A Phase 2 Trial of Neoadjuvant Temozolomide Followed by Hypofractionated Accelerated Radiation Therapy With Concurrent and Adjuvant Temozolomide for Patients With Glioblastoma

Accepted Manuscript A Phase II trial of Neo-adjuvant Temozolomide followed by Hypofractionated Accelerated Radiotherapy with Concurrent and Adjuvant Temozolomide for Patients with Glioblastoma George Shenouda, MBBCh, PhD, FRCP, Luis Souhami, MD, FASTRO, Kevin Petrecca, MD, Scott Owen, MD, Valerie Panet-Raymond, MD, Marie-Christine Guiot, MD, Andrea Gomez Corredor, PhD, Bassam Abdulkarim, MD PhD PII:

S0360-3016(16)33428-9

DOI:

10.1016/j.ijrobp.2016.11.006

Reference:

ROB 23894

To appear in:

International Journal of Radiation Oncology • Biology • Physics

Received Date: 19 August 2016 Revised Date:

31 October 2016

Accepted Date: 8 November 2016

Please cite this article as: Shenouda G, Souhami L, Petrecca K, Owen S, Panet-Raymond V, Guiot M-C, Gomez Corredor A, Abdulkarim B, A Phase II trial of Neo-adjuvant Temozolomide followed by Hypofractionated Accelerated Radiotherapy with Concurrent and Adjuvant Temozolomide for Patients with Glioblastoma, International Journal of Radiation Oncology • Biology • Physics (2016), doi: 10.1016/ j.ijrobp.2016.11.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Fifty patients with newly diagnosed Glioblastoma were accrued on a phase 2 study of neoadjuvant Temozolomide (TMZ) started 3 weeks from surgery for 2 weeks prior to delivering Hypofractionated Accelerated Radiotherapy (HART) with concurrent and adjuvant TMZ.

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Median follow-up for patients at risk was 44.0 months. The median OS and PFS were 22.3 months and 13.7 months respectively. This novel approach of neo-adjuvant TMZ is associated

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with an encouraging favorable long-term survival with acceptable toxicity.

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A Phase II trial of Neo-adjuvant Temozolomide followed by Hypofractionated Accelerated

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Radiotherapy with Concurrent and Adjuvant Temozolomide for Patients with Glioblastoma

George Shenouda MBBCh, PhD, FRCP1, Luis Souhami MD, FASTRO1, Kevin Petrecca MD2, Scott Owen MD3, Valerie Panet-Raymond MD1, Marie-Christine Guiot MD4, Andrea Gomez

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Corredor PhD5, Bassam Abdulkarim MD PhD1.

From the Departments of Radiation Oncology1, Neurosurgery2, Medical Oncology3 and Pathology4, McGill University Health Centre1, 3 and the Montreal Neurological Institute2, 4, Core Molecular Diagnostic Laboratory5, McGill University, Montréal, Québec, Canada.

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Corresponding author: George Shenouda, McGill University Health Centre, Department of Radiation Oncology, 1001 boulevard Décarie, Room DS1.1620, Montréal, Québec, Canada

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H4A 3J1. Telephone: 514 934 1934

Fax: 514 934 8392

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E-mail address: [email protected] Running title: Neo-adjuvant Temozolomide and hypofractionated RT for GBM ASTRO 2013 Poster discussion 55th ASTRO annual scientific meeting, Atlanta, Georgia, USA September 22, 2013 CARO 2014 Oral presentation 28th CARO annual scientific meeting, St. John’s, Newfoundland, Canada August 25, 2014 Disclaimers: none to disclose Clinical.trials.gov NCT01702610 1

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Abstract Background:

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We performed a phase II trial of neo-adjuvant Temozolomide (TMZ), followed by hypofractionated accelerated radiotherapy (HART) with concurrent TMZ, and adjuvant TMZ in patients with newly diagnosed Glioblastoma (GBM) to determine whether neo-adjuvant TMZ

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would safely improve outcomes in this group of patients prior to subsequent cytotoxic therapy. Methods:

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Newly diagnosed adult patients with GBM and KPS > 60 were eligible. Neo-adjuvant TMZ started 2 to 3 weeks from surgery at daily dose of 75 mg/m2 for 2 weeks prior to delivering HART (60 Gy in 20 daily fractions) with concurrent and adjuvant TMZ. The primary end-points were feasibility and toxicity. Secondary end-points included overall survival (OS) and

Results:

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progression-free survival (PFS).

