Description:
Background:
Wild-type gastrointestinal stromal tumor (GIST) is a cancer in the esophagus, stomach, or
intestines. It does not respond well to standard chemotherapy or radiation therapy. Most
people with GIST are treated with imatinib. But it may not work in many children with GIST.
Researchers think the drug SGI-110 may help treat people with GIST, pheochromocytoma and
paraganglioma (PHEO/PGL), or kidney cancer related to hereditary leiomyomatosis and renal
cell carcinoma (HLRCC).
Objective:
To learn if SGI-110 causes GIST tumors to shrink or slows their growth. Also to test how it
acts in the body.
Eligibility:
People ages 12 and older who have GIST, PHEO/PGL, or HLRCC that has not responded to other
treatments
Design:
Participants will be screened with:
- Physical exam
- Urine tests
- Computed tomography (CT) or magnetic resonance imaging (MRI), or fluorodeoxyglucose
(FDG)-positron emission tomography (PET) scan: A machine takes pictures of the body.
- Blood tests
Participants will be injected with SGI-110 under the skin each day for 5 days. This cycle
will repeat every 28 days. The cycles repeat until their side effects get too bad or their
cancer gets worse.
Participants will have tests throughout study:
- Physical exam and blood and urine tests before each cycle
- Blood tests on days 1, 7, 14, and 28 of the first cycle.
- Scans before cycle 1 and then every other cycle.
- Questionnaires about their pain and quality of life
- Tumor biopsy for those 18 and older: A needle removes a small piece of tumor.
After they stop treatment, participants will have a final visit. This includes an evaluation
of their health, pain, and quality of life.
...
Title
- Brief Title: A Phase II Trial of the DNA Methyl Transferase Inhibitor, Guadecitabine (SGI-110), in Children and Adults With Wild Type GIST,Pheochromocytoma and Paraganglioma Associated With Succinate Dehydrogenase Deficiency and HLRCC-associated Kidney Cancer
- Official Title: A Phase II Trial of the DNA Methyl Transferase Inhibitor, SGI-110 (Guadecitabine), In Children And Adults With Wild Type GIST, Pheochromocytoma And Paraganglioma Associated With Succinate Dehydrogenase Deficiency And HLRCC-Associated Kidney Cancer
Clinical Trial IDs
- ORG STUDY ID:
170088
- SECONDARY ID:
17-C-0088
- NCT ID:
NCT03165721
Conditions
- Paraganglioma
- Gastrointestinal Stromal Tumors
- Carcinoma, Renal Cell
- Renal Neoplasms
- Pheochromocytoma
Interventions
Drug | Synonyms | Arms |
---|
SGI-110 (guadecitabine) | guadecitabine | Patients ≥ 12 Years of Age w/HLRCC-associated Renal Cell Ca |
Purpose
Background:
Wild-type gastrointestinal stromal tumor (GIST) is a cancer in the esophagus, stomach, or
intestines. It does not respond well to standard chemotherapy or radiation therapy. Most
people with GIST are treated with imatinib. But it may not work in many children with GIST.
Researchers think the drug SGI-110 may help treat people with GIST, pheochromocytoma and
paraganglioma (PHEO/PGL), or kidney cancer related to hereditary leiomyomatosis and renal
cell carcinoma (HLRCC).
Objective:
To learn if SGI-110 causes GIST tumors to shrink or slows their growth. Also to test how it
acts in the body.
Eligibility:
People ages 12 and older who have GIST, PHEO/PGL, or HLRCC that has not responded to other
treatments
Design:
Participants will be screened with:
- Physical exam
- Urine tests
- Computed tomography (CT) or magnetic resonance imaging (MRI), or fluorodeoxyglucose
(FDG)-positron emission tomography (PET) scan: A machine takes pictures of the body.
- Blood tests
Participants will be injected with SGI-110 under the skin each day for 5 days. This cycle
will repeat every 28 days. The cycles repeat until their side effects get too bad or their
cancer gets worse.
Participants will have tests throughout study:
- Physical exam and blood and urine tests before each cycle
- Blood tests on days 1, 7, 14, and 28 of the first cycle.
