Bevacizumab, Lenalidomide, and Dexamethasone in Patients With Relapsed or Refractory Stage II or III Multiple Myeloma

Study Overview
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Brief Summary
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This phase II trial is studying how well giving bevacizumab together with lenalidomide and dexamethasone works in treating patients with relapsed or refractory stage II or stage III multiple myeloma. Monoclonal antibodies, such as bevacizumab, can block cancer growth in different ways. Some block the ability of cancer cells to grow and spread. Others find cancer cells and help kill them or carry cancer-killing substances to them. Bevacizumab and lenalidomide may stop the growth of multiple myeloma by blocking blood flow to the cancer. Dexamethasone may stimulate the immune system in different ways and stop cancer cells from growing. Giving bevacizumab together with lenalidomide and dexamethasone may kill more cancer cells.

Detailed Description
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PRIMARY OBJECTIVES: I. Determine the overall response rate (complete response and partial response) in patients with relapsed or refractory stage II or III multiple myeloma treated with bevacizumab, lenalidomide, and dexamethasone. SECONDARY OBJECTIVES: I. Determine time to progression in these patients. II. Determine the toxicity and tolerability of this regimen. III. Determine the effect of bevacizumab and lenalidomide on markers of myeloma activity in myeloma cells and stromal cells, including interleukin-6, macrophage inflammatory protein-1α, vascular endothelial growth factor, and STAT3. IV. Assess local cytokine milieu using tissue microarrays of bone marrow biopsy specimens. OUTLINE: This is a multicenter, open-label study. Patients receive bevacizumab IV over 30-90 minutes on days 1 and 15, oral lenalidomide on days 1-21, and oral dexamethasone on days 1, 8, 15, and 22. Courses repeat every 4 weeks in the absence of disease progression or unacceptable toxicity. Blood samples are collected at baseline and before courses 2 and 4. Blood samples are examined for vascular endothelial growth factor (VEGF) and VEGF receptor (VEGFR) polymorphisms by pyrosequencing and VEGF, VEGFR1, VEGFR2, interleukin-6, and macrophage inflammatory protein 1 by immunoenzyme techniques. Relationships between plasma cell myeloma and stroma and the effect of study treatment on these relationships are examined in tissue sections of bone marrow before and after treatment utilizing microvessel density measurements, VEGF staining, and STAT3 staining (by immunohistochemistry and fluorescent in situ hybridization [FISH]). After completion of study treatment, patients are followed periodically for at least 5 years.

Official Title
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Phase II Trial of Bevacizumab Combined With Lenalidomide and Dexamethasone (BEV/REV/DEX) in Relapsed or Refractory Multiple Myeloma

Conditions
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Multiple Myeloma in Relapse, Stage II Multiple Myeloma, Stage III Multiple Myeloma

Intervention / Treatment
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* Biological: bevacizumab
* Drug: lenalidomide
* Drug: dexamethasone


