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Cyclophosphamide, Topotecan, and Bevacizumab (CTB) in Patients With Relapsed/Refractory Ewing's Sarcoma and Neuroblastoma

Primary Purpose

Neuroblastoma, Sarcoma

Status
Completed
Phase
Phase 2
Locations
International
Study Type
Interventional
Intervention
Cyclophosphamide, Topotecan, and Bevacizumab
Sponsored by
Memorial Sloan Kettering Cancer Center
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Neuroblastoma focused on measuring Ewing's sarcoma, BEVACIZUMAB (AVASTIN), CYCLOPHOSPHAMIDE (CYTOXAN), TOPOTECAN, 11-183, POETIC

Eligibility Criteria

undefined - 21 Years (Child, Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Patients must have histologically confirmed relapsed/refractory Ewing's sarcoma or neuroblastoma.
  • Patients must have measurable disease. Patients with a diagnosis of neuroblastoma with MIBG avid disease only are permitted to enroll on this study.
  • Patients must be ≤ 21 years of age at time of diagnosis
  • Life expectancy ≥ 3 months
  • Lansky or Karnofsky performance ≥ 70%
  • Written informed consent
  • Organ and marrow function defined as follows:

Hematologic function, as follows

  • Absolute neutrophil count ≥ 1000/μL
  • Platelets ≥ 100 x 109/L (without transfusion < 14 days before enrollment) Hemoglobin ≥ 9 gm/dl

Renal function, as follows:

  • Serum creatinine ≤ ULN for age. Refer to Appendix H for normal values for serum creatinine in children.
  • If serum creatinine above these values, the calculated creatinine clearance or radioisotope GFR must be ≥ 60 ml/min/1.73 m2
  • Urinary protein < 2+ (unless total quantitative protein is < 500 mg protein/day as determined by 24 H urine collection) for pediatric patients please refer to the CTCAE V4.0 for values.

Hepatic function, as follows:

  • Total bilirubin ≤ 1.5x ULN
  • AST and ALT ≤ 2.5x ULN for institution or ≤ 5x ULN for institution if clearly attributable to liver metastases
  • Albumin ≥ 2.5 g/dl. Coagulation: INR ≤ 1.5x ULN.
  • Prior Treatment: Patients must have recovered from the acute toxic effects of all prior chemotherapy, immunotherapy, or radiation therapy prior to entry on study. Patients must have had at least one prior treatment regimen. Patients may have received treatment previously with cyclophosphamide or topotecan but no prior bevacizumab.
  • Myelosuppressive chemotherapy: Two weeks must have elapsed since administration of previous chemotherapy.
  • Biologic agents: At least 2 weeks must have elapsed since the completion of therapy with a monoclonal antibody. Seven days must have elapsed since the last dose of retinoids
  • Radiation therapy: For all patients, ≥ 4 weeks must have elapsed for local XRT; ≥ 6 months must have elapsed if prior radiation to ≥ 50% of the pelvis or if substantial bone marrow irradiation. Patients with a history of prior radiation with field including the heart (e.g. mantle) will be excluded.
  • Stem cell transplant: Patients who have undergone prior stem cell transplantation will not be excluded from study entry. At least 3 months must have elapsed since autologous or allogeneic stem cell transplantation. Patients must have no evidence of active graft versus host disease.

Exclusion Criteria:

