Oral ONC201 in Recurrent GBM, H3 K27M Glioma, and Midline Glioma
Oral ONC201 in Recurrent GBM, H3 K27M Glioma, and Midline Glioma
ONC201 is a new drug candidate that kills cancer cells but not normal cells in laboratory
 studies and has been previously evaluated in a phase I clinical trial in advanced cancer
 patients. This clinical trial will enroll patients with recurrent glioblastoma or recurrent
 WHO Grade IV gliomas with the H3 K27M mutation.
Inclusion Criteria:

 Histologically confirmed World Health Organization Grade IV glioblastoma. WHO Grade IV
 gliomas will be allowed on protocol. For Arm D: Must have a WHO Grade IV glioma as per
 above and tumor must harbor a histone H3 K27M mutation as evidenced by testing any tumor
 sample with an immunohistochemistry or DNA sequencing test. For Arm E: Must have clinical
 and/or radiographic evidence of a diffuse midline glioma defined as a WHO Grade IV glioma
 involving the brainstem, thalamus or spinal cord and be eligible for salvage surgical
 resection as deemed by the site Investigator. For Arm F: Must have a diffuse midline
 glioma, defined as a WHO Grade IV glioma involving the brainstem, thalamus or spinal cord,
 without the H3 K27M mutation or with unknown H3 mutation status.

 Unequivocal evidence of progressive disease on contrast-enhanced brain computerized
 tomography (CT) or magnetic resonance imaging (MRI) as defined by Response Assessment in
 Neuro-Oncology Criteria (RANO), or have documented recurrent glioblastoma on diagnostic
 biopsy.

 Previous first line therapy with at least radiotherapy and temozolomide. For Arms D, E, and
 F, previous first line therapy with at least radiotherapy

 For Arm A or D: Any number of recurrences are allowable. For Arm B: First recurrence (only)
 WHO Grade glioma. First recurrence is defined as progression following initial therapy
 (i.e., radiation ± chemotherapy). For participants who had prior therapy with radiation or
 chemotherapy for a low-grade glioma, the surgical diagnosis of a high-grade glioma will be
 considered the first recurrence. For patients who did not get additional treatment
 following surgery and diagnosis of low-grade glioma, surgical diagnosis of high grade
 glioma will not be considered the first recurrence. Instead, progression after treatment
 will be considered first recurrence. For Arm C: Patients must have clinical and/or
 radiographic evidence of first recurrence of glioblastoma and be eligible for salvage
 surgical resection as deemed by the site Investigator. For Arm E: Patients must have
 clinical and/or radiographic evidence of recurrence of diffuse midline glioma defined as a
 WHO Grade IV glioma involving the pons, thalamus or spinal cord, and be eligible for
 salvage surgical resection as deemed by the site Investigator.

 Must be 12 weeks from radiotherapy. If patients are within 12 weeks of radiotherapy, then
 the progressive lesion must be outside of the high-dose radiation target volume or have
 unequivocal evidence of progressive tumor on a biopsy specimen.

 From the projected start of scheduled study treatment, the following time periods must have
 elapsed: 5 half-lives from any investigational agent, 4 weeks from cytotoxic therapy
 (except 23 days for temozolomide and 6 weeks from nitrosoureas), 6 weeks from antibodies,
 or 4 weeks (or 5 half-lives, whichever is shorter) from other anti-tumor therapies.

 All adverse events Grade > 1 related to prior therapies (chemotherapy, radiotherapy, and/or
 surgery) must be resolved, except for alopecia.

 Male or Female age ≥16 years.

 Karnofsky Performance Status (KPS) ≥ 60% (see Appendix A).

 Adequate organ and marrow function as defined below, all screening labs should be performed
 within 14 days of treatment initiation:

 -  leukocytes ≥ 3,000/mcL

 -  absolute neutrophil count ≥ 1,500/mcL

 -  platelets ≥ 100,000/mcL

 -  hemoglobin > 8.0 mg/dL

 -  total bilirubin < 2.0 x upper limit of normal

 -  AST (SGOT)/ALT (SGPT) ≤2.5 × upper limit of normal creatinine OR creatinine clearance
 ≥60 mL/min/1.73 m2 for patients with creatinine levels above normal.

