be pregnant, study treatment should be immediately 
discontinued.  In addition a positive urine test must be confirmed by a serum pregnancy 
test.  If it is confirmed that the patient is not pregnant, the patient may resume treatment. 
 
If a female patient or female partner of a male patient becomes pregnant during therapy or 
within 4 months after the last dose of study treatment, the investigator must be notified in 
order to facilitate outcome follow-up. 
 
4.7 
Duration of Therapy 
 
If at any time the constraints of this protocol are considered to be detrimental to the 
patient’s health and/or the patient no longer wishes to continue protocol therapy, the 


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protocol therapy should be discontinued and the reason(s) for discontinuation documented 
in the case report form. 
 
In the absence of treatment delays due to adverse events, DSF treatment may continue 
until: 
 
 Documented and confirmed disease progression 
 Death 
 Adverse event(s) that, in the judgment of the investigator, may cause severe or 
permanent harm or which rule out continuation of study drug 
 General or specific changes in the patient’s condition render the patient 
unacceptable for further treatment in the judgment of the investigator 
 Suspected pregnancy 
 Serious noncompliance with the study protocol 
 Lost to follow-up 
 Patient withdraws consent 
 Investigator removes the patient from study 
 The sponsor (Cantex), the investigator, or the investigator’s institution decides to 
close the study 
 
In the case of tumor progression, both TMZ and DSF-Cu should be discontinued, and 
patient should be considered for second-line therapy. If TMZ is temporarily withheld due 
to toxicity, DSF-Cu should be continued until TMZ may be resumed again. If TMZ is 
discontinued, DSF-Cu may be continued as per the discretion of the treating physician. If 
DSF-Cu is discontinued due to toxicity, TMZ may be continued as per the discretion of the 
treating physician.  
 
4.8 
Duration of Follow-up 
 
Patients are evaluated for adverse events for 30 days after the last dose of DSF-Cu or until 
death, whichever occurs first. Patients removed from study for unacceptable adverse events 
will be followed until resolution or stabilization of the adverse event. Follow-up after the 
conclusion of the study participation will be per routine clinical care.  Two years after the 
patient goes off study, the patient’s chart will be reviewed to collect data on progression 
and survival. 
 
 
5.0 
RESPONSE ASSESSMENT 
 
For the purposes of this study, patients should be evaluated for response every 8 weeks   
 
Response and progression will be evaluated in this study using the updated RANO response assessment 
criteria for high-grade gliomas (Wen, et al. 2010).  
 
Criteria for Determining First Progression Depending on Time from Initial Chemoradiotherapy 


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First Progression 
Definition 
Progressive disease < 12 
weeks after completion of 
chemoradiotherapy 
Progression can only be defined using diagnostic imaging if there is new 
enhancement outside of the radiation field (beyond the high-dose region or 
80% isodose line) or if there is unequivocal evidence of viable tumor on 
histopathologic sampling (eg, solid tumor areas [ie, > 70% tumor cell nuclei 
in areas], high or progressive increase in MIB-1 proliferation index 
compared with prior biopsy, or evidence for histologic progression or 
increased anaplasia in tumor). Note: Given the difficulty of differentiating 
true progression from pseudoprogression, clinical decline alone, in the 
absence of radiographic or histologic confirmation of progression, will not 
be sufficient for definition of progressive disease in the first 12 weeks after 
completion of concurrent chemoradiotherapy.  
Progressive disease ≥ 12 
weeks after 
chemoradiotherapy 
completion 
1. New contrast-enhancing lesion outside of radiation field on 
decreasing, stable, or increasing doses of corticosteroids. 
2. Increase by ≥ 25% in the sum of the products of perpendicular 
diameters between the first post-radiotherapy scan, or a subsequent 
scan with smaller tumor size, and the scan at 12 weeks or later on 
stable or increasing doses of corticosteroids.  
3. Clinical deterioration not attributable to concurrent medication or 
comorbid conditions is sufficient to declare progression on current 
treatment but not for entry onto a clinical trial for recurrence.  
4. For patients receiving antiangiogenic therapy, significant increase 
in T2/FLAIR non-enhancing lesion may also be considered 
progressive disease. The increased T2/FLAIR must have occurred 
with the patient on stable or increasing doses of corticosteroids 
compared with baseline scan or best response after initiation of 
therapy and not be a result of comorbid events (eg, effects of 
radiation therapy, demyelination, ischemic injury, infection, 
seizures, postoperative changes, or other treatment effects).  
 
Criteria for Response Assessment Incorporating MRI and Clinical Factors (Adapted from (Wen, 
et al. 2010). 
Response 
Criteria 
Complete response 
 
Requires all of the following: complete disappearance of all enhancing 
measurable and non-measurable disease sustained for at least 4 weeks. 
 
