Pediatric Trial of Indoximod With Chemotherapy and Radiation for Relapsed Brain Tumors or Newly Diagnosed DIPG

Study Overview
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Brief Summary
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Indoximod was developed to inhibit the IDO (indoleamine 2,3-dioxygenase) enzymatic pathway, which is important in the natural regulation of immune responses. This potent immune suppressive mechanism has been implicated in regulating immune responses in settings as diverse as infection, tissue/organ transplant, autoimmunity, and cancer. By inhibiting the IDO pathway, we hypothesize that indoximod will improve antitumor immune responses and thereby slow the growth of tumors. The central clinical hypothesis for the GCC1949 study is that inhibiting the pivotal IDO pathway by adding indoximod immunotherapy during chemotherapy and/or radiation is a potent approach for breaking immune tolerance to pediatric tumors that will improve outcomes, relative to standard therapy alone. This is an NCI-funded (R01 CA229646, MPI: Johnson and Munn) open-label phase 2 trial using indoximod-based combination chemo-radio-immunotherapy for treatment of patients age 3 to 21 years who have progressive brain cancer (glioblastoma, medulloblastoma, or ependymoma), or newly-diagnosed diffuse intrinsic pontine glioma (DIPG). Statistical analysis will stratify patients based on whether their treatment plan includes up-front radiation (or proton) therapy in combination with indoximod. Central review of tissue diagnosis from prior surgery is required, except non-biopsied DIPG. This study will use the immune-adapted Response Assessment for Neuro-Oncology (iRANO) criteria for measurement of outcomes. Planned enrollment is up to 140 patients.

Detailed Description
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Disease-specific Cohorts : Cohort 1A, 1B: progressive glioblastoma (relapsed or refractory) Cohort 2A, 2B: progressive medulloblastoma (relapsed or refractory) Cohort 3A, 3B, 3C: progressive ependymoma (relapsed or refractory) Cohort 4C: newly-diagnosed DIPG (must have no prior radiation or other therapy) . Radiation (or proton) plan sub-cohorts: Sub-cohort A: for patients not eligible for re-irradiation Sub-cohort B: for patients who are eligible for partial re-irradiation Sub-cohort C: for patients who are eligible for full-dose radiation (All newly diagnosed DIPG patients and some relapsed ependymoma patients)

Official Title
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Phase 2 Trial of Indoximod With Chemotherapy and Radiation for Children With Progressive Brain Tumors or Newly Diagnosed DIPG

Conditions
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Glioblastoma, Medulloblastoma, Ependymoma, Diffuse Intrinsic Pontine Glioma

Intervention / Treatment
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* Drug: Indoximod
* Radiation: Partial Radiation
* Radiation: Full-dose Radiation
* Drug: Temozolomide
* Drug: Cyclophosphamide
* Drug: Etoposide
* Drug: Lomustine


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diagnosis: Progressive disease with histologically proven initial diagnosis of glioblastoma, medulloblastoma, or ependymoma; With confirmation of progression by either MRI or CSF analysis; Measureable disease is not required for study entry; Patients with progressive disease must have been previously treated with therapeutic radiation as part of treatment for the initial brain cancer diagnosis or for a prior relapse. Newly diagnosed DIPG (diffuse intrinsic pontine glioma) with no prior therapy (including no prior radiation); Biopsy is not required for DIPG. Central review of tissue diagnosis is required, except non-biopsied DIPG; Archival tumor tissue must be located and available prior to study entry. Patients with metastatic disease are eligible. Lansky or Karnofsky performance status score must be ≥ 50%. Adequate renal function: creatinine ≤ 1.5-times upper limit of age-adjusted normal. Adequate liver function: ALT ≤ 5-times upper limit of normal. Total bilirubin ≤ 1.5-times upper limit of normal. Adequate Bone marrow function: Absolute neutrophil count (ANC) ≥ 750/mcL. Platelets ≥ 75,000/mcL (transfusion independent). Hemoglobin ≥ 8 g/dL (transfusion independent). Central nervous system: seizure disorders must be well controlled on antiepileptic medication. Prior therapy DIPG patients must not have been treated with any prior radiation or medical therapy. Patients previously treated with indoximod are excluded. Patients previously treated with any other immunotherapy agent, including other IDO-targeted drugs, are eligible for enrollment. Patients previously treated with chemotherapy drugs included in this protocol are eligible for enrollment. Patients must be 14 days from the administration of any investigational agent or prior cytotoxic therapy with the following exceptions: Temozolomide dosed at or above 150 mg/m2 (allowed, but must be at least 21 days from the last dose of temozolomide). Must be 28 days from administration of antibody-based therapies (e.g., bevacizumab), tumor-directed vaccines, or cellular immune therapies (e.g., T cells, NK cells, etc). Must be 56 days from administration of tumor-directed therapies using infectious agents (e.g., viruses, bacteria, etc). Pregnant women are excluded from this study, where pregnancy is confirmed by a positive urine or serum hCG laboratory test. Patients must be able to swallow pills. . Exclusion Criteria: Patients who cannot swallow indoximod pills are excluded. Patients previously treated with indoximod are excluded. Patients with DIPG who have been treated with any prior radiation or medical therapy are excluded. Midline glioma that does not include significant brain stem involvement is not considered DIPG for enrollment purposes, and is excluded. Patients with active systemic infection requiring treatment, including any HIV infection or toxoplasmosis, are excluded. Patients with active autoimmune disease that requires systemic therapy are excluded. Pregnant women are excluded

