A Study to Compare Vincristine to Sirolimus for Treatment of High Risk Vascular Tumors
Information source: Children's Hospital Medical Center, Cincinnati
ClinicalTrials.gov processed this data on August 23, 2015 Link to the current ClinicalTrials.gov record.
Condition(s) targeted: Kaposiform Hemangioendothelioma (KHE); Kasabach-Merritt Syndrome; Tufted Angioma
Intervention: Vincristine (Drug); Sirolimus (Drug)
Phase: Phase 2
Status: Recruiting
Sponsored by: Children's Hospital Medical Center, Cincinnati Official(s) and/or principal investigator(s): Denise Adams, MD, Principal Investigator, Affiliation: Children's Hospital Medical Center, Cincinnati
Overall contact: Mary Sue Wentzel, Phone: 513-803-4862(HVMC), Email: HVMCresearch@cchmc.org
Summary
In this research study we want to learn more about which treatment works better for patients
diagnosed with a vascular tumor called Kaposiform Hemangioendothelioma (KHE) or other high
risk vascular tumors such as Tufted Angioma (TA). In these tumors, the blood cells that
help your blood clot called platelets become trapped in the tumor causing swelling, pain,
and bruising. Vascular tumors can be life threatening. There are few medical treatments that
will work to shrink the vascular tumor. Some doctors will use steroids and vincristine to
try and shrink vascular tumors.
In this research study, the study doctor will compare two different drugs to see which one
will work better to help shrink your vascular tumor. One of the drugs is vincristine.
Vincristine is approved by the Food and Drug Administration (FDA) to treat people with
cancer. Vincristine is used to stop the abnormal cells from growing such as cells that make
up blood vessels.
The other drug to be used in this study is sirolimus. Sirolimus is currently approved by the
Food and Drug Administration (FDA) to prevent transplanted organ rejection. Sirolimus is not
approved by the FDA for treatment of vascular abnormalities and is considered experimental.
Sirolimus belongs to a class of drugs call 'mTOR inhibitors'. mTOR (mammilian target of
rapamycin) helps cells to grow and may also help blood vessels to grow in a more normal
fashion. Sirolimus is currently being tested in patients with vascular tumors and cancer. In
vascular tumors, we hope sirolimus will stop the blood vessel growth.
Funding Source: FDA - OOPD (Office of Orphan Products Development)
Clinical Details
Official title: A Randomized Phase 2 Study of Vincristine Versus Sirolimus to Treat High Risk Kaposiform Hemangioendothelioma (KHE).
Study design: Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
Primary outcome: Change in hematologic parametersNumber of Serious and Non-Serious Adverse Events
Secondary outcome: Evaluation of Disease Response - MaintenanceNumber of serious and non serious adverse events - Maintenance Change in the serum levels of KHE biomarkers Identify genetic variants in drug metabolism enzymes.
Detailed description:
Kaposiform hemangioendotheliomas (KHE) are extremely rare life threatening tumors which can
be associated with Kasabach-Merritt Phenomenon consisting of profound thrombocytopenia and
hypofibrinogenemia causing a significant risk of bleeding and an associated mortality rate
as high as 20% to 30%. Despite the severity of potential complications, we lack uniform
guidelines for the treatment and response to treatment of children and young adults with
these tumors. KHE patients have been treated with a multitude of aggressive drug regimens
without prospective evaluation of response or safety. Presently, vincristine is considered
the standard of practice. We have treated a subset of these patients on study SIR-DA-0901
(FDA Grant# 5RO1FD003712-01). This study is a phase II trial assessing the efficacy and
safety of sirolimus for the treatment of complicated vascular anomalies. Although the
numbers are small, the response has been extremely promising with excellent tolerability.
There is pre-clinical and clinical data supporting the essential regulatory function of the
PI3 kinase/AKT/mTOR pathway in vascular growth and organization which suggests a therapeutic
target for patients with complicated vascular anomalies. The overall goal of this trial is
to objectively assess the efficacy of sirolimus compared to vincristine for the treatment of
patients with high risk KHE.
Hypothesis: Sirolimus treatment for children and young adults with Kaposiform
hemangioendotheliomas will be more effective than vincristine, assessed by time to response
in an induction period and provide equivalent safety parameters.
Study Rationale We propose a multi-center, phase II trial with participation from 8 sites.
The study will consist of two phases. The first of these is an initial induction phase in
which vincristine and steroids will be compared to sirolimus and steroids. Response in the
induction phase will be assessed as time to hematologic response. At the end of induction
phase, cross over can occur if there is failure to respond. Part 2 is a maintenance phase
which will be 1 year in length. Continued safety and efficacy data will be collected during
maintenance and there will be cross over at any time for patients who lose their response
following induction. Failure will be defined as worsening of hematological parameters on two
separate laboratory evaluations at any time during maintenance or if they meet the
definition of progressive disease following response assessments. Formal response in
maintenance will be evaluated by imaging studies, functional assessment, and quality of life
as per study SIR-DA-0901. Present therapies are very limited and new therapies are
desperately needed for this devastating disease. Based on our preliminary data, there is a
very good rationale for sirolimus therapy in KHE patients and so a phase II trial is
urgently needed to determine if this therapy is to become the new standard of care for KHE
patients.
