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Tumor Resection and Gliadel® Wafers, Followed by Temodar® With Standard Radiation or GammaKnife® for New GBM

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ClinicalTrials.gov Identifier: NCT02085304
Recruitment Status : Unknown
Verified December 2016 by St. Joseph's Hospital and Medical Center, Phoenix.
Recruitment status was:  Recruiting
First Posted : March 12, 2014
Last Update Posted : December 13, 2016
Sponsor:
Information provided by (Responsible Party):
St. Joseph's Hospital and Medical Center, Phoenix

Brief Summary:

A glioblastoma (GBM) is the most common malignant primary brain tumor, yet it is not easy to control. Recent studies show that survival improves for patients who get aggressive surgery to remove a tumor before starting radiation (RT) and chemotherapy (chemo) treatment. Surgery, RT and chemo are part of regular cancer care for GBM. RT is usually done in daily doses 5 days a week over about 6 weeks. Beams of radiation are aimed at the tumor site plus some of the normal brain tissue around the tumor area. GammaKnife® (GK) radiosurgery also delivers radiation but in a larger dose over one day. GK sends beams to a precise target (tumor location) and very little normal brain tissue that is nearby. This study will compare GK treatment to the usual RT treatment after surgery, and with chemo.

We want to know:

  • How well each treatment keeps the tumor from growing back.
  • What the effects (good and bad) of the treatments are.
  • How you rate your quality of life.
  • How the treatment affects your ability to think, understand, reason, and remember.
  • How you rate your ability to think, understand, reason, and remember.
  • If using a certain type of MRI scan can show the difference between new tumor growth and changes caused by treatment.
  • If certain features found in tumor cells can help doctors predict how tumors will respond to treatment.

Condition or disease Intervention/treatment Phase
Glioblastoma Procedure: Gross total resection and Gliadel(R) wafers implanted Radiation: GammaKnife(R) stereotactic Radiosurgery Radiation: Standard fractionated radiation therapy Drug: Temozolomide Phase 1 Phase 2

Detailed Description:

The primary purpose of this study is to determine if single fraction GK radiosurgical treatment to the resection bed can achieve equivalent local control and survival for patients with GBM after GTR, Gliadel® implant and temozolomide therapy compared to patients receiving standard postoperative RT with temozolomide, but offer improved quality of life and preserve cognitive function.

In Phase I, it is proposed that 20 patients with newly diagnosed glioblastoma multiforme (GBM) undergo gross total resection (GTR) with Gliadel® (carmustine) wafer implantation to the resection cavity at that time will be eligible for study. These patients will then receive Gamma Knife® (GK) radiosurgery to the resection cavity margin within 4 weeks following surgical resection and within 24 hours of starting temozolomide (Temodar®) induction therapy. Temozolomide (Temodar®) maintenance therapy would be administered for 12 months.

In Phase II, it is proposed that 60 patients with newly diagnosed glioblastoma multiforme (GBM) undergo gross total resection (GTR) with Gliadel® (carmustine) wafer implantation to the resection cavity at the time of initial resection will be eligible for study. These patients will then be randomized to either standard fractionated conformal radiation therapy (RT) or Gamma Knife® (GK) radiosurgery to the resection cavity margin. Fractionated RT would be administered with concurrent temozolomide Gamma knife® radiosurgery to the resection cavity margin will be administered within 24 hours of starting temozolomide induction therapy. Both the GK and RT will be administered within 4 weeks following surgical resection. Temozolomide (Temodar®) maintenance therapy would be administered to all patients in both arms of the study for 12 months.

It is believed that all patients will benefit from enrollment in the study regardless of the treatment arm to which they are randomized. All patients will be receiving focally aggressive surgical resection with Gliadel® implant in addition to temozolomide for prevention of both focal and distant recurrence.

