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Evaluation of Hippocampal-Avoidance Using Proton Therapy in Low-Grade Glioma

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ClinicalTrials.gov Identifier: NCT04065776
Recruitment Status : Recruiting
First Posted : August 22, 2019
Last Update Posted : September 5, 2019
Sponsor:
Information provided by (Responsible Party):
St. Jude Children's Research Hospital

Brief Summary:

Low-grade gliomas (LGGs) are the most common brain tumors in children, and a subset of these tumors are treated definitively with focal radiation therapy (RT). These patients often survive for many years after receiving RT and experience late deficits in memory. Verbal recall is an important measure of memory and is associated with other important functional outcomes, such as problem-solving, independence of every-day functioning, and quality of life. Decline in memory, as measured by verbal recall, is associated with RT dose to the hippocampi. Therefore, this phase II study investigates the feasibility of reducing RT doses to the hippocampi (i.e., hippocampal avoidance [HA]) by using proton therapy for midline or suprasellar LGGs.

Primary Objective:

  • To determine the feasibility of HA with proton therapy in suprasellar or midline LGGs. Feasibility will be established if 70% of plans meet the first or second dose constraints shown below.

    1. First priority RT dose constraints for bilateral hippocampi: volume receiving 40 CGE (V40CGE) ≤ 25%, dose to 100% of Hippocampus (D100%) ≤ 5CGE.
    2. Second priority RT dose constraints for bilateral hippocampi: V40CGE ≤ 35%, D100% ≤ 10 CGE.

      Secondary Objectives:

  • To estimate the 3-year event-free-survival (EFS) for LGGs treated with HA.
  • To estimate the change in California Verbal Learning Test short-term delay (CVLT-SD) from baseline to 3 years and from baseline to 5 years
  • To compare CVLT-SD and Cogstate neurocognitive scores in patients with proton therapy plans that: (1) meet first priority RT dose constraints, (2) meet second priority RT dose constraints but not first priority RT dose constraints, and (3) that did not meet either first or second RT priority dose constrains (i.e. HA was not feasible).
  • To investigate the effect of BRAF alteration, tumor histology and tumor location on progression-free survival (PFS) and overall survival (OS) in a prospective cohort of patients treated in a homogenous manner.
  • To investigate whether the methylation profiles of LGGs differ across tumor locations (thalamic/midbrain vs. hypothalamic/optic pathway vs. others) and histologies (pilocytic astrocytoma vs. diffuse astrocytoma vs. others), which, in conjunction with specific genetic alterations, may stratify patients into different subgroups and highlight different therapeutic targets.
  • To record longitudinal measures of circulating tumor DNA (ctDNA) in plasma and correlate these measures with radiographic evidence of disease progression.
  • To bank formalin-fixed, paraffin-embedded (FFPE)/frozen tumors and whole blood from subjects for subsequent biology studies not currently defined in this protocol.
  • To quantify and characterize tumor infiltrating lymphocytes (TILs) and to characterize the epigenetics of T cells and the T cell receptor repertoire within the tumor microenvironment.
  • To estimate the cumulative incidence of endocrine deficiencies, vision loss, hearing loss and vasculopathy after proton therapy and compare these data to those after photon therapy.

Exploratory Objectives:

  • To describe the change in overall cognitive performance from baseline to 3 years and from baseline to 5 years with an age appropriate battery, including gold standard measures shown in the published studies to be sensitive to attention, memory processing speed and executive function that will afford comparison to historical controls.
  • To characterize longitudinal changes in connection strength within brain networks in the first 3 years after proton therapy and to investigate associations between these changes and neurocognitive performance with focus on the hippocampi.
  • To correlate the distribution and change in L-methyl-11C-methionine positron emission tomography (MET-PET) uptake to tumor progression and from baseline to 3 years and to investigate whether cases of pseudoprogression exhibit a differential pattern of uptake and distribution than do cases of true progression after controlling for histology.
  • To investigate the effect of BRAF alteration, tumor histology and tumor location on PFS and OS in a prospective cohort of patients treated in a homogenous manner.
  • To record longitudinal measures of circulating tumor DNA (ctDNA) in plasma and correlate these measures with radiographic evidence of disease progression.
  • To bank formalin-fixed, paraffin-embedded (FFPE)/frozen tumors and whole blood from subjects for subsequent biology studies not currently defined in this protocol.
  • To quantify and characterize tumor infiltrating lymphocytes (TILs) and to characterize the epigenetics of T cells and the T cell receptor repertoire within the tumor microenvironment.
  • To estimate the cumulative incidence of endocrine deficiencies, vision loss, hearing loss and vasculopathy after proton therapy and compare these data to those after photon therapy.

