BEACON: Activity Study of Bevacizumab With Temozolomide ± Irinotecan for Neuroblastoma in Children

Sponsor

University of Birmingham (Other)

Overall Status

Active, not recruiting

CT.gov ID

NCT02308527

Collaborator

Cancer Research UK (Other), Roche Pharma AG (Industry), Imagine for Margo (Other), EUSA Pharma, Inc. (Industry)

225

Enrollment

Locations

Arms

161

Anticipated Duration (Months)

22.5

Patients Per Site

0.1

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

The purpose of this study is to investigate whether Bevacizumab (an anti-VEGF monoclonal antibody) added to a backbone chemotherapy regimen (Temozolomide, Irinotecan-Temozolomide or Topotecan-Temozolomide) demonstrates activity in children with relapsed or refractory neuroblastoma. Also, to investigate whether the addition of Irinotecan or Topotecan to Temozolomide increases the activity of chemotherapy.The primary objective of the study is the best response (Complete Response or Partial Response) while trial treatment, within 18 or 24 weeks depending on the arm of the trial the participant is randomised to. Secondary endpoints are assessing the side effects, the length of time before progression (Progression Free Survival) and overall survival (OS).

This trial will address two important questions:

does targeting blood vessel development using bevacizumab, (a monoclonal antibody against the Vascular Endothelial Growth Factor (VEGF)), add to the effect on a tumour when used with existing chemotherapy, compared to the effect of the existing chemotherapy alone (temozolomide)? NOTE- This question has been completed.
does the addition of a second chemotherapy drug (irinotecan or topotecan) increase the effect on a tumour compared to the effect of one alone (temozolomide) NOTE - This question has been completed.
does the addition of dinutuximab beta added to a backbone chemotherapy (temozolomide or temozolomide + topotecan) increase the effect of backbone alone.

Patients aged 1-21 years of age with relapsed or refractory high-risk neuroblastoma are randomised to one of two treatment arms: temozolomide-topotecan (TTo) or dinutuximab beta-temozolomide-topotecan (dBTTo). Temozolomide (T), irinotecan-temozolomide (IT), bevacizumab-T (BT), BIT (bevacizumab-IT), bevacizumab-temozolomide-topotecan (BTTo) and dinutuximab beta-temozolomide (dBT) are now closed to recruitment.

Condition or Disease	Intervention/Treatment	Phase
Neuroblastoma	Drug: Bevacizumab Drug: Temozolomide Drug: Temozolomide Drug: Irinotecan Drug: Bevacizumab Drug: Topotecan Drug: Temozolomide Drug: Dinutuximab Beta Drug: Cyclophosphamide	Phase 2

Detailed Description

This is an international open-label, randomised, multicentre phase II trial of temozolomide ± irinotecan, with or without bevacizumab, for the treatment of patients with relapsed or refractory neuroblastoma. The study will evaluate the safety and activity of these combinations.

Patients will be registered into the trial and randomised at the same time to one of the following two arms (approximately 30 patients per arm):

TTo: Temozolomide + Topotecan dBTTo: Dinuximab beta + Temozolomide + Topotecan

Arms which have now closed to recruitment:

dBT: Dinutuximab beat + Temozolomide Closed 28 ]Jan 2020 T: Temozolomide - Closed 28 Jan 2020 BT: Bevacizumab + Temozolomide - Closed 7 Feb 2019 IT: Irinotecan + Temozolomide - Closed 21

June 2018 BIT: Bevacizumab + Irinotecan + Temozolomide - Closed 21 June 2018 BTTo:

Bevacizumab + Temozolomide + Topotecan - Closed 7 Feb 2019

Randomisation will be via a secure on-line computer-based system at the Cancer Research Clinical Trial Unit (CRCTU), University of Birmingham, United Kingdom (UK) and patients will be allocated in a 2:1 ratio. Minimisation will be used to ensure balance across the arms for the important prognostic factors as described by London et al. [10]: a) relapsed, refractory disease, b) early (< 18 months), late relapse (≥18 months) and c) measurable versus evaluable disease (i.e. disease evaluated according to RECIST versus disease detectable only by MIBG scanning with or without bone marrow involvement as detected by local morphology) Patients will receive treatment for 6 courses, lasting 24 weeks.

Patients with a response (CR, PR) or stable disease (SD) while on the BEACON-Neuroblastoma trial will receive 6 cycles of trial treatment. If the patient has achieved a satisfactory response (i.e. CR, PR or SD) with acceptable toxicity, treatment may be extended beyond 6 cycles (up to 12 cycles) after discussion with the Sponsor and the Chief Investigator (CI).

