Conditions: Glial Cell Tumors Malignant Gliomas Glioblastoma Multiforme Anaplastic Astrocytoma Gliomatosis Cerebri Gliosarcoma Brainstem Glioma Diffuse Intrinsic Pontine Glioma
Keywords: brain tumor bevacizumab valproic acid radiation therapy
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 38
Healthy volunteers: no

Brief summary:
Currently, there are few effective treatments for the following aggressive brain tumors: glioblastoma multiforme, anaplastic astrocytoma, gliomatosis cerebri, gliosarcoma, or brainstem glioma. Surgery and radiation can generally slow down these aggressive brain tumors, but in the majority of patients, these tumors will start growing again in 6-12 months. Adding chemotherapy drugs to surgery and radiation does not clearly improve the cure rate of children with malignant gliomas.

The investigators are conducting this study to see if the combination of valproic acid and bevacizumab (also known as AvastinTM) with surgery and radiation will shrink these brain tumors more effectively and improve the chance of cure.

Detailed description:
With the exception of patients with diffuse intrinsic pontine glioma (DIPG), all patients should have the maximal surgical resection that can be safely performed prior to study entry. Submission of frozen tumor is strongly encouraged. After recovery from neurosurgery, all patients will start valproic acid (VPA) and radiation therapy.

VPA will be started at 15 mg/kg/day divided into three doses a day, ideally 48 hours prior to first day of radiation therapy, but no later than the first day of radiation therapy. Patients may also begin VPA sooner if they have post-operative seizures and require an anti-convulsant.

Radiation phase (week 1-6): Radiation therapy should begin within 30 days of definitive surgery or radiographic diagnosis, whichever is the later date. Date of surgery or radiographic diagnosis is considered day 1, and radiation should start no later than day 31. VPA will be continued daily without interruption during radiation therapy. VPA doses will be adjusted in increments of 5 mg/kg/day every 3-5 days to achieve and maintain trough concentrations between 85 to 115 mcg/ml. All patients will receive standard radiation therapy which will last approximately six week.

Post Radiation Phase (week 7-10): Patients will continue to receive VPA as previously dosed during radiation to maintain a trough concentration of 85-115 mcg/ml.

Maintenance Phase (starting week 11): Maintenance therapy will begin approximately 4 weeks after completion of radiation or week 11, whichever comes first.

Patients will continue VPA daily during maintenance therapy. All patients will start bevacizumab, 10 mg/kg intravenously every two weeks, at the start of maintenance therapy (week 11). Maintenance therapy will continue uninterrupted unless treatment related toxicities requires study drug interruption. In the absence of unacceptable toxicity or disease progression, patients will continue to receive protocol treatment for a maximum duration of two years (including the radiation phase).

Arms:
arm 1: radiation phase (week 1-6): daily valproic acid and radiation, for approximately 6 weeks post-radiation phase (week 7-10): valproic acid daily maintenance phase (starting week 11): daily valproic acid, and bevacizumab once every 2 weeks; to continue for a maximum duration of 2 years

Interventions: intervention 1: Valproic acid intervention 2: Bevacizumab intervention 3: Radiation therapy
Intervention descriptions: intervention 1: Daily (pre-XRT, During XRT, Post-XRT and Maintenance Therapy) Started at 15 mg/kg/day divided into three doses a day as soon as patients have recovered from surgery but no later than the first day of XRT.

Dosage will be adjusted in increments of 5 mg/kg/day every 3-5 days to achieve and maintain trough concentrations between 85 and 115 mcg/ml intervention 2: All patients will receive bevacizumab (10 mg/kg iv) during the maintenance phase every two weeks for a maximum duration of therapy of 24 months. intervention 3: Radiation therapy will start within 30 days of the definitive surgical procedure. Primary brain malignant gliomas will receive a total dose of between 54.0 and 59.4 Gy in 30-33 fractions over 6-7 weeks. Total dose will be 54.0 Gy for completely resected tumors and brainstem gliomas. The total dose will be 59.4 if the tumor is located in the brain but not the brainstem, and the tumor was incompletely resected. Primary spinal cord malignant gliomas will receive a total dose of between 50.4-54 Gy in 28-30 fractions over 5-6 weeks.

Protocol document:
Prot_SAP_ICF_000.pdf: 
Page 1 of 95 
TEXAS-OKLAHOMA PEDIATRIC NEURO-ONCOLOGY CONSORTIUM 
 
 
A PHASE 2 STUDY OF VALPROIC ACID AND RADIATION, FOLLOWED BY 
MAINTENANCE VALPROIC ACID AND BEVACIZUMAB IN CHILDREN WITH NEWLY 
DIAGNOSED HIGH-GRADE GLIOMAS OR BRAINSTEM GLIOMAS 
 
 
 
STUDY CO-CHAIRS 
Jack M. Su, MD, MS 
Texas Children’s Cancer Center  
Baylor College of Medicine 
6701 Fannin Street, CC1510 
Houston, Texas 77030 
Phone: (832) 822-4306 
Fax: (832) 825-1503 
e-mail: jmsu@txch.org 
 
Susan M. Blaney, MD 
Texas Children’s Cancer Center  
1102 Bates Avenue 
Houston, Texas 77030 
Phone: (832) 822-1482 
Fax: (832) 825-4299 
e-mail: sblaney@txch.org 
 
 
STUDY VICE-CHAIRS 
Daniel C. Bowers, MD 
Division of Pediatric Hematology-Oncology 
UT Southwestern Medical Center at Dallas 
5323 Harry Hines Blvd 
Dallas, TX 75390-9063 
Phone: 214-648-3896 
Fax: 214-648-3122 
 
 
Murali Chintagumpala, MD 
Texas Children’s Cancer Center  
Baylor College of Medicine 
6701 Fannin Street, CC1510 
Houston, Texas 77030 
Phone: (832) 822-4266 
Fax: (832) 825-1503 
e-mail: mxchinta@txch.org 


Page 2 of 95 
 
 
Research Coordinator 
Suzanne H. Wheeler, MPH, RN, CCRP 
Texas Children’s Cancer Center 
1102 Bates Avenue, Suite 1590 
Houston, Texas 77030 
Phone: (832) 824-4217 
Fax: (832) 825-1198 
e-mail: shwheele@txch.org 
 
Study Number: TOPNOC_001_08 
 
 
 
 
 
Protocol Version, Date:  Version 3.0, September 27, 2013  


Page 3 of 95 
TABLE OF CONTENTS 
 
                                                                                              Page 
ABSTRACT AND TREATMENT SCHEMA                                                                               
 5 
1.0 GOALS AND OBJECTIVES (SCIENTIFIC AIMS)................................................             7    
1.1 Primary Aims ....................................................................................................           
 7             
1.2 Secondary Aims ................................................................................................ 
    
 7 
2.0 BACKGROUND ....................................................................................................... 
 
 7 
2.1  High-Grade Gliomas and Brainstem Gliomas in Children ...............................      
 7 
2.2  Histone Deacetylase (HDAC) and Human Cancers .........................................           
 8 
2.3 Rationale for Studying VPA, an HDAC Inhibitor, in Pediatric High-Grade Gliomas   8 
2.4  Rationale for Bevacizumab in High-Grade Gliomas ........................................              10        
2.5 Rationale for Combining Radiation, VPA, and Bevacizumab .........................              12 
2.6 Proposed VPA Dosing and Targeted Trough Concentration ...........................              12 
2.7 Prognostic Markers for Predicting Response and Survival in High-Grade Gliomas      13 
3.0 AGENT INFORMATION .........................................................................................              13 
3.1 Valproic Acid ....................................................................................................              13 
3.2 Bevacizumab .....................................................................................................              17 
4.0 PATIENT ELIGIBILITY ..........................................................................................              23 
4.1 Inclusion Criteria                                                                                                             24 
4.2 Exclusion Criteria                                                                                                            25 
5.0 TREATMENT PLAN AND DOSE MODIFICATION ............................................              27 
         5.1 Treatment Plan ..................................................................................................              27 
         5.2 Valproic Acid Administration and Monitoring Guidelines  .............................              28 
         5.3 Bevacizumab Administration and Monitoring Guidelines ...............................              29 
         5.4  Valproic Acid Dose Modifications  ..................................................................              30 
         5.5 Bevacizumab Dose Modifications   ………………………………………….               32 
 
5.6    Discontinuation of Either VPA or Bevacizumab During Maintenance Treatment         35 
         5.7  Supportive Care ................................................................................................              35 
6.0 EVALUATION AND MEASUREMENT TO BE OBTAINED ..............................              38 
7.0 BIOLOGIC CORRELATIVE STUDIES ..................................................................              40 
8.0 EVALUATION CRITERIA ......................................................................................              41 
8.1 Response Criteria for Patients with Measurable CNS Tumors ........................              41 


Page 4 of 95 
8.2 Response Criteria for Patients with Evaluable CNS Tumors ...........................              41 
8.3 Best Response ...................................................................................................              42 
9.0  RADIATION THERAPY GUIDELINES .................................................................              43 
 
9.1       Equipment ......................................................................................................              43 
 
9.2       Target Volumes .............................................................................................              43 
 
9.3       Target Dose ....................................................................................................              44 
 
9.4       Treatment Technique .....................................................................................              45 
         9.5       Normal Tissue Sparing …………………………………………………….               45 
10.0 STATISTICAL CONSIDERATION .........................................................................              46 
         10.1     Sample Size and Study Duration ...................................................................              46 
 
10.2     Study Design and Data Analysis ...................................................................              46 
 
10.3     Measurement of Effect ..................................................................................              47 
 
10.4     Off Treatment Criteria ...................................................................................              47 
 
10.5     Off Study Criteria ..........................................................................................              48 
 
10.6     Correlative Biology Studies ...........................................................................              48 
11.0  CENTRAL REVIEW ................................................................................................              48 
 
11.1     Pathology Review ..........................................................................................              48 
 
11.2     Imaging Review .............................................................................................              48 
12.0 EVALUATION, RECORDING, AND REPORTING OF ADVERSE EVENTS ....              48 
         12.1     Definitions .....................................................................................................              49 
         12.2     Adverse Event Description ............................................................................              49 
         12.3     Reporting Adverse Events .............................................................................              50  
 
12.4     Monitoring of Adverse Events                                                                                     52 
13.0  RETENTION OF RECORDS  
 
 
 
 
 
                       52 
REFERENCES 
 
 
 
 
 
 
 
 
 
           53 
APPENDICES 
 
 
 
Appendix I:  
AvastinTM (Bevacizumab) Request and Inventory Forms  
 
           60                          
Appendix II:  
Procedure for Obtaining a Urine Protein / Creatinine Ratio 
                       62 
Appendix III: 
90th and 95th Percentile BP for Boys and Girls 1-17 Years  
                      63 
Appendix IV:     Valproic Acid Compliance Diary Form 
 
 
 
 
           65 
Appendix V:  
Comprehensive Adverse Events and Potential Risk Lists For Bevacizumab         66 
Appendix VI: 
Tumor Specimen and Correlative Study Transmittal Form                                    69 
Appendix VII:  Treatment Roadmaps                                                                                               71 
Appendix VIII: Model Consent Form 
 
 
 
                                                82 


Page 5 of 95 
ABSTRACT 
 
Despite recent advances in neurosurgery, radiation, and chemotherapy, children with high-grade 
gliomas and brainstem gliomas continue to have a dismal prognosis, highlighting the urgent need for 
novel therapeutic regimens. Valproic acid (VPA), a well-characterized drug used in children with 
seizures since the 1970’s, was recently identified as a histone deacetylase (HDAC) inhibitor and has 
been shown to have anti-tumor activity in multiple tumor types, including high-grade gliomas. Pre-
clinical studies have shown that VPA administered as a single agent inhibits growth of orthotopic 
xenografts derived from malignant gliomas. In addition, VPA has been shown to enhance the anti-
tumor activity of both radiation and chemotherapy. In a recently completed Children’s Oncology 
Group phase 1 study of valproic acid in children with recurrent solid tumors, a partial response was 
observed in a child with a refractory brainstem glioma and another patient with a refractory 
glioblastoma multiforme (GBM). Bevacizumab (Avastin), a monoclonal antibody against vascular 
endothelial growth factor, has also shown promising activity against multiple tumor types, including 
high-grade gliomas. Two recent studies of the combination of bevacizumab with irinotecan 
demonstrated an improvement in the 6-month progression free survival (PFS) of adults with recurrent 
GBM. A subsequent abstract reported at the 2008 American Society of Clinical Oncology Meeting 
showed that adults randomized to receive bevacizumab alone had statistically identical 6-month PFS 
versus subjects that received the combination of bevacizumab and irinotecan. As expected, there were 
fewer adverse events in the bevacizumab alone arm versus the combination arm.  We therefore propose 
a phase 2 trial to evaluate a novel treatment regimen for children with newly diagnosed high grade 
gliomas that includes administration of daily oral VPA during radiation therapy, followed by i.v. 
bevacizumab administered every two weeks plus daily oral VPA. The primary aims of this study are: 
1) to determine the anti-tumor activity of this regimen as measured by 1- year and 2-year event-free 
survival (EFS) rate, and 2) to evaluate the toxicities of this regimen. The secondary aims are to 
characterize several biologic pathways in malignant gliomas, including quantification of DNA repair 
proteins and markers of tumor angiogenesis, and to correlate these parameters with radiographic 
response and EFS. 
 
TREATMENT SCHEMA 
With the exception of patients with brainstem gliomas, all patients should have the maximal surgical 
resection that can be safely performed prior to study entry. Submission of frozen tumor is strongly 
encouraged. Please coordinate with neurosurgeons and pathologists in advance to ensure that an 
adequate tumor specimen is obtained (see section 7.0). After recovery from neurosurgery, all 
patients will start valproic acid and radiation therapy. 
 
 
Pre-XRT 
During XRT  
Post-XRT 
Maintenance Therapy 
 Day/Wk of Tx 
Day -2 to 0 
Weeks 1 - 6 
Weeks 7 - 10 
Weeks 11 - 105 
XRT 
None 
Mon - Fri 
* 
None 
Valproic acid 
Daily, oral 
Daily, oral 
Daily, oral 
Daily, oral 
Bevacizumab 
None 
None 
None 
Every two weeks, iv 
Tumor 
Evaluation 
Pre-XRT 
None 
Week 10 
Every 12 wks and as 
clinically indicated 
* XRT may continue into the post-XRT break if there were delays during weeks 1 - 6 


Page 6 of 95 
 
Pre-XRT Phase 
Valproic acid (VPA) will be started at 15 mg/kg/day divided tid up to 48 hours prior to the initiation of 
radiation therapy, but no later than the first day of radiation therapy.  Patients may begin VPA and 
radiation therapy as soon as they have adequately recovered from their definitive surgical resection or 
biopsy, but no later than 30 days after surgery.  Specific guidelines for VPA administration are 
provided in Section 5.2.  
 
During XRT Phase 
Radiation should begin within 30 days from surgery or radiographic diagnosis, whichever is the later 
date. VPA will be continued daily without interruption during radiation therapy. VPA doses will be 
adjusted in increments of 5 mg/kg/day every 3-5 days to achieve and maintain trough concentrations 
between 85 to 115 mcg/ml (See Section 5.2.2 and 5.2.3). During this time, patients will receive 
standard radiation therapy as outlined in Section 9.0. 
 
Post XRT Phase 
Patients will continue to receive VPA as during XRT. For patients that required discontinuation of 
VPA during radiation, they will not resume VPA until start of maintenance therapy.  If necessary, 
patients who had delays in XRT (e.g., secondary to schedule holidays or the need to have a new mask 
made) will complete their radiotherapy to the total prescribed protocol dose. 
 
Maintenance Therapy 
Maintenance therapy will begin 11 weeks after the initiation of radiation therapy. Patients will 
continue VPA daily during the 4-week break and throughout maintenance therapy. All patients will 
start bevacizumab, 10 mg/kg iv every two weeks, at the start of maintenance therapy (See Section 5.3). 
In the absence of unacceptable toxicity or disease progression, patients will continue to receive 
protocol treatment for a maximum total duration of two years (including the XRT phase). 


Page 7 of 95 
1.0 
GOALS AND OBJECTIVES (SCIENTIFIC AIMS) 
 
1.1 
Primary Aims 
 
1.1.1 To determine the efficacy of combining valproic acid (VPA) with radiation, 
followed by maintenance VPA and bevacizumab in children with newly 
diagnosed high-grade gliomas and brainstem gliomas, as measured by EFS at 
one-year and two-years. 
 
1.1.2 To determine the toxicities of VPA when combined with radiation and when 
combined with bevacizumab in the post-radiotherapy phase. 
 
 
 
1.2 
Secondary Aims 
1.2.1 To quantify proteins related to histone deacetylation (histone H3 and H4 
acetylation, HDAC 1 and 2), NHEJ (Ku70/Ku80, DNA-PK) and HRR (Rad51, 
BRCA1/2) pathway, tumor angiogenesis (VEGF, VEGF receptor 2), and tumor 
hypoxia (CD31, CA9, hypoxia-inducible factor 2) by Western analysis if 
frozen tumors resected at diagnosis and/or at later time points are available. 
 
1.2.2 To perform IHC studies of the molecular markers outlined in 1.2.1 if only 
paraffin-embedded tumors are available. 
 
1.2.3 To measure NHEJ activity in PBMCs before treatment and after 2 weeks of 
VPA and radiation. 
 
1.2.4 To measure HDAC2 level and histone acetylation in PBMCs before treatment 
and after 2 weeks of VPA and radiation. 
 
1.2.5 To quantify MGMT and PARP activity by enzymatic assays in frozen tumors 
resected at diagnosis and/or at later time points, if available. 
 
1.2.6 To explore potential correlation between the molecular parameters in aims 1.2.1 
to 1.2.5 with radiographic response rate and survival outcome. 
 
 
 
 
2.0 
BACKGROUND 
 
2.1 
High-Grade Gliomas and Brainstem Gliomas in Children 
Despite advances in neuro-surgery, radiation therapy, and chemotherapy, children with 
high-grade gliomas continue to have a dismal prognosis. Although a Children’s Cancer 
Study Group (CCG) trial (CCG-943) showed a promising 5-year EFS of 46% when 
prednisone, CCNU, and vincristine (PCV) were combined with radiation therapy (1), 
this result was not duplicated by a subsequent CCG-945 trial. The CCG-945 trial 
showed that PCV, when combined with radiation therapy, produced a 5-year EFS of 
16% and 28% for children with glioblastoma multiforme (GBM) and anaplastic 
astrocytoma (AA), respectively. Furthermore, a more intensive chemotherapy regimen 
(eight-drug-in-one regimen) combined with radiation produced nearly identical clinical 


Page 8 of 95 
outcomes (2, 3). Because of the promising results from a trial of temozolomide and 
radiation therapy in adults newly diagnosed with GBM (4), a similar trial was 
conducted through COG (study ACNS0126). The final results of ACNS0126 are 
pending, but a preliminary analysis showed that children with GBM in this trial had a 1-
year EFS of 36%, nearly identical to the 1-year EFS of 32% seen in CCG-945 (5). 
 
Children with brainstem gliomas also have dismal outcomes. A recent review of 22 
clinical trials in children with brainstem gliomas showed that only 92 out of 940 children 
survived, with no evidence that children in recent trials showed any improved EFS or 
overall survival (OS) compared to those in older series (6). In those children whose 
tumors were biopsied, the majority (153 out of 229 samples; 67%) were high-grade 
gliomas (6). Numerous clinical trials involving hyperfractionated radiation (7-10), 
chemotherapy (8, 10-14) or biologic agents (7, 15, 16), and myeloablative regimens with 
stem cell rescue (17, 18) uniformly failed to improve EFS or OS compared to historical 
series. Collectively, these trials showed dismal median EFS (5-8.8 months), median OS 
(8-12 months), and 2-year survival (5-15%) in children with brainstem gliomas (6). 
 
2.2  
Histone Deacetylase (HDAC) and Human Cancers 
The lack of improvement in clinical outcome for children with high-grade gliomas and 
brainstem gliomas from trials conducted in the last two decades highlight the urgent need 
for novel therapeutic strategies. Recently, HDAC inhibitors have demonstrated 
promising activity against various human cancers (19, 20). Nucleosomes, the basal unit 
of chromatin, are composed of DNA coils wrapped around a core of histones with 
lysine-rich amino terminal tails. The positive charge of the amino tails of histone attracts 
the negatively charged DNA, and this interaction partly regulates the chromatin structure 
and gene expression (19). Histone acetyltransferase (HAT) transfers an acetyl moiety 
from acetyl-CoA to the lysines on the amino tails and neutralizes the positive charge of 
the histones, leading to decreased affinity for DNA, relaxation of chromatin, and 
transcriptional activation (19, 21). HDAC removes the acetyl groups and restores the 
negative charge, leading to chromatin compaction and transcriptional repression (19, 22).  
 
Dysregulation in histone acetylation has been implicated in the development of several 
human cancers (19, 20), and alterations in the acetylation status of specific lysines have 
been associated with human cancers as well (23). It is hypothesized that aberrant histone 
acetylation leads to inappropriate transcriptional repressions and maintenance of the 
transformed states of human tumors. HDAC inhibitors are hypothesized to reactivate 
expressions of critical pathways that are abnormally silenced during tumorigenesis, and 
indeed treatment of multiple human tumor cells with HDAC inhibitors resulted in cell 
cycle arrest, apoptosis, and differentiation (19, 20). 
 
2.3  
Rationale for VPA, an HDAC Inhibitor, in Pediatric High-Grade Gliomas 
VPA, an anti-convulsant used in children for over 30 years, was recently found to inhibit 
HDAC (24). Pre-clinical studies have demonstrated that VPA has in vitro and in vivo 
activity against several human cancers (24), and clinical trials of VPA in adult and 
pediatric malignancies are in progress. 
 


Page 9 of 95 
Pre-Clinical Studies of VPA and Other HDAC Inhibitors in CNS Tumors 
We have shown that VPA has in vitro and in vivo activity against medulloblastoma (25, 
26). Anti-glioma activity of VPA has also been shown in several studies (24, 27-32).  In 
addition, other HDAC inhibitors, including trichostatin, MS-275, and suberoylanilide 
hydroxamic acid (SAHA) are also active against malignant glioma (33-36). 
 
Clinical Studies of VPA in Patients with CNS Tumors 
In one retrospective analysis of adults with newly diagnosed GBM who underwent 
radiation therapy followed by chemotherapy, overall survival (OS) was compared 
amongst patients not taking any anti-convulsant (group A), those taking VPA (group B), 
or those on enzyme-inducing anti-convulsants (EIAE; group C). The OS of group A and 
B were 11.6 months versus 13.7 months, and this difference, while not statistically 
significant, was a noteworthy trend (37). Patients on VPA had a statistically significant 
improvement in OS (13.7 months) versus those on EIAE (10.8 months, p = 0.042). 
 
A COG phase 1 study of VPA (ADVL0419) in children with recurrent/progressive solid 
tumors, including brain tumors, was recently completed. One out of three children with 
brainstem gliomas had a partial response (PR) that was sustained for 3 months. Another 
patient with a GBM (out of two children with high-grade gliomas) had a PR of 5 months 
duration (Su JM et al, unpublished results). The trough VPA concentrations in these 
responding patients ranged from 75-110 mcg/ml. In a German trial, a child with a 
progressive GBM after radiation and chemotherapy achieved a CR for 12 months while 
maintaining a VPA trough concentration of 160 mcg/ml, but treatment was stopped 
because of somnolence, and the tumor recurred after drug discontinuation (38). In 
treatment arm C of the German HIT-GBM trial, 22 children with progressive high-grade 
gliomas or brainstem gliomas after radiation and chemotherapy were given daily 
valproic acid as a single agent, and 3 patients have been recently reported as long-term 
survivors at 4.5, 4.95, and 5 years from time of diagnosis (39). 
 
There appears to be encouraging preliminary clinical data that support further studies of 
VPA as a novel agent in high-grade gliomas. However, given the non-durable responses 
observed with VPA as a single agent in children with high-grade gliomas, it is possible 
that the potential therapeutic value of VPA would be augmented if combined with 
radiation and/or other drugs. Pre-clinical studies have indeed shown that VPA enhances 
radiation effect in high-grade gliomas, and additional studies also suggest that VPA 
inhibits angiogenesis in human cancer models (see discussion below). 
 
VPA and Other HDAC Inhibitors Enhance Radiation Effect 
We have shown that VPA enhanced the anti-tumor activity of radiation against two 
medulloblastoma cell lines by 1.6 to 2.7 fold (Li XN et al, unpublished data). Other 
investigators have also confirmed that VPA (40-43) and other HDAC inhibitors (44-49) 
can enhance the radiation effect against various human cancer cell lines, including 
malignant glioma (40, 41, 44-46, 48) in vitro. Camphausen et al. (41) reported that VPA 
enhanced the in vivo radiation response of two subcutaneous xenografts of malignant 
gliomas, and Entin-Meer et al. (50) showed that another HDAC inhibitor (AN-9) 


Page 10 of 95 
combined with radiation significantly delayed tumor growth in mice with subcutaneous 
glioma xenografts.  
 
These studies identified that pre-treatment with VPA or other HDAC inhibitor followed 
by radiation led to significantly reduced expression of DNA repair proteins such as 
Ku70, Ku80, and DNA-PK in the non-homologous end-joining (NHEJ) pathway and 
BRCA1/2 and Rad51 in the homologous recombination repair (HRR) pathways. Since 
radiation is thought to exert its anti-tumor effect by inducing double-stranded DNA 
(dsDNA) breaks, and dsDNA breaks are repaired by the NHEJ and HRR pathways, it has 
been hypothesized that the radiation-enhancement effect of VPA and other HDAC 
inhibitors are partly mediated by decreased levels of DNA repair proteins. In all the pre-
clinical studies examining the radiosensitizing property of VPA and other HDAC 
inhibitors, optimal radiation enhancement was observed when HDAC inhibition 
preceded radiation by 24-72 hours and was continued concurrently with radiation.  
 
Anti-angiogenesis Effect of VPA 
Our previous studies demonstrated that VPA treatment led to in vitro and in vivo 
inhibition of angiogenesis in medulloblastoma (25, 26). Other pre-clinical studies also 
showed that VPA suppressed angiogenesis in various human cancers by reducing VEGF 
expression and protein level, inhibiting endothelial cell proliferation, and decreasing 
neovascularization (51-54). These pre-clinical studies suggest that a combination of VPA 
and an anti-angiogenesis agent may be a complementary approach in CNS tumors. 
 
