A Study of the Drug Selinexor With Radiation Therapy in Patients With Newly-Diagnosed Diffuse Intrinsic Pontine (DIPG) Glioma and High-Grade Glioma (HGG)

Inclusion Criteria:

• PRE ENROLLMENT: Patients must be =< 25 years of age at the time of enrollment onAPEC14B1 part A central nervous system (CNS)/high grade glioma (HGG) pre-enrollmenteligibility screening

• Please note:

• This required age range applies to pre-enrollment eligibility for all HGGpatients. Individual treatment protocols may have different age criteria.

• Non-DIPG patients with tumors that do not harbor an H3K27M-mutation andare >= 18 years of age will not be eligible to enroll on ACNS1821 (Step 1).

• PRE ENROLLMENT: Patient is suspected of having localized, newly diagnosed HGG,excluding metastatic disease, OR patient has an institutional diagnosis of DIPG

• Please note: there are specific radiographic criteria for DIPG patientenrollment on ACNS1821 (Step 1)

• As of February 14, 2025, stratum DIPG and stratum DMG have closed to accrual,and no patients will be enrolled on these strata after Amendment #4.

• PRE ENROLLMENT:

• For patients with non-pontine tumors: Patients and/or their parents or legalguardians must have signed informed consent for eligibility screening onAPEC14B1 Part A.

• For patients with DIPG: Patients and/or their parents or legal guardians musthave signed informed consent for ACNS1821.

• Note: As of February 14, 2025, stratum DIPG and stratum DMG have closed toaccrual, and no patients will be enrolled on these strata after Amendment #4.

• PRE ENROLLMENT:

• For patients with non-pontine tumors only, the specimens obtained at the timeof diagnostic biopsy or surgery must be submitted through APEC14B1 ASAP,preferably within 5 calendar days of definitive surgery

• STEP 1: Patients must be >= 12 months and =< 21 years of age at the time ofenrollment

• STEP 1: Patients must have newly-diagnosed DIPG or HGG (including DMG).

• STEP 1: Stratum DIPG (Closed with Amendment #4)

• As of February 14, 2025, stratum DIPG and stratum DMG have closed to accrual,and no patients will be enrolled on these strata after Amendment #4.

• Patients with newly-diagnosed typical DIPG, defined as tumors with a pontineepicenter and diffuse involvement of at least 2/3 of the pons on at least 1axial T2 weighted image, are eligible. No histologic confirmation is required.

• Patients with pontine tumors that do not meet radiographic criteria for typicalDIPG (e.g., focal tumors or those involving less than 2/3 of the pontinecross-sectional area with or without extrapontine extension) are eligible ifthe tumors are biopsied and proven to be high-grade gliomas (such as anaplasticastrocytoma, glioblastoma, high-grade glioma not otherwise specified [NOS],and/or H3 K27M-mutant) by institutional diagnosis.

• STEP 1: Stratum DMG (with H3 K27M mutation) (Closed with Amendment #4)

• As of February 14, 2025, stratum DIPG and stratum DMG have closed to accrual,and no patients will be enrolled on these strata after Amendment #4.

• Patients must have newly-diagnosed non-pontine H3 K27M-mutant HGG without BRAFV600 or IDH1 mutations as confirmed by Rapid Central Pathology and MolecularScreening Reviews performed on APEC14B1

• Note: Patients need not have either measurable or evaluable disease, i.e., DMGpatients may have complete resection of their tumor prior to enrollment.Primary spinal tumors are eligible for enrollment. For rare H3 K27M-mutant HGGin non-midline structures (e.g., cerebral hemispheres), these patients will beconsidered part of Stratum DMG.

• STEP 1: Stratum HGG (without H3 K27M mutation)

• Patients must have newly-diagnosed non-pontine H3 K27M-wild type HGG withoutBRAF V600 or IDH1 mutations as confirmed by Rapid Central Pathology andMolecular Screening Reviews performed on APEC14B1

• Please note:

• Patients who fall in this category and who are >= 18 years of age are noteligible due to another standard-of-care regimen (radiation/temozolomide)that is available

• Patients need not have either measurable or evaluable disease, i.e., HGGpatients may have complete resection of their tumor prior to enrollment.Primary spinal tumors are eligible for enrollment

• STEP 1: Patients must have a performance status corresponding to Eastern CooperativeOncology Group (ECOG) scores of 0, 1 or 2. Use Karnofsky for patients > 16 years ofage and Lansky for patients =<16 years of age. Patients who are unable to walkbecause of paralysis, but who are up in a wheelchair, will be considered ambulatoryfor the purpose of assessing the performance score.