  • Patients with centrally-located pulmonary or mediastinal primary tumors or metastases adjacent to or invading large blood vessels.
  • Prior left chest wall irradiation or a cumulative anthracycline dose of greater or equal to 300 mg/m2, unless the ejection fraction or fraction shortening is within normal institutional limits, in which case the patient can be enrolled.
  • Inability to comply with study and/or follow-up procedures
  • Life expectancy of less than 3 months
  • Current, recent (within 4 weeks of the first infusion of this study), or planned participation in an experimental drug study other than a Genentech-sponsored bevacizumab cancer study
  • Active second malignancy, other than superficial basal cell and superficial squamous (skin) cell, or carcinoma in situ of the cervix within last five years
  • History of other malignancies, except for other solid tumors curatively treated with no evidence of disease for > 3 years prior to enrollment.
  • Known infection with human immunodeficiency virus (HIV).
  • Uncontrolled hypertension (sBP >150 mmHg and/or diastolic BP > 100 mmHg, found on two consecutive measurements separated by a one week period of time despite adequate medical support).
  • Prior history of hypertensive crisis or hypertensive encephalopathy.
  • New York Heart Association (NYHA) Grade II or greater congestive heart failure
  • History of myocardial infarction or unstable angina within 6 months prior to Day - 3.
  • History of stroke or transient ischemic attack within 6 months prior to Day -3.
  • Known CNS disease, except for treated brain metastases.
  • Treated brain metastases are defined as having no evidence of progression or hemorrhage after treatment and no ongoing requirement for dexamethasone, as ascertained by clinical examination and brain imaging (MRI or CT) during the screening period. Anticonvulsants (stable dose) are allowed. Treatment for brain metastases may include whole brain radiotherapy (WBRT), radiosurgery (RS; Gamma Knife, LINAC, or equivalent) or a combination as deemed appropriate by the treating physician. Patients with CNS metastases treated by neurosurgical resection or brain biopsy performed within 3 months prior to Day -3 will be excluded.
  • Significant vascular disease (e.g., aortic aneurysm, requiring surgical repair or recent peripheral arterial thrombosis) within 6 months prior to Day -3.
  • History of hemoptysis (≥ 1/2 teaspoon of bright red blood per episode) within 1 month prior to Day -3.
  • Evidence of bleeding diathesis or significant coagulopathy (in the absence of therapeutic anticoagulation).
  • Major surgical procedure, open biopsy, or significant traumatic injury within 28 days prior to Day -3 or anticipation of need for major surgical procedure during the course of the study. (A major procedure constitutes an invasive procedure which requires general anesthetic support, hospitalization, and supportive care such as laparotomy, laminectomy, etc.)
  • Core biopsy or other minor surgical procedure, excluding placement of a vascular access device, within 7 days prior to Day 1. (Minor surgical procedures include minimally invasive procedures such as fine needle aspiration, core biopsy, etc requiring little if any supportive care excluding lumbar puncture and bone marrow aspiration/biopsy.)
  • History of abdominal fistula or gastrointestinal perforation within 6 months prior to Day -3.
  • Serious, non-healing wound, active ulcer, or untreated bone fracture.
  • Thrombolytics or treatment doses of warfarin within 28 days of initiating treatment. Patients who require low dose warfarin for central venous catheter patency are allowed to enter if their dose is < 2 mg per day total AND their International Normalized Ratio (INR) is ≤ 1.5.
  • Patients requiring treatment doses of heparin for any reason. The use of heparin flushes for maintenance of central venous catheters is permitted
  • Patients requiring aspirin > 325 mg per day or non-steroidal anti-inflammatory medications known to inhibit platelet function. Patients taking cyclooxygenase-2 inhibitors (COX-2) inhibitors are allowed to enroll.
  • History or clinical evidence of deep venous thrombosis including pulmonary embolus within 6 months of treatment.
  • Patients with proteinuria > 1+ on urine dipstick or UPC ratio ≥ 1.0 at screening. If >1+ proteinuria is detected on surveillance, a 24-hour collection must be performed if eligibility is desired. Patients with a 24-hour urine protein content of ≤ 500 mg are eligible.
  • Known hypersensitivity to any component of bevacizumab.
  • Pregnancy (positive pregnancy test) or lactation. (An effective means of contraception (men and women) in subjects of child-bearing potential must be used.)

Sites / Locations

  • Phoenix Children'S Hospital
  • University of Colorado Health Sciences Center and The Children's Hospital
  • MD Anderson Cancer Center Orlando at Arnold Palmer Hospital for Children
  • Children's Mercy Hospital & Clinics
  • Memorial Sloan Kettering Cancer Center
  • Pennsylvania State University College of Medicine
  • Alberta Children'S Hospital

Arms of the Study

Arm 1

Arm Type

Experimental

Arm Label

Cyclophosphamide, Topotecan, and Bevacizumab (CTB)

Arm Description

This is a multi-center, open label phase II study evaluating the safety and efficacy of the novel combination of agents consisting of bevacizumab, cyclophosphamide, and topotecan.

Outcomes

Primary Outcome Measures

Objective Response Rate
as measured by objective response rate (CR/PR) after 2 cycles of treatment and duration of response. after 2 cycles of treatment and duration of response according to the Revised RECIST guideline (version 1.1) Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.0) for target lesions and assessed by MRI: Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), >=30% decrease in the sum of the longest diameter of target lesions; Overall Response (OR) = CR + PR.

