A Prospective Pivotal Study to Evaluate the Efficacy and Safety of Avastin® Bevacizumab (BEV) With or Without Microbubble-mediated Focused Ultrasound (FUS-MB) Using NaviFUS System in Recurrent Glioblastoma Multiforme Patients

Official title

A Prospective, Randomized, Standard of Care Controlled, Parallel, Open-Label, Multicenter Pivotal Study to Evaluate the Efficacy and Safety of Avastin® in Combination With NaviFUS System Compared With Avastin® Alone for the Treatment of Recurrent Glioblastoma Multiforme (rGBM)

Overview

This will be a prospective, randomized, standard of care (SoC) controlled, parallel, open-label, multicenter pivotal study to investigate the efficacy and safety of Bevacizumab (BEV) in combination with or without microbubble (MB)-mediated FUS in patients with recurrent GBM. BEV represents the physician's best choice for the standard of care in rGBM after previous treatment with surgery (if appropriate), standard radiotherapy with temozolomide chemotherapy, and with adjuvant temozolomide.

Detailed description

The study aims to compare the efficacy of combining Bevacizumab with NaviFUS System relative to Bevacizumab alone in patients with rGBM who have previously undergone radiotherapy and temozolomide chemotherapy.

Any patient with a histological diagnosis of GBM who meets all of the specific eligibility criteria may participate in this study by signing informed consent in person or through their legal representative. Eligible patients will undergo a 2-week baseline observation screening period.

Up to 32 evaluable patients will be recruited in this study. Eligible patients will be randomized in a 1:1 ratio, with one group receiving the standard of care (SoC) BEV alone and the other group receiving treatment with microbubble-mediated FUS treatment in addition to BEV (FUS-MB+BEV).

Eligible patients who assigned to the SoC group will follow the standard operating procedures of BEV (10 mg/kg intravenous (IV) infusion over 30-90 minutes). On the other hand, eligible patients assigned to treatment group will initially receive the same BEV schedule. After at least 30 minutes, patients will be administered microbubbles (MB) (SonoVue® ) at a dose of 0.1 mL/kg, along with optimal ultrasound exposure doses determined by the acoustic emission feedback FUS power control algorithm of the NaviFUS System. The treatment will be administered every 2 weeks up to 34 weeks or until evidence of progression disease (PD), intolerable toxicity precluding further treatment, non- compliance with study follow-up, or withdrawal of consent, whichever occurs first.

Interventions

• Drug Bevacizumab
  An anti-angiogenic agent to block tumor growth
• Drug Microbubble
  Open the Blood-Brain Barrier (BBB) using focused ultrasound and microbubble
• Device Low-Intensity Focused Ultrasound
  Open the Blood-Brain Barrier (BBB) using focused ultrasound and microbubble

Primary outcome measures

• 6-month progression-free survival (PFS-6) of Bevacizumab (BEV) with or without microbubble-mediated focused ultrasound (FUS-MB) using NaviFUS System [Time frame: Up to 6 months]

Secondary outcome measures (12)

• 12-month progression-free survival (PFS-12) [Time frame: Up to 12 months]
• Progression-free survival time (PFS) [Time frame: Up to 62 weeks]
• One- and Two-year survival rates [Time frame: Up to 12 and 24 months]
• Overall survival (OS) [Time frame: Up to 36 months]
• Objective response rate (ORR) [Time frame: Up to 62 weeks]
• Clinical benefit rate (CBR) [Time frame: Up to 62 weeks]
• Local disease control on the MRI Images [Time frame: Up to 62 weeks]
• Corticosteroid consumption [Time frame: Up to 62 weeks]
• European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ-C30) [Time frame: Up to 62 weeks]
• European Organization for Research and Treatment of Cancer (EORTC) brain cancer questionnaire (QLQ-BN20, assessment specific to brain neoplasm) [Time frame: Up to 62 weeks]
• Severity and frequency of treatment-related adverse events (AEs) [Time frame: Up to 62 weeks]
• Karnofsky performance status (KPS) [Time frame: Up to 62 weeks]

Eligibility criteria

Inclusion criteria

• Male or female patients ≥ 18 years of age at the time of study enrollment.
• Body mass index (BMI) ≥ 17 kg/m2.
• Patients diagnosed with glioblastoma must have unequivocal evidence of recurrence, as determined by contrast-enhanced magnetic resonance imaging (CE-MRI), following prior radiotherapy and temozolomide chemotherapy.
• Patients may have undergone surgery for recurrence. The patients should have completed surgery and adequately recovered prior to the time of study enrollment.
• Patients must have radiographic evidence of either at least an 80% resection of enhancing tumor following recurrence or a maximal measurable residual tumor ≤ 20 cm3.
• If patients are receiving corticosteroids, they must have been on a stable or decreasing dose of corticosteroids for at least 1 week prior to the planned first treatment.
• At the time of study enrollment, the minimum interval since the last event:

