iSTAR is an open-label, multi-center, phase 1b study of oral XPO1 inhibitor selinexor and oral MDM2 inhibitor idasanutlin in children with progressive or recurrent atypical teratoid/rhabdoid tumors (AT/RT), malignant rhabdoid tumors (MRT) and synchronous/metachronous rhabdoid tumors. Primary Objectives * To determine the maximum tolerated dose (MTD) and the recommended phase 2 dose (RP2D) of combination treatment with oral idasanutlin and selinexor in children with recurrent or progressive AT/RT or MRT. * To characterize the plasma pharmacokinetics of oral idasanutlin and selinexor in children with recurrent or progressive AT/RT or MRT, to assess potential covariates to explain the inter- and intra-individual pharmacokinetic variability. Secondary Objectives * Evaluate safety of the combination treatment with oral idasanutlin and selinexor in children * Evaluate efficacy of the combination treatment of idasanutlin and selinexor as measured by objective response (partial response \[PR\] or complete response \[CR\]) rate separately in progressive/relapsed AT/RT and progressive/relapsed MRT * Estimate progression-free and overall-survival separately in progressive/relapsed AT/RT and progressive/relapsed MRT
Patients will receive idasanutlin dosed once daily on Days 1-5 of a 28-day cycle starting with 80% of the RP2D determined in the ongoing pediatric iMATRIX trial (NCT04029688) using single agent idasanutlin. Patients will receive selinexor on Day 4 of each of the first 3 weeks of a 28-day cycle. Selinexor will be skipped on week 4 of each cycle. The dose-finding/safety phase will test two dosing frequencies and two dose levels of selinexor \[100, and 75% of the RP2D from the COG trial (NCT02323880)\] using single agent selinexor and 2 dose levels of idasanutlin \[80% and 100% of the RP2D from the pediatric single agent idasanutlin iMATRIX study (NCT04029688)\]. In the COG trial, ADVL1414, the RP2D of single agent selinexor was 35mg/m2 administered weekly of a 28-day cycle without any break. In our trial we propose to skip selinexor during week 4 (dose levels 1). If unexpected toxicity is encountered in dose level 1, St. Jude will open dose level -1(reduced frequency of selinexor dosing) and dose level -2 (reduced dose and frequency of selinexor dosing). However, if dose level 1 is well tolerated, then the St. Jude will open dose level 2 for enrollment (100% of RP2D of single agent selinexor and idasanutlin). Once the RP2D is established, patients enrolled on the dose-finding/safety phase at this dose level will continue treatment and will be included in the response analysis in the expansion stage. Those patients who are enrolled on the dose-finding/safety phase at a lower dose level and are still on treatment will have their doses optimized following determination of the RP2D. Patients may continue treatment for a maximum of 2 years, or 26 cycles, in absence of progressive disease.
Study Type
INTERVENTIONAL
Allocation
NON_RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Patients will receive idasanutlin dosed once daily on Days 1-5 of a 28-day cycle starting with 80% of the RP2D determined in the ongoing pediatric iMATRIX trial using single agent idasanutlin.
Patients will receive idasanutlin dosed once daily on Days 1-5 of a 28-day cycle starting with the RP2D determined in the dose-finding/safety phase.
Patients will receive selinexor on Day 4 of each of the first 3 weeks of a 28-day cycle. Selinexor will be skipped on week 4 of each cycle.
Maximum tolerated dose (MTD) and recommended phase 2 dose (RP2D) of combination treatment with oral idasanutlin and selinexor in children with recurrent or progressive AT/RT or MRT in the dose finding/safety phase.
The MTD is empirically defined as the highest dose level at which six patients have been treated with at most one patient experiencing a DLT and the next higher dose level has been determined to be too toxic. The MTD estimate will not be available if the lowest dose level studied is too toxic or the highest dose level studied is considered safe. In the latter case, the highest studied safe dose may be considered at the recommended phase 2 dose (RP2D). The MTD estimate will be limited to evaluable patients and toxicity assessments from course 1 (28 days). The RP2D will be based on the MTD and the totality of the safety/efficacy data.
Time frame: 1 month after start of idasanutlin and selinexor treatment
Idasanutlin plasma apparent systemic clearance (CL/F) in children with recurrent or progressive AT/RT or MRT
For each patient, idasanutlin plasma concentration-time data will be analyzed using non-compartmental methods to estimate the plasma CL/F.
Time frame: 1 month after start of idasanutlin and selinexor treatment
Idasanutlin area under the plasma concentration time curve (AUC) in children with recurrent or progressive AT/RT or MRT
For each patient, idasanutlin plasma concentration-time data will be analyzed using non-compartmental methods to estimate the AUC.
Time frame: 1 month after start of idasanutlin and selinexor treatment
Objective response rate in subjects with progressive/relapsed AT/RT
An objective response is defined as a partial or complete response. Response must be at least a partial response in patients with measurable disease and at least a complete response in patients with evaluable disease and must be sustained for approximately 8 weeks (the time of the next regularly scheduled imaging assessment). The objective response rate will be reported with a 95% confidence interval.
Time frame: Approximately 2 years from start of treatment
Objective response rate in subjects with progressive/relapsed MRT
An objective response is defined as a partial or complete response. Response must be at least a partial response in patients with measurable disease and at least a complete response in patients with evaluable disease and must be sustained for approximately 8 weeks (the time of the next regularly scheduled imaging assessment). The objective response rate will be reported with a 95% confidence interval.
Time frame: Approximately 2 years from start of treatment
Progression-free survival in subjects with progressive/relapsed AT/RT
Progression-free survival is defined as the interval of time between date of initiation of protocol treatment and date of documentation of progression of disease (PD), death due to any cause, or date of last follow-up. Progression-free survival will be estimated using the method of Kaplan and Meier.
Time frame: Approximately 7 years from start of treatment
Progression-free survival in subjects with progressive/ relapsed MRT
Progression-free survival is defined as the interval of time between date of initiation of protocol treatment and date of documentation of progression of disease (PD), death due to any cause, or date of last follow-up. Progression-free survival will be estimated using the method of Kaplan and Meier.
Time frame: Approximately 7 years from start of treatment
Overall survival in subjects with progressive/relapsed AT/RT
OS is defined as the interval of time between date of diagnosis and date of death due to any cause or date of last follow-up. Overall survival will be estimated using the method of Kaplan and Meier.
Time frame: Approximately 7 years from start of treatment
Overall survival in subjects with progressive/ relapsed MRT
OS is defined as the interval of time between date of diagnosis and date of death due to any cause or date of last follow-up. Overall survival will be estimated using the method of Kaplan and Meier.
Time frame: Approximately 7 years from start of treatment
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