NRSTS2021, A Risk Adapted Study Evaluating Maintenance Pazopanib, Limited Margin, Dose-Escalated Radiation Therapy and Selinexor in Non-Rhabdomyosarcoma Soft Tissue Sarcoma (NRSTS)

Recruiting now · Phase 1/Phase 2

Conditions studied: Adipocytic Neoplasm, Liposarcoma, Atypical Fibroxanthoma, Angiomatoid Fibrous Histiocytoma, Fibrosarcoma NOS, Myxofibrosarcoma, Angiosarcoma, Osteosarcoma, Extraskeletal, Dedifferentiated Liposarcoma, Myxoid Liposarcoma, Pleomorphic Liposarcoma, Myxoid Pleomorphic Liposarcoma, Low Grade Fibromyxoid Sarcoma, Sclerosing Epithelioid Fibrosarcoma, Malignant Tenosynovial Giant Cell Tumor of Soft Tissue, Epithelioid Hemangioendothelioma, Glomus Tumor, Inflammatory Leiomyosarcoma, Leiomyosarcoma, Ossifying Fibromyxoid Tumor, Malignant, Myoepithelioma, Synovial Sarcoma, Epithelioid Sarcoma, Perineurioma, Malignant, Clear Cell Sarcoma, Extraskeletal Myxoid Chondrosarcoma, Granular Cell Tumor, Malignant, Melanotic Malignant Nerve Sheath Tumor, Malignant Peripheral Nerve Sheath Tumor, Perivascular Epithelioid Tumor, Malignant, Intimal Sarcoma, Myoepithelial Carcinoma, Undifferentiated Sarcoma, Pleomorphic Sarcoma, Undifferentiated, Round Cell Sarcoma, Undifferentiated, NTRK-Rearranged Spindle Cell Neoplasm, Phosphaturic Mesenchymal Tumor, Malignant, Round Cell Sarcoma, Well Differentiated Liposarcoma, Giant Cell Tumor of Soft Parts NOS, Low Grade Myofibroblastic Sarcoma, Dermatofibrosarcoma Protuberans, Fibrosarcomatous

In brief

The study participant has been diagnosed with non-rhabdomyosarcoma (NRSTS). Primary Objectives Intermediate-Risk * To estimate the 3-year event-free survival for intermediate-risk patients treated with ifosfamide, doxorubicin, pazopanib, surgery, and maintenance pazopanib, with or without RT. * To characterize the pharmacokinetics of pazopanib and doxorubicin in combination with ifosfamide in intermediate-risk participants, to assess potential covariates to explain the inter- and intra-individual pharmacokinetic variability, and to explore associations between clinical effects and pazopanib and doxorubicin pharmacokinetics. High-Risk * To estimate the maximum tolerated dose (MTD) and/or the recommended phase 2 dosage (RP2D) of selinexor in combination with ifosfamide, doxorubicin, pazopanib, and maintenance pazopanib in high-risk participants. * To characterize the pharmacokinetics of selinexor, pazopanib and doxorubicin in combination with ifosfamide in high-risk participants, to assess potential covariates to explain the inter- and intra-individual pharmacokinetic variability, and to explore associations between clinical effects and selinexor, pazopanib and doxorubicin pharmacokinetics. Secondary Objectives * To estimate the cumulative incidence of primary site local failure and distant metastasis-free, disease-free, event-free, and overall survival in participants treated on the risk-based treatment strategy defined in this protocol. * To define and describe the CTCAE Grade 3 or higher toxicities, and specific grade 1-2 toxicities, in low- and intermediate-risk participants. * To study the association between radiation dosimetry in participants receiving radiation therapy and the incidence and type of dosimetric local failure, normal adjacent tissue exposure, and musculoskeletal toxicity. * To evaluate the objective response rate (complete and partial response) after 3 cycles for high-risk patients receiving the combination of selinexor with ifosfamide, doxorubicin, pazopanib, and maintenance pazopanib. * To assess the relationship between the pharmacogenetic variation in drug-metabolizing enzymes or drug transporters and the pharmacokinetics of selinexor, pazopanib, and doxorubicin in intermediate- or high-risk patients. Exploratory Objectives * To explore the correlation between radiographic response, pathologic response, survival, and toxicity, and tumor molecular characteristics, as assessed through next-generation sequencing (NGS), including whole genome sequencing (WGS), whole exome sequencing (WES), and RNA sequencing (RNAseq). * To explore the feasibility of determining DNA mutational signatures and homologous repair deficiency status in primary tumor samples and to explore the correlation between these molecular findings and the radiographic response, survival, and toxicity of patients treated on this protocol. * To explore the feasibility of obtaining DNA methylation profiling on pretreatment, post-induction chemotherapy, and recurrent (if possible) tumor material, and to assess the correlation with this and pathologic diagnosis, tumor control, and survival outcomes where feasible. * To explore the feasibility of obtaining high resolution single-cell RNA sequencing of pretreatment, post-induction chemotherapy, and recurrent (if possible) tumor material, and to characterize the longitudinal changes in tumor heterogeneity and tumor microenvironment. * To explore the feasibility of identifying characteristic alterations in non-rhabdomyosarcoma soft tissue sarcoma in cell-free DNA (cfDNA) in blood as a non-invasive method of detecting and tracking changes during therapy, and to assess the correlation of cfDNA and mutations in tumor samples. * To describe cardiovascular and musculoskeletal health, cardiopulmonary fitness among children and young adults with NRSTS treated on this protocol. * To investigate the potential prognostic value of serum cardiac biomarkers (high-sensitivity cardiac troponin I (hs-cTnI), N-terminal pro B-type natriuretic peptide (NT-Pro-BNP), serial electrocardiograms (EKGs), and serial echocardiograms in patients receiving ifosfamide, doxorubicin, and pazopanib, with or without selinexor. * To define the rates of near-complete pathologic response (\>90% necrosis) and change in FDG PET maximum standard uptake value (SUVmax) from baseline to week 13 in intermediate risk patients with initially unresectable tumors treated with induction pazopanib, ifosfamide, and doxorubicin, and to correlate this change with tumor control and survival outcomes. * To determine the number of high-risk patients initially judged unresectable at diagnosis that are able to undergo primary tumor resection after treatment with ifosfamide, doxorubicin, selinexor, and pazopanib. * To identify the frequency with which assessment of volumes of interest (VOIs) of target lesions would alter RECIST response assessment compared with standard linear measurements.

