Amorphous, Eosinophilic, and Acellular Deposit, Constipation, Diarrhea, Early Satiety, Gastrointestinal Hemorrhage, Hepatomegaly, Lymphadenopathy, Macroglossia, Nausea, Primary Systemic Amyloidosis, Purpura, Recurrent Primary Amyloidosis, Refractory Primary Amyloidosis
Conditions
Brief summary
This phase II trial studies how well isatuximab works in treating patients with primary amyloidosis that has come back or does not respond to treatment. Monoclonal antibodies, such as isatuximab, may interfere with the ability of cancer cells to grow and spread.
Detailed description
PRIMARY OBJECTIVES: I. To assess the efficacy as measured by the confirmed overall hematologic response rate (partial response or better) of isatuximab in relapsed/refractory systemic light chain (AL) amyloidosis. SECONDARY OBJECTIVES: I. To evaluate toxicities in the treatment of relapsed/refractory AL amyloidosis with isatuximab. II. To evaluate time to hematologic response. III. To evaluate duration of response. IV. To evaluate progression-free survival (PFS). V. To evaluate overall survival (OS). TERTIARY OBJECTIVES: I. To evaluate efficacy of isatuximab in relapsed/refractory immunoglobulin amyloid light chain (AL) amyloidosis as measured by organ specific response rates (cardiac, renal, gastrointestinal \[GI\], liver, soft tissue, nerve), in the subset of patients that can be evaluated for organ response. II. To evaluate time to organ response in the subset of patients that can be evaluated for organ response. OUTLINE: Patients receive isatuximab intravenously (IV) on days 1, 8, 15, and 22 of course 1 and on days 1 and 15 of subsequent courses. Treatment repeats every 28 days for 24 courses in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up within 30 days and then every at least every 6 months for up to 4 years.
Interventions
BIOLOGICALIsatuximab
Given IV
OTHERLaboratory Biomarker Analysis
Correlative studies
Sponsors
National Cancer Institute (NCI)
SWOG Cancer Research Network
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patient must have relapsed or refractory primary systemic AL amyloidosis, histologically-confirmed by positive Congo red stain with green by birefringence on polarized light microscopy, OR characteristic appearance by electron microscopy AND confirmatory AL amyloid typing (mass spectrometry-based proteomic analysis or immunofluorescence) * Patient must have measurable disease within 28 days prior to registration; serum beta2 microglobulin, serum quantitative immunoglobulins (immunoglobulin \[Ig\]G, IgA, and IgM), serum free kappa and lambda, and serum protein electrophoresis (SPEP) with M-protein quantification must be obtained within 14 days prior to registration * Patient must demonstrate a difference in the involved serum free light chains (kappa or lambda) versus the uninvolved serum free light chain of \>= 4.5 mg/dL within 14 days prior to registration * Patient must have objective organ involvement defined by ONE (or more) of the following; all disease for involved organs must be assessed and documented on the AL baseline tumor assessment form * Kidney: albuminuria greater than or equal to 500 mg per day on a 24-hour urine specimen within 35 days prior to registration, OR prior kidney biopsy (at time of diagnosis) showing amyloid deposition * Heart: mean left ventricular wall thickness on echocardiogram greater than or equal to 12 mm in the absence of hypertension or valvular heart disease, OR N-terminal fragment brain natriuretic protein (NT-pro) brain natriuretic peptide (BNP) greater than 332 ng/mL provided that patient does not have impaired renal function (as defined by calculated creatinine clearance less than 25 mL/min) within 14 days prior to registration, OR prior cardiac biopsy (at time of diagnosis) showing amyloid deposition with past documented or presently noted clinical symptoms and signs supportive of a diagnosis of heart failure in the absence of an alternative explanation for heart failure * Liver: hepatomegaly (total liver span \> 15 cm) as demonstrated by computed tomography (CT) or magnetic resonance imaging (MRI) within 35 days prior to registration OR elevated alkaline phosphatase (ALP) greater than 1.5 times the upper limit of normal within 14 days prior to registration, OR prior liver biopsy (at time of diagnosis) showing amyloid deposition * Gastrointestinal tract: prior biopsy showing amyloid deposition AND symptoms such as GI bleeding or persistent diarrhea (\> 4 loose stools/day on most days over a consecutive 28-day period) * Autonomic or peripheral nervous system: orthostatic blood pressure, symptoms of