<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT03000335</url>
  </required_header>
  <id_info>
    <org_study_id>CW003</org_study_id>
    <nct_id>NCT03000335</nct_id>
  </id_info>
  <brief_title>Evaluation of ProALL miRs in Blood Specimen for Prediction of ALL Relapse Risk</brief_title>
  <official_title>Evaluation of ProALL microRNAs in Blood Specimen for Prediction of Acute Lymphoblastic Leukemia Relapse Risk</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>Curewize Health Ltd.</agency>
      <agency_class>Industry</agency_class>
    </lead_sponsor>
  </sponsors>
  <source>Curewize Health Ltd.</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
  </oversight_info>
  <brief_summary>
    <textblock>
      Previous findings have shown that a biomarker comprised of the three microRNAs (miRs)&#xD;
      miR-451, miR-151-5p and miR-1290 can independently predict precursor B-cell acute&#xD;
      lymphoblastic leukemia (B- ALL) patients' risk for relapse when measured in cells from a bone&#xD;
      marrow (BM) aspiration taken at diagnosis (Avigad et al., 2016: Genes, Chromosomes &amp; Cancer&#xD;
      55:328-339). Curewize Health recognizes that the development of a minimally invasive blood&#xD;
      test for frequent long-term monitoring can greatly benefit pediatric precursor B-ALL&#xD;
      patients. Therefore, the current study will investigate the monitoring ability of miR-451,&#xD;
      miR-151-5p and miR-1290 measured in blood samples. The study will be performed in two stages:&#xD;
&#xD;
      Stage 1-Cross-Sectional Study: Blood samples will be collected from relapsed pediatric B-ALL&#xD;
      patients and B-ALL patients in remission. Blood will be collected from each patient in three&#xD;
      tubes, for serum, plasma and whole blood analysis, in order to interpret the best blood&#xD;
      source for measuring miR-451, miR-151-5p and miR-1290. The level of the miRs in blood will be&#xD;
      compared between relapsed B-ALL patients to B-ALL patients in remission. If the Stage 1&#xD;
      Cross-Sectional study is successful, the investigators will continue the clinical trials to&#xD;
      the Stage 2 Prospective Monitoring study.&#xD;
&#xD;
      Stage 2-Prospective Monitoring Study: Blood will be collected from patients at diagnosis and&#xD;
      at routine clinical follow-up. Patients can be up to five years from diagnosis. The source of&#xD;
      blood found to be most optimal for measuring the miR levels is Stage 1 will be collected. The&#xD;
      final design of the Stage 2 study will be decided after completion of the Stage 1 study.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      1. Acute Lymphoblastic Leukemia Risk Based Treatment:&#xD;
&#xD;
           Children with ALL are usually treated according to risk groups defined by both clinical&#xD;
           and laboratory features. This approach allows children with signs of historically very&#xD;
           good outcome to be treated with modest therapy and to be spared more intensive and toxic&#xD;
           treatment, while allowing children with a historically lower probability of long-term&#xD;
           survival to receive more intensive therapy that may increase the ALL patients' chance of&#xD;
           cure. Study groups use varying criteria, with a strong emphasis on minimal residual&#xD;
           disease (MRD) measurements that quantify the number of leukemic cells that remain in the&#xD;
           patient during and after treatment. The most widely used MRD assays are based on&#xD;
           polymerase chain reaction (PCR) amplification of antigen-receptor genes, and on flow&#xD;
           cytometric detection of abnormal immunophenotypes (Campana, 2010). These techniques&#xD;
           identify the patients' specific leukemia clone in bone marrow before induction treatment&#xD;
           and measure the number of residual leukemic cells post-induction. Two widely used&#xD;
           examples of Risk stratification protocols are the Berlin-Frankfurt-Munster (BFM)&#xD;
           Protocol in Europe and the Children's Oncology Group Protocol in USA.&#xD;
&#xD;
        2. Previous ProALL miR Findings:&#xD;
&#xD;
           The ProALL prototype assay microRNAs (miRNAs) (Avigad et al., 2016) were discovered by&#xD;
           microarray analysis by hybridization of BM aspirates taken at diagnosis of 48 ALL&#xD;
           patients to 979 different miRNAs. The down-regulated expression levels of miR-451 and&#xD;
           miR-151-5p and the up-regulated expression level of miR-1290 associated with adverse&#xD;
           prognostic factors.&#xD;
&#xD;
           The second study focused on measuring the three miRs in BM samples taken from B-ALL&#xD;
           patients at diagnosis treated by the BFM protocol. ProALL miRs predicted high risk to&#xD;
           relapse (p&lt;0.0001, n=127). ProALL miRs were found to be an independent predictor when&#xD;
           tested with prognostic factors known at diagnosis and when tested with PCR-MRD. Similar&#xD;
           findings were found for patients treated by the DCOG protocol (n=32, p&lt;0.0001). In a&#xD;
           small feasibility study the investigators showed that ProALL miRs measured in blood&#xD;
           correlated with ProALL miRs measured in bone marrow (Avigad et al. Mir Expression&#xD;
           Profile of Peripheral Blood Lymphocytes Predicts Relapse in Pediatric Acute&#xD;
           Lymphoblastic Leukemia. Blood. 2016;128:1736 - Poster presentation at ASH 2016).&#xD;
&#xD;
        3. Study Rationale:&#xD;
&#xD;
           Though MRD has greatly contributed to the substantial increase in ALL patients' survival&#xD;
           and outcome, nearly 15% to 20% of young ALL patients eventually succumb to relapse,&#xD;
           resulting in relapsed ALL as being the 4th most common childhood malignancy (Locatelli&#xD;
           et al., 2012, Pui et al., 2012, Hunger and Mullighaan, 2015). Once relapse occurs only&#xD;
           30% to 50% of relapsed patients can be cured even with intensive chemotherapy and bone&#xD;
           marrow transplantation (Nguyen et al. 2008 and Locatelli et al., 2012). Relapsed ALL&#xD;
           patients with high MRD prior to hematopoietic stem cell transplantation (HSCT) have a&#xD;
           significantly worse probability of disease-free survival 10 years after relapse&#xD;
           treatment begins (Eckert et al., 2015). Therefore, it stands to reason that early&#xD;
           detection of relapse before a large increase in MRD can improve relapse patients&#xD;
           disease-free survival. Yet, many oncology groups don't incorporate monitoring in ALL&#xD;
           treatment protocols because of the labor intensity of MRD measurement; and the&#xD;
           invalidation of the feasibility of routine MRD monitoring. This is due to factors such&#xD;
           as variable kinetics of leukemic cell regrowth (van Dongen et al., 2015), and that&#xD;
           nearly 50% of ALL patients succumb to relapse from a new leukemia clone not identified&#xD;
