- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03206021
COZMOS:Phase I/Ib Trial of Combined 5'Azacitidine and Carboplatin for Recurrent/Refractory Pediatric Brain/Solid Tumors (COZMOS)
Phase I/Ib Trial of COmbined 5'aZacitidine and Carboplatin for Recurrent/Refractory Pediatric Brain and Solid Tumors
Study Overview
Status
Intervention / Treatment
Detailed Description
Aberrant DNA methylation is frequently observed in many pediatric solid tumors, but in particularly several entities such as ependymoma, medulloblastoma, embryonal tumor with multilayered rosettes, atypical/teratoid rhabdoid tumor, neuroblastoma and wilm's tumor have promoter hypermethylation. Treatment with DNMTi (DNA methyltransferase inhibitors) agents such as 5-azacytidine has been shown to be safe and efficacious in adult myelodysplastic syndromes, causing significant decreased DNA methylation in blood, with maximum effect at day 15 of each cycle. However, monotherapy with DNMTi has been shown to result in resistance in leukamia's and efficacy in solid tumours is limited. Synergy between DNMTi and platinum agents has shown promise in pre-clinical models including pediatric ependymoma, and in addition, the combination of demethylating agents with carboplatin has provided promising results in platinum resistant ovarian cancers. However, this approach has not been applied to pediatric solid malignancies, which are attractive targets due to their frequent epigenetic dysregulation.
Platinums are the backbone of therapy for most pediatric solid tumors, and as such it is an attractive hypothesis that part of the reason for resistance to upfront therapies is platinum resistance. Specifically, ependymoma's are highly chemoresistant tumors and studies in preclinical models of ependymoma support that this chemoresistance can be overcome with DNMTi.
There is a clear medical need for new therapies, particularly for relapsed solid tumors, specifically brain tumors. Although pre-clinical data from our group and others suggests DNA demethylase inhibitors to be promising therapies for high risk ependymoma, medulloblastoma and ETMR (embryonal tumor with multilayered rosettes), 5'azacitidine monotherapy has been disappointing in clinical studies of adult solid tumours. Previous studies have suggested that platinum therapy can be effectively combined with azacitidine therapy and based on adult studies, maximum demethylation occurs approximately 5-10 days after treatment with 5'azacitidine. As such combination of azacitidine and carboplatin is a rationale therapy for several pediatric brain tumours, particularly those with a hypermethylated phenotype.
Two phases of the study will be conducted. The Phase I will establish the maximum tolerated dose of carboplatin and 5'azacytidine in a rolling 6 design. 5'azacytidine will be administered on Days 1-7 followed by Carboplatin on Day 15. The initial dose level will be 5'Azacytidine 75mg/m2/day for 7 days with Carboplatin administered on Day 15 at AUC (Area under curve) 4. Carboplatin will be dose escalated to a maximum of AUC 6, or de-escalated to AUC 3. The Phase Ib will be an ependymoma specific expansion cohort at the established MTD (maximum tolerated dose), to determine the feasibility and initial efficacy of the combination of carboplatin and 5'azacytidine in patients with recurrent/refractory posterior fossa and supratentorial ependymoma.
Study Type
Enrollment (Actual)
Phase
- Phase 1
Contacts and Locations
Study Locations
-
-
-
Adelaide, Australia
- Women's and Children's Hospital
-
Clayton, Australia
- Monash Children's Hospital
-
Lambton, Australia
- John Hunter Children's Hospital
-
Perth, Australia
- Perth Children's Hospital
-
South Brisbane, Australia
- Queensland CHILDREN'S HOSPITAL
-
Sydney, Australia
- Sydney Children's Hospital
-
Westmead, Australia
- Children's Hospital at Westmead
-
-
Victoria
-
Melbourne, Victoria, Australia
- Royal Children's Hospital Melbourne
-
-
-
-
Alberta
-
Calgary, Alberta, Canada
- Alberta Children's Hospital
-
-
British Columbia
-
Vancouver, British Columbia, Canada
- BC Children's Hospital
-
-
Ontario
-
Hamilton, Ontario, Canada
- McMaster Children's Hospital
-
London, Ontario, Canada
- London Health Sciences Centre
-
Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario
-
Toronto, Ontario, Canada, M5G1X8
- Hospital For Sick Children
-
-
PQ
-
Montréal, PQ, Canada
- Centre Hospitalier Universitaire Sainte-Justine
-
Montréal, PQ, Canada
- Montreal Children's Hospital
-
-
-
-
District of Columbia
-
Washington, District of Columbia, United States, 20010
- Children's National Medical Center
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Greater than the age of 1 year and under age 18 at the time of study enrolment
- Recurrent or refractory brain or solid tumor, including recurrent or refractory ependymoma
- Tissue from diagnosis or resection prior to registration must be available (either flash frozen tissue or an FFPE block)
- Previous therapy with carboplatin will be permitted
- Failed first line treatment (surgery, radiation therapy or chemotherapy) and should not be eligible for treatment with curative potential.
