Combination Chemotherapy With or Without Ganitumab in Treating Patients With Newly Diagnosed Metastatic Ewing Sarcoma

PRIMARY OBJECTIVES:

I. To determine if the event-free survival (EFS) in patients with newly diagnosed metastatic
Ewing sarcoma treated with multiagent chemotherapy is improved with the addition of ganitumab
(AMG 479).

SECONDARY OBJECTIVES:

I. To describe the toxicity of the addition of ganitumab to multimodality therapy for
patients with newly diagnosed metastatic Ewing sarcoma.

II. To compare overall survival in patients with newly diagnosed metastatic Ewing sarcoma
treated with multiagent chemotherapy with and without the addition of ganitumab.

EXPLORATORY OBJECTIVES:

I. To compare bone marrow response rates in patients with newly diagnosed metastatic Ewing
sarcoma treated with multiagent chemotherapy with and without the addition of ganitumab.

II. To describe the toxicity of 6 months of ganitumab monotherapy as maintenance therapy
following multimodality therapy in patients with newly diagnosed metastatic Ewing sarcoma.

III. To describe trough levels of ganitumab in a cohort of patients with Ewing sarcoma < 21
years of age treated with 18 mg/kg.

IV. To describe the feasibility of and local failure rates following hypofractionated
stereotactic body radiotherapy (SBRT) directed at bone metastases in patients with newly
diagnosed metastatic Ewing sarcoma.

V. To determine if EFS, overall survival, bone marrow response rates, and toxicity differ
based on serum markers of the insulin-like growth factor 1 (IGF-1) pathway in patients with
newly diagnosed metastatic Ewing sarcoma treated with interval compressed chemotherapy with
and without the addition of ganitumab.

VI. To determine if EFS, overall survival, and bone marrow response rates differ based on
protein, deoxyribose nucleic acid (DNA), and ribonucleic acid (RNA) marker in patients with
newly diagnosed metastatic Ewing sarcoma treated with interval compressed chemotherapy with
and without the addition of ganitumab.

VII. To evaluate bone marrow micrometastatic disease and tumor cell surface IGF-1R expression
at diagnosis and after 3 and 6 cycles of study therapy in patients with newly diagnosed
metastatic Ewing sarcoma.

VIII. To determine if the presence of germline polymorphisms in EGFR correlate with response
to multiagent therapy with and without ganitumab.

IX. To investigate the ability of fludeoxyglucose F 18-positron emission tomography (FDG-PET)
to augment conventional response assessment of primary Ewing sarcoma tumors by magnetic
resonance imaging (MRI).

X. To explore FDG-PET response at the primary tumor as a prognostic marker and as a
predictive biomarker of clinical activity of IGF-1R inhibition in patients with newly
diagnosed metastatic Ewing sarcoma.

XI. To collect data on institutional testing for Ewing sarcoma breakpoint region 1 (EWSR1)
translocation status in patients enrolling on study.

XII. To explore the capacity of plasma cell-free DNA analysis to detect tumor-specific
genetic changes at initial diagnosis and after initiation of protocol therapy.

XIII. To collect a population of bone marrow metastatic tumor cells by flow cytometry for
genomic profiling.

OUTLINE: Patients are randomized to 1 of 2 treatment regimens.

REGIMEN A (vincristine sulfate, doxorubicin hydrochloride and cyclophosphamide [VDC] and
ifosfamide and etoposide [IE]):

INDUCTION THERAPY: Patients receive vincristine sulfate intravenously (IV) over 1 minute on
day 1; doxorubicin hydrochloride IV over 1-15 minutes on days 1 and 2; and cyclophosphamide
IV over 30-60 minutes on day 1 of weeks 1, 5, and 9; and ifosfamide IV over 1 hour on days 1
to 5 and etoposide IV over 1-2 hours on days 1 to 5 of weeks 3, 7, and 11.

