Fluorescence-guided Surgery for Low- and High-grade Gliomas (BALANCE)

January 4, 2017 updated by: St. Joseph's Hospital and Medical Center, Phoenix

Barrow 5-ALA Intraoperative Confocal Evaluation Trial

Gliomas are the most common primary brain tumor, yet remain a challenge to effectively treat. Mounting evidence suggests that survival improves with greater tumor removal, yet being able do a complete removal can be difficult due to the tumor's infiltrating nature. 5-aminolevulinic acid (5-ALA) is a natural compound that, when patients take it by mouth 3 hours before surgery, is selectively taken up by glioma cells and causes a red/pink fluorescence (glow) under a blue light that allows tumor margins to be seen during the course of surgery. While this compound is used as a standard-of-care agent in Europe, it remains under testing by the Food and Drug Administration (FDA). A recent clinical trial in Germany, however, has demonstrated a significant improvement in the rate of complete resection for certain brain tumors (65% vs. 34%).

The Barrow 5-ALA Intraoperative Confocal (BALANCE) Trial will measure the effect of 5-ALA on the amount of glioma tumor removal. To improve the usefulness of 5-ALA, a new special microscope fitted with a blue light, will be used to magnify microscopic fluorescence at the tumor margins. The investigators' hypothesis is that 5-ALA fluorescence with the use of the special microscope during surgery will greatly lower the amount of tumor left behind.

Study Overview

Status

Unknown

Conditions

Intervention / Treatment

Detailed Description

Gliomas are the most common primary brain tumor, yet are associated with a 12-14 month overall survival in the United States. Mounting evidence suggests that survival improves with greater extent of resection, yet achieving a complete radiographic resection is challenging due to the tumor's infiltrating nature. Oral 5-aminolevulinic acid (5-ALA/Gliolan®) is a natural compound that, when administered to patients within 3 hours prior to surgery, is selectively metabolized by glioma cells and induces a red/pink fluorescence under blue light that facilitates intraoperative identification of tumor margins. While this compound is used as a standard-of-care agent in Europe, it remains under examination by the Food and Drug Administration (FDA). A recent multicenter randomized, single-blind, controlled study in Germany demonstrated a significant improvement in the rate of complete resection for high-grade gliomas, as compared to conventional microneurosurgery (65% vs. 34%) (Stummer et al., Lancet Oncology 2006).

Patients with presumed newly-diagnosed glioma will be entered into the trial. On the basis of their expected extent of resection (low vs. high), they will be stratified in one of 2 groups - Group 1 (expected high extent or resection) or Group 2 (expected low extent of resection). Following stratification, patients with newly-diagnosed disease will be randomized to receive either study drug (5-ALA/Gliolan®) or placebo (ascorbic acid) prior to surgery. Those who have had previous biopsy only without further treatment will be eligible for randomization. Intraoperatively, 5-ALA/Gliolan® patients will undergo resection with combined fluorescence microscopy and confocal microscopy. Placebo patients will undergo resection with standard light microscopy. Postoperatively, patients will have an MRI scan with and without contrast within 48 hours of surgery. Subsequent analysis of each patient will include assessment of the primary endpoint, that is,volume of residual disease (VRD) by volumetrically quantifying the tumor before and after surgery using T1-weighted contrast-enhancement (high-grade gliomas) or T2-weighted hyperintensity (low-grade gliomas). Similarly, volumetric extent of resection will also be measured. Other secondary endpoints will include overall survival (OS), progression-free survival (PFS), and National Institute of Health Stroke Scale (NIHSS) (collected at baseline, 7-10 days post-op and at 6, 12, 18, and 24 months post op).

The Barrow 5-ALA Intraoperative Confocal (BALANCE) study will quantify the impact of 5-ALA/Gliolan(R) on low- and high-grade glioma extent of resection. To enhance the efficacy of 5-ALA/Gliolan(R), particularly for low-grade gliomas that fluoresce less vigorously due to their comparatively lower cellular metabolism, intraoperative confocal microscopy will be used to amplify microscopic fluorescence at the tumor margins. The investigators' hypothesis is that, for both low- and high-grade gliomas, 5-ALA/Gliolan(R) fluorescence in conjunction with intraoperative confocal microscopy will significantly lower the VRD.

Goals:

1. To determine the impact of intraoperative fluorescence and confocal microscopy on the volume of residual disease following resection of a newly-diagnosed glioma.

Sub-goals:

  1. To assess the feasibility and utility of combining intraoperative fluorescence with confocal microscopy.
  2. To determine the impact of this combined approach in improving volumetric extent of resection.
  3. To determine the impact of this combined approach in improving overall survival and 6-month progression-free survival.

