Refractory Ewing Sarcoma, Relapsed Ewing Sarcoma
Conditions
Keywords
Linsitinib, anti-IGF-1R/IR, Ewing Sarcoma, dual IGF-1R/IR inhibition, Relapsed Ewing Sarcoma, Refractory Ewing Sarcoma, Metastatic Ewing Sarcoma
Brief summary
This is an international, multi-centre, single arm Bayesian designed phase 2 study to identify and determine the safety and activity of anti-IGF-1/IR inhibition in patients with relapsed and/or refractory ESFT. Approximately 40 patients will be recruited from 5-7 European centres. Each patient will be treated with single agent linsitinib, 600 mg orally once a day for days 1-3, 8-10 and 15-17 on a 21 day cycle until disease progression or undue toxicity.
Detailed description
An important development in ES has been the identification of IGF-1R pathway dependency. The reasons for the remarkable single agent efficacy observed in a small subset of patients remains unknown, as is the relative lack of efficacy in the majority of patients. There may be heterogeneity in response due to partial signal pathway inhibition at the tumour level, inherent resistance in ES cells or the presence of alternative pathway activation through IR-A receptor signalling. Here we aim to establish pharmacodynamic responses in ES tumours using functional imaging 18FDG-PET-CT and repeat post treatment biopsy for biomarker responses, toxicity and clinical outcome to the dual anti-IGF-1R/IR kinase blocking single agent linsitinib. This is a single arm phase 2 study utilising adaptive Bayesian analysis. Approximately 40 patients will be recruited the national bone sarcoma centre in 5 EU countries over 18 months. Eligible patients will take 4x 150 mg tablets once a day, days 1-3 of the week followed by 4 days off - repeated for 3 weeks = one treatment cycle. Patients can remain on treatment for as long as they gain clinical benefit. The primary objectives are to determine the effect of linsitinib on the patient's tumours in terms of changes in biomarker and PET scans and to establish the safety of the trial drug (linsitinib) in Ewing sarcoma at the dose and treatment schedule being used in the trial.
Interventions
DRUGLinsitinib
Sponsors
European Organisation for Research and Treatment of Cancer - EORTC
European Commission
Astellas Pharma Inc
Oxford University Hospitals NHS Trust
University of Oxford
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 70 Years
Healthy volunteers
No
Inclusion criteria
* Histological or cytological confirmed original (no new biopsy required) diagnosis of Ewing sarcoma, preferably with EWSR in situ hybridisation break apart probe. * First, second or any relapse or refractory disease to conventional treatment * Current disease state for which there either is no known curative therapy or therapy proven to prolong survival with an acceptable quality of life * Has recovered from prior chemotherapy-related toxicity to ≤ grade 2 * Male or female, Age ≥ 18 and ≤70 years * Life expectancy of at least 4 months * WHO performance score of 0-2 * Must be able to take oral medication * Is willing and able to comply with the protocol for the duration of the study, and scheduled visits and examinations, including biopsies and PET-CT scans * Written (signed and dated) informed consent * Tumour at biopsy accessible site; in the case of lung metastases, accessible with VATS procedure * Tumour progression documented with imaging in the 6 months prior to study entry * At least one measurable lesion on CT scan performed in past 14 days of minimum size 1 cm and 18FDG uptake positive * Cardiac Ejection Fraction (Echocardiogram) ≥45% * Fasting glucose ≤ 150 mg/dL (8.3 mmol/L) with no history of diabetes. Concurrent use of non-insulinotropic anti-hyperglycaemic therapy for diabetes is permitted if the dose has been stable for ≥ 4 weeks at the time of enrolment * 16\. Haematological and biochemical indices within the specified ranges as below: * Haemoglobin (Hb) ≥9 g/dL (Previous transfusion is allowed) * Absolute neutrophil count (ANC) ≥1.0 x 109/L without growth factor support * Platelet count \> 80.x 109/L (Previous transfusion is allowed) * Direct Bilirubin \<1.5 times the upper limit of normal (ULN) * Serum alanine aminotransferase (ALT) \<2.5 x ULN for age and ≤ 5 x ULN if liver metastasis * Aspartate aminotransferase (AST) \<2.5 x ULN for age * Alkaline phosphatase \<2.5 x ULN for age * CPK \<2.5 x ULN for age * Serum creatinine ≤1.5 x ULN for age * Potassium, magnesium and calcium within normal limits (supplementation and re-testing is permitted)