VPA Induces Differentiation of Tumor and Stem Cells 
Our pre-clinical studies showed that VPA treatment led to neuronal and glial 
differentiation in medulloblastoma cells (25, 26). Additional studies also showed that 
VPA promoted differentiation of various neuronal progenitor cells (32, 55-58). The 
differentiating effect of VPA on other normal or cancerous stem cells has also been 
reported (59-61), including differentiation of acute myeloid leukemia cells in two clinical 
trials (62, 63). Since the quiescent cancer stem cell has been hypothesized to be resistant 
to radiation and chemotherapy, VPA-induced differentiation of the high-grade glioma 
stem cell may render them more susceptible to treatment. 
 
2.4  
Rationale for Bevacizumab in High-Grade Gliomas 
Angiogenesis and High-Grade Gliomas 
Vascular endothelial growth factor (VEGF) is a potent endothelial cell mitogen and 
inducer of vascular permeability. VEGF plays a critical role in glioma angiogenesis, as 
its expression and protein level are elevated in GBM tumor cells and in tumor 
endothelial cells, but not in the normal brain (64-66). Bevacizumab, a humanized 
monoclonal IgG1 antibody against the human VEGF-A isoform and its proteolytic 
fragments, has been shown to decrease vascular permeability and increase apoptosis in 
intracranial xenografts of human glioblastoma in SCID mice (67).  
 
Bevacizumab, either as a single agent or in combination with other chemotherapy agents, 
has been extensively studied in multiple clinical trials in more than 8,000 adults with 
various cancers (68-71). The addition of bevacizumab to various chemotherapy agents 


Page 11 of 95 
improved the PFS and overall survival (OS) in adults with metastatic colorectal cancer 
(trial AVF2107g and E3200), non-small cell lung cancer (trial E4599), and metastatic 
breast cancer (trial E2100; see Bevacizumab Investigator Brochure). 
 
Clinical Trials of Bevacizumab in Adults with Recurrent High-Grade Gliomas 
Two recent reports showed promising clinical outcomes in adults with recurrent 
malignant gliomas after combined bevacizumab and irinotecan treatment. In a phase II 
study, bevacizumab (10 mg/kg) and irinotecan (125 mg/ m2 in patients not on EIAE) 
were given every 2 weeks, and responses were seen in 60% (14 out of 23) of patients 
with GBM and in 67% (6 out of 9) of patients with AA (72). In a follow up study, in 
which additional patients with GBM were recruited, and the treatment regimen was 
modified (bevacizumab 15 mg/kg every 21 days, and irinotecan 125 mg/m2 weekly for 
four weeks repeated every 6 weeks), a response rate of 57% was observed (20 out of 35 
patients with GBM), and the 6-month PFS was 46% (73). Response rate between the first 
and second group of patients was nearly identical, suggesting that increased dose-
intensity of bevacizumab and/or irinotecan did not significantly improve tumor response. 
These results represent a significant improvement compared to historical 6-month EFS 
of < 30% and response rate of < 20% in adults with recurrent GBMs.  
 
In a phase II, randomized, non-comparative clinical trial, Genentech compared the 
clinical outcome and toxicities of adults with recurrent GBM treated with bevacizumab 
alone versus those who received bevacizumab and irinotecan (74)(Table 1). The median 
OS and 6-month PFS were statistically identical in both groups of patients, while those 
who received bevacizumab alone experienced lower incidences of various toxicities 
(Table 1). These results are consistent with prior clinical trials of irinotecan, whether as a 
single agent (75-81) or in combination with other chemotherapy agents (82-84), in adults 
with recurrent malignant gliomas that showed limited response rates from 0 to 15% and 
suggested that irinotecan has minimal activity in high-grade gliomas. 
 
Table 1: Efficacy and Toxicities of Bevacizumab Alone Versus Bevacizumab and 
Irinotecan in Adults with Recurrent GBM 
 
Bevacizumab  
(N = 85) 
Bevacizumab and 
irinotecan (N = 82) 
Efficacy 
 
 
Median OS, months 
9.2 
8.7 
6-month PFS, % 
42.6 
50.3 
ORR, % 
28.2 
37.8 
Adverse Events, Grade > 3, % 
47.6 
67.1 
Hemorrhage 
0 
2.5 
Gastrointestinal Perforation 
0 
1.3 
Arterial Thromboembolic Event (ATE) 
1.2 
2.5 
Venous Thromboembolic Event (VTE) 
3.6 
8.9 
Reversible Posterior Leukoencphalopathy 
Syndrome (RPLS) 
0 
1.3 
Proteinuria 
0 
1.3 
Wound Healing Complication 
2.4 
1.3 


Page 12 of 95 
Congestive Heart Failure 
0 
0 
Infection 
9.5 
13.9 
Grade 5 Adverse Events, % 
2.4 
1.3 
Bevacizumab discontinued due to AE, % 
3.5 
13.9 
 
 
Clinical Trials of Bevacizumab in Children with Cancers 
In a recently completed COG phase I study of bevacizumab in children with recurrent 
solid tumors (no patients with CNS tumors were included), no DLTs were observed in 
18 patients (85) who received up to 15 mg/kg every 2 weeks, and no hemorrhage or 
thrombosis were seen. Currently, there is an ongoing PBTC trial (PBTC022) of 
bevacizumab (10 mg/kg every 2 weeks) and irinotecan (125 mg/m2 every 2 weeks) in 
children with progressive malignant glioma, medulloblastoma, and ependymoma. 
 
2.5  
Rationale for Combining Radiation, VPA, and Bevacizumab 
VPA has been used in children since the 1970’s, can be taken orally with nearly 100% 
bioavailability, has a long half-life of 9-20 hours in children, passes through the blood 
brain barrier effectively (86, 87), and can be given chronically with well-characterized, 
acceptable toxicities. These biochemical, pharmacokinetic, and clinical properties make 
VPA an attractive agent for pediatric CNS tumors. Several pre-clinical studies have 
demonstrated VPA’s activity against malignant gliomas, and encouraging responses in 
children with malignant gliomas and brainstem gliomas were observed in ADVL0419 
and HIT-GBM. Additional studies also showed that VPA enhances the effect of radiation 
against malignant gliomas. Therefore, we hypothesize that combining VPA with up-front 
radiation is a novel approach worthy of investigation in children with newly diagnosed 
high-grade gliomas and brainstem gliomas. In both ADVL0419 and HIT-GBM, patients 
with recurrent tumors who have received prior radiation and chemotherapy tolerated 
trough VPA concentrations below 110 mcg/ml without DLTs, suggesting that combining 
VPA with radiation in newly diagnosed patients should be well tolerated. VPA has also 
been shown to inhibit angiogenesis and promote differentiation of neural progenitor and 
cancer stem cells. With recent encouraging responses to bevacizumab in adults with 
recurrent GBM, the combination of the anti-glioma and anti-angiogenic effects of VPA 
and bevacizumab represents a promising approach in children with high grade and 
brainstem gliomas. Because VPA and bevacizumab have few overlapping toxicities (see 
section 3.1 and 3.2), we do not anticipate additive or unexpected toxicities in combining 
VPA and bevacizumab. 
 
2.6  
Proposed VPA Dosing and Targeted Trough Concentration 
In HIT-GBM (39), serum trough VPA concentrations in 23 patients averaged 99 mcg/ml 
(range 52-175 mcg/ml), and no grade 3 or 4 DLTs were reported. Three patients had 
somnolence, one patient had difficulties in concentration, one patient had 
thrombocytopenia, and a patient had anemia (all grade 1 or 2). In the COG phase I study, 
ADVL0419, two patients experienced grade-3 somnolence with trough VPA 
concentration between 100 and 150 mcg/ml. No DLT was seen in six subsequent patients 
whose trough concentration was maintained between 70-110 mcg/ml (Su JM et al, 


Page 13 of 95 
unpublished data). With a starting dose of 15 mg/kg divided tid, all six patients achieved 
and maintained trough concentration > 75 mcg/ml within the first two weeks.  
 
Based on pre-clinical data demonstrating that the minimal anti-CNS tumor concentration 
of VPA is > 0.6 mM (~100 mcg/ml), whether as a single agent (25-30) or as an enhancer 
of radiation activity (40, 41), we propose to maintain VPA trough concentrations as close 
to 100 mcg/ml as possible. Due to variability in timing of trough sampling and VPA 
assay, which is estimated to be 10-15%, we propose to maintain VPA trough 
concentrations between 85-115 mcg/ml (100 +/- 15 mcg/ml) for initial patients.  
 
2.7  
Prognostic Markers For Predicting Response and Survival in High-Grade Gliomas 
In adults with newly diagnosed GBM receiving temozolomide and radiation, it was 
shown that those with methylated promoter of the MGMT (O6-methylguanine-DNA 
methyltransferase) DNA-repair gene in their tumors had improved clinical outcomes 
compared to those with absence of MGMT promoter methylation (88). Such a 
correlation of MGMT promoter methylation and/or MGMT activity with improved 
clinical outcome in children with high-grade gliomas has not been confirmed yet. 
 
In the two clinical trials of bevacizumab and irinotecan in adults with progressive 
malignant gliomas (72, 73), semi-quantitative immunohistochemistry (IHC) studies of 
VEGF, VEGF receptor 2, CD31 (surrogate marker for vascularity), hypoxia-inducible 
carbonic anydrase 9 (CA9), and hypoxia-inducible factor-2a were performed in 45 tumor 
specimens. High VEGF level was associated with increased likelihood of radiographic 
response, and high CA9 level was associated with poor survival outcome (89). Since we 
will be incorporating bevacizumab into the proposed maintenance chemotherapy, these 
molecular parameters should also be studied and correlated with clinical outcome. 
 
Because several pre-clinical studies have documented that VPA enhancement of 
radiation effect was associated with decreased levels of DNA repair proteins in the 
NHEJ and HRR pathways, we will also determine the levels of these DNA repair 
proteins in the untreated tumors and correlate them with clinical outcome. We will also 
quantify NHEJ activity in peripheral blood mononuclear cells (PBMC) before and after 2 
weeks of VPA and radiation to measure VPA’s potential inhibition of double-stranded 
DNA break repair. In addition, we also propose to study pre-treatment poly(ADP-ribose) 
polymerase (PARP) activity in pediatric high-grade gliomas, since PARP is a critical 
enzyme for activating both single stranded and double-stranded DNA break repair (90). 
 
Several pre-clinical studies have shown that inhibition of HDAC2 appears to be critical 
for various aspects of HDAC inhibitors’ anti-tumor effect, including chromatin 
decondensation and remodeling, transcriptional activation, and induced histone 
acetylation (91-94). Subsequent clinical trials have confirmed that baseline expression 
of HDAC2 in PBMCs (as surrogates for tumor specimens) correlated directly with 
increases in histone H3 and H4 acetylation after HDAC inhibitor treatment (92, 95-97). 
Therefore, baseline and post-treatment HDAC2 level in PBMCs may be an additional 
surrogate marker for measuring VPA’s biologic effect in tumors. 
 


Page 14 of 95 
2.8  
Rationale for Amending Eligibility Criterion Regarding Intra-Tumoral 
Hemorrhage 
 
Because of bevacizumab’s mechanism of action, intra-tumoral and/or intracranial 
hemorrhage was a potential concern with earlier clinical trials. With available published 
data, it is reassuring that the rate of intra-tumoral/intracranial hemorrhage is quite low, 
and revising or current eligibility criteria to include patients with asymptomatic intra-
tumoral hemorrhage, in a patient population that has a significant incidence of intra-
tumoral hemorrhage at the time of diagnosis, prior to initiation of any surgery or other 
treatment, with few effective treatments available, is a reasonable option. Final data 
from the phase II clinical trials of 163 adults with recurrent GBM receiving 
bevacizumab, either alone or in combination with irinotecan, showed a rate of 
intracranial hemorrhage of 2.4 (bevacizumab alone) and 3.8% (bevacizumab and 
irinotecan); patients with stable intra-tumoral/intracranial hemorrhage, regardless of 
size of hemorrhage, were eligible for this trial (98). A follow up clinical trial, in which 
125 adults with newly diagnosed GBM received bevacizumab, temozolomide, and 
radiation immediately after initial tumor resection, included patients with grade 1 
(asymptomatic) intracranial hemorrhage prior to study entry and showed rate of 
intracranial hemorrhage to be less than 1% (1 out of 125 patients) (99). In a recent 
pediatric phase II clinical trial, 31 children with either high-grade glioma or DIPG 
received bevacizumab and irinotecan, and patients with pre-existing and stable intra-
tumoral hemorrhage were eligible for study participation; 4 patients experienced 
asymptomatic grade 1 CNS hemorrhage. The currently open Children’s Oncology 
Group phase II clinical trial for high-grade gliomas (ACNS0822), which includes 
bevacizumab during and after radiation therapy, also allow patients with pre-existing 
and stable CNS hemorrhage to participate in the trial. 
 
 
Of the twenty seven children who have been enrolled onto our clinical trial, two patients 
experienced grade-1 CNS hemorrhage and another patient had a grade-2 hemorrhage, 
all occurring at the time of tumor progression. In a patient population with dismal 
prognosis and few effective treatment options, we feel that, in light of the published 
adult and pediatric data and our trial experience to date, it is reasonably safe to include 
patients with asymptomatic, stable intra-tumoral or intracranial hemorrhage < 1 cm in 
the widest dimension, and the eligibility guideline has been accordingly revised in 
section 4.1.6. 
 
2.9 
Addition of a Participate Site to TOPNOC 
 
Dr. Ben Carcamo will serve as the PI of University of Texas, El Paso, which will be 
added as a member of the consortium.  
 
3.0 
AGENT INFORMATION     
3.1  
Valproic Acid 
Depakene (syrup and capsule), Depakote (capsule and sprinkles), or other generic 
formulations of valproic acid are permissible. 
 
3.1.1 Structure and molecular weight: 2-propylpentanoic acid (NSC # 93819), 
molecular weight 144.21 


Page 15 of 95 
 
 
3.1.2 Supplier   
Commercially available 
 
3.1.3 Formulation 
 
The agent is supplied either as syrup (250 mg/5 ml) or as a capsule (125 or 250 
mg capsules).  
 
3.1.4 Storage 
 
The capsules should be stored at 15-25C, and the syrup should be kept at below 
25C until the time of use. 
 
3.1.5 Solution Preparation 
No preparation is necessary prior to administration.  
 
3.1.6 Stability 
 
The syrup and capsules are stable until the manufacturer’s suggested date of 
expiration. 
 
3.1.7 Administration 
 
The capsules can be swallowed whole without breakage, or alternatively, the 
content of the capsule can be sprinkled and mixed with water, juice, or food. 
Syrup can be mixed with water, juices, or food. 
 
3.1.8 Drug Interactions 
 
VPA has documented interactions with multiple anti-epileptics, and some of the 
severe toxicities of VPA, such as fatal hepatitis or hyperammonemia 
encephalopathy (see section 5.6.8 and 5.6.9), are associated with young children 
(age < 24 months) taking multiple anti-convulsants. Therefore, the use of other 
anti-epileptics should be avoided.  
 
Other drugs with documented effects on VPA metabolism include acyclovir, 
aspirin and other salilcylates, carbapenem antibiotics (imipenem, meropenem), 
cholestyramine, chlorpromazine, isoniazid, macrolide antibiotics (clarithromycin, 
azithromycin, erythromycin), and rifampin. If  any of these drugs need to be 
administered after a patient has achieved the targeted VPA concentration, 
then twice weekly VPA trough concentration, CBC, and liver function tests 
should be monitored for at least 2 consecutive weeks (longer if clinically 
indicated).  
 
VPA has documented effects on the metabolism of amitriptyline, nortriptyline, 
clonazepam, diazepam, nimodipine, tolbutamide, tricyclic anti-depressants, 
 


Page 16 of 95 
warfarin, and zidovudine. Patients on protocol therapy who are also taking those 
medications should be monitored closely for toxicities and/or therapeutic effects 
of those medications. 
 
3.1.9 Toxicities 
The most common side effects are gastrointestinal (nausea, vomiting, diarrhea), 
dermatological (dry skin, rash), and neurological (somnolence, ataxia, blurred 
vision, emotional lability) in nature, which seldom require discontinuation of 
treatment. See Table 2 for a complete listing of known VPA toxicities. 
 
Table 2: Known Toxicities of Valproic Acid in Children 
 
Common 
(21-100% 
Frequency) 
Occasional 
(5-20% 
Frequency) 
Rare 
(< 5% Frequency) 
Immediate: Within 1-2 days 
of receiving drug 
Nausea, vomiting, 
abdominal pain, 
diarrhea, headache 
Anorexia, 
dyspepsia, flu-like 
syndromes 
 
Prompt: Within 2-3 weeks, 
prior to next cycle. 
Somnolence, fatigue, 
tremor, asthenia, 
dizziness, alopecia, 
rash, dry skin, 
pruritis, paresthesia 
Diplopia, blurred 
vision, ataxia, 
nystagmus, 
headache, 
amnesia, 
insomnia, 
emotional lability, 
anxiety, tinnitus, 
weight gain or loss 
Stomatitis, 
gingivitis, 
confusion, 
hyperactivity, coma, 
erythema 
multiforme, Steven-
Johnson, toxic 
epidermal necrolysis 
Delayed: Anytime after 
above. 
 
Hypothyroidism, 
thrombocytopenia 
Anemia, 
neutropenia, 
lymphopenia, 
leukopenia, SIADH, 
periodontal abscess, 
amenorrhea, 
menstrual 
irregularities, 
urinary frequency, 
vaginitis, 
tachycardia, 
arrhythmia, 
hypertension, 
hearing loss, 
interstitial nephritis, 
pneumonia 
Late: Anytime after 
completion of treatment 
 
 
Tetratogenic effects 
on newborns 
Unknown Timing and 
Frequency 
 
 
Pancreatitis, 
hepatitis, 


Page 17 of 95 
hyperammonemia, 
encephalopathy, 
bone marrow aplasia 
or myelodysplastic 
syndrome, abnormal 
coagulation tests and 
von Willebrand 
panel, bleeding, 
neural tube defects 
to fetuses 
 
CNS toxicities 
Neurological symptoms such as ataxia, diplopia, somnolence, fatigue, dizziness, 
emotional lability, or difficulty with memory or concentration are almost always 
transient and resolve after temporarily discontinuing VPA or dose reduction. In 
ADVL0419, of the 20 children who maintained trough VPA concentration 
between 100-150 mcg/ml, two patients had grade 3 somnolence, which resolved 
in 48 hours after VPA was discontinued. Six subsequent patients received VPA 
to maintain trough concentration of 75-100 mcg/ml, and none experienced > 
grade 3 CNS toxicities. In the HIT-GBM-C treatment arm (39), of the 44 
children who maintained VPA concentration between 52-175 mcg/ml, three 
patients experienced grade 1 or 2 somnolence, and one patient had grade 1 or 2 
difficulty in concentration, but there was no apparent correlation between trough 
concentration and CNS toxicities.  
 
Hematologic toxicities 
Thrombocytopenia in children receiving VPA is generally transient and mild in 
severity, resolves with dose reduction, and is most commonly associated with 
serum trough > 140 mcg/ml (100, 101). Two large retrospective analyses 
showed that severe thrombocytopenia, defined as platelet count < 50,000/mm3, 
was rarely observed at serum concentrations < 150 mcg/ml (102, 103). There 
was no specific association between severity of thrombocytopenia and duration 
of treatment. Thrombocytopenia most commonly resolves despite continuation 
of VPA at lower doses (104, 105). In ADVL0419, only one patient experienced 
grade-4 thrombocytopenia, which resolved after reduction of the VPA dose to 
achieve a trough concentration < 100 mcg/ml. Seven instances of transient 
grade-1 and two of grade-2 thrombocytopenia occurred and all resolved without 
requiring drug discontinuation or dose reduction. In the HIT-GBM trial, only 
one patient had grade 2 thrombocytopenia. 
 
Anemia, neutropenia, and lymphopenia are less common than thrombocytopenia 
in children receiving VPA, occurring in < 5% of patients. In ADVL0419, one 
grade 4 anemia, one grade 4 lymphopenia, and one grade 3 neutropenia were 
reported, and no febrile neutropenia or bacteremia were documented. In HIT-
GBM-C, only one grade 2 anemia was reported. 
 


Page 18 of 95 
In summary, the myelosuppression of VPA is generally self-limited and well 
tolerated. However, rare cases of bone marrow aplasia and myelodysplastic 
syndrome have been previously reported in children on VPA (100). 
 
Hepatic encephalopathy and hyperammonemia 
One of the most severe toxicity of VPA is fatal hepatic failure, estimated at an 
incidence of one in 33,000 adults and children (86, 106). The syndrome is 
characterized by elevation in transaminase and bilirubin, decreased fibrinogen, 
with or without hyperammonemia, followed by rapid neurological deterioration, 
encephalopathy, and coma. Although there is no clear association with dose, 
duration, or serum drug concentration, children younger than 2 years of age and 
taking multiple anti-convulsants have been identified as the group with the 
highest risk, with an estimated incidence of 1:600 (106) to 1: 5000 (107). 
Therefore, we will be excluding children younger than 2 years of age and 
strongly discourage the use or other concomitant anti-convulsants. 
 
Hyperammonemia has been reported in association with VPA despite normal 
liver function tests, and in patients with unexplained lethargy, vomiting, and/or 
changes in mental status, hyperammonemic encephalopathy should be 
considered (108). Although there is no association with duration of treatment or 
serum VPA concentration, identified risk factors include multiple anti-
convulsants, carnitine deficiency, and urea cycle or other metabolic disorders. 
Discontinuation of VPA and supportive care, including carnitine 
supplementation, are the recommended treatments (109, 110). 
 
Pancreatitis 
Another potentially fatal toxicity of VPA is pancreatitis. The incidence of 
pancreatitis in children taking VPA is unknown; a recent retrospective review in 
the English literature of all 33 cases of pancreatitis in children taking VPA 
identified 9 fatal cases, with no association between pancreatitis and the dose or 
serum concentration of VPA (111). We will exclude any patient with a prior 
history of pancreatitis and/or abnormal lipase/amylase levels from this trial. 
 
Tetratogenicity 
There is an estimated 1-2% incidence of neural tube defects in babies of mother 
taking VPA (86), so all female patients of child-bearing age should have a 
negative urine pregnancy test prior to enrollment. 
 
3.2  
Bevacizumab (AvastinTM, rhuMAb VEGF) 
 
3.2.1 Description and molecular weight 
Bevacizumab is a recombinant humanized monoclonal anti-VEGF antibody, 
consisting of 97% human and 3% of murine amino acid sequences. The agent is 
composed of human IgG framework and murine antigen-binding 
complenmentarity-determining regions. Bevacizumab blocks the binding of 


Page 19 of 95 
VEGF to its receptor, resulting in inhibition of angiogenesis. Bevacizumab’s 
molecular weight is approximately 149,000 daltons. 
 
3.2.2. Supplied by 
Genentech Inc. will provide the drug to Texas Children’s Cancer Center who 
will then distribute to each site.  Please see Appendix IA for instructions to place 
a drug order. The pharmacy must be notified at least 5 working days in advance 
of the anticipated date of use. 
 
The bevacizumab to be supplied for this protocol is intended for patients 
enrolled on this clinical trial use only.  Commercially available AvastinTM should 
not be utilized in its place. 
 
3.2.3 Formulation 
Bevacizumab is a clear to slightly opalescent, colorless to pale brown, sterile 
liquid concentrate for solution for intravenous (IV) infusion.  Bevacizumab is 
supplied in 20-cc (400-mg) glass vials containing 16 mL bevacizumab (25 
mg/mL).  Vials contain bevacizumab with phosphate, trehalose, polysorbate 20, 
and Sterile Water for Injection (SWFI), USP.  Vials contain no preservative and 
are suitable for single use only. For further details and molecule 
characterization, see the Bevacizumab Investigator Brochure. 
 
3.2.4 Storage and stability 
Upon receipt of the study drug, vials are to be refrigerated at 2C – 8C  
(36F – 46F) and should remain refrigerated until just prior to use.  DO NOT 
FREEZE.  DO NOT SHAKE.   Vials should be protected from light. 
 
Opened vials must be used within 8 hours. VIALS ARE FOR SINGLE USE 
ONLY.  Vials used for 1 subject may not be used for any other subject.  Once 
study drug has been added to a bag of sterile saline, the solution must be 
administered within 8 hours. 
 
3.2.5 Route and method of administration 
The calculated dose of bevacizumab should be diluted in a total volume of 100 
mL of 0.9% Sodium Chloride Injection, USP. Administration will be as a 
continuous IV infusion. Anaphylaxis precautions should be observed during 
study drug administration.   
 
The initial dose will be delivered over 90 minutes. If the first infusion is 
tolerated without infusion-associated adverse events (fever and/or chills), the 
second infusion may be delivered over 60 minutes.  If the 60-minute infusion is 
well tolerated, all subsequent infusions may be delivered over 30 minutes.   
 
Immediately after completion of the infusion, flush the IV infusion line with 30 
mL of 0.9% sodium chloride at the same rate as the bevacizumab infusion. 
 


Page 20 of 95 
3.2.6 Bevacizumab-specific toxicities 
The major adverse events associated with bevacizumab are listed below. Please 
refer to the Investigator Brochure for detailed description of all toxicities. 
 
3.2.6.1 Infusion-related reactions 
Infusion reactions with bevacizumab are uncommon (< 3%) and rarely 
severe (0.2%). Infusion reactions may include rash, urticaria, fever, 
rigors, hypertension, hypotension, wheezing, hypoxia, or 
bronchospasm. Anaphylaxis precautions should be observed during 
study drug administration.   
 
3.2.6.2 Hypertension 
An increased incidence of hypertension has been observed in adults 
treated with bevacizumab, with an estimated incidence of 20-30% 
across trials.  Grade 4 and 5 hypertensive events are rare. Clinical 
sequelae of hypertension are rare but have included hypertensive crisis, 
hypertensive encephalopathy, and reversible posterior 
leukoencephalopathy syndrome (RPLS) (112, 113).  Hypertension 
requiring treatment was not observed in children enrolled on the initial 
pediatric phase I trial of bevacizumab (85). 
 
Monitoring of blood pressure is recommended during bevacizumab 
therapy.  Optimal control of blood pressure according to standard 
public health guidelines is recommended. Temporary interruption of 
bevacizumab therapy is recommended in patients with hypertension 
requiring medical therapy until adequate control is achieved.  
If hypertension cannot be controlled with medical therapy, 
bevacizumab therapy should be permanently discontinued.  
Bevacizumab should be permanently discontinued in patients who 
develop hypertensive crisis or hypertensive encephalopathy. 
 