nausea, early satiety, diarrhea or constipation, abnormal sensory and/or motor findings on neurologic exam, or gastric atony by gastric emptying scan; Note: pulse and blood pressure must be recorded with the patient supine (lying down), and then again after at least 1 minute, but less than 3 minutes of standing; this assessment must be repeated on 2 separate occasions (at least 1 day apart; e.g. day -3 and day -1) within a 28-day screening period * Soft tissue: macroglossia, or soft tissue deposits (including lymphadenopathy, recurrent peri-orbital purpura, peri-articular, skin or other soft tissue) requiring therapy * Patients must not have active symptomatic multiple myeloma, as defined by 2015 International Myeloma Working Group (IMWG) criteria (hypercalcemia, renal failure, anemia, and bone \[CRAB\] criteria; bone marrow plasmacytosis \> 60%); kappa: lambda ratio \> 100 is acceptable only if the clinical symptoms and sign are attributable only to amyloidosis and not multiple myeloma (hemoglobin \[Hgb\] \< 8 g/dL) * Patient must be relapsed or refractory to at least one prior line of therapy (such as: transplant, radiation, or chemotherapy) * Patients must have completed other systemic therapy \>= 14 days or investigational drug \>= 28 days prior to registration, surgery (other than biopsies) \>= 21 days prior to registration, and any autologous stem cell transplant (ASCT) \>= 100 days prior to registration * Patients must not have received any or supplements which have been known to have some anti-amyloidogenic effect (such as: doxycycline; curcumin; prednisone; dexamethasone; epigallocatechin gallate \[EGCG\]) within 14 days prior to registration * Patients must not have any known allergies to isatuximab or other monoclonal antibody therapies * Patients must not have received daratumumab within 56 days prior to registration nor have been refractory to daratumumab * Patients must not be eligible for autologous stem cell transplantation * Patients must have a complete medical history and physical exam within 14 days prior to registration * Within 14 days prior to registration: Total bilirubin =\< 2.0 x IULN (institutional upper limit of the norm) AND * Within 14 days prior to registration: Serum glutamic-oxaloacetic transaminase (SGOT)/aspartate aminotransferase (AST) and serum glutamate pyruvate transaminase (SGPT)/alanine aminotransferase (ALT) =\< 4.0 x IULN * Creatinine clearance (CrCl) \>= 25 mL/min, as measured by a 24-hour urine collection or as estimated by the Cockcroft and Gault formula; the serum creatinine value used in the calculation must have been obtained within 35 days prior to registration * Patients must have bone marrow aspirate, including fluorescence in situ hybridization (FISH) (including: del 17p; t11;14; t4;14, t14;16; and del 13q) and cytogenetic testing (normal ? XY; and all abnormalities) within 35 days prior to registration; central pathology analysis will not be required, however the local pathology report and FISH/cytogenetic data must be submitted in Medidata RAVE * Within 14 days prior to registration: Absolute neutrophil count (ANC) \>= 1,000 cells/mcl without growth factor support, AND * Within 14 days prior to registration: Platelets \>= 75,000 cells/mcl * Patients must have hemoglobin \>= 8 g/dL within 14 days prior to registration; patients may have received transfusion if greater than 7 days prior to registration * New York Heart Association (NYHA) \< class IV heart failure * Left ventricular ejection fraction (LVEF) by echocardiogram (ECHO) \>= 35% within 35 days prior to registration; and * NT-proBNP =\< 8500 ng/L within 14 days prior to registration * Patients must have a Zubrod performance status =\< 2 * Patients must not have any clinically significant uncontrolled systemic illness, including but not limited to uncontrolled, active infection requiring intravenous antibiotics, unstable angina pectoris, myocardial infarction within the past 6 months, uncontrolled cardiac arrhythmias, uncontrolled hypertension, or uncontrolled diabetes mellitus * Uncontrolled diabetes: patients who have a diagnosis of diabetes must have an glycosylated hemoglobin (HbA1C) \< 7% within 14 days prior to registration; the same criterion will be used in patients with confirmed diagnosis of diabetes mellitus who have been on a stable dietary or therapeutic regimen for this condition in the last three months * Uncontrolled blood pressure and hypertension: all blood pressure measurements within the 14 days prior to registration must be systolic blood pressure (SBP) =\< 160 and diastolic blood pressure (DBP) =\< 100; an exception