Glioblastoma
Conditions
Keywords
Glioblastoma, Neodjuvant Radiotherapy, Ultrahypofractionated Radiotherapy, Stereotactic Radiotherapy (SRT), Simultaneous Integrated Boost (SIB), Image Guidance
Brief summary
This is a prospective multicenter study of hypofractionated radiotherapy for the radiation treatment (RT) of solid tumors and in particular for Glioblastoma (in Aim 2). It is based on the results of ongoing studies at our Institute to validate the efficacy of extremely hypofractionated RT in neoadjuvant settings, which observed immunostimulatory effects of RT and the synergy with immune components. The collaboration between San Raffaele Hospital (Milan), the IRCCS Istituto Nazionale dei Tumori Fondazione G. Pascale (Naples) and the San Giuseppe Moscati Hospital of National Relief and High Specialty (Avellino) will ensure that patient recruitment, treatment and monitoring can be translated into facilities of the National Health System using common procedures. The various departments involved will treat patients with the same methods synergistically exploring the immuno/biological factors related to efficacy (and/or toxicity), based on new radioimmunotherapeutic approaches. Clinical and research activity will be developed jointly, drawing on the expertise in radiotherapy, radiomics, oncology, imaging and immunotherapy skills already available.
Detailed description
This is a prospective multicenter pilot study. Functional and spectroscopic neuroradiological imaging will be adopted for treatment planning. Specialized software will be used to perform radiomic feature extraction and analysis of pre-trained neural networks from the advanced MRI (magnetic resonance imaging) and CT (computed tomography) used for simulation, to identify distribution patterns of aggressive and radioresistant disease areas, with higher probability of disease recurrence, and to intensify the dose on the areas identified as more aggressive, in order to counteract intrinsic radioresistance. The hypofractionated radiotherapy paradigm claims the benefit of reduced treatment times, improved quality of life, better access to specialized treatment centers and potentially improved tumor outcomes with greater disease control and less tumor repopulation. The rationale for neoadjuvant RT is based on the idea of counteracting the tumor's aggressive mechanisms with radiotherapy before the disease is surgically removed, in order to maximize the immunostimulatory potential of RT, and therefore reduce recurrences. Neoadjuvant treatment offers numerous advantages, first of all the ability to adjust the dose to the pathological volume identified by MRI and limit the volume of irradiated healthy brain tissue. Furthermore, the use of imaging derived from functional neuroradiological and spectroscopic techniques for treatment planning would allow us to increase the dose on the areas identified as more aggressive, in order act against intrinsic radioresistance. One of the major risks could be the possibility of developing radionecrosis, but this would not be a cause for concern in the neoadjuvant setting, as all irradiated tissue will then be surgically removed. Patients who agree to participate in the study and who would be candidates for radical surgical treatment, according to the evaluation of the Neurosurgery Department of our Institute, will be treated. These patients will receive neoadjuvant radiation treatment in 5 fractions delivering 30 Gy on PTV and 35-50 Gy on GTV, with a dose-escalation modality that involves increasing the dose to 35-40-42.5-45-47.5-50 Gy in groups of 5 consecutive patients, using standard chemotherapy (TMZ) after surgery. Current diagnostic brain MRI allows a good definition of the initial disease and its most aggressive areas. Since relapses have always been found to occur in irradiated areas and recent studies have shown that reducing margins does not affect overall survival, smaller margins will be used from GTV to CTV and from CTV to PTV. Therefore, smaller volumes will be generated and treated with hypofractionation. Biological equivalent doses (BED) to the standard prescription will be delivered, with boost to a higher biological equivalent dose, in the most aggressive areas, in order to obtain better local control, maintaining an acceptable level of toxicity and therefore improve the evolution of the disease. CE marked devices (software) will be used according to the approved use, for the definition of the target (CT and MRI) and for the delivery of the treatment (linear accelerators) and the standard drug, which has the authorization for marketing, will be prescribed. Radiomic features related to local response and survival will be identified, to obtain a predictive model. At the same time, we will collect PMBC and patient serum in the biobank to identify presumed immunocorrelated of therapy efficacy and/or predictive biomarkers of response/toxicity to therapy. For comparative purposes, serum from healthy volunteers will also be collected, in numbers equivalent to patients and with sex and age characteristics comparable to the latter.
Interventions
RADIATIONNeoaddjuvant Stereotactic Radiotherapy with Simultaneous Integrated Boost
Patients with Glioblastoma will receive neoadjuvant stereotactic radiotherapy to Planning Target Volume (PTV) to 30 Gy in 5 fractions, and a Simultaneous Integrated Boost delivering 35-50 GY to GTV. Patients will be divided into groups of 5 and will receive (in the absence of 2 G4 toxicities per group), the following dose levels: 35-40-42.5-45-47.5 and 50 Gy. Standard Temozolomide chemotherapy will be prescribed after surgery.
