Sulfasalazine and Stereotactic Radiosurgery for Recurrent Glioblastoma

Glioblastoma Clinical Trial

— SAS-GKRS  

Official title:

Phase I Trial Combining Sulfasalazine and Gamma Knife Radiosurgery for Recurrent Glioblastoma

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT04205357
• Other study ID #: 2019/6834
• Status: Completed
• Phase: Phase 1
• Start date: March 1, 2020
• Est. completion date: October 14, 2022

Study information

• Verified date: March 2023
• Source: Haukeland University Hospital
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This study evaluates the safety associated with the addition of sulfasalazine to stereotactic radiosurgery for recurrent glioblastoma. Sulfasalazine is a potential tumor selective radiosensitizer.

Description:

Glioblastoma is the most aggressive and most common type of primary brain cancer. Standard treatment at diagnosis is surgery followed by high dose radiation therapy and chemotherapy. Despite initial treatment nearly all patients will experience recurrence of the tumor with a dismal prognosis. There is no consensus on standard of care at recurrence. Reoperation is associated with a high risk of complications and further conventional radiation therapy is often not possible as the maximum tolerated dose to the normal brain has already been given. In addition most tumors have developed resistance towards chemotherapy. Stereotactic radiosurgery (SRS) may be administered despite prior initial radiation treatment but in order to avoid radiation induced complications only limited doses to limited tumor volumes can be applied. Developing new strategies to improve the effect of radiation selectively on tumor cells without simultaneously increase the radiation induced damage of normal brain would be valuable. The investigators have shown in experimental studies that the drug sulfasalazine enhances the number of cancer cells that dies as result of radiation therapy and thereby improves survival in combination with SRS in animals with glioblastoma. Sulfasalazine inhibits the production of an antioxidant that normally protects the tumor against radiation. Hopefully the trial will result in a new and more effective treatment option for patients with recurrent glioblastoma.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 24
• Est. completion date: October 14, 2022
• Est. primary completion date: October 14, 2022
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Histologically verified glioblastoma multiforme with recurrence (first or second relapse, all subtypes) based on the Response Assessment in Neuro-Oncology criteria.
• Prior standard therapy for newly diagnosed glioblastoma consisting of surgery, standard fractionated radiotherapy to 60 Gy concomitant with Temozolomide
• Has been informed of other treatment options
• Must be eligible to gamma knife treatment
• Tumor size = 3 cm in diameter (= 15 cm3 ) on MRI dated no more than 30 days before SRS treatment
• Must be at least 18 years of age
• Must be ambulatory with a Karnofsky performance status of = 70
• Life expectancy > 12 weeks
• Laboratory parameters for vital functions should be in the normal reference range. Laboratory abnormalities that are not clinically significant are generally permitted, except for the following laboratory parameters, which must be within the ranges specified: Hematology: White blood cell count: = 3.0 x 109/l, Platelet count:: = 100 x 109/l, Hemoglobin: = 100 g/l, Total bilirubin level: <1.5 times the upper limit of normal (ULN) (except in patients with Gilbert's Syndrome who must have a total bilirubin less than 51,3 µmol/L), alanine aminotransferase < 3 times the ULN, Creatinine < 1.5 times the ULN, Normal prothrombin time / international normalized ratio (PT INR) < 1.4, Absolute neutrophil count: = 1 x109/L without the support of filgrastim.
• More than four weeks must have elapsed since any prior systemic therapy at the time the patient receives the preparative regimen, and patients' toxicities must have recovered to a grade 1 or less. Patients may have undergone minor surgical procedures within the past 3 weeks, as long as all toxicities have recovered to grade 1 or less or as specified in the eligibility criteria.
• Signed informed consent and expected cooperation of the patients for the treatment and follow up must be obtained and documented according to national/local regulations

Exclusion Criteria:

• Allergy to sulfa drugs
• Adverse reactions to salicylates
• Known hypersensitivity to sulfasalazine, its metabolites or any of the excipients (Povidone; Maize starch; magnesium stearate; colloidal silicon dioxide)
• Eligible to alternative standard treatments with temozolomide
• Treatment with sulfasalazine after glioblastoma diagnosis
• Participation in pharmacokinetic trial within 4 weeks
• Participation in immunotherapy trial within 4 weeks
• History of psychological symptoms affecting ability to consent to and/or fulfill the protocol
• Other malignant diseases and multiple sclerosis
• Pregnant or breast feeding patients.
• Porphyria
• Kidney of liver deficiencies
• Glucose-6-phosphate dehydrogenase deficiency
• Severe allergy or bronchial asthma
• History of erythema multiforme
• Significant heart failure or renal failure
• Intestinal or urinary obstruction
• Any reason why, in the opinion of the investigator, the patient should not participate (e.g. not able to comply with study procedures).