• 4 weeks out from invasive procedures (e.g., open biopsy, surgical resection, significant traumatic injury, or any other major surgery involving entry into a body cavity) and the patient must have recovered from the effects of surgery
• 1 week out from minor surgical procedures or core biopsies
• Patients must have recovered from the toxic effects of prior therapy at the time of study enrollment as follows:

• 4 weeks out from any investigational drug or device
• 4 weeks out from chemotherapy
• 6 weeks since the completion of a nitrosourea-containing chemotherapy regimen (e.g., Carmustine (BCNU))
• 12 weeks out from completion of radiotherapy
• Patients should have a life expectancy ≥ 12 weeks.
• Patients must have Karnofsky Performance Status (KPS) ≥ 70.
• Adequate hematopoietic, renal, hepatic, and coagulation function, defined as:

• Hemoglobin ≥ 10 g/dL
• Platelets ≥ 100,000/mm3
• Neutrophils ≥ 1,500/mm3
• Serum creatinine ≤ 1.5 × upper limit of normal (ULN)
• Urine protein creatinine ratio (UPCR) < 1 or urine dipstick for proteinuria ≤ 2+
• Alanine aminotransferase (ALT) < 3 × ULN
• Aspartate aminotransferase (AST) < 3 × ULN
• Total bilirubin (TBL) < 2 × ULN
• Prothrombin time ≤ 1.5 x ULN
• International Normalized Ratio (INR) < 1.5 These tests must be conducted within 2 weeks prior to the planned first treatment.
• The central of FUS exposure region is located with a minimum distance of at least 30 mm beneath the skull bone.
• Females of childbearing potential must have a negative pregnancy test documented within 2 weeks prior to first treatment. Females of childbearing potential and male patients with partners of childbearing potential must agree to adhere to an acceptable method of contraception (as outlined below) from prior to the first study treatment until at least 6 months after the completion of last treatment. Standard acceptable methods of contraception include the use of highly effective methods such as hormonal contraception, diaphragm, cervical cap, vaginal sponge, condom, spermicide, vasectomy, intrauterine device, or abstinence from sexual activity.
• Patients are able and willing to have peripheral intravenous (IV) line placement of Bevacizumab and are able to have hair shaved (either whole head or in the region where the coupling membrane will touch) prior to FUS treatment if assigned to treatment group.
• Patients or their legal representatives are able to provide written informed consent for participation in the trial and patients are willing to comply the procedures (i.e., study-related assessments), instructions, and restrictions outlined in this study in the duration of the study. Informed consent should also be given for biological materials and diagnostic imaging to be stored and used for future research on brain tumors.

Exclusion criteria

• Patients who have radiographic evidence of multifocal enhancing tumors.
• Patients who have undergone previous treatment with anti-angiogenic therapy, including Bevacizumab, or other VEGF inhibitors or VEGF-receptor signaling inhibitors.
• Patients who have previously received Carmustine wafers implantation during re-operation.
• Patients who have previously received or are currently undergoing tumor treating fields (TTF) treatment.
• Uncontrolled or significant cardiovascular disease, including any of the following:

• New York Heart Association (NYHA) Grade II or above congestive heart failure (CHF) within 12 months prior to study enrollment
• Unstable angina pectoris
• Medical history of myocardial infarction within 6 months prior to study enrollment
• Cardiac shunt
• Stroke (except for transient ischemic attack; TIA) within 6 months prior to study enrollment.
• Patients with implanted electronic device, for example, implanted cardioverter-defibrillator (ICD), cardiac pacemaker, permanent medication pumps, cochlear implants, responsive neurostimulator (RNS), deep brain stimulation (DBS), or other electronic devices implanted in the brain. Patients with contraindications for MRI as judged by Investigator, including non-MRI compatible metallic implant(s).
• Patients with inadequately controlled hypertension, defined as systolic blood pressure > 150 mmHg and/or diastolic blood pressure > 100 mmHg while on medication, within 2 weeks prior to first treatment.
• Patients with evidence of any thrombotic or hemorrhagic events, including but not limited to:

