Human stem cell-derived neuron

A dose escalation and expansion study of sonodynamic therapy in recurrent or progressive glioblastoma multiforme


Aminolevulinic acid sonodynamic therapy (ALA SDT) is a non-invasive combination therapy that uses a MRI-guided focused ultrasound system to activate SONALA-001, a small-molecule prodrug of protoporphyrin IX (PpIX). The activation of PpIX induces necrosis and apoptosis directly in the glioma tissue. This is a phase 1/2a study to assess the safety, dose-limiting toxicities, recommended Phase 2 schedule, and preliminary efficacy of ALA SDT in patients with recurrent or progressive GBM.

Inclusion Criteria
  1. Must be 18 years or older at screening visit.
  2. Histologically proven, primary (de novo) GBM, 2021 WHO Classification of Tumors of the Central Nervous System, (Louis et al. 2021) that has recurred or progressed (first or second recurrence, including this recurrence) and resection not indicated.
  3. A single recurrent or progressing tumor that must be supratentorial, contrast-enhancing, and bi-dimensionally measurable that is 5 mL to 30 mL in volume, based on MRI within 14 days prior to Day 1.
  4. Previous first-line treatment with at least standard-of-care radiotherapy and temozolomide (temozolomide required only if tumor has at least partial methylation of the O6-methylguanine-DNA methyltransferase promoter [MGMTp]). Temozolomide should be administered concurrent with RT and adjuvantly for newly diagnosed disease unless intolerant or ineligible for treatment.
  5. No recurrence within 12 weeks of completion of radiotherapy, defined from the imaging assessment immediately after completion or radiotherapy.
  6. Up to one prior systemic treatment for recurrent or progressing disease.
  7. If receiving corticosteroids, must be maintained on a stable or decreasing dosage of steroids for 7 days prior to the baseline MRI scan.
  8. If receiving corticosteroids, must be maintained on a stable or decreasing dosage of steroids for at least 7 days prior to Day 1.
  9. Karnofsky Performance Score (KPS) > 70.
  10. Must have adequate organ and marrow function as defined below:
    1. Absolute neutrophil count ≥ 1.5 × 109/L (1,500/μL), without the use of G-CSF within 7 days prior to Day 1 for short acting growth factors and 14 days for long-acting growth factors to meet eligibility.
    2. Platelets ≥ 75 × 109/L (100,000/μL), unsupported, defined as no platelet transfusion within 7 days prior to Day 1.
    3. Hemoglobin ≥ 9 g/dL, patients that require transfusion or growth factors need to demonstrate stable hemoglobin of ≥ 9 g/dL over at least a 7-day period immediately prior to Day 1.
    4. Total bilirubin ≤ 1.5 times institutional upper limit of normal (ULN), in patients with Gilbert syndrome, total bilirubin >1.5 ULN as long as direct bilirubin is normal.
    5. ALT (SGPT) less than 3 x institutional upper limit of normal.
    6. AST (SGOT) less than 3 x institutional upper limit of normal.
    7. Albumin ≥ 3 g/dl.
    8. Serum total calcium (correct for serum albumin) or ionized calcium ≥ LLN.
    9. Estimated creatinine clearance (CrCl) by the Cockcroft-Gault (C-G) equation or measured ≥ 60 mL/min. Actual body weight will be used for calculation of the Cockcroft-Gault equation. If estimated CrCl is abnormal, accurate measurement should be obtained by 24-hour urine collection to measure creatinine clearance.
  11. All colony-forming growth factor(s) (i.e., filgrastim, sargramostim or erythropoietin) must have been discontinued for at least 7 days prior to Day 1 or 14 days if PEG formulations were received.
  12. Have a life expectancy of at least 12 weeks.
  13. An understanding, ability, and willingness to fully comply with study procedures and restrictions.
  14. Ability to provide written, signed, and dated (personally or via a legally authorized representative) informed consent at screening as applicable to participate in the study.
  15. Females of childbearing potential (FOCP) must have a negative serum at screening. Patients of childbearing or child fathering potential must be willing to use highly effective birth control during the entire study. Acceptable forms of birth control include hormonal contraceptives (oral, injectable, transdermal, or intravaginal) or intrauterine device (IUD) for at least one week prior to study treatment, condom and spermicidal or diaphragm and spermicidal. Other acceptable forms of birth control include a) abstinence for patients who are not sexually active or b) if the subject is in a monogamous relationship with a partner who is sterile (e.g., vasectomy performed at least 6 months prior to subject’s first study treatment). Patients who become sexually active or begin to have relations with a partner who is not sterile during the trial must agree to use an effective form of birth control for the duration of the study. FOCP taking hormonal therapy must be on treatment for at least 12 weeks prior to Cycle 1 Day 1 and must not change their dosing regimen during the study.
Exclusion Criteria
  1. Secondary glioblastoma with IDH1 mutations (i.e., glioblastoma that progressed from low-grade diffuse astrocytoma or AA).
