Extensive Stage Lung Small Cell Carcinoma, Recurrent Lung Small Cell Carcinoma
Conditions
Brief summary
This partially randomized phase I/II trial studies the side effects and best dose of sunitinib malate and to see how well it works when given together with cisplatin or carboplatin and etoposide in treating patients with extensive-stage small cell lung cancer. Drugs used in chemotherapy, such as cisplatin, carboplatin, and etoposide, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Sunitinib malate may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth and by blocking blood flow to the tumor. It is not yet known whether cisplatin or carboplatin and etoposide are more effective when given with or without sunitinib malate in treating small cell lung cancer.
Detailed description
PRIMARY OBJECTIVES: I. To determine the phase II dose for sunitinib (sunitinib malate) combined with cisplatin and etoposide. (Phase IB) II. To compare the progression-free survival of patients with extensive stage small cell lung cancer treated with cisplatin or carboplatin and etoposide followed by maintenance sunitinib to patients receiving the same chemotherapy followed by placebo. (Phase II) SECONDARY OBJECTIVES: I. To assess the single agent response rate for sunitinib given as monotherapy after chemotherapy. (Phase II) II. To assess the overall survival of patients treated with cisplatin or carboplatin and etoposide followed by sunitinib. (Phase II) III. To evaluate the toxicity and tolerability of maintenance sunitinib after cisplatin or carboplatin and etoposide. (Phase II) IV. To determine the association between vascular endothelial growth factor (VEGF) plasma levels and tumor response. (Phase II) OUTLINE: This is a phase I, dose-escalation study of sunitinib malate followed by a randomized phase II study. PHASE I (close to accrual 5/17/08): COMBINATION THERAPY: Patients receive cisplatin or carboplatin intravenously (IV) on day 1, etoposide IV on days 1-3, and sunitinib malate orally (PO) once daily (QD) on days 1-14. Treatment repeats every 21 days for up to 6 courses in the absence of disease progression or unacceptable toxicity. MAINTENANCE THERAPY: Patients receive sunitinib malate PO alone QD. Treatment continues in the absence of disease progression or unacceptable toxicity. PHASE II: COMBINATION THERAPY: Patients receive cisplatin or carboplatin and etoposide as in Phase I. Treatment repeats every 21 days for up to 6 courses in the absence of disease progression or unacceptable toxicity. MAINTENANCE THERAPY: Beginning 3-8 weeks after completion of combination chemotherapy or \>= 4 courses of combination therapy, patients with a responding or stable disease are randomized to 1 of 2 treatment arms. All patients must be euthyroid before starting on maintenance therapy. ARM I: Patients receive sunitinib malate PO QD. Courses repeat every 3 weeks in the absence of disease progression or unacceptable toxicity. ARM II: Patients receive placebo PO QD. Courses repeat every 3 weeks in the absence of disease progression or unacceptable toxicity. Patients with disease progression may cross over to Arm I. After completion of study treatment, patients are followed up every 3 months for 1 year and then every 6 months for 2 years.
