Glioblastoma Multiforme
Conditions
Keywords
Glioblastoma, GBM, Brain Tumor, Glioma
Brief summary
Primary Objectives Cohort A -- monotherapy: To determine the efficacy of AMG 386 in participants with recurrent glioblastoma (GBM) as measured by 6-month progression-free survival (PFS6) Cohort B - combination therapy: Phase I To determine the maximum tolerated dose of AMG 386 in combination with bevacizumab given at 10mg/kg every 2 weeks in participants with recurrent glioblastoma. Phase II To determine the efficacy of AMG 386 plus bevacizumab in participants with recurrent glioblastoma (GBM) as measured by 6-month progression-free survival (PFS6). Secondary Objectives: To evaluate radiographic response in both cohort populations. To evaluate overall survival in both cohort populations. To assess time-to-progression in both cohort populations. To investigate the safety profile in both cohort populations. Exploratory Objectives: To evaluate expression of factors associated with tumor angiogenesis using a multiples cytokine assay among participants undergoing therapy with AMG 386 with response to therapy and development of resistance. This is an open-label Phase I/II study of AMG 386 monotherapy and AMG 386 in combination with bevacizumab. Two cohorts will accrue and will be assessed sequentially. Each cohort will enroll participants with recurrent GBM. Cohort A will assess recurrent GBM participants who receive AMG 386 monotherapy at 30 g/kg every week. (Cohort A initially accrued at a dose of 15mg/kg, but this was increased to 30 mg/kg every week following an amendment). Cohort B will assess recurrent GBM participants who receive weekly AMG 386 plus bi-weekly bevacizumab (10mg/kg). Cohort B will start with a Phase I component to determine the MTD of AMG 386 that is safe when used in combination with bevacizumab. AMG 386 is administered intravenously, and, when used in combination with intravenous bevacizumab, will be administered first. Patients will be required to come to the clinic weekly for study drug administration. For study purposes, a cycle of therapy will be 4 weeks. Treatment will continue until either evidence of progressive disease, unacceptable toxicity, non-compliance with study follow-up, or withdrawal of consent. The estimated rate of accrual is 60 participants per year. The estimated date of accrual completion is 1.5 years from study initiation. The estimated date of study completion will be approximately 12 months from enrollment of the last study participant.
Interventions
DRUGAmgen 386
For Cohort A, AMG 386 will be administered intravenously at 30 mg/kg every week. For Cohort B Phase I, AMG 386 will be administered intravenously at beginning at starting dose level of 15 mg/kg every week. For Cohort B Phase II, AMG 386 will be administered intravenously at the maximum tolerated dose determined in the Phase I portion of the study every week.
DRUGBevacizumab
The dose of bevacizumab will be 10 mg/kg and will be administered intravenously every other week.
Sponsors
Amgen
Dana-Farber Cancer Institute
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Signed informed consent approved by the Institutional Review Board prior to participant entry * Age ≥ 18 years. * Karnofsky ≥ 70% * Participant must be able and willing to comply with study and/or follow-up procedures Participants must have histologically confirmed diagnosis of GBM patients with either grade III or IV malignant glioma are eligible to the Phase I portion of the study) and radiographic evidence of recurrence or disease progression (defined as either a greater than 25% increase in the largest bidimensional product of enhancement, a new enhancing lesion, or significant increase in T2 FLAIR) following prior therapy (i.e. chemotherapy, XRT, other investigational therapies). * No more than 2 prior episodes of progressive disease (patients with more than 2 prior episodes of progressive disease are eligible for the Cohort B, Phase I portion of this study) * An interval of at least 4 weeks (to start of study agent) between prior surgical resection or one week from