  2. Tumor in the brainstem (not including fluid-attenuated inversion recover [FLAIR] changes), an infratentorial tumor, diagnosis of gliomatosis cerebri (highly infiltrative T2 hyperintense tumor with ill-defined margins encompassing at least three lobes of the brain.
  3. Prior surgical resection for recurrent or progressed GBM.
  4. Patients who have not recovered to grade 1 or baseline from adverse events (CTCAE v 5.0, or most current) related to prior anticancer therapy excluding alopecia, lymphopenia, peripheral neuropathy, and ototoxicity, which are excluded only if ≥ grade 3.
  5. Prior systemic anticancer treatment (i.e., chemotherapy, biologic therapy [i.e., small molecular inhibitors], monoclonal antibodies, investigational agents]) within 21 days or 5 half-lives, whichever is shorter, prior to Day 1 or per below:
    1. Temozolomide (low-dose, continuous administration) within 28 days prior to Day 1.
    2. Nitrosoureas within 6 weeks prior to Day 1.
    3. If a subject is receiving an anti-PD-1 or anti-PD-L1 antibody on a shorter frequency, i.e., every two weeks, then the subject is eligible if last dose within 2 weeks prior to Day 1.
    4. Bevacizumab within 2 weeks prior to Day 1.
  6. Prior therapy that included interstitial brachytherapy or Gliadel® Wafers (carmustine implants) for newly diagnosed GBM within 12 weeks prior to Day 1. Patients treated with interstitial brachytherapy or Gliadel® Wafers at first recurrence are excluded.
  7. Optune therapy for newly diagnosed GBM within 3 weeks prior to Day 1. Patients treated with Optune therapy at first recurrence are excluded.
  8. Radiation therapy within 12 weeks prior to Day 1.
  9. Use of potentially phototoxic substances (e.g., St. John’s wort, griseofulvin, thiazide diuretics, sulfonylureas, phenothiazines, tetracyclines, sulfonamides, quinolones, hypericin extracts, topical preparations containing ALA) within 24 hours before and after SONALA-001 infusion.
  10. Use of herbal and fish oil supplements within 7 days prior to Day 1.
  11. Use of blood thinning agents within 7 days prior to Day 1.
  12. Prior major surgery within 3 weeks prior to Day 1. Major surgery is defined as any significantly invasive procedure into a major body cavity (abdomen, cranium etc.) and/or surgery requiring extensive recuperation (joint replacement). Please discuss with Medical Monitor if there are any questions.
  13. An Overall Skull Density Ratio of 0.45 (±0.05) or less as calculated from the screening non-contrast CT.
  14. Diagnosis of porphyria.
  15. Hypersensitivity against porphyrins.
  16. Known history of allergy to gadolinium contrast agents.
  17. Inability to undergo MRI (e.g., presence of a pacemaker).
  18. Malignant disease, other than that being treated in this study. Note: Patients with basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or carcinoma in situ (e.g., breast carcinoma, cervical cancer in situ) that have undergone potentially curative therapy are not excluded. Other exceptions include malignancies that were treated curatively and have not recurred within 2 years prior to Day 1 and any malignancy considered indolent and has never required therapy.
  19. Has a known history of Human Immunodeficiency Virus (HIV). Note: No HIV testing is required unless mandated by local health authority.
  20. Has a known history of Hepatitis B (defined as Hepatitis B surface antigen [HBsAg] reactive or known active Hepatitis C virus (defined as HCV RNA [qualitative] is detected) infection. Note: no testing for Hepatitis B and Hepatitis C is required.
  21. Significant acute deterioration in neurologic status within 7 days prior to Day 1, in the opinion of the investigator including but not limited to new onset seizures and/or increasing doses of corticosteroids.
  22. Uncontrolled concurrent illness including, but not limited to:
    1. ongoing or active infection
    2. transfusion dependent thrombocytopenia or anemia that prevent meeting hematological inclusion criteria
    3. psychiatric illness/social situations that would limit compliance with study requirements
  23. Clinically significant, uncontrolled heart disease and/or cardiac repolarization abnormality, including any of the following:
    1. Symptomatic congestive heart failure
    2. Unstable angina pectoris or cardiac arrhythmia
    3. Baseline QTcF (Fridericia) ≥ 470 milliseconds
    4. Long QT syndrome or family history of idiopathic sudden death or congenital long QT syndrome
  24. Pregnancy or breastfeeding.
  25. A known or underlying medical condition that, in the opinion of the investigator or Sponsor, could make the administration of study drug/treatment hazardous to the patient, or could adversely affect the ability of the patient to comply with or tolerate the study.
  26. Inability to participate in the opinion of the investigator, by being unwilling or unable to return for required follow-up visits or to obtain follow-up studies to assess toxicity to therapy or to adhere to study plan, procedures, and restrictions.

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