• STEP 1: Peripheral absolute neutrophil count (ANC) >= 1000/uL (within 7 days priorto step 1 enrollment)

• STEP 1: Platelet count >= 100,000/uL (transfusion independent) (within 7 days priorto step 1 enrollment)

• STEP 1: Hemoglobin >= 8.0 g/dL (may receive red blood cell [RBC] transfusions) (within 7 days prior to step 1 enrollment)

• STEP 1: Creatinine clearance or radioisotope glomerular filtration rate (GFR) >= 70mL/min/1.73 m^2 (within 7 days prior to step 1 enrollment) or

A serum creatinine based on age/sex as follows (within 7 days prior to step 1 enrollment):

• Age / Maximum Serum Creatinine (mg/dL)

• 1 to < 2 years / male: 0.6; female: 0.6

• 2 to < 6 years / male: 0.8; female: 0.8

• 6 to < 10 years / male: 1; female: 1

• 10 to < 13 years / male: 1.2; female: 1.2

• 13 to < 16 years / male: 1.5; female: 1.4

• >= 16 years / male: 1.7; female: 1.4

• STEP 1: Total bilirubin =< 1.5 x upper limit of normal (ULN) for age

• STEP 1: Serum glutamate pyruvate transaminase (SGPT) (alanineaminotransferase [ALT]) =< 135 U/L. For the purpose of this study, the ULNfor SGPT is 45 U/L.

• STEP 1: Serum amylase =< 1.5 x ULN

• STEP 1: Serum lipase =< 1.5 x ULN

• STEP 1: No evidence of dyspnea at rest, no exercise intolerance, and apulse oximetry > 94% if there is clinical indication for determination.

• STEP 1: Patients with seizure disorder may be enrolled if onanticonvulsants and well controlled.

• STEP 1: Patients must be enrolled and protocol therapy must begin no laterthan 31 days after the date of radiographic diagnosis (in the case ofnon-biopsied DIPG patients only) or definitive surgery, whichever is thelater date (Day 0).

For patients who have a biopsy followed by resection, the date of resection will be considered the date of definitive diagnostic surgery. If a biopsy only was performed, the biopsy date will be considered the date of definitive diagnostic surgery.

Exclusion Criteria:

• STEP 1: Patients must not have received any prior therapy for their central nervoussystem (CNS) malignancy except for surgery and steroid medications.

• STEP 1: Patients who are currently receiving another investigational drug are noteligible.

• STEP 1: Patients who are currently receiving other anti-cancer agents are noteligible.

• STEP 1: Patients >=18 years of age who have H3 K27M-wild type HGG.

• STEP 1: Patients who have an uncontrolled infection.

• STEP 1: Patients who have received a prior solid organ transplantation.

• STEP 1: Patients with grade > 1 extrapyramidal movement disorder.

• STEP 1: Patients with known macular degeneration, uncontrolled glaucoma, orcataracts.

• STEP 1: Patients with metastatic disease are not eligible; MRI of spine with andwithout contrast must be performed if metastatic disease is suspected by thetreating physician.

• STEP 1: Patients with gliomatosis cerebri type 1 or 2 are not eligible, with theexception of H3 K27M-mutant bithalamic tumors.

• STEP 1: Patients who are not able to receive protocol specified radiation therapy.

• STEP 1:

• Female patients who are pregnant are ineligible since there is yet no availableinformation regarding human fetal or teratogenic toxicities.

• Lactating females are not eligible unless they have agreed not to breastfeedtheir infants. It is not known whether selinexor is excreted in human milk.

• Female patients of childbearing potential are not eligible unless a negativepregnancy test result has been obtained.

• Sexually active patients of reproductive potential are not eligible unless theyhave agreed to use two effective methods of birth control (including amedically accepted barrier method of contraception, e.g., male or femalecondom) for the duration of their study participation and for 90 days after thelast dose of selinexor. Abstinence is an acceptable method of birth control.