Clinical Trial

. 2025 Dec;26(12):1651-1664.

doi: 10.1016/S1470-2045(25)00492-9.

Microbubble-enhanced transcranial focused ultrasound with temozolomide for patients with high-grade glioma (BT008NA): a multicentre, open-label, phase 1/2 trial

Graeme F Woodworth¹, Pavlos Anastasiadis², Ahmad Ozair³, Jeremi Chabros⁴, Chetan Bettegowda⁵, Chixiang Chen⁶, Jakob V E Gerstl⁷, Christopher Douville⁸, Rania A Mekary⁹, Timothy R Smith⁷, Ying Meng¹⁰, Cynthia Hawkins¹⁰, Christopher B Pople¹⁰, Agessandro Abrahao¹¹, Maheleth Llinas¹¹, Chinthaka Heyn¹¹, Adomas Bunevicius¹², Ali R Rezai¹³, Anna J S Ball¹⁴, Kaitlyn Henry¹⁵, Arjun Sahgal¹⁶, Erickson Torio¹⁴, Haoyu Ren¹⁷, Haroon Ahmad¹⁵, Harshit Arora¹⁴, Howard Eisenberg¹⁸, James Perry¹¹, Jeffrey S Carpenter¹⁹, Kullervo Hynynen²⁰, Lily C Pham¹⁵, Mary Beth Anketell¹⁴, Mary Jane Lim-Fat²¹, Zhiyuan Xu¹⁹, Christopher P Cifarelli²², Jason P Sheehan²³, Nathan J McDannold²⁴, Dheeraj Gandhi²⁵, Alexandra J Golby²⁶, Nir Lipsman²⁷

Affiliations

¹ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Brain Tumor Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. Electronic address: gwoodworth@som.umaryland.edu.
² Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Brain Tumor Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
³ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Brain Tumor Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA; Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada.
⁴ Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA.
⁵ Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁶ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
⁷ Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA; Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
⁸ Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁹ Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA.
¹⁰ Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
¹¹ Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹² Department of Neurology, Columbia University, New York, NY, USA.
¹³ Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA; Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA.
¹⁴ Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹⁵ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Brain Tumor Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA.
¹⁶ Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁷ Department of Mathematics and Statistics, University of Maryland, Baltimore, MD, USA.
¹⁸ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
¹⁹ Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA.
²⁰ Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
²¹ Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
²² Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA.
²³ Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA.
²⁴ Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA.
²⁵ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
²⁶ Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA.
²⁷ Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.

PMID: 41308679
PMCID: PMC12757104
DOI: 10.1016/S1470-2045(25)00492-9

Clinical Trial

Microbubble-enhanced transcranial focused ultrasound with temozolomide for patients with high-grade glioma (BT008NA): a multicentre, open-label, phase 1/2 trial

Graeme F Woodworth et al. Lancet Oncol. 2025 Dec.

. 2025 Dec;26(12):1651-1664.

doi: 10.1016/S1470-2045(25)00492-9.

Authors

Affiliations

¹ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Brain Tumor Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. Electronic address: gwoodworth@som.umaryland.edu.
² Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Brain Tumor Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
³ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Brain Tumor Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA; Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada.
⁴ Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA.
⁵ Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁶ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
⁷ Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA; Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
⁸ Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁹ Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA.
¹⁰ Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
¹¹ Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹² Department of Neurology, Columbia University, New York, NY, USA.
¹³ Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA; Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA.
¹⁴ Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
¹⁵ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Brain Tumor Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA.
¹⁶ Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁷ Department of Mathematics and Statistics, University of Maryland, Baltimore, MD, USA.
¹⁸ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
¹⁹ Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA.
²⁰ Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
²¹ Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
²² Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA.
²³ Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA.
²⁴ Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA.
²⁵ Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
²⁶ Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA.
²⁷ Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.

PMID: 41308679
PMCID: PMC12757104
DOI: 10.1016/S1470-2045(25)00492-9

Abstract

Background: Brain-infiltrating tumour cells from high-grade glioma remain shielded from drug treatments by the blood-brain barrier, leading to inevitable recurrence. Microbubble-enhanced transcranial focused ultrasound (MB-FUS) enables controlled blood-brain barrier opening (BBBO), permitting localised drug delivery. We aimed to assess safety and feasibility of MB-FUS plus standard-of-care chemotherapy for individuals with high-grade glioma.

