Safety and Efficacy of Quizartinib in Children and Young Adults With Acute Myeloid Leukemia (AML), a Cancer of the Blood

Acute Myeloid Leukemia Clinical Trial

Official title:

A Phase 1/2, Multicenter, Dose-Escalating Study To Evaluate the Safety, Pharmacokinetics, Pharmacodynamics, and Efficacy Of Quizartinib Administered in Combination With Re-Induction Chemotherapy, and as a Single-Agent Continuation Therapy, in Pediatric Relapsed/Refractory AML Subjects Aged 1 Month to <18 Years (and Young Adults Aged up to 21 Years) With FLT3-ITD Mutations

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT03793478
• Other study ID #: AC220-A-U202
• Secondary ID: 2016-002919-18
• Status: Recruiting
• Phase: Phase 1/Phase 2
• Start date: August 15, 2018
• Est. completion date: May 1, 2027

Study information

• Verified date: December 2023
• Source: Daiichi Sankyo, Inc.
• Contact: Daiichi Sankyo Contact for Clinical Information
• Phone: 908-992-6400
• Email: CTRinfo[@]dsi.com
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Quizartinib is an experimental drug. It is not approved for regular use. It can only be used in medical research.

Children or young adults with a certain kind of blood cancer (FLT3-ITD AML) might be able to join this study if it has come back after remission or is not responding to treatment.

Description:

The medical condition being investigated is relapsed or refractory AML in participants aged ≥1 month to ≤21 years with Feline McDonough Sarcoma (FMS)-like tyrosine kinase 3 (FLT3)-internal tandem duplication (ITD) mutations (FLT3-ITD AML), following failure of front-line intensive chemotherapy.

The trial will be conducted in multiple phases. An independent data monitoring committee (DMC) will protect the rights, safety, and well-being of participants by monitoring the progress and results. The DMC will comprise qualified physicians and scientists who are not Investigators in the study and not otherwise directly associated with the Sponsor and will be convened at the end of Phase 1.

A. Dose Escalation/De-escalation Phase:

Number of participants is determined by age group. Participants will be enrolled by dose-level to determine the recommended Phase 2 dose (RP2D) of quizartinib for pediatric participants that provides similar exposure to adult patients treated at the target adult dose of 60 mg orally once daily.

B. Dose-Expansion Phase:

Participants will receive the RP2D of quizartinib for their respective age group.

During both dose escalation and dose expansion phases, participants will receive:

Re-Induction Therapy

• Intrathecal (IT) triple chemotherapy prophylaxis prior to and between cycles

• In re-induction Cycles 1 and 2, fludarabine/cytarabine (FLA) followed by quizartinib as a single agent

Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) Period:

After re-induction therapy, participants will be evaluated for eligibility to undergo allogeneic hematopoietic stem cell transplant (HSCT). Eligible participants may receive a single 28-day cycle of consolidation therapy (standard of care chemotherapy with or without quizartinib) if an allogeneic HSCT is not available immediately. The options for consolidation therapy are as follows:

• High intensity chemotherapy with quizartinib, or

• Low intensity chemotherapy alone, or

• Low intensity therapy with quizartinib as a single agent

Continuation Therapy:

Participants in remission after HSCT, or who are not eligible for HSCT but achieve at least a partial remission (PR) after re-induction, will receive up to 12 continuous 28-day cycles of quizartinib continuation therapy at the same dose received during re-induction in the dose expansion phase.

Long-term Follow-up:

The long-term follow-up phase begins upon completion of 12 cycles of quizartinib Continuation Therapy or permanent discontinuation of quizartinib at any time. After completion of the 30-day safety follow-up visit, subsequent visits will occur at the following frequencies to assess survival and anti-leukemic treatments:

• every 3 months for the first 2 years, and then

• once a year thereafter until the last participant enrolled has been followed for three years from the date of enrollment

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 65
• Est. completion date: May 1, 2027
• Est. primary completion date: May 1, 2027
• Accepts healthy volunteers: No
• Gender: All
• Age group: 1 Month to 21 Years

Eligibility

Inclusion Criteria:

Participants must meet all of the following criteria to be eligible for enrollment into the study:

• Has diagnosis of AML according to the World Health Organization (WHO) 2008 classification with =5% blasts in bone marrow, with or without extramedullary disease

• In first relapse or refractory to first-line high-dose chemotherapy with no more than 1 attempt (1 to 2 cycles of induction chemotherapy) at remission induction - prior HSCT is permitted

