Patients will receive BGB-290 twice daily, once in the morning and once in the evening. Temozolomide will be administered once daily. Dosing should occur in the morning together with the BGB-290 dose. Patients will be instructed to swallow the capsules whole, in rapid succession, with water. Patients receiving trial medications (BGB-290 and TMZ) may continue on study therapy for up to 24 months from the time of study entry.

In the target validation component, patients will receive BGB-290 monotherapy at the Phase I determined maximum tolerated dose for 7 days prior to the additional resection. Tissue will be acquired to measure tumor drug levels and drug will be restarted 14-28 days after recovery from surgery.

The estimated incidence of primary CNS tumors in children and adolescents ≤ 19 years of age is 5.6 cases per 100,000 person years. As the most common CNS tumors in children and adolescents, gliomas possess a diverse range of clinical behavior. Pediatric malignant gliomas share molecular similarities with adult secondary GBM, and investigators have questioned whether IDH mutations can be found in AYA HGG. In patients 14 years of age or older, IDH1 mutation were found in 7 out of 20 (35%) pediatric gliomas treated on Children’s Oncology Group ACNS0423. A precision medicine analysis of pediatric brain tumors also showed IDH1 mutations to be particularly concentrated in the adolescent age group. In contrast to adult low-grade gliomas (LGG), pediatric LGGs classically do not exhibit IDH1/2 mutations and malignant progression is uncommon. Among recurrent pediatric LGG, however, there is a rare subset of adult-type IDH-mutant glioma. Our trial would enroll patients with recurrent LGG and newly diagnosed or recurrent HGG.

Determine the safety and tolerability of the combination of BGB-290 and temozolomide (TMZ) in AYA subjects with IDH1/2-mutant glioma, including the maximum tolerated dose (MTD) and characterization of dose-limiting toxicities (DLTs) in both, newly diagnosed and recurrent treatment arms.

INCLUSION CRITERIA

• Arm A Only: Subjects must have histologically confirmed WHO grade III-IV newly diagnosed IDH1/2-mutant glioma
• Arm B Only: WHO grades I-IV recurrent IDH1/2 mutant glioma. Subjects in Arm B must have MRI confirming progressive disease; re-biopsy is encouraged, but not required at the time of recurrence for confirmation.
• Patients with a primary spinal tumor, secondary glioma, or multifocal disease in the brain, but without evidence of diffuse leptomeningeal spread, are eligible. In cases where there are questions about multifocality versus diffuse leptomeningeal spread, the Study Chair or Co-chair must be contacted to make a final decision on eligibility.
• Subjects must be between the ages of 13-25 years of age.
• Subjects must have IDH1 or IDH2 mutation associated with neomorphic activity of the encoded proteins.
• Subjects must be willing to provide archival formalin-fixed embedded (FFPE) and frozen tissue specimens for biomarker studies if available.
• Subjects in Arm A must have been treated with maximal safe resection of primary tumor followed by adjuvant RT. Treatment with TMZ during radiation is allowed but not required.
• Subjects in Arm B must have been treated with maximal safe resection of tumor.
  • LGG subjects who progressed after initial surgery alone are eligible. Any number of prior therapies are allowed.
  • HGG subjects enrolled on Arm B must have been treated with a minimum of maximal safe resection of primary tumor followed by adjuvant RT prior to recurrence. Any number of prior therapies are allowed.
• Subjects must have fully recovered from the acute toxic effects of all prior chemotherapy, immunotherapy, or radiotherapy prior to entering this study.
• Myelosuppressive chemotherapy: subjects must have received their last dose of known myelosuppressive anticancer chemotherapy at least three weeks prior to study registration or at least six weeks if nitrosourea.
• Biologic agent: subjects must have recovered from any toxicity related to biologic agents and received their last dose ≥ 7 days prior to study registration.
  • For agents that have known adverse events occurring beyond 7 days after administration, this period must be extended beyond the time during which adverse events are known to occur.  The duration of this interval should be discussed with the study chair.
  • For biologic agents that have a prolonged half-life, the appropriate interval since last treatment should be discussed with the study chair prior to registration.
• Monoclonal antibody treatment: at least three half-lives must have elapsed prior to registration, and subjects on bevacizumab must have received their last dose ≥ 32 days prior to study registration.
• Prior Radiation:
  • Subjects in Arm A should begin therapy with TMZ and BGB-290 4-6 weeks after completion of radiation therapy and when all other eligibility criteria are met.
  • For subjects in Arm B, patients must not have received radiation therapy within 4 weeks prior to the initiation of study treatment. Post-RT, the diagnosis of true progression versus “pseudo-progression” can be challenging when imaging modalities are exclusively used, and thus an additional resection is encouraged if clinically indicated.
• Organ Function Requirements
  • Adequate Bone Marrow Function Defined
  • Adequate Renal Function Defined
  • Adequate Liver Function Defined
  • Adequate Neurologic Function
• The effects of BGB-290 on the developing human fetus are unknown.  For this reason and because alkylating agents (such as TMZ) are known to be teratogenic, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation and 6 months after completion of BGB-290 or TMZ administration. 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.
• Subjects must be able to swallow capsules.
• Subjects must have the ability to undergo serial MRI scans (computerized tomography [CT] cannot substitute for MRI).
• A legal parent/guardian or patient must be able to understand, and willing to sign, a written informed consent and assent document, as appropriate.
• Karnofsky ≥ 50 for subjects > 16 years of age and Lansky ≥ 50 for subjects ≤ 16 years of age. Subjects who are unable to walk because of paralysis, but who are up in a wheelchair, will be considered ambulatory for the purpose of assessing the performance score.

