Immunotherapy’s promise as well as its challenges as a treatment for patients with brain cancer was the focus of a plenary session held November 15 at the Society of Neuro-Oncology’s (SNO) 2014 Annual Meeting in Miami Beach.

Immunotherapy is coming of age not only in general oncology, but also in neuro-oncology, noted SNO President David Reardon, MD, one of four experts speaking at the session: “When you think of immunotherapy in neuro-oncology, there’s always been some hesitancy in applying it.”

Reardon, clinical director, Center for Neuro-Oncology at the Dana-Farber Cancer Institute, explained that this is because of previous research that appeared to show the central nervous system has immune privilege; however, “new evidence suggests that this might not be true and that there is a dynamic interaction with the peripheral systemic immune system and the central nervous system,” giving immunotherapy the potential to treat neuro-oncology patients.

Vaccines under investigation within the subspecialty can be classified into three categories: tumor lysates (such as DCVax L, HSPPC-96, and Allogeneic GBM stem cell line), tumor associated antigens (ICT-107, SL-701, and IMA950), and tumor-specific antigens (rindopepimut, CMV, and NeoVax). Reardon said that the immunotherapies that are furthest along are DCVax-L, HSPPC-96, and rindopepimut, which are all in randomized phase III trials. Nearly all of the research into these treatments is ongoing, with the exception of ICT-107, which has a completed randomized phase II trial, and NeoVax, which will be studied in a phase I trial that will begin soon.

Other immunotherapeutic approaches include CAR T-cell therapies, which, Reardon said, have been shown to have a dramatic effect in patients who have failed on other therapies. “This takes T cells out, engineers them ex vivo, and gives the back to patients.”

Despite the positive findings related to immunotherapy and neuro-oncology, however, physicians and patients have some challenges to overcome, said Reardon. “These tumors adapt themselves to exploit many different mechanisms of suppressing immune reactivity.”

Additionally, patients with brain cancer tend to be significantly immunosuppressed. “Very dramatically, we see multiple mechanisms the tumor has exploited to generate a protective shield and protect itself from the immune system. These are the challenges that confront us using immunotherapy,” Reardon concluded, noting that it is likely that immunotherapy will be used in neuro-oncology in combination with other therapies, including cytotoxic therapies.

In another plenary session talk, John Sampson, MD, PhD, said the current focus on immunotherapy is a “paradigm shift” within cancer and that the idea of immune privilege does not seem as certain as it did in the past. “The idea that the blood—brain barrier is an absolute barrier is not true,” he said.

Sampson, the Dr. Robert H. Wilkins and Gloria Wilkins Professor of Neurosurgery and interim chief, Division of Neurosurgery, at Duke University Medical Center, provided several areas where immunotherapy can intervene in treatment: for the release of cancer cell antigens; cancer antigen preservation, priming, and activation; the trafficking of T cells to tumors; the infiltration of T cells into tumors; the recognition of cancer cells by T cells; and the killing of T cells.

The specificity of treatment that occurs with immunotherapy raises one concern, Sampson noted: “As we go to more tumor-specific targets, it’s wonderful, but we’re not getting to the heterogeneity of the disease.”

Future research will need to pinpoint how to optimize vaccine strategies for neuro-oncology patients, Sampson said.

The plenary session also included presentations from Gordon J. Freeman, PhD, associate professor of medicine, Harvard Medical School, who gave an overview of immune checkpoint biology and therapeutic translation, and a talk from Stephen Gottschalk, MD, director, Basic & Translational Research Division, Texas Children’s Cancer Center, on the topic of T cells as therapeutics for glioblastoma.

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Immunotherapy's promise as well as its challenges as a treatment for patients with brain cancer was the focus of a plenary session held November 15 at the Society of Neuro-Oncology's (SNO) 2014 Annual Meeting in Miami Beach.


Experts Discuss Immunotherapy's Potential in Neuro-Oncology

The oncolytic virus Delta-24-RGD can infect, replicate, and kill glioma cells in patients, according to phase I research presented at the 2014 Society for Neuro-Oncology (SNO) Annual Meeting in Miami.