• Has presence of the FLT3-ITD activating mutation in bone marrow or peripheral blood as defined in the protocol

• Is between 1 month and 21 years of age at the time the Informed Consent/Assent form is signed

• Has protocol-defined adequate performance status score

• Has fully recovered from the acute clinically significant toxicity effects of all prior chemotherapy, immunotherapy, or radiotherapy, per protocol guidelines

• Has protocol-defined adequate renal, hepatic and cardiac functions

• If of reproductive potential, is permanently sterile or agrees to use highly effective birth control upon enrollment, during the period of therapy, and for 6 months following the last dose of quizartinib, etoposide, fludarabine, methotrexate, or cytarabine, whichever is later

• If female of child-bearing potential, tests negative for pregnancy and agrees not to breast feed

• Male participants must be surgically sterile or willing to use highly effective birth control during the treatment period, and for 6 months following the last dose of quizartinib, etoposide, fludarabine, methotrexate, or cytarabine, whichever is later.

• Participant/legal representative is capable of understanding the investigational nature of the study, potential risks, and benefits, and the patient (and/or legal representative) signs a written assent/informed consent

Exclusion Criteria:

Participants who meet any of the following criteria will be disqualified from entering the study:

• Has been diagnosed with isolated central nervous system relapse, acute promyelocytic leukemia (APL), juvenile myelomonocytic leukemia, French-American-British classification M3 or WHO classification of APL with translocation, or with myeloid proliferations related to Down syndrome

• Has uncontrolled or pre-defined significant cardiovascular disease as detailed in the protocol

• Has systemic fungal, bacterial, viral or other infection that is exhibiting ongoing signs/symptoms related to the infection without improvement despite appropriate antibiotics or other treatment. The patient must be off vasopressors and have negative blood cultures for at least 48 hours prior to the start of systematic protocol therapy.

• Has known active clinically relevant liver disease (e.g., active hepatitis B or active hepatitis C)

• Has known history of human immunodeficiency virus (HIV)

• Has history of hypersensitivity to any of the study medications or their excipients

• Is receiving or is anticipated to receive concomitant chemotherapy, radiation, or immunotherapy other than as specified in the protocol

• Has any significant concurrent disease, illness, psychiatric disorder or social issue that would compromise subject safety or compliance, interfere with consent/assent, study participation, follow up, or interpretation of study results

• Is currently participating in another investigative interventional procedure (observational or long-term interventional follow-up is allowed)

• Is otherwise considered inappropriate for the study by the Investigator

Related Conditions & MeSH terms

• Acute Myeloid Leukemia
• Leukemia
• Leukemia, Myeloid
• Leukemia, Myeloid, Acute

Intervention

Drug:
• Quizartinib
Administered orally once daily starting on Day 6 and continuing through Day 28; Optional low intensity consolidation with chemotherapy: Administered orally once daily starting on Day 1 and continuing through Day 28
• Fludarabine
30 mg/m^2/day IV infusion given over 30 minutes on Days 1 through 5 (administered based on body weight)
• Cytarabine
2000 mg/m^2/day IV infusion given over 3 hours on Days 1 through 5 (begin 4 hours after the start of fludarabine) (administered in accordance with standard of care); Optional high intensity consolidation with chemotherapy and quizartinib: 500 mg/m^2/day as a continuous 96-hour IV infusion on Days 1 through 4; Optional low intensity consolidation with chemotherapy: 75 mg/m^2/day as once daily subcutaneous or IV on Days 1 through 4 and Days 15 through 18
• Intrathecal (IT) triple chemotherapy prophylaxis
IT cytarabine, methotrexate, and either prednisolone or hydrocortisone; doses are based on the participant's age and standard practice at each site
• Etoposide
Optional high intensity consolidation with chemotherapy and quizartinib: 100 mg/m^2/dose once daily as an IV infusion over 3 hours on Days 1 through 5