Related Conditions & MeSH terms

• Glioblastoma
• Glioma
• Recurrence
• Recurrent Glioblastoma

Intervention

Drug:
• Sulfasalazine
Sulfasalazine combined with stereotactic radiosurgery

Locations

Country	Name	City	State
Norway	Haukeland University Hospital	Bergen

Sponsors (6)

Lead Sponsor	Collaborator
Haukeland University Hospital	Helse Stavanger HF, Northwell Health, Norwegian Cancer Society, University of Bergen, Weill Medical College of Cornell University

Country where clinical trial is conducted

Norway, 

References & Publications (8)

Chung WJ, Lyons SA, Nelson GM, Hamza H, Gladson CL, Gillespie GY, Sontheimer H. Inhibition of cystine uptake disrupts the growth of primary brain tumors. J Neurosci. 2005 Aug 3;25(31):7101-10. doi: 10.1523/JNEUROSCI.5258-04.2005. — View Citation

Dodoo E, Huffmann B, Peredo I, Grinaker H, Sinclair G, Machinis T, Enger PO, Skeie BS, Pedersen PH, Ohlsson M, Orrego A, Kraepelien T, Barsoum P, Benmakhlouf H, Herrman L, Svensson M, Lippitz B. Increased survival using delayed gamma knife radiosurgery for recurrent high-grade glioma: a feasibility study. World Neurosurg. 2014 Nov;82(5):e623-32. doi: 10.1016/j.wneu.2014.06.011. Epub 2014 Jun 13. — View Citation

Robe PA, Martin DH, Nguyen-Khac MT, Artesi M, Deprez M, Albert A, Vanbelle S, Califice S, Bredel M, Bours V. Early termination of ISRCTN45828668, a phase 1/2 prospective, randomized study of sulfasalazine for the treatment of progressing malignant gliomas in adults. BMC Cancer. 2009 Oct 19;9:372. doi: 10.1186/1471-2407-9-372. — View Citation

Skeie BS, Enger PO, Brogger J, Ganz JC, Thorsen F, Heggdal JI, Pedersen PH. gamma knife surgery versus reoperation for recurrent glioblastoma multiforme. World Neurosurg. 2012 Dec;78(6):658-69. doi: 10.1016/j.wneu.2012.03.024. Epub 2012 Apr 4. — View Citation

Skeie BS, Wang J, Dodoo E, Heggdal JI, Gronli J, Sleire L, Bragstad S, Ganz JC, Chekenya M, Mork S, Pedersen PH, Enger PO. Gamma knife surgery as monotherapy with clinically relevant doses prolongs survival in a human GBM xenograft model. Biomed Res Int. 2013;2013:139674. doi: 10.1155/2013/139674. Epub 2013 Nov 10. — View Citation

Sleire L, Skeie BS, Netland IA, Forde HE, Dodoo E, Selheim F, Leiss L, Heggdal JI, Pedersen PH, Wang J, Enger PO. Drug repurposing: sulfasalazine sensitizes gliomas to gamma knife radiosurgery by blocking cystine uptake through system Xc-, leading to glutathione depletion. Oncogene. 2015 Dec 3;34(49):5951-9. doi: 10.1038/onc.2015.60. Epub 2015 Mar 23. — View Citation

Sontheimer H, Bridges RJ. Sulfasalazine for brain cancer fits. Expert Opin Investig Drugs. 2012 May;21(5):575-8. doi: 10.1517/13543784.2012.670634. Epub 2012 Mar 12. — View Citation

Takeuchi S, Wada K, Nagatani K, Otani N, Osada H, Nawashiro H. Sulfasalazine and temozolomide with radiation therapy for newly diagnosed glioblastoma. Neurol India. 2014 Jan-Feb;62(1):42-7. doi: 10.4103/0028-3886.128280. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Toxicity (Common Terminology Criteria for Adverse Event v 4.0)	Determining the maximum tolerated and recommended dose of sulfasalazine as radiosensitizer.	1 month
Secondary	Intratumoral Glutathione production	Monitor the effect of sulfasalazine on the level of Glutathione production in glioma cells.	4 days
Secondary	Presence of radiation necrosis	Monitor late toxicity of sulfasalazine combined with stereotactic radiosurgery on Positron Emission Tomography.	1 month
Secondary	Progression free survival	Monitor the preliminary effect of sulfasalazine combined with stereotactic radiosurgery on local tumor control.	1 year
Secondary	Overall survival	Assess the preliminary efficacy of sulfasalazine in combination with SRS on survival.	2 years
Secondary	Quality of life (Functional Assessment of Cancer Therapy-Brain)	Assess the preliminary efficacy of sulfasalazine in combination with SRS on changes in quality of life utilizing the brain cancer subscale of the functional assessment of cancer therapy-Brain (FACT-Br) questionaire. The brain cancer subscale consists of twenty-three items regarding neurological concerns (range: 0-76 points). The response to the items uses a five-point scale ranging from 0 (not at all) to 4 (very much). The higher the patient score, the better the quality of life.	1 year
Secondary	Karnofsky performance score (KPS)	Assess the preliminary efficacy of sulfasalazine in combination with stereotactic radiosurgery on changes in the Karnofsky performance score (range 0 - 100 points). The higher the score, the better is the functional performance status of the patient.	1 year
Secondary	Steroid use in mg over time	Assess the preliminary efficacy of sulfasalazine in combination with stereotactic radiosurgery on the patients´ need for steroid medication. The change in steroid use in mg from baseline up to 1 year following radiosurgery will be evaluated using descriptive statistics.	1 year