A Study of the Specificity and Sensitivity of 5- Aminolevulinic Acid (ALA) Fluorescence in Malignant Brain Tumors

Specific Aims:

This study is intended to investigate the utility, safety and efficacy of 5-aminolevulinic
acid (5-ALA) induced brain tumor fluorescence during malignant brain tumor resection.
Specifically this study is intended to:

Establish a safe dose for oral 5-ALA administration. Determine the sensitivity and
specificity of 5-ALA mediated fluorescence for malignant glioma tissue in the brain.

Compare the neurosurgeon's intra-operative estimate of the extent of malignant glioma
resection (as guided by tumor fluorescence) with the actual extent of resection determined by
post-operative imaging.

Compare time-to-progression and survival to that in comparable cases performed without the
aid of 5-ALA.

Background and Significance:

There is a considerable body of literature that suggests that completeness of resection is a
positive factor for longer term survival in individuals with malignant glioma. Unfortunately,
it is often difficult to completely remove a malignant brain tumor because during surgery it
is sometimes very difficult to distinguish tumor from normal brain. It would be very helpful
if there would be some way to help the surgeon make this distinction. Malignant glioma tumor
cells (more so than normal cells) contain the biosynthetic pathways to produce protoporphyrin
from a naturally occurring amino acid, 5-aminolevulinic acid (5-ALA). Protoporphyrin is the
immediate precursor to hemoglobin (it is hemoglobin without the iron atom) and is fluorescent
under blue light. When exogenous 5-ALA is provided at increased concentration, protoporphyrin
concentration in the malignant cell increases at a rate far greater than normal brain cells
and renders the malignant cell fluorescent red under blue light. This feature distinguishes
the tumor cells from normal cells intraoperatively and facilitates complete resection.

Recent studies in Germany have confirmed the utility of pre-operative oral 5-ALA and
intraoperative brain tumor fluorescence in aiding the resection of brain tumors in
individuals with malignant brain tumors. These studies have led to oral 5-ALA to be approved
for this indication by the European Medicines Agency (The European Medicines Agency comments
and approval can be found at:
http://www.emea.europa.eu/humandocs/PDFs/EPAR/gliolan/H-744-en6.pdf), but oral 5-ALA has not
been approved for this indication by the United States FDA. This proposal is a phase 1 and
phase 2 trial that will hopefully lead to FDA approval of oral 5-ALA for intra-operative
visualization of malignant brain tumors.

Experimental Plan and Methods:

In the phase 1 part of this proposed study, a minimum of 3 to a maximum of 18 patients will
be administered oral 5-ALA 4 hours prior to surgery in cohorts of 3 at five escalating doses
of 5-ALA (10, 20, 30, 40, or 50 mg/kg).

The following data will be collected:

- Dose-limiting toxicity data; i.e., nausea, vomiting, liver function, photo-sensitivity,
survival

- Tumor fluorescence assessed by neurosurgeon (0 to +++) in three distinct areas of
fluorescence (Strong fluorescence, Weak fluorescence, No fluorescence)

- Tumor density from biopsies obtained by the neurosurgeon in the same three distinct
areas of fluorescence and assessed by neuropathology (Solid tumor, Tumor mixed
infiltrating normal brain, No tumor)

- Neurosurgeon's intra-operative estimate of residual tumor

- Neuroradiologist's estimate of post-operative residual tumor on MRI

- Time to progression by MRI

- Survival (time to progression, one year survival rate and total survival)

This trial will evaluate:

- single dose toxicity of oral 5-ALA given pre-operatively;

- sensitivity and specificity of 5-ALA - Protoporphyrin IX (Pp IX) as an intraoperative
fluorescent detection agent and aid for resection of tumor tissue remaining in the walls
of the resection cavity of primary and recurrent malignant brain tumors;

- relationship of the neurosurgeon's estimate of the extent of malignant glioma resection
(as guided by tumor fluorescence) to the actual extent of resection determined by
post-operative imaging;

- time-to-progression, one year survival rate and total survival as a function of the
extent of resection.

Following completion of the phase 1 portion of this trial, an additional 15 subjects will be
entered at the recommended phase 2 dose level in order to further define the above parameters
at the recommended phase 2 dose level.

Discussions statisticians have led to the development of a number of 2x2 tables and 3x3
tables of data analysis that will lead to establishment of the sensitivity and specificity of
fluorescence-guided brain tumor resection compared to conventional brain tumor resection
techniques.

Inclusion Criteria:

- Patients must have clinically documented primary brain tumor for which resection is
clinically indicated.

- Age ≥ 18 years. Because no dosing or adverse event data are currently available on the
use of 5-ALA in patients <18 years of age, children are excluded from this study but
will be eligible for future pediatric phase 1 single-agent trials

- ECOG performance status <2 (Karnofsky >60%)

- Normal organ and marrow function as defined below:

- Leukocytes > 3,000/mcL

- Absolute neutrophil count > 1,500/mcL

- Platelets > 100,000/mcL

- Total bilirubin within normal institutional limits AST (SGOT)/ALT (SGPT) < 2.5 X
institutional upper limit of normal

- Creatinine within normal institutional limits OR Creatinine clearance > 60
mL/min/1.73 m2 for patients with creatinine levels above institutional normal

- Agreement by women of child-bearing potential and men to use adequate contraception
(hormonal or barrier method of birth control; abstinence) prior to study entry and for
the duration of study participation

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

Exclusion Criteria:

- Patients may not be receiving any other investigational agents at the time of entry
into the study

- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to 5-ALA

- Personal or family history of porphyrias

- 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
study requirements

- Pregnant women are excluded from this study because 5-ALA is of unknown 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 5-ALA,
breastfeeding should be discontinued if the mother is treated with 5-ALA