The document discusses optimizing chemotherapy for malignant glioma. Meta-analyses showed that combining temozolomide (TMZ) with radiotherapy improved survival rates compared to radiotherapy alone. A phase III trial demonstrated that concomitant and adjuvant TMZ with radiotherapy significantly improved progression-free and overall survival. Subset analyses found the benefit was consistent across patient subgroups. Methylation of the MGMT gene promoter was identified as predictive of benefit from TMZ therapy.

1. Optimizing Chemotherapy for Malignant Glioma State of the Art & Future Directions Roger Stupp, MD Multidisciplinary Oncology Center University Hospital (CHUV) Lausanne / Switzerland

2. Meta-analysis: Survival Lancet 359:1011-1018, 2002 12-mo surv: 40%  46% 24-mo surv: 15%  20% median: + 2 mo

3. Situation 1998 Synergy between RT and TMZ in vitro Continuous administration of TMZ feasible, increases drug exposure (Brock, Newlands et al. Cancer Res 58:4363-67, 1998) Improved outcome of concomitant chemoradiotherapy in other solid tumors (e.g. cervix cancer, head&neck cancer)

4. TMZ & RT: Treatment Scheme TMZ 75mg/m 2 qd x 6-7 wks TMZ 200 mg/m 2 qd x 5 day repeat every 28 days x 6 cycles wks Focal Radiotherapy (30 x 2 Gy, 60 Gy) Tumor volume with 2-3 cm margin

5. TMZ & RT: Promising Survival Stupp R et al. J Clin Oncol. 2002;20:1375-82 Stupp R & Hegi ME. ASCO Education Book, 2003

6. Phase III Trial of Concomitant and Adjuvant Temozolomide and Radiotherapy for Newly Diagnosed Glioblastoma Multiforme EORTC 26981-22981 and NCIC CE.3 Roger Stupp , WP Mason, MJ Van Den Bent, M Weller, B Fisher, MJB Taphoorn, K Belanger, AA Brandes, JG Cairncross, C Marosi, U. Bogdahn, J. Curschmann, RC Janzer, S Ludwin, T Gorlia, A Allgeier, D Lacombe, E Eisenhauer, RO Mirimanoff On behalf of the European Organization for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups and National Cancer Institute of Canada Clinical Trials Group

7. Treatment Schema Temozolomide 75 mg/m 2 po qd for 6 weeks, then 150–200 mg/m 2 po qd d1–5 every 28 days for 6 cycles Focal RT daily — 30 x 200 cGy Total dose 60 Gy Concomitant TMZ/RT* Adjuvant TMZ Weeks 6 10 14 18 22 26 30 RT Alone R 0 *PCP prophylaxis was required for patients receiving TMZ during the concomitant phase.

8. Patient Eligibility Newly diagnosed, histologically proven GBM Age 18–70 years WHO PS 0-2 ≤ 6 weeks since biopsy or resection No prior chemotherapy or RT Adequate bone marrow, hepatic and renal function Written informed consent

9. Patient Characteristics 17 16 Biopsy only 83 84 Debulking surgery 67 75 Baseline Steroids (%) 87/13 88/12 PS 0–1 vs 2 (%) 64/36 61/39 M/F (%) 56 (19–70) 57 (23–71) Median age, yr TMZ/RT n=287 RT Alone n=286

10. TMZ / RT Treatment and Surveillance TMZ 75 mg/m2 daily (7 days per week) from day 1 of RT until last day of RT (max 49 days, theoretical duration 40 days) TMZ approx. 1 hour before RT Antiemetic prophylaxis only first days; eg. Day 1-2: 5HT3 antagonist (e.g. Zofran 4 mg) Day 3-4: Metoclopramide or Motilium 10 mg Day 5+: try without any antiemetics RT daily Monday-Friday, 30 fraction of 2 Gy Complete blood count weekly Pneumocystis carinii prophylaxis with either Pentamidine inhalations every 4 weeks Trimethoprim/Sulfametoxazole (Bactrim forte) 3 x per wk

11. During RT ± TMZ: Grade 3/4 Toxicities Hemato. tox. Non-hem. tox. 1 1 Visual 3 2 Infection <1 1 Nausea/Vomiting 1 1 Rash/Dermatologic 9 6 Fatigue/Constitutional Sx 3 0 Thrombocytopenia 1 0 Febrile neutropenia 4 0 Neutropenia 3 0 Leukopenia <1 0 Anemia TMZ/RT n=287 % RT Alone n=286 %

