Sorafenib Tosylate, Combination Chemotherapy, Radiation Therapy, and Surgery in Treating Patients With High-Risk Stage IIB-IV Soft Tissue Sarcoma

Study Overview
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Brief Summary
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This phase II trial studies how well sorafenib tosylate, combination chemotherapy, radiation therapy, and surgery work in treating patients with high-risk stage IIB-IV soft tissue sarcoma. Sorafenib tosylate may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Drugs used in chemotherapy, such as epirubicin hydrochloride and ifosfamide, 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. Radiation therapy uses high energy x rays to kill tumor cells. Giving sorafenib tosylate, combination chemotherapy, radiation therapy, and surgery may be an effective treatment for soft tissue sarcoma.

Detailed Description
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PRIMARY OBJECTIVES: I. To determine the pathologic response rate (>= 95% necrosis) after preoperative treatment with sorafenib (sorafenib tosylate), epirubicin (epirubicin hydrochloride), ifosfamide, and hypofractionated radiation for high risk soft tissue sarcomas of the extremities or body wall. SECONDARY OBJECTIVES: I. To further characterize the safety of sorafenib plus chemoradiotherapy, including wound complication rate. II. To estimate time-to-event rates, including overall survival, overall disease-free survival, distant disease-free survival, and local disease-free survival in patients with high risk soft tissue sarcomas of the extremities or body wall treated with preoperative sorafenib plus chemoradiotherapy and postoperative sorafenib plus chemotherapy. OUTLINE: Patients receive sorafenib tosylate orally (PO) once daily (QD) on days 1-71 and 85-155, epirubicin hydrochloride intravenously (IV) over 3-5 minutes, and ifosfamide IV over 90 minutes on days 15-17, 36-38 (ifosfamide only), 57-59, 99-101, 120-122, and 141-143. Patients undergo external beam radiation therapy (EBRT) on days 36-45 and surgical resection on day 78. Patients with positive margins, undergo EBRT boost on days 91-98. After completion of study treatment, patients are followed up every 4 months for 2 years, every 6 months for 1 year, and then yearly for 2 years.

Official Title
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A Phase II Study of Sorafenib With Chemotherapy, Radiation, and Surgery for High-Risk Soft Tissue Sarcomas

Conditions
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Pleomorphic Rhabdomyosarcoma, Stage IIB Adult Soft Tissue Sarcoma AJCC v7, Stage III Adult Soft Tissue Sarcoma AJCC v7, Stage IV Adult Soft Tissue Sarcoma AJCC v7

Intervention / Treatment
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* Drug: Epirubicin Hydrochloride
* Radiation: External Beam Radiation Therapy
* Drug: Ifosfamide
* Other: Laboratory Biomarker Analysis
* Drug: Sorafenib Tosylate
* Procedure: Therapeutic Conventional Surgery


