Summary

This phase III trial compares the effect of adding chemotherapy (doxorubicin or epirubicin hydrochloride [epirubicin] with ifosfamide or dacarbazine) before standard surgery versus surgery alone in improving long-term survival in patients with retroperitoneal sarcomas that are able to be removed by surgery (resectable). Chemotherapy drugs, such as doxorubicin, epirubicin, ifosfamide, and dacarbazine, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving chemotherapy before surgery may make the tumor smaller and easier to remove and may increase patient survival, compared to surgery alone.

Objectives

PRIMARY OBJECTIVE:
I. To assess whether preoperative chemotherapy, as an adjunct to curative-intent surgery, improves the prognosis of high risk dedifferentiated liposarcoma (DDLPS) and leiomyosarcoma (LMS) patients as measured by disease free survival.

SECONDARY OBJECTIVES:
I. To assess whether there is a difference in the overall survival, recurrence free survival, distant metastases free survival, cumulative incidence of local recurrences and cumulative incidence of distant metastases between patients undergoing curative-intent surgery alone and those undergoing preoperative chemotherapy followed by curative intent surgery.
II. To assess tumor response in patients undergoing preoperative chemotherapy.
III. To assess the toxicity profile of preoperative chemotherapy given as "neoadjuvant" treatment to curative intent surgery in patients with retroperitoneal sarcoma (RPS), and of surgery alone.
IV. To assess whether there is a difference in quality of life between patients undergoing curative intent surgery alone and those undergoing preoperative chemotherapy followed by curative intent surgery.

OUTLINE: Patients are randomized to 1 of 2 arms.

ARM I: Patients undergo surgery on study. Patients also undergo collection of blood samples throughout the study and undergo computed tomography (CT) and/or magnetic resonance imaging (MRI) at screening and follow up.

ARM II: Patients receive doxorubicin (or equivalent epirubicin) IV bolus infusion on day 1 with ifosfamide IV over 4 hours on days 1-3 or dacarbazine IV over 15-30 minutes on days 1-4. Cycles repeat every 21 days for 3 cycles and then patients undergo surgery on study. Patients also undergo collection of blood samples and undergo CT and/or MRI throughout the study.

After completion of study treatment, patients are followed up at 12, 18, 24, 36 and 48 weeks and every 4 months until month 24 after randomization. After 24 months, patients are followed every 6 months until occurrence of recurrence or death.

