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Ependymoma can occur anywhere in the central nervous system (CNS), but often occurs near the ventricle of the brain and central canal of the spinal cord. Ependymoma accounts for 5.7% of all childhood and 1.9% of all adult CNS tumors. RELA fusion-positive ependymoma is a subgroup associated with supratentorial location, higher WHO grade and worse prognosis. Diffuse Midline Glioma (DMG) is another relatively rare CNS tumor, originating in the midline locations of the brain (including thalamus, pons and spinal cord), accounting for 10% of all childhood and less than 4% of adult CNS tumors. For ependymoma standard treatment includes surgery and radiation therapy, with limited systemic options other than clinical trials for recurrent disease. For DMG, surgical intervention is restricted to biopsy, with radiation as standard therapy. Systemic options for both ependymoma and DMG are limited.VAL-083 is a bi-functional DNA-targeting agent which rapidly induces inter-strand DNA cross-links at N7-guanine inducing double-strand breaks causing cell death and acts independent of MGMT DNA repair and H3F3 K27M mutation status in high-grade gliomas. We report on 2 patients: one with ependymoma and one with DMG, treated with VAL-083 under an expanded access program. Both patients had recent disease progression and limited therapeutic options. Case #1: a 47-year-old male who was diagnosed with a left parietal high grade (3) anaplastic ependymoma and with IDHwt and unmethylated MGMT promoter status. Inter- and intragenic fusion analysis of tumor tissue revealed RELA fusion-positive ependymoma. He had undergone 2 resections and had received radiation and multiple systemic treatment regimens. Case #2: a 21-year-old male who was diagnosed with DMG of the brain stem, with IDHwt and unmethylated MGMT promoter status. He had undergone radiation therapy, and multiple treatment regimens. Both patients were not eligible to participate in any clinical trial and received VAL-083 under an expanded access program. They initiated treatment with VAL-083 (30 mg/m2 for 3 consecutive days every 21 days) and have completed 3 cycles. Both are neurological and radiological stable, they continue to receive VAL-083. No adverse events have been reported and no dose reductions have been required. These cases highlight that VAL-83 may be a treatment option for recurrent RELA fusion-positive ependymoma and DMG refractory to other treatment regimens. Additional safety and efficacy outcomes related to patient status will be presented at the meeting.Clinicaltrials.gov Identifier: NCT03138629. The treatment plans for this EAP patient were approved by MD Anderson Cancer Center IRB. Citation Format: Carlos Kamiya-Matsuoka, Stephanie Knight, Teresa Hanna, Timothy A. Gregory, John Langlands, Dennis Brown, Vinay K. Puduvalli. RELA fusion-positive ependymoma and diffuse midline glioma treated with VAL-083 under expanded access - case reports [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr LB126.

Current standard-of-care for glioblastoma (GBM) includes surgery followed by concurrent therapy with radiation and temozolomide (TMZ) and adjuvant TMZ. Almost all GBM patients experience recurrent/progressive disease despite upfront standard of care treatment, with a median overall survival of 3-9 mo. after recurrence. There are limited treatment options available upon progression of disease which may include potential participation in clinical trials. However, patients may not meet the strictly defined entry criteria to participate in these clinical trials. VAL-083 is a first-in-class bifunctional alkylating agent that acts independent of O6-methylguanine-DNA-methyltransferase (MGMT) methylation status. Under an Expanded Access (EA) program, we have treated 24 patients with recurrent GBM, who were not eligible to participate in clinical trials with VAL-083. Four (4/24; 17%) patients had leptomeningeal disease (LMD) at time of enrolment. While safety data was assessed for all patients, those without LMD (20 patients) were evaluated for efficacy. All patients evaluated for efficacy received chemoradiation with TMZ, and the mean number of adjuvant TMZ cycles was 5 (± 6.2). The median time from last progression to start of VAL-083 was 0.65 mo. (95%CI: 0.32-1.55) and median KPS was 80 (25-75P: 70-90). Eight (8/20; 40%) patients had 2 or more prior recurrences, 9/20 (45%) patients had multifocal disease, and 5/20 (25%) had prior lomustine. Eighteen (18/20; 90%) patients had unmethylated promoter status for MGMT and 18/20 (90%) were IDH wild