           at diagnosis (Choi et al., 2007). The frequency of monitoring may also be limited,&#xD;
           especially in children, due to discomfort and practical difficulties posed by BM&#xD;
           aspiration (Coustan-Smith E. et al., 2002). A simple predictive test for ALL in blood&#xD;
           would increase the practicality of testing ALL patients more frequently and may&#xD;
           eventually lead to prevention of relapse by means of preemptive treatment.&#xD;
&#xD;
           Investigating if ProALL miRs can be measured in blood, in addition to BM, for predicting&#xD;
           relapse risk of ALL patients is vital due to the many advantages of such a blood test.&#xD;
           If ProALL levels can be tested more frequently in blood the probability of successfully&#xD;
           treating the patients' leukemia will increase by potentially enabling the physician to&#xD;
           take preemptive measures to prevent predicted relapse.&#xD;
&#xD;
        4. Study Design:&#xD;
&#xD;
           The study will be performed in two stages:&#xD;
&#xD;
           Stage 1-Cross-Sectional Study: Blood samples will be collected from relapsed pediatric&#xD;
           B-ALL patients and B-ALL patients in remission. Three Blood samples will be collected&#xD;
           from each patient in tubes in order to interpret the best blood source for measuring&#xD;
           miR-451, miR-151-5p and miR-1290. The sources that will be tested are serum, peripheral&#xD;
           blood lymphocytes and whole blood. The level of the miRs in blood will be compared&#xD;
           between relapsed B-ALL patients and B-ALL patients in remission (n=30). If the &quot;Stage 1&#xD;
           Cross-Sectional&quot; study is successful, the investigators will continue the clinical trial&#xD;
           to the &quot;Stage 2 Prospective Monitoring&quot; study.&#xD;
&#xD;
           Stage 2-Prospective Monitoring Study: Blood will be collected from patients at diagnosis&#xD;
           and/or at routine clinical follow-up. Patients can be up to five years from diagnosis&#xD;
           (n≈65 *3 samples). One source of blood will be collected. Patients will be followed for&#xD;
           3 years. The final design of the Stage 2 study will be after the completion of Stage 1&#xD;
           study.&#xD;
&#xD;
        5. Sample Size Considerations:&#xD;
&#xD;
           Stage 1 Cross-Sectional Study: For the sample size calculation the Primary end-point is&#xD;
           to test the ability of ProALL miRs measured in blood to differentiate B-ALL patients at&#xD;
           remission from patients at relapse. The sample size calculation is according to&#xD;
           Sampling: comparison of proportions of MedCalc (MedCalc Statistical Software version&#xD;
           16.1 (MedCalc Software bvba, Ostend, Belgium; https://www.medcalc.org; 2016). Type 1&#xD;
           error was 0.05 and Type 2 error was 0.20. Data for the sample size calculation was&#xD;
           obtained from the DCOG cohort in Avigad et al., 2016, which was chosen as a model for&#xD;
           the feasibility study due to its small size (n=32). Cross sectional analysis of the DCOG&#xD;
           cohort showed that there were significantly more patients with relapse event (p=0.001,&#xD;
           Fisher Exact test) positive for at least one miR (78%) compared to patients with no&#xD;
           relapse event (13%).&#xD;
&#xD;
           Data is taken from Figure 6 (from Avigad et al., 2016):&#xD;
&#xD;
             -  Patients at Relapse - At least one miR positive rate 0.78&#xD;
&#xD;
             -  Patients at Remission - No miR positive rate 0.13&#xD;
&#xD;
             -  Relapse/Remission was 0.39&#xD;
&#xD;
             -  The minimum number of enrollees needed are: a. Patients at Relapse - n=8 and b.&#xD;
                Patients at Remission - n=21.&#xD;
&#xD;
           B-ALL patients can be included in the study up to five years from diagnosis. After&#xD;
           completing the enrollment of the cross-sectional study, PI will be queried on&#xD;
           Remission/Relapse status of patients. Above is the minimum number of patients to be&#xD;
           enrolled. Up to 12 patients at relapse and 31 patents at remission can be enrolled.&#xD;
&#xD;
           Stage 2 Prospective Study: The sample size calculation is according to Sampling:&#xD;
           survival analysis (Time-to-Event) of MedCalc. Type 1 error was 0.05 and Type 2 error was&#xD;
           0.20. Data for the sample size calculation was obtained from Figure 3A Kaplan Meir curve&#xD;
           (Avigad et al., 2016).&#xD;
&#xD;
             -  Survival rate Profile B was 0.77&#xD;
&#xD;
             -  Survival rate Profile A was 0.29&#xD;
&#xD;
             -  Profile B/Profile A was 17&#xD;
&#xD;
             -  Number of enrollees needed is 62&#xD;
&#xD;
           At least 3 samples from 3 time points should be taken from each patient. A sample can be&#xD;
           taken at relapse if it is the 2nd or 3rd sample. Patients from Stage 1 can continue to&#xD;
           Stage 2. The final design of the study will be after Stage 1.&#xD;
&#xD;
        6. Blood Extraction and Handling of Samples:&#xD;
&#xD;
           No more than 0.8 mL of blood per kilogram of the enrollee's weight will be collected at&#xD;
           one visit. The total amount of blood to be collected for Stage 1 is between 7.5 mL to&#xD;
           10.5 mL according to the following:.&#xD;
&#xD;
             -  PaxGene Tube - 2.5 mL&#xD;
&#xD;
             -  Tube for Plasma - 2.5 mL to 4 mL&#xD;
&#xD;
             -  Tube for Serum - 2.5 mL to 4 mL&#xD;
&#xD;
        7. Biomarker Results and Clinical Data Flow:&#xD;
&#xD;
             -  The blood samples will be screened for the ProALL miRs by Curewize Lab.&#xD;
&#xD;
             -  Curewize will receive clinical data corresponding to the visit that the screened&#xD;
                blood sample was taken only after sending the clinical site the blood sample's miR&#xD;
                values.&#xD;
&#xD;
        8. Statistical Analysis Plan (SAP) for Stage 1-Cross Sectional Study:&#xD;
&#xD;
           Blood Biomarker Variables:&#xD;
&#xD;
             -  miR-451 relative expression (ddCt) level&#xD;
&#xD;
             -  miR-151-5p relative expression (ddCt) level&#xD;
&#xD;
             -  miR-1290 relative expression (ddCt) level&#xD;
&#xD;
           Covariates:&#xD;
&#xD;
             -  Age&#xD;
&#xD;
             -  Gender&#xD;
&#xD;
             -  MRD-PCR&#xD;
&#xD;
             -  BFM risk&#xD;
&#xD;
             -  Treatment group&#xD;
&#xD;
             -  White blood cell count at diagnosis and at blood collection if routinely tested.&#xD;
&#xD;
             -  Steroid response&#xD;
&#xD;
             -  Cytogenetic variables&#xD;
&#xD;
           Cross-Sectional Analysis:&#xD;
&#xD;
           Stage-1 is considered exploratory and will be used to design the analysis of Stage-2.&#xD;
&#xD;
