Patient case: 13-year-old male with acute myeloid leukemia; genetic feature: FLT3

Clinical trial: PLX3397 in Children and Young Adults With Refractory Leukemias and Refractory Solid Tumors Including Neurofibromatosis Type 1 (NF1) Associated Plexiform Neurofibromas (PN)

Summary: Background:
  - Some people with cancer have solid tumors. Others have refractory leukemia. This doesn t go away after treatment. Researchers want to see if a drug called PLX3397 can shrink tumors or stop them from growing.
  Objectives:
  - To find the highest safe dose and side effects of PLX3397. To see if it helps treat certain types of cancer.
  Eligibility:
  -  People ages 3 22 with a solid tumor or leukemia that has returned or not responded to cancer therapies.
  -  For Phase II, people ages 3 31 with a Neurofibromatosis Type 1 (NF1) Associated Plexiform Neurofibroma (PN) that cannot be removed with surgery.
  Design:
  -  Participants will be screened with:
  -  Medical history
  -  Physical exam
  -  Blood and urine tests
  -  Heart tests
  -  Scans or other tests of the tumor
  -  Participants will take PLX3397 as a capsule once daily for a 28-day cycle. They can do this for up to 2 years.
  -  During the study, participants will have many tests and procedures. They include repeats of the screening tests. Participants will keep a diary of symptoms.
  -  Participants with solid tumors will have scans or x-rays.
  -  Participants with NF1 PN will have MRI scans.
  -  Participants with leukemia will have blood tests. They may have a bone marrow sample taken.
  -  Some participants may have a biopsy.
  -  When finished taking PLX3397, participants will have follow-up visits. They will repeat the screening tests and note side effects.
  -  Phase II will follow the same procedures as Phase I above, but participants will also fill out questionnaires about their pain and quality of life.

Detailed description: Background
  -  Traditional therapeutic approaches to pediatric cancer have focused on cytotoxic agents and, more recently, targeted inhibition of cellular signaling pathways through the use of small molecule kinase inhibitors. Despite these interventions, significant numbers of pediatric cancer patients develop recurrent and resistant disease. Targeting the tumor microenvironment is a promising but incompletely explored strategy for the treatment of pediatric cancer and non-cancer tumors.
  -  This trial will begin to explore the disruption of the interaction between neoplastic cells and the myeloid component of the tumor microenvironment as a treatment strategy for pediatric cancers and neurofibromatosis type 1 (NF1) related plexiform neurofibromas (PN) and malignant peripheral nerve sheath tumor (MPNST).
  -  PLX3397 is an orally available small molecule inhibitor of class III protein tyrosine kinases including Kit, CSF1R (colony stimulating factor 1 receptor)/Fms (Feline McDonough Sarcoma), and oncogenic Flt3 (Fms like tyrosine kinase).
  Primary Objectives
  -  Phase I: Evaluate the safety and tolerability of PLX3397, and determine a recommended phase II dose of PLX3397 in pediatric patients with refractory solid tumors including NF1 MPNST and brain tumors or refractory leukemias, limited to acute myelogenous leukemia (AML) and acute lymphoblastic leukemia (ALL).
  -  Phase II: Determine the anti-tumor activity of PLX3397 in patients with NF1 PN. Objective response rate (ORR) will be defined as the proportion of patients with a partial response (PN volume decrease greater than or equal to 20% determined by volumetric MRI analysis). PN Cohort temporarily suspended as requested by the FDA due to IND Safety Report of 07 October 2016.
  Eligibility
  -  Tumor type:
  -  Phase I: Children (greater than or equal to 3 and lessthan or equal to 21 years of age) with recurrent or refractory solid tumors including primary neoplasms of the central nervous system and patients with NF1 and MPNST. NF1 PN only Cohort temporarily suspended as requested by the FDA due to IND Safety Report of 07 October 2016., or Children (greater than or equal to 3 and less than or equal to 21 years of age) with refractory leukemias (AML or ALL) (Phase 1).
  -  Phase II: Patients with NF1 and inoperable PN, that cause morbidity (greater than or equal to 3 and lessthan or equal to 35 years of age). PN Cohort temporarily suspended as requested by the FDA due to IND Safety Report of 07 October 2016.
  -  Subjects must have adequate performance status, be able to swallow tablets, may not be pregnant or breastfeeding, and have adequate major organ function. Subjects with history of severe or uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic cardiovascular or pulmonary disease, or history of prolonged QT syndrome will be excluded.
  Design
  -  Phase I
  -  Using a rolling-six phase I design with 2-6 subjects per dose level and standard definitions of MTD (during cycle 1) and DLT.
  -  PLX3397 will be administered orally (200 mg capsules) once daily on a continuous basis for cycles of 28 days without a rest period between cycles. Patients must be able to swallow intact capsules. Dosing will be based on body surface area (BSA), and the total weekly dose will be rounded to within 10% of calculated dose using a dosing nomogram.
  -  At the MTD, the recommended phase II dose level will be expanded to up to 12 patients with attempts made to enroll at least 3 patients with refractory solid tumors and 3 patients with refractory acute leukemia (ALL and AML) to gain more experience with the toxicities and pharmacokinetics of PLX3397 in these disease cohorts. Attempts will be made to enroll equal numbers of patients between the ages of 3 and 12 years and over 12 years of age to gain pharmacokinetic and safety data over a broad age range.
  -  Phase II (PN Cohort temporarily suspended as requested by the FDA due to IND Safety Report of 07 October 2016.)
  -  A Simon 2-stage design will be used: 9 evaluable patients with NF1 and inoperable PN that cause morbidity will be enrolled on the initial stage, and if greater than or equal to 1/9 patients have a response (PN volume decrease greater than or equal to 20% compared to baseline), enrollment will be expanded to a total of 17 evaluable patients.
  -  Impact of therapy on patient-reported outcomes will be evaluated in patients with PN. This study will assess both general health-related qualify of life (QOL) and pain (pain intensity and pain interference) as patient-reported outcomes (PROs).
  -  To complete both Phase I and Phase II portions, a maximum of (24 + 17= 41 plus up to 6 to replace inevaluable patients) 47 patients will be accrued in 2 to 2.5 years.