type. All patients had at least 1 mutation, with 11/20 (55%) having 5 or more mutations, and one patient had hypermutator phenotype with MSH6 mutation. The most common mutations were, TERT 11/20 (55%), PTEN 9/20 (45%), and TP53 6/20 (30%). All patients started treatment with VAL-083 at 30 mg/m2 administered on 3 consecutive days every 21 days. Seven patients received bevacizumab concurrently with VAL-083. VAL-083 was well tolerated and the main adverse events were consistent with prior experience, i.e., thrombocytopenia and neutropenia. Eight (8/24; 33%) patients had a dose reduction, 7 of which were due to thrombocytopenia, and 1 due to neutropenia. Five patients with thrombocytopenia had prior lomustine. As of cut-off date (05 Jan, 2023), median progression free survival (mPFS) and median overall survival (mOS) from last disease progression was 5.9 mo (95%CI: 3.9-7.9) and 9.4 mo (95%CI: 3.0-14.3), respectively. In patients without multifocal disease mOS was even longer, 14.3 mo (95%CI: 3.9-14.3). Use of VAL-083 in this expanded access study showed benefit in the treatment of recurrent GBM patients even those who have had multiple recurrences and were not candidates for the treatment through clinical trial. Additional safety and efficacy measures will be presented at the meeting.Clincialtrials.gov Identifier: NCT03138629. All EA treatment requests and plans were approved by MD Anderson Cancer Center IRB. Citation Format: Carlos Kamiya-Matsuoka, Shiao-Pei Weathers, Rebecca A. Harrison, Nazanin K. Majd, Ashley E. Aaroe, Stephanie Knight, Teresa Hanna, Timothy A. Gregory, John Langlands, Dennis Brown, Vinay K. Puduvalli. VAL-083 in patients with recurrent glioblastoma treated under expanded access program [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr LB127.

Gliomas are recalcitrant brain tumors. Differential tumor immune reactivity contributes to survival advantage of isocitrate dehydrogenase-mutant (IDHmut) over wild-type (IDHwt) gliomas. Despite this correlative pattern of immunity and survival, only a limited view of a highly complex immune contexture across IDH mutation classified gliomas is known. Herein, we present an unprecedented view of myeloid and lymphoid cell type diversity by single cell RNA sequencing and spectral cytometry-based interrogation of tumor-associated leukocytes from fifty-five IDH stratified primary and recurrent human gliomas and six non-glioma brains. Our analyses revealed twenty-two myeloid and lymphoid cell types within and across glioma subtypes. Glioma severity in relapsed IDHwt correlated with microglial attrition concomitant with a continuum of invading monocyte-derived microglia-like and macrophages amongst other infiltrating conventional T and NK lymphocytes and unconventional mucosa associated invariant T (MAIT) cells. Specifically, certain microglial and monocyte-derived subpopulations were associated with antigen presentation gene modules, akin to cross-presenting dendritic cells (DCs). As tissue macrophages exhibit multifaceted polarization in response to microenvironmental cues, we clarify the existence of microglia/macrophage functional states beyond M1/M2 paradigms exemplified by the presence of palmitic-, oleic- acid, and glucocorticoid responsive polarized states. Immune related gene ontology analysis identified enriched antigen presentation and phagocytosis gene modules in distinct microglia-like clusters. Importantly, the phagocytic immunomodulator; Triggering Receptor Expressed on Myeloid Cells 2 (TREM2) was upregulated in these microglia-like cells. Contrary to tumor promoting role of TREM2 myeloid cells in non-brain cancers, we identify TREM2 mediated anti-glioma axis as a regulator of antigen presentation Accelerated glioma growth was observed in Trem2 deficient mice implanted with CT2A glioma cells affirming the anti-glioma role of TREM2+ myeloid cells. In addition to providing an advanced landscape of glioma-specific immune contexture for immunotherapy applications, our reverse translational investigations discover TREM2 as a novel immunotherapy target for brain malignancies. Citation Format: Pravesh Gupta, Minghao Dang, Shivangi Oberai, Mekenzie Peshoff, Nancy Milam, Aml Ahmed, Krishna Bojja, Tuan M. Tran, Kathryn Cox, Huma Shehwana, Carlos Kamiya Matsuoka, Jianzhuo Li, Joy Gumin, Alicia Goldman, Sameer A. Seth, Atul Maheshwari, Frederick F. Lang, Nicholas E. Navin, Amy B. Heimberger, Karen Clise Dwyer, Linghua Wang, Krishna P. Bhat. Immunophenotyping of human brain tumors reveals myeloid cell mediated anti-glioma axis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 669.

