brain tumors, glioblastoma, newer treatment techniques, recent advances

1. Glioblastoma
Newer Advances
Dr. Vibhay Pareek

2. Introduction to
Glioblastoma

3. 3
CNS and the Blood-Brain Barrier
• CNS includes the brain and spinal cord[1]
– Brain is major control network for
every physiological, motor, and
thought process[4]
• CNS cell types include[2]
– Neurons: Structural and
functional cells of the CNS
– Glial cells: Perform neuronal
support and immune functions
Blood-brain
barrier
Blood-brain barrier (BBB)
protects the brain and maintains
a stable brain environment[3]
Astrocyt
e Oligodendrocytes
Microglial
cell
Capillary
Neurons
CNS, central nervous system.
1. SEER Training Modules- Anatomy and Function Areas of the
Brain and CNS. Available at:
http://training.seer.cancer.gov/brain/tumors/anatomy/.
Accessed December 17, 2015.
2. SEER Training Modules- Neurons and Glial Cells. Available at:
http://training.seer.cancer.gov/brain/tumors/anatomy/neurons.html.
Accessed December 17, 2015.
3. Yilmaz A et al. J Antimicrob Chemother. 2011. doi:10.1093/jac/dkr492.
4. Krucik G. Healthline: Brain. Available at
http://www.healthline.com/human-body-maps/brain#seoBlock.
Accessed December 17, 2015.
5. Allen NJ. Nature. 2009;457(7230):675-677.
Adapted from Allen NJ 2009.[5]

4. 4
Primary CNS Tumors
• CNS tumors arise from CNS cells and are categorized according to the cell
type/tissue from which they originate[1]
• Gliomas arise from glial cells and neuronal precursors, and constitute 80% of all
malignant primary brain and CNS tumors[2]
CNS, central nervous system; NOS, Not Otherwise Specificed
1. DeAngelis LM. N Engl J Med. 2001;344(2):114-123.
2. Ostrom QT et al. Neuro Oncol. 2013;15(Suppl 2):ii1-ii56.
3. Brain Tumor Information. Available at
http://www.braintumor.org/brain-tumor-information/.
Accessed December 17, 2015.
Brain metastases are
more common than
primary brain tumors[3]
Benign (63%)[2,3] Malignant (37%)[3]
Primary CNS Tumors (28%–40%)[3]
Other (20%)[2]
Glioblastoma
(54%)
Meningioma
Tumors of the
Pituitary
Vestibular
Schwannoma
Hernangioma
Craniopharyngioma
Ependymal Tumors
Lymphoma
Embryonal Tumors
Meningioma
Germ Cell Tumors
Diffuse Astrocytoma
NOS Malignant Glioma
Ependymal Tumors
Oligodendroglioma
Anaplastic Astrocytoma
Pilocytic Astrocytoma
Oligoastrocytic Tumors
Gliomas (80%)[2]
Brain Mets (60%–72%)[3]

5. 5
2. DeAngelis LM. N Engl J Med. 2001;344(2):114-123.
3. Louis DN et al. Acta Neuropathol. 2007;114(2):97-109.
4. Burkhard C et al. J Neurosurg. 2003;98(6):1170-1174.
5. NCCN Guidelines®. Central Nervous System Cancers. V1.2015.
6. Kleihues P, Ohgaki H. Neuro Oncol. 1999;1(1):44-51.
• Brain tumors are typically graded according to cellular origin and aggressiveness[1]
• WHO classification combines tumor type with degree of malignancy[1-3]
World Health Organization (WHO)
Grades of CNS Tumors
• Low proliferative potential
• Potentially curable with surgical resection aloneGrade I[3]
• Infiltrative properties
• Tendency to recur and progress to malignancy
despite low-level proliferation
Grade II[3]
Includes malignant astrocytomas
• Histological evidence of malignancy
• Often recur as higher grade tumors
Grade III[3,5,6]
Includes glioblastoma and variants*
• Cytologically malignant
• Rapid pre- and postoperative disease evolution
Grade IV[3]
High-gradeLow-grade
>10[4]
>5[3]
3[3]
1[1]
mOS (yrs)
* Gliosarcoma, giant cell glioblastoma, and small cell glioblastoma.[1]
CNS, central nervous system; mOS, median Overall Survival
1. Wen PY, Kesari S. N Engl J Med. 2008;359(5):492-507.

6. 6
Incidence and Mortality of Brain and
Other Nervous System Cancer
2012 Worldwide Brain and CNS Cancer Statistics*
Global[1] EU[1] Asia[1] US FR DE JP
New cases 256,213 43,136 131,452 22,850†[2] 4,770[4] 7,120[4] 5,700†[5]
Glioblastoma NA NA NA 11,140[3] 2,200[3] 3,740[3] 2,700[3]
Incidence rate‡ 3.4 6.9 3.0 5.3[1] 5.1[1] 5.3[1] 2.8[1]
Deaths 189,382 32,960 95,732 15,320†[2] 3,290[4] 5,660[4] 2,100†[5]
Mortality rate‡ 2.5 4.9 2.2 3.3[1] 3.2[1] 3.5[1] 1.0[1]
• CNS cancers are the 13th most commonly diagnosed cancer worldwide[1]
– Glioblastoma accounts for 54% of new glioma and 45% of primary malignant
tumors[6]
* Estimated 2012 unless otherwise noted.
† Estimated 2015.
‡ Estimated ASRs (W) per 100,000. Both sexes, all ages.
3. Decision Resources: Glioblastoma Multiforme. September 2013.
4. Ferlay J et al. Eur J Cancer. 2013;49(6):1374-1403.
5. National Cancer Center. Available at:
http://ganjoho.jp/en/public/statistics/short_pred.html. Accessed December 21, 2015.
6. Ostrom QT et al. Neuro Oncol. 2013;15:ii1-ii56.
ASR, age standardized rate; CNS, central nervous system; W, world.
1. GLOBOCAN 2012: Population Fact Sheets. Available at:
http://globocan.iarc.fr/Pages/fact_sheets_population.aspx.
Accessed December 21, 2015.
2. American Cancer Society. Cancer Facts and Figures 2015. Available at:
http://www.cancer.org/acs/groups/content/
@research/documents/webcontent/acspc-044552.pdf. Accessed December 21,
2015.

7. 7
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
US
France
Germany
Japan
Regional Incidence Trends for
Glioblastoma
• Number of newly diagnosed cases of glioblastoma is expected to
increase in the US, France, Germany, and Japan[1]
Projections for 2012–2022
2.0
1.3
1.0
1.0
Growth
(%/yr)
1. Decision Resources: Glioblastoma Multiforme. September 2013.

8. 8
Glioblastoma 5-Year Survival Rates by
Region
4.7%
US[1]
2.7%
Europe[2]
6.3%
Japan[3]
• Grade IV glioblastoma has the poorest prognosis of all primary brain
tumors[4]
– Overall 5-year survival worldwide <3%[4]
1. Ostrom QT et al. Neuro Oncol. 2013;15:ii1-ii56.
2. Sant M et al. Int J Cancer. 2012;131(1):173-185.
3. Nomura K et al. Int J Clin Oncol. 2000;5(6):355-360.
4. Roche Glioblastoma Backgrounder. Available at:
http://www.roche.com/backgrounder_glioblastoma__concise_
guide.pdf. Accessed December 17, 2015.

9. 9
• Etiology of brain tumors is not well understood[1]
– Ionizing radiation is the only established environmental risk factor[1,2]
Risk Factors for Glioblastoma
Non-
ionizing
radiation
Ionizing
radiation
Genetically
inherited
syndromes
Family
history
Male
gender
Urban
residence
Age
Caucasian
origin
Glioblastoma
Risk
Factors[1-3]
1. Grossman SA et al. Cancer Invest. 1999;17(5):299-308.
2. Neglia JP et al. J Natl Cancer Inst. 2006;98(21):1528-1537.
3. Deorah S et al. Neurosurg Focus 2006;20(4):E1.

10. 10
Prognostic Factors for Glioblastoma
Younger age
Single most
powerful
predictor of
outcome[1]
Methylated
MGMT
status[1,2]
Higher KPS
score[1]
Tumor
resectability
(size, location,
and number)[3,4]
Factors
associated
with better
prognosis
1. Hegi ME et al. N Engl J Med. 2005;352:997-1003.
2. Arvold ND et al. Clin Interv Aging. 2014;9:357-367.
3. Kawano H et al. Br J Neurosurg. 2014;14:1-7.
4. NCCN Guidelines®. Central Nervous System Cancers. V1.2015.
KPS, Karnosfsky performance status ; MGMT, O6-methylguanine DNA
methyltransferase.

