Optune for Children With High-Grade Glioma or Ependymoma, and Optune With Radiation Therapy for Children With DIPG

Inclusion Criteria:

   - Age: at the time of enrollment Stratum 1: ≥ 5 years but ≤ 21 Stratum 2: ≥ 3 years but
   ≤ 21

   - Diagnosis:

Stratum 1: Patients must have a histologically confirmed diagnosis of supratentorial
high-grade glioma or supratentorial ependymoma that is recurrent, progressive or
refractory.

Stratum 2: Patients with newly diagnosed DIPG

   - Patients with a typical DIPG on MR imaging, defined as a tumor with a pontine
   epicenter and diffuse involvement of more than 2/3 of the pons, are eligible without
   histologic confirmation.

   - Note: Patients with typical DIPG who undergo a biopsy are eligible provided the tumor
   is a diffuse glioma WHO Grade II-IV with OR without H3 K27M mutation.

   - Patients with pontine lesions that do not meet these MR imaging criteria will be
   eligible if there is histologic confirmation diffuse glioma WHO Grade II-IV with H3
   K27M-mutation.

      - Disease Status: Patients must have bi-dimensionally measurable disease, defined
      as at least one lesion that can be accurately measured in at least two planes

Stratum 1:

   - This disease must be located primarily in the supratentorial region

   - Patients with significant disease that is metastatic outside of the supratentorial
   region are ineligible

Stratum 2:

   - This disease must be located primarily in the pons

      - Prior Therapy:

Stratum 1: Patients must have recovered from the acute treatment related toxicities
(defined as ≤ grade 1) of all prior chemotherapy, immunotherapy, or radiotherapy prior to
entering this study.

Stratum 2: Patients may not have had any prior antitumor therapy except surgery and/or
steroids.

• Myelosuppressive Chemotherapy: Patients must have received last dose of known
myelosuppressive chemotherapy >21 days prior to enrollment; >42 days if nitrosourea.

   - Biologic Agent: Biologic agent must have recovered from any acute toxicity potentially
   related to the agent and received their last dose of the biologic agent > 7 days prior
   to study enrollment.

   - 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.

   - Immunomodulatory treatment: Patient must have received the last dose >21 days prior to
   enrollment.

   - Monoclonal antibody treatment and agents with known prolonged half-lives: Patient
   must have recovered from any acute toxicity potentially related to the agent and
   received their last dose of the agent ≥ 28 days prior to study enrollment. Radiation:

      - Stratum 1: Patients must have had their last fraction of:

      - Craniospinal irradiation (>24Gy) or total body irradiation or radiation to ≥
      50% of pelvis ≥ 42 days prior to enrollment

         - Focal irradiation ≥ 14 days prior to enrollment

         - Local palliative irradiation (small port) ≥ 14 days

      - Stratum 2: Patients must not have received any radiotherapy prior to enrollment.
      If clinically indicated, enrolled patients may receive up to 5 fractions of
      radiotherapy prior to starting Optune therapy.

   - Surgery:

   o Stratum 1: Optune device application start date must be at least 4 weeks (28 days)
   from CNS surgical procedure. Excluding VP shunts, Endoscopic Third Ventriculostomy
   (ETV) for which treatment could start 10 days post procedure. Non-CNS surgical
   procedures such as but not limited to central venous catheter insertion at the
   discretion of treating physician and study chair.

   o Stratum 2: Radiation therapy and Optune device application start date must be at
   least 5 days after the date of a tumor biopsy if obtained.

   - Inclusion of Women and Minorities: Both males and females of all races and ethnic
   groups are eligible for this study.

   - Neurologic Status:

      - Stratum 1: Patients with neurological deficits should be stable for a minimum of
      1 week prior to enrollment.

      - Stratum 2: Stable neurologic deficits are not an eligibility criterion for
      Stratum 2.

Performance Status: Stratum 1: Karnofsky Performance Scale (KPS for > 16 years of age) or
Lansky Performance Score (LPS for ≤ 16 years of age) assessed within two weeks of
enrollment must be ≥ 60. Patients who are unable to walk because of neurologic deficits,
but who are up in a wheelchair, will be considered ambulatory for the purpose of assessing
the performance score. There are no performance status requirements for Stratum 2 patients.

