Metronomic Chemotherapy in Patients With Advanced Solid Tumor With Bone Metastasis and Advanced Pretreated Osteosarcoma

Metronomic Cyclophosphamide and Methotrexate Combined With Zoledronic Acid and Sirolimus in Patients With Advanced Solid Tumor With Bone Metastasis and Advanced Pretreated Osteosarcoma. A Phase Ib Study From the French Sarcoma Group

This is a prospective open-labeled phase I trial based on a dose escalating study design assessing two dose levels of sirolimus when prescribed in combination with metronomic cyclophosphamide (CP), methotrexate (MT) and zoledronic acid (ZA) followed by an expansion cohort once the Maximum Tolerated Dose (MTD) is established.

The dose escalation part of the trial will be concerned on adults with advanced solid tumor with bone metastasis and young and adult patients with unresectable locally advanced or metastatic osteosarcoma.

The Expansion cohort will be conducted on young and adult patients with unresectable locally advanced or metastatic osteosarcoma.

Inclusion Criteria:

1. Histology:

   • Advanced solid tumor with radiologically proven bone metastasis, (dose escalation part)
   • Patients with osteogenic osteosarcoma (dose escalation part and expansion cohort) histologically confirmed by central review

2. Metastatic or unresectable locally advanced disease, not eligible for alternative local treatment (radiotherapy for instance)

3. Age > 18 years for patients with solid tumor and ≥ 13 years for patients with osteosarcoma

4. ECOG, performance status ≤ 1

5. Life expectancy > 3 months

6. Measurable disease according to RECIST v1.1. At least one site of disease must be uni-dimensionally ≥ 10 mm

7. Patients must have histologically confirmed diagnosis of locally advanced and/or metastatic solid tumors, which are not amenable to standard treatment, including for patients with osteosarcoma conventional agents such as anthracyclines, platinum salts, ifosfamide and/or methotrexate

8. At least three weeks since last chemotherapy, immunotherapy or any other pharmacological treatment and/or radiotherapy

9. Adequate haematological, renal, metabolic and hepatic function:

   • Haemoglobin ≥ 10 g/dl (patients may have received prior red blood cell transfusion, if clinically indicated); leucocytes ≥ 3 x 10^9/l, absolute neutrophil count ≥ 1.5 x 10^9/l, and platelet count ≥ 120 x 10^9/l.
   • Alanine aminotransferase and aspartate aminotransferase ≤ 2.5 x upper limit of normality (ULN)
   • Total bilirubin ≤ 1.5 x ULN
   • Calculated creatinine clearance > 40 ml/min/1.73 m² (according to MDRD formula)
   • Creatine phosphokinase ≤ 2.5 x ULN
   • Albumin > 25 g/l

10. No prior or concurrent malignant disease diagnosed or treated in the last 2 years except adequately treated in situ carcinoma of the cervix, basal or squamous skin cell carcinoma, or in situ transitional bladder cell carcinoma,

11. Recovery to grade ≤ 1 from any adverse event derived from previous treatment (excluding alopecia of any grade and non-painful peripheral neuropathy grade ≤ 2) according to the NCI-CTCAE, version 4

12. Patients with a French social security in compliance with the French law relating to biomedical research

13. Voluntarily signed and dated written informed consent prior to any study specific procedure

14. Women of childbearing potential must have a negative serum pregnancy test before study entry. Both women and men must agree to use a medically acceptable method of contraception throughout the treatment period and for six months after discontinuation of treatment

Exclusion Criteria:

1. Previous treatment with sirolimus

2. Concomitant diseases/conditions:

   • Clinically significant and/or rapidly accumulating ascites, pericardial and/or pleural effusions
   • Unstable cardiac disease, pulse oximetry saturation < 90% at rest
   • Clinically significant immunodeficiency, such as HIV or active Hepatitis B or C
   • History of auto-immune disease, transplantation

3. Central nervous system malignancy

4. Men or women of childbearing potential who are not using an effective method of contraception; women who are pregnant or breast feeding

5. Patients receiving any substances that are inhibitors or inducers of CYP450 3A4

6. Ongoing or recent (<6 weeks) dental problem, including any severe tooth or jaw infection (mandible and maxilla), dental trauma, dental or stomatological surgery (implants). Current dental cares are allowed

7. History of maxillary osteonecrosis or delayed healing after dental surgery

8. Participation to a study involving a medical or therapeutic intervention in the last 30 days

9. Previous enrolment in the present study

10. Patient unable to follow and comply with the study procedures because of any geographical, familial, social or psychological reasons

11. Known hypersensitivity to any involved study drug or any of its formulation components

12. Patients receiving live vaccines within 30 days prior to the first dose of study therapy and while participating in study