can be made by a healthcare provider for a patient with a single blood pressure elevation who upon rechecking has a normal blood pressure * Females of childbearing potential must have a negative baseline pregnancy test within 14 days prior to registration; this may be either a serum or urine pregnancy test, with a sensitivity of at least 50 mIU/mL; females of childbearing potential (FCBP) must also agree: (1) to have a pregnancy test prior to the start of each treatment cycle and (2) to either commit to continued abstinence from heterosexual intercourse or to use effective contraception while receiving study drug and for at least 12 weeks after receiving the last dose of study drug; females are considered to be of ?childbearing potential? if they have had menses at any time in the preceding 24 consecutive months; in addition to routine contraceptive methods, ?effective contraception? also includes heterosexual celibacy and surgery intended to prevent pregnancy (or with a side-effect of pregnancy prevention) defined as a hysterectomy, bilateral oophorectomy or bilateral tubal ligation; however, if at any point a previously celibate patient chooses to become heterosexually active during the time period for use of contraceptive measures outlined in the protocol, she is responsible for beginning contraceptive measures * Patients with evidence of hepatitis B virus (HBV) are eligible provided there is minimal hepatic injury and the patient has undetectable HBV on suppressive HBV therapy; patient must be willing to maintain adherence to HBV therapy; patients with previously treated and eradicated hepatitis C virus (HCV) who have minimal hepatic injury are eligible * Patients who are known to be human immunodeficiency virus (HIV)-positive at registration are eligible if at time of registration they meet all other protocol eligibility criteria in addition to the following: * Patient has undetectable HIV viral load by standard polymerase chain reaction (PCR) clinical assay * Patient is willing to maintain adherence to combination antiretroviral therapy * Patient has no history of acquired immunodeficiency syndrome (AIDS) defining condition (other than CD4 cell count \< 200 mm\^3) * Patient is otherwise likely to have a near normal lifespan if not for the presence of relapsed/refractory amyloid * No other prior malignancy is allowed except for the following: adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, adequately treated stage I or II cancer from which the patient is currently in complete remission, or any other cancer from which the patient has been disease free for at least two years
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Assess Efficacy by Confirmed Overall Hematologic Response | From date of enrollment until progression or death due to any cause, whichever occurs first, assessed up to 4 years | To assess the efficacy as measured by the confirmed overall hematologic response rate (partial response, very good partial response, complete response) of isatuximab in relapsed/ refractory systemic light chain (AL) amyloidosis. Measured as rate of partial response or better. Partial response is defined as a dFLC decrease of ≥ 50%, but remaining \> 4.0 mg/dL. Very good partial response is defined as the difference between involved and uninvolved FLCs \[dFLC\] \< 4.0 mg/dL. Complete response is defined as laboratory values within the normal range free light chain (FLC) ratio (0.25 - 1.65) and negative serum and urine immunofixation. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | From date of enrollment until progression or death due to any cause, whichever occurs first, assessed up to 4 years | Only adverse events that are possibly, probably or definitely related to study drug are reported. |
| Overall Survival (24 Month Estimate) | From date of enrollment up to 2 years | Overall survival is measured from date of registration to date of death due to any cause. Patients last known to be alive are censored at date of last contact. While OS was assessed up to 4 years, 4 year estimates were not reached. We are reporting the 24 month estimate (how many participants reached survival time of at least 24 months). |
| Duration of Response (24 Month Estimate) | Up to 2 years | Duration of response is measure as time between hematologic response and hematologic progression. Hematologic progression is defined as 50% increase from nadir. While duration of response was assessed up to 4 years, 4 year estimates were not reached. We are reporting the 24 month estimate (how many participants achieved 24 month duration of response) |
