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LCH-IV, International Collaborative Treatment Protocol for Children and Adolescents With Langerhans Cell Histiocytosis

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ClinicalTrials.gov Identifier: NCT02205762
Recruitment Status : Recruiting
First Posted : July 31, 2014
Last Update Posted : September 4, 2019
Sponsor:
Collaborator:
Histiocyte Society
Information provided by (Responsible Party):
North American Consortium for Histiocytosis

Brief Summary:
The LCH-IV is an international, multicenter, prospective clinical study for pediatric Langerhans Cell Histiocytosis LCH (age < 18 years).

Condition or disease Intervention/treatment Phase
Langerhans Cell Histiocytosis Drug: Prednisone Drug: Vinblastine Drug: mercaptopurine Drug: INDOMETHACIN Drug: Methotrexate Drug: Cytosine Arabinoside Drug: 2-chlorodeoxyadenosine Procedure: hematopoietic stem cell transplantation (RIC-HSCT) Biological: Intravenous immunoglobulin Phase 2 Phase 3

Detailed Description:

The international efforts of the past 20 years have shown that combination therapy with vinblastine and prednisone is an effective therapy for Multi-system (MS)-LCH. The previous prospective trial LCH-III confirmed this regimen as a standard regimen for MS-LCH in patients with and without risk organ involvement. It also showed that prolonged treatment in the latter group (treatment duration of 12 vs. 6 months) is superior in preventing disease reactivations. The results of this trial are encouraging and serve as a basis for the LCH-IV study design.Due to the complexity of the disease presentations and outcomes, the LCH-IV study seeks to tailor treatment based on features at presentation and on response to treatment, leading to seven strata:

  • Stratum I: First-line treatment for MS-LCH patients (Group 1) and patients with Single system (SS)-LCH with multifocal bone or "Central Nervous System (CNS)-risk" lesions (Group 2)
  • Stratum II: Second-line treatment for non-risk patients (patients without risk organ involvement who fail first-line therapy or have a reactivation after completion of first-line therapy)
  • Stratum III: Salvage treatment for risk LCH (patients with dysfunction of risk organs who fail first-line therapy)
  • Stratum IV: Stem cell transplantation for risk LCH (patients with dysfunction of risk organs who fail first-line therapy)
  • Stratum V: Monitoring and treatment of isolated tumorous and neurodegenerative CNS-LCH
  • Stratum VI: Natural history and management of "other" SS-LCH (patients who do not need systemic therapy at the time of diagnosis)
  • Stratum VII: Long-term Follow up (all patients irrespective of previous therapy will be followed for reactivation or permanent consequences once complete disease resolution has been achieved and the respective protocol treatment completed)

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 1100 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: LCH-IV, International Collaborative Treatment Protocol for Children and Adolescents With Langerhans Cell Histiocytosis
Study Start Date : July 2014
Estimated Primary Completion Date : July 2023
Estimated Study Completion Date : July 2023


Arm Intervention/treatment
Experimental: Stratum I

Stratum I The combination of Prednisone and vinblastine is the standard first-line combination for patients needing systemic therapy (Stratum I). Patients with MS-LCH and involvement of risk organs, who do not respond to 6-12 weeks of standard therapy, will be immediately switched to alternative treatment approaches (Stratum III or Stratum IV).

Further therapy prolongation (12 vs. 24 months) and intensification (± mercaptopurine) will further reduce the reactivation rate and the permanent consequences.

Drug: Prednisone
Stratum I

Drug: Vinblastine
Stratum I
Other Names:
  • Velban®
  • Vincaleukoblastine Sulfate

Drug: mercaptopurine
Stratum I
Other Names:
  • -Purinethol®
  • -6-MP

Experimental: Stratum II
A uniform "intensive" 24-week course consisting of prednisolone, vincristine and cytosine-arabinoside will be introduced in Stratum II for eligible patients. It will be followed by a continuation therapy to total treatment duration of 24 months. Participants who after SL-IT (week 24) have a response (NAD or AD better) are eligible for randomization between the continuation arms "INDOMETHACIN" and "6-MP/MTX" (mercaptopurine and Methotrexate).
Drug: Prednisone
Stratum I

Drug: Vinblastine
Stratum I
Other Names:
  • Velban®
  • Vincaleukoblastine Sulfate

Drug: mercaptopurine
Stratum I
Other Names:
  • -Purinethol®
  • -6-MP

Drug: INDOMETHACIN
Indomethacin fixed dose given daily orally in two divided doses with gastric protection for total treatment duration of 24 months.

Drug: Methotrexate
fixed dose weekly orally for total treatment duration of 24 months.