- Be at least 4 weeks from the completion of myelosuppressive chemotherapy and/or biologic agents before starting day 1 of this study treatment
- Be at least 14 days from the completion of radiation therapy and MIBG before starting day 1 of this study treatment
- Be at least 3 months post hematopoetic stem cell rescue following myeloablative therapy before starting day 1 of this study treatment
- Must have visible disease on imaging. Resection of visible disease is permitted while on study after two cycles including achievement of a gross total resection. If a resection is performed while on study, fresh frozen tissue should be submitted for analysis.
- Concurrent medications will be limited to supportive medications/agents including but not limited to anti-emetics, steroids, analgesics and non-enzyme inducing anticonvulsants. Strong inducers of the P450 system will not be permitted. Other concurrent medications require approval of the study Sponsor.
- Ability of the parent and/or child to understand and the willingness to sign a written informed consent document
- Karnofsky ≥ 50 for patients > 16 years of age and Lansky ≥ 50 for patients ≤ 16 years of age (See Appendix I for the Karnofsky-Lansky Scores). 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. Patients with posterior fossa syndrome/cerebellar mutism demonstrating clear improvement post-surgically can be enrolled based on physician discretion
Adequate hepatic, renal, marrow and cardiac function as defined below within 28 days prior to cycle 1 day 1:
- Serum creatinine within normal institutional limits or creatinine clearance greater than 60mL/min
- Serum bilirubin <1.5 times upper limit of institutional normal. Higher levels are acceptable if these can be attributed to active hemolysis or ineffective erythropoiesis
- AST, ALT and Alkaline Phosphatase <3 times upper limit of institutional normal. If liver metastases are present, then <5 times upper limit of normal is permitted.
- Normal QTc interval at screening ECG (baseline echocardiogram is not required)
Adequate marrow function defined below within 14 days prior to cycle 1 day 1:
- Leukocytes greater than or equal to 1000 x106/L
- Absolute neutrophil count greater than or equal to 0.75 x109/L
- Platelets greater than or equal to 75 x109/L
- Hemoglobin greater than or equal to 10g/dL (may be transfused).
Exclusion Criteria:
- Female patient who is pregnant or breast feeding (Lactating females must agree not to breast feed while taking azacitidine) or with childbearing potential and not willing to use a double method of contraception up to 3 months after the end of study treatment. Male patient who is not willing to use a barrier method of contraception up to 6 months after the end of study treatment.
- Patients may not be receiving any other investigational agents within 30 days prior to day 1 of protocol treatment
- Prior therapy with a DNA demethylase inhibitor
- Evidence of cardiac toxicity (shortening fraction below 28%; shortening fraction measures and ratios the change in the diameter of the left ventricle between the contracted and relaxed states)
- Abnormal coagulation parameters (PT >15 seconds, PTT>40 seconds, and/or INR >1.5)
Significant active cardiac disease within the previous 6 months including:
- NYHA class 3 or 4 CHF
- Unstable angina
- Myocardial infarction
- Known or suspected hypersensitivity to azacitidine or mannitol carboplatin
- Previous carboplatin exposure is not an exclusion criteria but previous allergic reaction to carboplatin will exclude enrolment.
- Patient must not require use of enzyme inducing anticonvulsants; patients who are receiving an enzyme inducing anticonvulsant must be able to switch to a non-enzyme inducing anticonvulsant such as Levetiracetam, Clobazam, Lacosamide, Valproate or Topiramate at least 2 weeks prior to study enrolment.
