Avastin in Combination With Temozolomide for Unresectable or Multifocal GBMs and Gliosarcomas

Avastin in Combination With Temozolomide for Unresectable or Multifocal Glioblastoma Multiformes and Gliosarcomas

Primary objective- To determine efficacy of Avastin, 10 mg/kg every other week, in combination with standard 5-day temozolomide in terms of response rate.

Secondary objective- To determine safety of Avastin & Temozolomide in unresectable glioblastoma patients

Subjects have histologically confirmed WHO gr IV primary malignant glioma that is unresectable/multifocal. This is Phase II study where up to 41 subjects will receive up to 4 cycles of Avastin & Temozolomide. Avastin administered at 10 mg/kg every 14 days beginning a minimum of 7 days after biopsy/28 days after craniotomy. Temozolomide dosed at 200 mg/m2 daily for 5 days in 28-day cycle. Patients will receive up to 4 cycles of Avastin & Temozolomide, then proceed with standard XRT. Study will use 2-stage "minimax" study design in which 21 subjects are accrued during 1st stage, with possibility that additional 20 patients accrued during 2nd stage. In initial Phase I & II trials, 4 potential Avastin-associated safety signals were identified: hypertension, proteinuria, thromboembolic events, & hemorrhage. Avastin-associated adverse events in Phase III trials include congestive heart failure, GI perforations, wound healing complications, & arterial thromboembolic events. Most common toxicity associated with Temozolomide has been mild myelosuppression.

Inclusion Criteria:

Patients have histologically confirmed diagnosis of WHO gr IV primary malignant glioma. Patients will be unresectable or have multifocal disease.

• Age ≥ 18years & life expectancy of >12 weeks
• Evidence of measurable primary CNS neoplasm on contrast enhanced MRI.
• Interval of <1 week between prior biopsy/4 weeks from surgical resection & enrollment on protocol
• Karnofsky ≥60%
• Hemoglobin ≥9g/dl, ANC ≥1,500 cells/microliter, platelets ≥125,000 cells/microliter
• Serum creatinine ≤1.5 mg/dl, serum SGOT & bilirubin ≤1.5 x ULN
• For patients on corticosteroids, they must have been on stable dose for 1 week prior to entry, if clinically possible, & dose should not be escalated over entry dose level
• Signed informed consent approved by IRB prior to patient entry
• No evidence of > grade 1 CNS hemorrhage on baseline MRI/CT scan
• If sexually active, patients will take contraceptive measures for duration of treatments

Exclusion Criteria:

• Pregnancy/breast feeding
• Co-medication that may interfere with study results
• Active infection requiring IV antibiotics
• Prior or current Treatment w XRT/chemo for brain tumor, irrespective of grade of tumor
• Evidence of > grade 1 CNS hemorrhage on baseline MRI or CT scan

Avastin-Specific Concerns:

• Inadequately controlled hypertension
• Any prior history of hypertensive crisis/hypertensive encephalopathy
• New York Heart Association Grade II or > congestive heart failure
• History of myocardial infarction/unstable angina < 6 months prior to study enrollment
• History of stroke/transient ischemic attack < 6 months prior to study enrollment
• Significant vascular disease
• Symptomatic peripheral vascular disease
• Evidence of bleeding diathesis/coagulopathy
• Major surgical procedure, open biopsy,/significant traumatic injury within 28 days prior to study enrollment/anticipation of need for major surgical procedure during course of study
• Core biopsy/other minor surgical procedure, excluding placement of vascular access device, <7 days prior to study enrollment
• History of abdominal fistula, GI perforation, /intra-abdominal abscess <6 months prior to study enrollment
• Serious, non-healing wound, ulcer, or bone fracture
• Proteinuria at screening as demonstrated by either
• UPC ratio ≥1.0 at screening OR
• Urine dipstick for proteinuria ≥2+
• Known hypersensitivity to any component of Avastin
• Pregnant/lactating. Use of effective means of contraception in subjects of child-bearing potential
• Current, ongoing treatment with full-dose warfarin or its equivalent