Combination Chemotherapy With or Without Gemtuzumab in Treating Young Patients With Newly Diagnosed Acute Myeloid Leukemia

This study is ongoing, but not recruiting participants.
Sponsor:
Collaborator:
Information provided by (Responsible Party):
Children's Oncology Group
ClinicalTrials.gov Identifier:
NCT00372593
First received: September 6, 2006
Last updated: February 25, 2014
Last verified: February 2014
  Purpose

RATIONALE: Drugs used in chemotherapy work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Monoclonal antibodies, such as gemtuzumab, can block cancer growth in different ways. Some block the ability of cancer cells to grow and spread. Others find cancer cells and help kill them or carry cancer-killing substances to them. Giving combination chemotherapy together with gemtuzumab may kill more cancer cells. It is not yet known whether combination chemotherapy is more effective with or without gemtuzumab in treating patients with newly diagnosed acute myeloid leukemia.

PURPOSE: This randomized phase III trial is studying combination chemotherapy and gemtuzumab to see how well they work compared with combination chemotherapy alone in treating young patients with newly diagnosed acute myeloid leukemia.


Condition Intervention Phase
Leukemia
Drug: asparaginase
Drug: cytarabine
Drug: daunorubicin hydrochloride
Drug: etoposide
Drug: gemtuzumab ozogamicin
Drug: mitoxantrone hydrochloride
Phase 3

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: A Phase III Randomized Trial of Gemtuzumab Ozogamicin (Mylotarg) Combined With Conventional Chemotherapy for De Novo Acute Myeloid Leukemia (AML) in Children, Adolescents, and Young Adults

Resource links provided by NLM:


Further study details as provided by Children's Oncology Group:

Primary Outcome Measures:
  • Event-free survival [ Time Frame: Time from study entry to time of induction failure, relapse, or death ] [ Designated as safety issue: No ]
    The Kaplan-Meier method will be used to calculate estimates of EFS. The log-rank test will be used to compare survival between treatment groups. Analysis of EFS of Down syndrome patients will be performed separately. Monitoring for efficacy of GMTZ with respect to OS and EFS will utilize monitoring based on the Lan-DeMets criterion with α-spending function αt^2 (truncated at 3 standard deviations) and 2.5% type I error.

  • Overall survival [ Time Frame: Time from study entry, assessed up to 10 years ] [ Designated as safety issue: No ]
    The Kaplan-Meier method will be used to calculate estimates of OS. Analysis of OS of Down syndrome patients will be performed separately. Monitoring for efficacy of GMTZ with respect to OS and EFS will utilize monitoring based on the Lan-DeMets criterion with α-spending function αt^2 (truncated at 3 standard deviations) and 2.5% type I error.


Secondary Outcome Measures:
  • Remission induction rate after 2 courses of induction therapy [ Time Frame: After 2 courses of induction (I and II) therapy, assessed for up to 10 years ] [ Designated as safety issue: No ]
    Patients without an evaluable bone marrow at the end of Induction I will be excluded from the calculation of remission rate after 2 courses of therapy because their responses are not evaluable. The following patients will be considered to not be in complete remission (CR) after 2 courses of therapy: (1) patients who die during Induction I and II; (2) patients with ≥ 5% blasts or extramedullary disease at the end of Induction II.

  • Disease-free survival [ Time Frame: Time from the end of course 3 (Intensification I) to death or relapse; assessed for up to 10 years ] [ Designated as safety issue: No ]
    The Kaplan-Meier method will be used to calculate estimates DFS. Analysis of DFS of Down syndrome patients will be performed separately.

  • Mortality [ Time Frame: During the first three courses of therapy ] [ Designated as safety issue: No ]
  • Time to marrow recovery [ Time Frame: At 25 days after treatment with Induction I, Induction II, and Intensification I ] [ Designated as safety issue: No ]
  • Toxicities, including infectious complications [ Time Frame: From the time therapy is initiated, assessed up to 10 years ] [ Designated as safety issue: Yes ]

Enrollment: 1070
Study Start Date: August 2006
Primary Completion Date: August 2013 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Active Comparator: Arm I (standard therapy)

Patients receive intrathecal (IT) cytarabine (ARA-C) at diagnosis or on day 1 of treatment or twice a week for up to 6 doses. They also receive an infusion of ARA-C on days 1-10; a 6-hour infusion of daunorubicin hydrochloride on days 1, 3, and 5; and a 4-hr infusion of etoposide on days 1-5.

