Panobinostat, Bortezomib, and Vincristine Sulfate Liposome with Re-induction Therapy in Treating Younger Patients with Relapsed or Refractory T-cell Acute Lymphoblastic Leukemia or Lymphoma
This phase II trial studies how well panobinostat, bortezomib, and vincristine sulfate liposome and re-induction therapy (strong chemotherapy) work in treating younger patients with T-cell acute lymphoblastic leukemia or lymphoma that has returned (relapsed) or does not respond to treatment (refractory). Panobinostat and bortezomib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Drugs used in chemotherapy, such as mitoxantrone hydrochloride, pegaspargase, dexamethasone, cytarabine, vincristine sulfate liposome, methotrexate, mercaptopurine, nelarabine, cyclophosphamide, and etoposide, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving panobinostat, bortezomib, and vincristine sulfate liposome together with re-induction therapy may kill more cancer cells.
Inclusion Criteria
- Participants must have relapsed or refractory acute lymphoblastic leukemia or lymphoma: * Stratum I: T-cell lymphoblastic leukemia or lymphoma in first relapse or refractory to one or two courses of frontline induction therapy * Stratum II: B-cell or T-cell lymphoblastic leukemia or lymphoma in second or third relapse or refractory to 2 or 3 induction or re-induction attempts; patients with Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL) must be refractory or relapsed after treatment with a regimen that included a tyrosine kinase inhibitor (TKI)
- Relapse in ALL is defined as the reappearance (in a patient who has previously achieved remission) of leukemic blasts in the bone marrow * Should flow cytometric analyses suggest relapse (by the reappearance of a similar immunophenotype to the original leukemia) in the presence of < 5% blasts morphologically, a repeat bone marrow test is recommended to confirm relapse * Molecular or genetic relapse is characterized by the reappearance of a cytogenetic or molecular abnormality
- Able to swallow capsules
- Karnofsky or Lansky performance score is >= 60%; the Lansky performance score should be used for participants < 16 years and the Karnofsky performance score for participants >= 16 years
- Prior therapy: * There is no waiting period for participants who relapse while receiving therapy if they are free from side effects attributable to such therapy * Emergent radiation therapy, one dose of intrathecal chemotherapy and up to 7 days of steroids or hydroxyurea are permitted before start of treatment in participants who relapse after completion of frontline therapy; other circumstances must be cleared by principal investigator (PI) or medical designee * At least 90 days have elapsed since bone marrow transplant and participant is off immune suppression for >= 2 weeks, if applicable
- Glomerular filtration rate >= 60 cc/min/1.73 m^2 or serum creatinine based on age as follows: * 1 to 2 years: 0.6 mg/dL for males and females * 2 to 6 years: 0.8 mg/dL for males and females * 6 to 10 years: 1 mg/dL for males and females * 10 to < 13 years: 1.2 mg/dL for males and females * 13 to 16 years: 1.5 mg/dL for males and 1.4 mg/dL for females * > 16 years: 1.7 mg/dL for males and 1.4 mg/dL for females
- Direct bilirubin =< 1.4 mg/dL (if total bilirubin > 1.4 mg/dL)
- Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 5 x upper limit of normal (ULN) for age
- Adequate cardiac function defined as shortening fraction of >= 27% or ejection fraction >= 45%
- Lymphoma participants without bone marrow involvement must have absolute neutrophil count (ANC) >= 1,000/mm^3; Note: these criteria are waived for participants with leukemia or lymphoma participants with bone marrow involvement
- Lymphoma participants without bone marrow involvement must have platelet count >= 50,000/mm^3 (without transfusion support); Note: these criteria are waived for participants with leukemia or lymphoma participants with bone marrow involvement
- Written, informed consent and assent following Institutional Review Board, National Cancer Institute (NCI), Food and Drug Administration (FDA) and Office for Human Research Protections (OHRP) guidelines
Exclusion Criteria
- Prior HDAC, deacetylase (DAC), heat shock protein (HSP)90 inhibitors or valproic acid for treatment of cancer
- Patients who will need valproic acid for any medical condition during the study or within 5 days prior to first panobinostat treatment
- Impaired cardiac function or clinically significant cardiac diseases, history of arrhythmia (including ventricular fibrillation or torsade de pointes), bradycardia < 50 beats per minute (bpm), screening electrocardiogram (ECG) with prolonged corrected QT (QTc) or uncontrolled hypertension
- Impairment of gastrointestinal (GI) function or GI disease that may significantly alter the absorption of panobinostat
- Patients with diarrhea > Common Terminology Criteria for Adverse Events (CTCAE) grade 2
- Other concurrent severe and/or uncontrolled medical conditions (e.g., uncontrolled diabetes or active or uncontrolled infection) including abnormal laboratory values, that could cause unacceptable safety risks or compromise compliance with the protocol
- Patients using medications that have a relative risk of prolonging the QT interval or inducing torsade de pointes if treatment cannot be discontinued or switched to a different medication prior to starting treatment
- Patients who have received targeted agents within 2 weeks or within 5 half-lives of the agent and active metabolites (whichever is longer) and who have not recovered from side effects of those therapies
- Patients who have undergone major surgery =< 4 weeks prior to starting treatment or who have not recovered from side effects of such therapy
- Patients with known positivity for human immunodeficiency virus (HIV) or hepatitis B/C
- Inability to swallow capsules
- Active, uncontrolled infection or severe concurrent medical disease, including but not limited to congestive heart failure, cardiac arrhythmias, or psychiatric illness
- Isolated extramedullary relapse (leukemia) or isolated CNS lymphoma
- Pregnant or lactating (female participant of childbearing potential must have negative serum or urine pregnancy test required within 7 days prior to start of treatment); male or female of reproductive potential has agreed to use effective contraception method for duration of study treatment
- Down syndrome
- Inability or unwillingness or research participant or legal guardian/representative to give written informed consent
Study sponsor and potential other locations can be found on ClinicalTrials.gov for NCT02518750.
