This phase II/III trial studies how well vocimagene amiretrorepvec (Toca 511) and extended release flucytosine (Toca FC) work when added to the usual treatment (temozolomide and radiation therapy) in treating patients with newly diagnosed glioblastoma. Toca 511 is a live virus that has been built to carry a gene into tumor cells. This gene carries instructions that cause the tumor cells to turn Toca FC, typically used to treat fungal infections, into a drug that may kill the tumor cells. Drugs used in chemotherapy, such as temozolomide, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Radiation therapy uses high energy x-rays to kill tumor cells and shrink tumors. Giving Toca 511 and Toca FC in addition to the usual treatment (temozolomide and radiation therapy) may help shrink or stabilize cancer or extend the life of patients with newly diagnosed glioblastoma.
PRIMARY OBJECTIVES: I. To compare the progression-free survival (PFS) of patients with newly diagnosed glioblastoma treated with Toca 511 at the time of tumor resection followed by Toca FC in combination with standard of care (SOC) treatment to patients with newly diagnosed glioblastoma treated with SOC after tumor resection. (Phase II) II. To compare the overall survival (OS) from time of randomization of all patients with newly diagnosed glioblastoma treated with Toca 511 at the time of tumor resection followed by Toca FC in combination with SOC treatment to patients with newly diagnosed glioblastoma treated with SOC after tumor resection. (Phase III) SECONDARY OBJECTIVES: I. To evaluate the safety of each arm as administered in this study. II. To compare the OS between arms (only for phase II part of the study). III. To compare the PFS between arms using Response Assessment in Neuro-Oncology (RANO) (only for phase III part of the study). IV. To evaluate the objective response rate (ORR) in patients with measurable disease at the post-surgical scan. V. To evaluate the effect of IDH mutation status on survival outcomes between arms. VI. To evaluate the PFS and OS by extent of resection. VII. To evaluate the effect of MGMT methylation status on survival outcomes between arms. EXPLORATORY OBJECTIVES: I. To evaluate the duration of response (DoR) in patients with measurable disease at the post-surgical scan using mRANO. II. To evaluate the effect of corticosteroids administration on efficacy of Toca 511 and Toca FC. III. To optimize quality assurance methodologies and processes for radiotherapy and imaging. IV. To determine if there is a tumor-microenvironment signature based on ribonucleic acid (RNA) sequencing that is associated with a selective increase in benefit from the addition of Toca 511 and Toca FC. V. To compare regional genomic heterogeneity and molecular profiles, as measured by RNA sequencing and methylation analyses between arms. VI. To compare quality of life (QOL), as measured by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) and Brain Cancer Module (BN20), between arms. VII. To compare health utilities, as measured by the EuroQoL 5-Dimension 5-Level (EQ-5D-5L), between arms. OUTLINE: Patients are randomized to 1 of 2 arms. ARM I: Beginning on week 5 following standard of care surgery, patients undergo radiation therapy over 30 fractions 5 days per week for up to 6 weeks, and receive temozolomide orally (PO) once daily (QD) for up to 49 days. At the discretion of treating physician, patients may also receive novoTTF-100A (Optune) device 0-7 weeks following radiation and temozolomide treatment. One month following completion of radiation therapy, patients continue to receive temozolomide PO QD on days 1-5. Treatment repeats every 28 days for up to 12 cycles in the absence of disease progression or unacceptable toxicity. ARM II: Patients receive vocimagene amiretrorepvec via intracranial injection during surgery on day 1. Beginning on week 5 following surgery, patients receive extended release flucytosine PO three times daily (TID) for 7 consecutive days every 7 weeks. Patients also undergo radiation therapy and receive temozolomide as in arm I. After completion of radiation therapy and at the discretion of the treating physician, patients may continue to receive extended release flucytosine PO TID for 7 consecutive days every 8 weeks in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up until progression then, every 3 months for 1 year, every 4 months for 1 year, and then every 6 months thereafter.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Given PO
Receive Optune device
Ancillary studies
Ancillary studies
Undergo radiation
Given PO
Undergo standard of care surgery
Given via intracranial injection
Progression free survival (PFS) (Phase II)
Analysis of treatment comparison between the experimental and standard-of-care arms will be performed once the required number of centrally-reviewed PFS events is reached . The Kaplan-Meier method will be used to calculate the PFS rates for each of the two arms. Hazard ratio (HR) on the treatment effect will be calculated using the stratified Cox proportional hazard model. A one-sided stratified log-rank test will be used to test the difference in PFS between the two arms.