After 3 weeks of rest, patients receive IT ARA-C on day 1. They also receive an infusion of ARA-C on days 1-8; a 6-hr infusion of daunorubicin on days 1, 3, and 5; and a 4-hr infusion of etoposide on days 1-5.

After 3 weeks of rest, some patients receive IT ARA-C on day 1 and 1-hr infusions of ARA-C and etoposide on days 1-5.

After 3 weeks of rest, some patients receive IT ARA-C on day 1; a 2-hr infusion of ARA-C on days 1-4; and a 1-hour infusion of mitoxantrone on days 3-6. After 3 weeks of rest, they receive a 3-hr infusion of ARA-C on days 1, 2, 8, and 9 and an injection of asparaginase on days 2 and 9.

Drug: asparaginase
Given intramuscularly
Other Names:
  • E.coli
  • E.coli L-asparaginase
  • EC 3.5.2.2
  • colaspase
  • L-asnase
  • Elspar
  • Kidrolase
  • Crasnitin
  • Leunase
  • NSC 109229
Drug: cytarabine
Given IV
Other Names:
  • Cytosine arabinoside
  • Ara-C
  • Cytosar
  • NSC # 63878
Drug: daunorubicin hydrochloride
Given IV over 6 hours
Other Names:
  • Daunomycin
  • rubidomycin
  • Cerubidine
  • NSC #82151
Drug: etoposide
Given IV over 1-4 hours
Other Names:
  • VePesid
  • Etopophos
  • VP-16
  • NSC #141540
Drug: mitoxantrone hydrochloride
Given IV over 1 hour
Other Names:
  • Novantrone
  • CL 232315
  • DAD
  • DHAD
  • Mitozantrone
  • NSC #301739
Experimental: Arm II

Pts receive IT ARA-C at diagnosis or on day 1 of treatment or twice a week for up to six doses. They also receive an infusion of ARA-C on days 1-10; a 6-hr infusion of daunorubicin on days 1, 3, and 5; a 4-hr infusion of etoposide on days 1-5; and a 2-hour infusion of gemtuzumab ozogamicin on day 6.

After 3 weeks of rest, patients receive IT ARA-C on day 1. They also receive an infusion of ARA-C on days 1-8; a 6-hr infusion of daunorubicin on days 1, 3, and 5; and a 4-hour infusion of etoposide on days 1-5.

After 3 weeks of rest, some patients receive IT ARA-C on day 1 and 1-hr infusions of ARA-C and etoposide on days 1-5.

After 3 weeks of rest, some patients receive IT ARA-C on day 1; a 2-hr infusion of ARA-C on days 1-4; and a 1-hr infusion of mitoxantrone hydrochloride on days 3-6. They also receive a 2-hr infusion of gemtuzumab on day 7. After 3 weeks of rest, they receive a 3-hr infusion of ARA-C on days 1, 2, 8, and 9 and an injection of asparaginase on days 2 and 9.

Drug: asparaginase
Given intramuscularly
Other Names:
  • E.coli
  • E.coli L-asparaginase
  • EC 3.5.2.2
  • colaspase
  • L-asnase
  • Elspar
  • Kidrolase
  • Crasnitin
  • Leunase
  • NSC 109229
Drug: cytarabine
Given IV
Other Names:
  • Cytosine arabinoside
  • Ara-C
  • Cytosar
  • NSC # 63878
Drug: daunorubicin hydrochloride
Given IV over 6 hours
Other Names:
  • Daunomycin
  • rubidomycin
  • Cerubidine
  • NSC #82151
Drug: etoposide
Given IV over 1-4 hours
Other Names:
  • VePesid
  • Etopophos
  • VP-16
  • NSC #141540
Drug: gemtuzumab ozogamicin
Given IV over 2 hours
Drug: mitoxantrone hydrochloride
Given IV over 1 hour
Other Names:
  • Novantrone
  • CL 232315
  • DAD
  • DHAD
  • Mitozantrone
  • NSC #301739

