This phase 1b trial studies the side effects and best dose of telaglenastat in combination with radiation therapy and temozolomide in treating patients with IDH-mutated diffuse or anaplastic astrocytoma. Telaglenastat may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Radiation therapy uses high energy x-rays to kill tumor cells and shrink tumors. Chemotherapy drugs, such as temozolomide, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving telaglenastat with radiation therapy and temozolomide may work better than surgery, radiation therapy, and temozolomide in treating patients with IDH-mutated diffuse astrocytoma or anaplastic astrocytoma.
PRIMARY OBJECTIVE: I. Determine the maximum tolerated dose (MTD) and/or the recommended phase 2 dose (RP2D) of telaglenastat (CB-839) hydrochloride (HCl) when combined with radiation therapy (RT) and temozolomide (TMZ) in patients with newly diagnosed IDH-mutated diffuse astrocytoma (DA) and anaplastic astrocytoma (AA). SECONDARY OBJECTIVES: I. To observe and record anti-tumor activity. II. Determine the safety and tolerability of RT/TMZ/telaglenastat (CB-839) HCl in patients based on physician reported adverse event (AE) data. III. Estimate the 2-year progression-free survival (PFS2) of RT/TMZ/telaglenastat (CB-839) HCl in patients with IDH-mutated glioma based on the Response Assessment in Neuro-Oncology (RANO) criteria. IV. Estimate the 2-year overall survival (OS2) of RT/TMZ/telaglenastat (CB-839) HCl in patients with IDH-mutated glioma based on RANO criteria. CORRELATIVE OBJECTIVES: I. Determine the minor response rate (MRR) and clinical benefit rate (CBR) for the combination of telaglenastat (CB-839) HCl and RT/TMZ in IDH-mutated glioma based on RANO criteria. II. Determine the patient-reported tolerability of RT/TMZ/telaglenastat (CB-839) HCl using the MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) instrument to measure self-reported symptom severity and interference with daily activities. II. Determine the neurocognitive impact of telaglenastat (CB-839) HCl when used in combination with RT/TMZ. III. Determine the effect of telaglenastat (CB-839) HCl/RT/TMZ on plasma oncometabolite levels of glutamine, glutamate, aspartate, asparagine, and 2-hydroxyglutarate (2-HG) in patients with IDH-mutated glioma and associate the changes with disease response. IV. Determine the effect of telaglenastat (CB-839) HCl/RT/TMZ on tumor glutamine and glutamate MRS signals in patients with IDH-mutated glioma and associate the signal with disease response. V. Determine the pharmacokinetics (PK) of telaglenastat (CB-839) HCl when used alone and in combination with TMZ. VI. To perform molecular profiling assays on archived tumor tissue and peripheral blood, including, but not limited to, low-pass whole genome sequencing (WGS), whole exome sequencing (WES), and messenger ribonucleic acid (RNA) sequencing (RNA-Seq) in order to VIa. Identify potential predictive and prognostic biomarkers beyond any genomic alteration by which treatment may be assigned. VIb. Identify resistance mechanisms using genomic deoxyribonucleic acid (DNA)- and RNA-based assessment platforms. VII. To contribute genetic analysis data from de-identified biospecimens to Genomic Data Commons (GDC), a well annotated cancer molecular and clinical data repository, for current and future research; specimens will be annotated with key clinical data, including presentation, diagnosis, staging, summary treatment, and if possible, outcome. VIII. To bank formalin-fixed, paraffin-embedded (FFPE) tissue, blood (for cell-free DNA analysis), and nucleic acids obtained from patients at the Experimental Therapeutics Clinical Trials Network (ETCTN) Biorepository at Nationwide Children's Hospital. OUTLINE: This is a dose escalation study of telaglenastat. Patients receive telaglenastat orally (PO) twice daily (BID) 7 days a week, temozolomide PO once daily (QD) 7 days a week, and undergo RT 5 days a week for up to 5.5 weeks (diffuse astrocytoma) or 6.5 weeks (anaplastic astrocytoma) in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up every 3 months for up to 2 years.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
40
Mayo Clinic Hospital in Arizona
Phoenix, Arizona, United States
Mayo Clinic in Arizona
Scottsdale, Arizona, United States
UC San Diego Moores Cancer Center
La Jolla, California, United States
UC Irvine Health/Chao Family Comprehensive Cancer Center
Orange, California, United States
Sibley Memorial Hospital
Washington D.C., District of Columbia, United States
Maximum tolerated dose (MTD) and recommended phase 2 dose (RP2D)
MTD is defined as the dose level below the lowest dose that induces dose limiting toxicity (DLT) in at least 2 patients (out of 6). A total of 6 patients must be treated at the MTD. It is possible that the MTD will be unknown after this study (e.g., if the highest tested dose has fewer than 2 patients with DLT, out of 6). In this case, the highest dose is defined as the RP2D. A 3 + 3 cohort expansion design to determine toxicity-based dose escalation of telaglenastat (CB-839) hydrochloride (HCl) and external beam fractionated radiation therapy (RT) with concurrent temozolomide (TMZ) among patients with IDH-mutated diffuse astrocytoma (DA) or anaplastic astrocytoma (AA).