 CT or MRI within 14 days prior to start of study drug.

 Corticosteroid dose must be stable or decreasing for at least 5 days prior to the scan. For
 Arm B: Corticosteroid dose must be stable or decreasing for at least 2 weeks prior to study
 entry.

 The effects of ONC201 on the developing human fetus are unknown. For this reason, women of
 childbearing potential and men must agree to use adequate contraception (hormonal or
 barrier method of birth control; abstinence) prior to study entry and for the duration of
 study participation. Should a woman become pregnant or suspect she is pregnant while she or
 her partner is participating in this study, she should inform her treating physician
 immediately. Male subjects should agree to use adequate method of contraception starting
 with the first dose of study therapy through 120 days after the last dose of therapy.

 Archival tissue for evaluation of correlative objectives (if available). Archival tissue is
 required for Arms B and C.

 Ability to understand and the willingness to sign a written informed consent document.

 Exclusion Criteria:

 History of allergic reactions attributed to compounds of similar chemical or biologic
 composition to ONC201 or its excipients.

 Current or planned participation in a study of an investigational agent or using an
 investigational device.

 Uncontrolled intercurrent illness including, but not limited to, ongoing or active
 infection or psychiatric illness/social situations that would limit compliance with study
 requirements.

 Active infection requiring systemic therapy.

 Prior stereotactic radiotherapy, convection enhanced delivery (CED) or brachytherapy must
 have had a biopsy to confirm radiographic progression is consistent with progressive tumor
 and not treatment-related necrosis. If the recurrent lesion is outside of any prior
 high-dose radiation target volume or distant from the prior CED or brachytherapy site,
 subjects will be considered eligible

 Pregnant women because ONC201 is novel agent with unknown potential for teratogenic or
 abortifacient effects. Because there is an unknown but potential risk for adverse events in
 nursing infants secondary to treatment of the mother with ONC201, breastfeeding should be
 discontinued if the mother is treated with ONC201.

 Known HIV-positive test on combination antiretroviral therapy.

 Known history of cardiac arrhythmias including atrial fibrillation, tachyarrhythmias or
 bradycardia. Receiving therapeutic agents known to prolong QT interval will be excluded.
 History of CHF, or MI or stroke in the last 3 months will be excluded.

 Active illicit drug use or diagnosis of alcoholism.

 For Arms A, B, C, prior bevacizumab for treatment (allowable for Arms D, E, and F).

 Tumors with isocitrate dehydrogenase 1 (IDH1) or IDH2 mutations as determined by
 immunohistochemistry for the IDH1 R132H variant or by direct sequencing. IDH1/2-mutant
 gliomas have a markedly longer overall survival rate compared to those with IDH1/2-wildtype
 glioma (Parsons et al., 2008; Yan et al., 2009), indicating IDH1/2-mutant gliomas have a
 distinct natural history.

 Known additional malignancy that is progressing or requires active treatment within 3 years
 of start of study drug. Exceptions include basal cell carcinoma of the skin, squamous cell
 carcinoma of the skin, or in situ cervical cancer that has undergone potentially curative
 therapy.

 Any surgery (not including minor diagnostic procedures such as lymph node biopsy) within 2
 weeks of baseline disease assessments; or not fully recovered from any side effects of
 previous procedures.

 Concomitant use of CYP3A4/5 inhibitors during the treatment phase of the study and within
 72 hours prior to starting study drug administration.

 Concomitant use of potent CYP3A4/5 inducers, which include enzyme inducing antiepileptic
 drugs (EIAEDs) (see Appendix B), during the treatment phase of the study and within 2 weeks
 prior to starting treatment.

 Planned concurrent use Optune™. Prior use of the device is allowable.

 For Arm D and F: Evidence of leptomeningeal spread of disease.