Eligibility

1. Histologically proven primary high risk leiomyosarcoma (LMS) or liposarcoma (LPS) of retroperitoneal space or infra-peritoneal spaces of pelvis * LMS: ** Grades 2 and 3 LMS of minimum size 5 cm * LPS (diagnosis based on MDM2 and CDK4 expression on immunohistochemistry [IHC]; additional proof of MDM2 amplification is highly recommended but not mandatory): ** Grade 3 DDLPS OR ** Confirmed grade 2 DDLPS on biopsy only if: *** Federation Nationale des Centres de Lutte Contre Le Cancer (FNCLCC) score = 5 AND clear necrosis on imaging (whether or not present on the biopsy) OR *** High risk gene profile as determined by the Complexity INdex in SARComas (CINSARC-high)
2. Unifocal tumor
3. Resectable tumor: resectability is based on pre-operative imaging performed within 28 days before randomization (CT-abdomen, potentially also with MRI) and has to be defined by the local treating sarcoma team. A patient is not considered resectable when the expectation is that only an R2 resection is feasible * Criteria for non-resectability are: ** Involvement of the superior mesenteric artery, aorta, coeliac trunk and/or portal vein ** Involvement of bone ** Growth into the spinal canal ** Progression of retro-hepatic inferior vena cava leimyosarcoma towards the right atrium ** Infiltration of multiple major organs like liver, pancreas and or major vessels
4. Patient must have radiologically measurable disease (Response Evaluation Criteria in Solid Tumors [RECIST] 1.1), as confirmed by imaging within the 28 days prior to randomization. CT thorax abdomen pelvis with IV contrast is the preferred imaging modality. In case of any contra-indications (medical or regulatory), it is allowed to perform a non-contrast CT thorax + MRI abdomen & pelvis
5. Collection of tumor tissue and blood samples for central pathology review and translational research are mandatory. If tumor tissue is not available and/or patient does not consent, patient will not be eligible for this trial
6. >= 18 years old (no upper age limit)
7. World Health Organization (WHO) performance status =< 2
8. Hemoglobin > 9.0 g/dL or 5.6 mmol/L (within 21 days prior to randomization) * Note: Platelet transfusions is allowed to achieve these baseline values; red blood cell transfusion is not allowed
9. Absolute neutrophils > 1.5 x 10^9/L (within 21 days prior to randomization) * Note: Platelet transfusions is allowed to achieve these baseline values; red blood cell transfusion is not allowed
10. Platelets > 100 x 10^9/L (within 21 days prior to randomization) * Note: Platelet transfusions is allowed to achieve these baseline values; red blood cell transfusion is not allowed
11. Partial thromboplastin time =< 1.0 times upper limit of normal (1.0 x ULN) of institutional limits and prothrombin time =< 1.0 x upper limit of normal (ULN) of institutional limits (within 21 days prior to randomization) * Note: for patient under anticoagulant treatment international normalized ratio (INR) must be controlled and in the therapeutic target range according to local guidelines
12. Estimated glomerular filtration rate (eGFR) > 50 ml/min/m^2 (modification of diet in renal disease [MDRD] formula) (within 21 days prior to randomization)
13. No proteinuria >= grade 2 (Common Terminology Criteria for Adverse Events [CTCAE] version [v] 5.0) (within 21 days prior to randomization)
14. Bilirubin =< 1.0 x ULN of institutional limits (within 21 days prior to randomization). If isolated elevated bilirubin < 2 x ULN and Gilberts syndrome suspected, suggest repeating bloods after food. If bilirubin improves to meet the criteria above this is acceptable. More severe persistent hepatic impairment of whatever cause would exclude the patient from treatment till resolved
15. Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) =< 1.5 x ULN (within 21 days prior to randomization)
16. Clinically normal cardiac function based on left ventricular ejection fraction (LVEF) >= 50% as assessed either by multi-gated acquisition scan (MUGA) or cardiac ultrasound and 12 lead electrocardiogram (ECG) without clinically relevant abnormalities (within 21 days prior to randomization)
17. American Society of Anaesthesiologist (ASA) score < 3
18. Women of child bearing potential (WOCBP) must have a negative serum pregnancy test within 3 days prior to randomization * Note: a woman is considered of childbearing potential, i.e. fertile, if she is following menarche. She remains of childbearing potential until she becomes post-menopausal or permanently sterile. Permanent sterilization methods include hysterectomy, bilateral salpingectomy and bilateral oophorectomy. A postmenopausal state is defined as no menses for 12 months without an alternative medical cause. A high follicle stimulating hormone (FSH) level in the postmenopausal range may be used to confirm a post-menopausal state in women not using hormonal contraception or hormonal replacement therapy. However in the absence of 12 consecutive months without menses, a single FSH measurement is insufficient
19. WOCBP in both arms should use highly effective birth control measures, during the study treatment period and for at least 6 months after the last dose of chemotherapy or date of surgery (except for women receiving chemotherapy with ifosfamide who should continue contraception until 1 year after last day of treatment). A highly effective method of birth control is defined as a method which results in a low failure rate (i.e. less than 1% per year) when used consistently and correctly
20. For men in the experimental arm: agreement to remain abstinent (refrain from heterosexual intercourse) or use contraceptive measures, and agreement to refrain from donating sperm
21. Female subjects who are breast feeding should discontinue nursing prior to the first day of study treatment and until 6 months after the last study treatment
22. Before patient randomization, written informed consent must be given according to International Conference on Harmonisation (ICH)/Good Clinical Practice (GCP), and national/local regulations

Treatment Sites in Georgia