No new lesions; stable or improved non-enhancing (T2/FLAIR) lesions. 
 
Patients must be off corticosteroids (or on physiologic replacement doses only) 
and stable or improved clinically. Note: Patients with non-measurable disease 
only cannot have a complete response; the best response possible is stable 
disease.  
Partial response 
Requires all of the following:  
 
≥ 50% decrease compared with baseline in the sum of products of 
perpendicular diameters of all measurable enhancing lesions sustained for at 
least 4 weeks. 
 
No progression of non-measurable disease. 


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Response 
Criteria 
 
Stable or improved non-enhancing (T2/FLAIR) lesions on same or lower dose 
of corticosteroids compared with baseline scan; the corticosteroid dose at the 
time of the scan evaluation should be no greater than the dose at time of 
baseline scan. 
 
Stable or improved clinically. Note: Patients with non-measurable disease only 
cannot have a partial response; the best response possible is stable disease.  
Stable disease 
Requires all of the following:  
 
Does not qualify for complete response, partial response, or progression. 
 
Stable non-enhancing (T2/FLAIR) lesions on same or lower dose of 
corticosteroids compared with baseline scan. In the event that the corticosteroid 
dose was increased for new symptoms and signs without confirmation of 
disease progression on neuroimaging, and subsequent follow-up imaging 
shows that this increase in corticosteroids was required because of disease 
progression, the last scan considered to show stable disease will be the scan 
obtained when the corticosteroid dose was equivalent to the baseline dose.  
Progression 
Defined by any of the following:  
 
≥ 25% increase in sum of the products of perpendicular diameters of enhancing 
lesions compared with the smallest tumor measurement obtained either at 
baseline (if no decrease) or best response, on stable or increasing doses of 
corticosteroids*. The absolute increase in any dimension must be at least 5mm 
when calculating the products. 
 
Significant increase in T2/FLAIR non-enhancing lesion on stable or increasing 
doses of corticosteroids compared with baseline scan or best response after 
initiation of therapy* not caused by comorbid events (e.g. radiation therapy, 
demyelination, ischemic injury, infection, seizures, postoperative changes, or 
other treatment effects). 
 
Any new measureable lesion. 
 
Clear clinical deterioration not attributable to other causes apart from the tumor 
(e.g. seizures, medication adverse effects, complications of therapy, 
cerebrovascular events, infection, and so on) or changes in corticosteroid dose. 
 
Failure to return for evaluation as a result of death or deteriorating condition; or 
clear progression of non-measurable disease.  
 
NOTE. All measurable and non-measurable lesions must be assessed using the same techniques as at 
baseline. 
 
Abbreviations: MRI, magnetic resonance imaging; FLAIR, fluid-attenuated inversion recovery. 
 
Stable doses of corticosteroids include patients not on corticosteroids.  
 
5.1 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started).  The patient's best response 
assignment will depend on the achievement of both measurement and confirmation criteria. 
 
Summary of the RANO Response Criteria (Adapted from (Wen, et al. 2010). 


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Criterion 
CR 
PR 
SD 
PD 
T1 gadolinium 
enhancing disease 
None 
≥ 50% ↓ 
< 50% ↓ but < 25% 
↑ 
≥ 25% ↑* 
T2/FLAIR 
Stable or 
↓ 
Stable or 
↓ 
Stable or ↓ 
↑* 
New lesion 
None 
None 
None 
Present* 
Corticosteroids 
None 
Stable or 
↓ 
Stable or ↓ 
NA† 
Clinical status 
Stable or 
↑ 
Stable or 
↑ 
Stable or ↑ 
↓* 
Requirement for 
response 
All 
All 
All 
Any* 
Abbreviations: RANO, Response Assessment in Neuro-Oncology; CR, complete response; PR, partial 
response; SD, stable disease; PD, progressive disease; FLAIR, fluid-attenuated inversion recovery; NA, not 
applicable.  
* Progression occurs when this criterion is present.  
† Increase in corticosteroids alone will not be taken into account in determining progression in the absence 
of persistent clinical deterioration.  
NOTE: Patients may continue on treatment and remain under close observation and evaluation at 4-8 week 
intervals if there is uncertainty regarding whether pseudoprogression may be present as determined by the 
investigators. If subsequent radiographic or clinical assessments suggest that the patient is in fact 
experiencing progression, then the date of progression should be the time point at which this issue was first 
raised.  Similarly, stable disease may be assigned in cases of presumed “pseudoprogression” associated with 
decreased steroid use. 
 