In addition, patients randomised to TTo may recieve an optional regimen of dinutuximab beta + topotecan + cyclophosphamide (up to 6 cycles).

Study Design

Study Type:

Interventional

Actual Enrollment :

225 participants

Allocation:

Randomized

Intervention Model:

Factorial Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

A Randomised Phase IIb Trial of Bevacizumab Added to Temozolomide ± Irinotecan for Children With Refractory/Relapsed Neuroblastoma - BEACON-Neuroblastoma Trial

Actual Study Start Date :

Jul 1, 2013

Actual Primary Completion Date :

Aug 1, 2021

Anticipated Study Completion Date :

Dec 1, 2026

Arms and Interventions

Arm	Intervention/Treatment
Active Comparator: Temozolomide Temozolomide Days 1-5 every 4 weeks	Drug: Temozolomide 200mg/m2/d PO (capsule taken orally) on Days 1 to 5 of a 4 week cycle, for 6 cycles or until progression Other Names: Temodal
Experimental: Bevacizumab + Temozolomide Bevacizumab Day 1 and 15 + Temozolomide Days 1-5 every 4 weeks	Drug: Bevacizumab 10mg/kg IV (in the vein) on Days 1 and 15 of a 4 week cycle, for 6 cycles or until progression Other Names: Avastin Drug: Temozolomide 200mg/m2/d PO (capsule taken orally) on Days 1 to 5 of a 4 week cycle, for 6 cycles or until progression Other Names: Temodal
Experimental: Irinotecan + Temozolomide Irinotecan Days 1-5 + Temozolomide Days 1-5 every 3 weeks	Drug: Temozolomide 100mg/m2/d PO (capsule taken orally) on Days 1 to 5 of a 3 week cycle, for 6 cycles or until progression Other Names: Temodal Drug: Irinotecan 50mg/m2/d IV (in the vein) on Days 1 to 5 of a 3 week cycle, for 6 cycles or until progression Other Names: Campto
Experimental: Bevacizumab + Irinotecan + Temozolomide Bevacizumab Day 1 + Irinotecan Days 1-5 + Temozolomide Days 1-5 every 3 weeks	Drug: Temozolomide 100mg/m2/d PO (capsule taken orally) on Days 1 to 5 of a 3 week cycle, for 6 cycles or until progression Other Names: Temodal Drug: Irinotecan 50mg/m2/d IV (in the vein) on Days 1 to 5 of a 3 week cycle, for 6 cycles or until progression Other Names: Campto Drug: Bevacizumab 15mg/kg IV (in the vein) on Day 1 of a 3 week cycle, for 6 cycles or until progression Other Names: Avastin
Experimental: Temozolomide + Topotecan Temozolomide Days 1-5+ Topotecan Days 1-5 every 4 weeks	Drug: Topotecan 0.75mg/m2/d IV (in the vein) on Days 1-5 of a 4 week cycle, for 6 cycles or until progression Drug: Temozolomide 150mg/m2/d PO (capsule taken orally) on Days 1 to 5 of a 4 week cycle, for 6 cycles or until progression Other Names: Temodal
Experimental: Bevacizumab + Temozolomide + Topotecan Bevacizumab Day 1 and 15 + Temozolomide Days 1-5 + Topotecan Days 1-5 every 4 weeks	Drug: Bevacizumab 10mg/kg IV (in the vein) on Days 1 and 15 of a 4 week cycle, for 6 cycles or until progression Other Names: Avastin Drug: Topotecan 0.75mg/m2/d IV (in the vein) on Days 1-5 of a 4 week cycle, for 6 cycles or until progression Drug: Temozolomide 150mg/m2/d PO (capsule taken orally) on Days 1 to 5 of a 4 week cycle, for 6 cycles or until progression Other Names: Temodal
Experimental: Dinutuximab beta + Temozolomide Dinutuximab beta Days 1-7 + Temozolomide Days 1-5 every 4 weeks	Drug: Temozolomide 200mg/m2/d PO (capsule taken orally) on Days 1 to 5 of a 4 week cycle, for 6 cycles or until progression Other Names: Temodal Drug: Dinutuximab Beta 10mg/m2/d IV (in the vein) on Days 1 to 7 of a 4 week cycle, for 6 cycles or until progression Other Names: Qarziba
Experimental: Dinutuximab beta + Temozolomide + Topotecan Dinutuximab beta Days 1-7 + Temozolomide Days 1-5 + Topotecan Days 1-5 every 4 weeks	Drug: Temozolomide 200mg/m2/d PO (capsule taken orally) on Days 1 to 5 of a 4 week cycle, for 6 cycles or until progression Other Names: Temodal Drug: Topotecan 0.75mg/m2/d IV (in the vein) on Days 1-5 of a 4 week cycle, for 6 cycles or until progression Drug: Dinutuximab Beta 10mg/m2/d IV (in the vein) on Days 1 to 7 of a 4 week cycle, for 6 cycles or until progression Other Names: Qarziba
Other: Dinutuximab beta + Topotecan + Cyclophosphamide Dinutuximab beta Days 1-7 + Topotecan Days 1-5 + Cyclophosphamide Days 1-5 every 4 weeks	Drug: Topotecan 0.75mg/m2/d IV (in the vein) on Days 1-5 of a 4 week cycle, for 6 cycles or until progression Drug: Dinutuximab Beta 10mg/m2/d IV (in the vein) on Days 1 to 7 of a 4 week cycle, for 6 cycles or until progression Other Names: Qarziba Drug: Cyclophosphamide 250mg/m2/d IV (in the vein) on Days 1 to 5 of a 4 week cycle, for 6 cycles or until progression

