Description:
This phase 1b trial studies the side effects and best dose of glutaminase inhibitor CB-839
hydrochloride (CB-839) in combination with radiation therapy and temozolomide in treating
patients with IDH-mutated diffuse or anaplastic astrocytoma. CB-839 may stop the growth of
tumor cells by blocking some of the enzymes needed for cell growth. Radiation therapy uses
high energy x-rays to kill tumor cells and shrink tumors. Chemotherapy drugs, such as
temozolomide, work in different ways to stop the growth of tumor cells, either by killing the
cells, by stopping them from dividing, or by stopping them from spreading. Giving CB-839 with
radiation therapy and temozolomide may work better than surgery, radiation therapy, and
temozolomide in treating patients with IDH-mutated diffuse astrocytoma or anaplastic
astrocytoma.
Title
- Brief Title: CB-839 With Radiation Therapy and Temozolomide in Treating Patients With IDH-Mutated Diffuse Astrocytoma or Anaplastic Astrocytoma
- Official Title: A Phase 1b Trial of CB-839 in Combination With Radiation Therapy and Temozolomide in Patients With IDH-Mutated Diffuse Astrocytoma and Anaplastic Astrocytoma
Clinical Trial IDs
- ORG STUDY ID:
NCI-2018-00876
- SECONDARY ID:
NCI-2018-00876
- SECONDARY ID:
10218
- SECONDARY ID:
10218
- SECONDARY ID:
UM1CA186686
- SECONDARY ID:
UM1CA186709
- NCT ID:
NCT03528642
Conditions
- Anaplastic Astrocytoma, IDH-Mutant
- Diffuse Astrocytoma, IDH-Mutant
Interventions
Drug | Synonyms | Arms |
---|
Telaglenastat Hydrochloride | CB-839 HCl, Glutaminase Inhibitor CB-839 Hydrochloride | Treatment (CB-839, temozolomide, RT) |
Temozolomide | CCRG-81045, Imidazo[5,1-d]-1,2,3,5-tetrazine-8-carboxamide, 3, 4-dihydro-3-methyl-4-oxo-, M & B 39831, M and B 39831, Methazolastone, RP-46161, SCH 52365, Temcad, Temodal, Temodar, Temomedac, TMZ | Treatment (CB-839, temozolomide, RT) |
Purpose
This phase 1b trial studies the side effects and best dose of glutaminase inhibitor CB-839
hydrochloride (CB-839) in combination with radiation therapy and temozolomide in treating
patients with IDH-mutated diffuse or anaplastic astrocytoma. CB-839 may stop the growth of
tumor cells by blocking some of the enzymes needed for cell growth. Radiation therapy uses
high energy x-rays to kill tumor cells and shrink tumors. Chemotherapy drugs, such as
temozolomide, work in different ways to stop the growth of tumor cells, either by killing the
cells, by stopping them from dividing, or by stopping them from spreading. Giving CB-839 with
radiation therapy and temozolomide may work better than surgery, radiation therapy, and
temozolomide in treating patients with IDH-mutated diffuse astrocytoma or anaplastic
astrocytoma.
Detailed Description
PRIMARY OBJECTIVE:
I. Determine the maximum tolerated dose (MTD) and/or the recommended phase 2 dose (RP2D) of
CB-839 hydrochloride (HCl) (telaglenastat) when combined with radiation therapy (RT) and
temozolomide (TMZ) in patients with newly diagnosed IDH-mutated diffuse astrocytoma (DA) and
anaplastic astrocytoma (AA).
SECONDARY OBJECTIVES:
I. To observe and record anti-tumor activity. II. Determine the safety and tolerability of
RT/TMZ/CB-839 HCl (telaglenastat) in patients based on physician reported adverse event (AE)
data.
III. Estimate the 2-year progression-free survival (PFS2) of RT/TMZ/CB-839 HCl
(telaglenastat) in patients with IDH-mutated glioma based on the Response Assessment in
Neuro-Oncology (RANO) criteria.
IV. Estimate the 2-year overall survival (OS2) of RT/TMZ/CB-839 HCl (telaglenastat) in
patients with IDH-mutated glioma based on RANO criteria.
CORRELATIVE OBJECTIVES:
I. Determine the minor response rate (MRR) and clinical benefit rate (CBR) for the
combination of CB-839 HCl (telaglenastat) and RT/TMZ in IDH-mutated glioma based on RANO
criteria.
II. Determine the patient-reported tolerability of RT/TMZ/CB-839 HCl (telaglenastat) using
the MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) instrument to measure self-reported
symptom severity and interference with daily activities.
