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Inducing a Hypothyroxinemic State in Patients With Recurrent Glioblastoma or Gliosarcoma

Primary Purpose

Recurrent Glioblastoma, Recurrent Gliosarcoma

Status
Withdrawn
Phase
Early Phase 1
Locations
Study Type
Interventional
Intervention
Liothyronine
Lomustine
Methimazole
Sponsored by
Emory University
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Recurrent Glioblastoma

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Age >= 18 years
  • Eastern Cooperative Oncology Group (ECOG) performance status =< 2 (Karnofsky >= 70%) within a 14-day window prior to randomization
  • Patients must have histologically confirmed glioblastoma (or gliosarcoma) at first or second recurrence after initial standard, control or experimental, therapy that includes at least radiation therapy (RT) and temozolomide (TMZ)
  • Evidence of progressive disease (PD) by modified response assessment in neuro-oncology criteria (using the post-chemoradiation time point as baseline), defined by any of the following:

    • >= 25% increase in sum of products of perpendicular diameters of measurable enhancing lesions, compared with the smallest tumor measurement obtained either at the post-chemoradiation baseline (if no decrease) or best response (on stable or increasing steroid dose).
    • Any new measurable (> 1 x 1 cm) enhancing lesions after the post-chemoradiation scan
  • A total of at least 2 serial magnetic resonance imaging (MRI) scans documented at Screening including: 1) a scan at the time of suspected tumor progression; and 2) a scan prior to the time of progression. Patients must have progressed after standard of care treatment (it typically includes surgery, radiation and temozolomide). Pseudoprogression or radiation necrosis has been ruled out
  • Hemoglobin >= 9.0 g/dl (no transfusions allowed within 7 days of cycle 1 day 1 to meet entry criteria) (within 14 days of starting treatment)
  • Absolute neutrophil count (ANC) >= 1,500/mcL (after at least 7 days without growth factor support or transfusion) (within 14 days of starting treatment)
  • Platelets >= 100,000/mcL (no transfusions allowed within 7 days of cycle 1 day 1 to meet entry criteria) (within 14 days of starting treatment)
  • International normalized ratio (INR) =< 1.5 (within 14 days of starting treatment)
  • Partial thromboplastin time (PTT) < 1.5 x upper limits of normal (ULN) (within 14 days of starting treatment)
  • Total bilirubin =< 1.5 times the institutional upper limit of normal (ULN) (within 14 days of starting treatment)
  • Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =< 2.0 times the ULN (within 14 days of starting treatment)
  • High amylase or lipase above upper normal limit (UNL) (within 14 days of starting treatment)
  • Serum creatinine =< 1.5 x ULN or creatinine clearance >= 60 mL/min/1.73 m^2 for patients with creatinine levels > 1.5 x ULN. Creatinine clearance should be calculated per institutional standard (within 14 days of starting treatment)
  • Electrocardiogram corrected QT interval by Fridericia's formula (QTcF) < 450 ms (within 14 days of starting treatment)
  • Clinically significant toxic effect(s) of the most recent prior anti-cancer therapy must be grade 1 or resolved (except alopecia)
  • A minimum time of 28 days elapsed from the administration of any prior cytotoxic agents
  • Have undergone recent surgery for recurrent or progressive brain tumor are eligible provided that:

    • Prior to surgery there was imaging evidence of measurable progressive disease (PD) as described above.
    • Craniotomy or intracranial biopsy site must be adequately healed and free of drainage or cellulitis, and the underlying cranioplasty must appear intact at the time of randomization.
    • Initiation of study treatment is at least 14 days from prior surgery/biopsy
  • Availability of tumor tissue representative of glioblastoma (GBM) from initial definitive surgery and/or, recurrent surgery, if performed
  • Female of child-bearing potential (FCBP) must have a negative serum or urine pregnancy test prior to starting therapy
  • FCBP and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately. Men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study, for the duration of study participation, and 4 months after completion of study administration. A female of childbearing potential (FCBP) is a sexually mature woman who: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months)
  • Willingness and ability of the subject to comply with scheduled visits, drug administration plan, protocol-specified laboratory tests, other study procedures, and study restrictions. Evidence of a personally signed informed consent indicating that the subject is aware of the neoplastic nature of the disease and has been informed of the procedures to be followed, the experimental nature of the therapy, alternatives, potential risks and discomforts, potential benefits, and other pertinent aspects of study participation

Exclusion Criteria:

  • Patients who received temozolomide within 28 days prior to starting first cycle under this study
  • Optune device is not allowed
  • Patients who received prior lomustine, carmustine wafers, bevacizumab or any other anti-angiogenic agent
  • Dexamethasone at time of study entry is not allowed. After a stable dose of methimazole and T3 is reached, dexamethasone can be used with a dose determined by treating physician
  • Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
  • Computed tomography (CT) scan with contrast within 6 weeks from enrollment as it may influence thyroid tests due to the iodine content
  • History of cardiac arrhythmias (in particular, sinus bradycardia, atrial fibrillation or flutter, atrioventricular [AV] block, prolonged QTc, ventricular arrythmias, pacemaker, or implantable cardiac defibrillator).). Significant cardiovascular disease (eg, myocardial infarction, arterial thromboembolism, cerebrovascular thromboembolism) within 6 months prior to start of study therapy; angina requiring therapy; symptomatic peripheral vascular disease; left ventricular ejection fraction less than or equal to 35%;New York Heart Association class 3 or 4 congestive heart failure; or uncontrolled grade >= 3 hypertension (diastolic blood pressure >= 100 mmHg or systolic blood pressure >= 160 mmHg) despite antihypertensive therapy, or use of amiodarone within the last 6 months.
  • Uncontrolled type 2 diabetes mellitus (T2DM) (HbA1C greater than 8%) or a history of frequent hypoglycemia, or significantly uncontrolled hyperglycemia
  • Pregnant women are excluded from this study because of the potential for teratogenic or abortifacient effects of the study drugs. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with study drugs breastfeeding should be discontinued if the mother will be on treatment
  • Early disease progression prior to 3 months (12 weeks) from the completion of RT-TMZ, unless histologically proven to be recurrent GBM
  • Had more than 2 prior lines for chemotherapy administration. NOTE: In the 1st line adjuvant setting, combination of TMZ with an experimental agent, is considered one line of chemotherapy
  • Any prior treatment with an intracerebral agent
  • Receiving additional, concurrent, active therapy for GBM outside of the trial
  • Extensive leptomeningeal disease and defined by the principal investigator (PI)
  • History of allergy or hypersensitivity to any of the study treatments or any of their excipient
  • Unable or unwilling to undergo brain MRI scans with gadolinium
  • History of another malignancy in the previous 2 years, with a disease-free interval of < 2 years. Participant with prior history of in situ cancer or basal or squamous cell skin cancer are eligible
  • Serious, non-healing wound, ulcer, bone fracture, or abscess
  • Any cerebrovascular accident (including transient ischemic attacks) within the last 6 months prior to initiation of study treatment
  • Any hemorrhage or bleeding event that is >= grade 3 based on National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE), grade 2 intracranial hemorrhage, or persistent thrombotic/embolic event within 4 weeks prior to the start of study medication
  • History of interstitial lung disease, history of slowly progressive dyspnea and unproductive cough, sarcoidosis, silicosis, idiopathic pulmonary fibrosis, pulmonary hypersensitivity pneumonitis, or symptomatic pleural effusion
  • Active, known or systemic suspected autoimmune disease, including systemic lupus erythematosus, scleroderma, polyarteritis nodose, or auto-immune hepatitis
  • Known history of hepatitis B, human immunodeficiency virus (HIV), or active hepatitis C infection requiring treatment with antiviral therapy
  • History of bleeding diathesis (irrespective of severity)
  • History of agranulocytosis
  • History of pancreatitis
  • Uncontrolled psychiatric illness or any condition that could make the subject noncompliant with the study procedures and/or study requirements
  • Participant has not been on a stable dose of anticoagulants for at least 2 weeks before randomization

Sites / Locations

    Arms of the Study

    Arm 1

    Arm Type

    Experimental

    Arm Label

    Treatment (methimazole, lomustine, liothyronine)

    Arm Description

    See Outline in Detailed Description.

    Outcomes

    Primary Outcome Measures

    Incidence of adverse events
    Descriptive statistics (e.g., frequency and percentage) for each adverse event/severe adverse event will be tabulated by association and grade.

    Secondary Outcome Measures

    Overall response rate
    Will be assessed by Response Assessment in Neuro-Oncology Criteria. Will be summarized with the 2-sided 95% confidence interval using the Clopper-Pearson method.
    Progression free survival
    Kaplan-Meier methods will be used to estimate median survival time or time-specific survival rate with a 95% confidence interval.
    Overall survival
    Kaplan-Meier methods will be used to estimate median survival time or time-specific survival rate with a 95% confidence interval.

