Bevacizumab in Combination With Metronomic Temozolomide for Recurrent Malignant Glioma

Phase 2

Completed

Brief Summary: This is a phase II study of the combination of Avastin and metronomic temozolomide in recurrent malignant glioma patients. The primary objective will be to determine the efficacy of Avastin (bevacizumab) and metronomic temozolomide in malignant glioma patients. The secondary objective will be to determine the safety of Avastin, 10 mg/kg every other week, in combination with metronomic temozolomide in terms of progression-free survival.

Detailed Description: This is a phase II trial of the combination of Avastin and metronomic temozolomide in recurrent WHO grade IV malignant glioma patients. Patients will receive up to 12 cycles of Avastin and temozolomide and cycles are continuous 28 days. Patients will receive daily temozolomide at a dose of 50mg/m2 and will receive Avastin every other week at a dose of 10mg/kg. Patients will be required to have a baseline MRI within 2 weeks of starting treatment and a repeat MRI every 8 weeks. A total of 32 patients will be enrolled at Duke.

Patients with recurrent malignant gliomas have a very poor prognosis, so new therapies are needed. Given the activity of metronomic temozolomide and the safety and activity of Avastin against malignant glioma, it is reasonable to study the combination in recurrent malignant glioma patients.

Recruitment & Eligibility

Inclusion Criteria

Patients must have histologically confirmed diagnosis of WHO grade IV primary malignant glioma
Karnofsy Performance Status (KPS) >/= 60%
Evidence of measurable primary CNS neoplasm on contrast-enhanced MRI.
An interval of at least 4 weeks between prior surgical resection or 1 week from a biopsy and enrollment on this protocol
An interval of at least 4 weeks from the end of prior radiotherapy or one week from the end of a cycle of chemotherapy and enrollment on this protocol.
No evidence of CNS hemorrhage on the baseline MRI or CT scans

Exclusion Criteria

Life expectancy < 8 weeks
Pregnancy or breast feeding
Progression to metronomic temozolomide, defined as tumor progression while taking daily temozolomide or progression within 4 weeks of stopping metronomic temozolomide
Inadequately controlled hypertension (defined as systolic blood pressure >150 and/or diastolic blood pressure > 100 mmHg on antihypertensive medications)

Arm && Interventions

Group	Intervention	Description
Bevacizumab and Metronomic Temozolomide	Metronomic Temozolomide	Patients will receive up to 12 cycles of bevacizumab (Avastin) and metronomic temozolomide (Temodar), and each cycle is 28 days. Bevacizumab will be administered at 10 mg/kg every other week beginning a minimum of 7 days after a biopsy or 28 days after a craniotomy. Temozolomide will be dosed at 50 mg/m2 daily in a 28-day cycle.
Bevacizumab and Metronomic Temozolomide	Bevacizumab	Patients will receive up to 12 cycles of bevacizumab (Avastin) and metronomic temozolomide (Temodar), and each cycle is 28 days. Bevacizumab will be administered at 10 mg/kg every other week beginning a minimum of 7 days after a biopsy or 28 days after a craniotomy. Temozolomide will be dosed at 50 mg/m2 daily in a 28-day cycle.

Primary Outcome Measures

Name	Time	Method
6-Month Progression-free Survival	6 months	Percentage of participants surviving six months from the start of study treatment without progression of disease. PFS was defined as the time from the date of study treatment initiation to the date of the first documented progression according to the Macdonald criteria, or to death due to any cause. \[Optional: Macdonald criteria are standard criteria in neuro-oncology. Tumor assessment was made according to the adapted MacDonald criteria based on the combined evaluation of: 1) assessment of the MRI scan for measurable, evaluable, and new lesions (made by the independent external expert too), 2) overall assessment of neurological performance (made by the investigator), 3) concomitant steroid use (as reported by the investigator).\]

Secondary Outcome Measures

Name	Time	Method
Response Rate	27 months	The number of participants with complete or partial response as determined by a modification of the Macdonald criteria. Complete response was defined as complete disappearance on MR/CT of all enhancing tumor and mass effect, off all corticosteroids (or receiving only adrenal replacement doses), accompanied by a stable or improving neurologic examination, and maintained for at least 4 weeks. Partial Response was defined as greater than or equal to 50% reduction in tumor size on MR/CT by bi-dimensional measurement, on a stable or decreasing dose of corticosteroids, accompanied by a stable or improving neurologic examination, and maintained for at least 4 weeks.
Incidence and Severity of CNS Hemorrhage and Systemic Hemorrhage	27 months	Number of participants experiencing a Central Nervous System (CNS) hemorrhage or systemic hemorrhage
Incidence of Grade ≥ 4 Hematologic or Grade ≥ 3 Non-hematologic Toxicity	27 months	Number of participants experiencing a grade ≥4 hematologic or grade ≥3 non-hematologic toxicity