- Scans before cycle 1 and then every other cycle.
- Questionnaires about their pain and quality of life
- Tumor biopsy for those 18 and older: A needle removes a small piece of tumor.
After they stop treatment, participants will have a final visit. This includes an evaluation
of their health, pain, and quality of life.
...
Detailed Description
Background
- Loss of activity of the Krebs cycle components succinate dehydrogenase (SDH) complex or
fumarate hydratase (FH), has been identified as a mechanism of tumorigenesis in subsets
of gastrointestinal stromal tumor (GIST), pheochromocytoma and paraganglioma (PHEO/PGL),
and renal cell carcinoma.
- Deoxyribonucleic acid (DNA) hypermethylation has been demonstrated in these cancers.
Loss of activity of SDH or FH leads to accumulation of the metabolites succinate and
fumarate, respectively. Succinate and fumarate act as inhibitors of a broad array of
alpha-ketoglutarate dependent dioxygenases. The Ten-eleven Translocation (TET) family of
alphaKG-dependent dioxygenase enzymes convert 5-methylcytosine to
5-hydroxymethylcytosine leading to DNA demethylation. Inhibition of these enzymes due to
SDH and FH deficiency causes DNA hypermethylation and has been verified in preclinical
models.
- Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor of the
gastrointestinal tract, resistant to cytotoxic chemotherapy and radiation therapy. KIT
and Platelet Derived Growth Factor Receptor Alpha (PDGFRA) mutations have been
identified as tumor initiating events in 85% of adult patients with GIST and these
tumors are responsive to the tyrosine kinase inhibitor, Imatinib. In pediatric patients,
however, 85% of GISTs lack KIT and PDGFRA mutations (wild-type) and imatinib is not
effective.
- Recent work in the Pediatric and Wild-Type (wt) GIST Clinic at the National Cancer
Institute (NCI) led to the identification of succinate dehydrogenase (SDH) deficiency in
approximately 90% of wildtype GIST.
- In addition to wild-type GIST, SDH deficiency is also present in 30% of pheochromocytoma
and paraganglioma (PHEO/PGL) and a subset of renal carcinoma. Loss of succinate
dehydrogenase complex iron sulfur subunit B (SDHB) protein expression is seen in
PHEO/PGL and wtGIST either due to mutation in SDH subunit genes or hypermethylation of
the SDHC promoter region.
- Mutations leading to loss of function of FH have been identified in PHEO/PGL as well as
type II papillary renal cell carcinoma in patients with hereditary leiomyomatosis and
renal cell cancer (HLRCC). An FH-deficient paraganglioma had DNA hypermethylation as
demonstrated by array and immunohistochemistry showed increased 5hmC levels in
paragangliomas and pheochromocytomas.
- SGI-110 is a small molecule derivative of decitabine that acts as a DNA
methyltransferase (DNMT) inhibitor and is resistant to inactivation by cytidine
deaminase, hence may thus have a more favorable pharmacokinetic profile compared to
decitabine. Subcutaneously administered SGI-110 is gradually converted to decitabine
resulting in prolonged exposure with a several fold increase in apparent T1/2 compared
to intravenous decitabine. SGI-110 has been demonstrated in preclinical models to induce
a dose-dependent decrease in global DNA methylation and up-regulate expression of
specific genes including Melanoma-associated antigen 1 (MAGE-A1) and New York esophageal
squamous cell carcinoma 1 (NY-ESO-1) through decreased methylation.
- We are proposing a phase II trial with SGI-110 in these SDH-deficient and fumarate
hydratase (FH)-deficient tumors.
Objectives:
-To assess the clinical activity of SGI-110 in patients with wt-GIST, SDH-deficient PHEO/PGL,
and HLRCC-associated renal cell carcinoma (RCC) using Response Evaluation Criteria in Solid
Tumors (RECIST).
Eligibility:
- Adults and children (greater than or equal to 12 years of age) with wt-type GIST, SDH
deficient PHEO/PGL, or HLRCC-associated RCC and measurable disease will be eligible.