stereotactic biopsy * An interval of at least 12 weeks (to start of study agent) from the end of prior radiotherapy unless there is a new area of enhancement consistent with recurrent tumor outside of the radiation field, or there is histological confirmation of unequivocal tumor progression * From the projected start of scheduled study treatment, the following time periods must have relapsed: 4 weeks (or 5 half lives, whichever is shorter) from any investigational agent, 4 weeks (or 5 half lives, whichever is shorter) from cytotoxic therapy (except 23 days for temozolomide and 6 weeks from nitrosoureas), 6 weeks from antibodies (or 5 half lives, whichever is shorter), or 4 weeks (or 5 half lives, whichever is shorter) from other anti-tumor therapies. * Participants must have recovered to a grade 0 or 1 from the toxic effects of prior therapy (with the exception of lymphopenia, which is common after therapy with temozolomide, and alopecia). * No evidence of hemorrhage on the baseline MRI or CT scan other than those that are ≤ grade 1 and either post-operative or stable on at least two consecutive scans. Clinical Labs - performed within 14 days prior to enrollment * Hematocrit ≥ 29%, ANC ≥ 1,000 cells/μl, platelets ≥ 100,000 cells/μl ; * Serum creatinine ≤ 1.5 mg/dl, serum SGOT and bilirubin ≤ 1.5 times upper limit of normal; * PTT or aPTT ≤ 1.5 times upper limit of normal and INR ≤ 1.5 * Calculated creatinine clearance ≥ 40 mL/min according to the Cockcroft-Gault formula OR per 24 hour urine collection * Urinary protein quantitative value of \< 30 mg/dL in urinalysis or \<1+ on dipstick, unless quantitative protein is \< 1000 mg in a 24 hour urine sample; * Participants of child-bearing potential who have not undergone a bilateral salpingo-oophorectomy and are sexually active must consent to use an accepted and highly effective non-hormonal method of contraception (i.e. double barrier method \[e.g., condom plus diaphragm\]) from signing the informed consent through 6 months after last dose of study drug.
Exclusion criteria
* Prior anti-angiogenic therapy targeting VEGF or VEGF receptor including prior bevacizumab. * Prior AMG 386 therapy or other molecules that inhibit the angiopoietins or Tie2 receptor. * Co-medication that may interfere with study results; e.g. immunosuppressive agents other than corticosteroids. * Active infection requiring intravenous antibiotics * Current or within 30 days prior to enrollment treatment with immune modulators such as systemic cyclosporine and tacrolimus. * Current us of warfarin sodium or any other Coumadin-derivative anticoagulant. Participant must be off Coumadin-derivative anticoagulants for at least seven days prior to starting study drug. ow molecular weight heparin is allowed. * Current, recent (within 4 weeks of the first infusion of this study), or planned participation in an experimental drug study other than supportive care or epidemiologic studies. * Herbal preparations/medications are not allowed throughout the study. These herbal medications include, but are not limited to: St. John's wort, Kava, ephedra (ma huang), gingko biloba, dehydroepiandrosterone (DHEA), yohimbe, saw palmetto, ginseng. Participants should stop using any herbal medications 7 days prior to first dose of study drug. * History of clinically significant bleeding within 6 months of enrollment * History of allergic reactions to bacterially produced proteins * Known hypersensitivity to any component of bevacizumab (cohort B only) * Known sensitivity to any of the products to be administered during dosing * History of venous or arterial thromboembolism within 12 months prior to enrollment. * Severe hepatic insufficiency (ongoing grade 3 or greater hepatic adverse events) or known active chronic hepatitis. * Inadequately controlled hypertension (defined as systolic blood pressure \>140 and/or diastolic blood pressure \> 90 mmHg). The use of anti-hypertensive medications to control hypertension is permitted. * Any prior history of hypertensive crisis or hypertensive encephalopathy * Clinically significant cardiovascular