Exclusion criteria
* Females: Pregnant or breast-feeding, or of childbearing potential unless effective methods of contraception are used. Males: Unless effective methods of contraception are used. * Significant active cardiac disease including: History (within last 6 months) of significant cardiovascular disease unless the disease is well-controlled. Significant cardiac disease includes second/third degree heart block; clinically significant ischemic heart disease; superior vena cava (SVC) syndrome; poorly controlled hypertension; congestive heart failure of New York Heart Association (NYHA) Class II or worse (slight limitation of physical activity; comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea). * History of arrhythmia (multifocal premature ventricular contractions \[PVCs\], bigeminy, trigeminy, ventricular tachycardia, or uncontrolled atrial fibrillation) that is symptomatic or requires treatment (≥ grade 3), left bundle branch block (LBBB), or asymptomatic sustained ventricular tachycardia are not allowed. Patients with atrial fibrillation controlled by medication are not excluded; uncontrolled high blood pressure (no greater than 2 SD above the mean for age for SBP and DBP), unstable angina, congestive heart failure, myocardial infarction within the previous 6 months, or serious cardiac arrhythmias * Mean QTcF interval ≥ 450 msec based on analysis of screening visit and pre-dose ECGs. * 5\. Use of drugs that have a known risk of causing Torsades de Pointes (TdP) within 14 days prior to registration * Use of the potent CYP1A2 inhibitors ciprofloxacin and fluvoxamine within 7 days prior to registration. Linsitinib is primarily metabolized by CYP1A2 and inhibitors/inducers of CYP1A2 could alter the pharmacokinetics of linsitinib. Other less potent CYP1A2 inhibitors/inducers are not excluded * Other psychological, social or medical condition, physical examination finding or a laboratory abnormality that the Investigator considers would make the patient a poor trial candidate or could interfere with protocol compliance or the interpretation of trial results * Any other active malignancy, with the exception of adequately treated cone-biopsied in situ carcinoma of the cervix uteri and non-melanoma skin lesions * History of cerebrovascular accident (CVA) within 6 months prior to entry that resulted in ongoing neurologic instability * Patients with symptomatic brain metastases. Patients with previously diagnosed brain metastases are eligible if they have completed their CNS treatment and have recovered from the acute effects of radiation therapy or surgery prior to the start of study medication, have discontinued corticosteroid treatment for these metastases for at least 4 weeks, and are neurologically stable * Major surgery within 4 weeks prior to study treatment * Prior anti- IGF-1R treatment * Treatment with any other investigational agent, or participation in another clinical trial within 28 days prior to enrolment * Patients who are known to be serologically positive for Hepatitis B, Hepatitis C or HIV
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of Participants With a Metabolic Response as Evaluated by PERCIST v1.0 | Pre- and Post- dose responses following 1 cycle (21 days) of treatment | Metabolic response measured by PERCIST v1.0 using SULpeak. This methodology used SULpeak to measure change in glucose uptake in the tumour. Complete Metabolic Response - Complete resolution of 18F-FDG uptake within measurable target lesion so that it is less than mean liver activity and indistinguishable from surrounding background blood-pool levels. Partial Metabolic Response - Reduction of minimum of 30% in target measurable tumour 18F-FDG SULpeak. Absolute drop in SUL must be at least 0.8 SUL units, as well. No new lesions. Positive Metabolic Response - Participants having either Complete Metabolic Response or Partial Metabolic Response. Stable Metabolic Disease - Not CMR, PMR or PMD. Progressive metabolic disease - Increase of more than 30% in 18F-FDG SUL peak. OR: Visible increase in extent of 18F-FDG tumour uptake (75% in TLG volume with no decline in SUL. OR: New 18F-FDG-avid lesions that are typical of cancer and not related to treatment effect or infection. |