3.2.6.3 Proteinuria  
An increased incidence of proteinuria has been observed in patients 
treated with bevacizumab, with up to 38% of patients experiencing 
proteinuria. The severity of proteinuria has ranged from asymptomatic 
and transient events detected on routine dipstick urinalysis to nephrotic 
syndrome; the majority of proteinuria events have been grade 1. NCI-
CTC grade 3 proteinuria was reported in up to 3% of bevacizumab-
treated patients, and grade 4 in up to 1.4% of bevacizumab-treated 
patients. The proteinuria seen in bevacizumab clinical trials was not 
associated with renal impairment and rarely required permanent 
discontinuation of bevacizumab therapy. In adults with recurrent 
GBMs, the incidence of > grade 3 proteinuria was 1.3% in those who 
received bevacizumab and irinotecan, compared to 0% in patients who 
received bevacizumab alone (74). Patients with a history of 


Page 21 of 95 
hypertension may be at increased risk for the development of 
proteinuria when treated with bevacizumab.  
 
3.2.6.4 Venous thromboembolism (VTE) 
  
In clinical trials across all indications the overall incidence of VTE 
events was 2.8% to 17.3% in the bevacizumab-containing arms 
compared with 3.2% to 15.6% in the chemotherapy control arms. The 
use of bevacizumab with chemotherapy does not substantially increase 
the risk of VTE event compared with chemotherapy alone.   
 
 
In adults with recurrent GBMs, the incidence of > grade 3 VTE was 
8.9% in those who received bevacizumab and irinotecan, compared to 
3.6% in patients who received bevacizumab alone (74). None of the 
children who received bevacizumab in the COG phase 1 trial (85) 
experienced any venous thrombotic complications. 
 
3.2.6.5   Arterial thromboembolic events (ATE) 
An increased incidence of ATE events has been observed in patients 
treated with bevacizumab compared with those receiving control 
treatment.  ATE events include cerebrovascular accidents, myocardial 
infarction, transient ischemic attacks (TIAs), and other ATE events.  In 
a pooled analysis of data from five randomized Phase II and III trials 
(mCRC [AVF2107g, AVF2192g, AVF0780g]; locally advanced or 
metastatic NSCLC [AVF0757g]; metastatic breast cancer 
[AVF2119g]), the incidence rate of ATE events was 3.8% (37 of 963) 
in patients who received chemotherapy  bevacizumab compared with 
1.7% (13 of 782) in patients treated with chemotherapy alone.  ATE 
events led to a fatal outcome in 0.8% (8 of 963) of patients treated with 
chemotherapy  bevacizumab and 0.5% (4 of 782) of patients treated 
with chemotherapy alone. Cerebrovascular accidents (including TIAs) 
occurred in 2.3% of patients treated with chemotherapy 
and bevacizumab and 0.5% of patients treated with chemotherapy 
alone.  Myocardial infarction occurred in 1.4% of patients treated with 
chemotherapy  bevacizumab compared with 0.7% of patients treated 
with chemotherapy alone. 
 
In adults with recurrent GBMs, the incidence of > grade 3 ATE was 
2.5% in those who received bevacizumab and irinotecan, compared to 
1.2% in patients who received bevacizumab alone (74). None of the 
children who received bevacizumab in the COG phase 1 trial (85) 
experienced any arterial thrombotic complications. 
 
3.2.6.6  Gastrointestinal perforation 
Patients with metastatic carcinoma may be at increased risk for the 
development of gastrointestinal perforation and fistula when treated 
with bevacizumab and chemotherapy. A causal association of intra-


Page 22 of 95 
abdominal inflammatory processes and gastrointestinal perforation to 
bevacizumab  treatment has not been established. Nevertheless, caution 
should be exercised when treating patients with intra-abdominal 
inflammatory processes with bevacizumab. Gastrointestinal perforation 
has been reported in other trials in non-colorectal cancer populations 
(e.g., ovarian, renal cell, pancreas, breast, and NSCLC) and may be 
higher in incidence in some tumor types. 
 
 
In adults with recurrent GBMs, the incidence of > grade 3 
gastrointestinal perforation was 1.3% in those who received 
bevacizumab and irinotecan, compared to 0% in patients who received 
bevacizumab alone (74).  
 
3.2.6.7   Fistula 
Bevacizumab use has been associated with serious cases of fistulae 
including events resulting in death.  Fistulae in the GI tract are 
common (1%–10% incidence) in patients with metastatic CRC, but 
uncommon (0.1%1%) or rare (0.01%–0.1%) in other indications.  In 
addition, fistulae that involve areas of the body other than the GI tract 
(e.g., tracheoesophageal, bronchopleural, urogenital, biliary) have been 
reported uncommonly (0.1%–1%) in patients receiving bevacizumab in 
clinical studies and postmarketing reports.  Events were reported at 
various time points during treatment, ranging from 1 week to  1 year 
following initiation of bevacizumab, with most events occurring within 
the first 6 months of therapy.  
 
3.2.6.8  Wound healing complications 
Wound healing complications such as wound dehiscence have been 
reported in patients receiving bevacizumab. In an analysis of pooled 
data from two trials in metastatic colorectal cancer, patients 
undergoing surgery 28-60 days before study treatment with 5-FU/LV 
plus bevacizumab did not appear to have an increased risk of wound 
healing complications compared to those treated with chemotherapy 
alone. Surgery in patients currently receiving bevacizumab is not 
recommended. No definitive data are available to define a safe interval 
after bevacizumab exposure with respect to wound healing risk in 
patients receiving elective surgery; however, the estimated half life of 
bevacizumab is 21 days.  
 
In adults with recurrent GBMs, the incidence of > grade 3 wound 
healing complication was 1.3% in those who received bevacizumab 
and irinotecan, compared to 2.4% in patients who received 
bevacizumab alone (74).  
 
3.2.6.9   Hemorrhage: Overall, grade 3 and 4 bleeding events were observed in 
4.0% of 1132 patients treated with bevacizumab in a pooled database 


Page 23 of 95 
from eight phase I, II, and III clinical trials in multiple tumor types. 
The hemorrhagic events that have been observed in bevacizumab 
clinical studies were predominantly tumor-associated hemorrhage (see 
below) and minor mucocutaneous hemorrhage.  
 
Tumor-Associated Hemorrhage: Major or massive pulmonary 
hemorrhage or hemoptysis has been observed primarily in patients with 
NSCLC.  Life-threatening and fatal hemoptysis was identified as a 
bevacizumab-related adverse event in NSCLC trials.  These events 
occurred suddenly and presented as major or massive hemoptysis.  
Among the possible risk factors evaluated (including squamous cell 
histology, treatment with anti-rheumatic/anti-inflammatory drugs, 
treatment with anticoagulants, prior radiotherapy, bevacizumab 
therapy, previous medical history of atherosclerosis, central tumor 
location, and cavitation of tumors during therapy), the only variables 
that showed statistically significant correlations with bleeding were 
bevacizumab therapy and squamous cell histology. GI hemorrhages, 
including rectal bleeding and melena have been reported in patients 
with CRC, and have been assessed as tumor-associated hemorrhages. 
Tumor-associated hemorrhages were also seen rarely in other tumor 
types and locations, including a case of CNS bleeding in a patient with 
hepatoma with occult CNS metastases and a patient who developed 
continuous oozing of blood from a thigh sarcoma with necrosis. 
 
In adults with recurrent GBMs, the incidence of > grade 3 hemorrhage 
was 2.5% in those who received bevacizumab and irinotecan, 
compared to 0% in patients who received bevacizumab alone (74). 
None of the children who received bevacizumab in the COG phase 1 
trial (85) experienced any tumor-associated hemorrhage. 
 
Mucocutaneous Hemorrhage: Across all bevacizumab clinical trials, 
mucocutaneous hemorrhage has been seen in 20%-40% of patients 
treated with bevacizumab. These were most commonly NCI-CTC 
Grade 1 epistaxis that lasted less than 5 minutes, resolved without 
medical intervention and did not require any changes in bevacizumab 
treatment regimen. There have also been less common events of minor 
mucocutaneous hemorrhage in other locations, such as gingival 
bleeding and vaginal bleeding.  
 
3.2.6.10 Reversible Posterior Leukoencephalopathy Syndrome (RLPS) 
There have been rare reports of bevacizumab-treated patients 
developing signs and symptoms that are consistent with RPLS, a rare 
neurologic disorder that can present with the following signs and 
symptoms (among others):  seizures, headache, altered mental status, 
visual disturbance, or cortical blindness, with or without associated 
hypertension. In adults with recurrent GBMs, the incidence of RPLS 


Page 24 of 95 
was 1.3% in those who received bevacizumab and irinotecan, 
compared to 0% in patients who received bevacizumab alone (74). 
None of the children who received bevacizumab in the COG phase 1 
trial (85) experienced RLPS. 
 
3.2.6.11 Congestive heart failure (CHF):  
 
In clinical trials CHF was observed in all cancer indications studied to 
date, but predominantly in patients with metastatic breast cancer.  In 
the Phase III clinical trial of metastatic breast cancer (AVF2119g), 7 
(3%) bevacizumab-treated patients experienced CHF, compared with 
two (1%) control arm patients.  These events varied in severity from 
asymptomatic declines in left ventricular ejection fraction (LVEF) to 
symptomatic CHF requiring hospitalization and treatment.  All the 
patients treated with bevacizumab were previously treated with 
anthracyclines (doxorubicin cumulative dose of 240360 mg/m2).  
Many of these patients also had prior radiotherapy to the left chest 
wall.  Most of these patients showed improved symptoms and/or left 
ventricular function following appropriate medical therapy (114). 
 
None of the adults with recurrent GBMs treated with bevacizumab +/- 
irinotecan experienced CHF (74). None of the children who received 
bevacizumab in the COG phase 1 trial (85) experienced CHF. 
 
3.2.6.12  Neutropenia: Increased rates of severe neutropenia, febrile neutropenia,   
or infection with severe neutropenia (including some fatalities) have 
been observed in patients treated with myelotoxic chemotherapy 
regimens plus bevacizumab in comparison to chemotherapy alone 
(115). In adults with recurrent GBMs, the incidence of > grade 3 
infection was 13.9% in those who received bevacizumab and 
irinotecan, compared to 9.5% in patients who received bevacizumab 
alone (74). Neutropenia was not a dose-limiting toxicity in those 
children who received bevacizumab in the COG phase 1 trial (85). 
 
3.2.6.13  Bone defects in growing children: The growth plates of actively 
growing bones consist of avascular cartilage that is replaced by bone. 
This is mediated by ingrowth of metaphyseal blood vessels that is 
directed by a VEGF gradient. Studies in mice indicate that trabecular 
bone formation can be suppressed by VEGF inhibitors (116). Similarly, 
VEGF inhibitors caused metaphyseal dysplasia (hypertrophied 
chondrocytes and loss of metaphyseal capillary invasion) only in 
monkeys with open growth plates that was reversible on cessation of 
treatment (117). Although large studies of the effects of bevacizumab 
on bone growth in humans are unavailable, a recent case report seems 
to suggest that bevacizumab was possibly causative in the occurrence 
of metaphyseal lytic lesions in a child with viscero-cutaneous 


Page 25 of 95 
angiomatosis (118). There was complete healing of these lesions 
following cessation of bevacizumab (118). 
 
3.2.7 Bevacizumab Inventory Records 
 
The investigator, or a responsible party designated by the investigator, must 
maintain a careful record of the inventory and disposition of bevacizumab 
received and administered during protocol therapy. Please complete Appendix 
IB and fax to Sue Burlingame (Phone: 832-824-1532; Fax: 832-825-1198) or 
Monica Rodriguez (Phone: 832-824-1531; Fax 832-825-2005) every 12 weeks 
during maintenance therapy. 
 
 
4.0 
PATIENT ELIGIBILITY 
 
All clinical and laboratory studies to determine eligibility must be performed within 7 days 
prior to enrollment unless otherwise indicated.  If more than 7 calendar days elapse 
between the date eligibility studies outlined in Section 6.0 were obtained and the start date 
of treatment, then the following studies must be repeated prior to treatment: CBC with 
differential, bilirubin, ALT (SGPT) and serum creatinine.  If any of these repeat laboratory 
studies are outside the parameters required for eligibility (labs may again be repeated 
within 48-72 hours), then the patient will not be eligible for protocol therapy.  Imaging 
studies are required within 2 weeks prior to start of protocol therapy. 
 
Important note: The eligibility criteria listed below are interpreted literally.  All clinical 
and laboratory data required for determining eligibility of a patient enrolled on this trial 
must be available in the patient’s medical or research record which will serve as the 
source document for verification at the time of audit. 
 
4.1  
Inclusion Criteria 
 
4.1.1 Age: Patient must be > 3 years and < 21 years of age at the time of study 
enrollment. 
 
4.1.2 Diagnosis: Patients must have histologic verifications of a glioblastoma 
multiforme, anaplastic astrocytoma, gliomatosis cerebri (WHO grade III or IV 
glioma with diffuse parenchymal and/or leptomeningeal involvement), or 
gliosarcoma at the time of study enrollment.  
 
 
Patients with newly diagnosed intrinsic brainstem gliomas, defined as tumors 
with a pontine epicenter and diffuse rather than focal involvement of the pons, 
with or without extension to adjacent medulla or midbrain, are eligible without 
histologic confirmation. Patients with brainstem tumors that do not meet these 
criteria or not considered to be typical intrinsic pontine gliomas will only be 
eligible if the tumors are biopsied and proven to be a grade III or IV glioma 
(anaplastic astrocytoma, glioblastoma multiforme, gliosarcoma). 
 


Page 26 of 95 
4.1.3 Performance Level:  Patients must have Karnofsky Performance Score (for 
patients > 16 years of age) or Lansky Performance Score (for patients  16 years 
of age) > 50% assessed within two weeks of study enrollment. Patients who are 
unable to walk because of paralysis, but who are up in a wheelchair, will be 
considered ambulatory for the purpose of assessing the performance score. 
 
4.1.4 Prior Therapy: Patients must not have received any prior chemotherapy, 
radiation therapy, biologic therapy, or bone marrow transplant. Surgery and 
dexamethasone are permitted prior to study entry. In patients who require anti-
convulsants prior to study entry, it is permissible to start VPA, but trough VPA 
concentration must be repeated within 48 hours of study entry. 
 
4.1.5 Organ Function Requirements: 
 
4.1.5.1 Adequate bone marrow function defined as: 
a. Hgb > 8 gm/dL (transfusion independent) 
b. Platelet count > 100,000/mm3 (transfusion independent) 
c. Absolute neutrophil count (ANC) > 1,000/ mm3 
 
4.1.5.2 Adequate liver function defined as: 
a. Bilirubin (sum of conjugated + unconjugated)  1.5 times 
institutional upper limit of normal (ULN) for age. 
b. SGPT (ALT)  2.5 times institutional ULN for age. 
c.  Serum albumin  2 g/dL. 
 
4.1.5.3 Adequate renal function defined as:  
a. Urine protein (albumin)/creatinine ratio of < 1.0 (See Appendix II) 
b. Creatinine clearance or radioisotope GFR > 70 ml/min/1.73m2 OR 
c. A serum creatinine based on age and gender as follow: 
 
 
 
Age 
 
Maximum Serum 
Creatinine (mg/dL) 
 
 
Male 
Female 
 
2 to < 6 years 
0.8 
0.8 
 
6 to < 10 years 
1 
1 
 
10 to < 13 years 
1.2 
1.2 
 
13 to < 16 years 
1.5 
1.4 
 
≥ 16 years 
1.7 
1.4 
The threshold creatinine values in this table were derived 
from the Schwartz formula for estimating GFR (Schwartz 
et al. J. Peds, 106:522, 1985) utilizing child length and 
stature data published by the CDC. 
 
4.1.5.4 Amylase and Lipase:  Amylase and lipase < 2 times 
institutional ULN for age. 
 


Page 27 of 95 
4.1.5.5 Coagulation:  Patients must NOT have a prolonged PT or 
PTT (greater than 1.2 times the institutional upper limit of 
normal), AND  the INR must be < 1.5. 
 
4.1.6 
CNS Hemorrhage:  MRI ECHO gradient sequences are required to evaluate 
for the presence or absence of CNS hemorrhage. Patients with intra-tumoral 
and/or CNS hemorrhage are eligible for study entry if they fulfill the following 
guideline: 
 Patients with an asymptomatic intra-tumoral/intracranial hemorrhage 
measuring < 1 cm in the widest dimension on MRI, at the time of 
diagnosis, after surgery, and/or any time prior to study enrollment, are 
eligible; hemorrhage must not have progressed on MRI prior to 
initiation of protocol therapy; patients must not have developed 
progressive symptoms thought to be related to the intra-
tumoral/intracranial hemorrhage prior to initiation of protocol therapy 
 patients with > 1 asymptomatic intra-tumoral/intracranial hemorrhage 
but all measuring < 1 cm in the widest dimension on MRI are eligible if 
they fulfill the guidelines described above 
 Patients with asymptomatic post-operative hemorrhage in and/or around 
the surgical cavity are eligible for study entry if they otherwise fulfill the 
guidelines described above.  
 Patients with an intra-tumoral hemorrhage > 1 cm at diagnosis but who 
demonstrates minimal post-operative hemorrhage as described above 
after tumor resection are eligible for study 
 
4.1.7 Surgery:  Patients must begin radiation therapy within 30 days of surgery or 
radiographic diagnosis, whichever is the later date. Date of surgery or 
radiographic diagnosis is considered day 1 (radiation treatment must start no 
later than day 31).  If a patient has a biopsy followed by a surgical resection then 
the date of the surgical resection is considered day 1. 
 
4.1.8 Informed Consent:  All patients and/or their legal guardians must sign a written 
informed consent.  Assent, when appropriate, will be obtained according to 
institutional guidelines. 
 
4.1.9 Patient Registration: Treating physicians or designees should contact the Study 
Chair to confirm the availability of study slots prior to consenting 
patients/families. Patients’ on-study registration must be confirmed before 
starting protocol therapy. Please contact Suzanne Wheeler (Phone: 832-824-
4217; Fax: 832-825-1198) or Sue Burlingame (Phone: 832-824-1532; Fax: 832-
825-1198) to register a patient. A signed eligibility checklist and the signed 
informed consent form along with supporting source documents (pathology 
report, MRI reports, laboratory studies, etc.) must be faxed at the time of study 
registration. 
 
4.2 
Exclusion Criteria 


Page 28 of 95 
4.2.1 Pregnancy or Breast-Feeding: Females of reproductive potential must not be 
pregnant or lactating. Males or females of reproductive potential may not 
participate unless they have agreed to use an effective contraceptive method. 
 
4.2.2 Cardiac Function: Patients with active or history of cardiac (CHF, myocardial 
infarction, myocarditis) disease are excluded from this trial. 
 
4.2.3 Concomitant Medications: Patients receiving any of the following medications 
are not eligible for study: 
a. Anti-cancer therapy or investigational agents 
b. Anti-coagulants (except for heparin to maintain the patency of central 
venous catheters). 
c. Growth factors for white blood cell, red blood cell or platelet support 
d. Aspirin (> 81 mg/day) 
e. Non-steroidal anti-inflammatory drugs 
f. Clopidogrel (Plavix), dipyridamole (Persantine), or any other drug that 
inhibits platelet functions  
g. Anti-convulsants: patients on any anti-convulsant with the exception of VPA 
are eligible for study entry. It is STRONGLY RECCOMMENED that a 
neurology consult be obtained to enable discontinuation of all anti-
convulsant other than VPA, whenever possible. 
 
4.2.4 
Infection:  Patients who have an uncontrolled infection are not eligible. 
 
4.2.5 
Hypertension: 
 Patients with inadequately controlled systemic hypertension (SBP and/or 
DBP > 95th percentile for age and height; see Appendix III) 
 Patients with a prior history of hypertensive crisis and/or hypertensive 
encephalopathy   
 
If a BP measurement prior to registration is > 95th percentile for age and height, 
it must be rechecked and documented to be < 95th percentile for age and height 
prior to registration.  If a patient falls between the height or weight percentiles, 
site should average the value as appropriate.  For patients ≥ 18 years, use adult 
normal ranges for blood pressure. Patients with hypertension are eligible if their 
blood pressures become < 95th percentile after anti-hypertensive medications. 
 
4.2.6 
Prior Ischemic Events:  Patients with a history of stroke, myocardial infarction, 
or unstable angina within 6 months prior to registration are not eligible. 
 
4.2.7 
Vascular Disease:  Patients with significant vascular disease (e.g., aortic 
aneurysm requiring surgical repair or recent peripheral arterial thrombosis) 
within 6 months prior to registration will not be eligible. 
 
4.2.8 
Bleeding /Coagulopathy: Patients with a history of hemoptysis, bleeding 
diathesis, known platelet disorder, or coagulopathy are not eligible. 


Page 29 of 95 
 
4.2.9 
Gastrointestinal:  Patients with a history of abdominal fistula or GI perforation 
within 6 months prior to registration are not eligible. 
 
4.2.10 Urea Cycle Disorder:  Patients with a known or suspected urea cycle or other 
metabolic disorder are not eligible. 
 
4.2.11 Metaphyseal Plate Abnormality: Patients with abnormality of the tibial 
metaphyseal plate on plain X-ray prior to study entry are not eligible. 
 
4.2.12 Patients with a history of a serious non-healing wound, ulcer, or bone fracture 
are not eligible. 
 
4.2.13 Patients with any clinically significant systemic illness, including serious 
infection, pulmonary, hepatic, or other organ impairment, that would 
compromise tolerance and/or timely completion of protocol therapy. 
 
4.2.14 Patients who, in the opinion of the investigator, may not be able to comply with 
the safety monitoring requirements and/or follow-up studies of this trial. 
 
4.2.15 Patients with a known hypersensitivity to any component of bevacizumab are 
not eligible for this trial. 
 
5.0  
TREATMENT PLAN AND DOSE MODIFICATION 
 
 
5.1  
Treatment Plan 
With the exception of patients with brainstem gliomas, all patients should have the 
maximal surgical resection that can be safely performed prior to study entry. 
Submission of frozen tumor for biology studies is strongly encouraged. Please 
coordinate with neurosurgeons and pathologists in advance to ensure that an 
adequate tumor specimen is obtained (See section 7.0). After recovery from 
neurosurgery, all patients will start valproic acid and radiation therapy. 
 
 
Pre-XRT 
During XRT  
Post-XRT 
Maintenance Therapy 
 Day/Wk of Tx 
Day -2 to 0 
Weeks 1 - 6 
Weeks 7 - 10 
Weeks 11 - 105 
XRT 
None 
Mon - Fri 
* 
None 
Valproic acid 
Daily, oral 
Daily, oral 
Daily, oral 
Daily, oral 
Bevacizumab 
None 
None 
None 
Every two weeks, iv 
Tumor 
Evaluations 
Pre-XRT 
None 
Week 10 
Every 12 wks and as 
clinically indicated 
* XRT may continue into the Break if there were delays during weeks 1 - 6 
 
5.1.1 Pre-Radiation Phase 
VPA will be started at 15 mg/kg/day divided tid, ideally 48 hours prior to first 
day of radiation therapy, but no later than the first day of radiation therapy. 
Patients may also begin VPA sooner if they have post-operative seizures and 


Page 30 of 95 
require an anti-convulsant.  Guidelines for VPA administration are provided in 
Section 5.2.  
 
 
5.1.2 Radiation Phase 
Radiation therapy should begin within 30 days of definitive surgery or 
radiographic diagnosis, whichever is the later date. Date of surgery or 
radiographic diagnosis is considered day 1, and radiation should start no later 
than day 31. VPA will be continued daily without interruption during radiation 
therapy. VPA doses will be adjusted in increments of 5 mg/kg/day every 3-5 
days to achieve and maintain trough concentrations between 85 to 115 mcg/ml 
(See Section 5.2.2 and 5.2.3). During this time patients will receive standard 
radiation therapy as outlined in Section 9.0. 
 
5.1.3 Post Radiation Phase 
Patients will continue to receive VPA as during XRT.  If necessary, patients 
who had delays in XRT (e.g., secondary to schedule holidays or the need to have 
a new mask made) will complete their radiotherapy to the total prescribed 
protocol dose (See Section 9.0). 
 
5.1.4 Maintenance Phase 
Maintenance therapy will begin 4 weeks after completion of radiation or week 
11, whichever comes first. Patients with new hemorrhage on MRI will not be 
eligible for starting maintenance therapy, with the exception of asymptomatic 
punctate hemorrhage. Patients with improving or resolved pre-existing 
hemorrhage will be permitted to start maintenance treatment.  
 
Patients will continue VPA daily during maintenance therapy. All patients will 
start bevacizumab, 10 mg/kg iv every two weeks, at the start of maintenance 
therapy (See Section 5.3). Maintenance therapy will continue uninterrupted if all 
laboratory tests as outlined in section 6.0 continue to meet on-study criteria as 
defined in Section 4.1.5. In the absence of unacceptable toxicity or disease 
progression, patients will continue to receive protocol treatment for a maximum 
total duration of two years (including the XRT phase). 
 
 
5.2 
Valproic Acid (VPA) Administration and Monitoring Guidelines 
5.2.1 Drug Administration 
Valproic acid will be administered daily in three divided doses.  There will be 
no planned dosing interruptions.  Dose modifications for toxicity are outlined in 
Section 5.4. 
 
5.2.2 Starting Dose and Dose Escalations 
The starting dose of VPA will be 15 mg/kg/day, divided tid. Trough VPA 
concentration (measured 30 to 60 minutes before the next dose) will be 
measured every 3 to 5 days (if day 3 falls on a weekend) to reach a target trough 
VPA concentration of 100 mcg/mL (range, 85-115 mcg/ml). The VPA dose will 


Page 31 of 95 
be adjusted in increments of 5 mg/kg/day to reach the desired trough 
concentration. Patients who initially reached the desired VPA concentration 
range but then required subsequent dose escation(s) to maintain targeted trough 
concentration should also have trough VPA, CBC, and liver functions measured 
every 3-5 days until target is reached. Adjustment of VPA dose MUST be 
calculated based on the most recent weight.  
 
If available, a liquid/syrup preparation of valproic acid is preferred, and the dose 
should be rounded to the nearest 5 mg. Doses with Depakote sprinkles or 
capsule should be rounded down to the nearest 125 mg (unit dose for sprinkles 
or capsule). Use of extended release tablets of valproic acid is not permitted.  
 
Patients/families should attempt to adhere to a strict q 8 hour administration 
schedule (e.g. 7 am - 3 pm -11 pm schedule) as much as possible. Medication 
diaries (see Appendix IV) are required to document compliance. During 
radiation therapy, medication diaries should be checked and faxed weekly. After 
radiation therapy, medication diaries should be checked every 2 weeks and 
faxed every 4 weeks (see section 6.1, Table 5). Diaries should be faxed to 832-
825-1198 and a copy should be kept in the research chart.  
 