Delta-24-RGD is a novel replication-competent, tumor-selective, oncolytic adenovirus that has enhanced infectivity, according to lead author Frederick F. Lang, MD, who presented the data. After preclinical studies demonstrated promising results, researchers began a first-in-human phase I study to assess the virus’s capacity to replicate in human gliomas.

Study objectives included a focus on the maximum-tolerated dose of Delta-24-RGD administered directly into the tumor or via the post resection catheter, determine local and systemic toxicity of the virus after intracranial injection, and determine the biological effects at the molecular level with the examination of post-treatment tumor specimens.

“We wanted to show it could do what it was meant to do at a biological level,” said Lang, who is a professor and director of clinical research in the Department of Neurosurgery at The University of Texas MD Anderson Cancer Center.

The study assigned 37 patients with recurrent high-grade gliomas to two arms. Arm A (n = 25) received one intratumoral injection of Delta-24-RGD into biopsy-proven recurrent glioma. The biological endpoint cohort, arm B (n = 12), had an initial intratumoral injection via an implanted catheter and then 14 days later via en bloc tumor/catheter resection, which was done to obtain posttreatment specimens. There was then a subsequent injection in arm B of Delta-24-RGD into the postresection cavity.

One requirement of the study’s eligibility criteria was that each patient’s glioma type was limited to glioblastoma, gliosarcoma, anaplastic gliomas, anaplastic infiltrating glioma, mixed anaplastic glioma, and anaplastic ependymoma. All patients had to have unequivocal evidence of tumor recurrence or progression via MRI within 15 days before the baseline procedure. Patients had to have failed prior surgical resection, biopsy, chemotherapy, or radiation. Physician investigators had to agree that the injection would not deliver Delta-24-RGD into the ventricular system. Additionally, patients may or may not have had previous chemotherapy.

Researchers escalated the dose in eight cohorts. The maximum tolerated dose was 3 x 10

Median overall survival was 11 months. Three patients (12%) had complete responses, which Lang said was a particularly noteworthy result. These patients are still alive and have no evidence of disease 3.2, 2, and 1.75 years after treatment. A review of serial MRIs showed increased enhancement before tumor regression, which was consistent with inflammatory-mediated responses. These three responders had 10- to 1000-fold increases in interleukin 12p70, the latter of which induces Th1 responses and cell-mediated immunity.

In a symptomatic patient in group A, histological analysis of a resected tumor identified macrophages and CD8 inflammatory-mediated responses during the period of increased MRI enhancement.

As noted, the biological specimens showed that the virus is capable of infecting, replicating in, and killing glioma cells in patients, the researchers concluded. “Viral-induced and anti-tumor immunity likely plays a role in the antiglioma effect,” said Lang, noting that researchers came to this conclusion based on imaging and correlative histological and cytokine studies.

Delta-24-RGD had a “favorable toxicity profile,” according to Lang et al.

Future research will include what may be unique about the immune system of the three patients who responded to the virus, Lang said. Researchers also want to see what can be applied to others based on the findings from those responders. “Can we make patients who didn’t respond look like the 12% who did in some way? This is a great area of research we need to work on,” he said.

	Lang FF, Conrad C, Gomez-Manzano C, et al. Phase I clinical trial of oncolytic virus Delta-24-RGD (DNX-2401) with biological endpoints: implications for viro-immunotherapy. Presented at: 19th Annual Meeting of the Society for Neuro-Oncology; November 13-16, 2014; Miami, FL. Abstract NT-18.

Oncolytic Virus Shows Early Promise in Glioma

Use of the Novo Tumor Treating Fields (NovoTTF) system along with adjuvant temozolomide led to longer progression-free survival and overall survival in patients with glioblastoma, according to late-breaking results from a phase III trial presented at the Society for Neuro-Oncology (SNO) Annual Meeting.

“A new cancer treatment modality has been born,” said Roger Stupp, MD, the trial’s principal investigator, reporting the data from the EF-14 study, a prospective, multicenter, international trial of NovoTTF-100A in combination with temozolomide conducted across 83 sites in 12 countries.  Stupp is a professor and chairman of the Department of Oncology, and director, University Hospital Cancer Center, at the University of Zurich in Switzerland.