5.2 
Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for complete response (CR) or partial response (PR) 
(whichever is first recorded) until the first date that recurrent or progressive disease is 
objectively documented (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met 
for CR until the first date that progressive disease is objectively documented. 
 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment 
until the criteria for progression are met, taking as reference the smallest measurements 
recorded since the treatment started, including the baseline measurements.  
 
5.3 
Neurological Exam and Performance Status  
 
Patients will be graded using the KPSscale and their neurological function evaluated as 
improved, stable or deteriorated in addition to objective measurement of tumor size. These 
parameters will be used to determine the overall response assessment. 
 


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5.4 
Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression or 
death, whichever occurs first. 
 
 
6.0 
DOSE MODIFICATIONS 
 
6.1 
Temozolomide Dose Modifications 
 
TMZ dosage modification is at the discretion of treating physician as per routine clinical care. 
 
6.2 
Disulfiram Dose Modifications 
 
If a patient experiences any grade 2 or higher non-hematologic toxicity considered by the 
investigator to be possibly, probably, or definitely related to DSF, the dose of DSF may be 
decreased by 50% (i.e., from 80 mg TID to 40 mg TID) once. Special attention should be 
paid to neurological symptoms such as delirium/psychosis, gait disturbance/ataxia, and 
peripheral neuropathy. A grade 2 toxicity of the above neurological symptoms should 
prompt a consideration for further work-up and dose reduction. No second dose reduction 
is allowed—if a second dose reduction is required, DSF and Cu will be discontinued and 
the patient will be taken off study. Of note, hematologic toxicity is uncommon for DSF and 
is likely related to TMZ. 
 
6.2.1 Administration of DSF to Patients with Abnormal Hepatic Function 
 
DSF-Cu should only be administered if hepatic function is within the parameters 
established in the eligibility criteria. Hepatic toxicity from DSF-Cu is uncommon 
but may occur. Therefore, hepatic dysfunction that occurs while the patient is on 
study should prompt an evaluation to determine the cause, including the possibility 
of hepatotoxicity from concurrent medications.  
 
6.2.2 Hypersensitivity Reactions  
 
Hypersensitivity reactions rarely occur. If they do occur, minor symptoms such as 
flushing, skin reactions, dyspnea, lower back pain, hypotension, or tachycardia may 
require no intervention; however, severe reactions, such as hypotension requiring 
treatment, dyspnea requiring bronchodilators, angioedema, or generalized urticaria 
require immediate discontinuation of study drug administration and aggressive 
symptomatic therapy. Patients who experience a severe hypersensitivity reaction to 
DSF should discontinue DSF immediately and not be re-challenged.    
 
 
7.0 
REGULATORY AND REPORTING REQUIREMENTS 
 
7.1 
Adverse Events (AEs) 


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Definition: any unfavorable medical occurrence in a human subject including any 
abnormal sign, symptom, or disease. 
 
Grading: the descriptions and grading scales found in the revised NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for all 
toxicity reporting.  A copy of the CTCAE version 4.0 can be downloaded from the CTEP 
website: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
Attribution (relatedness), Expectedness, and Seriousness: the definitions for the terms 
listed that should be used are those provided by the Department of Health and Human 
Services’ Office for Human Research Protections (OHRP).  A copy of this guidance can 
be found on OHRP’s website: 
http://www.hhs.gov/ohrp/policy/advevntguid.html 
 
7.2 
Unanticipated Problems 
 
Definition: 
 
 unexpected (in terms of nature, severity, or frequency) given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document; and (b) the 
characteristics of the subject population being studied; 
 related or possibly related to participation in the research (in this guidance 
document, possibly related means there is a reasonable possibility that the incident, 
experience, or outcome may have been caused by the procedures involved in the 
research); and 
 suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized. 
 
7.3 
Noncompliance 
 
Definition: failure to follow any applicable regulation or institutional policies that govern 
human 
subjects 
research 
or 
failure 
to 
follow 
the 
determinations 
of 
the 
IRB.  Noncompliance may occur due to lack of knowledge or due to deliberate choice to 
ignore regulations, institutional policies, or determinations of the IRB. 
 
7.4 
Serious Noncompliance 
 
Definition: noncompliance that materially increases risks, that results in substantial harm 
to subjects or others, or that materially compromises the rights or welfare of participants. 
 
7.5 
Protocol Exceptions 
 


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Definition: A planned deviation from the approved protocol that are under the research 
team’s control. Exceptions apply only to a single participant or a singular situation. 
 
Protocol exceptions are not expected or encouraged, and should be discussed first with the 
Study Sponsor. 
 