Condition or disease Intervention/treatment Phase
Glioma Pilocytic Astrocytoma Pilomyxoid Astrocytoma Pleomorphic Xanthoastrocytoma Ganglioglioma Optic Pathway Glioma Diffuse Astrocytoma Radiation: Hippocampal-avoidance proton therapy Not Applicable

Detailed Description:
All patients will receive HA proton therapy to 52.2 CGE or 54 CGE in 29 or 30 fractions, depending on tumor location. Patients will receive weekly magnetic resonance imaging (MRI) scans during the course of proton therapy to monitor changes in solid tumor or cystic volume. Such changes may prompt adaptive therapy to improve coverage or minimize the RT dose to healthy structures. Neurocognitive outcomes, sensitive to measures of memory and learning, will be collected at baseline and continue to 5 years post therapy. Disease evaluation will be monitored with brain MRI.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 74 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: A Phase II Study of Hippocampal-Avoidance Using Proton Therapy in Low-Grade Glioma
Estimated Study Start Date : September 2019
Estimated Primary Completion Date : May 2023
Estimated Study Completion Date : May 2028


Arm Intervention/treatment
Experimental: Hippocampal-avoidance proton therapy
Hippocampal-avoidance proton therapy
Radiation: Hippocampal-avoidance proton therapy
Hippocampal-avoidance proton therapy




Primary Outcome Measures :
  1. Percentage of plans meet the first or second dose constraints. [ Time Frame: 4 years after activation ]
    To determine the feasibility of HA with proton therapy in suprasellar or midline LGGs. Feasibility will be established if 70% of plans meet the first or second dose constraints. First RT dose constraints for bilateral hippocampi: volume receiving 40 CGE (V40CGE) ≤ 25%, dose to 100% of hippocampus (D100%) ≤ 5CGE. Second RT dose constraints for bilateral hippocampi: V40CGE ≤ 35%, D100% ≤ 10 CGE.


Secondary Outcome Measures :
  1. EFS of LGGs treated with HA [ Time Frame: 3 years ]
    EFS will be calculated from the date of RT starts until disease progression, second malignancy, death of any cause or last follow up date.

  2. The change in CVLT-SD scores from baseline to 3 years [ Time Frame: Baseline evaluation date, 3 years after treatment ]
    CVLT-SD scores change of patients with HA feasible from baseline evaluation date to 3 years after treatment

  3. The change in CVLT-SD scores from baseline to 5 years [ Time Frame: Baseline evaluation date, 5 years after treatment ]
    CVLT-SD scores change from baseline evaluation date to 5 years after treatment

  4. Cogstate neurocognitive scores [ Time Frame: Baseline evaluation date ]
    Cogstate neurocognitive scores in patients with proton therapy plans

  5. Cogstate neurocognitive scores [ Time Frame: 3 years after treatment ]
    Cogstate neurocognitive scores in patients with proton therapy plans

  6. Cogstate neurocognitive scores [ Time Frame: 5 years after treatment ]
    Cogstate neurocognitive scores in patients with proton therapy plans

  7. CVLT-SD neurocognitive scores [ Time Frame: Baseline evaluation date ]
    CVLT-SD neurocognitive scores in patients with proton therapy plans

  8. CVLT-SD neurocognitive scores [ Time Frame: 3 years after treatment ]
    CVLT-SD neurocognitive scores in patients with proton therapy plans

  9. CVLT-SD neurocognitive scores [ Time Frame: 5 years after treatment ]
    CVLT-SD neurocognitive scores in patients with proton therapy plans