NovoTTF, manufactured by Novocure, is a portable, noninvasive, battery-operated device which attaches to the patient’s head to deliver tumor treating fields to the brain. The NovoTTF appears to slow and reverse tumor growth by inhibiting mitosis. “It was shown in preclinical data that the device could inhibit tumor growth,” Stupp explained.

Patients use the system at home and may wear it as long as 20 to 22 hours a day. As manufacturers refine the device, it continues to get smaller, Stupp added. The NovoTTF-100A system is approved by the FDA to treat adults 22 and older with GBM that recurs or progresses after receiving chemotherapy and radiation therapy.

After receiving radiotherapy with concomitant temozolomide, the study’s 315 patients were randomized 2:1 to receive NovoTTF and temozolomide in combination (n = 210) or temozolomide alone (105 patients). The study’s primary endpoint was progression-free survival (PFS), and its secondary endpoint was overall survival (OS).

Eligibility criteria included pathologic evidence of glioblastoma using World Health Organization classification criteria, being aged 18 or older, having maximal debulking surgery and radiotherapy along with temozolomide, a Karnofsky performance status of 70% or higher, and a life expectancy of at least 3 months. Patients had to have used a stable or decreasing dose of steroids, and the interval since radiation therapy had to have been more than 29 days but fewer than 49 days.

Patient characteristics were similar in both groups, with an average age of 57 for the combination group and 58 for the temozolomide-only control arm. Tumor resection was 89% and 90%, respectively, and Karnofsky performance status was 90% in both groups. Of the 60% of patients who were assessable for MGMT promoter methylation status, 39% and 41% were methylated, respectively.

Median PFS was 7.1 months with the combination and 4 months in the temozolomide-only group (HR = 0.63; 

= .001). OS was 19.6 months and 16.6 months, respectively (HR = 0.75; 

= .034), and the 2-year survival rate was 43% and 29%, respectively.

“If you are a patient, [those numbers] are meaningful. If you are an investigator, you want more. However, it’s a step forward,” Stupp said. The results led to early termination of the trial, and all patients in the control arm were allowed to receive the combination.

Skin irritation occurred in 45% of patients. Severe seizures occurred at a frequency of 7% in both groups.

The data reported at the SNO meeting were after a minimum 18-month follow-up. Researchers had compiled and analyzed the data 4 weeks before the meeting, Stupp noted. Future research will evaluate quality of life and survival at 1 and 2 years.

Although researchers wondered if patients would feel anxious about using the device, Stupp said in his own clinical experience, patients actually feel motivated by it. “They feel like they’re doing something [to help themselves],” he said. “That was striking to me.”

	Stupp R, Wong E, Scott C, et al. Interim analysis of the EF-14 trial: a prospective, multicenter trial of NovoTTF-100A together with temozolomide compared to temozolomide alone in patients with newly diagnosed GBM. Presented at: 19th Annual Meeting of the Society for Neuro-Oncology; November 13-16, 2014: Miami, FL.

Use of the NovoTTF system along with adjuvant temozolomide led to longer progression-free survival and overall survival in patients with glioblastoma.

Survival Improvement With NovoTTF Leads to Early End of Phase III Trial

The vaccine rindopepimut appears to help progression-free survival (PFS) and overall survival (OS) in patients with 

epidermal growth factor receptor variant III 

) in glioblastoma—a patient group with traditionally poor outcomes.

Evangelia Razis, MD, PhD, Hygeia Hospital, Athens, Greece, spoke of the compassionate use of rindopepimut in combination with other anticancer treatments at the Society for Neuro-Oncology’s (SNO) annual meeting in Miami Beach, Fla, on November 14, 2014.

Rindopepimut has a unique EGFRvIII peptide sequence conjugated to keyhole limpet hemocyanin (KLH). It is delivered intradermally with granulocyte macrophage colony-stimulating factor. The vaccine generates a specific immune response against 

-expressing glioblastoma, according to Razis.