PRIMARY OBJECTIVES:
I. To estimate the complete remission (CR) rate for patients with T-cell lymphoblastic leukemia and lymphoma in first relapse.
SECONDARY OBJECTIVES:
I. To evaluate minimal residual disease (MRD) levels at end of each block of therapy.
II. To describe the toxicities of vincristine sulfate liposome injection (VSLI) when used in combination with chemotherapy and bortezomib.
EXPLORATORY OBJECTIVES:
I. To identify molecular determinants and biomarkers of histone deacetylase (HDAC) inhibitor response.
II. To study the pharmacokinetics of panobinostat.
III. To establish xenografts of relapsed T-cell lymphoblastic leukemia for downstream studies of cytotoxicity and therapy resistance.
IV. To perform genomic studies of leukemic cells at relapse, diagnosis and MRD (where available) to investigate clonal evolution and identify targets for therapeutic intervention.
V. To validate new markers and methods for MRD detection.
VI. To genotype natural killer (NK) cell receptors and measure their expressions at diagnosis and before Block C, and to associate these features with treatment outcome.
VII. To perform a comprehensive analysis of the intestinal microflora in patients with relapsed hematologic malignancies prior to and subsequent to each block of intensive salvage chemotherapy using next generation sequencing technologies as an exploratory approach.
VIII. To describe the frequency and severity of gastrointestinal illnesses during 3 blocks of intensive salvage chemotherapy in patients who did and those who did not have changes in intestinal microbiota.
OUTLINE:
BLOCK A:
Patients receive dexamethasone orally (PO) or intravenously (IV) thrice daily (TID) on days 1-8 and 15-22; intrathecal therapy comprising methotrexate, therapeutic hydrocortisone, and cytarabine (ITMHA) on days 1, 7, 14, 21, and 28; panobinostat PO once daily (QD) on days 2, 4, and 6; vincristine sulfate liposome IV on days 7, 14, 21, and 28; mitoxantrone hydrochloride IV over 1 hour on days 7 and 14; pegaspargase* IV over 1 hour or intramuscularly (IM) on days 9 and 23; and bortezomib IV over 3-5 seconds on days 16, 19, 23, and 26. Additional doses of ITMHA may be given on days 10 and 17 in patients with central nervous system (CNS) 2, 3 or traumatic tap with blasts.
BLOCK B:
After count recovery from Block A, patients receive high-dose methotrexate IV over 24 hours on day 1 (on days 1 and 8 in patients with prior cranial irradiation); mercaptopurine PO on days 1-14, ITMHA on day 1, and high-dose cytarabine IV over 2 hours every 12 hours on days 15 and 16.
BLOCK C:
After count recovery from Block B, patients receive nelarabine IV (or clofarabine IV on days 1-5 in patients with B-lymphoblastic leukemia and lymphoma in stratum II), cyclophosphamide IV, and etoposide IV on days 1-5.
*Note: Patients experiencing an allergic reaction or intolerance to pegaspargase may receive asparaginase Erwinia chrysanthemi IV over 30-60 minutes or IM three times a week over 2 weeks.
After completion of study treatment, patients are followed up periodically.
Trial PhasePhase II
Trial Typetreatment
Lead OrganizationSaint Jude Children's Research Hospital
Principal InvestigatorSima C. Jeha
- Primary IDTSALV
- Secondary IDsNCI-2015-00935
- ClinicalTrials.gov IDNCT02518750