Studies

This is a prospective, non-randomized clinical trial that aims to describe the efficacy and toxicity of commercially available, targeted anticancer drugs* prescribed for treatment of patients with advanced cancer with a potentially actionable variant as revealed by a genomic or protein expression test. The study also aims to simplify patient access to approved targeted therapies that are contributed to the program by collaborating pharmaceutical companies and to perform next generation sequencing on tumor biopsies for biomarker analyses. Eligible patients have an advanced solid tumor, multiple myeloma or B cell non-Hodgkin lymphoma for which standard treatment options are no longer available and acceptable performance status and organ function. A genomic or protein expression test must have been performed on the tumor and the results must identify at least one potentially actionable molecular variant as defined in the protocol. Results from the molecular profiling test will be used to determine an appropriate drug(s) from among those available in the protocol. The choice of drug will be supported by a list of potential profiles, a molecular tumor board, a knowledge library and by study coordinators for review and approval of the match. The protocol-specified treatment will be administered to the patient once any drug-specific eligibility criteria are confirmed and a fresh pre-treatment biopsy is performed for future genetic studies. All patients who receive treatment with a drug available in the protocol will be followed for standard efficacy outcomes including tumor response, progression-free and overall survival as well as duration of treatment. In addition, treatment related toxicity will be evaluated.

Adult (age >18 years) patient with a histologically-proven locally advanced or metastatic solid tumor, multiple myeloma or B cell non-Hodgkin lymphoma who is no longer benefitting from standard anti-cancer treatment or for whom no such treatment is available or indicated. * For GBM patients: Histologically confirmed recurrent or de novo glioblastoma (primary), with unequivocal first progression after radiotherapy and concurrent/adjuvant chemotherapy, at least 3 months after the concomitant part of the chemo-radiotherapy, and with stable or decreasing dosage of steroids for at least 7 days prior to the baseline MRI scan. ECOG performance status 0-2 Patients must have acceptable organ function as defined below. However, specific inclusion/exclusion criteria specified in the drug-specific study manual will take precedence: Absolute neutrophil count ≥ 1.5 x 109/l Hemoglobin > 5.6 mmol/l Platelets > 75 x 109/l Total bilirubin < 2 x ULN AST (SGOT) and ALT (SGPT) < 2.5 x institutional ULN (or < 5 x ULN in patients with known hepatic metastases) Serum creatinine ≤ 1.5 × ULN or calculated or measured creatinine clearance ≥ 50 mL/min/1.73 m2 Patients must have objectively evaluable or measurable disease (by physical or radiographic examination, according to RECIST v1.1 for patients with solid tumors, or according to IMWG, Lugano, RANO or GCIG criteria, resp., for patients with multiple myeloma, non-Hodgkin lymphoma, glioblastoma or ovarian cancer in case of CA125-based evaluation (please refer to appendices for further details) [16, 17]. Results must be available from a tumor genomic or protein expression test. Eligible tests may include any of the following technologies: fluorescence in situ hybridization (FISH), polymerase chain reaction (PCR), comparative genomic hybridization (CGH), next generation sequencing (NGS) or immunohistochemistry (IHC). The test may have been performed on the primary tumor or a metastatic deposit, in a diagnostic laboratory or within the context of another CPCT study, and must reveal a potentially actionable variant as defined in Section 5. The test results (full pathology or molecular diagnostics report) must be uploaded in the eCRF. Patients must have a tumor profile for which single agent treatment with one of the EMA approved targeted anti-cancer drugs included in this study has potential clinical benefit based on preclinical data or clinical information (see section 5). A new (obtained ≤2 months before inclusion, and without any type of anti-cancer therapy within those ≤2 months ) fresh frozen tumor biopsy specimen for extensive biomarker testing is mandatory before the start of treatment with a targeted agent included in the protocol. *For GBM patients: The mandatory fresh frozen tumor biopsy sample can be obtained through standard-of-care surgical procedures (i.e., performed at progression, for cytoreduction, to proof progressive disease, or to reduce mass effect on the surrounding brain tissue). Thus, surgical procedures are standard-of-care and not part of trial participation. Fresh frozen tumor tissue must have been obtained ≤2 months before inclusion, and without any type of anti-cancer therapy within those ≤2 months. After surgical procedures, patients must meet the following inclusion criteria: i. Surgery must have confirmed the recurrence. ii. A post-surgery MRI should be available within 48 hours following surgery, and must show residual and measurable disease. iii. Craniotomy or intracranial biopsy site must be adequately healed free of drainage or cellulitis, and the underlying cranioplasty must appear intact at the time of study inclusion. Ability to understand and the willingness to sign a written informed consent document. For orally administered drugs, the patient must be able to swallow and tolerate oral medication and must have no known malabsorption syndrome. Because of the risks of drug treatment to the developing foetus, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) for the duration of study participation, and for four months following completion of study therapy. Male patients should avoid impregnating a female partner. Male patients, even if surgically sterilized, (i.e. post-vasectomy) must agree to one of the following: practice effective barrier contraception during the entire study treatment period and through 4 months after the last dose of study drug, or completely abstain from sexual intercourse.

