Patient case: 4-year-old female with leukemia; genetic feature: ABL1

Clinical trial: Moxetumomab Pasudotox for Advanced Hairy Cell Leukemia

Summary: Background:
  - Moxetumomab pasudotox is an experimental non-chemotherapy cancer treatment drug. It targets CD22, a molecule on the surface of essentially all hairy cell leukemia cells. Moxetumomab pasudotox binds to CD22, goes into the cell, and releases a toxin which kills the cell. In a phase I trial it had activity in relapsed/refractory hairy cell leukemia with safety profile supporting further clinical study (http://ncbi.nlm.nih.gov/pubmed/22355053). This is a phase III multicenter trial designed to confirm these results.

Detailed description: Background:
  -  Hairy cell leukemia is an indolent B-cell leukemia comprising 2% of all leukemias, or approximately 900 of the 44,000 new cases of leukemia/year in the US
  -  Over the last two decades, immunotoxin research has accumulated to support a role for CD22-targeted therapy in the treatment of HCL.
  -  Moxetumomab pasudotox is a recombinant immunotoxin containing an Fv fragment of an anti-CD22 monoclonal antibody and truncated Pseudomonas exotoxin.
  -  Moxetumomab pasudotox has demonstrated a high complete response (CR) rate in patients with chemoresistant hairy cell leukemia (HCL) and has shown activity in pediatric acute lymphoblastic leukemia as well.
  -  Modification of the structure of moxetumomab pasudotox has greatly improved binding and cytotoxicity toward CD22 expressing malignant cells compared to the precursor molecule. Preclinical and clinical studies have demonstrated that this increase in binding affinity results in improved antitumor activity and tolerability
  -  Currently there are no approved agents with significant efficacy for HCL patients after failure of standard therapy
  Design:
  -  This is a multicenter, single-arm study of moxetumomab pasudotox in patients with relapsed/refractory hairy cell leukemia.
  -  77 patients will be enrolled to receive moxetumomab pasudotox IV on days 1, 3 and 5 of each 28 day cycle for a maximum of 6 cycles or until disease progression, unacceptable toxicity occurs, the subject begins alternate therapy, or documented CR (for subjects who have no assessable minimal residual disease and not to exceed 6 cycles). If less than or equal to 2 of the first 25 patients do not achieve durable CR, no additional patients will be accrued.
  -  The overall IRB accrual ceiling is currently set at 80 to allow for a small number of patients that cannot be assessed for response.

Eligibility: -  INCLUSION CRITERIA:
  -  Patients must have histologically confirmed hairy cell leukemia or hairy cell leukemia variant .with a need for therapy
  -  Patients must be Pseudomonas-immunotoxin naive
  -  Patients must have had at least 2 prior purine analogs, or at least 1 course of purine analog and 1 of either rituximub or BRAF inhibitor.
  -  Men or women age greater than or equal to 18 years.
  -  ECOG performance status less than or equal to 2.
  -  Patients must have adequate organ function
  EXCLUSION CRITERIA
  -  Patients who have had chemotherapy, immunotherapy or radiotherapy within 4 weeks prior to entering the study.
  -  Patients who are receiving any other investigational agents.
  -  Patients with known brain metastases should be excluded from this clinical trial
  -  Patients with clinically significant ophthalmologic findings during screening
  -  Pregnant or breastfeeding females.
  -  Positive for Hepatitis B core antibody surface antigen unless the patient is on Lamivudine or Entecavir and Hepatitis B Viral DNA load is less than 2000 IU/mL.
  -  Lymph nodes greater than 4cm or prior splenectomy
  -  Active second malignancy requiring treatment other than minor resection of indolent cancers like basal cell and squamous skin cancers
  -  HIV-positive patients unless taking appropriate anti-HIV medications with a CD4 count of greater than 200.
  -  History of allogeneic bone marrow transplant.
  -  Patients with history of both thromboembolism and known congenital hypercoagulable conditions.
  -  Uncontrolled pulmonary infection, pulmonary edema.
  -  Aequate oxygen saturation
  -  Radioimmunotherapy within 2 years prior to enrollment in study.
  -  Adequate hematologic function
  -  Adequate lung function
  -  Patients with history of thrombotic microangiopathy or TTP-HUS.
  -  Patients with QTc interval (Federica) elevation > 500 msec based on at least 2 separate 12-lead ECGs
  -  Patient on high dose estrogen
  -  Patients with clinical evidence of disseminated intravascular coagulation

Relevance to patient case: not relevant