Drug: Cytosine Arabinoside
Other Name: Cytarabine, Ara-C

Experimental: Stratum III

Salvage treatment for risk LCH To assess the efficacy of the combination 2-CdA/Ara-C (Cytosine Arabinoside and 2-chlorodeoxyadenosine) in MS-LCH (patients with risk organ involvement, who fail to respond to front-line (Stratum I) therapy.

The initial therapy consists of 2 courses of 2-CdA/Ara-C. Continuation of outlined treatment to be assessed at assigned intervals in each stratum.

Drug: 2-chlorodeoxyadenosine
Other Names:
  • 2-CdA
  • Cladribin®
  • Leustatin®

Experimental: Stratum IV
To determine the overall and disease free survival at 1 and 3 years after reduced intensity conditioning hematopoietic stem cell transplantation (RIC-HSCT). Salvage treatment option for MS-LCH patients with risk organ involvement, who fail to respond to front-line therapy (Stratum I) OR to the salvage 2- CdA/Ara-C regimen (Stratum III).
Procedure: hematopoietic stem cell transplantation (RIC-HSCT)
Experimental: Stratum V

Stratum V Monitoring and Treatment of isolated tumorous and neurodegenerative CNS-LCH

- Special regimens will be offered to patients with isolated tumorous CNS-LCH (repeated 2-CdA courses) and to patients with clinically manifested ND-CNS-LCH (+/- extracranial LCH manifestations). For the last group monotherapy with Ara-C courses or (Intravenous immunoglobulin)IVIG will be offered depending on physician's choice.

Drug: Cytosine Arabinoside
Other Name: Cytarabine, Ara-C

Drug: 2-chlorodeoxyadenosine
Other Names:
  • 2-CdA
  • Cladribin®
  • Leustatin®

Biological: Intravenous immunoglobulin
Other Name: IVIG

Experimental: Stratum VI

Natural history and management of "other" SS-LCH not eligible for stratum I group 2.

  • Treatment Options- Management (mostly "wait & see" and topical treatment) is left to the discretion of the treating physician. All treatments and disease responses must be reported in the database. In the case of uncertainties please contact your National Coordinator.
  • Patients being followed on Stratum VI who have progression of disease to MSLCH, multifocal bone disease or CNS-risk bone lesions should be enrolled on Stratum I therapy.
  • Patients being followed on Stratum VI who develop isolated tumorous or neurodegenerative CNS-LCH should be enrolled on Stratum V.
Drug: Prednisone
Stratum I

Drug: Vinblastine
Stratum I
Other Names:
  • Velban®
  • Vincaleukoblastine Sulfate

Drug: mercaptopurine
Stratum I
Other Names:
  • -Purinethol®
  • -6-MP

Drug: Cytosine Arabinoside
Other Name: Cytarabine, Ara-C

Drug: 2-chlorodeoxyadenosine
Other Names:
  • 2-CdA
  • Cladribin®
  • Leustatin®

Biological: Intravenous immunoglobulin
Other Name: IVIG




Primary Outcome Measures :
  1. Percentage of Patients with Reactivation Free Survival [ Time Frame: 12 Months ]
    Stratum I, II, VI

  2. Response Rate of Second Cycle [ Time Frame: 9 weeks ]
    Stratum III

  3. Overall and disease free survival at 1 and 3 years after reduced intensity conditioning hematopoietic stem cell transplantation (RIC-HSCT) [ Time Frame: 3 Years ]
    Stratum IV

  4. The cumulative incidence of radiological and clinical neurodegeneration in patients with isolated tumorous CNS-LCH, DI, anterior pituitary dysfunction, and those with CNS-risk lesions [ Time Frame: 2 Years ]
    Stratum V

  5. The time interval and cumulative incidence of progression of radiological neurodegeneration to clinically manifested ND-CNS-LCH [ Time Frame: 2 Years ]
    Stratum V

  6. Cumulative incidence of specific Permanent Consequences e.g. diabetes insipidus (DI), growth hormone deficiency (GHD), neuropsychological impairment, etc. [ Time Frame: 2 Years ]
    From all treatment stratum via long-term follow up in Stratum VII


Secondary Outcome Measures :
  1. Overall Survival [ Time Frame: 2 Years ]
    Stratum I

  2. Number of Participants with Serious and Non-Serious Adverse Events [ Time Frame: 2 Years ]
  3. Incidence of Permanent Consequences [ Time Frame: 2 Years ]
    All Stratum

  4. Cumulative incidence of reactivations in risk organs [ Time Frame: 2 Years ]
  5. Time to complete disease resolution [ Time Frame: 2 Years ]
    Stratum III