Ongoing toxicity > grade 2, other than alopecia. Patient is receiving any other anti-cancer therapy (cytotoxic, biologic, radiation, or hormonal other than for replacement) except for medications that are prescribed for supportive care but may potentially have an anti-cancer effect (e.g., megestrol acetate, bisphosphonates). These medications must have been started ≥ 1 week prior to enrollment on this study. Patient is pregnant or nursing. Patients with known active progressive brain metastases. Patients with previously treated brain metastases are eligible, provided that the patient has not experienced a seizure or had a clinically significant change in neurological status within the 3 months prior to registration. All patients with previously treated brain metastases must be stable for at least 1 month after completion of treatment and off steroid treatment prior to study enrollment. * Additional exclusion criteria specific for glioblastoma patients: Patients who require anti-convulsant therapy must be taking non-enzyme inducing antiepileptic drugs (non-EIAED). EIAED are prohibited. Patients previously on EIAED must be switched to non-EIAED at least 2 weeks prior to randomization. No radiotherapy within the three months prior to the diagnosis of progression. No radiotherapy with a dose over 65 Gy, stereotactic radiosurgery or brachytherapy unless the recurrence is histologically proven. Patients with clinically significant preexisting cardiac conditions, including uncontrolled or symptomatic angina, uncontrolled atrial or ventricular arrhythmias, or symptomatic congestive heart failure are not eligible. Patients with known left ventricular ejection fraction (LVEF) < 40% are not eligible Patients with stroke (including TIA) or acute myocardial infarction within 3 months before the first dose of study treatment are not eligible Patients with any other clinically significant medical condition which, in the opinion of the treating physician, makes it undesirable for the patient to participate in the study or which could jeopardize compliance with study requirements including, but not limited to: ongoing or active infection, significant uncontrolled hypertension, or severe psychiatric illness/social situations.

Meander Medical Center Recruiting Amersfoort, Utrecht, Netherlands, 3818 ES Contact: H.J. Bloemendal, MD Principal Investigator: G.A. Cirkel, MD Noordwesr ziekenhuis Alkmaar (NWZ) Recruiting Alkmaar, Netherlands Contact: M.P. Hendriks, MD, PhD Principal Investigator: M.P. Hendriks, MD, PhD Ziekehuisgroep Twente Recruiting Almelo, Netherlands Contact: Siemerik Principal Investigator: Siemerik Netherlands Cancer Institute Recruiting Amsterdam, Netherlands, 1066CX Contact: E.E. Voest, prof.    0031205129111    DRUP@nki.nl Contact: L. Zeverijn, MD    0031205129111    DRUP@nki.nl VUMC Recruiting Amsterdam, Netherlands, 1081 HV Contact: M Labots Principal Investigator: M Labots Amsterdam UMC Recruiting Amsterdam, Netherlands, 1105AZ Contact: Adriaan Bins, MD, PhD       a.d.bins@amc.uva.nl Principal Investigator: A Bins, MD, PhD Onze Lieve Vrouwe Gasthuis (OLVG) Recruiting Amsterdam, Netherlands Contact: E.D. Kerver Principal Investigator: E.D. Kerver Gelre ziekehuizen Recruiting Apeldoorn, Netherlands Contact: S.C.S. Tromp Principal Investigator: S.C.S. Tromp Rijnstate Recruiting Arnhem, Netherlands Contact: van Voorthuizen Principal Investigator: van Voorthuizen Amphia Hospital Recruiting Breda, Netherlands Contact: H. Westgeest, MD, PhD Principal Investigator: H. Westgeest, MD, PhD Reiner de Graaf Gasthuis Recruiting Delft, Netherlands Contact: V.O. Dezentje Principal Investigator: V.O. Dezentje Haaglanden medisch centrum Recruiting Den Haag, Netherlands Contact: Jeurissen Principal Investigator: Jeurissen Haga ziekehuis Recruiting Den Haag, Netherlands Contact: Hautsma Principal Investigator: Hautsma Deventer ziekenhuis Recruiting Deventer, Netherlands Contact: Imholz Principal Investigator: Imholz Ziekehuis Nij Smellinghe Recruiting Drachten, Netherlands Contact: Hovenga Principal Investigator: Hovenga Ziekehuis Gelderse Vallei Recruiting Ede, Netherlands Contact: de Mol Principal Investigator: dr Mol Maxima Medisch Centrum Recruiting Eindhoven, Netherlands, 5631 BM Contact: G Vreugdenhil, MD, PhD Principal Investigator: G Vreugdenhil, MD, PhD Orbis Concern Recruiting Geleen, Netherlands, 6162 BG Contact: F L Erdkamp, MD Principal Investigator: F L Erdkamp, MD Rivas zorggroep Recruiting Gorinchem, Netherlands Contact: M.A. Davidis Principal Investigator: M.A. Davidis Martini Recruiting Groningen, Netherlands Contact: van Rooijen Principal Investigator: van Rooijen University Medical Center Groningen Recruiting Groningen, Netherlands Contact: D.J.A. de Groot, MD, PhD Principal Investigator: D.J.A. de Groot, MD, PhD Spaarne gasthuis Recruiting Haarlem, Netherlands Contact: G.J. de Klerk Principal Investigator: G.J. de Klerk Treant zorggroep Recruiting Hoogeveen, Netherlands Contact: Oldenhuis Principal Investigator: Oldenhuis Medisch Centrum Leeuwaarden Recruiting Leeuwarden, Netherlands Contact: de Graaf Principal Investigator: de Graaf Leiden University Medical Center Recruiting Leiden, Netherlands Contact: A.J. Gelderblom, MD, PhD Principal Investigator: A.J. Gelderblom, MD, PhD Maastricht University Medical Center Recruiting Maastricht, Netherlands Contact: A. Hoeben, MD, PhD Principal Investigator: A. Hoeben, MD, PhD St. Antonius ziekhuis Recruiting Nieuwegein, Netherlands Contact: Los Principal Investigator: Los Radboud umc Recruiting NIjmegen, Netherlands, 6225GA Contact: C.M.L. van Herpen, MD, PhD Principal Investigator: H Verheul, MD, PhD Bravis Recruiting Roosendaal, Netherlands Contact: Boudewijn Principal Investigator: Boudewijn St. Fransicus Gasthuis Recruiting Rotterdam, Netherlands, 3045 PM Contact: A P Hamberg, MD Principal Investigator: A P Hamberg, MD Erasmus MC Recruiting Rotterdam, Netherlands Contact: M.J.A. de Jonge, MD, PhD Principal Investigator: M.J.A. de Jonge, MD, PhD St. Elisabeth Recruiting Tilburg, Netherlands, 5022 GC Contact: L.V. Beerepoot, MD, PhD Principal Investigator: L.V. Beerepoot, MD, PhD University Medical Center Utrecht Recruiting Utrecht, Netherlands, 3584CX Contact: M.H.G. Langenberg, MD, PhD Principal Investigator: L Devriese, MD, PhD Viecuri Recruiting Venray, Netherlands Contact: van der wouw Principal Investigator: van der Wouw Isala Recruiting Zwolle, Netherlands Contact: de Groot Principal Investigator: de Groot