Glioblastoma (GBM) is the most common and aggressive primary brain cancer. Current standard-of-care for glioblastoma (GBM) includes surgery followed by concurrent therapy with radiation and temozolomide (TMZ) followed by adjuvant TMZ (days 1-5 every 28 days). Almost all GBM patients experience recurrent/progressive disease, with a median survival of 3-9 months after recurrence. Second-line treatment for recurrent GBM with bevacizumab (BEV) has not improved survival, and effective therapies for GBM are lacking. Unmethylated promoter status for O6-methylguanine DNA methyltransferase (MGMT) is a validated biomarker for TMZ-resistance and is correlated with poor prognosis. VAL-083 is a bi-functional DNA-targeting agent rapidly inducing interstrand cross-links at N7-guanine, leading to DNA double-strand breaks and cell death. VAL-083's cytotoxicity is independent of MGMT status, and VAL-083 overcomes TMZ-resistance in GBM cell lines, GBM cancer stem cells, and in vivo GBM models. The trial described here is an open-label two-arm biomarker-driven phase 2 clinical trial in MGMT-unmethylated GBM patients with either recurrent disease (Group 1) or newly diagnosed GBM patients requiring adjuvant therapy after chemoirradiation with temozolomide (Group 2). Patients receive VAL-083 IV at 30 or 40 mg/m2/day on days 1, 2, and 3 of a 21-day cycle. The primary objective of this study is to determine the effect of VAL-083 on median overall survival (mOS) in MGMT-unmethylated recurrent GBM patients (Group 1) compared to historical control, and progression-free survival (PFS) in newly diagnosed GBM patients requiring adjuvant therapy after chemoirradiation with temozolomide (Group 2), compared to historical control. Secondary efficacy endpoints include progression-free survival (PFS) (Group 1), overall response rate (ORR), duration of response (DOR), and quality-of-life (QoL). Tumor response will be assessed by MRI approximately every 42 days, as per RANO criteria. The initial starting dose in this study was 40 mg/m2/day, which was subsequently reduced to 30 mg/m2/day to improve tolerance due to myelosuppression. As of 21st January 2020, thirty-five (35) subjects had enrolled at a starting dose of 40 mg/m2/day, and 31 subjects had enrolled at a starting dose of 30 mg/m2/day in Group 1, and 9 subjects enrolled at a starting dose of 30 mg/m2/day in Group 2. As anticipated from prior studies with VAL-083, myelosuppression (thrombocytopenia and neutropenia) has been the most common adverse event observed. Enrollment and safety data update will be provided at the meeting. Clinicaltrials.gov identifier: NCT02717962 Citation Format: Barbara J. O'Brien, Carlos Kamiya-Matsuoka, Shiao-Pei Weathers, Alfred Yung, Monica Loghin, Rebecca Harrison, Nazanin Majd, Jeffrey A. Bacha, Dennis M. Brown, Anne Steino, Gregory Johnson, Sarath Kanekal, John Langlands, Lorena M. Lopez, Richard M. Schwartz, Marta Penas-Prado, John F. de Groot. Phase 2 study of dianhydrogalactitol (VAL-083) in patients with MGMT-unmethylated, bevacizumab-naïve glioblastoma in the recurrent or adjuvant setting [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT272.

Glioblastoma (GBM) is the most common and aggressive primary brain cancer. Current standard-of-care includes surgery followed by concurrent therapy with radiation and temozolomide (TMZ) and maintenance TMZ. Almost all GBM patients experience recurrent/progressive disease, and median survival after recurrence is 3-9 months. Effective therapies for recurrent GBM (rGBM) are lacking, representing a significant unmet medical need. The unmethylated promoter for O6-methylguanine-DNA-methyltransferase (MGMT) is a validated biomarker for TMZ-resistance and is correlated with poor prognoses. Second-line treatment with the anti-angiogenic agent bevacizumab (BEV) has not improved survival, and 5-year survival is less than 3%. VAL-083 is a bi-functional DNA-targeting agent that rapidly induces interstrand cross-links at N7-guanine, leading to DNA double-strand breaks and cell-death. VAL-083’s cytotoxicity is independent of MGMT status, and VAL-083 overcomes TMZ-resistance in GBM in vitro and in vivo models. We previously completed a 3+3 dose-escalation trial of VAL-083 in TMZ- and BEV-refractory rGBM. 40mg/m2/day given on days 1-3 of a 21-day cycle was generally well-tolerated, and this dose was selected for further clinical evaluation in Phase II trials. The trial described here is an ongoing