Wee1 Kinase Inhibitor AZD1775 and Combination Chemotherapy in Treating Children, Adolescents and Young Adults With Relapsed or Refractory Acute Myeloid Leukemia

PRIMARY OBJECTIVES:

I. To estimate the maximum tolerated dose (MTD) and/or recommended phase 2 dose of wee1
kinase inhibitor AZD1775 (AZD1775) administered orally daily for 5 days in combination with
FLAG (fludarabine, cytarabine, filgrastim) chemotherapy in children and adolescents with
recurrent or refractory acute myeloid leukemia (AML).

II. To define and describe the toxicities of AZD1775 in combination with FLAG chemotherapy
administered on this schedule.

III. To characterize the pharmacokinetics AZD1775 in combination with FLAG chemotherapy in
pediatric patients with relapsed or refractory AML.

SECONDARY OBJECTIVES:

I. To preliminarily define the antitumor activity of AZD1775 plus FLAG within the confines
of a phase 1 study.

II. To evaluate pharmacodynamic biomarkers of wee1 inhibition with administration of AZD1775
including cyclin-dependent kinase 1 (CDC2) phosphorylation at tyrosine 15 (Tyr15) and
induction of gamma H2AX in pre- and post-treatment leukemic blasts.

III. To explore mechanisms of apoptosis induction and cell death in leukemic blasts treated
with AZD1775 plus chemotherapy.

IV. To identify genomic alterations in leukemic blasts that may correlate with response to
therapy with AZD1775 plus FLAG chemotherapy.

OULTINE: This is a phase I dose escalation study of wee1 kinase inhibitor AZD1775.

Patients receive filgrastim intravenously (IV) or subcutaneously (SC) daily, fludarabine
intravenously IV over 30 minutes, cytarabine IV over 1-3 hours and wee1 kinase inhibitor
AZD1775 orally (PO) on days 1-5. Patients who meet criteria for complete remission (CR),
complete remission with partial recovery of platelet count (CRp) or partial response (PR)
may receive a second course of therapy. Courses repeat every 28 days for up to 2 courses in
the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up periodically.

Inclusion Criteria:

- Patients must have had histologic verification of AML at original diagnosis; AML is
defined according to World Health Organization (WHO) classification with >= 5% blasts
in the bone marrow (M2/M3 bone marrow), with or without extramedullary disease

- Relapsed patients:

- Second or greater relapse OR

- AML in first relapse AND has received >= 450 mg/m^2 daunorubicin equivalents

- NOTE: for the purposes of determining eligibility for this protocol, the
following cardiotoxicity multipliers will be used to determine daunorubicin
equivalents:

- Doxorubicin: 1

- Mitoxantrone: 3

- Idarubicin: 3

- Epirubicin: 0.5

- Refractory patients:

- Patients must have received at least two attempts at remission induction, which
may consist of up to two different therapy courses; Children's Oncology Group
(COG) AAML1031 de novo therapy including induction I and induction II is one
remission attempt

- Patients must have the status of central nervous system (CNS)1 or CNS2 only, and no
clinical signs or neurologic symptoms suggestive of CNS leukemia, such as cranial
palsy

- Patients must have a body surface area >= 0.35 m^2 at the time of study enrollment

- Patient's current disease state must be one for which there is no known curative
therapy or therapy proven to prolong survival with an acceptable quality of life

- Karnofsky >= 50% for patients > 16 years of age and Lansky >= 50 for patients =< 16
years of age; patients who are unable to walk because of paralysis, but who are up in
a wheelchair, will be considered ambulatory for the purpose of assessing the
performance score

- Patients must have recovered from the acute toxic effects of all prior chemotherapy,
immunotherapy, stem cell transplant or radiotherapy prior to entering this study; all
prior treatment-related toxicities must have resolved to =< grade 2 or meet the
inclusion/exclusion criteria prior to enrollment

- Myelosuppressive chemotherapy:

- Must be 14 days after the last dose of myelosuppressive chemotherapy
(excluding hydroxyurea)

- Cytoreduction with hydroxyurea can be initiated and continued for up to 24
hours prior to the start of therapy

- Intrathecal cytotoxic therapy:

- No waiting period is required for patients having received intrathecal
cytarabine, methotrexate, and/or hydrocortisone

- At least 14 days must have elapsed since receiving liposomal cytarabine
(DepoCyte) by intrathecal injection

- Intrathecal cytarabine given at the time of diagnostic lumbar puncture (LP)
to evaluate for relapse prior to study enrollment is allowed

- Biologic (anti-neoplastic agent):

- At least 7 days since the completion of therapy with a biologic agent such
retinoids, or DLI (donor lymphocyte infusion without conditioning)

- Note: for agents that have known adverse events occurring beyond 7 days
after administration, this period must be extended beyond the time during
which acute adverse events are known to occur

- Interleukins, Interferons and Cytokines (other than hematopoietic growth
factors):

- >= 21 days after the completion of interleukins, interferon or cytokines
(other than hematopoietic growth factors)

- Antibodies:

- >= 21 days must have elapsed from infusion of last dose of antibody, and
toxicity related to prior antibody therapy must be recovered to grade =< 1