           Variables will be tested for normality with Shapiro Wilk's test. The level of expression&#xD;
           of miR-451, miR151-5p and miR-1290 will be compared between patients during remission&#xD;
           and patients during relapse by Mann-Whitney U test. Continuous data will be depicted in&#xD;
           box plots showing median and interquartile range. Logistic regression will be used to&#xD;
           test the miR values [nominal (positive/negative) and continuous] with each other and&#xD;
           with other variables comparing between patients at remission and patients at relapse.&#xD;
           The optimal combination Classifier will be created according to the above analysis.&#xD;
           Categorical variables will be summarized by frequency tables, indicating numbers and&#xD;
           frequencies of miR status (positive versus negative). Data will be compared by Fisher&#xD;
           exact for dichotomous (2x2 tables) values or chi-square or chi-square for trend for&#xD;
           tables. Odds ratios and likelihood ratios will be calculated. Receiver operating&#xD;
           characteristic curves will be created, the independent variables are miR-451 or&#xD;
           miR-151-p, miR-1290 and dependent variable is relapse or remission. Receiver operating&#xD;
           characteristic curves will be created for the combined Classifier. Additional analyses&#xD;
           will be performed if results from planned analyses give reasonable warrant.&#xD;
&#xD;
        9. Statistical Analysis Plan (SAP) for Stage 2-Prospective Study Will be created after&#xD;
           report of results of Stage-1 Cross Section Study.&#xD;
&#xD;
       10. Ethical Considerations The study will be conducted according to the principles of the&#xD;
           World Medical Association Declaration of Helsinki Ethical Principles for Medical&#xD;
           Research Involving Human Subjects JAMA. 2013;310(20):2191-2194 and in accordance with&#xD;
           local GCP regulations.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Unknown status</overall_status>
  <last_known_status>Recruiting</last_known_status>
  <start_date>December 2016</start_date>
  <completion_date type="Anticipated">December 2021</completion_date>
  <primary_completion_date type="Anticipated">May 2020</primary_completion_date>
  <study_type>Observational</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <observational_model>Case-Control</observational_model>
    <time_perspective>Other</time_perspective>
  </study_design_info>
  <primary_outcome>
    <measure>Stage 1: Abilty of miR-451, miR-151-5p and miR-1290 to Differentiate B-ALL Patients in Relapse from Patients in Remission</measure>
    <time_frame>Maximum One and half years after enrollment of first patient</time_frame>
    <description>Investigate the ability of miR-451, miR-151-5p and miR-1290 measured in blood samples to differentiate between B-ALL patients who are in remission to patients who are in relapse.</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Stage 2: Ability of miR-451, miR-151-5p and miR-1290 to Monitor B-ALL Patients</measure>
    <time_frame>Three and a half years from enrollment of first patient</time_frame>
    <description>Investigate the ability of miR-451, miR-151-5p and miR-1290 measured in blood samples as a surveillance monitoring tool to detect molecular relapse before overt clinical relapse and to confirm sustained molecular remission.</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>Stage 1: Optimal Blood Source for Measuring miR-451, miR-151-5p and miR-1290 for Monitoring B-ALL Patients</measure>
    <time_frame>Maximum One and half years after enrollment of first patient</time_frame>
    <description>Investigate the optimal source of blood for the measurement of miR 451, miR-151-5p and miR-1290 for monitoring B-ALL patients for molecular relapse before overt clinical relapse and confirm sustained molecular remission.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Stage 1: Decide if to Continue to Stage 2 Prospective Monitoring Study of the three miRs.</measure>
    <time_frame>Maximum One and half years after enrollment of first patient</time_frame>
    <description>If results from Outcome 1 are positive then the study will continue to Stage 2.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Stage 1: Finalize the design of Stage 2 Prospective Monitoring Study.</measure>
    <time_frame>Maximum One and half years after enrollment of first patient</time_frame>
    <description>Sample size considerations and design of Stage 2 of the study will be finalized according to results of Stage 1.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Stage 2: Combined Classifier for Monitoring B-ALL Patients for Overt Clinical Relapse or Sustained Remission</measure>
    <time_frame>Four years from enrollment of first patient</time_frame>
    <description>Develop ProALL monitoring classifier based on the measurement of miR-451, miR 151-5p and miR-1290 in blood. An algorithm will be created that includes the most optimal combination and level changes of the microRNA to use as a surveillance monitoring tool of B-ALL patients.</description>
  </secondary_outcome>
  <number_of_groups>2</number_of_groups>
  <enrollment type="Anticipated">65</enrollment>
  <condition>B-cell Acute Lymphoblastic Leukemia</condition>
  <arm_group>
    <arm_group_label>Relapse</arm_group_label>
    <description>B-ALL patients who have succumbed to relapse</description>
  </arm_group>
  <arm_group>
    <arm_group_label>Remission</arm_group_label>
    <description>B-ALL patients who are in remission</description>
  </arm_group>
  <biospec_retention>Samples Without DNA</biospec_retention>
  <biospec_descr>
    <textblock>
      Blood samples will be collected and transcribed to RNA. RNA samples will be retained.&#xD;
    </textblock>
  </biospec_descr>
  <eligibility>
    <study_pop>
      <textblock>
        -  B-ALL patients at relapse&#xD;
&#xD;
          -  B-ALL patients at remission&#xD;
      </textblock>
    </study_pop>
    <sampling_method>Non-Probability Sample</sampling_method>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  Written inform consent was given for the clinical trial by the subject or subject's&#xD;
             legally acceptable representative.&#xD;
&#xD;
          -  Patient with a final diagnosis of B-ALL&#xD;
&#xD;
          -  Male or Female&#xD;
&#xD;
          -  Age from 2 to 19 years at diagnosis.&#xD;
&#xD;
          -  Patient during remission at least 3 months after starting treatment.&#xD;
&#xD;
          -  Patient is up to five years from diagnosis at the baseline visit.&#xD;
&#xD;
          -  Patient at relapse before starting treatment for relapse.&#xD;
&#xD;
          -  Patient weighs at least 9.4 kg.&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  Discovery of an alternative disorder other than B-cell acute lymphoblastic leukemia.&#xD;
&#xD;
          -  The subject has known human immunodeficiency virus (HIV), hepatitis B surface antigen,&#xD;