11. 11
Prognostic Factors for Glioblastoma: Age
Survival Rates by Age Group[2]
Age Group
(yrs)
1-Year
Survival, %
5-Year
Survival, %
0-19 57.2 19.2
20-44 66.5 16.9
45-54 52.7 5.9
55-64 40.7 3.8
65-74 23.7 1.7
75+ 9.2 0.8
Glioblastoma
incidence
0
20–44
10
20
30
40
45–54 55–64 65–74 75+
Age Groups
Age-AdjustedIncidence
Rateper100,000
Incidence Rate by Age Group[2]
• Elderly* patients represent ~50% of newly diagnosed glioblastoma[1]
– Virtually all elderly glioblastoma tumors are primary and characterized by
genetic differences[1]
• Glioblastoma incidence: increases with age[1,2]
• Glioblastoma survival rates: decrease with age[1,2]
1. Arvold ND et al. Clin Interv Aging. 2014;9:357-367.
2. Ostrom QT. Neuro Oncology. 2013;15(Suppl 2):ii1-ii56.* Definition of “elderly” varies, with most randomized trials including
patients aged 60, 65, or 70 years and older.[1]

12. 12
• Potential of prognostic biomarkers in identifying specific patient populations has
not yet been fully realized[6]
• MGMT methylation status is the only biomarker with predictive implications on
treatment outcomes identified to date[6]
Select Biomarkers in Glioblastoma
Biomarker Prognostic Indication Favorable Poor
MGMT methylation[1]
• Methylated in 30%–60% of cases
• Methylated MGMT increases response to chemotherapy
• Unmethylated MGMT decreases response to
chemotherapy

IDH1/2 mutations[2,3]
• More common in lower grade glial tumors
• IDH1/2 mutation occurs in approximately 3.7% of primary
GBMs versus 73.3% in secondary GBM

EGFR amplification[4,5] Observed in ~50% of primary glioblastomas 
EGFRvIII mutation[4]
• EGFR-amplified cells often contain EGFRvIII mutation,
which confers constitutive activity
• 30% glioblastoma tumors express EGFRvIII

Prognostic
Association
1. Preusser M et al. Ann Neurol. 2011;70(1):9-21.
2. Nobusawa S et al. Clin Cancer Res. 2009;15(19):6002-6007.
3. Yan H et al. N Engl J Med. 2009;360(8):765-773.
4. Johnson H et al. Mol Cell Proteomics. 2012;11(12):1724-1740.
5. Stupp R et al. Ann Oncol. 2014;25(Suppl 3):iii93-iii101.
6. McNamara MG et al. Cancers. 2013;5(3):1103-1119.
EGFR, epidermal growth factor receptor; IDH1/2, isocitrate
dehydrogenase 1/2; MGMT, O6-methylguanine DNA methyltransferase.

13. 13
• Glioblastomas are highly heterogeneous at the molecular level[1]
• Four transcriptional subclasses have recently been defined based on
tumor expression profiles[2]
Toward a Molecular Signature: The Cancer Genome
Atlas Histological Subtypes of Glioblastoma
Classical
EGFR amplification/
mutations
Significantly
decreased mortality
Mesenchymal
High expression of
tumor necrosis
factor pathway
genes
Significantly
decreased mortality
Neural
Neuronal marker
expression
Efficacy suggested
Proneural
IDH1 mutations
No difference in
survival
Transcriptional
profile
includes:[2]
Response to
intensive
treatment*:[2]
• Classifying glioblastoma tumors according to expression profiles may
help predict response to certain treatments and assess patient
prognosis[2]
1. Olar A, Aldape KD. J Pathol. 2014;232(2):165-177.
2. Verhaak RG et al. Cancer Cell. 2010;17(1):98-110.
* Concurrent chemotherapy and radiation or more than four cycles
of chemotherapy.
EGFR, epidermal growth factor receptor; IDH1, isocitrate
dehydrogenase.

14. 14
Summary of Treatment Approaches and
Unmet Needs
NATURE AND
PREVALENCE OF
TUMORS
• Glioblastomas are the most common and most aggressive
primary brain cancer[1]
• Lower-grade gliomas (WHO grade II and III gliomas)
eventually progress into grade IV within 5–10 years[2]
BLOOD-BRAIN
BARRIER
• Physical, metabolic, and immunological privilege
status of the brain limits therapeutic potential[3]
BIOMARKERS
• Potential of prognostic/predictive biomarkers in
identifying specific patient populations has not been
fully realized[4]
1. Olar A, Aldape KD. J Pathol. 2014;232(2):165-177.
2. Zong H et al. Expert Rev Mol Diagn. 2012;12(4): 383-394.
3. Wei X et al. Acta Pharmaceutica Sinica B. 2014;4(3):193-201.
4. McNamara MG et al. Cancers. 2013;5(3):1103-1119.WHO, World Health Organization

15. Treatment Guidelines
in Glioblastoma

16. 16
• Time between onset of symptoms and diagnosis of glioblastoma is often
short[1]
– Headaches, memory loss, and motor weakness are among the most
common presenting symptoms[1]
• Early diagnosis and treatment do not improve disease outcomes[2]
Glioblastoma Presentation
Glioblastoma
presenting
symptoms
General[1]
(Related to increased ICP)
• Headaches
• Slowed cognitive function
• Seizures
• Nausea/vomiting
• Personality changes
Focal[2]
(Related to tumor location)
• Aphasia
• Hemiparesis
• Sensory/visual loss
1. Chang SM. JAMA. 2005;293(5):557-564.
2. Omuro A, DeAngelis LM. JAMA. 2013;310(17):1842-1850.ICP, intracranial pressure.

17. 17
• MRI: Preferred imaging modality for
high-grade glioma diagnosis and
treatment-planning[3]
– BBB disruption results in
enhancement on contrast MRI[4]
• Challenging to distinguish
between grade III and IV glioma
by MRI
• No lab studies can currently suggest
or confirm diagnosis of glioblastoma[2]
– Tissue diagnosis is mandatory[6]
Glioblastoma Workup and Diagnosis
1. Uddin ABMS. Medscape, Neurologic manifestations of glioblastoma
multiforme workup. Available at:
http://emedicine.medscape.com/article/1156220-workup#showall.
Accessed December 17, 2015.
2. Bruce JN. Medscape. Glioblastoma multiforme workup. Available at:
http://emedicine.medscape.com/article/283252-workup#showall.
Accessed December 17, 2015.
3. Omuro A, DeAngelis LM. JAMA. 2013;310(17):1842-1850.
4. DiStefano AL et al. Biomed Res Int. 2014;2014:154350.
5. Pope WB, Hessel C. AJNR Am J Neuroradiol. 2011;32(5)794-797.
6. Stupp R et al. Ann Oncol. 2014;25(Suppl 3):iii93-iii101.
T1-weighted MRI*
Contrast-enhanced[1]
Irregular margins
may make defining
exact tumor size
challenging[2]
T2-weighted/
FLAIR MRI*†
Not contrast-
enhanced[1,2]
May result in
improved definition
of tumor volume[5]
* MRI images of same glioblastoma tumor.[1]
† Image shows T2 MRI.
BBB, blood-brain barrier; FLAIR, fluid-attenuated inversion recovery;
MRI, magnetic resonance imaging.

18. 18
• There are no curative therapies for glioblastoma[1]
– Glioblastoma recurrence rate is nearly 100%
• Treatment goals are focused on preserving PS/QOL, neurological function, and
extending survival[2]
– NCCN recommends glioblastoma patients receive palliative care from
diagnosis[3]
Goals of Therapy for Glioblastoma
Surgery[4]
• Pathological diagnosis
• Alleviate mass effect
• Increase survival
(mainly GTR)
• Facilitate adjuvant
therapy
• Decrease
corticosteroid need
Radiotherapy[5]
• Increase survival after
surgery in newly
diagnosed patients
Chemotherapy[6]
• Extend survival
• Potentially increase
therapeutic effect of
RT[1]
1. Rulseh AM et al. World J Surg Oncol. 2012;10:220.1-6.
2. Henriksson R et al. J Neurooncol. 2011;104(3):639-646.
3. NCCN Guidelines®. Central Nervous System Cancers. V1.2015.
4. Sanai N, Berger MS. Neurosurgery. 2008;62(4):753-766.
5. Valduvieco I et al. Clin Transl Oncol. 2013;15(4):278-282.
6. Stupp R et al. J Clin Oncol. 2007;25(26):4127-4136.
GTR, gross total resection; NCCN, National Comprehensive Cancer
Network; PS, performance status; QOL, quality of life; RT, radiotherapy.

19. Guidelines for Standard of Care
Diagnosis
GBM
Craniotom
y
Maximal
Surgical
resection
or Biopsy
Fit
KPS>60
Unfit
KPS<60
Age <70
Age >70
Radiotherapy short course or
Temozolamide or
BSC: steroids, anticonvulsants etc.
Radiotherapy 60Gy/30#/6weeks
+ concurrent Temozolamide 75mg/m2
Followed by 6 cycles adjuvant
Temozolamide 150 mg/m /day for 5d
every 28d
Methylate
d
Unmethylated
1. NCCN Guidelines®. Central Nervous System Cancers. V2.2014.
2. Stupp R et al. Ann Oncol. 2014;25(Suppl 3):iii93-iii101.
3. Weller M et al. Lancet Oncol. 2014;15(9):e395-e403
KPS 60 - Ambulatory and capable of most self-care but requires occasional
assistance. Unable to carry out any work activities.
KPS 50 - Capable of only limited self-care, confined to bed or chair more than
50% of waking hours. Requires considerable assistance and frequent medical
care
Temozolamide
Radiotherapy
60Gy/30#/6week
s

