Trial of Nelarabine, Etoposide and Cyclophosphamide in Relapsed T-cell ALL and T-cell LL

A Phase I Trial of NECTAR (Nelarabine, Etoposide and Cyclophosphamide in T-ALL Relapse): A Joint Study of TACL and POETIC

Nelarabine has shown significant activity in patients with T-cell malignancies. This study will determine the safety and maximum tolerated dose of the combination of nelarabine, cyclophosphamide and etoposide in patients with first bone marrow relapse of T-ALL, or first relapse of T-LL.

Study Overview

• Status: Terminated
• Conditions: Relapsed T-Cell Acute Lymphoblastic Leukemia; Relapsed T-Cell Lymphoblastic Lymphoma
• Intervention / Treatment: Drug: Nelarabine; Drug: Etoposide; Drug: Cyclophosphamide; Drug: Methotrexate; Drug: Filgrastim

• Study Type: Interventional
• Enrollment (Actual): 23
• Phase: Phase 2; Phase 1

Contacts and Locations

Study Locations

• Australia
  • Sydney, Australia
    • Sydney Children's Hospital
  • New South Wales
    • Westmead, New South Wales, Australia
      • Children's Hospital at Westmead
  • Queensland
    • Brisbane, Queensland, Australia
      • Royal Children's Hospital
  • Victoria
    • Melbourne, Victoria, Australia
      • Royal Children's Hospital, Melbourne
• Austria
  • Vienna, Austria
    • St. Anna Children's Hospital
• Canada
  • Vancouver, Canada
    • British Columbia Children's Hospital
  • Ontario
    • Toronto, Ontario, Canada
      • Hospital for Sick Kids
  • Quebec
    • Montreal, Quebec, Canada
      • Sainte Justine University Hospital
• France
  • Lille, France
    • CHU Lille
• Italy
  • Rome, Italy
    • Bambino Gesu Hospital
• Netherlands
  • Rotterdam, Netherlands
    • Erasmus MC - Sophia
• United States
  • California
    • Los Angeles, California, United States, 90027
      • Childrens Hospital Los Angeles
    • Orange, California, United States
      • Children's Hospital Orange County
    • San Francisco, California, United States, 94143-0106
      • UCSF School of Medicine
  • Colorado
    • Aurora, Colorado, United States, 80045
      • The Children's Hospital, University of Colorado
  • District of Columbia
    • Washington, District of Columbia, United States
      • Children's National Medical Center
  • Florida
    • Miami, Florida, United States, 33136
      • University of Miami Cancer Center
  • Georgia
    • Atlanta, Georgia, United States
      • Children's Healthcare of Atlanta, Emory University
  • Illinois
    • Chicago, Illinois, United States
      • Lurie Children's Hospital
  • Maryland
    • Baltimore, Maryland, United States
      • Johns Hopkins University
  • Massachusetts
    • Boston, Massachusetts, United States
      • Dana Farber
  • Michigan
    • Ann Arbor, Michigan, United States, 48109-0914
      • C.S. Mott Children's Hospital
  • Minnesota
    • Minneapolis, Minnesota, United States, 55404-4597
      • Childrens Hospital & Clinics of Minnesota
  • Missouri
    • Kansas City, Missouri, United States, 64108
      • Children's Mercy Hospitals and Clinics
  • New York
    • New York, New York, United States, 10016
      • New York University Medical Center
    • New York, New York, United States, 10032
      • Children's Hospital New York-Presbyterian
  • North Carolina
    • Charlotte, North Carolina, United States, 28203
      • Levine Children's Hospital at Carolinas Medical Center
  • Ohio
    • Cleveland, Ohio, United States
      • Rainbow Babies
    • Columbus, Ohio, United States
      • Nationwide Childrens Hospital
  • Oregon
    • Portland, Oregon, United States
      • Oregon Health and Science University
  • Tennessee
    • Memphis, Tennessee, United States, 38105-3678
      • St. Jude
    • Nashville, Tennessee, United States
      • Vanderbilt Children's Hospital
  • Texas
    • Dallas, Texas, United States
      • University of Texas at Southwestern
    • Fort Worth, Texas, United States
      • Cook Children's Hospital
  • Utah
    • Salt Lake City, Utah, United States
      • Primary Children's
  • Washington
    • Seattle, Washington, United States, 98105
      • Seattle Children's Hospital
  • Wisconsin
    • Milwaukee, Wisconsin, United States
      • Medical College of Wisconsin