             or hepatitis C antibody or other dangerous contagious disease.&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>2 Years</minimum_age>
    <maximum_age>19 Years</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>Isaac Yaniv, MD</last_name>
    <role>Study Chair</role>
    <affiliation>Schneider Children's Medical Center, Israel</affiliation>
  </overall_official>
  <overall_contact>
    <last_name>Jennifer Yarden, PhD</last_name>
    <phone>972-524897823</phone>
    <email>jenyarden@curewize.com</email>
  </overall_contact>
  <overall_contact_backup>
    <last_name>Nir Dotan, PhD</last_name>
    <phone>972-544516239</phone>
    <email>nirdotan@curewize.com</email>
  </overall_contact_backup>
  <location>
    <facility>
      <name>Rambam Health Care Campus</name>
      <address>
        <city>Haifa</city>
        <zip>3109601</zip>
        <country>Israel</country>
      </address>
    </facility>
    <status>Recruiting</status>
    <contact>
      <last_name>Maysaa Saab-Kamal, BSc</last_name>
      <phone>972-4-777-4716</phone>
      <email>m_saab@rambam.health.gov.il</email>
    </contact>
    <investigator>
      <last_name>Nira Arad-Cohen, MD</last_name>
      <role>Principal Investigator</role>
    </investigator>
  </location>
  <location>
    <facility>
      <name>Schneider Children's Medical Center of Israel</name>
      <address>
        <city>Petah Tiqva</city>
        <zip>4920235</zip>
        <country>Israel</country>
      </address>
    </facility>
    <status>Recruiting</status>
    <contact>
      <last_name>Michal Rada, MPH</last_name>
      <phone>972-3-9253484</phone>
      <email>michalra6@clalit.org.il</email>
    </contact>
    <investigator>
      <last_name>Gil Gilad, MD</last_name>
      <role>Principal Investigator</role>
    </investigator>
  </location>
  <location_countries>
    <country>Israel</country>
  </location_countries>
  <link>
    <url>http://www.curewize.com</url>
    <description>Sponsor</description>
  </link>
  <reference>
    <citation>Eckert C, Hagedorn N, Sramkova L, Mann G, Panzer-Grumayer R, Peters C, Bourquin JP, Klingebiel T, Borkhardt A, Cario G, Alten J, Escherich G, Astrahantseff K, Seeger K, Henze G, von Stackelberg A. Monitoring minimal residual disease in children with high-risk relapses of acute lymphoblastic leukemia: prognostic relevance of early and late assessment. Leukemia. 2015 Aug;29(8):1648-55. doi: 10.1038/leu.2015.59. Epub 2015 Mar 9.</citation>
    <PMID>25748682</PMID>
  </reference>
  <reference>
    <citation>Choi S, Henderson MJ, Kwan E, Beesley AH, Sutton R, Bahar AY, Giles J, Venn NC, Pozza LD, Baker DL, Marshall GM, Kees UR, Haber M, Norris MD. Relapse in children with acute lymphoblastic leukemia involving selection of a preexisting drug-resistant subclone. Blood. 2007 Jul 15;110(2):632-9. doi: 10.1182/blood-2007-01-067785. Epub 2007 Mar 19.</citation>
    <PMID>17371950</PMID>
  </reference>
  <reference>
    <citation>Coustan-Smith E, Sancho J, Hancock ML, Razzouk BI, Ribeiro RC, Rivera GK, Rubnitz JE, Sandlund JT, Pui CH, Campana D. Use of peripheral blood instead of bone marrow to monitor residual disease in children with acute lymphoblastic leukemia. Blood. 2002 Oct 1;100(7):2399-402. doi: 10.1182/blood-2002-04-1130.</citation>
    <PMID>12239148</PMID>
  </reference>
  <reference>
    <citation>Hunger SP, Mullighan CG. Redefining ALL classification: toward detecting high-risk ALL and implementing precision medicine. Blood. 2015 Jun 25;125(26):3977-87. doi: 10.1182/blood-2015-02-580043. Epub 2015 May 21.</citation>
    <PMID>25999453</PMID>
  </reference>
  <reference>
    <citation>Locatelli F, Schrappe M, Bernardo ME, Rutella S. How I treat relapsed childhood acute lymphoblastic leukemia. Blood. 2012 Oct 4;120(14):2807-16. doi: 10.1182/blood-2012-02-265884. Epub 2012 Aug 15.</citation>
    <PMID>22896001</PMID>
  </reference>
  <reference>
    <citation>Nguyen K, Devidas M, Cheng SC, La M, Raetz EA, Carroll WL, Winick NJ, Hunger SP, Gaynon PS, Loh ML; Children's Oncology Group. Factors influencing survival after relapse from acute lymphoblastic leukemia: a Children's Oncology Group study. Leukemia. 2008 Dec;22(12):2142-50. doi: 10.1038/leu.2008.251. Epub 2008 Sep 25.</citation>
    <PMID>18818707</PMID>
  </reference>
  <reference>
    <citation>Pui CH, Mullighan CG, Evans WE, Relling MV. Pediatric acute lymphoblastic leukemia: where are we going and how do we get there? Blood. 2012 Aug 9;120(6):1165-74. doi: 10.1182/blood-2012-05-378943. Epub 2012 Jun 22.</citation>
    <PMID>22730540</PMID>
  </reference>
  <results_reference>
    <citation>Avigad S, Verly IR, Lebel A, Kordi O, Shichrur K, Ohali A, Hameiri-Grossman M, Kaspers GJ, Cloos J, Fronkova E, Trka J, Luria D, Kodman Y, Mirsky H, Gaash D, Jeison M, Avrahami G, Elitzur S, Gilad G, Stark B, Yaniv I. miR expression profiling at diagnosis predicts relapse in pediatric precursor B-cell acute lymphoblastic leukemia. Genes Chromosomes Cancer. 2016 Apr;55(4):328-39. doi: 10.1002/gcc.22334. Epub 2015 Dec 19.</citation>
    <PMID>26684414</PMID>
  </results_reference>
  <verification_date>January 2019</verification_date>
  <study_first_submitted>December 19, 2016</study_first_submitted>
  <study_first_submitted_qc>December 21, 2016</study_first_submitted_qc>
  <study_first_posted type="Estimate">December 22, 2016</study_first_posted>
  <last_update_submitted>January 31, 2019</last_update_submitted>
  <last_update_submitted_qc>January 31, 2019</last_update_submitted_qc>
  <last_update_posted type="Actual">February 4, 2019</last_update_posted>
  <responsible_party>
    <responsible_party_type>Sponsor</responsible_party_type>
  </responsible_party>
  <keyword>microRNA</keyword>
  <keyword>relapse</keyword>
  <keyword>blood</keyword>
  <keyword>in vitro diagnostics</keyword>
  <keyword>prediction</keyword>
  <keyword>lab test</keyword>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Leukemia</mesh_term>
    <mesh_term>Precursor Cell Lymphoblastic Leukemia-Lymphoma</mesh_term>
    <mesh_term>Leukemia, Lymphoid</mesh_term>
    <mesh_term>Recurrence</mesh_term>
  </condition_browse>
  <patient_data>
    <sharing_ipd>No</sharing_ipd>
  </patient_data>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT03000335
org study id: CW003
nct id: NCT03000335
lead sponsor: 
has dmc: No
Previous findings have shown that a biomarker comprised of the three microRNAs (miRs)
      miR-451, miR-151-5p and miR-1290 can independently predict precursor B-cell acute
      lymphoblastic leukemia (B- ALL) patients' risk for relapse when measured in cells from a bone
      marrow (BM) aspiration taken at diagnosis (Avigad et al., 2016: Genes, Chromosomes & Cancer
      55:328-339). Curewize Health recognizes that the development of a minimally invasive blood
      test for frequent long-term monitoring can greatly benefit pediatric precursor B-ALL
      patients. Therefore, the current study will investigate the monitoring ability of miR-451,
      miR-151-5p and miR-1290 measured in blood samples. The study will be performed in two stages:

      Stage 1-Cross-Sectional Study: Blood samples will be collected from relapsed pediatric B-ALL
      patients and B-ALL patients in remission. Blood will be collected from each patient in three
      tubes, for serum, plasma and whole blood analysis, in order to interpret the best blood
      source for measuring miR-451, miR-151-5p and miR-1290. The level of the miRs in blood will be
      compared between relapsed B-ALL patients to B-ALL patients in remission. If the Stage 1
      Cross-Sectional study is successful, the investigators will continue the clinical trials to
      the Stage 2 Prospective Monitoring study.

      Stage 2-Prospective Monitoring Study: Blood will be collected from patients at diagnosis and
      at routine clinical follow-up. Patients can be up to five years from diagnosis. The source of
      blood found to be most optimal for measuring the miR levels is Stage 1 will be collected. The
      final design of the Stage 2 study will be decided after completion of the Stage 1 study.
1. Acute Lymphoblastic Leukemia Risk Based Treatment:

           Children with ALL are usually treated according to risk groups defined by both clinical
           and laboratory features. This approach allows children with signs of historically very
           good outcome to be treated with modest therapy and to be spared more intensive and toxic
           treatment, while allowing children with a historically lower probability of long-term
           survival to receive more intensive therapy that may increase the ALL patients' chance of
           cure. Study groups use varying criteria, with a strong emphasis on minimal residual
           disease (MRD) measurements that quantify the number of leukemic cells that remain in the
           patient during and after treatment. The most widely used MRD assays are based on
           polymerase chain reaction (PCR) amplification of antigen-receptor genes, and on flow
           cytometric detection of abnormal immunophenotypes (Campana, 2010). These techniques
           identify the patients' specific leukemia clone in bone marrow before induction treatment
           and measure the number of residual leukemic cells post-induction. Two widely used
           examples of Risk stratification protocols are the Berlin-Frankfurt-Munster (BFM)
           Protocol in Europe and the Children's Oncology Group Protocol in USA.