20. 20
• Virtually all patients relapse and there is no defined SOC[1,2]
• Clinical trial enrollment is suggested by ESMO and always recommended by NCCN[1]
Treatment of Recurrent Glioblastoma
Good PS [1,3]
Poor PS
Re-resection† ±
/ + BCNU†
Surgery to
alleviate mass
effect‡
BSC
Chemotherapy
TMZ
NU
PCV
BEV ± IRI
± NU
± TMZ
± Carb
CP
Carb
Erlotinib
Imatinib
Re-irradiation TTFBevacizumab use
in glioblastoma is
increasingly
widespread[1]*
2A 4C
2A 2B
1A
2B
2A 3C
2B
2C
2B 4C 3
BSC
NCCN
ESMO
Both
1. NCCN Guidelines®. Central Nervous System Cancers. V1.2015.
2. Decision resources. Glioblastoma Multiforme. 2013.
3. Stupp R et al. Ann Oncol. 2014;25(Suppl 3):iii93-iii101.
4. Wick W et al. J Clin Oncol. 2010;28(12):e188-e189.
IFNβ-based
regimens are also
used in Japan[4]
BCNU, carmustine; BEV, bevacizumab; BSC, best supportive care; Carb,
carboplatin; CP, cisplatin; EMA, European Medicines Agency; ESMO,
European Society of Medical Oncology; IFNβ, interferon beta; IRI,
irinotecan; NCCN, National Comprehensive Cancer Network; NU,
nitrosourea; PCV, vincristine; PS, performance status; SOC, standard of
care; TMZ, temozolomide; TTF, tumor treating fields.
* BEV is used in parts of EU despite not having received EMA approval[4]; † For local recurrent disease, the NCCN Guidelines recommend re-resection,
when feasible[1]; ‡ Recommended by NCCN for recurrent disease with diffuse/multiple tumors.[1]

21. 21
• All patients should receive BSC[1]
• Neurological function is closely monitored and lab tests are performed according
to treatment regimen[2]
• MRI scans are routinely performed
– Early detection of recurrence is desirable[1]
– Management of recurrent tumors is guided by patient condition and extent of
disease[1]
Follow-Up/Monitoring
NCCN[1]
• Serial scans starting at 2–6 weeks
after RT to titrate corticosteroid
dose
• Then every 2–4 months for 2–3
years to monitor for recurrence
ESMO[2]
• Scans every 3–4 months unless
otherwise clinically indicated
Monitoring MRI scans
1. NCCN Guidelines®. Central Nervous System Cancers. V1.2015.
2. Stupp R et al. Ann Oncol. 2014;25(Suppl 3):iii93-iii101.
BSC, best supportive care; ESMO, European Society for Medical
Oncology; MRI, magnetic resonance imaging; NCCN, National
Comprehensive Cancer Network; RT, radiotherapy.

22. 22
• Treatment-induced changes in brain permeability introduce challenges in
detecting response to therapy and disease recurrence by MRI[1]
Challenges in Response Assessment:
Pseudoprogression and Pseudoresponse
Pseudoprogression
Apparent increase of tumor lesion
on imaging that is not due to
actual tumor growth[1-3]
Pseudoresponse
Apparent decrease of tumor lesion
on imaging that does not reflect
true tumor reduction[1]
Often occurs with antiangiogenic
agents such as bevacizumab[1]
Observed in 5%–31% patients* after
RT/chemotherapy[2]
• “Pseudoprogression” has also been observed after treatment with
immunotherapies, but is often followed by tumor regression[4,5]
– Apparent increases in tumor lesions in these cases may be a result of
immune-cell infiltration of the tumor[4]
* More common in MGMT-methylated patients.[2]
MGMT, O6-methylguanine DNA methyltransferase; MRI, magnetic
resonance imaging; RT, radiotherapy.
1. Hygino da Cruz LC et al. AJNR Am J Neuroradiol.
2011;32(11):1978-1985.
2. Stuplich M et al. J Clin Oncol. 2012;30(31):e180-183.
3. Brandsma D et al. Lancet Oncol. 2008;9(5):453-461.
4. Wolchok JD et al. Clin Cancer Res. 2009;15(23)7412-7420.
5. Lipson EJ. Oncoimmunology. 2013;2(4):e23661.

23. 23
iRANO Criteria for Glioblastoma
Assessment
RANO
Criteria[1,2] CR PR SD PD*
T1 enhancing
disease
None ≥ 50%
< 50% if ↓ but
< 25% if ↑
≥ 25% ↑
T2/FLAIR Stable/improved Stable/improved Stable/improved Worsened
New lesion None None None Present
Corticosteroid
use
None Stable or ↓ Stable or ↓ NA†
Clinical status
Stable/
improved
Stable/
improved
Stable/
improved
Declined
iRANO[2]
• Further guidance on confirmation scans
• New lesions are incorporated into total lesion area
• Further guidance on considerations for corticosteroid use
* Progression occurs when any one of these criteria are present[1]; † Increase in corticosteroids alone will not determine PD without persistent clinical
deterioration.[1]
1. Wen PY et al. J Clin Oncol. 2010;28(11):1963-1972.
2. Okada H et al. Lancet Oncol. 2015;16(15):e534-e542.
CR, complete response; FLAIR, fluid-attenuated inversion recovery; iRANO, Immunotherapy
RANO; NA, not available; PD, progressive disease;
PR, partial response; RANO, Response Assessment in Neuro-Oncology; SD, stable disease.

24. 24
Summary of and Challenges in
Glioblastoma Treatment
Diagnosis
• Early diagnosis and treatment do not improve outcomes for
glioblastoma, precluding the utility of screening efforts[1]
Biomarkers
• Although molecular characterization is specified in
guidelines for glioblastoma (eg, MGMT status), biomarkers
have not yet translated into making clinical decisions[2]
Treatment
• SOC for glioblastoma is MSR/Biopsy→RT/TMZ→TMZ[3,4]
• PS is the main criterion in deciding to administer SOC[3,4]
Recurrence
• Virtually all glioblastomas recur, and there is no
defined SOC for this setting[3,5]
MGMT, O6-methylguanine DNA methyltransferase; MSR, maximal surgical
resection.; PS, performance status; RT, radiotherapy; SOC, standard of
care; TMZ, temozolomide.
1. Omuro A. JAMA. 2013;310(17):1842-1850.
2. Jackson CM et al. Clin Cancer Res. 2014;20(14):3651-3659.
3. NCCN Guidelines®. Central Nervous System Cancers. V1.2015.
4. Stupp R et al. Ann Oncol. 2014;25(Suppl 3):iii93-iii101.
5. Decision resources. Glioblastoma multifigure. 2013.

25. Treatment Options
for Glioblastoma
Module 3

26. 26
• RT with concurrent and adjuvant temozolomide is SOC for
newly diagnosed patients[1-3]
Current Treatment Options for
Newly Diagnosed Glioblastoma
Newly Diagnosed
• Surgery (MSR or biopsy) ± carmustine wafer
− 5-ALA dye*
• Radiation
• Systemic chemotherapy
− Temozolomide
• Clinical trials (NCCN)
• Bevacizumab (Japan only†)
* Approved in Europe, Japan, and Canada.[4]
† As part of SOC.[3]
5-ALA, aminolevulinic acid; MSR, maximal safe resection; NCCN, National
Comprehensive Cancer Network; RT, radiotherapy; SOC, standard of
care.
1. NCCN Guidelines. Central Nervous System Cancers. V1. 2015
2. Stupp R et al. Ann Oncol. 2014;25(Suppl3):iii93-iii101.
3. Takano S et al. Onco Targets Ther. 2014;7:1551-1562.
4. Roberts DW et al. Neurosurg Clin N Am. 2012;23(3):271-377.

27. 27
• Adjuvant radiotherapy has long been a mainstay of glioblastoma therapy[1]
– RT is administered to T1-enhanced tumor region + 2–3-cm margin on T2 or
FLAIR abnormality[2]
• Key randomized clinical trials demonstrated mOS benefit of 5 mo for RT in newly
diagnosed patients:
Radiotherapy
Trial Setting N Experimental Arms Control Arms mOS
NCI (1978)[3] 1L, Anaplastic
gliomas
303
RT
BSC
36 wks
14 wksRT + IV BCNU 34.5 wks
IV BCNU 18.5 wks
Scandinavian
Glioblastoma
Study Group[4]
1L 118
RT+ bleomycin
BSC
10.8 mo
5.2 mo
RT 10.8 mo
1L, first line; BCNU, 3-bis (2-chloroethyl 1)-1-nitrosourea (carmustine);
BSC, best supportive care; EBRT, external beam radiation therapy; IFRT,
involved-field radiation therapy; FLAIR, fluid-attenuated inversion
recovery; IV, intravenous; MGMT, O6-methylguanine DNA
methyltransferase; mOS, median overall survival; NCI, National Cancer
Institute; PS, performance score; RT radiotherapy.
1. Brandes AA et al. J Clin Oncol. 2009;(8):1275-1279
2. Dhermain F. Chin J Cancer. 2014;33(1):16-24.
3. Walker MD et al. J Neurosurg. 1978;49(3):333-343.
4. Kristiansen K et al. Cancer. 1981;47(4):649-652.
5. NCCN Guidelines. Central Nervous System Cancers. V1. 2015.
6. Malmstrom A et al. Lancet Oncol. 2012;13(9):916-926.
• Fractionated EBRT and IFRT: Most commonly used RT modalities[5]
• Hypofractionated radiotherapy: Often preferred in elderly/poor PS patients,
especially when lacking MGMT promoter methylation[6]