7.6 
Reporting to the Institutional IRB 
 
The PI is required to promptly notify the IRB of the following events: 
 
 Any unanticipated problems involving risks to participants or others which occur 
at WU, any BJH or SLCH institution, or that impacts participants or the conduct of 
the study. 
 Noncompliance with federal regulations or the requirements or determinations of 
the IRB. 
 Receipt of new information that may impact the willingness of participants to 
participate or continue participation in the research study. 
 
These events must be reported to the IRB within 10 working days of the occurrence of the 
event or notification to the PI of the event.  The death of a research participant that qualifies 
as a reportable event should be reported within 1 working day of the occurrence of the 
event or notification to the PI of the event. 
 
 
7.7 
Reporting to the FDA 
 
The conduct of the study will comply with all FDA safety reporting requirements.  
PLEASE NOTE THAT REPORTING REQUIREMENTS FOR THE FDA DIFFER 
FROM REPORTING REQUIREMENTS FOR HRPO/QASMC.  It is the 
responsibility of the investigator to report any unanticipated problem to the FDA as 
follows: 
 
 Report any unexpected fatal or life-threatening adverse experiences associated with 
use of the drug (i.e., there is a reasonable possibility that the experience may have 
been caused by the drug) by telephone or fax no later than 7 calendar days after 
initial receipt of the information.  A life-threatening adverse experience is defined 
as any adverse drug experience that places the subject (in the view of the 
investigator) at immediate risk of death from the reaction as it occurred, i.e., it does 
not include a reaction that, had it occurred in a more severe form, might have caused 
death. 
 Report any serious, unexpected adverse experiences, as well as results from animal 
studies that suggest significant clinical risk within 15 calendar days after initial 
receipt of this information.  A serious adverse drug experience is defined as any 
adverse drug experience occurring at any dose that results in any of the following 
outcomes: 
o Death 


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o A life-threatening adverse drug experience 
o Inpatient hospitalization or prolongation of existing hospitalization 
o A persistent or significant disability/incapacity (i.e., a substantial disruption 
of a person’s ability to conduct normal life functions) 
o A congenital anomaly/birth defect 
o Any other experience which, based upon appropriate medical judgment, 
may jeopardize the subject and may require medical or surgical intervention 
to prevent one of the outcomes listed above 
An unexpected adverse drug experience is defined as any adverse drug experience, 
the specificity or severity of which is not consistent with the current investigator 
brochure (or risk information, if an IB is not required or available). 
 
All MedWatch forms will be sent by Cantex to the FDA at the following address or by fax: 
 
Food and Drug Administration 
Center for Drug Evaluation and Research 
Division of Oncology Drug Products 
5901-B Ammendale Rd. 
Beltsville, MD 20705-1266 
FAX: 1-800-FDA-0178 
 
Secondary sites must submit a completed MedWatch form to Cantex within 4 calendar 
days (for fatal or life-threatening adverse experiences) or 11 calendar days (for serious, 
unexpected adverse experiences).  Cantex will be responsible for submitting all MedWatch 
forms to the FDA within the timeframes specified above. 
 
7.8 
Timeframe for Reporting Required Events  
 
Reportable adverse events will be tracked for 30 days after the last dose of DSF.  
 
 
8.0 
PHARMACEUTICAL INFORMATION 
 
8.1 
Disulfiram 
 
8.1.1 Disulfiram Description 
 
DSF is an alcohol antagonist drug approved by the FDA for the treatment of 
alcoholism. Its powder is white, odorless, and almost tasteless. It is soluble in water 
to the extent of about 20mg in 100mL, and in alcohol to the extent of about 3.8 g 
in 100 mL. 
 
Molecular formula: C10H20N2S4 
Chemical name: bis(diethylthiocarbamoyl) disulfide.  
Molecular weight: 296.54. 
 


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8.1.2 Clinical Pharmacology 
 
DSF is mostly known as an irreversible inhibitor of aldehyde dehydrogenase, which 
affects alcohol metabolism and causes accumulation of acetaldehyde. However, 
increasing preclinical studies have shown that DSF is also a proteasome inhibitor, 
specifically the chymotrypsin-like activity. GBM cells and its stem-like 
subpopulation (also referred to as CSC) may be more susceptible to the effect of 
proteasomal inhibition than normal brain cells.  DSF is very lipophilic and readily 
crosses the blood-brain barrier. 
 
8.1.3 Supplier 
 
DSF will be manufactured and provided by Cantex Pharmaceuticals for the study 
participants.  
 
8.1.4 Dosage Form 
 
DSF is supplied as 40 mg capsules.  
 
8.1.5 Storage and Stability 
 
DSF is dispensed in a tight, light-resistant container. It should be stored at 
controlled room temperature (20° to 25°C or 68° to 77°F) in its original container 
to protect from bright light.  
 
