High Dose Ascorbate With Preoperative Radiation in Patients With Locally Advanced Soft Tissue Sarcomas

Phase 1b/2 Neoadjuvant High Dose Ascorbate With Concurrent Preoperative Radiation in Patients With Locally Advanced Soft Tissue Sarcomas of Extremity, Trunk and Retroperitoneum

This is a single-arm open-label phase Ib/II clinical study assessing the efficacy of concurrent high dose ascorbate in combination with radiotherapy in patients with locally advanced, resectable, high grade sarcomas.

Study Overview

• Status: Completed
• Conditions: Soft Tissue Sarcoma
• Intervention / Treatment: Drug: Ascorbate

Detailed Description

Phase Ib:

The phase Ib portion of this study is to ensure the safety and tolerability of high dose ascorbate in combination with external beam radiation therapy (EBRT) as assessed by incidence of dose-limiting toxicities (DLT). EBRT will be given at the standard dose for resectable soft tissue sarcomas according to the NCCN sarcoma guidelines.2 Patients will receive 50 Gy over 5 weeks, during which time they will be receiving three times a week IV high dose ascorbate. IV ascorbate infusions will be continued until the end of radiation therapy. Surgery will be performed 4-6 weeks from the end of radiation to allow for adequate tissue healing and resolution of acute toxicities.

Phase 2:

The phase 2 part of the study will provide an estimate of the relative treatment effect of pharmacological ascorbate in combination with preoperative EBRT in subjects with locally advanced, resectable, extremity, trunk or retroperitoneal high grade sarcomas, as measured by pathological response rates.

As above, patients will receive the first dose of pharmacological ascorbate intravenously on day 1 of week 1 provided no reactions are seen to the test dose. This will be followed by 3 times a week dosing at Dose 0 until completion of EBRT. Standard doses of radiation for resectable soft tissue sarcomas according to the NCCN sarcoma guidelines will be administered.2 Patients will receive preoperative radiation at a dose of 50 Gy over 5 weeks starting on week 1 day 1. Subjects will be followed either by clinic visit or phone contact every 12 weeks for approximately 24 months after the end of the treatment phase, at which time the initial survival data and disease recurrence will be assessed.

• Study Type: Interventional
• Enrollment (Actual): 25
• Phase: Phase 2; Phase 1

Contacts and Locations

Study Locations

• United States
  • Iowa
    • Iowa City, Iowa, United States, 52242
      • University of Iowa Hospitals and Clinics

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Subject or subject's legally acceptable representative has provided informed consent.

2. Histologically confirmed diagnosis of locally advanced soft tissue sarcoma of extremity, trunk or retroperitoneum that is unresectable with clear wide margins, for which preoperative radiotherapy is considered appropriate

   - Including metastatic (stage IV) disease for which radiotherapy and surgical resection of the primary tumor are indicated.

3. Patients with locally recurrent sarcoma after surgery alone are eligible for enrollment if other inclusion criteria are met.
4. Patients do not have histologic subtypes: GIST, Desmoid, Ewing sarcoma, bone sarcomas and Kaposi sarcoma.
5. Age ≥18 years.
6. Patients with a history of non-melanomatous skin cancer, in situ carcinoma, or low-risk prostate cancer can be enrolled.
7. ECOG performance status </=1.
8. Tolerate one test dose (15g) of ascorbate.

9. Patient must have measurable disease:

   • Tumor size at least >/= 5 cm in the longest diameter as measured by CT scan or MRI for which radiation is feasible and indicated.

Exclusion Criteria:

1. Inadequate organ function within 21 days of Day 1 of study as defined by:

   • Hemoglobin < 9.0 g/dL
   • Absolute neutrophil count (ANC) </= 1500 per mm3
   • Platelet count </= 100,000 per mm3
   • Total bilirubin >/= 1.5 × ULN. Subjects with direct bilirubin < ULN with total bilirubin levels > 1.5 X ULN will not be excluded.
   • Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) > 2.5 × ULN
   • Alkaline phosphatase > 2.5 × ULN
   • PT (or INR) and PTT (or aPTT) >/= 1.5 × ULN
   • Creatinine > 2.0 × ULN
2. G6PD (glucose-6-phosphate dehydrogenase) deficiency.
3. Prior history of symptomatic oxalate kidney stones within the last year.
4. Prior radiation therapy in excess of 20 Gy to the site of the current diagnosis of sarcoma. No overlap with prior radiation fields in excess of 20 Gy is allowed.
5. Prior history of receiving pharmacological ascorbate.
6. Patients actively receiving insulin therapy and needing daily fingerstick for glucose monitoring.
7. Concurrent, clinically significant, active malignancies within two years of study enrollment.
8. Female subjects who are pregnant or breast-feeding, or planning to become pregnant during study treatment and through 3 months after the last dose of study treatment.
9. Female subjects of childbearing potential or male subjects who are unwilling to use 2 highly effective methods of contraception during study treatment and through 3 months after the last dose of study treatment.
10. Currently receiving treatment in another invasive investigational device or drug study, or less than 30 days since ending treatment on another investigational device or drug study(s).
11. Patients who are on the following drugs and cannot have a drug substitution: flecainide, methadone, amphetamines, quinidine, and chlorpropamide. High dose ascorbic acid may affect urine acidification and, as a result, may affect clearance rates of these drugs.
12. Known CNS disease, except for treated brain metastasis: Treated brain metastases are defined as having no evidence of progression or hemorrhage after treatment and no ongoing requirement for dexamethasone, as ascertained by clinical examination and brain imaging (MRI or CT) during the screening period. Anticonvulsants (stable dose) are allowed. Treatment for brain metastases may include whole brain radiotherapy (WBRT), radiosurgery (RS; Gamma Knife, LINAC, or equivalent) or a combination as deemed appropriate by the treating physician. Patients with CNS metastases treated by neurosurgical resection or brain biopsy performed within 3 months prior to Day 1 will be excluded.
13. History of allergic reactions attributed to compounds of similar chemical or biologic composition to ascorbate.
14. Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements.
15. Known HIV-positive and hepatitis B & C individuals. High-dose ascorbate acid is a known CYP450 3A4 inducer, which results in lower serum levels of antiretroviral drugs.
16. Patients who are on warfarin and cannot have a drug substitution or who decline the drug substitution.