| Time to Hematologic Response | From registration to time of confirmed hematologic progression | To evaluate time to hematologic response. Partial response is defined as a dFLC decrease of ≥ 50%, but remaining \> 4.0 mg/dL. Very good partial response is defined as the difference between involved and uninvolved FLCs \[dFLC\] \< 4.0 mg/dL. Complete response is defined as laboratory values within the normal range free light chain (FLC) ratio (0.25 - 1.65) and negative serum and urine immunofixation. |
| Progression-free Survival (24 Month Estimate) | From registration to time of confirmed hematologic progression | To evaluate progression-free survival (24 month estimate) Hematologic progression is defined as 50% increase from nadir, or from baseline (if there was no response) in any ONE OR MORE of the following: 1. Serum M-protein: 50% increase in Serum M protein to a value greater than 0.5 g/dL. 2. Urine M protein: 50% increase in Urine M protein to a value greater than 200 mg/day (a visible peak must be present) 3. Free light chain increase of 50% to a value greater than 10 mg/dL |
Countries
United States
Participant flow
Recruitment details
43 participants were enrolled of which 35 were eligible and analyzable.
Participants by arm
| Arm | Count |
|---|---|
| Treatment (Isatuximab) Patients receive isatuximab IV on days 1, 8, 15, and 22 of course 1 and on days 1 and 15 of subsequent courses. Treatment repeats every 28 days for 24 courses in the absence of disease progression or unacceptable toxicity.
Isatuximab: Given IV
Laboratory Biomarker Analysis: Correlative studies | 35 |
| Total | 35 |
Baseline characteristics
| Characteristic | Treatment (Isatuximab) |
|---|---|
| Age, Continuous | 70 Years |
| Cardiac Involvement No | 10 Participants |
| Cardiac Involvement Yes | 25 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 1 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 32 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 2 Participants |
| GI Tract Involvement No | 33 Participants |
| GI Tract Involvement Yes | 2 Participants |
| IgG (mg/dL) | 700 mg/dL |
| Involved Light Chain Kappa | 10 Participants |
| Involved Light Chain Lambda | 23 Participants |
| Involved Light Chain None | 1 Participants |
| Involved Light Chain Unknown | 1 Participants |
| Kidney Involvement No | 21 Participants |
| Kidney Involvement Yes | 14 Participants |
| Liver Involvement No | 34 Participants |
| Liver Involvement Yes | 1 Participants |
| Mayo Cardiac Biomarker Stage Not assessed - no cardiac involvement at baseline | 10 Participants |
| Mayo Cardiac Biomarker Stage Stage I | 7 Participants |
| Mayo Cardiac Biomarker Stage Stage II | 8 Participants |
| Mayo Cardiac Biomarker Stage Stage III | 8 Participants |
| Mayo Cardiac Biomarker Stage Stage IV | 1 Participants |
| Mayo Cardiac Biomarker Stage Unknown | 1 Participants |
| Nervous System Involvement No | 26 Participants |
| Nervous System Involvement Yes | 9 Participants |
| Organ Involvement Multiple Organ involvement | 17 Participants |
| Organ Involvement Single Organ Involvement | 18 Participants |
| Performance Status PS 0 | 8 Participants |
| Performance Status PS 1 | 25 Participants |
| Performance Status PS 2 | 2 Participants |
| Plasma Cells (%, Bone Marrow) | 6 % of Bone Marrow |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 1 Participants |
| Race (NIH/OMB) Black or African American | 1 Participants |
| Race (NIH/OMB) More than one race | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 4 Participants |
| Race (NIH/OMB) White | 29 Participants |
| Sex: Female, Male Female | 16 Participants |
| Sex: Female, Male Male | 19 Participants |
| Soft Tissue Involvement No | 30 Participants |
| Soft Tissue Involvement Yes | 5 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 1 / 35 |
| other Total, other adverse events | 32 / 35 |
| serious Total, serious adverse events | 15 / 35 |
Outcome results
Primary
Assess Efficacy by Confirmed Overall Hematologic Response
To assess the efficacy as measured by the confirmed overall hematologic response rate (partial response, very good partial response, complete response) of isatuximab in relapsed/ refractory systemic light chain (AL) amyloidosis. Measured as rate of partial response or better. Partial response is defined as a dFLC decrease of ≥ 50%, but remaining \> 4.0 mg/dL. Very good partial response is defined as the difference between involved and uninvolved FLCs \[dFLC\] \< 4.0 mg/dL. Complete response is defined as laboratory values within the normal range free light chain (FLC) ratio (0.25 - 1.65) and negative serum and urine immunofixation.