Interventions
DRUGCarboplatin
Given IV
DRUGCisplatin
Given IV
DRUGEtoposide
Given IV
OTHERLaboratory Biomarker Analysis
Correlative studies
OTHERPlacebo Administration
Given PO
DRUGSunitinib Malate
Given PO
Sponsors
National Cancer Institute (NCI)
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Investigator)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* All patients must have histologically or cytologically documented small cell lung cancer * Eligible disease stages: the extensive disease classification for this protocol includes all patients with disease sites not defined as limited stage; limited stage disease category includes patients with disease restricted to one hemithorax with regional lymph node metastases, including hilar, ipsilateral and contralateral mediastinal, and/or ipsilateral supraclavicular nodes; extensive stage patients are defined as those patients with extrathoracic metastatic, malignant pleural effusion, bilateral or contralateral supraclavicular adenopathy or contralateral hilar adenopathy * All patients must have measurable disease: * Measurable disease is defined as at least one lesion that can be accurately measured in at least one dimension (longest diameter to be recorded) as \>= 20 mm with conventional techniques or as \>= 10 mm with spiral computed tomography (CT) scan * Lesions that are considered non-measurable, which would make the patient not eligible, include the following: * Bone lesions * Leptomeningeal disease * Ascites * Pleural/pericardial effusion * Lymphangitis cutis/pulmonis * Abdominal masses that are not confirmed and followed by imaging techniques * Cystic lesions * No prior chemotherapy for small cell lung cancer (SCLC) * Radiation therapy must have been completed at least one week before initiation of protocol therapy * Common Toxicity Criteria (CTC) performance status: * Phase IB: 0-1 * Phase II: 0-2 * No "currently active" second malignancy other than non-melanoma skin cancers * No history of brain metastases, spinal cord compression, or carcinomatous meningitis * No ongoing cardiac dysrhythmias, atrial fibrillation, or QTc interval \>= 500 msec; the use of agents with proarrhythmic potential (e.g., quinidine, procainamide, disopyramide, sotalol, probucol, pedridel, haloperidol, risperidone, indapamide, flecainide) is not recommended while on protocol therapy * Patients with class I New York Heart Association (NYHA) are eligible; patients with a history of class II NYHA are eligible, provided they meet the following criteria: * Patients with a history of class II heart failure who are asymptomatic on treatment * Patients with prior anthracycline exposure * Patients who have received central thoracic radiation that included the heart in the radiotherapy port * Patients with a history of class III or IV NYHA heart failure within 12 months prior to registration are not eligible * Additionally, no myocardial infarction, severe/unstable angina, coronary/peripheral artery bypass graft or stenting, cerebrovascular accident including transient ischemic attack, or pulmonary embolism within the last year * Patients with hypertension that cannot be controlled by medications (\> 150/100 mmHg despite optimal medical therapy) are not eligible * Patients who require use of therapeutic doses of coumarin-derivative anticoagulants such as warfarin are excluded, although doses of up to 2 mg daily are permitted for prophylaxis of thrombosis; Note: Low molecular weight heparin is permitted provided the patient's prothrombin time (PT) international normalized ratio (INR) is =\< 1.5 * No evidence of hemoptysis within 4 weeks prior to starting study treatment; patients with blood-tinged or blood streaked sputum will be permitted on study if the hemoptysis amounts to less than 5 mL of blood per episode and less than 10 mL of blood per 24-hour period in the best estimate of the investigator * None of the following within 28 days of treatment: abdominal fistula, gastrointestinal perforation, intra-abdominal abscess, serious or non-healing wound, ulcer, or bone fracture * The use of the following specific inhibitors and inducers of cytochrome p450, family 3, subfamily A, polypeptide 4 (CYP3A4) is not permitted; the following inhibitors of CYP3A4 are prohibited within 7 days before and during treatment with sunitinib: azole antifungals (ketoconazole, itraconazole), diltiazem, clarithromycin, erythromycin, verapamil, delavirdine, and human immunodeficiency virus (HIV) protease inhibitors (indinavir, saquinavir, ritonavir, atazanavir, nelfinavir); the following inducers of CYP3A4 are prohibited within 12 days before beginning and during treatment with sunitinib: rifampin, rifabutin, carbamazepine, phenobarbital, phenytoin, St. John's Wort, efavirenz, tipranavir * Other inhibitors and inducers of CYP3A4 may be used if necessary, but there use is discouraged * Non-pregnant and non-nursing * Granulocytes \>= 1,500/ul * Platelets \>= 100,000/ul * Creatinine clearance \>= 70 ml/min * Total bilirubin =\< 1.5 mg/dl * Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =\< 2.5 x upper limit of normal (ULN) (patients w/ liver metastases may have AST/ALT =\< 5 x ULN) * Partial thromboplastin time (PTT) =\< 1.5 x ULN
