Ixazomib Citrate, Lenalidomide, and Dexamethasone in Treating Patients With POEMS Syndrome

Study Overview
=================
Brief Summary
-----------------
This phase II trial studies how well ixazomib citrate, lenalidomide, and dexamethasone work in treating patients with polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome. Ixazomib citrate may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Chemotherapy drugs, such as lenalidomide, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Anti-inflammatory drugs, such as dexamethasone lower the body's immune response and are used with other drugs in the treatment of some types of cancer. Giving ixazomib citrate, lenalidomide, and dexamethasone may work better in treating patients with POEMS syndrome.

Detailed Description
-----------------
PRIMARY OBJECTIVE: I. Normalization of VEGF after 3 cycles of therapy. SECONDARY OBJECTIVES: I. Toxicity and safety of the combination of ixazomib citrate (ixazomib), lenalidomide, and dexamethasone. II. Hematologic response after 3 cycles of therapy. III. Hematologic response rates and/or VEGF response at 12 months. IV. Overall survival. EXPLORATORY OBJECTIVES: I. Improvement of peripheral neuropathy (Overall Neuropathy Limitations Scale [ONLS], Modified Neurological Impairment Score for POEMS [mNIS+7POEMS], and performance score), ascites/effusions, diffusing capacity of the lungs for carbon monoxide (DLCO) after 3 cycles of therapy. II. Improvement of peripheral neuropathy (ONLS, mNIS+7POEMS, and performance score), ascites/effusions, DLCO, and positron emission tomography (PET)-scan (if abnormal at baseline) at 12 months (both groups) and at 24 and 36 months (group 2 only). III. Time to VEGF response, hematologic response, and clinical response. IV. Time to VEGF progression, hematologic progression, and clinical progression. V. Doses delivered will be tabulated to establish tolerance of study drugs. CORRELATIVE RESEARCH OBJECTIVES: I. To describe changes in bone biomarkers with treatment of ixazomib, lenalidomide, and dexamethasone. OUTLINE: Patients are assigned to 1 of 2 groups. GROUP I: Patients receive ixazomib citrate orally (PO) on days 1, 8, and 15, lenalidomide PO once daily (QD) on days 1-21, and dexamethasone PO on days 1, 8, 15, and 22. Treatment repeats every 28 days for up to 3 cycles in the absence of disease progression or unacceptable toxicity. Patients undergo standard of care autologous stem cell transplant (ASCT) after completing 3 cycles of treatment. GROUP II: Patients receive ixazomib citrate PO, lenalidomide PO QD, and dexamethasone PO as in Group I. Treatment repeats every 28 days for up to 13 cycles in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up every 3 months until disease progression and then every 6 months for up to 36 months.

Official Title
-----------------
Ixazomib, Lenalidomide, and Dexamethasone for Patients With POEMS Syndrome

Conditions
-----------------
Plasmacytoma, POEMS Syndrome

Intervention / Treatment
-----------------
* Drug: Dexamethasone
* Drug: Ixazomib Citrate
* Drug: Lenalidomide
* Other: Questionnaire Administration