Secondary Outcome Measures

Number of Participants With Adverse Events
Safety will be assessed by physical examination, interim history, and laboratory assessments. Adverse events will be graded according to the NCI-CTCAE, version 4.0

Full Information

First Posted
December 12, 2011
Last Updated
October 28, 2019
Sponsor
Memorial Sloan Kettering Cancer Center
Collaborators
Genentech, Inc., Children's Mercy Hospital Kansas City, Penn State University, University of Colorado, Denver, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Phoenix Children's Hospital Center for Cancer & Blood Disorders, Alberta Children's Hospital, MD Anderson Cancer Center Orlando, M.D. Anderson Cancer Center
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1. Study Identification

Unique Protocol Identification Number
NCT01492673
Brief Title
Cyclophosphamide, Topotecan, and Bevacizumab (CTB) in Patients With Relapsed/Refractory Ewing's Sarcoma and Neuroblastoma
Official Title
A Phase II Trial of Cyclophosphamide, Topotecan, and Bevacizumab (CTB) in Patients With Relapsed/Refractory Ewing's Sarcoma and Neuroblastoma
Study Type
Interventional

2. Study Status

Record Verification Date
October 2018
Overall Recruitment Status
Completed
Study Start Date
December 2011 (Actual)
Primary Completion Date
October 31, 2018 (Actual)
Study Completion Date
October 31, 2018 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Memorial Sloan Kettering Cancer Center
Collaborators
Genentech, Inc., Children's Mercy Hospital Kansas City, Penn State University, University of Colorado, Denver, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Phoenix Children's Hospital Center for Cancer & Blood Disorders, Alberta Children's Hospital, MD Anderson Cancer Center Orlando, M.D. Anderson Cancer Center

4. Oversight

5. Study Description

Brief Summary
The purpose of this study is to find out what effects, good and/or bad treatment with a new combination of drugs, cyclophosphamide, topotecan, and bevacizumab has on the patient and their cancer. The medications, cyclophosphamide and topotecan, are standard drugs often used together for the treatment of cancer in children with either Ewing's sarcoma or neuroblastoma. Bevacizumab is an experimental drug called an antibody that targets a protein important in the growth of cancer cells called vascular endothelial growth factor (VEGF). VEGF is made by tumor and other surrounding cells to help make blood vessels needed for the growth and spread of cancer cells in the body. The way that bevacizumab works is to stop the cancer cells from making their own blood supply, causing the tumor to stop growing bigger or from spreading. In adult clinical trials, bevacizumab has shown promising anti-cancer activity in patients with cancer of the colon/rectum (colorectal) and breast. It has been approved by the Food and Drug Administration (FDA) for use in patients with colorectal cancer but not in cancers found in children. Bevacizumab has been tested in early clinical studies in children and has been shown to be safe. Other goals of this study will include research tests designed to test the following changes in the patient or their cancer: to see how the body handles and breaks down bevacizumab (pharmacokinetics), to look at changes in proteins in the blood that may affect the way the cancer responds to the combination (angiogenic profile, angiogenesis associated serum biomarkers), to look at changes in genes that may affect how the cancer responds to treatment with this combination of medications (metabolic signature), and to monitor the effects of changes in the way the body grows and develops before and after bevacizumab is given.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Neuroblastoma, Sarcoma
Keywords
Ewing's sarcoma, BEVACIZUMAB (AVASTIN), CYCLOPHOSPHAMIDE (CYTOXAN), TOPOTECAN, 11-183, POETIC

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Single Group Assignment
Masking
None (Open Label)
Allocation
N/A
Enrollment
9 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Cyclophosphamide, Topotecan, and Bevacizumab (CTB)
Arm Type
Experimental
Arm Description
This is a multi-center, open label phase II study evaluating the safety and efficacy of the novel combination of agents consisting of bevacizumab, cyclophosphamide, and topotecan.
Intervention Type
Drug
Intervention Name(s)
Cyclophosphamide, Topotecan, and Bevacizumab
Intervention Description
The treatment schedule for this study will consist of a 21-day cycle. Dose modification will only occur with administration of the investigational agent, bevacizumab. The schedule of administration is summarized as follows. Administration of bevacizumab will precede the administration of the cyclophosphamide and topotecan by 3 days (Day - 3) to allow for vascular stabilization prior to initiation of chemotherapy. The chemotherapy backbone will consist of cyclophosphamide and topotecan administered as follows: cyclophosphamide 250 mg/m2/day IV over 30 minutes ± 5 minutes on Days 0-4 followed by topotecan 0.75 mg/m2/day IV over 30 minutes ± 5 minutes on Day 0-4 of every cycle. The dosing of cyclophosphamide and topotecan will be fixed.
Primary Outcome Measure Information:
Title
Objective Response Rate
Description
as measured by objective response rate (CR/PR) after 2 cycles of treatment and duration of response. after 2 cycles of treatment and duration of response according to the Revised RECIST guideline (version 1.1) Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.0) for target lesions and assessed by MRI: Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), >=30% decrease in the sum of the longest diameter of target lesions; Overall Response (OR) = CR + PR.
Time Frame
2 years
Secondary Outcome Measure Information:
Title
Number of Participants With Adverse Events
Description
Safety will be assessed by physical examination, interim history, and laboratory assessments. Adverse events will be graded according to the NCI-CTCAE, version 4.0
Time Frame
2 years