        2. Previous ProALL miR Findings:

           The ProALL prototype assay microRNAs (miRNAs) (Avigad et al., 2016) were discovered by
           microarray analysis by hybridization of BM aspirates taken at diagnosis of 48 ALL
           patients to 979 different miRNAs. The down-regulated expression levels of miR-451 and
           miR-151-5p and the up-regulated expression level of miR-1290 associated with adverse
           prognostic factors.

           The second study focused on measuring the three miRs in BM samples taken from B-ALL
           patients at diagnosis treated by the BFM protocol. ProALL miRs predicted high risk to
           relapse (p<0.0001, n=127). ProALL miRs were found to be an independent predictor when
           tested with prognostic factors known at diagnosis and when tested with PCR-MRD. Similar
           findings were found for patients treated by the DCOG protocol (n=32, p<0.0001). In a
           small feasibility study the investigators showed that ProALL miRs measured in blood
           correlated with ProALL miRs measured in bone marrow (Avigad et al. Mir Expression
           Profile of Peripheral Blood Lymphocytes Predicts Relapse in Pediatric Acute
           Lymphoblastic Leukemia. Blood. 2016;128:1736 - Poster presentation at ASH 2016).

        3. Study Rationale:

           Though MRD has greatly contributed to the substantial increase in ALL patients' survival
           and outcome, nearly 15% to 20% of young ALL patients eventually succumb to relapse,
           resulting in relapsed ALL as being the 4th most common childhood malignancy (Locatelli
           et al., 2012, Pui et al., 2012, Hunger and Mullighaan, 2015). Once relapse occurs only
           30% to 50% of relapsed patients can be cured even with intensive chemotherapy and bone
           marrow transplantation (Nguyen et al. 2008 and Locatelli et al., 2012). Relapsed ALL
           patients with high MRD prior to hematopoietic stem cell transplantation (HSCT) have a
           significantly worse probability of disease-free survival 10 years after relapse
           treatment begins (Eckert et al., 2015). Therefore, it stands to reason that early
           detection of relapse before a large increase in MRD can improve relapse patients
           disease-free survival. Yet, many oncology groups don't incorporate monitoring in ALL
           treatment protocols because of the labor intensity of MRD measurement; and the
           invalidation of the feasibility of routine MRD monitoring. This is due to factors such
           as variable kinetics of leukemic cell regrowth (van Dongen et al., 2015), and that
           nearly 50% of ALL patients succumb to relapse from a new leukemia clone not identified
           at diagnosis (Choi et al., 2007). The frequency of monitoring may also be limited,
           especially in children, due to discomfort and practical difficulties posed by BM
           aspiration (Coustan-Smith E. et al., 2002). A simple predictive test for ALL in blood
           would increase the practicality of testing ALL patients more frequently and may
           eventually lead to prevention of relapse by means of preemptive treatment.

           Investigating if ProALL miRs can be measured in blood, in addition to BM, for predicting
           relapse risk of ALL patients is vital due to the many advantages of such a blood test.
           If ProALL levels can be tested more frequently in blood the probability of successfully
           treating the patients' leukemia will increase by potentially enabling the physician to
           take preemptive measures to prevent predicted relapse.

        4. Study Design:

           The study will be performed in two stages:

           Stage 1-Cross-Sectional Study: Blood samples will be collected from relapsed pediatric
           B-ALL patients and B-ALL patients in remission. Three Blood samples will be collected
           from each patient in tubes in order to interpret the best blood source for measuring
           miR-451, miR-151-5p and miR-1290. The sources that will be tested are serum, peripheral
           blood lymphocytes and whole blood. The level of the miRs in blood will be compared
           between relapsed B-ALL patients and B-ALL patients in remission (n=30). If the "Stage 1
           Cross-Sectional" study is successful, the investigators will continue the clinical trial
           to the "Stage 2 Prospective Monitoring" study.

           Stage 2-Prospective Monitoring Study: Blood will be collected from patients at diagnosis
           and/or at routine clinical follow-up. Patients can be up to five years from diagnosis
           (n≈65 *3 samples). One source of blood will be collected. Patients will be followed for
           3 years. The final design of the Stage 2 study will be after the completion of Stage 1
           study.

