Outcome of patients with recurrent/refractory osteosarcoma enrolled in three recent phase II trials: A report from the Children’s Oncology Group.
Authors: Rao Seema , Han Ruxu , Krailo Mark D. , Buxton Allen , Hingorani Pooja , Chou Alexander J. , Gorlick Richard Greg , Reed Damon R. , Janeway Katherine A. , Kopp Lisa M. , Weigel Brenda , Isakoff Michael 
Published: June 2021

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Background: Based on seven prior Phase 2 Children’s Oncology Group (COG) trials, the 4-month event-free survival(EFS) and associated confidence interval for relapsed osteosarcoma with measurable disease according to RECIST was determined to be 12% (95% CI 6 - 19%). Three prospective clinical trials were conducted using this historical benchmark to detect activity defined by an EFS improvement of double the upper confidence interval. This report summarizes the outcome of these studies, describes whether the historical data remains an accurate baseline, and considers implications for future phase II trial study design in relapsed osteosarcoma measurable according to RECIST. Methods: We conducted an analysis of outcome for patients with recurrent/refractory osteosarcoma enrolled in three recent prospective COG phase II trials; AOST1321 (unresected cohort), AOST1322 and AOST1521 that used EFS at 4 months as the primary endpoint. Patients were eligible if they had osteosarcoma that had recurred or become refractory after standard therapy and had measurable disease according to RECIST. We assessed whether risk of an EFS event is modified by age, sex, race/ethnicity, number of prior chemotherapy regimens, or time to first relapse. Results: In each of the three phase II trials (unresected group of AOST1321, AOST1322, AOST1521), the drugs tested (denosumab, eribulin and glembatumumab) were concluded to be not effective due to a failure of the patient populations to meet the prespecified active 4-month progression free survival endpoint. The 4-month EFS for the 57 evaluable patients enrolled on these trials was 7% (95% CI 2 – 16%), similar to the 4-month EFS for 96 patients in the previous seven phase II trials of 12% (95% CI 6 - 19%). The combined EFS at 4 months for all 10 studies is 10% (95% CI 6 – 15%).There was no significant difference in EFS across trials based on age, sex, ethnicity, number of prior treatment regimens, consistent with prior analysis. Data from AOST1321 and AOST1521 were analyzed to determine the impact of time to first recurrence on EFS. Two different quantifications were applied: 1 year or less versus 2 or more years; and 2 years or less versus 3 years or more. Neither categorization was statistically significant. Conclusions: The EFS at 4 months in the three new phase II trials is similar to the previous seven phase II single arm trials. The combined analysis of 153 patients from 10 trials tightens the confidence interval, moving the upper 95% CI to 15%. Modification to future study designs could be considered based on this updated analysis. EFS at 4 months remains a robust primary endpoint. Single-arm trials using this endpoint based on the historical benchmark have accrued rapidly and allowed assessment of multiple novel agents in osteosarcoma. The negative trial results and continued poor outcome highlight the need for new approaches for relapsed osteosarcoma. Clinical trial information: NCT02097238, NCT02470091, NCT02487979.