10. Eligibility

Sex
All
Maximum Age & Unit of Time
21 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Patients must have histologically confirmed relapsed/refractory Ewing's sarcoma or neuroblastoma. Patients must have measurable disease. Patients with a diagnosis of neuroblastoma with MIBG avid disease only are permitted to enroll on this study. Patients must be ≤ 21 years of age at time of diagnosis Life expectancy ≥ 3 months Lansky or Karnofsky performance ≥ 70% Written informed consent Organ and marrow function defined as follows: Hematologic function, as follows Absolute neutrophil count ≥ 1000/μL Platelets ≥ 100 x 109/L (without transfusion < 14 days before enrollment) Hemoglobin ≥ 9 gm/dl Renal function, as follows: Serum creatinine ≤ ULN for age. Refer to Appendix H for normal values for serum creatinine in children. If serum creatinine above these values, the calculated creatinine clearance or radioisotope GFR must be ≥ 60 ml/min/1.73 m2 Urinary protein < 2+ (unless total quantitative protein is < 500 mg protein/day as determined by 24 H urine collection) for pediatric patients please refer to the CTCAE V4.0 for values. Hepatic function, as follows: Total bilirubin ≤ 1.5x ULN AST and ALT ≤ 2.5x ULN for institution or ≤ 5x ULN for institution if clearly attributable to liver metastases Albumin ≥ 2.5 g/dl. Coagulation: INR ≤ 1.5x ULN. Prior Treatment: Patients must have recovered from the acute toxic effects of all prior chemotherapy, immunotherapy, or radiation therapy prior to entry on study. Patients must have had at least one prior treatment regimen. Patients may have received treatment previously with cyclophosphamide or topotecan but no prior bevacizumab. Myelosuppressive chemotherapy: Two weeks must have elapsed since administration of previous chemotherapy. Biologic agents: At least 2 weeks must have elapsed since the completion of therapy with a monoclonal antibody. Seven days must have elapsed since the last dose of retinoids Radiation therapy: For all patients, ≥ 4 weeks must have elapsed for local XRT; ≥ 6 months must have elapsed if prior radiation to ≥ 50% of the pelvis or if substantial bone marrow irradiation. Patients with a history of prior radiation with field including the heart (e.g. mantle) will be excluded. Stem cell transplant: Patients who have undergone prior stem cell transplantation will not be excluded from study entry. At least 3 months must have elapsed since autologous or allogeneic stem cell transplantation. Patients must have no evidence of active graft versus host disease. Exclusion Criteria: Patients with centrally-located pulmonary or mediastinal primary tumors or metastases adjacent to or invading large blood vessels. Prior left chest wall irradiation or a cumulative anthracycline dose of greater or equal to 300 mg/m2, unless the ejection fraction or fraction shortening is within normal institutional limits, in which case the patient can be enrolled. Inability to comply with study and/or follow-up procedures Life expectancy of less than 3 months Current, recent (within 4 weeks of the first infusion of this study), or planned participation in an experimental drug study other than a Genentech-sponsored bevacizumab cancer study Active second malignancy, other than superficial basal cell and superficial squamous (skin) cell, or carcinoma in situ of the cervix within last five years History of other malignancies, except for other solid tumors curatively treated with no evidence of disease for > 3 years prior to enrollment. Known infection with human immunodeficiency virus (HIV). Uncontrolled hypertension (sBP >150 mmHg and/or diastolic BP > 100 mmHg, found on two consecutive measurements separated by a one week period of time despite adequate medical support). Prior history of hypertensive crisis or hypertensive encephalopathy. New York Heart Association (NYHA) Grade II or greater congestive heart failure History of myocardial infarction or unstable angina within 6 months prior to Day - 3. History of stroke or transient ischemic attack within 6 months prior to Day -3. Known CNS disease, except for treated brain metastases. Treated brain metastases are defined as having no evidence of progression or hemorrhage after treatment and no ongoing requirement for dexamethasone, as ascertained by clinical examination and brain imaging (MRI or CT) during