Fifty patients were accrued. Median follow-up for patients at risk was 44.0 months, and 22.3

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months for all 50 patients. Except for one patient who developed infection, and another one who

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progressed during HART, all patients completed protocol therapy as planned. The median OS and PFS were 22.3 months (95% CI, 14.6-42.7) and 13.7 months (95% CI, 8.0-33.3), respectively. The 4-year OS rates were 30.4% for the entire cohort, 53.3% and 14.0% for patients with Methylated (n=21) and Unmethylated (n=27) MGMT-gene promoter tumors, respectively. One patient experienced grade-5 pancytopenia during HART and another one had transient grade-4 hepatotoxicity. Thirteen patients underwent second surgery: 2 had intracranial infection, 3 recurrences, 4 recurrences and radiation-induced damage, and 4 radiation-induced damage only. 2

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Conclusion: This novel approach of neo-adjuvant TMZ is associated with an encouraging favorable long-term

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survival with acceptable toxicity. Future comparative trial of efficacy of this regimen is

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warranted.

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Introduction The outcome for patients with Glioblastoma (GBM) remains poor with median survival of 16

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months and overall survival (OS) rates of 27% and 10% at 2- and 5-years, respectively1. The European Organization for Research and Treatment of Cancer (EORTC)/National Cancer Institute of Canada (NCIC) study established conventionally fractionated radiation therapy (RT)

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given concomitantly with Temozolomide (TMZ) and followed by adjuvant TMZ as the standard treatment 1.

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Secondary analysis of the EORTC/NCIC study 2 showed that the benefit conferred by TMZ was primarily limited to patients with methylated MGMT (MGMT-M) gene promoters. The hypermethylation of the MGMT gene promoter reduced the cancer cells’ ability to repair DNAdamage leading to an augmented cytotoxic response in contrast to patients with Unmethylated

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(MGMT-UM) promoter. Tolcher et al 3 demonstrated that prior exposure to TMZ itself leads to a marked inactivation of the MGMT activity, thereby increasing the efficiency of subsequent

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exposure to TMZ.

An innovative approach in GBM radiation research is the use of hypofractionated accelerated RT 4-7

report median overall survival times similar to the

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(HART). Multiple HART GBM studies

combination of standard RT and chemotherapy, with good tolerance and shortening of the overall RT time by 2 weeks. The use of a larger dose per fraction and the accelerated RT regimen may represent a radiobiological advantage allowing the delivery of RT in a shorter overall treatment time, thus reducing tumor repopulation.

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In 2009, we began a prospective Phase II study (ClinicalTrials.gov # NCT01702610) to determine whether the use of neo-adjuvant TMZ prior to the administration of HART with

outcomes for patients with newly diagnosed GBM. Patients and Methods

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Patients

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concurrent and adjuvant TMZ was safe, and to determine the impact of this new approach on the

Patients were eligible for the trial if they were > 18 years with a histologically proven GBM, a

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Karnofsky performance status (KPS) > 60, and adequate hematologic, renal, and hepatic functions (defined as absolute neutrophil counts > 1500/ml, platelet count > 100 000/ml, serum creatinine between 60 and 103 umol/L, bilirubin of 3 to 21 umol/L, ALT and AST ≤ 3 x normal range). All pathological specimens were reviewed for confirmation of diagnosis by one co-

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author (MCG).

Fourteen days prior to registration, all patients had history and physical examination, blood tests, post-operative contrast-enhanced brain magnetic resonance imaging (MRI) with Gadolinium or

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computed tomography (CT) if MRI was not possible. Patients must have been on a tapering-off or stable dose of steroids for one week before starting treatment. Prior to study entry, all patients

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signed a study specific informed consent form approved by the Institutional Review/Ethics Board.