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   6 Years to 21 Years   (Child, Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Patients must have a diagnosis of pilocytic astrocytoma, pilomyxoid astrocytoma, pleomorphic xanthoastrocytoma, ganglioglioma, optic pathway glioma, diffuse astrocytoma, low-grade neuroepithelial tumor, low-grade glioneuronal tumor or LGG, or not otherwise specified (NOS).
  • Patients must have had histologic verification of disease at original diagnosis EXCEPT for patients with optic pathway gliomas or other tumors of the optic apparatus. Patients with optic pathway gliomas or other tumors of the optic apparatus can be enrolled without histologic verification but with radiologic verification. Repeat biopsy is not required EXCEPT for recurrent tumors that enhance but were originally non-enhancing or if a high index of suspicion regarding high-grade transformation is present.
  • Tumor must be located in the suprasellar region or midline structures. Midline structures include, but are not limited to, the thalamus, basal ganglia, internal capsule, midbrain, tectum, third ventricle, fourth ventricle, cerebellum, pons, and medulla. Tumors may involve the optic pathway. For questions about tumor locations that are not specified on this list, please contact the Study PI.
  • Patients must be at least 6 years but less than 22 years of age at the time of enrollment.
  • Patients must have a performance status greater or equal to 70 (use Karnofsky scale for patients aged 16 years and older and Lansky scale for patients aged less than 16 years).
  • Patients may not receive concurrent chemotherapy or targeted therapy, including but not limited to BRAF-inhibitors and MEK-inhibitors.
  • All patients must be able to undergo contrast-enhanced brain MRI.
  • All patients must have adequate organ function as described below.

    • Peripheral absolute neutrophil count (ANC) ≥ 1000/µL
    • Platelet count ≥ 10,000/µL (transfusion independent)
    • Patients with seizures may be enrolled if well controlled on anticonvulsants

Exclusion Criteria:

  • Patients may not have received prior CNS radiation.
  • Patients with gross total resection and no measurable disease via MRI are not eligible. Patients must have measurable disease of at least 1 cm via MRI.
  • Patients with evidence of metastatic disease are not eligible.
  • Patients with WHO grade II midline tumors that harbor the H3K27M mutation, IDH-mutant gliomas, grade II ependymomas and subependymomas, pituicytomas, spindle cell oncocytomas, or granular cell tumors of the sellar region are not eligible.
  • Patients with tumors that directly invade the hippocampus or with gross tumor volumes that extend into the hippocampus are not eligible.
  • Patients with tumors in the spine or cervicomedullary junction.
  • Females of child-bearing potential cannot be pregnant or breast feeding. Female participants > 10 years of age or post menarche must have a negative serum or urine pregnancy test before enrollment. Males and females of reproductive potential may not participate unless they have agreed to use an effective contraceptive method.
  • Patients with NF-1.
  • Patients who are status post resection of bilateral hippocampi. Patients who are status post resection of one hippocampus will be eligible for the study and the hippocampal dose constraints will be applied to the intact hippocampus.
  • Patients who are not able to undergo neuro-cognitive testing, including children lacking English comprehension or children with premorbid neurological/neurodevelopmental disorders such as Down's syndrome or autism.

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): NCT04065776


Contacts
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Contact: Sahaja Acharya, MD 866-278-5833 referralinfo@stjude.org

Locations
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United States, Tennessee
St. Jude Children's Research Hospital Recruiting
Memphis, Tennessee, United States, 38105
Contact: Sahaja Acharya, MD    866-278-5833    referralinfo@stjude.org   
Principal Investigator: Sahaja Acharya         
Sponsors and Collaborators
St. Jude Children's Research Hospital
Investigators
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Principal Investigator: Sahaja Acharya, MD St. Jude Children's Research Hospital

Additional Information:
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Responsible Party: St. Jude Children's Research Hospital
ClinicalTrials.gov Identifier: NCT04065776     History of Changes
Other Study ID Numbers: HALGG
First Posted: August 22, 2019    Key Record Dates
Last Update Posted: September 5, 2019
Last Verified: August 2019

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: Yes
Device Product Not Approved or Cleared by U.S. FDA: No
Pediatric Postmarket Surveillance of a Device Product: No
Product Manufactured in and Exported from the U.S.: Yes
Additional relevant MeSH terms:
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Glioma
Astrocytoma
Ganglioglioma
Neoplasms, Neuroepithelial
Neuroectodermal Tumors
Neoplasms, Germ Cell and Embryonal
Neoplasms by Histologic Type
Neoplasms
Neoplasms, Glandular and Epithelial
Neoplasms, Nerve Tissue