- Uncontrolled systemic fungal, bacterial or viral infection (defined as ongoing signs/symptoms related the infection without improvement despite appropriate antibiotics, antiviral therapy and/or other treatment)
- Active viral infection with HIV or hepatitis type B or C Patients with advanced malignant hepatic tumors
- Patients with advanced malignant hepatic tumors
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Non-Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Phase I Dose-escalation
5'azacytidine will be administered on Days 1-7 at a dose of 75mg/m2/day, followed by escalating doses of Carboplatin on Day 14 in a rolling 6 design.
Carboplatin will be dosed initially at AUC 4. Dose level -1 will reduce 5'azacytidine to 50mg/m2/day.
|
Dose escalation of carboplatin combined with 5'azacytidine
Other Names:
|
Experimental: Posterior Fossa Ependymoma Expansion Arm
5'azacytidine will be administered on days 1-7 and carboplatin will be administered on day 14 at the maximum tolerated dose achieved in the Phase I dose escalation to 20 patients with recurrent/refractory posterior fossa ependymoma.
|
Dose escalation of carboplatin combined with 5'azacytidine
Other Names:
|
Experimental: Recurrent Brain and Solid Tumour Expansion Arm
5'azacytidine will be administered on days 1-7 and carboplatin will be administered on day 14 at the maximum tolerated dose achieved in the Phase I dose escalation up to 12 patients with recurrent/refractory brain and solid tumour.
|
Dose escalation of carboplatin combined with 5'azacytidine
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Establish maximum tolerated dose of carboplatin in combination with 5'azacytidine
Time Frame: 1 year
|
Number of participants with treatment-related adverse events as assessed by the CTCAE4.0
|
1 year
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Characterization of the pharmacodynamics of 5'-azacitidine in combination with carboplatin
Time Frame: 3 years
|
Plasma pharmacodynamics will be assessed using methylation profiling of whole blood collected before and after administration of 5'Azacytidine, and after administration of carboplatin.
|
3 years
|
Assessment of intratumoral DNA demethylation as a preliminary indication of biological efficacy of this combination.
Time Frame: 3 years
|
Where feasible, two cycles of 5'azacytidine and carboplatin will be administered prior to a biopsy and/or gross total resection, and intratumoral DNA methylation profiles will be generated to determine the degree of intratumoral DNA demethylation.
|
3 years
|
Assessment of disease response as a preliminary indication of efficacy of this combination against recurrent, refractory pediatric brain and solid tumors
Time Frame: 3 years
|
Response to therapy, particularly in ependymoma will be evaluated to determine if a larger Phase II study is warranted.
|
3 years
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Eric Bouffet, MD, The Hospital for Sick Children
- Principal Investigator: Vijay Ramaswamy, MD PhD FRCPC, The Hospital for Sick Children
- Principal Investigator: Peter Dirks, MD PhD FRCSC, The Hospital for Sick Children
- Principal Investigator: Daniel Morgenstern, MD PhD, The Hospital for Sick Children
Publications and helpful links
General Publications
- Mack SC, Witt H, Piro RM, Gu L, Zuyderduyn S, Stutz AM, Wang X, Gallo M, Garzia L, Zayne K, Zhang X, Ramaswamy V, Jager N, Jones DT, Sill M, Pugh TJ, Ryzhova M, Wani KM, Shih DJ, Head R, Remke M, Bailey SD, Zichner T, Faria CC, Barszczyk M, Stark S, Seker-Cin H, Hutter S, Johann P, Bender S, Hovestadt V, Tzaridis T, Dubuc AM, Northcott PA, Peacock J, Bertrand KC, Agnihotri S, Cavalli FM, Clarke I, Nethery-Brokx K, Creasy CL, Verma SK, Koster J, Wu X, Yao Y, Milde T, Sin-Chan P, Zuccaro J, Lau L, Pereira S, Castelo-Branco P, Hirst M, Marra MA, Roberts SS, Fults D, Massimi L, Cho YJ, Van Meter T, Grajkowska W, Lach B, Kulozik AE, von Deimling A, Witt O, Scherer SW, Fan X, Muraszko KM, Kool M, Pomeroy SL, Gupta N, Phillips J, Huang A, Tabori U, Hawkins C, Malkin D, Kongkham PN, Weiss WA, Jabado N, Rutka JT, Bouffet E, Korbel JO, Lupien M, Aldape KD, Bader GD, Eils R, Lichter P, Dirks PB, Pfister SM, Korshunov A, Taylor MD. Epigenomic alterations define lethal CIMP-positive ependymomas of infancy. Nature. 2014 Feb 27;506(7489):445-50. doi: 10.1038/nature13108. Epub 2014 Feb 19.