LOCAL CONTROL THERAPY: Between weeks 13-18, patients undergo surgery and/or radiation
therapy.

CONSOLIDATION THERAPY: Patients receive vincristine sulfate IV over 1 minute on day 1 of
weeks 1, 7, 9, and 13; doxorubicin hydrochloride IV over 1-15 minutes on days 1 and 2 of
weeks 1 and 7; cyclophosphamide IV over 30-60 minutes on day 1 of weeks 1, 7, 9, and 13;
ifosfamide IV over 1 hour on days 1 to 5 of weeks 3, 5, 11, and 15; and etoposide IV over 1-2
hours on days 1 to 5 of weeks 3, 5, 11, and 15.

METASTATIC SITE IRRADIATION: Patients with lung metastases undergo definitive SBRT or
external beam radiation therapy (EBRT) over 5 days.

REGIMEN B (VDC/IE + ganitumab):

INDUCTION THERAPY: Patients receive Induction therapy as in Regimen A and receive ganitumab
IV over 30-60 minutes or 60-120 minutes on day 1 of weeks 1, 3, 5, 7, 9, and 11.

LOCAL CONTROL THERAPY: Between weeks 13-18, patients undergo surgery and/or radiation
therapy.

CONSOLIDATION THERAPY: Patients receive Consolidation therapy as in Regimen A and ganitumab
IV over 30-60 minutes or 60-120 minutes on day 1 of weeks 7, 9, 11, 13, and 15.

METASTATIC SITE IRRADIATION: Patients with lung metastases undergo definitive SBRT or EBRT
over 5 days.

MAINTENANCE THERAPY: Patients receive ganitumab IV over 30-60 minutes or 60-120 minutes on
day 1 in weeks 1, 4, 7, 10, 13, 16, 19, and 22.

After completion of study treatment, patients are followed for 10 years.

Inclusion Criteria:

- Patients with histologic diagnosis (by institutional pathologist) of newly diagnosed
Ewing sarcoma or peripheral primitive neuroectodermal tumor (PNET) arising from bone
or soft tissue and with metastatic disease involving lung, bone, bone marrow, or other
metastatic site

- For the purpose of this study metastatic disease is defined as one or more of the
following:

- Lesions which are discontinuous from the primary tumor, are not regional lymph
nodes, and do not share a bone or body cavity with the primary tumor; skip
lesions in the same bone as the primary tumor do not constitute metastatic
disease; skip lesions in an adjacent bone are considered bone metastases; if
there is any doubt whether lesions are metastatic, a biopsy of those lesions
should be performed

- Contralateral pleural effusion and/or contralateral pleural nodules

- Distant lymph node involvement

- Patients with pulmonary nodules are considered to have metastatic disease if the
patient has:

- Solitary nodule >= 0.5 cm or multiple nodules of >= 0.3 cm unless lesion is
biopsied and negative for tumor

- Patients with solitary nodule < 0.5 cm or multiple nodules < 0.3 cm are not
considered to have lung metastasis unless biopsy documents tumor

- Bone marrow metastatic disease is based on morphologic evidence of Ewing sarcoma
based on hematoxylin and eosin (H&E) stains; in the absence of morphologic
evidence of marrow involvement on H&E, patients with bone marrow involvement
detected ONLY by flow cytometry, reverse-transcriptase (RT)-polymerase chain
reaction (PCR), fluorescence in situ hybridization (FISH), or
immunohistochemistry will NOT be considered to have clinical bone marrow
involvement for the purposes of this study

- This study requires bilateral bone marrow biopsies at study entry; the
suggested approach for patients with large pelvic tumors in which a
posterior iliac crest bone marrow biopsy would track through the tumor is to
instead undergo 2 marrow biopsies on the contralateral side (either 2
posterior biopsies or one posterior and one anterior biopsy)

