Ewing Sarcoma, Ewing Family of Tumors, Ewing's Tumor Metastatic, Ewing's Sarcoma Metastatic, Ewing's Tumor Recurrent, Rare Diseases, Sarcoma, Neoplasms, Connective and Soft Tissue, Neoplasms by Histologic Type, Neoplasms, Bone Tissue, Neoplasms, Connective Tissue, Sarcoma, Ewing, Neoplasms
Conditions
Keywords
ESFT, Immunotherapy, Phase 3, irinotecan, temozolomide, First Relapse, Second Line, Vigil, vaccine, orphan drug, soft bone, pediatric, FLI, EWS, Molecular Mechanisms of Pharmacological Action, Antineoplastic Agents
Brief summary
The goal of this clinical trial was to compare participants with first relapse or refractory Ewing's sarcoma when treated with investigational product (Vigil) in addition to the standard treatment of irinotecan and temozolomide compared to the standard treatment of irinotecan and temozolomide alone. The main question it aimed to answer is Will participants who receive Vigil in addition to irinotecan and temozolomide have a prolonged time to progression and improved quality of life compared to the participants who receive irinotecan and temozolomide alone?.
Detailed description
This was a multicenter, Phase III study in participants with metastatic Ewing's sarcoma Family of Tumors (ESFT) refractory/intolerant or recurrent to 1 prior line of chemotherapy. Participants who agreed to participation had tumor tissue harvested from a scheduled standard surgical procedure (e.g., tumor biopsy or palliative resection). The tumor tissue removed was shipped to Gradalis, Inc. to attempt to manufacture the investigational product, Vigil. Subjects who met eligibility criteria including manufacture of a minimum of 4 doses of Vigil were randomized 1:1 to either Group A (Vigil + Irinotecan + Temozolomide (Tem/Iri)) or Group B (Irinotecan + Temozolomide). Screening for the main portion of the study occurred as early as one week but no later than 8 weeks following tumor procurement. Subjects received repeat cycles of treatment until disease progression, unacceptable toxicity, withdrawal of consent or other criterion was met for discontinuation from study. Subjects randomized to Group A (Vigil + Tem/Iri) received up to 12 doses depending upon the quantity of Vigil manufactured from the surgical specimen. 1 cycle = 21 days. If irinotecan + temozolomide was administered beyond 12 cycles, it was administered off study. Subjects randomized to Group B (Tem/Iri) may have crossed over to receive single agent Vigil every 21 days following End of Treatment assessment and documented disease progression confirmed by central radiology vendor, for up to 12 doses of Vigil depending upon the quantity of Vigil manufactured. Participants were managed in an outpatient setting. Hematologic function, liver enzymes, renal function and electrolytes will be monitored. Blood for immune function analyses including IFNγ-ELISPOT analysis of cytotoxic T cell activation in response to autologous tumor antigens will be collected at tissue procurement, post-procurement screening and Day 1 (prior to chemotherapy administration) at Cycles 2, 4, and 6, end of treatment (EOT), 3 months after EOT, and every 6 months thereafter. Blood for ctDNA analysis was collected at tissue procurement, prior to chemotherapy administration at baseline and on Day 1 prior to chemotherapy administration at Cycles 2, 3, 4, and 6, and EOT. After progression, participants were contacted quarterly for documentation of post study therapies and survival status information.
Interventions
BIOLOGICALVigil
Vigil is composed of autologous tumor cells harvested from the patient at the time of initial de-bulking surgery which are then transfected extracorporeally, with a plasmid encoding for the gene for GM-CSF, an immune-stimulatory cytokine, and a bifunctional, short hairpin RNA which specifically knocks down the expression of furin, the critical convertase responsible for production of the two TGβ isoforms.
DRUGIrinotecan
Injectable formulation of irinotecan was distributed from central supplier. 1 Cycle (5 doses of 50 mg/m2 per syringe) was drawn into provided oral syringes and dispenses to the subject with instructions to refrigerate until administration.
DRUGTemozolomide
Dose: 100 mg/m2 daily, oral Schedule: Days 1-5, every 21 days Administered at least 1 hour before Irinotecan.
Sponsors
Gradalis, Inc.
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
Participants were randomized 1:1 to either Group A (Vigil + irinotecan and temozolomide) or Group B (irinotecan and temozolomide alone). Participants randomized to Group B were able to receive Vigil (Cross-Over) after confirmation of progression by central radiologist and sponsor approval.