  Hide Detailed Description

Detailed Description:

OBJECTIVES:

Primary

  • Compare the event-free survival (EFS) and overall survival (OS) of young patients with newly diagnosed acute myeloid leukemia (AML) treated with conventional combination chemotherapy with vs without gemtuzumab ozogamicin (GMTZ).

Secondary

  • Compare the remission induction rates after two courses of therapy in these patients.
  • Compare disease-free survival and OS in patients who are eligible for an HLA-matched family donor (MFD) stem cell transplant (SCT) by virtue of their risk classification, with patients assigned to MFD SCT if a MFD is available, or to chemotherapy if a MFD is not available.
  • Determine the outcome of patients with Down syndrome who are 4 years of age or older at diagnosis and treated with conventional combination chemotherapy without GMTZ.
  • Compare the EFS and OS of patients with de novo AML treated with conventional combination chemotherapy with vs without GMTZ censoring MFD SCT recipients.
  • Determine the prevalence and prognostic significance of molecular abnormalities of KIT, CEBPα and MLL-PTD genes in these patients.
  • Determine the leukemic involvement of hematopoietic early progenitor and its role in defining response to therapy.
  • Assess the ability of a second-generation flow cytometric assay to predict patients at high risk for relapse during periods of clinical remission.
  • Examine whether GMTZ significantly improves EFS and OS in patients with higher CD33 concentrations/intensity.
  • Examine whether GMTZ significantly improves complete remission, EFS, and OS in each of the cytogenetic risk groups (high-, intermediate-, and low-risk) identified in prior Medical Research Council trials.
  • Utilize fluorescence in situ hybridization (FISH) analysis to identify variant patterns among subgroups of patients who demonstrate the same G-banded chromosomal abnormality (e.g., inv[16]/t[16;16], t[8;21], 11q23 abnormality) and determine whether these variant patterns account for the heterogeneity of responses to therapy.
  • Examine the impact of complex karyotypes (≥ 3, ≥ 4, and ≥ 5 abnormalities) on OS and EFS in intermediate-risk patients for whom no high-risk or low-risk cytogenetic abnormalities exist.

OUTLINE: This is a randomized, multicenter study. Patients are stratified according to relapse risk (high vs intermediate vs low). Patients are randomized to 1 of 2 treatment arms. Patients with Down syndrome are nonrandomly assigned to arm I (but do not undergo allogeneic stem cell transplant [SCT]).

  • Arm I (standard therapy):

    • Induction 1: Patients receive cytarabine IT at the time of diagnosis or on day 1*. Patients also receive cytarabine IV on days 1-10, daunorubicin hydrochloride IV over 6 hours on days 1, 3, and 5, and etoposide IV over 4 hours on days 1-5. After 3 weeks of rest, all patients (regardless of remission status) proceed to induction 2.

NOTE: *Patients with CNS disease receive cytarabine IT twice weekly until the cerebrospinal fluid is clear, followed by two additional IT treatments. Patients with refractory CNS leukemia after 6 doses of IT treatment are removed from the study.