Contact: E.E. Voest, prof. 0031205129111 DRUP@nki.nl Contact: D.L. vd Velden, MD 0031205129111 DRUP@nki.nl

In this study, patients who have been diagnosed with gastrointestinal stromal tumor (GIST) and have been treated with adjuvant imatinib for 3 years after surgery will be randomly allocated in a 1:1 ratio to receive imatinib (Gleevec) for 2 more years (Arm A) or to stop imatinib (Arm B). The study participants are required to have histologically verified GIST with a high risk of GIST recurrence despite removal of all macroscopic GIST tissue at surgery and 3 years of adjuvant imatinib. The high risk of GIST recurrence is defined as one of the following: gastric GIST with mitotic count >10/50 high power fields (HPFs) of the microscope, non-gastric GIST with mitotic count >5/50 HPFs, or tumor rupture. Study participants allocated to Arm A will receive imatinib 400 mg/day for 24 months after the date of randomization. All study participants will be followed up using blood tests and computerized tomography (or MRI) of the abdomen. The computerized tomography examinations will be performed at 6 month intervals. A total of 300 patients will be entered to the study. The study hypothesis is that adjuvant imatinib given for a total of 5 years may prevent some of the GISTs to recur as compared to patients who receive adjuvant imatinib for 3 years, and there may be a difference in the rate of GIST recurrence between the two groups.

Age ≥ 18 years. Morphological and immunohistological documentation of GIST (immunostaining for KIT and/or DOG-1 positive, or mutation of KIT or PDGFRA present in tumor tissue). Macroscopically complete surgical resection of GIST (either R0 or R1 resection). Mutation analysis of KIT and PDGFR genes has been carried out. A high risk of GIST recurrence; either gastric GIST with mitotic count >10/50 HPFs, or non-gastric GIST with mitotic count >5/50 HPFs, or tumor rupture. Eastern Cooperative Oncology Group performance status ≤ 2. Adequate organ function. Female patients of childbearing potential must have a negative pregnancy test within 14 days before initiation of study drug dosing. Postmenopausal women must have amenorrhea for at least 12 months to be considered of non-childbearing potential. Male and female patients of reproductive potential must agree to employ an effective barrier method of birth control throughout the study and for up to 3 months following discontinuation of study drug. Patient willing to be followed up at the study site regardless of the result of randomization. Patient has provided a written, voluntary informed consent prior to study-specific screening procedures.