12. Adjuvant TMZ Treatment Delivery n=287* *22% (n=64) randomized to TMZ/RT did not receive any adjuvant TMZ. Reason for Early Discontinuation: Cycle completed

13. Progression Free Survival months 0 6 12 18 24 30 36 42 0 10 20 30 40 50 60 70 80 90 100 RT TMZ/RT Median PFS, mo: 5.0 6.9 1-yr PFS: 9% 27% 2-yr PFS: 2% 11% HR [95% C.I.]: 0.54 [0.45-0.64] p <0.0001 TMZ/RT RT TMZ/RT RT % Stupp et al. N Engl J Med 2005, 352:987-996 O N Number of patients at risk : 281 286 104 26 11 4 0 0 260 287 154 77 51 24 8 1

14. Overall Survival months 0 6 12 18 24 30 36 42 0 10 20 30 40 50 60 70 80 90 100 RT TMZ/RT Median OS, mo: 12.1 14.6 2-yr survival: 10% 26% HR [95% C.I.]: 0.63 [0.52-0.75] p <0.0001 RT TMZ/RT TMZ/RT RT % Stupp et al. N Engl J Med 2005, 352:987-996 O N Number of patients at risk : 261 286 240 144 59 23 2 0 219 287 246 174 109 57 27 4

15. Subset Analysis Overall Survival 0.0 0.5 1.0 1.5 2.0 Hazard Ratio with 95% C.I. Stupp et al. N Engl J Med 2005, 352:987-996 (appendix) Males (175/185) Females (110/102) Baseline steroids (215/193) No Baseline steroids (70/94) Mini-mental status ≥ 29 (148/149) ≤ 28 (126/128) WHO PS = 0 (112/116) PS = 1 (140/135) PS = 2 (34/36) Biopsy Only (46/47) Resected (240/240) Age < 50 (81/90) ≥ 50 (205/197) ITT Population (286/287)

16. Implications - Paradigm Change Chemotherapy improves outcome in patients with malignant glioma, incl. long-term survival (years !) Prognosis is now comparable or even superior to many of the common solid tumors (e.g. NSCLC) Concomitant chemoradiotherapy and treatment early in the disease course is of importance. Identification of patients most likely to benefit from therapy is needed. Clinical criteria alone not helpful. Molecular Analyses: MGMT

17. 06-Methylguanine-DNA Methyltransferase (MGMT) N N N N O dR MGMT Gene located on CHR 10q26 encodes DNA repair enzyme removes methyl -groups from O 6 alkylguanine linked with resistance to alkylating agent therapy TMZ, methylating agent NH 2 O 6 - methyl guanine CH 3 MGMT NH 2 NH CH 2 CH CO COOH HS repair Guanine N N N NH 2 O dR NH irreversible inactivation degradation NH 2 NH CH CH CO COOH S 2 CH 3

18. MGMT repair gene silencing by gene promoter methylation MGMT GENE expression Promoter region expression Normal Tumor Tumor No repair protein No repair of TMZ treatment induced DNA damage Response to tumor treatment Improved survival of glioblastoma patient methylated no « turned off »

19. MGMT Promoter Methylation is Prognostic 0 5 10 15 20 25 30 35 40 0 10 20 30 40 50 60 70 80 90 100 months Overall Survival Unmethylated N = 114 (55%) Methylated, N = 92 (45%) N=206 Unmeth Meth Median OS, mo: 12.2 18.2 HR [95% CI]: 0.45 [0.32-0.61] Logrank test: p <0.0001 Risk of death reduced by 55% Hegi et al. N Engl J Med, 352: 997-1003, 2005

20. MGMT is Predictive for Benefit from TMZ Treatment Unmethylated MGMT RT TMZ/RT Median OS, mo: 11.8 12.7 2-yr survival: 1.9% 13.8% Logrank : p = 0.062 Logrank : p = 0.0074 Hegi et al. N Engl J Med 2005, 352:997-1003 months 0 4 8 12 16 20 24 28 32 36 40 0 10 20 30 40 50 60 70 80 90 100 Overall Survival TMZ / RT RT Methylated MGMT 0 5 10 15 20 25 30 35 40 0 10 20 30 40 50 60 70 80 90 100 TMZ / RT RT months RT TMZ/RT Median OS mo: 15.3 21.7 2-yr surviva,l 22.7% 46.0%