        5. Sample Size Considerations:

           Stage 1 Cross-Sectional Study: For the sample size calculation the Primary end-point is
           to test the ability of ProALL miRs measured in blood to differentiate B-ALL patients at
           remission from patients at relapse. The sample size calculation is according to
           Sampling: comparison of proportions of MedCalc (MedCalc Statistical Software version
           16.1 (MedCalc Software bvba, Ostend, Belgium; https://www.medcalc.org; 2016). Type 1
           error was 0.05 and Type 2 error was 0.20. Data for the sample size calculation was
           obtained from the DCOG cohort in Avigad et al., 2016, which was chosen as a model for
           the feasibility study due to its small size (n=32). Cross sectional analysis of the DCOG
           cohort showed that there were significantly more patients with relapse event (p=0.001,
           Fisher Exact test) positive for at least one miR (78%) compared to patients with no
           relapse event (13%).

           Data is taken from Figure 6 (from Avigad et al., 2016):

             -  Patients at Relapse - At least one miR positive rate 0.78

             -  Patients at Remission - No miR positive rate 0.13

             -  Relapse/Remission was 0.39

             -  The minimum number of enrollees needed are: a. Patients at Relapse - n=8 and b.
                Patients at Remission - n=21.

           B-ALL patients can be included in the study up to five years from diagnosis. After
           completing the enrollment of the cross-sectional study, PI will be queried on
           Remission/Relapse status of patients. Above is the minimum number of patients to be
           enrolled. Up to 12 patients at relapse and 31 patents at remission can be enrolled.

           Stage 2 Prospective Study: The sample size calculation is according to Sampling:
           survival analysis (Time-to-Event) of MedCalc. Type 1 error was 0.05 and Type 2 error was
           0.20. Data for the sample size calculation was obtained from Figure 3A Kaplan Meir curve
           (Avigad et al., 2016).

             -  Survival rate Profile B was 0.77

             -  Survival rate Profile A was 0.29

             -  Profile B/Profile A was 17

             -  Number of enrollees needed is 62

           At least 3 samples from 3 time points should be taken from each patient. A sample can be
           taken at relapse if it is the 2nd or 3rd sample. Patients from Stage 1 can continue to
           Stage 2. The final design of the study will be after Stage 1.

        6. Blood Extraction and Handling of Samples:

           No more than 0.8 mL of blood per kilogram of the enrollee's weight will be collected at
           one visit. The total amount of blood to be collected for Stage 1 is between 7.5 mL to
           10.5 mL according to the following:.

             -  PaxGene Tube - 2.5 mL

             -  Tube for Plasma - 2.5 mL to 4 mL

             -  Tube for Serum - 2.5 mL to 4 mL

        7. Biomarker Results and Clinical Data Flow:

             -  The blood samples will be screened for the ProALL miRs by Curewize Lab.

             -  Curewize will receive clinical data corresponding to the visit that the screened
                blood sample was taken only after sending the clinical site the blood sample's miR
                values.

        8. Statistical Analysis Plan (SAP) for Stage 1-Cross Sectional Study:

           Blood Biomarker Variables:

             -  miR-451 relative expression (ddCt) level

             -  miR-151-5p relative expression (ddCt) level

             -  miR-1290 relative expression (ddCt) level

           Covariates:

             -  Age

             -  Gender

             -  MRD-PCR

             -  BFM risk

             -  Treatment group

             -  White blood cell count at diagnosis and at blood collection if routinely tested.

             -  Steroid response

             -  Cytogenetic variables

           Cross-Sectional Analysis:

           Stage-1 is considered exploratory and will be used to design the analysis of Stage-2.

           Variables will be tested for normality with Shapiro Wilk's test. The level of expression
           of miR-451, miR151-5p and miR-1290 will be compared between patients during remission
           and patients during relapse by Mann-Whitney U test. Continuous data will be depicted in
           box plots showing median and interquartile range. Logistic regression will be used to
           test the miR values [nominal (positive/negative) and continuous] with each other and
           with other variables comparing between patients at remission and patients at relapse.
           The optimal combination Classifier will be created according to the above analysis.
           Categorical variables will be summarized by frequency tables, indicating numbers and
           frequencies of miR status (positive versus negative). Data will be compared by Fisher
           exact for dichotomous (2x2 tables) values or chi-square or chi-square for trend for
           tables. Odds ratios and likelihood ratios will be calculated. Receiver operating
           characteristic curves will be created, the independent variables are miR-451 or
           miR-151-p, miR-1290 and dependent variable is relapse or remission. Receiver operating
           characteristic curves will be created for the combined Classifier. Additional analyses
           will be performed if results from planned analyses give reasonable warrant.

        9. Statistical Analysis Plan (SAP) for Stage 2-Prospective Study Will be created after
           report of results of Stage-1 Cross Section Study.