Patients who are randomized to receive GK radiosurgical treatment to the resection bed margin may benefit from increased local control based on a prior non-randomized study. However these patients will be treated in a non-standard fashion and may be subjected to a higher incidence of focal radiation necrosis or a higher incidence of failure beyond the resection margin compared to standard patients.

The GK treated patients however, will be spared the standard 6 weeks of RT postoperatively. It is hypothesized that those receiving GK will therefore have an improved quality of life with respect to having less fatigue, lack of hair loss and a decreased incidence of delayed cognitive decline associated with standard RT.


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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 80 participants
Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Phase I/II Randomized Prospective Trial for Newly Diagnosed GBM, With Upfront Gross Total Resection, Gliadel®, Followed by Temodar® With Concurrent IMRT Versus GK
Study Start Date : October 2012
Estimated Primary Completion Date : June 2017
Estimated Study Completion Date : December 2017

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Experimental: GammaKnife(R) stereotactic radiosurgery
Following surgery for Gross total resection and Gliadel(R) wafers implanted , the patient will receive a one-day GammaKnife(R) stereotactic radiosurgery procedure and will also take temozolomide (Temodar(R)) chemotherapy daily for six weeks with a one month break before taking temodar for additional 12 monthly cycles.
Procedure: Gross total resection and Gliadel(R) wafers implanted
Complete removal of tumor and implant of Gliadel(R) wafers that are small, dime-sized wafers designed to deliver the chemo drug, carmustine, directly into the cavity made when the brain tumor was removed.

Radiation: GammaKnife(R) stereotactic Radiosurgery
GammaKnife® (GK) radiosurgery dose of 15 Gy in one fraction to the resection cavity margin

Drug: Temozolomide
temozolomide 75 mg/m2 daily for 42 days, will be administered to all patients beginning within 24 hours of GK/RT initiation as is routine clinical care. There will be a one month drug holiday following the 42 days before adjuvant chemotherapy begins. Adjuvant temozolomide administered 5 days monthly at 150-200 mg/m2/day will be administered for 12 months as is routine clinical care.
Other Name: Temodar(R)

Active Comparator: Standard fractionated radiation therapy
Following surgery for Gross total resection and Gliadel(R) wafers implanted , the patient will receive six weeks of standard fractionated radiation therapy plus daily temozolomide (Temodar(R)) chemotherapy for six weeks. This is followed by a one month break before taking temodar for additional 12 monthly cycles.
Procedure: Gross total resection and Gliadel(R) wafers implanted
Complete removal of tumor and implant of Gliadel(R) wafers that are small, dime-sized wafers designed to deliver the chemo drug, carmustine, directly into the cavity made when the brain tumor was removed.

Radiation: Standard fractionated radiation therapy
standard fractionated RT of 60 Gy in 30 fractions (over approximately six weeks)

Drug: Temozolomide
temozolomide 75 mg/m2 daily for 42 days, will be administered to all patients beginning within 24 hours of GK/RT initiation as is routine clinical care. There will be a one month drug holiday following the 42 days before adjuvant chemotherapy begins. Adjuvant temozolomide administered 5 days monthly at 150-200 mg/m2/day will be administered for 12 months as is routine clinical care.
Other Name: Temodar(R)




Primary Outcome Measures :
  1. Change in health related quality of life [ Time Frame: Every two months from baseline, postoperatively before start of radiation/GK up to 24 months ]
    health related quality of life (HRQOL) evaluations using the EORTC Quality of Life Questionnaire-Core 30/Brain Cancer Module-20 (EORTC-QLQ C30/BCM20) and the The Functional Assessment of Cancer Therapy-Brain (FACT-Br, version 4) and cognition, (FACT-Cog, version 3) questionnaires.

  2. time without Cognitive impairment [ Time Frame: Time to event assessed every four months from baseline up to 24 months ]
    Intellectual functioning, processing speed, attention and concentration, language and verbal fluency and motor skill as well as mood, depression, and memory assessments will be done prior to RT/GK treatment and at 4 month intervals. A self-report of perceived cognition, will also be completed by patient. Therefore, there will be both an objective measurement of cognition and subjective measurement as a part of quality of life.