Eligibility
Sex/Gender
ALL
Age
2 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Tissue Procurement Inclusion Criteria: 1. Histologically confirmed Ewing's Sarcoma Family of Tumors (ESFT). 2. Age greater than or equal to 2 years. 3. Estimated survival greater than or equal to 6 months. 4. Evidence of EWS translocation by FISH or RT-PCR or Next Generation Sequencing (NGS). If available, NGS sequencing report should be submitted to Gradalis. 5. Recurrence or refractory to 1 line of systemic chemotherapy, including but not limited to doxorubicin, vincristine, and ifosfamide. 6. Planned standard of care surgical procedure (e.g., tumor biopsy or palliative resection or thoracentesis) and expected availability of a cumulative soft-tissue mass of \ 10-30 grams tissue (grape to golf-ball size / approximately 2 cm total diameter on imaging) or pleural fluid estimated volume ≥ 500mL (from a primary or secondary thoracentesis, yielding in a high volume of tumor cells) for immunotherapy manufacture. 7. Tumor intended for immunotherapy manufacture is not embedded in bone and does not contain luminal tissue (e.g. bowel, ureter, bile duct). 8. Ability to understand and the willingness to sign a written protocol specific informed consent for tissue harvest or a parental/guardian informed consent and pediatric assent when appropriate. Tissue Procurement
Exclusion criteria
1. Medical condition requiring any form of chronic systemic immunosuppressive therapy (steroid or other) except physiologic replacement doses of hydrocortisone or equivalent (no more than 30 mg hydrocortisone or 10 mg prednisone equivalent daily) for \< 30 days duration. 2. Known history of other malignancy unless having undergone curative intent therapy without evidence of that disease for ≥ 3 years except cutaneous squamous cell and basal cell skin cancer, superficial bladder cancer, in situ cervical cancer or other in situ cancers are allowed if definitively resected. 3. Brain metastases unless treated with curative intent (gamma knife or surgical resection) and without evidence of progression for ≥ 2 months. 4. Any documented history of autoimmune disease with exception of Type 1 diabetes on stable insulin regimen, hypothyroidism on stable dose of replacement thyroid medication, vitiligo, or asthma not requiring systemic steroids. 5. Known HIV or chronic Hepatitis B or C infection. 6. Known hypersensitivity to any temozolomide component or to dacarbazine (DTIC). 7. Known hypersensitivity to irinotecan or its excipients. 8. Known history of allergies or sensitivities to gentamicin. 9. History of or current evidence of any condition (including medical, psychiatric or substance abuse disorder), therapy, or laboratory abnormality that might confound the results of the study, interfere with the patient's participation for the full duration of the study, or is not in the best interest of the patient to participate, in the opinion of the treating Investigator. Study Enrollment Inclusion Criteria: 1. Completed manufacture of at least 4 vials of Vigil. 2. Karnofsky performance status (KPS) / Lansky performance status (LS) ≥80 percent. 3. Normal organ and marrow function as defined below: Absolute granulocyte count ≥1,000/mm3, Absolute lymphocyte count ≥400/mm3, Platelets ≥75,000/mm3, Hemoglobin ≥ 8.0 mg/dL, Total bilirubin ≤ institutional upper limit of normal\*, AST(SGOT)/ALT(SGPT) ≤2x institutional upper limit of normal, Creatinine \<1.5 mg/dL \* documented Gilbert's syndrome may be considered after medical monitor review 4. Subject has recovered to CTCAE Grade 1 (except for parameters noted in Item 3, above) or better from all adverse events associated with prior therapy or surgery. Pre-existing motor or sensory neurologic pathology or symptoms, or dermatologic must be recovered to CTCAE Grade 2 or better. 5. If female of childbearing potential, has a negative urine or serum pregnancy test. If the urine test is positive or cannot be confirmed as negative, a negative serum test will be required for study entry. 6. Ability to understand and the willingness to sign a written informed protocol specific consent or a parental/guardian informed consent and pediatric assent when appropriate. Study Enrollment
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Progression Free Survival (PFS) | From date of randomization until the date of first documented progression (assessed up to 3 years). | Progression Free Survival (PFS) is defined as the time from randomization to the event of disease recurrence/progression according to Response Evaluation Criteria In Solid Tumors (RECIST) criteria (version 1.1) for target lesions and assessed CT/MRI by local investigator. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Overall Survival (OS) | From date of randomization until date of death from any cause, whichever came first (assessed up to 3 years). | OS is defined as time from randomization to death or to the date of last follow-up. The date of last follow-up confirming survival will be used as the censoring date for subjects who are alive and/or do not have a known date of death. |
| Overall Response Rate (ORR) | 6 months after treatment with Vigil. | ORR is defined as the proportion of participants who have prolonged stable disease or a partial or complete response or complete response to therapy according to RECIST 1.1. |
| Vigil Manufacture Success Rate: Number of Participants Eligible for Treatment on the Main Study. | From manufacturing start date until 4 weeks post manufacturing for each tissue procurement (assessed up to 17 months). | Participants were considered eligible for treatment, if the tissue submitted to Gradalis met all criteria, including manufacturing product release criteria. |
Countries
United States
Participant flow
Pre-assignment details
Thirty-two (32) subjects signed consent for the tissue procurement portion of the study. Twenty-seven (27) subjects were not eligible to enroll into the main treatment portion of the study. Five (5) subjects were randomized into the main treatment portion of the study. Group B - crossover to receive 2nd Intervention with Vigil only: One (1) subject in Group B was not eligible to crossover to receive treatment with Vigil and 1 subject from Group B crossed over to receive Vigil.