8.1.6 Disulfiram Administration 
 
DSF is taken by mouth three times daily. It should be taken with meals to improve 
absorption. It should not be taken within one hour of TMZ. Patients should not have 
consumed any alcohol at least 12 hours prior to the first dose. In the rare event of a 
severe hypersensitivity reaction, discontinue DSF immediately. 
 
 
9.0 
CORRELATIVE STUDIES 
 
Blood samples will be collected for possible future correlative studies. The correlative studies will 
not be mandated for this protocol. The correlative studies may include assay of inhibition of 
proteasome activity and analysis of gamma-H2AX via Western blot. Approximately 40 mL of 
peripheral blood (10 mL into each of 4 green top tubes containing sodium heparin) will be drawn 
at the baseline, at Week 2 (+2 days/-4 days), and after 1 month of DSF (but before the start of next 
cycle of TMZ). For patients at Washington University, the blood should be submitted at room 
temperature to the laboratory of Albert Kim, M.D, Ph.D. at Washington University. Blood samples 
should be centrifuged at 6600g for 10 min at 4 ºC. Resulting whole blood cell pellets and 
supernatant should then be stored separately at -80 ºC. For other participating institutions outside 
of Washington University, the whole blood cell pellets and supernatant should be prepared as 


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above and then frozen at -80 ºC. The frozen samples can be shipped to Dr. Kim’s laboratory in dry 
ice.  
 
 
 


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10.0 
STUDY CALENDAR 
 
Screening/baseline evaluations are to be conducted within 2 weeks prior to start of protocol 
therapy.  Scans and x-rays must be done no more than 4 weeks prior to the start of the protocol 
therapy.  Each treatment cycle is 28 days. 
 
 
Screening / 
Baseline 
Within 
10 Days 
Before 
Each 
Cycle 
End of Every 
Even-Numbered 
Cycle 
End of 
Treatment 
Follow-
Up1 
Informed consent 
X 
 
 
 
 
H&P incl. neurologic 
exam, KPS 
X 
X 
 
X 
 
Evaluation of 
corticosteroid usage 
X 
X 
 
 
 
CBC 
X 
 
 
 
 
LFTs 
X 
 
 
 
 
Brain MRI 
X 
 
X3 
X 
 
Temozolomide 
 
Days 1-5 of each cycle4 
 
 
Disulfiram 
 
Days 1-28 of each cycle5 
 
 
Copper gluconate 
 
Days 1-28 of each cycle5 
 
 
AE assessment 
X --------------------------------------------------- X6 
 
1. Follow-up will be as clinically indicated.  A chart review will be done at 2 years after the last dose of DSF 
to look for progression and survival. 
2. Women of childbearing potential only. 
3. A confirmatory MRI should be considered in 4-8 weeks after documentation of complete response (CR) or 
partial response (PR) if consistent with the institutional standard of care 
4. To be taken at bedtime on an empty stomach.  Must not be taken within an hour of DSF. 
5. To be taken three times a day with meals. 
6. AEs will be tracked for 30 days after the last dose of DSF. 
 
 
11.0 
DATA SUBMISSION SCHEDULE 
 
Case report forms with appropriate source documentation will be completed according to the 
schedule listed in this section. 
 
Case Report Form 
Submission Schedule 
Original Consent Form 
Prior to registration 
Registration Form 
Eligibility Form 
On-Study Form 
Prior to starting treatment 
Treatment Form 
Every cycle 
Toxicity Form 
Continuous 
Treatment Summary Form 
Completion of treatment 


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Follow Up Form 
Day 30 
Year 2 
Tumor Measurement Form 
Baseline 
End of every even numbered cycle 
End of treatment 
MedWatch Form 
See Section 7.0 for reporting requirements 
 
Any queries generated by Washington University must be responded to within 28 days of receipt 
by the participating site.  The Washington University research team will conduct a regular review 
of data status at all secondary sites, with appropriate corrective action to be requested as needed. 
 
 
 