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Histologically or cytologically confirmed symptomatic multiple myeloma: Stage II or III disease Relapsed or refractory disease after >= 2 courses of prior chemotherapy Measurable levels of monoclonal protein (M protein) > 1.0 g/dL by serum protein electrophoresis OR > 200 mg of monoclonal light chain by 24-hour urine protein electrophoresis Measurable bone disease, defined as >= 1 unidimensionally measurable lesion (longest diameter to be recorded) >= 20 mm with conventional techniques OR >= 10 mm with spiral CT scan (for patients with lytic bone disease) No known brain metastases ECOG performance status (PS) 0-2 OR Karnofsky PS 70-100% Patients with PS of 3 are eligible if it is due to pain that is likely to improve with treatment Life expectancy > 6 months No known HIV positivity No abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess within the past 6 months No active infections requiring oral or intravenous antibiotics within the past week No proteinuria (i.e., albuminuria) > 1,000 mg/24 hours unless related to the diagnosis of multiple myeloma Patients with light chain (i.e., Bence-Jones) proteinuria are still eligible if the non-light chain component of protein is < 1,000 mg/24 hours No serious nonhealing wound or ulcer No blood pressure > 150/90 mm Hg (even with medication) No significant traumatic injury within the past 28 days No clinically significant peripheral vascular disease No evidence of bleeding diathesis or coagulopathy No unstable angina or myocardial infarction within the past 6 months No stroke within the past 6 months No New York Heart Association class III or IV heart failure No secondary malignancy within the past 2 years except squamous cell or basal cell carcinoma of the skin or carcinoma in situ of the cervix Hemoglobin > 9 g/dL (may be supported by transfusion or growth factors) WBC >= 2,000/mm^3 Absolute neutrophil count >= 1,000/mm^3 Platelet count >= 75,000/mm^3 Bilirubin =< 2.5 mg/dL At least 4 weeks since prior chemotherapy or radiotherapy and recovered More than 7 days since prior minor surgical procedures, fine-needle aspirations, or core biopsies: More than 24 hours since prior bone marrow biopsy or central veinous access placement More than 28 days since prior major surgical procedure or open biopsy At least 4 weeks since prior and no concurrent participation in another experimental drug study Prior autologous peripheral blood stem cell transplantation allowed No prior lenalidomide Concurrent full-dose anticoagulants allowed provided all of the following criteria are met: No active bleeding or pathological condition that carries a high risk of bleeding (e.g., tumor involving major vessels or known varices) No thrombocytopenia requiring transfusion Platelet count > 75,000/mm3 INR 2-3 and stable No concurrent major surgery No concurrent sargramostim (GM-CSF) No other concurrent investigational agents No other concurrent anticancer agents or therapies AST and ALT =< 5 times upper limit of normal Creatinine < 2.5 mg/dL Not pregnant or nursing Negative pregnancy test Fertile patients must use 2 methods of effective contraception 4 weeks before, during, and 4 weeks after completion of study treatment No history of allergic reactions attributed to compounds of similar chemical or biological composition to lenalidomide and/or bevacizumab or other agents used in the study

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

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


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Arm I<br>Patients receive bevacizumab IV over 30-90 minutes on days 1 and 15, oral lenalidomide on days 1-21, and oral dexamethasone on days 1, 8, 15, and 22. Courses repeat every 4 weeks in the absence of disease progression or unacceptable toxicity. | Biological: bevacizumab<br>* Given IV<br>* Other names: rhuMAb VEGF;Drug: lenalidomide<br>* Given orally<br>* Other names: Revlimid;Drug: dexamethasone<br>* Given orally<br>* Other names: DXM;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Confirmed Anti-tumor Response Rate (Complete Response and Partial Response) to the Combination of Bevacizumab and Lenalidomide | Patient response to the treatment were determined by the definitions for complete response, partial response, marginal response, stable disease, and progressive disease outlined by IMBTR/ABMTR (Blade criteria). Responses were analyzed by descriptive statistics and summarized in tabular format (frequency tables). Furthermore, two-sided 95% confidence intervals for the proportions of subjects with a confirmed anti-tumor response were computed using the method proposed by Chang, which takes into account the multiplicity problem associated with the two-stage testing procedure. The objective response rate was estimated by using Whitehead's bias-adjustment approach. | Up to 5 years | 
| Progression Free Survival (Time to Progression) | Patient response to the treatment were determined by the definitions for complete response, partial response, marginal response, stable disease, and progressive disease outlined by IMBTR/ABMTR (Blade criteria). Progression free survival was summarized using point estimates of the median time to progression and associated 95% confidence intervals. The data was presented graphically using Kaplan-Meier plots. Exploratory analysis, including multivariate Cox regression with demographic variables and markers of myeloma activity as covariates was performed. | up to five years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Toxicity and Tolerability of the Bevacizumab and Lenalidomide Combination | Adverse events/toxicities were collected during regular clinical visits. Confidence intervals for the estimate of the true number of patients suffereing from grade 3 or 4 toxicities per common terminology criteria were calculated using the Wilson interval. Ninety-five percent confidence intervals for the proportions of patients with complications (grade 3 or higher toxicities) were constructed. | Up to 5 years | 
| Effect of Bev/Rev on Markers of Myeloma Activity in Myeloma Cells and Stromal Cells at Baseline | A Wilconxon signed-rank test conducted to determine if biomarker levels differed between baseline levels and those after three full cycles of treatment for all patients. | Baseline | 
| Local Cytokine Milieu Using Tissue Micro Arrays of Bone Marrow Biopsy Specimens |  | Up to 5 years | 
| Effect of Bev/Rev on Markers of Myeloma Activity in Myeloma Cells and Stromal Cells at 3 Months Post-baseline | A Wilconxon signed-rank test conducted to determine if biomarker levels differed between baseline levels and those after three full cycles of treatment for all patients. | Up to Course 4 Day 1 (3 Months Post-baseline) |