28. 28
Chemotherapy: Carmustine Wafer (BCNU)
• Biodegradable polymer wafers loaded with nitrosourea carmustine (BCNU) are
implanted into the surgical cavity at the time of initial resection[1]
• A key phase III trial demonstrated survival benefit* for BCNU wafers in newly
diagnosed malignant glioma patients (N=240)[2,3]
* P=0.03.[2]
BCNU, 3-bis (2-chloroethyl 1)-1-nitrosourea (carmustine); CI,
confidence interval; Gliadel, poly [carboxyphenoxy-propane/sebacic
acid] anhydride wafers containing 3.85% carmustine; HR, hazard ratio;
NS, not significant; OS, overall survival; PBO, placebo.
100
90
80
70
60
50
40
30
20
10
0
0 6 12 14 16 18 22 24
Months From Implant Surgery
SurvivalRate(%)
42 20108
BCNU
Placebo
• At 3-year follow-up,
glioblastoma patients
who received BCNU had
22% reduced risk of
death (NS)[3]
• Survival benefit of
BCNU wafer for
glioblastoma remains
unclear[2,3]
• Implanting wafers may
impact clinical trial
enrollment[4]
1. Valtonen S et al. Neurosurgery. 1997;41(1):44-49.
2. Westphal M et al. Neuro Oncol. 2003;5(2):79-88.
3. Westphal M et al. Acta Neurochir (Wein). 2006;148(3):269-275.
4. NCCN Guidelines. Central Nervous System Cancers. V1. 2015.
Median OS (mo)
BCNU
(n=101)
13.5 HR (95% CI):
0.76 (0.55–1.05)
P=0.10PBO
(n=106)
11.4
Glioblastoma Subgroup (n=207)[2]
Minimum
follow-up:
12 mo

29. 29
Chemotherapy: Temozolomide (TMZ)
TMZ is an alkylating agent prodrug
• Alkylating agents bind to DNA, impairing
replication/transcription and ultimately leading
to cell death[1]
• TMZ is able to cross the BBB and is
spontaneously converted into the active
metabolite in the CNS[2]
• TMZ is a standard treatment for newly
diagnosed glioblastoma[3]
− Administered daily concomitantly with RT
and as maintenance thereafter*[3]
− Available in oral and IV formulation[4]
* Alternative TMZ dosing regimens have not demonstrated improved efficacy, but
continue to be investigated (see Module 4 for further details).
Tumor
cell
TMZ
Replication
Transcription
1. Fu D et al. Nat Rev Cancer. 2012;12(2):104-120.
2. Agarwala SS, Kirkwood JM. Oncologist. 2000;5(2):144-151.
3. NCCN Guidelines. Central Nervous System Cancers. V1. 2015.
4. TEMODAR [package insert]. Whitehouse Station, NJ:
Merck & Co, Inc; 2014.
5. Wesolowski JR et al. Am J Neuroradiol. 2010;31(8):1383-1384.
BBB, blood-brain barrier; CNS, central nervous system; DNA,
deoxynucleic acid; IV, intravenous; RT, radiotherapy; TMZ, temozolomide.
Adapted from Wesolowski et al 2010.[5]

30. 30
TMZ in Glioblastoma: Phase III
EORTC/NCIC Trial
Daily TMZ + RT→
6 cycles TMZ
Key Inclusion Criteria[1]
• 18–70 years old
• Newly diagnosed
glioblastoma
• WHO PS<2
R
RT alone
N=573
• ~2 month increase in mOS[1]
• 2-yr survival: 26.5% vs 10.4%[1]
• 5-yr survival: 10% vs 2%[2]
0
0 6 12 18 24 30 36 42
10
20
30
40
50
60
70
80
90
100
Months
ProbabilityofOverallSurvival(%)
RT + TMZ
RT
The widespread use of TMZ in glioblastoma is based on the EORTC/NCIC trial
1. Stupp R et al. N Engl Med. 2005;352(10):987-996.
2. Stupp R et al. Lancet Oncol. 2009;10(5):459-466.
CI, confidence interval; EORTC, European Organization for Research and
Treatment of Cancer; HR, hazard ratio; mOS, median OS; NCIC, National
Cancer Institute of Canada; OS, overall survival; PS, performance status;
R, randomization; RT, radiotherapy; TMZ, temozolomide; WHO, World
Health Organization.
Median OS (mo)[1]
RT+TMZ
(n=287)
14.6 HR (95% CI):
0.63 (0.52–0.75)
P<0.001RT
(n=286)
12.1

31. 31
• Alkylating agents, such as TMZ,
cause cell death by binding to
DNA[1,2]
• The MGMT protein can reverse
alkylation*[1]
• MGMT methylation leads to loss
of MGMT protein and thus,
ineffective DNA repair[1]
‒ TMZ remains effective
• Unmethylated MGMT retains
MGMT protein synthesis and
therefore, DNA repair[1]
‒ TMZ ineffective
MGMT Methylation Status in Glioblastoma:
Predictive Biomarker for TMZ
100 EORTC/NCIC Trial[2]
80
60
40
20
0
0 6 12 18 24 30 36 42
Months
ProbabilityofOS(%)
Methylated
MGMT
promoter
Unmethylated
MGMT
promoter P<0.001
1. Esteller M et al. N Engl J Med. 2000;343(19):1350-1354.
2. Hegi ME et al. N Engl J Med. 2005;352(10):997-1003.
* If alkylation is at the O6 position of guanine.[1]
EORTC, European Organisation for Research and Treatment of Cancer;
MGMT, O-methylguanine DNA methyltransferase; OS, overall survival;
NCIC, National Cancer Institute of Canada; TMZ, temozolomide.

32. 32
• Non-invasive medical device that applies tumor-treating fields (TTF) via
electrodes placed on the scalp, shown to have antimitotic activity[1,2]
• Phase III trial in newly diagnosed glioblastoma was terminated at interim analysis
due to early success[3]
– Control arm pts are now crossing over to receive SOC + TTF[3]
TTF for Newly Diagnosed Glioblastoma
1. Vymazal J, Wong ET. Semin Oncol. 2014;41(Suppl6):S14-24.
2. Stupp R et al. Eur J Cancer. 2012;48(14):2192-2202.
3. PR Newswire. Novocure EF-14 PhIII. www.prnewswire.com/
news-releases/novocure-announces-the-ef-14-phase-iii-clinical-
trial-of-tumor-treating-fields-in-patients-with-newly-diagnosed-
glioblastoma-has-been-terminated-at-the-interim-analysis-due-
to-early-success-282808841.html. Accessed December 17, 2015.
Trial[4] Study Arms N mPFS[3] mOS[3] 2-yr Survival[3]
EF-14
NCT00916409
Phase III
SOC + TTF*
vs
SOC
315[3]
(interim
analysis)
7.1 vs 4 mo
HR=0.63;
P=0.001
19.6 vs 16.6
mo
HR=0.75;
P=0.034
43% vs 29%
HR, hazard ratio; mOS, median overall survival; mPFS, median
progression-free survival; SOC, standard of care; TTF, tumor-treating
fields.
* Administered as 4 insulated electrode arrays placed on scalp.[4]

33. 33
• Virtually all patients eventually relapse[1]
• There is no standard of care for relapsed patients[2]
Overview of Current Treatment Options
for Recurrent Glioblastoma
• Chemotherapy
− Temozolomide
− Nitrosoureas
− PCV
− Cyclophosphamide
− Cisplatin/Carboplatin
• Targeted therapies
− Bevacizumab* ±
chemotherapy
− Erlotinib/Imatinib†
• Re-resection ± carmustine
wafer
• Alternating electric field
therapy
• Re-irradiation‡
• Clinical trials (NCCN and
ESMO/EANO)
BEV, Bevacizumab; EANO, European Association for Neuro-Oncology;
ESMO, European Society for Medical Oncology; EMA, European Medicines
Agency; FDA, Food and Drug Administration; NCCN, National
Comprehensive Cancer Network; PCV, procarbazine/lomustine/vincristine.
1. Felsberg J et al. Int J Cancer. 2011;129(3):659-670.
2. Gil-Gil MJ et al. Clin Med Insights Oncol. 2013;7:123-135.
3. NCCN Guidelines. Central Nervous System Cancers. V1. 2015
4. Stupp R et al. Ann Oncol. 2014;25(Suppl3):iii93-iii101.
* Currently approved by FDA but not EMA. BEV + chemo considered if BEV monotherapy fails (NCCN); BEV ± Irinotecan is
Category 3C in ESMO.
† Recommended in ESMO guidelines (Category 2C) but not in NCCN guidelines.
‡ Data are lacking on re-irradiation of recurrent glioblastomas, and its use is controversial.
Recurrent Disease[3,4]

34. 34
• Even before the 2009 accelerated approval in US, bevacizumab has been used for
management of recurrent glioblastoma in US and parts of Europe[1]
• In Japan, BEV use has been increasing since its approval[2]
• Despite PFS benefit, no significant effect of bevacizumab on mOS has been reported in phase
III trials[3,4]
Bevacizumab: Registrational Trial Data
Trial Study Arms Ph Study Setting N ORR, % mPFS, mo mOS, mo
BRAIN[5]
BEV
II
Recurrent
glioblastoma
167
28 4.2 9.2
BEV + irinotecan 38 5.6 8.7
NCI[6] BEV II
Recurrent
glioblastoma
48 35 16 wks 31 wks
JO22506[7] BEV II
Recurrent
glioblastoma
(Japan)
31 28 3.3 10.5
AVAglio[3] BEV + RT + TMZ vs
Placebo + RT + TMZ
III
Newly diagnosed
glioblastoma
921 NA 10.6 vs 6.2* 16.8 vs 16.7†
* Statistically significant.
† Not statistically significant (P=0.10).
BEV, bevacizumab; mOS, median overall survival; mPFS, median PFS; NA,
not applicable; NCI, National Cancer Institute; ORR, objective response
rate; PFS, progression-free survival; Ph, phase; RT, radiotherapy;
TMZ, temozolomide.
1. Wick W et al. J Clin Oncol. 2010;28(12):e188-189.
2. CancerMPact® Japan, 2013. April 2014, v1.1.
3. Chinot OL et al. N Engl J Med. 2014;370(8):709-722.
4. Gilbert MR et al. N Engl J Med. 2014;370(8):699-708.
5. Friedman HS et al. J Clin Oncol. 2009;27(28):4733-4740.
6. Kreisl TN et al. J Clin Oncol. 2009;25(5):740-745.
7. Nagane M et al. Jpn J Clin Oncol. 2012;42(10):887-895.