    Full Information

    First Posted
    July 28, 2021
    Last Updated
    November 30, 2022
    Sponsor
    Emory University
    Collaborators
    National Cancer Institute (NCI)
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    1. Study Identification

    Unique Protocol Identification Number
    NCT05017610
    Brief Title
    Inducing a Hypothyroxinemic State in Patients With Recurrent Glioblastoma or Gliosarcoma
    Official Title
    A Single Arm Pilot Study to Evaluate the Safety and Feasibility of Inducing a Hypothyroxinemic State in Patients With Recurrent Glioblastoma
    Study Type
    Interventional

    2. Study Status

    Record Verification Date
    November 2022
    Overall Recruitment Status
    Withdrawn
    Why Stopped
    Per the PI-slow accrual
    Study Start Date
    October 20, 2021 (Actual)
    Primary Completion Date
    October 14, 2022 (Actual)
    Study Completion Date
    October 14, 2022 (Actual)

    3. Sponsor/Collaborators

    Responsible Party, by Official Title
    Principal Investigator
    Name of the Sponsor
    Emory University
    Collaborators
    National Cancer Institute (NCI)

    4. Oversight

    Studies a U.S. FDA-regulated Drug Product
    Yes
    Studies a U.S. FDA-regulated Device Product
    No
    Data Monitoring Committee
    Yes

    5. Study Description

    Brief Summary
    This early phase I trial studies the safety and feasibility of inducing a hypothyroxinemic state in patients with glioblastoma or gliosarcoma that has come back (recurrent). This trial aims to see if giving a specific thyroid hormone, such as methimazole and liothyronine, is safe and could benefit cancer treatment.
    Detailed Description
    PRIMARY OBJECTIVE: I. To evaluate the safety and feasibility of inducing a hypothyroxinemic state in patients with recurrent glioblastoma. SECONDARY OBJECTIVES: I. To evaluate the anti-tumor activity of inducing hypothyroxinemic state by assessing progression-free survival (PFS) and overall survival (OS). II. To evaluate the correlation of PFS and OS with thyroid hormone levels. III. To evaluate the correlation of overall response rate (ORR) with thyroid hormone levels. IV. To evaluate the correlation of potential side effects with T3 levels or methimazole dose. OUTLINE: CATEGORY 1 (normal baseline thyroid function and no levothyroxine replacement): Patients receive methimazole orally (PO) daily and lomustine daily. Treatment with lomustine repeats every 6 weeks for up to 6 cycles or 12 months. Patients may receive liothyronine PO twice daily (BID) when thyroid-stimulating hormone (TSH) is above upper normal limit. Treatment continues in the absence of disease progression or unacceptable toxicity. CATEGORY 2 (baseline primary hypothyroidism in patients taking levothyroxine): Patients receive liothyronine PO BID to maintain lower free T4 below lower limit of normal and TSH and free T3 in the normal range. At the time of cessation of exogenous T4, patients receive lomustine every 6 weeks for up to 6 cycles or 12 months. Treatment continues in the absence of disease progression or unacceptable toxicity. CATEGORY 3 (secondary/tertiary hypothyroidism): Patients receive liothyronine PO BID to maintain lower free T4 below lower limit of normal and free T3 within normal range. At the time of cessation of exogenous T4, patients receive lomustine every 6 weeks for up to 6 cycles or 12 months. Treatment continues in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up at 30 days and then every 6 and 8 weeks.

    6. Conditions and Keywords

    Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
    Recurrent Glioblastoma, Recurrent Gliosarcoma

    7. Study Design

    Primary Purpose
    Treatment
    Study Phase
    Early Phase 1
    Interventional Study Model
    Single Group Assignment
    Masking
    None (Open Label)
    Allocation
    N/A
    Enrollment
    0 (Actual)