Key facts

Study ID

NCT06239272

Run by

St. Jude Children's Research Hospital

People needed

139

Starts

2024-03-27

Expected to finish

2037-06-01

Last updated by the study team

2026-08-03

Who can join

Age: any, up to 30. Sex: any. Healthy volunteers: not accepted.

You may qualify if…

• Inclusion Criteria - All Patients
• Patients must be 1-30 years at the time of the biopsy that established the diagnosis of NRSTS.
• Surgical Resection: Patients who had an upfront resection prior to enrollment will be eligible if they are able to begin therapy within 28 days of resection assuming other eligibility criteria are met. Delayed resection is preferred for all patients with intermediate and high-risk disease.
• Lansky performance status score ≥ 60 for patients ≤ 16 years of age. Karnofsky performance status score ≥ 60 for patients >16 years of age. Note patients who are unable to walk because of paralysis, but who are up in a wheelchair, will be considered ambulatory for the purpose of assessing the performance score.
• Diagnosis
• Patients with CIC-DUX 4 rearranged sarcomas will be enrolled on the high-risk stratum only, regardless of presence of metastasis, size, or resection status.
• Patient has low-risk disease if the patient has a:
• Low-grade tumor of any size where R0 or R1 surgical margins are anticipated or achieved.
• High-grade tumors that are < 5 cm where R0 or R1 resection margins are anticipated or achieved.
• Patient must have adequate organ function in the organs that will be within the radiotherapy field.
• Adequate renal function defined as:
• Creatinine clearance or radioisotope GFR > 70 mL/min/1.73 m2, or
• A normal serum creatinine based on age/gender as follows
• Age Maximum Serum Creatinine (mg/dL) Male Female 2 to < 6 years 0.8 0.8 6 to < 10 years 1 1 10 to < 13 years 1.2 1.2 13 to < 16 years 1.5 1.4 > 16 years 1.5 1.4
• Adequate liver function defined as:
• Total bilirubin < 1.5 x upper limit of normal (ULN) for age
• SGOT (AST) or SGPT (ALT) < 2.5 x ULN for age
• Adequate cardiac function defined as:
• Ejection fraction of > 55% by echocardiogram or cardiac MRI
• QTc < 480 msec
• Adequate pulmonary function defined as:
• No evidence of dyspnea at rest, no exercise intolerance, and a resting pulse oximetry reading > 94% on room air if there is clinical indication for determination.
• Inclusion Criteria - Intermediate and High Risk Participants
• Patient has intermediate-risk if the patient has a:
• Low-grade non-metastatic initially unresectable disease at study enrollment where delayed resection is planned.

