This phase I trial studies the side effects and best dose of wild-type reovirus when combined with carfilzomib and dexamethasone in treating patients with multiple myeloma that has come back following treatment (relapsed) or does not respond to treatment (refractory). Chemotherapy drugs, such as dexamethasone and carfilzomib, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. A virus called wild-type reovirus may be able to kill cancer cells without damaging normal cells and seems to work best when given with chemotherapy. Giving wild-type reovirus with chemotherapy may be a more effective treatment than chemotherapy alone.
PRIMARY OBJECTIVES: I. Determine safety and tolerability, and define the maximum tolerated dose of pelareorep (Reolysin), carfilzomib and dexamethasone in patients with relapsed multiple myeloma. II. Obtain evidence of reovirus entry into myeloma cells via localization of reoviral ribonucleic acid (RNA) in multiple myeloma (MM) cells (in situ hybridization \[ISH\]), and active viral proliferation/replication via localization of reoviral capsid protein (immunohistochemistry \[IHC\]) in MM cells in cycle 1 day 9 bone marrow biopsies in all patients enrolled in dose escalation cohorts. SECONDARY OBJECTIVES: I. Obtain preliminary data on response as determined by International Myeloma Working Group criteria after protocol therapy. II. Obtain overall and progression free survival data for all treated patients. III. Assess cytokine arrays of peripheral blood obtained on days 1, 2, 9, 15 and once during days 22-28 of cycle 1, and day 1 of cycle 2 and each successive cycle to obtain exploratory data regarding inflammatory cytokine concentrations and their correlation with response. IV. Investigate pretreatment cycle 1 days 1 and 9 bone marrow aspirate interferon (IFN)-beta in MM cells as a potential marker of Reolysin resistance. V. Measure the induction of endoplasmic reticulum (ER) stress and autophagy markers to explore their respective roles in MM cell death following combination Reolysin and carfilzomib in patients treated in all dose escalation cohorts. VI. Evaluate pretreatment cycle 1 days 1 and 9 peripheral blood to explore the antiviral humoral response by measuring the production of neutralizing reoviral antibody (NARA) using a functional killing assay. VII. Obtain cycle 1 day 1 pretreatment and 1 and 4 hours after treatment, and pretreatment cycle 1 days 2 and 9 peripheral blood, and pretreatment cycle 1 days 1 and 9 bone marrow aspirate samples to investigate the role of carfilzomib in modulating the antiviral immune mediated response. OUTLINE: This is a dose escalation study of Reolysin. Patients receive dexamethasone intravenously (IV), carfilzomib IV over 30 minutes, and Reolysin IV over 60 minutes on days 1, 2, 8, 9, 15, and 16. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up for 4 weeks and then every 6 months thereafter.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
12
Emory University Hospital/Winship Cancer Institute
Atlanta, Georgia, United States
Ohio State University Comprehensive Cancer Center
Columbus, Ohio, United States
Huntsman Cancer Institute/University of Utah
Salt Lake City, Utah, United States
Number and severity of adverse events
Based on Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Adverse events will be perceived causal relationship to the study therapy.
Time frame: Up to 4 weeks post treatment
Maximum tolerated dose of combination carfilzomib and wild-type reovirus
Assessed by CTCAE version 5.0. Maximum tolerated dose defined as the highest dose with fewer than 33% dose limiting toxicities observed in cycle 1 or 2 evaluated using CTCAE version 5.0. Frequency distributions and other descriptive measures will form the basis of the analysis of these variables.
Time frame: Up to 28 days
Number of patients who required dose modifications and/or dose delays in subsequent cycles
Frequency distributions and other descriptive measures will form the basis of the analysis of these variables.
Time frame: Up to 4 weeks post treatment
Proportion of patients who go off treatment due to adverse reactions of refuse further treatment for lesser toxicities that inhibit their willingness to continue participation on the trial
Frequency distributions and other descriptive measures will form the basis of the analysis of these variables.
Time frame: Up to 4 weeks post treatment
Reoviral capsid protein production via immunohistochemical analysis
Will include graphical evaluation of these immunologic correlative markers at baseline as well as at the various timepoints.
Time frame: Up to day 9 of cycle 1
Presence and location of intracellular reoviral ribonucleic acid (RNA) assessed by in situ hybridization
Will include graphical evaluation of these immunologic correlative markers at baseline as well as at the various timepoints.
Time frame: Up to day 9 of cycle 1
Number and percentage of subjects experiencing objective response
Summary statistics will be computed for baseline biomarkers. The absolute and percent change from baseline will be calculated for each subsequent measurement. Summary statistics will be computed for each collection time point. The objective response rate will be analyzed by using a 95% confidence interval for the proportion responding at trial closure in the treated population.
Time frame: Up to 4 weeks post treatment
Clinical benefit endpoint described as that portion of patients experiencing complete response, very good partial response, or partial response
The objective response rate will be analyzed by using a 95% confidence interval for the proportion responding at trial closure in the treated population.
Time frame: Up to 4 weeks post treatment
Duration of response
This time-to-event distribution will be evaluated using the methods of Kaplan and Meier, with a focus on graphical evaluation as well as early timepoint and median estimates of survival distributions.
Time frame: Duration from first observation of partial response to the time of disease progression, up to 4 weeks post treatment
Progression free survival
This time-to-event distribution will be evaluated using the methods of Kaplan and Meier, with a focus on graphical evaluation as well as early timepoint and median estimates of survival distributions.
Time frame: Duration from start of treatment to disease progression or death, regardless of cause of death, whichever comes first, up to 2 years
Time to progression
This time-to-event distribution will be evaluated using the methods of Kaplan and Meier, with a focus on graphical evaluation as well as early timepoint and median estimates of survival distributions.
Time frame: Time from the start of the treatment until the criteria for disease progression are met, up to 4 weeks post treatment
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