Presence of distant metastases or local recurrence of GIST. Not willing to donate tumor tissue and/or blood samples for the study molecular studies. Presence of a substitution mutation at PDGFRA codon D842 (usually D842V). Administration of adjuvant imatinib longer than for 3 years is planned regardless of the result of randomization, or “life long” imatinib administration is planned. Prior adjuvant (+ neoadjuvant) therapy with imatinib mesylate for at least 35 months has not been completed, or the total duration of prior adjuvant (+ neoadjuvant) imatinib administration exceeds the total duration of 37 months. Neoadjuvant imatinib for a duration that exceeds 9 months. Longer than 4-week break during adjuvant imatinib administration. The dose of imatinib at completion of 3 years of adjuvant imatinib was 200 mg per day or less or greater than 800 mg per day. Patient has received any investigational anti-cancer agents during adjuvant imatinib or between completion of adjuvant imatinib and the date of randomization. Patient has been free of another malignancy for less than 5 years except if the other malignancy is not currently clinically significant nor requiring active intervention, or if the other malignancy is a basal cell skin cancer or a cervical carcinoma in situ. Recent existence of any other malignant disease is not allowed. Patient with Grade III/IV cardiac disease as defined by the New York Heart Association Criteria (i.e., congestive heart failure, myocardial infarction within 6 months of study entry). Female patients who are pregnant or breast-feeding. Severe and/or uncontrolled medical disease (i.e., uncontrolled diabetes, severe chronic renal disease, or active uncontrolled infection). Known diagnosis of human immunodeficiency virus (HIV) infection. Patient with a significant history of non-compliance to medical regimens or with inability to grant reliable informed consent.

Leids Universitair Medisch Centrum (Leiden) Nederlands Kanker Instituut – Antoni van Leeuwenhoek (Amsterdam) Radboud Universitair Medisch Centrum (Nijmegen) Universitair Medisch Centrum Groningen (Groningen)  

Prof. dr. Gelderblom – LUMC

This is an observational, non-interventional, multicenter study. The study will be performed within the Dutch GIST consortium (NKI-AvL, Erasmus MC, Radboud UMC, LUMC and UMCG). Patients diagnosed with GIST with a KIT exon 11 mutations that can be detected by our ddPCR assay are eligible. In this way we will study a homogenous patient population with GIST that (usually) responds very well to initial TKI treatment. Therefore, the KIT mutation status must be known. Patients can enter the study at any time point of their disease trajectory. Patients included in GALLOP-11 will have follow-up as described in the European Society of Medical Oncology and Dutch guidelines but with blood draws for ctDNA assessment at similar time points. The primary objective is the negative predictive value (NPV) of the ddPCR assay result in relation to the results of the CT-scan and/or MRI scan (according to RECIST 1.1) at the same time point. Concordance of these results will be determined, from which the negative predictive value (NPV) of our ddPCR assay will be calculated. This is considered the most important value, as the most harmful scenario would be to miss progressive disease because not seen on ctDNA while it could have been seen on CT (and/or MRI). That would mean that ctDNA analysis is not reliable enough to replace CT-scan (and/or MRI) follow-up in the future. To determine the negative predictive value, at least 250 patients need to have an evaluable follow-up strategy. To pursue a solid follow-up period within an achievable timeline, patients with at least four ctDNA measurements, accompanied by a CT-scan (and/or MRI scan), will be considered evaluable for the NPV analysis. Patients who have progression within four scans are always evaluable, since a positive outcome outweighs negative outcomes because it is known that ctDNA should have had measured change once it is seen on CT-scans (and/or MRI scans).

Patients with GIST with a biopsy confirmed primary KIT exon 11 mutation covered by our KIT exon 11 ddPCR assay (mutation/deletion within target sequence of c.1665_1736); Patients with an indication for at least 4 CT-scans concomitant with regular laboratory examination in a neoadjuvant, adjuvant and/or palliative care trajectory within the time frame of the study; Age ≥18 years; Written informed consent provided

 Patients who are unable to comply with study procedures and follow up

Netherlands Cancer Institute Amsterdam, Netherlands Contact: N. Steeghs, MD, PhD Principal Investigator: N. Steeghs, MD, PhD University Medical Center Groningen Groningen, Netherlands Contact: A. K.L. Reyners, MD, PhD +31 50 361 6161 a.k.l.reyners@umcg.nl Contact: R. Bleckman, MD +31 50 361 6161 Principal Investigator: A. K.L. Reyners, MD, PhD LUMC Leiden, Netherlands Contact: A. J Gelderblom, MD, PhD Principal Investigator: A J Gelderblom, MD, PhD Radboud UMC Nijmegen, Netherlands Contact: I. Desar, MD, PhD Principal Investigator: I. Desar, MD, PhD Erasmus MC Rotterdam, Netherlands Contact: R HJ Mathijssen, MD, PhD Principal Investigator: R HJ Mathijssen, MD, PhD

A. K.L. Reyners, MD, PhD +31 50 361 6161 a.k.l.reyners@umcg.nl R.F Bleckman, MD +31 50 361 6161 r.f.bleckman@umcg.nl

This is a multi-centre, open label, randomized phase 3 selection study (1:2:2 randomization). After confirmation of the eligibility criteria, 185 patients will be randomized 1:2:2 to either the control arm (doxorubicin 60-75 mg/m² IV every 3 weeks) or experimental arm 1 (doxorubicin 12 mg/m2 IV every week) or experimental arm 2 (cyclophosphamide 100 mg orally BD plus prednisolone 10-20 mg orally on day 1 to day 7 of each 14 day cycle). Health-related quality of life (HRQoL) assessment will be performed every 3 weeks during the first 12 weeks and every 12 weeks thereafter until month 12 after start of treatment. Disease evaluation will be performed every 12 weeks until progression. The primary endpoint of the study is difference among the study arms in physical and role functioning at 12 weeks.

