Preoperative Thalidomide With Radiation Therapy For Patients With Low-Grade Primary Soft Tissue Sarcoma or Thalidomide With Radiation Therapy and Chemotherapy For Patients With High-Grade or Intermediate-Grade Primary Soft Tissue Sarcoma of the Arm, Leg, or Body Wall

Study Overview
=================
Brief Summary
-----------------
Thalidomide may stop the growth of soft tissue sarcoma by stopping blood flow to the tumor. Radiation therapy uses high-energy x-rays to damage tumor cells. Drugs used in chemotherapy, such as doxorubicin, ifosfamide, and dacarbazine, work in different ways to stop tumor cells from dividing so they stop growing or die. Giving thalidomide together with radiation therapy and/or chemotherapy before surgery may shrink the tumor so that it can be removed. This phase II trial is studying how well giving preoperative (before surgery) thalidomide together with radiation therapy works in treating patients with low-grade primary soft tissue sarcoma, and how well giving thalidomide together with radiation therapy, doxorubicin, ifosfamide, and dacarbazine works in treating patients with high-grade or intermediate-grade primary soft tissue sarcoma of the arm, leg, chest wall, or abdominal wall.

Detailed Description
-----------------
OBJECTIVES: I. Determine the treatment delivery and toxicity of the combination of thalidomide and radiotherapy in patients with low-grade primary soft tissue sarcoma of the extremity or body wall. II. Determine the treatment delivery and toxicity of the combination of thalidomide and doxorubicin, ifosfamide, dacarbazine, and radiotherapy in patients with high- or intermediate-grade primary soft tissue sarcoma of the extremity or body wall and compare these results with those of patients treated on RTOG-9514. III. Determine the feasibility of using specific tissue and circulating biomarkers of antiangiogenic response in patients treated with these regimens, in a multi-institutional setting. IV. Determine the quantitative changes and patient variabilities of these biomarkers before, during, and after therapy with these regimens. V. Determine the baseline data sets of biomarkers, particularly circulating endothelial cells, in patients treated with these regimens. VI. Determine the tolerance to long-term post-operative thalidomide in these patients. VII. Determine the clinical response to pre-operative therapy in these patients. VIII. Correlate local control and disease-free survival with surrogate biological endpoints in patients treated with these regimens. OUTLINE: This is a pilot, cohort study. Patients with high- or intermediate-grade tumors >= 8 cm in diameter are assigned to cohort A and patients with low-grade tumors > 5 cm in diameter are assigned to cohort B. Cohort A: Patients receive doxorubicin, ifosfamide, and dacarbazine IV continuously on days 1-3, 22-24, and 43-45. Patients receive filgrastim (G-CSF) subcutaneously beginning on days 4, 25, and 46 and continuing until blood counts recover. Patients undergo radiotherapy once daily on days 7-11, 14-18, 21, 28-32, 35-39, and 42. Patients receive oral thalidomide once daily on days 7-21 and 26-42. Patients undergo surgical resection between days 84 and 98. Beginning 2 weeks after surgery, patients receive oral thalidomide once daily for 12 months in the absence of unacceptable toxicity. Cohort B: Patients receive oral thalidomide once daily beginning on day 1 and continuing until 1 week before surgery. Patients undergo radiotherapy once daily, 5 days a week, on weeks 1-5. Patients undergo surgical resection between days 77 and 91. Beginning 2 weeks after surgery, patients receive oral thalidomide once daily for 6 months in the absence of unacceptable toxicity. Patients are followed every 3 months for 2 years and then every 6 months for 4 years. PROJECTED ACCRUAL: A total of 44 patients (22 per cohort) will be accrued for this study within 17 months.

Official Title
-----------------
A Pilot Phase II Study of Pre-Operative Radiation Therapy and Thalidomide (IND 48832; NSC 66847) for Low Grade Primary Soft Tissue Sarcoma or Pre-Operative MAID/Thalidomide/Radiation Therapy for High/Intermediate Grade Primary Soft Tissue Sarcoma of the Extremity or Body Wall

Conditions
-----------------
Recurrent Adult Soft Tissue Sarcoma, Stage I Adult Soft Tissue Sarcoma AJCC v7, Stage II Adult Soft Tissue Sarcoma AJCC v7, Stage III Adult Soft Tissue Sarcoma AJCC v7

Intervention / Treatment
-----------------
* Drug: Dacarbazine
* Drug: Doxorubicin Hydrochloride
* Biological: Filgrastim
* Drug: Ifosfamide
* Other: Laboratory Biomarker Analysis
* Radiation: Radiation Therapy
* Drug: Thalidomide
* Procedure: Therapeutic Conventional Surgery