Methods: BT008NA was an open-label, single-arm, phase 1/2 trial conducted at five sites in the USA and Canada (part of the ReFOCUSED Consortium). Key eligibility criteria were participants with newly diagnosed high-grade glioma (glioblastoma as per WHO 2016 classification), aged 18-80 years, with normal organ function, a baseline Karnofsky Performance Status score of 70 or higher, who had received maximal safe resection and 6-week chemoradiotherapy and were to start standard-of-care monthly adjuvant temozolomide chemotherapy (150 mg/m² of body surface area). MRI-guided, 220 kHz transcranial MB-FUS treatments were delivered in periresectional (tumour-infiltrative) regions, on any of the first 3 days of a 28-day temozolomide cycle, for up to six cycles. Primary outcomes were safety (adverse events) and feasibility (BBBO: new contrast enhancement on post-procedure T1-weighted MRI). Protocol-prespecified secondary outcomes were overall survival and progression-free survival. Analyses were done in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT03551249 (USA) and NCT03616860 (Canada), and is closed to enrolment.

Findings: Between Oct 16, 2018, and March 9, 2022, we enrolled 34 participants, all evaluable for prespecified primary and secondary endpoints, with a mean age of 51·5 years (SD 13·0) and median follow-up 44·5 months (95% CI 34·9-57·3). By self-reporting, 18 (53%) participants were female and 16 (47%) male, 28 (82%) were White, and 34 (100%) were non-Hispanic. 176 adverse events were captured: 54 (31%) chemotherapy-related, 10 (6%) disease-related, 87 (49%) related to undergoing MB-FUS (40 [46%] grade 1, 46 [53%] grade 2, and one [1%] grade 3), and 25 (14%) unrelated. Two (1%) of the adverse events were grade 5 (disease-related deaths), three (2%) grade 4 (temozolomide-related haematological abnormalities), and eight (5%) grade 3 (three [2%] temozolomide-related, one [1%] MB-FUS-related, three [2%] disease-related, and one [1%] unrelated); these occurred across seven (21%) of 34 participants. No treatment-related deaths occurred during the trial. BBBO was visualised in all treatments. Median overall survival was 31·3 months (95% CI 21·1-not reached) and median progression-free survival was 13·5 months (9·9-26·9) with patient-specific disease courses found concordant with trajectories of MB-FUS-enriched plasma cell-free DNA.

Interpretation: MB-FUS plus temozolomide is a safe combinatorial therapeutic approach for individuals with high-grade glioma, with the potential to improve survival and enable non-invasive plasma biomarker-based disease surveillance (sono-liquid biopsy), warranting randomised controlled trials.

Funding: National Institutes of Health and Insightec.

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Conflict of interest statement

Declaration of interests GFW reports grants from the Focused Ultrasound Foundation, the National Institutes of Health (NIH), and the Maryland Stem Center Research Foundation; and clinical trial support from Insightec and the Keep Punching Foundation. CB reports consultancy for Haystack Oncology, Privo Technologies, and Bionaut Labs; and being co-founder of OrisDx and Belay Diagnostics. AS reports grants (institutional) from Elekta, Varian, Seagen, and Brainlab; consulting fees and travel support from Varian, Elekta, and Brainlab; honoraria from AstraZeneca, Elekta, Varian, Brainlab, Seagen, Cerapedics, and CarboFix; participation on a data and safety monitoring board for Elekta; and leadership on ISRS and Elekta Gamma Knife Icon groups. CD reports consulting fees from and stock or stock options in Exact Sciences and Belay Diagnostics; and royalties and travel support from Exact Sciences. AA reports grants from the Focused Ultrasound Foundation. DG reports grants from the Focused Ultrasound Foundation, MicroVention, the University of Calgary with NoNo Therapeutics, and the University of Maryland Innovation Gateway; and clinical trial support from Insightec. AJG reports clinical trial support from Insightec; and stock shareholding in Merck. HE reports clinical trial support from Insightec. JS reports service on the board of directors for the American Association of Neurological Surgeons; and clinical trial support from Insightec. KHy reports being an inventor on patents licensed to Insightec; and travel support from Insightec. MJL-F reports honoraria from Servier and Novocure; and unpaid service on the board of directors for the Society for Neuro-Oncology. JP reports honoraria from Servier, Novocure, Chimerix, and Merck; stock shareholding in Synaptive Medical; and stipends for leadership roles from the Canadian Brain Tumour Consortium and the Global Coaliton for Adaptive Research. NJM reports grants from the Focused Ultrasound Foundation and Insightec. NL reports grants or support from the Focused Ultrasound Foundation, the Midas Touch Foundation, and the Weston Brain Institute; and clinical trial support from Insightec. All other authors declare no competing interests.