12.0 
STATISTICAL CONSIDERATIONS 
 
12.1 
Definition of Primary Endpoint and Analytical Plan 
 
The co-primary endpoints will be objective response rate (ORR) and progression-free 
survival at 6 months (PFS6). ORR will be defined as the percentage of patients with 
complete response (CR) or partial response (PR) according to the RANO criteria as 
described in Section 6.0. PFS6 will be defined as proportion of patients that are free from 
progressive disease (PD) as per RANO criteria or death at 6 months from the date of the 
first dose of DSF/Cu. PFS6 and median PFS will be estimated using the Kaplan-Meier 
product-limit method. For recurrent TMZ-resistant GBM, continuing TMZ should yield 
ORR of less than 5% and PFS6 of less than 10% (Quinn, et al. 2009). To justify future drug 
development of DSF for GBM, we hypothesized that the addition of DSF/Cu to TMZ 
would improve ORR to 20% or increase PFS6 to 30%. The sample size is calculated based 
on the above hypotheses with one-sided exact test at an approximate α level of 0.10 and 
80% statistical power.  At these type I and II error rates, 20 patients will detect a proportion 
of patients who have ORR significantly higher than 5% or PFS6 significantly higher 10%. 
Of note, previous phase II study testing addition of OBG (a MGMT inhibitor) to TMZ for 
TMZ-resistant GBM used similar hypothesis and observed a disappointing ORR of 3% and 
PFS6 of 9% (Quinn, et al. 2009). This negative phase II study has detailed information on 
ORR, PFS, and OS as well as associated estimated 95% CIs and will serve as a historical 
comparison for this study.  
 
12.2 
Definition of Secondary Endpoints and Analytical Plans 
 
The secondary endpoints will be toxicity, OS, and pharmacodynamic effect of proteasome 
inhibition. 
 
1. Toxicities that are possibly/probably/definitively related to DSF will be graded by 
NCI CTCAE version 4.0 and will be tabulated by type and grade. 
2. OS will be measured from the date of the first dose of DSF/Cu to the date of death 
or, otherwise, the last follow-up date on which the patient was reported alive. 


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Median OS and OS12 (proportion of patients that are alive at 12 months) will be 
estimated using the Kaplan-Meier product-limit method. 
3. Proteasome inhibition of DSF/Cu will be performed on peripheral blood cells using 
fluorometric 20S proteasome assay as described in section 10.0. They will be 
normalized to the baseline activity and reported as mean and SD (standard error). 
4. Gamma-H2AX expression, a marker of DNA damage, will be analyzed by Western 
blot. The expression level will be normalized to the baseline activity and reported 
as mean and SD.  
 
 
13.0 
REFERENCES 
REFERENCES 
 
Chen, D., et al. 
 
2006 Disulfiram, a clinically used anti-alcoholism drug and copper-binding agent, 
induces apoptotic cell death in breast cancer cultures and xenografts via inhibition of the 
proteasome activity. Cancer Res 66(21):10425-33. 
Child, G. P., and M. Crump 
 
1952 The toxicity of tetraethylthiuram disulphide (antabuse) to mouse, rat, rabbit and 
dog. Acta Pharmacol Toxicol (Copenh) 8(3):305-14. 
Chinot, O. L., et al. 
 
2014 Bevacizumab plus radiotherapy-temozolomide for newly diagnosed glioblastoma. 
N Engl J Med 370(8):709-22. 
Cvek, B., et al. 
 
2008 Ni(II), Cu(II), and Zn(II) diethyldithiocarbamate complexes show various 
activities against the proteasome in breast cancer cells. J Med Chem 51(20):6256-8. 
Faiman, M. D., D. E. Dodd, and R. E. Hanzlik 
 
1978 Distribution of S35 disulfiram and metabolites in mice, and metabolism of S35 
disulfiram in the dog. Res Commun Chem Pathol Pharmacol 21(3):543-67. 
Faiman, M. D., J. C. Jensen, and R. B. Lacoursiere 
 
1984 Elimination kinetics of disulfiram in alcoholics after single and repeated doses. 
Clin Pharmacol Ther 36(4):520-6. 
Friedman, H. S., et al. 
 
2009 Bevacizumab alone and in combination with irinotecan in recurrent glioblastoma. 
J Clin Oncol 27(28):4733-40. 
Fuller, R. K., and E. Gordis 
 
2004 Does disulfiram have a role in alcoholism treatment today? Addiction 99(1):21-4. 
Gilbert, M. R., et al. 
 
2014 A randomized trial of bevacizumab for newly diagnosed glioblastoma. N Engl J 
Med 370(8):699-708. 
Gilbert, M. R., et al. 
 
2013 Dose-dense temozolomide for newly diagnosed glioblastoma: a randomized phase 
III clinical trial. J Clin Oncol 31(32):4085-91. 
Grossmann, K.F. , et al. 


Version 02/04/16 
 
page 35 of 40 
 
2011 A phase I clinical study investigating disulfiram and copper gluconate in patients 
with advanced treatment-refractory solid tumors involving the liver. Cancer Res 71(Suppl 
8):[Abstract] nr 1308. 
Guild, J., and N. B. Epstein 
 
1951 Psychosis during the treatment of alcoholism with tetraethylthiuram disulfide. Q J 
Stud Alcohol 12(3):360-6. 
Hothi, P., et al. 
 
2012 High-throughput chemical screens identify disulfiram as an inhibitor of human 
glioblastoma stem cells. Oncotarget 3(10):1124-36. 
Huang, J., et al. 
 