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 2 years to 17 years (Child, Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients to be enrolled in the dose-escalation portion of this study must have T-cell ALL or T-cell lymphoblastic lymphoma (LL) in first relapse or must have failed primary induction chemotherapy (ie, never attained a complete remission following an initial course of standard therapy for T-ALL or T-LL). Patients to be enrolled in the cohort expansion portion of this study (ie, those treated at the recommended phase 2 dose) must have T-cell ALL in first relapse or must have failed primary induction chemotherapy (ie, never attained a complete remission following an initial course of standard therapy for T-ALL). T-LL patients are not eligible for the cohort expansion phase.
• Patients with T-cell ALL must have greater than 25% blasts in the bone marrow with or without extramedullary disease.
• Patients with T-cell LL must have recurrent disease, documented by clinical or radiographic criteria, as well as histologic verification of the malignancy at original diagnosis. Patients with T-cell LL enrolled in the phase I dose-escalation study are not required to have measurable disease; however, patients enrolled in the phase II cohort expansion at the MTD must have measurable disease.
• Patients may have CNS 1 or CNS 2 disease but not CNS 3.
• ECOG 0-2 or Karnofsky ≥ 50% for patients > 16 years of age; Lansky ≥ 50% for patients ≤16 years of age.
• Patients may be enrolled on study regardless of the timing of prior Intrathecal therapy; however, they MAY NOT BEGIN TREATMENT ON THIS PROTOCOL UNTIL A MINIMUM OF 7 DAYS HAS ELAPSED SINCE PRIOR INTRATHECAL THERAPY.
• At least 6 weeks must have elapsed since administration of nitrosureas.
• At least 12 weeks must have elapsed since administration of craniospinal or hemipelvic radiation.
• Female patients of childbearing potential must have a negative urine or serum pregnancy test confirmed within 2 weeks prior to enrollment.
• Female patients with infants must agree not to breastfeed their infants while on this study.
• Male and female patients of child-bearing potential must agree to use an effective method of contraception approved by the investigator during the study and for a minimum of 6 months after study treatment.
• Adequate renal function defined as serum creatinine ≤ 1.5x upper limit of normal (ULN) for age. If the serum creatinine is above these values, the calculated creatinine clearance or radioisotope GFR must be ≥ 70 mL/min/1.73m2.
• Total bilirubin ≤ 1.5x ULN for age. If the total bilirubin is elevated, patient will still be eligible if the conjugated (direct) serum bilirubin ≤ ULN for age.
• ALT ≤ 5x ULN of normal for age.
• Adequate cardiac function defined as shortening fraction of ≥ 27% by echocardiogram or ejection fraction ≥ 45% by gated radionuclide study.
• No evidence of dyspnea at rest
• No exercise intolerance
• A pulse oximetry ≥ 94% at sea level (≥ 90% at altitude ≥ 5000 feet) if there is clinical indication for determination.
• Patients and/or their parents or legal guardians must be capable of understanding the investigational nature, potential risks and benefits of the study. All patients and/or their parents or legal guardians must sign a written informed consent.

Exclusion Criteria:

• Patients with Down syndrome are excluded.
• Patients with pre-existing Grade 2 (or greater) peripheral motor or sensory neurotoxicity per the CTCAE 3.0 as determined by the treating physician or a neurologist.
• Patients with a history of prior veno-occlusive disease (VOD) or findings consistent with a diagnosis of VOD, defined as: conjugated serum bilirubin >1.4 mg/dL AND unexplained weight gain greater than 10% of baseline weight or ascites AND hepatomegaly or right upper quadrant pain without another explanation, OR reversal of portal vein flow on ultrasound, OR pathological confirmation of VOD on liver biopsy.
• Previous hematopoetic stem cell transplantation.
• Patients with a prior seizure disorder requiring anti-convulsant therapy are not eligible to receive nelarabine. For the purposes of this study, this includes any patient that has received anticonvulsant therapy to prevent/treat seizures in the prior two years.
• Positive blood culture within 48 hours of study enrollment.
• Fever above 38.2 within 48 hours of study enrollment with clinical signs of infection.
• Plan to administer non-protocol chemotherapy, radiation therapy, or immunotherapy during the study period.
• Any significant concurrent disease, illness, psychiatric disorder or social issue that would compromise patient safety or compliance, interfere with consent, study participation, follow up, or interpretation of study results.

Study Plan

How is the study designed?