Histologically proven advanced unresectable or metastatic soft tissue sarcoma Representative formalin fixed, paraffin embedded tumor blocks or a minimum of 10 unstained tissue slides, either from the primary tumor or a metastatic lesion, must be available for histological central review. Histological central review is not required before treatment start but it is mandatory to send at least 10 unstained tumor slides (blocks optional) at time of study entry. Local histopathological diagnosis will be accepted for entry into this trial. Age ≥ 65 years of age (patients between 65 and 69 years old are eligible if G8 score ≤ 14; patients ≥ 70 years old are eligible independent of G8 score) WHO performance status 0 – 2 Life expectancy based on other significant morbidity of ≥ 6 months Presence of measurable disease (according to RECIST 1.1), as confirmed by imaging within the 28 days prior to randomization. CT 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 + MRI. Progressive disease at entry based on RECIST 1.1 Patients amenable to receive doxorubicin according to investigator’s assessment Adequate haematological and organ function assessed prior to randomization: Haematological function: Haemoglobin ≥ 9.0 g/dL or 5.6 mmol/L Absolute neutrophil count (ANC) ≥ 1.5 x 109/L Platelet count ≥ 100 x 109/L Coagulation: partial thromboplastin time (PTT) ≤ 1.0 times upper limit of normal (1.0 x ULN) of institutional limits and prothrombin time (PT) ≤ 1.0 x ULN of institutional limits 11. Renal function: estimated glomerular filtration rate (eGFR) > 50 ml/min/m2 (calculated by the MDRD formula in appendix E); no proteinuria ≥ grade 2 (CTCAE version 5.0); 12. Hepatic function: bilirubin ≤ 1.0 x ULN of institutional limits, alanine aminotransferase (ALT) or aspartate aminotransferase (AST) ≤1.5 x ULN. 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. 13. Cardiac function: clinically normal function based on the institutional lower limit of normal for left ventricular ejection fraction (LVEF) as assessed either by multi-gated acquisition scan (MUGA) or cardiac ultrasound and 12 lead electrocardiogram (ECG) without clinically relevant abnormalities. Measurement should include investigator assessment of a potential participant’s risk for heart failure with a validated clinical classification system, i.e. the New York Heart Association Functional Classification. Only patients with NYHA class 1 and 2 according to appendix D are eligible. 13. Completion of EORTC QLQ-C30 and EORTC QLQ-ELD14 at baseline. 14. Assessment of G8 geriatric screening tool 15. Assessment of Katz Index of Independence in Activities of Daily Living (ADL) 16. For men: agreement to remain abstinent (refrain from heterosexual intercourse) or use contraceptive measures, and agreement to refrain from donating sperm, as defined below: 17. With female partners of childbearing potential, men must remain abstinent or use a condom during the treatment period and for a period of 6 months after the last dose of doxorubicin-based chemotherapy and for a period of 12 months after the last dose of cyclophosphamide-based chemotherapy. Men must refrain from donating sperm during this same period. Contraception should be considered for the female partners of childbearing potential as well. 18. With pregnant female partners, men must remain abstinent or use a condom during the treatment period and for a period of 6 months after the last dose of doxorubicin-based chemotherapy and for a period of 12 months after the last dose of cyclophosphamide-based chemotherapy to avoid exposing the embryo. 19.Before patient registration/randomization, written informed consent must be given according to ICH/GCP, and national/local regulations including commitment to completing questionnaires during the course of the study.

Symptomatic or known brain metastasis Any prior treatment with anthracyclines Any prior systemic treatment for metastatic STS Inability to swallow and/ or retain oral tablets Rare hereditary galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption Hypersensitivity to doxorubicin, cyclophosphamide, prednisolone or to any of their metabolites or to any of their excipients Uncontrolled severe illness, including but not limited to: Congestive heart failure Angina pectoris Acute inflammatory heart disease Myocardial infarction within 1 year before randomization Arterial hypertension defined as blood pressure ≥ 150/100 mm Hg despite optimal medical therapy Uncontrolled cardiac arrhythmia Increased haemorragic tendency Uncontrolled diabetes Bone marrow aplasia Psychosis Active or uncontrolled infections among which those requiring systemic antibiotics or antimicrobial therapy. Inflammation of the urinary bladder (interstitial cystitis) and/or obstructions of the urine flow. Vaccination with live vaccines within 30 days prior to study entry Patients with a prior or concurrent malignancy whose natural history or treatment has the potential to interfere with the safety or efficacy assessment of the investigational regimen are not eligible for this trial. Known contraindication to imaging tracer or contrast medium and contraindication to MRI Any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and its active requirements (including completion of questionnaires) and follow-up schedule; those conditions should be discussed with the patient before randomization in the trial