  6. Response rate to the combination of prednisone, vincristine and cytarabine [ Time Frame: 2 years ]
    Stratum II

  7. The proportion of patients alive and free of disease without permanent consequences (e.g. diabetes insipidus, anterior pituitary dysfunction, radiological or clinical neurodegeneration) [ Time Frame: 2 Years ]
    Stratum II

  8. Percentage of treatment-related toxicities [ Time Frame: 2 Years ]
    Stratum II

  9. Reactivation rates after continuation treatment with Indomethacin vs. 6-MP/MTX. [ Time Frame: 2 years ]
    Stratum II

  10. The type of subsequent intensive and/or maintenance therapy utilized [ Time Frame: 2 Years ]
    Stratum III

  11. Early and late mortality [ Time Frame: 2 Years ]
    Stratum II

  12. Early and late toxicity [ Time Frame: 2 Years ]
    Stratum III

  13. d+100 transplant related mortality [ Time Frame: 2 Years ]
    Stratum IV

  14. Incidence of hematopoietic recovery, and donor chimerism at d+100 and 1 year post RIC-HSCT [ Time Frame: 2 Years ]
  15. Record all occurrence of skin, GI or liver abnormalities fulfilling criteria of Grades II-IV acute GVHD [ Time Frame: 2 Years ]
    Stratum IV: Hematopoetic Stem Cell Transplantation for Risk LCH

  16. Percentage of Participants with incidence of chronic GVHD [ Time Frame: 2 Years ]
    Stratum IV

  17. Response Rate to ND-CNS-targeted therapy at 12 and 24 months after start of therapy [ Time Frame: 2 years ]
    Stratum V

  18. Response of isolated tumorous CNS-LCH to 2-CDA [ Time Frame: 2 Years ]
    Stratum V

  19. Frequency of ND-CNS-LCH in patients with isolated tumorous CNS-LCH [ Time Frame: 2 Years ]
    Stratum V

  20. Methods of early identification of ND-CNS-LCH [ Time Frame: 2 Years ]
    Stratum V - Exploration of the value of neurochemistry, neurophysiology, and neuropsychology methods in early identification of ND-CNS-LCH and in assessing its severity, and comparison to MRI findings.

  21. Need for systemic therapy later during disease course [ Time Frame: 2 Years ]
    Stratum VI

  22. Identify possible risk factors for permanent consequences (PC) [ Time Frame: 2 Years ]


Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   up to 18 Years   (Child, Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Stratum I

    • Patients must be less than 18 years of age at the time of diagnosis.
    • Patients must have histological verification of the diagnosis of Langerhans cell histiocytosis according to the criteria described in Section 6.1
    • Signed informed consent form
  • Stratum II

    • Patients of Stratum I who have:
    • Progressive disease (AD worse) in non-risk organs after 6 weeks (Initial Course
    • AD intermediate or worse in non-risk organs or AD better in risk organs after 12 weeks (Initial Course 2)
    • Disease progression (AD worse) in non-risk organs at any time during continuation treatment
    • Active disease at the end of Stratum I treatment
    • Disease reactivation in non-risk organs at any time after completion of Stratum I treatment
  • Stratum III

    • Patients from Stratum I who fulfill the following criteria:
    • AD worse in risk organs after week 6 (after Initial Course 1), or AD worse or AD intermediate in risk organs after week 12 (after Initial Course 2).
    • Presence of unequivocally severe organ dysfunction at the above mentioned evaluation points (hematological dysfunction, liver dysfunction, or both of them) as

      • Hb <70 g/L (<7.0 g/dl) and/or transfusion dependency
      • PLT <20 x109/L (20,000/μL) and/or transfusion dependency (both criteria have to be fulfilled) AND/OR
      • Liver dysfunction (or digestive involvement with protein loss)
      • Total protein <55 g/L or substitution dependency
      • Albumin <25 g/L or substitution dependency (at least one of the two criteria to be fulfilled)
  • Stratum IV

    • Patients from Stratum I or Stratum III who fulfill the following criteria:
    • AD worse in risk organs after week 6 (after Initial Course 1), or AD worse or AD intermediate in risk organs after week 12 (after Initial Course 2) of Stratum I OR
    • AD worse after the 2nd and 3rd 2-CdA/Ara-C course, and those AD worse or AD intermediate after the 4th 2-CdA/Ara-C course of Stratum III AND
    • Presence of unequivocally severe organ dysfunction at the above mentioned evaluation points (hematological dysfunction, liver dysfunction, or both of them) as defined in Table XI (see Section 10.3.1).
    • Informed consent: All patients or their legal guardians (if the patient is <18 years of age) must sign an Ethics or institutional Review Board approved consent form indicating their awareness of the investigational nature and the risks of this study. When appropriate, younger patients will be included in all discussions in order to obtain assent.
    • Adequate organ function: Patients should have adequate hepatic, renal, cardiac and pulmonary function to undergo reduced intensity HCT based upon local institutional guidelines, or at a minimum meet requirements noted in eligibility checklist Appendix A-VIII_1. However, significant hepatic and pulmonary dysfunction, if secondary to underlying LCH disease activity, will not exclude patients from protocol enrollment and should be discussed with the National PI Coordinator and the Coordinating Principal Investigator.
  • Stratum V