 EXCLUSION CRITERIA

• Subjects who are receiving any other investigational agents and/or subjects previously treated with small molecule inhibitors of mutant IDH1 or IDH2 proteins at any time may not be enrolled
• Subjects who have received a PARP inhibitor previously.
• Subjects with active infection requiring antibiotics at time of therapy start.
• Subjects with other diagnosis of malignancy.
• Subjects with clinically significant active bleeding disorder, hemoptysis, or melena ≤ 6 months prior to Day 1.
• Subjects on therapeutic anti-coagulation with heparin, warfarin, or other anticoagulants
  • use of low-dose aspirin and/or non-steroidal anti-inflammatory agents are allowed.
  • use of thrombolytics to establish patency of indwelling venous catheters is allowed.
  • prophylactic anticoagulation for venous access devices is allowed as long as INR is ≤ 1.5 and aPTT ≤ 1.5 x institutional ULN.
  • use of low-molecular weight heparin is allowed.
• Subjects with known disseminated leptomeningeal disease.
• Subjects with DIPG (diffuse intrinsic pontine glioma) are not eligible for this study.
• Unresolved acute effects of any prior therapy of Grade ≥2, except for AEs not constituting a safety risk by investigator judgement.
• Use ≤10 days (or ≤5 half-lives, whichever is shorter) prior to Day 1 or anticipated need for food or drugs known to be strong or moderate CYP3A inhibitors or strong CYP3A inducers (Appendix F).
• History of allergic reactions attributed to compounds of similar chemical or biologic composition to TMZ or BGB-290.
• 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.
• Female subjects of childbearing potential must not be pregnant or breast-feeding.  Female subjects of childbearing potential must have a negative serum pregnancy test within 7 days of first dose.
• HIV-positive subjects on combination antiretroviral therapy are ineligible because of the potential for pharmacokinetic interactions with BGB-290 and TMZ.  In addition, these subjects are at increased risk of lethal infections when treated with marrow-suppressive therapy.
• Subjects with inability to return for follow-up visits or obtain follow-up studies required to assess toxicity to therapy.

Note: Other protocol Inclusion/Exclusion criteria apply

Funding is provided by BeiGene, CureSearch for Children’s Cancer and The Gateway Foundation