single-arm, biomarker-driven Phase II trial in MGMT-unmethylated BEV-naïve adult rGBM. In this trial, patients are receiving VAL-083 at 30 or 40mg/m2/day on days 1-3 of a 21-day cycle. Tumor response is assessed by MRI approximately every 42 days, per RANO criteria. The primary objective of this study is to determine if VAL-083 improves median overall survival (mOS) for MGMT-unmethylated rGBM patients compared to a historical mOS of 7.1 months for such patients treated with lomustine (EORTC26101). Secondary efficacy endpoints include progression-free survival (PFS), overall response rate (ORR), duration of response (DOR), and quality-of-life (QOL) evaluation using the MD Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) self-reporting tool. Thirty-five (35) subjects have received 40 mg/m2/day VAL-083 as the starting dose. Consistent with prior studies, myelosuppression (thrombocytopenia and neutropenia) is the most common adverse event in this study, and we observed that a higher potential for myelosuppression appears to be inversely correlated with the number of cycles of prior TMZ maintenance therapy, (>5 cycles vs. ≤5 cycles, p Citation Format: Barbara O'Brien, John De Groot, Carlos Kamiya-Matsuoka, Shiao-Pei Weathers, Jeffrey Bacha, Dennis Brown, Anne Steino, John Langlands, Richard Schwartz, Sarath Kanekal, Lorena Lopez, Marta Penas-Prado. Phase II study of dianhydrogalactitol (VAL-083) in patients with MGMT-unmethylated, bevacizumab-naïve recurrent glioblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT115.

Glioblastoma (GBM) is the most common and aggressive primary brain cancer. Current standard of care includes surgery followed by concurrent therapy with radiation and temozolomide (TMZ) and maintenance TMZ. The vast majority of GBM patients experience recurrent/progressive disease within a year from initial diagnosis, and median survival after recurrence is 3-9 months. Effective therapies for recurrent GBM (rGBM) are lacking and these patients have a dismal prognosis, representing a significant unmet medical need. Unmethylated promoter status for O6-methylguanine-DNA-methyltransferase (MGMT), a validated biomarker for TMZ-resistance, is strongly correlated with TMZ-resistance. Second-line treatment with the anti-angiogenic agent bevacizumab has not improved survival and 5-year survival is less than 3%. VAL-083 is a bi-functional DNA-targeting agent rapidly inducing interstrand cross-links at N7-guanine, leading to DNA double-strand breaks and cell-death. VAL-083's cytotoxicity is independent of MGMT status in vitro and VAL-083 overcomes TMZ-resistance in GBM cell lines, GBM cancer stem cells and in vivo GBM models. We completed a 3:3 dose-escalation trial of VAL-083 in TMZ- and bevacizumab-refractory rGBM. 40mg/m2/day given on days 1, 2, and 3 of a 21-day cycle was well-tolerated with 6% grade 3 or 4 thrombocytopenia. This dose was selected for further clinical development in a pivotal Phase 3 study in TMZ- and bevacizumab-refractory rGBM. The trial described here is an ongoing single-arm, biomarker-driven Phase 2 clinical trial in MGMT-unmethylated bevacizumab-naïve adult rGBM. 48 patients will receive VAL-083 40mg/m2/day on days 1, 2, and 3 of a 21-day cycle. Tumor response will be assessed by MRI approximately every 42 days, according to RANO criteria. The primary objective of this study is to determine if VAL-083 improves overall survival (OS) for MGMT-unmethylated rGBM patients compared to a historical median survival control of 7.2 months for MGMT-unmethylated rGBM patients treated with lomustine (Wick et al, EORTC26101). Secondary efficacy endpoints include progression-free survival (PFS), overall response rate (ORR), duration of response (DOR), and to evaluate the occurrence of symptoms and to evaluate quality of life (QOL) measures during the progression-free period using the MD Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) self-reporting tool. Enrollment and safety data update will be provided at the meeting. Clinicaltrials.gov identifier: NCT02717962. Citation Format: Barbara J. O'Brien, John De Groot, Carlos Kamiya-Matsuoka, Shiao-Pei Weathers, Jeffrey A. Bacha, Dennis M. Brown, Anne Steino, John Langlands, Richard Schwartz, Sarath Kanekal, Lorena Lopez, Marta Penas-Prado. Phase II study of dianhydrogalactitol (VAL-083) in patients with bevacizumab-naive recurrent glioblastoma, MGMT-unmethylated [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT167.

