Vorinostat Combined With Isotretinoin and Chemotherapy in Treating Younger Patients With Embryonal Tumors of the Central Nervous System

Study Overview
=================
Brief Summary
-----------------
This pilot clinical trial studies the side effects and the best way to give vorinostat with isotretinoin and combination chemotherapy and to see how well they work in treating younger patients with embryonal tumors of the central nervous system. Vorinostat may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Drugs used in chemotherapy, such as isotretinoin, vincristine sulfate, cisplatin, cyclophosphamide, and etoposide phosphate, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving vorinostat with isotretinoin and combination chemotherapy may be an effective treatment for embryonal tumors of the central nervous system. A peripheral blood stem cell transplant may be able to replace blood-forming cells that were destroyed by chemotherapy. This may allow more chemotherapy to be given so that more tumor cells are killed.

Detailed Description
-----------------
PRIMARY OBJECTIVES: I. To investigate the feasibility of administering vorinostat (SAHA) and isotretinoin for three days prior and concomitant with cisplatin based chemotherapy over three courses of induction chemotherapy. II. To describe the toxicity of administering vorinostat (SAHA) and isotretinoin for three days prior and concomitant with cisplatin based chemotherapy over three courses of induction chemotherapy. III. To investigate prognostic values of histopathological classification and biological markers in the context of a feasibility study. SECONDARY OBJECTIVES: I. To estimate the preliminary response rate of this approach in patients with measurable residual disease (primary site and/or metastatic sites). II. To estimate disease specific progression-free and overall survival, in the context of a feasibility study. III. To explore the predictive values of biological markers in cerebrospinal fluid (CSF), plasma, urine tumor material in the context of a feasibility study. OUTLINE: INDUCTION THERAPY: Patients receive vorinostat orally (PO) once daily (QD) and isotretinoin PO twice daily (BID) on days 1-4; vincristine sulfate intravenously (IV) on days 4, 11, and 18; cisplatin IV over 6 hours on day 4; cyclophosphamide IV over 1 hour on days 5-6; and etoposide phosphate IV over 1 hour on days 4-6. Treatment repeats every 21 days for 3 cycles in the absence of disease progression or unacceptable toxicity. Patients also undergo peripheral blood stem cell (PBSC) harvesting after each course. CONSOLIDATION THERAPY: Within 6 weeks (10 weeks if patient is re-staged) after completion of induction therapy, patients receive carboplatin IV over 2 hours and thiotepa IV over 2 hours on days 1-2. Patients also receive autologous PBSC rescue infusion over 6 hours on day 4. Treatment repeats every 28 days for 3 cycles in the absence of disease progression or unacceptable toxicity. Beginning 3 weeks later, patients with M0 non-desmoplastic medulloblastoma also undergo conformal radiotherapy* to the tumor bed. NOTE: *Patients with supratentorial primary tumors or metastatic disease undergo radiotherapy at the discretion of treating physician. MAINTENANCE THERAPY: Beginning 4 weeks after completion of radiotherapy or immediately after completion of consolidation therapy, patients receive vorinostat PO QD on days 1, 3, 5, 6, 8, 10, 12, and 13 and isotretinoin PO BID on days 1-14. Treatment repeats every 28 days for up to 12 cycles in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up every 3 months for 2 years and then every 6 months for 3 years.

Official Title
-----------------
A Feasibility Study of Vorinostat (SAHA) Combined With Isotretinoin and Chemotherapy in Infants With Embryonal Tumors of the Central Nervous System

Conditions
-----------------
Medulloblastoma, Pineoblastoma, Supratentorial Embryonal Tumor, Not Otherwise Specified

Intervention / Treatment
-----------------
* Radiation: 3-Dimensional Conformal Radiation Therapy
* Drug: Carboplatin
* Drug: Cisplatin
* Drug: Cyclophosphamide
* Drug: Etoposide Phosphate
* Drug: Isotretinoin
* Other: Laboratory Biomarker Analysis
* Procedure: Peripheral Blood Stem Cell Transplantation
* Drug: Thiotepa
* Drug: Vincristine Sulfate
* Drug: Vorinostat