The compassionate use study includes patients who did not qualify for enrollment in an open-label trial of the vaccine, she explained.

“We’re now presenting data from 64 patients treated at 23 sites in 6 countries,” she said.

Patients included in the study had recently diagnosed and histologically confirmed glioblastoma, confirmed 

mutation, previous or planned standard conformal radiation therapy with temozolomide, systemic corticosteroid use of 2 mg or less daily, and no autoimmune disease or concurrent conditions that would affect a patient’s ability to benefit from dosing.

Most patients received a monthly dose of rindopepimut after receiving an initial dose for 2-week periods.

Razis reported on data from 42 patients, 12 who had newly diagnosed glioblastoma that was resected or inoperable, and 30 with recurrent disease.

The median patient age was 53 years (15-70 years), and the median time from diagnosis was 14.5 months. 

) methylation was present in 9/17; all patients tested were negative for isocitrate dehydrogenase-1 (IDH1) and IDH2.

Researchers found that rindopepimut was well tolerated when given in combination with temozolomide (57%), bevacizumab (57%), and other agents (17%). Treatment duration was a median of 3.7 months.

Many patients had mild reactions at the site of injection; one patient had serious cerebral edema that was thought to be treatment related, and another patient had a grade 1 headache. No patients had to discontinue therapy, although one patient decided to stop. Fourteen patients still use rindopepimut, according to Razis.

The median peak rindopepimut-induced anti-

 titer was 1:1,200, according to the study abstract.

Tumor response—indicated by more than 50% shrinkage&mdash;was seen by researchers in 9 patients who had received the vaccine along with other agents. Three of the 9 patients had newly diagnosed glioblastoma, and 6 patients had recurrent disease. Eight of the 9 patients received recurrent temozolomide, and 4 patients received bevacizumab.

There was one patient who had complete response (CR) during treatment with several agents, including rindopepimut, erlotinib, temozolomide, and bevacizumab. This same patient has continued rindopepimut for more than 5 years with no recurrence of disease.

Another patient who received rindopepimut and temozolomide for approximately 9 months was shown on biopsy to have eliminated 

The median PFS was 9.1 and 2.5 months in in patients with newly diagnosed and recurrent glioblastoma, respectively.

“Six patients had PFS for more than a year on treatment,” Razis said. Three of those patients had newly diagnosed disease, while the other 3 had recurrent disease. Overall survival was 15.7 and 8.7 months from the first vaccination, respectively.

Rindopepimut is undergoing further investigation. “The efficacy of rindopepimut is being studied in the ACT-IV trial,” as well as in the phase II ReACT clinical study, data from which was presented earlier in the SNO meeting by David Reardon, MD, from Dana-Farber Cancer Institute, Boston, Massachusetts. Researchers from ReACT found a 27% PFS at 6 months for patients receiving both the vaccine and bevacizumab compared with 11% for those receiving the control and bevacizumab.

Future research should also pair rindopepimut with bevacizumab, additional tumor antigens, and selected chemotherapy radiation, according to Razis.

“Rindopepimut in combination with various anticancer therapies resulted in robust anti-

humoral response with minimal toxicity,” she concluded.

	Razis E, Vlahovic G, Recht L, et al. Vaccination against epidermal growth factor receptor variant III in glioblastoma: the rindopepimut compassionate use experience. Presented at the Society for Neuro-Oncology’s Annual Meeting. Miami Beach, Florida. November 14, 2014. Abstract IT-28

The vaccine rindopepimut appears to help PFS and OS in patients with epidermal growth factor receptor variant III mutation in glioblastoma-a patient group with traditionally poor outcomes.

Rindopepimut Leads to Improved PFS in Compassionate Use Study

The next-generation ALK inhibitor ceritinib (Zykadia) showed clinically significant antitumor activity in patients with ALK-rearranged non-small cell lung cancer (NSCLC), including those with brain metastases, said Ranee Mehra, MD, attending physician, Fox Chase Cancer Center, Philadelphia, who reported study results at the 2014 Society for Neuro-Oncology’s (SNO) Annual Meeting in Miami Beach, Florida.

