Rituximab for Patients With Relapsed Acute Lymphoblastic Leukemia (Rituximab)

November 26, 2014 updated by: Todd M. Cooper, Emory University

A Trial of Rituximab Combined With Prednisone/Ifosfamide/Etoposide for Relapsed Acute Lymphoblastic Leukemia (ALL)

This is a pilot study of a drug called rituximab used together with other drugs-prednisone, etoposide, and ifosfamide. Prednisone, etoposide, and ifosfamide have been used as part of standard chemotherapy for relapsed Acute Lymphoblastic Leukemia (ALL). Rituximab was approved by the Food and Drug Administration in 1997. However, the use of rituximab with prednisone, etoposide, and ifosfamide in pediatric patients with relapsed or refractory ALL is considered experimental.

This study is for patients who have ALL in second or greater relapse, or in first relapse and not responding to treatment.

The goals of this study are:

  • To see if using rituximab with prednisone, etoposide, and ifosfamide is beneficial to leukemia treatment
  • To find out what side effects this combination of drugs can cause

A total of 15 participants (30 years old or younger) will be enrolled, over a period of 2 years.

Study Overview

Status

Terminated

Intervention / Treatment

Detailed Description

Rationale for study design:

The combination of etoposide and ifosfamide is a reinduction regimen used in many previous studies for pediatric B lineage acute lymphoblastic leukemia (ALL). It does not use anthracyclines, and therefore can be safely used in patients at risk for cardiac toxicity due to previous anthracycline use.

Previous studies in adult patients with ALL have demonstrated safety and efficacy with the addition of rituximab to other induction regimens. Rituximab is an anti-CD20 monoclonal antibody. Approximately one-half of pediatric cases of B precursor ALL express the CD20 antigen on the leukemic blasts. The use of rituximab provides a potential target for CD20 positive cells, therefore improving the rates of cytotoxicity associated with the chemotherapy. Rituximab has been previously utilized in many pediatric and adult regimens in combination with other chemotherapeutic agents, and is expected to be safe with the combination of etoposide and ifosfamide. However, since it has never been studied with this combination of chemotherapy, strict stopping rules are in place to ensure that it is a safe combination.

A recent study demonstrated upregulation of CD20 expression on leukemic blasts exposed to one week of prednisone therapy. This increase in expression occurred in the majority of B-ALL patient samples, regardless of whether the patient initially expressed CD20 on the surface of the leukemic blasts. In those samples with upregulation of CD20 treated with rituximab, cytotoxicity from rituximab was more successful than in samples with a smaller percentage of CD20 expression.

Therefore, prednisone will be given for two weeks in combination with etoposide and ifosfamide. It is hoped that the percentage of leukemic blasts expressing CD20 will increase with this combination of medications, allowing the rituximab to be more effective when given weekly starting on day 8 of therapy. To better understand this process, samples of blood and bone marrow will be collected to quantify CD20 expression and the amount of leukemia present at multiple time points during the month of study duration.

Study Type

Interventional

Enrollment (Actual)

1

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

    • Georgia
      • Atlanta, Georgia, United States, 30322
        • Children's Healthcare of Atlanta
      • Atlanta, Georgia, United States, 30322
        • Emory University
    • Missouri
      • Kansas City, Missouri, United States, 64108
        • The Children's Mercy Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

1 year to 30 years (Child, Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  1. Age: Patients must be 1-30 years of age at initial diagnosis.
  2. Diagnosis: Patients must have histologically-confirmed relapsed/refractory Acute Lymphoblastic Leukemia (ALL).
  3. Disease Status:Patients must be in

    • second or greater bone marrow relapse (≥ 25% blasts by morphology), or
    • refractory to reinduction therapy with one or more attempts at remission reinduction (end of reinduction blasts ≥ 5% by morphology and/or end of reinduction MRD ≥ 1% by flow cytometry).
    • Patients with combined bone marrow and extramedullary relapse are eligible (CNS 3 patients excluded).
  4. Performance Status: Patients must have a performance status of ≥50 from the Lansky Scale if <10 years or ≥ 50 or from the Karnofsky Scale if ≥ 10 years. Patients who are unable to walk because of paralysis, but who are up in a wheelchair will be considered ambulatory for the purpose of assessing the performance score.
  5. Prior Therapy: Patients must have fully recovered from the acute toxic effects of all prior chemotherapy, immunotherapy, or radiotherapy prior to entering this study and meet time restrictions from end of prior therapy as stated below:

    • Myelosuppressive chemotherapy: must not have received within 2 weeks of entry onto this study (4 weeks in the case of nitrosurea containing therapy). Patients who relapse while receiving ALL maintenance chemotherapy will not be required to have a waiting period before entry onto this study. Cytoreduction with hydroxyurea can be initiated and continued for up to 24 hours prior to the start of therapy.
    • XRT: must be ≥ 4 weeks since the completion of radiation therapy.
    • Study specific limitations: must be ≥ 7 days since the completion of corticosteroid therapy.
    • Growth factor(s): Must not have received any hematopoietic growth factors (GCSF, Neulasta, or GMCSF) within 7 days of study entry.
    • Stem Cell Transplant: Patients must be at least two months from stem cell transplant, must be off immunosuppressives, and must have no evidence of active graft versus host disease.

    Biologic (anti-neoplastic agent): At least 7 days since the completion of therapy with a biologic agent. For agents that have known adverse events occurring beyond 7 days after administration, this period must be extended beyond the time during which adverse events are known to occur. The duration of this interval must be discussed with the study chair.

  6. Institutional review board approval.
  7. Individual informed consent per local guidelines and federal and state regulations.
  8. Organ Function: All patients must have adequate organ function defined as:

    • Renal Function: Patients must have a calculated creatinine clearance or radioisotope GFR ≥ 70mL/min/1.73m2 or a normal serum creatinine based on age/gender.
    • Liver Function: Total bilirubin ≤ 1.5 x institutional upper limit of normal (ULN) for age, AND SGPT (ALT) ≤ 5 x institutional ULN for age
    • Cardiac Function: Ejection fraction > 50% on echocardiogram or MUGA Scan, OR Shortening fraction ≥ 27% on echocardiogram or MUGA Scan
    • Reproductive Function: Due to potential teratogenic effects of the drugs, all post-menarchal female patients must have a negative serum beta HCG prior to study enrollment. In addition, all patients of childbearing or child-fathering potential must agree to a medically acceptable form of contraception, including abstinence, while on study.

Exclusion Criteria:

  1. Patients with an active and uncontrolled infection, defined as need for pressors, and/or positive cultures for 24 hours.
  2. Patients recovering from allogeneic bone marrow transplantation who are still on immunosupressants.
  3. Pregnant or lactating females. Women of childbearing age will agree to use contraception during the protocol.
  4. Patients currently receiving other investigational agents, medications, or supplements with a known anti-leukemic effect.
  5. Patients who, in the opinion of the investigator, will not be able to comply with safety monitoring requirements of the study.
  6. Patients with reactivation of hepatitis B prior to starting therapy.
  7. Patients who are HIV positive.
  8. Patients must not have CNS 3 involvement.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: N/A
  • Interventional Model: Single Group Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: rituximab
study drug given
375 mg/m2/dose on days 8, 15, 22, and 29 (diluted in NS to a final concentration of 1 mg/ml for ease of administration). (Premedicate with Acetaminophen 15 mg/kg po (max 650 mg) and Diphenhydramine 1 mg/kg IV/PO (max 50 mg)).

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
4 Month Event Free Survival (EFS)
Time Frame: one year after enrollment
To estimate the 4 month EFS after therapy with rituximab and cytotoxic chemotherapy (prednisone/etoposide/ifosfamide) in patients with second relapse/refractory ALL.
one year after enrollment
Toxicities of Rituximab
Time Frame: two months after treatment
To describe the toxicities of rituximab in addition to prednisone, etoposide, and ifosfamide.
two months after treatment
Remission Induction Rate
Time Frame: one month
To estimate the remission induction rate of the addition of rituximab to cytotoxic chemotherapy (prednisone/etoposide/ifosfamide) in patients with second relapse/refractory ALL.
one month

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Minimal Residual Disease
Time Frame: one month after treatment
To perform serial minimal residual disease (MRD) measurements to provide an objective determination of the effectiveness of this therapy.
one month after treatment
Prednisone Effect
Time Frame: one month after treatment
To correlate the effect of prednisone on CD20 expression using serial measurements of CD20 expression in leukemic blasts.
one month after treatment

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Principal Investigator: Todd Cooper, DO, Emory University/Children's Healthcare of Atlanta

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

September 1, 2010

Primary Completion (Actual)

October 1, 2012

Study Completion (Actual)

October 1, 2012

Study Registration Dates

First Submitted

October 23, 2010

First Submitted That Met QC Criteria

October 28, 2010

First Posted (Estimate)

October 29, 2010

Study Record Updates

Last Update Posted (Estimate)

December 1, 2014

Last Update Submitted That Met QC Criteria

November 26, 2014

Last Verified

November 1, 2014

More Information

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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