the screening period. Anticonvulsants (stable dose) are allowed. Treatment for brain metastases may include whole brain radiotherapy (WBRT), radiosurgery (RS; Gamma Knife, LINAC, or equivalent) or a combination as deemed appropriate by the treating physician. Patients with CNS metastases treated by neurosurgical resection or brain biopsy performed within 3 months prior to Day -3 will be excluded. Significant vascular disease (e.g., aortic aneurysm, requiring surgical repair or recent peripheral arterial thrombosis) within 6 months prior to Day -3. History of hemoptysis (≥ 1/2 teaspoon of bright red blood per episode) within 1 month prior to Day -3. Evidence of bleeding diathesis or significant coagulopathy (in the absence of therapeutic anticoagulation). Major surgical procedure, open biopsy, or significant traumatic injury within 28 days prior to Day -3 or anticipation of need for major surgical procedure during the course of the study. (A major procedure constitutes an invasive procedure which requires general anesthetic support, hospitalization, and supportive care such as laparotomy, laminectomy, etc.) Core biopsy or other minor surgical procedure, excluding placement of a vascular access device, within 7 days prior to Day 1. (Minor surgical procedures include minimally invasive procedures such as fine needle aspiration, core biopsy, etc requiring little if any supportive care excluding lumbar puncture and bone marrow aspiration/biopsy.) History of abdominal fistula or gastrointestinal perforation within 6 months prior to Day -3. Serious, non-healing wound, active ulcer, or untreated bone fracture. Thrombolytics or treatment doses of warfarin within 28 days of initiating treatment. Patients who require low dose warfarin for central venous catheter patency are allowed to enter if their dose is < 2 mg per day total AND their International Normalized Ratio (INR) is ≤ 1.5. Patients requiring treatment doses of heparin for any reason. The use of heparin flushes for maintenance of central venous catheters is permitted Patients requiring aspirin > 325 mg per day or non-steroidal anti-inflammatory medications known to inhibit platelet function. Patients taking cyclooxygenase-2 inhibitors (COX-2) inhibitors are allowed to enroll. History or clinical evidence of deep venous thrombosis including pulmonary embolus within 6 months of treatment. Patients with proteinuria > 1+ on urine dipstick or UPC ratio ≥ 1.0 at screening. If >1+ proteinuria is detected on surveillance, a 24-hour collection must be performed if eligibility is desired. Patients with a 24-hour urine protein content of ≤ 500 mg are eligible. Known hypersensitivity to any component of bevacizumab. Pregnancy (positive pregnancy test) or lactation. (An effective means of contraception (men and women) in subjects of child-bearing potential must be used.)
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Tanya Trippett, MD
Organizational Affiliation
Memorial Sloan Kettering Cancer Center
Official's Role
Principal Investigator
Facility Information:
Facility Name
Phoenix Children'S Hospital
City
Phoenix
State/Province
Arizona
ZIP/Postal Code
85016
Country
United States
Facility Name
University of Colorado Health Sciences Center and The Children's Hospital
City
Denver
State/Province
Colorado
ZIP/Postal Code
80045
Country
United States
Facility Name
MD Anderson Cancer Center Orlando at Arnold Palmer Hospital for Children
City
Orlando
State/Province
Florida
ZIP/Postal Code
32806
Country
United States
Facility Name
Children's Mercy Hospital & Clinics
City
Kansas City
State/Province
Missouri
ZIP/Postal Code
64108
Country
United States
Facility Name
Memorial Sloan Kettering Cancer Center
City
New York
State/Province
New York
ZIP/Postal Code
10065
Country
United States
Facility Name
Pennsylvania State University College of Medicine
City
Hershey
State/Province
Pennsylvania
ZIP/Postal Code
17110
Country
United States
Facility Name
Alberta Children'S Hospital
City
Calgary
State/Province
Alberta
ZIP/Postal Code
T2N 1N4
Country
Canada

12. IPD Sharing Statement

Links:
URL
http://www.mskcc.org/
Description
Memorial Sloan Kettering Cancer Center

Learn more about this trial

Cyclophosphamide, Topotecan, and Bevacizumab (CTB) in Patients With Relapsed/Refractory Ewing's Sarcoma and Neuroblastoma

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