Bortezomib and Combination Chemotherapy in Treating Younger Patients With Recurrent, Refractory, or Secondary Acute Myeloid Leukemia
Condition: Adult Acute Monoblastic Leukemia (M5a); Adult Acute Monocytic Leukemia (M5b); Adult Acute Myeloblastic Leukemia With Maturation (M2); Adult Acute Myeloblastic Leukemia Without Maturation (M1); Adult Acute Myeloid Leukemia With 11q23 (MLL) Abnormalities; Adult Acute Myeloid Leukemia With Del(5q); Adult Acute Myeloid Leukemia With t(15;17)(q22;q12); Adult Acute Myeloid Leukemia With t(16;16)(p13;q22); Adult Acute Myelomonocytic Leukemia (M4); Childhood Acute Basophilic Leukemia; Childhood Acute Eosinophilic Leukemia; Childhood Acute Erythroleukemia (M6); Childhood Acute Megakaryocytic Leukemia (M7); Childhood Acute Minimally Differentiated Myeloid Leukemia (M0); Childhood Acute Monoblastic Leukemia (M5a); Childhood Acute Monocytic Leukemia (M5b); Childhood Acute Myeloblastic Leukemia With Maturation (M2); Childhood Acute Myeloblastic Leukemia Without Maturation (M1); Childhood Acute Myelomonocytic Leukemia (M4); Recurrent Adult Acute Myeloid Leukemia; Recurrent Childhood Acute Myeloid Leukemia; Secondary Acute Myeloid Leukemia
MeSH terms: Leukemia; Leukemia, Myeloid; Leukemia, Myeloid, Acute; Neoplasm Metastasis; Leukemia, Myelomonocytic, Acute; Leukemia, Myelomonocytic, Chronic; Leukemia, Monocytic, Acute; Leukemia, Erythroblastic, Acute; Leukemia, Basophilic, Acute; Leukemia, Eosinophilic, Acute; Leukemia, Megakaryoblastic, Acute; Hypereosinophilic Syndrome; Recurrence
Intervention: idarubicin; cytarabine; bortezomib; etoposide; laboratory biomarker analysis
Intervention description: Given IV; Given IV or IT; Given IV; Given IV; Correlative studies
Intervention MeSH terms: Cytarabine; Etoposide; Idarubicin; Etoposide phosphate; Bortezomib
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Enrollment: 52.0
Sex: All
Minimum age: 1 Year
Maximum age: 21 Years
Healthy volunteers: No

Summary:

      This phase II trial is studying the side effects and best dose of bortezomib and to see how
      well it works when given together with combination chemotherapy in treating younger patients
      with recurrent, refractory, or secondary acute myeloid leukemia (AML). Bortezomib may stop
      the growth of cancer cells by blocking some of the enzymes needed for cell growth. Drugs used
      in chemotherapy, such as idarubicin, cytarabine, and etoposide, work in different ways to
      stop the growth of cancer cells, either by killing the cells or by stopping them from
      dividing. Giving more than one drug (combination chemotherapy) together with bortezomib may
      kill more cancer cells
    

Eligibility criteria:

        Inclusion Criteria:

          -  Diagnosis of acute myeloid leukemia (AML) according to WHO classification

               -  At least 5% blasts in the bone marrow

               -  With or without extramedullary disease

          -  To be eligible for the dose-finding phase (closed as of 10/10) :

               -  Relapsed patients must meet the following criteria:

                    -  Must have had a prior diagnosis of AML, but may NOT have inv(16) or t(8;21)
                       cytogenetics

                    -  May be in first or any subsequent relapse

                    -  If in first relapse, remission duration must be less than one year

               -  Refractory patients must meet the following criteria:

                    -  Must have had a prior diagnosis of AML

                    -  May have received one or more attempt at remission induction

               -  Patients with treatment-related AML may be previously treated or untreated for
                  secondary AML

          -  To be eligible for the efficacy phase:

               -  Relapsed patients must meet the following criteria:

                    -  Must have had a prior diagnosis of AML, with no restriction on prior
                       cytogenetics

                    -  Must be in first relapse

                    -  Must not have received prior reinduction therapy

               -  Refractory patients must meet the following criteria:

                    -  Must have had a prior diagnosis of AML

                    -  Must not have received more than one attempt at remission induction (which
                       may consist of up to two therapy courses)

               -  Patients with treatment-related AML must be previously untreated for secondary
                  AML

          -  No juvenile myelomonocytic leukemia or acute promyelocytic leukemia (APL; FAB M3)

          -  Patients with the following CNS status are eligible only in the absence of neurologic
             symptoms suggestive of CNS leukemia, such as cranial nerve palsy:

               -  CNS 1, defined as absence of blasts in cerebral spinal fluid (CSF) on cytospin
                  preparation, regardless of the number of WBCs

               -  CNS 2, defined as presence of < 5/μL WBCs in CSF and cytospin positive for
                  blasts, or > 5/uL WBCs but negative by Steinherz/Bleyer algorithm:

                    -  CNS 2a: < 10/μL RBCs; < 5/μL WBCs and cytospin positive for blasts

                    -  CNS 2b: ≥ 10/μL RBCs; < 5/μL WBCs and cytospin positive for blasts

                    -  CNS 2c: ≥ 10/μL RBCs; ≥ 5/μL WBCs and cytospin positive for blasts but
                       negative by Steinherz/Bleyer algorithm