INTRODUCTION Hypermutation is the excessive accumulation of DNA mutation in cancer cells. This specific hypermutated genotype has been reported in low and high grade gliomas, specifically post-temozolomide treatment and is associated with treatment-resistance. Herein, we sought to identify an imaging-based signature for hypermutated gliomas using a radiomics-based approach. MATERIALS AND METHODS In this IRB-approved retrospective study, we analyzed a total of 101 patients with primary gliomas from the University of Texas MD Anderson Cancer Center. Next generation sequencing (NGS) platforms (T200 and Foundation 1) were used to determine the Mutation burden status in post-biopsy (stereotactic/excisional). Patients were dichotomized based on their mutation burden; 77 hypomutated (=30 mutations or RESULTS We found 100 radiomic features that can discriminate between hypermutated versus hypomutated gliomas, AUC 96.3% (CI: 90.2%-98.9%), Sensitivity 100%, Specificity 95%, p-value=3.769e-6. CONCLUSION Hypermutated gliomas has a unique radiomic quantitative signature that can be used to predict mutation burden regardless of tumor grade or histopathology. Citation Format: Islam Hassan, Aikaterini Kotrotsou, Carlos Kamiya Matsuoka, Kristin D. Alfaro-Munoz, Nabil Elshafeey, Nancy El Shafei, Pascal O. Zinn, John F. de Groot, Rivka R. Colen. A radiomic-based MRI phenotype is uniquely associated with hypermutated genotype in gliomas [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2955.

Glioblastoma (GBM) is the most common and aggressive primary brain cancer. Current standard of care includes surgery, radiation and treatment with temozolomide (TMZ), however nearly all tumors recur and the prognosis for recurrent GBM is dismal. Most GBM tumors have unmethylated promoter status for O6-methylguanine-DNA-methyltransferase (MGMT); a validated biomarker for TMZ-resistance. Second-line treatment with anti-angiogenic agent bevacizumab has not improved overall survival (OS) and 5-year survival is less than 3%. Dianhydrogalactitol (VAL-083) is a bi-functional alkylating agent targeting N7-Guanine and inducing interstrand cross-links, DNA double-strand breaks and cell-death in GBM cell-lines and GBM cancer stem cells. VAL-083’s cytotoxicity is independent of MGMT status and VAL-083 overcomes TMZ-resistance in vitro. Our recent phase I/II clinical trial in recurrent GBM patients failing both TMZ and bevacizumab, suggested VAL-083 offers clinically meaningful survival benefits for patients with recurrent GBM and pinpointing a new dosing regimen (40 mg/m2/d on days 1,2,3 of a 21-day cycle). A pivotal Phase 3 study in recurrent GBM after failing both TMZ and bevacizumab is being planned. If successful, this study will serve as the basis for a New Drug Application (NDA) submission for VAL-083. In addition, a single-arm Phase 2 study to confirm the tolerability of the new dosing regimen in combination with radiotherapy and to explore the activity of VAL-083 in newly diagnosed MGMT-unmethylated GBM patients whose tumors are known to express high MGMT levels is proceeding. In the present Phase 2 clinical trial, the main goal is to assess the overall survival (OS) in MGMT-unmethylated, recurrent, bevacizumab-naïve GBM. RATIONALE: The vast majority of GBM patients experience recurrent/progressive disease within a year from initial diagnosis and median survival after recurrence is 3-9 months. Chemotherapy regimens for these patients are lacking and there is a significant unmet medical need. Given VAL-083’s novel alkylating mechanism, promising clinical benefit, and favorable safety profile, a trial studying VAL-083 in MGMT-unmethylated recurrent GBM is warranted. METHOD: Open label, single-arm, biomarker-driven Phase 2 clinical trial in MGMT-unmethylated adult GBM patients at first recurrence/progression, prior to bevacizumab. 48 patients will be enrolled to determine if treatment with VAL-083 will improve OS at 9-months compared to historical control with lomustine. The patients will receive VAL-083 40mg/m2/day on days 1,2,3 of a 21-day cycle. Patients will be followed until death or for at least 9 months from enrollment, whichever occurs earlier. Survival will be compared to recently published EORTC26101 for recurrent MGMT-unmethylated GBM patients treated with lomustine. Secondary outcome measures include progression-free survival and overall response rate. Clinicaltrials.gov identifier: NCT02717962. Citation Format: Barbara J. O'Brien, Jeffrey A. Bacha, Dennis M. Brown, Anne Steino, Richard Schwartz, Sarath Kanekal, Lorena Lopez, Marta Penas-Prado. Phase II study of dianhydrogalactitol in patients with MGMT-unmethylated bevacizumab-naive recurrent glioblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT054. doi:10.1158/1538-7445.AM2017-CT054