Testing the Combination of Two Immunotherapy Drugs (Magrolimab and Dinutuximab) in Patients With Relapsed or Refractory Neuroblastoma or Relapsed Osteosarcoma

  • STATUS
    Recruiting
  • End date
    Jan 31, 2024
  • participants needed
    82
  • sponsor
    National Cancer Institute (NCI)
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Updated on 7 October 2022
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Summary

This phase I trial is to find out the best dose, possible benefits and/or side effects of magrolimab in combination with dinutuximab in treating patients with neuroblastoma that has come back (relapsed) or does not respond to treatment (refractory) or relapsed osteosarcoma. Magrolimab and dinutuximab are monoclonal antibodies that may interfere with the ability of tumor cells to grow and spread. The combination of magrolimab and dinutuximab may shrink or stabilize relapsed or refractory neuroblastoma or relapsed osteosarcoma. In addition, this trial may help researchers find out if it is safe to give magrolimab and dinutuximab after surgery to remove tumors from the lungs.

Description

PRIMARY OBJECTIVES:

I. Determine the safety and tolerability of Hu5F9-G4 (magrolimab) in combination with dinutuximab in children and young adults with relapsed/refractory (R/R) neuroblastoma (NBL) or relapsed osteosarcoma.

II. Determine the recommended phase 2 dose (RP2D) of Hu5F9-G4 (magrolimab) given in combination with dinutuximab in children and young adults.

III. Determine the safety and feasibility of administering Hu5F9-G4 (magrolimab) in combination with dinutuximab to patients that undergo pulmonary resection of metastatic osteosarcoma within three weeks of surgery.

SECONDARY OBJECTIVES:

I. Determine the pharmacokinetics (PK) of Hu5F9-G4 (magrolimab) in children and young adults.

II. Evaluate the event free survival (EFS) in two cohorts of patients who are treated at the recommended phase 2 dose (RP2D) (measurable relapsed osteosarcoma and patients with pulmonary relapse undergoing resection) and compare to historical controls.

III. Observe and record anti-tumor activity. IV. Evaluate the overall response rate (ORR) of patients in the NBL cohorts (measurable R/R NBL and evaluable R/R NBL) and osteosarcoma patients (measurable relapsed osteosarcoma) in the expansion cohorts treated at the RP2D.

EXPLORATORY OBJECTIVES:

I. To explore biomarkers of response and resistance including genomic (CD47 expression, Fc receptor [FcR] polymorphisms, SIRPa polymorphisms, and KiR phenotype) and immunologic (dinutuximab HACA, magrolimab ADA, peripheral and bone marrow immune subsets, and circulating cytokines).

II. To explore biomarkers of response in the tumor microenvironment through multiplexed ion beam imaging (MIBI) on resected tissue or archival tissues including comparison of pre- and post- treatment tumor tissues from patients undergoing staged resection of pulmonary osteosarcoma.

OUTLINE: This is a dose de-escalation study of magrolimab with fixed-dose dinutuximab followed by a dose-expansion study. Patients are assigned to 1 of 2 arms.

ARM A: Patients receive magrolimab intravenously (IV) over 2 hours on days 1, 8, and 15 of cycles 1-2 and days 1 and 15 of subsequent cycles, and dinutuximab IV over 10 hours on days 2-5 of each cycle. Treatment repeats every 21 days for up to 12 cycles in the absence of disease progression or unacceptable toxicity. Patients also undergo bone marrow aspiration, computed tomography (CT), and magnetic resonance imaging (MRI) at the end of cycles 2 and 4 and then every 4 cycles after that and undergo collection of blood samples throughout the study.

ARM B: Patients receive magrolimab IV over 2 hours on days 1, 8, and 15 of cycles 1-2 and days 1 and 15 of subsequent cycles, and dinutuximab IV over 10 hours on days 2-5 of each cycle. Treatment repeats every 21 days for up to 12 cycles in the absence of disease progression or unacceptable toxicity. Patients with pulmonary osteosarcoma may undergo surgical resection of tumor after cycle 1. After surgery, these patients continue receiving magrolimab and dinutuximab every 21 days for up to 5 cycles in the absence of disease progression or unacceptable toxicity. Patients also undergo bone marrow aspiration, CT, and MRI at the end of cycles 2 and 4 and then every 4 cycles after that and undergo collection of blood samples throughout the study.

After completion of study treatment, patients are followed up at 30 days, at 2, 4, 6, 9, and 12 months, and then yearly for 4 years.