Locations

Country	Name	City	State
Belgium	Universitair Ziekenhuis Gent	Gent
Canada	Montreal Children's Hospital	Montréal	Quebec
Canada	The Hospital for Sick Children	Toronto	Ontario
Canada	British Columbia Children's Hospital	Vancouver
Denmark	Rigshospitalet	Copenhagen
France	Centre Léon Bérard	Lyon
France	Hôpital Armand-Trousseau	Paris
France	Hôpital des Enfants	Toulouse
Israel	Rambam Medical Center	Haifa
Israel	Schneider Children's Medical Center of Israel	Petah Tikva
Israel	Tel Aviv Sourasky Medical Center	Tel Aviv-Yafo
Italy	Fondazione IRCCS San Gerardo dei Tintori	Monza
Italy	IRCCS Ospedale Pediatrico Bambino Gesù	Rome
Italy	Ospedale Infantile Regina Margherita	Torino
Netherlands	Prinses Maxima Centrum voor Kinderoncologie	Utrecht
Spain	Hospital Infantil Universitario Nino Jesus	Madrid
Spain	Hospital Universitario La Paz	Madrid
Sweden	Sahlgrenska Universitetssjukhuset - Drottning Silvias Barn- och Ungdomssjukhus	Göteborg
United Kingdom	NHS Greater Glasgow and Clyde - The Queen Elizabeth University Hospital	Glasgow
United States	Children's Healthcare of Atlanta	Atlanta	Georgia
United States	Children's Hospital Colorado	Aurora	Colorado
United States	Johns Hopkins	Baltimore	Maryland
United States	Cincinnati Children's Hospital Medical Center	Cincinnati	Ohio
United States	The University of Texas Southwestern Medical Center Children's Health	Dallas	Texas
United States	Riley Hospital for Children - Indiana University	Indianapolis	Indiana
United States	University of Mississippi Medical Center	Jackson	Mississippi
United States	Loma Linda University Cancer Center	Loma Linda	California
United States	University of Minnesota/Masonic Cancer Center	Minneapolis	Minnesota
United States	Columbia University/Herbert Irving Cancer Center	New York	New York
United States	Children's Hospital of Philadelphia	Philadelphia	Pennsylvania
United States	UPMC Children's Hospital of Pittsburgh	Pittsburgh	Pennsylvania
United States	Washington University School of Medicine	Saint Louis	Missouri
United States	University of California, San Francisco	San Francisco	California
United States	Seattle Children's Hospital	Seattle	Washington
United States	New York Medical College	Valhalla	New York
United States	Children's National Medical Center	Washington	District of Columbia
United States	A.I. duPont Hospital for Children	Wilmington	Delaware

Sponsors (3)

Lead Sponsor	Collaborator
Daiichi Sankyo, Inc.	Children's Oncology Group, Innovative Therapies For Children with Cancer Consortium