Design Details

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

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Nelarabine Dose Level 1; The study will begin at Dose Level 1 at 480 mg/m2 Nelarabine (75% of single agent maximum tolerated dose) and 330 mg/m2 Cyclophospamide and will escalate to the next Dose Level if the maximum tolerated dose (MTD) is not exceeded. The first 3 patients will be enrolled into Dose Level 1. If 0/3 experiences dose limiting toxicity (DLT) at a given dose level, then the dose is escalated to the next higher level and 3 more patients are enrolled. If 1/3 experiences DLT at current dose, the up to 3 more patients are accrued at the same dose level. If 2 or more DLTs are observed in a 3-patient or 6-patient cohort at a given dose level, then the MTD has been exceeded, dose escalation will be stopped, and up to 3 additional patients will be enrolled at the next lower dose level (unless 6 patients have already been treated at that prior dose). If the MTD is exceeded at Dose Level 0, the study will be closed.	Drug: Nelarabine; Dose will be assigned at study entry. Nelarabine will be given IV over 60 minutes (given at hours 0 to 1) on days 1 through 5.; Other Names: Arranon; Compound 506U78; Drug: Etoposide; 100 mg/m2/day IV over 2 hours (given at hours 1 to 3) on days 1 through 5; Other Names: VP-16; Etopophos; VePesid; Drug: Cyclophosphamide; Dose will be assigned at study entry, IV as a 30-60 minute infusion (given at hours 3 to 4) on days 1 through 5.; Other Names: Cytoxan; Drug: Methotrexate; Give between day 29 and 36 or when ANC>750 and PLTS>75,000 - whichever comes first (but not prior to day 22) at the dose defined by age below, ideally in conjunction with BM evaluation. Given intrathecally at the dose defined by age below. 8 mg for patients age greater than or equal to 1, but <2 years of age 10 mg for patients age greater than or equal to 2, but <3 years of age 12 mg for patients greater than or equal to 3, but < 9 years of age 15 mg for patients greater than or equal to >9 years of age; Other Names: MTX; Amethopterin; Trexall; Drug: Filgrastim; 5 micrograms/kg/day IV or SC will begin on Day 6 and end when the ANC is > 1000/mm3 for two consecutive days.; Other Names: Neupogen; granulocyte colony stimulating factor; GCSF
Experimental: Nelarabine Dose Level 2; Patients in this arm will be administered Nelarabine at 650 mg/m2 (100% of single agent MTD) and 330 mg/m2 Cyclophosphamide.	Drug: Nelarabine; Dose will be assigned at study entry. Nelarabine will be given IV over 60 minutes (given at hours 0 to 1) on days 1 through 5.; Other Names: Arranon; Compound 506U78; Drug: Etoposide; 100 mg/m2/day IV over 2 hours (given at hours 1 to 3) on days 1 through 5; Other Names: VP-16; Etopophos; VePesid; Drug: Cyclophosphamide; Dose will be assigned at study entry, IV as a 30-60 minute infusion (given at hours 3 to 4) on days 1 through 5.; Other Names: Cytoxan; Drug: Methotrexate; Give between day 29 and 36 or when ANC>750 and PLTS>75,000 - whichever comes first (but not prior to day 22) at the dose defined by age below, ideally in conjunction with BM evaluation. Given intrathecally at the dose defined by age below. 8 mg for patients age greater than or equal to 1, but <2 years of age 10 mg for patients age greater than or equal to 2, but <3 years of age 12 mg for patients greater than or equal to 3, but < 9 years of age 15 mg for patients greater than or equal to >9 years of age; Other Names: MTX; Amethopterin; Trexall; Drug: Filgrastim; 5 micrograms/kg/day IV or SC will begin on Day 6 and end when the ANC is > 1000/mm3 for two consecutive days.; Other Names: Neupogen; granulocyte colony stimulating factor; GCSF
Experimental: Nelarabine Dose Level 3; Patients in this arm will be administered Nelarabine at 650 mg/m2 (100% of single agent MTD) and 400 mg/m2 Cyclophosphamide	Drug: Nelarabine; Dose will be assigned at study entry. Nelarabine will be given IV over 60 minutes (given at hours 0 to 1) on days 1 through 5.; Other Names: Arranon; Compound 506U78; Drug: Etoposide; 100 mg/m2/day IV over 2 hours (given at hours 1 to 3) on days 1 through 5; Other Names: VP-16; Etopophos; VePesid; Drug: Cyclophosphamide; Dose will be assigned at study entry, IV as a 30-60 minute infusion (given at hours 3 to 4) on days 1 through 5.; Other Names: Cytoxan; Drug: Methotrexate; Give between day 29 and 36 or when ANC>750 and PLTS>75,000 - whichever comes first (but not prior to day 22) at the dose defined by age below, ideally in conjunction with BM evaluation. Given intrathecally at the dose defined by age below. 8 mg for patients age greater than or equal to 1, but <2 years of age 10 mg for patients age greater than or equal to 2, but <3 years of age 12 mg for patients greater than or equal to 3, but < 9 years of age 15 mg for patients greater than or equal to >9 years of age; Other Names: MTX; Amethopterin; Trexall; Drug: Filgrastim; 5 micrograms/kg/day IV or SC will begin on Day 6 and end when the ANC is > 1000/mm3 for two consecutive days.; Other Names: Neupogen; granulocyte colony stimulating factor; GCSF
Experimental: Nelarabine Dose Level 0; Patients in this arm will be administered Nelarabine 325 mg/m2 (50% of single agent MTD) and 330 mg/2 Cyclophosphamide. Patients will only enter this arm if the MTD at Dose Level 1 has been exceeded. If the MTD is exceeded at Dose Level 0, the study will be closed.	Drug: Nelarabine; Dose will be assigned at study entry. Nelarabine will be given IV over 60 minutes (given at hours 0 to 1) on days 1 through 5.; Other Names: Arranon; Compound 506U78; Drug: Etoposide; 100 mg/m2/day IV over 2 hours (given at hours 1 to 3) on days 1 through 5; Other Names: VP-16; Etopophos; VePesid; Drug: Cyclophosphamide; Dose will be assigned at study entry, IV as a 30-60 minute infusion (given at hours 3 to 4) on days 1 through 5.; Other Names: Cytoxan; Drug: Methotrexate; Give between day 29 and 36 or when ANC>750 and PLTS>75,000 - whichever comes first (but not prior to day 22) at the dose defined by age below, ideally in conjunction with BM evaluation. Given intrathecally at the dose defined by age below. 8 mg for patients age greater than or equal to 1, but <2 years of age 10 mg for patients age greater than or equal to 2, but <3 years of age 12 mg for patients greater than or equal to 3, but < 9 years of age 15 mg for patients greater than or equal to >9 years of age; Other Names: MTX; Amethopterin; Trexall; Drug: Filgrastim; 5 micrograms/kg/day IV or SC will begin on Day 6 and end when the ANC is > 1000/mm3 for two consecutive days.; Other Names: Neupogen; granulocyte colony stimulating factor; GCSF