II. Determine the neurocognitive impact of CB-839 HCl (telaglenastat) when used in
combination with RT/TMZ.
III. Determine the effect of CB-839 HCl (telaglenastat)/RT/TMZ on plasma oncometabolite
levels of glutamine, glutamate, aspartate, asparagine, and 2-hydroxyglutarate (2-HG) in
patients with IDH-mutated glioma and associate the changes with disease response.
IV. Determine the effect of CB-839 HCl (telaglenastat)/RT/TMZ on tumor glutamine and
glutamate MRS signals in patients with IDH-mutated glioma and associate the signal with
disease response.
V. Determine the pharmacokinetics (PK) of CB-839 HCl (telaglenastat) when used alone and in
combination with TMZ.
VI. To perform molecular profiling assays on archived tumor tissue and peripheral blood,
including, but not limited to, low-pass whole genome sequencing (WGS), whole exome sequencing
(WES), and messenger RNA sequencing (RNA-Seq) in order to VIa. Identify potential predictive
and prognostic biomarkers beyond any genomic alteration by which treatment may be assigned.
VIb. Identify resistance mechanisms using genomic deoxyribonucleic acid (DNA)- and
ribonucleic acid (RNA)-based assessment platforms.
VII. To contribute genetic analysis data from de-identified biospecimens to Genomic Data
Commons (GDC), a well annotated cancer molecular and clinical data repository, for current
and future research; specimens will be annotated with key clinical data, including
presentation, diagnosis, staging, summary treatment, and if possible, outcome.
VIII. To bank formalin-fixed, paraffin-embedded (FFPE) tissue, blood (for cell-free DNA
analysis), and nucleic acids obtained from patients at the Experimental Therapeutics Clinical
Trials Network (ETCTN) Biorepository at Nationwide Children's Hospital.
OUTLINE: This is a dose escalation study of CB-839.
Patients receive CB-839 orally (PO) twice daily (BID) 7 days a week, temozolomide PO once
daily (QD) 7 days a week, and undergo RT 5 days a week for up to 5.5 weeks (diffuse
astrocytoma) or 6.5 weeks (anaplastic astrocytoma) in the absence of disease progression or
unacceptable toxicity.
After completion of study treatment, patients are followed up every 3 months for up to 2
years.
Trial Arms
Name | Type | Description | Interventions |
---|
Treatment (CB-839, temozolomide, RT) | Experimental | Patients receive CB-839 PO BID 7 days a week, temozolomide PO QD 7 days a week, and undergo RT 5 days a week for up to 5.5 weeks (diffuse astrocytoma) or 6.5 weeks (anaplastic astrocytoma) in the absence of disease progression or unacceptable toxicity. | - Telaglenastat Hydrochloride
- Temozolomide
|
Eligibility Criteria
Inclusion Criteria:
- Patients must have histopathologic or molecular confirmation of either IDH-mutant DA
or IDH-mutant AA. Acceptable IDH mutations for study eligibility include any IDH1
mutation at codon 132 or any IDH2 mutation at codon 172.
- Age >= 16 years. The intended neurocognitive tests have not been validated in children
below the age of 16.
- Eastern Cooperative Oncology Group (ECOG) performance status =< 1 (Karnofsky >= 70%).
- Hemoglobin > 9.0 g/dL
- Leukocytes >= 3.0 x 10^9/L
- Absolute neutrophil count >= 1.5 x 10^9/L
- Platelets >= 100 x 10^9/L
- International normalized ratio (INR) =< 1.5 x upper limit of normal (ULN)
- Partial thromboplastin time (PTT) or activated partial thromboplastin time (APTT) =<
1.5 x ULN
- Patients on a stable dose of anti-coagulation therapy will be allowed to participate
if they have no signs of bleeding or clotting and the INR/PT and PTT/aPTT results are
compatible with an acceptable risk-benefit ratio as per the investigator's discretion.
- Total bilirubin =< 1.5 x institutional ULN and < 3 mg/dL for patients with Gilbert's
disease
- Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]) &
alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 3 x
institutional ULN
- Creatinine =< 1.5 x institutional ULN or creatinine clearance >= 60 mL/minute
- If there is history of human immunodeficiency virus (HIV) infection, patients must be
on effective antiretroviral therapy and HIV viral load must be undetectable within 6
months of study enrollment.
- If there is history of chronic hepatitis B virus (HBV) infection, patients must have
either been treated or are on suppressive therapy (as indicated), and HBV viral load
must be undetectable.
- If there is history of hepatitis C virus (HCV) infection, patients must have been
treated and HCV viral load must be undetectable.
- Patient must have measurable disease by RANO criteria (dose expansion cohort only).
- Patient must be at least 7 days beyond stereotactic biopsy and/or at least 14 days
beyond open craniotomy at the time of registration.
- Patients must have been on a stable or decreasing dose of corticosteroids over the
last 7 days at the time of registration.
- Patients must have been on a stable or decreasing dose of antiepileptic therapy over
the last 14 days at the time of registration.
- Females of childbearing potential must have a negative pregnancy test (=< 14 days)
prior to start of trial treatment. The effects of CB-839 HCl on the developing human
fetus are unknown. For this reason and because alkylating agents as well as TMZ are
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. 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. Men treated or enrolled
on this protocol must also agree to use adequate contraception prior to the study, for
the duration of study participation, and 4 months after completion of CB-839 HCl
(telaglenastat) administration.
- Ability to understand and the willingness to sign a written informed consent document.
- Patients with a prior or concurrent malignancy whose natural history or treatment does
not have the potential to interfere with the safety or efficacy assessment of the
investigational regimen are eligible for this trial.
- Patients with known history or current symptoms of cardiac disease, or history of
treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac
function using the New York Heart Association functional classification. To be
eligible for this trial, patients should be class 2B or better.
- Availability of archival FFPE tumor tissue collected within 12 months prior to
registration.
Exclusion Criteria:
- Patients must not have received prior chemotherapy to treat the glioma.
- Patients who are receiving any other investigational agents.
- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to CB-839 HCl (telaglenastat) or TMZ.
- Patient must not have received prior radiation therapy to the brain. Prior radiation
therapy to the head and neck is also excluded if radiation fields overlap.
- No prior use of Gliadel wafers.
- Patient must have no evidence of either infratentorial or spinal involvement with
tumor.
- Patients who are unable to swallow tablets.
- Patients who are at risk for impaired absorption of oral medication including, but not
limited to, refractory vomiting, gastric resection/bypass, and duodenal/jejunal
resection.
- Patients with uncontrolled intercurrent illness.
- Patients with a "currently active" second malignancy other than non-melanoma skin
cancers. Patients are not considered to have a "currently active" malignancy if they
have completed therapy and are free of disease for more than 3 years.
- Pregnant women are excluded from this study because CB-839 HCl (telaglenastat) is an
agent with the potential for teratogenic or abortifacient effects. Because there is an
unknown but potential risk for AEs in nursing infants secondary to treatment of the
mother with CB-839 HCl (telaglenastat), breastfeeding should be discontinued if the
mother is treated with CB-839 HCl (telaglenastat). These potential risks may also
apply to TMZ.
- Adolescent patients who require sedation for magnetic resonance imaging (MRI) or
magnetic resonance spectroscopy (MRS).
- Patients with psychiatric illness/social situations that would limit compliance with
study requirements.
- The primary language of communication for the patient must be English (dose expansion
cohort only). The intended neurocognitive tests have not been validated in patients
who do not primarily speak English.
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 16 Years |
Eligible Gender: | All |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | Maximum tolerated dose (MTD) and recommended phase 2 dose (RP2D) |
Time Frame: | Up to 6.5 weeks |
Safety Issue: | |
Description: | MTD is defined as the dose level below the lowest dose that induces dose limiting toxicity (DLT) in at least 2 patients (out of 6). A total of 6 patients must be treated at the MTD. It is possible that the MTD will be unknown after this study (e.g., if the highest tested dose has fewer than 2 patients with DLT, out of 6). In this case, the highest dose is defined as the RP2D. A 3 + 3 cohort expansion design to determine toxicity-based dose escalation of glutaminase inhibitor CB-839 hydrochloride (CB-839 HCl) and external beam fractionated radiation therapy (RT) with concurrent temozolomide (TMZ) among patients with IDH-mutated diffuse astrocytoma (DA) or anaplastic astrocytoma (AA). |
Secondary Outcome Measures
Measure: | Objective response rate (ORR) as defined by Response Assessment in Neuro-Oncology (RANO) criteria |
Time Frame: | Up to 6 months from the start of study treatment |
Safety Issue: | |
Description: | ORR is defined as the rate of either complete response (CR), partial response (PR), or minor response (MR) by RANO criteria for low-grade gliomas at 6 months after initiation of RT/TMZ/CB-839 HCl therapy. The ORR will be estimated using properties of the binomial distribution. 95% exact confidence intervals will also be calculated. |
Measure: | Clinical benefit rate (CBR) as defined by RANO criteria |
Time Frame: | Up to 6 months from the start of study treatment |
Safety Issue: | |
Description: | CBR is defined as the rate of either CR, PR, MR, or stable disease (SD) by RANO criteria for low-grade gliomas at 6 months after initiation of RT/TMZ/CB-839 HCl therapy. The CBR will be estimated using properties of the binomial distribution. 95% exact confidence intervals will also be calculated. |
Measure: | Incidence of adverse events graded according to Common Terminology Criteria for Adverse Events (CTCAE) |
Time Frame: | Up to 2 years |
Safety Issue: | |
Description: | The safety and tolerability of RT/TMZ/CB-839 HCl in patients is based on physician reported adverse event (AE) data. |
Measure: | Progression-free survival (PFS2) as defined by response assessment in neuro-oncology (RANO) criteria |
Time Frame: | Up to 2 years |
Safety Issue: | |
Description: | PFS2 rate will be estimated using properties of the binomial distribution. 95% exact confidence intervals will also be calculated. |
Measure: | Overall survival (OS2) as defined by RANO criteria |
Time Frame: | Up to 2 years |
Safety Issue: | |
Description: | OS2 rate will be estimated using properties of the binomial distribution. 95% exact confidence intervals will also be calculated. |
Measure: | Assessment of pharmacokinetic (PK) parameters |
Time Frame: | Pre-dose, 0.5, 1, 2, 4, and 8 hours post-dose on days -7, 1, and 15 |
Safety Issue: | |
Description: | The PK of CB-839 HCl will also be summarized using descriptive statistics and will be compared to historical data. Measurement of plasma concentrations of CB-839 HCl and its metabolites (if authentic standards are available) will be performed using validated liquid chromatography-tandem mass spectrometry (LC/MS/MS) assays. The plasma concentration-time data will be analyzed by standard noncompartmental analysis using the program Phoenix WinNonlin 6.4 to determine apparent total clearance of the drug from plasma after oral administration (Cl/F), area under the plasma concentration-time curve from time zero to time t (AUCt), area under the plasma concentration-time curve from time zero to infinity, Cmax, time to reach maximum plasma concentration following drug administration (Tmax), t1/2, and accumulation. |
Measure: | Assessment of self-reported symptoms as measured by MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) instrument |
Time Frame: | Up to 2 years |
Safety Issue: | |
Description: | MDASI-BT instrument is used to measure self-reported symptom severity and interference with daily activities. The study will use descriptive statistics to describe how patients rate symptom severity and interference with function at each time point. Compliance rates will be calculated as the number of received valid forms over the number of expected forms. Differences between groups in compliance will be tested by use of Fisher's exact test at every time point. |
Measure: | Assessment of neurocognitive impact |
Time Frame: | Baseline up to 2 years |
Safety Issue: | |
Description: | For each test in the battery, a standard error of measurement will be used to derive the Reliable Change Index (RCI) which will be used to represent the 90% confidence interval for the difference in raw scores from baseline to follow-up assessment will be coded as 1 (deterioration), 2 (no change), and 3 (improved) according to the RCI. Percentage of patients in each dose cohort who show meaningful losses or gains in the various tests or test domains over the course of the study will be provided by frequency tables. Dose cohort differences will be compared using chi-squared analysis. Time-to-progressions will be estimated by Kaplan-Meier method and analyzed by Cox regression model adjusting all stratification factors. |
Measure: | Assessment of plasma oncometabolites |
Time Frame: | Baseline up to day 71 |
Safety Issue: | |
Description: | Plasma oncometabolites (asparagine, aspartate, glutamine, glutamate, and 2-HG) will be compared using changes in values after treatment with the patient's individual baseline values using either the paired t-test or the Mann-Whitney nonparametric U-test as needed. A significant change is defined as a 10% change from baseline. |
Measure: | Assessment of tumor oncometabolites as measured by magnetic resonance spectroscopy (MRS) |
Time Frame: | Baseline up to day 45 |
Safety Issue: | |
Description: | Tumor oncometabolites (2-HG, glutamine, and glutamate, as measured by MRS) will be compared using changes in values after treatment with the patient's individual baseline values using either the paired t-test or the Mann-Whitney nonparametric U-test as needed. A significant change is defined as a 10% change from baseline. |
Details
Phase: | Phase 1 |
Primary Purpose: | Interventional |
Overall Status: | Recruiting |
Lead Sponsor: | National Cancer Institute (NCI) |
Last Updated
June 4, 2021