- Newly diagnosed patients with PHEO/PGL or HLRCC-associated RCC with localized,
resectable disease will not be eligible. Patients with PHEO/PGL or HLRCC-associated RCC
with unresectable localized disease and/or metastatic disease will be eligible.
- Newly diagnosed patients with wt-GIST with completely resectable disease will not be
eligible. Patients with wt-GIST with metastatic disease and/or residual or recurrent
tumor following surgical debulking will be eligible
- Patients with wt-GIST or HLRCC-associated RCC who have not previously received systemic
therapy are eligible as there are no standard chemotherapy regimens known to be
effective for these cancers.
- Must have adequate performance status, may not be pregnant or breastfeeding, and must
have adequate major organ function.
- No history of severe or uncontrolled inter-current illness including, but not limited
to, ongoing or active infection, symptomatic cardiovascular or pulmonary disease will be
excluded.
Design:
- This is a single site, open label, phase II study using a small optimal two-stage design
to evaluate the clinical response in three groups of patients:
1. wild-type GIST (GIST without KIT or PDGFRA mutation)
2. PHEO/PGL in patients with germline SDH subunit mutation, or
3. RCC associated with HLRCC
- SGI-110 will be administered subcutaneously at 45mg/m^2/day x 5 days on a 28-day cycle
to the three groups of patients.
- SGI-110 activity will be assessed by imaging response of measurable disease using
Response Evaluation Criteria in Solid Tumors (RECIST)v1.1, using computed tomography
(CT), magnetic resonance imaging (MRI) and/or positron emission tomography (PET).
- Patients will be closely monitored for development of toxicity with regular physical
examinations and laboratory evaluations. Toxicity will be graded using version 4.0 of
the National Cancer Institute (NCI) Common Toxicity Criteria.
- SGI-110 related toxicities greater than or equal to grade 3 will be considered treatment
limiting toxicities, unless they are reversible within 72 hours with supportive care.
Following recovery from toxicity up to 2 dose reductions will be allowed.
- Initially 7 evaluable patients in each group (strata) will be enrolled and if 0 of the 7
have a response, then no further patients will be accrued in that strata. If 1 or more
the first 7 (14.3% or more) have a response, then accrual would continue until a total
of 21 patients have enrolled in that strata. If at least 3 responses (at least 14.3%)
are observed among the 21 evaluable patients, the agent should be considered worthy of
further testing in this disease.
- Enrolling 2 patients/month, it is estimated to require 3 years to complete accrual to a
maximum of 70 patients, a maximum of 63 evaluable patients allowing for a small number
(7) of inevaluable patients.
Trial Arms
Name | Type | Description | Interventions |
---|
Patients ≥ 12 Years of Age w/Wild-Type GIST | Experimental | SGI-110 administered subcutaneously at 45mg/m^2/day x 5 days on a 28-day cycle
Gastrointestinal stromal tumor (GIST) | |
Patients ≥ 12 Years of Age w/PHEO/PGL with SDH-deficient PHE | Experimental | SGI-110 administered subcutaneously at 45mg/m^2/day x 5 days on a 28-day cycle
Pheochromocytoma and Paraganglioma (PHEO/PGL) with succinate dehydrogenase (SDH)-deficient PHE | |
Patients ≥ 12 Years of Age w/HLRCC-associated Renal Cell Ca | Experimental | SGI-110 administered subcutaneously at 45mg/m^2/day x 5 days on a 28-day cycle
Hereditary leiomyomatosis and renal cell carcinoma (HLRCC)-associated Renal Cell Ca | |
Eligibility Criteria
- INCLUSION CRITERIA:
Patients must:
- Have recurrent or refractory/unresectable disease for which there is no known curative
therapy.
---Wild type-gastrointestinal stromal tumors (GIST): Patients with recurrent or
progressive disease will be eligible. Newly diagnosed patients with resectable
localized disease will not be eligible. Newly diagnosed patients with metastatic
disease and newly diagnosed patients with residual tumor following surgical debulking
will be eligible.
