Ph 1/2 CTO With Lomustine for Bevacizumab-Naive Recurrent Glioma

In the Phase 1 component of the study, we will conduct a dose-escalation study of the
combination of CTO with lomustine among patients with recurrent malignant glioma (WHO grade
III or IV). All patients will be bevacizumab-naïve. The dose escalation will be a standard
"3+3" design to determine the MTD of CTO in combination with lomustine. The Phase 2 portion
of this study will be a randomized screening study comparing CTO alone (Arm A) versus CTO
with lomustine (Arm B) versus lomustine alone (Arm C) in patients with recurrent WHO grade
IV malignant glioma who are bevacizumab-naïve. Subjects will be randomized with a treatment
arm allocation ratio of 2:2:1.

Based on the results of patients who have already taken part in Phase 1 of the study, the
Principal Investigator has decided to reduce the dose of lomustine used in combination with
CTO in this study by 25% of the FDA-approved dose, due to hematologic side effects (side
effects related to lower than expected blood counts). Therefore, the dose of lomustine
received in combination with CTO is approximately 75% of the standard recommended dose.

Inclusion Criteria:

- Phase 1 portion: Patients must have recurrent histologically confirmed diagnosis of
WHO grade III or IV malignant glioma with no more than 3 prior progressions

- Phase 2 portion: Patients must have recurrent histologically confirmed diagnosis of
WHO grade IV malignant glioma (glioblastoma or gliosarcoma) with no more than 3 prior
progressions

- Patients should have received optimal surgical management and radiotherapy prior to
study enrollment

- Age ≥ 18 years

- Karnofsky Performance Status (KPS) ≥ 70%

- Bi-dimensionally measurable disease as assessed by magnetic resonance imaging based
on RANO criteria

- Absolute Neutrophil Count (ANC) ≥ 1000 cells/µl, Platelets ≥ 100,000 cells/µl
(without transfusion within 14 days before enrollment)

- Adequate renal function as indicated by the following: Serum creatinine < 1.25 times
upper limit of normal or calculated creatinine clearance ≥ 50 ml/minute and urine
dipstick for proteinuria < 2+ unless a 24-hour urine protein <1 g of protein is
demonstrated

- Prothrombin time (PT) ≤ 1.5 x upper limit of normal (ULN) and activated partial
thromboplastin time (aPTT) ≤ 1.5 x ULN within 14 days prior to first study treatment
for patients not receiving anti-coagulation. The use of full-dose oral or parenteral
anticoagulants is permitted as long as the PT or aPTT is within therapeutic limits
(according to the medical standard of the enrolling institution) and the patient has
been on a stable dose of anticoagulants for at least two weeks prior to the first
study treatment.

- For patients on corticosteroids, they must be on a stable dose for 7 days prior to
anticipated start of study drug, and the dose should not be escalated over entry dose
level, if clinically possible.

- Signed informed consent approved by the Institutional Review Board

- No evidence of > grade 1 active central nervous system (CNS) hemorrhage on the
baseline MRI or CT scan

- Female patients must not be pregnant or breast-feeding. Female patients of
childbearing potential (defined as < 2 years after last menstruation or not
surgically sterile) must use a highly effective contraceptive method (allowed methods
of birth control, [i.e. with a failure rate of < 1% per year] are implants,
injectables, combined oral contraceptives, intra-uterine device [intrauterine device
(IUD); only hormonal], sexual abstinence or vasectomized partner) during the trial
and for a period of > 6 months following the last administration of trial drug(s).
Female patients with an intact uterus (unless amenorrhea for the last 24 months) must
have a negative serum pregnancy test within 48 hours prior to first study treatment.

- Fertile male patients must agree to use a highly effective contraceptive method
(allowed methods of birth control [i.e. with a failure rate of < 1% per year] include
a female partner using implants, injectables, combined oral contraceptives, IUDs
[only hormonal], sexual abstinence or prior vasectomy) during the trial and for a
period of > 6 months following the last administration of trial drugs.