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Patients must have a histologically confirmed, newly-diagnosed medulloblastoma (except for patients with the histology of localized (M0) desmoplastic medulloblastoma or atypical teratoid/rhabdoid tumor [ATRT]) or supratentorial primitive neuroectodermal tumor (PNET) including pineoblastomas Patients must have not received any prior therapy other than surgery and/or steroids Patient must have adequate pre-trial formalin-fixed, paraffin-embedded (FFPE) tumor material available for use in the biology studies and central pathology review; if snap frozen tissue is not available, the study chair must be contacted to discuss eligibility Patient must be a suitable candidate, by institutional standards for stem cell apheresis Lansky performance score (LPS for =< 16 years of age) >= 30 assessed within two weeks prior to registration Absolute neutrophil count (ANC) >= 1000/ul (unsupported) (within 14 days of registration and within 7 days of the start of treatment) Platelets >= 100,000/ul (unsupported) (within 14 days of registration and within 7 days of the start of treatment) Hemoglobin >= 8 g/dL (may be supported) (within 14 days of registration and within 7 days of the start of treatment) Bilirubin < 1.5 times upper limit of normal for age (within 14 days of registration and within 7 days of the start of treatment) Serum glutamate pyruvate transaminase (SGPT) (alanine aminotransferase [ALT]) =< 1.5 times institutional upper limit of normal for age (within 14 days of registration and within 7 days of the start of treatment) Serum creatinine =< 1.5 times upper limit of institutional normal for age or glomerular filtration rate (GFR) >= 70 ml/min/1.73 m^2 or estimated GFR (Schwartz bedside) that is > 99 ml/min/1.73 m^2 (within 14 days of registration and within 7 days of the start of treatment) Parents/legal guardians must have the ability to understand and the willingness to sign a written informed consent document according to institutional guidelines Exclusion Criteria: Patients with diagnosis of atypical teratoid/rhabdoid tumor (ATRT by histology, immunohistochemistry and/or molecular analysis) and desmoplastic M0 medulloblastoma will be excluded from the study Patients with any clinically significant unrelated systemic illness (serious infections or significant cardiac, pulmonary, hepatic or other organ dysfunction), that would compromise the patient's ability to tolerate protocol therapy or would interfere with the study procedures or results Patients receiving any other anticancer or investigational drug therapy are excluded Patients having taken valproic acid within 2 weeks prior to initiation of treatment are excluded Patients with inability to return for follow-up visits or obtain follow-up studies required to assess toxicity to therapy Patients with a parabens allergy

Ages Eligible for Study
-----------------
Minimum Age: 2 Months
Maximum Age: 47 Months

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

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

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

Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Treatment (vorinostat, isotretinoin, chemotherapy)<br>See Detailed Description | Radiation: 3-Dimensional Conformal Radiation Therapy<br>* Undergo conformal radiation therapy<br>* Other names: Radiation, 3D Conformal;Drug: Carboplatin<br>* Given IV<br>* Other names: Ribocarbo;Drug: Cisplatin<br>* Given IV<br>* Other names: Platosin;Drug: Cyclophosphamide<br>* Given IV<br>* Other names: WR- 138719;Drug: Etoposide Phosphate<br>* Given IV<br>* Other names: Etopophos;Drug: Isotretinoin<br>* Given PO<br>* Other names: ZENATANE;Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Procedure: Peripheral Blood Stem Cell Transplantation<br>* Undergo PBSC<br>* Other names: Peripheral Stem Cell Transplantation;Drug: Thiotepa<br>* Given IV<br>* Other names: WR 45312;Drug: Vincristine Sulfate<br>* Given IV<br>* Other names: Vincristine, sulfate;Drug: Vorinostat<br>* Given PO<br>* Other names: Zolinza;|

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

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Dose-limiting toxicity of proposed vorinostat | Will be graded by the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. | Up to 21 days | 
| Feasibility in terms of completing 3 courses of induction therapy | Simon's two-stage optimal design will be used to assess feasibility. | Within 98 days | 
| Prognostic value of histopathological classification of pediatric medulloblastoma | Will be assessed by single-nucleotide polymorphism (SNP) analysis and gene expression analysis. Loss of heterozygosity (LOH) analysis and copy number analysis (CNA) will be performed using dChip SNP software (or R bioconductor package) for the paired samples. Association of copy number (and LOH) with gene expression data will be explored. Correlation analysis (Pearson or Spearman Correlation, as appropriate) will be used to estimate the strength of association between each SNP and expression signal. The multiplicity issue will be addressed through estimating the False Discovery Rate. | Up to 5 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Response rate of this approach in patients with measurable residual disease (primary site and/or metastatic sites) | Separate exact confidence interval estimates of objective responses following induction therapy will be constructed for patients with medulloblastomas (MBs) and PNETs. Cumulative incidence of objective responses as a function of course of therapy will also be provided. | Up to 5 years | 
| Progression-free survival (PFS) | Kaplan-Meier estimates of distributions of PFS will be provided. If sample sizes allow, these Kaplan-Meier estimates will be produced separately for patients with MBs and PNETs. | Up to 5 years | 
| Overall survival (OS) | Kaplan-Meier estimates of distributions of OS will be provided. If sample sizes allow, these Kaplan-Meier estimates will be produced separately for patients with MBs and PNETs. | Up to 5 years | 
| Predictive values of biological markers in CSF, plasma and urine in the context of a feasibility study | Frequency of the markers of interest present in this cohort will be provided and their associations with disease outcome will be explored. Similarly if sample size constraints make such analyses feasible, the associations between the markers of interest and clinical and demographic variables will be explored in a descriptive fashion. | Up to 5 years |