Details
Condition High Risk Neuroblastoma, Recurrent Neuroblastoma, Recurrent Osteosarcoma, Refractory Neuroblastoma, Resectable Osteosarcoma
Treatment computed tomography, magnetic resonance imaging, bone marrow aspiration, biospecimen collection, Dinutuximab, Resection, Magrolimab
Clinical Study IdentifierNCT04751383
SponsorNational Cancer Institute (NCI)
Last Modified on7 October 2022

Eligibility

 Yes No Not Sure

Inclusion Criteria

Patients must have a history of histologically or cytologically confirmed NBL or osteosarcoma
Patients must have
Relapsed/refractory high-risk neuroblastoma (NBL) (defined as disease recurrence after completion of therapy, progressive disease on therapy, or refractory disease during induction therapy) or
Relapsed osteosarcoma (relapsed after frontline therapy and/or there must not be any potentially curative treatment options available at the time of enrollment)
Cohort B1: Confirmed neuroblastoma: measurable NBL/ganglioneuroblastoma (defined as
those lesions that can be accurately measured in at least one dimension
(longest diameter to be recorded) as >= 10 mm with cross sectional imaging (CT
Cohort B4: Patients with relapsed resectable pulmonary osteosarcoma who are scheduled for a surgical resection
scan or MRI), or >= 10 mm with calipers by clinical exam). Chest x-ray cannot
Note: Subjects will not have measurable disease due to recently resected pulmonary metastases. Investigational therapy must begin within three weeks of resection. Staged resections are permissible; investigational therapy will be administered in between resections. Patients should receive one cycle of investigational therapy in between resections but can receive additional cycles to accommodate the most appropriate surgical schedule as determined by the treating physicians. Every effort will be made to have at least half of this cohort (five of ten patients) be those requiring a staged resection
be used to determine eligibility. Lesions must be iobenguane (MIBG) positive
positron emission tomography (PET) avid (if patient has a history MIBG
negative disease) or biopsy proven NBL/ganglioneuroblastoma
Hematopoietic growth factors: At least 7 days must have elapsed since the completion of therapy with a growth factor. At least 14 days must have elapsed after receiving pegfilgrastim
Cohort B2: Evaluable NBL (MIBG and/or bone marrow disease only)
At least 7 days must have elapsed since the completion of therapy with a biologic agent, targeted agent, tyrosine kinase inhibitor or a metronomic non-myelosuppressive regimen
Cohort B3: Measurable osteosarcoma (defined as those lesions that can be accurately measured in at least one dimension (longest diameter to be recorded) as >= 10 mm (>= 1 cm) with cross sectional imaging (CT scan, MRI, or calipers by clinical exam). Chest x-ray cannot be used to determine eligibility
At least 4 weeks must have elapsed since prior therapy with 131I-MIBG
There is no limit to the number of prior treatment regimens. Patients must have fully recovered from the acute toxic effects of all prior chemotherapy, immunotherapy, or radiotherapy prior to initiation of study treatment. Acute toxicity of any previous therapy must have resolved to grade 1 or less or stabilized, unless specified elsewhere
At least 7 days must have elapsed since the last pharmacologic dose of systemic steroids
Arm A: Age >= 1 or < 18 years of age
Myelosuppressive chemotherapy: Patients must not have received myelosuppressive chemotherapy within 3 weeks of initiation of study treatment (6 weeks if prior nitrosourea)
Arm B: Age >= 1 or =< 35 years of age
Eastern Cooperative Oncology Group (ECOG) performance status =< 2; Subjects > 16 years of age: Karnofsky >= 50%; Subjects =< 16 years of age: Lansky scale >= 50%
Monoclonal antibodies: At least 3 weeks must have elapsed since prior therapy that included a monoclonal antibody. Patients who have received prior therapy with GD2 antibodies, regardless of response to therapy, will be eligible
Absolute neutrophil count >= 1,000/mcL
Hemoglobin >= 9.5 g/dL, transfusion support acceptable
Platelets >= 100,000/mcL, independent of transfusions
Total bilirubin =< 1.5 X institutional upper limit of normal (ULN) for age (sum of conjugated and unconjugated)
Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 5 x institutional ULN
Creatinine =< institutional ULN OR glomerular filtration rate (GFR) >= 70 mL/min/1.73 m^2
Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial
For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated
Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load
Patients with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen are eligible for this trial
Patients with known history or current symptoms of cardiac disease, or history of treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac function using the New York Heart Association Functional Classification. To be eligible for this trial, patients should be class 2B or better
Female patients of childbearing potential must not be nursing or planning to be pregnant and must have a negative urine or serum pregnancy test within 30 days before enrollment and within 72 hours before the first administration of study treatment
Note: Females who have undergone surgical sterilization or who have been postmenopausal for at least 2 years are not considered to be of childbearing potential
Male patients who are sexually active with a woman of childbearing potential (WOCBP) and who have not had vasectomies must be willing to use a barrier method of contraception (condom plus spermicidal gel) and refrain from sperm donation during the study and for 4 months after the last dose of study treatment. If the partner is pregnant, male patients must use barrier method contraception (condom) during the study and for 4 months after the last dose of study treatment to prevent fetal exposure to study treatment
The effects of Hu5F9-G4 (magrolimab) monoclonal antibody on the developing human fetus
are unknown and dinutuximab is known to be teratogenic. For this reason
female patients of childbearing potential must be willing to use one highly
effective method of contraception (hormonal or barrier method of birth
control; abstinence) prior to study entry, during the study and continue for 4
months after the last dose of study treatment. Should a woman become pregnant
or suspect she is pregnant while she or her partner is participating in this
study, she should inform her treating physician immediately
All patients and/or their parents or legally authorized representatives must have the
ability to understand and the willingness to sign a written informed consent
Assent, where appropriate, will be obtained according to local institutional
policy
Cardiac ejection fraction >= 45% or shortening fraction >= 28%, no evidence of physiologically significant pericardial effusion as determined by an echocardiogram (ECHO), multigated acquisition scan (MUGA) or cardiac MRI. No clinically significant electrocardiogram (ECG) findings that in the judgment of the treating investigator would present a contraindication for treatment