Eligibility: -  INCLUSION CRITERIA:
  Enrollment in the cohort of patients with NF1 inoperable plexiform neurofibromas (PN) is temporarily suspended as of Amendment G as requested by the FDA due to IND Safety Report of 07 October 2016. Patient accrual of patients with NF1 and MPNST may continue in the Phase I Portion.
  -  Diagnosis:
  -  Phase I: Patients must have recurrent or refractory solid tumors or acute leukemia (limited to AML or ALL) or have been intolerant of prior therapies, confirmed by the Laboratory of Pathology, NCI, e.g., solid tumors including rhabdomyosarcoma, Ewing sarcoma, soft tissue sarcomas. These may include primary neoplasms of the central nervous system, such as high-grade (WHO grade III-IV) glioma. Patients with diffuse intrinsic pontine glioma (DIPG) or optic pathway glioma are exempt from histologic verification. For DIPG typical MRI findings must be present which include hypo- or isointense on T1-weighted imaging, hyperintense on FLAIR or T2-weighted imaging, epicenter in the pons in the face of a typical clinical presentation. Optic pathway glioma are located in the optic pathway and are typically hypo- or iso-intense on T1 and hyperintense on T2-weighted images.
  -  In addition, patients with NF1 and with malignant peripheral nerve sheath tumor (MPNST).
  -  Phase II temporarily suspended as requested by the FDA due to IND Safety Report of 07 October 2016
  -  Phase II: inoperable PN causing morbidity, such as (but not limited to) head and neck lesions that could compromise the airway or great vessels, brachial or lumbar plexus lesions that could cause nerve compression and loss of function, lesions that could result in major deformity (e.g., orbital lesions) or significant cosmetic problems, lesions of the extremity that cause limb hypertrophy or loss of function, and painful lesions in patients with NF1.
  -  Histologic confirmation of PN tumor is not necessary in the presence of consistent clinical and radiographic findings, but should be considered if malignant degeneration of a PN is clinically suspected.
  -  A PN is defined as a neurofibroma that has grown along the length of a nerve and may involve multiple fascicles and branches. A spinal PN involves two or more levels with connection between the levels or extending laterally along the nerve. In addition to PN, all study subjects must have either positive genetic testing for NF1 confirmed in a CLIA certified laboratory or have at least one other diagnostic criterion for NF1 listed below (NIH Consensus conference):
  -  Six or more cafe-au-lait macules (greater than or equal to 0.5cm in prepubertal subjects or greater than or equal to 1.5 cm in post pubertal subjects)
  -  Freckling in axilla or groin
  -  Optic glioma
  -  Two or more Lisch nodules
  -  A distinctive bony lesion (dysplasia of the sphenoid bone or dysplasia or thinning of long bone cortex)
  -  A first-degree relative with NF1
  -  Patients must have relapsed after or be refractory to effective standard therapies. For NF1 PN there is no standard medical therapy, and therefore no requirement for prior therapy. There are no limits on number of prior therapeutic regimens.
  -  Disease status: Phase I: Patients with refractory solid tumors including patients with NF1 and MPNST must have evaluable disease, patients with refractory leukemia must have M2 or M3 bone marrow.
  --Phase II: Patients must have measurable disease.Phase II temporarily suspended as requested by the FDA due to IND Safety Report of 07 October 2016
  -  Age (must have BSA greater than or equal to 0.55 m2):
  -  Phase I: greater than or equal to 3 and less than or equal to 21 years of age
  -  Phase II: greater than or equal to 3 and less than or equal to 35 years of age
  -  Informed Consent: All patients or their legal guardians (if the patient is<18 years old) must sign an IRB-approved document of informed consent to demonstrate their understanding of the investigational nature and the risks of this study before any protocol-related studies are performed. When appropriate, pediatric subjects will be included in all discussions.
  -  Patients must be able to swallow capsules.
  -  Performance Status: Karnofsky greater than or equal to 50% for patients > 16 years of age and
  Lansky greater than or equal to 50% for patients less than or eqal to 16 years of age. Subjects who are wheelchair bound because of paralysis will be considered ambulatory when they are up in their wheelchair. Subjects have to be able to travel to the NIH for evaluations.
  -Prior therapy:
  Patients must have fully recovered (to Grade 1) from the acute toxic effects of all prior anti-cancer therapy.
  -  Myelosuppressive chemotherapy: At least 21 days after the last dose of myelosuppressive chemotherapy (42 days if prior nitrosourea).