21. Treatment after Progression 22 17 Palliative Care only 5 4 Repeat RT 23 23 Surgery 25 65 Temozolomide 58 72 Any Additional Chemotherapy TMZ /RT n=287 % RT Alone n=286 % At the discretion of treating physician

22. PFS: MGMT Methylation Status: a predictive factor for TMZ benefit months 0 4 8 12 16 20 24 28 32 36 40 0 10 20 30 40 50 60 70 80 90 100 O N Number of patients at risk : 54 54 28 9 0 0 0 0 0 0 0 53 60 44 18 8 8 8 7 5 3 1 45 46 33 15 7 3 2 1 0 0 0 40 46 35 28 18 14 10 6 3 1 0 Unmeth, RT alone Unmeth, TMZ/ RT Meth, RT alone Meth, TMZ/ RT Overall Wald test: p <0.0001 (df=3) Progression Free Survival Meth, TMZ / RT Meth, RT Unmeth, TMZ / RT Unmeth RT Hegi et al. N Engl J Med 2005, 352:997-1003

23. RTOG0525/EORTC Intergroup Phase III Study TMZ daily x 6 wks R Radiotherapy (30 x 2 Gy) Concomitant Phase Adjuvant (maintenance) Phase (6 mo) Dose dense TMZ (100 mg/m2 daily x 21d) Stratify by: MGMT methylation Tissue For additional information contact: RTOG: www.rtog.org or EORTC: www.eortc.be ; or the study chairs: Mark Gilbert: [email_address] or Roger Stupp: [email_address]

24. 1p/19q LOH predicts response to PCV-chemotherapy J. Gregory Cairncross et al JNCI 90:1473-79, 1998

25. EORTC 26951: RT ± adj. PCV R Radiotherapy (33x1.8 Gy) Adj. PCV (6 cycles) N=185 N=183 Progression-free survival P=0.002 Overall survival P=0.226 van den Bent et al., Proc ASCO 2005 {abstr #1503} van den Bent et al., J Clin Oncol 24:2715-2722, 2006

26. EORTC 26951: Genetic markers 1p/19q LOH 1p LOH 19q LO H No LOH 1p/19q LOH No 1p LOH PCV + PCV - PCV + PCV - Overall survival by genetic marker Genetic marker and treatment van den Bent et al. J Clin Oncol 24: 2715-2722, 2006

27. RTOG 94-02: Chemo for oligos R Radiotherapy (33x1.8 Gy) Adj. PCV (6 cycles) N=185 N=183 Cairncross et al. J Clin Oncol 24:2707-2714, 2006

28. RTOG 94-02: Chemo for oligos R Radiotherapy (33x1.8 Gy) Adj. PCV (6 cycles) N=185 N=183 Cairncross et al. J Clin Oncol 24:2707-2714, 2006

29. TMZ in Oligos Adapted from Stupp et al. Curr Opin Neurol 2005

30. TMZ in low-grade glioma Adapted from Stupp et al. Curr Opin Neurol 2005

31. EORTC/NCIC 22033-26033: Phase III Trial in LGG CHEMOTHERAPY (PCV, TMZ) RADIOTHERAPY 50.4 Gy (28 x1.8 Gy) Eligibility: age > 40 tumor > 5 cm crossing midline/unresectable neurological symptoms Stratification: Age Resection Histology (Oligo vs. Astro vs. mixed) 1p loss (yes/no/unknown.) CHEMOTHERAPY TMZ 75 mg/m2 x 21d / q28d x 12 cy

32. New Paradigms Role of chemotherapy is now established Treat early in the disease course Concomitant chemoradiotherapy has shown promise in malignant glioma, similar to other solid tumors (e.g. head&neck cancer, cervix cancer, lung cancer) There is no justification to refuse treatment for malignant glioma patients as prognosis is equivalent and even superior to many other solid tumors. Temozolomide chemotherapy is a safe and commonly well tolerated treatment. Identification of patients most likely to benefit from therapy is needed. Clinical criteria alone not helpful Molecular analyses, availability of fresh tissue should become a mandatory and routine procedure just like the H&E stain