disease within 12 months prior to enrollment, including myocardial infarction, unstable angina, grade 2 or greater peripheral vascular disease, cerebrovascular accident, transient ischemic attack, congestive heart failure, or arrhythmias not controlled by outpatient medication, percutaneous transluminal coronary angioplasty/stent. * Evidence of bleeding diathesis or coagulopathy * Major surgical procedure, open biopsy, or significant traumatic injury within 28 days prior to study enrollment or anticipation of need for major surgical procedure during the course of the study * Core biopsy or other minor surgical procedure, excluding placement of a vascular access device, within 7 days prior to study enrollment. * History of abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess within 6 months prior to study enrollment. * Serious, non-healing wound, ulcer (including gastrointestinal), or bone fracture. * Any condition which in the investigator's opinion makes the subject unsuitable for study participation. * Pregnant (positive pregnancy test) or lactating. Refusal or inability to use highly effective means of contraception (men and women) in participants of child-bearing potential.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| 6-Month Progression-Free Survival (PFS6) [Cohort A and Cohort B] | 6 months | PFS6 is the proportion of patients remaining alive and progression-free at 6-months from study entry. Progressive disease was established based on Response Assessment in Neuro-Oncology (RANO) criteria (Wen et al JCO 2010). RANO criteria has 5 potential categories: Complete Response (CR), Partial Response (PR), Stable Disease (SD), Progressive disease (PD) and Unknown status. CR: disappearance of all enhancing lesions, stable or improved non-enhancing lesions, and stable or improved clinically. PR: \>= 50% decrease in sum of perpendicular diameters of all measurable enhancing lesions, no progression of non-measurable disease, stable or improved non- enhancing lesions, and stable or improved clinically. PD: \> 25% increase in sum of perpendicular diameters of all measurable enhancing lesions, significant increase of non-enhancing lesions, any new lesions, clear clinical deterioration, failure to return for evaluation due to death or deteriorating condition. SD: d |
| AMG 386 Maximum Tolerated Dose (MTD) [Cohort B Phase I] | Participants were assessed weekly while on study; the observation period for MTD evaluation was the first 28 days of study treatment. | The MTD of weekly AMG 386 intravenously (IV) in combination with bevacizumab 10 mg/kg intravenously (IV) on days 1 and 15 of each 28 day cycle is determined by the number of participants who experience a dose limiting toxicity (DLT). See subsequent primary outcome measure for the DLT definition. The MTD is defined as the highest dose at which fewer than one-third of patients experience a DLT. If no DLTs are observed, the MTD is not reached but the highest dose received may be the Recommended Phase II Dose (RP2D). |
| AMG 386 Dose Limiting Toxicity (DLT) [Cohort B Phase I] | Participants were assessed weekly while on study; the observation period for DLT evaluation was the first 28 days of study treatment. | A DLT is defined as an adverse event that (a) is related to the AMG 386 and/or bevacizumab with an attribution of possible, probable, or definite, and (b) occurs during and/or begins during the first 28 days of the study treatment, and (c) meets any of the following criteria: \>= grade 3 thrombocytopenia; grade 4 neutropenia lasting \> 7 days; grade 4 anemia lasting \> 7 days despite transfusion or growth factors; febrile neutropenia if ANC\<0.5x10\^9/L; clinically significant grade 3 non-hematologic toxicity despite maximal medical therapy lasting \> 7 days, with the exception of grade 3 proteinuria which was considered a DLT if lasting \> 14 days; grade 3 non-hematologic toxicity resulting in study drug discontinuation; grade 4 non-hematologic toxicity; \>= grade 1 new CNS hemorrhage; \>= grade 2 non-CNS hemorrhage. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Best Radiographic Response [Cohort A and Cohort B] | Disease was assessed radiographically for response every 8 weeks. | Radiographic response was established based on Response Assessment in Neuro-Oncology (RANO) criteria (Wen et al JCO 2010) with 5 potential categories: Complete Response (CR), Partial Response (PR), Stable Disease (SD), Progressive disease (PD) and Unknown status. CR: disappearance of all enhancing lesions, stable or improved non-enhancing lesions, and stable or improved clinically. PR: \>= 50% decrease in sum of perpendicular diameters of all measurable enhancing lesions, no progression of non-measurable disease, stable or improved non- enhancing lesions, and stable or improved clinically. PD: \> 25% increase in sum of perpendicular diameters of all measurable enhancing lesions, significant increase of non-enhancing lesions, any new lesions, clear clinical deterioration, failure to return for evaluation due to death or deteriorating condition. SD: does not qualify for CR, PR or PD, stable non-enhancing lesions, and stable clinically. |
| Overall Survival (OS) [Cohort A and Cohort B] | Participants were followed long-term for survival every 3 to 4 months from the end of treatment until death or lost to follow-up. On Cohort A and B participants were followed up to 554 days and 442 days. | OS based on Kaplan-Meier is defined as the time from study entry to death or date last known alive. |
| Progression-Free Survival (PFS) [Cohort A and Cohort B] | Disease was assessed radiographically to document clinical progression every cycle on treatment and post-treatment every 8 weeks. On Cohort A and B participants were followed for progression up to 36 days and 166 days. | PFS based on Kaplan-Meier is defined as the time from study entry to the earliest documentation of disease progression or death. Progressive disease was established based on Response Assessment in Neuro-Oncology (RANO) criteria (Wen et al JCO 2010). |
Countries
United States
Participant flow
Recruitment details
As of August 1, 2013, Cohort A was closed to new accrual following early interim analysis of first 10 participants enrolled on study showed insufficient efficacy per design.
Participants by arm
| Arm | Count |
|---|---|
| Cohort B: AMG 386 + Bevacizumab All Phase I & II Cohort B participants received bevacizumab 10 mg/kg intravenously (IV) on days 1 and 15 of each 28 day cycle and the assigned AMG 386 dose of 15 mg/kg or 30 mg/kg intravenously (IV) on days 1, 8, 15 and 22. Participants were treated until disease progression or unacceptable toxicity. | 37 |
| Cohort A: AMG 386 30 mg/kg All cohort A participants received AMG 386 intravenously (IV) at 30 mg/kg on days 1, 8, 15 and 22 of each 28 day cycle. Participants were treated until disease progression or unacceptable toxicity. | 11 |
| Total | 48 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 | FG002 | FG003 | FG004 |
|---|---|---|---|---|---|---|
| Overall Study | Adverse Event | 0 | 0 | 0 | 1 | 1 |
| Overall Study | Lack of Efficacy | 8 | 2 | 7 | 24 | 33 |
| Overall Study | Participant Non-Compliance | 0 | 0 | 0 | 1 | 1 |
| Overall Study | Withdrawal by Subject | 3 | 1 | 0 | 1 | 2 |
Baseline characteristics
| Characteristic | Cohort B: AMG 386 + Bevacizumab | Cohort A: AMG 386 30 mg/kg | Total |
|---|---|---|---|
| Age, Continuous | 63 years | 62 years | 62 years |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants | 1 Participants | 1 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 35 Participants | 10 Participants | 45 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 2 Participants | 0 Participants | 2 Participants |
| Number of Prior Relapses 1 | 23 participants | 8 participants | 31 participants |
| Number of Prior Relapses 2 | 14 participants | 2 participants | 16 participants |
| Number of Prior Relapses 3 | 0 participants | 1 participants | 1 participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) More than one race | 1 Participants | 1 Participants | 2 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 1 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) White | 35 Participants | 10 Participants | 45 Participants |