Sponsors
European Commission
Istituto Nazionale Tumori IRCCS - Fondazione G. Pascale
Azienda Ospedaliera di Rilievo Nazionale e di Alta Specialità San Giuseppe Moscati (Avellino)
IRCCS San Raffaele
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
This is study of feasibility in terms of toxicity of a dose escalation radiotherapy procedure, with 5 patients at each dose level, on 30 patients. The dose will be increased, moving to the next 5 patients, if no more than 1 acute toxicity of grade (G) 4 will be registered. The assumption is that the percentage of patients free from cumulative acute toxicity G≥3 (Common Terminology Criteria of Adverse Events-CTCAE- v5.0 scale) at 1 month after the end of treatment should not exceed 30%. A sample size of 30 patients results in a two-sided 95% confidence interval with a width of 0.328 (0.136-0.464) when the sample proportion is 0.300. Dropouts will be replaced by patients visited later, so as to reach the expected sample. Serum from 30 healthy volunteers, with sex and age characteristics comparable to the patients, will be collected to compare the level of immune biomarkers.
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Healthy volunteers
Yes
Inclusion criteria
* Diagnosis of Glioblastoma. * ECOG performance score 0-2 (defined during the first visit) * Surgically removable lesion (according to the operability criteria established by the Neurosurgery Unit) For healthy volunteers, people who are as comparable as possible with the patient population in terms of sex and age will be recruited
Exclusion criteria
* Previous stroke * Presence of another primary and/or metastatic tumor For healthy volunteers also, absence of primary and/or metastatic tumor
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Acute toxicity | one month | Incidence of acute toxicity of grade 3 or 4 as maximum toxicity value during the radiation treatment or in any case within a month of the end of SBRT, using Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 scale (toxicity from 0- patients without toxicity to 5-death from toxicity) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Disease Free Survival | From the date of radiotherapy end until the date of first documented clinical progression or date of death from any cause, whichever came first, assessed up to 36 months] | Absence of disease progression during the follow-up |
| Cancer Specific Survival | From the date of radiotherapy end until the date of first documented clinical progression or date of death from any cause, whichever came first, assessed up to 36 months] | Death from disease progression during the follow-up |
| Overall survival | From the date of radiotherapy end until the date of death from any cause, assessed up to 36 months | Survival from all causes |
| Local Relapse Free Survival | From the date of radiotherapy end until the date of local progression or date of death from any cause, whichever came first, assessed up to 36 months | Local control of the disease (at the treated site) |
| Intracranial Relapse Free Survival | From the date of radiotherapy end until the date of local progression or date of death from any cause, whichever came first, assessed up to 36 months | Intracranial control of the disease (glioblastoma recurrence outside the treatment field) |
| Extracranial Relapse Free Survival | From the date of radiotherapy end until the date of local progression or date of death from any cause, whichever came first, assessed up to 36 months | Distant metastases |
| Incidence of Treatment-Emergent Adverse Events as assessed with mental status questionnaires | 36 months | Survey with the questionnaire Mini Mental Status Examination (MMSE). A score of 24-30 indicates normal abilities, while a lower score indicates cognitive deficit. |
| Periferic mononuclear blood cells (PMBC) subtypes predictive for disease progression and death | Form the start of radiotherapy up to 6 months | Identification of immune prognostic factors, studying lymphocyte subpopulations and their impact on the results obtained. |
| Late toxicity | From three months after the start of radiotherapy until the end of follow-up or death, assessed up to 36 months | Toxicity developed after three months until the end of follow-up or death, assessed with Common Terminology Criteria for Adverse Events (CTCAE) v5.0 scale, assessed with Common Terminology Criteria for Adverse Events (CTCAE) v5.0 scale, which displayes grades from 1 to 5, with grade 1 meaning mild toxicity and grade 5 death related to toxicity |
| Subacute Toxicity | From one up to three months after the start of radiotherapy | Incidence of acute toxicity of grade 3 or 4 as maximum toxicity value registered from one to three months of the end of SBRT, using Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 scale (toxicity from 0- patients without toxicity to 5-death from toxicity) |
| Incidence of Treatment-Emergent Adverse Events as assessed with brain tumor specific quality of life questionnaires | 36 months | Survey with the questionnaire of European Organisation for Research and Treatment of Cancer (EORTC) Quality of life of brain tumor patients (EORTC QLQ BN20) which contains 25 questions on patients' quality of life with answers from 1, lowest grade, to 4, highest grade |
| Incidence of Treatment-Emergent Adverse Events as assessed with functional-social- emotional and general well being questionnaires | 36 months | Survey with the questionnaire FACT-Br on patients' quality of life with answers from 0, lowest grade, to 4, highest grade |
Other
| Measure | Time frame | Description |
|---|---|---|
| Predictive factors for disease progression and death | From radiotherapy end to date of local, regional progression, distant failure, or death, assessed up to 36 months | To identify potential risk factors, the association of clinical and radiation treatment factors with survival outcomes will be estimated using survival trees, univariate/multivariate Cox regression models |
| Radiomics | 36 months | Evaluation of radiomic characteristics: Mathematical extraction of the spatial distribution of signal intensities and pixel interrelationships of medical images of the patients, to quantify textural information resampled according to International Biomarker Standardization Initiative (IBSI). |
Countries
Italy
Contacts
Primary ContactNadia G Di Muzio, Prof
Backup ContactAndrei Fodor, MD
Outcome results
None listed