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Maximum Tolerated of Sunitinib Combined With Cisplatin and Etoposide (Phase I) | 21 days | The maximum tolerated dose is defined at the highest sunitinib dose at which less than one third of participants develop a dose limiting toxicity (DLT). A DLT is defined as: delay of beginning cycle 2 of chemotherapy by \> 7 days due to neutropenia, grade 4 hematologic toxicity lasting greater than 1 week (chemotherapy alone would be expected to cause significant grade 4 hematologic toxicity) or grade 3 or 4 nonhematologic toxicity (excluding grade 3 or 4 fatigue if the patient is found to be hypothyroid and responds to fatigue \< grade 3 with thyroid replacement therapy). |
| Progression-free Survival (Phase II) | Up to 3 years | Progression free survival (PFS) was defined as the time from maintenance randomization to progression or death of any cause. Progression free and alive patients were censored at the date of last follow-up. The median PFS with 95% CI was estimated using the Kaplan Meier method. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Overall Survival | Up to 3 years | Overall survival (OS) was defined as the time from randomization to death of any cause. Surviving patients were censored at the date of last follow-up. The median OS with 95% CI was estimated using the Kaplan Meier method. |
| Number of Participants With Overall Tumor Response | Up to 3 years | Response was defined using Response Evaluation Criteria In Solid Tumors (RECIST) criteria: Complete Response (CR): disappearance of all target lesions; Partial Response (PR) 30% decrease in sum of longest diameter of target lesions; Progressive Disease (PD): 20% increase in sum of longest diameter of target lesions; Stable Disease (SD): small changes that do not meet above criteria. Overall tumor response is the total number of CR and PRs. |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORNeal E Ready
Alliance for Clinical Trials in Oncology
Participant flow
Recruitment details
Between March 2007 and December 2011, 156 participants were recruited.
Participants by arm
| Arm | Count |
|---|---|
| Phase I Participants will receive the following combination chemotherapy for 6 cycles (21 days):
Cisplatin 80 mg/m\^2 by IV over 1 hour on day 1 every cycle Etoposide 100 mg/m\^2 by IV over 1 hour on days 1, 2, and 3 every cycle Sunitinib 25 mg oral, daily days 1-14 every cycle
Maintenance: Following 6 cycles of combination chemotherapy, start sunitinib at 150 mg on day 1, then 37.5 daily until disease progression. | 12 |
| Arm I (Combination Chemotherapy + Sunitinib Maintenance) Participants will receive the following combination chemotherapy for 4-6 cycles (21 days):
Cisplatin 80 mg/m\^2 by IV over 1 hour on day 1 every cycle OR Carboplatin AUC = 5\* by IV Etoposide 100 mg/m\^2 by IV over 1 hour on days 1, 2, and 3 every cycle
Maintenance: Following 4-6 cycles of combination chemotherapy, start sunitinib at 150 mg on day 1, then 37.5 daily until disease progression. | 44 |
| Arm II (Combination Chemotherapy + Placebo Maintenance) Participants will receive the following combination chemotherapy for 4-6 cycles (21 days):
Cisplatin 80 mg/m\^2 by IV over 1 hour on day 1 every cycle OR Carboplatin AUC = 5\* by IV Etoposide 100 mg/m2 by IV over 1 hour on days 1, 2, and 3 every cycle
Maintenance: Following 4-6 cycles of combination chemotherapy, start placebo at 150 mg on day 1, then 37.5 daily until disease progression. | 41 |
| Total | 97 |
Baseline characteristics
| Characteristic | Total | Phase I | Arm II (Combination Chemotherapy + Placebo Maintenance) | Arm I (Combination Chemotherapy + Sunitinib Maintenance) |
|---|---|---|---|---|
| Age, Continuous | 60 years | 57 years | 61 years | 60 years |
| Chemotherapy Agent Carboplatin | NA participants | NA participants | 30 participants | 32 participants |
| Chemotherapy Agent Cisplatin | NA participants | NA participants | 11 participants | 12 participants |
| Number of combination chemotherapy cycles < 6 cycles | NA participants | NA participants | 9 participants | 12 participants |
| Number of combination chemotherapy cycles 6 cycles | NA participants | NA participants | 32 participants | 32 participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 4 Participants | 0 Participants | 1 Participants | 3 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 93 Participants | 12 Participants | 40 Participants | 41 Participants |
| Region of Enrollment United States | 97 participants | 12 participants | 41 participants | 44 participants |
| Sex: Female, Male Female | 51 Participants | 4 Participants | 21 Participants | 26 Participants |
| Sex: Female, Male Male | 46 Participants | 8 Participants | 20 Participants | 18 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| other Total, other adverse events | 41 / 43 | 38 / 41 |
| serious Total, serious adverse events | 12 / 43 | 9 / 41 |
Outcome results
Primary
Maximum Tolerated of Sunitinib Combined With Cisplatin and Etoposide (Phase I)
The maximum tolerated dose is defined at the highest sunitinib dose at which less than one third of participants develop a dose limiting toxicity (DLT). A DLT is defined as: delay of beginning cycle 2 of chemotherapy by \> 7 days due to neutropenia, grade 4 hematologic toxicity lasting greater than 1 week (chemotherapy alone would be expected to cause significant grade 4 hematologic toxicity) or grade 3 or 4 nonhematologic toxicity (excluding grade 3 or 4 fatigue if the patient is found to be hypothyroid and responds to fatigue \< grade 3 with thyroid replacement therapy).