Exclusion Criteria

History of allergic reactions attributed to compounds of similar chemical or biologic composition to anti-GD2 monoclonal antibody (dinutuximab) or Hu5F9-G4 (magrolimab) monoclonal antibody or other agents used in this study
Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
Patients who are receiving any other investigational agents
Pregnant women are excluded from this study because Hu5F9-G4 (magrolimab) is a monoclonal antibody on the developing human fetus are unknown and dinutuximab may cause fetal harm. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with Hu5F9-G4 (magrolimab) or dinutuximab, breastfeeding should be discontinued if the mother is treated with Hu5F9-G4 (magrolimab) or dinutuximab
Patients who have received prior treatment with CD47 or SIRPalpha-targeting agents
Patients with red blood cell (RBC) transfusion dependence, defined as requiring more than 2 units of RBCs transfused during the 4-week period prior to screening. RBC transfusions are permitted during the screening period and prior to enrollment
Patients with known inherited or acquired bleeding disorders are not eligible
Patients with prior hemolytic anemia or Evans syndrome in the last 3 months
Patients with significant medical diseases that would worsen the risk-benefit ratio of participating in this study. This includes but is not limited to acute myocardial infarction within the last 6 months, unstable angina, significant acute or chronic infections, or severely immunocompromised state
Immunotherapy or immunosuppressive drugs (e.g. chemotherapy or systemic corticosteroids) EXCEPT for the following
The only exception is for patients known to require 2 mg/kg or less of hydrocortisone (or an equivalent dose of an alternative corticosteroid) as premedication for blood product administration in order to avoid allergic transfusion reactions. The use of conventional doses of inhaled steroids for the treatment of asthma is permitted, as is the use of physiologic doses of steroids for patients with known adrenal insufficiency
Herbal remedies with immunostimulating properties (e.g., mistletoe extract) or known to potentially interfere with major organ function (e.g. hypericin)
Growth factors (granulocyte colony stimulating factor or granulocyte macrophage
Patients on the following medications at the time of study treatment initiation
colony stimulating factor) EXCEPT for erythropoietin and darbepoietin alpha
Patients administered a live vaccine within 28 days prior to initiation of study
treatment
Patients with untreated central nervous system (CNS) metastasis
Patients with previous CNS tumor involvement that has been treated and is stable for at least 4 weeks following completion of therapy are permitted
Patients who are clinically stable as evidenced by no requirements for corticosteroids, no evolving neurologic deficits, and no progression of residual brain abnormalities without specific therapy, are permitted
Patients with asymptomatic subcentemeric CNS lesions are permitted if no immediate radiation or surgery is indicated
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