Crizotinib was the first ALK inhibitor to gain approval for patients with NSCLC; however, this treatment has limited efficacy in the central nervous system (CNS). In studies exploring crizotinib, approximately 46% of patients progressed in the CNS, reported Mehra.

Ceritinib, which recently received FDA approval for patients with ALK-rearranged advanced NSCLC, demonstrated efficacy in patients with brain metastases regardless of prior ALK inhibitor treatment. This efficacy could be related to ceritinib’s potency, which appears to be 20-fold greater than crizotinib, Mehra said.

In the phase I ASCEND-1 study, which was instrumental in the approval of ceritinib, ALK-inhibitor naÃ¯ve patients treated with ceritinib experienced an overall response rate (ORR) of 72.3% and a median progression-free survival (PFS) of 18.4 months. In ALK inhibitor treated patients, the ORR was 56.4% and the median PFS was 6.9 months.

Results presented at the SNO meeting were from a subset of patients with brain metastases who were part of the ASCEND-1 study.

 In this subset, researchers analyzed the response of patients with ALK-positive advanced NSCLC and clinically and neurologically stable brain metastases at baseline and who had received 750 mg/day of ceritinib. The response was based on investigator assessment.

In total, 124 patients in the ASCEND-1 study had brain metastases at baseline, including 98 with prior ALK inhibitor treatment and 26 who were ALK inhibitor-naÃ¯ve. The subset of patients with brain metastases had a median age of 51; the median time from the diagnosis of NSCLC to the first dose of ceritinib was 20.5 months. The median duration of exposure was 27 weeks.

For the full cohort, the ORR was 54%. The ORR was 50% and 69.2%, in patients who were ALK-inhibitor treated and naÃ¯ve, respectively. The median duration of response was 7 months for the full subset of patients with brain metastases, 6.9 months for the ALK inhibitor-treated cohort, and not estimable in the ALK inhibitor naÃ¯ve cohort. There was a median 6.9- and 8.3-month PFS in the ALK inhibitor-treated and ALK inhibitor naÃ¯ve groups.

Fourteen patients had measurable target lesions at baseline, with 50% achieving a response in the brain (4 ALK inhibitor-treated, 3 ALK inhibitor-naÃ¯ve) and 21.4% having stable disease. Patients with stable disease had all been treated with a prior ALK inhibitor.

In terms of safety, the most common all-grade adverse events experienced by the larger cohort versus patients with brain metastases were diarrhea (86% vs 79%), nausea (80% vs 82%), and vomiting (60% vs 63%). “All patients had at least one adverse event,” Mehra said.

Ceritinib is a novel, orally active small-molecule tyrosine kinase inhibitor of ALK. Inhibition of ALK causes the disruption of ALK-mediated signaling and cell growth. ALK alterations and gene rearrangements are associated with a variety of tumors. “Approximately 2% to 7% of patients with non-small cell lung cancer have an ALK gene rearrangement,” Mehra said.

Both patients who were ALK inhibitor naÃ¯ve and those who had used ALK inhibitors before showed durable intracranial responses, Mehra said. Due to limited data available, researchers could not evaluate the effect of prior intracranial radiation. A phase II study will be underway soon to evaluate ceritinib specifically for brain metastases, Dr. Mehra said.

Two phase III studies are enrolling patients to further explore the efficacy and safety of ceritinib in patients with ALK-positive NSCLC. In the first, ceritinib will be compared with chemotherapy in untreated patients with ALK-rearranged NSCLC (NCT01828099). The second will compare ceritinib to chemotherapy in ALK-positive patients with NSCLC following progression on chemotherapy and crizotinib (NCT01828112).

			Felip E, Kim D, Mehra R, et al. Efficacy and Safety of Ceritinib in Patients (pts) with Advanced Anaplastic Lymphoma Kinase (ALK)-rearranged (ALK+) Non-small Cell Lung Cancer (NSCLC): An Update of ASCEND-1. Presented at the: 2014 ESMO Annual Congress, Madrid, Spain. Abstract #1295P.