5.2.3 Measurement of Trough VPA Concentrations 
Because sampling true trough concentrations prior to the early morning dose 
may be logistically difficult, we recommend that VPA trough concentrations 
should be sampled 30 minutes to an hour prior to the afternoon dose. 
 
Once a patient has reached the targeted trough concentration 85-115 mcg/ml, 
VPA trough concentrations will be measured weekly during radiation therapy, 
and then monthly or as clinically indicated thereafter. 
 
5.3 
Bevacizumab Administration and Monitoring Guidelines 
5.3.1 Drug Administration 
All patients will receive bevacizumab (10 mg/kg iv) every two weeks for a 
maximal duration of therapy of 24 months (including XRT).  The initial infusion 
time will be over 90 minutes. If there is no reaction following the first dose, the 
second dose will be given over 60 minutes, and if tolerated, all subsequent doses 
will be given over 30 minutes.  Immediately after completion of the infusion, 
flush the IV infusion line with 30 mL of 0.9% sodium chloride to run at the 
same rate as the bevacizumab infusion. 
 
5.3.2 Monitoring Guidelines 
a. Use anaphylactic precautions 
b. Monitor vital signs prior to the infusion, every 15 minutes for the first 30 
minutes of the infusion, and then every 30 minutes until completed. 
c. See Table 3 for actions to be taken in the event of an infusional reaction. 
 
5.3.3 Premedication 


Page 32 of 95 
Pre-medication is not required for the first dose of bevacizumab. If a subject 
experiences an infusion–associated adverse event, acetaminophen, steroids, 
diphenhydramine, or other medications may be given for symptom control and 
as premedication for the next infusion; however, the infusion time may not be 
decreased for the subsequent infusion. If the next infusion is well tolerated with 
premedication, the subsequent infusion time may then be decreased by 30 
minutes as long as the subject continues to be premedicated.  If a subject 
experiences an infusion-associated adverse event with the 60-minute infusion 
despite pre-medication, all subsequent doses should be given over 90 minutes. 
Similarly, if a subject experiences an infusion-associated adverse event with the 
30-minute infusion, all subsequent doses should be given over 60 minutes. 
 
5.4  
Valproic Acid Dose Modifications 
Toxicities will be graded according to the NCI Common Terminology Criteria for 
Adverse Events v3.0 (CTCAE) http://ctep.cancer.gov/reporting/ctc.html.  The following 
dose modifications are for adverse events that are possibly, probably or definitely 
related to VPA. 
 
5.4.1  Criteria for Permanent Discontinuation of VPA  
a. Radiographic evidence of new or progressive CNS hemorrhage, except for 
punctate size lesions without clinical symptoms 
b. > Grade 2 CNS hemorrhage (excluding stable, pre-existing hemorrhage) 
c. > Grade 3 non-CNS hemorrhage 
d. Evidence of bone marrow aplasia or myelodysplastic syndrome on a bone 
marrow examination 
e. Need for anti-coagulation therapy 
f. Female patients becoming pregnant while on study 
g. Radiographic evidence of pancreatitis OR > grade 2 elevation in amylase 
and/or lipase, accompanied by abdominal pain, jaundice, vomiting, anorexia, 
or other symptoms possibly attributable to pancreatitis, in the absence of 
other apparent etiologies, such as, but not limited to, trauma or gall stones 
h. > grade 3 encephalopathy, with or without hyperammonemia 
 
5.4.2 Criteria for Discontinuation of VPA During XRT 
a. Interruption of planned radiation, other than mechanical or logistical 
reasons, for greater than 5 consecutive days or for greater than 10 days total. 
b. Any VPA-related adverse event, regardless of grade, that results in the need 
for permanent cessation of VPA therapy (see Section 5.4.1). 
c.  Occurrence of DLT despite maintaining VPA trough concentration < 85 
mcg/ml (see section 5.4.5 below) 
 
5.4.3 Dose Modifications for other Non-Hematological Toxicity During XRT  
5.4.3.1 VPA should be withheld if the patient experiences the following: 
 
a. Any grade 4 non-hematological toxicity 
b. Any grade 3 non-hematological toxicity except: 


Page 33 of 95 
-  Grade 3 nausea and vomiting of fewer than 5 days in duration 
-  Grade 3 transaminase elevation that returns to levels meeting 
initial eligibility criteria within 7 days of VPA interruption and 
does not recur upon re-challenge with VPA 
- 
Grade 3 fever or infection of fewer than 5 days in duration 
- 
Grade 3 hypophosphatemia, hypokalemia, hypocalcemia or 
hypomagnesemia responsive to oral supplementation 
c. Any grade 2 non-hematological toxicity that persists for > 14 days 
and is considered medically significant or sufficiently intolerable 
by patients such that it requires treatment interruption 
d. Any VPA-related adverse event requiring interruption of drug for > 
14 days or which recurs upon drug re-challenge. 
 
5.4.3.2 If the toxicity resolves to meet study eligibility parameters within 14 
days of discontinuation, the patient may resume treatment at a reduced 
dose as outlined in Section 5.4.5. 
 
5.4.4 Dose Modifications for Hematological Toxicity During XRT 
5.4.4.1 VPA should be withheld, and CBCs should be monitored at least twice 
weekly if the patient experiences the following: 
 
a. Grade 4 neutropenia (< 500/mm3) 
b. Grade 3 thrombocytopenia (platelets 25,000 to 50,000/mm3) on 
two consecutive determinations at least 7 days apart 
c. Grade 4 thrombocytopenia (platelet < 25,000/mm3) 
 
5.4.4.2 If the toxicity resolves to meet study eligibility parameters within 14 
days of discontinuation, the patient may resume treatment at a reduced 
dose as outlined in Section 5.4.5. 
 
5.4.5 Restarting VPA After Treatment Interruption  
a. VPA will be re-started at 5 mg/kg/day lower than the previous dose (for 
example, if a patient’s VPA was at 15 mg/kg/day divided tid at the time of 
the toxicity, then he/she should re-start at 10 mg/kg/day divided tid).  
b. VPA trough concentrations should then be monitored every 3-5 days (if day 
3 falls on a weekend), and dose adjustments in 5 mg/kg will be made to 
maintain a trough concentration between 50-85 mcg/ml in the event of a 
dose reduction. 
c. If a patient experiences another toxicity requiring that VPA be interrupted or 
held, despite maintaining the trough VPA concentration below 85 mcg/ml, 
then he/she will complete the remainder of radiation therapy without VPA.  
 
5.4.6 VPA Dose Modification During Post-XRT Period and Maintenance Therapy 
a. For patients that tolerated VPA during XRT, they will continue VPA during 
the post-radiation break and maintenance therapy to maintain the trough 
concentration previously tolerated. Guidelines outlined in section 5.4.1 


Page 34 of 95 
through 5.4.5 will be implemented for any VPA-related toxicities during the 
post-XRT period and during maintenance therapy. 
b. For patients that experience a VPA-related toxicity during maintenance 
therapy, bevacizumab will be administered on schedule, provided that there 
is no other contraindication for bevacizumab (see section 5.5 and Table 3). 
c. Patients who experience VPA-related toxicities during maintenance therapy 
despite maintaining trough concentration below 85 mcg/ml will complete 
maintenance therapy without re-starting VPA. 
d. If VPA is discontinued during XRT (except for any reason outlined in 
Section 5.4.1), VPA should be re-started with the first day of 
maintenance treatment.  The starting dose should be 10 mg/kg/day divided 
tid (or 5 mg/kg/day if patient experienced toxicities previously with 10 
mg/kg/day).  Dose escalations in increments of 5 mg/kg/day can then be 
made as outlined in Section 5.2.2 and 5.2.3 to maintain trough VPA 
concentration of 50-85 mcg/ml. Dose modification will be conducted as 
outlined in 5.4.1 through 5.4.5. 
e. For VPA interruption to accommodate an elective surgical procedure, see 
section 5.7.3b.  
 
5.5 
Bevacizumab Dose Modifications 
Toxicities will be graded according to the NCI Common Terminology Criteria for 
Adverse Events v3.0 (CTCAE) http://ctep.cancer.gov/reporting/ctc.html.  The following 
dose modifications are for adverse events that are possibly, probably or definitely 
related to bevacizumab. 
 
5.5.1 
There will be no dose reductions for toxicity related to bevacizumab. See Table 
3 for actions to be taken for bevacizumab related adverse events. If bevacizumab 
is held and a patient cannot resume treatment before the stipulated time for each 
toxicity, then this patient will discontinue bevacizumab. 
 
5.5.2 
See Appendix V for other toxicities that may possibly, probably or definitely 
attributable to bevacizumab. If a toxicity can be clearly attributed to 
bevacizumab, VPA will be continued while bevacizumab is being held. In the 
event that a toxicity may be attributable to either VPA or bevacizumab and 
requires treatment modification, then BOTH VPA and bevacizumab treatment 
will be modified accordingly. 
 
5.5.3 
For bevacizumab interruption to accommodate an elective surgery, see section 
5.7.3a. 
 
 


Page 35 of 95 
 
Proteinuria 
Proteinuria should be monitored by urine analysis for urine protein 
creatinine (UPC) ratio prior to every other dose of bevacizumab.  If UPC 
ratio is >1.0, obtain 24-hour urine collection for protein estimation 
Urine protein 
 < 3.5 gm/24 hrs 
Continue bevacizumab. 
UPC protein  
> 3.5gm/24 hrs 
Hold bevacizumab until urine protein is < 3.5 gms / 24 
hours.  If therapy is held for > 8 weeks due to proteinuria, 
discontinue bevacizumab.  
Grade 4 or 
nephrotic 
syndrome 
Discontinue bevacizumab. 
TABLE 3: Recommended Action for Bevacizumab Related Adverse Events 
Event 
CTCAE.v3.0 
Grade 
Action to be Taken 
Allergic reactions, 
 
or 
 
Acute infusional 
reactions/cytokine 
release syndrome 
Grade 1-3 
If infusion-related or allergic reactions occur, premeds 
should be given with the next dose, and infusion time may 
not be reduced for the subsequent infusion. 
 
For patients with Grade 3 reactions, 
Bevacizumab infusion should be stopped and not restarted 
on the same day.  At the physicians’ discretion, 
bevacizumab may be permanently discontinued or re-
instituted with premeds and at a rate of 90+15 min.  
 
If bevacizumab is re-instituted, the patient should be 
closely monitored for a duration comparable to or 
longer than the duration of the previous reactions. 
Grade 4 
Discontinue bevacizumab 
Arterial Thrombosis 
 Cardiac 
ischemia/infraction 
 CNS ischemia (TIA, 
CVA) 
 Any peripheral or 
visceral arterial 
ischemia/thrombosis 
 
Any 
Discontinue bevacizumab 
Venous Thrombosis 
Any 
Discontinue bevacizumab 
Hypertension 
[Treat with anti-hypertensive medication as needed. The goal of BP control 
should be consistent with general medical practice] 
Controlled BP Continue bevacizumab 
Persistent or 
symptomatic 
HTN 
Hold bevacizumab.  If treatment is delayed for > 4 weeks 
due to uncontrolled hypertension, discontinue 
bevacizumab. 
Grade 4 
Discontinue bevacizumab 


Page 36 of 95 
TABLE 3: Recommended Action for Bevacizumab Related Adverse Events 
Event 
CTCAE.v3.0 
Grade 
Action to be Taken 
CNS hemorrhage  
(except punctuate lesions) 
Any Grade 
Discontinue bevacizumab. 
Hemorrhage 
Grade 3 
 Hold bevacizumab until ALL of the following criteria 
are met: 
 the bleeding has resolved and Hgb 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. 
Wound dehiscence requiring medical or 
surgical intervention 
Discontinue bevacizumab. 
Reversible Posterior 
Leukoencephalopathy syndrome 
(RPLS) 
 BV should be held in patients with symptoms/signs 
suggestive of RPLS, pending work-up and 
management, including control of blood pressure.  
BV should be discontinued upon diagnosis of RPLS. 
GI perforation, GI leak or fistula 
Discontinue bevacizumab. 
Metaphyseal dysplasia (on plain X-ray 
or MRI) 
Discontinue bevacizumab 
Other clinically 
significant AEs 
attributable to 
bevacizumab (except 
controlled 
nausea/vomiting). 
Grade 3 
 Hold bevacizumab until symptoms resolve to < grade 2. 
 If treatment delay is > 4 weeks due to toxicity, 
discontinue bevacizumab. 
 
Grade 4 
 Discontinue bevacizumab. 
 Upon consultation with the study chair, resumption 
of bevacizumab may be considered if a patient is 
benefiting from therapy, and the G4 toxicity is 
transient, has recovered to < grade 2 and unlikely to 
recur with retreatment. 


Page 37 of 95 
5.6 
Discontinuation of Either VPA or Bevacizumab During Maintenance Treatment 
 
If either VPA or bevacizumab must be discontinued during maintenance treatment as 
defined in section 5.4 or 5.5, patients/parents and treating physicians have the option of 
keeping patients on study and continue receiving either agent alone. Patients/parents 
may also choose to come off treatment and seek other therapeutic options. 
 
5.7 
Supportive Care 
5.7.1 
Infusional reactions 
 
Routine premedication is not required for the first dose of bevacizumab. If 
infusional reactions occur, then the infusion should be stopped and 
acetaminophen, diphenhydramine, steroids, or other medications may be given 
for symptom control and for premedication as needed (see section 3.2.5 for 
adjustment of infusion length). Anaphylactic precautions should be observed 
during bevacizumab administration. 
 
5.7.2 
Hypertension 
Patients will have their blood pressure monitored every 2 weeks prior to each 
infusion of bevacizumab.  Anti-hypertensive therapy should be initiated and 
increased as needed per routine practice to maintain SBP and DBP < 95% for 
age (see Appendix III). 
 
5.7.3 
Surgery and wound healing:  
a. Bevacizumab-related concerns: 
If patients on treatment with bevacizumab require elective major surgery 
(see Table 4), it is recommended that bevacizumab be held for 4-8 weeks 
prior to the surgical procedure. Patients undergoing a major surgical 
procedure should not restart bevacizumab until 4 weeks after that 
procedure (in the case of high risk procedures such as liver resection, 
thoracotomy, or neurosurgery, it is recommended that bevacizumab not to 
be restarted until 8 weeks after surgery). For elective intermediate surgical 
procedures (see definition below), bevacizumab should be discontinued at 
least 2 weeks prior to surgery, and for elective minor procedure, 
bevacizumab should be discontinued at least 7 days prior to surgery. 
 
Table 4: Examples of Major, Intermediate, or Minor Surgical Procedures 
Major  
Intermediate  
Minor Procedures 
Major craniotomy for 
tumor resection 
Central line placement 
Incision and drainage of 
superficial skin abscess 
Organ resection 
Paracentesis 
Punch biopsy of skin lesions 
Bowel wall anastamosis 
Thoracocentesis 
Superficial skin suturing 
Arteriovenous grafts 
 
Bone marrow aspirate or biopsy 
Exploratory laparotomy 
 
Fine needle aspiration 
Thoracotomy 
 
PICC line placement 
 
 


Page 38 of 95 
b. Valproic acid-related concerns: 
Valproic acid can adversely affect platelet function and coagulation. For 
all elective surgical procedures, VPA should be withheld for a minimum of 
seven days, and pre-operative PT, PTT, platelet aggregation study, 
fibrinogen, and a von Willebrand panel should be performed. Prophylactic 
platelet transfusions should be considered for patients with a platelet count 
< 100,000/ mm3. Patients with any abnormal coagulation parameters 
should receive appropriate supportive care with blood or factor support. 
VPA should not be resumed until patient’s risk for post-operative bleeding 
is deemed minimal by the surgeons, and VPA should be started at the same 
dose as patient was receiving prior to surgery. Patients undergoing 
emergent surgical procedures should be supported as clinically indicated. 
 
5.7.4 
Proteinuria: Proteinuria will be monitored by urine protein:creatinine (UPC) 
ratio (see Appendix II) at least every 4 weeks.  
 
5.7.5 
Central venous catheters: Treatment via central venous catheters is 
recommended but not required. Placement of central venous catheters should 
be performed at least 2 weeks prior to initiating bevacizumab. Placement of a 
PICC line should be performed at least 48 hours before starting bevacizumab.  
 
5.7.6 
Concomitant medications:  
a. Concomitant use of other anti-convulsants is strongly discouraged. 
b. The routine use of growth factors (GCSF, GM-CSF, and erythropoietin) is 
not permitted, except for febrile neutropenia and/or sepsis.  
c. Appropriate antibiotics, blood products, antiemetics, fluids, electrolytes, and 
general supportive care are to be used as deemed clinically necessary by the 
treating physicians. 
d. Concomitant medications that may impact platelet function (e.g., ibuprofen 
or aspirin) or decrease platelet number should be avoided.   
e. See section 3.1.8 for VPA interactions with other medications. 
 
5.7.7 
Elevated MCV: In the event of a persistent elevation of MCV > 2 SD of age-
adjusted mean for two consecutive determinations at least 2 weeks apart and 
persistent > grade 3 cytopenias of at least two cell lines for at least 2 weeks, 
VPA should be withheld, and a bone marrow examination should be 
performed to rule out bone marrow aplasia or myelodysplastic syndrome. 
 
5.7.8 
Hepatitis/pancreatitis: In the event of unexplained abdominal pain, jaundice, 
vomiting, anorexia, weight loss, or other symptoms possibly attributable to 
hepatitis and/or pancreatitis, amylase/lipase, ALT, bilirubin, fibrinogen, and an 
abdominal ultrasound should be performed immediately, and VPA should be 
withheld pending the results of these tests.  
 
Patients who experience radiographic documentation of pancreatitis OR > 
grade 2 elevation in amylase/lipase accompanied by abdominal pain, jaundice, 


Page 39 of 95 
vomiting, anorexia, or other symptoms possibly attributable to pancreatitis, in 
the absence of other apparent etiologies, such as, but not limited to, trauma or 
gall stones, will discontinue VPA for the remainder of protocol therapy. 
 
5.7.9 
Hyperammonemia, encephalopathy, and carnitine supplementation: 
Hyperammonemia has been reported in association with VPA despite normal 
liver function tests. In patients who develop unexplained lethargy, vomiting, 
and/or changes in mental status, hyperammonemic encephalopathy should be 
considered, and an ammonia level should be checked immediately. In patients 
with > grade 3 encephalopathy, with or without hyperammonemia, VPA 
should be discontinued for the remainder of protocol therapy, and evaluations 
for urea cycle disorders should be considered, if clinically indicated. In 
patients with hyperammonemia encephalopathy, intravenous L-carnitine 
should be considered with other supportive measures (109, 110). 
 
Individual investigators may elect to supplement L-carnitine, at 50-100 
mg/kg/day, divided bid or tid, not to exceed 3 gram/day. Carnitine 
supplementation has been shown to ameliorate the CNS symptoms in those 
children with carnitine depletion as a result of VPA administration. 
 


Page 40 of 95 
6.0 
EVALUATION AND MEASUREMENT TO BE OBTAINED 
6.1 Required Observation During Protocol Therapy 
Laboratory tests to determine eligibility for protocol therapy must be obtained within 7 days of study registration/entry. MRI of 
brain +/- spine must be obtained within 2 weeks prior to study registration/entry and must include gradient echo imaging 
(GRE) sequences for identifying CNS/intra-tumoral hemorrhage. Histologic verification of tumors is required for all 
patients, except for those with a typical intrinsic brainstem glioma (see section 4.1).  
 
TABLE 5: Clinical, Laboratory, and Radiographic Assessments Required for Protocol Therapy 
 
Pre-XRT and 
XRT Phase 
Post -XRT 
Maintenance Treatment 
 
Study 
Entry 
Q Wk 
Q 2Wks  
Week 
10 
Pre
-Rx 
Q 2Wks Q 4Wks 
Q 12 
Wks 
Q 24 
Wks 
PHYSICAL EXAM 
 
 
 
 
 
 
 
 
 
History & Physical, 
including neuro exam 
X 
X 
X 
 
X 
 
 X1 
 
 
Vital Signs,  
X 
X 
X 
 
X 
 
 X1 
 
 
Performance Status 
X 
X 
X 
 
X 
 
X 
 
 
Height/Weight/BSA 
X 
X 
X 
 
X 
 
X 
 
 
Blood Pressure 
X 
X 
X 
 
X 
X 
 
 
 
LABORATORY  
 
 
 
 
 
 
 
 
 
CBC, diff, platelets 
X 
 X2 
 X2 
 
 X2 
  
 X2 
 
 
Lytes. BUN/Cr, Albumin 
X 
 
 
 
X 
 
X 
 
 
ALT, AST, bilirubin 
X 
 X2 
 X2 
 
X 
 
 X2 
 
 
Amylase & Lipase 
X 
 
 
 
X 
 
 
 
 
Urine protein/Cr3 
 X3 
   
 
  
 X3 
 
 X3 
 
 
PT, PTT & INR 
X 
 
 
 
X 
 
 
 
 
Pregnancy test4 
 X4 
 
 
  
 X4 
 
 
  
 
CSF cytology 
 X5 
 
 
 X5 
  
  
 
X5 
  
Valproic acid levels6 
See Guidelines in Sections 5.2.3 
Correlative Biology  
 X7 
 
 
 
 
 
 
 
 
Imaging Studies 
 
 
 
 
 
 
 
 
 
MRI of brain 
X 
 
  
  X8 
 
  
X10 
X9 
 
MRI of spine 
   X11 
 
   
   X11 
 
   
 
 X11 
  
X-ray of right knee12 
    
 
 
 
 X12 
 
 
 
 X12 
Patient Diary13 
 
 X13 
 X13 
  
 X13 
 X13 
 X13 
 
 


Page 41 of 95 
 
1 
For patients with newly identified punctate hemorrhage on MRI, physical exam, neurological assessment, and performance 
status should be evaluated every 2 weeks at least twice to closely monitor for signs/symptoms of worsening hemorrhage. 
2 
Patients with grade 4 neutropenia, anemia, and/or thrombocytopenia should have CBC checked twice weekly until the 
cytopenia(s) improves to grade 3 or better. Patients who require a subsequent dose escalation to maintain targeted trough 
concentration should also have trough VPA, CBC, and liver functions measured every 3-5 days until target is reached. 
3 
See Appendix II for Urine/Protein Creatinine ratio 
4 
For female patients of child-bearing potential 
5 
CSF cytology at the time of diagnosis and subsequently during protocol therapy should be performed as clinically indicated but 
is not required for study entry. 
6 
See Section 5.2.3 for monitoring valproic acid concentrations. 
7 
See section 7.0 for requirement and timing for correlative biology studies. 
8   For patients with possible radiographic progression on week 10 MRI, the next MRI should be performed at week 18 (see 
section 8.3). If week 18 MRI shows stable disease or better compared to week 10 MRI, then patients will continue MRI every 
12 weeks. 
9 
During maintenance therapy, MRI of brain, including GRE images, should be performed every 12 weeks until completion of 
protocol therapy.  
10  For patients with newly identified punctate hemorrhage on MRI, the next MRI, including GRE images, should be repeated 
every 4 weeks at least twice to monitor possible progression of hemorrhage. In the absence of radiographic progression of 
hemorrhage, the frequency of MRI studies can then return to every 12 weeks. 
11 For patients with high-grade gliomas, an MRI of spine should be performed at the time of study entry, but subsequent MRI of 
spine should only be repeated as clinically indicated. 
12 Pre-treatment tibial X-ray (AP and lateral views) of the right knee should be obtained in all patients younger than 16 years of 
age prior to starting maintenance therapy and repeated every 24 weeks while receiving bevacizumab. If abnormalities of the 
metaphyseal plates are detected on routine X-rays following initiation of treatment, an MRI scan of both knees should be 
performed. 
13 Medication diaries and treatment roadmaps should be checked and faxed weekly during radiation therapy. After completion of 
XRT, medication diaries and treatment roadmaps should be checked every 2 weeks and faxed every 4 weeks. Diaries should be 
faxed to 832-825-1198. Maintain copies of the patient diary in the research chart.  


 
 
Page 42 of 95
 
6.2   
Required Observations After Completion of Protocol Therapy 
After completion of protocol therapy, patients should have the following assessments and 
laboratory tests every 6 months for a minimum of 5 years, or until off study (Section 
10.5): history and physical examination, vital signs, including blood pressure, CBC with 
differential, urine protein:creatinine ratio, and MRI to assess disease status. Obtain all 
other tests as required for good clinical care. Complete Appendix VII: Protocol Roadmap 
for Follow-up and Fax to 832-825-1198 every six months. 
 
7.0  
BIOLOGIC CORRELATIVE STUDIES 
7.1 
Frozen Tissue Submission  
7.1.1 Proteins related to histone deacetylation (histone H3 and H4 acetylation, HDAC 1 
and 2), NHEJ (Ku70/Ku80, DNA-PK) and HRR (Rad51, BRCA1/2) pathway, 
tumor angiogenesis (VEGF, VEGF receptor 2), and tumor hypoxia (CD31, CA9, 
hypoxia-inducible factor 2) will be quantified by Western analysis if sufficient 
frozen tumors resected at diagnosis and/or at later time points are available. 
 
7.1.2 MGMT and PARP activity will be assessed by enzymatic assays in frozen tumors, 
if available. 
 
7.1.3 Submission of frozen tumor specimens is strongly encouraged. A minimum 
of 250 mg (wet weight prior to being frozen in liquid nitrogen; approximately 
1.5 x 1.5 x 1.5 cm of tumor sample) of tumor specimen is preferred. Please 
coordinate with neurosurgery and pathology in advance to ensure timely 
collection and freezing of tumors. In patients whose tumors are only biopsied, 
submission of as much frozen tumor specimen as possible is strongly encouraged, 
and Formalin-fixed, paraffin-embedded (FFPE) tumor blocks should also be 
submitted. 
 
7.1.4 Frozen tumors should be shipped on dry ice via over-night express delivery on 
Monday through Thursday. If a tumor is resected on Friday or over the weekend, 
the frozen specimen should be kept at –800C over the weekend and shipped on 
Monday. FFPE tumor blocks and unstained tumor section slides should be 
shipped at room temperature. Specimen Transmittal Form (Appendix VI) must 
accompany all shipments. All specimens should be shipped to the following 
address: 
 
Jack Su, MD 
Attention: Elizabeth Hinojosa 
Feigin Center, Baylor College of Medicine 
1102 Bates Street, Rm 1030 
Houston, Texas 77030 
(832) 824-4688 or (832) 822-4306 
 
7.2 
Slides for Immunohistochemistry Studies 
7.2.1 In patients with insufficient frozen tumor obtained for analysis of molecular 
markers outlined in 7.1.1, similar analysis will be performed by 
immunohistochemistry (IHC) in FFPE tumor blocks. Ten to twelve unstained 


 
 
Page 43 of 95
PLUS glass slides, containing 5-micron thick tumor sections from FFPE 
tumor blocks will be requested for performing studies outlined in 7.1.1. 
 