Study design and treatment

Patients started neo-adjuvant TMZ 2 to 3 weeks from the date of surgery for a period of 2 weeks after which they started the concomitant RT and TMZ. Four weeks after the completion of the

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concomitant RT and TMZ, patients started adjuvant TMZ. The study was approved by the Institutional Ethics Review Board.

Full details of RT have been published previously

5, 6

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Radiation Therapy . Briefly, HART started at the end of neo-

adjuvant TMZ and within 5 weeks from surgery. Patients were immobilized, then CT and MRI

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simulation were performed and images were co-registered with the post-operative MRI. The gross tumor volume (GTV) was defined as the surgical cavity and/or postoperative contrast-

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enhancing lesion on MRI. The PTV60 included the GTV plus a 5 mm margin and the PTV40 included the GTV plus a 15 mm margin. A dose of 60 Gy was delivered in 20 fractions to PTV60 while PTV40 received a dose of 40 Gy in the same 20 fractions. Treatment was planned using an inverse IMRT technique and a simultaneous integrated boost. The radiation dose to

40 Gy. Chemotherapy

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critical structures including the optic chiasm and optic nerves, and brainstem were limited to <

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TMZ was given at a daily dose of 75 mg/m2 for the neo-adjuvant and concomitant phases, and 150-200 mg/m2 for 5 consecutive days of a 28 day cycles, as adjuvant, for a maximum of 12

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cycles. Patients received appropriate antibiotic protection against Pneumocystis carinii infection as well as anti-emetic medications. Patient Evaluation and Follow-up Patient’s evaluation included a complete history and physical examination, a complete blood count, blood chemistry for renal and hepatic functions, and a quantitative serum β-HCG (for female patients of childbearing age). Imaging consisted of MRI pre-surgery, in the immediate 6

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post-operative period, 3 days prior to starting adjuvant TMZ, then every 3 months, and whenever there was a change of the patients’ condition.

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A gross total resection (GTR) was defined by a MRI obtained within 48 hours from surgery. Any residual lesion was considered a partial tumor resection (PTR), irrespective of the amount of residual disease.

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During radiotherapy, the patients underwent weekly evaluation with complete blood counts and blood biochemistry as well as toxicity assessment according to the national Cancer Institute’s

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Common Terminology Criteria for Adverse Events version 3.0.

Assessment of response depended upon the clinical condition of the patients as well as their imaging studies. The Response Assessment in Neuro-Oncology (RANO) criteria8 were used to assess response. Pseudo-progression was defined as an initial imaging finding of disease

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progression that resolved over time without a change in management. Patterns of failure definition

At time of failure, the location of recurrent tumors were analyzed on imaging with regards to

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their relation to the high dose volume (PTV60). The recurrent tumors were classified as “in-field”

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if >80% of the T1-enhancing recurrent tumor volume was located within the PTV60, “marginal” if >20 but ≤80% of the tumor volume was located within the PTV60, or distant if <20% of the tumor volume was located within the PTV60. In cases of multiple discrete sites of failure the pattern of failure was considered “multifocal”.

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Statistical Considerations Based on our previous experience with hypofractionated RT and TMZ (6) we expected that the current study design would improve the outcome by adding the radiosensitizing effect of

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neoadjuvant TMZ to the radiobiological advantage of hypofractionated RT as compared to current conventional RT and TMZ. A total number of 50 patients would be required in order to detect a 50% improvement of the median OS above the 14.6 months reported by the

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EORTC/NCIC study1. This sample size allowed a 10% loss of follow-up and ineligibility that

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may occur during the performance of the study

Progression-free-survival (PFS) and overall survival (OS) were determined from the date of diagnosis to the date of failure, death or last follow-up. The Kaplan-Meier method 9 was used to estimate OS and PFS, the differences between groups were tested using the Log-rank test

10, 11.

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For all endpoints, a p value ≤ 0.05 was considered statistically significant (two-sided). All analyzes were performed using GraphPad Prism version 6.0 (GraphPad Software, LaJolla,

Results

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California).