- Paraganglioma-Pheochromocytoma (PHEO/PGL): Patients with recurrent or progressive
disease will be eligible. Newly diagnosed patients with PHEO/PGL that is
metastatic at diagnosis and/or unresectable will be eligible Patients with
PHEO/PGL with localized (non-metastatic), resectable disease will not be
eligible.
- Renal cell cancer associated with HLRCC: Patients with localized, resectable
HLRCC-associated renal cell cancer will not be eligible. Patients with metastatic
and/or unresectable Hereditary leiomyomatosis and renal cell cancer
(HLRCC)-associated renal cell cancer will be eligible.
- Have one of the following confirmed histologically, cytologically, or through
biochemical testing:
- wild-type GIST (GIST without KIT or platelet derived growth factor receptor alpha
(PDGFRA) mutation);
- PHEO/PGL with a germline mutation in Succinate Dehydrogenase Complex Flavoprotein
Subunit A (SDHA), Succinate Dehydrogenase Complex Flavoprotein Subunit B (SDHB),
SDHC, or SDHD;
--renal cell cancer associated with HLRCC.
- Testing will be performed in Clinical Laboratory Improvement Amendments (CLIA)
certified labs using genetic tests for KIT/PDGFRA and testing panels developed for
patients with PHEO/PGL. Results from outside labs will be accepted. Pathologic
diagnosis will be reviewed and verified at the Clinical Center.
- Age: be greater than or equal to 12 years of age
Because there is no dosing or adverse event data currently available on the use of SGI-110
in children < 18 year of age, children < 12 years of age will be excluded from this study,
but may be eligible for future pediatric trials should the results of the study be
positive.
- Measurable disease:
Have measurable disease, defined as at least one lesion that can be accurately measured in
at least one dimension (longest diameter to be recorded for non-nodal lesions and short
axis for nodal lesions) as greater than or equal to 20 mm with conventional techniques or
as greater than 10 mm with spiral computed tomography (CT) scan.
- Prior Therapy
- Prior therapy requirements:
---Wt-GIST: Because there are no standard chemotherapy regimens known to be effective
for wt-GIST, previously untreated participants are eligible.
--PHEO/PGL with germline SDH subunit mutation: 131I-MIBG in patients with MIBG avid
tumors or cytotoxic chemotherapy (cyclophosphamide, vincristine, and dacarbazine (CVD)
or temozolomide) is required prior to enrollment on this trial. However, patients who
have refused cytotoxic chemotherapy or for whom treatment on this protocol prior to
receiving cytotoxic chemotherapy is felt to be in the best interest for the patient by
the local investigator will also be eligible.
---HLRCC-associated renal cell cancer: Because there are no standard chemotherapy
regimens known to be effective for HLRCC-associated renal cell cancer, previously
untreated participants are eligible.
- Prior therapy wash-out period requirements
--Participants must be at least 4 weeks from prior surgical procedures and surgical
incisions must be healed.
---Participants must have had their last fraction of external beam radiation therapy
at least 4 weeks prior to enrollment. Participants with prior radiation therapy must
be at least 4 weeks post therapy and have had progression of disease outside the
radiation port.
- Participants must have had their last dose of cytotoxic chemotherapy at least 28
days prior to enrollment, their last dose of biological therapy, such as
biological response modifiers (e.g., cytokines), immunomodulatory agents,
vaccines, differentiating agents, used to treat their cancer at least 28 days
prior to enrollment, their last dose of a monoclonal antibody at least 28 days
prior to enrollment, and their last dose of any investigational agent at least 28
days prior to enrollment.
- Participants must have recovered from the acute toxic effects of prior therapy to
a grade 1 level prior to enrollment (does not apply to alopecia).
- Performance Level: Eastern Cooperative Oncology Group (ECOG) performance status less
than or equal 2 or Karnofsky greater than or equal to 60% in patients greater than 16
years of age, Lansky greater than or equal to 60 for patients less than or equal to 16
years of age.