7.2.2 Specimen Transmittal Form (Appendix VI) must accompany all shipments. Slides 
should be shipped to Dr. Jack Su at the address provided in Section 7.1.4.  
 
7.3. 
Blood Samples Submission 
7.3.1 NHEJ activity, HDAC2 level, and histone acetylation in PBMCs: PBMCs will be 
isolated using Lymphoprep solution (Axis-Shield, Oslo, Norway), and protein 
lysates will be prepared by standard techniques. NHEJ activity will be analyzed 
via a published assay (119).  HDAC2 level will be quantified using Western 
analysis. Histone acetylation will be quantified using either Western analysis or a 
PathScan® Acetylated Histone H3 and H4 Sandwich ELISA Kit (Cell Signaling, 
Danvers, MA). 
 
7.3.2. Sampling Schedule (See Appendix VI) 
Blood samples should be collected prior to starting VPA and radiation, and then 
after completing two weeks of VPA and radiation (any weekday, except Friday, 
during 3rd week of radiation).  
 
7.3.3. Sample Collection and Handling Instructions 
Whole blood samples (a minimum of 5-10 ml for children < 12 kg, and 10-20 ml 
for children > 12 kg) should be collected in either heparinized (green tops, 
either sodium or lithium heparin is acceptable) or ACDA (yellow top) tubes.  
ACDA tubes are preferred if available. DO NOT collect blood samples on a 
Friday.  
 
7.3.4. Sample Processing 
No processing is required. Keep the whole blood at room temperature until the 
time of shipping.  
 
 
 
7.3.5. Sample Labeling 
Each tube must be labeled with the patient’s study ID number, and the date and 
time the sample was drawn.  Data should be recorded on the Correlative Study 
Form (Appendix VI), which must accompany the sample(s). 
 
7.3.6. Sample Shipping Instructions 
Each sample should be shipped immediately on the day of collection.  Please 
follow packaging instruction on the Specimen Transmittal Form (Appendix VI) 
Samples should be shipped by priority overnight via express carrier (Monday 
through Thursday only). Between April and October, please ship with an ice 
pack placed in the Styrofoam box (ice pack should not be placed directly next to 
the samples). 
 
Jack Su, MD 
Attention: Elizabeth Hinojosa 
Feigin Center, Baylor College of Medicine 
1102 Bates Street, Rm 1030 
Houston, Texas 77030 


 
 
Page 44 of 95
(832) 824-4688 or (832) 822-4306 
 
Prior to shipping, please contact Dr. Jack Su (832-822-4306 or jmsu@txccc.org), 
Dr. Li (832-824-4580 or xxli@txccc.org), or Elizabeth Hinojosa (832-824-4688) 
for notification of sample shipment. 
 
 
8.0 
EVALUATION CRITERIA 
 
8.1 
Response Criteria for Patients with Measurable CNS Tumors 
8.1.1 Measurable Disease 
The presence of at least one lesion that can be accurately measured in at least one 
dimension with the longest diameter at least 10 mm.  The investigator will 
identify up to 10 measurable lesions to be followed for response. 
 
8.1.2 Complete Response (CR)  
No evidence of disease at the primary tumor site. Patient is not on any steroids 
with stable or improving neurological examination.  
 
8.1.3 Partial Response (PR) 
A greater than 50% reduction in the product of the greatest tumor diameter and its 
perpendicular diameter on MRI scan, on a stable or decreasing dose of steroids with a stable 
or improving neurologic examination. 
 
8.1.4 Minor Response (MR) 
 A greater than 25% but less than 50% reduction in the product of the greatest tumor 
diameter and its perpendicular diameter on MRI scan, on a stable or decreasing dose of 
steroids with a stable or improving neurologic examination. 
 
8.1.5 Stable Disease (SD)  
A less than 25% reduction in the product of the greatest tumor diameter and its 
perpendicular diameter on MRI scan, on a stable or decreasing dose of steroids 
with a stable or improving neurologic examination. 
 
8.1.6 Progressive Disease (PD) 
Progressive Disease (PD) will be defined as a more than 25% increase in tumor 
size radiographically or the emergence of new lesions or CSF positivity. 
 
8.2 
Response Criteria for Patients with Evaluable CNS Tumors 
8.2.1 Evaluable Disease 
The presence of at least one lesion that cannot be accurately measured in at least 
one dimension (< 10 mm). Such lesions may include but are not limited to 
leptomeningeal tumor deposits and CSF positivity for tumor cells.  
 
8.2.2 Complete Response 
Disappearance of all evaluable disease. 
 
8.2.3 Partial response 
Partial responses cannot be determined in patients with evaluable disease 
 
 


 
 
Page 45 of 95
8.2.4 Stable Disease 
Any response that does not meet the criteria for complete response or progressive 
disease. 
 
8.2.5 Progressive Disease 
The appearance of one or more new lesions or evidence of laboratory, clinical, or 
radiographic progression. 
 
 
8.3 
Best Response 
Two objective determinations of disease status by MRI, obtained on two consecutive 
determinations, separated by at least a four week time period, are required to determine 
the patient’s overall best response (see Table 6).  Two objective status determinations of 
CR before progression are required for best response of CR.  Two determinations of PR 
or better before progression, but not qualifying for a CR, are required for a best response 
of PR.  Two determinations of stable/no response or better before progression, but not 
qualifying as CR or PR, are required for a best response of stable/no response; if the first 
objective status is unknown, only one such determination is required.  Patients with an 
objective status of progression on or before the second evaluations will have a best 
response of progressive disease.  Best response is unknown if the patient does not qualify 
for a best response of progressive disease and if all objective statuses after the first 
determination and before progression are unknown. 
 
Due to radiation related edema and inflammation, patients can show radiographic images 
suggestive of disease progression within the first two months after radiation, and these 
MRI findings then improve or resolve over the next 6-8 weeks. Therefore, for patients 
whose MRI images at week 10 suggest possible tumor progression, they should remain 
on study, start maintenance therapy, and repeat MRI around week 18. Patients with stable 
disease or better at week 18 (compared to week 10) will continue protocol therapy, and 
patients with progressive disease will come off protocol treatment. 
 
Table 6.  Sequences of objective statuses with corresponding best response. 
1st Status 
2nd Status 
3rd Status 
Best Response 
Progression1 
 
 
Progressive disease 
Stable, PR, CR 
Progression 
 
Progressive disease 
Unk 
Progression 
 
Progressive disease 
Stable 
Stable 
Progression 
Stable 
Stable, Unk 
PR, CR 
Progression 
Stable 
Stable, Unk 
Unknown 
Progression 
Unknown 
PR 
PR 
Progression 
PR 
PR 
CR 
Progression 
PR 
PR, CR 
Unknown 
Progression 
Unknown 
CR 
CR 
Progression 
CR 
Unknown 
Stable 
Progression 
Stable 
1 Except if week 10 MRI shows progressive disease, then the repeat MRI obtained around 
week 18 will be compared to week 10 MRI for the first response assessment. 
 
 
9.0 
RADIATION THERAPY GUIDELINES 


 
 
Page 46 of 95
Radiation therapy must begin within 30 days of surgery or radiographic diagnosis, whichever is 
the later date. Date of radiographic diagnosis or definitive surgical procedure is considered day 1, 
and radiation treatment must start no later than day 31. Primary brain malignant gliomas will 
receive a total dose of between 54.0 and 59.4 Gy in 30-33 fractions over 6-7 weeks. The total 
dose will be 54.0 Gy for completely resected tumors and brainstem gliomas. The total dose will 
be 59.4 Gy if the tumor is located in the brain but not the brainstem, and the tumor was 
incompletely resected. Primary spinal cord malignant gliomas will receive a total dose of 
between 50.4-54 Gy in 28-30 fractions over 5 - 6 weeks.   
 
 
9.1  
Equipment 
Modality: X-rays with nominal energy of 4 MV or greater or proton beam. 
 
9.2  
Target Volumes 
RT volumes for this study will be determined by the collective information that 
delineates the extent of disease both prior to and following surgical resection or biopsy. 
The required imaging studies are a contrast-enhanced pre-operative MRI scan, a contrast-
enhanced post-operative MRI scan (unless only a biopsy was performed), and a radiation 
treatment planning CT scan with the patient in the treatment position. Use of fusion 
image registration software is encouraged, if available. 
 
9.2.1 Gross Tumor Volumes (GTV) 
The GTV-1 will include all the tissues initially involved with disease and the 
entire residual tumor defined by the pre-operative and post-operative MRI scans. 
The GTV-1 will include both enhancing and non-enhancing areas of the tumor. 
The GTV-1 will take into account any changes in brain anatomy that have 
occurred as a result of tumor resection and/or CSF shunt placement. T-1, T-2, and 
FLAIR sequences of the MRI scans should all be reviewed, and the sequence that 
best defines the extent of initial disease should be used to determine the GTV-1. 
The GTV-2 will include only the residual tumor seen on the post-operative MRI 
scan. The GTV-2 will include both enhancing and non-enhancing areas of the 
residual tumor. T-1, T-2, and FLAIR sequences of the post-operative MRI scan 
should all be reviewed, and the sequence that best defines the extent of residual 
disease should be used to determine the GTV-2. If only a small biopsy has been 
performed, the GTV-2 may be identical to the GTV-1. If the tumor has been 
completely resected, there will not be a GTV-2 and the radiation therapy course 
will end with completion of the initial radiation fields. 
 
9.2.2  Clinical Target Volumes (CTV) 
The CTV includes the GTV with an added margin that is intended to treat 
subclinical microscopic disease and is anatomically confined. This means that 
margins of the CTV may be manually moved inward to the inner table of the bony 
calvarium or (for spinal cord tumors) the spinal canal. The CTV-1 will include the 
GTV-1 plus a 2 cm margin in all dimensions. For primary spinal cord tumors, the 
CTV-1 will be expanded in the cranial and caudal directions to include 2 vertebral 
bodies above and 2 vertebral bodies below the GTV-1. The CTV-2 will include 
the GTV-2 plus a 1 cm margin in all dimensions. For primary spinal cord tumors, 
the CTV-2 will be expanded in the cranial and caudal directions to include 1 
vertebral body above and 1vertebral body below the GTV-2. If there is not a 
GTV-2, there will not be a CTV-2. 


 
 
Page 47 of 95
 
9.2.3  Planning Target Volumes (PTV) 
The PTV includes the CTV with an added margin that is intended to account for 
patient movement and set-up variability. The treating radiation oncologist will 
select a margin between 3 and 5 mm that reflects the variability appropriate for 
the individual patient and facility. The PTV-1 will include the CTV-1 plus a 3-5 
mm margin in all dimensions. The PTV may extend beyond bone margins, but 
shall not extend beyond the skin surface. The PTV-2 will include the CTV-2 plus 
a 3-5 mm margin in all dimensions. The PTV may extend beyond bone margins, 
but shall not extend beyond the skin surface. If there is not a CTV-2, there will 
not be a PTV-2. 
 
9.3  
Target Dose 
9.3.1  Prescription Point 
The prescription point is at or near the isocenter. If IMRT is used, dose may be 
prescribed to an isodose surface that encompasses the PTV provided that the dose 
uniformity requirements in Section 9.3.5 are satisfied. 
 
9.3.2  Dose Definition 
                                    Dose is specified in Gy to muscle. 
 
9.3.3 Tissue Heterogeneity 
Calculations that take into account tissue heterogeneity are required for CT-based 
planning techniques. 
 
9.3.4  Prescription Point and Fractionation 
9.3.4.1 Planning Target Volume 1 (PTV-1) 
For brain tumors, the total dose to the PTV-1 prescription point will be 
54 Gy given in 30 fractions of 1.8 Gy each. For spinal cord tumors, the 
total dose to the PTV-1 prescription point will be 45 Gy given in 25 
fractions of 1.8 Gy each. The patient will be treated with one fraction per 
day. All fields will be treated each day. The total dose to the prescription 
point will be 54 Gy given in 30 fractions. The patient will be treated 
with one fraction per day with all fields treated per day. 1.80 Gy will be 
delivered to the isocenter. 
 
9.3.4.2 Planning Target Volume 2 (PTV-2) 
This boost is delivered only to those patients with gross residual disease 
other than brainstem tumors. For brain tumors with gross residual 
disease, the total boost dose to the PTV-2 prescription point will be 5.4 
Gy given in 3 fractions. The cumulative dose to the prescription point 
will be 59.4 Gy. The patient will be treated with one fraction per day. 
All fields will be treated each day. For spinal cord tumors with gross 
residual disease, the total boost dose to the PTV-2 prescription point will 
be between 5.4 Gy given in 3 fractions and 9 Gy given in 5 fractions. 
The treating radiation oncologist will prescribe between 3 and 5 
fractions based on his/her practice. The cumulative dose to the 
prescription point will be between 50.4 and 54 Gy. 
 


 
 
Page 48 of 95
9.3.5  Dose Uniformity 
For standard planning techniques, the dose variation in the PTV shall be within 
+7% and -5% of the prescribed dose. For conformal planning techniques (3D 
conformal and IMRT), the entire PTV shall be encompassed within the 95% 
isodose surface and no more than 10% of the PTV should receive more than 
110% of the prescription dose, as evaluated by dose volume histogram. 
 
9.3.6  Treatment Interruptions 
No treatment breaks in the radiation therapy component of this combined 
modality treatment are anticipated. Skin reactions should be treated supportively. 
Low blood counts are generally related to systemic therapy and are not caused or 
worsened by local field brain RT. 
 
9.4 
Treatment Technique 
 
9.4.1 Treatment Planning 
Two-dimensional or conformal (three dimensional) planning may be used in this 
study. 
 
9.4.2  Patient Position and Immobilization 
Reproducible setups are critical and the use of immobilization devices such as 
thermoplast mask, biteblock, etc. should be used for all pediatric patients and 
must be used for patients being treated with IMRT. 
 
9.4.3  Field Shaping 
Field shaping can be done with blocks or multi-leaf collimation. 
 
9.5 
Normal Tissue Sparing 
 
9.5.1  Lenses of the Eyes 
The lenses of the eyes must be excluded from the primary beam by the use of 
shielding blocks that are at least 5 HVL thick. 
 
9.5.2  Optic Nerve and Chiasm 
Whenever possible without shielding gross tumor, the dose to the optic nerves and 
chiasm should not exceed 54.0 Gy and the dose to the retinas of the eyes should 
not exceed 45.0 Gy, including the dose from the boost. 
 
9.5.3  Spinal Cord 
The dose to the spinal cord within the PTV shall not exceed 54 Gy. The dose to 
the spinal cord more than 5 mm outside the PTV should not exceed 46 Gy. 
 
10.0 
STATISTICAL CONSIDERATION  
 
10.1 
Sample Size and Study Duration 
There will be two major subgroups of patients: 
a. Patients with high-grade gliomas (GBM, anaplastic astrocytoma) 
b. Patients with other gliomas (gliosarcoma, gliomatosis cerebri, or diffuse intrinsic 
brainstem gliomas) 


 
 
Page 49 of 95
 
EFS and OS will be analyzed separately for each group. 
 
For high-grade gliomas, 30 patients will be enrolled over 3 years, with a minimum 
follow-up of 24 months. Using a one-year EFS of 36% for children with GBM in 
ACNS0126, this sample size will achieve 90% power (using a one-sided  = 0.05) in 
detecting a 20% improvement in one-year EFS (from 36% to 56%) in comparison. If only 
21 patients are enrolled, the proposed study will achieve 80% power in detecting a 20% 
improvement in one-year EFS.  
 
For other gliomas, the 1-year EFS of 17% for children with newly diagnosed brainstem 
gliomas from CCG-9941 (10) will be used for comparison. If 26 patients from this group 
are enrolled, this study will achieve 90% power (using a one-sided  = 0.05) in detecting 
a 20% improvement in one-year EFS (from 17% to 37%). If only 19 patients are enrolled, 
the proposed study will achieve 80% power in detecting a 20% improvement in one-year 
EFS. These calculations were performed for one-arm survival studies under the 
assumption of exponentially distributed endpoints. 
 
Based on the number of children newly diagnosed with high-grade gliomas in Texas in 
2006, we anticipate an accrual of 1-2 patients with high-grade gliomas per month. 
 
10.2 
Study Design and Data Analysis 
Toxicities will be described separately for the radiation phase (VPA and radiation) and 
the maintenance phase (VPA and bevacizumab) treatment.  
 
For the radiation phase of treatment, if more than one-third of patients enrolled (i.e. 
greater than two of the first three, three of the first six, four of the first nine patients, etc.) 
required discontinuation of VPA, as outlined in section 5.4.1 and 5.4.2, then all 
subsequent patients will receive radiation therapy without valproic acid. Patients who 
required discontinuation of VPA during XRT and subsequent patients who received XRT 
without VPA because this combination is considered not tolerable (as described 
previously) will still receive VPA and bevacizumab during maintenance, provided that 
there is no contraindication to VPA as described in 5.4.1. 
 
For the maintenance phase of treatment, if more than one-third of patients enrolled 
experienced  toxicities that require DISCONTINUATION OF BOTH VPA and 
bevacizumab (as defined in section 5.4 and 5.5), subsequent patients will not receive this 
combination of treatment.  Dose modifications due to toxicities that may be attributed to 
a single drug are addressed in sections 5.4-5.6. 
 
The Kaplan-Meier method will be used to estimate the one-year and two-year EFS and 
OS for each group with 95% confidence intervals. The one-sample logrank test (120) will 
be used to test for significant improvement in survival compared to the above-referenced 
historical trials for each group. Similar analyses will be performed for subgroups of 
children with completed resected and subtotally resected tumors.  
 
Although tumor response is not the primary endpoint of this trial, for patients with 
residual tumors after initial surgery or at the start of maintenance therapy, tumor response 
rate to radiation and VPA or to VPA and bevacizumab will be summarized by calculating 


 
 
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response rates along with exact 95% binomial confidence intervals.  Response will be 
documented by MRI at intervals outlined in Table 6.0 or as clinically indicated. 
Responses will be defined according to the criteria listed in Section 8.0. 
 
10.3 
Measurement of Effect 
10.3.1 Response Criteria 
 
See section 8.0 for assessment of best tumor response to treatment. 
 
10.3.2 Event Free Survival (EFS) 
 
Interval of time between study entry and documentation of disease progression 
(clinical or radiographic), secondary malignancy, death from other causes, or date 
of last follow-up. 
 
10.3.3 Overall Survival 
Interval of time between diagnosis and death due to any cause, or date last follow-
up. 
 
10.4 
Off Treatment Criteria 
10.4.1 
Disease progression as outlined in Section 8.0 
10.4.2 
Unacceptable toxicity as outlined in Section 5.4 and 5.5 
10.4.3 
Clinical progression manifested by deteriorating mental status, new or 
worsening neurological findings, or other symptoms/findings felt to be 
consistent with disease progression by the treating physician 
10.4.4 
Development of a medical or psychiatric illness, that in the investigators 
judgment renders the patient incapable of further therapy on this protocol. 
10.4.5 
The patient, parent or legal guardian refuses further treatment on this protocol. 
10.4.6 
Completion of all protocol defined treatment. 
10.4.7 
Pregnancy 
10.4.8 
Second malignant neoplasm 
10.4.9 
Need for anti-coagulation therapy 
10.4.10 Non-compliance that in the opinion of the investigator does not allow for 
ongoing participation 
10.4.11 Treating physician determines that continued participation is not in the patient’s 
best interest. 
 
Patients who have an on-going bevacizumab-related grade 4 or serious adverse event at 
the time of discontinuation of protocol therapy will be followed until resolution of the 
event or until the event is considered irreversible. 
 
10.5 
Off Study Criteria 
10.5.1 
Patient, parent or legal guardian withdraws consent for continued participation 
including documenting follow-up survival status. 
10.5.2 
Patient death while on study. 
10.5.3 
Patient lost to follow-up. 
 
10.6 
Correlative Biology Studies 
We will use descriptive statistics to explore potential correlations between the proposed 
molecular parameters in section 7.0 with radiographic response rate, EFS, and OS. 
 


 
 
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11.0 
CENTRAL REVIEW 
 
11.1 
Pathology Review 
A central review (except for patients with brainstem gliomas who do not undergo tumor 
biopsy) and a consensus on histopathology meeting study definition of high-grade 
gliomas will be conducted for all patients who have undergone tumor resection/biopsy. 
All H&E and immunohistochemical slides, ten unstained slides with 5-micron, FFPE 
tumor sections, and pathology report from the originating institution’s neuropathologist 
must be submitted by express mail to the following address: 
 
Adekunle M. Adesina, MD, PhD 
Department of Pathology, Baylor College of Medicine 
One Baylor Plaza, Room 286A 
Houston, Texas 77030 
832-824-2250 
 
Tumor histology will be reviewed by Drs. Adekunle Adesina (Baylor College of 
Medicine) and Greg Fuller (MD Anderson Cancer Center).  
 
11.2 
Imaging Review 
Pre- and post-surgery (except for patients with brainstem gliomas who do not undergo 
tumor biopsy) MRI images should be submitted on a CD-ROM for a central review by 
pediatric neuro-radiologists as soon as they are available. All subsequent MRI images 
should also be submitted after each study to be reviewed for tumor response and 
assessment of intra-tumoral hemorrhage. 
 
 
Please submit MRI images on CD to: 
 
 
Suzanne Wheeler 
 
Texas Children’s Cancer Center 
 
1102 Bates, Suite 1590 
 
Houston, Texas 77030 
 
12.0 
EVALUATION, RECORDING, REPORTING, AND MONITORING OF ADVERSE 
EVENTS 
Safety assessments will be made using the NCI Common Terminology Criteria for Adverse 
Events v3.0 (CTCAE) http://ctep.cancer.gov/reporting/ctc.html. Adverse event data collection 
and reporting are done to ensure the safety of patients enrolled in this study as well as those who 
will enroll in future trials using similar agents. 
 
12.1 
DEFINITIONS 
 
12.1.1  Adverse Events 
Adverse Events (AEs) are defined as any untoward medical occurrence in a 
patient that does not necessarily have a causal relationship with either valproic 
acid or bevacizumab. An AE for this study can therefore be any unfavorable or 
unintended sign (including an abnormal laboratory finding), symptom, or disease 
temporally associated with the use of either valproic acid and/or bevacizumab, 
whether or not attributable to these agents used in this investigational study. 


 
 
Page 52 of 95
 
AEs that are not described in the protocol, in published medical literature, in the 
patient’s informed consent, or in Investigator Brochure are defined as unexpected 
AEs. 
 
A pre-existing condition should not be reported as an AE unless the condition 
worsens or episodes increase in frequency during the adverse event reporting 
period. 
 
 
 
12.1.2 Serious Adverse Events 
 
Serious Adverse Events (SAEs) are defined as any untoward medical occurrence 
that: 
 Results in death  
 Is life-threatening  
 Requires in-patient hospitalization or prolongation of existing hospitalization  
 Results in persistent or significant disability and/or incapacity  
 Is a congenital anomaly/birth defect  
 Is any important medical event, based on appropriate medical judgment, that 
jeopardizes the patient and requires medical and/or surgical intervention to 
prevent one of the outcomes listed above. 
 
Hospital admission for elective/planned surgeries or administration of protocol 
therapy should not be reported as SAE2 unless an unpredicted complication 
results in a prolonged hospitalization.  
 
“Death” and “Disease Progression (PD)” should not be reported as SAEs. Death 
should be reported as an outcome of an SAE (i.e. the specific cause of death 
should be reported as the SAE). 
 
12.2 
ADVERSE EVENT DESCRIPTION  
 
The AE collection/reporting period will begin with the first day of valproic acid 
treatment. AEs after study registration but prior to the first day of valproic acid will be 
captured as ongoing concurrent secondary diagnoses and symptoms present at the start of 
study. AEs will be graded in accordance with the NCI Common Terminology Criteria for 
Adverse Events v3.0 (CTCAE) http://ctep.cancer.gov/reporting/ctc.html. If not described 
in the NCI-CTCAE, AEs will be graded according to their severity using the following 
criteria: grade 1 (mild), grade 2 (moderate), grade 3 (severe), and grade 4 (life-
threatening).  
 
The investigator will assign attribution of an AE to valproic acid, bevacizumab, or 
BOTH, as one of the following categories: 
 
 Unrelated 
 Unlikely 
 Possible 


 
 
Page 53 of 95
 Probable 
 Definite 
 
12.3 
REPORTING ADVERSE EVENTS   
 
All adverse events, regardless of perceived relationship to study treatment, will be 
reported and recorded on the appropriate CRFs. New AEs and AEs that are ongoing at 
the off-treatment visit will be followed for 30 days from the patient’s receipt of the last 
dose of protocol therapy, unless they have resolved earlier. SAEs and drug-related AEs 
ongoing at the end of study will be followed until resolution. 
 
The AE description will include the nature of the experience, the date of onset, the 
resolution date, the severity of each sign or symptom reported using the NCI-CTCAE 
(version 3.0), the seriousness of the event, the potential relationship to study treatment, 
the course of action taken, and the outcome of the experience. 
 
Any serious or immediately life-threatening adverse experience, including those resulting 
in death, occurring while the patient is receiving either valproic acid or bevacizumab, or 
within 30 days of the patient’s last dose of protocol therapy, regardless of the treating 
physician’s opinion regarding drug relationship, will be reported by telephone and/or e-
mail (within 24 hours of the event) to the Study Chair. A written report must be 
submitted via fax or e-mail within two working days to the study Chair. Individual 
institutions are responsible for reporting serious adverse events to their institutional 
review board (IRB) according to each board’s required time frame.  
 
All AE communications and reports should be submitted to: 
 
Jack Su, MD, MS 
Office telephone: 832-822-4306 
Cell phone: 713-858-8129 
Fax: 832-825-1503 
E-mail: jmsu@txccc.org 
 
Please “cc” Susan Blaney, MD on all AE communications:  sblaney@txccc.org 
 
12.4 
MONITORING OF ADVERSE EVENTS 
 
The Dan L. Duncan Cancer Center Pediatric Safety Monitoring Committee (Baylor 
College of Medicine) will monitor the adverse events for this clinical trial. 
 