35. 35
• The FDA conferred accelerated approval for bevacizumab (2009) based on
nonrandomized phase II trials[1]
– Approval based on durable objective responses observed in two single-arm trials,
AVF3708g and NCI 06-C-0064E.
Regulatory Approval of Bevacizumab
3. ESMO Oncology News. Available at
http://www.esmo.org/Oncology-News/European-Medicines-
Agency-Adopts-a-Final-Negative-Opinion-for-an-Extension-of-
Indications-for-Bevacizumab. Accessed December 17, 2015
4. ESMO Oncology News. Available at
http://www.esmo.org/Oncology-News/European-Medicines-
Agency-Recommends-to-Refuse-a-Change-to-the-Marketing-
Authorisation-for-Bevacizumab. Accessed December 17, 2015.
5. Roche Media Release, 2013. Available at
http://www.roche.com/media/media_releases/med-cor-2013-06-
17.htm Accessed December 17, 2015.
• The EMA rejected regulatory approval for bevacizumab in 2009 and 2014[2,3]
– Doubtful of ORR and PFS as endpoints and wary of lack of OS benefit[4]
• ORR is highly variable in independent assessments[2]
• Anti-angiogenic agents affect brain permeability and therefore imaging responses[2]
• The Japanese MHLW approved bevacizumab for both lines of therapy[5]
– Approval in the newly diagnosed setting was based on improved mPFS results in the
AVAglio study[5]
EMA, European Medicines Agency; FDA, Food and Drug Administration;
MHLW, Ministry of Health/Labor/and Welfare; ORR, objective response
rate; OS, overall survival; mPFS, median progression-free survival; PFS,
progression-free survival.
1. Cohen MH et al. Oncologist. 2009;14(11):1131-1138.
2. Wick W et al. J Clin Oncol. 2010;28(12):e188-e189.

36. 36
• Despite PFS improvement, no OS benefit observed in either trial[1,2]
• Due to discrepancy in QOL, it has been proposed that the investigators
of these studies should share their raw data with the US FDA[5]
Conflicting Quality of Life Outcomes
From RTOG 0825 Trial and AVAGlio
Trial N
Primary
Endpoint(s)
Key Efficacy Data Key Safety Data
RTOG 0825
NCT00884741[1,3] 637 OS, PFS
BEV vs PBO
• mOS: 15.7 vs 16.1 mo
• mPFS*: 10.7 vs 7.3
• Increased AE profile in BEV group
• Increased symptom burden, worse
QOL, declined neurocognition in
BEV group
AVAglio
NCT00943826[2,4] 921 OS, PFS
BEV vs PBO
• mOS: 16.8 vs 16.7 mo
• mPFS†: 10.6 vs 6.2 mo
• More frequent grade >3 AE in BEV
group
• QOL and PS maintained longer in
BEV group
1. Gilbert MR et al. N Engl J Med. 2014;370(8):699-708.
2. Chinot OL et al. N Engl J Med. 2014;370(8):709-722.
3. Clinicaltrials.gov. NCT00884741
4. Clinicaltrials.gov. NCT00943826
5. Fine HA. N Engl J Med. 2014;370(8):764-765.
* Did not meet prespecified cutoff for outcome benefit (P=0.007).
† Statistically significant (P<0.001).
Phase III RTOG 0825 and AVAglio trials compared SOC + BEV vs placebo in
newly diagnosed glioblastoma patients[1,2]
AE, adverse event; BEV, bevacizumab; OS, overall survival; mPFS, median
progression-free survival; PBO, placebo; PFS, progression-free survival;
PS, performance status; QOL, quality of life; RTOG, Radiation Therapy
Oncology Group; SOC, standard of care.

37. 37
• Recently reported results from a randomized trial evaluating BEV ± lomustine demonstrated
potentially meaningful OS benefit for the combination[1]:
Prespecified criteria for further phase III studies were met for the combination[2]
Bevacizumab in Combination With
Lomustine: BELOB and EORTC 26101
Trial[1] Experimental Arms Ph Study Setting N ORR, % 6-mo PFS, % 9-mo OS, %
BELOB
NTR1929
Lomustine
II
Recurrent
glioblastoma
148
5 13 43
BEV 38 16 38
Lomustine* + BEV 34 41 59
1. Taal W et al. Lancet Oncol. 2014;15(9):943-953.
2. Taal W et al. Presentation at SNO 2014. AT-55.
3. Clinicaltrials.gov : NCT01290939.
4. Wick W. et al SNO 2015 Abstract
1L, first line; 2L, second line; BEV, bevacizumab; EORTC, European
Organisation for Research and Treatment of Cancer; NTR, Netherlands
Trial Register; ORR, objective response rate; OS, overall survival; PFS,
progression-free survival.
* 90 mg/m2 dose, determined after interim safety analysis.
• EORTC 26101: Phase III Trial Exploring the Combination of Bevacizumab and Lomustine vs
Lomustine in Patients With First Recurrence of Glioblastoma3,4
Trial
Experimental
Arms Study design Ph N Primary Endpoint mPFS* mOS**
EORTC 26101
NCT01290939
Lomustine ±
BEV
Recurrent III 433 OS
1.54 mos (LOM;
n=149) vs.
4.17 mos (BEV+LOM;
n=288)
mOS 8.64 mos
(LOM; n=149) vs.
9.10 mos
(BEV+LOM;
n=288)
* Locally assess PFS was longer with the addition of BEV to LOM: HR 0.49 (95% CI 0.39, 0.61) P< .0001
** With 329 OS events (75.3%) OS was not superior in the combination therapy arm (HR: 0.95, CI: 0.74-1.21, p=0.650)
Toxicity was in the expected range with more events in the combination arm being also longer on treatment

38. 38
Key Adverse Events by Class of Therapy
VEGF-Targeted Agents[4-9]
• Hypertension and
diarrhea occur in all
VEGF/VEGFR inhibitors
• Other AEs include
gastrointestinal AEs
(diarrhea, nausea,
vomiting), dermatologic
AEs (HFS), and fatigue
• Bevacizumab has a black
box warning in the US for
GI perforation and
serious bleeding[9]
Alkylating Agents
(TMZ, BCNU)[2-3]
• Alopecia
• Fatigue
• Nausea/vomiting
• Thrombocytopenia
• Neutropenia
RT[1]
• Hair loss
• Nausea
• Fatigue
• Increased ICP
• Other AEs include
memory loss and
radiation necrosis
• Adverse events associated with TMZ are generally milder than other alkylating
agents[2]
AE, adverse event; BCNU, carmustine; GI, gastrointestinal; HFS, hand-foot
syndrome; ICP, intracranial pressure; RT, radiotherapy; TMZ,
temozolomide; VEGF, vascular endothelial growth factor; VEGFR, VEGF
receptor.
1. Lawrence YR et al. Br J Cancer. 2011;104(9):1365-1371.
2. Chang L et al. Onco Targets Ther. 2014;7:235-244.
3. Reithmeier T et al. BMC Cancer. 2010;10:30.
4. Eisen T et al. J Natl Cancer Inst. 2012;104(2):93-113.
5. SUTENT [package insert]. New York, NY: Pfizer Labs; 2014.
6. VOTRIENT [package insert]. Middlesex, UK: GlaxoSmithKline; 2014.
7. NEXAVAR [package insert]. Berlin, Germany: Bayer HealthCare
Pharmaceuticals Inc; 2013.
8. INLYTA [package insert]. New York, NY: Pfizer Labs; 2013.
9. AVASTIN [package insert]. San Francisco, CA: Genentech, Inc; 2013.