			Shaw A, Mehra R, Tan DSW, et al. Ceritinib (LDK378) for treatment of patients with ALK-rearranged (ALK+) non-small cell lung cancer (NSCLC) and brain metastases (BM) in the ASCEND-1 trial. Presented at the SNO Annual Meeting, Miami Beach, Florida. Abstract BM-32.Â 

The next-generation ALK inhibitor ceritinib showed clinically significant antitumor activity in patients with ALK-rearranged NSCLC, including those with brain metastases.

Ceritinib Effective in Patients With Brain Metastases

The vaccine rindopepimut (CDX110) plus bevacizumab induced tumor regression in a subset of patients with recurrent glioblastoma, according to David Reardon, MD, clinical director, Center for Neuro-Oncology, Dana-Farber Cancer Institute, at the Society for Neuro-Oncology’s (SNO’s) Annual Meeting in Miami Beach, Florida.

Reporting on the phase II results from the ongoing ReACT study, Reardon, the current president of SNO, said use of the vaccine and bevacizumab can induce “potent EGFRvIII-specific immune response” in patients who are naïve or refractory to bevacizumab.

The findings show promise for both progression-free survival (PFS) and overall survival (OS) for patients with the 

 mutation. “Growing data links EGFR expression to poor long-term survival,” Reardon said.

Rindopepimut has a unique EGFRvIII peptide sequence conjugated to keyhole limpet hemocyanin (KLH), according to the study abstract. It is delivered intradermally with granulocyte macrophage colony-stimulating factor. In addition to rindopepimut, the use of bevacizumab has the potential to augment EGFRvIII-specific immune response and antitumor activity by inhibiting vascular endothelial growth factor (VEGF) and its immunosuppressive properties, according to Reardon.

To be included in the study, patients were required to have a histological diagnosis of glioblastoma, have an EGFRvIII+ tumor, have relapsed glioblastoma; and have had previous treatment with surgery, conventional radiation therapy, and temozolomide.

A group of 72 patients who were bevacizumab-naïve (Group 1) were randomized 1:1 to receive bevacizumab along with a double-blinded injection of rindopepimut or KLH (the latter of which was used as the control). These patients also had not received any other VEGF inhibitors previously.

A second group of patients who were bevacizumab-refractory (Group 2/2C) received bevacizumab along with open-label rindopepimut. These patients had progression during or within 2 months of receiving bevacizumab. This group started as 25 patients but continues to expand.

The primary endpoint is a 6-month PFS rate and evaluation of antitumor activity related to rindopepimut. Researchers are also analyzing safety, tolerability, and EGFRvIII-specific immune response.

In Group 1, there was a 27% PFS at 6 months for those receiving both the vaccine and bevacizumab compared with an 11% PFS at 6 months for those receiving the control agent and bevacizumab (

 = .048). Of the 72 patients treated, 12 continue to receive treatment, and 30 are still tracked for survival. OS was improved by 53% with rindopepimut. The median was 12 months with the vaccine versus 8.8 months for single-agent bevacizumab (

The objective response rate in Group 1 for the vaccine and bevacizumab group compared with the control and bevacizumab using RANO criteria was 23% compared with 12%.

In the initial Group 2/2C cohort, all patients completed treatment, and 2 patients continue to be tracked for survival. “There was evidence of rare but prominent antitumor activity,” Reardon said. The expanded cohort of 28 additional patients for Group 2/2C have all completed treatment, and 11 patients are currently being tracked for survival.

Additionally, 2 other patients in Group 2/2C had prestudy progression more than 2 months after using bevacizumab. This patient maintained a complete response for about 11 months, and the second patient had an unconfirmed complete response, according to the study abstract.

There was a median peak rindopepimut-induced anti-EGFRvIII humoral response of 1:25,600. Prolonged OS was associated with rapid titer generation.

The most commonly reported adverse event was grade 1 to 2 injection-site reaction(s), along with grade 2 edema in a small percentage of patients, according to Reardon.

“The results show favorable potential for OS in the patients receiving rindopepimut,” Reardon said. “There was a survival benefit compared with bevacizumab alone.” Additionally, more patients who received rindopepimut were able to stop using steroids, Reardon added.