    8. Arms, Groups, and Interventions

    Arm Title
    Treatment (methimazole, lomustine, liothyronine)
    Arm Type
    Experimental
    Arm Description
    See Outline in Detailed Description.
    Intervention Type
    Drug
    Intervention Name(s)
    Liothyronine
    Other Intervention Name(s)
    L-Triiodothyronine, Therapeutic T3, Triiodothyronine
    Intervention Description
    Given PO
    Intervention Type
    Drug
    Intervention Name(s)
    Lomustine
    Other Intervention Name(s)
    1-(2-Chloroethyl)-3-cyclohexyl-1-nitrosourea, 1-Nitrosourea, 1-(2-chloroethyl)-3-cyclohexyl-, Belustin, Belustine, CCNU, Cecenu, CeeNU, Chloroethylcyclohexylnitrosourea, Citostal, Gleostine, Lomeblastin, Lomustinum, Lucostin, Lucostine, N-(2-Chloroethyl)-N''-cyclohexyl-N-nitrosourea, Prava, RB-1509, WR-139017
    Intervention Description
    Given PO
    Intervention Type
    Drug
    Intervention Name(s)
    Methimazole
    Other Intervention Name(s)
    Tapazole
    Intervention Description
    Given PO
    Primary Outcome Measure Information:
    Title
    Incidence of adverse events
    Description
    Descriptive statistics (e.g., frequency and percentage) for each adverse event/severe adverse event will be tabulated by association and grade.
    Time Frame
    Up to study completion, an average of 2 years
    Secondary Outcome Measure Information:
    Title
    Overall response rate
    Description
    Will be assessed by Response Assessment in Neuro-Oncology Criteria. Will be summarized with the 2-sided 95% confidence interval using the Clopper-Pearson method.
    Time Frame
    Up to study completion, an average of 2 years
    Title
    Progression free survival
    Description
    Kaplan-Meier methods will be used to estimate median survival time or time-specific survival rate with a 95% confidence interval.
    Time Frame
    Up to study completion, an average of 2 years
    Title
    Overall survival
    Description
    Kaplan-Meier methods will be used to estimate median survival time or time-specific survival rate with a 95% confidence interval.
    Time Frame
    Up to study completion, an average of 2 years

