Spectroscopic MRI-Guided Radiation Therapy Planning in Glioblastoma

PRIMARY OBJECTIVES:

I. To determine the feasibility of using spectroscopic MRI (sMRI) to guide dose-escalated radiation therapy (RT) for newly-diagnosed glioblastoma (GBM)s.

II. To determine the safety of using sMRI to guide dose-escalated RT for newly-diagnosed GBMs.

SECONDARY OBJECTIVE:

I. To determine whether the progression free survival at 1 year with sMRI-guided, dose-escalated RT is improved for newly-diagnosed GBMs.

TERTIARY OBJECTIVES:

I. To determine whether sMRI-guided, dose-escalated RT increases the overall survival of patients with newly diagnosed GBMs.

II. To determine whether sMRI data obtained after initiation of therapy (at 2 weeks after RT/TMZ start and prior to cycle 1 and 5 of adjuvant temozolomide \[TMZ\]) will provide early evidence of GBM progression not seen on standard MRIs.

III. To determine whether performance on neurocognitive and quality-of-life (QOL) assessments in newly-diagnosed GBM patients treated with sMRI-guided, dose-escalated RT differ from historical controls.

OUTLINE:

Patients undergo sMRI-guided radiation therapy daily for the first 5 days of every week (Monday - Friday) over 6 weeks. Patients also receive standard of care temozolomide orally (PO) daily during radiation therapy for up to 42 days.

After completion of study treatment, patients are followed up every 3 months for up to 2 years and then periodically.

• Dose-Escalated Radiation Therapy (Radiation), also known as RT, Radiation Therapy: Undergo sMRI-guided radiation therapy, dose painted to maximum of 75 Gy over six weeks
• Spectroscopic Magnetic Resonance Imaging (Procedure), also known as sMRI, MRSI, Magnetic Resonance Spectroscopic Imaging: Patients will undergo sMRI scans within a 14 day window prior to starting treatment
• Temozolomide (Drug), also known as Methazolastone, Temcad, Temodal, Temodar, Temomedac, TMZ: Given PO

Primary outcomes

• Feasibility as Assessed by Successful Co-registration of sMRI-based Treatment Volumes With Clinical Images Into the Radiation Treatment Execution Platform [Up to 2 years after completion of therapy]: Feasibility of this approach will be determined by whether treatment volumes based on sMRI can be co-registered with clinical images and transferred into the radiation treatment execution platform in a seamless manner, so that sMRI information can be efficiently applied to the patient treatment.
• Incidence of Adverse Event Assessed by Common Terminology Criteria for Adverse Events Version 4.0 [Up to 2 years after completion of therapy]: The safety of sMRI to guide dose-escalated RT will be confirmed by assessing toxicity potentially attributable to the RT.

Secondary outcomes

• Progression Free Survival (PFS) [2 years from the start of RT.]: Patients were followed at least every 3 months for 2 years from the start of RT.

Other outcomes

• Overall Survival (OS) [2.5 years from start of RT]: Patients were followed at least every 3 months for 2.5 years from the start of RT.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Patients must have a newly-diagnosed glioblastoma or gliosarcoma that has been confirmed pathologically by a board-certified neuropathologist
* Patients must be able to have MRI scans
* Patients must have the following lab values ≤ 14 days prior to registration:

  * White blood cell (WBC) ≥ 3,000/µL
  * Absolute neutrophil count (ANC) ≥ 1,500/µL
  * Platelet count of ≥ 75,000/µL
  * Hemoglobin ≥ 9.0 gm/dL (transfusion is allowed to reach minimum level)
  * Serum glutamic-oxaloacetic transaminase (SGOT) ≤ 2.0 x upper limit of normal (ULN)
  * Bilirubin ≤ 2 x ULN
  * Creatinine ≤ 1.5 mg/dL
* Patients must have a life expectancy of ≥ 12 weeks
* Patients must have a Karnofsky performance status (KPS) ≥ 60
* Patients who are women of childbearing potential must have a negative pregnancy test documented ≤ 14 days prior to registration; this is not specific to dose escalation and is mandatory for standard care for patients being treated with radiation therapy; the cost of this test will be covered by standard of care
* Patients must be able to understand and provide written informed consent
* Members of all races and ethnic groups are eligible for this trial; subjects will be approximately representative of the demographics of the referral base for the participating institutions
* Patient must be able to swallow capsules
* Patients must be willing to forego other cytotoxic and non-cytotoxic therapies against the tumor while being treated on this protocol