Currently, there is no consensus about the optimal treatment for patients with high grade soft tissue sarcomas (STS) which are localized in the extremities. To ensure overall survival, there is a tendency to operate with wide resection margins, but this has a high impact on quality of life especially when limb function must be sacrificed. (Neo)adjuvant radiotherapy allows for narrower surgical margins but is associated with significant short -and long-term side-effects. As evidence on the best treatment is lacking, treatment choice for individual patients should be driven by their weighing of the benefits and harms of the treatment options in light of their personal situation. However, current treatment decision-making in STS care is one-size fits all, and not informed by individualized risks of treatment options and patients’ preferences. Consequently, there is no guarantee that patients with STS will receive treatment that is appropriate for their situation, and patients experience uncertainty about which treatment is best for their personal situation (decisional conflict). From literature it is known that decision supporting interventions contribute to a better informed choice and less decisional conflict. Therefore, our research group developed a validated personalized risk assessment tool (Personalised Sarcoma Care: PERSARC) which provides patients and STS professionals insight into the personalized risks and benefits of each treatment option based on patient’s age, tumor size, tumor depth and histology in their decision-making process. It is hypothesized that use of PERSARC leads to significantly less decisional conflict in patients and more informed decisions compared to usual care (treatment decisions without use of PERSARC) by reducing the uncertainty regarding risks and benefits of treatment options in high-grade extremity STS patients.

Patients (>= 18 years) with primarily diagnosed (histologically confirmed) grade 2-3 extremity STS, who do not have a treatment plan yet and will be treated with curative intent. Patients with sarcoma subtypes or treatment options other than those mentioned in the PERSARC app are unable to participate. Furthermore, patients need to be Dutch fluency and literacy and mentally competent.

Patient that are treated without curative intent Patient that needs to be treated with chemotherapy or isolated limb perfusion Patients were surgery is not indicated Sarcoma subtypes not mentioned in the PERSARC app

Name: Anouk Kruiswijk Email: a.a.kruiswijk@lumc.nl Phone: 0631974532

The investigators will follow the EORTC QLG questionnaire development guidelines. First, a computerized search of the academic literature will be performed to identify all relevant HRQoL issues for and existing HRQoL questionnaires currently used among patients with sarcoma. In parallel, semi-structured interviews will be conducted worldwide with patients with sarcoma(N=179) and health care professionals (HCPs; N=35; phase 1a). The patient sample will be stratified to capture diversity across the sarcoma population tumour location (extremities, axial, head and neck, thorax, retroperitoneal/intra-abdominal and gynecological), stage (localized vs. metastatic disease ) and type or lines of treatment. This list of HRQoL issues generated by the a) literature search, b) relevant items from the Item Library, and c) semi-structured patient and HCP interviews, and will be consolidated into a comprehensive list of issues for all languages of collaborating countries. In phase 1b, the new list of HRQoL issues will be presented to another group of patients with sarcoma(N=475) and HCPs (N=72). Patients and HCPs will be asked to rate the HRQoL issues on relevance (4point Likert scale) and to prioritize the 10 most important issues.

Age at diagnosis 18 years or older Having a confirmed diagnosis of sarcoma

Having any psychiatric condition or cognitive impairment that would hamper participation in interview/completion of self-reported questionnaires. Patients with a Gastrointestinal Stroma Tumour (GIST) diagnosis, as they are quite unique in terms of type of disease and treatment. Patients with Kaposi sarcoma, as this disease occurs quite often in people with AIDS Patients with Carcinosarcoma as this disease is generally seen as a carcinoma

This is a multicenter, randomized, open label phase lll trial to assess whether preoperative chemotherapy, as an adjunct to curative-intent surgery, improves the prognosis of high risk DDLPS (dedifferentiated Liposarcoma) and LMS (Leiomyosarcoma) patients as measured by disease free survival. After confirmation of eligibility criteria, patients will be randomized to either the standard arm or experimental arm.

