Clinical Trials /

Study of Selinexor and Venetoclax in Combination With Chemotherapy in Pediatric and Young Adult Patients With Refractory or Relapsed Acute Myeloid Leukemia

NCT04898894

Description:

The purpose of this study is to test the safety and determine the best dose of venetoclax and selinexor when given with chemotherapy drugs in treating pediatric and young adult patients with acute myeloid leukemia (AML) or acute leukemia of ambiguous lineage (ALAL) that has come back (relapsed) or did not respond to treatment (refractory). Primary Objective - To determine the safety and tolerability of selinexor and venetoclax in combination with chemotherapy in pediatric patients with relapsed or refractory AML or ALAL. Secondary Objectives - Describe the rates of complete remission (CR) and complete remission with incomplete count recovery (CRi) for patients treated with selinexor and venetoclax in combination with chemotherapy at the recommended phase 2 dose (RP2D). - Describe the overall survival of patients treated at the RP2D. Exploratory Objectives - Explore associations between leukemia cell genomics, BCL2 family member protein quantification, BH3 profiling, and response to therapy as assessed by minimal residual disease (MRD) and variant clearance using cell-free deoxyribonucleic acid (DNA) (cfDNA). - Describe the quality of life of pediatric patients undergoing treatment with selinexor and venetoclax in combination with chemotherapy and explore associations of clinical factors with patient-reported quality of life outcomes. - Characterize the pharmacokinetics of selinexor when administered in combination with venetoclax. - Describe the clinical and genetic features associated with exceptional response to the combination of venetoclax and selinexor without the addition of chemotherapy.

Related Conditions:
  • Acute Leukemia of Ambiguous Lineage
  • Acute Myeloid Leukemia
Recruiting Status:

Not yet recruiting

Phase:

Phase 1

Trial Eligibility

Document

Title

  • Brief Title: Study of Selinexor and Venetoclax in Combination With Chemotherapy in Pediatric and Young Adult Patients With Refractory or Relapsed Acute Myeloid Leukemia
  • Official Title: A Phase I and Expansion Cohort Study of Selinexor and Venetoclax in Combination With Chemotherapy in Pediatric and Young Adult Patients With Refractory or Relapsed Acute Myeloid Leukemia

Clinical Trial IDs

  • ORG STUDY ID: SELCLAX
  • SECONDARY ID: NCI-2021-03435
  • NCT ID: NCT04898894

Conditions

  • Acute Leukemia of Ambiguous Lineage in Relapse
  • Acute Myeloid Leukemia, in Relapse
  • Refractory Acute Leukemia of Ambiguous Lineage
  • Refractory Acute Myeloid Leukemia

Interventions

DrugSynonymsArms
VenetoclaxVenclextra®, ABT-199Treatment
SelinexorKPT-330Treatment
CytarabineCytosine arabinoside, Ara-C, Cytosar®Treatment
FludarabineFludara®, Fludarabine phosphate, 2-fluoro-ara-AMPTreatment
FilgrastimG-CSFTreatment
MethotrexateMTX, amethopterin, Trexall®Treatment
methotrexate/hydrocortisone/cytarabineITMHA, Intrathecal triplesTreatment

Purpose

The purpose of this study is to test the safety and determine the best dose of venetoclax and selinexor when given with chemotherapy drugs in treating pediatric and young adult patients with acute myeloid leukemia (AML) or acute leukemia of ambiguous lineage (ALAL) that has come back (relapsed) or did not respond to treatment (refractory). Primary Objective - To determine the safety and tolerability of selinexor and venetoclax in combination with chemotherapy in pediatric patients with relapsed or refractory AML or ALAL. Secondary Objectives - Describe the rates of complete remission (CR) and complete remission with incomplete count recovery (CRi) for patients treated with selinexor and venetoclax in combination with chemotherapy at the recommended phase 2 dose (RP2D). - Describe the overall survival of patients treated at the RP2D. Exploratory Objectives - Explore associations between leukemia cell genomics, BCL2 family member protein quantification, BH3 profiling, and response to therapy as assessed by minimal residual disease (MRD) and variant clearance using cell-free deoxyribonucleic acid (DNA) (cfDNA). - Describe the quality of life of pediatric patients undergoing treatment with selinexor and venetoclax in combination with chemotherapy and explore associations of clinical factors with patient-reported quality of life outcomes. - Characterize the pharmacokinetics of selinexor when administered in combination with venetoclax. - Describe the clinical and genetic features associated with exceptional response to the combination of venetoclax and selinexor without the addition of chemotherapy.

Detailed Description

      This study will include two phases. The dose-escalation phase will characterize the
      dose-limiting toxicity (DLT) and determine the recommended phase 2 dose (RP2D) of venetoclax
      plus selinexor with and without chemotherapy. Two expansion cohorts (cohort A, patients
      without prior exposure to venetoclax; cohort B, patients with prior exposure to venetoclax)
      will further assess the safety and will explore the efficacy at the RP2D.

      Dosing of venetoclax and selinexor will be based on tolerability. Venetoclax will be given
      orally (po) once daily on days 1 through 21 and selinexor will be given orally (po) starting
      on days 1, 8, and 15 OR 1, 3, 8, 10, 15, and 17. Beginning on day 16, patients also receive
      fludarabine phosphate intravenously (IV) daily on days 16-20, cytarabine IV daily on days
      16-20, and granulocyte colony-stimulating factor (G-CSF) subcutaneously (SC) daily on days
      16-20. G-CSF may be omitted or extended at the discretion of the treating physician.
      Intrathecal (IT) chemotherapy will be given prior to cycle 1, but may be delayed if
      clinically indicated. IT cytarabine, IT methotrexate, and IT
      methotrexate/hydrocortisone/cytarabine (MHA) are all acceptable. Patients without evidence of
      central nervous system (CNS) leukemia will receive no further IT therapy during cycle 1.
      Patients with CNS disease will receive weekly IT therapy beginning on day 8, until the
      cerebrospinal fluid becomes free of leukemia.

      Chemotherapy is scheduled to begin on Day 16; however, patients with exceptional responses
      may, at the discretion of the treating physician, receive chemotherapy (fludarabine and
      cytarabine) on days 16-20 and continue venetoclax through day 21 and selinexor through day 15
      or 17 according to dose level. Alternatively, exceptional responders may continue venetoclax
      through day 28 and selinexor once or twice weekly according to dose level without
      chemotherapy and then undergo re-evaluation at day 29. For patients who do not receive
      chemotherapy on day 16-20, chemotherapy may be omitted completely or may be given on days
      30-34 at the discretion of the treating physician.

      Patients may receive up to 4 cycles of therapy in the absence of disease progression or
      unacceptable toxicity. After completion of study treatment, patients are followed up for 30
      days.
    

Trial Arms

NameTypeDescriptionInterventions
TreatmentExperimentalDose Escalation Phase: Venetoclax plus selinexor will initially be given at dose level 1 in combination with intravenous (IV) cytarabine and fludarabine. Dosing of venetoclax and selinexor will be based on tolerability. Intrathecal (IT) chemotherapy (IT cytarabine, IT methotrexate, and IT methotrexate/hydrocortisone/cytarabine (MHA) are all acceptable) will be given. G-CSF SC may be given. Dose Expansion Phase: Two expansion cohorts will be treated at the recommended phase 2 dose (RP2D). Cohort A will include venetoclax-naïve patients, whereas Cohort B will include patients with prior exposure to venetoclax.
  • Venetoclax
  • Selinexor
  • Cytarabine
  • Fludarabine
  • Filgrastim
  • Methotrexate
  • methotrexate/hydrocortisone/cytarabine

Eligibility Criteria

        Inclusion Criteria:

          -  Participants must have a diagnosis of AML or ALAL and meet the criteria below:

               -  Refractory leukemia, defined as persistent leukemia after at least two courses of
                  induction chemotherapy, OR

               -  Early relapsed leukemia, defined as the re-appearance of leukemia after the
                  achievement of remission and within one year of diagnosis, OR

               -  Relapsed leukemia that is refractory to at least one course of salvage therapy
                  (i.e., therapy given after the relapse has occurred), OR

               -  Relapsed leukemia following HCT, OR

               -  Second or greater relapse

               -  Patients with late first relapses, defined as the re-appearance of leukemia after
                  the achievement of remission and greater than one year of diagnosis, may be
                  enrolled in the dose expansion portion of the study after safety data from the
                  dose escalation portion is available.

        Patients must have ≥ 5% blasts in the bone marrow as assessed by morphology or flow
        cytometry. However, if flow cytometry cannot be performed or if an adequate bone marrow
        sample cannot be obtained (e.g., in a patient with acute megakaryoblastic leukemia with
        marrow fibrosis), patients may be enrolled if there is unequivocal evidence of leukemia
        with ≥ 5% blasts in the blood.

        In addition, patients in all categories must not be eligible to undergo curative therapy,
        such as immediate HCT, because of disease burden, time to identify a stem cell donor, or
        other reasons.

          -  Adequate organ function defined as the following:

               -  Direct bilirubin ≤ 1.5 x institutional upper limit of normal (ULN)

               -  Normal creatinine for age or a calculated creatinine clearance ≥ 30
                  mL/min/1.73m^2

               -  Left ventricular ejection fraction ≥ 40% or shortening fraction ≥ 25%

          -  Patients must be ≤ 30 years old. The upper age limit may be defined by each
             institution, but may not exceed 30 years. Patients treated at St. Jude Children's
             Research Hospital must be ≤ 24 years old.

          -  Performance status: Lansky ≥ 50 for patients who are ≤ 16 years old and Karnofsky ≥
             50% for patients who are > 16 years old.

          -  At least 14 days must have elapsed since the completion of myelosuppressive therapy or
             hypomethylating agents and the first doses of venetoclax and selinexor.

          -  At least 24 hours must have elapsed since the completion of low-dose or non-
             myelosuppressive therapy, such as hydroxyurea or low-dose cytarabine (up to 100
             mg/m^2/day), or leukapheresis, and the first doses of venetoclax and selinexor.

          -  For patients who have received prior HCT, there can be no evidence of GVHD and greater
             than 60 days must have elapsed since the HCT.

          -  At least 14 days must have elapsed since the completion of any calcineurin inhibitors
             (e.g. tacrolimus, cyclosporine).

          -  Patients may not receive strong or moderate CYP3A inducers, such as rifampin, within 3
             days of the first dose of venetoclax or during the administration of venetoclax.
             During the dose-escalation portion of the trial, we discourage the use of strong CYP3A
             inhibitors (e.g., ketoconazole, itraconazole, voriconazole, posaconazole) within 3
             days of the first dose of venetoclax or during the administration of venetoclax.
             However, if an azole is required for the treatment or prevention of fungal infection
             during any phase of the trial, venetoclax dosing will be reduced to 60 mg/m^2 (100 mg
             max) in patients who require treatment with voriconazole and reduced to 40 mg/m^2 (70
             mg max) in patients who require posaconazole.

        Exclusion Criteria:

          -  Must not be pregnant or breastfeeding. Male or female of reproductive potential must
             agree to use effective contraception for the duration of study participation.

          -  Patients with Down syndrome, acute promyelocytic leukemia, juvenile myelomonocytic
             leukemia, or bone marrow failure syndromes are not eligible.

          -  Uncontrolled infection. Patients with infections that are controlled on concurrent
             anti-microbial agents are eligible.

          -  Impairment of GI function or GI disease that, in the opinion of the treating
             physician, may significantly alter the absorption of venetoclax or selinexor.

          -  History of cerebellar toxicity or cerebellar neurological findings on exam.

          -  Previous toxicity or hypersensitivity directly attributed to venetoclax.
      
Maximum Eligible Age:30 Years
Minimum Eligible Age:N/A
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:The recommended phase 2 dose (RP2D) of venetoclax plus selinexor plus chemotherapy.
Time Frame:For each patient, the monitoring time period for dose-limiting toxicity will extend for 35 days from receipt of the first dose of protocol-directed selinexor or venetoclax.
Safety Issue:
Description:The primary endpoint is the recommended phase 2 dose (RP2D) of venetoclax plus selinexor plus chemotherapy.

Secondary Outcome Measures

Measure:The rates of complete remission (CR) for patients treated with selinexor and venetoclax in combination with chemotherapy at the RP2D.
Time Frame:The final response of each patient will be determined no later than day 42 from the start of chemotherapy.
Safety Issue:
Description:CR is defined as bone marrow with < 5% blasts confirmed by flow cytometry, ANC ≥ 500/μL and platelets ≥ 50,000/μL without transfusions, and no evidence of extramedullary disease.
Measure:The rates of complete remission with incomplete count recovery (CRi) for patients treated with selinexor and venetoclax in combination with chemotherapy at the RP2D.
Time Frame:The final response of each patient will be determined no later than day 42 from the start of chemotherapy.
Safety Issue:
Description:CRi is defined as bone marrow with < 5% blasts confirmed by flow cytometry, ANC < 500/μL or platelets < 50,000/μL without transfusions, and no evidence of extramedullary disease
Measure:The overall survival of patients treated at the RP2D.
Time Frame:Survival of each patient will be determined one year from enrollment.
Safety Issue:
Description:Overall survival is defined as the time elapsed from protocol enrollment to death, with data for living patients censored at last follow-up. We will report KM estimates with 95% CIs.
Measure:The rates of exceptional response for those patients treated during the Dose-escalation phase.
Time Frame:Day 15
Safety Issue:
Description:Exceptional Response is defined as patients who have at least 2-log (100-fold) reduction in bone marrow MRD at day 15 compared to bone marrow blast percentage at enrollment.
Measure:The rates of exceptional response for those patients treated during the Dose Expansion Phase (Cohort A).
Time Frame:Day 15
Safety Issue:
Description:Exceptional Response is defined as patients who have at least 2-log (100-fold) reduction in bone marrow MRD at day 15 compared to bone marrow blast percentage at enrollment.
Measure:The rates of exceptional response for those patients treated during the Dose Expansion Phase (Cohort B).
Time Frame:Day 15
Safety Issue:
Description:Exceptional Response is defined as patients who have at least 2-log (100-fold) reduction in bone marrow MRD at day 15 compared to bone marrow blast percentage at enrollment.

Details

Phase:Phase 1
Primary Purpose:Interventional
Overall Status:Not yet recruiting
Lead Sponsor:St. Jude Children's Research Hospital

Trial Keywords

  • Acute Myeloid Leukemia, in Relapse
  • Refractory Acute Myeloid Leukemia
  • Acute Leukemia of Ambiguous Lineage in Relapse
  • Refractory Acute Leukemia of Ambiguous Lineage
  • Pediatric
  • Young Adult

Last Updated

August 3, 2021