Participants by arm
| Arm | Count |
|---|---|
| Group A: Vigil in Combination With Irinotecan and Temozolomide Participants randomized to Group A received oral temozolomide 100 mg/m\^2 daily (Days 1-5), total dose 500 mg/m\^2/cycle) and oral irinotecan 50 mg/m\^2 daily (Days 1-5, total dose 250 mg/m\^2/cycle). Vigil immunotherapy was administered at a concentration of 1 X 10e6 cells/dose given via intradermal injection on Day 15 of each cycle. 1 cycle = 21 days
Participants continued treatment for a maximum of 12 cycles, or until disease progression, unacceptable toxicity, withdrawal of consent or other criterion is met for discontinuation from study. | 3 |
| Group B: Irinotecan and Temozolomide Participants randomized to Group B received oral temozolomide 100 mg/m\^2 daily (Days 1-5), total dose 500 mg/m\^2/cycle) and oral irinotecan 50 mg/m\^2 daily (Days 1-5, total dose 250 mg/m\^2/cycle).
1 cycle = 21 days
Participants continued treatment for a maximum of 12 cycles, or until disease progression, unacceptable toxicity, withdrawal of consent or other criterion is met for discontinuation from study. | 2 |
| Total | 5 |
Baseline characteristics
| Characteristic | Group B: Irinotecan and Temozolomide | Group A: Vigil in Combination With Irinotecan and Temozolomide | Total |
|---|---|---|---|
| Age, Categorical <=18 years | 2 Participants | 0 Participants | 2 Participants |
| Age, Categorical >=65 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants | 3 Participants | 3 Participants |
| Baseline Performance Status 100 | 0 Participants | 3 Participants | 3 Participants |
| Baseline Performance Status 80 | 2 Participants | 0 Participants | 2 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants | 2 Participants | 2 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 2 Participants | 1 Participants | 3 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 2 Participants | 3 Participants | 5 Participants |
| Region of Enrollment United States | 2 participants | 3 participants | 5 participants |
| Sex: Female, Male Female | 1 Participants | 1 Participants | 2 Participants |
| Sex: Female, Male Male | 1 Participants | 2 Participants | 3 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | 2 / 3 | 1 / 2 | 0 / 1 |
| other Total, other adverse events | 3 / 3 | 2 / 2 | 1 / 1 |
| serious Total, serious adverse events | 0 / 3 | 1 / 2 | 0 / 1 |
Outcome results
Primary
Progression Free Survival (PFS)
Progression Free Survival (PFS) is defined as the time from randomization to the event of disease recurrence/progression according to Response Evaluation Criteria In Solid Tumors (RECIST) criteria (version 1.1) for target lesions and assessed CT/MRI by local investigator.
Time frame: From date of randomization until the date of first documented progression (assessed up to 3 years).
Population: PFS is not adequately assessable for difference between cohorts given only 5 participants were enrolled and received treatment.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Group A: Vigil in Combination With Irinotecan and Temozolomide | Progression Free Survival (PFS) | 2.8 Months |
| Group B: Irinotecan and Temozolomide | Progression Free Survival (PFS) | 9.1 Months |
Secondary
Overall Response Rate (ORR)
ORR is defined as the proportion of participants who have prolonged stable disease or a partial or complete response or complete response to therapy according to RECIST 1.1.
Time frame: 6 months after treatment with Vigil.
Population: No subjects on trial achieved a partial or complete response, therefore the ORR was not determined.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Group A: Vigil in Combination With Irinotecan and Temozolomide | Overall Response Rate (ORR) | 0 Proportion of participants. |
| Group B: Irinotecan and Temozolomide | Overall Response Rate (ORR) | 0 Proportion of participants. |
Secondary
Overall Survival (OS)
OS is defined as time from randomization to death or to the date of last follow-up. The date of last follow-up confirming survival will be used as the censoring date for subjects who are alive and/or do not have a known date of death.
Time frame: From date of randomization until date of death from any cause, whichever came first (assessed up to 3 years).
Population: OS is not adequately assessable for difference between cohorts given only 5 participants were enrolled and received treatment.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Group A: Vigil in Combination With Irinotecan and Temozolomide | Overall Survival (OS) | 16.1 Months |
| Group B: Irinotecan and Temozolomide | Overall Survival (OS) | 3.3 Months |
Secondary
Vigil Manufacture Success Rate: Number of Participants Eligible for Treatment on the Main Study.
Participants were considered eligible for treatment, if the tissue submitted to Gradalis met all criteria, including manufacturing product release criteria.
Time frame: From manufacturing start date until 4 weeks post manufacturing for each tissue procurement (assessed up to 17 months).
Population: All enrolled subjects who completed tissue procurement and the tissue was received by Gradalis for Vigil Manufacture. Any subjects whose tissue was not submitted to Gradalis was excluded in the analysis.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Group A: Vigil in Combination With Irinotecan and Temozolomide | Vigil Manufacture Success Rate: Number of Participants Eligible for Treatment on the Main Study. | 4 Participants |