Histologically proven primary high risk leiomyosarcoma (LMS) or Liposarcoma (LPS) of retroperitoneal space or infra-peritoneal spaces of pelvis. LMS: Grades 2 and 3 of LMS can be included Minimum size of LMS tumor should be 5 cm LPS: Diagnosis should be confirmed based on MDM2 (Mouse double minute 2 homolog) and CDK4 (Cyclin-dependent kinase 4) expression on IHC (immunohistochemistry), while proof of MDM2 amplification is highly recommended. All grade 3 DDLPS can be included. DDLPS with confirmed grade 2 on biopsy can be included when: The grade 2 DDLPS has an FNCLCC score=5 (Fédération Nationale des Centres de Lutte Contre Le Cancer), has no necrosis on the biopsy but clear necrosis on imaging. The tumors carry a high risk gene profile as determined by the Complexity INdex in SARComas (CINSARC-high) Representative formalin fixed, paraffin embedded tumor blocks or unstained tissue slides must be available at baseline for histological central review. Unifocal tumor Absence of extension through the sciatic notch or across the diaphragm Resectable tumor: resectability is based on pre-operative imaging (CT-abdomen, potentially also with MRI) and has to be defined by the local treating sarcoma team. A patients 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 leiomyosarcoma towards the right atrium Infiltration of multiple major organs like liver, pancreas and/or major vessels Tumor not previously treated (no previous surgery (excluding diagnostic biopsy), radiotherapy or systemic therapy) Patient must have radiologically measurable disease (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. ≥ 18 years old (no upper age limit) WHO (World Health Organization) performance status ≤ 2 Adequate haematological and organ function: Haematological: haemoglobin > 9.0 g/dL or 5.6 mmol/L, absolute neutrophils > 1.5 x 109/L, platelets > 100 x 109/L Note: Platelet transfusions is allowed to achieve these baseline values Renal: estimated glomerular filtration rate (eGFR) > 50 ml/min/m2; No proteinuria CTCAE ≥ grade 2; Hepatic: Bilirubin ≤ 1.0 times upper limit of normal (1.0xULN) of institutional limits, ALT (alanine aminotransferase) and/or AST (aspartate transaminase) ≤1.5 x ULN. 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. Heart: 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 ECG without clinically relevant abnormalities. American Society of Anesthesiologist (ASA) score < 3 Women of child bearing potential (WOCBP) must have a negative serum pregnancy test within 7 days prior to the first dose of study treatment or surgery. Note: a woman is considered of childbearing potential (WOCBP), i.e. fertile, following menarche and until becoming post menopausal unless permanently sterile. Permanent sterilisation 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 months of amenorrhea, a single FSH measurement is insufficient. 15. Patients of childbearing / reproductive potential should use highly effective birth control             measures, as defined by the investigator, during the study treatment period and for at                   least 6 months after the last dose of treatment or date of surgery. 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. Such methods include: Combined (oestrogen and progestogen containing) hormonal contraception associated with inhibition of ovulation (oral, intravaginal, transdermal) Progestogen-only hormonal contraception associated with inhibition of ovulation (oral, injectable, implantable) Intrauterine device (IUD) Intrauterine hormone-releasing system (IUS) Bilateral tubal occlusion Vasectomized partner Sexual abstinence (the reliability of sexual abstinence needs to be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle of the patient) 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. Before patient registration/randomization, written informed consent must be given according to ICH/GCP, and national/local regulations.

Sarcoma originated from bone structure, abdominal or gynecological viscera Metastatic disease Tumors with extension through the sciatic notch or across the diaphragm Hypersensitivity to doxorubicin, ifosfamide, dacarbazine or to any of their metabolites or to any of their excipients Persistent myelosuppression Myocardial infarction within the last 6 months Uncontrolled cardiac arrhythmia Previous treatment with maximum cumulative doses (450mg/m² Doxorubicin or equivalent 900mg/m² EpiADM) of doxorubicin, daunorubicin, epirubicin, idarubicin, and/or other anthracyclines and anthracenediones Active and uncontrolled infections Vaccination with live vaccines within 30 days prior to study entry Inflammation of the urinary bladder (interstitial cystitis) and/or obstructions of the urine flow. Other invasive malignancy within 5 years, with the exception of adequately treated non-melanoma skin cancer, localized cervical cancer, localized and presumably cured prostate cancer. Uncontrolled severe illness, infection,medical condition (including, uncontrolled diabetes or hypertension), other than the Primary LPS or LMS of the retroperitoneum. Female patients who are pregnant or breastfeeding or female and male patients of reproductive potential who are not willing to employ effective birth control method. Any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before randomization in the trial Known contraindication to imaging tracer and to MRI

Currently, soft tissue sarcomas (STS) are preoperatively irradiated in a conventionally fractionated regimen of 25 x 2 Gy in five weeks. Recent radiobiological investigations, however, suggest sensitivity to (modest) hypofractionation. Within this study, patients will be randomized to receive either the conventional schedule of 25 x 2 Gy or a shorter preoperative regimen of 14 x 3 Gy, in the hypothesis that both the postoperative wound complication rate until 30 days after surgery, as well as the local control probability at two years are comparable in both arms.

Histologically confirmed newly diagnosed intermediate to high grade soft tissue sarcoma localized to the extremities, trunk and chest wall or the head and neck area, for which the standard treatment is a combination of and radiotherapy and surgery (deep seated and/or > 5cm in largest tumor diameter and/or an anticipated close resection margin and/or grade II/III according to the FNCLCC definition) Absence of regional and/or distant disease. Patients staged by at least a CT scan of the chest (. Staging may also be performed by FDG-PET scanning and or total body MRI scans. Patients with an uncertain metastatic status (e.g. small indifferent lung nodules) and patients with a low metastatic burden not precluding the application of both preoperative radiotherapy and definitive surgery, are allowed to participate WHO Performance Status ≤ 2 Able and willing to undergo preoperative radiotherapy Able and willing to undergo definitive surgery Able and willing to comply with regular follow-up visits Able and willing to complete patient reported outcome questionnaires (health-related quality of life and cost effectiveness) Able and willing to undergo randomization Age ≥ 18 years  