• Inherited bleeding diathesis or significant coagulopathy with the risk of bleeding (i.e., in the absence of therapeutic anticoagulation).
• History of pulmonary haemorrhage/haemoptysis ≥ grade 2 according to the CTCAE version 5.0 criteria within 1 month prior to study enrollment
• Arterial or venous thrombosis (e.g., pulmonary embolism) within 3 months prior to study enrollment
• Patients with unstable pulmonary disease or chronic obstructive pulmonary disease (COPD) exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at the time of study enrollment.
• Patients who have psychiatric illness/social situations that would limit compliance with study requirements.
• Known HIV-positive patient, however, that HIV testing is not required for entry into this study.
• Acute bacterial or fungal infection requiring intravenous antibiotics at the time of study enrollment.
• History or evidence of active gastroduodenal ulcer, gastrointestinal perforations/fistula, or intra-abdominal abscess within 6 months prior to study enrollment.
• Receiving anticoagulant (e.g., warfarin or LMW heparin) or antiplatelet (e.g., aspirin) therapy within 1 week prior to beginning treatment.
• Known sensitivity/allergy to Magnetic Resonance Imaging (MRI) contrast agents, Computer Tomography (CT) contrast agents, SonoVue®, Bevacizumab, or any of their components.
• Pregnant (positive pregnancy test) or breast-feeding women.
• Use of any recreational drugs or history of drug addiction.
• Other severe concurrent and/or uncontrolled concomitant medical conditions (e.g., active or uncontrolled infection, uncontrolled epilepsy, uncontrolled diabetes) that could cause unacceptable safety risks or compromise compliance with the protocol.
• Any other condition that, in the Investigator's discretion, might increase the risk to the patients or compromise the evaluation of the clinical trial endpoints.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Single blind

Primary purpose

Treatment

Study locations

Taiwan · 2 centers

• National Taiwan University Hospital — Taipei
• Linkou Chang Gung Memorial Hospital — Taoyuan

Publications

• Chen KT, Tsai HC, Huang CY, Liau CT, Ho KC, Toh CH, Chuang CC, Hsu PW, Huang YC, Chang TW, Yeap MC, Chen PY, Lee CC, Lin YJ, Feng LY, Airan RD, Li G, Lim M, Liu HL, Wei KC. Combination of Neuronavigation-Guided Focused Ultrasound and Bevacizumab for Patients With Recurrent Glioblastoma: A Pilot Study. Neurosurgery. 2026 Jul 1;99(1):149-159. doi: 10.1227/neu.0000000000003851. Epub 2025 Nov 24. PMID 41283685
• Liu HL, Hua MY, Chen PY, Chu PC, Pan CH, Yang HW, Huang CY, Wang JJ, Yen TC, Wei KC. Blood-brain barrier disruption with focused ultrasound enhances delivery of chemotherapeutic drugs for glioblastoma treatment. Radiology. 2010 May;255(2):415-25. doi: 10.1148/radiol.10090699. PMID 20413754
• Wei KC, Chu PC, Wang HY, Huang CY, Chen PY, Tsai HC, Lu YJ, Lee PY, Tseng IC, Feng LY, Hsu PW, Yen TC, Liu HL. Focused ultrasound-induced blood-brain barrier opening to enhance temozolomide delivery for glioblastoma treatment: a preclinical study. PLoS One. 2013;8(3):e58995. doi: 10.1371/journal.pone.0058995. Epub 2013 Mar 19. PMID 23527068
• Liu HL, Hsu PH, Lin CY, Huang CW, Chai WY, Chu PC, Huang CY, Chen PY, Yang LY, Kuo JS, Wei KC. Focused Ultrasound Enhances Central Nervous System Delivery of Bevacizumab for Malignant Glioma Treatment. Radiology. 2016 Oct;281(1):99-108. doi: 10.1148/radiol.2016152444. Epub 2016 May 18. PMID 27192459
• Chen KT, Lin YJ, Chai WY, Lin CJ, Chen PY, Huang CY, Kuo JS, Liu HL, Wei KC. Neuronavigation-guided focused ultrasound (NaviFUS) for transcranial blood-brain barrier opening in recurrent glioblastoma patients: clinical trial protocol. Ann Transl Med. 2020 Jun;8(11):673. doi: 10.21037/atm-20-344. PMID 32617293
• Chen KT, Chai WY, Lin YJ, Lin CJ, Chen PY, Tsai HC, Huang CY, Kuo JS, Liu HL, Wei KC. Neuronavigation-guided focused ultrasound for transcranial blood-brain barrier opening and immunostimulation in brain tumors. Sci Adv. 2021 Feb 5;7(6):eabd0772. doi: 10.1126/sciadv.abd0772. Print 2021 Feb. PMID 33547073

Identifiers

NCT: NCT06496971 · NF-2023-01

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