Figures

**Figure 1:. Trial summary**
(A) Trial schema, in the context of the standard of care for HGG. (B) Flow diagram showing trial cohort in blue, external control cohort in green, and cohort creation process in red. (C) Trial intervention (MB-FUS plus temozolomide) and blood sampling performed in subgroup. © 2025. University of Maryland, Baltimore—Ting I Wang. All rights reserved. (D) Swimmer plot. (E) Summary of trial participants included in the different sets of analyses, enrolled per trial site. BWH=Brigham and Women’s Hospital. cfDNA=cell-free DNA. HGG=high-grade glioma. IDH=isocitrate dehydrogenase. MB-FUS=microbubble-enhanced transcranial focused ultrasound. MGMT=O⁶-methylguanine-DNA methyltransferase. SB=Sunnybrook Health Sciences Center. UMD=University of Maryland. UVA=University of Virginia. WVU=West Virginia University. *The one missing MGMT status was treated with multiple imputation in the primary analysis (table 1 shows one imputation iteration of the many carried out).

**Figure 2:. Large-volume, contoured MB-FUS BBBO treatments**
Axial (A), coronal (B), and sagittal (C) MRI scans in a representative trial participant with overlaid subspot target grids and contouring around the resection cavity. Inset in (A) shows the distance between individual subspots at 3 mm along x and y planes. 3D cavity reconstruction (D), target grid comprised by sonication subspots in 3D (E), in terms of T1 contrast-enhancement and BBBO (F). Composite overlaid volumes from 3D–3F (G). Across the trial, targeting coverage based on the proportion of prescribed acoustic emissions dose achieved (left), and proportion of BBBO (right) (H). Although all cycles had investigator-assessed BBBO, per new enhancement on T1-weighted MRI with contrast, BBBO quantification could be pursued from those treatment cycles where images could be merged or co-registered without MRI artifacts (appendix pp 9–10). Median new T1c at 1 h after MB-FUS was 82% (IQR 60–94). MB-FUS=microbubble-enhanced transcranial focused ultrasound. BBBO=blood–brain barrier opening.

**Figure 3:. Clinical treatment effect estimation**
(A) Primary estimand, ATT, defined as the additional survival benefit conferred by monthly MB-FUS plus temozolomide compared with temozolomide alone in participants who had undergone resection plus 6-week adjuvant chemoradiotherapy. Four comparative approaches were used to evaluate ATT across four defined participant cohorts. N_trial=34 versus N_{matched cohort,standard}=195 was deemed the reference analysis for downstream statistical evaluations, with comparative survival curves after wCEM (B, C) and after wCEM plus Cox proportional hazards modelling (D, E). Panels (D) and (E) present probabilistic estimates after complex statistical analyses and thus do not have corresponding number at risk (number censored) data. Shaded areas represent 95% CIs. ATT=average treatment effect on the treated. HR=hazard ratio. MB-FUS=microbubble-enhanced transcranial focused ultrasound. wCEM=weighted coarsened exact matching.

**Figure 4:. Profiling of plasma sono-liquid biomarkers**
(A) Exploratory sono-liquid biomarker profiling was performed in a trial subset (figure 1E). Sensitivity analysis to evaluate the post-hoc selection of sono-liquid biomarkers. Last observed post-to-pre-procedure ratio of [cfDNA] (B) and FLR (C) in patients with active tumours, early progressors (median progression-free survival <10 months), and long-term survivors (median overall survival >24 months). (D) Temporal trajectory analysis of ratios of [cfDNA] and FLR for early progressors and long-term survivors over treatment cycles. (E) Concordance analysis of sono-liquid biomarker trajectories with survival outcomes. [cfDNA]=total plasma cell-free DNA concentration. FLR=fragment length ratio. HR=hazard ratio. MB-FUS=microbubble-enhanced transcranial focused ultrasound. ns=non-significant. *p<0·05. †p<0·01.

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References

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Microbubble-enhanced transcranial focused ultrasound with temozolomide for patients with high-grade glioma (BT008NA): a multicentre, open-label, phase 1/2 trial

Affiliations

Microbubble-enhanced transcranial focused ultrasound with temozolomide for patients with high-grade glioma (BT008NA): a multicentre, open-label, phase 1/2 trial

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

Substances

Associated data

Grants and funding

LinkOut - more resources

Full Text Sources

Medical

Miscellaneous