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: POEMS syndrome requiring therapy, previously treated or untreated Plasma vascular endothelial growth factor (VEGF) > 2 x upper limit of normal (ULN) Presence of a plasma cell clone (any of the following): Monoclonal protein in the serum or urine Measurable light chains by free light chain assay Measurable plasmacytoma Monoclonal plasma cells in bone marrow Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0, 1, 2, or 3 Absolute neutrophil count (ANC) >= 1000/uL obtained =< 14 days prior to registration Platelet count (PLT) >= 75,000/uL obtained =< 14 days prior to registration Total bilirubin =< 2.0 mg/dL unless due to known Gilbert's disease obtained =< 14 days prior to registration NOTE: If total bilirubin is > 2 mg/dL, a direct bilirubin should be performed and must be < 1.5 mg/dL for Gilbert's to be diagnosed Alanine aminotransferase (ALT/serum glutamic pyruvic transaminase [SGPT]) and aspartate aminotransferase (AST, serum glutamic oxaloacetic transaminase [SGOT]) =< 3 x upper limit of normal (ULN) obtained =< 14 days prior to registration Creatinine clearance >= 30 mL/min/1.73 m^2 (as determined by Cockcroft-Gault equation) obtained =< 14 days prior to registration Negative serum pregnancy test done =< 7 days prior to registration, for women of childbearing potential only NOTE: Females of reproductive potential must adhere to the scheduled pregnancy testing as required in the Revlimid Risk Evaluation and Mitigation Strategy (REMS) program Birth control Female patients of childbearing potential must be willing to use 2 methods of birth control or be surgically sterile, or abstain from heterosexual activity for the course of the study through 120 days after the last dose of study medication NOTE: Patients of childbearing potential are those who have not been surgically sterilized or have not been free from menses for > 1 year Male patients must agree to use an adequate method of contraception starting with the first dose of study therapy through 120 days after the last dose of study therapy NOTE: Abstinence is acceptable (for either males or females) if this is the established and preferred method of contraception for the subject Willing to adhere to the guidelines of the Revlimid REMS (formerly known as RevAssist) program NOTE: The counseling must be documented Provide written informed consent Willing to return to enrolling institution for follow-up (during the active monitoring phase of the study) Note: During the active monitoring phase of a study (i.e., active treatment and observation), participants must be willing to return to the consenting institution for follow-up No contraindication to be on a minimum of 81 mg aspirin a day (or other anticoagulant therapy as prescribed) for thromboembolism prophylaxis Willing to provide mandatory blood and bone marrow samples for research purposes Ability to complete questionnaire(s) by themselves or with assistance Exclusion Criteria: Recent prior chemotherapy: Newly diagnosed patients (regardless of group); any prior chemotherapy for POEMS with the following exceptions: Prior immunomodulators like azathioprine, cyclosporin, and/or corticosteroids are not exclusionary therapies if used for prior diagnosis of chronic inflammatory demyelinating polyneuropathy Prior chemotherapy directed at a myeloproliferative neoplasm like hydroxyurea is not exclusionary Previously treated patients (group 2) Alkylators (e.g. melphalan, cyclophosphamide) =< 28 days prior to registration Anthracyclines =< 28 days prior to registration High dose corticosteroids, immune modulatory drugs (thalidomide or lenalidomide), or proteosome inhibitors (e.g. ixazomib or bortezomib) =< 28 days prior to registration Requirement for concomitant high dose corticosteroids EXCEPTION: Patients may be on chronic steroids (maximum dose 20 mg/day prednisone equivalent) if they are being given for adrenal insufficiency, rheumatoid arthritis, etc Receiving any other investigational agent, which would be considered as a treatment for the primary neoplasm Participation in other clinical trials, including those with other investigational agents not included in this trial, =< 30 days prior to registration and throughout the duration of this trial Prior refractoriness to proteasome inhibitor or immunomodulatory drugs (IMiD) Any of the following because this study involves an agent that has known genotoxic, mutagenic and teratogenic effects: Pregnant women Nursing women Men or women of childbearing potential who are unwilling to employ adequate contraception Other active malignancy =< 3 years prior to registration EXCEPTIONS: Non-melanotic skin cancer, ductal carcinoma in-situ, or carcinoma-in-situ of the cervix NOTE: If there is a history of prior malignancy, they must not be receiving other specific treatment for their cancer Co-morbid systemic illnesses or other severe concurrent disease which, in the judgment of the investigator, would make the patient inappropriate for entry into this study or interfere significantly with the proper assessment of safety and toxicity of the prescribed regimens, e.g. uncontrolled infection (infection requiring systemic antibiotic therapy or other serious infection =< 14 days prior to registration); or uncompensated heart or lung disease Immunocompromised patients and patients known to be human immunodeficiency virus (HIV) positive and currently receiving antiretroviral therapy Systemic treatment with strong CYP3A inducers (rifampin, rifapentine, rifabutin, carbamazepine, phenytoin, phenobarbital), or use of St. John's wort =< 14 days prior to registration History of myocardial infarction =< 6 months prior to registration, or congestive heart failure requiring use of ongoing maintenance therapy for life-threatening ventricular arrhythmias Radiotherapy =< 14 days prior to registration Major surgery =< 14 days prior to registration Failure to fully recover (i.e. =< grade 1 adverse event [AE]) from the reversible effects of prior chemotherapy Known allergy to any of the study medications, their analogs, or excipients in the various formulations of any agent Known gastrointestinal (GI) disease or GI procedure that could interfere with the oral absorption or tolerance of the study drugs including difficulty swallowing Ongoing or active systemic infection or active hepatitis B or C virus infection