- Radiation therapy (RT):

- At least 14 days after local palliative x-ray telescope (XRT) (small port);
at least 84 days must have elapsed if prior traumatic brain injury (TBI),
craniospinal XRT or if >= 50% radiation of pelvis; at least 42 days must
have elapsed if other substantial bone marrow (BM) radiation

- Stem Cell Transplant (SCT) without TBI:

- No evidence of active graft vs. host disease and at least 84 days must have
elapsed after transplant or stem cell infusion

- Patients must be off all systemic immunosuppressive therapy for at least 2
weeks, excluding hydrocortisone for physiologic cortisol replacement

- Growth factors:

- At least 14 days after the last dose of a long-acting growth factor (e.g.
Neulasta) or 7 days for short-acting growth factor; for agents that have
known adverse events occurring beyond 7 days after administration, this
period must be extended beyond the time during which adverse events are
known to occur; the duration of this interval must be discussed with the
study chair

- Patients must not have received prior exposure to AZD1775

- Platelet count >= 20,000/mm^3 (may receive platelet transfusions); these patients
must not be known to be refractory to red cell or platelet transfusion

- 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: maximum serum creatinine (mg/dL) 1 to < 2 years: 0.6 (male), 0.6 (female) 2
to < 6 years: 0.8 (male), 0.8 (female) 6 to < 10 years: 1 (male), 1 (female) 10
to < 13 years: 1.2 (male), 1.2 (female) 13 to < 16 years: 1.5 (male), 1.4
(female) >= 16 years: 1.7 (male), 1.4 (female)

- Bilirubin (sum of conjugated + unconjugated) =< 1.5 x upper limit of normal (ULN) for
age

- Serum glutamic pyruvic transaminase (SGPT) (alanine aminotransaminase [ALT]) =< 225
units per liter (U/L); for the purpose of this study, the ULN for SGPT is 45 U/L

- Serum albumin >= 2 g/dL

- All patients and/or their parents or legally authorized representatives must sign a
written informed consent; assent, when appropriate, will be obtained according to
institutional guidelines

- Specimens for cytogenetic analysis are required, and must be obtained prior to
therapy initiation; for patient with refractory disease, the diagnostic specimen may
be used

Exclusion Criteria:

- Pregnancy or breast-feeding:

- Pregnant or breast-feeding women may not be entered on this study; pregnancy
tests must be obtained in girls who are post-menarchal

- Males or females of reproductive potential may not participate unless they have
agreed to use an effective double barrier contraceptive method for the entire
duration of protocol therapy

- Corticosteroids should not be used as anti-emetic therapy; corticosteroid therapy is
not permissible except for the following indications:

- As treatment or prophylaxis for anaphylactic reactions

- As a treatment for symptoms of cytarabine (Ara-C) syndrome (including fever,
rash, or conjunctivitis)

- Physiologic replacement stress-dosing as indicated for suspected or confirmed
adrenal insufficiency

- Patients who are currently receiving another investigational drug are not eligible

- Patients who are currently receiving other anti-cancer agents are not eligible except
for hydroxyurea (which may be continued until 24 hours prior to start of protocol
therapy)

- Anti-graft versus host disease (GVHD) agents post-transplant:

- Patients who are receiving cyclosporine, tacrolimus or other agents to prevent
graft-versus-host disease post bone marrow transplant are not eligible for this
trial

- Patients must be off all systemic immunosuppressive therapy for at least 2
weeks, excluding hydrocortisone for physiologic cortisol replacement

- Patients who are currently receiving drugs that are strong or moderate inhibitors
and/or inducers of cytochrome P450 family 3 subfamily A polypeptide 4 (CYP3A4) or
sensitive CYP3A4 substrates and CYP3A4 substrates with a narrow therapeutic range are
not eligible; the use of aprepitant as an antiemetic is prohibited due to early drug
interaction data demonstrating increased exposure to AZD1775; caution should be
exercised with concomitant administration of AZD1775 and agents that are sensitive
substrates of cytochrome P450 family 2 subfamily C polypeptide 8 (CYP2C8), family 2
subfamily C polypeptide 9 (2C9) and family 2 subfamily C polypeptide 19 (2C19), or
substrates of this enzyme with narrow therapeutic ranges, as well as agents that are
inhibitors or substrates of P-glycoprotein (P-gp)

- Patients must not have received enzyme inducing anticonvulsants for at least 14 days
prior to enrollment

- Patients must be able to swallow capsules whole; nasogastric or gastrostomy (G) tube
administration is not allowed

- Patients who have an uncontrolled infection are not eligible

- Patients with any of the following diagnoses are not eligible:

- Acute promyelocytic leukemia (APL)

- Down syndrome

- Fanconi anemia, Kostmann syndrome, Shwachman syndrome or any other known bone
marrow failure syndrome

- Wilson's disease and any other disorder of copper metabolism

- Juvenile myelomonocytic leukemia (JMML)

- Patients who have received a prior solid organ transplantation are not eligible

- Patients who in the opinion of the investigator may not be able to comply with the
safety monitoring requirements of the study are not eligible