Time frame: From date of enrollment until progression or death due to any cause, whichever occurs first, assessed up to 4 years
Population: 35 participants who received treatment and are analyzable.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Isatuximab | Assess Efficacy by Confirmed Overall Hematologic Response | 77.1 percentage of paticipants |
Secondary
Duration of Response (24 Month Estimate)
Duration of response is measure as time between hematologic response and hematologic progression. Hematologic progression is defined as 50% increase from nadir. While duration of response was assessed up to 4 years, 4 year estimates were not reached. We are reporting the 24 month estimate (how many participants achieved 24 month duration of response)
Time frame: Up to 2 years
Population: 27 participants with response to study treatment
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Isatuximab | Duration of Response (24 Month Estimate) | 81 Percent of Participants |
Secondary
Overall Survival (24 Month Estimate)
Overall survival is measured from date of registration to date of death due to any cause. Patients last known to be alive are censored at date of last contact. While OS was assessed up to 4 years, 4 year estimates were not reached. We are reporting the 24 month estimate (how many participants reached survival time of at least 24 months).
Time frame: From date of enrollment up to 2 years
Population: 35 eligible participants who received at least one dose of study drug.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Isatuximab | Overall Survival (24 Month Estimate) | 85 percent of participants |
Secondary
Progression-free Survival (24 Month Estimate)
To evaluate progression-free survival (24 month estimate) Hematologic progression is defined as 50% increase from nadir, or from baseline (if there was no response) in any ONE OR MORE of the following: 1. Serum M-protein: 50% increase in Serum M protein to a value greater than 0.5 g/dL. 2. Urine M protein: 50% increase in Urine M protein to a value greater than 200 mg/day (a visible peak must be present) 3. Free light chain increase of 50% to a value greater than 10 mg/dL
Time frame: From registration to time of confirmed hematologic progression
Population: 35 participants were analyzable
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Isatuximab | Progression-free Survival (24 Month Estimate) | 74 percentage of paticipants |
Secondary
Time to Hematologic Response
To evaluate time to hematologic response. Partial response is defined as a dFLC decrease of ≥ 50%, but remaining \> 4.0 mg/dL. Very good partial response is defined as the difference between involved and uninvolved FLCs \[dFLC\] \< 4.0 mg/dL. Complete response is defined as laboratory values within the normal range free light chain (FLC) ratio (0.25 - 1.65) and negative serum and urine immunofixation.
Time frame: From registration to time of confirmed hematologic progression
Population: Of the 35 analyzable participants, 27 achieved a response.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Isatuximab | Time to Hematologic Response | 1.1 Months |
Secondary
To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab.
Only adverse events that are possibly, probably or definitely related to study drug are reported.
Time frame: From date of enrollment until progression or death due to any cause, whichever occurs first, assessed up to 4 years
Population: Participants who completed at least one day of treatment.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Fatigue | 1 Participants |
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Atrial fibrillation | 1 Participants |
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Infections and infestations - Other, specify | 1 Participants |
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Infusion related reaction | 1 Participants |
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Lung infection | 2 Participants |
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Lymphocyte count decreased | 3 Participants |
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Pancreatitis | 1 Participants |
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Pruritus | 1 Participants |
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Skin infection | 1 Participants |
| Isatuximab | To Evaluate Toxicities in the Treatment of Relapsed/Refractory AL Amyloidosis With Isatuximab. | Syncope | 1 Participants |