Time frame: Time from randomization to the first documented progressive disease (PD) as determined by central review, or death due to any cause, whichever occurs first, assessed for up to 5 years
Overall survival (OS) (Phase III)
Analysis of the treatment comparison between the experimental and standard of care arms will be performed once the required number of deaths is reached. The Kaplan-Meier method will be used to calculate the OS rates for each of the two arms. The primary endpoint will be assessed using a one-sided stratified log-rank test, incorporating only stratification factors, to test the difference in OS between the two arms. Hazard ratio (HR) on the treatment effect will be calculated using the stratified Cox proportional hazard model adjusting for stratification factors. In addition to assessing the effect of treatment arm, IDH mutation status, MGMT status, the interaction between MGMT status and treatment arm, extent of resection, and use of Optune (in only the standard-of-care arm) will be assessed using a log-rank test and Cox proportional hazards models.
Time frame: The time from randomization to death due to any cause, assessed up to 5 years
Incidence of grade 3 or higher adverse events
Will be graded according to Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Counts of all adverse events (AEs) by grade will be provided by treatment arm. Frequencies and percentages will be provided for the worst grade AE experienced by the patient by treatment arm. The number of patients with at least 1 grade 3 or higher AE will be compared between the treatment arms. A comparison between treatment arms of grade 3 and higher AEs related to any aspect of protocol treatment will be tested. A comparison between arms of the following events will also be conducted: any new solid tumor, hematologic malignancy or myelodysplastic syndrome and any neurologic decline not attributed to tumor progression, and any toxicity that is possibly, probably or definitely related to protocol treatment. All comparisons will be tested using a chi-square test with a two-sided significance level of 0.05.
Time frame: Until death, assessed up to 5 years
Overall survival (OS) (Phase II)
The Kaplan-Meier method will be used to calculate the OS rates for each arm. HR on the group variable will be calculated using the Cox proportional hazard model. A two-sided stratified log-rank test will be used to test the difference in OS and PFS between the two arms at a significance level of 0.05.
Time frame: The time from randomization to death due to any cause, assessed up to 5 years
Progression free survival (PFS) (Phase III)
The Kaplan-Meier method will be used to calculate the PFS rates for the following sets of groups: treatment arms, IDH mutation status, or extent of resection. HR on the group variable will be calculated using the Cox proportional hazard model. A two-sided stratified log-rank test will be used to test the difference in OS and PFS between the two arms at a significance level of 0.05. In addition to assessing the effect of treatment arm, IDH mutation status, MGMT status, the interaction between MGMT status and treatment arm, extent of resection, and use of Optune (in only the standard-of-care arm) will be assessed using a log-rank test and Cox proportional hazards models.
Time frame: Time from randomization to the first documented PD as determined by central review, or death due to any cause, whichever occurs first, assessed for up to 5 years
Objective response rate (ORR)
Will be determined centrally. Frequencies and percent of responses will be provided for each group (treatment arm and IDH mutation status) for patients with measurable disease. Patients with a confirmed complete response (CR) or partial response (PR) will be considered responders. The percent of responders at 1 year will be of interest, although ORR will be calculated at 6 and 18 months as well. Between arm comparisons will be tested using a two-sided chi-square test with a significance level of 0.05.
Time frame: Up to 18 months
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.