  • Induction 2: Patients receive cytarabine IT on day 1, cytarabine IV on days 1-8, daunorubicin hydrochloride IV over 6 hours on days 1, 3, and 5, and etoposide IV over 4 hours on days 1-5. After 3 weeks of rest, patients in complete remission (CR) proceed to intensification 1. Patients with refractory disease are removed from protocol therapy.
  • Intensification 1: Patients receive cytarabine IT on day 1, high-dose cytarabine IV over 1 hour on days 1-5, and etoposide IV over 1 hour on days 1-5. After 3 weeks of rest, patients in remission proceed to intensification 2, followed by intensification 3. Patients in remission proceed to allogeneic SCT 2-8 weeks after blood counts recover. Patients with high-risk disease with an alternative donor proceed to intensification 2 and 3, followed by allogeneic SCT. Patients not in remission are removed from protocol therapy.
  • Intensification 2: Patients receive cytarabine IT on day 1, high-dose cytarabine IV over 2 hours on days 1-4, and mitoxantrone hydrochloride IV over 1 hour on days 3-6. After 3 weeks of rest, patients proceed to intensification 3.
  • Intensification 3: Patients receive high-dose cytarabine IV over 3 hours on days 1, 2, 8, and 9 and asparaginase intramuscularly on days 2 and 9.

    • Arm II:
  • Induction 1: Patients receive treatment as in induction 1 of arm I. Patients also receive gemtuzumab ozogamicin (GMTZ) IV over 2 hours on day 6.
  • Induction 2: Patients receive treatment as in induction 2 of arm I.
  • Intensification 1: Patients receive treatment as in intensification 1 of arm I.
  • Intensification 2: Patients receive treatment as in intensification 2 of arm I. Patients also receive GMTZ IV over 2 hours on day 7.
  • Intensification 3: Patients receive treatment as in intensification 3 of arm I.

    • Allogeneic SCT (for patients with intermediate- or high-risk disease):
  • MFD: Patients receive a conditioning regimen comprising busulfan IV over 2 hours every 6 hours on days -9 to -6 and cyclophosphamide IV over 1 hour on days -5 to -2. Patients undergo allogeneic SCT on day 0. Patients receive cyclosporine IV or orally twice daily on days -1 to 180 and methotrexate IV on days 1, 3, 6, and 11. Patients receive graft-vs-host disease (GVHD) prophylaxis comprising cyclosporine IV over 1-4 hours or orally twice daily on days -1 to 180 and methotrexate IV on days 1, 3, 6, and 11.
  • Matched alternative donor: Patients receive a conditioning regimen comprising busulfan and cyclophosphamide as above. Patients also receive antithymocyte globulin IV over 6-8 hours on days -3 to -1. Patients then undergo allogeneic SCT and receive GVHD prophylaxis as above.

After completion of study treatment, patients are followed periodically for 3 years and then annually thereafter.

PROJECTED ACCRUAL: A total of 1,012 patients will be accrued for this study.

  Eligibility

Ages Eligible for Study:   up to 29 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

DISEASE CHARACTERISTICS:

  • Newly diagnosed acute myeloid leukemia (AML)

    • Meets customary criteria for AML with ≥ 20% bone marrow blasts (by WHO classification)

      • Patients with < 20% bone marrow blasts and cytopenia or myelodysplastic syndromes (e.g., chronic myelomonocytic leukemia, refractory anemia [RA], RA with excess blasts, RA with ringed sideroblasts) are eligible provided 1 of the following criteria is met:

        • Karyotypic abnormality characteristic of de novo AML (t[8;21][q22;q22], inv[16][p13q22], t[16;16][p13;q22], or 11q23 abnormalities)
        • Unequivocal presence of megakaryoblasts (by WHO classification)
    • Isolated myeloid sarcoma (i.e., myeloblastoma or chloroma) allowed regardless of bone marrow results
  • Infants < 1 month of age with progressive disease* are eligible NOTE: *Infants < 1 month of age with AML may be given supportive care until it is clear that the leukemia is not regressing (i.e., the disappearance of peripheral blasts and the normalization of peripheral blood counts)
  • Patients with Down syndrome ≥ 4 years of age are eligible
  • No juvenile myelomonocytic leukemia
  • No Fanconi's anemia, Kostmann syndrome, Shwachman syndrome, or any other known bone marrow failure syndrome
  • No promyelocytic leukemia (M3)
  • No secondary or treatment-related AML
  • Matched family donor criteria (for patients with intermediate-risk or high-risk disease):