Exclusion Criteria:

* Patients with pacemakers, aneurysm clips, neurostimulators, cochlear implants, metal in ocular structures, history of being a steel worker, or other incompatible implants which makes MRI safety an issue are excluded
* Patients that have any significant medical illnesses that in the investigator's opinion cannot be adequately controlled with appropriate therapy or would compromise the patient's ability to tolerate this therapy are excluded
* Patients with a history of any other invasive cancer (except non-melanoma skin cancer and excluding carcinoma in-situ), unless in complete remission and off of all therapy for that disease for ≥ 3 years, are ineligible
* Patients with an active infection or serious intercurrent medical illness are ineligible
* Patients receiving any other investigational agents are excluded
* Patients who have received prior cytotoxic, non-cytotoxic or experimental drug therapies for brain tumor are excluded
* Patients with a history of prior cranial radiation are ineligible
* Patients may not be enrolled on any other therapeutic trial for which they are receiving an anti-tumor therapy
* Patients with GBMs located in the following anatomical regions known to have magnetic susceptibility or poor signal will be excluded: mesial temporal lobe, orbitofrontal cortex, prefrontal cortex, medial frontal gyrus, brainstem, and cerebellum
* The maximum radiation target volume for gross tumor volume 3 (GTV3) is 65 cc (per NRG Oncology guide); patient may be excluded after the first sMRI scan if the GTV3 volume is greater than 65 cc (we anticipate that contrast-enhancing tumor volume \[residual tumor volume following tumor resection\] would be less than 20 cc)

Participant flow

Outcome results

• Feasibility as Assessed by Successful Co-registration of sMRI-based Treatment Volumes With Clinical Images Into the Radiation Treatment Execution Platform (Primary), Count of participants, Participants: sMRI-Guided RT With TMZ 30
• Incidence of Adverse Event Assessed by Common Terminology Criteria for Adverse Events Version 4.0 (Primary), Number, Adverse Events: sMRI-Guided RT With TMZ 79 (62 to 99)
• Progression Free Survival (PFS) (Secondary), Median, Months: sMRI-Guided RT With TMZ 16.6 (11.6 to 24.0)
• Overall Survival (OS) (Other pre specified), Median, Months: sMRI-Guided RT With TMZ 23 (18.6 to 27.3)

Adverse events

Time frame: Up to 2 years after completion of therapy

Serious adverse events by term

Other adverse events by term

18 more terms not shown.

• Results publication: Trivedi AG, Kim SH, Ramesh KK, Giuffrida AS, Weinberg BD, Mellon EA, Kleinberg LR, Barker PB, Han H, Shu HG, Shim H, Schreibmann E. Applying a Radiation Therapy Volume Analysis Pipeline to Determine the Utility of Spectroscopic MRI-Guided Adaptive Radiation Therapy for Glioblastoma. Tomography. 2023 May 21;9(3):1052-1061. doi: 10.3390/tomography9030086. PMID 37218946
• Results publication: Ramesh K, Gurbani SS, Mellon EA, Huang V, Goryawala M, Barker PB, Kleinberg L, Shu HG, Shim H, Weinberg BD. The Longitudinal Imaging Tracker (BrICS-LIT):A Cloud Platform for Monitoring Treatment Response in Glioblastoma Patients. Tomography. 2020 Jun;6(2):93-100. doi: 10.18383/j.tom.2020.00001. PMID 32548285
• Results publication: Gurbani S, Weinberg B, Cooper L, Mellon E, Schreibmann E, Sheriff S, Maudsley A, Goryawala M, Shu HK, Shim H. The Brain Imaging Collaboration Suite (BrICS): A Cloud Platform for Integrating Whole-Brain Spectroscopic MRI into the Radiation Therapy Planning Workflow. Tomography. 2019 Mar;5(1):184-191. doi: 10.18383/j.tom.2018.00028. PMID 30854456

• Study Protocol and Statistical Analysis Plan (PDF, 2020-09-15)
• Informed Consent Form (PDF, 2019-03-13)

• Hui-Kuo Shu, MD, PhD, Principal investigator, Emory University/Winship Cancer Institute

NIH grants: R01CA214557, P30CA138292