Secondary Outcome Measures :
  1. incidence of symptomatic radiation necrosis [ Time Frame: time from RT/GK assessed every two months up to 24 months ]
  2. Disease-free survival [ Time Frame: Time from date of study enrollment until the date of first documented disease recurrence assessed up to 100 months ]
  3. Overall survival [ Time Frame: time from date of study enrollment to date of death assessed up to 100 months ]

Other Outcome Measures:
  1. Utility of perfusion MRI imaging [ Time Frame: time from baseline assessd up to 24 months ]
    Utility of perfusion MRI imaging for detection and differentiation between radiation toxicity and tumor recurrence

  2. Determine predictive value of gammaknife cell culture bioassay [ Time Frame: baseline and at recurrence assessed up to 100 months ]
    A new gamma knife cell culture bioassay developed at our center will be utilized to determine if it has a predictive value of responsiveness to radiosurgery in the clinical setting.



Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years to 80 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • single enhancing lesion of the brain with MRI appearance consistent with GBM
  • Must be appropriate for Gliadel® wafer implant
  • Pathologic confirmation of GBM
  • no gross residual tumor found on the immediate postoperative MRI scan
  • Volumetric measurements of the resection cavity margin being < 50 cc
  • Karnofsky performance status (KPS) 80% or better
  • Must be able to undergo MRI imaging with gadolinium
  • Willingness to have follow up visits at Barrow Neurological Institute(BNI)

Exclusion Criteria:

  • multi-focal tumors
  • tumors which extend across the corpus callosum,
  • residual nodular disease
  • Tumors, with a contraindication to Gliadel® implant, such as an anticipated extensive ventricular opening resulting from complete resection.
  • Tumor measuring greater than 50cc in volume (on post-operative scan) Volume < 50 cc if volume if a significant volume of eloquent tissue is included in the proposed treatment volume
  • Unable to undergo MRI with gadolinium
  • History of cancer within 2 years of GBM diagnosis (basal and squamous cell skin cancers are allowed)
  • Patient is not willing to follow up at BNI

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02085304


Locations
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United States, Arizona
Barrow Neurological Institute at St. Joseph's Hospital and Medical Center Recruiting
Phoenix, Arizona, United States, 85013
Contact: Norissa Honea, PhD, RN    602-406-6267    Norissa.Honea@dignityhealth.org   
Contact: Charlotte Myers, MS, ANP-C    602-406-5157    Charlotte.Myers@bnaneuro.net   
Principal Investigator: Kris A Smith, MD         
Sponsors and Collaborators
St. Joseph's Hospital and Medical Center, Phoenix
Investigators
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Study Chair: Kris A Smith, MD Barrow Neurological Institute at St. Joseph's Hospital and Medical Center

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Responsible Party: St. Joseph's Hospital and Medical Center, Phoenix
ClinicalTrials.gov Identifier: NCT02085304     History of Changes
Other Study ID Numbers: 12BN101
First Posted: March 12, 2014    Key Record Dates
Last Update Posted: December 13, 2016
Last Verified: December 2016
Keywords provided by St. Joseph's Hospital and Medical Center, Phoenix:
Glioblastoma
GBM
Radiation
GammaKnife(R)
Radiosurgery
Gliadel(R)
Temozolomide
Temodar(R)
Additional relevant MeSH terms:
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Glioblastoma
Astrocytoma
Glioma
Neoplasms, Neuroepithelial
Neuroectodermal Tumors
Neoplasms, Germ Cell and Embryonal
Neoplasms by Histologic Type
Neoplasms
Neoplasms, Glandular and Epithelial
Neoplasms, Nerve Tissue
Temozolomide
Carmustine
Antineoplastic Agents, Alkylating
Alkylating Agents
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents