Comparison of Chemotherapy Regimens in Treating Children With Relapsed or Progressive Rhabdomyosarcoma

A Groupwide Randomized Phase II Window Study of Two Different Schedules of Irinotecan in Combination With Vincristine And Pilot Assessment of Safety and Efficacy of Tirapazamine Combined With Multiagent Chemotherapy for First Relapse or Progressive Disease in Rhabdomyosarcoma and Related Tumors

Randomized phase II trial to compare the effectiveness of different combination chemotherapy regimens in treating children who have rhabdomyosarcoma. Drugs used in chemotherapy work in different ways to stop tumor cells from dividing so they stop growing or die. Combining more than one drug may kill more tumor cells

Study Overview

• Status: Completed
• Conditions: Recurrent Childhood Rhabdomyosarcoma; Previously Treated Childhood Rhabdomyosarcoma; Alveolar Childhood Rhabdomyosarcoma; Embryonal Childhood Rhabdomyosarcoma; Embryonal-botryoid Childhood Rhabdomyosarcoma
• Intervention / Treatment: Other: laboratory biomarker analysis; Drug: cyclophosphamide; Other: pharmacological study; Drug: etoposide; Drug: doxorubicin hydrochloride; Drug: vincristine sulfate; Biological: filgrastim; Other: pharmacogenomic studies; Drug: irinotecan hydrochloride; Biological: sargramostim; Drug: ifosfamide; Drug: tirapazamine

Detailed Description

OBJECTIVES:

I. Compare response rate in children with relapsed or progressive rhabdomyosarcoma, undifferentiated sarcoma, or ectomesenchymoma treated with 2 different schedules of irinotecan and vincristine in an upfront phase II window.

II. Determine the progression-free and overall survival of patients treated with multiagent chemotherapy.

III. Determine the toxic effects of tirapazamine, doxorubicin, and cyclophosphamide in these patients.

IV. Determine the toxic effects of irinotecan and vincristine in these patients.

V. Determine whether conversion of irinotecan to its active metabolite SN-38 predicts tumor response in these patients.

OUTLINE: This is a randomized, multicenter study. Patients are stratified according to risk status and window therapy eligibility (unfavorable risk and eligible vs unfavorable risk and ineligible vs favorable risk).

UNFAVORABLE-RISK PATIENTS ELIGIBLE FOR WINDOW THERAPY: Patients are stratified according to prior topotecan (yes vs no). These patients are randomized to 1 of 2 treatment arms.

ARM I: Patients receive vincristine IV on days 1 and 8 and irinotecan IV over 1 hour on days 1-5 and 8-12. Treatment repeats every 21 days for 2 courses in the absence of disease progression or unacceptable toxicity.

ARM II: Patients receive vincristine IV on days 1 and 8 and irinotecan IV over 1 hour on days 1-5. Treatment repeats every 21 days for 2 courses in the absence of disease progression or unacceptable toxicity.

Patients in both arms with partial response (PR) or complete response (CR) receive 5 additional courses of irinotecan and vincristine on the previous schedule. In addition, patients with PR or CR also receive cyclophosphamide/doxorubicin (CD) and ifosfamide/etoposide (IE) chemotherapy.

CD/IE CHEMOTHERAPY: Patients receive cyclophosphamide IV over 1 hour and doxorubicin IV over 15-30 minutes on day 1 of weeks 7, 16, 28, 37, and 40. Patients also receive ifosfamide IV over 1 hour and etoposide IV over 1 hour on days 1-5 of weeks 10, 19, 22, 31, and 43. Treatment continues in the absence of disease progression or unacceptable toxicity.

Patients with no response or progressive disease on arm I or II proceed to tirapazamine/cyclophosphamide/doxorubicin (TCD) and ifosfamide/etoposide (IE) chemotherapy.

TCD/IE CHEMOTHERAPY: Patients receive tirapazamine IV over 2 hours, cyclophosphamide IV over 1 hour, and doxorubicin IV over 15-30 minutes on day 1 of weeks 7, 10, 16, 25, and 34. Patients also receive ifosfamide IV over 1 hour and etoposide IV over 1 hour on days 1-5 of weeks 13, 19, 22, 28, 31, and 37.

PATIENTS WITH UNFAVORABLE RISK AND INELIGIBLE FOR WINDOW THERAPY: Patients receive tirapazamine IV over 2 hours, cyclophosphamide IV over 1 hour, and doxorubicin IV over 15-30 minutes on day 1 of weeks 1, 4, 10, 19, and 28. Patients also receive ifosfamide IV over 1 hour and etoposide IV over 1 hour on days 1-5 of weeks 7, 13, 16, 22, 25, and 31. Patients also receive filgrastim (G-CSF) or sargramostim (GM-CSF) subcutaneously (SC) beginning 1 day after each course of chemotherapy and continuing until blood counts recover. Treatment continues in the absence of disease progression or unacceptable toxicity.

PATIENTS WITH FAVORABLE RISK: Patients receive cyclophosphamide IV over 1 hour and doxorubicin IV over 15-30 minutes on day 1 of weeks 1, 4, 10, 19, and 28. Patients also receive ifosfamide IV over 1 hour and etoposide IV over 1 hour on days 1-5 of weeks 7, 13, 16, 22, 25, and 31. Patients also receive G-CSF or GM-CSF SC beginning 1 day after each course of chemotherapy and continuing until blood counts recover. Treatment continues in the absence of disease progression or unacceptable toxicity.

Patients are followed every 2 months for 1 year, every 4 months for 2 years, and then annually thereafter.

• Study Type: Interventional
• Enrollment (Actual): 150
• Phase: Phase 2

Contacts and Locations

Study Locations

• United States
  • California
    • Arcadia, California, United States, 91006-3776
      • Children's Oncology Group

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: No older than 20 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Histologically confirmed rhabdomyosarcoma, undifferentiated sarcoma, or ectomesenchymoma

  • First relapse or first occurrence of disease progression

• Unfavorable-risk patients eligible for study window therapy with irinotecan and vincristine meeting the following criteria:

  • Unfavorable risk defined by any of the following:

    • Embryonal histology with stage I or group I at initial diagnosis with distant recurrence or with local or regional recurrence after prior cyclophosphamide
    • Embryonal histology with initial stage II, III, or IV or group II, III, or IV with any relapse pattern
    • Alveolar histology with any stage or group at initial diagnosis
  • At least unidimensionally measurable disease
  • No prior irinotecan
  • Bone marrow must not be only site of relapse

• Unfavorable-risk patients ineligible for study window therapy with irinotecan meeting the following criteria:

  • Either no measurable disease OR patient received prior irinotecan
  • Bone marrow as only site of relapse allowed

• Favorable-risk patients meeting the following criteria:

  • Initial botryoid histology (any stage, any group, or any pattern of relapse)
  • Embryonal histology if either stage I or group I (with either local or regional recurrence)
  • No prior cyclophosphamide
• No CNS metastases
• Performance status - ECOG 0-2
• Performance status - Zubrod 0-2
• At least 2 months
• Absolute neutrophil count at least 750/mm^3
• Platelet count at least 75,000/mm^3 (transfusion independent)
• Hemoglobin at least 10.0 g/dL (red blood cell transfusion allowed)
• Bilirubin no greater than 1.5 times normal
• SGPT less than 2.5 times normal
• Creatinine no greater than 1.5 times normal
• Creatinine clearance or radioisotope glomerular filtration rate at least 70 mL/min
• Shortening fraction at least 27% by echocardiogram
• Ejection fraction at least 50% by MUGA
• No prior ischemic heart disease
• Seizure disorder allowed if well controlled by anticonvulsants
• No CNS toxicity greater than grade 2
• Not pregnant or nursing
• Negative pregnancy test
• Fertile patients must use effective contraception
• No prior myeloablative therapy with stem cell transplantation
• At least 1 week since prior antineoplastic biologic agent
• At least 1 week since prior growth factor(s)
• Recovered from prior immunotherapy
• No concurrent immunomodulating agents
• See Disease Characteristics
• See Biologic therapy
• No more than 1 prior chemotherapy regimen
• No prior doxorubicin or daunorubicin
• At least 2 weeks since prior myelosuppressive chemotherapy (4 weeks for nitrosoureas) and recovered
• No other concurrent anticancer chemotherapy
• Concurrent corticosteroid therapy allowed
• At least 2 weeks since prior small-port radiotherapy.
• At least 6 months since prior radiotherapy to 50% or more of pelvis
• At least 6 weeks since other prior substantial radiotherapy to bone marrow
• Recovered from prior radiotherapy
• Concurrent radiotherapy to localized painful lesions allowed provided at least 1 measurable lesion is not irradiated
• No concurrent intensity-modulated radiotherapy

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Arm I; Patients receive vincristine IV on days 1 and 8 and irinotecan IV over 1 hour on days 1-5 and 8-12. Treatment repeats every 21 days for 2 courses in the absence of disease progression or unacceptable toxicity.	Other: laboratory biomarker analysis; Correlative studies; Drug: cyclophosphamide; Given IV; Other Names: Cytoxan; Endoxan; CPM; CTX; Endoxana; Other: pharmacological study; Correlative studies; Other Names: pharmacological studies; Drug: etoposide; Given IV; Other Names: EPEG; VP-16; VP-16-213; Drug: doxorubicin hydrochloride; Given IV; Other Names: ADM; Adriamycin PFS; Adriamycin RDF; ADR; Adria; Drug: vincristine sulfate; Given IV; Other Names: VCR; leurocristine sulfate; Vincasar PFS; Biological: filgrastim; Given SC; Other Names: G-CSF; Neupogen; Other: pharmacogenomic studies; Correlative studies; Other Names: Pharmacogenomic Study; Drug: irinotecan hydrochloride; Given IV; Other Names: irinotecan; Campto; Camptosar; U-101440E; CPT-11; Biological: sargramostim; Given SC; Other Names: Leukine; Prokine; GM-CSF; Drug: ifosfamide; Given IV; Other Names: Cyfos; Holoxan; IFX; IFF; IPP; Drug: tirapazamine; Given IV; Other Names: SR 4233; Tirazone; WIN 59075
Experimental: Arm II; Patients receive vincristine IV on days 1 and 8 and irinotecan IV over 1 hour on days 1-5. Treatment repeats every 21 days for 2 courses in the absence of disease progression or unacceptable toxicity.	Other: laboratory biomarker analysis; Correlative studies; Drug: cyclophosphamide; Given IV; Other Names: Cytoxan; Endoxan; CPM; CTX; Endoxana; Other: pharmacological study; Correlative studies; Other Names: pharmacological studies; Drug: etoposide; Given IV; Other Names: EPEG; VP-16; VP-16-213; Drug: doxorubicin hydrochloride; Given IV; Other Names: ADM; Adriamycin PFS; Adriamycin RDF; ADR; Adria; Drug: vincristine sulfate; Given IV; Other Names: VCR; leurocristine sulfate; Vincasar PFS; Biological: filgrastim; Given SC; Other Names: G-CSF; Neupogen; Other: pharmacogenomic studies; Correlative studies; Other Names: Pharmacogenomic Study; Drug: irinotecan hydrochloride; Given IV; Other Names: irinotecan; Campto; Camptosar; U-101440E; CPT-11; Biological: sargramostim; Given SC; Other Names: Leukine; Prokine; GM-CSF; Drug: ifosfamide; Given IV; Other Names: Cyfos; Holoxan; IFX; IFF; IPP; Drug: tirapazamine; Given IV; Other Names: SR 4233; Tirazone; WIN 59075

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Response at week 6 of investigational window therapy (unfavorable risk patients)	At week 6
Incidence of DLT when tirapazamine is given in combination with cyclophosphamide and doxorubicin, graded according to the NCI CTC v 2.0	Up to 6 years

Secondary Outcome Measures

Outcome Measure	Time Frame
Incidence of toxicities associated with the two administration schedules of irinotecan in combination with vincristine, graded according to the NCI CTC v 2.0 (unfavorable risk patients)	Up to 6 years
Blood metabolite SN-38 levels (unfavorable risk patients)	Up to 6 years
Progression-free survival	Up to 6 years
Survival	Up to 6 years

Collaborators and Investigators

• Sponsor: National Cancer Institute (NCI)
• Investigators: Principal Investigator: Philip Breitfeld, Children's Oncology Group

Study record dates

Study Major Dates

• Study Start: November 1, 2001
• Primary Completion (Actual): October 1, 2007

Study Registration Dates

• First Submitted: October 11, 2001
• First Submitted That Met QC Criteria: January 26, 2003
• First Posted (Estimate): January 27, 2003

Study Record Updates

• Last Update Posted (Estimate): January 17, 2013
• Last Update Submitted That Met QC Criteria: January 16, 2013
• Last Verified: January 1, 2013

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Neoplasms, Connective and Soft Tissue; Neoplasms by Histologic Type; Neoplasms; Sarcoma; Neoplasms, Muscle Tissue; Myosarcoma; Rhabdomyosarcoma; Rhabdomyosarcoma, Embryonal; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Antirheumatic Agents; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Tubulin Modulators; Antimitotic Agents; Mitosis Modulators; Antineoplastic Agents, Alkylating; Alkylating Agents; Myeloablative Agonists; Antineoplastic Agents, Phytogenic; Topoisomerase II Inhibitors; Topoisomerase Inhibitors; Antibiotics, Antineoplastic; Topoisomerase I Inhibitors; Cyclophosphamide; Etoposide; Etoposide phosphate; Ifosfamide; Irinotecan; Doxorubicin; Liposomal doxorubicin; Vincristine; Sargramostim; Tirapazamine
• Other Study ID Numbers: NCI-2012-01864; U10CA098543 (U.S. NIH Grant/Contract); ARST0121; CDR0000068954 (Registry Identifier: PDQ (Physician Data Query))