When interpreting the study data, Reardon encouraged attendees to consider that the results focus on patients who are EGFRvIII+, a subset that can be more challenging and the prognosis in these patients is poor.

	Reardon D, Schuster J, Tran D, et al. ReACT: A phase II study of rindopepimut vaccine (CDX-110) plus bevacizumab in relapsed glioblastoma. Presented at the Society for Neuro-Oncology’s (SNO’s) annual meeting. Miami Beach, Florida, November 14, 2014. Abstract Number. IT-30

The vaccine rindopepimut plus bevacizumab induced tumor regression in a subset of patients with recurrent glioblastoma.

Rindopepimut Plus Bevacizumab Shows Prolonged Survival in Recurrent Glioblastoma

The combination of bevacizumab and lomustine showed superior efficacy compared with either agent alone in patients with recurrent glioblastoma, warranting further study, according to the phase II BELOB study presented by Martin van den Bent, MD, at the 2014 Society for Neuro-Oncology’s (SNO) Annual Meeting in Miami.

It is crucial to research recurrent glioblastoma treatments because of a scarcity of available choices, “There are only a few modestly active chemotherapy options in recurrent glioblastoma,” van den Bent, from the Erasmus MC Cancer Institute in Rotterdam, Netherlands, said. Although bevacizumab is approved as a second-line treatment for glioblastoma, this approval was based on an open-label study. At this point, there are few well-controlled randomized studies to support its use for recurrent glioblastoma, van den Bent noted.

In the phase II multicenter BELOB trial, 148 patients were assigned to bevacizumab at 10 mg/kg on days 1, 15, and 29, bevacizumab at 10 mg/kg on day 1, 15, and 29 in combination with lomustine orally on day 1 (90 mg/m

Earlier in the trial, a preplanned safety review led to the reduction of the lomustine dose in the combination arm to 90 mg/m

, van den Bent said. The dose was lowered because of hematological-related adverse events. Subsequently, 8 patients were treated with bevacizumab plus lomustine at 110 mg/m

 and 44 patients were treated at the 90-mg/m

Patients in the study were enrolled between December 2009 and November 2011 and had histologically proven glioblastoma, a first recurrence after chemoradiation with temozolomide, and had finished radiotherapy more than 3 months before entering the study. Patients had adequate bone marrow, renal, and hepatic function. The median age was 57 years and the median World Health Organization performance status was 1. The trial’s primary endpoint was 9-month overall survival (OS).

At the analysis, 130 patients were reviewed for a response. The 9-month OS was 43% in the lomustine arm, 38% in the bevacizumab arm, and 59% in patients who received both agents. The investigator-assessed objective response rate was 5% in the lomustine arm, 38% in the bevacizumab arm, and 34% in the bevacizumab/lomustine arm.

The results do not support a continuation of treatment with bevacizumab alone. “There was a high response rate to single-agent bevacizumab, but it didn’t translate into overall survival,” van den Bent said.

Hypertension was the most frequently reported toxicity (26% of bevacizumab patients, 7% of lomustine patients, and 25% of bevacizumab and lomustine patients). Other commonly reported toxicities included fatigue (4%, 9%, and 18%, respectively) and infections (6%, 4%, and 11%, respectively). When BELOB trial results were reported in 

 earlier this year, 97% of patients had died, and 2% remained on treatment.

In secondary analyses, researchers found isocitrate dehydrogenase 1 (

) mutations in 8 patients. Progression-free survival and OS were longer in patients with IDH1 mutations compared with wild-type mutations. The 9-month OS was 60% for patients with the 

 mutation in the combination arm. Additionally, the 

 promoter was methylated in 47% of patients and also indicated better responses. Researchers suggest that patients with 

 mutations should be assessed in separate clinical trials and should even be excluded from trials in the recurrent setting, due to the inherently better outcomes seen.

Findings from the phase II BELOB trial met prespecified criteria for the establishment of a phase III trial. The combination of bevacizumab and lomustine are being studied in the randomized, controlled phase III study EORTC trial 26101 trial, with results expected by next year’s SNO meeting, van den Bent said.

