Cladribine, Cytarabine, and Filgrastim in Combination with Selinexor in Treating Patients with Relapsed or Refractory Acute Myeloid Leukemia
This phase I/II trial studies the side effects and best way to give selinexor together with cladribine, cytarabine, and filgrastim, and to see how well they work in treating patients with acute myeloid leukemia that has returned after a period of improvement (relapsed) or has not responded to previous treatment (refractory). Selinexor may stop the growth of cancer cells by blocking some of the proteins needed for cell growth. Drugs used in chemotherapy, such as cladribine, cytarabine, and filgrastim, 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 more than one drug, combination chemotherapy, may kill more cancer cells. Giving selinexor together with cladribine, cytarabine, and filgrastim may be a better treatment for acute myeloid leukemia.
Inclusion Criteria
- Histologically confirmed AML (defined using World Health Organization [WHO] criteria) with one of the following: * Primary refractory disease following =< 2 cycles of induction chemotherapy, or * First relapse with no prior unsuccessful salvage chemotherapy, or * Relapsed or refractory to hypomethylating agent, defined as a lack of response, disease progression, loss of response, or intolerance as deemed by the study investigator
- Eastern Cooperative Oncology Group (ECOG) performance status =< 3
- Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) =< 2 x institutional upper limit of normal (IULN) except when in the opinion of treating physician is due to direct involvement of leukemia (e.g. hepatic infiltration or biliary obstruction due to leukemia) or Gilbert's disease
- Alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2 x IULN except when in the opinion of treating physician is due to direct involvement of leukemia (e.g. hepatic infiltration or biliary obstruction due to leukemia) or Gilbert's disease
- Total bilirubin =< 2 x IULN except when in the opinion of treating physician is due to direct involvement of leukemia (e.g. hepatic infiltration or biliary obstruction due to leukemia) or Gilbert’s disease
- Creatinine clearance > 50 ml/min, calculated using the formula of Cockcroft and Gault
- Left ventricular ejection fraction of >= 40% by multi-gated acquisition (MUGA) scan or echocardiogram
- To ensure that no patient will receive a dose of selinexor > 70 mg/m^2, body surface area (BSA) calculated by Dubois method must be > 1.43 m^2
- Patients should not become pregnant or father a baby while on this study; women should not breastfeed a baby while on this study; it is important patients understand the need to use birth control while on this study; it is not anticipated that female patients enrolling in this study will be able to conceive; however, in the rare event that this is possible, female patients of child-bearing potential must agree to use dual methods of contraception and have a negative serum pregnancy test at screening, and male patients must use an effective barrier method of contraception if sexually active with a female of child-bearing potential; acceptable methods of contraception are condoms with contraceptive foam, oral, implantable or injectable contraceptives, contraceptive patch, intrauterine device, diaphragm with spermicidal gel, or a sexual partner who is surgically sterilized or post-menopausal; for both male and female patients, effective methods of contraception must be used throughout the study and for three months following the last dose
- Ability to understand and willingness to sign an Institutional Review Board (IRB) approved written informed consent document (or that of legally authorized representative, if applicable)
Exclusion Criteria
- Acute promyelocytic leukemia (AML with t[15;17][q22;q11] and variants)
- Previous treatment with CLAG or other chemotherapy regimen containing both cladribine and cytarabine
- Colony stimulating factors within 2 weeks of study
- Active graft versus host disease (GVHD) after allogeneic stem cell transplantation; at least 2 months must have elapsed since completion of an allogeneic stem cell transplantation
- Less than 7 days from the completion of any previous cytotoxic chemotherapy (with the exception of hydroxyurea)
- Concurrent active malignancy under treatment except prostate or breast cancer undergoing treatment with hormonal therapy
- Treatment with any investigational agent within three weeks prior to first dose in this study
- Active central nervous system (CNS) involvement with leukemia
- Unstable cardiovascular function: * Symptomatic ischemia, or * Uncontrolled clinically significant conduction abnormalities (i.e. ventricular tachycardia on antiarrhythmics are excluded and 1st degree atrioventricular [AV] block or asymptomatic left anterior fascicular block [LAFB]/right bundle branch block [RBBB] will not be excluded), or * Congestive heart failure (CHF) of New York Heart Association (NYHA) class >= 3, or * Myocardial infarction (MI) within 3 months
- A history of allergic reactions attributed to compounds of similar chemical or biologic composition to KPT-330 or other agents used in the study
- Uncontrolled infection requiring parenteral antibiotics, antivirals, or antifungals within one week prior to first dose; infections controlled on concurrent anti-microbial agents are acceptable, and anti-microbial prophylaxis per institutional guidelines is acceptable
- Any medical condition which, in the investigator's opinion, could compromise the patient's safety
- Pregnant and/or breastfeeding; patient must have a negative urine pregnancy test within 5 days of study entry
- Unable to swallow tablets, or diagnosed malabsorption syndrome, or any other disease significantly affecting gastrointestinal function
- Known active hepatitis B virus (HBV) or C virus (HCV) infection; or known to be positive for HCV ribonucleic acid (RNA) or HBsAg (HBV surface antigen)
- Known human immunodeficiency virus (HIV) infection
- Serious psychiatric or medical conditions that could interfere with treatment
Study sponsor and potential other locations can be found on ClinicalTrials.gov for NCT02416908.