          -  Patients with CNS3 disease (presence of ≥ 5/μL WBCs in CSF and cytospin positive for
             blasts [in the absence of a traumatic lumbar puncture] and/or clinical signs of CNS
             leukemia) are not eligible

          -  CNS toxicity ≤ grade 2

          -  Lansky (patients ≤ 16 years of age) or Karnofsky (patients > 16 years of age)
             performance status (PS) 50-100%

          -  ECOG PS 0-2

          -  No Down syndrome

          -  No Fanconi anemia, Kostmann syndrome, Shwachman syndrome, or any other known bone
             marrow failure syndrome

          -  No evidence of active graft-vs-host disease

          -  Creatinine clearance or radioisotope glomerular filtration rate ≥ 70 mL/min OR serum
             creatinine based on age/gender as follows:

               -  0.4 mg/dL for patients 1 month to < 6 months of age

               -  0.5 mg/dL for patients 6 months to < 1 year of age

               -  0.6 mg/dL for patients 1 to < 2 years of age

               -  0.8 mg/dL for patients 2 to < 6 years of age

               -  1 mg/dL for patients 6 to < 10 years of age

               -  1.2 mg/dL for patients 10 to < 13 years of age

               -  1.5 mg/dL (male) or 1.4 mg/dL (female) for patients 13 to < 16 years of age

               -  1.7 mg/dL (male) or 1.4 mg/dL (female) for patients ≥ 16 years of age

          -  Total bilirubin ≤ 1.5 times upper limit of normal (ULN) for age

          -  ALT < 3.0 times ULN for age (unless elevation due to leukemia involvement)

          -  Shortening fraction ≥ 27% by ECHO OR LVEF ≥ 50% by gated radionuclide

          -  Normal respiratory rate and pulse oximetry > 94% on room air

          -  FEV_1 ≥ 80% of predicted

          -  FVC and DLCO > 50% (corrected for hemoglobin)

               -  Patients who are unable to perform pulmonary function tests (PFTs) (e.g., because
                  of young age) will be excluded provided they have a medical history of
                  significant prior pulmonary events or chronic pulmonary disease (e.g., pneumonia
                  requiring mechanical ventilation support, pulmonary GVHD, pneumonectomy, or
                  pulmonary toxin exposure)

               -  Children with histories of resolved bronchiolitis, resolved viral pneumonias and
                  well-controlled asthma are eligible, even if they are unable to perform PFTs

          -  Patients with seizure disorder may be enrolled if on a non-enzyme-inducing
             anticonvulsant and if seizures are well-controlled

          -  No uncontrolled infection

          -  No known allergy to idarubicin, cytarabine, etoposide, boron, mannitol or bortezomib

          -  Not pregnant or nursing

          -  Negative pregnancy test

          -  Fertile patients must use effective contraception

          -  Concurrent radiotherapy allowed for patients who present with a chloroma that is
             producing or threatens to produce an irreversible neurologic deficit

          -  Recovered from all prior chemotherapy, immunotherapy, or radiotherapy

          -  More than 2 weeks since prior cytotoxic chemotherapy (4 weeks for nitrosoureas),
             except for hydroxyurea, which is allowed up to 24 hours prior to first dose of study
             drug, and intrathecal chemotherapy, which is allowed immediately up to administration
             of study drug

          -  Prior steroid allowed as clinically indicated for patients with asthma

               -  Hydrocortisone and methylprednisolone allowed as premedication in patients with a
                  history of severe allergic reactions

          -  At least 7 days since prior biologic agents, such as steroids, retinoids, or donor
             lymphocyte infusion without conditioning

          -  At least 2 weeks since prior local palliative radiotherapy (small port)

          -  At least 8 weeks since prior craniospinal radiotherapy or ≥ 50% radiation of pelvis

          -  At least 6 weeks since prior other bone marrow radiation

          -  At least 1 day since prior green tea containing products, any products containing
             vitamin C, flavanoids or other antioxidants (e.g., vitamins, herbal supplements), and
             foods with high vitamin C content

          -  No prior radiotherapy to > 25% of lung volume

          -  No prior total-body irradiation as part of a hematopoietic stem cell conditioning
             regimen

          -  At least 2 months since prior stem cell transplantation

          -  No concurrent graft-vs-host disease prophylactic medication

          -  No prior bortezomib or other proteasome inhibitors

          -  No other concurrent investigational drugs

          -  More than 4 days since prior growth factors that support platelet or white cell number
             or function

          -  No concurrent enzyme-inducing anticonvulsant medications known to be potent inducers
             of the cytochrome P450 system, including phenytoin, carbamazepine, and phenobarbital

               -  Concurrent benzodiazepines and gabapentin allowed

          -  No concurrent grapefruit juice with bortezomib

          -  No other concurrent cancer chemotherapy or immunomodulating agents

          -  No concurrent corticosteroids as anti-emetic therapy

               -  Concurrent corticosteroids therapy allowed as treatment or prophylaxis for
                  anaphylactic reactions, symptoms of cytarabine syndrome, and as treatment for
                  presumptive bortezomib-induced pulmonary toxicity.