Countries where clinical trial is conducted

United States,  Belgium,  Canada,  Denmark,  France,  Israel,  Italy,  Netherlands,  Spain,  Sweden,  United Kingdom, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Number of dose-limiting toxicities (Phase 1)		Re-induction Cycle 1 Day 1 up to Day 28 (each cycle is 28 days)
Primary	Composite complete remission (CRc) rate among participants with acute myeloid leukemia (AML) (Phase 1 and 2)	CRc rate is defined as percentage of participants with best response of complete remission (CR) or CR with incomplete hematological recovery (CRi) after completion of up to 2 re-induction cycles	within 8 years, 8 months
Primary	Pharmacokinetic parameter area under the concentration curve for quizartinib and AC886 (Phase 1 and 2)		Re-induction Phase 1 and 2,Cycle 1: Days 6, 20:Predose, 1 hour (Phase 1 only), 2, 4, and 6 hours; Days 7 and 21:24 hours; Phase 1 and 2 Cycle 2: Days 6 and 20:predose, 3 hours; Continuation Cycle 1 Days 1 and 15:predose, 2-4 hours (each cycle, 28 days)
Primary	Pharmacokinetic parameter apparent clearance (CL/F) for quizartinib and AC886 (Phase 1 and 2)		Re-induction Phase 1 and 2,Cycle 1: Days 6, 20:Predose, 1 hour (Phase 1 only), 2, 4, and 6 hours; Days 7 and 21:24 hours; Phase 1 and 2 Cycle 2: Days 6 and 20:predose, 3 hours; Continuation Cycle 1 Days 1 and 15:predose, 2-4 hours (each cycle, 28 days)
Primary	Pharmacokinetic parameter apparent volume of distribution (Vz/F) for quizartinib and AC886 (Phase 1 and 2)		Re-induction Phase 1 and 2,Cycle 1: Days 6, 20:Predose, 1 hour (Phase 1 only), 2, 4, and 6 hours; Days 7 and 21:24 hours; Phase 1 and 2 Cycle 2: Days 6 and 20:predose, 3 hours; Continuation Cycle 1 Days 1 and 15:predose, 2-4 hours (each cycle, 28 days)
Secondary	Complete remission (CR) rate among participants with AML (Phase 1 and 2)	CR rate is defined as the percentage of participants achieving CR after completion of up to 2 re-induction cycles	on Day 56 (± 3 Days) for the last subject, within 4 years
Secondary	Complete remission with incomplete recovery (CRi) rate among participants with AML (Phase 1 and 2)	CRi rate is defined as the percentage of participants achieving CRi after completion of up to 2 re-induction cycles	on Day 56 (± 3 Days) for the last subject, within 4 years
Secondary	Duration of CR among participants with AML (Phase 1 and 2)	Duration of CR is defined as the time from the first documented CR until documented relapse	within 8 years, 8 months
Secondary	Duration of CRi among participants with AML (Phase 1 and 2)	Duration of CRi is defined as the time from the first documented CRi until documented relapse	within 8 years, 8 months
Secondary	Duration of composite complete remission (CRc) among participants with AML (Phase 1 and 2)	Duration of CRc is defined as the time from the first documented CR or CRi until documented relapse	within 8 years, 8 months
Secondary	Complete remission (CR) rate after completion of re-induction Cycle 1 among participants with AML (Phase 1 and 2)	CR rate after completion of re-induction Cycle 1 is defined as the percentage of participants achieving a CR after completion of re-induction Cycle 1	on Day 56 (± 3 Days) for the last subject, within 4 years
Secondary	Complete remission with incomplete recovery (CRi) rate after completion of re-induction Cycle 1 among participants with AML (Phase 1 and 2)	CRi rate after completion of re-induction Cycle 1 is defined as the percentage of participants achieving a CRi after completion of re-induction Cycle 1	on Day 56 (± 3 Days) for the last subject, within 4 years
Secondary	Composite complete remission (CRc) rate after completion of re-induction Cycle 1 among participants with AML (Phase 1 and 2)	CRc rate after completion of re-induction Cycle 1 is defined as the percentage of participants achieving CRc after completion of re-induction Cycle 1	on Day 56 (± 3 Days) for the last subject, within 4 years
Secondary	Time to relapse among participants with AML (Phase 1 and 2)	Time to relapse is defined as the time from the first documented response (CR, CRi) until documented relapse	within 8 years, 8 months
Secondary	Rate of relapse among participants with AML after 1, 2 and 3 years (Phase 1 and 2)	Rate of relapse is defined as the percentage of participants who achieved CRc at the end of re-induction and had relapsed at 3 categorical time points Categories: 1 year, 2 years, 3 years	within 8 years, 8 months
Secondary	Cumulative incidence of relapse among participants with AML at the end of study (Phase 1 and 2)	Cumulative incidence of relapse at the end of the study is defined as the percentage of participants who achieved CRc at the end of re-induction and relapsed by the end of the study	within 8 years, 8 months
Secondary	Overall survival among participants with AML at 1, 2, and 3 years (Phase 1 and 2)	Overall survival is defined as the time from the start of re-induction therapy until death from any cause	within 8 years, 8 months
Secondary	Event-free survival among participants with AML at 1, 2, and 3 years (Phase 1 and 2)	Event-free survival is defined as the time from the start of re-induction therapy until the earliest date of the following: Refractory disease at the end of re-induction; Relapse after CR or CRi; Death from any cause at any time during the study	within 8 years, 8 months
Secondary	Number of participants proceeding to high-dose conditioning therapy/allogeneic hematopoietic stem cell transplantation (HSCT) (including transplant-related mortality) among participants with AML (Phase 1 and 2)		within 8 years, 8 months
Secondary	Rate of CRc (CR or CRi) without minimal residual disease (MRD) using next generation sequencing among participants with AML (Phase 1 and 2)	MRD is defined as the presence of leukemic cells in the bone marrow detected above a predefined cut-off level by a validated assay in participants who achieved a CR or CRi; Categories: at screening, at re-induction cycle 1, at re-induction cycle 2, at time of relapse	within 8 years, 8 months
Secondary	Acceptability of including the palatability of quizartinib formulations among participants with AML (Phase 1 and 2)	Acceptability is assessed by palatability using a 5-point hedonic scale (from "Super bad" to "Super good") for participants who are developmentally able to answer. If unable, the caregiver provides information in a free text field stating whether the participant spit it out, may not have liked the flavor, etc.	within 8 years, 8 months