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Group I (ixazomib citrate, lenalidomide, dexamethasone, ASCT)<br>Patients receive ixazomib citrate PO on days 1, 8, and 15, lenalidomide PO QD on days 1-21, and dexamethasone PO on days 1, 8, 15, and 22. Treatment repeats every 28 days for up to 3 cycles in the absence of disease progression or unacceptable toxicity. Patients undergo standard of care ASCT after completing 3 cycles of treatment. | Drug: Dexamethasone<br>* Given PO<br>* Other names: ZoDex;Drug: Ixazomib Citrate<br>* Given PO<br>* Other names: Ninlaro;Drug: Lenalidomide<br>* Given PO<br>* Other names: Revlimid;Other: Questionnaire Administration<br>* Ancillary studies<br>|
| Experimental: Group II (ixazomib citrate, lenalidomide, dexamethasone)<br>Patients receive ixazomib citrate PO, lenalidomide PO QD, and dexamethasone PO as in Group I. Treatment repeats every 28 days for up to 13 cycles in the absence of disease progression or unacceptable toxicity. | Drug: Dexamethasone<br>* Given PO<br>* Other names: ZoDex;Drug: Ixazomib Citrate<br>* Given PO<br>* Other names: Ninlaro;Drug: Lenalidomide<br>* Given PO<br>* Other names: Revlimid;Other: Questionnaire Administration<br>* Ancillary studies<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of normalization of VEGF defined as VEGF value decreasing to below upper limit of normal (86 pg/mL) | In each group, the rate of normalization of VEGF by 3 months (post-3 cycles) will be examined along with the prognostic factors for patients accrued to this study. The proportion of successes will be estimated by the number of successes divided by the total number of evaluable patients. Ninety-five percent binomial confidence intervals for the true success proportion will be calculated. | Up to 3 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hematologic response rate | Hematologic response rate after 3 cycles of therapy (or 3 months after registration) will be estimated by the number of hematologic responses (partial response, very good partial response, or complete response) observed within 3 months of registration divided by the total number of evaluable patients. Exact binomial 95% confidence intervals for the true hematologic response rate after 3 cycles of therapy (or 3 months after registration) will be calculated. | Up to 3 months | 
| Hematologic response rate | Hematologic response rate after 13 cycles of therapy (or 12 months) will be evaluated. Exact binomial 95% confidence intervals for the true rates at 12 months will be calculated. | Up to 12 months | 
| Normalization of VEGF | Normalization of VEGF after 13 cycles of therapy (or 12 months after registration) will be evaluated. Exact binomial 95% confidence intervals for the true rates at 12 months will be calculated. | Up to 12 months | 
| Survival time | The distribution of survival time will be estimated using the method of Kaplan-Meier. | Time from registration to death due to any cause, assessed up to 3 years | 
| Incidence of adverse events evaluated according to National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0 | The maximum grade for each type of adverse event will be recorded for each patient, and frequency tables will be reviewed to determine patterns. Additionally, the relationship of the adverse event(s) to the study treatment will be taken into consideration. | Up to 3 years |