| Number of Participants With a Toxic Event | Following 6 cycles of treatment (up to 6 months) | A patient is defined as having a toxic event if they experienced at least one grade 3 adverse event (CTCAE v4.0 grade) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Clinical Outcome (PFS, DSS) | Duration of study (up to 18 months) | To determine the clinical outcome through assessment of * Progression free survival; where length of survival is defined in whole days as the time from entry into the study until Ewing sarcoma progression or death from any cause. Progression is defined using Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.1), as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. * Disease specific survival; where length of survival is defined in whole days as the time from entry into the study until death from Ewing sarcoma. |
| Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | Cycle 1 days 1,15,17, Cycle 2 day 3, Cycle 3 days 1 and 3, Cycle 4 day 1, Cycle 5 day 1, Cycle 6 day 1 and End of Treatment.0 | Plasma concentrations of linsitinib (ng/ml). Samples were taken 3 hours post-dose at Cycle 1 days 1,15,17, Cycle 2 day 3, Cycle 3 days 1 and 3, Cycle 4 day 1, Cycle 5 day 1, Cycle 6 day 1, and End of Treatment (this could occur at anytime during the 6 cycles). |
| Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Measured cycle 1 day 15, cycle 3 and cycle 6 | Radiological response measured using Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.1) Per RECIST for target lesions and assessed by CT: Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Progressive Disease (PD), \>20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions; Stable disease (SD), Not CR, PR or PD. |
| Number of Participants With a Metabolic Response as Evaluated by EORTC 1.0 | Measured cycle 1 day 15 | Metabolic response measured by PERCIST v1.0 using SULpeak. This methodology used SULpeak to measure change in glucose uptake in the tumour. Complete Metabolic Response - Complete resolution of 18F-FDG uptake within measurable target lesion so that it is less than mean liver activity and indistinguishable from surrounding background blood-pool levels. Partial Metabolic Response - Reduction of minimum of 30% in target measurable tumour 18F-FDG SULpeak. Absolute drop in SUL must be at least 0.8 SUL units, as well. No new lesions. Positive Metabolic Response - Participants having either Complete Metabolic Response or Partial Metabolic Response. Stable Metabolic Disease - Not CMR, PMR or PMD. Progressive metabolic disease - Increase of more than 30% in 18F-FDG SUL peak. OR: Visible increase in extent of 18F-FDG tumour uptake (75% in TLG volume with no decline in SUL. OR: New 18F-FDG-avid lesions that are typical of cancer and not related to treatment effect or infection. |
Countries
France, Germany, Italy, Netherlands, United Kingdom
Participant flow
Recruitment details
Patients were recruited from March 2014 until April 2016 at specialist cancer hospitals across Europe
Participants by arm
| Arm | Count |
|---|---|
| Linsitinib Linsitinib is to be taken orally once a day on days 1-3, 8-10 and 15-17 on a 21 day cycle. The starting dose is 600 mg | 16 |
| Total | 16 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Overall Study | Adverse Event | 1 |
| Overall Study | Disease Progression | 14 |
| Overall Study | Withdrawal by Subject | 1 |
Baseline characteristics
| Characteristic | Linsitinib |
|---|---|
| Age, Continuous | 26.3 years |
| Disease stage at screening - Metastatic | 16 Participants |
| Histology - Ewing Sarcoma | 16 Participants |
| Number of lines of previous treatment Second line | 1 Participants |
| Number of lines of previous treatment > third line | 14 Participants |