13.0 
RETENTION OF RECORDS 
Retain all documentation of adverse events, records of study drug receipt and dispensation, and 
all IRB correspondence for at least 2 years after the investigation is completed


 
 
Page 54 of 95
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2008;26(May 20 suppl; abstr 2010b). 
75. 
Friedman HS, Petros WP, Friedman AH, et al. Irinotecan therapy in adults with recurrent or 
progressive malignant glioma. J Clin Oncol 1999;17(5):1516-25. 
76. 
Cloughesy TF, Filka E, Kuhn J, et al. Two studies evaluating irinotecan treatment for recurrent 
malignant glioma using an every-3-week regimen. Cancer 2003;97(9 Suppl):2381-6. 
77. 
Chamberlain MC. Salvage chemotherapy with CPT-11 for recurrent glioblastoma multiforme. J 
Neurooncol 2002;56(2):183-8. 
78. 
Prados MD, Lamborn K, Yung WK, et al. A phase 2 trial of irinotecan (CPT-11) in patients 
with recurrent malignant glioma: a North American Brain Tumor Consortium study. Neuro Oncol 
2006;8(2):189-93. 
79. 
Batchelor TT, Gilbert MR, Supko JG, et al. Phase 2 study of weekly irinotecan in adults with 
recurrent malignant glioma: final report of NABTT 97-11. Neuro Oncol 2004;6(1):21-7. 
80. 
Buckner JC, Reid JM, Wright K, et al. Irinotecan in the treatment of glioma patients: current 
and future studies of the North Central Cancer Treatment Group. Cancer 2003;97(9 Suppl):2352-8. 
81. 
Raymond E, Fabbro M, Boige V, et al. Multicentre phase II study and pharmacokinetic 
analysis of irinotecan in chemotherapy-naive patients with glioblastoma. Ann Oncol 2003;14(4):603-
14. 
82. 
Reardon DA, Quinn JA, Rich JN, et al. Phase I trial of irinotecan plus temozolomide in adults 
with recurrent malignant glioma. Cancer 2005;104(7):1478-86. 
83. 
Loghin ME, Prados MD, Wen P, et al. Phase I study of temozolomide and irinotecan for 
recurrent malignant gliomas in patients receiving enzyme-inducing antiepileptic drugs: a north 
american brain tumor consortium study. Clin Cancer Res 2007;13(23):7133-8. 
84. 
Reardon DA, Quinn JA, Rich JN, et al. Phase 2 trial of BCNU plus irinotecan in adults with 
malignant glioma. Neuro Oncol 2004;6(2):134-44. 
85. 
Bender JL, Adamson PC, Reid JM, et al. Phase I trial and pharmacokinetic study of 
bevacizumab in pediatric patients with refractory solid tumors: a Children's Oncology Group Study. J 
Clin Oncol 2008;26(3):399-405. 
86. 
Loscher W. Valproate: a reappraisal of its pharmacodynamic properties and mechanisms of 
action. Prog Neurobiol 1999;58(1):31-59. 
87. 
Lindberger M, Tomson T, Wallstedt L, Stahle L. Distribution of valproate to subdural 
cerebrospinal fluid, subcutaneous extracellular fluid, and plasma in humans: a microdialysis study. 
Epilepsia 2001;42(2):256-61. 
88. 
Hegi ME, Diserens AC, Gorlia T, et al. MGMT gene silencing and benefit from temozolomide 
in glioblastoma. N Engl J Med 2005;352(10):997-1003. 
89. 
Sathornsumetee S, Cao Y, Marcello JE, et al. Tumor angiogenic and hypoxic profiles predict 
radiographic response and survival in malignant astrocytoma patients treated with bevacizumab and 
irinotecan. J Clin Oncol 2008;26(2):271-8. 


 
 
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90. 
Schreiber V, Dantzer F, Ame JC, de Murcia G. Poly(ADP-ribose): novel functions for an old 
molecule. Nat Rev Mol Cell Biol 2006;7(7):517-28. 
91. 
Marchion DC, Bicaku E, Daud AI, al e. Valproic acid alters chromatin structure by regulation 
of chromatin modulation proteins. Cancer Res 2005;65:3815-22. 
92. 
Marchion DC, Bicaku E, Turner JG, al e. HDAC2 regulates chromatin plasticity and enhances 
DNA vulnerability. Mol Cancer Ther 2009;8:794-801. 
93. 
Kim MS, Blake M, Baek JH, al e. Inhibition of histone deacetylase increases cytotoxicity to 
anticancer drugs targeting DNA. Cancer Res 2003;63:7291-300. 
94. 
Marchion DC, Bicaku E, Daud AI, al e. Sequence-specific potentiation of topoisomerase II 
inhibitors by the histone deacetylase inhibitor suberoylanilide hydroxamic acid. J Cell Biochem 
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Marquard L, Gjerdrum LM, Christensen IJ, al e. Prognostic significance of the therapeutic 
targets histone deacetylase 1, 2, 6 and acetylated histone H4 in cutaneous T-cell lymphoma. 
Histopathology 2008;53:267-77. 
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Munster P, Marchion D, Bicaku E, al e. Phase I trial of histone deacetylase inhibition by 
valproic acid followed by the topoisomerase II inhibitor epirubicin in advanced solid tumors: a clinical 
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Munster P, Marchion D, Bicaku E, al e. Clinical and biological effects of valproic acid as a 
histone deacetylase inhibitor on tumor and surrogate tissues: phase I/II trial of valproic acid and 
epirubicin/FEC. Clin Cancer Res 2009;15:2488-96. 
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Friedman HS, Prados MD, Wen PY, et al. Bevacizumab alone and in combination with 
irinotecan in recurrent glioblastoma. J Clin Oncol 2009;27(28):4733-40. 
99. 
Vredenburgh JJ, Desjardins A, Kirkpatrick JP, et al. Addition of bevacizumab to standard 
radiation therapy and daily temozolomide is associated with minimal toxicity in newly diagnosed 
glioblastoma multiforme. Int J Radiat Oncol Biol Phys;82(1):58-66. 
100. 
Acharya S, Bussel JB. Hematologic toxicity of sodium valproate. J Pediatr Hematol Oncol 
2000;22(1):62-5. 
101. 
Delgado MR, Riela AR, Mills J, Browne R, Roach ES. Thrombocytopenia secondary to high 
valproate levels in children with epilepsy. J Child Neurol 1994;9(3):311-4. 
102. 
Ko CH, Kong CK, Tse PW. Valproic acid and thrombocytopenia: cross-sectional study. Hong 
Kong Med J 2001;7(1):15-21. 
103. 
Henriksen O, Johannessen SI. Clinical and pharmacokinetic observations on sodium valproate - 
a 5-year follow-up study in 100 children with epilepsy. Acta Neurol Scand 1982;65(5):504-23. 
104. 
Allarakhia IN, Garofalo EA, Komarynski MA, Robertson PL. Valproic acid and 
thrombocytopenia in children: a case-controlled retrospective study. Pediatr Neurol 1996;14(4):303-7. 
105. 
Verrotti A, Greco R, Matera V, Altobelli E, Morgese G, Chiarelli F. Platelet count and function 
in children receiving sodium valproate. Pediatr Neurol 1999;21(3):611-4. 
106. 
Bryant AE, 3rd, Dreifuss FE. Valproic acid hepatic fatalities. III. U.S. experience since 1986. 
Neurology 1996;46(2):465-9. 
107. 
Koenig SA, Buesing D, Longin E, et al. Valproic acid-induced hepatopathy: nine new fatalities 
in Germany from 1994 to 2003. Epilepsia 2006;47(12):2027-31. 
108. 
Verrotti A, Trotta D, Morgese G, Chiarelli F. Valproate-induced hyperammonemic 
encephalopathy. Metab Brain Dis 2002;17(4):367-73. 
109. 
Bohan TP, Helton E, McDonald I, et al. Effect of L-carnitine treatment for valproate-induced 
hepatotoxicity. Neurology 2001;56(10):1405-9. 


 
 
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110. 
De Vivo DC, Bohan TP, Coulter DL, et al. L-carnitine supplementation in childhood epilepsy: 
current perspectives. Epilepsia 1998;39(11):1216-25. 
111. 
Grauso-Eby NL, Goldfarb O, Feldman-Winter LB, McAbee GN. Acute pancreatitis in children 
from Valproic acid: case series and review. Pediatr Neurol 2003;28(2):145-8. 
112. 
Glusker P, Recht L, Lane B. Reversible posterior leukoencephalopathy syndrome and 
bevacizumab. N Engl J Med 2006;354(9):980-2; discussion -2. 
113. 
Ozcan C, Wong SJ, Hari P. Reversible posterior leukoencephalopathy syndrome and 
bevacizumab. N Engl J Med 2006;354(9):980-2; discussion -2. 
114. 
Miller KD, Chap LI, Holmes FA, et al. Randomized phase III trial of capecitabine compared 
with bevacizumab plus capecitabine in patients with previously treated metastatic breast cancer. J Clin 
Oncol 2005;23(4):792-9. 
115. 
Sandler A, Gray R, Perry MC, et al. Paclitaxel-carboplatin alone or with bevacizumab for non-
small-cell lung cancer. N Engl J Med 2006;355(24):2542-50. 
116. 
Gerber HP, Vu TH, Ryan AM, Kowalski J, Werb Z, Ferrara N. VEGF couples hypertrophic 
cartilage remodeling, ossification and angiogenesis during endochondral bone formation. Nat Med 
1999;5(6):623-8. 
117. 
Ryan AM, Eppler DB, Hagler KE, et al. Preclinical safety evaluation of rhuMAbVEGF, an 
antiangiogenic humanized monoclonal antibody. Toxicol Pathol 1999;27(1):78-86. 
118. 
Smith AR, Hennessy JM, Kurth MA, Nelson SC. Reversible skeletal changes after treatment 
with bevacizumab in a child with cutaneovisceral angiomatosis with thrombocytopenia syndrome. 
Pediatr Blood Cancer 2008;51(3):418-20. 
119. 
Smeaton MB, Miller PS, Ketner G, Hanakahi LA. Small-scale extracts for the study of 
nucleotide excision repair and non-homologous end joining. Nucleic Acids Res 2007;35(22):e152. 
120. 
Woolson RF. Rank tests and a one-sample logrank test for comparing observed data to a 
standard population. Biometrics 1981;37:687-96. 
 
 


 
 
Page 61 of 95
APPENDIX IA 
AVASTINTM (BEVACIZUMAB) REQUEST FORM 
Investigator Sponsored Trials 
 
Complete and FAX this request form to Tara McCartney, RPh, or Jennifer Lynds, RPh, Pharm. D. 
at Texas Children’s Hospital Investigational Pharmacy Services (IPS), fax number 832-825-3901. 
Study drug may be ordered Monday through Friday, from 8 am to 4 pm (Central Standard Time). 
Please order study drug at least 5 days in advance. Contact IPS at 832-822-3899 if you have any 
questions. Please print all entries clearly. 
 
BEVACIZUMAB REQUEST FORM 
Weight (kg) 
Dose (mg) 
(10 mg/kg/dose) 
400 mg vial (20 ml) 
0-10 
0-100 
1 
10.1-20 
101-200 
1 
20.1-30 
201-300 
1 
30.1-40 
301-400 
1 
40.1-50 
401-500 
2 
50.1-60 
501-600 
2 
60.1-70 
601-700 
2 
70.1-80 
701-800 
2 
80.1-90 
801-900 
3 
90.1-100 
901-1000 
3 
# of 400 mg vial _________ x 6 (12-week supply) = _________ 400-mg vials requested 
 
 
DELIVERY TO: 
 
 
 
 
CONTACT: 
PHONE:  
 
Investigator’s Signature ________________________________  Date ____________________
A Phase 2 Study of Valproic Acid and Radiation, Followed by Maintenance Valproic Acid and 
Bevacizumab in Children with Newly Diagnosed High-Grade Gliomas or Brainstem Gliomas 
Investigator:  
 
Requestor: 
Institution: 
 
Phone Number:  
Patient ID Number:  
Weight (kg):                             Height (cm):                            BSA (m2): 


 
 
Page 62 of 95
APPENDIX IB 
AVASTINTM (BEVACIZUMAB) INVENTORY RECORD 
Investigator Sponsored Trials 
 
 
 
 
BEVACIZUMAB INVENTORY RECORD 
Date Given 
Weight (kg) 
Dose (mg) 
400 mg Vials 
Started 
400 mg Vials 
Used 
400 mg Vials 
Remaining 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please complete and fax Bevacizumab Inventory Record to Sue Burlingame (Phone: 832-824-1532; 
Fax: 832-825-1198) or Suzanne Wheeler (Phone: 832-824-4217; Fax 832-825-1198) every 12 
weeks. 
 
 
 
 
 
 
 
 
 
 
 
 
Investigator’s Signature ________________________________  Date ____________________
A Phase 2 Study of Valproic Acid and Radiation, Followed by Maintenance Valproic Acid and 
Bevacizumab in Children with Newly Diagnosed High-Grade Gliomas or Brainstem Gliomas 
Investigator:  
 
Inventory Recorder: 
Institution: 
 
Phone Number:  
Patient ID Number:  


 
 
Page 63 of 95
APPENDIX II 
Procedure for Obtaining a Urine Protein / Creatinine Ratio 
 
1)  Obtain at least 4 ml of a random urine sample (does not have to be a 24 hour urine)  
2)  Determine protein concentration (mg/dL)  
3)  Determine creatinine concentration (mg/dL)  
4)  Urine protein / creatinine ratio = protein concentration (mg /dL) divide by creatinine 
concentration (mg /dL) 
 
The UPC directly correlates with the amount of protein excreted in the urine per 24 hrs (i.e. a UPC 
of 1 should be equivalent to 1g protein in a 24hr urine collection) 
                                            
Protein and creatinine concentrations should be available on standard reports of urinalyses, not 
dipsticks. If protein and creatinine concentrations are not routinely reported at an Institution, their 
measurements and reports may need to be requested. 


 
 
Page 64 of 95
APPENDIX III 
90th and 95th Percentile Blood Pressure For Girls 1-17 Years 
 
 
 
 
 
 
 
 
 
 


 
 
Page 65 of 95
APPENDIX III 
90th and 95th Percentile Blood Pressure For Boys 1-17 Years 
 


 
 
Page 66 of 95
 
APPENDIX IV: VALPROIC ACID ADMINISTRATION DIARY DURING RADIATION, POST XRT, 
AND MAINTAINANCE THERAPY  
 
Patient initials: _______ Patient ID: ____________ Institution: __________________________________________ 
 
1) Circle name of drug given (Depakene, Depakote, or Valproic Acid) 
2) Record the date and time for each dose (circle AM or PM). Please try to adhere to a strict schedule of giving the drug every 8 
hours. 
3) Record the number of Depakene, Depakote, or Valproic Acid capsules given or the amount of syrup in milliliters (ml) given. 
4) The capsules can be swallowed whole without breakage, or alternatively, the content of the capsule can be sprinkled and 
mixed with water, juice, or food. Syrup can be mixed with water, juice, or food. 
 
Example: 
 
    Drug given: Depakene,  Depakote, or  Valproic Acid 
DAY 
      DATE 
MORNING 
 
AFTERNOON 
 
EVENING 
NUMBER OF 
CAPSULES? 
AMOUNT 
GIVEN? 
COMMENTS 
125 mg 
250 mg 
ML 
1 
    9/12/09 
  7 : 10 AM PM 
 3  : 20   AM PM 
 11 :00   AM PM 
2 
 
 
He felt nauseated 
after taking pills. 
 
 
Week # ___________  Drug given: Depakene,  Depakote, or  Valproic Acid 
DAY 
      DATE 
MORNING 
 
AFTERNOON 
 
EVENING 
NUMBER OF 
CAPSULES? 
AMOUNT  
SYRUP?  
COMMENTS 
125 mg 
250 mg 
ML 
1 
     
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
2 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
3 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
4 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
5 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
6 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
7 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
 
 
Week # ___________  Drug given: Depakene,  Depakote, or  Valproic Acid 
DAY 
      DATE 
MORNING 
 
AFTERNOON 
 
EVENING 
NUMBER OF 
CAPSULES? 
AMOUNT  
SYRUP?  
COMMENTS 
125 mg 
250 mg 
ML 
1 
     
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
2 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
3 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
4 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
5 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
6 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
7 
 
     :        AM PM 
     :        AM PM 
     :        AM PM 
 
 
 
 
 
 
This patient diary has been verified for accuracy by ______________________________ on ____ / ____ / ____ 


 
 
Page 67 of 95
 APPENDIX V: COMPREHENSIVE ADVERSE EVENTS AND POTENTIAL RISK LISTS 
FOR BEVACIZUMAB 
 
Category 
(Body 
System) 
Adverse Events with Possible 
Relationship to Bevacizumab 
(CTCAE v3.0 Term) 
‘Agent Specific Adverse Event List’ 
(ASAEL) 
ALLERGY/IMMUNOLOGY 
 
Allergic reaction/hypersensitivity 
(including drug fever) 
Allergic reaction/hypersensitivity (including 
drug fever) 
 
Allergic rhinitis (including 
sneezing, nasal stuffiness, 
postnasal drip) 
Allergic rhinitis (including sneezing, nasal 
stuffiness, postnasal drip) 
BLOOD/BONE MARROW 
 
Hemoglobin 
Hemoglobin 
 
Leukocytes (total WBC) 
Leukocytes (total WBC) 
 
Neutrophils/granulocytes 
(ANC/AGC) 
Neutrophils/granulocytes (ANC/AGC) 
CARDIAC ARRHYTHMIA 
 
Supraventricular arrhythmia NOS 
Supraventricular arrhythmia NOS 
 
Ventricular fibrillation 
 
CARDIAC GENERAL 
 
Cardiac ischemia/infarction 
Cardiac ischemia/infarction 
 
Cardiac troponin I (cTnl) 
 
 
Hypertension 
Hypertension 
 
Hypotension 
 
 
Left ventricular diastolic 
dysfunction 
 
 
Left ventricular systolic 
dysfunction 
 
CONSTITUTIONAL SYMPTOMS 
 
Fatigue (asthenia, lethargy, 
malaise) 
Fatigue (asthenia, lethargy, malaise) 
 
Fever (in the absence of 
neutropenia, where neutropenia is 
defined as ANC < 1.0 x 109/L) 
Fever (in the absence of neutropenia, where 
neutropenia is defined as ANC < 1.0 x 109/L) 
 
Rigors/chills 
Rigors/chills 
 
Weight loss 
 
DERMATOLOGY/SKIN 
 
Pruritus/itching 
Pruritus/itching 
 
Rash/desquamation 
Rash/desquamation 
 
Ulceration 
 
 
Urticaria (hives, welts, wheals) 
Urticaria (hives, welts, wheals) 
 
Wound complication, non-
infectious 
 
GASTROINTESTINAL 
 
Anorexia 
Anorexia 


 
 
Page 68 of 95
Category 
(Body 
System) 
Adverse Events with Possible 
Relationship to Bevacizumab 
(CTCAE v3.0 Term) 
‘Agent Specific Adverse Event List’ 
(ASAEL) 
 
Colitis 
 
 
Constipation 
Constipation 
 
Diarrhea 
Diarrhea 
 
Fistula, GI – Select 
 
 
Heartburn/dyspepsia 
Heartburn/dyspepsia 
 
Ileus (functional obstruction of 
bowel, i.e., neuroconstipation) 
 
 
Leak (including anastomotic), GI: 
large bowel 
 
 
Mucositis/stomatitis 
(functional/symptomatic) – Select 
Mucositis/stomatitis (functional/symptomatic) – 
Select 
 
Nausea 
Nausea 
 
Perforation, GI – Select 
 
 
Ulcer, GI – Select 
 
 
Vomiting 
Vomiting 
HEMORRHAGE/BLEEDING 
 
Hemorrhage, GI – Select 
Hemorrhage GI – Select 
 
Hemorrhage, CNS 
Hemorrhage, CNS 
 
Hemorrhage, GU: vagina 
Hemorrhage, GU: vagina 
 
Hemorrhage, pulmonary/upper 
respiratory: lung 
Hemorrhage, pulmonary/upper respirator: 
lung 
 
Hemorrhage, pulmonary/upper 
respiratory: nose 
Hemorrhage, pulmonary/upper respiratory: 
nose 
INFECTION 
 
Infection with normal ANC or 
Grade 1 or 2 neutrophils – Select 
 
 
Infection with normal ANC or 
Grade 1 or 2 neutrophils – Select 
(pelvis, peritoneal cavity, rectum, 
scrotum, skin, wound) 
 
METABOLIC/LABORATORY 
 
Alkaline phosphatase 
Alkaline phosphatase 
 
ALT, SGPT (serum glutamic 
pyruvic transaminase) 
ALT, SGPT (serum glutamic pyruvic 
transaminase) 
 
AST, SGOT (serum glutamic 
oxaloacetic transaminase) 
AST, SGOT (serum glutamic oxaloacetic 
transaminase) 
 
Bilirubin (hyperbilirubinemia) 
Bilirubin (hyperbilirubinemia) 
 
Creatinine 
 
 
Proteinuria 
Proteinuria 
NEUROLOGY 
 
CNS cerebrovascular ischemia 
CNS cerebrovascular ischemia 
 
Dizziness 
Dizziness 


 
 
Page 69 of 95
Category 
(Body 
System) 
Adverse Events with Possible 
Relationship to Bevacizumab 
(CTCAE v3.0 Term) 
‘Agent Specific Adverse Event List’ 
(ASAEL) 
 
Neurology – Other: 
(Leukoencephalopathy syndrome 
including reversible posterior 
leukoencephalopathy syndrome 
[RPLS]) 
 
PAIN 
 
Pain – abdomen NOS 
Pain – abdomen NOS 
 
Pain – chest/thorax NOS 
Pain – chest/thorax NOS 
 
Pain – head/headache 
Pain – head/headache 
 
Pain – joint 
Pain – joint 
 
Pain - muscle 
 
 
Pain – NOS 
 
PULMONARY/UPPER RESPIRATORY 
 
Bronchospasm, wheezing 
 
 
Cough 
Cough 
 
Dyspnea (shortness of breath) 
Dyspnea (shortness of breath) 
 
Fistula, pulmonary/upper 
respiratory – Select 
 
 
Nasal cavity/paranasal sinus 
reactions 
Nasal cavity/paranasal sinus reactions 
 
Voice changes/dysarthria (e.g., 
hoarseness, loss or alteration in 
voice, laryngitis) 
Voice changes/dysarthria (e.g., hoarseness, loss 
or alteration in voice, laryngitis) 
 
Pulmonary/Upper Respiratory – 
Other (nasal-septal perforation) 
 
RENAL/GENITOURINARY 
 
Fistula, GU – Select 
 
 
Renal failure 
 
SYNDROMES 
 
Cytokine release syndrome/acute 
infusion reaction 
Cytokine release syndrome/acute infusion 
reaction 
VASCULAR 
 
Thrombosis/thrombus/embolism 
Thrombosis/thrombus/embolism 
 
Visceral arterial ischemia (non-
myocardial) 
 
 


 
 
Page 70 of 95
APPENDIX VI: TUMOR SPECIMEN & CORRELATIVE STUDY  
TRANSMITTAL FORM  
 
This completed form should be sent with each shipment of tumor specimen, tumor slides, or blood samples for 
correlative studies. 
 
Institution Name: 
Institution Address: 
 
Patient initials: 
Patient ID #: 
Contact person: 
Phone number: 
Date of Surgery/Biopsy/Collection: 
Date of Shipment: 
□ FRESH FROZEN TUMOR MATERIAL     
A minimum of 250 mg (wet weight prior to being frozen in liquid nitrogen; approximately 1.5 x 1.5 x 1.5 cm of tumor 
sample) of tumor specimen is preferred. In patients whose tumors are only biopsied, submission of as much frozen tumor 
specimen as possible is strongly encouraged. Frozen tumors should be shipped on dry ice via over-night express delivery on 
Monday through Thursday. If a tumor is resected on Friday or over the weekend, the frozen specimen should be kept at –
800C over the weekend and shipped on Monday. Please include a pathology report if available. 
□ TUMOR SLIDES 
Ten to twelve unstained PLUS glass slides, containing 5-micron thick tumor sections from FFPE tumor blocks, should be 
shipped at room temperature. 
□ BLOOD SAMPLES 
Whole blood samples (a minimum of 5-10 ml for children < 12 kg, and 10-20 ml for children > 12 kg) should be collected in either 
heparinized (green tops, either sodium or lithium heparin is acceptable) or ACDA (yellow top) tubes.  ACDA tubes are 
preferred if available. DO NOT collect blood samples on a Friday.  
 
Seal the original tube(s) with paraffin and place the tube(s) inside an insulated container 
 
Place the container in a Styrofoam box.   
 
Between April-October: please ship with an ice pack placed in the Styrofoam box (ice pack should not be placed directly next 
to the samples). An ice pack is not necessary when shipping between November-March.  
 
Package sample as appropriate for biologic material 
 
PBMC Collection 
Date Collected 
Prior to first dose of VPA 
 
During week 3 of VPA and XRT 
 
 
PLEASE SEND ALL SAMPLES TO THE FOLLOWING ADDRESS 
 
Jack Su, MD 
Attention: Elizabeth Hinojosa 
Feigin Center, Baylor College of Medicine 
1102 Bates Street, Rm 1030 
Houston, Texas 77030 
(832) 824-4688 or (832) 822-4306 
 
Prior to shipping, please e-mail Dr. Jack Su (jmsu@txccc.org), Dr. Li (xxli@txccc.org), Elizabeth Hinojosa (ERHINOJO@txccc.org) 
and Suzanne Wheeler (shwheele@txccc.org) for notification of sample shipment.  
 
 
The site personnel who shipped the samples must sign and date this form below: 
 
Name (print):__________________________________ 
Date:________________________________ 
 
Phone number: ______________________________ 
 


 
 
Page 71 of 95
Appendix VII: Protocol Roadmap  
(Pre-XRT, XRT and Post XRT Phases - Weeks 1-10) 
 
Patient Initials: ____________________ Patient ID: ______________________________________ 
 
 
 
Week # 
Date 
*VPA dose 
(mg/kg/day) 
*Patient’s 
weight (kg) 
Assessments 
Pre-XRT, XRT Phase and Post XRT  
XRT Phase 
Week 1 
 
 
 
 
Pre-XRT – Study Entry: 
▪ History, physical & neuro exam 
▪ Vital signs, performance status, height, weight, 
BSA, blood pressure  
▪ Labs: CBC, differential, platelets, chem. 7,  
albumin,  
ALT, AST, bilirubin, amylase, lipase,  urine  
protein/CR (3), PT,  PTT, INR, pregnancy test (4)   
▪  CSF cytology (5)  
▪  Valproic acid levels (VPA) (2,  6)  
▪  If consented, correlative biology studies (7)     
▪  MRI brain and spine (8,9) 
XRT week 3 
▪  If consented, correlative biology studies (7)   
XRT Phase (q week) 
▪ History, physical, neuro exam 
▪ Vital signs, performance status, height, weight, 
BSA, blood pressure  
▪ Labs (2): CBC, differential, platelets, ALT, AST, 
bilirubin, Valproic acid levels (VPA) (2,  6) 
▪ Check patient diary & roadmap and fax weekly (10) 
Post-XRT (q 2 weeks) 
▪ History, physical & neuro exam 
▪ Vital signs, performance status, height, weight, 
BSA, blood pressure  
▪ Labs (2): CBC, differential, platelets, ALT, AST, 
bilirubin, Valproic acid levels (VPA) (2,  6) 
▪ Check patient diary (10) 
▪ Fax roadmap & patient diary after Post XRT 
Week 10 
▪ MRI brain (8) and spine (9)  
▪ CSF cytology (5)  
▪ X-ray Right Knee 
 
Week 2 
 
 
 
Week 3 
 
 
 
Week 4 
 
 
 
Week 5 
 
 
 
Week 6 
 
 
 
Post XRT 
Week 7  
(if needed) 
 
 
 
Week 8 
 
 
 
Week 9 
(if needed) 
 
 
 
Week 10 
 
 
 
 Post XRT (XRT may continue into break if there were delays 
during week 1-6). 
 