- Have normal organ and marrow function as defined below:
- absolute neutrophil count greater than or equal to 1,500/mcL
- platelets greater than or equal to 100,000/mcL
- total bilirubin within normal institutional limits
- Aspartate aminotransferase (AST) Serum glutamic oxaloacetic
transaminase(SGOT)/Alanine aminotransferase (ALT) Serum glutamic pyruvic
transaminase(SGPT) less than or equal to 2.5 x institutional upper limit of
normal
- creatinine within normal institutional limits
OR
----creatinine clearance greater than or equal to 60 mL/min/1.73 m^2 for patients with
creatinine levels above institutional normal.
-Birth Control:
The effects of SGI-110 on the developing human fetus are unknown. For this reason and
because decitabine is known to be teratogenic, women of child-bearing potential and men
must agree to use adequate contraception (hormonal or barrier method of birth control;
abstinence) prior to study entry and for the duration of study participation, and for 6
months following participation. Should a woman become pregnant or suspect she is pregnant
while she or her partner is participating in this study, she should inform her treating
physician immediately.
-Ability of subject or legal guardians (if the patient is <18 years old) to understand and
the willingness to sign a written informed consent document.
EXCLUSION CRITERIA:
Patients with any one the following will be excluded:
- Ongoing radiation therapy, chemotherapy, hormonal therapy directed at the tumor,
immunotherapy, or biologic therapy, including investigational agents for their
disease.
- History of allergic reactions to SGI-110 or decitabine.
- Uncontrolled intercurrent illness including, but not limited to, symptomatic
congestive heart failure, unstable angina pectoris, cardiac arrhythmia, symptomatic
pulmonary disease or psychiatric illness/social situations that would limit compliance
with study requirements.
- Pregnant or breastfeeding
Pregnant women are excluded from this study because SGI-110 is a derivative of decitabine
which has the potential for teratogenic or abortifacient effects. Because there is an
unknown but potential risk for adverse events in nursing infants secondary to treatment of
the mother with SGI-110, breastfeeding should be discontinued if the mother is treated with
SGI-110.
These potential risks may also apply to other agents used in this study.
- Any evidence of severe or uncontrolled systemic disease, active infection, active
bleeding diatheses, or renal transplant, including any patient known to have hepatitis
B, hepatitis C, or human immunodeficiency virus (HIV) will be excluded. Patients with
HIV who have adequate cluster of differentiation 4 (CD4) count, not requiring
antiretroviral medication, may be enrolled.
- Patients who, in the opinion of the investigator, may not be able to comply with the
safety monitoring requirements of the study.
Maximum Eligible Age: | 99 Years |
Minimum Eligible Age: | 12 Years |
Eligible Gender: | All |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | Number of Participants With an Overall Response (Complete Response or Partial Response) of SGI-11 Using the Response Evaluation Criteria in Solid Tumors (RECIST) |
Time Frame: | After the first 4 weeks, then every 8 weeks up to 65 weeks |
Safety Issue: | |
Description: | Clinical activity of SGI-11 was assessed using the RECISTv1.1. Complete Response (CR) is disappearance of all target lesions. Any pathological lymph nodes (whether target or non-target) must have reduction in short axis to <10 mm. Partial Response (PR) is at least a 30% decrease in the sum of the diameters of target lesions, taking as reference the baseline sum of diameters. |
Secondary Outcome Measures
Measure: | Change in Distress From Baseline |
Time Frame: | Baseline, end of cycle 4, and post therapy follow up, approximately 30 days after the final dose of study drug |
Safety Issue: | |
Description: | Change in distress from baseline was assessed by The Distress Thermometer (DT) visual analog scale. An overall score is derived from specific physical, emotional and family issues identified by the participant to be stressful. No distress (0-4), moderate stress (5) and high distress (6-10). |
Details
Phase: | Phase 2 |
Primary Purpose: | Interventional |
Overall Status: | Terminated |
Lead Sponsor: | National Cancer Institute (NCI) |
Trial Keywords
- Renal Cancer
- DNA Hypermethylation
- Gastrointestinal Stromal Tumors
- DNA Methyltransferase (DNMT) Inhibitor
- Succinate Dehydrogenase (SDH) Deficiency
Last Updated
July 30, 2021