Outcome Measures

Primary Outcome Measures

Best response (Complete Response or Partial Response) while on trial treatment, within 18 or 24 weeks depending on the arm of the trial participant is randomised to. [Within 18 or 24 weeks depending on the arm of the trial the participant is randomised to.]
To test whether bevacizumab added to a backbone chemotherapy regimen (temozolomide, irinotecan-temozolomide or topotecan-temozolomide) demonstrates activity in children with relapsed or refractory neuroblastoma To test whether the addition of irinotecan to temozolomide increases the activity of chemotherapy in children with relapsed or refractory neuroblastoma
For the bevacizumab part 2 only; Progression-free survival (PFS) [Assessment will be after 30 days after treatment or end of trial]
Progression-free survival (PFS)

Secondary Outcome Measures

To evaluate the toxicity of the regimens [Assessment will be after 30 days after treatment or end of trial]
Safety of the regimens: Incidence and severity of Adverse Events (AE)s
To evaluate the safety of the regimens [Assessment will be after 30 days after treatment or end of trial]
Safety of the regimens: Progression-free survival (PFS)
To evaluate the overall safety of the regimens [Assessment will be after 30 days after treatment or end of trial]
Safety of the regimens: Overall survival (OS)
To evaluate the safety of the regimens [Assessment will be after 30 days after treatment or end of trial]
Safety of the regimens: Event-free survival (EFS)

Eligibility Criteria

Criteria

Ages Eligible for Study:

1 Year to 21 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria

Histologically proven neuroblastoma as per International Neuroblastoma Staging System (INSS) definition
Relapsed: any relapsed or progressed high-risk neuroblastoma
Refractory high risk disease: Lack of adequate response to frontline therapy that precludes the patient from proceeding to consolidation therapies
Measurable disease by cross sectional imaging (RECIST) or evaluable disease
Age ≥1 to ≤21 years
Informed consent from patient, parent or guardian
Performance Status:Lansky ≥ 50%, Karnofsky ≥ 50% or Eastern Cooperative Oncology Group ≤3 (Patients who are unable to walk because of paralysis, but who are able to sit upright unassisted in a wheelchair, will be considered ambulatory for the purpose of assessing performance score)
Life expectancy of ≥12 weeks
No bone marrow disease: Platelets ≥75 x 10^{9/L (unsupported for 72 hours), absolute
neutrophil count ≥0.75 x10}9/L (no G-cerebrospinal fluid support for 72 hours), Haemoglobin ≥8 g/dL (transfusions allowed) Bone marrow disease: Platelets ≥50 x10^{9/L
(unsupported for 72 hours), absolute neutrophil count (ANC) ≥0.5 x 10}9/L (no granulocyte colony stimulating factor (G-CSF) for 72 hours), Haemoglobin ≥8 g/dL (transfusions allowed)
Renal function (within 72 hours of eligibility assessment): Absence of clinically significant proteinuria (early morning urine dipstick <2+). When the dipstick urinalysis shows a proteinuria ≥2+, a protein:creatinine (Pr/Cr) ratio must be <0.5 or a 24 hour protein excretion must be <0.5g
Serum creatinine ≤ 1.5 upper limit of normal for age, if higher, a calculated glomerular filtration rate (radioisotope) must be ≥60 ml/min/1.73 m2
Liver function (within 72 hours of eligibility assessment): aspartate aminotransferase (AST) or Alanine Aminotransferase (ALT) ≤2.5 ULN and Total bilirubin ≤1.5 upper limit of normal (ULN). In case of liver metastases, AST or ALT ≤5 ULN and Total bilirubin ≤2.5 ULN
Cardiac function, shortening fraction ≥29% on echocardiogram
Coagulation, patients not on anticoagulation must have an international normalized ratio (INR) ≤1.5 and activated partial thromboplastin time (APTT) ≤1.5 ULN for age. Anti-coagulation is permitted as long as the INR or APTT is within therapeutic limits (according to the medical standard of the institution) and the patient has been on a stable dose of anticoagulants for at least two weeks at the time of study enrolment
Blood pressure below 95th centile for age and sex. Use of antihypertensive medication is permitted
Males or females of reproductive potential may not participate unless they agree to use an effective contraceptive method, for the duration of study therapy and for up to 6 months after the last dose of trial drugs. A negative urine pregnancy test must be obtained within 72 hours prior to dosing in females who are post-menarche
No dyspnoea at rest and pulse oximetry > 94% in room air
Availability and willingness to place a double central venous access if needed for trial treatment and supportive care in case of treatment with chemo-immunotherapy

Exclusion Criteria:

Previous treatment with bevacizumab, temozolomide, irinotecan or any combination of these drugs
Known hypersensitivity to: Any study drug or component of the formulation, Chinese hamster ovary products or other recombinant human or humanised antibodies, Dacarbazine
Prior severe arterial thrombo-embolic events (e.g. cardiac ischemia, cerebral vascular accident, peripheral arterial thrombosis)
Any ongoing arterial thrombo-embolic events
Patient less than (at point of planned date of randomisation): 48 hours post bone marrow aspirate/trephine, 48 hours post central line insertion, Four weeks post major surgery, One week post core biopsy, Two weeks from prior chemotherapy, Six weeks from prior craniospinal radiotherapy or MIBG therapy and two weeks from radiotherapy to the tumour bed, Eight weeks from prior myeloablative therapy with haematopoietic stem cell rescue (autologous stem cell transplant), Three months from prior allogeneic stem cell transplant, 14 days or 5 half-lives (whichever occurs later) from last administration of an IMP in an IMP-trial, 6 months from presentation of lung haemorrhage/haemoptysis
Bleeding metastases (patients with CNS metastases can be enrolled as long as the metastases are not bleeding)
Invasion of major blood vessels
Use of enzyme inducing anticonvulsants within 72 hours of randomisation
History or evidence of inherited bleeding diathesis or significant coagulopathy at risk of bleeding (i.e. in the absence of therapeutic anticoagulation)
History of abdominal fistula, gastrointestinal perforation, intra-abdominal abscess or active gastrointestinal bleeding within 6 months prior to study enrolment
Current chronic intestinal inflammatory disease/bowel obstruction
Intolerance to galactose and fructose, lactase deficiency, and/or defect of absorption of galactose and fructose
Pregnant or lactating patient
Any uncontrolled medical condition that poses an additional risk to the patient (i.e. haemoptysis, non-healing, bone fracture, wound/ulcer)
Low probability of treatment compliance
Any uncontrolled medical condition that poses an additional risk to the patient
Planned immunisation with live vaccine

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	St Anna Children's Hospital and CCRI/Studies and Statistics	Vienna		Austria	A-1090
2	University Hospital	Gent		Belgium
3	University Hospital Rigshospitalet	Copenhagen		Denmark	DK-2100
4	Hopital des Enfants	Toulouse		France	31059
5	Our Ladys Children's Hospital Dublin	Dublin		Ireland	Dublin 12
6	Ospedale Pediatrico Bambino Gseu	Rome		Italy	00165
7	Princess Maxima Centre	Utrecht		Netherlands
8	Instituto de Investigacion Sanitaria	Valencia		Spain	46026
9	Swiss Paediatric Oncology Group	Bern		Switzerland	3008
10	The Royal Marsden NHS Foundation Trust and Institute of Cancer Research	Sutton	Surrey	United Kingdom	SM2 5PT