  -  Biologic (anti-neoplastic agent): At least 7 days after the last dose of a biologic agent. For agents that have known adverse events occurring beyond 7 days after administration, this period must be extended beyond the time during which adverse events are known to occur. The duration of this interval must be discussed with the study chair.
  -  Immunotherapy: At least 42 days after the completion of any type of immunotherapy, e.g. tumor vaccines.
  -  Monoclonal antibodies: At least 3 half-lives of the antibody after the last dose of a monoclonal antibody.
  -  XRT: At least 7 days after local palliative XRT (small port); At least 150 days must have elapsed if prior TBI or if greater than or equal to 50% radiation of pelvis; greater than or equal to 14 days from whole brain radiation, craniospinal radiation, or targeted radiation to CNS tumors. At least 42 days must have elapsed if other substantial BM radiation.
  -  HSCT: greater than or equal to 56 days from stem cell transplant with no evidence of active graft vs. host disease; must be off immunosuppressive therapy for at least 4 weeks and have no active graft-versus-host disease (GVHD) at the time of entry onto this trial.
  -  Surgery: greater than or equal to 14 days from surgery
  -  Others: greater than or equal to 7 days from last dose of short active hematopoietic growth factors, i.e. filgrastim, greater than or equal to 14 days for long-acting, i.e. pegfilgrastim.
  -  Steroids: Patients with CNS tumors who are managed with steroids are eligible if they have no worsening neurologic deficits and are on a stable or decreasing dose of corticosteroids for greater than or equal to 7 days prior to registration. Patients with leukemia receiving corticosteroids or hydroxyurea are eligible provided that the corticosteroids are not being used to manage GVHD and there has been no increase in corticosteroid of hydroxyurea dose for 7 days prior to starting PLX3397
  -  Patient must have adequate organ function:
  -  Adequate bone marrow reserve: ANC greater than or equal to 1000/mm3, Hemoglobin greater than or equal to 9 gm/dL (transfusion permitted), platelets greater than or equal to 100,000/mm3 (transfusion independent (except for patients with marrow involvement by disease where there is no blood count requirement, except for platelet count which must be greater than or equal to 25,000 prior to enrollment (can be achieved with transfusion).
  -  Adequate renal function: serum creatinine normal for age or calculated CrCl greater than or equal to 70 ml/min/1.73 m2
  -  Adequate hepatic function: AST and ALT less than or equal to 3.0 X ULN, Bilirubin less than or equal to 1.5 X ULN, and albumin greater than or equal to 2.5 gm/dl. However, in the presence of liver metastases or in patients with refractory leukemias, AST and ALT must be < 5 X ULN. Albumin greater than or equal to 2.8 gm/dl.
  -  Cardiac ejection fraction greater than or equal to 50%, and QTcF < 450 ms (male) or <470 ms (female) on ECG at Baseline. (Fridericia's Formula: QTcF = (QT)/RR0.33)
  -  Contraception: Women of child-bearing potential must agree to use an effective method of birth control during treatment and for 3 months after receiving their last dose of study drug. Fertile men must also agree to use an acceptable method of birth control while on study drug and for at least 3 months after last dose.
  EXCLUSION CRITERIA:
  -  Individuals who are pregnant or breast feeding or who become pregnant while enrolled on this trial will be excluded from participation, due to the unknown effects of PLX3397 on a growing fetus or newborn child.
  -  Individuals with malignant peripheral nerve sheath tumors will not be eligible to participate in the phase II portion of the trial.
  -  Ongoing treatment with any other cancer therapy or investigational agent, with the exception of IT chemotherapy for leukemia, when indicated.
  -  Individuals who require therapy with warfarin.
  -  Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements.
  -  Active untreated infection.
  -  Known chronic Hepatitis B or C, or HIV infection.
  -  History of allergic reactions attributed to compounds of similar chemical or biologic composition to PLX3397 or other agents used in study.
  -  Patients with PT and/or INR higher than or equal to 1.5 time upper limit of normal, unless patients have lupus anticoagulant in which case they are eligible if cleared by hematology.
  -  Drugs that strongly inhibit or potentiate CYP3A4:
  -  During Phase I: patients who have received these drugs within 14 days or within 5 half-lives of the drug (whichever is longer) prior to study initiation will be excluded.
  -  During Phase II: These drugs should be avoided if possible, as these drugs could increase or decrease blood levels of PLX3397.

Relevance to patient case: not relevant