Time frame: Up to 6.5 weeks
Objective response rate (ORR) as defined by Response Assessment in Neuro-Oncology (RANO) criteria
ORR is defined as the rate of either complete response (CR), partial response (PR), or minor response (MR) by RANO criteria for low-grade gliomas at 6 months after initiation of RT/TMZ/telaglenastat (CB-839) HCl therapy. The ORR will be estimated using properties of the binomial distribution. 95% exact confidence intervals will also be calculated.
Time frame: Up to 6 months from the start of study treatment
Clinical benefit rate (CBR) as defined by RANO criteria
CBR is defined as the rate of either CR, PR, MR, or stable disease (SD) by RANO criteria for low-grade gliomas at 6 months after initiation of RT/TMZ/telaglenastat (CB-839) HCl therapy. The CBR will be estimated using properties of the binomial distribution. 95% exact confidence intervals will also be calculated.
Time frame: Up to 6 months from the start of study treatment
Incidence of adverse events graded according to Common Terminology Criteria for Adverse Events (CTCAE)
The safety and tolerability of RT/TMZ/telaglenastat (CB-839) HCl in patients is based on physician reported adverse event (AE) data.
Time frame: Up to 2 years
Progression-free survival (PFS2) as defined by response assessment in neuro-oncology (RANO) criteria
PFS2 rate will be estimated using properties of the binomial distribution. 95% exact confidence intervals will also be calculated.
Time frame: Up to 2 years
Overall survival (OS2) as defined by RANO criteria
OS2 rate will be estimated using properties of the binomial distribution. 95% exact confidence intervals will also be calculated.
Time frame: Up to 2 years
Assessment of pharmacokinetic (PK) parameters
The PK of telaglenastat (CB-839) HCl will also be summarized using descriptive statistics and will be compared to historical data. Measurement of plasma concentrations of telaglenastat (CB-839) HCl and its metabolites (if authentic standards are available) will be performed using validated liquid chromatography-tandem mass spectrometry (LC/MS/MS) assays. The plasma concentration-time data will be analyzed by standard noncompartmental analysis using the program Phoenix WinNonlin 6.4 to determine apparent total clearance of the drug from plasma after oral administration (Cl/F), area under the plasma concentration-time curve from time zero to time t (AUCt), area under the plasma concentration-time curve from time zero to infinity, Cmax, time to reach maximum plasma concentration following drug administration (Tmax), t1/2, and accumulation.
Time frame: Pre-dose, 0.5, 1, 2, 4, and 8 hours post-dose on days -7, 1, and 15
Assessment of self-reported symptoms as measured by MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) instrument
MDASI-BT instrument is used to measure self-reported symptom severity and interference with daily activities. The study will use descriptive statistics to describe how patients rate symptom severity and interference with function at each time point. Compliance rates will be calculated as the number of received valid forms over the number of expected forms. Differences between groups in compliance will be tested by use of Fisher's exact test at every time point.
Time frame: Up to 2 years
Assessment of neurocognitive impact
For each test in the battery, a standard error of measurement will be used to derive the Reliable Change Index (RCI) which will be used to represent the 90% confidence interval for the difference in raw scores from baseline to follow-up assessment will be coded as 1 (deterioration), 2 (no change), and 3 (improved) according to the RCI. Percentage of patients in each dose cohort who show meaningful losses or gains in the various tests or test domains over the course of the study will be provided by frequency tables. Dose cohort differences will be compared using chi-squared analysis. Time-to-progressions will be estimated by Kaplan-Meier method and analyzed by Cox regression model adjusting all stratification factors.
Time frame: Baseline up to 2 years
Assessment of plasma oncometabolites
Plasma oncometabolites (asparagine, aspartate, glutamine, glutamate, and 2-HG) will be compared using changes in values after treatment with the patient's individual baseline values using either the paired t-test or the Mann-Whitney nonparametric U-test as needed. A significant change is defined as a 10% change from baseline.
Time frame: Baseline up to day 71
Assessment of tumor oncometabolites as measured by magnetic resonance spectroscopy (MRS)
Tumor oncometabolites (2-HG, glutamine, and glutamate, as measured by MRS) will be compared using changes in values after treatment with the patient's individual baseline values using either the paired t-test or the Mann-Whitney nonparametric U-test as needed. A significant change is defined as a 10% change from baseline.
Time frame: Baseline up to day 45
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