    • HLA-A, -B, -C, and -DRB1, identical or 1 antigen or allele mismatched by molecular high resolution technique
    • All available first-degree family members (parents and siblings) must be HLA typed
    • No syngeneic donors
  • Matched alternative donor criteria (for patients with high-risk disease):

    • HLA-A, -B, -C, and -DRB1, identical or 1 antigen or allele mismatched donor
    • HLA-A, -B, and -DRB1 4 of 6 antigen matched unrelated cord blood donor
    • Mismatched family member donor with ≥ 1 haplotype match or 5 of 6 antigen phenotypic match

PATIENT CHARACTERISTICS:

  • Not pregnant or nursing
  • Negative pregnancy test
  • Fertile patients must use effective contraception

PRIOR CONCURRENT THERAPY:

  • No prior chemotherapy, radiation therapy, or any antileukemic therapy

    • Topical or inhalation steroids for other conditions allowed
    • Intrathecal cytarabine given at diagnosis allowed
  • No other prior treatment for AML
  • No concurrent peripheral blood stem cell transplantation in patients with matched family donor
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00372593

  Show 198 Study Locations
Sponsors and Collaborators
Children's Oncology Group
Investigators
Study Chair: Alan S. Gamis, MD, MPH Children's Mercy Hospital
Study Chair: Richard Aplenc, MD, MSCE Children's Hospital of Philadelphia
  More Information

Additional Information:
Publications:
Responsible Party: Children's Oncology Group
ClinicalTrials.gov Identifier: NCT00372593     History of Changes
Other Study ID Numbers: AAML0531, COG-AAML0531, CDR0000487497
Study First Received: September 6, 2006
Last Updated: February 25, 2014
Health Authority: United States: Federal Government

Keywords provided by Children's Oncology Group:
adult acute myeloid leukemia with 11q23 (MLL) abnormalities
adult acute myeloid leukemia with inv(16)(p13;q22)
adult acute myeloid leukemia with t(16;16)(p13;q22)
adult acute myeloid leukemia with t(8;21)(q22;q22)
untreated adult acute myeloid leukemia
untreated childhood acute myeloid leukemia and other myeloid malignancies
adult acute basophilic leukemia
adult acute eosinophilic leukemia
adult acute minimally differentiated myeloid leukemia (M0)
adult acute myeloblastic leukemia without maturation (M1)
adult acute myeloblastic leukemia with maturation (M2)
adult acute myelomonocytic leukemia (M4)
adult acute monoblastic leukemia (M5a)
adult acute monocytic leukemia (M5b)
adult erythroleukemia (M6a)
adult pure erythroid leukemia (M6b)
adult acute megakaryoblastic leukemia (M7)
childhood acute basophilic leukemia
childhood acute eosinophilic leukemia
childhood acute minimally differentiated myeloid leukemia (M0)
childhood acute myeloblastic leukemia without maturation (M1)
childhood acute myeloblastic leukemia with maturation (M2)
childhood acute myelomonocytic leukemia (M4)
childhood acute monocytic leukemia (M5b)
childhood acute monoblastic leukemia (M5a)
childhood acute erythroleukemia (M6)
childhood acute megakaryocytic leukemia (M7)

Additional relevant MeSH terms:
Leukemia
Leukemia, Myeloid, Acute
Leukemia, Myeloid
Neoplasms by Histologic Type
Neoplasms
Etoposide phosphate
Gemtuzumab
Asparaginase
Cytarabine
Daunorubicin
Etoposide
Mitoxantrone
Antineoplastic Agents
Therapeutic Uses
Pharmacologic Actions
Antimetabolites, Antineoplastic
Antimetabolites
Molecular Mechanisms of Pharmacological Action
Antiviral Agents
Anti-Infective Agents
Immunosuppressive Agents
Immunologic Factors
Physiological Effects of Drugs
Antibiotics, Antineoplastic
Topoisomerase II Inhibitors
Topoisomerase Inhibitors
Enzyme Inhibitors
Antineoplastic Agents, Phytogenic
Analgesics
Sensory System Agents

ClinicalTrials.gov processed this record on August 21, 2014