2016 A phase I study to repurpose disulfiram in combination with temozolomide to 
treat newly diagnosed glioblastoma after chemoradiotherapy. J Neurooncol. 
Jacobsen, E. 
 
1952 Deaths of alcoholic patients treated with disulfiram (tetraethylthiuram disulfide) 
in Denmark. Q J Stud Alcohol 13(1):16-26. 
Jensen, J. C., M. D. Faiman, and A. Hurwitz 
 
1982 Elimination characteristics of disulfiram over time in five alcoholic volunteers: a 
preliminary study. Am J Psychiatry 139(12):1596-8. 
Johansson, B. 
 
1990 Plasma protein binding of disulfiram and its metabolite diethylthiocarbamic acid 
methyl ester. J Pharm Pharmacol 42(11):806-7. 
— 
 
1992 A review of the pharmacokinetics and pharmacodynamics of disulfiram and its 
metabolites. Acta Psychiatr Scand Suppl 369:15-26. 
Johansson, B., et al. 
 
1991 Dose-effect relationship of disulfiram in human volunteers. II: A study of the 
relation between the disulfiram-alcohol reaction and plasma concentrations of 
acetaldehyde, diethyldithiocarbamic acid methyl ester, and erythrocyte aldehyde 
dehydrogenase activity. Pharmacol Toxicol 68(3):166-70. 
Johnson, D. R., and B. P. O'Neill 
 
2012 Glioblastoma survival in the United States before and during the temozolomide 
era. J Neurooncol 107(2):359-64. 
Kreisl, T. N., et al. 
 
2009 Phase II trial of single-agent bevacizumab followed by bevacizumab plus 
irinotecan at tumor progression in recurrent glioblastoma. J Clin Oncol 27(5):740-5. 
Liu, P., et al. 
 
2012 Cytotoxic effect of disulfiram/copper on human glioblastoma cell lines and 
ALDH-positive cancer-stem-like cells. Br J Cancer 107(9):1488-97. 
Lun, X., et al. 
 
2016 Disulfiram when combined with copper enhances the therapeutic effects of 
temozolomide for the treatment of Glioblastoma. Clin Cancer Res. 
Major, L. F., et al. 
 
1979 Dopamine-beta-hydroxylase in the cerebrospinal fluid: relationship to disulfiram-
induced psychosis. Biol Psychiatry 14(2):337-44. 
Martensen-Larsen, O. 


Version 02/04/16 
 
page 36 of 40 
 
1951 Psychotic phenomena provoked by tetraethylthiuram disulfide. Q J Stud Alcohol 
12(2):206-16. 
Milandri, M., et al. 
 
1980 Effect of long-term disulfiram administration on rat liver. Pharmacology 
21(1):76-80. 
Nilsson, G. E., O. Tottmar, and G. Wahlstrom 
 
1987 Effects of aldehyde dehydrogenase inhibitors on hexobarbital sensitivity and 
neuroamine metabolism in rat brain. Brain Res 409(2):265-74. 
Ostrom, Q. T., et al. 
 
2014 CBTRUS statistical report: primary brain and central nervous system tumors 
diagnosed in the United States in 2007-2011. Neuro Oncol 16 Suppl 4:iv1-63. 
Paranjpe, A., et al. 
 
2014 Disulfiram is a direct and potent inhibitor of human O6-methylguanine-DNA 
methyltransferase (MGMT) in brain tumor cells and mouse brain and markedly increases 
the alkylating DNA damage. Carcinogenesis 35(3):692-702. 
Perry, J. R., et al. 
 
2010 Phase II trial of continuous dose-intense temozolomide in recurrent malignant 
glioma: RESCUE study. J Clin Oncol 28(12):2051-7. 
Piccioni, D. E., et al. 
 
2014 Deferred use of bevacizumab for recurrent glioblastoma is not associated with 
diminished efficacy. Neuro Oncol 16(6):815-22. 
Quinn, J. A., et al. 
 
2009 Phase II trial of temozolomide plus o6-benzylguanine in adults with recurrent, 
temozolomide-resistant malignant glioma. J Clin Oncol 27(8):1262-7. 
Schweizer, M. T., et al. 
 
2013 Pharmacodynamic study of disulfiram in men with non-metastatic recurrent 
prostate cancer. Prostate Cancer Prostatic Dis 16(4):357-61. 
Stewart, D. J., S. Verma, and J. A. Maroun 
 
1987 Phase I study of the combination of disulfiram with cisplatin. Am J Clin Oncol 
10(6):517-9. 
Stupp, R., et al. 
 
2005 Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N 
Engl J Med 352(10):987-96. 
Suh, J. J., et al. 
 