	Taal W, OOsterkamp H, Walenkamp A, et al. Single-agent bevacizumab or lomustine versus a combination of bevacizumab plus lomustine in patients with recurrent glioblastoma (BELOB trial): a randomised controlled phase 2 trial. 

The combination of bevacizumab and lomustine showed superior efficacy compared with either agent alone in patients with recurrent glioblastoma, warranting further study.

Adding Lomustine to Bevacizumab Improves Outcomes in Recurrent Glioblastoma

In a phase III study, a combination of radiation therapy and procarbazine, CCNU, and vincristine (PCV) prolonged both overall survival (OS) and progression-free survival (PFS) compared with radiation therapy (RT) alone for patients with grade 2 glioma, said Jan C. Buckner, MD, chair of oncology, Mayo Clinic, Rochester, Minnesota.

 The benefit appeared strongest for patients with oligodendroglioma (O) and oligo-astrocytoma (OA).

Buckner reported the results during the initial Plenary Session at the 2014 Society for Neuro-Oncology’s (SNO) Annual Meeting in Miami. The study results build on Buckner and colleagues’ previous work presented earlier this year at the 2014 ASCO Annual Meeting. The report at ASCO focused on the long-term results of PCV given with RT,

 and found that grade 2 glioma patients with less than gross total tumor resection or who were aged ≥40 years experienced a prolonged OS and PFS compared with RT alone. In that report, males and patients with A or A-dominant OA had worse outcomes.

A 2012 report from the same group found an improvement in OS but not PFS in the patient group receiving RT and PCV versus RT alone.

The data reported at SNO focused on the treatment impact of RT alone versus RT and PCV combination therapy according to histologic type. The 251 patients included in the study were either aged <40 years with a subtotal resection or biopsy or aged >40 years with some type of resection and supratentorial grade 2 O, OA, or astrocytoma (A). Patients were accrued for the study between 1998 and 2002; 107 had O, 79 had OA, and 65 had A.

Patients were divided by age, histology, Karnofsky Performance Status, and the presence or absence of contrast enhancement on the preoperative imaging study. Patients were then randomized to RT alone (54 Gy in 30 fractions) or RT followed by 6 cycles of PCV chemotherapy. A log rank test was used to compare survival and PFS distributions for each histologic type.

Median OS for the PCV versus control arms was 13.3 versus 7.8 years (

 = .002) overall, and not reached versus 10.8 years (

 = .31), in the O, OA, and A cohorts, respectively. Median PFS was 10.4 versus 4 years overall (

 <.001), and not reached versus 6 years (

This is the first prospective study to show treatment-related survival as it relates to PCV and RT, Buckner said.

There were no treatment-related deaths. The most common side effects in the study were fatigue, anorexia, nausea, and vomiting. Nausea was more common with the RT and PCV combination. “The toxicity level was acceptable and similar to many chemotherapy options,” Buckner said.

Researchers next plan to assess RT versus the RT and PCV combination according to the molecular markers 1p/19q codeletion, 

 mutations, and genomic analyses. The hypothesis is that patients with 1p/19q deletion and 

 mutations will likely benefit from PCV, Bucker said.

Buckner et al’s study involved a collaboration of researchers from around the United States and Canada, including Wake Forest University, The University of Texas MD Anderson Cancer Center, Wayne State University School of Medicine, and Barrow Neurological Institute.

			Buckner J, Shaw E, Pugh S, et al. R9802: Phase III study of radiation therapy (RT) with or without procarbazine, CCNU, and vincristine (PCV) in low-grade qlioma: results by histologic type. Presented at: 19th Annual Meeting of the Society for Neuro-Oncology; November 13-16, 2014; Miami, FL. Abstract AT-13.

			Shaw EG, Wang M, Coons SW, et al. Randomized trial of radiation therapy plus procarbazine, lomustine, and vincristine chemotherapy for supratentorial adult low-grade glioma: initial results of RTOG 9802. 

The combination of radiation therapy with procarbazine, CCNU, and vincristine prolonged OS and PFS compared with radiation therapy alone in grade 2 glioma.

Vanessa Caceres