Trametinib and Everolimus for the Treatment of Pediatric and Young Adult Patients With Recurrent Low Grade Gliomas (PNOC021)

  • STATUS
    Recruiting
  • End date
    Mar 1, 2023
  • participants needed
    50
  • sponsor
    University of California, San Francisco
Updated on 19 September 2021

Summary

This phase I trial studies the side effects and best dose of trametinib and everolimus in treating pediatric and young adult patients with low grade gliomas that has come back (recurrent). Trametinib acts by targeting a protein in cells called MEK and disrupting tumor growth. Everolimus is a drug that may block another pathway in tumor cells that can help tumors grow. Giving trametinib and everolimus may work better to treat low grade gliomas compared to trametinib or everolimus alone.

Description

PRIMARY OBJECTIVES:

I. To estimate the recommended phase 2 dose (RP2D) of trametinib given orally in combination with everolimus in pediatric and young adult patients with low-grade gliomas (LGGs).

II. To describe the toxicity profile and define the dose limiting toxicities (DLTs) of the combination of trametinib and everolimus in pediatric and young adult patients with recurrent LGGs.

III. To characterize the pharmacokinetic profile of trametinib and everolimus when given in combination.

EXPLORATORY OBJECTIVES:

I. To describe the objective response rate and the 2-year progression-free survival (PFS) of LGGs to this therapy in the context of a phase I study.

II. To assess quality of life (QOL) and cognitive measures in pediatric and young adult patients with LGGs.

III. To identify potential predictive biomarkers to targeted therapy in pediatric and young adult patients with LGGs.

IV. To assess endocrine outcomes in pediatric and young adult patients with LGGs.

V. To explore magnetic resonance (MR) quantitative measures of relative cerebral blood volume, permeability and apparent diffusion coefficient within the region of hyperintensity on T2-weighted images as markers of disease response and/or progression in comparison to institutional evaluation of disease response and/or progression and quantitative measures of tumor response as determined by central review (based upon both area and volumetric measures).

OUTLINE: This is a dose-escalation study.

Patients receive a combination of trametinib orally (PO) and everolimus in either of two dosing scheduled (continuous and intermittent). Treatment repeats every 28 days for up to 26 cycles in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up at 30 days, every 3 months for 1 year, then every 6 months for 5 years from the start of therapy.

Details
Condition Recurrent World Health Organization (WHO) Grade II Glioma, Recurrent World Health Organization (WHO) Grade II Glioma, Recurrent World Health Organization (WHO) Grade II Glioma, Recurrent World Health Organization (WHO) Grade II Glioma, Recurrent World Health Organization (WHO) Grade II Glioma, Recurrent World Health Organization (WHO) Grade II Glioma, Recurrent World Health Organization (WHO) Grade II Glioma, Recurrent World Health Organization (WHO) Grade II Glioma, Recurrent World Health Organization (WHO) Grade II Glioma, Recurrent World Health Organization (WHO) Grade II Glioma
Treatment Everolimus, Trametinib
Clinical Study IdentifierNCT04485559
SponsorUniversity of California, San Francisco
Last Modified on19 September 2021