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Patients Demographics

From March 2009 and July 2014, 50 patients, with a median age of 60 years (range 31-79), were accrued. The demographic details are summarized in Table 1. The MGMT gene-promoter methylation status was methylated in 21 patients, and unmethylated in 27 patients. There were inadequate tissues to determine MGMT gene-promoter methylation status in 2 patients (4%) due to small tumor specimens. 8

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Treatment Administration All patients received the neo-adjuvant TMZ as per protocol. Two patients had interruption of RT:

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one had disease progression after 7 fractions (21 Gy) with significant deterioration of his condition and died 1.4 month from the date of surgery, and the other had an intracranial infection which necessitated a craniotomy after which the treatment was resumed. Both patients are

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included in the final analysis.

The median number of adjuvant cycles of TMZ was 6 cycles (range 0-12). Four patients did not

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receive adjuvant TMZ: 2 patients died before starting adjuvant TMZ because of disease progression, the third one refused adjuvant TMZ, and the fourth patient had a grade 4, persistent

Treatment Outcomes Toxicity Assessment

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thrombocytopenia precluding further TMZ administration.

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Grade 5 pancytopenia occurred in one patient without evidence of disease recurrence during the adjuvant TMZ period. Grade 4 hepatic toxicity was observed in one patient at the end of the

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concomitant TMZ and HART, with recovery of hepatic functions 6 weeks after the discontinuation of TMZ. Grade 3 toxicities consisted of fatigue in 4, nausea and vomiting in 3, and electrolytes imbalances in 3 patients. Thirteen patients underwent a second surgery for suspected disease progression with a median time from initial surgery of 15.3 months (range 1.5 to 44.9). Maximal surgical resection was attempted with limitations depending on anatomical location of recurrent disease. 9

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Acknowledging the limitations to accurately determine the viability of residual cells in the reoperated surgical specimens, a tumor recurrence was considered if ≥ 20% cells were neoplastic, whereas a diagnosis of radiation-induced damage was made if ≥ 80% of the examined tissues

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were necrotic cells. Two of the re-operated patients had intracranial infection with no viable neoplastic cells. Another 3 patients had recurrence without evidence of radiation-induced damage. Four other patients had evidence of disease recurrence in addition to radiation-induced

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damage. The remaining 4 patients had radiation-induced damage only with no neoplastic cells demonstrated. Table 2 summarizes the patients’ characteristics as well as the outcomes of re-

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operation.

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Outcome Analysis

As of July 31, 2016 the median follow-up for patients at risk was 44.0 months (range 23.9 to 83.7) and 22.3 months for all patients (range 1.8 to 83.7). The median survival was 22.3 months

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(95% CI, 14.6 to 42.7) with median PFS of 13.7 months (95% CI, 8.0 to 33.3) (Fig. 1). The overall survival rates at 2 and 4 years were 47.9%, and 30.4%, respectively. In patients with

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MGMT-M these rates were 76.2% at 2 years, and 53.3% at 4 years, whereas in MGMT-UM the rates were 25.9%, and 14.4%, respectively (Fig. 2). Table 3 depicts the results of analysis of the prognostic factors of age, recursive portioning analysis (RPA) classification, extent of surgery, and MGMT methylation status with respect to OS and PFS. Age < 60 years, extent of surgery (GTR and PTR), RPA Class, and MGMT methylation status were found to have statistically significant effect on OS. The median OS for 10

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patients with the MGMT-M versus MGMT-UM was 53.8 months versus 16.2 months, respectively (p=0.01, HR 0.32 (95%CI, 0.15-0.66). Only MGMT status was significant for PFS,

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favoring MGMT-M vs. MGMT-UM. (Table 3) and (Fig. 3) Treatment at disease progression

Apart from the 13 patients who underwent a second operation, as described above, nine others

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received best supportive care at the time of disease progression. Two of the 13 patients who had a second surgery, had post-operative re-irradiation. Fourteen patients received further systemic

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therapy which varied, but the majority of patients were re-exposed to TMZ either alone or in combination with procarbazine and/or bevacizumab. At the last follow-up, 6 of the 15 alive patients were off and 12 were on steroids. KPS was 100 in 3 patients, 80-90 in 6, 60-50 in 5, and < 30 in one.