PRIMARY OBJECTIVES:
I. To determine the safety and tolerability of selinexor + cladribine, cytarabine, and filgrastim (CLAG) in patients with relapsed or refractory acute myeloid leukemia (AML) that requires treatment. (Phase I)
II. To determine the complete remission rate (complete remission [CR] + complete remission with incomplete hematologic recovery [CRi]) for selinexor + CLAG in patients with relapsed or refractory AML that requires treatment. (Phase II)
SECONDARY OBJECTIVES:
I. To determine the time to hematologic recovery (neutrophils and platelets) of patients with relapsed or refractory AML treated with selinexor + CLAG.
II. To determine the event-free survival of patients with relapsed or refractory AML treated with selinexor + CLAG.
III. To determine the duration of remission of patients with relapsed or refractory AML treated with selinexor + CLAG.
IV. To determine the relapse-free survival of patients with relapsed or refractory AML treated with selinexor + CLAG.
V. To determine the overall survival of patients with relapsed or refractory AML treated with selinexor + CLAG.
VI. To determine the number of patients with relapsed or refractory AML treated with selinexor + CLAG who were able to undergo hematopoietic stem cell transplantation.
TERTIARY OBJECTIVES:
I. To characterize the effects of selinexor on nuclear transport inhibition and changes in exportin 1 (XPO1) expression of patients with relapsed or refractory AML treated with selinexor + CLAG.
II. To evaluate the effects of selinexor on cell cycle arrest and apoptosis in patients with relapsed or refractory AML treated with selinexor (KPT-330).
III. To determine the pharmacokinetics and pharmacodynamics of selinexor.
OUTLINE: This is a phase I, dose-escalation study of selinexor followed by a phase II study.
Patients receive selinexor orally (PO) on days 1, 5, 10, and 12 or on days 1, 5, 10, 12, 17, and 19. Patients also receive filgrastim subcutaneously (SC) once daily (QD) on days 3-8, cytarabine intravenously (IV) over 4 hours QD on days 4-8, and cladribine IV over 2 hours QD on days 4-8. Courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.
MAINTENANCE PHASE: Patients who achieve a CR or CRi based on post-treatment bone marrow assessment and are either (1) transplant ineligible or (2) do not have a stem cell transplant donor available may receive selinexor as a maintenance therapy on days 1, 8, 15, and 22. Courses repeat every 28 days in the absence of disease progression, unacceptable toxicity, or the institution of additional antileukemic therapy including stem cell transplantation or donor leukocyte infusion.
After completion of study treatment, patients are followed up for 30 days and then every 3 months for up to 2 years.
Trial PhasePhase I/II
Trial Typetreatment
Lead OrganizationSiteman Cancer Center at Washington University
Principal InvestigatorGeoffrey L. Uy
- Primary ID201505084
- Secondary IDsNCI-2015-00828
- ClinicalTrials.gov IDNCT02416908