The primary objective of this study is to estimate the overall survival of children and
young adults with diffuse intrinsic pontine glioma treated (DIPG) with a molecularly based
treatment strategy, compared to historical controls.
Four Biopsies of tumor tissue will be obtained by surgical biopsy prior to treatment
stratification if tolerated. An MRI-guided frameless or frame-based stereotactic biopsy will
be performed approaching the pontine termentum through a trans-cerebellar or trans-frontal
route. The exact biopsy location will be determined by the treating neurosurgeon at the
designated participating site with the goal of minimizing procedural risk.
Following biopsy,all patients will receive local radiotherapy to consist of 59.4Gy delivered
using conventional conformal or other standard treatment planning with adjuvant bevacizumab.
Radiation planning can begin with the pre-operative images. Based upon molecular parameters
after biopsy, patients will potentially receive erlotinib and/or temozolomide at the start
of radiotherapy. Bevacizumab will be given concurrently with radiotherapy beginning at least
three weeks from the biopsy and at least two weeks after the start of radiation therapy to
ensure that primary wound healing has occurred. Once irradiation is complete, patients will
have a four week interim period before beginning the maintenance phase. Adjuvant
chemotherapy will be continued during the interim period.
The maintenance phase (approxmiately 40 weeks) will last for 10 cycles(28 days +/- 3 days).
Based upon molecular parameters as determined at the time of diagnostic biopsy, patients
will continue to receive erlotinib and/or temozolomide along with bevacizumab during the
Stratification will be based on O6-methylguanine-DNA methyltransferase (MGMT) promoter
methylation status and epidermal growth factor receptor (EGFR) expression in tumor biopsy
samples. If MGMT status and/or EFGR status are not determinable, patients may be treated as
per cohort #1(bevacizumab and irradiation) but will be analyzed separately.
Participants must meet the following criteria on screening examination to be eligible to
participate in the study:
1. Tumor: Newly diagnosed non-disseminated diffuse intrinsic pontine glioma based on
classic clinical AND radiographic finding.
2. No prior radiation therapy or chemotherapy.
3. Age: Patient must be 3 to < 18 years of age at the time of diagnosis.
4. Performance Score: Karnofsky Performance Scale > 12 y/o >/= 50 or Lansky
Performance Score for patients < 12y/o 50 assessed within two-weeks prior to
5. Participants must have normal organ and marrow function as defined below within two
week s prior to enrollment:
- Absolute neutrophil count > 1,000/mcL
- Platelets > 100,000/mcL (transfusion independent)
- Hemoglobin > 8gm/dL (can be transfused)
- Hepatic: Total bilirubin < 1.5 times the upper limit of normal; alanine
aminotransferase [SGPT (ALT)] and aspartate aminotransferase [SGOT (AST)] < 5
times the institutional upper limit of normal.
- Renal: Serum creatinine which is less than 1.5x the upper limit of institutional
normal for age or Glomerular Filtration Rate (GFR) > 70 ml/min/1.73m2.
6. Female patients of childbearing potential must have negative serum or urine pregnancy
test. Patient must not be pregnant or breast feeding.
7. Patients of childbearing or child-fathering potential must be willing to use a
medically acceptable form of birth control, which includes abstinence, while being
treated on this study.
8. Ability to understand and the willingness to sign a written informed consent
1. Patients must not have any significant medical illnesses that in the investigator's
opinion cannot be adequately controlled with appropriate therapy or would compromise
the patient's ability to tolerate this therapy.
2. Patients receiving any other anticancer or experimental drug therapy.
3. Patients with disseminated intrinsic diffuse brainstem gliomas in either brain or
spine (can be based on clinical evaluation).
4. Participants receiving any medications or substances that are strong/intermediate
inhibitors or inducers of Cytochrome P450 (CYP450), Cytochrome P3A4(CYP3A4) or
Cytochrome 1A2 (CYP1A2) are ineligible. Lists including medications and substances
known or with the potential to interact with the CYP450 CYP3A4 or CYP1A2 isoenzymes
are provided in Appendix I.
5. Use of hematopoietic growth factors within the 2 weeks prior to initiation of
6. Patients with evidence of spontaneous hemorrhage greater than 0.5cm unrelated to
7. Uncontrolled intercurrent illness including, but not limited to ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance with
8. Pregnant women are excluded from this study because bevacizumab, temozolomide and
erlotinib can have potential for teratogenic or abortifacient effects. Because there
is an unknown but potential risk of adverse events in nursing infants secondary to
treatment of the mother with these agents, breastfeeding should be discontinued.
Minimum Eligible Age: 3 Years
Maximum Eligible Age: 18 Years
Eligible Gender: Both
Safety and feasibility of performing biopsy and obtaining tissue useful for histologic diagnosis, immunohistochemistry and DNA analyses in newly diagnosed DIPG patients
Toxicity profiles of the 4 treatment strata
Progression free survival of children and young adults with diffuse intrinsic pontine glioma treated with a molecularly based treatment strategy, compared to historical controls (COG ACNS0126).
Molecular pathology analyses
Correlation of imaging including perfusion/diffusion, diffusion tensor imaging (DTI) and magnetic resonance imaging (MRS) scan with patient response and outcome