    10. Eligibility

    Sex
    All
    Minimum Age & Unit of Time
    18 Years
    Accepts Healthy Volunteers
    No
    Eligibility Criteria
    Inclusion Criteria: Age >= 18 years Eastern Cooperative Oncology Group (ECOG) performance status =< 2 (Karnofsky >= 70%) within a 14-day window prior to randomization Patients must have histologically confirmed glioblastoma (or gliosarcoma) at first or second recurrence after initial standard, control or experimental, therapy that includes at least radiation therapy (RT) and temozolomide (TMZ) Evidence of progressive disease (PD) by modified response assessment in neuro-oncology criteria (using the post-chemoradiation time point as baseline), defined by any of the following: >= 25% increase in sum of products of perpendicular diameters of measurable enhancing lesions, compared with the smallest tumor measurement obtained either at the post-chemoradiation baseline (if no decrease) or best response (on stable or increasing steroid dose). Any new measurable (> 1 x 1 cm) enhancing lesions after the post-chemoradiation scan A total of at least 2 serial magnetic resonance imaging (MRI) scans documented at Screening including: 1) a scan at the time of suspected tumor progression; and 2) a scan prior to the time of progression. Patients must have progressed after standard of care treatment (it typically includes surgery, radiation and temozolomide). Pseudoprogression or radiation necrosis has been ruled out Hemoglobin >= 9.0 g/dl (no transfusions allowed within 7 days of cycle 1 day 1 to meet entry criteria) (within 14 days of starting treatment) Absolute neutrophil count (ANC) >= 1,500/mcL (after at least 7 days without growth factor support or transfusion) (within 14 days of starting treatment) Platelets >= 100,000/mcL (no transfusions allowed within 7 days of cycle 1 day 1 to meet entry criteria) (within 14 days of starting treatment) International normalized ratio (INR) =< 1.5 (within 14 days of starting treatment) Partial thromboplastin time (PTT) < 1.5 x upper limits of normal (ULN) (within 14 days of starting treatment) Total bilirubin =< 1.5 times the institutional upper limit of normal (ULN) (within 14 days of starting treatment) Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =< 2.0 times the ULN (within 14 days of starting treatment) High amylase or lipase above upper normal limit (UNL) (within 14 days of starting treatment) Serum creatinine =< 1.5 x ULN or creatinine clearance >= 60 mL/min/1.73 m^2 for patients with creatinine levels > 1.5 x ULN. Creatinine clearance should be calculated per institutional standard (within 14 days of starting treatment) Electrocardiogram corrected QT interval by Fridericia's formula (QTcF) < 450 ms (within 14 days of starting treatment) Clinically significant toxic effect(s) of the most recent prior anti-cancer therapy must be grade 1 or resolved (except alopecia) A minimum time of 28 days elapsed from the administration of any prior cytotoxic agents Have undergone recent surgery for recurrent or progressive brain tumor are eligible provided that: Prior to surgery there was imaging evidence of measurable progressive disease (PD) as described above. Craniotomy or intracranial biopsy site must be adequately healed and free of drainage or cellulitis, and the underlying cranioplasty must appear intact at the time of randomization. Initiation of study treatment is at least 14 days from prior surgery/biopsy Availability of tumor tissue representative of glioblastoma (GBM) from initial definitive surgery and/or, recurrent surgery, if performed Female of child-bearing potential (FCBP) must have a negative serum or urine pregnancy test prior to starting therapy FCBP and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately. Men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study, for the duration of study participation, and 4 months after completion of study administration. A female of childbearing potential (FCBP) is a sexually mature woman who: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months) Willingness and ability of the subject to comply with scheduled visits, drug administration plan, protocol-specified laboratory tests, other study procedures, and study restrictions. Evidence of a personally signed informed consent indicating that the subject is aware of the neoplastic nature of the disease and has been informed of the procedures to be followed, the experimental nature of the therapy, alternatives, potential risks and discomforts, potential benefits, and other pertinent aspects of study participation Exclusion Criteria: Patients who received temozolomide within 28 days prior to starting first cycle under this study Optune device is not allowed Patients who received prior lomustine, carmustine wafers, bevacizumab or any other anti-angiogenic agent Dexamethasone at time of study entry is not allowed. After a stable dose of methimazole and T3 is reached, dexamethasone can be used with a dose determined by treating physician Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements Computed tomography (CT) scan with contrast within 6 weeks from enrollment as it may influence thyroid tests due to the iodine content History of cardiac arrhythmias (in particular, sinus bradycardia, atrial fibrillation or flutter, atrioventricular [AV] block, prolonged QTc, ventricular arrythmias, pacemaker, or implantable cardiac defibrillator).). Significant cardiovascular disease (eg, myocardial infarction, arterial thromboembolism, cerebrovascular thromboembolism) within 6 months prior to start of study therapy; angina requiring therapy; symptomatic peripheral vascular disease; left ventricular ejection fraction less than or equal to 35%;New York Heart Association class 3 or 4 congestive heart failure; or uncontrolled grade >= 3 hypertension (diastolic blood pressure >= 100 mmHg or systolic blood pressure >= 160 mmHg) despite antihypertensive therapy, or use of amiodarone within the last 6 months. Uncontrolled type 2 diabetes mellitus (T2DM) (HbA1C greater than 8%) or a history of frequent hypoglycemia, or significantly uncontrolled hyperglycemia Pregnant women are excluded from this study because of the potential for teratogenic or abortifacient effects of the study drugs. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with study drugs breastfeeding should be discontinued if the mother will be on treatment Early disease progression prior to 3 months (12 weeks) from the completion of RT-TMZ, unless histologically proven to be recurrent GBM Had more than 2 prior lines for chemotherapy administration. NOTE: In the 1st line adjuvant setting, combination of TMZ with an experimental agent, is considered one line of chemotherapy Any prior treatment with an intracerebral agent Receiving additional, concurrent, active therapy for GBM outside of the trial Extensive leptomeningeal disease and defined by the principal investigator (PI) History of allergy or hypersensitivity to any of the study treatments or any of their excipient Unable or unwilling to undergo brain MRI scans with gadolinium History of another malignancy in the previous 2 years, with a disease-free interval of < 2 years. Participant with prior history of in situ cancer or basal or squamous cell skin cancer are eligible Serious, non-healing wound, ulcer, bone fracture, or abscess Any cerebrovascular accident (including transient ischemic attacks) within the last 6 months prior to initiation of study treatment Any hemorrhage or bleeding event that is >= grade 3 based on National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE), grade 2 intracranial hemorrhage, or persistent thrombotic/embolic event within 4 weeks prior to the start of study medication History of interstitial lung disease, history of slowly progressive dyspnea and unproductive cough, sarcoidosis, silicosis, idiopathic pulmonary fibrosis, pulmonary hypersensitivity pneumonitis, or symptomatic pleural effusion Active, known or systemic suspected autoimmune disease, including systemic lupus erythematosus, scleroderma, polyarteritis nodose, or auto-immune hepatitis Known history of hepatitis B, human immunodeficiency virus (HIV), or active hepatitis C infection requiring treatment with antiviral therapy History of bleeding diathesis (irrespective of severity) History of agranulocytosis History of pancreatitis Uncontrolled psychiatric illness or any condition that could make the subject noncompliant with the study procedures and/or study requirements Participant has not been on a stable dose of anticoagulants for at least 2 weeks before randomization
    Overall Study Officials:
    First Name & Middle Initial & Last Name & Degree
    Jeffrey J. Olson, MD
    Organizational Affiliation
    Emory University Hospital/Winship Cancer Institute
    Official's Role
    Principal Investigator

    12. IPD Sharing Statement

    Plan to Share IPD
    No

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    Inducing a Hypothyroxinemic State in Patients With Recurrent Glioblastoma or Gliosarcoma

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