Prior malignancies; except another malignancy and disease-free for ≥ 5 years, or completely resected non-melanomatous skin carcinoma or successfully treated in situ carcinoma Patients with recurrent sarcomas who underwent prior radiotherapy to the target lesion (if the primary sarcoma was managed by surgery only and no perioperative RT, patients are eligible) Ewing sarcoma and other PNET family tumors, rhabdomyosarcomas (both pediatric and adult), osteosarcomas Any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial Female patients who are pregnant Intention to perform an isolated limb perfusion, instead of a tumor resection Neoadjuvant chemotherapy to be scheduled between end of radiotherapy and definitive surgery (neoadjuvant chemotherapy before radiotherapy is allowed)

The purpose of this study is to evaluate the overall response rate after 24 weeks of cemiplimab treatment in patients with locally advanced or metastatic secondary angiosarcomas

Adult patient aged ≥ 18 years Histologically confirmed diagnosis of progressive unresectable locally advanced or metastatic secondary angiosarcoma Patients in the first line of systemic treatment unfit for chemotherapy and patients in advanced lines of systemic treatment Measurable disease per RECIST 1.1 or per physical examination / daylight photography (WHO Offset Publication No. 48) as determined by the investigator] Tumour tissue material available (archival or recent tumour biopsy) WHO ECOG 0-2 Hepatic function: Total bilirubin ≤ 1.5 x ULN (if liver metastases: ≤ 3 x ULN). Transaminases ≤ 3 x ULN (if liver metastases: ≤ 5 x ULN). Patients with Gilbert’s Disease and total bilirubin up to 3x ULN may be eligible after communication with and approval from the medical monitor Alkaline phosphatase ≤ 2.5 x ULN (if liver OR bone metastases ≤5 x ULN) Renal function: serum creatinine ≤ 2 x ULN or estimated CrCl > 30 mL/min. Creatine phosphokinase (CPK) (also known as CK [creatine kinase]) elevation ≤ grade 2 Bone marrow function: Hemoglobulin ≥ 9.0 g/dL ANC ≥ 1.5 x 109/L Platelet count ≥ 75 x 109/L Expected life expectancy of at least 3 months as judged by the investigator  

Ongoing or recent (within 5 years) evidence of significant autoimmune disease that required treatment with systemic immunosuppressive treatments, which may suggest risk for irAEs. The following are not exclusionary: vitiligo, childhood asthma that has resolved, type 1 Diabetes mellitus, residual hypothyroidism that required only hormone therapy, or psoriasis that does not require systematic treatment Prior treatment with immune checkpoint inhibitors Continuous immunosuppressive corticosteroid treatment (doses > 10 mg prednisone daily or equivalent) within 4 weeks prior to the first dose of cemiplimab. Note: patients who require a brief course of steroids (e.g. as prophylaxis for imaging studies) are not excluded Active uncontrolled infection requiring therapy, including infection with HIV, active infection with HBV or HCV History of pneumonitis within the last 5 years Untreated brain metastasis(es) that may be considered active Note in clarification: Patients with previously treated brain metastases may participate provided that the lesion(s) is (are) stable (without evidence of progression for at least 6 weeks on imaging obtained in the screening period), and there is no evidence of new or enlarging brain metastases, and the patients do not require any immunosuppressive doses of systemic corticosteroids for management of brain metastasis(es) within 28 days of the first dose of cemiplimab Patients with allergy or hypersensitivity to cemiplimab or to any of the excipients must be excluded. Specifically, because of the presence of trace components in cemiplimab, patients with allergy or hypersensitivity to doxycycline or tetracycline are excluded History of documented allergic reactions or acute hypersensitivity reaction attributed to antibody treatments Patients with a history of solid organ transplant (patients with prior corneal transplants may be allowed to enroll after discussion with and approval from the medical monitor) Any anticancer treatment other than radiation therapy (chemotherapy, targeted systemic therapy, imiquimod, photodynamic therapy), investigational or standard of care, within 30 days of the initial administration of cemiplimab or planned to occur during the study period Receipt of live vaccines (including attenuated) within 30 days of first study treatment Prior use of PI3K-D inhibitors Women of childbearing potential (WOCBP)*, or sexually active men, who are unwilling to practice highly effective contraception prior to the initial dose/start of the first treatment prior to the start of the first treatment, during the study, and for at least 6 months after the last dose. Breastfeeding Positive serum pregnancy test (a false positive pregnancy test, if demonstrated by serial measurements and negative ultrasound, will not be exclusionary, upon communication with and approval from the medical monitor) Any other condition that might interfere with experimental treatment and the study procedures as judged by the investigator

To prospectively and retrospectively collect data of patients with bone or soft tissue sarcoma in the Netherlands to improve the knowledge and therefore the treatment care. Besides to create a continuous basis for a large variety of research purposes including prognostic and predictive research, health care policies and cost-effectiveness studies.

Age ≥ 18 years Histologically proven bone or soft tissue sarcoma, excluding Gastrointestinal Stromal Tumours

Altered mental status that would prohibit the understanding of any giving of informed consent

Radboudumc Radiotherapiegroep

Name: dr. P.M. Braam E-mail: p.braam@radboudumc.nl Phone: +31-243614515 Address: Radboudumc, Geert Grooteplein Zuid 32, 6525 GA Nijmegen