You may not qualify if…

• Patients with known primary CNS sarcoma or CNS metastases are not eligible. Note: Brain imaging is not an eligibility requirement. Tumors with intracranial extension will be allowed.
• Patients with the following histologic diagnosis are not eligible: intermediate locally aggressive tumors as defined by WHO, malignant rhabdoid tumor, alveolar soft part sarcoma, infantile fibrosarcoma, unresectable/metastatic dermatofibrosarcoma protuberans, inflammatory myofibroblastic tumor, desmoid fibromatosis, rhabdomyosarcoma, desmoplastic small round cell tumor, BCOR-CCNB3 fusion positive sarcoma.
• Bleeding diathesis: Patients with evidence of active bleeding or bleeding diathesis will be excluded (Note: Patients aged > 17 years with excess of 2.5 mL of hemoptysis are not eligible).
• Uncontrolled hypertension: Patients with uncontrolled hypertension (CTCAE v5 Grade ≥ 2) are ineligible. Hypertension must be well controlled on stable doses of medication for at least two weeks.
• Prior Therapy
• Patients must have had no prior systemic therapy for the treatment of the NRSTS
• Patients must have had no prior anthracycline or ifosfamide chemotherapy
• Patients must have had no prior use of pazopanib or similar multi-targeted TKI.
• Patients must have had no prior radiotherapy to tumor-involved sites.
• Note: Patients previously treated for a non-NRSTS cancer are eligible provided they meet the prior therapy requirements. Patients who have had chemotherapy or radiotherapy within 4 weeks (6 weeks for nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered from adverse events due to agents administered more than 4 weeks earlier are excluded.
• CYP3A4 Substrates WITH Narrow Therapeutic Indices: Patients chronically receiving medications known to be metabolized by CYP3A4 and with narrow therapeutic indices within 7 days prior to study enrollment, including but not limited to pimozide, aripiprazole, triazolam, ergotamine and halofantrine are not eligible. Note: the use of fentanyl is permitted.
• CYP3A4 Inhibitors: Patients chronically receiving drugs that are known potent CYP3A4 inhibitors within 7 days prior to study enrollment, including but not limited to itraconazole, clarithromycin, erythromycin, many NNRTIs, diltiazem, verapamil, and grapefruit juice are not eligible.
• CYP3A4 Inducers: Patients chronically receiving drugs that are known potent CYP3A4 inducers within 14 days prior to study enrollment, including but not limited to carbamazepine, phenobarbital, phenytoin, rifampin, and St. John's wort are not eligible (with the exception of glucocorticoids).
• Certain medications that are associated with a risk for QTc prolongation and/or Torsade's de Pointes, although not prohibited, should be avoided or replaced with medications that do not carry these risks, if possible.
• Subjects with any condition that may impair the ability to absorb oral medications/investigational product including:
• prior surgical procedures affecting absorption including, but not limited to major resection of stomach or small bowel
• active peptic ulcer disease
• malabsorption syndrome
• 4.12 Thyroid Replacement Therapy: Patients who require thyroid replacement therapy are not eligible if they have not been receiving a stable replacement dose for at least 4 weeks prior to study enrollment.
• 4.13 Subjects with any condition that may increase the risk of gastrointestinal bleeding or gastrointestinal perforation, including:
• active peptic ulcer disease
• known intraluminal metastatic lesions
• inflammatory bowel disease (e.g., ulcerative colitis, Crohn's disease) or other gastrointestinal conditions which increase the risk of perforation
• history of abdominal fistula, gastrointestinal perforation or intra- abdominal abscess within 28 days prior to beginning study treatment.
• 4.14 Pulmonary embolism or DVT. Patients must not have experienced:

Where it is running

• Children's Healthcare of Atlanta — Atlanta, Georgia, United States (enrolling)
• Lurie Children's Hospital of Chicago — Chicago, Illinois, United States (enrolling)
• Our Lady of the Lake Children's Hospital — Baton Rouge, Louisiana, United States (enrolling)
• Dana Farber Cancer Institute — Boston, Massachusetts, United States (enrolling)
• Washington University Medical Center — St Louis, Missouri, United States (enrolling)
• Cincinnati Children's Hospital Medical Center — Cincinnati, Ohio, United States (enrolling)
• St. Jude Children's Research Hospital — Memphis, Tennessee, United States (enrolling)

Full record on ClinicalTrials.gov

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