Ages Eligible for Study
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Minimum Age: 3 Years
Maximum Age: 21 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
Allocation: Non-Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Core Regimen, sub-cohort A<br>For patients not eligible for re-irradiation; Start with Core Regimen chemo-immunotherapy (indoximod with oral temozolomide). | Drug: Indoximod<br>* Indoximod will be taken by mouth twice daily during radiation and throughout each chemo-immunotherapy treatment cycle.<br>Drug: Temozolomide<br>* Temozolomide will be taken by mouth once daily, on days 1-5 of each chemo-immunotherapy treatment cycle.<br>|
| Experimental: Core Regimen, sub-cohort B<br>For patients who are eligible for partial re-irradiation; Start with indoximod plus up-front re-irradiation, using a palliative low-dose or partial-field radiation plan (low-dose radiation or not all disease sites included); Followed by Core Regimen chemo-immunotherapy (indoximod with oral temozolomide). | Drug: Indoximod<br>* Indoximod will be taken by mouth twice daily during radiation and throughout each chemo-immunotherapy treatment cycle.<br>Radiation: Partial Radiation<br>* Palliative low-dose or partial-field radiation plan (low-dose radiation or not all disease sites included).<br>Drug: Temozolomide<br>* Temozolomide will be taken by mouth once daily, on days 1-5 of each chemo-immunotherapy treatment cycle.<br>|
| Experimental: Core Regimen, sub-cohort C<br>For patients who are eligible for full-dose radiation; (All newly diagnosed DIPG patients and some relapsed ependymoma patients); Start with indoximod plus up-front radiation, using a palliative full-dose radiation plan to all known sites of disease (>50 Gy to brain, >45 Gy to spine); Followed by Core Regimen chemo-immunotherapy (indoximod with oral temozolomide). | Drug: Indoximod<br>* Indoximod will be taken by mouth twice daily during radiation and throughout each chemo-immunotherapy treatment cycle.<br>Radiation: Full-dose Radiation<br>* Palliative full-dose radiation plan to all known sites of disease (>50 Gy to brain, >45 Gy to spine).<br>Drug: Temozolomide<br>* Temozolomide will be taken by mouth once daily, on days 1-5 of each chemo-immunotherapy treatment cycle.<br>|
| Experimental: Salvage Regimen 1<br>For patients who wish to continue access to indoximod after progression on the Core Regimen; Cross-over to indoximod with oral metronomic cyclophosphamide and etoposide). | Drug: Indoximod<br>* Indoximod will be taken by mouth twice daily during radiation and throughout each chemo-immunotherapy treatment cycle.<br>Drug: Cyclophosphamide<br>* Cyclophosphamide will be taken by mouth once daily, on days 1-21 of each chemo-immunotherapy treatment cycle.<br>Drug: Etoposide<br>* Etoposide will be taken by mouth once daily, on days 1-21 of each chemo-immunotherapy treatment cycle.<br>|
| Experimental: Salvage Regimen 2<br>For patients who wish to continue access to indoximod after progression on the Core Regimen; Cross-over to indoximod with oral lomustine and temozolomide). | Drug: Indoximod<br>* Indoximod will be taken by mouth twice daily during radiation and throughout each chemo-immunotherapy treatment cycle.<br>Drug: Temozolomide<br>* Temozolomide will be taken by mouth once daily, on days 1-5 of each chemo-immunotherapy treatment cycle.<br>Drug: Lomustine<br>* Lomustine will be taken by mouth once daily, on day 1 of each chemo-immunotherapy treatment cycle.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 8-month iRANO-PFS (Progression-Free Survival, defined by immune-adapted iRANO criteria) | For patients with relapsed glioblastoma, medulloblastoma, or ependymoma. | Up to 5 years | 
| 12-month Overall Survival (OS) | For patients with newly diagnosed DIPG (diffuse intrinsic pontine glioma). | Up to 5 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Median Overall Survival (OS) | For each disease cohort | Up to 5 years | 
| Median iRANO-PFS (Progression-Free Survival, defined by immune-adapted iRANO criteria) | For each disease cohort | Up to 5 years | 
| Median Time to Regimen Failure (TTRF) | For each disease cohort | Up to 5 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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IDO, indoleamine 2,3-dioxygenase, indoximod, pediatric, childhood, brain tumor, glioblastoma, medulloblastoma, ependymoma, diffuse intrinsic pontine glioma, DIPG, radiation, temozolomide, cyclophosphamide, etoposide, lomustine, immunotherapy, immune, central nervous system, CNS