- Ramaswamy V, Hielscher T, Mack SC, Lassaletta A, Lin T, Pajtler KW, Jones DT, Luu B, Cavalli FM, Aldape K, Remke M, Mynarek M, Rutkowski S, Gururangan S, McLendon RE, Lipp ES, Dunham C, Hukin J, Eisenstat DD, Fulton D, van Landeghem FK, Santi M, van Veelen ML, Van Meir EG, Osuka S, Fan X, Muraszko KM, Tirapelli DP, Oba-Shinjo SM, Marie SK, Carlotti CG, Lee JY, Rao AA, Giannini C, Faria CC, Nunes S, Mora J, Hamilton RL, Hauser P, Jabado N, Petrecca K, Jung S, Massimi L, Zollo M, Cinalli G, Bognar L, Klekner A, Hortobagyi T, Leary S, Ermoian RP, Olson JM, Leonard JR, Gardner C, Grajkowska WA, Chambless LB, Cain J, Eberhart CG, Ahsan S, Massimino M, Giangaspero F, Buttarelli FR, Packer RJ, Emery L, Yong WH, Soto H, Liau LM, Everson R, Grossbach A, Shalaby T, Grotzer M, Karajannis MA, Zagzag D, Wheeler H, von Hoff K, Alonso MM, Tunon T, Schuller U, Zitterbart K, Sterba J, Chan JA, Guzman M, Elbabaa SK, Colman H, Dhall G, Fisher PG, Fouladi M, Gajjar A, Goldman S, Hwang E, Kool M, Ladha H, Vera-Bolanos E, Wani K, Lieberman F, Mikkelsen T, Omuro AM, Pollack IF, Prados M, Robins HI, Soffietti R, Wu J, Metellus P, Tabori U, Bartels U, Bouffet E, Hawkins CE, Rutka JT, Dirks P, Pfister SM, Merchant TE, Gilbert MR, Armstrong TS, Korshunov A, Ellison DW, Taylor MD. Therapeutic Impact of Cytoreductive Surgery and Irradiation of Posterior Fossa Ependymoma in the Molecular Era: A Retrospective Multicohort Analysis. J Clin Oncol. 2016 Jul 20;34(21):2468-77. doi: 10.1200/JCO.2015.65.7825. Epub 2016 Jun 6.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Pathologic Processes
- Nervous System Diseases
- Neoplasms by Histologic Type
- Neoplasms by Site
- Neoplasms, Glandular and Epithelial
- Disease Attributes
- Glioma
- Neoplasms, Neuroepithelial
- Neuroectodermal Tumors
- Neoplasms, Germ Cell and Embryonal
- Neoplasms, Nerve Tissue
- Nervous System Neoplasms
- Neoplasms
- Recurrence
- Central Nervous System Neoplasms
- Ependymoma
- Molecular Mechanisms of Pharmacological Action
- Enzyme Inhibitors
- Antimetabolites, Antineoplastic
- Antimetabolites
- Antineoplastic Agents
- Carboplatin
- Azacitidine
Other Study ID Numbers
- OZM-077
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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.