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Patterns of failure

The recurrent tumors were analyzed to determine the recurrent volume in relation to the high dose volume (PTV60), the low dose volume (PTV40), and the rest of the brain. We observed 24

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(72.7%) in-field failures with 3 of them being associated with multifocal recurrence within the CNS. In another 8 patients, there were marginal failures without any multifocal failure. Two

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patients failed with multifocal recurrence as the only pattern of failure. Discussion

The patients’ characteristics in the current study are not different from the patients’ characteristics reported by other large clinical trials in the literature

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with respect to age,

performance status, extent of initial surgery, and MGMT gene promoter methylation status.

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The current results compare favorably with current contemporaneous clinical trials

13, 14

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Acknowledging that comparison of results across different studies cannot be considered definitive, the RTOG study 13, which explored the use of dose-dense TMZ in the adjuvant setting

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with the objective of depleting MGMT, and the Optune trial15 exploring tumor treating fields, a device with antimitotic properties, reported median survival of 16.6 and 20.5 months, respectively.

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The current trial reports an OS rate > 30% at 3 and 4 years for patients with GBM. This

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encouraging OS was observed in each group of patients with MGMT-M and MGMT-UM tumors at the 3 and 4-year time points with, as expected, a significantly superior outcome for patients with MGMT-M. The median OS rates of 53.8 months for MGMT-M and of 16.2 months for MGMT-UM patients are encouraging but require further validation in a large randomized study. We hypothesize that several biological mechanisms could potentially have contributed to the

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observed results. The initial neo-adjuvant exposure to TMZ for 2 weeks prior to starting concurrent HART and TMZ may have resulted in an auto-sensitization as predicted by previous

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research 3. This auto-sensitization by MGMT gene promoter silencing may partially explain the favorable median survival of 16.2 months encountered in patients with MGMT-UM tumors.

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Furthermore, considering that sub-lethal doses of irradiation promote the migration and invasiveness of glioma cells 16, it is conceivable that the upfront neo-adjuvant use of TMZ had a dual effect on tumor control by interfering with the upstream signaling event triggered by the RT, preventing cell migration and also by promoting inhibition of glioma cell invasion as reported by Wick et al.17.

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Another explanation is that the HART schedule may have overcome the accelerated repopulation by tumor cells and may have also had an impact on the response of the Glioma Stem Cells (GSCs) which are considered to be the main cell population responsible for recurrence in GBM . Gao et al 20 reported that in vitro accelerated repopulation of GSCs was lower when single

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doses of 6 Gy were used as compared to 3 doses of 2 Gy each, suggesting that larger doses per fraction is more effective to counteract the irradiation-induced GSCs accelerated repopulation

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than conventionally fractionated doses.

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Recent series of high-dose hypofractionated radiotherapy and concurrent and adjuvant TMZ 6, 21, reported that the approach was tolerable and safe with an associated median survival varying

between 14.4 and 20 months. Moreover, the pattern of failures reported in the same series, using limited margins PTV margins, showed that disease recurrence was mostly central. The central pattern of recurrence was also reported in clinical trials where dose escalation was achieved with 23-25

. In a phase I dose-escalating study

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brachytherapy or stereotactic boost

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with accelerated

IMRT and concurrent TMZ, the median OS was 20 months, with a dose of 65 Gy in 25 fractions

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reported to be safe.

Pre-treatment with TMZ for 4 cycles of 28 days each before conventional radiotherapy was 27

in patients with anaplastic astrocytoma (AA) and GBM. The median

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reported by Gilbert et al

survival and PFS for the 21 patients with AA were 23.5 and 7.6 months, respectively. For the 36 patients with GBM, the median survival and PFS were 13.2 and 3.9 months, respectively. Ammiratia et al

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conducted a phase I study to determine the maximum tolerated dose of peri-

radiotherapy TMZ. All patients received TMZ 1 week before, 3 weeks during, and 1 week after IMRT with a dose of 52.5 Gy in 15 fractions. With a median follow-up of 10 months the median