 
*Valproic Acid (VPA) will be administered daily in three divided doses. See protocol 5.2 for VPA administration and 
monitoring guidelines and 5.4 for VPA dose modifications. Patient’s weight should be the weight used to calculate the 
current VPA dose. 
2) Patients with grade 4 neutropenia, anemia, and/or thrombocytopenia should have CBC checked twice weekly until the 
cytopenia(s) improves to grade 3 or better. Patients who require a dose escalation to maintain targeted trough 
concentration should also have trough VPA concentration, CBC, and liver functions measured every 3-5 days until target 
is reached. 
3) See Appendix II for Urine/Protein Creatinine ratio. 
4) For females of child-bearing potential 
5) CSF cytology at the time of diagnosis and subsequently during protocol therapy should be performed if clinically 
indicated but is not required for study entry. 


 
 
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6) See Section 5.2.3 for monitoring valproic acid concentrations. 
7) See section 7.0 for requirement and timing for correlative biology studies. Section 7.3.2 whole blood samples should be 
collected prior to starting VPA and radiation, and then at 2 weeks after starting VPA and radiation. 
8) For patients with possible radiographic progression on week 10 MRI, the next MRI should be performed at week 18 (see 
section 8.3). If week 18 MRI shows stable disease or better compared to week 10 MRI, then patients will continue MRI 
every 12 weeks. 
9) MRI of brain +/- spine must be obtained within 2 weeks prior to study registration/entry and must include gradient echo 
imaging (GRE) sequences for identifying CNS/intra-tumoral hemorrhage. For patients with high grade gliomas, an MRI 
of spine should be performed at the time of study entry, but subsequent MRI of spine should only be repeated as clinically 
indicated. 
10) Medication diaries and roadmap should be checked and faxed weekly during radiation therapy. Post- XRT medication 
diaries and roadmap should be checked every 2 weeks and faxed every 4 weeks. Fax documents to (832)824-1198. 
Maintain copies of the patient’s diary in the research chart. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
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Appendix VII: Protocol Roadmap (Maintenance Therapy – Weeks 11 - 34) 
 
Patient Initials: ____________________ Patient ID: ________________________________________ 
 
 
Week 
# 
Date 
^Bevacizumab 
(mg) 
^Patient’
s weight 
(kg) 
*VPA dose 
(mg/kg/day) 
*Patient’s 
weight 
(kg) 
Assessments 
Maintenance Therapy 
Week 11 
 
 
 
 
 
Pre-Rx 
▪ History, physical & neuro exam 
▪ Vital signs, performance status, 
height, weight, BSA, blood 
pressure  
▪ Labs: CBC, differential, platelets 
(2),  
       chem 7,  albumin, ALT, AST, 
bilirubin, amylase, lipase, 
urine protein/CR (3),  PT,  PTT, 
INR, pregnancy test (4) , 
Valproic acid levels (2, 6)  
▪  X-ray of right knee (12) 
▪ Fax roadmap and patient diary 
(13) 
Q 2 weeks 
▪ Blood pressure 
▪ Check patient diary (13) 
Q 4 weeks 
▪ History, physical & neuro exam 
(1) 
▪ Vital signs (1), performance 
status, height, weight, BSA,   
▪ Labs: CBC, differential, platelets 
(2),  
      chem 7, albumin;  
     ALT, AST, bilirubin(2);  
     urine protein/CR(3),  
     Valproic acid levels (2, 6)  
▪ MRI brain (10) 
▪ Fax roadmap and patient diary 
(13) 
Q 12 weeks 
▪ MRI brain (9) and spine (11)  
▪ CSF cytology (5)  
Q 24 weeks 
▪ X-ray of right knee (12) 
Week 12 
 
 
 
 
 
Week 13 
 
 
 
 
 
Week 14 
 
 
 
 
 
Week 15 
 
 
 
 
 
Week 16 
 
 
 
 
 
Week 17 
 
 
 
 
 
Week 18 
 
 
 
 
 
Week 19 
 
 
 
 
 
Week 20 
 
 
 
 
 
Week 21 
 
 
 
 
 
Week 22 
 
 
 
 
 
Week 23 
 
 
 
 
 
Week 24 
 
 
 
 
 
Week 25 
 
 
 
 
 
Week 26 
 
 
 
 
 
Week 27 
 
 
 
 
 
Week 28 
 
 
 
 
 
Week 29 
 
 
 
 
 
Week 30 
 
 
 
 
 
Week 31 
 
 
 
 
 
Week 32 
 
 
 
 
 
Week 33 
 
 
 
 
 
Week 34 
 
 
 
 
 
 
^ Bevacizumab will be administered during maintenance therapy every 2 weeks for a maximum of 24 months (including XRT). See protocol 5.3 for 
administration and monitoring guidelines and 5.5 for dose modifications. 
* Valproic Acid (VPA) will be given daily in three divided doses. See section 5.2 for administration and monitoring guidelines and 5.4 for dose 
modifications. 
1) For patients with newly identified punctuate hemorrhage on MRI, physical exam, neurological assessment, and performance status should be 
evaluated every 2 weeks at least twice to closely monitor for signs/symptoms of worsening hemorrhage.  


 
 
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2) Patients with grade 4 neutropenia, anemia, and/or thrombocytopenia should have CBC checked twice weekly until the cytopenia(s) improves 
to grade 3 or better. Patients who require a dose escalation to maintain targeted trough concentration should also have trough VPA, CBC, and 
liver functions measured every 3-5 days until target is reached. 
3) See Appendix II for Urine/Protein Creatinine ratio. 
4) For female patients of child-bearing potential 
5) CSF cytology at the time of diagnosis and subsequently during protocol therapy should be performed as clinically indicated but is not required 
for study entry. 
6) See Section 5.2.3 for monitoring valproic acid concentrations. 
8) For patients with possible radiographic progression on week 10 MRI, the next MRI should be performed at week 18 (see section 8.3). If week 
18 MRI shows stable disease or better compared to week 10 MRI, then patients will continue MRI every 12 weeks. 
9) During maintenance therapy, MRI of brain, including GRE images, should be performed every 12 weeks until completion of protocol 
therapy. 
10) For patients with newly identified punctate hemorrhage on MRI, the next MRI, including GRE images, should be repeated every 4 weeks at least 
twice to monitor possible progression of hemorrhage. In the absence of radiographic progression of hemorrhage, the frequency of MRI studies 
can then return to every    12 weeks.  
11) For patients with high grade gliomas, an MRI of the spine should be performed at the time of study entry, but subsequent MRI of the spine 
should only be repeated as clinically indicated. 
12) Pre-treatment tibial X-ray (AP and lateral views) of the right knee must be obtained in all patients younger than 16 years of age prior to 
starting maintenance therapy and be repeated every 24 weeks while receiving bevacizumab. If abnormalities of the metaphyseal plates are 
detected on routine X-rays following initiation of treatment, an MRI scan of both knees should be performed. 
13) Medication diaries should be checked and faxed weekly during radiation therapy. After completion of XRT, medication diaries should be 
checked every 2 weeks and faxed every 4 weeks. Diaries should be faxed to (832)825-1198. Maintain copies of the patient diary in the research 
chart. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
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Appendix VII: Protocol Roadmap (Maintenance Therapy – Weeks 35 - 58) 
 
Patient Initials: ____________________ Patient ID: ________________________________________ 
 
 
Week 
# 
Date 
^Bevacizumab 
^Patient’
s weight 
(kg) 
*VPA dose 
(mg/kg/day) 
*Patient’s 
weight 
(kg) 
Assessments 
Maintenance Therapy 
Week 35 
 
 
 
 
 
 
Q 2 weeks 
▪ Blood pressure 
▪ Check patient diary (13) 
Q 4 weeks 
▪ History, physical & neuro exam 
(1) 
▪ Vital signs (1), performance 
status, height, weight, BSA,   
▪ Labs: CBC, differential, platelets 
(2),  
      chem 7, albumin;  
     ALT, AST, bilirubin(2);  
     urine protein/CR(3),  
     Valproic acid levels (2, 6)  
▪ MRI brain (10) 
▪ Fax roadmap and patient diary 
(13) 
Q 12 weeks 
▪ MRI brain (9) and spine (11)  
▪ CSF cytology (5)  
Q 24 weeks 
▪ X-ray of right knee (12) 
Week 36 
 
 
 
 
 
Week 37 
 
 
 
 
 
Week 38 
 
 
 
 
 
Week 39 
 
 
 
 
 
Week 40 
 
 
 
 
 
Week 41 
 
 
 
 
 
Week 42 
 
 
 
 
 
Week 43 
 
 
 
 
 
Week 44 
 
 
 
 
 
Week 45 
 
 
 
 
 
Week 46 
 
 
 
 
 
Week 47 
 
 
 
 
 
Week 48 
 
 
 
 
 
Week 49 
 
 
 
 
 
Week 50 
 
 
 
 
 
Week 51 
 
 
 
 
 
Week 52 
 
 
 
 
 
Week 53 
 
 
 
 
 
Week 54 
 
 
 
 
 
Week 55 
 
 
 
 
 
Week 56 
 
 
 
 
 
Week 57 
 
 
 
 
 
Week 58 
 
 
 
 
 
 
^ Bevacizumab will be administered during maintenance therapy every 2 weeks for a maximum of 24 months (including XRT). See protocol 5.3 for 
administration and monitoring guidelines and 5.5 for dose modifications. 
* Valproic Acid (VPA) will be given daily in three divided doses. See section 5.2 for administration and monitoring guidelines and 5.4 for dose 
modifications. 
1) For patients with newly identified punctuate hemorrhage on MRI, physical exam, neurological assessment, and performance status should be 
evaluated every 2 weeks at least twice to closely monitor for signs/symptoms of worsening hemorrhage.  
2) Patients with grade 4 neutropenia, anemia, and/or thrombocytopenia should have CBC checked twice weekly until the cytopenia(s) improves 
to grade 3 or better. Patients who require a dose escalation to maintain targeted trough concentration should also have trough VPA, CBC, and 
liver functions measured every 3-5 days until target is reached. 
3) See Appendix II for Urine/Protein Creatinine ratio. 
4) For female patients of child-bearing potential 
5) CSF cytology at the time of diagnosis and subsequently during protocol therapy should be performed as clinically indicated but is not required 
for study entry. 
6) See Section 5.2.3 for monitoring valproic acid concentrations. 
8) For patients with possible radiographic progression on week 10 MRI, the next MRI should be performed at week 18 (see section 8.3). If week 
18 MRI shows stable disease or better compared to week 10 MRI, then patients will continue MRI every 12 weeks. 


 
 
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9) During maintenance therapy, MRI of brain, including GRE images, should be performed every 12 weeks until completion of protocol 
therapy. 
10) For patients with newly identified punctate hemorrhage on MRI, the next MRI, including GRE images, should be repeated every 4 weeks at least 
twice to monitor possible progression of hemorrhage. In the absence of radiographic progression of hemorrhage, the frequency of MRI studies 
can then return to every    12 weeks.  
11) For patients with high grade gliomas, an MRI of the spine should be performed at the time of study entry, but subsequent MRI of the spine 
should only be repeated as clinically indicated. 
12) Pre-treatment tibial X-ray (AP and lateral views) of the right knee must be obtained in all patients younger than 16 years of age prior to 
starting maintenance therapy and be repeated every 24 weeks while receiving bevacizumab. If abnormalities of the metaphyseal plates are 
detected on routine X-rays following initiation of treatment, an MRI scan of both knees should be performed. 
13) Medication diaries should be checked and faxed weekly during radiation therapy. After completion of XRT, medication diaries should be 
checked every 2 weeks and faxed every 4 weeks. Diaries should be faxed to (832)825-1198. Maintain copies of the patient diary in the research 
chart. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
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Appendix VII: Protocol Roadmap (Maintenance Therapy – Weeks 59 - 82) 
 
Patient Initials: ____________________ Patient ID: ________________________________________ 
 
 
Week 
# 
Date 
^Bevacizumab 
^Patient’
s weight 
(kg) 
*VPA dose 
(mg/kg/day) 
*Patient’s 
weight 
(kg) 
Assessments 
Maintenance Therapy 
Week 59 
 
 
 
 
 
 
Q 2 weeks 
▪ Blood pressure 
▪ Check patient diary (13) 
Q 4 weeks 
▪ History, physical & neuro exam 
(1) 
▪ Vital signs (1), performance 
status, height, weight, BSA,   
▪ Labs: CBC, differential, platelets 
(2),  
      chem 7, albumin;  
     ALT, AST, bilirubin(2);  
     urine protein/CR(3),  
     Valproic acid levels (2, 6)  
▪ MRI brain (10) 
▪ Fax roadmap and patient diary 
(13) 
Q 12 weeks 
▪ MRI brain (9) and spine (11)  
▪ CSF cytology (5)  
Q 24 weeks 
▪ X-ray of right knee (12) 
Week 60 
 
 
 
 
 
Week 61 
 
 
 
 
 
Week 62 
 
 
 
 
 
Week 63 
 
 
 
 
 
Week 64 
 
 
 
 
 
Week 65 
 
 
 
 
 
Week 66 
 
 
 
 
 
Week 67 
 
 
 
 
 
Week 68 
 
 
 
 
 
Week 69 
 
 
 
 
 
Week 70 
 
 
 
 
 
Week 71 
 
 
 
 
 
Week 72 
 
 
 
 
 
Week 73 
 
 
 
 
 
Week 74 
 
 
 
 
 
Week 75 
 
 
 
 
 
Week 76 
 
 
 
 
 
Week 77 
 
 
 
 
 
Week 78 
 
 
 
 
 
Week 79 
 
 
 
 
 
Week 80 
 
 
 
 
 
Week 81 
 
 
 
 
 
Week 82 
 
 
 
 
 
 
 
^ Bevacizumab will be administered during maintenance therapy every 2 weeks for a maximum of 24 months (including XRT). See protocol 5.3 for 
administration and monitoring guidelines and 5.5 for dose modifications. 
* Valproic Acid (VPA) will be given daily in three divided doses. See section 5.2 for administration and monitoring guidelines and 5.4 for dose 
modifications. 
1) For patients with newly identified punctuate hemorrhage on MRI, physical exam, neurological assessment, and performance status should be 
evaluated every 2 weeks at least twice to closely monitor for signs/symptoms of worsening hemorrhage.  
2) Patients with grade 4 neutropenia, anemia, and/or thrombocytopenia should have CBC checked twice weekly until the cytopenia(s) improves 
to grade 3 or better. Patients who require a dose escalation to maintain targeted trough concentration should also have trough VPA, CBC, and 
liver functions measured every 3-5 days until target is reached. 
3) See Appendix II for Urine/Protein Creatinine ratio. 
4) For female patients of child-bearing potential 
5) CSF cytology at the time of diagnosis and subsequently during protocol therapy should be performed as clinically indicated but is not required 
for study entry. 
6) See Section 5.2.3 for monitoring valproic acid concentrations. 
8) For patients with possible radiographic progression on week 10 MRI, the next MRI should be performed at week 18 (see section 8.3). If week 
18 MRI shows stable disease or better compared to week 10 MRI, then patients will continue MRI every 12 weeks. 


 
 
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9) During maintenance therapy, MRI of brain, including GRE images, should be performed every 12 weeks until completion of protocol 
therapy. 
10) For patients with newly identified punctate hemorrhage on MRI, the next MRI, including GRE images, should be repeated every 4 weeks at least 
twice to monitor possible progression of hemorrhage. In the absence of radiographic progression of hemorrhage, the frequency of MRI studies 
can then return to every 12 weeks.  
11) For patients with high grade gliomas, an MRI of the spine should be performed at the time of study entry, but subsequent MRI of the spine 
should only be repeated as clinically indicated. 
12) Pre-treatment tibial X-ray (AP and lateral views) of the right knee must be obtained in all patients younger than 16 years of age prior to 
starting maintenance therapy and be repeated every 24 weeks while receiving bevacizumab. If abnormalities of the metaphyseal plates are 
detected on routine X-rays following initiation of treatment, an MRI scan of both knees should be performed. 
13) Medication diaries should be checked and faxed weekly during radiation therapy. After completion of XRT, medication diaries should be 
checked every 2 weeks and faxed every 4 weeks. Diaries should be faxed to (832)825-1198. Maintain copies of the patient diary in the research 
chart. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
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Appendix VII: Protocol Roadmap (Maintenance Therapy – Weeks 83 – 105) 
 
Patient Initials: ____________________ Patient ID: ________________________________________ 
 
 
Week # 
Date 
^Bevacizumab 
(mg) 
*VPA dose 
(mg/kg/day) 
Cumulative 
VPA dose 
per week 
(mg) 
Patient’s 
weight 
(kg) 
Assessments 
Maintenance Therapy 
Week 83 
 
 
 
 
 
Q 2 weeks 
▪ Blood pressure 
▪ Check patient diary (13) 
Q 4 weeks 
▪ History, physical & neuro exam (1) 
▪ Vital signs (1), performance status, 
height, weight, BSA,   
▪ Labs: CBC, differential, platelets (2),  
      chem 7, albumin;  
     ALT, AST, bilirubin(2);  
     urine protein/CR(3),  
     Valproic acid levels (2, 6)  
▪ MRI brain (10) 
▪ Fax roadmap and patient diary (13) 
Q 12 weeks 
▪ MRI brain (9) and spine (11)  
▪ CSF cytology (5)  
Q 24 weeks 
▪ X-ray of right knee (12 
Week 84 
 
 
 
 
 
Week 85 
 
 
 
 
 
Week 86 
 
 
 
 
 
Week 87 
 
 
 
 
 
Week 88 
 
 
 
 
 
Week 89 
 
 
 
 
 
Week 90 
 
 
 
 
 
Week 91 
 
 
 
 
 
Week 92 
 
 
 
 
 
Week 93 
 
 
 
 
 
Week 94 
 
 
 
 
 
Week 95 
 
 
 
 
 
Week 96 
 
 
 
 
 
Week 97 
 
 
 
 
 
Week 98 
 
 
 
 
 
Week 99 
 
 
 
 
 
Week 100 
 
 
 
 
 
Week 101 
 
 
 
 
 
Week 102 
 
 
 
 
 
Week 103 
 
 
 
 
 
Week 104 
 
 
 
 
 
Week 105 
 
 
 
 
 
 
 
 
 
 
 
^ Bevacizumab will be administered during maintenance therapy every 2 weeks for a maximum of 24 months (including XRT). See protocol 5.3 for 
administration and monitoring guidelines and 5.5 for dose modifications. 
* Valproic Acid (VPA) will be given daily in three divided doses. See section 5.2 for administration and monitoring guidelines and 5.4 for dose 
modifications. 
1) For patients with newly identified punctuate hemorrhage on MRI, physical exam, neurological assessment, and performance status should be 
evaluated every 2 weeks at least twice to closely monitor for signs/symptoms of worsening hemorrhage.  
2) Patients with grade 4 neutropenia, anemia, and/or thrombocytopenia should have CBC checked twice weekly until the cytopenia(s) improves 
to grade 3 or better. Patients who require a dose escalation to maintain targeted trough concentration should also have trough VPA, CBC, and 
liver functions measured every 3-5 days until target is reached. 
3) See Appendix II for Urine/Protein Creatinine ratio. 
4) For female patients of child-bearing potential 
5) CSF cytology at the time of diagnosis and subsequently during protocol therapy should be performed as clinically indicated but is not required 
for study entry. 
6) See Section 5.2.3 for monitoring valproic acid concentrations. 
8) For patients with possible radiographic progression on week 10 MRI, the next MRI should be performed at week 18 (see section 8.3). If week 
18 MRI shows stable disease or better compared to week 10 MRI, then patients will continue MRI every 12 weeks. 
9) During maintenance therapy, MRI of brain, including GRE images, should be performed every 12 weeks until completion of protocol 
therapy. 


 
 
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10) For patients with newly identified punctate hemorrhage on MRI, the next MRI, including GRE images, should be repeated every 4 weeks at least 
twice to monitor possible progression of hemorrhage. In the absence of radiographic progression of hemorrhage, the frequency of MRI studies 
can then return to every    12 weeks.  
11) For patients with high grade gliomas, an MRI of the spine should be performed at the time of study entry, but subsequent MRI of the spine 
should only be repeated as clinically indicated. 
12) Pre-treatment tibial X-ray (AP and lateral views) of the right knee must be obtained in all patients younger than 16 years of age prior to 
starting maintenance therapy and be repeated every 24 weeks while receiving bevacizumab. If abnormalities of the metaphyseal plates are 
detected on routine X-rays following initiation of treatment, an MRI scan of both knees should be performed. 
13) Medication diaries should be checked and faxed weekly during radiation therapy. After completion of XRT, medication diaries should be 
checked every 2 weeks and faxed every 4 weeks. Diaries should be faxed to (832)825-1198. Maintain copies of the patient diary in the research 
chart. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
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Appendix VII: Protocol Roadmap for Follow-up 
 
 
Patient Initials: ____________________ Patient ID: ______________________________________ 
 
 
Date patient completed maintenance therapy: _________________ 
 
Months 
post 
therapy 
Date 
*Vital Status 
^Disease 
progression? 
 
 
Assessments 
Alive 
Decease
d 
No 
Yes 
6 months 
 
□ 
□ 
□ 
□ 
 
Q 6 months 
▪ History, physical exam 
▪ Vital signs, blood pressure   
  ▪ Labs: CBC, differential, 
platelets,  
    urine protein/creatinine ratio 
(see appendix II)  
▪ MRI brain  
▪ Fax roadmap  
 
12 months 
 
□ 
□ 
□ 
□ 
18 months 
 
□ 
□ 
□ 
□ 
24 months 
 
□ 
□ 
□ 
□ 
30 months 
 
□ 
□ 
□ 
□ 
36 months 
 
□ 
□ 
□ 
□ 
42 months 
 
□ 
□ 
□ 
□ 
48 months 
 
□ 
□ 
□ 
□ 
54 months 
 
□ 
□ 
□ 
□ 
60 months 
 
□ 
□ 
□ 
□ 
 
* Vital Status: if deceased, date of death _________________________ 
 
^ Disease Progression: if yes, date of progression _________________________ 
 
Please fax roadmap every 6 months to (832)825-1198 
 
 
 
 
 


 
 
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APPENDIX VIII: SAMPLE INFORMED CONSENT / PARENTAL PERMISSION FOR 
PARTICIPATION IN RESEARCH 
 
A Phase 2 Study of Valproic Acid and Radiation, Followed by Maintenance Valproic Acid and 
Bevacizumab in Children with Newly Diagnosed High-Grade Gliomas or Brainstem Gliomas 
 
The use of “you” in this document refers to you or your child; the use of “we” in this document 
refers to the doctors and other study staff. 
 
This study is a clinical trial, or a research study involving patients and a potential new treatment. 
Clinical trials include only patients who choose to take part. Your participation in this study is entirely 
voluntary. Please read the consent form carefully, and you will be given a copy of this consent if you 
decide to participate. You may discuss your decision with your friends and family if you would like.  
 
You are being asked to participate in this study because you have an aggressive brain tumor called 
glioblastoma multiforme, anaplastic astrocytoma, gliomatosis cerebri, gliosarcoma, or brainstem 
glioma. These brain tumors are collectively called “malignant gliomas.” This study is being conducted 
by the Texas-Oklahoma Pediatric Neuro-Oncology Consortium, which consists of nine pediatric 
cancer centers treating children with brain tumors in the state of Texas and Oklahoma.  
 
Currently, there are few effective treatments for your type of aggressive brain tumors. Surgery and 
radiation can generally slow down these aggressive brain tumors, but in the majority of patients, these 
tumors will start growing again in 6-12 months. Adding chemotherapy drugs to surgery and radiation 
does not clearly improve the cure rate of children with malignant gliomas. We are conducting this 
study to see if the combination of valproic acid and bevacizumab (also known as AvastinTM) with 
surgery and radiation will shrink your brain tumor more effectively and improve your chance of cure. 
 
Valproic acid (VPA) has been given to children with seizures (epilepsy) for many decades, and it has 
been approved by the Food and Drug Administration (FDA) but has not been approved specifically for 
treating children with brain tumors. From 40 years of clinical experience using VPA in children with 
epilepsy, we know that children can safely take this drug for many years. Based on laboratory and 
animal studies, we learned that VPA may kill malignant glioma cells. We also learned that VPA may 
make malignant glioma cells more sensitive to radiation. In two recently completed clinical trials, VPA 
given as a single drug was shown to shrink malignant gliomas in some children. However, we only 
have limited experience in giving VPA with radiation, and we have no past clinical experience in 
giving VPA with bevacizumab, the second drug that you will receive on this clinical trial. Therefore, 
the use of VPA with radiation and bevacizumab for your brain tumor is considered investigational. 
 
Tumors in general require extra blood vessels to support their rapid growth and high nutritional 
demands. A type of protein called vascular endothelial growth factor, or VEGF, has been shown to be 
produced at high levels in many human tumors, including malignant gliomas. Bevacizumab 
(AvastinTM) is a specific antibody (a protein that recognizes and binds to another protein) for the 
VEGF protein, and in animal studies, treatment with bevacizumab has been shown to decrease VEGF 
levels, cut off blood vessels, and shrink many human tumors, including malignant gliomas. More than 
eight thousand adults have received bevacizumab, either as a single drug or in combination with 
chemotherapy drugs, in numerous clinical trials, and this drug has been approved by the FDA for 


 
 
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treatment of colon and lung cancers. Recently, clinical trials in adults with recurrent malignant gliomas 
(tumors that started growing after initial surgery, radiation, and chemotherapy) showed that 
bevacizumab can shrink these tumors in more than 25% of patients. Bevacizumab has been tested in 
children with recurrent solid tumors, and there is a current clinical trial testing bevacizumab and 
chemotherapy in children with recurrent brain tumors. Bevacizumab was recently approved by the 
FDA as a treatment for patients with malignant gliomas; however, the combination of VPA and 
bevacizumab is considered investigational. 
 