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Histologically confirmed, soft-tissue sarcoma: excluding rhabdomyosarcoma (pleomorphic rhabdomyosarcoma patients are eligible), Ewing's, primitive neuroectodermal tumor (PNET), osteosarcoma, or gastrointestinal stromal tumor American Joint Committee on Cancer (AJCC) (7th edition) stage IIb, III, or IV patients planned for resection of the primary tumor > 5 cm in greatest dimension Intermediate or high-grade Superficial or deep Sarcoma located on upper (includes shoulder) or lower (includes hip) extremities or on body wall Intermediate or high-grade: grades 2 or 3 on scale of 1-3 Left ventricular ejection fraction (LVEF) >= 50% Absolute neutrophil count (ANC) >= 1500/uL Hemoglobin (Hgb) >= 9.0 g/dL Platelets >= 100,000/uL Creatinine =< 1.5 x upper limit of normal (ULN) Bilirubin =< 1.5 mg/dL Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =< 1.5 x ULN International normalized ratio (INR) < 1.5 or a prothrombin time (PT)/partial thromboplastin time (PTT) within normal limits; patients receiving anti-coagulation treatment with an agent such as warfarin or heparin may be allowed to participate; for patients on warfarin, the INR should be measured prior to initiation of sorafenib and monitored at least weekly, or as defined by the local standard of care, until INR is stable No prior chemotherapy, radiation, or biotherapy No major surgery within 4 weeks prior to study entry No contraindications to limb-sparing surgery; patient should be evaluated by a surgeon who specializes in sarcoma resections prior to study enrollment to ensure patient (pt) is a candidate for limb-sparing surgery No severe peripheral vascular disease Adequate contraception must be used and patients must not be pregnant or breastfeeding; women of childbearing potential and men must agree to use adequate contraception (barrier method of birth control) prior to study entry and for the duration of study participation; men and women should use adequate birth control for at least thirty days after the last administration of sorafenib Women of childbearing potential must have negative serum pregnancy test performed within 7-days prior to registration Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0-1 Patient must sign a study-specific consent form prior to registration Ability to understand and the willingness to sign a written informed consent; a signed informed consent must be obtained prior to any study specific procedures Exclusion Criteria: Patients with known brain metastases; patients with neurological symptoms must undergo a computed tomography (CT) scan/magnetic resonance imaging (MRI) of the brain to exclude brain metastases Uncontrolled intercurrent illness including, but not limited to, ongoing or active serious infection > Common Terminology Criteria for Adverse Events (CTCAE) grade 2, symptomatic congestive heart failure, unstable angina pectoris, cardiac ventricular arrhythmia requiring anti-arrhythmic therapy, or psychiatric illness/social situations that would limit compliance with study requirements; patients must not have unstable angina (angina symptoms at rest) or new onset angina (began within the last 3 months) or myocardial infarction within the past 6 months Uncontrolled hypertension defined as systolic blood pressure > 150 mmHg or diastolic pressure > 90 mmHg, despite optimal medical management Known human immunodeficiency virus (HIV) infection or chronic hepatitis B or C Thrombolic or embolic events such as a cerebrovascular accident including transient ischemic attacks within the past 6 months Pulmonary hemorrhage/bleeding event >= CTCAE grade 2 within 4 weeks of first dose of study drug Any other hemorrhage/bleeding event >= CTCAE grade 3 within 4 weeks of first dose of study drug Serious non-healing wound, ulcer, or bone fracture Evidence or history of bleeding diathesis or coagulopathy Major surgery or significant traumatic injury within 4 weeks of first study drug Use of strong cytochrome P450, family 3, subfamily A, polypeptide 4 (CYP3A4) inducers Known or suspected allergy to sorafenib or any agent given in the course of this trial Any condition that impairs patient's ability to swallow whole pills Any malabsorption problem Pregnant or lactating women are excluded from this study Patients with a currently active second malignancy other than non-melanoma skin cancers are not to be registered; patients are not considered to have a currently active malignancy if they have completed therapy and considered by their physician to be at less than 30% risk of relapse Any uncontrolled thyroid disease Requirement for hemodialysis or peritoneal dialysis

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: Treatment (sorafenib, chemotherapy, radiation, surgery)<br>Patients receive sorafenib tosylate PO QD on days 1-71 and 85-155, epirubicin hydrochloride IV over 3-5 minutes, and ifosfamide IV over 90 minutes on days 15-17, 36-38 (ifosfamide only), 57-59, 99-101, 120-122, and 141-143. Patients undergo EBRT on days 36-45 and surgical resection on day 78. Patients with positive margins, undergo EBRT boost on days 91-98. | Drug: Epirubicin Hydrochloride<br>* Given IV<br>* Other names: Pharmorubicin PFS;Radiation: External Beam Radiation Therapy<br>* Undergo EBRT<br>* Other names: external-beam radiation;Drug: Ifosfamide<br>* Given IV<br>* Other names: Z-4942;Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Drug: Sorafenib Tosylate<br>* Given PO<br>* Other names: sorafenib;Procedure: Therapeutic Conventional Surgery<br>* Undergo surgical resection<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pathologic Response Rate, Defined as the Percentage of Participants With Greater Than or Equal to 95% Necrosis. | Descriptive statistical analysis will be conducted. The proportion with 95% confidence interval will be summarized. | Assessed at surgical resection | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Grade 3-4 Adverse Events | Measured as the number of Grade 3-4 Adverse Events, graded according to National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) version 4.0 | Up to 5 years | 
| Number of Participants With Wound Complications | Wound complication rate, including 1) any secondary operation for wound repair, or 2) wound management without secondary operation including invasive procedures without general or regional anesthesia, readmission for wound care, or persistent deep packing for 120 days or longer. | At least 120 days | 
| Overall Survival at 2 Years | Percentage of patients alive at 2 years, Method of Kaplan-Meier used. | Time from registration until death from any cause | 
| Overall Disease-free Survival (Stage IIB-III Patients) | Time from surgical resection to local recurrence, distant metastatic disease or death, subjects with stage IV disease excluded. Method of Kaplan-Meier \used. | Time from surgical resection to local recurrence, distant metastatic disease, or death, whichever occurs first, assessed up to 2 years | 
| Distant Disease-free Survival (Stage IIB-III Patients) | Time from registration to development of distant metastatic disease or death, subjects with stage IV disease excluded. Method of Kaplan-Meier used. | Time from registration until development of distant metastatic disease or death, whichever occurs first, assessed up to 2 years | 
| Number of Participants With Local Recurrence | Number of patients with local recurrence after surgical resection of the primary tumor | Time from surgical resection until primary analysis ( Median follow-up for local recurrence 17.11 months, range 6.18 - 42.8 months) |