Sorafenib in Treating Patients With Relapsed Chronic Lymphocytic Leukemia

• Objective overall response rate [ Time Frame: Up to week 25 ] [ Designated as safety issue: No ]
  The 95% confidence intervals should be provided.
• Time to disease progression [ Time Frame: Up to 5.5 years ] [ Designated as safety issue: No ]
  Will be evaluated using the Kaplan-Meier estimator.
• Overall survival [ Time Frame: Up to 5.5 years ] [ Designated as safety issue: No ]
  Will be evaluated using the Kaplan-Meier estimator.

• Changes in the angiogenesis markers, including mean microvessel density and hotspot density [ Time Frame: Baseline and week 25 ] [ Designated as safety issue: No ]
  Will be examined using random-effects linear models.
• Changes in VEGF, VEGF receptors and bFGF [ Time Frame: Baseline and week 25 ] [ Designated as safety issue: No ]
  Indicator variables for these VEGF receptors will be added to the aforementioned random-effect models of angiogenesis measures to determine whether VEGF receptors at baseline are predictors of the changes in angiogenesis measures.
• Changes in plasma level of IL-8 [ Time Frame: Baseline and week 25 ] [ Designated as safety issue: No ]
  The pre- and post-treatment difference will be tested using a paired t test. The change in IL-8 will also be correlated with changes in angiogenesis activity measures using random-effect models, and with response using a two-sample t test.

Sorafenib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth and by blocking blood flow to the cancer. This phase II trial is studying how well sorafenib works in treating patients with relapsed chronic lymphocytic leukemia

PRIMARY OBJECTIVES:

I. Determine the objective response rate in patients with recurrent chronic lymphocytic leukemia (CLL) treated with sorafenib.

II. Determine the toxicity in patients treated with sorafenib.

SECONDARY OBJECTIVES:

I. Correlate bone marrow angiogenesis, CLL tumor cell expression of vascular endothelial growth factor (VEGF), VEGF receptors (flt-1, KDR, flt-4 and neuropilin-1), basic fibroblast growth factor, and plasma interleukin-8 levels with response.

OUTLINE: This is a multicenter study.

Patients receive oral sorafenib twice daily on days 1-28. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.

PROJECTED ACCRUAL: Approximately 40 patients will be accrued for this study.

• Refractory Chronic Lymphocytic Leukemia
• Stage I Chronic Lymphocytic Leukemia
• Stage II Chronic Lymphocytic Leukemia
• Stage III Chronic Lymphocytic Leukemia
• Stage IV Chronic Lymphocytic Leukemia

• Drug: sorafenib tosylate
  Given orally
  Other Names:

  • BAY 43-9006
  • BAY 43-9006 Tosylate Salt
  • BAY 54-9085
  • Nexavar
  • SFN
• Other: laboratory biomarker analysis
  Correlative studies

Inclusion Criteria:

• Histologically or cytologically confirmed chronic lymphocytic leukemia (CLL) by NCI-WG immunophenotype and blood criteria

  • Documentation of current or prior peripheral blood (PB) or bone marrow (BM) immunophenotype compatible with CLL

    • Patients who currently do not have > 5,000/mm³ absolute lymphocytosis are eligible if they have previously met PB lymphocytosis criteria and have a current immunophenotype documenting monoclonal B lymphocytosis morphologically and immunophenotypically compatible with CLL

• Intermediate-risk (Rai stage I or II) or high-risk (Rai stage III or IV) disease, including any of the following:

  • Rai stage I disease with lymphocytosis and enlarged nodes
  • Rai stage II disease with lymphocytosis plus splenomegaly and/or hepatomegaly (nodes positive or negative)
  • Rai stage III disease with lymphocytosis plus anemia
  • Rai stage IV disease with lymphocytosis and thrombocytopenia

• Must require treatment with active disease, experiencing disease related symptoms, or having deterioration of blood counts, meeting ≥ 1 of the following criteria:

  • Presence of ≥ 1 of the following disease-related symptoms:

    • Weight loss > 10% within the past 6 months
    • Extreme fatigue (i.e., ECOG performance status 2: cannot work or unable to perform usual activities)
    • Fever > 100.5°F for 2 weeks without evidence of infection
    • Night sweats without evidence of infection
  • Evidence of progressive marrow failure, as manifested by worsening of anemia (hemoglobin < 10 g/dL), thrombocytopenia (platelet count < 100,000/mm³), and/or neutropenia (neutrophil count < 2,000/mm³)
  • Massive (i.e., > 6 cm below left costal margin) or progressive splenomegaly or discomfort from splenomegaly
  • Massive nodes or clusters (i.e., > 10 cm in longest diameter), progressive adenopathy, or discomfort from lymphadenopathy
  • Deterioration of blood counts and/or progressive lymphocytosis, with an increase of ≥ 10% documented over a 2-month period OR an anticipated doubling time < 6 months

• Relapsed disease

  • Must receive at least 1, but no more than 3, prior chemotherapy regimens with any cytotoxic agent or antibody therapy

    • No fludarabine refractory disease

      • Responded to prior fludarabine without relapse or disease progression for at least 6 months
• Patients with a history of Coombs-positive hemolytic anemia are eligible provided recovery from treatment of hemolysis and off steroids
• No stage 0 CLL
• No known CNS involvement
• Life expectancy > 6 months
• ECOG performance status 0-2 OR Karnofsky performance status 70-100%
• Absolute neutrophil count ≥ 1,000/mm³
• Platelets ≥ 30,000/mm³
• Bilirubin ≤ 2 mg/dL
• AST/ALT ≤ 2.5 times upper limit of normal (ULN)
• Creatinine ≤ 1.5 times ULN OR creatinine clearance ≥ 60 mL/min (for patients with creatinine levels above normal)
• No currently active second malignancy
• Not pregnant or nursing
• Negative pregnancy test
• Fertile patient must use effective contraception prior to and during study participation

• No uncontrolled hypertension, defined as blood pressure (BP) > 150/100 mm Hg on 2 different measurements at least 1 day apart with either systolic or diastolic number meeting this definition

  • Patients may later enter the study, if they have achieved stable BP (i.e., < 140/90 mm Hg) on a regimen of ≤ 2 drugs after 6-8 weeks of therapy
• No history of allergic reactions attributed to compounds of similar chemical or biologic composition to sorafenib

• No uncontrolled intercurrent illness including, but not limited to, any of the following:

  • Symptomatic congestive heart failure
  • Unstable angina pectoris
  • Cardiac arrhythmia
  • Psychiatric illness or social situations that would limit compliance with the study requirements
• No active infection requiring systemic antibiotics
• No evidence of bleeding diathesis
• No evidence of bowel perforation or obstruction risk
• No swallowing dysfunction leading to difficulty taking the study drug
• See Disease Characteristics
• Recovered from prior therapy
• At least 2 weeks since prior antibiotic therapy
• At least 4 weeks since prior chemotherapy (6 weeks for nitrosoureas or mitomycin C) or radiotherapy
• At least 12 weeks since prior monoclonal antibody

• Concurrent warfarin for anticoagulation allowed provided all of the following are met:

  • On a stable therapeutic dose
  • INR ≤ 3
  • No active bleeding or pathological condition that carries high-risk of bleeding
• No prior MAPK signaling inhibitor agents or anti-angiogenesis agents
• No concurrent combination anti-retroviral therapy for HIV-positive patients
• No concurrent cytochrome P450 enzyme-inducing antiepileptic drugs (phenytoin, carbamazepine, or phenobarbital), rifampin, or Hypericum perforatum (St. John's wort)
• No other concurrent investigational agents