| Number of lines of previous treatment Third line | 1 Participants |
| Primary site Chest wall | 4 Participants |
| Primary site Extra-osseous site | 2 Participants |
| Primary site Lower extremity | 3 Participants |
| Primary site Pelvis | 5 Participants |
| Primary site Spine | 1 Participants |
| Primary site Upper extremity | 1 Participants |
| Prior chemotherapy | 16 Participants |
| Prior radiotherapy | 13 Participants |
| Prior surgery | 14 Participants |
| Region of Enrollment Germany | 2 participants |
| Region of Enrollment Italy | 4 participants |
| Region of Enrollment Netherlands | 2 participants |
| Region of Enrollment United Kingdom | 8 participants |
| Sex: Female, Male Female | 3 Participants |
| Sex: Female, Male Male | 13 Participants |
| Sites of metastases Bone | 3 participants |
| Sites of metastases Bone, Other | 8 participants |
| Sites of metastases Lung | 11 participants |
| Time since most recent relapse/progression (days) | 18 days |
| WHO performance status 0 | 5 Participants |
| WHO performance status 1 | 7 Participants |
| WHO performance status 2 | 4 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 13 / 16 |
| other Total, other adverse events | 15 / 16 |
| serious Total, serious adverse events | 3 / 16 |
Outcome results
Primary
Number of Participants With a Metabolic Response as Evaluated by PERCIST v1.0
Metabolic response measured by PERCIST v1.0 using SULpeak. This methodology used SULpeak to measure change in glucose uptake in the tumour. Complete Metabolic Response - Complete resolution of 18F-FDG uptake within measurable target lesion so that it is less than mean liver activity and indistinguishable from surrounding background blood-pool levels. Partial Metabolic Response - Reduction of minimum of 30% in target measurable tumour 18F-FDG SULpeak. Absolute drop in SUL must be at least 0.8 SUL units, as well. No new lesions. Positive Metabolic Response - Participants having either Complete Metabolic Response or Partial Metabolic Response. Stable Metabolic Disease - Not CMR, PMR or PMD. Progressive metabolic disease - Increase of more than 30% in 18F-FDG SUL peak. OR: Visible increase in extent of 18F-FDG tumour uptake (75% in TLG volume with no decline in SUL. OR: New 18F-FDG-avid lesions that are typical of cancer and not related to treatment effect or infection.
Time frame: Pre- and Post- dose responses following 1 cycle (21 days) of treatment
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by PERCIST v1.0 | Positive metabolic response | 1 Participants |
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by PERCIST v1.0 | Stable metabolic disease | 2 Participants |
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by PERCIST v1.0 | Progressive metabolic disease | 4 Participants |
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by PERCIST v1.0 | Not measurable at Baseline | 3 Participants |
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by PERCIST v1.0 | Not assessable - liver | 4 Participants |
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by PERCIST v1.0 | No repeat scan available | 2 Participants |
Primary
Number of Participants With a Toxic Event
A patient is defined as having a toxic event if they experienced at least one grade 3 adverse event (CTCAE v4.0 grade)
Time frame: Following 6 cycles of treatment (up to 6 months)
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Linsitinib | Number of Participants With a Toxic Event | Experienced a toxic event | 5 Participants |
| Linsitinib | Number of Participants With a Toxic Event | Did not experienced a toxic event | 11 Participants |
Secondary
Clinical Outcome (PFS, DSS)
To determine the clinical outcome through assessment of * Progression free survival; where length of survival is defined in whole days as the time from entry into the study until Ewing sarcoma progression or death from any cause. Progression is defined using Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.1), as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. * Disease specific survival; where length of survival is defined in whole days as the time from entry into the study until death from Ewing sarcoma.