2006 The status of disulfiram: a half of a century later. J Clin Psychopharmacol 
26(3):290-302. 
Triscott, J., et al. 
 
2012 Disulfiram, a drug widely used to control alcoholism, suppresses the self-renewal 
of glioblastoma and over-rides resistance to temozolomide. Oncotarget 3(10):1112-23. 
Wen, P. Y., et al. 
 
2010 Updated response assessment criteria for high-grade gliomas: response 
assessment in neuro-oncology working group. J Clin Oncol 28(11):1963-72. 
Wilk, W., et al. 
 
2015 Phase III trial exploring the combination of bevacizumab and lomustine in 
patients with first recurrence of a glioblastoma: the EORTC 26101 trial. Neuro Oncol 
17(suppl 5):v1 [abstract: LB-05]. 


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


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APPENDIX B: Concurrent Disulfiram and Copper Medication Diary 
 
Today’s Date:    
 
 
 
 
Agent:   Disulfiram/Copper 
Month: ____ 
 
Patient Name:    
 
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete one form for each month.  Take __ mg ( ___capsules) of disulfiram three times a day at with each meal 
l). Please also take 1.5 mg of copper gluconate supplement three times a day with each meal. Do not take 
disulfiram or copper within one hour of your dose of temozolomide. 
2. Record the date, and how many times you took disulfiram and copper on that date. 
3. If you have any questions or notice any side effects, please record them in the comments section.  Record the 
time if you should vomit. 
4. Please return the forms to your physician or your study coordinator when you go to your next appointment.  Please 
bring your unused study medications and/or empty bottles with you to each clinic visit so that a pill count can be 
done. 
5. Avoid consuming alcohol before and throughout the entire study.   
 
Day 
Date 
Check each time you take 
your disulfiram dose 
Check each time you take 
your copper dose 
Comments 
 
 
Breakfast 
Lunch 
Dinner 
Breakfast 
Lunch 
Dinner 
 
1 
 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
 
3 
 
 
 
 
 
 
 
 
4 
 
 
 
 
 
 
 
 
5 
 
 
 
 
 
 
 
 
6 
 
 
 
 
 
 
 
 
7 
 
 
 
 
 
 
 
 
8 
 
 
 
 
 
 
 
 
9 
 
 
 
 
 
 
 
 
10 
 
 
 
 
 
 
 
 
11 
 
 
 
 
 
 
 
 
12 
 
 
 
 
 
 
 
 
13 
 
 
 
 
 
 
 
 
14 
 
 
 
 
 
 
 
 
15 
 
 
 
 
 
 
 
 
16 
 
 
 
 
 
 
 
 
17 
 
 
 
 
 
 
 
 
18 
 
 
 
 
 
 
 
 
19 
 
 
 
 
 
 
 
 
20 
 
 
 
 
 
 
 
 
21 
 
 
 
 
 
 
 
 
22 
 
 
 
 
 
 
 
 
23 
 
 
 
 
 
 
 
 
24 
 
 
 
 
 
 
 
 
25 
 
 
 
 
 
 
 
 
26 
 
 
 
 
 
 
 
 
27 
 
 
 
 
 
 
 
 
28 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX C: Concurrent Temozolomide Medication Diary 
 
Today’s Date:    
 
 
 
 
Agent:   Temozolomide  
Month: ____ 
 
Patient Name:    
 
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete this form during radiation therapy.  Take _____mg ( ___capsules) of temozolomide daily as instructed 
by your oncologist. Temozolomide should be taken at bedtime on an empty stomach and should not be 
taken within one hour of your disulfiram or copper supplement. 
2. Record the date, the number of capsules taken, and when you took them. 
3. If you forget to take temozolomide before midnight, then do not take a dose that day.  Restart it the next day. 
4. If you have any questions or notice any side effects, please record them in the comments section.  Record the 
time if you should vomit. 
5. Please return the forms to your physician or your study coordinator when you go to your next appointment.  Please 
bring your unused study medications and/or empty bottles with you to each clinic visit so that a pill count can be 
done. 
6. Avoid consuming alcohol before and throughout the entire study.   
 
Day 
Date 
What time was 
dose taken? 
# of tablets 
taken 
Comments 
1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
6 
 
 
 
 
7 
 
 
 
 
8 
 
 
 
 
9 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
13 
 
 
 
 
14 
 
 
 
 
15 
 
 
 
 
16 
 
 
 
 
17 
 
 
 
 
18 
 
 
 
 
19 
 
 
 
 
20 
 
 
 
 
21 
 
 
 
 
22 
 
 
 
 
23 
 
 
 
 
24 
 
 
 
 
25 
 
 
 
 
26 
 
 
 
 
27 
 
 
 
 
28