39. 39
Summary of Currently Available Agents
Approved for Glioblastoma
Agent[1-4] MOA[1,3,5] Line[1,2] Admin[1,2,6-9] Guideline
Recommendation[1-4]
Temozolomide Alkylating agent ND, R PO/IV NCCN, ESMO
Carmustine (wafer) Alkylating agent ND, R Implant NCCN, ESMO
Carmustine (systemic) Alkylating agent R IV NCCN, ESMO*
Lomustine Alkylating agent R PO NCCN, ESMO
Bevacizumab VEGF inhibitor
ND
IV
Japan only
R NCCN, Japan
TTF device Anti-mitotic R Electrodes NCCN†, Japan‡
* Single agent nitrosourea therapy.[2]
† Not all panelists recommended TTF.[1]
‡ TTF has been made available on a restricted case basis for compassionate use in Japan.[4]
Admin, administration; ESMO, European Society for Medical Oncology;
IV, intravenous; NCCN, National Comprehensive Cancer Network; MOA,
mechanism of action; ND, newly diagnosed; PO, by mouth; R, recurrent;
TTF, tumor-treating fields; VEGF, vascular endothelial growth factor.
1. NCCN Guidelines ®. Central Nervous System Cancers. V1. 2015.
2. Stupp R et al. Ann Oncol. 2014;25(Suppl3):iii93-iii101.
3. Roche Press Release, June 17, 2013. Available at:
http://www.roche.com/media/store/releases/med-cor-2013-06-
17.htm. Accessed February 25, 2015.
4. Muragaki Y et al. Presentation at SNO 2014. NT-25.
5. Decision Resources: Glioblastoma Multiforme. September 2013.
6. TEMODAR [package insert]. Whitehouse Station, NJ: Merck & Co, Inc;
2014.
7. BiCNU [package insert]. Princeton, NJ: Bristol-Myers Squibb Company;
2011.
8. CeeNU [package insert]. Princeton, NJ: Bristol-Myers Squibb
Company; 2012.
9. AVASTIN [package insert]. South San Francisco, CA: Genentech, Inc;
2014.

40. 40
Additional Recommended Agents for
Glioblastoma
Agent[1,2] MOA[2-4] Line[1,2] Admin[3,4] Guideline Rec[1,2] Key Efficacy[2,4-6]
Cyclophosphamide Alkylating agent R PO NCCN
Modest mPFS
increase
PCV
Procarbazine
Alkylating
agents
R
PO
NCCN, ESMO
Comparable efficacy
with TMZ
Lomustine PO
Vincristine IV
Carboplatin DNA
crosslinking
agents
R IV NCCN
Modest activity
Cisplatin R IV NCCN
Bevacizumab VEGF inhibitor R IV ESMO
Steroid-sparing
effect†
Irinotecan
Topoisomerase
inhibitor
R IV NCCN, ESMO
Modest mPFS
increase (+BEV)†
Erlotinib EGFR inhibitor R PO ESMO Anti-tumor efficacy
not shown‡Imatinib PDGFR inhibitor R PO ESMO
Admin, administration; bev, bevacizumab; DNA, deoxynucleic acid; EGFR,
epidermal growth factor receptor; ESMO, European Society for Medical
Oncology; IV, intravenous; mPFS, median progression-free survival;
NCCN, National Comprehensive Cancer Network; PCV, procarbazine/
lomustine/vincristine; PDGFR, platelet-derived growth factor receptor; PO,
by mouth; R, recurrent; rec, recommendation; RR, response rate; TKI,
tyrosine kinase inhibitor; TMZ, temozolomide,
VEGF, vascular endothelial growth factor.
1. NCCN Guidelines®. Central Nervous System Cancers. V1. 2015
2. Stupp R et al. Ann Oncol. 2014;25(Suppl3):iii93-iii101.
3. Decision Resources: Glioblastoma Multiforme. September 2013.
4. Chamberlain MC, Tsao-Wei DD. Cancer. 2004; 100(6):1213-20.
5. Roci E et al. Med Arch. 2014;68(2):140-143.
6. Friedman HS et al. J Clin Oncol. 2009;27(28):4733-4740.
* As single agents in recurrent high grade gliomas[5]; † In a study of bevacizumab±irinotecan, there was a trend toward stabilization/decrease in steroid use,
in patients taking corticosteroids at baseline[6]; ‡ In unselected patient populations.[2]

41. 41
Limitations of Current Therapies
BBB, blood-brain barrier; mOS, median overall survival; mPFS, median
progression-free survival; RR, response rate; tx, treatment.
1. Patel MA et al. Cancers. 2014;6(4):1953-1985.
2. SEER Stat Fact Sheets: Brain and Other Neurons System
Cancer. Available at:
http://seer.cancer.gov/statfacts/html/brain.htmlAccessed
December 17, 2015.
Treatment
Outcomes
• Over the past 4 decades, treatment advances have only
modestly impacted overall patient survival[1,2]
• Recurrence rate remains ~100%[3]
• Prognosis for patients with relapsed glioblastoma remains
extremely poor[4]
− RR <4%–16%
− mPFS ~2.3 months
− mOS 3–9 months
Challenges and
Unmet Needs
• Imaging challenges due to tx-related changes in brain
permeability[5]
• Fewer tx options for elderly population despite higher
incidence[6]
• Drug delivery past the BBB[7]
• Neurotoxicity of treatments[7]
3. NCCN Guidelines. Central Nervous System Cancers. V1. 2015.
4. Gil-Gil MJ et al. Clin Med Insights Oncol. 2013;7:123-135.
5. Hygino da Cruz LC et al. AJNR Am J Neuroradiol.
2011;32(11):1978-1985.
6. Arvold ND, Reardon DA. Clin Interv Aging. 2014;9:357-367.
7. Chamberlain MC. Neurosurg Focus. 2006;20(4):E19.

42. Investigational Agents
for Glioblastoma
Module 4

43. 43
Investigational Agents:
Chemotherapies (cont’d)
VAL-083 (DelMar) is a novel alkylating agent under phase I/II development
for recurrent glioblastoma[1,2]
• Unaffected by MGMT methylation status in vitro[1]
Has orphan drug designation in US (2012) and Europe (2013) for gliomas[3]
Preliminary results of phase I/II dose escalation trial in newly diagnosed
pts*[2] have recently been reported[4]:
• Safety: Well-tolerated; MTD not yet reached
• Efficacy: Improved clinical signs in 3 pts reaching SD or PR†
1. Steino A et al. Mol Cancer Ther. 2013;12(11 suppl):B252.
2. Clinicaltrials.gov. NCT01478178.
3. DelMar Press Release. Available at:
http://www.delmarpharma.com/DelMarPharmaVAL-
083EUORPHANDRUG130107.pdf. Accessed February 17, 2015.
4. Shih KC et al. Poster presentation at ASCO 2014. 2093.
AE, adverse event; MGMT, O6-methylguanine DNA methyltransferase;
MTD, maximum tolerated dose; PR, partial response; SD, stable disease;
TMZ, temozolomide.
* Also enrolling patients previously treated with surgery and/or radiation who have failed on both TMZ and bevacizumab.[4]
† Maximum response of 28 cycles (84 weeks) prior to discontinuing due to unrelated AE.[4]

44. 44
Although approved in 1L and 2L settings, OS
benefit has not been observed[1]
Investigational Agents: Antiangiogenics
Other Antiangiogenic Agents
• TKIs targeting the VEGFR pathway have
shown limited or no clinical benefit in
glioblastoma, with some trials
demonstrating high toxicity rates[1,2]
• VEGF-targeting next-generation antibody
pegdinetanib is in phase II development for
glioblastoma[3]
Adapted from Oudard S et al 2012.[4]
PI3K
mTOR
AKT
Angiogenesis
VEGFR
VEGF
Tumor
cell
Bevacizumab*
*Bevacizumab is further discussed in Module 3
1. Wilson TA et al. Surg Neurol Int. 2014;5:64.
2. Reardon DA, Wen PY. Oncologist. 2006;11(2):152-164.
3. Evans JB, Syed BA. Nat Rev Drug Discov. 2014;13(6):413-414
4. Oudard S et al. Cancer Treat Rev. 2012;38(8):981-987.
1L, first line; 2L, second line; AKT, protein kinase B; mAb, monoclonal
antibody; mTOR, mammalian target of rapamycin; OS, overall survival;
PI3K, phosphoinositide-3 kinase; TKI, tyrosine kinase inhibitor; VEGF,
vascular endothelial growth factor; VEGFR, VEGF receptor.
Roche

45. 45
• DNA-histone H1 complex*
• Radioactive Iodine
Early Phase Targeted Agents for Glioblastoma:
Cytotoxic Antibody Conjugates
• Antibody-drug conjugates are designed to deliver cytotoxic drug activity
specifically to tumor cells[1]
• LRP-1†
• Anti-MT agent paclitaxel
• EGFR or mut EGFRvIII
• Anti-MT agent MMAF
131I-chTNT-1/B MAb[2]
ANG-1005[3]
ABT414[4]
Adapted from http://www.seattlegenetics.com/adc_technology.
1 ADC binds
to target
ADC receptor
complex is
internalized
2
Apoptosis4
Cytotoxic
agent is
released
3
1. Seattle Genetics. Advancing ADC technology. Available at:
http://www.seattlegenetics.com/adc_technology. Accessed December
17, 2015
2. Shapiro WR et al. J Clin Oncol. 2010;28:15s. Abstract 2039.
3. Drappatz J et al. Poster presentation at ASCO 2010. 2009.
4. Gan HK et al. Poster presentation at ASCO 2014. 2021.
* DNA-histone H1 complex is exposed in tumor necrotic core[2].
† LRP1 is expressed in BBB endothelium and in tumor cells[3].
ADC, antibody-drug conjugate; EGFR, epidermal growth factor
receptor; EGFRvIII, EGFR variant III; LRP-1, low-density lipoprotein
receptor-related protein 1; MMAF, monomethyl auristatin F; MT,
microtubule.; mut, mutated.
Peregrine
Angiochem
AbbVie