Our secondary aims will be addressing biomarker analysis. There are limited studies
describing the biology of these tumors. Per study SIR-DA-0901 there is some preliminary data
indicating the importance of VEGF-C and other upregulated markers in the mTor pathway. This
needs to be further investigated especially in KHE patients. Furthermore there are no clear
objective measurements to determine response data.
Eligibility
Minimum age: N/A.
Maximum age: 31 Years.
Gender(s): Both.
Criteria:
Inclusion Criteria:
- Diagnosis: All patients must have one of the following vascular anomalies as
determined by clinical, radiologic and histologic criteria (when possible). Biopsy
strongly recommended (but not required) with suggested immunostains: CD34, PROX-1 or
D240, Glut-1 and MIB-1.
1. Kaposiform Hemangioendotheliomas
2. Tufted angioma
High Risk Stratification: In addition to the above diagnosis, all of the following
criteria need to be met:
a. Kasabach Merritt Syndrome defined at a platelet counts less than 50,000 K/µl and/or
fibrinogen level < 100 mg/dl at the time of diagnosis.
- Age: Patients must be 0 - 31 years of age at the time of study entry. Enrollment
includes patients of both genders and all ethnic groups.
- Organ function requirements:
1. Adequate liver function defined as:
1. Total bilirubin ≤ 1. 5 x ULN for age, and
2. SGPT (ALT) ≤ 5 x ULN for age, and
3. Serum albumin >/= 2 g/dL.
4. Fasting LDL cholesterol of <160 mg/dL
5. Fasting triglyceride <400 mg/dl
2. Adequate Bone Marrow Function defined as:
1. Peripheral absolute neutrophil count (ANC) >/= 1000/uL
2. Hemoglobin >/= 8. 0 g/dL (may receive RBC transfusions)
3. No Platelet requirement
3. Adequate Renal Function Defined as:
1. A serum creatinine based on age as follows:
Age (Years) Maximum Serum Creatinine (mg/dL)
- 5 0. 8 6 to ≤10 1. 0 11 to ≤15
1. 2 >15 1. 5
2. Urine protein to creatinine ratio (UPC) < 0. 3 g/l
- Performance Status: Karnofsky >/= 50 (≥16 years of age) and Lansky >/= 50 for
patients <16 years of age.
- Prior therapy
1. Patients who have undergone surgical resection or interventional radiology
procedures for disease control are eligible if they meet all inclusion criteria
after surgery/procedure
2. Surgery: At least 2 weeks since undergoing any major surgery
3. Radiation: > 6 months from involved field radiation
4. Prior vincristine therapy is permitted. Patients may also have received up to 2
doses of vincristine prior to randomization.
Exclusion Criteria:
- Concurrent severe and/or uncontrolled medical disease that could compromise
participation in the study (e. g. uncontrolled diabetes, uncontrolled hypertension,
severe infection, severe malnutrition, chronic liver or renal disease, active upper
GI tract ulceration).
- Patients who require medications that are strong inhibitors/inducers CYP3A4 enzyme
activity, including anticonvulsants, (Appendix II) to control concurrent medical
conditions are not eligible. Patients who discontinue use of prohibited medications
with a one week washout prior to start of study treatment are eligible.
- Known history of HIV seropositivity or known immunodeficiency. Testing is not
required unless a condition is suspected.
- Impairment of gastrointestinal function or gastrointestinal disease that may
significantly alter the absorption of sirolimus (e. g. ulcerative disease,
uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome or small bowel
resection). A gastric tube or nasogastric tube is allowed.
- Females who are pregnant or breast feeding.
- Males or females of reproductive potential may not participate unless they have
agreed to use an effective contraceptive method during the period they are receiving
the study drug and for 3 months thereafter. Abstinence is an acceptable method of
birth control. Females of childbearing potential will be given a pregnancy test
within 7 days prior to administration of study treatment and must have a negative
urine or serum pregnancy test.
- Patients who have received prior treatment with an mTOR inhibitor.
- Patients unwilling or unable to comply with the protocol or who in the opinion of the
investigator may not be able to comply with the safety monitoring requirements of the
study.
- Patients who currently have an uncontrolled infection, defined as receiving
intravenous antibiotics.
Locations and Contacts
Mary Sue Wentzel, Phone: 513-803-4862(HVMC), Email: HVMCresearch@cchmc.org
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, United States; Recruiting Mary Sue Wentzel, RN, Phone: 513-803-4862, Email: HVMCResearch@cchmc.org Denise Adams, MD, Principal Investigator
Additional Information
Cincinnati Children's Hospital Medical Center Hemangioma and Vascular Malformation Center National Organization of Vascular Anomalies
Starting date: January 2015
Last updated: May 29, 2015
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