| Sex: Female, Male Female | 11 Participants | 5 Participants | 16 Participants |
| Sex: Female, Male Male | 26 Participants | 6 Participants | 32 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 30 / 37 | 8 / 11 |
| serious Total, serious adverse events | 5 / 37 | 0 / 11 |
Outcome results
Primary
6-Month Progression-Free Survival (PFS6) [Cohort A and Cohort B]
PFS6 is the proportion of patients remaining alive and progression-free at 6-months from study entry. Progressive disease was established based on Response Assessment in Neuro-Oncology (RANO) criteria (Wen et al JCO 2010). RANO criteria has 5 potential categories: Complete Response (CR), Partial Response (PR), Stable Disease (SD), Progressive disease (PD) and Unknown status. CR: disappearance of all enhancing lesions, stable or improved non-enhancing lesions, and stable or improved clinically. PR: \>= 50% decrease in sum of perpendicular diameters of all measurable enhancing lesions, no progression of non-measurable disease, stable or improved non- enhancing lesions, and stable or improved clinically. PD: \> 25% increase in sum of perpendicular diameters of all measurable enhancing lesions, significant increase of non-enhancing lesions, any new lesions, clear clinical deterioration, failure to return for evaluation due to death or deteriorating condition. SD: d
Time frame: 6 months
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| All Cohort B Participants: AMG 386 + Bevacizumab | 6-Month Progression-Free Survival (PFS6) [Cohort A and Cohort B] | 0.243 proportion of participants |
| Cohort A: AMG 386 30 mg/kg | 6-Month Progression-Free Survival (PFS6) [Cohort A and Cohort B] | 0 proportion of participants |
Primary
AMG 386 Dose Limiting Toxicity (DLT) [Cohort B Phase I]
A DLT is defined as an adverse event that (a) is related to the AMG 386 and/or bevacizumab with an attribution of possible, probable, or definite, and (b) occurs during and/or begins during the first 28 days of the study treatment, and (c) meets any of the following criteria: \>= grade 3 thrombocytopenia; grade 4 neutropenia lasting \> 7 days; grade 4 anemia lasting \> 7 days despite transfusion or growth factors; febrile neutropenia if ANC\<0.5x10\^9/L; clinically significant grade 3 non-hematologic toxicity despite maximal medical therapy lasting \> 7 days, with the exception of grade 3 proteinuria which was considered a DLT if lasting \> 14 days; grade 3 non-hematologic toxicity resulting in study drug discontinuation; grade 4 non-hematologic toxicity; \>= grade 1 new CNS hemorrhage; \>= grade 2 non-CNS hemorrhage.
Time frame: Participants were assessed weekly while on study; the observation period for DLT evaluation was the first 28 days of study treatment.
Population: All phase I Cohort B participants who completed 28 days on study treatment were evaluable. A participant was replaceable if they are taken off of study treatment due to progressive disease or withdrawal from study during before they completed the 28 day DLT period.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| All Cohort B Participants: AMG 386 + Bevacizumab | AMG 386 Dose Limiting Toxicity (DLT) [Cohort B Phase I] | 0 participants |
| Cohort A: AMG 386 30 mg/kg | AMG 386 Dose Limiting Toxicity (DLT) [Cohort B Phase I] | 0 participants |
Primary
AMG 386 Maximum Tolerated Dose (MTD) [Cohort B Phase I]
The MTD of weekly AMG 386 intravenously (IV) in combination with bevacizumab 10 mg/kg intravenously (IV) on days 1 and 15 of each 28 day cycle is determined by the number of participants who experience a dose limiting toxicity (DLT). See subsequent primary outcome measure for the DLT definition. The MTD is defined as the highest dose at which fewer than one-third of patients experience a DLT. If no DLTs are observed, the MTD is not reached but the highest dose received may be the Recommended Phase II Dose (RP2D).
Time frame: Participants were assessed weekly while on study; the observation period for MTD evaluation was the first 28 days of study treatment.