VPA is a commercially available drug. The bevacizumab that will be used in this clinical trial is for 
use in research studies only. Although there may be some minor differences between the bevacizumab 
used for research studies only and the commercial drug AvastinTM, both drugs are manufactured by a 
similar process and supplied by the same company (Genentech, Inc), meet similar standards for final 
product testing, and are expected to be similar in safety and effectiveness. 
 
Why is this study being done? 
We are testing the combination of VPA, a commonly drug for epilepsy in children, with a new 
drug, bevacizumab, for children who have just been diagnosed with malignant gliomas. This new 
combination of treatment will be given in addition to surgery and radiation, which are 
considered to be the standard treatment for children with malignant gliomas. 
 
The goals of this study are: 
 
To see if children with malignant gliomas treated with VPA and bevacizumab, in 
addition to surgery and radiation, will have a higher cure rate compared to children 
that received surgery, radiation, and chemotherapy in the past; 
 
To learn what kinds of side effects will occur in children with malignant gliomas 
when they receive VPA and bevacizumab, in addition to surgery and radiation; 
 
To learn if levels of proteins that are affected by VPA, in your brain tumor will 
predict your tumor’s response to VPA and/or radiation; 
 
To learn if levels of proteins that allow tumor cells to repair damage to genes in brain 
tumors will predict tumor response to VPA and/or radiation 
 
To learn if levels of certain proteins that are affected by bevacizumab will predict the 
response of a tumor to bevacizumab and/or radiation 
 
How many people will take part in the study? 
There will be about 23-34 patients participating in this study over the first 2 years.  About ___ will be 
treated at this hospital. If the analysis at 2 years showed that this new combination is beneficial for 
children with malignant gliomas, we will continue to recruit more patients; if not, this clinical trial will 
be closed, but if you have already started this clinical trial at the time of its closure, you can still 
continue to receive this combination of treatment. 
 
What will happen if I take part in this research study?   
Before you begin the study …  
You will need to have the following exams, tests or procedures to find out if you can be in the study.  
These exams, tests or procedures are part of regular cancer care and may be done even if you do not 
join the study.  If you have had some of them recently, they may not need to be repeated.  This will be 
up to your study doctor.   


 
 
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 A medical history 
 Physical exam, including a neurological exam 
 Vital signs (blood pressure, heart rate, temperature, weight, height, and body surface area) 
 Blood tests 
 Urine tests 
 Pregnancy test (if you are a woman who could have children) 
 MRI of brain and spine 
 A lumbar puncture (a spinal tap), if your doctor thinks it is safe and required for your care  
 Any other studies or tests your treating doctor thinks it is necessary to give you the best care 
 
If you are not done growing, you will also have to have an X-ray of your knee to monitor for any side 
effects that may be related to bevacizumab. 
 
Surgery 
If your neurosurgeon and your treating doctor think that surgery can be safely performed, you will first 
have a surgery (or more than one if needed) to remove as much of your brain tumor as possible. For 
some of you, surgery may not be safe and will not be performed. Please discuss the safety of surgery 
for your brain tumor with your neurosurgeon and treating doctor. 
 
Radiation 
Once you have recovered from your surgery, you will start VPA and radiation as described in the table 
below. You will meet with a radiation oncologist (doctors who will be giving you radiation to treat 
your brain tumor) to discuss the side effects of radiation therapy. VPA will be given to you by mouth, 
either as capsules, syrup, or a combination of both. You will take VPA three times a day (every 8 
hours), and we will ask you to keep a diary of the date and time when you take your VPA. 
 
Treatment and Tests Required During Your Radiation Treatment 
 
Monday through 
Friday 
Daily 
Once a week 
Radiation 
For about 6 weeks 
 
 
VPA 
 
3 times a day, by mouth 
 
Exam, blood tests 
 
 
Once a week; more if needed 
VPA drug diary 
 
Record with each dose 
 
 
Your radiation will last about 6 weeks. You will continue your VPA daily without interruption unless 
told to do so by your treating doctor.  
 
Rest period between radiation and maintenance treatment 
After you have completed your radiation, you will have a rest period of about 4 weeks before you start 
your maintenance treatment (combination of bevacizumab and VPA; see discussion below). Assuming 
that you have no side effect from VPA that require you to discontinue this drug, you will continue 
VPA three times daily without interruption during this rest period. If you have had side effects related 
to VPA and was instructed to discontinue this drug during radiation, then you will not re-start this drug 
until the start of your maintenance treatment (see below). Your will have an MRI at about 10 weeks 
after starting your radiation treatment to see if your tumor has responded to your treatment. 


 
 
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Maintenance treatment with bevacizumab and VPA 
Before starting your maintenance treatment, your treating doctor will repeat most of the blood tests that 
you already had at the beginning, to make sure that you can still tolerate your treatment. Bevacizumab 
will be given to you through your vein (i.v.) in the clinic every two weeks, and VPA will be given to 
you by mouth three times a day, as you have been taking this drug during radiation. Even if you have 
experienced side effects with VPA during radiation and needed to stop this drug, we will still ask you 
to re-start VPA, but at a lower dose to prevent the same side effect(s) from happening again.  
 
You will continue to receive bevacizumab and VPA, assuming that you do not experience any side 
effects that require you to stop either or both drugs, for a maximum period of 94 weeks. Therefore, the 
maximum length of your total treatment (radiation, VPA, and bevacizumab) will be two years (104 
weeks). During your maintenance treatment, you will have blood tests, urine tests, and MRIs done as 
described in the table below. These tests are to ensure that you are not having unsafe side effects from 
your treatment. If you experience side effects and have to stop either bevacizumab or VPA, you have 
the option of remaining on this clinical trial and continuing the other drug by itself. However, you may 
also elect to stop participating in this clinical trial and seek other treatment options. 
 
Treatment and Tests Required During Maintenance Therapy 
 
Daily 
Every 2 weeks 
Every 4 weeks 
Every 12 
weeks 
Every 24 weeks 
VPA 
3 times daily 
 
 
 
 
VPA drug diary 
Record each 
dose 
 
 
 
 
Bevacizumab 
 
i.v. every 2 weeks 
 
 
 
Blood pressure 
 
Every 2 weeks 
 
 
 
Exam and blood 
tests 
 
 
Every 4 weeks 
 
 
Urine tests 
 
 
Every 4 weeks 
 
 
MRI of brain 
 
 
 
Every 12 
weeks 
 
MRI of spine 
 
 
 
If needed 
If needed 
Spinal tap) 
 
 
 
 
If needed 
X-ray of knee 
 
 
 
 
Every 24 weeks 
 
Because VPA is given by mouth, and bevacizumab is given in your vein over 30-90 minutes, you will 
not have to be hospitalized to receive this treatment combination, unless you have side effects that 
require further treatment. You can either receive bevacizumab through a temporary catheter in your 
Treatment and Tests During the Rest Period After Radiation 
 
Daily 
Every 2 weeks 
Week 10 
VPA 
3 times a day, by mouth 
 
 
Exam, blood tests 
 
Every 2 weeks 
 
VPA drug diary 
Record with each dose 
 
 
MRI of brain 
 
 
Week 10 
MRI of spine 
 
 
If needed 
Spinal tap 
 
 
If needed 


 
 
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vein, which will have to be inserted and replaced every 2 weeks, or through a permanently placed 
catheter called a central line (which will require a surgery). Please discuss with you treating doctor 
regarding the safety of placing and maintaining a central line. 
 
Biological studies 
We would like to study the levels of some proteins in your blood and brain tumor because we think 
that they may predict how your tumor will respond to radiation, VPA, and/or bevacizumab. In 
addition, by studying these proteins in your blood and brain tumor, we hope to learn more about 
malignant gliomas in children and design more effective treatment in the near future. Participation in 
these biologic studies is entirely voluntary; your refusal to participate will not prevent you from 
receiving the treatment already described in this consent. If you weight more than 10 kilogram, you 
will have two teaspoons of blood drawn before starting treatment and once more at 2 weeks after 
starting VPA and radiation. If you weigh less than 10 kilogram, you will have only 1 teaspoon drawn 
twice as described above. These amounts of blood are safe to draw from children. You can agree to 
have just your tumor or blood studied, or you can agree to have both studied. 
 
Please indicate by initialing below whether you choose to participate in the biological studies. 
 
______/______ Yes, I agree to participate in the biological studies. 
 
 
If you answered “Yes,” please choose only one of the following options: 
 
 
 ______  I only agree to have my tumor used for the biological studies. 
 
 
 ______ I only agree to have my blood used for the biological studies. 
 
 
 ______ I agree to have both my blood and tumor used for the biological studies. 
 
______/______ No, I do not agree to participate in the biological studies. 
 
How long will I be in the study? 
You may be in the study for up to 24 months if you are responding to therapy and not having side 
effects that are dangerous for you.  Your doctor may decide to take you off study if any of the 
following occur: 
 The side effects of VPA and/or bevacizumab are too harmful for you 
 You need a treatment that is not allowed on this study 
 Your tumor has grown back or become larger despite receiving VPA and bevacizumab 
 You are not able to follow study-related treatment instructions 
 New information becomes available 
 The study is not in your best interest 
 The study is stopped because there is no benefit for your type of brain tumor 
 
After you are taken off treatment or after you have completed your treatment, your treating doctor will 
ask you to return for follow up exams and tests to ensure that you are not having dangerous side 
effects. Please continue to follow these instructions to ensure your safety.  
 


 
 
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Can I stop being in the study? 
Yes.  You can decide to stop at any time.  Tell the study doctor if you are thinking about stopping or 
decide to stop.  He or she will tell you how to stop safely.  
 
It is important to tell the study doctor if you are thinking about stopping so any risks from VPA and/or 
bevacizumab can be evaluated by your doctor.  Another reason to tell your doctor that you are thinking 
about stopping is to discuss what follow-up care and testing could be most helpful for you. 
 
The study doctor may stop you from taking part in this study at any time if he/she believes it is in your 
best interest; if you do not follow the study rules; or if the study is stopped. 
 
What side effects or risks can I expect from being in the study?  
 
Side Effects of Valproic Acid 
The side effects that we think valproic acid might have are listed below. There might be other 
side effects that we do not know about yet because we have only limited experience in using this 
drug to treat brain tumors in children. These side effects could be dangerous or life threatening. 
We will be checking you closely to see if any side effects are happening. Side effects of drugs like 
valproic acid usually get better if the treatment is stopped, but in some cases they can be serious 
and/or irreversible.  There is the risk of death.  If you do have side effects, we may recommend 
medicine or treatments to try to control them and make you comfortable.  You should talk to 
your study doctor as soon as possible about any side effects that you have while taking part in the 
study.   
  
Risks and side effects related to the valproic acid include the following: 
 
Likely: 
 
nausea 
 
vomiting 
 
abdominal pain 
 
diarrhea 
 
headache  
 
sleepiness 
 
tremor 
 
loss of strength and energy 
 
dizziness 
 
hair loss 
 
rash 
 
dry skin 
 
itching of the skin 
 
numbness and tingling of your hands and/or feet 
 
short-term weakness of your hands and/or feet 
 
Less Likely: 
 
loss of appetite 


 
 
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 
heartburns 
 
flu-like syndromes 
 
double vision 
 
blurred vision 
 
unsteadiness 
 
unsteady eye movement 
 
sleeplessness 
 
loss of memory 
 
moodiness 
 
anxiety or nervousness 
 
ringing in the ear 
 
weight gain or loss  
 
abnormal thyroid function 
 
low platelet count, which may cause easy bruising or bleeding 
 
abnormal blood clotting which can lead to excessive bleeding during and after surgery 
 
Rare but can be serious: 
 
pneumonia 
 
sores in the mouth or on the tongue 
 
hyperactivity 
 
confusion 
 
coma 
 
severe reactions involving skin, mouth, and eyes, including blisters 
 
redness, swelling, and/or peeling of your skin, resulting in pain and infection 
 
eye pain and irritation 
 
low white and/or red blood cell count  
 
abnormal effects on unborn babies (see “Risks of Pregnancy” below) 
 
severe to life-threatening inflammation of the pancreas and liver 
 
hearing loss 
 
abnormal sodium level in the blood 
 
fast and/or irregular heart beats, high blood pressure 
 
peeing frequently, vaginal yeast infection  
 
inflammation of the kidney 
 
irregularities in your periods, including complete stoppage of your periods 
 
gum bleeding or swelling, infection around your teeth 
 
abnormal change in the bone marrow leading to chronic transfusions, and possibly                 
leading to a pre-leukemia condition called myelodysplastic syndrome. 
 
abnormal clotting tests and possibly increased risk of bleeding 
 
Risks of Pregnancy: The drug on this study may affect an unborn baby. You should not become 
pregnant or father a baby while on this study. You should not nurse (breast feed) a baby while on this 
study. Ask about counseling and more information about preventing pregnancy.  
 
 
 
 


 
 
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Possible Drug Interactions Between Valproic Acid and Other Medications 
Valproic acid has interactions with multiple anti-seizure medications. Valproic acid also interacts with 
several other medications, including acyclovir, multiple antibiotics (azithromycin, erythromycin, 
imipenem, meropenem, etc.), aspirin, chlorpromazine, cholestyramine, isoniazid, rifampin, 
amitriptyline, nortriptyline, clonazepam, diazepam, nimodipine, tricyclic anti-depressants, tolbutamide, 
warfarin, and zidovudine. While you are allowed to take valproic acid and any of these medications 
together, you should notify your treating doctor immediately if another doctor starts you on one of 
these medications, because you will have to be closely monitored for valproic acid levels and the side 
effects of these medications.  
 
Side Effects of Bevacizumab 
The side effects that we think bevacizumab might have are listed below. There might be other 
side effects that we do not know about yet because we have only limited experience in using 
bevacizumab to treat brain tumors in children. These side effects could be dangerous or life 
threatening. We will be checking you closely to see if any side effects are happening. Side effects 
of drugs like bevacizumab usually get better if the treatment is stopped, but in some cases they 
can be serious and/or irreversible.  There is the risk of death.  If you do have side effects, we may 
recommend medicine or treatments to try to control them and make you comfortable.  You 
should talk to your study doctor as soon as possible about any side effects that you have while 
taking part in the study.   
 
Likely side effects: 
 Nose bleeds 
 High blood pressure – in most patients, blood pressure can be controlled with routine 
medications. Rarely, uncontrolled high blood pressure may lead to damage to the brain and 
other vital organ functions. 
 Fatigue 
 Skin reactions (itching, rash, flaking of the skin, or hives) 
 Headache 
 Soreness in mouth or throat 
 Stuffy or runny nose, sneezing, watery eyes, abnormal reactions in the nose or sinuses 
 Nausea or vomiting, loss of appetite 
 Diarrhea 
 Heartburn 
 Abnormal blood chemistry or electrolytes 
 Generalized pain or pain at the tumor site 
 Voice changes, hoarseness, laryngitis 
 Cough and/or shortness of breath 
 Dizziness 
 
Less likely side effects 
 Mild to moderate bleeding in the tumor, stomach, intestine, genitourinary tract, or other 
parts of the body 


 
 
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 Blood clots in the veins of the leg, lungs, or other parts of the body. These clots can be life-
threatening. 
 Clots in the arteries, including stroke or heart attack. These conditions can be life-
threatening or fatal. 
 Leakage of protein in the urine, which can rarely lead to damage to the kidney or kidney 
failure.  
 Reaction to bevacizumab – these reactions may include skin reactions (itching, rash, swelling, 
flaking of skin, and hives), respiratory symptoms (shortness of breath, cough, throat 
tightness, wheezing), cardiac symptoms (low blood pressure, dizziness), or others (chill, 
shivering) 
 Constipation 
 Decrease in white cell count (neutropenia) which may increase your risk of an infection 
 Decrease in red cell count, which may require a blood transfusion 
 
Rare but serious side effects 
 Reversible posterior leukoencephalopathy syndrome (RPLS) or similar leukoencephalopathy 
syndrome: RPLS is a medical condition related to leakiness of blood vessels in the brain and 
can cause confusion, blindness or vision changes, seizure, and other symptoms, as well as 
changes on your MRI. This condition is usually reversible, but in rare cases, it is potentially 
life-threatening and may have long-term side effects on brain functions. 
 Serious or fatal bleeding into the tumor, brain, gut, lungs, or other parts of the body 
 Bowel perforation and bowel anastomotic dehiscence. Bowel perforation occurs when an 
opening exists in the bowel wall allowing bowel contents to spill into the abdomen. Bowel 
anastomotic dehiscence is a breakdown in the surgical connection between two pieces of 
bowel. These events are rare in patients who have not had prior bowel surgeries, but they can 
lead to serious infections and will require surgery to repair the breaks. 
 Fistula formation: defect in the walls of luminal organs such as the upper airway, lungs, 
esophagus, rectum, or vagina. Fistula formation may lead to life-threatening complications, 
including serious infections, bleeding, or dysfunctions of organs. 
 Heart problems (including irregular heartbeats, fluid collections around the heart, heart 
attack, or heart failure). 
 Stroke 
 Fluid collection within tissues of the lungs 
 Delayed or poor wound healing 
 Severe allergic reactions that result in difficulty breathing, a severe drop in blood pressure, 
and possible death 
 Reversible changes in the liver functions 
 Serious and sometimes fatal infection when your white cell count is very low (severe 
neutropenia) 
 Sudden death of uncertain relationship to bevacizumab 
 
Growth and Development Risks Associated with Bevacizumab 
Animal studies of drugs that decrease blood vessels in tumor, such as bevacizumab, showed decreases 
in ovarian function and abnormal bone growth. These and other effects of bevacizumab may 


 
 
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potentially impair growth and development and decrease your chance of conceiving a child in the 
future. 
 
Abnormal changes in the bones after bevacizumab treatment have been observed in young children 
with developing bones. This side effect appeared to be reversible after the treatment was stopped, but 
its exact effect on bone development has not been fully understood with long-term use of this drug. 
 
Reproductive Risks Associated with Bevacizumab 
If you are able to become pregnant, a blood test will be performed before the study to ensure that you 
are not pregnant. Because bevacizumab can potentially affect an unborn baby and infants, you should 
not become pregnant or father a baby or breast feed while you are on this study. Also, bevacizumab 
remains in your body for weeks to months, and therefore you should continue to use adequate 
contraceptive measures and avoid nursing a baby for at least 6 months after your last dose of 
bevacizumab. 
 
Possible Side Effects of Radiation Therapy to the Brain 
Short-term side effects 
 Hair loss, both temporary and permanent 
 Irritation or redness of the skin with possible peeling of the skin at the sites of radiation 
 Areas of the ear canal exposed to radiation may develop inflammation and irritation weeks to 
months after treatment, causing plugging of ears and poor balance 
 Nausea, vomiting, and poor appetite 
 Weight loss from poor appetite 
 Fatigue 
 Short-term memory problems (difficulty remembering things, difficulty concentrating) 
 Sleeping too much  
 
Long-term side effects 
 Memory difficulties (difficulty remembering things, recalling things, performing complicated 
tasks, etc.) 
 Learning difficulties (problems with learning new tasks or skills, problems with academic 
performance in school, etc.) 
 Hearing loss 
 Changes in hormone function and levels, sometimes requiring hormone replacement 
 Growth failure, sometime requiring growth hormone 
 Vision problems 
 
You should discuss the potential side effects of radiation therapy in details with your radiation 
oncologist. 
 
Possible Side Effects of Surgery to Remove Your Brain Tumor 
Surgery to remove part or all of your brain tumor will only be performed if your neurosurgeon and 
your treating physician believe that such a surgery can be safely performed and its benefit outweighs 
its potential risk. Please discuss the benefit and risk of the surgery for your brain tumor with your 
neurosurgeon and treating physician.   
 


 
 
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Risks of blood drawing or placing an intravenous catheter for blood drawing 
Risks associated with drawing blood are slight, but some risks include: pain, excessive bleeding, 
fainting or feeling lightheaded, bruising, infection (a slight risk any time the skin is broken), and 
multiple punctures to locate veins. 
 
Lumbar puncture risks 
A lumbar puncture to see if your brain tumor has spread to the spines will only be performed if your 
treating physician thinks that it is necessary for the best care of your brain tumor. A lumbar puncture 
has a small risk of infection, bleeding, nerve damage, or headache.  Leakage of spinal fluid into the 
tissue can cause a severe headache that lasts for days to weeks.  Patients will be given medications to 
numb the pain and blur the memory before the test since it is painful. The pain is usually brief but 
occasionally may linger. Sometimes this procedure is done while the patient is under general 
anesthesia. 
 
We will tell you if we learn any new information that may affect your health, welfare, or decision 
to stay in this study.  
 
If you have more questions about the risks and side effects of this study, please discuss them in details 
with your treating doctor before consenting for the study. 
 
Are there benefits to taking part in the study? 
The potential benefit of this new treatment with valproic acid and bevacizumab is that it may shrink 
your tumor more effectively than with surgery and radiation alone and therefore may improve your 
chance of cure.  However, we do not know if you will benefit from taking part in this study. 
Information learned from this study may help future children with malignant gliomas. 
 
What other choices do I have if I do not take part in this study? 
 Treatment with surgery and radiation, with or without chemotherapy drugs that have 
been previously tried with your type of brain tumor. 
 Other types of investigational trial (if available). 
 No further treatment, and comfort care only. 
 
Please discuss these options with your treating doctor as well as other trusted persons or family 
members. 
 
Will my medical information be kept private?  
We will do our best to make sure that the personal information in your medical record will be 
kept private.  However, we cannot guarantee total privacy.  Your personal information may be 
revealed if required by law.  If information from this study is published or presented at scientific 
meetings, your name and other personal information will not be used. 
 
Your medical records are available to those caring for you at this hospital. Other people or 
groups who may see or copy your medical record because you are participating in this study 
include:  
 Physicians from other institutions in the Texas-Oklahoma Pediatric Neuro-Oncology 
Consortium 
9/22/05 


 
 
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 The FDA, the National Cancer Institute (NCI), or other governmental agencies involved 
in keeping research studies safe for children 
 The Institutional Review Board of your hospital 
 Representatives from Genentech, Inc. (the company that supplies bevacizumab) 
 
Otherwise your name will not be released without your written permission, unless required by law. If 
results of this study are published, your identity will remain confidential. 
 
What are the costs of taking part in this study? 
Genentech, Inc will provide bevacizumab at no cost to you and your treating doctor. You will not have 
to pay for the tumor biology studies if you choose to participate. Otherwise, you and/or your insurance 
company will be responsible for the cost of surgery, radiation, valproic acid, and all the office visits, 
blood tests, urine tests, MRI studies, and any other tests necessary to monitor your tumor, ensure your 
safety, or treat your side effects while you are on this study. You will not be paid any money for 
participating in this clinical trial. Please ask to speak to a financial counselor if you have any questions 
about the costs of being in this study. 
 
For more information on clinical trials and insurance coverage, you can visit the National Cancer 
Institute’s Web site at http://cancer.gov/clinicaltrials/understanding/insurance-coverage . You can 
print a copy of the “Clinical Trials and Insurance Coverage” information from this Web site. 
 
Another way to get the information is to call 1-800-4-CANCER (1-800-422-6237) and ask them to 
send you a free copy. 
 
What happens if I am injured because I took part in this study? 
It is important that you tell your study doctor, __________________ [investigator’s name(s)], if you 
feel that you have been injured because of taking part in this study.  You can tell the doctor in person 
or call him/her at __________________ [telephone number]. 
 
You will get medical treatment if you are injured as a result of taking part in this study.  You and/or 
your health plan will be charged for this treatment.   The study will not pay for medical treatment.   
 
What are my rights if I take part in this study? 
Taking part in this study is your choice.  You may choose either to take part or not to take part in the 
study.  If you decide to take part in this study, you may leave the study at any time.   No matter what 
decision you make, there will be no penalty to you, and you will not lose any of your regular benefits.  
Leaving the study will not affect your medical care.  You can still get your medical care from our 
institution.    
 
We will tell you about new information or changes in the study that may affect your health or your 
willingness to continue in the study. 
 
In the case of injury resulting from this study, you do not lose any of your legal rights to seek payment 
by signing this form.   
 
Whether you participate or not, you will continue to get the best medical care this hospital can provide. 


 
 
Page 94 of 95
 
Who can answer my questions about the study? 
You can talk to your study doctor about any questions or concerns you have about this study.  Contact 
your study doctor __________________ [name(s)] at __________________ [telephone number]. You 
can also contact Dr. Jack Su, the study chair of this clinical trial, by phone (832-822-4306) or by e-
mail (jmsu@txccc.org). 
 
For questions about your rights while taking part in this study, call the ________________________ 
[name of center] Institutional Review Board (a group of people who review the research to protect 
your rights) at __________________ (telephone number).  [Note to Local Investigator: Contact 
information for patient representatives or other individuals in a local institution who are not on the 
IRB or research team but take calls regarding clinical trial questions can be listed here.]    
 
Where can I get more information? 
You may call the National Cancer Institute's Cancer Information Service at:  
 1-800-4-CANCER (1-800-422-6237) or TTY: 1-800-332-8615 
 
You may also visit the NCI Web site at http://cancer.gov/ 
 For NCI’s clinical trials information, go to: http://cancer.gov/clinicaltrials/ 
 For NCI’s general information about cancer, go to http://cancer.gov/cancerinfo/ 
 
You will get a copy of this form. You will be given a copy of the protocol (full study plan) upon 
request.  If you want more information about this study, ask your study doctor. 
 
A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by 
U.S. Law. This Web site will not include information that can identify you. At most, the Web site will 
include a summary of the results. You can search this Web site at any time. 
 
 
SIGNATURES 
 
I have been given a copy of all 13 pages of this form.   
I have read it or it has been read to me.  
I understand the information and have had my questions answered.  I agree to take part in this study. 
 
 
PATIENT NAME:    
 
__________________________________________________ 
 
 
 
 
 
 
 
(Print Name)  
 
(Date) 
 
 
PARENT (OR GUARDIAN)  
__________________________________________________ 
 
 
 
 
 
 
 
(Signature) 
 
 
(Date) 
 
 


 
 
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PHYSICIAN OR INVESTIGATOR  __________________________________________________ 
 
 
 
 
 
 
 
(Signature) 
 
 
(Date) 
 
 
WITNESS 
 
 
 
__________________________________________________ 
 
 
 
 
 
 
 
(Signature) 
 
 
(Date)