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Diagnosis of primary soft tissue sarcoma T2a or T2b disease Superficial or deep tumor Grade 1, 2, 3, or 4 Tumor located on the upper extremity (including shoulder), lower extremity (including hip), or trunk Meets 1 of the following criteria: Tumor ? 8 cm in maximal diameter and grade 3 or 4 (intermediate or high grade) (cohort A) Tumor > 5 cm in maximal diameter and grade 1 or 2 (low grade) (cohort B) Locally recurrent disease allowed provided there has been no prior radiotherapy to the primary tumor No histologically confirmed rhabdomyosarcoma, extraosseous Ewing's primitive neuroectodermal tumors, osteosarcoma or chondrosarcoma, Kaposi's sarcoma, angiosarcoma, desmoid tumors, or dermatofibrosarcoma protuberans No overt evidence of lung metastases (CT scan evidence of small incidental lesions without histologic diagnosis allowed) No evidence of other metastases No sarcoma of the head, neck, intra-abdominal, or retroperitoneal region Performance status - Zubrod 0-1 At least 2 years Absolute neutrophil count ? 1,500/mm^3 Platelet count ? 120,000/mm^3 Hemoglobin ? 8.0 g/dL (cohort A) No known hypercoagulable disorders, such as the following: APC resistance (factor V Leiden) Protein S deficiency Protein C deficiency Antithrombin III deficiency Hyperhomocystinemia Dysplasminogenemia High plasminogen activator inhibitor Dysfibrinogenemia Antiphospholipid syndrome Thrombocythemia Dysproteinemia Fibrin split products < 2 times upper limit of normal (ULN) Fibrinogen > 200 mg/dL Bilirubin ? 1.5 mg/dL (1.0 mg/dL for patients with Gilbert's syndrome) AST and ALT ? 2.0 times ULN PT and PTT < 1.25 times ULN (except in patients treated with anticoagulants for unrelated medical conditions [e.g., atrial fibrillation]) No history of hepatic cirrhosis Creatinine ? 1.5 mg/dL Creatinine clearance > 60 mL/min No atherosclerotic coronary artery disease that required bypass surgery within the past year No uncompensated coronary artery disease by ECG or physical examination No myocardial infarction within the past 6 months No severe or unstable angina within the past 6 months No uncompensated congestive heart failure No New York Heart Association class II-IV heart disease No symptomatic peripheral vascular disease No history of deep vein thrombosis Cohort A only: EF ? 50% within the past 6 months LVEF > 50% No pulmonary embolus except if caused directly by foreign body implants (e.g., central venous catheters or portacaths) No global neurocognitive symptomatology No fatigue ? grade 2 No history of uncontrolled seizures or uncontrolled seizure disorder No sensory neuropathy ? grade 2 except for localized neuropathy due to mechanical cause or trauma No other malignancies within the past 3 years except non-invasive malignancies (e.g., carcinoma in situ of the cervix, breast, or oral cavity) or squamous or basal cell skin cancer No history of uncontrolled myxedema No hypothyroidism ? grade 3 No active uncontrolled bacterial, viral, or fungal infection No other significant illness that would preclude surgery No other major illness or psychiatric impairment that would preclude study therapy No known AIDS Not pregnant or nursing Negative pregnancy test Fertile patients must use 2 effective barrier methods of contraception for 4 weeks before, during, and for at least 4 weeks after study treatment No prior thalidomide No prior biologic therapy for this tumor No prior chemotherapy for this tumor See Disease Characteristics No prior radiotherapy for this tumor See Cardiovascular No other concurrent investigational drugs No concurrent sedating drugs No concurrent illegal sedating recreational drugs No concurrent alcohol intake of more than 1 drink per day

Ages Eligible for Study
-----------------
Minimum Age: 16 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: Cohort A (chemotherapy, radiation, thalidomide, surgery)<br>Patients receive doxorubicin, ifosfamide, and dacarbazine IV continuously on days 1-3, 22-24, and 43-45. Patients receive G-CSF subcutaneously beginning on days 4, 25, and 46 and continuing until blood counts recover. Patients undergo radiotherapy once daily on days 7-11, 14-18, 21, 28-32, 35-39, and 42. Patients receive oral thalidomide once daily on days 7-21 and 26-42. Patients undergo surgical resection between days 84 and 98. Beginning 2 weeks after surgery, patients receive oral thalidomide once daily for 12 months in the absence of unacceptable toxicity. | Drug: Dacarbazine<br>* Given IV<br>* Other names: WR-139007;Drug: Doxorubicin Hydrochloride<br>* Given IV<br>* Other names: Rubex;Biological: Filgrastim<br>* Given subcutaneously<br>* Other names: Tevagrastim;Drug: Ifosfamide<br>* Given IV<br>* Other names: Z-4942;Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Radiation: Radiation Therapy<br>* Undergo radiotherapy<br>* Other names: Therapy, Radiation;Drug: Thalidomide<br>* Given orally<br>* Other names: Thalomid;Procedure: Therapeutic Conventional Surgery<br>* Undergo surgical resection<br>|
| Experimental: Cohort B (thalidomide, radiation, surgery)<br>Patients receive oral thalidomide once daily beginning on day 1 and continuing until 1 week before surgery. Patients undergo radiotherapy once daily, 5 days a week, on weeks 1-5. Patients undergo surgical resection between days 77 and 91. Beginning 2 weeks after surgery, patients receive oral thalidomide once daily for 6 months in the absence of unacceptable toxicity. | Other: Laboratory Biomarker Analysis<br>* Correlative studies<br>Radiation: Radiation Therapy<br>* Undergo radiotherapy<br>* Other names: Therapy, Radiation;Drug: Thalidomide<br>* Given orally<br>* Other names: Thalomid;Procedure: Therapeutic Conventional Surgery<br>* Undergo surgical resection<br>|

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

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Treatment Delivery With Compliance Defined as Receiving at Least 95% of the Pre-operative Protocol Dose of RT, All 3 Cycles of MAID (if Applicable), and Receive Thalidomide on 75% of the Days During Radiation | Was to be estimated using a binomial distribution and accompanied by the associated 95% confidence interval. Due to early study closure, this endpoint could not be fully evaluated per the protocol plan. | Duration of treatment (which can continue up to approximately 15 months). | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Wound Complication (Grades 2, 3, 4, and 5) as Measured by CTCAE v3.0 | Will be estimated using a binomial distribution and accompanied by the associated 95% confidence interval. | From start of treatment to time of surgery | 
| Response to Pre-operative Therapy Assessed Using RECIST Criteria |  | From start of treatment to time of surgery. |