Time frame: 21 days
Population: Due to safety concerns, the study committee discontinued sunitinib from combination chemotherapy to study single agent sunitinib in the maintenance setting.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Cohort 1 | Maximum Tolerated of Sunitinib Combined With Cisplatin and Etoposide (Phase I) | 25 mg/day |
Primary
Progression-free Survival (Phase II)
Progression free survival (PFS) was defined as the time from maintenance randomization to progression or death of any cause. Progression free and alive patients were censored at the date of last follow-up. The median PFS with 95% CI was estimated using the Kaplan Meier method.
Time frame: Up to 3 years
Population: Participants who were randomized to maintenance were analyzed.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Cohort 1 | Progression-free Survival (Phase II) | 3.7 months |
| Cohort 2 | Progression-free Survival (Phase II) | 2.1 months |
p-value: 0.0270% CI: [1.27, 2.08]Log Rank
Secondary
Number of Participants With Overall Tumor Response
Response was defined using Response Evaluation Criteria In Solid Tumors (RECIST) criteria: Complete Response (CR): disappearance of all target lesions; Partial Response (PR) 30% decrease in sum of longest diameter of target lesions; Progressive Disease (PD): 20% increase in sum of longest diameter of target lesions; Stable Disease (SD): small changes that do not meet above criteria. Overall tumor response is the total number of CR and PRs.
Time frame: Up to 3 years
Population: Participants who were randomized to maintenance were analyzed.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Cohort 1 | Number of Participants With Overall Tumor Response | Complete Response | 3 participants |
| Cohort 1 | Number of Participants With Overall Tumor Response | Partial Response | 4 participants |
| Cohort 2 | Number of Participants With Overall Tumor Response | Complete Response | 0 participants |
| Cohort 2 | Number of Participants With Overall Tumor Response | Partial Response | 5 participants |
Secondary
Overall Survival
Overall survival (OS) was defined as the time from randomization to death of any cause. Surviving patients were censored at the date of last follow-up. The median OS with 95% CI was estimated using the Kaplan Meier method.
Time frame: Up to 3 years
Population: Participants who were randomized to maintenance were analyzed.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Cohort 1 | Overall Survival | 9.0 months |
| Cohort 2 | Overall Survival | 6.9 months |
Other Pre-specified
Change in Plasma Levels of PDGF
Correlated with clinical outcome (response and survival).
Time frame: Baseline to within 7 days of sunitinib/placebo therapy discontinuation
Other Pre-specified
Change in Plasma Levels of VEGF Prior to, During Single-agent, and Following Treatment With Sunitinib Malate
The frequency of tumor response by the optimally dichotomized VEGF levels will be tabulated and their association will be tested by Fisher's exact test as well as the maximally selected rank test. The association of the VEGF levels as continuous predictor with tumor response will be tested by Wilcoxon rank sum test. Further assessments of the association of the VEGF levels as\> continuous or binary variables and the tumor response will be implemented in a logistic regression while adjusting for other covariates such as performance status, weight loss and age
Time frame: Baseline to within 7 days of sunitinib/placebo therapy discontinuation