Eligibility

Yes No Not Sure

Inclusion Criteria

Subjects must have histologically confirmed diagnosis of a LGG (World Health Organization [WHO] grade I-II) that is recurrent or progressive after prior treatment (biologic, chemotherapy or radiation therapy)
Patients who have had surgery alone are not eligible
Patients with neurofibromatosis type 1 (NF1) are eligible but must have available tissue per study requirements NF status will be collected
Patients with spinal cord primaries or disseminated disease are eligible
Patients with a known K27M mutation are considered by current WHO as grade IV and are ineligible for this study
For enrollment, snap frozen tissue (150 mg) or 10 unstained 10 um formalin-fixed, paraffin-embedded (FFPE) slides for comprehensive genomic testing or results of prior testing is required
If clinical comprehensive testing has already been performed, the requirement for submission of tissue may be waived after discussion and review of results with study chairs
Patients must have evaluable disease
Prior therapy: Patients must have received prior therapy other than surgery and must have fully recovered from the acute toxic effects of all prior chemotherapy, biologics, immunotherapy, or radiotherapy prior to entering this study
Myelosuppressive chemotherapy: Patients must have received their last dose of known myelosuppressive anticancer chemotherapy at least three weeks prior to study registration or at least six weeks if they had received nitrosourea. Biologic agents: Patient must have recovered from any acute toxicity potentially related to the agent and received their last dose of the biologic agent >= 7 days prior to study registration. For biologic agents that have a prolonged half-life, at least three half-lives must have elapsed prior to registration
Patients may have received prior treatment with a MEK or mTOR inhibitor but must not have developed severe (grade III or IV) clinically significant toxicity. (Patients who developed grade III or IV toxicity which was not presumed by the treating physician to be medically significant should be discussed with the study chair or co-chair)
Monoclonal antibody treatment: Patients must have received their last dose at least four weeks prior to study registration
Radiation: Patients must have: had their last fraction of local irradiation to the primary tumor, craniospinal irradiation (> 24 Gy) or total body irradiation > 12 weeks prior to registration; investigators are reminded to review potentially eligible cases to confirm disease progression and avoid confusion with pseudo-progression
Bone marrow transplant: Patients must be: >= 6 months since allogeneic bone marrow transplant prior to registration; >= 3 months since autologous bone marrow/stem cell prior to registration
Corticosteroids: Patients who are receiving steroids must be on a stable or decreasing dose for at least 1 week prior to registration
Karnofsky >= 50 for subjects > 16 years of age and Lansky >= 50 for subjects =< 16 years of age. Subjects who are unable to walk because of paralysis, but who are up in a wheelchair, will be considered ambulatory for the purpose of assessing the performance score
Peripheral absolute neutrophil count (ANC) >= 1000/mm^3 (unsupported)
Platelet count >= 100,000/mm^3 (transfusion independent, defined as not receiving platelet transfusions for at least 7 days prior to enrollment)
Hemoglobin >= 8 m/dL (may be supported)
International normalized ratio (INR) =< 1.5
Creatinine clearance or radioisotope growth factor receptor (rGFR) >= 70 mL/min/1.73 m^2 or a serum creatinine based on age/gender as follows
to < 6 years: 0.8 (male), 0.8 (female)
to < 10 years: 1 (male), 1 (female)
to < 13 years: 1.2 (male), 1.2 (female)
to < 16 years: 1.5 (male), 1.4 (female)
>= 16 years: 1.7 (male), 1.4 (female)
Bilirubin (sum of conjugated + unconjugated) =< 1.5 x upper limit of normal (ULN) for age
Serum glutamate pyruvate transaminase (SGPT) alanine aminotransferase (ALT) =< 3 x ULN
Serum albumin >= 2 g/dL
Sodium, potassium, calcium and magnesium within 1.5 x institutional lower limit of normal (LLN) or ULN
Patients must have cholesterol level < 350 mg/dL and triglycerides < 400 mg/dL before starting therapy. In case one or both of these are exceeded, the patient can only be included after initiation of appropriate lipid lowering medication and documentation of cholesterol < 350 mg/dL and triglycerides < 400mg/dl before start of therapy
Subjects with seizure disorder may be enrolled if well controlled. Patients must be on non-enzyme inducing anticonvulsants which are not excluded on study therapy
Patients with neurological deficits should have deficits that are stable for a minimum of 1 week prior to registration
Corrected QT (QTc) interval =< 450 msecs
Left ventricular ejection fraction (LVEF) >= 50%
Pulse oximeter (Ox) > 93% on room air
Hypertension
Patients 3-17 years of age must have a blood pressure that is =< 95th percentile for age, height, and gender at the time of registration
Patients who are >= 18 years of age must have a blood pressure that is < 140/90 mm of Hg at the time of registration
Patients must agree to use adequate contraception: The effects of trametinib and everolimus on the developing human fetus are unknown. For this reason, women of child-bearing potential and males of child fathering potential must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation and 4 months after completion of trametinib and everolimus administration. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately
A legal parent/guardian or patient must be able to understand, and willing to sign, a written informed consent and assent document, as appropriate per institutional guidelines

Exclusion Criteria

Subjects who are receiving any other investigational agent for treatment of their tumor
History of allergic reactions attributed to compounds of similar chemical or biologic composition to everolimus or trametinib
Patients without available tissue from prior surgery. (If clinical comprehensive testing has already been performed, the requirement for submission of tissue may be waived after discussion and review of results with study chairs)
Patient is currently receiving any of the following medications and cannot be discontinued 7 days prior to enrollment
Known strong inducers or inhibitors of CYP3A4/5, including enzyme inducing anti-convulsant drugs (EIACDs), grapefruit, grapefruit hybrids, pomelos, starfruit, and Seville oranges
Substrates of CYP3A4/5 with a narrow therapeutic index
Herbal preparations/medications (except for vitamins) including, but not limited to: St. John's wort, Kava, ephedra (ma huang), gingko biloba, dehydroepiandrosterone (DHEA), yohimbe, saw palmetto, black cohosh and ginseng. Patients should stop using all herbal medications at least 7 days prior to enrollment
As part of the enrollment/informed consent procedures, the subject and/or legal parent or guardian will be counseled on the risk of interactions with other agents, and what to do if new medications need to be prescribed or if the subject is considering a new over-the-counter medicine or herbal product
Women of childbearing potential who are pregnant or breast-feeding
Female patients of childbearing potential must have a negative serum or urine pregnancy test within 72 hours of enrollment AND prior to receiving the first dose of study medication. If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required
Human immunodeficiency virus (HIV) positive patients will be ineligible if HIV therapy regimen has not been stable for at least 4 weeks or there is intent to change the regimen within 8 weeks following enrollment, or if they are severely immunocompromised
Patients with known hepatitis B or C are not eligible
Patients with any clinically significant unrelated systemic illness (serious infectious or significant cardiac, pulmonary, hepatic or other organ dysfunction), which in the opinion of the investigator would interfere with the study procedures or results
Patients with other factors that increase the risk of QT prolongation or arrhythmic events (e.g., heart failure, hypokalemia, family history of long QT interval syndrome) including heart failure that meets New York Heart Association (NYHA) class II or above are excluded
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