    • All patients with verified diagnosis of LCH and MRI findings consistent with ND-CNSLCH irrespective of previous treatments (also those not registered to other Strata ofLCH-IV).
    • Patients with isolated tumorous CNS-LCH (including isolated DI with mass lesion in the hypothalamus-pituitary axis). In patients with already established diagnosis of LCH and radiologic finding of CNS lesions compatible with LCH, a biopsy of the lesion is not obligatory. In all other cases a biopsy of the lesion is needed for inclusion into the study
  • Stratum VI

    -- Patients with newly diagnosed SS-LCH and localization other than "multifocal bone",isolated tumorous CNS lesion, or isolated "CNS-risk" lesion.

  • Stratum VII -- All patients registered in LCH IV (regardless of treatment) as long as consent for longterm follow-up has not been withheld.

Exclusion Criteria:

  • Stratum I

    • Pregnancy (patients of child-bearing age must be appropriately tested before chemotherapy)
    • LCH-related permanent consequences (e.g. vertebra plana, sclerosing cholangitis, lung fibrosis, etc.) in the absence of active disease
    • Prior systemic therapy
  • Stratum II

    • Patients with progressive disease in risk organs
    • Permanent consequences (e.g. sclerosing cholangitis, lung fibrosis, etc.) without evidence of active LCH in the same organ or in any other locations
    • No written consent of the patient or his/her parents or legal guardian
  • Stratum III

    • The presence of any of the following criteria will exclude the patient from the study:
    • Isolated sclerosing cholangitis without evidence of active hepatic LCH as the only evidence of risk organ involvement.
    • Inadequate renal function as defined by serum creatinine > 3x normal for age
  • Stratum IV

    • Pulmonary failure (requiring mechanical ventilation) not due to active LCH.
    • Isolated liver sclerosis or pulmonary fibrosis, without active LCH.
    • Uncontrolled active life-threatening infection.
    • Decreased renal function with a GFR of less than 50ml/1.73m2/min.
    • Pregnancy or active breast feeding
    • Failure to provide signed informed consent
  • Stratum VI

    • Patients with SS-LCH who have an isolated tumorous CNS lesion (they are eligible for Stratum V),
    • Patients with isolated "CNS-risk" or multifocal bone lesions (they are eligible for Stratum I, Group 2)

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02205762


Contacts
Layout table for location contacts
Contact: Heidi M Clough, RN, BSN 901-595-0362 Heidi.clough@stjude.org
Contact: Lane Faughnan, BSN 901-595-0364 Lane.faughnan@stjude.org

  Show 31 Study Locations
Sponsors and Collaborators
North American Consortium for Histiocytosis
Histiocyte Society
Investigators
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Study Chair: Milen Minkov, MD, Ph.D Children's Cancer Research Institute / St. Anna Children's Hospital
Study Chair: Carlos Rodriguez-Galindo, MD North American Consortium for Histiocytosis

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Responsible Party: North American Consortium for Histiocytosis
ClinicalTrials.gov Identifier: NCT02205762     History of Changes
Other Study ID Numbers: 13-428
2011-001699-20 ( EudraCT Number )
042011 ( Other Identifier: Children's Cancer Research Institute )
First Posted: July 31, 2014    Key Record Dates
Last Update Posted: September 4, 2019
Last Verified: August 2019
Keywords provided by North American Consortium for Histiocytosis:
Langerhans cell histiocytosis
Additional relevant MeSH terms:
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Histiocytosis, Langerhans-Cell
Histiocytosis
Lymphatic Diseases
Lung Diseases, Interstitial
Lung Diseases
Respiratory Tract Diseases
Cytarabine
Prednisone
Indomethacin
Methotrexate
Mercaptopurine
Vinblastine
Cladribine
Immunoglobulins
Antibodies
Immunoglobulins, Intravenous
gamma-Globulins
Rho(D) Immune Globulin
Abortifacient Agents, Nonsteroidal
Abortifacient Agents
Reproductive Control Agents
Physiological Effects of Drugs
Antimetabolites, Antineoplastic
Antimetabolites
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents
Dermatologic Agents
Enzyme Inhibitors
Folic Acid Antagonists
Immunosuppressive Agents