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Phase I dose escalation cohort; Participants will receive radiation therapy over 5 weeks, during which time they will be receiving ascorbate infusions three times a week. Ascorbate infusions will be continued until the end of radiation therapy. Surgery will be performed 4-6 weeks from the end of radiation.	Drug: Ascorbate; Phase 1 dose escalation: 75gm IV three times a week Phase II portion: 75gm IV three times a week if no dose limiting toxicities are experienced in the Phase I portion. Otherwise, ascorbate dose will be deescalated to 62.5 gm IV; Other Names: Vitamin C; Pharmacological ascorbate; Ascorbic Acid
Experimental: Phase II Cohort; Participants will receive radiation therapy over 5 weeks, during which time they will be receiving intravenous (IV) ascorbate infusions three times a week. Ascorbate infusions will be continued until the end of radiation therapy. Surgery will be performed 4-6 weeks from the end of radiation.	Drug: Ascorbate; Phase 1 dose escalation: 75gm IV three times a week Phase II portion: 75gm IV three times a week if no dose limiting toxicities are experienced in the Phase I portion. Otherwise, ascorbate dose will be deescalated to 62.5 gm IV; Other Names: Vitamin C; Pharmacological ascorbate; Ascorbic Acid

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants That Experienced Dose Limiting Toxicities (DLTs) Using CTCAE, Version 4.0	To examine the toxicity related to the therapy by measuring the number attributed adverse event (definite, probable or possible) according to CTCAE version 4.0.	Start of treatment up to 4 weeks after the last ascorbate infusion
Number of Participants With Pathologic Tumor Necrosis ≥ 95% Following Concurrent Radiation Therapy and Ascorbate	To estimate the efficacy of neoadjuvant ascorbate and radiotherapy as assessed by the pathological complete response rates (pCR) in subjects with locally advanced high grade soft tissue sarcomas.	Start of treatment up to 6 weeks after the last ascorbate infusion

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Disease Progression as Measured by Time to Disease Progression (TTP)	Time to disease progression (TTP) is defined as the time from enrollment until objective tumor progression including local and distant recurrences.	Enrollment or start of treatment up to 2 years following end of treatment
Overall Response Rate as Measured by RECIST 1.1	Overall response rate (ORR) preoperative as measured by RECIST 1.1 or a later tool for monitoring disease progression.	Enrollment or start of treatment up to 2 years following end of treatment
Overall Survival Estimated Using the Kaplan-Meier Method	Overall survival (OS) rate data gathered through passive chart review, phone call or scheduled follow-up visit and estimated using the Kaplan-Meier Method.	Enrollment or start of treatment up to 2 years following end of treatment
Skin Toxicity	Pathologist to grade radiation related skin toxicity overlying the tumor as compared to historical controls. Binomial exact tests will be utilized to identify differences in wound complication and Grade 3-4 dermatitis rates compared to historical controls.	Within two years following end of treatment
Labile Iron	To measure labile iron using T2* imaging sequence on MRI pre and post ascorbate treatments and compare with serum iron measurements	Within two years following end of treatment
Evaluate Diffusion Weighted Imaging Sequences	To evaluate diffusion weighted imaging sequences on MRI in pre and post treatment tumors and correlate it with necrosis and survival	Within two years following end of treatment

Collaborators and Investigators

• Sponsor: Mohammed Milhem
• Collaborators: University of Iowa
• Investigators: Principal Investigator: Mohammed Milhem, MBBS, University of Iowa

Study record dates

Study Major Dates

• Study Start (Actual): June 27, 2019
• Primary Completion (Actual): June 3, 2022
• Study Completion (Actual): June 2, 2024

Study Registration Dates

• First Submitted: April 13, 2018
• First Submitted That Met QC Criteria: April 23, 2018
• First Posted (Actual): April 26, 2018

Study Record Updates

• Last Update Posted (Actual): June 27, 2024
• Last Update Submitted That Met QC Criteria: June 17, 2024
• Last Verified: June 1, 2024

More Information

Terms related to this study

• Keywords: Sarcoma; Soft tissue
• Additional Relevant MeSH Terms: Neoplasms, Connective and Soft Tissue; Neoplasms by Histologic Type; Neoplasms; Sarcoma; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Protective Agents; Micronutrients; Vitamins; Antioxidants; Ascorbic Acid
• Other Study ID Numbers: 201901810

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No