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
To Determine the Presence of Dose-limiting Toxicities (DLTs) of Nelarabine, Etoposide and Cyclophosphamide When Given in Combination to Children With T-ALL and Bone Marrow Relapse or T-LL.	Patients will be evaluated based on Dose Level and total courses taken at each dose level and for presence of dose limiting toxicities. Not all patients enrolled at each dose level has been assessed to be evaluable for DLTs. Only those that have met criteria for being evaluable for DLT will be counted in the Overall Number of Participants Analyzed.	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
To Determine the Complete Remission Rate After 1 and 2 Courses of This Therapy in Children With T-ALL and Bone Marrow Relapse or T-LL.	Patients will be evaluated at each dose level and for assessment of response to treatment. Not all patients enrolled at each dose level has been assessed to be evaluable for response. Only those that have met criteria for being evaluable for response will be counted in the Overall Number of Participants Analyzed.	1-3 months

Collaborators and Investigators

• Sponsor: Therapeutic Advances in Childhood Leukemia Consortium
• Collaborators: GlaxoSmithKline; Novartis
• Investigators: Study Chair: Jim Whitlock, MD, The Hospital for Sick Children

Publications and helpful links

Helpful Links

• For more information about this and other clinical trials, please visit the TACL website

Study record dates

Study Major Dates

• Study Start: June 1, 2010
• Primary Completion (Actual): November 1, 2015
• Study Completion (Actual): July 18, 2016

Study Registration Dates

• First Submitted: September 9, 2009
• First Submitted That Met QC Criteria: September 18, 2009
• First Posted (Estimate): September 22, 2009

Study Record Updates

• Last Update Posted (Actual): October 1, 2020
• Last Update Submitted That Met QC Criteria: September 8, 2020
• Last Verified: September 1, 2020

More Information

Terms related to this study

• Keywords: Lymphoma; Lymphoblastic; Leukemia; T cell; Relapse; TACL; Nelarabine; NECTAR
• Additional Relevant MeSH Terms: Immune System Diseases; Neoplasms by Histologic Type; Neoplasms; Lymphoproliferative Disorders; Lymphatic Diseases; Immunoproliferative Disorders; Leukemia, Lymphoid; Leukemia; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Precursor T-Cell Lymphoblastic Leukemia-Lymphoma; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Nucleic Acid Synthesis Inhibitors; Enzyme Inhibitors; Antirheumatic Agents; Antimetabolites, Antineoplastic; Antimetabolites; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Antineoplastic Agents, Alkylating; Alkylating Agents; Myeloablative Agonists; Antineoplastic Agents, Phytogenic; Topoisomerase II Inhibitors; Topoisomerase Inhibitors; Dermatologic Agents; Adjuvants, Immunologic; Reproductive Control Agents; Abortifacient Agents, Nonsteroidal; Abortifacient Agents; Folic Acid Antagonists; Cyclophosphamide; Etoposide; Lenograstim; Methotrexate
• Other Study ID Numbers: T2008-002