Time frame: Duration of study (up to 18 months)
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Linsitinib | Clinical Outcome (PFS, DSS) | Disease specific survival | 7.1 months |
| Linsitinib | Clinical Outcome (PFS, DSS) | Progression free survival | 1.3 months |
Secondary
Number of Participants With a Metabolic Response as Evaluated by EORTC 1.0
Metabolic response measured by PERCIST v1.0 using SULpeak. This methodology used SULpeak to measure change in glucose uptake in the tumour. Complete Metabolic Response - Complete resolution of 18F-FDG uptake within measurable target lesion so that it is less than mean liver activity and indistinguishable from surrounding background blood-pool levels. Partial Metabolic Response - Reduction of minimum of 30% in target measurable tumour 18F-FDG SULpeak. Absolute drop in SUL must be at least 0.8 SUL units, as well. No new lesions. Positive Metabolic Response - Participants having either Complete Metabolic Response or Partial Metabolic Response. Stable Metabolic Disease - Not CMR, PMR or PMD. Progressive metabolic disease - Increase of more than 30% in 18F-FDG SUL peak. OR: Visible increase in extent of 18F-FDG tumour uptake (75% in TLG volume with no decline in SUL. OR: New 18F-FDG-avid lesions that are typical of cancer and not related to treatment effect or infection.
Time frame: Measured cycle 1 day 15
| Arm | Measure | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by EORTC 1.0 | Positive metabolic response | 2 Participants |
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by EORTC 1.0 | Stable metabolic disease | 5 Participants |
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by EORTC 1.0 | Progressive metabolic disease | 7 Participants |
| Linsitinib | Number of Participants With a Metabolic Response as Evaluated by EORTC 1.0 | No repeat scan available | 2 Participants |
Secondary
Number of Participants With a Radiological Response as Evaluated by RECIST v1.1
Radiological response measured using Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.1) Per RECIST for target lesions and assessed by CT: Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Progressive Disease (PD), \>20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions; Stable disease (SD), Not CR, PR or PD.
Time frame: Measured cycle 1 day 15, cycle 3 and cycle 6
| Arm | Measure | Group | Category | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|---|
| Linsitinib | Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Cycle 1 | No repeat scan available | 2 Participants |
| Linsitinib | Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Cycle 1 | Stable disease | 7 Participants |
| Linsitinib | Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Cycle 1 | Progressive disease | 7 Participants |
| Linsitinib | Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Cycle 3 | Stable disease | 2 Participants |
| Linsitinib | Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Cycle 3 | Progressive disease | 4 Participants |
| Linsitinib | Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Cycle 3 | No repeat scan available | 10 Participants |
| Linsitinib | Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Cycle 6 | Stable disease | 0 Participants |
| Linsitinib | Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Cycle 6 | Progressive disease | 0 Participants |
| Linsitinib | Number of Participants With a Radiological Response as Evaluated by RECIST v1.1 | Cycle 6 | No repeat scan available | 16 Participants |
Secondary
Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib)
Plasma concentrations of linsitinib (ng/ml). Samples were taken 3 hours post-dose at Cycle 1 days 1,15,17, Cycle 2 day 3, Cycle 3 days 1 and 3, Cycle 4 day 1, Cycle 5 day 1, Cycle 6 day 1, and End of Treatment (this could occur at anytime during the 6 cycles).
Time frame: Cycle 1 days 1,15,17, Cycle 2 day 3, Cycle 3 days 1 and 3, Cycle 4 day 1, Cycle 5 day 1, Cycle 6 day 1 and End of Treatment.0
Population: Data provided is as collected.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Linsitinib | Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | Screening | 1 ng/ml |
| Linsitinib | Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | Cycle 1 Day 1 | 4790 ng/ml |
| Linsitinib | Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | Cycle 1 Day 15 | 2163 ng/ml |
| Linsitinib | Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | Cycle 1 Day 17 | 4977 ng/ml |
| Linsitinib | Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | Cycle 2 Day 3 | 3409 ng/ml |
| Linsitinib | Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | Cycle 3 Day 1 | 6791 ng/ml |
| Linsitinib | Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | Cycle 3 Day 3 | 1964 ng/ml |
| Linsitinib | Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | Cycle 4 Day 1 | 3591 ng/ml |
| Linsitinib | Pharmacokinetics Assays of Following Linsitinib Treatment (Plasma Concentrations of Linsitinib) | End of treatment visit | 1 ng/ml |