• Organ Function: Stratum 1 patients must have organ and marrow function as defined below:
Absolute neutrophil count ≥ 1.0 X 109/L; Platelets ≥ 100 X 109/L (transfusion independent);
Hemoglobin ≥8g/dl (may receive transfusions); Total bilirubin ≤1.5 times institutional
upper limit of normal (ULN); ALT(SGPT) ≤3 times institutional upper limit of normal;
AST(SGOT) ≤3 times institutional upper limit of normal; Albumin ≥2 g/dl. Serum creatinine
based on age/gender as noted below. Patients that do not meet the criteria below but have a
24 hour Creatinine Clearance or GFR (radioisotope or iothalamate) ≥ 70 ml/min/1.73 m2 are
eligible.

Age Maximum Serum Creatinine (mg/dL) 3 to < 6 years 0.8 (Male) 0.8 (Female); 6 to < 10
years 1 (Male) 1 (Female); 10 to < 13 years 1.2 (Male) 1.2 (Female); 13 to < 16 years 1.5
(Male) 1.4 (Female);

   - 16 years 1.7 (Male) 1.4 (Female).

      - Stratum 2: Patients must have adequate organ and marrow function as defined
      below:

      o Absolute neutrophil count ≥ 1.0 X 109/L

      o Platelets ≥ 100 X 109/L (transfusion independent)

      o Hemoglobin ≥8g/dl (may receive transfusions)

      - Head circumference: Patients must have minimum head circumference of 44 cm.

      - Compliance in Optune Device Usage:

         - Stratum 1: Patients must be willing to use the Optune device ≥18 hours/day
         for at least 23 days in a 28-day cycle, and keep head shaved throughout
         treatment.

         - Stratum 2: During concurrent Optune therapy and RT, patients must be willing
         to use the Optune device ≥18 hours/day for at least 40 of the 49 days of the
         duration of the feasibility period. During subsequent cycles of Optune
         therapy alone, patients must be willing to use the Optune device ≥18
         hours/day for at least 23 days in a 28-day cycle. During concurrent Optune
         therapy and RT and Optune therapy alone, patients must be willing to keep
         their head shaved throughout treatment.

      - Pregnancy Status: Female patients of childbearing potential must have a negative
      serum or urine pregnancy test.

      - Pregnancy Prevention: Patients of childbearing or child fathering potential must
      be willing to use a medically acceptable form of birth control, which includes
      abstinence, while being treated on this study.

      - Informed Consent: The patient or parent/guardian is able to understand the
      consent and is willing to sign a written informed consent document according to
      institutional guidelines.

      - Steroids:

      o Stratum 1: If patient is on corticosteroids, the dose must be stable or
      decreasing for at least 5 days prior to enrollment.

         - Stratum 2: There are no eligibility requirements for corticosteroid dosing
         for Stratum 2.

Exclusion Criteria:

   - Systemic Illness: Patients with any clinically significant unrelated systemic illness
   (serious infections or significant cardiac, pulmonary, hepatic or other organ
   dysfunction), that in the opinion of the investigator would compromise the patient's
   ability to tolerate protocol therapy, put them at additional risk for toxicity or
   would interfere with the study procedures or results.

   - Other Malignancy: Patients with a history of any other malignancy.

   - Concurrent Therapy: Patients who are receiving any other anticancer or investigational
   drug therapy are not eligible.

   - Inability to Participate: Patients who in the opinion of the investigator are
   unwilling or unable to return for required follow-up visits or obtain follow-up
   studies required to assess toxicity to therapy or to adhere to device usage plan,
   other study procedures, and study restrictions.

   - Stratum 1 Tumor Location: Patients with primarily infra-tentorial or spinal cord tumor
   are not eligible.

   - Tumor Dissemination: Patients for who clinical suspicion is present of metastatic
   disease in the CSF or Spine must have MRI of Spine and CSF obtained (Lumbar puncture
   or through ommaya, EVD or Shunt) with negative cytology. Patients with CSF that is
   positive for tumor cells or metastatic disease found on MRI are ineligible.

   - Skull Defects: Patients with major skull defects (such as missing bone without
   replacement) are not eligible.

   - Neurological Disorder: Patients with active implanted electronic devices in the brain
   or spinal cord such as programmable VP shunts, deep brain stimulators, vagus nerve
   stimulators, are not eligible.

   - Cardiac Disorder: Patients with pacemaker, defibrillator, or documented significant
   arrhythmia, are not allowed.

   - Intracranial Objects: Patients with foreign body intracranially, such as bullet
   fragments, are not allowed, with the exception of VP-shunts (non-programmable) and
   Ommaya catheters.

   - Allergy: Patients with history of hypersensitivity to conductive hydrogel are not
   eligible.