Population: All phase I Cohort B participants who received at least one dose of the study drug were evaluable for MTD. A participant was replaceable if they are taken off of study treatment due to progressive disease or withdrawal from study during before they completed the 28 day DLT period.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| All Cohort B Participants: AMG 386 + Bevacizumab | AMG 386 Maximum Tolerated Dose (MTD) [Cohort B Phase I] | 30 mg/kg intravenously on days 1 and 15 |
| Cohort A: AMG 386 30 mg/kg | AMG 386 Maximum Tolerated Dose (MTD) [Cohort B Phase I] | 30 mg/kg intravenously on days 1 and 15 |
Secondary
Best Radiographic Response [Cohort A and Cohort B]
Radiographic response was established based on Response Assessment in Neuro-Oncology (RANO) criteria (Wen et al JCO 2010) with 5 potential categories: Complete Response (CR), Partial Response (PR), Stable Disease (SD), Progressive disease (PD) and Unknown status. CR: disappearance of all enhancing lesions, stable or improved non-enhancing lesions, and stable or improved clinically. PR: \>= 50% decrease in sum of perpendicular diameters of all measurable enhancing lesions, no progression of non-measurable disease, stable or improved non- enhancing lesions, and stable or improved clinically. PD: \> 25% increase in sum of perpendicular diameters of all measurable enhancing lesions, significant increase of non-enhancing lesions, any new lesions, clear clinical deterioration, failure to return for evaluation due to death or deteriorating condition. SD: does not qualify for CR, PR or PD, stable non-enhancing lesions, and stable clinically.
Time frame: Disease was assessed radiographically for response every 8 weeks.
Population: All participants who received at least one dose of the study drug were evaluable for response.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| All Cohort B Participants: AMG 386 + Bevacizumab | Best Radiographic Response [Cohort A and Cohort B] | Partial Response | 4 participants |
| All Cohort B Participants: AMG 386 + Bevacizumab | Best Radiographic Response [Cohort A and Cohort B] | Progressive Disease | 10 participants |
| All Cohort B Participants: AMG 386 + Bevacizumab | Best Radiographic Response [Cohort A and Cohort B] | Stable Disease | 20 participants |
| All Cohort B Participants: AMG 386 + Bevacizumab | Best Radiographic Response [Cohort A and Cohort B] | Unknown | 3 participants |
| All Cohort B Participants: AMG 386 + Bevacizumab | Best Radiographic Response [Cohort A and Cohort B] | Complete Response | 0 participants |
| Cohort A: AMG 386 30 mg/kg | Best Radiographic Response [Cohort A and Cohort B] | Unknown | 2 participants |
| Cohort A: AMG 386 30 mg/kg | Best Radiographic Response [Cohort A and Cohort B] | Complete Response | 0 participants |
| Cohort A: AMG 386 30 mg/kg | Best Radiographic Response [Cohort A and Cohort B] | Partial Response | 0 participants |
| Cohort A: AMG 386 30 mg/kg | Best Radiographic Response [Cohort A and Cohort B] | Stable Disease | 1 participants |
| Cohort A: AMG 386 30 mg/kg | Best Radiographic Response [Cohort A and Cohort B] | Progressive Disease | 8 participants |
Secondary
Overall Survival (OS) [Cohort A and Cohort B]
OS based on Kaplan-Meier is defined as the time from study entry to death or date last known alive.
Time frame: Participants were followed long-term for survival every 3 to 4 months from the end of treatment until death or lost to follow-up. On Cohort A and B participants were followed up to 554 days and 442 days.
Population: All participants who received at least one dose of the study drug were followed for OS.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| All Cohort B Participants: AMG 386 + Bevacizumab | Overall Survival (OS) [Cohort A and Cohort B] | 285 days |
| Cohort A: AMG 386 30 mg/kg | Overall Survival (OS) [Cohort A and Cohort B] | 341 days |
Secondary
Progression-Free Survival (PFS) [Cohort A and Cohort B]
PFS based on Kaplan-Meier is defined as the time from study entry to the earliest documentation of disease progression or death. Progressive disease was established based on Response Assessment in Neuro-Oncology (RANO) criteria (Wen et al JCO 2010).
Time frame: Disease was assessed radiographically to document clinical progression every cycle on treatment and post-treatment every 8 weeks. On Cohort A and B participants were followed for progression up to 36 days and 166 days.
Population: All participants who received at least one dose of the study drug were evaluable for PFS.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| All Cohort B Participants: AMG 386 + Bevacizumab | Progression-Free Survival (PFS) [Cohort A and Cohort B] | 108 days |
| Cohort A: AMG 386 30 mg/kg | Progression-Free Survival (PFS) [Cohort A and Cohort B] | 21 days |