- Bone metastasis: This study utilizes whole body FDG-PET scans to screen patients
for bone metastases; areas suspicious for bone metastasis based on FDG-PET scans
require confirmatory anatomic imaging with either MRI or computed tomography (CT)
(whole body FDG-PET/CT or FDG-PET/magnetic resonance [MR] scan acceptable); whole
body technetium bone scans may be performed at the discretion of the investigator
and are not required; for patients without other sites of metastatic disease
whose sole metastatic site to qualify for study entry is a single area suspicious
for bone metastasis identified by FDG-PET, confirmatory biopsy or anatomic
imaging evidence of an associated soft tissue mass at that site is required for
study entry

- Patients must have adequate tumor tissue to meet the minimum requirement for
submission

- Enrolling institutions are reminded that submission of pre-treatment serum, tumor
tissue and whole blood is required

- Patients should only have had a biopsy of the primary tumor without an attempt at
complete or partial resection; patients will still be eligible if excision was
attempted or accomplished as long as adequate anatomic imaging (MRI for most primary
tumor sites) was obtained prior to surgery

- Creatinine clearance or radioisotope glomerular filtration rate (GFR) >= 70
mL/min/1.73 m^2 or a serum creatinine based on age/gender as follows:

- Age < 6 months: Maximum serum creatinine (mg/dL): 0.4 for males and females

- Age 6 months to < 1 year: Maximum serum creatinine (mg/dL): 0.5 for males and
females

- Age 1 to < 2 years: Maximum serum creatinine (mg/dL): 0.6 for males and females

- Age 2 to < 6 years: Maximum serum creatinine (mg/dL): 0.8 for males and females

- Age 6 to < 10 years: Maximum serum creatinine (mg/dL): 1 for males and females

- Age 10 to < 13 years: Maximum serum creatinine (mg/dL): 1.2 for males and females

- Age 13 to < 16 years: Maximum serum creatinine (mg/dL): 1.5 for males and 1.4 for
females

- Age >= 16 years: Maximum serum creatinine (mg/dL): 1.7 for males and 1.4 for
females

- Total bilirubin =< 1.5 x upper limit of normal (ULN) for age (performed within 7 days
prior to enrollment), and

- Serum glutamate pyruvate transaminase (SGPT) (alanine aminotransferase [ALT]) < 3 x
upper limit of normal (ULN) for age (performed within 7 days prior to enrollment)
(except for patients with liver metastasis who may enroll if ALT < 5 times ULN for
age)

- Shortening fraction of >= 27% or

- Ejection fraction of >= 50%

- Patients must have a normal blood sugar level for age to participate; if an initial
random draw (ie. non-fasting) blood glucose value is out of range, it is acceptable to
repeat this test as a fasting draw

- All patients and/or their parents or legal guardians must sign a written informed
consent

- All institutional, Food and Drug Administration (FDA), and National Cancer Institute
(NCI) requirements for human studies must be met

Exclusion Criteria:

- Patients with regional node involvement as their only site of disease beyond the
primary tumor will not be eligible

- Patients whose primary tumors arise in the intra-dural soft tissue (eg. brain and
spinal cord) are not eligible

- Patients who have received prior chemotherapy or radiation therapy are not eligible

- Female patients of childbearing potential are not eligible unless a negative pregnancy
test result has been obtained; lactating females are not eligible unless they have
agreed not to breastfeed their infants for the duration of protocol therapy; sexually
active patients of reproductive potential are not eligible unless they have agreed to
use an effective contraceptive method for the duration of protocol therapy

- Patients with known pre-existing diabetes mellitus will be excluded from study

- Patients receiving chronic pharmacologic doses of corticosteroids are not eligible;
for the purposes of eligibility, chronic exposure is defined as anticipated exposure
of > 3 weeks, including the sum of both pre-enrollment and anticipated post-enrollment
dosing; patients on acute corticosteroid therapy (=< 3 weeks of total planned
exposure) must still meet the normal blood glucose requirement; patients receiving
chronic inhaled corticosteroids or chronic physiologic replacement doses of
corticosteroids are eligible