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PFS was 3.9 months and the overall survival 12.7 months with no irreversible grade 3 or higher acute toxicity. 29

reported the clinical experience of neo-adjuvant of TMZ or fotemustine and

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Bihan et al

Bevacizumab before starting conventional radiotherapy in 8 patients with GBM and severely compromised neurological impairment who underwent a biopsy only. The authors reported that the regimen was feasible and provided a rapid benefit in this group of patients with poor

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reported the results of a large multicentric phase II trial in order to determine the

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Brada et al

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prognosis.

effect of neo-adjuvant TMZ given to patients with AA or GBM following minimal surgical resection for 2 28-day cycles prior to starting conventional radiotherapy. Responses to the neoadjuvant 2 cycles of TMZ were assessed before radiotherapy, and the median survival was 16

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months for responders and 3 months for non-responders.

In conclusion, neo-adjuvant TMZ, followed by HART with concomitant and adjuvant TMZ is feasible and safe. The neo-adjuvant regimen is associated with results that compare favorably

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with clinical trials using concurrent TMZ and conventionally fractionated RT. The beneficial effect of the neo-adjuvant regimen resulted in an encouraging 30.4% OS at 4 years and an

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impressive improvement of outcomes, both OS and PFS of patients with GBM with MGMT-UM promoters, suggestive that the neo-adjuvant regimen may have modified the activity of MGMT as predicted in the literature3. In addition, a valuable shortening of the overall treatment time of 2 weeks is achievable relieving both the patients and their families from unnecessary pressure of transportation, especially those who live far from a radiotherapy facility. Health cost containment is an additional potential benefit that can help with increasing demands on limited health care 14

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resources. A future larger scale phase III clinical trial is warranted to confirm these encouraging

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Phase II study results.

Figure Legends

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Fig. 1 Overall Survival (A) and Progression-Free-Survival (B) showing 95% confidence intervals.

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Fig. 2 Overall Survival according to the 06-mathyl guanine methyl transferase (MGMT) genepromoter Methylation status (A) Methylated and (B) Unmethylated. The results are shown with the 95% confidence intervals.

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Fig. 3 Progression-Free-Survival according to the 06-mathyl guanine methyl transferase (MGMT) gene-promoter Methylation status (A) Methylated and (B) Unmethylated. The results are shown with the 95% confidence intervals.

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30.

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Impairment at Diagnosis. Case Rep Oncol 5:530–536, 2012 Brada M., Ashley S., Dowe A., et al. Neoadjuvant phase II multicentre study of new

AC C

agents in patients with malignant glioma after minimal surgery. Report of a cohort of 187 patients treated with Temozolomide Annals of Oncology 16: 942-949; 2005

19

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Table 1 - Patient characteristics

Number of patients (%)

RI PT

Age, years ≤60 >60 Gender Female Male Surgery Biopsy only Partial resection Gross total resection MGMT status Methylated Unmethylated Undetermined RPA class III-IV V

29 (58) 21 (42)

SC

20 (40) 30 (60)

M AN U

4 (8) 21 (42) 25 (50)

21 (42) 27 (54) 2 (4) 29 (58) 21 (42)

AC C

EP

TE D

Abbreviations: MGMT- O6- methyl guanine methyl transferase; RPA - Recursive Partitioning Analysis

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Table 2 - Characteristics of patients undergoing a second surgical procedure

Initial Surgery

49/M

PR

GTR

10

Unmethylated

Recurrence

Alive

Overall Survival (months) 18

55/F

PR

GTR

33

Methylated

Dead

68

59/M

PR

GTR

15

Methylated

Alive

52

54/F

PR

GTR

14

Unmethylated

Alive

77

54/F

PR

GTR

23

Methylated

Dead

26

36/F

PR

Abscess

2

Methylated

Radiation necrosis Recurrence and Radiation necrosis Radiation necrosis Recurrence and Radiation necrosis Abscess