46. 46
Early Phase Targeted Agents for Glioblastoma:
Cytotoxic Antibody Conjugates (cont’d)
Study N Efficacy Safety Status
131I-chTNT-
1/B MAb[1-3]
Phase II
Dose-
confirmatory in
pts at 1st relapse
41 • mOS: 9.3 mo
• 2-yr OS: 19%
Grade 3/4 AE in 22%
patients
• Orphan drug status,
FDA and EMA
• Fast-track status,
FDA
• No currently
ongoing trials*
ANG1005[4,5]
Phase I
(NCT005393
44)
Safety and
preliminary
efficacy in
recurrent
glioblastoma
and AG pts
63 2 CR and 2 PR
in glioblastoma
pts
• Well-tolerated
• No CNS toxicity
• Minimal systemic
toxicity
• Orphan drug status,
FDA[6]
• Fast-track status,
FDA[6]
• Phase II trial
currently ongoing[4]
ABT414[4,7]†
Phase I
+TMZ
(NCT018006
95)
Safety and
preliminary
efficacy in newly
diagnosed or
recurrent pts
21 1 CR and 3 PR
in TMZ-
refractory pts
MMAF-induced corneal
epithelial microcysts
• Orphan drug status,
FDA and EMA
• Trial still ongoing
1. Peregrine Press Release. 2012.
http://ir.peregrineinc.com/releasedetail.cfm?ReleaseID=725023 Accesed December 21,
2015
2. Peregrine Press Release. 2011.
http://ir.peregrineinc.com/releasedetail.cfm?ReleaseID=579150 Accesed December
21, 2015
3. Shapiro WR et al. J Clin Oncol. 2011;29. Abstract 2035.
4. Clinicaltrials.gov.
5. Drappatz J et al. Poster presentation at ASCO 2010. Abstract 2009.
6. Angiochem. Angiochem’s ANG1005 received orphan drug designation from FDA for
the treatment of glioblastoma multiform.
http://angiochem.com/angiochem%E2%80%99s-ang1005-received-orphan-drug-
designation-fda-treatment-glioblastoma-multiform. Accessed February 15, 2015.
7. Gan HK et al. Poster presentation at ASCO 2014. 2021.
AE, adverse events; AG, angioblastoma; CNS, central nervous system;
CR, complete response; EMA, European Medicines Agency; FDA, Food
and Drug Administration; mAb, monoclonal antibody; MMAF,
monomethyl auristatin F; mOS, median OS; OS, overall survival; TMZ,
temozolomide.
* Plans for phase III trial have been approved by FDA as of 2012.[5]
† Phase II trial is planned.[1]

47. 47
Phase III Failures of Targeted Agents Highlight
Need for New Treatment Modalities
Agent MOA Patient Population Results (Primary Endpoint)
Enzastaurin[1] Serine/threonine
kinase inhibitor
Recurrent Terminated following interim
futility analysis (no PFS benefit)
Cediranib[2] (REGAL trial) VEGF Inhibitor Recurrent No PFS, OS benefit demonstrated
Imatinib[3] TKI Recurrent No PFS benefit demonstrated
Cintredekin besudotox
(IL13-PE38)[4]
Cytotoxin Recurrent No OS benefit demonstrated
TransMID
(Tf-CRM107)[5,6]
Cytotoxin Progressive or
Recurrent (unresectable)
Terminated following interim
analysis (unlikely to meet trial
criteria for efficacy)
Trabedersen (AP12009)[7] TGF-β
oligonucleotide
Progressive or
Recurrent Grade III and
IV gliomas
Serious adverse events
Cilengitide[8,9] Integrin inhibitor Newly diagnosed,
MGMT-methylated
No OS, PFS benefit demonstrated
Nimotuzumab[10] EGFR mAb Newly diagnosed No PFS, OS benefit demonstrated
4. Kunwar S et al. Neuro Oncol. 2010;12(8):871-881. 5. Clinicaltrials.gov.
NCT00083447. 6. Drugs.com. Celtic terminates Transmid trial. Available at:
http://www.drugs.com/news/celtic-pharma-terminates-transmid-trial-ksb311r-
ciii-001-5246.html. Accessed December 17, 2015. 7. Clinicaltrials.gov.
NCT00761280. 8. Tactical Therapeutics. Glioblastoma—overcoming resistance
in malignant brain cancer. Available at: http://www.tacticaltherapeutics.com/
glioblastoma/. Accessed December 17, 2015. 9. Stupp R et al. Lancet Oncol.
2014;15(10):1100-1108. 10. Westphal M, Bach F. J Clin Oncol. 2012 (suppl):30.
Abstract 2033.
EGFR, epidermal growth factor receptor; mAb, monoclonal antibody;
MGMT, O6-methylguanine DNA methyltransferase; MOA, mechanism of
action; mOS, median OS; OS, overall survival; PFS, progression-free
survival; TGF-β, transforming growth factor-beta; Tf, transferrin; TKI,
tyrosine kinase inhibitor; VEGF, vascular endothelial growth factor.
1. Wick W et al. J Clin Oncol. 2010;28(7):1168-1174.
2. Batchelor TT et al. J Clin Oncol. 2013;31(26):3212-3218.
3. Dresemann G et al. J Neurooncol. 2010;96(3):393-402.

48. 48
PD-1/PD-L1 in Glioblastoma
PD-1 was found to be expressed in 29% of tumor-infiltrating lymphocytes
in glioblastoma tumor samples[1]*
• Expressed in 88% of newly diagnosed and 72% of recurrent glioblastomas†
PD-L1 was highly expressed in glioblastoma tumors[1]*:
• Low expression associated with proneural/G-CIMP glioblastoma subtypes[1]
• High expression associated with mesenchymal subtype[1]
• Immune suppressive heterogeneity has been observed between molecular
subtypes[2]
PD-L1 expression correlated with glioblastoma molecular subtypes:
1. Berghoff AS et al. Neuro Oncol. 2014;pii:nou307.
2. Gilbert MR. Oral presentation at EANO 2014.
* Expression assayed by IHC in retrospective cohort.[1]
† Expression pattern of variable extent.[1]
G-CIMP, glioma CpG island methylator phenotype; IHC,
immunohistochemistry; PD-1, programmed death-1; PD-L1, PD ligand-
1; TIL, tumor-infiltrating lymphocyte.

49. 49
PD-1/PD-L1 in Glioblastoma (cont’d)
*Retrospective analysis (N=563).[1]
• Correlation between PD-L1 expression and response to PD-1 pathway inhibitors
has been considerably variable across tumor types[1,2]
− Predictive value of PD-L1 expression remains under investigation in
ongoing trials, including trials in glioblastoma1
− Positivity cutoffs used in PD-L1 IHC assays can also affect correlation[3]
PD-L1 expression in tumor samples did not correlate with patient
survival*[1]
1. Berghoff AS et al. Neuro Oncol. 2014;pii:nou307.
2. Gettinger SN. Oral presentation at WCLC 2013. MO19.09.
3. Goodman A. The ASCO Post. 2014;5(7).
IHC, immunohistochemistry; PD-1, programmed death-1;
PD-L1, PD ligand-1.

50. 50
Emerging Biomarkers: PD-L1
Expression in[1,2]
Primary glioblastoma
(membranous)
16.7%–
38.3%
Primary glioblastoma
(diffuse/fibrillary)
72.2%–
88%
Prognostic Value
• Tumor cell expression of PD-L1 (and PD-1)
associated with poor outcomes in glioblastoma
patients[2]
Clinical Significance
• Lower expression of PD-L1 on monocytes
was predictive for improved survival in
glioblastoma patients treated with an
autologous peptide vaccine[3]
• Tumor-expressed PD-L1 is being evaluated
for value as a biomarker across multiple tumor
types[4]
PD-1, programmed death-1;
PD-L1, PD ligand-1. 1. Berghoff AS et al. Neuro Oncol. 2015;17(8):1064-1075.
2. Nduom EK et al. Neuro Oncol. 2016; 18(2): 195-205
3. Bloch O et al. Oral presentation at ASCO 2015. 2011.
4. Preusser M et al. Nat Rev Neurol. 2015;11(9):504-514. doi: 10.1038/nrneurol.2015.139.

51. Immunotherapeutic Approaches for
Glioblastoma

52. 52
• Out of all ongoing trials, 19 are Phase III trials*,†[1]
– All novel agents in Phase III trials are immunotherapies[1]
– Immunotherapies are the most likely adjuvant treatments to effectively target
glioblastoma with minimal toxicity[2]
Immunotherapies in Phase III Trials for
Glioblastoma
Trial[1] MOA Study Arms Study Eligibility
NCT01765088
(China)
Chemotherapy +
cytokine
RT  Adjuvant TMZ ± IFN-α
Newly diagnosed grade III
or IV glioma
NCT00045968 Vaccine
DCVax-L vs placebo with standard
treatment‡
Newly diagnosed,
resectable glioblastoma
NCT01480479 Vaccine
Rindopepimut +TMZ vs KLH+TMZ
with standard treatment‡
Newly diagnosed,
resectable EGFRvIII+
glioblastoma
NCT02017717
Checkpoint
Inhibition
Nivolumab vs
nivolumab+ipilimumab vs
bevacizumab after RT+TMZ
Recurrent glioblastoma
1. Clinicaltrials.gov. “Glioblastoma” + “Interventional” + “Adult” +
“Phase III” + “Recruiting” or “Active, not recruiting” search results.
Accessed December 22, 2015.
2. Bloch O, Parsa AT. Neuro Oncol. 2014;16(5):758-759.
* Criteria for Phase III: Open trials for agents that are intended to directly
treat tumors and that have not yet failed.
† 8 are academic/ISRs and 7 are industry-sponsored.[3]
‡ Standard therapy, involving (attempted) surgical resection and
chemoradiation.[3]
DCVax-L, dendritic cell vaccine L; EGFRvIII, epidermal growth factor
receptor variant III; IFN-α, interferon alfa; ISR, industry-sponsored
research; KLH, keyhole limpet hemocyanin; MOA, mechanism of action;
RT, radiotherapy; TMZ, temozolomide.