Exclusion Criteria:

- Pregnancy or breastfeeding

- Treated previously with vascular endothelial growth factor (VEGF) or vascular
endothelial growth factor receptor (VEGFR) therapies, including antibodies and
tyrosine kinase inhibitors

- Prior disease progression on lomustine

- Taking cytochrome P450 3A4 (CYP3A4) inducers and moderate or strong inhibitors. To
note: Corticosteroids are allowed, as long as patients have been on a stable dose for
7 days prior to anticipated start of study drug, and the dose should not be escalated
over entry dose level, if clinically possible.

- Co-medication that may interfere with study results; e.g. immuno-suppressive agents
other than corticosteroids

- Active infection requiring IV antibiotics 7 days before enrollment

- Prior, unrelated malignancy requiring current active treatment with the exception of
cervical carcinoma in situ and adequately treated basal cell or squamous cell
carcinoma of the skin

- Less than 12 weeks from radiation therapy, unless progressive disease outside of the
radiation field or 2 consecutive scans or histopathologic confirmation

- Treated with immunotherapeutic agents, vaccines, or monoclonal antibody (MAb) therapy
within 4 weeks before enrollment, unless the patient has recovered from the expected
toxic effects of such therapy

- Treated with alkylating agents within 4 weeks before enrollment or treated within 1
week before enrollment with daily or metronomic chemotherapy, unless the patient has
recovered from the expected toxic effects of such therapy

- Prior chemotherapy (non-alkylating agents) within 2 weeks before enrollment, unless
the patient has recovered from the expected toxic effects of such therapy

- Current, recent (within 4 weeks of the first infusion of this study), or planned use
of an experimental drug, unless the patient has recovered from the expected toxic
effects of such therapy

Vascular endothelial growth factor (VEGF) Inhibitor-Specific

Exclusion Criteria are:

- Inadequately controlled hypertension (defined as systolic blood pressure > 150 mmHg
and/or diastolic blood pressure > 100 mmHg) within 28 days of first study treatment

- Prior history of hypertensive crisis, hypertensive encephalopathy, reverse posterior
leukoencephalopathy syndrome (RPLS)

- Prior history of gastrointestinal perforation or abscess

- Clinically significant (i.e. active) cardiovascular disease, for example
cerebrovascular accidents ≤ 6 months prior to study enrollment, myocardial infarction
≤ 6 months prior to study enrollment, unstable angina, New York Heart Association
(NYHA) Grade II or greater congestive heart failure (CHF), or serious cardiac
arrhythmia uncontrolled by medication or potentially interfering with protocol
treatment

- History or evidence upon physical/neurological examination of central nervous system
disease (e.g. seizures) unrelated to cancer unless adequately controlled by
medication or potentially interfering with protocol treatment

- Significant vascular disease (e.g., aortic aneurysm requiring surgical repair or
recent arterial thrombosis) within 6 months prior to start of study treatment

- History of pulmonary hemorrhage/hemoptysis ≥ grade 2 (defined as ≥ 2.5 mL bright red
blood per episode) within 1 month of first study treatment

- History or evidence of inherited bleeding diathesis or significant coagulopathy at
risk of bleeding (i.e. in the absence of therapeutic anticoagulation)

- Current or recent (within 10 days of study enrollment) use of aspirin (>325 mg/day),
clopidogrel (>75 mg/day) or equivalent. Prophylactic or therapeutic low molecular
weight heparin (LMWH) is allowed

- Surgical procedure (including open biopsy, surgical resection, wound revision, or any
other major surgery involving entry into a body cavity) or significant traumatic
injury within 28 days prior to first study treatment, or anticipation of need for
major surgical procedure during the course of the study

- Minor surgical procedure, e.g. stereotactic biopsy, within 7 days of first study
treatment; placement of a vascular access device, within 2 days of first study
treatment

- History of intracranial abscess within 6 months prior to first study treatment

- History of active gastrointestinal bleeding within 6 months prior to first study
treatment

- Serious, non-healing wound, active ulcer, or untreated bone fracture