Clinical Trials on Childhood Solid Tumor
-
Anjali PawarRecruitingSolid Tumor | Solid Tumor, ChildhoodUnited States
-
Institut CurieRecruitingChemotherapy Effect | Solid Tumor, Adult | Solid Tumor, ChildhoodFrance
-
Institut National de la Santé Et de la Recherche...National Research Agency, France; Ligue contre le cancer, France; Programme hospitalier...Recruiting
-
Centre Oscar LambretBristol-Myers Squibb; Anticancer Fund, Belgium; CTD-CNO; ECS-Progastrin SASuspendedChildhood Solid TumorFrance, Belgium
-
Activartis BiotechCompletedChildhood Solid TumorAustria
-
Hospital Infantil Universitario Niño Jesús, Madrid...SPANISH HEALTH RESEARCH FUND (FIS)TerminatedChildhood Solid TumorSpain
-
Centre for Research and Technology HellasHannover Medical School; Brno University Hospital; Universität des SaarlandesRecruitingSolid Tumor, Childhood | Leukemia, ChildhoodCzechia, Germany
-
Australian & New Zealand Children's Haematology...Medical Research Future Fund; Minderoo Foundation; Children's Cancer Institute...RecruitingChildhood Cancer | Relapsed Cancer | Refractory Cancer | Childhood Leukemia | Childhood Solid Tumor | Childhood Brain TumorAustralia
-
Memorial Sloan Kettering Cancer CenterTerminatedSolid Tumor | Solid Carcinoma | Solid Tumor, ChildhoodUnited States
-
Wake Forest University Health SciencesNational Cancer Institute (NCI)RecruitingCollection and Storage of Tissue Samples From Patients Undergoing Surgery For Suspected Solid TumorsUnspecified Childhood Solid Tumor, Protocol Specific | Unspecified Adult Solid Tumor, Protocol SpecificUnited States
Clinical Trials on 5 Azacytidine
-
The University of Texas Health Science Center,...RecruitingRecurrent EpendymomaUnited States
-
M.D. Anderson Cancer CenterNational Cancer Institute (NCI)TerminatedAcute Myeloid Leukemia Arising From Previous Myelodysplastic Syndrome | Recurrent Acute Myeloid Leukemia | Refractory Acute Myeloid Leukemia | Acute Biphenotypic LeukemiaUnited States
-
Albert Einstein College of MedicineNational Cancer Institute (NCI)CompletedRecurrent Non-Small Cell Lung Carcinoma | Stage IV Non-Small Cell Lung CancerUnited States
-
M.D. Anderson Cancer CenterNational Cancer Institute (NCI)CompletedChronic Myelomonocytic Leukemia | Myelodysplastic Syndrome | High Risk Myelodysplastic Syndrome | Acute Myeloid Leukemia With Multilineage Dysplasia | Blasts 20-30 Percent of Bone Marrow Nucleated Cells | Blasts 20-30 Percent of Peripheral Blood White Cells | IPSS Risk Category Intermediate-2United States
-
Uma BorateSumitomo Pharma Oncology, Inc.CompletedAcute Myeloid Leukemia | Secondary Acute Myeloid Leukemia | Therapy-Related Acute Myeloid LeukemiaUnited States
-
National Cancer Institute (NCI)CompletedRecurrent Lung Non-Small Cell Carcinoma | Stage IV Lung Non-Small Cell Cancer AJCC v7United States
-
M.D. Anderson Cancer CenterNational Cancer Institute (NCI)RecruitingChronic Myelomonocytic Leukemia | Myelodysplastic Syndrome | Recurrent Chronic Myelomonocytic Leukemia | Recurrent Myelodysplastic Syndrome | Myeloproliferative Neoplasm | Recurrent Myeloproliferative NeoplasmUnited States
-
M.D. Anderson Cancer CenterNational Cancer Institute (NCI)RecruitingPrimary Myelofibrosis | Myelodysplastic/Myeloproliferative Neoplasm, Unclassifiable | Polycythemia Vera, Post-Polycythemic Myelofibrosis Phase | Myelofibrosis Transformation in Essential ThrombocythemiaUnited States
-
National Cancer Institute (NCI)CompletedRecurrent Acute Myeloid Leukemia | Refractory Acute Myeloid Leukemia | Leukemia Cutis | Acute Myeloid Leukemia With t(9;11)(p21.3;q23.3); MLLT3-MLLUnited States
-
M.D. Anderson Cancer CenterNational Cancer Institute (NCI)CompletedAcute Myeloid Leukemia | Myelodysplastic Syndrome | Myeloproliferative Neoplasm | Myelodysplastic/Myeloproliferative NeoplasmUnited States