53. 53
Cell-based vaccines[1,2]:
DCs pulsed with tumor cells or TAAs, or
tumor cell–derived vaccines transferred
back to body to induce immune response
Immunotherapeutic Approaches
in Glioblastoma: Vaccines
Tumor cells DCs
Peptide-based vaccine[1,2]:
Mimic TAAs or tumor-targeting peptides to induce
immune response (± adjuvant)
TAAs
1. Reardon DA et al. Expert Rev Vaccines. 2013;12(6):597-615.
2. Hegde M et al. Discov Med. 2014;17(93):145-154.
3. Mohme M et al. Cancer Treat Rev. 2014;40(2):248-258.DC, dendritic cell; TAAs, tumor-associated antigens.

54. 54
Phase III, randomized, double-blind study evaluating addition of DCVax-L to the
current standard of care in newly diagnosed glioblastoma[1]
DCVax-L: Phase III Trial in Newly Diagnosed
Glioblastoma
N=300
SOC + DCVax-L
SOC + Placebo
Key Inclusion Criteria
• Newly diagnosed, resectable
glioblastoma
• Age 18–70 years
• KPS ≥70
• No PD at the end of RT course
• Adequate BM and liver function
R
2:1
Start Date: December 2006
Estimated Primary Completion Date: September 2016
(Final data collection date for primary outcome
measure)
Status: Ongoing, but not recruiting
Study Director: Northwest Biotherapeutics
• Primary Outcome Measure: PFS
• Secondary Outcome Measure:
OS and TTP
Crossover
option upon PD
Cell-based vaccine
1. Clinicaltrials.gov. NCT00045968.
BM, bone marrow; DCVax-L, dendritic cell vaccine-L; KPS, Karnofsky
performance status; OS, overall survival; PD, progressive disease;
PFS, progression-free survival; R, randomized; RT, radiotherapy;
SOC, standard of care; TTP, time to progression.

55. 55
ICT-107: Phase II Clinical Data
Key Efficacy and Safety Data[3,4,6]
• PFS (ICT-107 vs placebo): 11.4 vs 10.1 mo
• QoL (FACT-BR): Similar between groups
• OS: Benefit not significant
• Strongest activity observed in HLA-A2 subgroup
• No treatment-related Grade > 4 AE observed
• Trend for less steroid use in ICT-107 arm (30% vs.
44%)
• KPS maintained longer in those receiving ICT-107
• ICT-107 (ImmunoCellular Therapeutics, Ltd): Autologous DC vaccine targeting six
different antigens associated with glioblastoma[1,2]
ICT-107
Placebo
R
Newly
diagnosed
glioblastoma
RT+TMZ TMZ or ICT-107 or placebo
Induction MaintenanceN=124
Phase II, randomized, double-blind study evaluating addition of ICT-107 to the current standard
of care in newly diagnosed glioblastoma[2]
• Phase III trial design currently being finalized[4]
• Orphan drug designation in US and Europe[5]
MGMT-stratified
Cell-based vaccine
1. Reardon DA et al. Expert Rev Vaccines. 2013;12(6):597-615.
2. Clinicaltrials.gov. NCT01280552.
3. Wen P et al. Oral presentation at ASCO 2014. 2005.
4. Market Watch. ICT-107. Available at: http://www.marketwatch.com/story/immunocellular-
therapeutics-presents-updated-ict-107-phase-ii-data-in-patients-with-newly-diagnosed-
glioblastoma-at-the-2014-asco-annual-meeting-2014-06-01. Accessed December 17, 2015.
5. ImmunoCellular Therapeutics, Ltd. Overiew of ICT-107. Available at:
http://www.imuc.com/pipeline/ict-107. Accessed December 17, 2015.
6. Wen P et al. Poster presented at ASCO 2015. 2036.
AE, adverse event; DC, dendritic cell; HLA-A2, human leukocyte
antigen A2; MGMT, O6-methylguanine DNA methyltransferase;
FACT-BR, Functional Assessment of Cancer Therapy –Brain ; KPS,
karnofsky Performance Status; OS, overall survival; PFS,
progression-free survival; QoL, quality of life; R, randomized; RT,
radiotherapy; TMZ, temozolomide.

56. 56
• Rindopepimut (Celldex Therapeutics): EGFRvIII-targeted peptide vaccine[1]
– Three Phase II clinical trials demonstrated consistent improvement in mPFS
and mOS over historical controls:
Rindopepimut: Phase II Clinical Data
Trial N Study Design Patients mPFS (mo) mOS (mo)
ACTIVATE[2] 18 RT+TMZ  rindopepimut
• Newly diagnosed
• EGFRvIII+
• GTR
• No PD through CRT
14.2 26
ACT II[3,5] 22
RT+TMZ  rindopepimut 
standard or dose-intensified
TMZ
Overall:
15.2
Overall:
23.6
ACT III[4,5] 65
RT+TMZ  rindopepimut 
TMZ
12.3 24.6
Peptide-based vaccine
– Safety: Across clinical trials, rindopepimut toxicity has been generally mild
and limited to skin reactions at injection site, fatigue, rash, nausea, and
pruritus[2-4]
• Rindopepimut is currently being investigated in Phase III and II trials[1,5]
1. Babu R, Adamson DC. Core Evidence. 2012;7:93-103.
2. Sampson JH et al. J Clin Oncol. 2010;28(31):4722-4729.
3. Sampson JH et al. Neuro Oncol. 2011;13(3):324-333.
4. Lai RK et al. Presentation at SNO 2011.
5. Clinicaltrials.gov. NCT00643097.
CRT, chemoradiotherapy; EGFRvIII, epidermal growth factor receptor
variant III; GTR, gross total resection; mo, months; mOS, median overall
survival; mPFS, median progression-free survival; PD, progressive
disease; RT, radiotherapy; TMZ, temozolomide.

57. 57
HSPPC-96: Overview and Key Data
HSPPC, heat shock protein peptide-complex; SOC, standard of care; mOS,
median overall survival; mPFS, median progression free survival; MGMT,
Hypermethylation of the O6-methylguanine-DNA-methyltransferase
1. Bloch O. Poster presentation at ASCO 2015. Abstract #2011.
2. Clinicaltrials.gov. NCT00905060.
HSPPC-96: Autologous tumor-derived heat shock protein peptide vaccine
A phase II clinical trial was designed to evaluate the addition of HSPPC-96
to SOC for newly diagnosed glioblastoma
Agenus Inc
Trial Design and Key Data[1,2]
Trial Ph Arm Patients N Key Data
Single arm[1] II
•HSPPC-96 administered at 25
µg per dose once weekly, then
monthly with SOC
• Newly diagnosed GBM
• ≥ 90 % tumor resection
46
• mOS = 23.8mo
• mPFS = 17.8mo
• PD-L1 High mOS = 18mo
• PD-L1 Low mOS =
44.7mo
• Adverse events = No
severe (grade 3/4)
adverse events; vaccine
well tolerated
Protein peptide vaccine
• Expression of PD-L1 on peripheral monocytes has been shown to be elevated in glioblastoma patients and was
evaluated as a predictor of survival [1]
• A multivariate proportional hazards model revealed MGMT methylation status and PD-L1 expression as the
greatest independent predictors of survival [1]

58. 58
Summary of Investigational Therapies
and Unmet Needs
Glioblastoma
Pipeline
• Most targeted agents yielding promising results in Phase I
and II trials have failed Phase III trials[1,2]
• 19 Phase III trials are currently ongoing[3]
Immunotherapy
for
Glioblastoma
• Immune escape mechanisms have emerged as a therapeutic
target[4]
• All four novel agents in Phase III are immunotherapies[3]
• Combining treatment modalities may result in increased
effectiveness[5,6]
Survival
• No treatment has improved mOS over TMZ in the past
10 years[1,2]
mOS, median overall survival; TMZ, temozolomide.
1. Anton K et al. Hematol Oncol Clin N Am. 2012;26(4):825-853.
2. Ohka F et al. Neurol Res Int. 2012; 2012:878425. doi:
10.1155/2012/878425.
3. Clinicaltrials.gov. “Glioblastoma” + “Interventional” + “Adult”
+ “Phase III” + “Recruiting” or “Active, not recruiting” search results.
December 17, 2015.
4. Jackson CM et al. Clin Cancer Res. 2014;20(14):3651-3659.
5. Zitvogel L et al. J Clin Invest. 2008;118(6):1991-2001.
6. Drake CG. Ann Oncol. 2012;23(suppl 8):viii41-viii46.