Study Type

Interventional

Enrollment (Anticipated)

192

Phase

  • Phase 3

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Arizona
      • Phoenix, Arizona, United States, 85013
        • Recruiting
        • St. Joseph's Hospital and Medical Center/Barrow Neurological Institute
        • Sub-Investigator:
          • Peter Nakaji, MD
        • Sub-Investigator:
          • Andrew Little, MD
        • Contact:
        • Sub-Investigator:
          • William White, MD
        • Sub-Investigator:
          • Randall Porter, MD
        • Sub-Investigator:
          • Taro Kaibara, MD
        • Sub-Investigator:
          • Mark Garrett, MD
        • Sub-Investigator:
          • John Wanebo, MD
        • Sub-Investigator:
          • Steve Chang, MD

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Presumed newly-diagnosed supratentorial glioma (previous biopsy-only/no adjuvant therapy are eligible for randomization)
  • Age > 18 years
  • Normal bone marrow function (WBC > 3000, Platelets > 100,000)

Exclusion Criteria:

  • Infratentorial tumors
  • Pregnancy
  • Hypersensitivity to 5-aminolevulinic acid hydrochloride or porphyrins
  • History of photosensitivity, porphyria, or exfoliative dermatitis
  • Hepatic dysfunction in the last 12 months (defined by AST, ALT, ALP, bilirubin > 2.5 x normal)
  • Serum creatinine > 180 µmol/L
  • Estimated Glomerular Filtration Rate (eGFR) < 60 ml/min/1.73m2
  • Inability to undergo MRI scan with contrast

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Single Group Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: 5-ALA/Gliolan® /5-Aminolevulinic acid
Within 3 hours prior to surgery, patient will orally ingest [or be given via Nasogastric (NG), Orogastric (OG), or Gastric tube (G-tube)] 5-ALA/Gliolan®/5-Aminolevulinic acid mixed with sterile water (20mg/kg)
Drug: 5-Aminolevulinic acid (ALA)
Following informed consent, within 3 hours prior to surgery, patient will orally ingest [or be given via Nasogastric (NG), Orogastric (OG), or Gastric tube (G-tube)] either (1) 5-ALA/Gliolan® mixed with sterile water (20mg/kg)
Other Names:
  • 5-ALA
  • 5-Aminolevulinic acid Hydrochloride
  • Gliolan®
Placebo Comparator: Placebo - ascorbic acid
Within 3 hours prior to surgery, patient will orally ingest [or be given via Nasogastric (NG), Orogastric (OG), or Gastric tube (G-tube)] 1.5 Gm. placebo - ascorbic acid in 50 ml sterile water.
Drug: Placebo - ascorbic acid
Within 3 hours prior to surgery, patient will orally ingest [or be given via Nasogastric (NG), Orogastric (OG), or Gastric tube (G-tube)] 1.5 Gm. placebo - ascorbic acid in 50 ml sterile water.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Volumetric extent of resection
Time Frame: Change in MRI from pre-operative to within 48 hours post-operative
Volumetric analysis of MRI contrast T1-weighted images (for low grade gliomas) will be compared to the preoperative sequences to calculate the volume of residual disease. Slice-by-slice assessment of pre- and postoperative tumor volume will be quantified by sequentially measuring the area of tumor on each slice and then integrating the combined measurements. This methodology has been previously reported (Sanai et al., Journal of Neurosurgery, 2010; Sanai et al, The New England Journal of Medicine, 2008)
Change in MRI from pre-operative to within 48 hours post-operative

Secondary Outcome Measures

Outcome Measure
Time Frame
Overall Survival rate(OS)
Time Frame: Time from randomization until date of death assessed up to 48 months
Time from randomization until date of death assessed up to 48 months
Progression-free survival rate (PFS)
Time Frame: Time from randomization until first date of progression assessed up to 48 months
Time from randomization until first date of progression assessed up to 48 months
National Institute of Health Stroke Scale (NIHSS)
Time Frame: Change in score from pre-operative at post-operative, 6, 12, 18 and 24 months
Change in score from pre-operative at post-operative, 6, 12, 18 and 24 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

St. Joseph's Hospital and Medical Center, Phoenix

Investigators

  • Principal Investigator: Nader Sanai, MD, St. Joseph's Hospital Medical Center, Phoenix

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

November 1, 2010

Primary Completion (Anticipated)

January 1, 2018

Study Completion (Anticipated)

June 1, 2018

Study Registration Dates

First Submitted

December 22, 2011

First Submitted That Met QC Criteria

December 29, 2011

First Posted (Estimate)

December 30, 2011

Study Record Updates

Last Update Posted (Estimate)

January 6, 2017

Last Update Submitted That Met QC Criteria

January 4, 2017

Last Verified

January 1, 2017

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • IRB#10BN132

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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