Mithramycin for Children and Adults With Solid Tumors or Ewing Sarcoma

* INCLUSION CRITERIA
* Diagnosis
* Patients current disease state must be one for which there is no known curative therapy or therapy proven to prolong survival with an acceptable quality of life.
* Phase I Portion: Measurable or evaluable refractory or recurrent extracranial solid tumors, excluding brain tumors and cerebral metastases.
* Phase II Portion adults and children: Refractory or recurrent extracranial Ewing sarcoma with Ewings sarcoma - friend leukemia integration 1 transcription factor (EWS-FLI1) fusion transcript. Patients enrolled to this cohort must have measurable disease. Presence of the transcript will be determined during histologic confirmation of disease with a Clinical Laboratory Improvement Amendments (CLIA) approved EWS-FLI paraffin assay in the Laboratory of Pathology Center for Cancer Research, National Cancer Institute (CCR, NCI), unless a pathology report documenting presence of the transcript using a CLIA approved assay is obtained from the referring institution.
* Histologic confirmation of disease in the Laboratory of Pathology, CCR, NCI, National Institutes of Health (NIH).
* Age
* Phase I Portion: greater than or equal to 12 months to less than or equal to 17 years
* Phase II Portion in adults initially: greater than or equal to 18 years
* Phase II Portion expanded in pediatrics after determination of phase II dose in children will include children greater than or equal to 12 months to less than or equal to 17 years
* Performance Score: Karnofsky (\> 10-17 years old) or Lansky (less than or equal to 10 years old) greater than or equal to 50%, or Eastern Cooperative Oncology Group (ECOG) 1 or 2 (adults)
* Prior therapy
* greater than or equal to 2 weeks must have elapsed since local palliative radiation (XRT) (small port);
* greater than or equal to 24 weeks must have elapsed since prior total body irradiation (TBI), craniospinal XRT, or if greater than or equal to 50%
* radiation of pelvis;
* greater than or equal to 6 weeks must have elapsed since other substantial BM radiation;
* greater than or equal to 12 weeks must have elapsed since stem cell transplant or infusion without TBI and no active graft vs. host disease;
* greater than or equal to 3 weeks must have elapsed from last dose of myelosuppressive chemotherapy (six

weeks for nitrosoureas);

at least 3 half-lives must have elapsed since monoclonal antibody1;(https://members.childrensoncologygroup.org/Disc/devtherapeutics/default.asp for listing of monoclonal antibody half-lives.)

* greater than or equal to 7 days must have elapsed from the last dose of biologic agents.
* greater than or equal to 7 days since the completion of therapy with a growth factor
* Recovered from acute toxicities of prior therapy to less than or equal to Grade 1; specifically

  a) Hematologic and Coagulation Parameters

  i. Peripheral absolute neutrophil count (ANC) greater than or equal to 1000/mcL

ii. Platelets greater than or equal to 75,000/ mcL (transfusion independent)

iii. Hemoglobin greater than or equal to 8 g/dL (packed red blood cell (PRBC) transfusions permitted)

iv. Normal prothrombin time (PT)/partial thromboplastin time (PTT) with the exception of a lupus anticoagulant, which is permitted, may be corrected with Vitamin K administration or transfusion. Fibrinogen greater than or equal to the lower limit of normal.

b) Hepatic Function

i. Bilirubin (total) less than or equal to 1.5 times upper limit of normal (ULN)

ii. Alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase (SGPT) less than or equal to 3.0 times ULN

iii. Albumin \> 2 g/dL

c) Renal Function

i. Creatinine clearance greater than or equal to 60 mL/min/1.73 m\^2, or serum creatinine base on age and gender as follows:

Age (years) Maximum Serum Creatinine (mg/dL)

2 to \< 6 0.8 0.8

6 to \< 10 1 1

10 to \< 13 1.2 1.2

13 to \< 16 1.5 1.4

greater than or equal to 16 1.7 1.4

* Normal calcium, magnesium and phosphorus (can be on oral supplementation
* Cardiac Function: Left ventricular ejection fraction (EF) within normal institutional limits by Echocardiogram or multi-gated acquisition scan (MUGA)
* Ability to give informed consent. For patients \< 18 years of age their legal guardian must give informed consent. Pediatric patients will be included in age appropriate discussion in order to obtain verbal assent.
* Female and male patients (and when relevant their partners) must be willing to practice birth control (including abstinence) during and for two months after treatment, if of childbearing potential during sexual contact with a female of childbearing potential.
* A durable power of attorney (DPA) will be offered to all patients greater than or equal to 18 years old.
* Eligibility criteria for mandatory serial tumor biopsies
* Age: greater than or equal to 18 years old
* Ewing sarcoma with EWS-FLI1 fusion transcript
* Hematologic and coagulation parameters within 2 days prior to each biopsy: Normal PT/PTT with exception of lupus anticoagulant, platelets greater than or equal to 75,000/mcL, peripheral ANC greater than or equal to 750/mcL
* Willing to undergo biopsies, which will only be performed on tumors amenable to percutaneous biopsy

EXCLUSION CRITERIA:

* Clinically significant systemic illness (e.g. serious active infections or significant cardiac, pulmonary, hepatic or other organ dysfunction), that in the judgment of the PI would compromise the patient s ability to tolerate protocol therapy or significantly increase the risk of complications.
* Patients with a history intracranial Ewing sarcoma including cerebral metastases
* Patients with evidence of active bleeding, intratumoral hemorrhage or history of bleeding diatheses
* Patients who are receiving anticoagulants other than prophylactic anticoagulation of venous or arterial access devices, provided that requirements for PT, PTT and fibrinogen are met, as described
* Investigational Drugs: Patients who are currently receiving another investigational drug
* Patients who are concurrently receiving agents, which may increase the risk for mithramycin related toxicities, such as hemorrhage including:
* Thrombolytic agents
* Anti-inflammatory drugs, nonsteroidal (nonsteroidal anti-inflammatory drugs (NSAIDs)) or aspirin or salicylate containing products, which may increase risk of hemorrhage
* Dextran
* Dipyridamole
* Sulfinpyrazone
* Valproic acid
* Anti-cancer Agents: Patients who are currently receiving other anti-cancer agents
* Lactating or pregnant females (due to risk to fetus or newborn, and lack of testing for excretion in breast milk).
* Patients with history of human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) due to potentially increased risk of mithramycin toxicity in this population.
* Hypersensitivity to plicamycin (mithramycin)
* Requirement for any of the contraindicated medications: nonsteroidal anti-inflammatory drugs, aspirin, dextran or other iron containing solutions (due to incompatibility), dipyridamole, sulfinpyrazone or valproic acid
* Patients who in the opinion of the investigator may not be able to comply with the safety monitoring requirements of the study.
* Patients receiving concurrently other therapies directed at their cancer.