       10. Ethical Considerations The study will be conducted according to the principles of the
           World Medical Association Declaration of Helsinki Ethical Principles for Medical
           Research Involving Human Subjects JAMA. 2013;310(20):2191-2194 and in accordance with
           local GCP regulations.
observational model: Case-Control
time perspective: Other
measure: Stage 1: Abilty of miR-451, miR-151-5p and miR-1290 to Differentiate B-ALL Patients in Relapse from Patients in Remission
time frame: Maximum One and half years after enrollment of first patient
description: Investigate the ability of miR-451, miR-151-5p and miR-1290 measured in blood samples to differentiate between B-ALL patients who are in remission to patients who are in relapse.
measure: Stage 2: Ability of miR-451, miR-151-5p and miR-1290 to Monitor B-ALL Patients
time frame: Three and a half years from enrollment of first patient
description: Investigate the ability of miR-451, miR-151-5p and miR-1290 measured in blood samples as a surveillance monitoring tool to detect molecular relapse before overt clinical relapse and to confirm sustained molecular remission.
measure: Stage 1: Optimal Blood Source for Measuring miR-451, miR-151-5p and miR-1290 for Monitoring B-ALL Patients
time frame: Maximum One and half years after enrollment of first patient
description: Investigate the optimal source of blood for the measurement of miR 451, miR-151-5p and miR-1290 for monitoring B-ALL patients for molecular relapse before overt clinical relapse and confirm sustained molecular remission.
measure: Stage 1: Decide if to Continue to Stage 2 Prospective Monitoring Study of the three miRs.
time frame: Maximum One and half years after enrollment of first patient
description: If results from Outcome 1 are positive then the study will continue to Stage 2.
measure: Stage 1: Finalize the design of Stage 2 Prospective Monitoring Study.
time frame: Maximum One and half years after enrollment of first patient
description: Sample size considerations and design of Stage 2 of the study will be finalized according to results of Stage 1.
measure: Stage 2: Combined Classifier for Monitoring B-ALL Patients for Overt Clinical Relapse or Sustained Remission
time frame: Four years from enrollment of first patient
description: Develop ProALL monitoring classifier based on the measurement of miR-451, miR 151-5p and miR-1290 in blood. An algorithm will be created that includes the most optimal combination and level changes of the microRNA to use as a surveillance monitoring tool of B-ALL patients.
arm group label: Relapse
description: B-ALL patients who have succumbed to relapse
arm group label: Remission
description: B-ALL patients who are in remission
Blood samples will be collected and transcribed to RNA. RNA samples will be retained.
study pop: 
sampling method: Non-Probability Sample
criteria: 
gender: All
minimum age: 2 Years
maximum age: 19 Years
healthy volunteers: No
last name: Isaac Yaniv, MD
role: Study Chair
affiliation: Schneider Children's Medical Center, Israel
last name: Jennifer Yarden, PhD
phone: 972-524897823
email: jenyarden@curewize.com
last name: Nir Dotan, PhD
phone: 972-544516239
email: nirdotan@curewize.com
facility: 
status: Recruiting
contact: 
investigator: 
facility: 
status: Recruiting
contact: 
investigator: 
country: Israel
url: http://www.curewize.com
description: Sponsor
citation: Eckert C, Hagedorn N, Sramkova L, Mann G, Panzer-Grumayer R, Peters C, Bourquin JP, Klingebiel T, Borkhardt A, Cario G, Alten J, Escherich G, Astrahantseff K, Seeger K, Henze G, von Stackelberg A. Monitoring minimal residual disease in children with high-risk relapses of acute lymphoblastic leukemia: prognostic relevance of early and late assessment. Leukemia. 2015 Aug;29(8):1648-55. doi: 10.1038/leu.2015.59. Epub 2015 Mar 9.
PMID: 25748682
citation: Choi S, Henderson MJ, Kwan E, Beesley AH, Sutton R, Bahar AY, Giles J, Venn NC, Pozza LD, Baker DL, Marshall GM, Kees UR, Haber M, Norris MD. Relapse in children with acute lymphoblastic leukemia involving selection of a preexisting drug-resistant subclone. Blood. 2007 Jul 15;110(2):632-9. doi: 10.1182/blood-2007-01-067785. Epub 2007 Mar 19.
PMID: 17371950
citation: Coustan-Smith E, Sancho J, Hancock ML, Razzouk BI, Ribeiro RC, Rivera GK, Rubnitz JE, Sandlund JT, Pui CH, Campana D. Use of peripheral blood instead of bone marrow to monitor residual disease in children with acute lymphoblastic leukemia. Blood. 2002 Oct 1;100(7):2399-402. doi: 10.1182/blood-2002-04-1130.
PMID: 12239148
citation: Hunger SP, Mullighan CG. Redefining ALL classification: toward detecting high-risk ALL and implementing precision medicine. Blood. 2015 Jun 25;125(26):3977-87. doi: 10.1182/blood-2015-02-580043. Epub 2015 May 21.
PMID: 25999453
citation: Locatelli F, Schrappe M, Bernardo ME, Rutella S. How I treat relapsed childhood acute lymphoblastic leukemia. Blood. 2012 Oct 4;120(14):2807-16. doi: 10.1182/blood-2012-02-265884. Epub 2012 Aug 15.
PMID: 22896001
citation: Nguyen K, Devidas M, Cheng SC, La M, Raetz EA, Carroll WL, Winick NJ, Hunger SP, Gaynon PS, Loh ML; Children's Oncology Group. Factors influencing survival after relapse from acute lymphoblastic leukemia: a Children's Oncology Group study. Leukemia. 2008 Dec;22(12):2142-50. doi: 10.1038/leu.2008.251. Epub 2008 Sep 25.
PMID: 18818707
citation: Pui CH, Mullighan CG, Evans WE, Relling MV. Pediatric acute lymphoblastic leukemia: where are we going and how do we get there? Blood. 2012 Aug 9;120(6):1165-74. doi: 10.1182/blood-2012-05-378943. Epub 2012 Jun 22.
PMID: 22730540
citation: Avigad S, Verly IR, Lebel A, Kordi O, Shichrur K, Ohali A, Hameiri-Grossman M, Kaspers GJ, Cloos J, Fronkova E, Trka J, Luria D, Kodman Y, Mirsky H, Gaash D, Jeison M, Avrahami G, Elitzur S, Gilad G, Stark B, Yaniv I. miR expression profiling at diagnosis predicts relapse in pediatric precursor B-cell acute lymphoblastic leukemia. Genes Chromosomes Cancer. 2016 Apr;55(4):328-39. doi: 10.1002/gcc.22334. Epub 2015 Dec 19.
PMID: 26684414
responsible party type: Sponsor
mesh term: Leukemia
mesh term: Precursor Cell Lymphoblastic Leukemia-Lymphoma
mesh term: Leukemia, Lymphoid
mesh term: Recurrence
sharing ipd: No