Alive

47

64/F

GTR

Abscess

18

Unmethylated

Abscess

Dead

45

64/F

GTR

GTR

8

Methylated

Alive

47

61/F

PR

GTR

12

Dead

16

56/M

PR

PR

Dead

24

63/M

PR

GTR

Alive

23

53/F

PR

PR

46/M

GTR

Status

15

Unmethylated

19

Methylated

Radiation necrosis Recurrence and Radiation necrosis Radiation Necrosis Recurrence

45

Unmethylated

Recurrence

Dead

54

Unmethylated

Recurrence

Alive

31

EP GTR

Pathology

SC

Initial MGMT promoter

M AN U

Interval (months)

Unmethylated

TE D

Second surgery

RI PT

Age/Gender

19

AC C

Abbreviations: MGMT – O6-methyl guanine methyl transferase; M - male; F - female; PR - partial resection; GTR - gross total resection

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Overall Survival p-value

Age ≤60 ≥60

27.2 15.7

0.008

MGMT Status Methylated Unmethylated

53.8 16.2

0.01

Extent of Surgery GTR & PTR Biopsy

24.2 8.8

0.001

HR (95%CI)

0.40 (0.17-0.71)

Median (mos)

SC

Median (mos)

Progression-free Survival

15.6 12.1

M AN U

Prognostic Factor

RI PT

Table 3- Analysis of prognostic factors and their impact on overall survival and progression-free survival

p-value

HR (95%CI)

0.60

0.85 (0.48-1.57)

0.47 (0.22-0.78)

0.40 (0.19-0.77)

19.6 8.5

0.01

0.18 (0.001-0.13)

20.3 10.8

0.47

0.69 (0.29-1.74)

AC C

EP

TE D

RPA Class III & IV 27.1 0.04 0.52 (0.25-0.99) 13.9 0.65 1.48 (0.63-2.10) V 16.3 13.7 Abbreviations- mos: months; MGMT: 06-mathyl guanine methyl transferase; GTR: gross total resection; PR: partial resection; RPA: recursive partitioning analysis;

RI PT

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O V E R A L L S U R V IV A L

SC

P e r c e n t s u r v iv a l

100

75

25

0 0

12

M AN U

50

24

36

48

60

72

84

2

1

96

T im e ( m o n th s )

P a tie n ts a t ris k

50

39

26

13

10

3

TE D

O v e r a ll P r o g r e s s io n - F r e e - S u r v iv a l

100

AC C

EP

P e r c e n t P r o g r e s s io n - F r e e S u r v iv a l

A

75

50

25

P a tie n ts a t ris k

0 0

12

24

36

48

60

T im e ( m o n th s ) 50

26

12

B Figure 1

8

4

1

ACCEPTED MANUSCRIPT

OS M GM T M ETHYLATED

RI PT

N = 21

SC

75

50

25

0 0

12

M AN U

P e r c e n t s u r v iv a l

100

24

36

48

60

72

P a tie n ts a t ris k

TE D

T im e ( m o n th s )

21

19

16

AC C

EP

A

Figure 2

10

8

2

0

ACCEPTED MANUSCRIPT

N = 27

SC

75

50

25

0 0

12

M AN U

P e r c e n t s u r v iv a l

100

RI PT

OS M G M T UNM ETHYLATED

24

36

48

60

72

84

1

1

P a tie n ts a t ris k

TE D

T im e ( m o n th s )

27

21

11

4

AC C

EP

B

Figure 2

3

2

96

ACCEPTED MANUSCRIPT

N = 21

RI PT

100

75

SC

50

25

0 0

M AN U

P r o g r e s s io n F r e e S u r v iv a l

PFS M GM T M ETHYLATED

12

24

36

48

60

72

T im e ( m o n th s )

21

17

8

TE D

P a tie n ts a t ris k

A

AC C

EP

Figure 3

7

4

1

PFS M GM T UNM ETHYLAYED N = 27

RI PT

100

75

SC

50

25

0 0

12

M AN U

P r o g r e s s io n F r e e S u r v iv a l

ACCEPTED MANUSCRIPT

24

36

48

T im e ( m o n th s )

P a tie n ts a t ris k

27

9

5

TE D

B

AC C

EP

Figure 3

2

1

60